Recognizing and responding to them
TOXIC REACTIONS AND CLINICAL EFFECTS | INTERVENTIONS | SELECTED CAUSATIVE DRUGS |
Anemia, aplastic ♦ Bleeding from the mucous membranes, ecchymoses, petechiae ♦ Fatigue, pallor, progressive weakness, shortness of breath, tachycardia (progresses to heart failure) ♦ Fever, oral and rectal ulcers, sore throat without characteristic inflammation | ♦ Discontinue the drug, if possible. ♦ Order vigorous supportive care, including transfusions, neutropenic isolation, antibiotics, and oxygen. ♦ Colony-stimulating factors may be given. ♦ For severe cases, a bone marrow transplant may be needed. | ♦ altretamine ♦ Antineoplastic agents ♦ aspirin (long-term) ♦ carbamazepine ♦ chloramphenicol ♦ co-trimoxazole ♦ ganciclovir ♦ Gold salts ♦ hydrochlorothiazide ♦ mephenytoin ♦ methimazole ♦ penicillamine ♦ Phenothiazines ♦ propylthiouracil ♦ triamterene ♦ zidovudine |
Anemia, hemolytic ♦ Chills, fever, back and abdominal pain (hemolytic crisis) ♦ Jaundice, malaise, splenomegaly ♦ Signs of shock | ♦ Discontinue the drug. ♦ Order supportive care, including transfusions and oxygen. ♦ Consider obtaining a blood sample for Coombs’ test. | ♦ carbidopa-levodopa ♦ Cephalosporins ♦ levodopa ♦ mefenamic acid ♦ methyldopa ♦ Penicillins ♦ phenazopyridine ♦ primaquine ♦ quinidine ♦ quinine ♦ Sulfonamides |
Bone marrow toxicity (agranulocytosis) ♦ Enlarged lymph nodes, spleen, and tonsils ♦ Septicemia, shock ♦ Progressive fatigue and weakness followed by sudden, overwhelming infection with chills, fever, headache, and tachycardia ♦ Pneumonia ♦ Ulcers in the colon, mouth, and pharynx | ♦ Discontinue the drug. ♦ Begin antibiotic therapy while awaiting the results of blood culture and sensitivity tests. ♦ Order supportive therapy, including neutropenic isolation, warm saline gargles, and oral hygiene. | ♦ Angiotensin-converting enzyme inhibitors ♦ aminoglutethimide ♦ carbamazepine ♦ choramphenicol ♦ clomipramine ♦ clozapine ♦ co-trimoxazole ♦ flucytosine ♦ Gold salts ♦ penicillamine ♦ Phenothiazines ♦ phenytoin ♦ procainamide ♦ propylthiouracil ♦ Sulfonylureas |
Bone marrow toxicity (thrombocytopenia) ♦ Fatigue, weakness, lethargy, malaise ♦ Hemorrhage, loss of consciousness, shortness of breath, tachycardia ♦ Sudden onset of ecchymoses or petechiae; large, blood-filled bullae in the mouth | ♦ Discontinue the drug or reduce the dosage. ♦ Order corticosteroids and platelet transfusions. ♦ Consider ordering platelet-stimulating factors. ♦ Monitor the patient for signs of bleeding (bleeding gums, melena, hematuria, and hematemesis). | ♦ anistreplase ♦ ciprofloxacin ♦ cisplatin ♦ colfosceril ♦ etretinate ♦ floxuridine ♦ flucytosine ♦ ganciclovir ♦ Gold salts ♦ heparin ♦ Interferons alfa-2a and alfa-2b ♦ lymphocyte immune globulin ♦ methotrexate ♦ penicillamine ♦ procarbazine ♦ quinidine ♦ quinine ♦ Tetracyclines ♦ valproic acid |
Cardiomyopathy ♦ Acute hypertensive reaction ♦ Atrial and ventricular arrhythmias ♦ Chest pain ♦ Heart failure ♦ Chronic cardiomyopathy ♦ Pericarditis-myocarditis syndrome | ♦ Discontinue the drug, if possible. ♦ Closely monitor the patient who is receiving concurrent radiation therapy. ♦ Institute cardiac monitoring at the earliest sign of problems. ♦ If the patient is receiving doxorubicin, limit the cumulative dose to 550 mg/m2 unless the cardioprotectant dexrazoxane is used concomitantly. | ♦ cyclophosphamide ♦ cytarabine ♦ daunorubicin ♦ doxorubicin ♦ idarubicin ♦ mitoxantrone |
