C

cabazitaxel

ka-baz-i-tax-el

(Jevtana)

BLACK BOX ALERT All pts should be premedicated with a corticosteroid, an antihistamine, and an H₂ antagonist prior to infusion. Severe hypersensitivity reaction has occurred. Immediately discontinue infusion and give appropriate treatment if hypersensitivity reaction occurs. Neutropenic deaths reported. CBC, particularly ANC, should be obtained prior to and during treatment. Do not administer with neutrophil count 1,500/mm³ or less.

Do not confuse cabazitaxel with paclitaxel or Paxil, or Jevtana with Januvia, Levitra, or Sentra.

classification

PHARMACOTHERAPEUTIC: Microtubule inhibitor. CLINICAL: Antineoplastic (see p. 83C).

Action

Disrupts microtubular cell network, essential for cellular function. Results in inhibition of mitotic and interphase cellular functions. Therapeutic Effect: Blocks cells in mitotic phase of cell cycle, leading to cell death.

Pharmacokinetics

Widely distributed. Protein binding: 89%–92%. Metabolized in liver. Excreted in feces (76%), urine (3.7%). Half-life: 95 hrs.

Uses

Used in combination with prednisone for treatment of hormone-refractory metastatic prostate cancer previously treated with docetaxel-containing regimen.

Precautions

Contraindications: Those with neutrophil count of 1,500/mm³ or less, history of hypersensitivity to polysorbate 80. Caution: Severe hepatic impairment (bilirubin equal to or greater than ULN or AST and/or ALT over 1.5 times ULN), elderly, pregnancy, renal impairment (creatinine clearance less than 50 ml/min). Avoid concurrent use of strong CYP3A4 inhibitors (e.g., atazanavir, clarithromycin, indinavir, itraconazole, ketoconazole, nelfinavir, ritonavir, saquinavir, voriconazole). Concurrent use of moderate CYP3A4 inhibitors (e.g., diltiazem, erythromycin, fluconazole, fosamprenavir, verapamil) or strong CYP3A4 inducers (e.g., carbamazepine, phenytoin, rifampin).

 ​Lifespan considerations

Pregnancy/Lactation: May cause fetal harm. Crosses placental barrier. Do not breastfeed. Pregnancy Category D. Children: Safety and effectiveness not established. Elderly: Those 65 yrs and older have 5% greater risk of developing neutropenia, fatigue, dizziness, fever, urinary tract infection, dehydration.

Interactions

DRUG: Concurrent use of strong CYP3A4 inhibitors (atazanavir, clarithromycin, indinavir, itraconazole, ketoconazole, nefazodone, nelfinavir, ritonavir, saquinavir, voriconazole) may increase concentration of cabazitaxel and is not recommended. Strong CYP3A4 inducers (carbamazepine, phenobarbital, phenytoin, rifabutin, rifampin, rifapentine) may decrease cabazitaxel concentration. Live virus vaccine may potentiate virus replication, increase vaccine’s side effects, decrease response to vaccine. HERBAL: St. John’s wort, valerian may increase CNS depression. Echinacea may decrease effect. FOOD: Grapefruit, grapefruit juice may increase concentration/effects. LAB VALUES: May increase serum bilirubin AST, ALT. May decrease Hgb, Hct, neutrophils, platelets.

Availability (Rx)

Injection, Single-Use Vials, 2 per Kit: 60 mg/1.5 ml polysorbate 80 vial and one vial containing 13% ethanol (in diluent).

Administration/handling

◀ ALERT ▶ Wear gloves during preparation, handling. Two-step dilution process must be performed under aseptic conditions to prepare second (final) infusion solution. Medication undergoes two dilutions. After second dilution, administration should be initiated within 30 min.

Reconstitution

Step 1, First Dilution: • Each vial of cabazitaxel contains 60 mg/1.5 ml; must first be mixed with entire contents of supplied diluent. • Once reconstituted, resultant solution contains 10 mg/ml of cabazitaxel. • When transferring diluent, direct needle onto inside vial wall and inject slowly to limit foaming. • Remove syringe and needle, then gently mix initial diluted solution by repeated inversions for at least 45 sec to ensure full mixing of drug and diluent. • Do not shake. • Allow any foam to dissipate.

Step 2, Final Dilution: • Withdraw recommended dose and further dilute with 250 ml 0.9% NaCl or D₅W. • If dose greater than 65 mg is required, use larger volume of 0.9% NaCl or D₅W so that concentration of 0.26 mg/ml is not exceeded. • Concentration of final infusion should be between 0.10 and 0.26 mg/ml.

Rate of Administration • Use in-line 0.22-micron filter during administration. • Infuse over 1 hr.

Storage • Store vials at room temperature. • First dilution solution stable for 30 min. • Final dilution solution stable for 8 hrs at room temperature or 24 hrs if refrigerated.

Indications/routes/dosage

◀ ALERT ▶ Antihistamine (dexchlorpheniramine 5 mg, diphenhydramine 25 mg, or equivalent antihistamine), corticosteroid (dexamethasone 8 mg or equivalent steroid), and H₂ antagonist (ranitidine 50 mg or equivalent H₂ antagonist) should be given at least 30 min prior to each dose to reduce risk/severity of hypersensitivity.

Hormone-refractory metastatic prostate cancer

◀ ALERT ▶ Monitoring of CBC is essential on weekly basis during cycle 1 and before each treatment cycle thereafter so that the dose can be adjusted.

IV Infusion: ADULTS, ELDERLY: 25 mg/m² given as 1-hr infusion every 3 wks in combination with 10 mg prednisone daily throughout treatment. Dose modifications: grade 3 neutropenia, febrile neutropenia, severe or persistent diarrhea: Reduce dosage to 20 mg/m².

Side effects

Frequent (47%–16%): Diarrhea, fatigue, nausea, vomiting, constipation, esthesia (decreased sensitivity to touch), abdominal pain, anorexia, back pain. Occasional (13%–5%): Peripheral neuropathy, fever, dyspnea, cough, arthralgia, dysgeusia, dyspepsia, alopecia, peripheral edema, weight decrease, urinary tract infection, dizziness, headache, muscle spasm, dysuria, hematuria, mucosal inflammation, dehydration.

