IV. RENAL MEDICATIONSA. ANTIINFECTIVES/ANTISEPTICS Generic Nitrofurantoin Brand/Trade Name Microdantin Dosage/Frequency and Route Oral Acute uncomplicated urinary tract infections Adult: 50-100 mg 4 times daily for 7 days. Dual-release preparation: 100 mg bid. Child: >3 mth and older children: 3 mg/kg daily in 4 divided doses. Oral Prophylaxis of uncomplicated UTI Adult: 50-100 mg at bedtime. Child: >3 mth and older children: 1 mg/kg once daily. Indication - Treatment of UTIs caused by susceptible strains of Escherichia coli, Staphylococcus aureus, Klebsiella, Enterobacter, Proteus - Prophylaxis or long-term suppression of UTIs Action Nitrofurantoin interferes with cell metabolism and cell wall synthesis by inhibiting several enzyme systems including acetyl coenzyme A. It is bactericidal to most gram-positive and gram-negative urinary tract pathogens. Absorption: Readily absorbed from the GI tract. Food may increase bioavailability and prolong the duration of therapeutic urinary concentrations. Distribution: Concentrations in blood and body tissues are low; crosses the placenta and the blood-brain barrier and distributes in breast milk (trace amounts). Metabolism: Hepatic and in most body tissues. Excretion: Via Side effects CNS: Peripheral neuropathy, headache, dizziness, nystagmus, drowsiness, vertigo Dermatologic: Exfoliative dermatitis, StevensJohnson syndrome, alopecia, pruritus, urticartia, angioedema GI: Nausea, abdominal cramps, vomiting, diarrhea, anorexia, parotitis, pancreatitis, hepatotoxicity Hematologic: Hemolytic anemia in G6PD deficiency; granulocytopenia, agranulocytosis, leukopenia, thrombocytopenia, eosinophilia, megaloblastic anemia Respiratory: Pulmonary hypersensitivity Other: Superinfections of the GU tract; hypotension; muscular aches; Nursing Responsibilities Take drug with food or milk. Complete the full course of drug therapy to ensure a resolution of the infection. Take this drug at regular intervals around the clock; consult your nurse or pharmacist to set up a convenient schedule. You may experience these side effects: Nausea, vomiting, abdominal pain (eat frequent small meals); diarrhea; drowsiness, blurring of vision, dizziness (observe caution driving or using dangerous equipment); brown or yellowrust urine (expected effect). Report fever, chills, cough, chest pain,

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

brown-rust urine

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

Generic Sulfonamides

Brand/Trade Name

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

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

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

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

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

Generic Fluroquinolones

Brand/Trade Name

Dosage/Frequency and Route Adults - Uncomplicated UTIs: 100250 mg PO q 12 hr for 3 days or 500 mg PO daily (ER tablets) for 3 days. - Mild to moderate UTIs: 250 mg PO q 12 hr for 714 days or 200 mg IV q 12 hr for 714 days. - Complicated UTIs: 500 mg bid PO q 12 hr for 714 days or 400 mg IV q 12 hr or 1,000 mg (ER tablets) PO daily for 714 days. - Chronic bacterial prostatitis: 500 mg PO q 12 hr for 28 days or 400 mg IV q 12 hr for 28 days. - Infectious diarrhea: 500 mg q 12 hr PO for 57 days. - Acute uncomplicated pyelonephritis: 1,000 mg ER tablets PO daily for 714 days. Pediatric Patient Not recommended; produced lesions of joint cartilage in immature

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

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

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

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

experimental animals. - Inhalational anthrax: 15 mg/kg/dose PO q 12 hr for 60 days or 10 mg/kg/dose IV q 12 hr for 60 days; do not exceed 500 mg/dose PO or 400 mg/dose IV. Patients with Impaired Renal Function For creatinine clearance of 3050 mL/min, give 250 500 mg PO q 12 hr. For creatinine clearance of 529 mL/min, give 250 500 mg PO q 18 hr or 200400 mg IV q 18 24 hr. For patients on hemodialysis, give 250500 mg q 24 hr, after dialysis.

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

B. ANALGESICS/NSAIDS Generic Celecoxib Brand/Trade Name Celebrex Dosage/Frequency and Route Adult Initially, 100 mg PO bid; may increase to 200 mg/day PO bid as needed. Acute pain, dysmenorrhea: 400 mg, then 200 mg PO bid. FAP: 400 mg PO bid. Pediatric Patient Safety and efficacy have not been established. Patients with Hepatic Impairment Reduce dosage by 50%. Indication - Acute and longterm treatment of signs and symptoms of rheumatoid arthritis and osteoarthritis - Reduction of the number of colorectal polyps in familial adenomatous polyposis (FAP) - Management of acute pain - Treatment of primary dysmenorrhea Action Analgesic and antiinflammatory activities related to inhibition of the COX-2 enzyme, which is activated in inflammation to cause the signs and symptoms associated with inflammation; does not affect the COX-1 enzyme, which protects the lining of the GI tract and has blood clotting and renal functions. Side effects CNS: Headache, dizziness, somnolence, insomnia, fatigue, tiredness, dizziness, tinnitus, ophthamologic effects Dermatologic: Rash, pruritus, sweating, dry mucous membranes, stomatitis GI: Nausea, abdominal pain, dyspepsia, flatulence, GI bleed Hematologic: Neutropenia, eosinophilia, leukopenia, pancytopenia, thrombocytopenia, agranulocytosis, granulocytopenia, aplastic anemia, decreased Other: Peripheral edema, anaphylactoid reactions to anaphylactic shock Nursing Responsibilities Take drug with food or meals if GI upset occurs. Take only the prescribed dosage. You may experience these side effects: Dizziness, drowsiness (avoid driving or the use of dangerous machinery while using this drug). Report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers; changes in vision.