Dermatologic toxicity ♦ May vary from phototoxicity to acneiform eruptions, alopecia, exfoliative dermatitis, lupus erythematosus-like reactions, and toxic epidermal necrolysis | ♦ Discontinue the drug. ♦ Topical antihistamines and analgesics may be ordered. | ♦ Androgens ♦ Barbiturates ♦ Corticosteroids ♦ Cephalosporins ♦ Gold salts ♦ hydralazine ♦ Interferons ♦ Iodides ♦ Penicillins ♦ pentamidine ♦ phenolphthalein ♦ Phenothiazines ♦ procainamide ♦ Psoralens ♦ Quinolones ♦ Sulfonamides ♦ Sulfonylureas ♦ Tetracyclines ♦ Thiazides |
Hepatotoxicity ♦ Abdominal pain, hepatomegaly ♦ Abnormal levels of alanine aminotransferase, aspartate aminotransferase, serum bilirubin, and lactate dehydrogenase ♦ Bleeding, low-grade fever, mental changes, weight loss ♦ Dry skin, pruritus, rash ♦ Jaundice | ♦ Reduce the dosage or discontinue the drug. ♦ Order monitoring of the patient’s vital signs, blood levels, weight, intake and output, and fluids and electrolytes. ♦ Promote rest. ♦ Perform hemodialysis, if needed. ♦ Order symptomatic care: vitamins A, B complex, D, and K; potassium for alkalosis; salt-poor albumin for fluid and electrolyte balance; neomycin for GI flora; stomach aspiration for blood; reduced dietary protein; and lactulose for blood ammonia. | ♦ amiodarone ♦ asparaginase ♦ carbamazepine ♦ chlorpromazine ♦ chlorpropamide ♦ cytarabine ♦ dantrolene ♦ erythromycin estolate ♦ ifosfamide ♦ isoniazid ♦ ketoconazole ♦ leuprolide ♦ methotrexate ♦ methyldopa ♦ mitoxantrone ♦ niacin ♦ phenobarbital ♦ plicamycin ♦ Quinolones ♦ Statins ♦ sulindac |
Nephrotoxicity ♦ Increased or decreased creatinine clearance ♦ Blurred vision, dehydration (depending on the part of the kidney affected), edema, mild headache, pallor ♦ Casts, albumin, or red or white blood cells in the urine ♦ Dizziness, fatigue, irritability, slowed mental processes ♦ Electrolyte imbalance ♦ Elevated blood urea nitrogen level ♦ Oliguria | ♦ Reduce the dosage or discontinue the drug. ♦ Perform hemodialysis, if needed. ♦ Order monitoring of the patient’s vital signs, weight changes, and urine volume. ♦ Give symptomatic care: fluid restriction and loop diuretics to reduce fluid retention and I.V. solutions to correct an electrolyte imbalance. | ♦ Aminoglycosides ♦ amphotericin B ♦ Cephalosporins ♦ cisplatin ♦ Contrast media ♦ Corticosteroids ♦ cyclosporine ♦ furosemide ♦ Gadolinium-based contrast agents ♦ gallium ♦ Gold salts (parenteral) ♦ Nitrosoureas ♦ Nonsteroidal antiinflammatory drugs ♦ penicillin ♦ pentamidine isethionate ♦ plicamycin ♦ vancomycin ♦ Vasopressors or vasoconstrictors |
Neurotoxicity ♦ Akathisia ♦ Bilateral or unilateral palsy ♦ Muscle twitching, tremor ♦ Paresthesia ♦ Seizures ♦ Strokelike syndrome ♦ Unsteady gait ♦ Weakness | ♦ Notify the physician as soon as changes appear. ♦ Reduce the dosage or discontinue the drug. ♦ Monitor the patient carefully for changes in his condition. ♦ Order symptomatic care. Remain with the patient, reassure him, and protect him during seizures. Provide a quiet environment, draw the shades, and speak in soft tones. Maintain the airway, and ventilate the patient as needed. | ♦ Aminoglycosides ♦ cisplatin ♦ cytarabine ♦ isoniazid ♦ nitroprusside ♦ polymyxin B injection ♦ Vinca alkaloids |
