Nursing2024 Drug Handbook

Chief Nurse: Anne Dabrow Woods, DNP , RN , CRNP , ANP - BC , AGACNP - BC , FAAN Acquisitions Editor: Susan M. Hartman

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This work is no substitute for individual patient assessment based upon health care professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data, and other factors unique to the patient. The publisher does not provide medical advice or guidance, and this work is merely a reference tool. Health care professionals, and not the publisher, are solely responsible for the use of this work, including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and health care professionals should consult a variety of sources. When prescribing medication, health care professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings, and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used, or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.

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Contents

Anatomy of a monograph .............................................inside front cover Contributors and consultants ................................................................. v How to use Nursing2024 Drug Handbook ® .......................................... vi Quick guide to special symbols, logos, and highlighted terms.............. ix Guide to abbreviations........................................................................... x General information 1. Drug actions, interactions, and reactions ........................................... 1 2. Drug therapy across the lifespan ........................................................ 6 3. Safe drug administration...................................................................13 4. Selected therapeutic drug classifications ............................................23 Alphabetical listing of drugs by generic name .............................. 63 Appendices ....................................................................................1609 1. Nursing process: Patient safety during drug therapy .................... 1609 2. Decision tree: Deciding about medication administration ............ 1610 3. Avoiding common drug errors: Best practices and prevention ...... 1611 4. Abbreviations to avoid (The Joint Commission) ........................... 1614 5. Do not use: Dangerous abbreviations, symbols, and dose designations (ISMP Canada) ....................................................... 1615 6. Therapeutic drug monitoring guidelines ....................................... 1616 7. Pregnancy risk categories: The FDA’s Final Rule ......................... 1624 8. Controlled substance schedules .................................................... 1624 9. Canadian National Drug Schedules ............................................. 1625 10. Safe disposal of unused drugs: What patients need to know ........ 1626 11. Prescription drug abuse: Identifying and treating toxicity ............ 1628 12. Serotonin syndrome: What you should know to protect your patient .......................................................................................... 1631 13. Tumor lysis syndrome: A life-threatening emergency ................... 1632 14. Severe cutaneous adverse reactions ............................................... 1633 15. Anaphylaxis ................................................................................. 1635 16. Understanding biosimilar drugs ................................................... 1636 17. Antacids: Indications and dosages ................................................ 1638 18. Antidiarrheals: Indications and dosages........................................ 1639 19. Laxatives: Indications and dosages ............................................... 1641 20. Vitamins and minerals: Indications and dosages ........................... 1645 21. Additional OTC drugs: Indications and dosages........................... 1652 22. Common combination drugs: Indications and dosages ................ 1657 23. Antidotes: Indications and dosages .............................................. 1672 New drugs ..................................................................................... 1582

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iv Contents 24. Selected ophthalmic drugs: Indications and dosages .................... 1679 25. Selected biologicals and blood derivatives: Indications and dosages ......................................................................................... 1687 26. Vaccines and toxoids: Indications and dosages ............................. 1693 27. Less commonly used drugs: Indications and dosages .................... 1701 Index ...............................................................................................1791

Contributors and consultants

Hannah McCaffery, PharmD Manager, Pharmacy Regulations and Implementations Health Partners Plans Philadelphia, PA Kimberly E. Ng, PharmD, BCPS Associate Professor St. John’s University Queens, NY Michael N. Perza, PharmD, BCPS Clinical Pharmacist Christiana Care Health System Newark, DE Christine Price, PharmD Clinical Coordinator/PGY1 Pharmacy Residency Director Morton Plant Hospital Clearwater, FL

Janine Barnaby, RPh, BCOP Director, Outpatient Infusion Pharmacy Lehigh Valley Health Network Allentown, PA David Bruch, BS, PharmD Associate Lecturer University of Wyoming–School of Pharmacy Laramie, WY Lawrence Carey, PharmD Assistant Dean for Assessment, Accreditation, and Quality Temple University School of Pharmacy Philadelphia, PA Jeffrey Cies, PharmD, MPH, BCPS-AQ ID, BCPPS, FCCP, FCCM, FPPA Pharmacy Clinical Coordinator, Critical Care and Infectious Diseases Clinical Pharmacist St. Christopher’s Hospital for Children Philadelphia, PA Jason C. Cooper, PharmD Clinical Specialist, MUSC Drug Information Center Medical University of South Carolina Charleston, SC

Janet Rader, BSN, RN Clinical Consultant New Tripoli, PA Melissa Rinaldi, PharmD Clinical Pharmacist Independence Blue Cross Philadelphia, PA Kerry Rinato, PharmD, BCPS Clinical Pharmacist Sunrise Hospital Las Vegas, NV

Lauren Falonk, PharmD Pharmacist in Charge Walgreens Pharmacy Camden, NJ Toshal Hallowell, PharmD Pharmacist Edward M. Kennedy Community Health Center Worcester, MA Rebecca Hoover, PharmD, MBA Associate Professor Idaho State University Pocatello, ID Jill Krabak, PharmD, BSPharm Clinical Pharmacist Justice Grown Dickson City, PA Chung-Shien Lee, PharmD, BCPS, BCOP

Maha Saad, PharmD, BCGP, BCPS Associate Clinical Professor St. John’s University College of Pharmacy and Health Sciences Co-Director Drug Information Center Long Island Jewish Medical Center–– Northwell Health Queens, NY Michele F. Shepherd, PharmD, MS, BCPS, FASHP Clinical Consultant Jordan, MN Michelle Smith, PharmD, BCPS Clinical Consultant Havre, MT Maggie White-Jones, PharmD Pharmacist Walgreens Pharmacy Berlin, MD

