meds simulation

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meds simulation
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  1. Amlodipine (Norvasc)
    • Classifications:
    • CALCIUM CHANNEL BLOCKER; ANTIHYPERTENSIVE AGENT
    • USES
    • mild to moderate hypertension
    • stable angina.
    • ASSESSMENT:
    • *interactions with other prescriptions, OTC meds, herbal products.
    • *take BP
    • *cardiac rhythm
    • *frequency & intensity of angina
    • *I & O ratio
    • *weight
    • *edema
    • *S&S of adverse rx at beginning of therapy &
    • INTERVENTION:
    • *Monitor BP for therapeutic effectiveness.
    • *S&S of dose-related peripheral or facial edema
    • *Monitor BP with postural changes.
    • Report postural hypotension
    • *heart rate
    • dose-related palpitations (common in women)may occur
    • NOTES:
    • grapefruit juice may increase amlodipine levels
  2. Amlodipine: Assessment & Intervention
    • Assessment & Drug Effects
    • -->Monitor BP for therapeutic effectiveness.

    • BP reduction is greatest after peak levels of amlodipine are achieved 6–9 h following oral doses.
    • -->Monitor for S&S of dose-related peripheral or facial edema that may not be accompanied by weight gain;
    • rarely, severe edema may cause discontinuation of drug.
    • -->Monitor BP with postural changes. Report postural hypotension.
    • -->Monitor more frequently when additional antihypertensives or diuretics are added.
    • -->Monitor heart rate
    • dose-related palpitations (more common in women) may occur.

    • Patient & Family Education
    • *Report significant swelling of face or extremities.
    • *Take care to have support when standing & walking *due to possible dose-related light-headedness/dizziness.
    • *Report to physician.
    • shortness of breath,
    • palpitations,
    • irregular heartbeat,
    • nausea,
    • constipation
  3. *Peak: Antihypertensive effect 7–14 d.
    • *Distribution: >98% protein bound.
    • *Metabolism: In the liver by CYP2D6 and CYP2C9.
    • *Elimination: Primarily through feces.
    • *Half-Life: 7–10 h.
  4. carvedilol (Coreg): A & I
    • Assessment & Drug Effects
    • -->Monitor for therapeutic effectiveness
    • indicated by lessening of S&S of CHF and improved BP control.
    • Lab tests:
    • -->Monitor LFT's (liver function tests) periodically
    • !!at first sign of hepatic toxicity (see Appendix F) stop drug and notify physician.
    • -->Monitor for worsening of symptoms in patients with PVD.
    • -->Monitor digoxin levels with concurrent use;
    • plasma digoxin concentration may increase.
    • Patient & Family Education
    • *Do not abruptly discontinue taking this drug.
    • *You may experience dizziness or faintness, as a risk of orthostatic hypotension.
    • *Do not engage in hazardous activities while experiencing dizziness.
    • *If you have diabetes, the drug may increase effects of hypoglycemic drugs and mask S&S of hypoglycemia.
  5. clopidogrel bisulfate (Plavix)
    • Classifications
    • ANTICOAGULANTS; ANTIPLATELET AGENT
    • Therapeutic:
    • ANTICOAGULANTS; ANTIPLATELET AGENT
    • MOA & THERAPEUTIC EFFECT
    • ->Inhibits platelet aggregation by selectively preventing the binding of adenosine diphosphate to its platelet receptor.
    • *analog of ticlopidine.
    • *The drug's effect on the adenosine diphosphate receptor of a platelet is irreversible.
    • -->Clopidogrel prolongs bleeding time, thereby reducing atherosclerotic events in high-risk patients
    • USES
    • Acute coronary syndrome (ST or non-ST elevations).
    • Secondary prevention of MI, stroke, and vascular death in patients with recent MI, stroke, unstable angina or established peripheral arterial disease.
    • UNLABELED USES
    • Reduction of restenosis after stent placement
    • CONTRAINDICATIONS
    • *intracranial hemorrhage, peptic ulcer, or any other active pathologic bleeding.
    • *Discontinue clopidogrel 7 d before surgery and during lactation.
    • *Safety and efficacy not established in children.
    • CAUTIOUS USE
    • *Concurrent use with drugs that might induce gastrointestinal bleeding;
    • *GI bleeding, peptic ulcer disease;
    • *hepatic impairment (moderate to severe); *severe renal impairment;
    • *patients at risk for increased bleeding; pregnancy (category B).
    • USAGE, ROUTE, DOSAGE
    • *Secondary Prevention Adult: PO 75 mg q.d.
    • *Acute Coronary Syndrome (Non-ST Elevation) Adult: PO 300 mg loading dose then 75 mg q.d. (use with aspirin)
    • ADMINISTRATION
    • Oral
    • !Do not administer to persons with active pathologic bleeding!
    • *Discontinue drug 7 d prior to surgery.
    • *Store at 15°–30° C (59°–86° F) in tightly closed container and protect from light.
    • ADVERSE EFFECTS
    • Body as a Whole: Flu-like syndrome, fatigue, pain, arthralgia, back pain.
    • CV: Chest pain, edema, hypertension, thrombocytopenic purpura.
    • GI: Abdominal pain, dyspepsia, diarrhea, nausea, hypercholesterolemia.
    • Hematologic: Thrombotic thrombocytopenic purpura, epistaxis.
    • CNS: Headache, dizziness, depression.
    • Respiratory: URI, dyspnea, rhinitis, bronchitis, cough.
    • Skin: Rash, pruritus.
    • INTERACTIONS
    • *Drug: NSAIDS may increase risk of bleeding events.
    • *Herbal: Garlic, ginger, ginkgo, evening primrose oil may increase risk of bleeding.
    • PHARMACOKINETICS
    • *Absorption: Rapidly from GI tract.
    • *Onset: 2 h; reaches steady state in 3–7 d.
    • *Distribution: 94–98% protein bound.
    • *Metabolism: Rapidly hydrolyzed in plasma to active metabolite.
    • *Elimination: 50% in urine and 50% in feces.
    • *Half-Life: 8 h.
  6. clopidogrel bisulfate (Plavix): A & I
    • Assessment & Drug Effects
    • Carefully monitor for and immediately report S&S of:
    • GI bleeding, especially when coadministered with NSAIDs, aspirin, heparin, or warfarin.
    • Lab tests:
    • Periodic platelet count and lipid profile.
    • Evaluate patients with unexplained fever or infection for myelotoxicity.
    • Patient & Family Education
    • *Report promptly any unusual bleeding (e.g., black, tarry stools).
    • *Avoid chronic aspirin or NSAID use unless approved by physician.
  7. digoxin (Lanoxin)
    • Distribution: Widely distributed; tissue levels significantly higher than plasma levels; crosses placenta.Distribution: Widely distributed; tissue levels significantly higher than plasma levels; crosses placenta.
    • Metabolism: 14% in liver.
    • Elimination: 80–90% by kidneys; may appear in breast milk.
    • Half-Life: 34–44 h.
  8. digoxin (Lanoxin): A & I
    Assessment & Drug Effects

    • **Take apical pulse for 1 full min,
    • note: rate, rhythm, and quality before administering drug.
    • **Withhold medication and notify physician if apical pulse falls below ordered parameters
    • adults: <50 or 60/min
    • children: <60 or 70/min
    • Be familiar with patient's baseline data as a foundation for making assessments.
    • **quality of peripheral pulses,
    • blood pressure,
    • clinical symptoms,
    • serum electrolytes, creatinine clearance
    • Lab tests:
    • Baseline and periodic serum digoxin, potassium, magnesium, and calcium.
    • *Draw blood samples for determining plasma digoxin levels at least 6 h after daily dose and preferably just before next scheduled daily dose.
    • Monitor for S&S of drug toxicity:
    • *In children, cardiac arrhythmias are usually reliable signs of early toxicity.
    • *Early indicators in adults:
    • *anorexia, nausea, vomiting, diarrhea, visual disturbances
    • rarely initial signs in children.
    • *Monitor I&O ratio during digitalization, particularly in patients with impaired renal function.
    • -->monitor for edema daily
    • -->auscultate chest for rales.
    • -->Monitor serum digoxin levels closely during concurrent antibiotic–digoxin therapy,
    • *can precipitate toxicity because of altered intestinal flora.
    • -->Observe patients closely when being transferred from one preparation (tablet, elixir, or parenteral) to another
    • when tablet is replaced by elixir, potential for toxicity increases since ≥30% of drug is absorbed.

    • Patient & Family Education
    • -->Report to physician if:
    • *pulse falls below 60 or
    • *rises above 110 or
    • *if you detect skipped beats or other changes in rhythm
    • when digoxin is prescribed for atrial fibrillation.
    • Suspect toxicity and report to physician if any of the following occur:
    • Anorexia, nausea, vomiting, diarrhea, or visual disturbances.
    • -->Weigh each day under standard conditions.--->Report weight gain >1 kg (2 lb)/d.
    • -->Take digoxin PRECISELY as prescribed. Do not skip or double a dose or change dose intervals, and take it at same time each day.
    • **Do not to take OTC medications
    • especially those for coughs, colds, allergy, GI upset, or obesity, without prior approval of physician.
    • -->Continue with brand originally prescribed unless otherwise directed by physician.
  9. ducosate sodium (Colace)
  10. Subcutaneous
    • -->Use a TB syringe or prefilled syringe to ensure accurate dosage.
    • !!Do not expel air bubble from the 30 or 40 mg prefilled syringe before injection.
    • -->Place patient in a supine position for injection of the drug.
    • **Alternate injections between left and right anterolateral and posterolateral abdominal wall.
    • Hold the skin fold between the thumb and forefinger and insert the whole length of the needle into the skin fold. Hold skin fold throughout the injection.
    • Do not rub site post injection.
    • Store at 15°–30° C (59°–86° F).
    • ADVERSE EFFECTS
    • Body as a Whole: Allergic reactions (rash, urticaria), fever, angioedema, arthralgia, pain and inflammation at injection site, peripheral edema, fever.
    • Digestive: Abnormal liver function tests.
    • Hematologic: Hemorrhage , thrombocytopenia, ecchymoses, anemia.
    • Respiratory: Dyspnea.
    • Skin: Rash, pruritus.
    • INTERACTIONS
    • Drug: Aspirin, NSAIDS, warfarin can increase risk of hemorrhage.
    • Herbal: Garlic, ginger, ginkgo, feverfew, horse chestnut may increase risk of bleeding.
    • PHARMACOKINETICS
    • Absorption: 91% absorbed from SC injection site.
    • Peak: 3 h.
    • Duration: 4.6 h.
    • Distribution: Appears to accumulate in liver, kidneys, and spleen. Does not cross placenta.
    • Elimination: Primarily in urine.
    • Half-Life: 4.6 h.
  11. enoxaparin (Lovenox): A & I
    Assessment & Drug Effects