Generic Meloxicam

Brand/Trade Name Mobic

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

Indication Relief from the signs and symptoms of osteoarthritis and rheumatoid arthritis

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

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

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

Generic Naproxen

Brand/Trade Name Naprelan

Dosage/Frequency and Route Adults - Rheumatoid arthritis or osteoarthritis, ankylosing spondylitis: Delayed-release (ECNaprosyn) 375500 mg PO bid. Controlled-release (Naprelan) 7501,000 mg PO daily. Naproxen sodium 275550 mg bid PO. May increase to 1.65 g/day for a limited period. Naproxen tablets 250500 mg PO bid. - Acute gout: Controlled-release (Naprelan) 1,0001,500 mg PO daily. Naproxen sodium 825 mg PO followed by 275 mg q 8 hr until the attack subsides. Naproxen 750 mg, followed by 250 mg q 8 hr until attack subsides. - Mild to moderate pain: Controlled-release (Naprelan) 1,000 mg PO daily.

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

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

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

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

Naproxen sodium 550 mg PO followed by 275 mg q 68 hr. - Mild to moderate pain: 500 mg followed by 500 mg q 12 hr or 250 mg q 6 8 hr. OTC 200 mg PO q 8 12 hr with a full glass of liquid while symptoms persist. Do not exceed 600 mg in 24 hr. Pediatric Patient - Juvenile arthritis: Naproxen 10 mg/kg/day given in two divided doses. Naproxen sodium Safety and efficacy not established. OTC Do not give to children < 12 yr unless under advice of physician. Geriatric Patients Do not take > 200 mg q 12 hr PO.

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

Generic Valdecoxib

Brand/Trade Name Bextra

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

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

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

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

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

C. CHOLINERGICS DRUG Generic name: bethanechol chloride Brand Name: Duvoid DOSAGE/FREQUE NCY AND ROUTE Adults: 10-50 mg P.O. t.i.d. to q.i.d. or 2.5-5 mg subcutaneously INDICATION Acute postoperative ad postpartum nonobstructive (functional) urine retention, neurogenic atony of urinary bladder with urine retention. ACTION Directly stimulates muscarinic cholinergic receptors, mimicking acetylcholine action, increasing GI tract tone and peristalsis and contraction of the detrusor muscle of the urinary bladder. SIDE EFFECTS CNS: headache, malaise CV: bradycardia, flushing EENT: lacrimation, miosis GI: abdominal cramps, diarrhea, excessive salivation, nausea, belching GU: urinary urgency Respiratory: bronchoconstriction, increased bronchial secretions Skin: diaphoresis NURSING RESPONSIBILITIES Give drug 1 hr before or 2 hrs after meals because it may cause nausea and vomiting if taken soon after eating. Monitor vital signs frequently, especially respirations. Always have atropine injection available, and be prepared to give 0.6 mg subcutaneously or b slow I.V. push. Provide respiratory support, if needed. Monitor patient for orthostatic hypotension. Watch for toxicity, especially for subcutaneous use. Watch closely for adverse reactions that may indicate drug toxicity. Tell patient to take oral form on an empty stomach and at regular intervals. Inform patient that drug is usually effective 30-90 minutes after oral use and 5-15 minutes after subcutaneous use.

D. ANTI-CHOLINERGICS DRUG DOSAGE AND ROUTE Generic Name: K citrate Brand Name: Acalka tab The aim of the treatment is to restore the level of urinary citrate and to increase the pH of urine to 6-7 and to this end, the dosage patterns are: Patients with Severe Hypocitraturia: Start the treatment with a dose of 60 mEq daily (6 tabs), divided into 3-4 intakes daily. Patients with Slight Hypocitraturia: Start the treatment with a dose of 30 mEq daily (3 tabs), divided into 3 intakes daily. It is recommended to take the tablets 30 min after meals. Approximately 24 hrs after having started the treatment, make a determination of urinary citrate and pH and adjust the dose in accordance with the needs of the patient. If necessary, the dose can be increased, though it is not advisable to exceed the dose of 100 mEq/day (10 tabs).

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

ACTION Inhibitor of crystallization.

