Levothyroxine (Rx)

(Skidmore, p.607-609)

Brands: Eltroxin, Levothroid, Levoxyl, Synthroid, Tirosint, Unithroid

Therapeutic Outcome: Correction of lack of thyroid hormone.

Action: Controls protein synthesis; increases: metabolic rate, cardiac output, renal blood flow, O₂ consumption, body temp, blodd vol., growth, development at a cellular level via action on thyroid hormone receptors.

Uses: Hypothroidism, myxedema coma, thyroid hormone replacement, thyrotoxicosis, congenital hypothyroidism, some types of thyroid cancer, pituitary TSH suppression.

Contraindications: Adrenal insufficiency, recent MI, thyrotoxicosis, hypersensitivity to beef, alcohol intolerance (inj. only).

Adverse Effects

-CNS:Anxiety, insomnia, tremors, headache, thyroid storm, excitabilty.

-CV:Tachycardia, palpitations, angina, dysrythmias, hypertension, cardiac arrest.

-GI:Nausea, diarrhea, increased/decreased apetite, cramps.

-MISC:Menstrual irregularities, weight loss, sweating, heat intolerance, fever, alopecia, decreased bone mineral density.

Levothyroxine (Rx)

Dosage/Routes

-Severe Hypothyroidism

Adult ≤50yr: PO 1.7mcg/kg/day, 6-8wk. Average dose 100-200mcg/day, max: 200mcg/day; IM/IV 50-100 mcg/day as a single dose or 50% of usual oral dosage.

Adult >50yr w/out heart disease or <50yr w/heart disease: PO 25-50mch/day, titrate q6-8wk.

Adult >50yr w/heart disease: PO 12.5-25mcg/day, titrate by 12.5-25mcg q6-8wk.

-Myxedema Coma

Adult: IV 200-500mcg; may increase by 100-300mcg after 24hr; give oral med ASAP.

-Subclinical Hypothyroidism

Adult: PO 1mcg/kg/day may be sufficient.

Nursing Considerations

-Determine if the patient is taking anticoagulants or antidiabetic agents.

-Take B/P, pulse before each dose; monitor I&O ratio and weigh every day.

-Monitor height, weight, psychomotor development and growth rate (if a child).

-Monitor T₃, T₄ (which are decreased); radioimmunoassay of TSH (which is increased); RAIU (which is increased if the dosage of med is too low).

-Monitor pro-time (may require decreased anticoagulant); check for bleeding, bruising.

-Assess for increased nervousness, excitability, irritability which may indicate too high a dosage of med, usually after 1-3wk of treatment.

-Assess cardiac status: angina, palpitations, chest pain, change in VS; the geriatric patient may have undetected cardiac problems and baseline ECG should be completed before treatment.

Isosorbide Mononitrate (Rx)/ Isosorbide Dinitrate (Rx)

(Skidmore, p.570-572)

Brands: Apo-ISDN (Canadian), Dilatrate-SR, Isochren, IsoDitrate, Isordil

Therapeutic Outcome: Relief and prevention of angina pectoris.

Action: Relaxation of vascular smooth muscle, which lead to decreased preload, afterload, thus decreasing L ventricular end-diastolic pressure, and systemic vascular resistance and reducing cardiac O₂ demand.

Uses: Treatment, prevention of chronic stable angina pectoris.

Adverse Effects

-CNS:Vascular headache, flushing, dizziness, weakness.

-CV:Orthostatic hypotension, tachycardia, collapse, syncope (fainting).

-GI:Nausea, vomiting.

-INTEG: Pallor (pale), sweating, rash

-MISC:Twitching, hemolytic anemia, methemoglobinemia, tolerance, xerostomia.

Isosorbide Mononitrate (Rx)/ Isosorbide Dinitrate (Rx)

Dosage/Routes

-Dinitrate

Adult: PO 5-20mg bid-tid, initially, maintenance 10-40mg bid-tid; SL (sublingual) buccal tab 2.5-5mg; may repeat q5-10min x 3 doses; ext rel (extended release) 40-80mg q8-12hr, max 160mg/day.

-Mononitrate

Adult: PO (Monoket) 10-20,g bid, 7hr apart; (Imdur) initiate at 30-60mg/day as a single dose, increase q3day as needed; may increase to 120mg/day; max: 240mg/day.

