A to Z case 24

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ISONIAZID

Class:Anti-infective/Antitubercular

ActionInterferes with lipid and nucleic acid biosynthesis in actively growing tubercle

bacilli.

IndicationsTreatment of all forms of tuberculosis. Unlabeled use(s):Improvement ofsevere tremor in multiple sclerosis.

ContraindicationsPrevious isoniazid-associated hepatic injury, drug fever, chills, or

arthritis; acute liver disease.

Route/Dosage

Tuberculosis

ADULTS: PO/IM5 mg/kg/day as single daily dose (max 300 mg/day). INFANTS &

CHILDREN: PO/IM10 to 20 mg/kg/day in single daily dose (max 300 mg/day).

Mul tiple Sclerosis

ADULTS: PO/IM300 to 400 mg/day, increased over 2 wk to 20 mg/kg/day.

Interactions

Aluminum salts:May reduce oral absorption of isoniazid; give isoniazid 1 to 3 hr before

aluminum salts. Carbamazepine:May result in carbamazepine toxicity or isoniazid

hepatotoxicity. Monitor carbamazepine concentrations and liver function.Disulfiram:May

result in increased incidence of CNS effects (eg, coordination difficulties, confusion,

irritability, aggressiveness).Enflurane:May result in high-output renal failure in rapid

acetylators. Monitor renal function.Hydantoins:May increase serum hydantoin levels.

Rifampin:May result in higher rate of hepatotoxicity.

Lab Test InterferencesNone well documented.

Adverse Reactions

CNS:Peripheral neuropathy; convulsions; toxic encephalopathy; optic neuritis and atrophy;

memory impairment; toxic psychosis.DERM:Morbilliform, maculopapular, purpuric or

exfoliative skin eruptions. GI:Nausea; vomiting; epigastric distress.HEMA:

Agranulocytosis; hemolytic, sideroblastic or aplastic anemia; thrombocytopenia;

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eosinophilia.HEPA:Hepatotoxicity, including elevated serum transaminase levels,

bilirubinemia, bilirubinuria, jaundice, severe and sometimes fatal hepatitis.META:

Pyridoxine deficiency; pellagra; hyperglycemia; metabolic acidosis; hypocalcemia;

hypophosphatemia. OTHER:Gynecomastia; rheumatic syndrome; systemic lupus

erythematosus-like syndrome; local irritation at IM injection site.

Precautions

Pregnancy:Safety undetermined.Lactation:Excreted in breast milk.Hepatic impairment:

Common prodromal symptoms of hepatotoxicity include anorexia, nausea, vomiting, fatigue,

malaise, and weakness. Patients with acute hepatic disease should have preventive

tuberculosis treatment deferred. Incidence of hepatic reaction increases in patients > 50 yr.

Hypersensitivity:Discontinue drug at first sign of hypersensitivity reaction. Restart only after

symptoms have cleared.Pyridoxine administration:Prophylactic concomitant administration

of pyridoxine (6 to 50 mg/day) is recommended in malnourished patients and those

predisposed to neuropathy (eg, alcoholics, diabetics).Renal impairment:Monitor patientswith severe renal dysfunction carefully.

PATIENT CARE

CONSIDERATIONS

Administration/Storage

Oral form available in tablet and syrup forms. Administer oral medication on empty stomach at least 1 hr before or 2 hr after meals. If GI irritation becomes problem, drug may be administered with food, although food

decreases absorption of drug.

Antacids may be given 1 hr before administration. Store at room temperature and protect from moisture.

Assessment/Interventions

Obtain patient history, including drug history and any known allergies. Assess mycobacterial studies and susceptibility tests before and periodically

throughout therapy to detect possible resistance.

Evaluate hepatic function studies before and monthly during therapy (SGOT [AST],SGPT [ALT]) and serum bilirubin.

Assess patient for adverse reactions: GI distress, peripheral neuritis, optic neuritis, orhypersensitivity reactions.

If nausea, vomiting, anorexia, or diarrhea develop, obtain order for antiemetic orantidiarrheal medication and assess for hepatotoxicity.

