Principles at1d Applicat vJ.

THIRD EDITION

EUGENIA M. FULCHER
RN, BSN, EdO, CMA (AAMA)
Allied llcalth lnmuctor

ROBERT M. FULCHER
BS Chem, BSPh, RPh
Pharmads1
CVS Ph.irmacy
Wayne!ilboro, Ceorgia

CATHY D. SOTO
PhD, MBA, CMA (AAMA)
Professor and Program Director
Medical Assisting Technology Program
Ill l'Jso Community College
El Paso. Texas

HARTFIEl.D UBRAR'V ELSEVIER

t!ENOEl!SO~ COMMUNITY COllEGE
2660 S, GREEN ST.
HENDRSOft, KY 42420

____________.._...............................
 1.SE\'IER
\I R'

~ ..,...1bncr'fM.litt1n 1hl.i kkl .ue con~landy ch.inging. M new rotarch and experience
btoldrn our 1,1ndt:nund111ic. thAngn tn rt1C'.1rch m<'lhods. profmion.d pr,.cticn.. or mC'dical
wtlJJ'le111 m.r1 ~vme neM.&ry.
Pnn1t100.f\ ,.n,J rt"WJrrhert must 11IWJ)"1 rt'I>' on lhdr own experitn<'t .ind knowledg~ in
mluo11inic .1.rn.l u~ulg .any i11forinadon. mtlhoJs.. rompo11ndi1. or apcrirnents d&ribed herein Jn
'
in.i~ uh intonn.,tlon 1m1ho<b they ~hould be rni11dfuJ or their own safety and the ~afety of
o&ht1" inh.J 11(11 (l:!nlN (or wholt1 lhc')' h,l\'l' l l>l'Ofe11sionJ I r~sponsibllil y.
\\-1th ll'\fWCI 10 any dnta 1)111h..1nnau1k.1I produ<ts ide1111tit.'CI, reclders are l<hiiSI co check 1he
"'11~ "'ntnl l11fotm,11lon prOY'idtd (I} On p10CCdUA:'.S fe,llUleJ 01 (ii) by lhe m,lnuf,u;turer o( e.lth
pr11Juo ~1 he .idnunljU'.'frd, 10 ve1ffy thf rtrommendL'tl d0$<' or fornusl.&, 1he method and
duuo11n ol .1dn11nlstr.ulon, 1tnd oonm1indlc.1don~ 11 is the rc~pon~ibility o( 11ractitioners. relying
""IJ"11111 own c1rrrlt1llt a.nJ lrinc.h\'ledgt> o( 1hefr l>.llitnt~. 10 make dl.1gn06t'S, to dct('n11ine dosages
ind lhr M1 Uf31JOC'IU ror t'~h 1ndiV'1du.il l)aLit'nt, ond to 1.tk~ ..ill ap1Hopriale saft"t)' Jlll"CltUtions.
ro thr Nllr\t C'-'Cm1ol d~ law, nthht-t tht l..,bll}he1nor tJ1(' .iuthors. <'Ontnbuto", or edito1~.
-..mr""' h..h1htl ll'f All)' in1UI')' Ind/Or dam. 10 JM:OOO$ or proprrty as 3 111.uter o( pro<fucu
f1.bU1n ~IJll'l'l<'t "'' ochtrw1se or from tiy uw or OfK"rtldon of aO)' 1ntthod.s, producu.
buuna..-cn. N ldt-.tt con1.uncd In tht 1na1CJ1AJ htrrin.

2011035202

Working rogcthl'r 111 gro

rnn11'd II\ tht UnunJ Scal(s
libraries in developing "''ir
t.t d!Jlt it tht rnru numbrr ' www.d~r.com I ~ 1.,.,. .~ .. 1l 1 '

87~5 4J z 1
 e dedicate this third t'<l111on to our parems. I larold I and Rosabel L Mills and Roben

W M and Lucy I I ulcher. who g.iw us dreams and the desire for and the me.111s to
obtain prore-sion.ll educauons, only 1vishing you were here to be proud ro uur Ons,
1,ce .uld Gene. and our grandchildren. Mac and Allie. we know you 11.lw dreams and we hope you
will ;,ucceed in reaching them We lh.tnk each of you for the low and suppon tha1 you have
provide'<! during the preparauon or 1his text lo our extended family. we appreciate all you haw
done LO .1~1st us. We also 1hank our >tudents who have bn supponiw when we needed 111ne to
co mplete manuscript. lo 1he many fnends and instructors who have had suggesuoM. "e haw
r
tried to include as many as pos>ible so your dreams can be found within the text. ro all allted
' health professionals who will use this text, may you ach1cw your professional dreams as both of
us h.we, for almost fifty years- lhcy can come true. You are 1hr r,,1>011 this text has been wrinen-
10 provide the needed educa1io11.1I hackground for pa1icm ,,,fety m health care.
Bobby and Genie Fulcher

dedicale. 1his third edition 10 the two men in my life for whom I will always be dttply gr.ueful

I because of their uncondi1ional low. encouragemem, and conunuous suppon in both my

professional and personal lifelong journey. It was my father. Ldward 0 . Oubeansl.'Y ( 1928
2009). a Korean War Veteran and par.1plcgic before I 1vas born, who taught me 10 love Cod and
family. to have dignity and respect towJrd everyone. 10 be selr disciplined, and to be,, volunteer
1h roughou1 lire. My husband. lose Soto Ill, has been by my side .111d my moral suppon for
v; years. who shared with 111c raising 1wo beautiful daugh 1crs (Jenny and June), who drive.'> me
cros.> country for seminars. workshops, volun1eer work, and of cour>e 10 see our grand babies
(Victoria Anna, Fernando Miguel, and Murdock Lee), sonsin-law (rcmando and l:.d), and a ll my
siblings and their families. I will alwa)'S treasure our times together!
Cathy D. Soto

> m\\
. .-.,unrries
 Reviewers
' ltricN G DtSen~tto, CMACHI Donna Larson, EdD, MT (ASCPI OLM
AS$bW11 Pl h <rur10< CPR IMtru<tOf MS. BA, BS
PipiltmtDI of Wd l'llyrtl> Dan, Allied Heahh
Mnlal Cum lmliru1< Allied Hl'3lth Division
ML Hood Community College
Own1l , ""'"""' Gresham, Oregon
Debt Downs. LPN. AAS, AMA IAMTI
l'IOgmn 11' , I lnlru<tot Terri L. Levien, PharmD
Drpanmm ol \l"lo.I A""""8 CliniCdl Associate l'rofessor
~ IC\hnK.il Coll<g< Depanmem of Pharmaootherapy
ll 1....,,,.. Washington State Univenity College of l'h.irn
Spok<lne, Washington
Gltnd.. H11cher, BSN, RN, CMA IAAMAI
~ t I ~ nt1ng ru.1R~lll D1r1or Ashley Moses, PhD
Ile, nwnt of All1nl I le.11th Assistant Professor of Mathematics
so.. 1h~.... <..-oig1.1 lhnlcal Coll<'g<' Mary Baldwin College
I~ n ""II" <.t0igl.1 Staunlon. Virginia

M1ryAnne Hochadel, PharmD, BCPS Joshua J . Neumiller. Pharm D

< I o\.'I t\.l.lnl l'roh'\'r
Assistant Professor, Pharmacology
l! !1111tn1 ol rh1rmo1ry PrafU(t
\\fdshing1on St.11e Universily
lln1vm.t1)1 of I londA
Spokane. Washington
(....,..,., It. f loriJ.l
OmQI l'lunn.1< "'
l:Jrponmtn1 of l'hlmMy ....,,.,.. Karen Snipe, CPhT, MEd
a.,1.,.,. \lnll <..-ntn Dei>artmem Head, PharmacyTechnician ,
Sc. l'<ttnbwg Flood Program Coordina1or
f.lllux 1.mrnna Gold \uncbrJ Depanmems of Allied Health and Diagno'"'
TJmpa. t ..., Imaging Services
Tridem T<'<hnkal Collq;e
P111I Ju1ng. PharmD Chariesion. Sou1h Carolina
~ r l'hatm.ac) r..ctKt
( Of I' ltmM) Rebecca Wrigh1, EdD
St ....... " AMisrant Profes.sor of A1athematics
Oakland City Unh'tt<ity
Oakland City. Indiana

Sandra Wright, MEd, PhD

C.nipus !'resident
l)epanment of Adminisc.rarion
Adama Medical A<ademy
Atlanta. Geoigia;
CEO, Mo.1ney Wright & Associa1e<
Atlanta, Georgia

vi
Preface
he fl0.1 1o f the d1ird edition of t'lt1mn11cology: rrrn-
T
dpk' 1111d Applicaticm is to help the studenl m.ISlcr
not onl) the prin<iples of pharmacology bu1 also
the critical 1hinking skills necessary 10 iransfer this
knowledge base to adnunister medications for pa1tcm
safety. We have sough1 10 achieve 1h is in various w.1ys,
Orne of which are found in oilier pharmacology 1exis
and 01he" of which ar~ unique to thi> ICXL
The purpose of 1h1s 1cx1 has remained cons1.1111- 10
provide an 11uroduc1ion 10 pharm.1cology tha1 give>
al lied he.1 1th professionals an in-dep1h hasic knowledge
abou1medications1.ha1 nre used on a day-to-day basis in
the ambul.uory and some inpa1.ien1 car<.' settings. Do;c
amounts .uc shown as a single dose because administra-
tion in 1hcse settingi; would be in th.1t form. 11le 1cxt
includes information on medications u~c<i to scabili1.e a
pa1 ien1 in ou1patien1 emergency s iwaiions but no1 medi-
cations frcquendy used in inpa1ie111 emergency si1ua-
tions. such as imensiw care units Similarly, bause
medira1ions tha1 are used on a ' s1a1, or immedia1e need
basis, in specialized intensive care unil>, .ind in surgical
areas are 1101 typically used in a mbul.11ory care seuings,
infom1a1ion abou1 these drugs is nm included or on ly
limited infomtation is provided.
As 1he world of medicine has evolved from a predomi-
nately inp.11ien1 se11ins for .1cu1e and ch ro nic care 10
ambu la10ry care form.my conditio ns previously seen on
an inpa1icn1 basis, allied heahh professiona ls have inie-
graied the sl.ills needed 10 complete 1as~ ordered by tl1c
health care provider 10 provide Mfe, nl'Cessary pa11ent
Cn? in 1hc .1mbula1ory seuing. Becau$C 1he iasks hc.1hh
profession ls are legally permitted 10 perform vary from
state 10 slate, it is imponant for all he.11th c.ue personnel
to undersiand scate s1am1es in their p.micular employ
mem selling while being awa re of any changes as 1hcy
occur. This 1ex1 is designed 10 provide ,, solid background
in pharmacology as well as the necessary skills 10 admin -
ister pr~ription and over-the-cou111er medications
safely and wi1h in the scope of practice. 11lis is basic
knowledge for a broad audience so 1he allied he.1hh
professional should keep Ct1rren1 wi1h nwdica1ions used
in the place o f employment and wi th the rules a1 the site
of practice. llemember 1ha1 local requirements may vary
from 1hose seen in this text, and local requirements
should always set 1he ba~is for prac1ice.
The org.tnization of material by body sys1em lends
i1self 10 the study of disease procc~se~ along wi th the
study of ml'<iir.ations u~ed to ther.1peutically and pro-
phylactirall)' ueat 1hcse diseases. This comprehensive
s1udy helps students achieve addi1ion,1I rompe1enq and
critical 1htnl..ingskills and helps prcpJre them for cxami-
na1io ns lhaL are re()Uired for licensure o r cer1ifica1ion .
The depth of ma1crial is sufficicn1 for critica l 1hinking
skills 1ha1 can be readily transferred 10 patien1 care and
patie111 teaching. If a review of ma1erials such as ana1omy
and physiology are required for understanding. s1udcnts
shou ld use an appropriate lei<l fnr 1his information
llerause pharmacology is a specific science a~soci
ated with many dis1in('1 health CJre fields, in1eraction
among the profes.~ionals who work in these various
heahh care seuings is essential 10 ensure patienl safety
and compliance wi1h therapeu1ic care. 1l1is profes
sional in1ercommu nic,11ion creates 5,1feguards for Lhe
patiem a' well as checks and balances amo ng 1>rofes-
sionals h is essen1ial for eacll professional- heahh
care provider. phannacist, and allied health profes-
sional - lo keep hb or her medic,nion knowledge as
Ct1rrcn t as possib le. In addition, communir.uion
among hehh care workers is important because of Lhe
muhi1udes of medications released each year and 1he
increase m indica1ions for usage of t".tablished medica-
tions. I laving all medications in 1his text is nol realis-
tic; how~ver, the authors have tried 10 make the lis1 of
drugs for 1his 1ex1 as runem as possible; the con,ta111
release of new medications by 1he rood and Drug
Adminis1ration and the new indica1ions for older drugs
makes this impossible. Always check current informa-
tion for any cJ1anges 1ha1 may seem to have occurred.
The allied health professional mus1 aJ,o be careful to
ensure 1Ju1 correc1 medications are being chanl'<I in
the ml'<lical record and are being relayed 10 1he phar-
ml1cis1 as allowed by s1,11e Jaws.
vii

f1;iff-frlffiilfrllihljij:i -
1 ~"" .....i Applic.,1wn.1 has been .orga
~ __ ., manner intended 10 fac1l11a1e
_........, m u1u.knt- 1ncnw) . 1
l1UCU
ihutudyol ,nh .,, L.Jch Chapter COntJIR$ Spla
..Jrm.Ko(nt.'I:
c!tlllt"~ thJL htlp mJ~e learning fun and easy.
Section I: General Aspects of
Phermacolo~g!_!Y:..__ _ _ _ _ _ _----:""_
"'11011 l an unrodunfon LO pharmacology, gives a shor1
lu>h>I\ o1 t hI' ..ucId nd h~
V"
it has changed our world
. fi
.
10 (11$U1< \.lrt1v for both the student and pauen~ spec c
ltgW.luon nd.(lhtul issues related 10 pha'.macology are
11rmnl lht di"'1S>JOn MSO includes basic pharmacol-
ttmunologi ind proudes an understanding of how
~ ;ur .-J b) the body and the skills nttded to read
:and ant.'"fl'<(I mnhrauon ordm and document med1ca
tlom "J'l<>p11a1d)'
Section II: Mathematics for
Pharmacology and Dosage
Calculations
---------~
\t't11011 II hS ,1 basic math review for the studen1 who
111...ds 10 pracucc n1dimentaiy math skills and necessaiy
conw11110 cakulatc drug dosages so that medications arc
.Jmmi<tcr,'d '>Jfdy. Ille discussion covers the th ree
\\")It m of meuurcmcnt used 10 prescril>e medications
:and the COO\'l>IOOS nttded to change a medication
Of.kr from ont S)"'Cm to another. The calrulation of
de><.._,, for dulis nd children and other special appli.
c 11 , ue 1'o d1scussro
(httk Your Understmding math re-iew boxes
.11,... \lud.-nis 10 check the application and calrulauon
concep11 th.11 they ha'"' learned as they work their way
throol!h <JCh mJth module (answeis 10 th~ sections
"<found 111 Appendix A)
Preteslli gauge siudenis' knowledge before each math
chapter nwcnal is c0<ered. allowing both insiruc1ors
and \ludcms to identify .ireas ofweakness. Pun her review
of the material an be accomplished by retaking the
pr,1c\t b<"fore completing the review section. This will
md1<a1e are.u. that n~ extra auention prior to complet
ong the chapttr-<"ndong Review Questions that CO\'tt
chAp1cr concq'IS related to the ambulatory care setting
~on Ill: Medication Administration
'it on 111 pr...,nis the ~eral principles of medication
.idmonmrauon rht d1SCUSS1ons about routes of medica
t~on admon1stra11on are organized according to the
CMI II P/ MALRll and ABHES runirulums, s1aning wiLh
enccral (routes th.11 b""in with introduaaon .11110 Ihe
f -o
llJStro1mc511na tract), followed by percutaneous (routes
through the skin and mucous membranes). and ending
,_,jth pare:nteral routes (by injection) .
Procedures for drug dose calculauon <111d admims-
1r.1tion are presente<I in storyboard form,11. di,pl.1ying
illustrations that present specific Steps 10 ol\\ISt the visual
learner. The Proce<lure Boxes include Icons 1h.11 repre.
sent OSI IA-mandate<! and me1hodo logy-relat1l proto-
cols that should be follo,~ed 1>rior 10 .1dmirm1ering
med ications. The following icons are prcs.:1111<1:
llandwashing required
Gloves required
Sharps container required a~ indic,11cd
Use the 3 befores and 7 rights
of me<lication admininl'ation.
Section IV: Pharmacology for
Multisystem Application and
Section V: Medications Related
to Body Systems
Sections IV and V are directly related to mnl1 1ions.
Section IV presents medicatio ns 1ha1 .1fku 11111l11ple
body systems, such as analgesics, imm111111.111111 .1111i-
microbials, and an1ineoplas1ics. l1w rapidl y il''" 111g use
of herbs and nutritio nal supplement'> .1nd 1h1 1 ac-
tions with other medications are alw addr1''""' , tion
V discusses medications specific 10 body '>Y\11 n .1hles
art included in these sections that pre'>(nt hor h ncric
and trade names for dru~ usual adult <In "Oical
routes of administration, and dnag intcrac '""
Each chapter in these sections lists the Com n Signs
and Symptoms of Oisea~ found 111 1h1 1 , .tble
body system. 111ese can be compared to 1h1 < mon
Side Effects of Medicatio ns rnmrnonlv I''' nhcd
for the diseases found in that ~ystem ><> 1h.1t 1l11 11 1 1 nti
rnl 1hinkingskills. the allied healt h profc,,ion.11" I h.wc
the needed background for que.~tioning ,1 I'" 11 111 tel
provide the information needed for 1hc 1v,1l11.11 ...11 by
the health care provider. Using 1hcsc LO<l". 11.. llied
health professional can learn 10 a<;<;i<;t in """" h111g
l>etween disease progression and mc.hc,11inn '' " '"by
asking peninent questions. This allow<; till' .111o..1 , ,Jlth
professional 10 teaclt patients which sign<; .1nd 5' l toms
must be reponed to the health care prov1d1 r .111d 'l111h
they might expect as side effoos-mform.111011 th , <nu-
cal for patient e<lucation. Medication 'l.1f111 " h<"'t lt"ln-
forced when the patient becom~ an acuw mcrnhcr >I the
medication administration process.
Easy Working Knowledge i'hlt'\ li\1 1111 d11.111on
classifications used with applicable body 'Y''""" '" \)'S
temk medications. This listing. which li c11" 1,,1,llc dis
cuss1011s of specific medication types, co1rc<;pnnth 10 the

quick reference of drug classificalions found inside thf
text's cowr. lbe studem can learn to group mediations
by systemic disease processes 10 help with accura1e docu
men1ation of medicines. When the student knows the
medica1ions used for speci fic body systems and specific
disease process, the poten1ial for drug errors is reduced
Icons represeming the body systems are located next
lO ,1ssoci.11ed medication " "mes. These icons, listed
l>elow, help studen ts begin to identify drug.o. as they
relate 10 partirular body systems
[!] Medications used for sensory system disorders
1,1 Medications used for infectious djscases
~ Medications used for immune system disorders
1E1i11 Medical ions used for endocrine
l2QI S)-Stem disorders
r>J Medications used for musculoskeletal
~ disorders
Medications used for gastrointestinal
~ system disorders
IAI Mediations used for respiratory 11ac1 disorders
Medications used for circulatory disorders
Medications used for blood disorders
Medication used for urinary system disorders
Medications used for reproductive
system conditio ns
Medications used for mental disorders
Medications used for neurological conditions
\ledications used for pain management
Medications used as antincoplastics
Medications used as nutritional supplemems
Medication used for subsrnnre abuse
WORKBOOK
lbe l~\lrkbook includes mtdtiple rl'View que~lions and
p ractice problems to not only promo1e continued learn
ing, but 10 also offer thought-provoking, critical thinking
Preface ix
questions on how a variety of realis1ic situations would
be handled safely by the allied health professional
INSTRUCTOR'S RESOURCE
MANUAL WITH TEACH
111e l11Stn1c1or's Resourte Manual ttorli TEACH, .1ccessed
through the Evolve web site. conrnins answer kc)'l> to the
text and workbook, a test bank and a nswer key, as well
~s detailed lesson plans and lecture outlines nie lesson
plans are linked to each chapter and are divided imo
SO- minute units in a three-column formal. The lecture
outlines in l'owerPoi111 provide talking point;., 1hough1
provoking questions. and unique idea;. for ll'ctures. 'fbe
electronic resource includes all the instructor's resource
manual assets plus 1he tes! bank in ExarnView. and
PowerPoim sl ides 10 help the instruetor save v.1luable
prepara1ion time and create a learni ng environment
that fully engages the student.
PURPOSE OF THE TEXTBOOK
Our goal has been 10 provide a s1udent-friendly pharma-
cology 1cx1 that helps 1he allied health professional
administer medications accura 1ely and safely and 10
teach pa1ients to admi nis1er ambulatory mediations
safely at home. The book's early introduction of drugs to
their corresponding body sys1ems i~ designed to help the
s ludem begin 10 recognit.e the dnigs that are most o f1en
used wi1h a specific body sys1em. 'rbe introductory
section on body system and sys1emic-rela1ed medica
1ions is designed to assist the allied health profruional
acrura1ely record inform,11ion about medica1ions adm in
istered for diseases o f that system and to obtain informa
lion from the patient tha1 "111 assist the heallh care
provider in deciding on the appropriate medicauons for
the spe(ific patien1. 1his mul1idisdplinary proces. mus1
be directed 10 eacl1 individual palicnt, wi1h the hea lth
care provider. pharmacist, a nd allied health professional
providing a sys1em of checks and balances for patient
safety.
As au1hors, we hope 1h,11the 1hird edition of P/111m111
rology: l'ri11dples arid App/icmic11s provides s1udents wi th
an enjoyable and basic in-depth way 10 learn how to
adrninis1er medications safely, document medications in
the medical record. and relay needed informa1ion 10
other health care profe:ionals and patients who are a
part of tlie mediation therapy process
Acknowledgments
Having worked in 1he medical field for almost 100 years
combined, we ba\'e seen the importance of having a
strong background in pharmacol<>g) to ensurO? patient
 PrefJCI
nJ rJuc.imin /IS health professionals-an
::i.:ory
1UnJ tht
carep.ment
nurll! Jnd apha1111acis1-we u1~de'.-
S.Jf( we is only as ~~ong as. the 1~d~
ridlul involwJ in nwJication adm1ntst.rauon. 1 his
boot ,. intenJ,-J 10 provide the foundauon for that
l~ <p<OI thn!.> to some special people at
fht<ltt
10
I.uni Augu$unr and Laurie Vordmcde. our
llt'\lopmenlJI I d11ors, who have been our fnends,
mind readers, and con1ultants. we give a big thanks for
,.i. 1>ell done. lo Susan Cole. E.xerutive Editor, we
1
.,.i..nowltJgt tht ume you ha" taken to ensure the wet
,. A' 1,hoold bt We do appreciate your undemanding
1
of umc nttJtd 10 complete t1>'0 text misions at the
umt ume. To Wrew Allen. Vice President and Pub-
'~"' your ronunuou1 ;uppon of our endea\'OIS is so
.1rp1<'<1Jted You hJw been a guide that has produced a
lll(ht to inc:rease our writing abilitie.< for many years. To
'"' llontschank. Administrative Assistant- you are
fn,nd m neru and a friend indeed. Your encouraging
""rJ> on so m.1m occ.is1ons helped U$ complete this
tat To \lf) Pohlmn m production. )'OU ha-e been
""nJcrful 10 "orl< wnh. )'OU ha-e spent hours being
"'" the tw 1s the beM 11 could be and we do appreci-
Jtt you We thank all of the Elsevier staff for being
1hcrc for us when wt needed assistance. You are the
gr~atnt'
lo our mif"CC' "e $.lY a big thank )'OU for provid-
ing guuunce 1hroughout 1he publiation or this text-To
100..- who m,e,.-J prC'VlOUS editions and gaw sugges-
uons tor the new cd111on-know that \\'I! ha-e uied to
incorporate )'OUr ideas To th~ who revil'wed the
dtJ(ltl'TS during the produaion or this edition. tl1ank
you for providing many ide.1s and guidance for this
ttlll ~ou att special people to take time to gi\'I! us 1he
1l<'t-ded assiYance lo the ins1ruaors who ha-e used
the 1m and haw pfO\idtd guidance \\'\' hope tha1 we
have helped you with teaching the information to your
students.
We also must thank some special individuals who
have provided background 111a1crials and direction, a~
wdi as moral suppon when nt-edcd. To our pt'rsonal
physicians who provided much guidance in th~ choice
of medicauons to be presented. thanks. To Don R.11a-..1
at the American Association for \ledical Assi~1.ints. 1>e
owe our gratitude for providing informatio n .1hnu1 the
medical pradice aas of tl1e Mates. 'lb Judy )0111.IJhl ai
Medical Assisting Education Review lloard, th.mk; for
being a friend who gave us moral support duri n11 this
busy lime. To all who have provided encourag~mrnt .tnd
guidance. a heartfelt thanks Special kudo tu o 11 " ' " '
Lee and Cene. for their patience and support 1h1 u houi
the enmc project. To our grandchildren (and 1hn are
really grand), Mac and Allie. you h.we been 1he lnht 1hat
made the long days seem sho1ier. 'llMn ks for h~1111 ' l1ch
gre.11 children during the times that we were buw wd ting
and you were visiting with u~ 11uough the lo" 1 ndcr.
standing. and patience of all who have helped 1 1his
book. our dream continues to be a reali1 e.1hty
that we will a.sist allied health ~tuMnts no\\ the
fu1ure.
Genie and 80/1111 1/d1rr
I wish to acknowledge Man 'lai 1.1m. MD, 1:1 r.1, 1 l'X ;t~.
in Private Practice for internal Medicine and 1 llOUS
Diseases. and Medical Oirea or for LI raso c01 llll)'
College's Medical Assisting Progr.un for th~ t 12
years, Or. I.am has participated 1n C\ ery Ad_,, >11rd
meeting. 'll1ank you, Or. L.lm for yo ur contin11 uu_l\
of encouragement and profe;,sio nal suppo n
I would also like to acknowledge "')' rn hurs,
Genie and !lobby, as wel I as the srnff at Lbn 11 11 .di
their hard work that vent into this edition
C111l11 \4110
 Preface xi

Critical Thinking Scenano

~e sceoanos stJmulate class d1sctmOO by introducing the real
world aspect of pilarmacology ~to_s_tud
_oo_u_____ _

.
._--
--- ------
.:=-:.-:...-:.::::----..

- . ... __
...::.:-::.-:...=-..:-
..----=
.. - ...:..--:
. --
=-----.....
--
-:.::._---
.. .:'::,:
--_.. ---
----
.._ -------
--__ .:."::.:.--=---- =..-.::::--

__ _,, _..,....__...,,,,,..,.....-- .
__---
__ ----
----- ---- -:..::
..---
==:..--:=::-:-"'::.:
:::-:---
..._
=~--
:-..:.::=:
.:=::::..-::--- -

_ ....--
.... .._"-
..
-
......._.....
_...__. _...--.........._..
.,,...--
____ _..
----- ......
==~-----
.~=:----
C I-
.:::::--~==:---::
::::-..-:~_

I
.
.... . . _.
~~---
-..--
::-...:..-:-:::---
. ._...
.::.. ..
....... __ -- --...-:::-
-- ......--'==-..
:::::::::::..
:...::~----:-
- - ...
......
_....,, ..........
._
--
---
_....
------~
::.~----
. -
~-:=::.::..- - --..
~':.'":"':....~
::-..:;-:- .:.~..-;:::
.... . ...
......
... -....::
' ,.;_~-...~:.~:...-:.":
..::..:..-
...._-::.:,..............
End ol Chapter Critical Thinking Exercises and Review
Question
End of ch.it~r Cn11col Th1nk1no (xcrclses and Review Oues11ons offer
Did You Know? box
- "''
.~
::-........ -...!: :-: ... ::.-

01d You Know? Boxes p<ovide enrichment facts about relova1111opics of

thallengrnq, llioughl provoking questions on how o variety of realistic interest. such as new medical uends. history, diagnostics. treatments.
situations would be handled by the allied health professional and diseases
Clinical Tip box
Cltn cal Tip boxes provide 1nfo1mauon abOut tile cl n1col
adminrsuauon of med cauons

--
- - ----_--.........--.
~
-:;:: -:;:..,
...;;...:-..-
:::.-
_....--:,....
------
--
.. . ___
.. ___..__
..::. ...
... --- ..
..
-:::----.::::.:--:
~-
-- ----
=:.::::::=-...-=...-::

--::... ----
:,...
-;::-
-::..-- ------
------:- . --
.:-.:.- ---
- ....

learning Ttp
Leaming Trp boxes give helpful h1111s about med1ca11ons and about
~
- _
.... ~ ...............
::.'"'::...... .. ......
--- ...... ...
- ... ...::=,:~....- ...
_...,.
- ......-..,......::.;=~~-
studying pharmacology
 Important fie~ box
Im ant Facts bOxes c:ootain oolfettld summations of p1w1ousfy
te:.:i maienal that provide an at a glance iesoutce tor studcnis 10

-=----
---.._ -.-. ,..._
consult in ieview111g im2._rlill1t topcs
~~:-:.:::.. ~--=
--..:::.-.::..
-.::-- .._
::::--===-=~~-.::
..-..
.... ..... -......::
- -- ----
..._-.,::::.

____....._..-:,:::...__...-::::,_.
..----.......:::---
---~ ---
;:""'~':"!:'=-::-;:.~

--..........
::::..~-==--
.-.:;;: %- _-;;.
::--:=::::.::--::::
...-
:::::::.---- ......
ptn1nem

-- --
--=-- -
I po.ssbla
==---
--- __
~ .... =-
.. . ..
5 btens1ve Math Review
All m th tlla~"s begin w th a pre1 t thllt highlights
with n the chapter If a stud '1t m.1 tars the pfct11St wit
al IX!Yeled
>mi Of
ons If a
. . . -- ==~
b<.tlCI. thestuderlt sllould then muvo on 10 the 1ev1fM
stud< t can scoie ~%or l>Jtll r on ooth he 0t 5110 is 10 move on
he piewt
to 1tie next chaptor Stud t a1u encouht<Jed lO go bn
IS
"hen 11"""'1g the chJp' IC thcdi fQI mastery of

------.. ----
lenlS.

-=-=--=-
-~=-- -
~~-.:::.:-==--=
:-...==.;:....::::...-=..
-..-----
==-=.::.::---=.-.."':..:
---.:::---
---
:=:.-:---:..-::.::

-..:::-- -- -~-
-- ...._
_. ....;::-.... -~--"-
---
=-..::: __ . -
~::::.-
::... :.::- --::-;
:::--
--
.............,:.::.--- -:::-..._. -__-....---=-..
::::.:.::::.._.
a:-..~==~
........--~-
.:.:.-r-..::=:::=. ~::
.. .. -- __...... -- ..
-~ .._

--

....
_.J,...-~ ---
;;;;;....-
.. -.:::-
...:::.......... -----
:----..
=..:.-:.:::_
-.....::- -..--
------ =---=::::..
-----::.:=-.
Medication Alert box
Modicmlon Ale<t boxn$ conia111 filUS about 6pf1tif11 dr thll goals of
IMI! dmmtrahon. and 11ny 1"1te111oal adwrsa rcactlllllS
Contents

SECTION J
GENERAL ASPECTS OF PHARMACOLOGY
1 Introduction to Pharmacology and its Legal and Ethical Aspects. Z
2 Basics of Pharmacology, 21
3 Drug Information and Drug Forms, 38
4 Understanding Drug Dosages for Special Populations, 53
5 Rea ding and Interpreting Medication Labels and Orders and Do cumenting Appropriately, 68

SECTION JI
MATHEMATICS FOR PHARMACOLOGY AND DOSAGE CALCULATIONS
6 Math Review, 84
7 Measurement Systems and Their Equivalents, 113
8 Converting Between Measurement Systems, 126
9 Calculating Doses of Nonparenteral Medications, 145
10 Calculating Doses of Parenteral Medications, 169

SECTION II I
MEDICATION ADMINISTRATION
11 Safety and Qua lity Assurance, 186
12 Enteral Routes, 196
13 Percutaneous Routes. Z05
14 Parenteral Routes, Z18

SECTION N
PHARMACOLOGY FOR MULTISYSTEM APPLICATION
15 Analgesics and Antipyretics, 140
16 Immunizations and the Immune System, 255
17 Antimicrobials, Antifungals, and Antivirals, 180
18 Antmeoplasttc Agents, 309
19 Nutritional Supplements and Alternative Medicines, 323

xiii
liv Contents

'C7'10N V
MEDICATIONS RELATED TO BODY SYSTEMS
20 Endocnne System Disorders. 344
t1 Eye and Ear Disorders, 369
12 Drugs for Skin Condruons, 385
Z3 Musculoskeletal System Disorders. 402
24 G1stro ~tesnnal System Disorders. 418
25 Respiratory System Disorders, 443
26 Corculatory System and Blood Disorders, 463
27 Unnrv System Disorders. 493
28 Reproducuve System Disorders. 503
2:9Drugs for Neurologic System Disorders, 526
JI Drugs for Mental Health and Behavioral Disorders, 558
31 Misused, Abused, and Addictive Drugs, 5&1

APPENOIXES
A Check Your Understanding Answers, 597
B DrugNutrient and OrugOrug Interactions, 601

GLOSSARY, 602
INDEX. 619

SECTION
Introduction to Pharmacology
and Its Legal and Ethical Aspects

Aftet $ rlldyinQ lh s chapier. you should be capable of the followmg:

f 1
Oescr1b ng lhe role of lhe allie<I health pro essoona
tn pha1macotherapy and the role of each
participant 1n med1cauon del~~e~.h 1 h
E ~plain1ng rhe need of the a ie ea 1
p1ofess10nal's knowledge base as a safeguard in
medcat1on adm1nistrauon.
Unde1srand1ng folk medicine and its effects on
med1cine1 ay
ad
Ootlerent1atong among maJOr governmental
ag~s and the role and regulauons of each in
medicatoo development and delivery
ldcnt lying the legal aspects of the Comprehensive
Drug Abuse PreventlOn and Control Act of 1970
Ind describing the hve schedules f0< controlled
~taoces found therein.
Oescnbing the registration and docume t on
recess for compliance with the Drug E: cement
~dministration with regard to adm1nisr1
dispensing, and prescribing con trolled rl1 JS
0 cr'b ng the role of the Food and Or
A~~i~1~tration in med1ca11on safety
. . d g dependonc
Different1a11ng among ru ug
abuse drug misuse. and hab1tuat1on
dd b sofdr gt md
Listing an escn ing sign u d '
ethics involved onaddress1ng these pro s with
pallents and medical profess10nals
ldenufy1ng ethical procedures regarding
prescnptions, including who may presc
medicattons, and the use of protocol to ure
that these measures are followed

Judy, a new allied heafrh profess10naf, has little background m pharmacology. Sara, a young m ot of a
2 year old. calls and states that her child has a cold with fever. She asks Judy to call in a preSCflf n
to the local pharmacy for the child Judy does not think that it is necessary to ask any f11rthor qu ons
about the child's condition because "a cold 1s a cold." Judy does pull the medical record and st Ila!
the chold is allergic 10 penicillin bur was given Augmenun previously. So. without consulting the
phySICan, Judy orders lhe same ant1bio11c. The next day Sara calls to soy the child has a ra.h co ng
tht> entrre body and cannot breathe properly. Judy tells Sara to continue me medicine because it
sounds e the child has measles and will be fine Later that day Judy /earns that the child is in
Nltons ve care a1 rhe local hospiral with an adverse r~tion.
What are some of the unpfteatoos for Judy?
W'iat has she done !hat could be grounds f0t lrtigatlOn?
Should she have ca~ 111 lhe p<escnptlOn without consufung the phys1C1an? E)(pla1n your answer
What IS !lie phys1C1an s respons1b1hty>
What is tne pharmacist's respons1bthty>

2
 CHAPTER I Introduction to Pharmacology and Its legal and Ethical Aspects 3

Administer Drug abuse Food and Drug Physical dependence

Adverse reaction Drug addiction Administration Physiology
Anatomy Drug dependence (FDA) Placebo
Bioequlvalence Drug efficacy Generic drug Prescribe
Brand-name drug Drug Enforcement Homeostasis Prescription
Bureau of Narcotics Administration legend drug Psychologic drug
and Dangerous (DEA) Medication dependence or
Drugs (BNDD) Drug purity Narcotic habituation
Clinical pharmacology Drug quality National Formulary Respondeat superior
Controlled substance Drug sample (NF) Side effect
Dangerous drug Drug s tandardization Over-the-counter (OTC) Standardization
Dispense Drug standards drug United States
Dosage Drug strength or drug Pathology Pharmacopoeia
Dos e potency Pharmacology (USP)

n unponant responsibility of allied health pro- eMCnual information about body pans and normal

A frt.s1onals is understanding drugs, theu interac-

uon,, Jnd routes of ,ldmmistration All heahh
..m professionals should know answers to questions
ibout mcdictloos such as the following: What is the
wrrt'ft do~e Lo be given? Is the dosgc with in normal
l11nitsl What are signs of d rug overdo;c? What are th e
mtcr.mions witl1 tile drug? What Ide effects or ad.-ersc
lion CJn occu r when drug are givn singly or in
, omhin,111on wnh other drugs! llow do routes of admin-
,.u.11ion fToo the drug's efTooiwness! With knowledge
of mcJ1c.mons. health care professionals can prepare the
p lll<nt for a realistic expectation and safe outcome.
The word pha1macology comes from the Greek p/1armakon.
wtu~h has three related meanings claim, poison, and remedy.
ph)"iical body function l'tholoio describes changes
from normal struaure and funCllon as well as the func-
tion of medications when the person is out of bomeo
~lash. f'>yr:/10/ogy provides an underMand ing of how a
1>erson's mental state and lifestyle influence medicatio n
compl iance. Allied health professionals must integrate
cstablbhed knowledge in the ba;ic healtll science
with information from the rapid ly advancing field of
phannacology.
<
Pha1macology 1s the study of drugs and their uses
Pharmacology draws 1nformat1on from many scientific
d1sc1pltnos
Why Study Pharmacology? --'"--'-~~~~~~~

rharm.1cology changed immensely in the last half of
the t\\cnticth century. Man) medications used today
wrrc not ,ivail,tble as recently as 10 )ears ago. New medi-
' """' Jnd new uses of older medicines are constantly
being researched and approved by the I ood nd Dn1g
ulmlnl\trJlion (FDA} for use. Developments in phar-
macology require consta nt and di ligent study for safe
1111dk,11ion admi nistration.
PHARMACOLOGY AND
HEAL TH SCIENCES
Dm~ing on many health care disciplines, pbarmacol-
o is the study of drugs, their uses. and their interaction
with living >)'l>t~ms. Anatomy and ph)lology provide
Before administering medications safely, health profes-
sionals must know forms of drugs a\'ailable and what
patient foaors could afTect aaions of the drugs. The
knowledge includes the expccted action and corroo
dosage of drug.~ methods and routes or adminisuation,
symptoms of abnormal reactions. and appropriate
patient ~ducation fo r safe delivery o f the medication.
Th( allied health profession.ii functions as a link in
the health care chain to ensure 1hat the physician is
aware of all medications, both preM'riplion and oer-
the-wunter (OfC), that the patient is laking (figure
I I) A complete history of med1c-at1on use must be doc-
umented with each patient encounter to assist the physi
cian in $Jfely and effooivefy prescribing medications.
&cause the names of some medications are spelled
simi larly or sound alike, the profes.ion.tl must ensure
 S{C00.'l I Gener11.Aspec1s of Pharmacology

Figure 1-1 The allied health professional playsama1or role by taking lhe
, nt Qlmlliele med ca11on and health hiSIOI'/
111

.k curaC\ in documenuuon ll5<: of alcohol, recreational

Jruo" and altem.iu'-e medications such as b~rbals and
-L-'d lA L. recorded These amons alone
, 1umms "'""" ~ "" lh
a-.i>I in pm-roting l~I and ethical problems for e
ph\>IOilD

Sound-al1ke-look-al1ke drugs ara labeled with high alert warn

1ngs for Vl!f1fica11on at lhe time of d1spens1ng medicaoon
In many cases allltd health professionals -.ill tttn
force patient teaching about a drug's purposes. its method
and route of adm1111stra1ion, and regimen for medira
1100 efficacy, especially with initial drug prescriptions,
for patient safety.
Wi1h !he growing number or OTC drugs, 1he avail
.1bility of information concerning their actions and their
interactions with pttr.crlptlon medications (or legend
drugs) .,,;11 pm-eat reactions detrimental to 1he patient
J'toplt' tocby frequently use OTC drugs pmiously avail-
able onlyby pmcription, to treat themsd\'t'S for common
Figuni 1-2 The dYee members of 1t.o h.~ thc.
of iN11taCOlogy lol pa!MJll 'IY A. l'llo<n.. B.
..,..,.. c. ~
how and when 10 take the 111cdica11on ( I 1~1 1 2) ro
administer a drug mean~ to give the 111ed1< " 1 by 1hc
route prescribed. Drug .1dmini\1rn1ion nl.1\ I <lone hy
1on.11 in
Lhe paLien1 personally or by J he.1l1h c.ire pr
a medical facility {see I igurc I 2. B) llll' 1 11 l~ the
in triJn
most imponant figure in 1hc dn1g adm11""
gle- Patient safety for all members in"'" II drug

allmentsori!IM"SSnwch as allergies. colds. anhritis. and
gmnc condiuons. without consuhing a physician. lllese
()TC items are mandated 10 be noted in the patient's
medical record as medka1ions being taken.
Role of Profeasionals
in Medication Administration
According 10 g111delines of the Drug Enforcement
Administntioo (DI.A), each person in the medication
pathway has a speo.fic duty. A ph)'Sidan presailK:s a
drug 10 be li~led by the ~harrnacy in an outpatient seiung
or an order m an mpauent seuing. The pharmacist dis
penses or distributes the drug in a correctly labeled
container with >pecific instruetions for the patient on
therapy focuses on the pauent (I 1gure 1- 1)
The physician. who 1s a central figure 111 1ll11un-
istration be<::ause he or >he dewnnmcs th< ' h1 drug
therapy required for a >pccific patient in ,1 'I 1tu ,11ua
1ion, may also dispense sample mcdic.11iou 1 .1d111in
is1er some drng.s, such a, a111ipyre1iC\ h ll'Vt:r or
analgesics for pain, in his or her mcd1,.ll 1...
Sixty percent of visits 10 3 physioJ n n, n ' 1lrt'
scription; thuefore phJrmJC1R~ are mvul" " 1 unl in
providing the correct drug product. but JI' hdpll18
to ensure its proper use l11e pharrnaci't en u 1h.1t th~
course of therapy prcscnhcd 1s >afc. efkcm , t 1111rt'(I
in.every detail. If a qucsuon concemin111h '"'''Pl' is
ev1dc111, !he pharrnaciM will contaC'l 1lw pli \I< 1.1n (or
verlfie<11ion.
 CHAPTER 1 Introduction to Pharmacology and Its legal and Ethical Aspects
Allied health
prolossional
Phannacist
f ure 1-3 Tiiangulat1on of health ca1e ptofelSonals 101 pateot saletv
' th mcdia>tlOfl use
I he allied health professional b<.'gins patient educa-
1on in rruper drug use while .1lso funetioning as a
h,11\011 between the physician .rnd 1>harm.Kist. n1e allied
lw.1lt h profes:.ional usually is the person who receives
phrnw r.1lls from patients with quetions about their
r "'rnpt ions or is the firot pcf\011 in the team to hca r
th.It the medication has caused problems or has not had
th" XJ'<Xted results. Most patients di>CUSS medications
th.It h.l\.: not had the desired efft'Ct with other health
CM<' profo-.,ion.1ls such as a pharmacist or office staff
rnl'ml><r r.1ther than the physic1.rn fherefore. imponam
"'"'' lor allied health profes.\ion,lis arc to provide knowl-
IAc,1blc ,1n\\vers and to include other health care pro-
It "1on.1ls uch as physicians and plurmacists in safe
p.Hit111 c.irc. The pathw,1y of medication delivery requires
th.It tlw ~ntire team know medications and their uses
.111.t miuscs, as well as the patil'nt who will be using the
drug\ Ju~I as 1he physici.rn and staff must know 1he
md1<.li needs of patients, so 1he pharmadst mus1 keep
updated records of all medications being 1aken by a
j>Jll<nt IO enure drug safe[)
A complete med1callon profile, includ111g both prescription
and over-the-counter drugs. must be documented for all
pal tent>
Allied healtll professionals must continue to learn aboo1 new
mc:!icatlOOs as they are released aod keep current on new
USI!$ for older drugs
Basically, physicians prescnbe. phannac1sts dispense. and
all ed health pioless1onals (depend ng on state lawl may
udmm1ster medications and be a liaison to other health care
5
!
Figure 1-4 foxglove /D1gi1al1s putptJteJI_ used for cardiac diso1ders. is an
~ of plaol matenals that ha\'8 been used as medications f0t many
cen.tunus
professionals. Therefore 1he phys1c1an, pharmacist, and
allied health professional must cooperate in a sys1em of
checks and balances to ensure patient safety.
Allied health professionals mus1 have a workmg knowledge
of all medications uslld at the s11e of employment. mclu<11ng
"""'drugs and new applica1100s of established drugs.
HISTORY OF PHARMACOLOGY
Ancien t civilizations recorded use o f drugs more than
2000 years ago. Through trial and error, humans discov-
ered which plams might be used fo r food and which had
medicinal \alue. Folk renwdies l,1rgely did, and still do,
use herbs and other plants. In previous generations,
serious illnesses were considered to be of supernatural
origin as a resuh of spells cast on the victim by an enemy,
a demon, or an offended god Ancient medicine men
using frog bile, pig 1eeth, spider webs, and sour milk
were actually witch dooors, wise men, root cloc1ors,
nmmderos. shamans, or sorcerers who treated Lhc whole
body. I lerbal treatments fo r ill nesses became a part or
every cu lLural heritage, wi1h """'Y
cultural communities
choosing healers and wi1h culture members seeing these
men as having cures" bcrause of their special knowl
edge of plants. Over the rears, folk uses of plants and
01her natural remedies became the basis for cenain
modern medicines used 1n phannacology 1oday. For
example. the digitalis plan~ .11~ c,1lled foxgloi"' (Digt111/is
purpur.a), is the basis of 1hc commonl) used cardiac
medication digoxin (Figure I4 ).
 JO" 1 General Aspects of Pharmacology

i11mm
ill 1m
. l=
1

, nts for ueaunenl of specific diseases and used molded bread foi treatment al
~ pla of "t""a Medica was written as a drug formulaiy al plants used for
r1'ect1C11t hlia s W!Sllll1 ""' ~ "
':es:.z tnrmulalv
lre3lJnU volume of concoctions prepared to restore and maintain body harmooy
':::::
Gred
(lldJMofia/was prescnbed IOI high blood pressure: and glllSenQ as a d1U1etic.
~ l!!lllC'allv alll HlfJIXlCfales. used ()Jium for pain. helbal remed es such as belladoma
fairoprne) IOI ro::sea 8!11 'oW":~. and Jesun's bait (ql~I for malaoa Greeks used natural Ctr'es
IOI diCtA'G fb18lS began 11$8 of prescnplJOllS IOI obtanng patient medicatms
EaN3rtl Jcmer ~mt vao:roe for untnll'lltv aga~ IXJWllOl lsma flml
~ t1~su-,d'nne 11817J. ~ltllne(1820t. and nicoone 118281were aeated
~ ArrericSI CMIWai carbonrc acid was used IOI svrgical aseps1s.
[Nnrg Spanisl>Amcritan Wi11. tWllOfd \'3IXll1l!S were <dTiinlSlered ID IJOOPS

Pron 1 11~ torerunnec of sulla drugs). Satvarsan 11910. synthellc alSl!ll c for ~hs). and
~1ta (1912. lor epilepsy! were creatlld
1916 lnsul n w-as isolated
91.4-1918 !Wor1Jl Wat II I etanus un111oxin was deeloped and used lor military personnel.
m D1Mie11avacc1ne l1922)wasaeated
Sulfa l11nt11nfoct1Yel. pienyto1n ID1lantin, for epolepsy). and yellow fever vaccine were created
1930s
1940s \World War Ill Pun1c1ll n (oot11nfectM1). Beriadryl 0945. an11histam1ne). t001sone 11948. immunosuppiessantl. 1011cs.
thrlmotherapeutJC agents. and influenza vaccine were inttoduced
1950s (Korean Watl Mt'd1cauons to ueat mental illness were int1oouced. Salk vaccine (1954. polio vaccinel and o,
contrawpuves were muoouced.
,~ Sabin oiol polio vaccine was introduced. Vaccines for rubella. measles lrubeola). and mump' 1
crnawd Beta blocl<ers were developed to tteat hypertension. ClotUng factors were develop
hemophilia
1970s C1me11dme tor 11eatment of peptlC ulcers and ibuf)lofen for treatment of inflammauon were mt 1,d
l!Bls ONA pioduted insulin (1980)was the first ONA-produced medication
Otl:k111po~ vaccine. modicat1ons IOI cardiac antiythmia and bemgn prostatic hypenrophy, and
lnglOIC!lll>tOJ1\'llllng enzyme tACEl 1nh1bltors were developed
l!llls Acqull9d ITTll!UlOdcfaency syndrome !AIDS) medicatJOns and chemotherapy dll\'eloped at a pace
to ueat these devas:awg dlresses. Newer forms of medicauons were developed to treat ~
ulcers. tml'Qle<a and dlalleleS. especially 00\\'et forms of flSUlin with fewel reattlOOS
New '*'Ill aanrutrat1011 tecMiques are berg~ such as msul11 deh"'1ed u nasal
~ oral tontraa!plJ011. and u'llaled anttbtotJcs Avacane IOI AIDS. moodlips for dr:
&OOmstratlOl1. and on therapy ae oo lhe luuoo. and antN<als and antobtotlCS for drug
l!icrobe 11111C19i151lg Ill runbers
------ -------
\tJll) mfJ1ut10M h.t\-e bttn rntroduced during tima
>
o( WM or t<"<hnok>g) has Jdl"anced See llox l l for
Bv lnal and error. early CMlizat1ons found plant 5() that
Jn annouted h1stocy o( pharmacology.
In th~ l\\<nt) fi"t etntucy. tranldermal Ptcha and oould be used to ueat disease processes This" ur
sot to lo k medicine.
small dots Jr< mcreas1nRJy being us.'CI for medication
adm1n1Mrauon for smoking cnsauon. hormone replace- In the sixteenth century. the Clunese created the
ment therP> contrall-puon and ewn treatment o ( macopoeia, winch listed drugs of animal vegQ
ttenuon <ltfic1t/hrr<rcttv1ty di~order (ADI ID) b"cause mineral origin that were used to ma1nta1n boov h
o( convenience lnsulm pum~ for type 1 diabeta mel- At the end of the nineteenth centuiy and begum
lnus .ind na5JI spr.1y~ for treating acute or chronic ill- twentieth century, many laws were enacted m th held of
""'scs .ire common!) UM'd lnh~lat' pharmacy to protect the public.
' 1 or1 n1e<1IC3l101l$

using aerosol p.1n1clcs are used to treat bron-h I Medications for previously latal chrome illnesses ~r 1nt10
thS{"JSC'S ' 1a duced dunng the first half of the twentieth centuiy Mony o1
 CHAPTER I lniroduction lO Pharmacology and Its legal and Ethical Aspects
lhese medicat1oos arose rut of Ille~ of uniformed 1111 ~
iarv petJOMel, especially thOse seMng m COl!t>at
The pharmaceutical field developed rapidly m the l8$t hall ol
tho 1Wellt1e1h cenwry This penod saw the introduction of
oral contraceptives, med1ca11ons for hypenens1on, nsubn
produced by recombinant ONA technology, drugs to ueat
eiec11le dysfuncl1on, and chemotherapeutic drugs, as well as
new adm1mstra11on techniques.
At the start of the twenty-first century, med1cat1on delivery
wstems that result in a prolonged elfect and do not neces-
sitate frequent application are available Among these delrv
cry systems are patches and insulin pumps with s1hcone
m1croch ps under 1nves11gaoon for use
Society and the N eed
for Drug Regulat ion
lh1<ughout history, some membe11> of soci<?lie< IM\'e
t hu't.-.n to misuse or even abuse n1edicin.1I ~uh\t a nces
from lw1h\ to chemicals. As societies bec. 111c more pro
f "'"ivc, govc1ning bodies saw the need to esrnblish rcgu-
l.1t1011s to conirol use of these substances by enacting
I,\\\'' .uu.I uKul,11 ions.
<;overnmcnt has also taken steps to enswc th.11 the
<1>fl\Ul11cr has high-quality dn1gs providing the expected
tlwr.1f1\'ut1c properties. Before the twentieth century, drug
ltgl\l.uion wouh.l have been almost impossible-dc1ailed
informauon ,1bout drugs was not avai lable bec.tuw there
"~' no means to analyze drugs as they were developed
~ d rui;'s pottn~ or strength, or concenira1ion of
IH" ingredientS. varied with the conditions under
h"i1 the drug was prepared. lhe drug con<istency
1gh1 vary from one bottle of medication to the next;
th '' 1>.1111nts' reaaions to medication also varied, affect-
' '(,-,en p.111en1safety. Since 1he beginning of the 1wcn-
11tth 1cntury, however, research methods mandated by
"""l,11ion have resulted in consistent manufacture of
1nldit,niuns and thus safety in 1heir prepc:,ration and
lltctivcncss. Legislat ion now also requires th.11 all new
mnlic.11lons undergo s1ri11gent testing before release 10
n'l1rc dru11 >tdndardi:r.alioo of these thcr.t1wu1ic agents
d tlwrdore consistency with use. Over the pas1<tuarter
lltuty the public has become more knowledgeable
aho111 med1c.uions as the number of ore medications
h,is innc.1\ed, making patient education about drug
Lntracuons and adverse reactions an important patient
ls.st.JC'
r1i.irm.1ceu11cal companies spend vast amounts of
mon<'Y on drug dC\-elopment and ad\'\'nising. therefore
1, l:"lation is necessary to protect consumers and com-
pani.-, and 10 enforce quality control of the medication.
Allvcniscmcnts for medication suess their posit ivc effects
Lo increase sales. I lowever, by law, adverse rc.trtions,
7
drug interactions, and other neg;iti\'e effect5 are required
10 be gi''ell equal ('()\'erage so people are given surlicient
information to make informed choices about the value
of the therapeutic agent lkcaus;, of toda)'s information
highways such as the Internet, the LI S government con-
tinues to imesligate wayi. to en\ure that information
gathered from computer sourc~ " accura1e and
complete.
Controls for ensunng safety and promotmg informed
choices haw been a direet re~u h of legislatio n a1 federal,
s1ate, and local levels. S1.1w and local regulations, such
as classification of certain co111rollcd drugs, are usually
more stringent and preci~ 1h.1n federal regulations.
Rcstric1ions found in policy .tnd procedure manuals of
individual offices or medical f,1cilities may be even more
stringent than gO\ernment fl>gul.uions Allied health
professionals m1l.ll ha''e a wor~ing knowledge of regula-
tions at all levels to comply w11h all restrictions
DRUG STANDARDS AND
PATIENT SAFETY
Drug standards assure consu mers that they are receiv-
ing safe medications. Legislation requires that 11// dn1gs
with the same name and dosage be of uniform sueng1h,
quality, and purity so each prescription filled for a
given medication is the s,tme in all pharmacies. Drug
manufacturers must meet stand.irds et in the llrritetl
States 1'/1an11acopeia NtJlior111/ l'ormulary ( USP-Nr)
for quality, effiacy, strength or potency, and purity
ofa drug. Drug purity spifies the type and concentra-
tion of a chemical subsw1ce present in a drug. Most
products are combinations of aai.-c ingredient with the
fillers, buffers. and soh-ems ncress.1ty 10 gi\-e form to
tablets and capsules, to make the product more palat-
able, or to change the absorption r.uc of the medication .
l'urity standards also ensure that excessive contaminants
are not found in 1he rnedica1ion. Orug potency or
st rength is the concentration of active ingredients in
the preparation 111e.1~urcd by chemical analysis. Drug
quality ensures that consumers rcnivc medications that
achieve the standMds required by the federa lly approved
USP-NF. Drug efficacy refers tO the ability of a drug to
produce the desired chemical change in the body. Clini-
cal trials are used to corn pare the response of volunteer
individuals to the drug with other \'Olunteers' response
to a placebo.
Because of the stnc1 regulation of safety standards for new
drugs in the market. drugs are often available mother countries
before they are found 1n the United States.
 SECTJ()'l I General Aspects of Pharmacology
rwn Oil Jrug> are nudied 10 make sure.they ar~f~:re
th rofessional guidance u ''
(Cf ;admmtwat":n ,., ou'ai': followed and that labels
nunuf.xtur<'f I .,irecuo<IS 83 Of'C
bt-ar suffica<nl .. amings and instrucuons. By 19
mtdiCJllOOS "\"tt tlu~
.L.. found safe or \\'t'rt removed
bl . of many nonstandardized dJngerou~ dru~ rt><,ulted in
fn>m ult <"<Pt b) prescription. One of the pro ems an
-' ,- -'J1 i that vitamin and herbal supplement
m'"'"n' uv , h h se
;tJnaJ.uJs Jr< no1 enforced by the FDA; rat er, Lde
__, s f..--" products accor ang
, 11 ppknwn11 Me superv1""" a vuu
to thl' ll..,, wenuous re;uictions of the Depanmelll o
\gnrnhur< lhese supplements may not have the sam~
l'unt) Jnll quality wiLh each manufacturer or batch,
th<rdoie co111umm must be careful to choose rcp.u1able
companies Jnd to carefully read labels 10 lower nsks of
i.tkfng roo1-<1wl11y supplements
In the 1llio1 drug marl<tt. the consumer does nm
ml"\ the protecuon of these siandar~ resulung in
mhn<'llt 11.mgcn similar to those found m the ume of
thl' m..J1onc man 'The use of illeg;il drugs has resulted
1n <J\crJ<&\ and death among those \villing 10 take the
n>k\ 1m'Oh...J
..
Orug 1ta lda1ds ensuic that consumers will receive safe
med1u11oos lhat are the drugs that were expected .
Drug pu111v specifies that the correct ac11ve 1ngred1ent is
prt 111 and m~nufactured wnllout excessive cootam1nents
Ill~ potency 01 strength is the concemraton of active
mgred t Earliest regulation included many loo pl
l)ug aJlly ensures that uie consume receives dflf,lS that
the standards ~ shed 11 the Un red S1ares f'harma.
'i tiulal fomWy
elflcacv as the alli ty ol ;iie drug wirodUCe the desired
llCll charige 11 Ille body
~. thHOulllel medacal:OnS must meet the same staooards
gend drugs
International, Federal, and
State Statutes for the Regulation
of Medications
The anwma1ional control or medications comes under
the .1u1hor11y of the World Health Organization of the
llnll<'<I 1'auons lnis group provides technical assistance
in the drug field and promotes research on drug abuse.
llwc no "l>r1d judicial groups enforce laws concern
mg drugs. drug con1rol \ones from counuy 10 country
Some nJUons hit\-., more stringent Jaws than statutes of
the llnrl<-d Su1es Harsh punishments including long
pnson ..,ntences and ""n death are imposed for posses-
\lon of allcgal drug. or drug trafficking in some countries.
01her countries have lenient laws and enforcement con.
cermng Jrug possession, even 10 the poini of allowing
use of some drug> that are illegal an 1he United Stotes.
Before the twentieth century, many drug~ con~1ining
um and the new miracle drug morphine did not
require a prescription, and P.hamlac1sts
op Jnd p hys1aans
were not required to hold a license. l~tbt!hng of ingredi-
ents on medication bottles 1"'5 1101 a requirement. Use
injury or death from their use. a<ld1c11on, or rnconsis-
iency in maaufacmre.
f
Before 1906, patent medicines were sold by rned1c111e men 1n
1ravelmg shows, by mail Older, 1n stores. by tranled phvsac1ans.
and even by individuals who 1ust called themselves "dottors.
Medrca!IOllS with Mmes like Or Smith's Miraculous Cough
Mediane or New Age Miracle Soo1h111g Syrup were popi; ar For
~Join S Pembenon. a pharmacist in Atlanta 1 made
Hench Wiiii! Coca-Ideal NeM1 and TOOIC Sr1mu/Jn1 885 In
1886 Pembenoo used coca leaves and calfeme from I Alrrc:an
kola nut as ingredients rn a ptoduct called Coca-Cola A nased
as a "dierapeucic agent" and "SCM!retgn remedy the ucker
p1cker-uP1Jer" became known by the nicknames o and
"Coke."
Federal Legislation Related t o Dr s
l'ure Food and On1g NI of l 906
' .tnd
Jack of enforcement abilities
Drugs found in interstate commerce co11 n il be
labeled as auative if the claim\ \ere fJI,, .I mis.
leading. but advenisemem b> word ol n th or
printed materials was not covered
lhe USP and the ~were created .t.\ the,< t ndia
comaining the official st.rnd.ud\ for Mr I .md
purity during manufacturing. i11rlull1 n1 l.ibel
showing the eleven specific d.1n11ernt" ' 111ic.lls
present that may cause drug add imon
Shirley 1\me11dmem of 1912
Prevented fraudulem 1hera1lcutic rJ,1i11 " ti rug
manufacturers.
1lani5on Narcotic /\cl or fet/rr11/ N11rtQIJ1 I >1 Id of
1914
Established 1he word r1arw1i1 and fl'\IUIH , '" use
or a stamp on the comaincrs of the...: d ru
f-or patient safety, regulated the 1mpon.1tu nan
ufaaure, sale. and use of opium, co.lcnw . 1 their
derivati\'t'S and compounds
Food, Drug. and CostntrJ< /\ct of 19 36
.Provided safety testing on all drug.-.
rhe FDA \<13S fonned to enforce the l.l\\' ..,ci1
goods that were improperly manuf,1c1tmd , r p.1ck
aged, and undertake criminal pro;ccu11on of tlw
responsible persons or fl rms.
 CHAPTER I Introduction to Pharmacology and Its Legal and Ethical Aspects
Required pharmaceutical finns to repon all ,1dve!M'
effects associated with their drugs at regular
mrerval>
lleqmred that all new drugs be tested for toxicity
before approval.
In the late 1930s sulfanilamide. an an11bactenal agent in a
raspberry.ftavored base. was a lethal elixir liecause the base
was not known to be toxic With no need for approval of safe
chemicals used in manufacture, the company did not use an
alcohol base that was indicated for an el1x1r. but made the drug
using an industrial-strength toxic liquid solvent. d1ethylene
9lyt0 ama1or 1ngred1ent rn anofreeze More than 100 children
d ed after 1ngesttng less than an ounce of the med1c1ne. and m
excess of 350 more children were poisoned
1>11rl1.1111-llumplrrey Amendmenr (19~1) replaced laws
of l'H8
lnd1c.11ed rei1ula1ions for prescription orders or drs-
pen>ing by designating prescription and arc med
1catio ns, with labeling ofprescri1>1ion mcdic.11 ions
hvinll m~r hy placing an nx on 1he label or the
nMnufdnurds bonle.
lkquired that all prescriptions be labeled caution:
f'i'lh-1.11 law prohibits dispensing without a
11rc><1iption.
lk >ignatcd the OTC drugs that were considered
\Uflid t>ntly -..1fe not to require a prescription
Requ iml warning labels on drug packaging.
l\tj.1111\Tlldrru 11.mmdmenr {1962)
\\',!\ p.1\Sell because drug companies were making
l.ug<' profits and engaging in misleading and ewn
f.115<: drug promotions.
Rl'<fu1rt'd proven effectiveness of a drug before mar-
k< ting. with o ld and new drugs requiring proof
tt'Sting.
1e mdnufacturer of thalidomide. a h'IJlflotic that was taken by
g 1ant women early in pregnancy, claimed 1t was a miracle
g for the nausea of Pll!!lrtancy and a sleepmg aid without
1mg the associated dangers of seve<e deform111es in fetuses.
ng to a wave of thahdomlde babies These mfants were
born with severe defomulies. especially nf hmbs Some preg
t women n the Northeast were prescribed the drug. but the
~ was mGfe a might-have-been" catastrophe than a
despread. actual one because a U.S Food and Orug Adm1fl1s
trat1on employee was suspicious of the drug and wanted mnre
tormat1on belore approving it for use in the United States
Sadly. the chemist who developed the drug later committed
su1c1de
9
Comprehen.1i1'I' Drug 11.hus.- l'rM..,lllion 11tul Conrrol NI
of 1970 (also called Comrollr1I S11b;1t1nc<'! /\a of
1970)
Repealed the 50 la\'S passed between 1914 and
1970 concerning drug control
Regulated manufacture, distrihution, and dispens-
ing of drugs with 1he flOtcntial for abuse.
Indicated drugs that h~d potential for abuse.. and
placed these medications in five schedules sorted
by potential for abuse or add inion to prevent
indiscriminate use of these drugs by limiting their
use.
Required se<"uri1y of controlled subsl~nces b)'
anyone who dispen<es, 1cccivcs, sells, or destroys
controlled substances using special DEA fonns to
show currem i1wentory
Regulated use of controlled substances to only
legitimate handlers to help reduce the widespread
illicit use of the-e drugs.
Provided for prevention of drug ~buse and drug
dependence and for 1rea11nent ,rnd rehabilitation
of abusers and dn1g.dependen1 persons.
Two important agencies had a role in the enforce-
ment of this Jct:
The Buruu nf Narcotic~ and Oangerous
Drugs (BNDD), in cxbtencc rrom t968 to
1973, with the following responsibilities:
To register all 1)ersons who manufacture. dis-
pense, prescribe, or administer any controlled
substances.
To provide for ne<"es~1ry revision of schedules
and dasscs of controlled drugs.
The Drug lnforcement Admlnlstntioo (DEA)
was established in 1973 to rontinue regulation
and enforcement of manufdcturing and dispens-
ing of dangerous and potentially abused drugs.
(See section on DhJ\ that follows.)
Po1Son Prewmion P,1ckag111g NI of 1970
Created standards to ensure 1ha1 both prescription
and OTC medications were in chifd. resis1anr
packages.
Drug I.isling An of 1972
Established Nat io nal Orug Code ror use by tl1e
l'DA to identify a drug's manufacturer. including
1he drug formulation and the size of the packag-
ing. by using a unique and 1>em1a1wm code for
drugs.
Drug Regulation 11tul R~fom1 II.ct of 1978
J\llowed for briefer investigation of new drugs and
to allow for faster access by the consumer.
Orphan Drug Ac! of 1981
tstablished in rcspon<e to the removal of dn1gs
because of potential danger. or the lack of research.
Established funding for resc.1rch for use of these
drugs in the treatment or r.1re ch ro nic ill nesses
tl1rough grant monies and tax incentives LO find
 SECT"ON 1 General Aspects of Pharmacology
"'"' Jru~ and nfW uS<'i for older drugs for condi
"
rK>ns ""h f,.,, pJ11en1S 1ha1 the manufaourer
would ~ unhktl) 10 recoup expenses once the
Jrug could be mark~ed
()"'~ Pn.~ c:cnp.-1111.n an</ l'attnt f1'1!11 /lt$lora1ion NI
(19M)
1.J>ttl miuaremenlS for marke1ing generic drugs by
allowing g;:ncnc Jrug compan1ts 10 prove bio-
l'tJU1valencc w11hou1 having 10 duplicate trials.
Fxtended length of 111ne Of patenLS lO compensate
for 1he 11me IO!ll in 1>remarke1ing tri.1ls.
()111111!111; 811<f.~t1 R1~011dllmlm1 Acl of L990 (OllRA
1990)
Ma1lll.11e,l 1ha1 (}fC drugs be considered ,m impor
1a111 p.lfl of 1hc mediral record and 1h.11 they be
documc111cd.
111wb111it Sr1roi1l.1 Cqrwol 11<1 of 1990
Placed anabolic s1croid; under umbrella of the
Corurolled Sulmances Ad of 1970.
l're.>rrlpumr Dmg J\mr,.d111t11U of 1992
Allmvro rapid approval or medications by the lDA.
c~pecially for life-dirca1cning disc.1scs and debili
1a1mg cond111ons.
llll.-.J r1114/ l>ro.~ Ailmmurr.11ro11 M<'<lmrr:.iirion J\cl ( 1997)
Allmro rapid approval of med1ca1ions by 1he FDA.
CSJl<"<:ially for lifc-1hre.uening diseases and debili-
1aung condruons
Other la"~ may come from rcgula1ory agencies such
as the I tdml Trade Commission, which regulates busi
~ pracucn rn 1he mtdrcal field. and the Consumer
ProJLICls S.fetv C.ommr\~ron. which has a rou1ine 1hat
mu\I be follo\\ed. <uch as for drug pacl<.lgjng 10 pm-em
po1'i0ni1111 rn children
DurlY,l lhe wclespread outtweal ol H1NI 1nftuenla 1n 2009 tile
FDA a lowed emergency use of the experunental drug pera~rm
fDf hosptralaed p.:i1 en1s who had not responded to d1e fOA-
aPIJl(Md ant1wals
Over 1he )'t'J~. federal kgisla1ion has es1ablished
~L1ntlMds for medicines 1ha1 provide patiem safety. Citi-
zens of 1he Un11cd Smes can feel assured thai their
d ~iions ha\'e been 1es1ed and found cfftCli\'C with
me ~ adverse reactions and '
minimal ~1al aII prc~rnr11011~
for
ihe same medication will contain 1he same 1hcr.1rcu1ic
ingredienlS.
The use of the ln!Emet lor medications has brought ethical and
safety di11nrnaS of its own New consumer salety regu!atrons
are being put 111to place 10 ensure safety lor patients v.ilo fill
medication imcnPlrons by usmg the lniemet or providers rn
otle counmes. The go.emmen1 rs even looking rnto ways to
erlSIJre !hat such lntemet srtes Jlfovide pa11ent safety and lllat
me medications are those specified and protected by regu atrons
pe11am1ng to tile manufacture and d1stnbu1ton of lhe drugs
Auhe state level, al most all states have l,1w' ~" ... med
by the state boards of pharn1acy concerning 1lw' 1ll\111u
tion of generic drugs for bnnd name d ru \omc
states and some: insurance companies pennit ~ncric
substitution by the pharmacist, although thl' P"'" 11 pre
scribing L11e medication, usually a physician, '"'"'" 1hc
right 10 require 1he dispensing of a brand-11.11111 .111g by
writing "brand necessary' on the prescrip1io11. 111 1 t.ue
has mandatOI)' subs1i1u1 ion, die pharn1acis1 " 1 111111d
10 use less expensive generic drugs for disptn, 1; II .1
generic name is used on the prescription. 1he pli i.11 i<I
may use his or her discretion 10 selec1 1hc dru 11h ,1
bioequivaleoce 10 the brand-name nwdica1ion nenc
medication mus1 go through 1cs1ing 10 ""'"" 11 the
inen ingredienlS provide bioequivalcncc .rnd 1 11 1he
acti"" ingredienlS ha'-e no1 changed from , , rn
1he 1tademalked drug.
THE FOOD AND DRUG
ADMINISTRATION AND THE
INTRODUCTION OF NEW DRUG
As an agency of 1he U.S. Depanmem of 11, r .ind
Human Services. the fDA is responsible fo r the re''"'
1esting of all dru~ before they are released w ti 1bli1
(Table 11). The dewlopmem process rs leng1h> A~ 1ng
6 10 12 years, and is expensive. Al 1he end. onl 1 nu1
one drug emerges for each 5000 10 10,000 d1fkri 11111
pounds 1es1ed. (Stt llox 1-2for1he drug 1cs11ni: pr '" )
At any time during the process or even .lf1cr .111'""'1,
the FDA may ask for additional informa1ion "" , 1hc
manufac1urer, for revisions in the 1rials or for 1h 111l'UI
cation to be returned to the company f~r funh<r ,, '""'h
or 1e~ung.
Th ereiore
< manu fac1urers tha1 dcwlop " 1ln1g
~re grven a 20-year paient on the rncdica1io11 HH 0\1'1 the
ume and expense of trials necessary 10 show 1h.11 1hc
 CHAPTER I Introduction to Pharmacology and Its legal and Ethical Aspects 11

TABLE 1 1 AGE NCIES RESPONSIBLE FOR DRUG SURVEILLANCE

-

AGENCY ANO
SUPERVISING
DEPARTMENT OF US
GOVERNMENT CONCERN RESPONSIBILITY
Food and Drug General safety Approves and removes products on the maltet
Adminostratoon IFDAI standards in the Regulates labeling and adven1sing of prescropuon drugs, cooperates
under Depanment of production of drugs. woth Federal Trade Commission on regulation of nonprescription
Health and Human foods, and cosmetics drugs
Services Regulates drug manufacturing practices
Engages in postmarketmg surveillance to detect unantocipated
adverse and therapeutic effects of drugs
Drug Enforcement Controlled substances Enforces laws against unlawful drug act1vit1es
Admonostratoon IDEAi only Assigns 1dent1ficauon numbers (DEA numbers) for those entities that
IJllder Depanment of prescnbe. dispense. and manufacture scheduled drugs
Justice Monitors scheduled drugs for need to change flOS$1ble abuse level

mz STEPS IN THE DEVELOPMENT OF NEW DRUGS

Development of e New Compound l'Mse 3 trials-experimental study of drug or treatment to

1 Pharmeceulical Company larger group of peQple (1000-3000) to confirm ellect1veness.
monitor side effects. compare to commonly used treatments
Pr linlcal Tasting in Animals and collect information that will drug or treatment to be used
Dougs aoe tested for toxicity, use of drug in lhe body, and possible safely
useful effects Phase 4 tnals- post-marketmg s1ud1es delineate add1t1onal onlor-
Ar rn<1I testing range of I to 3 years, uS1Jally 18 months matoon including the drug's rosks. benefits, and op11mal use

ood Md Drug Admin1strauon (FDA) safety review of testing New Drug Application (NDA) Sent to FDA
resuhs FDA review Range of 2 months to 7 years. usually 24 months
J.
c:t1ga1Jon1I New Drug Status if Approved FDA Approval of NOA
back to earhesi research 1f not approved.I Ill not aP!lfOYed. return to manufacturer for funher 1n111at testing
or further research.I
real Troals in Humans J.
R nge ol 2 ta 7 years, usually 5 years Postmarketing Surveillance
tong for safety, effectiveness. dosage range. and therapeutic Drug 1s released for use. permitting observatoon 111 large numbers
ue of patients.
f 1iase I troals-test of an experomental drug or treatment 1n a Surveys, sampling. and inspections by FDA and physicians using
smdll group of peQpfe (20-80) for evaluation of saletv. safe the medication are performed.
dos.iue ran9e, and 1denllfy side effects Adverse reactions are reported to FDA for analysis and
"'1.Jse 2 mals-experomental study of drug or treatment to larger reevaluation
~ooup of people (100-300) to funher evaluate effectiveness and
safety

drug ha' the intended therapeutic purpose on humans.

lhf' procc'' ofl'DA approval uses up to half ofthe patent
L ow leaving 1he compan) wi1h about 10 rears of mar-
kctabili1y unMr patent, or rrade name. Ar 1he end of th.11
rune. another com1>any may manufaaure the drug under
ano1her br.nd 11.111ne or u~ the generic name thiH hlts
hcen .migncd by 1he USP.
Many brand names may be available for the same generic drug.
For example. ibuprofen is sold under the brand names Mouon.
Nupr1n. and Advil. and naproxen is sold as Naprosyn at prescrop-
toon strength and as Aleve at over-the-counteo strength
 SECTION I General Aspects ol Pharmacology
12
rhr In,\ Jl;o rcvi<"'' propo>ah for n<"' indications
for .ilrJ} appmwJ drugs. wnh the clinical iesun_g
JlKr>l b<ing J'l'rforrn<-J as f01 a new drug. A nf\~ 111di-
ca1ion for an alr~ad) p.11cn1ed drug extends ihe ume of
!ht- rtent on 1he rned1Cauon Conversely, 1f a drug
arP""' 10 he J~<0<1a1ed "'ith 100 many ad-erse n:ac-
tk>n< 1he fOA or manufacturer h.u the nghl to "11h-
Jm- th< drug lrom the 11Url.<l after appM-al has been
panttd
Onlp tnal are deemed 111Safe rrtllY be remowd lrom !he mat'<et.
1$ot:arledM:ntne.oiunlal'fW11hdrawalollhecyclooxygertase-2
ICOX 2J inht!ilun Vv. and &;,ua. alter lliev were foultd 10
roease tne 1 k ol mulhple :id'<erse reac11ons sucll as heart
auatk lllld Slleie
Many prescription mcdicJtion~ arc boming OTC
drugs Jt s1re11g1h; dcn~ascd below the legend strength.
An Ol"C drug ha mcd1c.11io11, ,rnd as such, the consumer
must uw it as the ll)A ha1 approved ii for OTC use.
I duca11ng the patient 10 follow directions is an impor-
tant clenwnt in 1hc SJfc U$C of Ol'C drugs. See Table 1-1
for the role of the I DA in drug regulations.
Important Foctl
n DEA an agency ol 1tie US Department of Justice. 1s
10 pins.ble foi mon 1oruig cor trolled si.bstances The Food
d Drug AdmmistralKJn (fOA). an agency ol the US Depart-
"""'' 01 Hro th ard Human Servlces 1s responsible foe regu
1 ni lhe manufacture ~ safety of drugs.
T' Mopmen1 ol a new drug is a IEflgthy proce$$. ia<ing
12 years. and ontv one of up to 10.cm compourds
tul~ l!lil'f reach the siage of a new drug
A ~ mtrotkltg a new drug has lllllJll)xomall!ly 10
years ol e<dw;e use of lhe drug
l'led1111C31 ~ clmltal test~ mus1 be done on a new med~
callan to ensure llS safeiy Afr'( 8'Mlr$C reattlOllS 10 medica
llOllS ciieaarty reMv l!lil!keled <iugs shoold be reported
IO lhefOA
The Drug Enforcement Administration
and Controlled Substances
-------
Controlled sub;iances became regulated by the DEA
through the Controlled SubstJnres Act, Title 11 of the
Comprehen~1ve Drug Abuse Prevention and Control Act
M 1970 (~ lable 1-1). n1e drugs are d.1ssified accord-
ing 10 1he1r es1,~bh1hcd abuse potcmial, which applies
not only to pa111 relievers but also 10 drugs wi1h Ll1e
-
I be addictive or habi t Conning. such a~ ste-
po1en11a 10 c r I
.d d pressants1 and stimulants. n1cna 1or p .1ccmcnt
ro1 s, e
on the list include the following: . .
Evidence that the substance IS be111g US<"d 111 sum.
cienl amounts 10 pose a medical 1hrca1 lo 111dividu-
als or a hazard to the community
Significant diVt>rsion of the su~stancc from lt'glti-
mate use to illegal drug uaffickmg
Tendency of consumers to take the \Uh\t.rn<e on
their own initiath-e rather than on nw<lu .11 .1dv1ce
A Of\~ drug ~ith an action related to th, .mum of
a drug already on 1he controlled sulm.m"' list
until a decision is made concerning 1i- .1buse
potential
The controlled substances are grouped int<> f1 , lie
gories. or schedules, each with its own pres< np1 "' dnd
dispensing reslrietions [!"able 1-2) Med1t.111 "' "ith
highest potential for abuse and with no .1ccep1"d 111nlical
use are placed on Schedule I. Those wi1 h It .1busc
potential are placed on Schedule V. J\ drug 111.1~ I nnvcd
from one schedule 10 another or may be rem< d Irom
the list on reevaluation of abuse po1en1ial bv 1)1;\
Any revision of the list is sent 10 prac1i1iont1 o kl'cp
1he health professional's kno~ledge curren1.
Because 1he DEA s1riclly enforces reg11la1io11 11,\ifl a
ing 10 scheduled medications, precise and 111plc1e
records are required for Schedule II mcdic.nii I hcse
records must indicate the flow of 1lw '' lu incs
from lime of arrival at 1hc focili1y until
administered.
Important Facts
Coouo led substances are placed tn one ol I vc
schedules. eadlw1th restuctlOOS on p1esc11b ng or.:J
ing, based on the dangei of abuse OI mt~
DEA aJtllOlled Sllbstances may be moved betv.
oles on the aJt1rolled substances lts1 A current
all Schedule II medocatlOllS should be kepL If St
medocauons are dispeosed 1Ji the fac11tty. an
time is a so necessal'f
Cootrolled substan:es can be abused and mtsu lh 01
V.11hout prl!SCllptlOO use
The Drug Enforcement Administr
~nd Controlled Substances
m the Medical Office
Controlled substances are labeled so 1ln1 1hn .111 he
easily idemified. J\ large C shows that 1h~ <lruA 1, .1 w 11
!rolled drug. with the Roman nun.1eral of lhl' "hL"du lr
( I through V) appeanng w11 h.111 1he C. For ox.1111ph. ,1
 CHAPTER I Introduction to Pharmacology and Its Legal and Ethical Aspects 13

TABLE 12 DRUG CLASSIFICATIONS ACCORDING TO THE CO NTROLLED SUBSTANCES ACT OF 1970

'' ' .. .. ' . '

Schedule I High potential for abuse. severe
physical or psychologic
dependence
for research use only
Schedule II High potential IOI abuse, severe Dispensed by prescnptoon only
physical or psvcholog1c
dependence
Accepted medicinal use with
specific restnclions
Schedule Ill Moderate potentral fOI
abuse. high psycholog1c
dependence, tow physical
dependence
Accepted medicinal uses
Schedule IV lower potential IOI abuse than
Schedule Ill drugs
Limrted psychologic arid
physical dependence
Accepted medicinal uses
ScheduleV Low potenual fOI abuse
Abuse may lead to limited
physical or psycholog1c
dependence
Accepted medicinal uses
Drug Enf01cemet1I Mnon1suat1on IDEA!. US Oepar1ment of .histoat, Washing1on OC local DEA offices can pnMde current hsts of medatrons
1llese SCl>edules
l~g c acid d et~ode OTC..., the COIJlter. PCP. J)lleno/ci1d ne hydroellbode. THC. tetrahyO'ocannabinol
No accepted use in United States
Marijuana may be used in cancer
and glaucoma for research arid
may be obtained for patients in
research Situations
Oral emergency orders for
Schedule II drugs may be given.
but physician must supply
written prescription within 72 hr
Refills require a new written
prescription from physician
Dispensed by prescnpoon only
May be refilled five umes in 6 mo
with prescription authorization
by physician
Prescription may be phoned to
pharmacy
Dispensed by piescnptm only
May be refilled five times in 6 mo
w11h physicran authonza11on
Prescription may be phoned to
pharmacy
OTC narcotic drugs may be sold
by registered pharmacist
depending on state laws
Buyer must be 18 years of age.
show identification. and sign for
medications
Narcotics-llerom
Hallucinogens-peyote mescaline.
PCP. hashish, amphetamine
variants. LSD
Cannab1s-illanjuana, THC
Designer drugs-ecstasy. crack.
crystal meth
Narcoucs-opium. codeine.
morphine. methadone.
hydromorpllone (D1laud1d).
mependine !Demerol), oxycodone
(Dxycotin). fentanyl (Duragesic).
pentobarbital (Nembutal)
Stimulants-amphetamines.
amphetamine salts (Adderall).
methytphen1date (Ritalin)
llepressantspentobarbital
(Nembutal)
NarcotlCS-i)aregonc (opium
derivative). certain codeine
comb1na1ions (with
acetaminophen)
Depressants-pentobarbital
(Nembutal) (rectal route}
Stimulants-benzophetamine
1D1drex)
Narcotics-pentazocme (TalwinJ
Deiwessants-chloral hydrate
(NoctecJ. phenobarbital. d1azepam
(Valium). chlordia1epoxide
(Librium). alprazolam (Xanax).
clora1epate (TranxeneJ.
benzodiazepines (lorazepam
IAtivan], flurazepam [Dalmane}),
mldazolam (Versed). meprobamate
(Equaml). temazepam (RestoolJ.
Stunulants-phentermine (Ad1pex-I')
Preparations oonta1mng limited
quantmes of narcotics, geoerally
cough and antidiarrheal
prep<1ra11ons-cough syrups
with codeine. diphenoxylate
hydrochlonde with atropine
sulfate (lomotill and attapulg1te
!Parepectolinl
,, SICTION I General Aspects of Pharmacology
. tration of the medicatio n must be kept for
of the adm1ms
2 )~afS. b I. . I.
cdule 11 controlled su stances must "" ~ep1 sepa-
Sch tb-druo and b<' pl,1rcd Ill a St.'Ulrely locked
rate from o ~ "' bl
So states require a dou c 1oc~ on op101d prod.
1.

area. ,... me k of controlled sub$t,rncC\ \hould be kep1

uctS.1uestoc
. . m For the office 11e.,..1ng 1 I.ugt> ,1mounts of
figure I 5 Sy!lltlol lhal lllllcateS dn'9 15 1 Cit'trolled subSl'1f'Cll to a m1n1mu . .
Clml~lli -' substanc~ higher security nw,1~urc~ ~uch as
contro II "' ,,. em should '- "" .111 pIacc. I hc, ph >Sin.in
, . or
an t' Iarm s,-1 , I k I
. hr d-ia.iee should keep l 1e ey. I ic \ldtutes of
hisor ~ <I)' I I II' f
each state provide gu1dehncs on I w 1.111< ing o con.
Schedule 11 medlca1ion would be shown 3' appears in trolled substances. . . .
I 1gu1e I 5 ( h d If theft of inventory ocru~, 11 is s1g111 ric.int .md the
l'h)~icians or other health professionals sue as en local DEA office must be no116ed If theft hJ' <>rcurred,
um) who admont>ter. dispenSI'. or pr.escr1be controll~ ;1 is required that the local police Jcp.111mem be
wb,1.1nce> must ha>Y a rumnt <tair hcenSI'. must reg1s notified fil'Sl. as "ell as the state bure.1u narcotic
t.-r wnh thl' DU\ nd be assigned a DI.A numb<'r. and enfmcement If damage 10 or con1am1na11011 f signifi.
m "'me s1.11e> must ha\y a state comrolled-substance ant amounts of controlled substances ocrn1 1hc local
h<en\C L"epuons to this ruhng Jre ph) 1cians "ho are DEA office should b<' contaocd for .1ppropr1.11 Ji\posa)
1ntrm~ ll'>ld<nts. in the armed servic~ from a foreign
insuuctioos.
country. or on the staff of a \'f1erans Adm1ni~uauon
IJoloty. who dispense and prescribe using a special code
under the regl5lration of the hospital or in;tilution. ~t
1he appropriate lime for renewal (l'\'t'ry 3 years), the DEA Record Keeping and Inventory I nt rol
will au10111aucally send a renewal form 45 days before dica1ion
t\s controlled subslances are rl><:ciwd. th l
the renewal dare. If this form is 1101 rccei"ed. it is the
should be recorded on,, speci.11 inventory 11 {Figure
re111011sibilhy of the physician to nolify the OhA.
16). The receip1should be siww<l by 1wo c1n1 .ccs and
should show the exact amount ol Siil ~ Jication
received. lb take n invemory count, thl' 11 i health
Ordering and Securing professional counts the amount ol thl' nh uon on
Controlled Substances hand and compares this with the amount 1<-<l and
<;chl'dule II subsrances for use in the medical office or in the mount either administcrro or di>pt:n'< . .tuents.
the ph~~1cian's medical bag must be ordered from sup- lhe total of the medications on hand plu' 11 pt'llsed
plom using the ri!<leral friplia11e Order (0[.A k>rrn medications should equal the mwntory r'<
222) When scheduled medications are ordered. one An im'tlltory with im'01CC'i or cop1<' invoices
copy of the form goes 10 the DEA. the 5econd copy goes from the drug suppliers is rcquored by th I CWI} 2
ro the supplier. and the third copy is retained by the years. This in\'entory must rnnt,t111 th llowmg
ph)"l1ci.1n On receipt of the dn1~.1he physidan attaches information:
the dO<"umentation showing receipt of the medication to The name and t1u.111111y of l'<llh "mo lied
the retained copy. This documentation could be a packing substnce
slip with cash receipt showing payment for 1hc medka The name, .1ddress1nd DEA rel\i,tr.111 1 number
tion or 111,'0ice and a copy of the check showing 1Myment of the physicfon
Good record keeping not only is invaluable to the physi- The date and time of th1 inventory I"'
nan, but also assists the physician in following state and '!lie signamre of lhe P<'r'><l11(\) 1.1k111 1nven-
federal regulations related to controlled ;ubstances toiy; preferably two per'iOn' \hou I kt' the
'-<hl-dule 11 drug records must be kept separate from inwmory
other mfdlc.il records and must be readily available for If a medication for controlled sutm.on...,, lmmis-
JI klil 5 )Ul'S for inspection by the OF.A or gcl\'mlment h'O the
tered in the facility and none is J1,1><1ts
agencies interested in drug administrauon Records of medical record of the patient mu\t ) " uc.1Lioo
5 111
OlhlT scheduled drugs ma)' either be kepi sepArately or dministration and must be easily ,iv,ul.1hl
be easily rctnevable from profess10nal records " OF.A
review If controlled \Ub\tances .ire .lllnun rnl and
lo purchase controlled substances on Schedules 111
dispensed, records mu\t be m.m11.iull'<I '<'I 1tt from
through V, the ph~-sician does not use Form 222 but may
purchase these medications through local pharmacies. ~edical dians and mu't be re.1Jily av.1 d.ihh 111,pec
uon,_ Stites vary as to the exact r11uir'm11t .1 record
I lowe""r, the records of the suppliers' invoices with date
of rcceipl and quantity of drug received and a logoook of k~pmg. and allied health profos,ion,tls ,h<llllo he ,,\...art
the state regu 111011~
l\'hl're 1hey pr.1nin
 CHAPTER I Introduction to Pharmacology and Its Legal and Ethical Aspects 15

~
R09lw1n1 Name: IDEA Reg#: ADQOOOOOO
--
Address
WWI.,. !lorry, M.O.

4th &<r"'"I: and JonM Ave. Inventory of SchEMe' n_L 111,IV,V_ _

Coty/SI Zip lnve<>tory Date: 11101 01
Holly. Cl\ 00111
Inventory Tone OpefW1g of business ../
Close of business --
0Ng.'Propara110n Contaonefs eon1enis CSCon1en1S-
morphine a.i.l tat bottle 100' . - 15 ""
o.erol .>Cl sp1le 10 1.0 ... 25 "9
Porco<< ~ boct.le ~ tal:ls 5/32~.,

'

The above &loci< conlrolled subsl8flces was lnvenloned by the pe<Son(s) signed below, who
attesl 1ha1 the above lnven1ory is maintained at the k>catiion appeanng at the top ot this
Inventory and h.a.s boen 1TllHntrunod at the locabOn appearing at the top of thlS tnventory for
al 1eas11W0 years.

1nve9ta~~ C7qfi lnventtr~

Number of grams, tables, ounces. or other units per container.
"Controlled sub$tanoe content of each un;1

Drug Name Pa11on1 Dose Date Hoor MD MA

Reviewed by Revoewedby

, CMA , MD

Figura 16 Typocal lorm tor 1n11lfltory al contro ed substances

posing of Scheduled public. Incineration ma)' be necessary for medication~

d Nonscheduled Drugs such as topicals or injeaables that are dorficuh to
destroy.
' 'P'"" of controlled drugs. such as expired drugs.
111 tht" ne.ue't DLA office for instruCtions If the drug ' '
ust l>t' mailed, the allied he.11th proft?Mional should be
Stock labels for controlled substances are marted w11h C.
1h,u regi~tered mail 1s uS<XI to ensure safe shipment.
with the schedule number (in Roman numerals) within Ille
nre drugs have been destroyed, 1he or.A will issue a
letter
r,ipt that the physician mu~t plMe with controlled
OEA has specific forms that must be used when applying for
-.uhst.111c-e records.
a OEA number Fotms obtained from the OEA must be used
llutd.u ed, noncontrollcd medicaiion> do no1 come
to order Schedule II medications. Medications on Schedules
unucr these stringent regul ations. Depend ing on 1he
Ill through Vdo not requue lhe special form
'"'e law. 1hey 111<1y be nu<hcd down 1hc toilet, washed The phys1c1an has the specific responsibihty of renewing his
down a sink, or placed in the irash. 1r pl.iced in the
or her OEA registration every 3 years.
Lr.ish, the physician should maintain security to r nure
lhee medic,1\ions do nol r,111 into the h.mds or Lhc
 SEC'JON 1 General Aspecis of Phermacology
16
or lhe!t al C(JllI led substances must be re!XJCled
DEA 11 lhe!t haS occurted 1he ttul police departmellL
tueau narCOIJC enforcemC!!l and DEA must be
ied
Spedfic~lee;iing.~~andvenflcation
ol OllN of tile medoeatJOn. IS OOCe$S3l'I ~ hiW!-
cnntJDl]ed sullstarUS Eadl stalll mt require omer
siiecific recotd-1~ lectwQueS
Scieciic guide! lol sposal of sd1e:Med medications
t lristruC\JOllS are sent tJv uie DEA and must be lollu.wd
el3Ctlv
Preventing Drug Dependence
and Drug Abuse
Substance abuse is a n.111onal and internauon.tl problem
1ha1 affCCtS .111 of us I lcahh care worke~ have a re;pon
s1b1lity 10 p.11ie1m and 'iO<lety to as>ess the chances for
abuse or misu>e of medication>. A patic111's frequent
request for a siven drug ,rnJ doctor hopping may be
signs of po1cn1lal ,1buse or misuse. A pharmacist may
make the medical office aware of the patient's use of
muhiple medical faclliLics for prescriptions and will
provide 1he info1matlon 10 prevcm runher abuse. The
medical office prores\ional ~hould be ure the physicfon
i~ aware of any information provided by other health
care profC\>ional>. Other >ign' 1ha1 may indicate sub
\lance abu.e include pinpoint pu1>ils, lethargy, or a
chanl\e 1n or unusual lx>havior
Drug dcrendcnet may be both phyiic'11 dept'ndence
and p')Chologlul drug dependrnct, or habitHUon.
lbc ph)>irJI dqiendence bq\ins with use of a medica
1ion owr a prolonged p.:nod of ume and is a nonnal
adaptauon 10 continued drug use The medication may
lll\'OI\~ a drug u!i<!d 10 rche-e p;iin or 10 conuol physical
or t'tnouonal problems. or ll mil)' be one used for such
cond1110ns H blood pressure or mp1mory dise<lS'I. rsy.
chologJc drug dcpendcncc 1s a craving of a drug for
pleasure or 10 relu:w d1scomfon and a ps)'dlologic
crutch used 10 rche--e an~1el) 110\\'e\'tr. drug ddlction
is compuls1w u..e of a drug despite ph)'$ical harm and is
therefore a d)~funcuonal l)(h,1V1or
Drug abuse depends m pan on why i drug is taken
and what " cuhurall) defined JS acceptable drug use.
What 1s considered abuse in one culture may not be
considered abuse in another Drug abuse is use of a drug
111 a way that is not com1sten1 with medical or social
rea-oning or admlnis1ra11on or drug.~ in quantities over
an exce1,;1ve unw 1ha1 is inconshtcnt wiLh accepted
mecllc,,I pr,1cuce (~Cc Ch.1ptcr 31 ror a discus;ion or dru
abuse and misuse.) g pracucehact As agents. or represen1.1uvc"1
~ome actions by patients m,1y indicate 1>0>sible abuse,
as with the 1mlc111 who a;ks for a particular medication
. satisfied without that specific drug. Drug
and 1s not . b .
abusers, or those with drugse<'kdrng 'lie11av1ors, uually
'ch drugs they want an w1 co111 muc 10 ask
knO\\I' '"h . , drug rather than accept 11ie mcd1c.ll care
1
foraspro 6 ..
offered by the phys1c1an. Many umes .1 d ru11 'Ccking
,;11 state that he or she has lo\t ' pr;-v1ously
person w prescription or Jost tI1e med'1Cauo n .1ltcr the
obtained
rescription was filled and therefore need\ .1 ncw pre.
p n The ht>ahh care professional 'ho ul<I follow
scnpuo . . ed'
e protocol exactly by checkmg m 1c.11 r.-rnrds for
ffic of possible misuse o f med.1cauons.
ogns . sueI, " rcpe.11ed
51r--"ptions for pain medications. sedJtl\e<;. or hd1,l\.,or.
P<~ aJI prNnpuons
altering medications. ()ocUmenung pre.
sety is of utmost imponance for all pa11c1m ,,. that the
0
hysician can detect early signs of possible 1111,1i-c
p Finally, prescription pads should be safogu.irdrd JI all
times. Prescription pads should never ~ " ''\I " note
pads or for orders otht>r than those for prescnp 1nn med.
ications Signature lines may hJ\'t' the 1mp11 11 u l the
health care professional's signature, and d ru .1hu\ers
may copy the imprint made by signing muh11'k times
and forge a pres(ription. A pre;cription p.id ,i. Id nt-ver
be left in an examining room unanentkd 11 1>.11ient
who abuses medications may be able tn 11li1 1n d1ugs
more easily by stealing prescription bl.1nk' Ah I1 llf\h all
prescriptions should be documented in tli nwdirnl
record, another sareguard is 10 copy .111 pr. 1q11 i<111>
leaving the medical office and place copies 111 1i. 1111'dic31
records. The patient seeing this 1>roccd11n 111<1 cer.
1ainly be less likely 10 forge a prescriptio n I '""' the
phannacist could easily confirm 1ha1 till' 1 1ip1ion
had been written. Medical office personnd " ' 1mpor
tam link in preventing drug abuse ,.nd m1'11' 1>.in1ci
paling in the checks-and-balances 'Y'tcm I ' .. n 1Jw
physician and pharmacist Ibis system o il 11 1lw fil'\t
line of defense as early warn mg signs .uc uh , d and
proper action is taken.
ROLE OF ALLIED HEALTH
PROFESSIONALS IN M EDICA
ADMINISTRATION
The m(<)ical practice act of each state 1n wm1 1 "\1th
federal regulations provides the gu1dcl11u ' 11 """b-
mg. administering. storing. and d1spen\Hlf\ 11"11ca
tions by allied health professionals 11r,,111,, " " ,1llietl
health professionals ~rform 1a~ks und r kg,11
premise of ~espondut superior, th<' ph\ .111 .1llO
needs~ workrng understanding or \late .rnd" 1.11 l.1w'
governing legal job ~rformances 111 hh c11 I , 1,1tc of
rlllCUCe. Any legal interpretatio n Of thC l,1W I " I tllllle
ram.the agency in each state 1h.11 cnforn'' 1111 111tthc.1l
' I 1h1 1 I11 "0.111,
.
allied
1
. ea 1.h proress1onals work unM 1 tlll' l.1 , of 1hc
state m which they pracuce . their
. proft~i,1nn ,111d 1i.1vc a
 CHAPTER I Introduction to Pharmacology and Its legal and Ethical Aspects
leg.11 and ethiail responsibiliry to know what is allowed
under thdt state's medical practice act. When federal and
state laws concerning medication5 dirfer, which law pre-
v;til\I rlw stricter laws, whether they are federal or state,
prevail. llw office policy ,111d pro tocol concerning who
may hand le prescriptio ns and ,1,lmin ister medicines in
the medical ortice must be in compliance with state and
n11tional la\\'S.
Some states allow allied health professionals to write
pr<"riplions for a ph}-sidan's signature or allow a ph)'Si
cian's Jgen~ such as a nurse pr.1C11tioner. to sign. In other
\ t.ncs this practice is illeg;il Some Mates allow medica-
110 11 .ltlministration by allied health workers; other states
do no t llccause many medications have sim il ar names,
he.th h CJre professio nals should Ile sure that their knowl-
rdl(c of medications is adequate 10 perform telephone
ttansmi11,1I of prescriptions with accuracy. (See the Evolve
"" for \ound-alike and look-alike names.) For com-
monl} prescribed medications, health care professionals
'1ould know indications. normal dosage. side erfects.
ddWN rc.1rlio ns, and what patient education is neces-
l~fore handling telephone order~ 'lew medications
hould be researched before health care professionals
dmin 1stc" or relays orders for these.
.'
Tl o allied health waiter must understand laws as !hey
pcnain to !he medical practoce in the state where he or she
s emplQVed
Federal and state laws concem111g medica!JOnS and prescnp-
uons must be followed
hies of the Health Professiona l
1 Medication Management '--~~~~~~-
11 .. 1lly. the person admin istering a medication must
"" " a working knowledge of the medication-its
s.tgr mcngth, physical appearanre, side effeas, and
I rw reactions. If there is any doubt about the ph}'Si
n or he.llth care profcssional's order. the peln
drumtcring the medication ~hould .tsk for darifica-
'" With a written o r phoned prescription, this account-
11hty lwrollles a responsibility of the pharmacist. 1he
toh 1m.11c goal in medication admin istration is safety of
h l"llient and reduction of PO>sible mistakes.
All lw.thh professionals must use confidentiality in all
"' of medications and their administration. Some
t .;' indicate cenain conditions ;uch as a human
nmunodefidency virus (1 llV) mferuon. and the health
p of,-..~1on.ll must carefully protect pr~ription informa
lion from anyone who d<X'S not have a need or does not
Ii"' 1he patient's permission to see them. If prescrip-
11011, .ire ,em by facsim ile equipmen t or electron ically
scnt to pharmacies, a protocol must be in place to
17
s.1feguard confidentiality. The procedure wi.U vary among
medical ortices. but it mu>t be m place to protect the
provider against the possibility of leg.ii aetions and inva-
sion of privacy.
Drug Samples and Ethics
Drug \dmple are a m,mufJcturer's way of promo1ing
alt>S by providing free supplies of medicat ions to healt h
care professionals; drug s.1mples should not be sold
Sample drugs requiring a prescription are marked
"sample and bear the federal legend ij. These medica-
tion~ must be inventoried before being left with the
physici.111. Manufacturecs may also supply drug coupons
for a discounted price of prescribed drugs. These coupon~
may not be sold or traded for u;e o n a drug other th.111
1hc o ne idemified o n the cou1)0ll.
S.unplt>S are distributed to health care professionals
(prcscribers) only when the physician providt'S a wri tten
request for any sample and identifies the desired quan-
tity of the drug. manufaaurcr's name. and prescriber's
n.11ne. Medical personnel in the ph}'Sician's office may
not sign for samples; the ph}-sician must sign the required
form to receive samples. (Box t -3 outlines the protocol
for receiving drug samples and the DEA surveillance of
controlled substances.)
BOX 13 DRUG SAMPLES ANO DRUG ENFORCEMENT
ADMINISTRATION (OEAI SURVEILlANCE
Responsibilities of Manufacturer
Supply samples.
Provide documEl!ltat1on 10 DEA for scheduled med1caoons
Responsibilities of Sales Representative
Inventory drugs on receipt and yearly.
Show place for safe storage.
Maintain records of dtst11but1on
Report theft or loss
Venly WTent valid DEA registration of health care profes-
SJOOals recerving samples
Responsibilities of Medical Office
Provide prescnpllon or representative's form signed by the
health care professional
Safogua1d against theft and misuse by stonng m secure area
not accessible to patients
Document !hat samples are supplied to patients.
Dispose of unused or outdated samples properly
Retain samples at offia! once signed for. do not return to
manulac!Urer's representatM!
Dbta n author12at1on from health care professional to use
prescripuon samples.
Do not repacbge samples
Do not cha1ge for samples
 SECTl()"J I Gene11I Aspects of Pharmacology
18
"'1mpln mould oc 1mmtd1a1ely stor<'d man are::~
,1 not am-,>1bk io p.iurn!) and should be ~rga~iZ dat~
1nJ1uuon o( U.C or J1\l'J\e prt>COS and exp1rauon be
"1mpln awru."h1ng their l'l<pirauon date should
fll.K.:J tOl'ard th< front or tht Morage area so they a;~
u-...t hrsl ()tfl<< Jlfl'Onncl \hould iSSi<I tht ph)">iCWl
bring <Ur< thJt onh 1* mtdiciUOM that ..,u be used
ar" left II\ th< uln r<1'r"1'<tllill\\'. r>e-1rucuon of m~1-
nt1<>ns thai 3 , . not u)(J or d1smbuted by exp~rai~o~
J.ne mon be a"omphhnl b) ftu\hang the rotdaat~o
d<:Mll w tmlt1 r<>Unng liquid mtd1auons _into sank
du1n. (lolll"M,..t ~fluming w11h .. atcr). or mcmeraung.
l>rug dnuurnon rrqur"> ume and effon and should be
.--oidl-d 11 JI all l'<""ble D1smbu1ed drugs may nor be
rttumeJ to ult'$ r-rrn<ntJll''-" . as drug Sa'l'ples. and the tensions of the pr0fesS1on
1mJll). drug \ample" mus1 be provided 10 the pauen1
rn the mJnufanurd' pJck.1ge . .
Med1nl per-.inncl hould always ask penmss1on
from ilw ph)'>1C1an, and ofhct pro1ocol should be fol-
lowed ll4:fore d1m1buuon io patients or [or perwnal use.
Ethics of Medication$ with Medical Personnel
\lausc of 1hc ea\y JvJilab11i1y of medicines in the
rnedkal on.er, hcahh rar.: workers are a1 risk for drug
abu~ .md misu~r M.rny n1cdkalions, especially sample
mcdic.uion'I. .11e found in 1hc ou1pa1ie111 setting, which
can h'.1d 10 1hc lndlsrrimi11aie u>e of drugs. Career pres-
sures sue has me\s and lower back !Min place profession
.ll< .11 grea1er rl\k of drug ,1b11'>C and mimsc. Many people
begin 1he ro.1d 10 drug abu'>C by having medica1ions
prcsrntx>d for lcg11imaie health problems, only to find
they have bttome cht>mirally-dependent healDi care
workers
llie unpaarrd heahh rare professional 1s a danger not
only 10 h1m-;el( or hn-lf bu1 10 the pa1ient Ille palient
a< m danRff bausc of err.me belmior that auses enors
m 1udgmen1 and amJcnl5 Ille impaired health care
\\-Orlcr 1\ alsri J prublrm for co-workers becluse the)'
cannot depend on the per<on 10 perfonn ass1~ duties.
"'' the prohkm " handled 1s an ethical mailer (and
on srimt stat!'\ a k"gJI iSMW) that must be faced with eoch
\llUJUon \\hen the problem is confronied head-on,
p.iuem safety a< pro11ed and tht 1mpa11ed worker has
\he opponunlly 10 r;tl\C netdeJ are.
A ~ he.11th profCSllonals must have a WOik ng knowledlle
of I meditations used an 1he of1ic9 ol employment Health
prolesslO!lals with quc:mons about ij drug shoold invest gate
the drug poor to any actm n strahon
Have a wmkmg knowledge ol drug samples Be sure to
follow ofhce protocol when d1s1ribu11ng these samples
Know the 119115 ol drug abuse. and work w1th1na legal frame.
, be sure you do 00\ provide away IOI drug abuse woth
wor.m .th
tile medical office staff OI w1 pat1en1s
Wort i..-rth piannaceuucal sales representatives to ga n
knowledge of rteN medications. new uses for med1tn-.is, and
nrormatJCJl on drug samples left at the office
~ salf4lleSshoold be su table IOI the physacans practiCe
and should be IJl9illlaed tJy thetr use loi disease processes
Of drug categones All similar drugs should be grouped
iogemer. mose with the rearest e.p1ra11on date placed 1n
front
Health care professronals are at nsk of drug abuse Of m1SUSe
because of the ready ava1labd11.V of med1c111al aqents such
Orug abuse or m1Suse by health care professionals 1s o ptiys1
cal issue but more importantly an ethical problem because
or the impact on patient care
SUMMARY
As partners wi1h phar111.1cis1s and physin.1 .1llied
hcahh professionals are a major link in thl' 11 1 lir.uion
delivery patb,ay in 1oday's health care cnvinm 111. '11le
adminisuative assis1a111111us1know mcdir.t1io1 111 order
1o re[er medication ques1ions appropri.111'11 ruhcr
members of the heahh cMe 1ea111. Knowll'dg, drugs.
their aetions. their imeractio ns, their ~id1 i " .md
their ad1rse reaaions is necessary for 1ui.11e
paliem care. Depending on the laws of md 11 11 I ,1,ues,
allied health professionals may adrnini\ll'r n , 111ons.
whereas pb)'sidans prescribe and pharrnM" l'<'llW
The ideal working rela1ionship among .lll ol 11ro-
fessionals pfO\ides a system of checks ,rnd ha '""' for
pa1ient sareiy. All media1ions, whelher ro "' llllll or
OTC. sbould be documented in the mcdu "I o rJ to
pmm 0\-erdosing or adverse reaction\ fron uluple
medications from multiple providers I h rou l'tluca
lion about the imponance of providing m h r uon to
all physicians and taking mediation\ a' 111 .~1. the
patiem bomes an acti1'e participant in ph.u nlogac
therapy. and this role will only increa'>C an 111 111r~.
Tod3}1S health market has come a long'' '" m the
early twentieth century, when medicine ma 1.1wkcJ
their wares from wagons. Those wares wer1 r ' uhtl'<'I
to quality assurance oversight for ingrcd1cnl\ m " mJn
ufanure of the drug. One bonle or rned1t.111u11 ,1gh1 do
wonders, bu1 1he nex1 migh1 b{' lncffcctivt , 1k.1dly.
:oday with federal and stale lcgislaiitln, l'""I 1.111 be
~~11~ lha1 the mcdicailon prescribed .md 11! l'"nscd
wo of the same sireng1h dnd purhy twry 11111< 1hey
fill the prescription or receive 1hc 11wdi<1111 111 1hc
 CHAPTER I lntroducbon to Pharmacology and Its legal and Ellucal Aspects 19

physician's office. Through multiple statutes, the FDA
continues to follow previously re<:ogni1.cd drugs and
\tudies propos.ils of new uses of medications by manu
facturers while watching closely as new medications are
developed. nw process is long. time-con~uming. and
1xpensive, but the public can feel reassurrd that drugs
arc safe. If for an)' reason safety is questioned, drugs arc
recalled or taken off the market until their quality and
s.ifety can be established
Controlled substances have the potenti.11to be abused,
and through stringent laws these dn.1gs are watche1I
d o<ely by drug e nforcement agencies. Written prescrip
uons are rcqutred for drugs with the greatest potential
for abuse, and 1t is unlawful for a person to possess a
controlled \uhstance without a valid pre~cription. ~e
I ?70 Comrollcd Substances ACL was designed to provide
mcreased rcsc.irch into prcwntion of drug abuse and
on.g d ependtnce. It also r~quired special labels for drugs
v ith potenu.ll for abuse, dependence, or both to ensure
1hcv would be administered o r dispen1<:d by legal drug
handlers and not used illicit ly. To avoid illegal use of
these controlled substances, the public should be aware
of potentially abusive or dependent drugs and signs of
abuse or dependency.
Health care workers must know federal and state laws
because ignorance of the law is not a defense in court if
mishandling or pooradministration of drugs occurs. I he
allied health professional must know the laws in the
state of employment, because medical practice acts "ary
from state to state. Allied health pcrwnnel often worr..
under the doctrine of re,pomlear supenor. with the ph)"Si
cian assigning a protocol that is appropri,ue to a given
situation.
Ethics in the medical office requires ensuring confi.
dentialit) for the patient, s.ifeguardmg prescription pads.
and handling drug samples properly. ll)' working with
other health care profe,sionals such .1~ physician~ and
pham1acists, the allied health profes~ionaJ can be effcc
tive for patient safety Because drugs are re.1dily available
in the medical field, the allied health prof~'SSional should
be extremely careful about drug misu~c and drug abuse
and be observant for early ~igns and symptoms of misus~.

Scenario
M ary Ann, an adm1111srrar1ve allied health professional, 1s mannmg the phone at Dr. Merrys office.
Janelee calls to say that she has been to the pharmacy to get her medteatlOfl and has read on the
pat1enr mformatton sheet tha1 1he drug prescflbed should no1 be 1aken wilh asplfm, which she 1akes
daily.
I. What s hould Mary Ann do first?
2 Should she make a decision, or should she ask Dr. Merl)'?
3 The pharmacist had called earlier and asked to speak to Dr. Meny, but Mary Ann took a message
and did not give the message to Dr Merry. Why 1s 1t important that the information be given to the
physician as soon as possible?
4 W hat should be provided to the physician at the time the message is relayed?

, ' EVIEW QUESTIONS

Define:
Phamucology - - -- - -- -- -- - - - -- - -- - - - -- - - - -- - - -- - -

L>rug

\ledic.nion - - - -- -- - -- -- - -- -- - -- - - -- - -- -- - -- -- - -

Dispense _ __ _ __ __ _ __ _ _ _ __ __ _ __ _ _ __ __ __ _ __ _ __ __
 SfCOON I Gentrel Aspects ol Pharmacology
20

AJminl\ter : : : : : = = = = = = = = - - - -----================

rrncnpuon drug> ===========--- - - - - - - = = = ==========

l<og<nd Jrugi. ==========--- - - - - - - = = = = =======

()rugabu10:::::========----------===========-~=
()rugJep.:nJcn< ==========---- - - - - - - - - - --=::::::::::::::::::::::::

Orug \tandard\ =======:__----- - - - - -- - -- -- - -====-::-

Dn111 I nforrernent Adrnmlm.uion (nLAl - - - - - - - - - - - - - -- - - - - - -

lood and Dn111 A<hn1nistr.ition (1DAl - - - -- - - - - -- - - -- - -- - - - -

.ind
1 l'he three he.ilth professional> in uie medication pathway are . .
'I I I f "'ch
. Pc>Cn w t ie ro co rn 1n the =tern
. , ..
of checks and balances for s.1fe med1c.111011 ""

3 ;;amc and deline the fiw schedules found in uw Controlled Substances Act. Place common medic.1ti1>11' lI f,111

under thi\ lrg1slation in the coneo schedule. - - - - -- - - -- - - - - -- - -

4 Orug abuse, drug dependence. and hab1tuauon are real problems in the medical office. Describe s1gm th.11 nts
are abu~ or are dependent on cenain drugs. What measures can the medical office ~1ke to assist th\' ru t \ \'t
ensure that the office d0t1 not aid in funher abuse or dependency?- - -- - - - - -

~ Why Me ethics in handling .111d tl1.1pensing of medication samples so importam to health care wo rkt.- 1
Basics of Pharmacology

After srudying 1h1s chapter. you should be capable of doing the following
Prov1d1ng definitions of the keywords using the Describing the five fundamental categones of
glossary or a medical dictionary. pharmacology and how these factors influence
Stating health care workers' respons1b1hty with medications.
regard to adverse reactions. side effec1s, and toxic Descnbing ind1cat1ons for med1c1nes.
reactions Explaining drug interactions w ith other drugs,
Deftmng clrug. nutrients. and diseases.

Joyce works in a physician's office that has several patients who do not think that going to a physician
is necessary until an 11/ness becomes life-threatening.These patients ofren see folk healers and use
herbal supplements and over-the-counter IOTCJ prepar8t10ns rather than prescriptJOn mecl1cat1ons.
Joyce does nor rhmk 111s necessary to document herbal supplemenrs and OTC medK:ations in rhe
medical record.
Whal harm may Joyce cause these patients?
Th1nk1ng that the pauent 1s taking medications as ordered. the physician cannot understand why the
1l'a1ntenance dose is not working and increases the dosage. What are the dangers of cumulation
(accumulation), synergism. and antagonism)

Absorption Chelator Drug blood level local action

Active ingredient Clinical pharmacology Drug half-life Metabolism
Addiction Contraindication Drug interaction Mucosa I
Adverse reaction Cumulation Enteral Pharmacodynamics
Agonist (accumulation) Excretion Pharmacognosy
Alkaloid Curative (healing) First-pass effect Pharmacokinetics
Allergic reaction medication Free or unbound drug Pharmacotherapeutics
Analgesic Demulcent Habituation Potentiat ion
Anaphylaxis Dependence Hypersensitivity Prophylactic
Antagonism Depressant reaction Receptor site
Antagonist Desired therapeutic Ideal drug Recombinant DNA
Antidote effect or desired Idiosyncratic drug t echnology
Antiinflammatory effect reaction Safe drug
Anti metabolite Destructive agent Indication Sida effect
Antipyretic Distribution Inert ingredient Solubility
Biotransformation Drug Irritant Summation

21
 SCTION1 General Aspects of Pharmacology

Toxicology
TherllpeutiCS Usage
Synthetic or Tolerance
Suppottive manufactured drug
medication ToJCic
Systemic action
Synergism
d contain various components-active and
n no Most nigs rt) 111 gredients. An active ingfl'<iient is the
lh !he possible excepuon of computers. I cuve (or 1ne
d'I d form of chemica l tli.tl produ<~s an effea
W '.ire.1 of life during the twentieth and twent'..;
. 1
first centunes ,as teehnology transform.:u
I gy Drugs are
f\t"'\lay hvmg more ihan w1lh ph.1rmaco oh' . . t'rnes
1101'new; they ha~ been U><.-u -- since pre . 1stone . ' f
ma
Pure. unreli uteiven alone. UsuaII y .ll .IS COm I)lll('u
bul is ra . Yrt
or more
, rne
drugs acuon
. and may also co11ta111
.
. ' With

cl11c1m
111g1
. One
S Ingredients (or vehicle~) th.11 .1ssht in the
such as
through ,111 eras of civilization With the 1nuodu;u~7. ~ 0
tives colorings. and avor111g.>
m<tny II<'"' drugs and new uses for older drugs. I ea I P~ul drug, a theoretical con;t run " o ne that has
health professional is m;pons1ble for being curren~ ~n . es of efTecti\'en~s and s.ifcl) .llld produces
. .~ bod uies of admrms only quaI111 II h
the aC1Jon of drugs w1lh1n ut y; ro 'd c1tdfecU Or ad,er\t' rN<liOn\ \ t H 1.; no ideal
uauon. fonns of drugs for admrnistnuon, desutd s1 e noSJ existS. some charactensucs.
drug sue h J\ ti 1 I o 11 O\\~ng.

rfferu and to.lie tfferu and ad,~rst reacuons 0~ dru~ be! 3 drug draw near to ideal
on pa;1cnr.s of all ages. The alhtd heahh profess10nal s !' Predia.abili1y-Drug will 1noduce the me effect
under5undmg of pharmacology can bt criucal to !he each time the same d~ 1s g1wn
pauent-heahh profess1onaI reIauons h.1p, as well as to Ease of administrauon- Drug ~ s11111 10 admin-
the employer-employee relationship . . is1er. convenient to use. ,md rcc1uirn ' one dose
A drug .mists in mainuining or restonn~ homeostasis ct1ons for
3 day, to help the patient follow lhl
after a decline in body funaions caused b)' ill ness. Drugs the medication.
can become dangerous if lhcy are used to cre.1tc unneces- lnexpensive-1..mv rost wi ll help hJllll 1he finan-
sary dependence or irreversible harm, but 1vhe11 used

..
cial burden of taking nwdlc.11i011' m prolonged
Intelligently !hey provide a lifesaving ben.cfit:
When patients and prescribers use med1cauons.appro-
priatcly, medications can restore health, prolong hfe. and BOX 1 1 FOUR BASIC TERMS IN PHARMA
increase quality of life for patients.
D~ chem JI !hat c n at rving Pl .JS Uller
u.s broad OOJ; tJOn. aI chemicnls arc C(1: )fed drl9$
WHAT IS A DRUG? Yd1ell gM!ll ll .s la'9I enough to aitcf fleet hie
2 ......... Study ol dtUllS and the 1 m 1(111$ .. th
ll1e word d"'Jl comes from 1he Dutch wold drogr, '"ffJ ~ n d flflltion incllllcs the st of physg!
meaning dry. The tmn is appropriaie beca~ for centu- and chemical IJllP,'11 ?S ol drugs ., well a effects on
ries m0$t drugs used for treatment came from dried 1lle body 11 also 1ncluchl3 tho history ol drug r ~ces
pl.mis Today a drug is considered to bt any substance and uses.and how 1hey are used lly 1hc body ts a broad
that causes chemical changes withm the body. Vinually field. and d11s book will con11der only thow f pllarma
all chemicals, including such substances as tea and
cology relevant to an ambul.11ory med1c.1I sutt
cofTec, may be classified as drugs. I11 this book, a drug rpllon and
3. Clinical pharmacology Study ot drug
Is any rhemical used for a therapeutic application such
metabolism 1n human~. 1ncludinq thoso who healthy as
as treating an illness or relieving a symptom or for diag-
nosuc tC'lting. Drugs are chemical subs1a11ces that can w11ll as those who are not in homcoMas1s
help or hann individuals, ahering the biochemlc.tl func- 4 TllmpHtics ~se ot drugs 10 diagnose d (d1agn<15
uon in the body. tic age111sJ Jle\'!'llt d sca:e OI acond1hon sud pregnancy
R.esevchers 1oday build on lhe accumulated knowl- lfnlllht1ac!Jc dfPllJJ. 01 treat disease {the! ~IC dnigsl
edge of the~ 10 produce major new advances. Through llls defintllOI\ sunpy Staled IS tho mc1I ol drugs.
!he )ears, in~asing knowledge about d1Stase proctsS(S ewri dn9i SOttlll may cause advl!fse IAdwrJe
has led to !he nttd for n!fined mediations nd 10 rapid li<ICIOlS 1re 1lcse eltects lh.1t aic ~ "' lJllll"
changes m lhe field of pharmacology Phraucology tfllded l The 1e1111 lhetapeutics also 11flComi:;: the ballC
will conunue to change rapidly in 1he futurt as medical reasais for Ql'I ~ a particular drug 10 a part patreni. 111
research makes innovati\'e studies. 110\\'t>'er, the four a paltlcuiar dosage, by a particular roo10 and 1 pal'lltular
basic terms used in pharmacology-drug, plumnarology. schedule Knowledge ot ph.irrr,xology holi; <;how v.1131
<l/11lwl phannacology, and ll1erajl<'1HIC1-will remain strategies w111 promote bencl1t1JI dru~ ulft!cl e mrmmu
the same (Box 2-1). mg undesired ettects

periods. Because of ongoing expense e-~n moder-
a1ely pnced drugs can be financially de>.'llSlating.
ldentifica1ion-a name that b e.1sy to pronounce
.and remember.
No drug is completely safe, because all drugs have side
cffens, bur selecti,ity in 1>rescribing reduces the chance
of side cffl'Cl> and possible injury. A ~afo drug produces
only the response for which it is given, causing no
lurmful effects when taken over a long period of time.
fhe drug res1l0nse may be difficult to predict from person
to pcr<on and may change if the patient takes other
rnc'tlic.lliom l he health care ream should work together
10 <n\urc that medications arc producing the desired
ffrtt or 1111ended results, to minimi1.e the chance of a
Jna11induced injury.
'-'led cations aid n keeping the body in homeostasis and are
I fesav111g benefit when used correctly and wtth d1scf1m1
hon If used 1nconectly. drugs can cause meparable harm
J Ideal drug exists. All dtugs cause some side elfecrs Df
rse reactions. The allied health professional must be
ware of these effects and acquire an adequate med1cauon
nowlcdQe base for patient safety.
S.il~ drugs are those that can be taken in adequate doses
Mr long periods of ume with no harmful effects.
V~ BASIC CATEGORIES
~PHARMACOLOGY
hem,., dfe foreign maner 10 the body dnd are capable
, 1\1111\ unexpected results, as well as de\lred lhera-
h. Medications change body chemistry o r
r tum to diminish disease processes causing thesymp
11 m 1.11 lwr th,rn elimi nating the cause of the symptoms.
1 '"''" in pharmacology are pharmacognosy, or
"" of drugs; pbarmacokinctlC\, or how drugs are
:"SMd , hmucotlynamlc~, or aetions of drugs;
uthcrapcutics, or effects of drugs; and toxicol~
>r th~ s1udy of toxic or poisonous effects of drugs.
fundamental divisions in pharmacology are as follows:
Pt1armar.ognosy--Ongin of drugs
Pharmacok111et1cs-How the body processes drugs (what
the body does to the drug)
Pliarmac:odynamics--Orug actJoos on 1he body (what the
drug does to the body)
Pharmacotherapeut1cs-Effect of drugs 111 treatment of
disease
Tox1cology-Po1sonous effec1s of drugs on the body
CHAPTER 2 Basics of Pharmacology 23
Pharmacognosy-Origins of Drugs
Dru!!-' come from basically five sources: plan15, animals
(including humans), minerals or minera l products, syn-
thetic or chemic,'ll subsL1 nccs, and modern engineeri ng.
No longer is the drug industry bound to natu ral sub
srnnres in either crude or natura I stdtes. Today, chemicals
and even human tissues. such as in stem cell therapy, can
be manipulated to increase drug sources.
The e.uly m1de drugs came from all dried plant pans
and had unknown purity and varying strength. Often,
undesired materials entered the plants and produced
toxic effects. Later, aetive ingredients were separated from
the plant, resulting in more reliable substance adminis-
tration . (TJble 2-1 shows examples of plant sources.)
Minerals from the earth and soil are used as they
occi1r in nature or combined with other ingredients for
drugs. An example is coal tar. an acid lhJt yields sal icylic
acid, which was first used to manufaoure aspiri n (see
T.\ble 2. 1).
Drugs can be deri\'ed from animal sources induding
\'accines, oils. and fats used in treatment of endocrine
system diseases and for immunilations Human extracts
such as enzymes and hom1ones, m,1y be used for
treating diseases or potential conditions-for example,
RhoCAM for possible erythroblastosis fetal is (see Table
2- 1).
Chemists are producing drugs from living organisms
(organic substances) or nonliving materials (inorganic
substances) in e-er-incre;ising numbers. Chemically
de-elopcd drugs are frtt of the impurities found in
natural substances and are called > nlhcllc or muu
fctured drugs. Some drugs are both orgartic and inor-
ganic (e.g.. propylthiouracil, an antithyroid hormone)
(see fable 2-1).
Infection was the leading cause of death before the isolation
and productlOO of penicillin in a laboratOty 111 1942
Recombinillll OSA technolog}. the fastest growinfl
area in the pharmaceutical world, uses anifidally manip-
ulated DNA segments from differe111 organic sources by
transferring a cel l from a difffm11 species to a host cell
to ch.111ge the way the cell rc11roduces. In effect, the cell
becomes a small-scale protein factory that creates genetic
instruetions le.1ding the organism to produce chemical
substances for use as drugs. 111esc medications are spe-
cifically targeted outside cells, although the source of the
disease proteins is inside cells where the disease begins
(figure 2 I}. DNA research is now focusing on finding
ways to deliver enzymes and proteins inside the cell for
repair of diseased cells. The newer forms of insulin have
been produced by this technique, as h,1ve skin grafts for
 Step2

..-
S!er> 1

lABll I 1

.
CELLS EXTRACTED
GEllE ~ T1>8 cells conta..ng lht new
GeneS for nsened inlO the proteon are !hen ,.........,
fromlheor-
"'.:':='M'll orgarostn.
S1ep4
51e1>3

aiprll1
oil

MINEllALS HARVFSTEO
Gold SolQanal aurardn COPIES MADE
T1>8 desired 1Oletns are
The eels multiply slowly al
ln: 11nc o'de firs~ 111<!<1 in ifleteaslngly large< eioracted trorn the resi of
~I Ca 11.d C1tracal. Aolaids qua01ities IO svpply amounls the cell, punlo ~. Ond ma<lt
Ca needed lo< manulacl\Jrillg ln10 blOlogk m1xhcln8$
Tums o4 medications.
of mag..iSta. My!anta.
1111'1 .
F1gure 21 "ing
"""' of ONA technologic
. medica11ons
RP ''" I ,..bsiances.
M.ukix IRedri!I'~ 1,001 Marsiglio O: New miracle d1ugs, AA 11 '"<J9011ne,
A Amphoiel. Gr1us1I NDl'Oec 20091

ANIMALS
( cod lvtr od as hepatitis c have been in1roduced . Many her.; will be
brought 10 market in the fumre through 1 thods .such
lJnno Of mares
35 doning of salivary gland cel ls to prod u msul1n 10
Slnrr~ol~ uea1 diabetes (see Table 2 l ).
Anima 1hylnld g1.1nd$
l'lacena

SYNTHETICS ANO SEMISYNntmcs

The reasoo tha1 DNMec:hnolOQHl'oduced bco drugs and
lrugarnc
ga'1s are not used more oftl!jl 1s that 1hese m nes are so
~1vnes OYer $100.tm per year nd patoenu
cam alfm! Che pnce 11 1s piedlCled that by 20 '!lany of lhe

.
10Q 100 ct\igs v. II be boologlCS

RECOMBINANT DNA TECHNOLOGY

~
~ .
bum anJ Olhcr wouno.ls th.It .,, producod from the
l0<nlun ol 111.- Jl<'ft1' ( l\pl1pI)
"no1hcr tiio1n:hnolott11 mrthod of drug produaion
" u'IC ol ""' lrom an1mJI\ w11h .mtag<ns to produce
h~ h11J <<II thJI proJucr Jn11hod10 10 aucl tumors
.tnd JIC:rmll dltll>\I\ or mny cond111ons. fmm 3nemia
m "ph1h 111.,... drug.. r I' US<-d as anurejm1on
ml'J1,.111on\ 4hrr u111o1n 1rnsrlJn1.1uon lllrough bio-
l<'thnol'll). drug.. 10 prumu1r blood do1ung m hemo-
rh1h.1" n<I mlrrkmM lO comba1 viral \nfm1ons sucb
Important Facts
The origin of <tugs !hat began w111l use of nat plan1llll
anuna s<bs:.inces llas OON moved into Ihc labo 'fY. whete
scientis:s marufacrure drugs syn1he1aeally f chemica
~
Phannacokinetics- How the B ly
Processes Drugs
The word pliarmacoki11e1ics comes from 1lw 1~ck words
plaarmako, meaning drugs, and kinesis, mc.m 1111-1 11101io11,
hence, Plltlnn11co/1it1ttics refers 10 1hc 111ownH111 of drugs
 CHAl'JER 2 Basics of Pharmacology 25

-
BOX 2-2 FACTORS THAT AFFECT DRUG ACTIVITY

"ll ...,_ r 1 -Pal""'' n .nee or,.. ' "

Oisrntegra!IOll or d ssolUtJon ol drug-Availabi 11'( of~ fot
errors
40mg Ololy
abso11mon admonlstered diug ~ e
Pharmacokioo11cs- How body pioccsses drugs
Pharmacodynanucs D11J9"<ecep1or cell m1erac11011s
Route:
lnlenS ry ol ~ividual differences on response to
drugs related 10 ~1ologic leg age. genderl ~ychologic.
genettc. and dietary factors, d seasa states, and inteiac11011s
with other dugs
Stomach

lliOX 2-3 FOUR BASIC PROCESSES

, OF PHARMACOKINETICS

~ on
Ac1M! tngredienlS are abso<bcd aro 1ra0Sp0<1ed to sites ot
acoon
Amount of ilbSOrpllon depend$ on drug's ab1l11y 10 cross cell Figure 2-2 Pl>JrmdCOk!nes1s ts the tr<JVement ol drug$ lhroogh !he body
membranes. via absorption, d1sl11bu11on. me1abohsm, and eiu:re11on !From Klieger OM
$.iunde/s es<1'11t1als of medical assrstmg. ed 2. St Louis, 20t0. Elsevier I
b111ion
molecul~ are tran,por1od to vanotr.' body areas via
.ircula1111g body ftu1ds.
Permeab1hty of cap1lla11cs lo the drug de1011rnn0s rate of
d trbution

bolism IB1otr1nsfonnallon)
Drng 1s chemically altered by the act1011 of enl)'mes 1n Ille
l>lood. hvm, lungs, kidneys. and intestines to convert drug llntcral Rectal -+ Nasogastric -+ Oral
olecules into water-soluble compounds or metobohtes tor Parenteral Intravenous -+ Intramuscular -+
the body s use or ehmmauoo. Subcutaneous -+ lntrademtal
Pertutaneous or muoosal lnhala11on llungsl-+ Sublingua
et1on (tonguel-+ Transdermal
UnJsed drug molecules are remove<! from their sues of (through skin) -+ Topical
achan, usually through the unnary tract. respiratory tract. (on skin)
gasl!OUll!: llil I ll act. or sk n
' Ra"' of absorpi.on is spec.lie ID lllCh route of adnM11tration

1 110111<h the body. The four pro00>-~es involved in phar-

' okioctic'> ar~ bsorpllon, movement of a drug from
''" of admini\lration imo the blood; dl5tribullon,
mcnt of a drug from the blood into the ussues and
ti m<1.1holb m {or biotr.111,formulon), physical
.111<1 chemic.11 Jltcration of the drug in the hody; and
r ion {or diminalion), removal of waste products
I drug metdbohsm from 1he body {rigure 2-2; Boxes
land 2-3).
[tj LEARNING TIP
~nestS means motion ' movement lrecall ' k1ne11c exercises").
Pharmac0mie11CS is tl1e way drugs fTlO'<e through the body
Absorption
Ille rate of absorption of a medication is directly rela1ro
to the rout<' o f administration and lhe drug's solubilltt
or ns abili1y to dis.wive {l.1ble-12-2 and 2-3). Absorption
is dependent on the form of the drug .md the amount
of blood flow in the area; >Orne medica1ions dissolve
rapidly, whereas others dissolve slowly. rrimaiy sites of
ab50rplion are the muc05J of the mouth, lun115- stomach
small i111e<11incs. and recium and blood wssels in the
muscles and subcutaneous tissues. F..xamples include
nitroglycerin, placed under 1he tongue next to blood
vessels; albu1erol (Ventolin I ffA}, taken imo !he lungs
b) inhalation, and dexuose in water, administered intra
wnously dire.LI)' into the bloodsiream {s~ Box 2-3)
 utes of admin istration vcri.us time io
Table 24 shows fo . . r
. of medtcauons.
l J ORAi. mrwnoHSAHO THEIR
! A8ll ab sorpoon , h
.... t may cause v.mauon in t ~ absorp
other .actors " '" .
AISoarnDH llATtS 'nrlude the foll0\"1ng:
lion ratf i.~ . r h . . ..
adminis11a11on- oor tee niquc tn g1v1ng a
/,.-.orrteled. tion may destroy the drug before 11 H~ach4
m tea . f . S .,
the bloodstream or i~ sne o amon . Pt"C1t1c d1rec.
.
uons for adminisrrauon .must be g1w11 .ind fol.
IOl'-ed to enhanc~ a_bsorpuon. .
D gs of an aod1c pl I such as aspmn are easily
pH~~ in theacidic~urrounding.\ of tht stomach,
hen'aS alkaline med1cauons such .u /\la,ilo~ art

m readily absorbed
"ott . in the alkalinl' environment
of the small intesune.

