Copd

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DAVIS'S Drug Guide for NURSES TENTH EDITION





alendronate
(a-len-drone-ate)
Fosamax

CLASSIFICATION(S)
Therapeutic: bone resorption inhibitors
Pharmacologic: biphosphonates

Pregnancy Category C



INDICATIONS

• Treatment and prevention of postmenopausal osteoporosis
• Treatment of osteoporosis in men
• Treatment of Paget's disease of the bone
• Treatment of corticosteroid-induced osteoporosis in patients (men and women) who are receiving >7.5 mg of prednisone/day (or equivalent) with evidence of decreased bone mineral density

ACTION

• Inhibits resorption of bone by inhibiting osteoclast activity
• Therapeutic Effects: ○ Reversal of the progression of osteoporosis with decreased fractures
○ Decreased progression of Paget's disease


PHARMACOKINETICS

Absorption: Poorly absorbed (0.6-0.8%) after oral administration
Distribution: Transiently distributes to soft tissue, then distributes to bone
Metabolism and Excretion: Excreted in urine
Half-life: 10 yr (reflects release of drug from skeleton)

TIME OF ACTION

inhibition of bone resorption ONSET PEAK DURATION
PO 1 mo 3-6 mo 3 wk-7 mo†
†After discontinuation of alendronate

CONTRAINDICATIONS/PRECAUTIONS

Contraindicated in: • Renal insufficiency (CCr <35 ml/min)
• OB: Pregnancy or lactation
Use Cautiously in: • Patients with active GI pathology (dysphagia, esophageal disease, gastritis, duodenitis, ulcers)
• Pre-existing hypocalcemia or vitamin D deficiency

ADVERSE REACTIONS/SIDE EFFECTS*

*CAPITALS indicate life threatening; underlines indicate most frequent.

CNS: headache,
EENT: blurred vision, conjunctivitis, eye pain/inflammation,
GI: abdominal distention, abdominal pain, acid regurgitation, constipation, diarrhea, dyspepsia, dysphagia, esophageal ulcer, flatulence, gastritis, nausea, taste perversion, vomiting,
Derm: erythema, photosensitivity, rash,
MS: musculoskeletal pain,

INTERACTIONS

Drug-Drug:
• Calcium supplements , antacids , and other oral medications ↓ the absorption of alendronate
• Doses >10 mg/day ↑ risk of adverse GI events when used with NSAIDs
• IV ranitidine ↑ blood levels
Drug-Food:
• Food significantly ↓ absorption. Caffeine (coffee, tea, cola) , mineral water , and orange juice also ↓ absorption

ROUTE AND DOSAGE

• PO (Adults ): Treatment of osteoporosis --10 mg once daily or 70 mg once weekly. Prevention of osteoporosis--5 mg once daily or 35 mg once weekly. Paget's disease--40 mg once daily for 6 mo. Retreatment may be considered for patients who relapse. Treatment of corticosteroid-induced osteoporosis in men and premenopausal women--5 mg once daily. Treatment of corticosteroid-induced osteoporosis in postmenopausal women not receiving estrogen--10 mg once daily

AVAILABILITY
• Tablets: 5 mg, 10 mg, 35 mg, 40 mg, 70 mg
• Cost: 5 mg $75.44/30, 10 mg $75.44/30, 40 mg $177.89/30
• Oral solution (raspberry flavor) : 70 mg/75 ml in cartons of 4 unit-of-use bottles
• In combination with: Vitamin D (Fosamax plus D) See Appendix b

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NURSING IMPLICATIONS

ASSESSMENT

• Osteoporosis: Assess patients for low bone mass before and periodically during therapy
• Paget's Disease: Assess for symptoms of Paget's disease (bone pain, headache, decreased visual and auditory acuity, increased skull size)
• Lab Test Considerations: Osteoporosis: Assess serum calcium before and periodically during therapy. Hypocalcemia and vitamin D deficiency should be treated before initiating alendronate therapy. May cause mild, transient elevations of calcium and phosphate ○ Paget's Disease: Monitor alkaline phosphatase before and periodically during therapy. Alendronate is indicated for patients with alkaline phosphatase twice the upper limit of normal


POTENTIAL NURSING DIAGNOSES

• Risk for injury (Indications).

IMPLEMENTATION

• Do not confuse Fosamax (alendronate) with Flomax (tamsulosin)
• PO: Administer first thing in the morning with 6-8 oz plain water 30 min before other medications, beverages, or food

PATIENT/FAMILY TEACHING

• Instruct patient on the importance of taking exactly as directed, first thing in the morning, 30 min before other medications, beverages, or food. Waiting longer than 30 min will improve absorption. Alendronate should be taken with 6-8 oz plain water (mineral water, orange juice, coffee, and other beverages decrease absorption). If a dose is missed, skip dose and resume the next morning; do not double doses or take later in the day. If a weekly dose is missed, take the morning after remembered and resume the following week on the chosen day. Do not take 2 tablets on the same day. Do not discontinue without consulting health care professional ○ Caution patient to remain upright for 30 min following dose to facilitate passage to stomach and minimize risk of esophageal irritation. Advise patient to discontinue alendronate and notify health care provider if pain or difficulty swallowing, retrosternal pain or new/worsening heartburn occur
○ Advise patient to eat a balanced diet and consult health care professional about the need for supplemental calcium and vitamin D
○ Encourage patient to participate in regular exercise and to modify behaviors that increase the risk of osteoporosis (stop smoking, reduce alcohol consumption)
○ Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions
○ Advise patient to notify health care professional if blurred vision, eye pain or inflammation occur
○ Advise female patient to notify health care professional if pregnancy is planned or suspected or if she is breastfeeding


EVALUATION/DESIRED OUTCOMES

• Prevention of or decrease in the progression of osteoporosis in postmenopausal women
• Treatment of osteoporosis in men
• Decrease in the progression of Paget's disease
• Treatment of corticosteroid-induced osteoporosis

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amitriptyline
(a-mee-trip-ti-leen)
Apo-Amitriptyline, Elavil, Endep, Levate, Novotriptyn

CLASSIFICATION(S)
Therapeutic: antidepressants
Pharmacologic: tricyclic antidepressants

Pregnancy Category D

= Canadian drug name.

INDICATIONS

• Treatment of depression, often in conjunction with psychotherapy
• Unlabelled Uses: • Chronic pain syndromes


ACTION

• Potentiates the effect of serotonin and norepinephrine in the CNS
• Has significant anticholinergic properties
• Therapeutic Effects: ○ Antidepressant action


PHARMACOKINETICS

Absorption: Well absorbed from the GI tract
Distribution: Widely distributed
Protein Binding: 95% bound to plasma proteins
Metabolism and Excretion: Extensively metabolized by the liver. Some metabolites have antidepressant activity. Undergoes enterohepatic recirculation and secretion into gastric juices. Probably crosses the placenta and enters breast milk
Half-life: 10-50 hr

TIME OF ACTION

antidepressant effect ROUTE ONSET PEAK DURATION
PO 2-3 wk (up to 30 days) 2-6 wk days-wks
IM 2-3 wk 2-6 wk days-wks

CONTRAINDICATIONS/PRECAUTIONS

Contraindicated in: • Narrow-angle glaucoma
Use Cautiously in: • Geri: Appears on Beers list. Geriatric patients are at increased risk of adverse reactions including falls secondary to sedative and anticholinergic effects
• May ↑ risk of suicide attempt/ideation especially during dose early treatment or dose adjustment; risk may be greater in children or adolescents
• Patients with pre-existing cardiovascular disease
• Prostatic hypertrophy (increased risk of urinary retention)
• History of seizures (threshold may be ↓)
• OB: Pregnancy; use only if clearly needed and maternal benefits outweigh risk to fetusLactation (may result in sedation in infant)
• Pedi: Children < 12 yr (safety not established)

ADVERSE REACTIONS/SIDE EFFECTS*

*CAPITALS indicate life threatening; underlines indicate most frequent.

CNS: lethargy, sedation,
EENT: blurred vision, dry eyes, dry mouth,
CV: ARRHYTHMIAS, hypotension, ECG changes,
GI: constipation, hepatitis, paralytic ileus,
GU: urinary retention,
Derm: photosensitivity,
Endo: changes in blood glucose, gynecomastia,
Hemat: blood dyscrasias,
Misc: increased appetite, weight gain,

INTERACTIONS

Drug-Drug:
• Amitriptyline is metabolized in the liver by the cytochrome P450 2D6 enzyme, and its action may be affected by drugs that compete for metabolism by this enzyme, including other antidepressants , phenothiazines , carbamazepine , class 1C antiarrhythmics including propafenone , and flecainide ; when these drugs are used concurrently with amitriptyline, dosage ↓ of one or the other or both may be necessary. Concurrent use of other drugs that inhibit the activity of the enzyme, including cimetidine , quinidine , amiodarone , and ritonavir , may result in ↑ effects of amitriptyline
• May cause hypotension, tachycardia, and potentially fatal reactions when used with MAO inhibitors (avoid concurrent use--discontinue 2 wk before starting amitriptyline)
• Concurrent use with SSRI antidepressants may result in ↑ toxicity and should be avoided ( fluoxetine should be stopped 5 wk before starting amitriptyline)
• Concurrent use with clonidine may result in hypertensive crisis and should be avoided
• Concurrent use with levodopa may result in delayed or ↓ absorption of levodopa or hypertension
• Blood levels and effects may be ↓ by rifamycins ( rifampin , rifapentine , and rifabutin )
• Concurrent use with moxifloxaxin ↑ risk of adverse cardiovascular reactions
• ↑ CNS depression with other CNS depressants including alcohol , antihistamines , clonidine , opioids , and sedative/hypnotics
• Barbiturates may alter blood levels and effects
• Adrenergic and anticholinergic side effects may be ↑ with other agents having anticholinergic properties
• Phenothiazines or oral contraceptives ↑ levels and may cause toxicity
• Nicotine may ↑ metabolism and alter effects
Drug-Natural:
• St. John's wort may decrease serum concentrations and efficacy
• Concomitant use of kava, valerian, or chamomile can increase CNS depression
• Increased anticholinergic effects with jimson weed and scopolia

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ROUTE AND DOSAGE

• PO (Adults ): 75 mg/day in divided doses; may be increased up to 150 mg/day or 50-100 mg at bedtime, may increase by 25-50 mg up to 150 mg (in hospitalized patients, may initiate with 100 mg/day, increasing total daily dose up to 300 mg)
• PO (Geriatric Patients and Adolescents): 10 mg tid and 20 mg at bedtime or 25 mg at bedtime initially, slowly increased to 100 mg/day as a single bedtime dose or divided doses
• IM (Adults ): 20-30 mg 4 times daily

AVAILABILITY
• Tablets: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg
• Cost: 10 mg $17.90/100, 25 mg $35.75/100, 75 mg $85.25/100, 100 mg $108.00/100, 150 mg $108.86/100
• Syrup: 10 mg/5 ml
• Injection: 10 mg/ml


NURSING IMPLICATIONS

ASSESSMENT

• Monitor blood pressure and pulse before and during initial therapy. Notify physician or other health care professional of decreases in blood pressure (10-20 mmHg) or sudden increase in pulse rate. Patients taking high doses or with a history of cardiovascular disease should have ECG monitored before and periodically during therapy
• Geri: Geriatric patients started on amitriptyline may be at an increased risk for falls; start with low dose and monitor closely. Assess for anticholinergic effects (weakness and sedation).
• Depression: Monitor mental status and affect. Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient
• Pain: Assess intensity, quality, and location of pain periodically during therapy. May require several weeks for effects to be seen
• Lab Test Considerations: Assess leukocyte and differential blood counts, liver function, and serum glucose before and periodically during therapy. May cause an ↑ serum bilirubin and alkaline phosphatase. May cause bone marrow depression. Serum glucose may be ↑ or ↓

POTENTIAL NURSING DIAGNOSES

• Ineffective coping (Indications).
• Risk for injury (Side Effects).

IMPLEMENTATION

• Do not confuse Elavil (amitriptyline) with Oruvail (ketoprofen) ○ Dose increases should be made at bedtime because of sedation. Dose titration is a slow process; may take weeks to months. May give entire dose at bedtime. Sedative effect may be apparent before antidepressant effect is noted

• PO: Administer medication with or immediately after a meal to minimize gastric upset. Tablet may be crushed and given with food or fluids
• IM: For short-term IM administration only. Do not administer IV

PATIENT/FAMILY TEACHING

• Instruct patient to take medication exactly as directed. If a dose is missed, take as soon as possible unless almost time for next dose; if regimen is a single dose at bedtime, do not take in the morning because of side effects. Advise patient that drug effects may not be noticed for at least 2 wk. Abrupt discontinuation may cause nausea, vomiting, diarrhea, headache, trouble sleeping with vivid dreams, and irritability
• May cause drowsiness and blurred vision. Caution patient to avoid driving and other activities requiring alertness until response to drug is known
• Orthostatic hypotension, sedation, and confusion are common during early therapy, especially in geriatric patients. Protect patient from falls and advise patient to make position changes slowly
• Advise patient to avoid alcohol or other CNS depressant drugs during and for 3-7 days after therapy has been discontinued
• Instruct patient to notify health care professional if urinary retention occurs or if dry mouth or constipation persists. Sugarless candy or gum may diminish dry mouth, and an increase in fluid intake or bulk may prevent constipation. If symptoms persist, dose reduction or discontinuation may be necessary. Consult health care professional if dry mouth persists for more than 2 wk
• Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions
• Inform patient of need to monitor dietary intake. Increase in appetite may lead to undesired weight gain
• Advise patient to notify health care professional if pregnancy is planned or suspected or if breastfeeding
• Advise patient to notify health care professional of medication regimen before treatment or surgery. Medication should be discontinued as long as possible before surgery
• Therapy for depression is usually prolonged and should be continued for at least 3 months to prevent relapse. Emphasize the importance of follow-up exams to monitor effectiveness and side effects

EVALUATION/DESIRED OUTCOMES

• Increased sense of well-being ○ Renewed interest in surroundings
○ Increased appetite
○ Improved energy level
○ Improved sleep

• Decrease in chronic pain symptoms
• Full therapeutic effects may be seen 2-6 wk after initiating therapy

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ANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan
(can-de-sar-tan) Atacand

eprosartan
(ep-roe-sar-tan) Teveten

irbesartan
(ir-be-sar-tan) Avapro

losartan
(loe-sar-tan) Cozaar

olmesartan
(ole-me-sar-tan) Benicar

telmisartan
(tel-mi-sar-tan) Micardis

valsartan
(val-sar-tan) Diovan

CLASSIFICATION(S)
Therapeutic: antihypertensives
Pharmacologic: angiotensin II receptor antagonists

Pregnancy Category C (first trimester) D (second and third trimesters)



INDICATIONS

• Management of hypertension
• Treatment of type 2 diabetic nephropathy in patients with type 2 diabetes and hypertension (irbesartan and losartan only)
• Management of CHF in patients who cannot tolerate ACE inhibitors (candesartan and valsartan only)
• Reduced risk of stroke in patients with CHF and left ventricular hypertrophy; effect may be less in black patients (losartan only)

ACTION

• Blocks vasoconstrictor and aldosterone-producing effects of angiotensin II at receptor sites, including vascular smooth muscle and the adrenal glands
• Therapeutic Effects: ○ Lowering of blood pressure
○ Slowed progression of diabetic nephropathy (irbesartan, losartan)
○ Decreased hospitalizations in patients with CHF
○ Decreased risk of stroke


