Drugs Draft

DRUGS BY CLASSIFICATION
GENERAL ANESTHETIC
GENERIC NAME BRAND

NAME
ketamine hydrochloride Ketalar
injection
Dosage and Frequency
ADULT
IM: 3 mg/kg. If response is inadequate this

dose may be repeated 30 minutes after initial
dose
IV: The initial dose of Ketalar administered

intravenously may range from 1 mg/kg to 4.5
mg/kg (0.5 to 2 mg/lb). The average amount
required to produce five to ten minutes of
surgical anesthesia has been 2 mg/kg (1
mg/lb).
MECHANISM OF ACTION
IV anesthetic agents: Most agents produce

CNS depression
1
by action on the gamma-aminobutyric acid
(GABA)
receptor complex. GABA is the primary

inhibitory neurotransmitter
in the CNS. Ketamine produces dissociation
between the thalamus and the limbic system.
INDICATION
Ketalar is indicated as the sole anesthetic agent

for diagnostic and surgical procedures that do
not require skeletal muscle relaxation. Ketalar
is best suited for short procedures but it can be
used, with additional doses, for longer
procedures.
Ketalar is indicated for the induction

of anesthesia prior to the administration of
other general anesthetic agents.
Ketalar is indicated to supplement low-potency

agents, such as nitrous oxide.
2
CONTRAINDICATION
Ketamine hydrochloride is contraindicated in

those in whom a significant elevation of blood
pressure would constitute a serious hazard and
in those who have shown hypersensitivity to
the drug.
ADVERSE EFFECT
Emergence rxns, HTN, Increased cardiac

output, Increased ICP, Tachycardia, Tonic-
clonic movements, Visual hallucinations,
Vivid dreams, Bradycardia, Diplopia,
Hypotension, Increased IOP, Injection-site
pain, Nystagmus, Anaphylaxis,Cardiac
arrhythmia,Depressed, cough reflex,
Fasciculations, Hypersalivation, Increased,
IOP, Increased metabolic rate, Hypertonia,
Laryngospasm, Respiratory depression or
apnea with large doses or rapid infusions
NURSING RESPONSIBILITY
 closely monitor blood pressure and heart

rate (every 5 minutes for first 30
3
minutes, then every 15 minutes for an
additional hour)
 careful mouth care and airway
management (because of increased
salivation); be aware of possible
aspiratio
PATIENT & FAMILY EDUCATION
• Warn patient to avoid tasks requiring

motor coordination and mental
alertness for 24 hours after anesthesia.
4
GENERAL ANESTHETIC
GENERIC NAME BRAND

NAME
poprofol Diprivan
ADULT
IV: ,55 yr and ASA I/II IV (Diprivan or

generic):â•‡â•‰IV 40 mg q10sec until
induction onset; maintenance: 100-200
mcg/kg/min or IV BOL 20-50 mg prn, allow
3-5 min between adjustments; Fresenius
Propoven 1% IV 20-40 q10sec until induction
then 3-6 mg/kg/hr
PEDRIATIC
IV $3 yr or ASA I or II:â•‡â•‰IV
Induction: 2.5-3.5 mg/kg over 20-30 sec
when not premedicated or lightly
premedicated
Child 2 mo-16 yr maintenance:â•‡â•‰IV
125-300 mcg/kg/min, lower dose for ASA III
or IV.
5
MECHANISM OF ACTION
Inhibits sympathetic vasoconstrictor
nerve activity; decreases vascular resistance.
INDICATION
Perioperative nausea and vomiting
CONTRAINDICATION
Hypersensitivity to
eggs, egg products, soybean or soy products.
ADVERSE EFFECTS
extreme drowsiness, respiratory depression,
circulatory depression. Toorapid
IV administration may produce severe
hypotension, respiratory depression,
involuntary muscle movements. Pt may
experience acute allergic reaction,
characterized
by abdominal pain, anxiety,
restlessness, dyspnea, erythema, hypotension,
pruritus, rhinitis, urticaria.
6
• Changes urine color to green; abrupt
discontinuation of infusion may result
in rapid awakening of the patient
associated with anxiety, agitation, and
resistance to mechanical ventilation,
making weaning from mechanical
ventilation difficult; use a light level of
sedation throughout the weaning
process until 10-15 minutes before
extubation; titrate the infusion rate so
the patient awakens slowly. Tubing
and any unused portions of propofol
vials should be discarded after 12
hours
 Teach patient that this medication will

cause dizziness, drowsiness, sedation;
to avoid hazardous activities until drug
effect wears off
7
GENERAL ANESTHETIC
GENERIC NAME BRAND

NAME
midazolam Midazolam
ADULT
IV: 0.02–0.04 mg/kg.

IM: ADULTS, ELDERLY: 0.07–0.08 mg/kg
30–60 min before surgery. Usual dose:
5 mg.
PEDRIATIC
PO: CHILDREN: 0.25–0.5 mg/kg. Maximum:
20 mg.
8
IV: CHILDREN 6–12 YRS: 0.025–0.05
mg/kg.
CHILDREN 6 MOS–5 YRS: 0.05–0.1 mg/kg.
CHILDREN: 0.1–0.15 mg/kg 30– 60 min
before surgery. Maximum: 10 Mg
MECHANISM OF ACTION
Enhances action of gamma-aminobutyric
acid (GABA), one of the major inhibitory
neurotransmitters in the brain.
INDICATION
-Preop Sedation,
CONTRAINDICATION
Acute narrow-angle
glaucoma, allergies to cherries (syrup),
coma, shock.
9
ADVERSE EFFECTS
cerebral hypoxia, agitation, involuntary
movements, hyperactivity, combativeness.
Too-rapid IV rate, excessive doses,
or single large dose increases risk of
respiratory depression/arrest. Respiratory
depression/apnea may produce hypoxia,
cardiac arrest.
• Monitor respiratory rate, oxygen
saturation continuously during
parenteral administration for under
ventilation, apnea.
• Monitor vital signs, level of sedation
q3–
5min during recovery period
 Inform patient that he may not

remember procedure because
midazolam produces amnesia.
 Advice patient to avoid potentially
hazardous activities until drug’s
adverse CNS effect, such as
10
dizziness and drowsiness have worn
off.
 Instruct patient to avoid alcohol and
other CNS depressant for 24 hours
after receiving drug, unless directed
otherwise by prescriber
11
GENERAL ANESTHETIC
GENERIC NAME BRAND

NAME
etomidate Amidate
ADULT
IV: 0.2 and 0.6 mg/kg of body weight, and it

must be individualized in each case.
PEDRIATIC
IV: 0.2 and 0.6 mg/kg of body weight, and it

must be individualized in each case.
MECHANISM OF ACTION
Etomidate is an imidazole compound that

appears to depress CNS function via GABA.
Duration of action is intermediate between
thiopental and methohexital, and recovery
from a single dose is rapid with little residual
depression.
12
INDICATION
Intravenous injection for the induction of

general anesthesia.
CONTRAINDICATION
Sepsis, Intraarterial administration, Geriatric,

hypertension, Hypovolemia, trauma,
Esophageal varices, hepatic disease, Renal
impairment, Labor, obstetric delivery,
pregnancy, Breast-feeding, Children, infants,
neonates, Driving or operating machinery
ADVERSE EFFECT
Myoclonus, pain on injection, nausea,

vomiting, respiratory depression
 Implement breathing activities and

other therapeutic exercises to
encourage ventilation and help
overcome any residual effects of the
anesthetic.
13
 Because of the risk of arrhythmias and
abnormal BP responses, use caution
during aerobic exercise and other
forms of therapeutic exercise. Assess
exercise tolerance frequently (BP,
heart rate, fatigue levels), and
terminate exercise immediately if any
untoward responses occur.
 Guard against falls and trauma (hip
fractures, head injury) during the
immediate postoperative period.
Implement fall prevention strategies,
especially if patient exhibits sedation,
dizziness, or blurred vision.
Instruct patient to report other troublesome

postoperative effects such as severe or
prolonged injection site pain or GI problems
(nausea, vomiting)
14
LOCAL ANESTHETIC
GENERIC NAME
BRAND NAME
lidocaine
Xylocaine
ADULT
IV: 50 to 300 mg (10 to 60 mL of 0.5%

solution) for intravenous regional infiltration
anesthesia.
MECHANISM OF ACTION
Anesthetic: Inhibits conduction of nerve

impulses. Therapeutic Effect: Causes
temporary loss of feeling/sensation.
INDICATION
Infiltration, Nerve Block
CONTRAINDICATION
15
severe heart block; a heart rhythm disorder
called Stokes-Adams syndrome (sudden slow
heart beats that can cause you to faint); or a
heart rhythm disorder called Wolff-
Parkinson-White Syndrome (sudden fast
heartbeats that can cause you to faint or
become easily tired), allergy to corn products;
liver disease; kidney disease; heart disease
(unless you are being treated with lidocaine
injection for a heart condition); coronary
artery disease, circulation problems; or
malignant hyperthermia
ADVERSE EFFECT
Bradycardia, hypotension, arrhythmias,

agitation, anxiety, dizziness, seizures, pruritus,
rash, nausea, vomiting, altered taste, visual
changes, tinnitus, respiratory depression,
allergic reaction
 Be alert for new seizures or increased

seizure activity, especially during IV
16
or IM administration. Document the
number, duration, and severity of
seizures, and report these findings
immediately to the physician.
 Monitor cardiac symptoms at rest and
during exercise. Seek immediate
medical assistance if symptoms of
cardiac arrest develop, including
sudden chest pain, pain radiating into
the arm or jaw, shortness of breath,
dizziness, sweating, anxiety, and
nausea.
 Monitor signs of allergic reactions and
anaphylaxis, including pulmonary
symptoms (laryngeal edema,
bronchospasm, wheezing, cough,
dyspnea) or skin reactions (rash,
pruritus, urticaria). Notify physician or
nursing staff immediately if these
reactions occur.
 Assess heart rate, ECG, and heart

sounds, especially during exercise.
Although intended to treat certain
arrhythmias, this drug can unmask or
precipitate new arrhythmias
(proarrhythmic effect). Report any
rhythm disturbances or symptoms of
17
increased arrhythmias, including
palpitations, chest pain, shortness of
breath, fainting, and fatigue/weakness.
 Be alert for other signs of toxicity
during continuous systemic
administration or prolonged use of
lidocaine patches. Signs of toxicity
include confusion, nervousness,
tremor, blurred or double vision,
nausea, vomiting, slurred speech,
ringing in ears, tremors, twitching,
difficulty breathing, severe dizziness
or fainting, and unusually slow heart
rate. Report these signs to physician or
nursing staff immediately.
 When used for regional pain control or
neuropathic pain, use appropriate pain
scales and sensory testing to document
level of local anesthesia and analgesic
effects.
 Assess dizziness and drowsiness that
might affect gait, balance, and other
functional activities
18
• You will be monitored during infusion.
Do not get up without assistance.
Report dizziness, numbness, double
vision, nausea, pain or burning at
infusion site, nightmares, hearing
strange noises, seeing unusual visions,
or difficulty breathing
19
ANESTHETIC
GENERIC NAME BRAND NAME
fentaNYL ABSTRAL
ADULT
SL 100 mcg, another dose may be taken 30 min

after first, max 2 doses per episode of
breakthrough pain, $2 hr must elapse before
treating again, titrate stepwise over
consecutive episodes
MECHANISM OF ACTION
Anesthetic: Inhibits ascending pain pathways

in CNS, increases pain threshold, alters pain
perception by binding to opiate receptors.
Therapeutic Effect: Relief of pain, supplement
to anesthesia.
20
INDICATION
Breakthrough pain, in opioid-tolerant patients

already receiving and who are tolerant to
continuous opioid therapy for underlying
persistent cancer pain.
CONTRAINDICATION
Hypersensitivity to opiates, myasthenia gravis,

headache, migraine (Actiq), Astral, Fentora,
Lazanda, Onsolis, emergency dept use
(Abstral, Lazanda), outpatient surgeries
(Duragesic TD), opioid-naive patients,
respiratory disorders, depression
ADVERSE EFFECT
Dizziness, delirium, euphoria, sedation,

bradycardia, cardiac arrest, hypo/
hypertension, blurred vision, miosis, nausea,
vomiting, constipation. urinary retention, rash,
diaphoresis, muscle rigidity, respiratory
depression, arrest, laryngospasm
21
• Hypercholesterolemia: Monitor lipid levels
(triglycerides, LDL, HDL, total cholesterol),
fat content • Liver function tests, baseline and
periodically during treatment; CPK if muscle
pain occurs, CBC, Hct, Hgh, pro-time with
anticoagulant therapy F 425 Canada only
Adverse effects: italics = common; bold = life-
threatening fentaNYL • Assess for pancreatitis,
cholelithiasis, renal failure, rhabdomyolysis
(when combined with HMG-CoA reductase
inhibitors), myositis; product should be
discontinued • Assess nutrition: fat, protein,
carbohydrates, nutritional analysis should be
completed by dietitian.
PATIENT/FAMILY EDUCATION
• Inform patient that compliance is needed.
• Instruct patient not to consume chipped or

broken tabs (Triglide) • Teach patient that risk
factors—high-fat diet, smoking, alcohol
consumption, absence of exercise—should be
decreased.
• Caution patient to notify prescriber if

pregnancy is planned or suspected • Teach
22
patient to notify prescriber if the GI symptoms
of diarrhea, abdominal or epigastric pain,
nausea, or vomiting occur.
• Instruct patient to report GU symptoms:

dysuria, proteinuria, oliguria, decreased libido,
impotence.
• Advise patient to notify prescriber of muscle

pain, weakness, fever, fatigue, epigastric pain.
23
ANESTHETIC
fospropofol Lusedra
ADULT
IV bolus, as needed give supplemental doses

up to a max of 140 mg
IV/dose to achieve desired level of sedation,
give no more frequently than q4min; 61-89 kg,
initially 6.5 mg/kg (max 577.5 mg)
MECHANISM OF ACTION
Prodrug of propofol; produces dose-dependent