    • Lab tests:
    • Baseline coagulation studies;
    • periodic CBC,
    • platelet count,
    • urine and stool for occult blood.
    • -->Monitor platelet count closely.
    • Withhold drug and notify physician if platelet count less than 100,000/mm3.
    • -->Monitor closely patients with renal insufficiency and
    • *older adults who are at higher risk for thrombocytopenia.
    • -->Monitor for and report immediately any S&S of unexplained bleeding.
    • Patient & Family Education

    • Report to physician promptly signs of unexplained bleeding such as:
    • *pink, red, or dark brown urine;
    • *red or dark brown vomitus;
    • *bleeding gums or bloody sputum;
    • *dark, tarry stools.
    • !!Do not take any OTC drugs without first consulting physician.
  12. epoetin alpha (Procrit)
    • Classifications:
    • BLOOD FORMER; HEMATOPOIETIC GROWTH FACTOR
    • Therapeutic:
    • ANTIANEMIC; HUMAN ERYTHROPOIETIN
    • MOA & THERAPEUTIC EFFECT
    • Human erythropoietin is produced in the kidney and stimulates bone marrow production of RBCs (erythropoiesis).
    • *Hypoxia and anemia generally increase the production of erythropoietin.
    • *Epoetin alpha is a glycoprotein that stimulates RBC production.
    • *Stimulates the production of RBCs in the bone marrow of severely anemic patients.
    • USES
    • -->Elevates hematocrit of patients with anemia secondary to chronic kidney failure (CRF);
    • *patients may or may not be on dialysis;
    • *other anemias related to malignancies and AIDS.
    • *Autologous blood donations for anticipated transfusions.
    • -->Reduces need for blood in anemic surgical patients;
    • CONTRAINDICATIONS
    • *Uncontrolled hypertension
    • *known hypersensitivity to mammalian cell–derived products and albumin (human)
    • *hamster protein hypersensitivity;
    • *iron-deficiency anemia,
    • *pregnancy (category C);
    • lactation; neonates.
    • CAUTIOUS USE
    • Leukemia, sickle cell disease;
    • coagulopathy;
    • seizure disorders.
    • ROUTE AND DOSAGE
    • Anemia Adult: SC/IV Start with 50–100 U/kg/dose until target Hct range of 30–33% (max: 36%) is reached.
    • Hct should not increase by more than 4 points in any 2-wk period, rapid increase in Hct increases the risk of serious adverse reactions (hypertension, seizures).
    • -->May increase dose if Hct has not increased 5–6 points after 8 wk of therapy,
    • -->reduce dose after target range is reached or the Hct increases by >4 points in any 2-wk period
    • dose usually increased or decreased by 25 U/kg increments.
    • Child: SC/IV 50 U/kg/dose 3 times/wk initially, when Hct increased to 35%, decrease dose by 25 U/kg/dose until Hct reaches 40%
    • Anemia of CRF Adult: SC/IV Start with 50–100 U/kg/dose until target Hct range of 30–33% (max: 36%) is reached;
    • if Hgb increases more than 1 g/dL and approaches 12 g/dL, reduce dose by 25%. If after 4 wk there is less than 1 g/dL, increase dose by 25%.

    • ADMINISTRATION
    • Subcutaneous
    • Do not shake solution. Shaking may denature the glycoprotein, rendering it biologically inactive.
    • -->Inspect solution for particulate matter prior to use.
    • !!Do not use if solution is discolored or if it contains particulate matter.
    • -->Use only one dose per vial, and do not reenter vial.
    • !!Do not give with any other drug solution.
    • Intravenous
    • Prepare:: Direct: Give undiluted.
    • Administer:: Direct: Give direct IV as a bolus dose over 1 min.
    • Incompatibilities: Solution/Additive: D10W, normal saline.
    • *Discard any unused portion of the vial. It contains no preservatives.
    • *Store at 2°–8° C (36°–46° F). Do not freeze or shake.
    • ADVERSE EFFECTS
    • CNS: Seizures, headache.
    • CV: Hypertension.
    • GI: Nausea, diarrhea.
    • Hematologic: Iron deficiency, thrombocytosis, pure red cell aplasia, clotting of AV fistula.
    • Other: Sweating, bone pain, arthralgias.

    • INTERACTIONS
    • Drug: Do not give concurrently with darbepoetin alfa.

    • PHARMACOKINETICS
    • Onset: 7–14 d.
    • Metabolism: In serum.
    • Elimination: Minimal recovery in urine.
    • Half-Life: 4–13 h.
  13. epoetin alpha (Procrit): A & I
    • Assessment & Drug Effects
    • -->Control BP adequately prior to initiation of therapy
    • -->closely monitor and control during therapy. -->Hypertension is an adverse effect that must be controlled.
    • -->Be aware that BP may rise during early therapy as the Hct increases.
    • *Notify physician of a rapid rise in Hct (>4 points in 2 wk).
    • *Dosage will need to be reduced because of risk of serious hypertension.
    • -->Monitor for hypertensive encephalopathy in patients with CRF during period of increasing Hct.
    • -->Monitor for premonitory neurological symptoms (i.e., aura, and report their appearance promptly).
    • The potential for seizures exists during periods of rapid Hct increase (>4 points in 2 wk).
    • -->Monitor closely for thrombotic events
    • (e.g., MI, CVA, TIA), especially for patients with CRF.

    • Lab tests:
    • *Baseline transferrin and serum ferritin.*
    • -->Monitor aPTT & INR closely.
    • Patients may require additional heparin during dialysis to prevent clotting of the vascular access or artificial kidney.
    • -->Determine Hct twice weekly until it is stabilized in the target range (30–33%) and the maintenance dose of epoetin alfa has been determined;
    • *then monitor at regular intervals.
    • -->Perform CBC with differential and platelet count regularly.
    • -->Monitor BUN, creatinine, phosphorus, and potassium regularly.

    • Patient & Family Education
    • *Important to comply with antihypertensive medication and dietary restrictions.
    • *Do not drive or engage in other potentially hazardous activity during the first 90 d of therapy because of possible seizure activity.
    • **As Hct increases, there is an improved sense of well-being and quality of life.
    • It is important to continue compliance with dietary and dialysis prescriptions.
    • **headache is a common adverse effect.
    • Report if severe or persistent
    • may indicate developing hypertension.
    • **Keep all follow-up appointments.
  14. GI: Nausea, vomiting, constipation, ileus.
    • Respiratory: Laryngospasm, bronchoconstriction, respiratory depression or arrest.
    • Body as a Whole: Muscle rigidity, especially muscles of respiration after rapid IV infusion, urinary retention.
    • Skin: Rash, contact dermatitis from patch.
    • INTERACTIONS
    • Drug: Alcohol and other CNS DEPRESSANTS potentiate effects;
    • MAO INHIBITORS may precipitate hypertensive crisis.
    • PHARMACOKINETICS
    • Absorption: Absorbed through the skin, leveling off between 12–24 h.
    • Onset: Immediate IV; 7–15 min IM; 12–24 h transdermal.
    • Peak: 3–5 min IV; 24–72 h transdermal.
    • Duration: 30–60 min IV; 1–2 h IM; 72 h transdermal.
    • Metabolism: In liver by CYP3A4.
    • Elimination: In urine.
    • Half-Life: 17 h transdermal.
  15. fentanyl (Duragesic): A & I
    • Assessment & Drug Effects
    • -->Monitor vital signs and observe patient for signs of skeletal and thoracic muscle (depressed respirations) rigidity and weakness.
    • -->Watch carefully for respiratory depression and for movements of various groups of skeletal muscle in extremities, external eye, and neck during postoperative period.
    • These movements may present patient management problems; report promptly.
    • Duration of respiratory depressant effect may be considerably longer than narcotic analgesic effect.
    • Have immediately available oxygen, resuscitative and intubation equipment, and an opioid antagonist such as naloxone.
  16. furosemide (Lasix)
    • Classifications:
    • ELECTROLYTIC AND WATER BALANCE AGENT; LOOP DIURETIC; ANTIHYPERTENSIVE
    • Therapeutic:
    • LOOP DIURETIC; ANTIHYPERTENSIVE

    • ACTION & THERAPEUTIC EFFECT
    • Rapid-acting potent sulfonamide "loop" diuretic and antihypertensive.
    • -->Inhibits reabsorption of sodium and chloride primarily in loop of Henle and also in proximal and distal renal tubules;
    • -->decreases renal vascular resistance and may increase renal blood flow.
    • *An antihypertensive that decreases edema and intravascular volume.
    • USES
    • Treatment of edema associated with CHF, cirrhosis of liver, and kidney disease, including nephrotic syndrome.
    • *May be used for management of hypertension, alone or in combination with other antihypertensive agents, and for treatment of hypercalcemia.
    • *Has been used concomitantly with mannitol for treatment of severe cerebral edema, particularly in meningitis.
    • CONTRAINDICATIONS
    • History of hypersensitivity to furosemide or sulfonamides; increasing oliguria, anuria, fluid and electrolyte depletion states; hepatic coma; preeclampsia, eclampsia;
    • pregnancy (category C).
    • CAUTIOUS USE
    • Infants, older adults; hepatic disease; hepatic cirrhosis; renal disease, nephrotic syndrome; cardiogenic shock associated with acute MI; ventricular arrhythmias, CHF, diarrhea; history of SLE, history of gout; diabetes mellitus; patients receiving digitalis glycosides or potassium-depleting steroids, lactation.

