KMRADN L3 pharm 2

antiviral (acycloVIR for virus)

• PO: Recurrent genital herpes infections. Localized cutaneous herpes zoster infections (shingles) and chickenpox (varicella).
• IV: genital herpes in nonimmunosuppressed patients.Herpes simplex or herpes zoster (shingles).
• Topical: cold sores

interferes with viral DNA synthesis

• Pre-existing serious neurologic, hepatic, pulmonary, or fluid and electrolyte abnormalities• Renal impairment (dose alteration recommended if CCr <50 mL/min)• Geri: Due to age related ↓ in renal function• Obese patients (dose should be based on ideal body weight)• Patients with hypoxia

CNS: SEIZURES, dizziness, headache, hallucinations, trembling.GI: diarrhea, nausea, vomiting, elevated liver enzymes, hyperbilirubinemia, abdominal pain, anorexia.GU: RENAL FAILURE, crystalluria, hematuria, renal pain.Derm: STEVENS-JOHNSON SYNDROME, acne, hives, skin rashes, unusual sweating.Endo: changes in menstrual cycle.Hemat: THROMBOTIC THROMBOCYTOPENIC PURPURA/HEMOLYTIC UREMIC SYNDROME (HIGH DOSES IN IMMUNOSUPPRESSED PATIENTS) .Local: pain, phlebitis, local irritation.MS: joint pain.Misc: polydipsia.

• Probenecid ↑ blood levels of acyclovir• ↑ blood levels and risk of toxicity from theophylline ; dose adjustment may be necessary• ↓ blood levels and may ↓ effectiveness of valproic acid or hydantoins• Concurrent use of other nephrotoxic drugs ↑ risk of adverse renal effects• Zidovudine and IT methotrexate may ↑ risk of CNS side effects

• Assess lesions before and daily during therapy• Monitor neurologic status in patients with herpes encephalitisLab Test Considerations• Monitor BUN, serum creatinine, and CCr before and during therapy. ↑ BUN and serum creatinine levels or ↓ CCr may indicate renal failure

• antigout agents (beaker/zylophone)
• antihyperuricemics

PO: Prevention of attack of gouty arthritis and nephropathy• PO, IV: Treatment of secondary hyperuricemia, which may occur during treatment of tumors or leukemias

Inhibits the production of uric acid by inhibiting the action of xanthine oxidaseTherapeutic Effect(s): Lowering of serum uric acid levels

• Acute attacks of gout• Renal insufficiency (dose reduction required if CCr <20 mL/min)• Dehydration (adequate hydration necessary)• OB: Lactation: Rarely used• Geri: Begin at lower end of dosage range

CV: hypotension, flushing, hypertension, bradycardia, and heart failure (reported with IV administration).CNS: drowsiness.GI: diarrhea, hepatitis, nausea, vomiting.GU: renal failure, hematuria.Derm: rash (discontinue drug at first sign of rash), urticaria.Hemat: bone marrow depression.Misc: hypersensitivity reactions.

• Use with mercaptopurine and azathioprine ↑ bone marrow depressant properties—doses of these drugs should be ↓• Use with ampicillin or amoxicillin ↑ risk of rash• Use with oral hypoglycemic agents and warfarin ↑ effects of these drugs• Use with thiazide diuretics or ACE inhibitors ↑ risk of hypersensitivity reactions• Large doses of allopurinol may ↑ risk of theophylline toxicity• May ↑ cyclosporine levels

Monitor for joint pain and swelling. Addition of colchicine or NSAIDs may be necessary for acute attacks. Prophylactic doses of colchicine or an NSAID should be administered concurrently during the first 3–6 mo of therapy because of an increased frequency of acute attacks of gouty arthritis during early therapy

• Instruct patient to take allopurinol as directed. Take missed doses as soon as remembered. If dosing schedule is once daily, do not take if remembered the next day. If dosing schedule is more than once a day, take up to 300 mg for the next dose• Instruct patient to continue taking allopurinol along with an NSAID or colchicine during an acute attack of gout. Allopurinol helps prevent, but does not relieve, acute gout attacks

• agents atypical mycobacterium
• anti-infectives

• Treatment of the following infections due to susceptible organisms» Upper respiratory tract infections, including streptococcal pharyngitis, acute bacterial exacerbations of chronic bronchitis and tonsillitis» Lower respiratory tract infections, including bronchitis and pneumonia» Acute otitis media» Skin and skin structure infections» Nongonococcal urethritis, cervicitis, gonorrhea, and chancroid• Prevention of disseminated Mycobacterium avium complex (MAC) infection in patients with advanced HIV infection• Extended-release suspension (ZMax) Acute bacterial sinusitis and community-acquired pneumonia in adults

CNS: dizziness, seizures, drowsiness, fatigue, headache.CV: chest pain, hypotension, palpitations, QT prolongation (rare).GI: HEPATOTOXICITY, PSEUDOMEMBRANOUS COLITIS, abdominal pain,diarrhea, nausea, cholestatic jaundice, ↑ liver enzymes, dyspepsia, flatulence, melena, oral candidiasis, pyloric stenosis.GU: nephritis, vaginitis.Hemat: anemia, leukopenia, thrombocytopenia.Derm: STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, photosensitivity, rashes.EENT: ototoxicity.F and E: hyperkalemia.Misc: ANGIOEDEMA.

