Renal Medications

IV. RENAL MEDICATIONS

A. ANTIINFECTIVES/ANTISEPTICS

Generic Brand/Trade Name

Dosage/Frequency and Route

Indication Action Side effects Nursing Responsibilities

Nitrofurantoin Microdantin OralAcute uncomplicated urinary tract infectionsAdult: 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.OralProphylaxis of uncomplicated UTIAdult: 50-100 mg at bedtime.Child: >3 mth and older children: 1 mg/kg once daily.

- 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, vertigoDermatologic: Exfoliative dermatitis, Stevens-Johnson syndrome, alopecia, pruritus, urticartia, angioedemaGI: Nausea, abdominal cramps, vomiting, diarrhea, anorexia, parotitis, pancreatitis, hepatotoxicityHematologic: Hemolytic anemia in G6PD deficiency; granulocytopenia, agranulocytosis, leukopenia, thrombocytopenia, eosinophilia, megaloblastic anemiaRespiratory: Pulmonary hypersensitivityOther: Superinfections of the GU tract; hypotension; muscular aches;

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).

Report fever, chills, cough, chest pain, difficulty

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 breathing, rash, numbness or tingling of the fingers or toes.




Sulfonamides 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.

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 anemiaIntegumentary: Photosensitivity, exfoliative dermatitis, Stevens-Johnson syndrome, epidermal necrolysis, hypersensitivity reactionsGI: Nausea, vomiting, diarrhea, pancreatitisOthers: 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.

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.




Fluroquinolones 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 PatientNot recommended; produced lesions of joint cartilage in immature experimental animals.

- 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 using germ warfare)- Unlabeled use:

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

CNS: Headache, dizziness, insomnia, fatigue, somnolence, depression, blurred visionCV: Arrhythmias, hypotension, anginaEENT: Dry eye, eye pain, keratopathyGI: Nausea, vomiting, dry mouth, diarrhea, abdominal painHematologic: Elevated BUN, AST, ALT, serum creatinine and alkaline phosphatase; decreased WBC, neutrophil count, HctOther: Fever, rash

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.

- 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 FunctionFor 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.

Effective in patients with cystic fibrosis who have pulmonary exacerbations

B. ANALGESICS/NSAIDS




Celecoxib Celebrex AdultInitially, 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 PatientSafety and efficacy have not been established.Patients with Hepatic ImpairmentReduce dosage by 50%.

- Acute and long-term 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 anti-inflammatory 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 effectsDermatologic: Rash, pruritus, sweating, dry mucous membranes, stomatitisGI: Nausea, abdominal pain, dyspepsia, flatulence, GI bleedHematologic: Neutropenia, eosinophilia, leukopenia, pancytopenia, thrombocytopenia, agranulocytosis, granulocytopenia, aplastic anemia, decreased Other: Peripheral edema, anaphylactoid reactions to anaphylactic shock

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.




Meloxicam Mobic AdultsStarting dose, 7.5 mg PO daily. Maximum dosage, 15 mg PO daily.Pediatric PatientSafety and efficacy not established

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 effectsDermatologic: Rash, pruritus, sweating, dry mucous membranes, stomatitisGI: Nausea, dyspepsia, GI pain, diarrhea, vomiting, constipation, flatulenceGU: Dysuria, renal impairmentRespiratory: Dyspnea, hemoptysis, pharyngitis, bronchospasm, rhinitisOther: Peripheral edema, anaphylactoid reactions to anaphylactic shock

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.