    • ROUTE AND DOSAGE
    • Edema Adult: PO 20–80 mg in 1 or more divided doses up to 600 mg/d if needed IV/IM 20–40 mg in 1 or more divided doses up to 600 mg/d Child: PO 2 mg/kg, may be increased by 1–2 mg/kg q6–8h (max: 6 mg/kg/dose) IV/IM 1–2 mg/kg, may be increased by 1 mg/kg q2h if needed (max: 6 mg/kg/dose) Neonate: PO 1–4 mg/kg q12–24h IV/IM 1 mg/kg q12–24h
    • Hypertension Adult: PO 10–40 mg b.i.d. (max: 480 mg/d)
    • ADMINISTRATION

    Oral

    • Give with food or milk to reduce possibility of gastric irritation.
    • Schedule doses to avoid sleep disturbance (e.g., a single dose is generally given in the morning; twice-a-day doses at 8 a.m. and 2 p.m.).
    • Slight discoloration of tablets reportedly does not alter potency.
    • Store tablets at controlled room temperature, preferably at 15°–30° C (59°–86° F) unless otherwise directed. Protect from light.
    • Store oral solution in refrigerator, preferably at 2°–8° C (36°–46° F). Protect from light and freezing.
    • Intramuscular

    • Protect syringes from light once they are removed from package.
    • Discard yellow or otherwise discolored injection solutions.
    • Intravenous

    • Verify correct IV concentration and rate of infusion/injection with physician before administration to infants or children.
    • Prepare:: Direct: Give undiluted.
    • Administer:: Direct:

    • Give undiluted at a rate of 20 mg or a fraction thereof over 1 min.
    • With high doses a rate of 4 mg/min is recommended to decrease risk of ototoxicity.
    • Incompatibilities: Solution/additive: Amiodarone, buprenorphine, chlorpromazine, diazepam, dobutamine, erythromycin, fructose, gentamicin, isoproterenol, meperidine, metoclopramide, milrinone, netilmicin, pancuronium, papaveretum, prochlorperazine, promethazine, quinidine, thiamine. Y-site: Amrinone, amsacrine, azithromycin, chlorpromazine, ciprofloxacin, clarithromycin, diltiazem, dobutamine, dopamine, doxorubicin, droperidol, esmolol, fenoldopam, filgrastim, fluconazole, gemcitabine, gentamicin, hydralazine, idarubicin, labetalol, lansoprazole, levofloxacin, meperidine, methocarbamol, metoclopramide, midazolam, milrinone, morphine, netilmicin, nicardipine, ondansetron, quinidine, tetracycline, thiopental, tobramycin, vecuronium, vinblastine, vincristine, vinorelbine, TPN.

    • Use infusion solutions within 24 h.
    • Store parenteral solution at controlled room temperature, preferably at 15°–30° C (59°–86° F) unless otherwise directed. Protect from light.
    • ADVERSE EFFECTS
    • CV: Postural hypotension, dizziness with excessive diuresis, acute hypotensive episodes, circulatory collapse.
    • Metabolic: Hypovolemia, dehydration, hyponatremia, hypokalemia, hypochloremia, metabolic alkalosis, hypomagnesemia, hypocalcemia (tetany), hyperglycemia, glycosuria, elevated BUN, hyperuricemia.
    • GI: Nausea, vomiting, oral and gastric burning, anorexia, diarrhea, constipation, abdominal cramping, acute pancreatitis, jaundice.
    • Urogenital: Allergic interstitial nephritis, irreversible renal failure, urinary frequency.
    • Hematologic: Anemia, leukopenia, thrombocytopenic purpura; aplastic anemia, agranulocytosis (rare).
    • Special Senses: Tinnitus, vertigo, feeling of fullness in ears, hearing loss (rarely permanent), blurred vision.
    • Skin: Pruritus, urticaria, exfoliative dermatitis, purpura, photosensitivity, porphyria cutanea tarda, necrotizing angiitis (vasculitis).
    • Body as a Whole: Increased perspiration; paresthesias; activation of SLE, muscle spasms, weakness; thrombophlebitis, pain at IM injection site.
    • DIAGNOSTIC TEST INTERFERENCES
    • Furosemide may cause elevations in BUN, serum amylase, cholesterol, triglycerides, uric acid and blood glucose levels, and may decrease serum calcium, magnesium, potassium, and sodium levels.
    • INTERACTIONS
    • Drug: OTHER DIURETICS enhance diuretic effects; with digoxin increased risk of toxicity because of hypokalemia; NONDEPOLARIZING NEUROMUSCULAR BLOCKING AGENTS (e.g., tubocurarine) prolong neuromuscular blockage; CORTICOSTEROIDS, amphotericin B potentiate hypokalemia; decreased lithium elimination and increased toxicity; SULFONYLUREAS, insulin blunt hypoglycemic effects; NSAIDs may attenuate diuretic effects.
    • PHARMACOKINETICS
    • Absorption: 60% PO dose from GI tract.
    • Peak: 60–70 min PO; 20–60 min IV.
    • Onset: 30–60 min PO; 5 min IV.
    • Duration: 2 h.
    • Distribution: Crosses placenta.
    • Metabolism: Small amount in liver.
    • Elimination: Rapidly in urine; 50% of oral dose and 80% of IV dose excreted within 24 h; excreted in breast milk.
    • Half-Life: 30 min.
  17. furosemide (Lasix): A & I
    • Assessment & Drug Effects
    • Observe patients receiving parenteral drug carefully; closely monitor BP and vital signs. Sudden death from cardiac arrest has been reported.
    • Monitor for S&S of hypokalemia (see Appendix F).
    • Monitor BP during periods of diuresis and through period of dosage adjustment.
    • Observe older adults closely during period of brisk diuresis. Sudden alteration in fluid and electrolyte balance may precipitate significant adverse reactions. Report symptoms to physician.
    • Lab tests: Obtain frequent blood count, serum and urine electrolytes, CO2, BUN, blood sugar, and uric acid values during first few months of therapy and periodically thereafter.
    • Monitor I&O ratio and pattern. Report decrease or unusual increase in output. Excessive diuresis can result in dehydration and hypovolemia, circulatory collapse, and hypotension. Weigh patient daily under standard conditions.
    • Monitor urine and blood glucose & HbA1C closely in diabetics and patients with decompensated hepatic cirrhosis. Drug may cause hyperglycemia.
    • Excessive dehydration is most likely to occur in older adults, those with chronic cardiac disease on prolonged salt restriction, or those receiving sympatholytic agents.

    • Patient & Family Education
    • Consult physician regarding allowable salt and fluid intake.
    • Ingest potassium-rich foods daily (e.g., bananas, oranges, peaches, dried dates) to reduce or prevent potassium depletion.
    • Learn S&S of hypokalemia (see Appendix F). Report muscle cramps or weakness to physician.
    • Make position changes slowly because high doses of antihypertensive drugs taken concurrently may produce episodes of dizziness or imbalance.
    • Avoid replacing fluid losses with large amounts of water.
    • Avoid prolonged exposure to direct sun.
  18. glyburide (Diabeta)
    • Classifications: HORMONE; ANTIDIABETIC AGENT; SULFONYLUREA Therapeutic: ANTIDIABETIC; SULFONYLUREA
    • ACTION & THERAPEUTIC EFFECT
    • One of the most potent of the second-generation sulfonylurea hypoglycemic agents. Potency is enhanced by as much as 200-fold over first-generation agents. Appears to lower blood sugar concentration in both diabetic and nondiabetic individuals by sensitizing functioning pancreatic beta cells to release insulin in the presence of elevated serum glucose levels.
    • Blood glucose-lowering effect persists during long-term glyburide treatment, but there is a gradual decline in meal-stimulated secretion of endogenous insulin toward pretreatment levels.
    • USES
    • Adjunct to diet to lower blood glucose in patients with type 2 diabetes mellitus; after dietary control alone has failed.
    • CONTRAINDICATIONS
    • Hypersensitivity to glyburide or sulfonylureas; diabetic ketoacidosis; as sole therapy for type 2 diabetes mellitus; moderate or severe renal impairment (CrCl <50 mL/min) or renal failure; pregnancy (category C); withhold 14 d before labor and delivery; lactation. Safe use in children is not established.
    • CAUTIOUS USE
    • Limit use in patients with cardiovascular disease; thyroid disease; mild renal impairment or hepatic disease; older adults, debilitated, or malnourished patients; adrenal or pituitary insufficiency.
    • ROUTE AND DOSAGE

    • Control of Hyperglycemia Adult: PO 1.25–5 mg/d with breakfast, may increase by 2.5–5 mg q1–2wk; >15 mg/d should be given in divided doses with morning and evening meal (max: 20 mg/d); Micronized 1.5–3 mg/d (max: 12 mg/d)
    • ADMINISTRATION

    Oral

    • Give once daily in the morning with breakfast or with first main meal.
    • Store in tightly closed, light-resistant container at 15°–30° C (59°–86° F).
    • ADVERSE EFFECTS
    • Metabolic: Hypoglycemia.
    • GI: Epigastric fullness, heartburn, nausea, vomiting.
    • Skin: Pruritus, erythema, urticarial or cholestatic jaundice (rare) morbilliform eruptions.
    • Special Senses: Blurred vision.
    • INTERACTIONS
    • Drug: Alcohol causes disulfiram-like reaction in some patients; ORAL ANTICOAGULANTS, chloramphenicol, clofibrate, phenylbutazone, MAO INHIBITORS, SALICYLATES, probenecid, SULFONAMIDES may potentiate hypoglycemic actions; THIAZIDES may antagonize hypoglycemic effects; cimetidine may increase glyburide levels, causing hypoglycemia.
    • Herbal: Ginseng, garlic may increase hypoglycemic effects.
    • PHARMACOKINETICS
    • Absorption: Readily absorbed from GI tract.
    • Onset: 15–60 min.
    • Peak: 1–2 h.
    • Duration: Up to 24 h.
    • Distribution: Distributed in highest concentrations in liver, kidneys, and intestines; crosses placenta.
    • Metabolism: Extensively in liver.
    • Elimination: Equally in urine and feces.
    • Half-Life: 10 h.
  19. glyburide (Diabeta): A & I
    Assessment & Drug Effects

    • Monitor blood glucose levels carefully during the dangerous early treatment period when dosage is being individualized. Older adults are especially vulnerable to glyburide-induced hypoglycemia (see Appendix F) because the antidiabetic agent is long-acting.
    • The first signs of hypoglycemia may be hard to detect when the patient is also receiving a beta blocker or is an older adult.
    • Lab tests: Monitor at regular intervals: Blood and urine glucose, HbA1c, urine ketones, and liver function tests.
    • Patient & Family Education

    • Eat or drink some form of sugar (e.g., corn syrup, orange juice with 2 or 3 tsp of table sugar) when symptoms of hypoglycemia occur. Report reaction to physician promptly.
    • Remember that loss of control of diabetes may result from stress such as fever, surgery, trauma, or infection. Check blood glucose and urine for ketones more frequently during stress periods; transfer from the sulfonylurea to insulin may be necessary.
    • Keep all follow-up medical appointments and adhere to dietary instructions, regular exercise program, and scheduled urine and blood testing.
    • Report blurred vision to physician.
  20. insulin
    • antidiabetic agent
    • accucheck necessary
  21. isosorbide mononitrate (Imdur)
    • Classifications: NITRATE VASODILATOR Therapeutic: VASODILATOR; ANTIANGINAL
    • Prototype: Nitroglycerin
    • ACTION & THERAPEUTIC EFFECT
    • Isosorbide mononitrate is a long-acting metabolite of the coronary vasodilator isosorbide dinitrate. It decreases preload as measured by pulmonary capillary wedge pressure (PCWP), and left ventricular end volume and diastolic pressure (LVEDV), with a consequent reduction in myocardial oxygen consumption.
    • It is equally or more effective than isosorbide dinitrate in the treatment of chronic, stable angina. It is a potent vasodilator with antianginal and antiischemic effects.
    • USES
    • Prevention of angina. Not indicated for acute attacks.
    • CONTRAINDICATIONS
    • Hypersensitivity to nitrates; severe anemia; closed-angle glaucoma; recent MI; postural hypotension, head trauma, cerebral hemorrhage (increases intracranial pressure); pregnancy (category C). Extended form should not be used in patients with GI disease.
    • CAUTIOUS USE
    • Older adults, hypotension; lactation.
    • ROUTE AND DOSAGE

