DRUG DOSAGE
CARDIOVASCULAR AGENTS
SODIUM CHANNEL BLOCKERS
Quinidine TABLET
200mg (as sulfate)
300mg (as sulfate)
TABLET, EXTENDED-RELEASE
300mg (as sulfate)
324mg (as gluconate)
INJECTABLE SOLUTION
80mg/mL (as gluconate) -
discontinued from U.S. market
THERAPEUTIC ACTION
Used to treat abnormal heart
rhythm. This medicine may also
be used to treat malaria.
Depresses myocardial
excitability, conduction velocity, Lightheadedness (15%)
and irregularity of nerve impulse
conduction.
ADVERSE EFFECT CONTRAINDICATIONS NURSING CONSIDERATIONS
>10% Complete AV block (w/o functional pacemaker), Assessment & Drug Effects
Diarrhea (35%) myasthenia gravis, history of quinidine/quinine-
associated thrombocytopenic purpura. Observe cardiac monitor and report
Stomach cramping (22%) immediately the following indications for
Hypersensitivity or idiosyncrasy to quinine or stopping quinidine: (1) sinus rhythm, (2)
Cinchona derivatives; pregnancy (category C), widening QRS complex in excess of 25% (i.e.,
lactation. Thrombocytopenic purpura resulting >0.12 sec), (3) changes in QT interval or
QTc prolongation (modest from prior use of quinidine; intraventricular refractory period, (4) disappearance of P
prolongation common; excessive conduction defects, complete AV block, ectopic waves, (5) sudden onset of or increase in
prolongation rare & indicates toxicity) impulses and rhythms due to escape ectopic ventricular beats (extrasystoles, PVCs),
(>10%) mechanisms; thyrotoxicosis; acute rheumatic (6) decrease in heart rate to 120 bpm. Also
fever; subacute bacterial endocarditis, extensive report immediately any worsening of minor
Anorexia (>10%) myocardial damage, frank CHF, hypotensive side effects.
states; myasthenia gravis; digitalis intoxication. Continuous monitoring of ECG and BP is
Bitter taste (>10%) required. Observe patient closely (check
sensorium and be alert for any sign of toxicity);
Diarrhea (>10%) determine plasma quinidine concentrations
frequently when large doses (more than 2 g/d)
Upper GI distress (>10%) are used or when quinidine is given
parenterally (i.e., quinidine gluconate).
Nausea (>10%) Observe patient closely following each
parenteral dose. Amount of subsequent dose is
Vomiting (>10%) gauged by response to preceding dose.
Monitor vital signs q1–2h or more often as
1-10% needed during acute treatment. Count apical
Syncope (1-8%) pulse for a full minute. Report any change in
pulse rate, rhythm, or quality or any fall in BP.
Palpitation (7%), new or worsened Severe hypotension is most likely to occur in
arrhythmias (proarrhythmic effect), patients receiving high oral doses or parenteral
quinidine (i.e., quinidine gluconate).
Headache (7%) Be aware: Reversion to sinus rhythm in long-
standing fibrillation or when fibrillation is
Fatigue (7%) complicated by CHF involves some risk of
embolization from dislodgment of atrial mural
Angina (6%) emboli.
Quinidine can cause unpredictable rhythm
Rash (5%) abnormalities in the digitalized heart. Patients
with atrial flutter or fibrillation may be
Weakness (5%) pretreated with digitalis (until ventricular rate
is 100 bpm) to increase AV nodal block and
Sleep disturbance (3%) thus reduce possibility of paradoxic
tachycardia.
 Nervousness (2%) Lab tests: Periodic blood counts, serum
electrolyte determinations, and kidney and
Tremor (2%) liver function during long-term therapy.
Monitor I&O. Diarrhea occurs commonly
Incoordination (1%) during early therapy; most patients become
tolerant to this side effect. Evaluate serum
Blurred vision electrolytes, acid-base, and fluid balance when
symptoms become severe; dosage adjustment
Tinnitus may be required.

Wheezing Patient & Family Education

Report feeling of faintness to physician.

Flecainide Life-threatening Ventricular
Arrhythmias
Adult: PO 100 mg q12h, may
increase by 50 mg b.i.d. q4d
(max: 400 mg/d)
Child: PO 1–3 mg/kg/d in 3
divided doses (max: 8
mg/kg/d)
Oral
Do not increase dosage more
Clinically, causes both
hypotension and negative
entropy (in higher dose ranges)
and is an effective suppressant
of PVCs and a variety of atrial
and ventricular arrhythmias.
CNS: Dizziness, headache, light-
headedness, unsteadiness,
paresthesias, fatigue.
CV: Arrhythmias, chest pain,
worsening of CHF.
Special Senses: Blurred vision,
difficulty in focusing, spots before
eyes.
Hypersensitivity to flecainide; preexisting
second- or third-degree AV block, right bundle
branch block when associated with a left
hemiblock unless a pacemaker is present;
cardiogenic shock, significant hepatic
impairment. Safety during pregnancy (category
C), lactation, or in children <18 y is not
established.
"Quinidine syncope" is caused by quinidine-
induced changes in ventricular rhythm
resulting in decreased cardiac output and
syncope.
Note: Hypersensitivity reactions usually appear
3–20 d after drug is started. Fever occurs
commonly and may or may not be
accompanied by other symptoms. Inform
physician if these S&S occur.
Eat a balanced diet with no excesses in fruit or
fruit juices, milk, or a vegetarian diet. A diet
high in alkaline ash foods (vegetables, citrus
fruit, milk) may prolong half-life of quinidine by
decreasing its excretion and increasing danger
of toxicity.
Do not self-medicate with OTC drugs without
advice from physician.
Do not increase, decrease, skip, or discontinue
doses without consulting physician.
Notify physician immediately of disturbances
in vision, ringing in ears, sense of
breathlessness, onset of palpitations, and
unpleasant sensation in chest. Be sure to note
the time of occurrence and duration of chest
symptoms.
Do not breast feed while taking this drug.
Assessment & Drug Effects
Correct preexisting hypokalemia or
hyperkalemia before treatment is initiated.
Note: ECG monitoring, including Holter
monitor for ambulating patients, is essential
because of the possibility of drug-induced
arrhythmias.
Determine pacing threshold for patients with
pacemakers before initiation of therapy, after 1
wk of therapy, and at regular intervals
 frequently than every 4 d.
Store in tightly covered, light-
resistant containers at 15°–
30° C (59°–86° F) unless
otherwise directed.
BETA BLOCKERS
Propanolol Hypertension
(Inderal) Adult: PO 40 mg b.i.d., usually
need 160–480 mg/d in
divided doses; InnoPran XL
dose 80 mg q hs, may increase
to 120 mg hs
Child: PO 1 mg/kg/d in 2
divided doses (1–5 mg/kg/d)
Neonate: PO 0.25 mg/kg q6–
8h (max: 5 mg/kg/d) IV 0.01
mg/kg slow IV push over 10
min q6–8h prn (max: 0.15
mg/kg q6–8h)
Angina
Adult: PO 10–20 mg b.i.d. or
t.i.d., may need 160–320
mg/d in divided doses
Arrhythmias
Adult: PO 10–30 mg t.i.d. or
q.i.d. IV 0.5–3 mg q4h prn
Child: PO 1–4 mg/kg/d in 4
divided doses (max: 16
mg/kg/d) IV 10–20
mcg/kg/min over 10 min
Acute MI
Adult: PO 180–240 mg/d in
divided doses
Blocks cardiac effects of beta-
adrenergic stimulation; as a
result, reduces heart rate,
myocardial irritability (Class II
antiarrhythmic) and force of
contraction, depresses
automaticity of sinus node and
ectopic pacemaker, and
decreases AV and
intraventricular conduction
velocity. Hypotensive effect is
associated with decreased
cardiac output, suppressed renin
activity, as well as beta-
blockade. Also decreases
platelet aggregability.
GI: Nausea, constipation, change in thereafter.
taste perception. Body as a Whole: Monitor plasma level recommended, especially
Dyspnea, fever, edema. in patients with severe CHF or renal failure
because drug elimination may be delayed in
these patients.
Note: Effective trough plasma levels are
between 0.7–1 mcg/mL. The probability of
adverse reactions increases when trough levels
exceed 1 mcg/mL.
Attempt dosage reduction with caution after
arrhythmia is controlled.
Patient & Family Education
Note: It is VERY important to take this drug at
the prescribed times.
Report visual disturbances to physician.
Do not breast feed while taking this drug
without consulting physician.
Body as a Whole: Fever; pharyngitis; Greater than first-degree heart block; CHF, right Assessment & Drug Effects
respiratory distress, weight gain, LE-ventricular failure secondary to pulmonary
like reaction, cold extremities, leg hypertension; ventricular dysfunction; sinus Obtain careful medical history to rule out
fatigue, arthralgia, bradycardia, cardiogenic shock, significant aortic allergies, asthma, and obstructive pulmonary
anaphylactic/anaphylactoid reactions. or mitral valvular disease; bronchial asthma or disease. Propranolol can cause bronchiolar
bronchospasm, severe COPD, pulmonary edema, constriction even in normal subjects.
Urogenital: Impotence or decreased allergic rhinitis during pollen season; concurrent Monitor apical pulse, respiration, BP, and
libido. use with adrenergic-augmenting psychotropic circulation to extremities closely throughout
drugs or within 2 wk of MAO inhibition therapy; period of dosage adjustment. Consult
Skin: Erythematous, psoriasis-like abrupt discontinuation; major depression; physician for acceptable parameters.
eruptions; pruritus, Stevens-Johnson peripheral vascular disease, Raynaud's disease; Evaluate adequate control or dosage interval
syndrome, toxic epidermal necrolysis, pregnancy (category C). for patients being treated for hypertension by
erythema multiforme, exfoliative checking blood pressure near end of dosage
dermatitis, urticaria. Reversible interval or before administration of next dose.
alopecia, hyperkeratoses of scalp, Be aware that adverse reactions occur most
palms, feet; nail changes, dry skin. frequently following IV administration soon
after therapy is initiated; however, incidence is
CNS: Drug-induced psychosis, sleep also high following oral use in the older adult
disturbances, depression, confusion, and in patients with impaired kidney function.
agitation, giddiness, light- Reactions may or may not be dose related.
headedness, fatigue, vertigo, Lab tests: Obtain periodic hematologic, kidney,
syncope, weakness, drowsiness, liver, and cardiac functions when propranolol is
insomnia, vivid dreams, visual given for prolonged periods.
hallucinations, delusions, reversible Monitor I&O ratio and daily weight as
organic brain syndrome. significant indexes for detecting fluid retention
and developing heart failure.
CV: Palpitation, profound Consult physician regarding allowable salt
bradycardia, AV heart block, cardiac intake. Drug plasma volume may increase with
standstill, hypotension, angina consequent risk of CHF if dietary sodium is not
pectoris, tachyarrhythmia, acute CHF, restricted in patients not receiving
 peripheral arterial insufficiency
Migraine Prophylaxis resembling Raynaud's disease,
Adult: PO 80 mg/d in divided myotonia, paresthesia of hands.
doses, may need 160–240
mg/d Special Senses: Dry eyes (gritty
sensation), visual disturbances,
conjunctivitis, tinnitus, hearing loss,
nasal stuffiness.
GI: Dry mouth, cheilostomatitis,
nausea, vomiting, heartburn,
diarrhea, constipation, flatulence,
abdominal cramps, mesenteric
arterial thrombosis, ischemic colitis,
pancreatitis. Hematologic: Transient
eosinophilia, thrombocytopenic or
nonthrombocytopenic purpura,
agranulocytosis. Metabolic:
Hypoglycemia, hyperglycemia,
hypocalcemia (patients with
hyperthyroidism). Respiratory:
Dyspnea, laryngospasm,
bronchospasm.
Acebutolol (Sectral) Hypertension Decreases both systolic and Body as a Whole: Fatigue.
Adult: PO 400–800 mg/d in 1– diastolic BP at rest and during
2 divided doses (max: 1200 exercise. CNS: Dizziness, insomnia, drowsiness, children <12 y.
mg/d) confusion, fainting.
Overt CHF, second- or third-degree AV block,
severe bradycardia, cardiogenic shock; lactation;
concomitant diuretic therapy.
Fasting for more than 12 h may induce
hypoglycemic effects fostered by propranolol.
If patient complains of cold, painful, or tender
feet or hands, examine carefully for evidence
of impaired circulation. Peripheral pulses may
still be present even though circulation is
impaired. Caution patient to avoid prolonged
exposure of extremities to cold.
Patient & Family Education
Learn usual pulse rate and take radial pulse
before each dose. Report to physician if pulse
is below the established parameter or
becomes irregular.
Be aware that propranolol suppresses clinical
signs of hypoglycemia (e.g., BP changes,
increased pulse rate) and may prolong
hypoglycemia.
Understand importance of compliance. Do not
alter established regimen (i.e., do not omit,
increase, or decrease dosage or change dosage
interval).
Do not discontinue abruptly; can precipitate
withdrawal syndrome (e.g., tremulousness,
sweating, severe headache, malaise,
palpitation, rebound hypertension, MI, and
life-threatening arrhythmias in patients with
angina pectoris).
Be aware that drug may cause mild
hypotension (experienced as dizziness or
lightheadedness) in normotensive patients on
prolonged therapy. Make position changes
slowly and avoid prolonged standing. Notify
physician if symptoms persist.
Do not drive or engage in potentially
hazardous activities until response to drug is
known.
Consult physician before self-medicating with
OTC drugs.
Inform dentist, surgeon, or ophthalmologist
that you are taking propranolol (drug lowers
normal and elevated intraocular pressure).
Do not breast feed while taking this drug
without consulting physician.
Assessment & Drug Effects
Monitor BP and cardiac status throughout
therapy. Observe for and report marked
 Geriatric: PO 200–400 mg/d
(max: 800 mg/d)
Ventricular Arrhythmias
Adult: PO 200 mg b.i.d.
increased to 600–1200 mg/d
Angina Pectoris
Adult: PO 300–400 mg t.i.d.
Renal Impairment
Clcr <50 mL/min: reduce dose
by 50%; <25 mL/min: reduce
dose by 75%
DRUGS THAT PROLONG REPOLARIZATION
Bretylium (Bretylol) Ventricular Fibrillation
Adult: IV 5 mg/kg rapid IV
injection, may increase to 10
mg/kg and repeat q15–30 min
(max: 30 mg/kg/d); may also
give by continuous infusion at
1–2 mg/min IM 5–10 mg/kg,
may repeat in 1–2 h if
Suppresses arrhythmias with a
reentry mechanism and
decreases dispersion of ectopic
foci. PR, QT, and QRS intervals
are unchanged. Because onset
of desired action is delayed,
bretylium is not a first-line
antiarrhythmic agent.
CV: Bradycardia, hypotension, CHF.
GI: Nausea, diarrhea, constipation,
flatulence.
Hematologic: Agranulocytosis,
antinuclear antibodies (ANA).
Metabolic: hypoglycemia (may mask
symptoms of a hypoglycemic
reaction).
Respiratory: Bronchospasm,
pulmonary edema, dyspnea.
Urogenital: Decreased libido;
impotence.
CV: Both supine and postural
hypotension with dizziness, vertigo,
lightheadedness, faintness, syncope,
transitory hypertension, bradycardia,
increased frequency of PVCs,
exacerbation of digitalis-induced
arrhythmias. GI: Nausea, vomiting
(particularly with rapid IV).
No contraindications for use in life-threatening
refractory ventricular arrhythmias. Safety during
pregnancy (category C), lactation, or in children
is not established.
bradycardia or hypotension, especially when
patient is also receiving a catecholamine-
depleting drug (e.g., reserpine).
Monitor I&O ratio and pattern and report
changes to physician (e.g., dysuria, nocturia,
oliguria, weight change).
Monitor for S&S of CHF, especially peripheral
edema, dyspnea, activity intolerance.
Lab tests: Monitor for drug-induced positive
ANA titer during long-term therapy, especially
in women and older adults; periodic CBC with
long-term therapy.
Patient & Family Education
Know parameters for withholding drug (e.g.,
pulse less than 60).
Note: Common adverse effects include
insomnia, drowsiness, and confusion.
Do not drive or engage in potentially
hazardous activities until response to drug is
known.
Do not increase, decrease, omit, or discontinue
drug regimen without advice from the
physician. Abrupt withdrawal may worsen
angina or precipitate MI in patient with heart
disease.
Contact physician promptly at the first signs or
symptoms of CHF (see Appendix F).
Report muscle and joint pain to physician.
Discontinuation of drug therapy usually
reverses these adverse effects.
Monitor for loss of glycemic control if diabetic.
Note: Drug may mask symptoms of
hypoglycemia (see Appendix F) and potentiate
insulin-induced hypoglycemia in diabetics.
Avoid use of OTC oral cold preparations and
topical nasal decongestants unless approved
by the physician.
Do not breast feed while taking this drug
without consulting physician.
Assessment & Drug Effects
Anticipate vomiting. IV administration is
associated with a high incidence of nausea and
vomiting. These side effects can be minimized
by slow administration of drug (10 min).
Establish baseline readings and monitor BP and
ECG when drug is administered. Observe for
arrhythmia persists, then 5–
10 mg/kg q6–8h for
maintenance
Child: IV 5 mg/kg, may repeat
q10–20min (max: 30 mg/kg)
IM 2–5 mg/kg as single dose
Arrhythmias
Adult: PO Loading Dose 800–
1600 mg/d in 1–2 doses for 1–
3 wk PO Maintenance Dose
400–600 mg/d in 1–2 doses IV
Loading Dose 150 mg over 10
min followed by 360 mg over
next 6 h IV Maintenance Dose
540 mg over 18 h (0.5
mg/min), may continue at 0.5
mg/min Convert IV to PO
Duration of infusion <1 wk use
800–1600 mg PO, 1–3 wk use
600–800 mg PO, >3 wk use
400 mg PO
Child: PO Loading Dose 10–15
mg/kg/d or 600–800 mg/1.73
m2/d, in 1–2 divided doses for
4–14 d cycle or until adequate
By direct action on smooth
muscle, decreases peripheral
resistance and increases
coronary blood flow. Blocks
effects of sympathetic
stimulation.
Respiratory: Respiratory depression.
CNS: Peripheral neuropathy (muscle
weakness, wasting numbness,
tingling), fatigue, abnormal gait,
dyskinesias, dizziness, paresthesia,
headache.
CV: Bradycardia, hypotension (IV),
sinus arrest, cardiogenic shock, CHF,
arrhythmias; AV block.
Special Senses: Corneal
microdeposits, blurred vision, optic
neuritis, optic neuropathy,
permanent blindness, corneal
degeneration, macular degeneration,
photosensitivity.
GI: Anorexia, nausea, vomiting,
constipation, hepatotoxicity.
Hypersensitivity to amiodarone, or benzyl
alcohol; cardiogenic shock, severe sinus
bradycardia, advanced AV block unless a
pacemaker is available, severe sinus-node
dysfunction or sick sinus syndrome, bradycardia,
congenital or acquired QR prolongation
syndromes, or history of torsade de pointes;
severe liver disease, children. Safety during
pregnancy (category D) or lactation is not
established.
initial transient rise in BP, increased heart rate,
PVCs and other arrhythmias, or worsening of
existing arrhythmias, which may occur within a
few minutes to 1 h after drug administration.
Keep physician informed. Initial effect of
hypertension is usually followed within 1 h by a
fall in supine BP and by orthostatic
hypotension.
Use supine position until patient develops
tolerance to hypotensive effect of bretylium
(generally in several days). Hypotension can
occur in the supine position, particularly in
patients with severely compromised cardiac
function. It may not readily respond to therapy
(e.g., vasopressors, fluids); early reporting is
essential.
Raise or lower head of bed slowly; advise
patient to make position changes slowly in
order to prevent orthostatic hypotension.
Monitor I&O, particularly in patients with
impaired renal function.
Patient & Family Education
Make position changes slowly. If allowed to be
out of bed, dangle legs for a few minutes
before standing, but do not stand still for
prolonged periods. Men should sit on toilet to
urinate.
Do not breast feed while taking this drug
without consulting physician.
Assessment & Drug Effects
Monitor BP carefully during infusion and slow
the infusion if significant hypotension occurs;
bradycardia should be treated by slowing the
infusion or discontinuing if necessary. Monitor
heart rate and rhythm and BP until drug
response has stabilized; report promptly
symptomatic bradycardia. Sustained
monitoring is essential because drug has an
unusually long half-life.
Monitor for S&S of: Adverse effects,
particularly conduction disturbances and
exacerbation of arrhythmias, in patients
receiving concomitant antiarrhythmic therapy
(reduce dosage of previous agent by 30–50%
several days after amiodarone therapy is
started); drug-induced hypothyroidism or
hyperthyroidism (see Appendix F), especially
control of arrhythmia PO
Maintenance Dose 5 mg/kg/d Metabolic: Hyperthyroidism or
or 200–400 mg/1.73 m2/d hypothyroidism; may cause neonatal
once daily, may be able to hypo- or hyperthyroidism if taken
reduce to 2–5 mg/kg/d 5 d during pregnancy.
per week
Respiratory: (Pulmonary toxicity)
Alveolitis, pneumonitis (fever, dry
cough, dyspnea), interstitial
pulmonary fibrosis, fatal gasping
syndrome with IV in children.
Skin: Slate-blue pigmentation,
photosensitivity, rash.
Other: With chronic use,
angioedema.
during early treatment period; pulmonary
toxicity (progressive dyspnea, fatigue, cough,
pleuritic pain, fever) throughout therapy.
Lab tests: Baseline and periodic assessments
should be made of liver, lung, thyroid,
neurologic, and GI function. Drug may cause
thyroid function test abnormalities in the
absence of thyroid function impairment.
Monitor for elevations of AST and ALT. If
elevations persist or if they are 2–3 times
above normal baseline readings, reduce
dosage or withdraw drug promptly to prevent
hepatotoxicity and liver damage.
Auscultate chest periodically or when patient
complains of respiratory symptoms. Check for
diminished breath sounds, rales, pleuritic
friction rub; observe breathing pattern. Drug-
induced pulmonary function problems must be
distinguished from CHF or pneumonia. Keep
physician informed.
Anticipate possible CNS symptoms within a
week after amiodarone therapy begins.
Proximal muscle weakness, a common side
effect, intensified by tremors presents a great
hazard to the ambulating patient. Assess
severity of symptoms. Supervision of
ambulation may be indicated.
Patient & Family Education
Check pulse daily once stabilized, or as
prescribed. Report a pulse <60.
Take oral drug consistently with respect to
meals.
Become familiar with potential adverse
reactions and report those that are
bothersome to the physician.
Use dark glasses to ease photophobia; some
patients may not be able to go outdoors in the
daytime even with such protection.
Follow recommendation for regular
ophthalmic exams, including funduscopy and
slit-lamp exam.
Wear protective clothing and a barrier-type
sunscreen that physically blocks penetration of
skin by ultraviolet light (e.g., titanium oxide or
zinc formulations) to prevent a photosensitivity
reaction (erythema, pruritus); avoid exposure
to sun and sunlamps.
Do not breast feed while taking this drug