Nursing Considerations

-Assess for pain: duration, time started, activity being performed, character, intensity.

-Methemglobinemia (rare): Assess for cyanosis of lips, nausea/vomiting, coma, shock; usually caused by high dose of product, but may occur with normal dosing.

-Monitor for orthostatic B/P, pulse at baseline, during treatment and periodically thereafter.

Darbepoetin (Rx)

(Skidmore, p.271-272)

Brands: Aranesp

Therapeutic Outcome: Decreased anemia w/increased RBCs.

Action: Stimulates erythropoiesis by the same mechanism as endogenous erythropoietin; in response to hypoxia, erythropoietin is produced in the kidney and released into the bloodstream, where it interacts, w/progenitor stem cells to increase red cell production.

Uses: Anemia associated w/chronic renal failure in patients on and not on dialysis and anemic in non-myeloid malignancies receiving co-administered chemotherapy.  

Adverse Effects

-CNS:Seizures, sweating, headache, dizziness, stroke.

-CV:Hypo/hypertension, cardiac arrest, angina pectoris, thrombosis, CHF, acute MI, dysrhythmias, chest pain, transient ischemic attacks, edema.  

-GI:Diarrhea, vomiting, nausea, abdominal pain, constipation.

-HEMA: Red cell aplasia.

-MS: Bone pain, myalgia, limb pain, back pain.

-RESP: Upper resp. infection, dyspnea, cough, bronchitis, PE.

-SYST: Allergic reactions, anaphylaxis.

-MISC:Infection, fatigue, fever, fluid overload, dehydration, sepsis, vascular access hemorrhage, death

Darbepoetin (Rx)

Dosage/Routes

-Correction of anemia in chronic renal failure

Adult: SUB/IV 0.45 mcg/kg as a single inj, titrate max target Hgb of 12g/dil.

-Chemotherapy Treatment

Adult: SUB 2.5 mcg/kg/wk or 500mscg q3wk.

-Epoetin alfa to darbepoetin conversion

Adult: SUB/IV (epoetin alfa <2500 units/wk) 6.25mcg/wk; (epoetin alfa 2500-4999 units/wk) 12.5mcg/wk; (epoetin alfa 5000-10,999 units/wk) 25mcg/wk; (epoetin alfa 11,000-17,999 units/wk) 40mcg/wk; (epoetin alfa 18,000-33,999 units/wk) 60mcg/wk; (epoetin alfa 34,000-89,999 units/wk) 100mcg/wk; (epoetin alfa >90,000 units/wk) 200mcg/wk.

Nursing Considerations

-Assess for serious allergic reactions: rash, urticaria; if anaphylaxis occurs, stop product, administer emergency treatment (rare).

-Assess renal studies: urinalysis, protein, blood, BUN, creatinine.

-Assess B/P, Hct; check for rising B/P as Hct rises; antihypertensives may be needed.

-Assess CV status: hypertension may occur rapidly, leading to hypertensive encephalopathy; Hgb>12g/dl may lead to death.

-Assess I&O ration; report drop in output to <50ml/hr.

-Assess for seizures if Hgb is increased within 2wk by 4 points.

-Assess CNS systems: cold sensation, sweating, pain in long bones.

-Assess dialysis patients for thrill, bruit of shunts; monitor for circulation impairment.

Black Box Warning

-Assess blood studies: ferritin, transferrin monthly; transferrin sat ≥20%, ferritin ≥100ng/ml; Hgb 2x/wk until stabilized in target range (30%-33%), then at regular intervals; those w/endogenous erythropoietin levels of <500 units/L respond to this agent, if there is lack of response, obtain folic acid, iron, B₁₂ levels.

-Neoplastic disease: breast, non-small cell lung, head and neck, lymphoid or cervical cancers, increased tumor progression, use lowest dose to avoid RBC transfusion.

Nebivolol (Rx)

(Skidmore, p.737-738)

Brands: Bystolic

Therapeutic Outcome: Decreased B/P after 1-2wk.

Action: Competitively blocks stimulation of β-adrenergic receptors w/in vascular smooth muscle; decrease rate of SA node discharge, increases recovery time, slows conduction of AV node resulting in decreased heart rate (neg. chronotropic effect), which decreases O₂ consumption in myocardium due to β₁-rececptor antagonism; also decreases renin-aldosterone-angiotensin system at high doses, inhibits β₂-receptors in bronchial system (high doses).

