C
cabazitaxel
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.
classificationPrecautions
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.
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
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.
classificationPrecautions
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.
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
classificationInteractions
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.
IV compatibilities
IV incompatibilitiesIndications/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.
calcitonin
(Apo-Calcitonin 
, Calcimar 
, Caltine 
, Fortical, Miacalcin)
Do not confuse calcitonin with calcitriol, or Miacalcin with Micatin.
classification
Lifespan considerationsAdministration/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.
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.
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 gluconate
Do not confuse Citracal with Citrucel, OsCal with Asacol, or PhosLo with ProSom.
classificationAction
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.
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.
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
Gelcap (PhosLo): 667 mg (equivalent to 169 mg elemental calcium). Tablets (Eliphos): 667 mg (equivalent to 169 mg elemental calcium).
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).
Injection Solution: 10% (100 mg/ml) equivalent to 27.2 mg elemental calcium per ml.
Syrup: 1.8 g/5 ml (equivalent to 115 mg elemental calcium per 5 ml).
Injection Solution: 10% (equivalent to 9 mg elemental calcium per ml).
Administration/handling
IV
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.
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
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.
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.
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.
classification
Lifespan considerationscanagliflozin
classificationPrecautions
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.
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
(Apo-Candesartan 
, Atacand)
classificationPharmacokinetics
| 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.
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.
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.
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
BLACK BOX ALERT May increase anticoagulant effect of warfarin.
Do not confuse Xeloda with Xenical.
classificationUses
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 considerationsInteractions
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.
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.
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
(Apo-Capto 
, Capoten 
)
Do not confuse captopril with calcitriol, Capitrol, or carvedilol.
classificationAction
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.
Full access? Get Clinical Tree
