N

nabumetone

(Apo-Nabumetone , Novo-Nabumetone , Relafen )

BLACK BOX ALERT Increased risk of serious cardiovascular thrombotic events, including myocardial infarction, CVA. Increased risk of severe GI reactions, including ulceration, bleeding, perforation of stomach, intestines.

Administration/handling

PO

• Give with food, milk, antacids to decrease GI irritation, increase absorption.

Indications/routes/dosage

Rheumatoid arthritis (RA), osteoarthritis

PO: ADULTS, ELDERLY: Initially, 1,000 mg as a single dose or in 2 divided doses. May increase up to 2,000 mg/day as a single dose or in 2 divided doses.

Dosage in renal impairment

Creatinine Clearance	Dosage
30–49 ml/min	Initially, 750 mg/day. Maximum: 1,500 mg/day
Less than 30 ml/min	Initially, 500 mg/day. Maximum: 1,000 mg/day

Side effects

Frequent (14%–12%): Diarrhea, abdominal cramps/pain, dyspepsia. Occasional (9%–4%): Nausea, constipation, flatulence, dizziness, headache. Rare (3%–1%): Vomiting, stomatitis, pruritus, rash, tinnitus, edema, fatigue, diaphoresis, insomnia, somnolence.

Adverse effects/toxic reactions

Overdose may result in acute hypotension, tachycardia. Rare reactions with long-term use include peptic ulcer, GI bleeding, gastritis, nephrotoxicity (dysuria, cystitis, hematuria, proteinuria, nephrotic syndrome), severe hepatic reactions (cholestasis, jaundice), severe hypersensitivity reactions (bronchospasm, angioedema).

Nursing considerations

Baseline assessment

Assess onset, type, location, duration of pain/inflammation. Inspect appearance of affected joints for immobility, deformities, skin condition.

Intervention/evaluation

Monitor renal function tests in pts with renal insufficiency. Assist with ambulation if drowsiness, dizziness occurs. Monitor for evidence of dyspepsia. Monitor daily pattern of bowel activity, stool consistency. Assess for therapeutic response: relief of pain, stiffness, swelling; increase in joint mobility; reduced joint tenderness; improved grip strength.

Patient/family teaching

• May cause serious GI bleeding with or without pain. • Avoid aspirin, alcohol. • May take with food if GI upset occurs. • Avoid tasks requiring mental alertness, motor skills until response to drug is established. • Report GI symptoms.

nadolol

na-doe-lol

(Apo-Nadol , Corgard, Novo-Nadolol )

BLACK BOX ALERT Severe angina exacerbation, MI, ventricular arrhythmias noted in angina pts after abrupt withdrawal.

Do not confuse Corgard with Coreg, or nadolol with labetolol or atenolol.

Fixed-combination(s)

Corzide: nadolol/bendroflumethiazide (a diuretic): 40 mg/5 mg, 80 mg/5 mg.

classification

PHARMACOTHERAPEUTIC: Beta-adrenergic blocker. CLINICAL: Antianginal, antihypertensive (see p. 73C).

Action

Blocks beta₁– and beta₂-adrenergenic receptors. Large doses increase airway resistance. Therapeutic Effect: Slows heart rate, decreases cardiac output, B/P. Decreases myocardial ischemia severity by decreasing oxygen requirements.

Pharmacokinetics

Variable absorption after PO administration. Protein binding: 28%–30%. Not metabolized. Excreted unchanged in feces. Half-life: 20–24 hrs.

Uses

Management of mild to moderate hypertension; used alone or in combination with diuretics, esp. thiazide type. Management of chronic stable angina pectoris. Prophylaxis of migraine headaches. OFF-LABEL: Prophylaxis of variceal hemorrhage; management of thyrotoxicosis.

Precautions

Contraindications: Bronchial asthma, cardiogenic shock, sinus node dysfunction, second- or third-degree heart block (except with functioning pacemaker), sinus bradycardia, uncontrolled cardiac failure. Cautions: Compensated HF, concurrent use of verapamil, digoxin, or diltiazem, diabetes, renal impairment, myasthenia gravis, peripheral vascular disease, psychiatric disease.

