CLASS: Platelet agrregation

ACTION: Inhibits first and second phases of of ADP-induced effects in platelet aggregation

INDICATIONS: reduce the risk of stoke, MI, peripheral aterial disease in high-risk pateints, acute coronary syndrome, TIA, unstable angina

DOSAGE AND ROUTES:

Recent MI, stroke, peripheral arterial disease
Adult: PO 75 mg daily with or without aspirin

Acute coronary syndrome
Adult: PO loading dose 300 mg then 75 mg daily

SIDE EFFECTS: GI bleeding, pancreatitis, glomerulonephritis, bleeding, neutropenia, aplastic aneima, intracranial hemorrhage, Stevens-Johnsons syndrome, bronchospasm

CONTRAINDICATIONS: Hypersensitivity, active bleeding

Precautions: Pregnancy, past hepatic disease, breastfeeding, children, increased bleeding risk, neutrophenia, agranulocytosis, renal disease

PHARMACOKINETICS

Rapidly absorbed; peak 1–3 hr; metabolized by liver (CYP3A); excreted in urine, feces; half-life 8 hr; plasma protein binding 95%; effect on platelets after 3–7 days

INTERACTIONS

Increase: bleeding risk—anticoagulants, aspirin, NSAIDs, abciximab, eptifibatide, tirofiban, thrombolytics, ticlopidine

Increase: action of—some NSAIDs, phenytoin, TOLBUTamide, tamoxifen, torsemide, fluvastatin, warfarin

Drug/Herb

Increase: clopidogrel effect—bogbean, dong quai, feverfew, garlic, ginger, ginkgo biloba, green tea, horse chestnut

Increase: gastric irritation—arginine

Decrease: clopidogrel effect—bilberry, saw palmetto

Drug/Lab Test

Increase: AST, ALT, bilirubin, uric acid, total cholesterol, nonprotein nitrogen (NPN)

NURSING CONSIDERATIONS
Assess:

• Thrombotic/thrombocytic purpura: fever, thrombocytopenia, neurolytic anemia
• For symptoms of stroke, MI during treatment
• Hepatic studies: AST, ALT, bilirubin, creatinine (long-term therapy)
• Blood studies: CBC, diff, Hct, Hgb, PT, cholesterol (long-term therapy)

Administer:

• With food to decrease gastric symptoms

Evaluate:

• Therapeutic response: absence of stroke, MI

Teach patient/family:

• That blood work will be necessary during treatment
• To report any unusual bruising, bleeding to prescriber, that it may take longer to stop bleeding
• To take with food or just after eating to minimize GI discomfort
• To report diarrhea, skin rashes, subcutaneous bleeding, chills, fever, sore throat
• To tell all health care providers that clopidogrel is used; may be held 3–7 days before surgery

CLASS:

ACTION:

PURPOSE:

SIDE EFFECTS:

DOSAGE/ROUTES:

CLASS: Anticoagulant, antithrombtic

ACTION: Prevents conversion of fibrinogen to fibrin and prothrombin to thrombin by enhancing inhibitory effects of antithrombin III

INDICATIONS: Prevention of deep-vein thrombosis, pulmonary emboli, myocardial infarction, open heart surgery, disseminated intravascular clotting syndrome, atrial fibrillation with embolization, as an anticoagulant in transfusion and dialysis procedures, prevention of DVT/PE, to maintain patency of indwelling venipuncture devices; diagnosis, treatment of DIC

DOSAGE AND ROUTES:
Deep vein thrombosis/MI

Adult: IV BOL 5000-7000 units q4hr then titrated to PTT or ACT level; IV INF after bolus dose, then 1000 units/hr titrated to PTT or ACT level

Anticoagulation

Adult: SUBCUT 5000 units IV then 10,000-20,000 units, then 8000-10,000 units q8hr or 15,000-20,000 units q12hr INTERMITTENT IV BOL 10,000 units, then 5000-10,000 units q4-6hr; CONT IV INF 5000 units (35-70 units/kg), then 20,000-40,000 units given over 24 hr

Cardiovascular surgery

Adult: IV INF 150-300 units/kg

Prophylaxis for DVT/PE
Adult: SUBCUT 5000 units q8-12hr

Heparin flush
Adult and child: IV 10-100 units/ml

Arterial line patency
Neonate: IA 0.5–2 units/ml

AVAILABLE FORMS: Sol for inj 10, 100, 1000, 5000, 7500, 10,000, 20,000, 40,000 units/ml; premixed 1000 units/500 ml, 2000 units/1000 ml, 12,500 units/250 ml, 25,000 units/250 ml, 25,000 units/500 ml; lock flush preparations 10 units/ml

SIDE EFFECTS: Hematuria, hemorrhage, thrombocytopenia, anemia, anaphylaxis

CONTRAINDICATIONS: Hypersensitivity, hemophilia, leukemia with bleeding, peptic ulcer disease, severe thrombocytopenic purpura, severe renal/hepatic disease, blood dyscrasias, severe hypertension, subacute bacterial endocarditis, acute nephritis

Precautions: Pregnancy (C), alcoholism, geriatric patients, children, hyperlipidemia, diabetes, renal disease

