NurseSheet: Latest Drugs; Medicines; Chemotherapy

erythromycin

er-rith-row-my-sin

(A/T/S, Akne-Mycin, Apo-Erythro Base J, EES, Emgel, E-Mycin, Erybid J, Eryc, Eryc-125 J, Eryc-250 J, Erycette, EryDerm, Erygel, Erymax, EryPed, Ery-Tab, Erythra-Derm, Erythrocin, Erythromid J, PCE Dispertab, Romycin, Roymicin, Staticin, Theramycin, Theramycin Z, T-Stat)

Do not confuse erythromycin with azithromycin or Ethmozine, or Eryc with Emct.

FIXED-COMBINATION(S)

Eryzole, Pediazole: erythromycin/sulfisoxazole (sulfonamide): 200 mg/600 mg per 5 ml.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Macrolide. CLINICAL: Antibiotic, antiacne.

ACTION

A macrolide that reversibly binds to bacterial ribosomes, inhibiting bacterial protein synthesis. Therapeutic Effect: Bacteriostatic.

PHARMACOKINETICS

Variably absorbed from the GI tract (depending on dosage form used). Protein binding: 70%U90%. Widely distributed. Metabolized in the liver. Primarily eliminated in feces by bile. Not removed by hemodialysis. Half-life: 1.4U2 hr (increased in impaired renal function).

USES

Treatment of susceptible infections due to S. pyogenes, S. pneumoniae, S. aureus, M. pneumoniae, Legionella, diphtheria, pertussis, chancroid, Chlamydia, N. gonorrheae, E, histolytica, syphilis, nongonococcal urethritis, Campylobacter gastroenteritis including. Topical: Treatment of acne vulgaris. Ophthalmic: Prevention of gonococcal ophthalmia neonatorum. OFF-LABEL: Systemic: Treatment of acne vulgaris, chancroid, Campylobacter enteritis, gastroparesis, Lyme disease. Topical: Treatment of minor bacterial skin infections. Ophthalmic: Treatment of blepharitis, conjunctivitis, keratitis, chlamydial trachoma.

PRECAUTIONS

CONTRAINDICATIONS: Administration of fixed-combination product, Pediazole, to infants younger than 2 mo; history of hepatitis due to macrolides; hypersensitivity to macrolides; preexisting hepatic disease. CAUTIONS: Hepatic dysfunction. If combination therapy is used (Pediazole), consider precautions of sulfonamides. IV route may cause tachycardia, prolonged QT interval.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Distributed in breast milk. Erythromycin estolate may increase hepatic enzymes in pregnant women. Pregnancy Category B. Children/Elderly: No age-related precautions noted. High dosage in those with decreased hepatic or renal function increases risk of hearing loss.

INTERACTIONS

DRUG: Buspirone, cyclosporine, felodipine, lovastatin, simvastatin: May increase the blood concentration and toxicity of these drugs. Carbamazepine: May inhibit the metabolism of carbamazepine. Chloramphenicol, clindamycin: May decrease the effects of these drugs. Hepatotoxic medications: May increase the risk of hepatotoxicity. Theophylline: May increase the risk of theophylline toxicity. Warfarin: May increase warfarin's effects. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum alkaline phosphatase, bilirubin, AST, and ALT levels.

AVAILABILITY (Rx)

TOPICAL GEL (A/T/S, EMGEL, ERYGEL): 2%. INJECTION POWDER FOR RECONSTITUTION (ERYTHROCIN): 500 mg, 1 g. OPHTHALMIC OINTMENT (ROYMICIN): 0.5%. ORAL SUSPENSION (ERYPED, EES): 200 mg/5 ml, 400 mg/5 ml. TOPICAL OINTMENT (AKNE-MYCIN): 2%. TOPICAL SOLUTION: 1.5% (Staticin), 2% (A/T/S, Erymax, EryDerm, Erythra-Derm, Romycin, Theramycin Z, T-Stat). TOPICAL SWAB (ERYCETTE, T-STAT): 2%. TABLETS (CHEWABLE [ERY-PED]): 200 mg. TABLETS: 250 mg (E-Mycin, Ery-Tab, Erythrocin), 333 mg (Ery-Tab, E-Mycin, PCE Dispertab), 400 mg (EES), 500 mg (E-Mycin, Ery-Tab, Erythrocin, PCE Dispertab). CAPSULES (ENTERIC-COATED [ERYC]): 250 mg.

ADMINISTRATION/HANDLING

L IV

Reconstitution N Reconstitute each 500 mg with 10 ml sterile water for injection without preservative to provide a concentration of 50 mg/ml. N Further dilute with 100U250 ml D5W or 0.9% NaCl.

Rate of administration N For intermittent IV infusion (piggyback), infuse over 20U60 min. N For continuous infusion, infuse over 6U24 hr.

Storage N Store parenteral form at room temperature. N Initial reconstituted solution in vial is stable for 2 wk refrigerated or 24 hr at room temperature. N Diluted IV solutions stable for 8 hr at room temperature or 24 hr if refrigerated. N Discard if precipitate forms.

N Store capsules, tablets at room temperature. N Oral suspension is stable for 14 days at room temperature. N Administer erythromycin base, stearate 1 hr before or 2 hr following food. Erythromycin estolate, ethylsuccinate may be given without regard to meals, but optimal absorption occurs when given on empty stomach. N Give with 8 oz water. N If swallowing difficulties exist, sprinkle capsule contents on teaspoon of applesauce, follow with water. N Do not swallow chewable tablets whole.

OPHTHALMIC

N Place finger on lower eyelid, pull out until a pocket is formed between eye and lower lid. Place ¼U½ inch layer of ointment into pocket. N Have patient close eye gently for 1U2 min, rolling eyeball (increases contact area of drug to eye). N Remove excess ointment around eye with tissue.

D IV INCOMPATIBILITY

Fluconazole (Diflucan).

IV COMPATIBILITIES

Aminophylline, amiodarone (Cordarone), diltiazem (Cardizem), heparin, hydromorphone (Dilaudid), lidocaine, lorazepam (Ativan), magnesium sulfate, midazolam (Versed), morphine, multivitamins, potassium chloride, total parenteral nutrition (TPN).

INDICATIONS/ROUTES/DOSAGE

MILD TO MODERATE INFECTIONS OF THE UPPER AND LOWER RESPIRATORY TRACT, PHARYNGITIS, SKIN INFECTIONS

PO: ADULTS, ELDERLY: 250 mg q6h, 500 mg q12h, or 333 mg q8h. Maximum: 4 g/day. CHILDREN: 30U50 mg/kg/day in divided doses up to 60U100 mg/kg/day for severe infections. NEONATES: 20U40 mg/kg/day in divided doses q6U12h.

IV: ADULTS, ELDERLY, CHILDREN: 15U20 mg/kg/day in divided doses. Maximum: 4 g/day.

PREOPERATIVE INTESTINAL ANTISEPSIS

PO: ADULTS, ELDERLY: 1 g at 1 pm, 2 pm, and 11 pm on day before surgery (with neomycin). CHILDREN: 20 mg/kg at 1 pm, 2 pm, and 11 pm on day before surgery (with neomycin).

ACNE VULGARIS

TOPICAL: ADULTS: Apply thin layer to affected area twice a day.

GONOCOCCAL OPHTHALMIA NEONATORUM

OPHTHALMIC: NEONATES: 0.5U2 cm no later than 1 hr after delivery.

SIDE EFFECTS

FREQUENT: IV: Abdominal cramping or discomfort, phlebitis or thrombophlebitis. Topical: Dry skin (50%). OCCASIONAL: Nausea, vomiting, diarrhea, rash, urticaria. RARE: Ophthalmic: Sensitivity reaction with increased irritation, burning, itching, and inflammation. Topical: Urticaria.

ADVERSE REACTIONS/TOXIC EFFECTS

Antibiotic-associated colitis and other superinfections may occur. High dosages in patients with renal impairment may lead to reversible hearing loss. Anaphylaxis and hepatotoxicity occur rarely. Ventricular arrhythmias and prolonged QT interval occur rarely with the IV drug form.

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Question for history of allergies (particularly erythromycins), hepatitis.

INTERVENTION/EVALUATION

Determine pattern of bowel activity and stool consistency. Assess skin for rash. Assess for hepatotoxicity: malaise, fever, abdominal pain, GI disturbances. Evaluate for superinfection. Check for phlebitis (heat, pain, red streaking over vein). Monitor for high-dose hearing loss.

PATIENT/FAMILY TEACHING

N Continue therapy for full length of treatment. N Doses should be evenly spaced. N Do not swallow chewable tablets whole. N Take medication with 8 oz water 1 hr before or 2 hr following food or beverage. N Ophthalmic: Report burning, itching, inflammation. N Topical: Report excessive skin dryness, itching, burning. N Improvement of acne may not occur for 1U2 mo; maximum benefit may take 3 mo; therapy may last months or years. N Use caution if using other topical acne preparations containing peeling or abrasive agents, medicated or abrasive soaps, cosmetics containing alcohol (e.g., astringents, aftershave lotion).

enalapril maleate H

en-al-ah-pril

(AApo-Enalapril J, Vasotec)

Do not confuse enalapril with Anafranil, Eldepryl, or ramipril.

FIXED-COMBINATION(S)

Lexxel: enalapril/felodipine (calcium channel blocker): 5 mg/2.5 mg; 5 mg/5 mg. Teczem: enalapril/diltiazem (calcium channel blocker): 5 mg/180 mg. Vaseretic: enalapril/hydrochlorothiazide (diuretic): 5 mg/12.5 mg; 10 mg/25 mg.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Angiotensin-converting enzyme (ACE) inhibitor. CLINICAL: Antihypertensive, vasodilator.

ACTION

This ACE inhibitor suppresses the renin-angiotensin-aldosterone system, and prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor; may inhibit angiotensin II at local vascular, renal sites. Decreases plasma angiotensin II, increases plasma renin activity, decreases aldosterone secretion. Therapeutic Effect: In hypertension, reduces peripheral arterial resistance. In congestive heart failure (CHF), increases cardiac output; decreases peripheral vascular resistance, BP, pulmonary capillary wedge pressure, heart size.

PHARMACOKINETICS

Route Onset Peak Duration

PO 1 hr 4U6 hr 24 hr

IV 15 min 1U4 hr 6 hr

Readily absorbed from the GI tract (not affected by food). Protein binding: 50%U60%. Converted to active metabolite. Primarily excreted in urine. Removed by hemodialysis. Half-life: 11 hr (half-life is increased in those with impaired renal function).

