Renal Medications

IV. RENAL MEDICATIONS A. ANTIINFECTIVES/ANTISEPTICS Generic Nitrofurantoin

Brand/Trade Name Microdantin

Dosage/Frequency and Route Oral Acute uncomplicated urinary tract infections Adult: 50-100 mg 4 times daily for 7 days. Dual-release preparation: 100 mg bid. Child: >3 mth and older children: 3 mg/kg daily in 4 divided doses. Oral Prophylaxis of uncomplicated UTI Adult: 50-100 mg at bedtime. Child: >3 mth and older children: 1 mg/kg once daily.

Indication

Action

Side effects

- Treatment of UTIs caused by susceptible strains of Escherichia coli, Staphylococcus aureus, Klebsiella, Enterobacter, Proteus - Prophylaxis or long-term suppression of UTIs

Nitrofurantoin interferes with cell metabolism and cell wall synthesis by inhibiting several enzyme systems including acetyl coenzyme A. It is bactericidal to most gram-positive and gram-negative urinary tract pathogens. Absorption: Readily absorbed from the GI tract. Food may increase bioavailability and prolong the duration of therapeutic urinary concentrations. Distribution: Concentrations in blood and body tissues are low; crosses the placenta and the blood-brain barrier and distributes in breast milk (trace amounts). Metabolism: Hepatic and in most body tissues. Excretion: Via

CNS: Peripheral neuropathy, headache, dizziness, nystagmus, drowsiness, vertigo Dermatologic: Exfoliative dermatitis, StevensJohnson syndrome, alopecia, pruritus, urticartia, angioedema GI: Nausea, abdominal cramps, vomiting, diarrhea, anorexia, parotitis, pancreatitis, hepatotoxicity Hematologic: Hemolytic anemia in G6PD deficiency; granulocytopenia, agranulocytosis, leukopenia, thrombocytopenia, eosinophilia, megaloblastic anemia Respiratory: Pulmonary hypersensitivity Other: Superinfections of the GU tract; hypotension; muscular aches;

Nursing Responsibilities • Take drug with food or milk. Complete the full course of drug therapy to ensure a resolution of the infection. Take this drug at regular intervals around the clock; consult your nurse or pharmacist to set up a convenient schedule. • You may experience these side effects: Nausea, vomiting, abdominal pain (eat frequent small meals); diarrhea; drowsiness, blurring of vision, dizziness (observe caution driving or using dangerous equipment); brown or yellow-rust urine (expected effect).

urine (30-40% of a dose excreted rapidly as unchanged drug); some tubular reabsorption may occur in acid urine. Plasma half-life: 0.3-1 hr.

brown-rust urine

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Report fever, chills, cough, chest pain, difficulty breathing, rash, numbness or tingling of the fingers or toes.

Generic Sulfonamides

Brand/Trade Name

Dosage/Frequency and Route Tab Adult 1 tab 12 hrly. Susp Childn 6-12 yr 10 mL 6 mth-5 yr 5 mL, 2-5 mth 2.5 mL. To be taken 12 hrly. Pneumocystis carinii 15-20 mg/kg body wt TM & 100 mg/kg body wt SMZ 6 hrly; Prophylaxis 1 tab daily.

Indication

Action

Side effects

Spectrum of activity includes the following bacteria: Clamydia, Nocardia, Hemophilus, E. Coli, and Proteus. Used to treat trachoma, brain abscess and Pneumocystis carinii pneumonia in AIDS patient, Toxoplasma gondii, prevention of meningococcal meningitis.

The sulfa drugs competitively block the para-amino benzoic acid to prevent the synthesis of folic acid in susceptible bacteria that synthesize their own folates for the production of RNA and DNA

Blood: Hemolytic and aplastic anemia Integumentary: Photosensitivity, exfoliative dermatitis, StevensJohnson syndrome, epidermal necrolysis, hypersensitivity reactions GI: Nausea, vomiting, diarrhea, pancreatitis Others: Cross reactivity might occur with the different sulfonamides. Convulsions, (crystalluria, and hematuria common in early sulfonamides esp. sulfadiazine) toxic nephrosis, headache, peripheral neuritis, urticaria, ataxia. Should be avoided during the 3rd trimester of pregnancy to prevent kernicterus to occur.

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Nursing Responsibilities Increase in fluids intake is important. Administer sulfonamides with a full glass of water to prevent crystalluria and kidney stone formation. Advise pregnant women to avoid sulfonamides esp. during the last trimester. Warn client who has an allergy to one sulfonamide to avoid other sulfa drugs. Advise client to avoid direct sunlight and to use sunblock and protective clothing to avoid sunburn. Direct client to report bruising and bleeding and to have blood count monitored.

Generic Fluroquinolones

Brand/Trade Name

Dosage/Frequency and Route Adults - Uncomplicated UTIs: 100–250 mg PO q 12 hr for 3 days or 500 mg PO daily (ER tablets) for 3 days. - Mild to moderate UTIs: 250 mg PO q 12 hr for 7–14 days or 200 mg IV q 12 hr for 7–14 days. - Complicated UTIs: 500 mg bid PO q 12 hr for 7–14 days or 400 mg IV q 12 hr or 1,000 mg (ER tablets) PO daily for 7–14 days. - Chronic bacterial prostatitis: 500 mg PO q 12 hr for 28 days or 400 mg IV q 12 hr for 28 days. - Infectious diarrhea: 500 mg q 12 hr PO for 5–7 days. - Acute uncomplicated pyelonephritis: 1,000 mg ER tablets PO daily for 7–14 days. Pediatric Patient Not recommended; produced lesions of joint cartilage in

Indication

Action

Side effects

- For the treatment of infections caused by susceptible gram-negative bacteria, including E. coli, P. mirabilis, K. pneumoniae, Enterobacter cloacae, P. vulgaris, P. rettgeri, M. morganii, P. aeruginosa, Citrobacter freundii, S. aureus, S. epidermidis, group D streptococci - Otic: Treatment of acute otitis externa - Treatment of chronic bacterial prostatitis - IV: Treatment of nosocomial pneumonia caused by Haemophilus influenzae, K. pneumoniae - Oral: Typhoid fever - Oral: STDs caused by N. gonorrheae - Prevention of anthrax following exposure to anthrax bacilla (prophylactic use in regions suspected of

Bactericidal; interferes with DNA replication in susceptible bacteria preventing cell reproduction.

CNS: Headache, dizziness, insomnia, fatigue, somnolence, depression, blurred vision CV: Arrhythmias, hypotension, angina EENT: Dry eye, eye pain, keratopathy GI: Nausea, vomiting, dry mouth, diarrhea, abdominal pain Hematologic: Elevated BUN, AST, ALT, serum creatinine and alkaline phosphatase; decreased WBC, neutrophil count, Hct Other: Fever, rash

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Nursing Responsibilities If an antacid is needed take it at least 2 hr before or after dose. Do not touch tip of eye ointment or solution for this may contaminate the product. Drink plenty of fluids while you are taking this drug. You may experience these side effects: Nausea, vomiting, abdominal pain (eat frequent small meals); diarrhea or constipation; drowsiness, blurring of vision, dizziness (observe caution if driving or using dangerous equipment). Report rash, visual changes, severe GI problems, weakness, tremors.

immature experimental animals. - Inhalational anthrax: 15 mg/kg/dose PO q 12 hr for 60 days or 10 mg/kg/dose IV q 12 hr for 60 days; do not exceed 500 mg/dose PO or 400 mg/dose IV. Patients with Impaired Renal Function For creatinine clearance of 30–50 mL/min, give 250– 500 mg PO q 12 hr. For creatinine clearance of 5–29 mL/min, give 250– 500 mg PO q 18 hr or 200–400 mg IV q 18– 24 hr. For patients on hemodialysis, give 250–500 mg q 24 hr, after dialysis.

using germ warfare) - Unlabeled use: Effective in patients with cystic fibrosis who have pulmonary exacerbations

B. ANALGESICS/NSAIDS Generic Celecoxib

Brand/Trade Name Celebrex

Dosage/Frequency and Route Adult Initially, 100 mg PO bid; may increase to 200 mg/day PO bid as needed. Acute pain, dysmenorrhea: 400 mg, then 200 mg PO bid. FAP: 400 mg PO bid. Pediatric Patient Safety and efficacy have not been established. Patients with Hepatic Impairment Reduce dosage by 50%.

Indication

Action

Side effects

- Acute and longterm treatment of signs and symptoms of rheumatoid arthritis and osteoarthritis - Reduction of the number of colorectal polyps in familial adenomatous polyposis (FAP) - Management of acute pain - Treatment of primary dysmenorrhea

Analgesic and antiinflammatory activities related to inhibition of the COX-2 enzyme, which is activated in inflammation to cause the signs and symptoms associated with inflammation; does not affect the COX-1 enzyme, which protects the lining of the GI tract and has blood clotting and renal functions.

CNS: Headache, dizziness, somnolence, insomnia, fatigue, tiredness, dizziness, tinnitus, ophthamologic effects Dermatologic: Rash, pruritus, sweating, dry mucous membranes, stomatitis GI: Nausea, abdominal pain, dyspepsia, flatulence, GI bleed Hematologic: Neutropenia, eosinophilia, leukopenia, pancytopenia, thrombocytopenia, agranulocytosis, granulocytopenia, aplastic anemia, decreased Other: Peripheral edema, anaphylactoid reactions to anaphylactic shock

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Nursing Responsibilities Take drug with food or meals if GI upset occurs. Take only the prescribed dosage. You may experience these side effects: Dizziness, drowsiness (avoid driving or the use of dangerous machinery while using this drug). Report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers; changes in vision.

Generic Meloxicam

Brand/Trade Name Mobic

Dosage/Frequency and Route Adults Starting dose, 7.5 mg PO daily. Maximum dosage, 15 mg PO daily. Pediatric Patient Safety and efficacy not established

Indication

Action

Side effects

Relief from the signs and symptoms of osteoarthritis and rheumatoid arthritis

Anti-inflammatory, analgesic, and antipyretic activities related to inhibition of the enzyme cyclooxygenase (COX), which is required for the synthesis of prostaglandins and thromboxanes. Somewhat more selective for COX-2 sites (found in the brain, kidney, ovary, uterus, cartilage, bone, and at sites of inflammation) than for COX-1 sites, which are found throughout the tissues and are related to protection of the GI mucosa.

