Clopidogrel(Plavix)

Classification

Therapeutic:antiplateletagents
Pharmacologic:plateletaggregationinhibitors

Indications

Reductionofatheroscleroticevents(MI,stroke,vasculardeath)inpatientsatriskfor
sucheventsincludingrecentMI,acutecoronarysyndrome(unstableangina/nonQwave
MI),stroke,orperipheralvasculardisease.

Action

InhibitsplateletaggregationbyirreversiblyinhibitingthebindingofATPtoplatelet
receptors.
TherapeuticEffects:Decreasedoccurrenceofatheroscleroticeventsinpatientsatrisk.

Contraindications/Precautions

Contraindicatedin:Hypersensitivity;Pathologicbleeding(pepticulcer,intracranial
hemorrhage);ConcurrentuseofstrongCYP2C19inhibitors;ImpairedCYP2C19
functionduetogeneticvariation;Lactation:Lactation.

AdverseReactions/SideEffects

Incidenceofadversereactionssimilartothatofaspirin.
CNS:depression,dizziness,fatigue,headache.
EENT:epistaxis.
Resp:cough,dyspnea.
CV:chestpain,edema,hypertension.
GI:GIBLEEDING,abdominalpain,diarrhea,dyspepsia,gastritis.
Derm:pruritus,purpura,rash.
Hemat:BLEEDING,NEUTROPENIA,THROMBOTICTHROMBOCYTOPENIC
PURPURA.
Metab:hypercholesterolemia.
MS:arthralgia,backpain.
Misc:fever,hypersensitivityreactions.

Assessment

Assesspatientforsymptomsofstroke,peripheralvasculardisease,orMIperiodically
duringtherapy.

Patient/FamilyTeaching

Instructpatienttotakemedicationexactlyasdirected.
Takemisseddosesassoonaspossibleunlessalmosttimefornextdose;donot
doubledoses.
Donotdiscontinueclopidogrelwithoutconsultinghealthcareprofessional;may
increaseriskofcardiovascularevents.
AdvisepatienttoreadtheMedicationGuidebeforestartingclopidogrelandwith
eachRxrefillincaseofchanges.

Nitroglycerin
Classification

Therapeutic:antianginals
Pharmacologic:nitrals

Indications

Acute(translingual,SL,ointment)andlongtermprophylatic(oral,transdermal)
managementofanginapectoris.PO:AdjuncttreatmentofHF.IV:Adjuncttreatmentof
acuteMI.Productionofcontrolledhypotensionduringsurgicalprocedures.Treatment
ofHFassociatedwithacuteMI.

Action

Increasescoronarybloodflowbydilatingcoronaryarteriesandimprovingcollateralflow
toischemicregions.Producesvasodilation(venousgreaterthanarterial).Decreasesleft
ventricularenddiastolicpressureandleftventricularenddiastolicvolume(preload).
Reducesmyocardialoxygenconsumption.
TherapeuticEffects:Relieforpreventionofanginalattacks.Increasedcardiacoutput.
ReductionofBP.

Contraindications/Precautions

Contraindicatedin:Hypersensitivity;Severeanemia;Pericardialtamponade;Constrictive
pericarditis;Alcoholintolerance(largeIVdosesonly);ConcurrentuseofPDE5
inhibitor(sildenafil,tadalafil,vardenafil).

AdverseReactions/SideEffects

CNS:dizziness,headache,apprehension,restlessness,weakness.
EENT:blurredvision.
CV:hypotension,tachycardia,syncope.
GI:abdominalpain,nausea,vomiting.
Derm:contactdermatitis(transdermal).

Misc:alcoholintoxication(largeIVdosesonly),crosstolerance,flushing,tolerance.

Assessment

Assesslocation,duration,intensity,andprecipitatingfactorsofpatientsanginalpain.
MonitorBPandpulsebeforeandafteradministration.
PatientsreceivingIVnitroglycerinrequirecontinuousECGandBPmonitoring.
Additionalhemodynamicparametersmaybemonitored.

Patient/FamilyTeaching

Instructpatienttotakemedicationasdirected,eveniffeelingbetter.
Takemisseddosesassoonasrememberedunlessnextdoseisscheduledwithin2hr(6hr
withextendedreleasepreparations).
Donotdoubledoses.Donotdiscontinueabruptly;gradualdosereductionmaybe
necessarytopreventreboundangina.
Cautionpatienttochangepositionsslowlytominimizeorthostatichypotension.
Firstdoseshouldbetakenwhileinasittingorrecliningposition,especiallyingeriatric
patients.
Advisepatienttoavoidconcurrentuseofalcoholwiththismedication.Patientshould
alsoconsulthealthcareprofessionalbeforetakingOTCmedicationswhiletaking
nitroglycerin.