Naproxen Naprelan Adults- Rheumatoid arthritis or osteoarthritis, ankylosing spondylitis:Delayed-release (EC-Naprosyn)375–500 mg PO bid.Controlled-release (Naprelan)750–1,000 mg PO daily.Naproxen sodium275–550 mg bid PO. May increase to 1.65 g/day for a limited period.Naproxen tablets250–500 mg PO bid.- Acute gout:Controlled-release (Naprelan)1,000–1,500 mg PO daily.Naproxen sodium825 mg PO followed by 275 mg q 8 hr until the attack subsides.Naproxen750 mg, followed by 250 mg q 8 hr until attack subsides.- Mild to moderate pain:Controlled-release (Naprelan)1,000 mg PO daily.Naproxen sodium

- 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, anti-inflammatory, 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 effectsDermatologic: Rash, pruritus, sweating, dry mucous membranes, stomatitisGI: Nausea, dyspepsia, GI pain, diarrhea, vomiting, constipation, flatulenceGU: Dysuria, renal impairment, including renal failure, interstitial nephritis, hematuriaHematologic: Bleeding, platelet inhibition with higher doses, neutropenia, eosinophilia, leukopenia, pancytopenia, thrombocytopenia, agranulocytosis, granulocytopenia, aplastic anemia, decreased Hgb or Hct, bone marrow depression, menorrhagiaRespiratory: Dyspnea,

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

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:Naproxen10 mg/kg/day given in two divided doses. Naproxen sodiumSafety and efficacy not established.OTCDo not give to children < 12 yr unless under advice of physician.Geriatric PatientsDo not take > 200 mg q 12 hr PO.

hemoptysis, pharyngitis, bronchospasm, rhinitisOther: Peripheral edema, anaphylactoid reactions to anaphylactic shock




Valdecoxib Bextra Adults- Osteoarthritis and rheumatoid arthritis: 10 mg/day PO.- Primary dysmenorrhea: 20 mg PO bid as needed.Pediatric PatientSafety and efficacy not established in patients < 18 yr.

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

Analgesic and anti-inflammatory 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, anxietyCV: Arrhythmia, hypertension, CHF, hypotension, edemaDermatologic: Rash, pruritus, sweating, Stevens-Johnson syndrome, toxic epidermal necrolysis, dry mucous membranes, urticaria, exfoliative dermatitis, erythema multiformeGI: Abdominal pain, diarrhea, dyspepsia, nausea, flatulence, hemorrhoids, abdominal fullnessRespiratory: URI, sinusitis, coughing, dyspnea, rhinitisOther: Back pain, myalgia, anaphylaxis, angioedema

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 DOSAGE/FREQUENCY AND

ROUTE

INDICATION ACTION SIDE EFFECTS NURSING RESPONSIBILITIES

Generic name:bethanechol chloride

Brand Name:Duvoid

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.

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

CNS: headache, malaiseCV: bradycardia, flushingEENT: lacrimation, miosisGI: abdominal cramps, diarrhea, excessive salivation, nausea, belchingGU: urinary urgencyRespiratory: bronchoconstriction, increased bronchial secretionsSkin: diaphoresis

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-CHOLINERGICSDRUG DOSAGE AND

ROUTEINDICATION ACTION SIDE EFFECTS NURSING

RESPONSIBILITIES

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

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.

Inhibitor of crystallization.

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

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.

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DRUG DOSAGE, ROUTE and INDICATION

ACTION SIDE EFFECTS NURSING RESPONSIBILITIES

Generic Name:atropine

Brand Name:Sal-Tropine

IntravenousBradycardiaAdult: 500 mcg every 3-5 minutes. Total: 3 mg. Max Dosage: 0.04 mg/kg body weight.ParenteralPremedication in balanced anaesthesiaAdult: 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; 7-9 kg: 200 mcg; >3 kg: 100 mcg. Doses to be given via IM/SC admin 30-60 minutes before anaesthesia. ParenteralOrganophosphorus poisoningAdult: 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 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.

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.

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.




ParenteralOverdosage with other compounds having muscarinic actionsAdult: 0.6-1 mg IV/IM/SC, repeated every 2 hr.OphthalmicInflammatory eye disorders e.g. uveitis or iritisAdult: 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.OphthalmicEye refractionAdult: 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

Dosage/Frequency

Classification Indication Contraindication Side Effects Nursing Responsibilities

1. Oxybutynin Chloride

Apo-Oxybutynin (CAN), Ditropan, Ditropan XL, Novo-Oxybutynin (CAN), Oxytrol

ADULTS

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.

