B

INTRODUCTION

Indications

PO: Treatment of reversible spasticity due to multiple sclerosis or spinal cord lesions. Intrathecal: Treatment of severe spasticity originating in the spinal cord. Unlabeled Use: Management of pain in trigeminal neuralgia.

Action

Inhibits reflexes at the spinal level. Therapeutic Effects: Decreased muscle spasticity; bowel and bladder function may also be improved.

Adverse Reactions/Side Effects

CNS: SEIZURES (IT), dizziness, drowsiness, fatigue, weakness, confusion, depression, headache, insomnia. EENT: nasal congestion, tinnitus. CV: edema, hypotension. GI: nausea, constipation. GU: frequency. Derm: pruritus, rash. Metab: hyperglycemia, weight gain. Neuro: ataxia. Misc: hypersensitivity reactions, sweating.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Be alert for new seizures or increased seizure activity, especially during intrathecal (spinal) administration. Document the number, duration, and severity of seizures, and report these findings immediately to the physician.

• Assess patient's spasticity, ROM, functional ability, and posture (e.g., head control and trunk stability), especially when beginning baclofen treatment or during dose adjustments. Communicate with physician, family/caregivers, and other health professionals to determine if dosage is helping achieve desired functional outcomes.

• During intrathecal administration:

  • Monitor patient closely during initial (test) doses and titration. Resuscitative equipment should be immediately available for life-threatening or intolerable side effects.

  • Monitor sudden changes in spasticity, muscle strength, or CNS symptoms (confusion, somnolence, agitation, hallucinations) that might indicate pump malfunction.

  • Make sure patient and caregivers understand how to protect the pump and catheter, and adhere to an appropriate schedule for pump refills.

• Assess dizziness, drowsiness, and ataxia that might affect gait, balance, transfers, and other functional activities (See Appendix C). Report balance problems and functional limitations to the physician, and caution the patient and family/caregivers to guard against falls and trauma.

• Monitor signs of hypersensitivity reactions, including pulmonary symptoms (tightness in the throat and chest, wheezing, cough, dyspnea) or skin reactions (rash, pruritus, urticaria). Notify physician immediately if these reactions occur.

• Assess blood pressure periodically and compare to normal values (See Appendix F). Report low blood pressure (hypotension), especially if patient experiences dizziness, fatigue, or other symptoms.

• Assess peripheral edema using girth measurements, volume displacement, and measurement of pitting edema (See Appendix N). Report increased swelling in feet and ankles or a sudden increase in body weight due to fluid retention.

• Be alert for signs of hyperglycemia, including confusion, drowsiness, flushed/dry skin, fruit-like breath odor, rapid/deep breathing, polyuria, loss of appetite, and unusual thirst. Patients with diabetes mellitus should check blood glucose levels frequently.

• Monitor changes in mood and behavior including confusion and depression. Report these changes to the physician.

• If treating trigeminal neuralgia, use appropriate pain scales (visual analogue scales, others) to document whether this drug is successful in helping manage the patient's pain.

• Assess body weight periodically, and report a rapid or unexplained weight gain.

Interventions

• Implement aggressive therapeutic exercises (neuromuscular reeducation, postural stabilization, gait training, and/or other task-specific training) to help patient adjust to reduced spasticity and tone.

• Guard against falls and trauma due to sedation, dizziness, or abnormally low tone in the trunk and lower extremities.

• To minimize orthostatic hypotension, patient should move slowly when assuming a more upright position.

Patient/Client-Related Instruction

• Advise patient to avoid alcohol and other CNS depressants because of the increased risk of sedation and adverse effects.

• Caution patient and caregivers against abrupt baclofen withdrawal because it may precipitate an acute withdrawal reaction (hallucinations, increased spasticity, seizures, mental changes, restlessness). Baclofen should be discontinued gradually 2 wk or longer.

• Instruct patient or family/caregivers to report other bothersome side effects such as severe or prolonged headache, sleep loss, nasal congestion, ringing/buzzing in the ears (tinnitus), increased urination, skin reactions (rash, itching, sweating), or GI problems (nausea, constipation).

Pharmacokinetics

Absorption: Well absorbed after oral administration.

Distribution: Widely distributed; crosses the placenta.

Metabolism and Excretion: 70–80% eliminated unchanged by the kidneys.

Half-life: 2.5–4 hr.

Contraindications/Precautions

Contraindicated in: Hypersensitivity; Orally disintegrating tablets contain aspartame and should not be used in patients with phenylketonuria.

Use Cautiously in: Patients in whom spasticity maintains posture and balance; Patients with epilepsy (may ↓ seizure threshold); Renal impairment (↓ dose may be required); OB/Lactation/Pedi: Safety not established; Geri: Geriatric patients are at ↑ risk of CNS side effects.

Interactions

Drug-Drug: ↑ CNS depression with other CNS depressants, including alcohol, antihistamines, opioid analgesics, and sedative/hypnotics. Use with MAO inhibitors may lead to ↑ CNS depression or hypotension.

Drug-Natural: Concomitant use of kava, valerian, or chamomile can ↑ CNS depression.

Route/Dosage

PO (Adults): 5 mg 3 times daily. May increase q 3 days by 5 mg/dose up to 80 mg/day (some patients may have a better response to 4 divided doses).

Intrathecal (Adults): 100–800 mcg/day infusion; dose is determined by response during screening phase.

Intrathecal (Children): 25–1200 mcg/day infusion (average 275 mcg/day); dose is determined by response during screening phase.

Availability (generic available)

Tablets: 10 mg, 20 mg. Orally disintegrating tablets (Kemstro) (orange): 10 mg, 20 mg.

Intrathecal injection: 50 mcg/mL, 500 mcg/mL, 2000 mcg/mL.

INTRODUCTION

Indications

Treatment of mild-to-moderately active ulcerative colitis.

Action

Drug is metabolized in the colon to mesalamine (5-aminosalicylic acid), which is a local anti-inflammatory. Therapeutic Effects: Reduction in the symptoms of ulcerative colitis.

Adverse Reactions/Side Effects

GI: HEPATOTOXICITY, abdominal pain, diarrhea.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Be alert for signs of hepatotoxicity, including anorexia, abdominal pain, severe nausea and vomiting, yellow skin or eyes, fever, sore throat, malaise, weakness, facial edema, lethargy, and unusual bleeding or bruising. Notify physician of these signs immediately.

Patient/Client-Related Instruction

• Advise patient to avoid alcohol and foods that may cause an increase in GI irritation.

• Instruct patient to report troublesome GI effects such as diarrhea and abdominal pain.

Pharmacokinetics

Absorption: Absorption is low and variable; drug is delivered intact to the colon.

Distribution: Mostly delivered intact to the colon; remainder of distribution unknown.

Protein Binding: ≥99%.

Metabolism and Excretion: Following delivery to the colon, bacteria break balsalazide down into mesalamine (5-aminosalicylic acid) and an inactive metabolite; mostly excreted in feces.

Half-life: Mesalamine—12 hr (range 2–15 hr).

Contraindications/Precautions

Contraindicated in: Hypersensitivity to salicylates or other metabolites.

Use Cautiously in: Pyloric stenosis (may have prolonged gastric retention of capsules); OB: Use only if clearly needed; Lactation/Pedi: Safety not established.

Interactions

Drug-Drug: None known.

Route/Dosage

PO (Adults): 3 750-mg capsules 3 times daily for 8–12 wk.

PO (Children 5–17 yr): 3 750-mg capsules 3 times daily for up to 8 wk or 1 750-mg capsule 3 times daily for up to 8 wk.

Availability

Capsules: 750 mg.

INTRODUCTION

Indications

Prevention of acute organ rejection in patients undergoing renal transplantation; used with corticosteroids and cyclosporine.

Action

Binds to and blocks specific interleukin-2 (IL-2) receptor sites on activated T lymphocytes. Therapeutic Effects: Prevention of acute organ rejection following renal transplantation.

Adverse Reactions/Side Effects

Noted for patients receiving corticosteroids and cyclosporine in addition to basiliximab

CNS: dizziness, headache, insomnia, weakness. EENT: abnormal vision, cataracts. Resp: coughing. CV: HEART FAILURE, edema, hypertension, angina, arrhythmias, hypotension. GI: abdominal pain, constipation, diarrhea, dyspepsia, moniliasis, nausea, vomiting, GI bleeding, gingival hyperplasia, stomatitis. Derm: acne, wound complications, hypertrichosis, pruritus. Endo: hyperglycemia, hypoglycemia. F and E: acidosis, hypercholesterolemia, hyperkalemia, hyperuricemia, hypocalcemia, hypokalemia, hypophosphatemia. Hemat: bleeding, coagulation abnormalities. MS: back pain, leg pain. Neuro: tremor, neuropathy, paresthesia. Misc: HYPERSENSITIVITY REACTIONS, INCLUDING ANAPHYLAXIS, infection, weight gain, chills.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Be alert for signs of hypersensitivity reactions and anaphylaxis, including pulmonary symptoms (tightness in the throat and chest, wheezing, cough, dyspnea) or skin reactions (rash, pruritus, urticaria). Notify physician or nursing staff immediately if these reactions occur.

• Watch for signs of heart failure, including dyspnea, rales/crackles, peripheral edema, jugular venous distention, and exercise intolerance. Report these signs to the physician immediately.

• Monitor signs of GI bleeding (abdominal pain, vomiting blood, blood in stools, black/tarry stools) or other coagulation problems (bleeding gums, nosebleed, excessive bruising). Report these signs to the physician or nursing staff immediately.

• Assess blood pressure (BP) and compare to normal values (See Appendix F). Report changes in BP, either a problematic decrease in BP (hypotension) or a sustained increase in BP (hypertension).

• Assess heart rate, ECG, and heart sounds, especially during exercise (See Appendices G, H). Report any ECG abnormalities or signs of arrhythmias, including palpitations, chest discomfort, shortness of breath, fainting, and fatigue/weakness.

• Assess peripheral edema using girth measurements, volume displacement, and measurement of pitting edema (See Appendix N). Report increased swelling of feet and ankles or a sudden increase in body weight due to fluid retention.

• Monitor signs of hypoglycemia (weakness, malaise, irritability, fatigue) or hyperglycemia (drowsiness, fruity breath, increased urination, unusual thirst). Patients with diabetes mellitus should check blood glucose levels frequently.

• Be alert for signs of paresthesia and neuropathy, including numbness, tingling, and muscle weakness. Establish baseline electroneuromyographic values at the beginning of drug treatment whenever possible, and reexamine these values periodically to document drug-induced changes in peripheral nerve function.

• Monitor neuromuscular signs of acid-base imbalance (acidosis, alkalosis) or electrolyte imbalances (hypocalcemia, hypokalemia, hyperkalemia, hypomagnesemia, hypophosphatemia, hyponatremia), including headache, lethargy, irritability, insomnia, confusion, weakness, cramping, tremors, and changes in muscle excitability. Notify physician immediately if these signs occur.

• Assess any back or leg to rule out musculoskeletal pathology; that is, try to determine if pain is drug induced rather than caused by anatomic or biomechanical problems.

• Assess dizziness or weakness that might affect gait, balance, and other functional activities (See Appendix C). Report balance problems and functional limitations to the physician and nursing staff, and caution the patient and family/caregivers to guard against falls and trauma.

• Periodically assess body weight and other anthropometric measures (body mass index, body composition). Report a rapid or unexplained weight gain or increased body fat.

Interventions

• Implement appropriate strengthening, aerobic, and other therapeutic exercises to improve function and promote recovery following organ transplants.