Lifespan considerations

Pregnancy/Lactation: Crosses placenta; distributed in breast milk. Pregnancy Category C (D if used in second or third trimester). Children: Safety and efficacy not established. Elderly: No age-related precautions noted.

Interactions

DRUG: Digoxin may increase risk of bradycardia. May mask symptoms of hypoglycemia, prolong hypoglycemic effect of insulin, oral hypoglycemics. HERBAL: Ephedra, garlic, ginseng, yohimbe may worsen hypertension. Licorice may cause increased serum sodium, water retention, decreased serum potassium. FOOD: None known. LAB VALUES: May increase serum antinuclear antibody (ANA) titer, BUN, serum LDH, lipoprotein, alkaline phosphatase, bilirubin, potassium, uric acid, AST, ALT, triglycerides.

Administration/handling

PO

• Give without regard to meals. • Tablets may be crushed.

Indications/routes/dosage

Hypertension, angina

PO: ADULTS: Initially, 40 mg/day. May increase by 40–80 mg at 3- to 7-day intervals. Maximum: (Hypertension) 240–320 mg/day. (Angina): 160–240 mg. ELDERLY: Initially, 20 mg/day. May increase gradually. Range: 20–240 mg/day.

Dosage in renal impairment

Dosage is modified based on creatinine clearance.

Creatinine Clearance	Dosage
31–50 ml/min	q24–36 h
10–30 ml/min	q24–48 h
Less than 10 ml/min	q40–60 h

Side effects

Nadolol is generally well tolerated, with transient, mild side effects. Occasional (6% or less): Diminished sexual function, drowsiness, unusual fatigue/weakness, bradycardia, difficulty breathing, depression, cold hands/feet, diarrhea, constipation, anxiety, nasal congestion, nausea, vomiting, altered taste, dry eyes, pruritus.

Adverse effects/toxic reactions

Overdose may produce profound bradycardia, hypotension. Abrupt withdrawal may result in diaphoresis, palpitations, headache, tremors, exacerbation of angina, MI, ventricular arrhythmias. May precipitate HF, MI in pts with cardiac disease; thyroid storm in pts with thyrotoxicosis; peripheral ischemia in those with existing peripheral vascular disease. Hypoglycemia may occur in pts with previously controlled diabetes.

Nursing considerations

Baseline assessment

Assess baseline renal/hepatic function tests. Assess B/P, apical pulse immediately before drug administration (if pulse is 60/min or less or systolic B/P is less than 90 mm Hg, withhold medication, contact physician). Antianginal: Record onset, type (sharp, dull, squeezing), radiation, location, intensity, duration of anginal pain; precipitating factors (exertion, emotional stress).

Intervention/evaluation

Monitor B/P for hypotension, respiratory effort for dyspnea. Assess pulse for quality, irregular rate, bradycardia. Assess hands/feet for coldness, tingling, numbness. Assess for evidence of HF: dyspnea (particularly on exertion, lying down), night cough, peripheral edema, distended neck veins. Monitor I&O (increase in weight, decrease in urinary output may indicate HF).

Patient/family teaching

• Do not discontinue abruptly (may precipitate angina MI, ventricular arrhythmias). • Report difficulty breathing, night cough, swelling of arms/legs, slow pulse, dizziness, confusion, depression, rash, fever, sore throat, unusual bleeding/bruising. • Avoid tasks that require alertness, motor skills until response to drug is established. • Limit alcohol intake.

nafcillin

naf-sill-in

classification

PHARMACOTHERAPEUTIC: Penicillinase-resistant penicillin. CLINICAL: Antibiotic (see p. 29C).

Action

Binds to bacterial membranes. Therapeutic Effect: Inhibits cell wall synthesis. Bactericidal.