CNS: Headache, dizziness, somnolence, insomnia, fatigue, tiredness, dizziness, tinnitus, ophthalmologic effects Dermatologic: Rash, pruritus, sweating, dry mucous membranes, stomatitis GI: Nausea, dyspepsia, GI pain, diarrhea, vomiting, constipation, flatulence GU: Dysuria, renal impairment Respiratory: Dyspnea, hemoptysis, pharyngitis, bronchospasm, rhinitis Other: Peripheral edema, anaphylactoid reactions to anaphylactic shock

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Nursing Responsibilities Take drug with food if GI upset occurs. Take only the prescribed dosage. You may experience these side effects: Dizziness, drowsiness (avoid driving or using dangerous machinery while taking this drug). Report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers, changes in vision, black, tarry stools.

Generic Naproxen

Brand/Trade Name Naprelan

Dosage/Frequency and Route Adults - Rheumatoid arthritis or osteoarthritis, ankylosing spondylitis: Delayed-release (ECNaprosyn) 375–500 mg PO bid. Controlled-release (Naprelan) 750–1,000 mg PO daily. Naproxen sodium 275–550 mg bid PO. May increase to 1.65 g/day for a limited period. Naproxen tablets 250–500 mg PO bid. - Acute gout: Controlled-release (Naprelan) 1,000–1,500 mg PO daily. Naproxen sodium 825 mg PO followed by 275 mg q 8 hr until the attack subsides. Naproxen 750 mg, followed by 250 mg q 8 hr until attack subsides. - Mild to moderate pain: Controlled-release (Naprelan)

Indication

Action

Side effects

- Mild to moderate pain - Treatment of primary dysmenorrhea, rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, tendinitis, bursitis, acute gout - OTC use: Temporary relief of minor aches and pains associated with the common cold, headache, toothache, muscular aches, backache, minor pain of arthritis, pain of menstrual cramps, reduction of fever - Treatment of juvenile arthritis (Naproxen only)

Analgesic, antiinflammatory, and antipyretic activities largely related to inhibition of prostaglandin synthesis; exact mechanisms of action are not known.

CNS: Headache, dizziness, somnolence, insomnia, fatigue, tiredness, dizziness, tinnitus, ophthalmic effects Dermatologic: Rash, pruritus, sweating, dry mucous membranes, stomatitis GI: Nausea, dyspepsia, GI pain, diarrhea, vomiting, constipation, flatulence GU: Dysuria, renal impairment, including renal failure, interstitial nephritis, hematuria Hematologic: Bleeding, platelet inhibition with higher doses, neutropenia, eosinophilia, leukopenia, pancytopenia, thrombocytopenia, agranulocytosis, granulocytopenia, aplastic anemia, decreased Hgb or Hct, bone marrow depression, menorrhagia

Nursing Responsibilities • Take drug with food or meals if GI upset occurs; take only the prescribed dosage. • Dizziness, drowsiness can occur (avoid driving or the use of dangerous machinery) • Report sore throat; fever; rash; itching; weight gain; swelling in ankles or fingers; changes in vision; black, tarry stools

1,000 mg PO daily. Naproxen sodium 550 mg PO followed by 275 mg q 6–8 hr. - Mild to moderate pain: 500 mg followed by 500 mg q 12 hr or 250 mg q 6–8 hr. OTC 200 mg PO q 8– 12 hr with a full glass of liquid while symptoms persist. Do not exceed 600 mg in 24 hr. Pediatric Patient - Juvenile arthritis: Naproxen 10 mg/kg/day given in two divided doses. Naproxen sodium Safety and efficacy not established. OTC Do not give to children < 12 yr unless under advice of physician. Geriatric Patients Do not take > 200 mg q 12 hr PO.

Respiratory: Dyspnea, hemoptysis, pharyngitis, bronchospasm, rhinitis Other: Peripheral edema, anaphylactoid reactions to anaphylactic shock

Generic Valdecoxib

Brand/Trade Name Bextra

Dosage/Frequency and Route Adults - Osteoarthritis and rheumatoid arthritis: 10 mg/day PO. - Primary dysmenorrhea: 20 mg PO bid as needed. Pediatric Patient Safety and efficacy not established in patients < 18 yr.

Indication

Action

Side effects

- Relief of signs and symptoms of osteoarthritis and adult rheumatoid arthritis - Treatment of primary dysmenorrhea

Analgesic and antiinflammatory activities related to inhibition of COX-2 enzyme, which is activated in inflammation to cause the signs and symptoms associated with inflammation; not thought to affect the COX-1 enzyme, which protects the lining of the GI tract and has blood clotting and renal functions.

CNS: Headache, dizziness, neuralgia, neuropathy, tremors, anxiety CV: Arrhythmia, hypertension, CHF, hypotension, edema Dermatologic: Rash, pruritus, sweating, StevensJohnson syndrome, toxic epidermal necrolysis, dry mucous membranes, urticaria, exfoliative dermatitis, erythema multiforme GI: Abdominal pain, diarrhea, dyspepsia, nausea, flatulence, hemorrhoids, abdominal fullness Respiratory: URI, sinusitis, coughing, dyspnea, rhinitis Other: Back pain, myalgia, anaphylaxis, angioedema

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Nursing Responsibilities Take the drug with food or after meals if GI upset occurs. Do not exceed the prescribed dosage. You may experience these side effects: Drowsiness, dizziness (use caution when driving or operating dangerous machinery if these occur); GI upset, diarrhea (eat frequent small meals; consult with health care provider if severe). Report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers, severe abdominal pain

C. CHOLINERGICS DRUG Generic name: bethanechol chloride Brand Name: Duvoid

DOSAGE/FREQUE NCY AND ROUTE

INDICATION

Adults: 10-50 mg P.O. t.i.d. to q.i.d. or 2.5-5 mg subcutaneously

Acute postoperative ad postpartum nonobstructive (functional) urine retention, neurogenic atony of urinary bladder with urine retention.

ACTION Directly stimulates muscarinic cholinergic receptors, mimicking acetylcholine action, increasing GI tract tone and peristalsis and contraction of the detrusor muscle of the urinary bladder.

SIDE EFFECTS CNS: headache, malaise CV: bradycardia, flushing EENT: lacrimation, miosis GI: abdominal cramps, diarrhea, excessive salivation, nausea, belching GU: urinary urgency Respiratory: bronchoconstriction, increased bronchial secretions Skin: diaphoresis

NURSING RESPONSIBILITIES •

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Give drug 1 hr before or 2 hrs after meals because it may cause nausea and vomiting if taken soon after eating. Monitor vital signs frequently, especially respirations. Always have atropine injection available, and be prepared to give 0.6 mg subcutaneously or b slow I.V. push. Provide respiratory support, if needed. Monitor patient for orthostatic hypotension. Watch for toxicity, especially for subcutaneous use. Watch closely for adverse reactions that may indicate drug toxicity. Tell patient to take oral form on an empty stomach and at regular intervals. Inform patient that drug is usually effective 30-90 minutes after oral use and 5-15 minutes after subcutaneous use.

D. ANTI-CHOLINERGICS DRUG DOSAGE AND ROUTE Generic Name: K citrate Brand Name: Acalka tab

The aim of the treatment is to restore the level of urinary citrate and to increase the pH of urine to 6-7 and to this end, the dosage patterns are: Patients with Severe Hypocitraturia: Start the treatment with a dose of 60 mEq daily (6 tabs), divided into 3-4 intakes daily. Patients with Slight Hypocitraturia: Start the treatment with a dose of 30 mEq daily (3 tabs), divided into 3 intakes daily. It is recommended to take the tablets 30 min after meals. Approximately 24 hrs after having started the treatment, make a determination of urinary citrate and pH and adjust the dose in accordance with the needs of the patient. If necessary, the dose can be increased, though it

INDICATION Treatment of patients with renal lithiasis and hypocitraturia, chronic formers of calcium oxalate, phosphate calculi; uric acid lithiasis alone or accompanied by calcium lithiasis; and renal tubular acidosis with calcium nephrolithiasis.

ACTION Inhibitor of crystallization.

SIDE EFFECTS Slight GI disorders may appear which can be palliated by means of concomitant administration with food.

NURSING RESPONSIBILITIES

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Tell patient that if they have been given tablets, swallow them whole with a full glass of water. Do not crush, chew or suck them. Inform doctor if they have difficulty swallowing the tablets or if they get stuck in the throat. Tell patient that if they have been given the solution (syrup), dilute each dose with water before they take it. Drink lots of water after taking it.

is not advisable to exceed the dose of 100 mEq/day (10 tabs).

DRUG Generic Name: atropine Brand Name: Sal-Tropine

DOSAGE, ROUTE and INDICATION

Intravenous Bradycardia Adult: 500 mcg every 3-5 minutes. Total: 3 mg. Max Dosage: 0.04 mg/kg body weight. Parenteral Premedication in balanced anaesthesia Adult: 300-600 mcg IM/SC 30-60 minutes before anaesthesia. Alternatively, 300-600 mcg IV immediately before induction of anaesthesia. Child: >20 kg: 300-600 mcg; 12-16 kg: 300 mcg; 79 kg: 200 mcg; >3 kg: 100 mcg. Doses to be given via IM/SC admin 30-60 minutes before anaesthesia. Parenteral Organophosphorus poisoning Adult: 2 mg IV/IM, every 10-30 minutes until muscarinic effects disappear or atropine toxicity appears. In severe cases, dose can be given as often as every 5 minutes. In moderate to

ACTION

SIDE EFFECTS

Absorption: Readily absorbed from the GI tract; also absorbed from mucous membranes, eye, and through intact skin. Distribution: Distributes throughout the body and crosses the blood-brain barrier and placenta. Metabolism: Incomplete metabolism in the liver. Excretion: Excreted in urine as unchanged drug and metabolites. Half-life reported to be 4 hr.

Dry mouth, dysphagia, constipation, flushing and dryness of skin, tachycardia, palpitations, arrhythmias, mydriasis, photophobia, cycloplegia, raised intraocular pressure. Toxic doses cause tachycardia, hyperpyrexia, restlessness, confusion, excitement, hallucinations, delirium and may progress to circulatory failure and resp depression. Eye drops: Systemic toxicity esp in childn, on prolonged use may lead to irritation, hyperaemia, oedema and conjunctivitis. Increased intraocular pressure. Inhalation: Dryness of mouth, throat. Potentially Fatal: Atrial arrhythmias, AV dissociation, multiple ventricular ectopics.