• Because of the risk of arrhythmias and abnormal BP responses, use caution during aerobic exercise and other forms of therapeutic exercise. Assess exercise tolerance frequently (BP, heart rate, fatigue levels), and terminate exercise immediately if any untoward responses occur (See Appendix L).

Patient/Client-Related Instruction

• Because of immunosuppressant effects, advise patient to guard against infection (frequent hand washing, etc.) and to avoid crowds and contact with persons with contagious diseases.

• Advise patient that wound healing may be delayed; instruct patient to check skin regularly and report any nonhealing sores.

• Advise patient that this drug may cause problems in fat metabolism (hyperlipidemia). Remind patient that periodic blood tests may be needed to monitor plasma lipids.

• Instruct patient to report other bothersome side effects such as severe or prolonged headache, sleep loss, vision disturbances, cough, infections, chills, skin reactions (itching, acne), or GI problems (nausea, vomiting, diarrhea, constipation, indigestion, abdominal pain, infection/inflammation in or around the mouth).

Pharmacokinetics

Absorption: IV administration results in complete bioavailability.

Distribution: Unknown.

Metabolism and Excretion: Unknown.

Half-life: 7.2 days.

Contraindications/Precautions

Contraindicated in: Hypersensitivity; OB: May affect fetal developing immune system; Lactation: May enter breast milk.

Use Cautiously in: Women with childbearing potential; Geri: Due to greater incidence of infection.

Interactions

Drug-Drug: Immunosuppression may be ↑ with other immunosuppressants.

Drug-Natural: Concomitant use with echinacea and melatonin may interfere with immunosuppression.

Route/Dosage

IV (Adults and Children ≥35 kg): 20 mg given 2 hr before transplantation; repeated 4 days after transplantation. Second dose should be withheld if complications or graft loss occurs.

IV (Children <35 kg): 10 mg given 2 hr before transplantation; repeated 4 days after transplantation. Second dose should be withheld if complications or graft loss occurs.

Availability

Powder for reconstitution: 20 mg/vial, 10 mg/vial.

INTRODUCTION

Indications

Treatment of lower extremity diabetic neuropathic ulcers extending to subcutaneous tissue or beyond and having adequate blood supply.

Action

Promotes chemotaxis of cells involved in wound repair and enhances formation of granulation tissue. Therapeutic Effects: Improved healing.

Adverse Reactions/Side Effects

Derm: erythematous rash at application site. Misc: MALIGNANCY (MAY LEAD TO ↑ MORTALITY, ESPECIALLY WITH USE OF ≥3 TUBES).

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Assess the size, depth, color, drainage, and periwound area to help document whether drug therapy is successful in promoting wound healing.

• Monitor any new or increased skin reactions at the site of application, including rash, redness, and irritation. Be especially alert for any abnormal growth of tissues in/around the wound. Report any suspicious skin reactions to the physician.

Interventions

• Implement wound-care procedures (whirlpool, pulsed lavage, gentle débridement) as needed to cleanse ulcers. Make sure the drug is reapplied and dressings are changed according to the recommended procedures.

• When indicated, use appropriate physical agents (ultrasound, electric stimulation, ultraviolet light) to facilitate wound healing and augment drug effects.

• Use assistive devices (walker, crutches) as needed to minimize weight bearing and help protect foot ulcers.

Patient/Client-Related Instruction

• Check that the patient and family or caregivers understand topical application and wound-care procedures, and adhere to the recommended dosing schedule.

• Instruct patient and family/caregivers about proper footwear, hygiene, and visual inspection to prevent recurrence or development of new ulcers.

Pharmacokinetics

Absorption: Minimal absorption (<3%).

Distribution: Action is primarily local.

Metabolism and Excretion: Unknown.

Half-life: Unknown.

Contraindications/Precautions

Contraindicated in: Known hypersensitivity to becaplermin or parabens; Known neoplasm at site of application; Wounds that close by primary intention.

Use Cautiously in: Known malignancy; OB/Lactation/Pedi: Safety not established.

Interactions

Drug-Drug: None known.

Route/Dosage

Topical (Adults): Length of gel in inches from 15- or 7.5-g tube = length × width of ulcer area × 0.6; from the 2-g tube = length × width of ulcer area × 1.3. Length of gel in centimeters from 15- or 7.5-g tube = length × width of ulcer area ÷ 4; from the 2-g tube = length × width of ulcer area ÷ 2; for 12 hr each day.

Availability

Gel: 100 mcg/g (0.01%) in 2-, 7.5-, and 15-g tubes Rx.

INTRODUCTION

Indications

Maintenance treatment of asthma as prophylactic therapy. May decrease requirement for or eliminate use of systemic corticosteroids in patients with asthma.

Action

Potent, locally acting anti-inflammatory and immune modifier. Therapeutic Effects: Decreases frequency and severity of asthma attacks. Improves asthma symptoms.

Adverse Reactions/Side Effects

CNS: headache. EENT: cataracts, dysphonia, oropharyngeal fungal infections, pharyngitis, rhinitis, sinusitis. Resp: bronchospasm, cough, wheezing. Endo: adrenal suppression (increased dose, long-term therapy only), decreased growth (children). MS: back pain.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Assess pulmonary function periodically by measuring lung volumes, breath sounds, respiratory rate, and other symptoms (wheezing, dyspnea, shortness of breath) (See Appendices I, J, K). Report changes in pulmonary function to help document the effects of drug therapy in treating asthma.

• Observe for paradoxical bronchospasm (cough, wheezing, dyspnea), especially at higher or excessive doses. If condition occurs, advise patient to withhold medication and notify physician immediately.

• Assess muscle strength periodically during long-term use. Although inhalation reduces the risk of systemic musculoskeletal damage, some degree of weakness and bone loss may still occur during prolonged, extensive use.

• Assess any back pain to rule out musculoskeletal pathology; that is, try to determine if pain is drug induced rather than caused by anatomic or biomechanical problems.

• Report signs of adrenal suppression, including hypotension, weight loss, weakness, nausea, vomiting, anorexia, lethargy, confusion, and restlessness.

• Assess growth rate in children receiving chronic therapy; report delayed or stunted growth to the physician.

Interventions

• Implement resistive exercises and weight-bearing activities to minimize muscle wasting and osteoporosis. Use caution to prevent musculoskeletal damage in patients with preexisting muscle and bone loss.

• Design and implement appropriate aerobic exercise and respiratory muscle–training programs to maintain optimal cardiovascular and pulmonary function. Work with patient and family/caregivers to find forms of exercise (e.g., swimming) that can help improve respiratory function without triggering asthma attacks.

• Protect skin from breakdown, especially over bony prominences.

Patient/Client-Related Instruction

• Counsel patient on proper use of metered-dose inhaler; observe use of this device whenever possible to ensure proper technique.

• Advise patient to not exceed the recommended dose or frequency of inhalations. Contact physician immediately if bronchospasm is not relieved by medication or is accompanied by severe headache or other symptoms.

• Caution patient not to use this drug to treat acute symptoms. A rapid-acting inhaled beta-adrenergic bronchodilator is typically used for relief of acute asthma attacks.

• Instruct patient to report any loss of vision that might indicate cataracts or increased intraocular pressure.

• Advise patient that corticosteroids cause immunosuppression and may mask symptoms of infection. Instruct patient to avoid people with known contagious illnesses and to report possible infections immediately.

• Advise patient about the likelihood of upper respiratory tract infection or irritation, including pharyngitis, sinusitis, rhinitis, and problems with vocalization (dysphonia). Instruct patient to report severe or prolonged upper respiratory problems to the physician.

• Advise patients on long-term treatment to consult physician before stopping this medication. Stopping the medication suddenly may result in adrenocortical shock (severe hypotension, hypoglycemia, weakness, vomiting). If these signs appear, notify health care professional immediately; may be life threatening.

• Instruct patient and family/caregivers to report other troublesome side effects such as severe or prolonged headache.

Pharmacokinetics

Absorption: 20%. Action is primarily local following inhalation.

Distribution: Crosses the placenta and enters breast milk in small amounts.

Metabolism and Excretion: Following inhalation, beclomethasone dipropionate is primarily converted to beclomethasone 17–monopropionate (active metabolite); primarily excreted in feces (<10% excreted in urine).

Half-life: 2.8 hr.

Contraindications/Precautions

Contraindicated in: Hypersensitivity (product contains alcohol); Acute attack of asthma/status asthmaticus.

Use Cautiously in: Active untreated infections; Diabetes or glaucoma; Underlying immunosuppression (due to disease or concurrent therapy); Systemic corticosteroid therapy (should not be abruptly discontinued when inhalable therapy is started; additional corticosteroids needed in stress or trauma); OB/Lactation: Safety not established; Pedi: Safety not established in children <5 yr; prolonged or high-dose therapy may lead to complications.

Interactions

Drug-Drug: None known.

Route/Dosage

Inhalation (Adults and Children ≥12 yr): Previously on bronchodilators alone—40–80 mcg twice daily (not to exceed 320 mcg twice daily). Previously on inhaled corticosteroids—40–160 mcg twice daily (not to exceed 320 mcg twice daily).

Inhaln (Children 5–11 yr): Previously on bronchodilators alone—40 mcg twice daily (not to exceed 80 mcg twice daily). Previously on inhaled corticosteroids—40 mcg twice daily (not to exceed 80 mcg twice daily).

Availability

Inhalation aerosol: 40 mcg/metered inhalation in 7.3-g canister (delivers 100 metered inhalations), 80 mcg/metered inhalation in 7.3-g canister (delivers 100 metered inhalations).

INTRODUCTION

Indications

Treatment of active autoantibody-positive systemic lupus erythematosus (SLE) in patients currently receiving standard therapy.

Action

A monoclonal antibody produced by recombinant DNA technique that specifically binds to B-lymphocyte stimulator protein (BLyS), thereby inactivating it. Therapeutic Effects: ↓ survival of B cells, including autoreactive ones and ↓ differentiation into immunoglobulin-producing plasma cells. Result is ↓ disease activity with lessened damage/improvement in mucocutaneous, musculoskeletal, and immunologic manifestations of SLE.

Adverse Reactions/Side Effects

CNS: depression, insomnia, migraine. GI: nausea, diarrhea. GU: cystitis. Hemat: leukopenia. MS: extremity pain. Misc: allergic reactions including ANAPHYLAXIS, INFECTION, infusion reactions, fever.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Monitor signs of allergic reactions and anaphylaxis, including pulmonary symptoms (tightness in the throat and chest, wheezing, cough, dyspnea) or skin reactions (rash, pruritus, urticaria, dermatitis). Be especially alert for responses that occur during and after administration (infusion-related reactions). Notify physician or nursing staff immediately if these reactions occur.

• Be alert for signs of leukopenia and infections, including fever, sore throat, mucosal lesions, chills, nausea, vomiting, diarrhea, and localized inflammation. Notify physician or nursing staff of these signs immediately.

• Periodically assess symptoms of SLE such as joint pain/stiffness, muscle weakness, fatigue, skin lesions (rashes, bruising), Raynaud-like symptoms (decreased circulation to the fingers and toes), and changes in mood and behavior (depression, anxiety, memory deficits). Document whether drug therapy is successful in reducing these symptoms.

• Monitor personality changes, including depression and increased thoughts of suicide. Notify physician if these changes become problematic.

• Assess any extremity pain to rule out musculoskeletal pathology; that is, try to determine if pain is drug induced rather than caused by anatomic or biomechanical problems.

Interventions

• Design and implement strengthening activities, cardiac conditioning, and other therapeutic exercises as tolerated to maintain function and complement drug effects in patients with SLE.