USES

Treatment of hypertension alone or in combination with other antihypertensives. Adjunctive therapy for CHF. OFF-LABEL: Diabetic nephropathy, hypertension due to scleroderma renal crisis, hypertensive crisis, idiopathic edema, renal artery stenosis, rheumatoid arthritis, post MI for prevention of ventricular failure.

PRECAUTIONS

CONTRAINDICATIONS: History of angioedema from previous treatment with ACE inhibitors. CAUTIONS: Renal impairment, those with sodium depletion or on diuretic therapy, dialysis, hypovolemia, coronary/cerebrovascular insufficiency.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Distributed in breast milk. May cause fetal/neonatal mortality, morbidity. Pregnancy Category D (C if used in first trimester). Children: Safety and efficacy not established. Elderly: May be more susceptible to hypotensive effects.

INTERACTIONS

DRUG: Alcohol, antihypertensives, diuretics: May increase the effects of enalapril. HERBAL: None known. FOOD: None known. LAB VALUES: May increase BUN and serum alkaline phosphatase, serum bilirubin, serum creatinine, serum potassium, AST, and ALT levels. May decrease serum sodium levels. May cause positive ANA titer.

AVAILABILITY (Rx)

TABLETS: 2.5 mg, 5 mg, 10 mg, 20 mg. INJECTION: 1.25 mg/ml.

ADMINISTRATION/HANDLING

L IV

Reconstitution N May give undiluted or dilute with D5W or 0.9% NaCl.

Rate of administration N For IV push, give undiluted over 5 min. N For IV piggyback, infuse over 10U15 min.

Storage N Store parenteral form at room temperature. N Use only clear, colorless solution. N Diluted IV solution is stable for 24 hr at room temperature.

N Give without regard to food. N Tablets may be crushed.

D IV INCOMPATIBILITIES

Amphotericin B (Fungizone), amphotericin B complex (Abelcet, AmBisome, Amphotec), cefepime (Maxipime), phenytoin (Dilantin).

IV COMPATIBILITIES

Calcium gluconate, dobutamine (Dobutrex), dopamine (Inotropin), fentanyl (Sublimaze), heparin, lidocaine, magnesium sulfate, morphine, nitroglycerin, potassium chloride, potassium phosphate, propofol (Diprivan).

INDICATIONS/ROUTES/DOSAGE

HYPERTENSION ALONE OR IN COMBINATION WITH OTHER ANTIHYPERTENSIVES

PO: ADULTS, ELDERLY: Initially, 2.5U5 mg/day. May increase at 1U2 wk intervals. Range: 10U40 mg/day in 1U2 divided doses. CHILDREN: 0.1 mg/kg/day in 1U2 divided doses. Maximum: 0.5 mg/kg/day. NEONATES: 0.1 mg/kg/day q24h.

IV: ADULTS, ELDERLY: 0.625U1.25 mg q6h up to 5 mg q6h. CHILDREN, NEONATES: 5U10 mcg/kg/dose q8U24h.

ADJUNCTIVE THERAPY FOR CHF

PO: ADULTS, ELDERLY: Initially, 2.5U5 mg/day. Range: 5U20 mg/day in 2 divided doses.

DOSAGE IN RENAL IMPAIRMENT

Dosage is modified based on creatinine clearance.

Creatinine Clearance % Usual Dose

10U50 ml/min 75U100

Less than 10 ml/min 50

SIDE EFFECTS

FREQUENT (7%U5%): Headache, dizziness. OCCASIONAL (3%U2%): Orthostatic hypotension, fatigue, diarrhea, cough, syncope. RARE (less than 2%): Angina, abdominal pain, vomiting, nausea, rash, asthenia (loss of strength, energy).

ADVERSE REACTIONS/TOXIC EFFECTS

Excessive hypotension (“first-dose syncope”) may occur in patients with CHF and in those who are severely salt or volume depleted. Angioedema (swelling of face, lips) and hyperkalemia occur rarely. Agranulocytosis and neutropenia may be noted in patients with collagen vascular diseases, including scleroderma and systemic lupus erythematosus, and impaired renal function. Nephrotic syndrome may be noted in those with history of renal disease.

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Obtain BP immediately before each dose (be alert to fluctuations). In patients with renal impairment, autoimmune disease, or taking drugs that affect leukocytes/immune response, CBC should be performed before beginning therapy, q2wk for 3 mo, then periodically thereafter.

INTERVENTION/EVALUATION

Assist with ambulation if dizziness occurs. Monitor serum potassium, BUN, serum creatinine levels, BP. Monitor pattern of daily bowel activity and stool consistency.

PATIENT/FAMILY TEACHING

N To reduce hypotensive effect, rise slowly from lying to sitting position, permit legs to dangle from bed momentarily before standing. N Several weeks may be needed for full therapeutic effect of BP reduction. N Skipping doses or voluntarily discontinuing drug may produce severe, rebound hypertension. N Limit alcohol intake. N Inform physician if vomiting, diarrhea, excessive perspiration, swelling of face, lips, tongue, difficulty in breathing occurs.

efalizumab

ef-ah-liz-ewe-mab

(Raptiva)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Monoclonal antibody. CLINICAL: Immunosuppressive.

ACTION

A monoclonal antibody that interferes with lymphocyte activation by binding to the lymphocyte antigen, inhibiting the adhesion of leukocytes to other cell types. Therapeutic Effect: Prevents the release of cytokines and the growth and migration of circulating total lymphocytes, predominant in psoriatic lesions.

PHARMACOKINETICS

Clearance is affected by body weight, not by gender or race, after subcutaneous injection. Serum concentration reaches steady state at 4 wk. Mean time to elimination: 25 days.

USES

Treatment of adults 18 yr and older with chronic moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

PRECAUTIONS

CONTRAINDICATIONS: Concurrent use of immunosuppressive agents, hypersensitivity to any murine or humanized monoclonal antibody preparation. CAUTIONS: History of malignancy, chronic infection, history of recurrent infection, asthma, history of allergic reaction.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug is distributed in breast milk. Pregnancy Category C. Children: Not indicated for use in pediatric patients. Elderly: Age-related increased incidence of infection requires cautious use in the elderly.

INTERACTIONS

DRUG: Immunosuppressive agents: Increase the risk of infection. Live-virus vaccines: Decrease the immune response. HERBAL: None known. FOOD: None known. LAB VALUES: May increase the lymphocyte count.

AVAILABILITY (Rx)

POWDER FOR INJECTION: 150 mg, designed to deliver 125 mg/1.25 ml.

ADMINISTRATION/HANDLING

SUBCUTANEOUS

Reconstitution N Slowly inject 1.3 ml sterile water for injection provided into the efalizumab vial, using the provided prefilled diluent syringe. N Swirl vial gently to dissolve; do not shake (shaking causes foaming). N Dissolution takes less than 5 min.

Rate of administration N Administer into thigh, abdomen, buttocks, or upper arm.

Storage N Refrigerate unopened vial. N Reconstituted solution may be stored at room temperature for up to 8 hr.

INDICATIONS/ROUTES/DOSAGE

PSORIASIS

SUBCUTANEOUS: ADULTS, ELDERLY: Initially, 0.7 mg/kg followed by weekly doses of 1 mg/kg. Maximum: 200 mg (single dose).

SIDE EFFECTS

FREQUENT (32%U10%): Headache, chills, nausea, injection site pain. OCCASIONAL (8%U7%): Myalgia, flu-like symptoms, fever. RARE (4%): Back pain, acne.

ADVERSE REACTIONS/TOXIC EFFECTS

Hypersensitivity reaction, malignancies, serious infections (abscess, cellulitis, postoperative wound infection, pneumonia), thrombocytopenia, and worsening of psoriasis occur rarely.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Inform patient of treatment duration and required monitoring procedures. Obtain CBC to assess platelet count, lymphocyte before therapy and periodically thereafter. Inform patient of increased risk of developing an infection while undergoing treatment. Assess skin before therapy and document extent and location of psoriasis lesions.

INTERVENTION/EVALUATION

Assess skin throughout therapy for evidence of improvement of psoriasis lesions. Monitor for worsening of lesions. Offer patient teaching to assure accurate and sterile preparation and self-injection of medication.

PATIENT/FAMILY TEACHING

N If appropriate, patients may self-inject after proper training in the preparation and injection technique. N Inform physician or nurse if bleeding from the gums, bruising or petechiae of the skin, or onset of signs of infection occurs. N If new diagnosis of malignancy occurs, inform physician of current treatment with efalizumab. N Advise patients not to undergo phototherapy treatments.

efavirenz

eh-fah-vir-enz

(Sustiva)

Do not confuse Sustiva with Survanta.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Nonnucleoside reverse transcriptase inhibitor. CLINICAL: Antiretroviral.

ACTION

A nonnucleoside reverse transcriptase inhibitor that inhibits the activity of HIV reverse transcriptase of HIV-1 and the transcription of HIV-1 RNA to DNA. Therapeutic Effect: Interrupts HIV replication, slowing the progression of HIV infection.

PHARMACOKINETICS

Rapidly absorbed after PO administration. Protein binding: 99%. Metabolized to major isoenzymes in the liver. Eliminated in urine and feces. Half-life: 40U55 hr.

USES

Treatment of HIV infection in combination with other appropriate antiretroviral agents.

PRECAUTIONS

CONTRAINDICATIONS: Concurrent use with ergot derivatives, midazolam, or triazolam; efavirenz as monotherapy. CAUTIONS: History of mental illness, substance abuse, hepatic impairment.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Breast-feeding not recommended. Pregnancy Category D. Children: Safety and efficacy not established in those younger than 3 yr; may have increased incidence of rash. Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: Alcohol, psychoactive drugs: May produce additive CNS effects. Clarithromycin: Decreases clarithromycin plasma levels. Ergot derivatives, midazolam, triazolam: May cause serious or life-threatening reactions, such as arrhythmias, prolonged sedation, or respiratory depression. Indinavir, saquinavir: Decreases the plasma concentrations of these drugs. Nelfinavir, ritonavir: Increases the plasma concentrations of these drugs. Phenobarbital, rifabutin, rifampin: Lowers efavirenz plasma concentration. Warfarin: Alters warfarin plasma concentration. HERBAL: None known. FOOD: High-fat meals: May increase drug absorption. LAB VALUES: May produce false-positive urine test results for cannabinoid and increase total cholesterol, AST, ALT, and serum triglyceride levels.