• Assess patient for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and throughout therapy• Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results• Observe for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Notify health care professional immediately if these occur• Assess patient for skin rash frequently during therapy. Discontinueazithromycin at first sign of rash; may be life-threatening. Stevens-Johnson syndrome or toxic epidermal necrolysis may develop. Treat symptomatically; may recur once treatment is stopped.Lab Test Considerations• May cause ↑ serum bilirubin, AST, ALT, LDH, and alkaline phosphatase concentrations

• • Instruct patient not to take azithromycin with food or antacids
• Advise patient to use sunscreen and protective clothing to prevent photosensitivity reactions

anti-infectives

• Treatment of» Skin and skin structure infections» Bone and joint infections» Complicated and uncomplicated urinary tract infections» Uncomplicated gynecological infections including gonorrhea» Lower respiratory tract infections» Intra-abdominal infections» Septicemia» Meningitis» Otitis media• Perioperative prophylaxis

Contraindicated in:• Hypersensitivity to cephalosporins• Serious hypersensitivity to penicillins• Pedi: Neonates C28 days (use in hyperbilirubinemic neonates may lead to kernicterus)• Pedi: Neonates C28 days requiring calcium-containing IV solutions (↑ risk of precipitation formation)Use Cautiously in:• Combined severe hepatic and renal impairment (dose reduction/↑ dosing interval recommended)• History of GI disease, especially colitis• OB: Lactation: Pregnancy and lactation

CNS: SEIZURES (HIGH DOSES) .GI: PSEUDOMEMBRANOUS COLITIS, diarrhea, cholelithiasis, gallbladder sludging.Derm: rashes, urticaria.Hemat: bleeding, eosinophilia, hemolytic anemia, leukopenia, thrombocytosis.Local: pain at IM site, phlebitis at IV site.Misc: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS , superinfection.

Drug-DrugShould not be administered concomitantly with any calcium-containing solutions

• May cause positive results for Coombs' test» May cause increased serum AST, ALT, alkaline phosphatase, bilirubin, LDH, BUN, and creatinine» May rarely cause leukopenia, neutropenia, agranulocytosis, thrombocytopenia, eosinophilia, lymphocytosis, and thrombocytosis

Advise patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools) and allergy• Instruct patient to notify health care professional immediately if diarrhea, abdominal cramping, fever, or bloody stools occur and not to treat with antidiarrheals without consulting health care professionals

• antineoplastics
• immunosuppressants

• Alone or with other modalities in the management of» Hodgkin's disease» Malignant lymphomas» Multiple myeloma» Leukemias» Mycosis fungoides» Neuroblastoma» Ovarian carcinoma» Breast carcinoma, and a variety of other tumors• Minimal change nephrotic syndrome in children

• OB: Lactation: Pregnancy or lactationUse Cautiously in:• Active infections• Bone marrow depression• Other chronic debilitating illnesses• OB: Patients with childbearing potential

Resp: PULMONARY FIBROSIS.CV: MYOCARDIAL FIBROSIS, hypotension.GI: anorexia, nausea, vomiting.GU: HEMORRHAGIC CYSTITIS, hematuria.Derm: alopecia.Endo: gonadal suppression, syndrome of inappropriate antidiuretic hormone (SIADH).Hemat: LEUKOPENIA, thrombocytopenia, anemia.Metabolic: hyperuricemia.Misc: secondary neoplasms.

• Phenobarbital or rifampin may ↑ toxicity of cyclophosphamide• Concurrent allopurinol or thiazide diuretics may exaggerate bone marrow depression• May prolong neuromuscular blockade from succinylcholine• Cardiotoxicity may be additive with other cardiotoxic agents (e.g.,cytarabine , daunorubicin , doxorubicin )• May ↓ serum digoxin levels• Additive bone marrow depression with other antineoplastics orradiation therapy• May potentiate the effects of warfarin• May ↓ antibody response to live-virus vaccines and ↑ risk of adverse reactions• Prolongs the effects of cocaine

• • Monitor urinary output frequently during therapy. To reduce the risk of hemorrhagic cystitis, fluid intake should be at least 3000 mL/day for adults and 1000–2000 mL/day for children. May be administered with mesna.
• Monitor for bone marrow depression.
• May also cause thrombocytopenia (nadir 10–15 days), and rarely causes anemia

PO: Administer medication on an empty stomach. If severe gastric irritation develops, medication may be given with food

• • Instruct patient to take dose in early morning. Emphasize need for adequate fluid intake for 72 hr after therapy. Patient should void frequently to decrease bladder irritation from metabolites excreted by the kidneys. Report hematuria immediately. If a dose is missed, contact health care professional
• • Advise patient that this medication may cause sterility and menstrual irregularities or cessation of menses. This drug is also teratogenic, and contraceptive measures should continue for at least 4 mo after completion of therapy• Discuss with patient the possibility of hair loss. Explore methods of coping. May also cause darkening of skin and fingernails• Instruct patient not to receive any vaccinations without advice of health care professional

• immunosuppressants
• antirheumatics (DMARD: Disease-modifying antirheumatic drug)

• PO, IV: Prevention and treatment of rejection in renal, cardiac, and hepatic transplantation (with corticosteroids)• PO: Treatment of severe active rheumatoid arthritis (Neoral only)• Treatment of severe recalcitrant psoriasis in adult nonimmunocompromised patients (Neoral only)

• Hypersensitivity to cyclosporine or polyoxyethylated castor oil (vehicle for IV form)• OB: Lactation: Should not be given unless benefits outweigh risks• Disulfiram therapy or known alcohol intolerance (IV and oral liquid dose forms contain alcohol)• Psoriasis patients receiving immunosuppressants or radiation• Uncontrolled hypertensionUse Cautiously in:• Severe hepatic impairment (dose ↓ recommended)• Renal impairment (frequent dose changes may be necessary)• Active infection• Pedi: Larger or more frequent doses may be required

CNS: SEIZURES, tremor, confusion, flushing, headache, psychiatric problems.CV: hypertension.GI: diarrhea, hepatotoxicity, nausea, vomiting, abdominal discomfort, anorexia, pancreatitis.GU: nephrotoxicity.Derm: hirsutism, acne.F and E: hyperkalemia, hypomagnesemia.Hemat: anemia, leukopenia, thrombocytopenia.Metabolic: hyperlipidemia, hyperuricemia.Neuro: hyperesthesia, paresthesia.Misc: gingival hyperplasia, hypersensitivity reactions, infections (including activation of latent viral infections such as BK virus-associated nephropathy).

• Drug-Natural Products• Concomitant use with echinacea and melatonin may interfere with immunosuppression• Use with St. John's wort may cause ↓ serum levels and organ rejection for transplant patients.
• Tons of drugs that interact. Too many.