    • Prevention of Angina Adult: PO Regular release (ISMO, Monoket) 20 mg b.i.d. 7 h apart; Sustained release (Imdur) 30–60 mg every morning, may increase up to 120 mg once daily after several days if needed (max: dose 240 mg)
    • ADMINISTRATION

    Oral

    • Give first dose in morning on arising and second dose 7 h later with twice daily dosing regimen. Give in morning on arising with once daily dosing.
    • Store sustained release tablets in a tight container.
    • ADVERSE EFFECTS
    • CNS: Headache, agitation, anxiety, confusion, loss of coordination, hypoesthesia, hypokinesia, insomnia or somnolence, nervousness, migraine headache, paresthesia, vertigo, ptosis, tremor.
    • CV: Aggravation of angina, abnormal heart sounds, murmurs, MI, transient hypotension, palpitations.
    • Hematologic: Hypochromic anemia, purpura, thrombocytopenia, methemoglobinemia (high doses).
    • GI: Nausea, vomiting, dry mouth, abdominal pain, constipation, diarrhea, dyspepsia, flatulence, tenesmus, gastric ulcer, hemorrhoids, gastritis, glossitis.
    • Metabolic: Hyperuricemia, hypokalemia.
    • GU: Renal calculus, UTI, atrophic vaginitis, dysuria, polyuria, urinary frequency, decreased libido, impotence.
    • Respiratory: Bronchitis, pneumonia, upper respiratory tract infection, nasal congestion, bronchospasm, coughing, dyspnea, rales, rhinitis.
    • Skin: Rash, pruritus, hot flashes, acne, abnormal texture.
    • Special Senses: Diplopia, blurred vision, photophobia, conjunctivitis.
    • INTERACTIONS
    • Drug: Alcohol may cause severe hypotension and cardiovascular collapse. Aspirin may increase nitrate serum levels. CALCIUM CHANNEL BLOCKERS may cause orthostatic hypotension.
    • PHARMACOKINETICS
    • Absorption: Completely and rapidly absorbed from GI tract; 93% reaches systemic circulation.
    • Onset: 1 h.
    • Peak: Regular release 30–60 min; sustained release 3–4 h.
    • Duration: Regular release 5–12 h; sustained release 12 h.
    • Metabolism: In liver by denitration and conjugation to inactive metabolites.
    • Elimination: Primarily by kidneys.
    • Half-Life: 4–5 h.
  22. isosorbide mononitrate (Imdur): A & I
    Assessment & Drug Effects

    • Monitor cardiac status, frequency and severity of angina, and BP.
    • Assess for and report possible S&S of toxicity, including orthostatic hypotension, syncope, dizziness, palpitations, lightheadedness, severe headache, blurred vision, and difficulty breathing.
    • Lab tests: Monitor serum electrolytes periodically.
    • Patient & Family Education

    • Do not crush or chew sustained release tablets. May break tablets in two and take with adequate fluid (4–8 oz).
    • Do not withdraw drug abruptly; doing so may precipitate acute angina.
    • Maintain correct dosing interval with twice daily dosing.
    • Geriatric patients are more susceptible to the possibility of developing postural hypotension.
    • Avoid alcohol ingestion and aspirin unless specifically permitted by physician.
  23. lisinopril (Zestril)
    • Classifications: ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITOR; ANTIHYPERTENSIVE AGENT Therapeutic: ANTIHYPERTENSIVE AGENT; ACE INHIBITOR
    • Prototype: Enalapril
    • Pregnancy Category: C first trimester; D second and third trimester
    • ACTION & THERAPEUTIC EFFECT
    • Lowers BP by specific inhibition of the angiotensin-converting enzyme (ACE). This interrupts conversion sequences initiated by renin that form angiotensin II, a potent vasoconstrictor. ACE inhibition alters hemodynamics without compensatory reflex tachycardia or changes in cardiac output (except in patients with CHF).
    • Improved cardiac output and exercise tolerance due to inhibition of ACE also decreases circulating aldosterone, which is normally released in response to angiotensin II stimulation. Reduced aldosterone is associated with a potassium-sparing effect. Also decreases peripheral resistance (afterload) and pulmonary vascular resistance.
    • USES
    • Hypertension, alone or concomitantly with other classes of antihypertensive agents; CHF; to improve MI survival.
    • CONTRAINDICATIONS
    • Patients with a history of angioedema related to treatment with an ACE inhibitor, ACE inhibitor hypersensitivity; pregnancy (C first trimester, category D second and third trimester), children <6 y; lactation.
    • CAUTIOUS USE
    • Impaired kidney function, renal artery stenosis, renal disease, renal failure, hyperkalemia, patients on diuretic therapy; aortic stenosis, cardiomyopathy; cerebrovascular disease; collagen vascular disease; coronary artery disease, dialysis; older adults; heart failure, hyperkalemia, hypotension, hypovolemia; African Americans; autoimmune diseases, especially systemic lupus erythematosus (SLE).
    • ROUTE AND DOSAGE

    • Hypertension Adult: PO 10 mg once/d, may increase up to 20–40 mg 1–2 times/d (max: 80 mg/d) Child (6–16 y): PO Start at 0.07 mg/kg (max 5 mg) once/d (max: 40 mg/d) Geriatric: PO Initial 2.5–5 mg/d, may increase by 2.5–5 mg/d every 1–2 wk (max: 40 mg/d)
    • Heart Failure Adult: PO 5–40 mg/d
    • ADMINISTRATION

    Oral

    • Give an initial dose of 5 mg for diuretic-treated patients. Monitor drug effect for 2 h or until the BP is stabilized for at least 1 additional hour. Concurrent administration with a diuretic may compound hypotensive effect.
    • Give before dialysis; lisinopril is removed from blood by hemodialysis.
    • Store away from both moisture and heat.
    • ADVERSE EFFECTS
    • CNS: Headache, dizziness, fatigue.
    • CV: Hypotension, chest pain.
    • GI: Nausea, vomiting, diarrhea, anorexia, constipation, intestinal angioedema.
    • Hematologic: Neutropenia.
    • Respiratory: Dyspnea, cough.
    • Skin: Rash.
    • Metabolic: Azotemia, hyperkalemia, increased BUN, and creatinine levels.
    • INTERACTIONS
    • Drug: Indomethacin and other NSAIDs may decrease antihypertensive activity; POTASSIUM SUPPLEMENTS, POTASSIUM-SPARING DIURETICS may cause hyperkalemia; may increase lithium levels and toxicity.
    • PHARMACOKINETICS
    • Absorption: 25% absorbed from GI tract.
    • Onset: 1 h.
    • Peak: 6–8 h.
    • Duration: 24 h.
    • Distribution: Limited amount crosses blood–brain barrier; crosses placenta; small amount distributed in breast milk.
    • Metabolism: Is not metabolized.
    • Elimination: Primarily in urine.
    • Half-Life: 12 h.
  24. lisinopril (Zestril): A & I
    Assessment & Drug Effects

    • Place patient in supine position and notify physician if sudden and severe hypotension occurs within the first 1–5 h after initial drug dose; possible particularly in patients who are sodium- or volume-depleted because of diuretic therapy.
    • Measure BP just prior to dosing to determine whether satisfactory control is being maintained for 24 h. If the antihypertensive effect is diminished in less than 24 h, an increase in dosage may be necessary.
    • Monitor closely for angioedema of extremities, face, lips, tongue, glottis, and larynx. Discontinue drug promptly and notify physician if such symptoms appear; carefully monitor for airway obstruction until swelling is relieved.
    • Monitor serum sodium and serum potassium levels for hyponatremia and hyperkalemia.
    • Lab tests: Determine WBC count prior to initiation of treatment, every month for the first 3–6 mo of therapy, and at periodic intervals for 1 y. Withhold therapy and notify physician if neutropenia (neutrophil count <1000/mm3) develops; kidney function tests at periodic intervals, especially in patients with severe volume or sodium replacement or those with severe CHF.
    • Patient & Family Education

    • Discontinue drug and contact physician immediately for severe hypersensitivity reaction (e.g., hoarseness, swelling of the face, mouth, hands, or feet, or sudden trouble breathing).
    • Be aware of importance of proper diet, including sodium and potassium restrictions. Do NOT use salt substitute containing potassium.
    • Continued compliance with high BP medication is very important. If a dose is missed, take it as soon as possible but not too close to next dose.
    • Do not drive or engage in other potentially hazardous activities until response to the drug is known.
    • With concomitant therapy, lisinopril increases the risk of lithium toxicity.
    • Notify physician promptly of any indication of infection (e.g., sore throat, fever).
    • Do not store drug in a moist area. Heat and moisture may cause the medicine to break down.
  25. metoprolol tartate (Lopressor)
    • Classifications: BETA-ADRENERGIC ANTAGONIST; ANTIHYPERTENSIVE; ANTIANGINAL Therapeutic: ANTIHYPERTENSIVE; ANTIANGINAL
    • Prototype: Propranolol
    • ACTION & THERAPEUTIC EFFECT
    • Beta-adrenergic antagonist with preferential effect on beta1 receptors located primarily on cardiac muscle. At higher doses, metoprolol also inhibits beta2 receptors located chiefly on bronchial and vascular musculature. Antihypertensive action may be due to competitive antagonism of catecholamines at cardiac adrenergic neuron sites, drug-induced reduction of sympathetic outflow to the periphery, and to suppression of renin activity.
    • Reduces heart rate and cardiac output at rest and during exercise; lowers both supine and standing BP, slows sinus rate and decreases myocardial automaticity. Antianginal effect is like that of propranolol.
    • USES
    • Management of mild to severe hypertension (monotherapy or in combination with a thiazide or vasodilator or both); long-term treatment of angina pectoris and prophylactic management of stable angina pectoris reduce the risk of mortality after an MI.
    • UNLABELED USES
    • CHF.
    • CONTRAINDICATIONS
    • Cardiogenic shock, sinus bradycardia, heart block greater than first degree, overt cardiac failure, right ventricular failure secondary to pulmonary hypertension. Safety during pregnancy (category C) or in children is not established.
    • CAUTIOUS USE
    • Impaired liver or kidney function; cardiomegaly, CHF controlled by digitalis and diuretics; AV conduction defects; bronchial asthma and other bronchospastic diseases; history of allergy; thyrotoxicosis; diabetes mellitus; peripheral vascular disease.
    • ROUTE AND DOSAGE

    • Hypertension Adult: PO 50–100 mg/d in 1–2 divided doses, may increase weekly up to 100–450 mg/d Geriatric: PO 25 mg/d (range: 25–300 mg/d)
    • Angina Pectoris Adult: PO 100 mg/d in 2 divided doses, may increase weekly up to 100–400 mg/d
    • Myocardial Infarction Adult: IV 5 mg q2min for 3 doses, followed by PO therapy PO 50 mg q6h for 48 h, then 100 mg b.i.d.
    • ADMINISTRATION

    Oral

    • Ensure that sustained-release form is not chewed or crushed. It must be swallowed whole.
    • Give with food to slightly enhance absorption; however, administration with food not essential. It is important to give with or without food consistently to minimize possible variations in bioavailability.
    • Intravenous
    • Prepare:: Direct: Give undiluted.
    • Administer:: Direct:

    • Give at a rate of 5 mg over 60 sec.
    • Note conditions which are contraindications to drug administration.
    • Incompatibilities: Y-site: Amphotericin B cholesteryl complex.