Urinary Antispasmodic

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.

Relief of symptoms 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)

Contraindicated 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.

CNS: Drowsiness, 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

Assessment

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,

environmental temperatures secondary to loss of sweating

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

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

Antimuscarinic

Therapeutic actions

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

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

IMPAIRMENT

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

retention; impotence, UTIs

Other: Weight gain, pain, fatigue, acute myopia and secondary angle closure glaucoma (pain, visual changes, redness, increased IOP)

palpation; IOP, vision; liver function tests; renal function tests; skin color, lesions, texture; 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

ADULTS < 75 YR

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

Antimuscarinic

Antispasmodic

Therapeutic actions

Urinary incontinence, urgency, and frequency caused by

Contraindicated with allergy to trospium or any component of the drug; presence of

CNS: Headache, dry eyes, dizziness, blurred vision

GI: Dry

Assessment

History: Allergy to trospium or any component of the

ADULTS > 75 YR

Monitor patient response and adjust dosage down to 20 mg/day.

PEDIATRIC PATIENTS


PATIENTS WITH RENAL IMPAIRMENT

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

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

overactive bladder

or risk for urinary retention, gastric retention, uncontrolled narrow-angle glaucoma.

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

mouth, constipation, abdominal pain, dyspepsia, flatulence, vomiting

GU: Urinary retention

Other: Fatigue, decreased sweating

drug; presence of or risk for urinary retention, gastric retention, uncontrolled narrow-angle 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 Name/Brand Name

Dosage/Frequency

Classification Indication Contraindication Side Effects Nursing Responsibilities

A. Angiotensin-Converting Enzyme Inhibitor

1. Benazepril Hydrochloride

Lotensin

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


PATIENTS WITH RENAL IMPAIRMENT

For creatinine clearance < 30 mL/min/1.73 m2

Antihypertensive

Angiotensin-converting 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.

Treatment of hypertension alone or in combination with thiazide-type diuretics

Contraindicated with allergy to benazepril or other ACE inhibitors, second or third trimester of pregnancy.

Use cautiously with impaired renal function, immunosuppresion, CHF, hypotension, salt or volume depletion, lactation, pregnancy.

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

Dermatologic: Rash, pruritus, diaphoresis, flushing

GI: Nausea, abdominal pain, vomiting, constipation

Respiratory: Cough, asthma, bronchitis, dyspnea, sinusitis

Other: Angioedema,

Assessment

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

(serum creatinine > 3 mg/dL), 5 mg PO daily. Dosage may be gradually increased until BP is controlled, up to a maximum of 40 mg/day.

impotence, decreased libido, asthenia, myalgia, arthralgia

Interventions

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

Vasotec

ADULTS

Oral

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

AntihypertensiveACE 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 adrenals; both of these actions increase BP.

Treatment of hypertension alone or in combination with other antihypertensives, especially thiazide-type diuretics

Treatment of acute and chronic

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 volume-depleted patients

GI: Gastric irritation, nausea,

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

diuretics: Discontinue diuretic for 2–3 days if possible. If it is not 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

Enalapril blocks the conversion of angiotensin I to angiotensin II, decreasing BP, decreasing aldosterone 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.

CHF

Treatment of asymptomatic left ventricular dysfunction (LVD)

Unlabeled use: Diabetic nephropathy

vomiting, diarrhea, abdominal pain, dyspepsia, elevated liver enzymes

GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, urinary frequency, impotence

Hematologic: Decreased hematocrit and hemoglobin

Other: Cough, muscle cramps, hyperhidrosis

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 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

maintenance dose 20 mg/day in two divided doses.