PHARMACOKINETICS

Absorption: Candesartan--Candesartan cilexetil is converted to candesartan in the GI tract where 15% is absorbed; eprosartan--13% absorbed; irbesartan--60-80% absorbed; losartan--well absorbed; with extensive first-pass hepatic metabolism, resulting in 33% bioavailability; olmesartan--26% absorbed; telmisartan--42-58% absorbed following oral administration (bioavailability ↑ hepatic impairment); valsartan--25% absorbed following oral administration
Distribution: Unknown; candesartan--minimal penetration of the blood-brain barrier
Protein Binding: eprosartan--98%; olmesartan--99%
Metabolism and Excretion: Candesartan--Excreted mostly unchanged in urine and feces (via bile); minor metabolism by the liver; eprosartan--90% eliminated unchanged in feces via biliary elimination, 7% excreted in urine; irbesartan--some hepatic metabolism, some biliary excretion, some elimination as unchanged drug in urine; losartan-- extensive first-pass hepatic metabolism; 14% is converted to an active metabolite. 4% of losartan is excreted unchanged by the kidneys; 6% of active metabolite is excreted unchanged by the kidneys, some biliary elimination ; olmesartan--30-50% excreted unchanged in urine, remainder eliminated in feces via bile; telmisartan--excreted mostly unchanged in feces via biliary excretion, 11% metabolized by the liver; valsartan--20% metabolized by the liver; mostly excreted in feces via bile
Half-life: Candesartan--9 hr; eprosartan--5-9 hr;irbesartan--11-15 hr; losartan--2 hr (6-9 hr for metabolite); olmesartan--13 hr; telmisartan--24 hr; valsartan--6 hr

TIME OF ACTION

antihypertensive effect† ROUTE ONSET PEAK DURATION
Candesartan 2-4 hr 6-8 hr 24 hr
Eprosartan 1-2 hr unk 12-24 hr
Irbesartan within 2 hr 3-14 hr 24 hr
Losartan unknown 6 hr 24 hr
Olmesartan within 1 2 wk 24 hr
Telmisartan within 3 hr unknown 24 hr
Valsartan within 2 hr 4-6 hr 24 hr
†Maximum response may take 2-3 wk of treatment

CONTRAINDICATIONS/PRECAUTIONS

Contraindicated in: • Hypersensitivity
• OB: Pregnancy or lactation
Use Cautiously in: • CHF (may result in azotemia, oliguria, acute renal failure and/or death)
• Volume- or salt-depleted patients or patients receiving high doses of diuretics (correct deficits before initiating therapy or initiate at lower doses)
• Black patients (monotherapy may not be effective)
• Impaired renal function due to primary renal disease or CHF (may worsen renal function)
• Obstructive biliary disorders or hepatic impairment (lower initial doses of losartan, temisartan, or valsartan recommended)
• OB: Patients with childbearing potential
• Pedi: Children <18 yr (safety not established)

ADVERSE REACTIONS/SIDE EFFECTS*

*CAPITALS indicate life threatening; underlines indicate most frequent.

CNS: dizziness, fatigue, headache,
CV: hypotension,
GI: diarrhea, drug-induced hepatitis,
GU: RENAL FAILURE,
F and E: hyperkalemia,

INTERACTIONS

Drug-Drug:
• NSAIDs may ↓ antihypertensive effects
• ↑ antihypertensive effects with other antihypertensives and diuretics . Risk of hypotension ↑ by concurrent diuretics (use lower initial doses) and nitrates
• Telmisartan ↑ serum digoxin levels
• Concurrent use of potassium-sparing diuretics or potassium supplements may ↑ risk of hyperkalemia
• Candesartan may ↑ serum lithium levels; monitoring is required

ROUTE AND DOSAGE



Candesartan • PO (Adults ): As monotherapy--16 mg once daily. Patients receiving diuretics or who are volume depleted--initiate therapy at a lower dose (range 2-32 mg/day as a single dose or divided into two daily doses).CHF 4 mg once daily initially, dose may be doubled at 2 wk intervals up to target dose of 32 mg once daily

Renal Impairment
• PO (Adults ): Initiate therapy at a lower dose


Eprosartan • PO (Adults ): 600 mg once daily, may also be given in divided doses twice daily (usual range 400-800 mg/day)


Irbesartan • PO (Adults ): Hypertension--150 mg once daily; may be increased to 300 mg once daily. Patients receiving diuretics, who are volume depleted, or who are being hemodialyzed--initiate with 75 mg/day.Type 2 diabetic nephropathy--300 mg once daily


Losartan • PO (Adults ): Hypertension--50 mg/day initially (range 25-100 mg/day as a single daily dose or 2 divided doses). Patients receiving diuretics or who are volume depleted--25 mg/day initially; may be increased as tolerated.Patients with hypertension and CHF (stroke prevention--50 mg/day initially; hydrochlorothiazide 12.5 mg daily should be added and/or dose increased to 100 mg/day followed by an increase in hydrochlorothiazide to 25 mg/day based on blood pressure response.Type 2 diabetic nephropathy--50 mg once daily, may increase to 100 mg/daily depending on blood pressure response

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Hepatic Impairment

• PO (Adults ): 25 mg/day initially; may be increased as tolerated
• PO (Children > 6 yr): 0.7 mg/kg once daily (up to 1.4 mg/kg or 100 mg/day)


Olmesartan • PO (Adults ): 20 mg/day (patients who are volume-depleted should be started on lower doses)


Valsartan • PO (Adults ): Hypertension80 mg/day as a single dose initially in patients who are not receiving diuretics or other antihypertensives; may be increased to 160-320 mg/day; CHF--40 mg twice daily initially, may be titrated to 160 mg twice daily; concurrent ACE inhibitor and beta-blocker therapy not recommended; consider reduction of diuretics

AVAILABILITY


Candesartan • Tablets: 4 mg, 8 mg, 16 mg, 32 mg
• Cost: 4 mg $40.26/30, 8 mg $40.26/30, 16 mg $40.26/30, 32 mg $54.46/30
• In combination with: hydrochlorothiazide (Atacand HCT; see Appendix B )


Eprosartan • Tablets: 400 mg, 600 mg
• In combination with: hyhdrochlorothiazide (Teveten HCT; see Appendix B )


Irbesartan • Tablets: 75 mg, 150 mg, 300 mg
• Cost: 75 mg $41.05/30, 150 mg $43.21/30, 300 mg $51.95/30
• In combination with: hydrochlorothiazide (Avalide; see Appendix B )


Losartan • Tablets: 25 mg, 50 mg, 100 mg
• Cost: 25 mg $128.73/90, 50 mg $42.90/30, 100 mg $58.44/30
• In combination with: hydrochlorothiazide (Hyzaar; see Appendix B )


Olmesartan • Tablets: 5 mg, 20 mg , 40 mg
• In combination with: hydrochlorothiazide (Benicar HCT; see Appendix B )


Telmisartan • Tablets: 40 mg, 80 mg
• In combination with: hydrochlorothiazide (Micardis HCT; see Appendix B )


Valsartan • Capsules: 80 mg, 160 mg
• Cost: 80 mg $139.75/100, 160 mg $151.70/100
• Tablets: 80 mg, 160 mg, 320 mg
• In combination with: hydrochlorothiazide (Diovan HCT; See Appendix B )


NURSING IMPLICATIONS

ASSESSMENT

• Assess blood pressure (lying down, sitting, standing) and pulse periodically during therapy
• Monitor frequency of prescription refills to determine adherence
• Assess patient for signs of angioedema (dyspnea, facial swelling). May rarely cause angioedema; more common in patients who have had angioedema with ACE inhibitors
• CHF: Monitor intake and output ratios and daily weight. Assess for peripheral edema and auscultate lungs for rales/crackles during therapy
• Lab Test Considerations: Monitor serum creatinine and urinary protein in patients treated for diabetic nephropathy ○ May rarely cause ↑ in BUN and serum creatinine
○ May cause ↑ serum bilirubin
○ May occasionally cause hyperkalemia
○ Losartan may cause transient ↑ of ALT and AST, hemoglobin, and hematocrit and ↓ uric acid concentrations


POTENTIAL NURSING DIAGNOSES

• Risk for injury (Adverse Reactions).
• Noncompliance (Patient/Family Teaching).

IMPLEMENTATION

• Do not confuse Diovan (valsartan) with Zyban (buproprion) Do not confuse valsartan with losartan ○ Correct volume depletion , if possible, prior to initiation of therapy

• PO: May be administered without regard to meals

PATIENT/FAMILY TEACHING

• Emphasize the importance of continuing to take as directed, even if feeling well. Take missed doses as soon as remembered if not almost time for next dose; do not double doses. Medication controls but does not cure hypertension. Instruct patient to take medication at the same time each day. Gradual reduction of dose prior to discontinuation is suggested
• Encourage patient to comply with additional interventions for hypertension (weight reduction, low-sodium diet, discontinuation of smoking, moderation of alcohol consumption, regular exercise, stress management)
• Instruct patient and family on proper technique for monitoring blood pressure. Advise them to check blood pressure at least weekly and to report significant changes
• Caution patient to avoid sudden changes in position to decrease orthostatic hypotension. Use of alcohol, standing for long periods, exercising, and hot weather may increase orthostatic hypotension
• Advise women of childbearing age to use contraception and notify health care professional if pregnancy is suspected or planned
• May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known
• Advise patient to consult health care professional before taking any OTC or herbal cough, cold, or allergy remedies or other medications
• Instruct patient to notify health care professional of medication regimen prior to treatment or surgery
• Emphasize the importance of follow-up exams to evaluate effectiveness of medication

EVALUATION/DESIRED OUTCOMES

• Decrease in blood pressure without appearance of excessive side effects
• Slowed progression of diabetic nephropathy
• Decreased hospitalizations in patients with CHF
• Reduced risk of stroke

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DOCUSATE
(dok-yoo-sate)

docusate calcium
DC Softgels, Dioctocal, Pro-Cal-Sof, Sulfolax, Surfak

docusate sodium
Colace, Correctol Stool Softener Soft Gels, Diocto, Docu, Docusoft S, DOK, DOS Softgels, DOS, DOSS, DSS, Dulcolax Stool Softener, Ex-Lax Stool Softener, Fleet Sof-Lax, Modane Soft, Philliips Liqui-Gels, Regulax-SS, Regulex, Silace, Soflax, Stool Softener, Therevac SB

CLASSIFICATION(S)
Therapeutic: laxatives
Pharmacologic: stool softeners

Pregnancy Category C

= Canadian drug name.

INDICATIONS

• PO: Prevention of constipation (in patients who should avoid straining, such as after MI or rectal surgery)
• Rect: Used as enema to soften fecal impaction

ACTION

• Promotes incorporation of water into stool, resulting in softer fecal mass
• May also promote electrolyte and water secretion into the colon
• Therapeutic Effects: ○ Softening and passage of stool


PHARMACOKINETICS

Absorption: Small amounts may be absorbed from the small intestine after oral administration. Absorption from the rectum is not known
Distribution: Unknown
Metabolism and Excretion: Amounts absorbed after oral administration are eliminated in bile
Half-life: Unknown

TIME OF ACTION

softening of stool ROUTE ONSET PEAK DURATION
PO 24-48 hr (up to 3-5 days) unknown unknown
Rectal 2-15 min unknown unknown

CONTRAINDICATIONS/PRECAUTIONS

Contraindicated in: • Hypersensitivity
• Abdominal pain, nausea, or vomiting, especially when associated with fever or other signs of an acute abdomen
Use Cautiously in: • Excessive or prolonged use may lead to dependence
• Should not be used if prompt results are desired
• OB: Has been used during pregnancy and lactation

ADVERSE REACTIONS/SIDE EFFECTS*

*CAPITALS indicate life threatening; underlines indicate most frequent.

EENT: throat irritation,
GI: mild cramps,
Derm: rashes,

INTERACTIONS

Drug-Drug:
• None significant

ROUTE AND DOSAGE



Docusate Calcium • PO (Adults ): 240 mg once daily
• PO (Children >6 yr and Adults with Minimal Requirements ): 50-150 mg once daily


Docusate Sodium • PO (Adults and Children >12 yr): 50-500 mg once daily
• PO (Children 6-12 yr): 40-120 mg once daily
• PO (Children 3-6 yr): 20-60 mg once daily
• PO (Children <3 yr): 10-40 mg once daily
• Rect (Adults ): 50-100 mg or 1 unit containing 283 mg docusate sodium, soft soap, and glycerin

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AVAILABILITY


Docusate Calcium • Capsules: 50 mgOTC, 240 mgOTC


Docusate Sodium • Tablets: 100 mgOTC
• Cost: $4.25/100
• Capsules: 50 mgOTC, 100 mgOTC, 120 mgOTC, 240 mgOTC, 250 mgOTC
• Syrup: 20 mg/5 mlOTC
• Liquid: 150 mg/15 mlOTC
• Solution: 50 mg/5 mlOTC
• Enema: 283 mg/3.9-g capsuleOTC
• In combination with: stimulant laxativesOTC. See Appendix B


NURSING IMPLICATIONS

ASSESSMENT

• Assess for abdominal distention, presence of bowel sounds, and usual pattern of bowel function
• Assess color, consistency, and amount of stool produced

POTENTIAL NURSING DIAGNOSES

• Constipation (Indications).

IMPLEMENTATION

• This medication does not stimulate intestinal peristalsis
• PO: Administer with a full glass of water or juice. May be administered on an empty stomach for more rapid results ○ Oral solution may be diluted in milk or fruit juice to decrease bitter taste
○ Do not administer within 2 hr of other laxatives, especially mineral oil. May cause increased absorption


PATIENT/FAMILY TEACHING

• Advise patients that laxatives should be used only for short-term therapy. Long-term therapy may cause electrolyte imbalance and dependence
• Encourage patients to use other forms of bowel regulation, such as increasing bulk in the diet, increasing fluid intake (6-8 full glasses/day), and increasing mobility. Normal bowel habits are variable and may vary from 3 times/day to 3 times/wk
• Instruct patients with cardiac disease to avoid straining during bowel movements (Valsalva maneuver)
• Advise patient not to use laxatives when abdominal pain, nausea, vomiting, or fever is present
• Advise patient not to take docusate within 2 hr of other laxatives

EVALUATION/DESIRED OUTCOMES

• A soft, formed bowel movement, usually within 24-48 hr. Therapy may take 3-5 days for results. Rectal dose forms produce results within 2-15 min

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DIURETICS (POTASSIUM-SPARING)

amiloride
(a-mill-oh-ride)
Midamor

spironolactone
(speer-oh-no-lak-tone)
Aldactone, Novospiroton

triamterene
(trye-am-ter-een)
Dyrenium

CLASSIFICATION(S)
Therapeutic: diuretics
Pharmacologic: potassium-sparing diuretics

Pregnancy Category B (amiloride, triamterene) UK (spironolactone)

= Canadian drug name.

INDICATIONS

• Counteract potassium loss caused by other diuretics
• Used with other agents (thiazides) to treat edema or hypertension
• Hyperaldosteronism (spironolactone only)
• Unlabelled Uses: • Spironolactone: Management of CHF (low doses)


ACTION

• Cause loss of sodium bicarbonate and calcium while saving potassium and hydrogen ions
• Therapeutic Effects: ○ Weak diuretic and antihypertensive response when compared with other diuretics
○ Conservation of potassium


PHARMACOKINETICS

Absorption: Amiloride--15-25% absorbed from the GI tract; spironolactone-->90% absorbed; triamterene--30-70% absorbed
Distribution: Amiloride and triamterene--widely distributed; spironolactone--crosses the placenta; enters breast milk
Protein Binding: spironolactone and canrenone-->90%
Metabolism and Excretion: Amiloride--50% eliminated unchanged in urine, 40% excreted unabsorbed in the feces; spironolactone--converted by the liver to its active diuretic compound (canrenone); triamterene--partially metabolized by the liver, some excretion of unchanged drug
Half-life: Amiloride--6-9 hr; spironolactone--13-24 hr (canrenone); triamterene--100-150 min

TIME OF ACTION

diuretic effect ROUTE ONSET PEAK DURATION
Amiloride 2 hr† 6-10 hr† 24 hr†
Spironolactone unknown 2-3 days‡ 2-3 days‡
Triamterene 2-4 hr† 1-several days‡ 7-9 hr†
†Single dose
‡Multiple doses

CONTRAINDICATIONS/PRECAUTIONS

Contraindicated in: • Hypersensitivity
• Hyperkalemia
Use Cautiously in: • Hepatic dysfunction
• Geriatric or debilitated patients or patients with diabetes mellitus (increased risk of hyperkalemia,presence of age-related renal dysfunction; dosage adjustments may be necessary))
• Renal insufficiency (BUN >30 mg/dl or CCr <30 ml/min)
• History of gout or kidney stones (triamterene only)
• Pregnancy, lactation, or children (safety not established)

ADVERSE REACTIONS/SIDE EFFECTS*

*CAPITALS indicate life threatening; underlines indicate most frequent.

