VII.

DRUG STUDY Drugs Date ordered: 7/10/11 Generic Name: Isophane Insulin Brand name: Humulin N Classification: Anti-diabetic Dosage: 20 units pre-breakfast 15 units Pre-supper Subcutaneously Indication Treatment of type 2 diabetes mellitus that cannot be controlled by diet or oral drugs. Treatment of severe ketoacidosis. Treatment of adults with diabetes who require basal insulin for control of hyperglycemia. Action Insulin is a hormone secreted by beta cells of the pancreas that, by receptor-mediated effects, promotes the storage of the bodys fuels, facilitating the transport of metabolites and ions (potassium) through cell membranes and stimulating the synthesis of glycogen from glucose, of fats from lipids, and proteins from amino acids. Side Effects/ Adverse Reaction Side Effects Endo : hypoglycemia Local : lipoatrophy, lipohypertrophy, pruritus, edema, swelling Others: Hypersensitivity Reaction Adverse Effects Local : Stinging, redness, urticaria, warmth at injection site Nursing Consideration/ Patient Teachings

Assess for symptoms of hypoglycemia (anxiety, restlessness, mood changes, confusion, drowsiness, nausea).

Monitor blood glucose every 6 hours during therapy. Dosage is always expressed in USP units. remember to use only the syringes calibrated for the particular concentration of insulin administered

Be aware that some patients may develop insulin resistance and require large insulin doses to control symptoms of diabetes.

To mix insulin suspension, swirl vial gently or rotate between palms or between palm and thigh. dont shake vigorously: this causes bubbling and air in syringe

Know that lente, semilente, and ultralente insulins may be mixed in any proportion. Regular insulin may be mixed with NPH or lente insulins in any proportion. When mixing regular insulin with intermediate or long acting insulin, always draw up regular insulin into syringe first.

Note that switching from separate injections to a prepared mixture may alter patient response. Whenever NPH or lente in mixed with regular insulin in the same

syringe, give it immediately to avoid loss of potency.

Dont use insulin that changes color or becomes clumped or granular in appearance Check expiration date on vial before using contents Know that usual administration route is SC. for proper SC administration, remember to pinch a fold of skin with the fingers at least 3 inches apart, and insert at a 45- to 90-degree angle, depending on the type of syringe.

Press but do not rub site after injection. Rotate injection sites and chart to avoid overuse of one area. Know that diabetic patients may achieve better control if injection site is rotated within same anatomic region.

Store insulin in cool area. Refrigeration is desirable but not essential, except with regular insulin concentrated. Explain to patient that this medication controls hyperglycemia but does not cure diabetes. Therapy is long term.

Emphasize the importance of compliance with nutritional guidelines and regular exercise as directed by health care professionals.

Advise patient to notify the nurse if nausea, vomiting, or fever develops, if unable to eat regular diet, or if blood glucose levels are not controlled

Date ordered: 7/11/11 Generic Name: Insulin regular Brand name: Humulin R Classification: Anti-diabetic Dosage: 20 u TIV for Hgt 150-200mg/dL 15 u TIV for Hgt 201 -250 mg/dL 10 u TIV for 150200 mg/dL

Treatment of type 2 diabetes mellitus that cannot be controlled by diet or oral drugs. Treatment of severe ketoacidosis. Treatment of adults with diabetes who require basal insulin for control of hyperglycemia.

Insulin is a hormone secreted by beta cells of the pancreas that, by receptor-mediated effects, promotes the storage of the bodys fuels, facilitating the transport of metabolites and ions (potassium) through cell membranes and stimulating the synthesis of glycogen from glucose, of fats from lipids, and proteins from amino acids.

Side Effects Endo : hypoglycemia Local : lipodystrophy, erythema, pruritus, swelling Others: Hypersensitivity Reaction Adverse Effects Local : Stinging, redness, urticaria, warmth at injection site Others : Anaphylaxis

Assess for symptoms of hypoglycemia (anxiety, restlessness, mood changes, confusion, drowsiness, nausea).

Monitor body weight periodically. Changes in weight may necessitate changes in insulin dose. Monitor blood glucose every 6 hours during therapy. When mixing insulin, draw regular insulin into syringe first to avoid contamination of regular insulin. Store insulin in refrigerator. Do not use if cloudy, discolored, or unusually viscous. Administer regular insulin within 15-30 minutes before meal. Explain to patient that this medication controls hyperglycemia but does not cure diabetes. Emphasize the importance of compliance with nutritional guidelines and regular exercise as directed by health care professionals.