CNS depression by activation of GABA
receptor inhibition of NMDA subtype of
glutamate receptors by channel-gating
modulation. Therapeutic Effect: Anesthesia.
INDICATION
Peripheral nerve block, caudal

anesthesia, central neural block,
vaginal, epidural, spinal block
24
CONTRAINDICATION
Hypersensitivity to product.
Precautions: Pregnancy B, breastfeeding,

children, geriatric patients, respiratory
depression, severe respiratory disorders,
cardiac dysrhythmias, labor and delivery, renal
disease, hyperlipidemia.
ADVERSE EFFECT
Involuntary movement, headache, jerking,

fever, dizziness, shivering, tremor, confusion,
somnolence, paresthesia, agitation, abnormal
dreams, euphoria, fatigue, increased
intracranial pressure, impaired cerebral flow,
seizures, radycardia, hypotension,
hypertension, PVC, PAC, tachycardia,
abnormal ECG, ST segment depression,
asystole, bradydysrhythmias, blurred vision,
tinnitus, eye pain, strange taste, diplopia,
nausea, vomiting, abdominal cramping, dry
mouth, swallowing, hypersalivation,
pancreatitis, urine retention, green urine,
25
cloudy urine, oliguria, flushing, phlebitis,
hives, burning/ stinging at inj site, rash, pain of
extremities MS: Myalgia, apnea, cough,
hiccups, dyspnea, hypoventilation, sneezing,
wheezing, tachypnea, hypoxia, respiratory
acidosis
• Assess inj site: phlebitis, burning, stinging
• Monitor ECG for changes: PVC, PAC, ST

segment changes; monitor VS
• Assess CNS changes: movement, jerking,

tremors, dizziness, LOC, pupil reaction
• Assess for allergic reactions: hives
• Assess for respiratory depression, character,

rate, rhythm; notify prescriber if respirations
are ,10/min, hypoxemia is detectable by pulse
oximetry
26
• Teach patient that this medication will cause
dizziness, drowsiness, sedation
27
ANESTHETIC
ropivacaine Naropin
ADULT
Lumbar epidural block for C-section : 20-30

ml of 0.5% SOL, or 15-20 ml of 0.75% SOL
Thoracic epidural: 5-15 ml of 0.5%-0.75%
SOL
Major nerve block: 35-50 ml of 0.5% SOL or
10-40 ml of 0.75% SOL Labor pain epidural:
10-20 ml of 0.2% SOL, then 6-14 ml/hr
Postoperative (lumbar/thoracic epidural): 6-14
ml/hr of 0.2% SOL
Infiltration/minor nerve block Adult: 1-100 ml
of 0.2% SOL or 1-40 ml of 0.5% SOL577.5
mg)
MECHANISM OF ACTION
Competes with calcium for sites in

nerve membrane that control sodium
28
transport across cell membrane; decreases rise
of depolarization phase of action potential,
Therapeutic effect: Maintenance of local
anesthesia
INDICATION
intravenous sedative-hypnotic agent indicated

for monitored anesthesia care (MAC) sedation
in adult patients undergoing diagnostic or
therapeutic procedures.
CONTRAINDICATION
Children <12 yr, geriatric, hypersensitivity to

amide local anesthetics, severe liver disease,
severe hypotension, complete heart block
ADVERSE EFFECT
Anxiety, restlessness, seizures, loss of

consciousness, drowsiness, disorientation,
tremors, shivering, paresthesia, myocardial
depression, cardiac arrest, dysrhythmias,
bradycardia, hypo/hypertension, fetal
bradycardia, blurred vision, tinnitus, pupil
constriction, hypokalemia, nausea, vomiting,
29
urinary retention, rash, urticaria, allergic
reactions, edema, burning, skin discoloration
at injection site, tissue necrosis, status
asthmaticus, respiratory arrest, anaphylaxis
• Assess B/P, pulse, respiration during

treatment
• Assess fetal heart tones during labor
• Assess allergic reactions: rash, urticaria,

itching
• Assess cardiac status: ECG for dysrhythmias,

pulse, B/P during anesthesia
30
ANESTHETIC
meperidine Demerol
ADULT
PO/SUBCUT/IM 50-150 mg q3-4hr prn
PEDRIATIC
PO/SUBCUT/IM 1-1.8 mg/kg q3-4hr prn, max

single dose 150 mg
31
MECHANISM OF ACTION
Depresses pain impulse transmission

at the spinal cord level by
interacting with opioid receptors.
Therapeutic effect: Relief of pain
INDICATION
Moderate to severe pain,

preoperatively, postoperatively
CONTRAINDICATION
Hypersensitivity, severe respiratory

insufficiency
ADVERSE EFFECT
Drowsiness, dizziness, confusion,

headache, sedation, euphoria, increased ICP,
seizures, serotonin syndrome, palpitations,
bradycardia, hypotension, change in B/P,
tachycardia (IV), tinnitus, blurred vision,
miosis, diplopia, depressed corneal reflex,
nausea, vomiting, anorexia,
constipation, cramps, biliary spasm,
paralytic ileus, urinary retention, dysuria,
32
rash, urticaria, bruising, flushing,
diaphoresis, pruritus, respiratory depression,
anaphylaxis
• Assess pain: location, duration, intensity

before and 1 hr (IM, SUBCUT, PO), 5-10 min
(IV) after administration
• Assess renal function before initiating

therapy; poor renal function can lead to
accumulation of toxic metabolite and seizures
• Monitor VS after parenteral route; note

muscle rigidity, product history, liver, kidney
function tests, respiratory dysfunction:
respiratory depression, character, rate,
rhythm; notify prescriber if respirations are
,10/min
• Monitor CNS changes: dizziness,

drowsiness, hallucinations, euphoria, LOC,
pupil reaction; these are due to metabolite
produced; CNS stimulation occurs with
chronic or high doses
• Monitor allergic reactions: rash, urticaria
• Assess for constipation; increase fluids, bulk

in diet; give stimulant laxatives if needed
33
• Advise patients to avoid CNS depressants
(alcohol, sedative/hypnotics) for at least 24 hr
after taking this product
• Discuss with patient that dizziness,

drowsiness, and confusion are common; to
avoid getting up without assistance
• Discuss in detail with patient all aspects of

the product, including its purpose and what to
expect
• Caution patient to make position changes

carefully to lessen orthostatic hypotension
34
ANESTHETIC
GENERIC NAME
BRAND NAME
oxymorphone
Opana
ADULT
IV: ADULTS 18 YRS AND OLDER,

ELDERLY: Initially, 0.5 mg. Dose may be
cautiously increased until satisfactory response
is achieved.
IM/Subcutaneous: ADULTS 18 YRS AND

OLDER, ELDERLY: Initially, 1–1.5 mg every
4–6 hrs as needed.
MECHANISM OF ACTION
Binds to opiate receptor sites within CNS.

Therapeutic Effect: Reduces intensity of pain
stimuli, alters pain perception, emotional
35
response to pain. Parenterally, 1 mg
oxymorphone equivalent to 10 mg morphine.
INDICATION
Relief of moderate to severe acute pain.
CONTRAINDICATION
Hypersensitivity to morphine, acute asthma

attack, severe respiratory depression, paralytic
ileus, pulmonary edema secondary to chemical
respiratory irritants, moderate to severe hepatic
function impairment, hypercarbia.
ADVERSE EFFECT
Overdose results in respiratory depression,

skeletal muscle flaccidity, cold/ clammy skin,
cyanosis, extreme drowsiness progressing to
convulsions, stupor, coma. Tolerance to
analgesic effect, physical dependence may
occur with repeated use. Prolonged duration of
action, cumulative effect may occur in those
with hepatic/renal impairment.
36
Assess onset, type, location, duration of pain.
Obtain vital signs before giving medication. If
respirations are 12/min or lower, withhold
medication, contact physician. Effect of
medication is reduced if full pain recurs before
next dose.
• Discomfort may occur with injection.
• Change positions slowly to avoid postural

hypotension.
• Avoid tasks that require alertness, motor

skills until response to drug is established.
• Avoid alcohol.
• Tolerance/dependence may occur with

prolonged use of high doses.
37
Antaci
ds
38
DRUGS BY
CLASSIFICATION
I. ANTACIDS
GENERIC
BRAND
simethicone. Gas-
X
Dosage and Frequency:
Recommended Adult Dose for

Flatulence/gastric bloating:
kPO: 125 mg tablet, Adults: Swallow with

water 1 to 2 softgels as needed after meals and
at bedtime (125mg Cap PO p.c and h.s)
39
Recommended Children ages 2 - 12 Dose for
Flatulence/gastric bloating:
PO: 40 mg after meals and at bedtime, up to

240 mg daily (40mg cap p.c. and h.s.)
Recommended Children below 2 years Dose

for Flatulence/gastric bloating:
PO: 20 mg after meals and at bedtime, up to

240 mg daily (20mg cap p.c. and h.s.)
Mechanisms of action
Disperses or prevents formation of mucus

surrounded gas pockets in the GI tract and
Causes gas bubbles to coalesce and allows gas
to pass through GI tract via belching or passing
of flatus. Silicone antifoam spreads on surface
of aqueous liquids, forming a film of low
surface tension that causes foam bubbles to
collapse.
Indication
40
Excess gas in GI tract after surgery or from air
swallowing, dyspepsia, pepticulcer, or
diverticulitis
Contraindication
Hypersensitivity to drug. Intestinal

perforation or obstruction. For infant colic,
safety is unknown
Adverse Reaction
GI: belching, flatus
Nursing Responsibility
 Keep in mind that the drug doesn't

prevent gas formation.
 Look alike - sound alike: Don't
confuse simethicone with cimetidine.
 Monitor GI status to assess drug
efficacy
Patient and Family Teaching
 Tell patient to take after meals and at

bedtime as needed.
41
 Caution patient not to take dose higher
than indicated on package unless
prescriber approves.
I. ANTACIDS
GENERIC BRAND
aluminum hydroxide Alu-

Cap
42
Recommended Adult Dose for Indigestion:
PO: The usual dose is one capsule four times

during the day and one at bedtime.
(475 mg cap q.i.d and q.h.s)
Recommended Adult Dose for

