Medications review I:

Zometa, Clonidine, PPI

El Housseiny Fatmé, SDC
Mazen Alame, chief Pharmacist
Clonidine: catapress
 Presentation: Ampoules of 150 mcg
 Category: Alpha 2 adrenergic agonist
 USE:
 Management of HTN crises, usual dose: 150-300mcg as slow injection over
10-15min , can be repeated in 24 hrs(max : 5 amp)
 ADHD (oral)
 Epidural (continues infusion) as add on with opioids for the treatment of
severe pain in cancer patient
 Heroin or nicotine withdrawal

 Mode of action :
 Stimulate alpha 2 adenoceptor in the brain stem -> activating the inhibitory
neuron -> resulting in reduced sympathetic out flow from the CNS ->
producing a decrease in peripheral resistance and renal vascular resistance ->
decrease HR and BP
Clonidine: catapress
 Side effects:
CV: bradycardia, palpitation , arrthymia,, hypotension
raynaud phenomena,OH
CNS: drowsiness , headache, flushing, sedation
Dermatologic: localized skin reaction
Endocrine : sexual dysfunction, hyperglycemia
GI: mostly xerostomia, constipation , Nausea and vomiting
Hematologic: thrombocytopenia
Hepatic : increase in LFTs (hepatic enzymes)
EYE : accommodation disorder ,lacrimation disorder
Respiratory : epistaxis, nasal congestion , nasal dryness
Clonidine: catapress
 Drug-drug interaction:
 Clonidine level may be increased with :b-blockers, PDE inhibitor
 Clonidine level may be decreased with: alpha 2 agonist, 5HT/NE reuptake
inhibitors, TCA
 Alcohol intake increase clonidine level
 Pregnancy and lactation:
 not recommended since it cross the placenta barrier and decrease the HR of
the fetus
 Stability:
 Once opened , use immediately and discard unused contents
 Do not store above 30 c
 Keep the ampoule in the carton
 Dosage adjustment:
 Bradycardia, sedation and hypotension may be more likely to occur in patient
with renal failure -> give the minimal dose
Clonidine: catapress
 Monitoring parameters:
 BP & HR (standing or sitting )
 Mental status: (DROWSINEES is common so patient should not drive)

 Nursing considerations :
 Catapres ampoule are slowely injected into the vein over 10-15 min
 Catapres is not recommended in pediatric
 Oral clonidine may be taken with or without food
 Do not discontinue the drug abruptly -> gradually decrease the dose over
2-4days to avoid rebound hypertension
 Patches should be applied weekly at the same time to clean , non hairy
skin, on the upper outer arm ,rotate the patch site weekly , and redness
can be minimized by applying corticosteroid
ZOMETA
 Presentation: ampoules 4mg, 5ml
 Category: Bisphosphonate
 Use :
Hypercalcemia of malignancy.
Patients with multiple myeloma and patients with
documented bone metastases from solid tumors, in
conjunction with standard antineoplastic therapy.
Prostate cancer should have progressed after treatment with
at least one hormonal therapy.
Important limitation of use: The safety and efficacy of
Zometa has not been established for use in
hyperparathyroidism or non-tumor related hypercalcemia.
Zometa
 DOSAGE AND ADMINISTRATION:
 Hypercalcemia of malignancy
 4 mg as a single-use intravenous infusion over no less than 15 minutes.
 4 mg as retreatment after a minimum of 7 days.
 Multiple myeloma and bone metastasis from solid tumors
 4 mg as a single-use intravenous infusion over no less than 15 minutes every 3-4 weeks for
patients with creatinine clearance of greater than 60 mL/min.
 Reduce the dose for patients with renal impairment.
 Co administer oral calcium supplements of 500 mg and a multiple vitamin containing 400
international units of Vitamin D daily.
 Postmenopausal women require 1200mg Ca2+ and 800-1000IU vitamin D daily

 Special Dosing for Renal impairment:

 If Cr Clearance > 60: use the entire dose.
 If Cr Clearance 50-60: use 4.4ml of the vial.
 If Cr Clearance 40-50: use 4.1ml of the vial.
 If Cr Clearance 30-40: use 3.8ml of the vial.
 If Cr Clearance <30: Do not use Zometa.
Zometa
Stability of the drug:
Stable for 24hr after reconstitution if Refrigerated.
Administration:
Reconstitute with 5ml N/S (D5W).
Dilute in 100ml N/S (or D5W).
Infuse over 15-30min,
Flush lines before use.
Pre- med: Perfalgan 500mg, 30min before.
Zometa
Side effects:
nausea, vomiting
fatigue,
anemia,
bone pain,
constipation,
fever,
dyspnea,
hypocalcaemia, hypophosphatemia, and
hypomagnesaemia.
Zometa
 WARNINGS AND PRECAUTIONS:
 Patients being treated with Zometa should not be treated with ACLASTA®
 Adequately rehydrate patients with hypercalcemia of malignancy prior to
administration of Zometa and monitor electrolytes during treatment.
 Renal toxicity may be greater in patients with renal impairment. Do not use
doses greater than 4 mg. Treatment in patients with severe renal impairment
is not recommended. Monitor serum creatinine before each dose.
 Osteonecrosis of the jaw has been reported. Preventive dental exams should
be performed before starting Zometa. Avoid invasive dental procedures.
 Severe incapacitating bone, joint, and/or muscle pain may occur.
Discontinue Zometa if severe symptoms occur.
 Zometa is a pregnancy category D: can cause fetal harm. Women of
childbearing potential should be advised of the potential hazard to the fetus
and to avoid becoming pregnant.
Zometa
 WARNINGS AND PRECAUTIONS:
Atypical subtrochanteric and diaphyseal femoral fractures
have been reported in patients receiving bisphosphonate
therapy. These fractures may occur after minimal or no
trauma. Evaluate patients with thigh or groin pain to rule out
a femoral fracture. Consider drug discontinuation in patients
suspected to have an atypical femur fracture.
Hypocalcemia: Correct before initiating Zometa.
Adequately supplement patients with calcium and vitamin D
Administer through a separate vented infusion line and do
not allow coming in contact with any calcium or divalent
cation-containing solutions.
 Proton Pump Inhibitors
 Proton pump inhibitors (PPIs) are medicines that work by reducing
the amount of stomach acid made by glands in the lining of your
stomach.