• Reinforce the need for lifelong therapy to prevent transplant rejection. Review symptoms of rejection for transplanted organ, and stress need to notify health care professional immediately if they occur.
• • Instruct patient to avoid grapefruit and grapefruit juice to prevent interaction with cyclosporine

antineoplastics (Adrian = Rocky, sounds like he has cancer)

Alone or with other modalities in the treatment of various solid tumors including» Breast» Ovarian» Bladder» Bronchogenic carcinoma» Malignant lymphomas and leukemias

• OB: Lactation: Pregnancy or lactationUse Cautiously in:• History of cardiac disease or high cumulative doses of anthracyclines• Depressed bone marrow reserve• Liver impairment (reduce dose if serum bilirubin >1.2 mg/dL)• Children, geriatric patients, mediastinal radiation, concurrent cyclophosphamide (risk of cardiotoxicity)• OB: Patients with childbearing potential

Resp: recall pneumonitis.CV: CARDIOMYOPATHY, ECG changes.GI: diarrhea, esophagitis, nausea, stomatitis, vomiting.GU: red urine.Derm: alopecia, photosensitivity.Endo: sterility, prepubertal growth failure with temporary gonadal impairment (children only).Hemat: anemia, leukopenia, thrombocytopenia.Local: phlebitis at IV site, tissue necrosis.Metabolic: hyperuricemia.Misc: hypersensitivity reactions.

• • Monitor for bone marrow depression. (bleeding)
• It's a vesicant also.

• • Instruct patient to inspect oral mucosa for erythema and ulceration.
• • Discuss the possibility of hair loss with patient.
• • Instruct patient not to receive any vaccinations without advice of health care professional

antianemics

• Anemia associated with chronic renal failure• Anemia secondary to zidovudine (AZT) therapy in HIV-infected patients• Anemia from chemotherapy in patients with nonmyeloid malignancies• Reduction of need for transfusions after surgeryUnlabelled Use(s): Anemia of prematurity

• Hypersensitivity to albumin or mammalian cell-derived products• Uncontrolled hypertension• Patients with erythropoietin levels >200 mUnits/mL• Patients receiving chemotherapy when anticipated outcome is cure• Neutropenia in newbornsUse Cautiously in:• History of seizures• History of porphyria• OB: Evidence of fetal harm in animal studies—use only if potential benefit outweighs potential risk to fetus• OB: Lactation: Little published information, however, erythropoetin alfa is a normal constituent of breastmilk• Pedi: Multi-dose vials contain benzyl alcohol, which can cause potentially fatal gasping syndrome in neonates

CNS: SEIZURES, headache.CV: CHF, MI, STROKE, THROMBOTIC EVENTS (ESPECIALLY WITH HEMOGLOBIN >12 G/DL) , hypertension.Derm: transient rashes.Endo: restored fertility, resumption of menses.Misc: ↑ mortality and ↑ tumor growth (with hemoglobin B12 g/dL).

May ↑ requirement for heparin anticoagulation during hemodialysis

• Monitor blood pressure before and during therapy.
• • Monitor dialysis shunts (thrill and bruit) and status of artificial kidney during hemodialysis. Heparin dose may need to be increased to prevent clotting.

Institute seizure precautions in patients who experience greater than a 4-point increase in hematocrit in a 2-wk period or exhibit any change in neurologic status. Risk of seizures is greatest during the first 90 days of therapy

• Explain rationale for concurrent iron therapy (increased red blood cell production requires iron)» Discuss possible return of menses and fertility in women of childbearing age. Patient should discuss contraceptive options with health care professional» Discuss ways of preventing self-injury in patients at risk for seizures. Driving and activities requiring continuous alertness should be avoided

antifungal (Con a zole = con a mole, moles and fungus live underground)

• PO, IV: Fungal infections caused by susceptible organisms, including» Oropharyngeal or esophageal candidiasis» Serious systemic candidal infections» Urinary tract infections» Peritonitis» Cryptococcal meningitis• Prevention of candidiasis in patients who have undergone bone marrow transplantation• PO: Single-dose oral treatment of vaginal candidiasis

• Concurrent use with pimozideUse Cautiously in:• Renal impairment (dose reduction required if CCr <50 mL/min)• Underlying liver disease• OB: Safety not established• Lactation: Usually compatible with breastfeeding (AAP)• Geri: Increased risk of adverse reactions (rash, vomiting, diarrhea, seizures); consider age-related decrease in renal function in determining dose

CNS: headache, dizziness, seizures.GI: HEPATOTOXICITY, abdominal discomfort, diarrhea, nausea, vomiting.Derm: EXFOLIATIVE SKIN DISORDERS INCLUDING STEVENS-JOHNSON SYNDROME .Endo: hypokalemia, hypertriglyceridemia.Misc: allergic reactions,including anaphylaxis.

• ↑ activity of warfarin• Rifampin , rifabutin , and isoniazid ↓ levels• Fluconazole at doses >200 mg/day may inhibit the CYP3A4 enzyme system and effect the activity of drugs metabolized by this system• ↑ hypoglycemic effects of tolbutamide , glyburide , or glipizide• ↑ levels and risk of toxicity from cyclosporine , rifabutin , tacrolimus ,theophylline , zidovudine , alfentanil , and phenytoin• ↑ levels and effects of benzodiazepines , zolpidem , bispirone ,nisoldipine , tricyclic antidepressants , and losartan• May ↑ risk of bleeding with warfarin• May antagonize effects of amphotericin B

• Monitor BUN and serum creatinine before and periodically during therapy; patients with renal dysfunction will require dose adjustment» Monitor liver function tests before and periodically during therapy. May cause ↑ AST, ALT, serum alkaline phosphate, and bilirubin concentrations

• Instruct patient to notify health care professional if skin rash, abdominal pain, fever, or diarrhea becomes pronounced, if signs and symptoms of liver dysfunction (unusual fatigue, anorexia, nausea, vomiting, jaundice, dark urine, or pale stools) occur, if unusual bruising or bleeding occur, or if no improvement is seen within a few days of therapy

antineoplastics (FU = cancer)

