Question

Look up the following drugs for Medication Evaluation.

Pepcid (Famotidine) IVPB	Heparin SubQ
Vancomycin IVPB	Insulin (NPH & Regular) SubQ
Lasix (Furosemide) PO	Digoxin (Lanoxin) PO
Zofran (Ondansetron) IM	Maalox (Magnesium    hydroxide/aluminum hydroxide) PO
PPD (Tubersol) ID Morphine Sulfate IM	Augmentin      (Amoxicillin/Clavulanate) PO

Include the following information about the medications:

Brand and Generic Name of Drug	Adverse Reactions
Action of Drug	Nursing Considerations
Indication and Dosage	Patient Education
Interactions

Answer 1

1.Famotidine -

Famotidine
fam-oh′tah-deen
Pepcid, Pepcid AC
Pepcid, Pepcid AC,
Peptic Guard, Ulcidine
CATEGORY AND SCHEDULE
Pregnancy Risk Category: B
Rx (10-mg tablets, 20-mg tablets, 40-mg tablets, injection, orally disintegrating tablets, oral suspension)
OTC (10-mg tablets, 20-mg tablets)
Classification: Gastrointestinal agents, antiulcer agents, histamine H2 receptor antagonist
Table of contents:
MECHANISM OF ACTION
PHARMACOKINETICS
Rapidly, incompletely absorbed from the GI tract. Protein binding: 15%-20%. Partially metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 2.5-3.5 h (increased with impaired renal function).
AVAILABILITY
CONTRAINDICATIONS
DIAGNOSTIC TEST EFFECTS
IV INCOMPATIBILITIES
IV COMPATIBILITIES
SERIOUS REACTIONS
MECHANISM OF ACTION
An antiulcer agent and gastric acid secretion inhibitor that inhibits histamine action at H2 receptors of parietal cells. Therapeutic Effect: Inhibits gastric acid secretion when fasting, at night, or when stimulated by food, caffeine, or insulin.
PHARMACOKINETICS
Route
Onset
Peak
Duration
PO
1 h
1-4 h
10-12 h
IV
0.5-1 h
0.5-3 h
10-12 h
Rapidly, incompletely absorbed from the GI tract. Protein binding: 15%-20%. Partially metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 2.5-3.5 h (increased with impaired renal function).
AVAILABILITY
Tablets (OTC): 10 mg, 20 mg.
Chewable tablets (OTC): 10 mg.
Gelcaps (OTC): 10 mg.
Tablets (Rx): 10 mg, 20 mg, 40 mg.
Orally Disintegrating Tablets (Rx): 20 mg, 40 mg.
Oral Suspension (Rx): 40 mg/5 mL.
Injection (Rx): 10 mg/mL (1-mL, 2-mL, 4-mL, 20-mL, 50-mL vials; premixed 20 mg/50 mL).
INDICATIONS AND DOSAGES
‣ Acute treatment of duodenal and gastric ulcers
PO
Adults, Elderly, Children 17 yr and older. 40 mg/day at bedtime.
Children 1-16 yr. 0.5 mg/kg/day at bedtime. Maximum: 40 mg/day.
‣ Duodenal ulcer maintenance
PO
Adults, Elderly, Children 17 yr and older. 20 mg/day at bedtime.
‣ Gastroesophageal reflux disease (GERD)
PO
Adults, Elderly, Children 12 yr and older. 20 mg twice a day (maximum 40 mg BID).
Children aged 1-11 yr. 1 mg/kg/day in 2 divided doses (maximum 40 mg BID).
Children aged 3-12 mo. 0.5 mg/kg/dose twice a day.
Children younger than 3 mo. 0.5 mg/kg/dose once a day.
‣ Esophagitis
PO
Adults, Elderly, Children 12 yr and older. 20-40 mg twice a day.
‣ Hypersecretory conditions
PO
Adults, Elderly, Children 12 yr and older. Initially, 20 mg q6h. May increase up to 160 mg q6h.
‣ Acid indigestion, heartburn (OTC)
PO
Adults, Elderly, Children 12 yr and older. 10-20 mg 15-60 min before eating. Maximum: 2 doses per
day.
‣ Usual parenteral dosage
IV
Adults, Elderly, Children 12 yr and older. 20 mg q12h.
Children 1-11 yr. 0.25-0.5 mg 1 kg q12h.
‣ Dosage in renal impairment
Dosing frequency is modified on the basis of creatinine clearance. May decrease dose by 50% or modify frequency, as follows:
Creatinine Clearance(mL/min)
Dosage Interval
10-50
q36-48h
< 10
q36-48h
OFF-LABEL USES
Urticaria, prevention of paclitaxel hypersensitivity reactions, stress ulcer prophylaxis in critically ill.
CONTRAINDICATIONS
Hypersensitivity to famotidine or other H2 antagonists.
INTERACTIONS
Drug
Causes decreased oral absorption of following medications: May decrease the absorption of azole antifungals (monitor), atazanavir (boost with ritonovir), cefpodoxime (separate oral doses by 2 h), cefuroxime (separate oral doses by 2 h), dasatinib (avoid), saquinavir (monitor), gefitinib (monitor), cefditoren (avoid use), some modified release dosage forms may be altered as well.
Cyclosporine: Histamine H2 antagonists may increase the serum concentration of cyclosporine (monitor).
Herbal and Food
None known.
DIAGNOSTIC TEST EFFECTS
May rarely cause decreases in WBC counts.
IV INCOMPATIBILITIES
Amphotericin B cholesteryl sulfate complex (Amphotec), azathioprine, azithromycin (Zithromax), cefepime (Maxipime), dantrolene, diazepam (Valium), ganciclovir (Cytovene), lansoprazole (Prevacid), minocycline (Minocin), pantoprazole (Protonix), piperacillin/tazobactam (Zosyn), rocuronium (Zemuron), sulfamethoxazole/trimethoprim.
IV COMPATIBILITIES
Acyclovir (Zovirax), alfentanil (Alfenta), allopurinol (Aloprim), amifostine (Ethyol), aminophylline, amiodarone, anakinra (Kineret), anidulafungin (Eraxis), ascorbic acid, atracurium (Tracrium), atropine, aztreonam (Azactam), benztropine (Cogentin), bivalirudin (Angiomax), bretylium, bumetanide (Bumex), buprenorphine (Buprenex), butorphanol (Stadol), calcium chloride, calcium gluconate, carboplatin, caspofungin (Cancidas), cefazolin, cefotaxime (Claforan), ceftazidime (Ceptaz, Fortaz, Tazicef, Tazidime), cefuroxime (Zinacef), chlorpromazine, cisatracurium (Nimbex), cisplatin, cladribine (Leustatin), clindamycin (Cleocin), cyclophosphamide (Cytoxan), cytarabine (Tarabine), dactinomycin (Cosmegen), daptomycin (Cubicin), dexamethasone sodium phosphate, dextran 40, digoxin (Lanoxin), diltiazem (Cardizem), diphenhydramine (Benadryl), dobutamine, docetaxel (Taxotere), dopamine, doripenem (Doribax), doxorubicin (Adriamycin), doxorubicin liposome (Doxil), droperidol (Inapsine), enalaprilat, epinephrine, epirubicin (Ellence), ertapenem (Invanz), erythromycin lactobionate, esmolol (Brevibloc), etoposide (VePesid), fenoldopam (Corlopam), fentanyl citrate (Sublimaze), filgrastim (Neupogen), fluconazole (Diflucan), fludarabine (Fludara), fluorouracil, folic acid, gemcitabine (Gemzar), gentamicin, granisetron (Kytril), heparin, hydrocortisone, hydrocortisone sodium succinate (Solu-Cortef), hydromorphone (Dilaudid), hydroxyzine, imipenem/cilastatin (Primaxin), isoproterenol (Isuprel), ketorolac, labetalol (Trandate), levofloxacin (Levaquin), lidocaine, linezolid (Zyvox), lorazepam (Ativan), magnesium sulfate, mannitol, melphalan (Alkeran), meperidine (Demerol), methotrexate, methylprednisolone sodium succinate (Solu-Medrol), metoclopramide (Reglan), metoprolol (Lopressor), metronidazole (Flagyl), midazolam, milrinone (Primacor), mitoxantrone (Novantrone), morphine, nafcillin, naloxone (Narcan), nicardipine (Cardene), nitroglycerin, norepinephrine (Levophed), ondansetron (Zofran), oxacillin, oxaliplatin (Eloxatin), oxytocin (Pitocin), paclitaxel (Taxol), palonosetron (Aloxi), pemetrexed (Alimta), penicillin G potassium, penicillin G sodium, phenylephrine (Neo-Synephrine), phytonadione, potassium chloride, potassium phosphates, procainamide, promethazine, propofol (Diprivan), propranolol (Inderal), protamine, ranitidine (Zantac), remifentanil (Ultiva), rituximab (Rituxan), sargramostim (Leukine), sodium acetate, sodium nitroprusside (Nitropress), succinylcholine (Anectine, Quelicin), sufentanil (Sufenta), tacrolimus (Prograf), teniposide (Vumon), theophylline, thiamine, thiotepa (Thioplex), ticarcillin (Ticar), ticarcillin/clavulanate potassium (Timentin), tigecycline (Tygacil), tirofiban (Aggrastat), tobramycin, trastuzumab (Herceptin), vecuronium (Norcuron), verapamil, vincristine (Vincasar), vinorelbine (Navelbine), voriconazole
(Vfend).
SIDE EFFECTS
Occasional (2%-10%)
Headache.
Rare (1% or less)
Constipation, diarrhea, dizziness.
SERIOUS REACTIONS
• Rare: agranulocytosis, pancytopenia, leukopenia, thrombocytopenia.
Nursing consideration and patient education :
Caution is warranted in patients with moderate to severe renal impairment because CNS adverse reactions may occur. Famotidine crosses the placenta and is distributed in breast milk. No age-related precautions have been noted in elderly patients. RPD and chewable tablets contain aspartame (caution: phenylketonuria).
Storage
Store tablets at controlled room temperature.
Store injection vials in the refrigerator; do not freeze. Store premixed infusion at room temperature. If solution freezes, bring to room temperature; allow sufficient time to solubilize.
Solution is stable for 7 days at room temperature when added to or diluted with most commonly used IV solutions. When added to or diluted with sodium bicarbonate injection, a precipitate may form. Diluted solutions of famotidine injection should be refrigerated and used within 48 h.
Administration
IV push: Dilute no more than 20 mg to total volume 5 or 10 mL and inject over not < 2 min.
IV infusion: Dilute with 50-100 mL of solution and administer over 15-30 min.
Shake oral suspension well prior to each use. For oral use to relieve symptoms, may give without regard to meals. To prevent symptoms, give 60 min before eating food that causes heartburn

