zolpidem tartrate

zolpidem tartrate

(zol' pih dem)

Ambien, Ambien CR

Pregnancy Category B

Controlled Substance C-IV

Drug class

Sedative or hypnotic (nonbarbiturate)

Therapeutic actions

Modulates GABA receptors to cause suppression of neurons, leading to sedation, anticonvulsant, anxiolytic, and relaxant properties.

Indication

·        Short-term treatment of insomnia

·        Treatment of insomnia in adults who experience difficulties with sleep onset and sleep maintenance (ER tablets)

Contraindications and cautions

·        Contraindicated with hypersensitivity to zolpidem.

·        Use cautiously with acute intermittent porphyria, impaired hepatic or renal function, addiction-prone patients, pregnancy, lactation.

Available forms

Tablets—5, 10 mg; ER tablets—12.5 mg

Dosages

ADULTS

10 mg PO hs. Do not exceed 10 mg/day. ER tablets—12.5 mg/day PO.

PEDIATRIC PATIENTS

Safety and efficacy not established.

GERIATRIC PATIENTS

Increased chance of confusion, acute brain syndrome; initiate treatment with 5 mg PO or 6.25 mg/day PO ER tablets.

Pharmacokinetics

Route	Onset	Peak
Oral	45 min	1.6 hr

Metabolism: Hepatic; T_1/2: 2.6 hr

Distribution: Crosses placenta; may enter breast milk

Excretion: Urine

Adverse effects

·        CNS: Seizures, hallucinations, ataxia, EEG changes, pyrexia, morning drowsiness, hangover, headache, dizziness, vertigo, acute brain syndrome and confusion; paradoxical excitation, anxiety, depression, nightmares, dreaming, diplopia, blurred vision, suppression of REM sleep; REM rebound when drug is discontinued

·        GI: Esophagitis, vomiting, nausea, diarrhea, constipation

·        Hypersensitivity: Generalized allergic reactions; pruritus, rash

·        Other: Influenza-like symptoms, dry mouth, infection

Nursing considerations

Assessment

·        History: Hypersensitivity to zolpidem, acute intermittent porphyria, impaired hepatic or renal function, addiction-prone patients, lactation, pregnancy

·        Physical: T; skin color, lesions; orientation, affect, reflexes, vision examination; P, BP; bowel sounds, normal output, liver evaluation; CBC with differential; LFTs, renal function tests

Interventions

·        WARNING: Limit amount of drug dispensed to patients who are depressed or suicidal.

·        WARNING: Withdraw drug gradually if patient has used drug long-term or if patient has developed tolerance. Supportive therapy similar to that for withdrawal from barbiturates may be necessary to prevent dangerous withdrawal symptoms.

Teaching points

·        Take this drug exactly as prescribed. Do not exceed prescribed dosage. Long-term use is not recommended.

·        You may experience these side effects: Drowsiness, dizziness, blurred vision (avoid driving or performing tasks requiring alertness or visual acuity); GI upset (eat frequent small meals).

·        Report rash, sore throat, fever, bruising.

Adverse effects in Italic are most common; those in Bold are life-threatening.

zidovudine (azidothymidine, AZT, Compound S)

zidovudine (azidothymidine, AZT, Compound S)

(zid o vew' den)

Aztec, Retrovir

Pregnancy Category C

Drug class

Antiviral

Therapeutic actions

Thymidine analogue isolated from the sperm of herring; drug is activated to a triphosphate form that inhibits replication of some retroviruses, including HIV, HTLV III, lymphadenopathy-associated virus, ARV.

Indications

·        Management of certain adult patients with symptomatic HIV infection in combination with other antiretrovirals

·        Prevention of maternal–fetal HIV transmission

Contraindications and cautions

·        Contraindicated with life-threatening allergy to any component, pregnancy, lactation.

·        Use cautiously with compromised bone marrow, impaired renal or hepatic function.

