NurseSheet

dexamethasone

dex-a-meth-a-sone

(Adrenocot, Cortastat, Cortastat 10, Cortastat LA, Dalalone, Dalalone D.P., Dalalone L.A., Decadron, Decadron 5-12 Pak, Decadron Phosphate Injectable, Decaject, De-Sone LA, Dexacen-4, Dexamethasone Intensol, Dexasone, Dexasone LA, Dexpak Taperpak, Diodex J, Hexadrol, Hexadrol Phosphate, Maxidex, Solurex, Solurex LA)

Do not confuse dexamethasone with desoximetasone or dextramethophan, or Maxidex with Maxzide.

FIXED-COMBINATION(S)

Ciprodex Otic: dextramethasone/ciprofloxacin (antibiotic): 0.1%/0.3%. Dexacidin, Maxitrol: dexamethasone/neomycin/polymyxin (anti-infectives): 0.1%/3.5 mg/10,000 units per g or ml.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Long-acting glucocorticoid. CLINICAL: Corticosteroid.

ACTION

A long-acting glucocorticoid that inhibits accumulation of inflammatory cells at inflammation sites, phagocytosis, lysosomal enzyme release and synthesis, and release of mediators of inflammation. Therapeutic Effect: Prevents and suppresses cell and tissue immune reactions and inflammatory process.

PHARMACOKINETICS

Rapidly, completely absorbed from the GI tract after oral administration. Widely distributed. Protein binding: High. Metabolized in the liver. Primarily excreted in urine. Minimally removed by hemodialysis. Half-life: 3U4.5 hr.

USES

Acute exacerbations of chronic allergic disorders, cerebral edema, conditions treated by immunosupression, inflammatory conditions, ototis externa, ophthalmic conditions including corneal injury, inflammatory conditions, infective conjunctivitis. OFF-LABEL: Antiemetic, croup.

PRECAUTIONS

CONTRAINDICATIONS: Active untreated infections, fungal, tuberculosis, or viral diseases of the eye. CAUTIONS: Respiratory tuberculosis, untreated systemic infections, ocular herpes simplex, hyperthyroidism, cirrhosis, ulcerative colitis, hypertension, osteoporosis patients at high thromboembolic risk, CHF, seizure disorders, peptic ulcer, diabetes. Prolonged use may result in cataracts, glaucoma.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Distributed in breast milk. Pregnancy Category C (D if used in the first trimester). Children: Prolonged treatment with high-dose therapy may decrease short-term growth rate, cortisol secretion. Elderly: Higher risk for developing hypertension, osteoporosis.

INTERACTIONS

DRUG: Amphotericin: May increase hypokalemia. Digoxin: May increase digoxin toxicity caused by hypokalemia. Diuretics, insulin, oral hypoglycemics, potassium supplements: May decrease the effects of these drugs. Hepatic enzyme inducers: May decrease the effects of dexamethasone. Live-virus vaccines: May decrease the patient's antibody response to vaccine, increase vaccine side effects, and potentiate virus replication. HERBAL: None known. FOOD: None known. LAB VALUES: May increase blood glucose and serum lipid, amylase, and sodium levels. May decrease serum calcium, potassium, and thyroxine levels.

AVAILABILITY (Rx)

NASAL AEROSOL: 100 mcg. OPHTHALMIC OINTMENT (DECADRON, MAXIDEX): 0.05%. OPHTHALMIC SOLUTION (DECADRON): 0.1%. OPHTHALMIC SUSPENSION (MAXIDEX): 0.1%. ORAL CONCENTRATE (DEXAMETHASONE INTENSOL): 1 mg/ml. ORAL SOLUTION: 0.5 mg/5 ml, 1 mg/ml. TABLETS: 0.25 mg, 0.5 mg (Decadron), 0.75 mg (Decadron, Decadron 5U12 Pak), 1 mg, 1.5 mg (Dexpak Taperpak), 2 mg, 4 mg (Decadron, Hexadrol), 6 mg. TOPICAL AEROSOL: 0.01%, 0.04%. TOPICAL CREAM (DECADRON): 0.1%. TOPICAL GEL: 0.1%. INJECTABLE SOLUTION: 4 mg/ml (Adrenocot, Cortastat, Dalalone, Decadron Phosphate Injectable, Decaject, Dexacen-4, Dexasone, Hexadrol Phosphate, Solurex), 10 mg/ml (Cortastat 10, Dexasone, Hexadrol Phosphate). INJECTABLE SUSPENSION: 8 mg/ml (Cortastat LA, Dalalone LA, De-Sone LA, Dexasone LA, Solurex LA), 16 mg/ml (Dalalone D.P.).

ADMINISTRATION/HANDLING

L IV

O ALERT P Dexamethasone sodium phosphate may be given by IV push or IV infusion.

N For IV push, give over 1U4 min. N For IV infusion, mix with 0.9% NaCl or D5W and infuse over 15U30 min. N For neonate, solution must be preservative free. N IV solution must be used within 24 hr.

N Give deep IM, preferably in gluteus maximus.

N Give with milk or food.

OPHTHALMIC

N Place finger on lower eyelid and pull out until a pocket is formed between eye and lower lid. N Hold dropper above pocket and place correct number of drops (¼U½ inch ointment) into pocket. N Close eye gently.

Solution: Apply digital pressure to lacrimal sac for 1U2 min (minimizes drainage into nose and throat, reducing risk of systemic effects).

Ointment: Close eye for 1U2 min. Instruct patient to roll eyeball (increases contact area of drug to eye). Remove excess solution or ointment around eye with tissue. N Ointment may be used at night to reduce frequency of solution administration. N As with other corticosteroids, taper dosage slowly when discontinuing.

TOPICAL

N Gently cleanse area before application. N Use occlusive dressings only as ordered. N Apply sparingly and rub into area thoroughly.

D IV INCOMPATIBILITIES

Ciprofloxacin (Cipro), daunorubicin (Cerubidine), idarubicin (Idamycin), midazolam (Versed).

IV COMPATIBILITIES

Aminophylline, cimetidine (Tagamet), cisplatin (Platinol), cyclophosphamide (Cytoxan), cytarabine (Cytosar), docetaxel (Taxotere), doxorubicin (Adriamycin), etoposide (VePesid), granisetron (Kytril), heparin, hydromorphone (Dilaudid), lorazepam (Ativan), morphine, ondansetron (Zofran), paclitaxel (Taxol), potassium chloride, propofol (Diprivan), total parenteral nutrition (TPN).

INDICATIONS/ROUTES/DOSAGE

ANTI-INFLAMMATORY

PO, IV, IM: ADULTS, ELDERLY: 0.75U9 mg/day in divided doses q6U12h. CHILDREN: 0.08U0.3 mg/kg/day in divided doses q6U12h.

CEREBRAL EDEMA

IV: ADULTS, ELDERLY: Initially, 10 mg, then 4 mg (IV or IM) q6h.

PO, IV, IM: CHILDREN: Loading dose of 1U2 mg/kg, then 1U1.5 mg/kg/day in divided doses q4U6h.

NAUSEA AND VOMITING IN CHEMOTHERAPY PATIENTS

IV: ADULTS, ELDERLY: 8U20 mg once, then 4 mg (PO) q4U6h or 8 mg q8h. CHILDREN: 10 mg/m2/dose (Maximum: 20 mg), then 5 mg/m2/dose q6h.

USUAL TOPICAL DOSAGE

TOPICAL: ADULTS, ELDERLY, CHILDREN: Apply to affected area 3U4 times a day.

PHYSIOLOGIC REPLACEMENT

PO, IV, IM: CHILDREN: 0.03-0.15 mg/kg/day in divided doses q6-12h.

USUAL OPHTHALMIC DOSAGE, OCULAR INFLAMMATORY CONDITIONS

OINTMENT: ADULTS, ELDERLY, CHILDREN: Thin coating 3U4 times/day.

SUSPENSION: ADULTS, ELDERLY, CHILDREN: Initially, 2 drops q1h while awake and q2h at night for 1 day, then reduce to 3U4 times/day.

SIDE EFFECTS

FREQUENT: Inhalation: Cough, dry mouth, hoarseness, throat irritation. Intranasal: Burning, mucosal dryness. Ophthalmic: Blurred vision. Systemic: Insomnia, facial swelling or cushingoid appearance, moderate abdominal distention, indigestion, increased appetite, nervousness, facial flushing, diaphoresis. OCCASIONAL: Inhalation: Localized fungal infection, such as thrush. Intranasal: Crusting inside nose, nosebleed, sore throat, ulceration of nasal mucosa. Ophthalmic: Decreased vision, watering of eyes, eye pain, burning, stinging, redness of eyes, nausea, vomiting. Systemic: Dizziness, decreased or blurred vision. Topical: Allergic contact dermatitis, purpura or blood-containing blisters, thinning of skin with easy bruising, telangiectasis or raised dark red spots on skin. RARE: Inhalation: Increased bronchospasm, esophageal candidiasis. Intranasal: Nasal and pharyngeal candidiasis, eye pain. Systemic: General allergic reaction (such as rash and hives); pain, redness, or swelling at injection site; psychological changes; false sense of well-being; hallucinations; depression.

ADVERSE REACTIONS/TOXIC EFFECTS

Long-term therapy may cause muscle wasting (especially in the arms and legs), osteoporosis, spontaneous fractures, amenorrhea, cataracts, glaucoma, peptic ulcer disease, and CHF. The ophthalmic form may cause glaucoma, ocular hypertension, and cataracts. Abrupt withdrawal following long-term therapy may cause severe joint pain, severe headache, anorexia, nausea, fever, rebound inflammation, fatigue, weakness, lethargy, dizziness, and orthostatic hypotension.

BASELINE ASSESSMENT

Question for hypersensitivity to any of the corticosteroids. Obtain baselines for height, weight, BP, serum glucose, electrolytes.

INTERVENTION/EVALUATION

Monitor I&O, daily weight. Assess for edema. Evaluate food tolerance and bowel activity. Report hyperacidity promptly. Check vital signs at least twice a day. Be alert to infection: sore throat, fever, vague symptoms. Monitor serum electrolytes. Monitor for hypercalcemia (muscle twitching, cramps), hypokalemia (weakness, muscle cramps, numbness or tingling, especially lower extremities, nausea or vomiting, irritability). Assess emotional status, ability to sleep.

PATIENT/FAMILY TEACHING

N Do not change dose/schedule or stop taking drug. N Must taper off gradually under medical supervision. N Notify physician of fever, sore throat, muscle aches, sudden weight gain or edema. N Severe stress (serious infection, surgery, trauma) may require increased dosage. N Inform dentist, other physicians of dexamethasone therapy now or within past 12 mo. N Topical: Apply after shower/bath for best absorption.

*DOXOrubicin A

dox-o-roo-bi-sin

(Adriamycin, Adriamycin PFS, Adriamycin RDF, Caelyx, Doxil, Rubex)

Do not confuse doxorubicin with daunorubicin, or Adriamycin with idamycin or idarubicin.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Anthracycline antibiotic. CLINICAL: Antineoplastic.

ACTION

An anthracycline antibiotic that inhibits DNA and DNA-dependent RNA synthesis by binding with DNA strands. Liposomal encapsulation increases uptake by tumors, prolongs drug action, and may decrease toxicity. Therapeutic Effect: Prevents cell division.

PHARMACOKINETICS

Widely distributed. Protein binding: 74%U76%. Does not cross the blood-brain barrier. Metabolized rapidly in the liver to active metabolite. Primarily eliminated by biliary system. Not removed by hemodialysis. Half-life: 16 hr; metabolite, 32 hr.

USES

Adriamycin, Rubex: Treatment of acute lymphocytic, non-lymphocytic leukemia, breast, gastric, small cell lung, ovarian, epithelial, thyroid, bladder carcinomas, neuroblastoma, Wilms’ tumor, Hodgkin's, non-Hodgkin's lymphoma, osteosarcoma, soft tissue sarcoma. Doxil: Treatment of AIDS, related Kaposi's sarcoma, metastatic ovarian cancer. OFF-LABEL: Carcinoid tumors; Ewing's sarcoma; germ cell, gestational trophoblastic, and prostatic tumors; multiple myeloma; retinoblastoma; treatment of cervical, endometrial, esophageal, head or neck, nonUsmall cell lung, pancreatic carcinoma.

PRECAUTIONS

CONTRAINDICATIONS: Cardiomyopathy; preexisting myelosuppression; previous or concomitant treatment with cyclophosphamide, idarubicin, mitoxantrone, or irradiation of the cardiac region; severe CHF. CAUTIONS: Bone marrow suppression, CHF, hepatic impairment, life-threatening arrhythmias.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: If possible, avoid use during pregnancy, especially first trimester. Breast-feeding not recommended. Pregnancy Category D. Children/Elderly: Cardiotoxicity may be more frequent in those younger than 2 yr or older than 70 yr.

INTERACTIONS

DRUG: Antigout medications: May decrease the effects of these drugs. Bone marrow depressants: May increase myelosuppression. Daunorubicin: May increase the risk of cardiotoxicity. 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: May cause EKG changes and increase serum uric acid level. Doxil may reduce neutrophil and RBC counts.

AVAILABILITY (Rx)

INJECTION, POWDER FOR RECONSTITUTION: 10 mg (Adriamycin RDF), 20 mg (Adriamycin RDF), 50 mg (Adriamycin RDF, Rubex), 100 mg (Rubex), 150 mg (Adriamycin RDF). INJECTION SOLUTION (ADRIAMYCIN PFS): 2 mg/ml. LIPID COMPLEX (DOXIL): 2 mg/ml.