Associate Professor St. John’s University Queens, NY Celia Lu, PharmD, BCACP

Associate Professor–Industry Professional St. John’s University College of Pharmacy and Health Sciences Queens, NY

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How to use Nursing2024 Drug Handbook ® The best-selling nursing drug guide for

unused drugs, tumor lysis syndrome, serotonin syndrome, biosimilar drugs, and Canadian drug schedules and safe administration tools ⦁ Thoroughly updated appendices containing indications and dosages of various classes and groupings of drugs–antidotes, antidiarrheals, ophthalmic drugs, laxatives, antacids, biologi- cals and blood derivatives, vaccines and toxoids, vitamins and minerals, common combination drugs, and less commonly used drugs ⦁ Photoguide featuring 415 full-color, actual- sized tablets and capsules. Introductory chapters Chapter 1, “Drug actions, interactions, and re- actions,”explains how drugs work in the body. It provides a general overview of drug proper- ties (absorption, distribution, metabolism, and excretion) and other significant factors affecting drug action (including protein bind- ing, patient’s age, underlying disease, dosage form, and route and timing of administration). Also discussed are drug interactions, adverse reactions, and toxic reactions. Chapter 2, “Drug therapy across the lifespan,”discusses the dan- ger associated with indiscriminate use of drugs during pregnancy and breastfeeding and the special precautions women should take when medications are necessary. This chapter also covers the unique challenges of giving drugs to children and older adults and offers practical suggestions on how to minimize problems with these special populations. Chapter 3, “Safe drug administration,”explores the ongoing involve- ment of governmental and nongovernmental organizations weighing in on drug safety issues and the necessary measures nurses must take to prevent medication errors from occurring. Chapter 4, “Selected therapeutic drug classifications,” summarizes the indications, actions, and contraindications and cautions of more than 59 drug classes represented in Nursing2024 Drug Handbook . Generic drugs within each class are also listed, allowing nurses to quickly identify and compare similar drugs when patients can’t tolerate or don’t respond to a particular drug. Drug monographs Each generic drug monograph in Nursing2024 Drug Handbook includes the most pertinent clinical information nurses must know to administer medications safely, monitor for

44 years, Nursing Drug Handbook is meticu- lously reviewed and updated annually by phar- macists and nurses to include the most current, relevant information that practicing nurses and students need to know to administer medica- tions safely in any health care setting. As in previous editions, Nursing2024 Drug Handbook emphasizes nursing and safety aspects of drug administration without attempting to replace detailed pharmacology texts. Only the most essential information is included, and helpful graphic symbols, logos, and highlighting draw special attention to critical details that can’t be overlooked. Outstanding features The 44th edition provides a wealth of the latest drug information right at your fingertips: ⦁ Tabbed “NewDrugs” section–ensures quick access to 21 completely new drug monographs introduced in this edition ⦁ Features the latest information on thousands of generic, brand, and combination drugs in- cluded in 690 comprehensive drug monographs and 27 appendices ⦁ Drug safety always at the forefront–look for prominently displayed safety alerts, drug warn- ings, ISMP tall-man letters to help differentiate similarly spelled drug names, plus a special chapter on promoting safe drug administra- tion—with updated guidelines on administering opioid analgesics, preventing and treating IV extravasation injury, safe handling of hazardous drugs, and best practices to ensure patient safety and reduce drug errors ⦁ Special logos and symbols throughout to emphasize FDA boxed warnings, clinical alerts, new indications, necessary dosage adjustments, overdose signs and symptoms, off-label uses, drugs that shouldn’t be crushed or chewed, over-the-counter drugs, biosimilar drugs, Canadian drugs, look alike–sound alike drugs, and the dialyzability status of each drug ⦁ Genetic symbols pinpointing monographs and specific genetic-related information to help select and guide drug therapy ⦁ Pregnancy-Lactation-Reproduction section in each monograph–captures all relevant informa- tion in one convenient place ⦁ Key appendices reviewing prescription drug abuse, dangerous abbreviations to avoid, thera- peutic monitoring guidelines, safe disposal of

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within this section indicates the need for a special dosage adjustment for certain patients, such as older adults or those with renal or hepatic impairment. In some cases, a dosage adjustment may apply to all patient populations for all of the indications listed; this is marked accordingly. Administration Here, readers will find guidelines for safely administering drugs by all applicable routes, including PO, IV, IM, subcut, ophthalmic, in- halational, topical, rectal, vaginal, transdermal, and buccal. A special screened background highlights IV administration guidelines (includ- ing specific instructions on how to reconstitute, mix, and store IVmedications) and the major potential IV incompatibilities. Action This section succinctly describes the mechanism of action–that is, how the drug provides its therapeutic effect. For example, although all antihypertensives lower BP, they don’t all do so by the same process. Also included, in table form, are the onset, peak (described in terms of effect or peak blood level), and duration of drug action for each route of administration, if data are available or applicable. Values listed are for patients with normal kidney function unless otherwise specified. The drug’s half-life is also provided when known. Adverse reactions In this section, adverse reactions that are known to occur at a frequency of 1% or greater are list- ed according to body system. Life-threatening reactions appear in bold italic type. Interactions Within this section, readers can find each drug’s confirmed, clinically significant interac- tions (additive effects, potentiated effects, and antagonistic effects) with other drugs, herbs, foods, beverages, and lifestyle behaviors (such as alcohol use, sun exposure, or smoking). Interactions with a rapid onset are highlighted in color; interactions with a delayed onset are in bold type. Drug interactions are listed under the drug that’s adversely affected. For example, because magnesium trisilicate, an antacid ingredient, interacts with tetracycline to decrease tetracy- cline’s absorption, this interaction is listed under tetracycline. To check on the possible effects of

