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Personal DrugsAshley PeczkowskiWright State UniversityFirst Diagnosis: Left Ventricular Heart Failure in a Renal PatientA 45 year old male presents as a new patient to your cardiology practice. He has not seen a cardiologist since he was hospitalized three years ago for acute myocardial infarction (MI). The patient has expressed concern for increased leg swelling over the past week and a weight gain of three pounds. His history includes diabetes, end stage chronic kidney disease requiring hemodialysis, and MI. An in office echocardiogram shows a dilated left ventricle with a 40% ejection fracture (EF). Upon completion of history and physical his diagnosis is left ventricular heart failure (LVHF) with fluid overload. Laboratory tests have been ordered, including lipid panel, basic metabolic panel, complete blood count, B-type natriuretic peptide (BNP), and a urinalysis. Results are pending. Other tests ordered include an electrocardiogram (ECG) and chest x-ray. An in office blood glucose test was 152, blood pressure was 167/93 and his weight and height are 167 pounds (75.9 kilograms), five foot nine inches. Finally, he is set up to receive an additional hemodialysis treatment today for removal of excess fluid. I. Definition of DiagnosisHeart failure is defined by the Heart Failure Society of America (2013) as a syndrome, not a diagnosis, which can be caused by cardiac impairment. This can result from myocardial muscle dysfunction or destruction and is represented by either left ventricular dilation or hypertrophy or both (Albert et al., 2010). According to the 2009 heart failure guidelines, there are four different stages of heart failure. The first two stages (A and B) are not considered heart failure but rather at risk patients and include those with a history of hypertension (HTN), pervious MI, diabetes (DM), left ventricular (LV) remodeling and other pre heart failure (HF) diseases. The final two stages (C and D) are for those patients who have diagnosed heart failure. Stage C includes those with known structural cardiac deficits, shortness of breath (SOB), fatigue, and reduced tolerance for exercise. The final stage, stage D, are for patients who have maxed out on medical therapy and need specialized interventions such as hospice, heart transplant, or permanent mechanical support (Abraham et al., 2009). Diagnosis criteria are not exact and can depend on a variety of findings or symptoms. An echocardiogram is the most common tool used to diagnosis HF. A comprehensive 2-dimensional echocardiogram with Doppler flow studies can determine EF, structural abnormalities, ventricular wall thickness, wall motion, valvular abnormalities, and pericardial abnormalities (Abraham et al., 2009). The typical findings of a HF patient are an EF of 40 percent or less; however, the patient may still have HF with a higher EF (Heart Failure Society of America, 2002). Left ventricular dilation, hypertrophy, reduced EF, and symptoms such as fatigue, SOB, fluid retention, reduced exercise tolerance, palpations, and cough are all evaluated when diagnosing LVHF. II. Therapeutic ObjectivesTreatment objectives for patients with LVHF include life style changes, risk factor management, starting ACE inhibitors, Beta blockers, and insertion of a pacemaker/ defibrillator for appropriate patients. Life style changes such as smoking cessation, regular exercise, reduced alcohol use, and illicit drug use should be encouraged. The treatment goals according to the Heart Failure Practice Guidelines for 2010 are: HTN patients with renal insufficiency and ≤ one g/day of proteinuria need to sustain a blood pressure of 130/85, have a limited sodium diet, reduced BMI to < 30(Albert et al., 2010), and obtain management of hyperlipidemia (HDL > 50mg/dL and LDL < 100mg/dL) and diabetes (A1C < 7%) (American Diabetes Association, 2011). While HF is considered a progressive disease, it is important to stabilize myocardial dysfunction and improve remodeling. These outcomes are obtained by medication therapy through ACE inhibitors, beta-blockers, and diuretics. ACE inhibitors are given to those with increased risk of developing HF such as those with coronary artery disease, diabetes, peripheral vascular disease, or stroke. Beta blockers are given for those individuals who have suffered from a previous MI and diuretics are given to those with fluid overload and functioning kidneys (Albert et al., 2010). For those individuals with severe kidney impairment requiring hemodialysis, fluid overload should be treated with dialysis and ACE inhibitors should be avoided (Abraham et al., 2009).An implantable cardioverter-defibrillator (ICD) should be considered for those patients with sustained ventricular arrhythmias, cardiac arrest, or unexplained syncope to prevent sudden death. An ICD is contraindicated in those individuals with progressive decompensated HF because death is expected. Only in cases of planned cardiac transplant should the ICD then be considered (Abraham et al., 2009).III. Inventory of Effective Drug Groups: OralDrugEfficacySafetySuitabilityAngiotensin II Receptor Blockers (ARBs)Candesartan (Atacand?), Eprosartan (Teventen?), Irbesartan (Avapro?), Losartan (Cozaar?), Olmesartan (Benicar?), Telmisartan (Micardis?), Valsartan (Diovan?) (Lexi-comp, 2013)Pharmacodynamics:ARBs selective inhibition of angiotensin II by competitive antagonism of receptors. Displacement of angiotensin II from angiotensin I receptor to produce vasodilation, prohibit aldosterone release, catecholamine release, arginine vasopressin release, water intake and reduce hypertrophic response (Barraras & Gurk-Turner, 2003). PharmacokineticsAbsorption: Rapid Metabolism: Absorption via ester hydrolysis with intestinal wall, hepatic CYP2C9 and 3A4. Extensive first pass effectExcretion: Urine and feces (Clinical Pharmacology, 2013)Side effects:Common: Hyperkalemia, hypotension, dizziness, headache, drowsiness, diarrhea, metallic taste, and rash. Rare: Kidney impairment, hepatic impairment, angioedema, and leukocytosis (Lexi-comp, 2013).Monitor: Supine BP, CNS changes, hyperglycemia, electrolytes, serum creatinine, BUN, urinalysis, hypotension, tachycardia, and CBC (Lexi-comp, 2013).Substrate CYP2C9 (minor), Inhibits CYP2C8 (moderate), (weak), CYP2C19 (weak), CYP2D6 (weak), CYP3A4 (weak), CYP2C9 (weak), (moderate) and SLCO1B1 (Lexi-comp, 2013). This medication can be given with or without food. Avoid alcohol use (Lexi-comp, 2013).Contraindications:Hypersensitivity to ARBs or formulary components. Concomitant use of aliskiren in diabetic patients (Lexi-comp, 2013). Use Caution:May not be effective in African-American patients. Use with caution in Aortic/Mitral stenosis. Reduce dose in hepatic impairment, and use with caution in renal impairment, Bilateral renal artery stenosis, aortic/mitral stenosis, oral airway surgery, or history of angioedema. Watch for hyperkalemia in renal impairment, potassium-sparring diuretics, potassium supplements, and potassium salts. Watch for hypotension in volume depletion. May cause further renal dysfunction. May cause worsening Heart failure. Diabetics should monitor glucose closely (Access Medicine, 2013; Lexi-comp, 2013).Angiotensin-Converting Enzyme (ACE) InhibitorsBenazepril (Lotensin?), Captopril (Capoten?), Enalapril (Vasotec?, Renitec?), Fosinopril (Monopril?), Lisinopril (Lisodur?, Lopril?, Novatec?, Prinivil?, Zestril?), Perindopril (Cpversy?, Aceon?), Quinapril (Accupril?), Ramipril (Altace?, Tritace?, Ramace?, Ramwin?), Trandolapril (Mavik?) (Lexi-comp, 2013)Pharmacodynamics:Prevents conversion of angiotensin I to angiotensin II which in turn dilates arterioles and promotes excretion of sodium and water. (Song & White, 2002).Pharmacokinetics:Absorption: Moderately in gastrointestinal (GI) tractMetabolism: Rapid and extensive hepatic via enzymatic hydrolysis, 50%; Extensive first pass effect. Some drugs not metabolizedExcretion: Urine (unchanged) and hepatic depending on drug (Lexi-comp, 2013).Side effects:Common: Orthostatic effects, hypotension, headache, dizziness, cough, rash, hyperkalemia, weakness, and metallic tasteUnder certain conditions: Prolonged QT interval, gout, and bradycardiaRare: Kidney failure, neutropenia, angioedema, and Steven-Johnson syndrome (Access Medicine, 2013; Lexi-comp, 2013).Monitor:BUN, Serum creatinine, Renal function, Lithium levels, White blood count, Potassium, and CBC with differential in renal impairment or collagen diseasesSubstrate CYP2D6 (major) (Lexi-comp, 2013). Take on empty stomach one hour before or two hours before meal. Long term use can alter taste due to zinc deficiency. Avoid potassium rich diet (Lexi-comp, 2013). Contraindications:Hypersensitivity to ACE inhibitors, previous angioedema, and concomitant use of aliskiren in diabetic patients (Lexi-comp, 2013). Use Caution:Use caution with aortic stenosis, African Americans with angioedema history, cholestatic jaundice, cough, cardiovascular disease, collagen vascular diseases, hypertrophic cardiomyopathy, hyperkalemia, hypersensitivity reactions, hepatic impairment, neutropenia, agranulocytosis, renal artery stenosis, and renal impairment. Dose adjustment may be needed in renal impairment. Con-committed use with ARBs and renin inhibitors may cause hypotension, hyperkalemia, and increased renal impairment. (Clinical Pharmacology, 2013; Lexi-comp, 2013) Beta BlockersAcebutolol (Sectral?), Atenolol (Tenormin?), Betaxolol (Kerlone?, Betoptic?), Bisoprolol (Zebeta?), Carvedilol (Coreg?, Coreg CR?), Esmolol (Brevibloc?), Labetalol (Trandate?), Metoprolol (Lopressor?, Toprol-XL?), Nadolol (Corgard?), Nebivolol (Bystolic?), Penbutolol (Levatol?), Pindolol (Visken?), Propranolol (Inderal?, Inderal LA?, InnoPran XL?), Sotalol (Betapace?, Sorine?), Timolol (Betimol?, Blocadren?, Istalol?, Timoptic?) (Lexi-comp, 2013)Pharmacodynamics:Beta adrenoreceptor blocker or beta adrenoreceptor and alpha adrenergic blocker causing reduced cardiac output, exercise tachycardia, reduced reflex orthostatic tachycardia, vasodilation, lower peripheral vascular resistance, lower renal resistance, reduced plasma renin activity, increased atrial natriuretic peptide and in heart failure patients it reduced pulmonary wedge pressure, lower pulmonary artery pressure, increase stroke volume, and decrease right atrial pressure (Lexi-comp, 2013).Pharmacokinetics:Absorption: Rapid and extensiveMetabolism: Hepatic through CYP2c9, 2D6, 3A4, and 2C19. Three active metabolites. Extensive first pass effect. Plasma concentration in elderly and hepatic impaired are 50% and 4-7 times higher. Excretion: primary feces (2-60%), some urine (30-80%) (Lexi-comp, 2013).Side Effects:Common:Fatigue, cold hands, headache, GI distress, constipation, diarrhea, and dizziness.Rare:Shortness of breath, insomnia, decreased libido, and depression (Lexi-comp, 2013).Monitor:Blood pressure, heart rate, fluid balance, and glucose Substrate CYP2C19 (minor) and CYP2D6 (major). Inhibits CYP2D6 (weak) (Lexi-comp, 2013).This drug should be given with meals to reduce orthostatic hypotension. Do not crush or chew. Bradycardia may be more severe in elderly (Lexi-comp, 2013). Contraindication:Hypersensitivity to Beta blockers, Decompensated cardiac failure requiring intravenous inotropic therapy, Bronchial asthma, Bronchospastic conditions, Av block, Sick sinus syndrome, Sinus node dysfunction, Pregnancy, Severe bradycardia without pacemakers, Cardiogenic Shock, Severe hepatic impairmentUse Caution: Bronchospatic disease, Conduction abnormality, Diabetes, Heart failure, Hepatic impairment, Mesenteric Vascular Disease, Myasthenia gravis, Peripheral vascular disease, Pheochromocytoma, Psoriasis, Psychiatric Disease, Renal impairment, and Thyroid disease. Use caution when taking verapamil, diltiazem, digoxin, or inhaled anesthetics (Lexi-comp, 2013).Avoid: Dental epinephrine (Lexi-comp, 2013). Diuretic/ Anhydrase Diuretic Acetazolamide (Lexi-comp, 2013)Pharmacodynamics:Reverses inhibition of carbonic anhydrase causing reduced hydrogen ion secretion at renal tubule and increase excretion of sodium, potassium, bicarbonate, and water. Decreased aqueous humor and inhibits carbonic anhydrase in CNS to retard abnormal and excessive discharge (Clinical Pharmacology, 2013; Lexi-comp, 2013). Pharmacokinetics:Onset of Action: Two hoursPeak Effect: Eight -18 hoursDuration: 18-24 hoursTime to Peak: three-six hoursExcretion: Urine (70-100% Unchanged) (Lexi-comp, 2013).Side Effects:Common:Taste alterations, nausea, vomiting, diarrhea, polyuria, drowsiness, and dehydrationUnder Certain Condition: Numbness in extremities, blurred vision, and kidney stonesRare:Acidosis and confusion (Lexi-comp, 2013). Monitor: Intraocular pressure, serum electrolytes, CBC with differential, growth, and glucose in diabetics. Inhibits CTYP3A4 (weak) (Lexi-comp, 2013).Give with food to decrease GI upset. Can cause metallic taste (Access Medicine, 2013). Contraindications:Hypersensitivity to acetazolamide, sulfonamides, or any component. Hepatic disease or insufficiency. Decreased sodium/ potassium levels. Adrenocortical insufficiency. Cirrhosis, hyperchloremic acidosis. Severe renal disease. Long term use in non-congestive angle-closure glaucoma (Lexi-comp, 2013)Use Caution:Impairment of mental alertness, sulfa allergy, diabetes, hepatic impairment, and respiratory acidosis (Access Medicine, 2013).Avoid:High dose Aspirin (Lexi-comp, 2013). Diuretic/Loop DiureticsBumetanide (Bumex?), Ethacrynate (Edecrin?), Furosemide (Lasix?), Torsemide (Demadex?) (Lexi-comp, 2013)Pharmacodynamics:Inhibits reabsorption of sodium and chloride in ascending loop of Henle, distal tubules, and proximal renal tubule. Causes excretion of water, sodium, chloride, magnesium, phosphate, and calcium (Lexi-comp, 2013). Pharmacokinetics:Absorption: ExtensivelyMetabolism: Partially hepatic via CYPHalf-life: 0.5- 3.5 hoursExcretion: Urine (50-81%; 20-45% unchanged) and feces (2%) (Lexi-comp, 2013).Side Effects:Common: Hypokalemia, dizziness, headache, fatigue, constipation, abdominal pain, nausea, tinnitus, and hyperglycemia.Rare: Abnormal heart rhythms (Lexi-comp, 2013). Monitor:Weight, I&O, blood pressure, orthostasis, serum electrolytes, renal function, and hearing (Clinical Pharmacology, 2013). May decrease levels if taken with food. Some patients may need potassium supplements (Lexi-comp, 2013).Contraindicated:Anuria, Hepatic come, hypersensitivity to loop diuretics or any component, history of severe watery diarrhea caused by drug and severe electrolyte depletion (Access Medicine, 2013).Use Caution:Cirrhosis, ascites, fluid/ electrolyte loss, diabetes, prostatic hyperplasia, urinary stricture, SLE hypersensitivity reactions, hyperuricemia, nephrotoxicity, ototoxicity, photosensitivity, sulfa allergy, digoxin, and with other antihypertensive (Lexi-comp, 2013)Diuretics/Potassium Sparing DiureticAmiloride Hydrochloride, Spironolactone (Aldactone?), Triamterene (Dyrenium?) (Lexi-comp, 2013)Pharmacodynamics:Blocks sodium channels in late distal convoluted tubule and collecting duct. This causes reduced intracellular sodium decreasing Na+/K+ATPase, leading to potassium retention and excretion of calcium, magnesium, and hydrogen ions (Lexi-comp, 2013). Pharmacokinetics:Absorption: 15-25%Metabolism: Hepatic, multiple metabolitesHalf-life: 78 minutes to 23 hoursExcretion: Urine and feces (Lexi-comp, 2013).Side Effects:Common:Dizziness, nausea, rash, decreased libido, constipation, lethargy, and vomiting. Rare:Macromastia, confusion, Steven-Johnsons syndrome, and breast cancer (Lexi-comp, 2013). Monitor:Blood pressure, serum electrolytes, renal function, I&O, CNS changes, ECG changes, rash, dehydration, and daily weight (Lexi-comp, 2013).Avoid alcohol, licorice, and potassium rich foods. Do not use salt substitutes. May be taken with food if GI upset (Lexi-comp, 2013). Contraindications:Anuria, acute renal insufficiency, severe hepatic disease, hypersensitivity to potassium sparing diuretics or any component, diabetic nephropathy, and hyperkalemia (Lexi-comp, 2013).Use caution:Fluid or electrolyte loss, hyperkalemia, diabetes, photosensitivity, kidney stones, acidosis, gynecomastia, tumorigenic, adrenal vein catheterization, cirrhosis, heart failure, and taking potassium supplements (Lexi-comp, 2013).Diuretics/Thiazide DiureticsChlorothiazide (Diuril?) Chlorthalidone (Hygroton?), Hydrochlorothiazide (Hydrodiuril?, Microzide?), Indapamide (Lozol?), Methyclothiazide (Enduron?), Metolazone (Zaroxolyn?, Diulo?, Mykrox?) (Lexi-comp, 2013). Pharmacodynamics:Inhibits sodium and chloride reabsorption in distal tubules, Proximal segment of the distal tubule of the nephron, and cortical-diluting segment of the ascending loop of Henle causing excretion of sodium, chloride, and water. Product of mechanism results in diuresis. Also causes potassium, hydrogen ions, magnesium, phosphate, and bicarbonate loss (Lexi-comp, 2013). Pharmacokinetics:Absorption: Poor Metabolism: Not metabolized Half-life: 45 minutes -60 hours.Excretion: Urine (10-15%) (Clinical Pharmacology, 2013; Lexi-comp, 2013).Side