ADMINISTRATION/HANDLING

O ALERT P Wear gloves. If powder or solution comes in contact with skin, wash thoroughly. Avoid small veins; swollen or edematous extremities; areas overlying joints, tendons. Doxil: Do not use with in-line filter or mix with any diluent except D5W. May be carcinogenic, mutagenic, or teratogenic. Handle with extreme care during preparation/administration.

L IV

Reconstitution N Reconstitute each 10Umg vial with 5 ml preservative-free 0.9% NaCl (10 ml for 20 mg; 25 ml for 50 mg) to provide concentration of 2 mg/ml. N Shake vial; allow contents to dissolve. N Withdraw appropriate volume of air from vial during reconstitution (avoids excessive pressure buildup). N May be further diluted with 50 ml D5W or 0.9% NaCl and give as a continuous infusion through a central venous line.

Rate of administration N For IV push, administer into tubing of freely running IV infusion of D5W or 0.9% NaCl, preferably via butterfly needle over 3U5 min (avoids local erythematous streaking along vein and facial flushing). N Must test for flashback q30sec to be certain needle remains in vein during injection. N Extravasation produces immediate pain, severe local tissue damage. Terminate administration immediately; withdraw as much medication as possible, obtain extravasation kit, follow protocol.

Storage N Store at room temperature. N Reconstituted solution is stable for 24 hr at room temperature or 48 hr if refrigerated. N Protect from prolonged exposure to sunlight; discard unused solution.

DOXIL

Reconstitution N Dilute each dose in 250 ml D5W.

Rate of administration N Give as infusion over 30 min. Do not use in-line filters.

Storage N Refrigerate unopened vials. N After solution is diluted, use within 24 hr.

D IV INCOMPATIBILITIES

Doxorubicin: Allopurinol (Aloprim), amphotericin B complex (Abelcet, AmBisome, Amphotec), cefepime (Maxipime), furosemide (Lasix), ganciclovir (Cytovene), heparin, piperacillin and tazobactam (Zosyn), propofol (Diprivan). Doxil: Don't mix with any other medications.

IV COMPATIBILITIES

Dexamethasone (Decadron), diphenhydramine (Benadryl), etoposide (VePesid), granisetron (Kytril), hydromorphone (Dilaudid), lorazepam (Ativan), morphine, ondansetron (Zofran), paclitaxel (Taxol).

INDICATIONS/ROUTES/DOSAGE

TO PRODUCE REGRESSION IN ACUTE LYMPHOBLASTIC AND MYELOBLASTIC LEUKEMIA; BREAST, BRONCHOGENIC, GASTRIC, OVARIAN, THYROID, AND TRANSITIONAL CELL BLADDER CARCINOMAS; HODGKIN'S DISEASE; NON-HODGKIN'S LYMPHOMAS; NEUROBLASTOMA; PRIMARY LIVER CANCER; SOFT-TISSUE AND BONE SARCOMAS; AND WILMS' TUMOR

IV: ADULTS: 60U75 mg/m2 as a single dose every 21 days, 20 mg/m2 once weekly, or 25U30 mg/m2/day on 2U3 successive days q4wk. Because of the risk of cardiotoxicity, don't exceed a cumulative dose of 550 mg/m2 (400U450 mg/m2 for those previously treated with related compounds or irradiation of cardiac region). CHILDREN: 35U75 mg/m2 as a single dose q3wk or 20U30 mg/m2 weekly, or 60U90 mg/m2 as continuous infusion over 96 hr q3U4wk.

KAPOSI'S SARCOMA

IV (DOXIL): ADULTS: 20 mg/m2 q3wk infused over 30 min.

OVARIAN CANCER

IV (DOXIL): ADULTS: 50 mg/m2 q4wk.

DOSAGE IN HEPATIC IMPAIRMENT

Dosage is modified based on serum bilirubin level.

Serum Bilirubin Concentration % of Normal Dose

1.2U3 mg/dl 50%

Greater than 3 mg/dl 25%

SIDE EFFECTS

FREQUENT: Complete alopecia (scalp, axillary, pubic hair), nausea, vomiting, stomatitis, esophagitis (especially if drug is given on several successive days), reddish urine. Doxil: Nausea. OCCASIONAL: Anorexia, diarrhea; hyperpigmentation of skin, nailbeds, and phalangeal and dermal creases. RARE: Fever, chills, conjunctivitis, lacrimation.

ADVERSE REACTIONS/TOXIC EFFECTS

Myelosuppression may cause hematologic toxicity (manifested principally as leukopenia and, to lesser extent, anemia and thrombocytopenia), usually within 10U15 days of starting therapy. Blood counts typically return to normal levels by the third week. Cardiotoxicity (either acute, manifested as transient EKG abnormalities, or chronic, manifested as CHF) may occur.

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Obtain WBC, platelet, erythrocyte counts before and at frequent intervals during therapy. Obtain EKG before therapy, liver function studies before each dose. Antiemetics may be effective in preventing, treating nausea.

INTERVENTION/EVALUATION

Monitor for stomatitis (burning or erythema of oral mucosa at inner margin of lips, difficulty swallowing). May lead to ulceration of mucous membranes within 2U3 days. Assess skin, nailbeds for hyperpigmentation. Monitor hematologic status, renal and liver function studies, serum uric acid levels. Assess pattern of daily bowel activity and stool consistency. Monitor for hematologic toxicity (fever, sore throat, signs of local infection, unusual bruising or bleeding from any site), symptoms of anemia (excessive fatigue, weakness).

PATIENT/FAMILY TEACHING

N Alopecia is reversible, but new hair growth may have different color, texture. New hair growth resumes 2U3 mo after last therapy dose. N Maintain fastidious oral hygiene. 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. N Contact physician for persistent nausea or vomiting. N Avoid alcohol (may cause GI irritation, a common side effect with liposomal doxorubicin).

*DOXOrubicin A

dox-o-roo-bi-sin

(Adriamycin, Adriamycin PFS, Adriamycin RDF, Caelyx, Doxil, Rubex)

Do not confuse doxorubicin with daunorubicin, or Adriamycin with idamycin or idarubicin.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Anthracycline antibiotic. CLINICAL: Antineoplastic.

ACTION

PHARMACOKINETICS

USES

PRECAUTIONS

INTERACTIONS

AVAILABILITY (Rx)

ADMINISTRATION/HANDLING

L IV

Storage N Store at room temperature. N Reconstituted solution is stable for 24 hr at room temperature or 48 hr if refrigerated. N Protect from prolonged exposure to sunlight; discard unused solution.

DOXIL

Reconstitution N Dilute each dose in 250 ml D5W.

Rate of administration N Give as infusion over 30 min. Do not use in-line filters.

Storage N Refrigerate unopened vials. N After solution is diluted, use within 24 hr.

D IV INCOMPATIBILITIES

IV COMPATIBILITIES

Dexamethasone (Decadron), diphenhydramine (Benadryl), etoposide (VePesid), granisetron (Kytril), hydromorphone (Dilaudid), lorazepam (Ativan), morphine, ondansetron (Zofran), paclitaxel (Taxol).

INDICATIONS/ROUTES/DOSAGE

KAPOSI'S SARCOMA

IV (DOXIL): ADULTS: 20 mg/m2 q3wk infused over 30 min.

OVARIAN CANCER

IV (DOXIL): ADULTS: 50 mg/m2 q4wk.

DOSAGE IN HEPATIC IMPAIRMENT

Dosage is modified based on serum bilirubin level.

Serum Bilirubin Concentration % of Normal Dose

1.2U3 mg/dl 50%

Greater than 3 mg/dl 25%

SIDE EFFECTS

ADVERSE REACTIONS/TOXIC EFFECTS

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

INTERVENTION/EVALUATION

PATIENT/FAMILY TEACHING

*DOXOrubicin A

dox-o-roo-bi-sin

(Adriamycin, Adriamycin PFS, Adriamycin RDF, Caelyx, Doxil, Rubex)

Do not confuse doxorubicin with daunorubicin, or Adriamycin with idamycin or idarubicin.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Anthracycline antibiotic. CLINICAL: Antineoplastic.

ACTION

PHARMACOKINETICS

USES

PRECAUTIONS

CONTRAINDICATIONS: Cardiomyopathy; preexisting myelosuppression; previous or concomitant treatment with cyclophosphamide, idarubicin, mitoxantrone, or irradiation of the cardiac region; severe CHF. CAUTIONS: Bone marrow suppression, CHF, hepatic impairment, life-threatening arrhythmias.

INTERACTIONS

AVAILABILITY (Rx)

ADMINISTRATION/HANDLING

L IV

Storage N Store at room temperature. N Reconstituted solution is stable for 24 hr at room temperature or 48 hr if refrigerated. N Protect from prolonged exposure to sunlight; discard unused solution.

DOXIL

Reconstitution N Dilute each dose in 250 ml D5W.

Rate of administration N Give as infusion over 30 min. Do not use in-line filters.

Storage N Refrigerate unopened vials. N After solution is diluted, use within 24 hr.

D IV INCOMPATIBILITIES

IV COMPATIBILITIES

Dexamethasone (Decadron), diphenhydramine (Benadryl), etoposide (VePesid), granisetron (Kytril), hydromorphone (Dilaudid), lorazepam (Ativan), morphine, ondansetron (Zofran), paclitaxel (Taxol).

INDICATIONS/ROUTES/DOSAGE

KAPOSI'S SARCOMA

IV (DOXIL): ADULTS: 20 mg/m2 q3wk infused over 30 min.

OVARIAN CANCER

IV (DOXIL): ADULTS: 50 mg/m2 q4wk.

DOSAGE IN HEPATIC IMPAIRMENT

Dosage is modified based on serum bilirubin level.

Serum Bilirubin Concentration % of Normal Dose

1.2U3 mg/dl 50%

Greater than 3 mg/dl 25%

SIDE EFFECTS

ADVERSE REACTIONS/TOXIC EFFECTS

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

INTERVENTION/EVALUATION

PATIENT/FAMILY TEACHING

desloratadine

des-low-rah-tah-deen

(Aerius J, Clarinex, Clarinex Redi-Tabs)

Do not confuse Clarinex with Claritin.

FIXED-COMBINATION(S)

Clarinex-D 24 Hour: desloratadine/pseudoephedrine, (a sympathomimetic): 5 mg/240 mg. Clarinex-D 12 Hour: desloratadine/pseudoephedrine: 2.5 mg/120 mg.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: H1 antagonist. CLINICAL: Nonsedating antihistamine.

ACTION

A nonsedating antihistamine that exhibits selective peripheral histamine H1 receptor blocking action. Competes with histamine at receptor sites. Therapeutic Effect: Prevents allergic responses mediated by histamine, such as rhinitis and urticaria.

PHARMACOKINETICS

Rapidly and almost completely absorbed from the GI tract. Distributed mainly in liver, lungs, GI tract, and bile. Metabolized in the liver to active metabolite and undergoes extensive first-pass metabolism. Eliminated in urine and feces. Half-life: 27 hr (increased in the elderly and in renal or hepatic impairment).

USES

Relief of nasal symptoms of rhinitis (sneezing, rhinorrhea, itching or tearing of eyes, stuffiness), chronic idiopathic urticaria (hives).

PRECAUTIONS

CONTRAINDICATIONS: None known. CAUTIONS: Hepatic impairment. Safety in children younger than 6 yr unknown.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Excreted in breast milk. Pregnancy Category C. Children/Elderly: More sensitive to anticholinergic effects (e.g., dry mouth, nose, throat). Safety in children younger than 6 yr unknown.

INTERACTIONS

DRUG: Erythromycin, ketoconazole: May increase desloratadine blood concentration. HERBAL: None known. FOOD: None known. LAB VALUES: May suppress wheal and flare reactions to antigen skin testing unless the drug is discontinued 4 days before testing.

AVAILABILITY (Rx)

TABLETS (CLARINEX): 5 mg. TABLETS (ORALLY DISINTEGRATING [CLARINEX REDITABS]): 2.5 mg, 5 mg. SYRUP (CLARINEX): 2.5 mg/5 ml.

ADMINISTRATION/HANDLING

N Do not crush or break film-coated tablets.

INDICATIONS/ROUTES/DOSAGE

ALLERGIC RHINITIS, URTICARIA

PO: ADULTS, ELDERLY, CHILDREN OLDER THAN 12 YR: 5 mg once a day. CHILDREN 6U12 YR: 2.5 mg once a day. CHILDREN 1U5 YR: 1.25 mg once a day. CHILDREN 6U11 MO: 1 mg once a day.

DOSAGE IN HEPATIC OR RENAL IMPAIRMENT

Dosage is decreased to 5 mg every other day.

SIDE EFFECTS

FREQUENT (12%): Headache. OCCASIONAL (3%): Dry mouth, somnolence. RARE (less than 3%): Fatigue, dizziness, diarrhea, nausea.

ADVERSE REACTIONS/TOXIC EFFECTS

None known.

BASELINE ASSESSMENT

Assess lung sounds for wheezing; skin for urticaria, hives.

INTERVENTION/EVALUATION

For upper respiratory allergies, increase fluids to decrease viscosity of secretions, offset thirst, replace loss of fluids from diaphoresis. Monitor symptoms for therapeutic response.