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

NURSING RESPONSIBILITIES

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

DRUG Generic Name: atropine Brand Name: Sal-Tropine

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

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

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

NURSING RESPONSIBILITIES

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

every 5-10 minutes. Parenteral Overdosage with other compounds having muscarinic actions Adult: 0.6-1 mg IV/IM/SC, repeated every 2 hr. Ophthalmic Inflammatory eye disorders e.g. uveitis or iritis Adult: Instill 1-2 drops of a 0.5-1% solution up to 4 times daily. Child: As sulfate: Instill 1-2 drops of a 0.5% soln (or 1 drop of a 1% solution) up to tid. Ophthalmic Eye refraction Adult: Instill 1 drop of a 1% solution bid for 1-2 days before the procedure, or on a single occasion 1 hr before the procedure. Child: As sulfate: Instill 1 or 2 drops of a 0.5% soln (or 1 drop of a 1% solution) bid for 1-3 days before the procedure, with a further dose given 1 hr before the procedure. Incompatibility: Incompatible with hydroxybenzoate preservatives.

E. ANTISPASMODIC Generic Name/Brand Name 1. Oxybutynin Chloride ApoOxybutynin (CAN), Ditropan, Ditropan XL, NovoOxybutynin (CAN), Oxytrol Dosage/ Frequency ADULTS Classification Urinary Antispasmodic Indication Relief of symptoms of bladder instability associated with voiding in patients with uninhibited neurogenic and reflex neurogenic bladder ER tablets: Treatment of signs and symptoms of overactive bladder (incontinence, urgency, frequency) Contraindication Contraindicated with allergy to oxybutynin, pyloric or duodenal obstruction, obstructive intestinal lesions or ileus, intestinal atony, megacolon, colitis, obstructive uropathies, glaucoma, myasthenia gravis, CV instability in acute hemorrhage. Use cautiously with hepatic, renal impairment; pregnancy; lactation. Side Effects CNS: Drowsiness, dizziness, blurred vision, dilatation of the pupil, cycloplegia, increased ocular tension, weakness CV: Tachycardia, palpitations GI: Dry mouth, nausea, vomiting, constipation, bloated feeling GU: Urinary hesitancy, retention, impotence Hypersensitivity: Allergic reactions including urticaria, dermal effect Other: Decreased sweating, heat prostration in Nursing Responsibilities Assessment History: Allergy to oxybutynin, intestinal obstructions or lesions, intestinal atony, obstructive uropathies, glaucoma, myasthenia gravis, CV instability in acute hemorrhage, hepatic or renal impairment, pregnancy, lactation Physical: Skin color, lesions; T; orientation, affect, reflexes; ophthalmologic examination, ocular pressure measurement; P, rhythm, BP; bowel sounds, liver evaluation; renal and liver function tests,

5 mg PO bid or tid. Maximum dose is 5 mg qid. ER tablets5 mg PO daily, up to a maximum of 30 mg/day; transdermal patchone patch per day applied to dry, intact skin on the abdomen, hip, or buttock every 34 days. PEDIATRIC PATIENTS > 5 YR

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

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

high environmental temperatures secondary to loss of sweating

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

2. Tolterodine Tartrate Detrol, Detrol LA

ADULTS

Antimuscarinic

Therapeutic actions 2 mg PO bid, may be lowered to 1 mg PO bid based on individual response; ER capsules 4 mg PO taken once a day; may be lowered to 2 mg qd based on response. PEDIATRIC PATIENTS Competitively blocks muscarinic receptor sites; bladder contraction is mediated by muscarinic receptors blocking these receptors decreases bladder contraction.

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

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

CNS: Blurred vision, headache, dizziness, somnolence Dermatologic: Pruritus, rash, erythema, dry skin GI: Nausea, vomiting, constipation, dyspepsia, flatulence, dry mouth, abdominal pain GU: Dysuria, urinary

Assessment History: Presence of urinary retention; uncontrolled narrow-angle glaucoma; allergy to the drug or any of its components; renal or hepatic impairment; pregnancy, lactation Physical: Bowel sounds, normal output; normal urinary output, prostate

Safety and efficacy not established. PATIENTS WITH HEPATIC

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

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

palpation; IOP, vision; liver function tests; renal function tests; skin color, lesions, texture; weight Interventions Provide small, frequent meals if GI upset is severe. Provide frequent mouth hygiene or skin care if dry mouth or skin occur. Arrange for safety precautions if blurred vision occurs. Monitor bowel function and arrange for bowel program if constipation occurs.

3. Trospium Chloride Sanctura

ADULTS < 75 YR

Antimuscarinic Antispasmodic

20 mg PO bid taken on an empty stomach, at least 1

Urinary incontinence, urgency, and frequency

Contraindicated with allergy to trospium or any component of the

CNS: Headache, dry eyes, dizziness, blurred vision

Assessment History: Allergy to trospium or any

hr before meals. ADULTS > 75 YR

Therapeutic actions Competitively blocks muscarinic receptor sites; bladder contraction is mediated by muscarinic receptorsblocking these receptors decreases bladder contraction, relieving bladder spasm.

caused by overactive bladder

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

drug; presence of or risk for urinary retention, gastric retention, uncontrolled narrow-angle glaucoma. Use cautiously with renal or hepatic dysfunction, ulcerative colitis, intestinal atony, myasthenia gravis, bladder or gastric outlet obstruction, pregnancy, lactation.