 Mechanism of Action
 “The lack of the acid in the stomach will aid in the healing of duodenal
ulcers, and reduces the pain from indigestion and heartburn, which can
be exacerbated by stomach acid”.
 Acts as a pro-drug and must be activated by exposure to acidic pH (< 5).
 The activated species irreversibly binds to the H+, K+ - ATPase enzyme (proton
pump) in the parietal cell apical membrane inhibiting it’s activity. New enzyme
has to be synthesized to overcome the inhibition.
 Has little effect on gastric acid volume and does not affect gastric motility.
 Effective in decreasing gastric acid production by more than 95%.
PPI
 Indication
Dyspepsia
Peptic ulcer disease
Gastroesophageal reflux disease (GERD or GORD)
Laryngopharyngeal reflux
Barrett's esophagus (abnormal change /metaplasia in the cells of
the lower portion of the esophagus)
Eosinophilic esophagitis
Stress gastritis prevention
Gastrinomas and other conditions that cause hypersecretion of acid
Zollinger-Ellison syndrome (gastrin-secreting tumor of the
pancreas that stimulates the acid-secreting cells of the stomach to
maximal activity)
 PPI:
 Types of PPIs
 Omeprazole 10, 20, 40mg (Risek)
 Esomeprazole 20, 40mg and 10mg sachet (Nexium)
 Lansoprazole 15, 30mg Tab (Lanzor, Takepron)
 Rabeprazole 10, 20mg tab (Pariet)
 Pantoprazole 20, 40mg (Pantozol)
 Dexlansoprazole (Kapidex)

 Dose and administration

 In general, all PPIs are considered to be equivalent at their standard doses. No evidence exists to
support clinical superiority of any PPI over another.
 Rabeprazole has been reported to have a faster onset of effect than other PPIs
 Esomeprazole appears to reduce diazepam clearance by 45% and reduce phenytoin and warfarin
metabolism.
 Lansoprazole and omeprazole are reported to be safe and effective for treating acid-related disorders in
children. Lansoprazole is approved for the treatment of GERD in children 1-11 years of age.
Recommended starting doses are 1.5mg/kg/day.
 Omeprazole, esomeprazole, and lansoprazole capsules may be opened and sprinkled on food or mixed
in orange juice.
PPIs
Dosage and administration:
Risek: Reconstitute with 5ml N/S or D5W. Dilute in
100ml D5W or N/S; Infuse over 20-30min. Stable for
6hrs in D5W and for 12hrs in N/S at room T0
Pantoprazole: can be given as IV push (reconstitute
40mg with 10ml N/S, given over 2min). or as infusion
(Reconstitute with 10ml N/S, Dilute with 100ml D5W,
N/S, or LR; Infuse over 15min.) Stable for 4days in
refrig If reconstituted only and Stable for 12hrs if diluted.
PPIs:
 Drug interactions and side effects
 Interaction with clopidogrel. Clopidogrel (Plavix): it's hard on the
lining of the stomach and intestines, so it increases the risk of
gastrointestinal bleeding. So we have to give PPIs along with. The
trouble is that PPIs — and omeprazole in particular — inhibit an
enzyme called CYP2C19 that's crucial to one of the metabolic steps
that activates clopidogrel and its effects. In 2009, the FDA issued a
strong warning that said patients taking clopidogrel should avoid
taking omeprazole (and, secondarily, the related drug Nexium)
because they may cut clopidogrel's effectiveness in half.
 Study says that it is better to give Pantoprazole with Plavix (no Dx-Dx
interaction).
 Another strategy that has been proposed but not tested is taking a PPI and
clopidogrel at separate times. PPIs work best if they are taken first thing in the
morning, before breakfast, and clopidogrel could be taken at night.
PPIs:
 Drug interactions and side effects
Fracture risk. Calcium is absorbed in the small
intestine, not the stomach. But low stomach acid levels
can have downstream effects, especially in the
duodenum, and some research shows that one of them
could be reduced absorption of calcium, which could
lead to osteoporosis.
Pneumonia risk. Normally, stomach acid creates a
fairly inhospitable environment for bacteria, but if acid
levels are reduced by PPIs, the bacteria count can go up.
C. difficile risk.
Iron and B12 deficiency. it's a mild effect
PPIs
Patient education and consultation
Avoid foods and beverages that aggravate heartburn
Decrease the size of portions at mealtimes
Avoid tight fitting clothing
Lose weight if overweight
Take the evening meal at least three hours before
bedtime
Avoid lying down after eating
Questions ???

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