PHARMACOKINETICS

Half-life 1½ hr; excreted in urine; 95% bound to plasma proteins; does not cross placenta or alter breast milk; removed from the system via the lymph and spleen; partially metabolized in kidney, liver; excreted in urine (<50% unchanged)

SUBCUT: Onset 20-60 min, duration 8–12 hr, well absorbed

IV: Peak 5 min, duration 2–6 hr

INTERACTIONS:

• Resistance to heparin: streptokinase

Increase: diazepam action

Increase: heparin action—oral anticoagulants, salicylates, dextran, NSAIDs, platelet inhibitors, cephalosporins, penicillins, ticlopidine, dipyridamole

Decrease: corticosteroids action

Decrease: heparin action—digoxin, tetracyclines, antihistamines

Drug/Herb

Increase: risk of bleeding—agrimony, alfalfa, angelica, anise, basil, bay, bilberry, black haw, bogbean, bromelain, buchu, chamomile, chondroitin, cinchona bark, dong quai, fenugreek, feverfew, garlic, ginger, ginkgo, ginseng, horse chestnut, Irish moss, kelp, kelpware, khella, lovage, lungwort, meadowsweet, motherwort, mugwort, nettle, papaya, parsley (large amts), pau d´arco, pineapple, poplar, prickly ash, safflower, saw palmetto, tonka bean, turmeric, wintergreen, yarrow

Decrease: anticoagulant effect—coenzyme Q10, flax, glucomannan, goldenseal, guar gum

Drug/Lab Test

Increase: ALT, AST, INR, PT, PTT, potassium

Decrease: platelets, triglycerides, cholesterol, plasma free fatty acids

NURSING CONSIDERATIONS
Assess: Bleeding: gums, petechiae, ecchymosis, black tarry stools, hematuria, epistaxis, decrease in Hct, B/P; may indicate bleeding, hemorrhage; HIT may occur after product discontinuation

• Blood studies (Hct, occult blood in stools) q3mo
• Partial prothrombin time, which should be 1.5–2 × control; for continuous IV inf, check aPTT baseline 6 hr after initiation and 6 hr after any dose change; use aPTT for dosing adjustments; once 2 therapeutic aPTT has been measured, check aPTT daily
• Platelet count q2-3days; thrombocytopenia may occur on 4th day of treatment
• Hypersensitivity: rash, chills, fever, itching; report to prescriber

Administer:

• Cannot be used interchangeably (unit for unit) with LMWHs or heparinoids
• At same time each day to maintain steady blood levels
• Do not mistake heparin sodium inj 10,000 units/ml and Hep-Lock U/P 10 units/ml; they have similar blue labeling
• SUBCUT deep with 25G ⅜-in needle; do not massage area or aspirate when giving SUBCUT inj; give in abdomen between pelvic bones, rotate sites; do not pull back on plunger, leave in for 10 sec; apply gentle pressure for 1 min
• Changing needles is not recommended
• Avoiding all IM inj that may cause bleeding, hematoma

IV route

• Diluted in 0.9% NaCl, dextrose, Ringer's sol and given by direct, intermittent, or continuous inf; give 1000 units or less over 1 min; then 5000 units or less over 1 min; inf may run from 4–24 hr; use inf pump
• When product is added to inf sol for cont IV, invert container at least 6 times to ensure adequate mixing
• Blood after adding 7500 units/100 ml NaCl inj, add 6–8 ml of this sol/100 ml of whole blood

ADDITIVE COMPATIBILITIES: Aminophylline, amphotericin, ascorbic acid, bleomycin, calcium gluconate, cefepime, chloramphenicol, clindamycin, colistimethate, dimenhyDRINATE, DOPamine, enalaprilat, esmolol, floxacillin, fluconazole, flumazenil, furosemide, hydrocortisone, isoproterenol, lidocaine, lincomycin, magnesium sulfate, meropenem, methyldopate, methylPREDNISolone, metronidazole/sodium bicarbonate, nafcillin, norepinephrine, octreotide, penicillin G, potassium chloride, promazine, ranitidine, sodium bicarbonate, verapamil, vit B/C

SYRINGE COMPATIBILITIES: Aminophylline, amphotericin B, ampicillin, atropine, azlocillin, bleomycin, cefamandole, cefazolin, cefoperazone, cefotaxime, cefoxitin, chloramphenicol, cimetidine, cisplatin, clindamycin, cyclophosphamide, diazoxide, digoxin, dimenhyDRINATE, DOBUTamine, DOPamine, epINEPHrine, fentanyl, fluorouracil, furosemide, leucovorin, lidocaine, lincomycin, methotrexate, metoclopramide, mitomycin, moxalactam, nafcillin, naloxone, neostigmine, nitroglycerin, norepinephrine, pancuronium, penicillin G, phenobarbital, piperacillin, sodium nitroprusside, succinylcholine, trimethoprim-sulfamethoxazole, verapamil, vinCRIStine