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

after the first few doses of enalapril.

Monitor patient closely 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

MO–16 YR

Oral

Hypertension: 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.

been checked.

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

Antihypertensive

Angiotensin-converting enzyme (ACE) inhibitor

Therapeutic actions

Renin, synthesized by the

Treatment of hypertension, alone or in combination with thiazide-

Contraindicated with allergy to fosinopril or other ACE inhibitors; pregnancy.

Use cautiously with impaired renal

CV: Angina pectoris, orthostatic hypotension in salt- or volume-depleted patients,

Assessment

History: Allergy to fosinopril and other ACE inhibitors, impaired renal or hepatic function,

fosinopril therapy with 10 mg. Do not exceed maximum dose of 80 mg.

PEDIATRIC PATIENTS


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; 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.

type diuretics

Management of CHF as adjunctive therapy

Unlabeled use: Diabetic nephropathy

function, hyperkalemia, salt or volume depletion, lactation.

palpitations

Dermatologic: Rash, pruritus, diaphoresis, flushing

GI: Nausea, abdominal pain, vomiting, diarrhea

Respiratory: Cough, asthma, bronchitis, dyspnea, sinusitis

Other: Angioedema, asthenia, myalgia, arthralgia, hyperkalemia

hyperkalemia, 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

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

Apo-Lisinopril (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

AntihypertensiveAngiotensin-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 hypertension alone or in combination with thiazide-type diuretics

Adjunctive therapy in CHF for patients

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

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

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

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


GERIATRIC PATIENTS AND PATIENTS WITH RENAL IMPAIRMENT

Excretion is reduced in renal failure. Use

angiotensin-converting enzyme to angiotensin II, a potent vasoconstrictor that also causes release of aldosterone from the 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.

unresponsive to diuretics and digitalis alone

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

volume-depleted patients

GI: Gastric irritation, nausea, diarrhea, peptic ulcers, dysgeusia, cholestatic jaundice, hepatocellular injury, anorexia, constipation

GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, frequency

Hematologic: Neutropenia, agranulocytosis, thrombocytopenia, hemolytic anemia, pancytopenia

Other: Angioedema (particularly of the face,

perfusion; mucous membranes, bowel sounds, liver evaluation; urinalysis, renal 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

smaller initial dose, and adjust upward to a maximum of 40 mg/day PO.

extremities, lips, tongue, larynx); death has been reported with airway obstruction; cough, muscle cramps, impotence, rash, pruritis

that lisinopril 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 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. Candesartan 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


Angiotensin II receptor antagonistAntihypertensive

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 hypertension, alone or in combination with other antihypertensives

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

CV: Hypotension

Dermatologic: Rash, inflammation, urticaria, pruritus, alopecia, dry skin

GI: Diarrhea, abdominal pain, nausea, constipation,

Assessment

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

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

Interventions

Administer without regard to

dry mouth, dental pain

Respiratory: URI symptoms, cough, sinus disorders

Other: Cancer in preclinical studies, back pain, fever, gout

meals.

WARNING: Ensure that patient is not pregnant before beginning 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.

Angiotensin II receptor antagonist (ARB)Antihypertensive

Therapeutic actions

Selectively blocks the binding of

Treatment of hypertension as monotherapy or in combination with other

Contraindicated with hypersensitivity to irbesartan, pregnancy (use during the second or third trimester can cause injury or

CNS: Headache, dizziness, syncope, muscle weakness, sleep disturbance

Assessment

History: Hypersensitivity to irbesartan, pregnancy, lactation, hepatic or renal dysfunction,

Hypertension: 150 mg PO daily as one dose; adjust slowly to determine effective dose; 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 SALT-DEPLETED PATIENTS

75 mg/day PO.

angiotensin II to specific tissue receptors found in the 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.

antihypertensives

Slowing of the progression of nephropathy in patients with hypertension and type 2 (non–insulin-dependent) diabetes

Unlabeled use: CHF

even death to the fetus).