effects:Common:Hypokalemia, dizziness, nausea, and xerostomiaRare:Urinary retention, sudden vision changes, eye pain, or rash (Lexi-comp, 2013)Monitor:Serum electrolytes, renal function, blood pressure, weight, and I&O (Lexi-comp, 2013). Take dose in am or early day to avoid night time urinary frequency. If taking oral hypoglycemic, watch glucose closely. Decrease dietary sodium and calcium and increase dietary potassium, zinc, magnesium, and riboflavin (Lexi-comp, 2013). Contraindications: Hypersensitivity to Thiazide diuretics or any component, Sulfonamide-derived drugs, and anuria (Lexi-comp, 2013).Use Caution:Use caution with patients who have: Asthma, electrolyte imbalance, hypersensitivity reactions, ocular effects, photosensitivity, sulfa allergy, diabetes, gout, hepatic impairment, hypercalcemia, hypercholesterolemia, renal impairment, parathyroid disease, and systemic lupus erythematosus (Access Medicine, 2013; Lexi-comp, 2013).Digoxin (Lanoxin?) (Lexi-comp, 2013)Pharmacodynamics:Inhibits sodium/potassium APTase pump in myocardial cells causing increased intracellular sodium, promoting calcium influx creating increased contractility (Lexi-comp, 2013). Pharmacokinetics:Absorption: Passive diffusion in upper small intestineMetabolism: Sugar hydrolysis in stomach or reduced lactone ring in intestinal bacteriaExcretion: Urine (50-70% unchanged) (Lexi-comp, 2013).Side Effects:Common:Dizziness, dyspepsia, nausea, diarrhea, tachycardia, or bradycardiaRare:Confusion, weight gain, vision changes, anorexia, asthenia, rash, or abnormal heart conductions (Access Medicine, 2013)Monitor:Heart rate, Apical pulse, Rhythm, Periodic ECGs, Baseline and periodic serum creatinine, serum potassium, magnesium, and Calcium. Monitor for signs of toxicity including confusion and depression. Draw digoxin level 12-14 hours after initial dose or 3-5 days, and then every 5-7 days until at steady state then 7-14 days (Lexi-comp, 2013).Substrate of CYP3A4 (minor) (Lexicomp, 2013).End stage renal disease requires 50% reduce in loading dose. Needs potassium rich diet (Lexi-comp, 2013).Contraindication:Hypersensitivity to digoxin, digitalis forms, or any component. Ventricular fibrillation (Lexi-comp, 2013).Use caution:Proarrhythmic effects, Accessory bypass tract, Wolff-Parkinson-White syndrome, Acute MI (6 months or less), Atrioventricular block, Beri beri heart disease, electrolyte imbalance, Heart failure, Low EF, Cardiomyopathy, Constrictive pericarditis, Amyloid heart disease, Sinus rhythm, No HF symptoms, Hypermetabolic states, Hypertrophic Cardiomyopathy, Renal impairment, Sinus nodal disease, and Thyroid disease. Reduce digoxin with Amiodarone, propafenone, quinidine, and verapamil (Clinical Pharmacology, 2013).NitratesIsosorbide Dinitrate, Isosorbide Mononitrate (Imdur?, Monoket?), Nitroglycerin (Nitro-Dur?) (Lexi-comp, 2013)Pharmacodynamics:Stimulation of cyclic-GMP causing vascular smooth muscle relaxation. More prominent in veins. Decreases preload thus reducing cardiac oxygen demand and reduced afterload. Also improves coronary artery dilation. Nitroglycerin form free radical nitric oxide which works on the smooth muscle and increases guanosine 3’5’ monophosphate causing smooth muscle relaxation, reduces cardiac oxygen demand, decreased preload, reduced afterload, dilates coronary arteries, and improves collateral flow (Clinical Pharmacology, 2013)Pharmacokinetics:Absorption: 50% through mucous membranes in GI tractMetabolism: Extensive hepatic via liver reductase enzyme. Extensive first pass effect. Nonhepatic metabolism via red blood cells and vascular walls. Excretion: urine and feces (Lexi-comp, 2013).Side effects: Common:Headache, flushing, dizziness, upset stomach, vomiting, hypotension, and arrhythmiasRare:Fainting, restlessness, blurry vision, dry mouth, and rash (Access Medicine, 2013).Monitor: Blood pressure, heart rate, GI disturbances, volume depletion, hypotension, right ventricular infarction, and tolerance (Lexi-comp, 2013).Substrate CYP3A4 (major) (Lexi-comp, 2013). Allow for nitrate free intervals. Dose alternate timing. Alcohol can exacerbate hypotension (Lexi-comp, 2013).Contraindications:Hypersensitivity to Nitrates or any component, Organic nitrates, and Concurrent use of phosphodiesterase-5 inhibitors. Severe pericardial effusion, Severe anemia, increased Intracranial pressure, Hypotension, Extreme Bradycardia, Tachycardia in the absence of heart failure, and Right ventricular infarction (Lexi-comp, 2013). Use caution:Hypotension, Bradycardia, Inferior wall MI, Intracranial pressure increase, Hypertrophic cardiomyopathy, PDE-5 inhibitors, Extended release: Acute MI or Acute HF, Sublingual: acute anginal episode, and Tolerance: Overcome by short nitrate absence (Lexi-comp, 2013). IV. Effective Drug Classification: Beta Blocker OralDrug NameEfficacySafetySuitabilityCostBeta BlockersAcebutolol (Sectral?) (Lexi-comp, 2013)Onset: One to two hoursDuration: 12-24 hoursAbsorption: Oral 40%Protein binding: ~26%%Metabolism: Extensive first pass effect to equipotent and cardio-selective diacetolol metabolite. Bioavailability: 40%Half-life: Parent drug: Three to four hours; Metabolite: Eight to 13 hoursPeak time: Two to four hoursExcretion: primary feces (50- 60%), some urine (30-40%) (Clinical Pharmacology, 2013; Lexi-comp, 2013).Drug interactions: Floctafenine, and Methacholine (Lexi-comp, 2013).Increase Effect/Toxicity:Alpha/Beta-agonists, Alpha1-blockers, Alpha2-agnosist, Amifostine, Antihypertensives, Antipsychotic agents, Aripiprazole, Bupivacaine, Cardiac glycosides, Cholinergic agonists,Ergot derivatives, Fingolimod, Hypotensive agents, Insulin, Lidocaine, Mepivacaine, Methacholine, Midodrine, RiTuximab, and Sulfonylureas (Lexi-comp, 2013). Decrease Effect/Toxicity:Beta2-agnosits and Theophylline derviatives (Lexi-comp, 2013). Avoid:Beta2-angonist, Dong quai, Yohimbe, Ginseng, Bosutinib, Floctafenine, Methacholine, Pomalidomide, Topotecan, and VinCRIStine (Lexi-comp, 2013).Weak inhibitor of CYP2D6 substrates (Lexi-comp, 2013). -Teach diabetics about possible altered glucose.-Taper over two weeks when discontinuing.-Serum levels slightly increased with food intake.-Check pulse prior to taking drug.-Bradycardia may be more severe in elderly. -Geriatrics may need reduced dose. -Do not stop drug abruptly. -Do not stop prior to surgery. -Avoid herbs with hypertensive properties and hypotensive properties (Access Medicine, 2013; Lexi-comp, 2013). Acebutolol HCL oral: 200mg (100): $100.73400mg (100): $133.97Sectral ? oral: 200mg (100)L $399.19400mg (100) $530.75 (Lexi-comp, 2013)Beta BlockersAtenolol (Tenormin?) (Lexi-comp, 2013)Onset: One to two hoursPeak effect: 2-4 hoursDuration: 12-24 hoursAbsorption: Rapid and incompleteDistribution: Does not cross blood brain barrierProtein binding: 6-16% Metabolism: Limited hepaticPeak time: 2-4 hoursExcretion: Feces (50%) and Urine (40%) (Lexi-comp, 2013).Drug interactions: Floctafenine, and Methacholine (Lexi-comp, 2013)Increased Effect/Toxicity:Alpha/Beta-agonists, Alpha1-blockers, Alpha2-agnosist, Amifostine, Antihypertensives, Bupivacaine, Cardiac glycosides, Cholinergic agonists,Ergot derivatives, Fingolimod, Hypotensive agents, Insulin, Lidocaine, Mepivacaine, Methacholine, Midodrine, RiTuximab and Sulfonylureas (Lexi-comp, 2013).Decreased Effect/Toxicity:Beta2-agnosits and Theophylline derviatives (Lexi-comp, 2013)Avoid:Dong quai, Ephedra, Yohimbe, Ginseng and Garlic (Lexi-comp, 2013).-Teach diabetics about possible altered glucose.-Taper over two weeks when discontinuing.-May decrease concentration when taken with food.-Check pulse prior to taking drug.-Geriatrics may need reduced dose. -Do not stop drug abruptly. -Do not stop prior to surgery. -Decreased HDL levels.-Avoid herbs with hypertensive properties and hypotensive properties (Access Medicine, 2013; Lexi-comp, 2013).Atenolol oral: 25mg (100): $81.7550mg (100): $84.60100mg (30): $42.62Tenormin? oral: 25mg (100): $184.9950mg (30): $41.06100mg (30): $92.07 (Lexi-comp, 2013)Beta BlockersBetaxolol (Kerlone?, Betoptic) (Lexi-comp, 2013)Onset: 1-1.5 hoursAbsorption: ~100%Metabolism: Hepatic to multiple metabolismProtein Binding: ~50%Bioavailability: 89%Half-life: 14-22 hours, prolonged with hepatic or renal diseasePeak time:1.5-6 hoursExcretion: Urine (Lexi-comp, 2013).Drug interactions: Floctafenine, and Methacholine (Clinical Pharmacology, 2013).Increased Effect/Toxicity:Alpha/Beta-agonists, Alpha1-blockers, Alpha2-agnosist, Amifostine, Antihypertensives, Antipsychotic agents, Aripiprazole, Bupivacaine, Cardiac glycosides, Cholinergic agonists,Ergot derivatives, Fingolimod, Hypotensive agents, Insulin, Lidocaine, Mepivacaine, Methacholine, Midodrine, RiTuximab, and Sulfonylureas (Lexi-comp, 2013).Decreased Effect/Toxicity:Beta2-agonists and theophylline derivatives (Lexi-comp, 2013).Avoid:Herbs with antihypertensive effects (Lexi-comp, 2013).Increases metabolism of CYP1A2 (major) and CYP2D6 (minor) substrates. Inhibits CYP2D6 weak affect (Lexi-comp, 2013).-Geriatrics may bradycardia more frequently.-Taper down over two week when stopping drug.-Do not stop for surgery.-May take with meals.-Diabetics should watch glucose closely.-Do not abruptly stop. Can cause tachycardia and hypertension.-Do not stop for surgery (Access Medicine, 2013). Betaxolol HCL oral: 10mg (100): $123.0020mg (100): $186.00Kerlone? oral: 10mg (100): $156.8920mg (100): $235.25 (Lexi-comp, 2013)Beta BlockersBisoprolol (Zebeta?) (Lexi-comp, 2013)Onset: 1-2 hoursAbsorption: Rapid and almost completeDistribution: Widely; heart, liver, lungs and saliva; does cross the blood-brain barrierProtein binding: ~30%Metabolism: Hepatic Extensive first pass effect. Bioavailability: ~80%Half-life: 9-36 hours depending on renal and liver functionPeak time: 2-4 hoursExcretion: Urine (50% unchanged drug), and feces (2%) (Lexi-comp, 2013).Drug interactions: Floctafenine, Conivaptan, and Methacholine (Lexi-comp, 2013)Increased Effect/Toxicity: Alpha/Beta-agonists, Alpha1-blockers, Alpha2-agnosist, Amifostine, Antihypertensive, Antipsychotic agents, Bupivacaine, Cardiac glycosides, Cholinergic agonists,Ergot derivatives, Fingolimod, Hypotensive agents, Insulin, Lidocaine, Mepivacaine, Methacholine, Midodrine, RiTuximab, and Sulfonylureas (Lexi-comp, 2013).Drug may decrease:Beta2-agnosits and Theophylline derviatives (Lexi-comp, 2013). Avoid: Herbs with antihypertensive properties (Lexi-comp, 2013).Increases metabolism of substrate CYP2D6 (minor) and CYP3A4 (major) (Lexi-comp, 2013). -Treatment for anaphylaxis may be ineffective or have undesirable effects.-Do not abruptly stop.-Do not stop prior to non-cardiac surgery.-Can be given without regard to meals.-Watch glucose in diabetic patients.-Teach patients to monitor orthostatic hypotension (Access Medicine, 2013).Bisoprolol Fumarate oral: 5mg (30): $36.5910mg (30): $36.59Zebeta? oral: 5mg (30): $117.7810mg (30): $144.60 (Lexi-comp, 2013)Beta BlockersCarvedilol (Coreg, Coreg CR) (Lexi-comp, 2013)Onset: 1-2 hoursPeak: ~1-2 hoursAbsorption: Rapid and extensiveProtein binding: >98 to albuminMetabolism: Extensively hepatic via CYP2C9, 2D6, 3A4, and 2C19 in to three different metabolites; First pass effect; Plasma concentration in geriatrics and cirrhotic patient Bioavailability: Immediate release: 25-35%; Extended release: 85%Half-life: 7-10 hours depending on renal and liver functionPeak time: 5 hoursExcretion: Primarily feces (Lexi-comp, 2013).Drug interactions: Beta2-Agonists, Bosutinib, Floctafenine, Methacholine, pomalidomide, topotecan, and vincristine (Lexi-comp, 2013). Increased Effect/Toxicity: Alpha/Beta-agonists, Alpha1-blockers, Alpha2-agnosist, Amifostine, Antihypertensives, Antipsychotic agents, bosutinib, Bupivacaine, Cardiac glycosides, Cholinergic agonists, cholchine, cyclosporine, daigatran, etexilate, digoxin,Ergot derivatives, everolimus, Fingolimod, Hypotensive agents, Insulin, Lidocaine, Mepivacaine, Methacholine, Midodrine, p-glycoprotein/ABCB1 substrates, pomalidamide, prucalapride, RiTuximab, rivaroxaban, Sulfonylureas, topotencan, and vincristine (Lexi-comp, 2013).Drug may decrease:Beta2-agnosits and Theophylline derviatives (Lexi-comp, 2013).Avoid: Herbs with antihypertensive properties or hypotensive properties (Lexi comp, 2013).Increases metabolism of substrate CYP1A2 (minor), CYP2C9 (minor), CYP2D6 (major), CYP2E1 (minor), CYP3A4 (minor), and P-glycoprotein. Inhibits metabolism of P-glycoprotein. (Lexi-comp, 2013). -given with food to prevent orthostatic hypotension.-Do not abruptly stop.-Do not stop prior to non-cardiac surgery.-Can be given without regard to meals.-Watch glucose in diabetic patients.-Teach patients to monitor orthostatic hypotension.-Assess blood pressure and pulse rate before giving (Access Medicine, 2013). Coreg CR? oral: 10mg (30): $175.3620mg (30): $174.7640mg (30): $175.3680mg (30): $174.76Carvedilol oral:3.125mg (100): $213.406.25mg (100): $213.4012.5mg (100): $213.4025mg (100): $213.40Coreg? oral: 3.125mg 930): $96.216.25mg (30): $89.7112.5mg (30): $91.7525mg (30)L $89.11 (Lexi-comp, 2013)Beta BlockersLabetalol (Trandate?) (Lexi-comp, 2013)Onset: 20 minutes- 2 hoursPeak: 1-4 hoursAbsorption: CompleteDistribution: Can cross the blood-brain barrierProtein binding: 50%Metabolism: Hepatic primarily via glucuronide conjugation; extensive first pass effect Bioavailability: 25%; increased in elderly, hepatic impairment, and cimetidine useHalf-life: 6-8 hours Peak time: 1-2 hoursExcretion: Urine (Lexi-comp, 2013).Drug interactions: Beta2-agonists, Floctafenine, and Methacholine (Lexi-comp, 2013).Increased Effect/Toxicity: Alpha/Beta-agonists, Alpha1-blockers, Alpha2-agnosist, Amifostine, Antihypertensives, Antipsychotic agents, Bupivacaine, Cardiac glycosides, Cholinergic agonists,Ergot derivatives, Fingolimod, Hypotensive agents, Insulin, Lidocaine, Mepivacaine, Methacholine, Midodrine, RiTuximab, and Sulfonylureas (Lexi-comp, 2013).Drug may decrease:Beta2-agnosits and Theophylline derviatives (Lexi-comp, 2013). Avoid: Herbs with antihypertensive properties (Lexi-comp, 2013).-Treatment for anaphylaxis may be ineffective or have undesirable effects.-Do not abruptly stop.-Do not stop prior to non-cardiac surgery.-Serum levels increased with food intake.-Watch glucose in diabetic patients.-Teach patients to monitor orthostatic hypotension.-Not removed by dialysis.-Bradycardia more common in elderly (Access, Medicine, 2013). Labetalol HCL oral: 100mg (100): $51.31200mg (100): $72.79300mg (100): $96.83Trandate? oral: 100mg (100): $64.87200mg (100): $126.14300mg (100): $127.78 (Lexi-comp, 2013).Beta BlockersMetoprolol (Lopressor, Toprol-XL) (Lexi-comp, 2013)Onset: 1-2 hoursDuration: Variable depending on doseAbsorption: Rapid and completeProtein binding: ~10% to albuminMetabolism: Extensively hepatic via CYP2D6; Extensive first pass effect. Bioavailability: ~50%Half-life: 3-4 hoursExcretion: Urine (Lexi-comp, 2013).Drug interactions: Floctafenine, and Methacholine (Lexi-comp, 2013). Increased Effect/Toxicity: Alpha/Beta-agonists, Alpha1-blockers, Alpha2-agnosist, Amifostine, Antihypertensives, Antipsychotic agents, aripiprazole, Bupivacaine, Cardiac glycosides, Cholinergic agonists,Ergot derivatives, Fingolimod, Hypotensive agents, Insulin, Lidocaine, Mepivacaine, Methacholine, Midodrine, RiTuximab, and Sulfonylureas Lexi-comp, 2013).Drug may decrease:Beta2-agnosits and Theophylline derviatives (Lexi-comp, 2013). Avoid: Herbs with antihypertensive properties (Lexi-comp, 2013).Increases metabolism of substrate CYP2C19 (minor) and CYP2D6 (major). Inhibits metabolism of CYP2D6 (weak) (Lexi-comp, 2013). -Treatment for anaphylaxis may be ineffective or have undesirable effects.-Do not abruptly stop.-Do not stop prior to non-cardiac surgery.-Food can increased absorption. Give immediate release with food. Regular release can be given without regard to meals.-Watch glucose in diabetic patients-Teach patients to monitor orthostatic hypotension-May need to dose down in elderly due to bradycardia (Access Medicine, 2013).Metoprolol Succinate ER oral: 25mg (100): $105.3850mg (100): $105.38100mg (100): $158.35200mg (100): $251.95Toprol XL? oral: 25mg (100): $143.4650mg (30): $44.39100mg (30): $66.13200mg (30): $97.96Lopressor? oral: 50mg (30): $43.02100mg (30): $63.29Metoprolol Tartrate oral: 25mg (100): $24.2550mg (100): $55.50100mg (100): $80.10 (Lexi-comp, 2013).Beta BlockersNadolol (Corgard?) (Lexi-comp, 2013). Duration: 17-24 hourAbsorption: 30-40% Protein binding: 30%Metabolism: Not metabolized Half-life: 10-24 hours depending on renal and liver functionPeak time: 2-4 hoursExcretion: Urine (unchanged drug) (Lexi-comp, 2013).Drug interactions: Beta2-agonists Floctafenine, and Methacholine (Lexi-comp, 2013).Increased Effect/Toxicity: Alpha/Beta-agonists, Alpha1-blockers, Alpha2-agnosist, Amifostine, Antihypertensives, Bupivacaine, Cardiac glycosides, Cholinergic agonists,Ergot derivatives, Fingolimod, Hypotensive agents, Insulin, Lidocaine, Mepivacaine, Methacholine, Midodrine, RiTuximab, and Sulfonylureas (Lexi-comp, 2013). Drug may decrease:Beta2-agnosits and Theophylline derviatives (Lexi-comp, 2013).Avoid: Herbs with antihypertensive properties (Lexi-comp, 2013).Increases metabolism of substrate P-glycoprotein (Lexi-comp, 2013). -Treatment for anaphylaxis may be ineffective or have undesirable effects.