Hyperacidity:
PO: Adults: 500 to 1,500 mg (tablet or

capsule) P.O. 1 hour after meals and at
bedtime; or 5 to 30 ml (oral suspension)
between meals and at bedtime, as needed or
directed
(500-1,500 mg cap 1hr p.c. or h.s; or 5 to 30 ml

susp. int.c. and h.s. ad libitum.)
43
Dissolves in acidic gastric secretions, releasing
anions that partially neutralize gastric
hydrochloric acid. Also elevates gastric pH,
inhibiting the action of pepsin (an effect
important in pepticulcer disease).
Indication
Hyperacidity and indigestion.
Contraindication
Signs or symptoms of appendicitis or inflamed.
Use cautiously in patients with chronic renal

disease.
Adverse Reaction
CNS: encephalopathy, neurotoxicity malaise

(prolonged use)
GI: anorexia, constipation, intestinal
obstruction.
Metabolic: hypophosphatemia (prolonged
use)
Musculoskeletal: osteomalaciaosteomalacia
and chronic phosphate deficiency with bone
pain, malaise, muscle weakness (with
44
prolonged use) Other:
aluminum toxicity
 ALERT: Monitor long-term, high-dose

use in patient on restricted sodium
intake. Each tablet, capsule or 5 ml
suspension may contain 2 or 3 mg of
sodium. Refer to manufacturer’s label
for specific sodium content.
 Record amount and consistency of

stools. Manage constipation with
laxatives or stool softeners; alternate
with magnesium-containing antacids
(if patient doesn’t have renal disease).
 Monitor phosphate level
 Watch for evidence of

hypophosphatemia (anorexia, malaise,
and muscle weakness) with prolonged
use; also can lead to resorption of
calcium and bone demineralization.
45
 Aluminum hydroxide therapy may
interfere with imaging techniques
using sodium pertechnetate Tc-99m,
and thus impair evaluation of Meckel’s
diverticulum. It also may interfere with
reticuloendothelial imaging of liver.
Spleen or bone marrow using
technetium-99m sulfur colloid. It may
antagonize effects of pentagastrin
during gastric acid secretion test.
Because drug contains aluminum, it’s
used in patients with renal failure to
help control hyperphosphatemia by
binding with phosphate in the GI tract.
Patient and Family Teacing
 Instruct patient to shake suspension

well and to follow with a small amount
of mil or water to facilitate passage
 Advice patient not to take aluminum
hydroxide indiscriminately or to switch
antacids without prescriber’s advice
 Urge patient to notify prescriber about
signs and symptoms of GI bleeding,
46
such as tarry stools or coffee-ground
vomitus
 Instruct pregnant patient to sekk
medical advice before taking the drug
 Tell patient to take drug 1 hour after
meals and at bedtime.
 Caution patient not to take drug within
1 to 2 hours of anti-infectives, H2
blockers, iron, corticosteroids, or
enteric-coated drugs.
 Advise patient to take drug with water
or fruit juice.
 Instruct patient to report signs and
symptoms of GI bleeding and
hypophosphatemia (appetite loss,
malaise, muscle weakness).
 Recommend increased fiber and fluid
intake and regular physical activity to
help ease constipation.
 Inform patient that drug contains
sodium, so he should discuss drug
therapy with health care providers if
he’s later told to consume a low-
sodium diet.
47
 Advise patient that he’ll need to
undergo periodic blood testing and
bone mineral density tests if he’s
receiving long-term therapy.
 As appropriate, review all other
significant and life-threatening adverse
reactions and interactions, especially
those related to the drugs, tests, and
foods mentioned abov
I. ANTACIDS
GENERIC BRAND
48
Sodium bicarbonate
Citrocarbonate
Recommended dose for Adults and children

metabolic acidosis:
2 to 5 mEq/kg by I.V. infusion over 4 to 8

hours. However, dosage highly individualized
based on patient’s condition and blood pH and
carbon dioxide content.
Recommended adult dose for Urinary

alkalization:
Initially, 4 g P.O.; then 1 to 2 g P.O. q 4 hours
Recommended children dose for Urinary

alkalization:
1 to 10 mEq/kg/day P.O. in divided doses

given q 4 to 6 hours
Recommended adult dose for renal tubular

acidosis:
For distal tubular acidosis, 0.5 to 2 mEq/kg

P.O. daily in four to five equal doses. For
49
proximal tubular acidosis, 4 to 10 mEq/kg P.O.
daily in divided doses.
Recommended adult dose as Antacid:
Adults: 300 mg to 2 g P.O. up to q.i.d., given

with glass of water
Restores body’s buffering capacity; neutralizes

excess acid
Indication
Metabolic acidosis
Contraindication
 Hypocalcemia
 Metabolic or respiratory alkalosis
50
 Hypernatremia
 Hypokalemia
 Severe pulmonary edema
 Seizures
 Vomiting resulting in chloride loss
 Diuretic use resulting in
hypochloremic alkalosis
 Acute ingestion of mineral acids (with
oral form)
Adverse Reaction
CNS: headache, irritability, confusion,

stimulation, tremors, twitching, hyperreflexia,
weakness, seizures of alkalosis, tetany
CV: irregular pulse, edema, cardiac arrest
GI: gastric distention, belching, flatulence,

acid reflux, paralytic ileus
GU: renal calculi
51
Metabolic: hypokalemia, fluid retention,
hypernatremia, hyperosmolarity (with
overdose), metabolic alkalosis
Respiratory: slow and shallow respirations,

cyanosis, apnea
Other: weight gain, pain and inflammation at

I.V. site
 To avoid risk of alkalosis, obtain blood

pH, partial pressure of arterial oxygen
partial pressure of arterial carbon
dioxide, and electrolyte levels. Tell
prescriber laboratory results
 When giving I.V., closely monitor
arterial blood gas results and
electrolyte levels.
 Stay alert for signs and symptoms of
metabolic alkalosis and electrolyte
imbalances.
 Monitor fluid intake and output.
Assess for fluid overload.
 Avoid rapid infusion, which may
cause tetany.
52
 Watch for inflammation at I.V. site.
 Tell patient using drug as antacid that

too much sodium bicarbonate can
cause systemic problems. Urge him to
use only the amount approved by
prescriber.
 Advise patient not to take oral form
with milk. Caution him to avoid the
herb oak bark.
 Tell patient sodium bicarbonate
interferes with action of many common
drugs. Instruct him to notify all
prescribers if he’s taking oral sodium
bicarbonate on a regular basis.
 As appropriate, review all other
significant and life-threatening adverse
reactions and interactions, especially
those related to the drugs, tests, and
herbs mentioned above.
53
I. ANTACIDS
GENERIC
BRAND
calcium carbonate
Tums
Recommended adult dose for Acid

indigestion
350 mg to 1.5 P.O. or two pieces of chewing

gum 1 hour after meals and at bedtime, as
needed.
54
Reduces total acid load in GI tract, elevates

gastric pH to reduce pepsin activity,
strengthens gastric mucosal barrier, and
increases esophageal sphincter tone.
Indication
Acid ingestion, calcium supplement
Contraindication
 Contraindicated in patients with

ventricular fibrillation or
hypercalcemia.
 Use cautiously, if at all, if patient takes
a cardiac glycoside or has sarcoidosis
or renal or cardiac disease.
Adverse Reaction
55
 CNS: headache, irritability, weakness
 GI: nausea, constipation, flatulence,
rebound hyperacidity.
Nursing Responsibilities
 Record amount and consistency of

stools. Manage constipation with
laxatives or stool softeners.
 Monitor calcium level, especially in
patients with mild renal impairments.
 Watch for evidence of hypercalcemia
(nausea, vomiting, headache,
confusion, and anorexia).
Patient Teaching
 Advice patient not to take calcium

carbonate indiscriminately or to switch
antacids without prescriber’s advice.
 Tell patient who takes chewable tablets
to chew thoroughly before swallowing
and to follow with a glass of water.
56
 Tell patient who uses suspension form
to shake well and take with a small
amount of water to facilitate passage.
 Urge patient to notify prescriber about
signs and symptoms of GI bleeding,
such as tarry stools, or coffee-ground
vomitus
I. ANTACIDS
GENERIC
BRAND
Magnesium oxide
Recommended adult dose for acid

indigestion
57
140 mg P.O. with water or milk after meals and
at bedtime
Recommended adult dose for oral

replacement therapy in mild
hypomagnesemia
400 to 840 mg P.O. daily. Monitor magnesium

level.
Reduces total acid load in

GI tract, elevates gastric
pH to reduce pepsin
activity, strengthens
gastric mucosal barrier,
and increases esophageal sphincter tone.
Indication
Acid indigestion and oral replacement therapy

in mild hypomagnesemia
Contraindication
58
 Contraindicated in patients with severe
renal disease.
 Use cautiously in patients with mild
renal impairment.
Adverse Reaction
 GI: diarrhea, abdominal pain, nausea

 Metabolic: hypermagnesemia
 Alert: monitor magnesium level. With

prolonged use and renal impairment,
watch for evidence of
hypermagnesemia (hypotension,
nausea, vomiting, depressed reflexes,
respiratory depression, and coma).
 if diarrhea occurs, use a different drug.
Patient Teaching
 Advice patient not to take drug

indiscriminately or to switch antacids
without prescriber’s advice.
 Urge patient to report signs of GI
bleeding, such as tarry stools, or
coffee-ground vomitus.
59
60
Antian
ginals
61
ANTIANGINALS
1. GENERIC NAME: amlodipine

besylate
BRAND NAME: Norvasc, Katerzia
DOSAGE & FREQUENCY:
ADULT
Hypertension: 5 mg/day orally initially; may
be increased by 2.5 mg/day every 7-14 days;
not to exceed 10 mg/day orally; maintenance:
5-10 mg/day orally
Coronary Artery Disease: 5-10 mg/day orally
initially; maintenance: 10 mg/day orally
Angina: 5-10 mg/day orally; maintenance: 10
mg/day orally
62
Geriatric:
Hypertension: 2.5-5 mg/day orally initially;
may be increased by 2.5 mg/day every 7-14
days; not to exceed 10 mg/day orally;
maintenance: 5-10 mg/day orally Coronary
Artery Disease: 2.5-10 mg/day orally initially;
maintenance: 10 mg/day orally
PEDIATRIC
Hypertension: Children under 6 years: Safety

and efficacy not established. Children 6 years
and older: 2.5-5 mg/day orally
MECHANISM OF ACTION:
63
Normally, vascular smooth muscle contraction
initiates when calcium enters the cell via
voltage-dependent L-type calcium channels.
The calcium binds to intracellular calmodulin,
which subsequently binds to and activates
myosin light-chain kinase (MLCK). MLCK is
responsible for the phosphorylation of myosin
light-chain, ultimately leading to muscle
contraction and vasoconstriction. The vascular
smooth muscle contraction becomes further
amplified by calcium-induced calcium release
from the sarcoplasmic reticulum. This
sequence of events leads to a decreased
vascular cross-sectional area, increased
vascular resistance, and increased blood
pressure.
Amlodipine works by blocking the voltage-

dependent L-type calcium channels, thereby
inhibiting the initial influx of calcium.
Reduced intracellular calcium leads to
decreased vascular smooth muscle
contractility, increased smooth muscle
relaxation, and resultant vasodilation.
64
Ultimately, this causes a decrease in blood
pressure.
Amlodipine’s role in relieving stable angina is

due to the lowering of afterload secondary to
its vasodilatory and antihypertensive
properties. Reducing afterload leads to a
lowering of myocardial oxygen demand at any
level of exertion as the heart does not need to
work as hard to pump blood into the systemic
circulation.
Amlodipine also alleviates Prinzmetal or

variant angina by blocking coronary spasm and
restoring blood flow in the coronary arteries.
INDICATIONS:
Amlodipine is used with or without other

medications to treat high blood pressure.
Lowering high blood pressure helps prevent
strokes, heart attacks, and kidney problems.
Amlodipine belongs to a class of drugs known
as calcium channel blockers. It works by
relaxing blood vessels so blood can flow more
easily.
65
Amlodipine is also used to prevent certain
types of chest pain (angina). It may help to
increase your ability to exercise and decrease
the frequency of angina attacks. It should not
be used to treat attacks of chest pain when they
occur. Use other medications (such as
sublingual nitroglycerin) to relieve attacks of
chest pain as directed by your doctor.
CONTRAINDICATIONS:
The only absolute contraindication to

amlodipine is an allergy to amlodipine or any
other dihydropyridines.
Other situations occur, however, where

amlodipine generally should not be used. In
patients with cardiogenic shock, where the
heart's ventricles are not able to pump enough
blood, calcium channel blockers exacerbate
the situation by preventing the flow of calcium
ions into cardiac cells, which is required for the
heart to pump.While use in patients with aortic
stenosis (narrowing of the aorta where it meets
the left ventricle) since it does not inhibit the
ventricle's function is generally safe, it can still
66
cause collapse in cases of severe stenosis. In
unstable angina (excluding variant angina),
amlodipine can cause a reflex increase in
cardiac contractility (how hard the ventricles
squeeze) and heart rate, which together
increase the demand for oxygen by the heart
itself. Patients with severe hypotension can
have their low blood pressure exacerbated, and
patients in heart failure can get pulmonary
edema. Those with impaired liver function are
unable to metabolize amlodipine to its full
extent, giving it a longer half-life than typical.
Amlodipine's safety in pregnancy has not been

established, although reproductive toxicity at
high doses is known. Whether amlodipine
enters the milk of breastfeeding mothers is also
unknown.
Those who have heart failure, or recently had

a heart attack, should take amlodipine with
caution.
ADVERSE EFFECTS:
67
Body as a Whole: allergic reaction, asthenia,
back pain, hot flushes, malaise, pain, rigors,
weight gain, weight decrease
CNS: hypoesthesia, neuropathy peripheral,
paresthesia, tremor, vertigo
CV: arrhythmia (including ventricular
tachycardia and atrial fibrillation),
bradycardia, chest pain, peripheral ischemia,
syncope, tachycardia, vasculitis..
Special Senses: abnormal vision,
conjunctivitis, diplopia, eye pain, tinnitus.
GI: anorexia, constipation, dysphagia,
diarrhea, flatulence, pancreatitis, vomiting,
gingival hyperplasia..
NURSING RESPONSIBILITIES:
1. Monitor patient carefully (BP, cardiac

rhythm, and output) while adjusting
drug to therapeutic dose; use special
caution if patient has CHF.
2. Monitor BP very carefully if patient is

also on nitrates.
68
3. Monitor cardiac rhythm regularly
during stabilization of dosage and
periodically during long-term therapy.
4. Administer drug without regard to

meals.
PATIENT & FAMILY EDUCATION:
1. Take with meals if upset stomach

occurs
2. You may experience these side effects:

Nausea, vomiting (eat frequent small
meals); headache (adjust lighting,
noise, and temperature; medication
may be ordered).
3. Report irregular heartbeat, shortness of

breath, swelling of the hands or feet,
pronounced dizziness, constipation.
69
GENERIC NAME: atenolol
BRAND NAME: Tenormin
DOSAGE & FREQUENCY:
Hypertension
Adult: 25-50 mg/day orally initially; may be

increased to 100 mg/day orally
Pediatric (Off-label): 0.5-1 mg/kg/day orally;

not to exceed 2 mg/kg/day or 100 mg/day
Geriatric: 25 mg/day orally initially; may be

increased to 100 mg/day orally
Angina Pectoris
Adult: 50 mg/day orally; after 1 week, may be

increased to 100 mg/day orally; some patients
may require 200 mg/day
70
Geriatric: 25 mg/day orally; after 1 week, may
be increased to 100 mg/day; some patients may
require 200 mg/day
Post Myocardial Infarction (MI)
Adult: 100 mg orally once daily or divided

every 12 hours for 6-9 days after myocardial
infarction (MI)
Geriatric: 100 mg orally once daily or divided

every 12 hours for 6-9 days after MI
71
Atenolol is a cardioselective beta-blocker,
called such because it selectively binds to the
β1-adrenergic receptor as an antagonist up to a
reported 26 fold more than β2 receptors.
Selective activity at the β1 receptor produces
cardioselectivity due to the higher population
of this receptor in cardiac tissue. Some binding
to β2 and possibly β3 receptors can still occur
at therapeutic dosages but the effects mediated
by antagonizing these are significantly reduced
from those of non-selective agents. β1 and β2
receptors are Gs coupled therefore antagonism
of their activation reduces activity of adenylyl
cyclase and its downstream signalling via
cyclic adenosime monophosphate and protein
kinase A (PKA).
In cardiomyocytes PKA is thought to mediate

activation of L-type calcium channels and
ryanodine receptors through their
phosphorylation.L-type calcium channels can
then provide an initial rise in intracellular
calcium and trigger the ryanodine receptors to
release calcium stored in the sarcoplasmic
reticulum (SR) and increased contractility.
72
PKA also plays a role in the cessation of
contraction by phosphorylating
phospholamban which in turn increases the
affinity of SR Ca2+ ATPase to increase
reuptake of calcium into the SR. It also
phophorylates troponin I to reduce affinity of
the protein for calcium. Both of these events
lead to a reduction in contraction which, when
coupled with the initial increase in contraction,
allows for faster cycling and consequently
higher heart rate with increased contractility.
L-type calcium channels are also a major
contributor to cardiac depolarization and their
activation can increase frequency of action
potentials and possibly the incidence of ectopic
potentials.
Similar inihibitory events occur in the

bronchial smooth muscle to mediate relaxation
including phosphorylation of myosin light-
chain kinase, reducing its affinity for calcium.
PKA also inhibits the excitatory Gq coupled
pathway by phosphorylating the inositol
trisphosphate receptor and phospholipase C
resulting in inhibition of intracellular calcium
73
release. Antagonism of this activity by beta-
blocker agents like atenolol can thus cause
increased bronchoconstriction.
INDICATIONS:
Atenolol is used with or without other

medications to treat high blood pressure
(hypertension). Lowering high blood pressure
helps prevent strokes, heart attacks, and kidney
problems. This medication is also used to treat
chest pain (angina) and to improve survival
after a heart attack.
Atenolol belongs to a class of drugs known as

beta blockers. It works by blocking the action
of certain natural chemicals in your body, such
as epinephrine, on the heart and blood vessels.
This effect lowers the heart rate, blood
pressure, and strain on the heart.
CONTRAINDICATIONS:
74
Beta blockers are contraindicated in patients
hypersensitive to them and in patients with
cardiogenic shock, sinus bradycardia, heart
block greater than first degree, or bronchial
asthma.
Use beta blockers cautiously in patients with

nonallergic bronchospastic disorders, diabetes
mellitus, or impaired hepatic or renal function.
In pregnant women, use beta blockers
cautiously. Recommendations for
breastfeeding vary by drug; use beta blockers
cautiously. In children, safety and
effectiveness haven’t been established. Check
with prescriber before giving these drugs to
children. Elderly patients have an increased
risk of adverse reactions; use cautiously.
ADVERSE EFFECTS
CNS: Dizziness, Vertigo, Lightheadedness,

Tiredness, Fatigue Lethargy, Drowsiness,
Depression, Dreaming
GI: nausea, vomiting, diarrhea.
75
Hematologic: Agranulocytosis
Other: Erythematous rash
Furthermore, a number of patients who had

previously demonstrated established practolol
reactions were transferred to TENORMIN
therapy with subsequent resolution or
quiescence of the reaction.
1. Do not discontinue drug abruptly

after long-term therapy
(hypersensitivity to catecholamines
may have developed, causing
exacerbation of angina, MI, and
ventricular arrhythmias). Taper
drug gradually over 2 wk with
monitoring
2. Consult physician about

withdrawing drug if patient is to
undergo surgery (withdrawal is
controversial).

76
1. Take drug with meals if GI upset
occurs
2. Do not stop taking this drug unless

told to do so by a health care
provider
3. Avoid driving or dangerous

activities if dizziness or weakness
occurs.
4. You may experience these side

effects: Dizziness, light-
headedness, loss of appetite,
nightmares, depression, sexual
impotence.
5. Report difficulty breathing, night

cough, swelling of extremities,
slow pulse, confusion, depression,
rash, fever, sore throat.
77
GENERIC NAME: : diltiazem
hydrocholride
BRAND NAME: Tiazac
DOSAGE & FREQUENCY:
Adult: 120–240 mg daily PO for

hypertension—once daily dose; 120–180 mg
PO once daily for angina.
Pediatric
Safety and efficacy not established
78
Diltiazem HCl has been shown to produce

increases in exercise tolerance, probably due to
its ability to reduce myocardial oxygen
demand. This is accomplished via reductions
in heart rate and systemic blood pressure at
submaximal and maximal work loads.
Diltiazem has been shown to be a potent dilator

of coronary arteries, both epicardial and
subendocardial. Spontaneous and ergonovine-
induced coronary artery spasms are inhibited
by diltiazem.
79
INDICATIONS:
Angina pectoris due to coronary artery spasm

(Prinzmetal’s variant angina).
Effort-associated angina; chronic stable angina

in patients not controlled by beta-adrenergic
blockers, nitrates.
CONTRAINDICATIONS:
Diltiazem is contraindicated in (1) patients

with sick sinus syndrome except in the
presence of a functioning ventricular
pacemaker, (2) patients with second- or third-
degree AV block except in the presence of a
functioning ventricular pacemaker, (3) patients
with severe hypotension (less than 90 mm Hg
systolic), (4) patients who have demonstrated
hypersensitivity to the drug, and (5) patients
with acute myocardial infarction and
pulmonary congestion documented by x-ray on
admission.
ADVERSE EFFECTS
Cardiovascular: Angina, arrhythmia, AV

block (second- or third-degree), bundle branch
80
block, congestive heart failure, ECG
abnormalities, hypotension, palpitations,
syncope, tachycardia, ventricular
extrasystoles.
Nervous System: Abnormal dreams, amnesia,

depression, gait abnormality, hallucinations,
insomnia, nervousness, paresthesia,
personality change, somnolence, tinnitus,
tremor.
Gastrointestinal: Anorexia, constipation,

diarrhea, dry mouth, dysgeusia, mild
elevations of SGOT, SGPT, LDH, and alkaline
phosphatase (see WARNINGS, Acute Hepatic
Injury), nausea, thirst, vomiting, weight
increase.
Dermatological: Petechiae, photosensitivity,

pruritus.
Other: Albuminuria, allergic reaction,

amblyopia, asthenia, CPK increase,
crystalluria, dyspnea, edema, epistaxis, eye
irritation, headache, hyperglycemia,
hyperuricemia, impotence, muscle cramps,
nasal congestion, neck rigidity, nocturia,
81
osteoarticular pain, pain, polyuria, rhinitis,
sexual difficulties, gynecomastia.

rhythm, and output) while drug is being
titrated to therapeutic dose; dosage may
be increased more rapidly in
hospitalized patients under close
supervision.
2. Monitor BP carefully if patient is on

concurrent doses of nitrates.

periodically during long-term
therapy.
4. Ensure patient swallows ER

preparations whole; do not cut,
crush, or chew.
82
2. Swallow extended-release and long-
acting preparations whole; do not cut,
crush, or chew; do not drink grapefruit
juice while using this drug.

meals); headache (regulate light, noise,
and temperature; medicate if severe).
4. Report irregular heart beat, shortness of

pronounced dizziness, constipation
83
GENERIC NAME: : isosorbide dinitrate
BRAND NAME: Isordil
DOSAGE & FREQUENCY:
ADULTS
PO:
Angina pectoris: Starting dose, 2.5–5 mg

sublingual, 5-mg chewable tablets, 5- to 20-mg
oral tablets. For maintenance, 10–40 mg q 6 hr
oral tablets or capsules; SR, initially 40 mg,
then 40–80 mg PO q 8–12 hr.
Acute prophylaxis: Initial dosage, 5–10 mg

sublingual or chewable tablets q 2–3 hr.
PEDIATRIC
84
Isosorbide dinitrates is in the class drugs called

nitrates and it is used for treating and
preventing angina or heart pain. Nitrates are
vasolidator. Blood returning from the body in
the be pumped by the heart through the lungs
and into the bpdy’s arteries against the high
pressure in the arteries. In order to accomplish
85
the work, the heart muscle must produce and
use energy, and this requires oxygen. Angina
pectoris or heart pain is due to an inadequate
flow of blood and oxygen to the muscle of the
heart. Nitrates including isosorbide dinitrate,
improves the flow of blood and oxygen to the
heart and reduces the work that the heart must
do by dilating the arteries of the body. Dilation
of the veins reduces the amount of blood that
returns to the heart that must be pumped.
Dilation of the arteries lowers the pressure in
the arteries against which the heart must pump
As a consequence of both effects, the heart
works less and requires less blood and oxygen.
In addition, nitrates dilate the arteries that
supply the heart with blood so that the heart
receives more blood and oxygen.
INDICATIONS:
Isordil (isosorbide dinitrate) Titradose tablets

are indicated for the prevention of angina
pectoris due to coronary artery disease. The
onset of action of immediate-release oral
86
isosorbide dinitrate is not sufficiently rapid for
this product to be useful in aborting an acute
anginal episode.
CONTRAINDICATIONS:
Isordil Titradose is contraindicated in patients

who are allergic to isosorbide dinitrate or any
of its ingredients.
Do not use Isordil Titradose in patients who are

taking certain drugs for erectile dysfunction
(phosphodiesterase inhibitors), such as
sildenafil, tadalafil, or vardenafil. Concomitant
use can cause severe hypotension, syncope, or
myocardial ischemia.
Do not use Isordil Titradose in patients who are

taking the soluble guanylate cyclase stimulator
riociguat. Concomitant use can cause
hypotension.
ADVERSE EFFECTS:
CNS: Headache, apprehension, restlessness,

weakness, vertigo, dizziness, faintness
87
CV: Tachycardia, retrosternal discomfort,
palpitations, hypotension, syncope, collapse,
orthostatic hypotension, angina, rebound
hypertension, atrial fibrillation, postural
hypertension
Dermatologic: Rash, exfoliative dermatitis,

cutaneous vasodilation with flushing
GI: Nausea, vomiting, incontinence of urine

and feces, abdominal pain, diarrhea
GU: Dysuria, impotence, urinary frequency
Other: Muscle twitching, pallor, perspiration,

cold sweat, arthralgia, bronchitis
1. Give sublingual preparations under

the tongue or in the buccal pouch;
discourage the patient from
swallowing.
2. Create a nitrate-free period to

minimize tolerance.
3. WARNING: Give chewable tablets

slowly, only 5 mg initially, because
88
severe hypotension can occur;
ensure that patient does not chew or
crush sustained-release
preparations.
1. Place sublingual tablets under your

tongue or in your cheek; do not
chew or swallow the tablet. Take
the isosorbide before chest pain
begins, when activities or situation
may precipitate an attack.

