Acetaminophen and acyclovir drug guide

acetaminophen (N-acetyl-p-aminophenol)
(a seet a min' a fen)

Suppositories:
Abenol (CAN), Acephen
Oral:
Aceta, Apacet, Atasol (CAN), Genapap,
Genebs, Liquiprin, Mapap, Panadol,
apanol, empra, ylenol
Pregnancy Category B
!ru" classes
Antipyretic
Analgesic (nonopioid)
herapeutic actions
Antipyretic: Reduces fever by acting directly
on the hypothalamic heat-regulating center to
cause vasodilation and sweating, which
helps dissipate heat.
Analgesic: Site and mechanism of action
unclear.
#ndications
Analgesic-antipyretic in patients with
aspirin allergy, hemostatic
disturbances, bleeding diatheses,
upper ! disease, gouty arthritis
Arthritis and rheumatic disorders
involving musculos"eletal pain (but
lac"s clinically significant
antirheumatic and anti-inflammatory
effects)
#ommon cold, flu, other viral and
bacterial infections with pain and
fever
$nlabeled use: %rophylactic for
children receiving &%' vaccination to
reduce incidence of fever and pain
Contraindications and cautions
#ontraindicated with allergy to
acetaminophen.
$se cautiously with impaired hepatic
function, chronic alcoholism,
pregnancy, lactation.
A$ailable %orms
Suppositories()*, +,*, +,-, .**, .,-,
/-* mg0
chewable tablets()* mg0 tablets(+/*, .,-,
-**, /-* mg0
caplets(+/*, -**, /-* mg0
gelcaps(-** mg0 capsules(.,-, -** mg0
eli1ir()* mg2,.- m3, )* mg2- m3, +,* mg2-
m3, +/* mg2- m30 li4uid(+/* mg2- m3,
-** mg2+- m30
solution()* mg2+.// m3, +** mg2m30 drops
()* mg2*.) m30
sprin"le capsules()*, +/* mg
Dosages
A!&L'
%5 or %R
6y suppository, .,-7/-* mg 4 87/ hr or %5,
+,*** mg tid to 4id. &o not e1ceed 8 g2day.
P(!#A)#C PA#(N'
%5 or %R
&oses may be repeated 87- times2day0 do
not e1ceed five doses in ,8 hr0 give %5 or by
suppository.
Age &osage (mg)
*7. mo 8*
87++ mo )*
+,7,.
mo
+,*
,7. yr +/*
87- yr ,8*
/7) yr .,*
97+* yr 8**
++ yr 8)*
Pharmaco*inetics
Route 5nset %ea" &uration
5ral :aries *.-7, hr .78 hr
Metabolism+ ;epatic0 '
+2,
: +7. hr
!istribution+ #rosses placenta0 enters
breast mil"
(,cretion+ $rine
1
Ad$erse e%%ects
CN'+ ;eadache
C-+ #hest pain, dyspnea,
myocardial dama"e when doses of
-7) g2day are ingested daily for
several wee"s or when doses of 8
g2day are ingested for + yr
G#+ .epatic to,icity and %ailure,
<aundice
G&+ Acute "idney failure, renal
tubular necrosis
.ematolo"ic+ =ethemoglobinemia
(cyanosis0 hemolytic anemia(
hematuria, anuria0 neutropenia,
leu"openia, pancytopenia,
thrombocytopenia, hypoglycemia
.ypersensiti$ity+ Rash, fever
#nteractions
Drug-drug
!ncreased to1icity with long-term,
e1cessive ethanol ingestion
!ncreased hypoprothrombinemic
effect of oral anticoagulants
!ncreased ris" of hepatoto1icity and
possible decreased therapeutic
effects with barbiturates,
carbama>epine, hydantoins,
rifampin, sulfinpyra>one
%ossible delayed or decreased
effectiveness with anticholinergics
%ossible reduced absorption of
acetaminophen with activated
charcoal
%ossible decreased effectiveness of
>idovudine
Drug-lab test
!nterference with #hemstrip ,
&e1trosti1, :iside1 !! home blood
glucose measurement systems0
effects vary
Nursing considerations
Assessment
.istory+ Allergy to acetaminophen,
impaired hepatic function, chronic
alcoholism, pregnancy, lactation
Physical+ S"in color, lesions0 '0 liver
evaluation0 #6#, 3?'s, renal
function tests
Interventions
&o not e1ceed the recommended
dosage.
#onsult physician if needed for
children @ . yr0 if needed for longer
than +* days0 if continued fever,
severe or recurrent pain occurs
(possible serious illness).
Avoid using multiple preparations
containing acetaminophen. #arefully
chec" all 5'# products.
ive drug with food if ! upset
occurs.
&iscontinue drug if hypersensitivity
reactions occur.
'reatment of overdose: =onitor
serum levels regularly, N-
acetylcysteine should be available as
a specific antidote0 basic life support
measures may be necessary.
Teacing points
&o not e1ceed recommended dose0
do not ta"e for longer than +* days.
'a"e the drug only for complaints
indicated0 it is not an anti-
inflammatory agent.
Avoid the use of other over-the-
counter preparations. 'hey may
contain acetaminophen, and serious
overdosage can occur. !f you need
an over-the-counter preparation,
consult your health care provider.
Report rash, unusual bleeding or
bruising, yellowing of s"in or eyes,
changes in voiding patterns.
2
Adverse effects in Italics are most common0
those in /old are life-threatening.
acyclo$ir (acyclo"uanosine)
(ay sye' "loe ver)
Alti-Acyclo$ir (CAN), A$ira, (CAN),
0o$ira,
!ru" class
Antiviral
%urine nucleoside analogue
herapeutic actions
Antiviral activity0 inhibits viral &AA replication.
#ndications
!nitial and recurrent mucosal and
cutaneous ;S: + and , and varicella
>oster infections in
immunocompromised patients
Severe initial and recurrent genital
herpes infections in selected patients
;erpes simple1 encephalitis
'reatment of neonatal herpes
simple1 virus infections
Acute treatment of herpes >oster
(shingles) and chic"enpo1
5intment: !nitial ;S: genital
infections0 limited mucocutaneous
;S: infections in
immunocompromised patients
#ream: Recurrent herpes labialis
(cold sores) in patients B +, yr
$nlabeled uses: #ytomegalovirus
and ;S: infection following
transplant, herpes simple1 infections,
varicella pneumonia, disseminated
primary ec>ema herpeticum
acyclovir, sei>ures, #;?, renal
disease, lactation.
$se cautiously with pregnancy.
A$ailable %orms
'ablets(8**, )** mg0 capsules(,** mg0
suspension(,** mg2- m30 powder for
in<ection(-** mg2vial, +,*** mg2vial0
in<ection(-* mg2m30 ointment(-* mg2g0
cream(-* mg2g
Dosages
A!&L'
%arenteral
-7+* mg2"g infused !: over + hr, 4 ) hr
(+- mg2"g2day) for C7+* days.
5ral
Initial genital herpes: ,** mg 4 8 hr
while awa"e (+,*** mg2day) for +*
days.
Long-term suppressive therapy:
8** mg bid for up to +, mo.
Acute herpes zoster: )** mg 4 8 hr
for C7+* days.
Chickenpox: )** mg 4id for - days.
P(!#A)#C PA#(N'
%arenteral
HSV inections ! "# yr: +* mg2"g infused !:
over + hr 4 ) hr for C days.
Shingles$ HSV encephalitis: ,* mg2"g !:
over + hr 4 ) hr for +* days.
Neonatal HSV: +* mg2"g infused over + hr 4
) hr for +* days.
5ral
! # yr: Safety not established.
% # yr an& ! '( kg: #( mg)kg per &ose *i&
+,( mg)kg)&ay- or . &ays/
% '( kg: $se adult dosage.
% "# yr: $se adult dosage.
G()#A)#C PA#(N' 1) PA#(N'
2#. )(NAL #MPA#)M(N
5ral
?or creatinine clearance @ +* m32min,
,** mg 4 +, hr.
!:
#reatinine #learance
(m32min)
&osage (!:)
B -* - mg2"g 4 ) hr
3
,-7-* - mg2"g 4 +, hr
+*7,- - mg2"g daily
*7+* ,.- mg2"g daily
'opical
0intment +all ages-: Apply sufficient 4uantity
to cover all lesions / times2day (4 . hr) for C
days0 +.,--cm (*.--in) ribbon of ointment
covers ,.- cm
,
(8 in
,
) surface area.
Cream +% "# yr-: Apply sufficient 4uantity to
cover all lesions - times2day for 8 days.
Pharmaco*inetics
5ral :aries +.-7,
hr
Aot
"nown
!: !mmediate + hr ) hr
'opical Absorption
is minimal
Metabolism+ '
+2,
: ,.-7- hr
breast mil"
(,cretion+ $nchanged in urine
IV acts
Preparation+ Reconstitute -** mg vial in +*
m3 sterile water for in<ection or bacteriostatic
water for in<ection containing ben>yl alcohol,
+,*** mg vial in ,* m30 concentration will be
-* mg2m3. &o not dilute drug with
bacteriostatic water containing parabens.
$se reconstituted solution within +, hr0 dilute
!: solution to concentration of C mg2m3 or
less. &o not use biologic or colloidal fluids
such as blood products or protein solutions.
Darm drug to room temperature to dissolve
precipitates formed during refrigeration.
#n%usion+ Administer by slow !: infusion of
parenteral solutions0 avoid bolus or rapid
in<ection. !nfuse over at least + hr to avoid
renal damage.
#ncompatibilities+ &o not mi1 with diltia>em,
dobutamine, dopamine, fludarabine,
foscarnet, idarubicin, meperidine, morphine,
ondansetron, piperacillin, sargramostim,
vinorelbine.
Ad$erse e%%ects
Systemic administration
CN'+ ;eadache, vertigo,
depression, tremors,
encephalopathic changes
!ermatolo"ic+ !nflammation or
phlebitis at in<ection sites, rash, hair
loss
G#+ Nausea$ vomiting$ diarrhea,
anore1ia
G&+ #rystalluria with rapid !:
administration, hematuria
'opical administration
!ermatolo"ic+ 'ransient burning at
site of application
#nteractions
Drug-drug
!ncreased effects with probenecid
!ncreased nephroto1icity with other
nephroto1ic drugs
E1treme drowsiness with >idovudine
Assessment
.istory+ Allergy to acyclovir,
sei>ures, #;?, renal disease,
lactation, pregnancy
Physical+ S"in color, lesions0
orientation0 6%, %, auscultation,
perfusion, edema0 R, adventitious
sounds0 urinary output0 6$A,
creatinine clearance
Interventions
Ensure that the patient is well
hydrated.
Start treatment as soon as possible
after onset of signs and symptoms.
Dear a rubber glove or finger cot
when applying drug.
Teacing points
4
#omplete the full course of oral
therapy, and do not e1ceed the
prescribed dose.
5ral acyclovir is not a cure for your
disease but should ma"e you feel
better.
Avoid se1ual intercourse while
visible lesions are present.
Fou may e1perience these side
effects: Aausea, vomiting, loss of
appetite, diarrhea0 headache,
di>>iness.
Report difficulty urinating, rash,
increased severity or fre4uency of
recurrences.
Dear rubber gloves or finger cots
when applying the drug to prevent
autoinoculation of other sites and
transmission to others.
'his drug does not cure the disease0
application during symptom-free
periods will not prevent recurrences.
Avoid se1ual intercourse while
visible lesions are present.
'his drug may cause burning,
stinging, itching, rash0 notify your
physician if these are pronounced.
Adverse effects in Italic are most common0
albuterol sul%ate
(al byoo' ter ole)
AccuNeb, No$o-'almol (CAN), Pro$entil,
Pro$entil .3A, 'albutamol (CAN),
-entodis* (CAN), -entolin .3A
Pregnancy Category C
!ru" classes
Sympathomimetic
6eta
,
-selective adrenergic agonist
6ronchodilator
Antasthmatic
herapeutic actions
!n low doses, acts relatively selectively at
beta
,
-adrenergic receptors to cause
bronchodilation and vasodilation0 at higher
doses, beta
,
selectivity is lost, and the drug
acts at beta
,
receptors to cause typical
sympathomimetic cardiac effects.
#ndications
Relief and prevention of
bronchospasm in patients with
reversible obstructive airway disease
!nhalation: 'reatment of acute
attac"s of bronchospasm
%revention of e1ercise-induced
bronchospasm
$nlabeled use: Ad<unct in treating
serious hyper"alemia in dialysis
patients0 seems to lower potassium
concentrations when inhaled by
patients on hemodialysis
#ontraindicated with hypersensitivity
to albuterol0 tachyarrhythmias,
tachycardia caused by digitalis
into1ication0 general anesthesia with
halogenated hydrocarbons or
cyclopropane (these sensiti>e the
myocardium to catecholamines)0
unstable vasomotor system
disorders0 hypertension0 coronary
insufficiency, #A&0 history of stro"e0
#5%& patients with degenerative
heart disease.
$se cautiously with diabetes mellitus
(large !: doses can aggravate
diabetes and "etoacidosis)0
hyperthyroidism0 history of sei>ure
disorders0 psychoneurotic
individuals0 labor and delivery (oral
use has delayed second stage of
labor0 parenteral use of beta
,
-
adrenergic agonists can accelerate
5
fetal heart beat and cause
hypoglycemia, hypo"alemia,
pulmonary edema in the mother and
hypoglycemia in the neonate)0
lactation0 the elderly (more sensitive
to #AS effects).
A$ailable %orms
'ablets(,, 8 mg0 syrup(, mg2- m30 aerosol
(9* mcg2actuation0 solution for inhalation(
*.*).G, *.-G, +.,- mg2. m3, *./. mg2. m30
capsules for inhalation(,** mcg
Dosages
A!&L'
5ral
!nitially, , or 8 mg (+7, tsp syrup) tid74id %50
may cautiously increase dosage if necessary
to 8 or ) mg 4id, not to e1ceed ., mg2day.
!nhalation
Each actuation of aerosol dispenser delivers
9* mcg albuterol0 , inhalations 4 87/ hr0
some patients may re4uire only + inhalation
4 8 hr0 more fre4uent administration or larger
number of inhalations not recommended.
1revention o exercise-in&uce&
2ronchospasm: , inhalations +- min
prior to e1ercise.
Solution for inhalation
,.- mg tid to 4id by nebuli>ation.
!nhalation capsules
5ne ,** mcg capsule 4 87/ hr up to two
,** mcg capsules 4 87/ hr.
asthma: 5ne ,** mcg capsule
inhaled +- min before e1ercise.
P(!#A)#C PA#(N'
5ral, tablets
34"# yr: , mg tid74id. &o not e1ceed
,8 mg2day.
5ral, syrup
! # yr: Safety and efficacy not established.
#43 yr: !nitially, *.+ mg2"g tid, not to e1ceed
, mg (+ tsp) tid0 if necessary, cautiously
increase stepwise to *., mg2"g tid. &o not
e1ceed 8 mg (, tsp) tid.
34"' yr: , mg (+ tsp) tid74id0 if necessary,
cautiously increase dosage. &o not e1ceed
,8 mg2day in divided doses.
% "' yr: $se adult dosage.
!nhalation
#4"# yr: ?or child +*7+- "g, use +.,- mg0 for
child B +- "g, use ,.- mg.
Solution for inhalation
"(4". kg: +.,- mg bid or tid by nebuli>ation.
% ". kg: ,.- mg bid or tid by nebuli>ation.
!nhalation capsules
% ' yr: 5ne ,** mcg capsule inhaled 4 87
/ hr.
asthma: 5ne ,** mcg capsule
inhaled +- min before e1ercise.
G()#A)#C PA#(N' 1) PA#(N'
'(N'##-( 1 /(A-A!)(N()G#C
'#M&LA#1N
Restrict initial dose to , mg tid or 4id0
individuali>e dosage thereafter. %atients B /*
yr are more li"ely to develop adverse effects.
Pharmaco*inetics
5ral .* min ,7,.- hr 87) hr
!nhalation - min +.-7, hr .7) hr
+2,
: ,78 hr
breast mil"
(,cretion+ $rine
Ad$erse e%%ects
CN'+ 5estlessness$ apprehension$
anxiety$ ear$ CNS stimulation$
hyper"inesia, insomnia, tremor,
drowsiness, irritability, wea"ness,
vertigo, headache
C-+ Car&iac arrhythmias$
tachycardia, palpitations, %:#s
(rare), anginal pain
6
!ermatolo"ic+ S6eating$ pallor$
lushing
G#+ Nausea, vomiting, heartburn,
unusual or bad taste in mouth
G&+ !ncreased incidence of
leiomyomas of uterus when given in
higher than human doses in
preclinical studies
)espiratory+ Respiratory difficulties,
pulmonary edema, coughing,
bronchospasm, parado1ical airway
resistance with repeated, e1cessive
use of inhalation preparations
#nteractions
Drug-drug
!ncreased sympathomimetic effects
with other sympathomimetic drugs
!ncreased ris" of to1icity, especially
cardiac, when used with
theophylline, aminophylline,
o1triphylline
&ecreased bronchodilating effects
with beta-adrenergic bloc"ers (eg,
propranolol)
&ecreased effectiveness of insulin,
oral hypoglycemic drugs
&ecreased serum levels and
therapeutic effects of digo1in
Assessment
.istory+ ;ypersensitivity to
albuterol0 tachyarrhythmias,
tachycardia caused by digitalis
into1ication0 general anesthesia with
halogenated hydrocarbons or
cyclopropane0 unstable vasomotor
system disorders0 hypertension0
coronary insufficiency, #A&0 history
of stro"e0 #5%& patients who have
developed degenerative heart
disease0 diabetes mellitus0
hyperthyroidism0 history of sei>ure
disorders0 psychoneurotic
individuals0 lactation
Physical+ Deight0 s"in color, ',
turgor0 orientation, refle1es, affect0 %,
6%0 R, adventitious sounds0 blood
and urine glucose, serum
electrolytes, thyroid function tests,
E#
Interventions
$se minimal doses for minimal
periods0 drug tolerance can occur
with prolonged use.
=aintain a beta-adrenergic bloc"er
(cardioselective beta-bloc"er, such
as atenolol, should be used with
respiratory distress) on standby in
case cardiac arrhythmias occur.
%repare solution for inhalation by
diluting *.- m3 *.-G solution with
,.- m3 normal saline0 deliver over -7
+- min by nebuli>ation.
&o not e1ceed recommended
dosage0 administer pressuri>ed
inhalation drug forms during second
half of inspiration, because the
airways are open wider and the
aerosol distribution is more
e1tensive.
Teacing points
&o not e1ceed recommended
dosage0 adverse effects or loss of
effectiveness may result. Read the
instructions that come with
respiratory inhalant.
effects: &i>>iness, drowsiness,
fatigue, headache (use caution if
driving or performing tas"s that
re4uire alertness)0 nausea, vomiting,
change in taste (eat fre4uent small
meals)0 rapid heart rate, an1iety,
sweating, flushing, insomnia.
7
Report chest pain, di>>iness,
insomnia, wea"ness, tremors or
irregular heart beat, difficulty
breathing, productive cough, failure
to respond to usual dosage.
alendronate sodium
(ah len' dro nate)
3osama,
!ru" classes
6isphosphonate
#alcium regulator
herapeutic actions
Slows normal and abnormal bone resorption
without inhibiting bone formation and
minerali>ation.
#ndications
'reatment and prevention of
osteoporosis in postmenopausal
women
'reatment of men with osteoporosis
'reatment of glucocorticoid-induced
osteoporosis
'reatment of %agetHs disease of
bone in patients with al"aline
phosphatase at least two times
upper limit of normal, those who are
symptomatic, those at ris" for future
complications
biphosphonates0 hypocalcemia.
$se cautiously with renal
dysfunction, upper ! disease,
pregnancy, lactation.
A$ailable %orms
'ablets(-, +*, .-, 8*, C* mg0 oral solution(
C* mg
Dosages
A!&L'
1ostmenopausal osteoporosis:
+* mg2day %5 in A= with full glass
of water, at least .* min before the
first beverage, food, or medication of
the day, or C* mg %5 once a wee"
or one bottle of C*-mg oral solution
once a wee". Avoid lying down for .*
min after ta"ing drug.
7ales 6ith osteoporosis: +* mg2day
%5 or C*-mg tablet or one bottle C*-
mg oral solution once a wee".
1revention o osteoporosis:
- mg2day %5 or .- mg %5 once a
wee".
1aget8s &isease: 8* mg2day %5 in
A= with full glass of water, at least
.* min before the first beverage,
food, or medication of the day for /
mo0 may retreat after /-mo
treatment-free period.
9lucocorticoi&-in&uce&
osteoporosis: - mg2day %5 with
calcium and vitamin &0 +* mg2day
%5 for postmenopausal women not
on estrogen.
P(!#A)#C PA#(N'
Safety and efficacy not established.
PA#(N' 2#. )(NAL #MPA#)M(N
&osage ad<ustment not necessary for
creatinine clearance .-7/* m32min0 not
recommended if creatinine clearance @
.- m32min.