-Do not abruptly stop.-Do not stop prior to non-cardiac surgery.-Bradycardia may be seen more in elderly.-Can be given without regard to meals.-Watch glucose in diabetic patients.-Teach patients to monitor orthostatic hypotension (Access Medicine, 2013). Corgard? oral: 20mg (100): $384.0440mg (30): $78.4880mg (100): $617.29Nadolol oral: 20mg (100): $92.4940mg (100): $108.1580mg (100): $142.30 (Lexi-comp, 2013).Beta BlockersNebivolol (Bystolic?) (Lexi-comp, 2013)Absorption: Rapid Protein binding: ~98% mostly to albuminMetabolism: Hepatic via glucuronidation and CYP2D6; Extensive first pass effect. Bioavailability: ~12%Half-life: 10-12 hours Peak time: 1.5-4 hoursExcretion: Urine (38%), and feces (44%) (Lexi-comp, 2013).Drug interactions: Floctafenine, and Methacholine (Lexi-comp, 2013).Increased Effect/Toxicity: Alpha/Beta-agonists, Alpha1-blockers, Alpha2-agnosist, Amifostine, Antihypertensives, Antipsychotic agents, Bupivacaine, Cardiac glycosides, Cholinergic agonists,Ergot derivatives, Fingolimod, Hypotensive agents, Insulin, Lidocaine, Mepivacaine, Methacholine, Midodrine, RiTuximab, and Sulfonylureas (Lexi-comp, 2013).Drug may decrease:Beta2-agnosits and Theophylline derviatives (Lexi-comp, 2013).Avoid: Herbs with antihypertensive properties (Lexi-comp, 2013).Increases metabolism of substrate CYP2D6 (minor) (Lexi-comp, 2013). -Treatment for anaphylaxis may be ineffective or have undesirable effects.-Do not abruptly stop.-Do not stop prior to non-cardiac surgery.-Can be given without regard to meals.-Watch glucose in diabetic patients.-Teach patients to monitor orthostatic hypotension.-Watch bradycardia in geriatrics (Access Medicine, 2013). Bystolic? oral:2.5mg (100): $267.445mg (100): $267.4410mg (100): $267.4420mg (30): $81.49 (Lexi-comp, 2013).Beta BlockersPenbutolol (Levatol?) (Lexi-comp, 2013)Onset: 1.3-3 hoursDuration: >20 hoursAbsorption: ~100%Protein binding: 80-98%Metabolism: Hepatic –oxidation and conjugationBioavailability: ~100%Half-life: 5 hours Peak time: 2-3 hoursExcretion: Urine (Lexi-comp, 2013).Drug interactions: Beta2-agonists, Floctafenine, and Methacholine (Lexi-comp, 2013).Increased Effect/Toxicity: Alpha/Beta-agonists, Alpha1-blockers, Alpha2-agnosist, Amifostine, Antihypertensives, Antipsychotic agents, Bupivacaine, Cardiac glycosides, Cholinergic agonists,Ergot derivatives, Fingolimod, Hypotensive agents, Insulin, Lidocaine, Mepivacaine, Methacholine, Midodrine, RiTuximab, and Sulfonylureas (Lexi-comp, 2013).Drug may decrease:Beta2-agnosits and Theophylline derviatives.(Lexi-comp, 2013). -Treatment for anaphylaxis may be ineffective or have undesirable effects.-Do not abruptly stop.-Do not stop prior to non-cardiac surgery.-Can be given without regard to meals.-Teach patients to monitor orthostatic hypotension (Access Medicine, 2013). Levatol? oral: 20mg (100): $406.80 (Lexi-comp, 2013). Beta BlockersPindolol (Visken?) (Lexi-comp, 2013)Absorption: Rapid; 50-95%Protein binding: 40%Metabolism: Hepatic 60-65% to conjugatesHalf-life: 3-4 hours Peak time: ~1hourExcretion: Urine (35-40% unchanged drug), and feces (6-9%) (Lexi-comp, 2013).Drug interactions: Bet2-agonists, Floctafenine, and Methacholine (Lexi-comp, 2013).Increased Effect/Toxicity: Alpha/Beta-agonists, Alpha1-blockers, Alpha2-agnosist, Amifostine, Antihypertensives, Antipsychotic agents, aripirazole, Bupivacaine, Cardiac glycosides, Cholinergic agonists,Ergot derivatives, Fingolimod, Hypotensive agents, Insulin, Lidocaine, Mepivacaine, Methacholine, Midodrine, RiTuximab, and Sulfonylureas (Lexi-comp, 2013).Drug may decrease:Beta2-agnosits and Theophylline derviatives (Lexi-comp, 2013).Avoid: Herbs with antihypertensive properties (Lexi-comp, 2013).Increases metabolism of substrate CYP2D6 (minor). Inhibits metabolism of CYP2D6 (weak) (Lexi-comp, 2013). -Treatment for anaphylaxis may be ineffective or have undesirable effects.-Do not abruptly stop.-Do not stop prior to non-cardiac surgery.-Can be given without regard to meals.-Watch glucose in diabetic patients.-Teach patients to monitor orthostatic hypotension.-Half-life is ten time longer in cirrhosis patients (Access Medicine, 2013). Pindolol oral: 5mg (100): $103.7510mg (100): $141.36 (Lexi-comp, 2013).Beta BlockersPropranolol (Inderal?, Inderal LA?, InnoPran XL?) (Lexi-comp, 2013)Onset: 1-2 hoursDuration:6-12 hours Absorption: Rapid and completeProtein binding: ~90%Metabolism: Hepatic via CYP2D6 and CYP1A2 to 4-hydroxypropranolol and inactive compounds; Extensive first pass effect. Bioavailability: ~25%Half-life: 3-6 hours Peak time: 1-4 hoursExcretion: Urine (Lexicomp, 2013).Drug interactions: Beta2-agonists, bosutinib, Floctafenine, Methacholine, pomalidomide, topotecan, and vincristine (Lexi-comp, 2013).Increased Effect/Toxicity: Alpha/Beta-agonists, Alpha1-blockers, Alpha2-agnosist, Amifostine, Antihypertensives, Antipsychotic agents, aripiprazole, bosutinib, Bupivacaine, Cardiac glycosides, Cholinergic agonists,Dabigatran, etexilate, Ergot derivatives, everolimus, Fingolimod, Hypotensive agents, Insulin, Lidocaine, Mepivacaine, Methacholine, Midodrine, p-glycoprotein/ABCB1 substrates, pomalidomide, prucalopride, RiTuximab, rizatriptan, Sulfonylureas, topotecan, vincristine, and zolmitriptan (Lexi-comp, 2013).Drug may decrease:Beta2-agnosits, lacidipina, and Theophylline derviatives (Lexi-comp, 2013).Avoid: Herbs with antihypertensive properties (Lexi-comp, 2013).Increases metabolism of substrate Cyp1A2 (major), CYP2C19 (minor) CYP2D6 (major) and CYP3A4 (major). Inhibits metabolism of CYP1A2 (weak) (Lexi-comp, 2013). -Treatment for anaphylaxis may be ineffective or have undesirable effects.-Do not abruptly stop.-Do not stop prior to non-cardiac surgery.-Teach patients to monitor orthostatic hypotension.-Not dialyzable.-Bradycardia seen in hepatic impairment patients.-Smoking decreases serum plasma levels.-Alcohol can increase or decrease plasma levels.-Give medication on empty stomach (Access Medicine, 2013).Inderal LA? oral: 60mg (30): $56.3580 mg (30): $65.39120 mg (100): $247.03160 mg (100): $322.78InnoPran XL? oral:80 mg (30): $80.00120 mg (30): $80.00Propranolol HCL ER oral:60 mg (100): $132.5980 mg (100): $154.89120 mg (100): $192.09160 mg (100): $251.47Propranolol HCL oral:10mg (100): $33.5320mg (100): $36.3040mg (100): $60.0760mg (100):$121.8380mg (100): $63.39 (Lexi-comp, 2013).Beta BlockersSotalol (Betapace?, Sorine?) (Lexi-comp, 2013). Onset: 1-2 hoursDuration:8-16 hoursAbsorption: Decreased 20-30% when given with mealsProtein binding: noneMetabolism: none Bioavailability: 90-100%Half-life: 12 hoursPeak time: 2.5-4 hoursExcretion: Urine (Lexi-comp, 2013).Drug interactions: Beta2-agonists, Floctafenine, floctafenine, QT prolonging agents, ivabradine, Methacholine, mifepristone, and propafenone (Lexi-comp, 2013).Increased Effect/Toxicity: Alpha/Beta-agonists, Alpha1-blockers, Alpha2-agnosist, Amifostine, Antihypertensives, Antipsychotic agents, Bupivacaine, Cardiac glycosides, Cholinergic agonists,Ergot derivatives, Fingolimod, QT prolonging agents, Hypotensive agents, Insulin, Lidocaine, Mepivacaine, Methacholine, Midodrine, RiTuximab, and Sulfonylureas (Lexi-comp, 2013).Drug may decrease:Beta2-agnosits and Theophylline derviatives (Lexi-comp, 2013). Avoid: Ephedra (Lexi-comp, 2013). -Treatment for anaphylaxis may be ineffective or have undesirable effects.-Do not abruptly stop.-Do not stop prior to non-cardiac surgery.-Do not give with meals.-Watch glucose in diabetic patients.-Teach patients to monitor orthostatic hypotension.-Dialysis removes drug. Give dose post dialysis.-Closely monitor QT intervals.-Do not give to elderly (BEERS criteria) (Lexi-comp, 2013)Betapace AF? oral: 80mg (60): $259.50120mg (60): $346.25160mg (60): $433.07Betapace? oral: 80mg (100): $473.45120mg (100): $631.76160mg (100): $789.65Sorine? oral: 80mg (100): $260.89120mg (100): $346.39160mg (100): $430.98240mg (100): $559.97Sotalol HCL oral:80mg (100): $234.72120mg (100): $322.35160mg (100): $403.00240mg (100): $55.59 (Lexi-comp, 2013). Beta BlockersTimolol (Betimol, Blocadren, Istalol, Timoptic) (Lexi-comp, 2013)Onset: 15-45minutesDuration:~4 hours Absorption: Rapid and almost completeProtein binding: 60%Metabolism: Hepatic via CYP2D6; Extensive first pass effect. Bioavailability: 50%Half-life: 2-2.7 hours Peak time: 1-2 hoursExcretion: Urine (Lexi-comp, 2013).Drug interactions: Beta2-agonists, Floctafenine, and Methacholine (Lexi-comp, 2013)Increased Effect/Toxicity: Alpha/Beta-agonists, Alpha1-blockers, Alpha2-agnosist, Amifostine, Antihypertensives, Antipsychotic agents, Bupivacaine, Cardiac glycosides, Cholinergic agonists,Ergot derivatives, Fingolimod, Hypotensive agents, Insulin, Lidocaine, Mepivacaine, Methacholine, Midodrine, RiTuximab, and Sulfonylureas (Lexi-comp, 2013).Drug may decrease:Beta2-agnosits and Theophylline derviatives (Lexi-comp, 2013). Increases metabolism of substrate CYP2D6 (major).inhibits metabolism of CYP2D6 (weak) (Lexi-comp, 2013). -Treatment for anaphylaxis may be ineffective or have undesirable effects.-Do not abruptly stop.-Do not stop prior to non-cardiac surgery.-Can be given without regard to meals (Access Medicine, 2013). Timolol Maleate oral:5mg (100): $63.6610mg (100):$78.7520mg (100): $145.30 (Lexi-comp, 2013).V. Drug of Choice: CarvedilolThe recommended therapy for treating HTN and controlling HF in hemodialysis patient is the use of beta blockers (Abbott, Agodoa, Bakris, Taylor, & Trespalacios, 2004). There are several different beta blockers for use of HF but only Carvedilol was mentioned by name by the American Heart Association (AHA, 2008). Carvedilol is unique compared to the other beta blockers because it is beta blocker and an alpha blocker. This drug has a slight inverse agonist action and has a reduced negative chronotropic and inotropic effect. Carvedilol has shown to improve EF, reduce HF symptoms, increase stroke volume, stroke work, cardiac output, improved insulin sensitivity and adrenergic activity. The overall effect of Carvedilol is a reduction in mortality from all causes (DiNicolantonio, Fares, Lavie, Menezes, & O’Keefe, 2012). An Advanced Nurse Practitioner (APN) with a current certificate to prescribe (CTP) can prescribe Carvedilol according to the Ohio Board of Nursing Formulary (Ohio Board of Nursing, 2013). When giving a beta blocker, such as Carvedilol, close initial monitoring and follow up are necessary. While guidelines encourage an ACE inhibitor and a beta blocker for HF patients, those with severe renal impairment are only given beta blockers (Abbott et al., 2004). Carvedilol is given as 3.125 mg twice daily for two weeks and then increased to 6.25 mg twice daily if tolerated. Every two weeks the dose should be double as tolerated until the highest dose with the maximal benefit is reached. For this patient the recommended maximum dose is 25 mg twice daily. This medication should be given with food to help reduce the risk of hypotension. Close monitoring of the patients heart rate and blood pressure are needed to find optimum therapy dosage until goal is achieved. Blood test including renal studies, BUN, and liver function tests should be performed before each dose increase and then yearly when optimum dose is found. Carvedilol should be taken every day for the rest of the patient’s life unless hospice or change in diagnosis is made. This drug has a slight risk for increasing renal impairment. Carvedilol is metabolized in the liver and should not be given to those with liver impairment. This drug costs from $14.99 to $25.99 for 30 tablets depending on strength (Access Medicine, 2013). Second Diagnosis: Acute Clavicle Fracture A 23 year old Caucasian male presents to the emergency department complaining of right clavicle pain after falling off a stage. He states he was moving the stage set when he backed up into the curtain and fell off the stage catching himself with his right arm. He is in good health. He is a college student at the local community college and is majoring in stage manager assistant. After history and physical assessment and X-rays of the right shoulder, he is diagnosed with acute right clavicle fracture non-displaced. I. Definition of DiagnosisAcute clavicle fracture is one of the most common fractures seen in young active adults, accounting for 2.6% to 4% of all total fractures (Andriolo, Belloti, Faloppa, Gomes dos Santos, & Lenza, 2010). The Allman’s method classifies clavicle fractures into three sub groups which are: Group I- mid shaft fractures, Group II- Lateral fractures, and Group III- medial fractures. Group I (midshaft factures) account for up to 81% of all clavicle fractures and are usually displaced resulting in the need for surgery (Farsetti, Gumina, Postacchini, & Postacchini, 2010). Clavicle fractures results from a fall with an out stretched hand or from direct trauma. For non-displaced factures conservative treatment is best (Andriolo et al., 2010).II. Therapeutic ObjectivesThe choice of treatment for a non-displaced clavicle fracture is placement of the arm in a sling or placing the back in a figure eight bandage. One or both of these treatments can be used to achieve stabilization of the fracture. It is recommended that the patient be immobilized for two to six weeks for adequate healing. Some patients may need arm stretching exercises after, however, this incident is low (Adriolol et al., 2010). The second focused treatment should be pain control. Only 28-85% of all patients with a facture receive analgesic prescription and of that only 17-64% received an opioid. This statistic leaves a large number of patients who have an acute painful injury without or with poorly controlled pain management (Castelluccio et al., 2010). Patients without proper pain control and immobilization are generally more dissatisfied with their care (Farsetti, Gumina, Postacchini, & Postacchini, 2010).III. Inventory of Effective Drug Groups OralDrugEfficacySafetySuitabilityNon-Steroidal Anti-Inflammatory Drugs/ Acetic Acid DerivativesIndomethacin, Tolmetin, Sulindac, Etodolac, Ketorolac, Diclofenac (Valtaren?), Nabumetone (Lexi-comp, 2013)Pharmacodynamics:Inhibits cyclooxygenase 1 and 2 enzyme causing decreased prostaglandin precursors. This causes an antipyretic, analgesic, and anti-inflammatory effect (Clincial Pharmacology, 2013). Pharmacokinetics:Absorption: Immediate releaseMetabolism: HepaticExcretion: Urine (60-80%) and feces (9-33%) (Lexi-comp, 2013).Side Effects:Common:Dyspepsia, stomach ulcers, anemia, and GI bleedingRare:MI, heart failure, and hypertensionVery Rare:Kidney and liver impairment (Lexi-comp, 2013). Monitor:Pain response, inflammation, weight, edema, renal function, confusion, GI effects, CBC, Liver function, and bruising (Access Medicine, 2013).Substrate: CYP1A2 (minor), CYP2B6 (minor), CYP2C19 (minor), CYP2C8 (minor), CYP2C9 (minor), CYP2D6 (minor). Inhibits: CYP1A2 (weak) CYP2C19 (weak), CYP2E1 (weak), CYP3A4 (weak), CYP2C9 (weak), UGT1A6 (Lexi-comp, 2013).Contraindications:Hypersensitivity to NSAIDs or any component, perioperative setting for CABG, advanced renal impairment, and history of proctitis or rectal bleeding (Lexi-comp, 2013). Use Caution:Anaphylactoid reactions, cardiovascular events, CNS effects, GI events, hematologic effects, hyperkalemia, skin reactions, visual impairments, asthma, CABG, depression, hepatic impairment, hypertension, parkinsonism, photosensitivity reaction, and renal impairment (Lexi-comp, 2013). Non-Steroidal Anti-Inflammatory Drugs/ Cox-2 SelectiveCelecoxib (Celebrex) (Lexi-comp, 2013)Pharmacodynamics:Inhibits prostaglandin synthesis by decreasing enzyme cyclooxygenase-2. This causes an antipyretic, analgesic, and anti-inflammatory effect (Clinical Pharmacology, 2013; Lexicomp, 2013).Pharmacokinetics:Absorption: Not reportedMetabolism: Hepatic via CYP2C9Excretion: Feces (60%), urine (30%) (Lexi-comp, 2013).Side Effects:Common:GI upset, diarrhea, gas, dizziness, nervousness, headache, runny nose, sore throat, and skin rashRare:Chest pain, weakness, SOB, vision problems, melena, coughing up blood, weight gain, oliguria, nausea, stomach pain, anorexia, jaundice, sever skin reaction, and ecchymosis (Lexi-comp, 2013).Monitor:CBC, occult blood loss, liver function, renal function, pain response, blood pressure, weight gain, bruising, and GI effects (Clinical Pharmacology, 2013).Substrate: CYP 2C9 (major), CYP3A4 (monitor). Inhibits: CYP2C8 (moderate), CYP2D6 (moderate) (Lexi-comp, 2013).Contraindications:Advanced renal disease, hypersensitivity to celecoxib, sulfonamides, aspirin, NSAIDs, or any component, and perioperative CABG surgery (Lexi-comp, 2013)Use Caution: Anaphylactiod reactions, cardiovascular events, GI events, hematologic events, skin reactions, asthma, CABG, corticosteroid-dependent disease, cytochrome P450 isoenzyme 2C9 deficiency, hepatic impairment, and renal impairment (Lexi-comp, 2013).Non-Steroidal Anti-Inflammatory Drugs/ Enolic Acid (Oxicam) DerivativesPiroxicam, Meloxicam (Mobic?) (Lexi-comp, 