GI: Dry mouth, constipation, abdominal pain, dyspepsia, flatulence, vomiting GU: Urinary retention Other: Fatigue, decreased sweating

Safety and efficacy not established. PATIENTS WITH RENAL IMPAIRMENT

component of the drug; presence of or risk for urinary retention, gastric retention, uncontrolled narrow-angle glaucoma, renal or hepatic dysfunction, ulcerative colitis, intestinal atony, myasthenia gravis, bladder or gastric outlet obstruction, pregnancy, lactation Physical: Orientation, affect, vision, IOP; GI output, bowel sounds, liver evaluation; normal urinary output, prostate palpation; renal and liver function tests Interventions Administer drug on an empty stomach, at least 1 hour before meal. Provide

Creatinine clearance < 30 mL/min20 mg/day PO given hs.

small, frequent meals if GI upset is severe. Establish safety measures (accompany patient, siderails, etc.) if vision changes occur. Provide frequent mouth hygiene and sugarless lozenges if dry mouth is a problem. Monitor bowel function and arrange for appropriate bowel program if constipation occurs.

F. ANTIHYPERTENSIVE DRUGS Generic Dosage/ Classification Name/Brand Frequency Name A. Angiotensin-Converting Enzyme Inhibitor 1. Benazepril Hydrochlor ide Lotensin ADULTS Antihypertensiv e Angiotensinconverting enzyme (ACE) inhibitor Indication Contraindication Side Effects Nursing Responsibilities

Initial dose, 10 mg PO daily. Maintenance dose, 2040 mg/day PO, single or two divided doses. Patients using diuretics should discontinue them 23 d prior to benazepril therapy. If BP is not controlled, add diuretic slowly. If diuretic cannot be discontinued, begin benazepril therapy with 5 mg. Maximum dose, 80 mg. PEDIATRIC PATIENTS

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

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

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

CV: Angina pectoris, hypotension in salt- or volumedepleted patients, palpitations Dermatologic: Rash, pruritus, diaphoresis, flushing GI: Nausea, abdominal pain, vomiting, constipation Respiratory: Cough, asthma, bronchitis, dyspnea, sinusitis

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

Safety and efficacy not established. PATIENTS WITH RENAL IMPAIRMENT

For creatinine clearance < 30 mL/min/1.73 m2 (serum creatinine > 3 mg/dL), 5 mg PO daily. Dosage may be gradually increased until BP is controlled, up to a maximum of 40 mg/day.

Other: Angioedema, impotence, decreased libido, asthenia, myalgia, arthralgia

differential

Interventions WARNING: Alert surgeon, note use of benazepril on patient's chart; the angiotensin II formation subsequent to compensatory renin release during surgery will be blocked; hypotension may be reversed with volume expansion. Monitor patient for possible fall in BP secondary to reduction in fluid volume (excessive perspiration and dehydration, vomiting, diarrhea) because excessive hypotension may occur.

WARNING: Ensure that patient is not pregnant; fetal abnormalities and death have occurred if using during second or third trimester. Encourage use of contraceptive measures. Reduce dosage in patients with impaired renal function. Oral Hypertension: Patients not taking diuretics: Initial dose is 5 mg/day PO. Adjust dosage based on patient response. Usual range is 10 40 mg/day as a single dose or Treatment of hypertensi on alone or in combinati on with other antihypert ensives, especially thiazidetype diuretics Treatment of acute Contraindicated with allergy to enalapril. Use cautiously with impaired renal function; salt or volume depletion (hypotension may occur); lactation, pregnancy. CNS: Headache, dizziness, fatigue, insomnia, paresthesias CV: Syncope, chest pain, palpitations, hypotension in salt- or volumedepleted patients GI: Gastric

2. Enalapril Maleate Vasotec

ADULTS

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

Assessment History: Allergy to enalapril, impaired renal function, salt or volume depletion, lactation, pregnancy Physical: Skin color, lesions, turgor; T; orientation, reflexes, affect, peripheral

in two divided doses. Patients taking diuretics: Discontinue diuretic for 23 days if possible. If it is not possible to discontinue diuretic, give initial dose of 2.5 mg, and monitor for excessive hypotension. Converting to oral therapy from IV therapy: 5 mg daily with subsequent doses based on patient response. Heart failure: 2.5 mg PO daily or bid in conjunction with diuretics and digitalis. Maintenance dose is 5 20 mg/day given in two divided doses. Maximum daily dose is 40 mg.

adrenals; both of these actions increase BP. Enalapril blocks the conversion of angiotensin I to angiotensin II, decreasing BP, decreasing aldosterone secretion, slightly increasing serum K+ levels, and causing Na+ and fluid loss; increased prostaglandin synthesis also may be involved in the antihypertensive action. In patients with heart failure, peripheral resistance, afterload, preload, and heart size are decreased.

and chronic CHF Treatment of asymptom atic left ventricular dysfunctio n (LVD) Unlabeled use: Diabetic nephropat hy

irritation, nausea, vomiting, diarrhea, abdominal pain, dyspepsia, elevated liver enzymes GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, urinary frequency, impotence Hematologic : Decreased hematocrit and hemoglobin Other: Cough, muscle cramps, hyperhidrosis

sensation; P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver evaluation; urinalysis, renal and liver function tests, CBC, and differential

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

Asymptomatic LVD: 2.5 mg PO bid; target maintenance dose 20 mg/day in two divided doses. Parenteral Give IV only. 1.25 mg q 6 hr given IV over 5 min. A response is usually seen within 15 min, but peak effects may not occur for 4 hr. Hypertension: Converting to IV therapy from oral therapy: 1.25 mg q 6 hr; monitor patient response. Patients taking diuretics: 0.625 mg IV over 5 min. If adequate response is not seen after 1 hr, repeat the 0.625-mg dose. Give additional doses of 1.25 mg q 6 hr.