• IV: Used alone and in combination with other modalities (surgery, radiation therapy, other antineoplastics) in the treatment of» Colon cancer» Breast cancer» Rectal cancer» Gastric cancer» Pancreatic carcinoma• Topical: Management of multiple actinic (solar) keratoses and superficial basal cell carcinomas

• Dihydropyrimidine dehydrogenase deficiency (patients at ↑ risk of 5–FU toxicity)• OB: Lactation: Pregnancy or lactationUse Cautiously in:• Infections• Depressed bone marrow reserve• Other chronic debilitating illnesses• Obese patients, patients with edema or ascites (dose should be based on ideal body weight)

More likely to occur with systemic use than with topical useCNS: acute cerebellar dysfunction.GI: diarrhea, nausea, stomatitis, vomiting.Derm: alopecia, maculopapular rash, local inflammatory reactions (topical only), melanosis of nails, nail loss, palmar-plantar erythrodysesthesia, phototoxicity.Endo: sterility.Hemat: anemia, leukopenia, thrombocytopenia.Local: thrombophlebitis.Misc: fever.

• Combination chemotherapy with irinotecan may produce unacceptable toxicity (dehydration, neutropenia, sepsis)• Additive bone marrow depression with other bone marrow depressants , including other antineoplastics and radiation therapy• May ↓ antibody response to live-virus vaccines and ↑ risk of adverse reactions

» Assess mucous membranes, number and consistency of stools, and frequency of vomiting. Assess for signs of infection (fever, chills, sore throat, cough, hoarseness, pain in lower back or side, difficult or painful urination). Assess for bleeding (bleeding gums; bruising; petechiae; and guaiac test stools, urine, and emesis).

» Advise patient to rinse mouth with clear water after eating and drinking and to avoid flossing to minimize stomatitis. Viscous lidocaine may be used if mouth pain interferes with eating. Stomatitis pain may require treatment with opioid analgesics» Discuss with patient the possibility of hair loss. Explore methods of coping

• antirheumatics (DMARDs)
• gastroinestinal anti inflammatories

• Active rheumatoid arthritis (moderate to severe, with methotrexate)• Active Crohn's disease (moderate to severe)• Active psoriatic arthritis• Active ankylosing spondylitis• Active ulcerative colitis (moderate to severe) with inadequate response to conventional therapy: reducing signs and symptoms, and inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use• Plaque psoriasis (chronic severe)

• Decreased pain and swelling, decreased rate of joint destruction and improved physical function in ankylosing spondylitis, rheumatoid or psoriatic arthritis• Reduction and maintenance of closure of fistulae in Crohn's disease• Decreased symptoms, maintaining remission and mucosal healing with decreased corticosteroid use in ulcerative Colitis• Decrease in induration, scaling and erythema of psoriatic lesions

• Hypersensitivity to infliximab, murine (mouse) proteins, or other components in the formulation• Lactation: Lactation• CHFUse Cautiously in:• Patients being retreated after 2 yr without treatment (↑ risk of adverse reactions)• History of tuberculosis or exposure (latent tuberculosis should be treated prior to infliximab therapy)• Chronic obstructive pulmonary disease (↑ risk of malignancy)• Geri: Geriatric patients• OB: Use only if clearly needed• Pedi: Safety not established; ↑ risk of lymphoma, leukemia, and other malignancies

CNS: fatigue, headache, anxiety, depression, dizziness, insomnia.EENT: conjunctivitis.Resp: upper respiratory tract infection, bronchitis, cough, dyspnea, laryngitis, pharyngitis, respiratory tract allergic reaction, rhinitis, sinusitis.CV: chest pain, hypertension, hypotension, pericardial effusion, tachycardia, CHF.GI: HEPATOSPLENIC T-CELL LYMPHOMA, abdominal pain, nausea,vomiting, constipation, diarrhea, dyspepsia, flatulence, hepatotoxicity, intestinal obstruction, oral pain, tooth pain, ulcerative stomatitis.GU: dysuria, urinary frequency, urinary tract infection.Derm: acne, alopecia, dry skin, ecchymosis, eczema, erythema, flushing, hematoma, hot flushes, pruritus, psoriasis, rash, sweating, urticaria.Hemat: LEUKEMIA, neutropenia.MS: arthralgia, arthritis, back pain, involuntary muscle contractions, myalgia.Neuro: paresthesia.Misc: INFECTIONS (INCLUDING REACTIVATION TUBERCULOSIS, PNEUMONIA, AND INVASIVE FUNGAL INFECTIONS) , MALIGNANCY,fever, infusion reactions, chills, flu-like syndrome, herpes simplex, herpes zoster, hypersensitivity reactions, lupus-like syndrome, moniliasis, pain, peripheral edema, vasculitis.

• • Assess for signs and symptoms of systemic infections (fever, malaise, weight loss, sweats, cough, dyspnea, pulmonary infiltrates, serious systemic illness with or without concomitant shock). Ascertain if patient lives in or has traveled to areas of endemic mycoses. Consider empiric antifungal treatment for patients at risk of histoplasmosis and other invasive fungal infections until the pathogens are identified. Consult with an infectious diseases specialist. Consider stopping infliximab until the infection has been diagnosed and adequately treated.
• Rheumatoid Arthritis• Assess pain and range of motion prior to and periodically during therapyCrohn's Disease and Ulcerative Colitis• Assess for signs and symptoms before, during, and after therapyPsoriasis• Assess lesions periodically during therapy

• Advise patient to notify health care professional promptly if symptoms of fungal infection occur

• Ther. class.antihypertensives
• Pharm. class.ace inhibitors

• Alone or with other agents in the management of hypertension• Management of heart failure• Reduction of risk of death or development of heart failure after myocardial infarction

• Alone or with other agents in the management of hypertension• Management of heart failure• Reduction of risk of death or development of heart failure after myocardial infarction