PATIENT/FAMILY TEACHING

N Does not cause drowsiness; however, if blurred vision or eye pain occurs, do not drive or perform activities requiring visual acuity. N Avoid alcohol.

desmopressin

des-moe-press-in

(DDAVP, DDAVP Nasal, DDAVP Rhinal Tube, Minirin, Octostim J, Stimate)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Synthetic pituitary hormone. CLINICAL: Antidiuretic.

ACTION

A synthetic pituitary hormone that increases reabsorption of water by increasing permeability of collecting ducts of the kidneys. Also serves as a plasminogen activator. Therapeutic Effect: Increases plasma factor VIII (antihemophilic factor). Decreases urinary output.

PHARMACOKINETICS

Route Onset Peak Duration

PO 1 hr 2U7 hr 6U8 hr

IV 15U30 min 1.5U3 hr N/A

Intranasal 15 minU1 hr 1U5 hr 5U21 hr

Poorly absorbed after oral or nasal administration. Metabolism: Unknown. Half-life: Oral: 1.5U2.5 hr. Intranasal: 3.3U3.5 hr. IV: 0.4U4 hr.

USES

DDAVP Intranasal: Primary nocturnal enuresis, central cranial diabetes insipidus. Parenteral: Central cranial diabetes insipidus, hemophilia A, von Willebrand's disease (type I). Stimate intranasal: Hemophilia A, von Willebrand's disease (type I). PO: Central cranial diabetes insipidus. OFF-LABEL: Prophylaxis and treatment of central diabetes insipidus, treatment of hemophilia A, primary nocturnal enuresis, von Willebrand's disease.

PRECAUTIONS

CONTRAINDICATIONS: Hemophilia A with factor VIII levels less than 5%; hemophilia B; severe type I, type IIB, or platelet-type von Willebrand's disease. CAUTIONS: Predisposition to thrombus formation, conditions with fluid or electrolyte imbalance, coronary artery disease, hypertensive cardiovascular disease.

B LIFESPAN CONSIDERATIONS: Pregnancy Category B. Children: Caution in neonates, those younger than 3 mo (increased risk of fluid balance problems). Careful fluid restrictions recommended in infants. Elderly: Increased risk of hyponatremia, water intoxication.

INTERACTIONS

DRUG: Carbamazepine, chlorpropamide, clofibrate: May increase the effects of desmopressin. Demeclocycline, lithium, norepinephrine: May decrease effects of desmopressin. HERBAL: None known. FOOD: None known. LAB VALUES: None known.

AVAILABILITY (Rx)

TABLETS (DDAVP): 0.1 mg, 0.2 mg. INJECTION (DDAVP): 4 mcg/ml. NASAL SOLUTION (DDAVP): 100 mcg/ml. NASAL SPRAY: 1.5 mg/ml (150 mcg/spray) (Stimate), 100 mcg/ml (10 mcg/spray) (DDAVP).

ADMINISTRATION/HANDLING

L IV

Reconstitution N For IV infusion, dilute in 10U50 ml 0.9% NaCl.

Rate of administration N Infuse over 15U30 min. N For preop use, administer 30 min before procedure. N Monitor BP, pulse during IV infusion. N IV dose = @ intranasal dose.

Storage N Refrigerate. Stable for 2 wk at room temperature.

SUBCUTANEOUS

N Estimate response by adequate sleep duration. N Morning and evening doses should be adjusted separately.

INTRANASAL Refrigerate DDAVP nasal solution and Stimate nasal spray. Nasal solution and Stimate nasal spray are stable for 3 wk at room temperature if unopened. N DDAVP nasal spray is stable at room temperature. N A calibrated catheter (rhinyle) is used to draw up a measured quantity of desmopressin; with one end inserted in the nose, patient blows on the other end to deposit the solution deep in the nasal cavity. N For infants, young children, obtunded patients, an air-filled syringe may be attached to the catheter to deposit the solution.

INDICATIONS/ROUTES/DOSAGE

PRIMARY NOCTURNAL ENURESIS

PO: CHILDREN 12 YR AND OLDER: 0.2U0.6 mg once before bedtime.

INTRANASAL: CHILDREN 6 YR AND OLDER: Initially, 20 mcg (0.2 ml) at bedtime; use ½ dose in each nostril. Adjust to maximum of 40 mcg/day. Range: 10U40 mcg.

CENTRAL CRANIAL DIABETES INSIPIDUS

PO: ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: Initially, 0.05 mg twice a day. Range: 0.1U1.2 mg/day in 2U3 divided doses. CHILDREN YOUNGER THAN 12 YR: Initially, 0.05 mg; then twice a day. Range: 0.1U0.8 mg daily.

IV, SUBCUTANEOUS: ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: 2U4 mcg/day in 2 divided doses or @ of maintenance intranasal dose.

INTRANASAL (USE 100 mcg/ml CONCENTRATION): ADULTS, ELDERLY, CHILDREN OLDER THAN 12 YR: 5U40 mcg (0.05U0.4 ml) in 1U3 doses/day. CHILDREN 3 MOU12 YR: Initially, 5 mcg (0.05 ml)/day. Range: 5U30 mcg (0.05U0.3 ml)/day.

HEMOPHILIA A, VON WILLEBRAND'S DISEASE (TYPE I)

IV INFUSION: ADULTS, ELDERLY, CHILDREN WEIGHING MORE THAN 10 KG: 0.3 mcg/kg diluted in 50 ml 0.9% NaCl. CHILDREN WEIGHING 10 KG AND LESS: 0.3 mcg/kg diluted in 10 ml 0.9% NaCl.

INTRANASAL (USE 1.5 mg/ml CONCENTRATION PROVIDING 150 mcg/SPRAY): ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER WEIGHING MORE THAN 50 KG: 300 mcg; use 1 spray in each nostril. ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER WEIGHING 50 KG OR LESS: 150 mcg as a single spray.

SIDE EFFECTS

OCCASIONAL: IV: Pain, redness, or swelling at injection site; headache; abdominal cramps; vulval pain; flushed skin; mild BP elevation; nausea with high dosages. Nasal: Rhinorrhea, nasal congestion, slight BP elevation.

ADVERSE REACTIONS/TOXIC EFFECTS

Water intoxication or hyponatremia, marked by headache, somnolence, confusion, decreased urination, rapid weight gain, seizures, and coma, may occur in overhydration. Children, elderly patients, and infants are especially at risk.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Establish baselines for BP, pulse, weight, serum electrolytes, urine specific gravity. Check lab values for factor VIII coagulant concentration for hemophilia A, von Willebrand's disease; bleeding times.

INTERVENTION/EVALUATION

Check BP, pulse with IV infusion. Monitor patient weight, fluid intake, urine volume, urine specific gravity, osmolality, serum electrolytes for diabetes insipidus. Assess factor VIII antigen levels, aPTT, factor VIII activity level for hemophilia.

PATIENT/FAMILY TEACHING

N Avoid overhydration. N Teach proper technique for intranasal administration. N Inform physician if headache, shortness of breath, heartburn, nausea, abdominal cramps occur.

dexamethasone

dex-a-meth-a-sone

Do not confuse dexamethasone with desoximetasone or dextramethophan, or Maxidex with Maxzide.

FIXED-COMBINATION(S)

Ciprodex Otic: dextramethasone/ciprofloxacin (antibiotic): 0.1%/0.3%. Dexacidin, Maxitrol: dexamethasone/neomycin/polymyxin (anti-infectives): 0.1%/3.5 mg/10,000 units per g or ml.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Long-acting glucocorticoid. CLINICAL: Corticosteroid.

ACTION

PHARMACOKINETICS

USES

PRECAUTIONS

INTERACTIONS

AVAILABILITY (Rx)

ADMINISTRATION/HANDLING

L IV

O ALERT P Dexamethasone sodium phosphate may be given by IV push or IV infusion.

N For IV push, give over 1U4 min. N For IV infusion, mix with 0.9% NaCl or D5W and infuse over 15U30 min. N For neonate, solution must be preservative free. N IV solution must be used within 24 hr.

N Give deep IM, preferably in gluteus maximus.

N Give with milk or food.

OPHTHALMIC

Solution: Apply digital pressure to lacrimal sac for 1U2 min (minimizes drainage into nose and throat, reducing risk of systemic effects).

TOPICAL

N Gently cleanse area before application. N Use occlusive dressings only as ordered. N Apply sparingly and rub into area thoroughly.

D IV INCOMPATIBILITIES

Ciprofloxacin (Cipro), daunorubicin (Cerubidine), idarubicin (Idamycin), midazolam (Versed).

IV COMPATIBILITIES

INDICATIONS/ROUTES/DOSAGE

ANTI-INFLAMMATORY

PO, IV, IM: ADULTS, ELDERLY: 0.75U9 mg/day in divided doses q6U12h. CHILDREN: 0.08U0.3 mg/kg/day in divided doses q6U12h.

CEREBRAL EDEMA

IV: ADULTS, ELDERLY: Initially, 10 mg, then 4 mg (IV or IM) q6h.

PO, IV, IM: CHILDREN: Loading dose of 1U2 mg/kg, then 1U1.5 mg/kg/day in divided doses q4U6h.

NAUSEA AND VOMITING IN CHEMOTHERAPY PATIENTS

IV: ADULTS, ELDERLY: 8U20 mg once, then 4 mg (PO) q4U6h or 8 mg q8h. CHILDREN: 10 mg/m2/dose (Maximum: 20 mg), then 5 mg/m2/dose q6h.

USUAL TOPICAL DOSAGE

TOPICAL: ADULTS, ELDERLY, CHILDREN: Apply to affected area 3U4 times a day.

PHYSIOLOGIC REPLACEMENT

PO, IV, IM: CHILDREN: 0.03-0.15 mg/kg/day in divided doses q6-12h.

USUAL OPHTHALMIC DOSAGE, OCULAR INFLAMMATORY CONDITIONS

OINTMENT: ADULTS, ELDERLY, CHILDREN: Thin coating 3U4 times/day.

SUSPENSION: ADULTS, ELDERLY, CHILDREN: Initially, 2 drops q1h while awake and q2h at night for 1 day, then reduce to 3U4 times/day.

SIDE EFFECTS

ADVERSE REACTIONS/TOXIC EFFECTS

NURSING CONSIDERATION

BASELINE ASSESSMENT

Question for hypersensitivity to any of the corticosteroids. Obtain baselines for height, weight, BP, serum glucose, electrolytes.

INTERVENTION/EVALUATION

PATIENT/FAMILY TEACHING

diclofenac

dye-klo-feh-nak

(Cataflam, Diclotec J, Novo-Difenac J, Solaraze, Voltaren, Voltaren Ophthalmic, Voltaren XR)

Do not confuse diclofenac with Diflucan or Duphalac, or Voltaren with Verelan.

FIXED-COMBINATION(S)

Arthrotec: diclofenac/misoprostol (an antisecretory gastric protectant): 50 mg/200 mcg; 75 mg/200 mcg.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Nonsteroidal anti-inflammatory. CLINICAL: Analgesic, anti-inflammatory.

ACTION

An NSAID that inhibits prostaglandin synthesis, reducing the intensity of pain. Also constricts the iris sphincter. May inhibit angiogenesis (the formation of blood vessels) by inhibiting substance P or blocking the angiogenic effects of prostaglandin E. Therapeutic Effect: Produces analgesic and anti-inflammatory effects. Prevents miosis during cataract surgery. May reduce angiogenesis in inflamed tissue.

PHARMACOKINETICS

Route Onset Peak Duration

PO 30 min 2U3 hr Up to 8 hr

Completely absorbed from the GI tract; penetrates cornea after ophthalmic administration (may be systemically absorbed). Protein binding: greater than 99%. Widely distributed. Metabolized in the liver. Primarily excreted in urine. Minimally removed by hemodialysis. Half-life: 1.2U2 hr.

USES

Oral: (Immediate-release): Treatment of rheumatoid arthritis, oesteoarthritis, ankylosing spondylitis, primary dysmenorrhea. (Delayed-release): Treatment of rheumatoid arthritis, oesteoarthritis, ankylosing spondylitis. (Extended-release): Treatment of rheumatoid arthritis, oesteoarthritis. Ophthalmic: Treatment of photophobia and pain in patients undergoing corneal refractive surgery. Topical: Treatment of actinic keratoses. OFF-LABEL: Treatment of vascular headaches (oral); to reduce the occurrence and severity of cystoid macular edema after cataract surgery (ophthalmic form).

PRECAUTIONS

CONTRAINDICATIONS: Hypersensitivity to aspirin, diclofenac, and other NSAIDs; porphyria. CAUTIONS: CHF, hypertension, renal/hepatic impairment, history of GI disease. Avoid topical gel to open skin wounds, infections, exfoliative dermatitis, eyes, neonates, infants, children.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Unknown if distributed in breast milk. Avoid use during last trimester (may adversely affect fetal cardiovascular system: premature closure of ductus arteriosus). Pregnancy Category B (D if used in third trimester or near delivery; C for ophthalmic solution). Children: Safety and efficacy not established. Elderly: GI bleeding or ulceration more likely to cause serious adverse effects. Age-related renal impairment may increase risk of hepatic or renal toxicity; reduced dosage recommended.