Adverse effects/toxic reactions

Hypersensitivity reaction may include generalized rash, erythema, hypotension, bronchospasm. 94% of pts develop grade 1–4 neutropenia and associated complications, including anemia, thrombocytopenia, sepsis. GI abnormalities, hypertension, arrhythmias, renal failure may occur.

Nursing considerations

Baseline assessment

Offer emotional support. Obtain baseline EKG, electrolytes, CBC, liver function test, testosterone levels prior to initiation of therapy.

Intervention/evaluation

Assess CBC, ANC prior to each infusion. Monitoring of CBC, ANC on weekly basis during cycle 1 and before each treatment cycle thereafter; do not administer if ANC less than 1,500 cells/mm³. Monitor ALT, AST. Monitor for hypersensitivity reaction (rash, erythema, dyspnea). Encourage adequate fluid intake. Monitor daily pattern of bowel activity, stool consistency. Offer antiemetics if nausea, vomiting occur. Closely monitor for signs/symptoms of neutropenia.

Patient/family teaching

• Report fever, chills, persistent sore throat, unusual bruising/bleeding, pale skin, fatigue. • Avoid tasks that require alertness, motor skills until response to drug is established. • Maintain strict oral hygiene. • Do not have immunizations without physician approval (drug lowers body’s resistance). • Avoid those who have received a live virus vaccine. • Avoid crowds, those with cough, sneezing.

cabozantinib

ka-boe-zan-ti-nib

(Cometriq)

BLACK BOX ALERT Complications including GI perforation and fistula formation have occurred. Severe and sometimes fatal hemorrhaging including hemoptysis, GI bleeding occurred in 3% of pts. Discontinue if visceral perforation, fistula formation (GI, tracheal/esophageal), severe hemorrhaging occurs.

classification

PHARMACOTHERAPEUTIC: Tyrosine kinase inhibitor. CLINICAL: Antineoplastic.

Action

Inhibits tyrosine kinase activity in tumor cells. Inhibits cell migration, proliferation, survival, and angiogenesis (new blood vessel formation). Therapeutic Effect: Inhibits thyroid tumor cell growth and metastasis.

Pharmacokinetics

Well absorbed after PO administration. Metabolized in liver. Protein binding: greater than 99%. Peak plasma concentration: 2–5 hrs. Excreted in feces (54%), urine (27%). Half-life: 55 hrs.

Uses

Treatment of progressive, metastatic medullary thyroid cancer.

Precautions

Contraindications: None known. Cautions: Moderate to severe hepatic impairment, baseline thrombocytopenia, anemia, neutropenia, recent surgery or dental procedures, open wounds, chronic electrolyte imbalance, dehydration, diarrhea, hypertension, recent history of hemorrhage or hemoptysis.

 ​Lifespan considerations

Pregnancy/Lactation: May cause fetal harm. Not recommended in nursing mothers. Must either discontinue drug or discontinue breastfeeding. Unknown if distributed in breast milk. Contraception recommended during treatment and up to 4 mos after discontinuation. Pregnancy Category D. Children: Safety and efficacy not established. Elderly: No age-related precautions noted.

Interactions

DRUG: CYP3A4 inhibitors (e.g., atazanavir, clarithromycin, itraconazole, ketoconazole, saquinavir, voriconazole) may increase concentration. CYP3A4 inducers (e.g., carbamazepine, phenobarbital, phenytoin, rifampin) may decrease concentration. HERBAL: St. John’s wort may decrease effect. FOOD: Grapefruit, grapefruit juice may increase concentration. High fatty meals may increase absorption/exposure. LAB VALUES: May decrease lymphocytes, neutrophils, platelets, serum calcium, magnesium, phosphorus, potassium, sodium. May increase serum ALT, AST, alkaline phosphatase, bilirubin, lipase, TSH, urine protein.

Availability (Rx)

Capsules: 20 mg, 80 mg.

Administration/handling

PO

• Give on empty stomach only; do not eat for at least 2 hrs before or 1 hr after administration. • Give with water. • Avoid grapefruit juice. • Do not break, crush, dissolve, or divide capsules.

Indications/routes/dosage

Metastatic medullary thyroid cancer

PO: ADULTS: 140 mg once daily.

Dosage modification

Hematologic/Nonhematologic Reaction, Drug Intolerance: Interrupt treatment and restart at 100 mg once daily (if previously taking 140 mg), or 60 mg once daily (if previously taking 100 mg). If previously taking 60 mg/day, resume 60 mg once daily once effects resolve.

Side effects

Frequent (63%–34%): Diarrhea, stomatitis, weight loss, decreased appetite, nausea, fatigue, oral pain, dysgeusia. Occasional (27%–7%): Constipation, abdominal pain, vomiting, asthenia, dysphonia, dry skin, headache, alopecia, dizziness, arthralgia, dysphagia, muscle spasms, erythema, dyspepsia, anxiety, musculoskeletal pain, paresthesia, peripheral neuropathy, hyperkeratosis.

Adverse effects/toxic reactions

May cause GI perforation (3%), GI fistula formation (1%), severe GI hemorrhaging (3%). Malignant hypertension may occur despite continued medical management. Thromboembolic events including venous/arterial thromboembolism, cerebral infarction, myocardial infarction have been reported. May cause ineffective wound healing or wound dehiscence requiring medical intervention. Osteonecrosis of the jaw may include mandibular pain, jaw bone erosion, periodontal/gingival infection or ulceration, osteomyelitis, impaired healing of the mouth after dental procedures. Palmar-plantar erythrodysesthesia syndrome (PPES), a chemotherapy-induced skin condition that presents as redness, swelling, numbness, skin sloughing of the hands and feet, has been reported. Reversible posterior leukoencephalopathy syndrome (RPLS) was reported in less than 1% of pts. Proteinuria may indicate nephrotic syndrome.

Nursing considerations

Baseline assessment

Obtain vital signs, baseline CBC, serum chemistries, magnesium, phosphate, ionized calcium, urinalysis. Assess for recent surgeries, dental procedures. Question for possibility of pregnancy, current breastfeeding status. Obtain negative urine pregnancy before initiating treatment. Obtain full medication history including vitamins, supplements, herbal products. Question for history of hypertension, hepatic impairment.