2.Vancomycin
van-koe-mye′sin
Vancocin
CATEGORY AND SCHEDULE
Pregnancy Risk Category: B
Classification: Antibiotics, glycopeptides
Table of contents:
MECHANISM OF ACTION
PHARMACOKINETICS
AVAILABILITY
OFF-LABEL USES
CONTRAINDICATIONS
DIAGNOSTIC TEST EFFECTS
IV INCOMPATIBILITIES
IV COMPATIBILITIES
SERIOUS REACTIONS
MECHANISM OF ACTION
A tricyclic glycopeptide antibiotic that binds to bacterial cell walls, altering cell membrane permeability and inhibiting RNA synthesis. Therapeutic Effect: Bactericidal.
PHARMACOKINETICS
PO: Poorly absorbed from the GI tract. Some patients with enterocolitis may absorb effectively. Orally administered drug is primarily eliminated in feces. Parenteral: Widely distributed. Protein binding: 55%. Primarily excreted unchanged in urine. Not removed by hemodialysis. Half-life: 4-11 h (increased in impaired renal function).
AVAILABILITY
Capsules: 125 mg, 250 mg.
Powder for Injection: 500 mg, 1 g, 5 g, 10 g.
Infusion (Premix): 500 mg/100 mL, 1 g/200 mL.
INDICATIONS AND DOSAGES
‣ Treatment of bone, respiratory tract, skin, and soft-tissue infections, endocarditis, peritonitis, and septicemia; prevention of bacterial endocarditis in those at risk (if penicillin is contraindicated) when undergoing biliary, dental, GI, genitourinary, or respiratory surgery or invasive procedures
IV
Adults, Elderly. 15-18 mg/kg or
1 g q12h.
Children older than 1 mo.
40 mg/kg/day in divided doses q6-8h.
Neonates. Initially, 10-15 mg/kg q8-12h.
‣ Staphylococcal enterocolitis, antibiotic-associated pseudomembranous colitis caused by Clostridium difficile
PO
note: Oral vancomycin is not effective for systemic infection.
Adults, Elderly. 125-500 mg q6h for 7-10 days.
Children. 40 mg/kg/day in divided doses q6h for 7-10 days. Maximum: 2 g/day.
‣ Dosage in renal impairment
After a loading dose, subsequent dosages and frequency are modified based on creatinine clearance,
the severity of the infection,
and the serum concentration of
the drug.
OFF-LABEL USES
Treatment of brain abscess, perioperative infections, staphylococcal or streptococcal meningitis.
CONTRAINDICATIONS
Hypersensitivity.
INTERACTIONS
Drug
Aminoglycosides, amphotericin B, aspirin, bumetanide, carmustine, cisplatin, cyclosporine, ethacrynic acid, furosemide, streptozocin: May increase the risk of ototoxicity and nephrotoxicity of parenteral vancomycin.
Cholestyramine, colestipol: May decrease the effects of oral vancomycin.
Herbal
None known.
Food
None known.
DIAGNOSTIC TEST EFFECTS
May increase serum creatinine, BUN. Therapeutic peak serum level is 20-40 mcg/mL; therapeutic trough serum level is 10-20 mcg/mL. Toxic peak serum level is > 80 mcg/mL; toxic trough serum level is > 20
mcg/mL.
IV INCOMPATIBILITIES
Albumin, amphotericin B complex (Abelcet, AmBisome, Amphotec), aztreonam (Azactam), cefazolin (Ancef), cefepime (Maxipime), cefotaxime (Claforan), cefotetan (Cefotan), cefoxitin (Mefoxin), ceftazidime (Fortaz), ceftriaxone (Rocephin), cefuroxime (Zinacef), foscarnet (Foscavir), heparin, idarubicin (Idamycin), nafcillin (Nafcil), piperacillin and tazobactam (Zosyn), propofol (Diprivan), ticarcillin and clavulanate (Timentin).
IV COMPATIBILITIES
Amiodarone (Cordarone), calcium gluconate, diltiazem (Cardizem), hydromorphone (Dilaudid), insulin, lorazepam (Ativan), magnesium sulfate, midazolam (Versed), morphine, potassium chloride.
SIDE EFFECTS
Frequent
PO: Bitter or unpleasant taste, nausea, vomiting, mouth irritation (with oral solution).
Rare
Parenteral: Phlebitis, thrombophlebitis, or pain at peripheral IV site; dizziness; vertigo; tinnitus; chills; fever; rash; necrosis with extravasation.
PO: Rash.
SERIOUS REACTIONS
• Nephrotoxicity and ototoxicity may occur.
• “Red man” syndrome (redness on face, neck, arms, and back; chills; fever; tachycardia; nausea or vomiting; pruritus; rash; unpleasant taste) may result from too-rapid infusion.
• Neutropenia.
PRECAUTIONS & CONSIDERATIONS
Caution is warranted in patients with preexisting hearing impairment or renal dysfunction and in those taking other ototoxic or nephrotoxic medications concurrently. Vancomycin crosses the placenta; it is unknown whether it is distributed in breast milk. Close monitoring of serum drug levels is recommended in premature neonates and young infants. Age-related renal impairment may increase the risk of ototoxicity and nephrotoxicity in elderly patients. Dosage adjustment is recommended.
Notify the physician if rash, tinnitus, or signs and symptoms of nephrotoxicity occur. Laboratory tests are an important part of therapy. Assess skin for rash, intake and output, renal function, balance, and hearing acuity; assess IV site during vancomycin therapy.
Storage
Store capsules and unopened vials at room temperature. Once diluted for infusion, the infusions from the vials are stable for 7 days under refrigeration. Keep premix infusions frozen until time of thawing; once thawed, they are stable for 72 h at room temperature or up to 30 days refrigerated.
Administration
Oral capsules may be administered without regard to food; swallow whole.
! Give vancomycin by intermittent IV infusion (piggyback). Do not give by IV push, because this may result in exaggerated hypotension. For intermittent IV infusion (piggyback), reconstitute each 500-mg or 1-g vial with 10 mL or 20 mL, respectively, of sterile water for injection to provide a concentration of 50 mg/mL. Further dilute to a final concentration of no more than 5 mg/mL. Discard the solution if a precipitate forms. Administer the solution over 60 min or longer. Monitor the patient’s BP closely during the infusion. Infusion rate of no more than 10-15 mg/min is recommended in adults.

