Generic name:
paracetamol
Classification:
Analgesics
Muscle Relaxants
MECAHNISM OF ACTION
Decreases fever by inhibiting the effects of pyrogens on the hypothalamus heat
regulating centers & by a hypothalamic action leading to sweating & vasodilatation.
Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not have anti-
inflammatory action because of its minimal effect on peripheral prostaglandin synthesis.
INDICATIONS
Relief of mild-to-moderate pain; treatment of fever.
CONTRAINDICATIONS
Contraindicated to patients with:
Hypersensitivity
intolerance to tartrazine (yellow dye #5), alcohol, table sugar, saccharin
Contraindicated with allergy to acetaminophen
ADVERSE EFFECTS OF THE DRUG
Stimulation, drowsiness, nausea, vomiting, abdominal pain, hepatotoxicity, hepatic
seizure(overdose, Renal failure(high, prolonged doses), leucopenia, neutropenia,
hemolytic anemia (long term use) thrombocytopenia, pancytopenia, rash, urticaria,
hypersensitivity, cyanosis, anemia, jaundice, CNS, stimulation, delirium followed by
vascular collaps, convulsions, coma, death.
NURSING INTERVENTION and PRECAUTIONS
Assess patients fever or pain: typeof pain, location, intensity, duration, temperature,
and diaphoresis.
Assess allergic reactions: rash, urticaria; if these occur, drug may have to be
discontinued.
Teach patient to recognize signs of chronic overdose: bleeding, bruising, malaise,
fever, sore throat.
Tell patient to notify prescriber for pain/ fever lasting for more than 3 days.
Generic Name: Hyoscine-N-butylbromide
Brand Name: Buscopan Classification: Antispasmodic; Anticholinergic
Therapeutic Actions: Hyoscine-N-butylbromide (HNBB) acts by interfering with the
transmission of nerve impulses by acetylcholine in the parasympathetic nervous system.
Buscopan exerts a spasmolytic action on the smooth muscle of the gastrointestinal,
biliary and urinary tracts. As a quaternary ammonium derivative, hyoscine-N-
butylbromide does not enter the central nervous system. Therefore, anticholinergic side
effects at the central nervous system do not occur. Peripheral anticholinergic effects
result from a ganglion-blocking action within the visceral wall as well as from anti-
muscarinic activity. Indications: Buscopan Tablets are indicated for the relief of spasm of
the genito-urinary tract or gastro- intestinal tract and for the symptomatic relief of
Irritable Bowel Syndrome
Contraindications: Buscopan Tablets should not be administered to patients with
myasthenia gravis, megacolon and narrow angle glaucoma. In addition, they should not
be given to patients with a known hypersensitivity to hyoscine-N-butylbromide or any
other component of the product.
Adverse Effects: CNS: dizziness, anaphylactic reactions, anaphylactic shock, increased
ICP, disorientation, restlessness, irritability, dizziness, drowsiness, headache, confusion,
hallucination, delirium, impaired memory CV: hypotension, tachycardia, palpitations,
flushing GI: Dry mouth, constipation, nausea, epigastric distress DERM: flushing,
dyshidrosis GU: Urinary retention, urinary hesitancy Resp: dyspnea, bronchial plugging,
depressed respiration EENT: mydriasis, dilated pupils, blurred vision, photopobia,
increased intraocular pressure, difficulty of swallowing.
Nursing Considerations:
-Drug compatibility should be monitored closely in patients requiring adjunctive therapy
-Avoid driving & operating machinery after parenteral administration.
-Avoid strict heat
-Raise side rails as a precaution because some patients become temporarily excited or
disoriented and some develop amnesia or become drowsy.
-Reorient patient, as needed,
-Tolerance may develop when therapy is prolonged
-Atropine-like toxicity may cause dose related adverse reactions.
-Individual tolerance varies greatly Oerdose may cause curare-like effects, such as
respiratory paralysis. Keep emergency equipment available.
Generic Name:
Cefuroxime Axetil
Cefuroxime Sodium
Classification:
Anti-infectiveness
Indications:
* Pharyngitis, tonsillitis, infections of the urinary and lower respiratory tracts, and skin
and skin-structure infections caused by Streptococcus pneumoniae and S. pyogenes,
Haemophillus influenzae, Staphylococcus aureus, Escherichia coli, Moraxella catarrhalis
(including beta-lactamase-producing strains), Neisseria gonorrheae, and Klebsiella and
Enterobacter species.