Y-SITE COMPATIBILITIES: Acyclovir, aldesleukin, allopurinol, amifostine, aminophylline, ampicillin, ampicillin/sulbactam, atracurium, atropine, aztreonam, betamethasone, bleomycin, calcium gluconate, cefazolin, cefotetan, ceftazidime, ceftriaxone, chlordiazepoxide, chlorproMAZINE, cimetidine, cisplatin, cladribine, clindamycin, conjugated estrogens, cyanocobalamin, cyclophosphamide, cytarabine, dexamethasone, digoxin, diphenhydrAMINE, DOPamine, DOXOrubicin liposome, edrophonium, enalaprilat, epINEPHrine, esmolol, ethacrynate, etoposide, famotidine, fentanyl, fluconazole, fludarabine, fluorouracil, foscarnet, furosemide, gallium, gemcitabine, granisetron, hydrALAZINE, hydrocortisone, hydromorphone, insulin (regular), isoproterenol, kanamycin, leucovorin, linezolid, lidocaine, lorazepam, magnesium sulfate, melphalan, menadiol, meperidine, meropenem, methotrexate, methoxamine, methyldopate, methylergonovine, metoclopramide, metronidazole, midazolam, milrinone, minocycline, mitomycin, morphine, nafcillin, neostigmine, nitroglycerin, nitroprusside, norepinephrine, ondansetron, oxacillin, oxytocin, paclitaxel, pancuronium, penicillin G potassium, pentazocine, phytonadione, piperacillin, piperacillin/tazobactam, potassium chloride, prednisoLONE, procainamide, prochlorperazine, propofol, propranolol, pyridostigmine, ranitidine, remifentanil, sargramostim, scopolamine, sodium bicarbonate, streptokinase, succinylcholine, tacrolimus, theophylline, thiopental, thiotepa, ticarcillin, ticarcillin/clavulanate, tirofiban, trimethobenzamide, trimethaphan, vecuronium, vinBLAStine, vinorelbine, warfarin, zidovudine

Perform/Provide:

• Storage at room temperature

Evaluate:

• Therapeutic response: decrease of DVT, PTT 1.5-2.5 × control, free-flowing IV

Teach patient/family:

• To avoid OTC preparations that may cause serious product interactions unless directed by prescriber
• That product may be held during active bleeding (menstruation), depending on condition
• To use soft-bristle toothbrush to avoid bleeding gums, avoid contact sports, use electric razor, avoid IM inj
• To carry emergency ID identifying product taken
• To report to prescriber any signs of bleeding: gums, under skin, urine, stools
• To report to prescriber any signs of hypersensitivity: rash, chills, fever, itching

Treatment of overdose: Withdraw product, protamine 1 mg protamine/100 units heparin

CLASS: Antimetic

ACTION: Prevents nausea, vomiting by blocking serotonin peripherally, centrally, and in the small intestine

INDICATION: Prevention of nausea, vomiting associated with cancer chemotherapy, radiotherapy, and prevention of postoperative nausea, vomiting

UNLABELED USES: Pruritus (rectal use), alcoholism, hyperemesis gravidarum

DOSAGE AND ROUTES:
Prevention of nausea/vomiting of cancer chemotherapy

Adult and child 4–18 yr: IV 0.15 mg/kg infused over 15 min, 30 min before start of cancer chemotherapy; 0.15 mg/kg given 4 hr and 8 hr after first dose or 32 mg as a single dose; dilute in 50 ml of D5 or 0.9% NaCl before giving; RECT (unlabeled) 16 mg/day 2 hr prior to chemotherapy; PO 8 mg ½ hr prior to chemotherapy, repeat 8 hr later

Prevention of nausea/vomiting of radiotherapy Adult: PO 8 mg tid, may repeat q8hr

Prevention of postoperative nausea/vomiting Adult: IV/IM 4 mg undiluted over >30 sec prior to induction of anesthesia

Hepatic dose

Adult: PO/IM/IV Max dose 8 mg/day

Hyperemesis gravidarum (unlabeled)

Adult: PO/IV 4–8 mg bid-tid

Pruritus (unlabeled)

Adult: PO 4 mg bid

Alcoholism (unlabeled)

Adult: PO 4 mcg/kg bid

Available forms: Inj 2 mg/ml, 32 mg/50 ml (premixed); tabs 4, 8 mg; oral sol 4 mg/5 ml; oral disintegrating tabs 4, 8 mg

SIDE EFFECTS: Bronchspasm (rare)

CONTRAINDICATIONS: Hypersensitivity

Precautions: Pregnancy, breastfeeding, children, geriatric patients, granisetron hypersensitivity

PHARMACOKINETICS
IV: Mean elimination half-life 3.5-4.7 hr, plasma protein binding 70%-76%, extensively metabolized in the liver, excreted 45%-60% in urine

INTERACTIONS

Decrease: ondansetron effect—rifampin

NURSING CONSIDERATIONS
Assess:

• For absence of nausea, vomiting during chemotherapy
• Hypersensitivity reaction: rash, bronchospasm
• For EPS: shuffling gait, tremors, grimacing, rigidity

Administer:

IV route

• After diluting a single dose in 50 ml NS or D5W, 0.45% NaCl or NS; give over 15 min

Additive compatibilities: Cisplatin, cyclophosphamide, cytarabine, dacarbazine, dexamethasone, DOXOrubicin, etoposide, fluconazole, hydromorphone, meperidine, methotrexate, morphine

Solution compatibilities: May also be diluted with D5W, lactated Ringer's, D5/0.9% NaCl, D5/0.45% NaCl