Uses: Hypertension alone or in combination.

Adverse Effects

-CV:Bradycardia, MI, AV heart block, edema.

-GI:Nausea, diarrhea, vomiting, abdominal pain.

-GU: Impotence.

­-HEMA: Thrombocytopenia.

-INTEG: Rash, pruritus, vasculitis, urticarial, psoriasis, angioedema.

-RESP: Bronchospasm, dyspnea.

-MISC:Renal failure, pulmonary edema, hyperuricemia, hypercholesterolemia, withdrawal symptoms.

Nebivolol (Rx)

Dosage/Routes

-Hypertension

Adult: PO 5mg/day, may be increased to desired response q2wk; max 40mg/day.

-Geriatric: PO max 40mg/day.

-Renal dose

Adult: PO CCr<30mlmin, 2.5mg/day; may increase cautiously.

-Hepatic dose

Adult: PO (child-pugh class B) 2.5mg qd; use dose calculation cautiously.

-Heart failure (unlabeled)

Adult: PO 1.25mg titrated to max 10mg/day.

Nursing Considerations

-Hypertension: monitor B/P during beginning treatment, periodically thereafter; assess apical/radial pulses before administration; notify prescriber of any significant changes (pulse<50bpm); sign of CHF (dyspnea, crackles, weight gain, jugular vein distention).

-Assess baseline in renal/hepatic studies before therapy begins and periodically, do not use in child-pugh class>B.

-Monitor I&O, edema in feet and legs daily.

-Monitor skin turgor, dryness of mucous membranes for hydration status, especially geriatric patients.

-Assess blood glucose in diabetics.

Haloperidol (Rx)/ Haloperidol Decanoate (Rx)/ Haloperidol Lactate (Rx)

(Skidmore, p.498-500)

Brands: Haldol Decanoate, Haldol

Therapeutic Outcome: Decreased signs and symptoms of psychosis.

Action: Depresses cerebral cortex, hypothalamus, limbic system, which control activity and aggression; blocks neurotransmission produced by dopamine at synapse; exhibits strong α-adrenergic, anticholinergic blocking action; mechanism for antipsychotic effects unclear. 

Uses: Psychotic disorders, control of tics, vocal utterances in Tourette’s syndrome, short-term treatment of hyperactive children showing excessive motor activity, prolonged parenteral therapy in chronic schizophrenia, organic mental syndrome w/psychotic features, hiccups (short-term), emergency sedation of severely agitated or delirious patients, ADHD.

Adverse Effects

-CNS:EPS, pseudoparkinsonism, akathisia, dystonia, tardive dyskinesia, drowsiness, headache, seizures, neuroleptic malignant syndrome, confusion.

-CV:Orthostatic hypotension, hypertension, cardiac arrest, ECG changes, tachycardia, QT prolongation, sudden death.

-EENT: Blurred vision, glaucoma, dry eyes.

-GI: Dry mouth, nausea, vomiting, anorexia, constipation, diarrhea, jaundice, weight gain, ileus, hepatitis.

-GU: Urinary retention, urinary frequency, dysuria, enuresis, impotence, amenorrhea, gynecomastia.

­-INTEG: Rash, photosensitivity, dermatitis.

-RESP: Laryngospasm, dyspnea, respiratory depression.

-SYST:Risk of death (dementia).

Haloperidol (Rx)/ Haloperidol Decanoate (Rx)/ Haloperidol Lactate (Rx)

Dosage/Routes

-Acute Psychosis

Adult: IM/IV (lactate) 2-10mg, may repeat q1hr, convert to PO ASAP, PO should be 150% of total parental dose required.

-Chronic Schizophrenia

Adult: IM  (decanote)50-100mg q4wk, max 100mg for 1^st inj.

-Tourette’s Syndrome

Adult and Adolescent: PO 0.5-2mg bid-tid, increased until desired response occurs.

-ADHD

Child 3-12yr: PO 0.25-0.5mg/day in 2-3 divided doses, may increase by 0.025-0.5mg q5-7 days; maintenance 0.01-0.03mg.kg/day as a single dose.

-Autism (unlabeled)

Child: PO 0.04mg/kg/day or 1-3mg/day, max 4mg/day.

-Migraine (unlabeled)

Adult: PO/IM (lactate) 5mg at onset, may repeat once.