ENTRAL ROUllS Most med1cat1ons

30-fill 1!1111 A1 often as p0Ss1ble
Or Tablets. capsules
Safest and most coovefllent
Nitroglycerin for ang,1..
SttillllQUll Severa i: to l!Mlfa mn Rapid eHect
RaPld effect Fentanyl for pain
Buctnf Seveta
When oral med~ations camot be used Supj)Ositortes for nau ,J/
Reeta 15 30 mtn tlepend"'ll on
vomiting or for co1 1i;ation
contents ot rectum (e g, with nausea/vomiting! and
parenteral route is not indicated
for local effect Preparation H for ho11 rho1ds

PARENT{RALROUTES
mat 20-3' mm MedicabOns 1nact1vated by Insulin, vaccines
gastro>ntesl1nal tract or wlien fast
absorption s not 111:l1cated
l1M ~., m111. lhlrltr lhan Medications wIth poor abso<ptton or Nareoucs for pain. an tics.
SC IOU'.a, I5-25 mtn \'Alen more rapid effects are desir~ hormones
hp blood lelels are obtained faster
M v.iien tr.rned'ilte effuc!s are necessary; Cancef medications tcixics
vdlCl absaJllOn 111 lllJSdes IS IXJ1
~:e or tS damagiri;i ID tissues
lnlraarteflll AllP lOtal effects " :!111 an mma organ Select cancer med ns
PCRCUTA.NEOUS OR MUCOSAL ROUllS
T 1i ~ lO ~tMdecmtRJOl:S N1trogl'jte11n. estr01J nd
iibsaq)toi <nl S!Slemtt effects oYef fentanyt
ton
lnlra1lletal Several min local efla:ts nSO<na! cord Spinal anesthesia. ep rJIS
Wlllltm Aiilit 'mtl1ely I mtn loca effects on resp.tatary uact
Med1ca11ons for asthrr chronic
obsuuc11ve P1Jlmoo; disease.
Tcipal Aillxnmat lfy I IY oxygen
loca effects on slon. ears. (!'jes
Vag;na! 15-30 mtn Cieams. mntments, d1
lDcal effects
Urethral 15-30 mm Cieams. foams. 1uppo 11011es
lDcal effects
I.ti\ M !IUi s.; ieccndltl Gels. jellies

/'o<~l rn 511111wc/1-Food in the stomach slows the
absorption rate and decreases irritation, whereas
an empty >tomach increases the rate of absorption
and imtauon in most medications Some dru~
require food rn the inte<>tinal tract for absorption
LO take pl.Ke.
(<11 or lrphl 'Dlubiluy-Drugs that are highly soluble in
fab or lipids. such as alcohol and alcohol-
comammg substances. are readily absorbed in the
gastro1ntc\tinal tract, whereas those wuh low lipid
solubility .ue better .1b,orbed when given by other
routes.
/fl1g1/1 oj u>lll'1<1-Absorpuon of topic;il drugs is inOu
ence<l by the length of contact ume wuh the slon.
\ize of rontact area, skm thickness. and hydration
of tbM1cs .11 the site of .tpplication.
/nh.ila1i1m /l<IOll-Depth of respirations, surface area
of mucou\ membr.mes. hydration of the patient.
blood 'u11ply to the lungs. and drug concentration
influence the rapidity of absorption Inhalation is
actually one of the mo;t rapid fonm for medica
11on .1bsorvtio11.
I >m.~ comm1m1wn-H igh concentrations of drugs
tend to be absorbed mo~ rapidly; thus initial or
litst do'< may be larger than maintenance or daily
do"'' (sec llox 2-3 ).
stribution
11 I "<I is the amount of drug circulating in
Ii bloodmcam ready to tr.ivel through body Ouids to
ti\ "itl'-' of ,1ction or distribution. 1\reas \vi1h an extensive
ood supply receive a drug rapidly, whcr~as areas with
5 blood >upply ha''t' a delay in distribution. Althougli
/111.~ LS .tdnt~t.t 10 1l1e orga11or1wuts dmru.~11blood1..ss.-1!
1 I utpillt1rir;, rl.- -ffea oj lltt drug is Ill r/w 11.1.!lll'S. 1101 in
1/11 /ilt>o<l "'"''/.<. 11w rate at which a drug enters different
"'as of the hody depends on the permeability of the
p1llarics to the drug's molecules and to the chemical
~~up of th< drug. amount given, size of the person,
I 1d ,1mount of protein in blood.
l'wo factors 1h,1t influence drug distribution are fat
1l11hility and protei n binding. A sustained pharmaco-
' effect ts the result of the body providing storage
"-oi" in the fatty tissues for fat-soluble drug accu-
1ul.uion. &cause little blood flows through fat tissue.
I" \lorage sue fo r the drug is e~tablished and a relatively
'1.1hle reserve of the drug is maintained. I ipid-soluble
d1 ti> such as hormones giwn by injection an an oil
1:- tend to hae a longer lasung effect.
r1.1sma protein binding is attaching of drugs to pro-
t1 111~ in the b lood. decreasing the amount of free or
hound drug circulating in the body and thus Limiting
th.- amount of drug at the site of action. As the body uses
the free drug. the protein-bound drug breaks down for
U'><'. Because of this process, sulfa dru&'> remain in the
CHAPTER 2 Basics of Pharmacology 27
body with "11iinfeC11ve ae11on for longer periods of time
than other antibiotics
Some drugs cannot pass through cenam t)'J)CS of cell
membranes With the blood-brain bamcr the brain is
protected by the barrier's restnction of entrr of water
soluble electrolytes. but lipid-soluble drugs are allowed
distribution into the brain and cercbro~pinal fluid
because the brain is compo>ed of many ltp1ds. The pla
cental bamer. another membrane. is less ~k-cuve rn thl"
d1stribu11011 of medicauons. allowing water- and lipid
soluble drug;, to cross Many medications given to a
mother may al'o reach the fetus, producing either .1
therapeutk effect (such cardiac drugs that may bf
necessarr for the fetus) or harmful effects (such as ane;.
thetics, alcohol, and narcoucs) Other drugs may be dis-
tributed to selected specific sites.-for ex.1mple, sending
human chorionic gonadotropin (hCC) 10 the ovaries to
treat infenility (,;ee Box 1 l)
Metabolism or Biotransformation
Metabolism. o r biotransformation. is a cries of d1emical
reactions that alter and convcn drugs into w.uer-soluble
compounds for excretion Most drugs are detoxified, or
turned into a relatively harmless substance, to allow the
body to rid HS<:lf of the drug. Without metabolism, the
drug wou ld cont inue to have an effect o n the body and
could even tu.illy cause harm to the person by accumula-
tion to toxic lewl>.
Although other organs can contribute to metabolism
of drug.~. the liver is the pnmarr site for drug metabo-
lism. The amount of the drug that may be metabolized
during an ini1 ial pass through the liver varies fro m a
small amount to a suhstantial ponion of tl1e drug.
leav;ngonly a limited amount of the med1Cation to reach
the site of action. Thi$ is called the firlp.-s effect.
Drugs that are .1dministcred parenterally or sublingually
do not undergo a first.pass effect; therefore lower doses
may be required than for drugs given by enteral routes
(see Figure 2-2)
'!he rate of metabolism is an impon.111t issue in dntg
dosage. 1he drug half-llfe is the Lime the body takes to
metabol i?.e half of the available drug. Older adults or
persons with impaired liver or renal function may have
inefficient or insufficient m<'tabolism of the drug and
may be at risk for drug toximy because the drug's half.
life is prolonged (see Box 22).
Excreuon or Elimination
Ille rate of excretion or elimination depends on the
chemical composition of the drug. rate of metabol ism,
and route of administration (see Tables 2-2, 23, and
2-4). The functionality of excreting org.lns such as the
kidneys also determines how quickly and completely
excretion occurs.
 Re<ktceS 1lie 101terod111e (Oetrol)
aclMIY of rhe depresses the urge to
body functtOn VOid
phenytom (Otlantin)
dej'.lfesses seizure
act1v1ty
Stimulant Increases body Laxal!ves stimulate
func11on or peristalsis
activity Oral hypoglycemics
stimulate the pancreas
10 release insulm
Irritant Produces Ruorouracil IEuoex)
symptoms of 1rnta1es skin lestOnS for
tnftammattOn destruclton !he
Pharmacodynamic.-Orug Actions at s.1e of lesoon as a r1e effea
in the Body aw1oca1t0n lc;ht/lanvnol I eases the
~ o I) .m <> " IM ltrm fo< how J drug ~vn::
mflammat of boils
Its mrch.unw ol .o<uon 1n 1lw b<iJ) or th< b<xl) 5 ch Soothing action Hydroc0111SOOI' cream
cI f<'.ICtton 10 Jru~ In rhMm.1tod)'TIJm1c trim<, d",'& for im1a11on. soothes all c skin
1< lt<lllt llt b1ochem1tJI or rh)'10l<'ltJ< pr0<ts5l'S in usually to reactions
thl' hoJ~ or control 'hJngn CJU'l'\I by d1rsc l>nigl ldrl skm OI Lanolin smoo: s cracked
tnllh' rlit ""}'riv btiJ1 """ lur 1l1rr 1fo mll .~"" bc.iJy 1)]1111 mucous skin and de eases
an.I uuu,-. d ,.,.w fun, tt~111 membranes i111ta1ion

Iii! LEARNING TIP

Cl, arn<Plostonatu.ie ~ cs1efln
~ u ~ epbje" ln!O 8't01 rt the bodv
I~ t10n of drup u.Wll) tilli<f <low down or
<JtttJ UJ' orJuury Cl'!I J'C'O<<"Wl ind pr<>tl"CI the body
lrom .. uo"' of fomgn agents [lblc 2 -~ dacr1bn the
lour mJ1or drug an1oiu)
l'ou dntg h.\\ '1ngle acuon \\hen dntg rntcrs the
boJy, J pred1uablc chcmteal rcJ<t1on 1$ oroooo.
Iluw,.'\1:1 md1v1dual< rr.lct tn dntj;1 d1ffcrcn1ly, with
ni.iny unp1,J1n.1blc chrmic;il rcamons occurring. lhc
df'lrtd dlccl happens when the cpc<tcd responS<'
~<11"' ;uch o\\ llrn.11.lryl stopping watrry ryes caused
hy Jllcrwn 1lowcvcr. oihcr dToos that occur that arc
1h'<l1<t.1blc bu1 not tht dl"tred effects re <Id rfTU.
II< f'Juw mcdiuuon iffrct more thn ont boJy S)~lem.
ti..- ttton m.t\ not be \{llnc ind may uusc undt-
slr,-J rnroll>(S llw d'""'""'' that occurs with Betu.
Jn I b t"Xjl<(ln! nd 1> <omnuno th<-r.. ~tK' ia1on
u..-J 1on1h m1omm.1 u d<'<ncJ soJ, cffttt I.owning
t~ dos.igc ol ~ mtdt<Uon "'111 of1m rtduct si<k
<llt<U. but m <om<: c~ th< drug ma) hJ\'f 10 be dis.
ronunun.I btt.aus. of s1Jr tffom ( \<hTrs< reactions
thJt ttnd 10 ~ more 5tV<rc .re d1scuss.:d IJter m this
rhJpt<r)
The site of action of a drug may be t' tt local or
sysiemic. Loa! ction is limited 10 lhe \Ill adminis-
wtion and tissues immediately surround1 n applia-
tion site; examples of medications with I<> ion arc
nasal spr.I)~ and topical creams. When th >: efTea is
feh throughou1 the body. not just at lhe ~1H .1dminis-
nation. it is considered ~)Strmlc ictlon . Int nous and
imramuscular drugs lways reach systemic <I
l.nion for
their effect. whereas oral nnd oubcutanrou h ug.~ may
produce S}~temic or local cffee1s. 'Ihe >nnw 1g rllay be
manufactured for eilhcr system ic or lot.11 nt-a. An
example it is Benadryl, which is manufdctull' tCJpsuJes
for S)'S\cmic use and as a cream for topical o. 1c.il use.
Adrug that has its effect on a pan of tlw l Iv dis1an1
from 1he site of adminis1ra1ion is S<11d to h. .1 remote
effea; an example is nitroglycerin, placnl nder the
tOngti< to treat the acme symp1oms of angm -ctoris in
the bean.
Rather than having sys1ermc action, somr '\lg$ h3\'f
51>tti6c sites of aaion, such a$ 1hyroid horn n~ whidl
ha$ a primary site of action in the 1hyrt11 ~l.rnd for
hormone replacement in hypothyro idbm
Drugs may also fall into categories thJt J , .<ribe how
the body responds 10 medication or the 111trr.1c1ions a1
rccepior <ells. Box 2-4 describes four anion'

BOX 2-4 FOUR MAJOR CATEGORIES OF DRUG ACTIONS
O~pressam-A les rn1ng or suP1J1eSS1on of some body func
ioo or actMty (e g, omeprazole IPnlosec) to stJppress gastuc
.(! secretions)
St nulanr-An increase tn or strmulation of some body func
tion or actlVlty (e g., b1sacodyl fDulcolax) to increase penstat-
s1s m the colon for excretion of waste)
lmtanr-The producuoo of mffamma11on. generally by drugs
ooJ ied ID mucous membranes or the skin (e g , fluorouracil
le1L used toplt8lly to 1mtate kernt.OSls for destruction of
r feratrng cells)
Oemulcenr-Rehef of 1mtatron or the production of a sooth
1ng effect (e g. calamine lotion to relieve 1tch1ng and irma-
hDn of chickenpox)
Drugs do not h<lve a single action, although each drug h<ls
.in eitpecred act.on or desired effect Because drugs may not
specffic to a Slngle body system side elfec1s may OCCUI
~ aoothef system IS 111fiuenced
ug action is also related to the site of action A drug th<lt
1s not absorbed into the bloodstream 001 works at the site of
aprhcatron 1s said 10 act locally Systemic action refers to a
tal-body effect of a d!IJg that 1s absorbed into the blood
earn flemote action refers to the effect of a drug on tile
body at as te d stant from the Ste of adm1mstration
r ma1or d11J9 actions are stimulant. depressant. irritant.
nd demulcent.
armacothe rapeutics-lnd ications
or Effect s of Medication Use
------
I llk1en1 from drug 11tllo11 of ho1v and where a dnig ac1s
111 ',11 ious body sy,tcms, lhe ef/1<1 of a dnig is lhe sum
f till lnologic. physical, and psychologic changes that
ur m the body, or lhe result of the drug's action
I ft, " 1hat are no1 pan of lhe desired lherapeulic
r 'P mse do occur with dnigs given sys1emic.1lly because
111nrl' tl1.1n one 1yp<' of body tissue, nm just lhe target
1u q>tor sile, can be affected.
17
If wf' have therapy of any k111<1, we expect 11 to affect or change our
Uody in some way PharmacotherapelJ/lcs refers to how a drug
gt. wh<lt is occurring 1n the body or the therapeutic effect of
the mEU cation to treat symptoms or diseases such as a headache
or cc:
CHAPTER 2 Basics of Pharmacology 29
Dnig therapy 1s one pan of 1he physician's totaf
treatment plan for lhe medic.i i condition, but it does
no1 stand on il.S own. Illnesses manifest with signs and
symptoms, which may th<>n become indlu1tons, or
reasons, for treatment With certain med1c.u1ons, or
pharmacotherapy for lhe spec1'ic condition ll~gt' is
prescribing and applying or administering a med1cat1on
for a given purpose. Many dn1g~ produce 1hcr.1peutic
effects in several ways while Mi ll having tl1e same indi-
cations and uS.Jge. For example, aspirin is used as an
an..Jgeslc and ntip) rt'tic but It is also u5td to slow
bfood domng and as an ntlinR.unm.ltol) agent.
Diuretics may be used both 10 relieve edema nd 10
lower blood pressure, in this way affecting both lhe
urinary and circulatory systems. A final example i~ ibu-
profen, which was first introduced for 1he relief of
anhritic pain and is also used as an anupyretic and
analgesic.
As the field of pharmarology has evolved, a new
classification of indication~ for medication use has
come inio being. 'Ille broad terms tlterape111ic, di11g11osric,
1lesrrurrii.'. pl111nnarodyr11tm1r, and proph)'larrir rcprt>sent
the spectrum of drug indications (S Table 26 for an
explanation of these terms}
When a drug enters the body, a predictable chemical
reaction iHxpeeted. This intended response and expeeted
therapeutic r~;ult is called the desired effec1.
Because a medication may innuence more tl1an one
body system at a time. it may produce unpredinable
reactions. called side effeclS, which are usually mild but
sometimes annoying responses to 1he med1<a11on. In
some therapeutic cases, medications are used for the
side effects-for example. minoxid il (Rogainc), with its
~ide effect of hair growth, or drowsiness caused by anii-
histamin~. Ille incidence of side effect.s may decrease
when lhe medication is taken O\er an extended period
of time. Lowering the doS.Jge of the drug may reduce
some siM cffecl.S. In some instances, the dn1g must be
discontinued o r Stl)pped bec.1use of 1he .rnnoying
""ponse.
The eflect or e drug m the treatment of disease 1s referred
to as pharmacocherapeur1cs or pharmacorherapy and 1s a
combinatl(ln of the boolog1t, physical. and psychofog1t
cha~ induced as a result of the drug"s acnon
Drugs do not have a single action. althoogl1 each dnig has
an expected action or des11ed effect Because drugs may not
be specific to a single body system. side effects may occur
when another system is influenced
Side effects may be annoying responses to a medical.on DI
may be an maicatl(ln for the medcatlOll's use
 SCllON I Gener1I Aspem of Pharmacology
30
Aid Ill dlalJU'l'Q ~. aid
11 ot Iii!
patient. and permit disce'o-e'Y
ol 11111 nallJle Cl e1elll ol
~condrtJOm
Deswl c and tissues
A!te1 normal bodY fur1:t1on
PlllVtlnt occurrence ol 1llnesses
' d1wases
Toxicology- Poisonous Effects
o f Drugs on the Body
All dn111 or <henucal have 3 IOXJC le>-el; when taken in
rxic>. they ao a\ f'<ll>Ons Asingle dO'>I' of a medication
can mean the difference oct" e<:n a 1hcrapeuuc or toxic
cOeo llw gool of pharmacology 1s to S(lect a medic
uon m ,1 Joo,e that is therapeuuc and to avoid medica-
uons and doses that produce toxic cffoos. l'he differrnce
hct"cen a ther.iJll.'UllC dose and a toxic dOS<' is consid-
erI the margin of ~fcty Jwt a small increase m drug
lewis .-an cauw toxmty, whereas shghtl)' IO\\'mng the
blo<>J lt\ds of other drup may cause therapy failure.
\\"hen the 1oxK11) lt\cl has bttn exceeded. another drug
used a~ an antidote m.., be lll' Cn to stop the toxic
efreo
Ad'trw rt'~ctlon wually 1mpl) problems or S)'IIl~
toms more St\'ett than \1de effl'CIS Ad\'l'l"S( reamons are
unintended undl'>llabl<, and often unpredia.ilble effects
that cauo,e unmtenuonal pain or d15Comfon or unwanted
symptom\ \\ hl'fl Benadryl CJUS<!S unexptcd hyperac-
t1\1ty, the rcaoion i~ aderse >-crsus the side effect of
drow~mess llause the I ood and Drug Administr.nion
(I DA) m1uirl'1 sutmanual ll'1ting of drug,. b<!fore allow-
ing them to be m.u~eted, common adverse reactions
may be prcd1C1Jble. I he allied health professional has a
reipons1b1lity 10 momtor a patient for adverse re,1ctions.
The phys1mn takes 1he nccc;sary action for reponing
adverse re.m10M 10 apr ro1lriate authorities as desig-
nated by law
f!adiOisotopes ID ueat hypefiltl"'e gl<Wlds
cidals and anusepucs 10 destroy bacteria
11at:1eo .. ..._ de..~tlOll of matignan1 cells
ChefOOlherapeu uCS n >
Anesttel!CS for either sleell or 111Jmbness
eonuacepuves to aller hormone balance
Asponn for blood 'dlinn1ng"
Digitalis 10 increase heart muscle coo11act1ons
An11his1am nes for allergies
vaccines, toxids. immunizations
kt! CLINICAL TIP
All adverse reactions should be documented (usu~llv ridl in the
patient's record and should be noted in an obvious i' 10 prevent
the patient fnllll receiving thesame drugs again. e11I 1hc office
or as a prescnpnoo
nlth ii)
Allerg;c tt<ictions are a 1ype of h \ I"
reaction that may occur after only onl' dn 1t ,1 drug
has been taken; these reaetions occur cnli. r .IU\C the
drug was taken many years before or bl~'"'' ICl'l\'!Wn
is alletgic to a similar antigenic 5ubMan1 I 11111gen
antibody ~ion appears with "ngk or 111 1pk dose
administration of the drug and m.1y bl' 11111.t M"\.:ft tO
life-threatening. Signs and symptom\ ot ivc rcAC
lions are itching; rashes, hnes. d1lln11h , .11t11ng.
w~g; and swelling of eyes. hp~. ur 11 " ">me
reactions occur almost immediately, wh1r. 1 H.'f\ l1l1lV
be dela)'ed for hours or days Thow th.it , r.1piJly
are usually more serious The pauent \houi.t du1.t1td
to repon all mild adverse reamons lwlor. 1 hrr JOit
of the same mecl1cation is adm1n1s1crcd
ktj CLINICAL TIP
The allied health professional must use extrerrn mn when
gMng.any med1cat1on for the first time to n P"'" 11h known
allerg'.es to medications. foods, or other substaro 1 nplo with
allergies are mo1e susceptible to drug alleig11's

\n~ph)luh, or anaphylaoic shock. is a severe.
potemially fatal ad-erse reaoion occurring a short time
after drug adminiscration to .1 person who is sensitive or
allergic to the medication. Initial symptoms are rapid
s"elling of the mouth and throat with difficulty breath-
ing. Angioedem,1, J medical emergency requiring imme-
diate medical a11cntion, is 1he accumu lation of nu id in
the subcutaneou~ tissues of the eyelids. lips, mouth,
thro,ll hands, and feet. The symptoms of anaphylaxis are
hiw,, reddened skin, bronchospasm, initially elevated
blood pressure followed by a drop in blood pressure.
.vanosi;, dyspnea, vasrular collapse. loss of conscious-
neo.' cardiac arrh)'lhmias. and cardiac arresL Anaphr-
1.lxi' h,1' been noted most often after .1dministration of
amihiotics. especially penicillin and its deriva1ivcs, and
In, lN-d in diagno>tic studies. especially those contain
mg 10,hne but it could potentially occur with any medi-
c.111t>n ,1t any time. Insect stings and some foods such
" \hdlfish. peanuts, and eggs may also produce
"" ,~,;,
erots -,..ho have had seveie allergic reacuons to medica-
hould wear a medical alert bracelet or tag to 1dent1fy the
ernc substance All allergies should be listed on acard and
tn the walh t of a hypersensitive person Some people
1 to insect stings 0< bites may even be prescribed a small
ul emurgency medications containing Benadryl and epineph-
ta carry with them when they might be exposed to the
t allergen An example is the sting ng msect kit f0<
allergic to bee stings whose WO<tt or ac11v111es outdoors
"' ht put them in contact with bees or other stinging insects.
IC effectscanoa;urwith atldrugs.A small dosage change
I a med1tat1on may separate a thelapeutJC effcct from a
toxic effect.
Ad111>rse reactions can be an indication of hypersensitivity to
drug on response to changes m the immune system These
att ons have unpredictable effects includutg allergic reac-
tions and anaphylax1s.
Anaphylax1s is the most serious and dangerous of the adverse
eact1ons
- NTIFYING UNDESIRABLE
"EFFECTS OF DRUGS
\hoUI 'i0% of adverse reactions occur in patients older
than 60 )~ars of age. Deciding whether the patient is
experil'nc1ng advcr:.e reactions or some other symptom
CHAPTER 2 Basics of Pharmacology 31
------
BOX 2-5 QUESTIONS FOR DETERMINING
ADVERSE REACTIONS
Did the patient follow the directions accurately?
When did the symptoms first OCX'Ur7 How Jong after the first
use of the drug?
Has the patient staned anything else new or changed some
thing (such as adding herbals or vitamins)? Has a new house-
hold product such as a new detergent. been used?
If the drug was discontinued. did the signs and symptoms
disappear?
If the drug was restarted. did the same effects return?
Could the 1lness cause the symptoms? Ase the signs and
symptoms consistent with the diagnosis?
Could other drugs or products that are being used concur-
rently cause the reactioo?
Is there a possdllhty of a drug-<lrug OI drug-food
1nte1act1on?
BOX 2-6 REDUCING DRUG -DRUG INTERACTIONS
Consult physician or pharmacist before taking new drugs.
1ncludmg over-the-<ounter drugs and dietary supplements
Discuss any disoolers present and any prescnpbons being
taken,
Keep a list of all drugs being taken and disorders being
treated and dLSCtJss with physlCJan on a pe11od1c basis. Make
sure all physicians know all drugs being taken
Select a pharmacy that provides comprehensive services,
mclud1ng checking for possible in1eractims. and that main
talllS a drug profle on each person. Have all prescnpuons
filled at this site
Learn purpose. actions. and possible srde elfects of all drugs
prescribed
Learn how to take medications as instructed. what tome of
day they are to be taken. and whether they can be taken
during the same time period as other drugs.
Repon to the phys1c1an and/or plta1111i!Cist any new symp
toms that may be related to drug use
or an illnru may be difficult. f'he questions found in Box
2-5 will assht in helping the professional make this dcci
sion. If the drug regimen has caused no problems in 1he
past. then perhaps a new medication recently added
could be the CIU.SC.
Rl'ffiember that Idiosyncratic drug rcutioM-
unwanted reactions 1hat occur with 1he first dose of .t
drug or when a subsequent dose is given-are unpredict-
Jble and m.1y be from genetic pr<?dispositions. for drug
safe!)', risks of the drugs and probable bcnefi1s to 1he
patient should be evaluated, and a balance sought during
drug therapy. See Box 2-6 for me.ms to decrease undl'sir-
able drug effects.
32
SECTI<iN I General Aspects of Ph1rm1cologv===~--~-'---~
DRUGS AND THEIR
RECEPTOR SITES
l"Or d11111-\ 10 bl' efleuiw, the medication n1us1 attach
appropr1.11ely to J r<<tplor \lie. I[the d111g only moves
about 1he body In the blood, 1he desired effecl cannot
t.1ke pl.tr.' l'nr .1drug10 be 1her.1peu1ic, chemicals found
m 1ha1 Jrug must ~elrctivcly ,11t.Kh 10 the specific cell
rece1)tor ~11e-l<'ltt11w "'uon l'he receptor site on the
cell wall and the drug t hemical fit together like pieces of
a jig~aw pu1.1le (l1ll1Jre 2') Ille better the fit of the
drug anJ receptor "tr, the b;:11er the expected response
to mcd1c11on If the picre~ do not 611ogriher, the stim
ulation of rrccptor 111~ may not occur and the drug
may block another mcdicauon from being effecti,-e.
l'hu~ drujl> at rccq>tor sit" may either mimic or block
acuon of a mcd1rn1on A Jrug'~ selecu,11y of a specific
n.'(tplor \Ile, h"c-.cr. d<>CS not guarantee its safe medic
1nal use
\\'hen tht med1cauon i11mub1es the rn:eptor site. the
drug work.~ "uh the bod) to mimic its function, or is
<".tiled an agunlt. When drugs are at!.lehed strongly and
do not produce chemical rucuon but do prf\\'111 ago-
ni<ts from bmdrng at the rcet'ptor me. the medication is
calkd an antgonl\t . Antagonists that prn\'111 olher
dru~ from bmdmg 10 rec<ptor >1tes counteract th
expectcd cfftttS ol othn drugs
A "eak bond that pre\'ents other chemicals or drugs
from bmding to receptor sues on th cell wall is
called a p.mwf "S"'"" !><>me drugs aa by changing
cell wall permeab1li1y. whereas others ao as enqme
inh1b11or; ramples .tre anlldO!l'S. used tO neutralize
todc substances, chelator~. u-ro 10 treat mrtal poi-
sonings; .ind antlmetabollte\, used with cancer to
disrupt essen1i,1I cell metabohc process, either by
inhibiting e111,yme11 or by i111errupting DNA replication
and function
HANISMS OF
~:5G INTERACTIONS
- n ~rious ways with other dru> and
a<jnter.lct I . n
D ru':'" i\lhen multiple dru~ are gM:n together, some
numen~ are desirable but othe"' arc undesirable.
ioteraaions - tog.
me l!ll(lications are prescm><-u thcr to .1ch"1cve a
6
So ired response. other drugs ma)' cou ntcract or .1ugmcnt
des ~ effect if give~n toge1her; ffiJ) ht: wholl
each OlrJO S J I
. com tible together; and may . inte11cr~ \Vllh the
"' ~ m-bolism or excreuon of rnnl1c.111ons.
absorpuon. ~
. ns mu.st be addressed. or they 111.w rc\uh in
101eraat0 -~ily dam"'" or even deat h
permaoent """ ...,- .
Orug intenctlons, or the combmcd elk< t of drugs
administered together, may take the form <~I rgl\m,
tiatlon or ao1.1gonlsm. In add111on to drug.
:'.;':meracu'oas. there may also be nutricm drug and
disease.drug interaaions. for cx_amplc. ll'tr.1ryclmes
tract with milk. and alcohol mtcra< I\ "nh many
'"e -A
drugs. espt>Cially hypnotics, sn1a11ves, .111<I !lt1.1nxiety
edication.'l 11 is imponant 10 no1e 1h.11 v11.1 1111ts, min.
erals. and herbal supplemems can 1 n1tr.~<1 '"11I pre
tn
scribed medications, such as c,1bbagc with 'llrfarln
S<Hliurn (Coumadin).
Drug-Drug Interactions
When 1wo or more medicat ion~ arc pre\( 111> 1 l<IK<'lher,
(1) the drugs have no effect on each 01 la1 " 11011, (2)
1he dru!!ll increase 1he effca. or (3) 1lw <111 1 1kcre.1se
the effect of each. Mos1drugs do 1101 1111\'r.1< 1h other
drug.s or food, bu1 when such imer.1n1u11 o U(CUI,
some may be life-thre;itening Becau'<' 1.. ni; are
taking more than one medication for "'"'' lun one
disorder, the potential for duplication~ .111<1 r.1rnons
increases.
Some terms for drug efTecu m dmg dru~ 11 1.1wons
are 5)1lergism and anlilgonism, "hich nu\ ht k.irahle
orundesirable. l'otentiauon and tol<.,Anu 1 r to how
the expooed effect occurs m the lon11 !lrn1 ( I 1RUrt
24 and Table 2-7 for defin1uons anc.I .xpl 111on1 o(
drug-drug interactions.
kt! CLINICAL TIP
Orug-<iug imeracnons can dtange 111e ou1como of lheilVI
sigrnficanlfy The charice of undesirable mteract1011 Iewered
by reducing lhe number of med1ca11ons 1aken 11 a Ill taking
mu~iple drugs has unusual symp1oms. the poss1t v ol a d1ug
interaction should be considered The allied he.1111 rotess1onal
~Id take a.thorough history and ass1s1 by datum 1111 ,111 poS
ble medications and in finding ways to decrc.1se 11 number of
medK:aUons being take11
 CHAPTER 2 Basics of Pharmacology 33

Addition of Ingredient
BOX 2-7 COMMON NUTRIENT DRUG INTERACTIONS
Food/Drug Effects
Milk and calcium Tetracycline becomes
products/tetracycline insoluble, and ant1bactenal
properttes aie ineffec11ve
with btnd1ng to calcium
High-fiber diets with Reduce the absorption of
Add diluent wheat bran and oats many drugs
Ii Grapefruit. grapefruit Reduces effectiveness and
T~IO
I "'""' iuteersiatin"
drugs for
hypercholesterolemia
rarSP.s blood levels of
many medications such
as statins: with other
. and sildenafil med1cat1ons. stop the
(ViagraI action of the drug. 1uice
seems to affect drug
me1abolism even 1f
Synerglam
medicallon and juice are
more lhJn JUSI taken at different umes: the
ndMdual greater the amount of JUtCe
1ngred1ents) consumed, the greater 1he
inhibition of medica11ons
Wine. yogurt. cheese/ Cause po1ent1al 1oxic effects
monoam1ne oxidase when used together
.dd ng ll(lasoning inhibitors (MAOls
11nert Ingredient) that act as
antidepressants)
Caffeine or caffeine- Toxic sumulatton of neMIUS
ronta1ning foods/ system
central nervous
system s11mulants
Antagonism Salt substttutes/ Dangerously high potassium
ad<Mg potatoes potass1umspanng levels
absorbs satl. d1ure11cs
oecraases Citrus juices (orange Excessive absorption of
~)
juiceValum1num- aluminum
based ant<1C1ds
Brocroli, Brussels lnac11va1e 1he med1cat1on
sprouts.cabbage/ because they contain
warfann sodium vitamin K
Cumultlon (Coumad1nl
comb1nat10n
of ngrecuents All foods/ Decreased absorption and
or etfoe11veness) bisphosphonates drug effecuveness with any
food, drug us11Sally 1aken
Figure 2-4 How drug mtCfllCt1ons wortc with water 30-60 minutes
before eating or drinking
any 01her food subs1ance

food in the stomach. Some medic.1tions must be taken

11trient -Drug Interactions
utriem -drug interactions are poor!) understood. They
can induce toxic effect~ and/or c;iuse failure of therap).
I he ab>orpuon of dn1gs can be signifiramly changed by
o n an empty stomach for more rapid .tbsorption, whereas
other medications are taken o n a full stomach to maxi
mize the absorption rate. See Box 2-7 for common
nutriem-drug interactions.
 34
SECll(JI 1 Gener1I Aspects of
_:_:__~....:;::_.:______
~ ~'!el liu:I ~ talel1 UJgetrel
Oes:tallle 11'e p
\.Qlesirat!e s1nergisn
Poler: IJOll
Desirable poten llOll
lhlesirablo potentiatlOll
AAtJq001Sm
Oesu able antagonrsm
Undesirable antal)ll01sm
u1nn1atlnn or add1t1on
Cumulaton
Pse. ldoaddic.t.on
Tolerarc:e
ldicsyOOasy
0.-p.-ndn, addiC!JOn.
hhl111.ulnn
~IC dependence
~ dcpcntlente
Allergy
lnterleience
Pha~r~m~1c~o~lo~gy~~=~~=~------:::::::
llNg
recel0' sr. f
abe:ll a slllJ9!' eftect o
Ore~ . . .
DNg roeases !lie e~ of aoodJe< liuQ in
U'le blx!y
Otugs weaken or stop me effects of one
1111other when gi<en together
Conb1ning two drugs and ach eving
eiqiected medic nal effects of each by
add no drugs together
Drug has suooge< effect than expected
becall!e pr1N1DUS dose has not been
~tabo ited or e<ereted from the body
Abnormal behavior dewill!l'ng as direct
1esu\I of inadequa'e pain management
llNg has ess effect U1M e<per:ted. body
gcU used IO MJg Ima'( be aa1ed ()(
congenital)
Drug prOlb:8s different ettect tlliYI
e>pected
Body de!Jendeot on MJg IO fllflCtlOO
Emotl()(lal anachmem to or ua. 11\l for drug
f'llysiologic de!lendence "" th poss1bd11y of
withdrawal symptoms
HypetSl!nSlt1v1ty co rlrug, body develops
antigen-antibody reaction
'1e diug P1omotes the rapid eiu:reuonof
Jnother reducing the actMty of the first
mependllle 1l)emeroll IOI pain and
pronethalne (Phene<ganl fOI nausea-
the effects ol each
Cllflli,na!JOfl prolongs
waifann sodtum (Coumadnl and aspmn-
Cllfllbtna1J00 1ncreases bleeding tendencies
rneperid ne 1Demeroll and penta1ocine
(Talwml Ill Jl'Olong analgesH: elf .ts
cunet1dine (Tagametl and theophyl ne,
Tagamet mcteases the effects of
dlecphylhne
vuam 1n K decreases effects of w.i rin
asprrrn and 1bupiolen when g1von J 'ther
decrease action of both, totrac:y ~!S and
antacids cause decrease in ab 1 rion ol
te1racychnes
Anbh1stamme plus ant1b1011c 101
1nfect1on
HyperactlVllY caused by excess1v1 te ne
mgestlOll
Orug-$P.ek ng behaviOI, Paucnts for
pain management can be mis IOI
haw'!l ill1 addot tIOl1
Need f111 meased dosage ot opi tor
ie iel of pain
Allergic reactlOll
Need !0< more and more pa n tlOll IO
obtaul !1'le same result
Us ng sleep preparations w1tnout "9
1nsomn a
Us ng pa111 rned~Jt1ons over a Ion rrod ot
time. especldlly schcdulud drug
Most rommon 1s the Jllerg1c re.i to
pen1cillln. including rnsh. d1thcu i
breathing, and possible anaphv
Taling a laxa11v~ with an ent.ic1d

Medications ordered to be taken on an empty stomach
should be taken 2 hours after meals or 30-60 minutes before
meals
2 Grapefru t jUJce can 1nh bu the meiabohsm of some drugs.
ra sing the blood le-.els of drugs. l!';en 1f iuice and rnedica-
uons are taken at widelyseparated times
3. Drugs can interact when directly combined as found in par-
enterals. so two or more medications shoo Id not be combined
in a con!diner unless the person aclm1111steroog the med1ca-
11ons 1s sure that no 1nteracuon will occur
Disease-Drug Interactions
'omctinw\ drugs used for one diseJse are harm ful with
t,gard to Jnother d isorder o r disease present. Diabetes,
t~h or low blood pressure. an ulcer, gl.tucoma, an
I. g<~ pro~1.ue. poor bladder conirol, and msomnia
1 p.1r1il ulJrly import.mt because these conditions are
' m likdy to cause disease-drug interactions. For
nple o,<une beta blockers taken for heart disease or
~ ' on can "~>rsen asthma .rnd make it difficult
I " fll'r>on with diabetes to tel l when his or her blood
1:.u is ton low. Some cold prcp ralions <an worsen
u'"o"'' Jhesc in1{'ractions arr n1ore comn1on \Vilh
er Jul~ who tend 10 have more diseases and an
.l~t,f u~ of dru~ Awareness of all di'l,ases by the
I' ""d.rn htfore prescribi ng medications is most impor
"it for d1ug safety.
ntcd react ons can 0CC1Jr with all med1Cmes end should
d l"llffited If they occur.
op r dCt d1tterenlly to med1catJons. and 1d osyncratic
reacuons may result from genehc differences.
\1 cations shoold be prescribed and evaluated for use on
nd 'aal Ila! ~ "Id should nol be expec1ed 10 have the
ame e -:ts wrth a patients
Patien1s should be monnored on a regular basis 10 ensure
na medications are effective and that no unwanted reac
81 occumng
he geal of medication admimstrat1on ts to maxrmue benefils
t1s1ng the least amount of medication with no undesired
effocts
..led cm1oos may work together 10 ( 1I increase the expected
outcanes of each drug lsynerg1srnl. 121 decrease the actm
of one or more of 1he drugs (antagonism!. or 131 result in no
change in the abso1pt1on and metabolism of each drug
(agomsml
Drugs bind to receptor sites on ce wa Is The drug and
receptor site fit togelhet lrke pieces of a puizle
CHAPTER 2 Basics of Phanmacology 35
-----
Medrr.atm s are given together for ~rg1sm. potent1a11on.
or antagonistic acuons. ranging fromdes1rable to undesirable
to life threateni119.
01ugs accumulate rn the body (a process called cumu/atioffl
if meti1bol1sm or eAcrehon 1s not complete before another
dose is given.
Tolerance 10 a medication may occur if the patient receives
the drug over a p1olonged penod of time and more medica-
tion 1s needed to acllreve the same effect as formefly
Foods leg., grapefruit 1u1cel may have adverse effects on
drugs and may potent1ate or act as antagonists tn lhe drug
action Alcohol should be used w1lh caution. High.fiber diets
can attec1 the absorption of drugs
Interactions can occur between drugs and underlylng
diseases or cond1t1ons.
SUMMARY
A drug is a chemi<al compound used to prewnt, cure. or
treat dise.1;.e or 10 di.1gnose abnormal condiuons. ~o
drug is ide,11 because chemicals interact differently in
4.'ach person because of' the d istinct body functionality o r
each person. A drug with the fcwe~t side effoos and
ad\'efSt' reactions and the greatesl efficacy is considered
the medicauon of choice.
Drugs m,1y occu r in natural substances such as plants,
minerals. or Jnimals <lr may be made in chemical labo-
ratories "ith synthesis of new drugs. including the
manipulation of genes with recombinant 0-..:A tech-
niques. Th~ study of the o rigins of medicines is plwrnw-
cog11os)'. o ne of the five fundamental pharm,1cologic
c.negories The way drugs are proc~ by the body-
through ah>0rption, distribution, me1abolism, and
l'Xcre1ion- is their pl111111wcoki11eri.-;. Age. weight, gender,
route of admi nistration. and disease processes will :iffect
how a partirular drug acts. P/111mwr0<Jptami<s refers to
how and \Vhere drugs act in the bo<ly lo produce a thera-
peutic o r d1.1gnostic action. The silel> of action- local,
ystemic, s.-lecrive, remote, and specific-are wlwrr drul!I'
act on target cells o r th.sues. PliannacotJJer111u111ics refers
10 the physiologic changes brought about h)' a drug.
Drugi; are selec1ed to cure o r prcwnt .1 disease, p.111iate
;ympto rns, or reveal a diagnosis. Drugs may also produce
toxic effects including adverse, allergic. idiosyncratic, and
.rnaphylactic reactions Potential side efTeas and adverse
reaction;. are reported m drug in~rts for health care
professionals' awareness
No matter how careful the physici,1n or how coinpli
Jlll the pa tient. unde,irable reactions may occur. Decid-
ing whether an adverse reaction or an unde<iirable effect
is occurring may be diffic.-ult, but by eli minati ng posible

'""" ol lh<- ~ bnhb cart pro(cniOO.lb ci rt<
Of;IUll' iidwnc' mai:uom
Drug uu;;t .. complicllitd lJld .:arid b.aust cath
sui1n11 :an indiTiduJl with dill"mm ~and Ji1ftr
ml pl!)..ioloPC lJld llJlllttUllO ps)'choloP' J<1<f1111
runs 1br al in! ht:ahh pro!tulolW mll'l 1't" careful 10
...-~.ach p.;1lm1aun1nJMd~IJldmU>t i.tlud..uiled
mnllClll .nd ptwmxvlupc h1>101) 10 ""d Jrtnmental
lid< rth-CU and ad'" rtll<>M
\\1\ u l"'O or n'or(' mnhc,uont ll\' gl\l'O 1ogt1her,
1h<"v <An 1ncrra>e on~ anv1hd ~,uon Jec;rtase
acuons. or ha<e no effeci on actions. These .drugdl\lg
inlC1'JClions depend on ~~- 1he rece~1or sue o n the
all 1d the drugS 6t togeuoer. 1~ some instances, medi-
ations are gi><en to stop she acuons of other drugs that
might be detrimental to she body. In other cases, dmg,
u~ &i'"' to neutralize toJOns., Some drugs work locally,
whereas others wofi.: systemically. Drug-drug interac-
iions can be life-tlueatening: ~lso important are foods
that can interfere with med1c111cs. Some nu1rient-dl\lg
interactions can be dangerous. as c,11\ diseasc-dl\lg
interactions.

IS ICJFf# iMl:il;

Sunrio
lone3 each day wit/I graPefflJll Jli'C8 Since she staned drmlnng the
les 1" t.tle tteI trJfld;QllJOM
(JflPef 1paend1.11ino choleSteroUowenng medieatJOnS. her cholesterol level has nsen. although
hcf diet has no: changed A J1l0Wll offset of rne pee rs ro lowef !he effects of the med1CBt1ons
I Whal ll\*>l.otl$ would vou ask to c1e1ermme 1! Mrs Jones might be having potential side effe s?
2 Mrs Jon~ esk.s I she can tale tl9I me0ooe 2 hoors after drinking her 1u1ce beCBuse she th1r , the

3 When she a~s aoout Chang no h8I medications to keep drinking the 1u1ce, what would be yo
O 11)4llru t helps tier arthf1tis How would yOO respond?

t8$POOS01

f;i:W14''*iJtiil]Jt-=-
I \\ht " Jrug \n .o<tl\'I' m.utJ1<nll A \alt d r u g ' - - - - - - - - - -- - - - - -

J llruga art ~td l'I\ lour mull.,, \\'hl art lhei! Wlut organs are involwd m excretion' Which 1 T\ is most

commonly ' " o h . d i - - - - - - - - - -- - - - - -- - - - - - -

l What arc the d1lkrcnn'5 ,1mong J "de cnttt_a_n_a~d-vc---.

, --
rse reaaion, and-
an- - --
allergic ----
reaccionr

~ Orup
-- worl. at nou.
....,.,.,.1 C:hd.itoBI rtH"ptor <lln """ do gon1s1S
\num...ubohtnl
. ""'"'at rccepto . I
r sues. i\ntagonistS' Panial a, ,15! Anti-
 CHAPTER 2 Basics of Pharmacology 37

5. Drug-drug interactio ns occur when medication~ Jre taken together Some interactions are wanted. others are
undesirable and even life-1hreatening. Giw two reawns for giving medicatjons 1ogethcr. and cite two types of
dangerous drug interactions - -- - - - -- - - - - - - - -- - -- - - - -- -- - - - -

Ii What role do Ore drugs play m drug-drug inieractions? - -- - -- - -- - - -- -- - - - -

llchne <)T1<-rgm11. amagonism, poternwtwn, id1osyr1cr.111c drug "'"''"'" wmulati<'I' eff<'<I. and drug 1oler.111u _ __

llc><ribe wh.u happens in d rug food interactions Give examples of d rug-food interactio ns. - -- - - - -

Wll't is me.mt b) Jrug-dL<east' 1111tracrio11? Why is 1his found more often in older adults1 - - - -- - -- -

\\ hv" DNA technology so impon.tnt in today's medical practice/ - - - - -- -- -- - -- -- - -

Drug Information and Drug forms

Cootrasllll9 dru9 nomenclature

Oeorminino di!letcnl mc4'1$ ol ~ US1119 man sources of drug information
medatlOnS 1denblylllg and descnbong drug forms
~ what is meant bV otl.label meations

Susan WOtks ,,, /1 local physlCl8n's ollC6 that specralozes m gerontology. Mrs. Elder has come to 'e
the phys/Cliin 1bout a smal( pa nlul wound on her leg that will nor heal. Or. Merry asks Susan tL pply
a d1oss;ng ro Mrs Ekk>t's 1119 using sn omtmenr. Unable ro find an omrmenr in the medicine cal et,
Susan USO$ 11 cream INhen Mrs Eldnr t"8S to change the dtessing, ir has sruck to her leg.
''
Is t porrTIJssible Susan to swap an oontment and a cream? 'Why or why not?
Mrs Elder haS dil,cuhy swa!low1no pan medication because her mouth is dry Would you sugg that
'
she take medtCat;On$ on 1 capsulo a tablet lorml l.Nhyl
What c1fference would en Qlfltmcm ha\oe made on this scel\ano?

EffffVtuent pow der Off-label U$8 Suspensi o n

AefOSOI
Elixir Ointment Sustained" ase
A erosol foam
A mpule Emulsi on Package in58rt tcontrolle elea581
Buccal 1ablt1 Enterlccoated tablet Paste tablet
Bulfered t ablet Gel/ Gelcap Pellet Sust ained-re , ase
C1plet Granule Physicians' Desk capsule
Capsule Gum Reference (PDRI Syrup
Chewable t ablet Implant Plaster Tablet
Colloid suspension/ Insulin pen Powder T ampon
solut ion Legend drug Premeasured cartridge Tincture
Cre.m Liniment Reconstitution Top ical
Oel1yed-rele.se lot ion Shelf life Transderma'
cepaule Lounge Solution Transderma at ch/
Dispersion M 19ma Spirits disk
Douche Medicated enemas Spray Troche
Drug FIKts and Met ered dose inheler Sublingual tablet V ial
ComP11risons Nebulizer Su.ppository V iscous
Drug nomenclature

38
 ~~~~~~~~~~
rugs can be named and classi6ed in se-.~ral wa)'S.
D Sources ofinforma1 ion concerning med1ca11ons,
their names. and their classi6ca1io ns are .w.til
.1blc 10 provide safe dosages for each pa1ie111 In this lext
11rug\ MC classified according 10 1he body S)'S1em where
th therapeutic effeo ~expected. Icons for bod) S)'S1ems
,.,11 lw used 1hroughou1 1he remainder of 1he book 10
.i<m 1 m identifying med1Ca1ions .,;th reccp1or ~iles an
1h h1l<ly's organ S)'S1em Other drugs such as an11b1011cs
.111<1 an,1lgesics with sys1emic effect will be placed m
, h.tpll'" wi1hou1 rcl.11lonship 10 a specific bo<.ly system.
\11dira1ion fom1s vary according 10 roU1e of .1d111in
"Ir ,1uon and speed a1 which the body need> 10 absorb
1h dmg for 1herapeU1ic effect;, In lhis 1ex1 medir.11ion
1 rms are considered as en1eral 10 include ,111 routes
11 v ,,,,g 1he gas1roim~unal (Cl) uac1, paren1er.1I 10
"" 11 I all medicaiions miected into the bloodmeam
(1n111wnously (IV)), in10 the muscle (imramuscul,irly
p,\11). o r under the skin (subcutaneously (SCI o r intra
11 1111llv !ID)); or percU1aneous for drug.5 1h.11 are
hrJ through 1he skin. Refer to Tables 22 through
r 1hr rates of absorp1ion by rou1e.
CLASSIFICATIONS
i11 ing drugs is complCJ< and difficuh because a drug
c 111J1cated for use i11 irea1ing condilions in >evcral
'''ms. One cla.mfication is based on a drug's
P< " action on body org;ins; examplM are dauret
~ to relieve edema and analgesics used 10 relieve
lrugs may also be classified according 10 their
111 u<e. m which case 1he classifi(;l1ion is si milar 10
1h\'1,1peutic action, inv<llving such 1crm~ '"diuresis
111.1/~e<w. Fami lies of drugs may also be used for
ft< uon. such as raenicillins used as a111ibio1ics or
1dt" for diuresis h should be remembered 1ha1
mcdteations haH more lhan one use and ma) haw
, uuc ffectS on more 1han one body S)'S1em such
111dics. which al'\' used for diuresis and to lower
I nnssure, and aspiri n, used for analgesia, 10 reduce
.1111111.ition and as ,111 antithrombo lk (10 prevent
I doi.) with coronary dhease. Classifica1io ns by
, u1ic effect and by drug family are usu.illy found
reference ma1erials
are classified by 1heu med1cma uses and 1heir thera
uricact1011s. as well as by therapeutic family. A single drog
n y ha\11! more than one classification, may affect more than
body system. and may be used in sevBfal ways in treal
rrem of 1 lresses and cond1uoos
Mos1drug classificatoos are based on medacal 1ermonology
DI Ille symptoms OI d<Sease processes IOI -Mlach the drugs
llt1I LISl!d
CHAl'JrR 3 Drug Information and Drug Forms 39
"OFF-LABEL" USES FOR
MEDICATIONS
Drugs arc used for I Ood and Drug Adminis1ra11on
(I DA)- approwd condiuons found on the package
insert l lowl!\'t'f, some medacauons ha\'l' off-label u;c,
which means a med1cauon can be mdicated and pre-
scribed 1herapeuucally for a cond1uon 1ha1 ha; no1
been s1ud1ed by 1he manufJc1urer for FDA approv.11
11w on label use of d nigs i, becoming more wide
spread as phr--icia ns use medic.11io ns and repon 1hdr
uncxpted e!Tecis after inilial 1 DA approval. re>ulung
in .1 new 1herapeu1ic indacauon and use. Some drug'
used in 1he past now ha"e ffiA apprO\-al for off l.lb;:I
ind1ca11ons because of financial 8'Jin from required
funher 1cs1ing. Lxamples are Roga111e, origi nally dcvcl
oped as a blood P"''"u re 111edica1ion and now us\'d 10
preve111 or slow balding I lowever. some of Lhc o lder
medka1ion~ ,ire uuly used as off-l,1bel lherapy bec.iusc
of the money necessary for extra s1udies for I DA
appro\'al and success of nonapproved use in 1he pas1
An example 1s r:yproh"1'tadin~ (Peri act in), an an11h1s1a-
mine, used for weight ga111, u~uall> 111 geriatric patients
DRUG NOMENCLATURE
Dntg.\ arc named in a variety of ways, induding name~
lha1 include the family of drugs. For exa mple, cillin in
1w1oxicilli11 indicates tha1 1he dn1g is a penk illin derivJ
tive. Wi1h lhe FDA assigning names to any drug approvt>d
in the Unued S1a1es, all drugs manufaaured whh the
same gmmc or official name must have the same chemi-
cal name and suucture. Lis1ings of official drug names or
drug nomenclature can be found in drug reference
books such as lhe Utlirrd S1111es l'ltcm11acopoein- Na11011cll
Formrclmy (usr - NF).
litl C NICAL TIP
Health professionals musl check the exac1 spelling of all
med1ca11ons to be administered or piescnbed Some drug
names look and sound alrke 01 are spelled s1mtlarly, leading
to mistakes an documenta1aon "!len COilect drug nomencla1ure
is not ~ See the E'llOl\ll! websle for a fuU liSI of Do Not
Confuse drugs
 SECTIO.\ I General As;>etlS ol p11111~n1!'c~ol~og~?V'..,__~-,~--
'"'h drug lw. w-~1 .. .-.-. of being ~m..I th
~ chnrri<'a! """"' ol Jrug icknufin
o;J<I
-'lrnilaJ comrounJ
t
or m.J1<JIM>n .ind 11.S
mol<"<Ubr "1U1UI<
lh' urin-.: or MrtprrtflfVWf)' rwlfll. llO "II
td the
,,...,....,.. ""'"~ is tht on~ "''<n
...
a drug when
t
mJol.
l'O\'a
ufa<turer fint pmpo50 tt to tht fl>A 1or app.
lhe ~neric nam< ts nf\~r capttahad, IS e.isier to
remember than tht chemical n.1me. and is 001 the
propeny of the manufoctul'l'r Cencnc drugs are
oltcn used when presmb1ng in prercrcnce to pro
pnctary drugs because they mid to cost less. have
the IOl'l'St potenual for tfl'OI'), and identify the
Jrug no mmer "hat manuf.lcturcr
.,.._ <ra.I mtcrdtangeble terms for rr.i.klTlllrlml drugs
ol\t /rdik ""~ "'""" ""'"' nJ l'"-'l'Nfil'l' MmL
II r.-ftt to a drug name O\\ned by a specific ma.nu
f.a<turn and an be u\CJ onl~ by tht original man
ulJ<tum lbe S)mbol * lollO\\> a 1radt name
inJ1caung that the nJm< 11 a r<'tlJlttred trademark
nJ IS rrstnCled tO US' by the O"lltf or the name,
u~ually the manufacturer that owns the patenL
Ir.1de names ar~ designed to be eJS1ly remembered
(cg., Viagra, Clanun) The fim lener of .i trode
name is capitalized. and the name ma) suggest
some special feature of dw drug. such as Skelaxin,
a s~elml muscle relaxant. Confusion is possible
when trade names .ue u~ becau;e names for
cnurely different compounds may be pronounced
or spelled 11mibrl)
l.umples of drug nomenclature follow
Chemical name- 2-{4-isobuiylphen)I) propionic acid
lradc namt'-\lotnn
c.,nmc namt-1buproftn
Owr-1he.coumer (OTC) drug name-ibuprofen.
.-.Jv1I. 1'.uprin. \lolrin 18 (the la.s1 thrtt a.re also
propnewy names)
Chcm1calname-N-cyan0-N'ml'lhyl-N' l211 (5-meth)1
111 lmidawl-4-yl)methyl lthio)ethyl l guanidine
I r.1de name- ragamc1
c;cneric narne-- cune/Jd1ne
ore drug name- 1ag.1me1 llll (also a proprietary
name)
tqicnd drug is the name for drugs sold only by pre
-.cnpuon, such as rMp<'ridint (Den>erol) and dia.upam
(\'ahum). So named, these drugs must bear tht federally
mandated warning or legend-c.1u11on ffderal law
proh1b1ts dispensing "'thou1 a prescription" -thus tht
n~me kxcnJ drug
ore Jrugs do not require a prescription fhey att
found on the shel''l!S of phannacies. grocery stores, and
the hke and are sold m d~ that are considered safe 'f
m.inuf.tc1urer'sdirectionsare follo"ed Usu.illy the do~
are lower than found with pre<crip1ion strengths of the
>me drug.
lh care JJOfess.onalS should teath patients to read all
~ents ard drug 1111eractiOnS hsted on packag ng before
13 , og OTC .rugs
aro
GeneflC uade named drugs contain the same fonnulatlOQ
2 even the drug 1sma111Jfactured by different compames (e g .
11
Amoxil by Beecham " me S<Jme smoxic1/lm as iril110lt by
Apotheconl
kt] CLINICAL TIP -
OTC drogs beirv;i used are med1cat1ons and must always be listed
me clinical record. as these drugs can interact with prescr1pt011
111
medica~ons.
1mp.ortant' Facts
Orog nomencl~tlJfll refers to all Ille names by ch a d'1Jg
can be identified-ail drugs have a chemical n e. an offi-
c1al or a generic name, and a 1rade name, and Y ha"I! an
OTC name
The trade name belongs 10 lhe company thal d oped the
drug. The companv also owns 1he right 10 be lh 1le manu
facturer of lhe nfNI drug for 20 years afte1 th i tent has
beell filed
SOURCES OF DRUG INFOR
The USP-NF. the official drug list reroitnu J , the U.S
g<l\'l!mmem. is mised annual!)' wuh \Uppl nts twict
a yl'llr 10 l'ttp it updated hs prim.ll')' pl V)S,C IS lO
provide official standards adopted b)' the I r<'gardiog
iden1i1y, quality, strength, ,1nd puruy ul m, <I 1tions and
quality control or mcdic.11lons and nu1r11 1 1 1 supple-
ments produced in the United ~lJWS
Before a new drug is marketed, the m.111111 turcr must
develop an FDA-approved pdck.lRC In\"' (l 1(111e 3-t).
The insen prO\ides a com1>rchcnsiw .tnd , 111 ,,. descrip-
tion of the dmg (Table 3 I ) .111J mu\1 .11" , p.111)' each
packageoftheproduct rordiSP<'ll\lng. wtw1I 111 bottles
for pharmacy ustoron ~lmples a11hc phy"' 11" office;,
The Pltysirian$' 0.-h Rr/1n11u ( l'l>R ) 1 , ublished
)urly by Med1Cal l.conom1cs l'ubli\hmit a1u financed
~the pharmxeuucal mdu\try llit' puhlu .n includes
tnfo~uon . abou1 drugs m an r.l\il) " " le fonn.
malciog n a frequently u~ rcfcr.. nrc 111 a J>h"1cian'1
office The company al\O prov1d'" '><'Wt.ii '" 'plements
per year with revised mform.111un and mlor ~1.111on on
new products. Another l'DR for O I( druu, 1 11\0 avail
able. All dmm ..~ are cro\Hcfcrcncc<l hy" 111.mufocturer.
'
Irade aod generi c n,unes, and dtug d.l\sih1.11111n

The PDR consim of seven sections. each separated by
color for easy access
Section I (white), Manufaaurer Index: This seaion
includes an alphabetic listing of each manufaaurer
with the manufaaurer's address, an emergency
phone number, and ,, partial list of available
produas
Section II (pink), Brand and Generic Name Index:
this section is a comprehensive alphabetic listing
of medications by generic and trade n,11nes for
drut1s fou nd in the l'roduet Information Sect io n
(!.cc1io n V, while).
Section Ill (blue), Product Category Index: This
<rcuon subdivides medications by therapeutic class
(e g., antibiotics, ,rntianhritks, analgesics).
~<xtion IV (gray), Produa Identification Guide:
lMh m.rnufacturer supplies full-color photographs
of .ic1u.tl size tablets. capsules, and other drug
forms 1his $lion is invaluable for identifying
h und (1r.1de) name produas.
Sc'rnon V (wh ite), Product Information Seaion:
l lu' <ection contains information found o n
pa<~.1gr insen,. The seaion is alphabetized by
111.r nut1mirer ,rnd then by produCL
Sednlll VI (whi te), Diagnostic Product tnforma
110 11 ll1is section includes an alphabet ic listing of
many of till' di,1gnostic test medications and prod-
'"" 11\1d in hospitals and physicians' orfices.
s., 11011 VII (white). Miscellaneous: This <ection
'>5 mhlcs mi~ellaneous information including
we following:
Kt'\ to controlled substances categories
KC\ to rOA use.in-pregnancy ratings
L1s1 of Po'><>n Control Centers
FDA tdcphone directory
IJru~ information centers
Look-,llike sound-alike drug names
\dverw event repon forms
1 1rn.1c i'ls use 1>r11g Facts anti Con1parisous, a
k 11 b111dcr sou rce for comparison ai1d evaluation
o 1111i1.11ions, whilh is updated month ly. TI1e manu
' 1111. 101111 of packaging, and comparison 1ablcs of
l .1 11on~ a11' indudt.'d, along with a sea ion on orphan
1i.1gnos1ic aids, and drugs in developmental
It~ 1cfcrcnccs include books and eleruonic drug
manon <0urces such as Micromedex and l.cxi
r~ /Jru,~ ln/onr1111ton llm1dbook. Manufaeturers also
1 ud, lnlorma11on on their websites concerning the
Jru ' 1h1') manufacture. Reliable medication websites
su h d \ Rx!'" McdlinePlus. and WebMD rapidly provide
in'orm.1uon for the Internet user.
l'h.umaci<t\ .ire another professional source of
inlurm.11ion 'l11cy keep current on medica1ions a nd
have .lClC" 10 the patk.1ge inserts found on each medica-
tion houlc. With each prescrip1ion, pharmacists giw
CHAPTER 3 Drug Information and Drug Forms 41
patients drug information sheets abou1 their prescrip-
Lions (ligure 3-2).
Allied health professionals should make drug canh
for medications used at their employment selling II is
vital that anyone giving medicaiions be knowledgeable
abou1 any drugs being adm111istered. Trade .ind generic
names. as well as usual dosage. should be onduded,
along with side effects and adverse re.iction; rhese drug
cards should be readily available for answering que>tions
before ,1dministration of medications. New drug cards
sho uld be prepared as new medica1ions arc introduced
for clinical use.
Drug handbooks and textbook.< with information on
medications are available al different levels of detail.
Because information in books may not be completely
current, journal articles and news releases. as well as the
Internet should be read to update the information. Some
material tha1 passes for information on Internet sites is
not accurate: therefore health profe-sionals should be
selective in sites they review. Cood sites arc those associ-
ated with medical. nursing. and pharmacy schools. as
well as the FDA, National lns1i1u1e~ of I lea Ith, American
I lean Associa1ion, and sim ilar associations. m.1king spe-
ciali1.l'd and accurate information from m,1nufacturers
and government agencies only a dick away.
Knowi ng all 1here is to know about drugs on the
market is impossible. but the health care professional
must know how and where to ob1,1in 1hc necessary infor-
mation lo e nsure patient safety and compli ance with
medications.
Drug references inclucfng thig package insens. the Uruted
States Pharmacopoeia-NatlOfJa/ Formulal)l(USP-NF). the Fflys1-
ctans Desk f/efereoce (POR). drug handbooks. and drug cards
are important to ensure proper adm1nosua11on of med1ca11ons
and safety in drug usage. The allied health professional should
be knowledgeable about all medications 10 be administered
DRUG FORMS AND DRUG
DELIVERY SYSTEMS
Orugs come in many dosage forms that differ in their
rate of action, site of aetion, and amount of medication
delivered a1 the site of action. Dosage forms may be
solid, semisolid, liquid, or gas. 111c route of delivery
innuences erficiency and aaion of the drug Inc drug
1r1<1y be given orally (enterally), or through the Cl 1rac1;
paremcrally, or through routes outside tlw en teral route
(although this route is usually considered lo be by
 ........._......................
-
42 SECTION I Gener! Aspects of Pharmacology

---
.................. _........-:--..:::,..-
'"..................
_,.
~--
~-----~
....... ....__ .....
.. ------_
-------~---
.... -------...
....
.---..:.:-----
::::::..-------- .....:..----- ---~...-..-----
.----=:...--.::.:.-::.:::..-::...-:
_.,...-=----
~ -....-.

--
.........
,,_.--
___--
....... _ .........____
.....___.___._
.,._.,__..._.~
___ ,....
,,........ -
___
_____
..... ,,.,..-. .
----
-.....-::;: .............
__ ....
...._...
.
.............
.........
--=. .... ---------
___-:-..-.----_.....---
_ -......---"'
.........
________
,:..
-----........,... __... .
...-------.... ----- --~

--
.....
__ ,.._-.:.: -------------- . . .-:.--:: -:,,....-- :.-.......-.=::.:-..:.:::---=-:-.:::::
----- ....._--------- ... ---=--------. .. .__
-=--=-~

....... --- ....... - .......

........ -----.._
.........
,. . -------
....... _ ... ___
-------
--
-------.
,. ._...._
:-=...- - .... ----.....- ::::--_-..-
--------
-------.------- ----- .....-- .---i:__ . . ----=--=------------.
=:-:---.:.::::;..:=..::.: t--
--:-..::. _........,._
... ..--.---
.......
=~

--- ... .. - - :. ..............

...-::.:.
------
-- -....
- - . . ---
........
~"'._.

-- ------=--..........
=---=--:..-:..-=.-:=~:..::
. . -- - =---. =-------.
-- -.~: :=-..:.::-..
. . -
.....
-------------
-- ----~--
_________
~-------
_________
------------
-----------~
......
..... ........
....... ___
__
_ __
---
---==--,..._.,.-
:.=.t.9~-----~
-------:--
-----
----
. _,_ ................ ............. .. ,.,...............--- - ..:'.::
.........
------------ -- .,

---
: ..
.....,..-~-

-
.-
----=~,.=~~
....
......
........--
. .----.
-------- ..........
----------
. -- .....
IQ . . .

----------
------------
-----
___
..._______ _ .,...
----- - . . _.
....... . . .
-------~..........
. .=------. . . . ....... __
----- _____ --- ..-
............
-
~

__ -- ---------
- . . . . ft . . . .. . , , _ . . . . . . .. .

---------- .. ____
------ _ ::-_:-:.=:':...-~~-=
=-----"'":.i::::-------
..
___ _.,,,.._..
............ - . ____ ...... ..... ...
.,_,,,,,,
.., _..._____
~---------------
___ ...... .,..

_ ........- ...........
..._ .._ ::-::--=~..:== "':~.:

_
__..
----------
..------.-...-.-..------
-
------------ --------
.. ~-
.. ___
:..-:---:.........- "i::::,:.:
-------
.. --_.-"'::!' ...""-. .. . ... =- ............-__.....
------------ _.._.__
.::..-=..-::..-::.......:;::: --....
.-___
.-.:... . .............
..,. _....
_
'P'4 ........

-...-- _._.._... .........

------
--=~----- :::::..-:::::===-~ =:==-.-..--- ......
. . . . -llM---,...__.. - . .
" .-__......
:-....:.:.T--""'""'.....,..,._..,_
,_ ........ .....-
................. - ...,
::.:.:.:
-==

........ ..... ---

....
------
_.................
..... ......--
.......---
............. ----"
--
.. -
............. -
.....
-- -
"""'
0

0

H

-- .... :::-..:.-:.=--~-------
---__......-
...............
,,..,..,._
, _____ .,..... . . . .. . - i ~---

-
,. _..,.._.
~
.-. -..
___
..... ..........
..............
......... ------.-
.....- .....- ... -
.................. .......
---- - ................. ....... ...
.....,t.h#llll , .......... --- -
::=...--..:::"====:=~ :.:~:: __.. ,,,,,_.,, ,__
"" ,,,. ~
-- ...
=
..... ........__ .- --
_ .==-=-.:c.~=-==.:t
~ .............
..... .. ,_ _ ....1.: ,....- .... ,,_...~1............ - .. _ ............ i.... _ _ . . . . . ..., ........ . . . .
_... --'r.w.----..-- _...,....., -......-
=:;:::=:"-':::;-:."'~==
- - ........--.......
__ ........
____ ......_
........... l lil . _---.....-
......... ...- - -
-
=~.:.:::.-..-:.=.:..-:;::""

---------- __..____ ___ -.------

:-..:.====~-=-...::==-=-'=
____ ________
.. ....m::::.=:.-..:.=:
.."'::. .....
_ ...
:.:-.:;::::.-:.:.::.~:.:::.="..:.::
--,..-..---
_ _ _ _ _ _ _ _ _ c--1 ........... . .

..............
~ .................
.........~--
....--.-..
...........
........................
_.. __
.......... _-
........... ..... --
.. -
-
c:::.:.::::
.._ .__.._...
.._____
.:...-
...-.--- -----.-.i;.-11-----lt-
.... _
-----.....,- ------ ..- -.--
-
-
-------
-..-.-- - ..
,... .........
-
-,..._
===-~-=-.":'1.:-=-=
_._...IJ _ _ _ - -
__ - .
- -
..........----- ..-- --
- - - -.. - - t l \ J . t a -...... - .

-----
----------.,...._
__
--....---~----
._______._
._ ... _.,.
-------------
--------------
........... ---- ---
..._ ----
...
--- __ ..
___ ________
.,..._ _ _ _ _ i...._ .... .....,.-

................
----...---.--- ...,. __ ____ .... ------.
-'91'
__
_____
1 -...............
-.- ...................
---.
..
--.-.-------
--------
.._
..._...__......-- .- __ ... _ -- ___
--...--------
.....
.....___
------- ...__... .......__ --- ---...
--......-- ...... ...__.....
..........
-
_
_..
.,..._._...,....
--
-------
---------- ....------ ---_--
....-------
._
"_,. .,.
__
------
---- . ___ - .. _ -
....
-- ------
--------- ____
-.----- - ____ --- .... 11.------------ .............
.......... ---
....,._. ---------..-..-.-
__ ----- '"------..-.
-------
.....----------
.,...
---------------
___
------------
._
.....
,,

__ _
----....--------
---
----------
____
----
__________ .
-------------
-.-.----------..___ _____ _ ---
---------...,
_____
=-----------
---____
____
.._
.. .. ____... ___
_____
_ ..._
__
,.__
__
_
__ _ -__
....--
__
....... ___ ----
._,_.
____ .......
..... _ _ -
..., _,... .,,.
______ _ ----
________ __ _
'--

-----.-----
-----------
....
------
_..,...
..,...

-
.._,_
==:-=-.:.-=..:.-;.==:=':.... ---------
.....
..
_..,._.
_.,. -
--
------------
-------
-----------
__________
==-===:::-..:.:=.:....-:.:::.
....... ----.
.....--- ......
_ - ---..-.-----
- ..--- --
=.:.::-=
--
_,_
-----...--~--

______
=-~:.:=--==-
----
---------
-------- .. -------
.......----.----------
--..
...,_
-----..... -
..____
....--
..... _
- .. --
--------
ci..----
-
---
f'umon<I. New YOl1c I
--.~----

Figure 3-1 TV(l....it drug lnllOrt stv.w>ga warning bot See Table3 1as a uide for
g
. --
---- -
1111e<plt!Jllg the 1nse~. IRepnn1ed with pc1m1ss1on ul I 1 11>01 a1011es.
 CHAPTER 3 Orug Information and Orug Forms "3
---

TABLE 3-1 READI NG A PACKAGE INSERT

Drug lorm Tablet, syrup, elixir, etc.

Drug trado name followed by Manufacturer's registered name for drug
{cap1tali1ed first letter)
Drug gonenc name {IDWercase first letter USP-NF official name
and rn parentheses)
ChemJCal descoptlon and SllUCtural formula lndJCates chemical compound of drug
ClrnJC8f pharmacology Purpose of the drug and expected effec1S on the body
Ind cations and usage Therapeutic acuons of the drug. conditions or disease processes for drug use
Conua1od1cauoos Conditions in which drug should not Ile used
Warnings General risks when taking drug, include drug interactions, potenual toxic effec;ts, and
possible diseases or conditions that might be potentiatod
Black box indicates possible lilelhreatening interactions or eflects
Procaut1ons Reasons to ad1ust dosage or to discontinue use of drug, and pregnancy category
Adve<se reactions Compilauon of possible reactions to the drug
D abuse and dependence Information present only IOI drugs with potential IOI abuse dependence '
DEA scheduled cltug. 1f no c.
not scheduled
rdosa;Je Effects and treatment of overdosage
0 yo and administration UStJal dosage and route of adm1msuat1on
H N supplred Dosage of drug; desc11pt1on of rls lorms and how lhey are supplied. wilh NOC number
lor each supply source; how to store, also shows marking on drug for identification
u111pany Name, address, and logo of the drug manufacturer

_
of f>3tkage insert Information on when insen was wntten or last revised
l torwment Adm1111stratroo; NOC. Natrona! Drug Classrficatroo; USP-NF. UniuJd Srates PhannacopotM-Natiooal Fomwlary

... ....
Rx"9f=aq.'
c::::
"'''.- --- 1!TI" tL TAIUT MiS
----
nJOO<
_ ,.
f W I Ullll I YMWTlt fYUl'f' GA Y
tflll is WMITt OlllM- . . . fAaO ......4wllll 414 . . . llMI.
UlTIMllf GMlWt-Zll..._..
COWMtff lMMlt~ Z.111
RI Tilil ......_ilusd.....,. . . . . . . . . ..... ~~ ....... -....."\ . . . .1._dth I' t M

...
.... C'hlln. .... ........... ,....,.,.. . . . ,..,.. ........ ..., :l... ~""' ., ........ - .. ~---- .... ....

................................. ......._....____ ..
td_.,._........... ..,.,Wt.
................... . . ....
---.---
_,..... ......_._.. .... ......_T ......._.,_....., .........................
. . flnl:. . . .. . , . . . . . . . . l11111M ...........................................

......_ --....
_...._

-(ffKJS:
.............
.............................
. . . . . . . - .2 ......... i.. ..... ... .......
._ ~
. ........ 1 ........... ..

cm... ....... ...._. ..... ..,tuS . ....... ~ ......... ...,, .............................. ...
. . . ........... . . _ . . _ ....................... ...... . . . . . _ . . . . . . . . . . . . . . . ._ . . fllldt.
~ .

r11 ,_..,...._llf _,.,... _._.""'-11tuw:drnl,_ ....... __.,_ n.t ...

. . .......... ..... ,....... ..... ....-.................... ....-....
..... r11 ,.,.._.
U111..., ,..,..~_..
.......... Jtll ..................... ,.... . . ZZ/ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ....... .........
...,~
tltcu"'"""""~ ...,.._,
~ti'&- ~

i.cAUTlOIS; t.r.r t*'l P . . . HI .,.. '9t1

dM. . d,_..,._.,.. .. _._..._.._..__. """'*"'
jf.,_. n *'" .. it. it,_ llfft _, ......... Tia....._ lilliM .. '11 llN'll .....
... c..it,_ile ......il.,_i.rt:Millf..._............llil
-*""- 111 tw dH:'l .,.._111.,._,..... litl9rf. ...... et.hw ...M.,_.,Mta ....... Oil-*_ _.. .. _....,..._dalltt.....,
......""""'. ~ llltlillsMl-.hta .... ....... ltii.,..,,. ..... ......... lilltllt-1 . .c.... ....................
_,.IWTlMCTIHS; ,..,,...,.,..._.._,..._....... ..,.,...._ -..-.111111 _,_. '11 .......,..,_._ ........ lier\ . . .._... ltm
................... dwe'. . . . . . . . lnl ................................ .i ....~ ...... b I ~ .. ... ..,.

- ~11; ~ ........... . . . . . . t . . . . . . . . .tltl.. ...... .......

MIDlll: ...._

..,...._.,...,w.-..C*Cll c..-.-.-.-..,....... ........ c.uit. us .............
1 ca.m1m. c......~...,._,._.....,,...c.-.. _ .....,.

lrfU; . . . ..... ...............l*-Y. . . . . ....... _.....-...... ................... ..... ,.,......

-*-lllllllllltlt..................
- ............ - . - ........... . . .............. _
mst9llSI: , ,.._, ___ _ ___ , ........ . .
..'"- ~---
....
. . . tftldl. r-...,.. ..... _ .............. ..
... ....,. . . . . . . . . . . . . . .. . _................. ..
...... . . . an ..
1T1Ma; ,..._....,....n....,as.... Q -.. ~ ...,_...__.,_,n...,..Q....._.... ...
.......
~-------
.,..,_., ....... ..... 1011
~2'JIPfitll0.I...... ...
.... ,..,.,,.,,,...
............ .... ..._ ................ ..... ......, ....................................... c:...a ............. ....
.

Figure 3-2 Drug 1nfo1ma1ron sheet.


Oral Medication~--------.:
I~ oral ''" . 1n n II MIOllon b uk<R t'!' mo;::~
and -llowtJ b tM umpk>I "~ Ill JJn11m.icr m3 d
canon h I\ wu.ilh llK>ff conwurnt "'""""'"J\ 4:"
"
t.th r d..in oth<r n.u1n f\ Jnig u~rn h1 mouth '' IU 1 1
It> a.1lon> ol IM C.l uJCI JoJ mY bo. Jlrrrtt<I by :
"""' In l'<"rtt.ilili. g.i>1r1< '"'"11011 JnJ v1h<r C.I .nc
'""'~ \omlllng anJ Jmh<A m.1l Jlll'I ml.Jicauon 10
ll\a L&billl) tor ;ibturpuon .lnJ mV '"'" bt reason
ll>'DlJ IM oul admmmr.auon 111<" Jis.t.h-aoigt ot lhr
or.al route 1t 1!u1 drop adm1nlut1rJ oully Jrt Jbto~
tlowh anJ &1 an unr<tdl<ubk r.it bcou.t o( p.tum
10-r.aunu Jtff<rm< o In gntrK fun<tion '.><>n>r drup.
au< II &1 mwhn. air .ks\r01td b) Jig.'\IM OuiJs Jnd
mu>1 oc admm1>tttt'd I>) DIM roult>
l lrI Jn11t lomu mduJr whJi. hquiJ l"""ck"' and
.~1111 m1wrllint"OUS form 1111 "'"" ~,Nti .and l""lt
h-" r.11.ac:td 1hr term roll a 11 rm dtJI hould not be
u ....-.t 11><!1
Solid Oral Preparations
I.ahlc-h arr Jm-d powJ<r fonn nl 1m.Jic.1tion 1ha1hJV<?
l><~n rnmpr"'~ into " rtMll 1hk 1>1 whd m,u,< avail-
.thll" 1n mny hpe< color< .and """ ( [Jblt 3-2) In
aJJ111on 10 JC\1\1' intvrd<lll< whlrlS con1a1n onacti~
1ngml1rn1S w.h ;u bondrn (adhnlv.'> 10 hold the sub-
.i1n<n l~<ther) d.-ont<grJI<>" (.ub>uncr> 1hJ1 mcour
ag Jwolving on !he body) lubnc.anl\ (10 gJ'f !he tablet
\hn-n tor ~ on "'llow1n11 .and 10 ;&ISi wnh the
mnul 1unni procn>). nJ &lkr> (mm mgrt'dirnis
1hJ1 ma~e the ubltt conwnocnl we) \omt orJI medi
cauons un be mu.td -..11h food tor more acceptable
1a,1.-, ~>mt must be IJ~rn wnh f<>t><l whtrtas 01hers
mu~t I><' !JI.en on an empty '10m.ith (lk1x l 1)
CJJl\ule<i arr l\\'t> pieced cylindric gelatin con1ainers
1h.11 ht 1ogcther llus form 1s .1 conwn1cn1 way for giving
11mh<J1ton\ "1th .1n unplca.am odor m tas1c. Capsules
usuJlly conwn powder. granuln. or .1 comblnallon of
1he '""and may ha'" one or more JCll\'C ingrt<l1en1s. In
'""" c~ capsules aoo comam .1n men Idler subs1ancr
.and Jo not nttd fla,'Onngs becauM: the medication os
end~
kt] CLINICAL TIP
E~b~tap5Ules.~lni'fbeJUledapan
and Ille tl1Ue IXllll!nU ldlled IS powdel lO loods for pal 1erns ..+to
have dill1c11!1y sv.altv.t.""9. 11 pemiisslbie Nm-.. mi medoc:atlDr\S
in ~ 1ervong5 of food bicaUll lhe penon may nol ea1 all of
tt>e food
dl$SOIVe tn mou1h and discolor teelh s!Qild
I lil1JS tlJal may
nol ben!;''.::!lysJlOOld 001 be given 10 someone w!I() IS
2. t)a !()US. V(ll!lit ng or unable to swallow
.,.:orisc ared iablets should be swallowoo whole, 001
l ::i~r chewed. because the desired place of absorption
is in me intesunes.
Sustained-release 1ablets sllould not bed crushed because
4 crushuig changes the absorpuon rate an may resuh m an
"erdose
Pa ts should not swallow Of chew buccal or subli~ual
5 : nor sh"-ild these tabteis be taken with war because
:ater ~Id disso!ve table! 100 rapidly and prevenr desired
alWJ!lOI rate
a.al dissalv'll9 tablets should be allowed to d in lhe
6
l!llllidl a00 ~ not be swallowed whole l\Aouth must
,_ SLfitient moisture 10 alta.v tablet to d s
1 Timed<eieaSe products should newr be opcne
be swa lowed whole to maintam manufactur expected
rate ol absorption and pre\'ent an owrdose. or ng capsule
will atlef absorplon rate ond could result 1n a rdose of
the med1cat1on
Troches or lounges are hard medical 1m in a candy
or fruit base designed to dissolve in the m< h for local
effea. E.amples of lozenges are cough d " used for
relief of a sore throat.
Liquid Oral Preparations
Liquid oral preparations consis1 of one 0 1 >re actn't
ingmliems placed in a liquid medium M< rJI liquids
art divickd into two major -.uegories- ions and
dispersions- allhough some are oils or 1binations
with other fonns. ~uch as gck~ps, a " between
u psule and liquid medira1ions. Solu1ion re medica
tioos in which the active ingredient ha~ h1 " dissolved
in a liquid vehicle. In dtsperi.lons, 1hc 111rd1 uion is nol
dissolved in a liquid bul instead is dis1rih1t"'d as pani
des throughout 1he liquid. The mos1 con' 1011 type of
dispersion is a suspension ( r.1hlc 3-'\ and x 3-2).
Miscellaneous Oral Medications
MiscdLineous oral produru include p 0 ,., .tnd gran
ales comaining finely ground Jrug pam Granule$
art laig\'f and of irregular shape.. m.1ktn t'm beuer
sunedlhJn powders for use in solution~ h<, ,c powders
tend to Roat on the surface of .1 liquid t..~i..1 granules.
such as Metamudl, art used 10 relie.c ~stipatioo.
Effl!n'elttnl po-..der& are coarsely ground ~cnls "; th
an elfeivesceni Mlt 1ha1 releases c.1rbon ti 01xide for a
bubbling action when mixed with liquid I ,,unples are
analgesics, sudt as llC Powder and Alka-Selv~r.
I
 CHAPTER 3 Drug Information and Drug Forms 45

TABLE 3-2 SOLID ORAL PREPARATIONS

TABLETS
Ur-tored tab t Tablets 111tEnded to be sv.allowed wtiole aspom
Scored tablet TablelS that allow fClf par11al dosel by breaking furosemide (lasixl
tablet on scoong lme(sl
Enteric-co.u..d tabl<I Tablets with special coating so drug dissolves emenc-coated aspinn (Ecotnnl
mmtesnnes rather than stomach
Coated tablet Tablet coated with sugar for taste enhancement el)'thromycin 300 mg (EES-3001
or with film-coating for ease or swallowing
Chewable tablets Medications 1n a flavored or sugar base antacids (Tums). chewable v11amins
designed to be chewed
Sublingual tahh I Table!$ designed to dissolve under the tongue 111lloglyce11n
IOI short-term ralease ol medicatlOll
Tableis placed bet\\~ cheek and gum 10 fentanyt (fi!ntoral fClf pain
dissolve and be absotbed tlvough buccal
membrane lor short-temi release ol
medication
Tablets with antacids added 10 active aspinn (BuffennJ
ingred1011ts to prevent untat1on or stomach
and gas1ro1ntes11nal tract
I 1rd rchase Tablets manulactu1ed with a mamx that lorata<line-pseutdoephedrine
trolli-d rdc) 1eleases medication over a period of time. (ClaritinO 12 Hour)
I Is may allow ingredients to be found in layers
or a wax matrix to be released at diffe1ent
times; allows 1ncompat1ble active ingredients
to be given in one medication for release m
stages
Tablets shaped as capsule fOI ease of acetamioophen (Tyfenoll
swa lowing
~t4blet$ Tablets designed to dissolve in mouth desloratad ne (Clannexl soluble tablets

CAPSULES
Gelatinous containers that hold powdered amoxicillin (Amoxil)
medications
nf'd rcll"tl!t~ Medications Wllhm a capsule delivered over a venlafaxine (Effexor XRI
ulc~ specified period of time
d rd<.1sc c.ipulc Capsules prepared to release d1ugs at a theophy Iline (Theo-2 41
particula1 site. some of these medications
contain beads designed 101release at
different times or at a panicular site to meet
metabelism of the body, these capsules
provide a steady flow of med1cat1ons ove1 a
penod of lime

GlJMS
Gtrns ate usually polysaccharides that produce mconne (Nicorette)
thick substances and are sbcky when wet
and hard when di)'. at11act1ng and holding
water for formation of gelaun-like agent$
 I

SECTION I Generol Aspett~so~f!P~ha~rm~a~c~ol~og~y=:___ _ _ _....J9"!'"""--~--

docusate sodium (Colace)

gua1feneSJn iRobitussinJ
SOLUTIONS Scill.OIS sy,t?etened wr:I> sugar or sugar
lltl$:. :f ID disguise~ iaste. a>a'i
also cor.:.wi P.a'/O'PJS. color. ard aromanc
ager.:s
s-1ened. 11.r-iored medicallOllS (Olll31fllfl9
llbln (alail1ol and w:itetl alaJhol ard y.all!f to omprove solubility;
11 soluuon 1s mainly wa:llf. sweetener is
natuial sugar; 1f solut11111s mainly alcohol,
s;veetener is aru ficial
vanilla extract. pepperm t extract
Hghly concentrated preparauons that move
f.111tts lllllJ ftuid ! r11atlS IWJWI 0.-
des11ed matenats into a solution and thell
alcohol, or bothl
evaporate to leave a sy1up. mass. solid,
ointment-like substance. or dry powdef;
fluid eJ11tacts are lrom plant sources
used msy1ups; l!Jltracts are used in
compounding medications
camphorated tincture o 1um
llnmm (alcohol or Pote11t medications or fXire chemicalsor
(Paregoric)
hjdroalcoholsl extracts from plants
Soluuon containing volatile aromatic sp111ts of ammonia. pt 111 nt spint
'pint> (alcohol DI hydroalcoholsl
1ngred1e11ts that may be diluted wim water
before admm-stra11on; aromauc spirits
coma1lllng oils and other subsiances are
easily released into the air to prowle a
pleasant smell atXI are therefore used 1n
vaponzers illld humidifiers

Oil
l mineral od

DISPERSION
lhl ssolved Pil1ides of med!caoon mill!d amoi icolhn suspenz1on Xll Oral
w th. bit not d1~ 11, a solvent rrosi Su3pension)
die $USpel1SllllS teqlJlflllJ recoostJrutllln
usmg pm6ed or disnlled ,va!l!f
I mul\lon Watef"~ llllXture '"wlud1 ooe hqu d is Fat emulsion used tn 1 enteral
d soersed 1n another. liquids do not mx nu1nt1on whole mo k ti cream.
readily
011 mvoncqar
1;.,1 A semisolid 1elly-l1ke product containing large Oraiel
amount of water; thick viscous liquid mat
easily penetrates without a residue
Viscous _susPe1l51ons of medicabons
milk of magnesia. aluin m
~~:~101n9 ultrafine particles blended in hydroxide (Aludroxl
 - - - -CHAPTER
- 3 Drug lnforma11on and Drug Forms 47

The patient's mouth needs to be moist for the patient to be

able to swallow a gelcap, the gelcap will adhere to the dry
mucous membranes of the mouth. Figure 3-3 Paper for measunng transdermal niuogtvcerin oinimem.
2 If syrups are added to 1u1ce or milk, the person must drink
the entire amount to receive the total dose. Be careful in
using milk, because the mediGallon may change fl<Mlf or Con1I01 memb<ane
m k and a dlild might refuse to dnnk milk. Milk may also
change a property of the dtug r---<-..., - '"'~.o;::;!:=:::j,
(top view) 8jllllicatJon (side - >
J Because Gf the high sugar content ol ehx11s, care should be
wken when used with people having diabetes. Because ol A "-- -- - -- - - - - ' B
tho alcohol content, persons who are alcoliol dependent
hould not take these med1ca11ons, especially patients
LJ~1ng d1sulfiram !Atttabusel. c\ Behind ear tor
4 Elim~ may have to be diluted for children. The medication soopolamloo patch
ould be diluted one dose at a time to prevent actJVe
!lnts from precipitating out 1f water is added to the
bottle
:r.iihorated opoum texture should always be diluted
admmstrat1on
AJSJJ.,,..,on should always be shaken befClfe administra-
a suspension 1s not shaken. the active ingredient will Bunocks tor
tu t~e bottom or container and will not be adminis est1ogen 0<
nicotine
orrectly. patches
suspension has been reconstituted. 1t has a short
,
re (usually 7 to 14 days) at room temperature. Some
be under refrigeration for a 14-day shelf hie, such as Thighs tor
n The drug label will specify mstructJons. estrogen
palehes
a residue is expected on the spoon, medicme cup,
means used to administer a suspension. the con- 0
or administration shoold be cleaned between doses Figure 3-4 T~ awhcatJOnS of medicauoos. A, Side vtew of a
e proper dose with each administration. uansdermal patch. 8, Transdermal parch C, Transdermat spot D, S11es for
iuls1ons may be diluted with water immediately uansdermat medical applications and !he medi<:at1ons rypical for each sire
administration Shaking well ensuros mixing or medi
t i s 1ust before dispensing
quid iron preparations for children are given by
r or straw to prevent staining or teeth. Transdermal patches were used by asuonauts on !he space
shuttle to prevent nausea Patches have found a growing mafiet
as treatment fCif conditions such as angina, smoking cessation,
dlronic pain. and estrogen replacement therapy and for allergy
tesung

neous Medicat ions

~
~~~~~~~~~~

I' "'nus o r topical mcdic~ tions ('lable 3-4 and !lox
' 1 those applied to the skin and mucous mem
b ur foe,}] elTea.."1any arc OTC drogs that are not
d wstemically, but some preparations are
~ 11110 the bloodstream from the topical applica-
..1refers to application of medications direaly
t< ' hodr surface. Tran,d~rmI refers to absorption
nl d 11-; through the skin usi ng a form of topical appli
r.111011 \Uch ,1s a patrh or spot impregnated with a med i-
llh111 (i'igurcs 3-3 to 34).
CLINICAL TIP
Eardrops should be warmed 10 body temperature to prevent
vertigo (diuiness) Holding the medication bottle in the hand for
a few minutes will do !his
When one preparations are applied. the head should be tilted
away from the affecled side to prevent drainage of the medica
t1on from the ear.
Shake ear medication ma suspension for 10 seconds to place
the active ingredient back into suspension.
 -
I
l sOllP water, or alcohol applied to
Unlm<'l111 Drugs c:tJ1tanllO '~ f~ rel e: of mUStular ac11es and
$1 ~ wptOJcl!
Suspension-Aveeno oatmeal
or sollJ!OI CXJ'lii~ par11Cles
( ollold UJlf'D>lon
&elu1lon
6:::=.
pal'IS
s well as water..otaule ether. or
bath. Solu11on-Compotn1
W and flexible collodioo
alcOhol and laav ng residue on skin nncture of 1od1ne
Alcohol-based l1qu1ds that evaporate to disinfect skm Hand lotions, calamine lotion
TlnCtures frftcv, ng liQIJids or susperded ingredients 1n water for 11ch1ng
l0Uon1
Bacuoban cre.1m (a tunfectNel
Semi<nlid ~a1JOllS tit watet base tnat are absorbed all! corticosteroid cream.
ll'llD ~ f:>r slow. susuiined !tug releaS8 So1aica1ne
Tnple an1tb1011c o rtment; ~
Semisohd greasy preparations in 011 base that are not preparations
Omlln<nh !see Figute
easily absolbed 1nto skm; prevent adhereoce ot
3 Jf
bandages to the skin
Toothpaste
SemasOOd pre;iarations that are stiffer tflan Ointments
becacS8 lle/ CO\lillll mcwe soltd matetials_ apply more
ll>idly
Anuseptic. anulu and
Sem solid ~at1011 w th l1IQh prop(JllOO of water wnh
Cicts coouacepttve g nd
a drug plus a th~ken1ng agent. used to reduce fnct1on
lubncants, topic mestlleucs
and provide lub11ca11on
Salicylic acid spot "' removal
Solid or semisolid medicated or urvnedicated
preparations that adhere by means of a backing of corns Of wart
Wa'.fll-111-0ii emcllSIOfl thdt dispetses as sirav and sl!Ms Vaginal prepar;it
V31Dllil\OI 111 If prodocts
I rnW<rmI plchr ClnJg-Olnlallll!IJl reserw1rs of mecica\JOn awl ed to ~l1n Nicotine patches C3rlYf
an.t .thk> lsee figure 3 ~f for absorption of mcd1ca1>on lhrough skin patches. estrog patches for
menopause and ntracepuon
SupPOS1tories (see Medication placed 111 a base of cocoa butter, Glycerin suppos1tn vaginal
flf)Uf8 3 61 hydrogenatl!d vegetable 011, or glycerinated gelatin to suppos11ories
form solid dare for rseruon mto a body orifice. some
' - local atllOll, others ha-le SystetllC actOI
Emt a line dlSIJl!l'SIOI' of '""ids. solids_ or ~ Oecongestlllts, r. sone
matenals (flonasel. nitro r n;
Nasat-solu1>ons designed for both local and systemic sunscreeos, hor nes to
effects malrohof or water PIJmptype dispenser treat postmcnor ,sal
Transhngual-used under the tongue symptoms
Top.cal-applied to sk n
liquid ma pr85Slllillld can that releases ~ mist or
coaBe lipd sp:av
fire mist ol ~ications that aia breal!1 acllvated and albuteiol MDI
del~'l!led into respiratory tract to ueat airway diseases
Ory p<J'Mle1 mtlale<s fine powder med1cabons that are breath activated and Advair 01skus
dehvered mw ~spuatory tract to tJeat airway diseases
Small micron zed powders. as well as liquids, that deliver albuterol (Xopenc. I valbuterol
medicatJonS lfllO a r~r for inhalatJon mto the (Ventohn)
te$pratory tract
Oiitt:nalmic or ore soh.tJQDS Sterile sautms or
SU$penSIOns for use 11 eye fsterilel ~thalmic-Ocusol Vasoeon A
and 1U$1l81\SIOOS and ear. 115Med using adropper
Douches Ot1c -to11tspo11n
Solutt00s or suspensions used in body onfices s h
vagina or rectum uc as Vaginal douche

: ' .
1. Liniments should not be used with heaung pads or external
heat because the patient may be burned by the
combination.
2. Drug molecules in transdermal patches and disks are present
for absorption over a period of time. The drug flow persists
over a looger lime and provides a more constant blood level
than the up-and-down level found wnh oral and parenteral
medications.
3. Some patellas consist of a backing, a drug reservoir, a p1otec
tive stnp, and an adhesive layer, whereas others have medi
catmns embedded within the adhesive layers. The drug
moves by osmosis through the patch's controlled membranes
to the skin for systemic absorption In some patches the
absorption rate is controlled by the size of the openings in
the membrane; in others, control comes from the skin itself.
Body temperature and climate affect absorption rates depend
mg on the size of the pores
t. :, tes of application for patches or disks should be rotated with
J h application to ensure proper absorption and to prevent
lamage to the skin and blood vessels over a period of time.
r. 1tches should be wrapped before disposal to prevent acci-
' 1t ii overdose by a child or pet that may come into contact
,,, <he discarded patch.
t oerson applying the patch should wear gloves or wash
immediately after application to avoid unintended
rption of medication from application contact.
nal. rectal. and urethral suppositories are made to melt
'l<lY temperature for medication release and come in a
ty of ~hapes. depending on the site of administration and
Jnd gender of patient (see figure 3-6).
P ~ral Medications
r.m 11 medications, o r those given by injection, are
't 1 I ,.,1u1 ions or s1erile powders for reconstitution
It "' l
preparations. These drugli, stored in vials,
or premeasured cartridges (Figure 3-5), are
in , ti gl.1ss o r plastic con1ainers holding drugs. If the
d11. ' m powder form, it must be mixed with a sterile
liq htfore administration. When drugs are unstable
Js I t 1ds. they are packaged in powder form 10 provide
a 1, ,. " 1df life. After reconstitulion, most powdered
nul .nmns have a li mited shelf life.
!IL qased Parenteral Medications
~lrril, normal (isotonic) saline, a water-based solutio n
of ,,,If in water with approximately the same concen1ra-
1io11 ,J> found in body tissue, is usually used to reconsti
1u1e or d du1e drugs for injection and to replace lost body
Ouid' when given IV. Sterile distilled water is used sirni
IMly to sa line but tends 10 be more irritating because it
is not isotonic with the body nuids. When powders are
CHAPTER3 Drug Information and Drug Forms 49
8. Because of the large number of blood vessels m the reetum,
supposito11es are often used m comatose patients or those
with nausea and vomiting Suppositories with a local rectal
effect are used to stimulate defecation or administration of
medications for effect in the rectum. Vaginal suppositories
are used as antiinfectants and contraceptives.
9. If a suppositOI'/ is wrapped, the patient should be educated
to remove the outer wrapper befO!e administration.
10. Handling of suppositories should be kept to a minimum to
prevent melting before insertion into the body orifice.
11. Suppositories may have to be stored in a refrigerator dunng
warm weather so the med1ca11on remains solid for rnsemon.
t 2. Inhalants are being increasingly used to treat systemic condi
tions. as well as for their local effects.
13. Placing pressure on the inner canthus of the eye, blocking
ducts and reducing drainage for a few minutes after instilling
eye drops can diminish systemic absorption of eye
preparations.
14. Ophthalmic preparations must remain sterile and should be
used by only one person. Ca1e should be taken not to touch
body surfaces with applicato(s np.
15. All ophthalmic preparation may be used in the ear in an
emergency situation. but an otic preparation may never be
used in the eye. The sterility of an ophthalmic preparation
may be necesSal'( if tubes have been inserted into the
ea rd ruin.
I6. Sports creams should be used only as recommended by
manufactu1er. Overuse may lead to severe toxic effects, even
death, as the active ingredient (salicylatesl may be systemi
e<illy absorbed.
figure 35 Typical contamers lor injectable medications. A. Ampule.
B. S1ngle-Oose vial Cand 0, Multidose vials.
reconstituted, a so lution or suspension will be formed.
If a suspension predpilates after reconslitution, before
adminisiralion tl1e medicaLion wi ll always need to be
placed back in suspension un1il no preci pitate is
obseived.
lit] CLIN CAL TIP

S!Jlll(' nunuf.lctuttJ injtcubk 111.'I"""""' )U<h .u

_, ~J prti In m d w.11er
mwlin (Oma! ol 1~11 UuuWO1' ' ' d
l>.>W' lh<Y "''f""ll""'" nttd to!...- romeJ in the hJ~
(no1 lhl.m) ""'"'' aJm1n1>Ull<>ll hi fll\UICtht rcd1s-
I
U1ethral
mt.. 1 on ol lhr p.micln
figure H Typical shapes of suppos1to11es
01/.81sed P1rent11r1/ Mldiutions
~"'Pttt.al mn!lations al"' com< m n <Ml base
.. .. h l'f<Mdn Olow rrka!o<' and prolong. l>tolJ'UOn
11111(' and duration ol allKl'1 ll<au><' o( th 011) nature
' IM lllC'dia!IOfl. lhnr drup IR lhl< .. or \'"OU' '"
IJ'l'(".IWIC nd arr gnTn by inuvnwrulr m!<(lJOn for
In> lm1.111on ol boJ) 1-. Oil ~.... are 11"--d for mJny
hormoll('3 1lut "'' Ulrd 1n rrrla<tmrnt tlwuM nd for
ur ttrnt-nt ot ct'1U1n <Jin<l""'\_

Other Forms of Medication

In1pln1' or i><llrh Jrr dm.11\" Imm 1h.1t .ire pl~ced ID,
or undtr 1h< <km by mem ol mioor \urgrry or 6Jl<!clal
!0111 ll<ln\ flll\ Jrug form I\ u;. J lor long term 0011
trollt-d r<ka<t' ol mrd1c.1uon\ <">P<~llv ll(lm\Onl'S Jnd
raJ1<>.1<tl\< IW!Ope< u\<'J In trl dtm<nt o( cancer.
lmpon .... drug 1mr1<WUt-J r.1<h J>Ad6. or plugs
mod<" e>I ce>uon or srong." th t ,u, '"<"It<..! into body
onfi<l-. for rdrst of mtJIGltK>n Oou<hr. art " ter-
lust.J \Oluuon> u'IC'J to 1mg.1tr All\ p>n o( th bod)'-
1op1C.ilh ouc.alh ophthalm1ull} mllJC.l\1Unl\-or to
rk.111.., <UrgJc.al wounJ. \\n' ''J!llnal Jouchn Are avail
hie tJ IC: Mlinlrd tnrnu m.11 Ii<- order<..! to .1dm111-
"lt'r mrd1Ciuon tllh<r lo..111) or through S)~tcmic
ll'w>rpuon l'he m11cauon 1s su,p.nd<-d m a soluuon
for Jdmm1>tra11on m the renum .1nJ is ohcn used with
p.1tu.:nt) tn \\horn oral co n ~u1nption i\ 1cMrictrd or ,.,.ho
(:.111110\ ~Wdllow. OH relenuon t1 1l~.'"''~ to w rt('n feces are
.mother lYJ'I' of mro1Ca1eJ en1n1.1 Sup1>o,horle~ are
u.-J m boJ) onhces for rdra'><' o( mtJ1cat1on from a
m.itn 6uch as cocOJ buuer or gl1-.crin that will melt at
l><iJ) 1,mp.-raturr (I 1gure l 6)
Packaging Medications
for Patient Compliance
'w>m< ml'd1<Uons U< p.iclugtd for us' """nd
compli-
ance wch 06 lh.- comp.lCl.S uk'd for 0"11 contr.ictp11i-.s.
lhe cont.11nrr is dn1gntJ to rrmmJ 1he ll$<f to Llle
m<'lliruon 06 prn.:nbtd \utomatit Jeh'<IY')>tcms Are
lL\t-J for JdmmlStL'flllll lllSUllO fot <J~ O( (0ffipliance
\ n c11mple 1> the 'iovolm-l'en by <;qu1bb-\Jova, which
delivers either regulnr insulin, Pl I in~uln nr the com.
bination No\'Olin 70/30. A canridge cont 1ing insulin
is placed into the lnulln IX'" a nd rem '" attached
until ii is empiy. and then it should bt nperly dis.
posed. Af1er the empty can rid!l<' is di<ofl< of. a 1)(1>'
caruidgt> is loaded and set 10 ma1nt.1in th "red dose
This meihod of adminbtrauon ha~ .1 n li.1nism for
preseiting tht dose of insulin 10 redun '"' in dost
and contamination, which b esptt1.tl lldpful (or
patieotS with visual problem~ o r anhrit" ~ure 3-7).
lmportii'nt' Facts
Drugs comein solids and liquidsand are adm tered 01Blly.
pall!ntera ly, and topically. depending on the I m
The rateof absorption ol mod1ca11ons vanes h drug fonn
and rome of adm1n1s1ra11on Solid mod1tat o ust be dlS-
SOIYed before abso!ption Liquid medocat1ons m parentei-
a t; are absOlbed fastei lnl\alauon and Ui!ll! ogual S!J31S
' - last ~m Toptea1 medications to ~ a
ltri;er ab!aption 1une but also a longer actlll me
T1J111C31medicah<JIS cao have svs1cnuc as wen as 1oo11
effecs. alnough most are applied IOf local ac:lllll
Some medicatlOOS are packaged fOf ease of compliance
llrugfonns used must be adJusted 10 a pa11el'l lifestyleard
physica oondmon
 ~~~~~~~~~~~~~~~~~~-
CHAPTER 3 Drug lnformahon end Drug Forms 51

cross-referencing abilities Drug cards provide health care

SUMMARY
Drug\ .ire clJs\ified in several complex ways In !his book
drugs arc group<"d by their effem on body s~1ems, and
i(on~ Mc us~d 10 indica1e 1he body system where the
drug h,1 ' i1s usual effect. 'lhe all ied health professional
<hould acquire general knowledge of drug clasifications
and 1he1r indications for use relauw to medic.al
di.1gno'<.,,
Drug 11~m..11d'"""' refers to various ways in which
Jru1:1 .ue n.1med rite chemical name describes the
chrn11c.1J, mvo lved in the drug producuon !'or the allied
lll'.lhh profe\~ional, the generic, or official, name and the
tr.Hk 11.mw ,ire the imponam name~ 10 know, especially
for nwdil.lllo ns u~ed in the e111 ploymen1 setting. When
.1 n.-w drug i> proposed to the FDA. 1he manufacturer
.u>1g11' II .1 trade name and has the right to sole produc-
11 "' oft"' d rug for 20 years after a pat em is filed There-
0 1lwr companies may manufacture the drug and
th =r 1h" gneric name or a trade name of their own
g for the same compound Other terms applied
1< J1 limn\ are <>tr-1he-countt'f and kgmd drugs, "'
w ' ~ , nttolltJ substances.
\\ 1111 '" 111.my medications used 1oday, vari ous drug
rrf r 111,' \Ulh as drug handhooks, are used by health
c"' " "k""' de1lcn<lingon their spccial1y, 10 diotinguish
t ' huw; and ensure accurate ~1d1ninisLration. '"The
,1 1ht official gm'Clllmem source used to ensure
11 drug meets FDA regula1ions Ille drug inseru
"uh all marketed products are an excellent
< ' f information on all a<J>IS of the drug. The
prm ,,)t.., .1 compilation of drug insens. with many
professionals with a quick refer~nce on medications
routinely adminis1ered in the hea lth care sening. The
knowledge of medications ensure; 1hat checks and bal-
ances are in place for accura1e drug adminis1ra1ion.
Medic.uions come in many form. Solid d rugs are
given orally in tablet, ca)l;ule. and powder form
Liquids may be in a water base or 1n other bases such
as alcohol and may be gi\en orally (enterally). by injec-
tion (paremerally), or topicall~ (JX>rcutaneously). The
health care professional should know drug forms and
how they affect administratto n 1echn1ques. Disease
cond111o ns. such as alcoholism or diabetes mellitus. are
important foc1ors in deciding the form o f medication to
uw. More often the form of medicauon administered
relies on the ability of the p.11icn1 10 1,1ke oral medica-
tions, ouch as with nausea and vomiting. or child ren
and older adults who require a liquid because of the
inability to swallow solid drugs When a severe illness
occurs. o ral medications may not be appropriate. and
mtra\'e nous medica1ions may be administered because
of 1he rap1d11y of medication absorptton Patiem com-
pliance may also be considered when a medication
need~ sustained periods of 11me for admmistration.
Su<1ained-release or transdcrmal patches may be used
when d.1ily adminisuation is nm de~ired or necesS<lry.
l'i11ally, topical preparations may be used when o nly
local effects are required.
llcforc ad ministering medica1ions or performing
patient education about prescribed medications, 1he
allied health professional should be aware that many
factors affect the choice of medication and should be
sure 1hat contraindications have bttn documented.

EXERCISES

Scenario
n1th, 75, has d1fficvlry swallowing an enteric-c:oated tablet. Wl11Je yov are taking Mrs Smith 's
OIY her davghter tells you that she has been crushing thJs tablet and nuxing 11 with her food The
htcr is ccncerned that her mother may not be receMng all the medicine, as the food now tastes
r r tfrom the med1cat/Ofll and she may not be eating all of 1t.
1 What is your response to Mrs. Smith's daughter7
Is 11 safe to crush an emeric-coa ted tablet? Explain your answer.

REVIEW QUESTIONS
I \\ 11u " the tmponance of the USP-NF? What does the abbrev1auon mean! - - - -- - - -- -- --
 lh.tn injecrables. \vhy are sublingual medications (
:z I :.plmi win' om IJl(dic.wom m ~ more ' "" ~ 1 1
as1ei

~mm .,...no-i on1 nwdiatl""'i

~~----------------~~--
3 \\lut to tht ad.ant~ ol m C'CUl>k m<Jtouons whtn rapid action is desired! What are the dani;ers of giving
Jn<'<l1t-,11on IYI mi<"Cuonl \\hY Jo drul!' ta~t longer to be absorbed after oral adminisira1ion? - - - --

4 Ii you wJntnl to fmJ .a mrJK.auon lor '""'I.Ing cessation. in what pan of the POR would you lool-.! A manufac.
tWT Addi""! tdm11tiatlon ol .a mtJic.auon brougJ1110 lht oflict but not found in the medical !(<Ord! A IIadt
IWtlr for .i (ltll('flC drug''lllf tclt-phon< number of the local Poison Conuol Center _ _ _ _ _ _ _ __

~ llhy .tr"'"' med1c.111mu mon often presaibcd 1han olher forms of medication! - - - - - -

7 \\hat ,. tht d1ffer<n<( Ix~"""" h<1uiJ> lh.lt are solutions and those that are suspens1ons1
. 11 are tht
imp1'"''"' ol t.ach for tht .all1nl hc.alth professional' What patient teaching is nffiled ~
"''""""'>n>! or com '"'!:" .,;th

R IVh.111sthe ba~ of a cream! l\n o1111mc11tl \\ hich would you su es . .

\\'ho<h would you "'Kl!fSI If )'lu w~1w' I d' . gg llo keep a dress mg from sti1 ko ur ' a wound!
' "" ' te me oca11on to be absorb-' .
"'11uo I skin?
11e
Understanding Drug Dosages
for Special Populations

Aft 1 s tudying this Ch8pter, you should be capable of doing the followmg:
ss ng variables that affect dosages of
cations.
, I ~g general patient educatoon about
i~ d nd1ca11ons and precautions for medication
1 t1fy ng popula tions 1n which special
tJ standing of med1cat1on adm1nistrat1on may be
ou, such as pregnant and lactating women,
patients. and children.
ldenttfy1ng medicatoon 1nd1ca11ons. dosages. and
special precautoons or contra1nd1cat1ons with older
pauents. children. and pregnant or lactating
women.
Prov1d1ng essential 1nformat1on about med1ca11ons
to promote patient compliance.

a 29-year-old patient, calls the gynecologic office m November thinkmg that she may be 6 weeks
.qnant for the firs t time. She has been waiting co have a child because of employment opportunities.
M ny says she has been taking herbal supplements and over-th~ounter !OTC! medications for
1aches during the past 4 months and wants to know if it will be safe ro continue. She states th8t
as read about the dangers of herbal supplements and pregnancy. Her ocher concern is that she
a erg c rhm111s d unng the sprmg. for wf11ch she takes OTC antihistamines. She wants to know what
1COt10ns she can take at that lime, and when the danger from medications dunng pregnancy is the
test
W dl answ er would be appropriate for the allied health professional to give regarding the taking of
herbal supplements?
W Y is 11 important for her to not take medications before seeing the physician if she thinks she might
pregnant?
v would n be safer tor Mary to take OTC medications for allergtc rhinitis 1n the spnng rather than
unng the early months of pregnancy?
Wh advice should the allied health professional give Mary about medications for headaches'

Body surface area Contraindication Polypharmacy Teretogen

IBSA) Dentition Precaution

53
 S! t General Aspects of P~r"'icofogy
. able for use and can be downloaded on 1hc 1ncernl'I
. L -i Ml' related a,,.,,J sp org. In order to mec1 till' go3 I of p
from '\~'"'- u .
.-ffnt> ot nwJic~U<ru on uot """ used .. -'ed consumer .onfonnauon
IO p.uientS, lh
ro..
" J1ug Jousn .rnJ follll> of mt<IKJUOOS viding n= . , t
. I Council on ra11en1 1n1orma11on ant 1t ducati
'o un<" method of dct,-nnanmR -.,-- elli J ~,.- ,,1 11 guar Nauona k bo on
"'"" uftti I><'<~ 1nJ"iJU.JI doff<n-oct> on drug
kl 1olern'> mu>t t>C coru1J.-rnl npUlly '"
1

:is .
pauents wi
.. ..-la"-cbsice. "'"~1.1al a um. ori:;.10 pr"'"d
has del'UOl"'u
'th acruraie mfonnauon.

v., '

JM\ \'.l11bln -u< h:.. gm.t.-.. ;ag. \\dghL h<1ghL ~
K'lo. nJ Jrk'-. aff<'tl llO" th< .,..uen1 r<Sp<>nds to
ml1<11on ~ "-rwnu. art n.imontd t>i more th.none
rhl'>Kln ch.ln<n-
of polrph.rm.t<' ind drug tntef'
;JC
11on1 on.IT'- lh<" '}'lcm ol clk-0.. nd b.tlaJl(t'S nnong
1lw r'"'1dan. rhnn1'1 .nJ lhnl hr.ilth profe:ssio""1
ht'Hmn morr omporu 1lor p. urnl s.tfny "btrtd05'1&"
I\ con<t"rncJ
In IJOlr.11) 19>7, th< LI~ fooJ nd Orugi\dmonima
uon (I llA) \\JI co11<t'fn<-J th1 lack of onfonnauon was
J1.11l.1hk Ill paumu COO(l'f0111j1 possible rt'acl.IOOS 10
P'"""flllnn mrd1tauon leaJong 10 ompropa use of
Jrug1 lh.- I n.'\ a1>propn.111ons boll r<tjuored the pharma
<<uur.11 mJumy 10 d~rlop plan 10 prO<'idr useful
rnn1umr rnt-.lorJU<ln onforma1ion 10 95'111 of people
'"'""'"II pr,..,.np110111 /I plan was de1"eloped for
11111.uy cornplranc< by health professionals to p<01ide
.1cmr.11t. unb1.:1>Cd, undcmandable. timely, and useful
mforon.111011 10 pa11enu h w,15 determined 1ba1 by
l'mpowmng p.11lems w11h 1he knowledge of how drug
work\, when I() t,1ke 11, why they are 1aking it, what
rc,uh' are eJCpt'Cll-<l, ond what 1he risks or side effecl.'I
m111h1 b<, p1{'Wnt.1ble drugrclated illnesses could be
th.ht1t.1lly rrdutcd (flox 4 I). In response. the United
Sl.lll'> Ph.11marnprial (',oowenuon <Op)'Tigh1ed 81 stan-
dard11<-J 1iicmsra111s 111 1997-graphic images showing
pallent1 htJw a m-J1ca1ion os intended 10 be taken. as
well a> any waining.\ or precautions the patienl should
know lltc ll S Phannacor<"i.1 Pictogram Library is
Today wrineo patient mstnue11ons arc 1)rov1<lcd by th
harm ..~th each prescription disp<'nMd ('>Ct ngw;'
~-l) ~ prin1ed ma1erials indu~t> common ~
for the mediation; when the med1ca11011 \hould '
should not be used; what to do i~ a do"' " mi'-'>Ctl; how
tore and dispense the med1ca1.1on tlnig nuinen
10 S ' .mteracuon\. \\.1rnin~. and'
dru -disease and drug-crug
~ible side effeas. :erbal insl";lc:'iOn'> \huuld be pro-
,;ded 10 the patienl m the ph)-i>tctan '> ofh , and hen
should be reinforced at the pham1.1cy \ ph.tronac~1
responsibility is to counsel pa1ie111s rcg,u, "I\ media.
uons to be taken.
or imponance to all ied health prof('"' 11i,11.. is lht
liability risk if a problem occurs with 1h1 medication
and if the information provided w,,.. dth1 r onwmplett
\'OI or inaccurate. Information provided to 1 "nl'> in lht
medical office when sample medica1ion' " il"tributed
is subject to ihe same requirements "' 11 hMmacisi
\\'ere dispensing the medication. l.1h. 1 " llo record
ket!ping. and providing wriuen info1 nut100 ' mcc1 FDA
requirements are required.
Cultural inOue.nces on how medicatitlll' 1.1kcn and
interactions of medicalions 1hat ar~ nm p1 rilwd, such
asover-1he<oun1er (OfC) herbal supplc111 'wilh prc-
scription drugs. influence 1he way 1hc 1).11 1.1kc~ and
responds to medications. Basiccuhur.1 l an1 11111" beliefs
may even interfere wi1h prescribed t.ll .11 ing the
patient in danger.1lte need 10 g.1in mform n <OOC't'm
ing patient compliance is a nect>Ssity tor , .... !>.lftty
with each medical encoumer

BOX 41 QUESTIONS TO ASSIST WITH MEDICATION

COMPLIANCE VARIABLES AFFECTING DR
' ". aedlcatJMCXJRl(ine pi!llelll.'lskUd~lhe
DOSAGE AND ACTIONS
IW'>\ers to the ld1owing ei;iht questlfJ\S'.
1 Wh.11 IS the medocatiOn I haw been prescnbed'I to:o two pmons rtSpond ex.mly ahke to il r who<h IS
1 Whal IS Ul!$ prescnptian lor? why there is no idedl drug, f\'en 1lw '"'" f'\4)0 ~

3 How~ should 1lal.e 1111$ medoca1.JOn1 0~ respond in the samt' way to the \,urn , of a drug
4 What side effects can I l!.ti)etl IMtile raUig 1fE given on different occasions M>\-er.11 t.t 1 1nnuen
medicine' responses 10 medicition {I ogure 4 l)
5 Do anv Sl*lill instnJcc.oris apoly io iat ng lhos

-
mctl!ClllJOll? Age
6 Are lhcfe any foods, olher prescrop~on mechcabons or
OTC d<ugs (oncloo ng herbals. v1tam ns. dnd natural ~od Safe dosages for infanL\ children, .lduh\. ,11 Ider ond1
umJ !hat I shoold not ia<e with 11t1s medication? viduals
. have been establ'1s11e
c d ,1or som tlrr1
1 h111 ,1ppro-
1 Is an equally effeu ,~ generic lorm of lhe medication pnateb dosage strength also depend~ 011 ,. l'<'l'SOll'I
dVa1tahle al a l0>w.r price? meta o~1ism Many
lished d'"11-1 d o not It.wt' d 'f'.<'' c~1ab
8 If f am laking teveral medications. should I be aware ol stud' d ordall age groups becau~e ch1 ld1 1 .ul' r.irely
any pott'llual t01t1a.;11ons1
onlyelatel
an bdiffering d osage~ '~r gcri.11111 1 .111<111 11a~
Y ecome an area of 1111crc1 f h1 "ry young
 CHAPTER 4 Understanding Drug Dosages for Special Popula~ons 55

PRESCRIBED DOSE

~ -.......
ADMINISTERED DOSE
FACTORS THAT MODIFY
PRESCRIBED MEDICATION DOSES
Pharmacok1net1CI Alrarll!g Factors
AOO<>rplioo MGd1calion Errors
Distribution Pat10n1 Compliance
Metabolism Medocatoon Cos1s
Excreoon
/nc1rvdJal Pa/Jerll Facrots

~Olflerenc:H
Pathologtcal '"""""*'
GenebC O.tterences
CONCEITTRATION AT Lifestylo Differences
RECEPTOR/ACTION SITES Envlronmental Factors
Phllnnacodynamics
Receplct/drug intaracllon$
Patlltlt's l\Jnctional Slate

DRUG RESPONSES
No two pabenrs respond ldenlleally
Need IO ..0,USI drug the<apy to the
llldMdual

Figure 4-1 facto1s lhat affect drug respons~s in the body.

Ill """ ~ensiuve to medications beause of imrna- for the patient's weight but also for the relationship
tur ,. org.rns. O lder adults are more sensitive tlt.111 of wcif\ht 10 height (see Chapter 9 for calculation
adnll' because of organ degener.uion o r methodology).
I \t'OSlllYUy

w t
\\11 1 r the per.on is Lhin, average: or obese will have
111: nn dn1g effects. What is wanted in drug therapy
1tain concentration of a drug that provides
d thcraJ'<'Utic effects. Adult doses are based on an
a ge dnd body weight (usu.lily 18 to 65 years of
1 " weight of .1pproximately 150 lb) . Therefore
11 t\' sc1'm to need adj us Imen 1 for patients who do
'I within normal weigh1 and age limils, IHtl
the therapeutic effects may be adequate, these
JJUstmcnt> may not be necessary. Heavier indi-
' m.t\ nc..>d higher doses. and those with little
h ;it m.1y need lower doses. for example, highly fat-
" ' ' 11 ' medic.11ion> Lhat act on the central nervou~
'' mi 'uch a>fc1111111yl, require larger initial doses for
ob c adults, but maintenance doses may be 1hc same
d ~ normal ,1dults. The dosage may be determined
or tht b;l!," of hod~ surface aru (RSA) rather than
j11,t hod> size for highly toxic medications such as
hrn1otherapcu1ic drugs. This method ,1ccounts no1 only
~ CA
Because lhe correc1drug dosage can vary on the basis of paoenl's
height and weight. lhe allied health professional in medical facili-
ties should accurately measure wt?1gh1 and height, especially of
children and the older adult. al each office vrsit
Diet
Effects of certain dru~ arc altered by diet. Diets that
promote health will help to dicit a thcrapeu1ic effect of
a med1ca11on, whereas poor nutrition will promote
adverse effects-for ex.1mple, a high-fat diet may slow
the metabolism o f some dn.1g,~. Starvation produces a
more intense response to medicinal therapy. llven foods
eaten in a therapeutic diet may affe(I the potency, avail-
ability, metabolism, absorption, and therapeutic effect
of the medications. See Chapter 2 for drug-food
interactions.
 56
SECT N t GenlfI Aspetti of Ptiit1111cology
Gender
Women may react more monRlY than men to some
mcdicauons because of thrir ~mallrr 11Le .1nd lugher
proporuon of bod> fa1 Ri>mcmb.:r ih.11 body fa1.can!:
.i rcsel'\'()lr for lipid soluble mtd1cauon~ 1lowmg
drug excreuon
Genetics
\hght d1fTrm>Ces m me bod>'s mt1.1bohc P~
calH! by genetic pr"'11spos111on mJl..t some people
more ..,nsiu'-e or resmani 10 ccnam mcJ1c.i11ons. and
phJrm,1cokineucs are affected
Diseases
Somr diseases, especially renal and hepatic disorde<5'
impair body functions. including merabolism and excre
11on of mcdicauons R1mal d1~a~ reduce excretion of
wmc drugs If dosage is 001 ad1u11ed 111 a person .,;th
renal msuffidency, toxic lewis ma)' be rtachcd """with
low doses of medication The same 1s trut of hepatic
t11seases bttause the liwr os lht major <>tgan for m&bo-
hsm of most drugs (5tt Chapter 2)
M ental Stat e
Ille patient with a pomive a1111udc 11 mof'l' likely to
respond positively and po1en11aic the effem of medica-
l ions. Ille patient who is depressed or delopondent may
not 1ake me~ica1ion and may no1rcs1>0nd 10 some drugs.
S11ong emouons such as anger, fear. jealousy, or extreme
worry wi 11 ha-e an effect on mci.1bolismand other ph)~i
olog1c processes A str0ng belief 1ha1 a drug will be
helpful may miluence results posui"dy; conversely,
pauents wiih nega1i~ feelings and m1strus1 may ha\-e
dtcrcased medicinal dferu
Hist ory of Previous Medications
long-term use of a drug un resuh in incre;tl(d effects
bttause of accumulauon of me drug or ahematively can
rt?<1ul1 in rcducro response because ihe md1vidual has
d~~lopebd adtole~:n~e. In e~ihcr case the dosage may
nc...-u to e a JUSku ior con1111uing elTcaivene"-5.
dministration
Timeof A . _
- should bt iaken al 1he ume ordered by the pby.
~~ Some drugs need 10 be takm on an ernrv.
sioan. h. whertas 01hers require '--
vvu m th e gas11oi"'
sto~acl
tesuna era
Cl Stimulants sho uld not be taken just ~~
h h _,
Body functions change wit t e lime of day alld
as the body adjusts 10 pen'ods.of wor k anv' rest. roop1t
sleep.
~. nighl and sleep m 1he day probably ....11
who wo 31 h . "'
take medications differently thdn 1 O>e wnh dayiini,
.-ork hours.
Route of Administration
1be nearer rhe drug is administered 10 ilw blood suppl)'
or mucous membranes, the fas1cr the dru~ 1> absortJcj
and distribuied (see T.lble 24)
Environment
Broiuse local wea1her condiuons a1Tec1 1lu ze of blOOd
vi:ssel5' wi1h heal causing dilauon ol ><>d Vl'S!ds
and cold causing mns1rin ion of ves~eh iron menial
1emperalUre inOuencc<> drug elTem.. /\1 I ..:h ahiiudt'.I
less oxygen is available, which alTen dru .limibuiion
in blood. For 1he pa1ien1 wilh resp1r.11m 1lisorders, a
smoking environmem m.1y be of im pori" "' 111 medica
tion effectiveness; the patient with cmrh em requir-
ing prolonged standing m.1y have the ne1 r increased
medications for al'lhri1is One of dw ~" <1 environ.
mental f.mors is economic pauene. II\ 1 1n l>O'~
of1en annot afford mcd1cJ11oru. Jnd ''" chOOS(
between med1u1ions nd food \ho. ' 1 " of thew
p;ltients do not r.u an adcqua1c diet for :;. medication
adminisuation
Drug Dependence
Ph~~ical or psycholog1c drug dcpt'111t. 1 " leads to
increased drug use. nie pati1n1 cOn\unw' ">re medka
tion to achieve the same cffrc1s, c.w,1111 "' increased
danger of overdosagc o r undt"rdosagc
Patient Compliance
I' .
auen1 compliance in 1ak111g mcdic.11 11111, prescribed
aff,..... _..
--~ m=1cauon re<ponse OoS<:~ m"'' I "tra dO!tS
taken result in variations 111 intended 1, , 1 <e Palltlll
coo.iierauon
. w1 th medical therapy " '"" bu1 sucli
~nables as mJnual dCJ11cnty, Vl\1on Hll I tual capJC
: men1.1I SUit. a1111ude IOw,ud mcd1<.l11n .ind soc
a ~~?rn" facto~ (such as ab1 l11y 10 p.11 t, .!rugs) pU)'
[ JO< role in compliance I oc.11ion "h 1h~r dose ID
: ar fro~ pharmacies .111d public lrJn'I" t.11ion-an
de ~ ~a1or fanor In compli.mcc for "'onomically
pnvec people. In ru ral Ml'a, tr.1ni>ort.1111111 1>roblem~
 CHAPTER 4 Understanding Drug Dosages for Special Populations
medical availability. and o ther socioecono mic issues can
be exaggerated by great travel distances for medical care;
J>allent compliance may be an important reason for the
>uccess or failure of medicinal care. Poor educational
background or inability to fol low directions can result
in 1ife-thrc.1tcn ing situat io ns from u nderdosage o r
overdosagc.
PRECAUTIONS AND
CONTRAINDICATIONS
TO MEDICATION USE IN
CERTAIN POPULATIONS
Any mcdi,,1llon prescribed has an undesired effect o n
,nmc person. No two 1>cople are alike is a familiar
'dv1ng but o ne especially true with medications; one
pcrwn m.l\ c'h1bit an intense response. whereas another
person c.d11b1t no respon!>e. Several (actors cause COO
tr 11 to use of medications in certain popula
t1011', such .1~ tetracycl ines in pregnant women because
1l 1t: r11 i.lic."1on is a teratogtn in the fcLu~. Manufactur
t"r 1 at< lru&' for contraindications and provide this
mfo Jt1< .. to the ~DA for publication lnfonnation
u ~u~ t:' h\t (ontraind1calions and precoautions-
'I'' c11ic w.uningi; tha t should be considered when
.ul1 1 is1o "'II drugs to patien~ with specific condit ions
,r I ICh as the use of cough synJJ> in the person
" th """"' hen with a possible warning. the medica
It 1 lJY '"" b<' prescribed if benefits of use outweigh
l'<W bk lurm .
1e 1.~rch is focusing on genetic differences that predis
10 dverse reac11ons and affect how metabolism
..pie are poor metallolizers of dnJgs from birth.
""'tabolize medications very raptdly Of course.
m~tabolize drugs at Ille rate expected
ion Use during Pregnancy
":tation
~~~~~~~~~~~~~~
11 c "e of ny medka1ion-prescrip1ion, O'lC. or
"na ual"(su<h as herbals)-during pregnwry or lacta
11011 c.uld ~.i rry a risk for c.1using binh defects to the
<In .-l1>11111g fctu> or a risk that the d rug will be 1ransferrcd
tu 1.hc b.ihy in breast milk. Such factors .ts drug route.
J >.tge, .ind phMmacokinclic activities detem1ine the
.1moum of drug that will circulate in the blood of the
mother and its po1.en1i.1I effect on the baby or fetus-
<ithn thrrapcuuc or harmfu l.
57
No drug can be consideted 101a1ty safe because problems may
arise later 1n life or 1n subseqlJent generattons This occurred
wim d1ethylst1/besrrol (DESJ. used in the 1930s through early
1960s to prevent miscamages. The drug was later linked to an
increased risk of cervical alld vaginal cancer on female offspring
of DES useis
111e ftrs1 trimester is when 1.he developing embryo a nd
fetus arc .11 greatest risk for fetal defects or abnormalities
if exposed 10 tera1ogens Medications should be avoided
at this stage if at all possible and certainly limited 10 only
those absolutely neces~ary and approved by the phy.i
ciao before u~e.
Using cocaine and o ther recreational drugs. drinki ng
alcohol, and smoking are causes for 1era1ogenic effects
today; many states ha\'C passed legislation concerning
these activities during pregnancy due 10 the resultant
effects fou nd at birth . flecause of its vasoconstrictive
effects, coca ine can cause 1.h e placenta to mal function
and lead to intrauterine death. Exces~hc alcohol use can
cause fetal alcohol srndrome. Smoldng can cause preg-
nancy complications, pre1erm delivery, or a low infant
birth weigh t in additio n to serious chronic health prob
lems for the baby. Certain drugs s uch as the 111ea1le1-
mu111pJ-n1bella (MMR) vacdne should not be given
during the first trimester of pregnancy because of pos-
sible 1eratogenidty caused by the live virus in the vaccine.
Even use of tl!tracycll11" (a n amibio tic) by a pregnant
woman may cause s ta ined teeth in her b.1by later.
As a precaution, in 1981 the FDA established a S)'lilem
for dassify111g drugs into one of five pregnancy categories
(Box 4 2) according 10 their potential for fetal ri<ks.
Because the law docs not require ma nufocturers to clas-
sify drug~ used before 1983, many drugs have not been
assigned an fDA pregnancy category. When making a
decision about drug U'>t' in pregnancy, the physician's
decision should be based on the least toxic drug related
to fetal gestational age at the time of the d rug's ad minis
tration, how lo ng the therapy will be necessary, and what
other medications are bei ng taken (Boxes 4-3 and 4-4 ).
Unlike medications 1h,11 cross the placenta 10 the
fetus, dn1g~ during lactation are not transferred directly
to the breast-feed ing infant because the mother me1.1bo
lizes dru&>, reducing the dose before passage to 1he
infant ( llox 4-5) . The ;imount of medication tra nsferred
to the baby is based on the age of the infant. as well .ts
how much and when breast milk was consumed in rela-
tion 10 the time of the d rug's admi nistratio n. A1 times
breast-feed ing may be 1emporarily interrupted for a
mother's medicinal therapy. lncrea~ed o r decreased
changes in the activity le-.-el of a nursing infant may
signal effects from drugs in the milk Mothers should be
made aware of s igns of potential problems.

