Mosby's 2014 Nursing Drug Reference (112 page)

BOOK: Mosby's 2014 Nursing Drug Reference
5.96Mb size Format: txt, pdf, ePub

Canada only   Side effects:
italics
= common;
bold
= life-threatening   
Nurse Alert

cycloSPORINE (Rx)

(sye′kloe-spor-een)

Cyclosporine, modified Gengraf, Neoral, Pulminiq, Sandimmune

Func. class.:
Immunosuppressant

Chem. class.:
Fungus-derived peptide

Do not confuse:
cycloSPORINE
/cycloSERINE/cyclophosphamide
SandIMMUNE
/SandoSTATIN

ACTION:

Produces immunosuppression by inhibiting lymphocytes (T)

USES:

Organ transplants (liver, kidney, heart) to prevent rejection, rheumatoid arthritis, psoriasis

Unlabeled uses:
Recalcitrant ulcerative colitis, aplastic anemia, Crohn’s disease, GVHD, thrombocytopenia purpura, lupus, nephritis, myasthenia gravis, psoriatic arthritis, atopic dermatitis

CONTRAINDICATIONS:

Breastfeeding, hypersensitivity to polyxyethylated castor oil (inj only); psoriasis or RA in renal disease (Neoral/Gengraf); Gengraf/Neoral used with PUVA/UVB, methotrexate, coal tar; ocular infections

 

Black Box Warning:

Uncontrolled, malignant hypertension; radiation in psoriasis, neoplastic disease, sunlight (UV) exposure, renal disease/failure

Precautions:
Pregnancy (C), geriatric patients, severe hepatic disease

DOSAGE AND ROUTES
Calculator
Prevention of transplant rejection (nonmodified)

• Adult and child:
PO
15 mg/kg several hr before surgery, daily for 2 wk, reduce dosage by 2.5 mg/kg/wk to 5-10 mg/kg/day;
IV
5-6 mg/kg several hr before surgery, daily, switch to PO form as soon as possible

Prevention of transplant rejection (modified)

• Adult and child:
PO
4-12 mg/kg/day divided q12hr, depends on organ transplanted

Rheumatoid arthritis (Neoral/Gengraf)

• Adult:
PO
2.5 mg/kg/day divided bid, may increase 0.5-0.75 mg/kg/day after 8-12 wk, max 4 mg/kg/day

Psoriasis (neoral/gengraf)

• Adult:
PO
2.5 mg/kg/day divided bid, × 4 wk, then increase by 0.5 mg/kg/day q2wk, max 4 mg/kg/day

Idiopathic thrombocytopenia purpura (unlabeled)

• Adult:
PO
1.25-2.5 mg/kg bid

Severe aplastic anemia (unlabeled)

• Adult and child:
PO
12 mg/kg/day or 15 mg/kg/day (child) with antithymocyte globulin (ATG)

Atopic dermatitis (unlabeled)

• Adult/adolescent/child ≥2 yr:
PO
5 mg/kg/day

Crohn’s disease that is resistant to/intolerant of corticosteroids (unlabeled)

• Adult:
PO
2.5-15 mg/kg/day (nonmodified)

Available forms:
Oral sol 100 mg/ml; soft gel cap 25, 50, 100 mg; inj 50 mg/ml; sol for inh 300 mg/4.8 ml

Administer:
PO route

• 
Do not break, crush, or chew caps

• 
Use pipette provided to draw up oral sol; may mix with milk or juice; wipe pipette, do not wash (Neoral)

• 
For several days before transplant surgery; give at same time of day

• 
With corticosteroids

• 
With meals for GI upset or in chocolate milk, milk, or orange juice (SandIMMUNE)

• 
With oral antifungal for candida infections

Rheumatoid arthritis

• 
Give Neoral or Gengraf 2.5 mg/kg/day divided bid; may use with salicylates, NSAIDs, PO corticosteroids

• 
Always give the daily dose of Neoral/Gengraf in 2 divided doses on consistent schedule