Uses

Treatment of respiratory tract, skin/skin structure infections, osteomyelitis, endocarditis, meningitis; perioperatively, esp. in cardiovascular, orthopedic procedures. Predominant treatment of infections caused by susceptible strains of staphylococci.

Precautions

Contraindications: Hypersensitivity to any penicillin. Cautions: History of allergies, particularly cephalosporins, severe renal/hepatic impairment, asthma.

Lifespan considerations

Pregnancy/Lactation: Readily crosses placenta; appears in cord blood, amniotic fluid. Distributed in breast milk. May lead to rash, diarrhea, candidiasis in neonate, infant. Pregnancy Category B. Children: Immature renal function in neonate may delay renal excretion. Elderly: Age-related renal impairment may require dosage adjustment.

Interactions

DRUG: High doses (2 g q4h) may decrease effects of warfarin. HERBAL: None significant. FOOD: None known. LAB VALUES: May cause false-positive Coombs’ test.

Availability (Rx)

Injection, Powder for Reconstitution: 1 g, 2 g. Infusion (Premix): 1 g/50 ml, 2g/100 ml.

Administration/handling

◀ ALERT ▶ Space doses evenly around the clock.

IV

Reconstitution • Reconstitute each vial with 10 ml Sterile Water for Injection or 0.9% NaCl. • For intermittent IV infusion (piggyback), further dilute with 50–100 ml 0.9% NaCl or D₅W to maximum concentration of 40 mg/ml.

Rate of Administration • Infuse over 30–60 min. • Because of potential for hypersensitivity/anaphylaxis, start initial dose at few drops per min, increase slowly to ordered rate; stay with pt first 10–15 min, then check q10min. • Limit IV therapy to less than 48 hrs, if possible. Stop infusion if pt complains of pain at IV site.

Storage (IV infusion [piggyback]) • Stable for 24 hrs at room temperature, 96 hrs if refrigerated. • Discard if precipitate forms.

IM

• Reconstitute each 500 mg with 1.7 ml Sterile Water for Injection or 0.9% NaCl to provide concentration of 250 mg/ml. • Inject IM into large muscle mass.

IV incompatibilities

Aztreonam (Azactam), diltiazem (Cardizem), droperidol (Inapsine), fentanyl, gentamicin, insulin, labetalol (Normodyne, Trandate), methylprednisolone (Solu-Medrol), midazolam (Versed), nalbuphine (Nubain), vancomycin (Vancocin), verapamil (Isoptin).

IV compatibilities

Acyclovir, famotidine (Pepcid), fluconazole (Diflucan), heparin, hydromorphone (Dilaudid), lidocaine, lipids, magnesium, morphine, potassium chloride, propofol (Diprivan).

Indications/routes/dosage

Usual dosage

IV: ADULTS, ELDERLY: 0.5–2 g q4–6h. CHILDREN: 50–200 mg/kg/day in divided doses q4–6h. Maximum: 12 g/day. NEONATES: 25 mg/kg/dose in divided doses q6–12h.

IM: ADULTS, ELDERLY: 500 mg q4–6h. CHILDREN: 25 mg/kg twice daily.

Side effects

Frequent: Mild hypersensitivity reaction (fever, rash, pruritus), GI effects (nausea, vomiting, diarrhea). Occasional: Hypokalemia with high IV dosages, phlebitis, thrombophlebitis (common in elderly). Rare: Extravasation with IV administration.

Adverse effects/toxic reactions

Potentially fatal antibiotic-associated colitis, superinfections (abdominal cramps, severe watery diarrhea, fever) may result from altered bacterial balance in GI tract. Hematologic effects (esp. involving platelets, WBCs), severe hypersensitivity reactions, anaphylaxis occur rarely.

Nursing considerations

Baseline assessment

Question for history of allergies, esp. penicillins, cephalosporins.

Intervention/evaluation

Hold medication, promptly report rash (possible hypersensitivity), diarrhea (fever, abdominal pain, mucus/blood in stool may indicate antibiotic-associated colitis). Evaluate IV site frequently for phlebitis (heat, pain, red streaking over vein), infiltration (potential extravasation). Monitor periodic CBC, urinalysis, serum potassium, renal/hepatic function. Be alert for superinfection: fever, vomiting, diarrhea, anal/genital pruritus, oral mucosal changes (ulceration, pain, erythema).