Y-site compatibilities: Aldesleukin, amifostine, amikacin, aztreonam, bleomycin, carboplatin, carmustine, cefazolin, cefmetazole, cefotaxime, cefoxitin, ceftazidime, ceftizoxime, cefuroxime, chlorproMAZINE, cimetidine, cisatracurium, cisplatin, cladribine, clindamycin, cyclophosphamide, cytarabine, dacarbazine, dactinomycin, DAUNOrubicin, dexamethasone, diphenhydrAMINE, DOPamine, DOXOrubicin, DOXOrubicin liposome, doxycycline, droperidol, etoposide, famotidine, filgrastim, floxuridine, fluconazole, fludarabine, gallium, gentamicin, haloperidol, heparin, hydrocortisone, hydromorphone, hydrOXYzine, ifosfamide, imipenem/cilastatin, magnesium sulfate, mannitol, mechlorethamine, melphalan, meperidine, mesna, methotrexate, metoclopramide, miconazole, mitomycin, mitoxantrone, morphine, paclitaxel, pentostatin, piperacillin/tazobactam, potassium chloride, prochlorperazine, promethazine, ranitidine, remifentanil, streptozocin, teniposide, thiotepa, ticarcillin, ticarcillin/clavulanate, vancomycin, vinBLAStine, vinCRIStine, vinorelbine, zidovudine

Perform/provide:

• Storage at room temperature 48 hr after dilution

Evaluate:

• Therapeutic response: absence of nausea, vomiting during cancer chemotherapy

Teach patient/family:

• To report diarrhea, constipation, rash, or changes in respirations or discomfort at insertion site
• Headache requiring analgesic is common

CLASS: Calcium channel blocker

ACTION: Inhibits calcium ion influx across cell membrane during cardiac depolarization; produces relaxation of coronary vascular smooth muscle, peripheral vascular smooth muscle; dilates coronary vascular arteries; increases myocardial oxygen delivery in patients with vasospastic angina

INDICATIONS: Chronic stable angina pectoris, hypertension

DOSAGE AND ROUTES:
Hypertension

Adult: PO 20 mg tid initially, may increase after 3 days (range 20-40 mg tid) or 30 mg bid SUS REL, may increase to 60 mg bid or IV 5 mg/hr, may increase by 2.5 mg/hr q15min, max 15 mg/hr

Angina

Adult: PO 20 mg tid, may be adjusted q3 days, may use 20-40 mg tid

Renal dose

Adult: PO 20 mg tid or SUS REL 30 mg bid

Hepatic dose

Adult: PO 20 mg bid

Available forms: Caps 20, 30 mg; sus rel caps 30, 45, 60 mg; inj 2.5 mg/ml

SIDE EFEECTS: pulmonary edema, arrhythmias, CHF, hepatitis, acute renal failure, Stevens-Johnson syndrome

Contraindications: Sick sinus syndrome, 2nd-/3rd-degree heart block, hypersensitivity, advanced aortic stenosis

Precautions: Pregnancy (C), breastfeeding, CHF, hypotension, hepatic injury, children, renal disease, geriatric patients

PHARMACOKINETICS
Metabolized by liver, excreted in urine 60%, 35% feces

PO: Onset 30 min, peak 1–2 hr, duration 8 hr

PO-SR: Onset unknown, peak 2–6 hr, duration 10-12 hr, half-life 2–5 hr

INTERACTIONS
Increase: effects of digoxin, neuromuscular blocking agents, theophylline, other antihypertensives, nitrates, alcohol, quinidine

Increase: niCARdipine effects—cimetidine

Increase: toxicity risk—cycloSPORINE, prazosin, carbamazepine, quinidine, propranolol

Decrease: antihypertensive effect—NSAIDs, rifampin

Drug/Herb
Increase: effect—barberry, betel palm, burdock, goldenseal, khat, khella, lily of the valley, plantain

Decrease: effect—yohimbe

Drug/Food
Increase: hypotensive effect—grapefruit juice

NURSING CONSIDERATIONS

Assess:

• Cardiac status: B/P, pulse, respiration, ECG during long-term treatment
• Anginal pain: intensity, location, duration, alleviating factors
• Potassium, renal, hepatic studies, periodically
• CHF: weight gain, crackles, jugular venous distention, dyspnea, I&O

Administer

PO route:

• Do not break, crush, chew, or open sus rel cap
• Without regard to meals

IV route:

• Dilute each 25 mg/240 ml of compatible sol (0.1 mg/ml), give slowly
• Stable at room temperature 24 hr

Solution compatibilities: D5W, D5/0.45% NaCl, D5/0.9% NaCl

Y-site compatibilities: Diltiazem, DOBUTamine, DOPamine, epINEPHrine, fentanyl, hydromorphone, labetalol, lorazepam, midazolam, milrinone, morphine, nitroglycerin, norepinephrine, ranitidine, vecuronium

Evaluate:

• Therapeutic response: decreased anginal pain, decreased B/P

Teach patient/family:

• To avoid hazardous activities until stabilized on product, dizziness is no longer a problem
• To limit caffeine consumption, take no alcohol products
• To avoid OTC products unless directed by prescriber
• To comply in all areas of medical regimen: diet, exercise, stress reduction, product therapy
• To notify prescriber of irregular heartbeat, shortness of breath, swelling of feet and hands, pronounced dizziness, constipation, nausea, hypotension