INTERACTIONS

DRUG: Acetylcholine, carbachol: May decrease the effects of these drugs (with ophthalmic diclofenac). Antihypertensives, diuretics: May decrease the effects of these drugs. Aspirin, other salicylates: May increase the risk of GI side effects such as bleeding. Bone marrow depressants: May increase the risk of hematologic reactions. Epinephrine, other antiglaucoma medications: May decrease the antiglaucoma effect of these drugs. Heparin, oral anticoagulants, thrombolytics: May increase the effects of these drugs. Lithium: May increase the blood concentration and risk of toxicity of lithium. Methotrexate: May increase the risk of methotrexate toxicity. Probenecid: May increase diclofenac blood concentration. HERBAL: Ginkgo biloba: May increase the risk of bleeding. FOOD: None known. LAB VALUES: May increase BUN level; urine protein level; and serum LDH, potassium, alkaline phosphatase, creatinine, AST, and ALT levels. May decrease serum uric acid level.

AVAILABILITY (Rx)

TOPICAL GEL (SOLARAZE): 3%. TABLETS (IMMEDIATE-RELEASE [CATAFLAM]): 50 mg. TABLETS (DELAYED-RELEASE [VOLTAREN]): 25 mg, 50 mg, 75 mg. TABLETS (EXTENDED-RELEASE [VOLTAREN XR]): 100 mg. OPHTHALMIC SOLUTION (VOLTAREN OPHTHALMIC): 0.1%.

ADMINISTRATION/HANDLING

N Do not crush or break enteric-coated form. N May give with food, milk, or antacids if GI distress occurs.

OPHTHALMIC

N Place finger on lower eyelid and pull out until pocket is formed between eye and lower lid. Hold dropper above pocket and place prescribed number of drops in pocket. N Close eye gently. Apply digital pressure to lacrimal sac for 1U2 min (minimized drainage into nose and throat, reducing risk of systemic effects). N Remove excess solution with tissue.

INDICATIONS/ROUTES/DOSAGE

OSTEOARTHRITIS

PO (CATAFLAM, VOLTAREN): ADULTS, ELDERLY: 50 mg 2U3 times a day.

PO (VOLTAREN XR): ADULTS, ELDERLY: 100U200 mg/day as a single dose.

RHEUMATOID ARTHRITIS

PO (CATAFLAM, VOLTAREN): ADULTS, ELDERLY: 50 mg 2U4 times a day. Maximum: 225 mg/day.

PO (VOLTAREN XR): ADULTS, ELDERLY: 100 mg once a day. Maximum: 100 mg twice a day.

ANKYLOSING SPONDYLITIS

PO (VOLTAREN): ADULTS, ELDERLY: 100U125 mg/day in 4U5 divided doses.

ANALGESIA, PRIMARY DYSMENORRHEA

PO (CATAFLAM): ADULTS, ELDERLY: 50 mg 3 times a day.

USUAL PEDIATRIC DOSAGE

CHILDREN: 2U3 mg/kg/day in 2U4 divided doses.

ACTINIC KERATOSES

TOPICAL: ADULTS, ADOLESCENTS: Apply twice a day to lesion for 60U90 days.

CATARACT SURGERY

OPHTHALMIC: ADULTS, ELDERLY: Apply 1 drop to eye 4 times a day commencing 24 hr after cataract surgery. Continue for 2 wk afterward.

PAIN, RELIEF OF PHOTOPHOBIA IN PATIENTS UNDERGOING CORNEAL REFRACTIVE SURGERY

OPHTHALMIC: ADULTS, ELDERLY: Apply 1U2 drops to affected eye 1 hr before surgery, within 15 min after surgery, then 4 times a day for up to 3 days.

SIDE EFFECTS

FREQUENT (9%U4%): PO: Headache, abdominal cramps, constipation, diarrhea, nausea, dyspepsia. Ophthalmic: Burning or stinging on instillation, ocular discomfort. OCCASIONAL (3%U1%): PO: Flatulence, dizziness, epigastric pain. Ophthalmic: Ocular itching or tearing. RARE (less than 1%): PO: Rash, peripheral edema or fluid retention, visual disturbances, vomiting, drowsiness.

ADVERSE REACTIONS/TOXIC EFFECTS

Overdose may result in acute renal failure. Rare reactions with long-term use include peptic ulcer disease, GI bleeding, gastritis, a severe hepatic reaction (jaundice), nephrotoxicity (hematuria, dysuria, proteinuria), and a severe hypersensitivity reaction (bronchospasm or angioedema).

NURSING CONSIDERATION

BASELINE ASSESSMENT

Anti-inflammatory: Assess onset, type, location, duration of pain and inflammation. Inspect appearance of affected joints for immobility, deformities, skin condition.

INTERVENTION/EVALUATION

Monitor for headache, dyspepsia. Monitor pattern of daily bowel activity and stool consistency. Evaluate for therapeutic response: relief of pain, stiffness, swelling; increase in joint mobility; reduced joint tenderness; improved grip strength.

PATIENT/FAMILY TEACHING

N Swallow tablet whole; do not crush or chew. N Avoid aspirin, alcohol during therapy (increases risk of GI bleeding). N If GI upset occurs, take with food, milk. N Report skin rash, itching, weight gain, changes in vision, black stools, persistent headache. N Ophthalmic: Do not use hydrogel soft contact lenses. N Topical: Avoid exposure to sunlight or sun lamps. N Inform physician if rash occurs.

diflunisal

dye-flew-neh-sol

(Apo-Diflunisal J, Dolobid, Novo-Diflunisal J)

Do not confuse diflunisal with Dicarbosil or Dolobid with Slo-bid.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Nonsteroidal anti-inflammatory. CLINICAL: Antirheumatic, analgesic, vascular headache suppressant.

ACTION

A nonsteroidal anti-inflammatory that inhibits prostaglandin synthesis, reducing inflammatory response and intensity of pain stimulus reaching sensory nerve endings. Therapeutic Effect: Produces analgesic and anti-inflammatory effect.

PHARMACOKINETICS

Route Onset Peak Duration

PO 1 hr 2U3 hr 8U12 hr

Completely absorbed from the GI tract. Widely distributed. Protein binding: greater than 99%. Metabolized in liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 8U12 hr.

USES

Treatment of mild to moderate pain, rheumatoid arthritis, osteoarthritis. OFF-LABEL: Treatment of psoriatic arthritis, vascular headache.

PRECAUTIONS

CONTRAINDICATIONS: Active GI bleeding, factor VII or factor IX deficiencies, hypersensitivity to aspirin or NSAIDs. CAUTIONS: Renal or hepatic impairment, edema, elevated hepatic function tests, platelet or bleeding disorders, peptic ulcer disease, erosive gastritis, vitamin K deficiency.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Distributed in breast milk. Avoid use during last trimester (may adversely affect fetal cardiovascular system: premature closure of ductus arteriosus). Pregnancy Category C (D if used in third trimester or near delivery). Children: Safety and efficacy not established. Elderly: GI bleeding or ulceration more likely to cause serious adverse effects. Age-related renal impairment may increase risk of hepatic or renal toxicity; decreased dosage recommended.

INTERACTIONS

DRUG: Antihypertensives, diuretics: May decrease the effects of these drugs. Aspirin, salicylates: May increase the risk of GI bleeding and side effects. Bone marrow depressants: May increase the risk of hematologic reactions. Heparin, oral anticoagulants, thrombolytics: May increase the effects of these drugs. Lithium: May increase the blood concentration and risk of toxicity of lithium. Methotrexate: May increase the risk of toxicity of methotrexate. Probenecid: May increase diflunisal blood concentration. HERBAL: Ginkgo biloba: May increase the risk of bleeding. FOOD: None known. LAB VALUES: May increase serum AST and ALT levels. May decrease serum uric acid levels.

AVAILABILITY (Rx)

TABLETS: 250 mg, 500 mg.

ADMINISTRATION/HANDLING

N May give with water, milk, or meals. N Do not crush or break film-coated tablets.

INDICATIONS/ROUTES/DOSAGE

MILD TO MODERATE PAIN

PO: ADULTS, ELDERLY: Initially, 0.5U1 g, then 250U500 mg q8U12h. Maximum: 1.5 g/day.

OSTEOARTHRITIS

PO: ADULTS, ELDERLY: 500U750 mg/day in divided doses.

RHEUMATOID ARTHRITIS

PO: ADULTS, ELDERLY: 0.5U1 g/day in 2 divided doses. Maximum: 1.5 g/day.

SIDE EFFECTS

Side effects are less common with short-term treatment. OCCASIONAL (9%U3%): Nausea, dyspepsia (heartburn, indigestion, epigastric pain), diarrhea, headache, rash. RARE (3%U1%): Vomiting, constipation, flatulence, dizziness, somnolence, insomnia, fatigue, tinnitus.

ADVERSE REACTIONS/TOXIC EFFECTS

Overdosage may produce drowsiness, vomiting, nausea, diarrhea, hyperventilation, tachycardia, diaphoresis, stupor, and coma. Peptic ulcer, GI bleeding, gastritis, and severe hepatic reaction, including cholestasis, jaundice occur rarely. Nephrotoxicity, including dysuria, hematuria, proteinuria, and nephrotic syndrome, and severe hypersensitivity reaction, marked by bronchospasm and angioedema, occur rarely.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Assess onset, type, location, duration of pain and inflammation. Inspect appearance of affected joints for immobility, deformities, skin condition.

INTERVENTION/EVALUATION

Monitor for nausea, dyspepsia. Assess skin for evidence of rash. Monitor pattern of daily bowel activity and stool consistency. Evaluate for therapeutic response: relief of pain, stiffness, swelling; increase in joint mobility; reduced joint tenderness; improved grip strength.

PATIENT/FAMILY TEACHING

N Swallow tablet whole; do not crush or chew. N If GI upset occurs, take with food, milk. N Report GI distress, headache, rash.

digoxin A

di-jox-in

(Digitek, Lanoxicaps, Lanoxin)

Do not confuse digoxin with Desoxyn or doxepin, or Lanoxin with Levsinex or Lonox.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Cardiac glycoside. CLINICAL: Antiarrhythmic, cardiotonic.

ACTION

A cardiac glycoside that increases the influx of calcium from extracellular to intracellular cytoplasm. Therapeutic Effect: Potentiates the activity of the contractile cardiac muscle fibers and increases the force of myocardial contraction. Slows the heart rate by decreasing conduction through the SA and AV nodes.

PHARMACOKINETICS

Route Onset Peak Duration

PO 0.5U2 hr 28 hr 3U4 days

IV 5U30 min 1U4 hr 3U4 days

Readily absorbed from the GI tract. Widely distributed. Protein binding: 30%. Partially metabolized in the liver. Primarily excreted in urine. Minimally removed by hemodialysis. Half-life: 36U48 hr (increased with impaired renal function and in the elderly).

USES

Prophylactic management and treatment of CHF, control of ventricular rate in patients with atrial fibrillation. Treatment and prevention of recurrent paroxysmal atrial tachycardia.

PRECAUTIONS

CONTRAINDICATIONS: Ventricular fibrillation, ventricular tachycardia unrelated to CHF. CAUTIONS: Renal/hepatic impairment, hypokalemia, advanced cardiac disease, acute MI, incomplete AV block, cor pulmonale, hyperthyroidism, hypothyroidism, pulmonary disease, severe bradycardia, sick sinus syndrome, ventricular tachycardia, Wolff-Parkinson-White syndrome.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Distributed in breast milk. Pregnancy Category C. Children: Premature infants more susceptible to toxicity. Elderly: Age-related hepatic or renal impairment may require dosage adjustment. Increased risk of loss of appetite.

INTERACTIONS

O ALERT P Digoxin and regular human insulin are physically compatible for 3 hr in 0.9% sodium chloride. In dextrose 5% and water, a slight haze develops within 1 hr. Do not allow digoxin and insulin to come in contact with each other in an IV for over 15 min.

DRUG: Amiodarone: May increase digoxin blood concentration and risk of toxicity; may have an additive effect on the SA and AV nodes. Amphotericin, glucocorticoids, potassium-depleting diuretics: May increase risk of toxicity due to hypokalemia. Antiarrhythmics, parenteral calcium, sympathomimetics: May increase risk of arrhythmias. Antidiarrheals, cholestyramine, colestipol, sucralfate: May decrease absorption of digoxin. Diltiazem, fluoxetine, quinidine, verapamil: May increase digoxin blood concentration. Parenteral magnesium: May cause cardiac conduction changes and heart block. HERBAL: Siberian ginseng: May increase serum digoxin levels. St. John's wort: May reduce digoxin efficacy. FOOD: All food: May decrease peak digoxin concentrations. LAB VALUES: None known.

AVAILABILITY (Rx)

CAPSULES (LANOXICAPS): 50 mcg, 100 mcg, 200 mcg. ELIXIR (LANOXIN): 50 mcg/ml. TABLETS (DIGITEK, LANOXIN): 125 mcg, 250 mcg. INJECTION (LANOXIN): 100 mcg/ml, 250 mcg/ml.

ADMINISTRATION/HANDLING

O ALERT P IM rarely used (produces severe local irritation, erratic absorption). If no other route possible, give deep into muscle followed by massage. Give no more than 2 ml at any one site.

L IV

N May give undiluted or dilute with at least a 4-fold volume of sterile water for injection, or D5W (less than this may cause a precipitate). Use immediately. N Give IV slowly over at least 5 min.

N May give without regard to meals. N Tablets may be crushed.

D IV INCOMPATIBILITIES

Amphotericin B complex (Abelcet, AmBisome, Amphotec), fluconazole (Diflucan), foscarnet (Foscavir), propofol (Diprivan).