Patient/family teaching

• Continue antibiotic for full length of treatment. • Doses should be evenly spaced. • Discomfort may occur with IM injection. • Report IV discomfort immediately. • Notify physician in event of diarrhea, rash, other new symptoms.

nalbuphine

nal-bue-feen

classification

PHARMACOTHERAPEUTIC: Narcotic agonist, antagonist. CLINICAL: Opioid analgesic.

Action

Binds with opioid receptors within CNS. May displace opioid agonists, competitively inhibiting their action; may precipitate withdrawal symptoms. Therapeutic Effect: Alters pain perception, emotional response to pain.

Pharmacokinetics

Route	Onset	Peak	Duration
IV	2–3 min	2–3 min	3–4 hrs
IM	Less than 15 min	30 min	3–6 hrs
Subcutaneous	Less than 15 min	N/A	3–6 hrs

Well absorbed after IM, subcutaneous administration. Metabolized in liver. Primarily eliminated in feces by biliary secretion. Half-life: 3.5–5 hrs.

Uses

Relief of moderate to severe pain, preop analgesia, obstetric analgesia, adjunct to anesthesia. OFF-LABEL: Opioid-induced pruritus.

Precautions

Contraindications: None known. Cautions: Hepatic/renal impairment, respiratory depression, recent MI, recent biliary tract surgery, head trauma, increased intracranial pressure (ICP), pregnancy, pts suspected of being opioid dependent, obesity, thyroid dysfunction, prostatic hyperplasia, urinary stricture, adrenal insufficiency, cardiovascular disease.

Lifespan considerations

Pregnancy/Lactation: Readily crosses placenta. Distributed in breast milk. Breastfeeding not recommended. May cause fetal, neonatal adverse effects during labor/delivery (e.g., fetal bradycardia). Pregnancy Category B (D if used for prolonged periods or at high dosages at term). Children: Paradoxical excitement may occur. Those younger than 2 yrs more susceptible to respiratory depression. Elderly: More susceptible to respiratory depression. Age-related renal impairment may increase risk of urinary retention.

Interactions

DRUG: Alcohol, other CNS depressants may increase CNS effects, respiratory depression, hypotension. HERBAL: Gotu kola, kava kava, St. John’s wort, valerian may increase CNS depression. FOOD: None known. LAB VALUES: May increase serum amylase, lipase.

Availability (Rx)

Injection Solution: 10 mg/ml, 20 mg/ml.

Administration/handling

IV

Reconstitution • May give undiluted.

Rate of Administration • For IV push, administer each 10 mg over 3–5 min.

Storage • Store parenteral form at room temperature.

IV incompatibilities

Amphotericin B complex (Abelcet, AmBisome, Amphotec), cefepime (Maxipime), ketorolac (Toradol), nafcillin (Nafcil), piperacillin and tazobactam (Zosyn).

IV compatibilities

Dexmedetomidine (Precedex), diphenhydramine (Benadryl), droperidol (Inapsine), glycopyrrolate (Robinul), hydroxyzine (Vistaril), lidocaine, midazolam (Versed), prochlorperazine (Compazine), propofol (Diprivan).

Indications/routes/dosage

Analgesia

IV, IM, Subcutaneous: ADULTS, ELDERLY: 10 mg q3–6h as needed. Do not exceed maximum single dose of 20 mg or daily dose of 160 mg. CHILDREN 1 YR AND OLDER: 0.1–0.2 mg/kg q3–4h as needed. Maximum: 20 mg/dose, 160 mg/day.

Supplement to anesthesia

IV: ADULTS, ELDERLY: Induction: 0.3–3 mg/kg over 10–15 min. Maintenance: 0.25–0.5 mg/kg as needed.