Ocular toxicity ♦ Acute glaucoma ♦ Blurred, colored, or flickering vision ♦ Cataracts ♦ Corneal deposits ♦ Diplopia ♦ Miosis ♦ Mydriasis ♦ Optic neuritis ♦ Scotomata ♦ Vision loss | ♦ Notify the physician as soon as changes appear. ♦ Discontinue the drug, if possible. (Some oculotoxic drugs that are used to treat serious conditions may be given again at a reduced dosage after the eyes are rested and have returned to near normal.) ♦ Monitor the patient carefully for changes in symptoms. ♦ Treat the effects symptomatically. | ♦ amiodarone ♦ Antibiotics such as chloramphenicol ♦ Anticholinergics ♦ Cardiac glycosides ♦ chloroquine ♦ clomiphene ♦ Corticosteroids ♦ cyclophosphamide ♦ cytarabine ♦ ethambutol ♦ hydroxychloroquine ♦ lithium carbonate ♦ methotrexate ♦ Phenothiazines ♦ quinidine ♦ quinine ♦ rifampin ♦ tamoxifen ♦ Vinca alkaloids |
Ototoxicity ♦ Ataxia ♦ Hearing loss ♦ Tinnitus ♦ Vertigo | ♦ Notify the physician as soon as changes appear. ♦ Discontinue the drug or reduce the dosage. ♦ Monitor the patient carefully for symptomatic changes. | ♦ Aminoglycosides ♦ Antibiotics, such as colistimethate sodium, erythromycin, gentamicin, kanamycin, and streptomycin ♦ chloroquine ♦ cisplatin ♦ Loop diuretics ♦ minocycline ♦ quinidine ♦ quinine ♦ Salicylates ♦ vancomycin |
Pseudomembranous colitis ♦ Abdominal pain ♦ Colonic perforation ♦ Fever ♦ Hypotension ♦ Severe dehydration ♦ Shock ♦ Sudden, copious diarrhea (watery or bloody) | ♦ Discontinue the drug and order another antibiotic, such as vancomycin or metronidazole. ♦ Maintain the fluid and electrolyte balance. ♦ Check the serum electrolyte levels daily. If pseudomembranous colitis is mild, order an ion exchange resin. ♦ Monitor the patient’s vital signs and hydration status. ♦ Immediately report signs of shock to the physician. ♦ Observe the patient for signs of hypokalemia, especially malaise and weak, rapid, irregular pulse. | ♦ Antibiotics |
DRUG | LEVEL REDUCED BY HEMODIALYSIS |
acebutolol | Yes |
acetaminophen | Yes (may not affect toxicity) |
acetazolamide | No |
acyclovir | Yes |
allopurinol | Yes |
alprazolam | No |
amikacin | Yes |
amiodarone | No |
amitriptyline | No |
amlodipine | No |
amoxicillin | Yes |
amoxicillin and clavulanate potassium | Yes |
amphotericin B | No |
ampicillin | Yes |
ampicillin and sulbactam sodium | Yes |
aprepitant | No |
aspirin | Yes |
atenolol | Yes |
azathioprine | Yes |
aztreonam | Yes |
bivalirudin | Yes |
busulfan | Yes |
captopril | Yes |
carbamazepine | No |
carbenicillin | Yes |
carboplatin | Yes |
carmustine | No |
cefadroxil | Yes |
cefazolin | Yes |
cefepime | Yes |
cefonicid | Yes (only by 20%) |
cefoperazone | Yes |
cefotaxime | Yes |
cefotetan | Yes (only by 20%) |
cefoxitin | Yes |
cefpodoxime | Yes |
ceftazidime | Yes |
ceftibuten | Yes |
ceftizoxime | Yes |
ceftriaxone | No |
cefuroxime | Yes |
cephalexin | Yes |
cephalothin | Yes |
cephradine | Yes |
chloral hydrate | Yes |
chlorambucil | No |
chloramphenicol | Yes (very small amount) |
chlordiazepoxide | No |
chloroquine | No |
chlorpheniramine | No |
chlorpromazine | No |
chlorthalidone | No |
cimetidine | Yes |
ciprofloxacin | Yes (only by 20%) |
cisplatin | No |
clindamycin | No |
clofibrate | No |
clonazepam | No |
clonidine | No |
clorazepate | No |
cloxacillin | No |
codeine | No |
colchicine | No |
cortisone | No |
co-trimoxazole | Yes |
cyclophosphamide | Yes |
diazepam | No |
diazoxide | Yes |
diclofenac | No |
dicloxacillin | No |
didanosine | Yes |
digoxin | No |
diltiazem | No |
diphenhydramine | No |
dipyridamole | No |
doxazosin | No |