Treatment of overdose: Defibrillation, β-agonists, IV calcium, diuretics, atropine for AV block, vasopressor for hypotension

CLASS: Adrenergic direct-acting β1-agonist, cardiac stimulant

ACTION: Causes increased contractility, increased cardiac output without marked increase in heart rate by acting on β1-receptors in heart; minor α and β2 effects

INDICATIONS: Cardiac decompensation due to organic heart disease or cardiac surgery

Unlabeled uses: Cardiogenic shock in children; congenital heart disease in children undergoing cardiac cath

DOSAGE AND ROUTES:
Adult and child: IV INF 2.5-10 mcg/kg/min; may increase to 40 mcg/kg/min if needed

Available forms: Inj 12.5 mg/ml

SIDE EFFECTS: Anxiety, headache, dizziness, fatigue, PVC's, angina, nausea, vomiting, muscle cramps (leg), dyspnea

CONTRAINDICATIONS: Hypersensitivity, idiopathic hypertrophic subaortic stenosis

PRECAUTIONS: Pregnancy (B), breastfeeding, children, hypertension, CAD, MI, hypovolemia, dysrhythmias

PHARMACOKINETICS
IV: Onset 1–2 min, peak 10 min, half-life 2 min, metabolized in liver (inactive metabolites), excreted in urine

INTERACTIONS
Increase: severe hypertension—guanethidine

Increase: dysrhythmias—general anesthetics, bretylium

Increase: pressor effect, dysrhythmias—atomoxetine, COMT inhibitors, tricyclics, MAOIs, oxytocics

Decrease: DOBUTamine action—other β-blockers

NURSING CONSIDERATIONS
Assess:

• Hypovolemia; if present, correct first; administer cardiac glycoside before DOBUTamine
• Oxygenation/perfusion deficit (check B/P, chest pain, dizziness, loss of consciousness)
• Heart failure: S3 gallop, dyspnea, neck vein distention, bibasilar crackles in patients with CHF, cardiomyopathy, palpate peripheral pulses; report if extremities become cold or mottled or if peripheral pulses decrease
• ECG during administration continuously; if B/P increases, product is decreased; CVP or PCWP, cardiac output during inf; report changes
• Serum electrolytes, urine output
• Sulfite sensitivity, which may be life-threatening

Administer
IV route:

• Diluting each 250 mg/10 ml of sterile H2O or D5W for inj; may be further diluted in 50 ml or more given at prescribed rate; should be gradually increased to desired rate; use a CVP catheter or large peripheral vein, use inf pump, titrate to patient response
• Standard concentrations are 250 mcg/ml-1000 mcg/ml, max 5 mg of DOBUTamine/ml

Additive compatibilities: Amiodarone, atracurium, atropine, DOPamine, enalaprilat, epINEPHrine, flumazenil, hydrALAZINE, isoproterenol, lidocaine, meperidine, meropenem, metaraminol, morphine, nitroglycerin, norepinephrine, phentolamine, phenylephrine, procainamide, propranolol, ranitidine

Syringe compatibilities: Heparin, ranitidine

Y-site compatibilities: Amifostine, amiodarone, amrinone, atracurium, aztreonam, bretylium, calcium chloride, calcium gluconate, ciprofloxacin, cisatracurium, cladribine, diazepam, diltiazem, DOPamine, DOXOrubicin liposome, enalaprilat, epINEPHrine, famotidine, fentanyl, fluconazole, granisetron, haloperidol, hydromorphone, insulin (regular), labetalol, lidocaine, lorazepam, magnesium sulfate, meperidine, milrinone, morphine, niCARdipine, nitroglycerin, norepinephrine, pancuronium, potassium chloride, propofol, ranitidine, remifentanil, sodium nitroprusside, streptokinase, tacrolimus, theophylline, thiotepa, tolazoline, vecuronium, verapamil, zidovudine

Perform/provide:

• Storage of reconstituted solution for 24 hr if refrigerated

Evaluate:

• Therapeutic response: increased B/P with stabilization, increased urine output

Teach patient/family:

• The reason for product administration; to report dyspnea, chest pain, numbness of extremities, headache, IV site discomfort

Treatment of overdose: Administer a β1-adrenergic blocker; reduce IV or discontinue, ensure oxygenation/ventilation; for severe tachydysrhythmias

CLASS: Pituitary Hormone

ACTION: Promotes reabsorption of water by action on renal tubular epithelium; causes vasoconstriction

INDICATIONS: Diabetes insipidus (nonnephrogenic/nonpsychogenic), abdominal distention postoperatively, bleeding esophageal varices

DOSAGE AND ROUTES
Diabetes insipidus

• Adult: IM/SUBCUT 5–10 units bid-qid as needed; IM/SUBCUT 2.5–5 units q2–3 days (Pitressin Tannate) for chronic therapy; CONT IV INF 0.0005 units/kg/hr (0.05 milliunit/kg/hr), double dose q30min as needed

Abdominal distention

• Adult: IM 5 units, then q3-4hr, increasing to 10 units if needed (aqueous)

Available forms: Inj 20, 5 units/ml (tannate), spray, cotton pledgets

SIDE EFFECTS: Drowsiness, headache, lethargy, flushing, increased B/P, dysrhythmias, nausea, tremor, vertigo, urticaria, vomiting, flatus