NURSING RESPONSIBILITIES

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In adults, avoid doses less than 0.5 mg because of the risk of paradoxical bradycardia. Monitor fluid intake and urine output. Drug causes urine retention and urinary hesitancy. Each patient receiving oral form of drug how to handle distressing anticholinergic effects. Instruct patient to report serious or persistent adverse reactions promptly. Tell patient about potential for sensitivity of the eyes to the sun and suggest use of sunglasses.

severe poisoning, a state of atropinisation is maintained for at least 2 days and continued for as long as symptoms are present. Child: 20 mcg/kg given every 5-10 minutes. Parenteral Overdosage with other compounds having muscarinic actions Adult: 0.6-1 mg IV/IM/SC, repeated every 2 hr. Ophthalmic Inflammatory eye disorders e.g. uveitis or iritis Adult: Instill 1-2 drops of a 0.5-1% solution up to 4 times daily. Child: As sulfate: Instill 1-2 drops of a 0.5% soln (or 1 drop of a 1% solution) up to tid. Ophthalmic Eye refraction Adult: Instill 1 drop of a 1% solution bid for 1-2 days before the procedure, or on a single occasion 1 hr before the procedure. Child: As sulfate: Instill 1 or 2 drops of a 0.5% soln (or 1 drop of a 1% solution) bid for 1-3 days before the procedure, with a further dose given 1 hr before the procedure. Incompatibility: Incompatible with hydroxybenzoate

preservatives.

E. ANTISPASMODIC Generic Name/Brand Name 1. Oxybutynin

Dosage/ Frequency •

ADULTS

Classification •

Urinary

Indication Relief of symptoms

Contraindication

Contraindicated

Side Effects CNS: Drowsiness,

Nursing Responsibilities Assessment

Chloride ApoOxybutynin (CAN), Ditropan, Ditropan XL, NovoOxybutynin (CAN), Oxytrol

Antispasmodic 5 mg PO bid or tid. Maximum dose is 5 mg qid. ER tablets—5 mg PO daily, up to a maximum of 30 mg/day; transdermal patch—one patch per day applied to dry, intact skin on the abdomen, hip, or buttock every 3–4 days. •

PEDIATRIC PATIENTS > 5 YR

5 mg PO bid. Maximum dose is 5 mg tid.

Acts directly to relax smooth muscle and inhibits the effects of acetylcholine at muscarinic receptors; reported to be less potent an anticholinergic than atropine but more potent as antispasmodic and devoid of antinicotinic activity at skeletal neuromuscular junctions or autonomic ganglia.

of bladder instability associated with voiding in patients with uninhibited neurogenic and reflex neurogenic bladder ER tablets: Treatment of signs and symptoms of overactive bladder (incontinence, urgency, frequency)

with allergy to oxybutynin, pyloric or duodenal obstruction, obstructive intestinal lesions or ileus, intestinal atony, megacolon, colitis, obstructive uropathies, glaucoma, myasthenia gravis, CV instability in acute hemorrhage. Use cautiously with hepatic, renal impairment; pregnancy; lactation.

dizziness, blurred vision, dilatation of the pupil, cycloplegia, increased ocular tension, weakness CV: Tachycardia, palpitations GI: Dry mouth, nausea, vomiting, constipation, bloated feeling GU: Urinary hesitancy, retention, impotence Hypersensitivity: Allergic reactions including urticaria, dermal effect Other: Decreased sweating, heat prostration in high environmental temperatures secondary to loss of sweating

History: Allergy to oxybutynin, intestinal obstructions or lesions, intestinal atony, obstructive uropathies, glaucoma, myasthenia gravis, CV instability in acute hemorrhage, hepatic or renal impairment, pregnancy, lactation Physical: Skin color, lesions; T; orientation, affect, reflexes; ophthalmologic examination, ocular pressure measurement; P, rhythm, BP; bowel sounds, liver evaluation; renal and liver function tests, cystometry Interventions Arrange for cystometry and other

diagnostic tests before and during treatment. Arrange for ophthalmologic examination before therapy and periodically during therapy.

2. Tolterodine Tartrate Detrol, Detrol LA

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ADULTS

2 mg PO bid, may be lowered to 1 mg PO bid based on individual response; ER capsules— 4 mg PO taken once a day; may be lowered to 2 mg qd based on response. •

PEDIATRIC PATIENTS

Safety and efficacy not established. •

PATIENTS WITH HEPATIC IMPAIRMENT

Reduce dosage to 1 mg PO bid (2 mg daily ER capsules) and monitor patient.

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Antimuscarinic

Therapeutic actions

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Competitively blocks muscarinic receptor sites; bladder contraction is mediated by muscarinic receptors— blocking these receptors decreases bladder contraction.

Treatment of overactive bladder in patients with symptoms of urinary frequency, urgency, or incontinence

Contraindicated with urinary retention, uncontrolled narrow-angle glaucoma, allergy to the drug or any of its components. Use cautiously with renal or hepatic impairment, pregnancy, lactation.

CNS: Blurred vision, headache, dizziness, somnolence Dermatologic: Pruritus, rash, erythema, dry skin GI: Nausea, vomiting, constipation, dyspepsia, flatulence, dry mouth, abdominal pain GU: Dysuria, urinary retention; impotence, UTIs Other: Weight gain, pain, fatigue, acute myopia and

Assessment History: Presence of urinary retention; uncontrolled narrow-angle glaucoma; allergy to the drug or any of its components; renal or hepatic impairment; pregnancy, lactation Physical: Bowel sounds, normal output; normal urinary output, prostate palpation; IOP, vision; liver function tests; renal function tests; skin color, lesions, texture;

secondary angle closure glaucoma (pain, visual changes, redness, increased IOP)

weight Interventions Provide small, frequent meals if GI upset is severe. Provide frequent mouth hygiene or skin care if dry mouth or skin occur. Arrange for safety precautions if blurred vision occurs. Monitor bowel function and arrange for bowel program if constipation occurs.

3. Trospium Chloride Sanctura

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ADULTS < 75 YR

20 mg PO bid taken on an empty stomach, at least 1 hr before meals.

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ADULTS > 75 YR

Monitor patient response and adjust dosage down

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Antimuscarinic Antispasmodic

Therapeutic actions Competitively blocks muscarinic receptor sites; bladder contraction is mediated by muscarinic receptors—blocking these receptors decreases bladder contraction, relieving

Urinary incontinence, urgency, and frequency caused by overactive bladder

Contraindicated with allergy to trospium or any component of the drug; presence of or risk for urinary retention, gastric retention, uncontrolled narrow-angle

CNS: Headache, dry eyes, dizziness, blurred vision GI: Dry mouth, constipation, abdominal pain, dyspepsia, flatulence, vomiting GU: Urinary

Assessment History: Allergy to trospium or any component of the drug; presence of or risk for urinary retention, gastric retention, uncontrolled narrow-angle

glaucoma. to 20 mg/day. •

PEDIATRIC PATIENTS

Safety and efficacy not established. •

PATIENTS WITH RENAL IMPAIRMENT

Creatinine clearance < 30 mL/min—20 mg/day PO given hs.

bladder spasm.

retention Use cautiously with renal or hepatic dysfunction, ulcerative colitis, intestinal atony, myasthenia gravis, bladder or gastric outlet obstruction, pregnancy, lactation.

Other: Fatigue, decreased sweating

glaucoma, renal or hepatic dysfunction, ulcerative colitis, intestinal atony, myasthenia gravis, bladder or gastric outlet obstruction, pregnancy, lactation Physical: Orientation, affect, vision, IOP; GI output, bowel sounds, liver evaluation; normal urinary output, prostate palpation; renal and liver function tests Interventions Administer drug on an empty stomach, at least 1 hour before meal. Provide small, frequent meals if GI upset is severe. Establish safety measures (accompany

patient, siderails, etc.) if vision changes occur. Provide frequent mouth hygiene and sugarless lozenges if dry mouth is a problem. Monitor bowel function and arrange for appropriate bowel program if constipation occurs.

F. ANTIHYPERTENSIVE DRUGS

Generic Dosage/ Classification Name/Brand Frequency Name A. Angiotensin-Converting Enzyme Inhibitor 1. Benazepril Hydrochlor ide Lotensin

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ADULTS

Initial dose, 10 mg PO daily. Maintenance dose, 20–40 mg/day PO, single or two divided doses. Patients using diuretics should discontinue them 2–3 d prior to benazepril therapy. If BP is not controlled, add diuretic slowly. If diuretic cannot be discontinued, begin benazepril therapy with 5 mg. Maximum dose, 80 mg. •

PEDIATRIC PATIENTS

Safety and efficacy not established. •

PATIENTS WITH RENAL IMPAIRMENT

For creatinine clearance < 30 mL/min/1.73 m2 (serum creatinine > 3 mg/dL), 5 mg PO daily. Dosage may be gradually increased until BP is controlled,

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Antihypertensiv e Angiotensinconverting enzyme (ACE) inhibitor

Therapeutic actions Blocks ACE from converting angiotensin I to angiotensin II, a potent vasoconstrictor, leading to decreased BP, decreased aldosterone secretion, a small increase in serum potassium levels, and sodium and fluid loss; increased prostaglandin synthesis also may be involved in the antihypertensive action.

Indication

Treatment of hypertensi on alone or in combinati on with thiazidetype diuretics

Contraindication

Contraindicated with allergy to benazepril or other ACE inhibitors, second or third trimester of pregnancy. Use cautiously with impaired renal function, immunosuppr esion, CHF, hypotension, salt or volume depletion, lactation, pregnancy.

Side Effects

Nursing Responsibilities

CV: Angina pectoris, hypotension in salt- or volumedepleted patients, palpitations

Assessment

Dermatologic: Rash, pruritus, diaphoresis, flushing GI: Nausea, abdominal pain, vomiting, constipation Respiratory: Cough, asthma, bronchitis, dyspnea, sinusitis Other: Angioedema, impotence, decreased libido, asthenia, myalgia, arthralgia

History: Allergy to benazepril or other ACE inhibitors, impaired renal function, CHF, salt or volume depletion, lactation, pregnancy Physical: Skin color, lesions, turgor; T; P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver evaluation; urinalysis, renal and liver function tests, CBC and differential

Interventions

up to a maximum of 40 mg/day.

WARNING: Alert surgeon, note use of benazepril on patient's chart; the angiotensin II formation subsequent to compensatory renin release during surgery will be blocked; hypotension may be reversed with volume expansion. Monitor patient for possible fall in BP secondary to reduction in fluid volume (excessive perspiration and dehydration, vomiting, diarrhea) because excessive hypotension may occur. WARNING: Ensure that patient is not pregnant; fetal abnormalities and death have occurred if

using during second or third trimester. Encourage use of contraceptive measures. Reduce dosage in patients with impaired renal function.

