Mosby's 2014 Nursing Drug Reference (154 page)
Read Mosby's 2014 Nursing Drug Reference Online
Authors: Linda Skidmore-Roth
Canada only Side effects:
italics
= common;
bold
= life-threatening 
Nurse Alert
(ep-ler-ee′known)
Inspra
Func. class.:
Antihypertensive
Chem. class.:
Selective aldosterone receptor antagonist
Binds to mineralocorticoid receptor and blocks the binding of aldosterone, a component of the renin-angiotensin-aldosterone system (RAAS)
Hypertension, alone or in combination with thiazide diuretics, CHF, post-MI
Hypersensitivity; increased serum creatinine >2 mg/dl (male), >1.8 mg/dl (female); potassium >5.5 mEq/L, type 2 diabetes with microalbuminuria, hepatic disease, CCr <30 ml/min; CCr <50 ml/min in hypertension
Precautions:
Pregnancy (B), breastfeeding, child, geriatric patients, impaired renal/hepatic function, hyperkalemia
Calculator
• Adult:
PO
50 mg/day initially, may increase to 50 mg bid after 4 wk; start dose at 25 mg/day if patient is taking CYP3A4 inhibitors
• Adult:
PO
25 mg/day initially, may increase to 50 mg/day max after 4 wk
Available forms:
Tabs 25, 50 mg
•
Without regard to food
•
Do not use salt substitutes containing potassium
CNS:
Headache, dizziness, fatigue
CV:
Angina,
MI
GI:
Increased GGT diarrhea, abdominal pain, increased ALT
GU:
Gynecomastia, mastodynia (males), abnormal vaginal bleeding
META:
Hyperkalemia, hyponatremia, hypercholesteremia, hypertriglyceridemia, increased uric acid
RESP:
Cough
Peak 1½ hr; serum protein binding 50%; half-life 4-6 hr; metabolized in liver by CYP3A4 inhibitor; excreted in urine, feces
Increase:
hyperkalemia—ACE inhibitors, angiotensin II antagonists, NSAIDs, potassium supplements, potassium-sparing diuretics
Increase:
serum levels of lithium
Increase:
levels of eplerenone—CYP3A4 inhibitors (ketoconazole, itraconazole, saquinavir, erythromycin, verapamil, fluconazole); reduce dose of eplerenone
Decrease:
antihypertensive effect—NSAIDs
Decrease:
antihypertensive effect—ephedra
•
Grapefruit, grapefruit juice increase product level by 25%
•
Do not use salt substitutes containing potassium
Increase:
BUN, creatinine, potassium, cholesterol, lipids, uric acid
Decrease:
sodium
•
Hypertension:
B/P at peak/trough level of product, orthostatic hypotension, syncope when used with diuretic; monitor lithium level in those also taking lithium
•
Renal studies: protein, BUN, creatinine; increased LFTs, uric acid may be increased
•
Potassium levels, hyperkalemia may occur
•
Storage in tight container at ≤86° F (30° C)
•
Therapeutic response: decreased B/P
•
Not to discontinue product abruptly
•
Not to use OTC products (cough, cold, allergy) unless directed by prescriber; not to use salt substitutes containing potassium without consulting prescriber
•
To comply with dosage schedule, even if feeling better
•
That product may cause dizziness, fainting, lightheadedness; may occur during first few days of therapy
•
How to take B/P; and about normal readings for age group
Canada only Side effects:
italics
= common;
bold
= life-threatening Nurse Alert
(ee-poe′e-tin)
Epogen, Eprex
, Procrit
Func. class.:
Antianemic, biologic modifier, hormone
Chem. class.:
Amino acid polypeptide
Erythropoietin is 1 factor controlling the rate of red cell production; product is developed by recombinant DNA technology
Anemia caused by reduced endogenous erythropoietin production, primarily end-stage renal disease; to correct hemostatic defect in uremia; anemia due to AZT treatment in patients with HIV or those receiving chemotherapy; reduction of allogenic blood transfusion in surgery patients