Pharmaco*inetics
Route 5nset &uration
5ral Slow &ays
Metabolism+ Aot metaboli>ed0 '
+2,
: =ore
than +* yr
!istribution+ #rosses placenta0 may enter
breast mil"
8
(,cretion+ $rine
Ad$erse e%%ects
CN'+ Hea&ache
G#+ Nausea$ &iarrhea$ 9I irritation$
pain$ esophageal erosion
'*eletal+ Increase& or recurrent
2one pain$ focal osteomalacia
#nteractions
Drug-drug
!ncreased ris" of ! distress with
aspirin
&ecreased absorption if ta"en with
antacids, calcium, iron, multivalent
cations0 separate dosing by at least
.* min
Drug-!ood
Significantly decreased absorption
and serum levels if ta"en with food0
separate dosing from food and
beverage by at least .* min
CL#N#CAL AL()4
Name con!usion as occurred bet"een
#osama$ %alendronate& and #loma$
%tamsulosin&' use caution(
Assessment
.istory+ Allergy to bisphosphonates,
renal failure, upper ! disease,
Physical+ =uscle tone, bone pain0
bowel sounds0 urinalysis, serum
calcium
Interventions
2A)N#NG+ ive in A= with full
glass of water at least .* min before
the first beverage, food, or
medication of the day. %atient must
stay upright for .* min to decrease
ris" of potentially serious esophageal
erosion.
=onitor serum calcium levels before,
during, and after therapy.
Ensure /-mo rest period after
treatment for %agetHs disease if
retreatment is re4uired.
Ensure ade4uate vitamin & and
calcium inta"e.
%rovide comfort measures if bone
pain returns.
Teacing points
'a"e drug in morning with a full glass
of plain water (not mineral water), at
least .* minutes before any
beverage, food, or medication, and
stay upright for .* minutes and until
after the first food of the day0 mar"
calendar for once wee"ly dosing.
effects: Aausea, diarrhea0 bone pain,
headache (analgesic may help).
Report twitching, muscle spasms,
dar"-colored urine, severe diarrhea,
difficulty swallowing.
allopurinol
(al oh pure' i nole)
Aloprim, Apo-Allopurinol (CAN), Purinol
(CAN), 0yloprim
!ru" class
Antigout drug
herapeutic actions
!nhibits the en>yme responsible for the
conversion of purines to uric acid, thus
reducing the production of uric acid with a
decrease in serum and sometimes in urinary
uric acid levels, relieving the signs and
symptoms of gout
9
#ndications
=anagement of the signs and
symptoms of primary and secondary
gout
=anagement of patients with
malignancies that result in elevations
of serum and urinary uric acid
=anagement of patients with
recurrent calcium o1alate calculi
whose daily uric acid e1cretion
e1ceeds )** mg2day (males) or
C-* mg2day (females)
5rphan drug use: 'reatment of
#hagasH disease0 cutaneous and
visceral leishmaniasis
$nlabeled uses: Amelioration of
granulocyte suppression with
fluorouracil0 as a mouthwash to
prevent fluorouracil-induced
stomatitis
allopurinol, blood dyscrasias.
$se cautiously with liver disease,
renal failure, lactation, pregnancy.
A$ailable %orms
'ablets(+**, .** mg0 powder for in<ection(
-** mg
Dosages
A!&L'
9out an& hyperuricemia: +**7
)** mg2day %5 in divided doses,
depending on the severity of the
disease (,**7.** mg2day is usual
dose).
7aintenance: Establish dose that
maintains serum uric acid levels
within normal limits.
1revention o acute gouty attacks:
+** mg2day %50 increase the dose
by +** mg at wee"ly intervals until
uric acid levels are @ / mg2d3.
1revention o uric aci& nephropathy
in certain malignancies: /**7
)** mg2day %5 for ,7. days with a
high fluid inta"e0 maintenance dose
should then be established as
above.
5ecurrent calcium oxalate stones:
,**7.** mg2day %50 ad<ust dose
based on ,8-hr urinary urate
determinations.
1arenteral: ,**78** mg2m
,
2day !: to
ma1imum of /** mg2day as
continuous infusion or at /, ), +, hr
intervals.
P(!#A)#C PA#(N'
Secon&ary hyperuricemia
associate& 6ith various
malignancies:
34"( yr: .** mg2day %5.
! 3 yr: +-* mg2day0 ad<ust dosage
after 8) hr of treatment based on
serum uric acid levels.
1arenteral: ,** mg2m
,
2day !: as
continuous infusion or at /, ), +, hr
intervals.
G()#A)#C PA#(N' 1) PA#(N'
2#. )(NAL #MPA#)M(N
?or geriatric patients or patients with
creatinine clearance +*7,* m32min,
,** mg2day0 for creatinine clearance @ +*
m32min, +** mg2day0 for creatinine clearance
@ . m32min, e1tend intervals between doses
based on patientHs serum uric acid levels.
Pharmaco*inetics
Route 5nset %ea"
5ral Slow +7, hr
!: +*7+- min .* min
+2,
: +7+.- hr, then ,.7
,8 hr
breast mil"
(,cretion+ $rine
IV acts
10
Preparation+ &issolve contents of each vial
with ,- ml of sterile water for in<ection.
?urther dilute with ASS or &
-
D to final
concentration of @ / mg2ml. Administer within
+* hr of reconstitution.
#n%usion+ Administer as a continuous
infusion or infused 4 /, ), or +, hr with rate
dependent on volume used.
#ncompatibilities+ !ncompatible with many
other drugs0 do not mi1 with any other drug in
same solution.
Ad$erse e%%ects
CN'+ Hea&ache$ &ro6siness$
peripheral neuropathy, neuritis,
paresthesias
!ermatolo"ic+ )ashes5
maculopapular, scaly or
e,%oliati$e5sometimes %atal
G#+ Nausea$ vomiting$ &iarrhea$
abdominal pain, gastritis,
hepatomegaly, hyperbilirubinemia,
cholestatic <aundice
G&+ E1acerbation of gout and renal
calculi, renal failure
.ematolo"ic+ Anemia, leu"openia,
agranulocytosis, thrombocytopenia,
aplastic anemia, bone marrow
depression
#nteractions
Drug-drug
!ncreased ris" of hypersensitivity
reaction with A#E inhibitors
!ncreased to1icity with thia>ide
diuretics
!ncreased ris" of rash with ampicillin
!ncreased ris" of bone marrow
suppression with cyclophosphamide,
other cytoto1ic agents
!ncreased half-life of oral
anticoagulants
!ncreased serum levels of
theophylline
!ncreased ris" of to1ic effects with
thiopurines, /-=% (a>athioprine dose
and dose of /-=% should be reduced
to one-third to one-fourth the usual
dose)
Assessment
.istory+ Allergy to allopurinol, blood
dyscrasias, liver disease, renal
failure, lactation
Physical+ S"in lesions, color0
orientation, refle1es0 liver evaluation,
normal urinary output0 normal output0
#6#, 3?'s, renal function tests,
urinalysis
Interventions
Administer drug following meals.
Encourage patient to drin" ,.- to .
32day to decrease the ris" of renal
stone development.
#hec" urine al"alinity(urates
crystalli>e in acid urine0 sodium
bicarbonate or potassium citrate may
be ordered to al"alini>e urine.
2A)N#NG+ &iscontinue drug at first
sign of s"in rash0 severe to fatal s"in
reactions have occurred.
Arrange for regular medical follow-up
and blood tests.
Teacing points
'a"e the drug after meals.
Avoid over-the-counter medications.
=any of these preparations contain
vitamin # or other agents that might
increase the li"elihood of "idney
stone formation. !f you need an over-
the-counter preparation, chec" with
your health care provider.
effects: E1acerbation of gouty attac"
or renal stones (drin" plenty (,.-7
. 32day(of fluids while on this drug)0
11
nausea, vomiting, loss of appetite
(ta"e after meals or eat fre4uent
small meals)0 drowsiness (use
caution while driving or performing
ha>ardous tas"s).
Report unusual bleeding or bruising0
fever, chills0 gout attac"0 numbness
or tingling0 flan" pain, s"in rash.
alpra6olam
(al prah' >oe lam)
Alpra6olam #ntensol, Apo-Alpra6 (CAN),
Nira$am, No$o-Alpra6ol (CAN), Nu-Alpra6
(CAN), 7ana,, 7ana, ' (CAN), 7ana, 7)
Pregnancy Category D
Controlled Substance C-I)
!ru" classes
6en>odia>epine
An1iolytic
herapeutic actions
E1act mechanisms of action not understood0
main sites of action may be the limbic system
and reticular formation0 increases the effects
of gamma-aminobutyrate, an inhibitory
neurotransmitter0 an1iety bloc"ing effects
occur at doses well below those necessary to
cause sedation, ata1ia.
#ndications
=anagement of an1iety disorders,
short-term relief of symptoms of
an1iety0 an1iety associated with
depression.
'reatment of panic attac"s with or
without agoraphobia
$nlabeled uses: Social phobia,
premenstrual syndrome, depression
to ben>odia>epines, psychoses,
acute narrow-angle glaucoma,
shoc", coma, acute alcoholic
into1ication with depression of vital
signs, pregnancy (crosses the
placenta0 ris" of congenital
malformations, neonatal withdrawal
syndrome), labor and delivery
(Ifloppy infantI syndrome), lactation
(secreted in breast mil"0 infants
become lethargic and lose weight).
$se cautiously with impaired liver or
"idney function, debilitation.
A$ailable %orms
'ablets(*.,-, *.-, +, , mg0 JR tablets(*.-,
+, ,, . mg0 intensol solution(+ mg2m30
rapidly disintegrating tablets(*.,-, *.-, +,
, mg
Dosages
!ndividuali>e dosage0 increase dosage
gradually to avoid adverse effects.
A!&L'
Anxiety &isor&ers: !nitially, *.,-7
*.- mg %5 tid0 ad<ust to ma1imum
daily dose of 8 mg2day in divided
doses or ER form once per day in
the A= once dosage is established
(immediate release, intensol
solution).
1anic &isor&er: !nitially, *.- mg %5
tid0 increase dose at .- to 8-day
intervals in increments of no more
than + mg2day0 ranges of +7
+* mg2day have been needed0 ER
form once per day in A= once
dosage is established (:anax
products, Niravam).
&NLA/(L(! &'('
Social pho2ia: ,7) mg2day %5.
1remenstrual syn&rome: *.,- mg
%5 tid.
G()#A)#C PA#(N' 1) PA#(N'
2#. !(/#L#A#NG !#'(A'(
12
!nitially, *.,- mg bid7tid %50 gradually
increase if needed and tolerated0 ER tablets
(*.- mg %5 once each day
Pharmaco*inetics
5ral .* min +7, hr 87/ hr
+2,
: /..7,/.9 hr
breast mil"
(,cretion+ $rine
Ad$erse e%%ects
CN'+ ;ransient$ mil& &ro6siness
initially< se&ation$ &epression$
lethargy$ apathy$ atigue$ light-
hea&e&ness$ &isorientation$ anger$
hostility$ episodes of mania and
hypomania, restlessness$ conusion$
crying$ delirium, hea&ache$ slurred
speech, dysarthria, stupor, rigidity,
tremor, dystonia, vertigo, euphoria,
nervousness, difficulty in
concentration, vivid dreams,
psychomotor retardation,
e1trapyramidal symptoms0 mil&
para&oxical excitatory reactions
&uring irst # 6k o treatment
C-+ 6radycardia, tachycardia, #:
collapse, hypertension, hypotension,
palpitations, edema
!ermatolo"ic+ $rticaria, pruritus,
rash, dermatitis
((N+ :isual and auditory
disturbances, diplopia, nystagmus,
depressed hearing, nasal congestion
G#+ Constipation$ &iarrhea$ &ry
mouth$ salivation, nausea$ anore1ia,
vomiting, difficulty in swallowing,
gastric disorders, hepatic dysfunction
G&+ !ncontinence, changes in libido,
urinary retention, menstrual
irregularities
.ematolo"ic+ Elevations of blood
en>ymes(3&;, al"aline
phosphatase, AS', A3'0 blood
dyscrasias(agranulocytosis,
leu"openia
1ther+ ;iccups, fever, diaphoresis,
paresthesias, muscular
disturbances, gynecomastia. =rug
&epen&ence 6ith 6ith&ra6al
syn&rome 6hen &rug is
&iscontinue&< more common 6ith
a2rupt &iscontinuation o higher
&osage use& or longer than ' mo
#nteractions
Drug-drug
!ncreased #AS depression with
alcohol, other #AS depressants,
propo1yphene
!ncreased effect with cimetidine,
disulfiram, omepra>ole, isonia>id,
hormonal contraceptives, valproic
acid
&ecreased effect with
carbama>epine, rifampin,
theophylline
%ossible increased ris" of digitalis
to1icity with digo1in
&ecreased antipar"inson
effectiveness of levodopa with
ben>odia>epines
#ontraindicated with "etocona>ole,
itracona>ole0 serious to1icity can
occur
Drug-!ood
&ecreased metabolism and ris" of
to1ic effects if combined with
grapefruit <uice0 avoid this
combination
Drug-alternative terapy
Ris" of coma if combined with "ava
therapy
Additive sedative effects with
valerian root
13
CL#N#CAL AL()4
Name con!usion as occurred among
*ana$ %alpra+olam&, Cele$a %citalopram&,
and Cereby$ %!ospenytoin&, and bet"een
alpra+olam and lora+epam' use caution(
Assessment
ben>odia>epines0 psychoses0 acute
narrow-angle glaucoma0 shoc"0
coma0 acute alcoholic into1ication
with depression of vital signs0 labor
and delivery0 lactation0 impaired liver
or "idney function0 debilitation
Physical+ S"in color, lesions0 '0
orientation, refle1es, affect,
ophthalmologic e1amination0 %, 6%0
liver evaluation, abdominal
e1amination, bowel sounds, normal
output0 #6#, 3?'s, renal function
tests
Interventions
Arrange to taper dosage gradually
after long-term therapy, especially in
epileptic patients.
&o not administer with grapefruit
<uice.
'aper drug slowly0 decrease by no
more than *.- mg every . days.
Teacing points
'a"e this drug e1actly as prescribed0
ta"e e1tended-release form once a
day in the A=0 place rapidly
disintegrating tablet on top of tongue,
where it will disintegrate and can be
swallowed with saliva.
&o not drin" grapefruit <uice while on
this drug.
&o not stop ta"ing drug (in long-term
therapy) without consulting health
care provider.
Avoid alcohol, sleep-inducing, or
over-the-counter drugs.
effects: &rowsiness, di>>iness (these
effects will be less pronounced after
a few days, avoid driving a car or
engaging in other dangerous
activities if these occur)0 ! upset
(ta"e drug with food)0 fatigue0
depression0 dreams0 crying0
nervousness.
Report severe di>>iness, wea"ness,
drowsiness that persists, rash or s"in
lesions, difficulty voiding,
palpitations, swelling in the
e1tremities.
aminophylline (theophylline
ethylenediamine)
(am in o%%' i lin)
ruphylline
!ru" classes
6ronchodilator
Janthine
herapeutic actions
Rela1es bronchial smooth muscle, causing
bronchodilation and increasing vital capacity,
which has been impaired by bronchospasm
and air trapping0 in higher concentrations, it
also inhibits the release of slow-reacting
substance of anaphyla1is (SRS-A) and
histamine.
#ndications
Symptomatic relief or prevention of
bronchial asthma and reversible
bronchospasm associated with
chronic bronchitis and emphysema
14
$nlabeled uses: Respiratory
stimulant in #heyne-Sto"es
respiration0 treatment of apnea and
bradycardia in premature babies
to any 1anthine or to
ethylenediamine, peptic ulcer, active
gastritis0 rectal or colonic irritation or
infection (use rectal preparations).
$se cautiously with cardiac
arrhythmias, acute myocardial in<ury,
#;?, cor pulmonale, severe
hypertension, severe hypo1emia,
renal or hepatic disease,
hyperthyroidism, alcoholism, labor,
lactation, pregnancy.
A$ailable %orms
'ablets(+**, ,** mg0 li4uid(+*- mg2- m30
in<ection(,-* mg2+* m30 suppositories(
,-*, -** mg
Dosages
!ndividuali>e dosage: 6ase ad<ustments on
clinical responses0 monitor serum
theophylline levels0 maintain therapeutic
range of +*7,* mcg2m30 base dosage on
lean body mass0 +,C mg aminophylline
dihydrate K +** mg theophylline anhydrous.
A!&L'
5ral
Acute symptoms re*uiring rapi&
theophyllinization in patients not
receiving theophylline: An initial
loading dose is re4uired, as
indicated below:
%atient
roup
3oadin
g
?ollowe
d by
=aintenanc
e
Foung
adult
smo"ers
/ mg2"
g
. mg2"g
4 8 hr L
. doses
. mg2"g 4
/ hr
Adult
nonsmo"e
/ mg2"
g
. mg2"g
4 / hr L
. mg2"g 4
) hr
rs who are
otherwise
healthy
, doses
Long-term therapy: $sual range is
/**7+,/** mg2day %5 in three to
four divided doses.
Rectal
-** mg 4 /7) hr by rectal suppository or
retention enema.
P(!#A)#C PA#(N'
#hildren are very sensitive to #AS stimulant
action of theophylline0 use caution in younger
children who cannot complain of minor side
effects.
! 3 mo: Aot recommended.
! 3 yr: $se of timed-release products
not recommended.
5ral
Acute therapy: ?or acute symptoms
re4uiring rapid theophyllini>ation in
patients not receiving theophylline, a
loading dose is re4uired. &osage
recommendations are as follows:
%atient
roup
3oadin
g
?ollowe
d by
=aintenanc
e
#hildre
n / mo7
9 yr
/ mg2"
g
8 mg2"g
4 8 hr L
. doses
8 mg2"g 4 /
hr
#hildre
n 97+/
yr
/ mg2"
g
. mg2"g
4 8 hr L
. doses
. mg2"g 4 /
hr
Long-term therapy: +, mg2"g per ,8
hr %50 slow clinical ad<ustment of the
oral preparations is preferred0
monitor clinical response and serum
theophylline levels. !n the absence of
serum levels, ad<ust up to the
ma1imum dosage shown below,
providing the dosage is tolerated.
Age =a1imum &aily &ose
@ 9 yr .*.8 mg2"g2day
15
97+, yr ,-.. mg2"g2day
+,7+/ yr ,,.) mg2"g2day
B +/ yr +/.- mg2"g2day or
+,+** mg, whichever
is less
G()#A)#C PA#(N' 1) #MPA#)(!
A!&L'
$se caution, especially in elderly men and in
patients with cor pulmonale, #;?, liver
disease (half-life of aminophylline may be
mar"edly prolonged in #;?, liver disease).
5ral
Acute therapy: ?or acute symptoms
re4uiring rapid theophyllini>ation in
patients not receiving theophylline, a
loading dose is necessary as follows:
%atient
roup
3oadin
g
?ollowe
d by
=aintenanc
e
5lder
patients
and cor
pulmonal
e
/ mg2"
g
, mg2"g
4 / hr L
, doses
, mg2"g 4 )
hr
#;? / mg2"
g
, mg2"g
4 ) hr L
, doses
+7, mg2"g
4 +, hr
Pharmaco*inetics
5ral +7/ hr 87/ hr /7) hr
!: !mmediate .* min 87) hr
+2,
: .7+- hr
breast mil"
(,cretion+ $rine
IV acts
Preparation+ =ay be infused in +**7,** m3
of -G de1trose in<ection or *.9G sodium
chloride in<ection.
#n%usion+ &o not e1ceed ,- mg2min infusion
rate. Substitute oral therapy or !: therapy as
soon as possible0 administer maintenance
infusions in a large volume to deliver the
desired amount of drug each hour.
Adult+ / mg2"g. ?or acute symptoms
re4uiring rapid theophyllini>ation in patients
receiving theophylline: a loading dose is
re4uired. Each *./ mg2"g !: administered as
a loading dose will result in about a +
mcg2m3 increase in serum theophylline.
!deally, defer loading dose until serum
theophylline determination is made0
otherwise, base loading dose on clinical
<udgment and the "nowledge that .., mg2"g
aminophylline will increase serum
theophylline levels by about - mcg2m3 and is
unli"ely to cause dangerous adverse effects
if the patient is not e1periencing theophylline
to1icity before this dose. Aminophylline !:
maintenance infusion rates (mg2"g2hr) are
given below:
%atient roup ?irst +, hr 6eyond +,
hr
Foung adult
smo"ers
+ *.)
Adult
nonsmo"ers who
are otherwise
healthy
*.C *.-
Pediatric+ After an !: loading dose, these
maintenance rates (mg2"g2hr) are
recommended:
hr
#hildren / mo79
yr
+., +
#hildren 97+/ yr + *.)
Geriatric+ After a loading dose, these
maintenance infusion rates (mg2"g2hr) are
recommended:
hr
5ther patients, *./ *..