Intervention/evaluation

Monitor CBC, electrolytes, urinalysis. Routinely assess vital signs and report any change in blood pressure. Persistent diastolic hypertension may indicate hypertensive crisis. Reversible posterior leukoencephalopathy syndrome should be considered in pts with seizure, headache, visual disturbances, confusion, altered mental status. Assess hydration status; encourage PO intake; monitor daily pattern of bowel activity, stool consistency. Immediately report any hemorrhaging, bloody stools, abdominal pain, hemoptysis (may indicate GI perforation/fistula formation). Obtain EKG for palpitations, chest pain, hypokalemia, hyperkalemia, hypocalcemia, bradycardia, ventricular arrhythmias.

Patient/family teaching

• Blood levels will be routinely monitored. • Strictly avoid pregnancy. • Contraception should be utilized during treatment and up to 4 mos after discontinuation. • Report any yellowing of skin or eyes, abdominal pain, bruising, black/tarry stools, dark urine, decreased urine output, skin changes. • Report neurologic changes including altered mental status, seizures, headache, blurry vision, difficulty speaking, one-sided weakness (may indicate stroke, high blood pressure crisis, or life-threatening brain swelling). • Do not take herbal supplements. • Report any jaw pain or oral lesions, skin changes including skin sloughing or rash. • Notify physician before any planned surgeries or dental procedures. • Do not ingest grapefruit products. • Do not take with food; wait at least 2 hrs before or 1 hr after.

caffeine citrate

kaf-een sit-rate

(Cafcit)

classification

PHARMACOTHERAPEUTIC: Citrate salt of caffeine. CLINICAL: Bronchial smooth muscle relaxant.

Action

Stimulates medullary respiratory center. Appears to increase sensitivity of respiratory center to stimulatory effects of CO₂. Therapeutic Effect: Increases alveolar ventilation, reducing severity, frequency of apneic episodes.

Uses

Short-term treatment of apnea in premature infants from 28 wks to younger than 33 wks gestational age.

Precautions

Pregnancy Category C.

Interactions

DRUG: CNS stimulants may cause excessive CNS stimulation (e.g., nervousness, insomnia, seizures, arrhythmias). CYP1A2 inhibitors (e.g., cimetidine, ciprofloxacin) may increase concentration, risk of side effects. HERBAL: None significant. FOOD: None known. LAB VALUES: May increase or decrease serum glucose.

Availability (Rx)

Injection Solution: 20 mg/ml. Oral Solution: 20 mg/ml.

Administration/handling

PO

• May give without regard to meals. • May administer injectable solution orally.

IV

• Infuse loading dose over at least 30 min; maintenance dose over at least 10 min. • May give without further dilution.

IV compatibilities

Alprostadil, calcium gluconate, cefotoxime, dexamethasone, dobutamine, dopamine, gentamicin, heparin, vancomycin.

IV incompatibilities

Acyclovir, furosemide.

Indications/routes/dosage

Apnea

PO, IV: Loading dose: 10–20 mg/kg as caffeine citrate (5–10 mg/kg as caffeine base). If theophylline given within previous 72 hrs, a modified dose (50%–75%) may be given. Maintenance: 5 mg/kg/day as caffeine citrate (2.5 mg/kg/day as caffeine base) starting 24 hrs after loading dose. Dosage adjusted based on pt response. Maximum: 20 mg/kg/day.

Side effects

Frequent (10%–5%): Feeding intolerance, rash.

Adverse effects/toxic reactions

Sepsis, necrotizing enterocolitis may occur.

Nursing considerations

Baseline assessment

Baseline serum caffeine levels should be measured in infants previously treated with theophylline (preterm infants metabolize theophylline to caffeine).

Intervention/evaluation

Monitor respirations diligently. Assess skin for rash. Monitor heart rate, number/severity of apnea spells, serum caffeine levels.

calcitonin

kal-si-toe-nin

(Apo-Calcitonin , Calcimar , Caltine , Fortical, Miacalcin)

Do not confuse calcitonin with calcitriol, or Miacalcin with Micatin.

classification

PHARMACOTHERAPEUTIC: Synthetic hormone. CLINICAL: Calcium regulator, bone resorption inhibitor (see p. 143C).

Action

Decreases osteoclast activity in bones, decreases tubular reabsorption of sodium and calcium in kidneys, increases absorption of calcium in GI tract. Therapeutic Effect: Regulates serum calcium concentrations.

Pharmacokinetics

Nasal form rapidly absorbed. Injection form rapidly metabolized primarily in kidneys; primarily excreted in urine. Half-life: Nasal: 43 min; Injection: 70–90 min.

Uses

Parenteral: Treatment of Paget’s disease, hypercalcemia, postmenopausal osteoporosis. Intranasal: Postmenopausal osteoporosis. OFF-LABEL: Treatment of secondary osteoporosis due to drug therapy or hormone disturbance.

Precautions

Contraindications: Hypersensitivity to salmon protein. Cautions: None known.

 ​Lifespan considerations

Pregnancy/Lactation: Does not cross placenta; unknown if distributed in breast milk. Safe usage during lactation not established (inhibits lactation in animals). Pregnancy Category C. Children: Safety and efficacy not established. Elderly: No age-related precautions noted.

Interactions

DRUG: May decrease lithium concentration/effects. HERBAL: None significant. FOOD: None known. LAB VALUES: None significant.

Availability (Rx)

Injection Solution (Miacalcin): 200 international units/ml (calcitonin-salmon). Nasal Spray (Fortical, Miacalcin Nasal): 200 international units/activation (calcitonin-salmon).

Administration/handling

IM, subcutaneous

• IM route preferred if injection volume greater than 2 ml. Subcutaneous injection for outpatient self-administration unless volume greater than 2 ml. • Skin test should be performed before therapy in pts suspected of sensitivity to calcitonin. • Bedtime administration may reduce nausea, flushing.

Intranasal

• Refrigerate unopened nasal spray. Store at room temperature after initial use. • Instruct pt to clear nasal passages. • Tilt head slightly forward. • Insert spray tip into nostril, pointing toward nasal passages, away from nasal septum. • Spray into one nostril while pt holds other nostril closed and concurrently inspires through nose to deliver medication as high into nasal passage as possible. Spray into one nostril daily.