Unlabeled uses:
Anemia in premature preterm infants, anemia due to ribavirin and interferon-alfa therapy in hepatitic C
Hypersensitivity to mammalian-cell–derived products, human albumin; uncontrolled hypertension
Precautions:
Pregnancy (C), breastfeeding, children <1 mo, seizure disorder; multidose preserved formulation contains benzyl alcohol and should not be used in premature infants; porphyria, CV disease, hemodialysis, latex allergy, hypertension, history of CABG
Black Box Warning:
Hgb >12 g/dl, surgery, neoplastic disease
Calculator
• Adult/adolescent ≥17 yr:
SUBCUT/IV
Initially, 50–100 units/kg 3×/wk; for patients on dialysis, administer IV. For patients on dialysis, initiate treatment when hemoglobin (Hgb) is <10 g/dl. If Hgb approaches or exceeds 11 g/dl, reduce or interrupt the dose. For patients not on dialysis, consider initiating treatment only when Hgb is <10 g/dl and the rate of Hgb decline indicates the likelihood of requiring RBC transfusion and reducing the risk of alloimmunization and/or other RBC transfusion–related risks is a goal. If Hgb is >10 g/dl, reduce or interrupt the dose, and use the lowest dose sufficient to reduce the need for RBC transfusions. If the Hgb rises >1 g/dl in any 2-week period, reduce dose by 25% or more as needed to reduce rapid responses. In contrast, if Hgb has not increased >1 g/dl after 4 wk of therapy, increase the dose by 25%. For patients who do not respond adequately over a 12-wk escalation period, increasing the dose further is unlikely to improve response and can increase risks. Use the lowest dose that will maintain a Hgb concentration sufficient to reduce the need for RBC transfusions. Evaluate other causes of anemia, and discontinue if responsiveness does not improve
• Infant/child/adolescent
≤
16 yr:
SUBCUT/IV
50 units/kg 3×/wk initially. For dosage adjustments, see adult dosage.
≤
500 munits/ml who are receiving a dose of zidovudine
≤
4200 mg/week
• Adult:
SUBCUT/IV
Initially, 100 units/kg 3×/wk. If Hgb does not increase after 8 wk, increase by 50–100 units/kg at 4- 8-wk intervals until Hgb is at a concentration to avoid RBC transfusions or a dose of 300 units/kg is reached. If the Hgb is >12 g/dl, withhold, once Hgb is <11 g/dl resume at a dose 25% below the previous dose
• Adult:
SUBCUT
150 units/kg 3×/wk or 40,000 units 1×/wk only when the hemoglobin is <10 g/dl and only until the chemotherapy course is completed. Adjust the dosage to maintain the lowest Hgb concentration sufficient to avoid RBC transfusions. If no rise in Hgb ≥1 g/dl after 4 wk of therapy and Hgb is <10 g/dl, the dosage may be increased to 300 units/kg subcut 3×/wk or 60,000 units 1×/wk. Discontinue if after 8 wk of therapy there is no response as measured by Hgb concentrations or if transfusions are still required. Reduce the dosage by approximately 25% if Hgb increases by >1 g/dl in any 2-wk period or if Hgb reaches a concentration needed to avoid RBC infusion. If Hgb is increasing and exceeds a concentration necessary to avoid blood transfusions, hold therapy and reinstitute at a dose that is 25% lower when the Hgb reaches a concentration where transfusions may be needed
• Adolescent/child ≥5 yr:
IV
600 units/kg/wk only when the hemoglobin is <10 g/dl and only until the chemotherapy course is completed. Adjust the dosage to maintain the lowest Hgb concentration sufficient to avoid RBC transfusions. If no rise in Hgb ≥1 g/dl after 4 wk of therapy and Hgb is <10 g/dl, the dosage may be increased to 900 units/kg (up to 60,000 units)/wk IV. Discontinue if after 8 wk there is no response as measured by Hgb concentrations or if transfusions are still required. Reduce the dosage by approximately 25% if Hgb increases by more than 1 g/dl in any 2-wk period or if Hgb reaches a concentration needed to avoid