Nursing Considerations

-Assess mental status: orientation, mood, behavior, presence and type of hallucinations before initial administration and monthly; this product should significantly reduce psychotic behavior.

-Monitor I&O ration; palpate bladder if low urinary output occurs, especially in geriatric; urinalysis is recommended before/during prolonged therapy.

-Monitor bilirubin, CBC, liver function tests monthly.

-Assess affect, orientation, LOC, reflexes, gait, coordination, sleep pattern disturbances.  

-Monitor B/P w/patient sitting, standing and lying; take pulse and respirations q4hr during initial treatment; report drops of ≥30mm Hg; obtain baseline ECG; Q-wave and T-wave changes.

-Check for dizziness, faintness, palpitations, tachycardia on rising; sever orthostatic hypotension is common.

-Assess for neuroleptic malignant syndrome: hyperpyrexia, muscle rigidity, increased CPK, altered mental status; product should be discontinued immediately; if seizures, hypo/hypertension, tachycardia occur, notify prescriber immediately.

-Assess for EPS including akathisia (inability to sit still, no pattern to movements), tardive dyskinesia (bizarre movements of the jaw, mouth, tongue, extremities), pseudoparkinsonism (ragged tremors, pill rolling, shuffling gait); an antiparkinsonian product should be prescribed.

-Assess for constipation and urinary retention daily; if these occur, increase bulk, water in diet.

-Abrupt discontinuation: Do not withdraw abruptly, taper.

Imipramine (Rx)

(Skidmore, p.538-540)

Brands: Tofranil, Tofranil PM

Therapeutic Outcome: Decreased symptoms of depression after 2-3wk; decreased bedwetting in children.  

Action: Blocks reuptake of norepinephrine and serotonin into nerve endings, increasing action of norepinephrine and serotonin in nerve cells; has anticholinergic effects.

Adverse Effects

-CNS:Dizziness, drowsiness, confusion, headache, anxiety, tremors, stimulation, weakness, insomnia, nightmares, EPS (geriatric), increased psychiatric symptoms, paresthesia, seizures, ataxia.

-CV:Orthostatic hypotension, hypotension,ECG changes, tachycardia, hypertension, palpitations, dysrhythmias.

-EENT: Blurred vision, tinnitus, mydriasis.

-ENDO: Hyperglycemia, hypo/hyperthyroidism, goiter, SIADH.

-GI: Diarrhea, dry mouth, nausea, vomiting, paralytic ileus, increased appetite, cramps, epigastric distress, jaundice, hepatitis, stomatitis, constipation, taste change, weight gain.

-GU: Retention, acute renal failure, impotence, decreased libido.

-HEMA: Agranulocytosis, thrombocytopenia, eosinophilia, leukopenia.   

­-INTEG: Rash, urticarial, sweating, pruritus, photosensitivity, hyperpigmentation (rare).

Imipramine (Rx)

Dosage/Routes

-Depression

Adult: PO 75-100mg/day in divided doses; may increase by 25-50mg up to 200mg/day (outpatients), 300mg/day (inpatients); may give daily dose at bedtime.

Geriatric: PO  25-50mg at bedtime; may increase to 100mg/day in divided doses.

-Enuresis

Child 6-12yr: PO  10-25mg at bedtime, max 50mg.

Nursing Considerations

-Monitor B/P (w/patient lying, standing), pulse q4hr if systolic B/P drops 20mm Hg, hold product, notify prescriber; take VS q4hr in patients w/CV disease.  

-Monitor blood studies: CBC, leukocytes, differential, cardiac enzymes if patient is receiving long-term therapy.  

-Monitor hepatic studies: AST, ALT, bilirubin.

-Check weight weekly; appetite may increase w/product.   

-QT prolongation: Assess ECG for flattening of T-wave, bundle branch block, AV block, dysrhythmia, akathisia.

-Assess mental status: mood, sensorium, affect, suicidal tendencies,  increase in psychiatric symptoms: depression, panic.

-Monitor urinary retention, constipation; constipation is more likely to occur in children or geriatric.

-Assess for withdrawal symptoms: headache, nausea, vomiting, muscle pain, weakness, diarrhea, insomnia, restlessness; do not usually occur unless product was discontinued abruptly.

-Identify alcohol consumption; if alcohol is consumed, hold dose until AM.