* Serious lower respiratory tract infections, UTIs, skin and skin-structure infections,
bone and joint infections, septicemia, meningitis, and gonorrhea
* Uncomplicated UTIs
* Otitis Media
* Pharyngitis and Tonsillitis
* Perioperative Prevention
* Early Lyme Disease (erythema migrans) caused by Borrelia burgdorferi
* Secondary bacterial infection of acute bronchitis
* Uncomplicated gonorrhea
* Acute bacterial maxillary sinusitis caused by Streptococcus pneumoniae or
Haemophilus influenza (only strains that dont produce beta-lactamase)
Mechanism of Action:
Second-generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic
instability; usually bactericidal.
Adverse Reactions:
CV: phlebitis, thrombophlebitis
GI: pseudomembranous colitis, nausea, anorexia, vomiting, diarrhea
Hematologic: transient neutropenia, eosinophilia, hemolytic anemia, thrombocytopenia
Skin: maculopapular and erythematous rashes, urticaria, pain, induration, sterile
abscesses, temperature elevation, tissue sloughing at intramuscular injection site
Other: hypersensitivity reactions, serum sickness, anaphylaxis.
Effects on Lab Test Results:
* May increase ALT, AST, alkaline phosphatase, bilirubin, and LDH levels. May decrease
hemoglobin and hematocrit level.
* May increase PT and INR and eosinophil count. May decrease neutrophil and platelet
counts.
* May falsely increase serum or urine creatinine level in tests using Jaffe reaction. May
cause false-positive results of Coombs test and urine glucose tests using cupric sulfate
(Benedicts reagent or Clinitest).
Contraindications and Cautions:
* Contraindicated in patients hypersensitive to drug.
* Use cautiously in patients hypersensitive to penicillin because of possibility of cross-
sensitivity with other beta-lactam antibiotics.
* Use with caution in breast-feeding women and in patients with history of colitis or
renal sufficiency.
Responsibilities:
* Before administering, make sure patient is not allergic to penicillins or cephalosporins.
* Absorption of cefuroxime axetil is enhanced by food.
* Cefuroxime axetil tablets may be crushed if swallowing is a difficulty. Cefuroxime axetil
tablets may be dissolved in small amounts of apple, orange or grape juice, even
chocolate milk. However, drugs bitter taste is difficult to mask even with food.
* High-fat meals increased drug bioavailability.
* ALERT! Cefuroxime axetil film-coated tablet and oral suspension are not
bioequivalent.
* If large doses are given, therapy is prolonged, or patient is at high risk, monitor patient
for signs and symptoms of superinfection.
* Unlike other second generation cephalosporins, cefuroxime can cross the blood-brain-
barrier.
* ALERT! Do not confuse with other cephalosporins that sound alike.
* Take medication as prescribed, even after feeling better.
* Take oral form with food.
* If suspension is being used, shake the container well before measuring dose.
* Notify prescriber about rashes or superinfections.
* Notify prescriber about loose stools or diarrhea.
Metformin (BP, pronounced /mtfrmn/, met-FAWR-min; originally sold as Glucophage)
is an oral antidiabetic drug in the biguanide class. It is the first-line drug of choice for the
treatment of type 2 diabetes, in particular, in overweight andobese people and those
with normal kidney function.
[1][2][3]
Its use in gestational diabetes has been limited by
safety concerns. It is also used in the treatment of polycystic ovary syndrome, and has
been investigated for other diseases where insulin resistance may be an important
factor. Metformin works by suppressing glucose production by the liver.
Metformin is primarily used for type 2 diabetes, but is increasingly being used
in polycystic ovary syndrome (PCOS),
[7]
non-alcoholic fatty liver disease (NAFLD)
[8]
and
premature puberty,
[9]
three other diseases that feature insulin resistance; these
indications are still considered experimental. The benefit of metformin in NAFLD has not
been extensively studied and may be only temporary;
[10]
although some randomized
controlled trials have found significant improvement with its use, the evidence is still
insufficient.
[11][12]
Contraindications
Metformin is contraindicated in people with any condition that could increase the risk
of lactic acidosis, including kidney disorders (creatinine levels over 150 mol/l
(1.7 mg/dL),
[47]
although this is an arbitrary limit), lung disease and liver disease.