potential interactions and adverse effects, implement necessary care measures, and pro- vide appropriate patient teaching. Entries are arranged alphabetically, with the generic drug name prominently displayed–along with its “tall man” lettering (if applicable), pronuncia- tion, corresponding brand (or trade) names, therapeutic class, and pharmacologic class–on a shaded background for quick and easy iden- tification. Banners or symbols to identify drugs that warrant a special safety alert, designate biosimilar drugs, or indicate drugs that appear in the color photoguide are also included in this highlighted area. Specific information for each drug is then systematically organized under the headings below. Special icons and logos may be used throughout, as warranted, to point out the drug’s safety concerns. For example, a clinical alert logo ( t ) provides important advice about life-threatening effects associated with the drug or its administration; a boxed warning ( BoxedWarning ) represents a specific warning issued by the FDA. A special icon ( ) indicates oral drug forms that shouldn’t be crushed or chewed. (See Anatomy of a monograph , on the inside book cover, for a visual guide to the various symbols that may appear within a drug entry.) Available forms This section lists the preparations available for each drug (for example, tablets, capsules, solutions for injection) and specifies available dosage forms and strengths. Dosage strengths specifically available in Canada are designated with a maple leaf ( ). Preparations that may be obtained over the counter, without a pre- scription, are marked with an open diamond (◊). Liquid formulations that contain alcohol are indicated with an asterisk (*). Capsules or tablets that shouldn’t be crushed are marked with a “Do Not Crush” symbol ( ). Indications & dosages General dosage information for adults and children is found in this section. Dosage instruc- tions reflect current trends in therapeutics and can’t be considered absolute or universal. For individual patients, dosage instructions must be considered in light of the patient’s condition. Indications and dosages that aren’t approved by the FDA are followed by a closed diamond ( ♦ ). It should be noted that only highly evi- dence-based off-label uses are included in this edition. An Adjust-a-dose logo appearing

viii How to use Nursing2024 Drug Handbook ®

Photoguide to tablets and capsules

using two or more drugs simultaneously, refer to the interactions section for each drug. Effects on lab test results This section lists increased and decreased levels, counts, and other values in lab test results that may be caused by the drug’s systemic effects. It also indicates false-positive, false-negative, and otherwise altered results of lab tests a drug may cause. Contraindications & cautions This section outlines any conditions or special circumstances, such as diseases or conditions, in which use of the drug is undesirable or for which the drug should be given with caution. This section also contains information about whether or not the drug is dialyzable. When applicable, specific signs and symptoms of drug overdose are listed as the last bulleted item under this heading and highlighted by a special logo ( H Overdose S&S: ) for easy identification. Pregnancy–lactation–reproduction This section provides nurses with targeted, easy- to-understand safety information about each drug’s use during pregnancy and breastfeeding. It also provides information about fertility effects, contraception recommendations, and enrollment information for registries that moni- tor drug safety during pregnancy. Nursing considerations Within this section, readers can find practical information on patient-monitoring techniques and suggestions for the prevention and treat- ment of adverse reactions as well as helpful tips on promoting patient comfort. Patient teaching Concise guidelines for explaining the drug’s purpose, encouraging compliance, ensuring proper use and storage, and preventing or minimizing adverse reactions are included in this section. Appendices and other helpful aids Nursing2024 Drug Handbook includes 27 ap- pendices that provide nurses and students with hands-on access to a wealth of supportive data and clinical information. A handy visual “Quick guide to special sym- bols, logos, and highlighted terms”and “Guide to abbreviations” immediately follow this “How to use”piece.

To enhance patient safety and help make drug identification easier, Nursing2024 Drug Hand- book offers a 32-page full-color photoguide to the most commonly prescribed tablets and capsules. Shown in actual size, the drugs are arranged alphabetically by generic name for quick reference followed by the brand names and their most common dosage strengths. Be- low the name of each drug is a cross-reference to where information on the drug can be found in the book. Brand names of drugs that ap- pear in the photoguide are shown in text with a special capsule symbol ( i ). Page references to the drug photos appear in boldface type in the index (for example, C12 ). Photos for certain brands were provided by the following companies for use in this book: Novartis Pharmaceuticals (Enablex); Sepracor, Inc. (Lunesta); Teva Pharmaceuticals (Azilect); and Pfizer (Sutent). Additional photos were provided by Jeff Sigler of SFI Medical Publishing. Lippincott NursingCenter ® Readers also have online access to a wealth of drug-related information at https://www. nursingcenter.com. Included are monthly FDA drug updates, drug warnings, and drug news abstracts. Also included are drug quizzes, best- practice medication safety guidelines, admin- istration tips, real-life medication stories, CE tests, and so much more.

lamotrigine 841

• Teach parents or guardians signs and symp- toms of pancreatitis. Advise them to report signs and symptoms immediately.