Available forms

Capsules—100 mg; tablets—300 mg; CR tablets—30 mg; syrup—50 mg/5 mL; injection—10 mg/mL

Dosages

ADULTS

Oral

·        Symptomatic HIV infection: Initially, 100 mg q 4 hr (2.9 mg/kg q 4 hr) PO, around-the-clock, or 600 mg daily in divided doses as either 200 mg tid or 300 mg bid. Monitor hematologic indices every 2 wk. If significant anemia (Hgb < 7.5 g/dL, reduction of > 25%) or reduction of granulocytes > 50% below baseline occurs, dose interruption is necessary until evidence of bone marrow recovery is seen. If less severe bone marrow depression occurs, a dosage reduction may be adequate; or 1–2 mg/kg q 4 hr IV.

·        Asymptomatic HIV infection: 100 mg q 4 hr PO while awake (500 mg/day).

·        Maternal–fetal transmission: 100 mg PO five times/day from 14 wk gestation to the start of labor.

IV

1–2 mg/kg q 4 hr infused over 1 hr.

PEDIATRIC PATIENTS

6 wk–12 yr: 160 mg/m² q 8 hr; 90–180 mg/m² q 6–8 hr, not to exceed 200 mg per dose q 8 hr).

Infants born to HIV-infected mothers: 2 mg/kg q 6 hr starting within 12 hr of birth to 6 wk of age or 1.5 mg/kg IV over 30 min q 6 hr.

Pharmacokinetics

Route	Onset	Peak
Oral	Varies	30–90 min
IV	Rapid	End of infusion

Metabolism: Hepatic; T_1/2: 30–60 min

Distribution: Crosses placenta; may enter breast milk

Excretion: Urine

IV facts

Preparation: Remove desired dose from vial, and dilute in 5% dextrose in water to a concentration no greater than 4 mg/mL. Discard after 24 hr. Protect from light.

Infusion: Administer over 60 min; avoid rapid infusion. For a pregnant patient, when labor starts, given to the mother as a single 2 mg/kg dose infused over 1 hr followed by 1 mg/kg/hr given by continuous IV infusion until the umbilical cord is clamped.

Incompatibilities: Do not mix with blood or blood products.

Adverse effects

·        CNS: Headache, insomnia, myalgia, asthenia, malaise, dizziness, paresthesias, somnolence

·        GI: Nausea, GI pain, diarrhea, anorexia, vomiting, dyspepsia

·        Hematologic: Agranulocytopenia, severe anemia requiring transfusions

·        Other: Fever, diaphoresis, dyspnea, rash, taste perversion

Interactions

Drug-drug

·        Increased risk of hematologic toxicity if combined with nephrotoxic, cytotoxic, or bone marrow suppressing drugs, ganciclovir, interferon alfa

·        Increased risk of neurotoxicity when used with acyclovir

·        Severe drowsiness and lethargy with cyclosporine

Drug-alternative therapy

·        Decreased effectiveness if taken with St. John’s wort

Nursing considerations

CLINICAL ALERT!

Name confusion has been reported between ritonavir and Retrovir (zidovudine); use caution.

Assessment

·        History: Life-threatening allergy to any component; compromised bone marrow; impaired renal or hepatic function; pregnancy, lactation

·        Physical: Skin rashes, lesions, texture; T; affect, reflexes, peripheral sensation; bowel sounds, liver evaluation; LFTs, renal function tests, CBC and differential

Interventions

·        Monitor hematologic indices every 2 wk.

·        Give the drug around-the-clock; rest periods may be needed during the day due to interrupted sleep.

Teaching points

·        Take drug every 4 hours, around-the-clock. Use an alarm clock to wake you up at night; rest periods during the day may be needed. Do not share this drug; take exactly as prescribed.

·        Zidovudine is not a cure for AIDS or AIDS-related complex; opportunistic infections may occur; obtain continuous medical care.

·        Arrange for frequent blood tests; results of blood counts may indicate dosage needs to be decreased or drug discontinued temporarily.