16
cor pulmonale
#;?, liver
disease
*.- *.+7*.,
Compatibility+ Aminophylline is compatible
with most !: solutions, but do not mi1 in
solution with other drugs, including vitamins.
8-site incompatibility+ &obutamine,
hydrala>ine, ondansetron.
Ad$erse e%%ects
'erum theophylline le$els 9 :;
mc"<mL+ Adverse effects
uncommon
'erum theophylline le$els = :;>:?
mc"<mL+ Aausea, vomiting,
diarrhea, headache, insomnia,
irritability (C-G of patients)
'erum theophylline le$els = @;>@?
mc"<mL+ ;yperglycemia,
hypotension, cardiac arrhythmias,
tachycardia (B +* mcg2m3 in
premature newborns)0 sei6ures,
brain dama"e
CN'+ !rritability (especially children)0
restlessness, di>>iness, muscle
twitching, sei>ures, severe
depression, stammering speech0
abnormal behavior characteri>ed by
withdrawal, mutism, and
unresponsiveness alternating with
hyperactive periods
C-+ %alpitations, sinus tachycardia,
ventricular tachycardia, life-
threatening ventricular arrhythmias,
circulatory failure
G#+ 3oss of appetite, hematemesis,
epigastric pain, gastroesophageal
reflu1 during sleep, increased AS'
G&+ %roteinuria, increased e1cretion
of renal tubular cells and R6#s0
diuresis (dehydration), urinary
retention in men with prostate
enlargement
)espiratory+ 'achypnea, respiratory
arrest
1ther+ ?ever, flushing,
hyperglycemia, S!A&;, rash
#nteractions
Drug-drug
!ncreased effects with cimetidine,
erythromycin, troleandomycin,
clindamycin, lincomycin, influen>a
virus vaccine, fluoro4uinolones,
hormonal contraceptives
%ossibly increased effects with
thiabenda>ole, rifampin, allopurinol
!ncreased cardiac to1icity with
halothane0 increased li"elihood of
sei>ures when given with "etamine0
increased li"elihood of adverse !
effects when given with tetracyclines
!ncreased or decreased effects with
furosemide, levothyro1ine,
liothyronine, liotri1, thyroglobulin,
thyroid hormones
&ecreased effects in patients who
are cigarette smo"ers (+7, pac"s
per day)0 theophylline dosage may
need to be increased -*G7+**G
&ecreased effects with
phenobarbital, aminoglutethimide
!ncreased effects, to1icity of
sympathomimetics (especially
ephedrine) with theophylline
preparations
&ecreased effects of phenytoin and
theophylline preparations when
given concomitantly
&ecreased effects of lithium
carbonate, nondepolari>ing
neuromuscular bloc"ers given with
theophylline preparations
=utually antagonistic effects of beta-
bloc"ers and theophylline
preparations
17
Drug-!ood
Elimination is increased by a low-
carbohydrate, high-protein diet and
by charcoal-broiled beef
Elimination is decreased by a high-
carbohydrate, low-protein diet
?ood may alter bioavailability and
absorption of timed-release
theophylline preparations, causing
to1icity0 these forms should be ta"en
on an empty stomach
Drug-lab test
!nterference with spectrophotometric
determinations of serum theophylline
levels by furosemide,
phenylbuta>one, probenecid,
theobromine0 coffee, tea, cola
beverages, chocolate,
acetaminophen cause falsely high
values
Alteration in assays of uric acid,
urinary catecholamines, plasma free
fatty acids by theophylline
preparations
Assessment
.istory+ ;ypersensitivity to any
1anthine or to ethylenediamine,
peptic ulcer, active gastritis, cardiac
arrhythmias, acute myocardial in<ury,
#;?, cor pulmonale, severe
hypertension, severe hypo1emia,
renal or hepatic disease,
hyperthyroidism, alcoholism, labor,
lactation, rectal or colonic irritation or
infection (aminophylline rectal
preparations)
Physical+ 6owel sounds, normal
output0 %, auscultation, 6%,
perfusion, E#0 R, adventitious
sounds0 fre4uency of urination,
voiding, normal output pattern,
urinalysis, 3?'s, renal function tests0
liver palpation0 thyroid function tests0
s"in color, te1ture, lesions0 refle1es,
bilateral grip strength, affect, EE
Interventions
Administer to pregnant patients only
when clearly needed(neonatal
tachycardia, <itteriness, and
withdrawal apnea observed when
mothers received 1anthines up until
delivery.
#aution patient not to chew or crush
enteric-coated timed-release forms.
ive immediate-release, li4uid
dosage forms with food if ! effects
occur.
&o not give timed-release forms with
food0 these should be given on an
empty stomach + hr before or , hr
after meals.
=aintain ade4uate hydration.
=onitor results of serum theophylline
levels carefully, and arrange for
reduced dosage if serum levels
e1ceed therapeutic range of +*7,*
mcg2m3.
'a"e serum samples to determine
pea" theophylline concentration
drawn +-7.* min after an !: loading
dose.
=onitor for clinical signs of adverse
effects, particularly if serum
theophylline levels are not available.
Ensure that dia>epam is readily
available to treat sei>ures.
Teacing points
'a"e this drug e1actly as prescribed0
if a timed-release product is
prescribed, ta"e this drug on an
empty stomach, + hour before or ,
hours after meals.
&o not to chew or crush timed-
release preparations.
18
Administer rectal solution or
suppositories after emptying the
rectum.
!t may be necessary to ta"e this drug
around-the-cloc" for ade4uate
control of asthma attac"s.
Avoid e1cessive inta"e of coffee, tea,
cocoa, cola beverages, and
chocolate.
Smo"ing cigarettes or other tobacco
products impacts the drugHs
effectiveness. 'ry not to smo"e.
Aotify your health care provider if
smo"ing habits change while ta"ing
this drug.
?re4uent blood tests may be
necessary to monitor the effect of
this drug and to ensure safe and
effective dosage0 "eep all
appointments for blood tests and
other monitoring.
effects: Aausea, loss of appetite
(ta"ing this drug with food may help
if ta"ing the immediate-release or
li4uid dosage forms)0 difficulty
sleeping, depression, emotional
lability (reversible).
Report nausea, vomiting, severe !
pain, restlessness, sei>ures,
irregular heartbeat.
amiodarone hydrochloride
(a mee o' da rone)
Cordarone, Pacerone
!ru" classes
Antiarrhythmic
Adrenergic bloc"er (not used as
sympatholytic drug)
herapeutic actions
'ype !!! antiarrhythmic: Acts directly on
cardiac cell membrane0 prolongs
repolari>ation and refractory period0
increases ventricular fibrillation threshold0
acts on peripheral smooth muscle to
decrease peripheral resistance
#ndications
5nly for treatment of the following
documented life-threatening
recurrent ventricular arrhythmias that
do not respond to other
antiarrhythmics or when alternative
agents are not tolerated: Recurrent
ventricular fibrillation, recurrent
hemodynamically unstable
ventricular tachycardia. Serious and
even fatal to1icity has been reported
with this drug0 use alternative agents
first0 very closely monitor patient
receiving this drug
$nlabeled uses: 'reatment of
refractory sustained or paro1ysmal
atrial fibrillation and paro1ysmal
supraventricular tachycardia0
treatment of symptomatic atrial flutter
to amiodarone, sinus node
dysfunction, heart bloc", severe
bradycardia, hypo"alemia, lactation.
$se cautiously with thyroid
dysfunction, pregnancy.
A$ailable %orms
'ablets(,**, 8** mg0 in<ection(-* mg2m3
Dosages
#areful patient assessment and evaluation
with continual monitoring of cardiac response
are necessary for titrating the dosage.
'herapy should begin in the hospital with
continual monitoring and emergency
19
e4uipment on standby. 'he following is a
guide to usual dosage.
A!&L'
5ral
3oading dose: )**7+,/** mg2day %5 in
divided doses, for +7. w"0 reduce dose to
/**7)** mg2day in divided doses for + mo0 if
rhythm is stable, reduce dose to 8** mg2day
in one to two divided doses for maintenance
dose. Ad<ust to the lowest possible dose to
limit side effects.
!:
+,*** mg !: over ,8 hr(+-* mg loading
dose over +* min, followed by ./* mg over /
hr at rate of + mg2min. ?or maintenance
infusion, -8* mg at *.- mg2min over +) hr.
=ay be continued up to 9/ hr or until rhythm
is stable. Switch to oral form as soon as
possible.
P(!#A)#C PA#(N'
Pharmaco*inetics
5ral ,7. days .7C hr /7) hr
!: !mmediate ,* min !nfusion
+2,
: +* days, then 8*7
-- days
breast mil"
(,cretion+ 6ile, feces
IV acts
Preparation+ &o not use %:# container if
infusion is to e1ceed , hr0 use glass or
polyolefin instead. &ilute +-* mg in +** m3
&
-
D for rapid loading dose (+.- mg2m3).
&ilute 9** mg in -** m3 &
-
D for slow
infusions (+.) mg2m3). Store at room
temperature and use within ,8 hr.
#n%usion+ !nfuse loading dose over +* min.
!mmediately follow with slow infusion of
+ mg2min or .... m32hr. =aintenance
infusion of *.- mg2min or +/./ m32hr can be
continued up to 9/ hr. $se of an infusion
pump is advised.
#ncompatibilities+ &o not mi1 with
aminophylline, cefa>olin, meclocillin, heparin,
sodium bicarbonate0 do not mi1 in solution
with other drugs.
Ad$erse e%%ects
CN'+ 7alaise$ atigue$ &izziness$
tremors$ ataxia$ paresthesias, lac" of
coordination
C-+ Cardiac arrhythmias, #;?,
cardiac arrest, hypotension
((N+ Corneal micro&eposits
(photophobia, dry eyes, halos,
blurred vision)0 ophthalmic
abnormalities including permanent
blindness
(ndocrine+ Hypothyroi&ism or
hyperthyroi&ism
G#+ Nausea$ vomiting$ anorexia$
constipation$ a2normal L>;s$ li$er
to,icity
)espiratory+ Pulmonary to,icity?
pneumonitis, infiltrates (shortness of
breath, cough, rales, whee>es)
1ther+ 1hotosensitivity$ angioedema
#nteractions
Drug-drug
!ncreased digitalis to1icity with
digo1in
!ncreased 4uinidine to1icity with
4uinidine
!ncreased procainamide to1icity with
procainamide
!ncreased flecainide to1icity with
amiodarone
!ncreased phenytoin to1icity with
phenytoin, ethotoin
!ncreased bleeding tendencies with
warfarin
%otential sinus arrest and heart bloc"
with beta bloc"ers, calcium channel
bloc"ers
20
Drug-lab test
!ncreased '
.
levels, increased
serum reverse '
.
levels
CL#N#CAL AL()4
Name con!usion as occurred "it
amrinone %name as no" been canged to
inamrinone, but con!usion may still
occur&' use caution(
Assessment
amiodarone, sinus node
dysfunction, heart bloc", severe
bradycardia, hypo"alemia, lactation,
thyroid dysfunction, pregnancy

refle1es, gait, eye e1amination0 %,
6%, auscultation, continuous E#
monitoring0 R, adventitious sounds,
baseline chest 1-ray0 liver
evaluation0 3?'s, serum
electrolytes, '
8
, and '
.
Interventions
=onitor cardiac rhythm continuously.
=onitor for an e1tended period when
dosage ad<ustments are made.
2A)N#NG+ =onitor for safe and
effective serum levels (*.-7,.-
mcg2m3).
2A)N#NG+ &oses of digo1in,
4uinidine, procainamide, phenytoin,
and warfarin may need to be
reduced one-third to one-half when
amiodarone is started.
ive drug with meals to decrease !
problems.
Arrange for ophthalmologic
e1aminations0 reevaluate at any sign
of optic neuropathy.
Arrange for periodic chest 1-ray to
evaluate pulmonary status (every .7
/ mo).
Arrange for regular periodic blood
tests for liver en>ymes, thyroid
hormone levels.
Teacing points
&rug dosage will be changed in
relation to response of arrhythmias0
you will need to be hospitali>ed
during initiation of drug therapy0 you
will be closely monitored when
dosage is changed.
;ave regular medical follow-up,
monitoring of cardiac rhythm, chest
1-ray, eye e1amination, blood tests.
effects: #hanges in vision (halos, dry
eyes, sensitivity to light0 wear
sunglasses, monitor light e1posure)0
nausea, vomiting, loss of appetite
(ta"e with meals0 eat small, fre4uent
meals)0 sensitivity to the sun (use a
sunscreen or protective clothing
when outdoors)0 constipation (a
la1ative may be ordered)0 tremors,
twitching, di>>iness, loss of
coordination (do not drive, operate
dangerous machinery, or underta"e
tas"s that re4uire coordination until
drug effects stabili>e and your body
ad<usts to it).
Report unusual bleeding or bruising0
fever, chills0 intolerance to heat or
cold0 shortness of breath, difficulty
breathing, cough0 swelling of an"les
or fingers0 palpitations0 difficulty with
vision.
amitriptyline hydrochloride
(a mee trip' ti leen)
(ndep (CAN), ryptanol (CAN)
21
!ru" class
'#A0 tertiary amine
herapeutic actions
=echanism of action un"nown0 '#As inhibit
the reupta"e of the neurotransmitters
norepinephrine and serotonin, leading to an
increase in their effects0 anticholinergic at
#AS and peripheral receptors0 sedative.
#ndications
Relief of symptoms of depression
(endogenous most responsive)0
sedative effects may help when
depression is associated with an1iety
and sleep disturbance.
$nlabeled uses: #ontrol of chronic
pain (eg, intractable pain of cancer,
central pain syndromes, peripheral
neuropathies, postherpetic neuralgia,
tic douloureu1)0 prevention of onset
of cluster and migraine headaches0
treatment of pathologic weeping and
laughing secondary to forebrain
disease (due to =S), insomnia.
to any tricyclic drug0 concomitant
therapy with an =A5!0 recent =!0
myelography within previous ,8 hr or
scheduled within 8) hr0 lactation.
$se cautiously with electroshoc"
therapy0 pree1isting #: disorders
(severe coronary heart disease,
progressive heart failure, angina
pectoris, paro1ysmal tachycardia)0
angle-closure glaucoma, increased
!5%, urinary retention, ureteral or
urethral spasm0 sei>ure disorders0
hyperthyroidism0 impaired hepatic,
renal function0 psychiatric patients
(schi>ophrenic or paranoid patients
may e1hibit a worsening of
psychosis with '#A therapy)0 manic-
depressive patients0 elective surgery
(discontinue as long as possible
before surgery).
A$ailable %orms
!n<ection(+* mg2m30 tablets(+*, ,-, -*, C-,
+**, +-* mg
Dosages
=ay be given != if patients are unable or
unwilling to ta"e oral drug. Switch to oral
drug as soon as possible.
A!&L'
=epression$ hospitalize& patients:
!nitially, +** mg2day %5 in divided
doses: gradually increase to ,**7
.** mg2day as re4uired. =ay be
given != ,*7.* mg 4id, initially only
in patients unable or unwilling to ta"e
drug %5. Replace with oral
medication as soon as possible.
=epression$ outpatients: !nitially,
C- mg2day %5, in divided doses0
may increase to +-* mg2day.
!ncreases should be made in late
afternoon or hs. 'otal daily dosage
may be administered hs. !nitiate
single daily dose therapy with -*7
+** mg hs0 increase by ,-7-* mg as
necessary to a total of +-* mg2day.
=aintenance dose is 8*7
+** mg2day, which may be given as
a single bedtime dose. After
satisfactory response, reduce to
lowest effective dosage. #ontinue
therapy for . mo or longer to lessen
possibility of relapse.
Chronic pain: C-7+-* mg2day %5.
1revention o cluster or migraine
hea&aches: -*7+-* mg2day %5.
1revention o 6eeping in 7S
patients 6ith ore2rain &isease: ,-7
C- mg %5.
P(!#A)#C PA#(N' = A: 8)
+* mg tid %5 and then ,* mg hs.
P(!#A)#C PA#(N' 9 A: 8)
Aot recommended.
22
G()#A)#C PA#(N'
+* mg tid %5 with ,* mg hs
Pharmaco*inetics
5ral :aries ,78 hr ,78 w"
+2,
: +*7-* hr
breast mil"
(,cretion+ $rine
Ad$erse e%%ects
CN'+ =istur2e& concentration$
se&ation an& anticholinergic
+atropine-like- eects$ conusion
(especially in elderly), hallucinations,
disorientation, decreased memory,
feelings of unreality, delusions,
an1iety, nervousness, restlessness,
agitation, panic, insomnia,
nightmares, hypomania, mania,
e1acerbation of psychosis,
drowsiness, wea"ness, fatigue,
headache, numbness, tingling,
paresthesias of e1tremities,
incoordination, motor hyperactivity,
a"athisia, ata1ia, tremors, peripheral
neuropathy, e1trapyramidal
symptoms, sei>ures, speech
bloc"age, dysarthria, tinnitus, altered
EE
C-+ 0rthostatic hypotension,
hypertension, syncope, tachycardia,
palpitations, M#, arrhythmias, heart
bloc", precipitation of #;?, #:A
(ndocrine+ Elevated or depressed
blood sugar, elevated prolactin
levels, inappropriate A&; secretion
G#+ =ry mouth$ constipation, paralytic
ileus, nausea, vomiting, anore1ia,
epigastric distress, diarrhea,
flatulence, dysphagia, peculiar taste,
increased salivation, stomatitis,
glossitis, parotid swelling, abdominal
cramps, blac" tongue, hepatitis,
<aundice (rare), elevated
transaminase, altered al"aline
phosphatase
G&+ $rinary retention, delayed
micturition, dilation of the urinary
tract, gynecomastia, testicular
swelling0 breast enlargement,
menstrual irregularity and
galactorrhea0 increased or
decreased libido0 impotence
.ematolo"ic+ 6one marrow
depression, including
agranulocytosis0 eosinophilia,
purpura, thrombocytopenia,
leu"openia
.ypersensiti$ity+ Rash, pruritus,
vasculitis, petechiae,
photosensiti>ation, edema
(generali>ed, face, tongue), drug
fever
2ithdraBal+ Symptoms on abrupt
discontinuation of prolonged therapy:
nausea, headache, vertigo,
nightmares, malaise
1ther+ Aasal congestion, e1cessive
appetite, weight change0 sweating,
alopecia, lacrimation, hyperthermia,
flushing, chills
#nteractions
Drug-drug
!ncreased '#A levels and
pharmacologic (especially
anticholinergic) effects with
cimetidine, fluo1etine
!ncreased '#A levels with
methylphenidate, phenothia>ines,
hormonal contraceptives, disulfiram
;yperpyretic crises, severe sei>ures,
hypertensive episodes and deaths
with =A5!s, fura>olidone
!ncreased antidepressant response
and cardiac arrhythmias with thyroid
medication
23
!ncreased or decreased effects with
estrogens
&elirium with disulfiram
Sympathetic hyperactivity, sinus
tachycardia, hypertension, agitation
with levodopa
!ncreased biotransformation of '#As
in patients who smo"e cigarettes
!ncreased sympathomimetic
(especially beta-adrenergic) effects
of direct-acting sympathomimetic
drugs (norepinephrine, epinephrine)
!ncreased anticholinergic effects of
anticholinergic drugs (including
anticholinergic antipar"isonians)
!ncreased response (especially #AS
depression) to barbiturates
&ecreased antihypertensive effect of
guanethidine, clonidine, other
antihypertensives
&ecreased effects of indirect-acting
sympathomimetic drugs (ephedrine)
Assessment
.istory+ ;ypersensitivity to any
tricyclic drug0 concomitant therapy
with an =A5!0 recent =!0
myelography within previous ,8 hr or
scheduled within 8) hr0 lactation0
ES'0 pree1isting #: disorders0
angle-closure glaucoma, increased
!5%, urinary retention, ureteral or
urethral spasm0 sei>ure disorders0
hyperthyroidism0 impaired hepatic,
renal function0 psychiatric patients0
manic-depressive patients0 elective
surgery
Physical+ Deight0 '0 s"in color,
lesions0 orientation, affect, refle1es,
vision and hearing0 %, 6%, orthostatic
6%, perfusion0 bowel sounds, normal
output, liver evaluation0 urine flow,
normal output0 usual se1ual function,
fre4uency of menses, breast and
scrotal e1amination0 3?'s, urinalysis,
#6#, E#
Interventions
Restrict drug access for depressed
and potentially suicidal patients.
ive != only when oral therapy is
impossible.
&o not administer !:.
Administer ma<or portion of dose at
bedtime if drowsiness, severe
anticholinergic effects occur (note
that the elderly may not tolerate
single daily dose therapy).
Reduce dosage if minor side effects
develop0 discontinue if serious side
effects occur.
Arrange for #6# if patient develops
fever, sore throat, or other sign of
infection.
Teacing points
'a"e drug e1actly as prescribed0 do
not stop abruptly or without
consulting health care provider.
Avoid using alcohol, other sleep-
inducing drugs, over-the-counter
drugs.