    • Store at 15°–30° C (59°–86° F). Protect from heat, light, and moisture.
    • ADVERSE EFFECTS
    • Body as a Whole: Hypersensitivity (erythematous rash, fever, headache, muscle aches, sore throat, laryngospasm, respiratory distress).
    • CNS: Dizziness, fatigue, insomnia, increased dreaming, mental depression.
    • CV: Bradycardia, palpitation, cold extremities, Raynaud's phenomenon, intermittent claudication, angina pectoris, CHF, intensification of AV block, AV dissociation, complete heart block, cardiac arrest.
    • GI: Nausea, heartburn, gastric pain, diarrhea or constipation, flatulence.
    • Hematologic: Eosinophilia, thrombocytopenic and nonthrombocytopenic purpura, agranulocytosis (rare).
    • Skin: Dry skin, pruritus, skin eruptions.
    • Special Senses: Dry mouth and mucous membranes.
    • Metabolic: Hypoglycemia.
    • Respiratory: Bronchospasm (with high doses), shortness of breath.
    • DIAGNOSTIC TEST INTERFERENCES
    • In common with other beta blockers, metoprolol may cause elevated BUN and serum creatinine levels (patients with severe heart disease), elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase, and serum uric acid.
    • INTERACTIONS
    • Drug: BARBITURATES, rifampin may decrease effects of metoprolol; cimetidine, methimazole, propylthiouracil, ORAL CONTRACEPTIVES may increase effects of metoprolol; additive bradycardia with digoxin; effects of both metoprolol and hydralazine may be increased; indomethacin may attenuate hypotensive response; BETA AGONISTS and metoprolol mutually antagonistic; verapamil may increase risk of heart block and bradycardia; increases terbutaline serum levels.
    • PHARMACOKINETICS
    • Absorption: Readily from GI tract; 50% of dose reaches systemic circulation.
    • Onset: 15 min.
    • Peak: 1.5 h; IV form: 20 min.
    • Duration: 13–19 h.
    • Distribution: Crosses blood–brain barrier and placenta; distributed into breast milk.
    • Metabolism: Extensively in liver (CYP2D6).
    • Elimination: In urine.
    • Half-Life: 3–4 h.
  26. metoprolol tartate (Lopressor): A & I
    Assessment & Drug Effects

    • Take apical pulse and BP before administering drug. Report to physician significant changes in rate, rhythm, or quality of pulse or variations in BP prior to administration.
    • Monitor BP, HR, and ECG carefully during IV administration.
    • Expect maximal effect on BP after 1 wk of therapy.
    • Take several BP readings close to the end of a 12 h dosing interval to evaluate adequacy of dosage for patients with hypertension, particularly in patients on twice daily doses. Some patients require doses 3 times a day to maintain satisfactory control.
    • Observe hypertensive patients with CHF closely for impending heart failure: Dyspnea on exertion, orthopnea, night cough, edema, distended neck veins.
    • Lab tests: Obtain baseline and periodic evaluations of blood cell counts, blood glucose, liver and kidney function.
    • Monitor I&O, daily weight; auscultate daily for pulmonary rales.
    • Withdraw drug if patient presents symptoms of mental depression because it can progress to catatonia. Possible symptoms of depression: disinterest in people, surroundings, food, personal hygiene; withdrawal, apathy, sadness, difficulty in concentrating, insomnia.
    • Monitor patients with thyrotoxicosis closely since drug masks signs of hyperthyroidism (see Appendix F). Abrupt withdrawal may precipitate thyroid storm.
    • Patient & Family Education

    • Learn how to take radial pulse before each dose. Report to physician if pulse is slower than base rate (e.g., 60 bpm) or becomes irregular. Consult physician for parameters.
    • Reduce insomnia or increased dreaming by avoiding late evening doses.
    • Monitor blood glucose (diabetics) for loss of glycemic control. Drug may mask some symptoms of hypoglycemia (e.g., BP and HR changes) and prolong hypoglycemia. Be alert to other possible signs of hypoglycemia not affected by metoprolol and report to physician if present: Sweating, fatigue, hunger, inability to concentrate.
    • Protect extremities from cold and do not smoke. Report cold, painful, or tender feet or hands or other symptoms of Raynaud's disease (intermittent pallor, cyanosis or redness, paresthesias). Physician may prescribe a vasodilator.
    • Report immediately to physician the onset of problems with vision.
    • Learn measures to relieve dry mouth; rinse mouth frequently with water, increase noncalorie liquid intake if inadequate, suck sugarless gum or hard candy.
    • Relieve eye dryness by using sterile artificial tears available OTC.
    • Do not drive or engage in potentially hazardous activities until response to drug is known.
    • Do not alter established dosage regimen; compliance is very important.
    • Reduce dosage reduced gradually over a period of 1–2 wk when drug is discontinued. Sudden withdrawal can result in increase in anginal attacks and MI in patients with angina pectoris and thyroid storm in patients with hyperthyroidism.
  27. potassium chloride (K-dur)
    • Classifications: ELECTROLYTIC REPLACEMENT SOLUTION Therapeutic: ELECTROLYTE REPLACEMENT
    • ACTION & THERAPEUTIC EFFECT
    • Principal intracellular cation; essential for maintenance of intracellular isotonicity, transmission of nerve impulses, contraction of cardiac, skeletal, and smooth muscles, maintenance of normal kidney function, and for enzyme activity. Plays a prominent role in both formation and correction of imbalances in acid–base metabolism.
    • Effective in treatment of hypokalemia. Effectiveness measured by serum potassium concentration greater than 3.5 mEq/liter.
    • USES
    • To prevent and treat potassium deficit secondary to diuretic or corticosteroid therapy. Also indicated when potassium is depleted by severe vomiting, diarrhea; intestinal drainage, fistulas, or malabsorption; prolonged diuresis, diabetic acidosis. Effective in the treatment of hypokalemic alkalosis (chloride, not the gluconate).
    • CONTRAINDICATIONS
    • Severe renal impairment; severe hemolytic reactions; untreated Addison's disease; crush syndrome; early postoperative oliguria (except during GI drainage); adynamic ileus; acute dehydration; heat cramps, hyperkalemia, patients receiving potassium-sparing diuretics, digitalis intoxication with AV conduction disturbance; pregnancy (category C).
    • CAUTIOUS USE
    • Cardiac or kidney disease; systemic acidosis; slow-release potassium preparations in presence of delayed GI transit or Meckel's diverticulum; extensive tissue breakdown (such as severe burns); lactation.
    • ROUTE AND DOSAGE

    • Hypokalemia Adult: PO 10–100 mEq/d in divided doses IV 10–60 mEq/h diluted to at least 10–20 mEq/100 mL of solution (max: 200–400 mEq/d, monitor higher doses carefully) Child: PO 1–3 mEq/kg/d in divided doses; sustained release tablets not recommended IV Up to 3 mEq/kg/24 h at a rate <0.02 mEq/kg/min
    • ADMINISTRATION

    Oral

    • Give while patient is sitting up or standing (never in recumbent position) to prevent drug–induced esophagitis. Some patients find it difficult to swallow the large sized KCl tablet.
    • Do not crush or allow to chew any potassium salt tablets. Observe to make sure patient does not suck tablet (oral ulcerations have been reported if tablet is allowed to dissolve in mouth).
    • Swallow whole tablet with a large glass of water or fruit juice (if allowed) to wash drug down and to start esophageal peristalsis.
    • Follow directions for diluting various liquid forms of KCl exactly. In general, dilute each 20 mEq potassium in at least 90 mL water or juice and allowed to completely before administration.
    • Dilute liquid forms as directed before giving it through nasogastric tube.
    • Intravenous
    • Prepare:: IV Infusion:

    • Add desired amount to 100–1000 mL IV solution (compatible with all standard solutions).
    • Usual maximum is 80 mEq/1000 mL, however, 40 mEq/L is preferred to lessen irritation to veins. Note: NEVER add KCl to an IV bag/bottle which is hanging. After adding KCl invert bag/bottle several times to ensure even distribution.
    • Administer:: IV Infusion for Adult/Child:

    • KCl is never given direct IV or in concentrated amounts by any route. Too rapid infusion may cause fatal hyperkalemia.
    • IV Infusion for Adult: Infuse at rate not to exceed 10 mEq/h; in emergency situations, may infuse very cautiously up to 40 mEq/h with continuous cardiac monitoring.
    • IV Infusion for Child: Infuse at a rate not to exceed 0.5–1.0 mEq/kg/h.
    • Incompatibilities: Solution/additive: Furosemide, pentobarbital, phenobarbital, succinylcholine. Y-site: Amphotericin B cholesteryl complex, azithromycin, chlordiazepoxide, chlorpromazine, diazepam, ergotamine, methylprednisolone, phenytoin.