Indications/routes/dosage

Skin testing before treatment in pts with suspected sensitivity to calcitonin-salmon

Intracutaneous: ADULTS, ELDERLY: Prepare a 10-international units/ml dilution; withdraw 0.05 ml from a 200-international units/ml vial in a tuberculin syringe; fill up to 1 ml with 0.9% NaCl. Give 0.1 ml intradermally on inner aspect of forearm. Observe after 15 min; a positive response is the appearance of more than mild erythema or wheal.

Paget’s disease

IM, Subcutaneous: ADULTS, ELDERLY: Initially, 100 international units/day. Maintenance: 50 international units/day or 50–100 international units every 1–3 days.

Postmenopausal osteoporosis

IM, Subcutaneous: ADULTS, ELDERLY: 100 international units every other day with adequate calcium and vitamin D intake.

Intranasal: ADULTS, ELDERLY: 200 international units/day as a single spray, alternating nostrils daily.

Hypercalcemia

IM, Subcutaneous: ADULTS, ELDERLY: Initially, 4 international units/kg q12h; may increase to 8 international units/kg q12h if no response in 2 days; may further increase to 8 international units/kg q6h if no response in another 2 days.

Side effects

Frequent: IM, Subcutaneous (10%): Nausea (may occur soon after injection, usually diminishes with continued therapy), inflammation at injection site. Nasal (12%–10%): Rhinitis, nasal irritation, redness, mucosal lesions. Occasional: IM, Subcutaneous (5%–2%): Flushing of face, hands. Nasal (5%–3%): Back pain, arthralgia, epistaxis, headache. Rare: IM, Subcutaneous: Epigastric discomfort, dry mouth, diarrhea, flatulence. Nasal: Itching of earlobes, pedal edema, rash, diaphoresis.

Adverse effects/toxic reactions

Pts with a protein allergy may develop a hypersensitivity reaction (rash, dyspnea, hypotension, tachycardia).

Nursing considerations

Baseline assessment

Establish baseline serum electrolyte levels.

Intervention/evaluation

Ensure rotation of injection sites; check for inflammation. Assess vertebral bone mass (document stabilization/improvement). Assess for allergic response: rash, urticaria, swelling, shortness of breath, tachycardia, hypotension. Monitor serum electrolytes, calcium, alkaline phosphatase.

Patient/family teaching

• Instruct pt/family on aseptic technique, proper injection method of subcutaneous medication, including rotation of sites, proper administration of nasal medication. • Nausea is transient and usually decreases over time. • Immediately report rash, itching, shortness of breath, significant nasal irritation. • Improvement in biochemical abnormalities and bone pain usually occurs in the first few months of treatment. • Improvement of neurologic lesions may take more than a year.

calcium acetate

(Eliphos, PhosLo)

calcium carbonate

(Apo-Cal , Caltrate 600 , OsCal , Titralac, Tums)

calcium chloride calcium citrate

(Cal-Citrate, Citracal, Osteocit )

calcium glubionate

 

calcium gluconate

kal-si-um

Do not confuse Citracal with Citrucel, OsCal with Asacol, or PhosLo with ProSom.

classification

PHARMACOTHERAPEUTIC: Electrolyte replenisher. CLINICAL: Antacid, antihypocalcemic, antihyperkalemic, antihypermagnesemic, antihyperphosphatemic (see p. 13C).

Action

Essential for function, integrity of nervous, muscular, skeletal systems. Plays an important role in normal cardiac/renal function, respiration, blood coagulation, cell membrane and capillary permeability. Assists in regulating release/storage of neurotransmitters/hormones. Neutralizes/reduces gastric acid (increases pH). Calcium acetate: Binds with dietary phosphate, forming insoluble calcium phosphate. Therapeutic Effect: Replaces calcium in deficiency states; controls hyperphosphatemia in end-stage renal disease, relieves heartburn, indigestion.

Pharmacokinetics

Moderately absorbed from small intestine (absorption depends on presence of vitamin D metabolites, pH). Primarily eliminated in feces.

Uses

Parenteral (calcium chloride, calcium gluconate): Acute hypocalcemia (e.g., neonatal hypocalcemic tetany, alkalosis), electrolyte depletion, cardiac arrest (strengthens myocardial contractions), hyperkalemia (reverses cardiac depression), hypermagnesemia (aids in reversing CNS depression). Calcium carbonate: Antacid, treatment/prevention of calcium deficiency, hyperphosphatemia. Calcium citrate: Antacid, treatment/prevention of calcium deficiency, hyperphosphatemia. Calcium acetate: Controls hyperphosphatemia in end-stage renal disease. OFF-LABEL (Calcium chloride): Calcium channel blocker overdose, severe hyperkalemia, malignant arrhythmias associated with hypermagnesemia.

Precautions

Contraindications: All preparations: Calcium-based renal calculi, hypercalcemia, ventricular fibrillation. Calcium chloride: Digoxin toxicity. Calcium gluconate: Neonates: concurrent IV use with ceftriaxone. Cautions: Chronic renal impairment, hypokalemia, concurrent use with digoxin.

 ​Lifespan considerations

Pregnancy/Lactation: Distributed in breast milk. Unknown whether calcium chloride or gluconate is distributed in breast milk. Pregnancy Category C. Children: Extreme irritation, possible tissue necrosis or sloughing with IV. Restrict IV use due to small vasculature. Elderly: Oral absorption may be decreased.

Interactions

DRUG: Hypercalcemia may increase digoxin toxicity. Oral form may decrease absorption of biphosphonates (e.g., risedronate), calcium channel blockers, tetracycline derivatives, thyroid products. HERBAL: None significant. FOOD: Food may increase calcium absorption. LAB VALUES: May increase serum pH, calcium, gastrin. May decrease serum phosphate, potassium.

Availability

CALCIUM ACETATE

Gelcap (PhosLo): 667 mg (equivalent to 169 mg elemental calcium). Tablets (Eliphos): 667 mg (equivalent to 169 mg elemental calcium).

CALCIUM CARBONATE

Tablets: 1,250 mg (equivalent to 500 mg elemental calcium); 1,500 mg (equivalent to 600 mg elemental calcium) (Caltrate 600). Tablets (Chewable): 500 mg (equivalent to 200 mg elemental calcium) (Tums); 1,250 mg (equivalent to 500 mg elemental calcium).

CALCIUM CHLORIDE

Injection Solution: 10% (100 mg/ml) equivalent to 27.2 mg elemental calcium per ml.