Advise patient to notify the nurse if nausea, vomiting, or fever develops, if unable to eat regular diet, or if blood glucose levels are not controlled.

Date ordered: 7/12/11 Generic Name: Ranitidine Brand name: Zantac Classification: Anti-ulcer, Histamine H2 anatagonist Dosage: 150mg / tab q12

Treatment and prevention of ulcers in the stomach and intestines. It also treats conditions in which the stomach produces too much acid, such as Zollinger-Ellison syndrome. Ranitidine also treats gastroesophageal reflux disease (GERD) and other conditions in which acid backs up from the stomach into the esophagus, causing heartburn.

Ranitidine blocks the production of acid by acid-producing cells in the stomach. Histamine is a naturally occurring chemical that stimulates cells in the stomach (pariental cells) to produce acid. H2 blockers inhibit the action of histamine on the cells, thus reducing the production of acid by the stomach.

Side Effects CNS: Confusion, dizziness, drowsiness, hallucinations, headache CV: Arrhythmias GI: Altered taste, black tongue, constipation, dark stools, diarrhea, druginduced hepatitis, nausea GU:Decreased sperm count, impotence ENDO: Gynecomastia HEMAT: Agranulocytosis, Aplastic Anemia, neutropenia, thrombocytopenia LOCAL: Pain at IM site - reactions, vasculitis Adverse Effects CNS: arrythmias Hemat: agrunolocytosis, aplastic anemia

Potential toxicity results from decreased clearance (elimination) and therefore prolonged action; greatest in the older adult patients or those with hepatic or renal dysfunction.

Lab tests: Periodic liver functions. Monitor creatinine clearance if renal dysfunction is present or suspected. When clearance is <50 mL/min, manufacturer recommends reduction of the dose to 150 mg once q24h with cautious and gradual reduction of the interval to q12h or less, if necessary.

Be alert for early signs of hepatotoxicity jaundice (dark urine, pruritus, yellow sclera and skin), elevated transaminases (especially ALT) and LDH.

Long-term therapy may lead to vitamin B12 deficiency. Inform patient that it may cause drowsiness or dizziness Inform patient that increased fluid and fiber intake may minimize constipation. Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health car professional promptly.

Inform patient that medication may temporarily cause stools and tongue to appear gray black. Note: Long duration of action provides ulcer pain relief that is maintained through the night as well as the

day. Be aware that even if symptomatic relief is provided by ranitidine, this should not be interpreted as absence of gastric malignancy. Follow-up examinations will be scheduled after therapy is discontinued. Adhere to scheduled periodic laboratory checkups during ranitidine treatment. Do not supplement therapy with OTC remedies for gastric distress or pain without physicians advice (e.g., Mylanta II reduces ranitidine absorption). Do not smoke; research shows smoking decreases ranitidine efficacy and adversely affects ulcer healing. Date ordered: 7/12/11 Generic Name: Cilostazol Brand name: Pletal Classification: Anti-platelet, anticoagulant, thrombolytics Dosage: 50mg 1 tab q12 Use for reduction of the symptoms of intermittend claudication (pain in the legs that occurs with walking and disappears with rest). It is also use for prevention of onset of thrombotic disease. Inhinbits the enzyme cyclic adenosine monophosphate (cAMP) phosphatidase III (PDE III), which results in increased cAMP in platelets and blood vessels, producing inhibition of platelet aggregation and vasodilation. Side Effects Headache, dizziness, palpitations, diarrhea, abnormal stools; pain, infection; peripheral edema, nausea, vomiting Adverse Effects arrhythmias, chest pain, rhinitis, pharyngitis, ecchymosis and skin rash. Assess patient for intermittent caludication before and periodically during therapy. Assess location characteristics, extent of abdominal pain, note blood in emesis, stool/gastric aspirate. Administer on an empty stomach, 1 hour before or 2 hours after meals. Do not administer with grapefruit juice. May increase cilostazol levels. May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.

Date ordered: 7/12/11 Generic Name: Ciprofloxacin Brand name: Quinosyn Classification: Anti bacterial Dosage: 500mg 1 tab q12

Ciprofloxacin is used to treat infections of the skin, lungs, airways, bones, and joints caused by susceptible bacteria. Ciprofloxacin is also frequently used to treat urinary infections caused by bacteria E.coli. It is also effective against treating infectious diarrheas.

Inhibition of topoisomerase (DNA gyrase) enzymes, which inhibits relaxation of supercoiled DNA and promotes breakage of double stranded DNA.

