Mosby's 2014 Nursing Drug Reference (114 page)

BOOK: Mosby's 2014 Nursing Drug Reference
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Canada only   Side effects:
italics
= common;
bold
= life-threatening   
Nurse Alert

dabigatran

(da-bye-gat′ran)

Pradaxa

Func. class.:
Anticoagulant-thrombin inhibitor

ACTION:

Direct thrombin inhibitor that inhibits both free and clot-bound thrombin, prevents thrombin-induced platelet aggregation and thrombus formation by preventing conversion of fibrinogen to fibrin

USES:

Stroke/systemic embolism prophylaxis with nonvalvular atrial fibrillation

Unlabeled uses:
Deep venous thrombus (DVT), pulmonary embolism prophylaxis

CONTRAINDICATIONS:

Hypersensitivity, bleeding, prosthetic heart valves

Precautions:
Pregnancy (C), labor, obstetric delivery, breastfeeding, children, geriatric patients, abrupt discontinuation, anticoagulant therapy, renal disease, surgery

DOSAGE AND ROUTES
Calculator
Stroke prophylaxis

• Adult: PO
150 mg bid

For conversion from an alternative anticoagulant to dabigatran

• 
When converting from warfarin to dabigatran, discontinue warfarin and initiate dabigatran therapy when the INR is <2.0; when converting from a parenteral anticoagulant to dabigatran, initiate dabigatran 0-2 hr before the time of the next scheduled anticoagulant dose or at the time of discontinuation of a continuously administered anticoagulant (e.g., intravenous unfractionated heparin)

For conversion from dabigatran to warfarin


Adult:
CCr >50 ml/min, start warfarin 3 days before discontinuing dabigatran; CCr 31-50 ml/min, start warfarin 2 days before discontinuing dabigatran; CCr 15-30 ml/min, start warfarin 1 day before discontinuing dabigatran

For conversion from dabigatran to parenteral anticoagulants


Adult: PO
discontinue dabigatran, start parenteral anticoagulant 12 hr (CCr ≥30 ml/min) or 24 hr (CCr <30 ml/min) after the last dabigatran dose

Renal dose


Adult: PO
CCr 15-30 ml/min, 75 mg bid

Deep venous thrombus (DVT)/pulmonary embolism prophylaxis (unlabeled)


Adult: PO
220 mg or 150 mg/day × 28-35 days, starting with 1/2 dose 1-4 hr after surgery

Available forms:
Caps 75, 100 mg

Administer:

• 
Do not crush, break, chew, or empty contents of capsule

• 
If dose is missed, take as soon as remembered if on the same day; do not administer if <6 hr before next dose

• 
Without regard to food

• 
Store in original package at room temp until time of use; discard after 30 days, protect from moisture

SIDE EFFECTS

CNS:
Intracranial bleeding

CV:
Myocardial infarction

GI:
Abdominal pain, dyspepsia, peptic ulcer, esophagitis, GERD, gastritis,
GI bleeding

HEMA:
Bleeding, hemorrhagic erosive gastritis

INTEG:
Rash, pruritus

SYST:
Anaphylaxis (rare)

PHARMACOKINETICS

Protein binding 35%, half-life 12-17 hr (extended in renal disease), peak 1 hr, high-fat meal delays peak

INTERACTIONS

Increase:
bleeding risk—amiodarone, other anticoagulants, clopidogrel, ketoconazole, quiNIDine, thrombolytics, verapamil

Decrease:
dabigatran effect—rifampin

Decrease:
dabigatran effect—P-glycoprotein inducers (carBAMazepine, rifampin, tipranovir

Drug/Lab Test

Increase:
thrombin time, aPTT

NURSING CONSIDERATIONS
Assess:


 
Bleeding:
blood in urine or emesis, dark tarry stools, lower back pain; caution with arterial/venous punctures, catheters, NG tubes; monitor vital signs frequently; elderly patients more prone to serious bleeding, monitor aPTT, ecarin clotting time baseline and during treatment


 
Thrombosis/MI/emboli:
swelling, pain, redness, difficulty breathing, chest pain, tachypnea, cough, coughing up blood, cyanosis


 
Postthrombotic syndrome:
pain, heaviness, itching/tingling, swelling, varicose veins, brownish/reddish skin discoloration, ulcers; use of ambulation, compression stockings, adequate anticoagulation can prevent this syndrome


