citalopram (Rx) (sigh-tal'oh-pram) Function Class: Chemical Class: Antidepressant

Celexa

Selective serotonin reuptake inhibitor (SSRI) C

Pregnancy Category: Action:

Inhibits CNS neuron uptake of serotonin but not of norepinephrine; weak inhibitor of CYP450 enzyme system, making it more appealing than other products

Therapeutic Outcome: Uses:

Decreased symptoms of depression after 2-3 wk

Major depressive disorder

Unlabeled uses: Premenstrual disorders, panic disorder, social phobia, impulsive aggression in children, obsessive-compulsive disorder in adolescents, treatment of psychotic symptoms in nondepressed, demented patients, anxiety, hot flashes, menopause, adjunct in schizophrenia, PTSD Dosage and Routes Depression Adult: PO 20 mg daily am or pm, may increase if needed to 40 mg/day after 1 wk; maintenance: after 6-8 wk of initial treatment, continue for 24 wk (32 wk total), reevaluate long-term usefulness (max 60 mg/day) Hepatic dose/geriatric Adult: PO 20 mg/day, may increase to 40 mg/day if no response Panic disorder (unlabeled) Adult: PO 20-60 mg/day Premenstrual dysphoria, social phobia Adult: PO 20-40 mg/day used intermittently in premenstrual dysphoria Available forms: Tabs 10, 20, 40 mg; oral SOL 10 mg/5 ml

Adverse effects CNS: Headache, nervousness, insomnia, drowsiness, anxiety, tremor, dizziness, fatigue, sedation, poor concentration, abnormal dreams, agitation, seizures, apathy, euphoria, hallucinations, delusions, psychosis, suicidal attempts, malignant neuroleptic-like syndrome reactions CV: Hot flashes, palpitations, angina pectoris, hemorrhage, hypertension, 1st-degree tachycardia, 1st-degree AV block, bradycardia, MI, thrombophlebitis GI: Nausea, diarrhea, dry mouth, anorexia, dyspepsia, constipation, cramps, vomiting, taste changes, flatulence, decreased appetite GU: Dysmenorrhea, decreased libido, urinary frequency, urinary tract infection, amenorrhea, cystitis, impotence, urine retention INTEG: Sweating, rash, pruritus, acne, alopecia, urticaria MS: Pain, arthritis, twitching RESP: Infection, pharyngitis, nasal congestion, sinus headache, sinusitis, cough, dyspnea, bronchitis, asthma, hyperventilation, pneumonia SYST: Asthenia, viral infection, fever, allergy, chills, hyponatremia (geriatric patients)

Contraindications: Hypersensitivity Precautions: Pregnancy C, breastfeeding, geriatric, renal/hepatic disease, seizure disorder Black Box Warning: Children, suicidal ideation

Pharmacokinetics Absorption: Well absorbed Distribution: Unknown Metabolism: Liver, by CYP1A2, CYP2D6

Excretion: Kidneys, steady state 28-35 days Half-life: Unknown Pharmacodynamics: Onset: Unknown Peak: Unknown Duration: Unknown

Interactions Individual drugs Alcohol: increased CNS depression Carbamazepine, clonidine: decreased citalopram levels Lithium, trazodone: increased serotonergic effects Pimoside, ziprasidone: increased QTc interval; do not use together

NURSING CONSIDERATIONS -- Assessment  Monitor urinary retention, constipation; constipation is more likely to occur in children or geriatric  Monitor B/P (lying, standing), pulse q4hr; if systolic B/P drops 20 mm Hg, hold product and notify prescriber; take vital signs q4hr in patients with cardiovascular disease  Monitor blood studies: CBC, leukocytes, differential, cardiac enzymes if patient is receiving long-term therapy; check platelets; bleeding can occur  Monitor hepatic studies: AST, ALT, bilirubin  Assess ECG for flattening of T wave, bundle branch block, AV block, dysrhythmias in cardiac patients  Assess EPS primarily in geriatric: rigidity, dystonia, akathisia  Assess mental status: mood, sensorium, affect, suicidal tendencies; increase in psychiatric symptoms: depression, panic  Check weight qwk; appetite may increase with product  Identify patient's alcohol consumption; if alcohol is consumed, hold dose until am  Assess for withdrawal symptoms: headache, nausea, vomiting, muscle pain, weakness; usually do not occur unless product is discontinued abruptly