ActionAngiotensin-converting enzyme (ACE) inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II. ACE inhibitors also prevent the degradation of bradykinin and other vasodilatory prostaglandins. ACE inhibitors also ↑ plasma renin levels and ↓ aldosterone levels. Net result is systemic vasodilationTherapeutic Effect(s):• Lowering of blood pressure in hypertensive patients• Increased survival and decreased symptoms in patients with heart failure• Increased survival after myocardial infarction

• History of angioedema with previous use of ACE inhibitors• OB: Can cause injury or death of fetus – if pregnancy occurs, discontinue immediately.Lactation: Appears in breast milk; discontinue lisinopril or breastfeedingUse Cautiously in:• Patients with renal impairment, hypovolemia, hyponatremia, and concurrent diuretic therapy (initial dosage reduction recommended)• Black patients (monotherapy of hypertension less effective, may require additional therapy; higher risk of angioedema)• Surgery/anesthesia (hypotension may be exaggerated)• Women of childbearing potential• Pedi: Safety not established children <6 yr• Geri: Initial dosage reduction recommendedExercise Extreme Caution in:Family history of angioedema

CNS: dizziness, fatigue, headache, weakness.Resp: cough.CV: hypotension, chest pain.GI: abdominal pain, diarrhea, nausea, vomiting.GU: erectile dysfunction, impaired renal function.Derm: rashes.F and E: hyperkalemia.Misc: ANGIOEDEMA.

Drug-Drug• Excessive hypotension may occur with concurrent use of diuretics• Additive hypotension with other antihypertensive agents• ↑ risk of hyperkalemia with concurrent use of potassium supplements ,potassium-sparing diuretics , potassium-containing salt substitutes , or angiotensin II receptor antagonists• Antihypertensive response may be blunted by NSAIDs• ↑ levels and may ↑ the risk of lithium toxicity

• » Assess patient for signs of angioedema (dyspnea, facial swelling
• » May cause hyperkalemia» Monitor CBC periodically during therapy in patients with collagen vascular disease and/or renal disease. May rarely cause slight decrease in hemoglobin and hematocrit and agranulocytosis» May cause elevated AST, ALT, alkaline phosphatase, and serum bilirubin

• Caution patient to avoid salt substitutes containing potassium or foods containing high levels of potassium or sodium unless directed by health care professional.
• Watch for s/s of hypotension.

antihelmintics (parasitic worms)

• Impaired liver function• Crohn's ileitis• Ulcerative colitis• Pregnancy, lactation, or children <2 yr (safety not established; may be used in first trimester only if benefit justifies potential risk to fetus)

Most side effects and adverse reactions are seen with high-dose therapy onlyCNS: SEIZURES (RARE) , dizziness, headache.EENT: tinnitus.GI: abdominal pain, diarrhea, increased liver enzymes (high dose, long-term therapy), nausea, vomiting.Derm: rash, urticaria, alopecia.Hemat: agranulocytosis, reversible myelosuppression (leukopenia, thrombocytopenia).Neuro: numbness.Misc: fever.

• Drug-Food
• Absorption may be increased by fatty foods

gastroinestinal anti inflammatories

Inflammatory bowel diseases including» Ulcerative colitis» Proctitis» Proctosigmoiditis

Locally acting anti-inflammatory action in the colon, where activity is probably due to inhibition of prostaglandin synthesisTherapeutic Effect(s): Reduction in the symptoms of inflammatory bowel disease

• Hypersensitivity reactions to sulfonamides, salicylates, mesalamine, or sulfasalazine• Cross-sensitivity with furosemide, sulfonylurea hypoglycemic agents, or carbonic anhydrase inhibitors may exist• G6PD deficiency• Hypersensitivity to bisulfites (mesalamine enema only)• Urinary tract or intestinal obstruction• PorphyriaUse Cautiously in:• Severe hepatic or renal impairment• OB: Safety not established• Lactation: Has caused side effects in some infants; careful observation required

CNS: headache, dizziness, malaise, weakness.EENT: pharyngitis, rhinitis.CV: pericarditis.GI: diarrhea, eructation (PO), flatulence, nausea, vomiting.GU: interstitial nephritis, pancreatitis, renal failure.Derm: hair loss, rash.Local: anal irritation (enema, suppository).MS: back pain.Misc: ANAPHYLAXIS, acute intolerance syndrome, fever.

Inflammatory Bowel Disease• Assess abdominal pain and frequency, quantity, and consistency of stools at the beginning of and during therapyLab Test Considerations• Monitor urinalysis, BUN, and serum creatinine prior to and periodically during therapy. Mesalamine may cause renal toxicity» Mesalamine may cause ↑ AST and ALT levels, serum alkaline phosphatase, GGTP, LDH, amylase, and lipase

• Rect: Instruct patient to use rectal suspension at bedtime and retain suspension all night for best results

Ther. class.immunosuppressants

Prevention of heart, kidney, or liver transplant rejection

• OB: Lactation: ↑ risk of congenital anomalies or spontaneous abortionUse Cautiously in:• Active serious pathology of the GI tract (including history of ulcer disease or GI bleeding)• Phenylketonuria (oral suspension contains aspartame)• Severe chronic renal impairment (dose not to exceed 1 g twice daily (CellCept) if CCr <25 mL/min/1.73 m2); careful monitoring recommended• Delayed graft function following transplantation (observe for increased toxicity)• Geri: ↑ risk of adverse reactions related to immunosuppression• OB: Patients with childbearing potential• Pedi: Mycophenolate mofetil approved in children B3 mo for renal transplant; mycophenolic acid approved in children B5 yr for renal transplant; safety not established for other age groups

CNS: PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY, anxiety,dizziness, headache, insomnia, paresthesia, tremor.CV: edema, hypertension, hypotension, tachycardia.Derm: rashes.Endo: hypercholesterolemia, hyperglycemia, hyperkalemia,hypocalcemia, hypokalemia, hypomagnesemia.GI: GI BLEEDING, anorexia, constipation, diarrhea, nausea, vomiting, abdominal pain.GU: renal dysfunction.Hemat: leukocytosis, leukopenia, thrombocytopenia, anemia, pure red cell aplasia.Resp: cough, dyspnea.Misc: fever, infection (including activation of latent viral infections such as BK virus-associated nephropathy), ↑ risk of malignancy.