Avoid prolonged e1posure to sunlight
or sunlamps0 use a sunscreen or
protective garments.
effects: ;eadache, di>>iness,
drowsiness, wea"ness, blurred
vision (reversible0 if severe, avoid
driving and tas"s re4uiring alertness
while these persist)0 nausea,
vomiting, loss of appetite, dry mouth
(eat fre4uent small meals0 use
fre4uent mouth care and suc" on
sugarless candies)0 nightmares,
inability to concentrate, confusion0
changes in se1ual function.
Report dry mouth, difficulty in
urination, e1cessive sedation.
24
amlodipine besylate
(am loe' di peen)
Am-a6, Nor$asc
!ru" classes
#alcium channel-bloc"er
Antianginal drug
Antihypertensive
herapeutic actions
!nhibits the movement of calcium ions across
the membranes of cardiac and arterial
muscle cells0 inhibits transmembrane calcium
flow, which results in the depression of
impulse formation in speciali>ed cardiac
pacema"er cells, slowing of the velocity of
conduction of the cardiac impulse,
depression of myocardial contractility, and
dilation of coronary arteries and arterioles
and peripheral arterioles0 these effects lead
to decreased cardiac wor", decreased
cardiac o1ygen consumption, and in patients
with vasospastic (%rin>metalHs) angina,
increased delivery of o1ygen to cardiac cells.
#ndications
Angina pectoris due to coronary
artery spasm (%rin>metalHs variant
angina)
#hronic stable angina, alone or in
combination with other drugs
Essential hypertension, alone or in
combination with other
antihypertensives
amlodipine, impaired hepatic or renal
function, sic" sinus syndrome, heart
bloc" (second or third degree),
lactation.
$se cautiously with #;?, pregnancy.
A$ailable %orms
'ablets(,.-, -, +* mg
Dosages
A!&L'
!nitially, - mg %5 daily0 dosage may be
gradually increased over +*7+8 days to a
ma1imum dose of +* mg %5 daily.
P(!#A)#C PA#(N'
G()#A)#C PA#(N' 1) PA#(N'
2#. .(PA#C #MPA#)M(N
!nitially, ,.- mg %5 daily0 dosage may be
gradually ad<usted over C7+8 days based on
clinical assessment.
Pharmaco*inetics
Route 5nset %ea"
5ral $n"nown /7+, hr
+2,
: .*7-* hr
breast mil"
(,cretion+ $rine
Ad$erse e%%ects
CN'+ =izziness$ light-hea&e&ness$
hea&ache$ asthenia, atigue$
lethargy
C-+ 1eripheral e&ema$ arrhythmias
!ermatolo"ic+ >lushing$ rash
G#+ Nausea$ abdominal discomfort
#nteractions
Drug-drug
%ossible increased serum levels and
to1icity of cyclosporine if ta"en
concurrently
25
CL#N#CAL AL()4
Name con!usion as been reported
bet"een Norvasc %amlodipine& and Navane
%tioti$ene&' use caution(
Assessment
.istory+ Allergy to amlodipine,
impaired hepatic or renal function,
sic" sinus syndrome, heart bloc",
lactation, #;?
Physical+ S"in lesions, color,
edema0 %, 6%, baseline E#,
peripheral perfusion, auscultation0 R,
adventitious sounds0 liver evaluation,
! normal output0 3?'s, renal
function tests, urinalysis
Interventions
2A)N#NG+ =onitor patient carefully
(6%, cardiac rhythm, and output)
while ad<usting drug to therapeutic
dose0 use special caution if patient
has #;?.
=onitor 6% very carefully if patient is
also on nitrates.
=onitor cardiac rhythm regularly
during stabili>ation of dosage and
periodically during long-term therapy.
Administer drug without regard to
meals.
Teacing points
'a"e with meals if upset stomach
occurs.
effects: Aausea, vomiting (eat
fre4uent small meals)0 headache
(ad<ust lighting, noise, and
temperature0 medication may be
ordered).
Report irregular heartbeat, shortness
of breath, swelling of the hands or
feet, pronounced di>>iness,
constipation.
amo,icillin trihydrate
(a mo1 i sill' in)
Amo,il, Amo,il Pediatric !rops, Apo-
Amo,i (CAN), !isperMo,, No$amo,in
(CAN), Nu-Amo,i (CAN), rimo,
!ru" class
Antibiotic (penicillin7ampicillin type)
herapeutic actions
6actericidal: !nhibits synthesis of cell wall of
sensitive organisms, causing cell death.
#ndications
!nfections due to susceptible strains
of Haemophilus inluenzae$
@scherichia coli$ 1roteus mira2ilis$
Neisseria gonorrhoeae$
Streptococcus pneumoniae$
@nterococcus aecalis$ streptococci,
non7penicillinase-producing
staphylococci
Helico2acter pylori infection in
combination with other agents
%ost-e1posure prophyla1is against
Aacillus anthracis
$nlabeled use: Chlamy&ia
trachomatis in pregnancy
#ontraindicated with allergies to
penicillins, cephalosporins, or other
allergens.
$se cautiously with renal disorders,
lactation.
A$ailable %orms
#hewable tablets(+,-, ,**, ,-*, 8** mg0
tablets(-**, )C- mg0 capsules(,-*,
-** mg0 powder for oral suspension(
-* mg2m30 +,- mg2- m3, ,** mg2- m3,
26
,-* mg2- m3, 8** mg2- m30 tablets for oral
suspension(,**, 8** mg
Available in oral preparations only.
Dosages
A!&L' AN! P(!#A)#C PA#(N' = C;
DG
B5Is$ 9B inections$ skin an& sot-
tissue inections: ,-*7-** mg %5 4
) hr or )C- mg %5 bid.
1ost-exposure anthrax prophylaxis:
-** mg %5 tid.
Lo6er respiratory inections: -** mg
%5 4 ) hr or )C- mg %5 bid.
Bncomplicate& gonococcal
inections: . g amo1icillin with + g
probenecid %5.
#. trachomatis in pregnancy: -** mg
%5 tid for C days or )C- mg %5 bid.
1revention o SA@ in &ental$ oral$ or
upper respiratory proce&ures: , g +
hr before procedure.
1revention o SA@ in 9I or 9B
proce&ures: , g ampicillin plus
+.- mg2"g gentamicin != or !: .*
min before procedure, followed by +
g amo1icillin0 for low-ris" patients, ,
g + hr before procedure.
;. pylori inections: + g bid with
clarithromycin -** mg bid and
lansopra>ole .* mg bid for +8 days.
P(!#A)#C PA#(N' 9 C; DG
B5Is$ 9B inections$ skin$ an& sot-
tissue inections: ,*78* mg2"g2day
%5 in divided doses 4 ) hr.
1ost-exposure anthrax prophylaxis:
)* mg2"g2day %5 divided into .
doses.
1revention o SA@: =ental$ oral$ or
upper respiratory proce&ures:
-* mg2"g + hr before procedure.
1revention o SA@ in 9I or 9B
proce&ures: -* mg2"g ampicillin plus
, mg2"g gentamicin != or !: .* min
before procedure followed by
,- mg2"g amo1icillin. ?or moderate-
ris" patients, -* mg2"g %5 + hr
before procedure.
P(!#A)#C PA#(N' 9 A: 2D
$p to .* mg2"g daily in divided doses 4 +,
hr.
P(!#A)#C PA#(N' = @ M1
7il& to mo&erate B5Is$ 9B
inections$ an& skin inections:
,* mg2"g daily in divided doses 4
) hr or ,- mg2"g in divided doses 4
+, hr.
>or lo6er respiratory inections$ or
severe B5Is$ 9B$ or skin inections:
8* mg2"g daily in divided doses 4 )
hr or 8- mg2"g daily in divided doses
4 +, hr.
Pharmaco*inetics
5ral :aries + hr /7) hr
Metabolism+ '
+2,
: +7+.8 hr
breast mil"
(,cretion+ $rine, unchanged
Ad$erse e%%ects
CN'+ 3ethargy, hallucinations,
sei>ures
G#+ 9lossitis$ stomatitis, gastritis$
sore mouth$ furry tongue, blac"
IhairyI tongue, nausea$ vomiting$
&iarrhea$ a2&ominal pain$ bloody
diarrhea, enterocolitis,
pseudomembranous colitis,
nonspecific hepatitis
G&+ Aephritis
.ematolo"ic+ Anemia,
thrombocytopenia, leu"openia,
neutropenia, prolonged bleeding
time
.ypersensiti$ity+ 5ash$ ever$
6heezing$ anaphyla,is
27
1ther+ Superinections(oral and
rectal moniliasis, vaginitis
#nteractions
Drug-drug
!ncreased effect with probenecid
&ecreased effectiveness with
tetracyclines, chloramphenicol
&ecreased efficacy of hormonal
contraceptives
Drug-!ood
&elayed or reduced ! absorption
with food
Assessment
.istory+ Allergies to penicillins,
cephalosporins, or other allergens0
renal disorders0 lactation
Physical+ #ulture infected area0 s"in
color, lesion0 R, adventitious sounds0
bowel sounds0 #6#, 3?'s, renal
function tests, serum electrolytes,
;ct, urinalysis
Interventions
#ulture infected area prior to
treatment0 reculture area if response
is not as e1pected.
ive in oral preparations only0
amo1icillin is not affected by food.
#ontinue therapy for at least , days
after signs of infection have
disappeared0 continuation for +* full
days is recommended.
$se corticosteroids, antihistamines
for s"in reactions.
Teacing points
'a"e this drug around-the-cloc".
'a"e the full course of therapy0 do
not stop because you feel better.
'his antibiotic is specific for this
problem and should not be used to
self-treat other infections.
effects: Aausea, vomiting, ! upset
(eat fre4uent small meals)0 diarrhea0
sore mouth (fre4uent mouth care
may help).
Report unusual bleeding or bruising,
sore throat, fever, rash, hives, severe
diarrhea, difficulty breathing.
ampicillin
(am pi sill' in)
ampicillin sodium
Oral:
Ampicin (CAN), Apo-Ampi (CAN), No$o-
Ampicillin (CAN), Nu-Ampi (CAN),
Penbritin (CAN), Principen
!ru" classes
Antibiotic
%enicillin
herapeutic actions
6actericidal action against sensitive
organisms0 inhibits synthesis of bacterial cell
wall, causing cell death.
#ndications
'reatment of infections caused by
susceptible strains of Shigella$
Salmonella$ @/ coli$ H/ inluenzae$ 1/
mira2ilis$ N/ gonorrhoeae$
enterococci, gram-positive
organisms (penicillin 7sensitive
staphylococci, streptococci,
pneumococci)
=eningitis caused by Neisseria
meningiti&is
$nlabeled use: %rophyla1is in
cesarean section in certain high-ris"
patients
28
#ontraindicated with allergies to
penicillins, cephalosporins, or other
allergens.
$se cautiously with renal disorders.
A$ailable %orms
#apsules(,-*, -** mg0 powder for oral
suspension(+,- mg2- m3, ,-* mg2- m30
powder for in<ection(,-*, -** mg, +, , g
Dosages
=a1imum recommended dosage: )7
+8 mg2day (+8 g should be reserved for
serious infections, such as meningitis,
septicemia)0 may be given !:, !=, or %5. $se
parenteral routes for severe infections, and
switch to oral route as soon as possible.
A!&L'
1revention o 2acterial en&ocar&itis
or 9I or 9B surgery or
instrumentation: , g ampicillin != or
!: with gentamicin +.- mg2"g != or
!: within .* minutes of starting
procedure. Si1 hours later give + g
ampicillin != or !: or + g amo1icillin
%5.
or &ental$ oral$ or upper respiratory
proce&ures: , g ampicillin != or !:
within .* minutes of procedure.
S;=s in pregnant 6omen an&
patients allergic to tetracycline: ..- g
ampicillin %5 with + g probenecid.
1rophylaxis in cesarean section:
Single !: or != dose of ,-7
+** mg2"g immediately after cord is
clamped.
A!&L' AN! P(!#A)#C PA#(N'
5espiratory an& sot-tissue
inections:
% '( kg: ,-*7-** mg !: or != 4 / hr.
! '( kg: ,-7-* mg2"g2day != or !: in
e4ually divided doses at /7) hr
intervals.
% #( kg: ,-* mg %5 4 / hr.
! #( kg: -* mg2"g2day %5 in e4ually
divided doses 4 /7) hr.
9I an& 9B inections$ inclu&ing
6omen 6ith A. gonorrhoeae:
% '( kg: -** mg != or !: 4 / hr.
! '( kg: -*7+** mg2"g2day != or !:
in e4ually divided doses 4 /7) hr.
% #( kg: -** mg %5 4 / hr.
! #( kg: +** mg2"g2day %5 in
e4ually divided doses 4 /7) hr.
9onococcal inections: -** mg 4 /
hr for penicillin-sensitive organism or
for patients B 8- "g, single dose of
..- g %5 with + g probenecid.
Aacterial meningitis: +-*7
,** mg2"g2day by continuous !: drip
and then != in<ections in e4ually
divided doses 4 .78 hr.
Septicemia: +-*7,** mg2"g2day !:
for at least . days, then != 4 .78 hr.
P(!#A)#C PA#(N'
or 9I or 9B surgery or
instrumentation: -* mg2"g ampicillin
!= or !: with +.- mg2"g gentamicin
!= or !: within .* minutes of
procedure. Si1 hours later give
,- mg2"g ampicillin != or !: or
,- mg2"g amo1icillin %5.
or &ental$ oral$ or upper respiratory
proce&ures: -* mg2"g ampicillin !=
or !: within .* minutes of procedure.
Pharmaco*inetics
5ral .* min , hr /7) hr
!= +- min + hr /7) hr
!: !mmediate - min /7) hr
Metabolism+ '
+2,
: +7, hr
breast mil"
29
IV acts
Preparation+ Reconstitute with sterile or
bacteriostatic water for in<ection0 piggybac"
vials may be reconstituted with sodium
chloride in<ection0 use reconstituted solution
within + hr. &o not mi1 in the same !:
solution as other antibiotics. $se within + hr
after preparation because potency may
decrease significantly after that.
#n%usion+ &irect !: administration0 give
slowly over .7- min. Rapid administration
can lead to sei>ures.
#- drip+ =ilute as a2ove 2eore urther
&ilution/
#- pi""ybac*+ A&minister alone or urther
&ilute 6ith compati2le solution/
Compatibility+ Ampicillin is compatible with
*.9G sodium chloride, -G de1trose in water,
or *.8-G sodium chloride solution, +*G
invert sugar water, =2/ sodium lactate
solution, lactated RingerHs solution, sterile
water for in<ection. &iluted solutions are
stable for ,7) hr0 chec" manufacturerHs
inserts for specifics. &iscard solution after
allotted time period.
#ncompatibility+ &o not mi1 with lidocaine,
verapamil, other antibiotics, de1trose
solutions.
8-site incompatibility+ &o not give with
epinephrine, hydrala>ine, ondansetron.
Ad$erse e%%ects
CN'+ 3ethargy, hallucinations,
sei>ures
C-+ #;?
G#+ 9lossitis$ stomatitis$ gastritis$
sore mouth$ furry tongue, blac"
IhairyI tongue, nausea$ vomiting$
&iarrhea$ abdominal pain, bloody
diarrhea, enterocolitis,
pseudomembranous colitis,
nonspecific hepatitis
G&+ Nephritis
.ematolo"ic+ Anemia,
neutropenia, prolonged bleeding
time
.ypersensiti$ity+ 5ash$ ever$
6heezing$ anaphyla,is
Local+ 1ain$ phle2itis$ thrombosis at
in<ection site (parenteral)
1ther+ Superinections?oral and
rectal moniliasis, vaginitis
#nteractions
Drug-drug
!ncreased ampicillin effect with
probenecid
!ncreased ris" of rash with allopurinol
!ncreased bleeding effect with
heparin, oral anticoagulants
&ecreased effectiveness with
tetracyclines, chloramphenicol
&ecreased efficacy of hormonal
contraceptives, atenolol with
ampicillin
Drug-!ood
5ral ampicillin may be less effective
with food0 ta"e on an empty stomach
Drug-lab test
?alse-positive #oombsH test if given
!:
&ecrease in plasma estrogen
concentrations in pregnant women
?alse-positive urine glucose tests if
#linitest, 6enedictHs solution, or
?ehlingHs solution is used0 en>ymatic
glucose o1idase methods (#linisti1,
'es-'ape) should be used to chec"
urine glucose
Assessment
.istory+ Allergies to penicillins,
cephalosporins, or other allergens0
renal disorders0 lactation
Physical+ #ulture infected area0 s"in
color, lesion0 R, adventitious sounds0
bowel sounds0 #6#, 3?'s, renal
30
function tests, serum electrolytes,
;ct, urinalysis
Interventions
#ulture infected area before
treatment0 reculture area if response
is not as e1pected.
#hec" !: site carefully for signs of
thrombosis or drug reaction.
&o not give != in<ections in the same
site0 atrophy can occur. =onitor
in<ection sites.
Administer oral drug on an empty
stomach, + hr before or , hr after
meals with a full glass of water0 do
not give with fruit <uice or soft drin"s.
Teacing points
'a"e this drug around-the-cloc".
'a"e the full course of therapy0 do
not stop ta"ing the drug if you feel
better.
'a"e the oral drug on an empty
stomach, + hour before or , hours
after meals0 do not ta"e with fruit
<uice or soft drin"s0 the oral solution
is stable for C days at room
temperature or +8 days refrigerated.
'his antibiotic is specific to your
problem and should not be used to
self-treat other infections.
effects: Aausea, vomiting, ! upset
(eat fre4uent small meals), diarrhea.
Report pain or discomfort at sites,
unusual bleeding or bruising, mouth
sores, rash, hives, fever, itching,
severe diarrhea, difficulty breathing.
aspirin
(ass' pir in)
Apo-A'A (CAN), Asper"um, /ayer,
(asprin, (cotrin, (mpirin, (ntrophen
(CAN), Genprin, .al%prin EA, A<: .al%prin,
.eartline, NorBich, No$asen (CAN), PM'-
A'A (CAN), 01)prin
6uffered aspirin products:
Al*a-'elt6er, Ascriptin, Asprimo,,
/u%%erin, /u%%e,, Ma"naprin
!ru" classes
Antipyretic
Analgesic (nonopioid)
Anti-inflammatory
Antirheumatic
Antiplatelet
Salicylate
ASA!&
herapeutic actions
Analgesic and antirheumatic effects are
attributable to aspirinHs ability to inhibit the
synthesis of prostaglandins, important
mediators of inflammation. Antipyretic effects
are not fully understood, but aspirin probably
acts in the thermoregulatory center of the
hypothalamus to bloc" effects of endogenous
pyrogen by inhibiting synthesis of the
prostaglandin intermediary. !nhibition of
platelet aggregation is attributable to the
inhibition of platelet synthesis of
thrombo1ane A
,
, a potent vasoconstrictor
and inducer of platelet aggregation. 'his
effect occurs at low doses and lasts for the
life of the platelet () days). ;igher doses
inhibit the synthesis of prostacyclin, a potent
vasodilator and inhibitor of platelet
aggregation.
#ndications
=ild to moderate pain
?ever
31
!nflammatory conditions(rheumatic
fever, rheumatoid arthritis,
osteoarthritis
Reduction of ris" of recurrent '!As or
stro"e in males with history of '!A
due to fibrin platelet emboli
Reduction of ris" of death or nonfatal
=! in patients with history of
infarction or unstable angina pectoris
=! prophyla1is
$nlabeled use: %rophyla1is against
cataract formation with long-term use
salicylates or ASA!&s (more
common with nasal polyps, asthma,
chronic urticaria)0 allergy to tartra>ine
(cross-sensitivity to aspirin is
common)0 hemophilia, bleeding
ulcers, hemorrhagic states, blood
coagulation defects,
hypoprothrombinemia, vitamin M
deficiency (increased ris" of
bleeding)
$se cautiously with impaired renal
function0 chic"enpo1, influen>a (ris"
of ReyeHs syndrome in children and
teenagers)0 children with fever
accompanied by dehydration0
surgery scheduled within + w"0
pregnancy (maternal anemia,
antepartal and postpartal
hemorrhage, prolonged gestation,
and prolonged labor have been
reported0 readily crosses the
placenta0 possibly teratogenic0
maternal ingestion of aspirin during
late pregnancy has been associated
with the following adverse fetal
effects: low birth weight, increased
intracranial hemorrhage, stillbirths,
neonatal death)0 lactation.
A$ailable %orms
'ablets()+, +/-, .,-, -**, /-*, 9C- mg0 SR
tablets(/-*, )** mg0 suppositories(+,*,
,**, .**, /** mg
Dosages
Available in oral and suppository forms. Also
available as chewable tablets, gum0 enteric
coated, SR, and buffered preparations (SR
aspirin is not recommended for antipyresis,
short-term analgesia, or children @ +, yr.)
A!&L'
7inor aches an& pains: .,-7/-* mg
4 8 hr.