    • Take extreme care to prevent extravasation and infiltration. At first sign, discontinue infusion and select another site.
    • ADVERSE EFFECTS
    • GI: Nausea, vomiting, diarrhea, abdominal distention.
    • Body as a Whole: Pain, mental confusion, irritability, listlessness, paresthesias of extremities, muscle weakness and heaviness of limbs, difficulty in swallowing, flaccid paralysis.
    • Urogenital: Oliguria, anuria.
    • Hematologic: Hyperkalemia.
    • Respiratory: Respiratory distress.
    • CV: Hypotension, bradycardia; cardiac depression, arrhythmias, or arrest; altered sensitivity to digitalis glycosides. ECG changes in hyperkalemia: Tenting (peaking) of T wave (especially in right precordial leads), lowering of R with deepening of S waves and depression of RST; prolonged P-R interval, widened QRS complex, decreased amplitude and disappearance of P waves, prolonged QT interval, signs of right and left bundle block, deterioration of QRS contour and finally ventricular fibrillation and death.
    • INTERACTIONS
    • Drug: POTASSIUM-SPARING DIURETICS, ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS may cause hyperkalemia.
    • PHARMACOKINETICS
    • Absorption: Readily from upper GI tract.
    • Elimination: 90% in urine, 10% in feces.
  28. potassium chloride (K-dur): A & I
    Assessment & Drug Effects

    • Monitor I&O ratio and pattern in patients receiving the parenteral drug. If oliguria occurs, stop infusion promptly and notify physician.
    • Lab test: Frequent serum electrolytes are warranted.
    • Monitor for and report signs of GI ulceration (esophageal or epigastric pain or hematemesis).
    • Monitor patients receiving parenteral potassium closely with cardiac monitor. Irregular heartbeat is usually the earliest clinical indication of hyperkalemia.
    • Be alert for potassium intoxication (hyperkalemia, see S&S, Appendix F); may result from any therapeutic dosage, and the patient may be asymptomatic.
    • The risk of hyperkalemia with potassium supplement increases (1) in older adults because of decremental changes in kidney function associated with aging, (2) when dietary intake of potassium suddenly increases, and (3) when kidney function is significantly compromised.
    • Patient & Family Education

    • Do not be alarmed when the tablet carcass appears in your stool. The sustained release tablet (e.g., Slow-K) utilizes a wax matrix as carrier for KCl crystals that passes through the digestive system.
    • Learn about sources of potassium with special reference to foods and OTC drugs.
    • Avoid licorice; large amounts can cause both hypokalemia and sodium retention.
    • Do not use any salt substitute unless it is specifically ordered by the physician. These contain a substantial amount of potassium and electrolytes other than sodium.
    • Do not self-prescribe laxatives. Chronic laxative use has been associated with diarrhea-induced potassium loss.
    • Notify physician of persistent vomiting because losses of potassium can occur.
    • Report continuing signs of potassium deficit to physician: Weakness, fatigue, polyuria, polydipsia.
    • Advise dentist or new physician that a potassium drug has been prescribed as long-term maintenance therapy.
    • Do not open foil-wrapped powders and tablets before use.
  29. prednisone
  30. prednisone: A & I
  31. promethazine (Phenergan)
    • Classifications: PHENOTHIAZINE; ANTIEMETIC; ANTIVERTIGO AGENT Therapeutic: ANTIEMETIC; ANTIVERTIGO
    • Prototype: Prochlorperazine
    • ACTION & THERAPEUTIC EFFECT
    • In common with other antihistamines, exerts anti-serotonin, anticholinergic, and local anesthetic action. Antiemetic action thought to be due to depression of CTZ in medulla.
    • Long-acting derivative of phenothiazine with marked antihistamine activity and prominent sedative, amnesic, antiemetic, and anti–motion-sickness actions.
    • USES
    • Symptomatic relief of various allergic conditions, to ameliorate and prevent reactions to blood and plasma, and in prophylaxis and treatment of motion sickness, nausea, and vomiting. Preoperative, postoperative, and obstetric sedation and as adjunct to analgesics for control of pain.
    • CONTRAINDICATIONS
    • Hypersensitivity to phenothiazines; acute MI; angina, atrial fibrillation, atrial flutter, cardiac arrhythmias, cardiomyopathy uncontrolled hypertension; MAOI therapy; comatose or severely depressed states; children with Reye's syndrome, hepatic encephalopathy, hepatic diseases; acutely ill or dehydrated children; children <2 y; pregnancy (category C), lactation, newborn or premature infants.
    • CAUTIOUS USE
    • Impaired liver function; epilepsy; bone marrow depression; cardiovascular disease; peripheral vascular disease; asthma; acute or chronic respiratory impairment (particularly in children); hypertension; narrow angle glaucoma; stenosing peptic ulcer, pyloroduodenal obstruction; prostatic hypertrophy; bladder neck obstruction; older adult or debilitated patients; children >2 y.
    • ROUTE AND DOSAGE

    • Motion Sickness Adult: PO/PR 25 mg q12h prn Child (>2 y): PO/PR 10.5 mg/kg/dose q12h prn (max: 25 mg/dose)
    • Nausea Adult: PO/PR/IM/IV 12.5–25 mg q4–6h prn Child (>2 y): PO/PR/IM/IV 0.25–0.5 mg/kg q4–6h prn (max: 25 mg/dose)
    • Allergies Adult: PO/PR 12.5 mg q.i.d. or 25 mg h.s. IM/IV 25 mg, repeat in 2 h if necessary, switch to PO Child (>2 y): PO 0.1 mg/kg q6h and 0.05 mg/kg at bedtime prn
    • Sedation Adult: PO/PR/IM/IV 25–50 mg/dose Child (>2 y): PO/PR/IM/IV 12.5–25 mg/dose (max: 50 mg)
    • ADMINISTRATION

    Oral

    • Give with food, milk, or a full glass of water may minimize GI distress.
    • Tablets may be crushed and mixed with water or food before swallowing.
    • Oral doses for allergy are generally prescribed before meals and on retiring or as single dose at bedtime.
    • Intramuscular

    • Give IM injection deep into large muscle mass. Aspirate carefully before injecting drug. Intraarterial injection can cause arterial or arteriolar spasm, with resultant gangrene.
    • Subcutaneous injection (also contraindicated) can cause chemical irritation and necrosis. Rotate injection sites and observe daily.
    • Intravenous
    • Prepare:: Direct:

    • The 25 mg/mL concentration may be given undiluted.
    • Dilute the 50 mg/mL concentration in NS to yield no more than 25 mg/mL (e.g., diluting the 50 mg/mL concentration in 4 mL yields 10 mg/mL).
    • Inspect parenteral drug before preparation. Discard if it is darkened or contains precipitate.
    • Administer:: Direct: Give each 25 mg or fraction thereof over at least 1 min.
    • Incompatibilities: Solution/additive: Aminophylline, ampicillin, carbenicillin, cefazolin, cefotetan, ceftizoxime, chloramphenicol, chlordiazepoxide, chlorothiazide, dexamethasone, dimenhydrinate. furosemide, heparin, hydrocortisone, ketorolac, methicillin, methohexital, nalbuphine, nitrofurantoin, penicillin G sodium, pentobarbital, phenobarbital, thiopental. Y-site: Aldesleukin, allopurinol, amphotericin B cholesteryl complex, cefepime, cefmetazole, cefoperazone, cefotetan, doxorubicin liposome, foscarnet, furosemide, heparin, methotrexate, piperacillin/tazobactam, TPN.

    • Store at 15°–30° C (59°–86° F) in tight, light-resistant container unless otherwise directed.
    • ADVERSE EFFECTS
    • Body as a Whole: Deep sleep, coma, convulsions, cardiorespiratory symptoms, extrapyramidal reactions, nightmares (in children), CNS stimulation, abnormal movements.
    • Respiratory: Irregular respirations, respiratory depression, apnea.
    • CNS: Sedation drowsiness, confusion, dizziness, disturbed coordination, restlessness, tremors.
    • CV: Transient mild hypotension or hypertension.
    • GI: Anorexia, nausea, vomiting, constipation.
    • Hematologic: Leukopenia, agranulocytosis.
    • Special Senses: Blurred vision, dry mouth, nose, or throat.
    • Skin: Photosensitivity.
    • Urogenital: Urinary retention.
    • DIAGNOSTIC TEST INTERFERENCES
    • May interfere with blood grouping in ABO system and may produce false results with urinary pregnancy tests (Gravindex, false-positive; Prepurex and Dap tests, false-negative). Promethazine can cause significant alterations of flare response in intradermal allergen tests if performed within 4 d of patient receiving promethazine.
    • INTERACTIONS
    • Drug: Alcohol and other CNS DEPRESSANTS add to CNS depression and anticholinergic effects.
    • PHARMACOKINETICS
    • Absorption: Readily from GI tract.
    • Onset: 20 min PO/PR/IM; 5 min IV.
    • Duration: 2–8 h.
    • Distribution: Crosses placenta.
    • Metabolism: In liver (CYP2D6, 2B6).
    • Elimination: Slowly in urine and feces.
  32. promethazine (Phenergan): A & I
    Assessment & Drug Effects

    • Supervise ambulation. Promethazine sometimes produces marked sedation and dizziness.
    • Be aware that antiemetic action may mask symptoms of unrecognized disease and signs of drug overdosage as well as dizziness, vertigo, or tinnitus associated with toxic doses of aspirin or other ototoxic drugs.
    • Patients in pain may develop involuntary (athetoid) movements of upper extremities following parenteral administration. These symptoms usually disappear after pain is controlled.
    • Monitor respiratory function in patients with respiratory problems, particularly children. Drug may suppress cough reflex and cause thickening of bronchial secretions.
    • Patient & Family Education

    • For motion sickness: Take initial dose 30–60 min before anticipated travel and repeat at 8–12 h intervals if necessary. For duration of journey, repeat dose on arising and again at evening meal.
    • Do not drive or engage in other potentially hazardous activities requiring mental alertness and normal reaction time until response to drug is known.
    • Avoid sunlamps or prolonged exposure to sunlight. Use sunscreen lotion during initial drug therapy.
    • Do not take OTC medications without physician's approval.
    • Avoid alcohol and other CNS depressants.
    • Relieve dry mouth by frequent rinses with water or by increasing noncaloric fluid intake (if allowed), chewing sugarless gum, or sucking hard candy. If these measures fail, add a saliva substitute (e.g., Moi-Stir, Orex, Xero-Lube).
  33. rosuvastatin (Crestor)
    • Classifications: HMG-COA REDUCTASE INHIBITOR (STATIN); ANTILIPEMIC Therapeutic: ANTIHYPERLIPEMIC; STATIN
    • Prototype: Lovastatin
    • Pregnancy Category: X
    • ACTION & THERAPEUTIC EFFECT
    • Rosuvastatin is a potent inhibitor of HMG-CoA reductase, an enzyme that catalyzes the conversion of HMG-CoA to mevalonic acid, an early and rate-limiting step in cholesterol biosynthesis. Interference with this enzyme reduces the quantity of mevalonic acid, a precursor of cholesterol.
    • Reduces total cholesterol and LDL cholesterol; additionally, lowers plasma triglycerides and apolipoprotein B while increasing HDL.
    • USES
    • Adjunct to diet for the reduction of LDL cholesterol and triglycerides in patients with primary hypercholesterolemia and mixed dyslipidemia.
    • CONTRAINDICATIONS
    • Hypersensitivity to any component of the product, active liver disease, pregnancy (category X), women of child-bearing potential not using appropriate contraceptive measures, lactation.
    • CAUTIOUS USE
    • Concomitant use of cyclosporine and gemfibrozil; excessive alcohol use or history of liver disease; renal impairment; advanced age; hypothyroidism.
    • ROUTE AND DOSAGE