 
Surgery:
discontinue 24-48 hr before surgery in those with CCr ≥50 ml/min, 72-96 hr in those with CCr <50 ml/min; longer times may be needed in major surgery

Evaluate:

• 
Therapeutic response: decreased thrombus formation/extension, absence of emboli, post-thrombotic effects

Teach patient/family:

• 
About the purpose and expected results of this product, to take at same time of day, not to skip or double doses

• 
To take without regard to food, swallow cap whole

• 
To avoid all other products unless approved by prescriber

• 
To notify all providers that this product is being used


 
To report any bleeding including blood in stool, emesis, urine; nosebleeds

HIGH ALERT
dacarbazine (Rx)

(da-kar′ba-zeen)

DTIC
, DTIC-Dome

Func. class.:
Antineoplastic alkylating agent

Chem. class.:
Cytotoxic triazine

ACTION:

Alkylates DNA, RNA; inhibits DNA, RNA synthesis; also responsible for breakage, cross-linking of DNA strands; activity is not cell-cycle–phase specific

USES:

Hodgkin’s disease, malignant melanoma

Unlabeled uses:
Malignant pheochromocytoma in combination with cyclophosphamide and vinCRIStine, metastatic soft-tissue sarcoma in combination with other agents, carcinoma meningitis, neuroblastoma

CONTRAINDICATIONS:

Breastfeeding, hypersensitivity

Precautions:
Renal disease

 

Black Box Warning:

Pregnancy (C) 1st trimester, radiation therapy, hepatic disease, bone marrow suppression, secondary malignancy

DOSAGE AND ROUTES
Calculator
Metastatic malignant melanoma


Adult: IV
2-4.5 mg/kg/day × 10 days or 100-250 mg/m
2
/day × 5 days; repeat q3-4wk depending on response

Hodgkin’s disease


Adult: IV
150 mg/m
2
/day × 5 days with other agents, repeat q4wk; or 375 mg/m
2
on days 1 and 15 when given in combination, repeat q28days

Osteogenic sarcoma (unlabeled)

• Adult and child: IV
250 mg/m
2
/day as continuous inf × 4 days q28days

Soft-tissue sarcoma (unlabeled)

• Adult and child: IV
250-300 mg/m
2
/day as continuous inf × 3 days q21-28days

Carcinoma meningitis (unlabeled)


Adult: INTRATHECAL
5-30 mg in a fixed dose 2-3 ×/wk until disease controlled

Available forms:
Powder for inj 10, 100, 200 mg

Administer:

• 
Antiemetic 30-60 min before giving product to prevent vomiting, nausea; vomiting may subside after several doses

• 
Antibiotics for prophylaxis of infection

IV route

• 
Use cytotoxic handling precautions

Direct IV route

• 
After diluting 100 mg/9.9 or 200 mg/19.7 ml of sterile water for inj (10 mg/ml), give by direct IV over 1 min through
Y
-tube or 3-way stopcock

Intermittent IV INF route

• 
May be further diluted in 50-250 ml D
5
W or NS for inj, given as an inf over 1/2 hr

• 
Watch for extravasation; stop infusion, apply ice to area

Y-site compatibilities:
Amifostine, anidulafungin, atenolol, aztreonam, bivalirudin, bleomycin, caspofungin, DAPTOmycin, dexmedetomidine, DOCEtaxel, DOXOrubicin, ertapenem, etoposide, fenoldopam, filgrastim, fludarabine, gemtuzumab, granisetron, levofloxacin, mechlorethamine, melphalan, nesiritide, octreotide, ondansetron, oxaliplatin, PACLitaxel, palonosetron, pamidronate, quinupristin-dalfopristin, sargramostim, teniposide, thiotepa, tigecycline, tirofiban, vinorelbine, voriconazole, zoledronic acid

SIDE EFFECTS

CNS:
Facial paresthesia, flushing, fever, malaise; confusion, headache,
seizures, cerebral hemorrhage,
blurred vision (high doses)

GI:
Nausea, anorexia, vomiting
,
hepatotoxicity
(rare)

HEMA:
Thrombocytopenia, leukopenia,
anemia

INTEG:
Alopecia
, dermatitis, pain at inj site, photosensitivity; severe sun reactions (high doses)

MISC:
Flulike symptoms, malaise, fever, myalgia, hypotension

SYST:
Anaphylaxis

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