Arthritis an& rheumatic con&itions:
..,7/ g2day in divided doses.
Acute rheumatic ever: -7) g2day0
modify to maintain serum salicylate
level of +-7.* mg2d3.
;IAs in men:+,.** mg2day in divided
doses (/-* mg bid or .,- mg 4id).
7I prophylaxis: C-7.,- mg2day.
P(!#A)#C PA#(N'
Analgesic an& antipyretic: /- mg2"g
per ,8 hr in four to si1 divided doses,
not to e1ceed ../ g2day. &osage
recommendations by age:
Age (yr) &osage
(mg 4 8 hr)
,7. +/,
87- ,8.
/7) .,8
97+* 8*-
++ 8)/
+, /8)
Cuvenile rheumatoi& arthritis: /*7++*
mg2"g per ,8 hr in divided doses at
/- to )-hr intervals. =aintain a serum
level of +-*7.** mcg2m3.
Acute rheumatic ever: !nitially,
+** mg2"g2day, then decrease to
C- mg2"g2day for 87/ w".
'herapeutic serum salicylate level is
+-*7.** mg2d3.
Da6asaki &isease: )*7
+)* mg2"g2day0 very high doses may
32
be needed during acute febrile
period0 after fever resolves, dosage
may be ad<usted to +* mg2"g2day.
Pharmaco*inetics
5ral -7.* min +-7+,*
min
.7/ hr
Rectal +7, hr 87- hr /7) hr
Metabolism+ ;epatic (salicylate)0 '
+2,
: +-
min7+, hr
breast mil"
(,cretion+ $rine
Ad$erse e%%ects
Acute aspirin to,icity+ Respiratory
al"alosis, hyperpnea, tachypnea,
hemorrhage, e1citement, confusion,
asteri1is, pulmonary edema,
sei>ures, tetany, metabolic acidosis,
fever, coma, #: collapse, renal and
respiratory failure (dose related, ,*7
,- g in adults, 8 g in children)
Aspirin intolerance+ E1acerbation
of bronchospasm, rhinitis (with nasal
polyps, asthma, rhinitis)
G#+ Nausea$ &yspepsia$ heart2urn$
epigastric &iscomort$ anore1ia,
hepatoto1icity
.ematolo"ic+ 0ccult 2loo& loss$
hemostatic &eects
.ypersensiti$ity+ Anaphylactoid
reactions to anaphylactic shoc*
'alicylism+ =izziness$ tinnitus$
&iiculty hearing$ nausea$ vomiting,
diarrhea, mental confusion, lassitude
(dose related)
#nteractions
Drug-drug
!ncreased ris" of bleeding with oral
anticoagulants, heparin
!ncreased ris" of ! ulceration with
steroids, phenylbuta>one, alcohol,
ASA!&s
!ncreased serum salicylate levels
due to decreased salicylate e1cretion
with urine acidifiers (ammonium
chloride, ascorbic acid, methionine)
!ncreased ris" of salicylate to1icity
with carbonic anhydrase inhibitors,
furosemide
&ecreased serum salicylate levels
with corticosteroids
&ecreased serum salicylate levels
due to increased renal e1cretion of
salicylates with aceta>olamide,
metha>olamide, certain antacids,
al"alini>ers
&ecreased absorption of aspirin with
nonabsorbable antacids
!ncreased methotre1ate levels and
to1icity with aspirin
!ncreased effects of valproic acid
secondary to displacement from
plasma protein sites
reater glucose lowering effect of
sulfonylureas, insulin with large
doses (B , g2day) of aspirin
&ecreased antihypertensive effect of
captopril, beta-adrenergic bloc"ers
with salicylates0 consider
discontinuation of aspirin
&ecreased uricosuric effect of
probenecid, sulfinpyra>one
%ossible decreased diuretic effects
of spironolactone, furosemide (in
patients with compromised renal
function)
$ne1pected hypotension may occur
with nitroglycerin
Drug-lab test
&ecreased serum protein bound
iodine (%6!) due to competition for
binding sites
33
?alse-negative readings for urine
glucose by glucose o1idase method
and copper reduction method with
moderate to large doses of aspirin
!nterference with urine --;!AA
determinations by fluorescent
methods but not by nitrosonaphthol
colorimetric method
!nterference with urinary "etone
determination by the ferric chloride
method
?alsely elevated urine :=A levels
with most tests0 a false decrease in
:=A using the %isano method
Assessment
.istory+ Allergy to salicylates or
ASA!&s0 allergy to tartra>ine0
hemophilia, bleeding ulcers,
hemorrhagic states, blood
coagulation defects,
hypoprothrombinemia, vitamin M
deficiency0 impaired hepatic function0
impaired renal function0 chic"enpo1,
influen>a0 children with fever
accompanied by dehydration0
surgery scheduled within + w"0
pregnancy0 lactation
Physical+ S"in color, lesions0 '0
eighth cranial nerve function,
orientation, refle1es, affect0 %, 6%,
perfusion0 R, adventitious sounds0
liver evaluation, bowel sounds0 #6#,
clotting times, urinalysis, stool
guaiac, 3?'s, renal function tests
Interventions
ive drug with food or after meals if
! upset occurs.
ive drug with full glass of water to
reduce ris" of tablet or capsule
lodging in the esophagus.
&o not crush, and ensure that patient
does not chew SR preparations.
&o not use aspirin that has a strong
vinegar-li"e odor.
2A)N#NG+ !nstitute emergency
procedures if overdose occurs:
astric lavage, induction of emesis,
activated charcoal, supportive
therapy.
Teacing points
'a"e e1tra precautions to "eep this
drug out of the reach of children0 this
drug can be very dangerous for
children.
$se the drug only as suggested0
avoid overdose. Avoid the use of
other over-the-counter drugs while
ta"ing this drug. =any of these drugs
contain aspirin, and serious
overdose can occur.
'a"e the drug with food or after
meals if ! upset occurs.
&o not cut, crush, or chew
sustained-release products.
5ver-the-counter aspirins are
e4uivalent. %rice does not reflect
effectiveness.
effects: Aausea, ! upset, heartburn
(ta"e drug with food)0 easy bruising,
gum bleeding (related to aspirinHs
effects on blood clotting).
Report ringing in the ears0 di>>iness,
confusion0 abdominal pain0 rapid or
difficult breathing0 nausea, vomiting,
bloody stools.
atenolol
(a ten' o lole)
Apo-Atenolol (CAN), Gen-Atenolol (CAN),
No$o-Atenol (CAN), enormin
34
!ru" classes
6eta
+
-selective adrenergic bloc"ing agent
Antianginal
Antihypertensive
herapeutic actions
6loc"s beta-adrenergic receptors of the
sympathetic nervous system in the heart and
<u1taglomerular apparatus ("idney), thus
decreasing the e1citability of the heart,
decreasing cardiac output and o1ygen
consumption, decreasing the release of renin
from the "idney, and lowering 6%.
#ndications
'reatment of angina pectoris due to
coronary atherosclerosis
;ypertension, as a step + agent,
alone or with other drugs, especially
diuretics
'reatment of =!
$nlabeled uses: %revention of
migraine headaches0 alcohol
withdrawal syndrome, treatment of
ventricular and supraventricular
arrhythmias
#ontraindicated with sinus
bradycardia, second- or third-degree
heart bloc", cardiogenic shoc", #;?,
pregnancy.
$se cautiously with renal failure,
diabetes or thyroto1icosis (atenolol
can mas" the usual cardiac signs of
hypoglycemia and thyroto1icosis),
lactation, respiratory disease.
A$ailable %orms
'ablets(,-, -*, +** mg0 in<ection(- mg2+*
m3
Dosages
A!&L'
Hypertension: !nitially, -* mg %5
once a day0 after +7, w", dose may
be increased to +** mg2day.
Angina pectoris: !nitially, -* mg %5
daily. !f optimal response is not
achieved in + w", increase to +** mg
daily0 up to ,** mg2day may be
needed.
Acute 7I: !nitially, - mg !: given over
- min as soon as possible after
diagnosis0 follow with !: in<ection of
- mg +* min later. Switch to -* mg
%5 +* min after the last !: dose0
follow with -* mg %5 +, hr later.
'hereafter, administer +** mg %5
daily or -* mg %5 bid for /79 days
or until discharge from the hospital.
P(!#A)#C PA#(N'
G()#A)#C PA#(N' 1) PA#(N'
2#. )(NAL #MPA#)M(N
&osage reduction is re4uired because
atenolol is e1creted through the "idneys. 'he
following dosage is suggested:
#reatinine
#learance
m32min
;alf-life
(hr)
=a1imum
&osage
+-7.- +/7,C -* mg2day
@ +- B ,C ,- mg2day
?or patients on hemodialysis, give ,-7-* mg
after each dialysis0 give only in hospital
setting0 severe hypotension can occur.
Pharmaco*inetics
5ral :aries ,78 hr ,8 hr
!: !mmediate - min ,8 hr
Metabolism+ '
+2,
: /7C hr
breast mil"
(,cretion+ 6ile, feces, urine
IV acts
35
Preparation+ =ay be diluted in de1trose
in<ection, sodium chloride in<ection, or
sodium chloride and de1trose in<ection.
Stable for 8) hr after mi1ing.
#n%usion+ !nitiate treatment as soon as
possible after admission to the hospital0
in<ect - mg over - min0 follow with another --
mg !: in<ection +* min later.
Ad$erse e%%ects
Aller"ic reactions+ %haryngitis,
erythematous rash, fever, sore
throat, laryn"ospasm, respiratory
distress
CN'+ &i>>iness, vertigo, tinnitus,
fatigue, emotional depression,
paresthesias, sleep disturbances,
hallucinations, disorientation,
memory loss, slurred speech
C-+ Ara&ycar&ia$ CH>$ car&iac
arrhythmias$ sinoatrial or AV no&al
2lock$ tachycar&ia$ peripheral
vascular insufficiency, claudication,
#:A, pulmonary edema,
hypotension
!ermatolo"ic+ Rash, pruritus,
sweating, dry s"in
((N+ Eye irritation, dry eyes,
con<unctivitis, blurred vision
G#+ 9astric pain$ latulence$
constipation$ &iarrhea$ nausea$
vomiting$ anore1ia, ischemic colitis,
renal and mesenteric arterial
thrombosis, retroperitoneal fibrosis,
hepatomegaly, acute pancreatitis
G&+ Impotence$ &ecrease& li2i&o$
%eyronieHs disease, dysuria,
nocturia, fre4uent urination
Musculos*eletal+ Noint pain,
arthralgia, muscle cramps
)espiratory+ /ronchospasm,
dyspnea, cough, bronchial
obstruction, nasal stuffiness, rhinitis,
pharyngitis (less li"ely than with
propranolol)
1ther+ =ecrease& exercise
tolerance$ &evelopment o
antinuclear anti2o&ies$
hyperglycemia or hypoglycemia,
elevated serum transaminase,
al"aline phosphatase, and 3&;
#nteractions
Drug-drug
!ncreased effects with verapamil,
anticholinergics, 4uinidine
!ncreased ris" of orthostatic
hypotension with pra>osin
!ncreased ris" of lidocaine to1icity
with atenolol
%ossible increased 6%-lowering
effects with aspirin, bismuth
subsalicylate, magnesium salicylate,
sulfinpyra>one, hormonal
contraceptives
&ecreased antihypertensive effects
with ASA!&s, clonidine
&ecreased antihypertensive and
antianginal effects of atenolol with
ampicillin, calcium salts
%ossible increased hypoglycemic
effect of insulin
Drug-lab test
%ossible false results with glucose or
insulin tolerance tests
Assessment
.istory+ Sinus bradycardia, second-
or third-degree heart bloc",
cardiogenic shoc", #;?, renal
failure, diabetes or thyroto1icosis,
Physical+ 6aseline weight, s"in
condition, neurologic status, %, 6%,
E#, respiratory status, renal and
thyroid function tests, blood and
urine glucose, cholesterol,
triglycerides
Interventions
36
2A)N#NG+ &o not discontinue drug
abruptly after long-term therapy
(hypersensitivity to catecholamines
may have developed, causing
e1acerbation of angina, =!, and
ventricular arrhythmias). 'aper drug
gradually over , w" with monitoring.
#onsult physician about withdrawing
drug if patient is to undergo surgery
(withdrawal is controversial).
Teacing points
'a"e drug with meals if ! upset
occurs.
&o not stop ta"ing this drug unless
told to do so by a health care
provider.
Avoid driving or dangerous activities
if di>>iness or wea"ness occur.
effects: &i>>iness, light-headedness,
loss of appetite, nightmares,
depression, se1ual impotence.
Report difficulty breathing, night
cough, swelling of e1tremities, slow
pulse, confusion, depression, rash,
fever, sore throat.
ator$astatin calcium
(ah tor' va stah tin)
Lipitor
Pregnancy Category *
!ru" classes
Antihyperlipidemic
;=-#oA inhibitor
herapeutic actions
!nhibits ;=-#oA, the en>yme that
cataly>es the first step in the cholesterol
synthesis pathway, resulting in a decrease in
serum cholesterol, serum 3&3s (associated
with increased ris" of #A&), and increases
serum ;&3s (associated with decreased ris"
of #A&)0 increases hepatic 3&3 recapture
sites, enhances reupta"e and catabolism of
3&30 lowers triglyceride levels.
#ndications
Ad<unct to diet in treatment of
elevated total cholesterol, serum
triglycerides, and 3&3 cholesterol in
patients with primary
hypercholesterolemia (types !!a and
!!b) and mi1ed dyslipidemia, primary
dysbetalipoproteinemia, and
homo>ygous familial
hypercholesterolemia whose
response to dietary restriction of
saturated fat and cholesterol and
other nonpharmacologic measures
has not been ade4uate
'o increase ;&3-# in patients with
primary hypercholesterolemia and
mi1ed dyslipidemia
Ad<unt to diet to treat elevated serum
triglyceride levels
Ad<unct to diet in treatment of boys
and postmenarchal girls ages +*7+C
with hetero>ygous familial
cholesterolemia if diet alone is not
ade4uate to control lipid levels and
3&3-# levels are B +9* mg2d3 or if
3&3-# level is B +/* mg2d3 and
there is a family history of premature
#: disease or the child has two or
more ris" factors for the
development of coronary disease
%revention of #: disease in adults
without clinically evident coronary
disease but with multiple ris" factors
for #A& such as age B -- yr,
smo"ing, hypertension, low ;&3-#,
family history of early #A&0 to
reduce the ris" of =! and ris" for
revasculari>ation procedures and
angina
37
atorvastatin, fungal byproducts,
active liver disease or une1plained
and persistent elevations of
transaminase levels, pregnancy,
lactation.
$se cautiously with impaired
endocrine function.
A$ailable %orms
'ablets(+*, ,*, 8*, )* mg
Dosages
A!&L'
!nitially, +* mg %5 once daily without regard
to meals0 for maintenance, +*7)* mg %5
daily. =ay be combined with bile acid7
binding resin.
P(!#A)#C PA#(N' A;>AF 8)
!nitially, +* mg %5 daily. =a1imum,
,* mg2day0 do not change dose of intervals @
8 w".
Pharmaco*inetics
Route 5nset %ea"
5ral Slow +7, hr
Metabolism+ ;epatic and cellular0 '
+2,
: +8 hr
breast mil"
(,cretion+ 6ile
Ad$erse e%%ects
CN'+ Hea&ache$ asthenia
G#+ >latulence$ a2&ominal pain$
cramps$ constipation$ nausea$
dyspepsia, heartburn, li$er %ailure
)espiratory+ Sinusitis, pharyngitis
1ther+ )habdomyolysis Bith acute
renal %ailure, arthralgia, myalgia
#nteractions
Drug-drug
%ossible severe myopathy or
rhabdomyolysis with erythromycin,
cyclosporine, niacin, antifungals,
other ;=-#oA reductase inhibitors
!ncreased digo1in levels with
possible to1icity if ta"en together0
monitor digo1in levels
!ncreased estrogen levels with
hormonal contraceptives0 monitor
patients on this combination
Drug-!ood
&ecreased metabolism and ris" of
to1ic effects if combined with
grapefruit <uice0 avoid this
combination.
CL#N#CAL AL()4
Name con!usion as been reported
bet"een "ritten orders !or -ipitor
%atorvastatin& and .yrtec %certiri+ine&( /se
e$treme caution(
Assessment
.istory+ Allergy to atorvastatin,
fungal byproducts0 active hepatic
disease0 acute serious illness0
pregnancy, lactation
Physical+ 5rientation, affect, muscle
strength0 liver evaluation, abdominal
e1amination0 lipid studies, 3?'s,
renal function tests
Interventions
5btain 3?'s as a baseline and
periodically during therapy0
discontinue drug if AS' or A3' levels
increase to . times normal levels.
2A)N#NG+ Dithhold atorvastatin in
any acute, serious condition (severe
infection, hypotension, ma<or
surgery, trauma, severe metabolic or
endocrine disorder, sei>ures) that
may suggest myopathy or serve as
38
ris" factor for development of renal
failure.
Ensure that patient has tried
cholesterol-lowering diet regimen for
.7/ mo before beginning therapy.
Administer drug without regard to
food, but at same time each day.
Atorvastatin may be combined with a
bile acid7binding agent. &o not
combine with other ;=-#oA
reductase inhibitors or fibrates.
#onsult dietitian regarding low-
cholesterol diets.
2A)N#NG+ Ensure that patient is
not pregnant and has appropriate
contraceptives available during
therapy0 serious fetal damage has
been associated with this drug.
Teacing points
'a"e this drug once a day, at about
the same time each day, preferably
in the evening0 may be ta"en with
food. &o not drin" grapefruit <uice
while ta"ing this drug.
!nstitute appropriate dietary changes.
Arrange to have periodic blood tests
while you are ta"ing this drug.
Alert any health care provider that
you are on this drug0 it will need to
be discontinued if acute in<ury or
illness occurs.
&o not become pregnant while you
are on this drug0 use barrier
contraceptives. !f you wish to
become pregnant or thin" you are
pregnant, consult your health care
provider.
effects: Aausea (eat fre4uent small
meals)0 headache, muscle and <oint
aches and pains (may lessen over
time).
Report muscle pain, wea"ness,
tenderness0 malaise0 fever0 changes
in color of urine or stool0 swelling.
atropine sul%ate
(a' troe peen)
Parenteral and oral preparations:
AtroPen, Minims (CAN), 'al-ropine
Optalmic solution:
Atropine 'ul%ate 'G1GPG, #sopto Atropine
1phthalmic
!ru" classes
Anticholinergic
Antimuscarinic
%arasympatholytic
Antipar"insonian
Antidote
&iagnostic agent (ophthalmic preparations)
6elladonna al"aloid
herapeutic actions
#ompetitively bloc"s the effects of
acetylcholine at muscarinic cholinergic
receptors that mediate the effects of
parasympathetic postganglionic impulses,
depressing salivary and bronchial secretions,
dilating the bronchi, inhibiting vagal
influences on the heart, rela1ing the ! and
$ tracts, inhibiting gastric acid secretion
(high doses), rela1ing the pupil of the eye
(mydriatic effect), and preventing
accommodation for near vision (cycloplegic
effect)0 also bloc"s the effects of
acetylcholine in the #AS.
#ndications
Antisialagogue for preanesthetic
medication to prevent or reduce
respiratory tract secretions
39
'reatment of par"insonism0 relieves
tremor and rigidity
Restoration of cardiac rate and
arterial pressure during anesthesia
when vagal stimulation produced by
intra-abdominal traction causes a
decrease in pulse rate, lessening the
degree of A: bloc" when increased
vagal tone is a factor (eg, some
cases due to digitalis)
Relief of bradycardia and syncope
due to hyperactive carotid sinus
refle1
Relief of pylorospasm, hypertonicity
of the small intestine, and
hypermotility of the colon
Rela1ation of the spasm of biliary
and ureteral colic and bronchospasm
Rela1ation of the tone of the detrusor
muscle of the urinary bladder in the
treatment of urinary tract disorders
#ontrol of crying and laughing
episodes in patients with brain
lesions
'reatment of closed head in<uries
that cause acetylcholine release into
#S?, EE abnormalities, stupor,
neurologic signs
Rela1ation of uterine hypertonicity
=anagement of peptic ulcer
#ontrol of rhinorrhea of acute rhinitis
or hay fever
Antidote (with e1ternal cardiac
massage) for #: collapse from
overdose of parasympathomimetic
(cholinergic) drugs (choline esters,
pilocarpine), or cholinesterase
inhibitors (eg, physostigmine,
isoflurophate, organophosphorus
insecticides)
Antidote for poisoning by certain
species of mushroom (eg, Amanita
muscaria)
5phthalmic preparations
&iagnostically to produce mydriasis
and cycloplegia-pupillary dilation in
acute inflammatory conditions of the
iris and uveal tract
to anticholinergic drugs.