·        Zidovudine does not reduce the risk of transmission of HIV to others by sexual contact or blood contamination; use precautions.

·        You may experience these side effects: Nausea, loss of appetite, change in taste (eat frequent small meals); dizziness, loss of feeling (use precautions); headache, fever, muscle aches.

·        Report extreme fatigue, lethargy, severe headache, severe nausea, vomiting, difficulty breathing, rash.

Adverse effects in Italic are most common; those in Bold are life-threatening.

zafirlukast

zafirlukast

(zah fur' luh kast)

Accolate

Pregnancy Category B

Drug classes

Antasthmatic

Leukotriene receptor antagonist

Therapeutic actions

Selectively and competitively blocks receptor for leukotriene D₄ and E₄, components of SRS-A, thus blocking airway edema, smooth muscle constriction, and cellular activity associated with inflammatory process that contribute to signs and symptoms of asthma.

Indications

·        Prophylaxis and long-term treatment of bronchial asthma in adults and children > 5 yr

·        Unlabeled use: Chronic urticaria

Contraindications and cautions

·        Contraindicated with hypersensitivity to zafirlukast or any of its components; acute asthma attacks; status asthmaticus.

·        Use cautiously in patients who previously required corticosteroid therapy to control asthma; with hepatic or renal impairment; as oral steroid use is decreased; pregnancy; lactation.

Available forms

Tablet—10, 20 mg

Dosages

ADULTS AND CHILDREN > 12 YR

20 mg PO bid on an empty stomach.

PEDIATRIC PATIENTS 5–11 YR

10 mg PO bid on an empty stomach.

Pharmacokinetics

Route	Onset	Peak
Oral	Rapid	3 hr

Metabolism: Hepatic; T_1/2: 10 hr

Distribution: Crosses placenta; enters breast milk

Excretion: Feces, urine

Adverse effects

·        CNS: Headache, dizziness, myalgia

·        GI: Nausea, diarrhea, abdominal pain, vomiting, liver enzyme elevation

·        Other: Generalized pain, fever, accidental injury, infection; Churg-Strauss syndrome (eosinophilia, vasculitic rash, pulmonary and cardiac complications) when oral steroid dose is reduced

Interactions

Drug-drug

·        Increased risk of bleeding with warfarin; these patients should have PT done regularly and warfarin dose decreased accordingly

·        Potential for increased effects and toxicity of calcium channel-blockers, cyclosporine

·        Decreased effectiveness with erythromycin, theophylline

·        Possible severe reaction when oral steroid dose is reduced while on zafirlukast; monitor patients very closely

Drug-food

·        Bioavailability decreased markedly by presence of food; administer at least 1 hr before or 2 hr after meals

Nursing considerations

Assessment

·        History: Hypersensitivity to zafirlukast; impaired renal or hepatic function; pregnancy, lactation; acute asthma or bronchospasm

·        Physical: T; orientation, reflexes; R, adventitious sounds; GI evaluation; LFTs, renal function tests

Interventions

·        Administer on an empty stomach 1 hr before or 2 hr after meals.

·        Ensure that drug is taken continually for optimal effect.

·        WARNING: Do not administer for acute asthma attack or acute bronchospasm.

Teaching points

·        Take this drug on an empty stomach, 1 hour before or 2 hours after meals.

·        Take this drug regularly as prescribed; do not stop taking it during symptom-free periods; do not stop taking it without consulting your health care provider.

·        Do not take this drug for acute asthma attack or acute bronchospasm; this drug is not a bronchodilator; routine emergency procedures should be followed during acute attacks.

·        Avoid use of over-the-counter medications while using this drug; many of them contain products that can interfere with drug or cause serious side effects. If you feel that you need one of these products, consult your health care provider.

·        You may experience these side effects: Dizziness (use caution when driving or performing activities that require alertness); nausea, vomiting (eat frequent small meals); headache (analgesics may be helpful).

·        Report fever, acute asthma attacks, severe headache.