• Assess for signs of progressive multifocal leukoencephalopathy (hemiparesis, apathy, confusion, cognitive deficiencies, and ataxia) periodically during therapy

• Inform female patients of the importance of simultaneously using two reliable forms of contraception, unless abstinence is the chosen method, prior to beginning, during, and for 6 wk following discontinuation of therapy

• Ther. class.anti-infectives
• Pharm. class.aminoglycosides

• Preparation of the GI tract for surgery• Treatment of diarrhea caused by Escherichia coli• To decrease the number of ammonia-producing bacteria in the gut as part of the management of hepatic encephalopathy

Therapeutic Effect(s): Bactericidal actionSpectrum: Notable for activity against» Klebsiella pneumoniae» Escherichia coli» Proteus» Serratia» Acinetobacter» Staphylococcus aureus

• Intestinal obstructionUse Cautiously in:• Renal impairment (lower doses are recommended)• Hearing impairment• Geriatric patients• Neuromuscular diseases such as myasthenia gravis• Pregnancy, lactation, infants, and neonates (safety not established)

GI: diarrhea, nausea, vomiting.Misc: hypersensitivity reactions.

• Advise patient of the importance of drinking plenty of liquids

• Ther. class.antipsychoticsmood stabilizers
• Pharm. class.thienobenzodiazepines

• Acute and maintenance treatment of schizophrenia• Acute treatment of manic episodes associated with bipolar I disorder (may be used alone or with lithium or valproate)• Maintenance therapy of bipolar I disorder• Acute agitation due to schizophrenia or bipolar I mania (IM)• Depressive episodes associated with bipolar I disorder (when used with fluoxetine)• Treatment-resistant depression (when used with fluoxetine)Unlabelled Use(s):• Management of anorexia nervosa• Treatment of nausea and vomiting related to highly emetogenic chemotherapy

• Antagonizes dopamine and serotonin type 2 in the CNS• Also has anticholinergic, antihistaminic, and anti–alpha1-adrenergic effectsTherapeutic Effect(s): Decreased manifestations of psychoses

• Lactation: Discontinue drug or bottle feed• Orally disintegrating tablets only: Phenylketonuria (orally disintegrating tablets contain aspartame)Use Cautiously in:• Patients with hepatic impairment• Patients at risk for aspiration• Cardiovascular or cerebrovascular disease• History of seizures• History of attempted suicide• Diabetes or risk factors for diabetes (may worsen glucose control)• Prostatic hyperplasia• Angle-closure glaucoma• History of paralytic ileus• Dysphagia and aspiration have been associated with antipsychotic drug use; use with caution in patients at risk for aspiration• OB: Safety not established• Geri: Geriatric patients (may require ↓ doses; ↑ risk of mortality in elderly patients treated for dementia-related psychosis)

CNS: NEUROLEPTIC MALIGNANT SYNDROME, SEIZURES, SUICIDAL THOUGHTS, agitation, dizziness, headache, restlessness, sedation,weakness, dystonia, insomnia, mood changes, personality disorder, speech impairment, tardive dyskinesia.EENT: amblyopia, rhinitis, ↑ salivation, pharyngitis.Resp: cough, dyspnea.CV: orthostatic hypotension, tachycardia, chest pain.GI: constipation, dry mouth, abdominal pain, ↑ appetite, weight loss or gain, nausea, ↑ thirst.GU: ↓ libido, urinary incontinence.Hemat: AGRANULOCYTOSIS, leukopenia, neutropenia.Derm: photosensitivity.Endo: amenorrhea, galactorrhea, gynecomastia, hyperglycemia, goiter.Metabolic: dyslipidemia.MS: hypertonia, joint pain.Neuro: tremor.Misc: fever, flu-like syndrome.

» Monitor patient for onset of akathisia (restlessness or desire to keep moving) and extrapyramidal side effects (parkinsonian—difficulty speaking or swallowing, loss of balance control, pill rolling of hands, mask-like face, shuffling gait, rigidity, tremors; and dystonic—muscle spasms, twisting motions, twitching, inability to move eyes, weakness of arms or legs) every 2 mo during therapy and 8–12 wk after therapy has been discontinued. Report these symptoms if they occur, as reduction in dose or discontinuation of medication may be necessary. Trihexyphenidyl or benztropine may be used to control symptoms» Monitor for tardive dyskinesia (uncontrolled rhythmic movement of mouth, face, and extremities; lip smacking or puckering; puffing of cheeks; uncontrolled chewing; rapid or worm-like movements of tongue, excessive blinking of eyes). Report immediately; may be irreversible» Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control). Notify health care professional immediately if these symptoms occur• Monitor for symptoms related to hyperprolactinemia (menstrual abnormalities, galactorrhea, sexual dysfunction)

• • Inform patient of possibility of extrapyramidal symptoms and tardive dyskinesia. Instruct patient to report these symptoms immediately to health care professional
• Advise patient to use sunscreen and protective clothing when exposed to the sun. Extremes of temperature (exercise, hot weather, hot baths or showers) should also be avoided; this drug impairs body temperature regulation

Ther. class.antiemetics

• Prevention of nausea and vomiting associated with chemotherapy or radiation therapy• IM, IV: Prevention and treatment of postoperative nausea and vomiting

• Orally disintegrating tablets contain aspartame and should not be used in patients with phenylketonuriaUse Cautiously in:• Liver impairment (daily dose not to exceed 8 mg)• Abdominal surgery (may mask ileus)• OB: Lactation: Pregnancy, lactation, or children C3 yr (safety not established)

CNS: headache, dizziness, drowsiness, fatigue, weakness.GI: constipation, diarrhea, abdominal pain, dry mouth, ↑ liver enzymes.Neuro: extrapyramidal reactions.