Patient/Client-Related Instruction

• Advise patient to guard against infection (frequent hand washing, etc.) and to avoid crowds and contact with persons with contagious diseases.

• Instruct patient to report other troublesome side effects such as prolonged or severe insomnia, migraine headaches, bladder pain/irritation, fever, or GI problems (nausea, diarrhea).

Pharmacokinetics

Absorption: IV administration results in complete bioavailability.

Distribution: Unknown

Metabolism and Excretion: Unknown

Half-life: 19.4 days

Contraindications/Precautions

Contraindicated in: Hypersensitivity; Concurrent use of other biologicals or cyclophosphamide; Concurrent use of live vaccines; Lactation: Breast-feeding not recommended.

Use Cautiously in: Infections (consider temporary withdrawal for acute infections, treat aggressively); Previous history of depression or suicidal ideation (may worsen); Geri: May be more sensitive to drug effects, consider age-related changes in renal, hepatic, and cardiac function, concurrent drug therapy, and chronic disease states; OB: Use during pregnancy only if potential maternal benefit outweighs potential fetal risk; women with childbearing potential should use adequate contraception during and for 4 mo following treatment.

Interactions

Drug-Drug: ↑ risk of adverse reactions and ↓ immune response to live vaccines; should not be given concurrently.

Route/Dosage

PO (Adults): 10 mg/kg every 2 wk for 3 doses, then every 4 wk.

Availability

Lyophilized powder for IV administration (requires reconstitution and dilution): 120 mg/vial, 400 mg/vial.

INTRODUCTION

Indications

Alone or with other agents in the management of hypertension.

Action

Angiotensin-converting enzyme (ACE) inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II. ACE inhibitors also prevent the degradation of bradykinin and other vasodilatory prostaglandins. ACE inhibitors also increase plasma renin levels and reduce aldosterone levels. Net result is systemic vasodilation. Therapeutic Effects: Lowering of blood pressure in patients with hypertension.

Adverse Reactions/Side Effects

CNS: dizziness, drowsiness, fatigue, headache. Resp: cough. CV: hypotension. GI: nausea. GU: impaired renal function. Derm: rashes. F and E: hyperkalemia. Misc: ANGIOEDEMA.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Monitor signs of angioedema, including rashes, raised patches of red or white skin (welts), burning/itching skin, swelling in the face, and difficulty breathing. Notify physician of these signs immediately.

• Assess blood pressure periodically and compare to normal values (See Appendix F) to help determine antihypertensive effects. Report low blood pressure (hypotension), especially if patient experiences dizziness, fatigue, or other symptoms.

• Assess dizziness and drowsiness that might affect gait, balance, and other functional activities (See Appendix C). Report balance problems and functional limitations to the physician, and caution the patient and family/caregivers to guard against falls and trauma.

• Be alert for signs of high plasma potassium levels (hyperkalemia), including bradycardia, fatigue, weakness, numbness, and tingling. Notify physician because severe cases can lead to life-threatening arrhythmias and paralysis.

Interventions

• Avoid physical therapy interventions that cause systemic vasodilation (large whirlpool, Hubbard tank). Additive effects of this drug and the intervention may cause a dangerous fall in blood pressure.

• To minimize orthostatic hypotension, patient should move slowly when assuming a more upright position.

Patient/Client-Related Instruction

• Remind patients to take medication as directed to control hypertension and other cardiac conditions even if they are asymptomatic.

• Counsel patients about additional interventions to help control blood pressure, including regular exercise, weight loss, sodium restriction, stress reduction, moderation of alcohol consumption, and smoking cessation.

• Instruct patient to report signs of impaired renal function, including decreased urine output, cloudy urine, or sudden weight gain due to fluid retention.

• Instruct patient to notify physician of a prolonged dry cough; drug therapy may need to be altered to resolve this side effect.

• Instruct patient or family/caregivers to report other troublesome side effects such as severe or prolonged headache, nausea, or skin rash.

Pharmacokinetics

Absorption: 37% absorbed after oral administration.

Distribution: Crosses the placenta; enters breast milk in small amounts.

Protein Binding: 95%.

Metabolism and Excretion: Converted by the liver to benazeprilat, the active metabolite; 20% excreted in urine; 11–12% nonrenal (biliary) elimination.

Half-life: Benazeprilat: 10–11 hr.

Contraindications/Precautions

Contraindicated in: Hypersensitivity; History of angioedema with previous use of ACE inhibitors; OB: Can cause injury or death of fetus—if pregnancy occurs, discontinue immediately; Lactation: Appears in breast milk; patient must discontinue benazepril or provide alternate to breast milk.

Use Cautiously in: Patients with renal impairment, hypovolemia, hyponatremia, and concurrent diuretic therapy; Black patients (monotherapy for hypertension less effective, may require additional therapy; higher risk of angioedema); Surgery/anesthesia (hypotension may be exaggerated); Lactation: Safety not established; Pedi: Safety not established children <6 yr; Geri: Initial dosage reduction recommended.

Exercise Extreme Caution in: Family history of angioedema.

Interactions

Drug-Drug: Excessive hypotension may occur with concurrent use of diuretics. Additive hypotension with other antihypertensives. Increased risk of hyperkalemia with concurrent use of potassium supplements, potassium-sharing diuretics, potassium-containing salt substitutes, or angiotensin II receptor antagonists. Antihypertensive response may be blunted by NSAIDs. Increases levels and may increase risk of lithium toxicity.

Route/Dosage

PO (Adults): 10 mg once daily, increased gradually to maintenance dose of 20–40 mg/day in 1–2 divided doses (initiate therapy at 5 mg once daily in patients receiving diuretics).

PO (Children ≥6 yr): 0.2 mg/kg once daily; may be titrated up to 0.6 mg/kg/day (or 40 mg/day).

Renal Impairment

PO (Adults): CCr <30 mL/min—Initiate therapy with 5 mg once daily.

Renal Impairment

PO (Children ≥6 yr): CCr <30 mL/min—Contraindicated.

Availability (generic available)

Tablets: 5 mg, 10 mg, 20 mg, 40 mg. In combination with: amlodipine (Lotrel) and hydrochlorothiazide (Lotensin HCT). See Appendix B.

INTRODUCTION

Indications

Treatment of chronic lymphocytic leukemia.

Action

Damages DNA resulting in death of rapidly replicating cells. Therapeutic Effects: Decreased proliferation of leukemic cells.

Adverse Reactions/Side Effects

CNS: fatigue, weakness. Resp: cough. GI: nausea, vomiting, diarrhea. Derm: skin reactions. Hemat: anemia, LEUKOPENIA, NEUTROPENIA, THROMBOCYTOPENIA. Metab: hyperuricemia. Misc: TUMOR LYSIS SYNDROME, allergic reactions, including anaphylaxis, fever, infusion reactions.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Monitor signs of leukopenia and neutropenia (fever, sore throat, signs of infection), thrombocytopenia (bruising, nose bleeds, bleeding gums), or unusual weakness and fatigue that might be due to anemia. Report these signs to the physician or nursing staff immediately.

• Be alert for signs of electrolyte imbalances that might indicate tumor lysis syndrome. Signs include severe muscle weakness or paralysis due to increased plasma potassium (hyperkalemia), or muscle hyperexcitability and tetany due to phosphate and calcium imbalances (hyperphosphatemia and hypocalcemia). Notify physician or nursing staff immediately if these signs occur.

• Monitor signs of allergic reactions and anaphylaxis, including pulmonary symptoms (tightness in the throat and chest, wheezing, cough, dyspnea) or skin reactions (rash, pruritus, urticaria). Reactions may be especially prevalent during or immediately after administration (infusion reactions). Notify physician or nursing staff immediately if these reactions occur.

Interventions

• For patients who are medically able to begin exercise, implement appropriate resistive exercises and aerobic training to maintain muscle strength and aerobic capacity during cancer chemotherapy or to help restore function after chemotherapy.

Patient/Client-Related Instruction

• Advise patient to guard against infection (frequent hand washing, etc.) and avoid crowds and contact with persons with contagious diseases.

• Advise patient that weakness and fatigue are likely, and may be severe. Implement assistive devices (walker, crutches, cane) and appropriate safety precautions to guard against falls due to weakness.

• Instruct patient to report other bothersome side effects, including severe or prolonged cough, fever, skin reactions, or GI problems (nausea, vomiting, diarrhea).

Pharmacokinetics

Absorption: IV administration results in complete bioavailability.

Distribution: Distributes freely into red blood cells.

Protein Binding: 94–96%.

Metabolism and Excretion: Mostly metabolized (partially by the CYP1A2 enzyme system; 90% excreted in feces; some renal elimination. Although metabolites have antineoplastic activity, levels are extremely low.

Half-life: approximately 40 minutes

Contraindications/Precautions

Contraindicated in: Hypersensitivity to bendamustine or mannitol; CCr <40 mL/min. Use with caution in lesser degrees of renal impairment; Moderate or severe hepatic impairment; OB: Pregnancy or lactation.

Use Cautiously in: Patients at risk for tumor lysis syndrome (concurrent allopurinol recommended); Mild hepatic impairment; Mild-to-moderate renal impairment; Patients with childbearing potential; Geri: Elderly patients may be more susceptible to adverse reactions; Pedi: Safe use in children not established.

Interactions

Drug-Drug: Concurrent use of CYP1A2 inducers/inhibitors can alter levels of bendamustine. Inhibitors of CYP1A2, including fluvoxamine and ciprofloxacin may ↑ levels of bendamustine and ↓ levels of active metabolites. Inducers of CYP1A2, including omeprazole and smoking, may ↓ levels of bendamustine and ↑ levels of its active metabolites. Consider alternative treatments.

Route/Dosage

IV (Adults): 100 mg/m² on days 1 and 2 of a 28-day cycle, up to 6 cycles; dose modification required for toxicity.

Availability

Lyophilized powder for injection (requires reconstitution): 100-mg vial.

INTRODUCTION

Indications

Relief of nonproductive cough due to minor throat or bronchial irritation from inhaled irritants or colds.

Action

Anesthetizes cough or stretch receptors in vagal nerve afferent fibers found in lungs, pleura, and respiratory passages. May also decrease transmission of the cough reflex centrally. Therapeutic Effects: Decrease in cough.

Adverse Reactions/Side Effects

CNS: headache, mild dizziness, sedation. EENT: burning sensation in eyes, nasal congestion. GI: constipation, GI upset, nausea. Derm: pruritus, skin eruptions. Misc: chest numbness, chilly sensation, hypersensitivity reactions.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Assess frequency and nature of cough and lung sounds (See Appendix K) to help document whether this drug is effective in reducing cough.

• Monitor signs of hypersensitivity reactions, including pulmonary symptoms (tightness in the throat and chest, wheezing, cough, dyspnea) or skin reactions (rash, pruritus, urticaria). Notify physician immediately if these reactions occur.

• Assess dizziness that might affect gait, balance, and other functional activities (See Appendix C). Report balance problems and functional limitations to the physician, and caution the patient and family/caregivers to guard against falls and trauma.

Patient/Client-Related Instruction

• Advise patient to minimize cough by avoiding irritants, such as cigarette smoke, fumes, and dust. Humidification of environmental air, frequent sips of water, and sugarless hard candy may also decrease the frequency of dry, irritating cough.

• Advise patient that any cough lasting more than 1 wk or accompanied by fever, chest pain, persistent headache, or skin rash warrants medical attention.