Adverse effects in Italic are most common; those in Bold are life-threatening.

warfarin sodium

warfarin sodium

(war' far in)

Coumadin

Pregnancy Category X

Drug classes

Oral anticoagulant

Coumarin derivative

Therapeutic actions

Interferes with the hepatic synthesis of vitamin K-dependent clotting factors (factors II-prothrombin, VII, IX, and X), resulting in their eventual depletion and prolongation of clotting times.

Indications

·        Venous thrombosis and its extension, treatment, and prophylaxis

·        Treatment of thromboembolic complications of atrial fibrillation with embolization, and cardiac valve replacement

·        Pulmonary embolism, treatment, and prophylaxis

·        Prophylaxis of systemic embolization after acute MI

·        Unlabeled uses: Prevention of recurrent TIAs, prevention of recurrent MI, adjunct to therapy in small-cell carcinoma of the lung

Contraindications and cautions

·        Contraindicated with allergy to warfarin; SBE; hemorrhagic disorders; TB; hepatic diseases; GI ulcers; renal disease; indwelling catheters, spinal puncture; aneurysm; diabetes; visceral carcinoma; uncontrolled hypertension; severe trauma (including recent or contemplated CNS, eye surgery; recent placement of IUD); threatened abortion, menometrorrhagia; pregnancy (fetal damage and death); lactation (suggest using heparin if anticoagulation is required).

·        Use cautiously with CHF, diarrhea, fever; thyrotoxicosis; senile, psychotic, or depressed patients.

Available forms

Tablets—1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 mg; powder for injection—5.4 mg reconstitutes to 2 mg/mL

Dosages

Adjust dosage according to the one-stage PT to achieve and maintain 1.5–2.5 times the control value or prothrombin activity 20%–30% of normal; PT ratio of 1.3–1.5 or INR of 2–3. IV use is reserved for situations in which oral warfarin is not feasible. Dosages are the same for oral and IV forms.

ADULTS

Initially, 2–5 mg/day PO. Adjust dose according to PT response. For maintenance, 2–10 mg/day PO based on PT ratio or INR.

GERIATRIC PATIENTS

Lower doses are usually needed; begin with smaller doses than those recommended for adults and closely monitor PT ratio or INR.

Pharmacokinetics

Route	Peak	Duration
Oral	1.5–3 days	2–5 days

Metabolism: Hepatic; T_1/2: 1–2.5 days

Distribution: Crosses placenta; enters breast milk

Excretion: Feces and urine

IV facts

Preparation: Reconstitute vial with 2.7 mL of sterile water. Protect from light. Use within 4 hr of reconstitution.

Infusion: Inject slowly over 1–2 min; switch to oral preparation as soon as possible.

Adverse effects

·        Dermatologic: Alopecia, urticaria, dermatitis

·        GI: Nausea, vomiting, anorexia, abdominal cramping, diarrhea, retroperitoneal hematoma, hepatitis, jaundice, mouth ulcers

·        GU: Priapism, nephropathy, red-orange urine

·        Hematologic: Granulocytosis, leukopenia, eosinophilia; hemorrhage— GI or urinary tract bleeding (hematuria, dark stools; paralytic ileus, intestinal obstruction from hemorrhage into GI tract); petechiae and purpura, bleeding from mucous membranes; hemorrhagic infarction, vasculitis, skin necrosis of female breast; adrenal hemorrhage and resultant adrenal insufficiency; compressive neuropathy secondary to hemorrhage near a nerve

·        Other: Fever, "purple toes" syndrome

Interactions

Drug-drug

·        Increased bleeding tendencies with salicylates, chloral hydrate, phenylbutazone, clofibrate, disulfiram, chloramphenicol, metronidazole, cimetidine, ranitidine, co-trimoxazole, sulfinpyrazone, quinidine, quinine, oxyphenbutazone, thyroid drugs, glucagon, danazol, erythromycin, androgens, amiodarone, cefamandole,cefoperazone, cefotetan, moxalactam, cefazolin, cefoxitin, ceftriaxone, meclofenamate, mefenamic acid, famotidine, nizatidine, nalidixic acid