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

PEDIATRIC PATIENTS 1 MO16 YR

been checked.

Oral Hypertension: Initial dose is 0.08 mg/kg PO once daily; maximum dose is 5 mg. GERIATRIC PATIENTS AND PATIENTS WITH RENAL IMPAIRMENT

Oral Excretion is reduced in renal failure; use smaller initial dose, and adjust upward to a maximum of 40 mg/day PO. For patients on dialysis, use 2.5 mg on dialysis days. Treatment of hypertensi on, alone or in combinati Contraindicated with allergy to fosinopril or other ACE inhibitors; pregnancy. CV: Angina pectoris, orthostatic hypotension in salt- or volume-

3. Fosinopril Sodium Monopril

ADULTS

Antihypertensive Angiotensin-converting enzyme (ACE) inhibitor Therapeutic actions

Assessment History: Allergy to fosinopril and other ACE inhibitors,

Initial dose, 10 mg PO daily. Maintenance dose, 2040 mg/day PO as a single dose or 2 divided doses. In

patients receiving diuretic therapy, begin fosinopril therapy with 10 mg. Do not exceed maximum dose of 80 mg. PEDIATRIC PATIENTS

Safety and efficacy not established.

Renin, synthesized by the kidneys, is released into the circulation where it acts on a plasma precursor to produce angiotensin I, which is converted by angiotensin-converting enzyme to angiotensin II, a potent vasoconstrictor that also causes release of aldosterone from the adrenals; fosinopril blocks the conversion of angiotensin I to angiotensin II, leading to decreased BP, decreased aldosterone secretion, a small increase in serum potassium levels, and sodium and fluid loss; increased prostaglandin synthesis may be involved in the antihypertensive action.

on with thiazidetype diuretics Managem ent of CHF as adjunctive therapy Unlabeled use: Diabetic nephropat hy

Use cautiously with impaired renal function, hyperkalemia, salt or volume depletion, lactation.

depleted patients, palpitations Dermatologi c: Rash, pruritus, diaphoresis, flushing GI: Nausea, abdominal pain, vomiting, diarrhea Respiratory: Cough, asthma, bronchitis, dyspnea, sinusitis Other: Angioedema, asthenia, myalgia, arthralgia, hyperkalemia

impaired renal or hepatic function, hyperkalemia, salt or volume depletion, lactation, pregnancy Physical: Skin color, lesions, turgor; T; P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver evaluation; urinalysis, renal and liver function tests, CBC, and differential Interventions WARNING: Alert surgeon and mark patient's chart with notice that fosinopril is being taken; the angiotensin II formation subsequent to compensatory renin release during surgery will be blocked; hypotension may be reversed with volume

expansion. Arrange to switch to a different drug if pregnancy occurs; suggest using barrier contraceptives. Monitor patient closely for a fall in BP secondary to reduction in fluid volume (excessive perspiration and dehydration, vomiting, diarrhea) because excessive hypotension may occur. Treatment of hypertensi on alone or in combinati on with thiazidetype diuretics Adjunctiv e therapy Contraindicated with allergy to lisinopril or enalapril. Use cautiously with impaired renal function, CHF, salt or volume depletion, pregnancy, lactation. CNS: Headache, dizziness, insomnia, fatigue, paresthesias CV: Orthostatic hypotension, tachycardia, angina pectoris, MI, Raynaud's syndrome, CHF, severe

4. Lisinopril ApoLisinopril (CAN), Prinivil, Zestril

ADULTS NOT TAKING DIURETICS

Antihypertensive Angiotensin-converting enzyme (ACE) inhibitor

Assessment History: Allergy to lisinopril or enalapril, impaired renal function, CHF, salt or volume depletion, lactation, pregnancy Physical:

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

Therapeutic actions Renin, synthesized by the kidneys, is released into the circulation where it acts on a plasma precursor to produce

DIURETICS Discontinue diuretic for 23 days. If it is not possible to discontinue, give initial dose of 5 mg, and monitor for excessive hypotension. CHF: 5 mg PO daily with diuretics and digitalis. Effective range: 520 mg/day. Acute MI: Start within 24 hr of MI with 5 mg PO followed in 24 hr by 5 mg PO; 10 mg PO after 48 hr, then 10 mg PO daily for 6 wk. PEDIATRIC PATIENTS

angiotensin I, which is converted by angiotensin-converting enzyme to angiotensin II, a potent vasoconstrictor that also causes release of aldosterone from the adrenals. Lisinopril blocks the conversion of angiotensin I to angiotensin II, leading to decreased BP, decreased aldosterone secretion, a small increase in serum potassium levels, and sodium and fluid loss.

in CHF for patients unresponsi ve to diuretics and digitalis alone Treatment of stable patients within 24 hr of acute MI to improve survival with beta blocker, aspirin, or thromboly tics

hypotension in salt- or volumedepleted patients GI: Gastric irritation, nausea, diarrhea, peptic ulcers, dysgeusia, cholestatic jaundice, hepatocellular injury, anorexia, constipation GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, frequency Hematologic: Neutropenia, agranulocytosis , thrombocytope nia, hemolytic anemia, pancytopenia Other: Angioedema

Skin color, lesions, turgor; T; P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver evaluation; urinalysis, renal and liver function tests, CBC and differential Interventions Begin drug within 24 hr of acute MI; ensure that patient is also receiving standard treatment (eg thrombolytics, aspirin, beta blockers). WARNING: Keep epinephrine readily available in case of angioedema of the face or neck region; if breathing difficulty occurs, consult physician, and administer epinephrine.