2013).Pharmacodynamics:Inhibits cyclooxygenase 1 and 2 enzymes which cause decreased prostaglandin precursors. This causes antipyretic, analgesic, and anti-inflammatory response (Lexi-comp, 2013).Pharmacokinetics:Protein Binding: 99%Metabolism: Heptaic via CYP2C9Half-life: 50 hoursPeak Time: Three to five hoursExcretion: Urine and feces (Lexi-comp, 2013). Side Effects:Common:GI upset, diarrhea, bloating, flatulence, dizziness, nervousness, headache, rhinitis, sore throat, and skin rashRare:Chest pain, weakness, headache, pruritus, severe rash, anorexia, bleeding, constipation, confusion, anxiety, depression, somnolence, perforation, vomiting, anemia, increased bleeding time, tinnitus, micturition, flu-like symptoms, falls, and angina (Clinical Pharmacology, 2013).Monitor:Periodic: Occult blood loss, CBC, BMP, liver function tests, and eye exams (Access Medicine, 2013).Substrate: CYP3A4 (minor), CYP2C9 (major). Inhibits: CYP2C9 (weak) (Lexi-comp, 2013).Contraindications:Severe renal impairment, severe hepatic impairment, hypersensitivity or asthma reaction to piroxicam, aspirin, NSAIDs, or any component, perioperative CABG surgery, and severe heart failure (Access Medicine, 2013).Use Caution: Anaphylactiod reactions, cardiovascular events, CNS events, GI events, hematologic events, skin reactions, hyperkalemia, serum sickness, asthma, CABG, hepatic impairment, hypertension, and renal impairment (Lexi-comp, 2013).Non-Steroidal Anti-Inflammatory Drugs/ Fenamic Acid Derivatives (Fenamates)Mefenamic acid (Ponstel?), Meclofenamate (Lexi-comp, 2013)Pharmacodynamics:Inhibits cyclooxygenase 1 and 2 enzymes which cause decreased prostaglandin precursors. This causes antipyretic, analgesic, and anti-inflammatory response (Clinical Pharmacology, 2013; Lexi-comp, 2013).Pharmacokinetics:Absorption: RapidMetabolism: Hepatic via CYP2C9Excretion: Urine (52-70%) and feces (20-30%) (Lexi-comp, 2013). Side Effects:Common:Headache, dizziness, itching, abdominal cramps, heartburn, nausea, vomiting, diarrhea, constipation, dyspepsia, gastritis, and bleedingRare:Nervousness, itching, fluid retention, LFTs increase, and tinnitus (Lexi-comp, 2013)Monitor:Renal function and dehydration (Lexi-comp, 2013).Substrate: CYP2C9 (minor). Inhibits: CYP2C9 (weak) (Lexi-comp, 2013). Contraindications:Hypersensitivity to mefenamic acid, aspirin, NSAIDs, or other components, perioperative CABG surgery, GI ulcerations, and renal disease (Lexi-comp, 2013).Use Caution: Anaphylactoid reactions, cardiovascular effects, CNS effects, GI events, hematologic effects, hyperkalemia, skin reactions, asthma, hepatic impairment, hypertension, and renal impairment (Lexi-comp, 2013). Non-Steroidal Anti-Inflammatory Drugs/ Propionic Acid DerivativesIbuprofen (Motrin?) (Children’s Motrin?), Naproxen (Aleve?, Midol?), Oxaprozin (Daypro?), Fenoprofen (Nalfon?), Ketoprofen, Nuprin, Flurbiprofen (Lexi-comp, 2013)Pharmacodynamics:Inhibits cyclooxygenase 1 and 2 enzymes which cause decreased prostaglandin precursors. This causes antipyretic, analgesic, and anti-inflammatory response (Lexi-comp, 2013).Pharmacokinetics:Absorption: RapidMetabolism: hepatic via oxidationExcretion: Urine, some feces (Lexi-comp, 2013). Side Effects:Common:dizziness, headache, rash, itching, heartburn, nausea, abdominal pain, anorexia, and constipationRare:Edema, nervousness, fluid retention, dyspepsia, vomiting, weakness, tremor, and tinnitus (Access Medicine, 2013).Monitor:CBC, chemistry profile, occult blood loss, liver function tests, pain response, inflammation, weight gain, edema, bleeding, GI effects, confusion, blood pressure, urine output, and eye exams (Access Medicine, 2013).Substrate: CYP1A2 (minor), CYP2C19 (minor), CYP2C9 (minor). Inhibits CYP2C9 (weak) (Lexi-comp, 2013).Contraindications:Severe hepatic impairment, anuria, oliguria, hypersensitivity to NAIDS or any component, asthma, urticarial, allergic type response, and perioperative CABG surgery (Lexi-comp, 2013)Use Caution: Anaphylactoid reaction, cardiovascular events, CNS effects, GI events, hematologic effects, hyperkalemia, ophthalmic events, skin reactions, aseptic meningitis, asthma, CABG surgery, hepatic impairment, hypertension, and renal impairment (Lexi-comp, 2013). Non-Steroidal Anti-Inflammatory Drugs/ SalicylatesAcetylsalicylic acid (Aspirin?), Choline Magnesium Salicylate, Sulfasalazine, Diflunisal, Salsalate (Lexi-comp, 2013)Pharmacodynamics:Irreversibly inhibits cyclooxygenase 1 and 2 enzymes by acetylation causing decreased prostaglandin precursors (thromboxane A2). This causes an antipyretic, analgesic, and anti-inflammatory effect (Lexi-comp, 2013).Pharmacokinetics:Absorption: Rapid, stomach and small intestinesMetabolism: hydrolyzed in GI mucosa, red blood cells, synovial fluid, and blood. Hepatic conjunction. Excretion: Urine (Lexi-comp, 2013). Side Effects:Common:Diarrhea, headache, abdominal pain, nausea, and rhinitisRare:Hypotension, tachycardia, dysrhythmias, edema, rash, angioedema, urticarial, acidosis, gastric erosions, bleeding, hepatitis, weakness, asthma, bronchospasm, and Reye’s syndrome (Access Medicine, 2013).Monitor:Bleeding disorders, dehydration, GI diseases, asthma, renal function, and hepatic function (Lexi-comp, 2013). Substrate: CYP2C9 (minor) (Lexi-comp, 2013). Contraindications:Hypersensitivity to salicylate, NSAIDs, or any component, asthma, rhinitis, nasal polyps, bleeding disorders, and children less than 26 years of age (Lexi-comp, 2013)Use Caution: Salicylate sensitivity, tinnitus, upper GI events, bleeding disorders, dehydration, ethanol use, hepatic impairment, renal impairment, alteplase, NSAIDs, elderly, children, and surgery patients (Lexi-comp, 2013). Opioids/Esters of MorphineDihydrocodeine (Synalgos?) (Lexi-comp, 2013)Pharmacodynamics:Bind to opiate receptors in CNS, inhibiting ascending pain pathways altering pain response. Suppresses cough by direct action in medulla (Lexi-comp, 2013). Pharmacokinetics:Absorption: Not reported Metabolism: HepaticExcretion: Urine unchanged(Lexi-comp, 2013). Side Effects:Common:Lightheadedness, dizziness, drowsiness, sedation, puritus, skin reactions, nausea, vomiting, constipation, hypotension, and respiratory depression. Rare:Palpitations, bradycardia, increased ICP, biliary tract spasm, urinary tract spasm, and miosis (Lexi-comp, 2013).Monitor:Respiratory and CNS effects (Lexi-comp, 2013). Contraindications:Hypersensitivity to dihsrdocodeine or any component, and pregnancy (Access Medicine, 2013).Use Caution: CNS depression, phenanthrene hypersensitivity, salicylate sensitivity, tinnitus, abdominal conditions, adrenal insufficiency, biliary tract impairment, bleeding disorders, CNS depression/ coma, drug abuse, ethanol use, GI diseases, head trauma, hepatic impairment, prostatic hyperplasia, renal impairment, respiratory diseases, and thyroid dysfunction (Lexi-comp, 2013). Opioids/Opioid AlkaloidsCodeine , Morphine (Kadian?, MS Contin?) (Lexi-comp, 2013)Pharmacodynamics:Bind to opiate receptors in CNS, inhibiting ascending pain pathways altering pain response. Suppresses cough by direct action in medulla (Lexi-comp, 2013). Pharmacokinetics:Absorption: GI 50% Metabolism: Hepatic via UGT2B7, UGT2B4, CYP2D6,and CYP3A4; conjugated with glucuronic acidExcretion: Urine (90%) and feces (Lexi-comp, 2013). Side Effects:Common:Weight loss, constipation, diarrhea, nausea, vomiting, abdominal pain, anorexia, flushing, headache, dizziness confusion, insomnia, and abnormal dreamsRare:Apnea, bradycardia, stiffness, seizure, clammy skin, confusion, weakness, SOB, tachycardia, and bleeding (Access Medicine, 2013).Monitor:Pain relief, respiratory and mental status, blood pressure, and heart rate (Clinical Pharmacology, 2013).Substrate: CYP2D6 (major) (Lexi-comp, 2013). Contraindications:Hypersensitivity to codeine or any component, respiratory depression, acute/severe asthma, hypercarbia, or paralytic ileus (Lexi-comp, 2013)Use Caution: CNS depression, constipation, hypotension, phenanthrene hypersensitivity, respiratory depression, abdominal conditions, adrenal insufficiency, biliary tract impairment, CND depression/coma, drug abuse, GI obstruction, head trauma, hepatic impairment, obesity, prostatic hyperplasia, renal impairment, respiratory disease, seizure disorder, and thyroid dysfunction (Lexi-comp, 2013). Opioids/Semisynthetic Opioids:Hydrocodone (Lortab?, Vicodin?, Lorcet?), Hydromorphone (Dilaudid?), Oxycodone (Oxycontin?, Roxicodone?), Oxymorphone (Opana?) (Lexi-comp, 2013)Pharmacodynamics:Blocks pain reception in the cerebral cortex by binding to receptor molecules in the synapses preventing pain impulses to higher centers in the brain. Mu and Kapa are two of the receptor sites that are bound (Lexi-comp, 2013). Pharmacokinetics:Absorption: Not reportedMetabolism: Hepatic: O-demethyation via CYP2D6 to hydromorphone; N-demethylation via CYP3A4 to norhydrocodone; and 40% other non-CYP pathways; via glucuronidationExcretion: Urine (Lexi-comp, 2013).Side Effects:Common;Hypotension, drowsiness, faint feeling, dizziness, weakness, and ill feelingInfrequent:Bradycardia, bronchospasm, tachycardia, SOB, confusion, vision problems, dry mouth, nervous ness, anxious, and addiction Rare:Depression, tinnitus, hypertension, hepatitis, itching, hallucinations, rash, thrombocytopenia, nightmares, and insomnia (Lexi-comp, 2013) Monitor:Pain relief, respiratory and mental status, blood pressure, liver disease, ethanol abuse, falls, and withdrawal (Access Medicine, 2013).Substrates: CYP2D6 (minor), CYP3A4 (major) (Lexi-comp, 2013). Contraindications:Hypersensitivity to semisynthetic opioids, acetaminophen, or any component, CNS depression, GI obstruction, and severe respiratory depression (Lexi-comp, 2013)Use Caution: CNS depression, hepatotoxicity, hypersensitivity/anaphylactic reactions, constipation, hypotension, phenanthrene hypersensitivity, respiratory depression, abdominal conditions, adrenal insufficiency, biliary tract impairment, G6PD deficiency, CYP3A4 inhibitors, CNS depression/coma, delirium tremens, drug abuse, GI obstruction, head trauma, hepatic impairment, ethanol use, obesity, prostatic hyperplasia, psychosis, renal impairment, respiratory disease, seizure disorder, and thyroid dysfunction (Lexi-comp, 2013).Opioids/Synthetic Opioids/AnilidopiperidinesFentanyl- Lozenge (Lexi-comp, 2013)Pharmacodynamics:Increased pain threshold, alters pain reception, and inhibits ascending pain pathways by blocking many receptor cites (Lexi-comp, 2013). Pharmacokinetics:Absorption: rapid buccal, 50% saliva, and slow GIMetabolism: Hepatic via CYP3A4Excretion: Urine (75%), Feces (9%) (Lexi-comp, 2013). Side Effects:Common:Bradycardia, CNS depression, confusion, fatigue, headache, sedation, constipation, nausea, vomiting, weakness, dyspnea, and diaphoresis.Rare:Edema, xerstomia, and miosis (Access Medicine, 2013). Monitor:Respiratory and cardiovascular status, blood pressure, pain relief, heart rate, signs of misuse, abuse, or addiction (Access Medicine, 2013).Substrate: CYP3A4 (major). Inhibits: CTP3A4 (weak) (Lexi-comp, 2013). Contraindications:Severe renal or hepatic impairment and hypersensitivity to fentanyl or any component (Lexi-comp, 2013)Use Caution: CNS depression, opioid agonist toxicities, respiratory depression, allergic rhinitis, bradycardia, drug abuse, head trauma, hepatic impairment, oral mucositis, renal impairment, respiratory disease, CNS depressants, CYP3A4 inhibitors, and MOA inhibitors (Lexi-comp, 2013).Opioids/Synthetic Opioids/Diphenylpropylamine deriverativesMethadone (Dolophine?) (Lexi-comp, 2013)Pharmacodynamics:Binds to receptor sites preventing ascending pain pathways and altering pain perception (Lexi-comp, 2013)Pharmacokinetics:Absorption: Rapid in stomachMetabolism: Hepatic via CYP3A4, CPY2B6, and CYP2C19Excretion: Urine (Lexi-comp, 2013). Side Effects:Common:Hypotension, dizziness drowsiness, dysphoria and weaknessRare:Arrhythmias, bradycardia, agitation, confusion, rash, decreased libido, anorxia, constipation, impotence, thrombocytopenia, vision problems, respiratory depression, and death (Lexi-comp, 2013)Monitor:Dependence need, QT, blood pressure, CNS and respiratory status, sedation, and falls (Access Medicine, 2013).Substrate: CYP2B6 (major), CYP2C19 (minor), CYP2C9 (minor), CYP2D6 (minor), CYP3A4 (major). Inhibits: CYP2D6 (moderate), CYP3A4 (weak) (Lexi-comp, 2013). Contraindications:Severe liver disease, hypersensitivity to methadone or any component, respiratory depression, asthma, hypercarbia, paralytic ileus, or selegiline use (Lexi-comp, 2013)Use Caution: CNS depression, hypotension, QT prolongation, respiratory depression, abdominal conditions, anxiety disorders, adreal insufficiency, drug abuse, depression, head injury, renal impairment, and seizure disorder (Lexi-comp, 2013). Opioids/Synthetic Opioids/OthersTramadol (Ultram?), Tapentadol (Nucynta?) (Lexi-comp, 2013)Pharmacodynamics:Inhibits reuptake of norepinephrine and serotonin modifying ascending pain pathways while binding to u-opiate receptors blocking ascending pain pathways which alters response to pain (Lexi-comp, 2013). Pharmacokinetics:Absorption: Rapid and completeMetabolism: Hepatic via CYP3A4 and CYP2B6, glucuronidation, and sulfationExcretion: Urine (Lexi-comp, 2013). Side Effects:Common:Flushing, dizziness, headache, insomnia, constipation, nausea, vomiting, weakness, and hypotensionRare:Chest pain, anxiety, confusion, and vertigo (Lexi-comp, 2013). Monitor:Pain relief, respiratory rate, blood pressure, pulse, sings of tolerance, abuse, or suicide (Access Medicine, 2013).Substrates: CYP2B6 (minor), CYP2D6 (major), CYP3A4 (major), CYP2C9 (minor) (Lexi-comp, 2013). Contraindications:Hypersensitivity to tramadol, opioids, or any component, intoxication, hypnotics, analgesics, opioids, psychotropic drugs, asthma, hypercapnia, and respiratory depression (Lexi-comp, 2013).Use Caution: Anaphylactoid reactions, CNS depression, seizures, abdominal conditions, drug abuse, ethanol use, head trauma, hepatic or renal impairment, respiratory disease, or suicide risk (Lexi-comp, 2013). Opioids/Synthetic Opioids/Morphinan Derivatives Levorphanol (Lexi-comp, 2013)Pharmacodynamics:Alters perception of pain by interacting with opioid receptors in the CNs and other tissues (Lexi-comp, 2013). Pharmacokinetics:Absorption: Not reportedMetabolism: HepaticExcretion: Urine (Lexi-comp, 2013).Side Effects:Common:Hypotension, CNS depression, drowsiness, nausea, vomiting, constipation, and weakness Rare:Palpitation, bradycardia, shock, nervousness, headache, anorexia, coma, convulsion, hallucinations, diplopia, apnea, cyanosis, and dependence (Lexi-comp, 2013).Monitor:Pain relief, respiratory and mental status, and blood pressure (Lexi-comp, 2013). Reduce dose with renal or hepatic impairment. Contraindications:Hypersensitivity to levorphanol or any component (Lexi-comp, 2013).Use Caution: CNS depression, hypotension, phenanthrene hypersensitivity, abdominal conditions, adrenal insufficiency, biliary tract impairment, drug abuse, head trauma, obesity, respiratory disease, or thyroid disease (Lexi-comp, 2013).Opioids/Synthetic Opioids/PhenylpiperdineMeperidine (Demerol?) (Lexi-comp, 2013)Pharmacodynamics:Binds to opioid receptors in the ascending pathways altering perception of pain and depressing the CNS (Lexi-comp, 2013).Pharmacokinetics:Absorption: Erratic and highly variableMetabolism: Hepatic; hydrolyzed Excretion: Urine (Lexi-comp, 2013).Side Effects:Common:Pre-syncope, fatigue, blurred vision, confusion, vertigo, nausea, and constipation Rare:Bradycardia, arrest, hypotension, shock, delirium, anorexia, ileus, dyspnea, and dependence (Lexi-comp, 2013)Monitor:Pain relief, respiratory and metal status, blood pressure, CNS depression, seizure, and respiratory depression (Lexi-comp, 2013)Contraindications:Hypersensitivity to meperidine or any component, respiratory depression, and the use of a MAO inhibitor within the last 14 days (Access Medicine, 2013).Use Caution:CNS depression, CNS events, hypotension, abdominal conditions, adrenal insufficiency, biliary tract impairment, coma, delirium, drug abuse, head trauma, hepatic impairment, obesity, pheochromocytoma, prostatic hyperplasia, psychoses, renal impairment, respiratory depression, sickle-cell disease, tachycardia, and thyroid dysfunction (Lexi-comp, 2013)Acetaminophen (Tylenol?) (Lexi-comp, 2013)Pharmacodynamics:Inhibit synthesis of prostaglandins in the CNS. In the peripheral it blocks pain impulse generation. Inhibits hypothalamus heat-regulating center to produce antipyresis (Lexi-comp, 2013). Pharmacokinetics:Absorption: Variable; Primarily in small intestineMetabolism: Primarily hepatic to sulfate and glucuronide conjugates; small amount by CYP2E1Excretion: Urine (Lexi-comp, 2013).Side Effects:Common:Nausea, confusion, dyspepsia, jaundice, anorexia, asthenia, and rashRare:Anemia, neutropenia, ammonia increase, nephropathy, and hypersensitivity (Clinical Pharmacology, 2013; Lexi-comp, 2013)Monitor:Serum APAP levels, liver function tests, pain relief, and temperature (Lexi-comp, 2013).Substrate: CYP1A2 (minor), CYP2A6 (minor), CYP2C9 (minor), CYP2D6 (minor), CYP2E1 (minor), CYP3A4 (minor). Inhibits: CYP3A4 (weak) (Lexi-comp, 2013). Contraindications:Hypersensitivity to acetaminophen or any component, severe hepatic impairment, and liver disease (Lexi-comp, 2013). Use Caution: Hepatotoxicity, anaphylactic reactions, ethanol use, G6PD deficiency, hepatic impairment, hypovolemia, and renal impairment (Lexi-comp, 2013). IV. Effective Drug Classification: Opioid/Semisynthetic Opioids OralDrug NameEfficacySafetySuitabilityCostOpioids/Semisynthetic OpioidsHydrocodone (Lortab?, Vicodin?, Lorcet?) (Lexi-comp, 2013)Hydrocodone:Onset of Action: Ten to 20 minutesDuration: Four to eight hoursMetabolism: Hepatic: O-demethyation via CYP2D6 to hydromorphone; N-demethylation via CYP3A4 to norhydrocodone; N-demethylation via CYP#A$ to norhydrocodone and ~40% other non-CYP pathways including 6-ketosteroid reduction to 6-alpha-hydrocol and 6-beta-hydrocolHalf-life: 3.3 -4.4 hoursExcretion: Urine (Lexi-comp, 2013).Acetaminophen:Onset of action: less than one hourDuration: Four to six hoursAbsorption: Primarily small intestine; varies by doseProtein binding: Ten to 25%Metabolism: Hepatic to sulfate and glucuronide conjugates; small amount CYP2E1: substrate of CYP1A2 (minor), CYP2A6 (minor), CYP2C9 (minor), CYP2D6 (minor), CYP2E1 (minor), CYP3A4 (minor); inhibits CYP3A4 (weak).Half-life: ~2 hoursPeak Time: ImmediateExcretion: Urine (Lexi-comp, 2013).Drug Interactions:Azelastine, conivptan, paraldehyde, MAO inhibitors, and pimozide (Lexi-comp, 2013).Increased Effect/ Toxicity:Alcohol, alvimopan, aripiprazole, azelastine, busulfan, CNS depressants, dasatinib, desmopressin, imatinib, lomitapide, metyrosine, mipomersen, mirtazapine, paraldehyde, pimozide, pramipexole, prilocaine, ropinirole, rotigotine, SSRIs, sorafenib, thiazide diuretics, vitamin K antagonists, and zolpidem (Lexi-comp, 2013). Decrease Effect/ Toxicty:Pegvisomant, Ammonium chloride, anticonvulsants, barbiturates, carbamazepine, cholestyrmine resin, mixed agonist/ antagonist opioids, peginterferon alfa-2b, rifampin, St Johns wort, tocilizumab, and quinidine (Lexi-comp, 2013).Avoid:More than three alcoholic beverages, MAO inhibitors, other sedatives, and herbs (valerian, St John’s wort, SAMe, and kava kava) (Lexi-comp, 2013). -CYP2D6 poor or extensive metabolizers may have varied effects and toxicity.