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metipranololβblocker: nonselective Why is pt receiving this? Primarily for open angle glaucoma, also in acute angle closure glaucoma. Lower IOP by decreasing production of aqueous humor. Dose 1 drop of .3% solution twice daily SE Systemic absorption can lead to bradycardia and atrioventricular heart block, bronchospasm, conjunctivitis, decrease visual acuity, occular burning, rash Med admin CONTRAINDICATED IN PTS w/ AV heart block, sinus bradycardia, cardiogenic shock. Use in caution in pts w/ HF. Monitor pulse rate. SE addative w/ other cardiac suppressive meds. Other adverse rxns may occur including bronchospasm or delirium in geriatric patients. Concurrent use w/ ophthalmic epinephrine may decrease effectiveness. Use betaxolol for pts w/ asthma or COPD. Lasts 24 hrs Pt education Teach correct administration. Notify for cardiac s/sx. Teach how to monitor cardiac pulse. Administering ocular solutions and ointments Solutions: Have pt lie back or look up Pull down lid to create pocket, instill soln, and apply pressure 1-2 min Wait 5 min for next dose Ointment Hold in hand to warm. Squeeze small amt into eyelid (1/4-1/2 in. Close eye and have pt roll eye around w/ eyes closed Wait 10 min before administering another med AND don’t allow bottle/cap to touch eyelatanoprost (Xalatan) Prostaglandin analog Why is pt receiving this? Open angle glaucoma and ocular hypertension. As effective as beta blockers w/ fewer side effects. Lowers IOP by facilitating aqueous humor outflow by relaxing ciliary muscle. Dose 1 drop of 0.005% solution once daily in evening. SE local irritation, foreign sensation, increased eyelash growth, hyperpigmentation of iris. Med admin concerns Forms ppt w/ thimerosal containing products. Pigmentation is harmless but generally irreversible. Pt education Proper administration technique brimonidine (Alphagan P) Alpha2 adrenergic agonists (Sympathomimetics) Why is pt receiving this? Open angle glaucoma or ocular hypertension . Decreases formation of aqueous humor. Dose Adults and children greater than or at 2 yo. 1 drop of 0.1%-0.2% solution tidSE Adverse cardiac rxns. Ophthalmic irritation, drowsiness, dizziness, dry mouth, HA, weakness, muscular pain Med admin Avoid concurrent use w/ MAOI’s. Tricyclic antidepressents may decrease effectiveness; addative CNS depression. Addative cardiovascular agents. Pt education Reprot adverse s/sx immediately. Teach administration technique. May cause dizziness (fall risk, don’t operate machinery) atropine (Isopto Atropine, Atropine-care) Cycloplegic drugs, anticholinergic drugs Why is pt receiving this? Mydriasis and cycloplegia for ophthalmic surgery. Also used for treatment of uveitis. Dose 1-2 drops of 1% soln 1 hr pre procedure. Uveitis: 1-2 drops of 1% solution 4 times daily or 0.3-0.5 cm strip of ointment up to 3 times daily SE Irritation, blurred vision, photophobia. Systemic anticholinergic effects (dry mouth, constipation, fever, tachycardia and CNS depression) Med admin Addative CNS depression. Monitor for s/sx of muscarinic poisoning. Pt education Effects on accommodation may last 6 days; mydriasis may last 12 daysoxymetazoline (OcuClear) Ocular decongestants Why is pt receiving this? Decrease ocular congestion due to irritation by vasoconstricting conjunctival blood vessels. Stronger solns may have mydriatic effects. Dose Decongestant: 1-2 drops of 0.12% soln up to 4 times daily PRN (for up to 3 days). Mydriasis (dilation of pupil): 1 drop of 2.5-10% solution, may repeat in 10-60 min as needed. SE ophthalmic-blurred vision, irritation, systemic-diziness, tachycardia, hypertension, paleness, sweating, trembling Med admin Systemic absorption may result in adverse cardiac rxns (monitor appropriately). Excessive/prolonged use may produce rebournd hyperemia. Use cautiously in patients at risk for ACUTE ANGLE CLOSUre GLAUCOMA. Cardiac effects may be exaggerated by MAOI , may increase risk of arrhythmias w/ inhalation anesthetics Pt education REPORT PAIN IMMEDIATELY (acute angle closure glaucoma). Monitor for cardiac SE. Report s/sx. Sunscreen Highly protective: BROAD SPECTRUM (protects against UVA [contains avobenzo] and UVB) w/ SPF of 15 or greater Protective against sunburn, skin cancer, and photoaging Moderately protective: BROAD SPECTRUM w/ SPF 2-14 Protective against sunburn but