tablet) no faster than 100 mg/day each week to achieve the monotherapy maintenance dosage of 250 to 300 mg/day. ➤ Conversion to monotherapy using extended-release formula in patients with partial seizures who are receiving adjunc- tive treatment with valproate Adults and children age 13 and older: Add 25 mg extended-release PO every other day for 2 weeks; then increase to 25 mg PO daily for weeks 3 and 4. Increase to 50 mg PO daily for week 5, 100 mg PO daily for week 6, and 150 mg PO daily for week 7. Maintain dosage at 150 mg PO daily while decreasing val- proate dosage by no more than 500 mg/day each week until 500 mg/day is achieved; maintain for 1 week. Then, simultaneously in- crease extended-release tablet to 200 mg/day while decreasing valproate to 250 mg/day; maintain for 1 week. Increase to 250 or 300 mg PO daily as maintenance dosage and discontinue valproate. ➤ Conversion to monotherapy using extended-release formula in patients with partial seizures who are receiving treat- ment with a single drug other than an enzyme-inducing AED or valproate Adults and children age 13 and older: Add 25 mg extended-release PO daily for 2 weeks; then increase to 50 mg PO daily for weeks 3 and 4. Increase to 100 mg PO daily for week 5. Starting with week 6, continue increasing dosage each week by 50 mg PO daily until a dosage of 250 to 300 mg PO daily is achieved; then withdraw concomitant AED therapy by 20% decrements each week over a 4-week period. No additional lamotri- gine (extended-release tablet) adjustment is needed. ➤ Adjunctive treatment of partial seizures or primary generalized tonic-clonic seizures caused by epilepsy or generalized seizures of Lennox-Gastaut syndrome Adults and children older than age 12 taking valproate: 25 mg immediate-release PO every other day for 2 weeks; then 25 mg PO daily for 2 weeks. Continue to increase, as needed, by 25 to 50 mg daily every 1 to 2 weeks un- til an effective maintenance dosage of 100 to 400 mg daily given in one or two divided doses is reached. When added to valproate alone, the usual daily maintenance dose is 100 to 200 mg. Adults and children age 13 and older taking valproate: 25 mg extended-release PO every

lamo TRI gine la-MO-tri-geen

LaMICtal, Subvenite

Therapeutic class: Anticonvulsants Pharmacologic class: Phenyltriazines AVAILABLE FORMS Tablets: 25 mg, 100 mg, 150 mg, 200 mg Tablets (chewable dispersible): 2 mg, 5 mg, 25 mg Tablets (extended-release) : 25 mg, 50 mg, 100 mg, 200 mg, 250 mg, 300 mg Tablets (ODTs): 25 mg, 50 mg, 100 mg, 200 mg INDICATIONS & DOSAGES Alert: Extended-release formula isn’t for use as initial monotherapy or for conversion to monotherapy from two or more concomi- tant AEDs. Adjust-a-dose (for all indications): Gener- ally, reduce initial, escalation, and mainte- nance doses by approximately 25% in patients with moderate and severe hepatic impairment without ascites and 50% in patients with se- vere hepatic impairment with ascites. May adjust escalation and maintenance doses ac- cording to clinical response. In patients with renal impairment, base initial doses on pa- tients’ concomitant medications; reduced maintenance doses may be effective for pa- tients with significant renal impairment. ➤ Conversion to monotherapy using extended-release formula in patients with partial seizures who are receiving treat- ment with a single enzyme-inducing AED (except valproate) Adults and children age 13 and older: Add 50 mg extended-release tablet PO daily to current drug regimen for 2 weeks, followed by 100 mg PO daily for 2 weeks. Then, in- crease by 100 mg every week until a dosage of 500 mg PO daily is reached. The concomi- tant enzyme-inducing AED can then be grad- ually reduced by 20% decrements each week over a 4-week period. Two weeks after com- pleting withdrawal of the enzyme-inducing AED, decrease lamotrigine (extended-release

L

i Photoguide

Canada

OTC Off-label use

Do not crush *Liquid contains alcohol

Genetic

842 lamotrigine

other day for 2 weeks; then 25 mg PO daily for 2 weeks; then 50 mg PO daily for 1 week; then 100 mg PO daily for 1 week; then 150 mg PO daily for 1 week. Daily main- tenance dose is 200 to 250 mg. Adults and children age 13 and older not tak- ing carbamazepine, phenytoin, phenobarbi- tal, primidone, or valproate: 25 mg extended- release PO daily for 2 weeks; then 50 mg PO daily for 2 weeks; then 100 mg PO daily for 1 week; then 150 mg PO daily for 1 week; then 200 mg PO daily for 1 week. Daily main- tenance dose is 300 to 400 mg. Adults and children older than age 12 taking anticonvulsant drugs but not carbamazepine, phenytoin, phenobarbital, primidone, or val- proate: 25 mg immediate-release PO daily for 1 to 2 weeks; then 50 mg PO daily for another 2 weeks. Continue to increase by 50 mg/day every 1 to 2 weeks until an effective main- tenance dose is reached. Daily maintenance dose is 225 to 375 mg PO daily in two divided doses. Adults and children older than age 12 tak- ing carbamazepine, phenytoin, phenobarbi- tal, or primidone but not valproate: 50 mg immediate-release PO daily for 2 weeks; then 100 mg PO daily in two divided doses for 2 weeks. Increase, as needed, by 100 mg daily every 1 to 2 weeks. Usual maintenance dosage is 300 to 500 mg PO daily in two di- vided doses. Adults and children age 13 and older tak- ing carbamazepine, phenytoin, phenobarbi- tal, or primidone but not valproate: 50 mg extended-release PO daily for 2 weeks; then 100 mg PO daily for 2 weeks; then 200 mg PO daily for 1 week; then 300 mg PO daily for 1 week; then 400 mg PO daily for 1 week. Daily maintenance dose is 400 to 600 mg. Children ages 2 to 12 weighing 6.7 to 40 kg taking valproate: 0.15 mg/kg immediate- release PO daily in one or two divided doses (rounded down to nearest whole tablet) for 2 weeks. Increase to 0.3 mg/kg daily in one or two divided doses for 2 weeks, followed by increasing the daily dose every 1 or 2 weeks with an additional 0.3 mg/kg daily in one or two divided doses. Thereafter, usual main- tenance dosage is 1 to 5 mg/kg daily (max- imum, 200 mg daily in one to two divided doses). In patients weighing less than 30 kg, maintenance dosage may need to be increased by as much as 50% based on clinical re- sponse.