CNS: dizziness, spironolactone only: clumsiness, headache,
CV: arrhythmias,
GI: amiloride: constipation, GI irritation (increased with spironolactone),
GU: impotence, triamterene--bluish urine, nephrolithiasis,
Derm: triamterene: photosensitivity,
Endo: spironolactone: gynecomastia,
F and E: hyperkalemia, hyponatremia,
Hemat: spironolactone and triamterene: dyscrasias,
MS: muscle cramps,
Misc: allergic reactions,

INTERACTIONS

Drug-Drug:
• ↑ hypotension with acute ingestion of alcohol , other antihypertensives , or nitrates
• Use with ACE inhibitors , angiotensin II receptor antagonists , indomethacin , potassium supplements , or cyclosporine ↑ risk of hyperkalemia
• ↓ lithium excretion
• Effectiveness may be ↓ by NSAIDs
• Spironolactone may ↑ effects of digoxin
• Triamterene ↓ effects of folic acid (leucovorin should be used)
• Triamterene may ↑ risk of toxicity from amantadine

ROUTE AND DOSAGE



Amiloride • PO (Adults ): 5-10 mg/day (up to 20 mg)


Spironolactone • PO (Adults ): 25-400 mg/day as a single dose or 2-4 divided doses. CHF--12.5-25 mg/day (unlabeled use)
• PO (Children ): 1-3 mg/kg/day (30-90 mg/m2/day as a single dose or 2-4 divided doses (not to exceed 3 times initial dose)


Triamterene • PO (Adults ): 100 mg twice daily (not to exceed 300 mg/day; lower doses in combination products)
• PO (Children ): 2-4 mg/kg/day (120 mg/m2/day) in divided doses given daily or every other day (not to exceed 6 mg/kg/day or 300 mg/day)

AVAILABILITY


Amiloride • Tablets: 5 mg
• Cost: $57.65/100
• In combination with: hydrochlorothiazide (Moduretic, {Moduret}). See Appendix B


Spironolactone • Tablets: 25 mg, 50 mg, 100 mg
• Cost: Aldactone--25 mg $55.75/100, 50 mg $97.91/100, 100 mg $164.16/100; generic--25 mg $8.94/100
• In combination with: hydrochlorothiazide (Aldactazide, {Novo-Spirozine}, Spirazide). See Appendix B


Triamterene • Capsules: 50 mg, 100 mg
• Cost: 50 mg $94.52/100, 100 mg $171.88/100
• Tablets: 50 mg, 100 mg
• In combination with: hydrochlorothiazide (Apo-Triazide, Dyazide, Maxzide, {Novo-Triamzide}). See Appendix B

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NURSING IMPLICATIONS

ASSESSMENT

• Monitor intake and output ratios and daily weight during therapy
• If medication is given as an adjunct to antihypertensive therapy, monitor blood pressure before administering
• Monitor response of signs and symptoms of hypokalemia (weakness, fatigue, U wave on ECG, arrhythmias, polyuria, polydipsia). Assess patient frequently for development of hyperkalemia (fatigue, muscle weakness, paresthesia, confusion, dyspnea, cardiac arrhythmias). Patients who have diabetes mellitus or kidney disease and geriatric patients are at increased risk of developing these symptoms
• Periodic ECGs are recommended in patients receiving prolonged therapy
• Lab Test Considerations: Serum potassium levels should be evaluated before and routinely during therapy. Withhold drug and notify physician or other health care professional if patient becomes hyperkalemic ○ Monitor BUN, serum creatinine, and electrolytes before and periodically during therapy. May cause ↑ serum magnesium, uric acid, BUN, creatinine, potassium, plasma renin activity, and urinary calcium excretion levels. May also cause ↓ sodium levels
○ Discontinue potassium-sparing diuretics 3 days before a glucose tolerance test because of risk of severe hyperkalemia
○ Spironolactone may cause false ↑ of plasma cortisol concentrations. Spironolactone should be withdrawn 4-7 days before test
○ Monitor platelet count and total and differential leukocyte count periodically during therapy in patients taking triamterene


POTENTIAL NURSING DIAGNOSES

• Excess fluid volume (Indications).

IMPLEMENTATION

• PO: Administer in AM to avoid interrupting sleep pattern ○ Administer with food or milk to minimize gastric irritation and to increase bioavailability
○ Triamterene capsules may be opened and contents mixed with food or fluids for patients with difficulty swallowing


PATIENT/FAMILY TEACHING

• Emphasize the importance of continuing to take this medication, even if feeling well. Instruct patient to take medication at the same time each day. Take missed dosesas soon as remembered unless almost time for next dose. Do not double doses ○ Caution patient to avoid salt substitutes and foods that contain high levels of potassium or sodium unless prescribed by health care professional
○ May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known
○ Advise patient to consult with health care professional before taking any OTC decongestants, cough or cold preparations, or appetite suppressants concurrently with this medication because of potential for increased blood pressure
○ Advise patients taking triamterene to use sunscreen and protective clothing to prevent photosensitivity reactions
○ Instruct patient to notify health care professional of medication regimen before treatment or surgery
○ Inform patient that triamterene may cause bluish-colored urine
○ Advise patient to notify health care professional if muscle weakness or cramps; fatigue; or severe nausea, vomiting, or diarrhea occurs
○ Emphasize the need for follow-up exams to monitor progress

• Hypertension: Reinforce need to continue additional therapies for hypertension (weight loss, restricted sodium intake, stress reduction, moderation of alcohol intake, regular exercise, and cessation of smoking). Medication helps control but does not cure hypertension ○ Teach patient and family the correct technique for checking blood pressure weekly


EVALUATION/DESIRED OUTCOMES

• Increase in diuresis and decrease in edema while maintaining serum potassium level in an acceptable range
• Decrease in blood pressure
• Prevention of hypokalemia in patients taking diuretics
• Treatment of hyperaldosteronism

Front 6

esomeprazole
(es-o-mep-ra-zole)
Nexium

CLASSIFICATION(S)
Therapeutic: antiulcer agents
Pharmacologic: proton-pump inhibitors

Pregnancy Category B



INDICATIONS

• GERD including: ○ erosive esophagitis

• With amoxicillin and clarithromycin to eradicate Helicobacter pylori in duodenal ulcer disease or history of duodenal ulcer disease
• Decrease risk of gastric ulcer during continuous NSAID therapy

ACTION

• Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumen
• Therapeutic Effects: ○ Diminished accumulation of acid in the gastric lumen with lessened gastroesophageal reflux
○ Healing of duodenal ulcers
○ Decreased incidence of gastric ulcer during continuous NSAID therapy


PHARMACOKINETICS

Absorption: 90% absorbed following oral administration; food decreases absorption
Distribution: Unknown
Protein Binding: 97%
Metabolism and Excretion: Extensively metabolized by the liver (cytochrome P450 [CY P450] system, primarily CY P2 C19 isoenzyme); <1% excreted unchanged in urine
Half-life: 1.0-1.5 hr

TIME OF ACTION

blood levels* ROUTE ONSET PEAK DURATION
PO rapid 1.6 hr 24 hr
IV rapid end of infusion 24 hr
*Resolution of symptoms takes 5-8 days

CONTRAINDICATIONS/PRECAUTIONS

Contraindicated in: • Hypersensitivity
• OB: Lactation (not recommended)
Use Cautiously in: • Severe hepatic impairment (daily dose should not exceed 20 mg)
• OB: Pregnancy (use only if clearly needed)
• Pedi: Children <18 yr (safety not established)

ADVERSE REACTIONS/SIDE EFFECTS*

*CAPITALS indicate life threatening; underlines indicate most frequent.

CNS: headache,
GI: abdominal pain, constipation, diarrhea, dry mouth, flatulence, nausea,

INTERACTIONS

Drug-Drug:
• May ↓ absorption and effects of drugs where gastric pH is a determinant of bioavailability, including digoxin , ketoconazole , and iron salts
• May ↑ risk of bleeding with warfarin (monitor INR and PT)

ROUTE AND DOSAGE

Gastroesophageal Reflux Disease

• PO (Adults ): Healing of erosive esophagitis--20 mg or 40 mg once daily for 4-8 wks; maintenance of healing of erosive esophagitis--20 mg once daily; symptomatic GERD--20 mg once daily for 4 wks (additional 4 wks may be considered for nonresponders)
• IV (Adults ): 20 or 40 mg once daily
H. pylori Eradication to Reduce the Risk of Duodenal Ulcer Recurrence (Triple Therapy)

• PO (Adults ): 40 mg once daily for 10 days with amoxicillin 1000 mg twice daily for 10 days and clarithromycin 500 mg twice daily for 10 days
Decrease gastric ulcer during continuous NSAID therapy

• PO (Adults ): 20 or 40 mg once daily for up to 6 mo
Severe Hepatic Impairment

• PO, IV (Adults ): Daily dose should not exceed 20 mg

AVAILABILITY
• Delayed-release capsules: 20 mg, 40 mg
• Cost: 20 mg $129.44/30, 40 mg $129.44/30
• Powder for IV injection (requires reconstitution): 20 mg/vial , 40 mg/vial


NURSING IMPLICATIONS

ASSESSMENT

• Assess patient routinely for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate
• Lab Test Considerations: May cause ↑ serum creatinine, uric acid, total bilirubin, alkaline phosphatase, AST, and ALT ○ May alter hemoglobin, WBC, platelets, serum sodium, potassium, and thyroxine levels

Back 6

POTENTIAL NURSING DIAGNOSES

• Acute pain (Indications).

IMPLEMENTATION

• Antacids may be used while taking esomeprazole
• PO: Administer at least 1 hr before meals. Capsules should be swallowed whole ○ For patients with difficulty swallowing, place 1 tbsp of applesauce in an empty bowl. Open capsule and carefully empty the pellets inside onto applesauce. Mix pellets with applesauce and swallow immediately. Applesauce should not be hot and should be soft enough to swallow without chewing. Do not store applesauce mixture for future use. Tap water, orange juice, apple juice, and yogurt have also been used. Do not crush or chew pellets
○ For patients with an NG tube, delayed-release capsules can be opened and intact granules emptied into a 60 ml syringe and mixed with 50 ml of water. Replace plunger and shake syringe vigorously for 15 seconds. Hold syringe with tip up and check for granules in tip. Attach syringe to NG tube and administer solution. After administering, flush syringe with additional water. Do not administer if granules have dissolved or disintegrated. Administer immediately after mixing
○ Antacids may be used concurrently

• Direct IV: Reconstitute each vial with 5 mL of 0.9% NaCl, LR, or D5W. Do not administer solutions that are discolored or contain a precipitate. Stable at room temperature for up to 12 hrs Rate: Administer over at least 3 min
• Intermittent Infusion: Dilute reconstituted solution to a volume of 50 mL. Solutions diluted with 0.9% NaCl or LR are stable for 12 hr and those diluted with D5W are stable for 6 hr at room temperature Rate: Administer over 10-30 min
• Y-Site Incompatibility: Do not administer with other medications or solutions. Flush line with 0.9% NaCl, LR, or D5W before and after administration

PATIENT/FAMILY TEACHING

• Instruct patient to take medication as directed for the full course of therapy, even if feeling better. Take missed doses as soon as remembered but not if almost time for next dose. Do not double doses
• Advise patient to avoid alcohol, products containing aspirin or NSAIDs, and foods that may cause an increase in GI irritation
• Advise patient to report onset of black, tarry stools; diarrhea; abdominal pain; or persistent headache to health care professional promptly

EVALUATION/DESIRED OUTCOMES

• Decrease in abdominal pain or prevention of gastric irritation and bleeding. Healing of duodenal ulcers can be seen on x-ray examination or endoscopy
• Decrease in symptoms of GERD. Sustained resolution of symptoms usually occurs in 5-8 days. Therapy is continued for 4-8 wk after initial episode

Front 7

fenofibrate
(fen-o-fi-brate)
Antara, Lofibra, Tricor, Triglide

CLASSIFICATION(S)
Therapeutic: lipid-lowering agents
Pharmacologic: fibric acid derivatives

Pregnancy Category C



INDICATIONS

• With dietary therapy to decrease LDL cholesterol, total cholesterol, triglycerides, and apoliporotein B in adult patients with hypercholesterolemia or mixed dyslipidemia
• With dietary management in the treatment of hypertriglyceridemia (types IV and V hyperlipidemia) in patients who are at risk for pancreatitis and do not respond to nondrug therapy

ACTION

• Fenofibric acid primarily inhibits triglyceride synthesis
• Therapeutic Effects: ○ Lowering of triglycerides with subsequent decreased risk of pancreatitis


PHARMACOKINETICS

Absorption: Well absorbed (60%) after oral administration; absorption is increased by food
Distribution: Unknown
Protein Binding: 99%
Metabolism and Excretion: Rapidly converted to fenofibric acid, which is the active metabolite; fenofibric acid is metabolized by the liver. Fenofibric acid and its metabolites are primarily excreted in urine (60%)
Half-life: 20 hr

TIME OF ACTION

lowering of triglycerides ROUTE ONSET PEAK DURATION
PO unknown 2 wk unknown

CONTRAINDICATIONS/PRECAUTIONS

Contraindicated in: • Hypersensitivity
• Hepatic impairment (including primary biliary cirrhosis)
• Pre-existing gallbladder disease
• Severe renal impairment
• Concurrent use of HMG-CoA reductase inhibitors
• OB: Lactation
Use Cautiously in: • Concurrent warfarin therapy
• OB: Pedi: Pregnancy or children (use in pregnancy only if benefits outweigh risks to the fetus; safety not established)

ADVERSE REACTIONS/SIDE EFFECTS*

*CAPITALS indicate life threatening; underlines indicate most frequent.

CNS: fatigue/weakness, headache,
CV: arrhythmias,
GI: cholelithiasis, pancreatitis,
Derm: rash, urticaria,
MS: rhabdomyolysis,
Misc: hypersensitivity reactions,

INTERACTIONS

Drug-Drug:
• ↑ anticoagulant effects of warfarin
• Concurrent use with HMG-CoA reductase inhibitors ↑ risk of rhabdomyolysis (combined use should be avoided)
• Absorption is ↓ by bile acid sequestrants (fenofibrate should be given 1 hr before or 4-6 hr after)
• ↑ risk of nephrotoxicity with cyclosporine

ROUTE AND DOSAGE



Primary hypercholesterolemia/mixed dyslipidemia • PO (Adults ): Antara- 130 mg/day initially; Lifibra- 200 mg/day initially; Tricor- 145 mg/day initially; Triglide- 160 mg/day initially


Hypertriglyceridemia • PO (Adults ): Antara- 43-130 mg/day ; Lifibra- 67-200 mg/day initially; Tricor- 48-145 mg/day initially; Triglide- 50-160 mg/day initially


Renal impairment/Geriatric patients • PO (Adults ): Antara- 43 mg/day;Lifibra- 67 mg/day; Tricor- 48mg/day

AVAILABILITY
• Tablets (Tricor): 48 mg, 145 mg
• Tablets (Triglide): 50 mg, 160 mg
• Micronized capsules (Antara): 43 mg, 87 mg, 130 mg
• Micronized capsules (Lofibra): 67 mg, 134 mg, 200 mg

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NURSING IMPLICATIONS

ASSESSMENT

• Obtain a diet history, especially with regard to fat consumption. Every attempt should be made to obtain normal serum triglyceride levels with diet, exercise, and weight loss in obese patients before fenofibrate therapy is instituted
• Assess patient for cholelithiasis. If symptoms occur, gallbladder studies are indicated. Therapy should be discontinued if gallstones are found
• Lab Test Considerations: Monitor serum lipids before therapy to determine consistent elevations, then monitor periodically during therapy ○ Monitor serum AST and ALT periodically during therapy. May cause ↑ levels. Therapy should be discontinued if levels rise >3 times the normal limit
○ If patient develops muscle tenderness during therapy, CPK levels should be monitored. If CPK levels are markedly ↑ or myopathy occurs, therapy should be discontinued
○ May cause mild to moderate ↓ in hemoglobin, hematocrit, and WBCs. Monitor periodically during first 12 mo of therapy. Levels usually stabilize during long-term therapy
○ Patients taking anticoagulants concurrently should have prothrombin levels monitored frequently until levels stabilize


POTENTIAL NURSING DIAGNOSES

• Noncompliance (Patient/Family Teaching).