not against skin cancer and photoaging Least Protective: UVB protection onlyProtective against sunburn ONLY Topical glucocorticoids Review glucocorticoids: used to decrease inflammation (biggest side effect is adrenal suppression and immunosuppression requiring tapering off) Topicals classified into 4 potency groups: low, medium, high, and super high Should be applied in a thin film, gently rubbed in. Should be advised not to use occlusive dressings unless prescriber tells them (can increase percutaneous absorption by as much as 10 fold) Drug schema for acne drugs Mild acne Topical Antimicrobial Retinoid agents Moderate Oral Oral abx w/ comedolyticsHormonal agents for women (i.e. spironolactone) Severe Oral Isotretinoin (Accutane) tretinoin (topical) (Atralin) Anti-acne agents; retinoids Why is pt receiving this? Mgmt of acne vulgaris and (w/ .05% water in oil cream formula): decreased facial dermal effects of photoaging. Decreases formation of micromedomes and stimulates turnover of follicular epithelium. Dose Apply once daily at hs SE photosensitivity, redness, blistering, edema, crusting, hyperpigmentation, hypopigmentationMed admin concern Apply once daily before HS. Cover entire area. Wash hands immediately after application. Addative skin irritation w/ keratolytic agents. Addative risk of photosensitivity. Risk of irritation. Pt education May feel transient warmth/stinging. Do not apply excessive amounts (will increase SE w/ no added benefit). Temporary worsening of acne may begin at onset of treatment. Use sunscreen w/ at least SPF 15 and minimize sun exposure to prevent photosensitivity. isotertinoin (Accutane) retinoids ; PREGNANCY CATEGORY X Why is pt receiving this? Mgmt of sever nodular acne resistant to conventional therapy and systemic antibiotics. NOT TO BE USED UNDER ANY CIRCUMSTANCES DURING PREGNANCY. Reduces sebaceous gland size and differentiation Dose PO .5-1mg/kg/day (up to 2 mg/kg/day in 2 divided doses for 15-20 wk. Once disconstinued, may reinstitute if relapsing occurs. SE SUICIDAL ATTEMPTS, behavioral changes, psychosis, conjunctivitis, epistaxis, blurred vision, edema, chelitis, dry mouth, n/v, abd pain, anorexia, hepatitis, SJS, TENS, photosensitivity, skin infections, anemia, decrease in HDL, hypercholesterolemia, hypertriglyceridemia, hyperglycemia, hyperuricemia, SEVERE BIRTH DEFECTS Med admin Addative toxicity w/ vitamin A (fat soluble vitamin) and drugs w/ anticholinergic products, use w/ ETOH promotes hypertriglyceridemia, addative drying effects, VERIFY PT IS REGISTERD W/ IPLEDGE PROGRAM, monitor behavioral changes, assess for rash. Monitor LFTs, blood lipids, and periodic CBC. Administer w/ meals. Pt education Explain the purpose and requirements of IPLEDGE program. Take as directed. Must read med guide and conset at onset of therapy. Use two forms of contraception 1 mo before therapy, throughout and at least 1 mo after discontinuation. Pt must have 2 negative serum or urine pregnancy test. Notify rash, change in behavior/thoughts/mood, and other adverse s/sx . May cause decrease in night vision (caution) . Do not donate blood while on this medication. Need for follow up. Oral contraceptives and acne : YAZ, Estrostep, Ortho Tri-Cyclen Indicated for women at least 15 yo who want contraception, have reached menarche, and have not responded to topical drugs Estrogen in combo pills blocks ovarian androgens and produces sex hormone binding globulin which binds androgens Androgens cause sebum production, turnover of follicular epithelia cells, leading to comedo [plugs]Drug schema for ear infections Decision to treat based on: age, illness severity, and degree of diagnostic severity Note: ANTIBIOTICS SHOULD NOT BE USED IN Otitis Media w/ Effusion (OME) 1° for OM: high dose amoxicillin Antibiotic resistant OM: Augmentin (Amoxicillin/calulanate) Acute OE: Treated w/ 2% acetic acid w/ ETOH. Can also be used w/ hydrocortisone or an abx (ciprofloxacin and certain floriquinolones) Administering otic medicationsEar drops should be warmed prior to administration IF using wick should be removed q 48 hrs amoxicillin + clavulanate (Augmentin) Just like Unasym (ampicillin + sulbactam) Aminopenicillins/betalactamase inhibitors Why is pt receiving this? Treatment of variety of infections; penicillin binds to cell wall to inhibit synthesis (bact. cell lysis) and betalactamase