• Instruct patient or family/caregivers to report other problematic side effects such as severe or prolonged headache, sedation, burning sensation in the eyes, nasal congestion, chills, chest numbness, skin reactions (itching, skin eruptions), or GI problems (nausea, upset stomach, constipation).

Pharmacokinetics

Absorption: Unknown.

Distribution: Unknown.

Metabolism and Excretion: Unknown.

Half-life: Unknown.

Contraindications/Precautions

Contraindicated in: Hypersensitivity to benzonatate. Cross-sensitivity with other ester-type local anesthetics (tetracaine, procaine, and others) may occur.

Use Cautiously in: OB/Lactation: Safety not established; Pedi: Safety not established in children <10 yr.

Interactions

Drug-Drug: Additive CNS depression may occur with antihistamines, alcohol, opioids, and sedative/hypnotics.

Route/Dosage

PO (Adults and Children ≥10 yr): 100 mg 3 times daily (up to 600 mg/day).

Availability (generic available)

Capsules: 100 mg.

INTRODUCTION

Indications

Adjunctive treatment of all forms of Parkinson's disease, including drug-induced extrapyramidal effects and acute dystonic reactions.

Action

Blocks cholinergic activity in the CNS, which is partially responsible for the symptoms of Parkinson's disease. Restores the natural balance of neurotransmitters in the CNS. Therapeutic Effects: Reduction of rigidity and tremors.

Adverse Reactions/Side Effects

CNS: confusion, depression, dizziness, hallucinations, headache, sedation, weakness. EENT: blurred vision, dry eyes, mydriasis. CV: arrhythmias, hypotension, palpitations, tachycardia. GI: constipation, dry mouth, ileus, nausea. GU: hesitancy, urinary retention. Misc: decreased sweating.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Assess patient's gait and motor function to help document antiparkinson effects, especially when starting drug therapy, or during dosing changes or addition of other antiparkinson drugs. Motor function should be assessed at different times of the day, such as when drugs are reaching therapeutic levels (i.e., 1–2 hr after oral dose), as well as when drug effects are minimal (just before the next dose).

• Assess heart rate, ECG, and heart sounds, especially during exercise (See Appendices G, H). Report fast heart rate (tachycardia) or signs of other arrhythmias, including palpitations, chest discomfort, shortness of breath, fainting, and fatigue/weakness.

• Assess blood pressure (BP) periodically and compare to normal values (See Appendix F). Report low blood pressure (hypotension), especially if patient experiences dizziness, fatigue, or other symptoms.

• Assess dizziness and drowsiness that might affect gait, balance, and other functional activities (See Appendix C). Report balance problems and functional limitations to the physician and nursing staff, and caution the patient and family/caregivers to guard against falls and trauma.

• Monitor confusion, hallucinations, depression, and other psychologic problems. Repeated or excessive symptoms may require change in dose or medication.

Interventions

• Implement therapeutic exercises (coordination exercises, gait training, cardiovascular conditioning) to compliment the effects of drug therapy and help achieve optimal function.

• Because of the risk of arrhythmias and abnormal BP responses, use caution during aerobic exercise and other forms of therapeutic exercise. Assess exercise tolerance frequently (BP, heart rate, fatigue levels), and terminate exercise immediately if any untoward responses occur (See Appendix L).

• Guard against falls and trauma (hip fractures, head injury, and so forth). Implement fall-prevention strategies (see Appendix E), especially if patient exhibits Parkinson's symptoms (postural instability, rigidity) combined with drug side effects (dizziness, blurred vision, weakness).

Patient/Client-Related Instruction

• Instruct patient to report other bothersome side effects, including severe or prolonged headache, vision problems, decreased sweating, urinary problems (hesitancy, retention), or GI problems (nausea, constipation, dry mouth).

Pharmacokinetics

Absorption: Well absorbed following PO and IM administration.

Distribution: Unknown.

Metabolism and Excretion: Unknown.

Half-life: Unknown.

Contraindications/Precautions

Contraindicated in: Hypersensitivity; Children <3 yr; Angle-closure glaucoma; Tardive dyskinesia.

Use Cautiously in: Prostatic hyperplasia; Seizure disorders; Cardiac arrhythmias; OB/Lactation: Safety not established; Geri: ↑ risk of adverse reactions.

Interactions

Drug-Drug: Additive anticholinergic effects with drugs sharing anticholinergic properties, such as antihistamines, phenothiazines, quinidine, disopyramide, and tricyclic antidepressants. Counteracts the cholinergic effects of bethanechol.

Antacids and antidiarrheals may ↓ absorption.

Drug-Natural: ↑ anticholinergic effect with angel's trumpet, jimson weed, and scopolia.

Route/Dosage

Parkinsonism

PO (Adults): 1–2 mg/day in 1–2 divided doses (range 0.5–6 mg/day).

Acute Dystonic Reactions

IM, IV (Adults): 1–2 mg, then 1–2 mg PO twice daily.

Drug-Induced Extrapyramidal Reactions

PO, IM, IV (Adults): 1–4 mg given once or twice daily (1–2 mg 2–3 times daily may also be used PO).

Availability (generic available)

Tablets: 0.5 mg, 1 mg, 2 mg. Injection: 1 mg/mL.

INTRODUCTION

Indications

Treatment of itching associated with allergic conjunctivitis.

Action

Acts as a histamine H₁ receptor antagonist; also inhibits the release of histamine from mast cells; does not bind to or inactivate histamine. Therapeutic Effects: Decreased ocular itching associated with allergic conjunctivitis.

Adverse Reactions/Side Effects

CNS: headache. EENT: nasopharyngitis. GI: taste in mouth following instillation.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Monitor eye pain, itching, and inflammation to help document whether drug therapy is successful in resolving allergic conjunctivitis.

Patient/Client-Related Instruction

• Check that the patient and family or caregivers understand ophthalmic application procedures and adhere to the recommended dosing schedule.

• Instruct patient and family/caregivers to report other troublesome side effects such as severe or prolonged headache, altered taste, or inflammation of the nose and pharynx.

Pharmacokinetics

Absorption: Some systemic absorption follows ophthalmic administration.

Distribution: Unknown

Metabolism and Excretion: Minimally metabolized by the liver; 75–90% excreted unchanged in urine

Half-life: Unknown

Contraindications/Precautions

Contraindicated in: Hypersensitivity.

Use Cautiously in: Contact lens use OB: Use during pregnancy if potential maternal benefit justifies the potential risk to fetus; Lactation: Use cautiously during breastfeeding; Pedi: Safe and effective use in children <2 yr has not been established.

Interactions

Drug-Drug: None noted

Route/Dosage

Ophthalmic (Adults): 1 drop in affected eye(s) twice daily.

Availability

Ophthalmic solution: 1.5%

INTRODUCTION

Indications

Treatment and prophylaxis of respiratory distress syndrome (RDS, hyaline membrane disease) in premature infants.

Action

Replaces endogenous pulmonary surfactant in premature infants, allowing normal surface activity in alveoli. Consists of natural bovine lung extract. Therapeutic Effects: Decreased incidence, mortality, and complications from RDS.

Adverse Reactions/Side Effects

Resp: oxygen desaturation (as a result of administration process). CV: transient bradycardia.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Monitor oxygen saturation levels following administration. Notify physician or nursing staff immediately about a sudden decrease is oxygen saturation.

• Assess heart rate, and report a sustained decrease in heart rate (bradycardia).

Interventions

• When indicated, implement chest physical therapy interventions such as positioning, suctioning, and chest percussion/vibration to maintain respiratory function and augment drug effects in premature infants.

Pharmacokinetics

Absorption: Administered directly to site of action. Systemic absorption not known.

Distribution: Rapidly distributes to lung tissue.

Metabolism and Excretion: Enters surfactant pathways in which recycling and reutilization occur.

Half-life: Unknown.

Contraindications/Precautions

Contraindicated in: No known contraindications.

Use Cautiously in: No known cautions. Nosocomial infections may be more common.

Interactions

Drug-Drug: None known.

Route/Dosage

Intratracheal (Infants, Premature): 100 mg phospholipids/kg birth weight (4 mL/kg birth weight); 4 doses may be given in first 48 hr of life, no closer than q 6 hr apart.

Availability

Intratracheal suspension: 25 mg phospholipid/mL—4-mL and 8-mL vials.

INTRODUCTION

Indications

Treatment of bacterial conjunctivitis.

Action

Inhibits bacterial DNA synthesis by inhibiting DNA gyrase. Therapeutic Effects: Death of susceptible bacteria with decreased symptoms and sequelae of bacterial conjunctivitis. Spectrum: Active against CDC coryneform group G, Corynebacterium pseudodiphtheriticum, C. striatum, Haemophilus influenzae, Moraxella lacunata, Staphylococcus aureus, S. epidermidis, S. hominis, S. lugdunensis, Streptococcus mitis group, Str. oralis, Str. Pneumoniae, and Str. Salivarius.

Adverse Reactions/Side Effects

CNS: headache. EENT: conjunctival redness, blurred vision, eye irritation, eye pain, eye pruritus.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Monitor eye pain, itching, and inflammation to help document whether drug therapy is successful in resolving bacterial conjunctivitis.

• Watch for any new or increased eye reactions, including pain, redness, irritation, itching, or blurred vision. Report severe or worsening eye reactions to the physician.

Patient/Client-Related Instruction

• Check that the patient and family or caregivers understand ophthalmic application procedures and adhere to the recommended dosing schedule.

• Instruct patient and family/caregivers to report other troublesome side effects such as severe or prolonged headache.

Pharmacokinetics

Absorption: Minimal absorption follows ophthalmic use.

Distribution: Unknown

Metabolism and Excretion: Unknown

Half-life: 7 hr

Contraindications/Precautions

Contraindicated in: Contact lens use.

Use Cautiously in: OB: Use during pregnancy only if potential benefit justifies potential risk to fetus; Lactation: Use cautiously during lactation; Pedi: Safe use in children <1 yr not established.

Interactions

Drug-Drug: None noted

Route/Dosage

Ophth (Adults and Children ≥1 yr): 1 drop in affected eye(s) 3 times daily (4–12 hr apart) for 7 days.

Availability

Ophthalmic suspension: 0.6% 5 mL in 7.5-mL bottle.

INTRODUCTION

Indications

Management of adrenocortical insufficiency; chronic use in other situations is limited because of mineralocorticoid activity. Used systemically and locally in a wide variety of chronic diseases, including Inflammatory; Allergic; Hematologic; Neoplastic; Autoimmune disorders. Replacement therapy in adrenal insufficiency. Unlabeled Use: Short-term administration to high-risk mothers before delivery to prevent respiratory distress syndrome in the newborn.

Action

In pharmacologic doses, suppresses inflammation and the normal immune response. Has numerous intense metabolic effects (see Adverse Reactions and Side Effects). Suppresses adrenal function at chronic doses of 0.6 mg/day. Has negligible mineralocorticoid activity. Therapeutic Effects: Suppression of inflammation and modification of the normal immune response. Replacement therapy in adrenal insufficiency.

Adverse Reactions/Side Effects

Adverse reactions/side effects are much more common with high-dose/long-term therapy

CNS: depression, euphoria, headache, increased intracranial pressure (children only), personality changes, psychoses, restlessness. EENT: cataracts, increased intraocular pressure. CV: hypertension. GI: PEPTIC ULCERATION, anorexia, nausea, vomiting. Derm: acne, decreased wound healing, ecchymoses, fragility, hirsutism, petechiae. Endo: adrenal suppression, hyperglycemia. F and E: fluid retention (long-term high doses), hypokalemia, hypokalemic alkalosis. Hemat: THROMBOEMBOLISM, thrombophlebitis. Metab: weight gain, weight loss. MS: muscle wasting, osteoporosis, aseptic necrosis of joints, muscle pain. Misc: cushingoid appearance (moon face, buffalo hump), increased susceptibility to infection.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Monitor signs of thrombophlebitis (lower extremity swelling, warmth, erythema, tenderness) and thromboembolism (shortness of breath, chest pain, cough, bloody sputum). Notify physician immediately, and request objective tests (Doppler ultrasound, lung scan, others) if thrombosis is suspected.