-Do not abruptly stop in chronic use. May cause withdrawal.-High potential of abuse.-Avoid fatty meals. -Take one before eating or two hours after eating.-May cause constipation. (Access Medicine, 2013; Lexi-comp, 2013).Hydrogesic? oral (capsules): 5-500mg (100): $25.00Lortab? oral (elixir) 7.5-500mg/15ml: (473ml): $220.50Hycet? oral (solution): 7.5-325/15ml (473ml): $227.77Hydrocodone-acetaminophen oral (solution): 7.5-325mg/5ml (473ml): $139.777.5-500mg/15ml (471ml): %58.12Liquicet? oral (solution): 10-500mg/15ml (473ml): $201.03Zamicet? oral (solution) 10-325mg/15ml (473ml): $173.12Zolivt? oral (solution): 10-300mg/15ml (473ml): $92.40Co-Gesic? oral (tablets): 5-500mg (100): $137.58Hydrocodone-acetaminophen oral (tablets): 2.5-500mg (40): $21.285-300mg (100): $191.045-325mg (100): $54.225-500mg (30): $26.655-500mg (30): $26.657.5-300mg (100): $214.277.5-325mg (100): $61.857.5-500mg (100): $57.217.5-650mg (100): $69.507.5-750mg (100): $48.9210-300mg (100): $276.4410-325mg (100): $83.0010-500mg (100): $70.1010-650mg (60): $713.8010-660mg (100): $71.5010-750mg : (100): $11.55Lorcet? 10/650 (tablets): 10-650mg (20): $45.12Lorcet? plus oral (tablets): 7.5-650mg (100): $130.45Lortab? oral (tablets): 5-500mg (100): $103.457.5-500mg (12): $13.3210-500mg (100): $138.80Maxidone? oral:10-750mg (100): $216.85Norco? oral (tablets): 5-325mg (15): $33.007.5-325mg (30): $70.5610-325mg (30): $59.53(Lexi-comp, 2013). Opioids/Semisynthetic OpioidsHydromorphone (Dilaudid?) (Lexi-comp, 2013)Onset of Action: 15 to 30 minutesDuration: Three to 13 hoursAbsorption: Delayed and variableProtein Binding: Eight to 19%Metabolism: Hepatic: via glucuronidationHalf-life: Two -11 hoursPeak Time: Less than an hour to 16 hoursExcretion: Urine (Lexi-comp, 2013).Drug Interactions:Azelastine, paraldehyde, and MAO inhibitors (Access Medicine, 2013).Increase Effect/ Toxicity:Alcohol, alvimopan, azelastine, CNS depressants, desmopressin, metyrosine, mirtazapine, paraldehyde, pramipexole, ropinirole, rotigotine, SSRIs, sorafenib, thiazide diuretics, zolpidem,Amphetamines, antipsychotic agents, droperidol, hydroxyzine, magnesium sulfate, MAO inhibitors, perampanel, probenecid, sodium oxybate, and succinylcholine (Access Medicine, 2013). Decreased Effect/Toxicity:Pegvisomant, Ammonium chloride, and mixed agonist/ antagonist opioids (Access Medicine, 2013).Avoid:MAO inhibitors, other sedatives, and herbs (valerian, gotu kola, and kava kava) (Lexi-comp, 2013). -Do not crush, chew, dissolve or inject medication.-May be taken with or without food.-Alcohol can increase,-Does not have a histamine reaction. -Do not abruptly stop in chronic use. -High potential of abuse. (Lexi-comp, 2013).Dilaudid-5? oral (liquid): 1mg/ml (473ml): $239.66Hydromorphone HCL oral (liquid): 1mg/ml (473ml): $189.12Hydromorphone HCL rectal (suppository): 3mg (6): $73.60Exaglo? oral (24 hour tablet): 8mg (100): $1154.06Dilaudid? oral (tablets):2mf (100): $109.274mg (100): $178.388mg (100): $132.00(Lexi-comp, 2013). Opioids/Semisynthetic OpioidsOxycodone (Oxycontin?, Roxicodone?) (Lexi-comp, 2013)Onset of Action: ten to 15 minutesPeak Effect: 0.5-1 hourDuration: Three to 12 hoursProtein Binding: ~45%Metabolism: Hepatic: via CYP3A4 to noroxycodone, noromorphone, and apla/beta-noroxycodol. CYP2D6 to oxymorphone, alpha/beta-oxymorphol. Substrates of CTP2D6 (minor) and CYP3A4 (major)Half-life: Two -~ five hoursExcretion: Urine (Lexi-comp, 2013).Drug Interactions:Azelastine, conivptan, and paraldehyde (Lexi-comp, 2013). Increased Effect/Toxicity: Alcohol, alvimopan, azelastine, CNS depressants, desmopressin, metyrosine, mirtazapine, paraldehyde, pramipexole, ropinirole, rotigotine, SSRIs, thiazide diuretics, zolpidem, Amphetamines, antipsychotic agents, conivaptan, dasatinib, droperidol, hydroxyzine, magnesium sulfate, perampanel, sodium oxybate, and succinylcholine (Lexi-comp, 2013). Increased Effect/ Toxicity: Pegvisomant, Ammonium chloride, mixed agonist/ antagonist opioids, rifampin, St Johns Wort, and tocilizumab (Lexi-comp, 2013).Avoid:MAO inhibitors, other sedatives, and herbs (valerian, St John’s wort, and kava kava) (Lexi-comp, 2013). -Use of CYP3A4 inhibitors with oxycodone can result in increased effects.-Do not moisten, dissolve, cut, crush, break, or chew.-Drink full glass of water with pills.-Laxatives should be given to avoid constipation.-Do not abruptly stop in chronic use. -High potential of abuse. (Lexi-comp, 2013).Oxycodone HCL oral (capsules): 5mg (60): $48.99Oxycodone HCL oral (concentrate): 20mg/ml (30ml): $221.88Oxycontin? oral (12 hour tablet):10mg (20): $61.9515mg (60): $209.4620mg (20): $100.4230mg 960): $407.5040mg (30): $280.4360mg (30): $395.9180mg (60): $1022.37Oxecta? oral (tablets): 5mg (100): $320.407.5mg (100): $320.40Oxycodone HCL oral (tablets):5mg (100): $47.9410mg (100): $62.5015mg (100): $75.7920mg (90): $99.0030mg (100): $143.90Roxicodone? oral (tablets): 15mg (100): $175.1030mg (90): $278.65(Lexi-comp, 2013). Opioids/Semisynthetic OpioidsOxymorphone (Opana?) (Lexi-comp, 2013)Onset of Action: Five to ten minutesDuration: Three to six hoursProtein Binding: ten to 12 %Metabolism: Hepatic: via glucuronidationHalf-life: Seven to 11hoursExcretion: Urine (Lexi-comp, 2013).Drug Interactions:Azelastine, paraldehyde, and MAO inhibitors (Lexi-comp, 2013).Increased Effect/ Toxicity:Alcohol, alvimopan, azelastine, CNS depressants, desmopressin, metyrosine, mipomersen, paraldehyde, pramipexole, ropinirole, rotigotine, SSRIs, sorafenib, thiazide diuretics, zolpidem,Amphetamines, antipsychotic agents, droperidol, hydroxyzine, magnesium sulfate, MAO inhibitors, perampanel, sodium oxybate, and succinylcholine (Lexi-comp, 2013). Deceased Effect/Toxicity:Pegvisomant, Ammonium chloride, and, mixed agonist/ antagonist opioids (Lexi-comp, 2013). Avoid:Alcoholic beverages, MAO inhibitors, other sedatives, and herbs (valerian, St John’s Wort, and kava kava) (Lexi-comp, 2013). -Do not abruptly stop in chronic use. -High potential of abuse. –Do not break, crush, dissolve, or chew.-Use safety measures to prevent falls.-Use laxatives to prevent constipation.-Avoid fatty meals. -Take one before eating or two hours after eating. (Lexi-comp, 2013).Opana? ER oral (12 hour tablet):5mg (60): $143.567.5.mg (60): $209.6010mg (60): $275.6615mg (600: $382.2820mg (60): $488.9330mg (60): $703.7340mg (60): $918.54Oxymorphone HCL ER oral (tablets): 7.5mg (100): $283.5215mg (60): $565.00Opana? oral (tablets): 5mg (56): $215.1410mg (100): $534.93Oxymorphone HCL oral (tablets):5mg (100): $294.6110mg (100): $534.93 (Lexi-comp, 2013). V. Drug of Choice: Hydrocodone-Acetaminophen OralHydrocodone-Acetaminophen is the drug of choice for many emergency departments for treating simple acute clavicle fractures in young healthy adults. Opioids such as hydrocodone act in preventing the transmission of the pain receptive neurons by blocking the mu receptors. Among the opioids the most common prescribed are oxycodone and hydrocodone. When compared to each other, both have the same pain control effectiveness and similar side effects. Only hydrocodone showed an increase in constipation and therefore should not be given to the elderly or those with constipation difficulties. A stool softener should be prescribed in combination with the hydrocodone (Black, Buderer, Marco, Plewa, & Roberts, 2008). Hydrocodone-acetaminophen is a relatively safe opioid for the treatment of moderate to severe pain. Thorough review of the patient’s history and physical is needed because this drug has the potential for abuse. This drug is most commonly dosed as hydrocodone 5mg and acetaminophen 500mg, one to two tablets by mouth every four to six hours as needed for pain for a maximum of seven days. Hydrocodone is a cheap medicine only costing $11.99 for thirty pills in generic form. The patient should be well educated on the proper use of taking this medication such as , do not take while driving, use with alcohol or other sedatives, and do not take with other forms of Tylenol as this may cause the patient to exceed their daily limit. Side effects of this medication are vast and should be discussed with the patient. Have the patient follow up in two weeks to ensure adequate healing (Access Medicine, 2013). An Advance Practice Nurse can prescribe this medication only with a valid Certificate to Prescribe (CPT) and they can only write for a seven day maximum in the hospital setting (Ohio Board of Nursing, 2013). Third Diagnosis: New on Set of Epilepsy after an Subdural HematomaA 32 year old man develops new onset of tonic-clonic seizures one month after suffering a stable subdural hematoma (SDH) from a fall. He was witnessed to have seizure like activity this morning while getting dressed for work. He is an otherwise healthy individual who works as an accountant. While being admitted to the hospital, staff witnessed a tonic-clonic seizure. Head computed tomography (CT) showed a resolving subdural hematoma without any ischemia. After a through history and physical he is diagnosed with new onset of generalized tonic-clonic seizures after a stable SDH.I. Definition of DiagnosisA subdural hematoma is caused by tearing of a vein in minor head injuries. It is associated with a low risk a seizure development and therefore patients are not routinely placed on anti-convulsant afterward. The seizure itself is caused by abnormal excessive or synchronous neuronal activity in the brain. A generalized tonic-clonic seizure is defined by being bilaterally distributed across both hemispheres causing loss of consciousness with ridged motor movement. The seizure is abrupt, without warning, and absent of any aura. The tonic-clonic seizure, characterized by its name, has two parts with tonic being sustained muscle contraction (10-20 seconds) followed by clonic, which is recurrent contractions of the muscle (30 seconds). This type of seizure is serious because of the increased risk of death if it were to be sustained (status epilepticus). The patient can experience: Incontinence, elevated blood pressure, increased heart rate, mydriasis, apnea, cyanosis, or death. The post ictal phase of recovery is characterized by lethargy and confusion. Based on the reasoning of the seizure a CT, Magnetic Resonance Imaging (MRI), or Electroencephalography (EEG) may be needed for evaluation along with blood work (Bruni, 2008).II. Therapeutic ObjectivesTherapeutic objectives for new set of seizures after an acute SDH is the same as any other seizure in that the goal is to remain seizure free, remain side effect free, have easy drug convenience, low cost, and aim for low dose mono-therapy drug treatment (Dobrin, 2012). Treatment for seizures post SDH is with Valproic acid; however, more recently providers are choosing Levetiracetam due to its lower side effect profile. Drug choice should be chosen on effectiveness and minimalizing side effects to ensure the best quality of life for the patient. Once the patient is stabilized intense education of condition, medication, and changes in daily living are needed (Kumlien & Zelano, 2011). III. Inventory of Effective Drug Groups OralDrug EfficacySafetySuitabilityAnti-epileptic/BarbituratePhenobarbital PO (Lexi-comp, 2013)Pharmacodynamics: Depresses the sensory cortex, decreases motor activity, alters cerebellar function and causes sedation. In high doses this drug has anti-convulsant activity (Lexi-comp, 2013). Pharmacokinetics:Absorption: 70-90%Metabolism: Hepatic via hydroxylation and glucuronide conjunctionExcretion: Urine (50% unchanged drug) (Lexi-comp, 2013).Side Effects:Common: Pre-syncope, fatigue, blurred vision, illogical thinking, an dizzinessRare: bradycardia, nausea, vomiting, rash, laryngospasm, and constipation (Access Medicine, 2013).Monitor: Vitamin D levels, phenobarbital levels, mental status, CBC, LFTs, and seizure activity (Access Medicine, 2013).Substrate: CYP2C19 (major), CYP2C9 (minor); Induces: CYP1A2 (strong), CYP2A6 (strong), CYP2B6 (strong), CYP2C9 (strong), CYP3A4 (strong) (Lexi-comp, 2013). Contraindications: Hypersensitivity to barbiturates or any component, hepatic impairment, dyspnea, airway obstruction, porphyria, intra-arterial administration, subcutaneous administration, drug addiction, and nephritic patients (Lexi-comp, 2013).Use Caution:CNS depression, hypotension, paradoxical response, respiratory depression, depression, hepatic impairment, hypoadrenalism, renal impairment, substance abuse, with sedatives, and in elderly (Lexi-comp, 2013).Anticonvulsant/HydantoinEthotoin(Paganone?)Phenytoin(Dilantin?, Phenytek?)(Lexi-Comp, 2013) PharmacodynamicsStabilizes neuronal membranes and reduced seizure activity by increasing efflux or decreasing influx of sodium ions in the motor cortex. This prolongs refractory period (Lexi-comp, 2013)Pharmacokinetics:Absorption: SlowMetabolism: Hepatic; undergoes enterohepatic recirculationExcretion: Urine (Lexi-comp, 2013).Side Effects Common: Suicidal ideation, rash, nausea, vomiting, ataxia, fatigue, headache, insomnia, drowsiness.Rare: Chest pain, numbness, and diplopia (Clinical Pharmacology, 2013).Monitoring:CBC,EEG, LFT’s,Suicidality, trough concentrations, and depression (Clinical Pharmacology, 2013).Substrate: CYP2C19 (major), CYP2C9 (major), CYP3A4 (minor), Induces: CYP2B6 (strong), CYP2C19 (strong), CYP2C8 (strong), CYP2C9 (strong), CYP3A49 strong) InhibitsCYP2C19(weak) (Lexi-Comp, 2013)Contraindications:Hematologic disease, hypersensitivity to hydatoin or any component, hepatic disease, and suicidal ideation (Lexi-comp, 2013).Use Caution:Blood dyscrasias, bone effects, cardiovascular events, skin reactions, hypoabluminemia, hypothyroidism, porphyria, seizures, Asian ancestry, and elderly (Lexi-comp, 2013). Anticonvulsant/Neuronal Potassium Channel OpenerEzogabine(Potiga?) (Lexi-Comp, 2013)PharmacodynamicsBinds to KCNQ voltage-gated potassium channels stabilizing channels in open formation and enhancing M-current. This regulates epileptiform activity. Alterations of GABA-mediated currents are also a suspected mechanism (Lexi-comp, 2013).Pharmacokinetics:Absorption: Rapid Metabolism: Glucuronidation via UGT1A4, UGT1A4, UGT1A9, UTG1A1 and acetylation via NAT2Excretion: Urine 85%, Feces(Lexi-Comp, 2012).Side Effects:Common: Dizziness, fatigue, confusion, vertigo, tremors, diplopia, attention disturbance, balance disturbance, memory impairmentRare: Alopecia, appetite increase, coma, hallucination, liver enzyme increase, malaise, muscle spasms, and syncope (Lexi-comp, 2013). Monitoring:Seizures, electrolytes, bilirubin, ALT, SAT, creatinine, QT interval, urinary retention, sedation, and behavioral changes(Lexi-Comp, 2013).Contraindications:No contraindications.Use Caution:CNS effects, neuropsychiatric disorders, QT prolongation, suicidal ideas, urinary retention, and hepatic or renal impairment (Lexi-comp, 2013). Anticonvulsant/ SuccinmideEthosuximide(Zarontin?),Methsuximide(Celontin?)