RBC infusion. If the Hgb is increasing and exceeds a concentration necessary to avoid blood transfusions, hold therapy and reinstitute at a dose that is 25% lower when the Hgb reaches a concentration where transfusions may be needed
>
10 and
≤
13 g/dl) scheduled to undergo elective, noncardiac, nonvascular surgery
• Adult:
SUBCUT
300 units/kg/day × 10 days before surgery, on the day of surgery, and for 4 days after surgery (14 days total) or 600 units/kg 1×/wk, 21, 14, and 7 days before surgery plus 1 dose on the day of surgery
Available forms:
Inj 2000, 3000, 4000, 10,000, 20,000, 40,000 units/ml
•
Do not shake vial
•
Use 1 single-use vial/dose, once syringe has entered single dose vial, sterility cannot be guaranteed, do not administer with other product, multidose vials can be stored in refrigerator up to 21 days once opened
•
Before injecting preservative free-, single-dose formulation may be admixed using 0.9% NaCl with benzyl alcohol 0.9% at a 1:1 ratio to reduce inj site discomfort
•
Additional heparin to lower chance of clots
•
By direct inj or bolus into IV tubing or venous line at end of dialysis
•
Decrease dose by 25 units/kg if Hct increases by 4% in 2 wk; increase dose if Hct does not increase by 5-6 pts after 8 wk of therapy; suggested target Hct range 30%–36%
Solution compatibilities:
Do not dilute or administer with other sol
CNS:
Seizures,
coldness, sweating, headache
CV:
Hypertension
,
hypertensive encephalopathy, CHF,
edema,
DVT
INTEG:
Pruritus, rash, inj site reaction
MISC:
Iron deficiency
MS:
Bone pain
RESP:
Cough
IV:
Metabolized in body, extent of metabolism unknown, onset of increased reticulocyte count 2-6 wk, peak immediate
•
Need for increased heparin during hemodialysis
•
Renal studies: urinalysis, protein, blood, BUN, creatinine; I&O, report drop in output <50 ml/hr
Black Box Warning:
Blood studies: ferritin, transferrin, serum iron monthly; transferrin sat ≥20%, ferritin ≥100 ng/ml; Hct 2×/wk until stabilized in target range (30%-36%) then at regular intervals; those with endogenous erythropoietin levels of <500 units/L respond to product; monitor Hct 2×/wk with chronic renal failure; patients treated with zidovudine or patients with cancer should be monitored weekly then periodically after stabilization; death may occur with Hgb >12 g/dl
•
B/P; check for rising B/P as Hct rises, antihypertensives may be needed; hypertension may occur rapidly, leading to hypertensive encephalopathy
•
CNS symptoms: coldness, sweating, pain in long bones; for seizures if Hct is increased within 2 wk by 4 pts
•
Hypersensitivity reactions: skin rashes, urticaria (rare), antibody development does not occur
Pure cell aplasia (PRCA)
in absence of other causes; evaluate by testing sera for recombinant erythropoetin antibodies; any loss of response to epoetin should be evaluated
•
Dialysis patients: thrill, bruit of shunts; monitor for circulation impairment
•
Seizures:
place patient on seizure precautions if increase of ≥4 points HCT in 2 wk, increased B/P; more common in chronic renal failure during the first 90 days of treatment
•
Therapeutic response: increase in reticulocyte count in 2-6 wk, Hgb/Hct; increased appetite, enhanced sense of well-being
•
To avoid driving or hazardous activities during beginning of treatment
•
To monitor B/P
•
To take iron supplements, vit B
12
, folic acid as directed