CALCIUM CHANNEL BLOCKERS
Losartan (Cozaar) TABLET
25mg
50mg
100mg
HTN 50 mg once daily, may be Antihypertensive effect results
increased to 100 mg once
daily. Patient w/ intravascular vasoconstricting and
vol-depletion 25 mg once
daily. Reduction in the risk of angiotensin II.
CV morbidity & mortality in
patient w/ left ventricular
hypertrophy 50 mg once daily.
A low dose of
hydrochlorothiazide should be
added &/or the dose of
losartan K should be
increased to 100 mg once
daily based on BP response.
Nephropathy in type 2
diabetic patient w/
proteinuria 50 mg once daily,
may be increased to 100 mg
once daily.
Valsartan (Diovan) TABLET
40mg
80mg
160mg
320mg
Adult HTN 80 or 160 mg once
daily. May be increased to
320 mg once daily or add
another antihypertensive (eg,
diuretic) if BP reduction is
inadequate. Heart failure
Initially 40 mg bid, up-titrated
to 80 & 160 mg bid as
tolerated. Max: 320 mg daily
in divided doses. Post-MI
Initially 20 mg bid, up-titrated
to a max of 160 mg bid as
tolerated. Hypertensive
patients w/ IGT at CV risk
Progression of type 2 diabetes
80 or 160 mg once daily.
When started on 80 mg, up-
titrate to 160 mg as tolerated.
Selectively blocks the binding of
angiotensin II to the
AT1 receptors found in many
tissues (e.g., vascular smooth
muscle, adrenal glands).
from blocking the
aldosterone-secreting effects of
Blocks angiotensin II, which
results in vasodilation and
blocking of the aldosterone-
secreting effects of angiotensin
II, thus resulting in an
antihypertensive effect.
CNS: Dizziness, insomnia, headache.
GI: Diarrhea, dyspepsia.
Musculoskeletal: Muscle cramps,
myalgia, back or leg pain. Respiratory:
Nasal congestion, cough, upper
respiratory infection, sinusitis.
Body as a Whole: Arthralgia. CNS:
Headache, dizziness.
GI: Diarrhea, nausea.
Respiratory: Cough, sinusitis.
Metabolic: Hyperkalemia.
Selectively blocks the binding of angiotensin II to
the AT1 receptors found in many tissues (e.g.,
vascular smooth muscle, adrenal glands).
Antihypertensive effect results from blocking the
vasoconstricting and aldosterone-secreting
effects of angiotensin II.
Hypersensitivity to valsartan or losartan;
pregnancy [(category C) first trimester, (category
D) second and third trimesters], lactation; severe Monitor BP periodically; take trough readings,
heart failure with compromised renal function.
without consulting physician.
Assessment & Drug Effects
Monitor BP at drug trough (prior to a
scheduled dose).
Monitor drug effectiveness, especially in
African-Americans when losartan is used as
monotherapy.
Inadequate response may be improved by
splitting the daily dose into twice-daily dose.
Lab tests: Monitor CBC, electrolytes, liver &
kidney function with long-term therapy.
Patient & Family Education
Notify physician of symptoms of hypotension
(e.g., dizziness, fainting).
Notify physician immediately of pregnancy.
Do not breast feed while taking this drug.
Assessment & Drug Effects
just prior to the next scheduled dose, when
possible.
Lab tests: Monitor liver function tests, BUN
and creatinine, serum potassium, and CBC with
differential, periodically.
Patient & Family Education
Inform physician immediately if you become
pregnant.
Note: Maximum pressure lowering effect is
usually evident between 2 and 4 wk after
initiation of therapy.
Notify physician of episodes of dizziness,
especially those that occur when making
position changes.
Do not breast feed while taking this drug.
 Childn & adolescents 6-18 yr
HTN Initially 40 mg (<35 kg)
or 80 mg (≥35 kg) once daily.
BETA-ADRENERGIC BLOCKERS
Atenolol 25 mg, 50 mg, 100 mg
(Tenormin) tablets; 5 mg/10 mL vial
Oral
Crush tablets, if necessary,
before administration and
give with fluid of patient's
choice.
Intravenous
PREPARE: Direct: Use
undiluted or diluted in 10–50
mL of NS, D5W, D5/NS,
D5/0.45NS, or 0.45NS.
ADMINISTER: Direct: Give
over 5 min.
Store in tightly closed, light-
resistant container at 15°–30°
C (59°–86° F) unless otherwise
directed.
Bisoprolol (Zebeta) 20 mg, 40 mg, 80 mg, 120
mg, 160 mg tablets
Oral
Do not discontinue abruptly;
reduce dosage over a 1–2-wk
period. Abrupt withdrawal
can precipitate MI or thyroid
storm in susceptible patients.
Store at 15°–30° C (59°–86°
F); protect drug from light.
Reduces rate and force of
cardiac contractions (negative
inotropic action); cardiac output
is reduced, as well as systolic
and diastolic BP. Atenolol
decreases peripheral vascular
resistance both at rest and with
exercise.
Reduces heart rate and cardiac
output at rest and during
exercise, and also decreases
conduction velocity through AV
node and myocardial
automaticity. Decreases both
systolic and diastolic BP at rest
and during exercise. Suppression
of beta2-adrenergic receptors in
bronchial and vascular smooth
muscle can cause bronchospasm
and a Raynaud's-like
phenomenon.
ANTIHYPERTENSIVE
CNS: Dizziness, vertigo, light-
headedness, syncope, fatigue or
weakness, lethargy, drowsiness,
insomnia, mental changes,
depression
CV: Bradycardia, hypotension, CHF,
cold extremities, leg pains,
dysrhythmias.
GI: Nausea, vomiting, diarrhea.
Respiratory: Pulmonary edema,
dyspnea, bronchospasm. Other: May
mask symptoms of hypoglycemia;
decreased sexual ability.
Body as a Whole: Hypersensitivity
(rash, pruritus, laryngospasm,
respiratory disturbances). CV:
Bradycardia, peripheral vascular
insufficiency (Raynaud's type),
palpitation, postural hypotension,
conduction or rhythm disturbances,
CHF. GI: Dry mouth. CNS: Dizziness,
fatigue, sedation, headache,
paresthesias, behavioral changes.
Special Senses: Blurred vision, dry
eyes. Skin: Dry skin. Urogenital:
Impotence.
Sinus bradycardia, greater than first-degree AV
heart block, uncompensated heart failure,
cardiogenic shock, peripheral vascular disease,
Raynaud's disease, hypotension; abrupt
discontinuation, pulmonary edema. Safety
during pregnancy (category D), or lactation is not
established.
Bronchial asthma, severe COPD, inadequate
myocardial function, sinus bradycardia, greater
than first-degree conduction block, overt cardiac
failure, cardiogenic shock. Safety during
pregnancy (category C), lactation, and in children
<18 y is not established.
Assessment & Drug Effects
Neonates born to mothers who are receiving
atenolol at parturition or breast–feeding may
be at risk for hypoglycemia.
Check apical pulse before giving oral drug,
especially in patients receiving digitalis (both
drugs slow AV conduction). If below 60 bpm
(or other ordered parameter), withhold dose
and consult physician.
Monitor apical pulse, BP, respirations, and
peripheral circulation throughout dosage
adjustment period. Consult physician for
acceptable parameters.
Patient & Family Education
Adhere rigidly to dose regimen. Sudden
discontinuation of drug can exacerbate angina
and precipitate tachycardia or MI in patients
with coronary artery disease, and thyroid
storm in patients with hyperthyroidism.
Make position changes slowly and in stages,
particularly from recumbent to upright
posture.
Do not breast feed while taking this drug.
Assessment & Drug Effects
Assess heart rate and BP before administration
of each dose. Withhold drug and notify
physician if apical pulse drops below 60 bpm or
systolic BP below 90 mm Hg.
Monitor weight. Advise patient to report
weight gain of 1–1.5 kg (2–3 lb) in a day and
any other possible signs of CHF (e.g., cough,
fatigue, dyspnea, rapid pulse, edema).
Evaluate effectiveness for patients with angina
by reduction in frequency of anginal attacks
and improved exercise tolerance. Improvement
should coincide with steady state serum
concentration reached within 6–9 d. Keep
physician informed of drug effect.
Monitor patients with diabetes mellitus
closely. Beta-adrenergic blockade produced by
nadolol may prevent important clinical