• Monitor and report signs of peptic ulcer, including heartburn, nausea, vomiting blood, tarry stools, and loss of appetite.

• Assess any muscle or joint pain. Report persistent or increased musculoskeletal pain to determine presence of bone or joint pathology (aseptic necrosis, fracture).

• Assess muscle strength periodically to document the degree of muscle wasting during long-term use.

• Measure blood pressure periodically and compare to normal values (See Appendix F). Report a sustained increase in blood pressure (hypertension) to the physician.

• Assess peripheral edema using girth measurements, volume displacement, and measurement of pitting edema (See Appendix N). Report increased swelling in feet and ankles or a sudden increase in body weight due to fluid retention.

• Monitor personality changes, including depression, euphoria, restlessness, hallucinations, and psychosis. Notify physician if these changes become problematic.

• Assess signs of increased intracranial pressure in children, including changes in mood and behavior, decreased consciousness, headache, lethargy, seizures, and vomiting. Notify physician of these signs immediately.

• Be alert for signs of low potassium levels (hypokalemia) and metabolic acidosis, including hyperventilation, cardiac arrhythmias, dizziness, and confusion. Notify physician immediately if these signs occur.

• Report signs of adrenal suppression, including hypotension, weight loss, weakness, nausea, vomiting, anorexia, lethargy, confusion, and restlessness.

• Monitor signs of hyperglycemia (confusion; drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing; polyuria; loss of appetite; unusual thirst). Insulin dosages may need to be adjusted to prevent repeated episodes of hyperglycemia.

• Periodically assess body weight and other anthropometric measures (body mass index, body composition). Report a rapid or unexplained weight gain or weight loss.

Interventions

• Implement resistive exercises and weight-bearing activities to minimize muscle wasting and osteoporosis. Use caution to prevent musculoskeletal damage in patients with preexisting muscle and bone loss.

• Protect skin from breakdown, especially over bony prominences.

Patient/Client-Related Instruction

• Advise patient that wound healing may be delayed; instruct patient to check skin regularly and report any nonhealing sores.

• Advise patient that corticosteroids cause immunosuppression and may mask symptoms of infection. Instruct patient to avoid people with known contagious illnesses and to report possible infections immediately.

• Advise patients on long-term treatment to consult physician before stopping this medication. Stopping the medication suddenly may result in adrenocortical shock (severe hypotension, hypoglycemia, weakness, vomiting). If these signs appear, notify the physician immediately; may be life threatening.

• Instruct patient to report any loss of vision that might indicate cataracts or increased intraocular pressure.

• Advise patient about possible “cushingoid” appearance, including puffiness in the face (moon face), increased fat in the torso, thin arms and legs, abdominal skin striations, bruising, and deposition of fat at the posterior base of the neck (buffalo hump). Discuss possible effects on body image, and help patient explore coping mechanisms.

• Instruct patient and family/caregivers to report other troublesome side effects such as severe or prolonged headache or skin reactions (acne, hair growth).

Pharmacokinetics

Absorption: Well absorbed after oral administration. Sodium phosphate salt is rapidly absorbed after IM administration. Acetate salt is slowly but completely absorbed after IM administration. Absorption from local sites (intra-articular, intralesional) is slow but complete.

Distribution: Widely distributed; crosses the placenta and probably enters breast milk.

Metabolism and Excretion: Metabolized mostly by the liver.

Half-life: 3–5 hr (plasma), 36–54 hr (tissue); adrenal suppression lasts 3.25 days.

Contraindications/Precautions

Contraindicated in: Active untreated infections (may be used in patients being treated for tuberculous meningitis); Traumatic brain injury (high doses may ↑ mortality); Lactation: Avoid chronic use; Some products contain bisulfites and should be avoided in patients with known hypersensitivity.

Use Cautiously in: Chronic treatment (will lead to adrenal suppression; use lowest possible dose for shortest period of time); Hypothyroidism; Cirrhosis; Ulcerative colitis; Stress (surgery, infections); supplemental doses may be needed; Potential infections may mask signs (fever, inflammation); OB: Safety not established; Pedi: Chronic use will result in decreased growth; use lowest possible dose for shortest period of time.

Interactions

Drug-Drug: Additive hypokalemia with thiazide and loop diuretics or amphotericin B. Hypokalemia may ↑ risk of digitalis glycoside toxicity. May ↑ requirement for insulins or oral hypoglycemic agents. Phenytoin, phenobarbital, and rifampin stimulate metabolism; may ↓ effectiveness. Oral contraceptives may block metabolism. ↑ risk of adverse GI effects with NSAIDs (including aspirin). At chronic doses that suppress adrenal function, may ↓ antibody response to and ↑ risk of adverse reactions from live-virus vaccines.

Route/Dosage

PO (Adults): 0.6–7.2 mg/day as single daily dose or in divided doses.

PO (Children): Adrenocortical insufficiency—17.5 mcg/kg (500 mcg/m²)/day in 3 divided doses. Other uses—62.5–250 mcg/kg (1.875–7.5 mg/m²)/day in 3 divided doses.

IM, IV (Adults): 0.5–9 mg IM as betamethasone sodium phosphate/acetate suspension. Prevention of respiratory distress syndrome in newborn—12 mg IM daily for 2–3 days before delivery (unlabeled).

IM (Children): Adrenocortical insufficiency—17.5 mcg/kg (500 mcg/m²)/day in 3 divided doses every 3rd day or 5.8–8.75 mcg/kg (166–250 mcg/m²)/day as a single dose. Other uses—20.8–125 mcg/kg (0.625–3.75 mg/m²) of the base q 12–24 hr.

Availability (generic available)

Syrup: 0.6 mg/5 mL. Suspension for injection (sodium phosphate and acetate): 6 mg (total)/mL.

INTRODUCTION

Indications

Management of hypertension.

Action

Blocks stimulation of beta₁ (myocardial)–adrenergic receptors. Does not usually affect beta₂ (pulmonary, vascular, uterine) receptor sites. Therapeutic Effects: Decreased blood pressure and heart rate.

Adverse Reactions/Side Effects

CNS: fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia, memory loss, mental status changes, nightmares. EENT: blurred vision, stuffy nose. Resp: bronchospasm, wheezing. CV: BRADYCARDIA, CHF, PULMONARY EDEMA, hypotension, peripheral vasoconstriction. GI: constipation, diarrhea, liver function abnormalities, nausea, vomiting. GU: erectile dysfunction, decreased libido, urinary frequency. Derm: rashes. Endo: hyperglycemia, hypoglycemia. MS: arthralgia, back pain, joint pain. Misc: drug-induced lupus syndrome.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Assess heart rate, ECG, and heart sounds, especially during exercise (See Appendices G, H). Report an abnormally slow heart rate (bradycardia) or symptoms of other arrhythmias, including palpitations, chest discomfort, shortness of breath, fainting, and fatigue/weakness.

• Assess routinely for signs of CHF and pulmonary edema, including dyspnea, rales/crackles, weight gain, peripheral edema, and jugular venous distention. Report these signs to the physician immediately.

• Assess blood pressure periodically and compare to normal values (See Appendix F) to help document antihypertensive effects.

• Assess symptoms of bronchospasm (wheezing, coughing, tightness in chest). Perform pulmonary function tests to quantify suspected changes in ventilation and respiration (See Appendices I, J, K). Repeated or prolonged bronchoconstriction may require a change in dose or medication.

• Monitor signs of peripheral vasoconstriction, such as extreme coldness in the hands and feet, cyanosis, and muscle cramping. Notify physician of severe or prolonged signs of vasoconstriction.

• Be alert for signs of hypoglycemia (weakness, malaise, irritability, fatigue) or hyperglycemia (drowsiness, fruity breath, increased urination, unusual thirst). Medication may mask some signs of hypoglycemia, but dizziness and sweating may still occur. Patients with diabetes mellitus should check blood glucose levels frequently.

• Assess any back, joint, or muscle pain to rule out musculoskeletal pathology; that is, try to determine if pain is drug induced rather than caused by anatomic or biomechanical problems.

• Monitor mood and personality changes, including depression, anxiety, nervousness, memory loss, or other changes in behavior. Notify physician if these changes become problematic.

• Assess dizziness and drowsiness that might affect gait, balance, and other functional activities (See Appendix C). Report balance problems and functional limitations to the physician, and caution the patient and family/caregivers to guard against falls and trauma.

• Monitor excessive fatigue or weakness. Beta blockers often cause some degree of fatigue and weakness, but any sudden or severe change in muscle strength or energy levels should be reported.

• Monitor signs of drug-induced lupus syndrome, including increased blood pressure (BP), fever, joint pain, skin rashes, and redness/irritation of the eye (uveitis). Notify physician promptly if these signs appear.

Interventions

• Because of an increased risk of CHF and cardiac arrhythmias, use caution during aerobic exercise and endurance conditioning. Terminate exercise if patient exhibits untoward symptoms (chest pain, shortness of breath, unusual fatigue) or displays other criteria for exercise termination (See Appendix L).

• Establish aerobic exercise workloads that account for the effects of beta blockers on heart rate. Some heart rate guidelines may not be appropriate because beta blockers typically decrease maximal HR by 20–30 bpm. Use other guidelines such as rating of perceived exertion (RPE, modified Borg scale) to determine exercise workloads.

• To minimize orthostatic hypotension, patient should move slowly when assuming a more upright position.

Patient/Client-Related Instruction

• Remind patients to take medication as directed to control hypertension even if they are asymptomatic.

• Counsel patients about additional interventions to help control BP, including regular exercise, weight loss, sodium restriction, stress reduction, moderation of alcohol consumption, and smoking cessation.

• Instruct patient or family/caregivers to report other troublesome side effects such as severe or prolonged insomnia, nightmares, blurred vision, stuffy nose, increased urinary frequency, decreased libido, erectile dysfunction, skin rash, or GI problems (nausea, vomiting, constipation, diarrhea).

Pharmacokinetics

Absorption: Well absorbed after oral administration.

Distribution: Widely distributed.

Metabolism and Excretion: Mostly metabolized by the liver, 20% excreted unchanged by the kidneys.

Half-life: 15–20 hr.

Contraindications/Precautions

Contraindicated in: Uncompensated CHF; Pulmonary edema; Cardiogenic shock; Bradycardia or heart block.

Use Cautiously in: Renal or hepatic impairment; Pulmonary disease (including asthma; beta₁ selectivity may be lost at higher doses); avoid use if possible; Diabetes mellitus; Thyrotoxicosis; Patients with a history of severe allergic reactions (intensity of reactions may be increased); OB/Lactation/Pedi: Safety not established; all agents cross the placenta and may cause fetal/neonatal bradycardia, hypotension, hypoglycemia, or respiratory depression; Geri: ↑ sensitivity to beta blockers; initial dosage reduction recommended.