Medication U1e in Children
( h1IJrrn arc nn1 mmwure adults. lbt1r ab1l11y 10 absorb.
meuholu and o.m I< mtdaooru is '"'I d1fferem
from 1ha1 of aJul1' rnulung m difftttncn m lhe medi
cauon amoun1 nn'<ltd 10 prodUtt enhcr a lherapnmc or
tom dlt..-1 An apprtl\'ed standard med1auon dO""&f
for ch1ld1<n I\ marly nonei<isien~ and drug> art ordfred
JccorJmg to body ..,.c1g)11 or BSA
Agt 1s no long~r considered a rellabl' guide for
a.dmrn1s1cnn11 mtdications to mfantsand lmJllchildren.
Mtd1Cauon U"-11< <upphtd to children should be rttal
rulattd rq:ularly !U ch1ldttn 8J" ph)~1olopc changes
m th<- l.L\I W<""mg l>od) affttt pharrnacodynamiQ 01
how !he drug .l<U '" 1h' ""' Evahuoon or <I.in h)'d...
uon in infants " important when using topical "lcr-
'lubk Jl\IR) c.... mc aoduy and g.ulllC mouh1y caust
dJfft'f~n<< in ahsmpuon lbe abihly 10 ~wallo.. mcdica-
uons as \\tit a< tht <izc and fonn or lhc or~I prepamion
ND DRUG ADMINISTRATION
ox i 2 FOOD A
~REGNANCY CATEGORIES
oescnpuon .
Remote risk of letal harm-Studies have noi
demonstra1ed risk to felus in first
trimester, and there is no risk in the
s8C(llld and third trimesters
Sltghlly more nsk than category A-T'Ml
B groups of drugs exis1 One is that anirna
$1ud1es ha';e not demoosttated rislc to
fetus. but studies are inadequate 1n
pregnan1women The other is that an.mai
studies have demonstra1ed adverse
effects, but s1ud1es in pregnant women
have not demonstrated a risk during anyof
the mmes1ers of pregnancy
Gieater 11sk than category B-0 1 category
c 15 that animal studies have nwn adverse
effects 111 letus. bu1 there a w ~I!
stud es m pregnant women. "e other
group is that there are no a !llill
reproduction studies and no tud1es 10
humans
0 Pioven 11sk of fetal har~tud ' in 'Mlmon
have shown proof of fetal d" iage, but
potential benefits of use duru 'I f)legnancy
may make adm1nistra11on a 1able
despite the risk.
x Proven fetal risk-One category that
studies show a defimte nsk fetal
abnonnalit1es 11 eithef hlJrnJ or animal$.
Another category 1s that ad r e reacti0n
reports md1ca1e evidence ol I tal risk The
11sks clearly outweigh any po 1ble benefit
are impor1ant foclOlll for medication' w 1Lh )'Oung
children.
Chronologic agt' rorrela1es poorly wrtl ~.111 S)~lm
<ln"'Pmenl lleight is a beuer correla1i 111 childltll
wilh le.in body mass. whereas larger, Ill ohcse chil-
dren may nctd higher dosages bec'lu'< 1 .,eight and
heigh~ or drugs need calculation acro1 111111 IO 115/\
Because pediairic 1>a1ienis are more sen" 1w to drugi
and respond on an individual basis, the ch.11 it,.or ,1dvt'l'S<'
reactions and sensi1ivity are heightened, , 'I'"' 1.illy \\lith
1opical medications in Lhin-skinned babi<' '11th as prt-
matureand newborn infants. Drug dosage "' quaniiLI
li\T. wilh lhe incrtased inherem risk or me.:" u1on erf()(!
caused by the nm! 10 measure or dilute '' doses and,'
or possible miscalculation or doses.
Premaiure infants and newborn; h.we 1n1en1t
responses tosomedrugs. llecause 1hei r org.111 '>"tcmsart
no1 develop.oo, medica1ions may remain 111 rhc IJ?dY
longer than 111 old~r children. Bmh prol on~<'<I drug 11me
 CHAPTER 4 Understanding Drug Dosages for Special Popul1tJons
---
BOX 4.3 SELECTED DRUGS WITH POSSIBLE
TERATOGENICITY DURING PREGNANCY
ACE rl1 b t -all fespec1ally 1n second and
third tnme5lefS) especially those '" Categ0ry x
taplOfXI/ (CapotEni
enalapot (Vasotecl
benazepnl (Lotenstnl
Anticancer agents. immunosuppressams
busulfan (Myleranl Busulfex
cyr:lophosphamide (Cytoxan)
methorrexate (Aheumatrex Tre.alll
rhaftdom1de
Antise1zura drugs
carbamiJlepme(Carbatrol. Tegetoll
phenytom I01lantinl
tnmellladlOne (Tnchonel
valptOIC ur.1d(Oepakeflel
Vitamin A derivatives
erretmate ITeg1sonl
1sotrellllom fAccutanel
V1Ci1mln A fAquasoi A)
Sex hormones
estrogens. pmgestms (in last mmesterl.
androgens
"1111um fEskahth. l.11hob1d (Category Oand should
be discontinued 11 poss1ble)l
1errl!C)Cllflll !V1b<amycin, M1noc:1nl
watfarm ICoumadin. Jantovenl
HMGCoA reductase inhibitors or statms (l 1p1tor.
Zocorl
l.Jve Vact111CS
Other drugs
alcohol in la~e or continuous doses (exact
am01Jnt not known)
'
cocaine n l0tge cont<OUOUS doses (exact
amount not ltnownJ
m1SC1ptOStOI (Cytotec)
ACl A1 J'Dtensmconverttng enzyme.
nnJ Jd:n ed responses may change the drug's pharma
>k1 "''as well a\ the safety and effectiveness. Of most
1m n 1nce is that g.istric emptying time~ vary, and thus
th1 1111pan of a dnig cannot be pred ieted.
With the lo.v metabolic rate of dnt(lll in infants up to
l ) ar of age and the young child because of immaturity
of tilt" Ji,er, the d<><ages and the time between doses may
be 'honer. and o ften doses are reduced because of rapid
mrt.1bolism of drugs Doses for healthy infants older
th.111 I to 2 week. of age may be c.1kulated on the
59
BOX 44 SELECTED DRUGS CONTRAINDICATED DURING
LACTATION
Cmt1olled substa~
amphetamines aro ~tamane-1 c& drugs
cocallll!
heroin
man1uana
phencycl1d1ne
nicoune
AntJCanC:er agen!S, irnrnunosupprests
cyrlophosphiJmtde (Cytoxan)
cyctosponne (Neoral, Sand1m1111Joel
doxorub1cm IAdr1am)'tt0, Oox1I)
merho1rexate IRheumauex. Trexalll
Other drugs
lxomocn/WllB 1Pat1odel. ~losetl
8ffJOliJmme (Ergom<1r)
gold salts IA1daura)
nU010Q1J1nolones such as c1prollaxacm !Cipro)
sulfa preparations
m1soprosrol (Cytotec)
milligram -per-kilogram basis (see Chapter 9) lly I year
of age, 1hc liver ,1nd kidneys have matured to a point that
the infant has the ability to metabolize drugs phanna
ceutically dose to the adult level. Children do metabo-
lize drugs faster, especially after the second binhday and
ilg<1in at pubeny.
Young children are also more vulnerable to adverse
re.1c1ions b~~ause of the immature state of the body
organs and ongoing growth and development. L>ffects
such as suppression of growth and development by glu
coconicosteroids may occur when medications are gi\'en
during times of rapid growth and development Table
4-1 lists medications that should be avoided or wed with
atreme raution in children.
Ped1atnc patients caMOt Ile 1rea1ed witll med1ca11ons used
for adults unless some adjustments are made to dosage.
Children are not small adults; their metabolism and excretion
are not well developed lnfanls ~nd very young children have
invnature organ systems, making them highly sensitl\'ll to
medcauons
60 SECTKlN I General AspeC1S al f'tllnnacolo9Y
. t"on Use in Older Patie nts
Medtca t
- the normal physio log11 changes :U
AS Jdu!~~g~cs Individuals ..;111 chronic di~ ~
""'m'"'""'nu1
,,.- . risk for toXJc
greater . ef'~<1<. adl'e~ ....Pio.
cesses are a1 . ,... h . -.
. 1 ck of thempcuuc e 11ects t .rn p.111enis with
uons. ;i~=~ Some older adults wt'igh no rnore thaii
acute large child, and some " 1~h "'en lei.\
an 1"
often thtsl' people are pr~n"bed
il\'tl';igt
,.. norm.1I aduh ~
1
d"ng to potential for toxic e11ects
ea~e geriairic popula1io11 (those o ld1r th.l11 65), rep"-
. pproximately 12% of the ll .S 1>opula11on uu
Sl'J)Ung a . <l J ~
approxom.ately 30% of .111 prcscnbc.o<l n11 ' ..1nd ~ ol

allarc medications O\'l!r long pen \ lime btt.1111(
of chronic diseases.
Expens now estimate that by the ) ''" '030, at lea11
zo%of tlie population wi11 be ~Ider th.111 c. ve.us of agr.
making seniors the fas1~s1gro~vmg !>C!lfll 1 uf the popu.
lation The result is an 10creas1ng da ng.- l<ll'erse IQ:.
iions and drug interactions and an 111< r d percent ol
BOX 4 5 MEDICATIONS CONSIDERED RELATIVELY SAFE medical complications in the total 1><11" 1.nion. Oldtr
DURING LACTATION adults are more sensitive 10 drugs th.111 nnger adulu
and exhibit wider variJtion in how "" a1ioru Jfftn
~ . lactr.on ha\'t Ille polelll>a 10 bf'
thrir bodi...s. llause of the high r.1h medicat10G
passed 10 Ille inlanl u..ougi bre3sl :1 tk:1 itugs :!18 -rt
.eco11r11e11ded for use dunng lactalllln mrl should be carefu ly use the older adult experiences "" drug-related
w.iluated by e health care JJ1ofess1on.il befoie adm1mstra11on incidents.
factors leading 10 possible dJngrn111' liens calll(d
Analgesics by the accumulation of drug.s includ1 'r mnabo-
l!tlillOqjletl (ly1en0fl lism; poor circulauon ind impa1r.-d t tion o( tht
amne li\'t'f, tu~ kidn~ or central nen1111' m Chronk
A11111nloct1vts or debiliiating condition~ with deh)d1.11 11 or electro-
cephalnspoMs lyte in1balance can affect how the agi llK h h uws a drug
cetadi " IDuricefJ
celJrolin !Ancel)
rein !Jn MelO.<_ill) TABlf : 1 MEDICATIONS TO AVOID DR
celtnaxOl1ff tRocepl11nJ EXTREME CAUTION IN CHILDREN
erythrom~m IEMycinl
tSOO/a/ld I'NAHi MEDICATION ADVERSE R
ai;~IZPail
salqlates. a5pllln fleve's syndrt:r.
Cardiu>-:iscular ~ wal d:sc
d1goxm llano>1nl (must be monitored very closely! ch1ckeopox il
guaneth1d oo Usmehnl androgens Premature clos
lliuretics 81J<physeal I
~(Aldactlnl) g!uamtmds (including Suppress growt
1rl>alers)
Endocnne medicalJOnS sudl as h\1XJ9lycem1cs
(insul1nl hexachlOlophene fpH1soHexl Cemral neM>us rem 1oxic11Y
Th)rOld preparations tmust be lllOOltored more fluoroqu nolones Weaken and c rupturad
clo$elvl fCJllloloai. levo~...an tendons
~.,.
Vacone
Immune globul ns IRhoGAMI pheno1h1a11nes Sudden infant d h syndrome
sulfonamiles Kernictcrus. fnu ce and
Gastrointest1nal drugs
Amactds tMJa 1ox. Mv1antdl COllUCIJOO ol t 1n Ille
La..itJWS (ella!lll caara ~ der!vativesl spcne aod bt a
letli!Cythoes
S1amoo ttwth
 CHAPTER 4 Understanding Drug Dosages for Special Populanons
and may interfere with expected therapeu tic elYects. Esti
mHes indicate that 70% to 80% of all adverse drug reac-
uon~ in the older aduh are related 10 drug dosage.
tll'cause body pharmacokinetics are diminished, tissues
rct.1in a higher level of the medication, resulting in
adverse reactions. A narrow separatic>n bet:\vccn
maximum drugelYectiveness and drug toxicity is common
m the older aduh 1lle use of multiple drugs simuhane
ousl and poor compliance by many older adults add 10
the problem~ a~sociated with medication administration
in th is population.
O lder adults who are physically active will have
nummal changes. whereas lhose who are inactive o r
btJndd~n will exhibil dramatic changes. Slowed gas1ric
,mJ 111test111.1l emp1ying time allows medications to
1cmain 111 the ~lomach, increasing absorption and
111rrcasing the risk of stomach irritation . nw amoun1 of
th drug's ora l dose absorbed does not change with age,
but JelawJ ~tomach emptying may cause another dose
of drugs 10 h .1dminis1ered before total absorption of
1he pre,iou\ dose. Oistrihu1ion is different bec;1use of
di.111ges in bo<ly fat/ water ratio, reduced muscle mass,
,1.,..,,J mct.1h<>li\m caused by reduced blood llow 10 the
hv t and d< rcJ!>ed enzyma1ic activity neroed 10 metab-
olll un .1nd excretio n is delayed by reduced blood
lhJw "'th~ kidm)'>. l11ese ch.111ges in the body increase
th<' drug , h.1lf life, allowing drug accumulation and thus
c.1usmg, HIC<ntralion o f a drug to rise to a higher level.
lhc drug elf'Cl\ home more intense. Dosage and mon
norm for dt'\ired and undesired effrcl> must be
111Jl\1 l1nhLcJ
I '""ii!" .111d dfects of medicat ions applied topicall y
and lnsdcrm.111\ may also be difficult 10 predict in
old pauerm \I though skin thickness decreases. dr);ng.
''T' k ng. .1n~ decreased hair follicles may change the
r.11e "' absorp1ion. Decreased cardiac output may also
.111, o tlw r.11c .11 which medic<ttions areabso1bed through
th kin lh'cau\e of d ecreased salivary secretion now,
~uh i;ual 1.1bkts may no 1 be properly dissol"ed and
.1b td nm nMy table1s be swallowed easily.
<lth r considerations include dentition, which
'hnuld be tvaluated before givi ng chew.1ble tablets,
ht 1 ~'"' oldc1 ,1dults may have insufficienl teeth to chew
1.1bl ts \lany drug:; can affect the mental status of older
md" dual, k.1ding 10 confusion and unmtemional
ovtr k~:lge of 111cdications.
P' lnumacy in t he Older Adult
\\ti> incre.rnng numbers of geriatric patients and
"" n "cd med1c,111o ns found a;, OTC preparations, older
.1d11lh bnonw caught in tht vicious circle of polyph ar-
111.10 rhe era of medical specialization has on ly added
to th1~ problem because a person who ;.ees multiple
j>hystnlns for multiple problems is usually prescribed
multiple medications without discontinuance of any of
61
BOX 46 QUESTIONS TO ASK TO PREVENT
POLYPHARMACY
What d1eta1y supplemenu. Vitamins, and OTC drugs do yoo
take?
What pharmacies have you used in the past 2 years 10 fill
your presclipllons?
Who are all of the physicians that yoo see. and v.flat medica
11ons has each prescnbed for you?
How would yoo descnbe your ability to read medication
labels?
When do you take your medications? Of those bmes. at
wluch ate you most likely to forget to take the doses? How
often do you forget yotJf medications?
Oo you have any quesuons aboot your medications and how
to take them?
BOX 4.7 CONDITIONS THAT MAY RESULT
FROM POLYPHARMACV
Cardiac arrhythmias
Disturbances in balance
Cogrnt1on changes, confusion. depression. suicidal idea11on
Consttpa1100
Gastric ulcers
Hypenens1on or hypotens1on
Rash
Unexpected failure of treatment
the dru~ previously prescribed. The problem is increased
by the patient's self-medication with OTC drugs. Sy
taking accurate medical histories (Box 4 6), including
full documentation of all medications being taken. the
allied health professional assbis in the elimination of
inappropria1e medications and thus improves 1he
patient's quality of life and reduces undesirable effc<ts
of polypharmacy (Box 4 7).
Some polypharmacy is apparent when th e pal ient
receives more than one drug in the same class of medica
tions or SNeral different medications fro m different
medication classes to treal the same symptoms. Mo re
likely, mediG1tions are added to treat the side effects of
anoth er medication, leading to use of more and more
drug:; wi1h possible negative outcomes. Negative effects
include adverse drug reaction; drug-drug. drug-nutrient.
and drugdtsease interactions; medication error5;
increased treatment costs; and increased risk ofhosp11al
izat io n. llccausc of these inherent problems. it is impor-
tant to use Lhe lowest effective dose in Lhe geriatrk
palienl.
1lle older person is in a constant state o f physiologic
change, and medications and dosages must change also.
 COON I GenttI ,Asptcts ol PNnnacology
As1l1tln9 th Older Adult with
Medlctlon Complienc
lh<'alhtdh r ' "" t><a.. aretba140"o
or mot' of olJn lnJ1Vidu.ah Jo noc u~ theo~~:
11011 rnm'< II> ''"'~ fall lo ~ pres< npuons Othcfs
11~11, whth..- olh<'f> nt'\<'f rtfill tht p1<..cnp1ion
do no1 follow
Jo nu1 aJh..h' 10 1ht r'"" ""'" .,.u.ig.: or
' L . I .L
I d
tht "'h...Juk lor 1Jlmg mt-J1un" lht"e l.1<1or; un ea
tu totC t tlt"1. tt hon1 '"'rJ011.1g.:" or nonlrc.aunent from
un.krJn.Jit Un.I rJo-.1~' nJ fJllurc 10 ""pond 10 a
nlt<l1t.H1un .th? 1nort~ commnn by (Jr accounung for
JJ>pr11.,m.111I> <)(l"lo ol rht pwhlem llnin1enuonal non
mrn(lll.1111" m.1y reuh lrom forgcrluln'SS:. ~rom. nor
1111<ltn1,1nJ11111111mucli1H1\ OC'(Jll'>t of poon1s1on. mad
tJUJIC lw.1nn14. or Jttt<.l\l'tl ah1l11y to under;1and; or
Irom rlw H>1n111t-x11y ul rrmtrnbcring how 10 take mul
tlplr dniJ4.' \.1<lly. ho... twr. 7S% uf noncornpliance is
1111<1111011,1' lhr fll'l\Oll frd> n1r<lione is 1101 necessary
or hnd5 1ht >ilk d i> unpk.1;.1111 A mjor reason for
nonrn111phan1c m.iy he Inability of people oo a 6xed
111Wllll' to p.ty ror <ini!15 lltt.1U~ mcJ1r.11lons are neces-
5'11) lor i;ooJ trt.llmtnl, 1h< allil>J heahh professional
\houltl l"l<n anti J;k \u(hucn1 qut!l.Uons 10 obrain a full
h"rory ol mt'\11c111t-. lking t.iken and to look for dues
th.u mJ} \lgTIJI an unll'(ognv<d nonrompliance
prohkm
It> hdp olJer p.iutnrs comply with med1cauon ordm.
simplify 1M1rucuon1 for taking ml'<l1c.t1JOns. being sure
1ht mtdic.tuon 1<ht-Juk 1s conwmm1 for 1he P'timt.
I ncour>jtl" the (IJll<nl 10 ~ all labeh carefully ;md to
u>< only one ph.tnn.cy lh, fMllCnl shoold makt a list
of .ill mt-.l1c.iuon, l.t~cn along" nh lheu \trenglh. !heir
dooe anJ the length ol 11m.- uch has been W.Cm. This
h\t shoul<l "" l~cn to ..,, h phi,,1cun ..,,lh each '1Sit so
thI 1he medK.tl fl"<Ord 111 cMh office can be upda1ed.
Ille Jlh<-J hulth prolt'>oS1onal should thoroughly explain
the m<-J1cuon icht-.lulc. making the medKallon times
hi .n cl05t:ly 10 the pcoon's S<.hedule as ~1ble. The
rc.tson for aJm1n1s1rauon should be explamed dearly
an<l rnnmdy. lollo"cd with preo~ wnuen instructions.
llsmg a c.11l'nd.u ur a weekly pill con1ainer will assist in
reminding the flJll<nt to t.ike the medicines as pre-
..-nb<"J I 1n.1lly. providing ~1mple mediauoos to !hose
who cnno1 ,1fford the mt>dicmcs may help with compli-
,mce .md will provide rn1.1tl a111ounts of medications for
111al b<"lorc exp<>ns1vc (ITl'SCnpllons .ue dispensed and
side effoo~ Jll('W111 the nll'\ltcinc's use.
peoPJe are usually more sens1trve to medica1.it11;
l)tder of ~ metabohsm and excretion. Illus ll'fJ
tJecaUSI!of oo.erdoSe is increased
:!at- llllJ$l be 1od1viduah1ed fOf the older adlil
tJecaUSI! al changeS 111 body organ systems and in drug ~
~ asscciated with boct1 changes espeQai!y
~ly ,11 r1 debrMated patients
MtsSe reactlOllS more oonvron 111 otdel IJC!SOJS. may be
caused bot po1yitiarmacv severe illness presence ol miitt'lllt
diieases aild resultant use of multiple d~
0
~IS conJ110f1 About 75% OI ~'illte
lflll!ldd aild is a result ol expense. side etleus. .,. r.e
pilllt!lll's tJeiiel tl1at the med Qtion 1s not nceessarv
l)ndnlional noncompliance 1s usually ca ,(l by lorgetlll-
ness r1 lallure ro unde1Staod treatment. will' al l~ast 40\
of older 1001wklals not complyuig with m00 11 treatmenl
Alie< the age ol 50. only mree med1cat1ons uld be ta<fn
the same time If more than three medic ns are netes
31
531'1 the patient sllould be instructed 10 w l 10 m111t11es
between each dose to allow for absorption
The health care professional should 'I ul rime wnh
each patien1 10 ensure 1ha1 he or '"" 11 ""rands ~t
condition, treaUTienl prescribed, and '"" for and
actions of the medica1ion ordered 10 1111 ,,. rhe Iii.di
hood rha1 the patienr will rake prN< nl 11udica1ioo1
routinely. Some phannaceutical com1 ,.... lll'Ol'idt
audio, \'ideo, and "'Tinen materials 10 " w II h fM litlll
education for new medic.llions A.\k1111 fl.llltnt to
explain wlm he or she has heard .10.t , cmood c.n
rewal infonnation that ha5 not bn .1.!11 1dr rowml
Compliance will be more easily accomp' , J 1f affonl-
able methods of procuring med1cJt1011 rr di~
wilh the patimt. Ifa 1rade-name mt'tlu .11 11\ nquiml
for wmpl~ the health care proft-s\100.11 11 he Jblt Ill
provide the patient with s.1mpl~. and '"' ph.umam>
tical manufacturers ha1't' sl)ial progTJ m r 1hosewho
cannot afford 1heir medica1io1ts M tm ,,f
needs 10 be completed by both the JM 1 .ind heahh '"'flt!"'"'
care provider, so the neces.\ary paperw" nnds to bl
accessible in rhe medical office. :Oee ww" ,1ymcd1 Oil
for more infonnarion .
The medical olfice should keep a 1 1 ~1 ol .ul,thle locJl
<el;ources 1ha1 c-an as.~i$t wi1h medica11on "npli.1nce. In
some communities l)harmacies couiwr. 11 , wi 1h 01twr
medical enuues
to provide low-cos1 IH<'so 11p1ion COflJY
mems. Some health agencies ivill comc '" rlll' home ,u1d
 CHAPTER 4 Understanding Drug Dosages for Special Populations
prepare medications for the patient or will assist with
tr.tnsponauon to ob1.1in medicines
ror some older patients, it may be the caregiver who
needs to understand the medication administrat ion. In
these ca,cs the caregiver should be present w hen medica-
tions arc discussed. Conditions that in\'olve loss of
memory \'1s1on. heanng. or mo'l?ment. as well as socio-
t'conom1c .rnd physical situations resulting in inadequate
1r.1nsron.111on or fina nci,11 resources, may cause rea l bar-
riers for \Ome patients
\ p.111cnt who is illiterate and is embarrassed to ask
tor help in reading prescription labels or OTC labels is
JI ri>k for 111.1dvertent double dosaging. adverse re.1ctio ns
to med1c.1tinns. and dangerous dn1s intcraet io ns. Because
''"" m<> t liter.uc people are not medication literate. it
1, unpon nt to provide an incre1sed knowledge base for
r..Hhng drug ingredien ts It is not commonly understood
hY most p.111nts, for l'Xample, that medicatio ns such as
or<. "1J.1d1e preparaLions with salicylat~. such as
"Pl rr " 1.tusc excess"'!? bleeding in the person who
" 11 11g rfarin sodiu m (an anticoagulant) and its
Ju. ,,1111" nr that ilwprofe11 and aspirin should not be
tdl-. to tltt'r becau\e ibuprofe11 is an aspirin .like
tn 10 minutes to explain areas of concern can
'" 11111, that could be involved if a problem has to
h< , 11 I l.11er after adverse effects have occurred .
c 1n taking medications and making lifestyle
h< r' a person comply with treatment.
t1<'1ll\ who have difficulty with medication com-
\\1 illcn instructions can hel l' ensure accuracy of
nH health care facilities have printed materials
' d checklists for the areas of compliance that
11 111 attention. Written instructions provide a
1;111d 1I1.11 t.111 be followed at ho me. Remember that
111 llcnts are nervous in the medical office and
"t I 1hou1 50% of the information discussed.
barriers such as language. hearing. V1s1on. culture.
1eligmn can cause noncompliance. the patient noods
lle evaluated before any medicauoos are
ibelt
1 truct1ons should be provided for patients v.tio
c1lhculty remembering desired schedules or who have
lies Uiat mal.e compliance difficult.
red health profesSJonal should be sure that pauents
1literate or v.tio have language bamm undefstard
cnuon 111struc11ons before leaving the phys1c1ans
office
t a patient reQU res a caregiver, the caregiver should be
pr wllell medicatoon adrmmstration 1s discussed
63
MEDICATIONS AND CULTURAL
DIFFERENCES
Perceptions about medicatio ns that inOuence acceptance
or refusal of medicinal treallTient come from cultural.
social. and religious beliefs and convictions. lly under-
standing some of these cultural differenc~. the health
care professio nal can as;ist with (Ommunication to
improve patient care and compliance.
Ethnic and rultural differences M!ldom aff~'O the
action of medications (even though some diseaws occur
only in certain racial or eth nic groups), b ut a 1)atient's
compliance with the physician's o rders can he greatly
affected by the patient's understanding of the therapy
and by good communication bet"'l?en patient and pro-
vider concerning the need for therapy. In some cultures,
people may refrain from expressi ng views that mnOict
with views of others, especially those in medical com-
munities. llirough awareness of sociocultural differ-
ences, health cJre professionals can surmount certain
obstacles to good hea lth care. Remember, even nonvcr-
h.il commu nicJtion can hinder compliance.
The allied health professional must be aware of his or
her attitudes because thew attitudes, transmitted both
verbally and nonverbally, can affect patient compliance.
Self-analysis o f o ur own beliefs, ex1,ectations, at titudes,
and practices establishes the way we accept differences.
An open mind and willingness 10 expand per;onal
knowledge of diversity assist in establishing patient-
ca regiver in teractions. Bnrriers to con11nunication c.u1 be
overcome th rough tone of voice, f)ody language. and
actions that convey reassurance. Exercising patience with
patients and allowing time to ensure that the patient
understands medicatio n orders are important step~ in
pro moting com1, liance with medica l therapy.
In 1989 Albers Herberg noted t.h at attitudes tow.ird
health and illness generally rellec:t one of three views:
scientific-bio medical, ho listic, and magicoreligious. Each
perspective regards illness and health in different, cultur-
ally determined ways (Table 4-2). In tlie United States
the scientific-biomedical paradigm predominates. with
professionals undergoing extensive training in the bio-
medical sciences. tn the scientific-biomedical domain.
disease a nd ill ness have a cause, and the goal of health
care is to find a rure_ Scientific research is based on
finding rurcs for diseases and illnesses.
Ille holistic paradigm focuses on achievi ng harmony
of body, mind, nd spirit to prevent illness. Disharmony
or imba lanre among these natural components leads to
disease or illness. Once the person is in harmony, health
is restored. TI1us health requires mind, body, and spirit
balance (Figure 4-2).
The magicoreligio us paradigm regards hum,rns as
under the control of supernatural, m)'litical forces. Witch-
craft, good and evil spirits. spells. voodoo, and other
 KN I General Aspects ol Pharmacology
ac!Jl'\tn all
~
l!ro4I oerase
~ali
nlO- Clu$H!leCI ~Ill
M'.IS:--
iear ~ fl) Cle tnly.
00 ICDden!S. qunes.
4seases. in! ctoema!
mUtm: tot;
f1MO'iS IS a m:idiine.
mnl and tnly iltl !'Ml
Cstirict entites
Sociele 111 wtldi boloef W!liUI AmerUIS
plldomin.ltel Eurcpe:>os
figure4 2 Theirl!Mlllltwtll11lofc !th-toe~~
~ tile cty.mrn,c lllteroct.Gns tmllll ti-. i:tivU:ill. IOOal
11'1' 11111 and CIO'll"' _.,at penon
lore<"\ brmg ,1bout illness ,md d1~ase. Health ts a b1<$5-
ong frorn (.od for h\'ing good, whereas Illness is a sign
1lw 111diviJu.1I ha1 not camtd out Cod's will 111n<$5 may
or m.ly nm h\' ran or Cod's plan. but it comes from
supematural force$
I
Reward of God's blessings and
Em ronmenL be113"iOf aod good will
ltuial factOIS influence
SOCIOCU the
and rnaifltall1 flealtll and
rieventoM of illneSS Ill
~.~and
restlJ'fl!I ~dl are ~ a
Cause or hea llh and 1lllle$$ is
Ocsease ctemoeal ll ~
lllt;alarxe. ali ctiaos OCtUI not QrgaiAIC but ~total. f'lil
111-ten aws GI llarll01'( and
rewral (Jalarl;e have been
51J1nts. sorcery. taboos. and
supernatural fQrtCS cause
illness humans are at the
~roman 11fe is only
melt\' of good and ~11 loii:es.
one part of oosrnos.
eoie<'(tlllng !las IS place and which may 1m11ao diseases
or illnesses with or Wllhout a
role 10 ma1nta111 Older
reason
Alncan American
Nan~ Amencans
Persons of H1span culture
Vanous Asian groups
Qolture must be considered when no 11< .nions art
used for treatment of illnesses. One th11 .I of' the U.S
population consists of individuals from 1.1 .II, cthnic, or
ruhural subgroups lha1 arc referred h 1, 111111ori110.
Beginning in the twenty.first cen1ury, h11 11r, persons
from a minority background account fo1 11 ''" than 50%
of the total population, making the rwl'd know and
undl'fSland di"ersity a necessity to mc11 11 health cart
aeeds of patients. For an accurate and nh 11 ngful galh
ering of data. care must be sensitive to d rt.'nces and
respoothoseideasthatarc inconflia woth 1 h1omcdl(J.I
scientific outlook prevalent on Ameroc.10 111 ht.ii in<titu
lions. People draw on their cultural h.l< kr 111J and rd)
on ''arioos personal relationships in "'' s .1\s1st1nct
,.;th decisions. In some cultures ond1V1tl ~k a<m-
wice from family members, and parent' ' r.mJparml)
mai make decisions about health m.11 r In other
groups the patient may makt decision\ "h1i< a\SnSl'1
how the diston will alfttt the enur~ It"' p o r fam1~
lo )'ti 00\(r groups the indi\'idual mak1, I or her 0\>'11
health care decisions. Although fomih n rnb<'r\ mJy
participate 10 some degr~e e11her through 1illucn
en.Jllcr'al through panicipation in therapy, iden11 I\, the person
who makes the decisions about medic.ii , 1 .md indud
i~g.tha1 person in <>aching ~ions will .1 " t wllh pro-
v1dmg successful therapy.
.A number of people in the Llniwd ~1 ""' havt a
Pmnary language that is not Cnglish 'In nmply '~ilh
drug therapy, 1he pa1iem must firs1 und1"1.1ml the Ian
guag~ of i~~lruction. For the person who """' nol speak
English, givmg 1he directions in Engli'h wil l 111>1 lc;1d to
 CHAPTER 4 Understanding Drug Dosages for Special Populaoons 65

comprehension and compliance. Instruction ~heelS in

the pa1ien1\ language or pictogr.1phs will assbt with
comprehen;1on. A perwn who can act as an interpreter
Jnd who will .1ccom1)any the pa11en1 to the phy.ician's
office wi ll funher a~si>1 with compliance.
lndi,<iduals from certain cuhural backgrounds may
consider home remedies such as roots. teas, and poul
lice> w b<' more eflcctive than prescription or non
prescr1p1io11 medication,. (1 lome remedies and folk
1mdidnl' .ue discussed in Chapter I?.} The all ied health
pn ("'" >n.tl should auempl 10 discover home remedies
the pJti< 11l 1~ using bt'<'ause these remedies could inter-
[crt' with pr~>cribed medical trea1menL Under>1,i nd ing
ruhu1.1I dilkrences regarding illness and treatment is an
1m1x>n...11 '1e1> toward g'1ining patient confidence and
l ofnp 1Jn, ,_. '"'lh pres.cribed trt>-atrnents.
mication and
CoN
M tion Com pliance
( nm Jnl .111on, both verbal and nonverbal. is vital to
ro111pl intt' \Vith medicaLion treatnlcnt. Nonverbal com-
mun 1 n hctwecn per..ons of different cuhurcs may
, ptance or inadvenenily show disrespect for
r wn eye coniact is inierpreted differcmly by
Life t>xperiences, hhtorical and n 1hural
1> r 11i11tt'S.
1 .i,, and the patient's perception of the situa
1,11 factors 1hat the allied health professional
n <rnderstand while remaining nonjudgmental
to cl.rify any information that cou ld have
11111nunicatcd. In today's multicuhural world,
Ill 11th professional should adapt medical
meet a \'ariet)' of cultural needs Written
11 "'" not suffice for a patient who cannot read
Wiit<. c,1using ,, lack understanding of why the
I medical 1hera1>y is impon.1n1.
Cultural d fferences on how people regatd 1Uness and health
can aflec1 compliance nol only w11h med1ca11ons bul also
with 101al medical care
Problems on communoca11on can lead to noncomphance with
lleat!:'.-'flt
SUMMARY
l'a1ien1 variabks such as age, weight, gender. diet, genet
ics, concurrent diseases, and mental s1a1e must be con
s1dered "'hen prescribing medicauons. Some JX'Ople
respond to pl.1cebos when psycholog1c need i~ more
intense th.m physiologic response. I low a medicine is
given, what medicines have been pr~iously prescribed,
and the ~1b1liiy of drug dependence are all imponam
factors 1he physician must consider when prescribing
drug uearnwnt. Older palienlS and children have difrer
ent rates of metabolism than 1he average ad ult, 1he
subject for whom the .werage medication dos.1ge is
designed Dosages must be adjusted on individuals with
spedal precautio ns. Pregnancy and lactation m.1y pre
elude the use of some drugs because of the danger to the
fetus and infan1.
People from different rultures ha-e difrerem perspec
tives on the role of medications in sickness and health.
'11wir coopera1ion with medical 1rea1ment may be cul-
turally biased. me allied health professional mu>t be
sure that n1hural differences do not interfere with
therapy and that the patient complies with the course of
1rea1rne111, u'i ng and undersianding education for
con1pliance.

Sc n11rio
23 years. thinks she may be pregnant because she has missed one menstrual period.
,ng. and she has a history of allergic rhini11s that causes sinus headaches. She asks you,
ned1c8I assistant, what medications she may take for her allergies. The physician previously
r k>d an ant1h1stamme for the condition, and she wants you to call in the same prescription to the
me: y
IV a. should you do?
2 What do you need to tell Jane about taking medicines during the first trimester of pregnancy?
3 If there were medications that could be safely given during the first trimester. in what pregnancy
_gvry would the medicatooos be listed?
 . body function~ afTC<1 dosages for the old ... .1duh1
3 Ilow dn \arMtmns m 1>t 1gh1 and tht gradual deeIine m _

4 Why "med1c.111on therapy pot~ntially harmful in the first trimester of pregnnncyl - - -- --

5 <..ommun1cJ11on hamm and cuhunl differenCt'S may cause noncompliance wilh drug ther.1p' low can tht
alhed htahh professional be surt ~m those from other cultures comply with medication themp\

6 Compart the scienuficbiomed1cal. hoh\uc. and magicoreligious p.ll'adigms of health and illn llow can
tht .1111<..t health professional work wnh 1hose of different cuhwes 10 promote undemand111 1 medional
1rta1me1111 _ _ __ _ _ _ _ _ _ __ _ _ _ _ _ __ _ _ __ _ _ __

1 Wlm vanabln (we1ghL heighL and 50 on) affeo drug dosage and acuons 1 \\lha1 does the all1<~1 1 11th profes
soon.11 m.'<:d 10 do to enswe corrrn dos.igfl
- - - -- -- -

8 What .ire lhr<>e of the neg.u;,.., outcomes of poIypharrnacy? _ __ _ _ _ __ __ -

-
 CHAPTtR 4 Understanding Drug Dosages for Special PopulatJons 67

9. Why is il important to obtai n weight and heighl at each medical visit! - - - - - - - - - - - - - - -

10 Why is age a v.iriable in drug dosages? - - - - -- - -- - - - - - - - - - - - - - -- --

11 Wh" is it important for the person to obtain all medications from the same phannacy1 - -- -- -- - -

12 I t thr~l'" reason~ that patients are noncompliant with medication administration I low can allied health profes-
"onals J<\i\l with compliance with these issues! - - - - - - - - - - - - - - - -- -- - -- -
Reading and Interpreting Medica~i on
Labels and Orders and Documenting
Appropriately

Airer srudymg rh1s chapter, you should be capable of doing the following:
h pla1n1ng lhe parts of a National Drug Code
(NOC)
L1sttng warning and caution label 1nformat1on and
its relevance
D1st1ngu1sh1ng between a prescflption and a
med1cat1on order
Using correct abbreviations when assrSlng with
prescriptions
Descnbing parts of a prescnption
Descnbing steps necessary to ptepare
prescr1pt.ons for a physlCl8n's s9natu1e.
Telephoning prescnp11ons 10 pharma< and
medication orders lo health fac1h11es
.1rders in
Documenting prescriptions and m edK
pauenl records
Safeguarding prescnp11on pads
Recognizing when presc11p11on refills Jhl be
necessary. and transferring Ofders for 11s
accurately by telephone or electron
WntJng a prescnpuon for phys1c1ans ature.
Interpreting a physt00n' s med1cat1on rs.

T'/:ya, an allied health professional, knows rhat Mrs Kime sees several physicians concurrent )f

:.ronic con</l/1ons Tonya asks Mrs. Kime to give her a list of medicines thsz sho 15 toking 011 gular
vosis so that she can enter 1h1s mlormatton mto the medical r 1e can
rememOer some of her medicines but not all of rhem ecord Mrs. Kime tells Tonya t/1

whyTonya
Does not~ need to get me<11c1nes from a , physicrans
or 1ust those prescribed by the tntorn1~ 'Jhy or
If Mrs Kline uses the same phaunacy to r 1a1 prescr 1n the
needed 1nformaoon 1 Expla n your answer 1Poons, can Tonya call that pharmacy to
ts that ethica11 Why or why not1
Should Toova te I M rs Kime to bring a 01 he< med
the physt00n? Why or why 0011 tCallOns or a list of medocat.ons each tom<t sees
If samples are grven to Mrs 1(1ne. what steps does T a
ony need to take to ensure patient salo

68

I
 CHAPTER 5 Reading and Interpreting Medication Labels and Orders and Documenting Appropriately 69

Auxiliary labels Dosage strength Refill Superscription

Compounding (weightl Signature (Sig or Vehicle
Concentra t ion Inscription signal Verbal order
DEA number Medication order Standard protoc,o l Volume
Docume ntation National Drug Code Standing order
(NOC) Subscription

edications may be prescribed, dispensed, or patiem cduca1ion sheet abou11he drug for the pa1ie111 to

M Jdminis1ered in a medical office but more

often are adminis1ered after being ordered in
heallh rar. faciliues Sample medications or other medi
t.lliom ;upplied by 1he health care provider and given
take home and read (see Hgure 3-2).

Parts of a Medication Label

101hl p.11ie111 are considered d ispensed, ahhough a phar-
m.1risi 111 a pharmacy selling does mos1 of the dispens-
ing 11,ing.1ble to corrt('l ly read lhe label on a medication,
wlH 1h r prescrip1ion or over-lhe-coun1er (OTC), is a
mxl'' 11 mr allied hcahh professionals. f.orgeuing 10
read 1 laht>I or improperly identifying the information
on .1 h"tl (look-Jl ike-sound-alike medications or
dm 18 <..ollcrence on some medications) may resuh in
thl' wr "K medica1ion or dosage form being given. If lhe
l,11 l'I ;, 1\'lt read in i1s cn1ire1y, u ndermedici1 ion or over-
m1 d1 11 '" side effects, improper usage and Morage,
pr ~'"' prepamion of lhe dose may occur. Reading
mprehending l,1bels that contain bo1h generic and
lf3 mes .1nd dt1,.tgt 'trenglh provide an under
\{,If r lhe siandardi1.ed formal of labels for both
pre .r1p11on medica1ions and OTC purchases 10 ensure
pr"i'' 1 "'"!\e of medic.uions.
l'r 1 ribmg medica1ion~ is a daily routine in physi-
' I <es !be allied health professional play; a role
pl1on therapy by assisting lhe ph)'$ici.m with
phoning or electronically dt'livering prescrip-
11nn t harrnacies. and documentingadmin1s1<a1ion of
m<JK 11 ons lo p>1ien1s 1his role varies with individual
~1.11( I,"'" anJ with pro1ocols of the specific health care
\l'lllOj;
In 1he following section lhe pans of a label are indicaled
by a lc11er of 1he alphabet, wi1h 1he figures showing each
part of the label.
A. Trade (Proprietary or Brand) Name
The trade name is a copyrighled name assigned 10 the
medica1ion af1er initial pa1en1 Mid acceptance by 1he U.S.
f.ood and Drug Administr.n ion and can be used only by
the company lha1 crea1ed the drug. Trade names are
always capirnlized and are usually seen first on the d rug
label in hold type. The ~mbols for regis1ered trade-
mark or f t for trademark will follow lhe name. f t is used
until the ll.S. l'atelll and Trademark Office has regis1ered
the name, and then is the correct symbol. In Figures
5-1 and 5-2, Oi laudid is 1he lrJde name.
8 . Generic Name
Also called offici11/ 11ame, the generic nam e is given to the
medical ion by lhe l/nrlfrl S1111es Phamwcopeia-N111ior111/
Fonm1/al}' and lhe manufacturer uses lowercase le11ers
Aft~ the pa1en1 rights have expired. the drug may be
H

R- :l'!IG A LABEL FOR

S_ MEDICATIONS B

Ttw 11' '114/.iciurer's /11bel found on s lock medkation

0
r.... ............ ___ ,..,
bo11l1s w111ain; informn1ion about the q uanlily in lhe --""-~--~-
.,
....
--~--. f#'lllt-..0~. 2001

bonl<. lh<' strength of llw medica1ion, and 01her impor-

~"""'* 00,.
1.1111 (1rt' that are necessary in providing 1he correc1 +--='""
=-=-- - --
m,d1ra11on for patien1 safe1y Some labels coniain more
K ._...,,......., .......,_,.....-.i-.
d<'ta1I lhdn others. but reading lhe entire label is most
11nponant for quali1y assurance in patieni care. If a
p.111cn1 '' \uppl ied with a new medical.ion, pa1ien1 coun-
\tli ng " requi red by law, and pharmacies provide a Figure 51
 ---
........
B c

Figure 5-5

F H K l BOX 5 1 ABB REVIATIONS THAT MODIFY DRUG FORMS

Ex amp I
Allbrewiations
Jf ;'f
. - -... ~ .-! Sil= Sus1a1ned release
eaan-SR
Sinemet l
If ell = conuolled release
LA ()(XL Long acung B1c1llin LA. 0 rocardia Xl
t B-PHENOBAllBIT AL
l j o - TABLETS, USP as= Double suength Septra OS
G1lphex 111
c-Gm
r f
TR = Timed release
v -~ ..._ ... - ..... XR or ER = E.ttended release Adde<all x
(>Un()H ,..... us .
i II ..__..,_.......
' J ........,..,.....,,,..._

figure 5-3 or Other indication of the. volum<>

. ol 111 1ca1ion. lne
dosage sireng1h or a 111ed1cauon m.1y "' in various
weighu. lhe labels in Figures 5-1 and '> ' hcate Dilau.
did 2 mg per tablet and 4 mg per n11lhl11 esproiwlY
H c In f"igurn 5.3 and 5-4, note lhal the '' media lion
F may come in d1fTerem suengihs. and ofl1i1 leis fonhe

B
-2$
NDCOOS4-

PHENOBARBITAL K
same drug may l!\'ell be or different colo1
boih. 10 prC\'eni med icinal errors
~hapes. OI

D TABLETS USP IV
CW11nlnf:Mty ...... lonn"11 )

,''.. D. Form
Fonn indicates whether lhe medk .11 11111
tlblets. capsules. powders), liquid (l' II
w lid (eg,.
uuons. di$.
J

- [j]~~
Figure 5-4
... persions. syrups). or semisolid (e 11 "" 1
supposi1oncs). (Stt Chapter 3 for null
drug release times.) Some medic,11io n l.1h.
1ions of spedfic dosage-release forn"
()fJ1lmtnt1
relaced lO
lJ\'e ind1a
h as those
shown i11 Box 5 I.

manufJctured by olher companies under lhe same E. Route of Administration

l\<'nm< name but w1lh another trade n.ime In I 1gura Romeof adminis1ra1ion ind1c.a111> the" .n drugenim
~ I Jnd 5-1 lhe gmenc name 1$ IJrlfroorpllC>M llCL. parenteral
lhe body Some labels. especially 1ho"
In I 1gures 5-3 and 5-4, 1he drug does no1 ha\'t a trade use, tell the acceptable route> for med" .II .1dminis1r~
nJme-phenob.ar'7ilal 1~ the generic name. lion. Other labels do not provid~ the fO\ 10 be used.
but tablec$, caplets, capsules, and ml 11 1 nedir.ations
C. Drug Strength (Weight}
found in Table 2-4 are to be adm1ni\ll'1t'll ,, .illy, as are
Drug screnglh (or weiglll)-<!Xpressed, for example. in
the oral liquids found in Table 2 l Nm. , 11 the label
1mlh11rams. micnwams. or milliequivalents-is ihe
<OR<~Rlr~tlon Of J (ll\( lngredltnl or medocallon in
for fl/cmoNrbua/ in Figure 5-3 is for a 1.1hl, nd does DOC
gi\'I! lhe route or administrauon, wh , auopine
Jo-..111e form In tablets lh1s IS the amount or actil'I' ongie-
d1rnl m the 1able1- In hquid form lhe medication is 1he (Figure SS) 1s parenceral and the l.1hd "' that !ht
" '"llht of med1c.mon m .1 Spttified number of milliliters medication may bl' gi\'l!n subcu1.111to1"h (~C). in1r~
muscularly (IM), and i111rave11ousl) (IV)
 CHAPTERS Reading and Interpreting Medication Labels and Orders and Documenting Appropriately 71

...
.,,...,,
H

~
l G. Directions for Reconstitution
Labels for medications that must be mixed with a diluem
before administration will provide direetions for recon-
LANOXIN
fi If
stitution (see Figures 5-7 and 5-8)
(OIGOXIN)
!
ELIXIR H. National Drug Code

F
PEDIATRIC
[ldli ml cOfltliM
H ~t (G.05mtl
f\EASNITLy f\AYOAtO
llllith
11,.1111
All mcdica1fons are assigned Nallonal Drug Code
(1'DC) numbers 10 idenrify manufac1urer, product, and
siJ~ of container. The code number shown on the label,
containing al lease 10 digits. is preceded by the leuers

---
Gl.uoWdfcome
.....,.r.....
. . .. ......
M C I,.
....... '491
NOC
An ex;imple of the NOC code and its meaning (related
to I igure S-4) is 0002-1037-04.
The drug manufacturer number 0002 is assigned 10
J
Eli Li lly, Inc.
Figure 56 The product, pheno barbital, is coded 1037.
111e si1,e o f the conta iner is drsign.11ed as 04 for 1000
lablets.
H E G
iHll I. Manufacturer's Name
I ,-,., NDC
1If,. JI
I
'rhe name of the manufacturer, sometimes with the
address. is found on the label (see Figure 5-6).

I =-=
---~-
ROeRIG . . ~'
I 11'" ~
!1
;;JI I
11, s
I !I
i
J. Expiration Date
' I he expira1ion date is the lase da ce for safe use o f the
med ic.11ion. After this date, the drug s hould be d isca rded
(sec l'igure 5-5). Lot numbers are also included with the
figure S-7 expira1 ion da1eso that ifa product is recalled, the patiem
can be notified and 1he medication either d iscarded or
returned 10 the manufacturer
F H
K. Labels for Controlled Drugs
The symbol for controlled drugs and a ,,..arning that the

-
- - 0
... """"' ""'"" Mo40t medk.uion may be habi1 forming are found on medica-
KEFLEX* tions 1ha1 are listed in Comrolled Drug Schedules (see
Figures 5- 1 and 5-3).

J G E about use or special handling of medication (S(!C Figure
Figure S-8
F. T 4mount of Medication in Container
Ih, .u '' <11111 of medication in the container is ind icated
hy th 1r l ti number of 1able1s, capsu les, a nd so o n of
'<1lid 1 t lnrms of medication (s.!e Hgure 5-3). With
01~1 1 ""' I ""'<lic.uions, total volume of medication in
the u.un<r and weight per volume of medication are
indud I on 1he label (Figure 5-6). Medications found
in f'O'dCITJ fonn for recons1i1u1ion to a liquid
C:.h,1p1 r '!) will provide 101al weight of medication, as
''"'ell 11~ <onc~ntration after rcconstilution for eith er
injm.1hl~ or or.11 medications (figures 5-7 and 5-8).
L. Auxiliary Labeling
F The auxlllary labels placed by 1he pham1 acy give spe
cine additional infonnation and advice to the patient
5-8). 111es.! labels include s1oragc labels stating that the
mcdicauon must be stored at a cenain temperature and
under cenain conditions. More 1han one direct ion may
be found on a single label, with insu1.1c1ion> for pa1ients,
and precau1ions and cautions for 11se. Auxiliary labe ls are
no1 M!Cll o n a ll containers. bu1 1hosc needed for pa1ie111
s.1fc1y with a specific medicatio n arc.
Labeling of Over-The-Counter
Medications
c- OTC medications can be bough1 by an)one, but many
people do not bother to read dirl"Clions on the label
and fabely believe tha1 becau~e the mwica1ion is
avai lable without a prescription the ingredients are
72 !ION I General Aspe'1 of P11annacol09Y

IOX ~ 1 FOOD AND DllUG ADMJNISTllATION !FOAi

lAIEUHG GUIOEUNES FOR OVER THE -COUNTER
MEDICATIONS IOTCI

~
.a.erse
10 Slllp using h aug
~
Yl IO
:tJOllS end c:osage chal ORilNAL l'W'lllf
bil mnber
1lJf'( ol contents
'iltlOll ll.Jte 30CHEWA8L
TABLETS I
FOIL PACK(

noc h.11111(111 lk.'\.lU\t' 1he I edcr.11 Irade Commission

rt'Wf\111/1'<1 1h.i1 m.rny CJIC mcdica1ions were being 111 ~! II~
0088- t 175-30 J
ml\U'>('<I. llxI guideline~ wilh mor~ ~dfic informa-
11011 ,.,.. now 111 plJcr lnform.ulon musl be in a rec- Figure 59
t>!(nl1ahk .mJ si.111dard11.;'d formI 111 a language lha1
I\ u111.k,..,tand.1bk by mo\I pco11le ror inform.nion
lounJ tin l.lb<I\ of 0 I(' nu-J1cations. rcft.r to Box 5-2
and I 1(\ur< ~ 9 ~Blf I 1 THE JOINT COMMISSIO N OFFI
USE" LIST -

ORDERING MEDICATIONS 00 NOT USE iOLO USU

ABBREVIATION I TERM
\11-J1c.11Km dttml'd nttdt-J may be ordcml for lhe u(ur.itJ Unit
p.aucni b) mtIM of tither a procripuon or a mediation
IU llntematJOOa tht) Intern.':' lklt
orJ<-r OrJen mJy I>< wn11cn ordm or dtronic ordets
as p"-..:npuon' meJicat1on otck" ,'tfbal ordrn. or 0.0 . 00. Q.d qd (da ly) Daily
s1andmR orJcn Ille uft-.1 anJ prefttable form for order- 0.0.D. <m. q.o.d . QOd (ewry E-.'f\I o day
ing mt-.l1Cauon\ 1\ "nncn, U<h .u pmcnptions or elec- fAher day!
tronic tran<m1'>11>n ~tanJarJ medical abbre\i.luons are Trailing ll!IO (X 0 ~I Xmg
ohen u:J a\ meJ1cal shonh~ I.act of lead1119rem1.x mgl OX mg
MS. MSO. MgSO, morp/? ulfate
Common Abbre viat ions Used in
Prescr i ptions and M edication Orders
ll1e .1lhtd helth pmf~s1onal mus1 be familiar wilh
inside the back cover of this texl Ri 11 \ Ihe loint
Imm .ind .1bhrev1.111on> US<.-J in writing prescriptions or
m1-d1CJU011 ordcn Ih~ abbrev1o111ons come from J.atin
Com
. .mss1on. -r rfC) made rccommcnd.1111 "' 111 "'' ofli
or c.m:k words, ... shonhand ror dtrecllons. and are aal Do Not use list LO prcvenc cmm '" nwtlicdtion
ll'><'d dally m the medical field lhe hst of common! .admi nislflluon.
Mowcver. these ~hh11' 1.11ion1 are
u~ s1and.ud abbreviauon>. such as qid, tid. q4h, an~ mcluded in the abbreviation li11of1hi< 11\I hl'1.tu>e ust
IS Still ~11 111
. , h
the like, for wriung prescriptions or orders can be found . some ambula1ory rncdtc.11 sl'tltn~< ,rnd t t
meanmg mus1 be known [1:1ble 5- 1).
 CHAPTER 5 Reading and Interpreting Medication Labels and Orders and Oocumenung Appropriately
Only standard abbreviatioos should be used as shol1hand
n.. abbreviation must be understood bv other healtll ca1e
r'IJ llS$1on31S
prew1p1 on 1s a legal documellL and 1oca1 abbrevia
1 "" Of 1hose not universally accepted. should no1 be
included because lhe prescription could be m1smterpre1ed 11
nol filled locally
When used appropr1a1ely. abbreviauons are a clear and
conc10 means ol writing orders, whether on a prescription
or med1ca11on order.
Ve .I Orders
\\ r ~ ph\'\ICta n tells an allied health 1>rofessional
\\h1ch d111g or Jru~ 10 administer to a patieni. 1he ph~'Si
nan 1< rn1g .1 'Crb.;tl order (V/ O). The order is for a
111tn1 .rnd designates the medica1ion 10 be
c turm o f 1he medication, time. and rouie of
,111on Orders should not be routinely given
'" rh , '" .111" o f the possibility of error and confu
\ lllll 1 V<'r, when an order is given verball y, 1he
per.><> ' 'IVi1111 the order should read ii back 10 1hc
I'"'" loe g.we it. If 1here is J possibility of confusio n,
1 1lw drug n.rnicsounds like o ther drug 11.uncs,
1t11111 name should be spelled to reduce the
11or Oowmentatlon of all \erba l orders
1r<nmphshed as soon as possible to pr<"'ent
dm1ni,1rauon of the medication. wo should
J 111 the wriuen order to show tha1 the order
>II" en /..t'g,dl}: any order not t/oromented /uu
j<Jm1~,/. 10 ensure correctness, the order
n ti< countersigned by the person gMng the
on J~ po~sible. If there is a question concern-
! or,l.r, .1hv.l)'S get clarification before mcdka
t1t1n ' 1n1~1r.u1on or sending the order to another
h..111 il"'ional.
l'h\ i. m.ty h.we &l.;anding orders that are as~igncd
for n rn 1fic instances. An example of a standing
1ght lw 10 give a specific antipyretic. such as
htn, 10 a child with a high fl'\-erwho is waiting
t ph) \ln,m l'hysidans may also use a slndud
"hich 1s a signed se1 of orders to be used
1fic procedures; an example is the use of a sup
po a l.ixauw. and/or an enema before a colon-
o'"'fl) s1.indard protocol" may be the documema1ion
wmt,n 111 the medical record; the allied health profes
sinn.11 ~110\V> wh,11 the physician CXpeclS and performs
sped he 1.isk' l'Xaclly ,1s they are documented in office
m~nu.1 ls t he hea lth care worker should ascertain the
73
appropriateness, dose. allergy. and we1gh1 information
before administering med1ca1ions in filling standing
orders and standard protocols for 1he pauen1 or 1ransfer-
ring to other health focili1ies fha1 1he paueni has no
condition thal would cause adverse reacuons should be
=enained Standard protocols and standing orders
should be kepi in a designated place. and documems
should be signed by a physician for lcgal 1>urpo~es. Af1er
drug administration or procedures. docume111a1ion in
the medical record should be performed immediately.
Verbal orders should always be read back to lhe person v.00
gave Ille ordef II there is a chaoce or m smterpreta11on of a
drug. the drug name should be spelled
Physicians use standing otders Of standatd pro1ocols lor
certarn s1tuatLOOS. Both should be in wm1ng and signed by
lhe phys1c1an These orders a1e to be lollowed as 11 wntten
as a single order for an 1ndMdual patient
Belore administering any medication, lhe allied health
professional mus1 ha\11! a working knowledge of the
medication.
Always ask the health care proless1onal 1here is any poss1bil
11'{ of misin1erpre1ation ol orders
Medication Orders
A medication order, telling allied health professionals
which drug or dnug.s 10 adminis1er, ~hould be written bu1
may be gi"en verbally. It is 1101 given 10 the p.niem for
filling at a pharmaq'. but rather is used for administra
1ion of drug.s in hospitals and ambula1ory fodliues. In
the physician's office. medica1ion order may be called
s1muli11s onlers or standard protocols. I he allied heahh pro
f~sional has the responsibility 10 follow these o rders
wi1hin his o r her legal scope of prar1icc, which varies by
state staLuie. nie six componenis of medic;uion orders
.uc listed in Box 53.
BOX 5.3 SIX COMPONENTS OF MEDICATION ORDERS
1 Dale
2 Patient's name
3 MedicatlOO name
4 Dosage or amount of medication
5 Route of admirnsttatloo Ill no rou1e is QM!ll. oral edm n1stra
1100 1s apprtillr1a1e. II there 1s doubt as to the route of adm1n
1strat1on, 1he allied health professonal sho\Jld a/wa;-sask 1he
physician who ordered 1he med1cat1on)
6. Time or frequency of adminis1rauoo
74 SECT~ I GenerI Aspects of P111nnacology
Amedocaoon order rdudes dal patient s rme. medica1JOI
ll!lll dosage. roota of admm1Slf"t1on and frequency of
uauon. much 1kB a prescnpt ~
ml a8*f profess;ll 131 rni!Y legally alJ!tilllSfUr
:tatJan l:lJn av.n:lBI 11 a .ebal rrefl;aUJl crdeJ
~ lie ~'Sal lie $latll II v.!lli:h he Ill !Ile ~
Prescription s - - - - - - - - - - -
/\ P"-s<npuon mJocat> the mediauon needed and
dirm ion' for ust m meet medication nttds of the
pauent for whom n w,1s prescribed Medicines are pre
scnb<.'d Jfter the ph)"ridn (or nur.e praetiiioners .ind
ph)~1nan's assistants as ~110\>ed b) the medical prnctice
act tif th.-ir s1.1te of prw1ce) hAS rvaluated the pauent's
>ymp1oms and h.1~ made diagnosis of the disease or
condnlon that requires medication. Ihe wordpre.<niprio11
comnmnly refm to a shp of papt'r on which a physi
cia1i's orders are wrntcn for compounding, disp<nsing.
or Jmmmering of m<-d1cines t0 a panirular patient. Tht'
ord1-r \hould alwa>~ be re<erdcd m tht patient's mtd1cal
re<or<l /\It hough only licensed health care profe.1Sional1
may ,1gn prescriptions. orten the .1llied health profes.
sional may be deleg.11ed the responsibility of complctmg
the prcscripuon form for signature. llie physician uht
mately has the rcspon.,bility of checking infonnation
for accuracy before signing.
Prescription Preparation
--''--------
11ny <lru.g _not availa~lc as an OTC drug requires
a prcscnpuon. l'll"iCnption orders may be wrincn
on .1 prescription blank or sub111h1ed electronically
, hnnacist t0 dis1>ense. No m,rncr how tra.
1or a p " n~
. ed prescriptions have several p.ms-four 1.,
milt , .....,, (su""rscrlpt I on, m)cr I plum, . sibnt '"II
are requ r< ..- ..,. urt
(Sig or stgnaJ . and ~ubscrtpllon) with Oth!t
'
. na1 1 nformauon-and should
opuo . , .llway, . be wn'tt'11
.Ulpt'nnanent blue or Mack .
mk. r
I It)"> it 1ans also
r Ult
computer.generated presc.n puon 1orm~ or refills. 'Ilic
ph)~ician ne<>d only sign these rnmpuier-prin~
blanks. !.ome physicians prefer blank\ th.u ha\'e ~
for one medicat_ion per s~~t. whert:.1' others ~
prefer multiple-line p~escnp110~ .bl.rnk' lor patients
whose conditions require prescribing ol \t'Veral med~
cines at the same time. If not all presniption lines on
a multipleline form art u5'!d. unuM'<I lines shouJd
be crossed through. rhysicians should tll'\n sign Prt
scription blanks that arc not preraml Im a specific
patient.
Some states require a. muJtiplenll'' prescription
progtam (MCPP) to dt'ltr illegal dl\~r" 1 f drugs. In
those states the physician is required tn 11e prescrip.
tions for Schedule II controlled ;ubst.t nu triplirate-
one copy for pharmacist, one for till' M.lll drug .tgency.
and one for the physician's records. 11111111 l<-copy prt'.
saiptions art not used. man)' offices 111.11. practict of
copying all prescriptions for the mcd1r.1l r "rd to llact
the source of possible errors if needed
Parts of a Prescription
1l1e following descriptions should be ro1111 1<-<l with 1he
sample prescriptions shown in Figur~ ~ 11
UneA
Prescriptions arc preprinted with the pit\ 1.tn's name.
address. and phone number.

Uw<"""" Mtny. M 0
A " Slrttt ll'ICI Jonel Avt
Holly,OA00,11
"'cwll 00 I .560-21 11
'---Mony. MO
... s..." Jcit"'9"""
,...,.....,. ...,.,..., ,
Holy GACOlll .-.. ~ , ~. ~.,...r
....,.. 11.-.nJt
.l4 A i. .
lQ. ........ Nomt """'-""" O.ta ""1a2f>XX

k
Addrw f@Jr:=::yU15.t""'1:...,if'A.

ll ..... Z!SO..,," .. ~
'
ti ,. "'
L .. S..'"""''t0..,. .. .f. ij ,.
 CHAPTER 5 Reading and ln1erpreting Medication Labels and Orders and Oocumenting Appropriately
Line B
The pa1icn1 hc.1ding indudes the patient's name and
address. da1e the prescription was wrinen, and patient's
age if a child lhe date is important because prescrip-
tions mu' t be filled within 12 months of writing. and
some prcscrir1ions may be refilled for t2 months af1er
initial filling. Pre'><'riptions for Schedules II through V
conirolled sub~tances must be filled within 6 mo111hs of
original d.u c. Variations of this may occur with individ
ual ph.11 macics .ind st.ne regulations.
Line C
the superscrirHion rontains the symbol J~. meaning
' take 1hou" o r 'recipe:
Line D
th<' 1nscr1p11on s1>ifit'S the name and strength of the
druK L>r IO!;<l'\limt\ and the quantity to be included m
each ,lose tht .lmounl (weight) of the active ingredient
shown s 111 mil ligrams. or other pharmacologic weight
found in '" h 1.1blet. c.1psule, or 01her dosage forms.
Weight "'u.1lly indicates the strength of a medica1ion,
1111 n .is 1 fh11d 11w.1surement indicates the volume (e.g..
mi111ht1 " l'l'POOns, ounces) of the medication. If med dst has the correct medication and dosage before con-
icinc t. liq111d, the concentra1 io n o r weight per fluid
voluom '11 h .is mil ligr.11ns per milliliter is used. If it is
a 10111. I """litlion, Lhe strength is indicated by 1hc
pcrcc111 '\ nt thl' medication in the vehicle.
Line
Ille M or "gn.lturc (Sig) gives the directions. usually
in at>hr " lion\. for the patient for taking the mt'dira
1io11 1 1luec11ons should include the route of admin
1w.11 n ml tht kngth of ume the patient is to take the
med lt n 1f applicable.
Line
Thr '"r riruon deign.11~ the number of doses. quan
lily tc I .r1,p1t1\t'<I, .md form of the drug.
Line
for th prisnip1io11 10 be a legal document, 1hc phY'i
coan 1111 1 \lgtl 1he bl.ink. If 1he physician wan1s 1hc
r au, 111 " r<' dw d brandname drug. he or she mus1
writl' n 1hc prl'~ription. "Dispense as Wrinen, Rrand
Nee,~ or Medically 'lecessary: rermissibili1y of
subslltUllJJtl ~ n<'ric drugs for brand-name drugs depends
on la ' of each state Many third-pani insurers require
USt' of gr nenc medocations if no medical need is dOCU
"'' llh ~ r br.md name drugs
Line Ii
The h11<' designates the number of refills perm in ed.
Thi lonr ~houl!I nwer b<' left blank. If no refills arc des
ign.urd, ei1hcr ' none or o should be insencd. The use
of " 12" or ' rm will allow the prescription 10 be fi lled
75
as needed for up to a year. Permined refills expin.' if not
used within a year of initial filling.
Une f
lhe line for the Drug Enforcement Administration
number (DEA number) may be found on prescrip1ion
blanks This number is required for prl?)cribing con
trolled substances. To prevent abuse of com rolled drugs,
the DEA number should be wrincn only on those pre-
scriptions that require its use; these numbers should 1101
be preprinted. The heah h professio nal's state license
number is required on the prescription pad for 1hird
pJny paymenL~ in some states.
Before prescriptions are 1ransmi11ed to the pharmacy.
1he patient's record should be reviewed by the physician
and refill orders or new medication orders should be
documented in the record. If the ph)'$ician refuses to
prescribe for the patient. this too should be documented,
either by the physician or by 1he allied health profes-
sional, showing that the physician refused 1he request.
When transmitting verbal prescriptions by phone. the
allied health professional should a~k 1he pharmacis1 to
read back 1he prescription and confirm 1ha11he pharma
cluding the conversation. If 1here is a chance of
misinterpretation or confusion with o ther nwdirations,
1he pharmacist should spell the name of the urug.
'l11e allied health professional should maintain patien1
confidentiali ty by being sure any faxed prescrip1ion i
either placed in the medical record or d!">irored . l11is
prevents its improper use or the chance that it will be
dispensed twice by mis1<1ke. 'Ille fax machine should
be located in an area accessible only by medical person-
nel to provide confidentiality
. : ..
Prescnb1n9 medications and refilhng prescriptions are ma1or
tasks in a medical office The role or the alhed health profes
sional 1n the prescrip1ion process depends on the statutes of
Iha state of practice.
Prescnptioos are wrinen or electronically submitted orders
for a drug or 11eatment that rs usually dispensed by a phar-
mac1s1 Medication orders may be e11her written 01 verbal
and are commonly used on chnical settings
New and refill prescroptoons are legal documents and should
be recorded on the medical rectlfd Plescropt1ons may be
wrrneo by the allied health professional but must be signed
by a pract1t1one. licensed to preSCtlbe in the state ol practice
All Schedule II med canons requ re a physocoan's signature.
Some states allow the alfied health professional to relay
prescnptioo orders verbally to other health professionals
sucll as pharmacists, other states do not The laws ol the
state where the person is employed apply
76 SCTIUN I General Aspem ol Pharmacology
, Important Facts about
Pre1cription~ont'd
Presc ription Refills
l'rc.cro1l 11on refill, may be conveyed 10 the pharmacy
dther In wrh 1ng tll elemonlcJlly, or verbally over the
phone ~chcdulc II mcd lc.11lonscannot be refilled ei<cept
in an emergency situ,uion-and then only a 72-hour
'"Jlply m.1y be dl,pc1bcd fl new wrinen and signed
prr.crlpuon must he av.ulable al 1he pharmacy within
72 hours of emergency dispensong. For convenience,
1u1lerm Ill.I) phone 111 a request for a prescription 10 the
alhcd he,1hh p1ofess1onal with specific information
needed hy the ph~'Siclan (Box 5-4). Phoned requests
m.1uore the ph)~1ri.1n to make decisions about refills on
the ha\" of 1nform.11ion obtained during the phone coa-
\'Cl">.111on l'hMmacim may also call with requests for
refills In enher mcunmance the allied health profes-
"onal should obta111 the patient's medical record for the
phy>1n,10 to use on evahuung the medication need.
Verbal orders for rrlillsshould be wnuen into the medial
'<'Ord 1mmed1atd)' and the ph)'Sician should coofi.nn
all prescnp11ons lxfore allied health professionals phone
m refills
BOX 5-4 INFORMATION NEEDED FOR REFIUS
Theo 1 .lhn u c,
fhe pharmacy to be called end ts phone numbe< {be sure
ta obta n rhe correct locatoon and nlJ!lber for a cha n
pharmacy!
The rnedl(;Jt on desored. its strength. and the last nme the
prescupuon was refi led
How the pa11eot 1s 1.1kmg !lie med1ca11on
A telephone number where rile p;ment can be reached of
ques1ions shootd arise
Signature of person remvong the phoned request
h 1Sician prefers 10 have p.11 icn1 me~
.often: l~f,\n 3 designated place for t'valuaiion ai
iaken an fthe day because he or slw doc~ 1101 iva
nain mnes o . . n1
ce d' rbtd while exanunmg paucnt., l'lie allild
to be ist~~ional should follow offie< l"<>1<xo1 r.
health pro"~ .
fusion for pauents anu' Ph.mn.1nsts. w-hoo
decre;se '~piions. the allied he.1hh l'rofessi<>naJ
call 1or P . h
should W"" an approJCJmate um~ t e p<:r'><lll can~
piion IO be pho ned 1n 10 the pharmacy f0r
the P~ To ensure the refill will be .l\.1ilable w-
disptOS'"S.
needed. patients should be ms1rucku -~ '.o l.I11 I or 2 d.1)1
"'"
before refill is aoually ~ed. fonh) ( 1glu hour ~ict
of nttd for 3 relill allm--s ume fort c olhu to nouf)' !ht
. con-ing
pauent ....,.. the s1a1us
. of the requ,..,1
When the ph}'Sician rev1e'S the rcquc\l ht or she~
--' on the request form or m.1\ l<><Ument -
note apP'"''" ""'
refill in the medical record: If the pill" 1.111 has not
d()(Umented the refill, the allied health P"' '"on.11who
calls in the refill should document it 11111 <h.uely. l hr
allied health professional should .11,0 h, urc all pr,.
scriplions have been conveyed to the ph.1 in.Ky before
!he medical record is filed and the order\ I1 " ' heen !(nt
before the end of the work day.
If a refill request is denied, the 1>.Hh 'hould br
notified and given ins1ruc1ions for foll n up visits or
inrormed of the physician's concerns II 'u l)hysician
,;ants 10 see the patient, Lhe allied lw.111 r11f,-;1ional
should call 1he patient and m.11 ,, patieni
appoin1men1.
If the patiem uses mail o rder for pr rpt lon<. two
prescriptions will be necessary-one 10 h d .n a local
pharmacy for use umil the mail order I" 11p1ron c1n
arri''e. and the other 10 be sent lo tlw m r<lcr phar
macy for longtenn medication ava1l.1hol If 1he prfo
saiption is for refills, the patient should \ufhciem
time for shipment of the medicatron 1'11 \ \\'hO wail
until the last minute 10 obtain refill, nu\ 1 th.11 doso
are missed because of lack of med 11 nw I the thm
peutic effeo is diminished r-or the p.lllt t h l) C011Sis-
tently waits too long for appm,al ol nu 1oon rrfills.
the allied health professional should , ..i,
about the timing needed for the entrr. 1 ... ,
Important Information a bout
Prescription Refills
~ot refills and mcdica1ron 0tdc 1oodone
111 atimely manner The ~vs c1.1n. and rn son
pract~1oners and physician's a~1stJnls a11
may B11P1M a refill requas1 A refilled Plll3Cl
new PleSCnptoon The phys1c1<in should on<l1 t
of allowable refills
llocumentatron os essfntial An 1111docur 11r 1 d oodor 1$
legally anoneruoty Remember, "Not docurnr 1111 d, not clono'
 CHAPTEJI 5 Reading and Interpreting Medication labels and Orders and Documenting Appropriately
The allied health professional should always check for aller-
gies and adverse reactions before relaying refill requests and
should morutllf for therapetJIJc effects as appiopriate
The pharmaost. the phys1C1an and the allied hoo11h profes-
sional woric as partOOfS to meet prescnptton needs of the
patient This tnangular P'OCess provides checks and balances
'"prescribing med1ca11ons A stenographer's pad placed near
the phone for prcscnpt1on refill requests will assist with
comphance. One column may be used to take the patient's
request in either blue or black mk, and the other column may
be l:Sed for the physician's respoose. preferably 1n another
color 1rl With tlus system. refill veoficallon is easily Ylewed
The U S Depanmem of Health and HumanServices has adopted
t :eans of prescnb1ng medications (e-prescubmg) and
trcmc health records (EHRs~
S i., ding Prescription Pads
1'1"m 11 '" pad~ ~hould be handled cMerully and
'hollld ' s.1fcguarded at all rimes to prevent u naud1o r-
11td lh< pr=riprion blank should be designed so
1ha1 r surt> i' immediately apparent and so that it
""'" 1 b, rnunterfeired or duplicared by photocopying.
C.om 1 t prevention may be accomplished by usi ng
rnlrn d .1pcr, color(d ink, or a watermark or the blank.
i\11011" w.1y 10 s,1fl>guard prescriprio n pnds is to use
r.111 l ,, duplica tes. The o riginal copy of the pre.crip-
ri< n ncn to the patient. and the duplicare is placed
m rh nt\ rt,>cord I inally. prescriprion pads ;hould
haH p ' nnMI number. so that theft of 1he contents of
.1 r pt1on pad can be easily detroed and reported.
It I' d pr.Kure to keep all prescription pads locked
in. '1 ,. pl.1r~. with only ,1single pad kepi on rhe physi-
cian' rn,nn or in a pl;ice that can on ly be accessed by
art'" J ifii-e peMnnel.
Ix r ,n,ed drug abusers and drug seekers can takt>
nu u' or sheet~ wnhout being seen. Drug Skers
forg I \Oiprion' ,ind take them 10 areas where the
ph\. 1 1 s handwriring and signature are not readily
id1 11,fi 1 If the pharmadst becomes suspiciou; of a
fori;" I 111.-c-ription, .1 call to the physician's o ffice for
wrihllion ;hould occur. 11w allied health proressional
huu d heck the mcdkal record to \'erify any prescrip-
11011 hut hould al'>Q inform the physician and verify the
'ta111~ of the prcscripuon if a copy is not in the medical
rtcorJ
Pr<' r11)t1on blanks should be used on ly 10 write pre-
srnp11ons. l'hey shou ld not be used as notepaper. Orders
77
for anything other than medications should be wri11en
on notepaper or memo pads, and o rders for labora1ory
1es1s should be wriuen on a labo ratory requesl form .
Prescriptions sho uld nor be used fo r o rdering stock
medicines for the office. Srock botdes should be ordered
on a pharmacy order form On delivery of these mroica-
1ions, the invoice should be checked against the med1ca-
1ions recei11ed, and the invoice shotdd be filed with the
records of the o ffice.
' . . '
A safe practice for legal pro1ect1on is to add a copv of all
prescripoons to Ille medical record If carbooless prescnpbon
pads are not used, the alhed health P'Ofess1onal should pho-
tocopy 1he written prescription.
Prescription pads must be safeguarded against theft and
misuse and should be IJ'mted lo prevent coumerfe1ting or
photocopying of blank sheets
Prescnption blanks are never to be used as notepads but are
used only for wronng medication prescnpnons Orders fOf
laboratory tests should be on a laboratory request form. and
1nstruct1ons sllould be written on memo pads. not prescrip-
tion pads.
SUMMARY
Allied health professionals have responsibiliries for
reading. interpreting. and documenting medication
o rders. Th eir duties may incl ude writing p1escriptio ns in
prepara1io n for a physician'ssignnture. Al lied hea lth pro-
fessio nals may be allowed 10 relay prescripl io ns verbally
10 a pharmacist, depending on the medical s1a1u1es of
the stare. To relay medication ordeis or prescriptions
correctly, the aUied health professional musr f..now medi-
caLions prescribed by 1he physician. Medication errors
can occur because of si mil arities in d rug names; there-
fore allied health prorcssionals sho uld be carerul lO
repeal all verbal orders to rhe physician as he o r she gives
them . In relaying the informaLio n, me healt h prores-
siona l should ask the pharmacist or nurse (cg .. in an
inpatient facility) to repeat rhe orders.
Tht> allied health professional needs a working f..nowl-
edge or the pans or a prescriprion and abbreviarions
used in writing a prescriptio n. Refills of prescrip1ions
have a majo r role in rhe medical o ffice. Rerore 1hc physi-
cia n can evaluare the appropriateness o f refill requests,
Lhe allied health professional needs to obtain informa-
tion from the patienr concerning any adverse ceanions
thar mighr have ocrurred and whether medicarions
prescribed were taken properly. Proper documentation
of refills is an imponant task of rhe a llied health
professio nal.
 w

RE
In
12
Scenario
O; s ~ c wn:a presetCLcns tor J Re tor medications for her arrhmis. She takes
itJuptofen 600 mg htlN mes a dar-'l 11reaHas1 111 che midaftemoon. and ac bedtime Ibuprofen
~ ro M wen..., tood. "flll:h maybe snack at bedr/tl18. Dr Merry wants J. to have a 1-tnonrh
~ rMY bB re'lied three !lf1ll1S AJso needed is Extra-Strength Tylenol
tl
~ ~ce
luPPIY a a lllJM! rhll
cap!e lllllltY 4 ro 6 ""'as need8d /or pam F1naOy. one Norf/tJ>. 1QO-mg tablet to be raken
da~11111tt111lr.is1 and t>edr1me .s prescrbBd This should also be for a I-month supply
I1
1 What PfMCrlptlOl\5 need
What oocumentatJOll 10 be
should bewritten?
included in the medical record for these medications?
2 Is there mc:licauon order that needs no pr05enp11on' If so. what wr111en ins1ructions are needed?
3
I~

16

In
SU

17

1 Wh.u is the generic narncl

4
1\\ hhJtJurrii~~thehetrade -,;:-;:;:;=====----.....:========
2 What the nJmel -=======-------------
stor.tgl rcquarcmerusl

minurwu1crs name!=====--------======
~

6Wh.1115is osage =======---==========-

\\'hat c;iutioM ;aregl\<nl
1

~ _,;;======~---==========
the explr,111on d,,:-:
,e;I

897W
Whathat' dstorg.: COnlJl~:IUI ; :OC~c~od; -I-=====------=======--
e mcni:th
th
is the manuf,1t1u1t(s
What IS the e
=====---=========
t 0 \\1m " the mu~I doSt'!
1 ,~,'CTI~I========~==========
-

11 \\'hat are the warnings

 CHAPTER 5 Readmg and Interpreting Medrcetron Labels and Orders end Oocumenung Appropriately 79

rading and Writing Prescriptions

the following exercises, interpret the o rder o( the physician .
. ,, 11\eflcx 250 mg #20, Sig c.1p i po qid with food