    • Hyperlipidemia Adult: PO 10 mg once daily (5–40 mg/d), max dose 40 mg/d. If taking cyclosporine, start with 5 mg/d. Geriatric: Initial dose of 5 mg/d
    • Renal Impairment CrCl <30 mL/min: 5 mg once daily (max: 10 mg/d)
    • ADMINISTRATION

    Oral

    • Persons of Asian descent may be slow metabolizers and may require half the normal dose.
    • May give any time of day without regard to food.
    • Store at or below 30° C (86° F).
    • ADVERSE EFFECTS
    • Body as a Whole: Asthenia, back pain, flu syndrome, chest pain, infection, pain, peripheral edema.
    • CNS: Headache, dizziness, insomnia, hypertonia, paresthesia, depression, anxiety, vertigo, neuralgia.
    • CV: Hypertension, angina, vasodilatation, palpitations.
    • GI: Diarrhea, dyspepsia, nausea, abdominal pain, constipation, gastroenteritis, vomiting, flatulence, gastritis.
    • Endocrine: Diabetes.
    • Hematologic: Anemia, ecchymosis.
    • Musculoskeletal: Myalgia, arthritis, arthralgia, rhabdomyolysis (especially with dose >40 mg).
    • Respiratory: Pharyngitis, rhinitis, sinusitis, bronchitis, increased cough, dyspnea, pneumonia, asthma.
    • Skin: Rash, pruritus.
    • Urogenital: UTI.
    • INTERACTIONS
    • Drug: Cyclosporine, gemfibrozil, niacin, may increase risk of rhabdomyolysis; ANTACIDS may decrease rosuvastatin absorption; may cause increase in INR with warfarin.
    • PHARMACOKINETICS
    • Absorption: Well absorbed.
    • Peak: 3–5 h.
    • Metabolism: Limited metabolism in the liver (not CYP3A4).
    • Elimination: Primarily in feces (90%).
    • Half-Life: 20 h.
  34. rosuvastatin (Crestor): A & I
    Assessment & Drug Effects

    • Monitor for and report promptly S&S of myopathy (e.g., skeletal muscle pain, tenderness or weakness).
    • Withhold drug and notify physician if CPK levels are markedly elevated (≥10 × ULN) or if myopathy is diagnosed or suspected.
    • Lab tests: CPK levels for S&S of myopathy; periodic LFTs; more frequent INR values with concomitant warfarin therapy.
    • Monitor CV status, especially with a known history of hypertension or heart disease.
    • Monitor diabetics for loss of glycemic control.
    • Patient & Family Education

    • Do not take antacids within 2 h of taking this drug.
    • Females should use reliable means of contraception while taking this drug to prevent pregnancy.
  35. theophylline
    • SLOW RELEASE. DO NOT CRUSH
    • Classifications: BRONCHODILATOR (RESPIRATORY SMOOTH MUSCLE RELAXANT); XANTHINE Therapeutic: BRONCHODILATOR
    • ACTION & THERAPEUTIC EFFECT
    • Xanthine derivative that relaxes smooth muscle by direct action, particularly of bronchi and pulmonary vessels, and stimulates medullary respiratory center with resulting increase in vital capacity.
    • Effective for relief of bronchospasm in asthmatics, chronic bronchitis, and emphysema.
    • USES
    • Prophylaxis and symptomatic relief of bronchial asthma, as well as bronchospasm associated with chronic bronchitis and emphysema. Also used for emergency treatment of paroxysmal cardiac dyspnea and edema of CHF.
    • UNLABELED USES
    • Treatment of apnea and bradycardia of premature infants and to reduce severe bronchospasm associated with cystic fibrosis and acute descending respiratory infection.
    • CONTRAINDICATIONS
    • Hypersensitivity to xanthines; coronary artery disease or angina pectoris when myocardial stimulation might be harmful; severe renal or liver impairment; pregnancy (category C).
    • CAUTIOUS USE
    • Compromised cardiac or circulatory function, hypertension; acute pulmonary edema; multiple organ failure; CHF; hyperthyroidism; peptic ulcer; prostatic hypertrophy; glaucoma; diabetes mellitus; older adults, children, and neonates.
    • ROUTE AND DOSAGE

    • Bronchospasm Adult/Child: PO/IV Loading Dose 5 mg/kg Adult: PO/IV Maintenance Dose* Nonsmoker, 0.4 mg/kg/h; Smoker, 0.6 mg/kg/h; with CHF or cirrhosis, 0.2 mg/kg/h Child: PO/IV Maintenance Dose* 1–9 y, 0.8 mg/kg/h; 10–12 y, 0.6 mg/kg/h Infant: PO/IV Maintenance Dose* 0.5–0.7 mg/kg/h Neonate: PO/IV Maintenance Dose* 0.13 mg/kg/h *IV by continuous infusion, PO divided q6h (immediate release) or q8–12h (sustained release)
    • Obesity Dose based on IBW.
    • ADMINISTRATION

    • All doses based on ideal body weight.
    • Oral

    • Wait 4–6 h after the last IV dose, when switching from IV to oral dosing.
    • Give with a full glass of water and after meals to minimize gastric irritation.
    • Give sustained release forms and enteric-coated tablets whole. Chewable tablets must be chewed thoroughly before swallowing. Sustained release granules from capsules can be taken on an empty stomach or mixed with applesauce or water.
    • Timing of dose is critical. Be certain patient understands necessity to adhere to the correct intervals between doses.
    • Intravenous
    • Prepare:: Direct/Intermittent: Dilute, as needed, to a maximum concentration of 20 mg/mL.
    • IV Infusion: Typically diluted to 0.8 mg/mL with D5W.
    • Administer:: Direct/Intermittent: Typically infused over 20–30 min. DO NOT EXCEED 20 mg/min.
    • IV Infusion: Infuse at a rate based on patient's weight.
    • Incompatibilities: Solution/additive: Ascorbic acid, ceftriaxone, cimetidine, hetastarch. Y-site: Hetastarch, phenytoin.
    • ADVERSE EFFECTS
    • CNS: Stimulation (irritability, restlessness, insomnia, dizziness, headache, tremor, hyperexcitability, muscle twitching, drug-induced seizures).
    • CV: Palpitation, tachycardia, extrasystoles, flushing, marked hypotension, circulatory failure.
    • GI: Nausea, vomiting, anorexia, epigastric or abdominal pain, diarrhea, activation of peptic ulcer.
    • Urogenital: Transient urinary frequency, albuminuria, kidney irritation.
    • Respiratory: Tachypnea, respiratory arrest.
    • Body as a Whole: Fever, dehydration.
    • DIAGNOSTIC TEST INTERFERENCES
    • False-positive elevations of serum uric acid (Bittner or colorimetric methods). Probenecid may cause false high serum theophylline readings, and spectrophotometric methods of determining serum theophylline are affected by a furosemide, sulfathiazole, phenylbutazone, probenecid, theobromine.
    • INTERACTIONS
    • Drug: Increases lithium excretion, lowering lithium levels; cimetidine, high-dose allopurinol (600 mg/d), tacrine, QUINOLONES, MACROLIDE ANTIBIOTICS, and zileuton can significantly increase theophylline levels; tobacco use significantly decreases levels.
    • Herbal: St. John's wort may decrease theophylline efficacy. Daidzein (in soy), black pepper increase serum concentrations and adverse effects.
    • PHARMACOKINETICS
    • Absorption: Most products are 100% absorbed from GI tract.
    • Peak: IV 30 min; uncoated tablet 1 h; sustained release 4–6 h.
    • Duration: 4–8 h; varies with age, smoking, and liver function.
    • Distribution: Crosses placenta.
    • Metabolism: Extensively in liver.
    • Elimination: Parent drug and metabolites excreted by kidneys; excreted in breast milk.
  36. theophylline: A & I
    Assessment & Drug Effects

    • Monitor vital signs. Improvement in respiratory status is the expected outcome.
    • Observe and report early signs of possible toxicity: Anorexia, nausea, vomiting, dizziness, shakiness, restlessness, abdominal discomfort, irritability, palpitation, tachycardia, marked hypotension, cardiac arrhythmias, seizures.
    • Monitor for tachycardia, which may be worse in patients with severe cardiac disease. Conversely, theophylline toxicity may be masked in patients with tachycardia.
    • Lab tests: Monitor plasma level of theophylline. Be aware that therapeutic plasma level ranges from 10–20 mcg/mL (a narrow therapeutic range). Levels exceeding 20 mcg/mL are associated with toxicity.
    • Monitor drug levels closely in heavy smokers. Cigarette smoking induces hepatic microsomal enzyme activity, decreasing serum half-life and increasing body clearance of theophylline. An increase of dosage from 50–100% is usual in heavy smokers.
    • Monitor plasma drug level closely in patients with heart failure, kidney or liver dysfunction, alcoholism, high fever. Plasma clearance of xanthines may be reduced.
    • Take necessary safety precautions and forewarn older adult patients of possible dizziness during early therapy.
    • Monitor patients on sustained release preparations for S&S of overdosage. Continued slow absorption leads to high plasma concentrations for a prolonged period.
    • Neonates of mothers using this drug have exhibited slight tachycardia, jitteriness, and apnea.
    • Monitor CLOSELY for adverse effects in infants <6 mo and prematures; theophylline metabolism is prolonged as is the half-life in this age group.
    • Patient & Family Education

    • Take medication at the same time every day.
    • Avoid charcoal-broiled foods (high in polycyclic carbon content); may increase theophylline elimination and reduce the half-life as much as 50%.
    • Limit caffeine intake because it may increase incidence of adverse effects.
    • Cigarette smoking may significantly lower theophylline plasma concentration.
    • Be aware that a low-carbohydrate, high-protein diet increases theophylline elimination, and a high-carbohydrate, low-protein diet decreases it.
    • Drink fluids liberally (2000–3000 mL/d) if not contraindicated to decrease viscosity of airway secretions.
    • Avoid self-dosing with OTC medications, especially cough suppressants, which may cause retention of secretions and CNS depression.
  37. warfarin (Coumadin)
    • Classifications: ANTICOAGULANT Therapeutic: ANTICOAGULANT
    • Pregnancy Category: X