Take safety precautions if patient experiences adverse CNS symptoms such asconfusion or incoordination.

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OVERDOSAGE:SIGNS& SYMPTOMSNausea, vomiting, dizziness, slurring of speech,

blurring of vision, visual hallucinations, respiratory

distress, CNS depression, stupor, coma, severe

seizures

Patient/Family Education

Teach patient and family the name, dose, action, and side effects of isoniazid. Advise patient to minimize daily alcohol consumption while taking isoniazid because

of the increased risk of hepatitis.

Instruct patient to report the following symptoms to physician: Weakness; fatigue;loss of appetite; nausea and vomiting; yellowing of skin or eyes; darkening of urine;

numbness or tingling in hands or feet.

Emphasize to patient that treatment will be lengthy and that patient must completeentire course of therapy. Relapse of tuberculosis is higher if chemotherapy is

discontinued prematurely.

Advise patient to return for laboratory follow-up. Caution patient not to perform activities that require mental alertness if adverse CNS

symptoms occur.

RIFAMPISIN

(RIFF-am-pin)

Rifadin, Rimactane, Rofact

Class:Anti-infective/Antitubercular

ActionInhibits DNA-dependent RNA polymerase in susceptible strains of bacteria.

IndicationsAdjunctive treatment of tuberculosis; short-term management to eliminate

meningococci from nasopharynx inNeisseria meningitidiscarriers. Unlabeled use(s):

Treatment of infections caused by Staphylococcus aureusand Staphylococcus epidermidis;treatment of gram-negative bacteremia in infancy; treatment ofLegionella; management of

leprosy; prophylaxis ofHaemophilus influenzaemeningitis.

ContraindicationsHypersensitivity to any rifamycin.

Route/Dosage

Tuberculosis

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ADULTS: PO/IV600 mg once daily. CHILDREN: PO/IV10 to 20 mg/kg/day (max 600

mg/day).

Meningococcal Carr iers

ADULTS: PO/IV600 mg once daily for 4 consecutive days. CHILDREN 1 Mo: PO/IV10mg/kg q 12 hr for 2 consecutive days. CHILDREN < 1 MO: 5 mg/kg q 12 hr for 2

consecutive days.

Interactions

Oral anticoagulants, azole antifungal agents, benzodiazepines, beta-blockers, buspirone,

chloramphenicol, clarithromycin, clozapine, oral contraceptives, corticosteroids,

cyclosporine, delavirdine, digitoxin, disopyramide, doxycycline, erythromycin, estrogens,

haloperidol, hydantoins, indinavir, losartan, methadone, mexiletine, morphine, nelfinavir,

ondansetron, quinidine, quinine, ritonavir, sulfonylureas, tacrolimus, tamoxifen,theophyllines, tocainide, toremifene, tricyclic antidepressants, troleandomycin, verapamil,

zolpidem:Therapeutic efficacy may be decreased due to liver enzyme-inducing properties of

rifampin.Digoxin:May decrease digoxin serum concentrations.Enalapril:May significantly

increase BP.Halothane:Hepatotoxicity and hepatic encephalopathy have been reported with

concomitant administration.Isoniazid:May result in higher rate of hepatotoxicity.

Ketoconazole:May cause treatment failure of either ketoconazole or rifampin.Probenecid:

Elevates rifampin levels.

Lab Test InterferencesMay inhibit standard microbiological assays for serum folate

and vitamin B12. Thus, use alternate assay methods. Transient abnormalities in liver function

tests (eg, elevation in serum bilirubin, abnormal bromsulfophthalein excretion, alkaline

phosphatase, serum transaminases) and reduced biliary excretion of contrast media used for

visualization of gallbladder may occur. Therefore, perform these tests before the morning

dose of rifampin.

