Pharmacologic ClassesAlkylating DrugsPREGNANCY CATEGORY DTherapeutic actionsAlkylating drugs are cytotoxic: They alkylate cellular DNA, interfering with the replication of susceptible cells and causing cell death. Indications Palliative treatent of chronic lyphocytic leukeia! alignant lyphoas, including lyphosarcoa, giant follicular lyphoa! brain tuors! "odgkin#s lyphoa! ultiple yeloas! testicular cancers! pancreatic cancer! ovarian and breast cancers $sed as part of ultiple%drug regiens Contraindications and cautions &ontraindicated with hypersensitivity to the drugs, concurrent radiation therapy, heatopoietic depression, pregnancy, lactation. Adverse eects CN!" Tremors, muscular twitching, confusion, agitation, ataxia, flaccid paresis, hallucinations, sei'ures Der#atologic" Skin rash, urticaria, alopecia, keratitis GI" Nausea, voiting, anorexia, hepatoto$icity G%" (terility &e#atologic" Bone marrow depression, hyperuriceia Respiratory" )ronchopulonary dysplasia, pul#onary i'rosis Other" Cancer, acute leukemia Nursing considerations*Assess#ent &istory" "ypersensitivity to drug, radiation therapy, heatopoietic depression, pregnancy, lactation Physical" T! weight! skin color, lesions! +, adventitious sounds! liver evaluation! &)&, differential, "gb, uric acid, ,-Ts, renal function tests InterventionsBlack box warning:Arrange for blood tests to evaluate heatopoietic function priorto and weekly during therapy! severe bone arrow suppression is possible. +estrict dosage within . wk after a full course of radiation therapy or cheotherapy because of risk of severe bone arrow depression. /nsure that patient is well hydrated before treatent. Arrange for fre0uent sall eals and dietary consultation to aintain nutrition if 12 upset occurs. Arrange for skin care for rashes. Black box warning: (uggest use of contraception! serious fetal abnoralities or death is possible.Teaching points (ide effects: Nausea, voiting, loss of appetite 3dividing dose ay help! fre0uent sall eals ay help! aintain fluid intake and nutrition! drink at least *45*6 glasses of fluid each day7! infertility 3potentially irreversible and irregular enses to aenorrhea and asperia! discuss feelings with your health care provider7! these drugs can cause severe birth defects! use birth control ethods while on these drugs. +eport unusual bleeding or bruising! fever, chills, sore throat! cough, shortness of breath! yellowing of the skin or eyes! flank or stoach pain. Representative drugsaltretainebusulfancarustinechlorabucilcyclophosphaide6dacarba'ineestraustineifosfaideloustineechlorethaineelphalanstrepto'ocinthiotepa Alpha()adrenergic *lockersPREGNANCY CATEGORY CTherapeutic actionsAlpha*%adrenergic blockers selectively block postsynaptic alpha*%adrenergic receptors, decreasing sypathetic tone on the vasculature, dilating arterioles and veins, and lowering both supine and standing )P! unlike conventional alpha%adrenergic blockers 3phentolaine7, they do not also block alpha6 presynaptic receptors, so they do not cause reflex tachycardia. They also relax sooth uscle of bladder and prostate.Indications Treatent of hypertension 3alone or with other drugs7 Treatent of )P" 3alfu'osin, doxa'osin, tera'osin, tasulosin7 $nlabeled uses: 8anageent of refractory &"- and +aynaud#s vasospas! treatent of prostatic outflow obstruction! syptoatic treatent of chronic abacterial prostatitis 3tera'osin7 Contraindications and cautions &ontraindicated with hypersensitivity to any alpha*%adrenergic blocker, lactation. $se cautiously with &"-, renal failure, pregnancy. Adverse eects CN!" Dizziness, headache, drowsiness, lack of energy, weakness, nervousness, vertigo, depression, paresthesias 9 C+" Palpitations, sodiu and water retention, increased plasa volue, edea, dyspnea, syncope, tachycardia, orthostatic hypotension Der#atologic" +ash, pruritus, lichen planus EENT" )lurred vision, reddened sclera, epistaxis, tinnitus, dry