2. Enalapril Maleate

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ADULTS

Oral

Antihypertensive ACE inhibitor Therapeutic actions

Vasotec Hypertension: Patients not taking diuretics: Initial dose is 5 mg/day PO. Adjust dosage based on patient response. Usual range is 10– 40 mg/day as a single dose or in two divided doses. Patients taking diuretics: Discontinue diuretic for 2–3 days if possible. If it is not

Renin, synthesized by the kidneys, is released into the circulation where it acts on a plasma precursor to produce angiotensin I, which is converted by angiotensin-converting enzyme to angiotensin II, a potent vasoconstrictor that also causes release of aldosterone from the adrenals; both of these actions increase BP. Enalapril blocks the conversion of angiotensin I to angiotensin II, decreasing BP, decreasing aldosterone

Treatment of hypertensi on alone or in combinati on with other antihypert ensives, especially thiazidetype diuretics Treatment of acute and chronic CHF Treatment of asymptom

Contraindicated with allergy to enalapril. Use cautiously with impaired renal function; salt or volume depletion (hypotension may occur); lactation, pregnancy.

CNS: Headache, dizziness, fatigue, insomnia, paresthesias CV: Syncope, chest pain, palpitations, hypotension in salt- or volumedepleted patients GI: Gastric irritation, nausea, vomiting, diarrhea, abdominal pain, dyspepsia, elevated liver

Assessment History: Allergy to enalapril, impaired renal function, salt or volume depletion, lactation, pregnancy Physical: Skin color, lesions, turgor; T; orientation, reflexes, affect, peripheral sensation; P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver evaluation; urinalysis, renal

possible to discontinue diuretic, give initial dose of 2.5 mg, and monitor for excessive hypotension. Converting to oral therapy from IV therapy: 5 mg daily with subsequent doses based on patient response. Heart failure: 2.5 mg PO daily or bid in conjunction with diuretics and digitalis. Maintenance dose is 5– 20 mg/day given in two divided doses. Maximum daily dose is 40 mg. Asymptomatic LVD: 2.5 mg PO bid; target maintenance dose 20 mg/day in two divided doses.

secretion, slightly increasing serum K+ levels, and causing Na+ and fluid loss; increased prostaglandin synthesis also may be involved in the antihypertensive action. In patients with heart failure, peripheral resistance, afterload, preload, and heart size are decreased.

atic left ventricular dysfunctio n (LVD) Unlabeled use: Diabetic nephropat hy

enzymes GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, urinary frequency, impotence Hematologic : Decreased hematocrit and hemoglobin Other: Cough, muscle cramps, hyperhidrosis

and liver function tests, CBC, and differential

Interventions WARNING: Alert surgeon, and mark patient's chart with notice that enalapril is being taken; the angiotensin II formation subsequent to compensatory renin release during surgery will be blocked; hypotension may be reversed with volume expansion. Monitor patients on diuretic therapy for excessive hypotension after the first few doses of enalapril. Monitor patient closely

Parenteral Give IV only. 1.25 mg q 6 hr given IV over 5 min. A response is usually seen within 15 min, but peak effects may not occur for 4 hr. Hypertension: Converting to IV therapy from oral therapy: 1.25 mg q 6 hr; monitor patient response. Patients taking diuretics: 0.625 mg IV over 5 min. If adequate response is not seen after 1 hr, repeat the 0.625-mg dose. Give additional doses of 1.25 mg q 6 hr. •

PEDIATRIC PATIENTS 1 MO–16 YR

Oral Hypertension:

in any situation that may lead to a drop in BP secondary to reduced fluid volume (excessive perspiration and dehydration, vomiting, diarrhea) because excessive hypotension may occur. Arrange for reduced dosage in patients with impaired renal function. WARNING: Monitor patient carefully because peak effect may not be seen for 4 hr. Do not administer second dose until BP has been checked.

Initial dose is 0.08 mg/kg PO once daily; maximum dose is 5 mg. •

GERIATRIC PATIENTS AND PATIENTS WITH RENAL IMPAIRMENT

Oral Excretion is reduced in renal failure; use smaller initial dose, and adjust upward to a maximum of 40 mg/day PO. For patients on dialysis, use 2.5 mg on dialysis days.

3. Fosinopril Sodium Monopril

•

ADULTS

Initial dose, 10 mg PO daily. Maintenance dose, 20–40 mg/day PO as a single dose or 2 divided doses. In patients receiving diuretic therapy, begin fosinopril therapy with 10 mg. Do not exceed maximum dose of 80 mg. •

PEDIATRIC

Antihypertensive Angiotensin-converting enzyme (ACE) inhibitor Therapeutic actions Renin, synthesized by the kidneys, is released into the circulation where it acts on a plasma precursor to produce angiotensin I, which is converted by

Treatment of hypertensi on, alone or in combinati on with thiazidetype diuretics Managem ent of

Contraindicated with allergy to fosinopril or other ACE inhibitors; pregnancy. Use cautiously with impaired renal function, hyperkalemia, salt or volume depletion, lactation.

CV: Angina pectoris, orthostatic hypotension in salt- or volumedepleted patients, palpitations Dermatologi c: Rash, pruritus,

Assessment History: Allergy to fosinopril and other ACE inhibitors, impaired renal or hepatic function, hyperkalemia, salt or volume depletion, lactation, pregnancy

PATIENTS Safety and efficacy not established.

angiotensin-converting enzyme to angiotensin II, a potent vasoconstrictor that also causes release of aldosterone from the adrenals; fosinopril blocks the conversion of angiotensin I to angiotensin II, leading to decreased BP, decreased aldosterone secretion, a small increase in serum potassium levels, and sodium and fluid loss; increased prostaglandin synthesis may be involved in the antihypertensive action.

CHF as adjunctive therapy Unlabeled use: Diabetic nephropat hy

diaphoresis, flushing GI: Nausea, abdominal pain, vomiting, diarrhea Respiratory: Cough, asthma, bronchitis, dyspnea, sinusitis Other: Angioedema, asthenia, myalgia, arthralgia, hyperkalemia

Physical: Skin color, lesions, turgor; T; P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver evaluation; urinalysis, renal and liver function tests, CBC, and differential Interventions WARNING: Alert surgeon and mark patient's chart with notice that fosinopril is being taken; the angiotensin II formation subsequent to compensatory renin release during surgery will be blocked; hypotension may be reversed with volume expansion. Arrange to switch to a different drug if pregnancy occurs; suggest using barrier

contraceptives. Monitor patient closely for a fall in BP secondary to reduction in fluid volume (excessive perspiration and dehydration, vomiting, diarrhea) because excessive hypotension may occur.

4. Lisinopril ApoLisinopril (CAN), Prinivil, Zestril

•

ADULTS NOT TAKING DIURETICS

Initial dose, 10 mg/day PO. Adjust dosage based on response. Usual range is 20– 40 mg/day as a single dose. •

ADULTS TAKING DIURETICS

Discontinue diuretic for 2–3 days. If it is not possible to discontinue, give initial dose of 5 mg, and monitor for excessive hypotension.

Antihypertensive Angiotensin-converting enzyme (ACE) inhibitor

Therapeutic actions Renin, synthesized by the kidneys, is released into the circulation where it acts on a plasma precursor to produce angiotensin I, which is converted by angiotensin-converting enzyme to angiotensin II, a potent vasoconstrictor that also causes release of aldosterone from the

Treatment of hypertensi on alone or in combinati on with thiazidetype diuretics Adjunctiv e therapy in CHF for patients unresponsi ve to diuretics and digitalis alone

Contraindicated with allergy to lisinopril or enalapril. Use cautiously with impaired renal function, CHF, salt or volume depletion, pregnancy, lactation.

CNS: Headache, dizziness, insomnia, fatigue, paresthesias CV: Orthostatic hypotension, tachycardia, angina pectoris, MI, Raynaud's syndrome, CHF, severe hypotension in salt- or volumedepleted patients GI: Gastric

Assessment History: Allergy to lisinopril or enalapril, impaired renal function, CHF, salt or volume depletion, lactation, pregnancy Physical: Skin color, lesions, turgor; T; P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver evaluation; urinalysis, renal

CHF: 5 mg PO daily with diuretics and digitalis. Effective range: 5–20 mg/day. Acute MI: Start within 24 hr of MI with 5 mg PO followed in 24 hr by 5 mg PO; 10 mg PO after 48 hr, then 10 mg PO daily for 6 wk. •

PEDIATRIC PATIENTS

Safety and efficacy not established. •

GERIATRIC PATIENTS AND PATIENTS WITH RENAL IMPAIRMENT

Excretion is reduced in renal failure. Use smaller initial dose, and adjust upward to a maximum of 40 mg/day PO.

adrenals. Lisinopril blocks the conversion of angiotensin I to angiotensin II, leading to decreased BP, decreased aldosterone secretion, a small increase in serum potassium levels, and sodium and fluid loss.

Treatment of stable patients within 24 hr of acute MI to improve survival with beta blocker, aspirin, or thromboly tics

irritation, nausea, diarrhea, peptic ulcers, dysgeusia, cholestatic jaundice, hepatocellular injury, anorexia, constipation GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, frequency Hematologic: Neutropenia, agranulocytosis , thrombocytope nia, hemolytic anemia, pancytopenia Other: Angioedema (particularly of the face, extremities, lips, tongue, larynx); death has been reported with airway

and liver function tests, CBC and differential Interventions Begin drug within 24 hr of acute MI; ensure that patient is also receiving standard treatment (eg thrombolytics, aspirin, beta blockers). WARNING: Keep epinephrine readily available in case of angioedema of the face or neck region; if breathing difficulty occurs, consult physician, and administer epinephrine. WARNING: Alert surgeon, and mark patient's chart with notice that lisinopril is being taken. The angiotensin II formation subsequent to compensatory

obstruction; cough, muscle cramps, impotence, rash, pruritis

renin release during surgery will be blocked. Hypotension may be reversed with volume expansion. Monitor patients on diuretic therapy for excessive hypotension following the first few doses of lisinopril. Monitor patients closely in any situation that may lead to a decrease in BP secondary to reduction in fluid volume (excessive perspiration and dehydration, vomiting, diarrhea) because excessive hypotension may occur. Arrange for reduced dosage in patients with impaired renal function. Suggest the

use of contraceptives; if pregnancy should occur, discontinue drug as soon as possible.

Angiotensin II Receptor Blockers 1. Candesarta n Cilexetil Atacand

•

ADULTS

Usual starting dose, 16 mg PO daily. Can be administered in divided doses bid with a total daily dose of 32 mg/day. Dose range: 8– 32 mg a day. •

PEDIATRIC PATIENTS

Safety and efficacy not established.

Angiotensin II receptor antagonist Antihypertensive Therapeutic actions Selectively blocks the binding of angiotensin II to specific tissue receptors found in vascular smooth muscle and adrenal gland; this action blocks the vasoconstriction effect of the renin–angiotensin system as well as the release of aldosterone leading to decreased BP.