Digoxin(Lanoxin)
Classification

Therapeutic:antiarrhythmic,inotropics
Pharmacologic:digitalisglycosides

Indications

Heartfailure.Atrialfibrillationandatrialflutter(slowsventricularrate).Paroxysmal
atrialtachycardia.

Action

Increasestheforceofmyocardialcontraction.ProlongsrefractoryperiodoftheAVnode.
DecreasesconductionthroughtheSAandAVnodes.
TherapeuticEffects:Increasedcardiacoutput(positiveinotropiceffect)andslowingof
theheartrate(negativechronotropiceffect).

Contraindications/Precautions

Contraindicatedin:Hypersensitivity;Uncontrolledventriculararrhythmias
AVblock(inabsenceofpacemaker)

Diopathichypertrophicsubaorticstenosis
Constrictivepericarditis
Knownalcoholintolerance(elixironly).

AdverseReactions/SideEffects

CNS:fatigue,headache,weakness.
EENT:blurredvision,yelloworgreenvision.
CV:ARRHYTHMIAS,bradycardia,ECGchanges,AVblock,SAblock.
GI:anorexia,nausea,vomiting,diarrhea.
Hemat:thrombocytopenia.
Metab:electrolyteimbalanceswithacutedigoxintoxicity.

Assessment

Monitorapicalpulsefor1fullminbeforeadministering.
Withholddoseandnotifyhealthcareprofessionalifpulserateis<60bpminanadult,
<70bpminachild,or<90bpminaninfant.
Alsonotifyhealthcareprofessionalpromptlyofanysignificantchangesinrate,rhythm,
orqualityofpulse.

Patient/FamilyTeaching

Instructpatienttotakemedicationasdirected,atthesametimeeachday.
Teachparentsorcaregiversofinfantsandchildrenhowtoaccuratelymeasure
medication.
Takemisseddoseswithin12hrofscheduleddoseoromit.
Donotdoubledoses.
Consulthealthcareprofessionalifdosesfor2ormoredaysaremissed.
Donotdiscontinuemedicationwithoutconsultinghealthcareprofessional.

DigoxinimmuneFab(DigiFab)
Classification
Therapeutic:antidotes
Pharmacologic:antibodyfragments
Indications

Seriouslifethreateningoverdosagewithdigoxin.

Action

Anantibodyproducedinsheepthatbindsantigenicallytounbounddigoxininserum.
TherapeuticEffects:Bindingandsubsequentremovalofdigoxin,preventingtoxiceffects

inoverdose.
Contraindications/Precautions

Contraindicatedin:Noknowncontraindications.

AdverseReactions/SideEffects

CV:reemergenceofatrialfibrillation,reemergenceofHF.

Assessment

MonitorECG,pulse,BP,andbodytemperaturebeforeandduringtreatment.
Patientswithatrialfibrillationmaydeveloparapidventricularresponseasaresultof
decreaseddigoxinlevels.
AssesspatientforincreaseinsignsofHF(peripheraledema,dyspnea,rales/crackles,
weightgain).

Patient/FamilyTeaching

Explaintheprocedureandpurposeofthetreatmenttothepatient.
Instructpatienttonotifyhealthcareproviderimmediatelyifsignsofdelayedallergic
reaction(rash,pruritus,urticaria)occurafterhospitaldischarge.

Carvedilol(Coreg)
Classification

Therapeutic:antihypertensives
Pharmacologic:betablockers

Indications

Hypertension.HF(ischemicorcardiomyopathic)withdigoxin,diuretics,andACE
inhibitors.
Leftventriculardysfunctionaftermyocardialinfarction.

Action

Blocksstimulationofbeta1(myocardial)andbeta2(pulmonary,vascular,anduterine)
adrenergicreceptorsites.
Alsohasalpha1blockingactivity,whichmayresultinorthostatichypotension.
TherapeuticEffects:DecreasedheartrateandBP.Improvedcardiacoutput,slowingof
theprogressionofHFanddecreasedriskofdeath.

Contraindications/Precautions

Contraindicatedin:Historyofserioushypersensitivityreaction(StevensJohnson
syndrome,angioedema,anaphylaxis)
Pulmonaryedema
Cardiogenicshock
Bradycardia,heartblockorsicksinussyndrome(unlessapacemakerisinplace)
UncompensatedHFrequiringIVinotropicagents(weanbeforestartingcarvedilol)
Severehepaticimpairment;Asthmaorotherbronchospasticdisorders.