3.furosemide :

Furosemide
fur-oh′se-mide
Lasix
Do not confuse Lasix with Lidex, Luvox, or Luxiq, or furosemide with torsemide.
CATEGORY AND SCHEDULE
Pregnancy Risk Category: C (D if used in pregnancy-induced hypertension)
Classification: Diuretics, loop
Table of contents:
MECHANISM OF ACTION
PHARMACOKINETICS
AVAILABILITY
OFF-LABEL USES
CONTRAINDICATIONS
DIAGNOSTIC TEST EFFECTS
IV INCOMPATIBILITIES
IV COMPATIBILITIES
SERIOUS REACTIONS
MECHANISM OF ACTION
A loop diuretic that enhances excretion of sodium, chloride, and potassium by direct action at the ascending limb of the loop of Henle. Therapeutic Effect: Produces diuresis and lowers BP.
PHARMACOKINETICS
Route
Onset (min)
Peak
Duration
(h)
PO
30-60
1-2 h
6-8
IV
5
20-60 min
2
IM
30
N/A
N/A
Well absorbed from the GI tract. Protein binding: 91%-97%. Partially metabolized in the liver. Primarily excreted in urine (nonrenal clearance increases in severe renal impairment). Not removed by hemodialysis. Half-life: 30-90 min (increased in renal or hepatic impairment, and in neonates).
AVAILABILITY
Oral Solution: 10 mg/mL.
Tablets: 20 mg, 40 mg, 80 mg.
Injection: 10 mg/mL.
INDICATIONS AND DOSAGES
‣ Edema, hypertension
PO
Adults, Elderly. Initially, 20-80 mg/dose; may increase by 20-40 mg/dose q6-8h. May titrate up to 600 mg/day in severe edematous states.
Children. 1-6 mg/kg/day in divided doses q6-12h.
IV, IM
Adults, Elderly. 20-40 mg/dose; may increase by 20 mg/dose q1-2h. Once desired dosage confirmed, give once or twice daily to maintain effect. Maximum: 80 mg/dose. Usual initial dose for pulmonary edema is 40 mg.
Children. 1-2 mg/kg/dose q6-12h. Maximum: 6 mg/kg/day.
Neonates. 1-2 mg/kg/dose q12-24h.
Maximum: 1 mg/kg/day if premature.
IV infusion
Adults, Elderly. Bolus of 0.1 mg/kg, followed by infusion of 0.1 mg/kg/h; may double q2h. Maximum: 0.4
mg/kg/h.
Children. 0.05 mg/kg/h; titrate to desired effect.
OFF-LABEL USES
Hypercalcemia.
CONTRAINDICATIONS
Anuria, hepatic coma, severe electrolyte depletion, hypersensitivity to furosemide.
INTERACTIONS
Drug
Amphotericin B, nephrotoxic and ototoxic medications: May increase the risk of nephrotoxicity and ototoxicity.
Lithium: May increase the risk of lithium toxicity.
Other hypokalemia-causing medications: May increase the risk of hypokalemia.
Herbal and Food
None known.
DIAGNOSTIC TEST EFFECTS
May increase blood glucose, BUN, and serum uric acid levels. May decrease serum calcium, chloride, magnesium, potassium, and sodium levels.
IV INCOMPATIBILITIES
Cimetidine, ciprofloxacin (Cipro), diltiazem (Cardizem), dobutamine (Dobutrex), dopamine (Intropin), doxorubicin (Adriamycin), droperidol (Inapsine), esmolol (Brevibloc), famotidine (Pepcid), filgrastim (Neupogen), fluconazole (Diflucan), gemcitabine (Gemzar), gentamicin (Garamycin), idarubicin (Idamycin), inamrinone, labetalol (Trandate), meperidine (Demerol), metoclopramide (Reglan), midazolam (Versed), milrinone (Primacor), nicardipine (Cardene), ondansetron (Zofran), quinidine, thiopental (Pentothal), vecuronium (Norcuron), vinblastine (Velban), vincristine (Oncovin), vinorelbine (Navelbine).
IV COMPATIBILITIES
Aminophylline, bumetanide (Bumex), calcium gluconate, heparin, hydromorphone (Dilaudid), lidocaine, nitroglycerin, potassium chloride, propofol (Diprivan).
SIDE EFFECTS
Expected
Increased urinary frequency and urine volume.
Frequent
Nausea, dyspepsia, abdominal cramps, diarrhea or constipation, electrolyte disturbances.
Occasional
Dizziness, light-headedness, headache, blurred vision, paresthesia, photosensitivity, rash, fatigue, bladder spasm, restlessness, diaphoresis.
Rare
Flank pain.
SERIOUS REACTIONS
• Vigorous diuresis may lead to profound water loss and electrolyte depletion, resulting in hypokalemia, hyponatremia, and dehydration.
• Sudden volume depletion may result in increased risk of thrombosis, circulatory collapse, and sudden death.
• Acute hypotensive episodes may occur, sometimes several days after beginning therapy.
• Ototoxicity—manifested as deafness, vertigo, or tinnitus—may occur, especially in patients with severe renal impairment.
• Furosemide use can exacerbate diabetes mellitus, systemic lupus erythematosus, gout, and pancreatitis.
• Blood dyscrasias have been reported.
PRECAUTIONS & CONSIDERATIONS
Caution is warranted in patients with hepatic cirrhosis. Furosemide crosses the placenta and is distributed in breast milk. Neonates may require an increased dosage interval because the drug’s half-life is increased in this age group. Elderly patients may be more sensitive to the drug’s electrolyte and hypotensive effects and are at increased risk for circulatory collapse and thromboembolic effects. Age-related renal impairment may require a dosage adjustment in elderly patients. Consuming foods high in potassium, such as apricots; bananas; legumes; meat; orange juice; raisins; whole grains, including cereals; and white and sweet potatoes, is encouraged. Avoid prolonged exposure to sunlight.
An increase in the frequency and volume of urination and hearing abnormalities, such as a sense of fullness or ringing in the ears, may occur. BP, vital signs, electrolytes, intake and output, and weight should be monitored before and during treatment. Be aware of signs of electrolyte disturbances such as hypokalemia or hyponatremia. Hypokalemia may cause arrhythmias, altered mental status, muscle cramps, asthenia, and tremor. Hyponatremia may result in cold and clammy skin, confusion, and thirst.
Storage
Store all products at room temperature and protected from light (amber containers).
Administration
Take furosemide with food to avoid GI upset, preferably with breakfast to help prevent nocturia.
The solution for injection normally appears clear and colorless. Discard yellow solutions. Furosemide is compatible with D5W, 0.9% NaCl, and lactated Ringer’s solution, but it may also be given undiluted. Administer each 20-40 mg or less by IV push over 1-2 min. Do not exceed an infusion administration rate of 4 mg/min in adults or 0.5 mg/kg/min in children.
After IM use, monitor for temporary pain at the injection site.