Use cautiously with hepatic or renal dysfunction, hypovolemia, lactation, pregnancy.

CV: Hypotension, orthostatic hypotension, flushing


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


Other: Cancer in preclinical studies, back pain, fever, gout, fatigue, neutropenia

hypovolemia

Physical: Skin lesions, turgor; T; reflexes, affect; BP; R, respiratory auscultation; liver 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. ADULTS Angiotensin II receptor blocker

Treatment

Contraindicated

CNS: Headache,

Assessment

Valsartan

Diovan80 mg PO daily; range 80–320 mg/day.

Heart failure: Starting dose is 40 mg bid, titration to 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


PATIENTS WITH HEPATIC OR RENAL IMPAIRMENT

Exercise caution and monitor patient frequently.

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 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.

of hypertension, alone or in combination with other antihypertensives

Treatment of heart failure in patients who are intolerant of angiotensin-converting enzyme (ACE) inhibitors

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

Use cautiously with hepatic or renal dysfunction, hypovolemia.

dizziness, syncope, muscle weakness

CV: Hypotension


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


Other: Cancer in preclinical studies, back pain, fever, gout, hyperkalemia

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

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

Plendil, Renedil (CAN)

ADULTS

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


GERIATRIC PATIENTS OR PATIENTS WITH HEPATIC IMPAIRMENT

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

Calcium channel-blockerAntihypertensive

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.

· Essential hypertension, alone or in combination with other antihypertensives

· Contraindicated with allergy to felodipine or other calcium channel-blockers, sick sinus syndrome, heart block (second or third degree), lactation.

· Use cautiously with pregnancy, impaired hepatic function.

· CNS: Dizziness, light-headedness, headache, asthenia, fatigue, lethargy

· CV: Peripheral edema, arrhythmias

· Dermatologic: Flushing, rash

· GI: Nausea, abdominal discomfort, reflux, constipation

Assessment

· 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

ADULTS AND PATIENTS > 12 YR

Oral

· Monotherapy: Initial dosage is 2.5–5 mg/day PO as a single dose. Daily dosage can be

AntihypertensiveVasodilator

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

· Severe hypertension that is symptomatic or associated with target organ damage and is not manageable with

· Contraindicated with hypersensitivity to minoxidil or any component of the topical preparation (topical); pheochromocytoma (may stimulate release of catecholamines from tumor); acute

· CNS: Fatigue, headache

· CV: Tachycardia (unless given with beta-adrenergic blocker or other sympatholytic drug),

Assessment

· History: Hypersensitivity to minoxidil or any component of the topical preparation; pheochromocytoma; acute MI, dissecting aortic aneurysm;

Strengthincreased to 10, 20, then 40 mg in single or divided doses. Effective range is usually 10–40 mg/day PO. 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

orthostatic hypotension but does cause reflex tachycardia and renin release, leading to sodium and water retention; mechanism in stimulating hair growth is not known, possibly related to arterial dilation.

maximum therapeutic doses of a diuretic plus two other antihypertensive drugs; use in milder hypertension not recommended

· Topical use (when compounded as a 1%–5% lotion or 1% ointment): Alopecia areata and male pattern alopecia

MI; dissecting aortic aneurysm; lactation.

· Use cautiously with malignant hypertension; CHF (use diuretic); angina pectoris (use a beta-blocker); pregnancy.

pericardial effusion and tamponade; changes in direction and magnitude of T-waves; cardiac necrotic lesions (reported in patients with known ischemic heart disease, but risk of minoxidil-associated cardiac damage cannot be excluded)

· Dermatologic: Temporary edema, hypertrichosis (elongation, thickening, and enhanced pigmentation of fine body hair occurring within 3–6 wk of starting therapy; usually first noticed on temples,

malignant hypertension; CHF; angina pectoris; lactation, pregnancy

· 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,

on renal function for maintaining salt and water balance; the following diuretic dosages have been used when starting minoxidil therapy: Hydrochlorothiazide, 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

between eyebrows and extending to other parts of face, back, arms, legs, scalp); rashes including bullous eruptions; Stevens-Johnson 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)

·

including topical corticosteroids, retinoids, and petrolatum or agents known to enhance 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

recommended when starting minoxidil therapy: Propranolol, 80–160 mg/day; other beta-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

Respiratory: Bronchitis, URI, sinusitis (topical use)

from children).