Children ages 2 to 12 weighing 6.7 to 40 kg taking anticonvulsant drugs but not carba- mazepine, phenytoin, phenobarbital, prim- idone, or valproate: 0.3 mg/kg immediate- release PO daily in one or two divided doses (rounded down to the nearest whole tablet) for 2 weeks; then 0.6 mg/kg PO daily in two divided doses for another 2 weeks; then in- crease the daily dose every 1 to 2 weeks with an additional 0.6 mg/kg PO daily in two di- vided doses. Thereafter, usual maintenance dose is 4.5 to 7.5 mg/kg PO daily. Maximum dose is 300 mg daily in two divided doses. In patients weighing less than 30 kg, mainte- nance dosage may need to be increased by as much as 50% based on clinical response. Children ages 2 to 12 weighing 6.7 to 40 kg taking carbamazepine, phenytoin, pheno- barbital, or primidone but not valproate: 0.6 mg/kg immediate-release PO daily in two divided doses (rounded down to near- est whole tablet) for 2 weeks. Increase to 1.2 mg/kg PO daily in two divided doses for 2 weeks; then increase the daily dose every 1 to 2 weeks with an additional 1.2 mg/kg daily in two divided doses. Usual mainte- nance dosage is 5 to 15 mg/kg PO daily (max- imum 400 mg daily in two divided doses). In patients weighing less than 30 kg, main- tenance dosage may need to be increased by as much as 50% based on clinical response. ➤ To convert patients from therapy with an enzyme-inducing AED alone to lamo- trigine therapy Adults and children age 16 and older: Add 50 mg immediate-release PO once daily to current drug regimen for 2 weeks, followed by 100 mg PO daily in two divided doses for 2 weeks. Then increase daily dosage by 100 mg every 1 to 2 weeks until maintenance dose of 500 mg daily in two divided doses is reached. The concomitant hepatic enzyme- inducing AED can then be gradually reduced by 20% decrements weekly for 4 weeks. ➤ To convert patients with partial seizures from adjunctive therapy with valproate to therapy with lamotrigine alone Adults and children age 16 and older: Add immediate-release form until 200 mg daily is achieved; then gradually decrease valproate to 500 mg daily by decrements of no more than 500 mg daily per week. Maintain these dosages for 1 week, then increase lamotrigine to 300 mg daily while decreasing valproate to 250 mg daily. Maintain these dosages for

Reactions in bold italics are life-threatening . Interactions may have a rapid onset or a delayed onset .

lamotrigine 843

1 week, then stop valproate completely while increasing lamotrigine by 100 mg daily every week until a dose of 500 mg daily is reached. ➤ Bipolar disorder for maintenance treat- ment to delay time to occurrence of mood episodes (depression, mania, hypomania, mixed episodes) in patients treated for acute mood episodes with standard therapy Adults: Initially, 25 mg immediate-release PO once daily for 2 weeks; then 50 mg PO once daily for 2 weeks. Dosage may then be doubled at weekly intervals, to maintenance dosage of 200 mg daily. Adults taking carbamazepine or other enzyme-inducing drugs without valproate: Initially, 50 mg immediate-release PO once daily for 2 weeks; then 100 mg daily in two divided doses for 2 weeks. Dosage is then in- creased by 100 mg weekly to maintenance dosage of 400 mg daily, given in two divided doses. Adults taking valproate: Initially, 25 mg immediate-release PO every other day for 2 weeks; then 25 mg PO once daily for 2 weeks. Dosage may then be doubled at weekly intervals to maintenance dosage of 100 mg daily. ADMINISTRATION PO • Starter and titration kits are available to provide doses consistent with recommended titration schedule for the first 5 weeks of treat- ment. • Patient may swallow chewable dispersible tablets whole, chew them, or disperse them in a small amount of water or diluted fruit juice. • If tablets are chewed, give a small amount of water or diluted fruit juice to aid in swal- lowing. • Place ODTs on the tongue and have patient move them around in the mouth. • Patient may swallow ODTs with or without water and without regard to food. • Give extended-release tablets once daily with or without food. Patient must swallow tablets whole and must not chew, crush, or divide them. ACTION Inhibits release of glutamate (an excitatory neurotransmitter) in the brain via action at voltage-sensitive sodium channels. Is a weak inhibitor of the 5-HT 3 receptor.

Route

Onset

Peak Duration

PO (immediate- release) PO (extended- release)

Unknown 1–5 hr Unknown

Unknown 4–11 hr Unknown

Half-life: 7 to 148 hours, depending on age, dosage schedule, use of other anticonvulsants, and other medical conditions.

ADVERSE REACTIONS CNS: ataxia, dizziness, drowsiness, headache, migraine, somnolence, fatigue, anxiety, ab- normal thinking, amnesia, depression, con- fusion, dysarthria, emotional lability, fever, incoordination, insomnia, irritability, hypoes- thesia, dream abnormality, malaise, pain, as- thenia, speech disorder, concentration dis- turbance, seizure exacerbation. CV: pal- pitations, chest pain, edema, hemorrhage. EENT: blurred vision, diplopia, vision ab- normality, nystagmus, rhinitis, epistaxis, dry mouth, pharyngitis, sinusitis. GI: nausea, vomiting, abdominal pain, anorexia, consti- pation, diarrhea, dyspepsia, flatulence, rectal hemorrhage, peptic ulcer. GU: amenorrhea, dysmenorrhea, urinary frequency, vagini- tis, UTI. Hematologic: lymphadenopathy. Metabolic: weight loss. Musculoskeletal: arthralgia, back pain, muscle spasm, neck pain, weakness. Respiratory: cough, dys- pnea, bronchitis, bronchospasm. Skin: rash, pruritus, dermatitis, dry skin, diaphoresis, photosensitivity. Other: infection, acciden- tal injury, flulike syndrome. INTERACTIONS Drug-drug. Acetaminophen: May decrease therapeutic effects of lamotrigine. Monitor patient. Atazanavir–ritonavir, ethosuximide, lopinavir–ritonavir, oxcarbazepine, phenobarbital, phenytoin, primidone, rifampin: May decrease lamotrigine level. Monitor patient closely; adjust lamotrigine dosage. Carbamazepine : May decrease effects of lam- otrigine while increasing toxicity of carba- mazepine. Consider alternative therapy. Ad- just doses and monitor patient. Hormonal contraceptives containing estro- gen: May decrease lamotrigine level. Adjust dosage based on individual hormonal prod- uct used. By the end of the “pill-free” week, lamotrigine level may double.