outh, nasal congestion GI" Nausea, voiting, diarrhea, constipation, abdoinal discofort or pain G%" $rinary fre0uency, incontinence, ipotence Other" Diaphoresis InteractionsDrug)drug , (everity and duration of hypotension following first dose of drug ay begreater in patients receiving beta%adrenergic blockers 3propranolol7, verapail7Nursing considerationsAssess#ent &istory" "ypersensitivity to alpha*%adrenergic blocker, &"-, renal failure, lactation Physical" :eight! skin color, lesions! orientation, affect, reflexes! ophthalologicexaination! P, )P, orthostatic )P, supine )P, perfusion, edea, auscultation!adventitious sounds, status of nasal ucous ebranes! bowel sounds, noral output! voiding pattern, noral output! renal function tests, urinalysis InterventionsAdinister, or have patient take, first dose at night to lessen likelihood of first%dose syncope believed to be caused by excessive postural hypotension. 8onitor patient for orthostatic hypotension: ost arked in the orning, accentuated by hot weather, alcohol, exercise. 8onitor edea, weight in patients with incipient cardiac decopensation! arrangeto add a thia'ide diuretic to the drug regien if sodiu and fluid retention, signs of ipending &"- occur. . /stablish safety precautions if &N(, hypotensive changes occur 3side rails, accopany patient7. Provide consultations to help patient cope with sexual dysfunction and priapis. Teaching points Take these drugs exactly as prescribed. Take the first dose at bedtie. Do not drive a car or operate achinery for . hours after the first dose. !ide eects" Di''iness, weakness ay occur when changing position, in the earlyorning, after exercise, in hot weather, and after consuing alcohol! tolerance ay occur after taking these drugs for a while, but avoid driving or engaging in tasks that re0uire alertness while experiencing these syptos! change position slowly, and use caution in clibing stairs! lie down if di''iness persists! 12 upset 3fre0uent sall eals ay help7! ipotence 3discuss this with your health care provider7! dry outh 3sucking on sugarless lo'enges, ice chips ay help7! stuffy nose. 8ost of these effects will stop with continued therapy. +eport fre0uent di''iness or faintness. Representative drugsalfu'osindoxa'osinpra'osintasulosintera'osin A#inoglycosidesPREGNANCY CATEGORY DTherapeutic actionsAinoglycosides are antibiotics that are bactericidal. They inhibit protein synthesis in susceptible strains of gra%negative bacteria! appear to disrupt the functional integrity of bacterial cell ebrane, causing cell death. ;ral ainoglycosides are very poorly absorbed and are used for the suppression of 12 bacterial flora.Indications (hort%ter treatent of serious infections caused by susceptible strains of Pseudomonas species, Escherichia coli, indole%positive Proteus species, A Arrange for culture and sensitivity tests before beginning therapy. &ontinue therapy for 6 days after the signs and syptos of infection have disappeared. Adinister oral drug * hr before or 6 hr after eals with a glass of water. /nsure that patient is well hydrated during course of drug therapy. Adinister antacids, if needed, at least 6 hr after dosing. 8onitor clinical response! if no iproveent is seen or a relapse occurs, repeat culture and sensitivity. /nsure ready access to bathroo if diarrhea occurs. Arrange for appropriate bowel training progra if constipation occurs. Provide fre0uent sall eals if 12 upset occurs. Arrange for onitoring of environent 3noise, teperature7 and analgesics, for headache. /stablish safety precautions if &N(, visual changes occur. /ncourage patient to coplete full course of therapy. Teaching points Take oral drugs on an epty stoach, * hour before or 6 hours after eals. 2f youneed an antacid, do not take it within 6 hours of ciprofloxacin dose. Drink plenty of fluids. Side effects: Nausea, voiting, abdoinal pain 3fre0uent sall eals ay help7! diarrhea or constipation 3consult your health care provider7! drowsiness, blurring of vision, di''iness 3observe caution if driving or using ha'ardous e0uipent7. +eport rash, visual changes, severe 12 probles, weakness, treors. Representative drugsciprofloxacingeifloxacin>Clevofloxacinloefloxacinoxifloxacinnorfloxacinofloxacinsparfloxacin &ista#ine8 .