(Lexi-Comp, 2013)PharmacodynamicsIncreases seizure threshold and suppresses paroxysmal spike and wave pattern in the motor cortex (Access Medicine, 2013; Lexi-comp, 2013). Pharmacokinetics:Absorption: Rapidly through GI tract Metabolism: HepaticExcretion: Urine (Slowly) and small amount through feces (Lexi-comp, 2013). Side Effects:Common: Abdominal pain, agitation, dizziness, elevated hepatic enzymes, fatigue, headache, drowsiness, ataxia, aplastic anemia, rash, nightmares, vomitingRare: Agranulocytosis, vaginal bleeding, paranoid psychosis, and myopia (Access Medicine, 2013).Monitoring:CBC, LFT’s, Urinalysis, seizures, trough serum, platelets, and rash (Access Medicine, 2013).Substrate: CYP3A4 (major) (Lexi-comp, 2013)Contraindications:Succinimide hypersensitivity or any component (Access Medicine, 2013). Use Caution:Blood dyscrasias, CNS depression, skin reactions, SLE, suicide ideas, hepatic impairment, renal impairment, with sedatives, and watch for withdrawal when stopping (Lexi-comp, 2013). Anticonvulsant/ Triazole DerivativesRufinamide(Banzel?)(Lexi-Comp, 2013)PharmacodynamicsExact mechanism unknown but it prolongs the inactive state of sodium channels limiting repetitive firing of sodium –dependent action which reduces convulsions (Clinical Pharmacology, 2013; Lexi-comp, 2013). Pharmacokinetics:Absorption: Slow and extensive; increased with food.Metabolism: Carboxylesterase-mediated hydrolysis of the carboxylamide group CGP 47292, weak inhibitor of CYP2E1 and weak inducer of CYP3A4Excretion: Urine 85%(Lexi-Comp, 2013).Side Effects:Common: QT shortening, headache, vomiting, fatigue, dizziness, nausea, ataxia, rash, anemia, tremor, diplopiaRare: AV block, BBB block, hematuria, incontinence, and lymphadenopathy (Clinical Pharmacology, 2013).Monitoring:Suicidal ideations, seizure, serum levels of anticonvulsants (Clinical Pharmacology, 2013).Inhibits: CYP2E1 (weak); Induces CYP3A4 (weak/moderate) (Lexi-Comp, 2013) Contraindications:Patients with familial short QT syndrome, hypersensitivity to triazole and derivatives (Lexi-comp, 2013). Use Caution:Abnormal cardiac conductions, CNS effects, rash, suicidal ideas, and hepatic impairment (Lexi-comp, 2013). Anticonvulsant/MiscellaneousAcetazolamide(Diamox?, Serquels?)(Lexi-Comp, 2013)Pharmacodynamics:Decrease production of aqueous humor inhibits carbonic anhydrase in CNS to slow abnormal and excessive discharge (Lexi-comp, 2013). Pharmacokinetics:Absorption: Rapidly absorbed from GI tract Metabolism: Not reportedExcretion: UrineMetabolism: no(Lexi-Comp, 2013)Side Effects:Common: nausea, xerostomia, and diarrheaRare: Flushing, ataxia, confusion, fatigue, electrolyte imbalance, parenthesis, and myopia (Lexi-comp, 2013).Monitoring:Intraocular pressure, serum electrolytes, CBC, growth in pediatric patients, blood glucose (Lexi-comp, 2013).Inhibits CYP3A4(Lexi-comp, 2013)Contraindications:Adrenal insufficiency, hepatic disease, renal disease, hypokalemia, electrolyte imbalance, hypersensitivity sulfonamide, acetazolamide or any component (Lexi-comp, 2013). Use Caution:CNS effects, sulfa allergy, diabetes, hepatic impairment, respiratory acidosis, aspirin use, and elderly (Lexi-comp, 2013). Anticonvulsant/MiscellaneousCarbamazepine(Carbatrol?,Epitol?, Equetro?, Tegretol? (Lexi-Comp, 2013)PharmacodynamicsDepresses activity in the nucleus ventralis of the thalamus or decreases synaptic transmission or decreases temporal stimulation by limiting influx of sodium ions across cell membranes (Lexi-comp, 2013)Pharmacokinetics:Absorption: SlowMetabolism: Hepatic via CYP3A4Excretion: Urine(Lexi-comp, 2013)Side Effects:Common: Diplopia, ataxia, drowsiness, GI upset, hyponatremia, Rare: leucopenia, rash and hepatic dysfunction (Lexi-comp, 2013) Monitoring:CBC, platelets, serum iron, LFT’s. renal panel, serum carbamazepine levels, thyroid functions, and suicidality (Access Medicine, 2013).Substrate: CYP2C8 (minor), CYP3A4 (major); Induces CYP1A2 (strong), CYP2B6 (strong), CYP2C19 (strong), CYP2C8 (strong), CYP2C9 (strong), p-glycoprotein(Lexi-Comp, 2013). Contraindications;Hypersensitivity to carbamazepine and tricyclic antidepressants or any component, bone marrow depression, MAO inhibitors, or use of nefazodone (Lexi-comp, 2013). Use Caution:Blood dyscrasia, CNS depression, skin reactions, Hyponatremia, anticholinergic sensitivity, cardiovascular disease, hepatic impairment, renal impairment, and drug abuse (Lexi-Comp, 2013).Anticonvulsant/Miscellaneous Divalproex, Valproic Acid(Depakote?) (Lexi-comp, 2013)PharmacodynamicsAllows for increased availability of gamma-aminobutyric acid (GABA) to brain neurons and enhances the action of GABA or mimics its action at receptor sites (Access Medicine, 2013; Lexi-comp, 2013).Pharmacokinetics: Absorption: Not reported Metabolism: extensive hepatic via glucuronide and mitochondrial beta-oxidationExcretion: Urine(Lexi-comp, 2013). Side Effects:Common: Nausea, vomiting, GI upset, abdominal pain, heartburn, weight gain, hair loss (Access Medicine, 2013). Monitoring:Liver panel, CBC, platelets, PT/PTT, serum ammonia, serum valproate levels, and suicidality (Access Medicine, 2013).Substrate: CYP2A6, 2B6, 2C9, 2C19, 2E1 (minor); Inhibits: CYP2C9, 2C19, 2D6, 3A4 (weak); induces CYP2A6 (weak) (Lexi-comp, 2013)Contraindications:Hypersensitivity to Valproic acid, divalproex, derivatives of any component, hepatic disease, or cycle disorders (Lexi-comp, 2013). Use Caution:Hepatic disease, pancreatitis, pregnancy, CNS depression, hypothermia, suicidal ideas, thrombocytopenia, and acute head trauma (Lexi-comp, 2013). Anticonvulsant/MiscellaneousFelbamate(Felbatol?)(Lexi-Comp, 2013)PharmacodynamicsMechanism unknown, weak inhibitory effects on GABA, benzodiazepine receptor binding, and activity at MK-801 receptor binding site of the NMDA receptor complex (Lexi-comp, 2013).Pharmacokinetics:Absorption: Rapid and almost completeMetabolism: Not reported Excretion: Urine(Lexi-comp, 2013)Side Effects:Common: drowsiness, dizziness, blurred vision, fever, insomnia, fatigue, nervousness, nausea, vomiting, anorexia, and dry mouthRare: Aplastic anemia, hepatitis, insomnia, fever, fatigue, nervousness, and purpura (Lexi-comp, 2013). Monitoring:AST, ALT, hematological evaluation before therapy and frequently during therapy, and suicidality (Lexi-comp, 2013).Substrates: CYP2E1 (minor), CYP3A4 (major); Inhibits CYP2C19 (weak); Induces CYP3A4 (weak/moderate) (Lexi-Comp, 2013). Contraindications:Hypersensitivity to drug or any component, blood dyscrasia, or hepatic dysfunction (Lexi-Comp, 2013). Use Caution:Aplastic anemia, hepatic failure, renal impairment, and suicide ideas (Lexi-comp, 2013). Anticonvulsant/MiscellaneousGABA Derivatives: Gabapentin(Gralise?, Neurontin?)Gabapentin Enacarbil(Horizant?) (Lexi-comp, 2013)PharmacodynamicsModify release of GABA, GABA sites throughout brain correspond to presence of calcium channels such as alpha-2-delta-1 subunits this releases excitatory neurotransmitters which assist with epileptogenesis and nociception (Clinical Pharmacology, 2013; Lexi-comp, 2013). Pharmacokinetics:Absorption: variable, small bowel by L-amino transport systemMetabolism: Does not induce hepatic enzymesExcretion: Urine(Lexi-comp, 2013).Side Effects:Common: Dizziness, fatigue, ataxia, fever, diarrhea, leucopenia, tremor, weakness, increased appetite. Rare: Cushingoid appearance, encephalopathy, erythema multiform, facial paralysis, fecal incontinence, glaucoma, glycosuria, hearing loss, heart block, hematuria, hemiplegia, hemorrhage, hepatitis, hepatomegaly, myoclonus, lymphadenopathy, lymphocytosis, MI, migraine, nephrosis, nerve palsy, non-Hodgkin's lymphoma (Clinical Pharmacology, 2013).Monitoring:Suicidality and drug levels (Lexi-Comp, 2013)Contraindications:Hypersensitivity to gabapentin or any component (Lexi-comp, 2013). Use Caution: CNS depression, suicidal thoughts, renal impairment, seizure disorder, and sedative use (Lexi-comp, 2013). Anticonvulsant/MiscellaneousLacosamide(Vimpat?) (Lexi-Comp, 2013)Pharmacodynamics:Enhances slow inactivation of voltage gated sodium channels, with stabilization of hyperexcitability neuronal membranes and inhibition of neuronal firing (Access Medicine, 2013; Lexi-comp, 2013). Pharmacokinetics:Absorption: CompletelyMetabolism: HepaticInhibits CYP2C19(weak)Excretion: Urine and feces (Lexi-Comp, 2013)Side Effects:Common: Dizziness, headache, nausea, and diplopia Rare: syncope, vomiting, tremor, weakness, nystagmus, and tremor (Access Medicine, 2013).Monitoring:EKG prior to therapy, CBC, and suicidal ideas (Lexi-Comp, 2013)Contraindications:Hypersensitivity to drug, MI, atrial flutter, AV block, bradycardia, heart failure, suicidal, pregnancy, renal failure (Lexi-comp, 2013) Use caution: Hepatic failure, renal failure, CNS depression, depression, abnormal heart conductions, and sedative use (Lexi-comp, 2013)Anticonvulsant/Miscellaneous Lamotrigine(Lamictal?)(Lexi-Comp, 2013)Pharmacodynamics: Triazine derivative inhibits release of glutamate and inhibits voltage-sensitive sodium channels and stabilizes neuronal membranes. This also has a weak inhibitory effect on 5-HT3 receptor (Lexi-comp, 2013). Pharmacokinetics:Absorption: Rapid and completeMetabolism: Hepatic and renalExcretion: Urine 94% and feces (Lexi-comp, 2013). Side Effects:Common: pre-syncope, fatigue, blurred vision, illogic thinking, dizziness, imbalance, headache, and nauseaRare: Abdominal pain, acne, agitation, anorexia, anxiety, agitation, back pain, edema, rash, weakness, dry skin (Lexi-comp, 2013).Monitoring:Serum levels, LFTs, BMP, reactions, seizures, suicide ideas, depression, an behavior (Lexi-comp, 2013)Contraindications: Hypersensitivity to drug and component (Lexi-comp, 2013). Use Caution:Aseptic meningitis, blood dyscrasia, CNS depression, skin reaction, suicidal thoughts and hepatic and renal impairment (Lexi-comp, 2013). Anticonvulsant/MiscellaneousLevetiracetam(Keppra?) (Lexi-Comp, 2013) PharmacodynamicsInhibition of voltage-dependent N-type calcium channels, facilitation of GABA inhibitory transmission through negative modulators, reduced rectifier potassium current, and binging to synaptic proteins to reduce neural discharge (Clinical Pharmacology, 2013; Lexi-comp, 2013). Pharmacokinetics:Absorption: Rapid, complete Metabolism: Not extensive; mainly through enzyme hydrolysis Excretion: Unchanged in urine (Lexi-comp, 2013). Side Effects:Common: pre-syncope, fatigue, blurred vision, illogical thinking, imbalance, headache, mood changes, rhinorrhea, pharyngitis, asthenia, nausea, and emotional imbalanceRare: anorexia, weakness, cough, infection, facial edema, confusion, bruising, dehydration, leukopenia, neck pain, diplopia, ear pain, and albuminuria (Access Medicine, 2013).Monitoring:Suicidality (Lexi-comp, 2013)Contraindications: None (Lexi-comp, 2013)Use Caution: CNS effects skin reactions, hematologic effect, hypertension, psychiatric disorders, renal impairment, and sedative use (Lexi-comp, 2013)Anticonvulsant/MiscellaneousMagnesium Sulfate (Lexi-comp, 2013)Pharmacodynamics: Decreases acetylcholine in motor nerves reducing transmission (Lexi-comp, 2013). Pharmacokinetics: Absorption: Not reportedMetabolism: Not reportedExcretion: Urine (Lexi-comp, 2013).Side effects: Common: hypotension, and diarrhea Rare: angina, tachycardia, dizziness, asthenia, vision changes, illogical thinking, flushing and rash (Lexi-comp, 2013).Monitoring: Respiratory rate, deep tendon reflexes, and renal function (Lexi-comp, 2013).Contraindications: Hypersensitivity to drug or components, heart block and myocardial damage (Lexi-comp, 2013).Use Caution: Neuromuscular disease, renal impairment, and with aluminum use (Lexi-comp, 2013). Anticonvulsant/MiscellaneousOxcarbazepine(Trileptal?) (Lexi-Comp, 2013) PharmacodynamicsBlocks voltage-sensitive sodium channels stabilizing hyper excited neuronal membranes inhibiting firing and decreasing propagation of impulses (Lexi-comp, 2013). Pharmacokinetics:Absorption: Complete Metabolism: Hepatic to 10-monohydroxy metabolite then glucuronidated to 10,11 dihydroxy metaboliteInduces CYP3A4(strong)Excretion: Urine 95%, feces (Lexi-Comp, 2013) Side Effects:Common: Dizziness, somnolence, headache, ataxia, fatigue, vertigo, nausea, tremor, abnormal gait, rash, weight gain, and constipation Rare: aggressiveness, alopecia, anxiety, aplastic anemia, dysphagia, hemiplegia, palpitations, and xerophthalmia (Lexi-comp, 2013).Monitoring:Serum sodium CNS depression, serum levels, seizures, and suicidality (Lexi-comp, 2013).Induces: CYP3A4 (Lexi-Comp, 2013) Contraindications:Hypersensitivity to Oxcarbazepine or any component (Lexi-comp, 2013)Use Caution: Blood dyscrasias, CNS effects, skin reactions, Hyponatremia, suicidal ideas, sedative use, and oral contraceptives (Lexi-comp, 2013). Anticonvulsant/Miscellaneous Perampanel (Lexi-comp, 2013)Pharmacodynamics:The exact mechanism of action is unknown but is thought to have a noncompetitive antagonist of the AMPA glutamate receptor on postsynaptic neurons (Lexi-comp, 2013). Pharmacokinetics:Absorption: Rapid and completeMetabolism: Extensive via oxidation mediated by CYP3A5 and sequential glucuronidationExcretion: Feces (48%) and urine (22%) (Lexi-comp, 2013). Side Effects:Common: Dizziness, somnolence, headache, fatigue, irritability, weight gain, and nauseaRare: Ataxia, anxiety, hypersomnia, mood changes Hyponatremia, arthralgia, parenthesis, and diplopia (Lexi-comp, 2013).Monitoring:Seizure activity, suicidality, and weight (Lexi-comp, 2013).Substrate: CYP3A4; Induces CYP3A4 (Lexi-comp, 2013). Contraindications:None reported (Lexi-comp, 2013).Use Caution:Neuropsychiatric disorders, CNS effects, suicidal thoughts, hepatic impairment, renal impairment, fall risk, and withdrawal (Lexi-comp, 2013). Anticonvulsant/Miscellaneous Phenetermine, Topiramate (Qsymia?) (Lexi-comp, 2013)Pharmacodynamics:Stimulates the hypothalamus and releases norepinephrine while blocking neuronal voltage dependent sodium channels, enhancing GABA activity, antagonizes AMPA glutamate receptors, and weakly inhibits carbonic anhydrase (Lexi-comp, 2013). Pharmacokinetics:Absorption: Well absorbedMetabolism: hepatic via hydroxylation, hydrolysis, and glucuronidationExcretion: Mainly urine (Lexi-comp, 2013). Side Effects:Common: Somnolence, headache, constipation, fatigue, irritability, weight gain, and nauseaRare: Ataxia, dizziness, anxiety, hypersomnia, mood changes Hyponatremia, arthralgia, parenthesis, and diplopia (Lexi-comp, 2013).Monitoring:Seizure activity, suicidality, resting heart rate, serum bicarbonate, potassium, glucose, serum creatinine, blood pressure, glaucoma, symptoms of acidosis, and weight (Lexi-comp, 2013).Inhibits: CYPC19 (weak); Induces (CYP3A4 (weak/moderate) (Lexi-comp, 2013). Contraindications:Hypersensitivity or idiosyncrasy to drug or any component, hyperthyroidism, glaucoma, MAO inhibitor use, or pregnancy (Lexi-comp, 2013).Use Caution:Cardiovascular effect, CNS effects, glaucoma, hyperthermia, hypokalemia, hypotension, metabolic acidosis, renal calculus, suicidal thoughts, renal impairment, Diabetes, hepatic impairment, and withdrawal (Lexi-comp, 2013). Anticonvulsant/Miscellaneous Pregabalin (Lyrica?) (Lexi-comp, 2013)Pharmacodynamics:Binds to aplh2-delta subunit of calcium channels inhibiting excitatory neurotransmitter release (Lexi-comp, 2013). Pharmacokinetics:Absorption: Not reportedMetabolism: NagligibleExcretion: Mainly urine (Lexi-comp, 2013). Side Effects:Common: Edema, dizziness, Somnolence, headache, constipation, fatigue, weight gain, and nauseaRare: Ataxia, drunken feeling, anxiety, hypersomnia, mood changes, hyponatremia, arthralgia, parenthesis, and diplopia (Lexi-comp, 2013).Monitoring:Seizure activity, suicidality, myopathy, ocular disturbances, skin integrity, and weight (Lexi-comp, 2013).Contraindications:Hypersensitivity to drug or any component (Lexi-comp, 2013).Use Caution:Angioedema, CNS effects, hypersensitivity, peripheral edema, platelet count, PR interval, rhabdomyolysis, Visual disturbances, weight gain, cardiovascular disease, suicidal thoughts, renal impairment, tumorigenic potential, and withdrawal (Lexi-comp, 2013). Anticonvulsant/Miscellaneous Primidone(Mysoline?)