.IAl Breth inc 5 mg #JO, Sig; tab i po tid

- 1. .1 llc~tori l IS ms #10, Sig: cap i hs pm sleep
~~~~~~~~~~~~~~~~~~~~~~~~--

I/ I "'Proxcn \cxhurn 275 mg #60, Sig: tab i tid

4' luroscmide lO mg tabs 190, Sig: 40 mg qam and 20 mg@ I pm

th folk wi ni: c.<ercises, write the prescription for signature by the physician. Check a dnig reference to be
re t', ""''Ile I~ .1ppropriate. If the dosage is incorrect, n1.1ke note of that fact.

11. M~rry w,1ois Arthur Rice lo have ibuprofen 600 mg rnblcts four times a day for ten days for his arthritis.
.[
llwrrofon should be take n after meals and at bedtime with a snack. Decide on the number of r ahleL~
.t I u w 111pli.111cc. 11w prescriplion may be refilled three times.
"'

Lawrence Merry, M 0
4th Street and Jot-. Ave
Holly, GA 00111
- 001565-217&
Palktnt Name_ __ _ _ _ _ _ _ Date _ __
Address_ _ _ __ _ _ _ __

ReM _ _

OEM- - - - - - -
 h to ha'-e a prescription for Tylenol No. 3 for
~ ttun fdl and mnuml h<f kg. Or l<fl};nts; she ma)' take one or 1wo tablets every four~111 21
I lie wanu lht pmalPCloa ID :allo h<f th~ lt<let>.~ Dr Merry's DEA number is AMO<JOoooo
houn n nttdtd (or p.a lytmol ~o 3 b control <U .

a Can lht pn:oairUo11 bt rr611td \n 'o

b Can gmmc oubsli!lllt bt u>td \n 'o

......,....,...
...- - - -- - - Date---
Mlltlll~~~~~~-

-- Do
I? ~ Or \Im) hu ottn '-"', llli ;,gr l. r"r a ba.aerial upper respiratory tract infection. I le wa11:' her to hJVt 01>
~ prncnpuon for ~ ot ol tm<>X1t1lhn \u.<pension. [Write in lhe apothecary measure.) She " to be gh'ell 22
unr 1<-.upoonful 1h1t"t un11: dJy for 1en day-. or until all !he mooication has been taken. No 11 !ill.

l.8...,noe Meny, M.D.

111 Street and Jones Ave.
Hol'(. GAOOtlt
PflOl'lt 001-556-2176

"*------ - - -- Date ___

~---------
II

20 r.l llr
~
DEA---- - -

\\tny al<O want\ \uMt to ha"~ some llenadryl for h

llen<lryl l1<1u1d ror ~u;ie. wnh orders for h
no<e.
---,r
II . . ..
IJlk h a erg1c rhrn1M. I le o rders a 6 o 1nce bottle ol
eno e a a teaspoonful eveiy four 10 six h<11 rs for runll)'

l.8..,,.nce Meny, M.D.

lh &reet and Jones Ave.

=--------
Holt/. GA 001 ti
Pt.,,.. 00156&-2176

o.i. _ __

Relill_
DEA------
 CHAPTER 5 Reading and lnterpreong Medicahon Labels and Orders and Oocumenong Appropnately 81

21 ( I Or Mcny wants H)'wants

tension to
pn..,~ure. Or Merry
ta~
1.opressor 50-mg t.lblcb Jt breakfast and dinner for his high blood
1ableb dispensed now, with refills for 1hrtt months. but he wants the label
60
10 r<mmd I ly 10 get his blood preMure checked once a week .111d to call the office ir it drop~ twlow 130/70.

l..llwrence Metry, M 0
41h Street and Jones Avt
Holly, GA 00111
Phone 001-555-2179
Pa!Jetll Namt_ _ _ __ _ _ __ Dtie - - -
~--------~
R

AellU _ __
DEA#-------

Doc tstion
Dcxu 1hc lollowing exercises as they would appear in a medical record.
2l 1 hnn(!.' the following medicines from other physicians 10 the office 10 be included in her medical record:
d1i;oxm 250 micrograms, 1.1ken daily at breakfast

h 1111lnmethacin 25 milligrams, taken three times daily with meals

mkd1pme XL 30 milligrams. taken daily

d I """''sor 50 milligrams, one tablet taken a1 breakfast and ag.1in at bedtime

a ldlnmophen 325 milligrams, one or two tablets taken every 4 to 6 hours as needed for pain
SECTION
Math Review

Converting fractions and mixed numb.,rs to

ldonttfy ng ll'OP r mjl(opcl and equivalent
docimals.
tractoons Add ng, subtracting, multiplying, and 1111ding
Chang.no imptopcr tracuons to m ed numbeB
decimals
Roduang trac:oons to lowest terms Chang ng percents to decimals
Finding the lowes1 common denoo11 1&'0f IOf
Chang ng decimals to percents.
tracuons
Mult plying and dividing percents
Add ng sublractmg multiplying and d viding
Using fractions to figure percents.
tractlOlls and l'llled numbers
Using proportions to figure percent
Rounding decimals to whole numbers, tenths,
huoorlldthS, end thousanclths

Declmet Improper fraction Mixed number Proportio1

Denominator Lowest common Numerator Proportion 11 method
Dividend denominator (LCDI Percent Quotient
Divisor Lowest common Product Ratio
Equlvetent fraction multiple (LCM) Proper fraction Reciprocal

Chapter 6 PRETEST

Frac1ions and Mixed Numbers 37

Wm the folluw1ng ,1\ Improper fracuons 4, -=
4
3 73
I, 4'.j----- 5. -=
9
1
2. 6
2 Simplify the following fractions 10 thr In , 11em1s
tA1rwen the follow11111 m mixed numbcn
Answers will be whole numbers.
144
) 15 ..
6 ----
6. n---- - -
32
7. 8 "-- --

84

Chapter 6 PRETEST-cont' d
-- --

~0 11.. Simplify to the lowest terms. 24. 72.S 66.409 = _ _ - - -

1
11 <3--7= - - - -- 25. 66 34 66 7 + 91 .3
3
3 I Solve b) muluplying decimals Round answer to the
11. 8-2--4 =
4 7 ----- neare<1t thous.rndth.
1 2
10. I +'i--2-= - - -- - 26. 7 .214 x 124.35 =-----
6 3
1 1 27. 27 x 0 0001 = - - - - -
11. 4 x6-=
l 3
1 I 28. 61.0001 x 34 .75 = - - - - -
12 1 X:; =
< ' Solve by d1v1ding decimals Round answer to the
I 2 nearest hundredth.
11. ) x4-x 3 a
3
'
11
29. 98 5514 + 88.58 = - - - - -
14 l=
8
30. 47 5 + 22 =- - - - -
I r, 4I 'I -
~--
'i Percents
Change the decimals 10 percents
0
31. 0.050 = - - - --
Ho11111 tli" decimal 10 1he nearest whole numher.
32. 0 172
I f1 64 =- - - - - -
Change the percents to decimals
17 ) 2

R1>1 " th< decimal to the nearest hundred1h. 33. I 10% - - - -- -

34. 47.55%= _ _ _ __
I H 88.0lO =-----
35. 14.88% = - - - - -
l'J I UOIO = - - - - -
Muhipl)' percents.
20 000 0016 =- - - - -
36. 6% of 17 = - -- - -
( ( }\ l the franion to ,1 decimal.
l 37. 25% of 34 = - - - - -
ll
Divide percents. Round the answer to a whole
number

38. 3 i~ wh.u percent of 701 - -- --

~ll\c by adding or subtracting decimals Round
.1n ''l' to the ne;tres1 tenLh. 39. 12 i~ what percent of 60? _ _ _ __

ll. 80 - 54.33 + 17.21 = - - -- -

40. 25 i1 what percent of 175? - - -- -
 d Dosage Calculations
86 SECTlDN 11 Mthemat ca for Ptiarmacology an

Ratio and Proportion .

\olw for the unknown prrccnl Sohv for x using propomons.

41 , Wlut IS I 5% or SOO! - - - -
46. 2:x :: 100:300 - - - -
42. What IS 90% or ')01 47. s:I00::20:x _ _ __

\olt for the unknO\ n number using proponions.

48. 4:x :: 8:32 - ---

t:soo:: ~:x - - - -
4 I . 20 is 60% of what number! - - - -
49.
44 . 4 5 is 25% of what number! - - --
1 I
so. 12:x::2:200 - - - - -
15 . 48 is 30% or wh.11 numbtt1 - - --

EXAMPU 3: In the fraction !, 5 is the n 1cra1or and

FRACTIONS 6
s1a1es how many equdl pit'< of the Pizzi
I w1ions. used in the apothecary and household sysrem, have been taken nie denor '' 11or 6 s1a1es
.He ,1 method of writing a whole number 1ha1 has been that there are six equal picc, ' make on'
divided inro pans (eg., 1, 3 2 ) I ranions are written
2 5
whole piua. So ~ of the I' "' has been
with , numertor (number over rhc line). ,1 li11e caken.
(meaning "divided by"), and,, denominator (number
under rhe line). When rhe number 111 the nu111era1or is
d1v1ded by the same number in the denominaror. the
equivalcnr is I
2 3 12
EXAMPLE 1: - = I, - = I, - I, and so fonh
2 3 12

Proper Fractions
Wirh rroper frctJons, the numerator is always a lower
number than the denominator
EXAMPLE 2: In the fraction.!., I is 1hc numernror and
2
2 is the denomln.11or. lfa pi1.za is used as
an example, the numerator stares how
many pieces of pi.7.z.1 have been taken, or
a numerator of I '!he denominator of 2
states how many equal pieces 1he whole
p~ has bttn di'1ded into, or 2 equal
pieces.
Improper Fractions
Improper frllClroru are fractions in which rh 11 mera1or i1
equal 10 or grea1er than the dcnom1n.11rn 1 example
if two or more whole piuas .ire l'qually 1 1dro and a
ponion is taken, an improper fr.inion , .1 he formed.
Improper fractions can be simplified 10 sh1, how many
whole pizzas+ p;tnial 1Jiu,1s (ricccs of I'' n ) exist. A
wbole number is formed when tht' 111 ttr.uor and
denominator are the s.ime or 1he 11u1111utor can be
divided evenly by the denominator A "I le number
plus a fraction occurs when the numcr.11< , not divis-
ible evenly by the deno111ina1or The fr.1111 1.11 ponion
left foUowing division iJ 1he remamdcr

EXAMPLE t If a pia,a IS CUI into 8 t'\jl pieces .ind

CD t
we take all 8 pieces, the 1111 p
to express 1his is
8
11u 1 uon ~ 1~
!
er fraction

8
considered 'improper he< '"'" a whole
nun1ber can be bhown i11;1c,1d l11e whole
number would be 1.
 CHAPTER 6 Math Review 87

Two piu..is would be needed 10 increase lhe numera-

Simplifying Fract ions
ior to a number larger lhan 8 With two pizzas, each
to t he Lo w est Term
being cquJll) cut inio 8 pieces, 1here are now 16 possible
piece; ,,, numerators (8 pieces from o ne piua and 8 frac1ions should be reduced 10 1he lowes1 terms, or sim-
p1ercs from the second pizza). plified. 10 simplify a fraction, divide 1he numerator and
denominator by the larges1 number that d ivides evenly
EXAMPLES: 'l\vo pizzas cut into 8 r>il'CC> are available, into both.
and you take 11 rierel>. nie improper
fraction to describe the pizza 1aken would 3
EXAMPLE 7: Ilie frac1ion can be simplified 10 iis
6
be.!...!.. lowest 1crms by dividing the numera1or
8
.
anddenomma1or by 3. 3- + 3- = -I
6 3 2
Equivalent Fraction s
1.qu , tr <lions show rwo or more different frac- And 1he larges1 number 1ha1 wi ll equally divide iruo
tions 1h.11 ,ue the same portion of 1he whole. Equivalenl 4 . 4 4 J
IS 4: +-=-
fr.inion' (qual fractions) can be simplified 10 1.he same 8 8 4 2
frat tion
Hnally. Lo simplify., the l,irgcsl number 10 divide
1111 fr t1<ms have differem numerical values but are 12
I 2
ftJUI\ 11 nu r.11ch as - and -. by is6 .+~=.!.
2 4 12 6 2
3 4
EXAMPU 6: One pizza can be divided into any number In lhos example, lhe fractions , , and . are also
''' equal pieces, such J~ 6 pieces, 8 pieces. 6 8 12
equivalent (orequal) fraaions becau~e when divided by
or even 12 pieces.
1hc largest number possible, 1hey are all simplified 10 1he
same final franion of.!.. Therefore i1 can be stated 1ha1
2
'\ 4 6 1
- =-=-.
6 8 12 2

EXAMPLE I:
One p!ZU, 8 .,..... One pczza. 12 poece$

, . . h' I 6 8
lh 111;1lt nt 1raCUOnS 10 t IS ex,lrnp e are 6' S'
I
anJ '" h pi1"'a were divided into 1wo equal halves,
1
1hc cqu ' lo m lr.1c1 ions for each half of1he 1>izza would
3 4 6 ~ 1 of the
8
2 1 oflhe
1htn n ,1\ -. -, and -. 2 plua r2=2 pizza
6 8 12

our Understanding: FRACTIONS BOX 6-1

- - ---- --
ltkn:1l) c" h fr.1c1ion; wri1e {P) for a proper fraction, 6
{I) ltr "nnproper fraction, or {Ii) for a fraaion 3. -=
5
~4 11 11 lo I
I
I.
4. -=
2
3
I 5.
2. 1
Ill

Co11tir11ud
 nd ()osage Calculabons
LUlllemll:tS fllf P!ia:l!'l colOQY I

Change to as many equivalent fractions as pos:.ible.

6 -
II
5 u.
30
-=
90
7.
-..
3 6
12. -=
14
8
20
30 - 13.
IS
-=
60
9.
-
l
I 14.
8
-=
32
2
10 10
I S. - =
40

EXAMPLE 10: Always simplify the fraction '" us lowni

M hced Numbers possible term If we had tal r 12 pieces
I proper fr Uo are th00< an "hich IM numcrtor of piaa from l:Umple 5. improper
"grcattr thn th drnomumur \\hen an am proper frac 12
fraaion would be - an the mixed
tmn "~1mphf1fd ,ind wntten with ,1 whole number and 8
.1 fr.1etiun . the "''uh i' CJllcd J mlud number.
number would be Ii wl " h can be
EXAMPl.E t: In Lumplt S two pu.z.is Wert e.ach nil . 1~-~ I
into 8 paec:~ and II pieces "ut l.lken samp ''""'to 1-.
2
lht unprorer frmion of .!..!. can be
8
;unplified to I ~. meaning one whole The mixed number for 2.3. 1.!. (one wh '"' pi1.2<1 ~nd
8 8 2
ptl.IJ plus thrtt plC' Of the second piaa ~ of th second pi1.za).
\Wf< loll.en

Remember 10 l.ecp the 8 .ti tht denominator bause

h<11hpi.ua .U<' cut Imo 8 pieces
II
Ih ereforl' the Improper fraetaon is - and lhe mixed
number" 1-' 8
8

Improper fraction 12
8

. Shoncur: When changing a mixed n umlwr 10 an

damproper
. fraa aon, muluply
the whole number and
. enomma1or, lhen add the numerator tu obtain 1ht
mproper fraaion.
 CHAPTER 6 Math Review 89

Check Your Understanding: MIXED NUMBERS BOX 6 -~ - _

- -- -

('h,mge the improper fr.mions to mixed numbers. l

16. 2 -
14 11
I.

2.
..,
l

=
17. 17-c
I
~

l l
-=
l.
ll
~
.. 18. 16

19. 5-
7
5

17 10
-1 . : - -- --
I
20. 70
l
=
5.
Simpl ify to lowest t"rms .rnd show as mixed
numbers.
70
21. 8 = - - --
7
50
22.
24
26
19 23.
'). 6
30
24.
Ill. 4
l5
25. - =
( h e mixed numbers to improper frMtoons 10

II. 26. -759

12. 27.
-
JO
20
10
28. - =
4
70
14 29. - ~

16
52
15. 30.
14

Ad el ract ions and Mixed Numbers I 2 3

wit h Same Denominator The denominators are the s.1me, so -+- = -
4 4 4
To .1dd r cq o ns with the same denominator. .1dd the
l!cfore .1 mixed number can be used for calrnl'iions,
numu.11or of the fractions, then carry fonard the
it often h,ts to be changed to an improper fraction fo
dcnomm.11<1r. Be sure 10 simplify improper fractions and
do this. )'OU need to know how to add fractions.
mox,-' " , her.. to theor lowest terms. Recall that any fraction with the same numerator and
denominator is equal to 1 ( ~
I 2
EXAMPLE It Solve: - t - =? I).
4 4
 90
Do !he malh:
UAMl'lf 11: Cung.- i I lnlo n ilnPf"l"f fr.ru<>ll 8 I 8
4 5 . . :5
8. 2. 16
mP I ~ die' ..t>olr nwnb<f llllO (QUJ\"'1ltn1 5 . 2. 10
8 3 24
(r..nlom
5 . 3 = 15
8 4 32
5 . ~ . 20
3 4 ......
4 .. ..
umrnM)1~JI l+Lbtau>C ~=) 5 .5.25
8. 5. 40
56=30
STtp l Add lllf cf !ht fractlOllS .and
mlfll('f.llOn 5. 7. 35
<"An)' (on.-itd !ht dmomlnJtC>r 5 8=40
4 4 4
I ll (4 4 4 I Ill 8 doing me math, v.-e can. '-erify tha1 no number
.. .. 4 .. fier than 40 divides equally tntO bo1h Jcnomin.tlOtt
lhnt-forr IM mb.td numbn l ! i> (Qlll>WI 10 1he
lsMtd SJ; therefore 40 is the LCD.
Replace each denomona1or wuh th< number 40
I) 2 1 3 i
1mJ'foi><'f fr.acuon 5= 40 and3=40
4
2 I
Adding Frectlon1 end Mi xed Numbers STEP IA: Write the firs1 fraction:
5 10
with Different Den omi nat or
t >hrn th J 1 c r\IUJlor ot tr Uoni to~ us...-.J are not STEP 18: Solve for 1 by d ividing lh< lt-nominatQf
du Utll 1K> t14tJ111on.d ~hr\ .lh' Ol"\t. '\Jff bt'(aust the in1040.
lc"'<'>I cornmon J<nc>mtrlJtm mu\I I'>< lound before
""'""!!- I or '""unrh~ ur1~< 1hm .m 1w.> p11.7-'15 The Do lhe math: 40 + 5 = 8
'"" p1u.1 i.1111 oruo 5 ...,...1r11~-- .1ml 1hc M'(OnJ pizz
"tlU tnto 8 flltit'I STEP 1c: Take tlw answer from Step 111 .incl multi
ply it by the numerator.

Do the ma1h: 8 x 2 = 16
The first new equivalent frac1ion is !5 I,,0
8
Recall from Example 4 tha1 S is 1hc \.t 1~ ,1s I. llert
IPIUa.S_..
I potn - 2 8 1<1
is another way tO do me math: - X-
11 l rono rr IALtn from 1hr h.-.i ru.u. 1he fr.ruon 5 8 1ll
2 Continue mis step by 1aking 1he secon .11 llon and
" S II l rono A11' t.tl.tn from me \\"<Ond r>zu. me rq>t>Ating Steps IA. I 8, and I C.
l
trarnon " ll~ 101AI amoon1 t.tkcn from !he two
8 STEP IA: Write me second fraction J 1
2 l 8 10
plU.1' un l>t Jrt<'f1l'lmnl 1,,. JJ1ng - + -
s 8 STEP 18: Soh-e for ? by dividing 1hc , < nom10Jt0f
1 l into 40: 40 + 8 = 5
DAMN ll: '>oh.-: - - f
\ R
STfP I \Ulr l>o1h Jmoo11n.toro me s.ime. STEP IC: Take me aMwer from Step .ind muhi
ply it by 1he numerator
llo lhl\ by hnJing 1hr \mJllnt numbtt lllJI each
Jmom1111or "'111 <11-.J.. 11110 w11hou1 leaving any 0othemam:3xS= 15
1<rn.11nJ<'r lht "ulkJ hnJmg lh lo"<51 common 15
tlcnnmlnIOr (I< I>). llw numh<-r mus1 be lhe same for The scxond new equivalen1 frac1ion ;,
~o
l>o1h lr.1c uuns ~ncl mut he J muhople of 1he onginal
cknurn111.l1<>1'\ !ln.IU\\' \ >< 8 40. '>('( tf any number STEP2: Add lhe numeraiors. and c.1rn lorw.rd the
'""'""' th.m Ill ,.ut I'<' d1>1J,-d by l>o1h 5 and 8 (lhe like denomina1ors:
<knnmm.1111") lhh method I\ JI' c.illed finding the
16 15 31
'"""'' common mulllpl~ {I ( '1). -+-=-
40 40 40
 CHAPTER 6 Math Review 91

' l herefore: EXAMPLE 14: Simplify the fraction in the following

problem to the lowest form :
2 3 31
-+-=-
5 8 40 1323 55 1
-T--+-=-+-= -
STEP 3; Simplify your final answer if possib le. In 5 10 10 10 10 5 2
31
this example, the answer - cannot be
40
tunher simplified

Chee~< Your Understanding: ADDING FRACTIONS BOX 6 -3

-- - - - - - - -- - - - -- - -- - --

Find tht lowt.,,t commo n denominato r for the two Add the fractions. Simplify your answer if possible.
fraction' I 3
ll. -+-=
2 I 2 4
I. -;; I\
5 1
12. -+-=
l 6 4
2.
I I
13. -+ =
l 8
3. ,, 2
4
s
14. -+-
4. 3 8
I I
15. --t--=
7 5
5. -
6
16.
2
-+-=
s
6. 5 6
I I 2
17. -+--
4 1
7.
~
,, 4 1
18. - +-=
8
5 6
I 4
19. -+ =
3 1
9. ,,
6 3
20. -+-=
1 5
l

Sub t1 g Fractions 2
'------- ------ - STEP 3 Simpli fy 1he final fractio n if possible

*.
Sub rr , lions uses the >.i me steps to find the LCD 6
tl) ddtlin , :r "tion~. can be simplified to
EXAMPLE IS Solve: ]_ _ I = ?
6 2
Subtracting Fractions and
snr 1 \lake both denominators 1he same. l'!ie Mixed Numbers
l <:o fo r the denominators of 6 and 2 is 6 .
r, 1 3 Subtracting fractions th.11 use mixed numbers requires
does not change; - bcromes - . you to first change 1he mixed number to an improper
6 2 6
fraction.
STEP 2. ~ubtraa the numerators and carry fomard
.k d . 5 3 2 1 3
t I1e l 1 e cnorn1nators: ---= - EXAMPLE 16: Solve: 1- - - = ?
6 6 G 2 4
 -.. _,_ind Dosage Calculauons
111 !MlllemltiU for rn""''"""''
1x2
STEP i: fle\>"nle as :1x5 = !
STIP 1 Oungt' 1.!. io an 1mJ'fOl"'f lr"'uon (~
2
I 3
I.ump!~ 12) Ii"" l STEP z: Muhiply the numerators, then 1he dcnomi-
nJtors: 1 x 2 = 2 and 4 x 5 20, so the
STEP? '''~' 1h< d<non11naton 1hc ;.ime lCD (4 .
fraction is wnnen as
2
l 6 3 20
Ill tluua><) - - Jnd -
2 4 .a 2
STPl '>ubu.a.t 1~ numcnton .tnJ "mplofy th~ SW' 3: Simplify answer f
possibl e: -
20
=-101
amwn 1( rc...U.lr 6___3 ,,_3
4 1 4 use the following shoncuts to save tim( in ob1ami11g
the answer.
Multiplying Fractions s1wrteu1: Cancel any numerator and denominator that
-'----- can be divided equally by the same nurnhcr. In this
lo multiply'"" lr.uuon~. lin1 multiply thr two numera I )'
ion. 1hrn 111ull1ply 1ht 1wo denomin.11or$ Simplify your
problem. 1he canceling would be as follows ,( XS
am.,<r 1l po"1hll-
l
Therefore the answer w1'II be -I x -I or - I
EXAMPl.f 17 \ul" .!. x _! 2 s 10
1 ~

Check Your Understanding: SUBTRACTING FRACTIONS

MIXED NUMBERS BOX 6 4
- - - - - -

I md the I ( ll, 1hrn 'ub1r.1c1 Simplify Jn1wer when Change the mixed numbers in10 impropt"r .1rlions.,
1J<>SS1hle then subtract. Simpli fy answer to lowest l< 1' \vhen
possible.
I
I. I I
7 ~
IL 16--4-= - - - - -
5 I 2 3
2.
l
3 I
< 12. 1---= - - - - -
8 2
J.
7
8 4 -
I
13. 12.!.-6~
4 7
----
4.
?
10 -- I
l
14.
I I
55-44= - - - -
s. s 2
---
? 7 1 2
l5. 9--7-=
l I 8 3 ----
6. ---
II
4 3 5
16. 3- -1 -=
7. -85 -
16
l
1
8
I
16

17. 4- - 2- =
----

5 I 4 2 ----
8. 7 -
12 - -- - - 7 5
18. 10--8- =
9. ---
2
l
I
6
8 6 ----
1 4
19. 6--5-=
7 l
10. --- 6 5 ----
II
' 20. 14.!.-12! a
3 4 ----
 CHAPTER 6 Math Review 93

M ultiplying Mixed Numbers STEP 4 Simplify lhe fraa1on. and change it onto a
1
l mixed number if po"iblc: ~ = 20
EXAMPLE 18: Solve: l JO X5 = ? 2 2
l
STEP 1 Change 4 - to an impro1:>er fraafon: 2 3
LO EXAMPLE 19: Solve: - x 3 x 2 ?
41
I
3 4
~ -=-
10 40 STEP l Change to improper fraaions

10 10 10 10 l 41
2 3 11
( lmteadof -+ +-+-+-= ,
10 10 10 10 10 10 - x-x- =
3 I 4
multiply 4x10+ I - ~)
10
STEP 2. Simplify numerator~ and denommatOr-$
111'n change 5 to an improper fraction b) placing lhe
s owr th~ I or 2 I he problem now looks like lhis:
-x-x -
11
41 ; I I l 2
x
10 I

STEP 7 <ancel (if po~~ible) any numerator.. and STEP 3: Multiply acros. to solve:
4.h:non11nator'):

41 5 41 /
1
41 I
IX1Xll
lxlx2
--112
-x - -x -=-x-
lt) I }ef I 2 l STEP 4: Simplify the fraction, and change it into a
i
mixed nu mber if possible:
STEP 1 ~luhipty across the numerator li ne and
41xl 41 Il I
denominator lrne to solve: - - - -=5-
2xl 2 2 2

our Understanding : MULTIPLYING FRACTIONS AND

UMBERS BOX 6 -5
- - -- -

CJn the numer.11or and denominator that can be Change the whole number into ,\ fraction.
liiv1tl. I ' 1u.1lly by the ,ame number. then multiply.
Sirnpld when poihle. 6. 17 _ _ __ _

l. 7. 6
8.4 ~ _ _ __ _
2.
9. 12 ~-----
~ g =----- 10. 3 .. _ _ _ __
Ill )( 1
4. = Multiply, then simplify the answer when possible.
12 2
I l I 5
s. x =
4 7
11. -x2 x- = - -- --
3 8
 1 2 1
I
12 2->< 1-><I> - - - - -
I 11 4"3"2=
2 2
1 I
$ I 18. 3Jx11x24 =
11 4 ><1- >< - - - - -
' !) I I 2
~ 19. 2-x2-x2-=
5 4 3
- - - --
U I x~>< 4 - - - - -
111
11
2 I 20. 4x-x3= - - - --
I~. -><I X8 - - - - - 12
~ ~

5 I
II> i 7 x l xl-
7 -----

STEP4: Simplify the frac1ion, Jnd ch.11 ~e ii into a

Dividing Frac tion mixed number if possible
When 1hv1donR fr.1rnon5. inwn tlw wcond fraction (also
c.1lled the fl"< lprt><~I) .111d then muluply the two frac- 3 1
-=1-
11011~ I he r;1lproul ol .1 frarilon lsthe fr.1Ction 'Hipped' 2 2
1
or 1n\Wted lht r.ciproc.11 ol Is !, the reciprocal of
2 I
11 2
tS ~. and so fonh. Simplify
1 4
1s , the rmpr0<al of Dividing Mixed Numbers
I I JO 11
the amwrr .1h.r rnuh1rlicauon when possible. and wri1e To diviM mixed numbers, the mixed nu n ' mu1t first
du .tO\\\tl d\ .a n11ll'tl nunlber be changed to an improper fraction Nn1 11 tc whole
numbers as fractions. and solve by itwcn " 1he SC('()nd
fraction (the reciprocal) and muhirlytn 1mplify if
ncccssaiy.
- '
I
I l
I
EXAMPU 21: Solve:
5 I
STEP t I md tht rt<tprocal of the Sond fraction 3-+2-=1
and change div1~1on ~811 to muluplication 8 2
\lgll
STEP I: Oiange to improper framnn
l I J l
-+- becomn - x -
4 l 4 I
3~=~and2.!. = 5
8 8 2 2
The problem now looks like thi<:
STEP 2 Cancel 1he numemors and denominatoo
that d1v1de e\enly 29 5
- + - =1
8 2
i I'
;
,
-I STEP 2: lnvt'n the second fraction, .111 h.inge tht
sign from division to mulupl 111011
29 2
STEP 3 Mulupl> JCTtl$.1 to solve: -X-=l
8 5
I )( I 3
2 I 2 STEP 3: Cancel the numerators .111.t d1'nll1t1i11Jtors
that divide evenly:
 CHAPTER 6 Math Re111ew 95

I STEP 5 Simplify the frac1ion, and change it into a

29j 29
-x- = - x -
1 mixed number if possible:
i 5 4 5
29 9
STEP 4 Muluply across to solve: - =l-
20 20
2'> I 29
-x = -
4 'i 20

Check Your Understanding: DIVIDING FRACTIONS AND

Ml~~D . NUMBERS BOX 6-6
- - - - ----- - - - - - --
( hange 1he mixed numbers 10 improper fractions. 5

I.
,__4
8. 7 + 2-s
8
'i 4 I
9. 5 + 2-=
~I 9 3
l.
II I
10. 2-+ 4 =
I 2
~. l
11 . 4 +-
s
6
4 4 -
I 3
12. 6-+2-=
2 4
5. 0
5 I
13. 8- +6-=
9 l
D" "l n 'implify I.he answer if possible.
I S
1 14. I -+-=
( 4 ' 36 8
I l
15. 10-+ I =
7. 5 4
1

.
our Understanding : FRACTION REVIEW BOX 6 - 7
- - --- - - -- - - --
Ch.in 10 11n1l roper fractions. Change 10 mixed number>.

I 1]
II
6. -8 =-- - - -
7
2. 2 7. -
2
= -- - -
l
7
Chang o '" many equ ivalem fractions as possible. 8. -= - - -- -
4

.l.
Simplify to 1he lowest possible terms.
8 27
4. = 9. - =
24 4
17 18
5. -= IO.
>1 12

<:Ct11inutd
-------------:---;;:::::::::;:-;;;;~
1ndd Do~s~a;
ge Calculations
96 ~ II Mnlltma!ICS 101 Pharmacology

BO
C he
Xck Your Understanding: FRACTION REVIEW
6 - 7-cont ' d __ - - .---~- -- - ..-

_..,.
I
__
I
2 4
16. 3-x-x-=
5 1 2
I
II.
s 2
2 I 3
l 11 -x-x-=
12. (>+I- . 3 2 8
8
I -
I 18. 43+3-
ll . 7- 2-
l
2 I
I 2 19. 6-+ 4-=
14 4 - - J- 5 2
2 l
3 I
5 l 20. 4-+1-=
IS 1 ---c 4 2
II ~

DECIMALS !lJ LEARNING TIP

u, <inul are~ 10 show~ lr.an1on.1I ran or a number.
\1tinc mea~uremenl) are exri<..,.._'tl as d1m.1ls
lkc1m.1l plam P?t'M co the 1111 of a whole number
1h.11 I\ follQ\\<.'<I by a dccimal poinl 10 i11d1c.11e a number
k<< 1h.in I I( no d1g11 "10 1he lefl or the dcclmal poin~
.1 itro mu>t be in>enc'tl 10 prtwn1 error\ (e ~- 0.5),
The decimal poin1 acts as one place in the decuna
Rounding Decimals
Decimals can be rounded to I he nearesi whole number
or multiples of 10. usua lly in tenths, l11111d redlhs, or
lhousandths. Rounding sho riens a dccim.11 v dropping

----
EXAMPLE 22: Look .11 1h1s number 412 1568 one or more digits to the right of 1hc dcci m I point (e.g.
432 1568
0.76 =0.8 when rounding to tenths)
Wben rounding to a whole number. th , .l1git 5 will
lllr whole / \
Decimal Ille d1mal
determine how rounding will occur. If tht .m digit to
lhe right of the decimal is less than 5, the ", e number
number IS 1568
.. 4l2 does not change and the digits after the d i mal point
aJe dropjl(d. For e.umple to round 76 a wholt
II d<.~mal Glll be con><ned 10 a m1ro number or number. lhe whole number would remain 1>. ro round
lrac11un h) dropping lhe decimal poml using lhe fol- to places in lhe decimal. identify 1he desirt=.I lace, such
lowing rules as tenlh or hundrcd1h, and follow 1hc rut< nf rounding
Tlte d1gns 10 the lefl of lhe dt'timal pohu remain a using 5 as the decision point. To round to lundrcdlhs,
whole number. 16.444 would be rounded 10 16.44.
nie d1gm 10 lhe righl of 1he dt'Cimal point become When rlie ded111t1/ is 5 or lnrgrr, drop th. ,/l'cimal but
the numerator of the f1.1C11on. increase tlte iulrole 11u1nbcr 10 the 1u xt ul/rolc uun1ber. F'OT
1

nw denorninaior, when using decimal. becomes example, lO ro1111d 76.5 ton whole twm/Jei, 1/w 11/wle mmibtr
J power of 10, with one 1..ero added for e.1ch number
would be 77 111ul 1he .5 iJ droppe1/. If ro1111tl111g " lwntlredJ/i;.
or decimal place 10 the right or the decimal point. 88.876 u" uld be ro1111ded to 88.88.

EXAMPLE n Con~n 66 78 to J mi<eJ number. EXAMPlE 24: Round the following J -, 1mals to
66 is lhe whole number thous.1nd1hs
78 becomes lhe numaator 942.0099 - 942 .010 Ill lhis cast.
the fin.ll ro "'OUld
IOO is lhe denominator because 78 "two be dropp<'tl. and ~
places 10 the nght of the dcc1mal poin~ answer ' ould ht
mdiuung hundredth;
942 .01)
lhe mixed number is 66,2! 3.6666 - 3.667
100
0.9875 - 0.988
 CHAPTER 6 Math Review 97

EXAMPLE 25: Round the following decimals to EXAMPLE Z6: Round lhe following decimals to 1enihs
hundrcd1hs
88.569 - 88.6
78.754 - 78.75
12.69 - 12.7
9.553 - 9.55
92.385 - ?2.4
100.4893 - 100.49

Check
--.
.Your Understanding : ROUNDING DECIMALS BOX 6 - 8
-- -- - - - - - -- - - - --
Rmt11J 1h~ decimal 10 1he neares1 whole number. Round 1hc decimal> to the ncare,1 hundredlh.

I. 0 B II. 233 332 = - - - -

2. 12 3, =----- 12. l?.5726 = - ---

3.0'1> 13. 88.8883 c - ---

~. 1(1 ' 4 14. 78.654 =--- -

~. 6 15. 100.0593 = - - - -

,nm,1ls 10 the neares1 temh. Round the decimals 10 lhe nearest thousand1h .

<>. I l 16. 400.0099 =- - - -

7. ' 17. 234 5574 =- -- - -
8. 18. 16161616 = _ __ _

?. l 19. 357.9753 =- -- -

10 . I 1 \ - ----- 20. 357.9758 = - - --

Conv Fractions to Decimals 0.

fo <Oii\ p1oper frac1ion to a decimal, divide the 5~ (5 does not go into 4.
nun1cri1lt' v the c.lenonlinator. The answer \Viii be: a so add n ~c ro.)
fr.lction ' ' 11ole nu1r1bcr, or a deciJnal. 0.8

EXA~ 27- Conven 1hc fraction i to a dimal.

sr;D
5 4.0

SLP IJ1v1J e the numerator by lhe denominator.
J<l 1he number 0 as many times as nece:.
s uy 10 be ahk 10 comple1e the problem.
( lt1 the ex.1mple, 5 will not divide into 4.
hut 5 will divide into 40, so OllC 0 is added.)
&fore adding a O in lhe numcrntor, place
a decimal point after the numerator
number Then move the decimal point to
lhe same place on the equivalent (answer)
hne.
0 (Because a zero was added,
the answer will have a decimal
poin1.)
The answer is not 8, ii is 0.8. Remember 1hn1 any
number 1ha1 i> only a decimal should show 0 before the
decimal point to show no whole number is prl">ent
before the de(:imal.
4
fhercfore - = 0.8 (not .8)
5
 e Calculations
98 SECTIONII M1!hem111cs fOf Pti1rJ111cology and Dosag
-~------~

4,2
Wh.-n n 11111roi>tr lr.acuon,. conl'fttd to a decim_al.
thr nswn ,.,11 contain a "hole' number nd a rtmam srn<>
J.." ta t h"''TI 11> .i.~ amI

a <.on""' th<-
21
S to a
-
-20
10
WMl'U
Jt"cmul
1111pn>J>C'f frxuon
o
- JO
(Because a zero was added.
the ans"er will hae a dedm,11
point.)
STEP I IM nurobn ~ "'" go into 21 four tirnn
whh rrm.unJer ol I k 511rc th~ decimal
" in tM corrm plJ<< 21 r:-:-
- or s 121 = 4.2
5

To con~ a mixed number 10 a decim.11. li~t changt

the mixed nurober ro an improf)<'r fractaon Rc~at tht
math in Example 27 to convert the answer tu a decimal
(~ "'II no1go anu>I , "' Jd auro.)

Check Your Understanding : CONVERTING FRACTIONS :

TO DECIMALS BOX 6 -9
--- - - -- -
Conwrt the J>rt>!'><'< fr.1ctions to dt.'<"hnals Round 14
8. - =
)" "' ''"""'r tu the 1ieart.">t thousJnd1h s
5 8
l. - 9_ -=
!\ - - - - - 3
l 10
2. 10. - =
-I 7

' - -----
1
(1
Con\'ert the mixed numbers to decimals, 1 111<l to
the nearest hundredth.
4.
-
1
l I
11. 3- = - -- - -
2
~- -
l
I! 12. 6~= ----
5
<.on-.n the 1mpro1'1Cf frMuons to dtt111uls. round 3
.tn~"'"'" to the nt'.1rl-..t 1cnth 13. 4- = - - --
4
6 !!. 7
2 ----- 14. 5- = -- --
9
17
7. - 7
9 ----- 15. 2-= - - -- -
11

Adding and Subtracting Decimals

lo ,1JJ ~ suhtr.l(I numbers w ith d1:C1mals. the problem Place a decimal point a fter any wholl' nu mbers that
mmt I>< Sl't llfl ,\\ J liu or numlx-rs with the decimal are 00 1 followed by decimals.
po111t ol CMh number or the lis1 being wriuen directly lnsen a decimaJ pomt
and sufficic1
1t zero .11icr whoIe
below th1 u1'Cnn.1I point In the previous numbe Aft numbers to make all the decimals the so1nc h-11gth ,1s the
, h I . I L er deoma1with th . number of pl.Kc
. 1he
'' I1gn111g t l' 11'f1m.1 \do the math calculation. .
deama1pomt.
. e greatest lullow1ng
 CHAPTER 6 Math Review 99

EXAMPLE a Find the sum or 64.3 + 18.00 + 0.33. EXAMPLE 30t Find the differt'nce or 69.3 - 5.94
64.30
18.00 69.30
0.33 -5.94
82.63 63.36

-
Check Your Understanding: ADDING AND SUBTRACTING
DECIMALS BOX 6-10
~ ... -~ - - --- -- -

\dJ th< tollowing decimals. SubtraC1 1he following decimals

I. 71 4 + 16.32 + 18 = - -- - - 11. 38 672 - 32.43 = - - - - -

2. 5 l t 14 762 + 9.3 - - - - - 12. 142.637 - 14.263 = - - - - -

l. lll~+66.7+ 124 5. 121= _ _ __ _ 13. 77.4 37.46 = - -- - -

4. 4 OI .I S + 78 667 14. 44.62 - 14 01 =- -- - -

s. () 001 + l 34 + 654 2 = - - - - - 15. 5.04 - 1.67 = - - - --

'' 1ll ~7 t 17.6 + 0.003 = - - -- - 16. 374.5 - 98.44 = - -- - -

7. ll 688.8 + 99.99 = - - - - - 17. 98.7 - 8.662 = - - --

8. 26 45 761 + 0.9 = - -- - - 18. 0.4 0.016= _ _ _ __

,, ') 2l + 765 124 - - - - - - 19. l.06 0.92= _ _ __

Lo. P , ,, $40.1 .. _ __ __ 20. 246 0 .91 =- - - -

92.3
x 4.66
Mult1r J Decimals
----------
When mulnlving decimals, align 1he numbers whl1out
5538
5538
regard In '' ,kcimal points and calcula1e using regular 3692
muh1p1 , t rulesc., 430118
li> <IC1 ,. where 10 insen 1he decimal point after
muh1phcJ11 n roum the number of decimal places in STEP 2. After finding an ans<.-er, find the number of
e.ich lint o u1e multiplicauon problt>m. In the answer, dccimal places in the answer by coun1ing
pl.Kc 1hc de< im.tl poim at the sum of 1he decimal the one decimal place in 92.3 and two
pince\ trnm each line, being sure to couau fro m right decimal places in 4.66. There are three
tokh. deci mal places total. Show the answer wi1h
three decimal plac~: 430. 118.

EXAMPLE 31. De1ennine the produa of 92.3 x 4 66. Drop 1eros that are not followed by an)' other digit in
the an~wer whea they are to the right of the decimal
ST(P I \1ultiply without considering the decimal place. Remember to count decimal places from righ1 10
place;: left or 1he an;wer.
 nd Dosage Calculations
SECTION 11 Mathcmaucs for Pharmacology a

. . ULTIPLYING DECIMALS
Check Your Undorstanding. M
BOX 6 -11 ____ - - - -
- - ----
\lulupl) tlk- foil"" mg Jttun.il<. roonJ .ins--..,. to
s. 31.97 x 16.3 " - - - -
n<aa~ hunJrt'<l1h
6. 0.41 )( 2.34 " - - - -

7. 1.0I x 0.011 =- - --
l 14 I X l6 --~-
8. 4.012 x 77 = - - - -
1 H Oii x 1792 - -- - 9. 89.98 )( 76.4 = - -- -
4. 0~8Rx 94 201 ----
10. 22.73 x 15.5 " - - - -

Dividing Decimal - - - - - - - - 0 _68 [48:2"" fillil, mo''I! the 1wo deC"im.111 .11~ 1n the
'--' divisor.
lo d1v1dt' dtt1m.11\. the dil\or must hrst be changed to
J wholt' numlwr by moving the decimal pomL for each 6814820. Now move the two decim,tl " ice~ in the
pl.Kt' 1h.11 thc decimal po111t 1s ma>'Cd to the right in the '-' dividend, add a 1.ero 10 M W 11nod.11c the
J1vhor. the dt-tl111.1I romt In the dildend is moved the decimal move, and drop the' 1111al point
~.1111e m1111b.:r of plates ttl the right Add leros if neces
in the divisor and place .1 d. 111al point
\My in thr dlvi<knil 10 h.10dle movement if decimal
after the o in tJ1c dividend
pl.tee,'"" 11oi 11ftir1c111 for 1he numlwr of places needed.
Do the math: The quo1lcn1 is 70.~' I his can
. 5.32 be rounded to 70.9 or. if a whole nu mb " (ksirro,
EXAMPLE 32: Dc1crm1ne the quouent - -
8 71.
0 6C>'i
a I~ 1JO
48 70.88
~2
- 48 0@148.~00
-47 6
40
600 {68 will not go Imo
- 40
- 544 so add zero.)
0
560 (68 will not go into
EXAMPU 33 l>t~cmune the quoll(Tlt of 48 2 + 0.68 to -544 so add zero.)
the hundredth 16

Check Your Understanding: DIVIDING DECIMALS BOX 6 -,

-- - - - - ----- - - - - - - - -

Dovidt the foll0\<1ng dtt1mals round answer to

n~M.Sl ICnth
5. 2.3 + 0.76 =- - --

I. 726+ ll ; . _ _ __ _ 6. 165 + 41.5 = - - --

2. 061 + Ill _ _ _ __ 7. 39.7 + 18.4 = - -- - -

8. 40.6 + 5.12"
J . 41 l ? + (> 777 -----
4. 21.9 + 1 n - ----- 9, 99,8+ 16.22 =----
10. 73.2 + 37.8 =
----
 Check Your Understanding : DECIMAL REVIEW BOX 6 - 13
--- - - - - - - - --

Convert to mixed numl>cri.. Do not simpli fy answer. Convert 10 decimals.

7
1. U.84 = - - - - - 14.
8
2. 4ll.67= _ _ _ __ 2
IS. 17- - - - - -
5
Houn<l to the nearest whole number. Add; then round 10 the nearest hundredth.

1. H U 3 = - - - - - 16. 34 75 + 16 333 + 8 + 16.479 = - - - --

4 . 11199 = - - - - - 17. 16.334 +31.6+34.567 + 17.889 - _ _ _ __

5. 0 88
18. 91.25 + 44.337 + 16.4 + 88 + 391.24 = - - -

lloun<l lo the neare.i tenth.

Subtract; then round to the near~t tenth.
6 0 476
19. 598.7 394.621 = - - - -
7. I .17
20. 34.5 - l.047 = - -- -

ltound lo tlw nearest hund redth. Multiply: then simplify 10 the ncare>t who le
number.
8. t)') ?1' "":: - - - - -
21. 91.47 x 16.3 =- -- - -
9. 0 l ]6= - - - - -
22. 19X 18.2X66.234 = _ _ _ __
lO. I 1'i r, !l =- - - - -
Divide; then simplify to the nc.ucst thousandth .

Round to he ncarc't thousandth. 23. 7.49 + 6.33 = - - - - -

II. <" 246" = 24. JS.92 + 14.64 = - - - - -

l 3.
I '46!1

1().17. 218
25. 97 + 33.66 = - - - - -

IQ@;t3 a decimal, remember that the r<?Sult or number is sull a

percentage that must be changed to a decimal number
rcrunt ("n) means 'hundredths' or 'pans ,,er lOO.' for further CJlculations.
Percent nuy "" s~en as J fraction (such as .!.% ), a
4
decimal (>uch '" 0.25%), a whole number (such as
25%). or a mixed number (such as 1-% ).
I lll ARNING TIP
4 Remember 10 change a fraction 10 a decimal by dividing the numera
lmrortJnl step: When changing a percent that is tor by the denom1na1or.
exprcs<>d as a fraction, 10 a percent that is expressed as
llARTF1 ELD LIBRARY
t!ENOERS011 COMMUNITY COUEGE
2660 S. GREEN ST.
HE.NOfRSOft. KY 42420
102 SEC N II M11hemebcs for Pharmacology and Dosage Calculations

2.!.%=2.5%. then divide by 100

2 so

I 22=0.025
anJ I - " I 2S~ JOO
~

Changi ng Percents to Decimals Hint: lk' sure to keep the decimal point in the correa
place in the numerator when dividing by 100.
Orop th< ~ .. Slflll lllm dl\1d by 100 beatlS<' lM word
"pcrtcnt mcJns pan<>( hundred Thrd1visioncauses
the dt"mal to m"'.: t\\O pixes to the l</r
4
Changing Decimals to Pe rcent s
---
first multiply the decimal by 100. Thi\ c.1u~ tht
EXAMPLE J5. 4% bo.'<OOll~ - - or 0 04 decimal to be moved two places to the nght St'< t>nd, add
100 .....
I8
a%sign.
I 11% hnomn - - or 0 018
100
EXAMPLE 37: 2.64 becomes 264%
I hni Rcmcml><:r to CJrT) tlie dtc1mal point from the
JX"r<~nl problt-m to the fraetional problem. 2.64 x 100 =264.0
..__,
l'trcent< that coni.11n J fraction must first be changed 264 becomes 264%
to liecim.>I ~rccnts lwfore dividing by 100.

EXAMPLE 36: I % 0.25% th.n divide by 100, so EXAMPLE 31: 0.022 becomes 2.2%
4
0.022 x I00 = 2.2
~
25
100 0.0025 2.2 becomes 2.2%

Checl< Your Understanding: CHANGING PERCENTS

TO DECIMALS BOX 6 - 14
--- ----- - -~

C:hangc the IWf(CntS to decimals. Round your 5. 31%= _ _ __

answeN to the nearest hundredth
6. 5.5% = - -- -
2
I. - ~o
1 7
7. 7-%=
2.8% _ __ _
8
I
8. 3-% =
3
3. 4.!.%
2
. ----
9. 112.%= - - - - -
JO
7
10. 98-%=
10 ----

Check Your Understanding: CHANGING DECI

TO PERCENTS BOX 6 15 MALS
- ------- - - -- - -- - -- - - - - -
Change the decimals 10 pt!rcenlj; simplify answers to
nc,1re~1 tenth
3. 0.06=
----
4. 7.34 =- - - -
I. 1.59
5. 0.047 =
2. 44.2 .. - - - - - ----
,,,
CHAPTER 6 Math Review 103

6. 0.0152 = - - - - - 9. 0.055 = - - --

l 8.
7. 78.421
I 17_=-----------------10_._3_._67_2_=~~~~~~~~~-----------'
=- - - --

In the next example. an additional step must be Jler

Multiplying Percents
formed because the mixed number must be changed to
In lh< stdl<n> m 1111d 5% of 20. the 1enn 'of' means decimal form. Change the mixed number to an improper
10 multiply .1 number by a percenL The first step is to fraaion, then (as in Example 28) conven the improper
change the parent 10 a decimal: 5% becomes O.OS. Next, fraaion to a decimal before .111emp1ing to find the
multiply the number found in the problem by the percen L.
decimJI 20 0.05 - 100 [before correct decimal place
mcnt) Ihe 111 I , irp ;, 10 input the correct nu mber o f EXAMPLE40: !'ind 3_!.% of 90
dfCimal p l es Jn the example, 0.05 has two decimal 2
plact-< "' th in'" 100. would need two decimal STEP I : 3.!. is the same as ?..., which 111 decimal
plan.'> 111c '<' " I (I ~O ).
2 2
1
t11m K 1 r IO move decimal places from right form is 3.5 ( can be changed 10 0.5% by
2
to Jrft, ,11a ""'' drop ieros that PJ)e.tr after the
divid ing 2 imo I 10 obtain 3.5%)
d~<imal I'"'" ..
11Jcd trail ing zeros).
STEP 2: Change% w a decimal: 3.5% = 0.035
EXAMPU J l% of H STEP 3. Multiply 90 x 0 035 = 3150

STEP IS< % to .1 decimal: 3% = 0.03 STEP 4 Input decimal places as needed. Three deci-
mals in step 2 (0.035) means the answer
STEP . ulu ply: 4 2 x 0.03 = 126 has three decimal places. Answer = 3. 150
(sa me as 3.15 because the last zero shou ld
STEP ut decimal 1>l.1ces as needed . 1\vo deci be deleted bec.1use it is not neces~ary, as
s n ''"I'
l (0.03) means the an;wer has 15 hundredths is equivalent to 150 thou
,1, mul places. Answer 1.26 sandths. drop the trailing zero)

\tultipl)
hundr
.
our U nderstanding:

pcr(t'nt. round an~\vets to neares1

MULTIPLYING PERCENTS
--

5 . 19%of75= _ _ __
-

6. 27% of 10 = _ _ __
I. 11 I '>
I ,, 7. 48% of 100 = - - - - -
2. l nf 17 =
l 8. 11%of20 = _ __ _
3. 62 IBO- _ __ __
9. 82%ofl9= _ _ __
.l
I 10. -41 % of 11 = _ _ _ __
4. 5-% of 14 - - - -- -
4 2
 d Dosage Calculations
-~1~CM~~S~CT~IO'l~l~l~M~a~~~em
'".!!1~uc~s~l~
".'._'_P~h~rm
=~e~o~
l o~
gy~-"~-
EXAMPLE Cl: 15 is what percent of 4 51
Dividing Percents . 15
[)1 I f ICC 1t-. ~l ' l h...~ qunuo n
of what fo STEP I: Write as a fracu on: 45
linJ .,. hJt J>l'ffcOIAI:< on numbt-r is ofinomttnumber.
Uk' thnt trt" , . 15 I
STEP 2: Simplify the 1ramon:
45
= '.j
STP 1 "'1 up the problem .. a lr1ct1on

STlP 2 'mr!tfy tht fm11<>n (of pos>1ble) STEP 3: DMde 3J l.OO = 0.33

SrEP l 1>1'1.k th<- lr.kt1on~

Jrnomonator into Its STEP 4: Change Step 3 answer to .1 percmt
numrmor 10 o1>1.11n Jtom.11 0.33 = 33%

.
Check Your Understanding: DIVID ING PERCENTS _BOX 6 - 1
. ' i:. _

1>1v1dl' by J pcr<mt Round your answer 10 tenths. 6. 15 is what percent of 19? - - - --

7. 2 is what percent of 13? _ _ _ __
l. 70 h wh,11 J)<l<tnt of 841

l. 11 ,, wh,11 percent of 501 - - - - - s. 44 is what percent of 63 ? ---~

l . I I I~ whJ t per<tnl of 771 - - - - 9. 7 is what percent of 77? - - --

4. 11 is wlut 1wrcl'nt of 157 - - - - - 10. 4 is what percent of 9? - - - --

Us ing Fractions to Figure Percentages may be a number found in the probl 1r maybe
the unknown.
\\ nh this method. two fracttons will be dettrmmed. The c- Nurneratorforfraction two will bea I 111of100
h"t fraoion will show the numbeng1wn m the problem. (the number or unknown followeJ h) .md may
111e 'il' ond frCl<>n will show number as a percentage be the unknown.
ol 100 Ille unknown number m either fracuon 1s labeled d- Denominator for fraction two will 11 'be 100
" ~t up the t\\O fro1C11ons .u shown in the following when solving for percents.
example 11lcn ~lw for x-1dcn116cd by "what Use an The letters a. b, or c can be the uni.no'' 1 >.my one
equals sign (c). 1drnt1hloJ by "1s. to mdtCJte equality of these letters can be labeled :t in ,1 it problem
when sh"tng the relaU0Mh1p b..'twttn 1...0 equ.11 frac- When percents are being found. the leucr ti hJ)'S 100
tion~ Ah'')"' round tht JOS\>cr to the n"arest whole because it signifies 100%.
number
a c For example: What is 20% of 2001
I ormulJ for fracuons h d

a- 'lumcrJtor for framon one 1s the amount or pan

l l l
of " whole ponion being compared 10 the base. a = c x b
M.1y he" number found in the problem or may be
1hc unknown . Note: The 20% is c because the% sign '' .111.iched. d
h Dcnomrn.nor for franion one is the base or the is always JOO; what is lmknown; 200 i\ Ii.iv
whole 111 the problem or standard used for com.
p.1mon I he h.l\e often folio~ the word "of. This
'
CHAPTER G Math Review 105

~ problem r.in be stated three different ways when STEP t. Set up the problem as two equh..Uent
fraaions ar~ u'>Cd lhe following three examples show fractions:
...ach war the que,tion can be asked, followed by the
solution lht most difficult pan of the problem is under- 15 (ponion of base) _ 2.!_ (percent)
standing wh.u "unknown and then correctly placing the x (base) 100
underst00<I \ 1nl!l either the a. b. or c pan of the
fraction STEP 2; Cross-multiply:
EXAMPLE 42: I<; is wh.i1 percem of 45? 33x = 1500

When ,1 prohkm is asked like Example 42, the

STEP 3: Isolate x:
unkntl\\'n ' wh.11" i' the percentage The number beside
the word i- btwme' che numeracor of fraction one. 1500
x=--
The num1>11 h< 'itle the word or becomes the denomi 33
nator of f1 ac11011 o ne. In the second fraaion, x is used
x = 45.45
for the pt"r e nt i; owr 100. Using the formula shown
earlier. thr ten r 1 = I 1, b = 4 5. c =x, and d = 100.
STEP 4: Show the answer as a whole number only.
I lint: Always remember what you are
STEP I Sc up the problem as two equivalent
solving for. You may be solving for a percent
tlOJl\
or a number. In this problem, )'OU Me
porllon of base) x (percent) looking for a number, so:
=--
x= 45
(""") 100

STEP 2 t < multiply: EXAMPLE 44: What number is 33% of 451

(1) 15 x 100
' 1100
In W<ample 44, the unknown ' wh.11" is a number;
STEP 3 '" the x so that it is by itself (by divid- tlwrefore 1he unknown xis in 1hc first fraction, and the
> 1th sides b) 45): 33
second fraction is . Because there is no number
1500 100
r; beside the word "is: the numerator in franion one is x.
lhe denominator in fraaion one is 4 5. Use the fonnula
l Hl
shown previously.
STEP 4 mlwr that you must still mo\'e the
m.11 two places to the left and add a
en ''Sn to obtain an ans\..-er shov. n as STEP 1 Set up the problem as cwo equivalent
11 t'nt Show final answer in whole per- fractions:
''!\' number only:
.!._ (p0nion of base) _ .!!_ (percent)
'1 l l wi ll be wriuen as 33%.
45 (base) 100
The fr.ll I I in this problem could have been
simplified the ;,ime as..!.. The answer would s1 ill STEP 2: Cross-mu lti ply:
3
be the sam
IOOx = 1485

EXAMPlc 1 " ll% of what number? STEP 3 Isolate x:

100.t 1485
In lxamp 4 l the unknown what is a number --=-
100
-
100
Therefor~ th< unknown xis in the first fraction, and the
33 x = 14.85
Sond fr.tc1hJll " . rhe number beside the word
100
' is" bemm,' lht nunwr.uor of fraction one. 'lhe denom- STEP 4: Show the answer as a whole number.
inator of rr.h tlnn one is the unk-nown. .t = 15
 --~----~---=---==-::; d n;
D sage Calculations
106 SECTION 11 Miltiemauc1 l0t Phum1cology an o

s. 5 is IO% of what number? - - - - -

u... II 111' "!tuhon method. ttan,lt IM foll.,,.ing
a11J "I" 11...unJ tn "hol~ numbcl" 6. Whal number is 3% of 901

I. Wh1 number " 2S'No ol 40! - - - - 7. What number is 25% of 500' - - - - -

8. 4 is what% of 80! - - - - -
l. I~ "~ ol wh1 nurnl><'.rl - - - - - 9. I 2 is 40% of what number! - - - --
4 , lO ""hJI 'No ol 901 _ _ __
lO. I 3 is 5% of what number? - - - --

EXAMPlE 46: 15 i~ 33% of wha1 number/

Uing a n Equation to Figure
a Pa rcantage !I! ! !
1u <K>lw P<'llen1.1gt prubknu using an equation. the 15 = .33 x x
pam ol lht rmbl<rn are 1r.u11l.11eJ 10 the equivalent .33x= 15
Jl'"' K<m .. mbcr or ttJn~IJll'$ 10 umes , wha1" 1rans x = 45.45 or 45
1.-ue~ 10 lhl.. unknown or x*; is 1r.ui.sla1es LO ;:
I or cx.imrle. wh.11 (x) h { .) 20% of {x) 2001
' 0.2 x 200 EXAMPU: 47: Whal number is 33% of l '

Nmc 20" o has been ch.11111ed 10 a decimal for

calrnlauon
! =- .33
! ! !.
x
x= 14.85 or 15
' 40
llw followrng are 1he \llme as l..Jcdmples 42 10 44,
pl.'tl 111 the <'Qu.11ion mc1hod

EXAMPLHS: 15 " wha1 perccn1 of 45!

I~ x 45
4~ IS
xHH%orH~

Check Your Understanding : PERCENT REVIEW BOX 6 - 19

- - - - - - - - - - -- -
Change 10 Jtc1m3IS Change 10 percenis.
I
I. -%
1
6. 1.89 =

2. l 1% 7. 72.34 =
4
l. I 14%" 8 . 0 .0631 =
4. 7 H,, 9. 0 .05 =
s. H 1oU 10. 0.1 L =
I
''
CHAPTER 6 Math Review 107

Check Your Understanding: PERCENT REVIEW

BOX 6 - 19- cont' d
- -- - - - - - - - - - - - -- -- - -- -

Soh-e. round a nswer 10 nearest tenth. Sol'-e for the number. Round ans.,er 10 a hole
number
11. 27o of 2 = - - -- -
21. 6 1s 10% of what number?-- - - -
12. 70% of 44
22. 20 is 25% of what number! - - - - -
13. 66.<>7% of 4'! =
23. 2'i is 'i0% of what number' - - - - -
14. H4 I
2
o o f 99
24. 30 is 70% of what number?-- - - -
15. 33..!.% ol >O 25. 2 is 60% of what number? _ _ __
l

Solve. "nun " a pcrcem Round answer to a whole !.Dive for the number. Round answer 10 a whole
pem:~nt number.

16. 20 "what percent of 801 _ _ _ __ 26. What number is 15% of 45?

17. 67 ;, ,. h.H 1wrt cnt of 2001 - - -- - 27. What number is 40% of 80?
1
18. - 1 wh.11 1itrcc11t of 21 - -- - - 28. Wh,11 number is 5% of 55?
1
19. l O "w1 11 percent of 45? _ _ _ __ 29. What number is 80% of 60?
I
20. 4 - '' w 111wrcent of 19? _ _ _ __ 30. What number is 25% of 161
l

muluply the extremes together (I x 8) and then multiply

the means together (4 x 2) . Therefore I x 8 - Ix 2.
n l.11ionship betwern two numbers by
q>.trJle the numbers. extremes "1J
' hows the relationship between two
1: 4 2:8
tr,H ttons
I he p I method is used 10 find the rela !!,, means dl
tionshil" (>, t\\1 ,n r.11ios, including find ing unknowns
and doai;< , d1 1l.11io ns.
the two "'""' ( . ) to show a relationship between Knowing that proponions must be equal makes it
cwo ratio!. easy to solve for an unknown pan oft lw cqu,uion. Let x
stand for the unknown.
EXAMPLE ., ~1 1' " ,,ratio: I : 3 If the problem is x: 3 :: 2: 6, solve for the unknown x
hl' '' J ratio: 2:6 by multiplying.
Thu 1sa proponion: 1:3 :: 2:6
STEP I Multiply the extremes together xx 6 = 6.1'
'lote th.11 11 y(IU divide the second ratio by 2, the '" o
ratio. arc 1d ntic,11 STEP t Multiply the means together 3 x 2 ~ 6

STEP 3: 1 he problem would now be 6.1' 6. Isolate

Solving o x in a Proportion x by dividing e<lch side by the number th,11
In a propon inn, the prnduct of the means must equal is in front of x. In this problem, divide by
the product n l thl' ~xtrcmes. In the following proponio11, 6. This will allow x to be cqu~ I LO I.
 d Dosage Calculations
108 SlCTIONII Methemat1cs lor Phermaco!ogy an
STEP 3: Isolate x b)' divid ing by 2:
laongx in the
STEP 4 """"the compuuuon by rep . "-e ix 8
-LI . h )'Ollr am\<ef.h '"
0 ngona1 ruv rm wn
anS\\<rl or th~ mum and extremes s o
uld 2 =2
be f<lUll x=4

EXAMPlf ct- '"' for on tlus proponion .

1x .. 28

STEP 4: Prove answer: I : 4 :. 2 8 The means and
STEP t Muluply ntrcmt'> I x 8 z 8 extremes are equal; lhercfor~ this 1s a trut
proponion.
STEP 2 Mulupl} means l xx lX

C h eck Your Understanding : RAT

BOX 6 - 20 __ _
10 AND PROPORTION
_
I
-

Solve for ' on tht propon1ons

u. x:5 :: 12: IO x----
5" :. 4 : 20 12. 64 : 2 :: 32:x ----
X _ _ __
;r 13. 1:9 :: x:81
2 I l .. 3:

l. II :22 : x 44 X 14. 8 :250 :: x: 125 X -- - -

.t _ _ __
4. 16 ' 20 4 :.t X 15. 6:x :: 3 : I
x = _ __
s 16. x:9 :: 3: I
. . . ___
5() \ :: 3 ? X

(>, 4 \ :: ll t6 ;r. 17. 2 :x :: 4 :250

.r- _ __
7 x 14 : 12 24

8 (> 24 I :>
X

X
18. x: 325 :: I: 650

19. 3:600 :: 2 :x ... ___

X _ __
') 8 2 ... 4 X 20. 10: 100 :: 25 :x

10 lO SI> X

Formula for Ratio and r roponion

USING RATIO AND PROPORTION
TO FIGURE PERCENTS
rhc method or using rauo and proponion to figure the
percent is simllM to the fraciional method once you ba,i:
determined x 'l11e first rauo will show the numbers in
the problem. and the second ratio will show number
'" ,, perccnt.1gc of 100 I he unknown number in eilher
rauo i ~ labeled " ~ct up the two ratios as a proponion
(as shown in the following example). Remember to use
o ne colon (:) between the number> in a ratio and two
colo ns(:: ) 10 show .1 relatio nship between the two ratios.
Rou nd 1hc answer to the ncarc;1 whole number.
a : b ::c: d
a = One of the extremes is the amount 1 p.1n or tht
whole ponion being compared with th .1w11Wil)o1
a number or the unknown variabk 11 tlu hl')t m io.
b = One of the means or the whok 1111111lwr in tht
problem or the standard used 1111 w 1np.irison.
always a number or lhe unknown ,. 111.thle in tht
first ratio.
C= One of the means: when figuring JWll l'lll" c ~ill
always be a percent of 100. In pr.u t 11 .11 ,1pphc.t
Lions, 1his number is a po rtio n o l th1 tot,11 or an
item.

CHAPTER 6 Math Revrew 109

d "'one of the l'Xtrcmes; when figuri ng percents, this STEP 1 Set up the two ra1ios. l"he numbers in the
will alwap bc 100. When using practical applica- first ratio are given rite 'what" is the
uons this number is the total amount of an item. percent:
The following thrtt CX3mples show each way a ratio
21: 35 :: .r: 100
and proponion qut"lion can be asked using percents,
followed h) the M>luuon.
STEP 2: Multiply the means and the extremes:
The kncr 11. I>. or' CJn be the unknO"-'tl, so any one
of these lrtter\ can be labeled x in a given problem. In 2 1 x I00=35xx
the following cx.1111ple,, letter dis always 100 for 100%.
2100 =35x
EXAMPLE 50: I'> h what % of 4!F
STEP3: Isolate the x:
In this ci<o1111plr, the two numbers bei ng compared arc x = 60
15 and 45 \tt 1h1 hm ratio up to express this compari-
son Ille second 1a1io i~ asking 'what' percent 15 is to STEP 4 The problem is asking for a per<cnt, so the
H . so the m~nown ts a percent. Hint: Recall that a answer will be 60%.
proponion " 1 rnmpariwn between two equivalent
ratios Using the~ nmula shown earlier. the letter a = IS,
EXAMPLE 52: 21 is 60% of what number1
b = 45 , c - ' and J 100.

STEP I ~t up th<' two ratios. The numbers in the STEP 1: Set up the 1wo ra1ios. Only onl' number in
fir..1r1110 .ire given. The "what" is the percent: the first ratio is given. The "what' is the
second number. The percents are given:
I' I .c lOO
21 :x :: 60 : 100
STEP 2 ~1.il11ply thl' nw.ins and the extremes:
STEP 2: Multiply the means and the cx1remes:
II\ x 100
21 x 100 = GO x .t
Iu 1 ;00
2100 = 60x
STEP 3; I 11 tht .\ '-0 that it is by itself (by divid
un1h "Jes by 45) STEP 3: Isolate the r.
liOO x= 35
I I\
STEP 4 The problem is asking for a number, so the
lH
answer will be 35.
STEP 4 "''"the 4ues1ion is asking fora percent,
1 11ral nil .1s needed, add a percent sign, EXAMPLE 53: What nu mber is 60% of 35!
111.t w11t...1s a whole number:
11 l l will he written as 33% STEP 1: Set up the 1wo ratios. Only o ne nu mber in
the first ratio is giw n. The "wha1" is the first
If you wr t > prove your answer, repl ace the x with num ber. The percents arc given:
33 in the or r 11 problem.
.r:35 :: 60: 100
15 4'\ 1 ()I}
STEP 2 Multiply the means and the extreme~
The ans\\ <orrl-cl because 1500 is approximately
equal to 118 Rem,l'lberth.n you rounded from 33.33% x x 100 = 35 x 60
to 33%.
IOOx= 2100
The prnbl1 111 b< Jsked thrtt different ways depend-
ing on wh.u 1 kmn or given. as well as where the tis
STEP 3: Isolate 1he >:
placed in tt ... pr.ipunion In l.x.1mples so to 53, the same
numbe" louml 111 pr.>vrous CX3mples are used to show .v = 21
how to set 111 tin problem using ratios and proportions.
STEP 4: 111e problem is aski ng fo r a nu m ber, so the
EXAMPLE 51: 21 b wh,11 percent of 35? answer will be 21.
 osage Calculations
110 ;ECTION 11 Mathem1t1cs for Pharmacology en d D

Solw for the unlmown number using the

\oh, for the unl.n<M n number using the . al method Round answer to the nc.irest
propomoo
proportional mt1hod Round ans"ct to the n~ whole number.
"holr numb.:r
ll. 16 is 25% of what number'---- -
t \\'hJt numb..'f 1~ 12'9 of SOO' - - - -
12. 32 is 10% of what number/ - -- -
l. Whal numb..'f 1s 70% of 1501 - - - - -
l3. SO is 4~ of what number! - -- -
3. Wh.11numlxr1\ 81% of 111 _ _ __
14_ 5 is 33~% of what number! - - -
4. WhJI numlxr 1\ 66% of 751 - - - - -
IS. 14 is 75% of what number? - --
<;, What number 1s N% of 601 - - - - -
l6. 3 is 20% of what number? _ __ ~
6. Wh.1t numb.:r 11 12% of 211 - - - - -
17. 7 is 15% of what number! - -- -
7. What numb.:r 1~ 47% of 400? - - - -
18. It is 5% of what number? - -- -
8. What number is H% of 191 - - - - -
19. 72 is 90% of what number/ _ _ _
9. What number 11 J8% of 701 - - - - -

10. Wh.11 numll<'r is 8';% of 901 - - - - - 20. 60 is SO"Ai of what number?

PRACTICAL AP PUCATIONS STEP 2: Multiply the means and th <rncs:

I xx= 2 x 24
Many pphcauons in a med1Cal facility require the praai-
cal use of ba1ic mathematic.ti ulculations. The math x= 48
problems will not be set up for you. and often setting up
th<' problem correctly is the most difficult pan of finding
a :.oluuon Al"a)'S check )'Our calrulations by placing STIP 3: :-iorrnally you need to 1~lau \ Ill ~tep
)'OUr an1"er into the original math problem in place of 3 but because xx I - \. \ktp ' J Ill th15
x nu~ following 5tt110n sho..'S a ration and proportion problem.
math calculation used 1n inventory replacement and in
de1ermu11ng medocauon administration.
STEP 4: Determine what the prohkn 1'king for
EXAMPLE 54: Ihere are 24 ampules of Xylocaine in one (ampules). Since x - 48, 1h1 , rnl .111S1>'tl
box of medication. How many ampules of is 48 ampules.
Xylornne are in two boxes/ l~I

STEP t: ~cl up the two ratios- The nurnbers in the When working with ratios and prop !lions th&l
tim ra1 io .ire given.
contain unit of measure descriptions "" h " mg. ml..
inches, and teaspoons, both rat ios in th pro1w nlon
24 ampule... : I box :: \ ampules:: 2 boxes musl contain Lhe: same units.

CHAPTER 6 Meth Review 111

EXAMPLE 55: A dose of 500 mg of amoxicillin sodium STEP 3: Isolate the x by muhiplymg both sides by
IS prescribed. On hand is amoxicillin 250:
sodium 250 mg/5 ml. I low many milli-
liters would be given for the o rder using 250 x 2500
the dosage strength o n hand ? I'-I --=--
250 250

STEP 1: Set up the cwo ra 1ios. The numbers in the x = JO

first ralio are given.
STEP 4: Determine what the problem is asking for
2~0 mg:5 ml::500 mg: x (milliliters}. Be sure to include the proper
mt'aSurement in your answer The corroo
STEP 2 \luhiply the means and the excremes: dnswer is 10 mL

l'iO xx= 5 x 500

2'illx = 2500

r Understanding : RATIO ANO PROPORTION

x 6 -22
--- -- - -
Solve tor

I. I ,\ X

2..\ X
2
3. 4 '> .r

4. 4 ' X

5. 0.1 ,, 0.16 X

Solv~ llH 1 ''mg word problems. Set each one up as a ratio and a proponion.

6. A fJt a' 1/Juprofm that is available in 100 mg/5 mL llw ph)'sician desires 1hat ibuprofen 50 mg be
.1dm1 d What quanticy of ibuprofen should be administered to the patient! - - - - -

7. A pr <>n reads 'take two t,1blets four times a day.' If the patient takes the prescription correcdy, how
n1.1n' I t' "ill he or she haw 1aken by the end of I week/ (Hin1: Figure the number of 1ablets needed
in .1 d 1"1.) - - - - -

,.. '"tituting a medication. if a 200-mg dosage sLrength is prescribed, what volume of the
ml solution would be prepared to provide a 200-mg dose? _ _ __

9. If 2 I 1blcts of dexrrrumpltett1n1111~ contain 25 mg of medication, how many tablets equal 15 mgl

2

CotJtinuetl
 J ... bnd is Prozac 20 mg/5 mL. How many millili1cr~ of l'ro"
~ ""' 0 1 mg l' prescruxu. 0 n ~
Ln L -..

lo. rtl;lh '"" -.o(

"oulJ Ix Ill""" for 1hr order u"ng lht dosage sirenglh oo hand!--- - -

II . \\ h<n llumlm R t) 100 u 1 ml . how llWl)' milliliters would 20 units of Humulin R be! - - - - -

12 Whm '"'""' c:n 80 unt" 1 ml 15 3,a1table for an order, how many milliliters would be needed fo r \ct/
1111

c..-1 <O um"! - - - - -

11. One ~1logrJm 1s "lu1valcn1101.2 pounds. What is !he kilogram equi\-alenl for 110 pound~l - - - - -

14. Ont k1lcwJm tH<ju1vJlcn110 2.2 pounds. An 80 kg person would weigh how many pounds'

I ~. ll1e JMllent's tot.ii Jaily dose of sulJ.11nr1ho.tiWlk is IOOO mg. The drug is avail,1ble in 500 mg 1.1hll't\. Ilow
m.iny 1.1hlm woulu the p.1uen1 take daily! - - - - -

16. A clc.rning soluuon i\ 10 be d1lu1ed I teaspoon 10 64 oz of water. llow much water would lw .1ddcd to a
1
con1.1inrr com.11ning teaspoon of cleaning solution!-----
4

17. O ne hour ls 60 minutes. WhJt fractional part of an hour is 45 minutes? _ __ __

1
18. I( I 1.1blc1 of tlrlnMl1i1w1/r (Oiuril) is equivalent to 250 mg. how many milligrams would ) l , ohlrn bel

19. 1000 mg 1> equivalent 10 I g. What is lhe milligram equh-alent for 0.9 gl - - - - -
Measurement Systems
and Their Equivalents
After s tudy1nCJ 1111s chapter, you should be capable of doing the lollowmg
tJJs1c units of measure 1n the metric Using symbols and Roman numerals 1n the
r abbreviations. apothecary system.
ldenllfymg the basic units of measure 1n the
notauon household system and their abbreviations.
Convert rnetnc measurement units. Expla1n1ng units and molhequovalents on determining
01SCU$ 0 1 m ted use of the apothecary drug measurements.
systelT' a units of measure w1th1n the Identifying current trends in the use of symbols
system and abbreviations.

Apothecary Grain Liter Milliequivalent

Apothecary y tern Gram Meter Minim
Dram Household system Metric system Unit

RETEST: MEASUREMENT SYSTEMS AND THEIR
;rs
--------- -

Answer ti " mg questions.

1. Nault.' r II hrt'C base metric unics or lllC.Jsure. - - -- - - - - - -- - - -- - - -

2. Provid " llvi.11ions for the following metric terms:

microgran1 - - - --
"
Ct.'fHlll lcr - - - -- milliliter---- -

3. Writt 1111 <>rrrcl metric notation for three hundred 1wemy centime1ers. - - -- - - - -- -

Co11Linued

113
 do
114 ;tC 1 N 11 Methemaucs for Pharmacology an sage Calculations
T SYSTEMS AND THEIR
Chapter 7 PRETEST: MEASUREMEN
EQUIVALENTS-cont' d _ _ __
- - - - - - - -- -

4 . Dt:tcrmmt 1ht an""

2500 mcg= mg
28 m cm
3250 cc= mL
8'i0 mg g

2.8 l= mL
0 78 kg g

5 , ~uppl) 1he l'\IUi>alenu u~ing the household measurement system.

)() gtlS - - -- -
l q1 .. _____ c

I c

18 Ill

_ _ __ lb
8 Ot.

METRIC SYSTEM all less than one whole unit. '111c fol Im " ' hould be
memorized:
'l11e m~trlc > lem originated in rmnce more than 200 deci =0.1 (one tenth of o ne unit)
year.. ago It ;, sometimes referred to as the SI system, anri = 0.01 (one hundred th of ont ii)
from the I rench words. S)'51~mr lnimiarion11/. The metric milli = 0.001 (one 1ho usand1h of 01> 1111)
~y,1cm, u'\t'd in more than 90% of developed countries, micro= 0.000001 (one millionth ol 11 unn)
1< b.1wd on the decimal system and is the international kilo =1000 (one thousand units)
standard fot scicnufic and indmtrial measurements. The To reduce medication errors, a 1.-m 1 lw,l~'S u!(d
llnned Stales h.n been slow to adopt the metric S)'Ste.m befMt the decimal point if the unit i\ It" 11 rnc \vholt
and sull rdil"i heavily on the household method of mea- unit For exampl<'. .78 would be wri11cn '" ~ I r.1iling
'ureme111 (somt'times refmed 10 as the Eng/W. rM<ISUre zeros 10 the right of the number.. follm, r " dt'Cim~
rnrnl S)11ern) Inda) m the United States. many items are
labeled 111 the metric and household systems. 1be metric
system u~ thedimal (or base 10} numbering system.
Ry <imply moving the decimal point. one can move
"ilhm the metric system 10 other metric units (e.g.,
12mm l2cm)
Three basic units of measure exist m the metric system.
The ba.IC urut of "eight is the grm. The basic unit of tO units~ deka
volume i the llttr.1l1e basic unn of length is the meter. j 1 basic unit of measore
l n medical applications, weight usu.illy references a ma~
(such .is the eight of a pathology specimen) or a solid
(such as 1hr .1mour11 of medka1ion in a tablet or capsule --
of medicine) VolL1mc usu.illy references a liquid or a gas,
.rnd leng1h references distance.
A prefix 111.1y he added 10 each of the root vords
(.~mm, l111r. and 1111111). I igur~ 7 1 shows the relation-
ships of the common prefixes to their decim.ll value. As Figure .71 ~e basic units of measu11i- gram, 111..r 11 I mete1- "" lh
ixefixes iooicanng larger or smaller measures . fhus r/i l.r I ""'"I relers 10
Figure? I ;hows, c.kd., renti, milIi, and micro units are
lOh.lsic ooits, and dee/- ("len1h ) rereis 10 ono wmh of 1111 basic unit

CHAPTER 7 Measurement Systems and Their Equivalents 115

point should be deleted . For example, 1.0100 would be

TABLE 7 t COMMON METRIC UNITS USED IN
I 01. MEDICINE
Jlie base units are abbre-.1ated as follow~ gram (g),
liter (L). and meter {m). Common unit~ with prefixes METRIC TERM UNIT VALUE ABBREVIATION
med in medicine for weight Mc kilogram {abbreviated
kg, 1 kilogram = 1000 grams, o r I kg = IOOO g); milli- WEIGHT OR MASS
gram (abbrcvi.md mg; one thousandth I0.001) of a kilogram 1000 units or grams kg
gram. 1000 mg I g); and microgram (abbreviated mcg. gram base unit g
one millionth of J gmm )0.000001 g); 1.000,000 mcg = milligram 0.001 of a gram mg
1 g). t\ common prefixed unit used for liquids is the microgram 0.00000 I of a gram mcg
milliliter (abbrcvi,1ted m l ~ one thousa ndth of a liter
IO 001 L). 1000 1111 = I I). Common prefixed units used
VOLUME OR LIQUID
for measuring 1, ngth are the cenumeter (abbreviated cm;
one hundrl'<hh of a meter )0.01 ml; 100 cm = I m) and liter base unit L
the millim~tcr (,1bbreviated mm; o ne thousandth of a m1lllliter' 0.001 or a hter ml
met~r 10.00I m I. IOOO mm I 111). Clinica l applications
of the>e dill( 1t nt un its of measure include measuring a LENGTH
p.llient's " ,.. ,,ht (in kilograms), measuring the concen- meter base unit m
trJUOn of a m ation (i n gr,1ms. milligrams, or micro- centimetl!f 0.01 of a me1er cm
grams), and "" l'lH Hlg a surgic.11wound (in centimeters m1fhme1e1 0.001 of a meter mm
or 1nillimeH:>r'1 Note: Basic un11s are m boldlace.
In the nH t ')'tcm, dlYimals are used instead o r 'One millihte1 fmU : 1 cubic centmete1 (cct cc should not be used
fractions (' not
1 ~) . llecause decimals are used, uses g. Uwr may be abbreviated as I. (in the SI S}'Stcm)
it 1s simple 1 en from one unit to another in the or as lowerc.1s" I; either may be used. 'lable 7- 1 shows
n1ctric sysh11 ~ n 111g the dcdmal point to the right the metric units most often used in clinic.11 medicine,
(and addiur ") rabc the value by a llOwer of IO. alo ng with their unit value and abbreviation.
ror exampk n - 110 cm =1200 mm . Moving the 1lie cubic cen timeter (cc) is a measurement that is on
decimal pn left IO\\CfS the value by a power of llie Joint Commission's (nC's) possible inclusion on
10 for each "'~d for cx,1mple, 20 mm = 2 cm = a future Do Not Lise list. As of June 20 11 , "cc is still
0.02 111 o nly o n the Wdtch list. 'll1is mea;ure is still ;een o n mca
When 1 measurement is wri11e11, Lhe Arabic suring devices for ovcrthe-cou111er (OTC) n1ugh syrups,
nu1nbcr i'' "t. followed by the mctnc abbrevia- syringes used for oral mcdicdtions. and input measuring
uon for w \.lmplc. three hundred twenty-five devices such as patient hospital cups and urine collec-
milligrams rn as Jl<; mg, one hundred sixty-five tion comainen.. One cubic centimeter (er) is equh"alen1
ccnlimeters 1 11tcn JS I 65 cm, and three liters is to one milliliter {ml). The "cc may po;sibly be phdsed
\Vriuen as l. 1 out of medical documentation in the fu ture because "cc
In 1960t , 1 national Rureau of Weights and Mea- may be mistaken ror w1its when poorly wriuen. Milliliter
surement... l the ln1ema11onal System of units to (m L) is the preferred abbm1ation.
reduce P"'
common ahl
For examph
rrors in drug transcriptions. A few
.111o ns m,ty Still be wriuen the o ld way.
" o ften abbre,iated as gm instead o f
Ill LEARNING TIP
Memorize the equivalency 1 cc 1 ml.
g. as in th 'm Cither " appropriate lliis book

r U nderstanding : METRIC SYSTEM BASICS BOX 7 - 1

-- -- - -
ldentif} r the prefix 1s "greater than or "less 4. hecto _ __ __
than on unJt
5. kilo - - - --
I. cenu
6. micro - -- --
2. deci
7. milli _ __ __
3. deka

Co11u'111ud
 ;ec N11 Mathemaucs for Pharmacofogy and Dosage Calculations
116

TRIC SYSTEM BASICS BOX

Check Your Understanding: ME
7-1 - cont' d - - - - - - - - -- - - - -

Write me decimal correctly.

lden11fy th<' thr,.., bi"c unns or measure m lhe metric
'l)>t<m JI . 1.00100 _ _ __

8. Rsic un11 of kngth - - - - - 12. .001 _ _ __

9. Ra\tc unit of .-<1ght - - - - - n. o.oouo____

10 Ras1c un11 of \'Olume - - - - - 14. 1.010 _ _ __

15. . 101010 - - - -

Calculation Review
I"I> .mwcrs Jrt rf<IUlfl'<I for each or lhe rollowing. On the Ml line, identify 1he unit o [ mea<un I\ I
weight, volume, or len1t1h measurement Then write the metric notation using abbreviatio n<.
IDEN11FCATION M ETIU C
Of UNIT N 01i \TI 0 '\:

16. lour tenths of .1 milli liter

17. One hundred twenty cemimeters

18. Six hundred twenty-four milligrams

19. 11i ree 1hous.1ntl and seventyfi""' hundredlhs meters

20. l\\'O and th rf"'tcr11hs liters

21. One thousand micrograms

22. 1en gram~

23. Five J..ilogwns

24. One and one-half liters

25. Se-en hundred fifty kilometers

lll LEARNING TIP yardstick (36 inches). Other than for h

Remember thal the base me1nc un11s are gram. liter. and meter
LENGTH MEASUREMENT
AND CONVERSION IN THE
METRIC SYSTEM
1 he ba>k ~nil or length in the metric system is lhe meter.
A m~lcr 1< 39 37 inches, or slightly longer lhan a
is 100 long to be userul for mo\t m1 ,
,1 meter
menu in
medicine, so subdivisions or a meter, "' dkr uni1<.
are used. The centimeter (o ne hundrnh I ,t meter.
I cm = 0.01 m and 100 cm = I m ) ;, 1110 .. unmonl)
used. Approximately 2.5 cm equals 1 1111 Ii < .-111imctcrs
n:iay be used to measure a person's height. 1,, 11t'~v;ure thf
circumrerence of" newborn baby's he.id, "' 10 measure
l~e length or a wound. The milli meter (<HI<' 1housandlh
~ a meter; I mm = 0.001 m, IOOO mm
0 1 m. .111d
mm = 1 cm) is used fo r ve1y sm.111 t111,.,urconc111s

CHAPTER 7 Measurement Systems and Their Equivalents 117

such ,1s the length ofa sma! l lesion. A millimeter is about reverse. If we stan with 50.2 millimeters and want to
the size of the head of a p111 . know the amount in meters. we move the decimal place
three places to the lef1 (divide). bypassing cemimeters
and decimeters:
[lJ L ~R" G T P .
EXAMPLE 1: 50.2 mm= m
The corM!<s1ons to memo111e for length include

t m= 1000mm 50.2 mm 0.0502 m

Meter to ffil ITW':te'
Mote to ce"t mete< 1m 100cm
Ccnt1mr.ter to m1!hmeter 1cm= 10 mm Berause a meter is large in relation to a mill imeter,
1he v;1lue for 1he meter me;isurement wi ll be a s maller
decimal number. Remember 1h,1t length problems have
1-otc 1hat the conversion faC1or is always in muhiples of three co1wersions that rould be multiplied or divided,
10. thcwforc )OU can \imply mo'-e the decimal point in using numbers: 10, 100, or IOOO. Be careful 10 use the
the J111:c11on necJ,-J to obtain the desired unu Recall corrt'Cl conwrsion.
that the basi( length unit is J meter, and both the centi
meter ,111d the millimeter .ire subd ivis ions of one basic
unit. lo convert mc~1,u1 cnlcnts het\veen difrercnl n1etric
lengths. ~itlwr .litirlt by muhiples of 10 if a s11111//er un it
Ill LEARNING TIP
i~ given .rnd a Iare. r un it needs to be found, o r 11111/tiply When solving a p1oblem. if you are
b)' mulopk' <'f .u ii a /111xe1 unit is given and a smaller GIVEN tho smaller unit. divide to find the answer.
unit nc-J' to ht- found lo divide by 10, mow the GIVEN the latgernnit. multiply 10 find the answer.
dccnn.d point th< !ch one unit place for each unit
diffcrcucc 1~ r ' '"on of ~m.1ller units 10 larger units.
ro multiph , c mow the decimal point to the right EXAMPLE2: _ _ _ _ _ cm ~ 75 mm
for C\lCh Ullll rl dl"'d for un it conversion of 1'1rger UllilS
ro s111.1llcr un,, 1 '0111c c.1ses. to get the desired value GIVEN : Smaller unit, divide to find your answer.
in tlu.' nC\~ 1 1 H Jt.-limal point is n1ovcd n1ore Lhan
0
{llint I cm = 10 mm.)
one plac t i;ht or left. In moving 1he decimal
po1111 to th t '"' .1r<' multiplying by 10 for each 75 + 10 = 7.5, so 75 mm= 7 5 cm
spJce the ,1, null mows. Because a m ii Ii meter is
'l?ry sm,111. " 1housandth or a merer, we need EXAMPLE3: - - - - - mm = 2.5 m
nuny 111ill11 i r" ( 1000 ) to equal I meter (length) .
\.\'hen con' t rn ~ Iron1 111 iII irneLers to cent ilnetcrs, GIVEN: Larger unit, multiply to find your answ~r.
moving 1lw <l' mal point to the left. or dividing by JO, (ll i111: I m = 1000 mm.)
giws th<' l.H};L 1 w.u11cd for the millimeter measure
ment quickl d ol course. the same thing works in 2.5 x 1000 = 2500. so 2.5 m 2500 mm

ur 'U nderstanding: METRIC LENGTH CONVERSIONS

-- - -- - -
Oe1ermm th< r to multiply or divide based o n s. 90 mm = rm
uni1 GI\ f" the problem.
6. lm = cm
I. (>')00
" ----- m
7. 8.8 Clll - mm
2. 4 J ( 11 1nm
8. 1.7 cm - m
3. 4 l cm m
9. 1200 mm = cm

c mm
10. 12 mm - cm

Ciltllfflttfcl
 osage Calculations
118 SEC 'N 11 Methemallcs for Pharmacology and D

Practical Apphcation
'"'"<' lh<' following qu...uon<
Whal is the child's head circurnfercn1e m mil.
11 A 1 month old child hs a hedd orrurnfen>n 0 f 42 5 an.
hm<'lcr.!
d that is s (Ill long. I low many millimeters long
12 An cmc~ncy room paucn1 needs su1ures to dose a "'OUD _
IS the \\OUndl

, ..... wnent is 500 rnm. Wha1 is 1he height in <u 1111ncters!

t l. /\n 1nfan1 11 rneasuml from head to 1<>0L "'' measu

. , f cm How many millimeters is tht> cir1111nl.-rencel

-
14. /\ pr<ma1u1c bJb) has a head c11rum1erence o 13
-
15. /\ child <tand~ 1 rnc1er tJll Cilculate the height in cemirneters. - - - - - - -- - -

VOLUME MEASUREMENT Ill LEARNING TIP

AND CONVERSION IN THE Thecom-ersions to be remembered for volume inc following
METRIC SYSTEM
Li:ertomlditet ll 1000 ml
The bas1< unn of volume 111 the metric system is the
Iner In medtc1ne. hquod volumes are expressed in liters The same procedure used for coon, 1 n1c1ers as
or unn< of li1ers Ca;, "Olumes, such as -olume of used for con..ening li1ers. If gi ..en thr I uni1 and
oxygen arc aho measured on lners. For comparison, coO\>ening to a smaller unit, muhi11I> h) lhesamc
man)' soft d rinks are now >Old m 1-. 2-. or 3-liter prefixes are used with \'Olume as found " ..1gh1.
bonles Ille I -Iner bonle 1s approJUmately equivalent
to (sligh1ly more than) 32 ounces or I quan in the EXAMPl 4: - - - -- ml 4I
household S)'Slfm A g.-illon of milk is approximately
equivalent 10 4 liters {3 78 lners). Many arc cough GIVE.'/: larger unit, multiply to hnd
mctlocines no" come wnh a medicine cup calibrated in (Hint IL= 1000 mL)
mi llil11ers (ml.}. cubor cenumtters (cc), and teaspoons
( 1) or 1ablespoon1 (I) Many students find the -olume lOOO x 4 = 4000, so 4000 mL 4I
me,m11emcn1 e.tsoest to learn because there is only one EXAMPLE 5: 1 = 200 ml
conversion 10 rcnwmlwr-alwa~ multiply or divide by
1000.
GIVEN: Smaller un it, d ivide 10 find
ll1i sooion explores the volume (liquid or gas) (Him: IL = 1000 111 L).
measuremc1m or 1he milliliter and liter, which in
medicine measure ,1 pa1 ien1's Liquid intake and
200 + 1000 = 0.2, so 0.2 L = 200 ml
ou1pu1. ln1r.tvcnous solutions are usually measured in
liters, with 1hr dri11 vo lume measured in drops per
Alwaysrememberto !}lace a o to 1hc llt 11 l 1lll' clrci 111.1I
millili1cr.
(.2 is wriuen as 0.2).
'''
CHAPTER 7 Measurement Systems and Their Equivalents 119

Dctcnnme whether 10 mu ltiply or divide based on 5. 500 mL = I,

um\ GlvtN in the pro blem.
6. 2500 ml =
I. I ml= L
7. 1450 mL =
2. 0.5 I = mL
8. 4 I. = mI
J. G.4 L = ml.
9. 100 mL = I.
4 . 14 ml = l
10. 3000 ml -

Practical 1ratio n
Supply Jn' I< the following ques1ions.

.. \ructcd to drink 2 l of water every day to replace body fluids I low many millilitc,... 1s

12. You .,. .meted 10 measure the urine o utput of a pa1ie111 with a Foley rathc1cr. If the u ri ne collection
b~g c ,r ' J.S L or urine, what volu me in milliliters will you record when emptying the b.1g!

13. A ' t..111 .ra,cnous bag contains 1000 ml of liquid. llow many liters is lha1! - - -- - -- - -

14. 1\ p.ll ~l\C 250 ml of fluids I low many liters will the patient reiw! - - - - - -- - -

IS. A p.11 co rctt'iw 1000 m L of inir.tvenous fluids. I low many liters should be ordered from the
phJll

SUREMENT AND Ill LEARNING TIP

IN THE METRIC
The b.h c ur to mt'.ture weight (mass) in the
metric '}'Sl <'I " gr.un . Other units of interest are the
kilogram (1"1\. o1(1 g), mil ligram (mg; one tho usa ndth
or a gr.1111 111 ' !\I) .rnd mirl'OgrJm (mcg; one mi l-
lionth or IO 000001 gl) Newborn babies are
"~igh,-d in >g "'' unlc~ they arc premature. in
\\ hich CJ" h ffi J\ he so small 1hat their we1g)11 mus1
he ex11rc'>'t'\I 1n nrams A gra m 1s abou1 the weight of one
large p.1per <lq Drug wdgh1s .ire usually expressed in
gram;, milligrJ111> .rnd mi<l'ograms.
The conversions to be remembered fOf weight include the
foflowmg
Kilogram 10 gram l kg a lOO)g
Gram 10 m1lh9ram lg IOOO mg
Milligram to microgram 1m o 1000 mcg
Oicsc wcigh1 units are commonly used in med idne,
and 1hey haw an i111eres1ing relationship: each is o ne
thous.ind1h o f the next higher (used) weight. fhc same
ratio of I 1000 exists between the kilogram and the
gram, between the gram and 1he milligram. and between
the milligram and the mirrogrJ111 (thus a micJ'Ogram is
 d Dosage Calculations
120 NII Mathemaucs for Pharmacology an

635
+ 1000 =o.635, so 0.635 mg ' 635 mcg
thou:..mJ1h or. mrllrgram or. millionth or a ,gram).
~1emor111ng thl\ ftacurc of wecglm 'hould h~p l:O,u Remember: Add tl1e zero in rron1 or the decimal
r<mcml><-rchc con,a>1ons (Other un11.s such aH e -~
wam. ccnugram. ddugram and '<>on exist . but are """'
and EXAMPLES: _ _ _ _ g- 4.5 kg
mfrequ~ntfV 1R thf mt'JKaf ficfJ ) /U wllh lei;r 't,
'olum1 ro conh1'1 from larger unit to sma er ';';li GIVEN: Larger unit, muhiply to find the answu
mulupf\ If th1 \mall<r un111s 81'~ and~ '-alue 0 e (Hint: I kg= 1000 g.)
larger unit is \\anll'\l. dMde
_ _ _ _ mgc8g 4.5 x 1000 =4500, so 4500 g 4 5 ~ll
EXAMPUI.
EXAMPlE" g - l250 mil
(,I\ 1" f.;irtM unit. muluply to find 1he answer.
(lhnt lgIOOOmg) GNF.'1: Smaller unit, divide to get ''""'er (lfinL
J g =1000 mg.)
II 1000 11000. 'IO 8000 mg"' 8 g

EXAMPLE7: _ _ mg 6l5mcg 3250 + 1000 = 3.25, so 3 .25 g = 3250 m '

C. IVI N ~m.1ller u1111, d1v1de 10 find the unit. (Hint: Note thatthe zero following 3.25 is a 1ra1 "'ll Uroand
I mg 1000 mcg.)
has therefore been dropped.

Check Your Understanding: METRIC WEIGHT CONVERSI

BOX 7 -4
- - -- - - --- -
Decmnine wlwclwr co rnuhi1>ly or divide based on 5. 0.34 kg= - - - - I!
uni1 CIVI N 111 rhe problem. r>rop or add zeros as
.rpproprr.uc 6. 500 g =- -- - kg
_____ mg
l. I 500 mcg 7. 0.09 g = - - - - - mg

2. 400 mg - - - - - - g 8. 2.75 mg= _____ mcg

3. < 5 gc _____ mg
9. 0.03 kg=--- - g

4. 4800 mcg _____ mg

lO. i l l mg=----- g

Practical Application
Ans\\ er the following questions.

II. A premature b;ib) "e1ghs 2.2 kg. How many grams does the baby weigh1 - - -- - - -

12. A labora1ory spimen welghs 1850 g. Con,-en the gntm weight into kilograms. _ _ __

13. 1he dosage strength of l.tm<U'm is 500 mcg. The drug is prescribed in milligrams Convcn ti 00 mcg
avarlable to the prescribed d o s a g e . - - - - - - - - - - - - - -- -

14. 111e do;,1ge mength of X11n1u is 0.25 mg. lhe drug is prescribed in micrograms. Convcn O 2~ mi to micro
gr.1ms _

I S. A 111edka1io11 comes in a tablet with dosage strength of 88 mcg. The medication boule re.ids mil hgr.1ms.
What woul<l you expect the dosage lo read in milligrams? _
 ''
CHAPTER 7 Measurement Systems and Their EquJValents 121
--~------

TABLE 7-2 UNITS OF MEASURE IN THE APOTHECARY TABLE 73 HOUSEHOLD MEASUREMENT SYSTEM
SYSTEM
HOUSEHOLD
I I TERM UNIT VALUE ABBREVIATION
60 minims= 1 fluid dram (f3) 60 grains =1 dram WEIGHT OR MASS
8 ftuid drams (13 v11il- 1 ffuid ounce (f ! ii ounce oz
pound 16 oz lb

APOTHECARY SYSTEM VOLUME OR LIQUIO

drop gn
nw potbeun ' l~m is one of the o ldest S)'l>lcms for teaspoon 60-75 gtts LSp, t
indoc.iting druj\ m.1,~ or volume but is nearly obsolete
tablespoon lt Tbsp, T
today Oc<:au"' i1 hJ' been gradually replaced by 1he
metric system lh 1wlhecary basic unit of measure for ounce 2T oz
solid weight is till' g ain (gr). cup 8 oz c
1 gr.110 approximately the weight of 1
pint 2 c. 16 oz Pl
ra11 of wheat or rice quail 2pt4c;32oz qt
gallon 4 qt. 8 Pt. 16 C, 128 oz gal
When liqu 11 "'' measured, Lhe volume may be
expressed in " ' " " 'n, t.lrams, or ounces. A minion (rTJ) is LENGTH
still found me syringes, especially tuberculin
S)Tingt"> Th< rnmonl)' used apothecary unit for
inch In
a liquid" a ) lh1s unit i\ most of1cn found on foot 12m Ft
a rrcscripuo 1lll household measure of the tea- yard 3 ft; 36 in yd
spoon. So1m l 1<1.rns still u>c the ounc~ symbol
(!) on prl'sn > See ' fable 7-2 for 1he com monly
used apoth< nt'S.
'-umbc. "'' >0ls in 1he .1pothecary sys1em are are dispensed with the appropriate utensil for accurate
"'riuen in rL > .kr from the metric >)'Stem. In the me.1suremcm of the dose. The household '>)\lcm is also
mc1ric >)Stcn1 11.1111i1y is wrincn first, fo llowed by called the U.S. C11sw111nl') Sy:.tcm of Mens11rc111eru. 111is
the unn (c g 1, ll.). In the apo1het".ary sys1cm, ~1e system is used in ptient educa1ion in pharm.>cology for
~bot or " Ill comes first, followed by the quan- home adminimation of mroications, especially liquids
my, wh1Ch J m 10\' ercase Roman numerals. An and with diabetic and weight conuol management. It is
example is yr 1ch means 4 grains. Usually only the also used to increase patient compliance when compar-
digi1> I throu I, >o .ind JO .u~ expres...ed in Roman ing amounts of food and liquids that 111 ,1kc up o ne
numeral; .\1 11 ...1 quami1ies ,ire expressed in Arabic servi ng of a food o r liquid. '111c household measurement
numlxr.. H< II numeral\ arc wriuen in Arabic if >)'Stem is usually based on the number of ounces in a
the rnur~ un 1 ment i> wrillcn in full. l'Or example. measuring device when quantities of weight or volume
8 grain~ \\OU \\Tineo viii grain because 1he \\'Ord are measured. I he most commonly used hou!>Chold
"gr,1in" is \vntt 1111, 11 is eiLhcr .. 8 grains or "gr viii ". sytem of measuring volume ( liquids) arc the dropper.
Ano1her <l1 between the metric sys1em and the tea~poon, l.llblcspoon, ounce, and cup as uni1s of
apo1hecal) " 1 1ha1 framons are used in 1he apoth- measure. The pint, quart, and gallon a re also household
ecal)' S)~ter 11t'Ces&ll)' (Remember the meuk measurements, but 1hese mcasuremems arc no1 often
quan111ie' .ir ,l'<l m decim.1ls.) For example, Lhe associa1ed with medical use because Lhc metric mea-
fr.1ction thrn 1 1 h'ls is noted ,1; Y. in the ;ipothecary surernents are becon1i ng heller kno,..,n and are 111 ore
sys1e111 but a< 11 1 the metric >ystem. frequently used. Although 1hc household ;ys1em is
applicable primarily 10 liquid mcd ica1ions, 1he ounce
and pound could also be ~ to measure a patient's
solid food in1akc or a patient's weight. lhe common
MEASUREMENT household mea;u res oflcngth indude the inch, the foo~
and the yard. ' fable 7-3 shows the househo ld measure-
ment units mos1 o ften used. No1e Lha11he table identifies
Uin\umer.. 11 > m asurc drugs al home may use the the smalles1 mc.1sure first. When discussing food intake
houwhold nwmir<"mcm system because of case of avail- with a patient, the health professional should dearly
.1bility of the u11 n"I' I lowever, 1od.1y most medications d~fine the contcm amount of a cup, because there are
 d Dosage Calculations
122 sec N 11 Mathematics for Pharmacology an

3
ropriate without specifying exactly what dropPtf
tt.lCUJ'~. cort,..- CUJ" n1CJ\Ullllg cup<, and other siud PP.,.,,..,,n needs 10 use. Another problem with dropllerl
they~-- . . I , d
CUJ" all wnh dolkrcnt C.ll>.1C11t~ ed ~ . th diiferent pauents using tie san c r<>pper may
The hou..,holJ ~)'tlm I\ not rt-commend 0~
0
~ena~ different amount of force ~Yhen flinching tilt
meJM'.al mtaurcmcnu on a medical f.JahtY because
the dofkrcnt .,,..., of th< mca\Unng dl'\1Cts fo r oample. 1 n er of the dropper, thus dospen\mg difTrrcni
p u g015 of medication. r-or OTC and prescriplJOti
J Jroppn 01.1\ h.-, a IJrgt' or small hol~ (a~ure) for
tht' ml'11cmc. to p.1 through. and 1he medicmon
amou d . .
drugi that are to be a m1111s~er
ed by
a ll'JSllOOnful
medicine. most pharmaceuucal companu.:< are now
'
11~1( coold I>< cnlwr \l>Cou. or aqueous. which would
(bging the medicine wuh a graduatlJ mediu1ioo
changr the amount conumed ma drop unlN an appro- pap, 3 calibrated hollow-handle spoon, or a calibra1cd
pnatc dropper ,. prornled with the mediation. To cu
m'tn1ct the p.iuem to u.e few drops would nOt be dropper.

.
Check Your Understanding: HOU SEHOLD SYSTEM BOX 7
- - -

ldcnuty the hoo<ehold abbr.:vtJllon Write greater than, ' less than, or "eq11. I to make
each household measurement a true st.ttto "'nt
I. I
6. t _ _ _ _ Thsp
2. gu
7. tsp _ _ __ _ g11
1. r
s.r _ ___
4, I
9. T _ _ ___ c
~. lbsp
10. grt _ __ _ 'lbsp

Practical Application
ln.1n1a the p.111cnt on how to use the foLiowing OTC remedies,

11. ror the relief of occasional ronstiption, dissol,e 2 lew.l tsp of magnesium sulfate, USP, into t 11f 11 10
and take 1'0 - - - - - -- - - - -- - - - - - - - - - -

12. Md I 2 r of I psom salts to warm bath to soothe and refresh )'Ollf entire body. _ _

I l. for tcmporar)' ll'lief of coogh aused by bronchial irritation. uke elix &n}'li11, I tsp of q4h not ucet.'d
6 d()SC) d a i l y - - - - - - - - -- -- - - -- - -- - - - - --

Take Milk of Magnesia, I ounce PO after meals pm. - -- - -- - - - - - - --

lo increase moisture. 1ns11ll L1qu1jilm 1ars, 2 gtts in each eyt' pm. - - - - - - - -- -

llnloke on the mccric S)'Stem, which uses the move. UNITS

men 1 of decimals to identify equiy,ilents. the unit values
must he niemonLt'tl 10 find household equivalents.
Some drugs are measured in unit, l 11111 may be
I or c<.1 111p lc. to determine how many ounces are
expressed as IUs {International units) or l l~P (U11i11\I
found in .1 11-111011, you must first remember how many
S1J11<1S P/1armaceu1ical) units and are expH'wd " Arabic
ounces arc on .1 rup, how many cups are in a pint, how
many pirm arc in .1 quan, and how many quans are in numbers followed by 1he unit designati on. llU!\' mc'1
sured in uniis may be derived from p l.1111 ur ,111imal
a gallon or memorize all tlte conversions found in this
S)'StClll. sources or manufac1ured in a l.tbor.llory (\ynthecir
drugs). Most insulin drugs 1oday .He sy111h~1ically
..... CHAPTER 7 Measurement SySlems and Their Equivalents 123

0o Not use abbreviations would be de1.-eloped (s;>e

prCK luced to prevent "ariations in the insulin. Insulins
from ,rnim.11sources are b.isorn ' II y nonexisten
' t .mtod a,'s 1:1ble 5 I) . In May 2005, 1 IC mandated that all mcdiral
rkct ,1s most are ONA produced. facilit ies adhere to 1he changes on the 'Do Not Use' list.
lll.lC01111110n drugs C1tSpCll~Cd .111 UnllS
. .tnCIUCIe Itepmfo (a It was also determined that each year 11C would review
powerful anticoa~ul,dmt that p1evulems bl ood c~ots), i11sh11/i11 the list and possibly implement funher change> in addi-
(for peopk with'"'' equate ms m pr00 .. uC11on, sue a~ tional abbreviations, ,1rronyms, and symbols. lor the
ho~ with diabet~ mellnus), and pema/1111 (,and,,..,.,. most current information on any new changes. pltase
1
11,,. \' (anubiotics) Some fat-soluble vitamins such as refer to llC's website ("~"w joi111commission.org) under
:~1,111111u 11. D, and fare also dispensed in units. the tab of Patient Safety. I\ second website, from the
lnstitule for Safe Medication l'ractices (www.ismp.org),
E!J CUN includes not o nly the abbrevia1ions and symbols, but
a lso dose deignations and drug abbreviations that
AJwavs iead the label ca1efullv to obtain the correct dosage strength
should be avoided.
dP<; ted
SUMMARY
Milliequivalents
n1r tertll 11 I n t pcnains to the amou nt of a Several systems of measurement are encountered in dint
solute cont.ii mJ in .1 solu tion. Milliequivalem is abbre- ca l medicine for measuring mass, volume, and length.
viated mEq anu i\ usu.illy expressed as 111illicquivalen1 'lhe metric system is mosl common and isaccepicd world
per \'Olumc, ml I or ml.q/ml. mq/tab, o r mfalfcap. wide. OTC drug insiructions frequently refer to house-
To cx1m"' f ' 111 milliequivalents, the Arabic hold measures such asadroporrup. Cenain medications,
numbt'rs (nut di 0 through 9) are wriuen first. fol- such as insulin and penicillin, are measured in unit\.
10\\cd b' th<' t")uivaknt indicator. for ex.1mple, if Finally, the apothecaiy system, one of the oldest S)"ltems
the ph);icoan J r 100 un it~ of insulin, this is wriuen of measurement devised, is discussed. Because it is impor-
.11 100 u111ts .11vt mill1c~1uivalents is wriuen as 2 mEq . tant forallied health professionals to know a nd be ,1ble to
use all S)'>lems, the next chapter introduces conversions
among the commo nly used metric system and the less
frequently u>ed household and a1>0t lwcary S)'l>lems.
Weight $lie Abbreviations are imponant in most of tl1c measure-
Volume a ment systems. Being able to recognize the differences
among lhe various systems will help the student 10
understand how 10 read and imerpret medication orders,
NOS FOR SYMBOLS prepare drug inventoiy records ,ind M,n erial Safety Oata
IATIONS Sheets, and assist in pa1it.. nt educatio n when re:idi ng '1 1ld
interpret ing patient cha11S. The oo Not Use list as;,ists
In 2004 II ... , tnmincd 1ha1 in order to meet the in preventing medica1ion errors b> reducing misin1crpre-
Na1ional rat< "' Goal (NPSG), an official list of tation of abbreviations.

Supply r' " ng information in the followmg table of merric terms and abbreviations. The first row is
compler".:J , xample. INA not applicable.)

METRIC rra.1 UNIT VALUE PREFIX ROOTWORO ABBREVIATION TYPE OF UNIT

k1log1." 1000 umts ktlO gram kg weight (sohdl

micro mcg weight (sohdl
l untt NA length
0 001 of a unit mi Iii volume (liQutd)
l unit NA g
meter cm length
m1 gram m1ll1 gram
l unit NA liter volume (liquid)
m1ll1meter m1lh mm
 age calculations
124 SECT 'N 11 Methemaocs for Pharmacology and 0os

1111 In tht' blank. -' .

h
A drug dcmt-d from an anonul source. sue s tn sulin
is measwu. ' -----
.
. contained in a norma1 so1utton.
2 Ilic term refers to tht weight of a drug
he measuremem system
3 Conwmcn who measure drugs at homt' most often use t
I \ m1< rOflrJm 1s ahbrtviatt'J - - - - -
s (W>Lcm) quanuun are o:prnsed in decimals.
6 One ruboc ccnttmeter 1s equ1\'alcnt to - - - - -
and
7 lhc th""' bJ~IC unus m tht' metnc system are the -----'----~ ----~
Circle the correct notation.
8 100 LI or 100 unit\
9 n m11l1equivalfnts or l mLq
Match Lite corroo prefoc with the unit given.
10 1000 centi
II 0 1 deci
12. () 0 1 kilo
11 0.001

14 . 0.000001 rnilll
All of the following statements are filse. Oelermine the errors, and then write the correct a nswer' i1 complete
scntc nct. (Anwers can vary.)
15 A mi llihter is equal to a cubic millimeter. - - - - - -- - - - -- - - - - -- -

16 Con\umcrs who measure drugs at home most often use the apothecary system. - - - -- -

17 l11c household S)'>tem 1s ron,idered the international standard of measurement systems

18 \ hcrogmns are IJrgtt than m1lligrams. ____ __ __ __ __ _ _ _ _ _ __ _

19. Ilic m<>iric ~-stem sometimes has convelllion factor that is a power of 10.
------
20 Med1C.11ions prescribed in the metric system are measured in teaspoons and tablespoons ___ --
21. Millililcr. Jrc used to rneJ>ure solids . - - - - - -- - -- - - - - - - - -- - -

-

CHAPTER 7 Measurement Systems and Their Equivalents 125

II measurement systems d iscussed in this chapter are still in use today.--- -- -- -- -- - -- -

22. /\

23 Ilic meter wd the yMd are the same length. - -- -- - -- - -- - -- - - - - -- - - -- -

. Prern.uur~ babies .uc often weighed in metric pounds. _____________________

24

25 When rdcrring to in,ulin, the term millirqum1/m1 identifies the weight of the solution. - - - -- -- - - -
 Converting Between Measurement
Systems

After studying this chapter. you should be capable of d01ng rhe following:
Reading the time of day on the internauonal Computing and converting approxm< <eight
standard 24 hour clock and the 12-hour clock and equivalents within and between the 1 1c system
converting lime between the two time standards. and the household system or the m&1 'VS tern
Convcr11ng between Fahrenheit and Celsius scales. and the apothecary system.
Computing and converting approximate volume Compu1ing and converting from one I lh unit to
equivalents w11h1n and between metric. household, another within and between the me11 id
and apothecary systems household systems.

Celsius Convert Fahrenheit lnternation. Standard

Conversion factor Dimensional analysis ISO 860

Chapter 8 PRETEST- CONVERTING BETWEEN MEASURE

SYSTEMS
--- - -- --- -- - - -- - - ~

Answer the follo" mg quouon~.

1. Coll\cn the following Lnglish standard times into international standard notation.

I0.15 r" - 5:47 r"' =

1 ') 20 A\1 1:25 AM=
-----
2. Convcn the following temperatures between Fahrenheit and "-I R
u: s1us. ound to the nearest tenth
1s c = 1- so c = F
104' I - - - - - C 100' P= _____ C

126
 ''
CHAPTER 8 Convening Between Measurement Systems 127
------~--

Chapter 8 PRETEST- CONVERTING BETWEEN MEASUREMENT

SYSTEMS-cont'd
--~-- - - - - - - - - - ---- -- - - - -- -- - -

J . eooven 1hc following volume Ul1ilS between S~tems.

10 ml - - - -- - 1\P 32 o~ = - -- --ml

3 lbsp= _ _ _ _ _ mL
~qi =----- ml.
2
4. Conwn lh< followi ng weight units between systems.

30g= - 01. S lb = _ __ _ kg

_ _ mg

5. Convm 1h lollowing length unit.~.

l1 _ _ __ _ in
15 on=

150 nun - _ _ _ in

17.5 cm in

'JO COll\C"rl to change from o ne system to

another ""1 '"" m<'tlical field, it is often neces-
Solt)' to ch.I <-en measurement systems bause Because digital watches did not become Widely a-;a1labte in the
there i~ curr1 1 world Mandard for drug measure- United States until 1971, health care providers have been
rncni Manv \ measuremem sys1ems that arc com- trained 10 take vital signs using the second hand of the analog
monly IDCd ll ni1cd States are not used by watch
scirntlsts o professionals in other pans of the
world. Rec this, he.11th care providers must
become fam ii "th all 1he systems currently in u,e.
This chapter by d i;cussing the system of time 111e lili signifies the total complete hours that have
use<I in m 1< \\Orld; followed by 1emperature passed since midnight; the 111111 states the total minutes
co n\~rs 1on~ ieit and Celsiu~); and method; of that have passed since the Stan of 1hc hour; and the
convening 1 1cmc111> Jmong metric, apothecary, ss identifies the toLal seconds that have passed since
and househ1 I m"' wcighlS, and lengths. With 1he the start of the minuLe. For cxampl e, 25 seconds after
exception < lues, when numbers are conwned 10:20 "-" would be wrinen as 102025 (In most c.1scs,
from one~.. dnothcr. they will be approximately seconds are not included in the con\'Crsion. so o nly
equal. C0111 Iii.tr 1rr. 11pprolima1e/y eq1111/ may tliffer the hour and mi nutes would be documcn1ed-e.g., 1020
/ly 11s mud1 1 would be 10:20 AM.} Mos1 counLrics do not use 1he
abbreviations '"'1" and r,..
because 1hey do no1 1cc-
ognil<! the 12-hour notation that is used rn the United
States The history of the 12-hour dock da1cs back to
RSIONS the d.1rk ages when Roman numerals were used and
there was no symbol fo r the digit 'zero. A good example
lntern~tio rd ISO 8601 has been recogniM<l of how the 12-hour dock is still used is the analog
in most cou of the wo rld as the universal standard watch, which displays the numbers I through 12. l11e
for interprcu11 11111c anll wri1ing the date. The United 12 hour clock h.1s only the numbers I through 12, ~o
S1a1cs has nrn , 1<.kly adopied Lhis standard except i11 1he to di1Tere1uiaLe between mo rning and cw11i ng, the tirnc
military, in n 01nputer industry, in scientific publica- from midnigli1 10 noon is followed by the leners AM.
tions. and in I 11tdls. Ille mtemational standard nota- The hours from noon to midnight are written ";th the
tion for the t11111 of day is llJrmms.s. letters P\I after the numbers. To unders1and how to
 sage Calculations
128 c N 11 Mathemaucs for Pharmacology an d Do
k increasi ng b}' one digit for each ho ur. On
ron,,n from the 12-hour (A""'''
format to the 24-hour the:i4-hour clock. AM and ' rM a_re no1. usc<l ?ecaui,e
fom\,11 rd<r to Rox 8 I (for the hour desig11atcd). No~ o'clock in the afternoon IS Wlll len 1100,'
that miJnight stan\ the 24 hour clock at 0000. Ca one o'clock is wnnen 1400, a nd so on M1nut\'S

ho11r 1\ 'hown by the hrst t"> J 1gitS. which art' num tWO d' r II
are written as the two 1g1ts .'o owrng t 1e hour I
Jxn-J from 00 to 14 Wlwn you get to noon ( 1200). and are numbered from 00 to 59, 1ust as 111 the familiar
12.bour system. (Seconds do not vary between t~
BOX 11 THE 12-HOUR CLOCK ANO THE "Stems either.) 'The d ock in Figure 8 I $hO"' the com
24-HOUR CLOCK ~son of homs bet"-een the two system\
12- Hour Clock 24-Hour Clock
00l) (2400!
EXAMPlE 1: 8:20 "-" =_ _ intemauo n.11 11me
12 midnight
Iw 0100
'The ..._, uymbol tells )'OU 1ha1 this i$ in 12-hour formal
2 AM 0200 so change the formal to 24-hour not.1111>11 hy drol>-
J A/,I 0300 ping the AM, adding a zero before the Ii.mJ deleting
4 .w 0400 the colon.
SAM 0000
So, 8:20 .v.1 is 0820 in 24-hour no ta11on
6 Al.I 0000
7 Al.I 0700
EXAMPLE 2: 11:55 PM = - - intem.\11011 1l 1111w
BAM 0800
9AM 0900 llie rM S)'ltlbol tells you that 1hi< i< 111 11 12 hour
10 AM 1000 format and that ii is in Llw evening, Ml .Hi.I one digit
11 AM 1100 for each hour after noon, dro1> the l'M 11tbol, .incl
12 nooo 1200 delete the colon.
1 PM 1300
2 PM 1400 12 + II = 23 .1'herefore 1he time is l l >
3 l'M 1500
4 PM 1600
Several valid reasons 10 use the intcrn,\11" I \landard
time in the medical field instead of 1h1 hI I 'nglish
S PM 1700
12.hour clock exist. With the 24-ho ur clo1 1<'rc is less
6 PM 1800 chance for human error because there;, II 1 plkation
7 PM 1900 in the hours of the day. With the 12 1>0111 k, if the
BPM 2000 symbols AM and PM are nol used, mi \tak"' ' w made.
9 Pt.I 2100 especially when medications are meant to "en only
IO PM 2200 once C\-et) 24 hours.
11 PM 2300 Another way to remember how 10 ch 1 from the
English 12-hour clock to the 2400 intern. 1 11 clock IS
12 modntghl 2400(0000)
described as follows (see figure 8- 1)

- Slandard doclt
12 12 2-IOO
12 11 2300 1200 12 1300
1100 0100

1 012t2
8
e
ot

7 6 5
3
4
12 + 10

12
ZIOO 1000

12. 9 = 2100 0000

e = 2000 ~
0 0200 12

0300

0400
12

12
t
2

4
3
1400

t500

1600

t2 + 7 - 1900 0700 0600 0500 12 5 1700

12 + 6 1800
A t2hoo English clock. ""' n<l PM B 2400 intetnatiooal clock. Black mldnigjit to noon:
green = noon to midnight
Figure 8-1 A. Starxlard clock and B, interna1ional slarxlard cloct
 CHAPTtR 8 Converting Between Measurement Systems 129
----

!)raw two circll>s. international dock, and 0001 is I minute after

On the first circle. dmw a second circle inside the
larger circle and label the 12-hour clock.
On the second circle using the number 12, add each
number from the 12-hour Fnglish clock to obtain
the 2400 d0< k. 2400 is midnight on the
midnight. The first 12 hours after 111i dnigh1 are
wri11cn the same on boc h clocks; however, the
English clock will idem ify AM and the imemational
dock is always written using four digits

-"" .
Check Y_o_'!r Understanding: TIME CONVERSION 8 - 1
. . - ---

Conven chc cim<' 'hown inco in1c1natio nal standard Convert the interna cio na l cimc 10 the I2-hour
tin-H?. English time.

I. 4AO AM 11 . 2121 - - - - -

2. 6:25 PM 12. 1615 = - -- --

3. 11:02 "' 13. 0045

4. 2:56 14. 1234 = _ __ _ _

15. 2400 - - -- -

6. 8: 10 I'
16. 1830 = _ _ __

7. 12 H 17. 0210

8. 10:00 IS. 1605 - - - - --

9. 33~ I 19. 1515 =-- - --

10. 7 17 20. 1357 ~ - - -- -

temperamrcs are always nwasured in degrees. J'or

TEMPERATURE example. o Celsius is equivalent to 32" on the I ahren-
heit scale. ( l11e small !')'mbol stands for degrees.)
In Chapter 111<1ric system was introduced as chc Table 8-1 shows a comparison of some common equiva-
intern.1 1ion.1' .l.ud lor scientific and industrial mea lents between the Celsius and I ahrenhei t scales.
surcnlcnts. \1 if 1h.: \\1orld mcal\ures te:n1pern1urc in
the metric " ,n t<mperature is measured using chc
~lsius '><" ,1 !Inned States the lahrcnheit scale is
TABLE 8-1 COMMON BASELINES FOR FAHRENHEIT
prcdominam t lsius scale .. as introduced in the
mid 1700s .lr llm referred to as the umigmde scale. ANO CELSIUS TEMPERATURES
Because tlw 1 , 111 'Y'Mm is the l'rcdominant mathc- CELSIUS FAHRENHEIT
macical sys1e11 """I
in much of chc rest o r the world, ic
is important 1 h, .1hk to co1wen fro m the F~hrenhcic Water boils 100 212
scale to the c., tu '"'le. Nomial body temperature 37 98.6
Ille Cehms ten ..:rature is always the lower number Room tempetatute 20" 68
when tcmpcllllrt 1\ ,hown with the equivall'llt degrees
Water freezes ()" 32
on the ~ahrcnh .. 11 s. .11<-. lloth Celsiu~ and Fahrenheit
130 fCTION 11 Mathemaucs for Pharmacology and Dosage Calculations

Review the two formulas:

'>omc \pt<'lJI coru1dcrJuons should be rernembe~ed
when placm11 dl'C1mal 111 tht' Jnsw.:r when con\'erung From f 10 c From c to ' I
tcmf>("murl'\ llw J<"Ctmal place 1s used in troths
onlv and ma' n;'\J to be rounded off For examplt. ;r C"'~(P-32) F"- (~c ) 12
the anS\HI IS H ss the Jns,,cr would be wntten as 9
lS 6 C.

TEMPERATURE CONVERSIONS
Method 2
use the formula c = ('F - 32} + 1.8 to h.mge from
Fahrenheit t0Celsius. ( In this fonnula, 1.8 1s the decimal
-
equh<alent or r. .)
Thm! .lrc t"O "J) tu C()O\trl bet"'"'" uls1us md F.tht
cnheot ,\lthuu!lh both mdhods can be used to obtain EXAMPLE 5: _ _ _ _ C = 99 8 I
the cum"Ct re;i1ll\ you should memorize only one or
tht'm and rnnmtt'ntl) uw thJt method to avoid confu-
sion when conHlllng bet"'"'" Celsius and fahrenheit. Using the formula c = ( F - 32) + 1 8 th .. first step
Both nll'lho<ls ar" expl.lin<'tl, and you should choose the wouldbe tosubtraa(9?.8 F- 32) <> I 8 l lll's..'(ond
one th.u wor~ J>.:,t for you AlwJ)~ round your anser and final step is to divide 67.8 + 1.8 17 u Remem-
to the nc.11c>1 tcmh ber 10 round your answer to tenth,,

Therefore 37.7 C = 99.8 E

Some students find that Method 2 is 1 r bcc.tuse

Method 1 only tWO Steps instead o f three ore 11CCC".ll \ tt> find the
'lo dungc from I ahrcnhcit to Celsius, use 1his formula: correcl anS\ver.
Method 2 can also be used to convert rm1 ' 1.1h renheit
5
C = (F0 l2) to Celsius using the formula r = 1.8 ( . ( ) I}
?
EXAMPLE&: - - - - - I' 22 C:
EXAMPLE3: C 104 ' I
Using the fonnula 1; = l.8( 0 C) + l2, 1 lirM step
l l~ingthe fom1ul.1, the fi~t .iep would be to do the would be to multipl)'( 1.8 x 22 C) "' 11) I hen just
calculation 111 p.uenthcscs by sul>trJcting 104 F - 32 add 32 to your answer: 39.6 + 32 = 71 <>
- 72 Ilic second Mep o> to muhiply 72 x S = 360. The
final step would be to divide 360 by 9 =40. Therefore 22' C =71.6 " F.
TI1erefore ~O C 104 I When changing from l'ahrenheit t11 (.d,11 , )U nlUSl
remember to do what is in parenthl"<" In I 32)
To change from Ccls1us 10 Iahrenhei~ use this formula: before attempting 10 di\ide by 1.8. Whtn c i:mg /"""
Celsius to Fahrenheit, remember to muht1 1 s x c
before adding the 32.
"" -( (. )~ J2 Review the two fonnulas ag.1in
From c 10 f From rto
Multiply c by 1.8 S11brma l2 fr1 11 1
EXAMPLE4: - - - - - I = 38.J C Md32 Dwi1lf hy I 8

Usong the fonnulJ, the first step would be to do

1he c.1lculation in parentheses by multiplying 38.3 x
9 344.7 nie second step would be to divide:
144.7 + s 68 94 Ill LEARNING TIP
rhe fin,11step is to add: 68.94 + 32 =100.94. When pelforming 1empera1ure calcula11ons, rememh r t l1rs1 cOffl
Rot111c.J 10 100.ci 1; "
100.9 r = 38.J c. plete the opetation in parenthesis
'''
CHAPTER 8 Converting Between Measurement Systems 131

Checl< Your Understanding: TEMPERATURE CONVERSIONS 8 - 2

--- -- - - -- - - - - -- - - ----- - --- -
Practice Problems 10. c = 97 2 ~
c;onwn the temperatures and round to the nearellt
icnih. Use the one m~thod that is most comfonable 11. r= 14c
ror you.
12. I'= 30' c
I. C = 99.6 F
13. F = 5 C
2. C- 76' F
14. F = 21 " C
3. c- 103 1
15. 'F=96'C
4. c 100.s r

5. -
. ( -80 F
16. i: =so c

6. . ( = 98.6' F
17.

18.
F = 42.J C

r = 18.8' c
7. c. 11r r
19. 'F=ll'C
8. ( -68' F
20. ' F=SJc
9. c 0 F

BETWEEN ... d . .__. . ( 1 ml. 2 ml )

bo u< enon11nators .,.,mg 111 gus: - - = - - - .
15 gtlS 30 gtlS
T SYSTEMS USING
ROPORTION This can also be wriuen a' a linear proponion as follows:
I mL: 15 gus :: 2 ml : JO gllS. When the proportio n
So1nc1i inc~ ,1 n .._ 1t ion will be orderl'd in an amount contains an unknown 1nea~url! n1ent, the unknown
lha1 is not in 11 " mcasuremenl S)'lHem as the medi should be identified with an ~-. After determin ing 1he
cation on 1 this occu~ you must be able to unknown measurement, a proportion, either fr.Ktional
conven b.:t' < >'llm~ to obtain th~ corrooamount
or linear, may be fonned. In the propon:ion, u<>e the first
or nwdic.1uor l< m1n1,trJ.tion. ratios for the known element that corresponds to 1he
Sever.ii flit u- 1 .1n: used to conv~n betwet:n n1ea un known desired and the second w io for the identified
suren1cnt u11 11~ f.1'iicst conversion mclhod is usi ng unknown. lb solve for x in the second r;it io, cross-
ratio and 1no1 "" lo solw for an unknown variable, muhiply the fr.1ctions o r muhiply the means and
a compariw1 to' will provide an ans\\ er for solving extremes.
for x. Ile surt tlP unu "alues in both rauos are iden
tifictl 'Oie nui ttc"" must be in the same units and 1he EXAMPLE 7:
denominators rnu,t be in the same uni1~ for ratio and
lg X xg
proport ion 10 b, 11'cd For example: I mL is equal 10 2 mL 4;;;L or lfl: 2 mL :: x g : 4 ml
IS gus, so 2 ml s rq11.1l to 30 gtLS. (Note that both ml.
values Jr<' in lh<' s.1111<' place in the ratios and the gu 2.r= 4 (2 mlx rg = 4 mLx I g)
valu~ arc m th, sam.: place.) This can be wriuen with x=4+2
both numcratof'. 111 tracuonal units being in ml. and x=2g
 d Dosage calculations
132 >t:CTION II Methomaucs for Pharmacology an

Chec:_k Your Understanding: RATIO AND PROPORTION 8 -3

- -- -- --- -- - - - - -

Replace the follo,>'ing fractions with the ra110

Calcul1t1on Review . equivalent.
Rt-plJcc lht' following mios with the fractiona1
3
('(jUl\'Jknl
6. 4=----
I . IS - - - -- 1
7.
2. 16 _ _ __ _ 2

1 25 _ _ _ __ 8. -=
IO
I
4. ~ 5 _ _ _ __ 9. -100
s. 9 10 - - - - -- 4
10. - =
9

[lj L c ARNING T IP TABLE 82 VOLUME MEASUREMENTS

When :;-0111ng up bo1h 1a11os. bo sure to label all of the 1erms. includ HOUSEHOlO
ing the x. w11h the correct measurement 10 llilsure that the equa METRIC SYSTEM SYSTEM
11ons am equ1valon1s 0.06 ml 1drop (gttl ll'J
t ml 15 01 16' drops IT) 16
4 mll5mll' 1 1easpoon (t. tspl :;
15 ml 1 tablespoon (T. ~
SYSTEM CONVERSIONS Tbsp, 1bsp)
30ml 2 tablespoons. 1 01 ~
TI1is w<"lion compares approximate equivalents among 2411 ml (250 mu I cup (cl. 8 01
three different S)~rems-metric, apothecary, and
houwhold rommonly used to find weigh~ length, and 49l ml (500 ml)' 1 pint (ptl. 16 01
\'Olume 1n the medical field. The metric ~tern is the 960 ml (lCXXl ml)'. 1 l I quan (qtl. 32 01
mo't often u;cd ')'lotem of measurement for drug labels 3400 ml (3.48 LI 1 gallon, 4 QI
in the llntted Stai~ It is 1mponan1 that )'OU are able to
na1e1bel that ar'l\<ersi:rls are appn>.Litnate measur
con"rn these untts mong the S}~tems The first two
measuremcms, \Olume and "''gh~ ~re used primarily
in the field of medicine for dosage calrulations. Volume.
measured in m1lhhms or liters. is usually associated Also, do 001 forget that the 10% vari.1nu >1<1dered
with OrJI liquid med1c.111ons. contenlS of a syringe. equivalent when comparing the cqu" 1 .1rnong
intake and output of a patient, and intmoenous (IV) systems.
medications Weigh~ used to measure solid mJS$. is
u\uall) .mociatcd with medic.uions meJSUred m milli-
grJm~. grams. or micrograms. where:s body weight is
Volume
u'ually me.mired 1n kilograms or pounds. F.xcep1 in a Table 8-2 compares the 11pprox1111111r tq111 H' found
few caws. such as wilh 111rroglfr:tm1 omimen~ length between the metric. household, and .1po1h1 ' ;yi.1ems
me.i<uremcnlS are not usually JSSOCiated with dosage 10 calculate different units of liquid voh11 l.quiva
c.1lcu la1ions I ength 1s pnmarily used for measuring lents are known as conversion facto,. \I 1nugh it is
body surface .ucJs ,me! medical equipment such as
best to memori'l,e the equivalents, sonw I 1h1ics wi!I
necillcs or >ttlllre 1hickne;ses and to measure medical
nave equivalency tables available, 11>L1.1ll)' 1 1hc med
appli.1nccs for ~pecific patients. Understanding tl1at there cation room.
wi ll he .1s mud1 .t< a 10% variation in dosage calrulations
As previously stated, th is table show' .1pproxi111a1c
when convening ,1mong the sy.ierns is 1'1!ry i111porw111.
equivalents. The four generally accepted .unounts in
 CHAPITR 8 Converting Between Measurement Systems 133

ihc mctric sptem ( 5 m L "' I 1; 250 ml "' I c, or 8 01.; EXAMPLE 9: 750 ml"' - - - - - pint(s)
ml ., 1 pt. or 16 oz. and 1000 mL or I I - I qt, or
500
oz) ,1re usually rounded. for ease of calrulatio1~s for Set up the known ratio first Known rauo: 500 ml =
31
ie. r~Mding the equ1\'alems betwttn mcinc and I pint. Next. set up the SOnd ratio with the gi\'en
.x.1m P L . th .
household S)~tem-.. 4 or 5 m m e mcmc system is and unknown informauon \our prohlem now looks
,II) accepted d' being equi'lllent to a teaspoon in the like these linear or fractional proporuons
U'LI
household 'Y>l<' ffi and l dram m the apothecary system.
Similarly. whl'n wnvcning .between the metric and 500mL 750m L
household S)"'lflll, 480 ml ts usually rounded up to I pint x pinlS
SOO ml. and is con,idered equivalent to a l)int: and
960 ml. is usually toundcd up to 1000 mL and is con. or
sidercd cquiv,1lr111 IO a quan. Examples in 1his 1cxt use
the roundl'<.I <'qUIVJknts (5 ml, 250 mt.. 500 ml, and 500 mL : I pint :: 750 ml. : x pint
1000 1111.) Rl'nwmlwr 10 use the correct expression (such
as decimal\ o r ft.1< tums) in your answer when convening Cross-multiply:
bct\\'CCll ~\'>lt'lll' In the mecric system, an~wers are
shown m d<-ctmal format. ,,hereas the household S)'!.tem 500mL X 750_ml
usually u...-. Ir l on' but can also use decimals lhe I pint xpmt
apathec.111 " t m u<e' fractions with Arabic numerals
but Jl\O u'S R 111 numerals for the digits I through or
r Y..
~.
10. 20. 30. ,\nt

500 mL: I pim :: 750 ml : .f

Convertin fume Measurement
Units bet S ystems ~
Use 1he i 11 Im ,, provided in this section for ratios, 111e problem now looks like this:
prop-0nio11!-I, ,11 I 1 nv,r1.,ions LO determine 1he vo lu1nc
1ne.1surc!nll'l\t' ,, " n the metric, household, and 500 x= 750
apothc'CI) ''
' ext. solve for x by dividing both ski~ by 500.
EXAMPLE I ml
500x 750
SetUp t A n r.1110: 30 mL"' I oz. 500 "' 500
30ml 750
\\'rite a\ c t fr." uon or a linear ratio: or \\'e no\v have x =- - -
I 01 500
30ml Simplifying. the answer rs x - I 5.

Next, bt:t up t t ltHH.I rdtio with the unknO\Vll infor x was expressed in pints, :,o the anS\\'t:'f ren1ains in
n1.1tio11 ' " 1 1 nporllon wi 11 look as follows: pints.

750 111 L"' 1.5 pints or IY, pints.

30ml 1 I
,,, 30 mL: I OL :: x ml : 24 Oz
I 01 1

NO\V Cr<l' n h ,Jy the .rnsw!'r will be in milliliters

,,------- -
'Oml
' x"
I 01
11
I oz
or

30mL I oz. x ml : 24 01 lll LEARNING TIP
\.___.) RemerOOel Ille ans......er may be Wlllen as 750 ml IX pints or

30 ml " . I x .t
750 ml = 1 5 pints because ptnts are household measurements
and either fracuons or decimals mav be used
Also note that 1f you try to use 1he exacl equivalent of
?20 ml 480 ml= 1 pint. instead of the appf0x1mauon that 500 ml = I
pint. your final answer becomes more diffic11h to calcula1e
The a11;wc1 " 1 1 01. 720 ml_
134 SECTION II Mathematics tor Pharmacology and Dosage Calculations
LIQUID dr
TIME hr
60 55
eo
5
55 5

50

S -
I
mn . - - - 15 ,'4
10

~.
so
45 -
t
minlms(nj -
10

15 14

20
1
20

35
1
35 25 30
30
I
v, '
1.'. ht = 1s ,,., "''Cit
' (:;)
(:;)
1511)
30 II)
v21w = 30,,,..,
31,hf = 45 mn "'Cit(:>) II)
f igure 82 CoNeni01 docl IOI ~ medic<i1lOllS 1 hr ,. 60 min 1 dr (:;) 00 II)
be""' mo:mc .""1 ll'OllleCillY ry~tems ~ulcl1er A. Note 1 dram I ISP
Fulcher Moth calcul.ill/lfl$ la~ llldlnocians 1 "l gn
a ..o?.re>t. SI lou1s 1007 Saunders I

EXAMPLE 10. f3 x _____ ml.

4 mL x ml r---
4 mL : f31 :: xml '
3 10
f3x1= f310 or
\...._,,)
lkr.111 1hat in the .1pothccary ;ystem f3x means
10 fluid dr.1m~ bcca11;e 1he a1)olheca1y system uses l Xx=x
llom.111 numcr.tls.
4 x JO = 40
Set up the known r,uion: 4 ml f3i.
x= 40 mL
Write" ei 1hcr a fr.inion or a linear ratio:
xis expressed in mL so the answer will 111 ml.
4 111 I
. "' 1 ml f31 Although no1 used often, a conversion nl 11d~in thr
f 31
apothecary S)'Stem includes 60 minim~ (rTJ to a fluid
'<ext, <et up the >ond rauo with the unknown infor- dram (f3). Think of a dock with 60 m11111 ~ .tn hour.
mauon 'the proponion will look as follows: A founh ofa dram is 15 minims JUM " 1nutes is .i
founh of an hour (Figure 8-2). Please not ' .1t llR and
4 ml .tm l DR (abbreviations with r) are on th le of tht
, , (3;" pr 4 ml f31 x ml f3x
dock with minims and minutes (ahb1
3 llc.lllS \\1th
m) are in the center of the clock llm 1 .lSSlSl )'OU
'' cross mulupl)" chang111g the apolhaJ)' in remembering the known element\ "'"" for 'hang
Roman numrrls to Arabic numbers. ing minims to drams.

Checl< Your Understanding : VOLUME CONVERSION 9 . 4

- - -- -- - - - -

Calculation Review 3. I mL= gu

Convcn the follO\ing volume units 10 the reques1cd
equivalent rnc,tsuremen1s. 4. 30 mL = 0?

l . 45 ml _____ 1bsp 5. 3 oz = mL
____ c
2. 2 1>1 6. 1000 ml = pl
,,,
CHAPTER 8 Converting Between Measurement Systems 135

1. 250 ml .. - - - - - c 9. I pl ; -- - - - ml
_ _ _ ml
s. 4 tsp -_ 10. 30 gns : _ __ _ mL

Practical Application
Determine the following conversio ns.

II. A p.1ticn1 t.ills st.Hi ng that he misplaced the med ici ne cup for his nigtm ime medicine. The dirwions s.1y
to tJkc 10 1111 before bedtime. Mow many tables1>00n> wou ld you direct the patieni to take? _ _ __

I 2. A ph\" 1111 tel l' the patient that he needs to drink two pints of CoLYfELY. Record !his amount in his chan,
u\ing thr metric \y>tcm. - - - - -- - - - - - - -- - - - -- - - - - - - - - - - -

IJ. Dr 11 1 '"Ill' hi> patient to force fluids. I le requests !hat )'OU conven 2000 ml into a hoUS('hold equiva-
lent i p.1ucnt's infomution. _ _ _ __ _

14. A p.ltl 111\lnJCtcd to instill 2 drops of medication into each eye. I low many minums vould be equiva-
lcnl h thnppcr measured in !he apothecary system! - - - -- - - - -- - - - - - - - -

15. You,, , tcd to give a patient 30 mL of medication, but the medicine cup is calibrated in ou nces. I low
ffi illl\ I l'' c'fC equivalent LO 30 n1L? - - - - - - - - - - -- - - - - -- - - - - - - -

approximate, not an exact measurement, 1:1blc 8-.l iden-

Weight tific; the mo~t common weight equivalcncie>. Ille table
Most of th< on\ done in the medical field are for may look difficult to remember, but there are basically
rom-ening ""igh t~ or solid measurements. The only t\\'O conversions to memorize, and all other mea-
same rull"' convening weights as for volume. surements can be derh'l'd from these con\'Crsion~ using
Remembc- fiN rorn'<'rl the quanritks 10 lie USl'1l the mformation on ratio and proponion provided
tnco tht ~'" n1 ,uurt' U'idut1 the sa1ne n1easur"nten1 in Chapter 7. The com-ersion needed for convening
If VO
S)'Sll'lll. " ' n mg among the metric, house- between !he apothecary and metric systems is I gr ;
hold, or J P' ' "tems, you will need to set up a 60 mg, or I g = 15 gr.
ratio and p n problem 10 obtain the equivalent
weights with' .imc syMems firsL Then do the math
conversion no:in r omn1011 \veight conversion
bet\\1(fl) tht I .ind household systems is from kilo - TABLE 83 WEIGHT MEASUREMENTS
grams to P 1l\)\\ICVCf, in lhe adn1inistratiOn Of
medication' lw ,1111ount of prescribed medication
and the dn' 1l.1hle 111.1y be convened between 1hc
apolhecary t ir \)'\tcms such as grains to milli 0 008 gram (gl = 8 gr X
grams or!: 1 milligrams (mgl
Another 1 1111 fact to remember is that drug 001g = 10mg gr X
companiC'> 111<, use different equivall'J\ts for a 0015g~ 15mg gr Y.
measure In t, the most common source of dis
000g = 60mg gr 1
crepancy is 1 1 111 the .1polhecary S)'$tem's basic unit
of solid me '>om< tables will show 65 mg equal to 0 I g c 100 mg gr IX
I gr; other 1.1 1 I how 60 mg equal to I gr. Both me,1 I g ; 1000 mg gr 15
sures are co11 ,1 correct In this text, we will use the 30 g I ounce loll
most common!\ """' ~quiv,1lencc of 60 mg equals I gr. 0 45 kilogram lkg) I pound (lb)
Remember th.lt wh"n rnnvening between different mca- I kg IOOO g 22 lb
suremem 'Y''"""
the mcasureme111 obtained is only
 d o sage Calculations
136 SfCTIONII Mathem111cs for Pharmacology an
WEIGHT QI
TIME hr 11,0
60
60 55 s

l
55 5

i"""
1.
10 50 10
50

15 :v, 45 mg -
12
.. 15
'
45
" '
40
35
T
30
25
20 'Is 40
35
!
30
25
20 I

v,
11, hr= 15 flW\
gr 11,15 rnv
gr '1 30mg
''2 hr 30 """ gr:V, 45mg
~.. hr 45 mon
Figure 1-3 ea...nian cfed far ..~tor IOl.i !Mil EO l1Wl gr 1 60mg
1 hr
surementi !Fu~ R F~ E MJt!I Qlcu/J!.(ltl$ far gr v, 20mg
JtlJ"nacy rliCfrllaans 1 -ltd S1 Louts. 2007 gr'I, 40 '!IQ
Sal#ldcrsl

Converting Weight Measurem Units

hr between Systems
gr
dr
Converting weight units among sysirm' 1 'imilar to
55
60 convening volume units among ~>01>Wm 1111 ,,1fcst way
5
is by setting up a ratio and pro po nion 1q1 mn. Then

"'
50

45
l
11)
mg
10

15
"
solve the problem using basic math.

Ill LEARNING TIP

m10
40 20 Always use the correct notation rn your answer w convening
between systems. For example. in !he apothecary the ablJre.
35 25
30 viati<Jl gr is written first. followed by the q Which IS
written in lowercase Roman numerals. it the num OOSSstJ
" X. 1 to 10. 15, 20. or 30 In the metroc and hou

-
P1oct .. ..,,, . - !he terns. the
quanrity IS written first using an Arabic digrt (0 t llowoo br
- """ .. Y' - !he the abtxeviation. The following examples lllus11
Figure 8-4 CcNeoioo clod for hcpd llld solid lllN$llenel1IS lfukter
R, Fulcher E MJlfl ~IOIS 11 p/lamllcy ~ a Wfrir.e>t SI
Louis. 2007 Saunden-1 EXAMPLE 11: 300 mg= gr-- - - -

Set up the known ratio fim

Known ratio: 60 mg = gr i

Write as a fraction or ratio:

A NING TIP
Weight measurement oomparosons are easier to remember using 60mg
- -. OR 60 mg: gri
the convefSlon clock shown Think of 1 hour= 60 minutes 11 hr= gr I
60 min). 1ust as 1 grarn 60 mrlhgrams 11 gr 60 mg). Use Figure
83 10 make the conversion easier. finally you may place all three Ne.<t, set up the second ratio ,is .1 fr.lltl''" with 1he
clocks 1oge11lcr 10 assrsl with conversion of hqurd to solid mea- given and unknown info rm.1tio n. Th, I' 1hlcm now
suremem found w11h 1he apolllecary system Remember lhat the looks like this proportion:
abbrev1a11ons con1a1ning "r" remain ou1srde lhe clock while the
abbrev1a11ons con1a1nrng m remain 1ns1de the clock (Figure 8-4). 60mg 300mg
g;-r-- x gr OR 60 mg : gr i :: lllll mi;: r gr
 CHAPTER 8 Converting Between Measurement Systems 137

cross-muJ1iply, cancell ing the .1bbrevia1ions, as appro- Rewri1e the equation as 2.2 x = 206 kg.
priate, and change Jpothecary Roman numerals 10 Solve for x by dividing each side by 2 .2:
Ar.1bic numbers usnl in the metric sy>lem

60-'
~
x -iOO~ or
2.2x 206 kg
--=---
2.2 2.2
grl x gr
Remember x was in kg; therefore your answer will be
expressed in kilograms.

x = 93.6; therefore 206 lb = 93.6 kg. In most cases,

kilograms can be rounded to a whole number so that
dosage calcula1ions will be easier, so 93.6 kg would
be rounded to 94 kg.
300 x 1 gr 100 gr
Sometimes the cOn\'ersion canno1 be immedia1ely cal
Re\,Tile 1hc <1uauon JS cula1ed because )'OU may need to determine the corrcn
unil conversions before solving the problem. 'lni\ oc~urs
60x =300 !('
if )'OU are gi\'en a problem where you musl firs1 change
the measurement units, such as changing ounces to
Sol\'e for .\ I cl\ id 1ng both sides by 60. pounds or milligrams to grams or microgram~ to milli
grams, so the units you are seeking are the sa me. Af1cr
you find the same units, then set up the proportion .
_
60x ,,,_
30(1
Study the following example. Note that the requested
60 (,()
answer is nol in Lhe same unit as the: given inforn1ation,
B<: sure to r oher 1h.ll the unknown for x was gr; ~o an extra step is made at the begi nning o f 1he problem
therefore Y 1 111,\Vl'I' \viii be cxprt!ssed in grains. 10 convert 1he numerators and denom in ,llors w the
When co1111 " : the math, x '>. Tlwrcfo1e 300 mg same uni 1s. Arter making the units the same, proceed to
= gr v. 1111 r is exrresscd in Homnn num erals solve the problem by setting up the proportions .is previ-
because the <'r b in the a1>othec,1ry sys1em. ously sl10wn.

EXAMPLE 12 - - _ _ kg
I I EXAMPLE 13: A physician order. nitroglycerin
600 mcg to be given to a p.uient
Set up th ' ' tJllO firsi Known ra1io: 2.2 lb
I kg. Wr11o r 1<uon or r~uio; with angina.

2.21b 0 lhe medicine label reads gr Y... per tablc1.

lh I kg
I kg To convert, you must first change micrograms 10 mil
ligrams; then convert to grains. first change mcg
1<ond r.lltO as a fraction wi1h 1he 10 mg.
giwn ,m d vn mformatio n Your problem now
looks lik< p >nion 600 mcg = 0.6 mg
KnO\\'ll' 60 mg = I gr
2.2lb Set up the problem like this:
--=
I kg
Oil l 2 lb I kg 206 lb x kg
60mg 0.6mg
- - = - -- or 60mg : lgr :: 0 .6mg :xgr
Cross-m ull ca' mg off 1he .1bbrev1,nions: !gr xgr

2.2 lh 'lh Cro<.~multiply, leaving ofT the measurement

or
I kg abbreviations:

60mg X 0.6mg
2.2%: I kg >ocdlf x' kg --
I gr
- - - or
xgr
\. ~

206 x 1 kg 'llh kg
~
60 pl{: I gr :: 0.6 .Pl&: x gr
2.2xx 2.h \.._...}
 osage Calculations
138 SECTION 11 M1themat1cs for Pharmacology an d D
s. Cross out unwanted uni~ that arc in both lht
C.Ot Ob numerator and the denominator.
0" 6 600 n?g x I rpg x I gr
X - or
c.o 600 X l 1000 ~ 60 IJ>g

I 6. Multipl)' the numerators and deno mina1ors and

- gr soh't' the calculation .
100
lhc dow pf m.J1uuon would be one W>let beause 600 I lgr
t".l h tJhlt~ I\ gr K x= -1- x loOO x 6o
600gr
x=-
60000
ILi LEARNING TI P X=
6 gr
600J)O'
Always maie Ille cori;llnOI 10 the label of dosage on ao.-ailable
med CJIJOO I
x=gr-
100

Since the a9ailable medication is 11i1 :ly<erin gt

Another nwthod uf compleung this ex;imple is to 1/100 table1, one tablet should b" drninistertd
c,1lnd.11c the cnure problem using dimensional analy- I
'" D1mcmmnal ,rn.1l~is I~ ,1 n1athematical means of because gr - = 600 mcg .
100
c.mrt'llni: unw.1n1t'd unit\ (c.tllcd factors) in conversion
of tmu et1uiv,1lcncy or Jn extended r.uio and proportion.
In 1x.1mplc 13. instead of two calculations of micro-
11""'" to milli11rams and then the conversion to the
apoihrrary 'Y"Cm, the c.1lcul.11ion may be perfonned Ill LEARNING TIP
u1ing cwr.11 1.11ios in the proportional equation. Each Dimensional analysis is helpful when more than 1 onve1s1on is
f.1cto1 i w11 11cn as a fraction, and the faaors must be needed 10 complete a calcula1ion This will be d1 , P-d again in
related to each other for the prohlem to be solved. If the Chaptl!f 9
unit~ Jr~ no1 111 1he s..11nc 1neasure1nent sy~tem, the con
version may be made within the one proportional cqua-
11011 Ille following 1tcps are needed 10 solve using
d1mcn,ional anal)'SIS lhcse h,we been related to the The physician desires the weight o( a Jlrcn 1 '" baby 10
problem g1Ve11 1n I x.1mple 13 be OOn\'t ned to kilograms to be able It ul.11e tht
needed dosage for a medication. n1e ph) 1 ,, ,1\k> )'OU
10 conven the pounds and ounces to kilt 1
r.iiiil EXAMPU 14< A physician orders mrrogl)wrin "
l '!.J 600 mcg to be ghyn 10 a patient EXAMPU 15: A premature baby weigh lb 3 oz.
wuh ,1ngina lhe .1'1.Ulable medica- Con-en this weight 10 l<il<'I: '
11on 1s niuogl)>ttnn gr 1/ 100
tablets Howehold S1stem:
Known: 16 oz= I lb
lhcrc are si d1stma steps in setUng up dimensional To solve. first change the 4 lb 10 ourt< then add
or fr,1a1011al Jnaly>1s here and with all dimerisional 3 oz.
analys1\ pmbkms
I I ind the known 4uant11y gr } 4x 16=64+3=67oz
l What 1s the desired amount! 600 mcg
3 Wh.u i the conversion faaor! gr i = 60 mg and; You wam 10 conven ounces 10 kilogr,1m'
1000 mcg I mg
4 !.ct up the problem wilh the a\'.lilable com-ersion Metric System:
(.1<tor~. placing the desired amount in the first frac-
tion over l
Known: I kg = 2.2 lb o r 0.45 kg = I lh
Now you can set up the pro1>onion, and olw.
600 mcg I 111g I ar
16oz 67oz
X X-'-"'-
1 IOOOmcg 60mg - -=--
0.45 kg x kg "
>? 01.: x kg
OR 16oz : 0.45 ko -. C
 CHAPTER8 Converting Between Measurement Systems 139

cross-multiply. leaving off the abbrevia1ions: Finally, round lhe answer lo a whole number for
easier dosage calculation: 1.88 ;: 2. So lhe final answer
16 02 -./ 670.t
- or is 4 lb 3 oz= 2 kg.
04 5 kg ,,,.-,. \ kg
Remember lha1 x was expressed in kg so your answer
will be in kilograms.
' 045 kg 6i pf: '.t kg
16 p{ To compu1e using dimensional analysis:
670L I lb !kg
x=--x--x--
1 16 oz 2.2 lb

16xx=l61 67pi 1)1) lkg

x =--x--x--.
I 16pi 2.2)b
0.45 kgx 67 JO 15 kg
67 I 1 kg
x= - x - x -
Wri1e a> dll cqu.111nn l 6.1 - 30. 15 kg 1 16 2.2
Owide each s1<lc hv I( 10 find
67kg
x=--
16x 30 l~ki: 35.2
-=-
16 IC
x =J.88 kg x = 1.88 or 2 kg

~ Understanding : WEIGHT CONVERSIONS 8 -5

- - - - --
5. grv= _ _ __ _ g
Calcula 1 w
Conwn tJ1, ' 1wing wcigh1 u11i1s to the reques1ed
equivalclll 1 ., Round decimals 10 1hc ncares1 6. 2.45 kg = -- - - g
1enlh.
7. 360 mg= _ _ _ _ _ gr
l
1. gr mg 1
8. gr 60 = - - --mg
2. 12 It>
_ _ kg
9. gr vi= _ _ _ __ mg
3. gr .,, ~-- mg
10. 15 kg- _ __ _ g
_ _ _ _ mg
4. 0.01

Practical ation
Sol"e lh~ mg com emons

11. A prrm e ont.1111 weighs 1426 g. llow many pounds does lhe baby weigh? (Round 10 the nearest pound.}

12. A p.llh l wngh' 45 lb. Whal 1s 1he pa1icm's weigh1 in kilograms!-- -- - -- - - - - - - -

13. I lo" 1 v mi lligrams of pe11irilll11 art> lef1 in a vial containing penicillin 5 g a fter 750 mg are removed!

14. A phv" 1.111 wmcs an o rder fo r asplri11 gr v. I low many grams would !his be!--- - - - - - - -

15. A biopsy "11npk w~igh> 2Y, ounces. Record 1his in grams._ _ _ _ _ _ _ _ _ _ _ _ _ _ __

 :ECTION II Mathematics for Pharmacology and Dosage Calculations
140
Cross-multiply, dropping the abbreviations.
TABLE I 4 LENGTH MEASUREMENTS 2.San
_ X xan
~or

METRIC HOUSEHOLD 1 in 14 m
0' " .Ko inch (in)
10 nulhme'Cf llmll 1 cm
2 5 centJmetCfS (on) 1 lldl ~
2.5 an : 1)0 :: x cm : 14,H<
30cm
I loot !It) = 12 ll'l:hes
\._.,)
~cm l van!
UXl cm I mctei lml 39 ' " 39x. n;lles 2.5><14=35

I xx=xcm

x =35, Therefore 14 inches - 35 cm lkmemtiu 1

Le n g th was expressed in cm therefore 1hc """ 15 in
ce_ntime:ters.
llw unot mcJ\urcment of length is the most \'el'Sdtile of
the ba~ic conwmon> we study bause length can be EXAMPLE 17: A patiem is 185 cm tall lkw1<1 this usmg
mca;urt>U for nuny d1fferelll reasons and in many differ the household meanircn1l'1 o f feet and
c111 w.1y~ I or cx.1mple, p.11ie111 supplies such as medical
inches.
g.1rme1m, cla;11c Mocking.\. Ace bandages, and even
g.1u1c p.1ds are .111 made to specified sizes that could be
mc.1surl'd 111 term of a body area circumference. length, This problem can also be sci up " " proponion
Known ratio: 30 cm = 12 in or 2 .~ c111 l 111. Either
or hc1gh1 I 111c.ir mc.mircments are recorded in medical
ratio can be used; both arc showll in th "X.1111ple.
record for lcnsth' of urgicaJ indions; lengths of
wounds l>cing sutured: baseline areas for tests such as
the pwifil'tl pro1i111 1/c1fr111lw (l'PD) test for tuberculosis Set up a propo11ion wi1 h 1he known 1 I unknown
(Tll); alHJ even tlw di.unctcr of moles and other lesions. information, using the conversion 11 . , you most
Inc ncwhorn' length, rhes1. and head circumference are easily remember. Your problem will 11 like either
111e.1su red Onho11edic .tppliances are measun.'<l to 61 a of these:
specific pa1ic111 u~ually by sinh, length, or both. Table
84 shm"" 1hc length mca~urcmcn1 con\'\'rsions practi 30an _1sscm
__
Al J2in or 30 cm : 12 in I ni x in
uonc" m11s1 know llS wi1h 1he other conversions, these .tin
Jre ~tpproximauons

Con vertin g Length M easurement Units 2.San __ 185an

b etween Syst em s Bl or 2.5cm l in I 11 "in
lin .rin
Wnh medical mca>urcments. man)' of the instruments
used .ire c.1hhra1ed m mctnc and household units. but Cross-multiply, dropping 1he abhrt"' 1.11
)'OU m.1y ~cas1on,tlly need 10 con\'en between those 1wo
mcamrcmelll \)~tcms usmg l,tble 6-4. Tltc metric units
ar< used on mca~unng lesions and lacerations ror insur- A)--
30on X 185cm
- - - "'
ance coding. whereas household measurements are used 12 in xin
10 measure hc1glu and hypodermic nttdle lengths.

EXAMPLE 16' An abdominal cavo1y w;u opened using a

14-mch incision. Conven this measure
mcnl 11110 a metric length.

1>c1 1his problem up as a proportion. Known ratio:

2. S u11 - I in Se1 up a proportion with 1he known B) 2.5.cm X 185 cm
.111d unknown inform,11ion 10 look li ke this: I '" x in or

2.5 cm
~
X (Ill
Oil 2.5cm : I in::xcm : 14 in 2.5 .Pri : I in :: 185 : x i n
I in 14 in \.._..)

- -CHAPTER
- 8 Convening Between Measurement Systems 141

A) 3oxx ,. JOx or 8) 2.5xx=2.5x

r-~
A) 12 x 185 = 2220 or ll) I x 185 = 185 l ft: 12;rl':: xft:74;rl'
\_J
!.ohc for x b)' dividing bo1h sides by 30 or 2.S as
shO\\'O

30 t l 2l0
A) jo~W 74 x I = 74

or Solve for x by dividing both sides by 12.

2.SA 18> 12.x 74
1!)25-T<i - =
12 12
x = 6 feet wilh 2 inches left over.
8' <11her me1hocl. x 74 inches. bul remember 1ha1
th 1., n1C"J.,un:rnttnt i' in inches bet"ause x \Vi\$ in inrhes. Remember lhis musl be in feet, as x was expressed in
Bccau~c th problem .1sks you to identify feet Jnd feet.
inchcs. the nexl .iep is necessary.
Known cqui\',1len l 12 in = I ft. 185 cm 6 ft 2 in
Sci up dw I hlcm to <lc1crmine how many feel are
in 74 inches Using dimensional analysis the ~ua1ion would be as
follows
I fl f t 85 nn 1 in lft
<JR I h 12 in:: x ft : 74 in x= x - - x --
12 in i t I I 2.Scm 12 in

18sprl" 1;r< 1ri

Cross muli ih x x- - x- -
1 2.s .ctn 12 Jn

12m
I (1 >< tn
or .r= -
185
30
x = 6.16 ft or 6 ft 2 in

Q 9nderstanding: LENGTH CONVERSIONS 8 -6

- - - - ----

Calcula1 view 5. 60 nn _ __ _ f1
Sol\'\ lh< ' h cumcr<;ion~ Round answers to
neJrt.~t '' 6. 80 cm - - - - -- m

I. A 111 ___ cm 7. 75 in = _ _ __ _ m

___ cm _ _ __ _ n1 1n
2. s fl b 8. 2 in

3. 3 Ill _ _ _ _ fl 9. 3.!. ft - _ _ _ __ m
2
4. 21\ 111 '11 cm 10. 13 mm = _ _ _ _ cm

Prac1ic .. 1 I cation
De1errni1h 1he tollo\..1ing conversions.

11 . I\ p.111, t r..-.:d' .1 dressing changed when her wound drainage on the bandage measures 2.5 cm. rlie rurrcnt
measures 50 mm. What is the difference in millimetecs betwttn the measuremcntsl
Ji;t' drainage
_ _ _ _ _ _ _ _ ___,Does 1he dressing need 10 be changed? - - - - - - - -- - -
 age Calculations
142 SEC I'; II Mith1m1t1cs for Pharmacology and Dos

- -- . l<>St 3 tong faceration. What is the minimum number of

12. A ph)>1<1an O'th 75 cm of w1ure marenal 10 c the suiure uay! (Round 10 whole number.) _ __
fr<t of >111u1~ ma1r-nal wu "ould need 10 P1acr o0

1 l. A ,mall nr"'bom 11 18 mches long, Record this in centimeters.---------- - - - -

11. ~ l"-Jraurc ch.in 10 me.uurt hvgh1 me.isures up 10
. _ _,
I~ A ph)"uan ordl't'S ntrtOfl1,.... .. n o1nunen1 1
I low nlJn) 1nthc> of orntmtnt should be applied 10 the paper or a
SUMMARY
llm ch.tptcr by rn1roducmg the 1111emational
lx>ft111>
~1.111d.ud !or tune, 1he 14 hour dock lemper.11ure con-
wr-;lons lwl\wcn 1,1hrenhe11 .md Celsius are then dis
cu1wd llll' 111a1orilyor1hc chapter focu1cs on conversions
amon!l lhc metric, household, .rnd apothecary nieasure-
mcm S}">lc1111 foo unhs of volume. weigh1, and length.
Ihe convc,.ion method~ shown in this chapter are ratio
.ind pro1)tmlon .111d dinie1hion.1I analysis. Ahhough
moM A111crica111 arc most familiar with household
120 cm How many inches is this1 _ _
5 an The measurement paper for the ointment
I\ m inches
. ~ dministrationl
--------
-
measuremenrs. the metric sysrem i\ the 1 1<domman1
method used by health GJre providers .111J 11 other paru
of the world. A general knowledge of all th ' measure-
ment s~~tems is necessary in o rder to "" Mcura1ely
with patients, to complete accurate nwdii .11 locumenta
tion, and to read medical information
The next chapter introduces calcul.11111 dcl\ages or
nonparenteral medications. The infor111 Jl11 learned in
this chapter will be used to understand hn 110111,aren
1eral dosages can be calculated using ac111.1I 11g do~ages
and drug names.

CRITICAL!

Study each case lfldopendent/y The icon for 1he body system m which 1he drug is used 1s SI
Determine each answer by solving for the m1ssrng 1nformar10n. Be sure to show your ca/cula t1 on a
separate sheet of paper
lr;J Cyclophospl1om ld1 tCytoxanl is used intravenously m chemotherapy to 111h1b1t the grOW" I
C::::I neoplasms The vial of medrcatlOll oonta1ns Cytoxan 1 g. Could you prepare a dose of mg
from this container? Expla n your answer - - - - - -- - - - - - - - -- -
2 r-1 The physocoan orders phmobarlri1al 100 mg. Available are phenobart>ital gr ss
tablets YoU
C!J admonoster this medicatlOl'I with the tablets supplied? Show your work. _ _ _ __
3 ,,.,, A pationt 1s prescnbed fnof..nadiru (Allegra) for seasonal a.lerg c rh111111s If the pauo to
take IWO tablets a day. ha I of the dose 1n the morning and the other hall 12 hours la ve
the 1nternatoonal standard tome for the second dose if the first one was taken at 1o30 AM
4 rm I/ I For 1uvemle anhntJs. the physician might prescribe iltuporofm (Motnnl. If the LI
dosage for a child 1s based on weight in kilograms and the child weighs 66 pou how
many kilograms does the child weigh'--- -- -- -- - - - - - -- - -
5 The physician's 0H1ce has scales that weigh 1n kilograms. The pauent asks you how much "' ght he

6
has lost when the scale shows 22 kg of weight loss. -- -- - - - - -- - -
[!] Testosteroroe tOepo-Testosterone) is a hormone used for replacement in the hypogon~ct -
male.
This medication is adm1111stered by 1n1ect1on with vials that need to be stored at 20 1 25 c
C Conven this temperature 10 Fahrenheit. Would this medication be 1 d f h
your work. s ore 1n a re ngerator , ow
 CHAPTER 8 Converting Between Measurement Systems 143
~~~~~~----

REVIEW QUESTIONS
Practical Applica tion .
Sohe by using the method of cakulauoo you feel most comfortable using.

1 If J dosJg< ~tr<ngth is 2 gin 10 ml. what is the correct ,1mount of liquid when 4 g are ordered I - - - - -

--
2. When prq,.trin!l \urgic,11 packs for autoclaving, you need one Allis tissue forcep~ and 1hree hcmos1.11s for each
pack you prcp.H~. What are your propon ions for six packs! - - - - - - - - - - - - - -

3. A mcdir.11io11 rnntJin> 1 pan pure drug 10 25 l'an> of solu te. What is the ratio and wha1 is the fr.1<1io111

How m.111) p.1rh nl rure drug are in 150 pans of solu1cl - - - - - - -- - - - - -

4 The do\.lf; ut phtnobarbital ordered is gr Y.. Ilic tablets available are phenobarbital gr \S in a scored 1.1bleL
How m.1 I l<1 would )'Ou administer to 1he paticrnl - - -- - - -- - - - - - -
All of the foll" ! \latemeots are fa~ Determine the error(s) and rewrite the statement, giving completely
correct infom ll '" in the space provided.
5. i\ mcd1<.11 ;, to be given once a day before lx><hime ( 10:00 l'M) is given at 2000. - - - - - - - -

6. 'I he PP" " ilue of 500 ml. is I quart.--- - - - - -- - - - -- - - - - - - - - -

7. In 1hc m11 " 1'111. ih<' primary measurcrnems used for dosage calcu lations are volume and lcng1h. - - - -

8. In th< .1111 wMem, 16 oi are equal 10 I lb.

9 A SC.tr th ur'"' 14 cm is approximate!) 2 inches long. - - -- - - -- - - - - - - - - - -

10 A biOJ''I'> n \\cighs 45 g. lhis would be approxirna1ely a half pound in the household 'l)"\lcm _ __

II. A rauo >1mon of two fractions that arc considered equ1valenL - -- - -- - - - - - - - -

12. Convcr,1 111 be immediately calculated because you do 1101 need 10 determine uni1 pro1,onions before
solving

13. A mctm 1 tthoredic appliance measures 6 inches in length. - - - - - - - - - - - - - - - -

14 A mcdi<u 1i;htng gr v would be equivalent 10 200 g. - - - -- - - - -- - - - - - - - - -

IS. The 2 h ock "often used in the United States

16. When rnnv ng between measurement systems. answers will usually vary by I%. - - - -- - - - - -

17. Volumt r<lu to w e i g h t . - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

144 SEtl 1~111 Methematocs lor Pharmacology and Dosage Calculations

18 ~o C.cl"u' would he J comronable room temperature . - - - - - - - - - -- - - - - - - - -

19 \\'hen conhnmg from <.:Isms to rahrenhei~ remember to multiply first because Fahrcnhc11 ;, the sinaJ;
number---------------------------------

lO In the apothtc.ll'\' ~>tern 15 droj .ire the equi\'alent or I metric mL - - - - -- - - - - - - -

21 lony Ii< '-gar, t"<ju1vah:n1 to I lb. - - - - - -- - - - - - - - -- - - - - - - - - -

22 The acccpt.1blc metnc niu1..alrncy or one-half teaspoon is 2 mL - - - -- - - - - - -

2l \ <cnumttcr I\ smaller than a mtlhmeter. and a centimeter is smaller than an inch. - - - - - -- ---
24 II mcd1cauon 1s orderc'd for gr V.. and the available amount is 30 mg. The proper amount 10 ad1111 n"ter is onf
t.1hlct
Calculating Doses of Nonparenteral
Medications

After stvdyrng apter. you should be capable of doing 1he following:

Determ1n n correct dose of medication to be Calculatong the doses of nonparenteral drugs

administer Ad on a phys1c1an's order. administered 1n liquid form. using ratios and
Calculating ses of nonparenteral drugs proportions, formulas, or the dimensional analysis
adm1n1ster ..,lid form. using ratio and method.
propon1011, ola. or the dimensional analysis Calculating doses on the basis of body surface
method area and weight in kilograms.

Body surfac Formula method Nonparenteral Reconstitution

(BSAJ calc on Nomogram medications Unit
Factors

RETEST- CALCULATING DOSES OF

iTiERAL MEDICATIONS
----- -- --
Calcul.1tl ch I I >wing doses.

HOS--30mL 2T8S-30mL
_ _ ,.ml -25ml

1. l ill in I
'""
--20""-
t f8S-15nrll
2 15"
1TSP-lfnl
10fll.
2. Fill in 25 mL
----
--20ml.