IMPLEMENTATION

• Patients should be placed on a triglyceride-lowering diet before therapy and remain on this diet throughout therapy ○ Dose may be increased after repeated serum triglyceride levels every 4-8 wk
○ Brands are not interchangeable

• PO: Administer Antara, Lofibra, and Tricor products with meals. Triglide formulation may be taken without regard to meals

PATIENT/FAMILY TEACHING

• Instruct patient to take medication as directed, not to skip doses or double up on missed doses. Medication helps control but does not cure elevated serum triglyceride levels
• Advise patient that this medication should be used in conjunction with diet restrictions (fat, cholesterol, carbohydrates, alcohol), exercise, and cessation of smoking
• Instruct patient to notify health care professional if unexplained muscle pain, tenderness, or weakness occurs, especially if accompanied by fever or malaise
• Instruct female patients to notify health care professional promptly if pregnancy is planned or suspected
• Advise patient to notify health care professional of medication regimen before treatment or surgery
• Emphasize the importance of follow-up exams to determine effectiveness and to monitor for side effects

EVALUATION/DESIRED OUTCOMES

• Decrease in serum triglycerides to normal levels. Therapy should be discontinued in patients who do not have an adequate response in 2 months of therapy

Front 8

FLUOROQUINOLONES
(floor-oh-kwin-oh-lones) ciprofloxacin†
(sip-roe-flox-a-sin)
Cipro, Cipro XR, Proquin XRgatifloxacin
(ga-ti-flox-a-sin)
Tequingemifloxacin
(gem-i-flox-a-sin) Factivelevofloxacin
(le-voe-flox-a-sin)
Levaquin lomefloxacin
(loe-me-flox-a-sin)
Maxaquinmoxifloxacin†
(mox-i-flox-a-sin)
Aveloxnorfloxacin†
(nor-flox-a-sin)
Noroxinofloxacin†
(oh-flox-a-sin)
Floxinsparfloxacin
(spar-flox-a-sin)
Zagam

CLASSIFICATION(S)
Therapeutic: anti-infectives

Pregnancy Category C


†See Appendix B for ophthalmic use




INDICATIONS

• PO: IV: Treatment of: ○ Urinary tract and gynecologic infections
○ Gonorrhea (may not be considered first line agents due to increasing resistance)
○ Prostatitis (ciprofloxacin, levofloxacin, ofloxacin)
○ Respiratory tract infections including sinusitis (not norfloxacin)
○ Skin and skin structure infections (gatifloxacin, levofloxacin, moxifloxacin, ciprofloxacin, ofloxacin)
○ Bone and joint infections (ciprofloxacin)
○ Infectious diarrhea (ciprofloxacin)
○ Intra-abdominal infections (ciprofloxacin with metronidazole)

• Perioperative prophylaxis before transurethral procedures (lomefloxacin)
• Febrile neutropenia (ciprofloxacin)
• Post-exposure treatment of inhalational anthrax (ciprofloxacin, levofloxacin)

ACTION

• Inhibit bacterial DNA synthesis by inhibiting DNA gyrase
• Therapeutic Effects: ○ Death of susceptible bacteria

• Spectrum: • Broad activity includes many gram-positive pathogens: ○ Staphylococci including methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis
○ Streptococcus pneumoniae
○ Bacillus anthracis

• Gram-negative spectrum notable for activity against: ○ Escherichia coli
○ Klebsiella spp
○ Enterobacter
○ Salmonella
○ Shigella
○ Proteus vulgaris
○ Providencia stuartii
○ Providencia rettgeri
○ Morganella morganii
○ Pseudomonas aeruginosa
○ Serratia
○ Haemophilus spp
○ Acinetobacter
○ Neisseria gonorrhoeae and Neisseria meningitidis
○ Moraxella catarrhalis
○ Yersinia
○ Vibrio
○ Brucella
○ Campylobacter
○ Aeromonas spp

• Active against the following anaerobic pathogens: ○ Bacteroides fragilis and Bacteroides intermedius (sparfloxacin)
○ and Clostridium welchii
○ Gardnerella vaginalis
○ Peptococcus niger
○ Peptostreptococcus spp

• Additional spectrum includes: ○ Chlamydia pneumoniae and Chlamydia trachomatis
○ Legionella pneumoniae
○ Mycobacterium tuberculosis
○ Mycoplasma pneumoniae
○ Urea urealyticum



PHARMACOKINETICS

Absorption: Well absorbed after oral administration (ciprofloxacin--70%; moxifloxacin--90%; gatifloxacin--96%; gemifloxacin--71%; levofloxacin--99%; lomefloxacin--95-98%; norfloxacin--30-40%; ofloxacin--89%; sparfloxacin--92%
Distribution: Widely distributed. High tissue and urinary levels are achieved. All agents appear to cross the placenta. Ciprofloxacin, ofloxacin, and sparfloxacin enter breast milk
Metabolism and Excretion: Ciprofloxacin--15% metabolized by the liver, 40-50% excreted unchanged by the kidneys; gatifloxacin--70% excreted unchanged in urine; gemifloxacin--Minimal metabolism, 61% excreted unchanged in feces, 36% excreted unchanged in urine; levofloxacin--87% excreted unchanged in urine, small amounts metabolized; lomefloxacin--65% excreted unchanged by the kidneys, 10% excreted unchanged in feces; moxifloxacin--mostly metabolized by the liver, 20% excreted unchanged in urine, 25% excreted unchanged in feces; norfloxacin--10% metabolized by the liver, 30% excreted unchanged by the kidneys, 30% excreted unchanged in feces; ofloxacin--70-80% excreted unchanged by the kidneys; sparfloxacin--partially metabolized by the liver, 10% excreted unchanged in urine
Half-life: Ciprofloxacin--4 hr; gatifloxacin--7.1-7.8 hr; gemifloxacin--7 hr (range 4-12 hr); levofloxacin--6-8 hr; lomefloxacin--8 hr; moxifloxacin--12 hr; norfloxacin--6.5 hr; ofloxacin--5-7 hr (all are increased in renal impairment); sparfloxacin--20 hr

TIME OF ACTION

blood levels ROUTE ONSET PEAK DURATION
Ciprofloxacin--PO rapid 1-2 hr 12 hr
Ciprofloxacin--PO-ER rapid 1-4 hr 24 hr
Ciprofloxacin--IV rapid end of infusion 12 hr
Gatifloxacin--PO rapid 1-2 hr 24 hr
Gatifloxacin--IV rapid end of infusion 24 hr
Gemifloxacin--PO rapid 0.5--2 hr 24 hr
Levofloxacin--PO rapid 1-2 hr 24 hr
Levofloxacin--IV rapid end of infusion 24 hr
Lomefloxacin--PO rapid unknown 24 hr
Moxifloxacin--PO within 1 hr 1-3 hr 24 hr
Moxifloxacin--IV rapid end of infusion 24 hr
Norfloxacin--PO rapid 2-3 hr 12 hr
Ofloxacin--PO rapid 1-2 hr 12 hr
Ofloxacin--IV rapid end of infusion 12 hr
Sparfloxacin--PO rapid 3-6 hr 24 hr

CONTRAINDICATIONS/PRECAUTIONS

Contraindicated in: • Hypersensitivity. Cross-sensitivity among agents may occur (including cinoxacin and nalidixic acid)
• OB: Pedi: Pregnancy or Children <18 yr (except for use of ciprofloxacin for anthrax and complicated urinary tract infections)
• Sparfloxacin: ○ History of photosensitivity to other agents; unavoidable exposure to sun; bright, natural light; or UV rays
○ Gatifloxacin, gemifloxacin, moxifloxacin, sparfloxacin--concurrent use of amiodarone, disopyramide, erythromycin, pentamidine, phenothiazines, pimozide, procainamide, quinidine, sotalol, or tricyclic antidepressants
○ Known QT prolongation or concurrent use of agents causing prolongation

Use Cautiously in: • Underlying CNS pathology
• Renal impairment (dosage reduction if CCr <50 ml/min for ciprofloxacin, levofloxacin, ofloxacin, sparfloxacin; <30 ml/min for norfloxacin; <40 ml/min for gatifloxacin, gemifloxacin or lomefloxacin)
• Cirrhosis
• Geri: Geriatric patients, dialysis patients (increased risk of adverse reactions)
• OB: Lactation (safety not established except for post-exposure inhalational or cutaneous anthrax)

ADVERSE REACTIONS/SIDE EFFECTS*

*CAPITALS indicate life threatening; underlines indicate most frequent.

CNS: SEIZURES, dizziness, drowsiness, headache, insomnia, acute psychoses, agitation, confusion, hallucinations, increased intracranial pressure, tremors,
CV: gemifloxacin, moxifloxacin, norfloxacin, sparfloxacin: ARRHYTHMIAS, QT prolongation, vasodilation,
GI: PSEUDOMEMBRANOUS COLITIS, abdominal pain, diarrhea, nausea, altered taste,
GU: interstitial cystitis, vaginitis,
Derm: photosensitivity (increased with lomefloxacin), phototoxicity (sparfloxacin), rash,
Endo: hyperglycemia, hypoglycemia,
Local: phlebitis at IV site,
MS: tendinitis, tendon rupture,
Neuro: peripheral neuropathy (gemifloxacin, lomefloxacin, levofloxacin, norfloxacin, ofloxacin),
Misc: HYPERSENSITIVITY REACTIONS INCLUDING ANAPHYLAXIS, STEVENS-JOHNSON SYNDROME, lymphadenopathy,

INTERACTIONS

Drug-Drug:
• ↑ risk of serious adverse cardiovascular reactions with concurrent use of gatifloxacin, gemifloxacin, moxifloxacin or sparfloxacin and amiodarone , disopyramide , erythromycin , pentamidine , phenothiazines, pimozide , procainamide , quinidine , sotalol , tricyclic antidepressants
• ↑ serum theophylline levels and may lead to toxicity
• Administration with antacids, iron salts, bismuth subsalicylate , sucralfate , and zinc salts decreases absorption of fluoroquinolones
• May alter the effects of warfarin
• May ↓ blood levels and effectiveness of phenytoin
• Concurrent use with glyburide and other antidiabetics may result in hypoglycemia
• Serum levels of fluoroquinolones may be ↓ by antineoplastics
• Cimetidine may interfere with elimination of fluoroquinolones
• Beneficial effects of ciprofloxacin may be antagonized by nitrofurantoin
• Probenecid ↓ renal elimination of fluoroquinolones
• Fluoroquinolones may ↑ risk of nephrotoxicity from cyclosporine
• Concurrent use of ciprofloxacin with foscarnet may ↑ risk of seizures
• Concurrent therapy with corticosteroids may ↑ the risk of tendon rupture
• May ↑ risk of hypoglycemia when used with antidiabetics
Drug-Natural:
• Fennel ↓ the absorption of ciprofloxacin
Drug-Food:
• Absorption is impaired by concurrent tube feeding (because of metal cations)
• Ciprofloxacin should not be taken with milk or yogurt alone, but may be taken with other dietary calcium
• Absorption of norfloxacin is decreased by food and/or dairy products (take 1 hr before or 2 hr after)

ROUTE AND DOSAGE



Ciprofloxacin • PO (Adults ): Most infections--500-750 mg q 12 hr. Urinary tract infections--250-500 mg q 12 hr; or 1000 mg q 24 hr for 10-14 days as extended-release tablets.Uncomplicated urinary tract infections--100 mg every 12 hr for 3 days or 500 mg every 24 hr for 3 days as extended-release tablets. Gonorrhea--250-mg single dose. Inhalational anthrax (post exposure) or cutaneous anthrax--500 mg every 12 hr for 60 days
• PO (Children ): Complicated urinary tract infections in children 1-17 yr--10-20 mg/kg every 12 hr for 10-21 days (not to exceed 750 mg/dose)
• IV (Adults ): Most infections--400 mg q 12 hr. Urinary tract infections--200 mg q 12 hr.Inhalational anthrax (post exposure)--400 mg q 12 hr for 60 days
• IV (Children ): Inhalational anthrax (post exposure)--10 mg/kg q 12 hr for 60 days (not to exceed 400 mg/dose); complicated urinary tract infections in children 1-17 yr--6-10 mg/kg every 8 hr for 10-21 days (not to exceed 400 mg/dose)

Renal Impairment
• PO (Adults ): CCr 30-50 ml/min--250-500 mg q 12 hr; CCr 5-29 ml/min--250-500 mg q 18 hr
• IV (Adults ): CCr 5-29 ml/min--200-400 mg q 18-24 hr


Gatifloxacin • PO, IV (Adults ): Acute bacterial exacerbation of chronic bronchitis, skin/skin structure infections, complicated urinary tract infections, acute pyelonephritis --400 mg q 24 hr for 7-10 days. Acute sinusitis--400 mg q 24 hr for 10 days. Community-acquired pneumonia--400 mg q 24 hr for 7-14 days. Uncomplicated urinary tract infections, cystitis--400-mg single dose or 200 mg q 24 hr for 3 days. Uncomplicated urethral gonorrhea in men or endocervical/rectal gonorrhea in women--400-mg single dose

Renal Impairment
• PO, IV (Adults ): CCr <40 ml/min--400 mg initially, then 200 mg every 24 hr


Gemifloxacin • PO (Adults ): Acute bacterial exacerbation of chronic bronchitis--320 mg once daily for 5 days; Community-acquired-pneumonia (CAP)--320 mg once daily for 7 days

Renal Impairment
• PO (Adults ): PO (Adults ): CCr < 40 ml/min--AECB160 mg once daily for 5 days; CAP--160 mg once daily for 7 days


Levofloxacin • PO, IV (Adults ): 250-750 mg q 24 hr; inhalational anthrax (post-exposure)--500 mg daily for 60 days

Renal Impairment
• PO, IV (Adults ): Most Infections:--CCr 20-49 ml/min--500 mg initially then 250 mg q 24 hr; CCr 10-19 ml/min--500 mg initially then 250 mg q 48 hr. Urinary tract infections:--CCr 10-19 ml/min--250 mg q 48 hr


Lomefloxacin • PO (Adults ): Bronchitis/urinary tract infections--400 mg once daily. Perioperative prophylaxis (transurethral surgery)--400 mg 2-6 hr before surgery

Renal Impairment
• PO (Adults ): CCr <40 ml/min-- 400 mg initially, then 200 mg once daily


Moxifloxacin • PO, IV (Adults ): Community-acquired pneumonia/bacterial sinusitis--400 mg once daily for 10 days. Acute bacterial exacerbation of chronic bronchitis--400 mg once daily for 5 days. Skin/skin structure infections--400 mg/day for 7-21 days