Treatment of hypertensio n, alone or in combination with other antihyperten sives

Contraindicated with hypersensitivity to candesartan, pregnancy (using during the second or third trimester can cause injury or even death to the fetus), lactation. Use cautiously with renal dysfunction, hypovolemia.

CNS: Headache, dizziness, syncope, muscle weakness

Assessment

CV: Hypotension

History: Hypersensitivity to candesartan, pregnancy, lactation, renal dysfunction, hypovolemia

Dermatologi c: Rash, inflammation , urticaria, pruritus, alopecia, dry skin

Physical: Skin lesions, turgor; T; reflexes, affect; BP; R, respiratory auscultation; kidney function tests

GI: Diarrhea, abdominal pain, nausea, constipation, dry mouth, dental pain Respiratory: URI

Interventions Administer without regard to meals. WARNING: Ensure that patient is not pregnant before beginning

symptoms, cough, sinus disorders Other: Cancer in preclinical studies, back pain, fever, gout

therapy, suggest the use of barrier birth control while using candesartan; fetal injury and deaths have been reported. Find an alternate method of feeding the baby for a nursing mother. Depression of the renin-angiotensin system in infants is potentially very dangerous. WARNING: Alert surgeon and mark patient's chart with notice that candesartan is being taken. The blockage of the renin–angiotensin system following surgery can produce problems. Hypotension may be reversed with volume expansion. If BP control does not reach desired levels, diuretics or

other antihypertensives may be added to candesartan. Monitor patient's BP carefully. Monitor patient closely in any situation that may lead to a decrease in BP secondary to reduction in fluid volume–excessive perspiration, dehydration, vomiting, diarrhea– excessive hypotension can occur.

2. Irbesartan Avapro

•

ADULTS Diabetic neuropathy: 300 mg/day PO as a single dose. Hypertension: 150 mg PO daily as one dose; adjust slowly to determine effective dose;

Angiotensin II receptor antagonist (ARB) Antihypertensive Therapeutic actions Selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland; this action blocks the vasoconstriction effect of the reninangiotensin system as well as the release of

Treatment of hypertensio n as monotherap y or in combination with other antihyperten sives

Contraindicated with hypersensitivity to irbesartan, pregnancy (use during the second or third trimester can cause injury or even death to the fetus).

Slowing of the progression of

Use cautiously with hepatic or renal dysfunction, hypovolemia,

CNS: Headache, dizziness, syncope, muscle weakness, sleep disturbance CV: Hypotension, orthostatic hypotension, flushing Dermatologi

Assessment History: Hypersensitivit y to irbesartan, pregnancy, lactation, hepatic or renal dysfunction, hypovolemia Physical: Skin lesions, turgor; T; reflexes, affect; BP; R, respiratory auscultation; liver

maximum daily dose—300 mg. •

PEDIATRIC PATIENTS

< 6 yr: Not recommended. 6–12 yr: 75 mg/day PO, titrate to a maximum of 150 mg/day. 13–16 yr: 150 mg/day PO; maximum dose, 300 mg. VOLUME- OR SALTDEPLETED PATIENTS

aldosterone, leading to decreased BP.

nephropathy in patients with hypertensio n and type 2 (non– insulindependent) diabetes Unlabeled use: CHF

lactation, pregnancy.

c: Rash, inflammation , urticaria, pruritus, alopecia, dry skin GI: Diarrhea, abdominal pain, nausea, constipation, dry mouth, dental pain Respiratory: URI symptoms, cough, sinus disorders

75 mg/day PO. Other: Cancer in preclinical studies, back pain, fever, gout, fatigue, neutropenia

and kidney function tests Interventions Administer without regard to meals. WARNING: Ensure that patient is not pregnant before beginning therapy; suggest using barrier birth control while using irbesartan; fetal injury and deaths have been reported. Find an alternative method of feeding the baby if giving drug to a nursing mother. Depression of the renin-angiotensin system in infants is potentially very dangerous. WARNING: Alert surgeon and mark patient's chart with notice

that irbesartan is being taken. The blockage of the renin-angiotensin system following surgery can produce problems. Hypotension may be reversed with volume expansion. Monitor patient closely in any situation that may lead to a decrease in BP secondary to reduction in fluid volume (excessive perspiration, dehydration, vomiting, diarrhea); excessive hypotension can occur.

3. Valsartan Diovan

•

ADULTS

80 mg PO daily; range 80–320 mg/day. Heart failure: Starting dose is 40 mg bid, titration to

Angiotensin II receptor blocker Antihypertensive Therapeutic actions Selectively blocks the binding of angiotensin II to specific tissue receptors found in

Treatment of hypertensio n, alone or in combination with other antihyperten sives

Contraindicated with hypersensitivity to valsartan, pregnancy (use during second or third trimester can cause injury or even death to

CNS: Headache, dizziness, syncope, muscle weakness CV: Hypotension

Assessment History: Hypersensitivity to valsartan; pregnancy, lactation; hepatic or renal dysfunction;

fetus), lactation. 80 mg and 160 mg bid should be done to the highest dose, as tolerated by the patient. Maximum daily dose is 320 mg daily given in divided doses. Concomitant use with an ACE inhibitor and a beta blocker is not recommended. •

PEDIATRIC PATIENTS

Safety and efficacy not established. •

PATIENTS WITH HEPATIC OR RENAL IMPAIRMENT

Exercise caution and monitor patient frequently.

the vascular smooth muscle and adrenal gland; this action blocks the vasoconstricting effect of the renin– angiotensin system as well as the release of aldosterone, leading to decreased BP; may prevent the vessel remodeling associated with the development of atherosclerosis.

hypovolemia Treatment of heart failure in patients who are intolerant of angiotensinconverting enzyme (ACE) inhibitors

Use cautiously with hepatic or renal dysfunction, hypovolemia.

Dermatologi c: Rash, inflammation , urticaria, pruritus, alopecia, dry skin GI: Diarrhea, abdominal pain, nausea, constipation, dry mouth, dental pain Respiratory: URI symptoms, cough, sinus disorders Other: Cancer in preclinical studies, back pain, fever, gout, hyperkalemia

Physical: Skin lesions, turgor; T; reflexes, affect; BP; R, respiratory auscultation; liver and renal function tests Interventions Administer without regard to meals. WARNING: Ensure that patient is not pregnant before beginning therapy; suggest using barrier birth control while using drug; fetal injury and deaths have been reported. Find alternative method of feeding infant if drug is being given to nursing mother. Depression of renin–angiotensin system in infants

is potentially very dangerous. WARNING: Alert surgeon and mark patient's chart that valsartan is being given. Blockage of renin– angiotensin system following surgery can produce problems. Hypotension may be reversed with volume expansion. Monitor patient closely in any situation that may lead to decrease in BP secondary to reduction in fluid volume— excessive perspiration, dehydration, vomiting, diarrhea —as excessive hypotension can occur. Calcium Channel Blockers

1. Felodipine

•

ADULTS

Calcium channelblocker

· Essential

· Contraindicated

· CNS: Dizziness,

Assessment

Antihypertensive Plendil, Renedil (CAN)

Initially, 5 mg PO daily; dosage may be gradually increased over 10–14 days. Usual dose is 2.5–10 mg PO daily. Doses greater than 10 mg PO daily are associated with an increased risk of peripheral edema. •

PEDIATRIC PATIENTS

Safety and efficacy not established. •

GERIATRIC PATIENTS OR PATIENTS WITH HEPATIC IMPAIRMENT

Monitor carefully; begin with 2.5 mg daily, and do not exceed 10 mg daily PO.

Therapeutic actions Inhibits the movement of calcium ions across the membranes of cardiac and vascular smooth muscle cells; greater selectivity for vascular smooth muscle as compared to cardiac muscle; leads to arterial and coronary artery vasodilation and decreased peripheral vascular resistance.

hypertensio n, alone or in combination with other antihyperten sives

with allergy to felodipine or other calcium channelblockers, sick sinus syndrome, heart block (second or third degree), lactation. · Use cautiously with pregnancy, impaired hepatic function.

lightheadedness, headache, asthenia, fatigue, lethargy · CV: Peripheral edema, arrhythmias · Dermatologic: Flushing, rash · GI: Nausea, abdominal discomfort, reflux, constipation

· History: Allergy to felodipine, impaired hepatic function, sick sinus syndrome, heart block, lactation, pregnancy · Physical: Skin lesions, color, edema; P, BP, baseline ECG, peripheral perfusion, auscultation, R, adventitious sounds; liver evaluation, GI normal output; liver function tests, urinalysis

Interventions · Have patient swallow tablet whole; do not chew or crush. · Monitor patient carefully (BP, cardiac rhythm and output) while drug is being

adjusted to therapeutic dose. · Monitor cardiac rhythm regularly during stabilization of dosage and periodically during long-term therapy. · Administer drug without regard to meals.

Vasodilators

1. Minoxidil Oral: Loniten, Minox (CAN) Topical: Minoxigaine (CAN), Rogaine, Rogaine Extra Strength

•

ADULTS AND PATIENTS > 12 YR

Oral · Monotherapy: Initial dosage is 2.5–5 mg/day PO as a single dose. Daily dosage can be increased to 10, 20, then 40 mg in single or divided doses. Effective range is usually 10– 40 mg/day PO.