IV COMPATIBILITIES

Cimetidine (Tagamet), diltiazem (Cardizem), furosemide (Lasix), heparin, insulin regular (physically compatible for 3 hr in 0.9% NaCl. In D5W, a slight haze develops within 1 hr.), lidocaine, midazolam (Versed), milrinone (Primacor), morphine, potassium chloride.

INDICATIONS/ROUTES/DOSAGE

RAPID LOADING DOSE FOR THE MANAGEMENT AND TREATMENT OF CHF; CONTROL OF VENTRICULAR RATE IN PATIENTS WITH ATRIAL FIBRILLATION; TREATMENT AND PREVENTION OF RECURRENT PAROXYSMAL ATRIAL TACHYCARDIA

PO: ADULTS, ELDERLY: Initially, 0.5U0.75 mg, additional doses of 0.125U0.375 mg at 6- to 8-hr intervals. Range: 0.75U1.25 mg. CHILDREN 10 YR AND OLDER: 10U15 mcg/kg. CHILDREN 5U9 YR: 20U35 mcg/kg. CHILDREN 2U4 YR: 30U40 mcg/kg. CHILDREN 1U23 MO: 35U60 mcg/kg. NEONATE, FULL-TERM: 25U35 mcg/kg. NEONATE, PREMATURE: 20U30 mcg/kg.

IV: ADULTS, ELDERLY: 0.6U1 mg. CHILDREN 10 YR AND OLDER: 8U12 mcg/kg. CHILDREN 5U9 YR: 15U30 mcg/kg. CHILDREN 2U4 YR: 25U35 mcg/kg. CHILDREN 1U23 MO: 30U50 mcg/kg. NEONATES, FULL-TERM: 20U30 mcg/kg. NEONATES, PREMATURE: 15U25 mcg/kg.

MAINTENANCE DOSAGE FOR CHF; CONTROL OF VENTRICULAR RATE IN PATIENTS WITH ATRIAL FIBRILLATION; TREATMENT AND PREVENTION OF RECURRENT PAROXYSMAL ATRIAL TACHYCARDIA

PO, IV: ADULTS, ELDERLY: 0.125U0.375 mg/day. CHILDREN: 25%U35% loading dose (20%U30% for premature neonates).

DOSAGE IN RENAL IMPAIRMENT

Dosage adjustment is based on creatinine clearance. Total digitalizing dose: decrease by 50% in end-stage renal disease.

Creatinine Clearance Dosage

10U50 ml/min 25%U75% usual

Less than 10 ml/min 10%U25% usual

SIDE EFFECTS

None known. However, there is a very narrow margin of safety between a therapeutic and toxic result. Long-term therapy may produce mammary gland enlargement in women but is reversible when drug is withdrawn.

ADVERSE REACTIONS/TOXIC EFFECTS

The most common early manifestations of digoxin toxicity are GI disturbances (anorexia, nausea, vomiting) and neurologic abnormalities (fatigue, headache, depression, weakness, drowsiness, confusion, nightmares). Facial pain, personality change, and ocular disturbances (photophobia, light flashes, halos around bright objects, yellow or green color perception) may be noted.

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Assess apical pulse for 60 sec (30 sec if on maintenance therapy). If pulse is 60 or less/min (70 or less/min for children), withhold drug, contact physician. Blood samples are best taken 6U8 hr after dose or just before next dose.

INTERVENTION/EVALUATION

Monitor pulse for bradycardia, EKG for arrhythmias for 1U2 hr after administration (excessive slowing of pulse may be a first clinical sign of toxicity). Assess for GI disturbances, neurologic abnormalities (signs of toxicity) q2U4h during loading dose (daily during maintenance). Monitor serum potassium, magnesium levels. Therapeutic serum level: 0.8U2 ng/ml; toxic serum level: greater than 2 ng/ml.

PATIENT/FAMILY TEACHING

N Stress importance of follow-up visits, blood tests. N Teach patient to take apical pulse correctly and to report pulse 60 or less/min (or as indicated by physician). N Ensure patient understands signs of toxicity and need to notify physician if any occur. N Wear/carry identification of digoxin therapy and inform dentist, other physician of taking digoxin. N Do not increase or skip doses. N Do not take OTC medications without consulting physician. N Inform physician of decreased appetite, nausea/vomiting, diarrhea, visual changes.

diltiazem hydrochloride

dil-tye-a-zem

(Apo-Diltiaz J, Cardizem, Cardizem CD, Cardizem LA, Cardizem SR, Cartia XT, Dilacor XR, Diltia XT, Diltiazem Hydrochloride XT, Novo-Diltiazem J, Taztia XT, Tiazac)

Do not confuse Cardizem with Cardene or Cardene SR, or Tiazac with Ziac.

FIXED-COMBINATION(S)

Teczem: diltiazem/enalapril (angiotensin-converting enzyme [ACE] inhibitor): 180 mg/5 mg.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Calcium channel blocker. CLINICAL: Antianginal, antihypertensive, antiarrhythmic.

ACTION

An antianginal, antihypertensive, and antiarrhythmic agent that inhibits calcium movement across cardiac and vascular smooth-muscle cell membranes. This action causes the dilation of coronary arteries, peripheral arteries, and arterioles. Therapeutic Effect: Decreases heart rate and myocardial contractility, slows SA and AV conduction and decreases total peripheral vascular resistance by vasodilation.

PHARMACOKINETICS

Route Onset Peak Duration

PO 0.5U 1 hr N/A N/A

PO 2U3 hr N/A N/A

IV 3 min N/A N/A

Well absorbed from the GI tract. Protein binding: 70%U80%. Undergoes first-pass metabolism in the liver to active metabolite. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 3U8 hr.

USES

PO: Treatment of angina due to coronary artery spasm (Prinzmetal's variant angina), chronic stable angina (effort-associated angina). Extended-Release: Treatment of essential hypertension, angina. Cardizem LA: Treatment of chronic stable angina. Parenteral: Temporary control of rapid ventricular rate in atrial fibrillation/flutter. Rapid conversion of paroxysmal supraventricular tachycardia (PSVT) to normal sinus rhythm.

PRECAUTIONS

CONTRAINDICATIONS: Acute MI, pulmonary congestion, hypersensitivity to diltiazem or other calcium channel blockers, second- or third-degree AV block (except in the presence of a pacemaker), severe hypotension (less than 90 mm Hg, systolic), sick sinus syndrome. CAUTIONS: Renal or hepatic impairment, CHF.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Distributed in breast milk. Pregnancy Category C. Children: No age-related precautions noted. Elderly: Age-related renal impairment may require dosage adjustment.

INTERACTIONS

DRUG: Beta blockers: May have additive effect. Carbamazepine, quinidine, theophylline: May increase diltiazem blood concentration and risk of toxicity. Digoxin: May increase serum digoxin concentration. Procainamide, quinidine: May increase risk of QT-interval prolongation. HERBAL: None known. FOOD: None known. LAB VALUES: PR interval may be increased.

AVAILABILITY (Rx)

CAPSULES (SUSTAINED-RELEASE [CARDIZEM SR]): 60 mg, 90 mg, 120 mg. CAPSULES (EXTENDED-RELEASE [CARDIZEM CD]): 120 mg (Cardizem CD, Cartia XT, Dilacor XR, Diltia XT, Taztia XT, Tiazac), 180 mg (Cardizem CD, Cartia XT, Dilacor XR, Diltia XT, Taztia XT, Tiazac), 240 mg (Cardizem CD, Cartia XT, Dilacor XR, Diltia XT, Taztia XT, Tiazac), 300 mg (Cardizem CD, Cartia XT, Taztia XT, Tiazac), 360 mg (Cardizem CD, Taztia XT, Tiazac), 420 mg (Tiazac). TABLETS (CARDIZEM): 30 mg, 60 mg, 90 mg, 120 mg. TABLETS (EXTENDED-RELEASE [CARDIZEM LA]) 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg. INJECTION (READY-TO-HANG INFUSION): 1 mg/ml.

ADMINISTRATION/HANDLING

L IV

Reconstitution N Add 125 mg to 100 ml D5W, 0.9% NaCl to provide a concentration of 1 mg/ml. Add 250 mg to 250 or 500 ml diluent to provide a concentration of 0.83 mg/ml or 0.45 mg/ml, respectively. Maximum concentration: 1.25 g/250 ml (5 mg/ml).

Rate of administration N Infuse per dilution/rate chart provided by manufacturer.

Storage N Refrigerate vials. N After dilution, stable for 24 hr.

N Give before meals and at bedtime. N Tablets may be crushed. N Do not crush sustained-release capsules.

D IV INCOMPATIBILITIES

Acetazolamide (Diamox), acyclovir (Zovirax), aminophylline, ampicillin, ampicillin/sulbactam (Unasyn), cefoperazone (Cefobid), diazepam (Valium), furosemide (Lasix), heparin, insulin, nafcillin, phenytoin (Dilantin), rifampin (Rifadin), sodium bicarbonate.

IV COMPATIBILITIES

Albumin, aztreonam (Azactam), bumetanide (Bumex), cefazolin (Ancef), cefotaxime (Claforan), ceftazidime (Fortaz), ceftriaxone (Rocephin), cefuroxime (Zinacef), cimetidine (Tagamet), ciprofloxacin (Cipro), clindamycin (Cleocin), digoxin (Lanoxin), dobutamine (Dobutrex), dopamine (Intropin), gentamicin (Garamycin), hydromorphone (Dilaudid), lidocaine, lorazepam (Ativan), metoclopramide (Reglan), metronidazole (Flagyl), midazolam (Versed), morphine, multivitamins, nitroglycerin, norepinephrine (Levophed), potassium chloride, potassium phosphate, tobramycin (Nebcin), vancomycin (Vancocin).

INDICATIONS/ROUTES/DOSAGE

ANGINA

PO (CARDIZEM): ADULTS, ELDERLY: Initially, 30 mg 4 times a day. Range: 180U360 mg/day.

PO (CARDIZEM CD, CARTIA XT, DILACOR XR, DILTIA XT, TIAZAC): ADULTS, ELDERLY: Initially, 120U180 mg/day. Maximum: 480 mg/day.

PO (CARDIZEM LA): ADULTS, ELDERLY: Initially, 180 mg/day. May increase at intervals of 7U14-day intervals. Maximum: 360 mg/day.

HYPERTENSION

PO (CARDIZEM CD, CARTIA XT, DILACOR XR, DILTIA XT, TIAZAC): ADULTS, ELDERLY: Initially, 180U240 mg/day. Range: 180U420 mg/day, Tiazac: 120U540 mg/day.

PO (CARDIZEM SR): ADULTS, ELDERLY: Initially, 60U120 mg twice a day. May increase at 14-day intervals. Maintenance: 240U360 mg/day.

PO (CARDIZEM LA): ADULTS, ELDERLY: Initially, 180U240 mg/day. May increase at 14-day intervals. Range: 120U540 mg/day.

TEMPORARY CONTROL OF RAPID VENTRICULAR RATE IN ATRIAL FIBRILLATION OR FLUTTER, RAPID CONVERSION OF PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA TO NORMAL SINUS RHYTHM.

IV PUSH: ADULTS, ELDERLY: Initially, 0.25 mg/kg actual body weight over 2 min. May repeat in 15 min at dose of 0.35 mg/kg actual body weight. Subsequent doses individualized.

IV INFUSION: ADULTS, ELDERLY: After initial bolus injection, may begin infusion at 5U10 mg/hr; may increase by 5 mg/hr up to a maximum of 15 mg/hr. Infusion duration should not exceed 24 hr.

SIDE EFFECTS

FREQUENT (10%U5%): Peripheral edema, dizziness, light-headedness, headache, bradycardia, asthenia (loss of strength, weakness). OCCASIONAL (5%U2%): Nausea, constipation, flushing, EKG changes. RARE (less than 2%): Rash, micturition disorder (polyuria, nocturia, dysuria, frequency of urination), abdominal discomfort, somnolence.

ADVERSE REACTIONS/TOXIC EFFECTS

Abrupt withdrawal may increase frequency or duration of angina. CHF and second- and third-degree AV block occur rarely. Overdose produces nausea, somnolence, confusion, slurred speech, and profound bradycardia.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Concurrent therapy of sublingual nitroglycerin may be used for relief of anginal pain. Record onset, type (sharp, dull, squeezing), radiation, location, intensity, duration of anginal pain, and precipitating factors (exertion, emotional stress). Assess baseline renal and liver function tests. Assess BP, apical pulse immediately before drug is administered.

INTERVENTION/EVALUATION

Assist with ambulation if dizziness occurs. Assess for peripheral edema behind medial malleolus (sacral area in bedridden patients). Monitor pulse rate for bradycardia. With IV therapy, assess BP, renal and liver function tests, EKG. Question for asthenia, headache.

PATIENT/FAMILY TEACHING

N Do not abruptly discontinue medication. N Compliance with therapy regimen is essential to control anginal pain. N To avoid hypotensive effect, rise slowly from lying to sitting position, wait momentarily before standing. N Avoid tasks that require alertness, motor skills until response to drug is established. N Contact physician or nurse if palpitations, shortness of breath, pronounced dizziness, nausea, or constipation occurs.

diltiazem hydrochloride

dil-tye-a-zem

(Apo-Diltiaz J, Cardizem, Cardizem CD, Cardizem LA, Cardizem SR, Cartia XT, Dilacor XR, Diltia XT, Diltiazem Hydrochloride XT, Novo-Diltiazem J, Taztia XT, Tiazac)

Do not confuse Cardizem with Cardene or Cardene SR, or Tiazac with Ziac.

