Read Mosby's 2014 Nursing Drug Reference Online
Authors: Linda Skidmore-Roth
Mosby's 2014 Nursing Drug Reference (412 page)
Canada only Side effects:
italics
= common;
bold
= life-threatening 
Nurse Alert
(val-gan-sy′kloh-veer)
Valcyte
Func. class.:
Antiviral
Chem. class.:
Synthetic nucleoside
Do not confuse:
valGANciclovir
/valACYclovir
Valcyte
/Valtrex
Metabolized to ganciclovir; inhibits replication of human cytomegalovirus in vivo and in vitro by selective inhibition of viral DNA synthesis
Cytomegalovirus (CMV) retinitis in immunocompromised persons, including those with AIDS, after indirect ophthalmoscopy confirms diagnosis; prevention of CMV with transplantation; prevention of CMV in at-risk patient going through transplant (kidney, heart, pancreas)
Unlabeled uses:
Colitis, Epstein-Barr virus, esophagitis, herpes simplex type 1, 2; human herpesvirus 6, 8; multicentric Castleman’s disease, varicella-zoster virus
Breastfeeding, hypersensitivity to ganciclovir, valACYclovir; absolute neutrophil count <500/mm
3
; platelet count <25,000/mm
3
; hemodialysis; liver transplantation
Precautions:
Pregnancy (C), children, geriatric patients, renal function impairment; hypersensitivity to acyclovir, penciclovir, famciclovir
Black Box Warning:
Preexisting cytopenias, secondary malignancy, infertility, anemia
Calculator
• Adult and adolescent (unlabeled):
PO
induction 900 mg bid × 21 days with food; maintenance 900 mg/day with food
• Adult/adolescent >16 yr:
PO
900 mg/day with food starting 10 days prior to transplantation until day 100 after transplantation
• Infant ≥4 mo/child/adolescent ≤16 yr:
PO
give within 10 days of heart/kidney transplant; calculate dose as 7 × BSA × CCr, give as single daily dose
• Adult:
PO
CCr ≥60 ml/min, same as above; CCr 40-59 ml/min, 450 mg bid for 21 days then 450 mg/day; CCr 25-39 ml/min, 450 mg/day then 450 mg q2days; CCr 10-24 ml/min, 450 mg q2days then 450 mg 2×/week
Available form:
Tabs 450 mg, powder for oral sol 50 mg/ml
•
With food for better absorption; avoid getting product on skin; do not break
•
Measure 9 ml purified water in graduated cylinder, shake bottle to loosen powder, add 1/2 liquid, shake well, add remaining water, shake; remove child-resistant cap and push bottle adapter into neck of bottle, close with cap, give using dispenser provided
•
Store liquid in refrigerator; do not freeze; throw away any unused after 49 days
CNS:
Fever
, chills,
coma,
confusion
, abnormal thoughts, dizziness, bizarre dreams,
headache, insomnia
, psychosis, tremors, somnolence,
paresthesia, weakness
,
seizures
EENT:
Retinal detachment with CMV retinitis
GI:
Abnormal LFTs,
nausea, vomiting, anorexia, diarrhea, abdominal pain
,
hemorrhage
GU:
Hematuria,
increased creatinine, BUN
HEMA:
Granulocytopenia, thrombocytopenia, irreversible neutropenia, anemia, eosinophilia
INTEG:
Rash
, alopecia,
pruritus
, urticaria, pain at site, phlebitis,
Stevens-Johnson syndrome
MISC:
Local and systemic infections,
sepsis
Metabolized to ganciclovir, which has a half-life of 3-4½ hr; excreted by kidneys (unchanged); crosses blood-brain barrier, CSF
Increase:
Severe granulocytopenia: immunosuppressants, zidovudine, antineoplastics, radiation; do not use together
Increase:
toxicity—dapsone, pentamidine, flucytosine, vinCRIStine, vinBLAStine, adriamycin, DOXOrubicin, amphotericin B, trimethoprim-sulfamethoxazole combinations or other nucleoside analogs, cycloSPORINE
Increase:
effect of both drugs—mycophenolate
Increase:
seizures—imipenem-cilastatin
Increase:
effect of didanosine; monitor for adverse effects, toxicity
Decrease:
renal clearance of valGANciclovir—probenecid
Increase:
absorption, high-fat meal
Increase:
creatinine
Decrease:
RBC/WBC, Hct/Hgb
•
CMV retinitis by ophthalmoscopy before beginning treatment, q2wk; culture for CMV retinitis
Black Box Warning:
Leukopenia/neutropenia/thrombocytopenia: WBCs, platelets q2days during 2×/day dosing then q1wk; leukopenia with daily WBC count in patients with prior leukopenia with other nucleoside analogs or for whom leukopenia counts are <1000 cells/mm
3
at start of treatment
•
Serum creatinine or CCr ≥q2wk
•
Therapeutic response: decreased symptoms of CMV
•
That product does not cure condition; that regular ophthalmologic and blood tests necessary
•
That major toxicities may necessitate discontinuing product
•
To use contraception during treatment; that infertility may occur; that men should use barrier contraception for 90 days after treatment
•
To take with food
Blood dyscrasias: bruising, bleeding, petechiae; seizures, dizziness; to avoid hazardous activities