Safety and efficacy not established. GERIATRIC PATIENTS AND PATIENTS WITH RENAL IMPAIRMENT

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

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

WARNING: Alert surgeon, and mark patient's chart with notice that lisinopril is being taken. The angiotensin II formation subsequent to compensatory renin release during surgery will be blocked. Hypotension may be reversed with volume expansion. Monitor patients on diuretic therapy for excessive hypotension following the first few doses of lisinopril. Monitor patients closely in any situation that may lead to a decrease in BP secondary to reduction in fluid volume (excessive perspiration and dehydration, vomiting, diarrhea) because excessive

hypotension may occur. Arrange for reduced dosage in patients with impaired renal function. Suggest the use of contraceptives; if pregnancy should occur, discontinue drug as soon as possible.

Angiotensin II Receptor Blockers 1. Candesarta n Cilexetil Atacand ADULTS Angiotensin II receptor antagonist Antihypertensive Therapeutic actions Selectively blocks the binding of angiotensin II to specific tissue receptors found in vascular smooth muscle and adrenal gland; this action blocks the vasoconstriction effect of the reninangiotensin system as well as the release of aldosterone leading to decreased BP. Treatment of hypertensio n, alone or in combination with other antihyperten sives Contraindicated with hypersensitivity to candesartan, pregnancy (using during the second or third trimester can cause injury or even death to the fetus), lactation. Use cautiously with renal dysfunction, hypovolemia. CNS: Headache, dizziness, syncope, muscle weakness CV: Hypotension Dermatologi c: Rash, inflammation , urticaria, pruritus, alopecia, dry skin GI: Assessment History: Hypersensitivity to candesartan, pregnancy, lactation, renal dysfunction, hypovolemia Physical: Skin lesions, turgor; T; reflexes, affect; BP; R, respiratory auscultation; kidney function tests

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

Safety and efficacy not established.

Diarrhea, abdominal pain, nausea, constipation, dry mouth, dental pain Respiratory: URI symptoms, cough, sinus disorders Other: Cancer in preclinical studies, back pain, fever, gout

Interventions Administer without regard to meals. WARNING: Ensure that patient is not pregnant before beginning therapy, suggest the use of barrier birth control while using candesartan; fetal injury and deaths have been reported. Find an alternate method of feeding the baby for a nursing mother. Depression of the renin-angiotensin system in infants is potentially very dangerous.

WARNING: Alert surgeon and mark patient's chart with notice that candesartan is being taken. The blockage of the reninangiotensin system following

surgery can produce problems. Hypotension may be reversed with volume expansion. If BP control does not reach desired levels, diuretics or other antihypertensives may be added to candesartan. Monitor patient's BP carefully. Monitor patient closely in any situation that may lead to a decrease in BP secondary to reduction in fluid volumeexcessive perspiration, dehydration, vomiting, diarrhea excessive hypotension can occur. Treatment of hypertensio n as Contraindicated with hypersensitivity to irbesartan, CNS: Headache, dizziness, syncope, muscle

2. Irbesartan

ADULTS Diabetic

Angiotensin II receptor antagonist (ARB) Antihypertensive

Assessment History: Hypersensitivit y to irbesartan,

Avapro

neuropathy: 300 mg/day PO as a single dose. Hypertension: 150 mg PO daily as one dose; adjust slowly to determine effective dose; maximum daily dose300 mg. PEDIATRIC PATIENTS

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

monotherap y or in combination with other antihyperten sives Slowing of the progression of nephropathy in patients with hypertensio n and type 2 (non insulindependent) diabetes Unlabeled use: CHF

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

weakness, sleep disturbance CV: Hypotension, orthostatic hypotension, flushing Dermatologi c: Rash, inflammation , urticaria, pruritus, alopecia, dry skin GI: Diarrhea, abdominal pain, nausea, constipation, dry mouth, dental pain Respiratory: URI symptoms, cough, sinus disorders Other: Cancer in preclinical studies, back pain, fever, gout, fatigue, neutropenia

pregnancy, lactation, hepatic or renal dysfunction, hypovolemia Physical: Skin lesions, turgor; T; reflexes, affect; BP; R, respiratory auscultation; liver and kidney function tests Interventions Administer without regard to meals. WARNING: Ensure that patient is not pregnant before beginning therapy; suggest using barrier birth control while using irbesartan; fetal injury and deaths have been reported. Find an alternative method of feeding the baby if giving