Norfloxacin • PO (Adults ): Urinary tract infections--400 mg q 12 hr. Gonorrhea--800-mg single dose

Renal Impairment
• PO (Adults ): CCr <30 ml/min--400 mg once daily


Ofloxacin • PO, IV (Adults ): Most infections--400 mg q 12 hr. Prostatitis/chlamydial infections--300 mg q 12 hr. Urinary tract infections--200 mg q 12 hr. Gonorrhea--400-mg single dose
• Otic (Adults and Children > 6 mo): Otitis Externa 6 months to 13 yr--5 drops instilled into affected ear once daily for 7 days; Otitis Externa >13 yr-- 10 drops instilled into affected ear once daily for 7 days. Acute Otitis Media in pediatric patients 1-12 yr old with tympanostomy tubes--5 drops instilled into the affected ear twice daily for 10 days. Chronic Suppurative Otitis Media with perforated tympanic membranes in patients > 12 yr--10 drops instilled into the affected ear twice daily for 14 days

Renal Impairment
• PO, IV (Adults ): CCr 20-50 ml/min--100% of the usual dose q 24 hr; CCr <20 ml/min--50% of the usual dose q 24 hr


Sparfloxacin • PO (Adults ): 400 mg initially, then 200 mg q 24 hr for 10 days

Renal Impairment
• PO (Adults ): CCr <50 ml/min--400 mg initially, then 200 mg q 48 hr

AVAILABILITY


Ciprofloxacin • Tablets: 250 mg, 500 mg, 750 mg
• Cost: 500 mg $435.00/100
• Extended-release tablets: 500 mg , 1000 mg
• Cost: Cipro XR — 500 mg $866.25/100, 1000 mg $986.25/100
• Oral suspension (strawberry flavor) : 250 mg/5 ml in 100-ml bottle, 500 mg/5 ml in 100-ml bottle
• Injection: 200 mg/20 ml, 400 mg/40 ml, 200 mg/100 ml premixed in D5W, 400 mg/200 ml premixed in D5W, 1200 mg/120 ml bulk package
• In combination with: hydrocortisone Cipro HC (see Appendix B )


Gatifloxacin • Tablets: 200 mg, 400 mg
• Cost: 400 mg $411.16/50
• Oral suspension (fruit) : 200 mg/5 ml in 1,2,3 and 4-g unit of use bottles
• Injection: 200mg/20-ml vial, 400mg/20-ml vial


Levofloxacin • Tablets: 250 mg, 500 mg, 750 mg
• Cost: 500 mg $892.87/100
• Concentrated solution for injection: 500 mg/20 ml
• Premixed solution for injection: 250 mg, 500 mg


Lomefloxacin • Tablets: 400 mg
• Cost: 400 mg $138.68/20


Moxifloxacin • Tablets: 400 mg
• Injection, pre-mixed: 400 mg/250-ml bags


Norfloxacin • Tablets: 400 mg
• Cost: 400 mg $81.05/20


Ofloxacin • Tablets: 200 mg, 300 mg, 400 mg
• Cost: 400 mg $101.90/20
• Injection: 20 mg/ml, 40 mg/ml
• Premixed injection: 200 mg/50 ml, 400 mg/100 ml
• Otic solution: 0.3% in 5- and 10-mL dropper bottles

Back 8

NURSING IMPLICATIONS

ASSESSMENT

• Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC; urinalysis; frequency and urgency of urination; cloudy or foul-smelling urine) prior to and during therapy
• Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results. To prevent development of resistant bacteria, therapy should only be used to treat infections that are proven or strongly suspected to be caused by susceptible bacteria
• Observe for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue drug and notify physician or other health care professional immediately if these problems occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in case of an anaphylactic reaction. Patients taking gemifloxacinwho are at greater risk for rash are those receiving gemifloxacin for >7 days, <40 yrs of age, females, and postmenopausal females receiving hormone replacement therapy
• Lab Test Considerations: Fluoroquinolones may cause ↑ serum AST, ALT, LDH, bilirubin, and alkaline phosphatase ○ May also cause ↓ WBC; ↑ or ↓ serum glucose; and glucosuria, hematuria, proteinuria, and albuminuria
○ Ciprofloxacin and norfloxacin may also cause crystalluria and ↑ BUN and serum creatinine concentrations
○ Moxifloxacin may cause hyperglycemia, hyperlipidemia, and altered prothrombin time. It may also cause ↑ WBC; ↑ serum calcium, chloride, albumin, and globulin; and ↓ glucose, hemoglobin, RBCs, neutrophils, eosinophils, and basophils
○ Monitor prothrombin time closely in patients receiving fluoroquinolones and warfarin; may enhance the anticoagulant effects of warfarin


POTENTIAL NURSING DIAGNOSES

• Risk for infection (Patient/Family Teaching).

IMPLEMENTATION

• Do confuse norfloxacin with Norflex (orphenadrine)
• PO: Administer norfloxacin and ofloxacin on an empty stomach 1 hr before or 2 hr after meals, with a full glass of water. Moxifloxacin and gemifloxacin, may be administered without regard to meals. Antacids containing magnesium or aluminum, iron, or zinc preparations should not be taken within 4 hr before and 2 hr (8 hr for moxifloxacin) after administration ○ If gastric irritation occurs, ciprofloxacin and lomefloxacin may be administered with meals. Food slows and may slightly decrease absorption
○ Milk and yogurt decrease the absorption of ciprofloxacin. Do not administer concurrently
○ Ciprofloxacin 5% and 10% oral suspension should not be administered through a feeding tube due to unusual physical characteristics. Shake solution for 15 seconds prior to administration. Do not chew microcapsules in solution
○ Gemifloxacin and ciprofloxacin extended-release tablets should be swallowed whole; do not crush, break, or chew

Ciprofloxacin

• Intermittent Infusion: Dilute to a concentration of 1-2 mg/ml with 0.9% NaCl or D5W. Stable for 14 days at refrigerated or room temperature Rate: Administer over 60 min into a large vein to minimize venous irritation
• Y-Site Compatibility: ♦amifostine ♦amiodarone ♦aztreonam ♦bivalirudin ♦calcium gluconate ♦ceftazidime ♦cisatracurium ♦dexmedetomidine ♦digoxin ♦diltiazem ♦diphenhydramine ♦dobutamine ♦docetaxel ♦dopamine ♦doxorubicin liposome ♦etoposide ♦fenoldopam ♦gemcitabine ♦gentamicin ♦granisetron ♦lidocaine ♦linezolid ♦lorazepam ♦LR ♦metoclopramide ♦midazolam ♦midodrine ♦milrinone ♦piperacillin ♦potassium acetate ♦potassium chloride ♦promethazine ♦quinupristin-dalfopristin ♦ranitidine ♦remifentanil ♦0.9% NaCL ♦tacrolimus ♦teniposide ♦thiotepa ♦tobramycin ♦verapamil
• Y-Site Incompatibility: Manufacturer recommends temporarily discontinuing other solutions when administering ciprofloxacin ♦aminophylline ♦ampicillin/sulbactam ♦azithromycin ♦dexamethasone ♦furosemide ♦heparin ♦hydrocortisone ♦methylprednisolone ♦phenytoin ♦potassium phosphates ♦propofol ♦sodium phosphates ♦warfarin
Gatifloxacin

• Intermittent Infusion: Dilute to a concentration of 2 mg/ml with D5W, 0.9% NaCl, D5LR, or D5/0.9% NaCl. Solution is stable for 14 days if refrigerated or at room temperature Rate: Administer over 60 min. Avoid rapid or bolus IV infusion
• Y-Site Compatibility: ♦acyclovir ♦alfentanil ♦amikacin ♦aminophylline ♦ampicillin ♦ampicillin/sulbactam ♦aztreonam ♦buprenorphine ♦butorphanol ♦calcium chloride ♦calcium gluconate ♦carboplatin ♦cefazolin ♦cefotetan ♦ceftazidime ♦ceftizoxime ♦ceftriaxone ♦chlorpromazine ♦cimetidine ♦cisatracurium ♦cisplatin ♦clindamycin ♦cyclophosphamide ♦cyclosporine ♦cytarabine ♦dexamethasone ♦dexmedetomidate ♦digoxin ♦diphenhydramine ♦dobutamine ♦dopamine ♦doxorubicin ♦droperidol ♦enalaprilat ♦esmolol ♦etoposide ♦famotidine ♦fenoldopam ♦fentanyl ♦fluconazole ♦fluorouracil ♦ganciclovir ♦gemcitabine ♦gentamicin ♦granisetron ♦haloperidol ♦hydrocortisone sodium succinate ♦hydromorphone ♦ifosfamide ♦imipenem/cilastatin ♦labetalol ♦leucovoran ♦lidocaine ♦lorazepam ♦magnesium sulfate ♦mannitol ♦meperidine ♦mesna ♦methotrexate ♦methylprednisolone ♦metoclopramide ♦metronidazole ♦midazolam ♦mitoxantrone ♦morphine ♦nalbuphine ♦naloxone ♦nitroglycerin ♦ondansetron ♦paclitaxel ♦pentamidine ♦pentobarbital ♦phenobarbital ♦potassium chloride ♦prochlorperazine ♦promethazine ♦propranolol ♦ranitidine ♦remifentanil ♦sodium bicarbonate ♦sodium phosphates ♦sufentanil ♦theophylline ♦ticarcillin ♦ticarcillin/clavulanate ♦tobramycin ♦trimethoprim/sulfamethoxazole ♦vecuronium ♦verapamil ♦vinblastine ♦vincristine ♦vinorelbine ♦zidovudine
• Y-Site Incompatibility: Do not mix or administer with other medications. Temporarily discontinue other solutions when administering gatifloxacin. Flush IV line before and after administration ♦amphotericin B ♦amphotericin B cholesteryl sulfate ♦cefoperazone ♦cefoxitin ♦diazepam ♦furosemide ♦heparin ♦phenytoin ♦piperacillin ♦piperacillin/tazobactam ♦potassium phosphates ♦vancomycin
Levofloxacin

• Intermittent Infusion: Dilute to a concentration of 5 mg/ml with 0.9% NaCl, D5W, D5/0.9% NaCl, D5/0.45% NaCl, D5/LR, 5% sodium bicarbonate, D5, Plasmalyte 56, or sodium lactate. Also available in premixed bottles and flexible containers with D5W, which need no further dilution. Discard unused solution. Diluted solution is stable for 72 hr at room temperature and 14 days if refrigerated Rate: Administer by infusion over at least 60 min for 250 mg or 500 mg doses and over 90 min for 750 mg dose. Avoid rapid bolus injection to prevent hypotension
• Y-Site Compatibility: ♦amikacin ♦aminophylline ♦ampicillin ♦bivalirudin ♦caffeine citrate ♦cefotaxime ♦cimetidine ♦clindamycin ♦dexamethasone ♦dexmedetomidate ♦dobutamine ♦dopamine ♦epinephrine ♦fenoldopam ♦fentanyl ♦gentamicin ♦isoproterenol ♦lidocaine ♦linezolid ♦lorazepam ♦metoclopramide ♦morphine ♦oxacillin ♦pancuronium ♦penicillin G ♦phenobarbital ♦phenylephrine ♦sodium bicarbonate ♦vancomycin
• Y-Site Incompatibility: ♦acyclovir ♦alprostadil ♦azithromycin ♦furosemide ♦heparin ♦indomethacin ♦nitroglycerin ♦nitroprusside ♦propofol
• Additivie Compatibility: ♦potassium chloride
Moxifloxacin

• Intermittent Infusion: Premix bags should not be further diluted. Use transfer set whose piercing pin does not require excessive force; insert with a gentle twisting motion until pin is firmly seated Rate: Administer over 60 min. Avoid rapid or bolus infusion
• Solution Compatibility:
• Y-Site Incompatibility: Temporarily discontinue administration of other solutions during moxifloxacin
Ofloxacin

• Intermittent Infusion: Dilute to a concentration of 4 mg/ml with 0.9% NaCl, D5W, D5/0.9% NaCl, D5/LR, 5% sodium bicarbonate, D5, Plasmalyte 56, or sodium lactate. Also available in premixed bottles and flexible containers with D5W that need no further dilution. Discard unused solution Rate: Administer by infusion only over at least 60 min
• Y-Site Compatibility: ♦ampicillin ♦cisatracurium ♦docetaxel ♦etoposide ♦gemcitabine ♦granisetron ♦linezolid ♦propofol ♦remifentanil ♦thiotepa
• Y-Site Incompatibility: ♦amphotericin B cholesteryl sulfate ♦cefepime ♦ doxorubicin liposome

PATIENT/FAMILY TEACHING

• Instruct patient to take medication as directed at evenly spaced times and to finish drug completely, even if feeling better. Take missed doses as soon as possible, unless almost time for next dose. Do not double doses. Advise patient that sharing of this medication may be dangerous. Caution patients that fluoroquinolones should only be used to treat bacterial infections; they are not effective against viral infections, such as the common cold
• Advise patients to notify health care professional immediately if they are taking theophylline
• Encourage patient to maintain a fluid intake of at least 1500-2000 ml/day to prevent crystalluria
• Advise patient that antacids or medications containing iron or zinc will decrease absorption and should not be taken within 2 hr before norfloxacin or ofloxacin; 3 hr before gemifloxacin; 4 hr before moxifloxacin; 6 hr before ciprofloxacin or lomefloxacin; and 2 hr (moxifloxacin--8 hr) after taking this medication
• May cause dizziness and drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known
• Advise patient to notify health care professional of any personal or family history of QTc prolongation or proarrhythmic conditions such as recent hypokalemia, significant bradycardia, or recent myocardial ischemia. Patients with this history should not receive fluoroquinolones
• Caution patient to use sunscreen and protective clothing to prevent phototoxicity reactions during and for 5 days after therapy. Notify health care professional if a sunburn-like reaction or skin eruption occurs
• Instruct patients being treated for gonorrhea that partners also must be treated
• Instruct patient to consult health care professional before taking any other Rx, OTC, or herbal products
• Advise patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools)
• Instruct patient to notify health care professional if fever and diarrhea develop, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional
• Instruct patient to notify health care professional immediately if rash or tendon pain or inflammation occur. Therapy should be discontinued

EVALUATION/DESIRED OUTCOMES

• Resolution of the signs and symptoms of infection. Time for complete resolution depends on organism and site of infection
• Resolution of the signs and symptoms of urinary tract infection ○ Negative urine culture

• Post exposure treatment of inhalational anthrax or cutaneous anthrax

Front 9

levalbuterol
(leev-al-byoo-ter-ole)
Xopenex

CLASSIFICATION(S)
Therapeutic: bronchodilators
Pharmacologic: adrenergics

Pregnancy Category C



INDICATIONS

• Bronchospasm due to reversible airway disease (short-term control agent)

ACTION

• R-enantiomer of racemic albuterolBinds to beta-2 adrenergic receptors in airway smooth muscle leading to activation of adenylcyclase and increased levels of cyclic-3', 5'-adenosine monophosphate (cAMP). Increases in cAMP activate kinases, which inhibit the phosphorylation of myosin and decrease intracellular calcium. Decreased intracellular calcium relaxes bronchial smooth muscle
• Therapeutic Effects: ○ Relaxation of airway smooth muscle with subsequent bronchodilation
○ Relatively selective for beta--2 (pulmonary) receptors


PHARMACOKINETICS

Absorption: Some absorption occurs following inhalation
Distribution: Unknown
Metabolism and Excretion: Metabolized in the liver to an inactive sulfate and 3-6% excreted unchanged in the urine
Half-life: 3.3-4 hr

TIME OF ACTION

bronchodilation ONSET PEAK DURATION
Inhalation 10-17 min 90 min 5-6 hr

CONTRAINDICATIONS/PRECAUTIONS

Contraindicated in: • Hypersensitivity to levalbuterol or albuterol
Use Cautiously in: • Cardiovascular disorders (including coronary insufficiency, hypertension, and arrhythmias)
• History of seizures
• Hypokalemia
• Hyperthyroidism
• Diabetes mellitus
• Unusual sensitivity to adrenergic amines
• Pregnancy, lactation, or children <2 yr (safety not established)
Exercise Extreme Caution in: • Concurrent use or use within 2 weeks of tricyclic antidepressants or MAO inhibitors (may increase the risk of adverse cardiovascular reactions)

ADVERSE REACTIONS/SIDE EFFECTS*

*CAPITALS indicate life threatening; underlines indicate most frequent.