• 
Give initial SandIMMUNE PO dose 4-12 hr prior to transplantation as a single dose of 15 mg/kg, continue the single daily dose for 1-2 wk, then taper 5%/wk to a maintenance dose of 5-10 mg/kg/day

Intermittent IV INF route

• 
After diluting each 50 mg/20-100 ml of 0.9% NaCl or D
5
W; run over 2-6 hr, use an inf pump, glass inf bottles only

Continuous IV INF route

• 
May run over 24 hr

• 
For SandIMMUNE parenteral,
give 1/3 of PO dose, initial dose 4-12 hr before transplantation as a single IV dose 5-6 mg/kg/day, continue the single daily dose until PO can be used

Solution compatibilities:
D
5
W, NaCl 0.9%

Y-site compatibilities:
Abciximab, alatrofloxacin, alfentanil, amikacin, aminocaproic acid, aminophylline, amphotericin B lipid complex, anidulafungin, argatroban, ascorbic acid injection, atenolol, atracurium, atropine, azaTHIOprine, aztreonam, benztropine, bivalirudin, bleomycin, bretylium, bumetanide, buprenorphine, butorphanol, calcium chloride/gluconate, CARBOplatin, carmustine, caspofungin, cefamandole, ceFAZolin, cefmetazole, cefonicid, cefoperazone, cefotaxime, cefoTEtan, cefOXitin, ceftaroline, cefTAZidime, ceftizoxime, ceftobiprole, cefTRIAXone, cefuroxime, cephalothin, cephapirin, chloramphenicol, chlorproMAZINE, cimetidine, ciprofloxacin, CISplatin, clindamycin, codeine, cyanocobalamin, cyclophosphamide, cytarabine, DACTINomycin, DAPTOmycin, DAUNOrubicin, dexamethasone, dexmedetomidine, digoxin, diltiazem, diphenhydrAMINE, DOBUTamine, DOCEtaxel, DOPamine, doripenem, doxacurium, DOXOrubicin, doxycycline, enalaprilat, ePHEDrine, EPINEPHrine, epirubicin, epoetin alfa, eptifibatide, ertapenem, erythromycin, esmolol, etoposide, famotidine, fenoldopam, fentaNYL, fluconazole, fludarabine, fluorouracil, folic acid, furosemide, gallium, ganciclovir, gatifloxacin, gemcitabine, gentamicin, glycopyrrolate, granisetron, heparin, hydrocortisone, HYDROmorphone, hydrOXYzine, ifosfamide, imipenem-cilastatin, indomethacin, irinotecan, isoproterenol, ketorolac, labetalol, lansoprazole, levofloxacin, lidocaine, linezolid, LORazepam, mannitol, mechlorethamine, meperidine, meropenem, methicillin, methotrexate, methoxamine, methyldopate, methylPREDNISolone, metoclopramide, metoprolol, metroNIDAZOLE, mezlocillin, micafungin, miconazole, midazolam, milrinone, minocycline, mitoXANtrone, morphine, moxalactam, multiple vitamins injection, nafcillin, naloxone, nesiritide, netilmicin, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, PACLitaxel, palonosetron, pamidronate, pancuronium, pantoprazole, papaverine, PEMEtrexed, penicillin G potassium/sodium, pentamidine, pentazocine, phentolamine, phenylephrine, phytonadione, piperacillin, piperacillin-tazobactam, polymyxin B, potassium acetate/chloride, procainamide, prochlorperazine, promethazine, propofol, propranolol, protamine, pyridoxine, quiNIDine, quinupristin-dalfopristin, ranitidine, ritodrine, sargramostim, sodium acetate/bicarbonate, succinylcholine, SUFentanil, tacrolimus, teniposide, theophylline, thiamine, thiotepa, ticarcillin, ticarcillin-clavulanate, tigecycline, tirofiban, tobramycin, trimetaphan, urokinase, vancomycin, vasopressin, vecuronium, verapamil, vinCRIStine, vinorelbine, zoledronic acid