Interactions

Drug-Drug: General anesthetics, IV phenytoin, and verapamil may cause additive myocardial depression. Additive bradycardia may occur with digoxin. Additive hypotension may occur with other antihypertensives, acute ingestion of alcohol, or nitrates. Concurrent use with amphetamine, cocaine, ephedrine, epinephrine, norepinephrine, phenylephrine, or pseudoephedrine may result in unopposed alphaadrenergic stimulation (excessive hypertension, bradycardia). Concurrent thyroid preparation administration may decrease effectiveness. May alter the effectiveness of insulins or oral hypoglycemic agents (dosage adjustments may be necessary). May decrease the effectiveness of theophylline. May decrease the beneficial beta₁-cardiovascular effects of dopamine or dobutamine. Use cautiously within 14 days of MAO inhibitor therapy (may result in hypertension).

Route/Dosage

PO (Adults): 10 mg once daily, may be increased to 20 mg after 7 days; start with 5 mg in geriatric patients.

Renal Impairment

PO (Adults): start with 5 mg once daily.

Availability (generic available)

Tablets: 10 mg, 20 mg.

INTRODUCTION

Indications

Metastatic colon or rectal carcinoma (with IV 5-fluorouracil). First-line treatment of patients with unresectable, locally advanced, recurrent or metastatic nonsquamous, non–small cell lung cancer with carboplatin and paclitaxel.

Action

A monoclonal antibody that binds to vascular endothelial growth factor (VEGF), preventing its attachment to binding sites on vascular endothelium, thereby inhibiting growth of new blood vessels (angiogenesis). Therapeutic Effects: Decreased metastatic disease progression and microvascular growth.

Adverse Reactions/Side Effects

CNS: reversible posterior leukoencephalopathy syndrome (RPLS). CV: ARTERIAL THROMBOEMBOLIC EVENTS, CHF, hypertension, hypotension. Resp: HEMOPTYSIS, nongastrointestinal fistulas, nasal septum perforation. GI: GI PERFORATION. GU: nephrotic syndrome, proteinuria. Hemat: BLEEDING. Misc: WOUND DEHISCENCE, impaired wound healing, infusion reactions.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Continually monitor for signs of arterial thrombosis that leads to MI (sudden chest pain, pain radiating into the arm or jaw, shortness of breath, dizziness, sweating, anxiety, nausea) or ischemic stroke (sudden severe headache, confusion, nausea, vomiting, paralysis, numbness, speech problems, visual disturbances). Seek immediate medical assistance if patient develops these signs.

• Monitor and immediately report any bleeding problems, including coughing up blood or other abnormal bleeding (nosebleeds, bleeding gums, excessive bruising).

• Be alert for signs of bowel perforation, including sudden severe abdominal pain accompanied by nausea, vomiting, chills, and fever. Report these signs immediately to the physician or nursing staff.

• Monitor signs of CHF (dyspnea, rales/crackles, peripheral edema, jugular venous distention, exercise intolerance); report these signs to the physician.

• Monitor signs of reversible posterior leukoencephalopathy syndrome, including headache, confusion, seizures, and loss of vision. Early recognition and adjustment of drug dosage is important in resolving this syndrome.

• Assess blood pressure periodically and compare to normal values (See Appendix F). Report a sustained increase in blood pressure (hypertension) or a problematic decrease in blood pressure (hypotension).

• Monitor and report signs of nephrotic syndrome, including edema and weight gain from fluid retention.

Interventions

• Protect suture lines and wounds to prevent reopening (dehiscence). Implement physical agents whenever possible to promote wound healing.

• For patients who are medically able to begin exercise, implement appropriate resistive exercises and aerobic training to maintain muscle strength and aerobic capacity during cancer chemotherapy or to help restore function after chemotherapy.

• Because of the risk of MI and stroke, use extreme caution during aerobic exercise and other forms of therapeutic exercise. Assess exercise tolerance frequently (blood pressure, heart rate, fatigue levels), and terminate exercise immediately if any untoward responses occur (See Appendix L).

Patient/Client-Related Instruction

• Advise patient and family or caregiver about the signs of MI and stroke (see signs above in Examination and Evaluation) and to seek immediate medical assistance if these signs develop.

• Instruct patient and family or caregiver to immediately report signs of bowel perforation or abnormal bleeding (see signs above in Examination and Evaluation).

Pharmacokinetics

Absorption: IV administration results in complete bioavailability.

Distribution: Unknown.

Metabolism and Excretion: Unknown.

Half-life: 20 days (range 11–50 days).

Contraindications/Precautions

Contraindicated in: Hypersensitivity; Recent hemoptysis or other serious recent bleeding episode; First 28 days after major surgery; OB: Angiogenesis is critical to the developing fetus. Contraindicated unless benefit to mother outweighs potential fetal harm; Lactation: Discontinue nursing during treatment and, due to long half-life, for several weeks following treatment.

Use Cautiously in: Cardiovascular disease; Pedi: Safety not established; Geri: ↑ risk of serious adverse reactions, including arterial thromboembolic events.

Interactions

Drug-Drug: ↑ blood levels of SN 38 (the active metabolite of irinotecan); significance is not known.

Route/Dosage

Colon Cancer

IV (Adults): 5 mg/kg infusion every 14 days.

Lung Cancer

IV (Adults): 15 mg/kg infusion every 3 wk.

Availability

Solution for injection (requires dilution): 100 mg/4 mL vial, 400 mg/16 mL vial.

INTRODUCTION

Indications

Treatment of metastatic prostate carcinoma in conjunction with luteinizing hormone–releasing hormone (LHRH) analogues (goserelin, leuprolide).

Action

Antagonizes the effects of androgen at the cellular level. Therapeutic Effects: Decreased spread of prostate carcinoma.

Adverse Reactions/Side Effects

CNS: weakness, dizziness, headache, insomnia. Resp: dyspnea. CV: chest pain, hypertension, peripheral edema. GI: constipation, diarrhea, nausea, abdominal pain, increased liver enzymes, vomiting. GU: hematuria, erectile dysfunction, incontinence, nocturia, urinary tract infections. Derm: alopecia, rashes, sweating. Endo: breast pain, gynecomastia. Hemat: anemia. Metab: hyperglycemia, weight loss. MS: back pain, pelvic pain, bone pain. Neuro: paresthesia. Misc: generalized pain, hot flashes, flu-like syndrome, infection.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Assess blood pressure periodically and compare to normal values (See Appendix F). Report a sustained increase in blood pressure (hypertension) to the physician.

• Monitor cardiopulmonary symptoms such as chest pain or difficult, labored breathing. Report severe or unexpected cardiac and respiratory problems to the physician.

• Assess peripheral edema using girth measurements, volume displacement, and measurement of pitting edema (See Appendix N). Report increased swelling in feet and ankles or a sudden increase in body weight due to fluid retention.

• Monitor signs of anemia, including unusual fatigue, shortness of breath with exertion, bruising, and pale skin. Notify physician immediately if these signs occur.

• Be alert for signs of hyperglycemia, including confusion, drowsiness, flushed/dry skin, fruit-like breath odor, rapid/deep breathing, polyuria, loss of appetite, and unusual thirst. Patients with diabetes mellitus should check blood glucose levels frequently.

• Assess any back, pelvic, or other bone or generalized pain to rule out musculoskeletal pathology; that is, try to determine if pain is drug induced rather than caused by anatomic or biomechanical problems.

• Be alert for signs of paresthesia (numbness, tingling). Establish baseline electroneuromyographic values at the beginning of drug treatment whenever possible, and reexamine these values periodically to document drug-induced changes in peripheral nerve function.

• Assess dizziness and weakness that might affect gait, balance, and other functional activities (See Appendix C). Report balance problems and functional limitations to the physician and nursing staff, and caution the patient and family/caregivers to guard against falls and trauma.

• Periodically assess body weight and other anthropometric measures (body mass index, body composition). Report a rapid or unexplained weight loss.

Interventions

• For patients who are medically able to begin exercise, implement appropriate resistive exercises and aerobic training to maintain muscle strength and aerobic capacity during cancer chemotherapy or to help restore function after chemotherapy.

• Because of cardiopulmonary side effects, use caution during aerobic exercise and other forms of therapeutic exercise. Assess exercise tolerance frequently (respiratory symptoms, blood pressure, heart rate, fatigue levels), and terminate exercise immediately if any untoward responses occur (See Appendix L).

Patient/Client-Related Instruction

• Advise patient and family/caregivers that fatigue and weakness are likely and may be severe. Functional abilities may be limited, and patient may need to use assistive devices during ambulation.

• Advise patient about the likelihood of GI reactions such as diarrhea, nausea, vomiting, constipation, and abdominal pain. Instruct patient or family and caregivers to report severe or unexpected GI reactions.

• Advise patient that hair loss and other skin reactions (rashes, sweating) are likely. Report other severe or unexpected skin reactions to the physician.

• Instruct patient to report problems with urination, including blood in the urine, increased nighttime urination, incontinence, or pain and burning that might indicate a urinary tract infection.

• Instruct patient or family/caregivers to report other troublesome side effects including severe or prolonged headache, sleep loss, erectile dysfunction, breast pain/enlargement, hot flashes, or flu-like symptoms (fever, chills, body aches).

Pharmacokinetics

Absorption: Well absorbed after oral administration.

Distribution: Unknown.

Protein Binding: 96%.

Metabolism and Excretion: Mostly metabolized by the liver.

Half-life: 5.8 days.

Contraindications/Precautions

Contraindicated in: Hypersensitivity; OB: Not for use in women.

Use Cautiously in: Moderate-to-severe liver impairment; Patients with childbearing potential; Lactation: Not for use in women; Pedi: Safety not established.

Interactions

Drug-Drug: May increase the effect of warfarin.

Route/Dosage

PO (Adults): 50 mg once daily (must be given concurrently with LHRH analogue or following surgical castration).

Availability (generic available)

Tablets: 50 mg.

INTRODUCTION

Indications

Adjunctive treatment of all forms of Parkinson's disease, including drug-induced extrapyramidal effects and acute dystonic reactions.

Action

Blocks cholinergic activity in the CNS, which is partially responsible for the symptoms of Parkinson's disease. Restores the natural balance of neurotransmitters in the CNS. Therapeutic Effects: Reduction of rigidity and tremors.

Adverse Reactions/Side Effects

CNS: confusion, depression, dizziness, hallucinations, headache, sedation, weakness. EENT: blurred vision, dry eyes, mydriasis. CV: arrhythmias, hypotension, palpitations, tachycardia. GI: constipation, dry mouth, ileus, nausea. GU: hesitancy, urinary retention. Misc: decreased sweating.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Assess patient's gait and motor function to help document antiparkinson effects, especially when starting drug therapy, or during dosing changes or addition of other antiparkinson drugs. Motor function should be assessed at different times of the day, such as when drugs are reaching therapeutic levels (i.e., 1–2 hr after oral dose), as well as when drug effects are minimal (just before the next dose).

• Assess heart rate, ECG, and heart sounds, especially during exercise (See Appendices G, H). Report fast heart rate (tachycardia) or signs of other arrhythmias, including palpitations, chest discomfort, shortness of breath, fainting, and fatigue/weakness.

• Assess blood pressure (BP) periodically and compare to normal values (See Appendix F). Report low BP (hypotension), especially if patient experiences dizziness, fatigue, or other symptoms.

• Assess dizziness and drowsiness that might affect gait, balance, and other functional activities (See Appendix C). Report balance problems and functional limitations to the physician and nursing staff, and caution the patient and family/caregivers to guard against falls and trauma.

• Monitor confusion, hallucinations, depression, and other psychologic problems. Repeated or excessive symptoms may require change in dose or medication.

Interventions

• Implement therapeutic exercises (coordination exercises, gait training, cardiovascular conditioning) to complement the effects of drug therapy and help achieve optimal function.