effects: Dizziness, lightheadedness
(may be transient; use care to
change positions slowly); headache
(lie down in a cool environment,
rest; over-the-counter preparations
may not help; take drug with
meals); flushing of the neck or face
(reversible).
3. Report blurred vision, persistent or

severe headache, rash, more
89
frequent or more severe angina
attacks, fainting.
GENERIC NAME: : isosorbide mononitrate
BRAND NAME: Imdur
DOSAGE & FREQUENCY:
ADULTS
PO:
5Prevention of angina: 20 mg PO bid given 7

hr apart; ER tablets—30–60 mg/day PO may
be increased to 120 mg/day if needed. In
smaller patients, start with 5 mg (one-half of
10-mg tablet) but then increase to at least 10
mg by day 2 or 3 of therapy. Give first dose
when waking and second dose 7 hr later. This
creates a nitrate-free period and minimizes
tolerance to drug.
PEDIATRIC
90
Like all organic nitrates, isosorbide

mononitrate acts as a donor of nitric oxide
(NO). NO causes a relaxation of vascular
smooth muscle via the stimulation of guanylyl
cyclase and the subsequent increase of
intracellular cyclic guanosine monophosphate
(cGMP) concentration. A cGMP-dependent
protein kinase is thus stimulated, with resultant
alteration of the phosphorylation of various
proteins in the smooth muscle cell. This
eventually leads to the dephosphorylation of
91
the light chain of myosin and the lowering of
smooth muscle tone.
INDICATIONS:
Ismo (isosorbide mononitrate) tablets are

indicated for the prevention of angina pectoris
due to coronary artery disease. The onset of
action of oral isosorbide mononitrate is not
sufficiently rapid for this product to be useful
in aborting an acute anginal episode.
CONTRAINDICATIONS:
Contraindicated with allergy to nitrates, severe

anemia, head trauma, cerebral hemorrhage,
hypertrophic cardiomyopathy, narrow-angle
glaucoma, postdural hypotension. Use
cautiously with pregnancy, lactation, acute MI,
CHF.
ADVERSE EFFECTS:

92
orthostatic hypotension, angina, rebound
hypertension, atrial fibrillation, postural
hypertension

cutaneous vasodilation with flushing

and feces, abdominal pain, diarrhea
GU: Dysuria, impotence, urinary frequency
Other: Muscle twitching, pallor, perspiration,

cold sweat, arthralgia, bronchitis
1. Give oral preparations on an empty

stomach, 1 hr before or 2 hr after meals;
take with meals if severe, uncontrolled
headache occurs.
2. WARNING: Keep life support

equipment readily available if overdose
occurs or cardiac condition worsens.
93
3. WARNING: Gradually reduce dose if
anginal treatment is being terminated;
rapid discontinuation can lead to
problems of withdrawal
1. do not chew or crush sustained-release

preparations; do not take isosorbide
mononitrate to relieve acute anginal
episodes.

Dizziness, lightheadedness (may be
transient; use care to change positions
slowly); headache (lie down in a cool
environment, rest; over-the-counter
preparations may not help; take drug
with meals); flushing of the neck or
face (reversible).
3. Report blurred vision, persistent or

severe headache, rash, more frequent or
more severe angina attacks, fainting
94
GENERIC NAME: metoprolol
BRAND NAME: Apo-Metoprolol (CAN),

Betaloc (CAN), Lopressor, Novo-metoprol
(CAN), Nu-Metop (CAN) ,Toprol-XL
,Lopressor Injection
DOSAGE & FREQUENCY:
ADULTS
Hypertension: Initially, 100 mg/day PO in
single or divided doses; gradually increase
dosage at weekly intervals. Usual maintenance
dose is 100–450 mg/day.
Angina pectoris: Initially, 100 mg/day PO in

two divided doses; may be increased gradually,
effective range 100–400 mg/day.
MI, early treatment: Three IV bolus doses of 5

mg each at 2-min intervals with careful
monitoring. If these are tolerated, give 50 mg
PO 15 min after the last IV dose and q 6 hr for
48 hr. Thereafter, give a maintenance dosage
of 100 mg PO bid. Reduce initial PO doses to
25 mg, or discontinue in patients who do not
tolerate the IV doses.
95
MI, late treatment: 100 mg PO bid as soon as
possible after infarct, continuing for at least 3
mo and possibly for 1–3 yr.
MECHANISM OF
ACTION:
Metoprolol is a beta-1-adrenergic receptor

inhibitor specific to cardiac cells with
negligible effect on beta-2 receptors. This
inhibition decreases cardiac output by
producing negative chronotropic and inotropic
effects without presenting activity towards
membrane stabilization nor intrinsic
sympathomimetics.
INDICATIONS:
96
Hypertension, alone or with other drugs,
especially diuretics
Immediate-release tablets and injection:

Prevention of reinfarction in MI patients who
are hemodynamically stable or within 3–10
days of the acute MI
Long-term treatment of angina pectoris
Toprol-XL only: Treatment of stable,

symptomatic CHF of ischemic, hypertensive,
or cardiomyopathic origin.
CONTRAINDICATIONS:
Hypersensitivity to Lopressor and related

derivatives, or to any of the excipients;
hypersensitivity to other beta blockers (cross
sensitivity between beta blockers can occur).
Myocardial Infarction
Lopressor is contraindicated in patients with a

heart rate < 45 beats/min; second- and third-
degree heart block; significant first-degree
heart block (P-R interval ≥ 0.24 sec); systolic
blood pressure < 100 mmHg; or moderate-to-
severe cardiac failure
97
2nd or 3rd degree AV block; sick sinus
syndrome; decompensated heart failure;
clinically relevant sinus bradycardia. Severe
peripheral arterial circulatory disorders.
Cardiogenic shock. Asthma.
Phaeochromocytoma (without α-blockade),
systolic BP <100 mmHg. Metabolic acidosis.
Pregnancy (2nd and 3rd trimesters).
ADVERSE EFFECTS:
CV: Intensification of AV block
GI: Diarrhea, Nausea, dry mouth, gastric pain,

constipation, flatulence, and heartburn,
Vomiting.
CNS: Reversible mental depression
progressing to catatonia; an acute reversible
syndrome characterized by disorientation for
time and place, short-term memory loss,
emotional lability, slightly clouded sensorium,
and decreased performance on
neuropsychometrics.
Respiratory: Dyspnea of pulmonary origin

Skin: Pruritus or rash, photosensitivity and
worsening of psoriasis
98
Hematologic: Agranulocytosis,
nonthrombocytopenic purpura, and
thrombocytopenic purpura.
1. Do not discontinue drug abruptly

after long-term therapy
(hypersensitivity to catecholamines
may have developed, causing
exacerbation of angina, MI, and
ventricular arrhythmias). Taper
drug gradually over 2 wk with
monitoring
2. Ensure that patient swallows the

ER tablets whole; do not cut, crush,
or chew. Toprol XL tablets may be
divided at the score; divided tablets
should be swallowed whole, not
crushed or chewed.
3. Consult physician about

withdrawing drug if patient is to
undergo surgery (controversial).
4. Give oral drug with food to

facilitate absorption.
99
5. Provide continual cardiac
monitoring for patients receiving
IV metoprolol.
1. Do not stop taking this drug unless

instructed to do so by a health care
provider.
2. Swallow the extended-release

tablets whole; do not cut, crush, or
chew them. If using Toprol XL,
you can divide the tablets at the
score; divided tablets must be
swallowed whole, not crushed or
chewed.

effects: Dizziness, drowsiness,
light-headedness, blurred vision
(avoid driving or dangerous
activities); nausea, loss of appetite
(eat frequent small meals);
nightmares, depression (discuss
change of medication); sexual
impotence.
100
4. Report difficulty breathing, night
cough, swelling of extremities,
slow pulse, confusion, depression,
rash, fever, sore throat.
GENERIC
NAME: : : nifedipine
BRAND NAME: Procardia, Procardia XL,

Adalat, Nifedical XL
DOSAGE & FREQUENCY:
ADULTS
PO:
Hypertension: The starting dose is 30 mg or 60
mg by mouth once per day. The dosage can be
increased every 7 to 14 days until the
maximum dosage of 90–120 mg per day is
reached
Vasospastic Angina: The starting dose is 30
mg or 60 mg by mouth once per day. The
dosage can be increased every 7 to 14 days
until the maximum dosage of 180 mg per day
101
is reached.
Chronic Stable Angina: The starting dose is 30
mg or 60 mg by mouth once per day. The
dosage can be increased every 7 to 14 days
until the maximum dosage of 90–120 mg per
day is reached
Nifedipine decreases arterial smooth muscle

contractility and subsequent vasoconstriction
by inhibiting the influx of calcium ions through
L-type calcium channels. Calcium ions
entering the cell through these channels bind to
calmodulin. Calcium-bound calmodulin then
binds to and activates myosin light chain
kinase (MLCK). Activated MLCK catalyzes
the phosphorylation of the regulatory light
chain subunit of myosin, a key step in muscle
contraction. Signal amplification is achieved
by calcium-induced calcium release from the
sarcoplasmic reticulum through ryanodine
receptors. Inhibition of the initial influx of
calcium inhibits the contractile processes of
smooth muscle cells, causing dilation of the
coronary and systemic arteries, increased
102
oxygen delivery to the myocardial tissue,
decreased total peripheral resistance,
decreased systemic blood pressure, and
decreased afterload. The vasodilatory effects
of nifedipine result in an overall decrease in
blood pressure.
INDICATIONS:
For the management of vasospastic angina,

chronic stable angina, hypertension, and
Raynaud's phenomenon. May be used as a first
line agent for left ventricular hypertrophy and
isolated systolic hypertension (long-acting
agents).
CONTRAINDICATIONS:
Calcium channel blockers are contraindicated

in patients with severe hypotension or heart
block greater than first degree (except with
functioning pacemaker).
Use calcium channel blockers cautiously in

patients with hepatic or renal impairment,
bradycardia, heart failure, or cardiogenic
103
shock. In pregnant women, use beta blockers
cautiously. Recommendations for
breastfeeding vary by drug; use beta blockers
cautiously. In children, safety and
effectiveness haven’t been established. Check
with prescriber before giving these drugs to
children. Elderly patients have an increased
risk of adverse reactions; use cautiously.
ADVERSE EFFECTS:
Body as a Whole: leg cramps, chest pain, leg

pain, allergic reaction, asthenia, cellulitis,
substernal chest pain, chills, facial edema, lab
test abnormal, malaise, neck pain, pelvic pain,
pain, photosensitivity reaction
CNS: paresthesia, vertigo, Headache,
Dizziness, anxiety, confusion, decreased
libido, depression, hypertonia, hypesthesia,
insomnia, somnolence
GI: Nausea, vomiting, anorexia, abdominal
pain, diarrhea, constipation, abdominal pain,
diarrhea, dry mouth, dysphagia, dyspepsia,
eructation, esophagitis, flatulence,
104
gastrointestinal disorder, gastrointestinal
hemorrhage, GGT increased, gum disorder,
gum hemorrhage, vomiting
Hematologic: Aplastic
anemia, leukopenia (transient),
leukocytosis, agranulocytosis, eosinophilia,
thrombocytopenia.
CV:atrial fibrillation, bradycardia, cardiac
arrest, extrasystole, hypotension, migraine,
palpitations, phlebitis, postural hypotension,
tachycardia, cutaneous angiectases
Skin: angioedema, petechial rash, pruritus,
sweating,
Urogenital: impotence, urinary frequency
1. Monitor patient carefully (BP,

cardiac rhythm, and output) while
drug is being adjusted to
therapeutic dose; the dosage may
be increased more rapidly in
supervision. Do not exceed 30
mg/dose increases.
105
2. Ensure that patients do not chew or
divide sustained-release tablets.
3. Taper dosage of beta-blockers

before nifedipine therapy
4. Protect drug from light and

moisture.
1. Do not chew, cut, or crush sustained-

release tablets. Swallow whole.