CONTRAINDICATIONS: Hypersensitivity, chronic nephritis

PRECAUTIONS: Pregnancy (C), breastfeeding, CAD, asthma, renal/vascular disease, mirgaines, seizures

PHARMACOKINETICS

Nasal: Onset 1 hr; duration 3–8 hr; half-life 15 min; metabolized in liver, kidneys; excreted in urine

NURSING CONSIDERATIONS
Assess:

• Nasal mucosa if given by intranasal spray; for irritation
• Pulse, B/P, when giving product IV or IM
• I&O ratio, weight daily, fluid/electrolyte balance; check for edema in extremities;  if water retention is severe, diuretic may be prescribed
• H2O intoxication: lethargy, behavioral changes, disorientation, neuromuscular excitability

Evaluate:

• Therapeutic response: absence of severe thirst, decreased urine output, osmolality

Teach patient/family:

• To measure and record I&O
• To avoid alcohol, all OTC medications unless approved by prescriber

CLASS: Bronchodilator nonselective adrenergic agonist, vasopressor

ACTION: β1- and β2-agonist causing increased levels of cAMP producing bronchodilation, cardiac, and CNS stimulation; high doses cause vasoconstriction via α-receptors; low doses can cause vasodilation via β2-vascular receptors

INDICATIONS: Acute asthmatic attacks, hemostasis, bronchospasm, anaphylaxis, allergic reactions, cardiac arrest, adjunct in anesthesia, shock

Unlabeled uses: Bradycardia, chloroquine overdose

DOSAGE AND ROUTES
Asthma

Adult and child: INH 1–2 puffs of 1:100 or 2.25% racemic q15min

Bronchodilator

Adult: SUBCUT/IM 0.3-0.5 mg (1:1000 sol) q10-15min-4hr, max 1 mg/dose

Anaphylactic reaction/asthma
Adult: SUBCUT/IM 0.3-0.5 mg, repeat q10-15min, max 1 mg/dose; epINEPHrine susp 0.5 mg SUBCUT, may repeat 0.5-1.5 mg q6hr

Cardiac arrest (ACLS)
Adult: IV 1 mg q3-5min; ENDOTRACHEAL 2–2.5 mg; INTRACARDIAC 0.3-0.5 mg

Symptomatic bradycardia/pulseless arrest (PALS)
Child: IV 0.01 mg/kg, may repeat q3-5min up to 0.1-0.2 mg/kg; ENDOTRACHEAL give 2–10 × IV dose diluted to a volume of 3–5 ml of 0.9% NaCl, followed by positive pressure ventilation

Available forms: Aerosol 0.16 mg/spray, 0.2 mg/spray, 0.25 mg/spray; inj 1:1000 (1 mg/ml), 1:200 (5 mg/ml), 0.01 mg/ml (1:100,000), 0.1 mg/ml (1:10,000), 0.5 mg/ml (1:2000); sol for nebulization 1:100, 1.25%, 2.25% (base)

SIDE EFFECTS: tremors, anxiety, insomnia, headache, dizziness, confusion, hallucinations, cerebral hemorrhage, weakness, drowsiness, palpitations, tachycardia, hypertension, dysrhythmias, increased T wave, anorexia, nausea, vomiting, sweating, dry eyes, yspnea

CONTRAINDICATIONS: Hypersensitivity to sympathomimetics, angle-closure glaucoma, nonanaphylactic shock during general anesthesia

Precautions: Pregnancy (C), breastfeeding, cardiac disorders, hyperthyroidism, diabetes mellitus, prostatic hypertrophy, hypertension, organic brain syndrome, local anesthesia of certain areas, labor, cardiac dilation, coronary insufficiency, cerebral arteriosclerosis, organic heart disease

PHARMACOKINETICS
Crosses placenta, metabolized in liver

SUBCUT: Onset 5–15 min, duration 20 min-4 hr

INH: Onset 1–5 min, duration 1–3 hr

INTERACTIONS

• Do not use with MAOIs or tricyclics; hypertensive crisis may occur
• Toxicity: other sympathomimetics

Decrease: hypertensive effects—α-adrenergic blockers

NURSING CONSIDERATIONS
Assess:

• ECG during administration continuously; if B/P increases, decrease dose; B/P and pulse q5min after parenteral route; CVP, ISVR, PCWP during inf if possible; inadvertent high arterial B/P can result in angina, aortic rupture, cerebral hemorrhage
• Inj site: tissue sloughing; administer phentolamine with NS
• Sulfite sensitivity, which may be life-threatening

Administer:

• Increased dose of insulin in diabetic patients if glucose is elevated
• Check for correct concentration, route, dosage before administering

IM/SUBCUT route

• Rotate inj sites, massage after inj, shake before using

Endotracheal route

•    Give directly via endrotracheal tube, use 1:10,000 sol; for small dose further dilute dose prior to administration, follow with quick insufflations

Inhalation route

• Place in nebulizer (10 gtt of a 1% base sol)
• Dilute racepinephrine 2.25% sol

IV route

• Parenteral dose slowly, after reconstituting 1 mg (1:1000 sol)/10 ml or more 0.9% NaCl; to prepare a 1:10,000 sol for maintenance, may be further diluted in 500 ml D5W; give 1 mg or less over 1 min or more through Y-tube or 3-way stopcock; 1 mg = 1 ml of 1:1000 or 10 ml of 1:10,000; protect from light, use large vein