AdverseReactions/SideEffects

CNS:dizziness,fatigue,weakness,anxiety,depression,drowsiness,insomnia,memory
loss,mentalstatuschanges,nervousness,nightmares.
EENT:blurredvision,dryeyes,intraoperativefloppyirissyndrome,nasalstuffiness.
Resp:bronchospasm,wheezing.
CV:BRADYCARDIA,HF,PULMONARYEDEMA.
GI:diarrhea,constipation,nausea.
GU:erectiledysfunction,plibido.
Derm:STEVENSJOHNSONSYNDROME,TOXICEPIDERMALNECROLYSIS,
itching,rashes,urticaria.
Endo:hyperglycemia,hypoglycemia.
MS:arthralgia,backpain,musclecramps.
Neuro:paresthesia.
Misc:ANAPHYLAXIS,ANGIOEDEMA,druginducedlupussyndrome.

Assessment

MonitorBPandpulsefrequentlyduringdoseadjustmentperiodandperiodicallyduring
therapy.
Assessfororthostatichypotensionwhenassistingpatientupfromsupineposition.
Monitorintakeandoutputratiosanddailyweight.Assesspatientroutinelyforevidence
offluidoverload(peripheraledema,dyspnea,rales/crackles,fatigue,weightgain,jugular
venousdistention).Patientsmayexperienceworseningofsymptomsduringinitiationof
therapyforHF.

Patient/FamilyTeaching

Instructpatienttotakemedicationasdirected,atthesametimeeachday,eveniffeeling
well.Donotskipordoubleuponmisseddoses.Takemisseddosesassoonaspossible
upto4hrbeforenextdose.Abruptwithdrawalmayprecipitatelifethreatening
arrhythmias,hypertension,ormyocardialischemia.
Advisepatienttomakesureenoughmedicationsavailableforweekends,holidays,and
vacations.Awrittenprescriptionmaybekeptinwalletincaseofemergency.
TeachpatientandfamilyhowtocheckpulseandBP.Instructthemtocheckpulsedaily
andBPbiweekly.Advisepatienttoholddoseandcontacthealthcareprofessionalif

pulseis<50bpmorBPchangessignificantly.
Maycausedrowsinessordizziness.
Cautionpatientstoavoiddrivingorotheractivitiesthatrequirealertnessuntilresponse
tothedrugisknown.

Losartan(Cozaar)
Classification

Therapeutic:antihypertensives
Pharmacologic:angiotensinIIreceptorantagonists

Indication

Aloneorwithotheragentsinthemanagementofhypertension.
Treatmentofdiabeticnephropathyinpatientswithtype2diabetesandhypertension
(irbesartanandlosartanonly).
ManagementofHF(NewYorkHeartAssociationclassIIIV)inpatientswhocannot
tolerateACEinhibitors(candesartanandvalsartanonly)orincombinationwithanACE
inhibitorandbetablocker(candesartanonly).
Preventionofstrokeinpatientswithhypertensionandleftventricularhypertrophy
(losartanonly).
Reductionofriskofdeathfromcardiovascularcausesinpatientswithleftventricular
systolicdysfunctionafterMI(valsartanonly).
Reductionofriskofmyocardialinfarction,stroke,orcardiovasculardeathinpatients>55
yrwhoareathighriskforcardiovasculareventsandareunabletotakeACEinhibitors
(telmisartanonly).

Action

BlocksvasoconstrictorandaldosteroneproducingeffectsofangiotensinIIatreceptor
sites,includingvascularsmoothmuscleandtheadrenalglands
TherapeuticEffects:LoweringofBP.Slowedprogressionofdiabeticnephropathy
(irbesartanandlosartanonly).
ReducedcardiovasculardeathandhospitalizationsduetoHFinpatientswithHF(can
desartanandvalsartanonly).
Decreasedriskofcardiovasculardeathinpatientswithleftventricularsystolic
dysfunctionwhoarepostMI(valsartanonly).
Decreasedriskofstrokeinpatientswithhypertensionandleftventricularhypertrophy
(effectmaybelessinblackpatients)(losartanonly).

Contraindications/Precautions

Hypersensitivity
OB:Cancauseinjuryordeathoffetus
Lactation:Discontinuedrugorprovideformula.

