Mosby's 2014 Nursing Drug Reference (72 page)

Black Box Warning:

QT prolongation, use of heating pad, accidental exposure, potential for overdose/poisoning, substance abuse

• Adult: IM/IV
0.3 mg q6hr prn, reduce dosage in geriatric patients, may repeat after 30-60 min;
EPIDURAL
(unlabeled) 4 mcg/kg or 2 mcg/kg (epidural inj);
TD
each patch is worn for 7 days (moderate-severe pain);
opioid-naive patients
(those taking <30 mg of oral morphine or equivalent before beginning treatment with TD buprenorphine), 5 mcg/hr q7days, overestimating dose can be fatal;
conversion from other opiate agonist therapy,
titrate from other opioids for up to 7 days to no more than 30 mg oral morphine or equivalent before beginning TD therapy, begin with 5 mcg/hr q7days; for those with daily dose of 30-80 mg oral morphine or equivalent, start with 10 mcg/hr q7days; for those taking >80 mg oral morphine or equivalent, start with 20 mcg/hr q7days

• Child 2-12 yr: IM/IV
2-6 mcg/kg q4-6hr

Additive compatibilities:
Bupivacaine, glycopyrrolate, haloperidol

Syringe compatibilities:
Glycopyrrolate, haloperidol, heparin, midazolam

Y-site compatibilities:
Acyclovir, alfentanil, allopurinol, amifostine, amikacin, aminocaproic acid, amphotericin B liposome (AmBisone), anidulafungin, ascorbic acid injection, atenolol, atracurium, atropine, aztreonam, benztropine, bivalirudin, bleomycin, bumetanide, butorphanol, calcium chloride/gluconate, CARBOplatin, cefamandole, ceFAZolin, cefepime, cefmetazole, cefonicid, cefoperazone, cefotaxime, cefoTEtan, cefOXitin, cefTAZidime, ceftizoxime, cefTRIAXone, cefuroxime, cephalothin, cephapirin, chloramphenicol, chlorproMAZINE, cimetidine, cisatracurium, CISplatin, cladribine, clindamycin, cyanocobalamin, cyclophosphamide, cycloSPORINE, cytarabine, D
₅
W-dextrose 5%, DACTINomycin, DAPTOmycin, dexamethasone, dexmedetomidine, digoxin, diltiazem, diphenhydrAMINE, DOBUTamine, DOCEtaxel, DOPamine, doxacurium, DOXOrubicin HCl, doxycycline, enalaprilat, ePHEDrine, EPINEPHrine, epirubicin, epoetin alfa, eptifibatide, ertapenem, erythromycin, esmolol, etoposide, famotidine, fenoldopam, fentaNYL, filgrastim, fluconazole, fludarabine, gatifloxacin, gemcitabine, gentamicin, glycopyrrolate, granisetron, heparin, hydrocortisone, hydrOXYzine, IDArubicin, ifosfamide, imipenem-cilastatin, inamrinone, insulin (regular), irinotecan, isoproterenol, ketorolac, labetalol, lactated Ringer’s injection, levofloxacin, lidocaine, linezolid, LORazepam, magnesium sulfate, mannitol, mechlorethamine, melphalan, meperidine, metaraminol, methicillin, methotrexate, methoxamine, methyldopate, methylPREDNISolone, metoclopramide, metoprolol, metroNIDAZOLE, mezlocillin, miconazole, midazolam, milrinone, minocycline, mitoXANtrone, morphine, moxalactam, multiple vitamins injection, mycophenolate mofetil, nafcillin, nalbuphine, naloxone, nesiritide, netilmicin, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, palonosetron, pamidronate, pancuronium, papaverine, PEMEtrexed, penicillin G potassium/sodium, pentamidine, pentazocine, phenylephrine, phytonadione, piperacillin, piperacillin-tazobactam, polymyxin B, potassium chloride, procainamide, prochlorperazine, promethazine, propofol, propranolol, protamine, pyridoxine, quiNIDine, ranitidine, remifentanil, Ringer’s injection, ritodrine, riTUXimab, rocuronium, sodium acetate, succinylcholine, SUFentanil, tacrolimus, teniposide, theophylline, thiamine, thiotepa, ticarcillin, ticarcillin-clavulanate, tigecycline, tirofiban, TNA (3-in-1), tobramycin, tolazoline, TPN, trastuzumab, trimetaphan, urokinase, vancomycin, vasopressin, vecuronium, verapamil, vinCRIStine, vinorelbine, voriconazole

Increase:
effect with other CNS depressants—alcohol, opioids, sedative/hypnotics, antipsychotics, skeletal muscle relaxants, MAOIs