CNS: anxiety, dizziness, headache, nervousness,
Resp: increased cough, paradoxical bronchospasm, turbinate edema,
CV: tachycardia,
GI: dyspepsia,
Endo: hyperglycemia,
F and E: hypokalemia,
Neuro: tremor,

INTERACTIONS

Drug-Drug:
• Concurrent use or use within 2 weeks of tricyclic antidepressants or MAO inhibitorsmay ↑ risk of adverse cardiovascular reactions (use with extreme caution)
• Beta blockers block the beneficial pulmonary effects of adrenergic bronchodilators (choose cardioselective beta blockers if necessary and with caution)
• May ↑ risk of hypokalemia from potassium-losing diuretics
• May ↓ serum digoxin levels
• May ↑ risk of arrhythmias with hydrocarbon inhalation anesthetics or cocaine
Drug-Natural:
• Use with caffeine-containing herbs ( guarana, tea , coffee ) ↑ stimulant effect

ROUTE AND DOSAGE

• Inhaln (Adults and Children > 12 yr): 0.63 mg via nebulization three times daily (every 6-8 hr); may be increased to 1.25 mg three times daily (every 6-8 hr)
• Inhaln (Children 6-11 yr): 0.31 mg three times daily (not exceed 0.63 mg three times daily)
• Inhaln (Children 2-11 yr): 0.16-1.25 mg single doses have been used safely

AVAILABILITY
• Inhalation solution: 0.31 mg/vial in green foil pouch containing 12 vials, 0.63 mg/vial in yellow foil pouch containing 12 vials, 1.25 mg/vial in red foil pouch containing 12 vials

Back 9

NURSING IMPLICATIONS

ASSESSMENT

• Assess lung sounds, pulse, and blood pressure before administration and during peak of medication. Note amount, color, and character of sputum produced. Closely monitor patients on higher dose for adverse effects
• Monitor pulmonary function tests before initiating therapy and periodically during course to determine effectiveness of medication.
• Observe for paradoxical bronchospasm (wheezing). If condition occurs, withhold medication and notify physician or other health care provider immediately
• Lab Test Considerations: May cause ↑ serum glucose and ↓ serum potassium

POTENTIAL NURSING DIAGNOSES

• Ineffective airway clearance (Indications).

IMPLEMENTATION

• Inhaln: Allow at least 1 min between inhalations of aerosol medication ○ For nebulization, levalbuterol solution does not require dilution prior to administration. Once the foil pouch is opened, vials must be used within 2 weeks; open vials may be stored for 1 week. Discard vial if solution is not clear or colorless


PATIENT/FAMILY TEACHING

• Instruct patient in the proper use of the nebulizer (see Appendix B ) and to take levalbuterol exactly as directed. Caution patient not to exceed recommended dose; may cause adverse effects, paradoxical bronchospasm, or loss of effectiveness of medication
• Advise patient to consult health care professional before taking any OTC medications or alcohol concurrently with this therapy. Caution patient to also avoid smoking and other respiratory irritants
• Instruct patient to contact health care professional immediately if shortness of breath is not relieved by medication or is accompanied by diaphoresis, dizziness, palpitations, or chest pain
• Advise patients to use levalbuterol first if using other inhalation medications, and allow 5 min to elapse before administering other inhalant medications unless otherwise directed
• Advise patient to rinse mouth with water after each inhalation dose to minimize dry mouth
• Instruct patient to notify health care professional if no response to the usual dose of levalbuterol

EVALUATION/DESIRED OUTCOMES

• Prevention or relief of bronchospasm

Front 10

ipratropium
(i-pra-troe-pee-um)
Atrovent HFA

CLASSIFICATION(S)
Therapeutic: allergy, cold, and cough remedies, bronchodilators
Pharmacologic: anticholinergics

Pregnancy Category B



INDICATIONS

• Inhaln: Maintenance therapy of reversible airway obstruction due to COPD
• Intranasal: Rhinorrhea associated with allergic and nonallergic perennial rhinitis (0.03% solution) or the common cold (0.06% solution)
• Unlabelled Uses: • Inhaln: Adjunctive management of bronchospasm caused by asthma


ACTION

• Inhaln: Inhibits cholinergic receptors in bronchial smooth muscle, resulting in decreased concentrations of cyclic guanosine monophosphate (cGMP). Decreased levels of cGMP produce local bronchodilation
• Intranasal: Local application inhibits secretions from glands lining the nasal mucosa
• Therapeutic Effects: ○ Inhaln: Bronchodilation without systemic anticholinergic effects
○ Intranasal: Decreased rhinorrhea


PHARMACOKINETICS

Absorption: Minimal systemic absorption (2% for inhalation solution; 20% for inhalation aerosol; <20% following nasal use)
Distribution: Does not appear to cross the blood-brain barrier
Metabolism and Excretion: Small amounts absorbed are metabolized by the liver.
Half-life: 2 hr

TIME OF ACTION

bronchodilation ROUTE ONSET PEAK DURATION
Inhalation 5-15 min 1-2 hr 3-4 hr (up to 8 hr)
Intranasal 15 min unknown 6-12 hr

CONTRAINDICATIONS/PRECAUTIONS

Contraindicated in: • Hypersensitivity to ipratropium, atropine, belladonna alkaloids, bromide or fluorocarbons
• Peanut or soy allergy (inhaler contains soy lecithin)
• Avoid use during acute bronchospasm
Use Cautiously in: • Patients with bladder neck obstruction, prostatic hypertrophy, glaucoma, or urinary retention
• Geri: Geriatric patients (may be more sensitive to effects)
• OB: Pedi: Pregnancy, lactation, or children <5 yr (safety not established)

ADVERSE REACTIONS/SIDE EFFECTS*

*CAPITALS indicate life threatening; underlines indicate most frequent.

CNS: dizziness, headache, nervousness,
EENT: blurred vision, sore throat, nasal only: epistaxis, nasal dryness/irritation,
Resp: bronchospasm, cough,
CV: hypotension, palpitations,
GI: GI irritation, nausea,
Derm: rash,
Misc: allergic reactions,

INTERACTIONS

Drug-Drug:
• Potential ↑ fluorocarbon toxicity when used with other inhalation bronchodilators having a fluorocarbon propellant
• ↑ anticholinergic properties with other drugs having anticholinergic properties ( antihistamines , phenothiazines , disopyramide )

ROUTE AND DOSAGE

• Inhaln (Adults ): Metered-dose inhaler--1-4 inhalations 3-4 times daily (not to exceed 24 inhalations/24 hr or more frequently than q 4 hr). During initial therapy, up to 8 inhalations may be repeated. During acute exacerbations 6-8 inhalations q 3-4 hr using a spacer device may be needed. Via nebulization--250-500 mcg 3-4 times daily given q 6-8 hr as needed (up to 500 mcg q 4 hr)
• Inhaln (Children 5-12 yr): Metered dose inhaler--1-2 inhalations q 6-8 hr as needed.Via nebulization--125-250 mcg 3-4 times daily given q 4-6 hr as needed
• Intranasal (Adults and Children >12 yr): Perennial rhinitis--2 sprays of 0.03% solution in each nostril 2-3 times daily (21 mcg/spray); perennial rhinitis--2 sprays of 0.06% solution in each nostril 3-4 times daily (42 mcg/spray) for up to 4 days

AVAILABILITY
• Aerosol inhaler (chlorofluorocarbon-free, contains soy lecithin): 18 mcg/spray in 14-g canister (200 inhalations)
• Cost: Atrovent--$44.56/inhaler, $44.56/refill
• Inhalation solution: 0.0125%, 0.02% in single-dose vials containing 500 mcg, 0.025%
• Nasal spray: 0.03% solution--21 mcg/spray in 30-ml bottle (345 sprays/bottle), 0.06% solution--42 mcg/spray in 15-ml bottle (165 sprays)
• In combination with: albuterol (Combivent, Duoneb). See Appendix B


NURSING IMPLICATIONS

ASSESSMENT

• Assess for allergy to atropine and belladonna alkaloids; patients with these allergies may also be sensitive to ipratropium. Assess for peanut or soy allergy (inhaler contains soy lecithin)
• Inhaln: Assess respiratory status (rate, breath sounds, degree of dyspnea, pulse) before administration and at peak of medication. Consult physician or other health care professional about alternative medication if severe bronchospasm is present; onset of action is too slow for patients in acute distress. If paradoxical bronchospasm (wheezing) occurs, withhold medication and notify physician or other health care professional immediately
• Nasal Spray: Assess patient for rhinorrhea

POTENTIAL NURSING DIAGNOSES

• Ineffective airway clearance (Indications).
• Activity intolerance (Indications).

Back 10

IMPLEMENTATION

• Do not confuse Atrovent with Alupent (metaproterenol)
• Inhaln: See Appendix B for administration of inhalation medications ○ When ipratropium is administered concurrently with other inhalation medications, administer adrenergic bronchodilators first, followed by ipratropium, then corticosteroids. Wait 5 min between medications
○ Solution for nebulization can be diluted with preservative-free 0.9% NaCl. Diluted solution should be used within 24 hr at room temperature or 48 hr if refrigerated. Solution can be mixed with preservative-free albuterol, cromolyn, or metaproterenol if used within 1 hr of mixing


PATIENT/FAMILY TEACHING

• Instruct patient in proper use of inhaler, nebulizer, or nasal spray and to take medication as directed. Take missed doses as soon as remembered unless almost time for the next dose; space remaining doses evenly during day. Do not double doses ○ Advise patient that rinsing mouth after using inhaler, good oral hygiene, and sugarless gum or candy may minimize dry mouth. Health care professional should be notified if stomatitis occurs or if dry mouth persists for more than 2 wk

• Inhalation: Caution patient not to exceed 12 doses within 24 hr. Patient should notify health care professional if symptoms do not improve within 30 min after administration of medication or if condition worsens ○ Explain need for pulmonary function tests prior to and periodically during therapy to determine effectiveness of medication
○ Caution patient to avoid spraying medication in eyes; may cause blurring of vision or irritation
○ Advise patient to inform health care professional if cough, nervousness, headache, dizziness, nausea, or GI distress occurs

• Nasal Spray: Instruct patient in proper use of nasal spray. Clear nasal passages gently before administration. Do not inhale during administration, so medication remains in nasal passages. Prime pump initially with 7 actuations. If used regularly, no further priming is needed. If not used in 24 hr, prime with 2 actuations. If not used for >7 days, prime with 7 actuations ○ Advise patient to contact health care professional if symptoms do not improve within 1-2 wk or if condition worsens


EVALUATION/DESIRED OUTCOMES

• Decreased dyspnea ○ Improved breath sounds

• Decrease in rhinorrhea from perennial rhinitis or the common cold

Front 11

furosemide
(fur-oh-se-mide)
Apo-Furosemide, Furoside, Lasix, Lasix Special, Myrosemide, Novosemide, Uritol

CLASSIFICATION(S)
Therapeutic: diuretics
Pharmacologic: loop diuretics

Pregnancy Category C

= Canadian drug name.

INDICATIONS

• Edema due to: ○ CHF
○ Hepatic or renal disease

• Hypertension
• Unlabelled Uses: • Hypercalcemia of malignancy


ACTION

• Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule
• Increases renal excretion of water, sodium, chloride, magnesium, hydrogen, and calcium
• May have renal and peripheral vasodilatory effects
• Effectiveness persists in impaired renal function
• Therapeutic Effects: ○ Diuresis and subsequent mobilization of excess fluid (edema, pleural effusions)
○ Decreased blood pressure


PHARMACOKINETICS

Absorption: 60-75% absorbed after oral administration (↓ in acute CHF and in renal failure); also absorbed from IM sites
Distribution: Crosses placenta, enters breast milk
Protein Binding: 91-97%
Metabolism and Excretion: Some 30-40% metabolized by liver , some nonhepatic metabolism, some renal excretion as unchanged drug
Half-life: 30-60 min (↑ in renal impairment and neonates, markedly ↑ in hepatic impairment)

TIME OF ACTION

diuretic effect ROUTE ONSET PEAK DURATION
PO 30-60 min 1-2 hr 6-8 hr
IM 10-30 min unknown 4-8 hr
IV 5 min 30 min 2 hr

CONTRAINDICATIONS/PRECAUTIONS

Contraindicated in: • Hypersensitivity
• Cross-sensitivity with thiazides and sulfonamides may occur
• Pre-existing electrolyte imbalance, hepatic coma, or anuria
• Some liquid products may contain alcohol, avoid in patients with alcohol intolerance
Use Cautiously in: • Severe liver disease (may precipitate hepatic coma; concurrent use with potassium-sparing diuretics may be necessary)
• Electrolyte depletion
• Geri: Geriatric patients may have increased risk of side effects, especially hypotension and electrolyte imbalance, at usual doses
• Pedi:
• Increased risk of renal calculi and patent ductus arteriosis in premature neonatesDiabetes mellitus
• Increasing azotemia
• Pregnancy and lactation

ADVERSE REACTIONS/SIDE EFFECTS*

*CAPITALS indicate life threatening; underlines indicate most frequent.