CALCIUM CHANNEL BLOCKERS
Amlodipine
(Norvasc) Adults
The usual initial
antihypertensive oral dose of
NORVASC is 5 mg once daily,
and the maximum dose is 10
mg once daily.
Small, fragile, or elderly
patients, or patients with
hepatic insufficiency may be
started on 2.5 mg once daily
and this dose may be used
when adding NORVASC to
other antihypertensive
therapy.
Adjust dosage according to
blood pressure goals. In
general, wait 7 to 14 days
between titration steps.
Titrate more rapidly, however,
if clinically warranted,
provided the patient is
assessed frequently.
Angina
The recommended dose for
chronic stable or vasospastic
NORVASC is a type of medicine
known as a calcium channel
blocker (CCB). It is used to
treat high blood
pressure (hypertension) and a
type of chest pain called angina.
It can be used by itself or with
other medicines to treat these
conditions.
Cardiovascular: arrhythmia (including NORVASC is contraindicated in patients with
ventricular tachycardia and atrial
fibrillation), bradycardia, chest pain,
peripheral ischemia, syncope,
tachycardia, vasculitis.
Central and Peripheral Nervous
System: hypoesthesia, neuropathy
peripheral, paresthesia, tremor,
vertigo.
Gastrointestinal: anorexia,
constipation, dysphagia, diarrhea,
flatulence, pancreatitis, vomiting,
gingival hyperplasia.
General: allergic reaction,1 asthenia,
back pain, hot flushes, malaise, pain,
rigors, weight gain, weight decrease.
Musculoskeletal System: arthralgia,
arthrosis, muscle cramps,1 myalgia.
Psychiatric: sexual dysfunction
(male1 and female), insomnia,
nervousness, depression, abnormal
dreams, anxiety, depersonalization.
Respiratory
System: dyspnea,1 epistaxis.
Skin and Appendages: angioedema,
erythema multiforme,
pruritus,1 rash,1 rash erythematous,
manifestations of hypoglycemia (e.g.,
tachycardia, BP changes).
Monitor I&O ratio and creatinine clearance in
patients with impaired kidney function or with
cardiac problems. Dosage intervals will be
lengthened with decreases in creatinine
clearance.
Patient & Family Education
Check pulse before taking each dose. Do not
take your medication if pulse rate drops below
60 (or other parameter set by physician) or
becomes irregular. Consult your physician right
away.
Do not stop taking your medication or alter
dosage without consulting your physician.
Do not drive or engage in potentially
hazardous activities until response to drug is
known.
Do not breast feed while taking this drug
without consulting physician.
Assessment & Drug Effects
known sensitivity to amlodipine.
Neonates born to mothers who are receiving
atenolol at parturition or breast–feeding may
be at risk for hypoglycemia.
Check apical pulse before giving oral drug,
especially in patients receiving digitalis (both
drugs slow AV conduction). If below 60 bpm
(or other ordered parameter), withhold dose
and consult physician.
Monitor apical pulse, BP, respirations, and
peripheral circulation throughout dosage
adjustment period. Consult physician for
acceptable parameters.
Patient & Family Education
Adhere rigidly to dose regimen. Sudden
discontinuation of drug can exacerbate angina
and precipitate tachycardia or MI in patients
with coronary artery disease, and thyroid
storm in patients with hyperthyroidism.
Make position changes slowly and in stages,
particularly from recumbent to upright
posture.
Do not breast feed while taking this drug.
 angina is 5–10 mg, with the
lower dose suggested in the
elderly and in patients with
hepatic insufficiency. Most
patients will require 10 mg for
adequate effect.
Coronary Artery Disease
The recommended dose
range for patients with
coronary artery disease is 5–
10 mg once daily. In clinical
studies, the majority of
patients required 10 mg
[see Clinical Studies].
Children
The effective antihypertensive
oral dose in pediatric patients
ages 6–17 years is 2.5 mg to 5
mg once daily. Doses in excess
of 5 mg daily have not been
studied in pediatric patients
[see CLINICAL
PHARMACOLOGY, Clinical
Studies].
Diltiazem
(Cardizem,
Tiazac)
Tiazac® (diltiazem hydrochloride)
is a calcium ion cellular influx
inhibitor (slow channel blocker).
Chemically, diltiazem
hydrochloride is 1,5-
Benzothiazepin-4(5H)-one, 3-
(acetyloxy)-5-[2-
(dimethylamino)ethyl]-2, 3-
dihydro-2-(4-methoxyphenyl)-,
monohydrochloride, (+)-cis-.
rash maculopapular.
Special Senses: abnormal vision,
conjunctivitis, diplopia, eye pain,
tinnitus.
Urinary System: micturition
frequency, micturition disorder,
nocturia.
Autonomic Nervous System: dry
mouth, sweating increased.
Metabolic and
Nutritional: hyperglycemia, thirst.
Hemopoietic: leukopenia, purpura,
thrombocytopenia.
Hypertension
Dosage needs to be adjusted by
titration to individual patient needs.
When used as monotherapy, usual
starting doses are 120 to 240 mg
once daily. Maximum
antihypertensive effect is usually
observed by 14 days of chronic
therapy; therefore, dosage
adjustments should be scheduled
accordingly. The usual dosage range
studied in clinical trials was 120 to
540 mg once daily. Current clinical
experience with 540 mg dose is
limited; however, the dose may be
increased to 540 mg once daily.
Angina
Dosages for the treatment of angina
should be adjusted to each patient's
needs, starting with a dose of 120 mg
Cardiovascular: Angina, arrhythmia, AV block
(second- or third-degree), bundle branch
block, congestive heart failure, ECG
abnormalities, hypotension, palpitations, syncop
e, 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, pru
ritus.
Other: Albuminuria, allergic
reaction, amblyopia, asthenia, CPK increase,
crystalluria, dyspnea, edema, epistaxis, eye
irritation,
headache, hyperglycemia, hyperuricemia, impot
ence, muscle cramps, nasal congestion, neck
rigidity, nocturia, osteoarticular pain,
Assessment & Drug Effects
Neonates born to mothers who are receiving
atenolol at parturition or breast–feeding may
be at risk for hypoglycemia.
Check apical pulse before giving oral drug,
especially in patients receiving digitalis (both
drugs slow AV conduction). If below 60 bpm
(or other ordered parameter), withhold dose
and consult physician.
Monitor apical pulse, BP, respirations, and
peripheral circulation throughout dosage
adjustment period. Consult physician for
acceptable parameters.
Patient & Family Education
Adhere rigidly to dose regimen. Sudden
discontinuation of drug can exacerbate angina
and precipitate tachycardia or MI in patients
with coronary artery disease, and thyroid
storm in patients with hyperthyroidism.
Make position changes slowly and in stages,
to 180 mg once daily. Individual pain, polyuria, rhinitis, sexual particularly from recumbent to upright
patients may respond to higher doses difficulties, gynecomastia. posture.
of up to 540 mg once daily. When In addition, the following postmarketing events Do not breast feed while taking this drug.
necessary, titration should be carriedhave been reported infrequently in patients
out over 7 to 14 days. receiving diltiazem hydrochloride: acute
generalized exanthematous
Concomitant Use With Other pustulosis, alopecia, erythema multiforme,
Cardiovascular Agents exfoliative dermatitis, Stevens-Johnson
syndrome, toxic epidermal necrolysis,
1. Sublingual Nitroglycerin extrapyramidal symptoms, gingival
(NTG). May be taken as hyperplasia, hemolytic anemia, increased
required to abort acute anginal bleeding time, photosensitivity (including
attacks during diltiazem lichenoid keratosis and hyperpigmentation at
hydrochloride therapy. sun-exposed skin
2. Prophylactic Nitrate areas), leukopenia, purpura, retinopathy,
Therapy. Diltiazem and thrombocytopenia. In addition, events such
hydrochloride may be safely as myocardial infarction have been observed
coadministered with short- and which are not readily distinguishable from the
long-acting nitrates. natural history of the disease in these patients. A
3. Beta-blockers (see WARNINGS
number of well-documented cases of generalized
and PRECAUTIONS.) rash, characterized as leukocytoclastic vasculitis,
4. Antihypertensives. Diltiazem have been reported. However, a definitive cause
hydrochloride has an additive and effect relationship between these events
antihypertensive effect when and diltiazem hydrochloride therapy is yet to be
used with other established.
antihypertensive agents.
Therefore, the dosage of
diltiazem hydrochloride or the
concomitant antihypertensives
may need to be adjusted when
adding one to the other.

Hypertensive or anginal patients who

are treated with other formulations
of diltiazem can safely be switched to
Tiazac capsules at the nearest
equivalent total daily dose.
Subsequent titration to higher or
lower doses may, however, be
necessary and should be initiated as
clinically indicated.

Sprinkling The Capsule Contents On

Food

Tiazac (diltiazem hydrochloride)

Extended-release Capsules may also
be administered by carefully opening
the capsule and sprinkling the
capsule contents on a spoonful of
applesauce. The applesauce should

CENTRALLY-ACTING ALPHA2 AGONIST
Methyldopa Hypertension
Adult: PO 250 mg b.i.d. or
t.i.d., may be increased up to
3 g/d in divided doses IV 250–
500 mg q6h, may be increased
up to 1 g q6h
Geriatric: PO 125 mg b.i.d. or
t.i.d., may increase gradually
(max: 3 g/d)
Child: PO 10–65 mg/kg/d in
2–4 divided doses (max: 3
g/d) IV 20–65 mg/kg/d in 4
divided doses
Lowers standing and supine BP,
and unlike adrenergic blockers,
is not so prone to produce
orthostatic hypotension, diurnal
BP variations, or exercise
hypertension. Reduces renal
vascular resistance; maintains
cardiac output without
acceleration, but may slow heart
rate; tends to support sodium
and water retention.
be swallowed immediately without
chewing and followed with a glass of
cool water to ensure complete
swallowing of the capsule contents.
The applesauce should not be hot,
and it should be soft enough to be
swallowed without chewing. Any
capsule contents/applesauce mixture
should be used immediately and not
stored for future use. Subdividing the
contents of a Tiazac (diltiazem
hydrochloride) Extended-release
Capsule is not recommended.
Body as a Whole: Hypersensitivity
(Fever, skin eruptions, ulcerations of
soles of feet, flu-like symptoms,
lymphadenopathy, eosinophilia).
CNS: Sedation, drowsiness,
sluggishness, headache, weakness,
fatigue, dizziness, vertigo, decrease in
mental acuity, inability to
concentrate, amnesia-like syndrome,
parkinsonism, mild psychoses,
depression, nightmares.
CV: Orthostatic hypotension,
syncope, bradycardia, myocarditis,
edema, weight gain (sodium and
water retention), paradoxic
hypertensive reaction (especially with
IV administration).
GI: Diarrhea, constipation,
abdominal distension, malabsorption
syndrome, nausea, vomiting, dry
mouth, sore or black tongue,
sialadenitis, abnormal liver function
tests, jaundice, hepatitis, hepatic
necrosis (rare).
Hematologic: Positive direct Coombs'
test (common especially in African-
Americans), granulocytopenia.
Special Senses: Nasal stuffiness.
Endocrine: Gynecomastia, lactation,
decreased libido, impotence,
hypothermia (large doses), positive
tests for lupus and rheumatoid
factors.
Skin: Granulomatous skin lesions.
Active liver disease (hepatitis, cirrhosis);
pheochromocytoma; blood dyscrasias. Safety
during pregnancy (category C) is not established.
Assessment & Drug Effects
Check BP and pulse at least q30min until
stabilized during IV infusion and observe for
adequacy of urinary output.
Take BP taken at regular intervals in lying,
sitting, and standing positions during period of
dosage adjustment if physician requests.
Be aware that transient sedation, drowsiness,
mental depression, weakness, and headache
commonly occur during first 24–72 h of
therapy or whenever dosage is increased.
Symptoms tend to disappear with continuation
of therapy or dosage reduction.
Supervision of ambulation in older adults and
patients with impaired kidney function; both
are particularly likely to manifest orthostatic
hypotension with dizziness and light-
headedness during period of dosage
adjustment.
Monitor fluid and electrolyte balance and I&O.
Report oliguria and changes in I&O ratio.
Weigh patient daily, and check for edema
because methyldopa favors sodium and water
retention.
Lab tests: Schedule baseline and periodic
blood counts and liver function tests especially
during first 6–12 wk of therapy or if patient
develops unexplained fever; periodic serum
electrolytes.
Be alert to and report symptoms of mental
depression (e.g., anorexia, insomnia,
inattention to personal hygiene, withdrawal).
Drug-induced depression may persist after
drug is withdrawn.