4.(Ondansetron)

Ondansetron Hydrochloride
on-dan-seh′tron high-droh-klor′ide
Zofran, Zofran ODT, Zuplenz
Do not confuse Zofran with Zantac or Zosyn.
CATEGORY AND SCHEDULE
Pregnancy Risk Category: B
Classification: Antiemetics, selective 5-HT3 serotonin receptor antagonists
Table of contents:
MECHANISM OF ACTION
PHARMACOKINETICS
AVAILABILITY
OFF-LABEL USES
CONTRAINDICATIONS
DIAGNOSTIC TEST EFFECTS
IV INCOMPATIBILITIES
IV COMPATIBILITIES
SERIOUS REACTIONS
MECHANISM OF ACTION
An antiemetic that blocks serotonin, both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone. Therapeutic Effect: Prevents nausea and vomiting.
PHARMACOKINETICS
Readily absorbed from the GI tract. Protein binding: 70%-76%. Metabolized in the liver. Primarily excreted in urine. Unknown whether removed by hemodialysis. All tablets are bioequivalently interchangeable. Half-life: 4 h.
AVAILABILITY
Oral Solution (Zofran): 4 mg/5 mL.
Orally Disintegrating Film, (Zuplenz): 4 mg, 8 mg.
Tablets (Zofran): 4 mg, 8 mg, 24 mg.
Tablets (Orally Disintegrating [Zofran ODT]): 4 mg, 8 mg.
Injection (Zofran): 2 mg/mL.
Injection (Premix): 32 mg/50 mL.
INDICATIONS AND DOSAGES
‣ Prevention of chemotherapy-induced nausea and vomiting
PO
Adults, Elderly, Children older than 11 yr. 24 mg as a single dose 30 min before starting chemotherapy, or 8 mg 30 min before chemotherapy and again 8 h after first dose; then q12h for 1-2 days.
Children 4-11 yr. 4 mg 30 min before chemotherapy and again 4
and 8 h after chemotherapy, then q8h for 1-2 days.
IV INFUSION
Adults, Elderly, Children 4-18 yr. 32 mg as a single dose, or 0.15 mg/kg/dose 30 min before chemotherapy, then 4 and 8 h after chemotherapy.
‣ Prevention of radiation-induced nausea and vomiting
PO
Adults, Elderly. 8 mg 1-2 h before radiation, followed by 8 mg 3 times a day, or if radiation is intermittent, 8-mg single dose 1-2 h before radiation.
‣ Prevention of postoperative nausea and vomiting
IV, IM
Adults, Elderly. 4 mg undiluted over 2-5 min.
Children weighing < 40 kg. 0.1 mg/kg.
Children weighing≥40 kg. 4 mg.
PO
Adults, Elderly. 16 mg given as two 8-mg tablets 1 h before anesthesia.
OFF-LABEL USES
Hyperemesis gravidarum.
CONTRAINDICATIONS
Hypersensitivity to ondansetron or other selective 5-HT3 receptor antagonists. Use with apomorphine.
INTERACTIONS
Drug
Apomorphine: Causes profound hypotension and loss of consciousness; contraindicated.
Phenytoin, carbamazepine, rifampicin: May decrease levels of ondansetron.
Tramadol: May increase patient-controlled administration of tramadol.
Herbal and Food
None known.
DIAGNOSTIC TEST EFFECTS
May transiently increase serum bilirubin, AST (SGOT), and ALT (SGPT) levels.
IV INCOMPATIBILITIES
Acyclovir (Zovirax), allopurinol (Aloprim), aminophylline, amphotericin B (Fungizone), amphotericin B complex (Abelcet, AmBisome, Amphotec), ampicillin (Polycillin), ampicillin and sulbactam (Unasyn), cefepime (Maxipime), cefoperazone (Cefobid), ertapenem, 5-fluorouracil, furosemide, insulin (regular), lansoprazole, lorazepam (Ativan), meropenem (Merrem IV), methylprednisolone (Solu-Medrol), micafungin, pantoprazole.
IV COMPATIBILITIES
Carboplatin (Paraplatin), cisplatin (Platinol), cyclophosphamide (Cytoxan), cytarabine (Cytosar), dacarbazine (DTIC-Dome), daunorubicin (Cerubidine), dexamethasone (Decadron), diphenhydramine (Benadryl), docetaxel (Taxotere), dopamine (Intropin), etoposide (VePesid), gemcitabine (Gemzar), heparin, hydromorphone (Dilaudid), ifosfamide (Ifex), magnesium, mannitol, mesna (Mesnex), methotrexate, metoclopramide (Reglan), mitomycin (Mutamycin), mitoxantrone (Novantrone), morphine, paclitaxel (Taxol), potassium chloride, teniposide (Vumon), topotecan (Hycamtin), vinblastine (Velban), vincristine (Oncovin), vinorelbine (Navelbine).
SIDE EFFECTS
Frequent (5%-13%)
Anxiety, dizziness, somnolence, headache, fatigue, constipation, diarrhea, hypoxia, urine retention.
Occasional (2%-4%)
Abdominal pain, xerostomia, fever, feeling of cold, redness and pain at injection site, paresthesia, asthenia.
Rare (1%)
Hypersensitivity reaction (including rash and pruritus), blurred vision.
SERIOUS REACTIONS
• Overdose may produce a combination of central nervous system (CNS) stimulant and depressant effects.
• Rare case of dystonic reactions.
• Rare cases of temporary vision loss, for a few minutes up to 48 h.
• Liver failure and death have been reported in patients with cancer receiving concurrent potentially hepatotoxic chemotherapy and antibiotics.
PRECAUTIONS & CONSIDERATIONS
Ondansetron is not a drug that stimulates gastric or intestinal peristalsis. It should not be used instead of nasogastric suction. Animal data have not indicated fetal harm. In humans, it is unknown whether ondansetron crosses the placenta or is distributed in breast milk. The safety and efficacy of ondansetron have not been established in neonates. No age-related precautions have been noted in elderly patients. Alcohol, barbiturates, and tasks that require mental alertness or motor skills should be avoided.
Dizziness or drowsiness may occur. Pattern of daily bowel activity and stool consistency, hydration status, bilirubin, AST (SGOT), and ALT (SGPT) levels should be monitored. Onset of sudden blindness, which usually resolves in 2-3 h, should be immediately reported as it may indicate overdosage.
Storage
Store vials and oral products at room temperature. The infusion is stable for 48 h after dilution.
Administration
! Give all oral doses 30 min before chemotherapy and repeat at 8-h intervals, as prescribed.
Take ondansetron without regard to food. Orally disintegrating film or tablets may be dissolved on tongue without water.
For IV use, ondansetron may be given undiluted as an IV push over 2-5 min for doses up to 4 mg only. For IV infusion, dilute with 50 mL D5W or 0.9% NaCl before administration, and infuse over 15 min. May also give IM if dose is 4 mg or less.