CALCIUM GLUBIONATE

Syrup: 1.8 g/5 ml (equivalent to 115 mg elemental calcium per 5 ml).

CALCIUM GLUCONATE

Injection Solution: 10% (equivalent to 9 mg elemental calcium per ml).

Administration/handling

IV

Dilution

Calcium Chloride • May give undiluted or may dilute with 0.9% NaCl or Sterile Water for Injection.

Calcium Gluconate • May give undiluted or may dilute with 100 ml 0.9% NaCl or D₅W.

Rate of Administration

Calcium Chloride • Note: Rapid administration may produce bradycardia, metallic/chalky taste, hypotension, sensation of heart, peripheral vasodilation. • IV push: Infuse slowly at maximum rate of 50–100 mg/min (in cardiac arrest, may administer over 10–20 sec). • IV infusion: Dilute to maximum final concentration of 20 mg/ml and infuse over 1 hr or no faster than 45–90 mg/kg/hr. Give via a central line. Do NOT use scalp, small hand or foot veins. Stop infusion if pt complains of pain or discomfort.

Calcium Gluconate • Note: Rapid administration may produce vasodilation, hypotension, arrhythmias, syncope, cardiac arrest. • IV push: Infuse slowly over 3–5 min or at maximum rate of 50–100 mg/min (in cardiac arrest, may administer over 10–20 sec). • IV infusion: Dilute 1–2 g in 100 ml 0.9% NaCl or D₅W and infuse over 1 hr.

Storage • Store at room temperature. • Once diluted, stable for 24 hrs at room temperature.

PO

Calcium Acetate • Administer with plenty of fluids during meals to optimize effectiveness.

Calcium Carbonate • Administer with or immediately following meals with plenty of water (give with meals if used for phosphate binding). Thoroughly chew chewable tablets before swallowing.

Calcium Citrate • Give without regard to food (give with food when used to treat hyperphosphatemia).

Calcium Glucobionate • Give with or following meals (give on empty stomach before meals when used to treat hyperphosphatemia).

IV incompatibilities

Calcium chloride: Amphotericin B complex (Abelcet, AmBisome, Amphotec), pantoprazole (Protonix), phosphate-containing solutions, propofol (Diprivan), sodium bicarbonate. Calcium gluconate: Amphotericin B complex (Abelcet, AmBisome, Amphotec), fluconazole (Diflucan).

IV compatibilities

Calcium chloride: Amikacin (Amikin), dobutamine (Dobutrex), lidocaine, milrinone (Primacor), morphine, norepinephrine (Levophed). Calcium gluconate: Ampicillin, aztreonam (Azactam), cefazolin (Ancef), cefepime (Maxipime), ciprofloxacin (Cipro), dobutamine (Dobutrex), enalapril (Vasotec), famotidine (Pepcid), furosemide (Lasix), heparin, lidocaine, lipids, magnesium sulfate, meropenem (Merrem IV), midazolam (Versed), milrinone (Primacor), norepinephrine (Levophed), piperacillin and tazobactam (Zosyn), potassium chloride, propofol (Diprivan).

Indications/routes/dosage

Hyperphosphatemia

PO (Calcium Acetate): ADULTS, ELDERLY: 2 tablets 3 times a day with meals. May increase gradually up to 4 tablets 3 times a day to decrease serum phosphate level to less than 6 mg/dl as long as hypercalcemia does not develop.

PO (Calcium Carbonate): ADULTS, ELDERLY, CHILDREN: 1 g with each meal. Maximum: 4–7 g/day.

Hypocalcemia

PO (Calcium Carbonate): ADULTS, ELDERLY: 1–2 g/day in 3–4 divided doses. CHILDREN: 45–65 mg/kg/day in 3–4 divided doses. NEONATES: 50–150 mg/kg/day in 4–6 divided doses. Maximum: 1 g/day.

PO (Calcium Glubionate): ADULTS, ELDERLY: 6–18 g/day in 4–6 divided doses. CHILDREN, INFANTS: 0.6–2 g/kg/day in 4 divided doses. NEONATES: 1.2 g/kg/day in 4–6 divided doses.

IV (Calcium Gluconate): ADULTS, ELDERLY: 1–2 g over 2 hrs. May repeat q60 min until level resolved. CHILDREN: 200–500 mg/kg/day in 4 divided doses. NEONATES: 200–800 mg/kg/day in 4 divided doses.

Antacid

PO (Calcium Carbonate): ADULTS, ELDERLY: 1–2 tabs (5–10 ml) q2h as needed. CHILDREN 6–11 YRS: 2 tabs (800 mg). Maximum: 6 tabs/day. CHILDREN 2–5 YRS: 1 tab (400 mg). Maximum: 3 tabs/day.

Osteoporosis

PO (Calcium Carbonate): ADULTS, ELDERLY: 1,200 mg/day.

Cardiac arrest

IV (Calcium Chloride): ADULTS, ELDERLY: 500–1,000 mg over 2–5 min. May repeat as necessary. CHILDREN, NEONATES: 20 mg/kg. May repeat in 10 min as necessary.

Hypocalcemia tetany

IV (Calcium Chloride): CHILDREN, NEONATES: 10 mg/kg over 5–10 min. May repeat q6–8h. Maximum: 200 mg/kg/day.

IV (Calcium Gluconate): ADULTS, ELDERLY: 1–3 g over 10–30 min; may repeat after 6 hrs. CHILDREN, NEONATES: 100–200 mg/kg/dose over 5–10 min. May repeat after 6 hrs. Maximum: 500 mg/kg/day.

Supplement

PO (Calcium Citrate): ADULTS, ELDERLY: 0.5–2 g 2–4 times a day. CHILDREN: 45–65 mg/kg/day in 4 divided doses.

Side effects

Frequent: PO: Chalky taste. Parenteral: Pain, rash, redness, burning at injection site; flushing; nausea; vomiting; diaphoresis; hypotension. Occasional: PO: Mild constipation, fecal impaction, peripheral edema, metabolic alkalosis (muscle pain, restlessness, slow respirations, altered taste). Calcium carbonate: Milk-alkali syndrome (headache, decreased appetite, nausea, vomiting, unusual fatigue). Rare: Urinary urgency, painful urination.

