General Anesthetic Generic Name Brand Name

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

neurotransmitter
in the CNS. Ketamine produces dissociation
1
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 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
3
• Warn patient to avoid tasks requiring motor coordination
and mental alertness for 24 hours after anesthesia.
GENERALANESTHETIC
poprofol Diprivan
4
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.
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,
5
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.
• 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
6
 Teach patient that this medication will cause dizziness,
drowsiness, sedation; to avoid hazardous activities until
drug effect wears off
GENERALANESTHETIC
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
7
PO: CHILDREN: 0.25–0.5 mg/kg. Maximum:
20 mg.
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.
8
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 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
9
GENERAL ANESTHETIC
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.
INDICATION
Intravenous injection for the induction of general anesthesia.
10
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.
 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.
11
Instruct patient to report other troublesome postoperative effects
such as severe or prolonged injection site pain or GI problems
(nausea, vomiting)
LOCAL
ANESTHETIC
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

12
impulses. Therapeutic Effect: Causes
temporary loss of feeling/sensation.
INDICATION
Infiltration, Nerve Block
CONTRAINDICATION
13
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 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
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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 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.
15
 Assess dizziness and drowsiness that might affect gait,
balance, and other functional activities
• 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
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ANESTHETIC
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.
INDICATION
17
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
• 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
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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 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.
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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
20
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
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,
21
vomiting, abdominal cramping, dry mouth, swallowing,
hypersalivation, pancreatitis, urine retention, green urine, 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
22
• Teach patient that this medication will cause dizziness,
drowsiness, sedation
ANESTHETIC
23
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 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
24
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, 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
25
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
26
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, rash, urticaria, bruising, flushing,
diaphoresis, pruritus, respiratory depression, anaphylaxis
27
• 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
• 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
28
ANESTHETIC
oxymorphone Opana
ADULT
IV: ADULTS 18 YRS AND OLDER, ELDERLY: Initially, 0.5

mg. Dose may be cautiously increased until satisfactory response is
achieved.
29
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
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.
30
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.
31
Antacids
DRUGS BY
CLASSIFICATION
32
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)
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
33
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
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

34
 Tell patient to take after meals and at bedtime as needed.
 Caution patient not to take dose higher than indicated on
package unless prescriber approves.
I. ANTACIDS
GENERIC BRAND
aluminum hydroxide Alu-Cap
35
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.)
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).
36
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 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
37
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.
 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
38
 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, 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.
 Advise patient that he’ll need to undergo periodic blood
testing and bone mineral density tests if he’s receiving
long-term therapy.
39
 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
Sodium bicarbonate
Citrocarbonate
Recommended dose for Adults and children metabolic

acidosis:
40
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 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
41
Restores body’s buffering capacity; neutralizes excess acid
Indication
Metabolic acidosis
Contraindication
 Hypocalcemia
 Metabolic or respiratory alkalosis
 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
42
CV: irregular pulse, edema, cardiac arrest
GI: gastric distention, belching, flatulence, acid reflux, paralytic

ileus
GU: renal calculi
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.
 Watch for inflammation at I.V. site.
43
 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.
44
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.
45
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
 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.
46
 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.
 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
47
Magnesium oxide
Recommended adult dose for acid indigestion
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
48
Contraindication
 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.
49
50
Antiangina
ls
51
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
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;
52
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:
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
53
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. 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:
54
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.
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 cause collapse in
cases of severe stenosis. In unstable angina (excluding variant
55
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:
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,
56
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.
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.
57
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
58
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
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
59
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. 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
60
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 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.
61
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:
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
62
GI: nausea, vomiting, diarrhea.
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).
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
63
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.
GENERIC NAME: : diltiazem hydrocholride
64
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
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.
65
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.
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 block, congestive heart failure, ECG
66
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, osteoarticular
pain, pain, polyuria, rhinitis, sexual difficulties, gynecomastia.

while drug is being titrated to therapeutic dose; dosage may
be increased more rapidly in hospitalized patients under
close supervision.
67
2. Monitor BP carefully if patient is on concurrent doses of
nitrates.

4. Ensure patient swallows ER preparations whole; do not

cut, crush, or chew.
2. Swallow extended-release and long-acting preparations

whole; do not cut, crush, or chew; do not drink grapefruit
juice while using this drug.