Antihypertensive Vasodilator Therapeutic actions Acts directly on vascular smooth muscle to cause vasodilation, reducing elevated systolic and diastolic BP; does not interfere with CV reflexes; does not usually cause orthostatic hypotension but does cause reflex tachycardia and renin release, leading to sodium and water retention; mechanism in stimulating hair growth

· Severe hypertensio n that is symptomati c or associated with target organ damage and is not manageable with maximum therapeutic doses of a diuretic plus two other antihyperten sive drugs;

· Contraindicated with hypersensitivity to minoxidil or any component of the topical preparation (topical); pheochromocytoma (may stimulate release of catecholamines from tumor); acute MI; dissecting aortic aneurysm; lactation. · Use cautiously with malignant

· CNS: Fatigue, headache · CV: Tachycardia (unless given with betaadrenergic blocker or other sympatholyti c drug), pericardial effusion and tamponade; changes in direction and magnitude of T-waves;

Assessment · History: Hypersensitivit y to minoxidil or any component of the topical preparation; pheochromocyt oma; acute MI, dissecting aortic aneurysm; malignant hypertension; CHF; angina pectoris; lactation, pregnancy

Maximum dosage is 100 mg/day. If supine diastolic BP has been reduced less than 30 mm Hg, administer the drug only once a day. If reduced more than 30 mm Hg, divide the daily dosage into two equal parts. Dosage adjustment should normally be at least at 3-day intervals; in emergencies, q 6 hr with careful monitoring if possible. · Concomitant therapy with diuretics: Use minoxidil with a diuretic in patients relying on renal function for maintaining salt and water balance; the following diuretic dosages

is not known, possibly related to arterial dilation.

use in milder hypertensio n not recommend ed · Topical use (when compounde d as a 1%– 5% lotion or 1% ointment): Alopecia areata and male pattern alopecia

hypertension; CHF (use diuretic); angina pectoris (use a betablocker); pregnancy.

cardiac necrotic lesions (reported in patients with known ischemic heart disease, but risk of minoxidilassociated cardiac damage cannot be excluded) · Dermatologi c: Temporary edema, hypertrichosi s (elongation, thickening, and enhanced pigmentation of fine body hair occurring within 3–6 wk of starting therapy; usually first noticed on temples, between eyebrows and extending to other parts of face, back, arms, legs, scalp); rashes

· Physical: Skin color, lesions, hair, scalp; P, BP, orthostatic BP, supine BP, perfusion, edema, auscultation; bowel sounds, normal output; CBC with differential, kidney function tests, urinalysis, ECG Interventions · Apply topical preparation to affected area; if fingers are used to facilitate drug application, wash hands thoroughly afterward. · Do not apply other topical agents, including topical corticosteroids, retinoids, and petrolatum or agents known to enhance

have been used when starting minoxidil therapy: Hydrochlorothi azide, 50 mg bid; chlorthalidone, 50–100 mg daily; furosemide, 40 mg bid. If excessive salt and water retention result in weight gain > 5 lb, change diuretic therapy to furosemide; if patient already takes furosemide, increase dosage. · Concomitant therapy with beta-adrenergic blockers or other sympatholytics: The following dosages are recommended when starting minoxidil therapy: Propranolol, 80–160 mg/day ; other beta-

including bullous eruptions; StevensJohnson syndrome; darkening of the skin · GI: Nausea, vomiting · Hematologic : Initial decrease in Hct, Hgb, RBC count · Local: Irritant dermatitis, allergic contact dermatitis, eczema, pruritus, dry skin/scalp, flaking, alopecia (topical use) · Respiratory: Bronchitis, URI, sinusitis (topical use)

cutaneous drug absorption. · Do not apply topical preparation to open lesions or breaks in the skin, which could increase risk of systemic absorption. · Arrange to withdraw oral drug gradually, especially from children; rapid withdrawal may cause a sudden increase in BP (rebound hypertension has been reported in children, even with gradual withdrawal; use caution and monitor BP closely when withdrawing from children). · Arrange for echocardiograp hic evaluation of possible pericardial

blockers, dosage equivalent to the above; methyldopa 250–750 mg bid (start methyldopa at least 24 hr before minoxidil); clonidine, 0.1– 0.2 mg bid. Topical Apply 1 mL to the total affected areas of the scalp twice daily. The total daily dosage should not exceed 2 mL. Twice daily application for > 4 mo may be required before evidence of hair regrowth is observed. Once hair growth is realized, twice daily application is necessary for continued and additional hair regrowth. Balding process reported to return to untreated state 3–4 mo after cessation of the drug. •

PEDIATRIC PATIENTS <

effusion; more vigorous diuretic therapy, dialysis, other treatment (including minoxidil withdrawal) may be required.

12 YR Experience is limited, particularly in infants; use recommendations as a guide; careful adjustment is necessary. Initial dosage is 0.2 mg/kg/day PO as a single dose. May increase by 50%–100% increments until optimum BP control is achieved. Effective range is usually 0.25– 1 mg/kg/day; maximum dosage is 50 mg daily. Experience in children is limited; monitor carefully. GERIATRIC PATIENTS OR PATIENTS WITH IMPAIRED RENAL FUNCTION Smaller doses may be required; closely supervise to prevent cardiac failure or exacerbation of renal failure.

G. DRUGS FOR ELECTROLYTE IMBALANCES

Generic name, Brand name

Dosage/frequency and route

Indication, Action

Side effects

Nursing responsibilities

Dehydrosol® [sachet]

Dissolve 1 sachet into 1 L of water. Adult & older childn Drink as needed, childn 210 yr 100-200 mL, <2 yr 50-100 mL.

Treatment of dehydration due to diarrhea.

None specified

May be given with or without food

Cholyte Plus With Zinc® [sachet

Dehydration due to diarrhea 50-100 mL or 2-3 oz of the oral rehydration soln after each large watery stool for infant & childn.

Prevention & treatment of mild to moderate dehydration. Provides zinc for faster recovery from diarrhea

None specified

May be given with or without food

Source of K & Cl ions.

None specified

Contraindications -Untreated Addison's disease, heat cramps, acute dehydration, adynamia episodica hereditaria & hyperkalemia

Elin Potassium Chloride® [vial]

Elin Potassium Chloride® [vial]

Adult Plasma K level >2.5 mEq/L 10 mEq/hr-200 mEq/day, <2 mEq/L 40 mEq/hr400 mEq/day. Childn 3 mEq/kg:vol of soln proportional to body size. Acute hypokalemia Up to 100 mEq by slow IV infusion w/ ECG control at rate not >20 mEq/hr of a soln not >40 mEq/L. Adult Plasma K level >2.5 mEq/L 10 mEq/hr-200 mEq/day, <2 mEq/L 40 mEq/hr400 mEq/day. Childn 3

Special Precautions- Cardiac or renal diseases.

Source of K & Cl ions.

None specified

Contraindications- Untreated Addison's disease, heat cramps, acute dehydration, adynamia episodica hereditaria & hyperkalemia. Special Precautions- Cardiac or renal diseases

Glucost® [sachet]

Deficit therapy Dissolve 2 packs in 200 mL of water. Mild dehydration Adult & childn 30 mL/kg. Infant ≤2 yr 50 mL/kg. Moderate dehydration Childn 60 mL/kg. Infant 100 mL/kg. To be given w/in 46 hr. Maintenance: Dissolve 1 pack in 200 mL of water. Adult & childn 60 mL/kg/day. Infant 100 mL/kg/day. To be given w/in the next 24 hr. Active replacement therapy Adult 200

Electrolyte replenisher

None specified

May be given with or without food

mL. Childn 100 mL. Infant 50 mL

Hospira Sodium Bicarbonate® [vial]

Cardiac arrest Rapid IV Adult 200-300 mEq. IV Infant up to 2 yr 4.2% soln. Max: 8 mEq/kg/day. Less urgent forms of metabolic acidosis Adult & older childn Initially 2-5 mEq/kg body wt over 4-8 hr period, depending upon the severity.

Treatment of metabolic acidosis.

Chemical cellulitis because of alkalinity. Tissue necrosis, ulceration or sloughing at the site of infiltration

Contraindications- Patients who are losing Cl by vomiting or from continuous GI suction. Patients receiving diuretics Special Precautions- Patients w/ CHF, severe renal insufficiency, edema w/ Na retention, oliguria, anuria. Patients receiving corticosteroids or corticotropin. Rapid inj of hypertonic soln into neonates & childn <2 yr may produce hypernatremia, decrease in CSF & possible intracranial hemorrhage. Diminished renal function. Extravascular infiltration. Pregnancy.

Hydrite® [tab]

Tab Reconstitute in water as follows: Deficit therapy (upon recognition of dehydration) 2 tab/200 mL. Active replacement therapy (to replenish on going losses at the start of a diarrheal episode or when diarrhea continues after deficit therapy) 1 tab/200 mL. Maintenance therapy or for replacement of fluid & electrolyte losses associated w/ vigorous exercise & athletics 1 tab/200 mL. Vol (mL) of soln requirement/day: Mild dehydration Adult & childn 30 mL/kg. Infant <2 yr 50 mL/kg. Moderate dehydration Childn 60 mL/kg, infant 100 mL/kg. Granules Dissolve 1 sachet in every 200 mL water. Prevention of dehydration w/in the 1st 4 hr Childn <2 yr ½-¼ glass (50100 mL), 2-10 yr ½-1 glass (100-200 mL), >10 yr As much fluid as they want. Treatment of

Treatment of childn & adults w/ dehydration due to diarrhea. Replaces fluid & electrolytes lost due to diarrhea & vomiting.

None specified

May be given with or without food

Ion-O-Trate Potassium Chloride® [inj]

dehydration <4 mth or <5 kg 1-2 glasses (200-400 mL), 4-11 mth or 5-7.9 kg 2-3 glasses (400-600 mL), 12-23 mth or 810.9 kg 3-4 glasses (600-800 mL), 2-4 yr or 11-15.9 kg 4-6 glasses (800-1200 mL), 5-14 yr or 1629.9 kg 6-11 glasses (1200-2200 mL), ≥15 yr or ≥30 kg 11-20 glasses (2200-4000 mL). Individualised dosage

Treatment of K states when oral replacement therapy is not feasible

None specified Contraindications- Diseases where high K levels may be encountered. Special Precautions- Cardiac disease, pain in digitalized patients or in presence of renal disease

Kalimate® [powd]

Adult 15-30 g PO bid-tid, or 30 g by rectal route suspended in 100 mL water or 2% methylcellulose soln & left in the intestinal tract for 30 min-1 hr. Childn Acute Hyperkalemia: 1 g/kg body wt. daily in divided doses. Maintenance Therapy: 0.5 g/kg body wt daily in divided doses

Prevention & treatment of hyperkalemia resulting from acute or chronic renal failure.

Constipation, anorexia & nausea. Hypopotassemia.

Special Precautions- Careful administration in patients with hyperparathyroidism (blood concentration of calcium may be increased by ion exchange) and patients with multiple myeloma (blood concentration of calcium may be increased by ion exchange). Important: Kalimate should be administered while measuring the serum potassium and serum calcium levels regularly to prevent overdose. If any abnormal findings are observed, appropriate measures eg, reduction of dose or withdrawal of the drug should be taken. Others: It has been reported that the oral administration of sorbitol suspension of calcium polystyrene sulfonate may cause colon necrosis, colon ulcer, etc. Use in pregnancy & lactation: The safety of Kalimate in pregnant women has not been established. Use in the elderly: Since elderly patients often have reduced physiological function, careful supervision and measures eg, reducing dose are recommended. Cautions For Usage- Oral: It has been reported that the oral administration of sorbitol suspension of a similar drug (sodium polystyrene sulfonate) may cause perforation in the intestine, necrosis in mucous membrane of intestine, large intestine ulcer, colon necrosis, etc. Rectal: Animal studies (rat) have shown that the administration of sorbitol via the rectal route may cause intestinal necrosis. It

has also been reported outside Japan that the administration via rectal route of sorbitol suspension of a cation exchange resin of polystyrene sulfonate type may cause colon necrosis. In case of the administration via rectal route, sorbitol solution should not be used.