• Because of the risk of arrhythmias and abnormal BP responses, use caution during aerobic exercise and other forms of therapeutic exercise. Assess exercise tolerance frequently (BP, heart rate, fatigue levels), and terminate exercise immediately if any untoward responses occur (See Appendix L).

• Guard against falls and trauma (hip fractures, head injury, and so forth). Implement fall-prevention strategies (See Appendix E), especially if patient exhibits Parkinson's symptoms (postural instability, rigidity) combined with drug side effects (dizziness, blurred vision, weakness).

Patient/Client-Related Instruction

• Instruct patient to report other bothersome side effects, including severe or prolonged headache, vision problems, decreased sweating, urinary problems (hesitancy, retention), or GI problems (nausea, constipation, dry mouth).

Pharmacokinetics

Absorption: Well absorbed after oral or IM administration.

Distribution: Unknown.

Metabolism and Excretion: Unknown.

Half-life: Unknown.

Contraindications/Precautions

Contraindicated in: Hypersensitivity; Angle-closure glaucoma; Bowel obstruction; Megacolon; Tardive dyskinesia.

Use Cautiously in: Prostatic enlargement; Seizure disorders; Cardiac arrhythmias; OB/Lactation: Safety not established; Geri: Increased risk of adverse reactions; lower doses may be necessary.

Interactions

Drug-Drug: Additive anticholinergic effects with drugs sharing anticholinergic properties, such as antihistamines, phenothiazines, quinidine, disopyramide, and tricyclic antidepressants. Counteracts the cholinergic effects of bethanechol. Antacids or antidiarrheals may ↓ absorption.

Drug-Natural: ↑ anticholinergic effects with angel's trumpet and jimson weed, and scopolia.

Route/Dosage

Parkinsonism

PO (Adults): 2 mg 3–4 times daily initially (not to exceed 16 mg/day).

Extrapyramidal Reactions

PO (Adults): 2 mg 1–3 times daily.

IM, IV (Adults): 2 mg, may repeat q 30 min (not to exceed 8 mg or 4 doses/24 hr).

IM (Children): 40 mcg (0.04 mg)/kg or 1.2 mg/m², may repeat q 30 min (not to exceed 4 doses/24 hr).

Availability

Tablets: 2 mg. Injection: 5 mg/mL.

INTRODUCTION

Indications

Management of hypertension.

Action

Blocks stimulation of beta₁ (myocardial)–adrenergic receptors. Does not usually affect beta₂(pulmonary, vascular, uterine) receptor sites. Therapeutic Effects: Decreased blood pressure and heart rate.

Adverse Reactions/Side Effects

CNS: fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia, memory loss, mental status changes, nervousness, nightmares. EENT: blurred vision, stuffy nose. Resp: bronchospasm, wheezing. CV: BRADYCARDIA, CHF, PULMONARY EDEMA, hypotension, peripheral vasoconstriction. GI: constipation, diarrhea, liver function abnormalities, nausea, vomiting. GU: erectile dysfunction, decreased libido, urinary frequency. Derm: rashes. Endo: hyperglycemia, hypoglycemia. MS: arthralgia, back pain, joint pain. Misc: drug-induced lupus syndrome.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Assess heart rate, ECG, and heart sounds, especially during exercise (See Appendices G, H). Report an abnormally slow heart rate (bradycardia) or symptoms of other arrhythmias, including palpitations, chest discomfort, shortness of breath, fainting, and fatigue/weakness.

• Assess routinely for signs of CHF and pulmonary edema, including dyspnea, rales/crackles, weight gain, peripheral edema, and jugular venous distention. Report these signs to the physician immediately.

• Assess blood pressure (BP) periodically and compare to normal values (See Appendix F) to help document antihypertensive effects. Report low BP (hypotension), especially if patient experiences dizziness, fatigue, or other symptoms.

• Assess symptoms of bronchospasm (wheezing, coughing, tightness in chest). Perform pulmonary function tests to quantify suspected changes in ventilation and respiration (See Appendices I, J, K). Repeated or prolonged bronchoconstriction may require a change in dose or medication.

• Monitor signs of peripheral vasoconstriction, such as extreme coldness in the hands and feet, cyanosis, and muscle cramping. Notify physician of severe or prolonged signs of vasoconstriction.

• Be alert for signs of hypoglycemia (weakness, malaise, irritability, fatigue) or hyperglycemia (drowsiness, fruity breath, increased urination, unusual thirst). Medication may mask some signs of hypoglycemia, but dizziness and sweating may still occur. Patients with diabetes mellitus should check blood glucose levels frequently.

• Assess any back, joint, or muscle pain to rule out musculoskeletal pathology; that is, try to determine if pain is drug induced rather than caused by anatomic or biomechanical problems.

• Monitor mood and personality changes, including depression, anxiety, nervousness, memory loss, or other changes in mental status and behavior. Notify physician if these changes become problematic.

• Assess dizziness and drowsiness that might affect gait, balance, and other functional activities (See Appendix C). Report balance problems and functional limitations to the physician, and caution the patient and family/caregivers to guard against falls and trauma.

• Monitor excessive fatigue or weakness. Beta blockers often cause some degree of fatigue and weakness, but any sudden or severe change in muscle strength or energy levels should be reported.

• Monitor signs of drug-induced lupus syndrome, including increased BP, fever, joint pain, skin rashes, and redness/irritation of the eye (uveitis). Notify physician promptly if these signs appear.

Interventions

• Because of an increased risk of CHF and cardiac arrhythmias, use caution during aerobic exercise and endurance conditioning. Terminate exercise if patient exhibits untoward symptoms (chest pain, shortness of breath, unusual fatigue.) or displays other criteria for exercise termination (See Appendix L).

• Establish aerobic exercise workloads that account for the effects of beta blockers on heart rate. Some heart rate guidelines may not be appropriate because beta blockers typically decrease maximal HR by 20–30 bpm. Use other guidelines such as rating of perceived exertion (RPE, modified Borg scale) to determine exercise workloads.

• To minimize orthostatic hypotension, patient should move slowly when assuming a more upright position.

Patient/Client-Related Instruction

• Remind patients to take medication as directed to control hypertension even if they are asymptomatic.

• Counsel patients about additional interventions to help control BP, including regular exercise, weight loss, sodium restriction, stress reduction, moderation of alcohol consumption, and smoking cessation.

• Instruct patient or family/caregivers to report other troublesome side effects such as severe or prolonged insomnia, nightmares, blurred vision, stuffy nose, increased urinary frequency, decreased libido, erectile dysfunction, skin rash, or GI problems (nausea, vomiting, constipation, and/or diarrhea).

Pharmacokinetics

Absorption: Well absorbed after oral administration, but 20% undergoes first-pass hepatic metabolism.

Distribution: Unknown.

Metabolism and Excretion: 50% excreted unchanged by the kidneys; remainder renally excreted as metabolites; 2% excreted in feces.

Half-life: 9–12 hr.

Contraindications/Precautions

Contraindicated in: Uncompensated CHF; Pulmonary edema; Cardiogenic shock; Bradycardia or heart block.

Use Cautiously in: Renal impairment (dosage reduction recommended); Hepatic impairment (dosage reduction recommended); Pulmonary disease (including asthma; beta₁ selectivity may be lost at higher doses); avoid use if possible; Diabetes mellitus (may mask signs of hypoglycemia); Thyrotoxicosis (may mask symptoms); Patients with a history of severe allergic reactions (intensity of reactions may be increased); OB/Lactation/Pedi: Safety not established; crosses the placenta and may cause fetal/neonatal bradycardia, hypotension, hypoglycemia, or respiratory depression; Geri: Increased sensitivity to beta blockers; initial dosage reduction recommended.

Interactions

Drug-Drug: General anesthetics, IV phenytoin, and verapamil may cause additive myocardial depression. Additive bradycardia may occur with digoxin. Additive hypotension may occur with other antihypertensives, acute ingestion of alcohol, or nitrates. Concurrent use with amphetamine, cocaine, ephedrine, epinephrine, norepinephrine, phenylephrine, or pseudoephedrine may result in unopposed alphaadrenergic stimulation (excessive hypertension, bradycardia). Concurrent thyroid preparation administration may decrease effectiveness. May alter the effectiveness of insulins or oral hypoglycemic agents (dosage adjustments may be necessary). May decrease the effectiveness of theophylline. May decrease the beneficial beta₁-cardiovascular effects of dopamine or dobutamine. Use cautiously within 14 days of MAO inhibitor therapy (may result in hypertension).

Route/Dosage

PO (Adults): 5 mg once daily; may be increased to 10 mg once daily (range 2.5–20 mg/day).

Renal Impairment

Hepatic Impairment

PO (Adults): CCr <40 mL/min—Initiate therapy with 2.5 mg/day, titrate cautiously.

Availability (generic available)

Tablets: 5 mg, 10 mg. In combination with: hydrochlorothiazide (Ziac). See Appendix B.

INTRODUCTION

Indications

Used in conjunction with aspirin to reduce the risk of acute ischemic complications in patients with unstable angina who are undergoing percutaneous transluminal angioplasty (PCTA) or percutaneous coronary intervention (PCI). Patients with or at risk of heparininduced thrombocytopenia (HIT) and thrombosis syndrome (HITTS) who are undergoing PCI.

Action

Specifically and reversibly inhibits thrombin by binding to its receptor sites. Inhibition of thrombin prevents activation of factors V, VIII, and XII; the conversion of fibrinogen to fibrin; platelet adhesion and aggregation. Therapeutic Effects: Decreased acute ischemic complications in patients with unstable angina (death, MI, or the urgent need for revascularization procedures).

Adverse Reactions/Side Effects

CNS: headache, anxiety, insomnia, nervousness. CV: hypotension, bradycardia, hypertension. GI: nausea, abdominal pain, dyspepsia, vomiting. Hemat: BLEEDING. Local: injection site pain. MS: back pain. Misc: pain, fever, pelvic pain.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Assess signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; black, tarry stools; hematuria; fall in hematocrit or blood pressure). Notify physician or nursing staff immediately of these signs.

• Assess blood pressure (BP) and compare to normal values (See Appendix F). Report changes in BP, either a problematic decrease in BP (hypotension) or a sustained increase in BP (hypertension).

• Assess heart rate, ECG, and heart sounds, especially during exercise (See Appendices G, H). Report an abnormally slow heart rate (bradycardia) or signs of other arrhythmias, including palpitations, chest discomfort, shortness of breath, fainting, and fatigue/weakness.

• Assess any back pain or pelvic pain to rule out musculoskeletal pathology; that is, try to determine if pain is drug induced rather than caused by anatomic or biomechanical problems. Be especially alert for sudden back pain that might indicate abdominal hemorrhage.

• Monitor and report anxiety, nervousness, or other problematic changes in mood and behavior.

• Monitor injection site for pain, swelling, and irritation. Report prolonged or excessive injection site reactions to the physician or nursing staff.

Interventions

• Use caution with any physical interventions that could increase bleeding, including wound débridement, chest percussion, joint mobilization, and application of local heat.

Patient/Client-Related Instruction

• Instruct patient to immediately report signs of GI bleeding, including abdominal pain, vomiting blood, blood in stools, or black, tarry stools.

• Instruct patient to report other bothersome side effects such as severe or prolonged fever, sleep loss, or GI problems (nausea, vomiting, indigestion, abdominal pain).

Pharmacokinetics

Absorption: IV administration results in complete bioavailability.

Distribution: Unknown.

Metabolism and Excretion: Cleared from plasma by a combination of renal mechanisms and proteolytic breakdown.