2~10fllll.

~'~'"'~

145
146 i!CllON 11 Ma!hemaocs for Phannecologv 1nd Dosage Calculations

On the provided lines. explain exaa ly wha1quantity of medication and the numbe r o f doses of mcd icaiions
hould be 1.lken
3. Ordered hyJrochlorothiazide 5-0 mg PO bid with morning and early arternoon meal.
A'ailabk h)Jrochlorothiaz1de 25 mg tablets.
Dose to bt> llJ'<n - - - - - - - - - -
I low oltcn' - - - -- - - - - -

4. Ordered allopurinol 300 mg PO daily

Ava1lahlc. ,1llopunnol 100 mg tablets.
no~ to be giwn: - - -- - - - - - -
I low often! - - - -- -- - - -

5. Ordered / yn ec 10 mg PO daily.
Available /yrtec I mg/I ml syrup. Plea54! gh-e the dose in metric and household measures
~to i>t' gJ\Cn . - - -- - - - - - -
llow o ftcn l - -- - -- - - - -
6. Ordered warfarin sodium 6 mg PO daily.
Ava1lahle warfarin sodium 4 mg scored tablets.
Oosc to be given: -- -- - - - - - -
I low oftenr - - - -- -- - - -
7. Ordered Amoxil chewable 400 mg tablets q t 2h.

'I Available t\moxil 200 mg chewable tablets

Dos.- to be fll\-en: - - - -- - - - --
llo" often / - - -- - - -- - -
fA 8. Ima has an infection with moderate.pain and was prescribed Lonab rlixir 15 mg/IOOO mi; u.t ., Using
the following label, calculate the desired dose to be given:
Oose to be given: - - -- - - - -- -
I low o f1enr - - - - - - -- - -

,... ~
ucb Pharma
.... ....4
I

.....
...__

_
=::. ..
..-....
_
.-...o-..,,.
 ---
CHAPTER 9 Calculaung Doses of Nonparenteral Medications
=---
' nparenter~I medications .ire usually drugs taken
~Ill 0 1 b) 111hala1ion. In 1hi\ chapter. a comparison of
~r.,,; dilfcren1 me1hcxls for calrulating dosages for non-
parenieral mediotioM 1s shO\ n It is ~ot im~nam that
:ou mcmori1e ,111 three mc1hods. It is more 1mponant
; 1,,,1 you choo~c ~ne me1hod and use 1ha1 method 10
prevent 1,otcntial med ic~1ion ~rrors th.at could resuh
from swi1t hi ng amo ng 1hc methods. Wtth the firsi two
methods (r.11io and proportion and the form ula
method), 1hc mo't important concept is alwa>~ 10 be
sure th.11 the un ts ordn cd and the units on hand are
rncasuml m the ,.1mc ' )'\tern and 1he same weigh1 or
volume 11w,1surnnent. fo r example, if1he drug requested
is given in 11ram' but you only h.we mi lligrams, the rir>t
siep 111us1be lO conven mill igrams to grams or vice ve1'SJ.
In another .-.1mplt- the rhrician may write the medk.t
uon in the .1po1~rcarv ')"'>lem for a drug 1ha1 is available
in 1he ml'tnc S} 1 then gram~ (apothecary measure)
mus1 be con' rt J le mi lligrams, micrograms. or a
measure o f th dnc S~'>tem 1\S 11 role of rl111mb, wllen
tlrfitl111g u l11c:l1 1111.: 1rt'nrtnt to find in the f11u'l c:o,11 ers14't1,
1 1
she firu,/ dc"' tir t 1 r ttJ nu1bu1'' s1'ould 11ull~l1 Liu 11r1it fo uud
ou du uuHrUnt 1 oj .u,1i/,,b/r 1'1e1Ur111;ou. T11r coru11rsiori
shtnlld l)l' ''"l ti. ~hrftneru
In a!><:' " t d. ~II drui;s would come in the same
measumnmt ' m .111d wo uld be found in a uni1-dose
system lhrn" rulation~ would be necessary 10 find
a specific d<N ". i r,iinistration errors would be decreased
to a 1nin1r11 u1 1 " 1fn t in\~,~ the health care provider \viii
n~ed to dctcm11 .111d prepare the pro11er doses using
con\crc;ion\ h n t n \~s1c1ns v.ihcn the an1ount of n1edi-
cation ordr"J" 'no1 m.1tch the medication on hand.
By rcvicwmg a < b.1'ic guidelines about the various
medicauon'I. ~ m m.1ke sure that adminis1ra1ion of
drugs is suit < Box 9 I covers the basic guidelines.
ERAL DOSAGE GUIDELINES
Do "'lt a cap ~I
Tall :ts CJI scored are not intended to be dMded
A tablet ored may be d vided or ~olten.
An entE 1 tablet or caplet should not be broken or
cruSlled
Buccal and s~b 1ngual tablets should not be broken, c<ushod,
or swallnw
Susla ned 11 Jed-release tablets should not be bro4<en
or crushed
Before tru ng or tnaking any tablet or caplet. always
cl1eck to be sure tl'l1s act100 wlll not affect the drugs purpose
and phys1c1an s permission has been obta1n00.
147
11 is imponant to avoid math errors when cakula1ing
the drug dose. A rew basic rul~ can help you remember
to calculate wit h confidence. rirst, ,1lways be sure to use
the same unit> of measure when selling up the problrm
unless convcr..ion is needed. If a conversion to the sa me
units of measure is neecled, 1he conversion will be 1he
firs1 step. unless dimensional analysis is being used
Make the needed conversion only when using the ra1io
and proponion or the formula method. Next, even if the
problem seem> easy, work 1he math on paper 10 find a
solutio n. Ah hough ii is always i11111or1an1 to rake the 1ime
to do 1he calcu lations, thinking ahead can prevent errors.
If l""r rnlt11/1111oru do nor rrs11/1 in rlre solution )'OU ""'" 1
palM or tlo nor semi seruib/P, r& /reek all (11/cularions. Af1er
calculating the dosage. ahva)"S be sure 10 check and
recheck decimals or fractions If the dose is calcul,11cd
according 10 body surface area (llSA), insert the appro-
priate foc1ors into the fonm1la and !lien make the calcu
lations: use a calculator with 1hes~ measurements 10
determine the appropriate dose, as many of these m.ty
be long and complicated. Final!)' read 1he health care
provider's order one more time to ensure )'OU are calru
lating for the dose ordered before administering 1he
medication Mos1 medicalions arc designed to be ad min
istered as a whole tablet or capsule, so 1r you are dividing
the medication form, i1 should he vailable as a scored
tablet or a pour,tble liquid.
A few additional words of warning about combining
different dosages to substi1u1c for the strengih on hand
Dilferem dosage strengths mus1 be considered before
starting dose calculations. With some oral medication
orders. using combinations of dosage strengths of 1he
desi red medicatio n is appropriate. I lowever. be careful
wi1h dela)cd-rdease and sustained-release medicatio ns.
With these 1ypcs of medic,11ions. administering 1wo
5 mg tablets 10 make a 10 mg dose is not equivalcm
because 1he release time is not 1hc ~ame as when taking
one JO mg 1ablcL Therefore. as a rule of thumb, 1imcd
release medic.1tions-whether delayed or sustained-are
not intcrchangt!.1ble; the dose should be given only
in the dosa11e strengih and in the medication form
prescribed.
Remen1bcr, ror conversion'> beC\Yecn 1neasure1ncn1
systems, 1hc answer will only be 11ppro.1ima11. Jn rcalny.
today mos1 physicians prescribe medications in the man-
ufactured dos.1ge strength and form I lowewr, you will
have to convert from grains to grams or milligram~ on
some occasio ns. With prescriptions from ambulatory
care faci lities. 1he pharmacist wil l usually make the c.11
culation per 1he physician's order. I lowever. 1hc allied
health professiona l may be expecied 10 make 1he convcr
sion when administering medica1ion; in the ambulatory
care setting or when providing physician ordered samples
that are not in a strength tha1 has hl'cn ordered. If >'OU
have any doub1s about the mcdic.l!ion calculation,
ahvays ask 1h,11 someone verify you r Gtlcu la1ions before
148 ~ECTION II Malhemabcs for Pharmacology and Dosage Calculations

wu administer me medicauon llm may mean 1ha1 you
wnfy the G1lcub11on with ~ fellow cmplO)tt or that )'OU
wnfy the mediation onltt anJ 1hc calculation of the
dose "nh the ph)'Sician
l'..lch drug calculauon problem "111 ha-e t\\'O pans.
lhe fim pan of the problem tdls you what the ph)'sician
has ordered and is somcumes referred to as 'dose
desired" or 'dose ordered' (DO) lhe S('('Ond pan of the
problem 1el1' you the mediGJuon you havt' on hand and
is 11su.1lly referred to as 'dose available" (l)A). Regardless
of the method you choose to use, r~member that this
b.1sk nwihod applies to all do;e calculations.
lhe following steps are nece)sary to calculate a dose
of medicacion
t 1'ote the mfonnation provided on the medica
uon bottle on hand, or what the 011J1/11b/e medi
cauon is (DA) lhis 1s also referred to as 1<'1lat
""" '""'"
2 Detennine what is asked for on the ph)'Sician's
order. or what dose is onlrrttl (DO) lhis is also
referred to as 1<'1lar 1ou M\lnl.
3 ldenufy the available unit of measure for the fonn
that will be used to sup1lly the desired dose (DO),
or dose to be given, such as t.1blets, c.1psules, mil
liliters, and ounces.
4. Be sure all units Jr~ in the same meaSUrein
system. The com-ers1on should be to the 'II
found on the available medkalion bottle. Coultlts
0\"!t.
sion between S)'Strms must be done before ~
calculation of the dose except with dimensiollll
analysis.
s. Cakula1e the de:sirl'd dose.
6. Verify 1he dose calculation with the medicatioQ
order using the correct measurement system 101
,
your ansv.rer.
h!:f1tjJ;W112i- -
Dosage forms are presented in Chapter J l"his section ii
added as a shon review of medic,uion I. ,rm5 and 1ht
calculation of d0St'$ given orally. SoliJ dications ar,
designated as the weight of medkauon r< d osage form.
sudi as milligrams per tablet or milligra 1 per millilita
for liquids. &cause mos1 people do not utensils for
measuring in the metric system, conwr.i, o the holll(.
hold s~-stems of teaspoons and tablrs1~< . 1s appropn.
ate. Always be sure that pat ients underst 1 1 exaa ly how
LO measUte a dose for adminis1ra1ion

Check Your Understanding : DOSAGE MEASUREMENTS

BOX 9 - 1
----- - - -- -~ -

Calculation Review
Identify the amount of soluuon in each calibrated medication container.
t . _ _ _ __ tsp

__..
2TBS-30rrt.

- -
,,.._

20ml

1 tBS-a~in1.

2 1'9P-t0Jlll.

1TSP-sm1.

l. _ _ __ _ tsp

- I
 CHAPTER 9 Calculaung Doses of Nonparenteral Medications 149

111ffriIIII IflJi II iu 111Ill

1111 .. -

_ _ _ __ tsp
4

- t

s. ___ ml

nas---30""
- 2 $ ...
_ _ _ 20 ...

1TBS---15mL

2TSP-10ml

ITSP-ia

OS OF does 11or conven measuremems imo equi\'alem unilS as

- DOSES
TI1c lll'Xl lhr< >l'Cllnl1' wi ll ~how you how tO Calculate
drug dos"' ll\ "''"f: diffrrcm meLho<ls o r calculation. h
i~ impo nJ111 , ' w c.1ch method independent ly. ll1cn
choo'c 1he 1 nd thJl is ea\il'St for you to use for cal
culauo n'> I< prt'\'t'llt c.llrulation errorr., use 011/1 011e
of the thrl'C .hod> ,\h,,l)'S keep in mind that if the
ans1'cr you rmutcd d oc' not seem logical, you should
redo the 111.uh.
'I he fir.L nHthml ""'' r111w 1111.t proportion and requires
the prcp.trn "' lim convert llw problem so that Lhe
mrai,.ure111 e111 ~ i11 the problr1n are in the s:une n1easure
mem '>)~trn1 l11t> ...-rond method is called thl' fonnula
'""tho.I " him al" requires conwrsion so that factors arc
conwned lo <'quh<tlcm measurements in me same mea
suremc111 ' )Mn. ln e third method or drug calculations
i> c.1lled ''"'"'11>101111l t11111ly>1>. In th is method the problem
a separate step. ro solve a problem using dimen~1onal
analysis. one extended fractional equation is neccssJry,
and unils .>re cancell ed. The following sections explain
the 1hrec methods forther.
Calculating Doses Using Ratio
and Proportion
When a phy~idan requests that ,1 drug be given to a
patient, sometimes the dosage avail able (dosage 0 11
hand) will no l be in the same measurement unit"' the
physician preS<ribed. When this occurs, you must be able
to convcn, or change, measurement systems 10 provide
the p;itiem with the correct dose lo unders1and the rauo
and proponron method, fim analy.te the terrns r,uio"
and "proponron." &e Box 9-2 for the terminology used
with thh mclhod.
150 ;EC ON 11 M1them1t1cs for Pherm1cology ind Dosage Calculations

The easiest way to show proponion between m.,h.

. th k ...,..If.
BOX 9 2 UNDERSTANDING THE TERMINOLOGY ment systems is by companng e nown ratio (ill'i!J.

~
1 I

"'-'""'
1 1 4 1
2

L,-1
-
OF RATIO AND PROPORTION

~, .....
2
I

l
(r: : )
(2 I 4 l)
able) to the unknown ~tio. To set up the problem, 6111
identify the known rauo. Next. set up the second ratio
using x to signify the unknown umt. Be careful to ~
the same order for the units in setting up the second rati
as used in the first ratio. Then solve for .f in the secon~
ratio by muhi~lying 1he means and extremes, reducing
bl,...,,.. when approprra1c.
A ra110 is a compa11son between IWO numbers 12 I).
A proportion 1s a compansoo be1ween rwo ra11os 12 I 4 2)
Means are the two tMer numbers 1n a pr01JOn1on EXAMPLE 1:
htremes are the two outllf number1 in a propo111on
As YoU piev1ously learned m coo,ersions. these rauos may be Ig 2g
wnnen as fractKllls SI.Ch as Y, " r, and cross-mull plied - -
!OmL
X --
xm 1
or I 8 : 10 mL .. 2 g x ml

I x .r = 2 x 10
If you did not know one of the p;iru of the mtio. you
could find u by using a symbol sU<h asx to stand for the x= 20
unknown number Suppose you know only the first com-
plete IJtio: 3 : I. In the second ratio )'OU know the first In this problem, xis Slall'<I in milliliter ecause mil
number is G. You can find the Sttond ratio by replacing lilite" were the unknown.
the second number with .r. II would look like this:
J : I :: 6 : x. Now multi ply the means and the extremes to Therefore sulfamc1hoxazole oral suspcnwm 20 mt is
solve ror x. You should have the re~u Its or 3.r = 6. so x is the dose 10 Ix> given.
equal 10 2. Put the number 2 into the second ratio and
)'Ou have J: I :: 6 : 2, or Y, = Y, . which shows an equiva- Now solve for 1he 1c~s1)()()ns in hous.-11 I I
lmcy when you multiply means and e:xtremes. 13'1 sure measure1nnrts.
to identify the unil valua of both of the ratios. l'lte
mm1<'1'a1on and denommorors must bt of tM same ""'asure I tsp x tsp
mrru urnu. raptai""~' For ex.imple I ml . IS gtts is the SmL = 20mL or I tsp: S ml :: x tsp L
same as 2 ml:30 gtts and would be wriuen with both
numerators expressed in ml and both denominators
expressed in gm,: or 5xx= Ix 20 (Note that the appropn.11< l>reviatioru
for measurement sysiems have been d r ocd.)
I ml 2 mL
- - = --orlmL:ISgtL:: 2m l 30gtts
15 g11s 30 g11s 5x= 20

Use the following formula to find medication doses x= 4

using ratios or proponions.
Remember Lhat the x represent> 1e.-1>< "
Dos.1ge Available (DA):Dosage rorm {DF)::Dosage
Ordered (DO): Dose 10 be Civcn (DC) ln household measurements the dost be given is
4 tsp.
If using rraaions, the formula would be as follows:

,, I PROBLEM: Sulfamethoxazolt' oral suspension is

supplied as I g/10 ml !'he ph)~ician
orders ~ulfamethox.vole 2 g. How
Ill LEARNING TIP
many mill ilite" would be adminis- When salting up both ratios, be sure to label all ol 1 terms mclud
tered? I low many teaspoons would mg lhe .'with Ille correct measurement unit 10 lie ,ure equations
be given! are equivalenu.
 ---
CHAPTER 9 Calculabng Doses of Nonparenteral Medications 151

Checl< Your Understanding : RATIO AND PROPORTION

BOX 9 -2

Calculation Review Replace the following fractions with the correct ratio
Rl:place the follo,>ing ratios wi_th th_e correct equivalent. Do not simplify.
frawon,1 1<quh-alent. IJo not simplify. 2
6. - = - -- - -
500
l. 2 3 = - - -- -
7. -1=
2. 1:50 - - - - - 250

J . 1 150- _ _ __ 8. -31
4. 2soo- 1
9. --
1000
5. 2 7 = 2
10. -
7
..
Practical ti on
~up the~ ng prohkms using the ratio and proponion method. Ile sure to use a conversion ratio if
OC(l"-"11' ll I"

11. /.olnl! 'mg PO is ordered. The strength av,1i l.1ble is Zoloft 50 mg scored t,1hle1. llow many tablct(s)
\\'Olll<l 10,1de lhe dt1,ircd amou nl ? - - - - -

12. ,\tell< r ,Q mg 110 h ordered. 1 he strength available is Metformin 0.5 g tablet I low many tablet(s)
\\OUJJ ""'Y to fill the desired order/ - - - - -
n. 1...c q 1'0 " ordered The strength available is K-CI 20 mlq tableL How many tablet(s) would be
nt.'t l u the d..-wcd order? - - - - -

14 . Anlll' 1 11 or,11 \Ll<pension 500 mg 1'0 is ordered. Available is ,1moxicillin 125 111g/S mL llow many
Ill i 11 d vn11ld he .1dminis1ereu for the desired order? - - - - -
11< " , , .hpoon~ wo uld be administered! - - - - -

15. i. xm, 0 5 mg PO is ordered. Strength available is 125 mcg tablet. How many t.tblet(s) would be
nc. r thl' dcs1rl'<l order! - - - - -

The formula is as follmvs:

Calcula o ses Using t he
Formula od Do~agc
Order (DO)
The firM stq 1kulating drug dosage when using the Dosage Available (DA)
formul,1 mttl11 ..1 "to che1k th.11 tl1c strength of the drug x Quantily (form o r unit of m~asure)(DF)
ordered .rnd 11 t,enwh o f 1hc drug available nre in lhe = Dose to be Given (DC)
same untt ol, ,asun.>. for example, if the drug is ordered
as 0 5 g and t e J\-ailablc dnig is in milligrams. the first The formula Cdn be abbreviated as
step "Ould be to ch,mge the grms to milligram\ lhen
DO
set up the formula I lm>cver. of the drug ordered is in -xDI - DC
srms .md tht J\-aolablc dmg is in grams, then skip the
DA
first step .rnd go directly 10 the formula. I lcr(' is how the formula method can be a n,1lyzed:
 152 SECT'O'i 11 Me1hemeocs for Ph11mecology and Dosage Calculations

(DO) lo find !ht desircd pan of 1hc fonnula. answer ~x~

rhos question. "\\1u1 did the ph) 1oan order!' I tsp x
(DI\) The JM.Ju a1u11.ib/~ pJn of the fonnulJ answers
lhe question. "\\'ILlt do>Jg< srrength of medication
1s a.01ilab1e1
(DI) fhe dm.Jgt form idenufics 1he ph)~cal charaaer
1s11cs of an available medteauon I-or oampk. solid
medications may come 1n 1able1s or capsules;
hqu1d medications may be syrups or solutions;
while 01her med1c.11ion fonns mlgh1 include sup-
poshories, 1ransdermal 1>a1clw'i. or an ,1erosol mis1.
Ill LEARNING TIP -
(DC) lhe ,1moun1 10 give rcprcsen1s the t111knO"'" Remember that the med1ca1ion on hand and the medication ordered
doM> of the drug 1ha1 you will wJnl 10 administer. must be in 1he same unit measurement before solving using lhe
I ike the quantity, the d- gn'l'n will be staled in 1he formula method.
'Olume or dosage fonn of the arnlable drug

Ill LEARNING TIP

Here are some addi1ional examples ming the guid(.
lines pl'O\ided.
Always remember to perl0tm dosage uieulaltOllS mwn11og and not
(NI EXAMPLE 3: Ordered Clucophagl' i'iO mg PO
1n your head Written uk:ula11ons reduce 1he chance of error and
thus increase patient safety It 1s always 1mportan110 chedr.ulcula-
1221 daily with meal
llOns w11h a calculator
Available: Clucophage 850 mg 1,1hle1

Are 1he units 1hc same mca;u remem ? (\<'')

PROBLEM; Sulfamethoxazole ornl suspension
I g/10 ml is 1he available medication. 111e What is 1he desired uni11 850 mg 1abk1 1ily
physician orders 2 g. Ilow many milliliters
would be prepared for adminis1ra1ion! 850mg(DO)
SSOmg(DA) xi 1ablc1(Dl')- .nablc1 ( Jt,)
I low many teaspoons should be
adminis1l'!ed1
B!ilf9'!( (DO)
B!ilf9'!( (OA) x I tlb (01) < 1.1bk ( )C)
Dcrermine the dosage ordered, dosage on hand,
do.,.1ge form. and dose 10 be gi"ell
I
-x I rabler = x
DO =2 g; DA = I g; OJ = 10 ml. DC x mL I

x = 1 tablet
Now set up lhe formula
Because lhc anlOlllU of medication c.lt: . . u J and 1hr
EXAMPLE 2: amount available are e<1ual 10 I 1.1bkt, 11 Jose LO bt
2 g (DO) given is 1 tablet
I g(DA) x tOrnL(QryorDt'):x mL(OC)
I&! EXAMPLE 4; Ordered: phenob.irhi1 I w iii ro
-
2,g"
x lOmL =x ml
CTI daily h>
1,8"
Available: phenobarbital 100 mg <;cor~d 1 hlets
l
xlO=Aml
I Are the units in the same me.1surcmcnt. ( "o)
20 Whal.'~'
. he equ1valency

-=xml for conversion' r 1= 60 mg
I or gr 155 =approximately JOO mg (wt: .ible 83)
x lOml
First conven to 1he same measu rerncm system using
Now solve for 1he 1easpoons: one of _he following conver.ions. Using gr iss as the
conversion factor:
 CHAPTER 9 Calcula~ng Doses of Nonparenteral Medications 153
-----

I Now solve lhe problem by 1he formula method.

~= gr 3 or gr 1.1...1oomg::gr3 :x mg 2
00 mg (OO) x I lable1(DI') - x (DC)
1oomg .tmg 2
100 mg (DA)
200mg
- - " ' X I tab = X
1
JI" 3 .,, y I
2
I 00 mg ::)11'1 x mg IOOmg
t mg
2
-x 1ab =x
I
1.!.r = 300 mg
2 2 tab = .t
Next, chngc I Y: 10 an i111pro1Jer frac1 io n ( Y, ) and
soh't' for x (cro"-mul11ply) The dose to be given is 2 table1s.

!ximg=1 ,oomgor l 100::3:x

2
rAl EXAMPLE 5: Ordered oxybutynin I ICI 10 mg PO
1 Ul!J bid

Av,1il ,1blc; oxybutynin I ICI 5 mg scon:d table1s

Arc 1hc unit; in 1hc same measuremem? (Yes)

IO rng (OO) x I table1 (DI") = t (DC)

1 =lOOmg 5 mg (DA)
1O mg x I tab =x
lhercfor~ th > 10 be g"en 1s 200 mg Smg

Using w 1 - .,, n~ as 1hc conversio n far1or: '%;nj(

--'---"" x I tab =x
,.Y.m!(
t w.60 mg::l :.r mg 2 x I 1ab - x (DC)

x=lx<>Om 2 lab - I

.\ 11!11 'llg
The dose 10 be given is 2 1ablcts 1wice daily.
gr iii - 11;11 1 r rounded 10 100 mg
(Rec.lit rn11' ""'" .uc only approximate: in this
cx,unpll' .-o 11'\vcr 10 200 nlg.)

U nderstanding : FORMULA METHOD BOX 9 - 3

- - --
Show yow , rl. on ,, wr.ir.He sheet of pa1>~r. Save your workshcc1.
KeOex 500 mg . .
I. LI'" t 1 tnnnul.1 equation x 5 ml = 2.5 ml , 1dcn11fy:
KeOex I 000 mg
,, \\ h ph)'\ici.111 o rdered - - - - -
h \\ tr,ng th is on 1he shelf _ _ _ __
c \\ 1 "' the unit of measure _ __ __
d 11 ' mu<h of the drug will be admini1tcrcd - - - - -

2. ll'i"~ liu fnrrnul.1 c.1uation

a
h
warfarin ;,od ium I 0 mg
, . d"
wari ann so 1um 20 mg
''I 1 th.- ph)"iciJn o rdered - - - - -
\~h 1 meng1h is on the shelf _ _ _ __
I
x Lrnh - 2 rnb, identify:

c \\'hat b the unit of measure--- - -

d Ilow much of the drug will be admims1ered - - - --
 --~-~-~----;d:;:O::o=
sage Calculations
15-4 SEC ~ 11 Mathemat1es for Pharmacology an

. . ORMULA METHOD
Check Your Understanding. F
BOX 9 -3-cont' d _ __ _ - - -
- - - --
- -- - - - ---
. Oiov,111 160 mg x 1 tab=..!. tab, identify:
3. Usmg the formula equauon Diov.111 320 mg 2
a WhJt 1he physician ordered - - - --

b What ~trength is on the shelf - - - --

< \\hat 1s the unu of measure - - - --
d I low much of the drug will be dmini~tered - - - - -
. dimenhydrinate 22.Smg x5 mL= 7.5 mL, identify:
4. Using the formula equauon dimenhydrinate 15 mg
a Wh.1t the physician ordered - - -- -
b. What s1rcng1h is on the shelf _ _ _ __
c What i> 1he unit of measure - - - -
d I low much of the drug will be administered - - - --

. gua1fencsin 400 mg x5 ml= 10 ml identify

5 . lhing the formula equation guaifenesin 200 mg '
a \\hat the physician ordered-- - --
b. What Mrcngth is on the shelf _ _ __

" c
d.
Wh.11 1~ the unit of measure - - - --
I low much of the drug will be administered - - - --

Practical Application .
11 1nc
ll>ing the same set of problems found in the ratio and prop0ruon method, set up the problem> th1
using the formula method. Be sure 10 use a conversion ratio if necessary, then solve.

6. /.oloft 75 mg PO is ordered The strength available is Zoloft 50 mg scored tableL I lo" m.11 1.11>let(s)
would provide the desired amount I - -- - -

7. \letforn1111 750 mg PO is ordered The strength available is Metformin 0.5 g tablet. How ma 1.1blct(s)
would be nccNary to fill the desired order?-- - --

8. K-CI 10 ml\q 1'0 is ordered. l'hc strength available is K-CI 20 mEq tablet. llow many tablet (') wnuld be
neccss.1ry ror the desired order'-----

9. Amoxicillin oral suspension soo mg PO is ordered. Available i! amoxicillin 125 mg,15 ml I v many
milliliters would be administeroo for the desired order!--- - -
I low rnJny tt>Jspoons would be administered! - - - - -

10. Levothyroxine 0.5 mg PO is ordered. Strength available is 125 mcg t.1blet. I low many tabkt (')
would bf necesS<1ry for the desired order! - - - - -

Ca lc ulating Doses U sing

Di m en sional Analysis
The dime"'ion.11 analysis method of dose calculation is
different from the pre\1ous two methods discussed
because this method does not require the con\'etsion
between umts 111 order to soke the problem. Recall in
the ratio and proponion method and in the formula
method. the first step i~ to change the strength of the
drug ordered .rnd the s1reng1h of 1he drug available to
1he same 11ni1 of measure, and then the problem can be
solved. In the dimensional analy;is nwth only one
linear eqUJJlio11 is us;?d. Linear equation' h,1" 1 right sidt
and a left side separated by an equJI> , \ simplt
example ofa linear equation is x = 2. lh< 1 this linear
equation represents the measurement \<>II " loo~i~
for (typically milliliters. capsules, or t.11" 1 .) Ah"3)1
begin 1hc dimensional analysis problem I" 1. 1~rmining
what unit of mc,1sure your a11swer shnul tl h< 111. and
place this uni1 of measure on the kft "'k of the
equals sign.
 CHAPTER 9 Calculaung Doses of Nonparenteral Medications 155

r-:ext, on dimensional analysis there will be a series or gr iii 60 mg

fractions (or ratios) in which the numerator and den~m .t= - - x
I gr i
. toi coniain related conwrs1o n factors. A factor is a
mammon fr,1c1ion 1hat shows a re I,1uons' l'b
11 p etwecn two Now you want to use the math equation that will give
co mbcrs ;uch as 60 mg = I gr or I tsp = 5 ml~ Using you a denominator of milligrams.
:::'e dimrn\ional analysi\ .method avoids the need to
norm multiple calnil.u1ons to solve drug dosages The problem looks like this:
:Cauw the process involve\ writing fractional factors gr iii 60 mg I tab
that in< ludc the conversion factors that Me needed 10 x= - x--x---
:.olw the ralrulation. The .i.irting foClor (first fraction l gri !OOmg
a(rer the cqu.1ls sign on the li nc,1r equation) wil l always Take off all abbreviations so that only 1he numbers
be the nwa\urcmcnt you .ire looking for in your answer rem;:iin :
as the numerator .ind the number I as the denominator. 3 60 I
!'ext. dctcmune the comersion factors needed to make x=-x-x -
1 I 100
thestamng factor cancel out Remember that the numer-
ator .1bhrL-v1a11on in the staning factor will be the 180
denomin.nor 111 the next conversion factor, with the x=-
100
same happening throughout the equation.
The most d1thcuh 1.1sk in computing problems using When you fin ish 1he math, you have the a/1proximall'
dimcn>ional .111al~'" is 10 'ct up the o riginal linear equa- answer. bu1 to make sense you need to round the answer
tion corf<'lth ro 'l"I up the common fraction correct ly, from '"Y... to 1"9{,~ 10 get the number or 1able1s 10
remember that tlk numerator will show the name or administer
abbrE'\1a11on of t!ie ordered medication. Then con1inue
10 add f.1<10" i ,1,tion), one at a time as needed so Sox= 2 1.1ble1>
1ha1 1he line "u.u1on r,1n be cancelled out and the
answer h('<llllH s nbviou' Mob! o f 1he ti me the wrong or using 100 mg = gr iss as a conversion, again ,1a11
an'wcr for tl11 J1,e 01dercd (DO) can be recognized b)' sming up your linear equation:
becauw tht' .11 ' Jocs not make sense. gr iii
x=--
1
IA1 EXAMPLE 6: Ordered phenobarbital gr iii tab PO Add the known conversion 10 >'Our staning factor
C!J hs griii IOOmg
.r = - - x
Availabk meJ1<a1ion: J)hcnobarhital 100 mg scored I gr iss
table I\ Add the final fa(tor:
griii IOOmg llab
\\'rited< h l ha1 \'OU knOIY x=--X X---
griSS JOOmg
Fin.t 1h, 1 1,.. "t.1blc1s Take off al l abbrf\~ations and do 1he math:

Ncxi. the \l.1:11ng fonor is gr iii. 3 I I

.r.=-x - x-
1 l.5 I
C<inv.1"" 1 .. do!\ needed 10 solve this probkm 3
include 60 mg= gr i or 100 mg = gr iss x= -
1.5

DA - OOm x=2
I h
Using <>ll 11 g = gr i a~ rnnversion. set up the line.it In the above example, because you used an approxi-
equation: ma1c cquiv.1lent { 100 mg = gr i'5) ~I the beginning of
the problem, the answer came out wi1 ho u1 the nc~d
t = gr111 lo es1imate 1he number or tablets.
I
The abo" SI< p ~how' 1us1 the staning factor. rernem
bcr. twill b~ tablets Ill RNING TIP
Rlr each factor added. Ille numera1or should match Ille prev1oos
Add the hN known conver;io n factor, which will 1)ut factor's denominator so that you can cancel the unnecessary units
1hc gr,1ins a.s the clcno1nina.1or.
156 SEC N II Mathematics for Pharmacology and Dosage Calculations

EXAMPLE 7' \ulfamc1ho..vole oral suspemion 1s sup-

phcJ u I rJIO ml Jhe phpician orders
2 g, I lo" many milhhms "ould be pre
p.1r.'<1, anJ how many teaspoons would be 4
JC=-
admm,.tneJ! )

U"ng d1mcn\1on.ll Jn.il)~S to soh-e this problem, 6rst x=4

"t't up the hncJr f<lUJUOn On the left side of the
'\JU.111on pla<r an x RA!member. the problem is
loo~mg for 1.:.upoons The starung factor is
tht mlwr fJrn1f\ nt""Sdl)' to sol\-e this using DA are:
10 ml " I g and I t\p S ml
Now sho" your \\t>rk
llw >t.1rt111g f.1t1or ~
2
K
l'l.ue your next conversion in 1he problem
Sin you are looking for teaspoons 4 t\p.
lg
-. and 1'ote that whro th e second factor "as .1dded, &raml
I became the denominator so that the st.ming fact()(
numerator grams could cancel out Repeat this method
of adding factors and canceling the prC'\iou' f.ictor until
you can sol\'e the problem because all of tic measurt-
ment factors except the desired mea\urcnwnt have betn
cancelled ouL Remember, in clirnension.11 .m,1l)sis. do
not conven between measurement unll' hu1 rathet
make the measurement units factors in th1 1ua1ion.

lg 101111
x - x--
1 I g CHOOSING A CALCULATIO
Now 111cl udc 1hc las1 conversion so the problem looks METHOD '
hkc thi~
'lhree methods of dosage calculation h.w. ht'<'ll iclenti
lg
x 101111 x -
I " Jl
- fied in this chapter. The e.xamplc probJcu, 111der each
1 lg 5 1111 method is the same so 1ha1 yo u will be ahl tu sec how
lake out .111 1hc abbr('Viations. leaving only the each method differs. Ii is strongly sugw ,J 1h.11 you
11111nbcr,, r.intcl numbers a11propria1ely, and cross choose only one of 1he three me1hod ~ an<I .11 1v' use 1ha1
multiply method 10 avoid confusion and reduc ,. 111 ..rrors.

C h eck Your Understanding : DIMENSIONAL ANALYSIS

BOX 9 -4

Show )'Our worJ.. on a separate sh~ of paper. Saw your worksheet.

'lhc \t,1011111 fanor 1s gown first Using the guidelines for dimensional analysis, circle the corrl'<t "r I f.t(lor

IOml lg JOOOmg
I. x ml or
250mg IOOOmg lg
I cap IOOOmcg I mg
2. x c,lp or
600mcg I mg IOOO mcg

3. t' tsp 2 t'Jl ~ IO mL

or
20ml 10 ml 200 mg
187mg IOOOmg Ig
4. x mg or
~ml lg 1000 mg
11.tb IOOO mg
5 .. 1.1b - -
0 .2~ g lg
or
Ig
JOOOmg
 CHAPTER 9 Calculating Doses of Nonparenteral Medications 157

Check Your Understanding: DIMENSIONAL ANALYSIS

eox 9 - 4 - cont'd
Practical Application
,ing the ~me set of probl~ms found in the raiio and proponion method and in the formula method, solve
11
uwig dimenion.11 analysi ~how your work on a separate sheet of paper. Save your \\Ooohttt

6. /.oloft 75 mg 1'0 I\ ordered. The strength available is Zoloft 50 mg scored tablet I low many tablet(s)
would provide the desired amount? - - - - - - - - - - -

1. \lctform in 750 mg l'C> is ordered. The strength .1vailable is Metformin 0.5 g tablet. I low many tablet(s)
wnuld be nert"S.U)' 10 fill the desired o r d e r ? - - - - - - - - - - -

8. 1(-\.1 40 mFq ro i\ ordered. 111e strength available is K-Cl 20 mEq tablet. !low many table1(s) would be
1w<c'"'" for the dc~ired order? - - - - -- - - -- -

?. Amuxicillin or.ti suspension 500 mg J>O is ordered. Available is amoxicillin 125 mg/5 mL. I low many
mill ili1er' would Ile adm inisiered for the desired order?-- -- - - - - - --
llow man1 1ca,p1>ons would be adminis1emH - - - - - - - - - - -

l<'\uth\TO:<tm 0 5 mg PO is order<'<!. !>trength a"ailable is 125 mcg tablet. How many tablet(s) would
, 1 0.
l>t: ll"< ry lor the desired o r d e r ? - - - - - - - - - - -

Understanding: DOSAGE CALCULATIONS

. -- - - - -

Show your 1>01k on ,1 >Cparatc ~heet of paper. Identify the method you use. Save your worksheel.

Calculati view
Using nnlv , ol 1he c.1lrula1ing methods, calrula1e the following ;olid drug doses. 1l1cn write in the numlx-1
of tJblt1' or ;:isult'\ for each dose. Interpret the orders 10 show the number of lime$ the dose is taken
ech dJ)

I. Ord< ,J. t.lurophage l g PO bid with meals. Available: ~00 mg 1ablets.

Do'c to lw i11vcn:

2. Ord ,, I .hcophyllinc, 300 mg PO I h J)C q6h. Available: 100 mg tablets.

D o be giwn

3 Ordc J d1pyritfamol~ 100 mg 1'0 qid Available: 50 mg tablets.

no be 11iven - - -- - - - - - - -
4. 01dl'rcd phcnytoi n sodium 300 mg c.1p PO daily. Available: 100 mg capsules.
110\' I< I be given

5. Ordcred griseofulvin I g PO dail). Avail,1ble: 250 mg tablets.

nose to be given----- ------
 Dosage Calculations
158 SC N11 M1th1m1t1cs ror Pharmacology en d

SAGE CALCULATIONS
Check Your Understanding: DO
BO X 9 -5 -cont' d
- - -- --- - - -- - -- -

6. OrJ<1<-J luru.cm1J( 40 mg l'O dlil)' "'"ilable: 20 mg iablets.

l'>oie toll\ IP''"----------
7. Ordt'T<-J lnuth)'TOllnt <odrum O025 mg PO daily. Mailable: 0.05 mg tablelS.
lloot w he IP"'" - ---------
8 , OrJcr...J bupropron h)Jrochloridt 200 mg PO ql2h. Available: 100 mg tablets
l>o><' Ill h. IP'~" --- -- -----
9. Or.kred Jllopurmol 600 mg ro dail) m divided doses to be given bid. Available: 300 mg 1.1hlt-1s
llilW Ill ll<' jl)WO - - -- - -----

10. Order.'\! cimclldmc lOO mg PO q8h. Available: 100 mg tablets.

Dow 10 he fll'CO - -- - - - - - - -

RECONSTITUTING A POWDER
Some mcdir.11ion; must be rero11s1i1u1ed from powder
w liquid fo1m before JdministrJtion. 'l11e label on these
nwdic,1tions will giw the total strength of 1he medica-
1ion in llw houlc .lnd 1he $1teng1h per volume of the
mrdlca1ion af1cr it has hecn recons1i1u1ed with the
required dilucnts (I igurc 9 I) lithromax suspension
will rnnt.1in a111hrom)'<'in 200 rng in eveiy 5 ml when
the mrdira11011 h.1s OCt'n properly m:ons1i1u1ed. The
label on Zithromax shows the total s1rcn1 1 11f mcdic.1
tion, the volume of solute to be used, "'" he strength
of medication per volume when the sol 1 has bttn
added.
Table 9-1 shows the rcconslllullon ol 11 hrom.ix by
total strength and volume of medication 1 the bottle
The weight (amount) of dnig is measured 11 111 dligram~
so the azithrom)'cin is available with contents
Jl"r bottle being either 300 mg, 600 m~ >00 mg. or
1200 mg. The amount of solute (watN) dco.I 10 ~lt

TABLE 9 1 RECONSTITUTING INSTRUCTIONS FORZITHROMAX

TOTAL VOLUME AFTER

TOTAL AMOUNT AMOUNT OF WATER RECONSTITUTION AZllHRDMVCIN
OF ZITHROMAX TO BE ADDEO (AZJTHROMYCIN CONTENT) AFTER RECONST
JOO rng ol drug 9nt ISnt. 100 mg/S m
600 mg or dllJQ 9 rrt 15 rrt 200 mg/S
~mgo! drug 12 rrt 22.5nt. 200 mg/S
1200 mg or drug ISnt 30 nt. 200 mg/S

3011lMitll ra~IOIWlett

Zithromax
(:I'=)
[ 200 mg per 5 ml

<1IJJI; ____ ...

._., ,
Pfiter Lab&

figure 9-1 label fo1 ZiUvomax.

 CHAPTER 9 Calculaung Doses of Nonparenteral Med1c1uons 159

,,ailable drug m.ikd the ~lution a dosage strength. If
L of ,,r,i1er ;, added 10 either the 300 mg or 600 mg
:iue,
9
the 1oa.il volume after reconstilution will be
15
mL of suspension The difference between the two
boitles wit! 15 ml. ofor.11 suspension is that the dosage
ngth in 1he azuhromycin 300 mg bo11le is
\ l,, mf1'5 ml .ind in th e .w'th romycin . 600-mg bottle,
100
ihc orJI su,pemion is 100 mg/5 ml af1er reconsti1u1ion .
~powder can he reconMi1u1ed from a vial into o nly o ne
Jo1><1ge sarength If a differrna dosage streng1h is ordered,
do tk'f add aJthU mal <0lu1ion, ins1ead stan O\'er with a
new vial so the powder is a1 full strength Many multi-
vial recons1itu1ed medica1ions do no1 have a long shelf
life. Ille medication mus1 be used or discarded usually
wi1hin a timefr.1me of as lit1le as an hour 10 ,1s much s
2 weeks. Ofaen the medication must be refrigera1ed afaer
reconslitution Read all manufacture labeb carefully.
Finally. always be sure to properly label reconstiluted
mediction wi1h the prepared dosage sarengah, 1he d.11e
and lime ofrecons1i1u1ion, and you r initials. More infor
ma1ion on recons1ituting guidelines can be found in
Chap1er 10 on parenteral routes.

~U nderstanding : RECONSTITUTING A POWDER

- - - - - - - - - - -- -- ---- - --

Practical ration
ll>ing 1he I 1 1 Hgurc 9-1 and the informaaion in Table 9- 1, assumins the medication is pro1)erly
rt"<On5tit1 "er the following questions

I. Accor 1 1he label, how much a2i1hromycin is available in 1he boule if i1 is properly reconstituted/

2. Acee- o the label. what dosage strength is available if properly reconsti1uted1 - - - - - - - -

3. Acw1 1 10 1hc l,lbel. what is the total volume of the bottle af1er recons1ilu1ionl - - - - - - - -

4. o., 1 dica1ion expire as soon as thesuggesteddosagcofoncedailyfor 5 day1;' iso"er1 _ __ __ _

.5. Woul 1 1 1nsm1ct ,, pa1ient to u>e a teaspoon fo r tlie 5-mL dose1 hxplain your answer._ _ _ __ __

6. \\'h.1 1hc in1tr1.1ctions would you give to the patient/ (Cive 1wo a11>wers.) _ _ _ _ _ _ _ __ _

lbing th 111 ~1gure 9 1 and assuming the medication 1s properly recons1i1uted, answer tlie following
question'

7. lft. 1cian ins1ructs ahe patient to take a teaspoon a day, bow many milligrams would the patienl be
tak. r day?----- - -- -- -

8. llo" n 1n1 millililers of water were added 10 the drug 1>owder? - - - - - - - -- --

9. H' \ days would this medication las1 if ahe patient were 10 take 5 mL a day1 - - - - -- - -

10. Could \'Ou .1dd less Ouid to make .1 s tronger dose! Why or why not? - - - - - - - - - - - - - -
 160
o age Calculations
<;ECTON II Methemeucs for Pharmacology and os

ONSTITUTING A POWDER
Check Your Understanding: REC
BOX 9 - 6 -cont'd __ ~- -~ ____ _
. tin suspension 400 mg/5 ml. answer qUl">llons 11
Usong the followong reconsutuung mstrucuons for Augmen
and 11
A.\IOUl'IT OF WATER REQUIRED FOR
8011USl/I SUSPENSION TO OBTAIN 400 mg/5 ml

SO ml. 44 ml
75 ml 66 ml
IOOml 87mL
___, dd to a IOO-mL bonle in order to have the /\ugmcnu n 'll'f"'nsion
11 I lo" much water wouId you nm1 to a
of 400 mg/S ml I _ __ _ _ _ _ __

\>\.1loll W C ,__ I' ---' fonu were adding only 66

uvll 1e WOU u you n"'" tO use I ; -
ml of water to obtain an \ui:mentin
SUSl)\'ll~iOn of 400 mg/5 ml? - -- - - - - - - -

children's and adult's nomograms. Thl' 1111111ngr.11n pie

SPECIAL CALCULATIONS
Not every l'Jticnt will be able to tolerate the 'dosage for
the avcr.1ge .ulult" so s1wcia l cakulations are used. Infants
and children, because of their small size and percentage
of fluids in their body makeup, cannot tolerate adult
nwdirations that arc simply reduced in volume or
amount of drug In f)\'diauic patients. this is referred LO
.- "imm,mare body ;,ystems." meaning that the bodi
systems m.1y not tolerate adult medications. Infants'
body \y..tcms are nol fully devclof)\'d, and they lack the
e1uymcs nec~ary to metaboliu drug1. Also. the child's
vo lume of tot.11 body water. when compared with that
of an adult. is much greater, so the medication will be
distributed differently, thus altering the effects of the
dru~ Th~ geriatric pauem may require more specific
calculauon of mcd1c~11on dosage because of the poten-
tial toxicity resulting from the decre.ise in body func-
tions finally, because of the toxioryof chemotherapeutic
agents the patient's height and weight become factors in
thl'fe ,1dminis1ra11on of chemotherapy drugs.
Calculations Using the Body Surface
Area Method
..:...:...;..;;,.;_~~~~~~~~-
lnfonh JnJ children can receive me<licalions via the
s.1111e route as .1dul1s-pare111eral and nonparemeraJ-
but hmh 'urlace .ire (BSA) Clculllon for determin.
ing the rorrm dosage is used for calculating special
dos.1gc' for children and geri,mic p.11ients, especially
with 1oxk drug.o; such .is antineoplaMics. There are both
1ure<I in Lhis book was developed fort hild 11.
BSA is found by placing the p.1tiln t hl'ight and
weight on a nomogram thal calc11la1cs th1 ><11ly ;urfoct
area, rather than prescribing medir.11 u>1 h.11<.>d on
' normal adult' size. Ir a ch ild is of norr 1 lll'ight for
weight. the BSA can be determined hy "' I t .tlorw, as
is calculated in the box found in the cent.., I the norno-
gram (Figure 92). I lowewr, if the height "eight of
the child are not proponional, the 110111 rn mar bf
used. The purpose of the nomogrm ;, tn ",1\ure tilt
totJtlsurfacearea in square meters (m') :-., 1 that height
is measured in both cm (centimeter.) .11 11 (inches)
and weight is in lb (pounds) and kg (kiln 1') When
using the nomogram, be careful that )1lu 1 he Ji>PR>-
priate calibration for both height and " t lo read i
nomogram, use a ruler to line up th< ("'trem(
left) and weight (extreme right) to oht. '" llSA m
square meters (m' ), that is found l><t" l h<'St' two
columns. (All patients who requir" th< 11 I a nomo-
gram should be weighed and mc.1~ur"d h r i:ht befort
calculations with the nomogram ar<' 1wrf nnl.) RtJd
the BSA at the point where the ruler'"""' , thr graph
The number found in the BSA (Olumn r , ll~A )OU
will record. Note that the calibr.11ions h """n desig-
nated numbers on BS/\ are not consi\ll'nt lrnm the top
to the bottom of the graph. Some ol thl' <.ti 11,11ions te
in 0.01 incremenl~, others arc in Cl. I """ nwnls an<l
some are even in 0.2 increniencs. 1h< 11 ouulAr.1111 1ne.t
sureme111s are in both metric .md Englhh 1111 .1'urcs. Ille
use of lhe n1easurernenLS arc in1crrh.ng~i1hh 'lO\" U')' i1
few examples to calculate llSA
 CHAPTER 9 Calculatmg Doses of Nonparenteral Medications 161

NOMOGRAM
Height For Children of BSA Weight
cm In Normal Height lb kg
for Weight
90
180 ao
t 30 160 70
ao 1.20

t~
70 1 10 60
240
90 1.00 50
220
200
8S
80
60
50 .90 r.11.4
I,
100
90 40
190 75 1.3 80
70 .80
180 40 1.2 70
11 30
170 65 70 60
160 I0 25
150 60 .60 50
30 09
140 55 55
.50
"'a:w 08
45
40
20
130 50 I;; 35
(/) ,45 ~ 07 15
120 0 20 w 30
45 z a:
110 :> .40 <( 06
:> 25
40 0 0 10
100 Q. 15 35 (/) 0.5
~
20 90
~ 18
90 35 I- .30 <( 80
r w 04 16 70
(!)
10 a: 14
80 iii <(
60
30 s: 9 .25 w
0 12
28 8 50
70 :t
a:
0.3 10
26 7 9
:> 4.0
24 6 20
(/) 8
60
22 7
3.0
5 02 6
50 20 2.5
19 4 . 15 5
18 20
17 4
16 3
1.5
15 3
14
13 .10
0. 1
2 1.0
30 12

Figure 9-2 W8$t body svrface area IOmOQI am

EXAMPLE ild w~i11hs 55 lb and is 85 cm 1all. STEP 3: llse a ruler 10 align 1he marks. TI1en look
) '""''n~ 1his child's BSA using 1he on the column marked BSA at 1he 1op, and
mugram. read the BSA from th,11 column.

Llsini; tht 1 omoi;r.un in r1gure 9-2, do the The answer is 0.82 m '.
followin11

STEP t I ' d an<l m.irk the child's height in 1he first EXAMPLE9: A child is of normal height forweigh1 and
column Re ~urc to find the height in ccn- weighs 32 lb. De1crmine this child's USA
t1mt.:tt.'l'!I.. not inchn. using the nomogram

STEP 2 I nc.1 and m.uk the chi ld's weigh1 in pounds Using the nomogram in I igure 92, <lo lhe
(nlll kilogr.1111~) in 1he lasl column. following:
162 )EC1 !JN II Mathemaocs lor Pharmacology and Dosage Calculatioos
STEP I 1ond the mode.lie column. headed "For Chil-
dren of !'>ormal I feighl and Weight. which
is cncloloed wnhm a boll
STEP 2 I md ind mJrl< the child's weight on the left
"Je of the ccnierhne.
STEP 3 list a ruler 10 read the co~ponding
number on the ngh1 sode of the cemerline.
nn, I\ the BM
Using Body Surface Area
Alier tk1cm1mmg 1hc BM of the pauem. 1he dosage
calcul.1uon o\ complc1cd by cn1ering !his information
onio J gown formula In the metnc system, square meters
( m ) are u'led for the >1.te of the body in height and
weight lhe .1~ump1oon is that the llSA of an average
.1duh wcig)ung 140 lb is 1.7 m'. Becau~ most medica-
tion~ .ur b.1srd on .wer.1ge .1dult dosage. this dose mus1
be .1d1u,1cd for the person who needs a special amoum
of mcdlca1ion, \Uth as an infant or child, an older person
who no longer h.1s llw avemge weighl for height, or
,, person 1.1king very 10J<ic medications such as
a111incoplas1k~.
Ihe fonnul.1 for c.1kul.11ing lite dose is:
USA m 1
x 1\c.luh dose = r>esired dose
I .7
I
1 ~ EXAMPLE 10: A ch ild weighs SS lh and is 85 cm
tall Ille ph)oi.ician orders amollicil-
lin based on llSA for the child. BSA
for llus child on the nomogram is
0.82 m' Ille adult dose of amoxi-
cillm is 500 mg. Whal is the dose
for the ch11d1
Check Your Understanding: USING A NOMOGRAM BOX
- -
Calculation Review
Use 1he nomogwn in I igure 9-2 10 calrula1e the
llSA in 111
L J\ chi ld is 60 cm and weighs 7 kg. - - -- -
2. A child is 15 lb and 72 cm. - - -- -
0.82 m'(BSA) x 500 mg= 24 1 mg
1.7
Now calrulate the dose of amoxidllin 1ha1 h 10 ht
given using the formula or the ratto and proponion
method. The ex;imple below uses 1he formula ml'lhod
The child's dose would be 241 mg. Amoxicillin SUs-
pension is available in 250 mg/S ml
241 mg(DO) .
.:...:..:..::;=;.,.._.:x5mL(D~)=4 .8 ml or5ml (DC)
2SO mg (DA)
This child would rcceh e I 1easpoon of .unox1cillon
1,1 EXAMPLE11: A child weighs 70 lh .md is 45
inches tall. Inc ph"''"Jn ordt"
albu1erol for 1hc <hold b.1sed on
the BSA. l'he llSA i I 2 m1 Tht
normal adult do" ' albu1erol
4 mg. What is 1hc """' for lhe
child!
1.2 m' (BSA)
' ( ) x4 mg (adultdosc) -l.H1. ~.or3 mg
1.7 m DA
The child's dose would be albu1crol I 1 Alhuierol
syrup available is 2 mg/5 mL.
3mg(DO)
mg (DA) x 5 mL (Dr} = 7.S ml. (O<.)
2
The child would be adminis1ered 7.'> 1 nr IY, isp
of albuterol.
- - ---
3. A child ii 45 inches and weighs 70 lh
4. A child is 20 kg and 90 cm
5 A ~hild is of nom1al weight and hcighi uul
weighs 7S lb. - - - - -
 CHAl'TER9 Calculanng Doses of Nonparenteral Medications 163
---

Checl< Your Understanding: BODY SURFACE AREA BOX 9 -8

Show your work on a s1pa rate sheet of paper. Save your workshcci.

Calculation Review
c;.11culate the following doses using BSA.

t. /I child weighs 65 lh .md is 42 inches tall. l11e physician orders erythromycin for the child. The normal
.uJult do~e is erythromycin 250 mg. /lvail,tble erythromycin or.11 suspension 250 mg/S mL. What is 1hc
llS/ll - - - - - - - -- - -
VJh,11 J ose and volume of medica1ion should be administered? - -- -- - - - - - -

2. \ child i~ 30 inches 1all and weighs 27 lb Ille physician o rders Claritin syrup for 1.hc child. 'll1e nom1al
adult Jo..: i< Oari1in 10 mg. Available is Clari1in syrup 10 mg/ 10 ml
\\ h.11 i' the llS:\I - - - -- - - -- - -
What do'' and volume of medica1ion should be administered? - - -- - -- - - - -

3. 11 child " 65 inches 1.ill .md weighs 95 lh. A physician orders predn isone for the child. The normal aduh
dn'l' i' prrJnisonc 5 mg. Available is prednbone S mg/S ml.
Wh.11 '1h< ll!>A? - - - -- - -- - - -
\\hJt d "'and volume of medication sh ould be adminis1cre<I' - -- - - - - - - --

4. A chi!.' h "<'ighs 10 lb and is the normal height for this weight has an order for Z<1ntac syrup. The
norm I 1cult dose h bntac 150 mg. Avail able is Z.1ntac syrup IS mg/ml.
Wh.ll 1 !< BSA'----- - -- - - -
Wh.11 d md volume of medication should l>e administered I - -- - -- - - - - -

S. \du 1 inchc~ 1all and weighs 70 lb. A physician orders cephalexin. The normal aduh dose is
c~pha 'i 10 mg A\'ailable is cephalexin suspension 250 mg/S mL
\\hat t < ~,.\I-----------
WhJI .10<! volume of medication should be administered I - - - - - - - - - - -

Calc u lat D ose U sing Milligrams EXAMPLE 12: 2.2 lb : I kg :: 22 lb .x kg

per K ilo
In m.1ny P' , .,- 'rt1 111g< the use of milligrams per kilo- 2.2 t 22 ~g
grams ( 111w ~ l " "'ell 10 express a standard dose. For x; 10 kg
example, ir lw 1lcalth M,1ln tenance Organiza1 ion
(I IMO) for 1 u' "'"the do;c informa1ion for amoxici llin Medication o rdered: amoxitilli n 50 mg/kfl/day in
is giv,n .1\ J to 5 l mg/kg/day for a standard dose and three divided doses
80 to 100 m ](g, da} for a high dose.
To c.1lrn'a Jos.igc using milligrams per kilogram, The child \\Ctghs 10 kg.
the fiM \lq> 1 tu change pounds 10 kilograms if the
weight h." lw1 n nb1a 111cd 111 pounds. Remember 1hat Calcul~1ion: 10 x 50 mg x I day ; 500 mg per day
2.2 lh I I,~ I he e.1sies1 method for conven ing 1hcse
mcasunmc111> J< by using ra1 io and proponion. Now divide the 1otal amount by three doses so 1ha1
each dose will l>e 167 mg (500 mg:3 doses 13 times

lllr LE
The m ~ g means to mult1(l4y the numbefs Therefore the
a dayl ::x I dose) of amoxicillin.

equahOCl accual v reads mg x kg x frequency of adm1mstrat1on

or dose
 164 SECTION 11 Mathemaocs lor Pharmacology an 0
d sage Calculations

Show )'Our \\Ork on a 5(J'arate sheet o f paper. Sa'-e your -.'Orksheet.

I. Order<-.! \<-.:lids 10 mg,/l.g/q8h for a child who weighs 55 lb.

t\\a1lablt med1ca11on \'<-e11ds 250 mg/5 ml.
Wh.11 1s the strength of medicau. on for one dose? ~- 61
Wha1 1\ the \olume of med1cauon to ...
"" S'''efl '"th that~ - - - -

2. Ordered Dtlanun l 5 mg/kg per dose for a child who "'l'ighs 44 lb.
t\va1lable m<-Jic.mon D1lanun chewable tablei(s} 30 mg
\\ h.11 is the strength of medicauon for one dose..
1
I low many chewable tablet(s) should be gl\'ffi with each dose. - - - - -

3. OrJcrt..J amox1colltn suspension 20 mg/kg/day .tn th rtt divided doses for a child who weigh\ 4' lh.
Available .unoxirilhn suspension 125 mg/5 ml
Wh.11 is 1he Strength of the medication for a day? - - - --
Wh,11 " 1he \lrength of the mroication for a dose?-----
Wh.u i' 1he volume of medication for a dose?-----
Wh.u 1; the volunw of the dn;e in household measurement? - - - - -

4. Ordered: Zynec ~yn1p 0. 1 mg/kg daily for a child weighing 55 lb.

/\V,1il.1blc nwdic.11ion: Zynec syrup 5 mg/5 mL
Whn1 i~ thl' sirrngth of nwdiraiion to be administered fo~ a da y ? - - - --
Wha1 is the volume of medic.11ion 10 be admintstered daily ! - - - --

5. Ordered: Zaron1in syru1l 20 mg/kg bid for a diild who weighs 54 lb.
/\vail.1blc mcdic1io11: Zarontin syrup 250 mg/5 mL
Wha1 i< 1lw 'ireng1h of 1he medica1ion 10 be gi,en with each dose? _ _ _ __
Wh.11 is 1he volu nw of medication 10 be given wi1h each dose1 - - -- -
Whal is 1he volume of medication 10 be given in household measurements? - - - - -

OTHER NONPARENTERAL to prime" the medication and then I?< HO detail

MEDICATIONS
Medicauons used for nonparemeral routes come in
se.'t'ral dosage forms other 1han 1he oral liquid and solid
forms Lxamplcs indude ophthalmic and olic drops.
which are almos1 ahva)'S prescribed with a dropper
because they .ire 1ns11lled into a bodyori6ce; nasal sprays.
inh,dauon solutions. and aerosols. which are prescribed
in metered doses; aerosol powde~ lotions, creams, oim
men is. .ind 1r,111sdermal patches. which are applied topi
cally; and chew.1ble tablets for children, which are
prescribed like other tablets, except tha1 the patient is
instrucied 10 dww 1he medication. The imponance o f
patienl educ.11ion canno1 be ;iressed enough, especially
wi1h .1 drug form 1hat 1he patient m.iy be unfamiliar
wi1h, le.1cli11g to the chance 1ha1 1he patiem may use it
inronwily. l'or ex;imple. the patiem ins1n.1ctio11 sheet for
1hc n.1sal spr.1y 1riamci11olo11c aceto11i1le tells the pa1ient
about how the patient should do 111;, I i.r. nlO.st
patients do not take the time to read 111< 1 npanying
literature. Jlie allied health care pmr,.,., should
explain and demonstrate the correct pron-.lu ind allow
the patient to ask open-ended que<uu " ronfirm
understanding of the correct adminl\tr. of the
medication.
SUMMARY
Medication is most frequently adm 1111'1 ..1 orally
because of the ease of adminis1ra1ion ,111d d .1i:c olcu
lation. Nonparentcral medic.uions arc dn1f:' 1h.11 u\ually
are taken o rally o r by inhal.11ion and conh 111 ~olid or
Liquid form. Some medication-. such ,,, louoni .111d
sprays, are prescribed for use on thr kin .111.I w ill be
prescribed by lhe n umber O( dose~ 10 tlW ,\l\',I prr dny.
 CHAPHR 9 Calculatong Doses of Nonparenteral Medications 165

This rhaptcr show> thr methods to calculate doses.
The first two methods. called the rario and propor11011
1t1h'1<I and the /cmm1l11 mtrlW<I. require you to firsr
n ,..,rt to li~e mc,l\urcmem systems w hen necessary .111
conder to sohc the drug ca Icu Iauon. '"-
111e th'~d method,
~;lied Jwum.1rc>m1/ 1111111}'>15, u'><'S common fraaions that
nclude the conwr,io11 for measurement systems as
~actors to ,11iow cancellat ion of unnecessary units to
solve the cnlrul.11ion using only one linear rrnct ion. It i~
recommended 1h.11 you choose o nly one or the 1hree
methods nnd 1ha1 the method chose11 be Lhe o ne with
which you .1r' till' most comfortable, 10 decrease math
errors.
Solid m1du.tt1o n\ >uch as tablets may be prescribed
in either p.m1.1l 0 1 whole tablets per dose. Capsules
cannot be divided, and timed-release medications should
be given in the prescribed dosage only. I iquid mroica
tions can easily be administered in the incorrect dosage
if proper measuring devices are not used
Some pauents are not what is considered normal
adults" .rnd may not tolerate adult mroications that
have not been clinically approved for their body s)'Stems.
Sometimes the BSA is measured to determine the
amount of medication to administer 10 chi ldren, older
adults, ,1nd persons taking highly toxic medica1ions
used in chemotherapy. '111e llSA method ror c,1lculating
doses is based on Lhe weight and heigh t or 1he patient.
This calcu lation is then com1>ared wi th the normal
adult llSA of l.7 m', so the normal adult dose may be
modified

Using th ca11on label provrded. calculate rhe oral dosage of each medication. Show your work On rhe
dosagtJ Pam exactly how much medrcatron is taken and how often the med1ca11on 1s raken.
1. . , .. V lters is taking an ant1ulcer medication 1n an effort to manage an acute duodenal ulcer.
,1 u rently taking ranitidme 150 mg PO bid
Dose I give n. - - - -- - - - - --

~ I!!H H'11
NOC (IO(l3~06
1
H1Hll
1, d*'11I
RANITIOIN E
~0
~
1f 1
1. 1 11
Tablets, USP
~~ iI r j
0 ,
iii 150 mg

-~
- -.::
1
~ 1:1i
l ,
---
---
.....
ljooly
wtm
,,,_
Q

T.Elln

chuga has type 2 diabetes mellitus and has been prescribed Prandin 2 mg by mouth
'h a meal, to regulate her blood glucose level

t,.s has been prescribed the antidepressant drug fluoxettne and is instructed to take
3. ~
t 1e 20 mg every morning.
Dos

_ if ... .,,,.......-.11 l .,
;;;;; ;;f '1"
j;
11\A.'IULDlt
UP01tl t ~

fti ~~
l,f
n--
--
PROZAC

-
0

,iP,
1~1
If; i
i1 -- ~
ra
rf
IH
,!
-
20mg
I
JU
'
~I ~
:=
Zr>
'?
0

Cmt1 1t111f'd
166 ,EC O~ 11 Mathemancs for Pharmacology end Dosage Calculabons

4 I I rn Ms Allison IS on a trip. and her

Purse
with her hean med1ca11on in 1t has been stolen.

- ..
She is taking the anucoagulant Coumadin 5 mg daily.
Dose to be given : - - - - - - - - - -

::--=:r... ...
----
__ --~ ~

.... ~
,..
::=:::: ---....- 'i' 11.

.........- _,.,
;;;;;;;;;;;I N

"'.. ~
---
---
....,._r~,,._..,

=--
-
~g
~
,....,_.,
""""""' s ...

~
!

5 f>l Mr Davis 1s being treated for Pagers disease with nsedrona te 30 mg daily at least 30 rrnnutes
~ before the first food or drink of the day, for the next 2 months.
Dose to be given
. . ...
--
~,...
Pm MSl llERE ...
.... _.
~
~w
30 T1bleC1
ltlltf lb.o.tv

6 IHNI After her thyroodectomy, Bernadette was instructed to 1ake levothyrox1ne tablets o nce av
Ul2I for the rest of her life. She currently takes levothyrox1ne 100 mcg daily
Dose to be given: - - -- - - - - - -

(/)
)>
s:
-0
r
m
7 I I Mr Rockwell has been diagnosed with congestive hean failure and will be prescnbed
10 mg daily to control his hypenens1on
opnl

Dose to be given:----- - - - --
_
.....
0
~

.,'
0
.._... 100-

~r
M
.=
".-. . '"'
~

--.----
=...--::..- ::
------
--
::-..=-
-
---
0
0' _,,..,
!iiiiii~
.....
 CHAPTER') Calculating Doses of Nonparenteral Med1cat1ons
_ _c _ __ 167

8 ~ >j Mark White expenenced constant muscte hyperacttv1ty after his car aooden1, and Dr Merry
< pr11scribed metaxalone 800 mg t1d.
Dose to be given - -- - - - - - - - -

9. j.. j M Marta had bacterial pneumonia and was prescribed azithromyc1n 400 mg the first day and
, 200 g tor days 2 through 5
Dose t grven on first day: - - - - - - -
Dose 1 be given on days 2 through 5: _ __

---
---
=::::'--.
--
--
.lot.==-
-
-----
....
----~ .......
.....--
-
---
:::=.;-.:.:.. -
..-

Calculatio w
ukulatc tilt w111g problems using 011/y one method. II<? sure that the dose is in the corrcet dosage form. Show
your \\.Ork o ' artc sheet of paper. Save your worksheet.

DOSE TO BE CIVL'
l!cn.1dryl 50 mg
ll<:nadryl 25 mg caps

2. llJ () d hlnrpromazine HCI 20 mg

"''. 1, lhor,tzine LO mg tabs

3. , . , 01 I I \\,1rf.tri11 sodium 10 mg
A\ 11 1l w.1rf.iri11 sodium 5 mg tabs

4. IAI<>111~v
1'1ow11til syrup 4 mg
l'rowntil syrup 2 mg/5 ml.
ulll )OU give this in household measure!
""

6.1 , I Or d .1moxicillin 500 mg

"' 111 hi" ~moxil 250 mg caps

7.1, I Or1l1 r1 I Bi.urn 150 mg

A\,til 1hk Jliaxin 250 mg/tsp
Wh,11 "tlw dose in ml?
 168 SECTION 11 Matllema~cs for Pharmacology and Dosage Calculations

DO~!: 10 81! CIV!;N

S r-1 Ordeml I\ Our 10 ml q

EJ .\\atlabk !\-Dur 20 mfq ~or.JI.lb>
') r,;J ! jAvailable d1menh)Jnn.11e
l:.':'..:l -
Order.J
Dr.1man11nc
1ICI 25 mg
12 5 mg tabs

Ill I >J~
Ordered Auvan I S mg
Available. Ativ.111 I mg tabs

REVIEW QUESTIONS -
All o( the following swements re fa/M. Dettrmine the error(s) and rewrite the answer, giving complete and
correct inforrnation in th~ space pro,lded.
I 8\A LS calculated b) measuring \\eight alone. - - - - - - - - - - - - - - - - - -- - - -

l A rompari\On of the rclauonsh1p between two ratios is railed the fomoula mttlood of dos.1ge calcul.1 on. _

l One household teaspoon i~ approximJ1ely equal 10 15 mill iliters. - - - - - - - - - - -

4 A v,1luc in a measurement sy>tcm is called a rwmogram. - - - -- - - - - - - - -- - ____

S When a medication needs to be rttons11tu1ed, adding more fluid than required will give you .1 ~llrr dosage unu.
Calculating Doses of Parenteral
Medications

Aftf!f StvdY' chapter. you should be capable of doing the following:

orrect synnge for adm1n1stratt0n Calculating doses of parenteral medications in
units
J of parenteral medications on the
metric sys' 1

Agitate
Parenteral
Unit

.
PRETEST- CALCULATING DOSES OF PARENTERAL
ONS
. -- -

Identify 1h 1 1 t .oppropriate syringe size to use to admi nister the medication given in Colu mn A. Use the
choice int , tumn II ,1, 11 1.111y times as 11cccssa1y. but use o nly 0 11e answer per question.

CO LUM CO l llMN B
I. t I ml A. insulin syringe
2. 116 UllllS of lJ-100 B tuberculin syringe
l. - - - 2.4 111(, C. 3-mL syringe
4. 0.22 mt
5. - - - - - 0.86 111 L
6. 0.25 units
7. O.H units ofll-100
C.1lrulJt< the ans"~rs to the following problems. then shade on the syringe with the exaC1 dose you would
adm1n1~u:r

( d"flflltl'll

169
 170 SECTION II Mathemebcs for Pharmacology and Oosage Calculations

ULATING DOSES OF PARENTERAL

Chapter 1 O PRETEST- CALC
MEDICATIONS-cont'd
. . onness of breath after ingesting mushrooms found near l
8. A pAllent comes to Dr \leny complaining of sh . . and prescribes atropine 0.5 mg SC, as an
ha> home. Ille ph)... ocian diagnoses mushroom poisomot
anudote Ille available atropine vi.ti 1s labeled 0.4 mg/m
Volume of dose to bl' adm1ms1ered - - - - - - - - - - - - - - - - - -

I I
111111 ij111,j1.nl1111I0 111
I

known all es. Dr. Meny prescribes VCillira K 400,()01 units IM

') After confirming 1ha1 che pauent h.1'1 no . l'Jgll bl . . ofV-Cillin K powder l million mit>.
b I ' eumococcal infecuon A'"'' a e. a vta1
tO COm Jt t I< patients pn . !' solution tO the powder 10 provid~ " do<age
Dir<'Cuon~ for r~nsmuuon state: Add 4.5 ml normal sa one
of I million unit~5 ml
Volume of medk.uion to be administered:------------- -

111 1111 1111111 111 iilfl11111 ii

Many drugs, such as some antibiotics," . '" 111 J pow.

PARENTERAL MEDICATIONS
Parcnccral mcdicauons can be injl'Cled, infused,
impl.101cd, or arc .1dministered to provide quick absorp-
tion of the drug mto che bloodstream or when a patient
r.innot takc or.11 medications. such as when the patient
is uncoopcrauw or unconscious Also, some medica-
uons cannot be administered orally h<>ause the gastro-
mtesunal tr.m e01)mes and acids do not allow for
proper absorption of the medication. lllis rnapter con-
ccntr.1t~ on c.llrulaung doses for p.1renteral medications
in the metric S);,tcm or in units. Also included is an
introducuon of the proper syringe size to~ when
preparing parenteral medacahons b<e<i on the results of
>-our c.1lcula11ons and the amount of fluid OCCl'S$<U)' to
admm1ster the in1ro1on Some calculations will use
recon~tituted powders I anally, calculations for medica-
tions fount! in unll.'I per \'Olume and reading percentages
of ~olu1ion> that .u.- JISO indicated in the metric system
M<' prrwntcd Drugs may be labeled in both percentage
strength> and in meiric system units. for example, the
label for litloro/11 I/Cl inJ. 1% USP will also indicate
the amount of nwdic,11ion (drug) per milliliter, and is
written a~ 10 m&'m I. thu> for every one milliliter offluid
drawn into a syringe, thcrr will be IO milligrams of the
drug also being d r,1wn imo th~ syringe.
dered fonn and must be reco nst ituccd t< liquid for
parenteral administration. These drug' .u. 1>.1tkaged in
dry form because they are unstable for prol ' :'ll pcnods
of time in liquid form. After recomtitutaon 11 >hclflife
is short. with rapid loss of potency .111tl 1,~ tl\-Cll!'IS
When reconstituting medications. it" XII wly 1mpor
tam to read and understand the vial I.th or package
insen h<>ause in some cases different dn \trengths
are detennined by the amount of diluent 1 <kd to the
'~al; in other vials a specific \'Olumc of h I must ht
added to provide only one dosage ~m 1g1 \ media
lion can ha\-e only one dosage strength f><: 111 once 11
has been reconstituted. In other """' 11>rC fluid
cannot be added 10 the vial 10 111.1~" the I -... weaket
after the powder has been reco11<11tutcd tf "' .lmount
of the medication has been withdr.1M1 I n the vial
During re(Onstitution, the dirooiom " Jlt'Clfically
instruet the allied health professional cnh w roll tht
medicacion to dissolve the powder or to'" ,~ . (.1gii.tt)
the vial to modify the dry ingredient\ 1111< doc nffiled
liquid state for injection. Some mtlu .111ons. when
found as a suspension, will have to h.lw t lo prrcir11ate
placed back into the liquid before prqi.11 in!( tlw medirJ
tion for injection; in o ther cases, th e llll'tli1 .111011 becomes
a solution that does not need .1git.111 on with each
administration.
 CHAPTER 10 Calcula11ng Doses of Parenteral Medications
Drug> are usually reconsututed with sterile water or
0 9% sodium chloride (no'.mal saline INS I so~ution ). If
.
,, drug comes packaged with a. s pecific soluuon to be
s<-d in reconstituting the mcd1cat1on, never subst1tuie
unoihcrliqu id. Some medications for reconstitution wi ll
3 Figure 10-1 Typ.cal 3 ml syrmge
ome m single-dose vials that are reconstituted for
~mmediate use. Single-doe vi,1ls should never be recon-
utuicd before the time for use. When muhiple.dose
: ,,,is .ue prepared. the recons1iluted med ication should
be labeled with the rccon;,tituted dosage strength, the
reconstitution date and time, a nd the expiration date.
l'he person doing 1he rcconstilu1ion should initial the
,;al for patient safe1y. ~bcling of medication should be
done cons11ten1I\ by all personnel. It is imponant when
adm1nistermg rcconsututed medications to check the
expirauon d.lle oi the original vial and the expiration
d:ur aftl'r rL'(On<ttilution
READINGjVRINGES
FOR PAR ERAL DRUG
ADMINIS TION
Intramuscular I~) medications are ad ministered
directly into ,, u ft> tor r.1pid absorption. Antibiotics,
antihi!tt1\n1inl . .-.it>roid,ll antiinOamn1a1ory drugs,. pain
medicaticm' 11 ' 1mmuni1.11ions are all exa mples o r
t~ of mnl I< I " 1hat JrC administered intramUSCU
larly. lntrMn r i111<etions are typically administered
in \'Oluml'S up m1llilncrs depending on the site of
the mjcctto. mo>t ca\<"i. \yringes used for IM injec-
1ions are c,1! 1h ' "' ttnth of a milliliter (ml.) with the
3-ml. syri ngt h a , 1he typical choice (Figure 10-1).
Subcutaneou \ C) injcc1 io ns are administered into
the ~uhcut.111 I 1wr of t i1>suc. which is between the
muscle ar I mal l.1ycr of skin. The \'Olume of a
subrutan u .ron is usually 0.5 to I ml~ the
maxm1un of Ouid that can be injected SC is
2 mL. dcprn nn the we of the person. Ille 3-mL
syringe m.l\ 1 " d for ~C injectio ns, bu1 in specific
instances tuhe1. 1111 syringes may be used when small
amou1m of me In auon art ordered. Insulin syringes are
used only fn ti, .1dmini,trJtion of insulin (l'igurcs 102
and 10-l)
lntradttl:' ID) injernon\ arc used to ,1dmimster
medicauon 1 11 the dennis layer of the skin. The dermis
are. i\ lcx:at ' ' .1bovc the subcutaneous layer 'l'he
\'Olume ol tlrni; a<lminis1crcd is usually 0.1 ml o r less
EXAMPLE 1: ) 2 1111 is >hown here:
171
N
Figure 102 lyprcal metnc measured syringes Leh 10 nyht, 12ml, 6-mL
3-nt. and 1ml tuberculin S)f"1Qes
but is always less than 0.2 ml I he syri nge used is the
1-mL tubcrn din syringe, which is ralibrated in 0.01
increments fro m 0.01 ml. to l mt. 11w calcula1io11' of
the mcdic.i tions for ID injcc1ion use are performed in
the same manner as for other parenteral medical ions.
Calculations to find doses or parenteral medications
a<e performed in a manner similar to that introduced
in Chapter ? for nonparenteral medications. I lowevcr.
instead of calculating how many tabletS, cap~ulcs.
1easpoons. or even mi ll ili1ers to ad minister o rally. you
will be calculating the num ber of milliliters, o r the
volume of medication (liquid), to be dmvn into a
syringe. lb calculate the do~age using the 3 mL
syringe, first observe that the numbers on the syringe
stan with T1 and are in increments of Y, . so they
include the numbers Y,, I, IY,, 2, 2.V,. and 3 l\etwccn
each number arc markings that sign ify one tenth of
1 m l.. 111 crcforc the syri nge has four shon markings
fo r tenths between tlw longer marki ngs that show
Y.-ml. increments. Medira1ion dose would not typi-
cally be written as Y,; it would be written as 0 5 ml
becallS<' the designation is in the metric system. Recall
that when no number appears bt'.fore the decimal
p0m t. a zero should be placed in front of the decimal
place to aid in reducin g caku l.nion errors. To calculate
a dose in a syringe. read 1he Oukl level from the
1ip of the plunger just even with 1he calibration mark.
172 ~ECT'ON II Methemaucs for Pharmacology and Oosage Calculations
ir_a medicatio1~ has to be rcco11sti1uwd, the calc:u4 .
!>amt mcdocauons such as penicillin are given in tion 1s perfonned m the same manner .u for other 111..,.1
un11\ per m11lil11~r When you see units per ml. always ~ h pervo Iumeorm1111gr.1msl)\'rmill'J''~
cationsinsueni;u
check to ><:e how many units of mcd1cauon are equi I Iler
after reconsutuuon.
valcm 10 I mI Jncn work the problem by calrul
aung unns per "olume or milliliters to provide the
nrt-dcJ dow

figure 1t-3 TY11C3llJ.IOOms1Jill1$ll'lllQ8

Check Your Understanding : READING SYRINGES BOX

- - - - -- -
10
Calculation Review
!lead ,,uh syringe ,1nd write the .1moun1 of medication that is indicated.

----
I'
2. _ _ __

J. _ _ __

I, t tl 111 tl111 il111 ti

4 . _ _ _ __

s. ____

You arc given the dose. Draw a line and shad .

syringe eon the exact numlx>r of milliliters that would ,Jim, I tll\'

6. 1.4 ml
:. :"~"c:.":.:.'.:.!l..'1 .:"C''..!.!"~"'.'. ''.!"~"'.'. "'.!' . '"~IL_
- "-1!1.:.' ."~ r - - - - -- II
 CHAPTER 10 Calculating Doses of Parenteral Medications 173

Check Your Understanding: READING SYRINGES BOX

10 - 1-cont'd
r 7. O'> ml
J 1111 J 111 ii 111 ti 111 1J 11 I o J 11 I 1J

8. 2.1 ml .--r("'
~~-----w...
...
I -
I
II 11I1111J11 I
;!!
I N
I l\j
I
d II II I 1111J1111 i
"'q
I
------------iUfl

9. I I ml
"'ti 111111111111111111111110 I

10. O.S ml
1111111 1 il1111ii11 oi111 il1111I

11 .0lml
I II ' J 11 I ii II I ii II I ii " II I 11 11 J

12. l.b ml
111d111 il111 d1111 l111 iJ111 ii

13. I ') ml

- J1111 J111 ii Ill oJ111 il1111l1111J

14. 2 ml

I I
II ' oi 1' 11 1II oi 11 11 I 1111 11 ' ' I

15. 2.'l ml

1111J11 Iii IIII1111iiIIII11111 J

 174 SECTION JI Mathemabcs for Pharmacology and Dosage Calculations

Tubclculin
lnsul n 1 100uruts10 01 !It= I 11111)

ln\ulrn is mJnufJnured in unots per rnJIJiliter; there- lrAI EXAMPLE 2: Ordered: rn~peri1I
100 rng IM CVCJ'\ ~
(Oemerol)
fore in\ulm should ,1Jw,t>"> be administered using an hours for
1n;ulin '>)'rmge 1h,tt 1s calibrated in uni IS. not milliliteis. pain managernen1
When find mg 1he answer 10 dosage calculations, a few
ponm shou Id be remembered rirsi, ,111 c.tlculations in Dose Available: 50 mg.II mL
milliliters requiring 1he u>e of a 3 mL syringe are carried
ou1 1wo decimal place' ,md then rounded 10 me nearest Calculating Dose U sing th e f io
tenth if nt><c.-,1ry. lor !'Xarnple, 1.25 mL would be and Proportion M ethod
rounded 10 1.3 ml 111cJ 1.24 ml. would be rounded 10
1.2 ml. l'or 1ulwrculin syringe>, when calculating rnilli- Compare 1he dose available r.t1 io 10 th t>\l' ordered
li tl'r., carry c.1 lcul,uions ou1 to duce decimal places and ratio.
round 10 1hc nea1c;1 hundredth, because the wberculin Dose /\\'3ilable (DA): 50 mg : I ml.
~yringc i m,1rkcd in hundredths (0.01) of a 111ill ili1cr. For Dose Ordered (DO): 100 mg
example, 0.836 rn l wou ld be rounded to 0.84. Table Use the formula: D1\ : DF :: DO : l>C:
10-1 show> I he rnmp,irison between syringes and dosage Set up 1he proportional equation: 50 (IM ) llW) :: 100
volu111(',. (DO): x (DC)
50x = 100, >O ;r = 2. Recall that the dnti; t an is in 1nil
lilitets, so draw 2 ml. inco a l-rnl \)fll
Administer Demerol 2 ml. IM cwn I to
CALCULATING PARENTERAL
MEDICATIONS USING
THE METRIC SYSTEM Calculating D ose U sing
the Formula M ethod
llnhke calculaung a dose of oral medication mat ran be Set up me formula:
111\C\l'fill solid and liquid fom1s, parenieral medic11ions
wilJ ,ll\\,1)~ be in a liquid form-in most cases. milliLiters DO
or units The basic strength uni! for parenteral medica- -xDF=DC
DA
uons is usuallr the m11ligram. ahhough unit!, grams. or 100 mg (DO)
mrllicqui>alcnis mai be used When using any of the 50mg(DA) xi ml (01)-1(1
wc1gh1 designauons. me cancellauon of the designation DC= Demerol 2 ml qi 1 h
during calculauon will allow the final dose to be in a
liquid form
The ''Olume of the drug 10 draw into t ml wnngt
One, you h,wc pracuccd reading the volume in is2 ml.
syringe., the ncxi ~cep is to calculate the dose using o ne
of the method~ le,1rned in Chapter 9. If the medication
requirN conversions be1\veen nie-.-.surement systems, use C~lcula~ing D ose Using th e
the conwr;ion information found in Chapter 8, which
indudes 1he aciu.11 step; for calculating medications
using r.uio .ind proportion, the formula method, and
D1mens1onal Analysis Method
-
The first step is 10 set up 1hc equaiion will , o n the Ifft
"nd ihe starting factor in the linear cqu.111011 lwing the
dimensiona l .1n.1lysis. Some steps in Examples 2 through
4 h.we been ;hortcned . dos.e ordered over I . n1 is should I><' follow<'d by the
available medicaiion.
 - - - -CHAPTER 10 Calculating Doses of Parenteral Medications 175

The problem looks like this: Cancel when appropriate.

IOOmg The dose to be given is Demerol 2 m I, IM q3-4h.
x=

Recall tlhlt the second factor must cancel the numera-

or of the sL1rting factor (100 mg), so the denominator l.ll LEARNING TIP
~f the second faClor must be in m_illigrams. Regardless of the method of cafculat100. the dose to be drawn into
'lhc problem now looks hke this: the sy11nge must be a liquid volume. so the answer must be
JOO mg l ml. expressed as a liquid as designated on the container. Addrtiooally,
t= x always be thinking ahead to what syringe s1ie you will need
I 50mg

r Understanding : CALCULATING DOSES IN THE
STEM BOX 10-2
- - - -- -- - - -- -- - -

Calcula t ew
C.1lnil.ul h owing pare111cral doses rhea show the correct amount of Auid in the syringe. Show your
\\'Of~ on ' ,Ht sheet of paper. Save your worksheei. (Label your answ~r on the syringe with the correct
11 u 111 b(' r o I I ilers.)

1. Ordrr1d , or1 isone sodium phosphate 125 mg IM. Av.1ilable: hydroconisonc sodium phosphate
50 mg.
Dt-,nt..
ShO\ t um on the <yringe.

I " II ' " I

" ' '" I . II I " 1111 11 ' I

2. Ordnr , naitle 25 mg IM. Av,1ilable: furosemide 10 mg/mL.

DcsiHd '
Show r 1 1oun1 on the syringe.

"'
l 111d111 ' 111ol11 11l' " ' '"ll'

3. Ord< 111e su lfau 0.5 mg IM. Available: atropine sulfate I mg/mL

~how ,1 11ount on the >yringe.

c l IL 1 !l11h11l11 '~uh1I '~llh 1 '~II ,Jqf---------i~

4. Ordmd aupam 2 mg IM every 3-4 hours. A\ailable: dia1epam 5 mg/mL
Oe.111d J ,. _ _ __
Sh'' tho Jmouni on the syringe

I 11 II I11 I " I
II II 1II " II I " 1111 l

Co11l11111r1I
 S. Ordertd digoxln 375 mcg1\1 sm Available: digoxin 0.125 mgfmL.
Demed dose: - - - - -
Show this amount on the syringe.

11 1i111 1l1111 i 1111I111 d 1111I

_, I) 25 mg. Available: meLhylprednisolonc reconstituted to

6. Ordered: metl1ylprtd11f,olo11 (Sol uM<-uro 1
62.5 mg/mL
Desired dose: - - - - -
~h ow thi> amount on the >ynnge.

11(1111lt' ln11ln11l1111 f

CALCULATING DOSES OF 1he tuberculin syringe has a capacil} f I ml, and

PARENTERAL DRUGS IN UNITS
Aqueous-based medic.1tions such ,\S an.1lgcsics (opioids),
v1tan1in 8 1 ~, epinephrine, certdin vaccines. insulin,
heparin, and anticoagulants. of less than 2 milliliter may
be given subcutaneously Medicatiom that are injected
111tr.1dermallyor are less than I milliliter. including those
111 units (except for irtsulin), are prepMed in a tuberculin
~yr111ge. Insulin, howewr, should alway> be prepared in
an insulin syringe that is marked m units. liep.uin is
designated in units. but the doses art' ind1c.11ed 1n mil
hliters, so the medkation is prepared in a tuberculin
syringe for doses less than I milliliter.
is calcula1ed in hundrcchhs of a milli litu (0.01}. The
l l-100 insulin syringe holds 100 unit;, (I '"!.)of medi
cation and is calibraced in unit>. The 1111uil>cr of unit;
of insulin indicates the amount of in,uli being given
The standard insulin syringe used tod,1 the ll lOO
t ml (loo units), buc insulin \yringn "' come in
a 0.5-ml (50-unit) si,oe and a O 3ml < -unit) sizt.
The U-50 insulin syringes arc marked m ones'
and are therefore mo re prt>Cisc when in,'1 t ' is ordatd
in an odd number of less than 50 um1 he syringtS
holding the smaller vo lume are for u by proplt
with visual impairment and are U\lllf, mly small
doses.

Calculation Review
Read the syringe and wrne che amount o( medication that is indicated.

I. - - -- -

-
8 UNITS
 CHAJ7TER 10 Calculating Doses of Parenteral Medications 177

Check Your Understanding: READING INSULIN ANO

NONINSULIN DOSES IN UNITS BOX 10-3 - cont'd
~- - -- - - - - - -- - -

2.----
lI --- - ... ---
3 _ _ __

4. _ _

5. _ _

=~--~11 1 1 1 1l1 1 l1 1 1l 1 1 1l1 1d111 I

~ ~ g ~ ~ 1il R g 5: 8 UNITS
n,__---"~
~
~

You arc g1 , "'"" Draw a line and shade in the exact amou nt (volume) 1ha1 would show in the ;yringe.

6. 80 u tlon

22St:WM81i!'tl8
. . . . . 1 , , . . . . . . . . . . 1o .......... .
':!'''".!!'"jQ'" ............ ~ -; J

7. 46 UnL 1111

laj1111111 11 1l1111l1111l1111l1111l1111I 111l1111l l_:--{1..___ _______ --1~

e :;::;i~:i\S!Rlillil ""iiiiJ
8. 36 u 11 1 1 uhn

= ---=-=1Jt1JW11111l1111l1111l1111hml11ul1111hml11111
2 iii g ~ :i! 5! R lil !i ~
11
-{]---------~~
!>. 5000 hrp.mn ( 10.000 units/ mt)

2 I~ ~ ~ , .~~-------!~
... ... ..

10. 2500 ur 1 ht pari n (5000 units/ ml)

 178 .EC 1 "I 11 M1themaocs for Ph1rm1cology 1nd Dosage Calculations

The drug form is in milliliters

.
so draw 0.8 ml into~

IME!l~IH.yn;Yw&m
J.mL syringe or lm L S)nnge.
Adminis1er penicillin G 0.8 ml IM.

lo calculate un111, .c1 up the problem as shown previ Calculating Units Using th e
ously using o ne of the three methods of calcul.11ion. Dimensional Analysis M eth od

Ill ~RNIN T P
xis on 1he lef1 of the linear equation (lch >idc of the
equal sign), and the drug ordered over I " 1lw stalling
factor (on 1he right side of the equal sign) <:.incel OUt
When calcwmng vv th numbers VVlth mutuple zeros at tne end. SIJCh
as 200.lm. c:aial as many zeros as poss ble 10 mace 1he caltuia as malt)' zeros as possible so your probkm \\:tup looLs
oons ea~~ like this: 20units
x=
~ EXAMPU 3: Ordered: penicillin C 200,000 unils
~ IM Cancel 1he srnr1ing factor by adding .1 'ccond faQor
(dose available) with ' uni1s' as the d rnornin,ttor The
Dose Availahle prnidllin C 250,000 units/ml problem now looks like 1his:
20 units l m I.
~ = x ---
Calculating Units Using the Ratio 25 unils
and Proportion Method 4
x=-
Dose Ava1l.1hle (OA) 2S0,000 uni1s{ml 5
Dose Ordered (DO) 200,000 unils This answer mus! be shown in lh nc S).,.tem.
Use the formula l)A : DF :: DO : DC Y. =0.8
Cancel ou1 JS many zeros from the DO and DA The drug form is in milli li1ers, so dr.1\\ II mtinroa
as possible. I he proponional equa1ion looks like l m L syringe or 3m L >Yringe.
1his: Adminis1cr penicillin G 0.8 ml IM .
25 units : I ml 20 units : x ml
20 = 25.t Remember 10 complete the addition.1 p\ for par-
4
enteral doses:
x:;-
5
What size syringe would you choo\e' ( nl tubemi-
The answer mu.st be changed to the metric system: lin or 3 ml. syringe)
Y. = 08 How much penicillin C would you , 1w into lhis
syringe? (0.8 mL)
x = 0.8ml What paren1eral route is used' (lnir.111111" 11 1.ir llMJ)
The drug form i> in milliliters. so draw 0.8 ml. into a
l mL synngr or 1-mL syringe. Calculating Heparin Doses ir nit s
Adminis1er penicillin G 0.8 mL IM. Heparin is a\ailable in unitsfmL Order' ll'l''rin art
wriuen in units bm the dose 10 be giH'I lw in mi~
Calculating Units Using liliters. If 1he d()S(' is less than 1 ml mcJICdtioD
the Formula Method should be prepared in a tuberculin syri1 ,, -1ccuracy
If the dose is larger th,1n 1 ml. the nml1 I l<ln will be
DO prepared in a lml. >yringe.
- xDF=DC
DA
EXAMPLE 4: Dose Ordered: heparin 2500 111111'
Cancel out JS n~any .teros from the DO and DA as pos
Dose Avai lable: heparin IOOOO units/ml
s1ble. The cqu.111on looks like this:
20
- Xl=X Calculating Heparin Units Using R o
25 and Proportion
x=-
4 DA: io 1.,.
5
DO: 2500 units
Change 1lw .1nswer to the melric system: ., o8
so x = 0.8 111 L " ~ . ' Use the formula . DA : OF :: DO : DC
Cancel 1-eros.
 ----- - -CHAPTER
- 10 CalculaMg Doses of Parenteral Medications 179

unot\ 1 ml :. 25 units x mL 25 I
100 X=-X -
100 x 25 1 100

, Y. unii-, which mu'' be changed 10 metrics: Y. = x = Y., which must be changed 10 the metric system:
o.25 ml . . Y. =0.25
Dow to be gi\en 1s hepann 0.25 ml. Dose 10 be given: heparin 0 .25 ml.
use the I-ml syringe for the most accurate Because this 1s a small dose volume. a 1-mL tuberculin
meJ\Urtrn~nt syringe \hould be used.

Calculating Heparin Units Using

Measuring Insulin in Units
the Formula M ethod ---- - - -
Set up 1he formul.l Insulin is mea;ured in unit>. and ;ome fonns of insulin
may be mixed for administration.
DO Insulin is a/u.ii~ prepared and administered using
-xDl-OG
DA only an insulin syringe. Do 1101 IJ.lt' a rultm:ulir1 S}'rmge for
iruu/in aup1 t1S directed by a pl1~~1tum 111 ar1 emerger1cy'
canct'l 1m:" from origin.11 cx.1111ple. Parenteral routes (Chapter 14) will describe the correct
Problem i' M:I up loke this: method of combining two types or insu lin, along with
the propc1 1>rocedu re 10 inject a parenteral medication .
2~
- x i =" This chapter iniroduces how to rakulate the wral
100 amount of medication. When calculating die total
amount of insulin 10 be drawn into the syringe, ind1
vidual dose units of each insulin type must be added
together to find the total dose unit '-olume 10 be
Chang~ to nu'"'- - 0.25 administered.
Dose w h( ~""" ht'parin 0.2~ m l. SC
Use ohc I ml '' gc fi!lil'I EXAMPLE 5: Ordered: I lumulin R 22 units and
ll2l2J Humulin 26 units
Calculatin!I in Units Using
Dimension ysis Available: 10-mL vials of I lumulin R U-100 and
x is on th the linc.u equation, and the drug Humulin r:.. ll-100
ordered OH< I 1 " >1.uting foctor (on the right of the I low much insulin would you draw into a ll -100
equJI "ll" ) syringe?
Cancel 1.l n1,,. !wm origin.ti example: the problem To do 1hc math, add the number of units for each ty1>c
would look hk< ; o r insulin.
22 uniL~ + 26 units = 48 total unit~
25
.t = The insulin syringe would have a total of 48 units
of insulin. llccause 48 units is close to full capacity
\lulupl) a l t.uwr (<lose available) to cancel the of the 50-un ot syringe, a 100-unit syringe would be
starting f.tt111r t rut:rator preferred .
.
r U nderstanding: CALCULATING INSULIN AND
IN DOSES IN UNITS BOX 10- 4
-- - - - - - - --

Calculau view
Compu1< t i !lowing doses m units. Then draw m the correa amount of fluid on the S)'t'inge. Show your
work on .1 ' ,,,u.1te sheet of paper. Save your work$heet

1. Orlit'r~d 1lumulin R JS units SC

Av.1il,1h1. llumuli n R LI 100 10 ml. vial
Dt'\11 <d Jost"

- =-===tO:il 1111l1111hml1111l1111l1111 hml11ul:111l1111I I

"' ~ !! Ii: lQ i;I !!! ~~~ UNITS
nl---------1~
u
2. Ordered: NPI I uuulin 66 units SC ac 8:00 AM
1wa1lable: t'Pll insulin U-100 10 ml vial
Dbared d o s e : - - - -

---c=.....:::::ml1111!1111!1111!1111h111!1111l1111!11111!111!11ul
2 l<i !ii ~ !1 ii 11 i i ~~
.nl-------------j~
l Ordered liumuhn.N l.4 units and Humuhn R 50 uni1s SC ac 7;30 AM
1
.
\vailable: Humuhn N insulin U-100 and llumu1an R U 100 .an 10 ml vta s
Desired 101al dose: - -- -

---c:==atl1111l11111tml1111l1111!1111l1111!1111l1111!1111! I
!!t<i!i!~:ilfill!ii~UNITS ~
nl-----------j~
4. Ordered: Novolan N 25 u and NO\"ohn R 20 units SC every Ml
Available: l'.O\"Ohn 1' ll-100 and Novolin R ll 100 JO ml viab
Desired dose: - - - - -

---c:==!ftl 1111l1111l1111l1111l1111l11111!111h111l111d1111! I
.,,, 2 ~ ~ ~ ~ ~ ~ '!/ ~ UNITS
~1--------1~
~
~- Ordered. Humuhn 70/30 15 units e--ery AM and e--ery PM
Available: Humulin 70/30 insulin U-100 10 ml vials
Desired dose: - - - --

---c:=:::::lll:tl11ul1111l1111l1111l1111l1111l1111l1111l11uh111I
"'2~1ill<l:oll'l~'#5l;u
!---fl_______nu
6. Ordered: u.unus immune globulin 150 units IM
A\ailable: letanus immune globulin 250 un1tsfml
Desired dose: - - - - -

=~--<t::=~!: ''~!I Wl~rl ~J 1~J ,}q---------1~

J !!! J':i' 1
0H J

Using 1he information provided, determine 1he answers 10 questions 7 10 JO.

PENICILLIN C POTASSIUM, 1,000.000 UNnS

DESIRED CONCEN"llV:l ION ML OF DILUEN"rTO BE ADDED

50,000 units/ml 20 ml
100,000 units/ml 10 ml
250.000 unilS/ml 4 mL
500,000 units/ml 1.8 mL
 CHAPTER 10 Calculanng Doses of Parenteral Medications 181
------

Ch eck Your Understanding: CALCULATING INSULIN AND

NONINSULIN_DOSES IN UNITS ~~X 10-4-cont' d

1 . Cllculaie the number of milli liters 10 be given per dose for a patient who was prescribed penicillin C
pot.IDwn 400,000 units daily IM in four divided doses when the volume of diluent added was 10 mL
Dl">irt'd dose: - - - - -
Show this amount on the syringe.
~ ~ N <">8

~
s. lhr physkian prescribed penicillin G potassium 400,000 units 10 be administered IM bid. Diluen t added:
~ ml to obtain the desired dosage strength . Identify the dosage strength per milliliter and calculate the
"ilum< pa dose to be administered.
001><lg< mmgth
Volume ptr dose:-----

9, Itow much diluent shou ld be added to the 1>enicillin C potassium to make a concentration of
soo.ooo "'"/m l dosage Slrength? - -- - -
JO. I :1 h w ><> many do<>.1ge strengths are possible with just one vial of medication.

which they are most comfortable, that produces the

This chaph. dud"' th~ calculation of medications
~ion of th tbook At this poiat, the successful
student shoul I r comfonable with calculating doses
for parentrr.11 ar t nonp.lrcnteral medication delivery.
Thi~ clldptcr cmph.1sizcs the importance of always
knowing th" dt.tgc available o n hand before attempting
to com11utc th d~"'cd dose (dosage ordered). 111is
chapter al"' mu rn inrroduC'lion to the selection of
the corrt'<'t u ge size when preparing medication.
Throughout th cC'lion. all math calculation examples
are shown u g nuo and proponion, the formula
method, ,rnd 1ensional .1nalysis. If a review of the
exact sicp.\ nu "'try in these calculations is needed,
the student "'"'':, go back ro Chapters 8 and 9 for the
informJlion S J ms shou ld find the method with
correct results, and then use that method with con~b
tency. Do~ calculation errors are less likely to occur if
the student consistently computes dose calculations
using only one method.
Three basic syringes are used Lo admin ister most
parenteral medications in ambul.ttory care facilitiE">.
Choosing the correct syringe for the nmoum of medica
Lion to be ,1dm inistered is extremely impo nanr. Insu lin
and heparin are both calibrared in units and must be
administered in exact doses. Insulin Wlits should be
administered wuh an insulin syringe that is standard at
ll IOO/ ml . whereas heparin units should be adminis
tered with a tuberculin syringe. Met other medications
a re administered in calibrated syri nges using mil liliters.
111e syri nge size that is most frequently used is a 3 m l.
(3 cc) syri nge.

ti ~
U l'. U nderstanding : REVIEW BOX 10-5
- - -- - - -

Calculat. R view
Calcul.11" ti r lollowing problems. Show your work o n a separate sheet of paper. Save your worksheer.

Ordrrd rnn1uga1ed estrogens 2.5 mg SC

A'-ail,1bl...- ">n1ugated estrogens 5 mg/ml
I. Ol"'ll 'I dose
2. What sue syringe would you use? - - - - -
Order<-d Dt'mcrol 75 mg IM
\v,11lable ll;:mcrol SO mg/mL
J, 0..>sored dose - - - - -
4. Wh,u we syringe '">uld you use!-----

OrJrrcJ procaine penocollon G I 200,000 units 1.\1

Avaol.tblc proc~one pemcilhn G 600,000 unitsfmL
S O..>sor<'<l d~ - - - - -
6. Wh.tt %te synnge would you use!----

Ordered ampoollon I g IM
Av.11l.1blc ampicillon recons111u1ed 2 g/1.8 ml
7. [),..,,,,'() d~; - - - - -
8. What s11e syrmge would ~'Ou use? - - - - -

Ordered furoscmode 2 mg IM
Available; furoscmide 10 mg/mL
9. Desired Jose
10. Whal site ~yringe would you use?--- - - -

EXERCISES

Name each of the syringes shown, and then identify the characteristics of each. Then circle> ,
appropnate m1ecr1on route(s) for each.
1 Type of synnge - - - - - - - - - -
Volume capactty: - - - -- - - - - -
Calobratton: - - - - - - - - - -- -
Typically used for lntradermal Subcutaneous Intramuscular

2 Type of synnge: - - - - -- - - -
Volume capacity - - -- -- -- -
Cal1bratoon - - - - - - -- - - -
TYPteaily used for. lntradermal Subcutaneous Intramuscular

111f1111fm1f1111f1111f1111f

3. Type of syringe - - - - -- - - -
Volume capacity - - - -- - - - - -
Calibration -:--:---,------- - - -
Typically used for : lntradermal Subcutaneous Intramuscular

--===~~~i~~~1tt11~fli~1 'k~l~1;~1,1~~~'...,.;;dij~===========~
 CHAPTER 10 Calculaong Ooses of Parenteral Medications 183
~-------

REVIEW QUESTIONS
All of the follo,.ing statements are fa1IS<!. Determine the error(s) and rewrite the answer gi\ing completely
correct information in the space provided.
1. To calculate a syringe dose, read the fluid leve l fro m the Lip of the plunger just above the ca li bratio n mark. _

2. A tubernd1n syri nge is calibrated in units only. - -- -- - -- - -- - -- - -- -- -- - - -

-
3. usuall) onh '>Olutinns of 2 to 3 ml are given subcutaneously. - -- - - - -- - - - - - - - - - -

~. The m<t c mmon 111\ulin syringe 1s called the llSO. - - - - - - -- - - - -- - - - -- -- - -

5. Ileparin t rr.nlly 11ivcn using an insulin syringe.

6. The ty11ir 1 11mm< ular syringe holds IOO units o f medication .

7. The sm 11 ,1 nconstituted medication can be changed by .idding more powder. - -- -- - -- --

8. Typic.1! em1lin syringe is u<W to administer an antibiotic. - - -- - -- -- - - - - - - - -

9 . .\\any m1 ""'given SC are irritating to the tissues. - - - - - - - - - - -- -- -- - - - --

IO. Insuli n r ''e .id mi nistered in a 3 cc syringe if it is calibrated In units. - - -- - -- - -- - - - - -

11. When u " .1 2. or 3 ml. syringe, <1lways round calcul,1tions to the nearest whole number. - - -- -- - -

Calculate th fo' ow ing problems. Show your work on a separate sheet of paper. Sa\'e you r worksheeL Deter-
mine the cu r < amount o f medication to draw into the syringe (Desired Dose), then detem1ine which
syringe to" " from the following choices: 3 ml. syringe, I ml syringe, 100 unit insulin syringe, or SO unit
insulin syri ng..:

12. [!: Ordered furosemide 10 mg IM

\ailahle: l.1six 40 mg/S ml.
IJesired dose: - -- - -
Syringe chosen: - - - - -- -
184 SECTION JI Mathemaucs lor Pharmacology and Dosage Calculations

13. 1, IA\J1l.1ble
Ordered procaine penicilhn C 500.00-0 uniis IM
procinc ixnicillin C 250.00-0 uniis/ml
llt\ucd dose - - - - -
'>)Tinge chosen - - - - - -

14 r:ml
~
IAI Ordered lknadryl 25 mg l.\1
Available Bcndryl 50 mg/ml
Desired dose:----
'>)Tin~ chosen - - - -

15 r; Ordmd Phencrgan 75 mg IM
I!:!' "' a1lable: rhrongan 50 mg/ml
Ot><iired dose: - - - -
~ynnge chos<>n - - - - -

16 Ordered heparin 400-0 units SC

Available- heparin 10,00-0 unilS/ml
Desired dose:----
Syring<' cho,en _ _ __

17. mN! Ordered 1lumulin R 35 units

l2Ql Avail.1ble: I lumulin R U 100
l.>cslrcd do;,e: _ _ __
Syringe chosen:----

18. IfAl Ordered: Rocephin

Avail~ble:
500 mg IM
llocephin 1000 mg/4 ml,
Desired dose: _ _ __
Syringe chosen: _ _ __
SECTION
 Safety and Quality Assurance

Airer srudymg chis chapter. you should be capable of doing the following:
fapla1n1ng the 1mpor1ance or safety when using
over-the-counter !OTC) med1cat1ons.
Descnb1ng legal. ethical. and other measures to
protect health care personnel during medication
adm1n1strat1on.
Describing quahty assurance 1n medication
administrauon
Explaining the rela11onsh1p of the medical
office and Occupational Safety and Health
Administration !OSHA! regulations r ed
to pharmacology.
Discussing three "befores" and sev rights" of
administering medications.
Explaining procedures necessary to f 'Vent
medication errors and documentat1011 1 quired in
the event an error occurs.
Describing routes by which med1cat1t 11 ~re
delivered to the body

Betty, an silted healrh professional ma physician's office, is asked by a co-worker ro admm1st a

physician-ordered dose of Decadron to Joseph, m Room 5. who has arthmis. Betty prcks up mle
that appears ro be Decadron from the shelf. She draws the dose and adm1msrers rt to the par t tn
Room 2 without asking the pa/lent his name because she chinks she knows the par1ent Ac ( Betty
has drawn an estrogen preparation and given it to Mac. The orher allied health profess1011BI w ngm
the area lacer realtzes that Betty has given the wrong medtC8tion to the wrong patient
What rules of medication adm1n1strauon has Betty failed to follow?
What 1nformat1on does Betty need to document?
Does she need to notify the physician? 'Why or why not?

Medication Medication error

administration Quality assurance (QA)
member. safety with medications. whether the

lli edication 1s an over-the-counter (OTC) or a pre-

ription a.gem. is an important factor in thera-
peutic patient c.uc. Allied health professionals ha,e the
rt>sponsibility to ob1,1in a lis1 of all medications-
prescrip1ion, h~rbal, and OTC-that a patient is taking
so that safety 111 drug u'Jge occurs. A complete list of
mcdica1ions includes both drugs 1akcn regularly and
those 1akcn as needed (or prn).
When teaching patients about CYI< d r 1 the alhed
health professional should be sure th1 I nnt rcdlizel
th~e preparations areactuallydrugs ,rnd 111 " 'to be taken
with thesame precaution as prescrip11011 mn hdncs. 'lliis
m_eans taking OTC drugs as they .ire m<.1111 to be taken.
with 1he patient reading all insmiction' ,111 d following the
manufacturer-recommended dosages for .1g1 .1ml weigllt.
The safe dose in a 24-hour period as nott'll 011 1he labfl
on the container should no1be exceeded .\II ingredients

186

11 arc mcdic.11ion should be evaluated by the palien ~
in aperson 1Iw mcc11cauon,
administering . beiore
' I
11e.~e
orcparalion~ arc used, to be sure that harmful ingred ients
~t have cau~ drug intolerances, allergies. and ad,erse
acuons are not found in the drug. An imponant faet is
~JI Oi'C medic.111011> may have changes in inen ingredi
,,,15 between purcha,es, so the label should be read e.1ch
;;me before buying 10 ensure allcrgir reactions and intol-
cr.mces will not occur because of changes.
SAFETY WITH MEDICATIONS
TAKEN BY PATIENTS
~lf-medic,11ion may delay needed medical care because
c>re dru!l' <~II nusk imponant symptoms. Wl1en
ore medic.111on .ire taken. printouts supplying drug
interactions ,ire 111 l pro,ided, and the patient is therefore
not aware ol 1 -1ble dangers. llox II-I lists safety tips
NSURE SAFETY IN MEDICATION ADMINISTRATION
2 e med1ca1100 to be taken. Some med1ca-
1aken w1lll meals, whereas others need to
rnply stomach. Some drugs need to be taken
' each day; olllers may need to bo taken
day with no rela11-011sllip to a specific time.
3 ldetly or has difficulty remembenng the
t '11.lking a chart 01 caleroar to remember
1.;ations A la1ge calendar may bo used to
1t1ons lllroughou1 the day. Me<lications that
or more than one dose per day may be dis
s with reminder mecharusms such as
lor daily medications or d11ferent<Olored
fferent times ol day
4 11 ent knows how long the medication 1s to be
taken. So1r l'tgs are prescribed for short-term therapy and
others term. even hlet1me, use If shortttme med1
t1i>IO!JCS are prescnbed. the patient should
complete the entue course or treatment For
'lfld,!1100- the patient should be instructed to con
tmue kl cation as directed until pl1ys1cian stops the
med1cat.ur1 1 lhJI 1s the physician's protocol.
5 Be S\Jle t 1 nt knows that some medications such as
antihyp... nay make him or Iler feel worse wf11le the
body is 1ng closer toward homeosras1s Also. the
patien be taught symptoms of dangerous side
effects. 1t afions shoold be d1scoo11nued only on advice
of the pliy. 11:1an
6 The palier t hould be instructed that some medications
(e g. prr '"'tranquilizers) cannot be stopped abruptly
but roost be tapered off as ins1ruc1ecl by the physlcian
7 The pa~ 1should be taught the side effects of the medica
non (e g , orowsmess from ant1h1stammes) and safety
CHAPTER 11 Safety and Quality Assurance 187
for patiem administration of medications. I unhermore,
with self.medication, chemical ingredients of all OTC
submnces induding drugs and herbals must be evalu-
ated for their potential detrimental elfms related to the
patient's ph)'Sical condition and the po1en1ial for life
threatening efTCCIS. The following are 1mponant faetors
regarding use of OTC preparations for sci f-Lreatmem:
lor safety. document ei<cessive use of drugs such as
alcohol or caffeine (found in coffee, soft drinks,
energy drinks, and Lea) and nicotine (tobacco
produru).
ore and herbal dru~ may be obtained without a
prescription, and u~e should be completely docu
memed in the medical record.
Spend extra time with the 1>a1icn1 who takes OTC
mcdkations to be ~ure the patient is aware of pos
sible dangers of self-treatment in conjunetion with
the use of prescription drugs. Remind the patient
that O'IC preparations should be used only as
measures 10 follow wh le 1abng the medicine (e.g . avoid
drMng or operating mach1neiy with nart0tic analgesics)
8 Inform the patient thal all adverse react1oos should be
reported so they can be noted in the medical record and
ad1ustments to medications can be made as needed.
9 The patient should be told that misuse of any medicat100
might lead to dangerous side effects. such as bleeding
ulcers with asp11111 or drug dependerice with pain relievers
10 Proper storage or med1ca11ons should be discussed with the
pharmac1st. Warmth and dampness of bathrooms and sunny
windowsills make these places inappropriate storage snes.
11 Old medicines should be discarded by removing drugs from
their ong1nal cootaioo and mixing with an undesirable sub-
stance (i e. aiffee grounds or kitty liner). and place in an
rmpermeable. non-destroctMl cootamer 10 prevent ingest1on
by children or pets. Then place in trash or 1nc1ne1ate. See
federal acceptable government guidelines for disposal of
medications at www WhiteHouseDrugPollcy.gov.
12 Expired meclicat1oos lose efficacy, and their effects are
unpredictable, even toxic
13 Medications are prescribed for a certain person with a spe-
cific cond1t1011 and should not be shared with others. A
person who takes drugs prescnbed for someone else might
experience severe adverse reactions.
14 The patient should always chock with the pha1macist or
Ji!ysician befufe m1x1ng mecl1calJOrlS with alcollol. tobacx:o.
or other medicatioos. 1nclud1ng OTC drugs and herbals.
15 Medications should be taken m well-lighted areas so the
label can be safely read. Never assume a bonle of medicuie
is the correct bonle; always read the label For a person with
poor eyes1gh1. print on the bottle label should be large, or
the patten! should have someone else prepare the medica-
11ons Ask the pharmacist to aSSlst 111 providing aids for safe
adm1mstrat1on l'llth lowvis100 1ndNiduals
 188 SECTION 111 Med1cauon Adm1ms1r1uon
duected on the labels after always reading 1he label
carefully.
lnfonn the p;itiem that dosagnof manyOfCdnJ8.1
ne low. so the dose may not suppl) the pa1ien1
with adequa1e med1ca11on 10 hJ\'\' a suflidem
therapeutic effect-for example. Ale-e (200 mg)
one or 1wo 1.Jblets twice daily for arthritis com-
pared with the prescrip1ion meng1h of napf'OXfl
or 375 10 500 mg l\ke 10 three rimes day. nie
amount of OTC medic.nion used may even mask
1he 1rue severity of symptoms
ore medic:ufons often contain more 1han one
active ingredient, allowing drug inreraclions 10
occur Remember 1ha1 only one of the active ingre
d1en1S may be needed 10 cause an inreraction, such
ai. guaifmesln (for coughs) and anuhypenensh'\'
medications.
Any ad,-erse or allergic readlons the pauen1 has
experienced with any med1cauon should be docu-
mented in the medical record
11nally. p;itientS may nor be aware that ingei.1ion of
the same medication under differenr names such
as Advil. Motrin, and lbuprafer may cause an over-
dose. Some persons may also take multiple doses
of the same prescription medication if the appear-
ance of the generic drug has chan11ed (e.g., because
Lhe manufaourer is difTcren1).
If,! 4.1 !q+S i lfrii li!il frlfii;tSilfr
M.111y laypeople think that adminis1ering med ications is
the main thrust of phannacology. In reality, phannacol
ogy is the knowledge necessary 10 g"-e medicines safely.
Med~c~~on administnUon means ginng a dose of
med1ca11on to a penon. (If the medica1ion has been
d1spe.11Sed. the patient self-adminis1ers the drug in most
cond1uons.) All three persons in the professional medical
tdangle (physician, pharmacis1. allied health profes-
sional) arc necessary for safe drug therapy.
. rro~er .cchniqu.es in giving mcdica1ions using seven
rights (nght pauen~ medical ion, dose. route. rime
ll'<'hnique. and documen1a1ion) and 1hrt-c "l>efores;
(before removing from s1orage. before 1>rcparing mediai-
uon, a~d before retu"'.'ing 10 storage) and proper safety
precauuons as ~etermined by regul.11ory agencies cannot
be O\'\'remphasized to ensure high-<Jualiry patient care_
!n Ju~y 1992 the Occupa1ional Safoty and I leahh Ad min.
1str,11101~ (OSI IA} sL~ncd 10 enforce workplace controls
concernmg bloodborne p.ithogens. llody Ouids may
contain pathogenic microorg;misms capable of ClUSi
disease. Each medical facility must have its o"'n ~
control plan dioa1ing how the facility will comply ,..Ith
OSHA siandards
Standards that are specific to giving mediati0ns
indude the fol101~ing;
Barrier equipmen t should be worn if a chanc or
splashing o~ ~pray'.ng ?f body Ouids during m~i
cation adm1n1srra11on 1s possible.
flil When performing injections, '1eahh care per.
1=-.1 sonnel shouId wear , .gloves to protect aoin
,,.. !I
possible cross con1a1111nauon.
n;:ii Used needles and other single-use equip.
~ mcn1 such as vaginal applicators or inhala.
Lion devices 1hat have con1ac1 with po1entially
infectious body secretions must be property dis-
posed of in puncture-resistant com.1iners.
All disposable syringes and needlt" <hould ~
reiracrable safety caps and should t placed in a
punaure-resistant con1,1iner locate , lose 10 lht
area of use (rigures 11 1 and 11-2)
If the needle must be rec.1pped aflCI a'<'. place ont
hand behind your back and 'scoop he cover 01...,
the needle (Figure II 3) . Sterile n. dies are noi
comam inated by body Ouids .1nd m. be recap~
after 1hey have been used to wi1hdr.1 medica1ions
from vials.
A needle should never be directed It ..ud any pan
of the allied hea lth professional's I 1,.
Figure 111 Disposable syringes and sharps shoulrl b . J sposed of in a
PlJnctu<eproof oomainer (from Young AP. Procror OB Kmn's the medical
assl$1am, ed 11. SI Louis. 201 1, [lsovior 1