According to the prescribing information, heart failure, in particular, unstable or acute
congestive heart failure, increases risk of lactic acidosis with metformin.
[48]
A
2007 systematic review of controlled trials, however, suggested metformin is the only
antidiabetic drug not associated with any measurable harm in people with heart failure,
and that it may reduce mortality in comparison with other antidiabetic agents.
[49]
Metformin is recommended to be temporarily discontinued before any radiographic
study involving iodinated contrast agents, (such as a contrast-enhanced CT
scanor angiogram), as the contrast dye may temporarily impair kidney function,
indirectly leading to lactic acidosis by causing retention of metformin in the
body.
[50][51]
Metformin can be resumed after two days, assuming kidney function is
normal.
[50][51]
[edit]Adverse effects
The most common adverse effect of metformin is gastrointestinal upset,
including diarrhea, cramps, nausea, vomiting and increased flatulence; metformin is
more commonly associated with gastrointestinal side effects than most other
antidiabetic drugs.
[17]
The most serious potential side effect of metformin use is lactic
acidosis; this complication is very rare, and the vast majority of these cases seem to be
related to comorbid conditions, such as impaired liver or kidney function, rather than to
the metformin itself.
[52]
Metformin has also been reported to decrease the blood levels of thyroid-stimulating
hormone in people with hypothyroidism,
[53]
and, in men, testosterone.
[54][55]
The clinical
significance of these changes is still unknown.
[edit]Gastrointestinal
In a clinical trial of 286 subjects, 53.2% of the 141 given immediate-release metformin
(as opposed to placebo) reported diarrhea, versus 11.7% for placebo, and 25.5%
reported nausea/vomiting, versus 8.3% for those on placebo.
[56]
Gastrointestinal upset can cause severe discomfort; it is most common when metformin
is first administered, or when the dose is increased. The discomfort can often be
avoided by beginning at a low dose (1 to 1.7 grams per day) and increasing the dose
gradually. Gastrointestinal upset after prolonged, steady use is less common.
[citation needed]
Long-term use of metformin has been associated with
increased homocysteine levels
[57]
and malabsorption of vitamin B
12
.
[58][59]
Higher doses
and prolonged use are associated with increased incidence of vitamin
B
12
deficiency,
[60]
and some researchers recommend screening or prevention
strategies.
[61]
[edit]Lactic acidosis
The most serious potential adverse effect of biguanide use is lactic acidosis, the
incidence for which is 9 per 100,000 person-years.
[62]
Phenformin, another biguanide,
was withdrawn from the market because of an increased risk of lactic acidosis (rate of
40-64 per 100,000 patient-years).
[62]
However, metformin is safer than phenformin, and
the risk of developing lactic acidosis is not increased by the medication as long as it is
not prescribed to known high-risk groups.
[63]
Lactate uptake by the liver is diminished with metformin administration because lactate
is a substrate for hepatic gluconeogenesis, a process that metformin inhibits. In healthy
individuals, this slight excess is simply cleared by other mechanisms (including uptake by
the kidneys, when their function is unimpaired), and no significant elevation in blood
levels of lactate occurs.
[16]
When there is impaired renal function, however, clearance of
metformin and lactate is reduced, leading to increased levels of both, and possibly
causing lactic acidosis due to a buildup of lactic acid. Because metformin decreases liver
uptake of lactate, any condition that may precipitate lactic acidosis is a contraindication
to its use. Common causes of increased lactic acid production include alcoholism (due to
depletion of NAD+stores), heart failure, and respiratory disease (due to inadequate
oxygenation of tissues); the most common cause of impaired lactic acid excretion is
kidney disease.
[64]
Metformin has also been suggested to increase production of lactate in the small
intestine; this could potentially contribute to lactic acidosis in those with risk
factors.
[65]
However, the clinical significance of this is unknown, and the risk of
metformin-associated lactic acidosis is most commonly attributed to decreased hepatic
uptake rather than increased intestinal production.
[16][64][66]
Interactions
The H
2
-receptor antagonist cimetidine causes an increase in the plasma concentration
of metformin, by reducing clearance of metformin by the kidneys;
[81]
both metformin
and cimetidine are cleared from the body by tubular secretion, and both, particularly
the cationic (positively charged) form of cimetidine, may compete for the same
transport mechanism.