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Genetic

844 lamotrigine

PREGNANCY-LACTATION-REPRODUCTION • Drug may increase risk of congenital mal- formations in the first trimester. Use during pregnancy only if potential benefit justifies fetal risk. • Patients should enroll in the North American Antiepileptic Drug Preg- nancy Registry (1-888-233-2334 or www.aedpregnancyregistry.org). • Drug appears in human milk. Use cau- tiously during breastfeeding. Discontinue breastfeeding if infants develop drug toxic- ity. NURSING CONSIDERATIONS Alert: Closely monitor all patients taking or starting AEDs for changes in behavior indi- cating worsening of suicidality or depression. Symptoms such as anxiety, agitation, hostil- ity, mania, and hypomania may be precursors to emerging suicidality. • Don’t stop drug abruptly because this may increase seizure frequency. Instead, taper drug over at least 2 weeks. Boxed Warning Serious rashes, including SJS and TEN, and rash-related death have been reported. Serious rash occurs more fre- quently in children than in adults, when ad- ministered with valproate, or when initial recommended dose or escalation dose is ex- ceeded. Benign rashes may also occur but it’s impossible to predict which rash will become serious or life threatening. Stop drug at first sign of rash, unless rash is clearly not drug- related. Boxed Warning Stopping treatment may not prevent a rash from becoming life-threatening or permanently disabling or disfiguring. Boxed Warning Extended-release form isn’t approved for children younger than age 13. Alert: Drug may cause aseptic meningi- tis. Monitor patient for symptoms such as headache, fever, neck stiffness, nausea, vom- iting, rash, and photophobia. Discontinue drug if no other cause of meningitis is found. • Evaluate patients for changes in seizure ac- tivity. Check adjunct anticonvulsant level. Alert: Monitor patient for HLH (persis- tent fever, hepatosplenomegaly, rash, lym- phadenopathy, neurologic symptoms, cytope- nias, high serum ferritin level, and liver func- tion and coagulation abnormalities). Evalu- ate patient with fever or rash promptly, and discontinue drug if HLH or another serious

Organic cation transporter 2 substrates (dofetilide): May increase lamotrigine or dofetilide plasma level. Don’t coadminister. Strong CYP3A4 inducers (phenytoin, rifam- pin): May decrease lamotrigine level. Use cautiously together; adjust lamotrigine dosage. Valproate : May decrease clearance of lamo- trigine, which increases lamotrigine level; also decreases valproate level. Monitor pa- tient for toxicity. Reduce lamotrigine dosage if added to a multidrug regimen that includes valproic acid. Drug-lifestyle. Sun exposure: May cause photosensitivity reactions. Advise patient to avoid excessive sun exposure. EFFECTS ON LAB TEST RESULTS • May result in false-positive readings in rapid urine drug screens, particularly for phencyclidine. CONTRAINDICATIONS & CAUTIONS • Contraindicated in patients hypersensitive to drug or its components. Alert: Rare, multiorgan hypersensitivity reactions that can be fatal have occurred. Alert: Drug may cause hemophagocytic lymphohistiocytosis (HLH), a rare and life- threatening immune system reaction. • Use cautiously in patients with renal, he- patic, or cardiac impairment. • Drug isn’t recommended for treatment of acute manic or mixed episodes of bipolar dis- order because effectiveness hasn’t been estab- lished. Alert: Use cautiously in patients with struc- tural and functional heart disorders, including HF, valvular heart disease, congenital heart disease, conduction system disease, ventric- ular arrhythmias, cardiac channelopathies, ischemic heart disease, or multiple risk fac- tors for CAD, especially when used in combi- nation with sodium channel blockers (carba- mazepine, phenytoin, topiramate); drug may increase risk of serious or life-threatening ar- rhythmias. Assess whether potential benefits of lamotrigine outweigh risk of arrhythmia for each patient. • Dialyzable drug: 20%. • H Overdose S&S: Ataxia, nystagmus, in- creased seizures, decreased level of con- sciousness, coma, intraventricular conduction delay.