&8/ AntagonistsPREGNANCY CATEGORY *Therapeutic actions"6 antagonists inhibit the action of histaine at the "6 receptors of the stoach, inhibiting gastric acid secretion and reducing total pepsin output! the resultant decrease inacid allows healing of ulcerated areas.Indications (hort%ter and aintenance treatent of active duodenal ulcer and benign gastriculcer Treatent of pathologic hypersecretory conditions 3Qollinger%/llison syndroe7 and erosive 1/+D Prophylaxis of stress%induced ulcers and acute upper 12 bleed in critically ill patients Treatent of 1/+D, heartburn, acid indigestion, sour stoach Contraindications and cautions &ontraindicated with allergy to "6 antagonists, ipaired renal or hepatic function,or lactation. Adverse eects CN!" Di''iness, sonolence, headache, confusion, hallucinations, peripheral neuropathy, syptos of brain ste dysfunction 3dysarthria, ataxia, diplopia7 C+" &ardiac arrhythias, arrest! hypotension 32B use7 @4 GI" Diarrhea &e#atologic" 2ncreases in plasa creatinine, seru transainase Other" 2potence 3reversible with drug withdrawal7, gynecoastia 3long%ter treatent7, rash, vasculitis, pain at 28 in=ection site InteractionsDrug)drug , 2ncreased risk of decreased white blood cell counts with antietabolites,alkylating agents, other drugs known to cause neutropenia ? 2ncreased seru levels and risk of toxicity of warfarin%type anticoagulants, phenytoin, beta%adrenergic blockers, alcohol, 0uinidine, lidocaine, theophylline, chloro0uine, certain ben'odia'epines 3alpra'ola, chlordia'epoxide, dia'epa, flura'epa, tria'ola7, nifedipine, pentoxifylline, tricyclic antidepressants, procainaide, carbaa'epine when taken with "6 antagonistsNursing considerationsAssess#ent &istory" Allergy to "6 antagonists, ipaired renal or hepatic function, lactation Physical" (kin lesions! orientation, affect! pulse, baseline /&1 3continuous with 2B use7! liver evaluation, abdoinal exaination, noral output! &)&, ,-Ts, renal function tests Interventions Adinister drug with eals and at bedtie. Decrease doses in renal and hepatic ipairent. Adinister 28 dose undiluted, deep into large uscle group. /nsure ready access to bathroo. Provide cofort easures for skin rash, headache. /stablish safety easures if &N( changes occur 3side rails, accopany patient7. Arrange for regular follow%up, including blood tests to evaluate effects. @*Teaching points Take these drugs with eals and at bedtie! therapy ay continue for .5> weeks or longer. Take prescribed antacids exactly as prescribed! be careful of the tie. 2nfor your health care provider about your cigarette soking habits. &igarette soking decreases the effectiveness of these drugs. "ave regular edical follow%up while on this drug to evaluate your response. +eport sore throat, fever, unusual bruising or bleeding, tarry stools, confusion, hallucinations, di''iness, uscle or =oint pain. Representative drugscietidinefaotidineni'atidineranitidine &1G)CoA Inhi'itorsPREGNANCY CATEGORY 9Therapeutic actions"81%&oA inhibitors are antihyperlipideic. They are a fungal etabolite that inhibits the en'ye that cataly'es the first step in the cholesterol synthesis pathway in huans, resulting in a decrease in seru cholesterol, seru ,D,s 3associated with increased risk of &AD7, and either an increase or no change in seru "D,s 3associated with decreased risk of &AD7.Indications Ad=unct to diet in the treatent of elevated total and ,D, cholesterol in patients with priary hypercholesteroleia 3types 22a and 22b7 whose response to dietary restriction of saturated fat and cholesterol and other nonpharacologic easures has not been ade0uate Priary prevention of coronary events 3lovastatin, pravastatin7 (econdary prevention of &B events 3fluvastatin, lovastatin, pravastatin, sivastatin7.