Adverse Reactions

CV:Hypotension; shock. CNS:Headache; drowsiness; fatigue; dizziness; inability to

concentrate; mental confusion; generalized numbness; behavioral changes; myopathy.DERM:Rash; pruritus; urticaria; pemphigoid reaction; flushing.EENT:Visual disturbances;

exudative conjunctivitis. GI:Heartburn; epigastric distress; anorexia; nausea; vomiting; gas;

cramps; diarrhea; sore mouth and tongue; pseudomembranous colitis; pancreatitis. GU:

Hemoglobinuria; hematuria; renal insufficiency; acute renal failure. HEMA:Eosinophilia;

transient leukopenia; hemolytic anemia; decreased hemoglobin; hemolysis;

thrombocytopenia.HEPA:Asymptomatic elevations of liver enzymes and hepatitis.RESP:

Shortness of breath; wheezing. OTHER:Ataxia; muscular weakness; pain in extremities;

osteomalacia; myopathy; menstrual disturbances; fever; elevations in BUN; elevated serum

uric acid; possible immunosuppression; abnormal growth of lung tumors; reduced 25-

hydroxycholecalciferol levels; edema of face and extremities; discoloration of body fluids.

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Precautions

Pregnancy:Category C.Lactation:Excreted in breast milk. Discontinue nursing or drug.

Body fluids:Medication may cause harmless red-orange discoloration of urine, feces, saliva,

sputum, sweat, and tears. Soft contact lenses may be permanently stained.Hepaticimpairment:Dosage adjustment is necessary.

PATIENT CARE

CONSIDERATIONS


Administer oral form 1 hr before or 2 hr after meals. Observe IV site closely for extravasation. For IV infusion, reconstitute powder in 10 mL of Sterile Water for Injection and swirl

gently. Reconstituted solution is stable at room temperature for 24 hr. Withdraw

appropriate dose of drug, mix with 500 mL of D5W, and infuse over 3 hr. If ordered,

drug may be added to 100 mL and infused over 30 min. A less concentrated solution

infused over a longer period is preferred.

If D5W is contraindicated, use sterile saline. Do not mix with other solutions. Initial dilutions of drug in vial are stable for 24 hr at room temperature. Use final dilution (500 or 100 mL volumes) within 24 hr because precipitation may

occur after this time period. Administer solution for injection by IV route only. Do not administer IM or SC.


Obtain patient history, including drug history, history of medication noncompliance,and any known allergies.

Obtain baseline CBC and liver and renal function test results, and monitor at regularintervals.

Assess skin prior to starting drug and during treatment for rash, pruritus, flushing,urticaria, and jaundice.

Assess baseline neurologic status and observe for changes. Monitor I&O and assess for development of edema.

OVERDOSAGE:SIGNS& SYMPTOMSNausea, vomiting, increasing lethargy,

unconsciousness, liver enlargement, jaundice,

increased direct and total bilirubin levels, altered

hepatic enzyme levels

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Instruct patient to take drug on empty stomach, 1 hr before or 2 hr after meals. Inform patient that body fluids may turn red-orange in color and that soft contact

lenses may become permanently stained. Advise patient to wear glasses during courseof therapy.

Instruct patient to notify physician of persistent anorexia, nausea, vomiting, diarrhea,jaundice, fever, change in color or consistency of stools, malaise or right upper

quadrant abdominal pain, unusual bleeding or bruising, petechiae, hematuria, bleeding

gums, or pallor.

Tell patient to notify physician of drowsiness, fatigue, dizziness, inability toconcentrate, confusion, or visual or behavioral changes.

Advise patient who uses oral contraceptives to use nonhormonal form ofcontraception during therapy.

Advise patient that drug may cause drowsiness and to use caution while driving orperforming other tasks requiring mental alertness.

Advise patient of importance of medication compliance in treatment of TB.Medication noncompliance reduces efficacy and promotes resistance.

Caution patient to avoid alcohol.