5.heparin :

Heparin
hep′a-rin
Hep-Lock, Hep-Lock U/P
Hepalean, Hepalean-Lok
Do not confuse heparin with Hespan.
CATEGORY AND SCHEDULE
Pregnancy Risk Category: C
Classification: Anticoagulants
Table of contents:
MECHANISM OF ACTION
PHARMACOKINETICS
AVAILABILITY
CONTRAINDICATIONS
DIAGNOSTIC TEST EFFECTS
IV INCOMPATIBILITIES
IV COMPATIBILITIES
SERIOUS REACTIONS
MECHANISM OF ACTION
A blood modifier that interferes with blood coagulation by blocking the conversion of prothrombin to thrombin and fibrinogen to fibrin. Therapeutic Effect: Prevents further extension of existing thrombi or new clot formation. Has no effect on existing clots.
PHARMACOKINETICS
Well absorbed following subcutaneous administration. Protein binding: Very high. Metabolized in the liver. Removed from the circulation via uptake by the reticuloendothelial system. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 1-6 h.
AVAILABILITY
Injection: 10 units/mL, 100 units/mL, 1000 units/mL, 2500 units/mL,
5000 units/mL, 7500 units/mL, 10,000 units/mL, 20,000 units/mL.
Pre-mixed IV infusion: 25,000 units/500 mL infusion.
INDICATIONS AND DOSAGES
‣ Line flushing
IV
Adults, Elderly, Children. 100 units q6-8h.
Infants weighing < 10 kg. 10 units q6-8h. Caution: Always verify strength of solution before giving heparin flush to infants.
‣ Treatment of venous thrombosis, pulmonary embolism, peripheral arterial embolism, atrial fibrillation with embolism
INTERMITTENT IV
Adults, Elderly. Initially, 10,000 units, then 50-70 units/kg (5000-10,000 units) q4-6h, adjust to aPTT.
Children 1 yr and older. Initially, 50-100 units/kg, then 50-100 units q4h, adjust to aPTT.
IV INFUSION
Adults, Elderly. Loading dose: 80 units/kg, then 18 units/kg/h, with adjustments based on aPTT. Range: 10-30 units/kg/h.
Children 1 yr and older. Loading dose: 75 units/kg, then 20 units/kg/h with adjustments based on aPTT.
Children younger than 1 yr. Loading dose: 75 units/kg, then 28 units/kg/h, adjust to aPTT.
‣ Prevention of venous thrombosis, pulmonary embolism, peripheral arterial embolism, atrial fibrillation with embolism
SUBCUTANEOUS
Adult, Elderly. 5000 units q8-12h.
CONTRAINDICATIONS
Intracranial hemorrhage, severe hypotension, severe thrombocytopenia, subacute bacterial endocarditis, uncontrolled bleeding, history of heparin-induced thrombocytopenia (HIT).
INTERACTIONS
Drug
Antithyroid medications, cefoperazone, cefotetan, valproic acid: May cause hypoprothrombinemia.
Other anticoagulants, platelet aggregation inhibitors, thrombolytics: May increase the risk of bleeding.
Probenecid: May increase the effects of heparin.
Herbal
Cat’s claw, dong quai, evening primrose, feverfew, red clover, horse chestnut, garlic, green tea, ginseng, ginkgo: May have an additive effect.
Food
None known.
DIAGNOSTIC TEST EFFECTS
May increase AST (SGOT) and ALT (SGPT) levels. May decrease serum cholesterol and triglyceride levels. Increases aPTT, may decrease platelets.
IV INCOMPATIBILITIES
Alatrofloxacin (Trovan), alteplase (Activase), amikacin (Amikin), amiodarone (Cordarone), amphotericin B complex (Abelcet, AmBisome, Amphotec), amsacrine (Amsa), atracurium (Tracrium), chlorpromazine (Thorazine), ciprofloxacin (Cipro), clarithromycin (Biaxin), cytarabine (Cytosar), dacarbazine (DTIC), daunorubicin (Cerubidine), diazepam (Valium), dobutamine (Dobutrex), doxorubicin (Adriamycin), doxycycline (Vibramycin), droperidol (Inapsine), erythromycin (Erythrocin), filgrastim (Neupogen), gatifloxacin (Tequin), gentamicin (Garamycin), haloperidol (Haldol), idarubicin (Idamycin), isosorbide dinitrate, kanamycin (Kantrex), labetalol (Trandate), levofloxacin (Levaquin), levorphanol (Levo-Dromoran), meperidine (Demerol), morphine (Avinza, Kadian, Roxanol), nicardipine (Cardene), phenytoin (Dilantin), promethazine (Phenergan), quinidine, tobramycin (Nebcin), vancomycin (Vancocin), warfarin (Coumadin).
IV COMPATIBILITIES
Acyclovir (Zovirax), aldesleukin (Proleukin), allopurinol (Alloprim), amifostine (Ethyol), aminophylline, ampicillin (Polycillin), ampicillin/sulbactam (Unasyn), ascorbic acid, atropine, aztreonam (Azactam), betamethasone sodium phosphate (Celestone), bleomycin (Blenoxane), calcium gluconate, cefamandole (Mandol), cefazolin (Ancef), cefepime (Maxipime), cefoperazone (Cefobid), cefotaxime (Claforan), cefotetan (Cefotan), cefoxitin (Mefixitin), ceftazidime (Fortaz), ceftriaxone (Rocephin), chloramphenicol (Chloromycetin), chlordiazepoxide (Librium), cimetidine (Tagamet), cisplatin (Platinol-AQ), cladribine (Leustatin), clindamycin (Cleocin), cyanocobalamin, cyclophosphamide (Cytoxan), cytarabine (Cytosar), dexamethasone sodium phosphate (Decadron), digoxin (Lanoxin), diltiazem (Cardizem), diphenhydramine (Benadryl), docetaxel (Taxotere), dopamine (Intropin), doxorubicin (Rubex), edrophonium (Tensilon), enalapril (Vasotec), epinephrine, erythromycin lactobionate (Erythrocin), esmolol (BreviBloc), estrogens (conjugated), ethacrynate (Edecrin), etoposide (VePesid), famotidine (Pepcid), fentanyl (Sublimaze), fluconazole (Diflucan), fludarabine (Fludara), fluorouracil (Efurix), foscarnet (Foscavir), furosemide (Lasix), gemcitabine (Gemzar), granisetron (Kytril), hydralazine (Apresoline), hydrocortisone sodium succinate (Solu-Cortef), hydromorphone (Dilaudid), insulin, isoproterenol (Isuprel), leucovorin, lidocaine, linezolid (Zyvox), lorazepam (Ativan), magnesium sulfate, methotrexate, methylprednisolone (Solu-Medrol), metoclopramide (Reglan), metronidazole (Flagyl), midazolam (Versed), milrinone (Primacor), minocycline (Minocin), mitomycin (Mutamycin), nafcillin (Unipen), neostigmine, nitroglycerin, norepinephrine (Levophed), ondansetron (Zofran), oxacillin (Bactocil), oxytocin (Pitocin), paclitaxel (Taxol), pancuronium (Pavulon), penicillin G potassium (Pfizerpen), pentazocine (Talwin), phytonadione, piperacillin (Piperacil), piperacillin/tazobactam (Zosyn), potassium chloride, procainamide (Pronestyl), propofol (Diprivan), propranolol (Inderal), pyridostigmine (Mestinon), ranitidine (Zantac), remifentanil (Ultiva), sargramostim (Leukine), scopolamine, sodium bicarbonate, sodium nitroprusside (Nitropress), streptokinase (Streptase), succinylcholine (Anectine), tacrolimus (Prograf), theophylline (Theodur), thiopental (Pentothal), thiotepa (Thioplex), ticarcillin (Ticar), ticarcillin/clavulanate potassium (Timentin), tirofiban (Aggrastat), trimethaphan camsylate (Arfonad), trimethobenzamide (Tigan), trimethoprim/sulfamethoxazole (Bactrim), vecuronium (Norcuron), vinblastine (Velban), vincristine (Oncovin), zidovudine (Retrovir).
SIDE EFFECTS
Occasional
Itching, burning (particularly on soles of feet) caused by vasospastic reaction.
Rare
Pain, cyanosis of extremity 6-10 days after initial therapy lasting 4-6 h; hypersensitivity reaction, including chills, fever, pruritus, urticaria, asthma, rhinitis, lacrimation, and headache.
SERIOUS REACTIONS
• Bleeding complications ranging from local ecchymoses to major hemorrhage occur more frequently in high-dose therapy, in intermittent IV infusion, and in women 60 yr of age and older.
• Antidote: Protamine sulfate 1-1.5 mg, IV, for every 100 units heparin subcutaneous within 30 min of overdose, 0.5-0.75 mg for every 100 units heparin subcutaneous if within 30-60 min of overdose, 0.25-0.375 mg for every 100 units heparin subcutaneous if 2 h have elapsed since overdose, 25-50 mg if heparin was given by IV infusion.
• Immune-mediated heparin-induced thrombocytopenia (HIT) and resulting risk of thrombosis.
PRECAUTIONS & CONSIDERATIONS
Caution should be used during menstruation in persons receiving IM injections and in those with peptic ulcer disease, recent invasive or surgical procedures, and severe hepatic or renal disease. Heparin should be used with caution in pregnant women, particularly during the last trimester and immediately postpartum, because it increases the risk of maternal hemorrhage. Heparin does not cross the placenta and is not distributed in breast milk. The benzyl alcohol preservative may cause gasping syndrome in infants. note: Extreme caution should be used during the preparation, dispensing, and administration of heparin flushes, heparin-containing fluids, and therapeutic doses of heparin for children and infants. Fatal hemorrhages have occurred in pediatric patients (including neonates) due to medication errors. Elderly patients are more susceptible to hemorrhage, and age-related decreased renal function may increase the risk of bleeding. Other medications, including OTC drugs, should be avoided. An electric razor and soft toothbrush should be used to prevent bleeding during therapy.
Notify the physician of bleeding from surgical site, chest pain, dyspnea, severe or sudden headache, swelling in the feet or hands, unusual back pain, bruising, weakness, black or red stool, coffee-ground vomitus, dark or red urine, or red-speckled mucus from cough. CBC, BUN and creatinine levels, BP, pulse, potassium, and stool for occult blood should be monitored. Be aware of signs of bleeding, including bleeding at injection or surgical sites or from gums, blood in stool, bruising, hematuria, and petechiae.
Storage
Store at room temperature.
Administration
! Do not give by IM injection because it may cause pain, hematoma, ulceration, and erythema. The subcutaneous route is used for low-dose therapy.
! Always confirm the choice of correct heparin vial or solution before administration. Fatal medication errors may occur with incorrect selections.
For subcutaneous use, after withdrawing heparin from the vial, change the needle before injection to prevent leakage along the needle track. Inject the heparin dose above the iliac crest or in the abdominal fat layer. Do not inject within 2 inches of umbilicus or scar tissue.
For IV use, dilute IV infusion in isotonic sterile saline, D5W, or lactated Ringer’s solution. Invert IV bag at least 6 times to ensure mixing and to prevent pooling of the medication. Use constant-rate IV infusion pump.