meals); dizziness, light-headedness,
vertigo (avoid driving and operating
dangerous machinery; take special
precautions to avoid falling); muscle
cramps, joint stiffness, sweating,
sexual difficulties (reversible).
3. Report irregular heartbeat, shortness of

pronounced dizziness, constipation.
106
GENERIC NAME: : nitroglycerin
BRAND NAME: Nitrostat
107
DOSAGE & FREQUENCY:
ADULTS
Acute attack: Dissolve 1 tablet under tongue or

in buccal pouch at first sign of anginal attack;
repeat every 5 min until relief is obtained. Do
not take more than 3 tablets/15 min. If pain
continues or increases, patient should call
physician or go to hospital.
Prophylaxis: Use 5–10 min before activities

that might precipitate an attack
PEDIATRIC
Safety and efficacy not established.
Nitroglycerin forms free radical nitric oxide

(NO)which activate
108
guanylate cyclase, resulting in an increase of
guansine 3'5' monophosphate (cyclic GMP) in
smooth muscle and other tissues. These events
lead to dephosphorylation of myosin light
chains, which regulate the contractile state in
smooth muscle, and result in vasodilatation.
INDICATIONS:
Nitrostat is indicated for the acute relief of an

attack or acute prophylaxis of angina pectoris
due to coronary artery disease.
CONTRAINDICATIONS:
Allergic reactions to organic nitrates are

extremely rare, but they do occur.
Nitroglycerin is contraindicated in patients
who are allergic to it. Sublingual nitroglycerin
therapy is contraindicated in patients with
early myocardial
infarction,severe anemia, increased

intracranial pressure, and those with a known
hypersensitivity to nitroglycerin.
Administration of Nitrostat is contraindicated
in patients who are using a phosphodiesterase-
109
5(PDE-5) inhibitor (e.g., sildenafil citrate)
since these compounds have been shown to
potentiate the hypotensive effects of organic
nitrates.
ADVERSE EFFECTS:


orthostatic hypotension, angina

cutaneous vasodilation with flushing, pallor,
perspiration, cold sweat, contact dermatitis—
transdermal preparations, topical allergic
reactions—topical nitroglycerin ointment

and feces, abdominal pain
1. Use cautiously in patients with

hypotension or volume depletion.
110
2. Closely monitor vital signs during
infusion, particularly blood pressure,
especially in patients with an MI.
3. Nitroglycerin may interfere with

cholesterol determination tests using the
Zlatkis-Zak color reaction, resulting in
falsely decreased values.
4. When stopping transdermal treatment of

angina, gradually reduce the dose and
frequency of application over4 to 6
weeks.
1. Nitrostat is a sublingual tablet

and should not be chewed,
crushed, or swallowed. If
possible, patients should sit
down when taking Nitrostat
tablets and should use caution
when returning to a standing
position. This eliminates the
possibility of falling due to
lightheadedness or dizziness.
111
1. One tablet should be dissolved
under the tongue or in the
buccal pouch at the first sign of
an acute anginal attack. The
dose may be repeated
approximately every 5 minutes,
until relief is obtained.
2. If chest pain persists after a

total of 3 tablets in a 15-minute
period, or the pain is different
than is typically experienced,
prompt medical attention is
recommended.
3. Nitroglycerin may produce a

burning or tingling sensation
when administered
sublingually; however, the
ability to produce a burning or
tingling sensation should not be
considered a reliable method
for determining the potency of
the tablets.
112
4. Headaches can sometimes
accompany treatment with
nitroglycerin. In patients who
get these headaches, the
headaches may be a marker of
the activity of the drug.
5. Nitroglycerin should be kept in

the original glass container and
must be tightly capped after
each use to prevent loss of
tablet potency.
GENERIC NAME: : ranolazine
BRAND NAME: Ranexa

113
DOSAGE & FREQUENCY:
ADULTS
PO:\
500 mg PO bid; may be increased to maximum

of 1,000 mg bid.
PEDIATRIC
The mechanism of action of ranolazine’s

antianginal effects has not been determined.
Ranolazine has anti-ischemic and antianginal
effects that do not depend upon reductions in
114
heart rate or blood pressure. It does not affect
the rate-pressure product, a measure of
myocardial work, at maximal exercise.
Ranolazine at therapeutic levels can inhibit the
cardiac late sodium current (INa). However,
the relationship of this inhibition to angina
symptoms is uncertain.
INDICATIONS:
Treatment of chronic angina in patients who

have not responded adequately to other
antianginal drugs; used with amlodipine, beta-
blockers, nitrates
CONTRAINDICATIONS:
Contraindicated with hypersensitivity to any

component of the drug; pre-existing QT
prolongation, concurrent use of QT-interval
prolonging drugs; hepatic impairment;
concurrent use of potent or moderately potent
CYP3A inhibitors, including diltiazem;
lactation. Use caution in severe renal
impairment, history of ventricular tachycardia,
pregnancy.
115
ADVERSE EFFECTS:
CNS: Dizziness, headache, tinnitus, vertigo
CV: Palpitations, peripheral edema, prolonged

QT interval
GI: Nausea, constipation, dry mouth,

vomiting, abdominal pain
Respiratory: Dyspnea
1. Obtain baseline ECG, LFTs, and renal

function tests before starting therapy.
2. Ensure that patient swallows tablets

whole; do not cut, crush, or let patient
chew the tablets.
3. Ensure that patient continues to use

other prescribed antianginal
medications.
4. Advise patient to avoid grapefruit juice

and grapefruit products while using
this drug.
116
5. Suggest use of contraceptive measures
while taking this drug; potential effects
on a fetus are not known.
6. Advise nursing mothers that another

method of feeding the baby will be
needed while taking this drug.
7. Provide safety measures if dizziness

and lightheadedness occur.
1. Take this drug twice a day. Swallow

the tablet whole; do not cut, crush, or
chew it.
2. If you miss a dose of the daily

medication, take it as soon as you
remember and then return to your
usual routine. Do not take more than
two doses in one day.
3. Do not take this drug for an acute

anginal attack; this drug helps chronic
117
chest pain. Continue to use your other
angina drugs as prescribed.
4. You may be asked to have periodic

ECGs and blood tests to monitor the
effects of this drug on your body.
5. Do not consume grapefruit juice or

grapefruit products while taking this
drug.
6. It is not known how this drug could

affect a nursing baby. If you are
nursing a baby, you should select
another method of feeding the baby.
7. 7.It is not known how this drug could

affect a fetus. If you are pregnant or
decide to become pregnant while on
this drug, consult your health care
provider.

effects: dizziness, lightheadedness (if
this occurs, avoid driving a car or
operating dangerous machinery);
headache, constipation (consult your
118
health care provider because
medications may be available to help).
9. Report palpitations, fainting spells,

severe constipation.
GENERIC NAME: verapamil
BRAND NAME: Calan, Verelan, Calan SR,

Isoptin
DOSAGE & FREQUENCY:
ADULTS
Angina: 80 mg orally every 8 hours initially;

usual range: 80-120 mg orally every 8 hours;
119
not to exceed 480 mg/day; 180 mg/day orally
at bedtime initially; maintenance: 180-540
mg/day orally at bedtime Hypertension: 80 mg
orally every 8 hours initially; maintenance: 80-
320 mg orally every 12 hours.
GERIATRIC:
Angina: 80 mg orally
every 8 hours initially; usual range: 80-120 mg
orally every 8 hours; not to exceed 480
mg/day; 180 mg orally at bedtime initially;
maintenance: 180-540 mg orally at bedtime
Hypertension: 40 mg orally every 8 hours
initially; maintenance: 80-320 mg orally every
12 hours
PEDIATRIC
IV: 1 yr: Initial dose, 0.1–0.2 mg/kg over 2
min; 1–15 yr: Initial dose, 0.1–0.3 mg/kg over
2 min. Do not exceed 5 mg. Repeat above dose
30 min after initial dose if response is not
adequate. Repeat dose should not exceed 10
mg. Supraventricular
Tachycardia: Children 1-15 years old: 0.1-0.3
mg/kg (not to exceed 5 mg) intravenously (IV)
120
over 2 minutes; second dose (not to exceed 10
mg) may be given after 30 minutes
Verapamil inhibits the calcium ion (and

possibly sodium ion) influx through slow
channels into conductile and contractile
myocardial cells and vascular smooth muscle
cells. The antiarrhythmic effect of Verapamil
appears to be due to its effect on the slow
channel in cells of the cardiac conductile
system. Electrical activity through the SA and
AV nodes depends, to a significant degree,
upon calcium influx through the slow channel.
By inhibiting this influx, Verapamil slows AV
121
conduction and prolongs the effective
refractory period within the AV node in a rate-
related manner. This effect results in a
reduction of the ventricular rate in patients
with atrial flutter and/or atrial fibrillation and a
rapid ventricular response. By interrupting
reentry at the AV node, Verapamil can restore
normal sinus rhythm in patients with
paroxysmal supraventricular tachycardias
(PSVT), including Wolff-Parkinson-White
(WPW) syndrome. Verapamil has no effect on
conduction across accessory bypass tracts.
Verapamil does not alter the normal atrial
action potential or intraventricular conduction
time but depresses amplitude, velocity of
depolarization, and conduction in depressed
atrial fiber
INDICATIONS:
Verapamil is used to treat high blood pressure.

Lowering high blood pressure helps prevent
strokes, heart attacks, and kidney problems.
122
Verapamil belongs to a class of drugs known
as calcium channel blockers. It works by
relaxing blood vessels so blood can flow more
easily.
Verapamil is also used to prevent chest pain

(angina). It may help to increase your ability to
exercise and decrease how often you may get
angina attacks. Verapamil is also used to
control your heart rate if you have a
fast/irregular heartbeat (such as atrial
fibrillation). It helps to lower the heart rate,
helping you to feel more comfortable and
increase your ability to exercise.
CONTRAINDICATIONS:
Verapamil hydrochloride injection is

contraindicated in:
1. Severe hypotension or
cardiogenic shock
2. Second- or third-degree AV
block (except in patients with a
123
functioning artificial
ventricular pacemaker)
3. Sick sinus syndrome (except in

patients with a functioning
artificial ventricular
pacemaker)
4. Severe congestive heart failure

(unless secondary to a
supraventricular tachycardia
amenable to Verapamil
therapy)
5.Patients receiving intravenous beta-

adrenergic blocking drugs (e.g., propranolol).
Intravenous Verapamil and intravenous beta-
adrenergic blocking drugs should not be
administered in close proximity to each other
(within a few hours), since both may have a
depressant effect on myocardial contractility
and AV conduction.
6. Patients with atrial flutter or atrial

fibrillation and an accessory bypass tract (e.g.,
WolffParkinson-White, Lown-Ganong-Levine
syndromes). These patients are at risk to
124
develop ventricular tachyarrhythmia including
ventricular fibrillation if Verapamil is
administered.
7. Ventricular tachycardia.
Administration of intravenous Verapamil to
patients with widecomplex ventricular
tachycardia (QRS≥ 0.12 sec) can result in
marked hemodynamic deterioration and
ventricular fibrillation. Proper pretherapy
diagnosis and differentiation from wide-
complex supraventricular tachycardia is
imperative in the emergency room setting.
8. Known hypersensitivity to Verapamil

hydrochloride
ADVERSE EFFECTS:
Body as a Whole: Throat and chest pain.

CNS: cerebrovascular accident, confusion,
equilibrium disorders, extrapyramidal
symptoms, insomnia, muscle cramps,
paresthesia, psychotic symptoms, shakiness,
somnolence.
Hematologic: ecchymosis or bruising.
CV: angina pectoris, atrioventricular
125
dissociation, ECG Abnormal*, chest pain,
claudication, hypertension*, myocardial
infarction, palpitations, purpura (vasculitis),
syncope.Symptomatic hypotension (1.5%);
bradycardia (1.2%); severe tachycardia (1.0%)
Special Senses: Blurred vision, tinitus
GI: diarrhea, dry mouth, elevated liver
enzymes, gastrointestinal distress, gingival
hyperplasia,abdominal discomfort.
Skin: arthralgia and rash, exanthema, hair loss,
hyperkeratosis, macules, sweating, urticaria,
Stevens-Johnson syndrome, erythema
multiforme.
Urogenital: gynecomastia,
galactorrhea/hyperprolactinemia, impotence,
increased urination, spotty menstruation.
Respiratory: dyspnea.
Other: allergy aggravated, asthenia.

rhythm, and output) while drug is being
titrated to therapeutic dose. Dosage
may be increased more rapidly in
126
supervision
2. Ensure that patient swallows SR tablets

whole; patient should not cut, crush, or
chew them.

periodically during long-term therapy.
4. Administer SR form in the morning

with food to decrease GI upset.
5. Protect IV solution from light..
6. Monitor patients with renal or hepatic

impairment carefully for possible drug
accumulation and adverse
reactions.Dosage adjustment may be
necessary.
127
Anticho
linergic
128
IV. ANTICHOLIGERNIC
GENERIC
BRAND
Atropine
AtroPen
Adults and children weighing over 90 lbs.