#ontraindicated with glaucoma0
adhesions between iris and lens0
stenosing peptic ulcer0
pyloroduodenal obstruction0 paralytic
ileus0 intestinal atony0 severe
ulcerative colitis0 to1ic megacolon0
symptomatic prostatic hypertrophy0
bladder nec" obstruction0 bronchial
asthma0 #5%&0 cardiac arrhythmias0
tachycardia0 myocardial ischemia0
impaired metabolic, liver, or "idney
function0 myasthenia gravis.
$se cautiously with &own syndrome,
brain damage, spasticity,
hypertension, hyperthyroidism,
lactation.
5phthalmic solution
#ontraindicated with glaucoma or
tendency to glaucoma.
A$ailable %orms
'ablets(*.8 mg0 in<ection(*.*-, *.+, *..,
*.8, *.-, *.), + mg2m30 ophthalmic ointment
(+G0 ophthalmic solution(*.-G, +G, ,G0
auto-in<ector(*.,-, *.-, +, , mg
Dosages
A!&L'
*.87*./ mg %5, !=, !:, or subcutaneously.
Hypotonic ra&iography: + mg !=.
Surgery: *.- mg (*.87*./ mg) != (or
subcutaneously or !:) prior to
induction of anesthesia0 during
surgery, give !:0 reduce dose to @
*.8 mg with cyclopropane
anesthesia.
40
Ara&yarrhythmias: *.87+ mg (up to
, mg) !: every +7, hr as needed.
Anti&ote: ?or poisoning due to
cholinesterase inhibitor insecticides,
give large doses of at least ,7. mg
parenterally, and repeat until signs of
atropine into1ication appear0 for
rapid type of mushroom poisoning,
give in doses sufficient to control
parasympathetic signs before coma
and #: collapse intervene. Auto-
in<ector provides rapid
administration.
5phthalmic solution
>or reraction: !nstill +7, drops into
eye(s) + hr before refracting.
>or uveitis: !nstill +7, drops into
eye(s) 4id.
P(!#A)#C PA#(N'
Refer to the following table:
Deight &ose (mg)
C7+/ lb (..,7C.. "g) *.+
+/7,8 lb (C..7+*.9 "g) *.+-
,878* lb (+*.97+).+ "g) *.,
8*7/- lb (+).+7,9.- "g) *..
/-79* lb (,9.-78*.) "g) *.8
B 9* lb (B 8*.) "g) *.87*./
Surgery: *.+ mg (newborn) to *./ mg
(+, yr) in<ected subcutaneously .*
min before surgery.
Anti&ote:
% E( l2: , mg auto-in<ector.
'(4E( l2: + mg auto-in<ector.
".4'( l2: *.- mg auto-in<ector.
! ". l2: *.,- mg auto-in<ector.
G()#A)#C PA#(N'
=ore li"ely to cause serious adverse
reactions, especially #AS reactions, in
elderly patients0 use with caution.
Pharmaco*inetics
!= +*7+- min .* min 8 hr
!: !mmediate ,78 min 8 hr
S# :aries +7, hr 8 hr
'opical -7+* min .*78*
min
C7+8
days
+2,
: ,.- hr
breast mil"
(,cretion+ $rine
IV acts
Preparation+ ive undiluted or dilute in +*
m3 sterile water.
#n%usion+ ive direct !:0 administer + mg or
less over + min.
Ad$erse e%%ects
CN'+ 6lurred vision, mydriasis,
cycloplegia, photophobia, increased
!5%, headache, flushing,
nervousness, wea"ness, di>>iness,
insomnia, mental confusion or
e1citement (after even small doses
in the elderly), nasal congestion
C-+ 1alpitations$ 2ra&ycar&ia (low
doses), tachycar&ia (higher doses)
G#+ =ry mouth$ altere& taste
perception$ nausea$ vomiting,
dysphagia, heartburn, constipation,
bloated feeling, paralytic ileus,
gastroesophageal reflu1
G&+ Brinary hesitancy an& retention<
impotence
1ther+ =ecrease& s6eating an&
pre&isposition to heat prostration$
suppression of lactation
5phthalmic preparations
Local+ ;ransient stinging
'ystemic+ Systemic adverse effects,
depending on amount absorbed
#nteractions
Drug-drug
!ncreased anticholinergic effects with
other drugs that have anticholinergic
41
activity(certain antihistamines,
certain antipar"insonian drugs,
'#As, =A5!s
&ecreased antipsychotic
effectiveness of haloperidol with
atropine
&ecreased effectiveness of
phenothia>ines, but increased
incidence of paralytic ileus
!f cholinesterase inhibitors and
atropine are given together,
opposing effects will render both
drugs ineffective
Assessment
anticholinergic drugs0 glaucoma0
adhesions between iris and lens0
stenosing peptic ulcer0
pyloroduodenal obstruction0 paralytic
ileus0 intestinal atony0 severe
ulcerative colitis0 to1ic megacolon0
symptomatic prostatic hypertrophy0
bladder nec" obstruction0 bronchial
asthma0 #5%&0 cardiac arrhythmias0
myocardial ischemia0 impaired
metabolic, liver, or "idney function0
myasthenia gravis0 &own syndrome0
brain damage0 spasticity0
hypertension0 hyperthyroidism0
lactation
Physical+ S"in color, lesions,
te1ture0 '0 orientation, refle1es,
bilateral grip strength0 affect0
ophthalmic e1amination0 %, 6%0 R,
adventitious sounds0 bowel sounds,
normal ! output0 normal urinary
output, prostate palpation0 3?'s,
renal function tests, E#
Interventions
Ensure ade4uate hydration0 provide
environmental control (temperature)
to prevent hyperpyre1ia.
;ave patient void before ta"ing
medication if urinary retention is a
problem.
Teacing points
Dhen used preoperatively or in other acute
situations, incorporate teaching about the
drug with teaching about the procedure0 the
ophthalmic solution is used mainly acutely
and will not be self-administered by the
patient0 the following apply to oral medication
for outpatients:
'a"e as prescribed, .* minutes
before meals0 avoid e1cessive
dosage.
Avoid hot environments0 you will be
heat intolerant, and dangerous
reactions may occur.
effects: &i>>iness, confusion (use
caution driving or performing
ha>ardous tas"s)0 constipation
(ensure ade4uate fluid inta"e, proper
diet)0 dry mouth (sugarless lo>enges,
fre4uent mouth care may help0 may
be transient)0 blurred vision,
sensitivity to light (reversible0 avoid
tas"s that re4uire acute vision0 wear
sunglasses in bright light)0 impotence
(reversible)0 difficulty in urination
(empty the bladder prior to ta"ing
drug).
Report rash0 flushing0 eye pain0
difficulty breathing0 tremors, loss of
coordination0 irregular heartbeat,
palpitations0 headache0 abdominal
distention0 hallucinations0 severe or
persistent dry mouth0 difficulty
swallowing0 difficulty in urination0
constipation0 sensitivity to light.
42
a6ithromycin
(ay >i thro my' sin)
0ithroma,, 0ma,
!ru" class
=acrolide antibiotic
herapeutic actions
6acteriostatic or bactericidal in susceptible
bacteria.
#ndications
'reatment of lower respiratory
infections: Acute bacterial
e1acerbations of #5%& due to H/
inluenzae$ 7oraxella catarrhalis$ S/
pneumoniae< community-ac4uired
pneumonia due to S/ pneumoniae$
H/ inluenzae
'reatment of lower respiratory
infections: Streptococcal pharyngitis
and tonsillitis due to Streptococcus
pyogenes in those who cannot ta"e
penicillins
'reatment of uncomplicated s"in
infections due to Staphylococcus
aureus$ S/ pyogenes$ Streptococcus
agalactiae
'reatment of nongonococcal
urethritis and cervicitis due to C/
trachomatis< treatment of %!&
'reatment of acute sinusitis
'reatment of otitis media caused by
H/ inluenzae$ 7/ catarrhalis$ S/
pneumoniae in children B / mo
'reatment of pharyngitis and
tonsillitis in children B , yr who
cannot use first-line therapy
%revention and treatment of
disseminated 7yco2acterium avium
comple1 (=A#) in patients with
advanced A!&S
'reatment of patients with mild to
moderate acute bacterial sinusitis
caused by H/ inluenzae$ 7oracellis
catarrhalis$ Streptococcus
pneumoniae +Fmax-
'reatment of mild to moderate
community-ac4uired pneumonia
caused by Chlamy&ophila
pneumoniae$ H/ inluenzae$
7ycoplasma pneumoniae$
Streptococcus pneumoniae +Fmax-
$nlabeled uses: $ncomplicated
gonococcal infections caused by N/
gonorrhoeae< gonococcal pharyngitis
caused by N/ gonorrhoeae<
chlamydial infections caused by C/
trachomatis< prophyla1is after se1ual
attac"
to a>ithromycin, erythromycin, or any
macrolide antibiotic.
$se cautiously with gonorrhea or
syphilis, pseudomembranous colitis,
hepatic or renal impairment,
lactation.
A$ailable %orms
'ablets(,-*, -**, /** mg0 powder for
in<ection(-** mg0 powder for oral
suspension(+** mg2- m3, ,** mg2- m3, +
g2pac"et0 bottles(, g to be reconstituted
with /* m3 water (Fmax)
Dosages
A!&L'
7il& to mo&erate acute 2acterial
exacer2ations o C01=$ pneumonia$
pharyngitis an& tonsillitis +as secon&-
line-: -** mg %5 single dose on first
day, followed by ,-* mg %5 daily on
days ,7- for a total dose of +.- g or
-** mg2day %5 for . days.
Nongonococcal urethritis an&
cervicitis &ue to #. trachomatis: A
single +-g %5 dose.
43
9onococcal urethritis an& cervicitis:
A single dose of , g %5.
=isseminate& 7AC inections: ?or
prevention, +,,** mg %5 ta"en once
wee"ly. ?or treatment, /** mg2day
%5 with etambutol.
Acute sinusitis: -** mg2day %5 for .
days.
7il& to mo&erate acute 2acterial
sinusitis$ community-ac*uire&
pneumonia: , g2day %5 as a single
dose (Fmax).
P(!#A)#C PA#(N'
0titis me&ia: !nitially, +* mg2"g %5
as a single dose, then - mg2"g on
days ,7- or .* mg2"g %5 as a single
dose.
Community-ac*uire& pneumonia:
+* mg2"g %5 as a single dose on
first day, then - mg2"g %5 on days
,7-.
1haryngitis or tonsillitis:
+, mg2"g2day %5 on days +7-.
Acute sinusitis: +* mg2"g2day %5 for
. days.
Pharmaco*inetics
5ral :aries ,.-7..,
hr
,8 hr
Metabolism+ '
+2,
: ++78) hr
breast mil"
(,cretion+ 6ile, urine(unchanged
Ad$erse e%%ects
CN'+ &i>>iness, headache, vertigo,
somnolence, fatigue
G#+ =iarrhea$ a2&ominal pain$
nausea$ dyspepsia, flatulence,
vomiting, melena,
pseudomembranous colitis
1ther+ Superinections$
an"ioedema, rash, photosensitivity,
vaginitis
#nteractions
Drug-drug
&ecreased serum levels and
effectiveness of a>ithromycin with
aluminum and magnesium-
containing antacids
%ossible increased effects of
theophylline
%ossible increased anticoagulant
effects of warfarin
Drug-!ood
?ood greatly decreases the
absorption of a>ithromycin
Assessment
a>ithromycin, erythromycin, or any
macrolide antibiotic0 gonorrhea or
syphilis, pseudomembranous colitis,
hepatic or renal impairment, lactation
Physical+ Site of infection0 s"in
color, lesions0 orientation, ! output,
bowel sounds, liver evaluation0
culture and sensitivity tests of
infection, urinalysis, 3?'s, renal
function tests
Interventions
#ulture site of infection before
therapy.
Administer on an empty stomach +
hr before or ,7. hr after meals. ?ood
affects the absorption of this drug.
%repare Oma1 by adding /* m3
water to bottle, sha"e well.
#ounsel patients being treated for
S'&s about appropriate precautions
and additional therapy.
Teacing points
44
'a"e the full course prescribed. &o
not ta"e with antacids. 'ablets and
oral suspension can be ta"en with or
without food.
%repare Oma1 by adding /* m3 (+28
cup) water to bottle, sha"e well, drin"
all at once.
effects: Stomach cramping,
discomfort, diarrhea0 fatigue,
headache (medication may help)0
additional infections in the mouth or
vagina (consult with health care
provider for treatment).
Report severe or watery diarrhea,
severe nausea or vomiting, rash or
itching, mouth sores, vaginal sores.
beclomethasone dipropionate
(be "loe meth' a sone)
Apo-/eclomethasone (CAN), /eclodis*
(CAN), /eclo%orte #nhaler (CAN),
/eclo$ent )otacaps (CAN), /econase AH,
Propaderm (CAN), H-A)
!ru" classes
#orticosteroid
lucocorticoid
;ormone
herapeutic actions
Anti-inflammatory effects0 local administration
into lower respiratory tract or nasal passages
ma1imi>es beneficial effects on these tissues
while decreasing the li"elihood of adverse
corticosteroid effects from systemic
absorption.
#ndications
Respiratory inhalant use: #ontrol of
bronchial asthma that re4uires
corticosteroids along with other
therapy
!ntranasal use: Relief of symptoms of
seasonal or perennial rhinitis that
respond poorly to other treatments0
prevention of recurrence of nasal
polyps following surgical removal
Respiratory inhalant therapy:
#ontraindicated with acute asthmatic
attac", status asthmaticus. $se
caution with systemic fungal
infections (may cause e1cerbations),
allergy to any ingredient, lactation
!ntranasal therapy: $se caution with
untreated local infections (may
cause e1acerbations)0 nasal septal
ulcers, recurrent epista1is, nasal
surgery or trauma (interferes with
healing)0 lactation
A$ailable %orms
Aerosol(8* mcg2actuation,
)* mcg2actuation0 nasal spray(*.*8,G
Dosages
Respiratory inhalant use
A!&L' AN! C.#L!)(N = AA 8)
8*7+/* mcg bid. &o not e1ceed .,*
mcg2bid.
P(!#A)#C PA#(N' ?>AA 8)
8* mcg bid. &o not e1ceed )* mcg bid.
P(!#A)#C PA#(N' 9 ? 8)
&o not use.
!ntranasal therapy
Each actuation delivers 8, mcg. &iscontinue
therapy after . w" if no significant
symptomatic improvement.
A!&L' AN! C.#L!)(N = AA 8)
5ne to two inhalations (8,7)8 mcg) in each
nostril bid (total dose +/)7../ mcg2day).
P(!#A)#C PA#(N' I>AA 8)
5ne inhalation in each nostril bid. 'otal dose,
+/) mcg. Dith more severe symptoms, may
45
increase to two inhalation in each nostril bid
(../ mcg).
Pharmaco*inetics
Route 5nset %ea"
!nhalation Rapid +7, w"
Metabolism+ 3ungs, !, and liver0 '
+2,
: .7+-
hr
breast mil"
(,cretion+ ?eces
Ad$erse e%%ects
Respiratory inhalant use
(ndocrine+ #ushingHs syndrome
with overdose, suppression of
hypothalamic-pituitary-adrenal (;%A)
function due to systemic absorption
Local+ 0ral$ laryngeal$ pharyngeal
irritation$ fungal infections
!ntranasal use
Local+ Aasal irritation, fungal
infections
)espiratory+ @pistaxis$ re2oun&
congestion$ perforation of the nasal
septum, anosmia
1ther+ Hea&ache$ nausea$ urticaria
Assessment
.istory+ Acute asthmatic attac",
status asthmaticus0 systemic fungal
infections0 allergy to any ingredient0
lactation0 untreated local infections,
nasal septal ulcers, recurrent
epista1is, nasal surgery or trauma
Physical+ Deight, '0 %, 6%,
auscultation0 R, adventitious sounds0
chest radiograph before respiratory
inhalant therapy0 e1amination of
nares before intranasal therapy
Interventions
2A)N#NG+ 'aper systemic steroids
carefully during transfer to
inhalational steroids0 deaths resulting
from adrenal insufficiency have
occurred during and after transfer
from systemic to aerosol steroids.
$se decongestant nose drops to
facilitate penetration of intranasal
steroids if edema, e1cessive
secretions are present.
Teacing points
'his respiratory inhalant has been
prescribed to prevent asthmatic
attac"s, not for use during an attac".
Allow at least + minute between
puffs (respiratory inhalant)0 if you
also are using an inhalational
bronchodilator (isoproterenol,
albuterol, metaproterenol,
epinephrine), use it several minutes
before using the steroid aerosol.
Rinse your mouth after using the
respiratory inhalant aerosol.
$se a decongestant before the
intranasal steroid, and clear your
nose of all secretions if nasal
passages are bloc"ed0 intranasal
steroids may ta"e several days to
produce full benefit.
$se this product e1actly as
prescribed0 do not ta"e more than
prescribed, and do not stop ta"ing
the drug without consulting your
health care provider. 'he drug must
not be stopped abruptly but must be
slowly tapered.
effects: 3ocal irritation (use the
device correctly), headache (consult
your health care provider for
treatment).
Report sore throat or sore mouth.
46
bena6epril hydrochloride
(ben a' >a pril)
Lotensin
Pregnancy Category C %!irst trimester&
Pregnancy Category D %second, tird
trimesters&
!ru" classes
Antihypertensive
A#E inhibitor
herapeutic actions
6loc"s A#E from converting angiotensin ! to
angiotensin !!, a potent vasoconstrictor,
leading to decreased 6%, decreased
aldosterone secretion, a small increase in
serum potassium levels, and sodium and
fluid loss0 increased prostaglandin synthesis
also may be involved in the antihypertensive
action.
#ndications
'reatment of hypertension alone or
in combination with thia>ide-type
diuretics
bena>epril or other A#E inhibitors,
second or third trimester of
pregnancy.
$se cautiously with impaired renal
function, immunosuppresion, #;?,
hypotension, salt or volume
depletion, lactation, first trimester of
pregnancy.
A$ailable %orms
'ablets(-, +*, ,*, 8* mg
Dosages
A!&L'
!nitial dose, +* mg %5 daily. =aintenance
dose, ,*78* mg2day %5, single or two
divided doses. %atients using diuretics
should discontinue them ,7. d prior to
bena>epril therapy. !f 6% is not controlled,
add diuretic slowly. !f diuretic cannot be
discontinued, begin bena>epril therapy with
- mg. =a1imum dose, )* mg.
P(!#A)#C PA#(N'
PA#(N' 2#. )(NAL #MPA#)M(N
?or creatinine clearance @ .* m32min (serum
creatinine B . mg2d3), - mg %5 daily.
&osage may be gradually increased until 6%
is controlled, up to a ma1imum of 8* mg2day.
Pharmaco*inetics
5ral *.-7+ hr .78 hr ,8 hr
+2,
: +*7++ hr
breast mil"
(,cretion+ $rine
Ad$erse e%%ects
C-+ Angina pectoris, hypotension in
salt- or volume-depleted patients,
palpitations
diaphoresis, flushing
G#+ Nausea$ abdominal pain,
vomiting, constipation
)espiratory+ Cough$ asthma,
bronchitis, dyspnea, sinusitis
1ther+ Angioedema, impotence,
decreased libido, asthenia, myalgia,
arthralgia
#nteractions
Drug-drug
!ncreased ris" of hypersensitivity
reactions with allopurinal
!ncreased coughing with capsaicin
47
with indomethacin and other ASA!&s
!ncreased lithium levels and
neuroto1icity may occur if combined
!ncreased ris" of hyper"alemia with
potassium-sparing diuretics or
potassium supplements
Assessment
.istory+ Allergy to bena>epril or
other A#E inhibitors, impaired renal
function, #;?, salt or volume
depletion, lactation, pregnancy
Physical+ S"in color, lesions, turgor0
'0 %, 6%, peripheral perfusion0
mucous membranes, bowel sounds,
liver evaluation0 urinalysis, 3?'s,
renal function tests, #6# and
differential
Interventions
2A)N#NG+ Alert surgeon, note use
of bena>epril on patientHs chart0 the
angiotensin !! formation subse4uent
to compensatory renin release
during surgery will be bloc"ed0
hypotension may be reversed with
volume e1pansion.
=onitor patient for possible fall in 6%
secondary to reduction in fluid
volume (e1cessive perspiration and
dehydration, vomiting, diarrhea)
because e1cessive hypotension may
occur.
2A)N#NG+ Ensure that patient is
not pregnant0 fetal abnormalities and
death have occurred if using during
second or third trimester. Encourage
use of contraceptive measures.
Reduce dosage in patients with
impaired renal function.
Teacing points
&o not stop ta"ing the medication
without consulting your health care
provider.
6e careful in any situation that may
lead to a drop in blood pressure
(diarrhea, sweating, vomiting,
dehydration)0 if light-headedness or
di>>iness occurs, consult your health
care provider.
Fou should not become pregnant
while on this drug. Serious fetal
abnormalities could occur0 use of
contraceptives is advised.
effects: ! upset, loss of appetite
(transient effects0 if persistent
consult health care provider)0 light-
headedness (transient0 change
position slowly, and limit activities to
those that do not re4uire alertness
and precision)0 dry cough (irritating
but not harmful0 consult health care
provider).