Increase:
buprenorphine effect—CYP3A4 inhibitors (erythromycin, indinavir, ketoconazole, ritonavir, saquinavir)

Increase:
QT prolongation—class IA, III antidysrhythmics

Decrease:
buprenorphine effect—CYP3A4 inducers (carBAMazepine, PHENobarbital, phenytoin, rifampin)

Increase:
CNS depression—St. John’s wort

• 
Pain:
intensity, location, type before treatment, after 5 min (IV); need for pain medication, tolerance

• 
I&O ratio; check for decreasing output; may indicate urinary retention

• 
Bowel pattern; severe constipation can occur

• 
CNS changes, dizziness, drowsiness, hallucinations, euphoria, LOC, pupil reaction; withdrawal in opioid-dependent persons; if dependence occurs, within 2 wk of discontinuing product
withdrawal symptoms
will occur

• 
Allergic reactions: rash, urticaria

• 
Respiratory dysfunction: respiratory depression, character, rate, rhythm; notify prescriber if respirations are <12/min

Black Box Warning:

Potential for overdose may occur from chewing, swallowing, snorting, or injecting extracted product from TD formulation

Black Box Warning:

QT prolongation:
in those taking class Ia, III antidysrhythmics; patients with hypokalemia, cardiac instability (TD), max TD 20 mcg/hr q7day

• 
Therapeutic response: decrease in pain, absence of grimacing

• 
To report any symptoms of CNS changes, allergic reactions

Black Box Warning:

That psychologic dependence leading to substance abuse may result when used for extended periods; that long-term use not recommended

• 
To avoid hazardous activities such as driving unless reaction known

Black Box Warning:

Children <18 yr, suicidal thinking/behavior (young adults)

• Adult: PO
100 mg bid initially then increase after 3 days to 100 mg tid if needed, max 150 mg single dose;
ER/SR
initially 150 mg
AM
, increase to 300 mg/day if initial dose is tolerated, after no less than 4 days; after several wk, titrate to 200 mg bid; Aplenzin 174 mg q
AM
, may increase to 348 mg q
AM
on day 4, may increase to 522 mg after several weeks if needed

• Geriatric: PO
50-100 mg/day, may increase by 50-100 mg q3-4days

• Adult: SR
150 mg q day × 3 days then 150 mg bid for remainder of treatment, initiate 1-2 wk before targeted “quit day,” continue for 7-12 wk; in combination with nicotine TD, 150 mg q day × 3 days then 150 mg bid for remainder of treatment, give ≥8 hr apart, max 300 mg/day, initiate 1-2 wk before targeted “quit day,” continue for 7-12 wk, may be continued for 8-20 wk

• Adult: PO
100 mg bid, after ≥3 days titrate to 100 mg tid; SR 300 mg/day, 200 mg 8
AM
, 100 mg 4
PM

• Adult: PO
SR 150-300 mg/day

Increase:
buPROPion toxicity—ritonavir

Increase:
buPROPion level—cimetidine

Increase:
buPROPion effect—CYP2D6/CYP2B6 inhibitors

Decrease:
effect of tamoxifen

Decrease:
buPROPion effect—carBAMazepine, cimetidine, PHENobarbital, phenytoin or other products (CYP2D6); CYP2B6 inducers

Increase:
CNS depression—kava, valerian

• 
Hepatic/renal function in patients with hepatic, kidney impairment

• 
For increased risk of seizures; if patient has excessively used CNS depressants and OTC stimulants, dosage of buPROPion should not be exceeded

• 
For smoking cessation after 7-12 wk; if progress has not been made, product should be discontinued

Black Box Warning:

Mental status: mood, sensorium, affect, suicidal tendencies, increase in psychiatric symptoms

• 
Assistance with ambulation during beginning therapy because sedation occurs

• 
Safety measures, primarily for geriatric patients

• 
Therapeutic response: decreased depression, ability to perform daily activities, ability to sleep throughout the night, smoking cessation

• 
That therapeutic effects may take 2-4 wk; not to increase dose without prescriber’s approval; that treatment for smoking cessation lasts 7-12 wk

• 
To use caution when driving, performing other activities that require alertness; sedation, blurred vision may occur

• 
To avoid alcohol, other CNS depressants; alcohol may increase risk of seizures

• 
Not to use with nicotine patches unless directed by prescriber; may increase B/P

• 
To notify prescriber immediately if urinary retention occurs

• 
That risk of seizures increased when dose exceeded, if patient has seizure disorder

Black Box Warning:

That suicidal ideas, behaviors, hostility, depression may occur in children or young adults

• 
To notify prescriber if pregnancy is suspected, planned