Read Mosby's 2014 Nursing Drug Reference Online
Authors: Linda Skidmore-Roth
Mosby's 2014 Nursing Drug Reference (358 page)
Xarelto
Func. class.:
Anticoagulant
Chem. class.:
Factor Xa inhibitor
A novel, oral anticoagulant that selectively and potently inhibits coagulation factor Xa
For deep venous thrombosis (DVT) prophylaxis/treatment, which may lead to pulmonary embolism (PE), in patients undergoing knee or hip replacement surgery; for stroke prophylaxis and systemic embolism prophylaxis in patients with nonvalvular atrial fibrillation
Severe hypersensitivity
Black Box Warning:
Active bleeding
Pregnancy (category C), breastfeeding, neonates, infants, children, adolescents, geriatric patients, moderate or severe hepatic disease (Child-Pugh Class B or C), hepatic disease associated with coagulopathy, creatinine clearance <30 ml/min for use as DVT prophylaxis and <15 ml/min for stroke and systemic embolism prophylaxis in nonvalvular atrial fibrillation, dental procedures, aneurysm, diabetes
retinopathy, diverticulitis, endocarditis, GI bleeding, hypertension, obstetric delivery, peptic ulcer disease, stroke, surgery
Black Box Warning:
Abrupt discontinuation, epidermal/spinal anesthesia
Patients, especially those with dental disease, should be instructed in proper oral hygiene, including caution in use of regular toothbrushes, dental floss, toothpicks
Calculator
• Adult:
PO
10 mg/day × 12 days after knee replacement surgery or × 35 days after hip replacement; administer the initial dose ≥6-10 hr after surgery once hemostasis has been established
• Adult:
PO
15 mg bid with food × 21 days then 20 mg q day for a total of 6 mo, may continue after 6 mo to reduce risk
•
Unless pathological bleeding occurs, do not discontinue rivaroxaban in the absence of alternative
• Adult:
PO
20 mg/day with evening meal (CrCl >50 ml/min)
•
Discontinue warfarin and start rivaroxaban when INR is <3
•
Start rivaroxaban 0-2 hr before the next scheduled evening administration of anticoagulant (omit that dose of anticoagulant); for continuous inf of unfractionated heparin, stop the inf and initiate rivaroxaban simultaneously
•
Discontinue rivaroxaban and give the first dose of the other anticoagulant (oral or parenteral) at the time that the next dose of rivaroxaban would have been administered
Available forms:
Tabs 10, 20, 50 mg
For DVT prophylaxis:
give daily without regard to food, give initial dose ≥6-10 hr after surgery when hemostasis has been established
For stroke/systemic embolism prophylaxis
: give daily with evening meal
•
If dose is not given at correct time, give as soon as possible on the same day
GI:
Increased hepatic enzymes, hyperbilirubinemia, jaundice, nausea, cholestasis,
cytolytic hepatitis
HEMA:
Bleeding, intracranial bleeding, epidural hematoma, GI bleeding, retinal hemorrhage, adrenal bleeding, retroperitoneal hemorrhage, cerebral hemorrhage, subdural hematoma, epidural hematoma, hemiparesis, thrombocytopenia
INTEG:
Pruritus, blister, hypersensitivity,
anaphylactic reaction, anaphylactic shock
SYST:
Stevens-Johnson syndrome
Bioavailability 80%-100%, protein binding (92%-95%) albumin, excreted in urine 66% (36% unchanged, 30% metabolites), 28% in feces (7% unchanged, 21% metabolites), unchanged drug excreted in urine (via active tubular secretion, glomerular filtration); terminal elimination half-life 5-9 hr, peak 2-4 hr; increased effect in hepatic/renal disease, Japanese patients, increased terminal half-life in geriatric patients
Increase:
rivaroxaban effect, possible bleeding—ketoconazole itraconazole, ritonavir, lopinavir/ritonavir; conivaptan, clarithromycin, erythromycin, salicylates, NSAIDs, other anticoagulants, thrombolytics, platelet inhibitors, niCARdipine
Decrease:
rivaroxaban effect—carBAMazepine, phenytoin, rifampin
Increase:
rivaroxaban effect in renal impairment—telithromycin, darunavir, mifepristone, nelfinavir, pantoprazole, posaconazole, saquinavir, tamoxifen, lapatinib, azithromycin, diltiazem, verapamil, quiNIDine, ranolazine, dronedarone, amiodarone, felodipine
Decrease:
rivaroxaban effect—St. John’s wort
Increase:
rivaroxaban effect in renal disease—grapefruit juice
Decrease:
rivaroxaban effect—food
Black Box Warning:
Bleeding:
monitor for bleeding, including bleeding during dental procedures (easy bruising, blood in urine, stools, emesis, sputum, epistaxis); there is no specific antidote
Black Box Warning:
Abrupt discontinuation:
avoid abrupt discontinuation unless an alternative anticoagulant in those with atrial fibrillation; discontinuing puts patients at an increased risk of thrombotic events; if product must be discontinued for reasons other than pathological bleeding, consider administering another anticoagulant
•
Pregnancy/breastfeeding:
pregnancy category C; identify if pregnancy is suspected or planned; pregnancy related hemorrhage may occur and anticoagulation cannot be monitored with standard laboratory testing; breastfeeding should be discontinued before beginning use of this product
Black Box Warning:
Epidural/spinal anesthesia:
epidural or spinal hematomas that result in long-term or permanent paralysis may occur in patients who have received anticoagulants and are receiving neuraxial anesthesia or undergoing spinal puncture; epidural catheter should not be removed <18 hr after the last dose of rivaroxaban; do not administer the next rivaroxaban dose <6 hr after the catheter removal; delay rivaroxaban administration for 24 hr if traumatic puncture occurs; monitor for neuro changes
•
Hepatic/renal disease:
increase in effect of product in hepatic disease (Child-Pugh Class B or C), hepatic disease with coagulopathy; renal failure/severe renal impairment (creatinine clearance <30 ml/min in DVT prophylaxis and <15 ml/min for stroke or systemic embolism prophylaxis in nonvalvular atrial fibrillation); product should be discontinued in acute renal failure; reduce dose in those with atrial fibrillation and CrCl 15-50 ml/min; monitor renal function periodically (creatinine clearance, BUN)
•
Storage at room temperature
•
Prevention of DVT, stroke and systemic embolism
•
To report if pregnancy is planned or suspected, not to breastfeed
Black Box Warning:
To report bleeding (bruising, blood in urine, stools, sputum, emesis, heavy menstrual flow); use soft toothbrush, electric shaver
•
To inform all health care providers of use
Black Box Warning:
To avoid abrupt discontinuation without another blood thinner
Canada only Side effects:
italics
= common;
bold
= life-threatening Nurse Alert
(riv-as-tig′mine)
Exelon, Exelon Patch
Func. class.:
Anti-Alzheimer agent
Chem. class.:
Cholinesterase inhibitor
Potent, selective inhibitor of brain acetylcholinesterase (AChE) and butyrylcholinesterase (BChE)
Mild to moderate Alzheimer’s dementia, mild to moderate Parkinson’s disease dementia (PDD)
Unlabeled uses:
Vascular dementia, dementia with Lewy bodies, Pick’s disease
Hypersensitivity to this product, other carbamates
Precautions:
Pregnancy (B), breastfeeding, children, respiratory/cardiac/renal/hepatic disease, seizure disorder, peptic ulcer, urinary obstruction, asthma, increased intracranial pressure, surgery, GI bleeding, jaundice
Calculator
• Adult:
PO
1.5 mg bid with food; after ≥4 wk, may increase to 3 mg bid; may increase to 4.5 mg bid and thereafter 6 mg bid, max 12 mg/day;
TRANSDERMAL
apply 4.6 mg/24 hr/day, after ≥4 wk may increase to 9.5 mg/24 hr/day
Available forms:
Caps 1.5, 3, 4.5, 6 mg; sol 2 mg/ml; transdermal patch 4.6, 9.5, 13.3 mg/24 hr
•
Oral sol, caps are interchangeable
•
With meals; take with morning and evening meal even though absorption may be decreased
•
Discontinue treatment for several doses, restart at same or next lower dosage level if adverse reactions cause intolerance
•
If treatment is interrupted for more than several days, treatment should be initiated with lowest daily dose and titrated as indicated previously
•
Oral sol:
measure dose with supplied syringe; may be given undiluted or diluted in a small amount of water, fruit juice, or soda; stir diluted sol well, entire amount should be swallowed; stable for 4 hr when mixed
•
Once a day to hairless, clean, dry skin, not in an area that clothing will rub; rotate sites daily, do not apply to same site more than once q14days; remove liner; apply firmly; may be used during bathing, swimming; avoid saunas, excess sunlight or external heat such as saunas; each 5 cm
2
patch contains 9 mg base, rate of 4.6 mg/24 hr, each 10 cm
2
patch 18 mg base, rate of 9.5 mg/24 hr
CV:
QT prolongation, AV block, cardiac arrest,
angina,
MI,
palpitations
CNS:
Tremors, confusion, insomnia
, psychosis, hallucination, depression, dizziness, headache, anxiety, somnolence, fatigue, syncope, EPS, exacerbation of Parkinson’s disease
GI:
Nausea, vomiting, anorexia, abdominal distress, flatulence
, diarrhea, constipation, dyspepsia, colitis, eructation, fecal incontinence,
GI bleeding/obstruction,
GERD, gastritis,
pancreatitis
MISC:
Urinary tract infection, asthenia, increased sweating, hypertension, flulike symptoms, weight change
Rapidly and completely absorbed; metabolized to decarbamylated metabolite; half-life 1.5 hr; excreted via kidneys (metabolites); clearance lowered in geriatric patients, hepatic disease and increased with nicotine use; 40% protein binding
Increase:
synergistic effect—cholinergic agonists, other cholinesterase inhibitors
Increase:
metabolism—nicotine
Increase:
GI effects—NSAIDs
Decrease:
rivastigmine effect—anticholinergics, sedating H
1
blockers, tricyclics, phenothiazines
•
Hepatic studies: AST, ALT, alk phos, LDH, bilirubin, CBC
•
Severe GI effects:
nausea, vomiting, anorexia, weight loss, diarrhea
•
B/P, heart rate, respiration during initial treatment; hypo/hypertension should be reported
•
Cognitive/mental status:
affect, mood, behavioral changes, depression, insomnia; complete suicide assessment
•
Assistance with ambulation during beginning therapy; dizziness may occur
•
Therapeutic response: improved mood/cognition
•
About the procedure for giving oral sol; use instruction sheet provided; how to apply transdermal product, to fold in half and throw away, not to get in eyes, to wash hands after application; not to use heating pad, sauna, tanning bed
•
To notify prescriber of severe GI effects
•
That product may cause dizziness, anorexia, weight loss
•
That effect may take weeks or months
•
To notify prescriber if pregnancy is planned or suspected