IBUPROFEN

(eye-BYOO-pro-fen)

dvil, Advil Liqui-Gels, Advil Migraine, Children's Advil, Children's Motrin, Genpril,

Haltran, Infant's Motrin, Junior Strength Advil, Junior Strength Motrin, Menadol, Midol

aximum Strength Cramp Formula, Motrin, Motrin IB, Motrin Migraine Pain, Nuprin,

PediaCare Fever, Pediatric Advil Drops, Actiprofen, Alti-Ibuprofen, Apo-Ibuprofen,

ovo-Profen, Nu-Ibuprofen

Class:Analgesic/NSAID

ActionDecreases inflammation, pain, and fever, probably through inhibition of

cyclooxygenase activity and prostaglandin synthesis.

IndicationsRelief of symptoms of rheumatoid arthritis, osteoarthritis, mild-to-moderate

pain, primary dysmenorrhea, reduction of fever. Unlabeled use(s):Symptomatic treatment of

juvenile rheumatoid arthritis, sunburn, resistant acne vulgaris.

ContraindicationsHypersensitivity to aspirin, iodides, or any other NSAID.

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hyponatremia; renal papillary necrosis.DERM:Rash; pruritus; erythema. OTHER:Muscle

cramps.

Precautions

Pregnancy:Pregnancy category undetermined.Lactation:Undetermined. Children:Safety

and efficacy not established.Elderly:Increased risk of adverse reactions. GI effects:Serious

GI toxicity (eg, bleeding, ulceration, perforation) can occur at any time, with or without

warning symptoms.Renal effects:Increased risk of dysfunction in patients with preexisting

renal disease.

PATIENT CARE

CONSIDERATIONS


Give medication soon after meals or with food, milk, or antacids to minimize GIirritation.


Obtain complete patient history, including drug history and any known allergies. Notify physician if visual changes or indications of GI distress or liver or renal

impairment occur.

Monitor patient's cardiac status: BP, pulse (quality and rhythm), edema, tachycardia,palpitations.

Assess renal function before and during therapy. Serum creatinine, creatinineclearance, and BUN should be monitored in patients with renal impairment.

Document any changes in liver function (AST, ALT), eye examinations and Hgb andHct in patients on long-term therapy.

Notify physician if indigestion, epigastric pain, unusual bleeding or bruising, or darktarry stools occur.

OVERDOSAGE:SIGNS& SYMPTOMSDrowsiness, lethargy, GI irritation/bleeding, nausea,

vomiting, tinnitus, sweating, acute renal failure,

epigastric pain, metabolic acidosis


Tell patient to take medication soon after meals or with food, milk, or antacids.

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Tell patient to avoid alcohol and medications containing aspirin, such as coldremedies.

Advise patient to discontinue drug and notify physician if any of the following occur:Persistent GI upset or headache, skin rash, itching, visual disturbances, black stools,

weight gain or edema, changes in urine pattern, joint pain, fever, blood in urine.

Instruct patient not to take otc preparation for > 3 days for fever and > 10 days forpain and to notify physician if condition does not improve.

Advise patient that drug may cause drowsiness and to use caution while driving orperforming other tasks requiring mental alertness.

Paracetamol

Class:Analgesic/antipyretic

ActionInhibits prostaglandins in CNS but lacks anti-inflammatory effects in periphery;reduces fever through direct action on hypothalamic heat-regulating center.

IndicationsRelief of mild-to-moderate pain; treatment of fever. Unlabeled use(s):Pain

and fever prophylaxis after vaccination.

ContraindicationsStandard considerations.

Route/Dosage

ORAL

ADULTS: PO325 to 650 mg prn q 4 to 6 hr or 1 g 3 to 4 times/day. Do not exceed 4 g/day.

CHILDREN: PO10 to 15 mg/kg dose prn q 4 to 6 hr; do not exceed 5 doses/24 hr.

SUPPOSITORIES

ADULTS: PR650 mg q 4 to 6 hr; do not exceed 6 suppositories/24 hr. CHILDREN: 36

YR: PR120 mg q 4 to 6 hr; do not exceed 720 mg/24 hr. CHILDREN: 612 YR: PR325 mgq 4 to 6 hr; do not exceed 2.6 g/24 hr.