@6Contraindications and cautions &ontraindicated with allergy to "81%&oA inhibitors, fungal byproducts, pregnancy, or lactation, concurrent gefibro'il therapy. $se cautiously with ipaired hepatic function, cataracts. Adverse eects CN!" .eadache, "lurred ision, di''iness, insonia, fatigue, uscle craps, cataracts GI" 0latulence, a"dominal pain, cramps, constipation, nausea, omiting, heartburn &e#atologic" /levations of &PE, alkaline phosphatase, and transainases 1usculoskeletal" +habdoyolysis with possible renal failure InteractionsDrug)drug , 8onitor patients receiving "81%&oA inhibitors for possible severe yopathy or rhabdoyolysis if taken with cyclosporine, erythroycin, gefibro'il, niacinDrug)ood , +isk of increased seru levels if cobined with grapefruit =uiceNursing considerationsAssess#ent &istory" Allergy to "81%&oA inhibitors, fungal byproducts! ipaired hepatic function! cataracts! pregnancy! lactation Physical" ;rientation, affect, ophthalologic exaination! liver evaluation! lipid studies, ,-Ts Interventions Adinister drug at bedtie! highest rates of cholesterol synthesis are between idnight and < A8. &onsult with dietitian about low%cholesterol diets. Arrange for diet and exercise consultation. @9 Arrange for regular follow%up during long%ter therapy. Provide cofort easures to deal with headache, uscle craps, nausea. Arrange for periodic ophthalologic exaination to check for cataract developent. ;ffer support and encourageent to deal with disease, diet, drug therapy, and follow%up. Teaching points Take these drugs at bedtie. 2nstitute appropriate diet changes. Mou ay experience these side effects: Nausea 3eat fre0uent sall eals7! headache, uscle and =oint aches and pains 3ay lessen with tie7. "ave periodic ophthalic exainations while you are using these drugs. +eport severe 12 upset, changes in vision, unusual bleeding or bruising, dark urine or light%colored stools! uscle pain, weakness. Representative drugsatorvastatinfluvastatinlovastatinpravastatinrosuvastatinsivastatin 1acrolide Anti'ioticsPREGNANCY CATEGORY * or C .dirithro#ycin/Therapeutic actions8acrolides are antibiotics. They are bacteriostatic or bactericidal in susceptible bacteria! they bind to cell ebranes and cause changes in protein function, leading to bacterial cell death.Indications@. Treatent of acute infections caused by sensitive strains of Streptococcus pneumoniae, %ycoplasma pneumoniae, -isteria monocytogenes, -egionella pneumophila/ $+2s, lower respiratory tract infections, skin and soft%tissue infections caused by group A beta%heolytic streptococci when oral treatent is preferred to in=ectable ben'athine penicillin! P2D caused by Neisseria gonorrhoeae in patients allergic to penicillin! intestinal aebiasis caused by Entamoe"a histolytica/ infections in the newborn and in pregnancy that are caused by Chlamydia trachomatis and in adult chlaydial infections when tetracycline cannot be used! priary syphilis 3Treponema pallidum7 in penicillin%allergic patients! eliinating Bordetella pertussis organiss fro the nasopharynx of infected individuals and as prophylaxis in exposed and susceptible individuals! superficial ocular infections caused by susceptible strains of icroorganiss! prophylaxis of ophthalia neonatoru caused by N5 gonorrhoeae or C5 trachomatis Treatent of acne vulgaris and skin infections caused by sensitive icroorganiss 2n con=unction with sulfonaides to treat $+2s caused by .aemophilus influenzae Ad=unct to antitoxin in infections caused by Coryne"acterium diphtheriae and Coryne"acterium minutissimum Prophylaxis against alpha%heolytic streptococcal endocarditis before dental or other procedures in patients allergic to penicillin who have