Side effects

Frequent (36%): Sedation. Occasional (9%–3%): Diaphoresis, cold/clammy skin, nausea, vomiting, dizziness, vertigo, dry mouth, headache. Rare (less than 1%): Restlessness, emotional lability, paresthesia, flushing, paradoxical reaction.

Adverse effects/toxic reactions

Abrupt withdrawal after prolonged use may produce symptoms of narcotic withdrawal (abdominal cramping, rhinorrhea, lacrimation, anxiety, fever, piloerection [goose bumps]). Overdose results in severe respiratory depression, skeletal muscle flaccidity, cyanosis, extreme drowsiness progressing to seizures, stupor, coma. Tolerance to analgesic effect, physical dependence may occur with chronic use.

Nursing considerations

Baseline assessment

Obtain vital signs before giving medication. If respirations are 12/min or less (20/min or less in children), withhold medication, contact physician. Assess onset, type, location, duration of pain. Effect of medication is reduced if full pain recurs before next dose. Low abuse potential.

Intervention/evaluation

Monitor for change in respirations, B/P, rate/quality of pulse. Monitor daily pattern of bowel activity, stool consistency. Initiate deep breathing, coughing exercises, particularly in pts with pulmonary impairment. Assess for clinical improvement, record onset of relief of pain. Consult physician if pain relief is not adequate.

Patient/family teaching

• Avoid alcohol. • Avoid tasks that require alertness, motor skills until response to drug is established. • May cause dry mouth. • May be habit forming.

naloxone

nah-lox-own

Do not confuse naloxone with Lanoxin or naltrexone.

Fixed-combination(s)

Embeda: naloxone/morphine (an opioid agonist): 0.8 mg/20 mg, 1.2 mg/30 mg, 2 mg/50 mg, 2.4 mg/60 mg, 3.2 mg/80 mg, 4 mg/100 mg. Suboxone (sublingual film): naloxone/buprenorphine (an analgesic): 0.5 mg/2 mg, 1 mg/4 mg, 2 mg/8 mg, 3 mg/12 mg.

classification

PHARMACOTHERAPEUTIC: Narcotic antagonist. CLINICAL: Antidote.

Action

Displaces opioids at opioid-occupied receptor sites in CNS. Therapeutic Effect: Reverses opioid-induced sleep/sedation, increases respiratory rate, raises B/P to normal range.

Pharmacokinetics

Route	Onset	Peak	Duration
IV	1–2 min	N/A	20–60 min
IM	2–5 min	N/A	20–60 min
Subcutaneous	2–5 min	N/A	20–60 min

Well absorbed after IM, subcutaneous administration. Metabolized in liver. Primarily excreted in urine. Half-life: 60–100 min.

Uses

Complete or partial reversal of opioid depression including respiratory depression. Diagnosis of suspected opioid tolerance or acute opioid overdose. Neonatal opiate depression. Coma of unknown origin. OFF-LABEL: Opioid-induced pruritus.

Precautions

Contraindications: None known. Cautions: Chronic cardiac/pulmonary disease, coronary artery disease, pts suspected of being opioid dependent, postop pts (to avoid cardiovascular changes), history of seizures.

Lifespan considerations

Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category B. Children/Elderly: No age-related precautions noted.

Interactions

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

Availability (Rx)

Injection Solution: 0.4 mg/ml, 1 mg/ml.

Administration/handling

IV

Reconstitution • May dilute 1 mg/ml with 50 ml Sterile Water for Injection to provide concentration of 0.02 mg/ml. • For continuous IV infusion, dilute each 2 mg of naloxone with 500 ml of D₅W or 0.9% NaCl, producing solution containing 0.004 mg/ml (4 mcg/ml).

Rate of Administration • May administer undiluted. • Give each 0.4 mg as IV push over 30 sec.

Storage • Store parenteral form at room temperature. • Use mixture within 24 hrs; discard unused solution. • Protect from light. • Stable in D₅W or 0.9% NaCl at 4 mcg/ml for 24 hrs.