Interactions

Ethanol:Chronic excessive use may increase risk of hepatotoxicity.Hydantoins,

sulfinpyrazone:May decrease therapeutic effect of APAP; concomitant long-term use may

increase risk of hepatotoxicity.

Lab Test InterferencesWith Chemstrip, bG Dextrostix, Visidex II home blood glucosemeasurement systems, drug may cause > 20% decrease in mean glucose.

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Adverse Reactions

HEMA:Hemolytic anemia; neutropenia; leukopenia; pancytopenia; thrombocytopenia.

HEPA:Jaundice. OTHER:Hypoglycemia; allergic skin eruptions or fever.

Precautions

Pregnancy:Category B.Lactation:Excreted in breast milk.Hepatic impairment:Chronic

alcoholics should not exceed 2 g/day.Persistent pain or fever:May indicate serious illness.

Physician should be consulted.

PATIENT CARE

CONSIDERATIONS


Administer with water 30 min before or 2 hr after meals. Store tablets and capsules at room temperature in tightly closed container. Refrigerate

suppositories. Refrigeration of elixir improves palatability.


Obtain patient history, including drug history and any known allergies. Assess for pain and fever before and 1 to 2 hr after administration. Assess serum glucose and liver enzyme levels before long-term therapy.

OVERDOSAGE:SIGNS& SYMPTOMSNausea, vomiting, abdominal pain, diarrhea,

anorexia, malaise, diaphoresis, confusion, low BP,

cardiac arrhythmias, jaundice, acute renal failure,

liver failure


Instruct family to consult physician for use in children < 3 yr and, not to continuetaking drug > 5 days unless advised by physician.

Instruct adult patients not to continue taking drug > 10 days for pain or 3 days forfever.

Instruct patient/family to contact physician if pain or fever (> 103F) persists > 3days.

Advise diabetic patients to use sugar-free form of drug.

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Ampisilin / sulbaktam

Class:Antibiotic/penicillin

ActionAmpicillin inhibits bacterial cell wall mucopeptide synthesis. Sulbactam inhibitsplasmid-medicated beta-lactamase enzymes commonly found in microorganisms resistant to

ampicillin.

IndicationsTreatment of infections of skin and skin structure, intra-abdominal and

gynecologic infections caused by susceptible microorganisms, and mixed infections caused

by ampicillin-susceptible organisms and beta-lactamaseproducing organisms.

ContraindicationsHypersensitivity to penicillins, cephalosporins or imipenem.

Route/Dosage

ADULTS: IV/IM1.5 to 3 g q 6 hr not to exceed 4 g/day sulbactam (1.5 g of product contains

0.5 g sulbactam). CHILDREN 1 YEAR OLD (< 40 KG): IV300 mg/kg/day (200 mg

ampicillin/100 mg sulbactam) in divided doses q 6 hr. CHILDREN 40 KG: IVDose

according to adult recommended doses; do not exceed total sulbactam dose of 4 g/day.

Interactions

Allopurinol:Increases potential for ampicillin-induced skin rash. Contraceptives, oral:May

reduce efficacy of oral contraceptives. Tetracyclines:May impair bactericidal effects of

ampicillin/sulbactam. INCOMPATIBILITIES: Do not mix with aminoglycosides (eg,

gentamicin).

Lab Test InterferencesMay cause false-positive urine glucose test results with

Benedict's Solution, Fehling's Solution, or Clinitesttablets (enzyme-based tests, eg, Clinistix,

Tes-tape, are recommended); falsepositive direct Coombs'test result in certain patient groups;false-positive protein reactions with sulfosalicylic acid and boiling test, acetic acid test, biuret

reaction and nitric acid test (the bromphenol blue test,Multistix, is recommended).