FIXED-COMBINATION(S)

Teczem: diltiazem/enalapril (angiotensin-converting enzyme [ACE] inhibitor): 180 mg/5 mg.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Calcium channel blocker. CLINICAL: Antianginal, antihypertensive, antiarrhythmic.

ACTION

PHARMACOKINETICS

Route Onset Peak Duration

PO 0.5U1 hr N/A N/A

PO 2U3 hr N/A N/A

IV 3 min N/A N/A

USES

PRECAUTIONS

INTERACTIONS

AVAILABILITY (Rx)

ADMINISTRATION/HANDLING

L IV

Rate of administration N Infuse per dilution/rate chart provided by manufacturer.

Storage N Refrigerate vials. N After dilution, stable for 24 hr.

N Give before meals and at bedtime. N Tablets may be crushed. N Do not crush sustained-release capsules.

D IV INCOMPATIBILITIES

IV COMPATIBILITIES

INDICATIONS/ROUTES/DOSAGE

ANGINA

PO (CARDIZEM): ADULTS, ELDERLY: Initially, 30 mg 4 times a day. Range: 180U360 mg/day.

PO (CARDIZEM CD, CARTIA XT, DILACOR XR, DILTIA XT, TIAZAC): ADULTS, ELDERLY: Initially, 120U180 mg/day. Maximum: 480 mg/day.

PO (CARDIZEM LA): ADULTS, ELDERLY: Initially, 180 mg/day. May increase at intervals of 7U14-day intervals. Maximum: 360 mg/day.

HYPERTENSION

PO (CARDIZEM CD, CARTIA XT, DILACOR XR, DILTIA XT, TIAZAC): ADULTS, ELDERLY: Initially, 180U240 mg/day. Range: 180U420 mg/day, Tiazac: 120U540 mg/day.

PO (CARDIZEM SR): ADULTS, ELDERLY: Initially, 60U120 mg twice a day. May increase at 14-day intervals. Maintenance: 240U360 mg/day.

PO (CARDIZEM LA): ADULTS, ELDERLY: Initially, 180U240 mg/day. May increase at 14-day intervals. Range: 120U540 mg/day.

TEMPORARY CONTROL OF RAPID VENTRICULAR RATE IN ATRIAL FIBRILLATION OR FLUTTER, RAPID CONVERSION OF PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA TO NORMAL SINUS RHYTHM.

IV PUSH: ADULTS, ELDERLY: Initially, 0.25 mg/kg actual body weight over 2 min. May repeat in 15 min at dose of 0.35 mg/kg actual body weight. Subsequent doses individualized.

IV INFUSION: ADULTS, ELDERLY: After initial bolus injection, may begin infusion at 5U10 mg/hr; may increase by 5 mg/hr up to a maximum of 15 mg/hr. Infusion duration should not exceed 24 hr.

SIDE EFFECTS

ADVERSE REACTIONS/TOXIC EFFECTS

NURSING CONSIDERATION

BASELINE ASSESSMENT

INTERVENTION/EVALUATION

PATIENT/FAMILY TEACHING

dinoprostone

dye-noe-pros-tone

(Cervidil, Prepidil, Prostin E2)

Do not confuse Cervidil or Prepidil with bepridil or Prostin with Prostigmin.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Prostaglandin. CLINICAL: Oxytocic, abortifacient, antihemorrhagic.

ACTION

A prostaglandin that directly acts on the myometrium, causing softening and dilation effect of the cervix. Therapeutic Effect: Stimulates myometrial contractions in gravid uterus.

PHARMACOKINETICS

Undergoes rapid enzymatic deactivation primarily in maternal lungs. Protein binding: 73%. Primarily excreted in urine. Half-life: Less than 5 min.

USES

Suppository: To induce abortion from the 12th wk of pregnancy through the second trimester; to evacuate uterine contents in missed abortion or intrauterine fetal death up to 28 wk gestational age (as calculated from the first day of the last normal menstrual period), benign hydatidiform mole. Treatment of postpartum or postabortion hemorrhage, induction of labor at or near term. Gel: Ripening unfavorable cervix in pregnant women at or near term with medical or obstetric need for labor induction. Induction of labor at or near term. Vaginal insert: Initiation and/or cervical ripening in patients having medical indication for induction of labor.

PRECAUTIONS

CONTRAINDICATIONS: Gel: Active cardiac, hepatic, pulmonary or renal disease; acute pelvic inflammatory disease (PID); fetal malpresentation; grand multiparae with 6 or more previous term pregnancy cases with nonvertex presentation; history of cesarean section or major uterine surgery; history of difficult labor and/or traumatic delivery; hypersensitivity to other prostaglandins; placenta previa or unexplained vaginal bleeding during this pregnancy; patients for whom vaginal delivery is not indicated, such as vasa previa or active herpes genitalia; significant cephalopelvic disproportion. Vaginal suppository: Active cardiac, hepatic, pulmonary, or renal disease; acute PID. CAUTIONS: Cervicitis, infected endocervical lesions or acute vaginitis, history of asthma, hypotension or hypertension, anemia, jaundice, diabetes, epilepsy, uterine fibroids, compromised (scarred) uterus, history of cardiovascular, renal, or hepatic disease.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Suppository: Teratogenic, therefore abortion must be complete. Gel: Sustained uterine hyperstimulation may affect fetus (e.g., abnormal heart rate). Pregnancy Category C. Children/Elderly: Not used in these patient populations.

INTERACTIONS

DRUG: Oxytocics: May cause uterine hypertonus, possibly resulting in uterine rupture or cervical laceration. HERBAL: None known. FOOD: None known. LAB VALUES: None known.

AVAILABILITY (Rx)

VAGINAL GEL (PREPIDIL): 0.5 mg. VAGINAL INSERTS (CERVIDIL): 10 mg. VAGINAL SUPPOSITORIES (PROSTIN E2 VAGINAL CREAM): 20 mg.

ADMINISTRATION/HANDLING

GEL

N Refrigerate. N Use caution in handling, prevent skin contact. Wash hands thoroughly with soap and water following administration. N Bring to room temperature just before use (avoid forcing the warming process). N Assemble dosing apparatus as described in manufacturer insert. N Place patient in dorsal position with cervix visualized using a speculum. N Introduce gel into cervical canal just below level of internal os. N Have patient remain in supine position at least 15U30 min (minimizes leakage from cervical canal).

SUPPOSITORY

N Keep frozen (less than 4°F); bring to room temperature just before use. N Administer only in hospital setting with emergency equipment available. N Warm suppository to room temperature before removing foil wrapper. N Avoid skin contact due to risk of absorption. N Insert high in vagina. N Patient should remain supine for 10 min after administration.

INDICATIONS/ROUTES/DOSAGE

ABORTIFACIENT

INTRAVAGINAL: ADULTS: 20 mg (or one suppository) high into vagina. May repeat at 3- to 5-hr intervals until abortion occurs. Do not administer for longer than 2 days. Maximum: 240 mg.

RIPENING OF UNFAVORABLE CERVIX

INTRACERVICAL (PREPIDIL): ADULTS: Initially, 0.5 mg (2.5 ml); if no cervical or uterine response, may repeat 0.5-mg dose in 6 hr. Maximum: 1.5 mg (7.5 ml) for a 24-hr period.

INTRACERVICAL (CERVIDIL): ADULTS: 10 mg over 12-hr period; remove upon onset of active labor or 12 hr after insertion.

SIDE EFFECTS

FREQUENT: Vomiting (66%), diarrhea (40%), nausea (33%). OCCASIONAL: Headache (10%), chills or shivering (10%), hives, bradycardia, increased uterine pain accompanying abortion, peripheral vasoconstriction. RARE: Flushing, vulvae edema.

ADVERSE REACTIONS/TOXIC EFFECTS

Overdose may cause uterine hypertonicity with spasm and tetanic contraction, leading to cervical laceration or perforation, and uterine rupture or hemorrhage.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Offer emotional support. Suppository: Obtain orders for antiemetics, antidiarrheals, meperidine, other pain medication for abdominal cramps. Assess any uterine activity, vaginal bleeding. Gel: Assess Bishop score. Assess degree of effacement (determines size of shielded endocervical catheter).

INTERVENTION/EVALUATION

Suppository: Check strength, duration, frequency of contractions and monitor vital signs q15min until stable, then hourly until abortion complete. Check resting uterine tone. Administer medications for relief of GI effects if indicated or for abdominal cramps. Gel: Monitor uterine activity (onset of uterine contractions), fetal status (heart rate), character of cervix (dilation, effacement). Have patient remain recumbent 12 hr after application with continuous electronic monitoring of fetal heart rate and uterine activity. Record maternal vital signs at least hourly in presence of uterine activity. Reassess Bishop score.

PATIENT/FAMILY TEACHING

N Suppository: Report fever, chills, foul-smelling/increased vaginal discharge, uterine cramps or pain promptly.

*DOBUTamine hydrochloride A

doe-byoo-ta-meen

(Dobutrex)

Do not confuse dobutamine with dopamine.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Sympathomimetic. CLINICAL: Cardiac stimulant.

ACTION

A direct-acting inotropic agent acting primarily on beta1-adrenergic receptors. Therapeutic Effect: Decreases preload and afterload, and enhances myocardial contractility, stroke volume, and cardiac output. Improves renal blood flow and urine output.

PHARMACOKINETICS

Route Onset Peak Duration

IV 1U2 min 10 min Length of infusion

Metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 2 min.

USES

Short-term management of cardiac decompensation.

PRECAUTIONS

CONTRAINDICATIONS: Hypovolemia patients, idiopathic hypertrophic subaortic stenosis, sulfite sensitivity. CAUTIONS: Atrial fibrillation, hypertension, hypovolemia, severe coronary artery disease, MI.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Has not been administered to pregnant women. Pregnancy Category B. Children/Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: Beta blockers: May antagonize the effects of dobutamine. Digoxin: May increase the risk of arrhythmias and enhance the inotropic effect of both drugs. Entacapone: May increase the risk of arrhythmias, hypertension, and tachycardias. MAOIs, oxytocics, tricyclic antidepressants: May increase the adverse effects of dobutamine, such as arrhythmias and hypertension. HERBAL: None known. FOOD: None known. LAB VALUES: Decreases serum potassium level.

AVAILABILITY (Rx)

INFUSION (READY-TO-USE): 1 mg/ml, 2 mg/ml, 4 mg/ml. INJECTION: 12.5-mg/ml vial.

ADMINISTRATION/HANDLING

O ALERT P Correct hypovolemia with volume expanders before dobutamine infusion. Those with atrial fibrillation should be digitalized before infusion. Administer by IV infusion only.

L IV

Reconstitution N Dilute 250-mg ampule with 10 ml sterile water for injection or D5W for injection. Resulting solution: 25 mg/ml. Add additional 10 ml of diluent if not completely dissolved (resulting solution: 12.5 mg/ml). N Further dilute 250-mg vial with D5W or 0.9% NaCl. Maximum concentration: 3.125 g/250 ml (12.5 mg/ml).

Rate of administration N Use infusion pump to control flow rate. N Titrate dosage to individual response. N Infiltration causes local inflammatory changes. N Extravasation may cause dermal necrosis.

Storage N Store at room temperature. Freezing produces crystallization. N Pink discoloration of solution (due to oxidation) does not indicate loss of potency if used within recommended time period. N Further diluted solution for infusion must be used within 24 hr.

D IV INCOMPATIBILITIES

Acyclovir (Zovirax), alteplase (Activase), amphotericin B complex (Abelcet, AmBisome, Amphotec), bumetanide (Bumex), cefepime (Maxipime), foscarnet (Foscavir), furosemide (Lasix), heparin, piperacillin/tazobactam (Zosyn).

IV COMPATIBILITIES

Amiodarone (Cordarone), calcium chloride, calcium gluconate, diltiazem (Cardizem), dopamine (Intropin), enalapril (Vasotec), famotidine (Pepcid), hydromorphone (Dilaudid), insulin (regular), lidocaine, lorazepam (Ativan), magnesium sulfate, midazolam (Versed), milrinone (Primacor), morphine, nitroglycerin, norepinephrine (Levophed), potassium chloride, propofol (Diprivan), total parenteral nutrition (TPN).

INDICATIONS/ROUTES/DOSAGE

SHORT-TERM MANAGEMENT OF CARDIAC DECOMPENSATION

IV INFUSION: ADULTS, ELDERLY, CHILDREN: 2.5U20 mcg/kg/min. Rarely, drug can be infused at a rate of up to 40 mcg/kg/min to increase cardiac output. NEONATES: 2U15 mcg/kg/min.

SIDE EFFECTS

FREQUENT (greater than 5%): Increased heart rate, increased BP. OCCASIONAL (5%U3%): Pain at injection site. RARE (3%U1%): Nausea, headache, anginal pain, shortness of breath, fever.

ADVERSE REACTIONS/TOXIC EFFECTS

Overdose may produce a marked increase in heart rate (by 30 beats/min or higher) marked increase in BP (by 50 mm Hg or higher), anginal pain, and premature ventricular contractions (PVCs).

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Patient must be on continuous cardiac monitoring. Determine weight (for dosage calculation). Obtain initial BP, heart rate, respirations. Correct hypovolemia before drug therapy.