(Lexi-Comp, 2013)PharmacodynamicsDecreases neuron excitability and raises seizure threshold (Lexi-comp, 2013). Pharmacokinetics:Absorption: 60-80% Metabolism: Hepatic to Phenobarbital by oxidation to PEMA by seission of the heterocyclic ringExcretion: Urine (Lexi-Comp, 2013).Side Effects:Common: Pre-syncope, fatigue, blurred vision, illogical thinking, dizziness, and nauseaRare: Ataxia, vertigo, anorexia, impotence, agranulocytosis, and diplopia (Lexi-comp, 2013).Monitoring:Serum primidone and phenobarb, neurological status, CBC, and behavioral changes (Lexi-comp, 2013). Induces: CYP1A2 (strong), CTP2B6 (strong), CYP2C8 (strong), CYP2C9 (strong), CYP3A4 (strong) (Lexi-Comp, 2013).Contraindications:Hypersensitivity to phenobarb and porphyria (Lexi-comp, 2013) Use caution: CNS depression, suicidal ideas, depression, hepatic and renal impairment, respiratory disease, and substance abuse (Lexi-comp, 2013). Anticonvulsant/MiscellaneousTiagabine(Gabitril?) (Lexi-comp, 2013)PharmacodynamicsEnhances GABA uptake activity in neurons and allows increased amount of GABA in postsynaptic neurons (Access Medicine, 2013; Lexi-comp, 2013) Pharmacokinetics:Absorption: Rapid; prolonged with foodMetabolism: Hepatic via CYP (primarily 3A4)Excretion: Feces mainly and urine (Lexi-comp, 2013). Side Effects:Common: pre-syncope, fatigue, blurred vision, illogical thinking, dizziness, nausea, diarrhea, xerostomia, increased appetite, tremors, nervousness, and anxietyRare: depression, imbalance, vision changes, eye pain, asthenia, and rash (Access Medicine, 2013).Monitoring:Seizures, CBC, LFT’s, renal functions, serum chemistry, and suicidality (Access Medicine, 2013).Substrate: CYP3A4 (major) (Lexi-Comp, 2013)Contraindications: Hypersensitivity to Tiagabine or any component (Lexi-comp, 2013)Use Caution: CNS depression, skin reactions suicidal ideas, hepatic impairment, with enzyme-inducing drugs, and with sedatives (Lexi-comp, 2013). Anticonvulsant/MiscellaneousTopiramate(Topamax)(LexiComp, 2012) PharmacodynamicsBlocks neuronal voltage-dependent sodium channels, enhances GABA activity, antagonizes AMPA/kainite glutamate receptors and weakly inhibits carbonic anhydrase (Lexi-comp, 2013). Pharmacokinetics:Absorption: Good, rapidMetabolism: minor amounts hepatic via hydroxylation, hydrolysis, and glucuronidationExcretion: Urine (Lexi-comp, 2013).Side Effects:Common: Somnolence, headache, fatigue, sedation, rash, blurred vision, dizziness, and tremors. Rare: hypotension, infections, diaphoresis, and paranoid reactions (Access Medicine, 2013). Monitoring:Seizures, hydration, electrolytes, creatinine, ammonia, intraocular pressure, and suicidal ideation (Access Medicine, 2013).Inhibits: CYP2C19 (weak); Induces CYP3A4 (weak/moderate) (Lexi-Comp, 2013).Contraindications:None Use Caution:CNS effects. Glaucoma, encephalopathy, hyperthermia, acidosis, renal calculus, suicidal ideas, and renal and hepatic impairment (Lexi-comp, 2013). Anticonvulsant/MiscellaneousZonisamide(Zonegran?) (Lexi-comp, 2013)PharmacodynamicsStabilizes neuronal membranes and suppresses neuronal hypersynchronization though sodium and calcium channels (Lexi-comp, 2013). Pharmacokinetics:Absorption: Not reportedMetabolism: Hepatic via CYP3A4Excretion: Urine (Lexi-comp, 2013)Side Effects:Common: Drowsiness, cognitive impairment, confusion, poor concentration, Rare: anorexia, headache, irritability, tiredness, abdominal pain (Lexi-comp, 2013). Monitoring:Metabolic profile, renal panel, serum bicarbonate, and suicidiality (Lexi-comp, 2013). Substrate: CYP2C19 (minor), CYP3A4 (minor) (Lexi-comp, 2013).Contraindications:Hypersensitivity of zonisamide or sulfonamides or any component (Lexi-comp, 2013). Use Caution:CNS effects, acidosis, renal stones, suicidal ideas, sulfonamide reactions, and renal and hepatic impairment (Lexi-comp, 2013).IV. Effective Drug Classification: Levetiracetam OralDrug NameEfficacySafetySuitabilityCostLevetiracetam(Keppra?) (Lexi-comp, 2013)Absorption: Rapid and completeProtein Binding: <10%Metabolism: Not Extensive. Mainly by enzymatic hydrolysisHalf-life: ~6-8 hours; increased in renal dysfunctionPeak Time: ~1 hour to ~4 hoursExcretion: Urine (Lexi-comp, 2013). Drug Interactions: Azelastine and paraldehyde (Lexi-comp, 2013)Increased Effect/Toxicity:Alcohol, azelastine, buprenorphine, CNS depressants, methotrimeprazine, metyrosine, mirtazapine, paraldehyde, pramipexole, ropinirole, rotgotine, SSRIs, zolpidem, droperidol, hydroxyzine, magnesium sulfate, methotrimeprazine, perampanel, and sodium oxybate (Lexi-comp, 2013).Decreased Effect/Toxicity:Ketorlac (nasal and systemic) and mefloquine (Lexi-comp, 2013). -This drug can be given to children and hemodialysis patients.-Monitor for behavioral changes and suicidal ideas.-Do not stop abruptly due to the possibility increased seizure frequency.-May be taken without regard to meals. -Alcohol increases CNS depression (Access Medicine, 2013; Lexi-comp, 2013).Keppra XR? oral (24 hour tablets)500mg (60): $374.36750mg (60): $562.13Levetiracetam ER oral (24 hour tablets)500mg (60): $266.82750mg (60): $400.64Keppra? oral (tablets)250mg (60): $206.02500mg (30): $145.88750mg (120): $1118.961000mg (30): $244.36Levetiracetam oral (tablets)250mg (120): $345.04500mg (120): $421.71750mg (120): $571.311000mg (60): $422.18 (Lexi-comp, 2013).V. Drug of Choice: LevetiracetamLevetiracetam is quickly becoming the drug of choice for patients who develop seizure activity after suffering an acute SDH. While traditionally it has been used for secondary line of treatment its equal effectiveness has brought it to the forefront. Unlike Valproic acid, Levetiracetam is a non-enzyme anti-epileptic drug with better tolerability by the patient, fewer side effects and drug to drug interactions, and does not require therapeutic index blood sampling. While this drug is more expensive, adherence to treatment is more likely due to the reduced side effect profile (Ghauri, Khan, Shamim, & Zafar, 2012). The appropriate dose is 500mg oral twice daily for two weeks that may be increased by 500mg oral every two weeks until maximum dose of 1500mg oral twice daily is reached or seizure activity is stopped. The patient should be seen at each dose increase and then one month after finding stabilization dose and then yearly. Doses may have to be lowered based on creatinine clearance. As with any drug, education about side effects is crucial along with developing goals and treatment plan with the patient. This drug is not to be stopped abruptly due to the possible increases in seizure frequency and should be taken until cleared by a neurologist. Avoid alcohol use with Levetiracetam. Do not break, crush, or chew tablet. This drug costs $29.99 for 30 pills of the 500mg oral (Access Medicine, 2013). An advance practice nurse with a current CTP may prescribe Levetiracetam (Ohio Board of Nursing, 2013). Fourth Diagnosis: Ventilator Assisted Pneumonia in a Renal PatientA 68 year old male has been in the intensive care unit for one week after suffering acute respiratory failure and has been intubated since admission. He is a long time dialysis patient due to stage four kidney disease. Over the past two days he has developed hyperthermia, increased tracheobronchial secretions, and leukocytosis. A bronchoalveolar lavage was completed and the sample was positive for Methicillin-resistant Staphylococcus Aureus (MRSA). Patient history included renal failure and previous MRSA infection of the skin. After a complete history and physical the patient is diagnosed with ventilator assisted pneumonia (VAP) culture positive for MRSA. I. Definition of DiagnosisVentilator assisted pneumonia is defined by new or increased pulmonary infiltrates in a intubated patient for more than 48 hours plus two or more infective criteria including: Fever, hypothermia, leukocytosis, purulent secretions, and reduced PaO2/FiO2. Methicillin-resistant Staphylococcus Aureus is defined by obtaining a positive culture. Effective treatment for VAP MRSA includes starting the correct antibiotics within 24 hours of sample collection (Bouza et al., 2011). The Center for Disease Control (2013) also recommends non medication therapy including raising the head of bed 30-45 degrees, extubate the patient as soon as medically possible, always wash hands before and after care, wear clean gloves, regularly clean inside the patients mouth, and clean or replace equipment between patient use. Contact precautions must be maintained per hospital protocol on all MRSA positive patients. The rate of occurrence of VAP MRSA varies greatly from hospital to hospital, patient co-morbidities, and reason for intubation. In house mortality is around 60% but is not an independent risk factor (Bouza et al., 2011). II. Therapeutic ObjectivesThe treatment goal for patients with VAP MRSA is effective treatment with antibiotics, reduction in mortality, and early extubation. Ventilator associated pneumonia MRSA requires immediate treatment once infection is suspected. Until susceptibilities are known, any hospital VAP infection should be treated with combination therapy of Vancomycin, Imipenem, and either an aminoglycoside or fluoroquinolone. Once the organism has been identified as MRSA, then therapy can be adjusted to Vancomycin or Linezolid depending on renal function. All other antibiotics can be stopped. Prevention of VAP MRSA through good mouth care, increased mobility of patient, and early extubation are very important and continue to be very important once VAP MRSA is established along with antibiotic treatment (Access Medicine, 2013). III. Inventory of Effective Drug Groups: Intravenous Administration AminoglycosidesAmikcan, Gentamicin, Kanamycin, Neomycin (Neo-Fradin?), Streptomycin, Tobramycin (Tobi?) (Lexi-comp, 2013)Pharmacodynamics:Aminoglycosides inhibit protein synthesis in susceptible bacteria by binding to 30S and 50S ribosomal subunits causing defective bacterial cell membrane (Access Medicine, 2013; Lexi-comp, 2013). Pharmacokinetics:Absorption: RapidMetabolism: Not reportedExcretion: Urine (98%) (Lexi-comp, 2013). Side Effects:Common: decreased renal function, hypotension, hypertension, neurotoxicity, nephrotoxicity and ototoxicityRare:Allergic reaction, dyspnea, eosinophilia, nausea, diarrhea, urinary retention, or rash (Access Medicine, 2013).Monitor: Urinalysis, BUN, serum creatinine, CBC, peak and trough, vital signs, temperature, weight, I&O, and hearing tests (Lexi-comp, 2013)Contraindications:Hypersensitivity to drug or component; cross sensitivity potential to aminoglycosides (Lexi-comp, 2013).Use Caution:Nephrotoxicity, neuromuscular blockade, neurotoxicity, superinfection, hearing-impairment, hypocalcemia, neuromuscular disorders, renal impairment, and with sulfite use (Lexi-comp, 2013).GlycopeptidesTelavancin (Vibativ?),Vancomycin (Vacocin?) (Lexi-comp, 2013)Pharmacodynamics:Binds to D-alanyl-D-alanine portion of cell wall precursor which blocks glycopeptide polymerization and inhibits bacterial cell wall synthesis (Lexi-comp, 2013). Pharmacokinetics:Absorption: Poor oral, rapid IVMetabolism: Not reportedExcretions: IV: urine; Oral: feces (Lexi-comp, 2013)Side Effects:Common:Dyspepsia, nausea, site irritation, flushing, and hypotensionRare:Diarrhea, loss of balance, tinnitus, hearing difficulty, urinary retention, and rash (Lexi-comp, 2013).Monitor:Renal function tests, urinalysis, WBC, and trough levels (Lexi-comp, 2013). Contraindications:Hypersensitivity to drug or any component (Lexi-comp, 2013). Use Caution:Nephrotoxicity, neurotoxicity, neutropenia, ototoxicity, superinfections, inflammatory bowel disease, renal impairment (Lexi-comp, 2013)OxazolidinoneLinezolid (Zyvox?) (Lexi-comp, 2013)Pharmacodynamics:Binds to bacterial 23S ribosomal RNA of the 50S subunit which prevents bacterial protein synthesis. Prevention of the formation of functional 70S initiation complex is completed (Clinical Pharmacology, 2013; Lexi-comp, 2013). Pharmacokinetics:Absorption: Rapid and extensiveMetabolism: hepatic via oxidation; minimally by cytochrome P450Excretion: Urine (80%) and feces (9%) (Lexi-comp, 2013)Side Effects:Common:Anemia, headache, nausea, and diarrhea.Rare:Dizziness, dyspnea, illogical thinking, balance problems, hypoglycemia, ecchymosis, bleeding, fatigue, vision changes, and rash (Clinical Pharmacology, 2013).Monitor:CBC, platelet count, and visual acuity with chronic use (Lexi-comp, 2013).Contraindications:Hypersensitivity to Linezolid or any component, use of MAO inhibitor within the past two weeks, uncontrolled hypertension, pheochromocytoma, thyrotoxicosis, taking sympathomimetics, vasopressive agents, dopaminergic agents, have carcinoid syndrome, taking SSRIs, tricyclic antidepressants, serotonin 5-HT1b1d receptor agonists, meperdine, and buspirone (Lexi-comp, 2013). Use Caution:Lactic acidosis, myelosuppression, peripheral and optic neuropathy, superinfection, carcinoid syndrome, diabetes, hypertension, hyperthyroidism, pheochromocytoma, seizures, and serotonin syndromes (Lexi-comp, 2013).RifamycinsRifampin (Lexi-comp, 2013)PharmacodynamicsInhibits bacterial RNA synthesis by binding to beta subunit of DNA-dependent RNA polymerase and blocking RNA transcription (Lexi-comp, 2013)Pharmacokinetics:Absorption: Well absorbedMetabolism: Hepatic; undergoes enterohepatic recirculationExcretion: Feces (60-65%) and urine (~30%) (Lexi-comp, 2013).Side Effects:Common:Orange colored body fluids, discolored contact lenses, dyspepsia, diarrhea, dizziness, and flu-like symptoms Rare:Nausea, anorexia, jaundice, fatigue, and rash (Lexi-comp, 2013).Monitor:Liver function tests, CBC, mental status, sputum culture, and chest x-ray (Lexi-comp, 2013)Substrate: P-glycoprotein, SLCO1B1; Induces: CYP1A2 (strong), CYP2A6 (strong), CYP2B6 (strong), CYP2C19 (strong), CYP2C8 (strong), CYP2C9 (strong), CYP3A4 (strong), P-glycoprotein (Lexi-comp, 2013). Contraindications:Hypersensitivity to drug or any component, concurrent use of amprenavir and saquinavir/ritonavir (Lexi-comp, 2013)Use Caution:Flu-like syndrome, hematologic effects, hyperbilirubinemia, hypersensitivity, superinfection,, alcoholism, hepatic impairment, meningococcal disease, porphyria, and hepatotoxicity medications (Lexi-comp, 2013).StreptograminsQuinuprstin, Dalfopristin (Synercid?) (Lexi-comp, 2013)PharmacodynamicsInhibits bacterial protein synthesis by binding to different sites on 50S ribosomal subunit which inhibits protein synthesis (Access Medicine, 2013; Lexi-comp, 2013).Pharmacokinetics:Absorption: Not reportedMetabolism: nonenzymatic reactionsExcretion: Mainly feces, some urine (Access Medicine, 2013).Side Effects:Common:Site irritation, headache, nausea, diarrhea, arthralgia, and myalgiaRare:Urine discoloration, jaundice, fatigue, ecchymosis, bleeding, and rash (Access Medicine, 2013).Monitor:Culture and sensitivity, hepatic and renal function, infusion site, and for side effects (Lexi-comp, 2013).Contraindications:Hypersensitivity to drug or component, pristinamycin, or vairginiamycin (Lexi-comp, 2013)Use Caution:Arthralgias, myalgias, hyperbilirubinemia, phlebitis, superinfection, cisapride, and drugs metabolized by CYP3A4 (Access Medicine, 2013).SulfonamidesSulfamethoxazole with Trimethoprim (Bactrim?, Septra?), Erythromycin with Sulfisoxazole (E.S.P.?), Sulfadiazine, Sulfur with Sulfacetamide (Lexi-comp, 2013).PharmacodynamicsInterferes with bacterial folic acid synthesis and growth via dihydrofolic acid formation and para-aminobenzoic acid inhibition. Also inhibits the enzymes of the folic acid pathway (Lexi-comp, 2013). Pharmacokinetics:Absorption: Almost completely Metabolism: N-acetylated and glucuronidated; to oxide and hydroxylated metabolitesExcretion: Urine (LExi-comp, 2013).Side Effects:Common:Nausea, vomiting, anorexia, rash, and urticariaRare:Life threatening conditions, skin reactions, fatigue, blood dyscrasia, and hepatotoxic reactions (Lexi-comp, 2013).Monitor:Culture and sensitivity, CBC, potassium level, creatinine, and BUN (Lexi-comp, 2013).Substrates: CYP2C9 (major), CYP2E1 (minor), CYP3A4; inhibits: CYP2C9 (strong) (Lexi-comp, 2013). Contraindications:Hypersensitvitiy to sulfa, trimethoprim, erythromycin, or any component, megaloblastic anemia, severe hepatic or renal failure, and breast-feeding (Lexi-comp, 2013).Use Caution:Blood dyscrasias, altered cardiac conduction, myasthenia gravis, skin reactions, hepatic necrosis, hyperkalemia, hypoglycemia, sulfonamide allergy, superinfection, leucovorin use, asthma, hepatic and renal impairment, thyroid dysfunction, AIDS population, elderly, G6PD deficiency, folate deficiency, and slow acetylators (Lexi-comp, 2013). MiscellaneousAztreonam (Azactam?, Cayston?) (Lexi-comp, 2013)Pharmacodynamics:Inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins. This inhibits final transpeptidation step inhibiting cell wall biosynthesis (Clinical Pharmacology, 2013; Lexi-comp, 2013)Pharmacokinetics:Absorption: Well absorbedMetabolism: HepaticExcretion: Mostly urine some feces (Lexi-comp, 2013). Side Effects:Common:Nausea and diarrheaRare:Dyspnea, site irritation, and rash (Clinical Pharmacology, 2013).Monitor:Liver function tests and anaphylaxis (Lexi-comp, 2013). Contraindications:Hypersensitivity to drug or component (Lexi-comp, 2013).Use Caution:Bronchospasms, cephalosporin/penicillin allergy, super infection, and renail impairment (Lexi-comp, 2013). Beta-lactamaseClavulanic acid with amoxicillin (Augmentin?), Clavulanic acid with ticarcillian (Timentin?), Sulbactam with ampicillin (Unasyn?), Tazobactam with piperacillin (Zosyn?) (Lexi-comp, 2013)Pharmacodynamics:Binds and inhibits beta-lactamases allowing other antibiotics to have expanded spectrum activity. Binds to penicillin-binding proteins preventing peptidoglycan synthesis and biosynthesis (Lexi-comp, 2013)Pharmacokinetics:Absorption: Not reportedMetabolism: HepaticExcretion: Urine (Lexi-comp, 2013).Side effects:Common:Diarrhea, rash, urticaria, abdominal pain, nausea, vomiting, vaginitis, vaginal mycosis, and moniliasis Rare:Alkaline phosphatase