• Assess patient for nausea, vomiting, abdominal distention, and bowel sounds prior to and following administration• Assess patient for extrapyramidal effects (involuntary movements, facial grimacing, rigidity, shuffling walk, trembling of hands) periodically during therapyLab Test Considerations• May cause transient ↑ in serum bilirubin, AST, and ALT levels

• PO: For orally disintegrating tablets, do not attempt to push through foil backing; with dry hands, peel back backing and remove tablet. Immediately place tablet on tongue; tablet will dissolve in seconds, then swallow with saliva. Administration of liquid is not necessary

• Advise patient to notify health care professional immediately if involuntary movement of eyes, face, or limbs occurs

• Ther. class.urinary tract antispasmodics
• Pharm. class.anticholinergics

• Urinary symptoms that may be associated with neurogenic bladder including» Frequent urination» Urgency» Nocturia» Urge incontinence• Overactive bladder with symptoms of urge incontinence, urgency, and frequency

Inhibits the action of acetylcholine at postganglionic receptors• Has direct spasmolytic action on smooth muscle, including smooth muscle lining the GU tract, without affecting vascular smooth muscleTherapeutic Effect(s):• Increased bladder capacity• Delayed desire to void• Decreased urge incontinence, urinary urgency, and frequency and decreased number of urinary accidents associated with overactive bladder

Use Cautiously in:• Hepatic/renal impairment• Bladder outflow obstruction• Ulcerative colitis• Benign prostatic hyperplasia• Cardiovascular disease• Reflux esophagitis or gastrointestinal osbstructive disorders• Patients with dementia receiving acetylcholinesterase inhibitors• Myasthenia gravis• OB: Lactation: Pregnancy or lactation• Pedi: Oral: Safety not established in children <5 yr ; Patch and gel: Safety not established in children < 18 yr• Geri: Appears on Beers list. Poorly tolerated due to anticholinergic effects. Initiate treatment at lower doses.

CNS: dizziness, drowsiness, agitation, confusion, hallucinations, headache.EENT: blurred vision.CV: tachycardia.GI: constipation, dry mouth, nausea, abdominal pain, diarrhea.GU: urinary retention.Derm: ↓ sweating, transdermal only: application site reactions, pruritus.Metabolic: hyperthermia.

• Monitor voiding pattern and intake and output ratios, and assess abdomen for bladder distention prior to and periodically during therapy. Catheterization may be used to assess postvoid residual. Cystometry is usually performed to diagnose type of bladder dysfunction prior to prescription of oxybutynin• Geri: Assess geriatric patients for anticholinergic effects (sedation and weakness)

• Instruct patient that frequent rinsing of mouth, good oral hygiene, and sugarless gum or candy may decrease dry mouth. Health care professional should be notified if mouth dryness persists >2 wk

• Ther. class.digestive agent
• Pharm. class.pancreatic enzymes

Pancreatic insufficiency associated with» Chronic pancreatitis» Pancreatectomy» Cystic fibrosis» GI bypass surgery» Ductal obstruction secondary to tumor

Contains lipolytic, amylolytic, and proteolytic activityTherapeutic Effect(s): Increased digestion of fats, carbohydrates, and proteins in the GI tract

Hypersensitivity to hog proteins

EENT: nasal stuffiness.Resp: dyspnea, shortness of breath, wheezing.GI: abdominal pain (high doses only), diarrhea, nausea, stomach cramps, oral irritation.GU: hematuria.Derm: hives, rash.Metabolic: hyperuricemia.Misc: allergic reactions.

• Antacids ( calcium carbonate or magnesium hydroxide ) may ↓ effectiveness of pancrelipase• May ↓ the absorption of concurrently administered iron supplementsDrug-FoodAlkaline foods destroy coating on enteric-coated products

• Assess patient's nutritional status (height, weight, skin-fold thickness, arm muscle circumference, and lab values) prior to and periodically throughout therapy• Monitor stools for high fat content (steatorrhea). Stools will be foul-smelling and frothy• Assess patient for allergy to pork; sensitivity to pancrelipase may existLab Test Considerations• May cause ↑ serum and urine uric acid concentrations

• Instruct patient not to chew tablets and to swallow them quickly with plenty of liquid to prevent mouth and throat irritation. Patient should be sitting upright to enhance swallowing. Eating immediately after taking medication helps further ensure that the medication is swallowed and does not remain in contact with mouth and esophagus for a prolonged period. Patient should avoid sniffing powdered contents of capsules, as sensitization of nose and throat may occur (nasal stuffiness or respiratory distress)

Ther. class.colony stimulating factors

To decrease the incidence of infection (febrile neutropenia) in patients with nonmyeloid malignancies receiving myelosuppressive antineoplastics associated with a high risk of febrile neutropenia

Filgrastim is a glycoprotein that binds to and stimulates neutrophils to divide and differentiate. Also activates mature neutrophils. Binding to a polyethylene glycol molecule prolongs its effectsTherapeutic Effect(s): Decreased incidence of infection in patients who are neutropenic from chemotherapy

Hypersensitivity to filgrastim or Escherichia coli -derived proteinsUse Cautiously in:• Patients with sickle cell disease (↑ risk of sickle cell crisis)• Concurrent use of lithium• Malignancy with myeloid characteristics• OB: Lactation: Pregnancy or lactation• Pedi: 6 mg fixed dose should not be used in infants, children, and adolescents weighing <45 kg

Resp: ADULT RESPIRATORY DISTRESS SYNDROME (ARDS).GI: SPLENIC RUPTURE.Hemat: SICKLE CELL CRISIS, leukocytosis.MS: medullary bone pain.Misc: ALLERGIC REACTION INCLUDING ANAPHYLAXIS .