< 6 yr: Not recommended. 612 yr: 75 mg/day PO, titrate to a maximum of 150 mg/day. 1316 yr: 150 mg/day PO; maximum dose, 300 mg. VOLUME- OR SALTDEPLETED PATIENTS 75 mg/day PO.

drug to a nursing mother. Depression of the renin-angiotensin system in infants is potentially very dangerous. WARNING: Alert surgeon and mark patient's chart with notice that irbesartan is being taken. The blockage of the renin-angiotensin system following surgery can produce problems. Hypotension may be reversed with volume expansion. Monitor patient closely in any situation that may lead to a decrease in BP secondary to reduction in fluid volume (excessive perspiration, dehydration, vomiting, diarrhea); excessive hypotension can

occur. Treatment of hypertensio n, alone or in combination with other antihyperten sives Treatment of heart failure in patients who are intolerant of angiotensinconverting enzyme (ACE) inhibitors Contraindicated with hypersensitivity to valsartan, pregnancy (use during second or third trimester can cause injury or even death to fetus), lactation. Use cautiously with hepatic or renal dysfunction, hypovolemia. CNS: Headache, dizziness, syncope, muscle weakness CV: Hypotension Dermatologi c: Rash, inflammation , urticaria, pruritus, alopecia, dry skin GI: Diarrhea, abdominal pain, nausea, constipation, dry mouth, dental pain Respiratory: URI symptoms, cough, sinus disorders Other: Cancer in

3. Valsartan Diovan

ADULTS

80 mg PO daily; range 80320 mg/day. Heart failure: Starting dose is 40 mg bid, titration to 80 mg and 160 mg bid should be done to the highest dose, as tolerated by the patient. Maximum daily dose is 320 mg daily given in divided doses. Concomitant use with an ACE inhibitor and a beta blocker is not recommended. PEDIATRIC PATIENTS

Angiotensin II receptor blocker Antihypertensive Therapeutic actions Selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland; this action blocks the vasoconstricting effect of the renin angiotensin system as well as the release of aldosterone, leading to decreased BP; may prevent the vessel remodeling associated with the development of atherosclerosis.

Assessment History: Hypersensitivity to valsartan; pregnancy, lactation; hepatic or renal dysfunction; hypovolemia Physical: Skin lesions, turgor; T; reflexes, affect; BP; R, respiratory auscultation; liver and renal function tests Interventions Administer without regard to meals. WARNING: Ensure that patient is not pregnant before beginning therapy; suggest using barrier birth control while using drug; fetal

Safety and efficacy not established. PATIENTS WITH HEPATIC OR RENAL

IMPAIRMENT Exercise caution and monitor patient frequently.

preclinical studies, back pain, fever, gout, hyperkalemia

injury and deaths have been reported. Find alternative method of feeding infant if drug is being given to nursing mother. Depression of reninangiotensin system in infants is potentially very dangerous. WARNING: Alert surgeon and mark patient's chart that valsartan is being given. Blockage of renin angiotensin system following surgery can produce problems. Hypotension may be reversed with volume expansion. Monitor patient closely in any situation that may lead to decrease in BP secondary to reduction in fluid

volume excessive perspiration, dehydration, vomiting, diarrhea as excessive hypotension can occur. Calcium Channel Blockers 1. Felodipine Plendil, Renedil (CAN) Calcium channelblocker Antihypertensive Therapeutic actions Inhibits the movement of calcium ions across the membranes of cardiac and vascular smooth muscle cells; greater selectivity for vascular smooth muscle as compared to cardiac muscle; leads to arterial and coronary artery vasodilation and decreased peripheral vascular resistance. Essential hypertensio n, alone or in combination with other antihyperten sives Contraindicated with allergy to felodipine or other calcium channelblockers, sick sinus syndrome, heart block (second or third degree), lactation. Use cautiously with pregnancy, impaired hepatic function. CNS: Dizziness, lightheadedness, headache, asthenia, fatigue, lethargy CV: Peripheral edema, arrhythmias Dermatologic: Flushing, rash GI: Nausea, abdominal discomfort, reflux, constipation Assessment History: Allergy to felodipine, impaired hepatic function, sick sinus syndrome, heart block, lactation, pregnancy Physical: Skin lesions, color, edema; P, BP, baseline ECG, peripheral perfusion, auscultation, R, adventitious sounds; liver evaluation, GI normal output; liver function tests, urinalysis

ADULTS

Initially, 5 mg PO daily; dosage may be gradually increased over 1014 days. Usual dose is 2.510 mg PO daily. Doses greater than 10 mg PO daily are associated with an increased risk of peripheral edema. PEDIATRIC PATIENTS

Safety and efficacy not established. GERIATRIC PATIENTS OR PATIENTS WITH HEPATIC IMPAIRMENT

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

Interventions

10 mg daily PO.

Have patient swallow tablet whole; do not chew or crush. Monitor patient carefully (BP, cardiac rhythm and output) while drug is being adjusted to therapeutic dose. Monitor cardiac rhythm regularly during stabilization of dosage and periodically during long-term therapy. Administer drug without regard to meals.