Adverse effects/toxic reactions

Hypercalcemia: Early signs: Constipation, headache, dry mouth, increased thirst, irritability, decreased appetite, metallic taste, fatigue, weakness, depression. Later signs: Confusion, drowsiness, hypertension, photosensitivity, arrhythmias, nausea, vomiting, painful urination.

Nursing considerations

Baseline assessment

Assess B/P, EKG and cardiac rhythm, renal function, serum magnesium, phosphate, potassium.

Intervention/evaluation

Monitor B/P, EKG, cardiac rhythm, serum magnesium, phosphate, potassium, renal function. Monitor serum, urine calcium. Monitor for signs of hypercalcemia.

Patient/family teaching

• Do not take within 1–2 hrs of other oral medications, fiber-containing foods. • Avoid excessive alcohol, tobacco, caffeine.

calfactant

cal-fak-tant

(Infasurf)

classification

PHARMACOTHERAPEUTIC: Natural lung extract. CLINICAL: Pulmonary surfactant.

Action

Reduces alveolar surface tension, stabilizing the alveoli. Therapeutic Effect: Restores surface activity to infant lungs, improves lung compliance, respiratory gas exchange.

Pharmacokinetics

No studies have been performed.

Uses

Prevention of respiratory distress syndrome (RDS) in premature infants younger than 29 wks of gestational age; treatment of premature infants younger than 72 hrs of age who develop RDS and require endotracheal intubation.

Precautions

Contraindications: None known. Cautions: None known.

 ​Lifespan considerations

Pregnancy/Lactation: Not indicated in this pt population. Pregnancy Category: Not indicated for use in pregnant women. Children: Used only in neonates. No age-related precautions noted. Elderly: Not indicated in this pt population.

Interactions

DRUG: None significant. HERBAL: None significant. FOOD: None known. LAB VALUES: None significant.

Availability (Rx)

Intratracheal Suspension: 35-mg/ml vials.

Administration/handling

Intratracheal

• Refrigerate. • Unused vials may be returned to refrigerator within 24 hrs for future use. Avoid repeated warming to room temperature. • Do not shake. • Enter vial only once, discard unused suspension.

Indications/routes/dosage

Respiratory distress syndrome (RDS)

Intratracheal: NEONATES: 3 ml/kg of birth weight administered as soon as possible after birth in 2 doses of 1.5 ml/kg. Repeat 3-ml/kg doses, up to a total of 3 doses given 12 hrs apart.

Side effects

Frequent: Cyanosis (65%), airway obstruction (39%), bradycardia (34%), reflux of surfactant into endotracheal tube (21%), need for manual ventilation (16%). Occasional: Need for reintubation (3%).

Adverse effects/toxic reactions

Reflux of calfactant into endotracheal tube, cyanosis, bradycardia, airway obstruction have occurred.

Nursing considerations

Baseline assessment

Drug must be administered in highly supervised setting. Clinicians must be experienced with intubation, ventilator management. Offer emotional support to parents.

Intervention/evaluation

Monitor infant with arterial or transcutaneous measurement of systemic O₂, CO₂. Auscultate lungs for adventitious breath sounds (rales, crackles, rhonchi). Frequent ABG sampling necessary to prevent post-dosing hyperoxia and hypocarbia.

canagliflozin

kan-a-gli-floe-zin

(Invokana)

classification

PHARMACOTHERAPEUTIC: Sodium-glucose co-transporter 2 (SGLT2) inhibitor. CLINICAL: Antidiabetic.

Action

Increases excretion of urinary glucose by inhibiting reabsorption of filtered glucose in kidney. Inhibits SGLT2 in proximal renal tubule. Therapeutic Effect: Lowers serum glucose levels.

Pharmacokinetics

Readily absorbed following PO administration. Metabolized in liver. Peak plasma concentration: 1–2 hrs. Protein binding: 99%. Excreted in feces (42%), urine (33%). Half-life: 11–13 hrs.

Uses

Adjunctive treatment to diet and exercise to improve glycemic controls in pts with type 2 diabetes mellitus.

Precautions

Contraindications: History of hypersensitivity to SGLT2 inhibitors, severe renal impairment, end-stage renal disease, dialysis. Cautions: Not recommended in type 1 diabetes, diabetic ketoacidosis. Concurrent use of diuretics, ACE inhibitors, angiotensin receptor blockers (ARB), other hypoglycemic or nephrotoxic medications, mild to moderate renal impairment, hypovolemia (dehydration/anemia), elderly, episode hypotension, hyperkalemia, genital mycotic infection.

 ​Lifespan considerations

Pregnancy/Lactation: Unknown if distributed in breast milk. Must either discontinue drug or discontinue breastfeeding. Pregnancy Category C. Children: Safety and efficacy not established in pts younger than 18 yrs of age. Elderly: May have increased risk for adverse reactions (e.g., hypotension, syncope, dehydration).

Interactions

DRUG: Rifampin, phenytoin may decrease concentration/effect. Potassium-sparing diuretics may increase serum potassium levels. ACE inhibitors, angiotension receptor blockers, calcium channel blockers, diuretics may increase risk of hypotension. Insulin, oral hypoglycemics may increase risk of hypoglycemia. May increase concentration/effect of digoxin. HERBAL: Herbs with hypoglycemic properties (e.g., fenugreek, garlic, ginger, ginseng, gotu) may increase risk of hypoglycemia. FOOD: None known. LAB VALUES: May increase low-density lipoprotein-cholesterol (LDL-C), hemoglobin, serum creatinine, magnesium, phosphate, potassium. May decrease glomerular filtration rate.

Availability (Rx)

Tablets: 100 mg, 300 mg.

Administration/handling

PO

• May give without regard to food. Give before first meal of the day.

Indications/routes/dosage

Type 2 diabetes mellitus

PO: ADULTS/ELDERLY: 100 mg daily before first meal. May increase to 300 mg daily if glomerular filtration rate (GFR) greater than 60 ml/min.

Renal impairment

GFR 45–60 ml/min: 100 mg daily (maximum). GFR less than 40 ml/min: Discontinue.

Side effects

Occasional (5%): Increased urination. Rare (3%–2%): Thirst, nausea, constipation.