AVAILABILITY (Rx)

CAPSULES: 50 mg, 100 mg, 200 mg. TABLETS: 600 mg.

ADMINISTRATION/HANDLING

N Give without regard to meals. N Avoid high-fat meal (may increase absorption).

INDICATIONS/ROUTES/DOSAGE

HIV INFECTION (IN COMBINATION WITH OTHER ANTIRETROVIRALS)

PO: ADULTS, ELDERLY, CHILDREN 3 YR AND OLDER WEIGHING 40 KG OR MORE: 600 mg once a day at bedtime. CHILDREN 3 YR AND OLDER WEIGHING 32.5 KGULESS THAN 40 KG: 400 mg once a day. CHILDREN 3 YR AND OLDER WEIGHING 25 KGULESS THAN 32.5 KG: 350 mg once a day. CHILDREN 3 YR AND OLDER WEIGHING 20 KGULESS THAN 25 KG: 300 mg once a day. CHILDREN 3 YR AND OLDER WEIGHING 15 KGULESS THAN 20 KG: 250 mg once a day. CHILDREN 3 YR AND OLDER WEIGHING 10 KGULESS THAN 15 KG: 200 mg once a day.

SIDE EFFECTS

FREQUENT (52%): Mild to severe: Dizziness, vivid dreams, insomnia, confusion, impaired concentration, amnesia, agitation, depersonalization, hallucinations, euphoria, somnolence (mild symptoms don't interfere with daily activities; severe symptoms interrupt daily activities). OCCASIONAL: Mild to moderate: Maculopapular rash (27%); nausea, fatigue, headache, diarrhea, fever, cough (less than 26%) (moderate symptoms may interfere with daily activities).

ADVERSE REACTIONS/TOXIC EFFECTS

Serious psychiatric adverse experiences (aggressive reactions, agitation, delusions, emotional lability, mania, neurosis, paranoia, psychosis, suicide) have been reported. BASELINE ASSESSMENT

Offer emotional support to patient and family. Obtain baseline AST, ALT in patients with history of hepatitis B or C; serum cholesterol or triglycerides before initiating therapy and at intervals during therapy. Obtain history of all prescription and OTC medication (high level of drug interaction).

INTERVENTION/EVALUATION

Monitor for CNS, psychological symptoms: severe acute depression, including suicidal ideation or attempts, dizziness, impaired concentration, somnolence, abnormal dreams, insomnia (begins during first or second day of therapy, generally resolves in 2U4 wk). Assess for evidence of rash (common side effect). Monitor hepatic enzyme studies for abnormalities. Assess for headache, nausea, diarrhea.

PATIENT/FAMILY TEACHING

N Avoid high-fat meals during therapy. N If rash appears, contact physician immediately. N CNS, psychological symptoms occur in more than half the patients and may manifest as dizziness, impaired concentration, delusions, depression. N Take medication every day as prescribed. N Do not alter dose or discontinue medication without informing physician. N Avoid tasks that require alertness, motor skills until response to drug is established. N Drug is not a cure for HIV infection, nor does it reduce risk of transmission to others.

etanercept

ee-tan-er-cept

(Enbrel)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Protein. CLINICAL: Antiarthritic.

ACTION

A protein that binds to tumor necrosis factor (TNF), blocking its interaction with cell surface receptors. Elevated levels of TNF, which is involved in inflammatory and immune responses, are found in the synovial fluid of rheumatoid arthritis patients. Therapeutic Effect: Relieves symptoms of rheumatoid arthritis.

PHARMACOKINETICS

Well absorbed after subcutaneous administration. Half-life: 115 hr.

USES

Reduces signs and symptoms of moderately to severely active rheumatoid arthritis (RA). Treatment of active juvenile RA, ankylosing spondylitis, psoriatic arthritis. Treatment of chronic moderate to severe plaque psoriasis. Improvement of physical function in patients with psoriatic arthritis. OFF-LABEL: Treatment of Crohn's disease, reactive arthritis.

PRECAUTIONS

CONTRAINDICATIONS: Serious active infection or sepsis. CAUTIONS: History of recurrent infections, illnesses that predispose to infection (e.g., diabetes).

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug is excreted in breast milk. Pregnancy Category B. Children: No age-related precautions noted in those 4 yr and older. Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES: None known.

AVAILABILITY (Rx)

POWDER FOR INJECTION: 25 mg. PREFILLED SYRINGE: 50 mg.

ADMINISTRATION/HANDLING

O ALERT P Do not add other medications to solution. Do not use filter during reconstitution or administration.

SUBCUTANEOUS

N Reconstitute with 1 ml of bacteriostatic water for injection (0.9% benzyl alcohol). Do not reconstitute with other diluents. N Slowly inject the diluent into the vial. Some foaming will occur. To avoid excessive foaming, slowly swirl contents until powder is dissolved (less than 5 min). N Visually inspect solution for particles, discoloration. Reconstituted solution should appear clear, colorless. If discolored, cloudy, or particles remain, discard solution; do not use. N Withdraw all the solution into syringe. Final volume should be approx. 1 ml. N Inject into thigh, abdomen, upper arm. Rotate injection sites. N Give new injection at least 1 inch from an old site and never into area where skin is tender, bruised, red, hard. N Refrigerate. N Once reconstituted, may be stored up to 6 hr if refrigerated.

INDICATIONS/ROUTES/DOSAGE

RHEUMATOID ARTHRITIS, PSORIATIC ARTHRITIS, ANKYLOSING SPONDYLITIS

SUBCUTANEOUS: ADULTS, ELDERLY: 25 mg twice weekly given 72U96 hr apart. Alternative weekly dosing: 0.8 mg/kg/dose once a week. Maximum: 50 mg/week. Maximum: 25 mg/dose.

JUVENILE RHEUMATOID ARTHRITIS

SUBCUTANEOUS: CHILDREN 4U17 YR: 0.4 mg/kg (Maximum: 25 mg dose) twice weekly given 72U96 hr apart. Alternative weekly dosing: 50 mg once weekly. Maximum: 25 mg/dose.

PLAQUE PSORIASIS

SUBCUTANEOUS: ADULTS, ELDERLY: 50 mg twice a week (give 3U4 days apart) for 3 mo. Maintenance: 50 mg once a week.

SIDE EFFECTS

FREQUENT (37%): Injection site erythema, pruritus, pain, and swelling; abdominal pain, vomiting (more common in children than adults). OCCASIONAL (16%U4%): Headache, rhinitis, dizziness, pharyngitis, cough, asthenia, abdominal pain, dyspepsia. RARE (less than 3%): Sinusitis, allergic reaction.

ADVERSE REACTIONS/TOXIC EFFECTS

Infections (such as pyelonephritis, cellulitis, osteomyelitis, wound infection, leg ulcer, septic arthritis, diarrhea, bronchitis, and pneumonia), occur in 38%U29% of patients. Rare adverse effects include heart failure, hypertension, hypotension, pancreatitis, GI hemorrhage, and dyspnea. The patient also may develop autoimmune antibodies.

NURSING CONSIDERATION BASELINE ASSESSMENT

Assess onset, type, location, duration of pain or inflammation. If a significant exposure to varicella virus has occurred during treatment, therapy should be temporarily discontinued and treatment with varicella-zoster immune globulin considered.

INTERVENTION/EVALUATION

Assess for joint swelling, pain, tenderness. Monitor erythrocyte sedimentation rate (ESR) or C-reactive protein level, CBC with differential, platelet count.

PATIENT/FAMILY TEACHING

N Instruct in subcutaneous injection technique, including areas of the body acceptable as injection sites. N Injection site reaction generally occurs in first month of treatment and decreases in frequency during continued therapy. N Do not receive live vaccines during treatment. N Inform physician if persistent fever, bruising, bleeding, pallor occurs.

enoxaparin sodium A

en-ox-ah-pear-in

(Klexane J, Lovenox)

Do not confuse Lovenox with Lotronex.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Low-molecular-weight heparin. CLINICAL: Anticoagulant.

ACTION

A low-molecular-weight heparin that potentiates the action of antithrombin III and inactivates coagulation factor Xa. Therapeutic Effect: Produces anticoagulation. Does not significantly influence bleeding time, PT, or aPTT.

PHARMACOKINETICS

Route Onset Peak Duration

Subcutaneous N/A 3U5 hr 12 hr

Well absorbed after subcutaneous administration. Eliminated primarily in urine. Not removed by hemodialysis. Half-life: 4.5 hr.

USES

Prevention of postop deep vein thrombosis (DVT) following hip or knee replacement surgery, abdominal surgery. Long-term DVT prevention following hip replacement surgery, nonsurgical acute illness. Treatment of unstable angina, nonUQ-wave MI, acute DVT (with warfarin). OFF-LABEL: Prevention of DVT following general surgical procedures.

PRECAUTIONS

CONTRAINDICATIONS: Active major bleeding, concurrent heparin therapy, hypersensitivity to heparin or pork products, thrombocytopenia associated with positive in vitro test for antiplatelet antibodies. CAUTIONS: Conditions with increased risk of hemorrhage, history of heparin-induced thrombocytopenia, renal impairment, elderly, uncontrolled arterial hypertension, history of recent GI ulceration or hemorrhage. When neuraxial anesthesia (epidural or spinal anesthesia) or spinal puncture is employed, patients anticoagulated or scheduled to be anticoagulated with enoxaparin for prevention of thromboembolic complications are at risk of developing an epidural or spinal hematoma which can result in long-term or permanent paralysis.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Use with caution, particularly during last trimester, immediate postpartum period (increased risk of maternal hemorrhage). Unknown if excreted in breast milk. Pregnancy Category B. Children: Safety and efficacy not established. Elderly: May be more susceptible to bleeding.

INTERACTIONS

DRUG: Anticoagulants, platelet inhibitors: May increase bleeding. HERBAL: None known. FOOD: None known. LAB VALUES: Increases (reversible) LDH, serum alkaline phosphatase, AST, and ALT levels.

AVAILABILITY (Rx)

INJECTION: 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml, 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml in prefilled syringes.

ADMINISTRATION/HANDLING

O ALERT P Do not mix with other injections or infusions. Do not give IM.