· Arrange for echocardiographic evaluation of possible pericardial effusion; more vigorous diuretic therapy, dialysis, other treatment (including minoxidil withdrawal) may be required.

3–4 mo after cessation of the drug.

PEDIATRIC PATIENTS < 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 IMBALANCESGeneric 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 2-10 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


Elin Potassium Chloride® [vial]

Adult Plasma K level >2.5 mEq/L 10 mEq/hr-200 mEq/day, <2 mEq/L 40 mEq/hr-400 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.

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.





Elin Potassium Chloride® [vial]

Adult Plasma K level >2.5 mEq/L 10 mEq/hr-200 mEq/day, <2 mEq/L 40 mEq/hr-400 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.

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

Glucolyte 60® [powd]

Replacement therapy 25-50 mL/kg body wt/day taken in 6-12 hr. Maintenance therapy 100 mL/kg body wt/day or 10 mL/kg body wt after each stool.

Acute dehydration secondary to gastroenteritis or other forms of diarrhea, except cholera. Other medical & surgical conditions where oral rehydration to replace fluids & electrolytes is needed as in burns, post-surgery replacement or maintenance, mild salt-losing syndrome. Heat cramps & heat exhaustion in adults.


Contraindications- Intestinal obstruction that requires surgical intervention

Special Precautions- Heart failure, renal failure, end-stage renal disease, intestinal obstruction, comatose patients on tube feeding.







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 4-6 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 mL. Childn 100 mL. Infant 50 mL

Electrolyte replenisher



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 (50-100 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.






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 8-10.9 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 16-29.9 kg 6-11 glasses (1200-2200 mL), ≥15 yr or ≥30 kg 11-20 glasses (2200-4000 mL).

Ion-O-Trate Potassium Chloride® [inj]

Individualised dosage Treatment of K states when oral replacement therapy is not feasible

None specifiedContraindications- 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

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).

http://www.mims.com/Page.aspx?menuid=mng&brief=true#Precautions



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

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

http://www.mims.com/Page.aspx?menuid=mng&brief=true#CAUTIONS

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.





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.










Pedialyte® [-45 soln]

Individualized dosage

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

None specifiedContraindications- 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


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 specifiedContraindications- Intractable vomiting, adynamic ileus, intestinal obstruction, bowel perforation

Special Precautions- Impaired renal function

May be given with or without food



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Phil Pharmawealth/Atlantic Potassium Chloride® [amp]

1-3 g daily by slow IV infusion

Treatment of hypokalemia & K-deficiency 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, non-thrombocytopenic purpura & exudative dermatoses; aid in antagonizing cardiac toxicity associated w/

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








hyperkalemia provided patient is not on digitalis.

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 60-120 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, 9-13 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/flk-3, 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 Factorsand 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 units-erythrocytes

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 FACTORGeneric Name /

Brand NameIndication

Dosage/Frequency and RouteAction Side Effects Nursing Responsisbilities

Epoetion alfa (erythropoietin) / Epogen, Eprex, Procrit

Anemia caused by chronic renal failureAdults: 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 patientsAdults: 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 chemotherapyAdults: initially, 150 units/kg subcutaneously three times weekly for 8 weeks or until target haemoglobin level is reached. If response isn’t satisfactory after 8 weeks,

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

Seizures, dizziness, fatigue, fever, headache, asthenia.

edema, hypertension, increased clotting of anteriovenous grafts

Nausea, vomiting, diarrhea

Hyperkalemia, hyperphosphatemia

Arthraglia cough, shortness of

breath infection, rash, pyrexia

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.