Side Effects CNS : agitation, headache, restlessness, confusion, delirium CV: orthostatic hypotension, vasculitis EENT: blurred vision, itchiness GI: nausea, vomiting, diarrhea, constipation, abdominal pain, flatulence GU: albuminuria, candiduria, renal calculi Skin: rash, exfoliative dermatitis Musculoskeletal: myalgia, tendon rupture, tendinitis Others: altered taste Adverse Effects CNS: Toxic psychosis GI: pseudomembranous colitis Skin: erythema mutliforme Others: anaphylaxis

Instruct patient not to take ciprofloxacin with dairy products such as milk or yogurt , or with calcium fortified juice. The patient may eat or drink dairy products or calcium fortified juice with a regular meal, but do not use them alone when taking ciprofloxacin. They could make the medication less effective.

Tell the patient that ciprofloxacin can cause side effects that may impair thinking or reactions. Tell patients to be careful if he plans to drive or do anything that requires him to awake and be alert.

Instruct patient to take ciprofloxacin with a full glass of water. Instruct patient to avoid taking antacids, vitamin or mineral supplements, sucralfate (Carafate), or didanosine (Videx) powder or chewable tablets within 6 hours before or 2 hours after taking the drug. It lessens the effectiveness of ciprofloxacin.

Inform patient that is may cause swelling or tearing of tendon especially in the Achilles tendon. Instruct patient to stop taking ciprofloxacin and call the doctor at once if the patient has sudden pain, tenderness, stiffness, or movement problems in any of joints.

Instruct patient to rest his joints until the patient receive a medical care or instructions.

Date ordered: 7/12/11 Generic Name: Metformin Brand name: Denkaform Classification: Antidiabetic Drug Dosage: 500mg 1 tab q12

Treatment with sulfonylurea and diet failed non-insulin dependent diabetes mellitus (NIDDM) especially if overweight

Improves hyperglycemia primarily by suppressing glucose production by the liver (hepatic gluconeogenesis). Metformin activates AMP-activated protein kinase (AMPK), an enzyme that plays an important role in insulin signaling, whole body energy balance, and the metabolism of glucose and fats; activation of AMPK is required for Metformin's inhibitory effect on the production of glucose by liver cells.

Side Effects Increased flatulence, decrease the blood levels of thyroidstimulating hormone in people with hypothyroidism, anorexia, weakness, myalgia, rashes Adverse Effects GI complaints resulting in nausea, vomiting, diarrhea, metallic taste in mouth, lactic acidosis.

Take with meals to avoid gastrointestinal problems. Notify health care staff of lactic acidosis symptoms, including hyperventilation, fatigue and myalgia. Must be taken daily and not discontinued abruptly. The patient must inform the prescriber if they have any long-term liver or kidney problems, heart failure, or if they are a heavy drinker or taking any other medication.

Advantages include lower incidence of weight gain. Gastrointestinal complaints are more common with higher doses. To avoid lactic acidosis do not use in patients with even mild renal problems. Store in a tight container in a cool place. Side-effects are common and advice about taking the drug with food.

Date ordered: 7/12/11 Generic Name: Sitagliptin Brand name: Januvia Classification: Antidiabetic Dosage: 50mg q12

Adjunct to diet and exercises to improve glycemic controls in patients with type 2 diabetes mellitus, may be used at monotherapy or combination therapy with metformin and a thiazolidinodione.

Inhibits the enzyme dipeptidyl peptidade-4 (DPP-4), which slows the inactivation of incretin hormones, resulting in increased blood levels of active incretin hormones. These hormones are released by the intestine throughout the day, and are involved in regulation of glucose homeostasis. Increased/prolonged incretin levels, increase insulin release and decrease glucagon levels.

Side Effects / Adverse Effects CNS : headache GI: nausea, diarrhea Respiratory: Upper respiratory tract infections, nasopharyngeatis. Others: hypersensitivity reaction, angioedema, rash, urticaria

Observe patient for signs and symptoms of hypoglycemic reactions (abdominal pain, sweating, hunger, weakness, dizziness, headache, tremor, tachycardia, anxiety).

Monitor hemoglobin A 1c prior to and periodically during therapy. Monitor renal function prior to and periodically during therapy. May be administered without regard to food. Instruct patient to take sitagliptin as directed. Take missed doses as soon as remembered, unless it is almost time for next does; do not double dose.

Explain to patient that sitagliptin helps control hyperglycemia but does not cure diabetis. Therapy is long term.

Encourage patient to follow prescribed diet, medication, and exercise regiment to prevent hyperglycemic or hypoglycemic episodes.

Instruct patient to notify health care professionals prior to taking any Rx, OTC, and herbal products.