6.insuline :

Insulin
in′sull-in
• Rapid Acting: Humulin R,
Novolin R, Novolog, Humalog, Apidra
• Intermediate Acting: Humulin N, Novolin N
• Long Acting: Lantus, Levemir
• Combinations: NovoLog Mix 70/30, Humalog Mix 50/50, Humalog Mix 75/25, Humulin 70/30, Novolin 70/30.
CATEGORY AND SCHEDULE
Pregnancy Risk Category: B
OTC; some forms are Rx-only, such as insulin analogues
Classification: Antidiabetic agents, insulins and insulin analogues
Table of contents:
MECHANISM OF ACTION
PHARMACOKINETICS
AVAILABILITY
INDICATIONS AND DOSAGES
‣Treatment of type 1 (insulin-dependent) OR type 2 diabetes mellitus
‣Emergency treatment of diabetic ketoacidosis (DKA) OR hyperosmolar hyperglycemic state of type 2 diabetes mellitus (regular insulin)
OFF-LABEL USES
CONTRAINDICATIONS
DIAGNOSTIC TEST EFFECTS
IV INCOMPATIBILITIES
SERIOUS REACTIONS
MECHANISM OF ACTION
Exogenous human insulins facilitate passage of glucose, potassium, and magnesium across the cellular membranes of skeletal and cardiac muscle and adipose tissue. Controls storage and metabolism of carbohydrates, protein, and fats. Promotes conversion of glucose to glycogen in the liver. Therapeutic Effect: Controls glucose levels in
patients with diabetes or hyperglycemia.
PHARMACOKINETICS
Drug Form/Analogue
Onset (h)
Peak
(h)
Duration (h)*
Regular Insulin
0.5-1
2-5
5-12
Insulin Aspart (Novolog)
0.16-0.33
1-3
3-5
Insulin Glulisine (Apidra)
0.25-0.5
0.75-1
4-5
Insulin Lispro (Humalog)
0.25
0.5-1.5
3-6
Insulin NPH
1-2
6-14
10-24
Insulin Detemir (Levemir)
1.1-2
6-8 (not pronounced)
6-24
Insulin Glargine (Lantus)
1.1
No pronounced peak
11-24
(most 18-24)
*Duration of action may vary from individual to individual.
AVAILABILITY
note: All insulins are available as 100 units/mL concentrations.
Rapid Acting: Humulin R, Novolin R, Novolog, Humalog, Apidra.
Intermediate Acting: Humulin N, Novolin N.
Combinations: NovoLog Mix 70/30, Humalog Mix 50/50, Humalog Mix
75/25, Humulin 70/30, Novolin 70/30.
Long Acting: Lantus, Levemir.
INDICATIONS AND DOSAGES
‣Treatment of type 1 (insulin-dependent) OR type 2 diabetes mellitus
SUBCUTANEOUS
Adults, Elderly, Children. Usually 0.5-1 unit/kg/day in divided doses (usual range 0.1-2.5 units/kg/day). Adjust doses to desired target blood sugar for the patient’s individualized goals (note: normal blood sugar is generally
80-110 mg/dL). Note that the dosage range given is quite general; patients with diabetes mellitus type 2 usually receive lower initial doses during initial treatment or if taking oral hypoglycemics. Basal insulins (e.g., insulin glargine, insulin detemir) will have different parameters for daily administration, and are usually initiated at 10 units/day or roughly 0.1-0.2
units/kg/day. Consult individual analog product literature for details of correct dosage, titration, and administration times.
Adolescents (during growth spurt). In general, 0.5-1 unit/kg/day, but may be adjusted to individual patient needs.
‣Emergency treatment of diabetic ketoacidosis (DKA) OR hyperosmolar hyperglycemic state of type 2 diabetes mellitus (regular insulin)
IV INFUSION (REGULAR INSULIN ONLY)
Adults. Initially, 0.15 unit/kg IV bolus, then 0.1 unit/kg/h continuous infusion. Additionally, adequate fluid therapy must be initiated; fluid type and hourly requirements based on estimated patient need and serum osmolality. Blood glucose levels are checked hourly, and the insulin infusion rate is adjusted accordingly. The insulin infusion should cause blood glucose to fall at a rate of about 50 to 75 mg/dL/h; faster blood glucose lowering may cause adverse reactions, like cerebral edema. When blood glucose is 250 mg/dL or less, the insulin infusion rate is usually decreased to 0.05-0.1 unit/kg/h IV and fluid therapy is changed to a dextrose-containing infusion; rates are adjusted to maintain a blood glucose of 150-250 mg/dL until the acidosis is corrected.
OFF-LABEL USES
Widely accepted for use to control blood glucose during hyperalimentation (regular insulin); also for emergency treatment of severe hyperkalemia (regular insulin).
CONTRAINDICATIONS
Hypersensitivity or insulin resistance may require change of type or species’ source of insulin.
INTERACTIONS
Drug
β-Adrenergic blockers: May increase the risk of hyperglycemia or hypoglycemia; may mask signs and prolong periods of hypoglycemia.
Glucocorticoids, thiazide diuretics: May increase blood glucose level.
Herbal
Chromium, garlic, gymnema: May increase hypoglycemic effects.
Food
Alcohol: May increase risk of hypoglycemia.
DIAGNOSTIC TEST EFFECTS
Expected to decrease blood glucose levels and also HbA1C over time. May decrease serum potassium concentrations. Rarely causes decrease in serum magnesium and phosphate concentrations.
IV INCOMPATIBILITIES
Regular insulin (ONLY) and the analogs Insulin Lispro and Insulin Glulisine (ONLY) are the only insulins that may be given IV: Consult specialized resources for Y-site and other compatibility.
SIDE EFFECTS
Occasional
Localized redness, swelling, and itching caused by improper injection technique or allergy to cleansing solution or insulin, hypoglycemia.
Infrequent
Hypokalemia; Somogyi effect, including rebound hyperglycemia with chronically excessive insulin dosages: systemic allergic reaction, marked by rash, angioedema, and anaphylaxis; lipoatrophy or depression at injection site from breakdown of adipose tissue (can avoid by using adequate injection site rotation).
Rare
Insulin resistance.
SERIOUS REACTIONS
• Severe hypoglycemia caused by hyperinsulinism may occur with insulin overdose, decrease or delay of food intake, or excessive exercise and in those with unstable diabetes.
• Diabetic ketoacidosis may result from stress, illness, omission of insulin dose, or long-term poor insulin control, even despite insulin therapy.
• Rarely, serious allergic reactions occur.
PRECAUTIONS & CONSIDERATIONS
Dose adjustments may be necessary in renal and hepatic dysfunction. Insulin is the drug of choice for treating diabetes mellitus during pregnancy, but close medical supervision is needed. Insulin needs may change in the postpartum period, so monitor closely after delivery. Insulin is not secreted in breast milk. Breast-feeding may alter maternal insulin requirements. No age-related precautions have been noted in children. Decreased vision and shakiness in elderly patients may lead to inaccurate insulin self-dosing. Be alert to conditions that alter blood glucose requirements, such as fever, increased activity, stress, or a surgical procedure. Food intake and blood glucose should be monitored before and during therapy. Be aware of signs and symptoms of hypoglycemia (anxiety, cool wet skin, diplopia, dizziness, headache, hunger, numbness in mouth, tachycardia, tremors) or hyperglycemia (deep rapid breathing, dim vision, fatigue, nausea, polydipsia, polyphagia, polyuria, vomiting); carry candy, sugar packets, or other sugar supplements for immediate response to hypoglycemia. Consult the physician when glucose demands are altered (such as with fever, heavy physical activity, infection, stress, trauma). Exercise, good personal hygiene (including foot care), not smoking, and weight control are essential parts of therapy.