Additive compatibilities: Cimetidine, DOBUTamine, floxacillin, furosemide, metaraminol, ranitidine, verapamil

Syringe compatibilities: Doxapram, heparin, milrinone

Y-site compatibilities: Atracurium, calcium chloride, calcium gluconate, cisatracurium, diltiazem, DOBUTamine, DOPamine, famotidine, fentanyl, furosemide, heparin, hydrocortisone sodium succinate, hydromorphone, labetalol, lorazepam, midazolam, milrinone, morphine, niCARdipine, nitroglycerin, norepinephrine, pancuronium, phytonadione, potassium chloride, propofol, ranitidine, remifentanil, vecuronium, vit B/C, warfarin

Perform/provide:

• Storage of reconstituted sol refrigerated no longer than 24 hr
• Do not use discolored sol

Evaluate:

• Therapeutic response: increased B/P with stabilization or ease of breathing

Teach patient/family:

• The reason for product administration
• To rinse mouth after use to prevent dryness after inhalation
• Not to take OTC preparations

Treatment of overdose: Administer an α-blocker and a β-blocker

CLASS: Adrenergic, directacting

ACTION: Powerful and selective (α1) receptor agonist causing contraction of blood vessels

INDICATIONS: Hypotension, paroxysmal supraventricular tachycardia, shock, maintain B/P for spinal anesthesia

DOSAGE AND ROUTES
Hypotension
Adult: SUBCUT/IM 2–5 mg; may repeat q10-15min if needed; do not exceed initial dose; IV 0.1-0.5 mg; may repeat q10-15min if needed; do not exceed initial dose

Supraventricular tachycardia
Adult: IV BOL 0.5–1 mg given rapidly, not to exceed prior dose by >0.1 mg, total dose ≤1 mg

Shock
Adult: IV INF 10 mg/500 ml D5W given 100-180 mcg/min (if 20 gtt/ml inf device), then maintenance of 40-60 mcg/min; use inf device

Available forms: Inj 1% (10 mg/ml)

SIDE EFFECTS: Headache, anxiety, tremor, insomnia, dizziness, alpitations, tachycardia, hypertension, ectopic beats, angina, reflex bradycardia, dysrhythmias, nausea, vomiting, necrosis, tissue sloughing with extravasation, gangrene, anaphylaxis

CONTRAINDICATIONS: Hypersensitivity, ventricular fibrillation, tachydysrhythmias, pheochromocytoma, angle-closure glaucoma, severe hypertension

Precautions: Pregnancy (C), breastfeeding, arterial embolism, peripheral vascular disease, geriatric patients, hyperthyroidism, bradycardia, myocardial disease, severe arteriosclerosis, partial heart block

PHARMACOKINETICS
IM/SUBCUT: Onset 10-15 min, duration 45-60 min

IV: Onset immediate, duration 20-30 min

INTERACTIONS

• Dysrhythmias: general anesthetics, digoxin, bretylium
• Do not use within 2 wk of MAOIs, or hypertensive crisis may result

Increase: in B/P—oxytocics

Increase: pressor effect—tricyclics, β-blockers, H1 antihistamines

Decrease: phenylephrine action—α-blockers

NURSING CONSIDERATIONS
Assess:

• I&O ratio; notify prescriber if output <30 ml/hr
• ECG during administration continuously; if B/P increases, product is decreased
• B/P and pulse q5min after parenteral route
• CVP or PWP during inf if possible
• For paresthesias and coldness of extremities; peripheral blood flow may decrease

Administer:
IV route

• Plasma expanders for hypovolemia
• IV after diluting 1 mg/9 ml sterile H2O for inj; give dose over ½-1 min; may be diluted 10 mg/500 ml of D5W or NS; titrate to response (normal B/P); check for extravasation, check site for infiltration, use inf pump

Additive compatibilities: Chloramphenicol, DOBUTamine, lidocaine, potassium chloride, sodium bicarbonate

Y-site compatibilities: Amiodarone, amrinone, cisatracurium, famotidine, haloperidol, remifentanil, zidovudine

Perform/provide:

• Storage of reconstituted sol if refrigerated for no longer than 24 hr
• Discard discolored sol

Evaluate:

• Therapeutic response: increased B/P with stabilization

Teach patient/family:

• The reason for administration
• To report pain at inf site or other adverse reactions immediately

Treatment of overdose: Administer an α-blocker

CLASS: Antilipidemic

ACTION: Inhibits HMG-CoA reductase enzyme, which reduces cholesterol synthesis

INDICATIONS: As an adjunct in primary hypercholesterolemia (types IIa, IIb), isolated hypertriglyceridemia (Frederickson type IV) and type III hyperlipoproteinemia, CAD

DOSAGE AND ROUTES
Adult: PO 20 mg/day in PM initially; usual range 5–40 mg/day in PM, not to exceed 80 mg/day; dosage adjustments may be made in 4-wk intervals or more; those taking verapamil and amiodarone max 20 mg/day