    • ACTION & THERAPEUTIC EFFECT
    • Indirectly interferes with blood clotting by depressing hepatic synthesis of vitamin K-dependent coagulation factors: II, VII, IX, and X.
    • Deters further extension of existing thrombi and prevents new clots from forming. Has no effect on already synthesized circulating coagulation factors or on circulating thrombi.
    • USES
    • Prophylaxis and treatment of deep vein thrombosis and its extension, pulmonary embolism; treatment of atrial fibrillation with embolization. Also used as adjunct in treatment of coronary occlusion, cerebral transient ischemic attacks (TIAs), and as a prophylactic in patients with prosthetic cardiac valves. Used extensively as rodenticide.
    • CONTRAINDICATIONS
    • Hemorrhagic tendencies, vitamin C or K deficiency, hemophilia, coagulation factor deficiencies, dyscrasias; active bleeding; open wounds, active peptic ulcer, visceral carcinoma, esophageal varices, malabsorption syndrome; hypertension (diastolic BP >110 mm Hg), cerebral vascular disease; heparin-induced thrombocytopenia (HIT); pericarditis with acute MI; severe hepatic or renal disease; continuous tube drainage of any orifice; subacute bacterial endocarditis; recent surgery of brain, spinal cord, or eye; regional or lumbar block anesthesia; threatened abortion; unreliable patients; pregnancy (category X).
    • CAUTIOUS USE
    • Alcoholism, allergic disorders, during menstruation, older adults, senility, psychosis; debilitated patients. Endogenous factors that may increase prothrombin time response (enhance anticoagulant effect): carcinoma, CHF, collagen diseases, hepatic and renal insufficiency, diarrhea, fever, pancreatic disorders, malnutrition, vitamin K deficiency. Endogenous factors that may decrease prothrombin time response (decrease anticoagulant response): edema, hypothyroidism, hyperlipidemia, hypercholesterolemia, chronic alcoholism, hereditary resistance to coumarin therapy.
    • ROUTE AND DOSAGE

    • Anticoagulant Adult: PO/IV Usual dose 2–10 mg daily with dose adjusted to maintain a PT 1.2–2 × control or INR of 2–3 Child: PO 0.1–0.3 mg/kg/d, adjust to maintain INR of 2–3
    • Pharmacogenetic Adjustment Variations in CYP2C9 or VKORC1 may require dose adjustments.
    • ADMINISTRATION

    • Antidote for bleeding—anticoagulant effect usually is reversed by omitting 1 or more doses of warfarin and by administration of specific antidote phytonadione (vitamin K1) 2.5–10 mg orally. Physician may advise patient to carry vitamin K1 at all times, but not to take it until after consultation. If bleeding persists or progresses to a severe level, vitamin K 15–25 mg IV is given, or a fresh whole blood transfusion may be necessary.
    • Oral

    • Give tablet whole or crushed with fluid of patient's choice.
    • Intravenous
    • Prepare:: Direct: Add 2.7 mL of sterile water for injection to the 5 mg vial.
    • Administer:: Direct: Give required dose over 1–2 min.
    • Incompatibilities: Solution/additive: Ammonium chloride, 5% dextrose, lactated Ringer's, atropine, calcium chloride, calcium gluconate, chloramphenicol, chlorothiazide, chlortetracycline, erythromycin, methicillin, nitrofurantoin, oxacillin, oxytetracycline, penicillin, pentobarbital, phenobarbital, promethazine, sodium bicarbonate, succinyl chloride, vitamin B with C. Y-site: Aminophylline, ammonium chloride, bretylium, ceftazidime, cephalothin, cimetidine, ciprofloxacin, dobutamine, esmolol, gentamicin, labetalol, metronidazole, promazine, Ringer's lactate, vancomycin.

    • Store at 15°–30° C (59°–86° F). Discard discolored or precipitated solutions. Protect all preparations from light and moisture.
    • ADVERSE EFFECTS
    • Body as a Whole: Major or minor hemorrhage from any tissue or organ; hypersensitivity (dermatitis, urticaria, pruritus, fever).
    • GI: Anorexia, nausea, vomiting, abdominal cramps, diarrhea, steatorrhea, stomatitis.
    • Other: Increased serum transaminase levels, hepatitis, jaundice, burning sensation of feet, transient hair loss.
    • Overdosage: Internal or external bleeding, paralytic ileus; skin necrosis of toes (purple toes syndrome), tip of nose, buttocks, thighs, calves, female breast, abdomen, and other fat-rich areas.
    • DIAGNOSTIC TEST INTERFERENCES
    • Warfarin (coumarins) may cause alkaline urine to be red-orange; may enhance uric acid excretion, cause elevation of serum transaminases, and may increase lactic dehydrogenase activity.
    • INTERACTIONS
    • Drug: In addition to the drugs listed below, many other drugs have been reported to alter the expected response to warfarin; however, clinical importance of these reports has not been substantiated. The addition or withdrawal of any drug to an established drug regimen should be made cautiously, with more frequent INR determinations than usual and with careful observation of the patient and dose adjustment as indicated. The following may enhance the anticoagulant effects of warfarin: Acetohexamide, acetaminophen, ALKYLATING AGENTS, allopurinol, AMINOGLYCOSIDES, aminosalicylic acid, amiodarone, ANABOLIC STEROIDS, ANTIBIOTICS (ORAL), ANTIMETABOLITES, ANTIPLATELET DRUGS, aspirin, asparaginase, capecitabine, celecoxib, chloramphenicol, chlorpropamide, chymotrypsin, cimetidine, clofibrate, co-trimoxazole, danazol, dextran, dextrothyroxine, diazoxide, disulfiram, erythromycin, ethacrynic acid, fluconazole, glucagons, guanethidine, HEPATOTOXIC DRUGS, influenza vaccine, isoniazid, itraconazole, ketoconazole, MAO INHIBITORS, meclofenamate, mefenamic acid, methyldopa, methylphenidate, metronidazole, miconazole, mineral oil, nalidixic acid, neomycin (oral), NONSTEROIDAL ANTI-INFLAMMATORY DRUGS, oxandrolone, plicamycin, POTASSIUM PRODUCTS, propoxyphene, propylthiouracil, quinidine, quinine, rofecoxib, salicylates, streptokinase, sulindac, SULFONAMIDES, SULFONYLUREAS, TETRACYCLINES, THIAZIDES, THYROID DRUGS, tolbutamide, tricyclic antidepressants, urokinase, vitamin E, zileuton. The following may increase or decrease the anticoagulant effects of warfarin: Alcohol (acute intoxication may increase, chronic alcoholism may decrease effects), chloral hydrate, DIURETICS. The following may decrease the anticoagulant effects of warfarin: barbiturates, carbamazepine, cholestyramine, CORTICOSTEROIDS, corticotropin, ethchlorvynol, glutethimide, griseofulvin, LAXATIVES, mercaptopurine, ORAL CONTRACEPTIVES, rifampin, spironolactone, vitamin C, vitamin K.
    • Herbal: Boldo, capsicum, celery, chamomile, chondroitin, clove, coenzyme Q10, danshen, devil's claw, dong quai, echinacea, evening primrose oil, fenugreek, feverfew, fish oil, garlic, ginger, ginkgo, glucosamine, horse chestnut, licorice root, passionflower herb, turmeric, willow bark may increase risk of bleeding; ginseng, green tea, seaweed, soy, St. John's wort may decrease effectiveness of warfarin.
    • Food: Cranberry juice may increase INR. Green leafy vegetables may affect efficacy. Avocado may decrease effectiveness of warfarin.
    • PHARMACOKINETICS
    • Absorption: Well absorbed from GI tract.
    • Onset: 2–7 d.
    • Peak: 0.5–3 d.
    • Distribution: 97% protein bound; crosses placenta.
    • Metabolism: In liver (CYP2C9).
    • Elimination: In urine and bile.
    • Half-Life: 0.5–3 d.
  38. warfarin (Coumadin): A & I
    Assessment & Drug Effects

    • Determine PT/INP prior to initiation of therapy and then daily until maintenance dosage is established.
    • Obtain a CAREFUL medication history prior to start of therapy and whenever altered responses to therapy require interpretation; extremely IMPORTANT since many drugs interfere with the activity of anticoagulant drugs (see INTERACTIONS).
    • Adjust dose to maintain PT at 1½–2½ times the control (12–15 sec), or 15–35% of normal prothrombin activity, or an INR of 2–4 depending on diagnosis.
    • Lab tests: For maintenance dosage, PT/INR determinations at 1–4-wk intervals depending on patient's response; periodic urinalyses, stool guaiac, and liver function tests. Blood samples should be drawn at 12–18 h after last dose (optimum).
    • Monitor closely older adult, psychotic, or alcoholic patients because they present serious noncompliance problems.
    • Patients at greatest risk of hemorrhage include those whose PT/INR are difficult to regulate, who have an aortic valve prosthesis, who are receiving long-term anticoagulant therapy, and older adult and debilitated patients.
    • Patient & Family Education

    • Understand that bleeding can occur even though PT/INR are within therapeutic range. Stop drug and notify physician immediately if bleeding or signs of bleeding appear: Blood in urine, bright red or black tarry stools, vomiting of blood, bleeding with tooth brushing, blue or purple spots on skin or mucous membrane, round pinpoint purplish red spots (often occur in ankle areas), nosebleed, bloody sputum; chest pain; abdominal or lumbar pain or swelling, profuse menstrual bleeding, pelvic pain; severe or continuous headache, faintness or dizziness; prolonged oozing from any minor injury (e.g., nicks from shaving).
    • Stop drug and report immediately any symptoms of hepatitis (dark urine, itchy skin, jaundice, abdominal pain, light stools) or hypersensitivity reaction (see Appendix F).
    • Avoid brand interchange, take drug at same time each day, and do NOT alter dose.
    • Notify physician if there is an unusual increase in menstrual bleeding (slightly increased or prolonged). Note: PT/INR are checked at least monthly in menstruating women.
    • Risk of bleeding is increased for up to 1 mo after receiving the influenza vaccine.
    • Fever, prolonged hot weather, malnutrition, and diarrhea lengthen PT/INR (enhanced anticoagulant effect).
    • A high-fat diet, sudden increase in vitamin K–rich foods (cabbage, cauliflower, broccoli, asparagus, lettuce, turnip greens, onions, spinach, kale, fish, liver), coffee or green tea (caffeine), or by tube feedings with high vitamin K content shorten PT/INR.
    • Maintain a well-balanced diet and avoid excess intake of alcohol.
    • Inform dentist or any new physician about anticoagulant therapy and duration of treatment.
    • Use a soft toothbrush and floss teeth gently with waxed floss.
    • Use barrier contraceptive measures; if you become pregnant while on anticoagulant therapy the fetus is at great potential risk of congenital malformations.
    • Do not take any other prescription or OTC drug unless specifically approved by physician or pharmacist. Carry medical identification at all times. It needs to indicate medical diagnosis, medication(s), physician's name, address, and telephone number.

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