Adverse effects/toxic reactions

Symptomatic hypotension (postural dizziness, orthostatic hypotension, syncope) may occur. Genital myocotic (yeast) infections reported in 10% of pts. Hypoglycemic events reported in 1.5% of pts (5% in elderly). Concomitant use of hypoglycemic medications may increase hypoglycemic risk. Hypersensitivity reactions including angioedema (tongue/lip swelling), urticaria, rash, pruritus, erythema occurred in 3%–4% of pts. May cause hyperkalemia (muscle weakness, palpitation, EKG changes).

Nursing considerations

Baseline assessment

Assess hydration status. Obtain serum chemistries, capillary blood glucose, hemoglobin A1C, LDL-C, digoxin level (if applicable). Assess pt’s understanding of diabetes management, routine home glucose monitoring. Receive full medication history including minerals, herbal products. Question history of co-morbidities, esp. renal or hepatic impairment.

Intervention/evaluation

Monitor digoxin levels, serum potassium, cholesterol, capillary blood glucose, hepatic/renal function tests. Assess for hypoglycemia (diaphoresis, tremors, dizziness, anxiety, headache, tachycardia, perioral numbness, hunger, diplopia, difficulty concentrating), hyperglycemia (polyuria, polyphagia, polydipsia, nausea, vomiting, fatigue, Kussmaul respirations), hypersensitivity reaction. Monitor for signs of hyperkalemia (palpitations, muscle weakness). Screen for glucose-altering conditions: fever, increased activity or stress, surgical procedures. Dietary consult for nutritional education. Encourage PO intake.

Patient/family teaching

• Diabetes mellitus requires lifelong control. • Diet and exercise are principal parts of treatment; do not skip or delay meals. • Test blood sugar regularly. • When taking combination drug therapy or when glucose demands are altered (fever, infection, trauma, stress), have low blood sugar treatment available (glucagon, oral dextrose). • Report suspected pregnancy or plans of breastfeeding. • Monitor daily calorie intake. • Go from lying to standing slowly to prevent dizziness. • Genital itching may indicate yeast infection. • Therapy may increase risk for dehydration/ low blood pressure. • Report any palpitations or muscle weakness.

candesartan

kan-de-sar-tan

(Apo-Candesartan , Atacand)

BLACK BOX ALERT May cause fetal injury, mortality if used during second or third trimester of pregnancy.

Fixed-combination(s)

Atacand HCT: candesartan/hydrochlorothiazide (a diuretic): 16 mg/12.5 mg, 32 mg/12.5 mg.

classification

PHARMACOTHERAPEUTIC: Angiotensin II receptor antagonist. CLINICAL: Antihypertensive (see p. 10C, 61C).

Action

Blocks vasoconstriction, aldosterone-secreting effects of angiotensin II, inhibiting binding of angiotensin II to AT₁ receptors. Therapeutic Effect: Produces vasodilation; decreases peripheral resistance, B/P.

Pharmacokinetics

Route	Onset	Peak	Duration
PO	2–3 hrs	6–8 hrs	Greater than 24 hrs

Rapidly, completely absorbed. Protein binding: greater than 99%. Undergoes minor hepatic metabolism to inactive metabolite. Excreted unchanged in urine and in feces through biliary system. Not removed by hemodialysis. Half-life: 9 hrs.

Uses

Treatment of hypertension alone or in combination with other antihypertensives, heart failure: NYHA class II–IV.

Precautions

Contraindications: Severe hepatic impairment and/or cholestasis, pregnancy, breastfeeding, concomitant use with aliskiren in pts with diabetes mellitus. Cautions: Significant aortic/mitral stenosis, renal/hepatic impairment, unstented (unilateral/bilateral) renal artery stenosis.

 ​Lifespan considerations

Pregnancy/Lactation: Unknown if distributed in breast milk. May cause fetal/neonatal morbidity/mortality. Pregnancy Category C (D if used in second or third trimester). Children: Safety and efficacy not established in pts younger than 1 yr. Elderly: No age-related precautions noted.

Interactions

DRUG: May increase risk of lithium toxicity. NSAIDs may decrease effects. HERBAL: Ephedra, ginseng, yohimbe may worsen hypertension. Garlic may increase antihypertensive effect. FOOD: None known. LAB VALUES: May increase BUN, serum alkaline phosphatase, bilirubin, creatinine, AST, ALT. May decrease Hgb, Hct.

Availability (Rx)

Tablets: 4 mg, 8 mg, 16 mg, 32 mg.

Administration/handling

PO

• Give without regard to food.

Indications/routes/dosage

Hypertension

PO: ADULTS, ELDERLY, PTS WITH MILD HEPATIC OR RENAL IMPAIRMENT: Initially, 16 mg once a day in those who are not volume depleted. Can be given once or twice a day with total daily doses of 8–32 mg. Give lower dosage in those treated with diuretics or with severe renal impairment. CHILDREN 6–16 YRS, GREATER THAN 50 KG: Initially, 8–16 mg/day in 1–2 divided doses. Range: 4–32 mg. Maximum: 32 g/day. 50 KG OR LESS: Initially, 4–8 mg in 1–2 divided doses. Range: 2–16 mg/day. Maximum: 32 mg/day. CHILDREN 1–5 YRS: Initially, 0.2 mg/kg/day in 1–2 divided doses. Range: 0.05–0.4 mg/kg/day.

Heart failure

PO: ADULTS, ELDERLY: Initially, 4 mg once daily. May double dose at approximately 2-wk intervals up to a target dose of 32 mg/day.

Side effects

Occasional (6%–3%): Upper respiratory tract infection, dizziness, back/leg pain. Rare (2%–1%): Pharyngitis, rhinitis, headache, fatigue, diarrhea, nausea, dry cough, peripheral edema.

Adverse effects/toxic reactions

Overdosage may manifest as hypotension, tachycardia. Bradycardia occurs less often. May increase risk of renal failure, hyperkalemia.

Nursing considerations

Baseline assessment

Obtain B/P, apical pulse immediately before each dose, in addition to regular monitoring (be alert to fluctuations).Question for possibility of pregnancy. Assess medication history (esp. diuretic). Question for history of hepatic/renal impairment, renal artery stenosis. Obtain BUN, serum creatinine, AST, ALT, alkaline phosphatase, bilirubin, Hgb, Hct.

Intervention/evaluation

Maintain hydration (offer fluids frequently). Assess for evidence of upper respiratory infection. Assist with ambulation if dizziness occurs. Monitor electrolytes, serum creatinine, BUN, urinalysis. Assess B/P for hypertension/hypotension. If excessive reduction in B/P occurs, place pt in supine position, feet slightly elevated.