valvular heart disease and against infection in inor skin abrasions $nlabeled uses: /rythroycin base is used with neoycin before colorectal surgery to reduce wound infection! treatent of severe diarrhea associated with Campylo"acter enteritis or enterocolitis! treatent of genital, inguinal, or anorectal lyphogranuloa venereu infection! treatent of .aemophilus ducreyi 3chancroid7. Contraindications and cautions &ontraindicated with allergy to any acrolide antibiotic. $se cautiously with hepatic ipairent or lactation 3secreted and ay be concentrated in breast ilk! ay odify bowel flora of nursing infant and interfere with fever workups7. Adverse eects CN!" +eversible hearing loss, confusion, uncontrollable eotions, abnoral thinking @< Der#atologic" /dea, urticaria, deratitis, angioneurotic edea GI" $"dominal cramping, anore'ia, diarrhea, omiting, pseudoebranous colitis, hepatotoxicity &ypersensitivity" Allergic reactions ranging fro rash to anaphyla$is 3ocal" (rritation, "urning, itching at site of application Other" Superinfections InteractionsDrug)drug , 2ncreased seru levels of digoxin ? 2ncreased effects of oral anticoagulants, theophyllines, carbaa'epine ? 2ncreased therapeutic and toxic effects of corticosteroids ? 2ncreased levels of cyclosporine and risk of renal toxicity ? 2ncreased irritant effects with peeling, des0uaating, or abrasive agents used with deratologic preparationsDrug)la' test , 2nterferes with fluoroetric deterination of urinary catecholaines ?Decreased urinary estriol levels caused by inhibition of hydrolysis of steroids in the gut.Nursing considerationsAssess#ent &istory" Allergy to acrolides, hepatic ipairent, lactation, viral, fungal, ycobacterial infections of the eye 3ophthalologic7 Physical" (ite of infection, skin color, lesions! orientation, affect, hearing tests! +,adventitious sounds! 12 output, bowel sounds, liver evaluation! culture and sensitivity tests of infection, urinalysis, ,-Ts Interventions &ulture site of infection before therapy. Adinister oral erythroycin base or stearate on an epty stoach, * hr before or 659 hr after eals, with a full glass of water 3oral erythroycin estolate, ethylsuccinate, and certain enteric%coated tablets! see anufacturer#s instructions! ay be given without regard to eals7. Adinister drug around the clock to axii'e therapeutic effect! scheduling ay have to be ad=usted to inii'e sleep disruption. @>Black box warning: 8onitor liver function in patients on prolonged therapy! serious toxicity can occur. 2nstitute hygiene easures and treatent if superinfections occur. 2f 12 upset occurs with oral therapy, soe preparations 3see previous7 ay be given with eals, or it ay be possible to substitute one of these preparations. Provide fre0uent sall eals if 12 probles occur. /stablish safety easures 3accopany patient, side rails7 if &N( changes occur. 1ive patient support and encourageent to continue with therapy. :ash affected area, rinse well, and dry before topical application. Teaching points Take oral drugs on an epty stoach, * hour before or 659 hours after eals, with a full glass of water, or, as appropriate, drug ay be taken without regard to eals. These drugs should be taken around the clock! schedule to inii'e sleep disruption. 2t is iportant that you finish the full course of the drug therapy. :ash and rinse area and pat it dry before applying topical solutions! use fingertipsor an applicator! wash hands thoroughly after application. Side effects: (toach craping, discofort 3taking the drug with eals, if appropriate, ay alleviate this proble7! uncontrollable eotions, crying, laughing, abnoral thinking 3will end when the drug is stopped7. +eport severe or watery diarrhea, severe nausea or voiting, dark urine, yellowing of the skin or eyes, loss of hearing, skin rash or itching. Representative drugsa'ithroycinclarithroycindirithroycinerythroycin NitratesPREGNANCY CATEGORY