INTERVENTION/EVALUATION

Continuously monitor for cardiac rate, arrhythmias. With physician, establish parameters for adjusting rate or stopping infusion. Maintain accurate I&O; measure urine output frequently. Assess serum potassium levels and dobutamine plasma level (therapeutic range: 40U190 ng/ml). Monitor BP continuously (hypertension greater risk in patients with preexisting hypertension). Check cardiac output and pulmonary wedge pressure or central venous pressure (CVP) frequently. Immediately notify physician of decreased urine output, cardiac arrhythmias, significant increase in BP, heart rate, or less commonly hypotension.

*DOBUTamine hydrochloride A

doe-byoo-ta-meen

(Dobutrex)

Do not confuse dobutamine with dopamine.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Sympathomimetic. CLINICAL: Cardiac stimulant.

ACTION

PHARMACOKINETICS

Route Onset Peak Duration

IV 1U2 min 10 min Length of infusion

Metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 2 min.

USES

Short-term management of cardiac decompensation.

PRECAUTIONS

CONTRAINDICATIONS: Hypovolemia patients, idiopathic hypertrophic subaortic stenosis, sulfite sensitivity. CAUTIONS: Atrial fibrillation, hypertension, hypovolemia, severe coronary artery disease, MI.

INTERACTIONS

AVAILABILITY (Rx)

INFUSION (READY-TO-USE): 1 mg/ml, 2 mg/ml, 4 mg/ml. INJECTION: 12.5-mg/ml vial.

ADMINISTRATION/HANDLING

O ALERT P Correct hypovolemia with volume expanders before dobutamine infusion. Those with atrial fibrillation should be digitalized before infusion. Administer by IV infusion only.

L IV

Rate of administration N Use infusion pump to control flow rate. N Titrate dosage to individual response. N Infiltration causes local inflammatory changes. N Extravasation may cause dermal necrosis.

D IV INCOMPATIBILITIES

IV COMPATIBILITIES

INDICATIONS/ROUTES/DOSAGE

SHORT-TERM MANAGEMENT OF CARDIAC DECOMPENSATION

IV INFUSION: ADULTS, ELDERLY, CHILDREN: 2.5U20 mcg/kg/min. Rarely, drug can be infused at a rate of up to 40 mcg/kg/min to increase cardiac output. NEONATES: 2U15 mcg/kg/min.

SIDE EFFECTS

FREQUENT (greater than 5%): Increased heart rate, increased BP. OCCASIONAL (5%U3%): Pain at injection site. RARE (3%U1%): Nausea, headache, anginal pain, shortness of breath, fever.

ADVERSE REACTIONS/TOXIC EFFECTS

Overdose may produce a marked increase in heart rate (by 30 beats/min or higher) marked increase in BP (by 50 mm Hg or higher), anginal pain, and premature ventricular contractions (PVCs).

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Patient must be on continuous cardiac monitoring. Determine weight (for dosage calculation). Obtain initial BP, heart rate, respirations. Correct hypovolemia before drug therapy.

INTERVENTION/EVALUATION

docetaxel A

dox-eh-tax-el

(Taxotere)

Do not confuse docetaxel with Taxol.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Antimitotic agent, taxoid. CLINICAL: Antineoplastic.

ACTION

An antimitotic agent belonging to the taxoid family that disrupts the microtubular cell network, which is essential for cellular function. Therapeutic Effect: Inhibits cellular mitosis.

PHARMACOKINETICS

Distributed into peripheral compartments. Protein binding: 94%. Extensively metabolized. Excreted primarily in feces, with lesser amount in urine. Half-life: 11.1 hr.

USES

Treatment of locally advanced or metastatic breast carcinoma after the failure of any prior chemotherapy. Treatment of metastatic nonUsmall cell lung cancer. Treatment of metastatic prostate cancer (with prednisone). Treatment of stomach cancer. OFF-LABEL: Bladder, esophageal, gastric, head and neck, ovarian, small cell lung carcinoma.

PRECAUTIONS

CONTRAINDICATIONS: History of severe hypersensitivity to drugs formulated with polysorbate 80, neutrophil count less than 1,500 cells/mm3. CAUTIONS: Hepatic impairment, bone marrow depression, herpes zoster, chickenpox, preexisting pleural effusion, infection, chemotherapy or radiation.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: May cause fetal harm. Unknown if distributed in breast milk; do not breast-feed. Pregnancy Category D. Children: Safety and efficacy not established in those younger than 16 yr. Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: Bone marrow depressants: May increase myelosuppression. Cyclosporine, erythromycin, ketoconazole: May significantly inhibit docetaxel metabolism. Live virus vaccines: May potentiate replication, increase vaccine side effects, and decrease the patient's antibody response to the vaccine. HERBAL: None known. FOOD: None known. LAB VALUES: May significantly increase BUN level and serum alkaline phosphatase, bilirubin, creatinine, AST, and ALT levels. Reduces blood neutrophil, thrombocyte, and WBC counts.

AVAILABILITY (Rx)

INJECTION: 20 mg/0.5 ml with diluent, 80 mg/2 ml with diluent.

ADMINISTRATION/HANDLING

O ALERT P Because docetaxel may be carcinogenic, mutagenic, or teratogenic, handle the drug with extreme care during preparation and administration.

O ALERT P Dilution is required before administration. Patient should be premedicated with oral corticosteroids (e.g., dexamethasone 16 mg/day for 5 days beginning day 1 before docetaxel therapy; reduces severity of fluid retention, hypersensitivity reaction).

L IV

Reconstitution N Withdraw contents of diluent (provided by manufacturer) and add to vial of docetaxel. N Gently rotate to ensure thorough mixing to provide a solution of 10 mg/ml. N Withdraw dose and add to 250 ml 0.9% NaCl or D5W in glass or polyolefin container to provide a final concentration of 0.3U0.9 mg/ml.

Rate of administration N Administer as a 1-hr infusion. N Monitor closely for hypersensitivity reaction (i.e., flushing, localized skin reaction, bronchospasm [may occur within a few min after beginning infusion]).

Storage N Refrigerate vial. Freezing does not adversely affect drug. N Protect from bright light. N Stand vial at room temperature for 5 min before administering (do not store in PVC bags). N Remixed solution is stable for 8 hr either at room temperature or if refrigerated.

D IV INCOMPATIBILITIES

Amphotericin B (Fungizone), doxorubicin liposomal (DaunoXome), methylprednisolone (Solu-Medrol), nalbuphine (Nubain).

IV COMPATIBILITIES

Bumetanide (Bumex), calcium gluconate, dexamethasone (Decadron), diphenhydramine (Benadryl), dobutamine (Dobutrex), dopamine (Inotropin), furosemide (Lasix), granisetron (Kytril), heparin, hydromorphone (Dilaudid), lorazepam (Ativan), magnesium sulfate, mannitol, morphine, ondansetron (Zofran), potassium chloride.

INDICATIONS/ROUTES/DOSAGE

BREAST CARCINOMA

IV: ADULTS: 60U100 mg/m2 given over 1 hr q3wk. If patient develops febrile neutropenia, a neutrophil count less than 500 cells/mm3 for longer than 1 wk, severe or cumulative cutaneous reactions, or severe peripheral neuropathy with initial dose of 100 mg/m2, dosage should be decreased to 75 mg/m2. If reaction continues, dosage should be further reduced to 55 mg/m2 or therapy should be discontinued. Patients who don't experience the above symptoms at a dose of 60 mg/m2 may tolerate an increased docetaxel dose.

NONUSMALL CELL LUNG CARCINOMA

IV: ADULTS: 75 mg/m2 q3wk. Adjust dosage if toxicity occurs.

PROSTATE CANCER

IV: ADULTS, ELDERLY: 75 mg/m2 q3wk with concurrent administration of prednisone 5 mg twice a day.

SIDE EFFECTS

FREQUENT: Alopecia (80%), asthenia (62%), hypersensitivity reaction such as dermatitis (59% decreases to 16% in those pretreated with oral corticosteroids), fluid retention (49%), stomatitis (43%), nausea and diarrhea (40%), fever (30%), nail changes (28%), vomiting (24%), myalgia (19%). OCCASIONAL: Hypotension, edema, anorexia, headache, weight gain, infection (urinary tract, injection site, indwelling catheter tip), dizziness. RARE: Dry skin, sensory disorders (vision, speech, taste), arthralgia, weight loss, conjunctivitis, hematuria, proteinuria.

ADVERSE REACTIONS/TOXIC EFFECTS

In patients with normal liver function tests, neutropenia (neutrophil count less than 2,000 cells/mm3) and leukopenia (WBC count less than 4,000 cells/mm3) occur in 96% of patients; anemia (hemoglobin level less than 11 g/dl) occurs in 90% of patients; thrombocytopenia (platelet count less than 100,000 cells/mm3) occur in 8% of patients; and infection occurs in 28% of patients. Neurosensory and neuromotor effects, such as distal paresthesias and weakness, occur in 54% and 13% of patients, respectively.

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Offer emotional support to patient and family. Antiemetics may be effective in preventing, treating nausea, vomiting. Patient should be pretreated with corticosteroids before therapy to reduce fluid retention, hypersensitivity reaction.

INTERVENTION/EVALUATION

Frequent monitoring of blood counts is essential, particularly neutrophil count (less than 1,500 cells/mm3 requires discontinuation of therapy). Monitor renal and liver function tests; serum uric acid levels. Observe for cutaneous reactions characterized by rash with eruptions, mainly on hands or feet. Assess for extravascular fluid accumulation: rales in lungs, dependent edema, dyspnea at rest, pronounced abdominal distention (due to ascites).

PATIENT/FAMILY TEACHING

N Alopecia is reversible, but new hair growth may have different color or texture. N New hair growth resumes 2U3 mo after last therapy dose. N Maintain fastidious oral hygiene. N Do not have immunizations without physician approval (drug lowers body's resistance). N Avoid those who have recently taken live virus vaccine.

dolasetron

dole-ah-seh-tron

(Anzemet)

Do not confuse Anzemet with Aldomet.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Selective receptor antagonist. CLINICAL: Antiemetic.

ACTION

A 5-HT3 receptor antagonist that acts centrally in the chemoreceptor trigger zone and peripherally at the vagal nerve terminals. Therapeutic Effect: Prevents nausea and vomiting.

PHARMACOKINETICS

Readily absorbed from the GI tract after PO administration. Protein binding: 69%U77%. Metabolized in the liver. Primarily excreted in urine. Unknown if removed by hemodialysis. Half-life: 5U10 hr.

USES

Oral: Prevention of nausea or vomiting associated with cancer chemotherapy, including high-dose cisplatin; prevention of postop nausea or vomiting. Injection: Treatment of postop nausea or vomiting. OFF-LABEL: Radiation therapy induced nausea and vomiting.

PRECAUTIONS

CONTRAINDICATIONS: None known. CAUTIONS: Those who have or may have prolongation of cardiac conduction intervals, hypokalemia, hypomagnesemia, those taking diuretics with potential for inducing electrolyte disturbances, congenital long QT syndrome, those taking antiarrhythmics that may lead to QT prolongation and cumulative high-dose anthracycline therapy.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug is distributed in breast milk. Pregnancy Category B. Children: Safety and efficacy not established in those younger than 2 yr. Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES: May transiently increase AST and ALT levels.

AVAILABILITY (Rx)

TABLETS: 50 mg, 100 mg. INJECTION: 20 mg/ml in single use 0.625 ml amps, 0.625 ml fill in 2 ml Carpuject and 5 ml vials.

ADMINISTRATION/HANDLING

L IV

Reconstitution N May dilute in 0.9% NaCl, D5W, D5W with 0.45% NaCl, D5W with lactated Ringer's, lactated Ringer's, or 10% mannitol injection to 50 ml.

Rate of administration N Can be given as IV push as rapidly as 100 mg/30 sec. N Intermittent IV infusion (piggyback) may be infused over 15 min.

Storage N Store vials at room temperature. N After dilution, solution is stable for 24 hr at room temperature or 48 hr if refrigerated.

N Do not cut, break, or chew film-coated tablets. N For children 2U16 yr, injection form may be mixed in apple or apple-grape juice for oral dosing at 1.8 mg/kg up to a maximum of 100 mg.

D IV INCOMPATIBILITIES

No information available for Y-site administration.

INDICATIONS/ROUTES/DOSAGE

PREVENTION OF CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING

PO: ADULTS: 100 mg within 1 hr of chemotherapy. CHILDREN 2U16 YR: 1.8 mg/kg within 1 hr of chemotherapy. Maximum: 100 mg.

IV: ADULTS, CHILDREN 1U16 YR: 1.8 mg/kg as a single dose 30 min before chemotherapy. Maximum: 100 mg.

TREATMENT OR PREVENTION OF POSTOPERATIVE NAUSEA OR VOMITING

PO: ADULTS: 100 mg within 2 hr of surgery. CHILDREN 2U16 YR: 1.2 mg/kg within 2 hr of surgery. Maximum: 100 mg.

IV: ADULTS: 12.5 mg 15 min before cessation of anesthesia or as soon as nausea occurs. CHILDREN 2U16 YR: 0.35 mg/kg 15 min before cessation of anesthesia or as soon as nausea occurs. Maximum: 12.5 mg.

SIDE EFFECTS

FREQUENT (10%U5%): Headache, diarrhea, fatigue. OCCASIONAL (5%U1%): Fever, dizziness, tachycardia, dyspepsia.