Adverse Reactions

CV:Thrombophlebitis at injection site. CNS:Dizziness; fatigue; insomnia; reversible

hyperactivity.DERM:Urticaria; maculopapular to exfoliative dermatitis; vesicular eruptions;

erythema multiforme; skin rashes.EENT:Itchy eyes; laryngospasm; laryngeal edema. GI:

Diarrhea; pseudomembranous colitis. GU:Interstitial nephritis (eg, oliguria, proteinuria,

hematuria, hyaline casts, pyuria); nephropathy; increased BUN and creatinine; vaginitis.HEMA:Decreased Hgb, Hct, RBC, WBC, neutrophils, lymphocytes, platelets; increased

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lymphocytes, monocytes, basophils, eosinophils and platelets.META:Elevated serum

alkaline phosphatase, glutamic oxaloacetic transaminase, ALT, AST, and LDH; reduced

serum albumin and total proteins. OTHER:Pain at injection site; hyperthermia.

Precautions

Pregnancy:Category B.Lactation:Excreted in breast milk. Children:Safety and efficacy not

established.Hypersensitivity:Reactions range from mild to life-threatening. Use cautiously in

cephalosporin-sensitive patients because of possible cross-allergenicity. Superinfection:May

result in overgrowth of nonsusceptible bacterial or fungal organisms.Renal impairment:Use

cautiously with altered dosing interval.

PATIENT CARE

CONSIDERATIONS


Do not mix in same IV solution with aminoglycosides. Administer IM and IV solutions within 1 hr of reconstitution. Allow foaming to subside before administering IV preparations. Do not administer if

discolored or cloudy. Use volumetric IV pump to regulate delivery over 10 to 15 min

period.

Do not infuse with other IV medications. Do not administer other antibiotics within 1 hr. Do not routinely exceed 14 days of IV therapy in children. Safety and efficacy of IM

administration have not been established.

Monitor renal function. Rotate IM injection sites. Keep refrigerated after reconstitution. Medication is stable for 2 hr at room

temperature, 72 hr if refrigerated.


Obtain patient history, including drug history and any known allergies. Review results of culture and sensitivity testing as available. Monitor I&O during therapy. Monitor patient's condition closely for several hours after administration even if there

is no history of known penicillin allergy. Notify physician of any signs and symptoms

of hypersensitivity or anaphylactic reaction.

OVERDOSAGE:SIGNS& SYMPTOMSHyperexcitability, convulsive seizures

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Explain rationale for hospitalization during course of therapy. Inform patient of potential side effects, and encourage a report of any problems. Encourage patient to increase fluid intake to 2000 to 3000 ml/day, unless

contraindicated.

Inform diabetic patients that this medication may cause false-positive glucose urinetest results, and identify types that will be more reliable.

If therapy is changed because of allergic reaction, explain significance of penicillinallergy, and inform of potential sensitivity to cephalosporins.

Prednison

Class:Corticosteroid

ActionIntermediate-acting glucocorticoid that depresses formation, release and activity

of endogenous mediators of inflammation, including prostaglandins, kinins, histamine,

liposomal enzymes and complement system. Also modifies body's immune response.

IndicationsEndocrine disorders; rheumatic disorders; collagen diseases; dermatologic

diseases; allergic states; allergic and inflammatory ophthalmic processes; respiratory

diseases; hematologic disorders; neoplastic diseases; edematous states (because of nephrotic

syndrome); GI diseases; multiple sclerosis; tuberculous meningitis; trichinosis with

neurologic or myocardial involvement. Unlabeled use(s):COPD; Duchenne's muscular

dystrophy; Graves ophthalmopathy.

ContraindicationsSystemic fungal infections; administration of live virus vaccines.

Route/Dosage

ADULTS: PO5 to 60 mg/day.

COPD

ADULTS: PO30 to 60 mg/day for 1 to 2 wk, then taper.

Duchenne's Muscular Dystrophy

ADULTS: PO0.75 to 1.5 mg/kg/day.

Graves Ophthalmopathy

ADULTS: PO60 mg/day; taper to 20 mg/day.

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Interactions

Anticholinesterases:Antagonizes anticholinesterase effects in myasthenia gravis.