Nursing Diagnoses     Coping, ineffective (uses) Injury, risk for (side effects) Knowledge, deficient (teaching) Noncompliance (teaching)

Implementation     Give with food or milk for GI symptoms Give dosage at bedtime if oversedation occurs during day Leave orally disintegrating tabs on tongue and allow to dissolve before swallowing Store at room temperature; do not freeze

Drug Classifications Anticoagulants, NSAIDs, salicylates, thrombolytics: increased risk of bleeding Antidepressants (tricyclics): increased effect, use cautiously Antifungals (azole), macrolides: increased citalopram levels -Adrenergic blockers: increased plasma levels of -blockers Barbiturates, benzodiazepines, CNS depressants, sedatives/hypnotics: increased CNS depression MAOIs: hypertensive crisis, seizures, fatal reactions; do not use together Quinolones: increased QTc interval; do not use together Serotonin receptor agonists, SNRIs, SSRIs: increased serotonin syndrome Drug/Herb SAM-e, St. John's wort: serotonin syndrome; do not use with citalopram; fatal reaction may occur Yohimbe: increased CNS stimulation

Drug/Lab Test Increased: serum bilirubin, blood glucose, alkaline phosphatase Decreased: VMA, 5-HIAA False increase: increased urinary catecholamines

Patient/Family Education  Teach patient that therapeutic effects may take 4-6 wk  Teach patient how to use orally disintegrating tabs  Instruct patient to use caution in driving or other activities requiring alertness because of drowsiness, dizziness, blurred vision; to avoid rising quickly from sitting to standing, especially geriatric patients  Instruct patient to increase fluids, bulk in diet if constipation, urinary retention occur, especially geriatric  Advise that suicidal ideas, behavior may occur in children or young adults  Advise patient not to discontinue medication quickly after long-term use: may cause nausea, headache, malaise  Advise patient to take gum, hard sugarless candy, or frequent sips of water for dry mouth  Caution patient to avoid alcohol ingestion, other CNS depressants Evaluation Positive Therapeutic Outcome  Decreased in depression  Absence of suicidal thoughts

loratadine (Rx, OTC) (lor-a' ti-deen)

Claritin

Alavert, Children's Loratadine, Children's ND Non-Drowsy Allergy, Claritin, Claritin Non-Drowsy Allergy, Clear-Atadine, Dimetapp, Tavist ND Function Class: Chemical Class: Antihistamine (2nd generation) Selective histamine (H1) receptor antagonist B

Pregnancy Category:

Action:

Binds to peripheral histamine receptors, which provides antihistamine action without sedation Decreased nasal stuffiness, itching, swollen eyes

Therapeutic Outcome: Uses:

Seasonal rhinitis, chronic idiopathic urticaria for those 2 yr

Dosage and Routes Adult and Child 6 yr: Renal Dose Adult: Hepatic Dose Adult: Available forms: Adverse Effects CNS: Sedation (more common with increased dosages), headache, fatigue, restlessness CV: Sinus tachycardia RESP: Wheezing Contraindications: Hypersensitivity, acute asthma attacks, lower respiratory tract disease Precautions: Pregnancy B, increased intraocular pressure, bronchial asthma, breastfeeding, hepatic/renal disease PO 10 mg/day Child 2-5 yr: PO 5 mg/day PO CCr <30 ml/min 10 mg every other day PO 10 mg every other day

Tabs 10 mg; rapid-disintegrating tabs 10 mg; orally disintegrating tabs 10 mg; syr 1 mg/ml; susp 5 mg/ml

Pharmacokinetics Absorption: Well absorbed Excretion: Kidneys Half-life 17-28 hr Onset: 1-3 hr Peak: 8-12 hr Duration: >24 hr Distribution: Unknown Metabolism: Liver, extensively, to active metabolite desloratadine

Pharmacodynamics:

Interactions Individual Drugs Alcohol: increased CNS depression Cimetidine, ketoconazole: increased loratadine level

Drug classifications Antidepressants, antihistamines (other), sedative/hypnotics: increased CNS depression Macrolides (clarithromycin, erythromycin): increased loratadine level MAOIs: increased antihistamine effects

Drug/herb Chamomile, hops, Jamaican dogwood, kava, khat, senega, skullcap, valerian: increased CNS depression Corkwood, henbane: increased anticholinergic effect

Drug/Lab Test False Negative: skin allergy tests (discontinue antihistamine 3 days before testing)