• Simultaneous use with antineoplastics may have adverse effects on rapidly proliferating neutrophils; avoid use for 24 hr before and 24 hr following chemotherapy• Lithium may potentiate the release of neutrophils; concurrent use should be undertaken cautiously

• Assess patient periodically for signs of ARDS (fever, lung infiltration, respiratory distress). If ARDS occurs, treat condition and discontinue pegfilgrastim and/or withold until symptoms resolve

• Pegfilgrastim should not be administered between 14 and 24 days after administration of cytotoxic chemotherapy» Keep patients with sickle cell disease receiving pegfilgrastim well hydrated and monitor for sickle cell crisis

• Advise patient to notify health care professional immediately if signs of allergic reaction (shortness of breath, hives, rash, pruritus, laryngeal edema) or signs of splenic rupture (left upper abdominal or shoulder tip pain) occur

Ther. class.antidotesvitaminsPharm. class.fat soluble vitamins

• Prevention and treatment of hypoprothrombinemia, which may be associated with» Excessive doses of oral anticoagulants» Salicylates» Certain anti-infective agents» Nutritional deficiencies» Prolonged total parenteral nutrition• Prevention of hemorrhagic disease of the newborn

Required for hepatic synthesis of blood coagulation factors II (prothrombin), VII, IX, and XTherapeutic Effect(s): Prevention of bleeding due to hypoprothrombinemia

• Hypersensitivity or intolerance to benzyl alcohol (injection only)Use Cautiously in:Impaired liver functionExercise Extreme Caution in:Severe life-threatening reactions have occurred following IV administration, use other routes unless risk is justified

GI: gastric upset, unusual taste.Derm: flushing, rash, urticaria.Hemat: hemolytic anemia.Local: erythema, pain at injection site, swelling.Misc: allergic reactions, hyperbilirubinemia (large doses in very premature infants), kernicterus.

• Large doses will counteract the effect of warfarin• Large doses of salicylates or broad-spectrum anti-infectives may ↑ vitamin K requirements• Bile acid sequestrants , mineral oil , and sucralfate may ↓ vitamin K absorption from the GI tract

The parenteral route is preferred for phytonadione therapy but, because of severe, potentially fatal hypersensitivity reactions, IV vitamin K is not recommended» Administration of whole blood or plasma may also be required in severe bleeding because of the delayed onset of this medication» Phytonadione is an antidote for warfarin overdose but does not counteract the anticoagulant activity of heparin

Caution patient to avoid IM injections and activities leading to injury. Use a soft toothbrush, do not floss, and shave with an electric razor until coagulation defect is corrected• Advise patient to report any symptoms of unusual bleeding or bruising (bleeding gums; nosebleed; black, tarry stools; hematuria; excessive menstrual flow)

• Ther. class.hypokalemicelectrolyte modifiers
• Pharm. class.cationic exchange resins

Mild to moderate hyperkalemia (if severe, more immediate measures such as sodium bicarbonate IV, calcium, or glucose/insulin infusion should be instituted)

Exchanges sodium ions for potassium ions in the intestine (each 1 g is exchanged for 1 mEq potassium)Therapeutic Effect(s): Reduction of serum potassium levels

Contraindicated in:• Life-threatening hyperkalemia (other, more immediate measures should be instituted)• Hypersensitivity to saccharin or parabens (some products)• Ileus• Known alcohol intolerance (suspension only)Use Cautiously in:• Geri: Geriatric patients• CHF, hypertension, edema• Sodium restriction• Constipation

GI: constipation, fecal impaction, anorexia, gastric irritation, nausea, vomiting.F and E: hypocalcemia, hypokalemia, sodium retention, hypomagnesemia.

Drug-Drug• Administration with calcium or magnesium-containing antacids may ↓ resin-exchanging ability and ↑ risk of systemic alkalosis• Hypokalemia may enhance digoxin toxicity

• Monitor response of symptoms of hyperkalemia (fatigue, muscle weakness, paresthesia, confusion, dyspnea, peaked T waves, depressed ST segments, prolonged QT segments, widened QRS complexes, loss of P waves, and cardiac arrhythmias). Assess for development of hypokalemia (weakness, fatigue, arrhythmias, flat or inverted T waves, prominent U waves)

• Explain purpose and method of administration of medication to patient• Advise patient to avoid taking antacids or laxatives during therapy, unless approved by health care professional; may cause systemic alkalosis• Inform patient of need for frequent lab tests to monitor effectiveness

• Ther. class.anti-infectives
• Pharm. class.folate antagonists

• Treatment of uncomplicated urinary tract infections• Treatment of uncomplicated otitis media in childrenUnlabelled Use(s):• Prophylaxis of chronic recurrent urinary tract infections• Treatment of head lice• With dapsone in the management of mild to moderate Pneumocystis jirovecii pneumonia (PCP)

• Ther. class.antiretrovirals
• Pharm. class.nucleoside reverse transcriptase inhibitors

• HIV infection (with other antiretrovirals)• Reduction of maternal/fetal transmission of HIVUnlabelled Use(s): Chemoprophylaxis after occupational exposure to HIV

• Following intracellular conversion to its active form, inhibits viral RNA synthesis by inhibiting the enzyme DNA polymerase (reverse transcriptase)• Prevents viral replicationTherapeutic Effect(s):• Virustatic action against selected retroviruses• Slowed progression and decreased sequelae of HIV infection• Decreased viral load and improved CD4 cell counts• Decreased transmission of HIV to infants born to HIV-infected mothers

CNS: SEIZURES, headache, weakness, anxiety, confusion, ↓ mental acuity, dizziness, insomnia, mental depression, restlessness, syncope.GI: HEPATOMEGALY (WITH STEATOSIS) , PANCREATITIS, abdominal pain, diarrhea, nausea, anorexia, drug-induced hepatitis, dyspepsia, oral mucosa pigmentation, vomiting.F and E: LACTIC ACIDOSIS.Derm: nail pigmentation.Endo: fat redistribution, gynecomastia.Hemat: anemia, granulocytopenia, pure red-cell aplasia, thrombocytosis.MS: back pain, myopathy.Neuro: tremor.

• ↑ bone marrow depression with other agents having bone marrow–depressing properties , antineoplastics , radiation therapy , organciclovir• ↑ neurotoxicity may occur with acyclovir• Toxicity may be ↑ by concurrent administration of probenecid orfluconazole• Levels are ↓ by clarithromycin

• Instruct patient that zidovudine should not be shared with others

• Decrease in viral load and increase in CD4 counts in patients with HIV• Delayed progression of AIDS and decreased opportunistic infections in patients with HIV• Reduction of maternal/fetal transmission of HIV