Clonidine Hypertension
Adult: PO 0.1 mg b.i.d. or
t.i.d., may increase by 0.1–0.2
mg/d until desired response is
achieved (max: 2.4 mg/d)
Transdermal 0.1 mg patch
once q7d, may increase by 0.1
mg q1–2 wk
Geriatric: PO Start with 0.1
mg once daily
Child: PO 5–10 mcg/kg/d
divided q8–12h, may increase
to 5–25 mcg/kg/d divided q6h
(max: 0.9 mg/d)
Severe Pain
Adult: Epidural Start infusion
at 30 mcg/h and titrate to
response. Use rates >40
mcg/h with caution
Child: Epidural Start infusion
at 0.5 mcg/kg/h and titrate to
response
ADDH
Child: PO 5 mcg/kg/d in 4
divided doses (average dose,
Decreases systolic and diastolic
BP and heart rate. Orthostatic
effects tend to be mild and occur
infrequently. Reportedly
minimizes or eliminates many of
the common clinical S&S
associated with withdrawal of
heroin, methadone, or other
opiates.
CV: Hypotension (epidural), postural
hypotension (mild), peripheral
edema, ECG changes, tachycardia,
bradycardia, flushing, rapid increase
in BP with abrupt withdrawal.
GI: Dry mouth, constipation,
abdominal pain, pseudo-obstruction
of large bowel, altered taste, nausea,
vomiting, hepatitis,
hyperbilirubinemia, weight gain
(sodium retention).
CNS: Drowsiness, sedation, dizziness,
headache, fatigue, weakness,
sluggishness, dyspnea, vivid dreams,
nightmares, insomnia, behavior
changes, agitation, hallucination,
nervousness, restlessness, anxiety,
mental depression.
Skin: Rash, pruritus, thinning of hair,
exacerbation of psoriasis; with
transdermal patch:
hyperpigmentation, recurrent herpes
simplex, skin irritation, contact
dermatitis, mild erythema.
Special Senses: Dry eyes.
Urogenital: Impotence, loss of libido.
Pregnancy (category C), lactation. Use of
clonidine patch in polyarteritis nodosa,
scleroderma, SLE.
Be alert that rising BP indicating tolerance to
drug effect may occur during week 2 or 3 of
therapy.
Patient & Family Education
Exercise caution with hot baths and showers,
prolonged standing in one position, and
strenuous exercise that may enhance
orthostatic hypotension. Make position
changes slowly, particularly from lying down to
upright posture; dangle legs a few minutes
before standing.
Avoid potentially hazardous tasks such as
driving until response to drug is known; drug
may affect ability to perform activities
requiring concentrated mental effort,
especially during first few days of therapy or
whenever dosage is increased.
Do not to take OTC medications unless
approved by physician.
Do not breast feed while taking this drug
without consulting physician.
Assessment & Drug Effects
Monitor BR closely. Determine positional
changes (supine, sitting, standing).
With epidural administration, frequently
monitor BP and HR. Hypotension is a common
side effect that may require intervention.
Monitor BP closely whenever a drug is added
to or withdrawn from therapeutic regimen.
Monitor I&O during period of dosage
adjustment. Report change in I&O ratio or
change in voiding pattern.
Determine weight daily. Patients not receiving
a concomitant diuretic agent may gain weight,
particularly during first 3 or 4 d of therapy,
because of marked sodium and water
retention.
Supervise closely patients with history of
mental depression, as they may be subject to
further depressive episodes.
Patient & Family Education
Although postural hypotension occurs
infrequently, make position changes slowly,
and in stages, particularly from recumbent to
upright position, and dangle and move legs a
 0.15–0.2 mg/d) Transdermal
0.2–0.3 mg/d q5–7d
ALPHA-ADRENERGIC BLOCKERS
Oral
Prazosin Benign prostatic hyperplasia,
Raynaud's syndrome
Adult: 500 mcg bid for 3-7
days, adjust dose according to
response. Max maintenance
dose: 2 mg bid.
Oral
Heart failure
Adult: Initially, 500 mcg 2-4
times daily, gradually increase
according to response.
Maintenance: 4-20 mg daily in
divided doses.
Oral
Hypertension
Adult: Initially, 500 mcg bid or
tid for 3-7 days, then
increased to 1 mg bid or tid
for the next 3-7 days if
tolerated, then gradually
increase thereafter according
to patient's response. Max: 20
mg daily in divided doses.
Oral
Terazosin Benign prostatic hyperplasia
Adult: Initially, 1 mg at
bedtime, increased gradually
at weekly intervals according
competitively inhibits
postsynaptic alpha1-
adrenoreceptors in vascular
smooth muscles, resulting to
vasodilation, and decrease in
total peripheral resistance and
blood pressure.
It competitively inhibits post-
synaptic α-receptors resulting to
relaxation of peripheral blood
vessels leading to gradual
decrease in blood pressure
Significant: Angina, CNS depression,
floppy iris syndrome, orthostatic
hypotension, syncope, loss of
consciousness, priapism.
Cardiac disorders: Dyspnoea,
palpitations, tachycardia.
Ear and labyrinth disorders: Tinnitus.
Eye disorders: Reddened sclera,
blurred vision, eye pain.
Gastrointestinal disorders: Vomiting,
diarrhoea, constipation, dry mouth,
abdominal pain.
General disorders and administration
site conditions: Asthenia.
Metabolism and nutrition
disorders: Oedema.
Nervous system
disorders: Paraesthesia, vertigo.
Psychiatric disorders: Insomnia,
depression, nervousness.
Respiratory, thoracic and mediastinal
disorders: Nasal congestion.
Skin and subcutaneous tissue
disorders: Rash.
Vascular disorders: Epistaxis, flushing,
vasculitis.
Significant: First-dose hypotensive
episodes (e.g. postural hypotension,
syncope), orthostatic hypotension,
priapism, floppy iris syndrome during
cataract surgery, drowsiness,
Conditions:
● orthostatic hypotension
● a form of low blood pressure
● cataract surgery
● floppy iris during eye surgery
History of micturition syncope in the treatment
of BPH.
few minutes before standing. Lie down
immediately if faintness or dizziness occurs.
Avoid potentially hazardous activities until
reaction to drug has been determined due to
possible sedative effects.
Do not omit doses or stop the drug without
consulting the physician.
Do not take OTC medications, alcohol, or other
CNS depressants without prior discussion with
physician.
Examine site when transdermal patch is
removed and report to physician if erythema,
rash, irritation, or hyperpigmentation occurs.
If transdermal patch loosens, tape it in place
with adhesive. The patch should never be cut
or trimmed.
Do not breast feed while taking this drug.
– Obtain baseline vital signs
• BP and HR
– Check for respiratory problems
– Check urine output
– Advise not to ABRUPTLY stop beta blockers
as REBOUND hypertension, tachycardia, and
angina attack may occur
– Monitor blood sugar
– Teach measures to avoid orthostatic
hypotension
– Mood changes may occur with beta blockers
– Beta blockers may cause impotence or
decreased libido
– Obtain baseline vital signs
• BP and HR
– Check for respiratory problems
– Check urine output
– Advise not to ABRUPTLY stop beta blockers
to patient’s response.
Maintenance: 5-10 mg once
daily.
Oral
Hypertension
Adult: As monotherapy or in
combination with diuretics or
other antihypertensive
agents: Initially, 1 mg at
bedtime, increased gradually
at weekly intervals according
to patient’s response.
Maintenance: 2-10 mg once
daily. Max: 20 mg daily in 1 or
2 divided doses.
followed by sustained somnolence. as REBOUND hypertension, tachycardia, and
antihypertensive action. Blood and lymphatic system angina attack may occur
disorders: Thrombocytopenia. – Monitor blood sugar
Cardiac disorders: Palpitations, – Teach measures to avoid orthostatic
tachycardia, arrythmia, atrial hypotension
fibrillation, chest pain. – Mood changes may occur with beta blockers
Endocrine disorders: Tinnitus. – Beta blockers may cause impotence or
Eye disorders: Blurred vision, decreased libido
amblyopia, visual impairment,
conjunctivitis.
General disorders and administration
site conditions: Asthenia, pyrexia, flu
symptoms.
Immune system
disorders: Anaphylactoid reaction,
angioedema, face oedema.
Investigations: Weight increased,
decreased hematocrit, decreased Hb,
decreased WBC count, decreased
total protein, decreased blood
albumin.
Metabolism and nutrition
disorders: Peripheral oedema,
oedema,
Musculoskeletal and connective
tissue disorders: Back pain, pain in
extremity, neck pain, shoulder pain,
gout, arthralgia, arthritis, joint
disorders, myalgia.
Nervous system disorders: Headache,
paraesthesia, vertigo.
Psychiatric disorders: Depression,
nervousness, anxiety, insomnia.
Renal and urinary
disorders: Pollakiuria, UTI, urinary
incontinence.
Reproductive system and breast
disorders: Libido decreased, erectile
dysfunction.
Respiratory, thoracic and mediastinal
disorders: Nasal congestion, rhinitis,
dyspnea, sinusitis, bronchitis,
pharyngitis, cold symptoms, cough.
Skin and subcutaneous tissue
disorders: Pruritus, rash,
hyperhidrosis.
Vascular disorders: Vasodilation,
epistaxis.
ADRENERGIC NEURON BLOCKERS
Guanethidine Hypertension
Adult: PO 10 mg once/d, may
be increased by 10 mg q5–7d
up to 300 mg/d (start with
25–50 mg/d in hospitalized
patients, increase by 25–50
mg q1–3d)
Geriatric: PO Start with 5 mg
once daily
Child: PO 0.2 mg/kg/d, may
increase by 0.2 mg/kg q1–3wk
if needed (max: 1–1.6
mg/kg/d)
It is more effective in lowering
orthostatic than supine BP.
Antihypertensive effect results
from venous dilatation with
peripheral pooling, decreased
venous return, and decreased
cardiac output.
CV: Marked orthostatic and exertional Pheochromocytoma, frank CHF (not due to
hypotension with dizziness, light-
headedness; bradycardia,
symptomatic sick sinus syndrome
(weakness, dizziness, blurred vision);
angina, edema with weight gain, CHF,
complete heart block.
Special Senses: Blurred vision, ptosis
of eyelids, parotid tenderness, nasal
congestion.
GI: Severe diarrhea, nausea,
vomiting, constipation, dry mouth.
Urogenital: Nocturia, urinary
retention, incontinence, inhibition of
ejaculation, impotence.
Skin: Skin eruptions, loss of scalp hair.
Other: Dyspnea, psychic depression,
weakness, fatigue, myalgia, tremor,
chest paresthesias, asthma, rise in
BUN, polyarteritis nodosa.
hypertension). Safe use during pregnancy
(category C) is not established.
Assessment & Drug Effects
Take BP first in supine position and then again
after patient has been standing for 10 min.
Ideal dosage reduces standing BP to within
normal range without faintness, dizziness,
weakness, or fatigue.
Monitor I&O, especially in older adults and
patients with limited cardiac reserve or
impaired renal function. Report changes in I&O
ratio.
Observe for evidence of edema and weight
gain. Sudden weight gain of 1 kg (2 lb) in 24 h
or more should be reported to physician.
Patients with limited cardiac reserve are
particularly susceptible to guanethidine-
induced sodium and water retention, with
resulting edema, CHF, and drug resistance.
Observe patients on antidiabetic therapy
closely for signs of hypoglycemia.
Patient & Family Education
Do not stop drug without consulting physician.
Ask for assistance with walking; older adults
are prone to develop orthostatic hypotension.
Understand that orthostatic hypotension is
most prominent shortly after arising from sleep
and when too rapid changes are made to
sitting or upright positions. Move gradually to
sitting position and make all position changes
slowly and in stages. Flex arms and legs slowly
before standing to augment venous return.
Orthostatic hypotension is intensified by
prolonged standing, hot baths or showers, hot
weather, alcohol ingestion, and strenuous
physical exercise (particularly if followed by
immobility).
Lie down or sit down (in head-low position)
immediately at the onset of dizziness,
weakness, or faintness.
Consult physician regarding allowable salt
intake.
Reduced dosage in presence of febrile
illnesses. Report fever to physician.
Consult physician or pharmacist before taking
any OTC drug; guanethidine may sensitize the
patient to some sympathomimetic agents

Guanadrel Hypertension
Adult: PO 5 mg b.i.d., may
increase up to 20–75 mg/d in
2–4 divided doses
Geriatric: PO Start with 5 mg
once daily
Blocking the release of
norepinephrine leads to
catecholamine depletion with
resulting relaxation of vascular
smooth muscle, reduction of
peripheral vascular resistance,
lowering of systolic and diastolic
BP, and a relative increase in
parasympathetic tone.
Decreases standing more than
supine BP and is more effective
in lowering systolic than diastolic
BP.
Body as a Whole: Musculoskeletal
aches, pains, or inflammation;
excessive weight gain or loss,
peripheral edema.
CNS: Fatigue, headache, drowsiness,
paresthesias, tremors, confusion,
depression or other psychologic
problems, sleep disorders.
CV: Morning orthostatic hypotension
(light-headedness, weakness),
orthostatic hypotension during the
day, palpitation, chest pain.
GI: Diarrhea, or increased number of
stools, indigestion, constipation, dry
mouth and thirst, anorexia, glossitis,
nausea, vomiting, abdominal distress
or pain.
Urogenital: Nocturia, urine retention,
urinary urgency or frequency,
hematuria, impaired ejaculation,
impotence.
Special Senses: Visual disturbances,
nasal stuffiness.
Respiratory: Cough, shortness of
breath at rest or with exercise.
Pheochromocytoma, CHF, patients taking MAO
INHIBITORS. Safe use during pregnancy (category
B), lactation, or in children is not established. Monitor and record BP in supine position and
found in OTC cold remedies and cause
hypertensive crisis.
Do not breast feed while taking this drug.
Assessment & Drug Effects
after standing 2–20 min. Record baseline
measurements for future comparison
purposes.
Evaluate the full effect of guanadrel on
standing (orthostatic) BP carefully before
discharging the hospitalized patient. For
ambulatory patients, take BP measurements
following exercise for complete assessment.
Monitor patients closely with cerebrovascular,
coronary artery, or peripheral vascular disease
because they are particularly prone to
orthostatic hypotension.
Monitor weight gain and assess for edema
formation. Guanadrel tends to enhance
sodium and water retention, but these effects
are generally controlled by concurrent diuretic
therapy.
Patient & Family Education
Be aware of the possibility of orthostatic
hypotension; do not get out of bed without
assistance during initial dosage adjustment
period. Make position changes slowly and in
stages, especially from recumbent to upright
posture throughout drug therapy.
Lie down immediately at first hint of faintness,
dizziness, weakness, or light-headedness. All
are possible manifestations of orthostatic
hypotension.
Monitor weight, check legs and ankles for
edema, and note if rings or shoes suddenly
seem too tight. Notify physician of peripheral
edema or unexpected weight gain of 1 kg (2
lb)/d.
Take drug at the same time(s) each day, in
relation to a daily routine activity.
Note: Most adverse effects disappear or at
least diminish in intensity after about 8 wk of
therapy.
Do not use OTC drugs for treatment of colds,
allergy, asthma, or appetite suppressants
without consulting the physician or
pharmacist. Many of these products contain