doxepin | No |
doxorubicin | No |
doxycycline | No |
enalapril | Yes |
erythromycin | Yes (only by 20%) |
ethacrynic acid | No |
ethambutol | Yes (only by 20%) |
ethchlorvynol | Yes |
ethosuximide | Yes |
famciclovir | Yes |
famotidine | No |
fenoprofen | No |
flecainide | No |
fluconazole | Yes |
flucytosine | Yes |
fluorouracil | Yes |
fluoxetine | No |
flurazepam | No |
foscarnet | Yes |
fosinopril | No |
furosemide | No |
gabapentin | Yes |
ganciclovir | Yes |
gemcitabine | Yes |
gemfibrozil | No |
gemifloxicin | Yes |
gentamicin | Yes |
glipizide | No |
glyburide | No |
haloperidol | No |
heparin | No |
hydralazine | No |
hydrochlorothiazide | No |
hydroxyzine | No |
ibuprofen | No |
imipenem and cilastatin | Yes |
imipramine | No |
indapamide | No |
indomethacin | No |
insulin | No |
irbesartan | No |
iron dextran | No |
isoniazid | Yes |
isosorbide | Yes |
isradipine | No |
kanamycin | Yes |
ketoconazole | No |
ketoprofen | Yes |
labetalol | No |
levofloxacin | No |
lidocaine | No |
lisinopril | Yes |
lithium | Yes |
lomefloxacin | No |
lomustine | No |
loracarbef | Yes |
loratadine | No |
lorazepam | No |
mefenamic acid | No |
meperidine | No |
meprobamate | Yes |
mercaptopurine | Yes |
meropenem | Yes |
mesalamine | Yes |
methadone | No |
methotrexate | Yes |
methyldopa | Yes |
methylprednisolone | No |
metoclopramide | No |
metolazone | No |
metoprolol | No |
metronidazole | Yes |
mezlocillin | Yes |
miconazole | No |
midazolam | No |
minocycline | No |
minoxidil | Yes |
misoprostol | No |
morphine | No |
nabumetone | No |
nadolol | Yes |
nafcillin | No |
naproxen | No |
nelfinavir | Yes |
nifedipine | No |
nimodipine | No |
nitrofurantoin | Yes |
nitroglycerin | No |
nitroprusside | Yes |
nizatidine | No |
nortriptyline | No |
octreotide | Yes |
ofloxacin | Yes |
olanzapine | No |
omeprazole | No |
oxacillin | No |
paroxetine | No |
penicillin G | Yes |
pentamidine | No |
pentazocine | Yes |
perindopril | Yes |
phenobarbital | Yes |
phenytoin | No |
piperacillin | Yes |
piperacillin and tazobactam | Yes |
prazosin | No |
prednisone | No |
primidone | Yes |
procainamide | Yes |
promethazine | No |
propoxyphene | No |
propranolol | No |
protriptyline | No |
pyrazinamide | Yes |
pyridoxine | Yes |
quinapril | No |
quinidine | Yes |
quinine | Yes |
ranitidine | Yes |
rifampin | No |
salsalate | Yes |
sertraline | No |
sotalol | Yes |
stavudine | Yes |
sucralfate | No |
sulbactam | Yes |
sulfamethoxazole | Yes |
sulindac | No |
tazobactam | Yes |
temazepam | No |
theophylline | Yes |
ticarcillin | Yes |
ticarcillin and clavulanate | Yes |
timolol | No |
tobramycin | Yes |
tocainide | Yes |
tolbutamide | No |
topiramate | Yes |
triazolam | No |
trimethoprim | Yes |
valacyclovir | Yes |
valproic acid | No |
valsartan | No |
vancomycin | Yes |
verapamil | No |
warfarin | No |
zolpidem | No |
DRUG | ACTION | NURSING CONSIDERATIONS |
Cimetidine (Tagamet) Severe anaphylaxis | ♦ Competes with histamine for histamine2-receptor sites ♦ Treats urticaria | ♦ Know that this drug is incompatible with aminophylline. ♦ Reduce the dosage for patients with impaired renal or hepatic function. |
Diphenhydramine (Benadryl) | ♦ Competes with histamine for histamine1-receptor sites ♦ Prevents laryngeal edema ♦ Controls localized itching | ♦ Administer I.V. doses slowly to avoid hypotension. ♦ Monitor the patient for hypotension and drowsiness. ♦ Give fluids as needed. The drug causes dry mouth. |