CTherapeutic actions@@Nitrates are antianginals. They relax vascular sooth uscle with a resultant decrease in venous return and decrease in arterial blood pressure, which reduces left ventricular workload and decreases yocardial oxygen consuption, relieving the pain of angina.Indications Treatent of acute angina 3sublingual, translingual, inhalant preparations7 Prophylaxis of angina 3oral sustained release, sublingual, topical, transderal, translingual, transucosal preparations7 Treatent of angina unresponsive to recoended doses of organic nitrates or beta%blockers 32B preparations7 8anageent of perioperative hypertension, &"- associated with acute 82 32B preparations7 Produce controlled hypotension during surgery 32B preparations7 $nlabeled uses: +eduction of cardiac workload in acute 82 and in &"- 3sublingual, topical7 and ad=unctive treatent of +aynaud#s disease 3topical7 Contraindications and cautions &ontraindicated with allergy to nitrates, angle%closure glaucoa, severe aneia, early 82, head traua, cerebral heorrhage, cardioyopathy, concoitant use with phosphodiesterase type < 3PD/R S >R area in a thin, unifor layer using the applicator. &over area with plastic wrap held in place by adhesive tape. +otate sites of application to decrease the chance of inflaation and sensiti'ation! close tube tightly when finished. Adinister transderal systes to skin site free of hair and not sub=ect to uch oveent. (have areas that have a lot of hair. Do not apply to distal extreities. &hange sites slightly to decrease the chance of local irritation and sensiti'ation. @C+eove transderal syste before attepting defibrillation or cardioversion. +eove old syste before applying new syste. Adinister transucosal tablets by placing the between the lip and gu above the incisors or between the cheek and gu. /ncourage patient not to swallow and not to chew the tablet. Adinister the translingual spray directly onto the oral ucosa! preparation is notto be inhaled. :ithdraw drug gradually! .5> wk recoended period for the transderal preparations. /stablish safety easures if &N( effects, hypotension occur. Eeep environent cool, di, and 0uiet. Provide periodic rest periods for patient. Provide cofort easures and arrange for analgesics if headache occurs. 8aintain life support e0uipent on standby if overdose occurs or cardiac condition worsens. Provide support and encourageent to deal with disease, therapy, and needed lifestyle changes. Teaching points Place sublingual tablets under your tongue or in your cheek! do not chew or swallow the tablet! the tablet should burn or Gfi''leH under the tongue. Take nitroglycerin before chest pain begins, when you anticipate that your activities or situation ay precipitate an attack. Do not buy large 0uantities! these drugs do notstore well. Eeep these drugs in a dark, dry place, in a dark%colored glass bottle with a tight lid! do not cobine with other drugs. Mou ay repeat your dose every< inutes for a total of three tablets! if the pain is still not relieved, go to an eergency roo. Do not chew or crush the tied%release preparations! take on an epty stoach. (pread a thin layer of topical ointent on the skin using the applicator. Do not rubor assage the area. &over with plastic wrap held in place with adhesive tape. :ash your hands after application. Eeep the tube tightly closed. +otate the sites fre0uently to prevent local irritation. A4 To use transderal systes, you ay need to shave an area for application. Applyto a slightly different area each day. $se care if changing brands! each syste has a different concentration. +eove the old syste before applying a new one. Place transucosal tablets between the lip and gu or between the gu and cheek. Do not chew! try not to swallow. (pray translingual spray directly onto oral ucous ebranes! do not inhale. $se

&ontraindicated with allergy to any of the tetracyclines, allergy to tartra'ine 3in 6