tiona Sa 1ety and Health Adm"1ostraUOO sug-
y, h retractble needle eo>on lffllnl YOlllg AP.
i1cal assisrJm, ed 11. St Loo1s. 201 l, Elsevier)
oeectes uw one haOO and a scoopng tednque.
r '" OB Krnn's rhe medical ass1srant ed 10. St Louis.
Contamu1.11~d waste must be dis1>osed of in accor
dance with federal. state, and local regulations.
Any ex1 "'"" mu~t be evaluated, and a postexpo-
sure !ullc w up plan for the facil uy compleu~d.
includini; Jn incident repon .rnd confidential
medic.ii 1v,1luation.
CHAPTER 11 Safety and Ouafrty Assurance 189
In subsequent chapters the icons shown are used for
procedures. to illustrate their need for different route5 of
medication administration
Important Facts '.atiout Me
Administration-and Occup
Safety and Health Adminis
(OSHA) Standards
When medications are adm n stered. the latest ap1opna1e
OSHA standards relatrng to splashes and possible cootlCt with
body nu1ds should be followed
QUALITY ASSURANCE IN
MEDICATION DELIVERY
Quality assur~nce (QA) - establishing standards of
excellence in patient care and tailoring professional pr.ic
tice to those standards-is the core of applied medicine.
Quality assurance is prescrihed by a set of policies and
procedures found in each o ffice and by various federal
regulations that affect medical practice When followed,
these rules provide a safety net for patients a nd prani-
tioners alike. If they are no1 followed, a multitude of
pro blems can result: medication errors. personnel expo-
sure 10 dangerous pathogens, and cosily litigation. QA
ensures that pranices result in the highest possible level
ofpa1ien1 care and that servires are consistent with high
prindples of proressional conduct. The allied health pro-
fessio nal should monitor all aspeas of patient care for
qual11y assurance.
To provide quality assurance, the fol lowing steps are
necessary:
When medi<"ation shipments arrive, the health pro-
fessional should dteck that medicatio ns have been
maintained at appropri.ue tempera1ure during
1r.1nspon.
A study on medications concluded that only 0% of drugs
sltiwed wem llflMng wtthtO the temperature and humidity
l1m1ts developed by manufacturers More than 26% were
subjected to excessive heat, and 65% ol these drugs were
subjected to temperatures of 86 F to 104 F. making drug
effectrveness less than optll!llm and on some cases
dangerous.
When ordering medications. the facility should
void having items in 1ransi1 during weekends or
holidays when timely delivery CMlllOt be made.
190 SECTION 111 Med1cabon Adm1mstrat1on
Med1ca11ons that require ~')X'cial considerations
should be stored in accordanct with relevant
controls
As m<'<l1ca11ons are stocked. strength, size of con
tarntr and drug uself should be checked agatnst
111\cntory and packmg shp and stolt'd in the appro
pnate location
\led1ca11on> should be placed m exact storage I~
uons with the label f<King toward the fron~ "'.' th
s.1me me.hcauons of the same stn'llgth being
stocked as prcv1ousl) found . .
Drug\ should be separated b) route of adm1~tra
uon. especially ophthalmic and ouc preparauons.
Drug> wuh spcc16c u~ (e g.. estrogen prepara
uons) should be stocl..ed together
ChN:k exporauon dates Possible loss of stock
bcc-ause of exp1m1on or use of more than one
conrainer at a urne may occur if stocking is done
1n .1n inronsistent n1anner
Al. new med1ca11ons arrive at the office. expiration
date- the indic,11or of shelf life-should be care
fully ob~crw<l I hose with an expiration dilte that
is soon may need to be returned to the purchase
source immediately.
Supplies should be pl.iced where they "re most
accessible yet protccied from damage and exposure
to such r lcmen1s as hea~ light, moisture, and air.
Check storage requirements with each order. as the
m.111ufatturer m.ty make changes. Most drugs
shouId be stored in a cool, dark are;i away from
direct ligh110 avoid deterioration.
Medications foreJ<ternal use should be stored sepa
rately from those for internal use.
Poisons and chemicals. including disinfect<lnts and
01hcr rleanmg agents. that may cause harm to a
pa1icnt if u~ in error should not be stored with
drug; and rhemic;tls used as drugs. either internally
or topically.
l.ahcls should be carefully preservtd, and all
medirnuons must be stored in their original
con1.11ners
A container w1thou1 a label or with a label so
damaged that n 1s difficult to know what is in the
container should be des1royed. NC\'ef relabel a
medicauon
Ouahry assurance 1n med1cat1on adm nistrabon eciStJres thal
the pahent receives h1gti quallry drugs gl'len safely using me
correct manner
Oual11y assurance ensures that a med1catioo has been prop-
erly rransponed and stored, has not expired. and 1s safe for
admin1strat100
.\ledications may be given only under diteo Ord"
and supervision of a health care provider 11""'""
the allied health prof=ional has .1 responsibility to
assess a situation and to add~~ problems related to
administering dru~ The phys1c1an performs a Ph)lq
assessment of the patien~ but the allied health prof"'
sional should agilin assess the pat1tn1 .ind tnvilfll>.
ment before gi1ing a drug. If ch.rngc' h.wc occurrtd
that would make administration of the drug u~11
able or improper, the allied health prot, "onal shoulc!
notify the health care provider for ad\'iet hcfore govuig
the medication.
Some faaors 1hat might cau~ vari.ir1c1 in drug \l3f
include the following:
Size and age of the patient
Changes in vital signs
Changes in organ system funcuon
Possible contraindications to d lrug (e.s..
previous illness, concurrent U\1 medication!
such as he~)arin or OTC mcdi1 " 111) or dnig
imeraaions
r'OOd or animal allergies that m prohibit the
use of a medication (e.g., allergic h ggs.111imal
dander)
Possible drug dependency
The patient's medical status migh1 1 ~c use of the
usual route of administration 111 "r.1ble (e.g .
oral administration for a llCr\on '' h,1, diffiruhy
swallowing. injuries at the site ol ropriate par
enteral or topical administration )
The proper dose or dosage of 1h1 1 1c.11 ion If io
doubt the allied health profo"-""" uu ld askdl(
health care provider to confirm t 11der Newt
hesitate to question tl1e 1l(mih1ht) t mis1al.ei1
interpreting a medication order
11le presence of an appropri.11c Jlt m the t\"111
that an allergic rearuon occurs I>< giw mrdl-
cations without a ph)'Sici.rn prt ll'\ en of tilt
drug has bttn ordered or given on oluple occa
sions) in case a si1uation rcqu1n n ' t , r~cncy ~~"
should occur.
The patient should no1 be at ri'~ 1111ury from a
fall or from in,1ppropria1e beh.wi<> 11 surround-
ings are espially imponant .1lh r '" media-
lions have bttn adminis1ercd
Medications should alw,1~ he"'"' 111 the $.!fit
place during cleaning or durrn11 11.ucment of
drugs. Potential for errors nuy O<lll , 11<'11 media
tions are moved from the u,u,11 pl .1<'
When a drug is admin istered, Cl'1t.1111 ruks 111us1 lit
foll01"ed to ensure safety. Box 11 J lists th~
imponant rules.
 ~~~~~~~~~~~~~--"
BOX 11-2 RULES TO FOLLOW WHEN ADMINISTERING MEDICATIONS
Give only medications that have been ordered by the health
care provider. either in writing or verbally. If there is no order.
do not give medication
Know lhe drug you are g1v ng If you are not familiar with a
crttalll medication. consult a drug reference before adm1ms
trat1on Cak:u a1e the needed dose in a Qtnet area whefe
you will not be interrupted If you are unsure of the dose.
ask someone else to check the medication order and any
calculations
Always wash your hands before administering medications.
Do not handle drugs directly
All prepared medications should be given immediately or
safety stored I admin1steted Do not give a/f'f med catlOflS
!Nt yoi1 d d net jle!SOllJlly prepare unless prepared m a
pharmacy for hJI patient. then check for proper patient
1den116cat1cn
lde11t1ly the patient and ask about possible allergies even
.r you it .l ~now the person and his or her medical
h1st01Y
Nev.N reW' cations that have been prepared to their
original con Al'rv med1ca11on not !l1Vllfl should be prop-
erly d1spo ..;er documentation of disposal of Drug
Enforcerner J n strat1on (DEA) scheduled med1cat1ons 1s
roqu1red
Labels or~m on all drugs and chemicals
The heat professional should be sure that he or
she undersi. the drug order If there is doubt concerning
the orde I ~d health professional should ask for
clanheat
EDICATION ERRORS
AdministrJll I drugs ~hould never become routine;
- correct drug is being used.
ii should b. ><g.mi,ed. concise procedure to ensure
safety for ti 1ent .tnd provision of high-quality ~are
b)' the allied. th profc'ional. Medication adminisua-
uon requi r...- t~ps to rnsure a hi!Viquality process.
Throughour 1 lf.<t. these steps are not repeated when
each rou1c ot 1<lm1nis1ration is discussed. Therefore
!hcse ru le'" '" be 1ndicawd by the icon B
When Lhb
icon appe.irs. iht,e nil es should be followed .
-
Three Be res
Before .1dm111"terini; ,111> drug. the professional-
whethcr 1hc allied hc.1hh pro fessional or health care
provider-should use 1he three befores for checking
CHAPTER 11 Safety and Quality Assurance 191
Never document adm1mstra11on of any medication before
giving it All documentation should be done immediately after
administration.
Observe the pallent for adverse reactions after adm1mstrat1on
of drugs
Give spectlic lllfonnatioo concerning the signs of advetse
reactions that need to be reported to the health care
provider
Pattents taking medicatmns such as penicillin or 1mmuno-
therapeut1c drugs that might cause allergic reactions should
be carefully monitored for a specified time in standard p<oto
col to be sure an alletg1c reaction does not occur
Alletgic reactions. no mauet how small. should be docu
mented so that careful ev.iluatlOll can occur before adm1n1s
1ra11on of future doses of the m001cat1on
If you make an error when adm1nisterrng medications. 1mme
diately rePort 1he error to the health C<Jre provider and docu
ment the error and any treatment required in the medical
record
MediGal drug references. HlClud1ng those for pediamc and
geriatnc doses. should be used fOf calculatmg doses, with the
calculation double-cllecked and compared with the available
drug Doses may be rounded to an easily administered amount
with permission from the health care provider.
labels. If medications are consistently stored according
10 medicinal use and prefcrcnc~. the befores will be more
easily processed.
The three befores in preparing a drug for medicatio n
adminis1r.1tion follow:
I. !lead labd on medic;ition before removing drug
from shelf. Be sure correct medication and
do~age strength arc obtained from storage for
administration.
2. Read label on medication btfo" preparing med ica
tio n for administration . Double-check 10 be sure
3. ltcad label on medication before returning drug to
stor.1ge aft er drug prepar.ition for admi nis1ra1io11.
Jlcr11eu1ber, never gi1'C nu'tUc111ion$ that you htnll' nor
pmo11111/y prepared.
Seven Ri ghts
Seven rights of medication adminis1mlion should be
adhered to without deviation. llefore administeri ng
medicatio n, ask yourself whether you have followed the
seven n!Vits (Figure 11-4) .
L R1glu p<11ie111-Even if )'OU believe you know the
pauent, address the patient by name 10 identify
any discrepancy in identification. Verify the name
on the medical record. If the person is not known,
192 SEC N 111 Medication Adm1n1su1t1on

3 lwa)1S check the expiration date Ntwr !<St

ask the p.tllent to pfO\ide htS or her name by expirttl tlrug when prepan.n~.
a dO'>e: A Iw:i}'S ~
pa1-
askmg. What as your name! ed' the label to protea JI; this is especially 1mporta
2 Right clru~- Using three befores. be surt the m . ~ -~
with liquid rnn11cauons . Ol
. cation is 'the one ordered. Compare the order ';';t J
the medicine on shelf. ~\lhen checking the la e 3. Risl1t dose-Compare the . ~edir?tio1~ . ~rder With
the dose prepared for admm1strat1011 . I hi s rcquire'3
reading the label carefu lly and cn,u1ing the d0st
Rlghl dnJg and order are in the same measurement system. Bt
sure the dose is within the acccpt,1ble dose rangr
for the palieni, and double-check any nee~
calculations. Use the proper adm inistration dtvict
that will give the most accurate rnra~urement ol
the dose.
4 . Right rime- Be sure. the mcd1<.11io1.1 is being
given at the 1>roper ume. espeo.1ll y wnh media.
lions thnt nre given in a series such'" .1llc'b'Y injec.
tions and immunizat ions. Tlw umc factor is
irnponant in maintaining consi, tlfll blood '""ls
of the drug. in maximizing eflClt1H 1iess of tltt
drug. and in ensuring proper .1h ption of t1tt
medication
5. Right ro111t-Be sure the form of ' 1Cation bring
prepared matches the route nl d mmistration
ordered and is appropriate for p<:r 1f\'CCivingth,
Righi technique Right !Olilt
medica1ion.
6. Ris/111ecl111iq11e-Af1cr a final revic " 1t 1hc media l
record and nn assessment or 1hr J 1kn1, selea an
appropriate site and route .111<1 .1ppropriatt
delivery techniques. Be surt u'it aseptic
technique.
7. Right iluml'nltllio11-For medirnl 1easoru. P"'
dsely and accurately enter the d< wntation in
the patient's record immedia1el111/1 mg mediQ.
lion to avoid medication erro1 11>111re 11-5). If
Right dorumentatlon
ad,-erse reacrio ns occur. record an 1.lvcrse symp
toms nnd any act io ns taken . , ' '"~uh . Jr the
- admini;tmion is documented 111 I "e it is per-
formed and the patiem then rdt the media
tion, an error in charting will h,m urrcd lfyoo
wait to document later, you m.1 t : l what was
given, or even worse. someone d" 11 r<-peat tilt
administration (Box 11-3)

Right Righi
Time 00$4!

Je,,. Doe

OS-28-xx Pt stated no allergies to any meos: _1.mL PGnlClllln given JM ;,., ,;git dofsoglute
sue 0 8:00am. Detained 20 minutes. Showed no untowatd reactJOn. Return visit 3 days s CMA

Figure 11-5 Documentation of the seven nghts of medicallon odminisuation.


BOX 11-3 CHECKLIST FOR DOCUMENTING MEDICATION
AOMINISTRA TION
llP.Cllfd on t~ medical record 3lrf patient assessmefllS
that were done before and after the medicatlOfl was
adm1rnstertld
RecoI the date. time. and name of the medicine and the
dose administered
If the trijatmem was an immunization, record the name of
the manufacwrer. exp1ra11on date, site of injection, and lot
number ol the vaccine
If a pmenteral or percutaneous route of adm1111stration was
used. record the route and site of administration.
RecoI any pat1 nt reactions that may have occurred If the
oc1ated with possible reactions (such as
d L1e wa1t1ng time of the patoem and
eX\::.llS occurred
rt patient edlll'atic111 Nas pnMded. record the educanon given
and the ired to grve 1t
If the pat med1call0fl, record the reason fllf the
refusal (see 11-51
If thCS(' ,,, 11',hlS .tre followed, the allied heall h
professional ' II b 1f'i11g the 'right knowledge base for
giving drtt!\' ' lo ensure safe medication admin is
tration. the h Ii , .ire professional must comply with
the 3 1' 7 Slq
' .
0tes" and seven "nghts" when prepanng
1bcl1ty of error. prepare medications 10 a
"Oil d environment
only medications that you prepare.
u are adm1niste11ng and the condition fOI
wi11ch 1t ascribed
After ad 11ng a medication. observe 1he patient for
posstbl v 1 ,d reactions.
Never " l1cat1ons U1at ha\lll been prepared to their
original 1 If not used. discard these medications
llflliltJflY
Alway poss1b e med1cat1on allergies before adm1n
1ster111Q Clletk the medical record and asll the patient
aboit a
.. nt1fy t bef0te g""ng medicine
M!-';ca occur ~ with the utmost of care If an
ass!?$$ the pattenl. notify the health care
J with needed therapy as directed, aod docu
hippencd Assess the cause of the s1tvat1on
cltl1.i ad1ustments so the same errOI does not
CHAPTER 11 Safety and Quality Assurance 193
SOURCES OF MEDICATION ERRORS
A medication error is at best an inconvenience and at
worst a uagedy. Each error is potentially tr.igic and costly
for pa1ienlS and professionals alike. The goal of medica
tion adminisualion is to correctly give medication on
each and every occasion (use the three before; and i.even
righ1s.) If this is done. no error in mcdica1ion ad minis-
1ra1ion should occur. However, mistakes are sometimes
mJdc, and adverse drug events and med ication errors do
occur. For e"ample. Celebre" is a mcdica1ion for arthritis,
Celexa is an antidepressant, and Cerebyx is an anliepi-
lcpsy drug; these names sound alike and are spelled
similarly. leading 10 the po1e111ial for errors.
\1edica1ion errors are not trivial. rre\'entablc medica-
tion errors cause approximately 2% of all hospitalia
lions. at acos1 ofS17 billion 10 S29 billion per year. Ille
need for extreme care in medication administration is
obvious. An inquiring attitude by the pa1ien1 and profes-
sional may make the difference between a medication
error and safety. Reporting any mistake 10 the proper
supervisor will ini1ia1e the needed measures 10 coun1er-
an the effect of the dmg as warranted . Appropria1e docu-
mentation after an error is essemial (I.lox 11 -4).
DELIVERY OF MEDICATIONS
l11e method of adminisualion depends panly on the
purpo>e of the dmg. Some drugscan be gi\'en in a varie1y
of ways. whereas others mus1 be admini>tered in ~peci6c
wJys to be effective. Generally, dmgs are gi\'en either
through enteral or parenteral rou1es 10 produce sys1emic
or general effe<:tS. Percutaneous administrauon occurs
when the drug is placed in direct comact with and is
absorbed through the skin, 1issuc, or mucous mem-
branes. Dmgs given for sys1emic efTec1 are absorbed and
circulate in 1he bloodstream to produce cffem on body
eelIs and tissues, whereas tho;e for local effect are given
BOX 114 If A MEDICATION ERROR OCCURS
Observe the patient and evaluate his or her reaction.
Notify the health care provider of the error and the pauent's
apparent reaction
Perlorm any corrective steps as duected by the health care
ll'CMder
Document the emir. including fil ng an 1nc1dent report 1f that 1s
the pollC'( of the facility If alepOll form 1s not available. docu-
ment the rnc1dent completely Use the guidelines of the hab1I
1ty insurance earner for proper placement of documentation
Evaluate the circumstances and make any necessary changes
in policy or procedure to prevent the same error from occur-
ring in the future.
 194 SECTION Ill Med1cauon Administration

andto 'The percutaneous routes are those in which abso

Joc.11ly tu remain at the site uf J d mm1stra11on . n ocrurs through skin or mucous mcmbr.1nes 111111 '1>
P~wnt S)'>temrc do>age . . uo
f cases . Ii d h . o~
the drug action is con ne . to t t' snc of applia
Mr.ii<.ill'" .1JmrnutMt1011 denotes the inuoducuon o
a drug mto or n~ applkauon to the bod)' The goal is to lion; in some cases. however, medicauon may be applild
transderrnally for systemic use such .1\ fe111any/ tran
deli> a precise. rdrable dose \\1th desired elf~ t? the
de<i1r.'d sue When the route of medication adm1n1Stra dermal patches for pain. Chances of a \)'Stemic rearu~
uon 1~ being cho~. Ii>'\' fdoors are considered: are reduced beaiuse the medication's .1mon 1s us~)~
Chemical propen1n of the drug confined to the place of application Disad,an~
Ph)">ICal propcnres of the drug include a slow rate of absorption (although this may also
Dl'<itrt-d site of JC11on be a reason to use this route), irritation Jt the applia11e1a
I low r.1p1dly the drug resp0rrse IS wanted .. site. difficult) in applying the drug. or mt>ssy rcsidur
l'h)-sical and mental health of the pel$0n recervmg occurring from the drug ba~. BecauS<c th, duration ol
the drug action is decreased in most instances. tht>o.' medic~tions
Routes of .tdminrstrauon dtSCUssed in this text are may require more frequent _applicauon I l<mever. S0111t
gas1ro1ntestmal 'i)">tem. or enteral routes (mediaicions of these medications remam. m plac, Im wvcral dil),
~w.1llowd hy mouth or given through rectal suppository depending on rate of absorpuon
or encnu), p~mtt<"r.11 routes of administration (subcu
tancous, intramuscular, l-trad. imradermal, and intra
vcnou~ routes of .ulm1nis1r.uion); and percutaneous
..
routes (through ~kin, by vaginal applications; through
mucous membranes sud1 as ~ e.u, mouth, or nose Medication administration requires kn"' kdge of 1 ~
ln>1illatlon<, and by inhalation). drug being given and proper roult' ol .1dministration
nw most commonly u;cd route for ambulatory care following the th ree beforcs and sewn ri l11s. All health
rnedk.1tions is the emeral route. Medicines given by this care workers must follow OSI IA guidt'l11 1o for personal
route h.wc ,1dv;im,\gl'S of being s.1fe, convenient for most and patient safery.
pa1icnts, rtl,1tivcly economical, and, in most Cllses, readily To give medications safely, Lhc p1olt inn.II ;hould
.1v,1i lalllc. l)is.1dva111,1ge> include slowness of action and demonstrate Lhe ability to follow the 11 11th care 1>ro-
low dCJ)Cndabi lity of .1bsorp1ion. Some medicines such vider's orders, calculate doses corrc{th 1d a>sess the
" imulin arc <lcstroycd by digestive Ruids and cam101 be patien~ drug. and environ men I bcfon: ,1d1 11nistcringtht
administered through Lhc gastrointl'Stinal tract. medicine. Following administr.11ion ol "'' 111 inc, pa1ien1
Gc1wrally, the parc111eral route is considered to be observation for possible adverse reamo11 " necessary,
adminim,uion of medications by injection, or under the including documentation of any adwr,, 11 tio11.
skin. With pa renter.ii route administration, drug action is When medication errors occur, the fl< 1 1 .tdminism
more rapid than with the enteral route. but the duration ing the medication must take rC\I"" 1itty for tht
of action is shoncr rn mos1 instances. Dosage with this mistake and repon and document th r. the treat
route tends 10 be smaller because absorption is more ment (if any) used to reverse the error ,J Jny subst
rapidly accompli~hed Disadvantages include greater cost quemad\'erseeffcct$. lnegoal is error frt-c 111nisuation
of suppltcs, an mcrcasetl chance of adverse patient reac- of a precise. reliable drug dose to 1.11 Mues "ith
tton, and such complications as infections and absce5$1?$, fewest side effects, but in reality crro" d "ur
which may occur bcc~u~ skin has bttn broken.

Scenario

Judy, an allied ~a/th care profess1ona( 1s to admmrster a dose of penicillin 10 Jim for an upper p1racory
1tac1 mfect1on. The physician has ordered a dose that Judy thinks is excessive for Jim but th s er opm
t0n based on her background. not on actual dosage charts.
1. What should Judy do hrst?
2. Judy finds that the dose is actually at the high end of the acceptable dosage range What ould
Judy do next?
3. After Judy talks with the health care provider and is assured the dose is acceptable. Jim , 11 her
1
that 111 the past, he might have had a rash after taking penicillin, but he guesses it does not matter.
Should Judy give the penicillin?
4. If not, what should she do? If so. what reaction should she look for?
 CHAPTER ll Safety and Quality Assurance 195

REVIEW EXERCISES
Documentation of Medications
Document the followi ng as h should appear in Lhe medical record. All enLries will be Lhc date and Lime the
exercise is performed. Sign Lhe documentatio n as a student in the field o f study.
1 ~ ~ra ~tedici. age 2. has come to Dr. Merry for a measles-mum1>s-rubella (MMR} vaccination. Dr. Merry orders
t.::J the vaccine to be given to Sara in the vastus lateralis muscle. lhe lot number h l'o. 12356, manufacmred
b) Sc>hol Drug.. Ille expiration date is 10/04/ n 'lhe dose for MMR is one vial (or I ml.) after m:onstitution You
informed the patiem's parent of the side effem to expect and possible reactions. includrng the possibility of a
r.ish ,ind low-grade lever in 2 to 3 days. - - - -- - - -- - - - - - - - - - - - -- -- - -

l. r::i] .\l,1f) Alleri has com<' to the ofJicc to receive her aJlergy injcetions. She has a standing order from Dr Merry
~ t<> rccdw the next ordered dose unless she had a reaction to the previous dose \ts Alleri tclls you that she
h.iJ no problt ms with the last dose. Toda)"s dose comes from Allergy Lxuacr Bottle o 4, 0.2 ml of extracr You
gw the inw<11on 111 the right deltoid are,1 subcutaneousl1 as ordered. Ms. Alleri alwai-s waits 20 minutes after
rectivu1g the m1c<1ion to be sure no reactions occur. When you check o n her, there is no redness or swelling at
the ;ite of mjc-ction, and she has no signs of an allergic reaction. - - - - - - - - - - -- - -- - -

REVIE UESTIONS
J'\\uranrtt? _ _ _ _ _ _ _ __ _ _ _ __ _ __ _ __ _ _ __ __ _ _ __

2 \.Vhat du1 p~rly st0ring medications" mean? Where docs an allied health professional obtrun the needed
Jn~Lrurt t th" t.isk' - - -- -- - - - -- - -- - -- - - -- - - -- - - - - -

l. '11w ph' " .. n must order and supervise any medicatio n administration in a medical o llice setting. Why is this
ill'lj">Ort.111 I

4 When '" J .111 .1ll1cd health professional question an order from a health care provider! Why? - - - - -

5. Wh.tt .tr 11 th m txfores of medication administration!--- - -- -- - - - - - - - - - - -

6. Wh,11 lrt' 1he <even righi> of medicatio n administration?-- - - - - - - - - - - - - - - - - - -

7 \\'h) 1> 1t 1mponant for a health care provider to be readily availabl~ when medications are administered, especially
by parrnte1al route?
 Enteral Routes

Afcer studying chis chapter. you should be capable of doing the following:
Expla1n1ng what is meant by enteral route of Discussing indications for use of a re
med1cat1on admin1strat1on suppository.
Describing forms of medications that are Administering medications using a re<
adm1n1stered orally suppository for absorption in rectal n ;a
Describing the role of the allied health professional Discussing indications for and contrn11 dt1ons to
in adm1n1stration of oral medications. a rectal enema.
Demonstrating procedures for administering oral Discussing how to administer a ract<1I 11ma.
medications. Explaining to a patient how to self ad uster
Preparing a sohd form of medication. medications rectally.
Preparing liquid medications using a medicine cup, Providing patient education for safety
dose spoon. and graduated-dose syringe. compliance with enteral route

Btlly, a 2-year-old with 8 cough and runny nose, 1s brought 10 Dr. Merry's office by his mother [) Merry
examines Brlly and prescnbes 1tqu1d medica(lon for his symproms. 811/y's mother re/ls you thar 9/.
ways wanes ro donk water after taking cough syrup.
Is this a matter that requires patient educanon? Why or why not?
Should Billy take cough syrup with meals? Why 0< why not?
What kind of measuring equipment would you tell Billy's mother to use for accurate adm1nist1 of
medicine?
Billy's mother also tells you she has to call mediane "candy" to get Billy to take 11. fs this a
practice? Why 0< why not?

Dose spoon Enema

Dose syringe Meniscus

T he general ndes for dnig administration were dis-

cussed in Chapter 11 and should be followed when
.1dminiswring medirn1ions by any route. but tech-
niques differ for e,1Ch route of administrntion. Although
the icon B is present, such common practices as the
three ~rores and seven "righis" ,111d h.1"' 111occdur(S
in medication administration arc not 111d 11 lnl hu1 are
shown as an icon in each procedure. It b "J'c<tcd th.II
you, u1e all ied hea lu1 professional, .uc now .iw.trc of the
necessity of these steps for personal and p.11 ll'nt s.1rc1y.

196

lliis chapter considers medications that are absorbed
Ii>' the gamoi mc<>tinal (Cl) 1rac1 (or emerally) through
the mouth or rc<1um through the mucous membranes.
OrJ/ mt'/1<1111<>11> arc administered by having a patiem
,,.;illo,. a drug. Drug> are absorbed in the Cl tract,
5
usually in the intc,unes-thus the name e11ter<1/ medica-
tions. R,rc1/ ml1u1t1<111> .ire administered into the rectum,
either by a suppository or by an enema, and are included
in this chapter bcc.1usc of absorption in the Cl tract.
Medications 111.1y ,1lso be administered into the Cf tract
through n.m>g,1S1ric or ga>tric wbes. 1liese are not as
common a< 01 .11 .ind rectal adminis1ration and are more
commonly found in inpatient senings.
With the 01.11 route of dministration, Occupational
Safety and llf.thh Administration (OSHA) standards
may not ""Im!< .my personal protective equ1pmem or
special d"pos.il of producu used for administration
because boJy llut<b arc not expected to be prcsem for
cross-conwnm 111111. I lcnvcver, with rectal administra
uon of encmJ or uppository medications. depending
on the conJ111 >n of fldtien~ a higher level of protective
equipment " h 1< .1 gown may be ncc=ry. and gloves
will ah~ay. I "' ,,;.1ry. Icons for OSI-IA standards are
also includu1 11h the procedures. One OSHA standard
nec:css~'ry 101 1d1111nistr.1lion of any nu~dication is hand
saniti.atio n..11ul thi' icon ID appears with procedure
guideline'
... ~'
ORAL AJMINISTRATION
OF ME !CATIONS
f,-en with po le de effect from oral administration
and length me for .1bsorption, it is the route of
choir.fur m I dnog therapy (Procedures 12-1to1 2-3).
Most pcor rn \l'lf admi nister medications with few
problem\ \..iH n d 111g> Jre pr.-~cribed for oral use. Occa-
sionally th< I 111111<' is not desirable, such as in the
following" 1.111n1h
Whl'n th1 d111g may be irritating 10 the stomach
when 1 hi n hy mouth
Wh<n t !kn of the drug may be altered by Cl
ju1ct\
In 1h1 I "" of vomiting. poor GI absorption,
and 111 '"Ity w \Wallow food or fluids (or drugs)
The 1m1 111 1i1<r.1u1ion with oral administration is
10 avoid r u1on of medications. Aspiration occurs
when me" an on' intended for the Cl tract are drawn
into the h 'I If tnf\ 11.1ct Ille risk can be reduced by first
a=~ing th< pllt\'111 \ ability 10 swallow.
When lor111s of medicine for oral ronsumption-
tableis. c.11h11l1 ' powder,_ elixirs, syrups. solutions, and
suspension' <'lll'r th~ mouth, the medication must
be sw.1llowcd to oc.uh llw stomach and then small
intestine fm .tb\orption (forms of medication for o ral
CHAPTER 12 Enteral Routes 197
administration are found in Chapter 3) I ood and diges-
tive disorders will change the rate of absorption and
How of medicine through the GI tract. Some medica-
tions cannot be gh-en orally because digestive o;ecretions
make the drug ineffective or slow absorption into the
bloodstream. Solid forms (tablets, capsules, and so o n)
should be LJken with Ouids. Many liquid prep,1ra1ions
>uch as cough syrups should not be 1.1kcn with another
Ouid to avoid diluting the medication . Ile sure 10 read
patient education materials and follow directions when
administering any medication (Box 12- 1). Finally, in
some instances food may be required for absorption,
whereas in others it is comraindicated (s~-e Chapter 2).
Alwa)'l> follow safety rules found in Chapter II for
med ications.
l ltTt1 ; 1 I..; E ,...... . . .. : \ l. I oI
All medicallons sltoold be gM!ll according to the general
rules of med1ca11on adm1nistra11on discussed 1n Chapter 11
The easiest. most desllable. safest. and most frequently used
route of drug adm1nos1ration os lite oral route because most
people can self-admomster med1ca11oos effe<:11vely
Persons who cannot swallow should not be given oral
med1ca11ons.
Aspuallon of medications 1n10 the respuatory tract is the
main danger of the oral route.
Oral medocallons may be adm1mstered msolid or liquid fomt
The presence or absence of food 1n the GI tract and digesuve
disorders affect the rate of absorption of Ol'al med1ca11ons
Adequate ftuids must be adrmn1s1ered w11h med1ca1ton so
that the patient can swallow solid preparattO!IS. whereas
ftuids are rarely grven after liquod p1epa1a11ons Extra ftuds
should be gwen w1lh sulfa med cations 10 pre-.ent
crystalhzatoon
Some med1cauons may be crushed or chewed f0t ease of
admmistrallon. whereas enter1c-coa1ed or tomedrelease
f01ms should not be altered belore lltey are swallowed With
permission of Lhe physician. sCTJred tablets may be d1v1ded
to give a partial dose of the medication. other medications
may be used by dividing them as directed.
RECTAL ADMINISTRATION
OF MEDICATIONS
RK!al medications are usually ghen as suppositories or
ointments or by enema, Because the rectal mucosa ha
an excellent blood supply in the rel,ttively small area.
these medications are rapidly absorbed into the blood-
stream. \>ledications insened imo the rectum are not
changed by the digestive juices and do not irrit.1te the
lining of the GI tract except possibly at the ;,it c of inser-
tion. M,111y rectal medications relieve discomfort locally
 198 >ECllON Ill Med1ca11on Adm1nis1retion

PROCEDURE 12-1 . . So11d Medications Orally

Administering
mw
Objective: lo safely acJminas1er solid _,.icauons
- orally

Guidelines ~ llJ
Equipment Needed
Medocauon order
C'.onmner of ordered med1ca1ion
Cup for mea\unng or holdmg medic.Ilion
I iqu1d for swalloMng medicauon
rablct spli11t-r 1f applicable
Methodology g
CJ d correct number into bottle cap.
D2. IfIf gwmg tabletS or capsules. open c~ntamer an tap h score line using a tablet spliuer as approru .1te 10
the 1.1bl4.'11~ scored and nl'eds d11r1dmg. brl'ak on t e
provide equal pans for 1he doSl' needed ti be these areas are considered clean, whcr the
3. Do not touch medicine or inside of cap or boi e f~se comaminalion inside of the med1c.111 boule
coumenop 1s con\idcrcd contaminated. To preveni h erld bet rned wi;h the inside up to pl. <>n
c.1p should no1 be placed on 1he countenop; the caps ou u
counier 1f neccss.11y ..
4 Af1er dispensing drug into ~11le c~p, u~nsfer d~1g 10 a med1c1nevc:fI\fficient liquid for S\vallm "
S Afier idemifying Jnd assessing paucnt, give med1cuie to pa11em' 1 s
6. Wa1ch pa1ie111 t.1ke medicine. b f aiient afler adm 1,11ion.
7. Dornme111 1hc medic.uion administered, your assessment, and o ~rvauon P ' 1
Answer p.nic111 ques1ions and ;,i1pply pa1ie111 education as appropnate.

TYPICAL DOCUMENTATION
3/15/n 9 10 llM acetaminophen 650 mg PO giwn with no appareni adverse reaaions _ _ _ (, ( L.'I, C.\ IA

(eg., anestheuc omtmems and creams used to treat

rectal discomfons) or may be used 10 slimula1e evarua-
1ion of 1he bowel or as a stool softener. Other supposi.
1orie; have sys1cm ic ac1ion and are used for rapid
absorp1ion in patiem; with nausea and vomiting or
fever. lhe recta l route is not as reliable as the oral or
parcn1eral routes, bu1 it is safe beoiuse, except for local
irritation, $ide efrt?Cl) (ro1n adn1inistration are rare,
ahhough medication side dl"ects remain the same as if
administered by another route.
Rectal ointmems and creams arc u~u.1lh lminis1ered
by means of an applica1or auached to ' ' , medication
tube. Most media11ion orders read to .1pp1 '1mment or
cream to 1he area, with no speci fie d0\,11\l 'n
Rec1al suppositories are manufactured 1 1 l\lycerin or
cocoa butter bllSl' 1ha1 melts on cont.ict "11h the body.
Most supposi1ories are bullet shaped ( 1'!.\"'' 12 I) with
rounded ends to prevem trauma to the rt'< 1.il 111uco;a on
insertion. Most suppositories adm inis1rml 1111lw .1mbu
la1ory care facility are for the 1reatme111 ol 1i.1u;ea and
 CHAPTER 12 Enteral Routes 199

PROCEDURE 12-2 Administerin g Liquid M edications Orally Using a

Medi cine Cup
Objective: ro safely administer oral liquid medications using a medicine rup.
Guidelines ~ [I]
Equipment Needed
Mcdicauon order
Comainer o l ordered medication
CalibratcJ nwdi<ine cup for holding medication
Methodology B
1. When ll1vi11J,\ d liquid medication, obtain a calibrated medicine cup and ordered medication. If necessary,
shake or rnll nwdication as appropriate for even dnig distribution.
2. Locate nrdtrI dosage on medicine cup and place a lhumbnail at that line.
1J 1told cup 1 , >Clevel and pour correct amount of liquid into container, reading to the meniscus. ro keep
med1cme f m Jrippmg on label, always pour away from label, or patm label.
4. After o ~u ng rn.dicine. place rup on a le"el surface and check le\'cl of medication 10 meniscus for acruracy.
If you h p<t red excess medicine. discard extra amount Do not return poured medicine 10 stock
con1.11n
s. ldcntil\ > nt ind give medicine. watching patielll 10 be sure all medication has been swallowed.
q111<I\ a rc usually not given after administration of a liquid medication.
111c cup and obserw patient for indications of adverse effects.

7. D OC\11111 1 d1CJtion administration and any observations of patient. Answer patient ques1io11s and supply
any p.11 .lur.11ion needed.

TYPICA UMENTATION
3/ 15/xx d>uprofen liquid, 100 mg (I tsp) 1'0 given with no apparent adverse reactions. _ G. 01.5t:N, CMA

\'Omitin~ n <lure fever in )'Oung children (Proce
dure 12 II
Enem," 1qu1J~ 111s11lled into the rectum; they may
be used 10 l n hJrd feces. relieve fecal impactions,
or e-acua1t 1 hm>d, or as a means of administering
medication (P ,,.,Jure 12-5). Single-useenemJssuch as
Fleet enem." 111.1> he prescribed for use before diagnostic
tests (hgu1< I ' J) Altho ugh enemas are rarely per-
formed in .111 .1111hul.1tory care sening. it may be
necessary to teach lhe patient the technique for home
use. l11e patient should be told 10 remove the cover on
the container tip, lubricate the tip with water or other
lubricant, and insen lhe enema tip into the r~'Ctum, then
administer the liquid. The patient should then hold lhe
medicatio n in the rectum for as long as possible to
obtain best possible results. The enema fluid breaks up
the feca l mass, s1re1ches the rect.11 wall, and induces the
defecation reAex.
 200 SECTION Ill Medication Administration
I "
T n Piii""'' tor fl'. r . meditations 10SO.Id lorm (tablets.
caplets) on the back of tongue for ease of swallowing Then
t1l11he head fDMllld to ~timulate Uie tongue and swa lowing
rcfte1 then 11 t the head batk lor 8tlllil swallowuig
The moum shoold be moist to pie"ent $Olid medJCauon fl!l11
a!lle11ng to the inside al a ~ mou1lt A ~ mo1;:ll tends 10
le swallow ng more wff1CUlt. 1ncreasmg lhe chatce of a
r- oocatlOll's dis3olW1g 111 the mouth
Or 11 medita!JOnS should not be stoted 111 Strong 19't. high
h ty, or ape11 a~ Oiscatd medicanons that hil\'e chariged
a.vr, are out ol date. or have an une.pected odor, sW1 as the
vinegar odor that oeturs with out-<lf-<late aspinn.
If a medication has the potential 10 s1a1n teeth (iron prepara-
llOllS 1od des), the liqu d med tatlOll should be ingested
through a str.rN If the pe1son has dentures. the dentures
should be remov00 before mgestion of stainng med1cat1ons
Patients should always rinse the mouth with water after taking
these medications
If a medication 10sohdform cannot be swallowed whole, oome
tablets may be crushed or spht for ease of adm1111suation
Med1cat1ons with entenc coating, sustamed release. or other
special relea1e capab1l111es should never be crushed. chewed,
or spilt unless 1hev ere scored Consult a drug reference and
ask tho physician's pe11111ss10fl 10 determine if the medicine
may be crushed, spht. or chewed
Effervescent tablets or powders should be given immediately
after the sohd torm has dissolved 1n water and while desired
effervescence is maintained
Some medications come in sohd spnnkles that are dispersed
on food 101adm1111suauon. such asvalprolc arid for seizures
Figure 121 Tho shapo and packaging of a 1ectal suppostory and small
enemas fo1infants !From Perry AG. Poller PA: Clmtca/ nursing skiffs and
rochmques. ed 7, St Louis, 2010, Mosby J
andtheophyUi11e lorasthma All food on which spc1nk esaie
appf ed roost be eaten for the des11ed dose 10 be
administered
Sprinkles should not be applied to hot lood because this atti
vares the medicanon. the drug should be apphcd only to IOQd
at room temperature or coldef to allow for absoflltion in ~
61!JaCI.
Unless 1X111traindJCated. medications that are d1ffiaift to
swallow may be placed 1n thick liquids such as alJlll&Sau!e
OI pudding 10 make swallowing eaSJet Produtts to lhlr ~
' quids ara1 make swallowing easier may be foulld <Mil th!
counter.
A SCOled tablet is usually a sign that the tat~ot may be sp1 t
or divided
Oral Medication Safety with Children ind Ill Elderly
Young children and older adults may have d1fficul1y swallow-
ing. If this is the case. check 10 see 1f ihe sol u 1parat1on is
available in a liquid form
To give oral medicatrons 10 ch1fd1en. approacl em as 11you
expect cooperation, and praise the child for t Dr.rating a~
taking the medication.
Never tell a child that medicine is candy ltecause Ille
child may take more med1catron than presc11h1 r thinking it is
candy.
Never trick a child about taking medicines
Never lr)I to force a child to swallow medic or hold the
child's nose or mouth shut, because this m~y Ml choking
Never give medicine to a cr;1ng child, becau f the chance
of asprrallon
Ile sure the wrapper CO\<ering the suppo t
tef1lO'led before lllSl!Ricn Lub11cate the end
lDIV v. rth eithel water-soltble lub11cant or\'.
Keep a ~srtoly oool before 1nsert1011 bee.: a soft 5UP'
posito1y isdifficul110 1nsen To keepmcd1cat rorn met~
do llOI hold the $UllP051tory 1n Y001 h.'lnd 11 SIJllllOSitClf\'
is Slllt. place n 111 the freerer for a lew m 10 hanlell.
but do not let the medicaoon freeze
Wear a glove Of1 the hand used for 1nsen Gently~
the r01Jnded end of Ille suppository past ti I sphincter
fa. retenllOn
Aema1n lying down for approximately 5 to J ninutes to
allow the suppository to melt Tell patients ta r st the urge
to have a bowel movement 1mmed1ately so h 11ed1cati-0n
can melt and be absorbed
Medicauons inserted into the rectum are n changed by
d1gest1ve juices and do not 1111tate Ille GI 1ra1 t, except pes
s1bly at lhe insertion site
 CHAPTER 12 Enteral Routes 201

PROCEDURE 12-3 Administering Oral Liquid Medication Using a Dose

Syrmge or Dose Spoon
Objective: lo safely administer oral liquid medications 115ing a dose syringe or d ose spoon
Guidelines lli:!J [II
Equipment Need ed
Medic.llion order
Con1.1i1wr of ordered medic11ion
Dose syrinlll' or dose spoon
Methodology B
a Placing \YI 111ge into liquid med icine, draw desired amo unt of medication in10 syringe or pour correct
amou111 111 1ncdication to meniscus imo dose spoon, ho lding spoon upright
2. Af1er 1d, "al;ing patient. slowly squin medicine in10 the side of pa1ient's mouth 10 preveru cho king. If using
dose 'i"'-"n illow person to slowly swallow medicine.
3 ~re''" ulll h" taken so the person taking medicine does not aspirate drug.
4 lmmnhat I~ '""'h the utensil to keep medicine from drying in the syringe or dose spoon
s Documt'tl <dJC.iuon administration and any observations of patient. Answer patiem questions Jnd supply
any p.rnt Jucation needed.

TY PICA JMENTATION
3/ 15/n 'l 1moxicillin 500 mg (IO ml) given PO with no apparent advctSe reactions _ _C. 0 1.SEN, CMA

Oral adm11 1111n of medicines is the easiest, safest,

and mo'1 nt lv '"lc'<l route. The drug is placed in
the mouth 1< 1llowed for absorption in the GI tract,
usually in ti a!. intestines. Some solid fonns of oral
medication 1 b.. CTUshed or divided for administra-
tion with I" r um of the physician; others hal'e spe
cific c0Jt111 1 lorm.s that should not be altered.
Medication m 1y rm tate the Cl uaa or may be altered
by juice. f, ~ the $lOmach and intestines. In these
cases lhc <Im .1y not be given via oral administration.
Danger ol .l\p11,111011 should be evaluated before ora l
medic.._uion\ .1 tt given P.uients ,vho cannot S\\'1lll ow Figure 122 Prepackaged enems (From Perry AG. Po11e1 PA Clmical
should 1101 lw 111w11 dr ugs o rally. rwtsmg skills and techniques. ed 7, S1Louis. 2010, Mosby l
202 SECTION Ill Medication Adm1n1stra11on

PROCEDURE 12-4 Administering Rectal Medications by Suppository

Objective: lo ufdy adm1111s1er a rectal suppository.

Guidelines [It!] [I}
Equipment Needed
Medic,uion orJcr
Appropnatc r.'Cl.tl \Uppos1tory for order
CIO\-es
Drape 10 cowr body for pmacy
\\',11eMolublc lubnc.im
I 1.;.sues
Methodology B
I ldenufy person and pl,1ce 1n ~1ms position, being sure to drape for privacy. (Children may be plac cd in
dors.11 recumbent pos111on Infants .ind small children may be placed supine so both I~ can hr .-ll'Vilted to
obsen.~ rC<tum)
2. Remove wrapper from suppository if necess.uy. Do not handle suppository more than neces\,HY cause
body temperature may lead to softening of suppository, and insertion into recmm may be hmd, <I
IJ t!>ing water wluble lubricant or w.ner. lubricate rounded end of suppository and the gloved 1111 r to be
uwd for in>crt ion
4. hlcvate the upper buttocks to show anal opening. Ask patient io ~1ke dee1> breaths through th mouth to
relax recta l sphincter.
Iii Whh a gloved hand, gently push suppository past anal sphincter into rectu m (about 4 inchc' ) 1"' not
in\crt s11p1>osiw1y into fec.11 matter because medication will not be absorbed.
6. Wipe excess lubricant from nnnl .irea wi~1 tissues.
7. Ask the paticm to remain quiet for about 5 10 JO minutes to allow medication to be absorbed othout a
bO\\t(d tnow1nenl occurri ng.
8. llcmovc glovo.'S and wJsh hands.
'>. Ob>crw the p.uicm for reactions, both expected and possibly adverse.
10. Document medicJliOn administration. If medication is for bowel evacuation, document re\uh , ,1 t,1incd.

TYPICAL DOCUMENTATION
3/ 15/
. xx
cd 1: 15
d PM Phencrgan 25-mg suppository insen-"
retain an symptom~ of nausea dt'C'reasro in 30 min . ___________
"" mto rectum wnh
no appircm sct fl
' ' c c C<
(, ' '(
1ppository
t\IN,CMA
 CHAPTER 12 Enteral Routes 203

PROCEDURE 12-5 Usin g an Enema to Administer Rectal Medications

Objective: To safely adminis1er a recial enema.

Guidelines l~~I [}]

Equipment Needed
Me.hcalion order
AppropnJle enema for medication order
Cloves
w.11er.>oluble lubricant
Tissues
Drat~ for privacy
Methodology B
1 ldcnul) palieni and place in Sims position, or other appropriate position; drape for privacy.
2. Remo" pla,lic cap and lubricate lip of 1he enema, if necessary. (Some enemas come prelubricated.) Clear
1ip of e1h'rnJ wi1h flu id 10 prevent insening air in10 recium.
3, l.ocatc m !um .rnd ask pa1ieru 10 breathe deeply and slowly 10 relax recial sphincter.
4. Cemly '""" fluid-filled lip inio rectum. If using a prepackaged enema, roll boule from bouom to lip umi l
all hqu , ,..., been delivered into rectum. If u~ing a nondisposablc enema, ho ld enema bag 6 to 8 inches
ab<l\l' r ' a nd slowly administer liquid .
S. lnstru t r to rctarn enema for a1 least S to 10 minutes before expelling fluid and any waste materials.
6 Rcmm . s wash h.inds.
7. AS\l\l r ., I I 10 bathroom at proper time.
8. Obs~m t1m from enema, if any.
9 Ob\en , i ' 11 t for any adverse effects.
10. ncxum rocedure including return from enema, as well as any adverse effects.

TY PICA MENTATION
3/16/ u ll~t enema administered with no adverse effects. Return of enema coniained large amounts of
hard. cons d feces C. OLSEN, Cl\.IA

Rce1al mu .111011s may be administered by either
supj)Oshory nema, with nci1her route being irritat-
ing to the l.I t ..xcep1 at the site of adminisiration.
The ba-..: lor ' r po'no ne- is usually either glycerin or
coc:oa h uu. , '"' of melung in the rectum. There-
fore suppo 1 sho uld not be handled any more
1han nee~" 1~ to prevc11t ch,mges in shape or me Iting
before insl'1 t 1 I nemas may be used for de.msing
purposes or 10 soften hardened feces. Medica1ions .uc
infrequen1ly administered recially in the ambulaiory
care sening, ><> the allied health professional's respon
sibility may be focused on teaching the pa1ien1 how
to adm1n1ster an enema at home r-or a person
who canno1 sw.lllow medica1ions, rectal admi111<tra-
tion, cspeci.1lly in a patienl wi1h vomiting, may be 1he
route of choice.

Scena1 10
Sally " 1mg pa/Jene education to an older patient, Mrs. Campo, who is havmg ddflculry swallow-
ing the ''" ~ tablets needed for her medical condition. She tells you th81 two of the tablets have "deep
lines ' thr igh rhe tablet and one has a vel)' hard coat. Mrs. Campo wants to know if there 1s any way
she can rn ~e swallowing the medicine easier
W hat formation can Sally grve her about scored tablets?
2 Ca ' the e tablets be crushed 0< divided lor easier adm1nastratt0n?
3 Wt at abcut the tablet that seems to have an enteric coating?
4. M rs Campo states the 1ablets seem to stick to her mouth because her mouth 1s so dry. What
rnstruc11ons should Sally give Mrs. Campo that will make swallowing easier?
204 SfCT ON 111 Med1c1bon Adrn1nistrabon

REVIEW QUESTIONS
I Why 1s oral adm1m;1mion of a medication lhe most desirable route! - - - - -- - - - - - - - - -

1 Wh) can ~m' mt<locauons not be gl\-rn orally! _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ __

l \\'hat medocauons can be divided ror doses! What medications should not be crushed for atlnunostr~tionr

4 What de><'\ 11 mean to pour a medication to the meniscus'! _ _ _ _ _ __ _ _ __ _

S. Why arc medications given by rectal suppository?---------- - - -- - -

6. "A ll medications given by rectum are for local effect.' Why is lhis statement false! - - - - --
Percutaneous Routes

Airer studying r1J1s c/Japcer. you should be capable of doing che following:
.utaneous routes of medication Administering ot1c med1cauons.
Describing how to properly use nasal
Adfrnn ste opica form s of medications mechcauons.
Adm1niste troglycenn ointment. Administering inhalation medicines using a
Describu g h testing for allergens. metered dose inhaler.
Explaining t w to apply transdermal drugs. Descnbmg use of vaginal suppositories and
D1scuss1nn is of sublingual and buccal forms of douches.
med1cne Providing patient education for safety and
Adm1niste phthalm1c liquids and ointments. compliance w ith the percutaneous routes.

Allie, ag as an earache and no other symptoms. Dr. Merry looks m Allie's ear and sees that ear
tubes ire place but rhe ear canal is red. He orders 011c drops for use four times a day.
At what c > 1ature should the drops be instilled to stop funher pain?
How h o 1 tell Allie's mother to hold Allie's ear to get the maximum ettect from the drops?
With t Al e's ears. can Allie's mother use any ear drops, or do drops need to be stenle? Explain
you ?
'Mly es mother massage Allie's ear after insening drops?

Aerochamb< r Excoriation Percutaneous Sublingual

Buccal Metered dose inhaler Rebound congestion Topical
Ory powder irihafer (MDII Spacer Transdermal
(OPI) Nebulizer

l'<lkations for 1~r<uuneous use are absorbed Both over-the-counter (OTC) and prescI11>uon drugs

M lhroui:h ' "'" o r mucous membranes. Rectal

medication' .ire induded and di~ in
thaptt'r 12 beraus.: o r the indusion in lhe gasuointesti-
n.11 (Cl) tra<t. b ut actually rectal medic.1tions are
~bsorbed thro ugh the murnus membranes of the rectu m.
m)' be giwn percutaneously, w11h these medic;itions
having locJI or S)'Stemic effects or sometimes both l'his
route of ,idministration includes ~ublingual and buccJI
medic;ition~. which are absorbed through mucous mem-
branes of the mouth; topical or su rface prepar,nions

205
206 SECTION 111 Mad1catron Adm1mstrat1on
\urh as Otntmcn1s, li111mems. and lotions; and tnnsder
mal or 1hrough lhNktn medications. induding pa1ches.
l'ercurancous rou1cs of admimMration are used when
Jirc'Cl ronWC1 of tht mcdicatton with skin is desired
because of ta\<' of adm1111stration and low risk of!)'$
1emic adwrsc reacuons Because of absorption rate dif-
fercnet>s of some topical agents. this route bas unreliable
') llCmtc JCltOn JnO SO IS seldom used for treating S)'S-
tl'mlC dt<i<easn Drug.\ absorbed percuuncously. except
those abwrbed 1hrough mucous membranes of the
mou1h. rectum. and lung.1. are slo-" acting and an: u~
when ''"' and l'Xtended mcd1cauon admininrauon tS
Ul~ir~o
TOPICAL MEDICATIONS
Mcdkauon~ m.1y be applied topically for local effect.
such a to rcltevt' nching (calamine lotion) or provide
w.irm1h (lleng<1y), or for systemic action, such ;tS relief
of un.1able .1ngi11.l using nitroglycerin ointmem or
parches. lopic.1l mcdica1ion> can cause systemic adverse
reanion and for safely should be applied as prescribed.
l)'pcs of skin prcp.ira1ions range from such common
fonns .1s crc.1n1s; ointm~nts, 11ncl powders to \Vt.l dress-
ing; and soaks for W(Jlllld care and 11a1ches for condi
1ion> ouch as hormone replaremem therapy. (For
disrns\ion of fo11ns of medication, see Chapler 3.)
Ilic area of skin for medka1ion application should be
dean, dry, .md frl>e of infection. rashes, encrustations.
open area. and dead 1is>ue unless a rash or wound is
being 1rca1cd lkfore topical medicaiions are applied,
skin should be in>JX!Cled for integri1y and deansed
wilh warer. lhc skin should be free of all soap residues
before .1pplicatton because soap can ahcr medication
absorption.
When .1pplytng topical medica1ions. adequa1e skin
h)dration is necessary 111e fas1es1 site for absorption of
tran~ermal mcdicauons is behind the eat The back.
chest. and abdomen are lhe next most rapid sites of
absorptton Slowest sues of absorpuon are the thigh and
forearm
If medicatton 1s md ca1ed 10 reduce 1tch1og 11 shoold be a~ied
wi1h gB11Ue sirokes If Ille drug 1s rubbed vigorously. fnctron will
heat the s<in. increasmg 1tcl11ng
Applying T opical M edications
Powders
To use powders such .is lhose for fungal conditions,
follow 1hcsc srcps:
Skin surface should be 1horough ly dry 10 minimii(
crus1i11g and caking of 1he powder
Skin surface should be fully exposed, wi1h folds of
skin spread open for powder appl1C.111on
Po"der should ~ liglnly dus~ed on10 the >Urfact,
Jwrjng a 6ne. thin layer A 1hm layer of powd".
moreabsoibent 1han a 1hick la) er, rcoucing frictio"
by increasing evapora1ion of moimtrt' n
Soaks, Compresses, and Wet Dressings
For soaks. compr~ and wc1 drl'\MnJ!' 'uch as ~
dine. the following points apply:
Active ingrediem is dissoln'\I m w,11erba1t11
solution 10 leave a film on 1hc \1.111
These substances con1ain a m lid '''"" :<m, pro.id
ing a soothing. cooling. and .rnupvr " dTcct when
used on blis1ered or oozing \I.in "'
Bandages may be soaked in '""" "il .rnd thtn
applied 10 skin. If appropri.uc.111 ir~n111y may
be soaked in 1he solution. With .1 1 drcs.ing. a
plastic wrap may be placed ovrr t dressing 10
keep i1 damp.
Creams, Ointments, Gels, and Lo 1s
Creams and oinunents nre semisolid pr 1.11ions used
for topical ;1pplica1ions; examples in, It 1 Nco>porin
and Triple Amibiotic Cream or Oinum 111
Aclive ingredicnlS for crea111s ,11l' in ,v,ucr base.
Creams are used 10 deliver dn111 d1 ly 10 or i1110
skin.
Creams are absorbed into skin .1111 '"h, usuall)'
having a cooli ng effect.
Oeams and oimmen1~ may be u'" .!diver anti-
pyrelics. amimicrobials. ,1nd o;of1w ' n 111 pounds
Oimmems are soft, fa11y ~ub\1anu .h 1he acti1~
ingredient carried in an oil, lanul 11 J>etrolcum
base.
Oinlments deliver drugs. \U< h a mucrobiab
and steriods. 10 the surface of lh< 10 rernam
in coniaa longer than a cream
The appUcatjon of an antirnicroh ntrnent or
cream is described in Procedure 1l I
Nitroglyurin oimmen~ used in 11< 1 of angiru
peaoris. is applied dirooly to the I.in on 1 d1cst, b.KL
upper arms. or thighs. The site \houltl I " .and rrla-
ti\'ely free of hair and scar ti\\Ue Jn I" 111 01erdw.
any oinuneni residue should be rcrnm fore a new
dose is applied. When ni1rogl>'Ccnn oint 111 1\ admin
istered, care should be taken 10 .M11d , , 1 .1< 1 with the
drug because a headache may n u1 """' ,1c<iden1al
contact. The procedure for applying nur" lyc~rin oin1
rnem is described in Procedure 1l -1.
Gels, such as K-Y Jelly, are 1hick w.11>' b.1wd sub
stances used for lubrka1ion or for ea"' ol l'Jllyingactive
drug 10 the skin. Some gels haw an oil 1 11~\rt'<licrll ,1dded
for bener coverage 1ha1 lasts for longi1 pniods of 1i1ne
 CHAPTUI 13 Percutaneous Routes 207

PROCED URE 13-1 Admin istering Topical Medications

Objective: To a pply top ical medicat ions appropriately.

Guidelines l~I [I]

Equipment Needed
Medication order
Medication ordered
Cloves
Supplies for clea nsing skin
Ore>sing and bandage> as applicable
Methodology 8
I After 1dc11111'.ing the pauem. cleanse skin and p.1t dry, using good aseptic technique.
2 Change ~I'"" if wet or contaminated after cleansing the skin.
3. If a 1opir I nwdica11on is to be applied, place medication in a cleanly gloved hand The applicator tip should
not tnuch he glove o r skin site. If medication is sterile, sterile 1echnique using a sieri le tongue blade to apply
the mcd11 , tion to steri le gau1..e should be used.
4. J lold m J1r m on in your hand to allow dw preparation to soften to body temperature 10 a llow the
mcdicau ' prcad easily and t:'\'enly.
5 Appl' m n 'm using long. even stt0kes to avo id irritating hair follides.
6. A di<'\ d b.rndage may be applied to keep the medicatio n in contaa with the skin. tf applicable.
1. In som< :-t<es mroication may be applied to the dressing. then the dressing is applied to the skin.
8. Oocunu < procedure.

TYPICAL MENTATION
6/30/XX I t .\hras1on on left knee cleanwd with soap and water and dried. r olymyicin 8 sulfate/ neom)'cin
sulfatc1~ u1ntment applied to lesion. Dry dressing applied No apparent sign o f adverse reaa ion.
~~~~~~~~~~~~~~~~~~~~~~~~C. OLS~~.C\.iA

Pa~ll-S ar otl or water-based compounds, such Medication released from the patch passes 1hrough
as zinc o fen u -.cd as sunblocks and to deli\'et the skin and imo circulatory system for cominuous
mediCJll 1lC. treatment without repeated dosing. Patches must
Lotion' 111 b,1 'cd compounds used 10 control be reapplied as indicated to maintain de.ired
itching (q "" folio11) or 10 relieve muscle ,md dos.1ge level.
joint pain {. 11cnLay), leaving the area feeli ng cool When a patch. dot, o r disk b .1pplied, the date and
after evapo r.11 of the WJter base. Lotio ns are applied time nf npplication should be written on 1he appli-
lightly to th, 1 .urf.ice using a gauze pad and stroking catio n material o r noted on a ca lendar whe n
in the dn, 1 hair growth. &>me lotions contain self-administered.
powder 1," thin film at the site of application If Remove old patch before applying the new patch
a lotion I\ I funn Of .l Suspension, the COntainer Transdcrmal fonns of medication should he
should lw ' 1gorously to mix solute in the solvent applied by the patient and should be hand led c;ire-
ftil ly 10 avoid con1act wi th the med ication, which
Patches, C,. and Transdermal Dots may be accidelllly absorbed {l'igure 13-1). Washing
Some topic.11 m Jications are prepackaged in 1r.111sder- hands immed iately after mcd ica1 io n apf)liration to
mal disk~. p. ' or dots io provide exte nded cffcas- a\Oid undesirable absorption and undesired s ide
up to S<'Wra a>" An ex,1111ple 1s uopolnmine patd1es effecu is imponant.
for mouon '''ncs'; Soop should not be used at the application site
llll'>< fo m' are a painless. conven ient method because soap enhances and prolongs absorption
or .1dm1 11'\ering mcdkatio ns for many medical See Box 13-1 for info nna1ion concerni ng medications
condit <ms. that typically come as tran~dcrmal p,11ches.
 208 ~ECTION Ill Mer~d1~c~et~1o~n~A~dm~1~ni~st~ra~o~on~----~-~-~------

. . o1 N.llrog lycerin Ointment

PROCEDURE 132 Apphcallon
0 f nitroglyceri n oimmen1.
Objective: lo properly apply ordered quanuiy
Guidelines l!!!J !IJ
Equipment Needed
~1ctlicauon order . . a rs
Nurogl)'Ccnn ointment w11h me'"ured apphcauon P pe
Glows
Supplies to cleanse skin (if applicable)
lape as appropriate
Methodology B
. o f res'dual nit<ogl'-cerin
I llftcr idenufying naticm. cleanse skin _, ointment. Site should be dry, rcl.mwly free of
,. ed d 1 basis.
h.tir, and without scar ussue and r~ta~ on a ~ Y Id be ueezed and mea~ured directly to th<
a fhe pre-;cribed dose Of nllrogl)'Ct'nn In inches S OU sq
manufJClurcr's applicator paper . lh beats/min. If below 60 beats/mm r .ult with
3 Check the p.111em's pul~ and ensure rate is greater an 60

physician before applying ointment . of adhesive tape may be appli1 ' u prevent
4. Apply ointment to skin and hold in place for LO seconds. A sinp
slippage of p.1pcr . . be added if the desired I'll t is not
5. A plastic or wax occlusive dressing that comes w11h lhe 01mment may
being arlurved
6. Document 1he prcxc<lu re.

TYPICAL DOCUMENTATION
7/13/XX 9 15 Mt Pulse 72. Nitrogl)'Cttin ointment 2 in(hes applied to lefi upper chest after skin cl1.1r
Tape applied 10 application paper 'lo apparen1 immedia1e adverse reaaions. (. U

Sprays and Aerosols Special Considerations for T c al

Some rnedica1ions. such .ts ethyl ch lorid,, come in
aerosol or spray applications. Before application
the skin rnusr be dean and dry. The container must
be vigorously shaken to ensure medication and pro-
pellant ,1rc e.11nly distributed before application.
nw comaincr label will specify lhe dis1ance to hold
the rncclica1io11 from skin; the usual distance is 6 lo
12 inches. Spray should be fine and even, applying a
thin mcdic,11io11 co.iring to skin. I lolding lhe con.
1aincr too dose 10 1he skin ma)' result in a thin.
walCI)' distribu1io11 .
Medications in Geria tri c Pat1 s
-
The skin of older people is fragile .111d tlu blood suppl)
is dose to the surface wi1h thin skm, 1111 .ong the risl.
of bruising. Medication should be .ipplutl '""' 1ly 10 1ht
skin with minimal friction, a~ the cld1 rh ,1ho h,wt
diminished sensations of pain, 1cmpcr.i1ur. .111d itching.
Skin should be observed on a regul.1 r h.1\1, 10 cmure thal
the medica1ion is not causing irrita1io11 .11al hrcJkdown
of lhe skin itself. With dry flaky sk111 "'' .11lon may
occur and any skin changes should lw ulhtrwd ,rnd
documented when ap1, lying 1opic.1 I llll'01< .111nns.
 CHAPTER 13 Percutaneous Routes 209

...
Pe1cutaneoos routes of medication adm1nrstratoon are those
through sJcrn and mucoos membranes
The percutaneous route is used because of ease of adm1nrs
tra11on. low nsk of systemic adverse reactoons. and to ach1~
a slow. steady, extended-dura11on drug effect
Because the amount of medicauon 1s not always delivered
w11h the same absorption rate. 1h1s route of admrnis1rat1on
cannot be used when reliable amounts of med1catron must
be absorbed
When a topical medication is applied 1n powder form, the
skin should be dry to prevent caking and crustrng of powder.
Figure 131 ll.fJ of a uansdermal medication patdl (fromVoong
;l)l1
and only a thrn layer of drug should be applied
AP. Ploc!OI DB K ths lllBdical ass1S1ant ed 11, St looos, 201 1, W8 Creams are absolhed into the skm because of their water
SatnlefS) base. whereas ointments have an oily base and tend to
<emaon on the SIJlface of the slun, whefe absorpoon is
BOX 131' ~ N MEDICATIONS IN TRANSDERMAl
prolonged
PATCHES DISKS
N1troglycenn omtment is applied directly to the chest to
N1trogly a Q na pectons 1s applred as a pa1ch to ma1nta1n a slow. continuous supply of medrcat1on for angina
upper che worn for 12 hO\lrs mIlle morning and then pecto11s When nitrog~errn orntment 1s used. any residual
removed mo with srte rotation on a daily basis. ointment should be removed before applying a new dose
Female I 1the form of utradiol dots and patches When nitroglycerin is admrnistered, the med1ca11on should
to reheVf "al symptoms such as hot Rashes. night not touch the person applying the drug because headaches
sweats. n 11 dryness should be applied to thighs and and other side effects may occur if nitroglycerin is absorbed
buttocks N ibsorption. Sites should be rotated on a through the fingers.
prescn~ ' le ~1 the prescnbed site Lotions, used to control itching and relieve joint pain, should
Scop<>I ed 10 P1event the nausea and vomihng be applied lightly to prevent increased irritation
of mot is applied as a dot behind the ear for Prepackaged disks and patches are used for multiple medical
oess. 1h1s medication should be applied cond1tt0ns rnclud1ng allergy testing Applicatoon sites are
ma"mum
4 hours vel. detem11ned by the indication for the modicauoo Body tern
IOU1ageS1C) patches are used as conunu perature may vary the rate ol absorpuon
ronoc parn These patches remain in place Topical medrcations should be applied gently to older
:e s te of application changed with each pe<soos Then skin is frag le and the blood supply is near the
awloea event slun 1rntatoon and possible lack of surface. causrng easy bru1smg
absorpt tJCS
l\'icol Jre used to assist with smoking cessa
1ion Pr J 3-month supply, the patch is changed
INBfY 2 fhe patien1 should be warned against BUCCAL AND SUBLINGUAL
smoking wearing the patch because the increased MEDICATIONS
nicotine ~v coronary symptoms.
Patches to assist with diagnosing allergies. Patches Sublingual medication administration involves placi ng
conta1~ mounts of 20 to 30 suspected allergens are the medk.uion form, such as tiny porous rablet~. a liquid
1od1111dua on forea1TTI Of back. covered with cellophane. squeezed from a capsule. or an aerosol spray. undcr the
and rea:! hours later. As with all patches. the allergen tongue for rapid absorption into the bloodstream
and <lat of apphcatlon shoold be oo the patch. through mucous membranes (Figure 132, A) . 'litrogl)'C
Contrace e applied to !Ups ~ry 7 days for 3 weeks erin is a drug typically gi"en in this manner.
O...ng1 \". k no patch is applied These patthes Buccal administration of medicauons in,"Ohi:s placi ng
ed to bollocks. upper outer alTTI, or upper the drug between the cheek and gums for absorption by
does not effect placement local mucous membranes. Buccal medications may also
"'~ (Ritalin) is applied as a patch in the be absorbed systemically when absorbed in 5<'11iva .tnd
morn ng a moved midafternoon (about 9 hours) swallowed (Hgure l 32, 8).
Patches o 111111ng 1esros1enme. a male hormone. are With these medications the patient's mouth should
available In 'oi ty application using IWO different applicauon be damp before administration . The patient should
sites Thi. m1 d1cat1on is also available in c<eams and gels avoid eating. drinking. or chewing while the medication
for 1op1cal application
 210 SECTION 111 Med1cet1on Adm1mst1ation
A
figure 13-2 A. Soot~ ac trat.an of medicatJOn B. 8'JO;al
admMtrat ~ of m. 'llication Ifrom Leahy JM. K111lav Pl l'cvndalltltlS of
nursmg Pictics a n>J1sing /l(CQ$S 'fl(XOJdl. PMadelphla t998. WB
Saunders I
b in place. Subllngual and buccal medications should
not be swallowed but should be retained in the desired
loc.11io11 un1il thry have dissolved. If medications are
swall owed, the 1imc for .1borption will be prolonged or
1hc 111cdica1ion may be changed by gasuic juices and be
incffc\tive.
OPHTHALMIC MEDICATIONS
Common ophthalmic preparations come in the form
of oin1rnenrs. liquids, and inrraocular di,ks. The disk
re..cmbles a comact kns and is placed in the conjw1aival
s.ic for a longer-lasting medication efTect. Af1er insertion
by pulling the lower lid awJ)' from the~ allowing the
disk to float on the sclcra, the disk remains in place for
the desired period of time. The patiem should be
instructed to not rub the eyes. to pre\'ent q-e irritation
or 100-rapid absorption.
Drugs applied to the eye must be sterile. and only
medicauons marked ophthalmic should be used in
eyes Th- drugs should not be appLied directly to the
corne.1 because the cornea has a rich supply of nef\-e
fibt>rs. The conjunctival s.1c is much less sensiti\"e and
therefore 1s a more .1ppropriate site for drug administra
tion. f.>oe drops should be warmed before they are
instilled 10 preven1 excessive irritation. Procedure 13.3
oulfines how to instill ophthalmic medica1ions.
OTIC MEDICATIONS
Internal car s1n1ctures are sensitive to 1emperaiure
ex1re111e., so all ear medications should be administered
at room tcmpcraiurc. If cold drops are placed in the ear,
venigo and nausea may occur. Dror>s can be wanned by
holding the medication bott le lmwccn 1hc hands r.
8 proximately 2 minutes. Although the outer ear is 1~
ferite. sterile drops and solution~ >houlJ be u~ if tht
~rdrum is rupiured or if tympanic tubc' are Pr\'Seot
Nonsterile solutions that reach the m 1ddll' car may aUSe
serious infections. Sterile opl11/111/mo/og11 1/r1r~ may"" r.s..t
as mic ineLlicatio1u. bur ouc ml't/1ca1im1<rn111101 i,,, llsM ff<
ophthalmic we. Never fill the car canal wuh a mediciot
dropper because this can cause pressure in the CJnal and
can cause funher injury to the eardrum 1'.,..,.,r_force any
solutions into the ear. fhc proccdurt- for tn\lllhng ottr
medications is outlined in Procedure I l I
Nasal medications. administered by .11om11.-r. dropper
or aerosol spray for local efTect, m.1y h .1h,orbed for
systemic efTects via the bloo<lst ream but 11 u\ually con.
sidered topical or local medication\ ' .11 drugs are
commonly used 10 stop nosebleed'> m " rnngestants
for blocked nasal passages resulting """' <inusitis or
upper respiratory symptoms. Nas.11 J ru1 .uc rdativcly
safe when administered in srn,111 do.. J> needed,
however, these dn1gs may change vi ial "I 1i1hcr imen-
rionall) or accidentally. Rcpcaicd U'>l' < ,J,rnngestanl
sprays, such as overuse of o.ryme111wl {Afrin), can
worsen nasal congestion, called rchm 1111ctlon.
To instill nasal drops:
Tilt the patient's head b.1ck nr r l.1 he patient in
the supine position wi1h thc 11<'.lll d b.Kkw.ircl
After medicat ion instillation, lilt ti ,,,cl forwud
to distribute the medication prop1. .tkmg short
quick breaths will help Pll-.td 1 nwdica1ion
evenly.
An) nose drops that spill into till' ti 1t should bt
expeaora1ed to pre\>ent S)"itcnuc 11 11.-cts.
Nasal sprays are used incre.1~1ni;I> tldrninista
various medications for rapid absorpu no 1he \-.sl
capillary supply in nasal pass.1gcs l lru 1r migraint
headacbes. smoking cessation agtnl\ .111 rtlSOnt and
decongestantS for sinus condiuon\ all 1 r.-" mahu
tions administered by means of 11.1'>.tl 'I' 1
Use of nasal sprays and ato mi.1,r 111\<ll\'CS tlw
following:
The parient should be sirung upugh uh the head
tilted l>aclnvard.
Before application, nas.11 ll"'' ' ' hould bt
cleared as much as possiblt-
To adm inister medication, occludt , 1111 noslril and
have the pa1ient inhale through 1111 11lu" .
Be certain the spray 1ip ;. ccnl'rnl 111 1hc nostnl
and not agains1 the na.\al cavity w.111
ro deliver medication, scr11cczt. ch-. , c1nt~uncr while
the applicator is inside 1he no"til
 CHAPTER 13 Percutaneous Routes 211

PROCEDURE 13-3 Instillation of Ophthalmic Medications

Objective: l o in~ull sterile ophthalmic eye medications
Guidelines lk!J llJ
Equipment Needed
Medication order
Gloves
Ophth.1hn1r mcdic,llion .1s ordered
Supplie' to clc.1me eye as needed
Methodology B
Instilling Eye Drops
1 After idcntih mg patient, cleanse any drainage from eye moving from inner to outer canthus.
2. Wrm l')'< d101" by holding in hands before instillation to prevent eye irritation. Be sure medication has
ophthahmc l.1b<'I
3 llold m<d1< uon dropper approximately Y, to Y. inch abow conjunctiva! sac. taking extreme C.1rC not to
contamm~t dropper by allowing tip to touch eye
D Drop pr.'SC"t d mount of medication into conjuncti\'al sac to prevent irritation to cornea. If person blinks
or d o<CS th ' l:>t>fore administration. repeat the procedure.
5 When .1dm t~nng a medication that may have a systemic effect, apply gentle pressure to nasolacrimal duct
for 30 t r, wnds after administration to prewnt overflow of medication into nasal and pharyngeal
pass.1g<
6. Instruct I .. 1 w dose eye to he.Ip distribute medication from conjunctival sac.
7. Docum11 ' 1>1occdure.

TYPICAL MENTATION
7/22/XX l I l'iloc.1rpine hydroch loride ophthalmic drops, gu i both eyes, with no apparent adverse reactions.
- - -- - - - - - - -- - - - - - - - - - - - C. OLSEN,CMA
Instilling >intm ent
I After 1d. 1111 1>atient, cleanse any drainage from eye, moving from inner to outer canthus.
2. Ile ~ll , , 1llnn has .in ophthalm ic label.
8 Ask p.1 tlook at ceiling. Hold ointment applicator Y, inch above lower lid and apply a thin stream of
ointmt 111 1g inner edge of lower lid from inner to outer canthus.
4. Ask the t to dose the eye slowly, then open and close the eye several times to further melt the
J Ji>mbute the medication across the eye.
c-., ml>dication on the eyelid, remo"e wnh a tissue from the inner to outer canthus
1 h is nl'Cess.Jry, apply dean one over eye and tape it surely without applying pressure to eye.
MO'lt mm rm mdy blur vision for up to 30 minutes.
7. D<xumuu pn><cdure.
 212 SECTION Ill Medocetion Administration

PROCEDURE 133 Medications- cont'd

Instillation of OphthaIm1c .

TYPICAL DOCUMENTATION .
7/15/XA 4 26 PM NcCKporm Opth. Oim y,- applied 10 Rt eye after deansing eye of residual m,111t No apparent
adverse r~acuons - - - - - - -- - -- - - - - - - - - - - --
( lSEN,CMA

Ihe he.id should rcm.oin 1ihcd back for about 5 Suppositories may require an .1ppl ior or rnay be
minutes, and the patient should not blow the nose. hand insened after being lubrit,11o 1r moistened
If aerosol mcdic.11 io11 is delivered as a metered with water for ease of i11scr1ion
dose, shake the rontainer well and insen the lip Most vaginal med ications arc pr,
"'''" for use at
i1110 the nostril. lnstruc1 the pal ient to hold his or bedtime and are best used wh lying down
her brc,11h du ring the admi nistration of the medi- Women should remain O~t for ,11 't 10 minutes
ci ne ( ligurc 13-3 ). after inscnion of a c-rt>arn or supp1 1ory.
111e medication course a; pre,cril> hy the ph)~i
cian should be completed lwr.111 h~ CdU'iati\t
VAGINAL MEDICATIONS condition may return if the ll1l'd11 11 is S10ppro
earl)~ even if i1nprovcmen1 c;ccn1' \rl'nt.
Vagonal medica11ons Lake the fonn of suppositories, Vaginal medicatio ns tend to rl"\ltl1 h.1imgr;wt
tablets, creams, or solutions and are absoibed through of pamy liners or tampon~. ii '' .1hle 10 !ht
mucous membranes for treallng local infect.ions. physician, will assist in keeping 11 111on in !ht
Solu11ons used for irrigating. or douches, may be vagina for absorp1ion
antiinfcctant5 Douches may be either prescription Be(ore insenion, vaginal ~uJlp< <'S shoold
or OTC preparations not be handled more than nnc 10 llfC\"'11
Creams and fo.1ms. available for contraception and premarure melting of the m<'tlir.11 I<' CO\eOng
to trea1 fungal mfections. are insened with
applicatOI$
on the suppositoty should ll< ""d btfo1t
insenion.

Figure 133 Adm1n1s1ra11on ol nasal rned1cabQn mom Cheste1 GA: Modern medical assistmg, Philadelphia. , WB SJ 111uri)
1998
 CHAPTER 13 Percutaneous Routes 213

PROCEDURE 13-4 Instilling Otic Medications

Object ive: lo instill ear medicarions.
Guidelines l(}-+ I [)]
Equipment Needed
Medirntion mder
Otic rnedica11on
Cloves
eonon 10 fill external auditory canal
Methodology B
1. After identifyi ng person, ask patient 10 lie still to prevent injury fi-om ear d ropper. I lead should he 1urned 10
side with .tlh'ctcd e.ar up.
2. llold mt:tl ion 10 warm solution
l. r-or olde1 ,1 1. . or aduh ear, straighten ear canal by pulling external ear up and oul or back If pa11en1 is 3
yers ol .Jfl< or younger, gently pull external eM down and hack.
D Slowlv a.tr mbtcr prescribed amoun1 of medication, holding dropper abou1 Y, inch above ear and aiming
drops 101. II of canal rather than toward eardrum.
s. ~nd} ,. outer ear to mo-e medication inward.
G. Ask pati.. 111 t remain in same position for 5 minutes 10 allow medica1ion to be absorbed.
7. Documcn 11ll>(cdure..

TYPICAL JMENTATION
7/13/XX 2 i <.onisporin Otic Solution, gns iii RL ear, whh no apparem adverse re.1etion. Pa1ienc insirueted
in proper n111 ''"I of ins1ill ing ear drops a1 home. G. Ol..5EN. CMA

. ..
The vagiria pr
therel01e fo
, its own secretions for an antiseptic ettect,
rlouching may change the acidity in the
f I

..
I I

"3Qlld4 cana king the woman more p1one to vaginal mfec- Bua:al and subhngual med1cahons are absorbed thtoogh
llom from e1 dent body ftora or 1nvad1ng bacteria. /!Jt.ier mucous membranes of the mouth Sublongual medications
11S1ng campa 1 ve caused women to believe douching 1s are absorbed rapidly because of the nch blood supply under
neces,saiy. in 1 11 v daily bathing should be sulftc1ent for clean the tongue.
l1ness Exce 000r and vaginal discharge are symptoms of Ophthalmic medications. usually drops or ointments. are for
on!ectoon llld eq~ re medical attentoon i:optc;al admm1stra11on. although some have system: eHects
Medication disks resembling contact lenses are also used to
provide prolonged medicauon application to the eye.
When adm1nis1ering ophthalmic medications. be sure the
med1catoon label reads "ophthalmic
 2 14 SECTION 111 Med1cabon Adm1mstrauon

Important Fact about,M edica.t ions . -

Aborbed through Mucou s .-..,_
embranes-cont'd o~~: - :,:
O medications &hould be at IOOfll tef11)1!fature before
trallOn If droPS n cold. nausea and dimness mav
l
Altetear mcdicatlOllS are ins~ ed. me patiern s!Wd remam
m a ly1ng positJOfl wi1h the affected ear facing ~ for at least
5 rnnnes
Before onsttlltng nasa mcdtcatlOOS, be sure nasal paSSageS
are deated ol mucus Although nasal prep;wa~ons are con-
Sldeled ropocal medicatJOflS these medic<tttOOS mayeotei the
S'(1temic blood SlflJPfy and change v tal S9lt especially d
rne medlClltJOfl is rwallowed
Rebound congestion may OCClJI 11 nasal preparations are used
too oftOfl or 1nappropr1Jtely
Nasal preparations ere now available for many types of
med1ca11ons. 1nclud1ng smoking cessauon agents. oort1coste-
ro1ds. end hormone rherapy
Vaginal med1ca1tons include suppos11ones, creams. tablels.
and solutions. many can be purthased over rhe coooter
INHALED MEDICATIONS
lnh,1lation mcdica1ions are supplied in the form of gases,
sprays. powders, and liquids to be inhaled into the respi-
ra1oiy lraC1 . 11ecausc of the rich blood supply of the
res1,iraiory tracr through Lhe alveolar-capillary ne1work,
medications arc absorbed more rapidly than with any
01her mucous membrane. Drugs for inhalation may be
used to liquefy bronchial secre1ions for expectoration or
10 dila1e bronchi to e.1se breathing. Inhalation is also
used for oxygen 1herapy and general anesthesia.
DI")' po.. der lnh,der\ (DPI) provide a gi\'en amount
of medica1ion as a dry powder. Breath activa1ed and
easier to use than 1he me1ered dose inhaler, DPls penni1
20% of 1he medication to reacb the lungs in most cases.
MNer~d do'" Inhaler<> (MDls) are handheld
dC\oices tha1 disperse medications imo airwa)'S and lungs.
l.lCh measured dose requires about 5 to 10 pounds of
pressure 10 activ.i1e the aerosol Older people may have
insufficient hand strength to aC1ivate the application, so
.1dapters or aerochmbera are available to assist wilh
coordmation for accurate administration (Hgure 13-4).
Use of an MDI also requires coordinating breathing
wilh med1ca1ion adminima1ion; ir coordination is not
presem, the medica1ion may be sprayed into the back or
the throa1 only with a small amounr of medication
rcacbing 1hedcsirl'<I si1e. ror the full amount of medicine
to reach the lung;, rhc inhJler must be depressed just as
the person breathes. Use of an MDI is outlined in Pro-
cedure 13-5.
111e fim inhalation of medica1ion opens airways
and reduces inOa111mation, whereas 1he second dose
figure 13-4 Ame1ereddose1maler tff(llllYoung AP Prouor~ A'i>ls
/!le medical assistam. ed 11 , Sll.oots. 2011. we Sa sI
penetra1es the deeper airways. MDI ml'lh .t11ons should
be administered a1 regular intervals tht hout the dil}
10 provide constant drug levels. F.x1r hi.es of MDI
aerosols should not be administered h" "''of pos.siblt
harn1ful side effects. If aerosol h,I\ nut I n adminis-
tered correaly, the person may haw .1 f' 1ng sens.11ion
caused by medication droplc1s on till' ll> ,. or pharynx.
Nebuli7~rs, also called 11ms11ts or,,,, .,,_ provide a
spray or mis1 of medication. With a n1lu1 r. the patien1
inser1s a moULhpiece i1110 the ora l cavil) I ~prays med.
ication while inhaling.
Rotadisk contains a mcdica1ion pm I he patient
should exhale as deeply as possible, in the mouth
piece into the oral cavity, punaun medication
poucb, and inhale the powder E.1ch 11 "k contaiiu
one dose of medic.it ion.
Curreot tteods mmedicatt0ns mclude muoduc of anttbiollCS
that are maled for treatment of lung infect 0t ihaled antbt
otics would proytde local ac!JOO 111 the llJIQs ra rhan systtlCllC
response foond with oral or parenteral adm n on
...
Drugs for .ma at1on come in the f0tm of lolders. gases.
sprays, and hqutds
Medocaoons given by 1nhatatJonare rap.div bed because
of the blood supply to lungs
Metered dose mhalers (MDls) are hand nltalers 1hat
disperse mhalatton med1catJons to the lung se of an MDI
requues coordination and srrength to push canister and
breathe at the same tune Thus elderly pJt ,,s may ha1e
difficulty using an MDI Ory powdc1 inhalers 11 Is) adm1n stlil
lxeath-activared powdered med1ca11ons 111to the lungs and
are easier 10 use than MOls
 -~-------~._CHAPTER 13 Percutaneous Routes 215

PROCEDURE 13 -5 Administration of M edication Using Metered

Dose Inhaler

Objective: To effectively admin ister medications using MDL

Guidelines ll)ll [)]
Equipment Needed
Medic.ttion order
MedicJuon o rdered
Cloves
MOI
sracer 1f indicated by age or physical condition
Methodologf B
8 ldenul' I 1en1 and remove co-er from MDI, gently shaking it to ensure panides in medication are
aerosoh1< I
2. IMtru<t r.111cnt to take a deep breath and exhak in order to prepare airways for medication.
II Position mh.1ler either in mouth with opening toward back of throat or, preferably, with mouthpiece I to
2 inchc' t " mouth, holdi ng inhaler with thumb and middle or index finger at top for compression of
inhakr >e r nuy be needed.
4 ln\ trun to u h head back slightly to distribute medication into airways and then to inhale slowly and
dt>t:pf, ti h mouth
B Pepr. 11ion canister fully and instruct person 10 hold his or her breath for approximately 10 seconds
to .1tlu .>nl med ication to reach deeper airway branches.
6. Patient J cx.h.1 k through pursed lips to keep small airways open during exhalation. If a second dose of
med ic.11 linuld follow, person should wait 2 to 5 minutes to allow fu ll distribution of med ication.
7. C'lea11' m mediately after use because an accumulation of medication around mouthpiece may
intcrf, 1 1edicatio n reaching desired locations. Some brands of MDls have different directions. so
manu r,.ickage insen should be read carefully to ensure proper use of inhaler.
8 If p.it1<n ddmuuster this medication at home, have patient repeat instruetions 10 you and provide
patll'nt n med anstruetions.
9. Docum procedure.

TYPICAL ~UMENTATION
7/12/XX ' , "Albutero l inhaler. two puffs as directed, with no apparent adverse reactions. Instructions given
for use at h ne with return demonstration by patient C. OLSEN, CMA
 216 SEC110N Ill Medication Admlmsttadon

site. rather than having to reach the sitr throu

SUMMARY
rcrrutaneous medtcauon administration is easily
accomplished and r~ults in absorption of the drug
through the \klll, mucous membranl'S. or al\'roli in
the lun~ lhc chance of S)'Stemic rearuons is reduced
because the mcdtcauon 1s administered at the desired
. 'fh . f d . . . <>'' I)\. 7
temic absorpuon. e sne o a m1111strauon ~hould bt
intact and adequately hydrated to .1hsorh the 1n.,.WI(~
ti on. use of percutaneous drugs LO t rcat S)'lnemi( ill
nesses is infrequen1 beca_use _ihc<>c a~cnis are absotbtd
slowly and dose absorpuon is unreliable nwPl'r
neous route may be the route of choice when a :;:. 8
extended.duration effect is desired

Scenario
Geor{/6 has a large abrasKNI on his lower leg from fat/mg while playing baseball. After the wound 1s
cleaned. the area is covered w11h an anr1b10t1c-1mpregnaced dressing. The allied health profess10nal needs
to reach George how co change chis dressing cwrce a day. George f1rsr asks why a systemic a 1ot1c
has not been ordered Dunng rhe ceachmg, George informs you char he has rhe same ant1b1011< 1eam 81
home and wanes co use char rather chan buy the oinrmenc form.
1. What do you tell him?
2 What do you tell George about residue from previous dressings?
3 . What can George do to make the medication go on smoothly with llUle 1erking motion to , .. kin?

REVIEW QUESTIONS '

t. What is percutaneous medic.1tion administration? Why are these routes used?

2. What are the disadvantages of percutaneous medication administration!

- -- -- -

l . Why are mcdicauons applied topically! What skin preparations and precautions should be t.lk<11

4 What prec;iuuons should be taken with percutaneous applications ofm--' '~ t.1on.s an oId er 11",-r,o
ai1,a

5 What must be on the label of medications that are used in the eye!
- - -- - -

6. What is 1hc rro11'!r position of the ear when instilling d .

rops '" a young child? In .111 adult!
 CHAPTER 13 Percutaneous Routes 217

\\'hat are common indications for nasal medications' What are some of the n~-er indications for nasal
7
spra)~ 1 ~---------------------------------~

B. \\'hat are tht form; of medications for vaginal administration' What documentation is nec~ry to ;how th.u the
patient ,,a~ t.1ught h ow to use medication correctly! - - - - - - - -- - -- - - - - - - - - - -
 Parenteral Routes

Afcer scudymg 1h1s chapcer, you shoold be capable of doing Che following:
Explaining parenteral routes of med1cat1on Reconstituting powders to liquid fo r for
administration and differences among routes. parenteral administration.
Describing how 10 select the appropnate syringe Administering med1catrons intradern (101,
and needle for administering parenteral subcutaneously !SC or SQ), and 1ntr" 1scularly
medications (IMI
Preparing med1cat1ons for parenteral administration Providing patient education for safotv id
from a vial and/or an ampule. compliance w ith the parenteral rou1t med1catt0n
M1x1ng parenteral medications for injection. administration.

Or Merry has ordered qa11ocoltalo111ill 1 mL subcutaneously once weekly, for Lynda, who has rni-
c1ous anemia Or Merry has asked yau 10 show Lynda how co give herself che m1ec11ons.
What are the appropriate sites for these 1n1ections?
How often should the 1n1ect1on sites be rotated?
Which syringe should Lynda use?
What length needle should be used for these injections?
What gauge needle should be used with this aqueous solutioo?
What do you need to teach Lynda about aseptic technique?

Ampule Diluent lntradermal Subcutane us

Aqueous Filter needle Intramuscular Vial
Aspirate Gauge Intravenous Viscous
Bevel lntraarticular Lumen Wheal
Compatible

P: "mrml/ (Creek: p..r11 plus tnrenm, intestine or

o utside 1hc alimentary canal) adminisuation of a
suhstance such as a dn1g entail> giving that sub-
\lancc by a rou 1c other than through the gasuointestinal
percutaneous routes. Injectable mcd1c.111 ll" 'hould bt
given only if a designated health profc\\t111 11 1~ available
to m1ervene in case o f adverse rcJc1ion' \ llied he.11th
professionals may prepMe and admini't"' medications.
(CJ) rraet; this route involves injection> 1hat are invasive
depending on the medical practice ,1u 11( th~ >tale of
procedures wi1h grc.1ter risks than with the oral or
employment. Parentera l injec1 ions .u c rn111111only givcn

218
 CHAPTER 14 Parenteral Routes 219

Infection is possible because the skin's protective

barrier has been broken
Once delivered under 1he skin, drugs canno1 be
retrieved; 1herefore full knowledge of the drug and
rou1e of administration. and asep1ic 1echniquc are
necessary for patiem safe1y.
Improper in1ection of medicauon may result in
damage 10 nerves, an overly rapid re~ponse 10 the
drug. locJlizcd bleeding into the skin, s1crile
abscesses, and death of tissue.

SPECIAL PRECAUTIONS WITH

Figure 14 1 1,,11aa11cular1oin1 1njec11oos areperfo1med by the physician PARENTERAL MEDICATIONS
., ., 8SSIStanee I a all ed Ilea th professional
The following \pecial precauuons are imponant:
lrri1ating and staining medica1ions are injecwd
ming the %-track me1hod for intramuscular
in10 the denm of 1he skin, or lntndermally (ID); into injections
subcu1anrom 11 ..uc or ubcutaneously (SC or SQ), Parenteral medications rnus1 be in s1erile liquid
1mo muscle r 1rJmurnlarly {IM); into joints, or form, except some sterile implan1s 1ha1 require sur-
tntraartirn ( I\); or into veins, or Intravenously gical inscriio n.
(IV). rhys1<11 1 niay ask assistance of allied health pro- A parenteral drug is usually adminis1ered in a solu-
fcss1onah "' ,ing imr.1anicular injections because tion that is minimally im1ating to ussue. such as
g1v111g in1cct1 nto 1oin1\ is beyond the scope of prac physiologk saline or sterile water. and may contain
1icc for alhl I" 11 th professionals (Figure 14-1) . a preserva1ive or a small amount of antibiotic agtnt
10 prevem harterial growth.
AIU'IJ}~ /., s11rc rile P<Jtirm receiving m1rclllble med1<11
~ S OF PARENTERAL 11ons iJ nor allergic ro 1U/t/11foes or rh<' O.ise fer r/1e
5m.! TION metlicinr wing adminisrered, suc/J 11s 11111ibio1ics /011111/
in so111e 11arcu1e.t
lhr folio" n ire reasons for using parcnieral
mL'<hca1io1
l.owt"r , o f medte.1tions are most often needed.
Medi<"" .1rc not ini1ially inactiv.1te<I by digcslive
1uiCL">
A\oil
I 1he li'7cr.
I I a drug is increased because the medi
. ..
cauon 1he circula1ion fas1er and wi1h less
inacu' 1 " 11 from metabolism before absorp1ion. Parenteral med1cat1ons are dehV1Jred through the skin, requir
r he J101111 '" o f anio n may be shoner than wi1h ing strict sterile technique and care in selecting the correct
enter t .ations gauge of needle. synnge. arod site for admmistration
lnjeu 1y be used when a patien1 is unable Rootes of medication admm s11at1on most frequently seen 10
lo S\\J 1 " !>e(ause of physical incap.1city or when ambulatory care settmgs are ID. SC. and JM A Ztrack JM
pa1ier"' h 1vc gastric disorders 1hat effect swallow mjection may be uood for 1rntat1ng medications or for drugs
ing 01 > plion of medicines. that stain skin
Agem r he added 10 injectable medicines to Parenteral medicatlOOS are used when enteral forms of drugs
prolon I "'ired effects. cannot be used. when a more rapid rate of <Kton rs desired.
or when the drug would be 1nact1vated by d1gesllve 1u1ces
Drawbacks to the parenteral administration of drugs include
AGES OF PARENTERAL pain on adm1111stration. 1nabtlity to retrieve medications grven
ATION in error. and the possibility of 111fec11on 1f asepbc tedruque
1s not followed
Oi;advam.1g,., mclude the following: Medications must be in a sterile liquid form Additives are
Pain oc1 u1 , on administration. foond m some parenteral medications. and 1he patient's sen
Strict adha cnce to aseptic technique is necessary s (rv1ty to add tM!S should be checked
,,,.ith p.1rtrnt.' rt1l adn1inistration.
 220 SECTION 111 Med1cat1on Admimstraoon

A plunger, used 10 deliwr 1hc nwdicat ion

EQUIPMENT SELECTION FOR
INJECTABLE MEDICATIONS
Medication Containers
ln1eaable medicines att supplied in dated single-dose
.. mpule,, single-dose or muhidose vi.Us, or pre6lled
syringes Ille person admuustermg the drug should
check the exporauon date and that the liquid does not
sh" dctenorauon from improper stor.ige.
remain s1erile within the barrel and hould mui1
. not ht
touched when OuL~1de the b.lrrd (Sl't' I igure 14 .
The plunger fits inside the h.mcl and SJ
back and forth, fom1ing .1 tight -.cal ~::
interior walls.
Some syringes such as 3-ml syringl' .ire scaled .
tenths of a milliliter_ (ml.). ?1bic ccn11111ctc~ (cc).:
minims (llJ). Those w~th .spcc1lk apphcatoons are SC~fd
in hundredths of a m1lhl11er, such .1s 1ulwrculin srrinl)!s

Syringes
Syringes. both nondospos;ible glass t)l'f'$ and disposable
one-use types. come on a variety or sizes. from 60 mL to
msul1n syring~ to some holding only 0.3 mL (Figure
14 2) Some syringes are p.ockaged with the needle
an.1che<l (I 1gure 143 ). Most commonly used syringes in
ambulatory selling~ are 1 ml, syringes and tuberculin
syringes. A 5 ml syringe may be used when larger doses
of med1c.11ion arc required. although the usual largest
.1cccpt.1blc .11noum or medication 10 be givea to an adult
IM h 4 ml. An in;ulin )'ringe is used only for adminis.
ir.uion of insulin
Syringcs consist of a cylindric barrel with a tip designed
10 hold 1hc nect.lle and a plunger for delivery of medici ne
(Figure 14 4 ). Syringe variations indudc the following:
A tip may be a plain tip, in which 1he needle slips
on10 the lip, o r a Luer-1.o k tip, in wh id1 the needle
muM be 1wi.ied onto the tip and locked in place
10 prevent acddcntJ I removal of the needle from
the syringe
A b.mcl, which holds the medication, is calibrated Figure 14-3 Var10us iypes of syr10ges wrlh II
for nw.1suring the dose. nie inide of the barrel up ma11ced in 0 I (tenths) 8, Luer Loi< sy11119c
mus1 remain s1erilc; the ouLSide of the barrel may C, Tuberculin synnge ma1ked 1n 0 01 fhu1'1rc'dll
be touched (I igures 14-4 and 145). marked 1n uJllts ffiO~ (Fmm l.illey l Hanington S
A flange keeps 1he cylindric syringe from rolling and die nvrsing process. ed &. St 1.Do1s. 201 I. Mosby
when placed on a fla1 surface and is used to steady
the hands when administering the injection.

top

l lol<llp
t 0.ml Syringe

t i wllll
urtmetlts
rt.ed

Plunqef

Figure 14-4 Ports ol a syr111gll

 CHAPTER 14 Parenteral Routes 221

'-.---1
Keep s1enle Measure dose Avoid looch1ng
hete
figure 14-5 Parts of a s;rmge 1ha1 musr not be toUChed {from l'e<ry A. Poiter P- Fundi!mentals of nmS"'fl. ed 7, Sr lout3, 2009. Mosby)

Figure 14-6 syrinqe with a reuoCUlble needle cover. as

reQuired bv Oc , 1 'r 1 Safety ond Healtll Adm1nis1ra1ion standards.

1n1taderma1
beV<ll

Figure 14-8 Types of needle points {From YOll19 AP. f'l'octor OB Klflll's
rlre medical ass1sram. an applied leommg approach. ed 11. St Louis. 2011.
Figure 14-7 pen tor ncedleless admin1stralloo of medication. Saunders.I

holding t nd U-100 insulin syringes holding continuous use and do not require cleaning and
100 units/1 11 Insulin ~yringes designated as IA1 Dose steriliz.ltion after use.
>)Tinges com o un it'> of insulin/0.5 mL o r 30 w1its/
0.3 ml fo "' wirh v1sual difficulties. If lhe latter
types of' .ire uwd. the medical record ~hould
Synnges may be disposable or nood1sposable. holding from
include 'I' 1 1 docu mcntation of the patient's
O3 ml to 60 ml. Syringes most commonly used 1n the ambu
t>referen<e
latory care selling are 3-ml and 1-ml 11Jbcrcultn syringes
fllf Q('PI 111nge !/l!CliOn j5 I/re Smal/esl Synnge
The smallest synnge that holds the amount of medicauon to
lhul u>ill I presmllt'J umounr of t11<'dica1io11 11iis
be given should be used
determina111 '" , 11~ur~ the 111ost accurate measuren1ent
ln1ector pens are available for use with irisulin 01 me
lwc,1use cah 1:1011' on 1hc syringe will more accurately
EpiPen for allergic reacltons.
show the ' 1 1 10 be giwn. Specialty syringes may be
found in <able forms. but most syringes used
in ambulat rt ~e111ngs are disposable. Needles
Safety wuh \ll nges includes lhe following: Needles for injection may be purchased separa1ely or on
Retra<1 needle covers prevent need lesticks from the w nnge a nd are available in many lengths and diam-
con111 d synnges (figure 14-6). e1cf1. or gauge~. lbe needle is actually a hollow me1al
0

Us. 11 ftor pen for insulin administration if
possibh (lrgure 1 47).Thetypeofpendcpend~on
Lhe nwdu mc and .1mounl dispensed with each
dose.
Use dr l'<,.1ble S)Tinges 10 prevent cross-infecuon.
Dispn,.1hk syringe~ do not sustain damage from
tube with a sharp poim for piercing skin
Needles are constructed with three specific points-
regular poinl for general injection use, short bcwl for
use with subcu1aneous injections. a11d intradermal b<>vel
for intradermal injections (Hgure 14-8) niter nttdle.
should be used when wi1hdrawing medications from
 222 SECTION 111 Med1cetton Adm1mstraaon
an ampult 10 pn.-vem in1ecting glass panides with
medication
four factofl art unpon.int when selecting needles:
safety, ra1e of med!fation Oow, patient comfon. and the
depth to which the net.'<lle must penetratt 10 deliwr the
drug at the appropriate sue. Ille drug's 1'1.!Cosi1y and sne
of the m1m1on are also considered in needle choice.
Needle gauges ran~ from sve 14, with the largest
lumen (open mg), 1osu.e JI, with thesmallest lumen. The
smalles1 ~1blc nttdlc that will admimster the desired
medication wnh 1he le.is1 pain 1s the needle of choice.
Thiny-onc- gauge needles are shon and most frequt>ntly
uS<'d on infection pens for insulin and in derma1ology
and plasuc surgery Ilic higher numbered g;iuge (29 or
27) h,u a small lumen and 11 shon (>, 10 r.
inch) to
prevent hendmg of the needle with in1tttions.
Tiie R.ugc' from 27 10 25 are usually shon needles (Y.
to .V. inch) commonly used for queous SC injections.
'I hese needles c.1uo;e minimal pain and less tissue damage.
L<1rger net'<lles, gauges 23 10 20, are used for IM injec
lions of l~rnus medications administered in muscle
1issue. 'I he needle mu>1 be at least I inch long and of
thickrr gauge for the suppor1 needed to reach muscle.
The poiicnt cannot feel the difference l>etween a 20-gauge
and 22-saugc needle, and the 20-gauge needle will
" 1pply medica1ions with k.s resistance when oil-based
viscous medications arc adm inistered (see l'igure 14-8).
111e general ru les for electing needles and syringes are
reviewed in Box 14 1.
Needles f0< m1ect1on come on many lengths and ga1J9es
Choice of ooedle depends on site and route of rn1ection. as
well as viscosity of the med1cat on to be g1Ven
Needles with retractable cmers meet Occupational flealth
and Safety Adm1111sua11on iOSHAi standa1ds
Four factors 1n neoole selection are safety. pat;ent comfon.
fta.v rate of the rr>dicatoon. and depth of in)8CtJoo needed to
dehlll!f the drug to the proper site
Di oosable 1-ffes ore sharp and coated with silicon for
eMe of iniectoon.
N<>oldles come with three specific potnts-<eg ai point for
g !fl'lflll 111jectoon use. short be>-el with SC route miectm. and
ontrade<mel bevel for 10 use
Needle gauges found tn ambulatory care are from 18 (a large
lumenl to 31 (smaHest ltJmen} Lengths found m the ambula-
tory care senuig are X inch to 2 inches and are selected
according 10 pa11en1 size. site of rnJection, and v1scos1ty of
med1catton
Aqueous med1ca11ons requ11e a smaller lulfll!fl, whereas
drugs on 011 or viscous bases are administered with a larger
lumen
OSHA standards tor needle handling should be followed a1
all times to prevent 1n1ul'f to the person gtv1ng the medication
and for patrent safety
BOX 14-1 GENERAL RULES FOR INJECTIONS
Disposable needle-synnge units are color Coded to1lleed~
gauge and length and a1e packaged in paper wraps or l'Ofd
plastic containers with shields ove1 the needle
use disposable synnges v.ilen possible to P>'e'vent
cross-ron1am1nation
Use asepttc 1ecmique when prepanng tnJeclable metlQ.
tions If contarn1natoon occurs. discard medlClltooo being lie.
pared and start over
Never swab the needle shaft
A1w"fS use a filter needle to withdraw mcdoca1100 frorn 1
glass al!llllle to prevent glass partrclll3 from be og aspirated
tnto fuid IDf llljectOO
Know characteriS1rcs of medication to be adm stered Ge;e
volumes of medication based on site betause l'Olumes too
large will cause pain and possible destruc ion of tnvol\ed
tissue
Recap needles on dehvel'f of medications t ic room v.1lere
the admin1strat1on will take place Oo not P needle 1n a
cotton ball Of wipe
Never combine two med1ca11ons on a synn nless spec1fi
cally ordered to do so
When preparing med1cat1ons for health car1 v1der to give.
place medicatiOll container beside filled y
Choose sites of injection that are flee of r t1ve clothing
and are not inareas where lymph nodes h<i rn surgical~
removed W1tl1 a postmastectomy p;i11en1 aim on the
side of the mastectomy should be avoided. 11ould an area
of trauma or burn
Use correct technique and 1dent1fy correct marks1"'*1
admimstenng medtcattons by 1n1ect1on
Tell pauent tl1at a little discomfort 1s to be cutd but wll
last oofy a short ume
Have assistance hold ng children to prev1 IY
Expla111 to parents the need foi inJet:troos I Id
Injections should never be used as a disc ry threat
Parenteral medications must be stcn 11 r come in
three 1ypes of containers-vials, ampuh 1~ure 149).
an~ prefilled syringes. Before using am 1.1ble med
cauons. be sure to check the expir.111n .nc and for
s1erili1y.
Ampules
Ampules are small, hermetically ~c.ikd ~I"' con1.tiners
1hat hold a single dose of sterile mcdu .1111111, lhe neck
of an ampule is thin for case of brc.ikinf\ Mrdicationl
111 ampules that are not used in cn1irc1y ,11011ld never~
 CHAPTER 14 Parenteral Routes 223

' e. Single-OOse vial c and o, MultJdosa ""'''

B fut s me medlcaJassisram an a{flll leam-
lorns. 2011, Saunders)

~ept for lat< 1 .-cause sterility cannot be assured (for

use of ampul <Procedure 14-l). B
Figure 14-10 Components of a closed prefilled inedicauon in1oc1ion
V ials syringe A. lMlassembled B, Assembled (Faom Yoong Af'. Proctor OB
/(m's the medical 8SS1$lilnl an a(fJ/l6d /eJming ~ ed 11. St LOOS.
Vi,1ls, m bod dose and multidose si.t.eS, are labeled
2011, Saunders I
wilh the n 11 ' the medication. A single-dose vial, a
small glass' o<r with a rubber stopper on top, holds
only one <l injectable medication or dHucnt for
reconslitut
Disposable Injection Units
Multido ontain enough medicine for multiple
uses. Mult1J 1.1ls may rontain I ml. to IOO m l. or Some medications come in single-dose prcfi lled syringes
more. Whe Jose vials are used, gre.it care must be that requi re use of a medication cartridge (Figure 14- 10).
exercised < ,he vial is entered to pm't'nt con- With these units. the health professional does not need
tam1ntJtio11 'uspcct contamination of a multidose to prepare the do~ except perhaps 10 expel a volume
vi:11 h.1s OCfl1 I I or if an error has been made in prepar- of medication in excess of the dose ordered by the
ing medi1 11 e 'card the vial and sian over. When physician. Prefilled medication injection ~)'stems u~e
mttlicatiofl thdrawn from a multidose vial. the a cartridge that slips into the reusable cartridge loader
drug shot. nhdrawn to the exact amount, and (Tubex and C1rpuject injection systems; Procedure
('XCe$S \Vilst~ uld be avoided . Pressure within the vial 14-3).
must be~. 1.1' by adding equal amounts of air to
replace th mt of medication being withdrawn
(Procedur< PREPARATION OF MEDICATION
Somesi ""vials con lain a powder that must be FOR INJECTION
recon~t i tuh lqu1d form. If reconstitut ion is requiied,
follow dire, 1<1ly. Each powder vial is labeled with Reconstitution of Powder Forms
name of th, uion and strength of medication per
of Medication
liquid volu mi!Jiliters), after reconstitution.
Some medications that arc un~table in liquid form are
packaged as a J>Owder for reconstitution to a liquid at
Prefille< inge the time of administration. 'J he vial label specifics the
A prcfilled a sterile, disposable syringe-and-nce- l)l)e and amount of diluent to be u~d to dissolve the
dle uni~ b 1 , ~ 1i;ec.l to supply a single dose. A prefilled powdered drug for the correct concentr.uion of medica-
syringe should never be used to admin ister an add ition.i i tio n. After reconslitut io n, weight/volume of medication
dose, cxrep1 nl new methods of insulin administratio n with the expiration and refonstitution dates and time
in a prefilku ui designed to be used repeatedly by the designated on the ,;at (Procedure 14-4)
Mme patient Tm '"n11nu.td on p 218
224 SECTION 111 Med1ceuon Administration

PROCEDURE 14-1 Preparing a Medication from an Ampule

Objective: lo accura1cly prepare a medication for adminimation from an ampule.
Guidelines lkiJ
Equipment Needed
'1ed1cauon order
Ampule of medicauon 10 meet mediation order
S>Tinge and filter needle
Alcohol swab
Sterile g.iu2e . . . .
1'ttdle of proper length for injection sitt and gauge for med1cauon vtscosuy
Methodology B
0 lo open an ampule. gently tap abo''I! neck 10 release medication in neck into larger bouom :...-.1wn of
con1.11ner
2. Wipe neck of ampule wuh an alcohol wipe 10 disinfect ou1side of con1ainer.
IJ Wi1h s1erile g.iiue .uound ampule, forcefully snap your wrists away from you so neck of am pul 'naps to
break in two If glass docs 1101 break easily, rotate ampule a quaner turn and try ag.1i11. If th.u d ' 1101 allow
opening. or 1f ampu le dO<'> not have a scored line. score neck with a file and disinfect ag.1in 11 i:l.1ss of
.1111pule is designed no1 to shatter or spill medication.
4. When ampule opens. you will hear a pop as the vacuum on the container is released. Disc.ml .11111>u lc 1op in
sharps container.
II Unc.1p filler nc<'<lle .md insen i1 i1110 ampule wilhou11ouching ampule sides. Cen1 ly pu ll bad.. , yringe
plunger. keeping 1ip of needle in liquid. If necessary, turn ampule 10 side 10 obtain all av.1il~hl 1 '"!l or
amou111 of dn.1g needed for desired dose. The container is designed 10 prevent spillnge on 1ip1>i1w
G. Recall fihcr n~edle and dispose in sharps container. Needle can be recapped because it is >till , , , 1<lered
s1crile.
7. lleplace with l)l'Of>er g.10ge and length needle for injection on the syringe.
8. Discard u'cd supplies in bioha'~'rd container. Dispose of syringe and needle in sharps coni.lin
 CHAPTER I 4 Parenteral Routes 225

PROCEDURE 14-2 Preparing a Medication from a Vial

Object i ve: 1o accur.Hely prep.ire a dose of medication fo r administr.ttion fro m a vial.
Guidel ines ll~lJ
Equipment Needed
, Medic.Ilion order
, Vial of dewed medication to meet medication order
, ~yri nge and needle a ppropriate for medication and injection site
, Alco hol '"Jb
Methodology B
1 If vial is hdng used fo r first time. metal or plastic cap covering rubber stopper must be remo\'ed.
l. Clean'' stopper from center o utward with an alcohol ,,; pc to prevent contamination of Ouid in vial.
3 Alter nmO>'mg needle cover, draw volume of air into syringt> to equal l'Olume of liquid to be withdrawn
from v1.1I \\ 11hdrawn medicatio n must be replaced with equal amount of air, maintaining equal pressure
within vi.11 10 prevel\l a vacuum from forming (for ease of aspiration). If too little air is injected, medication
"'ill br d1llilUh to remove because of the vacuum . If too much air is injected, air will fo rce medicatio n into
syrilll\l 1"11 t>Ul pu lling on plunger to withdraw iL.

I
lnn n 1mo center of rubber cap and injm air into loial.
lnwn 1 I th syringe in pl.1ce. being sure needle remains below liquid. If needle is out of liquid, air will be

a drav.n 1
Wuh<'
outsid1
ringe.
red amOUlll of medicine, then withdraw needle fro m vial. If air remains in syringe. Oick
rd holding needle pointing Straight up. Bubbles should Ooat into need le hub to be expelled.
Dr.1w I 11:h1ly o n plunger and then gently push plunger to expel ;iir, bei ng careful not to expel flu id . If
ncccs<.11 irn need le 10 vial to obtain correct dose.
7. Ncwr nuscd med ication to a multidose vial.
226 SECl ION 11 J Med1cat1on Admm1strauon

PROCEDURE 14-3 Preparing a Medication Using a Disposable

Injection Unit
Objective: lo acruratcl)' prepare a dose of medication for adminimation using a disposable inicoion uniL
Guidelines ~~
Equipment Needed
Medtca11on order
Prcfilll-.l dispos.1ble mjection unit to meet medication order
Appropriate m1cetor unn
Methodology B
D To load m1ector. hold injl'Clor m wmcal position with plunger rod in one hand With other luntl. tum
injector clockwise unul u stop>. J'his places assembly in open position for loading.
lnsen canridge wuh cO\ered needle t~ched lO open end.
I
4
furn cou111erclockw1se until prefilled syringe is tight and canridge is in closed position
I ng.1ge plunger rod onto threads of canridge plunger of sterile medication canridge.
5 Rotate plunger clockwise until r~i>tance is felt to indicate the system is ready for use and is \n ur'
II Measure ordered dose. Dispose of excess medication by pushing on plunger.
7 Inject ordered medication do.e .n appropriate site using proper technique (see Rox 14-2).
8. After .tdmimstration, remove plunger rod from canridge.
9. The prefilled can ridge is dispos..:1of in sharps container. holding injecior with needle down I l1r h
reusable and should be sanitized and saved. This system is designed to reduce risk of nccdlc.i11 I 111juries
 CHAPTER 14 Parenteral Routes 227

PROCEDURE 14-4 Reconstituting Medications from Powders

Objective: lo accurately reconstitute powdered medications to appropriate mength.
Guidelines ![!!
Equipment Needed
Powder for r~'onstitution to meet medication order
Vi.ii of dilm111 '"specified by manufacturer
Alcohol wipes
Appropri.llc 'yringe and needle
Methodology B
1 Using ind11.md diluent (as specified on medication packaging), witl1draw correct amount (as spedfied on
mcdic.111011 p.ukaging to provide proper strength) from vial or ampule. (Note: Some medications require
bartcrHl\tallr wat~r as a diluent, some call for Sterile nom1al saline. and yet others have diluent provided
with med1.-a11on.)
l Use ,,1m< rec.1ution~ to maintain sterility as when opening an ampule or vial-appropriately cleanse with
alcohol d en,ure sterile aseptic technique. Remember 10 add air to allow for withdrawal of diluenL
a lmcrt \
clean111
r ampule for ease of withdrawal or slightly inven vial or ampule to withdraw diluenL After
' of powder vial or ampule, insen needle into powdered medication vial or ampule and inject
diluent
4 Mix I" .md diluent by gently rolling vfol between your hands until mixing is complete. (Note: Some
mt.dh. '"'Juirc shaking ra1hcr than rolling, be sure 10 read medication label for directions.)
5. Ir ICflll 1 t d mcdic,11ion is in a multidose vial, write reconstituted strl'llgth, da1e of reconstitution, and
your 111 1 u1 vial. Store accordjng to label directions. (Note: Some medications must be refrigerated after
recon,11 tlfl)
228 SECTION 111 Med1cauon Adm1nistrab0n

cross-coniamination of mcdica1ions when usi ng multi

Mixing Two Medications
for Admin~
i1~t:.'..
ra :t~i~ n:.___ _ _ _ _ _ __
o::,:
Occasionally 1wo mcdic;i11ons from ,;als or ampul~
are mixed for ease of adminisiration wd to avoid
giving more 1han one injecuon Before mixing medica-
uons. 1he hcahh care professional should be sure
the medications to be milled are compatible- Lach
vial of metlicauon must ha\T the correct amount of
air added and then med1ca11on aspirated correctly to
pre\'cm a vacuum Care must be takro 10 pre\'t'DI
dose vials.
When medications arc ~ ixcd usm~ an a_m1>ule and
vial or in 1wo si ngle-dose vials, 1hc m1x111g i; relahi'dy
easy because i1 is no necessary 10 add .rn 10 the ampu1t
In me case of an ampule and vial, pr<'J>.lrl' the 11\fdiQ.
lion from 1he vial first and then from the .lmpu le. l\'htn
mixing from two single-dose vial$, add air to each and
withdraw medications as if preparing .rn lllJl'Clion usi11g
one vial. When mixing medicaliOn\ from 1wo muhidoit
vials. follow Procedure 14-S.

PROCEDURE 14-5 Mixing Medications Using Two Multidose Vials i _

.
Ob1ect1ve: lo Jccuraiely pr~~
.,,... two medicauons from two multidose vials for adminl\1r,1t1on as v~-
....,

in1ee1ion
Guidelines IIt!J [iJ
Equipment Needed
Metlication order
1\vo mcdka1 ion vi.lls to mttt medication order
!>yringe wi1h needle
CxHa needles as a1>propriatc for medication and site of injection
Alcohol wipes
Methodology B
I. Usi ng >1cri le syringe, aspirate \'Olwne of air needed to replace volume of medication 10 be rem I from
vial A.
IJ Inject air into vial A. Be sure needle doe.~ not touch solution in vial A.
1. I lo ld plunger do>rd and remove syringe from vial A. Aspirate air needed to re1>lace volume ol l I to bc
removed fro m vial B.
a lnsen syringe in10 vial B, inje(1ing air and removing proper volume of medication for dose md
Remember. If vial is multidose of controlled substance. this medication sho uld be drawn fil'\t
S. Wi1hdraw syringe and needle from vial B and check dosage to ensure proper volume has l>l'\'n ined.
Cha nge needle
11 1 ind point on syringe where 1otal of both medications should measure. lnsen needle into v1.1I mg
extreme care 001 10 allow medication from vial 8 to enter vial A Hold plunger and carefully" .1w
amoum of medication for ordered dose.
7 Withdraw needle and expel any excess air or fluid. Change needle as appropriate
8 Prepare medication for adminmration by the proper route.

II II
 CHAPTER 14 Parenteral Routes 229

If insulin i> to be prep.ired, special guidelines apply

BOX 142 GUIDELINES FOR INJECTING MEDICATIONS
.,hen mixing two types of insulin. lnis preparation o rder
is necessary 10 prevent precipitation of insulin 111 the Use smallest gauge and shortest length !N~le awropnate
syrmge barrel (I igme 14 1L).. Whe.n drawing .rwo types for medication to be given and in1ect1on sue
of insulin into ,1 synr1ge, the msuhn preparauons must If ltqu1d has coated needle while medication is being pre
!><'.from the \.lmc manufacturer. Regular insulin should pared. change needle so the medicatron w II not be uncom-
alwa)'S be dr.1wn into lhe S)rtnge first (M>e Chapter 20 for fortable gotng through subcutaneous tJssue
more infonmtion o n types of insulin). Find injection site, pos111on patient. and remove restnctive
clothing to seduce tension at sne
Medrcat1ons should not be given near bones or blood vessels.
. ' ' nor shou d they be in.iected into areas where lymph nodes
have been removed, such as in affected arms of posunastec
Occasionally two medications may be mixed for a single tomy patients
1n,ection Be re that the medications are compalble When giving 1n1ectJon, try to divert anention of the patient
When lllll ng no:dicauons from an ampule and a vial. draw lllSeft need e rnto bssue smoothly, quiddy, and without hes
the med1ci from the vial first If drawmg from two vials. tallOO. A 1etk1ng motron 1ooeases pain. When syringe is 1n
inject tl1e .i1 nto vial A before m1ectm9 air into vial 8, fol tissue, hold 1t steady 10 prevent damage to tissue.
lowed b\' n119 the drug from vial B Finally. return 10 vial Wilen rnject1ng medicaliOn, do so slowly but smoothly
A ro v. the needed medicine. tak ng care to not con- Withdraw needle at same angle of insertion Be sure to use
;e vials If one vial 1s multldose and the proper angle for type ol 1n19Ct1on berng grven {see F19ures
dose. draw from the mult1dose vial first 14-12 to 1414. and 1417 10 14-20) Wipe in1ect1on sue
with an alcohol pad after removing needle 10 reduce chance
of 1nfect1on The same aseptic techniques as are used m
fll"1llr surgety should be used to administer parentetal
ING INJECTABLE medications
NS Apply gentle pressure al in1ect1on site after edmin1strat1on 1f
appiop11ate for the medication given Massaging area will
Proper tec.1 "r adminima1ion of injectable medi- rnc:rease rate of absorption
CJlions is nt to prevent lhe following: Rotate rn1ectron sites to prevent formation of ateas of llldura-
lnjur. 1 1vcs, blood vessels, and tissues llOn or abscesses and to prevent th1cken1ng of skin from
'lbc pi .I llnv of infection locally or systemically con11nuous 1111ec11ons.
Und lur the patient Follow steps necessary for preparauon of medications 13 +
S.-c Bo. } lur tips for administering medications 71 lo1ecnons requrre use of gl~ and proper disposal of
by injecunn b1ohazardous waste OSHA gurdeltoes must be followed
lntiamuscular 1n1ec11ons in pediatric pauents have faster
IP absorption than in adults
Who in1ec C<Jt1ons are grven usmg tncorrec1 methodol
ogy. legal 1e. ons may occur due to patient m1ury.
ROUTES OF ADMINISTRATION AND
Step3 Step THE COMMON INDICATIONS
l"t'!(:I
ar
1n1e<:1 Cenain types of medications designate the route of
air
administration p :1ble 14 t ).

Adm inistering lntradermal Injections

lnsradermal injenions arc most frequently used for
tuberculin skin testing and allergy testing. The drug is
injected into the to p la)'e r of skin, where many ncsves
arc present, lhus causing momentary burning or stinging
(Procedure 14 6 ).
The need le is inserted ~la IO to 15-degree .111glc
NPfl ""' Reg1llar .;,,i in lhe skin's dermis (l 'igure 14-1 2).
Slop I Step 2 Ille injectio n is admmistered using a tuberculin
Figure 14 11 Mixing regular and NPH insulin mone syrmge syringe o r a small syringe with a short {generally
230 SECTION Ill Med1cat1on Admon1straMn

TABLE 14 t INDICATIONS FOR THE ROUTES

OF ADMINISTRATION

lnuadermal (101 Allergy. tuberculin skin testing

So0cu1aneoos 1sc1 lrMMtilaloons. msulll\ some
oonmolatong rnedlC<lllOOS
lntr~(IMI lmm11111ations. analgeslCS. anlJOOllCS,
hormones. CXJlllOOSteroods
Intramuscular Z lrak To PfMnl le<J<age of meclcatoons
11110 subcilianeous llSSUI!. especoa ly
'Wflell rnedatoons w1 dlscclor sbn figure 14-12 Needle angles lor .,iec11ng medoQ!lons. lfrllftl lbll SA
SaurJets t.mamenrats of metJaJ =rs11119 St loo 2007 Saunda.i)

PROCEDURE 14-6 Administering an lntradermal Injection .ft .

ru [I] [!]
Objective: fo giw an oniradermal injection that produces a wheal
Guidelines
Equipment Needed
Mcdic.11io11 order
Mcdkat ion appropriate 10 meet medical ion order
1\obcrculin or allergy syringe as a1>propriate
Shon. small.gauge, imradcrmal beveled needle
Alcoho l wi1w
Methodology B
I. Prepare 111cdka1ion do~c to physician's order.
2. Identify patie111, locate proper site for injection, and wipe site in a circular motion with alcohol I. from
center of injt'Clion site outward If injeaing in forearm, choose a nonhairy area.
3. Stretch skin taUI with your nondominant thumb and index finger to facilitate inject ing just und
a
II
lnscn needle. with bevel up, into outermost layer of skin at a 10 to 15-<legree angle.
Slowly mjea medication just under skin to fonn a wheal.
k m.