•
To use sunscreen to prevent burns
Canada only Side effects:
italics
= common;
bold
= life-threatening Nurse Alert
(val′proh-ate)
Depacon
(val′proh-ik)
Depakene, Stavzor
(dye-val′proh-ex)
Depakote, Depakote ER, Epival
Func. class.:
Anticonvulsant, vascular headache suppressant
Chem. class.:
Carboxylic acid derivative
Increases levels of γ-aminobutyric acid (GABA) in the brain, which decreases seizure activity
Simple (petit mal), complex (petit mal), absence, mixed, seizures; manic episodes associated with bipolar disorder, prophylaxis of migraine, adjunct for schizophrenia, tardive dyskinesia, aggression in children with ADHD, organic brain syndrome, mania, migraines; tonic-clonic (grand mal), myoclonic seizures
Unlabeled uses:
Rectal for seizures (valproic acid)
Hypersensitivity, urea cycle disorders
Black Box Warning:
Pregnancy (D), hepatic disease, pancreatitis
Precautions:
Breastfeeding, geriatric patients
Black Box Warning:
Children <2 yr
Calculator
• Adult and child:
PO
10-15 mg/kg/day in 2-3 divided doses, may increase by 5-10 mg/kg/day weekly, max 60 mg/kg/day in 2-3 divided doses;
IV
≤20 mg/min over 1 hr
• Adult:
RECT
400-600 mg PR as enema or wax-based suppository (not commercially available)
• Child:
RECT
20 mg/kg/dose
• Adult:
PO
750 mg/day in divided doses, max 60 mg/kg/day or 3000 mg/day
• Adult:
DEL REL CAP
750 mg/day in divided doses
• Adult:
PO
250 mg bid, may increase to 1000 mg/day if needed or 500 mg (Depakote ER) daily × 7 days, then 1000 mg/day
Available forms:
Valproate:
inj 100 mg/ml;
valproic acid:
caps 250 mg; oral solution 250 mg/5 ml; del rel cap (Stavzor) 125, 250, 500 mg;
divalproex:
gastro-resistant tabs 125, 250, 500 mg; ext rel tabs 250, 500 mg cap gastro-resistant; sprinkle cap 125 mg
•
Swallow tabs or caps whole; do not break, crush, or chew ext rel tabs
•
Sprinkle cap contents on food
•
Oral solution alone; do not dilute with carbonated beverage; do not give oral solution to patients with sodium restrictions
•
Give with food or milk to decrease GI symptoms
CNS:
Sedation, drowsiness
, dizziness, headache, incoordination, depression, hallucinations, behavioral changes, tremors, aggression, weakness,
coma, suicidal ideation, hypothermia
EENT:
Visual disturbances, taste perversion
GI:
Nausea, vomiting, constipation, diarrhea, dyspepsia
, anorexia, cramps,
hepatic failure, pancreatitis, toxic hepatitis,
stomatitis, weight gain
GU:
Enuresis, irregular menses
HEMA:
Thrombocytopenia, leukopenia, lymphocytosis,
increased PT, bruising, epistaxis
INTEG:
Rash
, alopecia, photosensitivity, dry skin
META:
Hyperammonemia
Metabolized by liver; excreted by kidneys, in breast milk; crosses placenta; half-life 6-16 hr; 90% protein binding
PO:
Peak 4 hr (regular rel); 4-17 hr (ext rel)
Increase:
valproic acid toxicity level—erythromycin, felbamate, salicylates, NSAIDs, rifampin
Increase:
CNS depression—alcohol, opioids, barbiturates, antihistamines, MAOIs, sedative/hypnotics, tricyclics
Increase:
action of, possible toxicity phenytoin, carBAMazepine, ethosuximide, barbiturates, zidovudine, LORazepam, rufinamide, lamoTRIgine
Increase:
bleeding—warfarin
Decrease:
seizure threshold—tricyclics
False positive:
ketones, urine
Interference:
thyroid function tests
Increase:
LFTs, bleeding time, ammonia
•
Seizure disorder:
location, aura, activity, duration; seizure precautions should be in place
Mental status: bipolar disorder: mood, activity, sleeping/eating, behavior; suicidal thoughts/behaviors
•
Migraines:
frequency, intensity, alleviating factors
•
Blood studies: Hct, Hgb, RBC, serum folate, PT/PTT, serum ammonia, platelets, vit D if patient receiving long-term therapy
Black Box Warning:
Hepatic studies: AST, ALT, bilirubin; hepatic failure has occurred
•
Hyperammonemic encephalopathy:
can be fatal in those with urea cycle disorders (UCD); lethargy, confusion, coma, CV, respiratory changes; discontinue
•
Blood levels: therapeutic level 50-100 mcg/ml, during seizures
Black Box Warning:
Pancreatitis;
may be fatal, report immediately nausea, vomiting, anorexia, abdominal pain
•
Therapeutic response: decreased seizures
•
That physical dependency may result from extended use
•
To avoid driving, other activities that require alertness
•
To drink plenty of fluids
•
Not to discontinue medication quickly after long-term use because seizures may result
•
To report visual disturbances, rash, diarrhea, abdominal pain, light-colored stools, jaundice, protracted vomiting, weakness to prescriber
•
To use contraception while taking this product; pregnancy category (D)
•
Overdose symptoms: heart block, coma