Report mouth sores0 sore throat,
fever, chills0 swelling of the hands,
feet0 irregular heartbeat, chest pains0
swelling of the face, eyes, lips,
tongue, difficulty breathing,
persistent cough.
betamethasone
(bay ta meth' a sone)
betamethasone
Topical dermatologic ointment, cream,
lotion, gel
betamethasone dipropionate
lotion, aerosol:
48
!iprolene, !iprolene A3, !iprosone,
Ma,i$ate, aro-'one (CAN), eladar
betamethasone sodium phosphate
Systemic, including I) and local in0ection:
/etnesol (CAN), Celestone Phosphate
betamethasone sodium phosphate and
acetate
Systemic, I1, and local intra-articular,
intralesional, intradermal in0ection:
Celestone 'oluspan
betamethasone $alerate
lotion:
/etaderm (CAN), /eta--al, Celestoderm
(CAN), Lu,iq, Pre$e, / (CAN), Psorion
Cream, -alisone
!ru" classes
#orticosteroid (long acting)
lucocorticoid
;ormone
herapeutic actions
6inds to intracellular corticosteroid receptors,
thereby initiating many natural comple1
reactions that are responsible for its anti-
inflammatory and immunosuppressive
effects.
#ndications
;ypercalcemia associated with
cancer
Short-term management of
inflammatory and allergic disorders,
such as rheumatoid arthritis,
collagen diseases (eg S3E),
dermatologic diseases (eg
pemphigus), status asthmaticus, and
autoimmune disorders
;ematologic disorders:
'hrombocytopenia purpura,
erythroblastopenia
$lcerative colitis, acute
e1acerbations of =S, and palliation
in some leu"emias and lymphomas
'richinosis with neurologic or
myocardial involvement
!ntra-articular or soft-tissue administration
Arthritis, psoriatic pla4ues, and so
forth
&ermatologic preparations
Relief of inflammatory and pruritic
manifestations of steroid-responsive
dermatoses
Systemic (oral and parenteral) administration
#ontraindicated with infections,
especially tuberculosis, fungal
infections, amebiasis, vaccinia and
varicella, and antibiotic-resistant
infections, lactation.
All forms
$se cautiously with "idney or liver
disease, hypothyroidism, ulcerative
colitis with impending perforation,
diverticulitis, active or latent peptic
ulcer, inflammatory bowel disease,
#;?, hypertension, thromboembolic
disorders, osteoporosis, sei>ure
disorders, diabetes mellitus.
A$ailable %orms
'ablets(*./ mg0 syrup(*./ mg2- m30
in<ection(8 mg, . mg betamethasone
sodium phosphate with . mg betamethasone
acetate0 ointment(*.+G, *.*-G0 cream(
*.*+G, *.*-G, *.+G0 lotion(*.+G, *.*-G0
gel(*.*-G
Dosages
A!&L'
!ndividuali>e dosage, based on severity and
response. ive daily dose before 9 A= to
49
minimi>e adrenal suppression. Reduce initial
dose in small increments until the lowest
dose that maintains satisfactory clinical
response is reached. !f long-term therapy is
needed, alternate-day therapy with a short-
acting corticosteroid should be considered.
After long-term therapy, withdraw drug slowly
to prevent adrenal insufficiency.
0ral +2etamethasone-: !nitial dosage,
*./7C., mg2day
IV +2etamethasone so&ium
phosphate-: !nitial dosage, up to
9 mg2day.
I7 +2etamethasone so&ium
phosphate< 2etamethasone so&ium
phosphate an& acetate-: !nitial
dosage, *.-79 mg2day. &osage
range is one-third to one-half oral
dose given 4 +, hr. !n life-threatening
situations, dose can be in multiples
of the oral dose.
!ntrabursal, intra-articular, intradermal,
intralesional (betamethasone sodium
phosphate and acetate)
*.,-7, m3 intra-articular, depending on <oint
si>e0 *., m32cm
.
intradermally, not to e1ceed
+ m32w"0 *.,-7+ m3 at .- to C-day intervals
for disorders of the foot.
'opical dermatologic cream, ointment
(betamethasone dipropionate)
Apply sparingly to affected area bid74id.
P(!#A)#C PA#(N'
!ndividuali>e dosage on the basis of severity
and response rather than by formulae that
correct adult doses for age or weight.
#arefully observe growth and development in
infants and children on prolonged therapy.
Pharmaco*inetics
Route 5nset &uration
Systemic :aries . days
+2,
: ./7-8 hr
breast mil"
IV acts
Preparation+ Ao further preparation needed.
#n%usion+ !nfuse by direct !: in<ection over +
min or into the tubing of running !: of
de1trose or saline solutions.
Ad$erse e%%ects
CN'+ Vertigo$ hea&ache$
paresthesias, insomnia, sei>ures,
psychosis, cataracts, increased !5%,
glaucoma (in long-term therapy)
C-+ ;ypotension, shoc",
hypertension, and #;? secondary to
fluid retention, thromboembolism,
thrombophlebitis, fat embolism,
cardiac arrhythmias
(lectrolyte imbalance+ Na
G
an&
lui& retention$ hypo"alemia,
hypocalcemia
(ndocrine+ Amenorrhea, irregular
menses, growth retardation,
decreased carbohydrate tolerance,
diabetes mellitus, cushingoid state
(long-term effect), increased blood
sugar, increased serum cholesterol,
decreased '
.
and '
8
levels,
hypothalamic-pituitary-adrenal (;%A)
suppression with systemic therapy
longer than - days
G#+ %eptic or esophageal ulcer,
pancreatitis, abdominal distention,
nausea, vomiting, increase&
appetite$ 6eight gain +long-term
therapy-
Musculos*eletal+ =uscle
wea"ness, steroid myopathy, loss of
muscle mass, osteoporosis,
spontaneous fractures (long-term
therapy)
1ther+ Immunosuppression$
aggravation$ or masking o
inections< impaire& 6oun& healing<
thin, fragile s"in0 petechiae,
ecchymoses, purpura, striae0
50
subcutaneous fat atrophy0
hypersensitivity or anaphylactoid
reactions
'he following effects are related to various
local routes of steroid administration:
#ntra-articular+ 5steonecrosis,
tendon rupture, infection
#ntralesional therapy+ 6lindness
when applied to face and head
opical dermatolo"ic ointments,
creams, sprays+ Local 2urning$
irritation$ acneiform lesions, striae,
s"in atrophy
#nteractions
Drug-drug
Ris" of severe deterioration of
muscle strength in myasthenia gravis
patients receiving ambenonium,
edrophonium, neostigmine,
pyridostigmine
&ecreased steroid blood levels with
barbiturates, phenytoin, rifampin
&ecreased effectiveness of
salicylates with betamethasone
Drug-lab test
?alse-negative nitroblue-tetra>olium
test for bacterial infection
Suppression of s"in test reactions
Assessment
.istory (systemic administration)+
!nfections, fungal infections,
amebiasis, vaccinia and varicella,
and antibiotic-resistant infections0
"idney or liver disease0
hypothyroidism0 ulcerative colitis with
impending perforation0 diverticulitis0
active or latent peptic ulcer0
inflammatory bowel disease0 #;?0
hypertension0 thromboembolic
disorders0 osteoporosis0 sei>ure
disorders0 diabetes mellitus0 lactation
Physical+ 6aseline weight, ',
refle1es and grip strength, affect and
orientation, %, 6%, peripheral
perfusion, prominence of superficial
veins, R and adventitious sounds,
serum electrolytes, blood glucose
Interventions
Systemic use
ive daily dose before 9 A= to
mimic normal pea" corticosteroid
blood levels.
!ncrease dosage when patient is
sub<ect to stress.
'aper doses when discontinuing
high-dose or long-term therapy.
&o not give live virus vaccines with
immunosuppressive doses of
corticosteroids.
'opical dermatologic preparations
E1amine area for infections, s"in
integrity before application.
Administer cautiously to pregnant
patients0 topical corticosteroids have
caused teratogenic effects and can
be absorbed from systemic site.
2A)N#NG+ $se caution when
occlusive dressings or tight diapers
cover affected area0 these can
increase systemic absorption of the
drug.
Avoid prolonged use near eyes, in
genital and rectal areas, and in s"in
creases.
Teacing points
Systemic use
&o not stop ta"ing the oral drug
without consulting your health care
provider.
'a"e single dose or alternate-day
doses before 9 A=.
Avoid e1posure to infections0 ability
to fight infections is reduced.
51
Dear a medical alert tag so
emergency care providers will "now
that you are on this medication.
effects: !ncrease in appetite, weight
gain (counting calories may help)0
heartburn, indigestion (eat fre4uent
small meals0 ta"e antacids)0 poor
wound healing (consult with your
care provider)0 muscle wea"ness,
fatigue (fre4uent rest periods will
help).
Report unusual weight gain, swelling
of the e1tremities, muscle wea"ness,
blac" or tarry stools, fever, prolonged
sore throat, colds or other infections,
worsening of original disorder.
!ntrabursal, intra-articular therapy
&o not overuse <oint after therapy,
even if pain is gone.
'opical dermatologic preparations
Apply sparingly0 do not cover with
tight dressings.
Avoid contact with the eyes.
Report irritation or infection at the
site of application.
bisoprolol %umarate
(bis oh' pro lole)
0ebeta
!ru" classes
6eta-selective adrenergic bloc"er
Antihypertensive
herapeutic actions
6loc"s beta-adrenergic receptors (primarily
beta
+
) of the sympathetic nervous system in
the heart and <u1taglomerular apparatus
("idney), thus decreasing the e1citability of
the heart, decreasing cardiac output and
o1ygen consumption, decreasing the release
of renin from the "idney, and lowering 6%.
#ndications
=anagement of hypertension, used
alone or with other antihypertensives
#ontraindicated with sinus
bradycardia, second- or third-degree
heart bloc", cardiogenic shoc", #;?.
$se cautiously with renal failure,
diabetes or thyroto1icosis (bisoprolol
can mas" the usual cardiac signs of
hypoglycemia and thyroto1icosis),
pregnancy, lactation, and in those
with bronchospastic disease.
A$ailable %orms
'ablets(-, +* mg
Dosages
A!&L'
!nitially, - mg %5 daily, alone or added to
diuretic therapy0 ,.- mg may be appropriate0
up to ,* mg %5 daily has been used.
P(!#A)#C PA#(N'
PA#(N' 2#. )(NAL 1) .(PA#C
#MPA#)M(N
!nitially, ,.- mg %50 ad<ust, and use e1treme
caution.
Pharmaco*inetics
5ral .*7/*
min
, hr +,7+- hr
+2,
: 97+, hr
breast mil"
(,cretion+ $rine
Ad$erse e%%ects
Aller"ic reactions+ %haryngitis,
erythematous rash, fever, sore
52
throat, laryn"ospasm, respiratory
distress
CN'+ &i>>iness, vertigo, tinnitus,
atigue$ emotional depression,
paresthesias, sleep disturbances,
hallucinations, disorientation,
memory loss, slurred speech
C-+ Ara&ycar&ia$ CH>$ car&iac
arrhythmias$ sinoatrial or AV no&al
2lock$ tachycar&ia$ peripheral
vascular insufficiency, claudication,
#:A, pulmonary edema,
hypotension
sweating, dry s"in
((N+ Eye irritation, dry eyes,
con<unctivitis, blurred vision
G#+ 9astric pain$ latulence$
constipation$ &iarrhea$ nausea$
vomiting$ anore1ia, ischemic colitis,
renal and mesenteric arterial
thrombosis, retroperitoneal fibrosis,
hepatomegaly, acute pancreatitis
G&+ Impotence$ &ecrease& li2i&o$
%eyronieHs disease, dysuria,
nocturia, fre4uent urination
Musculos*eletal+ Noint pain,
arthralgia, muscle cramp
)espiratory+ /ronchospasm,
dyspnea, cough, bronchial
obstruction, nasal stuffiness, rhinitis,
pharyngitis (less li"ely than with
propranolol)
1ther+ =ecrease& exercise
tolerance$ &evelopment o
antinuclear anti2o&ies$
hyperglycemia or hypoglycemia,
elevated serum transaminase,
al"aline phosphatase, and 3&;
#nteractions
Drug-drug
!ncreased effects with verapamil,
anticholinergics
!ncreased ris" of orthostatic
hypotension with pra>osin
%ossible increased 6%-lowering
effects with aspirin, bismuth
subsalicylate, magnesium salicylate,
sulfinpyra>one, hormonal
contraceptives
with ASA!&s
%ossible increased hypoglycemic
effect of insulin
Drug-lab test
%ossible false results with glucose or
insulin tolerance tests
CL#N#CAL AL()4
Name con!usion as occurred bet"een
.ebeta %bisoprolol& and DiaBeta
%glyburide&' use caution(
Assessment
.istory+ Sinus bradycardia, cardiac
arrhythmias, cardiogenic shoc",
#;?, renal failure, diabetes or
thyroto1icosis, pregnancy, lactation
Physical+ 6aseline weight, s"in
condition, neurologic status, %, 6%,
E#, R, 3?'s, renal function tests,
blood and urine glucose
Interventions
2A)N#NG+ &o not discontinue drug
abruptly after long-term therapy
(hypersensitivity to catecholamines
may have developed, causing
e1acerbation of angina, =!, and
ventricular arrhythmias). 'aper drug
gradually over , w" with monitoring.
#onsult with physician about
withdrawing drug if patient is to
undergo surgery (withdrawal is
controversial).
Teacing points
53
&o not stop ta"ing this drug unless
instructed to do so by a health care
provider.
Avoid over-the-counter medications.
Avoid driving or dangerous activities
if di>>iness, wea"ness occur.
effects: &i>>iness, light-headedness,
loss of appetite, nightmares,
depression, se1ual impotence.
Report difficulty breathing, night
cough, swelling of e1tremities, slow
pulse, confusion, depression, rash,
fever, sore throat.
brompheniramine maleate
(parabromdylamine maleate)
(brome fen irH a meen)
/idhist, /ro$e7, /ro$e7 C, Lodrane 7),
Lo.ist A: .our, -a0ol
!ru" class
Antihistamine (al"ylamine type)
herapeutic actions
#ompetitively bloc"s the effects of histamine
at ;
+
-receptor sites0 has anticholinergic
(atropine-li"e), antipruritic, and sedative
effects.
#ndications
Symptomatic relief of symptoms
associated with perennial and
seasonal allergic rhinitis(runny
nose, snee>ing, itching nose and
throat, watery eyes

#ontraindicated with allergy to any
antihistamines, allergy to tartra>ine
(Arove: C;), third trimester of
pregnancy (newborn or premature
infants may have severe reactions).
$se cautiously with lactation,
narrow-angle glaucoma, stenosing
peptic ulcer, symptomatic prostatic
hypertrophy, asthma attac", bladder
nec" obstruction, pyloroduodenal
obstruction. $se cautiously in the
elderly (this population is e1tremely
sensitive to anticholinergic side
effects of this drug).
A$ailable %orms
#hewable tablets(+, mg0 ER tablets(
/ mg0 ER capsules(+, mg0 li4uid(
, mg2- m30 oral suspension() mg2- m3,
+, mg2- m3
Dosages
A!&L' AN! P(!#A)#C PA#(N' = A:
8)
ER tablets: /7+, mg %5 4 +, hr. #hewable
tablets: +,7,8 mg %5 4 +, hr, ma1imum
8) mg2day. ER capsules: +,7,8 mg2day %5.
5ral suspension (Arove:): -7+* m3 (+,7
,8 mg) %5 4 +, hr0 ma1imum 8) mg2day.
5ral li4uid: +* m3 (8 mg) %5 8 times2day.
5ral suspension (Lo&rane :5): - m3 %5 4
+, hr0 do not e1ceed , doses2day.
P(!#A)#C PA#(N' I>A: 8)
ER tablets: / mg %5 4 +, hr. #hewable
tablets: /7+, mg %5 4 +, hr, ma1imum
,8 mg2day. ER capsules: +, mg2day %5.
5ral li4uid: - m3 (, mg) %5 8 times2day. 5ral
suspension (Arove:): - m3 (+, mg) %5 4 +,
hr0 ma1imum ,8 mg2day. 5ral suspension
(Lo&rane :5): ,.- m3 %5 4 +, hr0 up to -
m32day.
P(!#A)#C PA#(N' :>I 8)
#hewable tablets: / mg %5 4 +, hr0
ma1imum +, mg2day. 5ral li4uid: ,.- m3
(+ mg) %5 8 times2day. 5ral suspension
(Arove:): ,.- m3 (/ mg) %5 4 +, hr up to
+, mg2day. 5ral suspension (Lo&rane :5):
+.,- m3 %5 4 +, hr0 ma1imum ,.- mg2day.
54
P(!#A)#C PA#(N' A: M1>I 8)
5ral suspension: +.,- m3 (. mg) %5 4 +, hr
up to ,.- m3 (/ mg)2day. 5ral li4uid: 'itrate
dose based on *.- mg2"g2day %5 in e4ually
divided doses four times2day.
G()#A)#C PA#(N'
=ore li"ely to cause di>>iness, sedation,
syncope, to1ic confusional states, and
hypotension in elderly patients0 use with
caution.
Pharmaco*inetics
5ral +-7.* min +7, hr 87/ hr
+2,
: +,7.- hr
breast mil"
(,cretion+ $rine
Ad$erse e%%ects
CN'+ =ro6siness$ se&ation$
&izziness$ aintness$ &istur2e&
coor&ination$ fatigue, confusion,
restlessness, e1citation,
nervousness, tremor, headache,
blurred vision, diplopia, vertigo,
tinnitus, acute labyrinthitis, hysteria,
tingling, heaviness and wea"ness of
the hands
C-+ ;ypotension, palpitations,
bradycardia, tachycardia,
e1trasystoles
G#+ @pigastric &istress$ anore1ia,
increased appetite and weight gain,
nausea, vomiting, diarrhea or
constipation
G&+ $rinary fre4uency, dysuria,
urinary retention, early menses,
decreased libido, impotence
.ematolo"ic+ ;emolytic anemia,
hypoplastic anemia,
agranulocytosis, pancytopenia
.ypersensiti$ity+ $rticaria, rash,
anaphylactic shoc*,
photosensitivity
)espiratory+ ;hickening o
2ronchial secretions$ chest tightness,
whee>ing, nasal stuffiness, dry
mouth, dry nose, dry throat, sore
throat
#nteractions
Drug-drug
!ncreased sedation with alcohol,
other #AS depressants
!ncreased and prolonged
anticholinergic (drying) effects with
=A5!s
Assessment
.istory+ Allergy to any
antihistamines, tartra>ine, narrow-
angle glaucoma, stenosing peptic
ulcer, symptomatic prostatic
hypertrophy, asthmatic attac",
bladder nec" obstruction,
pyloroduodenal obstruction, third
trimester of pregnancy, lactation
Physical+ S"in color, lesions,
te1ture0 orientation, refle1es, affect0
vision e1amination0 %, 6%0 R,
adventitious sounds0 bowel sounds0
prostate palpation0 #6# with
differential
Interventions
ive orally with food if ! upset
occurs.
Teacing points
'a"e as prescribed0 avoid e1cessive
dosage0 ta"e with food if ! upset
occurs.
Avoid alcohol while on this drug0
serious sedation could occur.
5ral li4uid and oral suspensions
differ in strength0 do not use
interchangeably.
55
effects: &i>>iness, sedation,
drowsiness (use caution if driving or
performing tas"s that re4uire
alertness)0 epigastric distress,
diarrhea or constipation (ta"e with
meals)0 dry mouth (fre4uent mouth
care, suc"ing sugarless lo>enges
may help)0 thic"ening of bronchial
secretions, dryness of nasal mucosa
(try a humidifier).
Report difficulty breathing,
hallucinations, tremors, loss of
coordination, unusual bleeding or
bruising, visual disturbances,
irregular heartbeat.
budesonide
(bue des' oh nide)
Inalation:
(ntocort (CAN), Pulmicort )espules,
Pulmicort urbuhaler, )hinocort Aqua,
)hinocort urbuhaler (CAN)
Oral:
(ntocort (C
!ru" class
#orticosteroid
herapeutic actions
Anti-inflammatory effect0 local administration
into nasal passages ma1imi>es beneficial
effects on these tissues, while decreasing the
li"elihood of adverse effects from systemic
absorption.
#ndications
=anagement of symptoms of
seasonal or perennial allergic rhinitis
in adults and children0 nonallergic
perennial rhinitis in adults
;ur2uhaler
=aintenance treatment of asthma as
prophylactic therapy in adults and
children B / yr and for patients
re4uiring corticosteroids for asthma
!nhalation suspension
=aintenance treatment and
prophyla1is therapy of asthma in
children +, mo7) yr
5ral
'reatment of mild to moderate active
#rohnHs disease involving the ileum
or ascending colon
!nhalation
to drug or for relief of acute asthma
or bronchospasm.
$se cautiously with '6, systemic
infections, lactation.