SUBCUTANEOUS

N Parenteral form appears clear and colorless to pale yellow. N Store at room temperature. N Instruct patient to lie down before administering by deep subcutaneous injection. N Inject between left and right anterolateral and left and right posterolateral abdominal wall. N Introduce entire length of needle (½ inch) into skin fold held between thumb and forefinger, holding skin fold during injection.

INDICATIONS/ROUTES/DOSAGE

PREVENTION OF DVT AFTER HIP AND KNEE SURGERY

SUBCUTANEOUS: ADULTS, ELDERLY: 30 mg twice a day, generally for 7U10 days.

PREVENTION OF DVT AFTER ABDOMINAL SURGERY

SUBCUTANEOUS: ADULTS, ELDERLY: 40 mg a day for 7U10 days.

PREVENTION OF LONG-TERM DVT IN NONSURGICAL ACUTE ILLNESS

SUBCUTANEOUS: ADULTS, ELDERLY: 40 mg once a day for 3 wk.

PREVENTION OF ISCHEMIC COMPLICATIONS OF UNSTABLE ANGINA AND NONUQ-WAVE MI (WITH ORAL ASPIRIN THERAPY)

SUBCUTANEOUS: ADULTS, ELDERLY: 1 mg/kg q12h.

ACUTE DVT

SUBCUTANEOUS: ADULTS, ELDERLY: 1 mg/kg q12h or 1.5 mg/kg once daily.

USUAL PEDIATRIC DOSAGE

SUBCUTANEOUS: CHILDREN: 0.5 mg/kg q12h (prophylaxis); 1 mg/kg q12h (treatment).

DOSAGE IN RENAL IMPAIRMENT

Clearance of enoxaparin is decreased when creatinine clearance is less than 30 ml/min. Monitor patient and adjust dosage as necessary. When enoxaparin is used in abdominal, hip, or knee surgery or acute illness, the dosage in renal impairment is 30 mg once a day. When enoxaparin is used to treat DVT, angina, or MI the dosage in renal impairment is 1 mg/kg once a day.

SIDE EFFECTS

OCCASIONAL (4%U1%): Injection site hematoma, nausea, peripheral edema.

ADVERSE REACTIONS/TOXIC EFFECTS

Overdose may lead to bleeding complications ranging from local ecchymoses to major hemorrhage. Antidote: Protamine sulfate (1% solution) equal to the dose of enoxaparin injected. One mg protamine sulfate neutralizes 1 mg enoxaparin. A second dose of 0.5 mg protamine sulfate per 1 mg enoxaparin may be given if aPTT tested 2U4 hr after first injection remains prolonged.

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Assess CBC, including platelet count.

INTERVENTION/EVALUATION

Periodically monitor CBC, platelet count, stool for occult blood (no need for daily monitoring in patients with normal presurgical coagulation parameters). Assess for any sign of bleeding: bleeding at surgical site, hematuria, blood in stool, bleeding from gums, petechiae, bruising, bleeding from injection sites.

PATIENT/FAMILY TEACHING

N Usual length of therapy is 7U10 days. N Do not take any OTC medication (especially aspirin) without consulting physician.

epoetin alfa

eh-po-ee-tin al-fa

(Epogen, Eprex J, Procrit)

Do not confuse Epogen with Neupogen.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Glycoprotein. CLINICAL: Erythropoietin.

ACTION

A glycoprotein that stimulates division and differentiation of erythroid progenitor cells in bone marrow. Therapeutic Effect: Induces erythropoiesis and releases reticulocytes from bone marrow.

PHARMACOKINETICS

Well absorbed after subcutaneous administration. Following administration, an increase in reticulocyte count occurs within 10 days, and increases in Hgb, Hct, and RBC count are seen within 2U6 wk. Half-life: 4U13 hr.

USES

Treatment of anemia in patients receiving or who have received chemotherapy, those with chronic renal failure, HIV-infected patients on zidovudine (AZT) therapy, those scheduled for elective nonvascular surgery, reducing need for allogenic blood transfusions. OFF-LABEL: Anemia associated with frequent blood donations, anemia in critically ill patients, malignancy, management of hepatitis C, myelodysplastic syndromes.

PRECAUTIONS

CONTRAINDICATIONS: History of sensitivity to mammalian cell-derived products or human albumin, uncontrolled hypertension. CAUTIONS: Patients with known porphyria (impairment of erythrocyte formation in bone marrow); history of seizures.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established in those 12 yr and younger. Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: Heparin: An increase in RBC volume may enhance blood clotting. Heparin dosage may need to be increased. HERBAL: None known. FOOD: None known. LAB VALUES: May increase BUN, serum phosphorus, serum potassium, serum creatinine, serum uric acid, and sodium levels. May decrease bleeding time, iron concentration, and serum ferritin levels.

AVAILABILITY (Rx)

INJECTION (EPOGEN, PROCRIT): 2,000 units/ml, 3,000 units/ml, 4,000 units/ml, 10,000 units/ml, 20,000 units/ml, 40,000 units/ml.

ADMINISTRATION/HANDLING

O ALERT P Avoid excessive agitation of vial; do not shake (foaming).

L IV

Reconstitution N No reconstitution necessary.

Rate of administration N May be given as an IV bolus.

Storage N Refrigerate. N Vigorous shaking may denature medication, rendering it inactive.

SUBCUTANEOUS

N Use 1 dose per vial; do not reenter vial. Discard unused portion. May be mixed in a syringe with bacteriostatic 0.9% NaCl with benzyl alcohol 0.9% (bacteriostatic saline) at a 1:1 ratio (benzyl alcohol acts as a local anesthetic; may reduce injection site discomfort).

D IV INCOMPATIBILITIES

Do not mix with other medications.

INDICATIONS/ROUTES/DOSAGE

TREATMENT OF ANEMIA IN CHEMOTHERAPY PATIENTS

IV, SUBCUTANEOUS: ADULTS, ELDERLY, CHILDREN: 150 units/kg/dose 3 times a wk. Maximum: 1,200 units/kg/wk.

REDUCTION OF ALLOGENIC BLOOD TRANSFUSIONS IN ELECTIVE SURGERY

SUBCUTANEOUS: ADULTS, ELDERLY: 300 units/kg/day 10 days before day of, and 4 days after surgery.

CHRONIC RENAL FAILURE

IV BOLUS, SUBCUTANEOUS: ADULTS, ELDERLY: Initially, 50U100 units/kg 3 times a wk. Target Hct range: 30%U36%. Adjust dosage no earlier than 1-mo intervals unless prescribed. Decrease dosage if Hct is increasing and approaching 36%. Plan to temporarily withhold doses if Hct continues to rise and to reinstate lower dosage when Hct begins to decrease. If Hct increases by more than 4 points in 2 wk, monitor Hct twice a wk for 2U6 wk. Increase dose if Hct does not increase 5U6 points after 8 wk (with adequate iron stores) and if Hct is below target range. Maintenance: For patients on dialysis: 75 units/kg 3 times a wk. Range: 12.5U525 units/kg. For patients not on dialysis: 75U150 units/kg/wk.

HIV INFECTION IN PATIENTS TREATED WITH AZT

IV, SUBCUTANEOUS: ADULTS: Initially, 100 units/kg 3 times a wk for 8 wk; may increase by 50U100 units/kg 3 times a wk. Evaluate response q4U8 wk thereafter. Adjust dosage by 50U100 units/kg 3 times a wk. If dosages larger than 300 units/kg 3 times a wk are not eliciting response, it is unlikely patient will respond. Maintenance: Titrate to maintain desired Hct.

SIDE EFFECTS

PATIENTS RECEIVING CHEMOTHERAPY

FREQUENT (20%U17%): Fever, diarrhea, nausea, vomiting, edema. OCCASIONAL (13%U11%): Asthenia, shortness of breath, paresthesia. RARE (5%U3%): Dizziness, trunk pain.

PATIENTS WITH CHRONIC RENAL FAILURE

FREQUENT (24%U11%): Hypertension, headache, nausea, arthralgia. OCCASIONAL (9%U7%): Fatigue, edema, diarrhea, vomiting, chest pain, skin reactions at administration site, asthenia, dizziness.

PATIENTS WITH HIV INFECTION TREATED WITH AZT

FREQUENT (38%U15%): Fever, fatigue, headache, cough, diarrhea, rash, nausea. OCCASIONAL (14%U9%): Shortness of breath, asthenia, skin reaction at injection site, dizziness.

ADVERSE REACTIONS/TOXIC EFFECTS

Hypertensive encephalopathy, thrombosis, cerebrovascular accident, MI, and seizures have occurred rarely. Hyperkalemia occurs occasionally in patients with chronic renal failure, usually in those who do not conform to medication regimen, dietary guidelines, and frequency of dialysis regimen.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Assess BP before drug initiation (80% of patients with chronic renal failure have history of hypertension). BP often rises during early therapy in patients with history of hypertension. Consider that all patients eventually need supplemental iron therapy. Assess serum iron (should be greater than 20%) and serum ferritin (should be greater than 100 ng/ml) before and during therapy. Establish baseline CBC (especially note Hct). Monitor aggressively for increased BP (25% of patients on medication require antihypertensive therapy, dietary restrictions).

INTERVENTION/EVALUATION

Monitor Hct level diligently (if level increases greater than 4 points in 2 wk, dosage should be reduced); assess CBC routinely. Monitor temperature, especially in cancer patients on chemotherapy and zidovudine-treated HIV patients. Monitor BUN, serum uric acid, creatinine, phosphorus, potassium, especially in chronic renal failure patients.

PATIENT/FAMILY TEACHING

N Frequent blood tests needed to determine correct dosage. N Inform physician if severe headache develops. N Avoid potentially hazardous activity during first 90 days of therapy (increased risk of seizures in renal patients during first 90 days).

eprosartan

eh-pro-sar-tan

(Teveten)

FIXED COMBINATION(S)

Teveten HCT: eprosartan/hydrochlorothiazide (a diuretic) 400 mg/12.5 mg.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Angiotensin II receptor antagonist. CLINICAL: Antihypertensive.

ACTION

An angiotensin II receptor antagonist that blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II, inhibiting the binding of angiotensin II to the AT1 receptors. Therapeutic Effect: Causes vasodilation, decreases peripheral resistance, and decreases BP.

PHARMACOKINETICS

Rapidly absorbed after PO administration. Protein binding: 98%. Undergoes first-pass metabolism in the liver to active metabolites. Excreted in urine and biliary system. Minimally removed by hemodialysis. Half-life: 5U9 hr.