Kalium® [durule]

Adults & elderly Prophylaxis 2 durules daily. Hypokalemia Adjust dosage according to serum K level. Suggested dose: 2 durules bid or more until serum K is restored to normal, then prophylactic dosage.

Hypokalemia. Prophylaxis during treatment w/ diuretics.

None specified Contraindications- Renal insufficiency, hyperkalemia, untreated Addison's disease, constriction of the esophagus &/or obstructive changes in the alimentary tract. Special Precautions- Obstructive changes in the alimentary tract, stricture of the esophagus. Heart/kidney disease. Pregnancy & lactation. Should be taken with food (Swallow whole w/ 1/2 glass of liqd, do not break/chew/crush. Do not administer to a patient in a supine position.).

Oralite® [sachet]

Adult 200-400 mL for every loose motion. Childn 200 mL for every loose motion. Infant 1-1.5 mL times the usual feeding vol. Continue breastfeeding.

Oral replacement of electrolytes & fluids in patients w/ dehydration, particularly that associated w/ acute diarrhea of various etiologies.

Vomiting. Hypernatremia/overhydration, hypernatremia/hyperkalemia in patient w/ renal impairment

Contraindications- GI obstruction, oliguric/anuric renal failure. When parenteral rehydration is indicated in severe dehydration intractable vomiting.

Oreges® [sachet]

Dissolve 7 g powd to prepare a 250 mL soln. Mild to moderate dehydration Adult & childn >3 yr 1-2 L or 4-8 sachets, childn 1-3 yr 500 mL-1 L or 2-4 sachets, 1 mth-1 yr 250-500 mL or 1-2 sachets

Oral replacement of fluid & electrolyte loss & for the prevention of dehydration due to vomiting & acute diarrheal diseases.

None specified

May be given with or without food

Orhydrate® [syr]

Dilute 60 mL in 940 mL of water to prepare 1 L of soln. Dehydration due to diarrhea Adult & older childn 1-2 L. Childn 1-3 yr or 10-15 kg 0.5-1 L, 1 mth-1 yr or 3-10 kg 0.25-0.5 L. To be taken 2-4 oz (60-120 mL) after each watery stool. To be consumed w/in 24 hr after dilution.

Oral replacement of fluid & electrolytes in dehydrating conditions eg acute diarrhea, dengue fever & excessive sweating.

None specified

May be given with or without food

Pedialyte® [-45 soln]

Individualized dosage

Prevention of dehydration & maintenance of normal fluid electrolyte balance in mild to moderate diarrhea.

None specified Contraindications- Intractable vomiting, adynamic ileus, intestinal obstruction, bowel perforation. Special Precautions- Impaired renal function May be given with or without food

Pedialyte Mild 30® [soln]

Total daily intake should be adjusted based on individual needs.

To supplement fluid & electrolyte loss due to active play, prolonged sun exposure, hot & humid environment

None specified

May be given with or without food Special Precautions- Not for the treatment of acute diarrhea in childn.

Pedialyte® [-90 soln] Abbott [ Zuellig ]

Individualized dosage

Prevention of dehydration & maintenance of normal fluid electrolyte balance in mild to moderate diarrhea.

None specified Contraindications- Intractable vomiting, adynamic ileus, intestinal obstruction, bowel perforation Special Precautions- Impaired renal function May be given with or without food

Phil Pharmawealth/Atlantic Potassium Chloride® [amp]

1-3 g daily by slow IV infusion

Treatment of hypokalemia & Kdeficiency states

None specified

Special Precautions- Direct inj of KCl conc intended for dilution before use may cause instant death. Contraindications- Severe renal impairment, oliguria, anuria, azotemia, untreated adrenal cortical hypofunction, heat cramps & hypokalemia from any cause.

Phil Pharmawealth/Harson Calcium Gluconate® [amp]

Adult 5-20 mL by slow IV. Childn 500 mg/kg/day or 12 g/m2/day by slow IV.

Treatment of Ca deficiencies due to tetany, hypoparathyroidism, rapid growth or pregnancy. Treatment of black widow spider bites; adjunct in treatment of rickets, osteomalacia, lead colic & Mg sulfate overdosage; decrease capillary permeability in allergic conditions, nonthrombocytopenic purpura & exudative dermatoses; aid in antagonizing cardiac toxicity associated w/ hyperkalemia provided patient is not on digitalis.

Tingling sensation, sense of oppression or heat waves, chalky taste. Rapid IV: Vasodilation, decreased BP, bradycardia, cardiac arrhythmias, syncope & cardiac arrest. IM inj: Local necrosis, abscess formation

Special Precautions- Use in digitalized patients may precipitate arrhythmias

Phil Pharmawealth/Harson Sodium Bicarbonate® [amp]

Quantity to be infused IV is determined by blood gas value & by the following formula: Vol required (mL) = -ve base excess x kg body wt x 0.3 (proportion of extracellular fluid in relation to body fluid). Infusion rate: 20-40 drops/min or 60120 mL/hr.

Severe metabolic acidosis, lactic acidosis; rapid urine alkalinisation

None specified

Contraindications- Resp & metabolic acidosis, hypoventilation, hypernatremia, cardiac insufficiency, edema, HTN, eclampsia, renal impairment.

Philusa Sodium Chloride® [tab]

1 tab tid.

Prevention & treatment of heat cramps that result under conditions of intense perspiration. Occupations where excessive sweating is a factor, to compensate for the excessive NaCl loss

None specified

Should be taken with food

Sodalite® [sachet]

Dissolve contents in 200 mL cooled boiled water. Adult 1-2 glasses. Childn <2 yr ½ glass.

Treatment of dehydration due to diarrhea

None specified

None specified

Zinbee® [chewable tab]

Chewable tab >14 yr 1 tab, 913 yr ¾ tab, 4-8 yr ½ tab, 1-3 yr ¼ tab. Syr Childn 1-10 yr 5 mL, infants 6-12 mth 2.5 mL, 0-6 mth 1.5 mL.

Nutritional supplement to improve appetite, wt gain, height increase, resistance to infection & other clinical manifestations of Zn deficiency

Acute toxicity may cause diarrhea, vomiting & lethargy.

May be taken with or without food (Best taken at least 1 hr before or 2 hr after meals. May be taken w/ meals to reduce GI discomfort.). Special Precautions- Chronic administration equiv to 10x RDA can cause anemia due to concomitant copper deficiency & may depress plasma HDL cholesterol levels.

Hematopoietic Growth Factors Hematopoietic growth factors are a family of glycoproteins with important regulatory functions in the processes of proliferation, differentiation, and functional activation of hematopoietic progenitors and mature blood cells. Hematopoietic growth factors include erythropoietin, the colony-stimulating factors (CSFs), various interleukins (IL-1 to IL-13), stem-cell factor, newly described thrombopoietin (c-Mpl ligand) [4], and flt-2/flk3, a growth factor for early progenitor cells. The CSFs include granulocyte CSF (G-CSF, filgrastim [Neupogen®, Amgen Inc., Thousand Oaks, CA]), granulocyte-macrophage CSF (GM-CSF, sargramostim [Leukine®, Berlex Laboratories, Richmond, CA]), multipotential CSF (multi-CSF, also known as IL-3), and monocyte macrophage CSF (M-CSF, also known as CSF-1).

Hematopoietic Growth Factors and Their Targets Factor

Target

Interleukin-1

Induces other growth factors

Interleukin-2

T-cell growth factor

Interleukin-3 (multi-CSF)

Multipotent progenitors

Interleukin-4

B-cell growth factor

Interleukin-5

Eosinophil differentiation factor

Interleukin-6

B-/T-cell growth and differentiation; megakaryocytes

Interleukin-7

B-/T-cell precursor growth

Interleukin-8

Neutrophil chemotactic factor

Interleukin-9

T-cell growth factor; megakaryocytes and burst-forming unitserythrocytes

Interleukin-10

Cytokine synthesis inhibition in natural-liller (NK) and T-cells

Interleukin-11

B-cells, multipotent progenitors, and megakaryocyte growth

Interelukin-12

Stimulates natural-killer and cytotoxic T-cells

Granulocyte colony-stimulating factor (G-CSF)

Neutrophil growth and activation

Granulocyte-macrophage colony-stimulating factor (GM-CSF)

Growth and activation of neutrophils and macrophages

Erythropoietin

Erythroid growth and differentiation

SCF (c-kit ligand)

Stem-cell factor

Thrombopoietin

Thrombopoiesis

H. HEMATOPOIETIC GROWTH FACTOR

Generic Name / Brand Name Epoetion alfa (erythropoietin) / Epogen, Eprex, Procrit

Indication Dosage/Frequency and Route Anemia caused by chronic renal failure Adults: dosage is individualized. Starting dose is 50 to 100 units/kg subcutaneously or IV three times weekly. Maintenance dosage is highly individualized. Anemia from zidovudine therapy in HIV-infected patients Adults: initially, 100 units/kg IV or subcutaneously three times weekly for 8 weeks or until target haemoglobin level is reached. If response isn’t satisfactory after 8 weeks, increase dosage by 50 to 100 units/kg IV or subcutaneously three times weekly. After 4 to 8 weeks, further increase dosage in increments of 50 to 100 units/kg three times weekly, up to maximum of 300 units/kg IV or subcutaneously three times weekly. Anemia from chemotherapy Adults: initially, 150 units/kg subcutaneously three times weekly for 8 weeks or until target haemoglobin level is

Action Mimics effects of erythropoietin. Functions as growth factor and as a differentiating factor, enhancing RBC production.

Side Effects •

•

• • • • • •

Seizures, dizziness, fatigue, fever, headache, asthenia. edema, hypertension, increased clotting of anteriovenous grafts Nausea, vomiting, diarrhea Hyperkalemia, hyperphosphatemi a Arthraglia cough, shortness of breath infection, rash, pyrexia

Nursing Responsisbilities •

•

• •

• •

Before starting therapy, evaluate patient’s iron status. Patient should receive adequate iron supplementation beginning no later than when epoetin alfa treatment starts and continuing throughout therapy. Patient also may need vitamin B12 and folic acid. Monitor blood pressure before therapy. Most patients with chronic renal failure have hypertension. Blood pressure may increase, especially when hematocrit increases in the early part of therapy. Institute diet restrictions or drug therapy to control blood pressure. Monitor haemoglobin level twice weekly until it stabilizes in the target range (10 to 12 g/dl for most patients) and maintenance dose is established, then continue to monitor at regular intervals. Resume twice weekly testing following any dosage adjustments. Monitor blood counts; elevated hematocrit may cause excessive clotting. Patient may need additional heparin to prevent clotting during dialysis treatments.

reached. If response isn’t satisfactory after 8 weeks, increase dosage up to 300 units/kg subcutaneously three times weekly. Or, 40,000 units subcutaneously once weekly. If haemoglobin level hasn’t increased by at least 1g/dl (in the absence of RBC transfusion), increase dose to 60,000 units weekly.