inhibitor resists bacterial defense mechanisms beta lactamase destroys penicillin Dosage most infections PO 250 mg q 8 hrs or 500 mg q 12 hrs; serious infections and resp. infections PO 875 mg q 12 hr or 500 mg q 8 hr SE seizures (high doses), pseudomembranous colitis, diarrhea, hepatic dysfunction, n/v, vaginal candidiasis, ALLERGIC rxns Data used to assess effectiveness/goal Assess for infection before and throughout therapy, obtain hx of previous use/rxn to penicillin GOAL: resolution of s/sx of infectionMed administration concerns Administer PO med around the clock, can be given w/out regard to meals (can be given w/ meals to decrease GI side effects), AVOID HIGH FAT MEALS (decreases absorption of clavulanate) monitor for s/sx of anaphylaxis, pseudomembranous colitis ; decreases effectiveness of oral contraceptives, increases effects of warfarin, probenecid decreases excretion Pt/caregiver education report s/sx of suprainfection (fuzzy tongue, vaginal itching or discharge, loose or foul smelling stools), abnormal s/sx (fever, diarrhea, blood in stool), notify if symptoms do not improve, advise female pts using oral contraceptives to consult other b/c methodsamoxicillin Broad spectrum penicillins (aminopenicillins) Why is pt receiving this? treatment of skin and skin structure infections, otitis media, sinusitis, resp infections, gu infection, endocarditis prophylaxis, post exposure of anthrax inhalation and mgmt. of PUD caused by H pylori Dosage most infections: 250-500 mg PO q 8 hr or 500-875 mg q 12 hr (not to exceed 2-3 g/day)SE Seizures (high doses), pseudomembranous colitis, n/v, diarrhea, increased lvier enzymes, rash, ALLERGIC RXNS, superinfections Data used to assess effectiveness/goal Assess for infection before and throughout therapy, obtain hx of previous use/rxn to penicillin GOAL: resolution of s/sx of infection Med administration concerns Administer PO med around the clock, can be given w/out regard to meals (can be given w/ meals to decrease GI side effects), monitor for s/sx of anaphylaxis, pseudomembranous colitis ; decreases effectiveness of oral contraceptives, increases effects of warfarin, probenecid decreases excretion Pt/caregiver education report s/sx of suprainfection (fuzzy tongue, vaginal itching or discharge, loose or foul smelling stools), abnormal s/sx (fever, diarrhea, blood in stool), notify if symptoms do not improve, advise female pts using oral contraceptives to consult other b/c methods chloroquine (Aralen) DMARDs, antimalarials Why is pt receiving this? Drug of choice for prophylaxis/treatment of acute attacks of malaria. Unlabeled treatment of severe RA and SLE. Changes metabolic pathway (by inhibiting DNA/RNA polymerase) needed for reproduction of parasite. Dose Prophylaxis: 300 mg PO once weekly, starting 2 wk prior and for 8 wk afterwards. Tx: 600 mg PO initially (not to exceed 600 mg), then 5 mg/kg at 6 hr, 24 hr, and 48 hr after initial dose SE SEIZURES, anxiety, agitation, confusion, delirium, depression, blindness (reversible), hearing empairment, cardiomyopathy, ECG changes, abd cramps, anorexia, diarrhea, HEPATITIS, incr liver enzymes, n/v, SJS, TENS, agranulocytosis, aplastic anemia, leukopenia, thrombocytopenia Med admin concerns antacids may decrease absorption, blood levels may be increased by cimetidine, -mycins, and verapamil. May decrease absorption of ampicillin. Addative hepatotoxic risk. Urinary acidification may increase renal excreation and decrease effectivenss. Assess muscle weakness periodically (DTR), discontinue immediately w/ hearing impairment, ophthalmic exam, assess for improvement in s/sx, monitor CBC and LFTS. Administer w/ meals to decrease GI distress Pt education Take as directed, full course of therapy. Review methods of minizimng exposure to mosquitoes, advise avoiding ETOH, Explain need for periodic Opthalmic exams, notify adverse s/sx (most dose related) Females notify if pregnant or breastfeeding Mefloquine Newer med w/ once weekly dosingSafe in PedsNo photosensitivity Serious SE incl: psychological problems (severe anxiety, paranoia, hallucinations, unusual behaviors) metronidazole (Flagyl) Anti-infectives/antiprotozoals Why is pt receiving this: PO/IV: Tretment of protozal infections (may be used w/ a cephalosporin), obiglate anaerobes, and H. Pylori , PO: amebacide, IV: perioperative prophylactic ; prohibits prn