USES

Treatment of hypertension.

PRECAUTIONS

CONTRAINDICATIONS: Bilateral renal artery stenosis, hyperaldosteronism. CAUTIONS: Unilateral renal artery stenosis, preexisting renal insufficiency, significant aortic or mitral stenosis.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Has caused fetal and neonatal morbidity and mortality. Potential for adverse effects on breast-feeding infant. Do not breast-feed. Pregnancy Category C (D if used in second or third trimester). Children: Safety and efficacy not established. Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES: May increase BUN, serum alkaline phosphatase, serum bilirubin, serum creatinine, AST, and ALT levels. May decrease blood Hgb and Hgb levels.

AVAILABILITY (Rx)

TABLETS: 400 mg, 600 mg.

ADMINISTRATION/HANDLING

N Give without regard to food. N Do not crush or break tablets.

INDICATIONS/ROUTES/DOSAGE

HYPERTENSION

PO: ADULTS, ELDERLY: Initially, 600 mg/day. Range: 400U800 mg/day.

SIDE EFFECTS

OCCASIONAL (5%U2%): Headache, cough, dizziness. RARE (less than 2%): Muscle pain, fatigue, diarrhea, upper respiratory tract infection, dyspepsia.

ADVERSE REACTIONS/TOXIC EFFECTS

Overdosage may manifest as hypotension and tachycardia. Bradycardia occurs less often.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Obtain BP, apical pulse immediately before each dose, in addition to regular monitoring (be alert to fluctuations). Question for possibility of pregnancy (see Pregnancy Category), history of hepatic or renal impairment, renal artery stenosis. Assess medication history (especially diuretic).

INTERVENTION/EVALUATION

Monitor BP, electrolytes, serum creatinine, BUN, urinalysis, pulse for tachycardia.

PATIENT/FAMILY TEACHING

N Inform female patient regarding consequences of second and third trimester exposure to medication. N Avoid tasks that require alertness, motor skills until response to drug is established (possible dizziness effect). N Restrict sodium, alcohol intake. N Follow diet, control weight. N Do not stop taking medication. Discuss need for lifelong control. N Caution against exercising during hot weather (risk of dehydration, hypotension). N Check BP regularly.

eptifibatide A

ep-tih-fye-bah-tide

(Integrilin)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Glycoprotein IIb/IIIa inhibitor. CLINICAL: Antiplatelet, antithrombotic.

ACTION

A glycoprotein IIb/IIIa inhibitor that rapidly inhibits platelet aggregation by preventing binding of fibrinogen to receptor sites on platelets. Therapeutic Effect: Prevents closure of treated coronary arteries. Also prevents acute cardiac ischemic complications.

USES

Treatment of patients with acute coronary syndrome (ACS), including those managed medically and those undergoing percutaneous coronary intervention (PCI).

PRECAUTIONS

CONTRAINDICATIONS: Active internal bleeding, AV malformation or aneurysm, history of cerebrovascular accident (CVA) within 2 yr or CVA with residual neurologic defect, history of vasculitis, intracranial neoplasm, oral anticoagulant use within last 7 days unless PT is less than 1.22 times the control, recent (6 wk or less) GI or GU bleeding, recent (6 wk or less) surgery or trauma, prior IV dextran use before or during percutaneous transluminal coronary angioplasty (PTCA), severe uncontrolled hypertension, thrombocytopenia (less than 100,000 cells/mcL). CAUTIONS: Patients who weigh less than 75 kg; those 65 yr and older; history of GI disease; patients receiving thrombolytics, heparin, aspirin, PTCA less than 12 hr of onset of symptoms for acute MI, prolonged PTCA (greater than 70 min), failed PTCA. Pregnancy Category B.

INTERACTIONS

DRUG: Anticoagulants, heparin: May increase the risk of hemorrhage. Dextran, other platelet aggregation inhibitors (such as aspirin), thrombolytic agents: May increase the risk of bleeding. HERBAL: None known. FOOD: None known. LAB VALUES: Increases aPTT, PT, and clotting time. Decreases platelet count.

AVAILABILITY (Rx)

INJECTION SOLUTION: 0.75 mg/ml, 2 mg/ml.

ADMINISTRATION/HANDLING

L IV

Reconstitution N Withdraw bolus dose from 10-ml vial (2 mg/ml); for IV infusion withdraw from 100-ml vial (0.75 mg/ml). IV push and infusion administration may be given undiluted.

Rate of administration N Give bolus dose IV push over 1U2 min.

Storage N Store vials in refrigerator. Solution appears clear, colorless. Do not shake. Discard any unused portion left in vial or if preparation contains any opaque particles.

D IV INCOMPATIBILITIES

Administer in separate line; do not add other medications to infusion solution.

INDICATIONS/ROUTES/DOSAGE

ADJUNCT TO PERCUTANEOUS CORONARY INTERVENTION (PCI)

IV BOLUS, IV INFUSION: ADULTS, ELDERLY: 180 mcg/kg before PCI initiation; then continuous drip of 2 mcg/kg/min and a second 180 mcg/kg bolus 10 min after the first. Maximum: 15 mg/h. Continue until hospital discharge or for up to 18U24 hours. Minimum 12 hours is recommended. Concurrent aspirin and heparin therapy is recommended.

ACUTE CORONARY SYNDROME

IV BOLUS, IV INFUSION: ADULTS, ELDERLY: 180 mcg/kg bolus then 2 mcg/kg/min until discharge or coronary artery bypass graft, up to 72 hr. Maximum: 15 mg/h. Concurrent aspirin and heparin therapy is recommended.

DOSAGE IN RENAL IMPAIRMENT:

Creatinine clearance less than 50 ml/min: Use 180 mcg/kg bolus (Maximum: 22.6 mg) and 1 mcg/kg/min infusion (Maximum: 7.5 mg/h).

SIDE EFFECTS

OCCASIONAL (7%): Hypotension.

ADVERSE REACTIONS/TOXIC EFFECTS

Minor to major bleeding complications may occur, most commonly at arterial access site for cardiac catheterization.

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Assess platelet count, Hgb, Hct before treatment. If platelet count less than 90,000/mm3, additional platelet counts should be obtained routinely to avoid thrombocytopenia.

INTERVENTION/EVALUATION

Diligently monitor for potential bleeding, particularly at other arterial, venous puncture sites. If possible, urinary catheters, nasogastric tubes should be avoided.

ertapenem

er-tah-pen-em

(Invanz)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Carbapenem. CLINICAL: Antibiotic.

ACTION

A carbapenem that penetrates the bacterial cell wall of microorganisms and binds to penicillin-binding proteins, inhibiting cell wall synthesis. Therapeutic Effect: Produces bacterial cell death.

PHARMACOKINETICS

Almost completely absorbed after IM administration. Protein binding: 85%U95%. Widely distributed. Primarily excreted in urine with smaller amount eliminated in feces. Removed by hemodialysis. Half-life: 4 hr.

USES

Treatment of susceptible infections due to S. aureus (methicillin suceptible only), S. agalactiae, S. pneumoniae (penicillin susceptible only), S. pyogenes, E. coli, H. influenzae (beta-lactamase negative strains only), K. pneumoniae, M. catarrhalis, Bacteroides species, C. clostridioforme, Peptostreptococcus species, including moderate to severe intra-abdominal, skin and skin-structure infections; community-acquired pneumonia; complicated UTI; acute pelvic infection; adult diabetic foot infections without osteomyelitis.

PRECAUTIONS

CONTRAINDICATIONS: History of hypersensitivity to beta-lactams (imipenem and cilastin, meropenem), hypersensitivity to amide-type local anesthetics (IM). CAUTIONS: Hypersensitivity to penicillins, cephalosporins, other allergens; impaired renal function; CNS disorders, especially brain lesions or history of seizures.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Distributed in breast milk. Pregnancy Category B. Children: Safety and efficacy not established in those younger than 18 yr. Elderly: Advanced or end-stage renal insufficiency may require dosage adjustment.

INTERACTIONS

DRUG: Probenecid: Reduces renal excretion of ertapenem. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum alkaline phosphatase, AST and ALT levels. May decrease platelet count, blood Hct and Hgb levels, and serum potassium level.

AVAILABILITY (Rx)

INJECTION POWDER FOR RECONSTITUTION: 1-g.

ADMINISTRATION/HANDLING

L IV

Reconstitution N Dilute 1-g vial with 10 ml 0.9% NaCl or bacteriostatic water for injection. N Shake well to dissolve. N Further dilute with 50 ml 0.9% NaCl.

Rate of administration N Give by intermittent IV infusion (piggyback). Do not give IV push. N Infuse over 20U30 min.

Storage N Solution appears colorless to yellow (variation in color does not affect potency). N Discard if solution contains precipitate. N Reconstituted solution is stable for 6 hr at room temperature or 24 hr if refrigerated.

N Reconstitute with 3.2 ml 1% lidocaine HCl injection (without epinephrine). N Shake vial thoroughly. N Inject deep in large muscle mass (gluteal or lateral part of thigh). N Administer suspension within 1 hr after preparation.

D IV INCOMPATIBILITIES

Do not mix or infuse ertapenem with any other medications. Do not use diluents or IV solutions containing dextrose.

IV COMPATIBILITIES

Sterile water for injection, 0.9% NaCl.

INDICATIONS/ROUTES/DOSAGE

INTRA-ABDOMINAL INFECTION

IV, IM: ADULTS, ELDERLY: 1 g/day for 5U14 days.

SKIN AND SKIN STRUCTURE INFECTION

IV, IM: ADULTS, ELDERLY: 1 g/day for 7U14 days.

PNEUMONIA, UTI

IV, IM: ADULTS, ELDERLY: 1 g/day for 10U14 days.

PELVIC INFECTION

IV, IM: ADULTS, ELDERLY: 1 g/day for 3U10 days.

DIABETIC FOOT INFECTION

IV, IM: ADULTS, ELDERLY: 1 g/day for 7U14 days.

DOSAGE IN RENAL IMPAIRMENT

For adults and elderly patients with creatinine clearance less than 30 ml/min: dosage is 500 mg once a day.

SIDE EFFECTS

FREQUENT (10%U6%): Diarrhea, nausea, headache. OCCASIONAL (5%U2%): Altered mental status, insomnia, rash, abdominal pain, constipation, vomiting, edema, fever. RARE (less than 2%): Dizziness, cough, oral candidiasis, anxiety, tachycardia, phlebitis at IV site.