Epinephrine (Adrenalin) Severe anaphylaxis (drug of choice) | Alpha-adrenergic effects ♦ Increases blood pressure ♦ Reverses peripheral vasodilation and systemic hypotension ♦ Considered the drug of choice for treating anaphylaxis ♦ Decreases angioedema and urticaria ♦ Improves coronary blood flow by raising diastolic pressure ♦ Causes peripheral vasoconstriction Beta-adrenergic effects ♦ Causes bronchodilation ♦ Causes positive inotropic and chronotropic cardiac activity ♦ Decreases the synthesis and release of chemical mediators | ♦ Select a large vein for infusion. ♦ Use an infusion controller to regulate the drip rate. ♦ Check the patient’s blood pressure and heart rate frequently. ♦ Monitor the patient for arrhythmias. ♦ Check the solution strength, dosage, and label before administration. ♦ Watch for signs of extravasation at the infusion site. ♦ Monitor the patient’s intake and output. ♦ Assess the color and temperature of the extremities. |
Hydrocortisone (Solu-Cortef) Severe anaphylaxis | ♦ Prevents neutrophil and platelet aggregation ♦ Inhibits mediator synthesis ♦ Decreases capillary permeability | ♦ Monitor the patient’s fluid and electrolyte balance, intake and output, and blood pressure closely. ♦ Keep the patient on a prophylactic ulcer and antacid regimen. |
ADVERSE REACTIONS | |||||||||||||||||||||||
DRUG CLASSIFICATIONS | Agitation | Anxiety | Arrhythmias | Ataxia | Changes in appetite | Confusion | Constipation | Depression | Difficulty breathing | Disorientation | Dizziness | Drowsiness | Edema | Fatigue | Hypotension | Insomnia | Memory loss | Muscle weakness | Restlessness | Sexual dysfunction | Tremors | Urinary dysfunction | Vision changes |
Angiotensin-converting enzyme inhibitors | • | • | • | • | • | • | • | • | • | ||||||||||||||
Alpha1 adrenergic blockers | • | • | • | • | • | • | • | • | • | • | • | • | |||||||||||
Antianginals | • | • | • | • | • | • | • | • | • | • | • | • | • | ||||||||||
Antiarrhythmics | • | • | • | • | • | • | |||||||||||||||||
Anticholinergics | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | |||||||
Anticonvulsants | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | ||||||
Antidepressants, tricyclic | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | ||||
Antidiabetics, oral | • | • | |||||||||||||||||||||
Antihistamines | • | • | • | • | • | • | • | • | • | • | |||||||||||||
Antilipemics | • | • | • | • | • | • | • | • | |||||||||||||||
Antiparkinsonians | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | ||||||
Antipsychotics | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | |||||
Barbiturates | • | • | • | • | • | • | • | • | • | • | |||||||||||||
Benzodiazepines | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | |||||||
Beta-adrenergic blockers | • | • | • | • | • | • | • | • | • | • | • | • | |||||||||||
Calcium channel blockers | • | • | • | • | • | • | • | • | • | • | • | • | |||||||||||
Corticosteroids | • | • | • | • | • | • | • | • | |||||||||||||||
Diuretics | • | • | • | • | • | • | |||||||||||||||||
Nonsteroidal anti-inflammatory drugs | • | • | • | • | • | • | • | • | • | • | |||||||||||||
Opioids | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | • | ||||||
Skeletal muscle relaxants | • | • | • | • | • | • | • | • | • | • | • | ||||||||||||
Thyroid hormones | • | • | • | • | |||||||||||||||||||
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