[82]
A small double-blind, randomized study found
the antibiotic cephalexin to also increase metformin concentrations by a similar
mechanism;
[83]
theoretically, other cationic medications may produce the same
effect.
[82]
[edit]Mechanism of action
Metformin improves hyperglycemia primarily by suppressing glucose production by the
liver (hepatic gluconeogenesis).
[65]
The "average" person with type 2 diabetes has three
times the normal rate of gluconeogenesis; metformin treatment reduces this by over
one third.
[84]
Metformin activates AMP-activated protein kinase(AMPK), an enzyme that
plays an important role in insulin signaling, whole body energy balance, and the
metabolism of glucose and fats;
[85]
activation of AMPK is required for metformin's
inhibitory effect on the production of glucose by liver cells.
[86]
Research published in
2008 further elucidated metformin's mechanism of action, showing activation of AMPK
is required for an increase in the expression of SHP, which in turn inhibits
the expression of the hepatic gluconeogenic genesPEPCK and Glc-6-Pase.
[87]
Metformin
is frequently used in research along with AICAR as an AMPK agonist. The mechanism by
which biguanides increase the activity of AMPK remains uncertain; however, research
suggests that metformin increases the amount of cytosolic AMP (as opposed to a
change in total AMP or total AMP/ATP).
[88]
In addition to suppressing hepatic glucose production, metformin increases insulin
sensitivity, enhances peripheral glucose uptake (by phosphorylating GLUT-4 enhancer
factor), increases fatty acid oxidation,
[89]
and decreases absorption of glucose from
the gastrointestinal tract. Increased peripheral utilization of glucose may be due to
improved insulin binding to insulin receptors.
[90]
The increase in insulin binding after
metformin treatment has also been demonstrated in patients with NIDDM [91]. AMPK
probably also plays a role, as metformin administration increases AMPK activity in
skeletal muscle.
[92]
AMPK is known to cause GLUT4deployment to the plasma
membrane, resulting in insulin-independent glucose uptake. Some metabolic actions of
metformin do appear to occur by AMPK-independent mechanisms; a 2008 study found
"the metabolic actions of metformin in the heart muscle can occur independent of
changes in AMPK activity and may be mediated by p38 MAPK- and PKC-dependent
mechanisms
Brand Name: TRAMADOL
CLASSIFICATIONS
Therapeutic:
Analgesics (centrally acting)
ACTIONS
Physiologic Mechanism
Decreased pain.
Pharmacologic Mechanism
Binds to mu-opioid receptors.
Inhibits reuptake of serotonin and norepinephrine in the CNS.
INDICATION
Moderate to moderately severe pain
NURSING CONSIDERATIONS
Assess type, location, and intensity of pain before and 2-3 hr (peak) after
administration.
Assess BP & RR before and periodically during administration. Respiratory depression
has not occurred with recommended doses.
Assess bowel function routinely. Prevention of constipation should be instituted with
increased intake of fluids and bulk and with laxatives to minimize constipating effects.
Assess previous analgesic history. Tramadol is not recommended for patients
dependent on opioids or who have previously received opioids for more than 1 wk; may
cause opioid withdrawal symptoms.
Prolonged use may lead to physical and psychological dependence and tolerance,
although these may be milder than with opioids. This should not prevent patient from
receiving adequate analgesia. Most patients who receive tramadol for pain d not
develop psychological dependence. If tolerance develops, changing to an opioid agonist
may be required to relieve pain.
Tramadol is considered to provide more analgesia than codeine 60 mg but less than
combined aspirin 650mg/codeine 60 mg for acute postoperative pain.
Monitor patient for seizures. May occur within recommended dose range. Risk
increased with higher doses and inpatients taking antidepressants (SSRIs, tricyclics, or
Mao inhibitors), opioid analgesics, or other durgs that decrese the seizure threshold.
Overdose may cause respiratory depression and seizures. Naloxone (Narcan) may
reverse some, but not all, of the symptoms of overdose. Treatment should be
symptomatic and supportive. Maintain adequate respiratory exchange.
Encourage patient to cough and breathe deeply every 2 hr to prevent atelactasis and
pneumonia.
Generic name: gliclazide
Brand name: Diamicron 80 mg tablet
Category: anti-diabetes
Formulation: each scored tablet contains 80 mg gliclazide.
Description: Gliclazide is 1-3azobyclo [3.3.0] oct-3-yl) 3-(p-tolysulphonyl) urea.