ADVERSE REACTIONS/TOXIC EFFECTS

Antibiotic-associated colitis and other superinfections may occur. Anaphylactic reactions have been reported. Seizures may occur in those with CNS disorders (including patients with brain lesions or a history of seizures), bacterial meningitis, or severe renal impairment.

NURSING CONSIDERATION

ACTION

A carbapenem that penetrates the bacterial cell wall of microorganisms and binds to penicillin-binding proteins, inhibiting cell wall synthesis. Therapeutic Effect: Produces bacterial cell death.

PHARMACOKINETICS

USES

PRECAUTIONS

INTERACTIONS

AVAILABILITY (Rx)

INJECTION POWDER FOR RECONSTITUTION: 1-g.

ADMINISTRATION/HANDLING

L IV

Reconstitution N Dilute 1-g vial with 10 ml 0.9% NaCl or bacteriostatic water for injection. N Shake well to dissolve. N Further dilute with 50 ml 0.9% NaCl.

Rate of administration N Give by intermittent IV infusion (piggyback). Do not give IV push. N Infuse over 20U30 min.

D IV INCOMPATIBILITIES

Do not mix or infuse ertapenem with any other medications. Do not use diluents or IV solutions containing dextrose.

IV COMPATIBILITIES

Sterile water for injection, 0.9% NaCl.

INDICATIONS/ROUTES/DOSAGE

INTRA-ABDOMINAL INFECTION

IV, IM: ADULTS, ELDERLY: 1 g/day for 5U14 days.

SKIN AND SKIN STRUCTURE INFECTION

IV, IM: ADULTS, ELDERLY: 1 g/day for 7U14 days.

PNEUMONIA, UTI

IV, IM: ADULTS, ELDERLY: 1 g/day for 10U14 days.

PELVIC INFECTION

IV, IM: ADULTS, ELDERLY: 1 g/day for 3U10 days.

DIABETIC FOOT INFECTION

IV, IM: ADULTS, ELDERLY: 1 g/day for 7U14 days.

DOSAGE IN RENAL IMPAIRMENT

For adults and elderly patients with creatinine clearance less than 30 ml/min: dosage is 500 mg once a day.

SIDE EFFECTS

ADVERSE REACTIONS/TOXIC EFFECTS

escitalopram

es-sih-tail-oh-pram

(Lexapro)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Serotonin reuptake inhibitor. CLINICAL: Antidepressant.

ACTION

A selective serotonin reuptake inhibitor that blocks the uptake of the neurotransmitter serotonin at neuronal presynaptic membranes, increasing its availability at postsynaptic receptor sites. Therapeutic Effect: Relieves depression.

PHARMACOKINETICS

Well absorbed after PO administration. Primarily metabolized in the liver. Primarily excreted in feces with a lesser amount eliminated in urine. Half-life: 35 hr.

USES

Treatment of major depressive disorder exhibited as persistent, prominent dysphoria (occurring nearly every day for at least 2 wk) manifested by 4 of 8 symptoms: appetite change, sleep pattern change, increased fatigue, impaired concentration, feelings of guilt or worthlessness, loss of interest in usual activities, psychomotor agitation or retardation, suicidal tendencies. Treatment of generalized anxiety disorder (GAD). OFF-LABEL: Mixed anxiety and depressive disorder.

PRECAUTIONS

CONTRAINDICATIONS: Breast-feeding, use within 14 days of MAOIs. CAUTIONS: Hepatic/renal impairment; history of seizures, mania, hypomania; concurrent use of CNS depressants.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Distributed in breast milk. Pregnancy Category C. Children: May cause increased anticholinergic effects or hyperexcitability. Elderly: More sensitive to anticholinergic effects (e.g., dry mouth), more likely to experience dizziness, sedation, confusion, hypotension, hyperexcitability.

INTERACTIONS

DRUG: Alcohol, other CNS suppressants: May increase CNS depression. Antifungals, cimetidine, macrolide antibiotics: May increase plasma level of escitalopram. Carbamazepine: May decrease plasma level of escitalopram. Lithium: May increase lithium concentration and increase the risk of serotonin syndrome. MAOIs: May cause serotonin syndrome, marked by autonomic hyperactivity, coma, diaphoresis, excitement, hyperthermia, and rigidity, and neuroleptic malignant syndrome. Metoprolol: Increases plasma level of metoprolol. HERBAL: Ginkgo biloba, St. John's wort: May increase the risk of serotonin syndrome. FOOD: None known. LAB VALUES: May reduce serum sodium level.

AVAILABILITY (Rx)

ORAL SOLUTION: 5 mg/5 ml. TABLETS: 5 mg, 10 mg, 20 mg.

ADMINISTRATION/HANDLING

N Give without regard to food. N Do not crush film-coated tablets.

INDICATIONS/ROUTES/DOSAGE

DEPRESSION, GENERAL ANXIETY DISORDER (GAD)

PO: ADULTS: Initially, 10 mg once a day in the morning or evening. May increase to 20 mg after a minimum of 1 wk. ELDERLY, PATIENTS WITH HEPATIC IMPAIRMENT: 10 mg/day.

SIDE EFFECTS

FREQUENT (21%U11%): Nausea, dry mouth, somnolence, insomnia, diaphoresis. OCCASIONAL (8%U4%): Tremor, diarrhea, abnormal ejaculation, dyspepsia, fatigue, anxiety, vomiting, anorexia. RARE (3%U2%): Sinusitis, sexual dysfunction, menstrual disorder, abdominal pain, agitation, decreased libido.

ADVERSE REACTIONS/TOXIC EFFECTS

Overdose is manifested as dizziness, drowsiness, tachycardia, somnolence, confusion, and seizures.

NURSING CONSIDERATION

BASELINE ASSESSMENT

For patients on long-term therapy, liver/renal function tests, blood counts should be performed periodically. Observe/record behavior. Assess psychological status, thought content, sleep pattern, appearance, interest in environment.

INTERVENTION/EVALUATION

Supervise suicidal-risk patient closely during early therapy (as energy level improves, suicide potential increases). Assess appearance, behavior, speech pattern, level of interest, mood.

PATIENT/FAMILY TEACHING

N Do not stop taking medication or increase dosage. N Avoid use of alcohol. N Avoid tasks that require alertness, motor skills until response to drug is established.

esmolol hydrochloride A

ess-moe-lol

(Brevibloc)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Beta1 adrenergic blocker. CLINICAL: Antiarrhythmic.

ACTION

An antiarrhythmic that selectively blocks beta1-adrenergic receptors. Therapeutic Effect: Slows sinus heart rate, decreases cardiac output, reducing BP.

PHARMACOKINETICS

Rapidly metabolized primarily by esterase in the cytosol of red blood cells. Protein binding: 55%. Less than 1%U2% excreted in urine. Half-life: 9 min.

USES

Treatment of supraventricular tachycardia and atrial fibrillation or flutter, treatment of tachycardia and/or hypertension especially intraoperative or postop.

PRECAUTIONS

CONTRAINDICATIONS: Cardiogenic shock, overt cardiac failure, second- and third-degree heart block, sinus bradycardia. CAUTIONS: History of allergy, bronchial asthma, emphysema, bronchitis, CHF, diabetes, renal impairment.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta; distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: Insulin, oral hypoglycemics: May mask symptoms of hypoglycemia and prolong hypoglycemic effect of these drugs. MAOIs: May cause significant hypertension. Sympathomimetics, xanthines: May mutually inhibit effects. HERBAL: None known. FOOD: None known. LAB VALUES: None known.

AVAILABILITY (Rx)

INJECTION: 10 mg/ml, 20 mg/ml, 250 mg/ml.

ADMINISTRATION/HANDLING

O ALERT P Give by IV infusion. Avoid butterfly needles, very small veins.

L IV

Reconstitution N The 250 mg/ml ampule is not for direct IV injection but must be diluted to a final concentration not to exceed 10 mg/ml (prevents vein irritation). N For IV infusion, remove 20 ml from 500-ml container of D5W, Ringer's, D5W/Ringer's, D5W/lactated D5W/0.9% NaCl, D5W/0.45% NaCl, 0.9%NaCl, lactated Ringer's or 0.45% NaCl and dilute 250 mg/ml concentration esmolol to remaining 480 ml of solution to provide concentration of 10 mg/ml. Maximum concentration: 10 g/250 ml (40 mg/ml).

Rate of administration N Administer by controlled infusion device; titrate to tolerance and response. N Infuse IV loading dose over 1U2 min. N Hypotension (systolic BP less than 90 mm Hg) is greatest during first 30 min of IV infusion.

Storage N Use only clear and colorless to light yellow solution. N After dilution, solution is stable for 24 hr. N Discard solution if it is discolored or if precipitate forms.

D IV INCOMPATIBILITIES

Amphotericin B complex (Abelcet, AmBisome, Amphotec), furosemide (Lasix).

IV COMPATIBILITIES

Amiodarone (Cordarone), diltiazem (Cardizem), dopamine (Intropin), heparin, magnesium, midazolam (Versed), potassium chloride, propofol (Diprivan).

INDICATIONS/ROUTES/DOSAGE

ARRHYTHMIAS

IV: ADULTS, ELDERLY: Initially, loading dose of 500 mcg/kg/min for 1 min, followed by 50 mcg/kg/min for 4 min. If optimum response is not attained in 5 min, give second loading dose of 500 mcg/kg/min for 1 min, followed by infusion of 100 mcg/kg/min for 4 min. Additional loading doses can be given and infusion increased by 50 mcg/kg/min, up to 200 mcg/kg/min, for 4 min. Once desired response is attained, cease loading dose and increase infusion by no more than 25 mcg/kg/min. Interval between doses may be increased to 10 min. Infusion usually administered over 24U48 hr in most patients. Range: 50U200 mcg/kg/min, with average dose of 100 mcg/kg/min.

INTRA-OPERATIVE TACHYCARDIA OR HYPERTENSION (IMMEDIATE CONTROL)

IV: ADULTS, ELDERLY: Initially, 80 mg over 30 sec, then 150 mcg/kg/min infusion up to 300 mcg/kg/min.

SIDE EFFECTS

Esmolol is generally well tolerated, with transient and mild side effects. FREQUENT: Hypotension (systolic BP less than 90 mm Hg) manifested as dizziness, nausea, diaphoresis, headache, cold extremities, fatigue. OCCASIONAL: Anxiety, drowsiness, flushed skin, vomiting, confusion, inflammation at injection site, fever.