DIRECT-ACTING ARTERIOLAR VASODILATOR
Isosorbide dinitrate As noted under CLINICAL
(Isordil) PHARMACOLOGY, multiple-
dose studies with ISDN and
other nitrates have shown
that maintenance of
continuous 24-hour plasma
levels results
in refractory tolerance. Every
dosing regimen for Isordil
Titradose tablets must
provide a daily dose-free
interval to minimize the
development of this
tolerance. With immediate-
release ISDN, it appears that
one daily dose-free interval
must be at least 14 hours
long.
As also noted under CLINICAL
PHARMACOLOGY, the effects
of the second and later doses
have been smaller and
shorter-lasting than the
effects of the first.
Large controlled studies with
other nitrates suggest that no
dosing regimen with Isordil
Titradose tablets should be
expected to provide more
than about 12 hours of
continuous anti-anginal
efficacy per day.
As with all titratable drugs, it
is important to administer the
minimum dose which
produces the desired clinical
effect. The usual starting dose
of Isordil Titradose is 5 mg to
20 mg, two or three times
daily. For maintenance
therapy, 10 mg to 40 mg, two
or three times daily is
recommended. Some patients
may require higher doses. A
Isordil (isosorbide dinitrate) is a
nitrate indicated for the
prevention of angina due
to coronary artery
disease and congestive heart
failure. Isordil is available
in generic form.
Adverse reactions to isosorbide
dinitrate are generally dose-related,
and almost all of these reactions are
the result of isosorbide dinitrate’s
activity as a vasodilator. Headache,
which may be severe, is the most
commonly reported side effect.
Headache may be recurrent with
each daily dose, especially at higher
doses. Transient episodes of
lightheadedness, occasionally related
to blood pressure changes, may also
occur. Hypotension occurs
infrequently, but in some patients it
may be severe enough to warrant
discontinuation of therapy. Syncope,
crescendo angina, and rebound
hypertension have been reported but
are uncommon.
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.
adrenergic (sympathomimetic) amines, which
may interfere with hypotensive action of
guanadrel.
Do not breast feed while taking this drug
without consulting physician.
Assessment & Drug Effects
Neonates born to mothers who are receiving
atenolol at parturition or breast–feeding may
be at risk for hypoglycemia.
Check apical pulse before giving oral drug,
especially in patients receiving digitalis (both
drugs slow AV conduction). If below 60 bpm
(or other ordered parameter), withhold dose
and consult physician.
Monitor apical pulse, BP, respirations, and
peripheral circulation throughout dosage
adjustment period. Consult physician for
acceptable parameters.
Patient & Family Education
Adhere rigidly to dose regimen. Sudden
discontinuation of drug can exacerbate angina
and precipitate tachycardia or MI in patients
with coronary artery disease, and thyroid
storm in patients with hyperthyroidism.
Make position changes slowly and in stages,
particularly from recumbent to upright
posture.
Do not breast feed while taking this drug.
 daily dose-free interval of at
least 14 hours is advisable to
minimize tolerance. The
optimal interval will vary with
the individual patient, dose
and regimen.
Hydralazine Initiate therapy in gradually
(Apresoline) increasing dosages; adjust
according to individual
response. Start with 10 mg
four times daily for the first 2-
4 days, increase to 25 mg four
times daily for the balance of
the first week. For the second
and subsequent weeks,
increase dosage to 50 mg four
times daily. For maintenance,
adjust dosage to the lowest
effective levels.
The incidence of toxic
reactions, particularly the L.E.
cell syndrome, is high in the
group of patients receiving
large doses of Apresoline
(hydralazine) .
In a few resistant patients, up
to 300 mg of Apresoline
(hydralazine) daily may be
required for a significant
antihypertensive effect. In
such cases, a lower dosage of
Apresoline (hydralazine)
combined with a thiazide
and/or reserpine or a beta
blocker may be considered.
However, when combining
therapy, individual titration is
essential to ensure the lowest
possible therapeutic dose of
each drug.
ALPHA1 AND BETA1-ADRENERGIC BLOCKERS
Labetalol Hypertension
Adult: PO 100 mg b.i.d., may
gradually increase to 200–400
mg b.i.d. (max: 1200–2400
mg/d). IV 20 mg slowly over 2
min, with 40–80 mg q10min if
needed up to 300 mg total or
Apresoline is a prescription
medicine used to treat the
symptoms of
Severe Essential Hypertension,
chronic high blood
pressure, Hypertensive Crisis,
and Congestive Heart Failure.
Apresoline may be used alone or
with other medications.
Apresoline belongs to a class of
drugs called Vasodilators.
Acts as an adrenergic receptor
blocking agent that combines
selective alpha activity and
nonselective beta-adrenergic
blocking actions. Both actions
contribute to blood pressure
reduction.
Adverse reactions with Apresoline
(hydralazine) are usually reversible
when dosage is reduced. However, in
some cases it may be necessary to
discontinue the drug. The following
adverse reactions have been
observed, but there has not been
enough systematic collection of data
to support an estimate of their
frequency.
CNS: Dizziness, fatigue/malaise,
headache, tremors, transient
paresthesias (especially scalp
tingling), hypoesthesia (numbness)
following IV, mental depression,
drowsiness, sleep disturbances,
nightmares.
Hypersensitivity to hydralazine; coronary artery
disease; mitral valvular rheumatic heart disease.
Bronchial asthma; uncontrolled cardiac failure,
heart block (greater than first degree),
cardiogenic shock, severe bradycardia. Safe use
during pregnancy (category C), lactation, or in
children is not established.
Assessment & Drug Effects
Neonates born to mothers who are receiving
atenolol at parturition or breast–feeding may
be at risk for hypoglycemia.
Check apical pulse before giving oral drug,
especially in patients receiving digitalis (both
drugs slow AV conduction). If below 60 bpm
(or other ordered parameter), withhold dose
and consult physician.
Monitor apical pulse, BP, respirations, and
peripheral circulation throughout dosage
adjustment period. Consult physician for
acceptable parameters.
Patient & Family Education
Adhere rigidly to dose regimen. Sudden
discontinuation of drug can exacerbate angina
and precipitate tachycardia or MI in patients
with coronary artery disease, and thyroid
storm in patients with hyperthyroidism.
Make position changes slowly and in stages,
particularly from recumbent to upright
posture.
Do not breast feed while taking this drug.
Assessment & Drug Effects
Monitor BP and pulse during dosage
adjustment period. Use standing BP as
indicator for making dosage adjustments for
oral drugs and assessing patient's tolerance of
dosage increases. Take after patient stands for
 2 mg/min continuous infusion
(max: 300 mg total dose)
Geriatric: PO Start with 100
mg daily IV 20 mg slowly over
2 min, with 40–80 mg q10min
if needed up to 300 mg total
or 2 mg/min continuous
infusion (max: 300 mg total
dose)
Carteolol Hypertension
Adult: PO 2.5 mg once/d, may
increase to 5–10 mg if needed
(max: 10 mg/d)
Open-Angle Glaucoma
Adult: Ophthalmic 1 drop in
affected eye b.i.d.
Effective antihypertensive agent
by reducing BP to normotensive
range and useful in mananging
some angina, dysrhythmias, and
CHF by decreasing myocardial
oxygen demand and lowering
cardiac work load.
CV: Postural hypotension, angina
pectoris, palpitation, bradycardia,
syncope, pedal or peripheral edema,
pulmonary edema, CHF, flushing, cold
extremities, arrhythmias (following
IV), paradoxical hypertension
(patients with pheochromocytoma).
Special Senses: Dry eyes, vision
disturbances, nasal stuffiness,
rhinorrhea.
GI: Nausea, vomiting, dyspepsia,
constipation, diarrhea, taste
disturbances, cholestasis with or
without jaundice, increases in serum
transaminases, dry mouth.
Urogenital: Acute urinary retention,
difficult micturition, impotence,
ejaculation failure, loss of libido,
Peyronie's disease
Respiratory: Dyspnea,
bronchospasm.
Skin: Rashes of various types,
increased sweating, pruritus.
Body as a Whole: Myalgia, muscle
cramps, toxic myopathy,
antimitochondrial antibodies, positive
antinuclear antibodies (ANA), SLE
syndrome, pain at IV injection site.
Body as a Whole: Rash, muscle
cramps, bronchospasm.
CV: Increased angina, hypotension,
CHF, bradycardia.
GI: Abdominal pain, diarrhea, nausea. pregnancy (category C).
Endocrine: Hyperglycemia.
CNS: Headache, dizziness,
Sinus bradycardia, greater than first-degree heart Assessment & Drug Effects
block, cardiogenic shock, CHF secondary to
tachycardia treatable with beta-blockers, overt
cardiac failure, hypersensitivity to beta-blocking pulse is less than 50 bpm, withhold drug and
agents, persistent severe bradycardia, bronchial notify physician.
asthma or bronchospasm, and severe COPD;
10 min. Clarify with physician.
Monitor BP at 5 min intervals for 30 min after
IV administration; then at 30 min intervals for 2
h; then hourly for about 6 h; and as indicated
thereafter.
Monitor diabetic patients closely; drug may
mask usual cardiovascular response to acute
hypoglycemia (e.g., tachycardia).
Convert from IV to PO therapy only when
supine diastolic pressure rises about 10 mm
Hg.
Maintain patient in supine position for at least
3 h after IV administration. Then determine
patient's ability to tolerate elevated and
upright positions before allowing ambulation.
Manage this slowly.
Patient & Family Education
Note: Postural hypotension is most likely to
occur during peak plasma levels (i.e., 2–4 h
after drug administration).
Make all position changes slowly and in stages,
particularly from lying to upright position.
Older adult patients are especially sensitive to
hypotensive effects.
Do not drive or engage in other potentially
hazardous activities until response to drug is
known.
Note: Most adverse effects (e.g., scalp tingling)
are mild, transient, and dose related and occur
early in therapy.
Be sure to keep follow-up appointments. Get
liver and kidney function tests periodically
during therapy.
Discontinue drug gradually over 1–2 wk period
after chronic administration. Close monitoring
during this time is very important.
Do not breast feed while taking this drug
without consulting physician.
Assess heart rate prior to administration. If
Monitor BP and pulse frequently during period
of adjustment and periodically throughout
therapy.
If hypotension (systolic BP <90 mm Hg) occurs,
discontinue the drug and carefully assess the
 drowsiness, insomnia, anxiety, hemodynamic status of the patient.
tremor, paresthesia, weakness. Monitor daily weight and assess for evidence
of fluid overload since drug may precipitate
CHF (see Signs & Symptoms, Appendix F).
Monitor mental status. Mental depression may
be increased by use of this drug.
Assess respiratory status closely if the patient
has history of bronchitis or emphysema, assess
for respiratory difficulty.
Monitor diabetic for loss of diabetic control.
Drug may prevent the appearance of early S&S
of acute hypoglycemia (see Appendix F).
Drug may reduce tolerance to cold
temperatures in older adults or in those who
have circulatory problems.