Anticoagulants, oral:Alters anticoagulant dose requirements.Barbiturates, hydantoins (eg,

phenytoin), rifampin:Decreased pharmacologic effect of prednisone. Cyclosporine:Enhanced cyclosporine toxicity.Estrogens, ketoconazole, oral contraceptives:Decreased

clearance of prednisone.Nondepolarizing muscle relaxants:May potentiate, counteract, or

have no effect on neuromuscular blocking action. Salicylates:Reduced serum levels and

efficacy of salicylates. Somatrem:Inhibition of growth-promoting effects of somatrem.

Theophylline:Alterations in pharmacologic activity of either agent.

Lab Test InterferencesMay increase serum cholesterol; decrease serum levels of T3

and T4; decrease uptake of thyroid I131; and cause false-negative result on nitroblue-

tetrazolium test for systemic bacterial infection and suppression of skin test reactions.

Adverse Reactions

CV:Thromboembolism or fat embolism; thrombophlebitis; necrotizing angiitis; cardiac

arrhythmias or ECG changes; syncopal episodes; hypertension; myocardial rupture; CHF.

CNS:Convulsions; pseudotumor cerebri (increased intracranial pressure with papilledema);

vertigo; headache; neuritis/paresthesias; psychosis.DERM:Impaired wound healing; thin

fragile skin; petechiae and ecchymoses; erythema; lupus erythematosuslike lesions;

subcutaneous fat atrophy; purpura; striae; hirsutism; acneiform eruptions; allergic dermatitis;

urticaria; angioneurotic edema; perineal irritation.EENT:Posterior subcapsular cataracts;

increased intra-ocular pressure; glaucoma; exophthalmos. GI:Pancreatitis; abdominaldistention; ulcerative esophagitis; nausea; vomiting; increased appetite and weight gain;

peptic ulcer with perforation and hemorrhage; small and large bowel perforation. GU:

Increased or decreased motility and number of spermatozoa.HEMA:Leukocytosis.META:

Sodium and fluid retention; hypokalemia; hypokalemic alkalosis; metabolic alkalosis;

hypocalcemia. OTHER:Musculoskeletal effects (muscle weakness, steroid myopathy,

muscle mass loss, tendon rupture, osteoporosis, aseptic necrosis of femoral and humeral

heads, spontaneous fractures, including vertebral compression fractures and pathologic

fracture of long bones); endocrine abnormalities (menstrual irregularities, cushingoid state,

growth suppression in children secondary to adrenocortical and pituitary unresponsiveness,

increased sweating, decreased carbohydrate tolerance, hyperglycemia, glycosuria, increased

insulin or sulfonylurea requirements in diabetics, negative nitrogen balance because of

protein catabolism, hirsutism); anaphylactoid/hypersensitivity reactions; aggravation or

masking of infections; malaise; fatigue; insomnia.

Precautions

Pregnancy:Category C.Lactation:Excreted in breast milk. Children:Observe growth and

development of infants and children on prolonged therapy.Elderly:May require lower doses.

Adrenal suppression:Prolonged therapy may lead to hypothalamic-pituitary-adrenal

suppression. Cardiovascular effects:Use drug with great caution in patients who havesuffered recent MI.Hepatitis:Drug may be harmful in patients with chronic active hepatitis

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positive for hepatitis B surface antigen.Hypersensitivity:May occur, including anaphylaxis.

Immunosuppression:Do not administer live virus vaccines during treatment.Infections:May

mask signs of infection. May decrease host-defense mechanisms to prevent dissemination of

infection. Ocular effects:Use systemic drug cautiously in ocular herpes simplex because of

possible corneal perforation. Ophthalmic use:Prolonged use may result in glaucoma,

cataracts, or other complications.Peptic ulcer:May contribute to peptic ulceration, especiallywith large doses.Renal impairment:Use with caution; monitor renal function. Stress:

Increased dosage of rapidly acting corticosteroid may be needed before, during and after

stressful situations. Withdrawal:Abrupt discontinuation may result in adrenal insufficiency.