IV incompatibility

Amphotericin B complex (Abelcet, AmBisome, Amphotec).

IV compatibilities

Heparin, ondansetron (Zofran), propofol (Diprivan).

Indications/routes/dosage

Opioid overdose

IV, IM, Subcutaneous: ADULTS, ELDERLY: 2 mg q2–3min as needed. May repeat doses q20–60min. CHILDREN 5 YRS AND OLDER, WEIGHING 20 KG OR MORE: 2 mg/dose; if no response, may repeat q2–3min. May need to repeat doses q20–60min. CHILDREN YOUNGER THAN 5 YRS, WEIGHING LESS THAN 20 KG: 0.1 mg/kg (maximum: 2 mg); if no response, repeat q2–3min. May need to repeat doses q20–60min.

Reversal of respiratory depression with therapeutic opioid dosing

IV, IM, Subcutaneous: ADULTS, ELDERLY: Initially, 0.04–0.4 mg. May repeat until desired response achieved. CHILDREN: 0.001–0.005 mg/kg. Dose may be repeated as needed.

Postanesthesia narcotic reversal

IV: ADULTS, ELDERLY: 0.1–0.2 mg q2–3min. INFANTS, CHILDREN: 0.01 mg/kg; may repeat q2–3min.

Side effects

None known; little or no pharmacologic effect in absence of narcotics.

Adverse effects/toxic reactions

Too-rapid reversal of narcotic-induced respiratory depression may result in agitation, nausea, vomiting, tremors, increased B/P, tachycardia. Excessive dosage in postop pts may produce significant reversal of analgesia, agitation, tremors. Hypotension or hypertension, ventricular tachycardia/fibrillation, pulmonary edema may occur in pts with cardiovascular disease.

Nursing considerations

Baseline assessment

Maintain clear airway. Obtain weight of children to calculate drug dosage.

Intervention/evaluation

Monitor vital signs, esp. rate, depth, rhythm of respiration, during and frequently following administration. Carefully observe pt after satisfactory response (duration of opiate may exceed duration of naloxone, resulting in recurrence of respiratory depression). Assess for increased pain with reversal of opiate.

naltrexone

nal-trex-own

(ReVia, Vivitrol)

BLACK BOX ALERT Can cause hepatic injury in excessive doses.

Do not confuse naltrexone with naloxone, or ReVia with Revatio or Revex.

classification

PHARMACOTHERAPEUTIC: Opioid receptor antagonist. CLINICAL: Ethanol detoxification agent, antidote.

Action

Blocks effects of endogenous opioid peptides by competitively binding at opioid receptors. Therapeutic Effect: Alcohol deterrent: Decreases craving, drinking days, relapse rate. Antidote: Blocks physical dependence of morphine, heroin, other opioids.

Pharmacokinetics

Route	Onset	Peak	Duration
PO	N/A	N/A	24–72 hrs
IM	N/A	2 hrs	2–4 wks

Well absorbed following PO administration. Protein binding: 21%. Metabolized in liver. Reduction in first-pass hepatic metabolism when given by intramuscular route. Excreted primarily in urine; partial elimination in feces. Half-life: PO: 4 hrs; IM: 5–10 days.

Uses

Vivitrol: Treatment of alcohol dependence in pts able to abstain from alcohol in outpatient setting prior to initiation of treatment. Prevention of relapse to opioid dependence following opioid detoxification. ReVia: Blocks effects of exogenously administered opioids.

Precautions

Contraindications: Opioid dependence or current use of opioid analgesics, acute opioid withdrawal, failed naloxone challenge or positive urine screen for opioids, acute hepatitis, hepatic failure. Cautions: Active hepatic disease, history of suicide attempts, depression, history of bleeding disorders, concurrent anticoagulant therapy, renal impairment.

Lifespan considerations

Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established in pts younger than 18 yrs. Elderly: No age-related precautions noted.

Interactions

DRUG: May decrease effects of opioid analgesics. HERBAL: None significant. FOOD: None known. LAB VALUES: May increase serum transaminase, AST, ALT.