Patient & Family Education

Report the first sign or symptom of impending

CHF (see Signs & Symptoms, Appendix F) or
unexplained respiratory symptoms.
Do not discontinue medication abruptly, since
sudden withdrawal may precipitate or
exacerbate angina.
Do not use any OTC products such as nasal
decongestants and cold preparations without
consultation.
Report slow pulse rate, confusion or
depression, dizziness or light-headedness, skin
rash, fever, sore throat, or unusual bleeding or
bruising.
Be cautious while driving or performing other
hazardous activities until response to drug is
known.
Continue to take this medication as instructed
by your physician no matter how well you feel.
Take your BP at least twice a week and report
significant changes.
Take your pulse before and after taking the
medication. If it is much slower than normal
rate (or less than 50 bpm), check with your
physician.
Do not breast feed while taking this drug
without consulting physician.
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
Captopril Hypertension Effective in stepped protocol Body as a Whole: Hypersensitivity Angioedema, hypersensitivity to captopril or ACE Assessment & Drug Effects
Adult: PO 6.25–25 mg t.i.d., management of hypertension to reactions, serum sickness-like inhibitors; hypotension; pregnancy (category D),
may increase to 50 mg t.i.d. convert to normotensive range, reaction, arthralgia, skin eruptions. lactation. Monitor BP closely following the first dose. A
(max: 450 mg/d) and in congestive heart failure sudden exaggerated hypotensive response may
Child: PO 0.3–12.5 mg/kg with resulting decreases in CV: Slight increase in heart rate, first occur within 1–3 h of first dose, especially in
 q12–24h, may titrate up to
max of 6 mg/kg/d in 2–4
divided doses
Infant: PO 0.15–0.3 mg/kg,
may titrate up to 6 mg/kg/d in
1–4 divided doses
Neonate: PO 0.05–0.1 mg/kg
q8–24 h, may titrate up to 0.5
mg/kg q6–24 h
Premature infant: PO 0.01
mg/kg q8–12h
Congestive Heart Failure
Adult: PO 6.25–12.5 mg t.i.d.,
may increase to 100 mg t.i.d.
(max: 450 mg/d)
Renal Insufficiency
Clcr 10–50 mL/min = 75% of
dose, Clcr <10 mL/min = 50%
of dose
Lisinopril Hypertension
Adult: PO 10 mg once/d, may
increase up to 20–40 mg 1–2
times/d (max: 80 mg/d)
Child: PO 6–16 y, Start at 0.07
mg/kg (max 5 mg) once/d
(max: 40 mg/d)
Geriatric: PO Initial 2.5–5
mg/d, may increase by 2.5–5
mg/d every 1–2 wk (max: 40
mg/d).
dyspnea and improved exercise
tolerance.
Improved cardiac output and
exercise tolerance due to
inhibition of ACE also decreases
circulating aldosterone, which is
normally released in response to
angiotensin II stimulation.
Reduced aldosterone is
associated with a potassium-
sparing effect. Also decreases
peripheral resistance (afterload)
and pulmonary vascular
dose hypotension, dizziness, fainting.
GI: Altered taste sensation (loss of
taste perception, persistent salt or
metallic taste); weight loss, intestinal
angioedema.
Hematologic: Hyperkalemia,
neutropenia, agranulocytosis (rare).
Respiratory: cough. Skin:
Maculopapular rash, urticaria,
pruritus, angioedema,
photosensitivity.
Urogenital: Azotemia, impaired renal
function, nephrotic syndrome,
membranous glomerulonephritis.
Other: Positive antinuclear antibody
(ANA) titers.
CNS: Headache, dizziness, fatigue.
CV: Hypotension, chest pain.
GI: Nausea, vomiting, diarrhea,
anorexia, constipation, intestinal
angioedema.
Hematologic: Neutropenia.
Respiratory: Dyspnea, cough.
Patients with a history of angioedema related to
treatment with an ACE inhibitor, ACE inhibitor
hypersensitivity; pregnancy (category D),
children <6 y; lactation.
those with high BP or on a diuretic and
restricted salt intake.
Advise bed rest and BP monitoring for the first
3 h after the initial dose.
Monitor therapeutic effectiveness. At least 2
wk of therapy may be required before full
therapeutic effects are achieved.
Lab tests: Establish baseline urinary protein
levels before initiation of therapy and check at
monthly intervals for the first 8 mo of
treatment and then periodically thereafter.
Perform WBC and differential counts before
therapy is begun and at approximately 2-wk
intervals for the first 3 mo of therapy and then
periodically thereafter.
Patient & Family Education
Report to physician without delay the onset of
unexplained fever, unusual fatigue, sore mouth
or throat, easy bruising or bleeding
(pathognomonic of agranulocytosis).
Mild skin eruptions are most likely to appear
during the first 4 wk of therapy and may be
accompanied by fever and eosinophilia.
Consult physician promptly if vomiting or
diarrhea occur.
Report darkening or crumbling of nailbeds
(reversible with dosage reduction).
Taste impairment occurs in 5–10% of patients
and generally reverses in 2–3 mo even with
continued therapy.
Use OTC medications only with approval of the
physician. Inform surgeon or dentist that
captopril is being taken. Alert diabetic patient
that captopril may produce hypoglycemia.
Monitor blood glucose and HbA1c closely
during first few weeks of therapy.
Do not breast feed while taking this drug.
Assessment & Drug Effects
Place patient in supine position and notify
physician if sudden and severe hypotension
occurs within the first 1–5 h after initial drug
dose; possible particularly in patients who are
sodium- or volume-depleted because of
diuretic therapy.
Measure BP just prior to dosing to determine
whether satisfactory control is being
maintained for 24 h. If the antihypertensive
 resistance. effect is diminished in less than 24 h, an
Heart Failure Skin: Rash. Metabolic: Azotemia, increase in dosage may be necessary.
Adult: PO 5–40 mg/d hyperkalemia, increased BUN, and Monitor closely for angioedema of extremities,
creatinine levels. face, lips, tongue, glottis, and larynx.
Discontinue drug promptly and notify physician
if such symptoms appear; carefully monitor for
airway obstruction until swelling is relieved.
Monitor serum sodium and serum potassium
levels for hyponatremia and hyperkalemia.
Lab tests: Determine WBC count prior to
initiation of treatment, every month for the
first 3–6 mo of therapy, and at periodic
intervals for 1 y. Withhold therapy and notify
physician if neutropenia (neutrophil count
<1000/mm3) develops; kidney function tests at
periodic intervals, especially in patients with
severe volume or sodium replacement or those
with severe CHF.

Patient & Family Education

Discontinue drug and contact physician

immediately for severe hypersensitivity
reaction (e.g., hoarseness, swelling of the face,
mouth, hands, or feet, or sudden trouble
breathing).
Be aware of importance of proper diet,
including sodium and potassium restrictions.
Do NOT use salt substitute containing
potassium.
Continued compliance with high BP medication
is very important. If a dose is missed, take it as
soon as possible but not too close to next
dose.
Do not drive or engage in other potentially
hazardous activities until response to the drug
is known.
With concomitant therapy, lisinopril increases
the risk of lithium toxicity.
Notify physician promptly of any indication of
infection (e.g., sore throat, fever).
Do not store drug in a moist area. Heat and
moisture may cause the medicine to break
down.
Do not breast feed while taking this drug.
ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs)
Losartan (Cozaar) TABLET Selectively blocks the binding of CNS: Dizziness, insomnia, headache. Selectively blocks the binding of angiotensin II to Assessment & Drug Effects
25mg angiotensin II to the GI: Diarrhea, dyspepsia. the AT1 receptors found in many tissues (e.g.,
50mg AT1 receptors found in many Musculoskeletal: Muscle cramps, vascular smooth muscle, adrenal glands). Monitor BP at drug trough (prior to a
100mg tissues (e.g., vascular smooth myalgia, back or leg pain. Respiratory: Antihypertensive effect results from blocking the scheduled dose).

HTN 50 mg once daily, may be Antihypertensive effect results
increased to 100 mg once
daily. Patient w/ intravascular vasoconstricting and
vol-depletion 25 mg once
daily. Reduction in the risk of angiotensin II.
CV morbidity & mortality in
patient w/ left ventricular
hypertrophy 50 mg once daily.
A low dose of
hydrochlorothiazide should be
added &/or the dose of
losartan K should be
increased to 100 mg once
daily based on BP response.
Nephropathy in type 2
diabetic patient w/
proteinuria 50 mg once daily,
may be increased to 100 mg
once daily.
Valsartan (Diovan) TABLET
40mg
80mg
160mg
320mg
Adult HTN 80 or 160 mg once
daily. May be increased to
320 mg once daily or add
another antihypertensive (eg,
diuretic) if BP reduction is
inadequate. Heart failure
Initially 40 mg bid, up-titrated
to 80 & 160 mg bid as
tolerated. Max: 320 mg daily
in divided doses. Post-MI
Initially 20 mg bid, up-titrated
to a max of 160 mg bid as
tolerated. Hypertensive
patients w/ IGT at CV risk
Progression of type 2 diabetes
80 or 160 mg once daily.
When started on 80 mg, up-
titrate to 160 mg as tolerated.
Childn & adolescents 6-18 yr
HTN Initially 40 mg (<35 kg)
or 80 mg (≥35 kg) once daily.
muscle, adrenal glands).
from blocking the
aldosterone-secreting effects of
Blocks angiotensin II, which
results in vasodilation and
blocking of the aldosterone-
secreting effects of angiotensin
II, thus resulting in an
antihypertensive effect.
Nasal congestion, cough, upper
respiratory infection, sinusitis.
Body as a Whole: Arthralgia. CNS:
Headache, dizziness.
GI: Diarrhea, nausea.
Respiratory: Cough, sinusitis.
Metabolic: Hyperkalemia.
DIURETICS
THIAZIDE-LIKE
vasoconstricting and aldosterone-secreting
effects of angiotensin II.
Hypersensitivity to valsartan or losartan;
pregnancy [(category C) first trimester, (category
D) second and third trimesters], lactation; severe Monitor BP periodically; take trough readings,
heart failure with compromised renal function.
Monitor drug effectiveness, especially in
African-Americans when losartan is used as
monotherapy.
Inadequate response may be improved by
splitting the daily dose into twice-daily dose.
Lab tests: Monitor CBC, electrolytes, liver &
kidney function with long-term therapy.
Patient & Family Education
Notify physician of symptoms of hypotension
(e.g., dizziness, fainting).
Notify physician immediately of pregnancy.
Do not breast feed while taking this drug.
Assessment & Drug Effects
just prior to the next scheduled dose, when
possible.
Lab tests: Monitor liver function tests, BUN
and creatinine, serum potassium, and CBC with
differential, periodically.
Patient & Family Education
Inform physician immediately if you become
pregnant.
Note: Maximum pressure lowering effect is
usually evident between 2 and 4 wk after
initiation of therapy.
Notify physician of episodes of dizziness,
especially those that occur when making
position changes.
Do not breast feed while taking this drug.
CHLORTHALIDONE Hypertension Antihypertensive effect is correlated to CV: Orthostatic hypotension. GI: Anorexia, Hypersensitivity to sulfonamide derivatives; anuria,
the decrease in extracellular and nausea, vomiting, diarrhea, constipation, hypokalemia; pregnancy (category B), lactation.  Establish baseline BP measurements and check
Adult: PO 12.5–25 mg/d,
intracellular volumes. Decreased cramping, at regular intervals during period of dosage
may be increased to 100
volume results in reduced cardiac jaundice. Hematologic: Agranulocytosis, adjustment when chlorthalidone is used for
mg/d if needed
output with subsequent decrease in thrombocytopenia, aplastic hypertension.
Child: PO 2 mg/kg 3 peripheral resistance. anemia. CNS: Dizziness, vertigo,  Be alert to signs of hypokalemia (see Appendix
times/wk paresthesias, F). Older adult patients are more sensitive to
headache. Metabolic: Hypokalemia, hypona adverse effects of drug-induced diuresis because
Edema tremia, hypochloremia, hypercalcemia, of age-related changes in the cardiovascular and
Adult: PO 50–100 mg/d, glycosuria, hyperglycemia, exacerbation of renal systems.
may be increased to 200 gout. Skin: Rash, urticaria, photosensitivity,  Lab tests: Baseline and periodic: serum
mg/d if needed vasculitis. Urogenital: Impotence. electrolytes (particularly K, Mg, Ca), serum uric
acid, creatinine, BUN, and uric acid and blood
glucose (especially in patients with diabetes).
 Monitor lithium and digoxin levels closely when
either of these drugs is used concurrently.

METOLAZONE Edema Produces a decrease in the systolic and GI: Cholestatic jaundice. Body as a Anuria, hypokalemia; hepatic coma or precoma;
Adult: PO 5–20 mg/d diastolic BPs, and reduces edema in Whole: Vertigo, orthostatic hypersensitivity to metolazone and sulfonamides;  Anticipate overdosage and adverse reactions in
Child: PO 0.2–0.4 mg/kg/d CHF and kidney failure patients. hypotension. Hematologic: Venous pregnancy (category D), lactation. geriatric patients; may be more sensitive to
divided q12–24h Appears to be more effective as a thrombosis, effects of usual adult dose.
diuretic than thiazides in patients with leukopenia. Metabolic: Dehydration, hypok  Terminate therapy when adverse reactions are
Hypertension severe kidney failure. alemia, hyperuricemia, hyperglycemia. moderate to severe.
 Expect possible antihypertensive effects in 3 or
Adult: PO 2.5–5 mg/d;
4 d, but 3–4 wk are required for maximum
(Mykrox) 0.5–1 mg/d
effect.
 Lab tests: Determine serum potassium at regular
intervals. Prolonged treatment and inadequate
potassium intake increase potential for
hypokalemia (see Appendix F). Periodic plasma
glucose and urinalysis determinations.

LOOP DIURETICS
BUMETANIDE Edema Inhibits sodium and chloride Body as a Whole: Sweating, Hypersensitivity to bumetanide or to other sulfonamides;
Adult: PO 0.5–2 mg reabsorption by direct action on hyperventilation, anuria, markedly elevated BUN; hepatic coma; severe  Monitor I&O and report onset of oliguria or
once/d, may repeat at 4–5 proximal ascending limb of the loop of glycosuria. CNS: Dizziness, headache, electrolyte deficiency; lactation. Safety during pregnancy other changes in I&O ratio and pattern
h intervals if needed Henle. Also appears to inhibit weakness, fatigue. CV: Hypotension, ECG (category C) is not established. promptly.
(max: 10 mg/d) IV/IM 0.5– phosphate and bicarbonate changes, chest  Monitor weight, BP, and pulse rate. Assess for
1 mg over 1–2 min, reabsorption. Produces only mild pain, hypovolemia. GI: Nausea, vomiting, hypovolemia by taking BP and pulse rate while
hypotensive effects at usual diuretic abdominal or stomach pain, GI distress, patient is lying, sitting, and standing. Older
repeated q2–3h prn (max:
doses. diarrhea, dry adults are particularly at risk for hypovolemia
10 mg/d)
mouth. Metabolic: Hypokalemia, hyponatre with resulting thrombi and emboli.
Neonate: PO/IM/IV 0.01–
mia, hyperuricemia,  Lab tests: Serum electrolytes, blood studies,
0.05 mg/kg q24–48h hyperglycemia; hypomagnesemia; decreased liver and kidney function tests, uric acid
Infant/Child: PO/IM/IV calcium, chloride. Musculoskeletal: Muscle (particularly patients with history of gout), and
0.015–0.1 mg/kg q6–24h cramps, muscle pain, stiffness or tenderness; blood glucose. Determine values initially and at
(max: 10 mg/d) arthritic pain. Special Senses: Ear regular intervals; measurements are especially
discomfort, ringing or buzzing in ears, important in patients receiving prolonged
impaired hearing. treatment, high doses, or who are on sodium
restriction.
 Monitor for S&S of hypomagnesemia and
hypokalemia (see Appendix F) especially in
those receiving digitalis or who have CHF,
hepatic cirrhosis, ascites, diarrhea, or
potassium-depleting nephropathy.
 Monitor patients with hepatic disease carefully
for fluid and electrolyte imbalances which can
precipitate encephalopathy (inappropriate
behavior, altered mood, impaired judgment,
 confusion, drowsiness, coma).
 Question patient about hearing difficulty or ear
discomfort. Patients at risk of ototoxic effects
include those receiving the drug IV, especially at
high doses, those with severely impaired renal
function, and those receiving other potentially
ototoxic or nephrotoxic drugs (see Appendix F).
 Monitor diabetics for loss of glycemic control.