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

the hands or feet, pronounced dizziness, constipation
68
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.
69
Acute prophylaxis: Initial dosage, 5–10 mg sublingual or chewable
tablets q 2–3 hr.
PEDIATRIC
70
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 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 isosorbide dinitrate is not
71
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
CV: Tachycardia, retrosternal discomfort, palpitations,

hypotension, syncope, collapse, orthostatic hypotension, angina,
rebound hypertension, atrial fibrillation, postural hypertension
72
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 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.
73
2. You may experience these side 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 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
74
when waking and second dose 7 hr later. This creates a nitrate-free
period and minimizes tolerance to drug.
PEDIATRIC
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)
75
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 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:

76
hypotension, syncope, collapse, orthostatic hypotension, angina,
rebound hypertension, atrial fibrillation, postural hypertension

with flushing

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.
3. WARNING: Gradually reduce dose if anginal treatment is

being terminated; rapid discontinuation can lead to
problems of withdrawal
77
1. do not chew or crush sustained-release preparations; do not

take isosorbide mononitrate to relieve acute anginal
episodes.

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
GENERIC NAME: metoprolol
BRAND NAME: Apo-Metoprolol (CAN), Betaloc (CAN),

Lopressor, Novo-metoprol (CAN), Nu-Metop (CAN) ,Toprol-
XL ,Lopressor Injection
DOSAGE & FREQUENCY:
78
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.
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.
79
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:
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-
80
degree heart block (P-R interval ≥ 0.24 sec); systolic blood
pressure < 100 mmHg; or moderate-to-severe cardiac failure
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
Hematologic: Agranulocytosis, nonthrombocytopenic purpura,
and thrombocytopenic purpura.
81
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.
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.
82
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.
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
83
the maximum dosage of 180 mg per day 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 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:
84
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 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
85
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, 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
hospitalized patients under close supervision. Do not
exceed 30 mg/dose increases.
2. Ensure that patients do not chew or divide sustained-

release tablets.
86
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.

(eat frequent small 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 breath, swelling of

the hands or feet, pronounced dizziness, constipation.
87
GENERIC NAME: : nitroglycerin
BRAND NAME: Nitrostat
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.
88
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
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.
89
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-5(PDE-5) inhibitor (e.g., sildenafil
citrate) since these compounds have been shown to potentiate the
hypotensive effects of organic nitrates.
ADVERSE EFFECTS:


hypotension, syncope, collapse, orthostatic hypotension, angina

with flushing, pallor, perspiration, cold sweat, contact dermatitis—
transdermal preparations, topical allergic reactions—topical
nitroglycerin ointment
90
pain
1. Use cautiously in patients with hypotension or volume

depletion.
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.
91
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.
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.
92
GENERIC NAME: : ranolazine
BRAND NAME: Ranexa
DOSAGE & FREQUENCY:
ADULTS
PO:\
500 mg PO bid; may be increased to maximum of 1,000 mg bid.
PEDIATRIC
93
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 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;
94
lactation. Use caution in severe renal impairment, history of
ventricular tachycardia, pregnancy.
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.
5. Suggest use of contraceptive measures while taking this

drug; potential effects on a fetus are not known.
95
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 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.
96
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.
8. You may experience these side effects: dizziness,

lightheadedness (if this occurs, avoid driving a car or
operating dangerous machinery); headache, constipation
(consult your health care provider because medications
may be available to help).
9. Report palpitations, fainting spells, severe constipation.
97
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; 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
98
mg/kg (not to exceed 5 mg) intravenously (IV) 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 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
99
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. 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.
100
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 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 develop
101
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 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.
102
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.

while drug is being titrated to therapeutic dose. Dosage
may be increased more rapidly in hospitalized patients
under close supervision
2. Ensure that patient swallows SR tablets whole; patient

should not cut, crush, or chew them.

4. Administer SR form in the morning with food to decrease

GI upset.
5. Protect IV solution from light..
103
6. Monitor patients with renal or hepatic impairment carefully
for possible drug accumulation and adverse
reactions.Dosage adjustment may be necessary.
104
Anticholine
rgic
105
IV. ANTICHOLIGERNIC
GENERIC BRAND
Atropine AtroPen
Adults and children weighing over 90 lbs. (generally over 10 years

of age): AtroPen® (atropine) 2 mg (green)
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
106
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
(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 form), ocular
congestion with long-term use, conjunctivitis, contact dermatitis of
107
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.
 Document vital signs hourly and PRN.
 Monitor fluid balance.
 Ensure good oral care.
 Monitor temperature closely for hyperthermia.
 Observe for gastric distension.
108
 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.
109
IV. A
NTICHOLIGERNIC
GENERIC BRAND
Benztropine mesylate Cogentin
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.
110
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 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.
111
GI: dry mouth, constipation, nausea, 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.
 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.
112
 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
113
IV. . ANTICHOLIGERNIC
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.
114
Mechanisms of
action
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
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
115
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.
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
116
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, 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
117
Max dose: PO 7.5 mg qd
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 retention; uncontrolled narrow-angle glaucoma.
Adverse Reaction
118
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.
 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.
119
 Do not breast feed while taking this drug without
consulting physician.
IV. ANTACIDS
GENERIC BRAND
Tolterodine tartrate Toviaz
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.
120
Tolterodine acts as a competitive antagonist of acetylcholine at