Availability (Rx)

Injection Suspension, Extended-Release Kit (Vivitrol): 380 mg/4 ml vial. Tablets: (ReVia): 50 mg.

Administration/handling

◀ ALERT ▶ In pts with narcotic dependence, do not attempt treatment until pt has remained opioid free for 7–10 days. Test urine for opioids for verification. Pt should not be experiencing withdrawal symptoms.

IM

• Give in deep muscle mass of gluteal region, alternating buttocks. • Vivitrol must be suspended only in diluent supplied in kit.

Storage • Store entire diluent supplied in the kit. • All components (microspheres, diluent, preparation needle, administration needle with safety device) are required for preparation administration. Spare administration needle is provided in case of clogging.

PO

• Administer with food or antacids or after meals.

Indications/routes/dosage

Adjunct in treatment of alcohol dependence, prevention of relapse to opioid dependence

IM: ADULTS, ELDERLY: (Vivitrol): 380 mg once every 4 wks or once/mo.

Block effects of opioids, alcohol dependence

PO: ADULTS, ELDERLY: Initially, 25 mg. Observe for 1 hr. If no withdrawal signs appear, give 50 mg on day 2. Maintenance regimen is flexible, variable, and individualized. May be given as 50 mg daily, 50 mg/day Monday thru Friday and 100 mg on Saturday, 100 mg every other day, or 150 mg every 3 days for 12 wks.

Side effects

Common: IM: (69%): Injection site reaction (induration, tenderness, pain, nodules, swelling, pruritus, ecchymosis). Frequent: Alcohol Deterrent: (33%–10%): Nausea, headache, depression. Narcotic Addiction (10%–5%): Insomnia, anxiety, headache, low energy, abdominal cramps, nausea, vomiting, joint/muscle pain. Occasional: Alcohol Deterrent (4%–2%): Dizziness, anxiety, fatigue, insomnia, vomiting, suicidal ideation. Narcotic Addiction (5% or less): Irritability, increased energy, dizziness, anorexia, diarrhea, constipation, rash, chills, increased thirst.

Adverse effects/toxic reactions

Signs/symptoms of opioid withdrawal include stuffy/runny nose, tearing, yawning, diaphoresis, tremor, vomiting, piloerection (goose bumps), feeling of temperature change, arthralgia, myalgia, abdominal cramps, formication (feeling of skin crawling). Accidental naltrexone overdosage produces withdrawal symptoms within 5 min of ingestion, lasts up to 48 hrs. Symptoms present as confusion, visual hallucinations, drowsiness, significant vomiting, diarrhea. Hepatotoxicity may occur with large doses.

Nursing considerations

Baseline assessment

Treatment should not be instituted unless pt is opioid free for 7–10 days, alcohol free for 3–5 days before therapy begins. Obtain medication history (esp. opioids), other medical conditions (esp. hepatitis, other hepatic disease). If opioid dependence suspected, a naloxone challenge test should be performed (naloxone administered to verify opioid dependence and eligibility for admission to opioid treatment program).

Intervention/evaluation

Monitor for evidence of hepatotoxicity (abdominal pain that lasts longer than a few days, white bowel movements, dark urine, jaundice). Monitor serum AST, ALT, bilirubin.

Patient/family teaching

• If heroin, other opiates are self-administered, there will be no effect. However, any attempt to overcome naltrexone’s prolonged 24- to 72-hr blockade of opioid effect by taking large amounts of opioids is dangerous and may result in coma, serious injury, fatal overdose. • Naltrexone blocks effects of opioid-containing medicine (cough/cold preparations, antidiarrheal preparations, opioid analgesics). • Report abdominal pain lasting longer than 3 days, white bowel movement, dark-colored urine, yellow eyes.

naproxen

na-prox-en

(Aleve, Anaprox, Anaprox DS, Apo-Naproxen , EC-Naprosyn, Naprelan, Naprosyn, Pamprin)

Do not confuse Aleve with Allese, or Anaprox with Anaspaz or Avapro.