PATIENT CARE

CONSIDERATIONS


Administer with meal or snack. Give single daily dose before 9 AM; space multiple doses evenly throughout day. Do not administer to patients who have received live virus vaccine within last month.


Obtain patient history, including drug history and any known allergies. Note MI,diabetes, renal impairment, hepatitis, tuberculosis, peptic ulcer disease, ocular herpessimplex, or current infections.

Ensure that baseline laboratory tests have been obtained before beginning therapy,and monitor for possible hyperglycemia, hypokalemia, and hypocalcemia during

treatment.

Be aware that drug may mask signs of infection and that resistance to infection maybe diminished.

Observe for possible delayed wound healing. Monitor blood glucose of diabetic patient carefully. If menstrual irregularities, muscle wasting or weakness, rounded moon facies, fluid

retention, GI bleeding or mental status changes occur, notify physician.

Assess for signs of adrenal insufficiency (eg, fever, myalgia, arthralgia, malaise,anorexia, nausea, orthostatic hypotension, dizziness, fainting). Notify physician

immediately if this condition is suspected.

OVERDOSAGE:SIGNS& SYMPTOMSCushingoid changes, moonface, striae, central

obesity, hirsutism, acne, ecchymoses, hypertension,

osteoporosis, myopathy, sexual dysfunction,

diabetes mellitus, hyperlipidemia, peptic ulcer, GI

bleeding, increased susceptibility to infection,

electrolyte and fluid imbalance, psychosis

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Advise patient to take single daily doses or alternate day doses in morning (before 9AM) and to take multiple doses at evenly spaced intervals throughout day.

Instruct patient to take medication with meals or snack to avoid GI irritation. Caution patient not to discontinue drug suddenly, to avoid withdrawal syndrome.

Explain that dosage will be tapered slowly (until 5 mg/day) before stopping.

Warn patient to avoid people with known viral infections, particularly chickenpox ormeasles, and to inform physician if exposure occurs.

Explain that patient should not receive live virus vaccinations. Instruct diabetic patients to monitor blood glucose closely. Advise patient to notify health care providers of drug regimen before any surgical

procedure, emergency treatment, immunization, or skin test.

Tell patient to carry medical identification card at all times describing medicationbeing taken.

Tell patient about symptoms of adrenal insufficiency (eg, fever, myalgia, malaise,anorexia, nausea, orthostatic hypotension, dizziness, fainting) and need to report these

symptoms to physician immediately.

Instruct patient to report the folowing symptoms to physician: Black tarry stools,vomiting of blood, menstrual irregularities, unusual weight gain, swelling of lower

extremities, puffy face, muscle weakness, prolonged sore throat, fever, or cold.

Zink sulfat

(zink SULL-fate)

Eye-Sed, Orazinc, Verazinc, Zinc 15, Zinc-220, Zinca-Pak, Zincate, PMS-Egozinc

Class:Mineral

ActionActs as integral part of several enzymes important to protein and carbohydrate

metabolism, wound healing, maintenance of normal growth and skin hydration, and senses of

taste and smell.

IndicationsDietary supplementation; supplement to IV solutions given for TPN;treatment or prevention of zinc deficiencies. Ophthalmic solution used as mild astringent for

relief of eye irritation. unlabeled use(s):Treatment of acrodermatitis enteropathica and

delayed wound healing associated with zinc deficiency; treatment of acne, rheumatoid

arthritis, Wilson's disease.

ContraindicationsDirect injection of undiluted solution into peripheral vein.

Route/Dosage

Dietary Supplement

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ADULTS: PO25 to 50 mg/day.

Supplement to I V Solutions

METABOLICALLY STABLE ADULTS: IV2.5 to 4 mg/day. Add 2 mg/day for acute

catabolic state. STABLE ADULTS WITH FLUID LOSS FROM SMALL BOWEL: IVIncrease dose by 12.2 mg/L TPN or 17.1 mg/kg loose stool or ileostomy output. FULL-

TERM INFANTS & CHILDREN < 5 YR: IV100 mcg/kg/day. PREMATURE INFANTS

A to Z case 24

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