ETHACRYNIC ACID Edema Rapid and potent diuretic effect. Fluid CNS: Headache, fatigue, apprehension,
Adult: PO 50–100 mg 1–2 and electrolyte loss may exceed that confusion. CV: Postural
times/d, may increase by caused by thiazides. Hypotensive hypotension (dizziness, light-
25–50 mg prn up to 400 effect may be due to hypovolemia headedness). Metabolic: Hyponatremia, hyp
mg/d IV 0.5–1 mg/kg or secondary to diuresis and in part to okalemia, hypochloremic alkalosis,
50 mg up to 100 mg, may decreased vascular resistance. hypomagnesemia, hypocalcemia,
hypercalciuria, hyperuricemia, hypovolemia,
repeat if necessary
hematuria, glycosuria, hyperglycemia,
Child: PO 1 mg/kg q.d.,
gynecomastia, elevated BUN, creatinine, and
may increase to 3
urate levels. Special Senses: Vertigo,
mg/kg/d tinnitus, sense of fullness in ears, temporary
or permanent deafness. GI: Anorexia,
diarrhea, nausea, vomiting, dysphagia,
abdominal discomfort or pain, GI bleeding
(IV use), abnormal liver function
tests. Hematologic: Thrombocytopenia,
agranulocytosis (rare), severe
neutropenia (rare). Skin: Skin rash,
pruritus. Body as a Whole: Fever, chills,
acute gout; local irritation and
thrombophlebitis with IV injection.
History of hypersensitivity to ethacrynic acid; increasing
azotemia, anuria; hepatic coma; severe diarrhea,
dehydration, electrolyte imbalance, hypotension;
lactation, infants, parenteral use in pediatric patients.
 Observe closely when receiving the drug by IV
infusion. Rapid, copious diuresis following IV
administration can produce hypotension.
 Monitor IV site closely. Extravasation of IV
drug causes local pain and tissue irritation from
dehydration and blood volume depletion.
 Monitor BP during initial therapy. Because
orthostatic hypotension can occur, supervise
ambulation.
 Monitor BP and pulse throughout therapy in
patients with impaired cardiac function.
Diuretic-induced hypovolemia may reduce
cardiac output, and electrolyte loss promotes
cardiotoxicity in those receiving digitalis
(cardiac) glycosides.
 Establish baseline weight prior to start of
therapy; weigh patient under standard
conditions. Keep physician informed of weight
loss or gain in excess of 1 kg (2 lb)/d.
 Monitor I&O ratio. Drug should be
discontinued if excessive diuresis, oliguria,
hematuria, or sudden profuse diarrhea occurs.
Report signs to physician.
 Lab tests: Determine baseline and periodic
blood count, serum electrolytes, CO2, BUN,
creatinine, blood glucose, uric acid, and liver
function.
 Observe for and report S&S of electrolyte
imbalance: Anorexia, nausea, vomiting, thirst,
dry mouth, polyuria, oliguria, weakness, fatigue,
dizziness, faintness, headache, muscle cramps ,
paresthesias, drowsiness, mental confusion.
Instruct patient to report these symptoms
promptly to physician.
 Report immediately possible signs of
thromboembolic complications (see Appendix
F).
 Impaired glucose tolerance with hyperglycemia
and glycosuria has occurred in patients
receiving doses in excess of 200 mg/d.

OSMOTIC DIURETIC
MANNITOL Acute Kidney Induces diuresis by raising osmotic CNS: Headache, tremor, convulsions, Anuria; marked pulmonary congestion or edema; severe
pressure of glomerular filtrate, thereby dizziness, transient muscle CHF; metabolic edema; organic CNS disease, intracranial  Take care to avoid extravasation. Observe
Failure inhibiting tubular reabsorption of rigidity. CV: Edema, CHF, angina-like pain, bleeding; shock, severe dehydration, history of allergy; injection site for signs of inflammation or
Adult: IV Test Dose 0.2 water and solutes. Reduces elevated hypotension, hypertension, pregnancy (category C), lactation; concomitantly with edema.
g/kg or 12.5 g as a 15– intraocular and cerebrospinal pressures thrombophlebitis. Eye: Blurred blood.  Lab tests: Monitor closely serum and urine
 20% solution over 3–5
min Positive
Response 30–50 mL of
urine over next 2–3 h,
may repeat test dose 1
time. If still negative, do
not use. Treatment 50–
100 g as 15–20% solution
over 90 min to several
hours
Child: IV Test Dose 200
mg/kg (max: 12.5 g) over
3–5 min Positive
Response Urine flow of 1
mL/kg/h for 1–2
h Maintenance 0.25–0.5
g/kg q4–6 h
by increasing plasma osmolality, thus
inducing diffusion of water from these
fluids back into plasma and
extravascular space.
vision. GI: Dry mouth, nausea, electrolytes and kidney function during therapy.
vomiting. Urogenital: Marked diuresis,  Measure I&O accurately and record to achieve
urinary retention, nephrosis, proper fluid balance.
uricosuria. Metabolic: Fluid and electrolyte  Monitor vital signs closely. Report significant
imbalance, especially hyponatremia; changes in BP and signs of CHF.
dehydration, acidosis. Other: With  Monitor for possible indications of fluid and
extravasation (local edema, skin necrosis; electrolyte imbalance (e.g., thirst, muscle
chills, fever, allergic reactions). cramps or weakness, paresthesias, and signs of
CHF).
 Be alert to the possibility that a rebound
increase in ICP sometimes occurs about 12 h
after drug administration. Patient may complain
of headache or confusion.
 Take accurate daily weight.

Edema, Ascites
Adult: IV 100 g as a 10–
20% solution over 2–6 h

Elevated IOP or
ICP
Adult: IV 1.5–2 mg/kg as
a 15–25% solution over
30–60 min

Acute Chemical
Toxicity
Adult: IV 100–200 g
depending on urine
output

Measurement of
GFR
Adult: IV 100 mL of 20%
solution diluted with 180
mL NaCl injection infused
at a rate of 20 mL/min
UREA Reduction of Intracranial
or Intraocular Pressure,
Diuresis
Adult: IV 1–1.5 g/kg of
30% solution infused
slowly over 1–2.5 h at a
rate not to exceed 4
mL/min (max: 120 g/24 h)
Child: IV >2 y, 0.5–1.5
g/kg of 30% solution
infused slowly over 1–2.5
h at a rate not to exceed
4 mL/min; <2 y, 0.1–0.5
g/kg of 30% solution
infused slowly over 1–2.5
Volume and rate of urine flow is
increased. Increased blood toxicity
results in transudation of fluid from
tissue, including brain, cerebrospinal,
and intraocular fluid into the blood.
When used as an abortifacient, urea
(in dextrose) is injected into amniotic
sac, followed by IV oxytocin at a rate
of about 400 mU/min or prostaglandin
F2.
CNS: Somnolence (prolonged use in patients
with kidney dysfunction), headache, acute
psychosis, confusion, disorientation,
nervousness. CV: Tachycardia, hypotension,
syncope. GI: Nausea, vomiting, increased
thirst. Metabolic: Fluid and electrolyte
imbalance, dehydration. Special
Senses: Intraocular hemorrhage (rapid
IV). Skin: Skin rash, pain, irritation,
sloughing, venous thrombosis, chemical
phlebitis at injection site. Body as a
Whole: Hyperthermia. Hematologic: Hemo
lysis (rapid IV).
Severely impaired liver or kidney function; CHF; active
intracranial bleeding; marked dehydration; IV injection
into lower extremities, especially in older adult patients;
topical use for viral skin diseases or impaired circulation.
(Contraindications for intraamniotic urea: impaired
kidney function, frank liver failure, active intracranial
bleeding; marked dehydration, diabetes mellitus, sickle
cell anemia.)
 Monitor I&O. If diuresis does not occur within
6–12 h following administration or if BUN
exceeds 75 mg/dL, withhold drug and notify
physician so that kidney function may be
evaluated.
 Monitor vital signs and mental status; promptly
report any changes.
 Observe postoperative patients closely for signs
of hemorrhage. Urea reportedly may increase
prothrombin time and promote internal oozing
at suture sites.
 Withhold oral fluids and consult physician for
hydration parameters if patient complains of a
headache.
 Lab tests: Serum electrolytes and urinary
 h at a rate not to exceed
4 mL/min
Hydration of Dry Skin
Adult: Topical Apply 2–
40% cream or lotion to
affected area 1–3 times/d
Second-Trimester Abortion
Adult: Intraamniotic Instill
40–50% urea solution in
5% dextrose in volumes
equal to amount of
amniotic fluid removed
(max: 200–250 mL)
DORZOLAMIDE Glaucoma, Ocular
Hypertension
Adult/Child: Ophthalmic 1
drop in affected eye t.i.d.
DICLOFENAC Rheumatoid
SODIUM Arthritis
Adult: PO 150–200 mg/d
in 3–4 divided doses
Child: PO 25 mg b.i.d. or
t.i.d.
Osteoarthritis
Adult: PO 100–150 mg/d
in 3–4 divided doses 100
mg sustained release q.d.
Ankylosing
Spondylitis
Adult: PO 25 mg q.i.d.
and 25 mg h.s.
Cataract Surgery
Adult: Ophthalmic 1 drop
of 0.1% solution in
affected eye q.i.d.
beginning 24 h after
surgery and continuing for
2 wk
Actinic Keratosis
Lowers IOP in glaucoma or ocular
hypertension.
Nonsteroidal antiinflammatory drug
(NSAID) with analgesic and antipyretic
activity.
CARBONIC ANHYDRASE INHIBITORS
CNS: Headache. GI: Bitter taste,
nausea. Special Senses: Transient burning
or stinging, transient blurred
vision, superficial punctate keratitis, tearing,
dryness, photophobia, ocular allergic
reaction. Skin: Rash.
CNS: Dizziness, headache,
drowsiness. Special
Senses: Tinnitus. Skin: Rash,
pruritus. GI: Dyspepsia, nausea, vomiting,
abdominal pain, cramps, constipation,
diarrhea, indigestion, abdominal distension,
flatulence, peptic ulcer; liver enzymes,
transaminases increased, liver test
abnormalities. CV: Fluid retention,
hypertension,
CHF. Respiratory: Asthma. Body as a
Whole: Back, leg, or joint
pain. Endocrine: Hyperglycemia. Hematol
ogic: Prolonged bleeding time; inhibits
platelet aggregation.
Previous hypersensitivity to dorzolamide; pregnancy
(category C).
Hypersensitivity to diclofenac, patients in whom asthma,
urticaria, angioedema, bronchospasm, severe rhinitis,
shock, or other sensitivity reaction is precipitated by
aspirin or other NSAIDS, pregnancy (category B),
lactation.
sodium q12h. Frequent kidney function studies
are advised, particularly in patients suspected of
having kidney dysfunction.
 Watch for S&S of hyponatremia, hypokalemia,
dehydration, or transient overhydration (due to
hyperosmotic activity) (see Appendix F).
 Monitor for complaints of lower abdominal pain
following intraamniotic instillation. If patient
complains of lower abdominal pain, it may be
that drug is going into abdomen rather than into
the amniotic sac.
 See mannitol for additional nursing
implications.
 Inquire about previous hypersensitivity to
sulfonamides prior to therapy.
 Withhold drug and notify physician if S&S of
local or systemic hypersensitivity occur (see
Appendix F).
 Withhold the drug and notify the physician if
ocular irritation occurs.
 Lab tests: Monitor CBC, serum electrolytes, and
renal and liver function tests periodically with
long-term therapy.
 Monitor for therapeutic effectiveness. Up to 3
wks may be needed for beneficial effects with
rheumatoid arthritis or osteoarthritis.
 Lab tests: Periodic liver function, serum uric
acid concentrations Hct, PT/INR, and blood
glucose.
 Observe and report signs of bleeding (e.g.,
petechiae, ecchymoses, bleeding gums, bloody
or black stools, cloudy or bloody urine).
 Monitor BP for hypertension and blood sugar
for hyperglycemia.
 Monitor diabetics closely for loss of diabetic
control.
 Monitor for increased serum sodium and
potassium in patients receiving potassium-
sparing diuretics.
 Monitor weight and report gains greater than 1
kg (2 lb)/24 h.
 Monitor for signs and symptoms of GI irritation
and ulceration.
 Adult: Topical Apply to
affected area b.i.d. for 60–
90 d
METOLAZONE Edema
Adult: PO 5–20 mg/d
Child: PO 0.2–0.4 mg/kg/d
divided q12–24h
Hypertension
Adult: PO 2.5–5 mg/d;
(Mykrox) 0.5–1 mg/d
HYDROCHLOROTHI Edema
AZIDE Adult: PO 25–200 mg/d in
1–3 divided doses
Hypertension
Adult: PO 12.5–100 mg/d
in 1–2 divided doses
Child: PO 2.2 mg/kg/d in 2
divided doses
Neonate: PO <6 mo, 2–4
mg/kg/d in 2 divided
doses
CHOLESTYRAMINE Hypercholesterolemia
(QUESTRAN) Adult: PO 4 g b.i.d. to
q.i.d. a.c. and h.s., may
need up to 24 g/d
Child: PO 240 mg/kg/d in
3 divided doses
Hyperlipoproteinemia
Adult: PO 4–8 g b.i.d. to
q.i.d. a.c. and h.s. (32 g/d)
Pruritus
Adult: PO 4 g b.i.d. to
q.i.d. a.c. and h.s. (16 g/d)
Produces a decrease in the systolic and
diastolic BPs, and reduces edema in
CHF and kidney failure patients.
Appears to be more effective as a
diuretic than thiazides in patients with
severe kidney failure.
It has hypotensive action, elevates
plasma renin activity, and precipitates
diabetes in the prediabetic patient.
The resin anion-exchange agent
increases fecal loss of bile acids which
leads to lowered serum total
cholesterol by decreasing (LDL)
cholesterol, and reducing bile acid
deposit in dermal tissues (decreasing
pruritus). Serum triglyceride levels
may increase or remain unchanged.
POTASSIUM-SPARING DIURETICS
GI: Cholestatic jaundice. Body as a
Whole: Vertigo, orthostatic
hypotension. Hematologic: Venous
thrombosis,
leukopenia. Metabolic: Dehydration, hypok
alemia, hyperuricemia, hyperglycemia.
CNS: Mood changes, unusual tiredness or
weakness, dizziness, light-headedness,
paresthesias. CV: Irregular heartbeat, weak
pulse, orthostatic hypotension. GI: Dry
mouth, increased thirst, nausea, vomiting,
anorexia, diarrhea, pancreatitis,
jaundice. Hematologic: Agranulocytosis,
thrombocytopenia, aplastic anemia,
leukopenia. Metabolic: Hyperglycemia, glyc
osuria, hyperuricemia,
hypokalemia. Other: Hypersensitivity
reactions, photosensitivity, blurred vision,
yellow vision (xanthopsia), muscle spasm.
ANTILIPIDEMICS
BILE ACID SEQUESTRANT
Adverse
GI: Constipation, fecal impaction,
hemorrhoids, abdominal pain and
distension, flatulence, bloating sensation,
belching, nausea, vomiting, heartburn,
anorexia, diarrhea,
steatorrhea. Endocrine: Increased
libido. Metabolic: Weight loss or gain, iron,
calcium, vitamin A, D, and K deficiencies
(from poor absorption);
hypoprothrombinemia, hyperchloremic
acidosis, decreased erythrocyte folate
levels. Skin: Rash, irritations of skin,
tongue, and perianal areas. Special
Senses: Arcus juvenilis, uveitis.
Anuria, hypokalemia; hepatic coma or precoma;
hypersensitivity to metolazone and sulfonamides;
pregnancy (category D), lactation.
Hypersensitivity to thiazides or other sulfonamides;
anuria, pregnancy (category B), lactation.
Contra
Complete biliary obstruction, hypersensitivity to bile acid
sequestrants; pregnancy (category C), lactation. Safe use
in children 6 y not established.
 Anticipate overdosage and adverse reactions in
geriatric patients; may be more sensitive to
effects of usual adult dose.
 Terminate therapy when adverse reactions are
moderate to severe.
 Expect possible antihypertensive effects in 3 or
4 d, but 3–4 wk are required for maximum
effect.
 Lab tests: Determine serum potassium at regular
intervals. Prolonged treatment and inadequate
potassium intake increase potential for
hypokalemia (see Appendix F). Periodic plasma
glucose and urinalysis determinations.
 Monitor for therapeutic effectiveness.
Antihypertensive effects may be noted in 3–4 d;
maximal effects may require 3–4 wk.
 Lab tests: Baseline and periodic determinations
of serum electrolytes, blood counts, BUN, blood
glucose, uric acid, CO2, are recommended.
 Check BP before initiation of therapy and at
regular intervals.
 Monitor closely for hypokalemia; it increases
the risk of digoxin toxicity.
 Monitor I&O and check for edema.
 Note: Drug may cause hyperglycemia and loss
of glycemic control in diabetics.
 Note: Drug may cause orthostatic hypotension,
dizziness.
 Monitor therapeutic effect. Serum cholesterol
levels are reduced within 24–48 h after
treatment starts and may continue to decline for
a year. After withdrawal of cholestyramine,
cholesterol levels usually return to baseline level
in about 2 to 4 wk.
 Be alert to early symptoms of
hypoprothrombinemia (petechiae, ecchymoses,
abnormal bleeding from mucous membranes,
tarry stools) and report their occurrence
promptly. Long-term use of cholestyramine
resin can increase bleeding tendency.
 Preexisting constipation may be worsened in the
older adult, women, and in those taking >24 g/d.
 Consult physician regarding supplemental
vitamins A and D and folic acid that may be
required by patient on long-term therapy.
  Lab tests: Periodic CBC, platelet count, serum
electrolytes, and lipid profile.