6. Withdraw needle and wipe skin with an alcohol swab. Do not massage area because 1h1s will if ltnal
reading of lest Oo not apply pressure because this may force medica1ion to leak from under ' k
7 Discard syri nge and needle in sharps container. Discard glo"es in bioha7.ard wasie co111amc1 ~ hands
8. Oocumem procedure. Tell patient 10 return in designated time 10 have the results read

TYPICAL DOCUMENTATION
3/18/ XX 10: 15 /\.\1 l'l'O 0.1 mL adminis1~rcd ID, Rt foreann with no apparent side efTects. Told w k"I ' ,1rea clean
and 1101 10 massage. Jnwuctcd to rei um m 72 hours for reading of ies1. Appoinimem card giwn fot 1
,.,
1 reading.
- - - - - - - - - - -- - - - - - - - - -- - - - -- C ClL~hN, CMA

onch), fine-gauge needle {26 to 28 gauge or pos-
stbly smaller) with an intradermal bevel.
Ilse only small amou111s of the medication (usually
SO. I ml.) to form a wheal (Figure 14-13).
nie sites for inuadermal injroion are the forearm,
upper back upper dorsal aspect of the arm, and
uppt'r (hes {figure 14-14 ).
Avoid ~arred. blemi~hed, or hairy areas.
Administering Medications
Subcutaneously
- ~~~~~~~~~~~~~
~ubcutancou' or adipose ti~sue is not as richly supplied
wuh blO<l<I """"'' as muscle. so drugs administered SC
are not .u p1dh ab~orbed (Procedure 14-7) Connec-
tiw U~\U u 1Jrr the 'kin i~ sensitive to irritating solu-
tions .on<I m" fonn ab;cesscs. as medication collects
under 1he ' km 1t .lbsorpt ion does not occur.
ll~r th.- "' 111vi ng guideli nes for admin istering SC
injeC1io n'
~01.1111 ,.., (S2 ml .) of nonirritating. nonvis-
COU\ uon-. U\Ually in an aqueous base. are
app1< e for SC administration.
Subc )US
Figure 14 s foomod by an intradeimal in1ect100 (from
Hunt S.&. menrals of metf;caf aSSJsrmg, St lous. 2007.
~ mass should be avoided if at all possible.
Back
Figure 14-14 S , fur 111ua<Jennat 1n1ections !from Hum SA S<J(l(l<!en
flJfltkln1.,.1,1/s of med<eal ass1st111g, St Louis, 2007, Saunders I
CHAPTER 14 Parenteral Routes 23 1
Best sites for subcutaneous mjection include the
po~terior upper arm (in the fany tissue owr
the triceps), abdomen, and .mterior aspects of the
thigh. 'I he upper back and upper vemral or dorsJI
gluteal areas ma)' also be u;ed (Figure 14 15).
These areas. except for the upper back, are conve-
nient for the person who self.injects insulin
Injection sites should be free of onfection, lesions,
and scars and be away from bony prominences and
large underlying muscle or nerves.
The injection site should be rot,ued on a regular
basis lO preveru tissue daniage..
The amoum of adipose tissue determines cl10ice of
needle length and insenion angle; generally the
needle is 25 gauge, V. inch long, with a regular or
shon bevel, and the angle of insenion is 30 to 4S
degrees (see Figure 14 12). If the patient is obese.
a longer needle may be necei..ary to reach suhcu-
taneous tissue.
Administering Medications
Intramuscularly
lntramu<eular injections (rather than injection into sub
cutaneous tissue) are used to provide medication for
more rapid absorption because of the abundance of
blood vessel in muscle tisoue. if medication would be
irritating, or if the volume of medication is too great for
the subcutaneouo tissue.
Aqueous solutions are absorbed in 10 to 30
minutes.
Increased danger of injecting the medication into
a blood vessel exists because of increawd
vascu larity.
Viscouo medications should be injcaed into
muscle; however, muscle tissue that has loM muscle
Front
Figure 1415 Sites for sullcutaneous 1nl(ltt1ons (from Hoot SA Salff>.
tiers /und.1men1a/s al medical assrs!lllg. St Louis. 2007. Saunders)
232 SECTION Ill Med1cat1on Administration

PROCEDURE 14. 7 Administering a Subcutaneous Injection ~

Objective: 10 111w an !>C injection !>.tfcly.
Guidelines ~ [)] m
._.
Equipment Needed
Med1C'JllOn order
AppropnJte )Tinge (3-ml. 1uberrulin, or insulin syringe) . _
Net'tlle of appropriaie g.iuge and length (usually 25 10 27 gauge. Ya-inch length fmsulm 29 10 l l g.1ugf wnh
~ inch length()
Med1ca11on appropnate for med1c.11ion order
Alcohol wipe
Adhes" e bandage
Methodology B
I f'rep.ire medicauon dose according 10 medication order. _ _
2 ldcmify p.111en1 and locate pn>per injection site (see Figure 14-16). Wipe area m circular mo 11u1 from
injecuon 1>ite out"ard using alcohol wipe.
II Gr.t\p ~kin firmly w11h nondominam hand, gently pinching subcutaneous tissue between thu1111 111d index
finger 10 m111 imi/e dbcomfon.
4. Insert needle at 45-<kgree angle. Angle may increase 10 90 degrees in an obese person .111d dc< I< ,, 10 15 to
4'; degrees for thin or pediatric persons.
5. Relca;c skin and aspirate 011 plunger to be sure no blood enters hub. If no blood appears, Im I .i nd
1>1eadily inject medicatio n. If blood enters bub, immediately withdraw syringe and comprc'' ' "' If hlood
h~s mixed with medication, discard and prepare medication again. If need le is removed from "' 111d
medication is not contaminated with blood, change needle before injecting in another site.
6. Wit hdraw 11ccd le ;11 same angle of insertion.
7. Apply pressure with alcohol wir>e 10 keep site from bleeding. Cen1ly massage site if a1>pro1>1 i,u ,,
mcdicn1ion ,1dminis1crcd. Apply adhesive bandage as indicated.
8. Di-.c..ml yringc .ind needle in sharp container. Discard gloves in biohazard waste container. ~ , 11c hands.
~- Document prO<'l'durc If injection given was desensitization for allergies or otl1cr nwdicatiun ,, 1 nrrcased
posibi lity for allergic reactions, patient should stay for 20 minutes after injection, depcndin~ "' thee
policy.

TYPICAL DOCUMENTATION
3/18/ XX 11:00 A\I cy.rnocob.1lam in 0.5 mL SC in 1he Rt up""r arm w'th
t'"" 1 no appdrcnt ad ver~c n:.1<.l ,,,,. _
C. t 11 ~IN, CMA

11ic m.iximum safe dose for a well-developed adult
ii routinely 3 ml. although tolerance up LO 4 ml
of medication is possible in larger muscles such as
chc gluteus medius. '111in adults should receive a
maxm1um of 2 ml . Small ch ildren, especially
chose younger than 2 )'Cars of age, should receive
no more than I ml per IM injection site.
when giving an IM injenion, the appropriate
needle must penccracc beyond the fat layer.
A longer heavier-gauge needle is necessary co 1>as.s
inlO muscle tissue. Cenerally for an adult, a. 20- to
23gauge. 1- w IY,-inch needle is used 10 e111er
decp"r ussue at a 90-degree angle (see rigure
11 11)
l\'<11JlflC. geriatric or thin, emaciated pe>ns may
rl'(!UITC a smaller-g.iugc, shoner needle because of
le)' mu'flc m.1ss .
Always I< before injecting medic:uio n to be
sure th< 11.-cdle b not in ,1 blood vessel.
A , 1wci.1l' ot 1.\1 injwion is the Ztrack techn ique,
whoch I) rr< 'nded for irritating or staining medica-
tions sucl> n dexua n A zigzag path of insenion
seals chc tnck 10 prevent leakage back into oub-
nn.rneou' h nd 10 minimize pain. After medicine
10 be g1Vt'11 , Z-trac1' technique has been prepared,
ihe nc1dk " , svringc should be changed 10 prevent
irritation co 1 "ue as 1hc needle passes co the muscle.
'llle 11 !"placed downward or laterally for
.1bou1 1 co hl-s by holding ic 10 the side of the
Skin and
subctJtaneous
Hssue pulled
to one side
figure 1416 A
S<itndm> I
--
n steruig med ca11on usmg 1l1e Z-cract method !From H1111 SA 5.wndets fundamentals o/ medical ass1sr11>9_ St lou s. 2007,
OIAPTER I 4 Parenteral Routes 233
injeaion silt (Figure l 4-16) Before releasing the skin,
inject the drug slowly and remove the needle.
Sites for Intramuscular Injections
The common sites for IM injections are the delioid area
of the upper arm; dorsogluceal or upper ooter ponion of
the hip; ' entrogluteal or lateral outside ponion of the
hip; and vastus laceralis or midponion of the 1h1g/1
When administering IM injcctions. patient posiuoning
for observation of landmarks of the eniire she is of
utmost importance.
Deltoid Site. 1 he deltoid area of the arm sho uld lw
used on ly in adult IM injections of up 10 2 ml. and i>
often used because of easy accessibility (Figure 14 l 7)
Thl' ideal amounc of medication II'"""
in the deltoid area
is 0.5 co I mL Preferably, for landmarks 10 be ''isible,
the person is seated with the up1>er arm and shoulder
exposed. When locating the deltoid muscle, care is n~ces
sary because the rad ial and ulnar nerves and the brach i.11
anery lie within the same area. Relax the arm a1 Lhc side
and then flex the elbow 10 find che triangular area formed
by the deltoid muscle. 1be injection site is in the center
of the triangle, or about l co 2 inches below the aero
mion process.
Dorsogluteal Site. Tradi1ion.11ly, IM injections h.we
been given in dorsogluteal muscle. Extreme caut ion is
necessary when usi ng ch is area hecau;e of the undcrl)ii1g
sciatic nerve and major blood vessel> of the gluteal trunk.
Penetrating the sciatic nerve with a needle may cau!>e
Needle
removed
-
T1$$U8 returns
to normal pDSlbon
Medicabon
 234 SECTION 111 Medication Administration

Iliac cre11
Superior
INJECTION SITE
gkrteal nerve """-- -I._ Glu1eu1
muse1e
"'tdiua

--
Gluteus
o.t!Old _ _ _ maximUS 7fltf'7~:.(;~-f--An1eno.
musde l lllC liP'nO

- ----r
A :dlaty

~ _J.___..Jl/itr-1 -and
uNr ne<Ye
INJECTION
SITE

1111"Y - - - --
Deep Mlcl1lll - - --
~ --+------j
nerve figure 14-19 S11e for an 1n1ramU3Cllla m1ec1on
area. !From YOlllQ AP, Pmc10< DB K1nns rhe medca
Jeaming ilfl(ltoaCh. ed 11, SI loo1~ 2011 , Saur>tlcrs

Figure 14-17 Srte f0< an 1nuamoscular 1niect1on rn lhe deltoid area

(from Young AP, Proc10< DB K1nns the med1C1J/ assslil~t. an applied le.3m-
mg 8pptOi1Ch, ed 11, St LOU>S, 2011. Saunders I Ventrogluteal Site. Although ii b 11 " u>ed as often
as 01hcr muscle tissue. the gluteus m,'d11 ind rninimU1
muscles are considered safe for all 'll''' "< .lu>e the silt
Iliac Cl&St has a relatively large muscle mass .111d li ce of major
Gluteus Posterior nerves and blood vessels. All IM mcd1 .lions may bt
mo<Jlus lhacsplne injected here. including viscous rncd1t.11"'"' because ii
muscle
INJECTION is not associated with some of 1hc inju1" 'uc h as fibro-
SITE
Gluteus sis, 1issue necrosis, and ne1vc damage, th uc .1s~ociated
max1mue Imaginary line
with 01her IM injection sites. r<>r a child I rnch nffille
musclo Coccyx may be used, whereas for an obcc adult '" need le may
Greater need to be 2 10 2Y, inches long
Sciatic tnx:hantor
ol lemu1 To locate this area, place the heel of ti .111d over the
nerve
greater trochanter of 1he hip with tlw ' 1 .11 most per-
Sciatlc nerve
pendirular 10 the femur. u~i ng 1hc rii:ht d for the Im
Figure 14-18 Ste f<X an tntramuscuta< tnj8Cll00 "lhe do<sogluleai area. hip and the left hand for the right hq> mdcx 6ngn
Ifrom Yooog AP Proc10< DB Km s 1he metlQ/ assrstanl an il(l(JlisJledln should be on the anterior iliac spin, ' ' .J the middlt
Nlfl ~ ed 11 S1Urul 2011, Saur<leri I finger back as far as possible from 1 ndcx finger.
attempting 10 touch the cres1of1hc il1 u"' urc 14-19).
The cemer of the triangle formed b) 1h. , finger and
permanent or panial paralysis of 1he in'Oh'l'd leg. There- middle finger is the injection she
fore 1hc current recommendation is that 1his site should Vastus lateralis and Rectus Fem Sites. Tht
not be used rouunely. especially in infan1S or children vastus lateralis and rec1us fcmori~ nw n the thigh
)'Ounger th,m 12 )'<'ars o ld who ha'"' small muscle mass. are pans of the quadrkeps muo;clc .,,. lh1 \..SIUI
for the l'XJCl site locauon (rigure 14- 18), the patient la1eralis fills the midponoo n of the up outer thigh
should be prone with toes poimed inward to relax from one handbreadth above 1hc J..n ' one hand
mu<eles. Draw an imaginary d iagonal line staning at the breadlh below the greater 1roch.11ucr I ms femoris
greater uochanter of the femur, across the buttocks, to is on lhe anterior thigh (rigure l4 1 ) I he rniddlt
the posterior spine of the ilium. Locate bony promi- third of this group is preferred for 1111 11'C11011 si1~
nences 10 be sure you have the correct site. Injection is (Procedure 14-8),
made into the gluteus medius muscle several inches
below 1he il iac crei.t.
Because these muscles arc well d,., ,.,, ,,..,J
JI birth,
!hey are considered safe for u;c in inl.1111, \Otinger dMn
1\ lw.1ys 1iro1cct the patient's privacy when using the 7 monlhs old and adults becau~c fcw 111.1 1111 ncrws dnd
do rsogluteI site.
blood vessels are present. An ad uh m.1y ,1.1ml or si~ ~" 1
fie sure 1he 1){'r~on receiving 1he injection can move the sire is easier to fi nd with 1hc pcrMU> 111 the supine
his o r her lc11 ,1fter .1dministution. position.
 CHAPTER 14 Parenteral Routes 235

PROCEDURE 14-8 Administering an Intramuscular Injection

Objective: 10 .1dminister an intramuscular injection s.1fely in one of four acceptable sites.
Guidelines [[!] !)] ~
Equipment Needed
Physician\ order
Medi<ation to meet medicatio n order
Syringe of ,1ppropriate ~ize
, Needle of ,1p1Hollfiate length a11d gauge fo r med ication
, Alcohol wipe
Bandagl'
Methodolo 'V B
(~fer to I u 11 17 through 1420 for acceptable sites for admini;,teri11g IM medications.)
1 Prepar< med1ca11on dose 10 medication order.
2 Afwr pdll nt idmtification, locate deltoid, dorsogluteal. '"ntrogluteal, vastus lateralis. or rectus femoris site
indicatrd b\ age size and general physical condition of 1ierson and viscosity and \'Olume of medication
3. ChooSi lie of .1ppropriate length 10 reach muscle tissue at chosen site and gauge for viscosity of
med1c t
4 Po\ili111 111 correetly to access selected injection site.
11 wipt 1h alcohol wipe in circular motion from 1njooion site outward.
1'1 llold 1t injection site for dorsogluteal o r ventrogluteal injection taut with nondominant hand to
ni; of s kin during insertion of needle. When using the vastus la1eralis, rcctus femoris. or deltoid
preV('U I
site,, p1 1 ng of tissue with nondominant hand is acceptable.
a llold (>. I o t ,yringe like a dart in your domina nt hand and insert entire needle into ski n al a 90degree
angk I 1 ! pt l1 ensures that medication is inse11cd into muscle and not subcutaneous tissue.
8. Aspi1.11 '"Cl to cn~ure that blood does 110 1 appear In hub. If b lood appears, a blood vessel has been
entl'r 1, 111irt' process should be sta rted again, replacing medication unit. If there is no blood, in ject
medic ' lowly and smoothly to minimize discomfort and dimibute medication in10 muscle evenly.
9. Qu1ckl 1tl d rw needle at same angle as insertion to prevent further tissue trauma.
10. Appl\ I ar 10 MIC using alcohol swab to prevent Sttpage into subcutaneous tissue. If rapid absorption is
de-.ir. \lie for I to 2 minutes. Cover with bandage as needed.
11. Ois<:..l d , <1u1pmen1 in proper biohazard containers Sanitize hands.
12. [)(>('\; r.xedure.
for any signs of adverse reactions with tM injections because of rapid absorption of
mcdi 1110 b loodstream. If giving medication in dorsogluteal site, be sure patient is able 10 move leg
c.ly u~ed for injection as a means of Nafuating any trauma to sciatic nerve. Ile sure a health
1 r is r~.1dily available in case of a serious adver~e reaction.

TYPICAL OCUMENTATION
2/18/XX 11 ' ll ,\\1 l'cnicillin 300,000 units IM given in Lt upper thigh. Able to move left leg. No apparent adverse
reaction ahcr w.1itmg 20 mi nutes. G. OLSLN, CMA
236 SECTION 111 Med1cat1on Adm1n1strabon

administration. Each p~re1~teral route requires SPl.'d~I

skills to ensure 1~e med1cauon .reache~ tl.1c ~esired IOQ.
lion. The liquid 1s usually minimally 1rmaung 10 lissur
and ma)' contain preservatives or a ~mal l amount of
antibiotic. Always be sure the patient i~ nm allergic
additives or the base fluid of the med ication bet IO
.. -
adm1n1sternt. ~
Syringes are chosen according 10 the IYJl<' and \'OlUllJ(
of medication to be giwn. Needles come in differell
lengths and gauges and are matched . to 1njcciion si~
depth 10 give drug properly. and v1~0\ll) or mediGIJoo

-
romons

Figure 14-20 Sol~ for lflU~ 111f8CIJOO "' 1he Vast1JS latEra!1s
lfrom Pllff'I AG Po1wr PA F""1.Jm1Jr!rals of~ ed 7. St Louis. 2009.
The smallest possible needle 1ha1 will produce thf least
pain is the needle of choice. Needles Jr<' g.1uged from 14
(largest lumen) to 31 (smalles~ lumen)
Sterile parenteral med1cat1ons mu .t be in viab.
ampules, and prefilled syringes or liqu I \mpules art
small sealed glass containers 1ha1 ho ld ' mgle media.
Mosby! tion dose. Any medication left in .1n .11111, 1, ,1f1er ad min.
isuation should be discarded. When m uio n from in
ampule is being prepared, the needle po must be kept
SUMMARY below the meniscus of the liquid. Vi.11\ " n.rnufoctured
in single-dose and muhidosc sizes 'Jn I'' p,1re medica
lnjertio11s .ire i11v;1;.ive procedures 1ha1peneuate 1he skin tion, invert the vial, keeping 1he nccdl d1111 liquid 10
.md should be perfornwd only if allowed by the medical prevent aspirating air. !'refill ed syring< ,.1 disposable
pr.u 1icc nc1 of the state of employmelll and if a physician injection units have medica1ion rc.111 .111 injection,
or 01lwr he.11th care 1Hovider is readily available in case however, dosages must be calcu lated
or .1dwrsc reactions. Safety should be of utmost impor Dnigs unstable as a liquid com<' 1 powder for
ianrc wit h pare111eml medication adm inistration. f>aren reconstitution. To reconsti1ute, be \lll'<' 1 1 vou have lhe
1cra l adminis1ra1ion- intradermal. subcutaneous, or correct diluent in 1he correct amount I<> 11 the correct
intramuscular requires s1>ecial processes while main concemra1ion of medication . M11 n o ns1ituting
1aming sterile technique. powders, always write the dale Jnd 1111 ,f l<'<OllSlfUC-
Drug< given by injection are absorbed and activated 1ion on the multidose vial, the rcwn ll'd s1rength,
faster and m.1y no1have the duration of action of enteral and yow in itials 10 prevent medica11tin
' ""
TABLE 14 2 PARENTERAL ADMINISTRATION OF MEDICATIONS
-
NEEDLE INJECTION
INJECTION NEEDLE LENGTH MEDICATION ANGLE ,
METHOD GAUGE (INCHESI AMOUNT IDEGREESJ SYRINGE SIZE ~.
kllradermal 1101 26-29 XX AdulL child 10.15 Tubeft:u[1n fot
O.l&0-2ml
Subcutaneous 25-26 XX Adult .I. 2 ml or 45 Tubereulin. msuhn. Del
!SCI less 3ml.
Same as for Child 0.5-1 nt 45 Same as fOf adult
adult
Intramuscular 23-19 13 Small adult 12 ml 90 3-5 ml
(IM) Large adult 24 ml gluteal.
v rogluteal,
1s laterahs
Same as for Same as for Clutd 12 ml Same as fllf Same as for adult Veouogluteal.
adult adult adult vil urs laterahs
Intramuscular. Same as IM Same as IM Same as IM for Same as IM Same as IM Oor~nghJteal.
Zlrack a<lult and child vunuogluteal
 CHAPTER 14 Parenteral Routes 237

o ccJsionally, two medications may be mixed in one
syringe w avoid ghing more than one injection. Always
t>c sure the medicine; to be mixed are compatible and
maxing of the dru?s.is accept.1blcw the physician.
when giving 1111cciablc medicauons, correct tech
nique as impoltdnt to prevent trauma to nerves. blood
vessels. and tissue. Given correctly, injectable medac.1-
tions should c.1use little pain; if given incorrectly, 1hc
possibility of injury to tissue incre.1ses and leg.ii reper-
cussions may be significant. l,1ble 14 -2 summarii,cs the
parenteral administration of medications. 1'11ese guide
lines must bt' followed for pa11cn1 safet)'.

Scenario
Sally is 6 months old and needs several immunizations to be given JM as recommended by the Centers
fa< Disease Control and Prevention.
1 In wtia pos1tt0n should Sally be placed?
2. What muscle group should the allied health professional choose for giving this med1cat1on?
3. What ergth needle should be chosen?
4. Shaud med1ca11ons be mixed if the health care provider does not order mixing? Why or why not?
5 How would the allied health professional choose the size ol the syringe?
6 Since t se med1cattons are to be given intramuscularly, what angle shOuld be used for needle
msort l

l;liQ!l ESTIONS
1. \\fhl1l <l L" 11rt>nter,1I administration of 11"1edicalions mean?

2 \\'hdt r 1 ar~ u~c<l for .1dministering medications parenterally!

3. Wh.11 ai< llfl<? r<?,1sons for administering medications parentc1,1lly ra ther than orally! - -- - -- - - -

4 \\'h,u 1 , Jr.1wb.1C"5 to using parenteral routes of admini~tration? - -- -- - - - -- - -- - -

5. Wh.u l J1 structures may be damaged by giving injections incorrect ly! _ __ _ _ _ __ _ _ _ _ __

6 IVhJt 1 11... calibration on a 3-mL syringe/ On an insulin syringe! On a tuberculin syringe' Give a specific use
for CJ<h

7 IVh .1t are the foctors in choosing a needle for an injooion! What are the criteria for the needle of
choacd - - - - - - - -- - -- - - -- - -- - -- - -- - - - -- - - - - - -
238 SECTION 111 Med1cat1on Adm1n1strat1on

8 What ro111a111ers Jre used to hold parl'tlteral medications before preparation o f inject ions?

9 . 110\v much diluent is u><.'d to reconstitute powdered medications for injection! _ _ _ _ _ __

10 Why 1\ good ~uc technique so important when administering medications parenierally'

11 Why 1s 11unportant10 havt> a health professional available when giving medications by injection'

12 Why<hould methcations rn muhidose vials be drawn first when mixing medication in a single-dt> ,
for injection/ - - - - - -- - - - - - - - - - - - - - - -- - - -
 SECTION

ctionl
---
 Analgesics and Antipyretics

After studying this chapter, you should be capable of doing the following:
Defining analgesic, ant11nflammatory. and
ant1pyretoc med1cauons
Identifying analgesics that are regulated by the
Controlled Substances Act of 1970.
Descnbing therapeuuc effects of narcotic and
nonnarcotic pain relievers. nonsteroidal
ant1inflammatory drugs {NSAIDsl. and ant1pyretics
commonly used in ambulatory medical care.
Classifying commonly used nonop101d analgesics
and ant1pyreucs into categories according to their
therapeutic use
Providing patient educat10n for safe r11nistration
of nonprescription analgesics and an yret1cs and
poss1bilit1es of overdose with over th counter
(OTC) medications.
Educating patients about drug safety y making
them aware of the dangers of m1x11 ()TC and
legend (prescriptionl analgesics.
Providing patient education for corr 11 11ce
with medications used as analgesic ind
antipyreucs.

J8/lnne has a h1srory of headaches. for whrch she takes nonopioid analgesics for relief Jean11 Is Dr
Merry ro ask rhat the local pharmacy be called to refill her prescop11on. The pharmacist had ml ed
Jeanne when she last refilled her prescnption that the number of approved refills had been u
What questions do you ask to get her to describe the pain?
Why do you need to ask Jeanne when she last refilled the prescriptlOn'
Why do you need to have the medical record available for Dr Merry to evaluate when yau l w that
Jeanne gets this prescnption on a regular basis?

Addiction Ceiling effect Nonsteroidal Pain perce11tion

Adjuvant medication Coanalgesia antiinflammatory Pain thresl old
Aggregation Drug dependence drug (NSAID) Pain tolerunce
Analgesic Endorphin Opiate Pseudoadchction
Antiinflammatory Narcotic Opioid
Antipyretic Nonopioid medications

240
 CHAPTER 15 Analgesics and Antipyretics 241
--~

Qp101d (narcotic) and Yes. prescriptions for Yes. depending on B. C Conuol of moderate to
OIJ'Clte analgesics controlled substances state regulations severe pain
on Schedu e 1: must be
wntten. prescnpoons
for drugs on Schedules
Ill to Vmay be \11lrbal
Cof1\bmat1on opimd Yes; prescriptions for Yes, depending on 8, c Control of moderate
nollllptmd analgesics Schedule II drugs must state regulations pain: cough control;
be wntten; prescnp11ons control of diarrhea
for Schedules Ill to V
drugs may be wetbal
Nol>opold ana SICS, Yes. prescnptions for Yes B. C. Control of mild to
antipyret1cs Schedules Ill to Vdrugs 0-asprrin moderate pain.
antunftamn-a nes may be V1libal reduction of fever and
inflammation

N OWLEDGE OF INDICATIONS ANO SIOE EFFECTS

Common d Symptoms of Pain Common Side Effects of Analgesics

Conlorted I, <;>ress1ons Lrgh1headedness, d1uiness
Fist clench Orthos1a11c hypotension
Changes m Drowsiness
Holding br Coostipation
loo eased rnarmea
lmtd!Jhtv Headadles
Rest~ Nausea and possibly YOmrting
Guardi1111
Self.focus
Faugue

11,ij:fJ i person needs to know 1hat prescribed or over-the-

PJm b "h a pcr50n s.1ys it is and exists wherever
and when 11 person says it exisis. Pain is personal
and ;uh1rn 1 1th few objective findings. Reaction 10
pain dtp , "' th.it individual's pain perception,
pain t .ind pln tolerance, as well as physi-
ologic ch. t may c.1u;e pain.
Pam n ' m intensity m different or even similar
situauon .1s time o r day or weather conditions.
Mental roe 1 n physirJI stamina, and even ethnic
backgrou11u "J ~ .1ffcct pain because pain has both psy-
rhologir .md physio logic dcmcnis; undcl' mos1 circum -
stance$ tilt '~rson~ p,1in threshold remains constanL
(Rox 15 I)
l'lie "-" mn or pain, wurce or cause of pain. and
physiologrr and dise.1sc charaC1eriscics are factors in
deciding "ha1 medrcatio n i$ necessary for pain rel ief.
Rcspo11\e to medic.11ion' is individualized, and each
coumer (0 rq pain medicines are s.1re ;r taken as pre-
scribed or Jccord ing to the manufacturer's d irections.
Fears and myths about addiction or to lerance to pain
medicatio ns o ften result in the pa1ient not receiving an
adequate dosage to relieve symptoms.
When 1>ai n is being evalua1ed, 1he patient sho uld be
asked where pain is located. its duration, and 1hc inten-
sity or the pain on a scale or l to 10, with l being the
least u11ensc pain and 10 being the most intense. Any
precipi1ati11g faC1ors for pain o r for intensification of
pain sho u Id also be no ted.
Pai n and Emotional Responses
Pain is a stimulus to the nervo us system and somati<
and vi~eral organs. The nervous system recogn "~ the
siimulu\ .ind carries it from pain recepto rs to th e brain,
242 SECTION IV Pharmacology lor Multisystem Application

BOX 15-2 WAYS PATIENTS COMMUNICATE

BOX IS 1 FACTORS THAT AFFECT THE RESPONSE
PAIN LEVELS
TO PAIN
Pain 15 usually evaluated on the basis of pat 1enl's subJecti1t
F1cto111 Thlt lncrHst flctors Th1t Decrease
repotl of type. duration. site. and intensity Pain med1cauons ..,1
Stn1111v1ty Stn11bv1ty often preSCllbed on Iha basts of sub1ect1ve symptoms The allied
Sleeplessness Sloo? hea~h professtonal can evallJilte pain alld pain manilgemen1by
Anget Empa11y
obseMIY,l the following
Tiredness O~SICll
Facial expresslOlls
fear Tolerance
An ..ery Medocauons Posture
Pat1enfs grasping or holding a body part
Isola1oOll Mlictoo
Presente or absence of resuessness or 1mtabd1ty
Depression
Vital signs and their eval1Jill1on
H"'1'JCf In the drug abusel. the a 1ed heailh profes anal may rw.,
nonverbal expresslOllS m1ssuig lack of Ille hstcd signs Shel.Id
be repotled 10 Ille heallh care prtMder for funher evalua1100
dunng the physical exam1nat1on

where stimuli are interpreted as painful. nie brain

continuto; to react until the Mimulus causing pain is
removed lk11)onse of the nervous ;ystem causes a
stres< response to release endorphins that decrease
the stimulus Prolonged stress of pain, as well as J>rO In most cases the body .1djusi- t > hronic pain
longed use or 1>ain relievers, will decrease endorphin over a prolonged period of 1i11H ' -..1use ne11t
levels and inrrc.1sc an individual's perception of pain endings have decreased scn\it iv11 lhe patient
(llox 152). may not even report chronic p.1i11 IHt.1usc it has
Some p.1in is not apparent at the physical pain site become a way of life. An cx.1m 1>l1 " thl' patient
but is fell in a different body ,1rea. 111is pain is called with anhritis, who may get liule 1d1 1110111 routine
refeoTetl pmrt. Figure 15 I shows sites of referred pain. medications.
Asdrug toleranccdcvclops, thepc1 1 n1.1ybecorne
Pain and Medications
less responsi,e 10 analgesics, rnp '"ll
n higher
~~~~~~~~~~~~ medication dosage to relieve ch11 11 liscomfon
Pain may be acute or chronic. Additional drugs may be ackkd 1 1h1 primal)'
Acute pain warns of tissue damage in some pan of analgesic for greater pain relief
the body and is usually of short duration, respond- The person with chronic p.1111 I hu1lds up
ing to JnalgesiC'\. a tolerance to analgci.ic .1 ' , J nd~ffoo
Chronic pain has a longer duration and does not reaction-so analgesics nuy 'ode littlt
have the sole purpose or indicating body tissue relief in longtenn chronic p.1 k.1dmg to
damage pseudo~ddlctlon .

Heart I.Iver
SIOlnach
Gallbladcler
Ofaty
Colon
Appendix
K'ldney
A1gt11 ureter

Figure 151 Sites of 1eferred pain, anterior and posterioo views


Af,.lgesics are by definition. medications used for
pain relief J\nalges10 include opioid and opiate sub-
stances (contro lled by the Drug Enforcemem Adminis-
uation) and nonoploid medications, which may be
prescrlpuon or mcr-the~o_ume~ (OTC) drugs. Many of
nonopio1d and nonop101dop101d preparations also
work as ntlpyrellr ,rnd antllnflammatory agents ror
a desirable therapeutic effect
Pain ltivel is what the patient perceives it to be Pam is evalu
aied l'Y L'ie pal ent oo teveJs from 1 to 10
2 The r 1 nt family. and s19ni'can1 others lwth the patienrs
perm11 ion) should be oriented to the benefits of adequate
pain~, n:igement The patient's perception of pam and past
use ol pa n ocat ,,, are imoortant factllf' to be COl!Sldered
w1tt., a ~ c Y
3 Add1ct1or anj ur. kpcndcnce (see Chupter 31) are not
a pint,, ten pan medication is used for a short period
of ~ d not be COJ1S1derat100S in trea11119 term nal
pain Add nd drug dependeoce become a problem with
longt~n t 111c pain.
4 The g g unalgesics 1s to achieve sufficient pain
corurol r111ent comfon. espe< a ly n term nal
rllnes
5 Patients be taught that various pain medications are
ava1la c different levels of pain from OTC to
Jn ;d opiates Pain rehet management 1s
indiwd nu t t>e evaluated by the pat11lflt and phys1
un aP1Jropriate regimen.
6 d '! taught !hat fDf best pain management.
b.. taken before pain IM"omes severe
1la 10 moderate pain becomes excessive to
k p the patient from receiving the full analgesic
s.on of further pain can heighten per.
s n~nsrty
Pa t patient's psycholog r plt;Wlogic. ond
ut.~d and is one of the most common symp
se patients to seek medical a1ten11on.
c ~ <11.ute pain depends on the pe.-son's
lh<i.>hold. and tolerance. thus pain relief
1 Jual11ed.
a so work as ant1pyre1ics or ant11nflamma1ory
nalges1a 1s Ill Pfoduce pan relief that s
more o Ii .live 1f used before the onset of severe pain, Pain
IS mor tootrolled while 11 is mild to moderate.
Ana be ven by mou1h. by i0ject1on. by suflPO.'"
tory. >Oerm 1y, depending on how fast relief 1s
neede<I, t11u intensity of the pain. the ability of patient to
selfadm ster med1cat1on. and the availability of the med1
C81JOO f
_ _ _c_H_APTEA 15 Analgesics and Annpyreucs 243
TYPES OF ANALGESICS
Opioid and opiate medications are sirong analgesics
capable of reducing pain of any origin Nono1>ioids may
require a preM"ription or may be bought OTC Because
of ease and popularity of self-medication, O'IC medic.1 -
tions are often used today to rel ievc mild to moderate
pam and fewr Nonopioids ma)' also be used in coan
algesla o r as adjuvant therapy. Coanalgesics such as
codci11e and ace1arnlnopl1e11 are most often used for
chronic pain but may be u~d for acute pain 1hat requires
opioid use. Adju,-an t medlca.tlo M, such as dla.upam,
given with op1oids are not true analgesics but .tre used
with analgesics to potcntiate pain relief and reduce
pseudoaddiction
~ CLINICAL TIP
Pseudoaddicton occurs when inadequate analgesic therapy 10
reduce pnmary pain takes place. leading to m1st111s1 between
pallent and medical care giver
Opioid and Opiate Analgesics
"'lucotlc analgesics are derivatives of opium or synthetic
chemicals that produce pharmaceutic effects similar to
those of opium. If purified opium is naturally found in
the medication, such as codeine and morphine, the drug
is called an op1111e- Opioids are synthetic manufaaured
narcotics such as ~er/dine (Demerol) and fentanyl
(Duragesic) ('lable 15- t ).
Morphine, used for severe pain. is considered the standard for
narcot<e analgesia This means that the analgesic amount
achieved wrth a parucular drug 1s compared with amount of
analgesia achieved with the equivalent of morphine.
Morphine w.1s first isolated from dried S(>eds of the
opium poppy in 1815. 11 was named for the Creek god
of dreams, Morpheus, wbo was the son of the Creek god
of sleep, I lypnos. Morphine was used in the Ci,rjl War,
leaving many veterans .1ddicted after the war. l/eroln was
introduced in 1898 as a no naddining substitu te for mor-
phine. In 1939 meperidine was introduced with the
sam<> assumption . Both meperidme and heroin were
later found to be addicting.
llecause sedation is one of the side effects of narcotic
analgesia, anxi<>ty that acco mpani<>s pain is al\O reduced.
Most people stop taking the medication when pain
244 SECTION IV Pharmacology for MultisystemApplication

Aespiratocy Alcohol. muscle

CONTROU0 depresSJon. rela.ants.
SUBSTANCES consupatlOO, antlf)S)thotocs
oonaiv 1etent1on,
confuSJon.
euphoria. sedation.
d1wness.
lightheadedness.
orthoslatlC
hypotens1on.
resp1ratocy arrest
morplune sulfate MSIR. Ast.ramorpll. 5-15 mg SC. IM Moderate to
(II)'' Duramorph Hl30 mg PO Q3-4hr, severe pain
SC.IM
1560 mg PO Q4h. SC. Moderate to MA
codeine (Ill" Same
IM se\lllre pain
mependtne (11)11 Demerol 50 150 mg PO Q4h. Moderate to Circulatory collapse MA
SC. IM se\lll1e pain
lantanyl (II)' Ourages1c. 12100 mcg Se\lllre chrome Md1 11 raV11nous
transdenmal: pain including H 1npatibihues
50 HlO mcg IM. IV; cance1
Ac11q 200800 mcg buccal
oxycodone (11)' OxyConlln 10-40 mg PO q4h Moderate 10
severe pain
methadone (II)' Oolophine 2.5-10 mg PO q812h, Severe pam: opioid
SC.IM withdrawal
pentarocuie1 Talwin Nx. 50 mg PO q3-4h Moderate pain Hypertension
Talwin JO mg SC. IM Q3-4h

NONSCHEDULED
DRUGS
t.ramadol Ull1am 50-100 mg PO q4-fih Moderate dvonic D1wness. MA ieuroleptJCt
pa11 hallucmations. GI :3le1lfne
bleeding
pregabal1n Lynea 150 mg daily'" Perqiheral lliwness.
dMdeddoses neuropathy, somnolence m
jXlSlherpetic
f'letlralgra
GI. gasuoontes11nal. N. Wltmenously: IM. 1n11amuscw.1y: MAOls. moooam1ne oxidase imibitDrs. PO. orally, SC. sullcutQ'lOOUsly
'life-threatenong ad>erse reaction
'Op1otd med cations 1nterac1 "'m cen11al l1fJfVOUS system medca11011s and depressants such as JlS'IChoUopics. aloohol. sedatMl l"fl
ants. an11h1stamncs, an11-t1cs. anuarrhythmoes. and anbhypertens1ves.
'ld1osyncrat1c reactions include ag11auon. restlessness. itching and nausea.
'Not scheduled et present but 1s beng evaluated by lhe Food and Clfug Adminisuanen

tops. preferring not to have sedation and confusion.
~olcrancc to these medicatio ns and potential for depen-
den< ~ keep opiate and opioid medications from being
rouunely u>ed for chronic pain, except in terminally ill
patients or those with pain unresponsive to other relief
methods \lost narcotics are Schedule II drugs because
of their danger of addkuo n and dependence (Stt Chapter
1 for a list of \Chedulcs) Drugs containing small amounts
of a 11 ,1rcouc m combi nation wilh another medicmion-
'uch as sonw of the an111ussives that contain a narcotic,
usually codd ne. to control the cough reflex- may be
placed on ~chedules Ill, IV, and V. Because of lheir
limited abu>e potential, other medications can be found
on ~hcduk \ depending on state statutes.
Uses of 0 >i(lids and Opiates
Opiate> anl o pio ids, used to treat acute pain of moder-
ate to \ CV<''< intensity, alter the perception of pain by
mimickin~ c1dorphins 10 block neurouansmission of
painful 1111r1 , rnd increa~e the pain threshold.
l hr \\'t1rld <Ith Organi1.a1ion (WHO} has described
a thr<'C ,tc ~> 1 c.ic ladder in phannacologic treatment
of pam us l1uvant analgesics in conjunction with
op1oiJ, .111.t tes with e.1ch type of pain.
,\lilt/ r 1 Ilse acernminophen, aspirin, oranother
non I anlilnll,11nmatory drugs (NSAIO)
.1rnun clock.
.\1"1' 1P1-lf pain persists or increases, add a
m1hl ' u<h as codeine or hydrocodon".
,.,.,. - If pain persists or if it is moderate to
'''" utset. give d strong opioid or opiate such
,,, "'"'I fen1.111yl, o r me~ridioe. A nonopioid
m~d1 1 , , may also be continued to assist with
p,lin , i. ol or discontinued.
A11,1l1<< " prescribed hased on age, severity of
pain, cuhur rms, and patient's pain tolerance and
pain tin< 1 ' 5ome pauents need more than a stan-
dard do'C others need less with analgesic dosages
bemgad1u 1 to these id iosyncrasies. Metabolism of the
narcotlC I in o lder children and adolescents and
slower in ' "" J,J, rly- will determine how often medica-
tion is ,1dm ' tacd. TI1c ,111,1lgesic must provide relief
without 1 at '"! un.icceptable side effects. The cell lng
elleC1, '' n o piates not pure opioids, results in side
effects of n >t"d occurrence and intensity if the dose
is mcre,1>< ' liout pro\'1dmg increased relief.
ktl c TIP
The pat Ml u t be taught to take ordered medications cons1steotly
to manta n rn evels sufftc1ently high to produce relief without
ha<;ing breaks pan control This may mean havmg the patient
take med ca~ on a regular basts for a few days or 00111 acute pam
subsi<i~s
CHAPTER I S Analgesics and An11pyretics 245
-----
. .. . ..
'
Op101ds and opiates are derivatives of opium or opium-like
chemicals thal produce s1m1lar resulls to elevate pain thresh
olds and aller pain percepllOll
Optates and opoolds halle ant1tussive effects and may cause
respiratOIY depresslOll. espeoa ly 111 the elderly
Op1otds and opiates are used for acute pain of modetale 10
severe in1ens1ty and m terminal illnesses
Add1c1ton and psychologic dependence may occur with use
of s1rong analgesics for chrome pain. These analgesics a1e
effective and safe for shorHerm uwge
Aroundthe-c:lock administration ot opiotds and opiates is
used tor severe acute pain and chrome pain of tennmal
nlnesses
Opioid and Opiate Analgesic Precautions
Use of o pioid and opiate medications may lead 10
confusio n and respiratory depression.
If the person has liver and kidney impairmen~ meper
idine, and pet1lawcine rralwin) should be used with
caution be(ause of slowed excretion time.
Constipation is often a side effect.
The cough reflex is suppr<.>ssed, and respiratory centers
are especiJlly sensiti\e to narcotics
Meperidine and morphine are physically incompati
ble drugs when administered in the same syringe and
should not be used together because of dangerous
potentiation.
Men with benign prosrn1ic hypertrophy should be
educated about urinary retention that occurs with
opioids and opiates.
f't'ntanyl (Dumge..ic), a transdermal patch applied
e--ery 72 ho urs. provides continuo us opioid administra-
tion for chro nic persistent pain 1n adults ( Box 153)
BOX 153 USE OF TRANSDERMAL FENTANVL
Skin should be cleansed with water before apphcauon of a
patch Do not use soap. od. lot1on, alcohol, or other products
because absorption of the medicatlOll 1s alteted.
The patch should be applied as supplied to a nonhairy body
surface, Pfeferabty on 1he upper body
Do not use heat sources (e g . healing pads) bee<1use they
increase absorption rate and toxic effects.
Because ot slow onset of action. short-term analgesics may
be needed for pain until the transdermal patch takes effect
Fever increases the rate of absorption by about one third
Patches should be kept away lrom children and pets. To
discard a patch. fold it together on the adhesive side and
ftush n down the 101le1.
246 SECTION IV Pharmacologyfor Mulbsystem Application
BOX 15-4 CHARACTERISTICS OF NONOPIOIO
ANALGESICS
Thr ph Ill' olog1t useJ-ill\t11nl!ammatOI'(. analgesic.
and ant1pyr.11c-are loood with llCJlOl)IOid analgesics
Aspoun has a I tlVec qual ties. ~ 1$ wily 1t 1s so wodely
used
Acetaminailhen has analgesic and ant1P'1'etoc aclJOOS but
little antnnftammatory effect e>tept 111 h~ doses.
lbopfofen has antwetc and ant ~tCJY effects with
less analgesia
N<nopioid allil~ do not alt81 CllllSCKJUSlll!SS OI menial
foo hM to tne same ~ as QPIOlds and opiates
They relieve inllammatlOll and associated 11\Jld to moderately
inti nse pa n, d~ll aches. and v.igue pa ns that occur at bmes
tlvougllOIJt the body
Most reduce llMlf
Cullural. psycholog1c, and pllys1olog1c aspects ol pain are
mtoiwoven in a person's pain pc1cep11on and response to
an<Jlgcs1cs
2. Analgesics should be taken belo1e pain becomes severe, to
ensure needed rel1el J'1ev1ous doses should still be in effect
to me1nta111 optimum relief.
3 Op101d and opiate analgesics are lor sh-OrHerm treatment of
moderate to seve1e pain
4 The patient should be wamed about sudden positionchanges
because Olthostat1c hypotens1on occurs with use of
analgesics
5 Fiber 1n diets and fluids should be increased to relieve con
Sllpat<on that occurs as a side effect
6 Pain med1cat1oos should be taken with food to min m1ze
gastrointestinal distress
"
7 Patients should a.-oid driving, operating machinery, per
forming other hazardous actrvoues alter ta~mg pa111 medoca
1oons. because of possible sedation
8 Alcohol and other aintral neMlUs syslBm !CNS) dep1essants
should not be taken with Oj)Jl)ids because 01 the emanced
analges1t: elfect and lutther suppressioo of tile CNS and
respltallOll
9 lmponant IOI' men ....,1th benign p1ostat1t: hypertrophy urinary
retention rs possible
Nonopioid Analgesics
Nonopioi~I an~lgesics. usually the first step in pain
co111ro l, wnh mild to moderate pain differ from narcotic
analgesics in sw r ral ways (flox 15-4). Most of the non.
o pioid analgcsi~. such as aspirin, ibupro/er1, and acet
am inophen, arc avai lable JS CYl'C drugs and are not as
expensive or .1dd ictivc .1s 11arrotics (Table 15-2). Some of
these drugs. when. combined . with pai n. mcdk aLions such
as opioids or opiates, require a prescription.
Although not chemically o r suucturally related
morphine, some nono pio id analg,sics do prod to
CNS effects. UCt
Most nonopioid analgesics aet o n the Jleriphtqi
nervous system rather than the ( 'l~ Acet.lm
ph?' 1s cenuaIIy arnve. w11. h 1tt Ic to no periphtqi
no.
acuon.
onopioid analgesics alone .u, not ,ffcaive I
acme, S<'\"ere, sharp, or visceral p.1in '
Nonopioid analgesics usually "'' not pr<>d11<
physical dependency or tolerann, .ii though~ '
intestinal (GI) blttding as an .1dv<r,,._ rearuonro.
possible. II
A ceiling effect does occur; in thl c.iws advtnt
reactions increase in proponio to mcrea~
amount of drug being taken
Linder the Controlled Subst.ln<t \<t of 1970.
sorne of these prescription mcd1< ''" dre listed
as controlled substances becauSl , Heney.
Sa/icy/ate Analgesics
Salicylares, including aspirin (acctyb .ihn Ii .1dd), are the
oldest, most frequently used nonop1 1 l ,1nalgcsia..
Aspirin has fewer side effects than mtht opioid anal
gesics when taken over a prolonged 1wric 11time. Salic-
ylates may be combined wi th calTeim 11 h'nt iate their
action (e.g., Anacin, Exced rin) . 01 lw1 ' combined
with antacids or are enteric coated tu 1111 po>sible Cl
problems (e.g., BulTeri n, f.cotrin)
Aspirin has four distinet 1hcrapcu1u If\~;
I. It is an analgesic. relieving I"'" inhibiting
synthesis of prostaglandin I damaged
tissue.
2. It is an antiinflammatory, dccrc.1'1 itl.unmation
by reducing synthesis of prostapl 11
3. It is an antipyretic, reducing""' r IU>ing \'JSO
dilation and sweating, causing h t , lrom skin
It also resctS 1he temperature co u 11 the hypo
thalamus 10 normal.
4. It is an anticoagulant. prolon1111lg 11111 ume ~
prt'\'t'nting clot formation by n of platt
lets. Some layprople may think ol 11 tlunning
the blood, hut clot prl'\-cnuon ' " CJU5f of
decreased chance of heart atta1 ~'
Non-salicy/ates for Pain
Another common OTC nonopioid ,l11.1li: " .icetamin
ophen: a_ non-salicylate analgesic .l1u l .11 1pyr1'1ic, t1u1
aCJs w11h m the CNS to increase 1hc p.111 hrc\hold by
mhib1tmg prostaglandin synthesis Aut.1111111ophcn is
~sed to treat mild pain and l1.1s been lo1111d m be d Tec
llve as an antiinOammatory when allm1111,ti'1cd in high
doses for osteoarth ritis. Adva 111age' of .11 ..1.1mi11ophen
ove.r aspirin include the following:
 CHAPTER 15 Analgesics and AntJpyretics 247
----

SAUCVLATES Bleeding. onchlding GI

bleeding
.,, Bayer 81-325 mg Ant1pla1elet for Ml, NSAIOs.
asp1nn
(also available suppository, fe\/9r 1n children, mild antJcoagulams.
TR. ERi Bufferm.'1 325650 mg PO q4h. to moderate pain, some
Atka-Seltzer age dependent a11algeslc, antopyretic, anticonVtJlsants.
ant11nllammatory antid1abetoc
agents

NONSAUCVlATES Nausea
acetam1nopl Tylenol 325-650 mg PO Mild 10 moderate pain. Renal failure. liver Alcohol (causes
q4-6h, 80-650 mg analgesic. anupyret1c toxicity liver damage}
suppository

NSAIOS GI distress. gasmc

ulcef. GI bleeding
lbuprof 200-400 mg PO Mild pain analges1e. aspirin, Coumadon
q4-611 ant1pyretic.
R Motnn 600-800 mg PO qd antiinftammatory
naproxen OTC: Ale\19. Midol 250mg PO bid Mild to moderate pain. Coumadin, aspi11n
A Naprosyn, ZS0-500 mg PO bid analgesic.
Anaprox 275550 mg PO bid ant11nftamma1ory

" gasuomteStmal. Ml. myccatdlal llllarctlOI\ NSAIOs. nonstcroidal antunlanvnatory drugs OTC. CM< the axmtet; PO. orally.
TR. tm re
'Maior s1 relotMlly rare.
'As~nn 'I lfl , ministered to children with viral diseases. espec1allv chickenpo
'Bulklorm1nq w1ll roduc:e the absorption or aspirin and reduce the analgesic eflec1
\Asp1nl'I a1 d I lb1smu1h subsalicvlate} both con1a1n selicviaws and should not bo used togo1he1.
'Cont n L r 1 v.!11ch reduce gastric distress

I. All ,1 up;, from infants to the elderly, m~y use

~n1.1 rhen with relative safety.
2 An ar phen rarely causes GI upset and bleed- Extrastrength OTC drugs such as Extra-Strength Tylenol and
ing r m which can occur with aspirin. Anacrn usually contain 500 mg of analgesic per tablet. \'Alereas
3 Ac.-1.1 phen may be used in children because regularstrenglh formulations contain 325 mg per tablet.
11 h 1 hcen a~ocia1ed with Reye syndrome.
4 J\ct't.1 1 'rhen c.111 be taken with anticoagulant
n1c<ll< ions. Nonsteroidaf Antiinflammatory Drugs
5. At.m ophen can be used by people who are NSAIDs arc used for mild to moderate pain when opioids
allcrgr a'pirin .111d aspirin-like dnog>. are not indk,ued. Most NSAIOs are used for inflamma
l11e man. J..advantage of acetaminophen is liver tOI)' conditions such as anhritis (see Chapter 23) and
damage "hrn used for a prolonged period of lime or for d)'Smenorrhea and dental pain. NSAIOs are available
with inta~, f .1kohol. If medication is used at less than in OTC formulations in lower dosages and by prescrip-
4 g/day for mo>l pa1ien1s and 2 g or less for elderly and tion in stronger doses. such a~ ibuprofen 200 mg found
.1kohohc IMtients. the medication is relatively s.1fe. OTC and ibuprofen 600 mg o r 800 mg as prescription
2'8 SECTION IV Pharmacology for Mulbsystem Application
med1ca11ons NSAIDs should not be taken with other
OTC analgesics (a\pirm. acetaminophen, or other
NSAIDs) fhe acceptable ume limit ror taking NSAIDs is
10 da)'~ for pain, 3 da~'S for r~-er. or as prescribed by a
health care pro\'ider n1cse medications should not be
used m the last 3 months of pregnancy bec;iuse they
could h.l\'e an adverse effttt on the fl'lus and may cause
complications dunng deltery Alcohol with many of
these medications may result m drug interaaions (see
!able 152)
Combination Nonopioid Medications
Mcd1ca11ons m,1 be combmattons of sewral drugs to
enhance mcdocmal qu,1li11es or each More common
OTC combinauons include acetaminophen with salicy-
lates, buffers. or caffeine such as Goody's Powder or
Excedrin
Antacid;, such as found with Bufferin and Alka-
Seltler, dccre.1se gastric irritation, although some
researchers believe the .1mount of antacid in these
rnedirations is too liule to be effective.
Cffcrvcscent am,1cids found in such medications as
Alka Scluer speed medication dissolution, result-
ing in a more r.1pid analgesic absorption.
Adding caffeine is thought to produce beuer pain
relier 1ha n an analgesir given alone because it slows
.1,pirin excretion and keeps blood levels eleva1ed
for longer periods or lime.
li!J CLINICAL TIP
Effeivescen1 drugs often comain large amounts of sodium and
should be aw1ded by pa11en1S with cardiac or re11al problems
IBti8riiJ.Educat1on t OrJ:CO'iTiiiliance
If someone 1s alle1g1c to one nonopooid analgesic. care
should be talen bef0111 tllking another nonopioid anaJges.c.
2 Patients w11h lrver and kidney d sease. as well as P<E!gnant
or breast-feeding mothefs. should avoid analgesics and
should take only lhe dosage suggested by then Ilea th care
l)<O\'rdef
3 11 symptoms WOl'se!I. If new symptoms occu-. O! If pain
mcreases when taking nonop1oids. lhe health care provider
shotJld be con1.1cted
4 If s1omacl1 distress occurs. the medrcatron shoold be taken
with meals
5 Aspirin and aspirin like med1ca1Jons should be stopl)ed at
least 5 days before elective surgeiy These drugs slow
blood clotting by preventing sggregat1on of platelets. and
continued use could lead 10 bleeding comphca11ons
6 Aspirin should nol be placed on gums or mUC'1us
membfanes or on 1ee1h because 1t may irritate Of burn
tissues
~
Patient Ed ucatton
-- f or
Compliance-cont'd
7 If aspirin has a stroog vinegar odoi . 1t should not be used
as the odor is a sign of medication deterioration
a. The health caie provder should be notified 1f pain persis:.i
more thao 5 days. 1f fever lasts mO!e tha" 3 davs. 01 f
redness O! sv.~ 111g develops
9 ~ drUgs may cause drowsiness arid v.111 reduce the
coonlioa11on needed to drive. operate rnach neiy,01 pertlllll
manual laSlS
10 Patients should not eJIC8ed the recommended daily dose ol
an OTC medication
11 AcetarnIJOliien may cause a falsepostMl decrease 11
blood glucose levels
12. Use of acetaminophen with intake of a!coho 111CreaS8$ Jlle
nsk of hver damage
13 Asprnn and ibuprofen should not be tak n d nng lhe sarne
bme period because lWtl med1cauons slow 1he action of
each other and 111crease side eflects sud s GI bleeding
and the decreased amiplatelel effect al rin Howeier
if low doses of aspmn are prescribed 10 Jase pla1e1e;
agg1egation. the asp11in-1buprofcn com lion may be
used if aspinn is taken 2 hours before 1ti n.
. ..
Nonop1md analgesics may be prescrrptro
Opioid and nonop101d analgesics may be
OTC 11ems
alges1cs for
more effective pain relief and to dec1easo mmat1011.
Use of OTC analgesics may lead to polyph.J v. especially
in the elderly. because these mudoeauons eild1ly ava I
able and widely used for mild to modetat
OTC medrcatoOOS with analgesic. ant1PV1e ;d antnn~
matory effects 1roude sahcytates. acewn en. and non-
steroidal antunftammatory drugs (NSAIOs
Salitytates are also used to prolong don
NSAIOs are used fO! trealment o!
diseases
NOllO!Jloids. especially OTC mcdicatlOllS.
ceiling effect when the maxllllUm elfcct
111Creas111g dose does not tnerease lhe elf
Combining Analgesics
for Greater Effectiveness
Narcmic and nonnarco1ir medica1ion' .u 1h.-11 nivtn in
comb mauon
~
because the nonnarcoll< .1~: 111 provides
a founda1ion for ana lgesic reli rl, .illm" ng. 11arcolics
to be more effective; comhin.11io11 111.-d1 ..111011s will
reduce pain from s1 i111ula1io11 of 1wrw endi ng.> or p.1in
 CHAPTffi 15 Analgesics and Antipyretocs 249

ntensifie<l by the pauent's anxiety. When used together,

~ombonation medications provide greater relief of mod-
erate to severe p.1in than if used separately. Combina-
tion> with ,Ketaminophcn ~hou ld not be given with
addmonal acetamino phen; the same is true of aspirin
,..,1h othcr S<1licylate dru~ (fable 15-3).
Medocauons with the wood compoimd in their name usually
contain aspirin Drugs ending in -cet, such as Percocet. contain
acetaminophen. drugs ending in dan, such as Perrodan, contain
asponn

COMBINATIONS OF NARCOTICS AND NONNARCOTICS

asp111n w1tt ode n Empirin wtth 1 01 2 tabs PO Moderate to severe pain Alcohol. CNS depressants.
codeine q4-6h anticoagulants
15 mg (IVI 12
30mg jlV 13
60mgl #4
acetam~ '"Odeine Fi01icet with 1 or 2 tabs PO q4h Mode<ate to SE!\'1!18 pain Alcohol. CNS depressants
30 roo-bc II ) Codeme
asp111n- 1 .:odeme F1ormal wilh 1 oi 2 tabs PO q4h Moderate to severe pain Alcohol, CNS depressants.
30 mgl Codeine anticoagulants
acotammt'Ph t doocodone lortab, Vicodin. 1 tab PO q46h Moderate to severe pain Alcohol. CNS depressants
11111 lorcet 1 cap PO q4-6h
acetn uycodone Perrocet, Tylox 1 Of 2 tabs PO q6h Moderate to severe pain Alcohol, CNS depressants
uq
f'e<codan 1 or 2 tabs PO q6h Moderate to severe pain Alcohol. anucoagulants
1buproleo Vicoprofen '
1 2 tabs PO
q4-6h

NONNARr ll1C COMBINATIONS

asp.r ~ c OTCAllacin 1 or 2 tabs PO q6h Mild pain Coumadin
aspo1 bonate OTC Atka-Seltzer 1 or 2 effeM!scent Mild pain Coumadin
tabs 11 water PO
q4h
acetam1nop pmn- Excedrin. 1 or 2 tabs PO q6h
caffeine. Goody's Powders 1 plcg 1n water PO
q6h
talb1tal Fooncet 1 01 2 tabs PO Q4h Moderate to severe pain CNS depressants, alcohol

aspinn-l:u -caffe ne Ult) fooooal 1 or 2 tabs PO q4h Moderate to severe pain Coumad1n. CNS
depressants. alcohol
ace1am1nop tramadol Ultracet 1 ' 2 tabs PO Moderate oo severe pain
Q4-6h

M1jor Side E/fects DI Cambin1ttian Medications:

Sedat100 rl - s consupallon, hghtheadedness. onhostatic hypotens1on as found with separate drugs 10 other tables. Ma1or side
eff ' a "" the .ame as those found w11h each actrie ingredient.
CNS central
Note'. M,>d1cal
system. OTC. "''
!he counter. PO. orally
nnta1n1ng aSJJorin should not be used in persons taking anuc:oagulants w as warfario
'No1 scheduled in some s1mcs but scheduled inolhers
 250 SECTION IV Pharmacology for MulosystemApplication

TABLE t~-4 SEUCTED ADJUVANT MEDICATIONS

USUAL ADULT DOSE.
MAJOR SIDE - - --
4

ROUTE. AND
EFFECTS TYPE OF PAiN
DRUG CATEGORY/DRUG FREQUENCY DESIRED EFFECT
TillCVCUC ANTIDEPRESSANT Sedauon. d1wness.
10.25 mg PO hs To elevate mood. Neuropath1c pain
am1tnptylme (NTN)
enhance opioids. confusion. nausea described as dull
doxepin (NTN) 2550 mg PO hs and vomiting,
direct analgesic aching, or throbblng
1m1pramine (Toframl) 2&-50 mg PO qd constipation. as found m '
effect
nonnptyhne IPamelorl 50 100 mg PO daily in urinary retention headaches. herpes
d1v1ded do$es arthritis, back pain'

ANTICONVULSANTS
carbamazep ne ITegretoil
phenyto.n (01lantinl
torazepam fAllvanl
topramate !Topama~J
gabapentin (Neurontin)
200 mg PO bid To suppress Same as above Neuropalhic pain
100200 mg PO qd spontaneous neM! descnted as sharp,
slll!llli shoo ng. or burnllQ.
of>-1 mg PO da1ty in as f ~ in neuralgia_
divided doses
carice and herpes
2f>-50 mg PO qd
900-1800 mg PO qd

CORTICOSTEROIDS
dexamethasone (Oecadron)
prednisone (NTN)
0.7f>.2 mg PO qd To elevate mood, Nausea and Pamol 1 ebral or
10 mg PO daily in strong vomiting. weight spinal ~rd edema ()(
divided doses antiinflammatory gain, fluid penpt ral neive pain
actioo. to stimulate retention
appetite

ANTIHISTAMINES
hydroxyzine fVistaril) 1025 mg PO qd To relieve anxiety. Constipat on Pa1nwi ausea. and
inscmnla. nausea. arooe
and1tthng
NTN no ttade name: PO. O!affy

ADJUVANT MEDICATIONS
FOR ANALGESIA

A decrease in the amouni of pain medication with an
l n~rease in pain control is the object of adjuva nt therapy.
Ad1uv.1n1 analgesics enhance analgt>sic efficiency of
opioid and opiate medicatio ns, treat symptoms that
might exacerbate pain, and provide analgesia for sped.fie
types of pain. Adjuvant analgesia may also be used
to reduce side effects common to analgesics, such as
nausea, while also acting as synergists to analgesics
(lable 15-4 ).
Route of adminisualion of analgesics must be con-
sidered because of related side effects Side effects
ma> be rapid if the analgesic is given by injection
or slow whe_n given by mouth. Knowing the side
efTec~s ~nd ~1sadvantages of analgesics and adjuvant
med1cauons is a necessary !ego-ethical consideration
when administering medic,11ions together (Table
15-.S).
Orugs may be given with analgesics to pre> ausea, vom-
iling, coos11pa11on. and other side effects.
OTC and prescnpt1on mcd1callons may be u J as ad1uvant
drugs lo p1olon9 effects of p1escnp11on mr :ons
When two analgesics are given together. th t1on is coan-
algesia When analgesics and med1cauo 1, enhance the
analgesic a1e given together. ad1uvant mod t Oil adm1nis
uatioo occurs. Plesc11ptioo and OTC mediC s for coanal
gesia and ad1uvam medications may be prt bed with the
stronger analgeSlCS to provide pain rehef at gher level
13rn1.1;rn~tfr1.1.1u.11a i1 1 ~
Children and adults ex1>erie11ce P'"' but young children
can~ot express themselws to describe the degree of pain
or site of pain. Comfort meJsurcs 10 control pain and
 CHAPTER 15 Analgesics ind Antipyretics 251
-----

NONPRESCRIPTION
Ora analges1CS
(acetaminophen,
aspirin. NSAIOs)
Rectal analgesics
(acetam1nophnl
USEd for many types of rruld to moderate pa111 Ce1hng eHec1 for analgesia
reduces fever Gasmc and renal side eHects
Easily obtained. some OTC May affect bleeding time
Used as adjuvant-additive med1cat1CH1s with op101ds Increased effects m elderly and children
Easily administered by patient or family Ch ldren no asp1nn lor wal diseases
Nooadchctrwe. nonlegend medica(J(lnS
Relatively mexpensrve
Same as above Same as above
Can be used wrth nausea and vomiting May cause rectal irritatron

PRESCRIPTION
Ora (NSAI For generaliled and localized pain Side effects omit analgesic eHects
(Sthedul 11 VJ Ceiling effect CHlly from possible side effects or Regulated by smct prescriptioo regulauons
op101dsl long-term use Less eHect1va mpatients with alcollol or
Sedation and anxiety rehef useful for moderate to drug dependence
sevare pain Sttgma or fear of use
Multiple drug choices Gastric bleeding
Easily adm1msteted by pauem or family
lneXj)ens1ve to expensive
Transdo1mdl o 01ds Long duration of action (2472 hr) Side effects not easily reversed because of
lfentany Used in outpatient settings for patients who cannot time of action
tolerate m0tph1ne or related medications Slow onset of relief
USEd for chronte severe pain May require add1t1onal medications for
Easy use breakthrough pain
Continuous release without invasive techniques Skin irritat100
Easily administered by patiem or family Expensive
Rectal OP Relatively easy to use as an alternative to oral Rectal suppositories not easily accepted by
administration patients
Can be admin1steted by family Aeclal imtallOO
Moderately expensrve SIOWl!1 than lflJEICtable medicauons
Faster onset of action than 0tal May be expelled before complete absolpt100
Can be used with nausea and vomiting owing to stimula11on of the rectal muscles
11nhommatoiy drugs, OTC. ove1 the counter

fewr ' houl I" usd with children so rhey do no t suffer Table 156 lis1s safe dose.~ for OTC analgesics in
unncces'" I In pediatrics a low level of analgesia children.
ppropr .1 , r the chi ld's age should be administered.
and ll.t ral admi nistration should be avoided if
pos~ibk
Poi,onir . rndy rr\lllt from inappropriate use of
analgesic> hy d1ildrcn, especially because some of Pharmaceutical companies are aware of the danger of children
thew rnedi.:ations arc easily obtained witho ut a pre- taking baby aspmn as candy, so OTC bottles of baby aspirin
~ription \,pirin use in children, including teenagers. CCHltain only 36 tablets-less than a lethal dose If an entire
wnh acute 'iral infoctions has been associated with bottle is taken Fedefat law requires all aspirin to be in lock-top
possible development of Reye syndrome. so aspirin bottles for chrldren's safety.
thmpy should be avoided, especially with viral diseases.
 252 SECTION IV Pharmacology lor Mult1system Application

162 mg or 325 mg or 4 tabs

asponn lchewabla tablets. 81 mgl (equal 10 1 adult
2 tabs
aspinnl
0-3 mo 40mg 160mg 240mg 6-8 yr. 320 mg
acetam.~
910 VI' 400 mg
Ill "917 5 ml. lqlid lmlant st1l '4-11 IOO
12 VI' 411) mg
ll)mg
1-2 yr 120 mg
160 mglS ml etmr
160 mgl5 ml liquid
120-mg suppos1tones May also
80-mg chewable wblets fchlldr81ls suengthl be ba$ed
on body
16D-ffig chewa!Jje 1<1blets (Junior suengthl
we ght at
80 or 160 mg sprinlde 10-15 mg/
ibuprofen Based on body weight of 510 mg/kg, dependrnq
kg/dose
40 mg/ml oral drops
on amount of fever or parn, or physician's
suggestion; not to exceed 40 mg/l<g/24 hr
100 mg/5 ml suspension
50-mg chewable tablets
I 00-mg chewable tablets
200-mg tablets
"These doses wore do1erm111ecJ lor children of nonnal weight t0< age

1derly pa1ients arc more prone to 1 11( irri1ation

Chewable analgesics should not be called candy, because
children are attracted to sweel-flal'(l1ed colored tablets. The
result might be toxic to a child who chews more tablets than
reoomm81lded
THE ELDERLY ANO ANALGESICS
The geriatnc pauent may have undesirable effects bause
of age, coexisting medical conditions. and polyphar-
macy. Aimed pharmacokineiics and phamiacodynamics
111 1hc elderly can ~uh 111 a greater risk of adverse effects
and in drug inicract1ons. Also, 1he elderly frequently lake
muluplc medica1ions to relieve muhiple symp1oms of
pain, which .1lso leads 10 imernclions and adverse reac-
tion~. Ahhough nonopioid analgesics, indudingNSNDs
and acetaminophen, are appropriate for pain manage-
mcm in 1he elderly, pcntazocine f!',1lwin) is considered
inappropriate bcc.tuse of prolonged excretion time.
JJowcver, hcigh1enetl awareness of po1>:>ible OTC analge-
sic abuse .rnd a Lhorough a~scs.sment of the pain by
1hc hc.1hh c,irc professional are important steps in
safe pa1icm care.
and for greater risk for GI bleeding. a\ '" II rcn.1l 1oxic
ity and constipa1ion. Taking analg<''i" 1h food will
decrease this possibili1y. In addi1ion, 1h1 11ic111s CXl'f
rience higher peak levels and long<r 1h 1 n of action
wilh opioid medications. Sedation, "' um of tht
respiratory S)'Slem, and urinary retc111t r 1y occur in
elderly individuals who arc given nf>1 confusion.
ototoxidty, nausea. tinnitus. and ortl1< hypote11
sion are common side effects and ""'ti rul evalu
lion because of prolonged half-life ol p 11d ications
in older adults whose body function' h 1 lmH-d
Poi'jpharmacy on the elderly rnaeases the
effects and advern! reac~ons. Care should be
safety about polypltarmacy because OTC med
are so readily available leadrng to use
medrcations.
Pain, a major worldwide hca l1h rnn\ickr.111011, is often
disabling. For pain to be 1rea1ed, !he i111111"1y ,tnd 1y1>e
of pain must be evaluated ~o prop11 1hr1.1py can
 CHAPTER I 5 Analgesics and Anbpyrencs 253

bl' pr~abt.'<I Cultural. psychologic. and physiologic
consider.wons pl.1y 1mponam roles in how a patient
perceives pain and r~;p?nds to mo:die<H i.'1. Analg~sics
,-,uy from (YJ"C an,llge'CS SU Ch as asporo 11, acetamino-
phen, and 'W OS. which are alo;o amipyretic and anti-
onfl,imni.1tor)' agents. to opio1ds and opiates, which are
tightly rei;ul.11ed bc<.wse of the potentia l fo r addiction
or dependency. In cases of moderate to severe pain,
co.1nalgesi.1 .ind .ul1u\',Ull medications may be used for
increa.etl therapeutic effects.
some .malgesics 'uch as ,1spirin and p.:mazocine
arc adm 1ni,tl'rcd orally, whereas other medications
,uch as morphine and often meperidine are giwn by
injectio n lor foster .1bsorption The severity of pain
.rnd e.1S<' ol .1d mi11btration arc important factors 10
consider in sckning drugs and routes of administra-
tio n. Pnl\pl ar:naC\ an the elderly necessitates careful
.m.ilysis nl p 1in and its rel ief including any adjuv,111t
or altemati\'C therapies that are available and
being used.
Societal a111tudes often contribute to unnecessar,
undertreatment of pain . Fear of addiction or dependency
with opiates and opioids is a consideration when sched
uled dru~ are used. An opioid is typically used for mod
erate to severe pain over a shon 1>eriod of time. For
chronically ill people, the~ medications may lead to
dependency. For the terminally ill, the risk of depen
dence is no rea:.on to withhold medocations.
c.n C analgesics arc easi ly ob1J1incd and may be .1bused
i( taken o'er long periods of time. A common misnomer
is that OTC medications are completely safe, with no
ch.1nce o( O\"erdose or reacuon. Analgesics are perhaps
the most frequently adminbtered and most abused med
ications. Pain should be relie,ed .rnd eva luated on a
personal basis to be sure analgesin are being used
properly.

Scene r
Mrs age 76, takes an aspinn as anucoagutanr therapy. When the rheumarologis1 sees her, she 1s
gwen crpton for buprofen 800 mg tid for anhrms.
W1I rg these two medications together affect the absorption rate of either drug? Explain your
a
2 Wh ef .<;ts and adverse reactions should Mrs. Jones watch for with aspmn?
3. w some of the age-related polypharmacy problems associated with chronic pain control?

l1];illc- lCULATIONS
I. DO<l' I r" rylenol 650 mg 1'0 stat and 2. L)emerol 75 mg stat and then SO mg q4-6h prn pain
q4-6l1 p un Available medication
A\'a il.11> m d ica1io n:

325 mg
Regular Strength

BIOi...
....................... Demeror
150 Caplets meperidme
for Hospllol ond hydrochloride

--...
~ovmment UM Only

~ ........ _..., ..
injection, USP

100mg/ml
~
Interpret th order - -- -- -- - - - -- -

Dose to bt :ow n ; - - - - - - -- -- - - - -
 254 SECTION IV Pharmacology for Multisystem Application

Interpret the order.

Show the stan dose to be ghen on the syringe.
volume dose to be gi"en sm:
volume dose to be gi\'en pm
11Jm 1f 1111f1111f 1111f1111I

REVIEW QUESTION S ...

What families of drug," are Schedule II mediauions? What is 1he difference between an opioid and an
opiate1 - - -- - -- - - - - - -- - - - - - -- - - - - - -- -- - - - --

2 What is an analgesic! what 1s an anupyretic medication1 What is an antiinOammatory agent! < e examples o(
""ch What are thrtt types of medications that have all of th~ characteristics! - - - - - -

1. When are coanalgesics used! Name two drugs that are used as roanalgesics.

4. Why are salicybtes not administered to children with viral d iseases, especially d enpox and
inOuenMi?

5. Why are opioids. opiates, and other Schedule II analgesics used for shon-term acute pam rathl-r 1n long-tenn
chronic pain except in the terminally ill patient! - -- - - - -- - - - - - - - -

6. Name salicylates, acetaminophens, and NSAIDs commonly used as analgesics, amipyretics, or 11 , ntlammatOI)'
agents.

7 Why are adjuvam medications gjvcn with analgesics? - - - - - - - - - - - - - - -

8. Describe the routes of administration of the various analgesics, giving the advantages and dis ,(vantages of
each
Immunizations and the Immune System

After studv ills chapter, you should be capable of domg the followmg
Oef11" us types of agents used in acuve and Descnbmg why 1mmunosuppressams are
pass1vt 1 m1ty and their appropriate routes of necessary after transplantation of organs and for
admon n. autoimmune and allergic conditions.
Desc~ b 1c health guidelines for Discussing medical needs for 1mmunost1mulants.
1mm ard the 1ndicat>0ns and Providing patient education for compliance with
con tr on~ for administering each agent. medicauons used as 1mmunizat1ons and 1n the
D1scu 1gems that provide passive immunity. immune system.
Desc e of 1mmunoglobulins following
an R~ ,iat ble mother and child b1nh

Mic n allted health profess100B/ m a pediatric sewng. Dr Jones, using the accep1ed schedule, has
orde MMR. and IPV vaccines for an 18-montfl.cld child to provide immunity.
Are .ii iunizat1ons that are appropriate for a child this age being administered?
Wt>a! -11on does Michelle need to document in the chart both before Dr. Jones decides in favor
o' ne immunizations and after the 1mmunoza11ons have been administered?
Wh equ res this documentation?

Acquired Artificial passive Immunodeficiency Natural immunity

immu immunity lmmunoglobulins or Natural passive
Active im 1 .1ity Attenuated immune globulins immunity
Antibody Avirulent lmmunostimulant Passive immunity
Antibody tit~r Carcinogenic lmmunosuppressant Serum
Antigen Endemic Inactivated vaccines Teratogenic
Antigen-an 1body Endogenous Live or live attenuated Toxoid
response Genetic immunity vaccines Vaccination
Antiserum (inborn or natural Macrophage Vaccine
Antitoxin immunity) Mutagenic Virulence
Artificial active Immunity Natural active
immunity Immunization immunity

255
256 SECTION IV Pharmacology for Multisystem Application
No
Passive immunizing Yes. admm1s1er~ by
agents (e.g., immune phys1c1an's order
globulins. anrnoxmsl
No
lrnmooosuppressants Yes
lrMU10St11111Jlams Yes No c.o
EASY WORKING KNOWLEDGE OF INDICATIONS AND SIDE EFFECTS
Common Indications for lmmuniz1t1ons
lni11al 1mmunizauons against diseases mchildren
Booster immunizations against diseases as 1nd1ca1ed by age and
disease process-poten11al and actual
Passive immunization for those who cannot take active
1mmun1zat1ons
Passive 1mrnunizat1on in illnesses where active immunizallOn is
not available or apphcable
Common Indication for lmmunosupprtsunts
O.gan transplantaoon
Common Indications for lmmunos11mul1nts
Cancer
Acquued immunodeficiency syndrome (AJOSI
Auto1mmurie diseases
he immune system is based on cells, factors, and
T responses all working together to either destroy
microorganisms by cell-mediated mechanisms or
be the mechanism that uses an1ibodies to ncu1ralize or
destroy invading microorganisms. l'rodunion of anti-
bodies is significant for immunity after immunizations.
Antibodies. gamma globulins found in plasma. are the
body's defense system against tli~ase invaders. lmmu-
n ity may be eilher inborn or acquired and is sele<:ti\'e-a
person immune to one diseas<' may not be immune to
another Generic lmmunit) (Inborn nd ntur..t
lmmunlt)) is found because of genetic faetors and is
species specific. A substance must be delh-ered into lhe
body to produce acquired immunity. II may be obtained
by na1ural or anificial sources. such as immuni7.ations or
immune serums, and may produce aetive or passive
immunity (Figure 16-1and1:1ble 16 1).
Used in immunosuppresstve
conditions to achieve passive
immunity over a short periad
of 11me to reduce or prevent
disease processes
Organ transplamauon;
1mrnunosuppiession
St1rnulauon of unrnune re5Pll\!e
.
Common Side Effects of Immunizations
Tenderness al the in1ect1on site
Fever
El)'lhema and 1ndura11on at lhe m1ect1on site
Arthralg1a, myalgia
Common Side Effects of lmmunosuppressa rnd
lmmunostimulants
Nausea. vom111ng. diarrhea
Insomnia
Fever
Anmllgia
Increased $USCllpl1bollty to tnfeclloos
The development of vaccines has c1 rMd remark
able advances in disease prevention via .1. I' ii red immu
nity. Work on new vaccines offers hop for treating
new diseases as they emerge. Vaccines In shingles and
human papillomavirus (I ll'V) arc som1 uf the latest
introductions. with a vJccine to prcven1 numan immu
nodeficiency virus (1llV) and po~sibl} f, ns of rancer
on lhe horiton. Widespread use of immunizations h.u
had a great impact on health of pt.'Oplt the United
States by reducing the incidence of num """'e inf
tions by 99%. Two diwa= h,l\ c bce1 !r.tmatically
decreased through vaccinations polio. "hid1 has bttn
vinually eliminated from the Western I kmi, phere and
smallpox, which has been ~ucces~fully ch n11na1ed from
most of the world. Through increased p.1r~n1.1I educa
iion and community 1ian icipa tion, che go,ll of immu
nizing all suscept ible populations and the eliminauon
 - - - - CHAPTER
- 16 lmmunizanons and the Immune System 257

Species spoollc
from ONA

Natural

NATURAL NATURAL ARTIFICIAL ARTIFICIAL

PASSIVE ACTIVE PASSIVE ACTIVE
IMMUNITY IMMUNITY IMMUNITY IMMUNITY
Antibodies Invading viruses Temporary Acquired by
"51etted trom and~act ~ lll'VTIUn<ZallO With
mocher 10 as on onugen Immunity-acquired suspension oC 1iw
baby/fetus causing by giving ant1bod es anenuated or dead
via placenl&.I P<Oductlon ot in Immune serums organisms (vaccines)
b..-eas1m1lk antiboc:fies tllal have been Ot toxoods so
~MPORARY PERMANENT <ecow<ed trom antobodles are acwety
IMMUNITY IMMUNITY anolhef person's ~lnr-
FROM DISEASE bOtrowed annboc:ltes 10 1mmun~zat1on
PROCESS TEMPORARY PERMANENT OR
IMMUNITY SEMIPERMANENT
IMMUNITY
May require booster
immooizatlOns

Figure 16-1 The types and extents of immunity

PARISON OF ACTIVE AND PASSIVE IMMUNITY

ACTIVE IMMUNITY PASSIVE IMMUNITY

Purpose Disease prevention Disease preventmn and therapeutics
Souree Individually produced from various Other immune humans or ammals-<mmunity from another source
soorces- self-produced immunity
Effect,, High low to moderate ovet periods of ume; high for immediate protection
Method,, 1 I Contraction of the disease 1. From mother to fetus or baby
iMrr 2 lmmun11auon with toxoid or vaccine 2. Administration or antibody by in1ection
Respoi > 21 days Immediate
Duration LofllJ term. up to a hfetime Short term, days to a few months
Ease or, n Booster dose New administration; anaphy1axis possible, can be dangerous

of manv 11 uni,,1hle diseases would become more of specific anlihody in response to an antigen, the antibod -
a realtt) ies circulate throughout the body and auarh to a specific
nllgen, labeling these for destruction.
'J cells are responsible for cell-mediated immunity
YMPHOCYTES by d irectly attacking the invading antigen fou nd with
ITV viruses, cancer cells, foreign tissue C'ells, fungi, and pro
to1.oa. For example. 1 cells are im'Olved whether organ
LjmphO<)l". cells produced to fight infections, residein or tbsue transplantation is accepted or rejected. Macro
lymphoid ti'sue. ~uch as the spleen, to nsils, lymph phages work with T cells to recognize 'self" from
nodes, 01 h) mu' or 111 the reiiculoendothclial system nonself" and to boost the immune sys1em . 1' cells
Jnd in cmuJJung b lood. Once the body has produced a release substances that stimulate other lymphocytes
 258 SECTION IV Pharmacology for Mult1system Application
or macrophages 10 destroy anugens and suppress the
immune response; thus the second exposure to the
antigen ";u elicit a more PQ"erful response from the T
cell than the first exposure. .
Bcells. or Bltmphocytes. are responsible for anubody
mediated immunity (humoral 1mmuni1~) and. are
dormam on lymphoid tissue until a foreign anugen
ap1>ears. Exposure to specifi( anugcns Mimulates the B
cells 10 multiply rapidly and produrc imm~nity by.pr~
ducing antibodies that cirrulaie in body fluids. Unlike r
cells, 6 cells do not neutralize the antigen: rather. these
cell< take up residence in lymphoid tissue and cominue
to produce small amounlS of antibodies after the 1nfec-
1iou<1 state has been conquered. Select I! and T cells
become memory cells that will remember che pathogen
encouncered and ..; u mount a strong response if the
pachogen is detected again . 1ng pathogens twuses. bacterial that act as antJgens and
Specific antibodies are formed on response to specific
amigens. fhe shape of the antibody that circulates in the
bloodstream matches the shape of the amigen. and they
bind together. descroying or m.1etivating the antigen.
11'is is called the anllgen -;mllbody response and is
present in some way from birth until death. 11'is immu
ni1y protects the person from foreign subscances that
invade 1he body, o r selr, while not overreaccing and dam-
aging ohe body itself under normal r irrnmstances.
INBORN VERSUS
ACQUIRED IMMUNITY
Inborn or generic immunity, found wnh inhericed factors
making a human immune to diseases found in animals.
may also be called species specific. nacural, or inherited
immunity A person who S('emS resistant co certain dis
eases is also considered to ha\1' inborn immunity. lndi
vidual immunity may result from a genetic makeup chat
prevents the person from res1>0nding co antigens, resuh
ing in immunity to cena in diseases or condicions (Box
16 1 ).
Acquired immunity develops during a lifecime as the
person encounoers various agems thac may be disease
causing or as the person is immunized with agents thac
>Cimulate a similar imm une response as would occur
during exposure to the disease itself. The formation of
.mtibodies to the antigens by the body produces an
immune response (see Box 16-1). Acquired by the host
over a length of time, antibody response will become
more pocenc with each exposure to the antigen (Figure
16-2)
Natural Passive Immunity
-'------
When amibodies come from sources ocher than che
ind ividua l's own body. ohe immunicy is called passive
Immunity. Natural passive Immunity, omnsfer of
BOX 16 1 TYPES OF IMMUNITY
Inborn lmmumty
lnboln irntlllJlltv resulls from the genetic makelJll of an u.il\"CJ.
ual. an etl10lc group. or a spooes
Acquired Immunity
Acquired immunity tesults from the introduction into tile botlvo4
substances (e g , antigens) that prompt the immune svstem to
produce antibodies or substances chat already contain anblJod.
ies (e.g.. mother's milk. immune serum from another per$on)
Natural Immunity
No vaccines or 1oxo1ds are involved. the process is largely
endog..nous.
NatUlal active 1mmun1ty-Acqu red by eposure to onv~
ac~vate the ommooe system to produce a t bod es leg
an unvactonated penon is exposed ID U!asonal Jlll,i.
enza YlruS. gets sick. produces ant1bod1es t the V11Us. and
is immune when exposed aga n 10 the e viral Strillll
usually permanent 1mmun11Y
Natural passive 1mmunity-lmmuni1y uired by the
fetus or infant on transfer of maternal a , odies through
the placen1a or breast milk, result n temporal)'
immunity.
Artificial Immunity
Acquired by exogenous 1mmunuat1on.
Art1fu:1al active 1mmuni1y Acquired nmumzat1on
with vaccines or toxo1<ls. antibodies a e vely prodoced
in response to prescrce of a foreign a en to provide
semipermanent to peomaoent cnvnuruty
Artificial passr.e tllmJflcty-AcQuored Hl1111Ullll8!QI
w11h seium from anotntlf pewsoo Of an sourte that
cootaons ant1bod1es for ommed ate temporary
1mmum1Y
antibodies from mochcr co baby through 1 placenta or
breast milk, es1,cdall y in colo<trum, b th on ly example
of natural passiw immunity l!ccau\c .11hodies are
transferred from an outside oource the\ , ' not lase as
long as antibodies produced a$ .1 rcspor ' co specili<
antigens by the infanc, but the tr.ll1'f.r ><.'S prO\ide
protection for an infant until hos or lwr n immunt
S)'Stem is fully functional. ac approx m.u. h months to
I )"ear of age (set I ogure 16 I)
Natural Active Immunity
Natural active Immunity is pcrman~111 immunity
gained by having a d isease. Antigen' force the body LO
make ancibodies co cou111cr.tet or fighc the disease; ~,ese
 - - - - - CHAPTER 16 Immunizations and the Immune System 259

Natural

Actrve narura)- Act... ar111iaa1-

contract <'sease receive a vaec1naoon
alld produce and ptoduce
memory cells memory oens

Passive naturaJ- Passive artiftci.al-

reoe1ve matemaa receive an11$&f1Jm
lllbbodies through v.oth-
placenta "' breast lrom anott>e< hOsl
milk

Figure 16 f active and natural 1mmun1ty lfrnm Applegate E The anatomy and physm/ogy teaming system. ed 4, St Louis. 2011, Saunders)

Artllicoal Active Immunity

Antibodies
P<Ovenldosea!e
Building of P<O<:eSS "'
attenuate d'5ease
ent1b0d1es
Disease line Subcllnlcal
disease process
Figure 16-3 A111f1Cral act ve rmmunrty anl the respome ro disease proce$$8S

remain m i I) after the disease has subsided (1 igure
16.,l). Na tu Ii "tivei mmunity may last for ye-MS o r even
for a lifeli n' I h( host is engaged in the formation of
anubod1t 'l><>nse to a disease or toxic process f,ven
if the mfe,1 "subclinical or mild. the host's cells are
stimulated " form antibodies for .tC1he Immunity . If
sufficient anuhodies arc 1>1oduced. the 1>erson will not
contract th di,case in most cases during funhcr expo-
sure unJes, 111111.11 exposure to the disease was too mild
to provide immunity.
Artificial Active Immunity
Most immunity found within the wellness concept of
medical practice is artl6dI ctive Immunity-a pur-
posefully initiated immunity for protection of the sus-
ceptible person from a specific disease. With anificial
active immunity, "" antigen is introduced imo the body
by artificial means lo stimulate productio n of antibodies
when the person has not had the disease process and
immunity is desired. Rather than introducing the
260 SECTIONJV Pharmacology for MultisystemApplication

Mifi,QIUl-
virulent agent that might be pathogenic;. virulence in the
immune producing agelll IS reduced, or attenuated, for
adminisor.uion. to allow the body to produce antibodies
wuhout causing the pttSOn to ha\'e a serious illness. The
Vaccin~ and .coxoids are a~ail.able to provide anifi~
active 1mmun11y. Blood dcnvatovl.'S, such as plam ~
process o( lmmunl1.itlon may also be called '"cdna-
tlon because the agent used is usually a vaccine for baae- antitoxins provide anificial passive immunity a. and
rial and \'oral paohogens

Artificial Passive Immunity Vaccines

Vaccines contain a suspension o( whok or fraction ....
11 person with no 1mmun11y who has bttn exposed to a . . h d . . ~t<V
virulent organism is at danger for rontraeting the disease. m1aoorgan1Sms t at, on a monostr.uonn. CJUS(>$ tlit
To prevent the disease process. the person needs bor- recipient's immune system co produce .tnt1hotlies tlit ro
rO\\ed or 're.id)" made" anubodies found in immune antigen or microbe found in the v.icwu 1wo ~ .
. . . cd d 1 JjO!
cypes o f vaccones. maetl\<lt an "~ .llh n uat~'d. exi11.
'i<'rum to counteract the m1croorg;misms and to give
shon-term 1mmun11y rapidly The process of providing a
pcrwn with .rntibodies from another source is anilidal
P"he lmmunlt) . With use of immune serum globu-
l in~ (or .ontlerum) found in the blood from another
BOX 162 SOURCES OF IMMUNE GLO B jl;f#!.i
l. Diphtheria antotoxm, for dopllthena. QI, 1 from 1mmu.
source. the immunity is immediate and effective but mzecl horses
\hon lived (Hgure 16-4). Z. Tetanus immune globulin, used on prevent llf tetanus 01
1hc scra prepared for imm une purpo~ in emergen lockjaw. 1s from human sources
des arc often derived from human or animal sources, 3. Immune globtJhns fromhuman plasma arl' for hepa1111s
such as horses, and arc used when there is no time for A. measles, polio. and chickenpox
the body to develop its own antibodies or when the 4. Human hepatilis B immune globulms ar 1 1d to supply
disease process would cause imminent danger, as witl1 immunity to infants born to mothers who I hepa1i11s B.
exposure to rubcll.1 in nonin11nune pregnalll woman. 5. Rabies antiserum may be obtained tron1 r dnS to treat
ll~c or ani mal antibodies may produce a sensitivity
victims of bites from rabid ammals
rc~won called sm1111 sickness. "l11e patiem should be
6. Botulism antitoxin, obtained from horses 11 he used soon
skm tested for hypersensitivity before administration;
aftl!f exposure to be effecuve
howewr. this >cnsitivity react ion is not likely to occur if
human gamma globul ins are used. 7. Anti-s11akeb1te serum 1s an anuvenom c lo comba1
Some immune ser.1 roncain antibodies known as ami the effec1s of b1tos from poisonous s such as
toxins (Box 162). ranles11akes

Pnmaty

J ~response
JI0- 1....,ction 01
ant.iom0<
immune globulin

Prevents cisease
ttv0!9' antibodies
~--... fromou1sid$
souree

Disease ltne No IOng-term

immunity through
production or
setf made antibodies
~ponso to disease processes
Fig ure 16-4 Al\lfoc1al passive immunity and the r

lnactiated VJ(cines are made of whole killed or
inactiva1ed microbes or some of 1heir componenis.
Elc.1mples include injroed influenza, penussis, and
r~ibies vaccine\
l '''- \.;&Cl inc: .. or li'e attenu.il~d '~cdnes are
composed of ltve microbes 1ha1 have been weak
enetl or rendered nirulent; examples are vaccines
for polio (OPV); rotavirus; and measles, mu mps,
and rubella combined (MMR). lmmunocompro
mi.'<l individuals may be unable 10 fight the live
o r auenu.11ed v.1ccine. and pregnam \\'Omen may
h.iw .i mf.. for fetal 1era1ogenicily. Therefore the5e
pa1iems sho uld no1 receive 1hese v,1cci nes.
Toxoids ..:....-~~~~~~~~~~~~~
lo\ou.l are aC1~nal wxins that haw been changed 10 a
nonu:ixic \IJt<' I h< toxicity of the bacterial 1oxin has been
we.ikcn-d to 1hc point tha1 i1 does no1 cause the disease,
bul 1lw to"" is still capable of stimulating 1he body 10
form .inuho 11 , An t'xample is telanus loxoid (1T).
lmmur bulins
Serum or 1 I ,, drrovatives, or specific lmmunoglobu
tin or 11 ulmlfn,comain large concentratio ns
of .1111ihod ,., , .1 sp,dfic antigen or di.ease. '111ese pre1>-
ara1 ion' m m.111<' from blood producu. and provide
imm<-di.n I n 1.rm pa~ive immunity. Immune glob
ulm\ J rc ""' n ~cuic exposure to disea!>eS such as hep.1
1111s B and r es
Anti t o
\ntil ntiho<lies produced in response LO spe
cilk 10"" nd when .1dminisLercd have the ability to
ncutr.llL< ,,.. '!"'<Ifie Loxins (e.g., diphtheria, 1eLanus)
for ,1 per" i 1111\h risk for the disca;e or condition.
Anti1oxi 11' "c al'<1 used for sho n-1cnn prophylaxis in a
pcr<0n '"t tt .l( II\'~ immunity who has been exposed
10 a \)'~t\. 1 ., t n
' LO BE IMMUNIZED?
In tod.1y'
t t>,,Ith ,,,re environ ment, irnmunizations for
wellnc~'
.uc rouunc patient care. The period of required
immun1 on , from hinh through school entry, wilh
conunual 1r. 1hrough the school )'t'aB. but currenlly
immuniz.111un' arc recommended to continue through
.1<l11 hhood 10 P'<'VL'nt outbreaks of d isease in adults. 'l11e
required imm un.,..11ions are sugges1cd by tl1e Ceniers for
Dio;eaM: C~mtrol and Prevention {CDC). with the various
stale 1mmunoz.1tion rcqmrements based on age groups
On entry into school, the child mus1 meet the criLeria ~
by 1he Slate and by loc.11 schools. Aduhs should con1inue
CHAPTER 16 lmmuniumons and the Immune System 261
to receive cenain immuniz..1tions such as diphtheria
tetanus 1oxoid every JO years and influenza vaccine yearly
to main1ain irnmunity.
Cenain popula1ions ha\e been found 10 be at high
risk for contraC1ing immuni1.<.1ble diseases:
Aclolt.">C'ents, because of the dedinmg nttd for
immuni1a1ion; 10 meet requirements for school
auendanre
Ne\"' parcnls '''ho h,1ve Jllo,,ed their in1muni1y to
wane and who are now ex.posed to childhood dis-
eases or who may cany an illness po1entialli det
rimental to the newborn
Dcbil11,11ed persons, whe1her from physical dis-
abili1ies or from age-rel.11ed problems, who are
now more suscep1il>le 10 i ll ne~s
Migum workers and new immigran1s who are
inadet1ua1el)' immu1111ed or may nOI haw been
immuniLed al all
I leahh care workers who .ire not properly 1mmu
nized and are exposed 10 disease:.
In pa1 icnts who have been CX(lOsed to J dis~ase, an
IDtibody titer may be performed to de1ermine immu-
nity. Persons mtending 10 1ra,-el to areas where a djsease
is endemic should obtain 1he required and rl'(Om
mended immunizations before traveling n1e local
health dCflanmc111. in cooper.1t io n with the COC, can
provide a list of needed immunizations for 1ravel.
.
The need to be curreiit with 1mmunoza11ons as a means of
disease prevention is obvious Vaccinations do carry some 11sks.
but the more se11ous risk is contracting a disease for which a
vaccine is available An example of the future lla1ards from
disease piocesses that awear in adults IS chickenpox leading
to slllng es later 10 hie or~ being associated with develop-
ment of diabetes mellitus Coocems about vaccines causing
attenll0ndefic11/hypeiact1VJI)' disorder. autism. d1abe1es. and
sudden infant death syndrome have caused parems to question
immunizing children However. data from clinical trials do not
support neurolog1c or dEM!lopmlllltal harm Vaccines have
redl.a!d and even elimmated many diseases that killed or
severely disabled persons several generations ago Parents
should be educated r1l9ard1ng the benefits of vacc1na11on
1mmun11al1011S are vi1aJ to the maintenance of pOOlic health
Vaccines promote production of antibodies against bactena
and viruses. toxo1cls promote the building of an11bod1es
against bacterial toxins. 1101bactena 1hemselves.
lllaCtiva1ed vaccines are made of whole killed microbes or
their components Live vaccines are made lrom attenuated
'
weakened hve microbes. rendenng these av11ule111 mmost
pe!SOflS
262 SECTION IV Pharmacology for Mult1system Application
I IJI.1!tii [,] Jfj g.1 ;IM !Mifr Ifj.i i [,] ~ ~j
\'acones may be safel)' admmmered. after autho~
tio n by a health GJre provider, 10 a person wnh a mild
acute illness with or w11hou1 fl"tr unless chest c?n
gcstion is presenl Care 5/w11~/ bt rakm rhar mrmunwi
ri11n.1 arr 1101 nmllwly pc>srpm1e1/ b1111se of mrld 10
modt'f<11~ symp1011u. .
Mi ld to moderate local reactions fro111 previous
immunizations. such as soreness, erythema, or
~welling. are not contrai ndications 10 further
im1nunization.
Taking ant imicrobials, recovering from diseJse_ pro
cesscs, and having recently been exposed to an mfec
tious disease do not preclude the administration of
the vaccines.
A fl"er. e--en a high f"'-er. 1s no longer consider~ a
reason for not giving an immunization. nor are diar-
rhea, \'Omiting. and otitis
ktJ CAL
If a patient has sustained a wound. especially a puncture wound.
mfo1mat1on concerning the level of immunity to tetanus should be
obtained including when the last immunization against tetanus was
given If the patient does not remember or ll1e recotd is unavailable.
the health care provider will usually administer a booster of tetanus
toxo1d
CONTRAINDICATIONS
TO IMMUNIZATIONS
I ive vaccines should not be gl\'l?n to the following
111dividuals:
Patients receiving steroids. radiation therapy, or
ant ineoplastics
l'atients who are immunosuppressed or have a
current moderate to severe inrection that sup-
presses the immune system
P.11 ien1s who have received im n1une seru1n \Y"ithin
the past 3 months; the immune senun may prevent
adequate production or antibod ies.
Care must also be taken to ensure that those who are
immunized cannot harm susceptible persons in their
home or work environment. Lh-e vaccines take up to 30
days to be shed from the body. so the immunosup-
prcssed person must be protted during this time. An
example is the immunized child who is living in a home
with a chronically ill grandparent or in a home where
someone i< undergoing chemotherapy.
Vaccines should not be adminis1ered to persons who
are allergic 10 the substance or any component used in
manufacturing the vaccine, because of the danger of
anaphylal<is. Some vaccines have. egg as a component
others are made with ~rcse~uves such as mercuir.
and some vaccines contam anub1oucs such as neoml'au
or polym)'Xin B that were used to attenuate !ht
microorganisms.
Rubella and varicella vaccines are contraindicated 10
.,..nancy because of a rare but possible risk of terato-
pr"o . r d
genicity to the developmg 1etus cause by viraJ
exposure. .
A closer evaluatio n of the person who gives a history
of seizures or high-pitched screams over a prolong,d
time after the ,1dminist ration of vaccines should occur
before the admin i;ir.u ion of the immunization.
If a question exists conccrn i.n~ whether or not to
administer the vaccine, the phys1oan will make a deci.
sion by weighing the potential for bcn, It dgainst !ht
potential for risks and will provide suth umt inform..
tion for parents to make infonned d" isions boot
immunizations (See l\'Ol-e site for th< ,pecific pub.
fished contraindications and precaution' r immuniz..
tions for pediatric patients and '' ion vaccinr
contraindications for adults.)
ADVERSE REACTIONS
TO IMMUNIZATIONS
11\ p tection from
The importance of in1n1un i?'...-'l tions
infectious diseases canno t be sire~ nough, but
immuni7.ations also have a'>sociated n that an be
controlled by such measures as at nophm 1n
appropriate d~ before and after nun iia lions
and sponge baths The side effects are u 11)' mild and
1ransien1. with 5UCh symptoms as a ~11 ll"\-er. minor
rashes. or soreness at the injection site ll pdin and
malaise may be found with li\-e and inact ted vaccines.
Though these effects of immuniz.111<1 re common
and uncomfonable, the need ror va" to pr!'\'l.'llt
disease may tip the balance in fa vrn giving the
immunization.
Some people have unusual and sew1, ,1ctions that
are monitored by the Food and Drug I ministration
(FDA) and CDC. With any serious pro bl 1 encountered
with a vaccine, data mu~t be sent to the\ u ne Adverse
Event Reponing System (VAi RS) 10 pcm detection of
uncommon, severe, previously unwen o ire rcacLions.
Some of these rare reactions have ind d Cuillain
Barr~ syndrome with inOuen1.a vaccon encephalitis
with measles oaccine, and peripheral m ~pathy with
rubella -accine.
Anaphylactic reactions are a poib1h1 th immum
zations, as they are with any medicauon ('ox 16-3).
The advantages of immunity far outweigh the dangm
of vaccines in most instances. I leahh car.- professionals
should encourage parents to immunize their children.
Adults should also be reminded of tlw nt'ed for proper
 CHAPTER 16 Immunizations and the Immune System 263

BOX 163 TYPICAL SIDE EFFECTS ANO ADVERSE The medical record must show documentation of
REACTIONS FROM SELECTED VACCINES OR TOXOIDS the VIS publication date because revisions occur
from time 10 time. The revision date appears under
vaccine or Toxoid Serious Side Effects the enc logo.
Measles. mumps. Anaphylaxrs. thrombocytopema. dangers From a legal s1andpoin ~ the immun i1,.11ion
rubella of teratogemcrty rn pregnancy, should alwa}'S be recorded in the patient's medical
encephaht1s record 10 show that the medication has been
ophttwia. 1etanos. Encephalopathy, conwlstonS shoctd1ke given lhe following data must be included m
pellUSSIS states documentation:
Anaphylax1s Oate of vaccination
Hepatitis 8
Route and site o f vaccination
Varicella Anaphylax1s
V.1cdne type. manufacturer. lo t number, and
lnftuen1a Gu1lla1n-Barre syndrome expiration date
ame. address, and title of person administer-
ing the vaccine
immuOll.lllOn on a r<'gular basis to protea public and Oelil'ery of VIS 10 the appropriate person and
pt>Mn,11111 thh the date of VIS publication
Sig ning of pem1issio11 10 give medication hy
parent or guardian before adm inistration
These records ensure the 1mi.on, especially a ch iId,
In early 2 2010, outbfeaks of mumps and pertussis were receives the appropriate immunization and the rernrds
both docUI!' although both diseases had been virtually reduce chance of errors such .u duplicative vaccinations.
eradreat ruted States The pathogens were 011g1nally Reponing adverse reactions 10 the CDC br 1'3ccine, lot
thooght ID een brought to the country by WOl1d travelers number, manufacturer, and so on b imponam for lr.lCk
wllohadv untnes where 1mmumzat1oos are not cnlorced ing possible l ink~ 10 the reactions.
and wore I 10 persons whose antibody levels were not
suff c1cn nt the diseases. especially in adults who had
it ., 1mmumzed AGENTS FOR ARTIFICIAL
ACTIVE IMMUNITY
ATION OF Anificial active immunity produces a level of immunll}'
TIONS that requires frequent immunizations after 1he 1nuial
rounds. Live anenuated virus vaccine produces a mild,
The N.lU011 1ildhood Vaccine Injury Act of 1986 pro- subcl inical form of the disease 10 produce antibodies for
vi<lrd Im mpilation of Vaccine Information State- immunity. Ag~ms containing inactivated bacteria art>
mcnl\ (' ' the CDC for certain immunizations. shoncr acting and require multiple doses to produce .1
D(lCUm , available from the CDC's website p roper immune response; revacdnation doses (boosters)
(wwwr dincs/pubs/ vis/ defaulLhtm), or a set may be required for continued protooion.
may b "'1 br cdlling the CDC lmmuniz.11ion
llotlin< -Hl-2522 1urther smute requirements Vaccines for Diphtheria, Tetanus,
includ1 t it}\\ing:
and Pertussis (DTaP, Tdap, Td)
or legal guardian of a child, o r the adu lt
cin.ued, must be provided with a COl)Y o f DTaP (di1lhtheria, teta nus, and acellular pcnussis)
11 J ha1c ti me 10 read the materials showing vaccine is for patients )'Oungcr than 7 rears of age.
nd benefits of a vaccine before the admin- Ulal' contains acellular penussrs. a form less likely 10
he medical office may add an idenu6er cause adverse reactions.
~. but the CDC must approve any other Tdap {tetanus. diphtheria, and ,tcellular penussis),
co111ai ni ng a lower dose of the penussis component,
A I' ".1nem record of each mandated vaccin,11io n is used as booster dose after tht> initial i mmuni~a1ion
nlt1 '' '''given to a patient series fo r adolescents when adverse reactions arc less
VIS 11ments mu~l be provided for D'l:ll'. DTP, likely to occur. Adults should receive Tdap as a boo~tcr
I d. tR varicella, polio, llib, or hepatitis B dose instead of one of the booster doses of Td to
\:,)( I 1 maintain penussis immunity
v1-. , -uments Me not required but are recom The tetanus-diphtheria vaccine (Td) should be admin-
m~no,-J for inOuenza, pneumococGll. and hepati is1ered every IO years throughout the adult }'Cal'>
ti~ A \dCcines. (Table IG 2).
 ~
"'
~
::;:
DTaP (inactivated
bac1enal components)
Oaptacel,
lnfanrix. and
0.5 ml IM q48 wk x 4 doses beginning
at 2 mo. with boosters at 15-18 mo,
Oiphtlleria. tetanus. pertussis, ages
>2 mo to <7 yr
Swelling. local reactions. love.
imtability. crying. drowsiness.
<
-0
Tnpedia 4-6yr. 1112yr ~
DTaP-IPV/Htb Pentacel 0.5 ml IM x 4 doses at 2, 4, 6. and
15-18 mo
Protections for listed diseases for
children aged 6 wk through 4 yr
anorexia
Same as f0< DTP ..3
n
~
DTaP-IPV Ktnrix 05 ml IM Srngle dose booste< for OTaP for Same as for OTP !"1
ages 4-6 yr ~
Diphthena and Tetanus Oecavac 0 5 ml IM q10yl {adult) >7 yr. 05 ml IM 01phthe11a, tetanus on chddren local reactionS, headache$. myalgoa
;::
~
tOXO<dS [Td. adultl x 3 doses pediatnc f1n111al. then 4-8 wk. >7 yr old through adulthood. may hypotensoon. 1D4nt pain, stuffiness
then 6-t2 mo after 2nd. then ql()yrl be used with children who have ~..
cootra1nd1cauoos to penuss1s 3
vaccine ..,
>
Dtphthena and Tetanus
toxoids {OT, pediatflc)
NTN 0.5 ml IM at 2, 4, 1Q..16 mo. booster at
6 12 mo after 3rd dose
Tetanus and d1phthoroa ~
..g
n

Tetanus. reduced Adacel 0.5 ml IM x 1 dose lor persons aged Tetanus. diphtheroa. and pertussis Same as Td
diphtheria, acellular 1H>4 yr in adults
pertussis {adult Tdap)
Tetanus toxo1d fITJ NTN 0.5 ml SC I 12 yr Possible tetanus due to in1ury and Local reactions. fever. ch1lls, malaise.
1 dose after 12 mo of age. for prophylaxis myatgia
12 yr to adults 0.5 ml SC followed by a
second dose on 4-8 wk. then as needed
MMR M-M-RU 1 dose SC after 1215 mo. woth booster at Rubeola. mumps. rubella Fever. rash, jaw pain. headache.
4-li yr. 12 dos8s >t7 yr myalgia. sore tlvoat
Rubella vacxine Merwax II 1 dose SC Rubella Same as MMR except 1aw pain and
sore throat
Mumps vacx1ne Mumpsvax 0 5 ml SC Mumps Same as MMR
Polio vaccine IPOL 0.5 ml IM x 2 doses at 4 to 8-wk Pollo (in children or edults) Tenderness at in1ectoon site. fever.
lnacllvated IPV !Salk) intervals beginning at 2 mo with erythema
ste1 et B 18 'TlO. the11 1 b'O' ,

ft. Elisa u111ts: GI. ijils\101111cs11nal; JM. 1nuamuscutarly; IPV. inactlVated POl1omvehtS vaccine. MMR. measles, mumps. rubella, NIN no traele name. PO. orally, SC. subcutaneously. URI. uppor resplrmory
1ntect1on.
Haf!mO!lhllus influenza AttHIB (4 0 5 n"i IM at 2. 4, and 6 mo w11ll booste< Diseases caused by Haemop/lilus ~at nsection $118. !lM)<.
B(Hibl vaccrne doses) at 12 15 mo mnutmtae B such as sepsis, vomrting. d.armea
ot: arthnt
i. pne.1monio

Same as lor DTwP and H1b

Hepat111s B vaccine Recornbivax Birth, 1-2 mo, S.18 mo IM (see package Given 10 children and adults for Redness at 1n1ec11on site. headache,
HB. onsens and CDC schedule for doses. as hepatitis B protectlOfl nausea. myalg1a, 1aw pain. fever
EnoerixB these vacy with brand and age)
Hepa1111s A vaccrne Havnx 1440 El units for adults >18 yr old. 720 El Hepat111s A local side effects. fever. malaise,
units for 12 mo-18 yr old-2 doses anorexia. headache, nausea.
6moapan
VAOTA 50 units in adults; 25 units 1n children
Hepatitis A and B Tw1nnx 1 ml IM x 3 doses. wilh the second dose Hepa1111s A and B Pain. redness and swelling at
vaccine scheduled 1 mo after the first. and the injecnon sue. headache. lelhargy.
third dose 6 mo after the first dose IOI loss of appetite. feve<. and GI
ages <18 yr symptOmS
Varicella vaccine Varrvax O5 ml SC >12-15 mo. with second dose Varicella local reaction at m1ect1on SJte. rash,
al 4-6 yr Adults; 0.5 ml SC. wuh lever
second dose m 48 wk
Influenza vaccine NTN 6 mo-35 mo. 0.25 ml x 2 doses 2 mo
apan >3 yr, O5 ml yearly
Annual vaccination for influenza.
e.spec1ally indicated for lhose
local redness. fever. myalgia.
malaise
I
-
m
lnftuenza vaccine A and Fluvmn, Adults 0 5 ml IM single dose susceptible to UAls Runny nose. nasal congestion. cough.
SOie throat. low1)1ade fever.
"'
8, live Flurone IM as single dose
myalg.a. cholls. headache. lethargy
"'
3
3
Fluv111n 0 5 ml intranasal For use with healthy persons aged I C:

2 49 yr ..
::0
;:;
ct.

....
Pneumococcal 23-valent Pneumovax 23 Certain children 26 yr and adults Pneumococcal pneumonia and local reaction, fever, arthralg1a. c
::0
vaccine lPl'VI 0 5 ml SC, IM as single dose bac1erem1a. adults and children myalg1a, rash
>2 yr ...
~

Pneurnococcal 7-valem
conJUQate vaccine
Prevnar 0 5 Iii IM based on inn.al 1mmullllat1on
age.
lnvas1V8 pneumococcal infections
1n infants and toddlers
local rnac1ton. 1111tabclity. restless
sleep. drowsiness. decteased
..3
:;.

(PCV) 4 doses for infants at 2, 4, 6. and awe11te 3

12 15 mo; 3 doses for 7-1 1 mo. 2 doses
for 1223 mo. 1 dose lor 24 mo-9 yr
..
c:
::0

(I)

BCG (bactlle Calmette

Gu~nn) vaccine
Generic. TICE 0 20 3 ml percutaneously by small
puncture wounds
Tuberculosis 11 person is at high
risk
Swollen lymph nodes ..
~~

3
Ci1u1wJ
N

'"'
 N
8l
~
TABLE 162 SELECT AGENTS THAT PROVIDE ACTIVE IMMUNITY-<:ont'd
g
C>
z
IMMUNIZING AGENT TRADE NAME DOSE. ROUTE. ANO FREQUENCY INDICATIONS FOR PROTECTION SIDE EFFECTS <
Rotavirus wccone RotaTeq 3 {2 ml) doses PO at 2. 4.. 6 mo Prevents rotavorus Oianhea. VO!l1tting. fe-.11<. nmy nose. ..3
~
sore 1twoa1, wheeloog or coughing
and ear mfectoon
..
n
0
Ao1arox 211 mll doses PO a1 6 wit and 4 wk later Immunity to rot<Mrus Ciy1og. lussonq cough. runny nose. ~
fever loss of appeme. vormtoog -<
Men1ngococca1 ~
Meningitis ;:::
vacc1ne-MCV4
Menacira 05 ml IM for 1155yr ="'
Human papillomavirus
(HPV) recombinant
Gardas1I {HPV41 0 5 ml IM for each dose in females, first
dose followed by secolld dose 1 mo
Women aged 1126 YT for HPV. a
Fever. ra:>h
Pain. 1tch1ng. swelling. and redness i;I
cause of cervical cancer at in1ect1on site. fever. nausea, ..,)>
vaccine later, and 1h11d dose 6 mo after first dimness "i!.
c;
dose m
e.
Cervarix l~IPV2) 0.5 ml IM for each dose in males or Women same as above; males g
females: firs1 dose followed by second 9 18 yo
dose 2 mo laler. and third dose 6 mo
afler first dose
Herpes zosier vaccine Zostavax 0 65 ml SC to adults >60 yr. single dose Herpes zoster {shingles) Facial reddening. rash. lever
Rabies vaccine lmovax Preexposure 1 ml IM x 4 doses Rabies local reaction, headache. nausea.
Postexposure 1 ml IM x 5 doses abdomooal pain. muscle aches

SUPER SHOTS
Diphtheria and 1etanus Pedoarix OS ml IM at 2. 4. and 6 mo Diphtheria. tetanus. penussis. Same as with the individual vaccines
1oxo1ds. (DTaPI. hepatnis B. poliomyeh11s hsted earlier
Hepautis 8 and IPV
vaccines
MMR and vancella ProOuad 0 5 ml SC at 12 mo and 12 yr Rubeola. rubella. mumps. and Same as with the individual vaccines
vaccines cllickenpox listed eatlier
 CHAPTER 16 Immunizations and the Immune System 267

\'aCcinel. which 1s no longer available m the United

States) The use of ll'V is now recommended because of
Acetaminophen given in aPIJIOP11ate doses before and after the chance of acquiring polio as a disea;<? from Ol'V.
an 1mmuni1a11on will reduce d1scomf0f1 and side effects However, in other countries where polio is still .1 threat.
This vaccine should be withheld in a child with high fever. Orv is still used. l'olio vaccine is generally not given
chest congestion. and uncontrolled seizures If the series 1s to adults o lder tlldn the age of 18 ye.us unless 1hey
mterrupted. 1t is not necessaiy to restart the se11es have not been vaccinated, are traveling to an endemic
area, or are in a high-risk health care occupation (see
Table 16-2).
Tetanu s Toxoid (TT)
~~'--~~~~~~~~~
Vaccine for Haemophilus lnfluenzae
TtfanUS to.o"I 'hould be given to: Type B
The l'"r'on w11h less than three doses of a vaccine
co11Lai111ng 11 .1t any time Haemopl1/111s i11f1111m:uu type 8 (llil:J) vaccine is used
'Ow l'l'""ll with ,, wound who has met the proper to provide protection against the vin1s that is a common
scheduk of thrl'e or more vaccine doses but who cause of meningitis in young children. Ilic child who is
ha' not h ltl ,, booster in more than 10 years allergic 10 I lib vaccine or its component.> or is younger
11w I n. mcludi ng children. with a scwre or than 6 weeks of age should not be given the vaccine (see
dinv " I who has not had a tetanus immuniza- Table 162).
tion 1 "'(see Table 162)
Vaccines for Hepatitis A and B
Vaccin Measles (Rubeola),
Hepatitis 8 uaa:ine (Recombivax llB, Lngerix B) is an
Mu mp Ru bella (MMR)
inactive noninfectious viral antigen vaccine. ' I he vaccine
The MMJi 1 live virus vaccine. immuni1,cs against is required in many states for childcare facilities and
the 1hrcc <ii 1 , ' Ihe vaccine is given a1 ages 12 to t 5 school aucndancc and is recommended for health care
mo ru.tv'I a1 l to (> year~. with doses being at least 4 workers, 1)at iems o n hemodialysis or who rcceiw blood
weeks apM J to persons who have not had the dls- products, persons at high risk for sexually transmitted
(Oases or '' mt1hody titer shows insufficient numbers diseases, drug users, and persons in contact with hepati-
ofan1ibod immunity. Pregnant and breast feeding tis R. Hepatitis II vaccine is now given 10 infants, begin-
,,omen at 'who are immunosuppressed because ning with the first dose either at birth or ,11 I month of
of HI\ or rrulo~is (TB} should nor be gi"en 1his age. then at 2 and 4 months. with the founh injection at
\';:lccjne. 6 to I8 momh~ of age.
Worn ho might become preg11ant within I Hepatitis JI vaccine (Havrix), also an inactive viral
mo~t h 0111<! not receive this immunization. antigen, is provided Lo persons who are traveling Lo
M.\.11 1 ' " the reconstituted using a nuid supplied endemic areas for hcpa1i1is A and to all chi ldren 1 year
will\ "' "'" ine or Ouid with no an1ibac1erial or of age. with a second dose in G momhs. Persons with
ban ,111r .1Jditives. d ironic liver disease, those with employmen t situations,
Rub 111e (.\1eruvax 11). rubella and mumps such as health care workers, or lifestyles that put the
\'an Jvax). and mumps vaccine (\1umpsvax) individual at risk ma) be given the vaccine proph)'lacti
le for those persons requiring immunity cally. Leng1h of protection is unknown but is belil.'ved to
Ji-case (see Table 16-2). be up 10 JO y\'ars.
A combinauon of Hepatitis 8 and JI vaccine
(Twinrix) is available (see Table 16-2).

Some sta1 " 1ei1u1re a rubella antibody titer for all women Vaccine for Chickenpox
of childbe ge to show then immune stale before issuing
amamag however. the persoo may decline 1mmumty Varicella oacci111' (Varivax), an attenuated viral vacci ne,
testing is recommended at age 12 months of age and;,., required
in most statl'S for admission to school. Adults with no
evidence of immunity should receive two do~s of the
vaccine 4 weeks apan. The length of immunot) against
Poli om is Vaccines (IPV, OPV) chickenpox using this live attenuated varicella virus has
Two poho ' Cllll'\ are available for i111muniz.1tion not been confinned. but smdies indicate 1ha1 immunity
against pohomychtis: JPV (inaetivatcd poliovirus vaccine lasts at least six years. with the need for a booster not
!Salk vacci11cl) .1nd OPV (oml poliovirus vaccine !Sabin establhhed. /\II aJuh> with no evidence of immunity to
268 SECTION JV Pharmacology for Multisystem Application
varicella ~hould receive two doses of varicclla vaccine 4
weekl. apan
Vui,.ax should not be gJ\'en to persons wilh .hypersen
>1tiv1ty to components of !he vaccine. Wllh acuve
uncreated Ill, with febrile infections. with neoplasms of
the bone marrow o r lymphatic S')'Stem, or in an immu-
nosuppressed state flus "accine should not be gi~n ~o
pregnant wo men or !hose who may be pregnant w11hm
3 months of vaccination (see J.1ble 16-2).
Va ccines for Influenza
.:.....;....:..:..:..:.....;..~~~~~~~~
lnjlumzA 'OMMI, including injtttable and intranasal
type. produce immunity to only !hose strains of inOu-
enz.1 von1ses expecled to cause disease in !he United
SIJles in a given year Some strains of inOuenl'.a have
vacci nes developed o n a ye.uly basis based on !he viral
~trains that will possibly be prevalent-for txample. !he
111 NI (swine flu) vaccine in 2009 to 2010. These immu-
niz,11ioM are recommended yearly for all persons older
th.111 6 mo nths of age. I hose who have a special need for
immunization are J>erwns older than age 65 years; those
with chronic medical condition>; Lhose in long-term care
facilit ies; 1)eople with chronic pulmonary or cardiovas-
cular condi tions or with chronic me1abolic, renal. immu-
nosupprl''!Sive, or hem.uopoictic blood dise.1ses; d1ildren
6 months to 18 years of age on a;pirin therapy (reducing
the chance of influenia vi rus causing Reye syndrome);
and health care workers or members of households with
persons at high ri\k. People with an allergy 10 eggs or
neomycin should not receive any inOuenza vaccine
unlcs. de>en~iti1.ed . A person with a moderate lo severe
illness should delay taking this vaccine.
I or children )'Ounger than 2 years of age and nonpreg-
nant persons aged 5 to 49 years without ~'\'It medical
conduion<, an accepL!ble alternative 10 parenteral
11nmun11nion is FluMlsl, a live auenuated inOurnza
vaccine (U\IV) thJt is administered intranasally (see
lable 16-2)
Va ccine for Pneumonia
~~~~~~~~~
Two types of pneumococcal vaccine are available-one
for children and the other for adull5. Pneumococcal wn-
iugaud vaccine {PCV) is recommended for all children
aged 2 to 23 months. with alternative schedules for some
children aged 24 to 59 months. for Streptoroa:w pneu-
1110 11111<'. II final dose should be given at 12 yean of age.
nw vaccine .11>0 gives protection against me,ningitis and
offers some proteCtion ag.iinst otitis media.
/Ill aduhs o lder than age 65 years should receive one
dose or p11eumococcal polyu1ccharide 11acci11e (PPV) .
Persons with chronic disorders and adults aged 19 to
64 ye,1rs should receive PPV. l'ersons over age 65 should
be rcvaccinated if the init ial vaccination was more than
<; )'('ars prrviou,ly .111d ir the 1wrson was younger than
(,5 when 1hc initial vaccine w.1s administered. This
vaccine should be delayed in people with fever (~
Table 16-2).
Vaccine for Tuberculosis
Bacille QJlmelle-Cumn (BCC:J ".aufor is Used 10
immunize against 1'.3 The vaccine 1s commonly ul(d
only for persons at high nsk.for ~po'""' to Ill, such 11
those tra\'eling to attas wuh high lllC1denct of 1l.
persons with family members with Mii\ ,. 111, or health
care workers who an' routinely expos.'d ro the disea!f.
The adminislJlltion of BCC vaccine " I" fl ut.meoos, i,,.
rubbing 0.2 to 0.3 ml of the v.1ccinc on the skm and
!hen making small punctures in th.11 .tr<J Jhe aau
should be kept dry for 24 hours without drt"ISing. lht
person receiving !he medicarion shouJ, ~ Jware tlut
anv subsequent tuberculin skin tests ,11, 1 d show JlO!i
ti~ results and a radiograph wi 11 be nc< 1rv for furthtt
testing for TB (see !'able 162).
-
Vaccine for Rotaviru s
The vaccine for rotavirus, " common '. of diarrhea
in d1ildren younger than 3 years ol .1i lOllt~lins fivt
strains of rotavinises. Rotaariros v111 (lloMTrq),
given orally in three doses ac 2. 4, .111d f 11111ths of Jge,
may be administered wich other v.H 11 for i nfanis.
Rocarix is given to infants in two do" I h \\1CCks and
24 weeks (see 'Thble 16-2).
Vaccine for Meningitis
Meningacoaal uacdne is available 111 ' lorms--011e
that contains inactiuatl'd b11ct4'ri11 (4 4} and Ont
containing bacterial components co11111 I to diphtltt
ria lolroid proi.rin (MCV4). howcwr. , .l(dne does
not contain Jive bacteria. The mcnont; I conju~ct
vaccine proteas against four diffcrcm 1 of the caus-
ative bacteria for meningitis, NfL"'"''' r.~Ula l1x
MC\14 vaccine is 10 be admi1mtert"<I 11 tO 55 )'W
olds. but especially to college student' 11 in donni
tories or other persons at risk becau" nl t I or working
conditions. Ml'SV4 is an acceptJbk .111< ti\ c for chil
dren and adolescents Usually o ne ''" I vaccine is
adequate, but a sond dose 5 ycJr' I. 11.1y be 1ndi-
cated in persons at high risJ.. for conu.1. 1he diseast.
Some colleges now require that .ill Ir"'' "he 1mmu-
ni2ed before admission 10 prevent 11 '.1k~ of lht
disease The vaccine may be admini~tt'rt .J ,111 yone who
has been exposed during an outbrt'.tk 11 h1di 11g preg-
nant women (see Table 162 ).
Vaccine for Human Papillom ~iru!.__
ffPV IHlcclnes (C11rda1il and Cen111 rix) h.1\l hcc11 devel
Oped to preven1 cervical cancer, pr.c.1111 l'rt>ll~ gc11i13l
le.~ions, and genital w.irt; c.1usccl by 1ll'V 111r v.1crines

JrC 70% effective for ccrvic.11 cancer and 90% effective
for gcni1.1l wans lhe C:DC recommends rouune IH'V
v.iccinJtton for femalr' from 11 to 26 years of age using
cit he vJccine. to be given in thr~e doses. For males .1ged
9 10 26 years, Gardasi l is the recommended vac<ine. l11e
length of immunity is unknown at present but is at least
S WJ"' ("-"e Table 16-2)
Vaccine for Shingles ~~~~~~~~~~-
1he wsl<'I' l'tlcdrrr (Zos11ivax) provides pro1ec1io11
~g.iin;t ;hini:I<"> and the associated chro nic pa in . In
Octob'r 2006 the CDC recommended tl1a1 zos1crvaccine
be admin1>1<rcd to all people age 60 and older including
thO\C who ha.: previou\ly had shingles. Only one dose
i~ nu\;.m at present. lhc vaccine is not a substitute for
hcrr<'> mst<'T ,aconc for chickenpox in children (see
1.1n1e 1c. n
" Super ots "
RL""'Jrch '" developed and continue 10 test what
.ire b.:111~ >J 'super shots'-<:ombina1ions of vac-
dncs tha. a child protection for more dise.1ses wim
fewer 1111 ' Children can now receive up to 16
i111111u11 11J11<1w. in th~ firM 2 years of life; the new com-
bin.uion i1nm11niz,11 io ns reduce this number. Ry com-
bining \' JI i; hoped mat me likelihood of
compkt f me immunization schedule will be
mcrca" p1in for children and parents will be
reduced ( le 16 2)
One no;t important developments is a super
shot lor, ,,, ll'la nus, perlllssis, hepa ri1il 8, a rrd
polio 1"'' 1li11rix) Another approved su1>er shot
is 1lw<o111I a 10n of MMll vaccine wim varicclla vaccine
(ProQu" "'''(a comhination of DTal'. I lib, and
IP\') i\ ti ;n"ed for multiple immunizations in one
lfljl'(llOn
FOR
OPULATIONS
Vacci ,,
Rabi~l 1 c. gi,cn prophylactically 10 those persons
who~" "" 1rJ1ion or tr.we! puts them at high risk for
1>otcnti l,l lon1.lct \Vilh rabid anhnals. This vc1ccine is an
exccpllon to the n dc of immunization because the
V.lccinc b '" ..n in mo\! cases after potential exposure 10
the d1"'" r~.mi'm following an animal bite. Addi-
tional do"-'5 may be required after exposure is confirmed.
R.1b1rs " ,J, 10 dewlopmd me affected persons may
be vaccrn,1tcJ after uansmission of me organism and still
have \Ultidem time to build antibodies again>! the
invading org.rni~ms, providing act ive immunity. After
CHAPTER 16 Immunizations and the Immune System 269
receiving a dose of rabies immune globulin for shon-
1erm immunity, the affected person is then given the
killed virus vaccine.
PATIENT SAFETY WITH AGENTS
FOR ACTIVE IMMUNIZATION
With all immunizations, the pauent should remain in
the office for 15 10 30 minures .ifter adm inistration to
observe for .1dverse reactions such as shortness o fbrc,11h,
wheezing. or a drop in blood 1Hes~ur". If tl1e patient does
not remain, documemation of the leaving as well as the
time of immunization provides legal protection if
needed llause adverse reactions are often not reported
until the next appointment, the pdtient or parent should
be told 10 immediately report read io ns such as high
fever (temperature >104 r 10 105 F), collap~c. pcris-
tcnt cough (in excess of 3 hours). and seizures.
Do 1101 combine separate vaccines into the same
syringe for administration unles the health professio nal
approves and me package inscris state FDA approvJl of
compatibility. F,1ch vaccine should be given a a single
medication 10 prevent adverse readion.s and pos.sible
interao ions among me active immunization compo-
nents. T.ible 16 3 gives the m :o mmended schedule of the
most common immun izat io ns for ch ildren and <tdults,
and llox 16-4 gives a quick reference of the proper rou te
of admini51ra1ion for seleaed vaccines.
SAFETY WITH VACCINES
me CDC, .is a means of providing continued safety for
vaccines, ha~ supplied informatio n to the immunization
provider for storage and maintena nce of vaccines for
patient safety. Box 16-5 provides some safety tips related
10 vaccines Omers may be found at the CDC website
(www.cdc.gov/od/science/ iso/about_iso.htm).
..
lmmunllattOnS JlfO\'Kle antibody-antigen reac!Jons 10 produce
an11bod1es f0< long-!erm 1mmuni!y ....tleteas immone globu-
lins and anutoxms provtde an11bod1es for shon-term
immunity.
Active immunity provides long terrn disease protection. with
the person prodocing antibodies 10 lhe disease process.
whereas passive immuoi!y provides short-term disease pre-
.et11ton, with mvnuni!y provided with antibodies from other
SOOfC8S
Immunizations are adm1nrsua1ron of vaccines '
1oxo1ds
These produce artificial actrve immunity. with an11bod1es
Continu.... I
 TABLE 16 3 RECOMMENDED IMMUNIZATION SCHEDULE
Aged o Through 6 Years-united Stat es. 2010

--
Recommended Immunization Schedule 1~! Petart rso:~ see lhe catch-up schedule
For thoSe whO fall bell"' or s

_,_ -
Vaccine

_,,...
ltoi-B'
_.
Age II>
1

--- . --~
.....
2 4 6 U 1S .. t~l-3

.,..,. .,..,.
...

----.....
.......

-
OTaP

~'!~~~

-led-
a:;;t
-mocoocaP IPV

.,.,..,.,
-- --- 11

-
-M~, IU>elll"

Hlpel!DSA~

---
Mlllg '"

_.,, ______ ...__ .. __

.......lWI &
n. tchecUe a:fudes ikGIWE ' II ft tilM:& M ol Olc:M'Cllf' 15. 2009
lvfl/ doMnot d e:t N ....,idedlQl....,beadi--edala .. ,,,
_e..
...
~ . . . ...... ~end
DIM"'1 ~o.----...-.a.......,..'''41....:::ones.
~ "''*I ilndudt ~ 111
...... Tht ..... ol 100110lllllbon"'9CCftl:
Miit ...... ?O*'elll08, and

6. lnaetlvoled polioYIMI vocelno pPV) (M.nlmum age

t - - B voceine (HepB~ (M<wnllln OQt -
Al birth:
)
Admenlster monovalenl Hep8 to II newbOfN btforl hOlpi~ dltcNirge.
II molher ,. hel)Oll1il 8 suofooe On1'90" (HOoA(l)PGO""" alt!>lnlAtr HopB
The finll dole in the Hritf lhOlAd be .Onwil5fer
birthday anc1 a111as16 montht lollo'wfnO the prev1ou
It 4 doses 818 adrnWISerod i:>rlor to IQt 4 ye&tl a htth
.. &ttoul<S be atrnn-
and 0.5 ml ot hePatltis B rnmunt ~ (HBIG) Wtlhln 12 hours of blr1h. istered at ege 4 rhrough 8 ytrall. Sff MMWR 2009." m-Oo.
II motllOfs H8$AQ 51atu1 it uMnown. ctnlnltter HepB within 12 h04.lt$ or 1. tnftuenz.e vccfne (1ea1onal), (Mlnlm1,1m age 6 mon r lh\lalent Nici~
birth. Oe1ol'n'li"le mothlt's HO.Ag 11atu111 eoon at poMlbll and, id HB&Ag valeCI ~tuenza v&OeiM (TIVI. 2 yoara k>t live, attenua i
1
1Uen?8 \180c:lnt
poal!IY6. a0011n1&1er HSIG (no latitr than 101 1 wook). [LAIV))
After the birth dose: AdmOst&r 1nnud')I 10 Chlldfen Qed 6 months throi years.
The HepB series should be oon1)1eladwilhtkhlr ~ HepB or a com For heallhy childrtin agod 2 through e years (I ., tnosc ' do noc havt urQr.

--2-
binabon vacdne conta"-'g Hepa TM MCOl'ld dOM at'lould bt adr1*tiMBred lying medical c:ondlllOnl lhll pt9(11epo&e lhem k> in ;t complica~
at age I or 2 monlhs. Monc:Mlltnl Htp6 ~ ahNO bl UM<l lor doses either lNV orTIV mtlY be UMd, tXCtOI L.Arv lhould given IO Cllikhn
--.agee-That"'"'_.......,bt_no aged 2 lhrougl'l 4 )'Mtl who hlYI had wheezing .,
CNldlon 1900Mng TIV . , _ - 0 25 ml i "
'>1 12 montha.
'0Ugl>35 .......
, , _ bt -

- be----"' -1-
- bO<fl IO poo- -
HBoAg lor He.Ag and Ot 0.5 ... wIQld 3 Y'O" .. -
ll'llllboCfy H8sAo monh: ....
1 ID 2 ol do&el. OOi I $' CI It ..... 3 of lhe Acmn.all!lr 2 0011M {tepltatld bi/ II '9esl "'99lo.-s t>

--
.0
- ........ age 9 """9> 18 - (plfMtllly ..... - -- _.,,,.. .. _CUWIO,...,._,. ..,
hln 9 )18811who . . ~~"8CQne lor

,,._.a

c---,.
Adl1WiSll....,1ol4 dosee ol H1SJ8 to ..... peo11 P OOftlbnl.
llenwccine con&airwlg:Hepe ... . . . . . . . . . . . . . brl'J dme. The fDur1h .. for t&:GJWl& ....... 6buttal~A (H 1 N t
doe& shcUttlO..,..,. '*' 24 ....._
2. Ao<Mrusvacdne(RY).--8-)
llgt
l.
-
_- - - ...
--
MMWR 200t.$81Mo RR IOI
_ ln
_ o (l.
""""''I' l.
l.lA). 1M
. ,,_,
.Ad>- ......
-6dayS)
- .... """9> ,. -
.,__......,nocbt.,..todlor--15- _ _ _ ............. odbetoo11age 4
_ _ _ ... filll -
0 dayl - .
Tha - age lor 1he final -
In lht - ,. 8 - 0 days
" Aolarik is admlniS1efed at 8;Q9S 2 and 4 tnonlhl. I dote It &monchl is not
9. - I I voccW... (M"""'""' 12 ooe: "'"'")
Mmin1S1er lhe MOOnd dON rouelnely at age throu '11'5. HowMf, ..
lndk:aled. second dost may I 1dmnit11!9d bliore I OI 4 pr I leas1 3 mor'lllt
3. Diphtheria and tetanu1 toxold1 and tcltullir pertuI \llCdnt {DT1P).
(Minimum age: 6 week$) - For cNldren
- - 12
aged month
lht lhtOVgh 12 yoar5 the tr' ni
" "' dOt 'Tl 1n'9rval bflweeti
The tounh dose may bt actml1'111.010d u 11rly u agie 12 mon1hs, provided dOses is 3 montht . HOWGWr, It lhe MCOl'ld oosc .... , m51ered M loasl
en 1Ns1 & monttis ha.,. 11apsoc:1 linCt the 1hll'd dOM, 28 days at101 lhe fwtl dOlt. 11 can be accepted as 11a!
Administer tho tinal dOH in Iha MHIM l l 89f 4 I~ 8 yeatl. 10. Kepatlll.s A vacc:lnt (HopA). (Minimum age 12 mon(I

-
4, HHmopllltut /nl'lc.-lzff type b confug1t1 vaccine (Hlb), Actnlnl&1er IO all m 11e1mn aged I yur (1.e aged 1 1ugh 23 monlhf).
(Minimum age: s-.1 Mnlnia1er 2 CIOIGI at ..all 8 months apat1
'
II PRP-OMP ( - JB Comvax [Hop8HibD la Ml-IOd at ages 2
and 4 months. a dose 81 age 6 monlhl It noe lndlcallcl
Chllci'en not ti.Illy VIOcinlltd by age 2 year1 can oe v.t I :ed al sut>&eQl.ltl"!I
TriHi8"(0TaP-) and-(J>RP.T),,_nocbt-10>-8'agos
2. 4. or 6 monrhs fo< lt'I prtmlry wiel tu can be UMd as lhe dOM '" "'* HepA also II 1 ~1Wt1eod1d lor Older chlki'en '*"'
Clnaboo Pl'OQt'lml ~ oldtf" c::hlchin, Wf'IO art at il'tCI'

-l_3_
lCVI0--2-
aged 12 """'"" fNOugh. ,..,.,
- (PCV12_1or..............,,,...___
-
s. - - - - l n o . (Mmunago 8 - l o r,Pl>SVJ)
PCV - wt-loral _ _ _ _ 5 _ _
---
orb lllf'IOtn SnnuVty 1Q11Nt ,._,.ttllia A desired
11..Menffl90Cc cc9' ~lne. (Mn!'unege 2 yws tw
-=or.(MCVl and tw 11illoxo;:cM Cd)IJ I 'Ide
-VJ(lOCCiilW..-
-ne (MPSV'O-

_..
1- ol PCV1DalhHll1r-. .
noc w1:;p1elaf) wwwxwiidled tw .,.. IOI

- Seo
-Pf'SV20< _ _ _ ..,_olPCVIO-aged 2

---~--ldd>O
MMWR 1997;~No. A~)

The Aaccw1111ded
2.....,.58--ant

~ SCheo.llN IOf ,,......AQoclO~ 18 Y-.sate ~ byh """'*'1Colmtlttile ~ p~

.. . ..,_
.....-. ~._

~ MC'V4 D Chltllln ~ woc:nated

2009-.58.1042-3
_
10 _~
menl OOl4JOi ~ INIOrNC Ot lunctloNI .

oO<-odOIOQt 2 - -

--"'91
MCV4 Of MPS'
SOO MJIWA

f(......-.cdc-"oceh-oclp) ,,..,,_~d-(hllp:RWww-.o<v). and ... -~ .. F~ ....._ . .

_.,..,. .,,,,.._-..eon..,.,., rn-eoni...... _...,
From the Centers for Disease Coouol and P1ovont1on. Atlanta
 CHAPTER 16 Immunizations and the Immune System 271

BOX 16-4 PROPER ADMINISTRATION ROUTES FOR IMMUNIZATIONS

Subcutaneous lntramuscul1r Intranasal 0111

IJMR OTaP, OT, Td Hepam1sA RotaTeq
Hepat1~S 8 AuM1st
IP\/
Pneuroococcal polySatthande Hib HINt (swine ftu)
vaocella IPV
Meningococcal polysaccharide Meningococcal coniugate
Pneumococcal con1ugate Tetanus toxo1d
Hepatitis A

... BOX 165 SAFE STORAGE OF VACCINES

Inspect vaccines on delivery and m<WUtllf refrigerator and
a penod of ~me to plOVlde 1mmun1ty tor lr8elef t~aturas to ensure maintenance of the proper
~1s temperatt.re during delivery
Vaa: r. a suspension of whole or frat11onated Vaa:mes are fragile and must be kept at - l d e d tem
TOoids are bacterial toxins that have been peratures at all limes It 1s bentlf to not vaccmate than to
toxic state administer a dose of vaccine that has been mishandled
f although mild reactions are fairly common Rotate vaccine stock so that the oldest vaccines are used
effects rarely occur first. betng sure of the expiration date
liYe 'YI I ould not be given to immunocomprom1sed II reconstitution of medication 1s required. be sure to use
patient 1 irsons who have recently received gamma specified diluent.
globul 1 nity may not occur. Administer vaccines within the prescribed time period after
Yearly t is for Disease Control and Prevention (CDC) recoostilut1on.
issue ts of recommended vaccines. which should Watt lo draw vaccines into synnges until 1mmed1a1ely before
be ~ 1 regular basts to ensure proper vacc111at1on administration.
of pa Anyone who received compromised vaccme will have lo be
f()f d th tpeetfic vaccines, the routine tor adm nis revaa:mated. making parents Of caregrvers unhappy because
Ua!JOO should be obtamed from the CDC to ensure the rec1p1ent must receive repeat doses ol vaccines
to susceptible aieas. exposura to disease. II errors m vaoone swrage and adm1n1strauon occ111. tate
"tUmStances that 111dicate use of lhese corrnctive actlllfl immediately to prevent rec111rence. and
no~fy pubrte health authonties

kt! LIN CA -1p

To lessen pain ol vaccines with children, one technique 1s to have
children blow on a feather to blow away the pain Blowing lessens
perceived pain. Another technique is to swab the forearm with
The vacc 1he luture include those for cycomegalovirus. alcohol and have the child blow on the spot The person cannot
human f1c1ency virus (HIV). herpes simplex virus. perceive the difference in the cold of blowing and the pain from the
Staphfact reus, group B streptococci. and malaria immunization at the same time.

Antitoxins
OR ARTIFICIAL
MM UNITY Antitoxins are immune agents produced in response to
an anugen and capable of neutralizing toxins Before
Pas..'iivc 1n1111u1uly orrurs when ant ibodies are injected administration the patient should be skin tested to
imo th~ bn<l1 for n immediate. mpid but shnn protect from .maphylaxis caused by allergies. 1\ntitoxi ns
lived type nl 1111muni1y, lasting for only a few weeks or from human and animal sources are used for pro1,hylac
momh,, tic .rnd therapeut ic purposes for specific toxins.
272 SECTION IV Pharmacology for Mult1system Application
Immune G~l~
o b~u
~l~in
::..:.
~~~~~~~~~
Immune globulms are antibodies found in serum that
are used in the pre.,.ention of diseases such as hepatitis
8, t("lanus. and r.ib10 A(uve immunizing agents should
not be administered at the same time as immune globu-
lins. because the immune globulins may $lop the actions
of the immunving agents to produce antibodies.
Immune Globulins for Specific Conditions
Rho( DJ immun~ human globulin (RhoCAM) is an anti-
bo<l) preparation 8""'n after deli'"'IY to desensitize
Rh-ncg.111,e mothers who deh,"trs an Rh-positiw baby
(I igurc 16-5). l"hc sensitvA111on of the mother occurs
when any of the blood cells from the mfant enter the
bltx1ds1re,11n of the mother, usually at birth, causing
.tntibod)' formation in the mother If that mother has a
uhw<1ucn1 Rh posill\'\? infan~ the produced antibodies
may cause erythroblastosis fetalis in the second infant.
RhoGAM must be administered within 72 hours after
delivery 10 diminish antibody formation by the mother.
Respiratory Syncytial Virus Immune Globulin
ll1s/1imtory S)'l")'titll Vll"llS (l!SV) immwoe glob11/i11 for lower
respiratory disensc c.lllsed by RSV is produced using
DNA 1ech11ology. lm111unitatio11 with polyvaleni RSV-10
(Resplgam) and paliv/%mnab (a monoclonal antibody)
arc often used with premature babies to prevem respira-
tory problems. r>a1it111s, including ~iose who develop an
RSV infection. should continue to receive monthly doses
1hrougho111 the RSV season. Other selected age111s for
anificial pasivc immunity are found in Table 16-4.
First p<ognancy Rn mother eposed 10 Aft
Rh+ agglu11n~ns. er exposure, Rh-
"""' antlAh agglutinins
Figure 165 AhoGAM isne.:essary to p1even1 hemolytic disease'" an mfam whose Rh-
E. Tiie anaromy and p/lyS1ology /earm"IJ syscem. ad 4 St Louis. 2Ul l. Saundeosl mothei has boon exposed 10 on Ah JXJS1t1vu 1,,111 ll rom Ai>plegaia
EDUCATION CONCERNING
IMMUNIZATIONS
Jn today's world, many chi ldhood di\lases that "
.
fatal se>'\?ra I generauons ago are now almost erado
'tit
-
cated in the United States because of 1mmunizatio
Parents must understand the need for immunil:"'
children. State and federal laws rcquu..' immuniutio~
for school. although some parent\ may refust to
immunize their chi!d bausc '.'' cultural or relil!Jou.
bcliefs. For the child to obtatn maximum effe:a ol
immunizations. spacing of immuni1.111 1n, ~hould bt
at the CDCsuggcsted ti me interval' \It hough tilll(
in1em1ls longer than those recommt Hied may bt
acceptable in some cases, shoner m11n 11 for obtain
ing immunizations required by law .1r. 11naccep1ab1t
The child who is not properly immunt7 d during tbt
first year and a half of li fe and wh"' JMrems thtn
vait until school age in most ca will not bt
allowed 10 aucnd school until imn 1111.uions haw
been administered. 1\dminis1ering 111 lt q1le vaccines
over a shon period of time puts tlw 'hold at greater
risk for ad~rse reactions.
Adults have a higher incidence ul llUHC>mpliance
than children. 111e allied health prot 1n11al should
assist the adult pat ient in keeping rnrH "' with vaccines
such as dipht heria-tetanus (Td) v.u. ' lhe :itrisk
patient should be encourag~d 10 h,1v1 ' d11;n1.a immu
nizations yearly, and the pneumorn v.1ine as rec
ommended. As vaccines are ,1v.1il.1hl1 I ruficial actil'e
immunity, such as Hl'Vand shingle' v.1' m ,, .1dults and
mo<heo produces Second p<egnancy Wlh Rh I tut
Anti-Rh agglulln1ns wuse oqql 11 nation
or re1a1 red blood cells
 --------CHAPTER 16 Immunizations and the Immune System 273