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

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.

To decrease risk of infection in patients with non-myeloid malignant disease receiving myelosuppressive antineoplasticsAdults 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 neutropeniaAdults: 5mcg/kg subcutaneously daily. Adjust dosage based on patient response.

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.

Oprelvekin / Neumega

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

To prevent severe thrombocytopenia and reduce need for platelet transfusions after myelosuppressive chemotherapy with nonmyeloid malignanciesAdults: 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, nausea, vomiting, diarrhea

Anemia Dehydration,

hypocalcemia Dyspnea, cough,

pleural effusions Rash, skin

discoloration, exfoliative dermatitis

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.

Fluid retention can be severe; monitor patient closely.

Sagramostim (GM-CSF; 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 lymphomaAdults: 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 leukaemiaAdults 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 sargramostim

Binds to specific receptors on cell surfaces of target cells.

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 athralgias

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.

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 transplantationAdults: 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 delayAdults: 250mcg/m2 as a 2-hour IV infusion daily for 14 days. This course of therapy may be repeated after 7 days of no therapy. If engraftment 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 Indications Actions Side Effects

Darbapoetin alfa(aranesp)

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

Treatment of anemia associated with chronic renal failure, including

dialysis patients; treatment of chemotherapy-induced

anemia

Stimulates the production of RBC in the bone marrow

Head achefatigue asthenia

dizziness seizures

Epoetin alfa(epogen)

50-100 units/kg IV or SQ 3 times per week; 300 units/

kg/day SQ for 15 days (reduction of need for blood

transfusions)

Treatment of anemia associated with renal

failure; reduction in need for transfusions in surgical

patients ; treatment of anemia associated with

AIDS therapy

Not indicated Headache, hypertension and seizures. Hypertensive crisis with encephalopathy-like 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 PREPARATIONSDrug Name Dosage/ Frequency and Route Indications Actions Side Effects

Ferrous fumarate(feostat)

ferrous gluconate(fergon)

Ferrous sulfate(Feosol)

Ferrous sulfate exsiccated(ferralyn lanacaps, Slow FE)

100-200 mg/day POChildren 2-12 years old: 50-

100mg/day PO6,os-2 years old :6mg/kg/day

POInfants: 10-25 mg/day PO

Treatment of Iron deficiency Anemia

Not indicated GI disturbances, nausea, abdominal pain, vomiting,

diarrhea, constipation.

Iron Dextran(InFeD)

Mg iron =0.3 x (wt. In lb) x ((100-(hemoglobin in g/dl) x 100)/14.8) given IM using Z-

track

Parenteral treatment of IDA 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.

Iron Sucrose(Venofer)

100mg one to three times per week given IV during

dialysis sessions, slowly over 1 min

Treatment of ISA in patients undergoing chronic

hemodialysis or nondialysis patients with renal failure

who are also receiving supplemental erythropoeitin

therapy

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.

Sodium ferric gluconate complex(ferriecit)

10 ml diluted in 100 ml 0.9 % NaCl for injection over

60 min; initially 8 doses given at separate dialysis

sessions , then give periodically to maintain

hematocrit

Treatment of IDA in patients undergoing chronic

hemodialysis who are also receiving supplemental erythorpoeitin therapy

Not indicated Not indicated

FOLIC ACID DERRIVATIVES

Drug Name Dosage/ Frequency and Route Indications Actions Side Effects

Folic acid (folvite)

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

anemia


Leucovorin(wellcovarin)

1 mg/day IM for replacement; 12-15g/m2 PO then 10g/m2 PO q6h for 72

hours for rescue

Replacement of therapy and treatment of megaloblastic

anemia; rescue after chemotherapy


Renal Medications

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