CNS: dizziness, encephalopathy, headache, insomnia, nervousness,
EENT: hearing loss, tinnitus,
CV: hypotension,
GI: constipation, diarrhea, dry mouth, dyspepsia, nausea, vomiting,
GU: excessive urination,
Derm: photosensitivity, rashes,
Endo: hyperglycemia,
F and E: dehydration, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis,
Hemat: blood dyscrasias,
Metab: hyperglycemia, hyperuricemia,
MS: arthralgia, muscle cramps, myalgia,
Misc: increased BUN,

INTERACTIONS

Drug-Drug:
• ↑ hypotension with antihypertensives , nitrates , or acute ingestion of alcohol
• ↑ risk of hypokalemia with other diuretics , piperacillin , amphotericin B , stimulant laxatives , and corticosteroids
• Hypokalemia may ↑ risk of digoxin toxicity
• ↓ lithium excretion, may cause toxicity
• ↑ risk of ototoxicity with aminoglycosides and ethacrynic acid
• May ↑ the effectiveness of warfarin , thrombolytic agents , or anticoagulants
• Indomethacin ↓ effects of furosemide
• ↓ effects of furosemide when given at same time as sucralfate

ROUTE AND DOSAGE

• PO (Adults ): Edema--20-80 mg/day as a single dose initially, may repeat in 6-8 hr; may increase dose by 20-40 mg q 6-8 hr until desired response. Maintenance doses may be given once or twice daily or intermittently for 2-4 days/week (doses up to 2.5 g/day have been used in patients with CHF or renal disease). Hypertension--40 twice daily initially (when added to regimen, decrease dose of other antihypertensives by 50%); adjust further dosing based on response; Hypercalcemia--120 mg/day in 1-3 doses
• PO (Children > 1 month): 2 mg/kg as a single dose; may be increased by 1-2 mg/kg q 6-12 hr (1-2 mg/kg/day initially, up to 5-6 mg/kg/day)
• IM, IV (Adults ): Edema--20-40 mg, may repeat in 2 hr and increase by 20 mg every 2 hr until response is obtained, maintenance dose may be given once-twice daily; acute pulmonary edema--40 mg, after 1 hr may give additional 80 mg (in CHF and renal failure, daily doses of up to 2.5 g have been used); hypercalcemia--80-100 mg, may repeat every 1-2 hr, titrate by response.Continuous infusion-Bolus 0.1 mg/kg followed by 0.1 mg/kg/hr, double q 2 hr to a maximum of 0.4 mg/kg/hr
• IM, IV (Children ): 1-2 mg/kg/dose q 6-12 hr Continuous infusion-0.05 mg/kg/hr, titrate to clinical effect
• PO (Neonates ): 1-4 mg/kg/dose 1-2 times/day
• IM, IV (Neonates ): 1-2 mg/kg/dose q 12-24 hr

AVAILABILITY
• Tablets: 20 mg, 40 mg, 80 mg, 500 mg
• Cost: Lasix — 20 mg $21.12/100, 40 mg $29.57/100, 80 mg $23.91/50Generic — 20 mg $19.00/100, 40 mg $26.50/100, 80 mg $35.90/100
• Oral solution (10 mg/ml --orange flavor, 8 mg/ml --orange-pineapple flavor) : 8 mg/ml, 10 mg/ml
• Cost: 10 mg/ml $10.40/60 ml
• Injection: 10 mg/ml


NURSING IMPLICATIONS

ASSESSMENT

• Assess fluid status during therapy. Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes. Notify physician or other health care provider if thirst, dry mouth, lethargy, weakness, hypotension, or oliguria occurs
• Monitor blood pressure and pulse before and during administration. Monitor frequency of prescription refills to determine compliance in patients treated for hypertension
• Geri: Diuretic use is associated with increased risk for falls in older adults. Assess falls risk and implement fall prevention strategies
• Assess patients receiving digoxin for anorexia, nausea, vomiting, muscle cramps, paresthesia, and confusion. Patients taking digitalis glycosides are at increased risk of digitalis toxicity because of the potassium-depleting effect of the diuretic. Potassium supplements or potassium-sparing diuretics may be used concurrently to prevent hypokalemia
• Assess patient for tinnitus and hearing loss. Audiometry is recommended for patients receiving prolonged high-dose IV therapy. Hearing loss is most common after rapid or high-dose IV administration in patients with decreased renal function or those taking other ototoxic drugs
• Assess for allergy to sulfonamides
• Lab Test Considerations: Monitor electrolytes, renal and hepatic function, serum glucose, and uric acid levels before and periodically throughout therapy. May cause ↓ serum potassium, calcium, and magnesium concentrations. May also cause ↑ BUN, serum glucose, creatinine, and uric acid levels

POTENTIAL NURSING DIAGNOSES

• Excess fluid volume (Side Effects).

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IMPLEMENTATION

• Do not confuse furosemide with torsemide ○ Administer medication in the morning to prevent disruption of sleep cycle
○ IV route is preferred over IM route for parenteral administration

• PO: Administer orally with food or milk to minimize gastric irritation. Tablets may be crushed if patient has difficulty swallowing ○ Do not administer discolored solution or tablets

• When using furosemide for hypercalcemia, replace extracellular volume and sodium chloride to maintain fluid volume and increase calcium excretion effectively
• Direct IV: Administer undiluted Rate: Administer slowly over 1-2 min at a maximum rate of 0.5 mg/kg/min for doses < 120 mg
• Intermittent Infusion: Dilute large doses in D5W, D10W, D20W, D5/0.9% NaCl, D5/LR, 0.9% NaCl, 3% NaCl, 1/6 M sodium lactate, or LR. Use reconstituted solution within 24 hr Rate: Administer at a rate not to exceed 4 mg/min (for doses > 120 mg) in adults to prevent ototoxicity. Use an infusion pump to ensure accurate dosage
• Syringe Compatibility: ♦bleomycin ♦cisplatin ♦cyclophosphamide ♦fluorouracil ♦heparin ♦leucovorin calcium ♦methotrexate ♦mitomycin
• Syringe Incompatibility: ♦doxapram ♦doxorubicin ♦droperidol ♦metoclopramide ♦milrinone ♦vinblastine ♦vincristine
• Y-Site Compatibility: ♦allopurinol ♦amifostone ♦amikacin ♦amphotericin B cholesteryl sulfate ♦aztreonam ♦bleomycin ♦cefepime ♦cisplatin ♦cladribine ♦cyclophosphamide ♦cytarabine ♦docetaxel ♦doxorubicin liposome ♦epinephrine ♦etoposide ♦fentanyl ♦fludarabine ♦fluorouracil ♦foscarnet ♦granisetron ♦heparin ♦hydrocortisone sodium succinate ♦hydromorphone ♦indomethacin ♦kanamycin ♦leucovorin calcium ♦linezolid ♦lorazepam ♦melphalan ♦meropenem ♦methotrexate ♦mitomycin ♦nitroglycerin ♦norepinephrine ♦paclitaxel ♦piperacillin/tazobactam ♦potassium chloride ♦propofol ♦ranitidine ♦remifentanil ♦sargramostim ♦tacrolimus ♦teniposide ♦thiotepa ♦tobramycin ♦tolazoline ♦vitamin B complex with C
• Y-Site Incompatibility: ♦ciprofloxacin ♦diltiazem ♦droperidol ♦esmolol ♦filgrastim ♦fluconazole ♦gatifloxacin ♦gemcitabine ♦gentamicin ♦hydralazine ♦idarubicin ♦levofloxacin ♦metoclopramide ♦midazolam ♦milrinone ♦morphine ♦ondansetron ♦quinidine gluconate ♦thiopental ♦vecuronium ♦vinblastine ♦vincristine ♦vinorelbine

PATIENT/FAMILY TEACHING

• Instruct patient to take furosemide as directed. Take missed doses as soon as possible; do not double doses ○ Caution patient to change positions slowly to minimize orthostatic hypotension. Caution patient that the use of alcohol, exercise during hot weather, or standing for long periods during therapy may enhance orthostatic hypotension
○ Instruct patient to consult health care professional regarding a diet high in potassium (see Appendix B )
○ Advise patient to consult health care professional before taking OTC medication or herbal products concurrently with this therapy
○ Instruct patient to notify health care professional of medication regimen before treatment or surgery
○ Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions
○ Geri: Caution older patients or their caregivers about increased risk for falls. Suggest strategies for fall prevention
○ Advise patient to contact health care professional immediately if muscle weakness, cramps, nausea, dizziness, numbness, or tingling of extremities occurs
○ Advise patient taking furosemide tablets not to change brands when refilling prescription; bioavailability among brands is variable
○ Advise diabetic patients to monitor blood glucose closely; may cause increased blood glucose levels
○ Emphasize the importance of routine follow-up examinations

• Hypertension: Advise patients on antihypertensive regimen to continue taking medication even if feeling better. Furosemide controls but does not cure hypertension ○ Reinforce the need to continue additional therapies for hypertension (weight loss, exercise, restricted sodium intake, stress reduction, regular exercise, moderation of alcohol consumption, cessation of smoking)


EVALUATION/DESIRED OUTCOMES

• Decrease in edema ○ Decrease in abdominal girth
○ Increase in urinary output

• Decrease in blood pressure
• Decrease in serum calcium when used to manage hypercalcemia

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High Alert


POTASSIUM SUPPLEMENTS
(poe-tass-ee-um)

potassium acetate

potassium bicarbonate
K+Care ET, K-Electrolyte, K-Ide, Klor-Con/EF, K-Lyte, K-Vescent

potassium bicarbonate/potassium chloride
Klorvess, Klorvess Effervescent Granules, K-Lyte/Cl, Neo-K, Potassium Sandoz

potassium bicarbonate/potassium citrate
Effer-K, K-Lyte DS

potassium chloride
Apo-K, Cena-K , Gen-K, K+ Care, K+ 10, Kalium Durules, Kaochlor, Kaochlor S-F, Kaon-Cl, Kay Ciel, KCl, K-Dur, K-Lease , K-Long, K-Lor, Klor-Con, Klorvess Liquid, Klotrix, K-Lyte/Cl Powder, K-Med, K-Norm, K-Sol, K-Tab, Micro-K, Micro-K ExtenCaps, Micro-LS, Potasalan, Roychlor, Rum-K, Slow-K, Ten-K

potassium chloride/potassium bicarbonate/potassium citrate
Kaochlor Eff

potassium gluconate
Kaon, Kaylixir, K-G Elixir, Potassium-Rougier

potassium gluconate/potassium chloride
Kolyum

potassium gluconate/potassium citrate
Twin-K

trikates (potassium acetate/potassium bicarbonate/potassium citrate)
Tri-K

CLASSIFICATION(S)
Therapeutic: mineral and electrolyte replacements/supplements

Pregnancy Category C

= Canadian drug name.

INDICATIONS

• PO: IV: Treatment/prevention of potassium depletion
• IV: Arrhythmias due to digoxin toxicity

ACTION

• Maintain acid-base balance, isotonicity, and electrophysiologic balance of the cell
• Activator in many enzymatic reactions; essential to transmission of nerve impulses; contraction of cardiac, skeletal, and smooth muscle; gastric secretion; renal function; tissue synthesis; and carbohydrate metabolism
• Therapeutic Effects: ○ Replacement
○ Prevention of deficiency


PHARMACOKINETICS

Absorption: Well absorbed following oral administration
Distribution: Enters extracellular fluid; then actively transported into cells
Metabolism and Excretion: Excreted by the kidneys
Half-life: Unknown

TIME OF ACTION

increase in serum potassium levels ROUTE ONSET PEAK DURATION
PO unknown 1-2 hr unknown
IV rapid end of infusion unknown

CONTRAINDICATIONS/PRECAUTIONS

Contraindicated in: • Hyperkalemia
• Severe renal impairment
• Untreated Addison's disease
• Severe tissue trauma
• Hyperkalemic familial periodic paralysis
• Some products may contain tartrazine (FDC yellow dye #5) or alcohol; avoid using in patients with known hypersensitivity or intolerance
• Potassium acetate injection contains aluminum, which may become toxic with prolonged use to high risk groups (renal impairment, premature neonates)
Use Cautiously in: • Cardiac disease
• Renal impairment
• Diabetes mellitus (liquids may contain sugar)
• Hypomagnesemia (may make correction of hypokalemia more difficult)
• GI hypomotility including dysphagia or esophageal compression from left atrial enlargement (tablets, capsules)
• Patients receiving potassium-sparing drugs

ADVERSE REACTIONS/SIDE EFFECTS*

*CAPITALS indicate life threatening; underlines indicate most frequent.

CNS: confusion, restlessness, weakness,
CV: ARRHYTHMIAS, ECG changes,
GI: abdominal pain, diarrhea, flatulence, nausea, vomiting, tablets, capsules only: GI ulceration, stenotic lesions,
Local: irritation at IV site,
Neuro: paralysis, paresthesia,

INTERACTIONS

Drug-Drug:
• Use with potassium-sparing diuretics or ACE inhibitors or angiotensin II receptor antagonists may lead to hyperkalemia
• Anticholinergics may ↑ GI mucosal lesions in patients taking wax-matrix potassium chloride preparations

ROUTE AND DOSAGE

Expressed as mEq of potassium. Potassium acetate contains 10.2 mEq/g; potassium bicarbonate contains 10 mEq potassium/g; potassium chloride contains 13.4 mEq potassium/g; potassium gluconate contains 4.3 mEq/g

Normal Daily Requirements

• PO, IV (Adults ): 40-80 mEq/day
• PO, IV (Children ): 2-3 mEq/kg/day
• PO, IV (Neonates ): 2-6 mEq/kg/day
Prevention of hypokalemia during Diuretic Therapy

• PO (Adults ): 20-40 mEq/day in 1-2 divided doses;--40-100 mEq/day; single dose should not exceed 20 mEq
• PO (Neonates , Infants and Children): 1-2 mEq/kg/day in 1-2divided doses
Treatment of Hypokalemia

• PO (Adults ): 40-100 mEq/day in divided doses
• PO (Neonates , Infants and Children): 2-5 mEq/kg/day in divided doses
• IV (Adults ): Serum potassium >2.5 mEq/L--Up to 20 mEq/day as an infusion (not to exceed 10 mEq/hr or a concentration of 40 mEq/L via peripheral line (up to 100 mEq/L have been used via central line [unlabeled]).Serum potassium <2 mEq/L with symptoms--Up to 40 mEq/day as an infusion (rate should generally not exceed 20 mEq/hr)
• IV (Neonates , Infants and Children): 0.5-1 mEq/kg/dose (maximum 30 mEq/dose) as an infusion to infuse at 0.3-0.5 mEq/kg/hr (maximum infusion rate 1 mEq/kg/hr)

AVAILABILITY


Potassium Acetate • Concentrate for injection (contains aluminum): 2 mEq/ml in 20-, 50-, and 100-ml vials, 40 mEq/ml in 50-ml vials


Potassium Bicarbonate • Tablets for effervescent oral solution: 25 mEq


Potassium Bicarbonate/Potassium Chloride • Packets for effervescent oral solution: 20 mEq/2.8-g packet
• Tablets for effervescent oral solution: 12 mEq, 20 mEq, 25 mEq, 50 mEq


Potassium Bicarbonate/Potassium Citrate • Tablets for effervescent oral solution: 25 mEq, 50 mEq


Potassium Chloride • Extended-release tablets: 8 mEq, 10 mEq, 20 mEq
• Cost: 10 mEq $32.10/100, 20 mEq $58.46/100
• Extended-release capsules: 8 mEq, 10 mEq
• Oral solution: 10 mEq/15 ml, 20 mEq/15 ml, 30 mEq/15 ml, 40 mEq/15 ml
• Powder/packets for oral solution: 15-mEq/1.2-g packet, 20-mEq/1.5-g packet, 25-mEq/1.8-g packet
• Packets for oral suspension: 20-mEq/1.5-g packet
• Concentrate for injection: 0.1 mEq/ml in 10-mEq ampules and vials, 0.2 mEq/ml in 10- and 20-mEq ampules and vials, 0.3 mEq/ml in 30-mEq ampules and vials, 0.4 mEq/ml in 20- and 40-mEq ampules and vials, 1.5 mEq/ml, 2 mEq/ml, 3 mEq/ml
• Solution for IV infusion: 10 mEq/L in various dextrose and saline solutions in 250-, 500-, and 100-ml containers, 20 mEq/L in dextrose/saline/LRs in 250-, 500-, and 100-ml containers, 30 mEq/L in various dextrose and saline solutions in 250-, 500-, and 100-ml containers, 40 mEq/L in various dextrose and saline solutions in 250-, 500-, and 100-ml containers


Potassium Chloride/Potassium Bicarbonate/Potassium Citrate • Tablets for effervescent oral solution: 20 mEq


Potassium Gluconate • Tablets: 2 mEq, 5 mEq
• Elixir: 20 mEq/15 ml


Potassium Gluconate/Potassium Chloride • Oral solution: 20 mEq/15 ml
• Powder for oral solution: 20 mEq/5-g packet


Potassium Gluconate/Potassium Citrate • Oral solution: 20 mEq/15 ml


Trikates (Potassium Acetate/Potassium Bicarbonate/Potassium Citrate) • Oral solution: 15 mEq/5 ml


NURSING IMPLICATIONS

ASSESSMENT

• Assess for signs and symptoms of hypokalemia (weakness, fatigue, U wave on ECG, arrhythmias, polyuria, polydipsia) and hyperkalemia (see Toxicity and Overdose)
• Monitor pulse, blood pressure, and ECG periodically during IV therapy
• Lab Test Considerations: Monitor serum potassium before and periodically during therapy. Monitor renal function, serum bicarbonate, and pH. Determine serum magnesium level if patient has refractory hypokalemia; hypomagnesemia should be corrected to facilitate effectiveness of potassium replacement. Monitor serum chloride because hypochloremia may occur if replacing potassium without concurrent chloride
• Toxicity and Overdose: Symptoms of toxicity are those of hyperkalemia (slow, irregular heartbeat; fatigue; muscle weakness; paresthesia; confusion; dyspnea; peaked T waves; depressed ST segments; prolonged QT segments; widened QRS complexes; loss of P waves; and cardiac arrhythmias) ○ Treatment includes discontinuation of potassium, administration of sodium bicarbonate to correct acidosis, dextrose and insulin to facilitate passage of potassium into cells, calcium salts to reverse ECG effects (in patients who are not receiving digoxin), sodium polystyrene used as an exchange resin, and/or dialysis for patient with impaired renal function


POTENTIAL NURSING DIAGNOSES

• Imbalanced nutrition: less than body requirements (Indications).