Storage
Store extra unopened vials or unopened prefilled pens/cartridges in refrigerator; do not freeze.
Store currently used insulin vials at room temperature or refrigerated; avoid extreme temperatures and direct sunlight. Discard open vials after 28 days.
Prefilled pens or pens with cartridges should be stored in the vertical or oblique position to avoid plugging. Once in use and at room temperature, refer to the manufacturer advice for how long the pens/cartridges may be kept in use; recommendations vary depending on the device and insulin brand.
Administration
Know that insulin dosages are highly individualized and monitored. Adjust dosage, as prescribed, to achieve blood glucose goals and HbA1c targets.
! Most insulins and insulin analogues are given subcutaneously only; some may be used in subcutaneous external infusion pumps. For subcutaneous use; warm the drug to room temperature; do not give cold insulin. Roll the drug vial gently between hands; do not shake. Regular insulin normally appears clear. No insulin should have discoloration. Suspensions should be uniform in appearance. Gently roll/rock prefilled pens before use to mix the suspensions/solutions. Be sure to always use an insulin syringe (e.g., U-30, U-50, or U-100) for administration.
Use glucometer to check blood glucose before administration. In health care systems, have a second person double-check the insulin type and dose to be administered.
Administer most insulins approximately 30-60 min before a meal. Insulin lispro should be given 15 min before meals or immediately after a meal. Insulin aspart is given 5-10 min before starting a meal. Insulin glulisine is given 15 min before a meal or within 20 min of starting a meal. Insulin aspart is given immediately before a meal. Once-daily basal insulins, such as Lantus and Levemir, are given at any time of day but are usually initiated once daily at the evening meal or at bedtime.
Always draw either regular insulin, Novolog, Humalog, or Apidra first into the syringe when mixed with NPH. Mixtures must be administered immediately after preparation. NEVER give insulin mixtures intravenously. Lantus and Levemir should NOT be mixed with other insulins.
Give subcutaneous injections in the abdomen, buttocks, thigh, or upper arm. Maintain a careful record of rotated injection sites.
! ONLY regular insulin may be given IV. Novolog or Apidra have also been used in this manner, but use of these analogues is more rare; use of IV insulin should be limited to monitored clinical settings. May give bolus undiluted. An infusion of regular insulin is prepared by adding 100 units of regular insulin (only) to 100 mL of 0.9% NaCl. ONLY regular insulin may be added to hyperalimentation solutions. Administration rate must be individualized (see dosage). Use
with controlled infusion device.

7.magnesium hydroxide and aluminium hydroxide

Magnesium Hydroxide, Aluminum Hydroxide, Simethicone
mag-nee′zee-um hi-drox′ide, ah-loo′mih-num hi-drox′ide, sye-meth′i-cone
Almacone, Maalox, Maalox Max, Maalox Multi-Symptom Suspension, Mag-Al Plus, Mintox Plus, Mylanta, Mylanta Maximum Strength, Rulox
CATEGORY AND SCHEDULE
Pregnancy Risk Category: C
Classification: Gastrointestinal agents, antacid-antigas combination
Table of contents:
MECHANISM OF ACTION
PHARMACOKINETICS
AVAILABILITY
INDICATIONS AND DOSAGES
CONTRAINDICATIONS
DIAGNOSTIC TEST EFFECTS
SERIOUS REACTIONS
MECHANISM OF ACTION
An antacid combination that reduces gastric acid. Simethicone disperses gas pockets within the GI tract. Therapeutic Effect: Neutralizes acid and increases gastric pH; alleviates GI symptoms and eliminates gas.
PHARMACOKINETICS
In GI tract, antacids react with hydrochloric acid to form chloride salts and water, neutralizing the acid. Roughly 15%-30% of the magnesium chloride formed is available for oral absorption. Most aluminum chloride formed combines with dietary elements in the intestine and is excreted primarily via the feces. Any magnesium systemically absorbed is utilized in the body or excreted by the kidneys. Simethicone is not systemically absorbed. Magnesium may accumulate with chronic use in severe renal impairment.
AVAILABILITY
Chewable Tablets: 200 mg aluminum hydroxide, 200 mg magnesium hydroxide, and 25 mg simethicone per tablet.
Suspension, Regular Strength: 200 mg aluminum hydroxide, 200 mg magnesium hydroxide, and 20 mg simethicone/5 mL.
Suspension, Maximum Strength: 400 mg aluminum hydroxide, 400 mg magnesium hydroxide, and 40 mg simethicone/5 mL.
INDICATIONS AND DOSAGES
‣ Antacid (with flatulence)
PO
Adults, Elderly, Children 12 yr of age or older. 10-20 mL or 2-4 chewable tablets 4-6 times/day.
CONTRAINDICATIONS
Not recommended for those with severe renal impairment; hypermagnesemia.
INTERACTIONS
Drug
Bisphosphonates, ketoconazole, quinolones, tetracyclines: Antacids may decrease absorption of these medications; separate times of administration.
Methenamine: May decrease effects of methenamine.
Herbal
None known.
Food
None known.
DIAGNOSTIC TEST EFFECTS
May increase serum gastrin levels and gastric pH.
SIDE EFFECTS
Frequent
Chalky taste, mild constipation, stomach cramps, diarrhea.
Occasional
Nausea, vomiting.
Rare
Hypermagnesemia, hypophosphatemia, osteomalacia.
SERIOUS REACTIONS
• Prolonged constipation may result in intestinal obstruction.
• Excessive or chronic use may produce hypophosphatemia.
• Prolonged use may produce urinary calculi.
PRECAUTIONS & CONSIDERATIONS
Use caution in using magnesium- and aluminum-containing antacids in patients with mild to moderate renal impairment. Caution is warranted with Alzheimer disease, chronic diarrhea, cirrhosis, constipation, dehydration, edema, fecal impaction, fluid restrictions, gastric outlet obstruction, undiagnosed GI or rectal bleeding, heart failure, low sodium diets, symptoms of appendicitis, and in elderly patients. Do not use in children 6 yr or younger without physician approval. Elderly patients may be at increased risk of constipation and fecal impaction.
Storage
Store at room temperature.
Administration
Administer 1-3 h after meals for best antacid effect. Expect the dosage to be individualized based on the neutralizing capacity of the antacid. For chewable tablets, thoroughly chew before swallowing and then drink a glass of water or milk. If administering a suspension, shake well before use.