NURSING CONSIDERATIONS -- Assessment

 Assess allergy: hives, rash, rhinitis  Assess respiratory status: rate, rhythm, increase in bronchial secretions, wheezing, chest tightness; provide fluids to 2 L/day to decrease secretion thickness  Monitor LFTs, serum creatinine/bun Nursing diagnoses  Airway clearance, ineffective (uses)  Knowledge, deficient (teaching)  Noncompliance (teaching, overuse) Implementation  Give on an empty stomach, 1 hr before or 2 hr after meals to facilitate absorption  Place rapidly disintegrating tabs on tongue, then swallow after disintegrated with or without water  Use within 6 mo of opening pouch; immediately after opening blister pack  Store in airtight, light-resistant container

Patient/family education  Teach all aspects of product uses; to notify prescriber if confusion, sedation, hypotension occur; to avoid driving and other hazardous activity if drowsiness occurs; to avoid alcohol and other CNS depressants that may potentiate effect  Teach patient to take 1 hr before or 2 hr after meals to facilitate absorption  Teach patient that hard candy, gum, frequent rinsing of mouth may be used for dryness  Advise patient to use sunscreen or stay out of the sun to prevent burns  Caution patient not to exceed recommended dosage; dysrhythmias may occur

Evaluation Positive therapeutic outcome Absence of runny or congested nose, other allergy symptoms

azithromycin (Rx) (ay-zi-thro-my'sin)

Zithromax, Zmax

Function Class:

Antiinfective B

Chemical Class: Macrolide (azalide)

Pregnancy Category:

Action: Binds to 50S ribosomal subunits of susceptible bacteria and suppresses protein synthesis; much greater spectrum of activity than erythromycin; more effective against gram-negative organisms Therapeutic Outcome: Bacteriostaticagainst the following susceptible organisms:Moraxella catarrhalis, Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus, Haemophilus influenzae, Clostridium, Legionella pneumophila, Chlamydia trachomatis, Mycoplasma; no effect on methicillin-resistant S. aureus; in children: acute otitis media (H. influenzae, M. catarrhalis, S. pneumoniae) PO, acute pharyngitis/tonsillitis (group A streptococcal) PO; acute skin/soft tissue infections (PO); community-acquired pneumonia (C. pneumoniae, H. influenzae, M. pneumoniae, S. pneumoniae) PO; pharyngitis/tonsillitis (S. pyogenes)

Uses: Mild to moderate infections of the upper respiratory tract, in children: acute otitis media, lower respiratory tract; uncomplicated skin and skin structure infections, nongonococcal urethritis, or cervicitis; prophylaxis of disseminated Mycobacterium avium complex (MAC)

Dosage and Routes Most infections Adult: PO 500 mg on day 1, then 250 mg daily on days 2-5 for a total dose of 1.5 g Child 2-15 yr: PO 10 mg/kg on day 1, then 5 mg/kg 4 days

Pelvic Inflammatory Disease Adult: PO/IV 500 mg IV q24hr 2 doses, then 500 mg PO q24hr 7-10 days Cervicitis/Chlamydia/Chancroid/Nongonococcal Urethritis/Syphilis Adult: PO 1 g single dose Gonorrhea Adult: PO 2 g single dose Endocarditis, Prophylaxis Adult: PO 500 mg 1 hr prior to procedure Child: PO 15 mg/kg 1 hr prior to procedure Community-Acquired Pneumonia Adult: PO/IV 500 mg IV q24hr 2 doses, then 500 mg PO q24hr 7-10 days Disseminated MAC Infections Adult: PO 600 mg/day in combination with ethambutol Lower respiratory tract infections, acute skin/soft tissue infections, acute pharyngitis/tonsillitis Child: PO 3-day regimen, 10 mg/kg daily 3 days Acute Otitis Media Child: PO 30 mg/kg as a single dose or 10 mg/kg daily 3 days or 10 mg/kg as a single dose on day 1, max 500 mg/day, then 5 mg/kg on days 2-5, max 250 mg/day Prevention of acute otitis media Child: PO 10 mg/kg qwk 6 mo Available forms: Tabs 250, 500, 600 mg; powder for inj 500 mg; powder for oral susp 1 g/packet; susp 100, 200 mg/5 ml