ADVERSE REACTIONS/TOXIC EFFECTS

Overdose may produce profound hypotension, bradycardia, dizziness, syncope, drowsiness, breathing difficulty, bluish fingernails or palms of hands, and seizures. Esmolol administration may potentiate insulin-induced hypoglycemia in diabetic patients.

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Assess BP, apical pulse immediately before drug is administered (if pulse is 60 or less/min or systolic BP is 90 mm Hg or less, withhold medication, contact physician).

INTERVENTION/EVALUATION

Monitor BP for hypotension, EKG, heart rate, respiratory rate, development of diaphoresis, dizziness (usually first sign of impending hypotension). Assess pulse for quality, irregular rate, bradycardia, extremities for coldness. Assist with ambulation if dizziness occurs. Assess for nausea, diaphoresis, headache, fatigue.

esomeprazole

es-oh-mep-rah-zole

(Nexium, Nexium IV)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Proton pump inhibitor. CLINICAL: Gastric acid inhibitor.

ACTION

A proton pump inhibitor that is converted to active metabolites that irreversibly bind to and inhibit hydrogen-potassium adenosine triphosphates, an enzyme on the surface of gastric parietal cells. Inhibits hydrogen ion transport into gastric lumen. Therapeutic Effect: Increases gastric pH, reducing gastric acid production.

PHARMACOKINETICS

Well absorbed after oral administration. Protein binding: 97%. Extensively metabolized by the liver. Primarily excreted in urine. Half-life: 1U1.5 hr.

USES

Short-term treatment (4U8 wk) of erosive esophagitis (diagnosed by endoscopy); symptomatic gastroesophageal reflux disease (GERD). Used in triple therapy with amoxicillin and clarithromycin for treatment of H. pylori infection in patients with duodenal ulcer. Reduce risk of NSAID gastric ulcer.

PRECAUTIONS

CONTRAINDICATIONS: Hypersensitivity to benzimidazoles. CAUTIONS: None known.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category B. Children: Safety and efficacy not established. Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: Digoxin, iron, ketoconazole: May decrease the concentration of digoxin, iron, and ketoconazole. HERBAL: None known. FOOD: None known. LAB VALUES: None known.

AVAILABILITY (Rx)

CAPSULES (DELAYED-RELEASE, MAGNESIUM [NEXIUM]): 20 mg, 40 mg. POWDER FOR SOLUTION (SODIUM [NEXIUM IV]): 20 mg, 40 mg.

ADMINISTRATION/HANDLING

L IV

Reconstitution N Reconstitution for IV push, add 5 mL of 0.9% NaCl to the vial with esomeprazole. N When administering a 20 mg dose, use only half of the reconstituted solution. N Discard any unused solution.

Infusion N Dissolve the content of one vial with esomeprazole in up to 100 ml 0.9% sodium chloride for IV use.

Rate of administration N For IV push, administer over not less than 3 min. For intermittent infusion (piggyback) infuse over 15U30 min. N Flush line with 0.9% NaCl injection, lactated Ringer's, or D5W, both before and after administration.

Storage N Use only clear and colorless to very slightly yellow solution. N Discard solution if particulate matter is present.

N Give more than 1 hr before eating. N Do not crush or chew capsule; swallow whole. For those with difficulty swallowing capsules, open capsule and mix pellets with 1 tbsp applesauce. Swallow spoonful without chewing.

D IV INCOMPATIBILITIES

Don't mix esomeprazole with any other medications through the same IV line or tubing.

INDICATIONS/ROUTES/DOSAGE

EROSIVE ESOPHAGITIS

PO: ADULTS, ELDERLY: 20U40 mg once daily for 4U8 wk.

IV: ADULTS, ELDERLY: 20 or 40 mg once daily by IV injection over at least 3 minutes or IV infusion over 10U30 minutes.

TO MAINTAIN HEALING OF EROSIVE ESOPHAGITIS

PO: ADULTS, ELDERLY: 20 mg/day.

GASTROESOPHAGEAL REFLUX DISEASE, TO REDUCE THE RISK OF NSAID-INDUCED GASTRIC ULCER

PO: ADULTS, ELDERLY: 20 mg once a day for 4 wk.

DUODENAL ULCER CAUSED BY HELICOBACTER PYLORI

PO: ADULTS, ELDERLY: 40 mg (esomeprazole) once a day, with amoxicillin 1,000 mg and clarithromycin 500 mg twice a day for 10 days.

SIDE EFFECTS

FREQUENT (7%): Headache. OCCASIONAL (3%U2%): Diarrhea, abdominal pain, nausea. RARE (less than 2%): Dizziness, asthenia or loss of strength, vomiting, constipation, rash, cough.

ADVERSE REACTIONS/TOXIC EFFECTS

None known.

NURSING CONSIDERATION

INTERVENTION/EVALUATION

Evaluate for therapeutic response (i.e., relief of GI symptoms). Question if GI discomfort, nausea, diarrhea occur.

PATIENT/FAMILY TEACHING

N Report headache. N Take more than 1 hr before eating. N For patients with difficulty swallowing capsules, open capsule and mix pellets with 1 tbsp applesauce. Swallow spoonful without chewing.

etanercept

ee-tan-er-cept

(Enbrel)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Protein. CLINICAL: Antiarthritic.

ACTION

PHARMACOKINETICS

Well absorbed after subcutaneous administration. Half-life: 115 hr.

USES

PRECAUTIONS

CONTRAINDICATIONS: Serious active infection or sepsis. CAUTIONS: History of recurrent infections, illnesses that predispose to infection (e.g., diabetes).

INTERACTIONS

DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES: None known.

AVAILABILITY (Rx)

POWDER FOR INJECTION: 25 mg. PREFILLED SYRINGE: 50 mg.

ADMINISTRATION/HANDLING

O ALERT P Do not add other medications to solution. Do not use filter during reconstitution or administration.

SUBCUTANEOUS

INDICATIONS/ROUTES/DOSAGE

RHEUMATOID ARTHRITIS, PSORIATIC ARTHRITIS, ANKYLOSING SPONDYLITIS

SUBCUTANEOUS: ADULTS, ELDERLY: 25 mg twice weekly given 72U96 hr apart. Alternative weekly dosing: 0.8 mg/kg/dose once a week. Maximum: 50 mg/week. Maximum: 25 mg/dose.

JUVENILE RHEUMATOID ARTHRITIS

SUBCUTANEOUS: CHILDREN 4U17 YR: 0.4 mg/kg (Maximum: 25 mg dose) twice weekly given 72U96 hr apart. Alternative weekly dosing: 50 mg once weekly. Maximum: 25 mg/dose.

PLAQUE PSORIASIS

SUBCUTANEOUS: ADULTS, ELDERLY: 50 mg twice a week (give 3U4 days apart) for 3 mo. Maintenance: 50 mg once a week.

SIDE EFFECTS

ADVERSE REACTIONS/TOXIC EFFECTS

NURSING CONSIDERATION

BASELINE ASSESSMENT

INTERVENTION/EVALUATION

Assess for joint swelling, pain, tenderness. Monitor erythrocyte sedimentation rate (ESR) or C-reactive protein level, CBC with differential, platelet count.

PATIENT/FAMILY TEACHING

etoposide, VP-16 A

eh-toe-poe-side

(Etopophos, Toposar, VePesid)

Do not confuse VePesid with Pepcid or Versed.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Epipodophyllotoxin. CLINICAL: Antineoplastic.

ACTION

An epipodophyllotoxin that induces single- and double-stranded breaks in DNA. Cell cycle-dependent and phase-specific; most effective in the S and G2 phases of cell division. Therapeutic Effect: Inhibits or alters DNA synthesis.

PHARMACOKINETICS

Variably absorbed from the GI tract. Rapidly distributed, low concentrations in CSF. Protein binding: 97%. Metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 3U12 hr.

USES

Treatment of testicular tumors, small cell lung carcinoma. OFF-LABEL: Acute lymphocytic, acute nonlymphocytic leukemias; Ewing's and Kaposi's sarcoma; Hodgkin's and non-Hodgkin's lymphomas; endometrial, gastric, nonUsmall cell lung carcinomas; multiple myeloma, myelodysplastic syndromes, neuroblastoma, osteosarcoma, ovarian germ cell tumors; primary brain, gestational trophoblastic tumors; soft tissue sarcomas, Wilms’ tumor.

PRECAUTIONS

CONTRAINDICATIONS: Pregnancy. CAUTIONS: Hepatic/renal impairment, bone marrow suppression.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: If possible, avoid use during pregnancy, especially first trimester. May cause fetal harm. Breast-feeding not recommended. Pregnancy Category D. Children: Safety and efficacy not established. Elderly: Age-related renal impairment may require dosage adjustment.

INTERACTIONS

DRUG: Bone marrow depressants: May increase myelosuppression. Live-virus vaccines: May potentiate virus replication, increase vaccine side effects, and decrease the patient's antibody response to the vaccine. HERBAL: None known. FOOD: None known. LAB VALUES: None known.

AVAILABILITY (Rx)

CAPSULES (VEPESID): 50 mg. INJECTION (TOPOSAR, VEPESID): 20 mg/ml. INJECTION (WATER-SOLUBLE [ETOPOPHOS]): 100 mg/ml.

ADMINISTRATION/HANDLING

O ALERT P Administer by slow IV infusion. Wear gloves when preparing solution. If powder or solution comes in contact with skin, wash immediately and thoroughly with soap, water. May be carcinogenic, mutagenic, teratogenic. Handle with extreme care during preparation and administration.

L IV

Reconstitution

VEPESID N Dilute each 100 mg (5 ml) with at least 250 ml D5W or 0.9% NaCl to provide concentration of 0.4 mg/ml (500 ml for concentration of 0.2 mg/ml).

ETOPOPHOS N Reconstitute each 100 mg with 5U10 ml sterile water for injection, D5W, or 0.9% NaCl to provide concentration of 20 mg/ml or 10 mg/ml, respectively. N May give without further dilution or further dilute to concentration as low as 0.1 mg/ml with 0.9% NaCl or D5W.

Rate of administration

VEPESID N Infuse slowly, over 30U60 min (rapid IV may produce marked hypotension). N Monitor for anaphylactic reaction during infusion (chills, fever, dyspnea, diaphoresis, lacrimation, sneezing, throat, back, or chest pain).