Patient/family teaching

• Inform female pt regarding potential for fetal injury, mortality with second- and third-trimester exposure to candesartan. • Report suspected pregnancy. • Avoid tasks that require alertness, motor skills until response to drug is established. • Report any sign of infection (sore throat, fever). • Do not stop taking medication. • Hypertension requires lifelong control. • Caution against exercising during hot weather (risk of dehydration, hypotension).

capecitabine

kap-e-sye-ta-bine

(Xeloda)

BLACK BOX ALERT May increase anticoagulant effect of warfarin.

Do not confuse Xeloda with Xenical.

classification

PHARMACOTHERAPEUTIC: Antimetabolite. CLINICAL: Antineoplastic (see p. 83C).

Action

Enzymatically converted to 5-fluorouracil (5-FU). Inhibits enzymes necessary for synthesis of essential cellular components. Therapeutic Effect: Interferes with DNA synthesis, RNA processing, protein synthesis.

Pharmacokinetics

Readily absorbed from GI tract. Protein binding: less than 60%. Metabolized in liver. Primarily excreted in urine. Half-life: 45 min.

Uses

Treatment of metastatic breast cancer resistant to other therapy, colorectal cancer. Adjuvant (postsurgical) treatment of Dukes C colon cancer. OFF-LABEL: Gastric cancer, pancreatic cancer, esophageal cancer, ovarian cancer, metastatic renal cell cancer, metastatic CNS lesions, neuroendocrine tumors.

Precautions

Contraindications: Severe renal impairment (creatinine clearance less than 30 ml/min), dihydropyrimidine dehydrogenase (DPD) deficiency, hypersensitivity to 5-fluorouracil (5-FU). Cautions: Existing bone marrow depression, hepatic impairment, moderate renal impairment, previous cytotoxic therapy/radiation therapy, elderly (80 yrs of age or older).

 ​Lifespan considerations

Pregnancy/Lactation: May cause fetal harm. Unknown if distributed in breast milk. Pregnancy Category D. Children: Safety and efficacy not established in those younger than 18 yrs. Elderly: May be more sensitive to GI side effects.

Interactions

DRUG: May increase concentration, toxicity of warfarin, phenytoin. Myelosuppression may be enhanced when given concurrently with bone marrow depressants. Live virus vaccines may potentiate virus replication, increase vaccine side effects, decrease pt’s antibody response to vaccine. HERBAL: Echinacea may decrease levels/effect. FOOD: None known. LAB VALUES: May increase serum alkaline phosphatase, bilirubin, AST, ALT. May decrease Hgb, Hct, WBC count. May increase PT/INR.

Availability (Rx)

Tablets: 150 mg, 500 mg.

Administration/handling

• Give within 30 min after meals with water.

Indications/routes/dosage

Metastatic breast cancer, colorectal cancer, adjuvant (postsurgery) treatment of Dukes C colon cancer

PO: ADULTS, ELDERLY: Initially, 2,500 mg/m²/day in 2 equally divided doses approximately q12h apart for 2 wks. Follow with a 1-wk rest period; given in 3-wk cycles.

Dosage in renal impairment

Creatinine clearance 50–80 ml/min: No adjustment. Creatinine clearance 30–49 ml/min: 75% of normal dose. Creatinine clearance less than 30 ml/min: Contraindicated.

Side effects

Frequent (55%–25%): Diarrhea; nausea; vomiting; stomatitis; palmar-plantar erythrodysesthesia syndrome (PPES) presenting as redness, swelling, numbness, skin sloughing of hands and feet; fatigue; anorexia; dermatitis. Occasional (24%–10%): Constipation, dyspepsia, headache, dizziness, insomnia, edema, myalgia, pyrexia, dehydration, dyspnea, back pain. Rare (less than 10%): Mood changes, depression, sore throat, epistaxis, cough, visual abnormalities.

Adverse effects/toxic reactions

Serious reactions include myelosuppression (neutropenia, thrombocytopenia, anemia), cardiovascular toxicity (angina, cardiomyopathy, deep vein thrombosis), respiratory toxicity (dyspnea, epistaxis, pneumonia), lymphedema.

Nursing considerations

Baseline assessment

Assess sensitivity to capecitabine or 5-fluorouracil. Obtain baseline Hgb, Hct, serum chemistries, renal function.

Intervention/evaluation

Monitor for severe diarrhea, nausea, vomiting; if dehydration occurs, fluid and electrolyte replacement therapy should be initiated. Assess hands/feet for PPES. Monitor CBC for evidence of bone marrow depression. Monitor renal/hepatic function. Monitor for blood dyscrasias (fever, sore throat, signs of local infection, unusual bruising/bleeding from any site), symptoms of anemia (excessive fatigue, weakness).

Patient/family teaching

• Report nausea, vomiting, diarrhea, hand-and-foot syndrome, stomatitis. • Do not have immunizations without physician’s approval (drug lowers body’s resistance). • Avoid contact with those who have recently received live virus vaccine. • Promptly report fever higher than 100.5°F, sore throat, signs of local infection, unusual bruising/bleeding from any site.

captopril

kap-toe-pril

(Apo-Capto , Capoten )

BLACK BOX ALERT May cause fetal injury, mortality if used during second or third trimester of pregnancy.

Do not confuse captopril with calcitriol, Capitrol, or carvedilol.

Fixed-combination(s)

Capozide: captopril/hydrochlorothiazide (a diuretic): 25 mg/15 mg, 25 mg/25 mg, 50 mg/15 mg, 50 mg/25 mg.

classification

PHARMACOTHERAPEUTIC: Angiotensin-converting enzyme (ACE) inhibitor. CLINICAL: Antihypertensive, vasodilator (see p. 9C).

Action

Suppresses renin-angiotensin-aldosterone system (prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor; may inhibit angiotensin II at local vascular and renal sites). Decreases plasma angiotensin II, increases plasma renin activity, decreases aldosterone secretion. Therapeutic Effect: Reduces peripheral arterial resistance, pulmonary capillary wedge pressure; improves cardiac output, exercise tolerance.

Pharmacokinetics

Route	Onset	Peak	Duration
PO	0.25 hr	0.5–1.5 hrs	Dose-related

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