Adverse effects CNS: Dizziness, headache, vertigo, somnolence, myasthenia gravis CV: Palpitations, chest pain EENT: Hearing loss, tinnitus, loss of smell (anosmia) GI: Nausea, vomiting, diarrhea, hepatotoxicity, abdominal pain, stomatitis, heartburn, dyspepsia, flatulence, melena, cholestatic jaundice, pseudomembranous colitis, tongue discoloration GU: Vaginitis, moniliasis, nephritis HEMA: Anemia INTEG: Rash, urticaria, pruritus, photosensitivity SYST: Angioedema, Stevens-Johnson syndrome, toxic epidermal necrolysis

Contraindications: Hypersensitivity to azithromycin, erythromycin, or any macrolide Precautions: Pregnancy B, breastfeeding, child <6 mo for otitis media, child <2 yr for pharyngitis, geriatric, renal/hepatic/cardiac disease, tonsillitis

Pharmacokinetics Absorption: Rapid, (PO) up to 50% Metabolism: Unknown, minimal metabolism Distribution: Widely distributed Excretion: Unchanged (bile); kidneys, minimal Half-life: 11-70 hr

Pharmacodynamics:

PO: IV:

Onset: Unknown Onset: Unknown

Peak: 2-4 hr Peak: End of infusion

Duration: 24 hr Duration: 24 hr

Interactions Individual Drugs Bromocriptine, carbamazepine, cycloSPORINE, digoxin, disopyramide, methylPREDNISolone, phenytoin, theophylline, triazolam: increased effects of specific products Ergotamine: toxicity Pimozide: dysrhythmias; fatal reaction Triazolam: decreased clearance of triazolam Drug Classifications Aluminum, magnesium antacids: decreased levels of azithromycin Anticoagulants (orals): increased effect of oral anticoagulants Drug/Herb: Acidophilus: do not use with antiinfectives; separate by several hours Drug/Lab Test: Increased: bilirubin, alkaline phosphatase, CPK, BUN, creatinine, AST, ALT

Nursing diagnoses  Diarrhea (adverse reactions)  Infection, risk for (uses)  Knowledge, deficient (teaching)

NURSING CONSIDERATIONS -- Assessment

 Assess for signs and symptoms of infection: drainage, fever, increased WBC >10,000/mm3, urine culture positive, sore throat, sputum culture positive  Assess for superinfection: sore throat, mouth, tongue; fever, fatigue, diarrhea, anogenital pruritus  Monitor respiratory status: rate, character, wheezing, tightness in chest; discontinue product if these occur  Monitor allergies before treatment, reaction of each medication; place allergies on chart, notify all people giving products; skin eruptions, itching  Monitor I &O ratio, renal studies; report hematuria, oliguria in renal disease; check urinalysis, protein, blood  Monitor liver studies: AST, ALT, bilirubin, LDH, alkaline phosphatase; CBC with differential  Monitor C & S before product therapy; product may be taken as soon as culture is taken; C&S may be repeated after treatment  Monitor bowel pattern before, during treatment

Patient/Family Education  Instruct patient to report sore throat, black furry tongue, fever, loose foul-smelling stool, vaginal itching, discharge, fatigue; may indicate superinfection  Instruct patient to notify prescriber of diarrhea stools, dark urine, pale stools, yellow discoloration of eyes or skin, severe abdominal pain; cholestatic jaundice is a severe adverse reaction  Teach patient to complete dosage regimen; to notify prescriber if symptoms continue  Teach patient to notify prescriber if pregnancy is suspected Inform patient that sunburns may occur; wear protective clothing and sunscreen  Caution patient not to take aluminum/magnesium-containing antacids or food simultaneously with this product; blood levels of azithromycin will be decreased

Implementation PO route  Provide adequate intake of fluids (2 L) during diarrhea episodes  Give with a full glass of water; give susp 1 hr before or 2 hr after meals; tabs may be taken without regard to food; do not give with fruit juices  Store at room temperature  Reconstitute 1 g packet for susp with 60 ml water, mix, rinse glass with more water and have patient drink to consume all medication; packets not for pediatric use  Do not take aluminum/magnesium-containing antacids or food simultaneously with this product

IV route  Reconstitute 500 mg product/4.8 ml sterile water for inj (100 mg/ml), shake, dilute with 250 ml 0.9% NaCl, 0.45% NaCl, or LR to 1-2 mg/ml; diluted solution is stable for 24 hr or 7 days if refrigerated  Give 500 mg or more/1 hr, never give IM or as a bol

Evaluation Positive Therapeutic Outcome:  C & S negative for infection  WBC within 5000-10,000/mm3