Filgastrim (G-CSF; granulocyte-colony stimulating factor) / Neupogen

To decrease risk of infection in patients with non-myeloid malignant disease receiving myelosuppressive antineoplastics Adults and children: 5mcg/kg daily IV or subcutaneously as single dose given no sooner than 24 hours after cytotoxic chemotherapy. Doses may be increased in increments of 5mcg/kg for each chemotherapy cycle depending on duration and severity of the nadir of absolute neutrophil count (ANC). Idiopathic or cyclic neutropenia Adults: 5mcg/kg subcutaneously daily. Adjust dosage based on patient

A glycoprotein stimulates proliferation and differentiation of hemapoetic cells. Is specific for neutrophils.

• • • •

• • • • •

Fever, headache, weakness, fatigue MI, arrhythmias, chest pain, hypotension Nausea, vomiting, diarrhea, mucositis, stomatitis, constipation Hyperuricemia Bone pain Dyspnea, cough Alopecia, rash, cutaneous vasculitis Hypersensitivity reactions

•

•

•

Obtain baseline CBC and platelet count before therapy. Once a dose is withdrawn, don’t reuse vial. Discard unused portion. Vials are for single-dose use and contain no preservatives. Obtain CBC and platelet count two to three times weekly during therapy. Patients who receive drug also may receive high doses of chemotherapy, which may increase risk of toxicities. A transiently increased neutrophil count is common 1 or 2 days after therapy starts. Give daily for up to 2 weeks or until ANC has returned to 10,000/mm3 after the expected chemotherapy-induced neutrophil nadir.

response. Peripheral blood progenitor cell collection and therapy in cancer patients Adults: 10 mcg/kg subcutaneously daily. Give 4 days before leukapheresis and continue until last leukapheresis.

Oprelvekin / Neumega

To prevent severe thrombocytopenia and reduce need for platelet transfusions after myelosuppressive chemotherapy with nonmyeloid malignancies Adults: 50 mcg/kg as single daily subcutaneous injection until postnadir platelet count is at least 50,000/mm3. treatment beyond 21 days per course isn’t recommended.

Directly stimulates proliferation of hemapoietic stem cells and megakaryocyte progenitor cells. Also induces megakaryocyte maturation, resulting in increased platelet production.

• • •

•

•

•

Asthenia, fever, headache, insomnia, dizziness, syncope Atrial flutter or fibrillation, tachycardia, palpitations, edema Conjunctival infection, blurred vision, hemorrhage, pharyngitis Oral candidiasis,

•

• • • •

Give subcutaneously in the abdomen, thigh, hip, or upper arm. Don’t inject ID or intravascularly. Dosing should begin 6 to 24 hours after completing chemotherapy and end at least 2 days before starting next cycle of chemotherapy. Reconstitute each single-dose vial with 1 ml of supplied diluent. Avoid excessive or vigorous agitation. Discard unused portions. Use reconstituted drug within 3 hours. Store drug and diluent in refrigerator until ready to use. Don’t freeze. Closely monitor fluid and electrolyte status in patients receiving long-term diuretic therapy. Obtain a CBC before chemotherapy and at regular intervals during drug therapy.

• • • Sagramostim (GMCSF; granulocyte macrophagecolony stimulating factor) / Leukine

To accelerate hematopoietic reconstitution after autologous or allogenic bone marrow transplantation in patients with malignant lymphoma or acute lymphoblastic leukaemia or in patients with Hodgkin lymphoma Adults: 250mcg/m2 daily given as 2-hour IV infusion beginning 2 to 4 hours after bone marrow transplantation. Continue until absolute neutrophil count (ANC) is more than 1,500/mm3 for 3 consecutive days. Neutrophil recovery following chemotherapy in acute myelogenous leukaemia Adults 55 years and older: initially, 250 mcg/m2 IV once daily over 4 hours beginning day 11 or 4 days following completion of induction therapy; initiate only if bone marrow is hypoplastic with less than 5% blasts on day 10. if a second induction cycle is needed, begin

Binds to specific receptors on cell surfaces of target cells.

•

nausea, vomiting, diarrhea Anemia Dehydration, hypocalcemia Dyspnea, cough, pleural effusions Rash, skin discoloration, exfoliative dermatitis

•

Fluid retention can be severe; monitor patient closely.

•

If severe adverse reactions occur, reduce dose by 50% or temporarily stop drug and notify prescriber. Resume therapy when reactions decrease. Rapidly dividing progenitor cells may be sensitive to cytotoxic therapies, making the drug ineffective; don’t give within 24 hours of last dose of chemotherapy or within 12 hours of last dose of radiotherapy. If giving as subcutaneous injection, further dilution of injection or reconstituted solution isn’t needed. Monitor CBC with differential, including examinations for presence of blast cells, biweekly.

•

• •

•

• •

Asthenia, CNS disorders, fever, headache, malaise Hemorrhage, blood dyscrasias, edema, hypertension, supraventricular arrythmias, pericardial effusion Anorexia, diarrhea, GI disorders, nausea, vomiting, stomatitis, GI hemorrhage Abdominal kidney function, urinary tract disorders Liver damage

• •

sargramostim 4 days after completing chemotherapy and only if bone marrow is hypoplastic with less than 5% blasts. Continue until the ANC is more than 1,500/mm3 for 3 consecutive days or for a maximum of 42 days. Mobilization of peripheral blood progenitor cells (PBCP) Adults: give 250 mcg/m2 by continuous IV infusion over 24 hours or by subcutaneous injection once daily. Continue through PBCP collection. Post-PBCP transplantation Adults: give 250 mcg/m2 by continuous IV infusion over 24 hours or by subcutaneous injection once daily beginning immediately following PBCP infusion; continue until ANC more than 1,500/mm3 for 3 consecutive days. Bone marrow transplantation failure or engraftment delay Adults: 250mcg/m2 as a 2hour IV infusion daily for 14 days. This course of therapy may be repeated after 7 days of no therapy. If engraftment

•

athralgias

still hasn’t occurred, a third course of 500 mcg/m2 daily /iv for 14 days may be attempted after another therapy-free 7 days.

I.DRUGS USE FOR ANEMIA ERYTHROPOIETINS -patients who are no longer able to produce erythropoeitin in the kidney s may benefit from the treatment with erythropoeitin (EPO). Drug Name

Dosage/ Frequency and Route

Darbapoetin alfa (aranesp)

0.45mcg/kg IV or Sub Q once per week; 2.25 mcg/kg/wk Sub Q (with chemotherapy)

Epoetin alfa (epogen)

Indications

Actions

Treatment of anemia Stimulates the production of associated with chronic RBC in the bone marrow renal failure, including dialysis patients; treatment of chemotherapy-induced anemia

50-100 units/kg IV or SQ 3 Treatment of anemia times per week; 300 units/ associated with renal kg/day SQ for 15 days failure; reduction in need (reduction of need for blood for transfusions in surgical transfusions) patients ; treatment of anemia associated with AIDS therapy

Not indicated

Side Effects Head ache fatigue asthenia dizziness seizures

Headache, hypertension and seizures. Hypertensive crisis with encephalopathylike symptoms; thrombosis at vascular access sites and clotting in the dialyser. Transient increases in the platelet count. Flu-like symptoms including chills and myalgia; hyperkalaemia and skin rashes; anaphylactoid reactions. Rarely, pure red cell aplasia after prolonged treatment in patients with prolonged renal failure.

IRON PREPARATIONS Drug Name Ferrous fumarate (feostat) ferrous gluconate (fergon)

Dosage/ Frequency and Route

Indications

Actions

Side Effects

100-200 mg/day PO Treatment of Iron deficiency Children 2-12 years old: 50Anemia 100mg/day PO 6,os-2 years old :6mg/kg/day PO Infants: 10-25 mg/day PO

Not indicated

GI disturbances, nausea, abdominal pain, vomiting, diarrhea, constipation.

Mg iron =0.3 x (wt. In lb) x Parenteral treatment of IDA ((100-(hemoglobin in g/dl) x 100)/14.8) given IM using Ztrack

Not indicated

Adverse effects may be delayed 24-48 hr after IV admin or 3-4 days after IM admin. Flushing, dizziness, fever, chills, nausea, headache, diaphoresis. Chest pain or tightness, shock, MI, hypertension, tachycardia, bradycardia and arrhythmias. Local reactions, pain and staining may occur at the site of inj after IM inj. Potentially Fatal: Severe anaphylactoid reactions.

Ferrous sulfate (Feosol) Ferrous sulfate exsiccated (ferralyn lanacaps, Slow FE) Iron Dextran (InFeD)

Iron Sucrose (Venofer)

100mg one to three times Treatment of ISA in patients per week given IV during undergoing chronic dialysis sessions, slowly over hemodialysis or nondialysis 1 min patients with renal failure who are also receiving supplemental erythropoeitin therapy

Not indicated

Sodium ferric gluconate complex (ferriecit)

10 ml diluted in 100 ml 0.9 Treatment of IDA in patients % NaCl for injection over undergoing chronic 60 min; initially 8 doses hemodialysis who are also given at separate dialysis receiving supplemental sessions , then give erythorpoeitin therapy periodically to maintain hematocrit

Not indicated

Hypotension, chest pain, HTN, hypervolemia, CHF, cramps, musculoskeletal pain, diarrhea, nausea, vomiting, abdominal pain, elevated liver enzymes, skin irritation, pruritus, application site reaction, dizziness, dyspnea, pneumonia, cough, headache, fever, asthenia, malaise. Not indicated

Actions

Side Effects

FOLIC ACID DERRIVATIVES Drug Name

Dosage/ Frequency and Route

Indications

Folic acid (folvite)

1mg /day PO IM, SQ or IV Replacement of therapy and treatment of megaloblastic anemia

Not indicated

Not indicated

Leucovorin (wellcovarin)

1 mg/day IM for Replacement of therapy and replacement; 12-15g/m2 PO treatment of megaloblastic then 10g/m2 PO q6h for 72 anemia; rescue after hours for rescue chemotherapy

Not indicated

Not indicated