COLESTIPOL Hypercholesterolemia Binds with bile acids in Body as a Whole: Joint and muscle pain, Complete biliary obstruction, hypersensitivity to bile acid
(COLESTID) Adult: PO 15–30 g/d in 2–4 intestinal tract to form an arthritis, shortness of sequestrants; pregnancy (category C), lactation. Safe use  Watch for changes in bowel elimination pattern.
doses a.c. and h.s., or 1–2insoluble complex that is breath. GI: Constipation, abdominal pain or in children not established. Constipation should not be allowed to persist
tabs 1–2 times/d excreted in the feces, thus distention, belching, flatulence, nausea, without medical attention.
reducing circulating vomiting, diarrhea. Metabolic: Transient  Lab test: Monitor serum sodium and potassium
Digitalis Toxicity cholesterol and increasing increases in liver enzyme tests, serum levels. Monitor for and report S&S of
phosphorus and chloride; decreases in serum hyponatremia and hypokalemia (see Appendix
Adult: PO 10 g followed by serum LDL removal rate.
sodium and potassium. Skin: Dermatitis, F).
5 g q6–8h as needed Serum triglycerides are not
urticaria.
affected or are minimally
increased.
FIBRIC ACID
CLOFIBRATE Hyperlipidemia Reduces very low density lipoproteins CV: Increase or decrease in angina, CHF, Impaired renal or hepatic function, primary biliary
Adult: PO 2 g/d in 2–4 (VLDL) to a greater extent than it arrhythmias. GI: Nausea, vomiting, loose cirrhosis; pregnancy (category C), lactation. Safe use in  Lab tests: Baseline and periodic lipid profile;
divided doses reduces low density lipoproteins stools, diarrhea, flatulence, abdominal children <14 y not established. periodic liver function tests, CBC, renal
(LDL). distress, gastritis, stomatitis, function tests, and determinations of plasma and
Diabetes Insipidus cholelithiasis. Hematologic: Neutropenia, urine steroid levels, serum electrolyte levels, and
Adult: PO 1.5–2 g/d in 2–4 leukopenia, anemia, blood glucose.
eosinophilia, agranulocytosis, potentiation  Therapeutic response generally occurs during
divided doses
of anticoagulant effect. Metabolic: Elevated the first or second month of therapy. Rebound
AST and ALT. Musculoskeletal: Flu-like may occur in second or third month, followed by
symptoms. CNS: Drowsiness, dizziness, a further decrease, and may also occur with
headache. Skin: Swelling and phlebitis at sudden withdrawal of drug.
xanthoma sites, skin rash, allergy, urticaria,  Clofibrate therapy for increased serum
pruritus. Urogenital: Renal insufficiency, cholesterol and triglycerides is generally
impotence, decreased libido. withdrawn after 3 mo if the response is not
adequate.

FENOFIBRATE Hypertriglyceridemia
Adult: PO 54 mg q.d.
(max: 160 mg/d)
Indicated by reduction in the level of
serum triglycerides; interferes with
synthesis of serum triglycerides.
Body as a Whole: Asthenia, fatigue,
infections, flu-like syndrome, localized pain,
arthralgia. CNS: Headache, paresthesia,
dizziness,
insomnia. CV: Arrhythmia. GI: Dyspepsia,
eructation, flatulence, nausea, vomiting,
abdominal pain, constipation, diarrhea,
increased appetite. Respiratory: Cough,
rhinitis, sinusitis. Skin: Pruritus,
rash. Special Senses: Earache, eye floaters,
blurred vision, conjunctivitis, eye
irritation, Urogenital: Decreased libido,
polyuria, vaginitis.
Hypersensitivity to fenofibrate or other fibric acid
derivatives (e.g., clofibrate, benzofibrate); liver or severe
kidney dysfunction; unexplained liver function
abnormality; primary biliary cirrhosis; preexisting
gallbladder disease; pregnancy (category C); lactation;
thrombocytopenia. Safety and efficacy in children are not
established.
 Lab tests: Periodically monitor lipid levels, liver
functions, and CBC with differential.
 Discontinue therapy after 2 mo if adequate lipid
reduction is not achieved with the maximum
dose of 201 mg/d.
 Assess for muscle pain, tenderness, or weakness
and, if present, monitor CPK level. Withdraw
drug with marked elevations of CPK or if
myopathy is suspected.
 Monitor patients on coumarin-type drugs
closely for prolongation of PT/INR.

NIACIN (B2) Niacin Deficiency
Adult: PO 10–20 mg/d
IV/IM/SC 25–100 mg 2–5
times/d
Pellagra
Adult: PO 300–500 mg/d
in divided doses
Child: PO 50–100 mg t.i.d.
Hyperlipidemia
Produces vasodilation by direct action
on vascular smooth muscles. Inhibits
hepatic synthesis of VLDL,
cholesterol and triglyceride, and,
indirectly, LDL. Large doses
effectively reduce elevated serum
cholesterol and total lipid levels in
hypercholesterolemia and
hyperlipidemic states.
NICOTINIC ACID
CNS: Transient headache, tingling of
extremities, syncope. With chronic use:
nervousness, panic, toxic amblyopia,
proptosis, blurred vision, loss of central
vision. CV: Generalized flushing with
sensation of warmth, postural hypotension,
vasovagal attacks, arrhythmias
(rare). GI: Abnormalities of liver function
tests; jaundice, bloating, flatulence,
nausea, vomiting, GI disorders, activation of
peptic ulcer, xerostomia. Skin: Increased
sebaceous gland activity, dry skin, skin
Hypersensitivity to niacin; hepatic impairment; severe
hypotension; hemorrhaging or arterial bleeding; active
peptic ulcer; pregnancy (category C), lactation, and
children <16 y.
 Monitor therapeutic effectiveness and record
effect of therapy on clinical manifestations of
deficiency (fiery red tongue, excessive saliva
secretion and infection of oral membranes,
nausea, vomiting, diarrhea, confusion).
Therapeutic response usually begins within 24
h.
 Lab tests: Obtain baseline and periodic tests of
blood glucose and liver function in patients
receiving prolonged high dose therapy.
 Monitor diabetics and patients on high doses
 Adult: PO 1.5–3 g/d in
divided doses, may
increase up to 6 g/d if
necessary
Child: PO 100–250 mg/d
in 3 divided doses, may
increase by 250 mg/d q2–
3 wk as tolerated
EZETIMIBE Hypercholesterolemia
Adult: PO 10 mg q.d.
ATORVASTATIN Hypercholesterolemia
Adult: PO Start with 10–40
mg q.d., may increase up
to 80 mg/d
Child/Adolescent: PO 10–
17 y: Start with 10 mg
q.d., may increase up to
20 mg/d
ROSUVASTATIN Hyperlipidemia
Adult: PO 10 mg once
daily (5–40 mg/d), max
dose 40 mg/d. If taking
cyclosporine, start with 5
mg/d.
Geriatric: Initial dose of 5
mg/d.
Renal Impairment
Clcr <30 mL/min: 5 mg
once daily (max: 10 mg/d)
Lowers both total cholesterol and low-
density lipid (LDL) cholesterol; its
mechanism of action is complimentary
to statins.
Atorvastatin reduces LDL and total
triglyceride (TG) production as well as
increases the plasma level of high-
density lipids (HDL).
Reduces total cholesterol and LDL
cholesterol, and also lowers plasma
triglycerides and apolipoprotein B
while increasing HDL.
rash, pruritus, keratitis
nigricans. Metabolic: Hyperuricemia,
hyperglycemia, glycosuria,
hypoprothrombinemia, hypoalbuminemia.
CHOLESTEROL ABSORPTION INHIBITOR
Body as a Whole: Fatigue, arthralgia, back
pain, myalgia, angioedema,
myopathy. CNS: Dizziness,
headache. GI: Abdominal pain,
diarrhea. Respiratory: Pharyngitis,
sinusitis,
cough. Hematologic: Thrombocytopenia. S
kin: Rash. Other: Hepatitis, pancreatitis,
rhabdomyolysis.
STATINS
Body as a Whole: Back pain, asthenia,
hypersensitivity reaction, myalgia,
rhabdomyolysis. CNS: Headache. GI: Abdo
minal pain, constipation, diarrhea,
dyspepsia, flatulence, increased liver
function tests. Respiratory: Sinusitis,
pharyngitis. Skin: Rash.
Body as a Whole: Asthenia, back pain, flu
syndrome, chest pain, infection, pain,
peripheral edema. CNS: Headache,
dizziness, insomnia, hypertonia, paresthesia,
depression, anxiety, vertigo,
neuralgia. CV: Hypertension, angina,
vasodilatation, palpitations. GI: Diarrhea,
dyspepsia, nausea, abdominal pain,
constipation, gastroenteritis, vomiting,
flatulence,
gastritis. Endocrine: Diabetes. Hematologi
c: Anemia,
ecchymosis. Musculoskeletal: Myalgia,
arthritis, arthralgia, rhabdomyolysis
(especially with dose >40
mg). Respiratory: Pharyngitis, rhinitis,
sinusitis, bronchitis, increased cough,
Hypersensitivity to ezetimibe; concurrent use with HMG-
CoA reductase inhibitor in patients with active liver
disease or elevated serum transaminases; hepatic
insufficiency; concurrent administration with fibrates;
lactation; pregnancy (category C); children <10 y.
Hypersensitivity to atorvastatin, myopathy, active liver
disease, unexplained persistent transaminase elevations,
pregnancy (category X), lactation.
Hypersensitivity to any component of the product, active
liver disease, pregnancy (category X), women of child-
bearing potential not using appropriate contraceptive
measures, lactation.
closely. Hyperglycemia, glycosuria, ketonuria,
and increased insulin requirements have been
reported.
 Observe patients closely for evidence of liver
dysfunction (jaundice, dark urine, light-colored
stools, pruritus) and hyperuricemia in patients
predisposed to gout (flank, joint, or stomach
pain; altered urine excretion pattern).
 Lab tests: Monitor baseline and periodic lipid
profile; periodic Hgb & Hct and platelet count.
Monitor baseline LFTs and when used with a
statin, monitor periodic LFTs in accordance
with the monitoring schedule for that statin.
 Assess for and report unexplained muscle pain,
especially when used in combination with a
statin drug.
 Monitor closely patients who take both
ezetimibe and cyclosporine.
 Monitor for therapeutic effectiveness which is
indicated by reduction in the level of LDL-C.
 Lab tests: Monitor lipid levels within 2–4 wk
after initiation of therapy or upon change in
dosage; monitor liver functions at 6 and 12 wk
after initiation or elevation of dose, and
periodically thereafter.
 Assess for muscle pain, tenderness, or
weakness; and, if present, monitor CPK level
(discontinue drug with marked elevations of
CPK or if myopathy is suspected).
 Monitor carefully for digoxin toxicity with
concurrent digoxin use.
 Monitor for and report promptly S&S of
myopathy (e.g., skeletal muscle pain).
 Withhold drug and notify physician if CPK
levels are markedly elevated ( 10xULN) or if
myopathy is diagnosed or suspected.
 Lab tests: CPK levels for S&S of myopathy;
periodic LFTs; more frequent INR values with
concomitant warfarin therapy.
 Monitor CV status, especially with a known
history of hypertension or heart disease.
 Monitor diabetics for loss of glycemic control.
 dyspnea, pneumonia, asthma. Skin: Rash,
pruritus. Urogenital: UTI.

REFERENCE:

● RobHolland