AdverseReactions/SideEffects

CNS:dizziness,anxiety,depression,fatigue,headache,insomnia,weakness.
CV:hypotension,chestpain,edema,tachycardia.
Derm:rashes.
EENT:nasalcongestion,pharyngitis,rhinitis,sinusitis.
GI:abdominalpain,diarrhea,druginducedhepatitis,dyspepsia,nausea,vomiting.
GU:impairedrenalfunction.
FandE:hyperkalemia.
MS:arthralgia,backpain,myalgia.
Misc:ANGIOEDEMA.

Assessment

AssessBP(lying,sitting,standing)andpulseperiodicallyduringtherapy.
Notifyhealthcareprofessionalofsignificantchanges
Monitorfrequencyofprescriptionrefillstodetermineadherence.

Patient/FamilyTeaching

Emphasizetheimportanceofcontinuingtotakeasdirected,eveniffeelingwell.
Takemisseddosesassoonasrememberedifnotalmosttimefornextdose;
Donotdoubledoses.
Instructpatienttotakemedicationatthesametimeeachday.
Warnpatientnottodiscontinuetherapyunlessdirectedbyhealthcareprofessional.
Cautionpatienttoavoidsaltsubstitutescontainingpotassiumorfoodcontaininghigh
levelsofpotassiumorsodiumunlessdirectedbyhealthcareprofessional.SeeAppendix
M.
Cautionpatienttoavoidsuddenchangesinpositiontodecreaseorthostatichypotension.
Useofalcohol,standingforlongperiods,exercising,andhotweathermayincrease
orthostatichypotension.
Maycausedizziness.
Cautionpatienttoavoiddrivingorotheractivitiesrequiringalertnessuntilresponseto
medicationisknown.
InstructpatienttonotifyhealthcareprofessionalofallRxorOTCmedications,vitamins,
orherbalproductsbeingtakenandconsulthealthcareprofessionalbeforetakinganynew
medications,especiallycough,cold,orallergyremedies.
Instructpatienttonotifyhealthcareprofessionalofmedicationregimenpriortotreatment
orsurgery.

Trimethoprim/sulfamethoxazole(BactrimDS)
Classification

Therapeutic:antiinfective
Pharmacologic:angiotensinIIreceptorantagonists

Indication

Treatmentof:Bronchitis,Shigellaenteritis,Otitismedia,Pneumocystisjirovecii
pneumonia(PCP),Urinarytractinfections,Travelersdiarrhea.
PreventionofPCPinHIVpositivepatients.
UnlabeledUse:Biliarytractinfections,osteomyelitis,burnandwoundinfections,
chlamydialinfections,endocarditis,gonorrhea,intraabdominalinfections,nocardiosis,
rheumaticfeverprophylaxis,sinusitis,eradicationofmeningococcalcarriers,prophylaxis
ofurinarytractinfections,andanalternativeagentinthetreatmentofchancroid.
Preventionofbacterialinfectionsinimmunosuppressedpatients.

Action
Combinationinhibitsthemetabolismoffolicacidinbacteriaattwodifferentpoints.
TherapeuticEffects:Bactericidalactionagainstsusceptiblebacteria.

Contraindications/Precautions
Hypersensitivitytosulfonamidesortrimethoprim
Megaloblasticanemiasecondarytofolatedeficiency
Severerenalimpairment;

AdverseReactions/SideEffects

CV:hypotension
CNS:fatigue,hallucinations,headache,insomnia,mentaldepression,kernicterusin
neonates.
FandE:hyperkalemia.
GI:PSEUDOMEMBRANOUSCOLITIS,HEPATICNECROSIS,nausea,vomiting,
diarrhea,stomatitis,hepatitis,cholestaticjaundice,pancreatitis.
GU:crystalluria.
Derm:TOXICEPIDERMALNECROLYSIS,rash,photosensitivity.
Hemat:AGRANULOCYTOSIS,APLASTICANEMIA,hemolyticanemia,leukopenia,
megaloblasticanemia,thrombocytopenia.
Local:phlebitisatIVsite.
Misc:allergicreactionsincludingERYTHEMAMULTIFORME,STEVENSJOHNSON
SYNDROME,fever.

Assessment

Assessforinfection(vitalsigns;appearanceofwound,sputum,urine,andstool;WBC)at
beginningofandduringtherapy.
Obtainspecimensforcultureandsensitivitybeforeinitiatingtherapy.
Firstdosemaybegivenbeforereceivingresults.
InspectIVsitefrequently.Phlebitisiscommon.

Patient/FamilyTeaching

Instructpatienttotakemedicationaroundtheclockandtofinishdrugcompletelyas
directed,eveniffeelingwell.
Takemisseddosesassoonasrememberedunlessalmosttimefornextdose.
Advisepatientthatsharingofthismedicationmaybedangerous.