Half-life: 25 min (increased in renal impairment).

Contraindications/Precautions

Contraindicated in: Active major bleeding; Hypersensitivity.

Use Cautiously in: Any disease state associated with an increased risk of bleeding; Heparininduced thrombocytopenia or heparin-induced thrombocytopenia-thrombosis syndrome; Patients with unstable angina not undergoing PCTA; Patients with other acute coronary syndromes; Concurrent use with other platelet aggregation inhibitors (safety not established); Renal impairment (infusion rate reduction recommended if GFR <60 mL/min); Lactation/Pedi: Safety not established; OB: Use only if clearly needed.

Interactions

Drug-Drug: Risk of bleeding may be ↑ by concurrent use of abciximab, heparin, low-molecular-weight heparins/heparinoids, ticlopidine, thrombolytics, or any other drugs that inhibit coagulation.

Drug-Natural: ↑ risk of bleeding with arnica, chamomile, clove, dong quai, feverfew, garlic, ginger, gingko, Panax ginseng, and others.

Route/Dosage

IV (Adults): 0.75 mg/kg as a bolus injection, followed by an infusion at a rate of 1.75 mg/kg/hr for the duration of the PCI procedure. An activated clotting time (ACT) should be performed 5 min after bolus dose and an additional bolus dose of 0.3 mg/kg may be administered if needed. Continuation of the infusion (at a rate of 1.75 mg/kg/hr) for up to 4 hr postprocedure is optional. If needed, the infusion may be continued beyond this initial 4 hr at a rate of 0.2 mg/kg/hr for up to 20 hr. Therapy should be initiated prior to the procedure and given in conjunction with aspirin.

Renal Impairment

IV (Adults): No reduction in the bolus dose is needed in any patient with renal impairment. GFR 10–29 mL/min—Reduce infusion rate to 1 mg/kg/hr; Dialysis-dependent patients (off dialysis)—Reduce infusion rate to 0.25 mg/kg/hr. ACT should be monitored in all patients with renal impairment.

Availability

Powder for injection: 250 mg/vial.

INTRODUCTION

Indications

Treatment of Lymphomas, Squamous cell carcinoma, Testicular embryonal cell carcinoma, Choriocarcinoma, Teratocarcinoma. Intrapleural administration to prevent the reaccumulation of malignant effusions.

Action

Inhibits DNA and RNA synthesis. Therapeutic Effects: Death of rapidly replicating cells, particularly malignant ones.

Adverse Reactions/Side Effects

CNS: aggressive behavior, disorientation, weakness. Resp: PULMONARY FIBROSIS, pneumonitis. CV: hypotension, peripheral vasoconstriction. GI: anorexia, nausea, stomatitis, vomiting. Derm: hyperpigmentation, mucocutaneous toxicity, alopecia, erythema, rashes, urticaria, vesiculation. Hemat: anemia, leukopenia, thrombocytopenia. Local: pain at tumor site, phlebitis at IV site. Metab: weight loss. Misc: ANAPHYLACTOID REACTIONS, chills, fever.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Assess pulmonary function periodically by measuring lung volumes, breath sounds, and respiratory rate (See Appendices I, J, K). Notify physician immediately if patient experiences signs of pulmonary fibrosis or pneumonitis such as dry cough, dyspnea, chest pain, shortness of breath, cyanosis, and fever.

• Monitor signs of anaphylactoid reactions, including pulmonary symptoms (tightness in the throat and chest, wheezing, cough, dyspnea) or skin reactions (rash, pruritus, urticaria). Notify physician or nursing staff immediately if these reactions occur.

• Be alert for disorientation, aggressive behavior, or other alterations in mental status (See Appendix D). Notify physician promptly if these symptoms develop.

• Assess blood pressure (BP) periodically and compare to normal values (See Appendix F). Report low BP (hypotension), especially if patient experiences dizziness, fainting, or other symptoms.

• Monitor signs of peripheral vasoconstriction, such as extreme coldness in the hands and feet, cyanosis, and muscle cramping. Notify physician of severe or prolonged signs of vasoconstriction.

• Watch for signs of leukopenia (fever, sore throat, signs of infection), thrombocytopenia (bruising, nose bleeds, bleeding gums) or unusual weakness and fatigue that might be due to anemia. Report these signs to the physician or nursing staff.

• Periodically assess body weight and other anthropometric measures (body mass index, body composition). Report a rapid or unexplained weight loss or decreased body fat.

• Monitor IV injection site for pain, swelling, and inflammation. Report prolonged or excessive injection site reactions to the physician.

Interventions

• For patients who are medically able to begin exercise, implement appropriate resistive exercises and aerobic training to maintain muscle strength and aerobic capacity during cancer chemotherapy or to help restore function after chemotherapy.

• Because of the risk of pulmonary fibrosis and abnormal BP responses, use caution during aerobic exercise and other forms of therapeutic exercise. Assess exercise tolerance frequently (BP, heart rate, breathing responses, fatigue levels), and terminate exercise immediately if any untoward responses occur (See Appendix L).

Patient/Client-Related Instruction

• Advise patient about the likelihood of GI reactions including nausea, vomiting, loss of appetite, and inflammation in/around the mouth. Instruct patient to report severe or unexpected GI reactions.

• Advise patient that hair loss and other skin reactions (rash, itching, hives, blistering, changes in pigmentation) are likely. Severe or unexpected skin reactions should be reported to the physician or nursing staff.

• Advise patient to guard against infection (frequent hand washing, etc.) and avoid crowds and contact with persons with contagious diseases.

Pharmacokinetics

Absorption: Well absorbed from IM and SC sites. Absorption follows intrapleural and intraperitoneal administration.

Distribution: Widely distributed, concentrates in skin, lungs, peritoneum, kidneys, and lymphatics.

Metabolism and Excretion: 60–70% excreted unchanged by the kidneys.

Half-life: 2 hr (increased in renal impairment).

Contraindications/Precautions

Contraindicated in: Hypersensitivity; OB/Lactation: Potential for fetal, infant harm.

Use Cautiously in: Renal impairment (dose reduction required if <35 mL/min); Pulmonary impairment; Nonmalignant chronic debilitating illness; Patients with childbearing potential; Geri: Increased risk of pulmonary toxicity and related decrease in renal function.

Interactions

Drug-Drug: Hematologic toxicity ↑ with concurrent use of radiation therapy and other antineoplastics. Concurrent use with cisplatin ↓ elimination of bleomycin and may ↑ toxicity. ↑ risk of pulmonary toxicity with other antineoplastics or thoracic radiation therapy. General anesthesia ↑ the risk of pulmonary toxicity. ↑ risk of Raynaud's syndrome when used with vinblastine.

Route/Dosage

Lymphoma patients should receive initial test doses of 2 units or less for the first 2 doses.

IV, IM, SC (Adults and Children): 0.25–0.5 unit/kg (10–20 units/m²) weekly or twice weekly initially. If favorable response, lower maintenance doses given (1 unit/day or 5 units/wk IM or IV). May also be given as continuous IV infusion at 0.25 unit/kg or 15 units/m²/day for 4–5 days.

Intrapleural: (Adults): 15–20 units instilled for 4 hr, then removed.

Availability (generic available)

Injection: 15 units/vial, 30 units/vial.

INTRODUCTION

Indications

Multiple myeloma (as initial therapy or after progression); with melphalan and prednisone). Mantle cell lymphoma after at least one other therapy.

Action

Inhibits proteasome, a regulator of intracellular protein catabolism, resulting in disruption of various intracellular processes. Cytotoxic to a variety of cancerous cells. Therapeutic Effects: Death of rapidly replicating cells, particularly malignant ones.

Adverse Reactions/Side Effects

CNS: fatigue, malaise, weakness, dizziness, syncope. EENT: blurred vision, diplopia. CV: hypotension, CHF. Resp: pneumonia. GI: anorexia, constipation, diarrhea, nausea, vomiting. Hemat: BLEEDING, anemia, neutropenia, thrombocytopenia. Neuro: peripheral neuropathy. Misc: fever, tumor lysis syndrome.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Be alert for any unusual bleeding and signs of thrombocytopenia (bruising, nose bleeds, bleeding gums), neutropenia (fever, sore throat, signs of infection), or any unusual weakness and fatigue that could be due to anemia. Report these signs to the physician or nursing staff immediately.

• Assess any breathing problems or signs of pneumonia such as cough, fever, chills, and chest pain during inspiration and expiration. Monitor pulse oximetry and perform pulmonary function tests (See Appendices I, J, K) to quantify suspected changes in ventilation and respiratory function.

• Assess blood pressure (BP) periodically and compare to normal values (See Appendix F). Report low BP (hypotension), especially if patient experiences dizziness, syncope, or other symptoms.

• Monitor signs of congestive heart failure, including dyspnea, rales/crackles, peripheral edema, jugular venous distention, and exercise intolerance. Report these signs to the physician.

• Monitor neuromuscular signs of electrolyte imbalances that might indicate tumor lysis syndrome. Signs include severe muscle weakness or paralysis due to increased plasma potassium (hyperkalemia) or muscle hyperexcitability and tetany due to phosphate and calcium imbalances (hyperphosphatemia and hypocalcemia). Notify physician immediately if these signs occur.

• Monitor signs of peripheral neuropathy (numbness, tingling, decreased muscle strength). Establish baseline electroneuromyographic values at the beginning of drug treatment whenever possible, and reexamine these values periodically to document drug-induced changes in peripheral nerve function.

Interventions

• For patients who are medically able to begin exercise, implement appropriate resistive exercises and aerobic training to maintain muscle strength and aerobic capacity during cancer chemotherapy or to help restore function after chemotherapy.

• Because of possible heart failure and abnormal BP responses, use caution during aerobic exercise and endurance conditioning. Terminate exercise if patient exhibits untoward symptoms (chest pain, shortness of breath, etc.) or displays other criteria for exercise termination (See Appendix L).

Patient/Client-Related Instruction

• Advise patient to guard against infection (frequent hand washing, etc.) and avoid crowds and contact with persons with contagious diseases.

• Advise patient and family/caregivers that fatigue and weakness are likely and may be severe. Functional abilities may be limited, and patient may need to use assistive devices during ambulation.

• Advise patient about the likelihood of GI reactions (constipation, diarrhea, nausea, vomiting, loss of appetite). Instruct patient to report severe, prolonged GI problems.

• Instruct patient to report any vision disturbances, including blurred or double vision.

Pharmacokinetics

Absorption: IV administration results in complete bioavailability.

Distribution: Unknown.

Metabolism and Excretion: Mostly metabolized by the liver (P450 enzymes); excretion is unknown.

Half-life: 9–15 hr.

Contraindications/Precautions

Contraindicated in: Hypersensitivity to bortezomib, boron, or mannitol; OB: Potential fetal harm; Lactation: Potential for serious adverse reaction in nursing infants.

Use Cautiously in: OB: Women with childbearing potential; Hepatic impairment (may ↑ levels, risk of toxicity); History of or risk factors for CHF; Pedi: Safety not established.

Interactions

Drug-Drug: Concurrent neurotoxic medications, including amiodarone, some antivirals, nitrofurantoin, isoniazid, or HMG CoA reductase inhibitors may ↑ risk of peripheral neuropathy.

Route/Dosage

IV (Adults): 1.3 mg/m² twice weekly for 2 wk (days 1, 4, 8, and 11) followed by a 10-day rest; further cycles/doses depend on response and toxicity.

Availability

Lyophilized powder for injection (requires reconstitution): 3.5 mg/vial.

INTRODUCTION