SIDE EFFECTS

CNS:
Tremors, headache
,
seizures, confusion, encephalopathy,
migraine

GI:
Nausea, vomiting, diarrhea,
oral candida, gum hyperplasia
,
hepatotoxicity, pancreatitis

GU:
Albuminuria, hematuria, proteinuria, renal failure, hemolytic uremic syndrome, nephrotoxicity

INTEG:
Rash, acne,
hirsutism
, pruritus

META:
Hyperkalemia, hypomagnesemia, hyperlipidemia, hyperuricemia

MISC:
Infection, hypertension

PHARMACOKINETICS

Peak 4 hr; highly protein bound; half-life (biphasic) 1.2 hr, 25 hr; metabolized in liver; excreted in feces, 6% in urine; crosses placenta; excreted in breast milk

INTERACTIONS

Increase:
action, toxicity of cycloSPORINE—allopurinol, amiodarone, amphotericin B, androgens, azole antifungals, β-blockers, bromocriptine, calcium channel blockers, carvedilol, cimetidine, colchicine, corticosteroids, fluoroquinolones, foscarnet, imipenem-cilastatin, macrolides, metoclopramide, oral contraceptives, NSAIDs, melphalan, SSRIs

Increase:
effects of aliskiren, digoxin, etoposide, HMG-CoA reductase inhibitors, methotrexate, potassium-sparing diuretics, sirolimus, tacrolimus

Increase:
action toxicity of—digoxin, colchicine

Decrease:
cycloSPORINE action—anticonvulsants, nafcillin, orlistat, PHENobarbital, phenytoin, rifamycins, sulfamethoxazole-trimethoprim, terbinafine, ticlopidine

Decrease:
antibody reaction—live virus vaccines

Drug/Food

• 
Slowed metabolism of product: grapefruit juice, food

NURSING CONSIDERATIONS
Assess:

• 
Renal studies: BUN, creatinine at least monthly during treatment, 3 mo after treatment

• 
Product blood level during treatment 12 hr after dose, toxic >400 ng/ml

• 
Hepatic studies: alk phos, AST, ALT, bilirubin; hepatotoxicity:
dark urine, jaundice, itching, light-colored stools; product should be discontinued

• 
Serum lipids, magnesium, potassium, cycloSPORINE blood concentrations

 
Encephalopathy:
impaired cognition, seizures, visual changes including blindness, loss of motor function, movement disorders and psychiatric changes; dosage reduction or discontinuation may be needed in severe cases

 
Nephrotoxicity:
6 wk after surgery, acute tubular necrosis, CyA trough level >200 ng/ml, gradual rise in creatinine (0.15 mg/dl/day), creatinine plateau <25% above baseline, intracapsular pressure <40 mm Hg

 
Signs/symptoms of encephalopathy, lymphoma

Evaluate:

• 
Therapeutic response: absence of rejection

Teach patient/family:

• 
To report fever, chills, sore throat, fatigue, since serious infections may occur; tremors, bleeding gums, increased B/P

• 
To use contraceptive measures during treatment, for 12 wk after ending therapy; to notify prescriber if pregnancy is planned or suspected

• 
To take at same time of day, every day; not to skip doses or double dose; not to use with grapefruit juice or receive vaccines; that there are many drug interactions; not to add new or discontinued products without approval of prescriber

 

Black Box Warning:

To limit UV exposure

• 
That treatment is lifelong to prevent rejection; to identify signs of rejection

• 
To report severe diarrhea because drug loss may result

• 
About the signs of nephrotoxicity: increased B/P, tremors of the hands, changes in gums, increased hair on body, face

• 
To continue with all lab work and follow-up appointments

• 
That types of products are not interchangeable

• 
Not to wash syringe/container with water, variation in dose may result

Other books

Too Rich and Too Dead by Cynthia Baxter
The Price of Fame by Anne Oliver
Full Circle by Mariella Starr
The Wedding Hoax by Heather Thurmeier
Nemonymous Night by Lewis, D. F.
Broken Together by K. S. Ruff
Gods of Green Mountain by V. C. Andrews