Vasodilators 1. Minoxidil Oral: Loniten, Minox (CAN) Topical: Minoxigaine (CAN), ADULTS AND PATIENTS > 12 YR Antihypertensive Vasodilator Therapeutic actions Oral Monotherapy: Initial dosage is 2.55 mg/day Acts directly on vascular smooth muscle to cause vasodilation, reducing elevated systolic and diastolic Severe hypertensio n that is symptomati c or associated with target organ damage and is not Contraindicated with hypersensitivity to minoxidil or any component of the topical preparation (topical); pheochromocytoma (may stimulate CNS: Fatigue, headache CV: Tachycardia (unless given with betaadrenergic blocker or Assessment History: Hypersensitivit y to minoxidil or any component of the topical preparation; pheochromocyt

Rogaine, Rogaine Extra Strength

PO as a single dose. Daily dosage can be increased to 10, 20, then 40 mg in single or divided doses. Effective range is usually 10 40 mg/day PO. Maximum dosage is 100 mg/day. If supine diastolic BP has been reduced less than 30 mm Hg, administer the drug only once a day. If reduced more than 30 mm Hg, divide the daily dosage into two equal parts. Dosage adjustment should normally be at least at 3-day intervals; in emergencies, q 6 hr with careful monitoring if possible. Concomitant therapy with diuretics: Use

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

manageable with maximum therapeutic doses of a diuretic plus two other antihyperten sive drugs; use in milder hypertensio n not recommend ed Topical use (when compounde d as a 1% 5% lotion or 1% ointment): Alopecia areata and male pattern alopecia

release of catecholamines from tumor); acute MI; dissecting aortic aneurysm; lactation. Use cautiously with malignant hypertension; CHF (use diuretic); angina pectoris (use a betablocker); pregnancy.

other sympatholyti c drug), pericardial effusion and tamponade; changes in direction and magnitude of T-waves; cardiac necrotic lesions (reported in patients with known ischemic heart disease, but risk of minoxidilassociated cardiac damage cannot be excluded) Dermatologi c: Temporary edema, hypertrichosi s (elongation, thickening, and enhanced pigmentation of fine body hair occurring within 36 wk of starting therapy;

oma; acute MI, dissecting aortic aneurysm; malignant hypertension; CHF; angina pectoris; lactation, pregnancy Physical: Skin color, lesions, hair, scalp; P, BP, orthostatic BP, supine BP, perfusion, edema, auscultation; bowel sounds, normal output; CBC with differential, kidney function tests, urinalysis, ECG Interventions Apply topical preparation to affected area; if fingers are used to facilitate drug application, wash hands thoroughly afterward.

minoxidil with a diuretic in patients relying on renal function for maintaining salt and water balance; the following diuretic dosages have been used when starting minoxidil therapy: Hydrochlorothi azide, 50 mg bid; chlorthalidone, 50100 mg daily; furosemide, 40 mg bid. If excessive salt and water retention result in weight gain > 5 lb, change diuretic therapy to furosemide; if patient already takes furosemide, increase dosage. Concomitant therapy with betaadrenergic blockers or

usually first noticed on temples, between eyebrows and extending to other parts of face, back, arms, legs, scalp); rashes including bullous eruptions; StevensJohnson syndrome; darkening of the skin GI: Nausea, vomiting Hematologic : Initial decrease in Hct, Hgb, RBC count Local: Irritant dermatitis, allergic contact dermatitis, eczema, pruritus, dry skin/scalp, flaking, alopecia

Do not apply other topical agents, including topical corticosteroids, retinoids, and petrolatum or agents known to enhance cutaneous drug absorption. Do not apply topical preparation to open lesions or breaks in the skin, which could increase risk of systemic absorption. Arrange to withdraw oral drug gradually, especially from children; rapid withdrawal may cause a sudden increase in BP (rebound hypertension has been reported in children, even with gradual withdrawal; use caution and monitor BP closely when

other sympatholytics: The following dosages are recommended when starting minoxidil therapy: Propranolol, 80160 mg/day ; other betablockers, dosage equivalent to the above; methyldopa 250750 mg bid (start methyldopa at least 24 hr before minoxidil); clonidine, 0.1 0.2 mg bid. Topical Apply 1 mL to the total affected areas of the scalp twice daily. The total daily dosage should not exceed 2 mL. Twice daily application for > 4 mo may be required before evidence of hair regrowth is observed. Once hair growth is realized, twice daily application is necessary for continued and

(topical use) Respiratory: Bronchitis, URI, sinusitis (topical use)

withdrawing from children). Arrange for echocardiograp hic evaluation of possible pericardial effusion; more vigorous diuretic therapy, dialysis, other treatment (including minoxidil withdrawal) may be required.

additional hair regrowth. Balding process reported to return to untreated state 34 mo after cessation of the drug. PEDIATRIC PATIENTS < 12 YR

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

exacerbation of renal failure.

G. DRUGS FOR ELECTROLYTE IMBALANCES

Generic name, Brand name Dehydrosol [sachet]

Dosage/frequency and route Dissolve 1 sachet into 1 L of water. Adult & older childn Drink as needed, childn 210 yr 100-200 mL, 2.5 mEq/L 10 mEq/hr-200 mEq/day, 20 mEq/hr of a soln not >40 mEq/L. Adult Plasma K level >2.5 mEq/L 10 mEq/hr-200 mEq/day,