Reactions in bold italics are life-threatening . Interactions may have a rapid onset or a delayed onset .

lansoprazole 845

immune-related reaction is suspected or an alternative cause can’t be identified. • Look alike–sound alike: Don’t confuse lam- otrigine with lamivudine or levothyroxine. Don’t confuse Lamictal with Lamisil, labetalol, or Lomotil. PATIENT TEACHING Alert: Counsel family member or care- givers to monitor patient for changes in be- havior and to immediately report suicidality. • Instruct patient or caregiver to report wors- ening of seizures. • Inform patient that drug may cause rash, especially if administered with valproic acid. Tell patient to report rash or signs or symp- toms of hypersensitivity promptly to pre- scriber; drug may need to be stopped. • Strongly advise patient to visually inspect tablets with each prescription refill to verify the tablets are correct, to avoid medication errors. • Caution patient to report all medications being taken or changes to medications, espe- cially oral contraceptives or other hormone products. • Warn patient not to engage in hazardous activity until drug’s CNS effects are known. • Advise patient to seek immediate medical attention if signs or symptoms of HLH oc- cur, including fever; rash; abdominal pain, tenderness, or swelling; enlarged lymph nodes; yellowing of the skin or eyes; unusual bleeding; seizures; vision changes; or trouble walking. • Teach patient or caregiver to immediately report headache, fever, mouth ulcers, bruising or petechiae, signs of infection (fever, cough, dyspnea), neck stiffness, nausea, vomiting, rash, drowsiness, confusion, or light sensitiv- ity. • Warn patient that the drug may trigger sen- sitivity to the sun and to take precautions until tolerance is determined. • Warn patient not to stop drug abruptly. Alert: Advise patient of childbearing poten- tial to discuss drug therapy with prescriber if considering pregnancy. Alert: Caution patient to seek immediate medical attention for abnormal heart rate or irregular rhythm, or such signs or symptoms as racing heartbeat, skipped or slow heart- beat, shortness of breath, dizziness, or faint- ing.

lansoprazole lanz-AH-pray-zol Prevacid i

Therapeutic class: Antiulcer drugs Pharmacologic class: PPIs AVAILABLE FORMS Capsules (delayed-release) : 15 mg , 30 mg Tablets (ODT delayed-release): 15 mg, 30 mg INDICATIONS & DOSAGES Adjust-a-dose (for all indications): Recom- mended dosage in patients with severe he- patic impairment (Child-Pugh class C) is 15 mg PO daily. ➤ Short-term treatment of active duode- nal ulcer Adults: 15 mg PO daily before eating for 4 weeks. ➤ Maintenance of healed duodenal ulcers Adults: 15 mg PO daily. ➤ Short-term treatment of active benign gastric ulcer Adults: 30 mg PO once daily for up to 8 weeks. ➤ Short-term treatment of erosive esophagitis Adults: 30 mg PO daily before eating for up to 8 weeks. If healing doesn’t occur, 8 more weeks of therapy may be given. Maintenance dosage for healing is 15 mg PO daily. Children ages 12 to 17: 30 mg PO once daily for up to 8 weeks. Children ages 1 to 11 weighing more than 30 kg: 30 mg PO once daily for up to 12 weeks. Children ages 1 to 11 weighing 30 kg or less: 15 mg PO once daily for up to 12 weeks. ➤ Long-term treatment of pathologic hypersecretory conditions, including Zollinger-Ellison syndrome Adults: Initially, 60 mg PO once daily. In- crease dosage, as needed. Give daily amounts above 120 mg in evenly divided doses. ➤ Helicobacter pylori eradication to reduce risk of duodenal ulcer recurrence Adults: For patients receiving dual therapy, 30 mg PO lansoprazole with 1 g PO amox- icillin, each given t.i.d. for 14 days. For pa- tients receiving triple therapy, 30 mg PO lansoprazole with 1 g PO amoxicillin and

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OTC Off-label use

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Genetic

846 lansoprazole

500 mg PO clarithromycin, all given b.i.d. for 10 to 14 days. ➤ Short-term treatment of symptomatic GERD Adults: 15 mg PO once daily for up to 8 weeks. Children ages 12 to 17: 15 mg PO once daily for up to 8 weeks. Children ages 1 to 11 weighing more than 30 kg: 30 mg PO once daily for up to 12 weeks. Children ages 1 to 11 weighing 30 kg or less: 15 mg PO once daily for up to 12 weeks. ➤ NSAID-related ulcer in patients who continue NSAID use Adults: 30 mg PO daily for 8 weeks. ➤ To reduce risk of NSAID-related ulcer in patients with history of gastric ulcer who need NSAIDs Adults: 15 mg PO daily for up to 12 weeks. ➤ Dyspepsia Adults: 15 or 30 mg once daily for up to 8 weeks. ADMINISTRATION PO • Give before a meal. • Don’t crush or allow patient to chew cap- sules. • For patients who have difficulty swallowing capsules, the capsules can be opened and the intact granules sprinkled on 1 tablespoon of applesauce, Ensure pudding, cottage cheese, yogurt, or strained pears and swallowed im- mediately. Or, capsule contents may be emp- tied into a small volume (60 mL) of apple, orange, or tomato juice and swallowed. • Contents of capsule can be mixed with 40 mL of apple juice in a syringe and given within 3 to 5 minutes via an NG or nasojeju- nal tube. Flush with additional apple juice to give entire dose and maintain patency of the tube. • Place ODT on patient’s tongue and allow it to disintegrate with or without water until the particles can be swallowed. • To give ODTs using an oral syringe, dis- solve a 15-mg tablet in 4 mL water or a 30-mg tablet in 10 mL water and give within 15 min- utes. Refill syringe with about 2 mL (15-mg tablet) or 5 mL (30-mg tablet) of water, shake gently, and give any remaining contents. • To give ODTs through an 8 French or larger NG tube, dissolve a 15-mg tablet in 4 mL wa- ter or a 30-mg tablet in 10 mL water and give