ETOPOPHOS N May give over as little as 5 min up to 210 min.

Storage

VEPESID N Store injection at room temperature before dilution. N Concentrate for injection is clear, yellow. N Diluted solution is stable at room temperature for 96 hr at 0.2 mg/ml, 48 hr at 0.4 mg/ml. N Discard if crystallization occurs.

ETOPOPHOS N Refrigerate vials. N Stable for 24 hr after reconstitution.

Storage N Refrigerate gelatin capsules.

D IV INCOMPATIBILITIES

VePesid: Cefepime (Maxipime), filgrastim (Neupogen), idarubicin (Idamycin). Etopophos: Amphotericin B (Fungizone), cefepime (Maxipime), chlorpromazine (Thorazine), methylprednisolone (Solu-Medrol), prochlorperazine (Compazine).

IV COMPATIBILITIES

VePesid: Carboplatin (Paraplatin), cisplatin (Platinol), cytarabine (Cytosar), daunorubicin (Cerubidine), doxorubicin (Adriamycin), granisetron (Kytril), mitoxantrone (Novantrone), ondansetron (Zofran). Etopophos: Carboplatin (Paraplatin), cisplatin (Platinol), cytarabine (Cytosar), dacarbazine (DTIC-Dome), daunorubicin (Cerubidine), dexamethasone (Decadron), diphenhydramine (Benadryl), doxorubicin (Adriamycin), granisetron (Kytril), magnesium sulfate, mannitol, mitoxantrone (Novantrone), ondansetron (Zofran), potassium chloride.

INDICATIONS/ROUTES/DOSAGE

REFRACTORY TESTICULAR TUMORS

IV: ADULTS: 50U100 mg/m2/day on days 1 to 5, or 100 mg/m2/day on days 1, 3, 5 (as combination therapy).

ACUTE MYELOCYTIC LEUKEMIA

IV: CHILDREN: 150 mg/m2/day for 2U3 days and 2U3 cycles.

BRAIN TUMOR

IV: CHILDREN: 150 mg/m2/day on days 2 and 3 of treatment course.

NEUROBLASTOMA

IV: CHILDREN: 100 mg/m2/day on days 1U5 of treatment course; repeated q4wk.

SMALL-CELL LUNG CARCINOMA

PO: ADULTS: Twice the IV dose rounded to nearest 50 mg. Give once a day for doses 400 mg or less, in divided doses for dosages greater than 400 mg.

IV: ADULTS: 35 mg/m2/day for 4 consecutive days up to 50 mg/m2/day for 5 consecutive days (as combination therapy).

LEUKEMIA, RHABDOMYOSARCOMA

CHILDREN: 60U150 mg/m2/day for 2U5 days q3U6wk.

DOSAGE IN RENAL IMPAIRMENT

Creatinine Clearance 10U50 ml/min: 75% of normal dose. Creatinine clearance less than 10 ml/min: 50% of normal dose.

SIDE EFFECTS

FREQUENT (66%U43%): Mild to moderate nausea and vomiting, alopecia. OCCASIONAL (13%U6%): Diarrhea, anorexia, stomatitis. RARE (2% or LESS): Hypotension, peripheral neuropathy.

ADVERSE REACTIONS/TOXIC EFFECTS

Myelosuppression may result in hematologic toxicity, manifested as anemia, leukopenia (occurring 7U14 days after drug administration), thrombocytopenia (occurring 9U16 days after administration) and, to lesser extent, pancytopenia. Bone marrow recovery occurs by day 20.

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Obtain hematology tests before and at frequent intervals during therapy. Antiemetics readily control nausea, vomiting.

INTERVENTION/EVALUATION

Monitor Hgb, Hct, WBC, platelet count. Assess pattern of daily bowel activity and stool consistency. Monitor for hematologic toxicity (fever, sore throat, signs of local infection, unusual ecchymosis or bleeding from any site), symptoms of anemia (excessive fatigue, weakness). Assess for paresthesias (peripheral neuropathy). Monitor for stomatitis.

PATIENT/FAMILY TEACHING

N Alopecia is reversible, but new hair growth may have different color, texture. N Do not have immunizations without physician's approval (drug lowers body's resistance). N Avoid contact with those who have recently received live virus vaccine. N Promptly report fever, sore throat, signs of local infection, unusual bruising or bleeding from any site.

exemestane A

x-eh-mess-tane

(Aromasin)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Hormone. CLINICAL: Antineoplastic.

ACTION

Inactivates aromatase, the principal enzyme that converts androgens to estrogens in both premenopausal and postmenopausal women, thereby lowering the circulating estrogen level. Therapeutic Effect: Inhibits the growth of breast cancers that are stimulated by estrogens.

PHARMACOKINETICS

Rapidly absorbed after PO administration. Protein binding: 90%. Distributed extensively into tissues. Metabolized in the liver; eliminated in urine and feces. Half-life: 24 hr.

USES

Treatment of advanced breast cancer in postmenopausal women whose disease has progressed following tamoxifen therapy. Adjuvant treatment of postmenopausal women with estrogen-receptor positive early breast cancer after 2U3 yr of tamoxifen therapy for completion of 5 consecutive years of adjuvant hormonal therapy. OFF-LABEL: Prevention of prostate cancer.

PRECAUTIONS

CONTRAINDICATIONS: Pregnancy. CAUTIONS: Do not give to premenopausal women.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Indicated for post-menopausal women. Pregnancy Category D. Children: Not indicated in children. Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum alkaline phosphatase, AST, and ALT levels.

AVAILABILITY (Rx)

TABLETS: 25 mg.

ADMINISTRATION/HANDLING

N Give after a meal.

INDICATIONS/ROUTES/DOSAGE

BREAST CANCER

PO: ADULTS, ELDERLY: 25 mg once a day after a meal. 50 mg/day when used concurrently with potent CYP3A4 inducers (e.g., rifampin, phenytoin).

SIDE EFFECTS

FREQUENT (22%U10%): Fatigue, nausea, depression, hot flashes, pain, insomnia, anxiety, dyspnea. OCCASIONAL (8%U5%): Headache, dizziness, vomiting, peripheral edema, abdominal pain, anorexia, flu-like symptoms, diaphoresis, constipation, hypertension. RARE (4%): Diarrhea.

ADVERSE REACTIONS/TOXIC EFFECTS

MI has been reported.

NURSING CONSIDERATIONS

INTERVENTION/EVALUATION

Monitor for onset of depression. Assess sleep pattern. Monitor for and assist with ambulation if dizziness occurs. Assess for headache. Offer antiemetic for nausea and vomiting.

PATIENT/FAMILY TEACHING

N Notify physician if nausea, hot flashes become unmanageable. N Avoid tasks that require alertness, motor skills until response to drug is established. N Best taken after meals and at the same time each day.

ezetimibe

eh-zeh-tih-myb

(Zetia)

Do not confuse Zetia with Zestril.

FIXED-COMBINATION(S)

Vytorin: ezetimibe/simvastatin (Hydroxamethyglutaryl CoA [HMG-CoA] reductase inhibitor): 10 mg/10 mg, 10 mg/20 mg, 10 mg/40 mg, 10 mg/80 mg.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Antihyperlipidemic. CLINICAL: Anticholesterol agent.

ACTION

An antihyperlipidemic that inhibits cholesterol absorption in the small intestine, leading to a decrease in the delivery of intestinal cholesterol to the liver. Therapeutic Effect: Reduces total serum cholesterol, LDL cholesterol, and triglyceride levels; and increases HDL cholesterol concentration.

PHARMACOKINETICS

Well absorbed following oral administration. Protein binding: greater than 90%. Metabolized in the small intestine and liver. Excreted by the kidneys and bile. Half-life: 22 hr.

USES

Adjunct to diet for treatment of primary hypercholesterolemia (monotherapy or in combination with HMG-CoA reductase inhibitors), homozygous sitosterolemia, homozygous familial hypercholesterolemia (combined with atrovastatin or simvastatin).

PRECAUTIONS

CONTRAINDICATIONS: Concurrent use of an hydroxamethylglutaryl-CoA (HMG-CoA) reductase inhibitor (atorvastatin, fluvastatin, lovastatin, pravastatin, or simvastatin) in patients with active hepatic disease or unexplained persistent elevations in serum transaminase levels, moderate or severe hepatic insufficiency. CAUTIONS: Diabetes, hypothyroidism, obstructive liver disease, chronic renal failure, hepatic impairment.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established in patients 10 yr and younger. Elderly: Age-related mild hepatic impairment may require dosage adjustment. Not recommended in patients with moderate or severe hepatic impairment.

INTERACTIONS

DRUG: Aluminum and magnesium-containing antacids, cyclosporine, fenofibrate, gemfibrozil: Increase ezetimibe plasma concentration. Cholestyramine resin: Decreases drug effectiveness. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum alkaline phosphatase, serum bilirubin, AST, and ALT levels.

AVAILABILITY (Rx)

TABLETS: 10 mg.

ADMINISTRATION/HANDLING

N Give without regard to food.

INDICATIONS/ROUTES/DOSAGE

HYPERCHOLESTEROLEMIA

PO: ADULTS, ELDERLY: Initially, 10 mg once a day, given with or without food. If the patient is also receiving a bile acid sequestrant, give ezetimibe at least 2 hr before or at least 4 hr after the bile acid sequestrant.

SITOSTEROLEMIA

PO: ADULTS, ELDERLY: 10 mg/day.

SIDE EFFECTS

OCCASIONAL (4%U3%): Back pain, diarrhea, arthralgia, sinusitis, abdominal pain. RARE (2%): Cough, pharyngitis, fatigue.

ADVERSE REACTIONS/TOXIC EFFECTS

Hepatitis, hypersensitivity reactions, myopathy, and rhabdomyolysis occur rarely.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Obtain serum cholesterol, triglycerides, liver function tests, blood counts during initial therapy and periodically during treatment. Treatment should be discontinued if hepatic enzyme levels persist more than 3 times normal limit.

INTERVENTION/EVALUATION

Monitor pattern of daily bowel activity and stool consistency. Question patient for signs and symptoms of back pain, abdominal disturbances. Monitor serum cholesterol, triglyceride concentrations for therapeutic response.

PATIENT/FAMILY TEACHING

N Periodic laboratory tests are essential part of therapy. N Do not stop medication without consulting physician.

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Friday, September 10, 2010

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