·        Decreased anticoagulation effect may occur with barbiturates, griseofulvin, rifampin, phenytoin, glutethimide, carbamazepine, vitamin K, vitamin E,cholestyramine, aminoglutethimide, ethchlorvynol

·        Altered effects with methimazole, propylthiouracil

·        Increased activity and toxicity of phenytoin when taken with oral anticoagulants

Drug-lab test

·        Red-orange discoloration of alkaline urine may interfere with some lab tests

Drug-alternative therapy

·        Increased risk of bleeding if combined with angelica, cat's claw, chamomile, chondroitin, feverfew, garlic, ginkgo, goldenseal, grape seed extract, green leaf tea, horse chestnut seed, psyllium, and tumeric

Nursing considerations

Assessment

·        History: Allergy to warfarin; SBE; hemorrhagic disorders; TB; hepatic diseases; GI ulcers; renal disease; indwelling catheters, spinal puncture; aneurysm; diabetes; visceral carcinoma; uncontrolled hypertension; severe trauma; threatened abortion, menometrorrhagia; pregnancy; lactation; CHF, diarrhea, fever;thyrotoxicosis; senile, psychotic or depressed patients

·        Physical: Skin lesions, color, T; orientation, reflexes, affect; P, BP, peripheral perfusion, baseline ECG; R, adventitious sounds; liver evaluation, bowel sounds, normal output; CBC, urinalysis, guaiac stools, PT, LFTs, renal function tests

Interventions

·        Do not use drug if patient is pregnant (heparin is anticoagulant of choice); advise patient to use contraceptives.

·        Monitor PT ratio or INR regularly to adjust dosage.

·        Administer IV form to patients stabilized on Coumadin who are not able to take oral drug. Dosages are the same. Return to oral form as soon as feasible.

·        Do not change brand names once stabilized; bioavailability may be a problem.

·        WARNING: Evaluate patient regularly for signs of blood loss (petechiae, bleeding gums, bruises, dark stools, dark urine). Maintain PT ratio of 1.3–1.5, 1.5–2 with mechanical prosthetic valves or recurrent systemic embolism; INR ratio of 2–3, 3–4.5 with mechanical prosthetic valves or recurrent systemic emboli.

·        Do not give patient any IM injections.

·        WARNING: Double check all drugs ordered for potential drug interaction; dosage of both drugs may need to be adjusted.

·        Use caution when discontinuing other drugs; warfarin dosage may need to be adjusted; carefully monitor PT values.

·        Keep vitamin K readily available in case of overdose.

·        Arrange for frequent follow-up, including blood tests to evaluate drug effects.

·        Evaluate for therapeutic effects: INR within therapeutic range.

Teaching points

·        Many factors may change your body's response to this drug—fever, change of diet, change of environment, other medications. Your dosage may have to be changed repeatedly. Write down changes that are prescribed.

·        Do not start or stop taking any medication without consulting your health care provider. Other drugs can affect your anticoagulant; starting or stopping another drug can cause excessive bleeding or interfere with the desired drug effects.

·        Carry or wear a medical ID tag to alert emergency medical personnel that you are taking this drug.

·        Avoid situations in which you could be easily injured (contact sports, shaving with a straight razor).

·        Have periodic blood tests to check on the drug action. These tests are important.

·        Use contraception; do not become pregnant while taking this drug.

·        You may experience these side effects: Stomach bloating, cramps (transient); loss of hair, rash; orange-red discoloration to the urine (if upsetting, add vinegar to your urine and the color should disappear).

·        Report unusual bleeding (from brushing your teeth, excessive bleeding from injuries, excessive bruising), black or bloody stools, cloudy or dark urine, sore throat, fever, chills, severe headaches, dizziness, suspected pregnancy.

Adverse effects in Italic are most common; those in Bold are life-threatening.