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IMPLEMENTATION

• High Alert: Medication errors involving too rapid infusion or bolus IV administration of potassium chloride have resulted in fatalities. See IV administration guidelines below
• Do not confuse K-Dur with Imdur (isosorbide mononitrate). Do not confuse Micro-K with micronase (glyburide) ○ For most purposes, potassium chloride should be used, except for renal tubular acidoses (hyperchloremic acidosis), in which other salts are more appropriate (potassium bicarbonate, potassium citrate, or potassium gluconate)
○ If hypokalemia is secondary to diuretic therapy, consideration should be given to decreasing the dose of diuretic, unless there is a history of significant arrhythmias or concurrent digitalis glycoside therapy

• PO: Administer with or after meals to decrease GI irritation ○ Use of tablets and capsules should be reserved for patients who cannot tolerate liquid preparations
○ Dissolve effervescent tablets in 3-8 oz of cold water. Ensure that effervescent tablet is fully dissolved. Powders and solutions should be diluted in 3-8 oz of cold water or juice (do not use tomato juice if patient is on sodium restriction). Instruct patient to drink slowly over 5-10 min
○ Tablets and capsules should be taken with a meal and full glass of water. Do not chew or crush enteric-coated or extended-release tablets or capsules Micro-K ExtenCaps capsules can be opened and sprinkled on soft food (pudding, applesauce) and swallowed immediately with a glass of cool water or juice

• IV: Assess for extravasation; severe pain and tissue necrosis may occur.High Alert: Never administer potassium IV push or bolus
Potassium Acetate

• Continuous Infusion: High Alert: Do not administer undiluted. Each single dose must be diluted and thoroughly mixed in 100-1000 ml of dextrose, saline, Ringer's or LR, dextrose/saline, dextrose/Ringer"s, or LR combinations. Usually limited to 80 mEq/L via peripheral line (200 mEq/L via central line) Rate: High Alert: Infuse slowly, at a rate up to 10 mEq/hr in adults or 0.5 mEq/kg/hr in children on general care areas. Check hospital policy for maximum infusion rates (maximum rate in monitored setting 40 mEq/hr in adults or 1 mEq/kg/hr in children)
Potassium Chloride

• Continuous Infusion: High Alert: Do not administer concentrations of >1.5 mEq/ml undiluted; fatalities have occurred. Concentrated products have black caps on vials or black stripes above constriction on ampules and are labeled with a warning about dilution requirement. Each single dose must be diluted and thoroughly mixed in 100-1000 ml of IV solution. Usually limited to 80 mEq/L via peripheral line (200 mEq/L via central line) ○ Concentrations of 0.1 and 0.4 mEq/ml are intended for administration via calibrated infusion device and do not require dilution
Rate: High Alert: Infuse slowly, at a rate up to 10 mEq/hr in adults or 0.5 mEq/kg/hr in children in general care areas. Check hospital policy for maximum infusion rates (maximum rate in monitored setting 40 mEq/hr in adults or 1 mEq/kg/hr in children). Use an infusion pump
• Solution Compatibility:
• Y-Site Compatibility: ♦acyclovir ♦aldesleukin ♦allopurinol ♦amifostine ♦aminophylline ♦amiodarone ♦ampicillin ♦atropine ♦aztreonam ♦betamethasone ♦calcium gluconate ♦chlordiazepoxide ♦chlorpromazine ♦ciprofloxacin ♦cisatracurium ♦cladribine ♦cyanocobalamin ♦digoxin ♦diltiazem ♦diphenhydramine ♦dobutamine ♦docetaxel ♦dopamine ♦doxorubicin liposome ♦droperidol ♦edrophonium ♦enalaprilat ♦epinephrine ♦esmolol ♦conjugated estrogens ♦ethacrynate sodium ♦etoposide phosphate ♦famotidine ♦fentanyl ♦filgrastim ♦ fludarabine ♦fluorouracil ♦furosemide ♦gatifloxacin ♦gemcitabine ♦granisetron ♦heparin ♦hydralazine ♦idarubicin ♦inamrinone ♦indomethacin ♦insulin ♦isoproterenol ♦kanamycin ♦labetalol ♦lidocaine ♦linezolid ♦lorazepam ♦magnesium sulfate ♦melphalan ♦menadiol ♦meperidine ♦methoxamine ♦methylergonovine ♦midazolam ♦milrinone ♦minocycline ♦morphine ♦neostigmine ♦norepinephrine ♦ondansetron ♦oxacillin ♦oxytocin ♦paclitaxel ♦penicillin G potassium ♦pentazocine ♦phytonadione ♦piperacillin/tazobactam ♦procainamide ♦prochlorperazine ♦propofol ♦propranolol ♦pyridostigmine ♦remifentanil ♦sargramostim ♦scopolamine ♦sodium bicarbonate ♦succinylcholine ♦tacrolimus ♦teniposide ♦theophylline ♦thiotepa ♦tirofiban ♦trimethaphan ♦trimethobenzamide ♦vinorelbine ♦warfarin ♦zidovudine
• Y-Site Incompatibility: ♦amphotericin B cholesteryl sulfate complex ♦diazepam ♦ergotamine tartrate ♦phenytoin
• Additivie Compatibility: ♦calcium gluconate ♦cimetidine ♦lidocaine ♦ranitidine ♦sodium bicarbonate ♦vitamin B complex with C

PATIENT/FAMILY TEACHING

• Explain to patient purpose of the medication and the need to take as directed, especially when concurrent digoxin or diuretics are taken. A missed dose should be taken as soon as remembered within 2 hr; if not, return to regular dose schedule. Do not double dose
• Emphasize correct method of administration. GI irritation or ulceration may result from chewing enteric-coated tablets or insufficient dilution of liquid or powder forms
• Some extended-release tablets are contained in a wax matrix that may be expelled in the stool. This occurrence is not significant
• Instruct patient to avoid salt substitutes or low-salt milk or food unless approved by health care professional. Patient should be advised to read all labels to prevent excess potassium intake
• Advise patient regarding sources of dietary potassium (see Appendix B ). Encourage compliance with recommended diet
• Instruct patient to report dark, tarry, or bloody stools; weakness; unusual fatigue; or tingling of extremities. Notify health care professional if nausea, vomiting, diarrhea, or stomach discomfort persists. Dosage may require adjustment
• Emphasize the importance of regular follow-up exams to monitor serum levels and progress

EVALUATION/DESIRED OUTCOMES

• Prevention and correction of serum potassium depletion
• Cessation of arrhythmias caused by digoxin toxicity

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pramipexole
(pra-mi-pex-ole)
Mirapex

CLASSIFICATION(S)
Therapeutic: antiparkinson agents
Pharmacologic: dopamine agonists

Pregnancy Category C



INDICATIONS

• Management of idiopathic Parkinson's disease

ACTION

• Stimulates dopamine receptors in the striatum of the brain
• Therapeutic Effects: ○ Decreased tremor and rigidity in Parkinson's disease


PHARMACOKINETICS

Absorption: >90% absorbed following oral administration
Distribution: Widely distributed
Metabolism and Excretion: 90% excreted unchanged in urine
Half-life: 8 hr (increased in geriatric patients and patients with renal impairment)

TIME OF ACTION

blood levels ROUTE ONSET PEAK DURATION
PO unknown 2 hr 8 hr

CONTRAINDICATIONS/PRECAUTIONS

Contraindicated in: • Hypersensitivity
Use Cautiously in: • Geriatric patients (increased risk of hallucinations)
• Renal impairment (increased dosing interval recommended if CCr <60 ml/min)
• Pregnancy, lactation, or children (safety not established)

ADVERSE REACTIONS/SIDE EFFECTS*

*CAPITALS indicate life threatening; underlines indicate most frequent.

CNS: SLEEP ATTACKS, amnesia, dizziness, drowsiness, hallucinations, weakness, abnormal dreams, confusion, dyskinesia, extrapyramidal syndrome, headache, insomnia,
CV: postural hypotension,
GI: constipation, dry mouth, dyspepsia, nausea, tooth disease,
GU: urinary frequency,
MS: leg cramps,
Neuro: hypertonia, unsteadiness/falling,

INTERACTIONS

Drug-Drug:
• Concurrent levodopa increases the risk of hallucinations and dyskinesia
• Effectiveness may be increased by cimetidine
• Effectiveness may be decreased by dopamine antagonists , including butyrophenones , metoclopramide , phenothiazines , or thioxanthenes

ROUTE AND DOSAGE

• PO (Adults ): 0.125 mg 3 times daily initially; may be increased q 5-7 days (range 1.5-4.5 mg/day in 3 divided doses)

Renal Impairment
• PO (Adults ): CCr 35-59 ml/min--0.125 mg twice daily initially, may be increased q 5-7 days up to 1.5 mg twice daily; CCr 15-34 ml/min--0.125 mg once daily initially, may be increased q 5-7 days up to 1.5 mg once daily

AVAILABILITY
• Tablets: 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 1.5 mg
• Cost: 0.125 mg $47.75/90, 0.25 mg $90.54/90, 0.5 mg $177.66/90, 1 mg $177.66/90, 1.5 mg $177.66/90

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NURSING IMPLICATIONS

ASSESSMENT

• Assess patient for signs and symptoms of Parkinson's disease (tremor, muscle weakness and rigidity, ataxia) before and throughout therapy
• Assess patient for confusion or hallucinations. Notify physician or other health care professional if these occur
• Monitor ECG and blood pressure frequently during dosage adjustment and periodically throughout therapy
• Assess patient for drowsiness and sleep attacks. Drowsiness is a common side effect of pramipexole, but sleep attacks or episodes of falling asleep during activities that require active participation may occur without warning. Assess patient for concomitant medications that have sedating effects or may increase serum pramipexole levels (see Interactions). May require discontinuation of therapy

POTENTIAL NURSING DIAGNOSES

• Impaired physical mobility (Indications).
• Risk for injury (Indications). (Side Effects).

IMPLEMENTATION

• PO: An attempt to reduce the dose of levodopa/carbidopa may be made cautiously during pramipexole therapy ○ Administer with meals to minimize nausea; usually resolves with continued therapy


PATIENT/FAMILY TEACHING

• Instruct patient to take medication exactly as directed. Missed doses should be taken as soon as remembered if it is not almost time for next dose. Do not double doses. Consult health care professional before reducing dose or discontinuing medication
• May cause drowsiness and unexpected episodes of falling asleep. Caution patient to avoid driving or other activities requiring alertness until response to medication is known. Advise patient to notify health care professional if episodes of falling asleep occur
• Advise patient to change position slowly to minimize orthostatic hypotension. May occur more frequently during initial therapy
• Advise female patient to notify health care professional if pregnancy is planned or suspected or if currently breastfeeding or planning to breastfeed

EVALUATION/DESIRED OUTCOMES

• Decreased tremor and rigidity in Parkinson's disease

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What is chronic obstructive pulmonary disease (COPD)?
Chronic obstructive pulmonary disease (COPD) is a lung disease that makes it hard to breathe. It is caused by damage to the lungs over many years, usually from smoking.

COPD is often a mix of two diseases:

Chronic bronchitis (say "bron-KY-tus"). In chronic bronchitis, the airways that carry air to the lungs (bronchial tubes) get inflamed and make a lot of mucus. This can narrow or block the airways, making it hard to breathe.
Emphysema (say "em-fuh-ZEE-muh"). In a healthy person, the tiny air sacs in the lungs are like balloons. As you breathe in and out, they get bigger and smaller to move air through your lungs. But with emphysema, these air sacs are damaged and lose their stretch. Less air gets in and out of the lungs, which makes you feel short of breath.
COPD gets worse over time. You can't undo the damage to your lungs. But you can take steps to prevent more damage and feel better.

What causes COPD?
COPD is almost always caused by smoking. Over time, breathing tobacco smoke irritates the airways and destroys the stretchy fibers in the lungs.

Other things that may put you at risk include breathing chemical fumes, dust, or air pollution over a long period of time. Secondhand smoke is also bad.

It usually takes many years for the lung damage to start causing symptoms, so COPD is most common in people who are older than 60.

You may be more likely to get COPD if you had a lot of serious lung infections when you were a child. People who get COPD in their 30s or 40s may have a disorder that runs in families, called alpha1-antitrypsin deficiency. But this is rare.

What are the symptoms?
The main symptoms are:

A long-lasting (chronic) cough.
Mucus that comes up when you cough.
Shortness of breath that gets worse when you exercise.
As COPD gets worse, you may be short of breath even when you do simple things like get dressed or fix a meal. It gets harder to eat or exercise, and breathing takes much more energy. People often lose weight and get weaker.

At times, your symptoms may suddenly flare up and get much worse. This is called a COPD exacerbation (say "egg-ZASS-er-BAY-shun"). An exacerbation can range from mild to life-threatening. The longer you have COPD, the more severe these flare-ups will be.

How is COPD diagnosed?
To find out if you have COPD, a doctor will:

Do a physical exam and listen to your lungs.
Ask you questions about your past health and whether you smoke or have been exposed to other things that can irritate your lungs.
Have you do a simple breathing test called spirometry to find out how well your lungs work.
Do chest X-rays and other tests to help rule out other problems that could be causing your symptoms.

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If there is a chance you could have COPD, it is very important to find out as soon as you can. This gives you time to take steps to slow the damage to your lungs.

How is it treated?
The only way to slow COPD is to quit smoking. This is the most important thing you can do. It is never too late to quit. No matter how long you have smoked or how serious your COPD is, quitting smoking can help stop the damage to your lungs.

It’s hard to quit smoking. Talk to your doctor about treatments that can help. Using medicines and support increases the chance that you will quit for good. To learn more about how to quit, go to http://www.smokefree.gov, or call 1-800-QUITNOW (1-800-784-8669).

Your doctor can prescribe treatments that may help you manage your symptoms and feel better.

Medicines can help you breathe easier. Most of them are inhaled so they go straight to your lungs. If you get an inhaler, it is very important to use it just the way your doctor showed you.
A lung (pulmonary) rehab program can help you learn to manage your disease. A team of health professionals can provide counseling and teach you how to breathe easier, exercise, and eat well.
In time, you may need to use oxygen some or most of the time.
People who have COPD are more likely to get lung infections, so you will need to get a flu shot every year. You should also get the pneumonia vaccine. It may not keep you from getting pneumonia. But if you do get pneumonia, you probably will not be as sick.

There are many things you can do at home to stay as healthy as you can.

Avoid things that can irritate your lungs, such as smoke, pollution, and cold, dry air.
Use an air conditioner or air filter in your home.
Take rest breaks during the day.
Get regular exercise to stay as strong as you can.
Eat well so you can keep your strength up. If you are losing weight, ask your doctor or dietitian about ways to make it easier to get the calories you need.
What else should you think about?
As COPD gets worse, you may have flare-ups when your symptoms suddenly get much worse. It is important to know what to do if this happens. Your doctor can prescribe medicines to help. But if the attack is severe, you may need to go to the emergency room or call 911 .

Knowing you have a disease that gets worse over time can be hard. It’s common to feel sad or hopeless sometimes. If these feelings last, be sure to tell your doctor. Counseling and support groups can help you cope.

Be sure to talk to your doctor about what kinds of treatment you want if your breathing problems become life-threatening. You may want to write a living will. You can also choose a health care agent to make decisions in case you are not able to. It can be comforting to know that you will get the type of care you want.