5ral
to drug, lactation.
$se cautiously with '6,
hypertension, diabetes mellitus,
osteoporosis, peptic ulcer disease,
glaucoma, cataracts, family history of
diabetes or glaucoma, other
conditions in which
glucocorticosteroids may have
unwanted effects.
Aasal
to drug, nasal infections, nasal
trauma, nasal septal ulcers, recent
nasal surgery.
$se cautiously with lactation, '6,
systemic infection.
A$ailable %orms
Aerosol(., mcg2actuation0 dry powder for
inhalation(,** mcg (each actuation delivers
+/* mcg)0 inhalation suspension(*.,- mg2,
m3, *.- mg2, m30 capsules(. mg
56
Dosages
Aasal inhalation
A!&L' AN! PA#(N' = I 8)
!nitial dose, /8 mcg2day given as + spray in
each nostril morning and evening. After
desired clinical effect is achieved, reduce
dose to the smallest dose possible to
maintain the control of symptoms. enerally
ta"es .7C days to achieve ma1imum clinical
effect.
%ulmicort 'urbuhaler
A!&L'
1reviously on inhale& corticosteroi&s: !nitially,
,**78** mcg twice daily, ma1imum dose,
)** mcg bid (8 inhalations).
1reviously on 2roncho&ilators alone: ,**7
8** mcg bid.
1reviously on oral corticosteroi&s: 8**7
)** mcg bid.
P(!#A)#C PA#(N'
Chil&ren % 3 yr previously on inhale&
corticosteroi&s: ,** mcg bid.
Chil&ren % 3 yr previously on 2roncho&ilators
alone: ,** mcg bid.
Chil&ren % 3 yr previously on oral
corticosteroi&s: 8** mcg bid.
Respules
P(!#A)#C PA#(N' A: M1>E 8)
*.,-7+ mg once daily or in two divided doses
of 5espules$ using <et nebuli>er.
5ral
A!&L'
9 mg2day %5 ta"en in the morning for up to )
w". Recurrent episodes may be retreated for
)-w" periods. =aintenance treatment,
/ mg2day %5 for up to . mo, then taper until
cessation is complete.
P(!#A)#C PA#(N'
PA#(N' 2#. .(PA#C #MPA#)M(N
=onitor patients very closely for signs of
hypercorticism0 reduced dosage should be
considered with these patients.
Pharmaco*inetics
!ntranasal,
inhaled
!mmediate Rapid )7+, hr
5ral Slow *.-7
+* hr
$n"nown
+2,
: ,7../ hr (oral)0
'
+2,
: ,.) hr (inhalation)
breast mil"
(,cretion+ $rine
Ad$erse e%%ects
CN'+ Hea&ache$ &izziness$ lethargy,
atigue$ paresthesias, nervousness
!ermatolo"ic+ Rash, edema,
pruritus, alopecia
(ndocrine+ ;%A suppression,
#ushingHs syndrome with
overdosage and systemic absorption
G#+ Aausea, dyspepsia, dry mouth
Local+ Nasal irritation$ fungal
infection
)espiratory+ Epista1is, rebound
congestion, pharyngitis$ cough
1ther+ #hest pain, asthenia, moon
face, acne, bruising, 2ack pain
#nteractions
5ral use
Drug-drug
!ncreased ris" of corticosteroid to1ic
effects if combined with
"etocona>ole, itracona>ole, ritonavir,
indinavir, sa4uinavir, erythromycin, or
other "nown #F%.A8 inhibitors0 if
drugs must be used together,
decrease dosage of budesonide and
monitor patient closely
Drug-!ood
Ris" of increased to1ic effects if
combined with grapefruit <uice0 avoid
this combination.
Assessment
57
.istory+ $ntreated local nasal
infections, nasal trauma, septal
ulcers, recent nasal surgery,
lactation
Physical+ 6%, %, auscultation0 R,
adventitious sounds0 e1amination of
nares
Interventions
!nhalation
2A)N#NG+ 'aper systemic steroids
carefully during transfer to
inhalational steroids0 deaths from
adrenal insufficiency have occurred.
Arrange for use of decongestant
nose drops to facilitate penetration if
edema, e1cessive secretions are
present.
%rime unit before use for 1ulmicort
;ur2uhaler< have patient rinse mouth
after each use.
$se aerosol within / mo of opening.
Sha"e well before each use.
Store 5espules upright and
protected from light0 gently sha"e
before use0 open envelopes should
be discarded after , w".
5ral
=a"e sure patient does not cut,
crush, or chew capsules0 they must
be swallowed whole.
Administer the drug once each day,
in the morning0 do not administer
with grapefruit <uice.
Encourage patient to complete full )
w" of drug therapy.
2A)N#NG+ =onitor patient for signs
of hypercorticism(acne, bruising,
moon face, swollen an"les,
hirsutism, s"in striae, buffalo hump(
which could indicate need to
decrease dosage.
Teacing points
!nhalation
&o not use more often than
prescribed0 do not stop without
consulting your health care provider.
!t may ta"e several days to achieve
good effects0 do not stop if effects
are not immediate.
$se decongestant nose drops first if
nasal passages are bloc"ed.
%rime unit before use for 1ulmicort
;ur2uhaler< rinse mouth after each
use.
Store 5espules upright, protect from
light0 discard open envelopes after ,
wee"s0 gently sha"e before use.
effects: 3ocal irritation (use your
device correctly), dry mouth (suc"
sugarless lo>enges).
Report sore mouth, sore throat,
worsening of symptoms, severe
snee>ing, e1posure to chic"enpo1 or
measles, eye infections.
5ral
'a"e the drug once a day in the
morning. &o not cut, crush, or chew
the capsules, they must be
swallowed whole.
!f you miss a day, ta"e the capsules
as soon as you remember them.
'a"e the ne1t dayHs capsules at the
regular time. &o not ta"e more than
three capsules in a day.
'a"e the full course of the drug
therapy () wee"s in most cases).
&o not ta"e this drug with grapefruit
<uice0 avoid grapefruit <uice entirely
while using this drug.
Store 5espules upright, protected
from light0 discard open envelopes
after , wee"s. Sha"e before use.
effects: &i>>iness, headache (avoid
driving or operating dangerous
58
machinery if these effects occur)0
nausea, flatulence (fre4uent small
meals may help0 try to maintain your
fluid and food inta"e).
Report chest pain, an"le swelling,
respiratory infections, increased
bruising.
bumetanide
(byoo met' a nide)
/ume,, /urine, (CAN)
!ru" class
3oop (high ceiling) diuretic
herapeutic actions
!nhibits the reabsorption of sodium and
chloride from the pro1imal and distal renal
tubules and the loop of ;enle, leading to a
natriuretic diuresis.
#ndications
Edema associated with #;?,
cirrhosis, renal disease
!:: Acute pulmonary edema
$nlabeled use: 'reatment of adult
nocturia (not effective in men with
6%;)
bumetanide0 electrolyte depletion0
anuria, severe renal failure0 hepatic
coma0 lactation.
$se cautiously with S3E, gout,
diabetes mellitus, pregnancy.
A$ailable %orms
'ablets(*.-, +, , mg0 in<ection(*.,- mg2m3
Dosages
A!&L'
5ral
*.-7, mg2day %5 in a single dose0 may
repeat at 8- to --hr intervals up to a
ma1imum daily dose of +* mg. !ntermittent
dosage schedule of drug and rest days is .7
8 on2+7, off, which is most effective with
edema.
%arenteral
*.-7+ mg !: or !=. ive over +7, min. &ose
may be repeated at intervals of ,7. hr. &o
not e1ceed +* mg2day.
P(!#A)#C PA#(N'
Aot recommended for children @ +) yr.
G()#A)#C PA#(N' 1) PA#(N'
2#. )(NAL #MPA#)M(N
A continuous infusion of +, mg over +, hr
may be more effective and less to1ic than
intermittent bolus therapy.
Pharmaco*inetics
5ral .*7/* min +7, hr 87/ hr
!: =inutes +-7.*
min
.*7/*
min
Metabolism+ '
+2,
: /*79* min
breast mil"
(,cretion+ $rine
IV acts
Preparation+ =ay be given direct !: or
diluted in solution with -G de1trose in water,
*.9G sodium chloride, or lactated RingerHs
solution. &iscard unused solution after ,8 hr.
#n%usion+ ive by direct in<ection slowly, over
+7, min. ?urther diluted in solution0 give
slowly0 do not e1ceed +* mg2day.
Ad$erse e%%ects
CN'+ Asterixis$ &izziness$ vertigo,
paresthesias, confusion, fatigue,
nystagmus, 6eakness$ hea&ache$
&ro6siness$ fatigue, blurred vision,
tinnitus, irreversible hearing loss
59
C-+ 0rthostatic hypotension$ volume
depletion, cardiac arrhythmias,
thrombophlebitis
G#+ Nausea$ anorexia$ vomiting$
&iarrhea$ gastric irritation and pain,
dry mouth, acute pancreatitis,
<aundice
G&+ 1olyuria$ nocturia$ glycosuria,
renal failure
.ematolo"ic+ Hypokalemia$
leu"openia, anemia,
thrombocytopenia
Local+ 1ain$ phle2itis at inHection site
1ther+ =uscle cramps and muscle
spasms, wea"ness, arthritic pain,
fatigue, hives, photosensitivity, rash,
pruritus, sweating, nipple tenderness
#nteractions
Drug-drug
&ecreased diuresis and natriuresis
with ASA!&s
!ncreased ris" of cardiac glycoside
to1icity (secondary to hypo"alemia)
!ncreased ris" of ototo1icity if ta"en
with aminoglycoside antibiotics,
cisplatin
Assessment
.istory+ Allergy to bumetanide,
electrolyte depletion, anuria, severe
renal failure, hepatic coma, S3E,
gout, diabetes mellitus, lactation
edema0 orientation, refle1es,
hearing0 pulses, baseline E#, 6%,
orthostatic 6%, perfusion0 R, pattern,
adventitious sounds0 liver evaluation,
bowel sounds0 urinary output
patterns0 #6#, serum electrolytes
(including calcium), blood sugar,
3?'s, renal function tests, uric acid,
urinalysis
Interventions
ive with food or mil" to prevent !
upset.
=ar" calendars or use reminders if
intermittent therapy is best for
treating edema.
ive single dose early in day so
increased urination will not disturb
sleep.
Avoid !: use if oral use is possible.
Arrange to monitor serum
electrolytes, hydration, liver function
during long-term therapy.
%rovide diet rich in potassium or
supplemental potassium.
Teacing points
Record alternate day or intermittent
therapy on a calendar or dated
envelopes.
'a"e the drug early in day so
increased urination will not disturb
sleep0 ta"e with food or meals to
prevent ! upset.
Deigh yourself on a regular basis, at
the same time, and in the same
clothing0 record the weight on your
calendar.
effects: !ncreased volume and
fre4uency of urination0 di>>iness,
feeling faint on arising, drowsiness
(avoid rapid position changes0
ha>ardous activities, such as driving0
and alcohol consumption)0 sensitivity
to sunlight (use sunglasses,
sunscreen, wear protective clothing)0
increased thirst (suc" sugarless
lo>enges0 use fre4uent mouth care)0
loss of body potassium (a
potassium-rich diet, or supplement
will be needed).
Report weight change of more than .
pounds in + day0 swelling in an"les
or fingers0 unusual bleeding or
60
bruising0 nausea, di>>iness,
trembling, numbness, fatigue0
muscle wea"ness or cramps.
bupropion hydrochloride
(byoo proe' pee on)
2ellbutrin, 2ellbutrin '), 2ellbutrin 7L,
0yban
!ru" classes
Antidepressant
Smo"ing deterrent
herapeutic actions
'he neurochemical mechanism of the
antidepressant effect of bupropion is not
understood0 it is chemically unrelated to
other antidepressant agents0 it is a wea"
bloc"er of neuronal upta"e of serotonin and
norepinephrine and inhibits the reupta"e of
dopamine to some e1tent.
#ndications
'reatment of depression
Aid to smo"ing cessation treatment
(Fy2an)
$nlabeled uses: 'reatment of
neuropathic pain, A&;&
to bupropion0 history of sei>ure
disorder, bulimia or anore1ia, head
trauma, #AS tumor (increased ris"
of sei>ures)0 treatment with =A5!s0
lactation.
$se cautiously with renal or liver
disease0 heart disease, history of =!,
pregnancy.
A$ailable %orms
'ablets(C-, +** mg0 SR tablets(+**, +-*,
,** mg0 ER tablets(+-*, .** mg
Dosages
A!&L'
=epression: .** mg %5 given as
+** mg tid0 begin treatment with
+** mg %5 bid0 if clinical response
warrants, increase . days after
beginning treatment. !f 8 w" after
treatment, no clinical improvement is
seen, dose may be increased to
+-* mg %5 tid (8-* mg2day). &o not
e1ceed +-* mg in any one dose.
&iscontinue drug if no improvement
occurs at the 8-* mg2day level.
Sustaine& release: +-* mg %5 bid0
allow at least ) hr between doses.
@xten&e& release: !nitially,
+-* mg2day %5 as a once-a-day
dose0 range .**78-* mg2day.
Smoking cessation: +-* mg (Fy2an)
%5 daily for . days, then increase to
.** mg2day in two divided doses at
least ) hr apart. 'reat for C7+, w".
P(!#A)#C PA#(N'
Safety and efficacy in children @ +) yr not
established.
G()#A)#C PA#(N'
6upropion is e1creted through the "idneys0
use with caution, and monitor older patients
carefully.
Pharmaco*inetics
5ral :aries , hr )7+, hr
SR 5ral :aries . hr +/7,* hr
ER 5ral :aries - hr +-7,- hr
+2,
: +8 hr0 ,+ hr (SR)
!istribution+ =ay cross placenta0 may enter
breast mil"
(,cretion+ ?eces, urine
Ad$erse e%%ects
61
CN'+ Agitation$ insomnia$
hea&ache$ migraine$ tremor$ ata1ia,
incoordination, sei>ures, mania,
increased libido, hallucinations,
visual disturbances
C-+ =izziness$ tachycar&ia$ edema,
E# abnormalities, chest pain,
shortness of breath
!ermatolo"ic+ Rash, alopecia, dry
s"in
G#+ =ry mouth$ constipation$ nausea,
vomiting, stomatitis
G&+ Aocturia, vaginal irritation,
testicular swelling
1ther+ Ieight loss$ fluli"e symptoms
#nteractions
Drug-drug
!ncreased ris" of adverse effects with
levodopa
!ncreased ris" of to1icity with =A5!s
!ncreased ris" of sei>ures with drugs
that lower sei>ure threshold,
including alcohol
Assessment
bupropion, history of sei>ure
disorder, bulimia or anore1ia, head
trauma, #AS tumor, treatment with
=A5!, renal or liver disease, heart
disease, lactation
Physical+ S"in, weight0 orientation,
affect, vision, coordination0 %,
rhythm, auscultation0 R, adventitious
sounds0 bowel sounds, condition of
mouth
Interventions
ive drug three times a day for
depression0 do not administer more
than +-* mg in any one dose.
Administer SR forms twice a day
with at least ) hr between doses.
!ncrease dosage slowly to reduce
the ris" of sei>ures.
Administer +**-mg tablets four times
a day for depression, with at least 8
hr between doses, if patient is
receiving B .** mg2day0 use
combinations of C--mg tablets to
avoid giving B +-* mg in any single
dose.
Arrange for patient evaluation after /
w".
&iscontinue =A5! therapy for at
least +8 days before beginning
bupropion.
=onitor 3?'s and renal function tests
in patients with a history of liver or
renal impairment.
;ave patient 4uit smo"ing within first
, w" of treatment for smo"ing
cessation0 may be used with
transdermal nicotine.
2A)N#NG+ =onitor response and
behavior0 suicide is a ris" in
depressed patients.
Teacing points
'a"e this drug in e4ually divided
doses three to four times a day as
prescribed for depression. 'a"e
sustained-release forms twice a day,
at least ) hours apart. &o not
combine doses or ma"e up missed
doses. 'a"e once a day, or divided
into two doses at least ) hours apart
for smo"ing cessation.
Avoid or limit the use of alcohol while
on this drug. Sei>ures can occur if
these are combined.
=ay be used with transdermal
nicotine0 most effective for smo"ing
cessation if combined with
behavioral support program.
effects: &i>>iness, lac" of
coordination, tremor (avoid driving or
62
performing tas"s that re4uire
alertness)0 dry mouth (use fre4uent
mouth care0 suc" sugarless
lo>enges)0 headache, insomnia
(consult with care provider if these
become a problem0 do not self-
medicate)0 nausea, vomiting, weight
loss (eat fre4uent small meals).
Report dar" urine, light-colored
stools0 rapid or irregular heart beat0
hallucinations0 severe headache or
insomnia0 fever, chills, sore throat.
buspirone hydrochloride
(byoo spye' rone)
/u'par
!ru" class
An1iolytic
herapeutic actions
=echanism of action not "nown0 lac"s
antisei>ure, sedative, or muscle rela1ant
properties0 binds serotonin receptors, but the
clinical significance is unclear.
#ndications
=anagement of an1iety disorders or
short-term relief of symptoms of
an1iety
$nlabeled use: &ecreasing the
symptoms (aches, pains, fatigue,
cramps, irritability) of %=S
to buspirone0 mar"ed liver or renal
impairment0 lactation.
$se cautiously with pregnancy, mild
renal or hepatic impairment.
A$ailable %orms
'ablets(-, C.-, +*, +-, .* mg
Dosages
A!&L'
!nitially, +- mg2day %5 (C.- mg tid). !ncrease
dosage - mg2day at intervals of ,7. days to
achieve optimal therapeutic response. &o not
e1ceed /* mg2day. &ivided doses of ,*7
.* mg2day have been used.
P(!#A)#C PA#(N'
Safety and efficacy for children @ +) yr not
established.
Pharmaco*inetics
Route 5nset %ea"
5ral C7+* days 8*79* min
+2,
: .7++ hr
!istribution+ =ay enter breast mil"
(,cretion+ $rine
Ad$erse e%%ects
CN'+ =izziness$ hea&ache$
nervousness$ insomnia$ light-
hea&e&ness$ e1citement, dream
disturbances, drowsiness, decreased
concentration, anger, hostility,
confusion, depression, tinnitus,
blurred vision, numbness,
paresthesia, incoordination, tremor,
depersonali>ation, dysphoria, noise
intolerance, euphoria, a"athisia,
fearfulness, loss of interest,
disassociative reaction,
hallucinations, suicidal ideation,
sei>ures, altered taste and smell,
involuntary movements, slowed
reaction time
C-+ Aonspecific chest pain,
tachycardia or palpitations, syncope,
hypotension, hypertension
G#+ Nausea$ &ry mouth$ vomiting$
a2&ominal or gastric &istress$
&iarrhea$ constipation, flatulence,
anore1ia, increased appetite,
63
salivation, irritable colon and rectal
bleeding
G&+ $rinary fre4uency, urinary
hesitancy, dysuria, increased or
decreased libido, menstrual
irregularity, spotting
)espiratory+ ;yperventilation,
shortness of breath, chest
congestion
1ther+ =usculos"eletal aches and
pains, sweating, clamminess, sore
throat, nasal congestion
#nteractions
Drug-drug
ive with caution to patients ta"ing
alcohol, other #AS depressants
&ecreased effects with fluo1etine
!ncreased serum levels of buspirone
if ta"en with erythromycin,
itracona>ole0 decrease buspirone
dose to ,.- mg and monitor closely if
these combinations are used
Ris" of increased haloperidol levels if
combined
Drug-!ood
Ris" of increased serum levels and
to1icity if ta"en with grapefruit <uice
Assessment
buspirone, mar"ed liver or renal
impairment, lactation
Physical+ Deight0 '0 s"in color,
lesions0 mucous membranes, throat
color, lesions, orientation, affect,
refle1es, vision e1amination0 %, 6%0
R, adventitious sounds0 bowel
sounds, normal ! output, liver
evaluation0 normal urinary output,
voiding pattern0 3?'s, renal function
tests, urinalysis, #6# and differential
Interventions
%rovide sugarless lo>enges or ice
chips if dry mouth or altered taste
occurs.
Arrange for analgesic for headache
or musculos"eletal aches.
Teacing points
'a"e this drug e1actly as prescribed.
Avoid the use of alcohol, sleep-
inducing, or over-the-counter drugs
and grapefruit <uice0 these could
cause dangerous effects.
effects: &rowsiness, di>>iness, light-
headedness (avoid driving or
operating comple1 machinery)0 !
upset (eat fre4uent small meals)0 dry
mouth (suc" ice chips or sugarless
candies)0 dreams, nightmares,
difficulty concentrating or sleeping,
confusion, e1citement (reversible0
will stop when the drug is
discontinued).
Report abnormal involuntary
movements of facial or nec"
muscles, motor restlessness0 sore or
cramped muscles0 abnormal posture0
yellowing of the s"in or eyes.
64

Acetaminophen and acyclovir drug guide

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