within 15 minutes. Refill syringe with about 5 mL of water, shake gently, and flush the NG tube. • ODTs contain 2.5 mg phenylalanine/ 15-mg tablet and 5.1 mg phenylalanine/ 30-mg tablet. ACTION Reduces acid secretion in gastric parietal cells through inhibition of (H + , K + )-ATPase en- zyme system, inhibiting the final step in gas- tric acid production. Route Onset Peak Duration PO 1–3 hr 1.7 hr 24 hr Half-life: Less than 2 hours. ADVERSE REACTIONS CNS: headache, dizziness. GI: abdominal pain, constipation, diarrhea, nausea. GU: hematuria. INTERACTIONS Drug-drug. Amoxicillin, clarithromycin: May increase risk of adverse effects. Moni- tor patient. Atazanavir, nelfinavir: May reduce antiviral GI absorption and activity. Don’t use together. Cefuroxime: May reduce cefuroxime absorp- tion. Avoid combination. Clopidogrel: May decrease clopidogrel serum concentration. Monitor therapy or consider H 2 receptor antagonist (e.g., famotidine). Digoxin: May increase digoxin level. Monitor digoxin concentration; digoxin dosage adjust- ment may be needed. Erlotinib, iron salts, ketoconazole, mycophe- nolate mofetil: May inhibit absorption of these drugs. Monitor patient closely. Methotrexate: May increase methotrexate serum level. Monitor methotrexate concen- tration and adjust dosage as needed. Rilpivirine: May decrease rilpivirine concen- tration. Use together is contraindicated. Strong CYP2C19 or CYP3A inducers (riton- avir): May decrease lansoprazole level. Mon- itor therapy. Strong CYP2C19 or CYP3A4 inhibitors (voriconazole): May increase lansoprazole level. Use cautiously together. Sucralfate: May cause delayed lansoprazole absorption. Give lansoprazole at least 30 min- utes before sucralfate. Tacrolimus: May increase tacrolimus level, especially in patients with a transplant who

Reactions in bold italics are life-threatening . Interactions may have a rapid onset or a delayed onset .

lansoprazole 847

• Prolonged treatment (2 years or more) may cause vitamin B 12 malabsorption caused by hypochlorhydria or achlorhydria. Observe for clinical signs and symptoms consistent with vitamin B 12 deficiency. • Use oral solution cautiously in patients with phenylketonuria. • Prolonged PPI use beyond 1 year may in- crease risk of fundic gland polyps. Use the shortest duration of PPI therapy appropriate to the condition being treated. • Dialyzable drug: No. PREGNANCY-LACTATION-REPRODUCTION • There are no adequate studies during preg- nancy. Use during pregnancy only if clearly needed. • It isn’t known if drug appears in human milk. Evaluate risks and benefits of discon- tinuing breastfeeding or discontinuing drug. NURSING CONSIDERATIONS Alert: Monitor patient for signs and symp- toms of low magnesium level, such as ab- normal HR or rhythm, palpitations, mus- cle spasms, tremor, or seizures. In children, abnormal HR may present as fatigue, upset stomach, dizziness, and light-headedness. • New onset and exacerbation of existing cu- taneous lupus erythematosus and SLE have been reported in patients taking PPIs, includ- ing lansoprazole. Avoid administering PPIs for longer than medically indicated. Discon- tinue drug and refer patient to appropriate specialist for evaluation if indicated. Alert: May increase risk of CDAD. Evalu- ate for CDAD in patients who develop diar- rhea that doesn’t improve. • Patients with severe liver disease may need dosage adjustment, but don’t adjust dosage for older adults or patients with renal insufficiency. • Just because symptoms respond to therapy, gastric malignancy shouldn’t be ruled out. • Monitor patient for hypersensitivity reac- tions, including SCARs (SJS, TEN, DRESS syndrome, acute generalized exanthematous pustulosis). • Look alike–sound alike: Don’t confuse Pre- vacid with Pepcid, Prilosec, or Prevpac. PATIENT TEACHING • Teach patient safe drug administration. • Inform patient with phenylketonuria that ODTs contain 2.5 mg phenylalanine/15-mg tablet and 5.1 mg phenylalanine/30-mg tablet.

are intermediate or poor metabolizers of CYP2C19. Monitor tacrolimus level. Theophylline: May increase theophylline clearance. Adjust theophylline dosage when lansoprazole is started or stopped. Use to- gether cautiously. Warfarin: May increase bleeding time. Moni- tor INR and PT. Drug-herb. St. John’s wort: May increase risk of sun sensitivity. Advise patient to avoid excessive sunlight exposure. Drug-food. Any food: May decrease rate and extent of GI absorption. Advise patient to take before meals. EFFECTS ON LAB TEST RESULTS • May increase LFT values and creatinine, BUN, potassium, lipid, serum urea, gastrin, globulin, and LDH levels. • May increase or decrease cholesterol or electrolyte levels. • May decrease Hb level. • May increase or decrease WBC and platelet counts. • May cause abnormal RBC count. • May increase urinary albumin and glucose levels. • May cause urine crystals. • May cause positive fecal occult blood re- sult. • May cause false-positive results in diagnos- tic investigations for neuroendocrine tumors, urine screening tests for tetrahydrocannabi- nol, and gastrin secretion in response to se- cretin stimulation test. CONTRAINDICATIONS & CAUTIONS • Contraindicated in patients hypersensitive to drug or its components. Reactions may in- clude anaphylaxis, angioedema, acute inter- stitial nephritis, and urticaria. Alert: Prolonged use of PPIs or use with medications such as digoxin or drugs that may cause hypomagnesemia (e.g., diuret- ics) may require magnesium supplementation and possible discontinuation of drug. Monitor magnesium levels before starting treatment and periodically thereafter. Alert: Drug may increase risk of hip, wrist, and spine fractures with long-term and multi- ple daily dose use. • Acute interstitial nephritis has been ob- served in patients taking PPIs and may occur at any point during therapy. Discontinue drug if condition develops.

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OTC Off-label use

Do not crush *Liquid contains alcohol

Genetic