postganglionic muscarinic receptors. Both urinary bladder
contraction and salivation are mediated via cholinergic muscarinic
receptors.
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.
121
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.
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
122
 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.
 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)
123
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 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
124
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.
 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.
125
 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.
IV. ANTACIDS
GENERIC BRAND
Ipratropium bromide Atrovent
ADULT
Chronic Obstructive Pulmonary Disease
126
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
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
127
 ≥12 years (nebulizer): 500 mcg q20 min for 3 doses, then
PRN
Ipratropium bromide is an anticholinergic (parasympatholytic)

agent which, based on 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)
128
Musculoskeletal: osteomalaciaosteomalacia 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.
 Rinse mouth after medication puffs to reduce bitter taste.
 Discuss changes in normal urinary pattern with the

physician (more common in older adults).
129
 Call physician if you note changes in sputum color or
amount, ankle edema, or significant weight gain.

130
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
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
131
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.
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.
Special Senses: Mydriasis, blurred vision, cycloplegia, increased

ocular tension.
132
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.
 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.

133
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
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
134
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
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
135
Skin: Rashes
Special Senses: Cataract
Urogenital: Urinary tract infection
 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.
136
 Report any of the following: constipation, increased heart
rate, blurred vision, urinary difficulty.

137
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 5 mg/d. If severe
hepatic impairment, do not use.
Clcr (Creatinine clearance) <30 mL/min: max dose 5 mg/d
138
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
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
139
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 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.

140
141

General Anesthetic Generic Name Brand Name

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DRUGS BY CLASSIFICATION

GENERIC NAME BRAND NAME

ketamine hydrochloride Ketalar

Dosage and Frequency

IM: 3 mg/kg. If response is inadequate this dose may be repeated

IV: The initial dose of Ketalar administered intravenously may

IV anesthetic agents: Most agents produce CNS depression

by action on the gamma-aminobutyric acid (GABA)

receptor complex. GABA is the primary inhibitory

Ketalar is indicated as the sole anesthetic agent for diagnostic and

Ketalar is indicated for the induction of anesthesia prior to the

Ketalar is indicated to supplement low-potency agents, such

Ketamine hydrochloride is contraindicated in those in whom a

Emergence rxns, HTN, Increased cardiac output, Increased ICP,

 closely monitor blood pressure and heart rate (every 5

PATIENT & FAMILY EDUCATION

GENERIC NAME BRAND NAME

Dosage and Frequency

IV: ,55 yr and ASA I/II IV (Diprivan or generic):â•‡â•‰IV 40

PATIENT & FAMILY EDUCATION

GENERIC NAME BRAND NAME

Dosage and Frequency

IV: 0.02–0.04 mg/kg.

 Inform patient that he may not remember procedure

 Advice patient to avoid potentially hazardous activities

GENERIC NAME BRAND NAME

Dosage and Frequency

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

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

Etomidate is an imidazole compound that appears to depress CNS

Intravenous injection for the induction of general anesthesia.

Sepsis, Intraarterial administration, Geriatric, hypertension,

Myoclonus, pain on injection, nausea, vomiting, respiratory

 Implement breathing activities and other therapeutic

GENERIC NAME BRAND NAME

Dosage and Frequency

IV: 50 to 300 mg (10 to 60 mL of 0.5% solution) for intravenous

Anesthetic: Inhibits conduction of nerve

Infiltration, Nerve Block

Bradycardia, hypotension, arrhythmias, agitation, anxiety,

 Be alert for new seizures or increased seizure activity,

 Monitor cardiac symptoms at rest and during exercise. Seek

 Monitor signs of allergic reactions and anaphylaxis,

 Assess heart rate, ECG, and heart sounds, especially during

 Be alert for other signs of toxicity during continuous

 When used for regional pain control or neuropathic pain,

PATIENT & FAMILY EDUCATION

• You will be monitored during infusion. Do not get up

GENERIC NAME BRAND NAME

Dosage and Frequency

Anesthetic: Inhibits ascending pain pathways in CNS, increases

Hypersensitivity to opiates, myasthenia gravis, headache, migraine

Dizziness, delirium, euphoria, sedation, bradycardia, cardiac arrest,

• Hypercholesterolemia: Monitor lipid levels (triglycerides, LDL,

• Inform patient that compliance is needed.

• Instruct patient not to consume chipped or broken tabs (Triglide)

• Caution patient to notify prescriber if pregnancy is planned or

• Instruct patient to report GU symptoms: dysuria, proteinuria,

• Advise patient to notify prescriber of muscle pain, weakness,

GENERIC NAME BRAND NAME

Dosage and Frequency

IV bolus, as needed give supplemental doses up to a max of 140

Precautions: Pregnancy B, breastfeeding, children, geriatric