Fixed-combination(s)

Prevacid NapraPac: naproxen/lansoprazole (proton pump inhibitor): 375 mg/15 mg, 500 mg/15 mg.

Treximet: naproxen/sumatriptan (an antimigraine): 500 mg/85 mg. Vimovo: naproxen/esomeprazole (proton pump inhibitor): 375 mg/20 mg, 500 mg/20 mg.

classification

PHARMACOTHERAPEUTIC: NSAID. CLINICAL: Analgesic, anti-inflammatory (see p. 130C).

Action

Produces analgesic, anti-inflammatory effects by inhibiting prostaglandin synthesis. Therapeutic Effect: Reduces inflammatory response, intensity of pain.

Pharmacokinetics

Route	Onset	Peak	Duration
PO (analgesic)	1 hr	2–4 hrs	7 hrs or less
PO (antiinflammatory)	2 wks	2–4 wks	12 hrs

Completely absorbed from GI tract. Protein binding: 99%. Metabolized in liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 13 hrs.

Uses

Treatment of acute or long-term mild to moderate pain, primary dysmenorrhea, rheumatoid arthritis (RA), juvenile rheumatoid arthritis (JRA), osteoarthritis, ankylosing spondylitis, acute gouty arthritis, bursitis, tendonitis, fever. OFF-LABEL: Migraine prophylaxis.

Precautions

Contraindications: Hypersensitivity to aspirin, naproxen, other NSAIDs. Perioperative pain in setting of CABG surgery. Cautions: GI/cardiac disease, renal/hepatic impairment, asthma, HF, concurrent use of anticoagulants, smoking, use of alcohol, elderly, debilitated.

Lifespan considerations

Pregnancy/Lactation: Crosses placenta. Distributed in breast milk. Avoid use during third trimester (may adversely affect fetal cardiovascular system: premature closing of ductus arteriosus). Pregnancy Category C (D if used in third trimester or near delivery). Children: Safety and efficacy not established in those younger than 2 yrs. Children older than 2 yrs at increased risk for skin rash. Elderly: Age-related renal impairment may increase risk of hepatic/renal toxicity; reduced dosage recommended. More likely to have serious adverse effects with GI bleeding/ulceration.

Interactions

DRUG: May decrease effects of antihypertensives, diuretics. Aspirin, other salicylates may increase risk of GI side effects, bleeding. Bone marrow depressants may increase risk of hematologic reactions. May increase risk of bleeding with heparin, oral anticoagulants, thrombolytics. May increase concentration, risk of toxicity of lithium. May increase risk of methotrexate toxicity. HERBAL: Cat’s claw, dong quai, evening primrose, feverfew, garlic, ginger, ginkgo, ginseng, horse chestnut, red clover possess antiplatelet activity, may increase risk of bleeding. FOOD: None known. LAB VALUES: May prolong bleeding time. May increase BUN, serum creatinine, ALT, AST, alkaline phosphatase. May decrease Hgb, Hct, leukocytes, platelets, uric acid.

Availability (Rx)

Gelcaps (Aleve [OTC]): 220 mg naproxen sodium (equivalent to 200 mg naproxen). Oral Suspension (Naprosyn): 125 mg/5 ml naproxen. Tablets: 220 mg naproxen sodium (equivalent to 200 mg naproxen)(Aleve [OTC]), 250 mg (Naprosyn), 275 mg naproxen sodium (equivalent to 250 mg naproxen) (Anaprox), 375 mg, 500 mg, 550 mg naproxen sodium (equivalent to 500 mg naproxen) (Anaprox DS).

Tablets (Controlled-Release): 375 mg naproxen (EC-Naprosyn), 412.5 mg naproxen sodium (equivalent to 375 mg naproxen) (Naprelan), 500 mg naproxen (EC-Naprosyn), 550 mg naproxen sodium (equivalent to 500 mg naproxen) (Naprelan), 825 mg naproxen sodium (equivalent to 750 mg naproxen) (Naprelan).