8.augmentin :

Amoxicillin/Clavulanate
a-mox′i-sill-in clav-u-lan′ate
AmoClan, Augmentin, Augmentin ES 600, Augmentin XR Apo-Amoxi Clav, Clavulin
Do not confuse with amoxapine.
CATEGORY AND SCHEDULE
Pregnancy Risk Category: B
Classification: Antibiotics, penicillins, aminopenicillins, plus a beta-lactamase inhibitor.
Table of contents:
MECHANISM OF ACTION
PHARMACOKINETICS
AVAILABILITY
INDICATIONS AND DOSAGES
‣ Mild to moderate infections
‣ Respiratory tract, sinusitis, and other severe infections
‣ Otitis media
‣ Usual neonate dosage
‣ Dosage in renal impairment (adults)
OFF-LABEL USES
CONTRAINDICATIONS
DIAGNOSTIC TEST EFFECTS
SERIOUS REACTIONS
MECHANISM OF ACTION
Amoxicillin inhibits bacterial cell wall synthesis, while clavulanate inhibits bacterial β-lactamase. Therapeutic Effect: Amoxicillin is bactericidal in susceptible microorganisms. Clavulanate protects amoxicillin from enzymatic degradation.
PHARMACOKINETICS
Well absorbed from the GI tract. Protein binding: 20%. Partially metabolized in the liver. Primarily excreted in urine. Removed by hemodialysis. Half-life: 1-1.3 h
(increased in impaired renal function).
AVAILABILITY
Powder for Oral Suspension: 125 mg/31.25 mg per 5 mL,
200 mg/28.5 mg per 5 mL,
250 mg/62.5 mg per 5 mL,
400 mg/57 mg per 5 mL,
600 mg/42.9 mg per 5 mL.
Tablets: 250 mg/125 mg,
500 mg/ 125 mg, 875 mg/125 mg.
Tablets (Extended-Release, Augmentin XR): 1000 mg/62.5 mg.
Tablets (Chewable): 200 mg/28.5 mg, 250 mg/62.5 mg, 400 mg/57 mg.
INDICATIONS AND DOSAGES
note: Weight-based dosing is based on amoxicillin component.
‣ Mild to moderate infections
PO:
Adults, Elderly, Children weighing more than 40 kg. 250 mg q8h or
500 mg q12h.
Children weighing < 40 kg. 20 mg/kg/day in divided doses q8h or 25 mg/kg/day in divided doses q12h.
‣ Respiratory tract, sinusitis, and other severe infections
PO
Adults, Elderly, Children weighing more than 40 kg. 500 mg q8h or
875 mg q12h.
Children weighing < 40 kg. 40 mg/kg/day in divided doses q8h or 45 mg/kg/day in divided doses q12h.
PO (AUGMENTIN XR)
Adults. Usual dose 2 tablets q12h for community acquired pneumonia.
‣ Otitis media
PO
Children. 90 mg/kg/day in divided doses q12h for 10 days.
‣ Usual neonate dosage
PO
Neonates, Infants younger than
3 mo. 30 mg/kg/day in divided doses q12h.
‣ Dosage in renal impairment (adults)
Dosage and frequency are modified based on creatinine clearance.
Creatinine clearance 10-30 mL/min: 250-500 mg q12h.
Creatinine clearance < 10 mL/min: 250-500 mg q24h.
OFF-LABEL USES
Treatment of dental-related infections, periodontitis.
CONTRAINDICATIONS
Hypersensitivity to any penicillins, history of cholestatic jaundice/hepatic function impairment associated with amoxicillin/clavulanate; extended-release formulation also contraindicated in severe renal impairment (CrCl < 30 mL/min) and in hemodialysis patients.
INTERACTIONS
Drug
Allopurinol: May increase incidence of rash.
Methotrexate: May reduce the renal clearance of methotrexate.
Oral contraceptives: May decrease effects of oral contraceptives.
Probenecid: May increase amoxicillin and clavulanate blood concentration.
DIAGNOSTIC TEST EFFECTS
May increase serum AST (SGOT) and ALT (SGPT) levels. May cause a positive direct Coombs’ test.
SIDE EFFECTS
Frequent
GI disturbances (mild diarrhea, nausea, vomiting), headache, oral or vaginal candidiasis.
Occasional
Generalized rash, urticaria.
SERIOUS REACTIONS
• Antibiotic-associated colitis and other superinfections may result from altered bacterial balance.
• Severe hypersensitivity reactions, including anaphylaxis and acute interstitial nephritis, occur rarely.
• Hepatotoxicity (rare).
PRECAUTIONS & CONSIDERATIONS
Caution is warranted with antibiotic-associated colitis or a history of allergies, especially to cephalosporins. Amoxicillin and clavulanate cross the placenta, appear in cord blood and amniotic fluid, and are distributed in breast milk in low concentrations. Amoxicillin and clavulanate may lead to allergic sensitization, candidiasis, diarrhea, and skin rash in infants. Immature renal function in neonates and young infants may delay renal excretion of amoxicillin and clavulanate. Age-related renal impairment may require dosage adjustment in elderly patients.
History of allergies, especially to cephalosporins or penicillins, should be determined before giving the drug. Withhold and promptly notify the physician if rash or diarrhea occurs. Severe diarrhea with abdominal pain, blood or mucus in stool, and fever may indicate antibiotic-associated colitis. Signs and symptoms of superinfection, including anal or genital pruritus, black hairy tongue, diarrhea, increased fever, sore throat, ulceration or changes of oral mucosa, and vomiting, should be monitored.
Storage
Store capsules or tablets at room temperature. After reconstitution, the oral suspension is stable for 10 days refrigerated.
Administration
! Drug dosage is expressed in terms of amoxicillin. Dosage forms cannot be interchanged based on amoxicillin component alone; must also consider clavulanate content.
May be taken without regard to meals; however, absorption is enhanced and tolerability improved when taken at the start of a meal. Chew or crush chewable tablets thoroughly before swallowing. Shake oral suspension well prior to each use. Extended-release tablets should not be crushed or chewed. Space doses evenly around the clock and continue for the full course of treatment.