ADVERSE REACTIONS/TOXIC EFFECTS

Overdose may produce a combination of CNS stimulant and depressant effects.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Assess for dehydration if excessive vomiting occurs (poor skin turgor, dry mucous membranes, longitudinal furrows in tongue). Provide emotional support.

INTERVENTION/EVALUATION

Monitor for therapeutic relief from nausea or vomiting, EKG in high-risk patients. Maintain quiet, supportive atmosphere.

*DOXOrubicin A

dox-o-roo-bi-sin

(Adriamycin, Adriamycin PFS, Adriamycin RDF, Caelyx, Doxil, Rubex)

Do not confuse doxorubicin with daunorubicin, or Adriamycin with idamycin or idarubicin.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Anthracycline antibiotic. CLINICAL: Antineoplastic.

ACTION

PHARMACOKINETICS

USES

PRECAUTIONS

INTERACTIONS

AVAILABILITY (Rx)

ADMINISTRATION/HANDLING

L IV

Storage N Store at room temperature. N Reconstituted solution is stable for 24 hr at room temperature or 48 hr if refrigerated. N Protect from prolonged exposure to sunlight; discard unused solution.

DOXIL

Reconstitution N Dilute each dose in 250 ml D5W.

Rate of administration N Give as infusion over 30 min. Do not use in-line filters.

Storage N Refrigerate unopened vials. N After solution is diluted, use within 24 hr.

D IV INCOMPATIBILITIES

IV COMPATIBILITIES

Dexamethasone (Decadron), diphenhydramine (Benadryl), etoposide (VePesid), granisetron (Kytril), hydromorphone (Dilaudid), lorazepam (Ativan), morphine, ondansetron (Zofran), paclitaxel (Taxol).

INDICATIONS/ROUTES/DOSAGE

KAPOSI'S SARCOMA

IV (DOXIL): ADULTS: 20 mg/m2 q3wk infused over 30 min.

OVARIAN CANCER

IV (DOXIL): ADULTS: 50 mg/m2 q4wk.

DOSAGE IN HEPATIC IMPAIRMENT

Dosage is modified based on serum bilirubin level.

Serum Bilirubin Concentration % of Normal Dose

1.2U3 mg/dl 50%

Greater than 3 mg/dl 25%

SIDE EFFECTS

ADVERSE REACTIONS/TOXIC EFFECTS

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

INTERVENTION/EVALUATION

PATIENT/FAMILY TEACHING

drotrecogin alfa

dro-trae-coe-gin al-fa

(Xigris)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Activated protein C. CLINICAL: Antisepsis agent.

ACTION

A recombinant form of human-activated protein C that exerts an antithrombotic effect by inhibiting Factors Va and VIIIa and may exert an indirect profibrinolytic effect by inhibiting plasminogen activator inhibitor-1 and limiting the generation of activated thrombin-activatable-fibrinolysis-inhibitor. The drug may also exert an anti-inflammatory effect by inhibiting tumor necrosis factor (TNF) production by monocytes, by blocking leukocyte adhesion to selectins, and by limiting thrombin-induced inflammatory responses. Therapeutic Effect: Produces anti-inflammatory, antithrombotic, and profibrinolytic effects.

PHARMACOKINETICS

Inactivated by endogenous plasma protease inhibitors. Clearance occurs within 2 hr of initiating infusion. Half-life: 1.6 hr.

USES

Treatment of severe sepsis or septic shock with evidence of organ dysfunction in patients at high risk for death.

PRECAUTIONS

CONTRAINDICATIONS: Active internal bleeding, evidence of cerebral herniation, intracranial neoplasm or mass lesion, presence of an epidural catheter, recent (within the past 3 mo) hemorrhagic stroke, recent (within the past 2 mo) intracranial or intraspinal surgery or severe head trauma, trauma with an increased risk of life-threatening bleeding. CAUTIONS: Concurrent use of heparin, platelet count less than 30,000/mm3, prolonged PT, recent (6 wk or less) GI bleeding, recent (3 days or less) thrombolytic therapy, recent (7 days or less) anticoagulant or aspirin therapy, intracranial aneurysm, chronic severe hepatic disease.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if the drug can cause fetal harm. Unknown if excreted in breast milk. Pregnancy Category C. Children/Elderly: Safety and efficacy not established.

INTERACTIONS

DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES: May prolong aPTT.

AVAILABILITY (Rx)

POWDER FOR INFUSION: 5 mg, 20 mg.

ADMINISTRATION/HANDLING

L IV

Reconstitution N Reconstitute 5-mg vials with 2.5 ml sterile water for injection and 20-mg vials with 10 ml sterile water for injection. Resulting concentration is 2 mg/ml. N Slowly add the sterile water for injection by swirling; do not shake or invert vial. N Further dilute with 0.9% NaCl. N Withdraw amount from vial and add to infusion bag containing 0.9% NaCl for a final concentration of between 100 and 200 mcg/ml; direct the stream to the side of the bag (minimizes agitation). N Invert infusion bag to mix solution.

Rate of administration N Administer via a dedicated IV line or a dedicated lumen of a multilumen central venous line (CVL). N Administer infusion rate of 24 mcg/kg/hr for 96 hr. N If infusion is interrupted, restart drug at 24 mcg/kg/hr.

Storage N Store unreconstituted vials at room temperature. N Start infusion within 3 hr after reconstitution.

D IV INCOMPATIBILITIES

Don't mix drotrecogin alfa with other medications.

IV COMPATIBILITIES

Lactated Ringer's solution, 0.9% NaCl and dextrose are the only solutions that can be administered through the same line.

INDICATIONS/ROUTES/DOSAGE

SEVERE SEPSIS

IV INFUSION: ADULTS, ELDERLY: 24 mcg/kg/hr for 96 hr. Immediately stop infusion if clinically significant bleeding is identified.

SIDE EFFECTS

None known.

ADVERSE REACTIONS/TOXIC EFFECTS

Bleeding (intrathoracic, retroperitoneal, GI, GU, intra-abdominal, intracranial) occurs in about 2% of patients.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Criteria that must be met before initiating drug therapy: age older than 18 yr, no pregnancy or breast-feeding, actual body weight less than 135 kg, 3 or more systemic inflammatory response criteria (fever, heart rate over 90 beats/min, respiratory rate over 20 breaths/min, increased WBC count), and at least one sepsis-induced organ or system failure (cardiovascular, renal, respiratory, hematologic, or unexplained metabolic acidosis).

INTERVENTION/EVALUATION

Monitor closely for hemorrhagic complication.

duloxetine

dew-lox-ah-teen

(Cymbalta)

G CLASSIFICATION

CLINICAL: Antidepressant.

ACTION

An antidepressant that appears to inhibit serotonin and norepinephrine reuptake at CNS neuronal presynaptic membranes; is a less potent inhibitor of dopamine reuptake. Therapeutic Effect: Relieves depression.

PHARMACOKINETICS

Well absorbed from the GI tract. Protein binding: greater than 90%. Extensively metabolized to active metabolites. Excreted primarily in urine and, to a lesser extent, in feces. Half-life: 8U17 hr.

USES

Treatment of major depression exhibited as persistent, prominent dysphoria (occurring nearly every day for at least 2 wk) manifested by 4 of 8 symptoms: change in appetite, change in sleep pattern, increased fatigue, impaired concentration, feelings of guilt or worthlessness, loss of interest in usual activities, psycho-motor agitation or retardation, or suicidal tendencies. OFF-LABEL: Treatment of chronic pain syndromes, fibromyalgia, stress incontinence, urinary incontinence.

PRECAUTIONS

CONTRAINDICATIONS: End-stage renal disease (creatinine clearance less than 30 ml/min), severe hepatic impairment, uncontrolled angle-closure glaucoma, use within 14 days of MAOIs. CAUTIONS: Renal impairment, history of alcoholism, chronic liver disease, hepatic insufficiency, history of seizures, history of mania, conditions that may slow gastric emptying, those with suicidal ideation and behavior.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: May produce neonatal adverse reactions (constant crying, feeding difficulty, hyperreflexia, irritability). Unknown if distributed in breast milk; do not breast-feed. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: Caution required when increasing dosage.

INTERACTIONS

DRUG: Alcohol: Increases the risk of hepatic injury. Fluoxetine, fluvoxamine, paroxetine, quinidine, quinolone antimicrobials: May increase duloxetine plasma concentration. MAOIs: May cause serotonin syndrome, characterized by autonomic hyperactivity, coma, diaphoresis, excitement, hyperthermia, and rigidity. Tricyclic antidepressants (TCAs): May increase tricyclic antidepressant serum concentrations and potential toxicity. Thioridazine: May produce ventricular arrhythmias. Warfarin: May increase the warfarin plasma concentration. HERBAL: St John's wort: May increase adverse effects. FOOD: None known. LAB VALUES: May increase serum bilirubin, AST, and ALT levels.

AVAILABILITY (Rx)

CAPSULES: 20 mg, 30 mg, 60 mg.

ADMINISTRATION/HANDLING

O ALERT P Allow at least 14 days to elapse between the use of MAOIs and duloxetine.

N Give without regard to meals. Give with food or milk if GI distress occur. N Do not crush or chew enteric-coated capsules. N Do not sprinkle capsule contents on food or mix with liquids.

INDICATIONS/ROUTES/DOSAGE

MAJOR DEPRESSIVE DISORDER

PO: ADULTS: 20 mg twice a day, increased up to 60 mg/day as a single dose or in 2 divided doses.

DIABETIC NEUROPATHY PAIN

PO: ADULTS: 60 mg once a day.

SIDE EFFECTS

FREQUENT (20%U11%): Nausea, dry mouth, constipation, insomnia. OCCASIONAL (9%U5%): Dizziness, fatigue, diarrhea, somnolence, anorexia, diaphoresis, vomiting. RARE (4%U2%): Blurred vision, erectile dysfunction, delayed or failed ejaculation, anorgasmia, anxiety, decreased libido, hot flashes.

ADVERSE REACTIONS/TOXIC EFFECTS

Duloxetine use may slightly increase the patient's heart rate. Colitis, dysphagia, gastritis, and irritable bowel syndrome occur rarely.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Assess appearance, behavior, speech pattern, level of interest, mood, sleep pattern.

INTERVENTION/EVALUATION

For those on long-term therapy, serum chemistry profile to assess hepatic function should be performed periodically. Supervise suicidal risk patient closely during early therapy (as depression lessens, energy level improves, increasing suicide potential).

PATIENT/FAMILY TEACHING

N Therapeutic effect may be noted within 1U4 wk. N Do not abruptly discontinue medication. N Avoid tasks that require alertness, motor skills until response to drug is established. N Inform physician if intention of pregnancy or if pregnancy occurs. N Inform physician if anxiety, agitation, panic attacks, worsening of depression occurs. N Avoid heavy alcohol intake (associated with severe hepatic injury).

dutasteride

do-tah-stir-eyed

(Avodart)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Androgen hormone inhibitor. CLINICAL: Benign prostatic hyperplasia agent.

ACTION

An androgen hormone inhibitor that inhibits 5-alpha reductase, an intracellular enzyme that converts testosterone into dihydrotestosterone (DHT) in the prostate gland, reducing the serum DHT level. Therapeutic Effect: Reduces size of the prostate gland.

PHARMACOKINETICS

Route Onset Peak Duration

PO 24 hr N/A 3U8 wk

Moderately absorbed after PO administration. Widely distributed. Protein binding: 99%. Metabolized in the liver. Primarily excreted in feces. Half-life: Up to 5 wk.

USES

Treatment of benign prostatic hyperplasia (BPH). OFF-LABEL: Treatment of hair loss.

PRECAUTIONS

CONTRAINDICATIONS: Females, physical handling of tablets by those who are or may be pregnant. CAUTIONS: Hepatic disease or impairment, obstructive uropathy, preexisting sexual dysfunction (e.g., reduced male libido, impotence). Pregancy Category X.

INTERACTIONS

DRUG: Cimetidine, ciprofloxacin, diltiazem, ketoconazole, ritonavir, verapamil: May increase dutasteride plasma concentrations. HERBAL: None known. FOOD: None known. LAB VALUES: Decreases the serum prostate-specific antigen (PSA) level.

AVAILABILITY (Rx)

CAPSULE: 0.5 mg.

ADMINISTRATION/HANDLING

N Do not open or break capsules. N Give without regard to meals.

INDICATIONS/ROUTES/DOSAGE

BENIGN PROSTATIC HYPERPLASIA (BPH)

PO: ADULTS, ELDERLY (MEN ONLY): 0.5 mg once a day.

SIDE EFFECTS

OCCASIONAL: Gynecomastia, sexual dysfunction (decreased libido, impotence, and decreased volume of ejaculate).

ADVERSE REACTIONS/TOXIC EFFECTS

Toxicity may be manifested as rash, diarrhea, and abdominal pain. Allergic reaction characterized as rash, pruritus, urticaria, and localized edema, occurs rarely.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Serum PSA determination should be performed in patients with BPH before beginning therapy and periodically thereafter.

INTERVENTION/EVALUATION

Diligently monitor I&O. Assess for signs/symptoms of BPH (hesitancy, reduced force of urinary stream, postvoid dribbling, sensation of incomplete bladder emptying).

PATIENT/FAMILY TEACHING

N Discuss potential for impotence; volume of ejaculate may be decreased during treatment. N May not notice improved urinary flow for up to 6 mo after treatment. N Women who may be or are pregnant should not handle capsules (risk of fetal anomaly to male fetus).

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Friday, September 10, 2010

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