Action: Oral antidiabetic
Indication: Diamicron is recommended for type 2 diabetes, in cases where dietary
measures have failed.
Contraindications: This medication must not be used in the following cases:
-if you are allergic to gliclazide
-if you have diabetes requiring treatment with insulin,
-in case of diabetes complicated by ketosis and acidosis, diabetic precoma
-if you suffer from severe liver or kidney disease.
-in case of porphyria: accumulation of pigments (porphyria) in the body
-if you are presently taking a treatment with miconazole (see interactions with other
medications)
-if you are breast-feeding
Warnings: Hypoglycemia (decrease in blood sugar levels). You may suffer from
hypoglycemia in the course of your treatment. If this happens, it may be necessary to
hospitalize you to restore your sugar levels. After a hypoglycemic episode, your doctor
will monitor you closely for at least 24 hours.
The following information is necessary to avoid episode of hypoglycemia:
-it is important to eat regular meals, including breakfast, due to the increased risk of
hypoglycemia if a meal is missed or in the case of an inadequate diet or a diet low in
sugars.
-age, renal insufficiency, hepatic insufficiency and certain disorders of the adrenal
glands or the pituitary gland may increase the risk of hypoglycemia.
-the risk of hypoglycemia is heightened by the following: a diet which is to strict or
poorly balanced, considerable or prolonged exertion, consumption of alcohol or
combination treatment with other hypoglycemic medications (see interactions with
other medications)
Glycemic imbalance: in the case of surgery, trauma, fever or infection, your doctor may
discontinue this treatment and prescribe insulin for you.
Biological analyses: the levels of glucose in your blood and urine should be monitored
regularly.
Insulin
Pregnancy Category B
Drug classes: Antidiabetic agent, Hormone
Therapeutic actions
Insulin is a hormone that, by receptor-mediated effects, promotes the storage of the
body's fuels, facilitating the transport of metabolites and ions (potassium) through cell
membranes and stimulating the synthesis of glycogen from glucose, of fats from lipids,
and proteins from amino acids.
Indications
Treatment of diabetes mellitus type 1
Treatment of diabetes mellitus type 2 that cannot be controlled by diet or oral agents
Treatment of severe ketoacidosis or diabetic coma (regular insulin injection)
Treatment of hyperkalemia with infusion of glucose to produce a shift of potassium
into the cells
Highly purified and human insulins promoted for short courses of therapy (surgery,
intercurrent disease), newly diagnosed patients, patients with poor metabolic control,
and patients with gestational diabetes
Insulin injection concentrated indicated for treatment of diabetic patients with marked
insulin resistance (requirements of > 200 units/day)
Contraindications
Allergy to pork products (varies with preparations; use of human insulin removes this
caution); pregnancy (keep patients under close supervision; rigid control is desired;
following delivery, requirements may drop for 2472 hr, rising to normal levels during
next 6 wk); lactation (monitor mother carefully; insulin requirements may decrease
during lactation).
Adverse effects
Rash, anaphylaxis or angioedema
Allergy--local reactions at injection site--redness, swelling, itching; usually resolves in a
few days to a few weeks; a change in type or species source of insulin may be tried
Hypoglycemia; ketoacidosis
Drug Interactions:
Increased hypoglycemic effects of insulin with monoamine oxidase inhibitors, beta-
blockers, salicylates, alcohol
Delayed recovery from hypoglycemic episodes and masked signs and symptoms of
hypoglycemia if taken with beta-adrenergic blocking agents
Drug-alternative therapy
Increased risk of hypoglycemia if taken with juniper berries, ginseng, garlic, fenugreek,
coriander, dandelion root, celery
Nursing considerations
CLINICAL ALERT!
Name confusion may occur between Lantus and Lente insulin; use extreme caution.
Ensure uniform dispersion of insulin suspensions by rolling the vial gently between
hands; avoid vigorous shaking.
Give maintenance doses SC, rotating injection sites regularly to decrease incidence of
lipodystrophy; give regular insulin IV or IM in severe ketoacidosis or diabetic coma.
Monitor patients receiving insulin IV carefully; plastic IV infusion sets have been
reported to remove 20%80% of the insulin; dosage delivered to the patient will vary.
Do not give insulin injection concentrated IV; severe anaphylactic reactions can occur.