(generally over 10 years of age): AtroPen®
(atropine) 2 mg (green)
129
Children weighing 40 lbs. to 90 lbs. (generally
4 to 10 years of age): AtroPen® (atropine) 1
mg (dark red)
Children weighing 15 lbs. to 40 lbs. (generally

6 months to 4 years of age): AtroPen®
(atropine) 0.5 mg (blue)
Atropine inhibits the muscarinic actions of

acetylcholine on structures innervated by
postganglionic cholinergic nerves, and on
smooth muscles, which respond to endogenous
acetylcholine but are not so innervated.
Indication
It is used to treat some poisonings. In surgery,

it is used to lower secretions such as saliva. It
is used to treat muscle spasms of the GI
130
(gastrointestinal) tract, gallbladder system, or
urinary system. It is used when the heart is not
beating.
Contraindication
In the face of life-threatening poisoning by

organ phosphorous nerve agents and
insecticides, there are no absolute
contraindications for the use of atropine
Adverse Reaction
CNS: headache, restlessness, ataxia,

disorientation, hallucinations,
delirium, insomnia, dizziness, excitement,
agitation, confusion, especially in geriatric
patients (with systemic or oral form);
confusion, somnolence, headache (with
ophthalmic form).
CV: palpitations and bradycardia following
low-dose atropine, tachycardia after higher
doses (with systemic or oral form), tachycardia
(with ophthalmic form).
EENT: photophobia, increased intraocular
pressure, blurred vision,
mydriasis, cycloplegia (with systemic or oral
131
form), ocular congestion with long-term use,
conjunctivitis, contact dermatitis of eye, ocular
edema, eye dryness, transient stinging and
burning, eye irritation, hyperemia (with
ophthalmic form).
GI: dry mouth, thirst, constipation, nausea,
vomiting (with systemic or oral form); dry
mouth, abdominal distention in infants (with
ophthalmic form).
GU: urine retention, impotence (with systemic
or oral form).
Hematologic: leukocytosis (with systemic or
oral form).
Skin: dryness (with ophthalmic form).
Other: severe allergic reactions,
including anaphylaxis and urticaria (systemic
or oral form).
 Observe IV site for signs of

extravasation.
 Assess for signs of adverse effects.
 Continuous cardiorespiratory
monitoring.
132
 Document vital signs hourly and PRN.
 Monitor fluid balance.
 Ensure good oral care.
 Monitor temperature closely for

hyperthermia.
 Observe for gastric distension.
 Tell patient to report serious adverse

reactions promptly.
 Teach patient how to instill eye

medication.
 Warn patient to avoid hazardous activities

until blurry vision subsides.
 Advise patient to ease photophobia by

wearing dark glasses.
133
IV. ANTICHOLIGERNIC
GENERIC
BRAND
Benztropine mesylate
Cogentin

134
Since there is no significant difference in onset
of effect after intravenous or intramuscular
injection, usually there is no need to use the
intravenous route. The drug is quickly
effective after either route, with improvement
sometimes noticeable a few minutes after
injection. In emergency situations, when the
condition of the patient is alarming, 1 to 2 mL
of the injection normally will provide quick
relief. If the Parkinsonian effect begins to
return, the dose can be repeated.
Benztropine has anticholinergic effects.

Anticholinergic drugs block the action of
acetylcholine, a neurotransmitter (chemical)
that nerves use to communicate with other
nerves. In Parkinson's there is an imbalance
135
between levels of dopamine and acetylcholine
neurotransmitters.
Indication
For use as an adjunct in the therapy of all forms

of Parkinsonism. Useful also in the control of
extrapyramidal disorders (except tardive
dyskinesia due to neuroleptic drugs (e.g.,
phenothiazine).
Contraindication
Hypersensitivity to any component of

Cogentin injection. Because of its atropine-like
side effects, this drug is contraindicated in
pediatric patients under three years of age, and
should be used with caution in older pediatric
patients.
Adverse Reaction:
CNS: disorientation, hallucinations,

depression, toxic psychosis, confusion,
memory impairment, nervousness.
CV: tachycardia.
EENT: dilated pupils, blurred vision.
GI: dry mouth, constipation, nausea,
136
vomiting, paralytic ileus.
GU: urine retention, dysuria.
 Assess therapeutic effectiveness.

Clinical improvement may not be
evident for 2–3 d after oral drug is
started.
 Monitor input and output ratio and

pattern.
 Advise patient to report difficulty in

urination or infrequent voiding.
Dosage reduction may be indicated.
 Closely monitor for appearance of S&S

of onset of paralytic ileus including
intermittent constipation, abdominal
pain, diminution of bowel sounds on
auscultation, and distention.
 Monitor for and report muscle

weakness or inability to move certain
muscle groups. Dosage reduction may
be needed.
137
 Supervise ambulation and use bed side
rails as necessary.
 Report immediately S&S of CNS

depression or stimulation. These
usually require interruption of drug
therapy.
 Explain to patient that the full effect of

drug may not occur for 2 to 3 days.
 Caution patient not to stop drug

suddenly; dosage should be reduced
gradually.
 Tell patient that drug may increase

sensitivity of eyes to light
138
IV. . ANTICHOLIGERNIC
139
GENERIC
BRAND
Cyclopentolate hydrochloride
Cyclogyl
Adult: 1-2 gtt. of 1% solution in eye; may

repeat in 5 minutes PRN; cycloplegia &
mydriasis may last for 24 hours. Use 2% in
heavily pigmented iris
Pediatric: 1-2 gtt. of 0.5%, 1% or 2% solution

in eye; may repeat 5 minutes later by second
application of 0.5% or 1% solution if
necessary.
140
Cyclopentolate is an anticholinergic drug that

blocks the responses of the sphincter muscle of
the iris and the accommodative muscle of the
ciliary body to stimulation by acetylcholine.
Dilation of the pupil (mydriasis) and paralysis
of accommodation (cycloplegia) result.
Indication
141
Cyclopentolate hydrochloride ophthalmic
solution is used to produce mydriasis and
cycloplegia.
Contraindication
Cyclopentolate is contraindicated for use in

patients with untreated narrow angle glaucoma
(closed-angle glaucoma). Use cautiously in
those with Down's syndrome and in those
predisposed to increases in intraocular
pressure. Cyclopentolate contains
benzalkonium chloride, which may be
absorbed by contact lenses.
Adverse Reaction
CNS: irritability, confusion, somnolence,

hallucinations, ataxia, seizures, behavioral
disturbances in children.
CV: tachycardia.
EENT: eye burning on instillation, blurred
vision, eye dryness, photophobia, ocular
congestion, contact dermatitis in eye,
conjunctivitis, increased intraocular pressure,
transient stinging and burning, irritation,
hyperemia.
142
GU: urine retention.
Skin: dryness.
 Monitor cardiac status especially with

preexisting heart disease.
 Do not touch the dropper to any

surface, including your skin or eyes.
 Exercise caution when driving or

engaging in other potentially hazardous
activities as cyclopentolate ophthalmic
may cause blurred vision. If you
experience blurred vision, avoid these
activities.
 Protect your eyes when in bright light.

Cyclopentolate ophthalmic may cause
increased light sensitivity.
 Do not wear soft contact lenses when

the eye drops are being inserted.
 Report immediately any of the

following: difficulty breathing,
143
swelling of your lips, tongue, face or
hives; palpitations; and unusual
behavior.
 Do not breast feed while using this

drug.
IV. ANTICHOLIGERNIC
GENERIC
BRAND
Darifenacin hydrobromide
Enablex
Overactive Bladder
Adult: PO 7.5–15 mg qd
Moderate Hepatic Impairment
Max dose: PO 7.5 mg qd
144
Darifenacin works by blocking the M3

muscarinic acetylcholine receptor, which is
primarily responsible for bladder muscle
contractions. It thereby decreases the urgency
to urinate.
Indication
Treatment of overactive bladder with

symptoms of urge urinary incontinence,
urgency, and frequency.
Contraindication
Hypersensitivity to the drug; severe hepatic

impairment; urinary retention; gastric
145
retention; uncontrolled narrow-angle
glaucoma.
Adverse Reaction
Body as a Whole: Flu-like symptoms, urinary

tract infection.
CNS: Headache, asthenia, dizziness.
GI: Constipation, dry mouth, dyspepsia,

nausea, abdominal pain, diarrhea.
 Monitor for adverse effects of

concurrently used drugs that have a
narrow therapeutic window and are
metabolized by CYP26D (e.g.,
flecainide, thioridazine, or tricyclic
antidepressants).
 Monitor blood levels of digoxin with

concurrent therapy and assess for S&S
of digoxin toxicity.
Patient Teaching
 Follow directions for taking the drug.
146
 Do not drive or engage in potentially
hazardous activities until response to
drug is known.
 Use caution in hot environments to

minimize the risk of heat prostration.
 Report any of the following to a health

care provider: difficulty passing urine,
unexplained nausea, or persistent
constipation.
 Do not breast feed while taking this

drug without consulting physician.
IV. ANTACIDS
GENERIC
BRAND
Tolterodine tartrate
Toviaz
147
Overactive Bladder
Adult: PO 2 mg b.i.d. or 4 mg sustained

release q.d.
Hepatic Impairment
May decrease to 1 mg b.i.d. or 2 mg sustained

release q.d. in those with significantly reduced
liver function.
Tolterodine acts as a competitive antagonist of

acetylcholine at postganglionic muscarinic
receptors. Both urinary bladder contraction
and salivation are mediated via cholinergic
muscarinic receptors.
148
Indication
Overactive bladder (urinary frequency,

urgency, urge incontinence).
Contraindication
Gastric retention; hypersensitivity to

tolterodine; uncontrolled narrow-angle
glaucoma; urinary retention;
Adverse Reaction
Body as a Whole: Back pain, fatigue, flu-like

syndrome, falls, arthralgia, weight gain.
CNS: Headache, paresthesia, vertigo,

dizziness, nervousness, somnolence.
CV: Chest pain, hypertension.
GI: Dry mouth, dyspepsia, constipation,

abdominal pain, diarrhea, flatulence, nausea,
vomiting.
Urogenital: Dysuria, micturition frequency,

urinary retention, urinary tract infection.
149
Respiratory: Bronchitis, cough, pharyngitis,
rhinitis, sinusitis, upper respiratory tract
infection.
Skin: Pruritus, rash, erythema, dry skin.
Special Senses: Dry eyes, vision

abnormalities.
IV. Monitor intraocular pressure more

frequently with glaucoma patients.
V. Monitor vital signs carefully (HR and

BP), especially in those with
cardiovascular disease.
Patient Teaching
 Notify physician promptly if you

experience eye pain, rapid heartbeat,
difficulty breathing, skin rash or hives,
confusion, or incoordination.
 Report blurred vision, sensitivity to

light, and dry mouth (all common
adverse effects) to physician if
bothersome.
150
 Avoid the use of alcohol or OTC
antihistamines.