increase, cholestatiic jaundice, flatulence, headache, hepatic dysfunction, hepatitis, increased ptothrombin time, thrombocytosis, and vasculitis (Lexi-comp, 2013).Monitor:Infection and renal, hepatic, and hematologic functions (Lexi-comp, 2013).Contraindications:Hypersensitivity to drug or any component, cholestatic jaundice, hepatic dysfunction, severe renal impairment, and hemodialysis (Lexi-comp, 2013).Use Caution:Hypersensitivity, bleeding disorders, heart failure, seizures, diarrhea, hepatic effects, supreinfections, infectious mononucleosis, renal impairment, and phenylalanine products (Lexi-comp, 2013)Cyclic LipopeptideDaptomycin (Cubin?) (Lexi-comp, 2013)Pharmacodynamics:Bind to cell membrane components and causes rapid depolarization and inhibited intracellular synthesis of DNA, RNA, and proteins (Access Medicine, 2013; Lexi-comp, 2013). Pharmacokinetics:Absorption: Not reported Metabolism: Not reportedExcretion: Urine (78%), feces (6%) (Lexi-comp, 2013). Side effects:Common:Diarrhea, vomiting, constipations, edema, chest pain, hypertension, hypotension, headache, fever, dizziness, anxiety, rash, abdominal pain, dyspepsia, increased CPK, weakness, and back painRare:Anaphylaxis, atrial fibrillation, C-Diff, coma, hypomagnesium, rhabdomyolysis, vertigo, and vesiculobullous rash (Access Medicine, 2013).Monitor:Infection, CPK, muscle pain/weakness, and eosiniphilic pneumonia (Lexi-comp, 2013).Contraindications:Hypersensitivity to drug or component (Lexi-comp, 2013).Use Caution:Eosinophilic pneumonia, hypersensitivity, myopathy, peripheral neuropathy, superinfection, renal impairment, and pneumonia (Lexi-comp, 2013)FluoroquinoloneCiprofloxacin (Cipro?), Besifloxacin (Besivance?), Gatifloxacin (Zymaid?), Gemifloxacin, Levofloxacin (Leevaquin?), Moxifloxacin, Norfloxacin, Ofloxacin (Lexi-comp, 2013)Pharmacodynamics:Inhibits DNA-gryase, topoisomerase and relaxation of supercoiled DNA. This promotes breakage of double-stranded DNA (Lexi-comp, 2013).Pharmacokinetics:Absorption: RapidMetabolism: Partially hepaticExcretion: Urine (30-87%), and feces (4-61%) (Lexi-comp, 2013). Side effects:Common:Dyspepsia, nausea, and diarrheaRare:Tachycardia, joint pain, arthralgia, edema, asthenia, parasthesia, and rash (Lexi-comp, 2013).Monitor:CBC, renal function, and hepatic function (Lexi-comp, 2013).Substrates: P-glycoprotein; inhibits: CYP1A2 (strong), CYP3A4 (weak) (Lexi-comp, 2013). Contraindications:Hypersensitivity to drug or any component or use of tizanidine (Lexi-comp, 2013)Use Caution:Myasthenia gravis, tendon inflammation, altered cardiac conduction, CNS effects, crystalluria, glucose regulation, hypersensitivity, peripheral neuropathy, phototoxicity, superinfection, renal impairment, rheumatoid arthritis, seizures, syphilis, and with CYP1A2 substrates (Lexi-comp, 2013). CephalosporinsCefepime, Ceftazidime (Fortaz?, Tazicef?) (Lexi-comp, 2013)Pharmacodynamics:Binds to penicillin-binding proteins which inhibits peptidoglycan synthesis allowing cell wall biosynthesis inhibition (Lexi-comp, 2013)Pharmacokinetics:Absorption: Rapid and complete Metabolism: Minimally hepatic Excretion: Urine Side effects:Common:Nausea, diarrhea, site irritation, and vaginal yeast infectionRare:Confusion, ecchymosis and rash (Access Medicine, 2013).Monitor:Culture and sensitivity, prothrombin time, and renal function (Lexi-comp, 2013)Contraindications:Hypersensitivity to drug or any component, cephalosporin, penicillin or beta-lactams (Lexi-comp, 2013) Use Caution:Elevated INR, neurotoxicity, penicillin allergy, superinfection, gastrointestinal disease, renal impairment, and seizure disorders (Lexi-comp, 2013). CarbapenemDoripenem (Doribax?), Ertapenem (Invanz?), Impenem, Cilastatin (Primaxin?), Meropenem (Merrem?) (Lexi-comp, 2013)Pharmacodynamics:Binds to penicillin-binding protein (PBP-2, PBP-3, PBP-4), which inhibits peptidoglycan synthesis allowing cell wall biosyntheisi inhibition (Lexi-comp, 2013)Pharmacokinetics:Absorption: Almost completeMetabolism: Non-CYP mediated via hydrolysisExcretion: Urine (70%); feces (<1%) (Lexi-comp, 2013).Side effects:Common:Headache, nausea, diarrhea, anemia, and vaginal yeast infectionRare:Dizziness, syncope, and rash (Lexi-comp, 2013).Monitor:Renal function, hepatic fnction, and hematologic function (Lexi-comp, 2013).Contraindications:Hypersensitivity to drug, drug class, or any component or bet-lactam antibiotics (Lexi-comp, 2013).Use Caution:Hypersensitivity, CNS effects, superinfection, renal impairment, ventilator assisted pneumonia, and with Valproic acid use (Lexi-comp, 2013). IV. Effective Drug Classification: Oxazolidinone IVDrug NameEfficiencySafetySuitabilityCostLinezolid (Zyvox?) (Lexi-comp, 2013)Absorption: Rapid and extensiveProtein Binding: 31%Metabolism: Hepatic via oxidation of morpholine ring to aminoethoxyacetic acid, and hydroxyethyl glycine; minimally by cytochrome P450Half-life: Four to five hoursPeak Time: Oral: One to two hoursExcretion: Urine (~30% parent drug, ~50% metabolites; feces (~9) (Lexi-comp, 2013).Drug Interactions:Monoamine Oxidase; alpha/beta agonists, alpha1/2 agonits, amphetamines, anilidopiperidine opioids, antidepressants, atomoxatine, bezafibrate, buprenorphine, bupropine, buspirone, carbamazepine, clozapine, cyclobenzaprine, dexmethyphenidate, dextromethorphan, diathylpropion, hydromorphone, mao inhibitors, maprotiline, meperidine, methyldopa, methylene blue, methylphenidate, mirtazapine, oxymorphine, pizotifen, SSRIs, serotonin/norepinephrine reuptake inhibitors, tapentadol, tetrabenazine, tatrahydrozoline, trazodone, tricyclic antidepressants, and tryptophan (Lexi-comp, 2013).Increased Effect/ Toxicity:Alpha/beta agonists, alpha1/2 agonists, amphetamines, antidepressants, antihypertensives, atomoxatine, beta2 agonists, bezafibrate, bupropion, clozapine, dexmethylphenidate, dextromethorphan, diethylpropion, doxaprem, hydromorphine, hypoglycemia agents, lithium, meperidine, methadones, methlphenidate, methylene blue, methylphenidate, metoclopramide, mirtazapine, orthostatic hypotension producing agents, pizotifen, reserpine, SSRIs, serotonin 5-HT1D receptor agonists, serotonin/norepinephrine reuptake inhibitors, sympathomimetics, tetrahydrozoline, trazodone, tricyclic antidepressants, altrtamine, anilidopiperidine opioids, antipsychotics, buprenorphine, buspirone, carbamazepine, comt inhibitors, cyclobenzaprine, levodopa, mao inhibitors, maprotiline, oxymorphone, tapentadol, tetrabenazine, tramadol, and tryptophan (Lexi-comp, 2013).Decreased Effect/ Toxicity:None known (Lexi-comp, 2013).Avoid: Alcohol, tyramine foods, and large amounts of : caffeine, tyrosine, tryptophan, or phenylalanine (Lexi-comp, 2013). -Give after hemodialysis. -Monitor for hypoglycemia in diabetic patients. -Watch for seizures in patients with history of seizures. -Oral: Can give without regard to meals.-Avoid large amounts of tyramine foods.-Time-dependent kill characteristics.-Best predictor of efficacy is time which concentration remains above the MIC (Lexi-comp, 2013).Zyvox? Intravenous (solution)2mg/ml (100ml): $72.18 (Lexi-comp, 2013).V. Drug of Choice: LinezolidThe gold standard of treatment for VAP MRSA has always been Vancomycin but efficacy is limited due to poor penetration in the alveolar lining fluid. Linezolid has had comparable improvement rates and in some studies has slightly exceeded Vancomycin. In a retrospective analysis Linezolid had a higher improved survival rate and clinical cure rate (Chan et al., 2011). For this patient Linezolid is chosen over Vancomycin because Vancomycin is considered nephrotoxic and should be avoided in patients with existing renal impairment. Dosing for Linezolid should be 600mg IV every 12 hours for the course of seven to 21 days based on the patients clinical response. Since the patient is a dialysis patient, it is recommended that this drug be given after hemodialysis or given early on dialysis days. Monitor glucose levels closely in diabetic patient as this drug may cause hypoglycemia. Educate patient and family on potential side effects, although rare. This drug has many drug to drug interactions and should be given with caution and the patient monitored closely. For IV administrations give medication over 30-120 minutes and prevent mixing or infusing with other drugs. Always make sure the line has been flushed before and after administration with normal saline. Monitoring of the patient should include weekly complete blood count and visual test if patient remains on the drug for over three months or develops any visual symptoms (Access Medicine, 2013). This drug costs $72.18 for 100ml dose with the concentration being two mg/ml (Lexicomp, 2013). An advance practice nurse with a current CTP may prescribe this drug only when it has been physician initiated or written in the standard care arrangement with the collaborating physician as a physician consulted drug (Ohio Board of Nursing, 2013). ReferenceAbbott, K., Agodoa, L., Bakris, G., Taylor, A., & Trespalacios, F. (2004). Β-Blocker use in long-term dialysis patients: Association with hospitalized heart failure and mortality. Journal of the American Medicine Association, 164(22), 2465-2471. doi:10.1001/archinte.164.22.2465Access Medicine. (2013). ACE Inhibitors. Retrieved from Medicine. (2013). Acetazolamide. Retrieved from Medicine. (2013). Acetic Acid. Retrieved from Medicine. (2013). Aminoglycosides. Retrieved from Medicine. (2013). ARBS. Retrieved from: Medicine. (2013). Aspirin. Retrieved from Medicine. (2013). Atenolol. Retrieved from: Medicine. (2013). Betaxolol. Retrieved from: Medicine. (2013). Bisoprolol. Retrieved from: Medicine. (2013). Carbamazepine. Retrieved from Medicine. (2013). Carvedilol. Retrieved from Access Medicine. (2013). Cefepime. Retrieved from Medicine. (2013). Daptomycin. Retrieved from Medicine. (2013). Dalfopristin. Retrieved from Medicine. (2013). Divalproex. Retrieved from Medicine. (2013). Ethosuximide. Retrieved from Medicine. (2013). Fentanyl. Retrieved from Medicine. (2013). Furosemide. Retrieved from: Medicine. (2013). Hydrocodone and Acetaminophen. Retrieved from: Access Medicine. (2013). Hydromorphone. Retrieved from Medicine. (2013). Ibuprofen. Retrieved from Medicine. (2013). Labetalol. Retrieved from: Medicine. (2013). Lacosamide. Retrieved from Medicine. (2013). Linezolid. Retrieved from: Medicine. (2013). Meloxicam. Retrieved from Medicine. (2013). Meperidine. Retrieved from Medicine. (2013). Methadone. Retrieved from Medicine. (2013). Metoprolol. Retrieved from: Medicine. (2013). Morphine. Retrieved from Medicine. (2013). Nadolol. Retrieved from: Medicine. (2013). Nebivolol. Retrieved from: Medicine. (2013). Nitrates. Retrieved from: Medicine. (2013). Penbutolol. Retrieved from: Medicine. (2013). Phenobarbitol. Retrieved from Medicine. (2013). Pindolol. Retrieved from: Medicine. (2013). Propranolol. Retrieved from: Medicine. (2013). Staphylococcal Infections. Retrieved from: Medicine. (2013). Thiazide Diuretics. Retrieved from: Medicine. (2013). Tiagabine. Retrieved from Medicine. (2013). Timolol. Retrieved from: Medicine. (2013). Topiramate. Retrieved from , W., Casey, D., Feldman, A., Francis, G., Ganiats, T., Jessup, M., Konstam, M., Mancini, D., Rahko, P., Silver, M., Stevenson, L., & Yancy, C. (2009). 2009 focused updated: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults. Journal of the American College of Cardiology, 53(15), 1343-1383. doi: 10.1016/j.jacc.2008.11.009Albert, N. M., Boehmer, J. P., Collins, S. P., Ezekowitz, J. A., Givertz, M. M., Klapholz, M., Lindenfeld, J., Moser, D. K., Rogers, J. G., Starling, R. C., Stevenson, W. G., Tang, W. H. W., Teerlink, J. R., & Walsh M. N. (2010). Executive summary: HFSA 2010 comprehensive heart failure practice guidelines. Journal of Cardiology Failure, 16(6), 475-506. doi: 10.1016/j.cardfail.2010.04.005American Diabetes Association. (2011, October). Standards of medical care in diabetes-2012. Diabetes Care, 35, S11-S63. doi: 10.2337/dc12-s011Andriolo, R., Belloti, J., Faloppa, F., Gomes dos Santos, J., & Lenza, M., (2010). Conservative interventions for treating middle third clavicle fractures in adolescents and adults (Review). Cochrane Database of Systematic Reviews 2009, 2, 1-37. doi: 10.1002/14651858.CD007121.pub2 Barreras, A., & Gurk-Turner, C. (2003). Angiotensin II receptor blockers. Baylor University Medical Center Proceedings, 16(1), 123-126. Retrieved from: , C., Buderer, N., Marco, C., Plewa, M, & Roberts, A. (2008). Comparison of oxycodone and hydrocodone for the treatment of acute pain associated with fractures: A double-blind, randomized, control trail. Academic Emergency Medicine, 12(4), 282-288. doi: 10.1197/j.aem.2004.12.005Bonow, R., Carabello, B., Chatterjee, K., de Leon, A., Faxon, D., Freed, M., Gaasch, W., Lytle, B., Nishimura, R., O’Gara, P., O’Rourke, R., Otto, C., Shah, P., & Shanewise, J. (2008). 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Writing committee to develop guidelines for the management of patients with valvular heart disease). Circulation: Journal of the American Heart Association, 118, e523– e661. doi: 10.1161/CIRCULATIONAHA.108.190748Bouza, E., Bunsow, E., Giannella, M., Martin-Rabadan, P., Munoz, P., Perez Granda, M., & Torres, M. (2011). Ventilator-associated pneumonia due to methicillin-resistant Staphylococcus aureus: Risk factors and outcome in a large general hospital. Journal of hospital Infection, 80, 150-155. doi: 10.1016/j.jhin.2011.11.013Bruni, J. (2008). Episodic impairment of consciousness. In W. G. Bradley (Ed.), Neurology in clinical practice (pp. 11-20). Philadelphia, PA: Butterwoth Heinemann ElsevierCastelluccio, P., Hui, S., Kroenke, K., McGrath, R., Miller, D., & Terrell, K. (2010). Analgesic prescribing for patients who are discharged from an emergency department. Pain Medicine, 11, 1072-1077. doi: 10.1111/j.1526-4637.2010.00884.xCenters for Disease Control and Prevention. (2011). Methicillin-resistant Staphylococcus Aureus (MRSA) Infections. Retrieved March 7, 2013, from , J., Cuschieri, J., Dellit, T., Hessel, M., Neff, M., Pham, T., & Wong, J. (2011). Clinical outcomes for Linezolid vs Vancomycin in methicillin-resistant staphylococcus aureus ventilator-associated pneumonia: Retrospective analysis. Journal of Intensive Care Medicine, 26(6), 385-391. doi: 10.1177/0885066610392893Clinical Pharmacology. (2013). Acebutolol. Retrieved from Pharmacology. (2013). Acetazolamide. Retrieved from Pharmacology. (2013). Angiotensin-Converting Enzyme (ACE) Inhibitors. Retrieved from Pharmacology. (2013). Angiotensin Receptor Blockers (ARBS). Retrieved from Pharmacology. (2013). Aztreonam. Retrieved from Pharmacology. (2013). Carvedilol. Retrieved from Pharmacology. (2013). Celecoxib. Retrieved from Pharmacology. (2013). Digoxin. Retrieved from Pharmacology. (2013). Ethotoin. Retrieved from Pharmacology. (2013). Furosemide. Retrieved from Pharmacology. (2013). Gabapentin. Retrieved from Pharmacology. (2013). Hydrochlorothiazide. Retrieved from Pharmacology. (2013). Isosorbide Dinitrate. Retrieved from Pharmacology. (2013). Ketorolac. Retrieved from Pharmacology. (2013). Levetiracetam. Retrieved from Pharmacology. (2013). Linezolid. Retrieved from Pharmacology. (2013). Rufinamide. Retrieved from Pharmacology. (2013). Tylenol. Retrieved from , J., Ratilal, B., & Sampaio, C., (2009). Anticonvulsants for preventing seizures in patients with chronic subdural hematoma. Cochrane Database of Systematic Reviews 2005, 3, 1-12. doi: 10.1002/14651858.CD004893.pub2Dobrin, S. (2012). Seizures and epilepsy in adolescents and adults. Disease a Month, 58(12), 708-729, doi:10.1016/j.disamonth.2012.08.011DiNicolantonio, J., Fares, H., Lavie, C., Menezes, A., & O’Keefe, J. (2012). Meta-analysis of carvedilol versus beta 1 selective beta-blockers (Atenolol, bisoprolol, metoprolol, and nevivolol). The American Journal of Cardiology, 111,765-769. doi: org/10.1016/j.amjcard.2012.11.031Farsetti, P., Gumina, S., Postacchini, F., & Postacchini, R., (2010). Long-term results of conservative management of midshaft clavicle fracture. International Orthopedics, 34, 731-736. doi: 10.1007/s00264-009-0850-xGhauri, A., Khan, A., Shamim, M., & Zafar, S. (2012). Phenytoin versus Levetiracetam for seizure prophylaxis after brain injury- A meta-analysis. BioMed Central Neurology, 12(30), 1-8. doi: 10.1186/1471-2377-12-30Heart Failure Society of America. (2002, March). Questions about HF: How is heart failure Diagnosed? Retrieved from Failure Society of America. (2013). Retrieved from: , E., & Zelano, J. (2011). Lavetiracetam as alternative stage two antiepileptic drug in status epilepticus: A systematic review. Seizure, 21, 233-236. doi: 10.1016/j.seizure.2012.01.008Lexi-comp. (2013). Lexi-COMPLETE [Mobile application software]. Retrieved from Board of Nursing. (2013). The formulary developed by the committee on prescriptive governance. Retrieved from , J. & White, C. (2002). Clinical pharmacokinetics and selective pharmacodynamics of new angiotensin converting enzyme inhibitors. Drug Disposition, 41(3), 207-224. Retrieved from ................
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