Renal disease/those taking cycloSPORINE
Geriatric: PO 5 mg/day, initially

Cardiac/renal transplantation
Adult: PO 5 mg/day; max 10 mg/day

With amiodarone or verapamil
Adult: PO max 20 mg/day

With fibrates or niacin
Adult: PO max 10 mg/day

Available forms: Tabs 5, 10, 20, 40, 80 mg

SIDE EFFECTS: Headache, lens opacities, nausea, constipation, diarrhea, dyspepsia, flatus, abdominal pain, liver dysfunction, pancreatitis, rash, pruritus, photosensitivity, muscle cramps, myalgia, myositis, rhabdomyolysis, upper respiratory tract infection

CONTRAINDICATIONS: Pregnancy (X), breastfeeding, hypersensitivity, active hepatic disease

Precautions: Past hepatic disease, alcoholism, severe acute infections, trauma, severe metabolic disorders, electrolyte imbalances

PHARMACOKINETICS
Metabolized in liver (active metabolites); highly protein bound; excreted primarily in bile, feces (60%), kidneys (15%)

INTERACTIONS

Increase: effects of warfarin

Increase: myalgia, myositis—cycloSPORINE, gemfibrozil, niacin, erythromycin, clofibrate, clarithromycin, ketoconazole, itraconazole, protease inhibitors

Increase: serum level of digoxin

Drug/Herb

Increase: effect—glucomannan

Decrease: effect—gotu kola, St. John's wort

Drug/Lab Test

Increase: CPK, LFTs

NURSING CONSIDERATIONS
Assess:

• 12-hr fasting lipid profile: LDL, HDL, TG, cholesterol at 6–8 wk, and q6mo
• Hepatic studies q1-2mo during the first 1½ yr of treatment; AST, ALT, LFTs may increase
• For rhabdomyolysis: muscle tenderness, increased CPK levels; therapy should be discontinued
• Renal studies in patients with compromised renal system: BUN, I&O ratio, creatinine

Administer:

• Total daily dose in evening

Perform/provide:

• Storage in cool environment in tight container protected from light

Evaluate:

• Therapeutic response: decrease in cholesterol to desired level after 8 wk

Teach patient/family:

• That blood work and eye exam will be necessary during treatment
• To report blurred vision, severe GI symptoms, dizziness, headache
• That previously prescribed regimen will continue: low-cholesterol diet, exercise program

CLASS: Proton pump inhibitor

ACTION: Suppresses gastric secretion by inhibiting hydrogen/potassium ATPase enzyme system in gastric parietal cell; characterized as gastric acid pump inhibitor, since it blocks final step of acid production

INDICATIONS: Gastroesophageal reflux disease (GERD), severe erosive esophagitis, maintenance, long-term pathologic hypersecretory conditions including Zollinger-Ellison syndrome

Unlabeled uses: Duodenal/gastric ulcer, NSAID ulcer prophylaxis, H. pylori-associated ulcer, dyspepsia

DOSAGE AND ROUTES
GERD
Adult: PO 40 mg/day × 8 wk, may repeat course

Erosive esophagitis
Adult: IV 40 mg/day × 7–10 day PO 40 mg/day × 8 wk; may repeat PO course

Pathologic hypersecretory conditions
Adult: IV 80 mg q12hr; max 240 mg/day

Duodenal ulcer/gastric ulcer/NSAID ulcer prophylaxis (unlabeled)
Adult: PO 40 mg/day

H. pylori– associated ulcers (unlabeled)
Adult: PO 40 mg bid; may be used with other products

Available forms: Delayed rel tabs 20, 40 mg; powder for inj, freeze-dried 40 mg/vial

SIDE EFFECTS: Headache, insomnia, diarrhea, abdominal pain, flatulence, rash, hyperglycemia

CONTRAINDICATIONS: Hypersensitivity

Precautions: Pregnancy (C), breastfeeding, children

PHARMACOKINETICS
Peak 2.4 hr, duration >24 hr, half-life 1.5 hr, protein binding 97%, eliminated in urine as metabolites and in feces; in geriatric patients elimination rate decreased

INTERACTIONS

Increase: pantoprazole serum levels—diazepam, phenytoin, flurazepam, triazolam, clarithromycin

Increase: bleeding—warfarin

Decrease: absorption—sucralfate, calcium carbonate, vit B12

NURSING CONSIDERATIONS
Assess:

• GI system: bowel sounds q8hr, abdomen for pain, swelling, anorexia
• Hepatic studies: AST, ALT, alk phos during treatment

Administer:
PO route

• Swallow del rel tabs whole; do not break, crush, or chew
• Take del rel tabs at same time of day
• May take with or without food

IV route

• Reconstitute with 10 ml 0.9% NaCl, further dilute with 80 ml LR, D5, 0.9% NaCl (0.8 mg/ml), give over 15 min (≤6 mg/min) or as IV push over 2 min

Evaluate:

• Therapeutic response: absence of epigastric pain, swelling, fullness

Teach patient/family:

• To report severe diarrhea; product may have to be discontinued
• That diabetic patient should know hyperglycemia may occur
• To avoid hazardous activities; dizziness may occur
• To avoid alcohol, salicylates, ibuprofen; may cause GI irritation
• To notify prescriber if pregnant or plan to become pregnant, do not breastfeed