IV. ANTACIDS
GENERIC
BRAND
Hyoscyamine sulfate
Levsinex
Adult: IV/IM/SC 0.25–0.5 mg q6h or PO/SL

0.125–0.25 mg t.i.d. or q.i.d. prn
Child: PO 2–12 y, 0.0625–0.125 mg q4h prn

(max: 0.75 mg/d)
151
Blocks the action of acetylcholine at

parasympathetic sites in sweat glands, salivary
glands, stomach secretions, heart muscle,
sinoatrial node, smooth muscle in the
gastrointestinal tract, and the central nervous
system.
Indication
GI tract disorders caused by spasm and

hypermotility, as conjunct therapy with diet
and antacids for peptic ulcer management, and
as an aid in the control of gastric
hypersecretion and intestinal hypermotility.
Also symptomatic relief of biliary and renal
colic, as a "drying agent" to relieve symptoms
152
of acute rhinitis, to control preanesthesia
salivation and respiratory tract secretions, to
treat symptoms of Parkinsonism, and to reduce
pain and hypersecretion in pancreatitis.
Contraindication
Hypersensitivity to belladonna alkaloids,

narrow-angle glaucoma, prostatic
hypertrophy, obstructive diseases of GI or GU
tract, paralytic ileus or intestinal atony,
myasthenia gravis; children below 2 years old
Adverse Reaction
CNS: Headache, unusual tiredness or

weakness, confusion, drowsiness, excitement
in older adult patients.
CV: Palpitations, tachycardia.
Special Senses: Blurred vision, increased

intraocular tension, cycloplegia, and
mydriasis.
GI: Dry mouth, constipation, paralytic ileus.
Other: Urinary retention, anhidrosis,

suppression of lactation.
153
 Monitor bowel elimination; may cause

constipation.
 Monitor urinary output.
 Lessen risk of urinary retention by

having patient void prior to each dose.
 Assess for dry mouth and recommend

good practices of oral hygiene.
 Avoid excessive exposure to high

temperatures; drug-induced heatstroke
can develop.
 Do not drive or engage in other

potentially hazardous activities until
response to drug is known.
 Use dark glasses if experiencing

blurred vision, but if this adverse effect
persists, notify physician for dose
adjustment or possible drug change.
154
IV. ANTACIDS
GENERIC
BRAND
Ipratropium bromide
Atrovent
ADULT
Chronic Obstructive Pulmonary Disease
Inhaler: 2 actuations (34 mcg) q6hr, then

additional actuations PRN; not to exceed 12
actuations/day (408 mcg/day)
Nebulizer: 2.5
mL (500 mcg)
q6-8hr
Acute Asthma
Exacerbation
155
Inhaler: 8 actuations (136 mcg) q20min PRN
for 3 hrs.
Nebulizer: 500 mcg q20min for 3 doses, then

PRN
PEDIATRIC
Acute Asthma Exacerbation
 <5 years (inhaler): 2 inhalations

q20min for 1 hrs. if necessary
 5-12 years (inhaler): 4-8 actuations

q20 min PRN for up to 3 hrs.
 ≥12 years (inhaler): 8 actuations q20

min PRN for up to 3 hrs.
 <5 years (nebulizer): 0.25 mg (250

mcg) q20min for 1 hrs. if necessary
 5-12 years (nebulizer): 250-500 mcg

q20 min for 3 doses, then PRN
 ≥12 years (nebulizer): 500 mcg q20

min for 3 doses, then PRN
Ipratropium bromide is an anticholinergic

(parasympatholytic) agent which, based on
156
animal studies, appears to inhibit vagally-
mediated reflexes by antagonizing the action
of acetylcholine, the transmitter agent released
at the neuromuscular junctions in the lung.
Indication
Maintenance therapy in chronic obstructive

pulmonary disease including chronic
bronchitis and emphysema; nasal spray for
perennial rhinitis and symptomatic relief of
rhinorrhea associated with the common cold.
Contraindication
Use as primary treatment for acute episodes;

hypersensitivity to atropine or derivatives.
Safe use in children is not established.
Adverse Reaction
CNS: encephalopathy, neurotoxicity malaise

(prolonged use)
GI: anorexia, constipation, intestinal
obstruction.
Metabolic: hypophosphatemia (prolonged
use)
Musculoskeletal: osteomalaciaosteomalacia
157
and chronic phosphate deficiency with bone
pain, malaise, muscle weakness
Other: aluminum toxicity
 Monitor respiratory status; auscultate

lungs before and after inhalation.
 Report treatment failure (exacerbation

of respiratory symptoms) to physician.
 Allow 30–60 sec between puffs for

optimum results. Do not let medication
contact your eyes.
 Wait 5 min between this and other

inhaled medications. Check with
physician about sequence of
administration.
 Take medication only as directed,

noting some leniency in number of
puffs within 24 h. Supervise child's
administration until certain all of dose
is being administered.
158
 Rinse mouth after medication puffs to
reduce bitter taste.
 Discuss changes in normal urinary

pattern with the physician (more
common in older adults).
 Call physician if you note changes in

sputum color or amount, ankle edema,
or significant weight gain.

159
IV. ANTACIDS
GENERIC
BRAND
Oxybutynin chloride
Ditropan XL
Adult: PO 5 mg b.i.d. or t.i.d. (max: 20 mg/d)

or 5 mg sustained-release q.d., may increase up
to 30 mg/d Topical Apply 1 patch twice
weekly
160
Geriatric: PO 2.5–5 mg b.i.d. (max: 15 mg/d)
or 5 mg sustained-release
q.d., may increase up to
30 mg/d Topical Apply 1
patch twice weekly
Child: PO 1–5 y, 0.2

mg/kg b.i.d.–q.i.d.; >5 y,
5 mg b.i.d. (max: 15 mg/d)
Oxybutynin suppresses involuntary

contractions of the bladder's smooth muscle
(spasms) by blocking the release of
acetylcholine. This is referred to as an
"anticholinergic effect." Oxybutynin also
directly relaxes the bladder's outer layer of
muscle (the detrusor muscle).
Indication
To relieve symptoms associated with voiding

in patients with uninhibited neurogenic bladder
and reflex neurogenic bladder. Also has been
used to relieve pain of bladder spasm following
transurethral surgical procedures.
161
Contraindication
Hypersensitivity of oxybutynin; narrow angle

glaucoma, myasthenia gravis, partial or
complete GI obstruction, gastric retention,
paralytic ileus, intestinal atony (especially
older adult or debilitated patients), megacolon,
severe colitis, GU obstruction, urinary
retention, unstable cardiovascular status.
Adverse Reaction
Body as a Whole: Severe allergic reactions

including urticaria, skin rashes, suppression of
lactation, decreased sweating, fever.
CNS: Drowsiness, dizziness, weakness,

insomnia, restlessness, psychotic behavior
(over dosage).
CV: Palpitations, tachycardia, flushing.
GI: Dry mouth, nausea, vomiting,

constipation, bloated feeling.
Urogenital: Urinary hesitancy or retention,

impotence.
162
Special Senses: Mydriasis, blurred vision,
cycloplegia, increased ocular tension.
Skin: Pruritus at application site, rash,

application site vesicles, erythema.
 Periodic interruptions of therapy are

recommended to determine patient's
need for continued treatment.
Tolerance has occurred in some
patients.
 Keep physician informed of expected

responses to drug therapy (e.g., effect
on urinary frequency, urgency, urge
incontinence, nocturia, and
completeness of bladder emptying).
 Monitor patients with colostomy or

ileostomy closely; abdominal
distension and the onset of diarrhea in
these patients may be early signs of
intestinal obstruction or of toxic
megacolon.

163
 Do not drive or engage in potentially
hazardous activities until response to
drug is known.
 Exercise caution in hot environments.

By suppressing sweating, oxybutynin
can cause fever and heat stroke.

IV. ANTACIDS
GENERIC
BRAND
Tiotropium bromide
Spiriva
Adult Dose for Chronic Obstructive

Pulmonary Disease – Maintenance
Tiotropium inhalation powder, hard

capsule: 18 mcg (2 inhalations) orally once a
day
164
Tiotropium, solution for inhalation: 5 mcg
(2 inhalations) orally once a day
Dose for Asthma – Maintenance
Adult: 2.5 mcg (2 inhalations of 1.25 mcg)

orally once a day
Pediatric: (6 years or older) 2.5 mcg (2

inhalations of 1.25 mcg) orally once a day
A long-acting, antispasmodic agent. In the

bronchial airways, it exhibits inhibition of
muscarinic receptors of the smooth muscle
resulting in bronchodilation. The drug effect
can last up to 24 hours.
Indication
Maintenance treatment of bronchospasm

associated with chronic obstructive pulmonary
disease (COPD).
Contraindication
165
Hypersensitivity to tiotropium, atropine, or
ipratropium; pregnancy; children <18 y
Adverse Reaction
Body as a Whole: Nonspecific chest pain,

dependent edema, infection, moniliasis, flu-
like syndrome, cough, allergic reactions.
CNS: Dysphonia, paresthesia, depression.
GI: Abdominal pain, constipation, dry mouth,

dyspepsia, vomiting, reflux, and stomatitis
Metabolic: Hypercholesterolemia,
hyperglycemia
Musculoskeletal: Myalgia, skeletal pain.
Respiratory: Epistaxis, pharyngitis, rhinitis,

laryngitis, sinusitis, upper respiratory tract
infection
Skin: Rashes
Special Senses: Cataract
Urogenital: Urinary tract infection
166
 Withhold drug and notify physician if

S&S of angioedema occurs.
 Monitor for anticholinergic effects

(e.g., tachycardia, urinary retention).
Patient Teaching
 Do not allow powdered medication to

contact the eyes, as this may cause
blurring of vision and pupil dilation.
 Tiotropium bromide is intended as a

once-daily maintenance treatment. It is
not useful for treatment of acute
episodes of bronchospasm (i.e., rescue
therapy).
 Withhold drug and notify physician if

swelling around the face, mouth, or
neck occurs.
167
 Report any of the following:
constipation, increased heart rate,
blurred vision, urinary difficulty.

168
IV. ANTACIDS
GENERIC
BRAND
Solifenacin succinate
VESIcare
Overactive Bladder
Adult: PO 5 mg once daily; may be increased

to 10 mg once daily if tolerated (max of 5 mg/d
if taking drugs that inhibit CYP3A4)
Adjustment for Hepatic Impairment

If moderate hepatic impairment, do not exceed
169
5 mg/d. If severe hepatic impairment, do not
use.
Clcr (Creatinine clearance) <30 mL/min: max

dose 5 mg/d
Solifenacin is a selective muscarinic antagonist

that depresses both voluntary and involuntary
bladder contractions caused by detrusor
overactivity.
Indication
Treatment of overactive bladder (OAB) with

symptoms of urinary incontinence, urgency,
and frequency.
Contraindication
Hypersensitivity to solifenacin or any

component of its formulations; severe hepatic
impairment; pregnancy (category C); gastric
retention; uncontrolled narrow-angle
glaucoma; urinary retention; toxic megacolon;
GI obstruction; ileus; GERD.
Adverse Reaction
170
Body as a Whole: Edema, fatigue.
CNS: Dizziness, depression.
CV: Hypertension.
GI: Dry mouth, constipation, nausea,

vomiting, dyspepsia, upper abdominal pain
Respiratory: Cough.
Special Senses: Blurred vision, dry eyes
Urogenital: Urinary tract infection, urinary

retention
 Monitor ECG in patients with a known

history of QT prolongation or patients
taking medications that prolong the QT
interval.
Patient Teaching
 Stop taking this drug and report to

physician if urinary retention occurs.
 Report promptly any of the following:

blurred vision or difficulty focusing
171
vision, palpitations, confusion, or
severe dizziness.
 Report to physician problems with

bowel elimination, especially
constipation lasting 3 or more days.
 Exercise caution in hot environments,

as the risk of heat prostration increases
with this drug.

172

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DRUGS BY CLASSIFICATION

GENERIC NAME BRAND

ketamine hydrochloride Ketalar

Dosage and Frequency

IM: 3 mg/kg. If response is inadequate this

IV: The initial dose of Ketalar administered

IV anesthetic agents: Most agents produce

receptor complex. GABA is the primary

Ketalar is indicated as the sole anesthetic agent

Ketalar is indicated for the induction

Ketalar is indicated to supplement low-potency

Ketamine hydrochloride is contraindicated in

Emergence rxns, HTN, Increased cardiac

 closely monitor blood pressure and heart

PATIENT & FAMILY EDUCATION

• Warn patient to avoid tasks requiring

GENERIC NAME BRAND

Dosage and Frequency

IV: ,55 yr and ASA I/II IV (Diprivan or

PATIENT & FAMILY EDUCATION

 Teach patient that this medication will

GENERIC NAME BRAND

Dosage and Frequency

IV: 0.02–0.04 mg/kg.

 Inform patient that he may not

GENERIC NAME BRAND

Dosage and Frequency

IV: 0.2 and 0.6 mg/kg of body weight, and it

IV: 0.2 and 0.6 mg/kg of body weight, and it

Etomidate is an imidazole compound that

Intravenous injection for the induction of

Sepsis, Intraarterial administration, Geriatric,

Myoclonus, pain on injection, nausea,

 Implement breathing activities and

PATIENT & FAMILY EDUCATION

Instruct patient to report other troublesome

Dosage and Frequency

IV: 50 to 300 mg (10 to 60 mL of 0.5%

Anesthetic: Inhibits conduction of nerve

Infiltration, Nerve Block

Bradycardia, hypotension, arrhythmias,

 Be alert for new seizures or increased

 Assess heart rate, ECG, and heart

PATIENT & FAMILY EDUCATION

GENERIC NAME BRAND NAME

Dosage and Frequency

SL 100 mcg, another dose may be taken 30 min

Anesthetic: Inhibits ascending pain pathways

Breakthrough pain, in opioid-tolerant patients

Hypersensitivity to opiates, myasthenia gravis,

Dizziness, delirium, euphoria, sedation,

• Inform patient that compliance is needed.

• Instruct patient not to consume chipped or

• Caution patient to notify prescriber if

• Instruct patient to report GU symptoms:

• Advise patient to notify prescriber of muscle

GENERIC NAME BRAND NAME

Dosage and Frequency

IV bolus, as needed give supplemental doses

Prodrug of propofol; produces dose-dependent

Peripheral nerve block, caudal

Precautions: Pregnancy B, breastfeeding,

Involuntary movement, headache, jerking,