and DNA synthesis Dosage: Dosage varies based on infection IV: [5 mg/mL] over 30-60 min SE: Neurotoxicity, ALLERGY, superinfections, Disulfiram (antabuse like) rxn w/ alcohol, Seizures, dizziness, HA, asceptic meningitis/encephalopathy (IV), optic neuropothy, abd pain, anorexia, nausea, SJS, rash, urticarial; Phlebitis @ IV site Med Administration Concerns Cimetidine may decrease absorption, phenobarbitol and rifampin may increase metab (decrease effectiveness), increases effects of phenytoin, lithium, and warfarin; Disulfiram rxn can be so bad as to affect a person using mouthwash. Assess for rash. Pt caregiver education: Take as directed, finish regimen; when used for trichiminosis, sexual partners may be asymptomatic sources of reinfection (get tested); avoid use of alcohol until at least 3 days after last part of treatment; unpleasant medical taste; medication may turn urine darkpyrimethamine (Daraprim) Antimalarials, antiprotozoals Why is pt receiving this med? Used in combination w/ other antimalarials in tx of chloroquine resistant malaria. Used in combination w/ sulfonamide in tx of toxoplasmosis. Binds to enzymes in protozoans, resulting in depletion of folic acid. Dose PO: 50 mg-200 mg/day for 1- 2 days, then 25 -50mg /day for 2-6 wks in combination with sulfonamide SE SEIZURES (High doses), HA, malaise, dry throat, ARRYTHMIAS (LARGE DOSES), atrophic glossitis, anorexia, diarrhea, nausea, hematuria, abnormal pigmentation, dermatitis, megaloblastic anemia, pancytopenia, thrombocytopenia, fever Med admin Addative risk of bone marrow depression, risk of megaloblastic anemias w/ folate antagonists (methotrexate) Administer w/ meal or milk to minimize GI distress Pt education Take full course of therapy as directed. Notify for s/sx, D/c immediately at the sign of skin rash or no improvement. Emphasize importance of follow up lab work Drug schema for ectoparasitic infections Drug of choice is permetrin (Nix) If unresponsive may use lindane (Kwell) or Malathion Kwell: can cause neurologic problems in children, contraindicated in infants Malathion (Ovide): highly flammable and linked to chromosome abnormalities permethrin 5% (Nix) pediculocides Why is pt receiving this? Drug of choice for eradication of scabies. 1% also used for eradication/protection from pediculus capits (head lice) . Disrupts normal sodium transfer resulting in neurologic paralysis of lice Dose Massage 5% cream into all skin surfaces. Leave on for 8-14 hr. Then wash off. SE burning, itching, rash, redness, stinging, swelling, numbness, tingling Med admin No significant drug interactions. Assess skin before and after therapy. Pt education Avoid getting cream into eyes. If occurs, flush eyes . Discuss methods to prevent reinfestation and spread of parasites. Instruct pt to massage thoroughly into the skin from head to soles of feet . One application is curative. niclosamide (Nicolicide) antihelminticsFor flatworms Absorbed (poorly) from intestines to exert full effect on worm Destroys sclex (head) and proximal segments which then allows intestines to digest and excrete in feces SE: stomach pain, anorexia, n/v, bad taseDeemed “cured” only if stool sample is negative for minimum 3 mo mebendazole (Vermox) antihelmintics Why is pt receiving this? Treatment of roundworm (trichinosis/pinworm). Inhibits uptake of glucose and other nutrients by susceptible organisms. Dose PO 100 mg twice daily for 3 days. If not cured w/in 3-4 weeks, 2nd course is given. SE uncommon GI distress, n/v/d. Adverse rxns generally seen w/ high dose therapy only. Seizures (rare), tinnitus, rash, agranulocytosis, reversible myelosuppression Med admin absorption enhanced w/ fatty meals . Phenytoin and carbamazepine may increase metab (decrease effectiveness) of therapy. Stool examinations should be monitored before and 1-3 wk following treatment Pt education Take as directed, take full course and take missed dose ASAP (if on 2 doses/day, space missed and next dose 4-5 hr apart), advise hygiene precautions to minimize reinfection. May cause dizziness (fall risk, driving). Advise if no improvement seen w/in days. Importance of follow up exams piperazine Antihelmintic agent Causes paralysis of worm muscles-> loss of attachment-> excrement SE: GI distress, HA, dizziness, trembling, ataxia ................
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