. DOSE. ROUTE.
' TRADE NAME AND FREOUNECY INDICATIONS SIDE EFFECTS

ANTITOXINS
Oiphlhena an111o;un
(from 11otses, so
must skin test for
allergies)
NTN Prophylactic: 10,IXX> units IM Prevention or treatmeni of Redness at tnje<:hOO
Therapeutic 20,000 120,000 diphtheria Site
units IM or IV

SERUMS ANO IMMUNE GLOBULINS

Botulism 1111rr 1110 B<lbyBIG See package msen Prevention and treatment Given IV with the
globulin of botulism resultant side
effect$ and dangers
Rabies immune lmogam, 20 units/kg IM IX of dose may Exposure to rabies Fever. soreness at
globuf Hyperflab be used 10 infiltrate the 1n1ection Site
wound)
TetanllS 1m HyperTET ProitrfiacllC 250-500 001ts IM Passive immunization to Tendetness and
(human (children based oo weight) tetanus muscle suffness
Therapeutic 50().31XXJ unns IM
Hepat1t11 B HBIG, 0.06 mL/kg IM within 7 days ol Postexposure prophylaxis local reaction. fever.
globulu HyperHep B, exposure for most s1tua11oos to hepatitis B urticaria
Nabi-HB,
HepaGam B
Immune h 1um IV Camnune NF. 100-200 mg/kg IV q mo Passive immunity for Local reactioo, fever,
globul11 Felbogamma. 200-400 mg/leg IV q mo rubeola, hepatitis A. urticaria
Gammunex. O02-1 3 ml/kg IM l1 32 ml/kg vancella. and so on; use
Octagam. for adult$) dependmg on IV lor immunodeficiency
Priv1gen. reason for use syndrome
Gammagard
IM GamaSTA
so
RSV lllC'.'.-.: Synag1s Based on body weight IM during RSV 1n p-emature infants local reacbon. rash.
anu~ RSV season and susceptible children d1arthea. cough.
ipa IV OllllS
Resp rat 11 Resp1Gam 750 mg/leg IV Reduce lower respiratory Fever. diarrhea.
1mmu 1 tract 1nfeetions from RSV vomiting, wheezing
1n children <24 mo old
al high risk
Rh~O) 1m RhoGam 300 mg IM at 2628 wks, wimi11 Desensitization to RhoD in Lelhargy, myalgia,
globuhr 72 hr or after 72 hr have Rh negative momers 1rntation at
passed 11 Rh status 1s in1ect1on site
unknown
M tt1Uan
1
. 11\trll\OOOUS!y, NTN. no trade name. RSV, respira1ory syncytial wus; SC. subcutaneously.
274 SECTION IV Pharmacology for Multisystem Application

children should be encouraged 10 avail ll1emselves of

this pro1mion.
lmmuniza1ions save indirectly in medical and sod
etal cos1s Parenis mus1 do !heir pan 10 make sure !heir
children are immunized wilh rurrenl vaccines and
new immunizauons .u lhese become available. Although
95% of all school children ha\-t been vaccinated. parenlS
and children of m1gr.ui1 workers. new immigrants. and
others who may no1 be aware of me need for and ben-
efil5 of 1mmuni7.auon mus1 be educaied. The ri<k of
<1<111nng 1/1t dU<".IS<' 1.1 mu<h grttn lhan 111" ri5k associa1td
u11/1 Mcunes. When large numbers of a population are
nor 1mmuniud. chanM of exposure to infectious dis-
eases are increased
Persons traveling 10 foreign counuies should
coniact 1heir health care provider or 1()(3) health
dcpanmenl well in advance of the depanure dale for
needed (ehher required or sugges1ed) immuniza1ions.
Ihese immuni.r.ations mus1 be given in advance to
produce adequate immunity before traveling Cfable
16-5).
The CDC sets requirements to meet public health needs
Educaung parents about the need for 1mmu011at1ons for r;ljJ.
dren 1s an 1mp00ant role lor the allied health professiooai
eoomued immune states 1n adult pat1ems should be cheded
and proper 1mm111111a11ons given as indicated
11a ques11on of whelher to adm1nistllf an 1mmu1111at100 or l'Cll
exists, the potential lor benefit 1n1Jst be >Waghed against 0.
potential for r sics
Docunen1a11on of 1mmum1ations is specific and the Nat~
Ch kttood vacone Act of 1986 prOllldes the guidelines for
chartJng
i!f,!Miiflt11Q4;1i{i!ibti 0:-.
Wilh me advent of 1ransplanta1ion of h ly organs such
as me liver. heart, and kidney, a new tlr11 (.llegory was
necessary to decrease or prevent norn1.1I H 1 wnan1ibody

TABLE 16 5 IMMUNIZATIONS FOR TRAVEL TO FQREIGN COUNTRIES OR FOR SPECIFIC SITUATIONS '

IMMUNIZING INDICATIONS FDR

AGENT TRACE NAME DOSE. ROUTE. AND FREQUENCY PROTECTION

Cholera vaccine NTN 05ml SC or IM 2doses 1 wk to 1 mo Cholera for lravelers an tor 1ct1on. lever.
apan areas of high risk m e. headache
Plague vaccine NTN First dose 1 ml IM. second dose: 0.2 ml Plague for those at nsk Ma headache.
IM 23 mo alter first dose and again at for exposure I iythema
6 mo. lollowed by 0.1 to 0.2 ml boosters
q6 mo -Mule in the endemic region
Rabies vaccine lmllllax See package insert! ml IM x 4 doses Rabies preexposure 3tllOOS,
pre-exposure. secood dose 7 days after and pos1exposure lor headache.
first third dose 3-4 wl: after !irst; those at nsk. and a.abdorrun,i
4 doses post~xposure
RabAvett 3 doses 1 ml IM pr~re. 7 days. PrOl)liylax1s
14 days. 21-28 days, 5 doses fpreexpoS11rel
post~e
Typhoid NTN 05 ni SC wllh booster in 4 wl: or more Tr.M?lets who will be Loe JCt1ons.
Parenteral Typhlm VI 05ni1Mx 1 dose 111 oooou1es \'Mere e. myalgia.
Children <10 yr 0 25 ml. booster 0.5 ml typhoKI rs endemic
SCorO I ni IOqJyr
0.5 ml IM and q 2yr 11 needed owing 10
uavel to endemic areas
Oral Vrvo11I Berna l cap 1 hr ac x 4 doses tat least 1week GI ptoms. rash
Vaccine before potential exposure) with boosler
m 5 years
Yellow fever VF-VAX O.Sml SC Travelers who will be H".i Ms. myalga.
vaccme m countries where rash GI symptoms
yellow lever 1s
endemic
AC. before meals, GI, gasuomtestJnal. ID. 1mradermally: JM. inliamusculaily NTN no trade name.. SC. subcutaneously

sponsc or till' body. This new group or dnigs, known
res immuoo\up1>ressanls, is used mam
Iy in transp Ian ta
:,onbu h.1s other uses such '' in autoimmune diseases
Jnd S<'\ ere .1lkrgic reaaions When a foreign substance
or organ " transplanted into lhe body, lhe body's
immune rcspo"'e processes transplanted mauer as a
foreign sub\lancc. Withoui these agenis, tissue destruc-
uon and rctl'Ction of the transplanted organs would
rertJinly 0<cur lhe main adverse effeas of using immu
nosupP'<'" "" medication< are that these agents lower
the body's ,thility to fight d iseases. leaving the patient
more sus. c1'1illlc to inrcctions, infectious diseases, and
the pass1hd111 of malign.111cies. and the inherent side
ctfectS of .., '1 mcdication
CortJCO\t<to1ds have the abi lity to suppress immune
rc>ponsc' .rnd m used to produce potent .111t iinflamma-
torv and .111tttlkrgic effects by causing lymphocytes in
bl~ to I di>tributed in the bone marrow, lowering
the numl>- f h mphocytt~ in the blood Corticoste
ro1ds a1c r s trn.iuently u;ed in conjunction with other
immuno,uppr "'ivc agents (see Chapte1 20).
Other 1111 1 1110,upprcssivc agcms arc used. including
the folio
\z. (lmuran ). a derivative of the antineo-
pla' 1 ..1p1opurine, suppresses formation of
Oe'\ \ , I I cell' by suppressing ONA and RN1\
synt. "7..i thioprinc is mutagenlc, tcratogenlc,
and enlc.
C1 (&!ndimmune), a metabolite pro-
du a fungu~. 11 a potent immunosuppressive
ag.:ul 11t " 1101 cytotoxic. It suppresse~ Icell func
Lior 1 dlpressing the immu ne 1 csponse. When
thl\ 1 .1tio n is discontinued, normal T-cell
funr resumes. Admin1Stered along with corti
COSl rvclosponnc is used to pre--ent organ
reJt'.l lt 11 1ltl'r transpl.\n1ation.
My 11 /du mofctll (CeJICept) and 111ycopl1e
(\lyfortic) inhibit the activity ofT cells
1' 10 reduce the effectiveness of the
im >tcm The primary use of both of these
dni '"vention of rejection in renal transplan
1at H1J 1111 mycophcnola te may al>o be used with
Ii\ c I hcan 1ran,1>lantation (T.1ble t66}.
1 A per 1rig tmmunosuppressant drugs 1s susceptible to
Infect ~ is .ase bee<Juse these agents lower the body's
1mmu OOflSe.
2 No "' lOllS with hve virus vaccines should be admm
people taking rmmunosuppressants
3. Repon L I bleeding or blu1s1119. as well as sore tl11oat
and m, u 1 sores. to health care provider wllen taking
immuno pp1essants
4 Women o ch ldbearing age should not take these medica
trolls. 11egnancy must be avoided
CHAPTER 16 lmmunrzaoons and the Immune System 275
A,'11d graoefrun JUICe and grapelrurt wtien LJ1<1ng
C'jtlospornie
6. Cyclosponne should be taken consistently at tile same ume(s)
each day with meals
7 Ma nta n good dental hyg ene
IMMUNOSTIMULANTS
Drugs u~ to increase or sumulate the immune S)"tem
response to treat cancer and HIV infection are called
lmmuno~Umulants. n1e first agents, which bec.1me
available in the 1980s with lhe adven t of DNA 1echnol
ogy, are u~cd 10 stimul.1te lhe immune S)'Stem when
deficiencies exist and are a rapidly increasing group of
medications The acquired immunod~lich?OC)' may be
caused by medication' 'uch as chemot herapy or it may
be acquired through viral infections such .1s I llV. lmmu
nostimulant~ are expected to provide control of pain and
discomfort found with man)' illnesses lnterftron alfa
and inur/.,ukin2 (Prolcukin) are two of the earliest
medications to stimulate the production of fl cells .111d
ki ller 1 cells. By increasing the number of killer T cell>.
it is thought that lhesc dnigs provide the needed T cells
10 anack and destroy infections or cancers 111 the affectt'<l
person Many of these dnigs are more commonly used
and approved for use a~ ,1ntineoplastics (see Chapter 18)
or in the trearment of he1,atitis C infoction (see 1:1ble
166 for a s.1111ple of these agents).
'!MIOllOSl wessants are used 10 prevent organ reJl!C!lon
afler transplants and to treat autoimmune diseases such as
rheumatoid arthritis
lmmunosuppressants 111crease the risk of mfecllons and
lymphomas
Cyclosponne is one of the most ellectM! 11nmuno-
supp!essants.
Cort1costero1ds are oflen given as adiurict medications with
other 1mmunosuppressants
Azath1op11ne and other cytotoxic drugs suppress unmune
respons.is by B and T cells Many an11neoplas11c aqents
produce 1mmunosuppress1on as a side effect
Research regarding immunos11mulants is cncreasmg because
of their potential use 1n the treatment of human immuno
deficiency vtrus IHIV} nfect1on and other acqu red
mvnunodeficieocies
 ....
"'
"'
"'
-~
m
n

<
....3
-0
:7

IMMUNDSUPPRESSANTS Nausea. vomiting. decrease "'0

on blood cells. depression 8-<
of bane marrow 0~

azath1oprine lmuran. 35 mg/kg/day PO 1nit1ally; 13 mg/ Kidney 1ransplan1a11on allopunnol, hve virus vaccines. ;:
Azas.'ln kg/day as maintenance dose other 1mmunosuppress.1nts :.
cyclosponne Sand immune.
Neoral.
Gengraf
10 14 mg/kg/day PO. IV for 1 2 wl<.
then taper to maintenance dose
of 510 mg/kg/day
Renal damage Heart. kidney, or hver
transplant
Same as azath1oprine. plus
c1met1d1ne, danazol. d1lt1azem,
ACE inh1b1tors. K-spanng
..
~
!11
3
l>
d1ure11cs, er)'thromycin, K ~
0
supplements, ketoconazole
mycophenolate mofet1I CellCept Renal damage, insomnia, Kidney, heart. liver
"'g.
23 g/day PO. IV in 2 divided doses acyclo1111, ganc1clovir. antacids. ::I
(to be given with corticosteroids dysrhythmias. arthralgia transplantation probenec1d. cholestyramine,
and cyclosporlne) other 1mmunosuppressants,
live virus vaccines
mycophenolic acid Myfortic 720mg PO bid Renal damage, insomnia. Kidney transplant Same as above
dysmythmias. arthralgia
sirolimus Rapamune 6 mg PO stat. then 2 mg/day PD Kidney transplant None given
tacrohmus Prograf Sile package insert Heart, liver. and kidney An11lungals. am1nogtycos1des.
transplant calcium channel blockers,
c1met1d1ne, er)'thromycin
IMMUNOSTIMULA.NTS fe\ier. flulike symplllms.
nausea. diarrhea
1111erferon alfa Roferon-A Vanes among parients . IM, IV, SC AIOS-telated conditions. am1nophy1hne. zidcMJdine
Kaposi's s.'lrcoma.
other malignancies
 ~~~~~~~~~~~~-
CHAPTER 16 Immunizations and the Immune System 277

lmmuni1..ations are indicated for lifelong medical

SUMMARY
'""cines wcrt one of the grealesl achievements in the
medical field an lhe twentieth century. hnmuni.talions
lme altered the way Americans look at quality of lifo.>.
rrorn childhood through adolescence into aging Vicious
di;ea>es, \Udl .is smallpox. have been vinually erased,
,ind polio h expected 10 be eradic,lled early in this
(COLU!)'
lnimuni1.11ions may provide anificial acti\e immu-
nity, 111 y,h1d1 1he body builds its own antibod1e; to
foreign anli11cn,. This im 111unily is usually long acting.
sonmimc' l.1\ling a lifetime. Artificial active immunity
bl'gins a1 birth .111d con11nues throughout life. Parents
mU>t be t u~ht the dangers of not immunizing
children .111d lhc impon,ance of laws requiring 1hat
rrn,1in v.ll< Ill' he administered before a ch ild auends
;chool.
Anifiri 11 '"e immunity, or shon-term immunity,
1:. nHrodui.,"tl tt1rough anutoxins fron1 human or animaJ
~ources 01 .1, .itunune globuli ns in sen11n. Passive in1 111 u
mtv is di c1 im medi.1lely. as the serum or antitoxin
ro111.1ins "Ji"" needed to fight the 'peci6c
thse.ise
cart-from infants obtaining hepatitis B vaccine to
chronically ill older adults who receive mOuen~1 and
pneumonia v,1ccines. To achieve the full potential of v.1c-
cincs. adults muL recognize 1hat vaccines mobilize the
body's naturdl defenses, Jnd they should seek vaccina-
tions for themselves and their children I leahh care
workers are susceptible to nuny disease processes and
should av-ail themselves of specific immunizat ions for
protection ag.1inst pathogens found in medical set11ng..,.
nw vaccine deli'E'ty must be extended to adolC\Cents
and adults to ensure that they are protected from such
dise.1ses as tetanus. inOucnza. hepatitis H. and pnc111no-
coccal d isea<e.
lmmunosuppressants are used to prevent tissue re1ec-
tio11 by the antibody-an11gen re.tction wben foreign
1i~ue is introduced in to the body. uch as with org.1n
1r.111;plants. 1llV, cancers, and other au1oinununC' dis-
eases respond to immunostimulant.>, or agent< that
increase the activity of the immune S)'1>tem. The intro-
duction of new immunostimulants is one of the most
r.11>idly growing medical fields. lmmunotherapy is ,1 rcl.l-
tively new area of medicine coming into the forcfrom by
imitating the action of the immune system for the treat-
ment of HIV and with org.m transplants

HINKING EXERCISES

Seen lo
Pre hwa, who has an Rh-negative blood type, has 1ust given birth to Jason. who 1s Rh-posttrve.
.... , 11ud1ca tion is mdicated for Mrs. Wadhwa to prevent erythroblastosis fetalis if she should
be pregnant again?
2 .... he time 1m1t to< gMng this medication alter ch11db1nh?
3. ~rs. Wadhwa need the medication 1f Jason had been an Ah-negative mfant? Why or why
nn
4 Wt- would you tell Mrs. Wadhwa if she asked about the dangers of RhoGAM immunization?
5 Ii Id you answer if she asked about the source of the medication?
278 SECTION IV Pharmacology for Multi system Application

li;iii#IW!iillfit.Vt 2. Drug ordered: lmuran m

4 g/kg/d PO'
ay
-
1or a llelSOQ
I D~g ordered:_ ~ICept 500 mg who weighs 165 lb . .
A\"a1lable medtcauon: Available medication: azath1opnne 50 mg/tab
ICIC-.-01 Dose to be administered:--------~

~--
CellCept
(mycophenolote
mofetll capsules)
25Q mg

Dose to be administered: - - - -

REVIEW QUESTIONS
I. What is naturally acquired passive immunity! Naturally acquired active immunity! Anificialh
immunity? Artificially acquired active immunity?--- - - -- - - - - - - - --

2. Which oflhe t~ ofim munity listed in question I uses vaccines and toxoids? Which uses antitox1 ind immunt
globulins? Which immuni1y lasts longer? Why? - - - - - - -- - - - - - - - - -

3. Dicuss instances in which immuniza1ions would be contraindicated. Do conttaindicMions al" prevent the
adminisualion of an immuni7Allion? I low are the circumstances evaluatedl - - - - - --

4. List the data required to be included in documenlalion of imrnuni7.ations, mandated by the Nation 11 Childhood
Vaccine Aa of 1986. - - - - - - -- - - - - - - -- - - - - - - - - - -- - - -
 CHAPTER 16 Immunizations and the Immune Sys1em 279

s. Adults have a higher incidence of no nconformance with immuni1,ations. What can the allied health professional
do 10 lower the incidence of noni111111uni1.a1io n?

6 what 1s the main indication for using immunosuppress.1nts!

7 \\'hJt j\ the m.1in JC1ivity of an immunostimulant' - -- - - - - - - -- - - - -- -- - - - - -

Antimicrobials, Antifungals,
and Antivirals

After studying 1h1s chapter. ~ should b6 capable of doing the following

Expla,ning the difference between pathogenic and
nonpathogenoc bactena
Descnbing various forms of bacteria that are
pathogenic an the body
Describing factors that are 1mponant in choosing
an ant1b1otic or antimicrobial agent.
Explaining the ditference between bscteriostatic
and bactericidal agents.
Explaining how bacteria can acquire resistance to
specific antibioucs.
Knowing why ant1b1ot1cs. anumocrol:> s ant1wa s,
and ant1fungals may be used prop~ .t1ca ly and
when prophylacuc use as anappropr
Explaining why some infections are r ~t treated
with a multidrug regimen.
ldentrfying and classifying by family nt1b1otics.
antimicrobials, anuvirals, and ant1fun ;11s commonly
used today.
Providing pa ti en t education for con nee with
med1cat1ons used as ant1m1crob1als, , ufungals,
and antivirals

Richard is seen m Dr. Merry's offtee wrrh an infected lesion on his leg Dr Merry examines R d and
gNes him a prescnpt/Ofl for a topical anr1bloric robe applied to the lesion three times a day R 'dis
concerned because Dr Merry dtd nor grve him an antibiotic to rake orally
What as your response?
In the past. Richard has taken multiple antibiotics for Illnesses. How might this affect the efk veness
of antibiotics he takes an the future?
Why is a topical ant1biouc more likely to be used for localized infecuons? When as a systefT'1 t1b1011c
more likely to be indicated?

Aerobic bacteria Disinfectant or Host Phot osensitivity

Anaerobic bacteria germicidal agent Microbe Pro t ozoa (s.ngular,
Antibacterial drugs Empiric Microbiology p rotozoan)
Antibiotic Endemic Morphology Sanitization
Antimicrobial Facultative bacteria Narrow-spectrum Sem isyntl>etic
Antiseptic Fungicidal antibiotic Spo re
Bacteria (singular, Fungistatic Normal flora Sterilization
bacterium) Fungus (plural, Opportunistic Superinfection
Bactericidal fungi) infection Synt hetic
Bacteriostatic Germicide Parasite Vecto r
Broad-spectrum Germistatic agent Pathogen Virus
antibiotic Helminths

280
 ~~~~~~~~~~
CHAPTER 17 Antimicrobials, Ant1lungals, end Anuvirals 281

EASY WORKING KNOWLEDGE OF INDICATIONS ANO SIDE EFFECTS

common Indications for Antimicrobials. Antifungels. Common Side Effects of Antimicrobiela, Antifungels.
end ,lnt1V111ls and Anllvirels
lnfecnons caused by bactena. lung1. or wuses Anate.,a and chang~s m tast& sensatJOO
Prevention (prophylaxis) of infection or contamination m select Nausea. vomiting, and diarrhea
~res l'hota ...nithll}
Dis nlec1.1nts. geim :1dals, and antisep11cs used in med!CG set DWne!!, headache. insomnia tflootoqumolones)
ungs for aseps1s and cleaning Skin rashes an<I eruptions

EASY W~ING l<NOWLEDGE OF ANTIMICROBIALS. ANTI FUNGALS, ANO ANTIVIRALS

:; PRESCRIPTION OTC PREGNANCY CATEGORY MAJOR INDICATIONS

Yes Some topical B and C for most Bacterial infections
01mmenu antibiotics; 0 IOI
and creams am1noglycosldes and
1e1racycline

&llfon Yes No B and C. 0 near term of Bacterial infections. especially

J)fegnancy urinary tract mfecuons
Yes No B. C Tuberculos1s
Yes Yes (topocal) B, C{nystatn is prefened) Fungal inlectlOllS
AntMral Yes No B.C. X Viral infections. 1ncllld1ng human
immunodeficiency virus IHIVl
Antima
1tectants. and Yes No B. C Malaria
An11sept1 Yes. mcludi119 Yes N/A Cleaning and samtmng animate
gern pHisoHex in and inanimate objects to
some states remove microbes

l1scowry of sulfonam ides in the 1930s professionals in all field; can expect to spend time

Wthen. JT
d av.1it.1hility of penici ll in in the 1940s, a
" in infroion ireatment began. Since
J rugs h.we been produced to either kill or
ad ministering. docu menting. and providi ng patient edu-
cation about antimicrobials.

inhibit ti rowth of bacteri;i, fungi, and viruses. These

drugs h d diseases such as tuberculosis and some
t)'flt"\ u 1 -noni.1 that until the 1950s were penna-
nenlly J, Ii ,u ing to latal. 'llie average human life span
in dewl ,J ounuie' lengthened grc.1t ly, and fewer
years o " < lo\t to devastating infectious disease
In th I J41h. during World War II, the U.S. govern-
ment <'<1 t1 lv researched penicillin to ucat infections
among t ~ir<> members. With the advent of antimi-
crobial< 1 lib could be given relatively nontoxic med
ications tu Ontrol infections umil the immune ystem
could figl 11 the infection. Today. these medicines come
from pl. t' animals. or chemical synthesis.
Most r ople have infections at some point in life and
will be 111 lied for the pathogen wit h medications.
il.JUS(> p.1thogens .11e muhuudinous and common.
affect all lh ody syi.terns, and spare no one, health care
WHAT IS AN ANTIBIOTI C?
The term "ntibloUc (anti, against, plus Greek bros. life;
hence, against life") began with a description of a group
of diver;e chemicals, some of whicl1 were produced
to inh1b1t the growth of or kill other microorg.1nisms
when given in low concentration>. Major antibiotic
families were dicovered before 1955 by screening
thousands of cultures from a \<lriety of sources. For
example, cephalosporins were derivl!d from the mold of
genus Ceplialospori1111r, found in th e ocean near sewage
outflow; sireptomrcin was deri,ed from Srrepro1111-ces. a
bacterial genus found in the throat uf a contaminated
chicken; and lincomycin. produced by a variant of Strep-
tom)'Cl'S /i1u:o/1mms, came from the soil in Uncoln.
'ebrask.1
282 SECTION IV Pharmacology for Mulusystem Apphcation
lluough use of anaficial means, chemis1:5. have pro-
ducro druo resulting an the creation of famaltes of anu-
"" anubiotic m a family
baotics l;ach as s1 m11ar to the
original chemical. with propenies making it useful. fo~
treatang anfmions Anubaotics that conwn an ongma
chemical molecule from i microorganism but are funJi~
altered are called IM'.mlS)ntbclics-for example 1>emol-
lm v l'hose made completely in i laboratory are called
S)nthetlo, such as cephalosporins . tance in the medical field is the high dq>cndcncy of~
Anubiotics are funher dassified according to SUS
Cl'Ptible bacteria against which they are efTecti-e. or
their 111111!~1am;tl spt"<rrum Some drugs. called bro~d
spectrum intlblollcs, ha\'e a wade range of effeaiveno:ss
ag.inst both gram-posiu"e and gram-neg.ni\-e bact~~
With broad-spectrum antibiotics it is possible to elima-
n.uc pathogen~ without in11ially performing laboratory
tests to identify the exact pathogen involved. so tre~t
ment is not delayed Other antibiotics are efTecuve
against ,1 few or specific bacteria and are called narrow-
'P"<trum anllhlollcs.
CLASSIFICATION OF
MICROORGANISMS
Microhlnlogy is the study of micl'oscopic organisms, or
microbes, such a; fungi, molds, bacteria, and protozoa.
M.tny microorganisms live freely in soil and water, where
they .ire relatively harm les. When these microorganisms
leave the free environment and enter a susceptible hosi,
they may become pathogens. Normal Oora with ben
cficial relationship> for our bodies are the many rnicro-
org;inisms nom1ally living on our skin or in our bodies.
l'xamplcs arc ceatain strains of E.sclat'richitl roli that exist
in the g.1siroi111estinal (Cl) traC\ to assist with digestion
of food.
Racterl.. are a large group of one-celled organisms
without a nurlcu!>. baneria are found e-.-erywhere.
Viru,cs, minute infeCllOUS cell panides. are so small
that they are visible only through an electron micro-
scope. l'hey are actua.lly small amounts of genetic mate
rial wr.tpped an a protean coaL They can replicate only
within living cells ,md so are puuites on their hosts
for nutrition, metabolism, and reproduction. Some
can mutaie quickly m their hosts, making it difficult
to dewlop effective antiviral treatmenL Although
viruses arc not tnaly living microorg.nisrns, they
are often included when discussing microbiology and
antimicrobials.
Some researchers consider viruses to be parasitic panicles;
others consider them 10 have once been primitive organisms that
lost all cllaracterisucs outside of the host.
Crowing as a single cell (such as ye.1st) or in coloif
(SUch as mushrooms or, molds), certain fungi arc pa~"
d' . . Q.
genicand maycausesenous aseasc 1n susceptible P</~111
Protoroa are unicellular animals that m,ty coloniz.t
and become pathogenic in susceptibl~ l'><.'rsons
Parasites do not li'-e freely and require mtcr.1ction "ilh
other organisms. being dependent on their hosts. I u11g1
and viruseS are parasitic, as are other members of tht
animal kingdom such as lice and hl'I"'" ''" Ofim()OI.
sites on host cells for li\'clihood and .1h11ity to reprodua,
for the b;!st effective treatment o( an ink< llUll, the caus.
alive microorg;inism should be idcntafil'<I tlnng with drug
susceptibility to the medication known I Iii' r,quir~t.ht
identification of the microbe by ii~ m ' " '}
Shape
OJcci are round or spheric b.1l tl'ri.1 md Jre furl.her
subdivided by the way they comh1111 11 woups: 1/iplo.
cocci, cocci in 1>airs; sireptocmd, cmn 11 haIn>: sillp/Q
/ococci, dusters of cocci looki ng mucI '''" hunches of
grapes
Bacilli are rod shaped.
Spiri/la are spiral shn1>cd.
Gram Staining
Cram staining. a test for narro" in(\ h.1 1.11 dassifia
tion, entails applying crystal viokr .ind t<. follo~td
by an agent that decolorizcs the st,1111
Cram-positive bacteria ~1aan purpl
Cram-negati\'e bactcri,1 do n0t k~c
Need for Oxygen
Aerobic bacteria require oxygen I
Anaerobic buteria require an OX\ g h t't' environ-
ment. Anaerobic org.masms, "h" h ti l\C Ill tht
oxygen.free interior of the body. t<nJ pu><lucc viru-
lent infeoion and may be thffkuh to ;u.lic'-uc
Facululie bacteria can \urv1 Ill eit.hG
environment.
ANTIMICROBIALS VERSU
ANTIBIOTICS
Antimicrobials and antibiotics, both h,w11111 thr capabi~
ity to kill or sup1)ress growth of 111ie1 umg.mi>111s. art
distinguished by their origins. 'l11c tl'l'lll 11noblal

., bro.adn. 1ncludmg antibiotics. antifungals. dn11parasi1
ics. and drugs ~udt as mercury. /\ntimicrobidls reach
1.ugei cdls either thr~ugh localize? activicy of the drug
~1 the site of apphcauon ( e g. 1op1Cal. ouc, or ophthal
mic prcp.uauon>) or through sys1cmic di,lribution or
the drug. Drugs ,lbsorbed systemically call upset the
balance of norm.ii body Oora, eradicating some and
Jilowing o\'ergro"th of other organisms, resulung in an
irnbal,an<c 1ha1 c.1u,es a second, new infenion at a dif.
feren1 \Ile and wi1h a different causative organ ism-
necessrl.llrng irc.llment of the new infection
/\n11b1011cs .ue ~nhanced natural substa nces or syn
thetically formed 'ubstanccs originally obtained from
organit '' >Urces t'.ICh antibiotic-a term used tO describe
those drug> 1h.11 trea1 bacterial infection~-beats a
chemic.ti rc,embl,11\Ce to 1he original chemical sub
stance l h ual of therapy with antibiotics is 10 destroy
or supp. i;. 'th of the infecting organism for suffi.
cient t11n1 w .allow normal host defenses 10 conuol the
infer1in11 providing a resultant cure. Antibiotics alone
c.inno1 11 : rnduce a cure. These drugs may be used
111 con1um ,1 n w ith surgic.11 procedures such as incision
dnd dr.1111.. ,:c tlchridcmelll of wounds, and excision of
infecll't.I u personal fac1ors as cost Ahernative agen" may he
rm:
[l5i
IDAL VERSUS
STATIC
Amibiouc rn.1y lunction as bcterlosta1ic agents or as
bctl J , " lly inhibiting the growth of bacteria,
b.1ctenc t , JS Its inhibit growth of the microorgan
ism wi1h0111 '.1usmg death, allowing the body's defense
mccham m c>11.1 time 10 control and eradicate the
infectm I a r 1C1dal agents cause either death or
destru<11 >rl <I lhc b,1c1eri.1l cell .The antimicrobial action,
whethtr b 1<tcrinM.11ic or bactericidal, is nol firm with
some ~ i.. ' !><-cause dosage of the drug. drug con-
centra1 1 rnh('lron s11e, and virulence of 1he micro-
organ1'r11 ,111 co111ribute IO whether the cell is destroyed
oucrigl 1 mph inhibi1ed in its growth. 111us for some
medic.11 . 1 l qme agent may be ei1her bacteriostatir
or bactur. ,11 .1g.11nst 1he given microorganism. See the
familk, ' t cg<n ls discussed later in diis chap1er for the
effecti\ rt on < I t'arh against microorganisms.
S IN THE CHOICE
__SIOTICS
When 1rc;i1mg infections the goa l is 10 achieve the
maxima amim1nobial effect while causing minimal
patient h-'rm. Anum icrobial therapy tries to "ma1ch the
bug anti the drug while considering the patient's physi
cal rond 11rnn The appropriate antibiotic choice for each
mdi\1du.1l " ba\\'ll on the causative organism, its drug
CHAPTER 17 An11m1crobials, Ant1fungals. and Antivirals 283
scns1uviiy, the drug's ab1hry to pene1ra1e the infemon's
site, and the host factor; present The bes! antimicrobial
thernpy occurs when the infec1ing o rganism has been
idenllfied and is scnsiti"e 10 th<' drug sclC<'led for the
infection's causative org.m1sms. I lowe-'er, m some <.lS(!S
a bro,1d-spenr1.1 m med ication may be pre..cribed befo re
1he results of 1c\1ing are ob1ained; drug 1.hcr.lpy may 1hen
be narrowed once the results and scnsitivi1ics are known
Drug Sensitivity
The likely microbial 1ha1 rs effecuve agains1 the microor
ganism should be comidcred when the rnedica1ion is
being selected. If a 1ent.uivc iden1ificalion of the infcciive
org.1msm is d1fficuh to make, a brodspec1rum anubi
01ic can be prescribed, or several antibiotiN may be pre-
scribed to be t.lken concurremly. 11h widely thought 1h.ll
use of more th,m one antibiotic for empiric treaimcnt
may del.1y 1he rapid increase in bacterial resis1ance to
anlimirrobial drugs.
A cenain medica1ion may be preferred for reasons
such as grea1cr efficacy, 10\,'<'r toxicily, or greater scnsi11"
ity of the microorganisms to the medica tion or for ~uch
required if the patient is allergic to the drug of choice or
because of 1oxrc effetts.
ktJ C NI A
If 1herapy must be staned before culture and sensitivity results are
available. speamens fOf cuhure should be obtained before lherapy
begins. If the labo1atory sample 1s obtained alter the patient has
staned antimicrobial therapy, infecting agents may be supp1essed
and !her rden111ica1100 impeded
MEDICATION ALERT
The goal of ant1b1011c therapy 1s not 10 kill all the infecting
01gan1sms; rnther. the goal is to suppress the growth of the
microorganisms to allow the host's rmmune system to subdue
the infection and resolve the patrent's signs and symptoms of
disease.
Patient Factors
Patient factors may inOuence 1he choice of drug. route
of administration, or dos,1ge. In 1he 1mmunosuppres..ed
ind ividual, the im mu ne system is imponant because 1he
compromised s1a1e and drugs alone may suppress dis
ease~. Pacemakers, pros1hetic joints, and other foreign
o bjects may cause auack; on healthy cells ,11 the si1e
of implanta1ion, requiring the use of a111ibio1ics to
prevent an infection 1hat might necessi1a1e remo"al of
 284 SECTION IV Pharmacology lor Mulusystem Application
the prosthesis. Neonates and the elderly are pa".1cu IarIY
susceptible 10 drug toxicity b;luse of accumulauon ~nd
toxic drug le-.'l'ls in the blood J>rtgnancy and lanauon
po.e ~pecific problems in anub1otic trt>atmmt bau~
some drugs can cross the placenta or are excreted m
br~ast milk. .
Severe allergic re;iciions are more common with anti
biotics, especially penicillira, than with any other drug
classification. TI1e general rule is 1hat a person who has
h<1d an al lergic reaction to penicillin should not _r~e1.ve
it again. Symptoms of hypersensitivity to anub10.UC$
range from a mild rash, fever. Jnd urticaria wit h pruntus
to generalized erythema or ewn Jnaphylaxis.
A person can beaJme sensitized to a drug 8\'en tlv'D19l indirect
exposure such as eabng foods from animals given an11macro-
bials Sens11JZation may also be caused bv a pn!VIOOS use of
topocal amibootacs Microbe res1st.ince caused bv expostJre to
an11maaobials in the envtronment food. and water slJlllllies is
now considered a maioi public health problem that is being
studied by the Centers loi Disease Control and Pre.ent1on !COCJ
ANTIBIOTIC RESISTANCE
Jn recent years many discoveries .1bout the growing resis
tance of many microorganisms to antimicrobials have
been made. Resistance often occurs by mutation of the
microbe, or changing of the genetic structure, so that
currently available medications are no longer effective
Several bacteria- Staphylocomu aur<'U.I, F coli, and M)'C0-
1..aenum tub<'rculosis- are now serious clinical problems
because of drug resistance.
As a rule, microorganisms resistant to a certain drug
will tend to be resistant to otl1er chemically-related anti
microbials, a phenomenon known as cros.1resis1n11u. The
PffSOll does 1101 become resistmll to tire nmimirrobinl; rhe
microbe becomes resiswm to 1/re t1111g. 'Illus any person who
is infec1ed by the drugresistant microbe is now affected
because the medication will 1101 be as effective. The
microorganism may be disease rousing. .incl the more
rcist,mt microbe will grow in the environment because
of the drug ineffectiveness.
111e primary reason for development of drugrcsistant
bacteria is inappropriate use of antibiotics. The more an
antibiotic is used, the faster virulentrcsistant microor
ganisms emerge. Inept prescribing and inappropriate use
of medications may also increase the resistance of normal
Oora, turning them into possible pathogens. F.nviron
mental faaors such as overcrowd111g and poor sanitation
may play a role in microorganisms developing resistance
because of the repeated infections and/or repc.11ed use
of an timicrobials to fight infections.
SUPERINFECTION AND
ANTIBIOTIC USE
A supuin/t10t1 is a sccondaiy infection apJX>4ring
during the course of 1.reatment f~r a pri maiy infUo11.
such as a >-ea51 infec1101~ t.hat anscs dunng the COllJ';e
of treatment with penac1lhn for bact.:-nal pncumoni~.
Superinfection most often occurs when the antimicro.
bial inhibits or a hers the balance of normal Oora wilhin
the body.
Broadspoorum ant ibiotics tend to kil l off more
nonnal nora thn targeted drugs, and thcv .1lso promote
drug resistance of mu hi pie organisms Drugs that change
the body's immune responses, such " corticosteroi<h
and immunosuppressive drugs, may lso permit tht
emergence of superinfooions.
From 30% to 50% of antibiotics p ribe<l in lhe
Unite<l States arc used for propl1 l.111ic reasons
rather than to treat a current infection. \h1< h of prophy.
lactic use is not necessary, but in som ituations it is
appropriate and efTect ivc. An cxampl, ' appropriate
prophylaxh is the use of ciproflo for those
persons who have been exposed to . ira.< through
bioterrorism.
The risks of toxic cfTects. ;uperinlnt and otha
ad,-erse reactions of usmg anumicroh ' should ht
weighed against the advantages befor 1gs are used
prophylactically. l'eople wnh cong1mit.1I 1ln 1larhean
disease. those with some prosthL~, '"' ,. who hi~
had rheumatic fe-.<er may need proph\ I antibiotics
before surgeiy or dental procedures 10 , '.1se normal
Oora, reducing the chance nf endoc,mln 'eutropcnia
(low neutrophil counts) increases the 11 of infections
and may be another indication for pruJhylact ir use
Finally. antimicrobial agents are given '" phylat'tically
in single large doses to effectively treat pt 1 '"' who ha1e
been exposed to sexua lly trJnsmittcd di' "''but ha1e
not yet shown signs of infection.
Mi1Mi1ifrli!:itiil4J
Antibiotics are among the most comm"" pr~.ribed
medications and some of the most in trrcctly used
medications. Patients who are given clc.ir explanations
of why an antibiotk is 1>r~rribed are more likely to
complete the full course of therapy and will 1101 seek
uruieeded medicat io ns.

PJ1tents contribute 10 the problem of misuse of anu-
bioti<> by fJihng to ta~c the emirc prescribed course or
an 3111ibio1ic brcause 1he person feel;, beuer; 1he abbre-
,.;ait'tl course of 1rea1mem kills off only the more
suscciHihle microorga1mms, allowing more resis1am
ont">- 1hose 1ha1 need 10 be erad ica1ed-10 grow wh h
less compc1it1<111 An1ibio1ics are usually giwn for S 10
1~ J,1>~ w11h the most commonly ordered du mi on
being IO day,. I .onger treatmenl rourses may be pre-
scrihe<I for seriou;, bac1crial infec1ions or when appropri
aieh u'ing .murungals or amhiral dn1gs for cenain
susccpuble illnc"'cs. Thr danger of taking antimicrobi,11
mt'tli<.11 ions too briefly h the po1C111ial devdopmelll or
drug ""1s1am microorg.1nisms and relapse of 1he disease.
s.1, ini: unu.,.J medic.uions until ano1her illness occurs
is ano1hcr m 1~uM' of ,1111ibiotics; 1his practice allows
rem.1111mg llll rohes to grow, and the pa1ie111 will feel
1ha1 1hc me 111c didn't work. fven though a patiem
may 110 long r ht' experiencing the symp1oms, the medi-
c.ation m,1\ !Hll h.we had lime 10 kill the more virulent
micr..t0ry.an1 1
h>r 1110 t 11 mfce11ons. when antibiouc therapy
is i11.1p111'i'""tdy begun. the p.1ticnt is CXJlosed to .111
of 1hl' Jn 1 ~, without receiving benefits because
i rus.., Jre 11rroorg.m1sms susceptible to uea1ment
wi1h .111111> "1. i,11 ~. However, antibio1ics r1111 be appro
pria1dv u .1 nlll'r prcve111a1ively or therapeutically, to
treat 111fooion~ that m.1y occur with viral
Im mn<i 1111bio1ics to be most effective, they shou ld
be ta~< ' < v spaced imervals 10 maimain a ll1era
peu1ic .xi d th roughou1 a 24-hour period. l'o r
l.'Xampk 1f the order reads three 1imcs a day: the medi-
dnc '""' , u 11.1lly be 1aken every 8 hours. Not taking
me.h<.11 I use of ~Jeep o r other activities causes
erraut do md fluctua1ions in blood levels, making
the an11b1oth. h,!. effcc1ive.
l.1~111 'dllon~ prescribed for another person
wi1hou 1bt nmi; .1ppropriate medical cart is misuse,
abuse. nr horh
J'l.'\l' I ) lllplOffiOf more diseases than juSI a baCIC
rial 1111, 1trefore giving amibiolics jus1 because
son1eon~ t:Js 1 ll'vcr is inappropriate:. The one situation
in whi< Ii It' r .1lone is an indication for antibiotics is in
the 1mn 11 nr~ patiem (Sox 17-1).
o' ani b ot1cs rs commoo and should be discouraged
only a symptom and is not an indicatlOfl to begin
ant1b1otic ttltlr.Jpy
2 An11b1ot cs ~10 ineffective for the treatment of v11al mfecllOns
uni secondart bactenal .ifections are pre~nt
CHAPTER 17 Anum1crob1als, Anllfungals, and Anovrrals 285
SOX 17-1 IMPLICATIONS IN ANTIBIOTIC THERAPY
Selected antibiotic should be known to be elfectwe against
amnon Ofgarusms 1 ~led from nfection site
2 Min mum number of drugs neceS$<11'f to ueat 11fect1on should
be used
3 Drug of first choice should be used unless 11 1s contra1ndr-
cated. In children and elderly. caution is ooOOed kJI all
patients. dosage should take 1n10 accoont weight or body
surface area. organ function. and concurrent diseases
4 Unless benefit outweighs nsk. a drug should not be used
when previoos allergic or adverse reactions to that drug have
occurreil
5 Antibiotic therapy shoold be con1111ued as loog as infection
1s present but slloold not eiu:eed usual treatment tune for
suspected inrect1ve organrsms
. ..
Ant1b1ot1cs shoold be carefully chosen oo the basis of the
determined or suspec1ed sens1tMty of infecting organisms
Antib1ot1cs may be given llfOp/lylact1cally for surgery 01 on
exposure to unusual diseases such es an1hrax or malaria
Namiwspectrum ant1bioucs are elfecuve against few micto-
organisms. whereas broad-specllUm ant1b1ot1CS are used
against a wide range of mrcrobes.
The emergence of drug-resistani microorganisms is a maior
concern. therefore an11btotics should be prescribed only
when 1nd1cated by a disease process.
Bacteric11Jal drugs kill microorganisms. Bactenosratic drugs
suppress baaenal growth oool lhe pefSOn's mmune system
can effec11vely bring the body 11110 homeostasis
ANTIBACTERIAL DRUGS
Antimicrobial therapy became a pharmacologic entity
when Alexander Fleming discovered tha1 when mold fell
on a Petri dish containing Swp/1)/ococcus, growth of the
bacteria was inhibiled by the mold. Some penicillins
today are s1i ll made from the s.1me molds found IO be
effective by l'lcming. Several categories of nlibarlcrlal
drug' are effective against baeterial infections. 1his
section disru;,ses each family and the use of individual
drugs.
Penicillins
Penicillin, the firs1 true antibiotic, has been derived fro m
a number of strains of common molds found on bread
and fruit. Namral and semisymhetic penicilhns and 1hcir
related an tibiotics remai n the 111os1 effective ~nd leas1
wxic of antimicrobials lbese substances an by inhibit-
ing bcterial cell-wall synthesis. an action tha1 makes
 286 SECTION IV Pharmacology for Mulusystem Application

that are difficuh_to ueal..Th?e penicillins are given

mos1 penicillins bacrencidal, although in low doses emerally, often on comb111a11on lherapy with othc pa,
1hey may be 1Nut.nosta11c. A<h"' reactions are generally
microbials (see Table 17-1 ). ano.
all..rgjc reactions lha11end 10 occur more frequenlly and
5e''t'rely than wilh other mro1cauons.
Penicillins are ca1egoriud by thl'ir antimicrobial
s1>UUm imo four major groups. (I) narrow-spectrum
penicillins, (2) narrow.spectrum antimphylococcal
~ CLINICAL 1 IP -
penicillins, (3) broadspectrum penicillins (aminopeni
ci lli ns), and (4) extended-spectrum penicillins.
A person allergic to any pcnic11/m should be considered a/fer:
all penicillins 11a question a11ses aboui lhe possibility of .rID
penicillin 1eactions. the person should be considered allergic erg~

Most genenc names for penicillins end 1n c1/hn. and many older
trade names have pen m their names As an example. penidl- PATIENT ALERT
11rr c (genenc name) 1s known as Pfirerpeil by trade name Patients shoofd be asked aboot allergies each tune they are
seen mhealth cafe semngs with quest10t1. coo:erning any
possible allergic reactions to any med1cat100. socio as rashes.
Narrow-Spectrum Penicillins
hives. and nchang
Penicillin G was the first penidlhn dewloped and is
Patients w1tll penicolhn aUergies should ~ 'll' carry odeiiu.
suit 1he drug of choice for ueating many infections.
ficanon to prevent 1nadvel1ent administrat of perncilbn
The narrow-spectrum penicillins are considerro fitsl
generation penicillins; in general, they are effective
against (I) many gram-posi1ive org.misms such as strep-
1ococci and staphylococci; (2) gram-nega1ive bacteria
such as Neisseria and E. coli; {3) spiroche1es; and (4)
some anaerobic bacteria. Diseases susceptible to penicil- 1. Penicillins are best token on an empty s <ch with a full
lin arc infections such as pneumonia, throat and ear glass of water I hour before meals or 2 I after meals
infections, gonorrhea, and ;yphilis rrable 17- t).
2. All penicillin-class oral suspensions re, refr1geratoon
after r1JW1Slltut1on.
Narrow-Spectrum Antistaphy/ococcal
(Penicillin-Resistant} Penicillins 3. As a prncau1100. women taking arnp1C1 moiucdh11. or
peilicilhns G and V and who are also g estrogen.
"f!1e. aniis1aphylococcal penicillins (e.g., oxadllin, ru1/-
conta1mng conlr8CtJl)t1ves should use a ent form ol
n ll1n) have a narrow spectrum of action for infections
contracepbon while taking these an!lbiot Peports hale
and are specific for penicillin-resistani staphylococci
indicated a decreased effettiveness of coo1Jnl plls
strains (see lable 17-1).
vdlen penicolhn der1vatrves are used coot ly
Broad-Spectrum Penicillins (Aminopenicillins}
fly ahering naturally ocrurring S<?misynthetic broad-
spemum penicillins. second-generation penici llins are
cfrect1v~ aga ms1 a broader spoorum of microorganisms
(mdud1~1gsome gram-negative bacteri a). I lowever. these
.' .
Penicillins weaken cell walls. causing lys I cell death,
mcd1cauons ~re not efreClive for S. 1111re11J infeetions. making them bac1e11c1dal
Many arc available in oral prep.ir~tions (e.g.. ampidllin
Gram-negative bacteria are resistant to mar enic1lhns
and amo.d cilliro) (see 1able 17-1).
Pen1cilhns c<1use a high incidence of aller 1 actions rela
IMl to other ant1b1011cs
Extended-Spectrum Penicillins
A pauent allergic to one penicillin should be 1dered alier
Third-generation penicillins (e.g.. llcardllin), also
g1c to all penic1ll111S EVllll mild reac!tons SJ l be cons1d-
known as extmded-sptnim 11<'nicil/111J. have a wider ami-
ered an allergic reactoon
microbial .action than second-generauon penicillins.
llu~e m~icauons are used for more serious urinary 1raa
The pr1nc1pal d1ffeicnces among the per. :s are thet
spettl\fll of ilflhbattenal action. lhetr sta Ill Slomado
and respiratory 1ract infeaions and for infections caused
by gram-negative bacteria such as ~lomooas and ilC1ds. and their dlJratoo of actlOll
l'roll'U.I species (see Table 17-1). Nairow-spectrum pen1colhns Gand V are nat:ira ly occurnlYJ
Fou rth-generation ~n'.cilli n.s (e.g.. piperacillin ), substances Penic1lhn Gis administered by n1act on bet<luse
extended-s1>~n.1m anum1crob1als wiLh a111ipseudo- n 1s not stable m gastnc acids However pen c rm V can be
administered 01ally '
111onal acuvuy. are used for the 111os1 serious infections
 NARROW SPECTRUM
F1fSt Generarion
penir1lhn G' (Pfizerpen) 600.00>-4.IXXJ.IXXJ Types of baccena G1am-posi1Ne and Probenecld tnereases and
umts IM. IV q4-6h gramnegauve bactena, gram-posmV!l prolongs pemc1!11n levels
aerobic cocci. grampos1tJve aerobic in Ille blood
and anaerobic bacilli. spirochetes
Types of infectlOll Upper 1espirat01Y
uact infections. pneooicnia. dental
prophylaxis, unnaiy tract infections
pemc1tlin v 250-500 mg PO q61l Decreased effectiveness of
(NTN) tetracyclines

An~stapJr,lococcal (Penicrllinase Resistant)

nafc1!1 n (NTN] 2-12 g IM. IV Type of bactena Staphytorocci Ptobeuecid mcraases and
Type of infection prolongs pemcolhn levels
Staphylocoocal mfect1ons 1n the blood
oxacilhn (t-i 1~.1 2-12 g IM. IV
d1cloxanllt H"Jl 125-500 mg PO q6hr

BROAD !IFECTRUM (AMINDPENICIWNS)

Second n
amp1c1ll pen and 500 mg2 g PO q1d. Types of bacteoa Gram-positive and No significant 1nteractJoo
gene11 IM. IV gram-negative bacteria, gram-positive
amox1c1ll1 'J'N flX immediate 250500 mg POtid aerobic cocci. 9rampos1tiva aerobic
and anaerobic bac1ll1. spirochetes
1elea
Types of mfecttOO flesptratOI'( tract
infections. unnaiy tract mfections.
otJt1s media

EXTENDl'D SPlCTRUM (ANTIPSEUDOMONAL PENICILLINS)

Thlfd G "
1 !>-4 g IM. IV q4-6h Type of baclerra Pseudomonas No significant interaction
Type of 111fectt00 Pseudomonas
infections

EXTEND SPECTRUM PENICILLINS WITH ~-lACTAMASE INHIBITORS

Fourth: o
Jt 250-750 mg PO q8h Types of bacteria Gram.positive cocci. See amoxicilltn
non-Pseudomonal gram-negative and
anaerobic species
(Augm rtro s 600) (suspl' 600 mg PO 2 divided
doses for I0 days
(Aug XA) 2000 mg PO q12h
amp1col bactam IUnasyn) 1 5-3 gm IV q61l See ampicilhn
bactam (Zosyn) 3 375 g IV q6ll Types of bactena Non-melhicillin
resistant staphylococci,
Pseudomonas. and other g1am-
negative and anaerobic species
tica1c ll1n<Javulana1e (Ttmentin) 31 OIV q4-6h Same as for Zosyn

M1jor Sule Hrects of l'onicillias: Nausea and vomiting, diarmea. sore mouth. hMlS. 1tth1ng, anaphytaxfs
IM. 1n1ramuscularly, IV. intravenously: NrN, no uade name. PO, orally
rho eHeclttncss of oral contraceptives may be reduced with 1hesc p11<1icillins.
'Ped1aH1c medication
288 SECTION rv Pharmacology for Mul11sys1em Application
Cephalosporins
Like penicillins. cephalosporins were origmall) ~~~-ed
fro m a mold and are structurally related to pemolh.ns.
Ulphalosporins weaken the bacterial cell wall, resulung
in lysis and death of the bacterial cell; thus they are bac
tericidal. Cephalosporins are acuw against a bro~d spec-
trum of pathogens. Because of the chemical relauonsh1.p
of cephalosporins to penicillin, patienlS ~ho ~re alle~ic
to penicillin should be given ceph.tlosporms with cauuon
bemuse of the slight chance of cross allergy.
Most cephalosponns ha-.e the preliJt C1J1i>- Of eel on their name
An example 1s ufadro.ril (genetlC namel. wllich IS Ou1oeef
(uade name)
Classified in four generations. cephalosporins are
mos1 often used as substi1u1es for penicill ins \vith drug-
rcsistant baeleria and in trea111w111 of ccnain gram
negative in fections.
First-generation cephalos1>orins (e.g.. C"Pl1alexin)
are primarily active against gram-positive bacteria.
Second-generation drugs (e.g.. ufaclor) have
increased effectiveness ag;1ins1 gram.negative
rnicroorganisms.
Third and founh generations are more active
,1gainst gram-negative microbes, with the third gen-
eration (e.g., u/diro ir) not as effective againS1
gram-positive cocci. f.ourthgeneration drugs (e.g..
ufepime) are more resistant 10 1he inactivating
in1estinal enzymes that cause other cephalosporins
to be ineffective.
The expense of first- and second-generation ccphalo-
spori ns rarely makes these medications the drug of
choire for treating most infec1ions (!lox 17-2 and Table
17-2).
BOX 112 SUMMARY OF PENICILLIN VERSUS
CEPHALOSPORIN GENERATIONS
Pen1t:illin generations a.-e based on genw.i po1ency and abol1ty
to ueat 1ncteaStngly broadef mocroblal spectrum.
Cephalosponn ge11eratooos are based on effectrvooess aga nsi
lhe gram-nega1ove or gtam-po$1tM! microbes. no1 on the
bmadlh ol lhe drug effect,.,.eness spectrum
Each generatoon of penicillins represents an increase on potency,
whereas cephalosponns generations work on d1llerent
microbial spectrums
1 Cephalosponns should be taken with food if gastt1e llpSet
OCCUIS
2 Depending on package labels. many cephalospoon ~
Stons s00uld be refngciated once rec0C1slltuted. but a ie-.
mav be stOfed at room temperature
3 Afew cephalospOnns cannot be COfOb1ned wrlh alcohol Ind.
vidualswho are taktng these medications should not consume
alcohol during ueatmeni
4 Select cephalosporons tend to intensify bleeding tendencies
lndrvoduals who take oral an11coagulants mav be mo1e at risk
for this side effect
5_ Patients with d1abe1es mell1tus who check their unne shouid
be aware that cephalosporons tend to raise blood glueose
fevels and mav interfere with certain urine tes11ng melhods
6 Report any e~ diarrhea and easy bnr.song
. .. ..
Cephalosporons weaken the cell wall. caus ig death to bac
tena so these drugs are baclenac1dal
Cephalosporms are closelv related to pc: ms in their
chemical s1ructure
Cephalosponns are grouped into lour 9enc1 ons As drugs
p1ogress 1hrough the generations. there .1 os increased
actMty against gramnegatove bacteroa
The most common adverse reactions to c OSpollnS Sil!
d1armea and allergic reac11oos Persons a c to pen1c1l 1n
shruld be walthed carefully when adrrun d cephallJSllO'
nns because up to 3% to 5% of people to pen1emn
w aalso prove to Ile allergic to cephalospo:
Carbapenems
r-our carbapenems (l111ilJ"11~111. meropr r N'la~m.
and dorilJ"nerr1 ) have low itlxicity r.i h d 1ilc having
broad antimicrohi<tl s1>cc1ra but are 1101 " Live against
methicill in-resisl:lnt S. 11111'PllS {MIL~A) . l'.w .11cral admiu
isuation is necess.1ry for al l of 1lwsc d1 u;:' al presenL
Most drugs are well tolerated, with Cl "ni, 101m, rashei.
and headaches being possible adverst , trm P.-ople
allergic to cephalosporins may also I>< .1 rgic to these
dnt~ rrable t 7-3)
MacroI ides
The macrolide anubio1ics, called 111<1,1 h raust' of me
large siu of the chemical compoun<h .uc broa~
speorum antimicrobi,11~ that act by inh1hi1 ong pro1em
synthesis in bacteria. These drugs are primarily bacteno
static but may be hactcriridal in large dose' Macrolides
have a unique role in treating Legionnaires dbeas<> and
 __________CHAPT
c__ ER 17 An11m1crob1als, Anufungals, and AnllYirals 289

ARST GENERATION
cefadroxil (Durac1f)
t11fazolin !Ai fl
cephalexrn !Ketlex. Pamxine)
0.5-1 gm PO q12h
500 mg-1 g PO q8h
250-500 mg PO q5-12h
Types of bacteoa: Streptococci
and some staphylococci
Types of 111fection Staphylococcal
and sueciococcal infec11ons.
some urinary tract 1nfecuons.
bone and joint diseases. upper
respuatory tract infechon
Am1noglycos1de, polymyx1n B.
vancomycin
Probenecid increases the act1v1tv
of some cephalosponns
Some cephalosporins cause
Antabuse-llke reacuons
Decrease the effectiveness of
oral contracepti>es

SECONO GENERATION
cefactor '' ' 250-500 mg PO q8h Same as for first generation. plus cofadroxil plus aspirin,
Haemophtlus 111fluenzae and antJc:oagulants. NSAJDs
Neisseoa gononhoeae !because medtcauon may
promote bleeding)
cetoteta nt 12 g IM, IV q1224h
ceftJ.< tin 1-2 g IM. IV q6-8h
cefurox el) 750-1 5 g/kg IM, IV
q6-8h
Cefti 250-500 mg PO ql 2h
cefpro' 250-500 mg PO q12-24h

THIRD G > ATIDN

cefdm1r I 300 mg PO ql2h Types of bactena Less effective No significant interactions
Cf\ 400 mg PO/d dMded agaUlSt S1reptococci and
ql224h pneumococci. more effective

~) 400 mg POQd against gram-negallve and

ceftibuto
anamobic bacteria: generally
cefota ran) 1-2 g IM, IV qBh
used with senous infections
ceftaz dl TazicelJ 1-2 g fM. IV q1H2h Pseudomonas
celtria~ .ph1n) 1-2 g IM. IV q24h Drug of choice for men1ng111s
cefpudox IN) 100-500 mg PO q12h
cefd1t ' ro.;ef) 200-400 mg PO q1Zl1

FOURTH ERATION
ccfep1mo t x1: 1me) 0.52 g IM, IV q8-12h Types of infection: Aspinn, other NSAIDs.
Sim1la1 to third generation- anticoagulants, alcohol
gram-flegatr<e coverage

Major Sd fncts of Cephnlosporins: Headache, dizziness. weakness. fever. d1arrllea. anorexia. nephrotox1citv. rash, dyspnea,
blood 1as
rv "'"'venoo 1y: NSA/IJs. ncll1$teroodal ant1"1ftanvnil!O<Y drugs. NTN no trade name PO. ora ty
290 SECTION JV Pharmacology for Multisystem Application

if.!:ill@f411Hii.IJ.! : l : l . ! J j i l f o t -
GENERIC NAME/
TRADE NAME

11111penem-colasta1111/Pr.ma n
USUAL ADULT DOSE.
ROUTE. AND FREDUENCY
OF ADMINISTRATION

250500 mg IM. IV q6h

INDICATIONS FOR USE
Serious gram-positive and
gram-negative mfecuons
.
-
~

DRUG INTERACTIONS.
Antagon1s11c with other ant biotJcs

meropenen\/Menem lg1Vq8h
1 g,M,IVqd probenecld
enapenern/lrrvaol
dorll' !fl >f!l/()ol1ba 50Dmg 1Vq8h

Major Sii Effec11 11I C.tbafHnatM: Headaches. diarrhea. nausea

IM oniramu. "'"'"' rv .,,.,........,.iy

Cli/11mydui infoo1ons and in tre.uing and pmoenting
arypocdf pneumoni,is, especially with human immuno-
deficiency vino< (HIV) patien\S. Macrolides are often
u~d J< ,111 aherrmive to penicillin in penicillinallergic
patie1m.
Cry1/1rom ycl11 was the fir;t macrolide and is a treat-
ment o f choice for ;cveral infections. The newer macro-
lides, including az.ltliromydri ,ind clari1/1romycin, may
cause Cl syrn 1>1oms, as well as headaches and di7.Ziness.
J\ signifira 111 change in the Q'r in1eival with large doses
may resu lt in sudden cardiac deat h. Persons taking anti-
dysrhythmics, calcium channel blockers. azole antifun-
gals, and I l lV pro1e.1se inh ibi1ors should avoid
erythro mycin (l.1blc 174 ).
ktJ CLINICAL TIP
Etythromyc1n is most effective 1f ta~en on an empty stomach, but 11
may be given with food 1f gastrointestinal upset ocrurs.
The names of mac1ohde drlJgs typieally end 11 .,,,.,oo. The same
suffix is also used 11 naming some amnogfytosides (e.g. e1ytl1
romyc1n. amacrohde. and neomycin, a member of the amrogly-
cosde family) Thus the drug suffix cannot always be used as
1den11focatoon of the drug famliy
Tetracyclines
nie 1e1racyclines (e.g., u1 ra cycli11e, '"' line), med;.
cations that are bac1eriostatic and b.1< h 1 1l.1l, w~re the
first group of broad-specm1m antihioti" I h<'Y .ire used
t0 treat organisms incl uding tho~c t.1u"' .1rnc, Rocky
Mountain spoued fever. Lyme di''"'~'" u111111y 1r.1ct infec.
tions (lffls), bronch itis, and pcriodo111 I '"'"'se. Some
bacteria have become resist.ml to tt11.1 1 li1w; fl\ible
17-5 ).
PATIENT ALERT
Unused tetracycline products should be t away alter
their exp1rat1on date, decomposing tell 1e can be
harmful 1f ingested
The panent should avoid the sun bccau iger of rapid
sunburning; therefore care should be u presa1b1na
tetracycline for teenagers With acne bcc ens h<e 111
sunbathe The use of sunseteens is n ... uh these
medications.
These medications also canoot be used ren yoiiiger
than 8 years old or in IJlegnanL women of the per
manent discoloration of dewloping teeth
Supennfect1oos of the bowels OC:CUI w tn
especially with tellacychnes. so sogmfica
be repooed, as should vaginal and rectal
f\Jny appearance of the tongue These r
supe11nfect1ons

.. ~

Etythromycin 1s lhe prototype of macrolides and is bocterio

s1at1c in its mechanism of action.
Erythromycin, oflen used for pallentsWith penicillin allergies,
The suffix -cycflne 1s found with 1he to1racycl11111 Moch as doxy
is effective aga1ns1 the bils1c spectrum of microbes. cycli11E and mi11ocydirre.
 TABLE 17-4 SELECTED MACRDllDES

ERYTHROMYCINS
erythromyc1n !Erythrocrn) 250-500 mg PO. IV Types of bacteoa Gram-pos1t1ve and some carbamazepone, eytlosporone.
erythromytrn succinate qid, 400 mg PO gram-negative microorganisms statons. ergot alkaloids.
tEES. EryPedJ q6h Types of mfectl/Jfl RespualOfY '11nesses. rifabuun theophyll1ne. and
gastrorntestinal tract. skin. and soft !Issue. warlann an!Jcoagutants
drugs of choice for Leg1oona1res disease

Major Sid E/frcts of Eryrbromycins: Abdominal cramptng. diarrhea. oral ' vag nal candod1asis. heartng toss. headache. d1111ness

ERYTHROMYCIN DERIVATIVES
a.zithrorr 17thromax) 250-600 mg PO qd Types of bacteria Especially gramnegative Aluminum magnesium antacids,
cianttv"' o13A nJ 250-500 mg PO q12h (l(Qanisms and anaerobic 'ganosms theojlhy 1111e. Coumadrn.
(Biaxu 1000 mg PO qd Types of mfectioo. Haemophilus mRuenzae, catbamazepone
Leg1onnaioes disease. Chlamyrf1a. Lyme
disease
500 mg PO Solt 11ssue onfecllOOS with Stieprocoa:us
pneumoniae and Staphylococcus aureus.
Legionnaires disease

M1jor Sr Effects of Erythromycin Otriratwts: Same as for eiythromycrns. plus change in taste sensatlOll

KETOllDI
telith1 !el:) llOO mg PO qd Bronch1t1s, sonusius. pneumoo1a Same as for erythromytrns. plus
Jtieooharbttal. phenytoon

Major S1~ 1tects of Keto/ides: Nausea. vomiting, diarrhea

EES. er. ~ mote: N. 1ntriMl10USly; NrN no uade name: PO. cnily

'Also avao op co dnd oplllhillm1c preparauons
'Increased n w11h lood

ECT TETRACYCLIN ES
.
USUAL ADULT DOSE.
ROUTE. AND FREQUENCY
DF ADMINISTRATION INDICATIONS FOR USE DRUG INTERACTIONS
SHORT A flNG
tetracy. fN 250500 mg PO qid Types of bacteria Rickens1ae. Plegnancy category O
Mya:Jp/4sma pneumonlil8 Decreases effectiveness of
Types of infec11on: Cholera. cootracept1ves. antacids, calcium
Chlamyrf1s. Lyme disease. supplements, iron supplements,
acne magnesium laxatives, mtlk products

LONG ACTING
doXyt\' I V1Lramycin. 100-200 mg PO bid Same as short-acting agents,
~ l(<l plus gast11>1ntestinal diseases
Peroosta As directed t0!)1calty Peroodontal disease
minocytline IMrnocm) ZOO mg PO then 100 mg qlZh Same as short-acting agents,
plus acne

Maior Sid Effects of Tetracyclines: Photosens111v1ty, permanent stains m developing teeth in fetus and in children <8 yr of age
IM 1ntramu Iv IV nu....enoosly: NTN no uade ~me. PO. orally
 292 SECTION IV Pharmacology for Mult1system Application

aminoglycosides must ~ ~an>f~ lly monitored to ilVOJc!

~tOrJ.Complience renal toxicity and ototoXJaty (lable 176).
Teuaqdllll!S sl10Uld not be taken W>l/1 m < pn:d1cts. iron
supplements. or anta0ds Many antacid and mioetal supple-
ments interfere w th abslllpt1on of te11at'lci1nes Oo not PATIENT ALERT
adrmniste< any medicauons. 1nclud1ng mu tMtamns. with Patients receMng parenteral ammoglycosides should be
the minerals aluminum. calcium. magnesium. iron. oc zinc watched closely for unmtus. vertrgo, weakness. and changes in
within 4 houis of in1est1ng oral teuacychnes respiration. as well as for scant urinary output and proteinuna
2 Tetracycl111eshould be takenoo an empty stomach. but med1-
cattons in this class can cause gastrointestinal distress.

which can be reduced by taking the medication with meals
1f necessary Doxycycline and 111 lnoti<ll11r may be given
with darry products as necessary but milk products should
be avoided with othef tetracychnes
Aminoglycosides
Aminogli-cosides (e.g., genlamien) are a group of potent
bactericidal agents !hat inhibit protein synthesis; !hey are
usually resen1ed for serious or life-threatening infections.
Generally the main spectrum sensitive to these drugs
consists of gram-positive bacilli, but gr.1m-positive
microbes may also be affected. Aminoglycosides may be
used with cephalosporins or 11<111cornyd11 for ~)'nergistic
effects and with penicillin with certain conditions
such as neonatal sepsis. Topical, ophthalmic, and otic
use of aminoglycosides is relatively safe, with few side
effects. Patients receivi ng systemically adm inistered
. ...
'
Am1noglycos1des 11anow-spectrum ant1b1m1cs that aie
bactenc1dal-are used aga1ns1 g1am-negat bacilli
Aminoglycos1des a1e nephrotox1c and can bo ototoxic.
The ropical use of am111oglycosides is 1 vely safe. bJi
some adwlSe re<JCtlOlls are possible
Quinolones
Fluoroqui noloncs (e.g.. ciprojloxaci11 ). i.1d-spectn1m
antimicrobials and bJctericidals, an Y inhibiting
enzymes needed for the bactcrid's Df'. i\ "'ly absorbed
on oral admi11 is1mtion, these antimicrul 1Js are used 10
ueat bone and joint infections, UTI~. p .1.uitis, gonor.
rhea, pneumonia, and other diseases. ~1 d ds decrease

am1kacm {Amikin) 10-15 mg/'cg/day dMded rypes of bacteria: Serious gram-negative Extended-spectrum 1110s
q8- l 2h IV, IM, PO and some gram-positive organisms 1nact1vatc ammoq ides 11
gentam1cin (NTN) 3-5 mg/kg/day d1v1ded Types of infectioo Those caused by rmxed. increase of some
q8h IV. JM above bacteria, plus ruberculos1s muscle relaxants. with caution
topical (Kantrex) with other nephrot med1cabons
(Gentak) ophthalmalogic
kanamycm (NTN) 15 mg/kg/day qd IM. IV
neomycin (NTN) 1 g PO prior 10 GI Topical for skin and ocular infecllons
surgery
NeobiotlC Topical
Netiufizer
tobramyctn (NTN) 3-5 mg/kg/day tid IM. IV Pseudomcnas aetl/gla)$a. plus othef
!Tobrexl Ophthalmic gram-negative infections
ITOBIJ Nebulizer

Major Side Effects of Aminoglycosidn: Ototox1c11y blood dyscrasias nephrotoxic"" nausea d

..,, vooi11ing. an anorexia
GI, gastrointestinal. IM. mtramusculally; N. intravenously, NTN, no !fade name: PO. orally
Also available m ophthalmic and 1Dp1cal preparabons
 CHAPTER 17 An11m1crob1als, Anbfungals. and Antrvirals 293

the absorption of these dru~ and should not be given
for 2 hour> after the adminimation of 1he antibiouc
( l.1ble 177 ).
Most quinolones have Rox in the generic name
uea1 forms of meningitis, paratyphoid and typhoid fe"er.
typhus. Rocky \1oun1ain spoued fe--er. and baCterial
sepsh in life-1hreatening situations when 0 1her treat
ment options have not bwn effective. 11 sho u Id no t be
used in newborns unless no acceptable alternative is
available because of the potential risk of gray baby syn
dronw, a life threatening adverse cffcr1. It is not recom
mended for uw in pregnant or breast-feeding women

... (Table 178}

Lincomycin and Derivatives

Lincomycin derivatives are primarily bacteriostatic but
RoorDQtllllOlones are broadspectrt;m antomocmbials and
ma) bebaCteri<idal in high doses.Clindamycin (Cloocin)
bactenc 1 is a \t'misyntheiic derivative oflincomycin usM for bone
oo
l11e oral 1hsorp110n of fluoroquinolones may reduced by and joint dise.ise;, gynecologic diseases, skin and soft
ngest100 dairy products. antacids. calcium. magnesium or
tissue infections, and sept icem ia. II may be admi nistered
'
~ supplomen1S. lalW!ll\'es
either S)'Stemicall)' or topically. Oral doses should be
administered with a full glass of waler. Diarrhea and C l
side effects are common with oral therapy. Lincodn, a
.3iotics natural antibiotic, is used to ueat serious streptococcal,
Other
pneumococcal, and staphylococcal inf(.'('lions (Stt Table
Chiara~ '!icO/ 178).
Clrlora "' a hroad-speCLrum antibacterial and
antinck< ll gen1. 1\ baCteriostatic to a wide variety of Oxazolidinones
gram po , ,, u1d gram negative organisms. but i1 may Linezolid (Z)'VOX) is the fim member of the oxazoli
b bacten. l.11 111 laflle doses. Bo ne marrow toxicity is a dinones, a new class of drugs tha t are im pon.1n1 for
major dr"' J<k 1<> It\ u~e. Ch loramphenicol is use<.I to use with muh idrug-resistnnl gram-positive 1>a1hogens,

ROOUINOLO NES (OUINOLONE ANTIMICROBIALSI

USUAL ADULT DOSE,

OUTE. ANO FREQUENCY
Of ADMINISTRATION INDICATIONS FOR USE DRUG INTERACTIONS
crproftoxa pro) 500-750 mg PO q12h Type of bacteria Gram-pos11ive and Increases effect of
400 mg IV q12h gram-negauve microorganisms; drug anticoagulants. calfeine:
of choice fOf anthrax 1nlectroo or causes photosens11Mty;
(Cipro X qu1n 500 mg PO btd prophylaxis for anthrax rnfectron should not be used in
XAI Type of infection Wide variety cllrldren and infants
leYOllox msoo mg PO. IV Qd Btoochibs. urlflalY tract rnfectrons. uppet
(Levaqu resprratory rnfecuons. skrn rnfect1ons.
prieumonra
norfloxac 400 mg PO q12h U11nary tract infections and sexually
transmmed diseases
onoxacrn I lo x111') 200-400 mg PO Q12h Upper respirBIOfV rnfectrons. urinary tract
infections. gonorrhea. prostate
infections
gemrftox. ,fac11vel 320 mg PO Qd Same as for Cipro
moxiftoxaun 11\veloxl 400 mg PO. IV qd Gram-positive upper resprratory
infections

Maior Sida Effects of Fluoroquinolones: Oiw ness. drowsiness. restlessness. rnsomma, rashes. GI symptoms, hgament and canilage
damage. hypijrsens1t1v1ty, addruonally ototoxicrty with norfloxacrn
GI ,o&ln) ,, 'lllr.......sly: PO. orally
Also ava ~le as ophthalmoc and ouc preparations
 294 SECTION IV Pharmacology for Multisystem Application

50-75 ~day IV~

chloramphenlCOI (NTNI
metnJnidazole (Flagyt)
11fax1mm IX1faxan)
Types of bacrena Gram-nega11ve Oec1eased an11d1abetic
aerobic orgamsms &gents and 1ncreaseii
Types of infect/Ofl Menmgi11s. blood glucose IMts,
Aocty Mcxrita1n spotted lever. 11ltreasod balbituiates
paratyphoid feet, typhotd pllenv10lll, wadann
fever. bacteoal sepsis. typllJS Decreased by eiythr~
fever ....tier1 not respon5Ml ID hntOlll'jClll, and
odler medications cl1ndamyon
500 mg-I g PO tJd Types of lflfecrm Alcohol<00ta1mng
500 mg IV tld Trichornoniasis. g1ardias1s. medications. d1sulfiram;
amebiasis 1ncreas s effect1"veness
of antic 1<Julanrs
200mg PO Lid Escherichia coli. diarrhea Basically ne

Mjor Sid Eftcts: .

chloramphef!lcol-81ood dyscras1as. nausea. diarrhea. diuiness. depression: meUMidazole-D1umess, headache. G1 1urbanoes,
CNS tox1c1ty, cand1d1as1s

OTHER AGENTS
chndamycin (Cleocinl 100300 mg PO. IM, IV q6h Types of infection: Streptococcal. ery1hroruv1 1and
poeumococcat. and chlor~1 1 mcol,
staphyloooccal ant1d1 !BIS
vancomycin (Vancocml 125-500 mg PO q6h Types of infection: Severe asp1nn. 11 m1de.
1gtVq12h septicemia, meningitis, amnK sides. and
pseudomembranous cohlls other IU!ICS.
beca11 reases
hkehho if OIOIOXJClly
and ne (OXIClty
hnezohd (Zyvox) 600 mg PO. IV ql2'1 Broad-spectrum antunfectJve MAOls S s INH
qumupr1st1n-dalfopr1stin 7 5 mg/kg IV q8h MRSA (safe for PllfSOOS allergic tabol1sm al
(Synercidl to PCN and ce~losponns)
ugecycJ1ne (Tygaol) 100 mg IV mrtJally, then 50 mg Broad-specwn microbes S1rn1la1 t OC)tbnes
IV q12'1
altJll(lnam !Azactam) 1-2 g IM, IV q6-12'1 Antiinfectr1e. UTls Atlerg est N
ceph3 ns
Mjor Sit# Eftir
linezolld. qurnuptl$tllKialfO(Jf1s1m. tigecyc/lfll!. 8lld azueMlm-Oian'hea. supemfecoons. headache. prur1tus. nausea 11ng

TOPICAL ANTIBIOTICS
bac1uac1n end polymyxln Apply locally several times Dermatologic infections
8 (Neosponn) a day topically
re1apamu1in (Altabax.
mupirocm. Baciroban)

CNS. cenual nef\OOUs system, GI. gas11omtes1inal. IM, 1ntramuswlarly: INH. ISOmazid; IV. intravenously: MAO/s, ITIO!l(),jlllir 1
i1.1se 1nhib11cn
MRSA. me1tucllhnres1stan1 StiJJ)ilylocca:us aur8U$. PCN. peo1cilhn, PO. 01ally: SSRls, selectil'I! seiotonin reuplake inhibiiois UT/ 1111 , ry uatt 1nleciJllP
~~n . .

ioduding \iRSA Usually well tolerated, it may cause Cl
S}11lptom\ and headaches (see 1able 178).
Keto/ides
Ttlithromycin (Kctek} is in a new class of antibiotics.
~etolid<". that '' dosely related to the macrolides.
A)thOul!h tdithromycin is an effective drug, it is a;,soci
ated with a high 1isk of liver damage. ll1is medication
mould bt used only when absolutely necessar)' (stt
lable 17 8)
Vancomycin
11 bJctrrn 1u.1I. 1ancomycin is usually the drug of last
resort and hould be reserved for severe infections with
drug-rcmtJnt ~11111hylocoa:11s .111d Closrrldi11111. Vancomy
0n It"'"'tnua,,nously requires c.ueful therapeutic
monnu m bn..1use of the potential risks for oephrotox-
idty .md 1>1otoxicuy to help limit the chance that these
advcr..t..' rt. ll1ons \Vi ii occur. Vt1nco1nyf in is no1 well
absorb I , hut docs ha\oe some oral indications (stt
lable I
Metror ole
Metro ( l lagyl). a shon-acling bactericidal agent
that is t , ~11,. 1s used to treat infecuoos caused by
anaeroh11 l .. t,ri.1, protozoa, and diarrhea assodated
\\rith ( /1 1 m difficile. The patient may experience a
metallt< "" diarrhea Alcohol should be avoided
honidazole because of a disul.6.ram -like
adver"ir 11 on ('re T.1ble 17 8 ).
Tigee
Tigt')' ' .11 ti), J tetracycline deriv;itt;oe, was de>oel
Opfcf tu I r umc tetracycline drug resistance. 111c agent
is acth 1 11.i .1 broad spectrum of bac:teria. Adverse
effect 10 those of tetracrclme (see 1able
17-8)
er-the-Counter Antibiotics
Many .in tt" "'~ found in O\>er-the-counter (OTC)
prepar.111 for torkal use. A commonly recogni~ed
brand -,orin. a combination of polymyxi11 B,
ntom, .d '11citracin. These OTC antibiotics are
first-aid r.li"' for use either prophylactically o r
therap<'ttt.r illy for minor wou nds and Jbrasions; the
tndividu mpon<'nts are available in other fom1s for
other u
R.1111 cin is Li.eel topically for bacterial infections
$ttd1 is s1.1phylococcal ,md group A streptocorral
infClltOll.S
1'.l'Om)i:in 1s a member of the aminogl)'COside
fanuly uf antibiotics.
l'olymyxin R. ,1 bactericidal agent with a broad
Sf><'Ctrum of action ag.1inst aerobic gram-neg.1tive
b.111lh and used a$ a sterile topical treatment of eye
CHAPTER 17 Ant1m1crob1als, Anbtungals, and AntrVlrals 295
(by prescription), ear. and skin infecttons. is not
S)'Stem1cally absorbed, so S)'>temic effects. such as
neurocoxidty and nephrotoxidty, do not occur
~ .
;
Vancomyttn, With the potential to be neiDnta.tC and oto-
tox1c, 1s reserved for trooong senous 1nfec11ons. such as
drugres1s1ant gram-p0s111ve organisms
Chloramphcnoeol causes senoos blood dysaas1as and shoo Id
be used only when clearly ondteated
Me1rontda1ole is useful with protozoa and anaerobic
bacteria
Tapcal ant1btotic preparations. usually containing combtna
lJcnS of f18011in. bacitrac1n. and polymyx1n 8. aie not
absorbed svs1em1cally when applied topically
SULFONAMIDES (SULFA DRUGS)
Sulfonamides, or sulfa drugs. are not antibiotics (the
drugs did not originate in a microorganism) but are
awibacterials used to combat infection by slowing baclc
rial groMh while the body builds its own defenM'S. Most
o( the sulfonamides are synthetically produrt'd and are
primarily bactcriostatic, but some are bactericidal. These
agents are used in area~ where Ouids can Ouh away tlw
wastes of infection (such as the cres. urinary tract. and
sinuses} and for pneumonia and wft tissue infections.
Sulfonamides were discovered in the 1930> as a
byproduct of the dye indusuy. Th<'y were initially effec
tive against gram-posithe and gram-neg;itive miaoor-
ganisms. l lowever long-tem1 use of these dn1gs has led
to increased bacterial resistance.
Sulfonamides are subdivided into 1wo groups on
the basis of their duration of action-shon-acting and
intermediate-acting agenL\. Because sulfonamides are
ra1>idly excreted, high doses given at short imervals arc
necessary to maintain effective blood levels The major
indication for the sulfonamides is lfns, but these medi
cations are also used for toxoplasmosis. malaria, Nat
111ophil11s i11jlue11we infection, and topically for burns.
Sulfo derivatives (e.g.. s11/fasa lau11e) have been used in
colius of the lower Cl tract for their antiinOammatory
action. In the urinary traet, effectiveness is increased
berause the drug is actively secreted in uJinary tubul es.
Sulfonamides in Combinations
Sulfonamide> are combined with each o ther or with
other medications such as trime1hopri1n fl Ml'} to
innease the antimicrobial action and the 'pectrum of
 296 SECTION IV Pharmecology for Multisystem Application

and corneal ulcers S~i.n lotions are occasionally U5td

acuon Sulfam1t1homz.ole wilh lMP {SM.l-TMP), ~e
for seborrheic dermauus. acne ~gans. and skin inf't.
most commonly encoume1cd. is used for lnls. ouus
lions. Other topical preparallons such as P<>l>'den
media, bronchitis. shigellosis. and /'i1eumocyslu 11ro1ro,
and oimmenis are used to treat hums. These IOpiQJ
such as for prophylaxis and 1re~tment of Pneumoqms
preparations do have some S)'Stem1c absorption ffablt
pneumonia (PCP) in pa1iems wuh acquired immunode-
ficiency syndrome (AIDS). 'lhe combination dru~ are 17-9).
generally well tolerated, wilh rare toxic effects. The drug
forms of tablets. suspensions, and intravcnous soluuons
consis1 of one pan TM P 10 five pans SM7..
PATIENT ALERT
Topical Sulfonamide Preparations
While 1aking sulfonamides, the pa11ent must take large quani1.
lopkal preparations of su lfonamides are available in nes of fluids to p1event drug crystall1iat1on 1n the kidn~. a
SC\eral forms. Ophthalmic preparations such as s111fa- minimal danger when unne is kept dilute
utarnide (Sulamyd) are used for ronju nctivitis

LONG-ACTING AGENT
sulfasalazine (Azulfidine) J.4 g PO q8h Types of diseases Ulcera11ve Increases 1 , action of
colills. Crohn disease. 1uvenile anticoay n1s and oral
rheumatoid anhnl1s hypogty cs: decreases
the eff ess of oral
contrac .es

COMBINATION SULFONAMIDES
tnmethopnm {TMl')-SMZ 80 mg TMP/400 mg SMZ PO Types of infecnon Unnary tract
{Bacmm. SeptraJ Qd. IV infectlOllS. ot1bs media, vaginal
double-strSllgth TMPSMZ 160 mg TMP~ mg SMZ PO
{Bactnm OS, Seprra OSI q12h
erythromycin-sulfisoxarole 4()0 mg PO q6h Otitis media
(Ped1azole) 1200 mg PO Q6h

Major Side Effects of Systemic Sullonamid11: GI dislurbances. kidney damage, drug induced fever. diarrhea, headar.h 1ashes,
pruritus when taken PO or by parenteral routes

TOPICAL PREPARATIONS
sulfacetamide ophthalmic As duected. usually 1 drop in Type of 1nfect100 Ophthalmologic
ointment, solutJOO eye with solution 1nfecboo
(Sulamyd)
silver sulfad1awie (S1fvadene Apply topocally to aflecled area Bums and sbn 1nfect1oos
CtearnI
GI. gasuointest1nal. IV, ontraverously, PO. 0tally
 CHAPTER 17 Annm1crob1als, Anbfungals, and Annvirals
IPatient'IEducation f or Compliance
Ora sulfonamides should be taken w11h a full glass of water
on an empl'( slOmaCh The persoo should drink 8 to 10 glasses
of water a day to prevent crystalh1a11on of sulfa in the
t idreys
2 Sulfonandes may cause photosens111v11V reactoons. so pro-
tective clo1hmg should be worn and sunscreen used when m
the sun
. '
Sulf'c:-.J:nfd,es are used pnmanly to treat urinary trac1 onfec-
are used 111 comb111atm f0t other am infective
th other 1nfect1ons soch as malaria and
s
of tnmethopnm-sulfamethoxazole mh1b1t bac-
t al steps. mak1119 the< drugs fllOfe powerful
sed alone
111. the most common cause of uncomplica1ed
unna nfections. is suscepoblo to sulfonamides
'~fTREAT TUBERCULOSIS
With th nee of multidrug-resisl<lnt mycobacteria
.ts~ocja H. ~ " 1 \ IDS. tuberculosis has again become a
global pul li~.dth problem. M. wllcrculosis, the CJuse
of tube1 1s most often found in the lungs. but it
RIJ)' inf r body areas where the bacillus Gln grow
in a higl 11 level. 1 he bacilli may be dormant in
the bod\ 1 \l'oUS and reemerge when the immune
S)'l>tem b I wered ability 10 fight d isease. Multidrug
"" a recent development, and resi>tance
to ison -..;1 1) and rifampin, the two mainstays of
tubercul 1 '"'"'PY h.1s caused panicular concern.
1 mtitubcrcu lar drugs can be divided into
I ) medications that are fairly effective and
ntl (2) drugs that are more toxic and
o nly as necessary.
As pt< 1vr medicine for tuberculosis. a single drug
is u'uall 111mended- most frequently INI I, with
rifampi the second choice. I-or the treatment of
tubercul< , o or more dru~ should be used; initial
treaLmem 1 ;1111ens combine four agents until suscepti-
bility resul ll< known. !)rug therapy may even include
three o 1 ' "edication~ given for prolonged periods
of time combination of medications not only
decrease' 1h1 risk of resistance but also reduces the
chance ol a Ji,c.1se relapse.
Some dr1 ., such as !NH and rifampin, arc most
effective 11-nn\t rapid!) dividing bacilli, whereas others
such as ~ r 1zinami1le (P2A) are active against
297
intracelJular activity. The four recommended drul!l> in
combinations are l'IH, rifampin. P7A and either t tharn-
1111101 o r stre ptomycin; these agentS will provide the best
treatment over prolonged periods of timl'. often a year
or n1ore.
PL\ a ba(tericidal most often used for a(tivc tuber-
culosis. may also be used in rombinauon with
rif.impon or rifabu1i11 as a prophylJctic med1cJ11on
for !NI I-resistant infections.
Ethambuto l should always be given in combina-
tion with other medications.
Vitamin 8 6 (pyridoxint} may be added to the
theraJlY to prevent ncuropathies ( !able 17 10).
PATIENT ALERT
Because tubercular drugs are hepa101ox1c. ingestion ol
alcohol should be avoided Jaundice. pale stools, or other
signs of J.wr disease should be reponed
A1fampm will discolor urine. sweat, and salrva to a
red-orange color arid may permanently stain soft contact
lenses.
With meditatl()f)S for tubefcu!Osls. tile reason lot prolonged
mutodrug therapy must be explained 10 the patient The
length of 1herapy may make compliance a significant
problem
2 lsoniazod UNH) and nlafll)ln should be taken on an ~ty
stomach unless gastro1ntest1nal upset occurs. 1n which case
they may be taken with meals
3. Any changes on vision while taking ethambutol should be
reported because of the poss b rty of ocular tOXJOty
The ponc1pal cause of drug resistant strains of tuberculosis
1s inadequate drug therapy
The prolonged use of m lt1ple medications contnbutes to
lapses on med1cat1on therapy
To prevent drug resistance, tuberculosis should always be
treated with at least two drugs
The usual four-<lrug reg men to treat tuberculoSJs includes
1S0111aiid nfampm. pyraz1nam1de. and erther ethambl tol 01
streptomycin. These drugs can be used in all areas of tuber-
culosis treatment including drug-resistanl tuberculosis
IS011iazid 1s the only drug that has been proved effective in
preventing tuberculosis
298 SECTION IV Pharmacology for Mulusystem Application

.................~"""""i!M~L~l,~iWiiillk~
USUAL ADULT DOSE.
GENERIC NAME/ ROUTE. AND FREQUENCY
TRADE NAME OF ADMINISTRATION
FIRSTUNE DRUGS
1soniaz1d (INHI INTNJ 5-10 mg/kg PO (usually 300 mgl
qd
11lamp1n !Aifad1n} 600 mg PO. IV qd
pyraz10am1de (PlA) 15-30 mg/leg PO qd
ethambtJtol (Myambutoll 15-25 mg/l(g PO. usually
1000 mg Qd
streptomycin (an 0.5- t g IM lfor shon-term
aminoglycoside) INTN) therapy) qd
rifamprnINH 600/300 mg PO qd
IAifamate} 600/300 mg PO Qd
INDICATIONS FDR USE
Preventive therapy for
contacts of persons with
tuberculosis and as
treatment for those whose
skin test results have
recently convened from
negat1Ye to positive
Prophylactic 11eatment lor
rubelculos1s
Therapy for acuve tube1culos1s
Also for tularemia and plague
Preventive therapy for
tuberculosis alld treatment
of active tuberculosis
1-
DRUG INTERACTIONS
Increased abso!Jltion with
alcohol intake
Decreased D1lannn metaboliS!n
Increased hepatotoxicity when
combmed with drugs that
cause hepatotoxic effects
Increased absorotion with
alcohol mtake
Decreased D1lantm metaboi1S111
Increased hep.Jtotoxicrty when
combined Wiii! drugs dlal
cause hep.Jt toxic effec1s
Increased met bolism of
ant1d1abet1c r:ied1call0ns

Ma;or Side Eff1tets of RrstUne Dn11s:

Hepa101ox1c1ty. neurGtOXIClty. ocular toi.:1ty with elhambutol. an!vitis. goot. arthnus-h<e react100$ with pyraz1namiOO

SECOND-LINE DRUGS
kanamycin (see Table 17-61 Therapy for active tuberculosis
p-am1nosalicylic acid (PAS) 3-4 g PO ud
(NTN)
IM, inrraffi\JSctJfarly; NTN, no traoo name; PO. orally.

control. but muluplication is po\sihlt. c 1sing patho-

DRUGS TO TREAT
FUNGAL INFECTIONS
I ungi, including yeasts and molds. are ~pore-forming.
plantlike. colorless microorganisms. More complex than
viruses or haaeria. fungi are found in soil. air, and con-
taminated food. Thriving on dead plants and on animals
10 produce many irritaiing symptoms, they also cover the
cm ire body, eating dead tissue from 1hc skin. hair, and
nails. Bacieria a nd the im mune system kee1> fungi under
genicity in susceptible per5011s l-ung.1 membraM
have little resemblance to baetcnal celb ntrefore .mu
biotics are indTooive. Long-term a1111h1 therap)'.or
radiation thera1>y can create an cmironrr 111 conduo't
to rapid fungal growth by altering th<' bal 11ce of nonnal
flora or suppressing the im munc sys1cm
Antifungal drug.\ both systemic and topic.11, can. be
funglddal or funglstatl< based on 1h111 conccntra~on
in 1he body tbsues. 'l11crapy is usually prolo nged. 1aku'.g
several weeks because mycose; resis11re.11nwnt, and toxic
 CHAPTER 17 Antimicrobials. Anufung1ls, and Annvir1ls 299

dfeC1s from treatment may occur before a cure is
arhievcd. 11wse drugs are fairly specific for the dise,1se
piO<l>SS<'S (Table t 7 11 ).
Topi cal A ntifun_g_a_l_s_ _ _ __ _ __ _
ocrmatologic mycotic infections, with symptoms such
as inll'n>e itchinl\- discolored scali ng of the skin. loss of
h.1ir and skin pignwntation, and blistered or broken skin
bctff" the tOC'l .ire typically more annoying than
serious lO of the most common fungal infections are
ringwo rm 1nfec11ons (1111ea corporis or tinea capitis) and
athku,.s foot (11nca pcdis). U11decylcr1lc acid as a topical
.igcnt for supcrfid,11 mycoses is active against tinea
infections. 111e major indication is tinea pedis Another
fairly com mo n fungal condition is infection rau;cd by
Candida a/bim11s, such as thrush in tl1e mouth and can
didiasis in the vagina. Undecylenic acid, used to treat
tinea infecuons. 1s not effecm-e against candidi.rns. Many
topical and vaginal agents are available as OH. medic
lions (see Cha1lter 22 for more on topical antifung.1ls).
Syst em ic Anti fun gal s
---------
Systemic fungal or m}'COtic infections are diided into
two categories: (I) opportunl,Uc lofeaion~ (e g.. can
didiasis, as1>crgillosis. cryptococcosis, mucormycosis)
and (2) nonopponunistic uncom mon infection; (e.g..

TABLE 1 SELECT ANTIFUNGALDRUGS

SYSTEMIC llRUGS
ar'll' 1 r. OQ11one I 0.25-15 mg/kg IV qd topical Aspeig1llos1s. candid1as1s, lllCleased potential for d1g1tahs
coccidioidornytos1s. tOtClty
blastornycos1s
m1cafung Jm IMycam10e) 50-150 mg IV qd Candidiasis predmsone. tacrohmus, sirol1mus
caspofun .. nridas) 50 70 mg IV qd Cand1diasls, asperg1llosis
ftucytos "1) 50-150 mg/kg/day q6h Candida. cryptococci qu1n1dine. cytosine

M1ior Sift flff!dS of Sys11mic Drugs:

Heada GI disturbances, blurred v1s1on, conlus1on, hallucmauoos: bone marrow suppression

AZOLE Af TIFUNGALS
ftucooa n) I00.200 mg PO. IV qd Candidiasis, cryptococcal Increased liver toxicity with
mfect1oos. h1stoplasmosis: alcohol. increased effects of
srnilar to amphotenan B oial hypogfycemics. and
phenytoin
ketoconaJ c (NINJ 200400 mg PO qd Same as for amphotencm B See drug hte1ature
11racona1 'Sporanox) 200-400 mg PO qd Same pimo11de. quinidine. dofelllide
posacooa: 'loxafill I00-200 mg PO tid Prophylaxis lor Aspergiflus cyclosponne. tacrolimus.
aro Candida infections in suohmus. c1met1d1ne. and
1mmunosuppressed ochers
1ndhnduals

OTHER ANTIFUNGALS
g11seolul 1lvinVI 500 mg l'Oqd Tmea infections Decreased anticoagulant therapy
Tmea ped1s, onychomycosis such as Coumad1n and oral
COlltraallllrYeS
nystatin 1Myccstat1n, N1lstatl 400,000600.000 mg PO q1d, Mo111lia. cand1d1as1s No significant interact1oos
500.0001.000,000 mg PO q1d
as lozenge. suspension.
tablets
te<btnafine (lorrns I 250 mg l'Oqd Onychomycos1s, unea Alcohol
topical infections
GI, gasuo n1esi.oa1. W iotravenously; NTN. no trade name; PQ orally

300 SECTION IV Pharmacology for Mulusystem Application
histo plasmosis and blastomycosis) Amphouricin B is
aai\'e against a broad spectrum of fungi and is '!1e ~g
of choice for most systemic m)"C05CS Other.medi.cauons
frequently usro for systemic fungal mfecuons 1ndude
the azole group (see Table 17- ll}
Drugs for dennatologic fungal condiuons are dis-
cussed in Chapter 22.
PATIENT ALERT
Conon socks should be worn during treatment for foot fungal
mfec11ons. All slloes should be worn with socks.
For treating fungal 10fec:t1ons of the genitals or tinea of the
groin. men and women shoold preferably wear breathable
oonon undergarmenlS
[P~cation 1 tor Compliance ~..'
The feet. groin. and underarm areas are l1104ster than other skin
areas. thus requ1nng tile use of powders IOI topical rreatmoot
of fungal mfectioos. rather 1han creams 01 lotions, because
powders lend to absorb moisture
~~~~~~~~
Ant1ful1gals may be either fung1c11tal or lung1stahc and are
found as prescnptlOT1 and OTC preparations
Ant1fungals are de519ned to be used fOI 4 wee\$ ooless they
are berng used on nails wlle<e a longer penod of ~me is
needed However, the agent and organt1m may requlfl! a
timevanance
Vulvovag nal candod1as1s may be treated"' th a single oral
dose of ftuconazole
DRUGS TO TREAT
VIRAL INFECTIONS
Viruses are suands of genetic material wrapped in a
protein coating that prevents the virus from sustaining
iL'IClf independently. Viruses are parasitic on host cells
where the virus reproduces and range from viruses !hat
cause the common cold to those that cause devastating
illnesses such as HIV and AIDS rherefore difficulty lies
in the inability to suppress viral replication without
doing significant harm to ihe host.
Viruses attach to the outer membrane of the cell and
enter the cell nucleus, where DNA or RNA is covered
with a protein capsule. HIV virus. a retrovirus, auaches
10 1he RNA and replicates on DNA, causing new \iruses
10 be placed in circulo rion.
i
By !he lime signs and symptoms of a viral infttti0ci
ppear, viral replication is complete and the di~
~ourse has been determined. To be effective for all ,1~
diseases. antivirals would need to be gwen prophyl~.
cally, which is not practical, safe. or effecti,e in lllO!t
!s
instances. An exc~ption the ~ ?f antivirals prophy.
lactically in cena1n senmgs wuh infiuen7.a outbreah
Most antiviral drugs work by prc"enting the virus from
entering the host's cell or by interrupting replication.
Classification of Antiviral Drugs
The anliviml drugs are cl.1ssified according 10 their Ust
for either t llV infection or for non-Hrv infection. Drugs
for J UV infection are call ed m111retroLOrt1/ Jrugs. whcrus
drugs for non-1llV infections are act1v'" ai:ainst a narrow
spUUm of viruses.
Non-HIV Antiviral Medicati
-----
"
The non-H IV antiviral medications h.1 1mited ability
10 treat infections because the ''lru>e< p~nd on host
cells for replication. 'Ow herpes group 1dudes herpn
simplex viru> (11!.V) infections of tht 11talia, mouth
and face, and other sites and varicell,1 ,, . "virus (VZV),
the causative virus for varicclla (chir~e1. x) and herpes
zoster (shing.les). 'l11e effect ive drug o l oice for th~
conditions is acycloulr (Zovirax), wh11 1\ available in
topical, oml, and IV forms (see 'l,1blt 12 for olher
drugs used for herpes infeciions).
Cytomegalovirus (aw) and Lps1,, , virus (inf
tious mononucleosis) are also mcmbc. "' !he herpa
viral group. lmnsmission of CMV oca hrough body
fluids. blood transfusion, and organ t plants. By~
40, harl>oring of the virus is common J is of httk
1unocompro-
concern in healthy persons; howcwr
.e. H\'e drug!.
mised people are at high risk for the th
oral and intravenous, are used for m nt. Ophthal-
mic p1epam1ions for tlic;,c diseases discussed in
Chapter 21.
ln Ouenza, a serious viral respii'.llt 1 <ondition, is
caused by innuenza A nnd I! viruses. I lo ly contagious.
it can be minimi~ed by vaccination (< pter 16) and
with medic-.11ions for the prevention and .umenl of the
disease (Chapter 25).
Viral hepatitis is the most common 1 disease Stt
Chapter 24 for related drugs
HIV Antivirals
Although no cure for lllV infection 11' been found.
advances in drug treatment have been !rarnatic. a11d
presently the ability to delay progresston of 1llV inft'C
tion to AIDS occurs with appropriate u" ol antiretroviral
drugs. Advances i11 pharmaccut ical prep.uat ions are als_o
increasing quality of life for those affec tcd; the 1re11d '5
 CHAPTER 17 Antimicrobials. Antirungals, and Antivirals 301
------

NON-HIV ANTIVIRALS
c1dofov1r N1s11d~I
ganc:iclov1r (Cytovene)
valga11c1clov11 tValcytel
ramcickMr a11MI
IQSt3rr I
Major Sid N rcrs of Non-HIV Antivirals:
GI d1stre 1 ss,
5 mg/kg IV weekly Cytomegalovirus (CMVl, CMV No significant mterac11oos
to every olher wk re1ini11s
5 mg/kg IV daily to bid CMV zidovudine (AZT)
I000 mg PO tid
450-900 mg PO CMV
daily-bid
200 mg PO q1d HerpeS111rus iypes 1 and 2 and No significant mterac11ons
zoster
125 mg PO daily-ltd Ge01tal hefpes No s1!Jl1ficant 1nteract1ons
500 mg PO daily-tid Herpes zoster
Apply topically at sne Herpes simplex No s911fican1 interactions
500 mg PO btd Genital helpes. hefpes roster No sigmficant 1nteract1ons
40 mg/kg IV q8-12h Herpes viruses. CMV, Epstem- No sigmlicant mteracuons
Barr virus. varicella-roster
11nnitus, unpleasant taste; may be toxic, causing nephro1oxic1ty. hepatic dysfuncuon. blood dyscrasias

HIV ANTIVIRALS
Nucloos1d1 1 versl Transcriptase Inhibitors (NRnt)
abacavi n 300 mg PO bid HIV Alcohol. St John's won
d1danos Viet.xi 200 mg PO bid Advanced HIV Care w11l1 anti-TB drugs. alcohol,
furosem1de. estrogens. tetracyclines.
nitrofurantoin. diuretics
200 mg PO bid HIV No significant 111terac1ions
150 mg PO bid HIV St John's wort
750 mg PO tid HIV pradnisone. nfampcn. oral contraceptrves.
keto conarole. St John's won
StaV1Jd1 40 mg PO bid HIV zidovudine
tenofov r 300 mg POqd HIV No significant 1nteract1oos
zalc11ab11 1dl 0 75 mg PO ud HIV probenecid. cimeM1ne, Maalox.
metoclopramide. didanosine
zidovud111~ If 1111virl 600 mg/day PO in HIV with impaired immunity ganciclovir
divided doses
1 mg/kg IV
5-6 times/day

Nonnuc1' Reverse Trenscnpl8se lnhibolors INNTlsJ

delavud 400 mg PO nd Advanced HIV Multiple. see drug hterature
(Rescnptor)
newapcne lfilmune1 200 mg PO bid HIV Same as nelfinavu
Numerous hie-threatening mtl!fac!IOl'IS
(see literature)
efavuenz iSustrval 600 mg PO qd HIV Benzodiazepmes. ergot products
etrav111ne (lotolence) 200 mg PO bid HIV May interact with other HIV medications

CNS. central nioos sys1om, GI, gastro1n1estinal; HN. ~uman immunodofic1cncy vims; IV. inuavenously; PO, orally; TB. tuberculosis
used in comb u.atmn with other antivirals
302 SECTION IV Pharmacology for Mulrisystem Application

TABLE 17 12 SELECT ANTIVIRAL DRUGS~cont'd

ORUGINT<AACT~
USUAL ADULT
DOSE. ROUTE. AND
GENERIC NAME/ FREQUENCY Of
TRADE NAME ADMINISTRATION INDICATIONS FOR USE
Proreas lnlubltors (Pl/ c1sap11de, midarolam. warolam. rof~
1ndonavir ICnx,..anJ 800 mg PO q8l1 HIV infection
RescnptOf. keux:ooazole
HIV Ant1arouety agents. c1sap11c!e. tnepeiodo~.
ntonavor (NOMI) 600 mg PO bid
poroxoeam. propoxyphenc
HIV Ant TB. Oolan11n. nonsedatong
saqu1naW1r (lnvlrasel t00> mg PO bid
an11hlstam1nes
fosamprenaw (Lemal 700-1400 mg PO bod HIV See drug mfOfmatton
atazanavor (Rayatazl 300-400 mg PO Qd HIV See drug mformatooo
darunavir (gown with 600 mg PO bod HIV See drug mformatoon
efavorenzl (PoezostaJ

Other HIV Antivirals

raltegrav1r (lsenuessJ 400 mg PO bod HIV TB medications
maravoroc (Selzentry) 150-600 mg PO HIV St John's wort, TB m 11 ions,
anuconvulsant medlf JlS

Major Side EHects of HIV AnrMrals: . . ,

Ncphrotoxicity. nausea. vomiting, anorexia. renal tailure. diarrhea. headache, blood dyscras1as. fat red1str1bu11on. p.io ""111t1s.
blood glucose allerauons

for once-daily dosing with fewer tablets and no food
restrlc1ions.
Mcdica1ion~ for I IJV, which have OCen rapidly
approved by the I ood and Drug Administration (fl>A),
require a triple-drug regimen, often known as a "cock-
iail. These drug.s M1 10 reduce HIV levels in plasma.
1hercby slowing loss of immune fw1ction, preserving
heahh, and prolonging life. For 1his reason, combination
medicinal produru ha-e been I DA apprO\'Cd for decreas-
ing the nc'ed for administration of multiple doses of
different medications at the same time.
The benefi1s of the antiretrovirals for I llV are complex.
cos1 is high. and toxicity is great. l llV anuvirals exhibi1
muhiple drug 1111eraC1ions and cause noticeable side
efTcC1s Trt:atment does not elimina1e the HIV virus. but
drug' reduce viral levels. sometimes Lo the point of being
undetoo.1ble.
Nudeoside or nucleotide revellie transcriptase inhibi-
tors (NRTls). by preveming heailhy T cells in the body
from becoming infecied with I llV, are the prime focus
for once-a-day therapies and are the backbone for most
current r<'gimcn>. NRTls are chemical relatives of the
nuclcosidcs in DNA; 1hey suppr~ viral DNA. prevent-
ing conversion of RNA to DNA in infec1ed Tcells. These
drugs musl undergo iniracellular conversion 10 be effec-
1ivc. Non nuclcosidc reverse transcrip1ase inhibi1ors
(NNllTis) bind LO the ac1ivc ccnwo ot "e transcrip
tase and are effooive as adminis1crcd I' ' hcddaches.
and Cl symptoms occur with these" 1 >1mds.
Protease inhibitors (Pis) arc the m lfmh-e lllV
drugs available. Although these .1gcn1' r ,II 1olera1td.
Cl symptoms do occur. 01hcr sogmh 11 \ide efTU
include hyperglycemia, fai maldimth rl. mcrcN<l
bleeding tendencies. hypt>rlipid.-011.1 J d00taltd
bone mineral density. 1hesc drui:s 'h 1101 be used
alone. Drug informational m.1tcri,1l uld be read
when these medications are prl'.,Hlll\-J IUW Of IDUI
tiple side effects that are found wnh It I lu.11 drugs.
The only absolute co111ramdic.1tiu11 ' .,,. use of~
HIV antiviral drug is hypt>rsens11tvil) 1< 1lit med1G1tioo
or concurrem conditions or dnog 1h 1h,11 prewnu
the drug use. Because lllV is 1rea1,.,.1 wot w mbinauons
of antivirals, many drug.s arc now found r wl combona
tions for patient convenience, 0111 ti l'','"b1li1y of
nephrotoxici1y is very real (sCl' 'l,1hl l ' )
PATIENT ALERT
To be effechve. ant1v1rals for AIDS and HIV1el11ted d1se<1Se5
must be administered continuously for hfe. Stopping treatment
causes a dange1 ol producing drug-resistant HIV
 ~~~~~~~~~
CHAPTER 17 Ant1m1crob1als, Annfungals, and Anuvirals 303

lfati~ucatiOri" for Compliance
Drugs. especially acyclow and vatacyckMr. decrease sy1np-
ioms of gennal hefpes simplex 111lectim. but they do not
produce a cure If lesions are present. lhe disease 1s
communicable
2 Persons w11h HIV should adhere closely to prescribed dosage
sdleduleS
~ rwes live on host cells. so 11 1s difficult to suppress viral
reprodlll:tioo \11hout the host's body cells also being harmed
Acyclnw and valacyclovir are drugs of choice for herpes
simplex and varicella-zoster viral mfectioos.
Res1sl811r to Jnl1V1ral drugs is a ma1or concern To reduce
!he eme:qeno: ot resistant stra ns. drugs for HIV should be
I on.
111en 10 HIV pa11en1s should be ageflls lhat !he
1it previously taken und are not cross-resistant
ken drogs.
" iTREAT MALARIA
Malari<l, .11ic disease transmitted by a mosquito
that act> is charaaerized by high fewr with
recurrcr ,..,-.?re sweating. and jaundict brought
about b, l\lllg the liver.
Antimalarial drugs, with rl1loroquiue being the drug
or choice except with drug sensitivity issues, are admin
istered for prophylaxis and to prevent disease dewlop
ment after exposu1e. Prophylaxis should begin I 10 2
weeks before rravcl 10 an area where malaria is endemic
and should cont inue for 6 weeks after the individual
leaves the area. Drug.5 used during an acute anack of
malaria seleaively stop the multiplication or microor-
ganisms and arrest the disease.
Choice or anti malarial medications is based o n the
strain of malaria-causing pro1oroa involved and the
stage in org;inism's lire cycle. Travelers to areas where
malaria is endemic should contact the CDC for current
prophylaxis requirements (Table 1713)
CHEMICAL AGENTS USED AS
ANTISEPTICS AND GERMICIDES
AND DISINFECTANTS
Microorganisms are everywhere. migrating on skin, hair.
fumiture. and even in the air currents. Even in an optimal
environment, microorganisms can produce infection.
Antiseptics and disinfectants are used to reduce micro-
bial growth, wound comamina1ion, and ultimately the
risk or wound infection. See Hgure 171 for the chain
of infection. 1he 1erms anllcptk and disinfectant or
germiddal agent are not interchangeable. altbough
both t~ or agents are used to control and prevent
infection.

LECT ANTIMALARIALS

chloloqu e 300-700 mg/wk PO 2 wk before
exposure aoo for up to 8 wk
after leaving enderntt area
hydroxych ne/Plaquenil 400 mg/wk PO 2 wk before and
4 wk after leaving
5 tabs PO once (treatment),
250 mg/wtc PO Pfophylactic
py11mtt 25 mg PO once a wk up to 10 wk
pynmeth.11 n ,.,1th 50 mg PO qd
sulfadox fJns1dar
dOX'jC't. It '.1C. acyclineV 100 mg/day PO for 12 days
V1bram. belore !JaYel, con11nuoosly
throughout travel. and 4 wk
after travel
Acute malaria and prophylaxis
Acu1e attacks and PfOphylax1s
S<lme as for Plaquenil
PYophy1axis
Acute attack tor chloroquine
resistant disease
PYophy1axis
No significant in1eracuons
No significant interactions
Quinine. beta blockers.
calcium channel blockers
No significant interactions
No significant in1eract1ons
See interactions for
tetracyelines 1n Table 175

Mojor Sitle Elfects of Anr;JJUl1ri1Js; Nausea. diarmea. headaches, blurred vision. vertigo, rashes
PQ ora y
See All~btotia

304 SECTION IV Pharmacology for Mulusystem Application
8 Antisepiic and disinfectalll solu11ons vary in their anu
S.epoOle -
.,....,.,_.,.,
~-"'
Figure 17-1 Chain of mfection (From Young flJ', l'rocllll OB Kim's lhe
med<t:al llSSsranr. ed I I. St louos. 2011. Elsevier)
Figure 17-2 01s1nfectants used 10 samtll8 rooms
Antiseptics versus Disinfectants
a nd Germ....;;....:...:..:.~~~~~~~~~~~
icides
Antisep11cs are agents applied to living tissue to dean
wounds or 10 prepare skin for procedures. smgery, or
injections Ille objooive of antiseptic therapy is to
decrease 1he number of bacteria and climinale disease
or to serve as prophylaxis wi1h activities such as hand
washing. A111iscp1ics and disinfectanis should not be
taken orally bause o( their toxicity when ingested or
absorbed 1hmugh the skin
roo har>h for livi11g 1issue, disinfooanis are applied
to inanimate objecis 10 reduce bacterial growth (Figure
17 2). Disinfcc1an1S may no1 ki ll all types of microorgan-
isms, especially mold spores. viruses. "''d fungi.
Germicide, which kill microorg;misms, may be used
on e it her living or nonliving objl'(IS. Cem1icides may be
fur1 her subdivided into b.1ctericides, fungicides, viru-
cid<'l>. and amcbiddc>. Gcrmistallc agents may be used
i
for sanitization but do not kill 111 icrobe$ for
sterilization.
In clinical use cffooiven<?1>s of a111iscp1ics and dW
fectanlS is extremely variabl~, dc1~cnding on the PrOd~
how it is applied, and the suua11_on 1n which it is~
microbial potency, their spectrum of .1oivuy, and lilt
time they 1ake 10 act. as well as 1hear <lura1ion or 3Clioa
wjJh exposure tO chemicals for CX.llllplc, 7096 tl/io...,
reduces bacteria on skin by 50% in 16 'l.'<onds, w~
1>enzalltonium d1loride I : 1000 rcquirn 7 minutes ol
exposure for the s.1me effect
Some chemicals are broad spe<tnun or nonsele((J,'t
in their action, such as formaltltl1y1I~ lutaraldthr't,
and iodine. Rttat hlorophcne .ltld b.11 ~lkomum <hlo.
ride are primarily effective .1ga11l\I hoth gramposilJ\'f
and gram-negative bacteria Alcohol b.mericidal 10
vegetative formsofbothgram-posurv. a1 J gr.1111-negauvt
bacteria.
&tj CLINICAL TIP
After cleansing an mstmment. allied heallh I' ,f,'ss1onals should
be sure the instrument 1s dry before pla1:111q I 111 d d1sinlec1ant
to prevent diluting the disinlec11ng soh111oi "'' decreasing 11s
effectiveness.
Antiseptics
Iodine Preparations
Iodine preparations ( iodophor.) .11.- r 11 ti "1111g. po1en1
germicides tha1 are superior for 11,. 1 ly removing
microorganisms such as bartcri.1. 'm1 ' ind pro101.o.i
from skin. Tlnaure of iodine " t">P.'<l ' dfectiw. but
i1 causes residual skin s1a1ning .111.1 11 , oral stingi~
because of iis akohol base. l0<l11w I'" uons sud!..,
po11idqru-iodine ( lletadinc) .uc '""' h"nfect slan
before surgery. Allergic re.1ction' tu rod uc common
and should be carefully evalu.1tt"<I h<'> a , 1he resulun1
stain may mask redness and swdhn.:
Alcohol
Alcohol preparations ran be us.cd " r 1..p1ics eithtt
alone or in combination wuh 01lw1 t 1 11.11 agents 10
prepare skin for surgery or "'''~ 11un 1t ,,.1 alcohol ~
effeetive in concentratiOn(i of IC'"- th.tu 0 11 11; iso,,.,..,,
alcohol is bactericidal in contcn1r.lt11>11' ol 10'lo 10 9()%,
with 70% being the dcstted conccnu.111011 Alcohol is
added to other an1 isep1ics 10 1nrn""' 1lw .uuisepuc
dfec1, but 1his addi1ive may c.u"'' '""' mi1.ltio11. Tht
swabs or prep wipes for giving inic<11011' """"i n isopro-
pyl alcohol for its bac1ericid,il tff,ct lh<' .11c.1 should be
air-dried for ultimate cleani11g.
 ---~---'Cl!APT
_;_ ER 17 Anum1crob1als, Anbfungals, and Antivirals
HeJtachlorophene
/ltxA(hlorophnrr, u~ as a surgical Krub or &kin
cleanser, is cffec1iw against gram-positive microorgan
isms. 1hc usual b.1c1cria found o n skin. Willi repeated
use hnarhlorophcne ace"lnnulates on skin to maintain
anLibJCll'flal act1v11y
Hydrogen Peroxide
11ydrogm pnoxitle is an excellent disinfectam and steril
iiing ag,nt but i> u<t>less as an antiseptic because i1 does
not penc1r.11c skin and breaks down rapidly into oxyg~n
and w.11tr h' cff<-rvcscence m.1y facilitate mechanical
cleanmg ol od>m from a wound, but lh1s contact termi
n.it~ germ iJ.11 action. Use may b<' detrimental by
rausin!\ lll'W'"sue to slough.
Silver Pr ations
Silver prq " ''"'~ .ir~ antiseptics. Silver 11/trate i$ used
as ,11\ opht .,!11ni< ,Ultiseptir in eyes Of ne\Vb0 111S tO
pre-cn1 c.ll infections Silver sulfadiui11e (Sil
\'Jdenc) 1 1op1c.1lly for bums because of its ability
to belll'r I' 1r.ll< wounds.
Oisinf
Oisinft:l I' arc "'cd for de.ming and storage of surgi-
cal in\lrt ts. d1$infoc1 ion of operati ng rooms, nnd
steri. hi<'CIS that cannot be exposed to high
1emper 1 rn1.1ldehydc ,md glmaraldehyde are irri-
t:Uing lll .1nli \hou ld be used o nly on inanimate
objem t ommon disinfectants 1ha1 are also anti-
seplic. l1l'PO<hforiu (bleach) and alcohol
(fable I
We.1kl'1 .I ""1111111 hyporhlorite ( 10% dilution)
may b< ~n antisep1ic 10 disinfect countenops.
lloo" r -"rfaces as a virucide. Weaker solutions
JI(' 3\.11 (1)11/1i11 1olutio11), wi1h a maximum
toncentt.t ' of 05% .ll full sirength, to irrig.11e
\\'Ound
Bari. a nuld non1oxic bacteriostatic and fun-
gicidal ' mmonly used ,,, a surgic.11 eyewash or
irrigant I om1>nt111d is also found in medicatio n> for
first-aid I ems (>ce Table 17-14).
Arri dtlutu twochlor11e solutmn used for d1sonfec11ng surfaces
should be 1n the office daily because 11 remains fully potent
fOf ooy :: 6 ro. s 01lutJon should be 1 10 fat the solution to
be effect , d ~.nfuc11ng surfaces Care must be taken to dilute
sodium hypctl lorite solu1ron to prevent d1scolora11on of surfaces or
clothing Som faciliues purchase a pred1luted product because of
conven e and sofuuon stability
305
' .
Antiseptics are used oo IMng 11ssuB. and disinfectants are
used on inanimate ob,ects Gemvadts may be v<'ld on e Iller
an maie Ol ma0tmate objects
Bacte11c1d~ls kill m1cro(J(ganisrns. whereas an11sep11cs and
bacteflOSIBllCS only onh1b11 tile growth of microbes
II sodium hypochlorne 1$ used as a d1smfectant the sohmon
>hould be diluted 10 prewnt d1scoklfatJon of urfaces to
which ti 1s applied
Ant1sep11cs prevent development ol local infechons For an
established onfecoon, $'j5temsc ant onfectants are prefesred
f0t 1rea1men1
SUMMARY
Wi1h 1he advent of penicillin and sulfonamides, a new
era in health care was launched. Since the time penicillin
w.1s firs used in the early 1940s, anumicrobi.ils have
been used in medical offices on a daily basis. As bacteria,
fungi, and viruses become resistant to one 1y1~ of ami
mil'1'obial agent. new agents must be developed 10
rcpldce lhe agents !hat arc no longer effective. The FDA
approves new an1imicrobials many times a year. wi1h
special rapidity for agems used to 1rea1 debiliiating dis
cases such as lllV infection .
l'aLient cduca1 ion in the use of amim icrobi.ils. a major
responsibili1y of the allied health professional, should
include not \av1ng mcdic.uions but 10 complete 1he full
p1cscriptio n. If the drug is not taken for the prescribed
tinw, drug-rcsist.111t bac1eria become victors in the banlc
against disease (two of the major strains of drug-resistam
bacteria are those !hat cause 1uberculosis and those 1ha1
cause staphylococcal infections). When dmgs are taken
correctly, vim lent bacteria are ki lled or conirollcd until
1he body's own defense S)i;tem suppresses any remaining
microorganisms. Wi1hout lhe body's defen<e system,
antibiotic therapy would rarely be successful. People do
nol brconJe 1Jn1g resisca111; the n1irrt,orgcu1i.sn1 lx'Cotries dn'S
rrsuldnr, a111/ '1Uaobes 111/I conrim1r 10 mul11pl1 m a drog-
tl!l1s111nt suue.
The key to irea ting infcc1ion is 10 ma1ch 1hc medica.
tion to the microorg.1nism. Some antimicrobials are
effecti-e agains1 a broad spectrum of organisms. others
have narrow spectra. The !>st match can !> ohLained by
performing cultu re and scnsi1ivity testing. liffectiveness
of 1he antibiotk depend~ on i1S ability to concentrate at
lhe mfeaion Sile as well as olher factors. Superinfections
can become a problem with anlibiol ic lherapy. especially
when treaLmc111 is over a prolonged period of lime.
Antibiotics are available in sewral categories such
as penicillins. cephalosporins. macrolides. te1racycline\,
306 SECTIONIV Pharmacology for Multisystern Application

ALCOHOLS Vegetative bacteoa x

etha,.. I Ethyi alrohol x
1sopropy 170'AI Rubbing alrohol

ALOEHYDES Bactena spores. Yiruses. fungi x

fotrnakt- 'IV' 10' 37'!1.) x
glurarald- lhydl> IZ l Cldex

IODINE PREPARATIONS
Betad1ne. Iodine Vegetative rn1etoorganisms and x x
povtdone-1odine
(0 5% ID'lll) SPQ<es

1od1ne solution (2%)

x
11ncture of 1od1ne 12%1 Bacteria, spores, fungi. viruses x
CHLORINE COMPOUNDS
sodium hypochlorne Clorox Bacteoa, spores. lung1. viruses x x
10% -<11sinfectan1
0.15% 05% -ant1sep11c
oxychlorosene Clorpac11n Useful with local mfecnons that x
are drug resistant

PHENOL COMPOUND
hexachlorophene Oial soap, pH1soHex R Vegetative gram-positive bactena x
OTHERS
chlorhex1dme 1% Ex1dme cleanser, Spores. bacteria. fungi, viruses x
H1b1clens
bone ilC1d Bactena. fungi x
gentian violet Yeast infections x
hydrogen peroxide (1 5%) VegetalJVe rniCIOO(!jamsrns x
benza kon1um chlonde Zeplwan Vegetative grampos1t1ve bactena x x
I0~-05%1
Sliver nitrate 10 1%-0 5%) Vegetative bacteoa and tt.lg1 x
silver sulfadlazme (1 %)' S11vadeoe Vegeta!Jve bacteria and foog1 x
An115e1>1cs rd garmo:idals n d1s.nfec1M11S may cause Sidi Side effetlS as sbl lllltatJOn. rashes. ano 9:in ~
'Requwes a IQSCllptlOft

aminoglycosides. and some miscellaneous groups. Anti-
bioucs art' found for S)'Stemic ll5e by prescription and in
many 0 l'C preparations for topical use. OTC prepara-
tions are first-aid med ications used therapeutically or
prophylaC1ic.1lly with lacerations, abrasions. insect bites,
and so on.
Sulfon.1m idcs are not antibiotics but are amibacterials
used to treat an infection while the body responds with
its own defense mechanisms.
'l\1bcrculosis has tr.1dition.1lly been treated with
rif,11111, in and INll, but as the causative organism is
beooming resistant to these drui:' '"" 1 1g' are bei!li
introduced. Medications for 1uhtm1I" '""1 be gi'~
in combination to prevent dcwlopmcn1 .lrug-res15tanl
bacteria, to effectively eradic.lle org.111 ""' 1ml W ,JChir>t
synergistic effeC1s.
Topical or systemic med1c,11ion'> lor 11111>;.11 inrectionl
require long-term use. l ung.11 111fccti<ll" .1r. difficult to
cure because fungi live on dc.1d bo<ly ,1.111 "within bodY
tissues. Long-term ant ibio tic thcr.1py or 1.11 l1.11io11 therapy
allows naturally occurring fungi on >k111 111 wo'" wi~1out
natural controls, leading ca supeii11fc1lllll"
 CHAPTER I 7 Annm1crobials, Ant1lungals, and Antivirals 307

llt'GIU'iC viruses do 1101 respond to antibiotics, tl1ese
\hould not bc administered in viral infooions unless a
1t"Cond.uy b.J<terial infcion is pr-nt. The problem
wilh dcwlo11ing antiviral medications is that often the
vims is ' 'iriilc111 wit hi n tlw body before >igns and ;ymp-
torns of the di\Ca>e arc t>vident, and m.llly viruses rapidly
mutate and 1hangc as they replicaie.
l)rug' lor malaria may be gicn prophylaetically
before tl',wcl 10 regions where malaria is endemic and
ihcrareutic.lllv for the treatment of aetive malaria.
Anti..:pu<" <11sinfeetants. and germ1cidals are main-
sta)" of th< physici.10' \ office. Anus.:ptics are used on
living tissue, dbinfectants <>n inanimate objects, and ger-
micides on both. The agent should be chosen co match
medical use. Disinfectants indude s0<hum hypochlonce.
used to decontaminate surf.ices where body Ouid\ may
be found. Sodium hypochlorite is an c~cellent virudde,
but care muse be taken to a,oid discoloration of surfaces
where it is u~
Care must be taken in treating individuals who might
h.we had allergic reactions 10 antibiotics in the pa;1.
Medications should not be prescribed when they arc not
indicated because of the danger of drug-resistant m1uo-
org.111isms developing.

i'NKING !E XERCISES I

Scen11rio
Jan es to the office complainmg of a sore throat. hoarseness, cough, and runny nose. Dr. Merry
..cJJanie and told her that she has a virus. Jame tells you as she leaves that she 1ust does not
cm at! why Dr Merry did not give her an anribiot1c. Jame's health history is nons1gmficanr except for
sympt . of the present respiratory tract mfection.
1 on do you give Janie to explain why Dr Merry did not prescribe an antibiotic?
2 1ou tell Janie about the misuse of ant1b<otics?
3 hylact1c prescnpt1on for an ant1b1ot1c indicated 1n this case?

i];iil LCULATIONS
I . Ordc1 I pl illin 125 mg IM Stal 2. Order: dind.1mycin oral >Olution 1'>0 mg q8h
,\,ail 1 1 d icatinn: Available medication:

NDC0015--7
NSN esn.ec
lQUIVALENt
Cleocin
~OnlV
SOD mg Pedlatrice
STERIL.
SO ORJI
_,,.
F IM or l'f
--fOroral '""""'-
dindamvc1n palmitatt
sotutlon USP
USt.111 cnlCI ~ 5 tN.
l'l~fou' tt!eelliht

- '***'-" CDl."'Olllll
Wltnlnl "' ,. wecoon
fgr

- __...............
CAUllON. ' 00 NOT llt'llCIAATi

''"""" $l:Cll't: tOIUtlOt't It IOO'ft

75 mg ....,.,
per s ml
\\hat mt of diluent should be added to the

--- --
c;z::rMllld ~~lD"

....-
VI.JI to~ - "'""'USll
bCO!lftlQQ wen a total d
1S tnl. ~ . . . . . . fQl!Qws. Mid '
lat9t oortiOn d the WICOJ ll'ld
What ' '" o f medication should be administered Eo.W co 11 mows ml
.... .., .... ~D.O:::ln

Sho1'
fo

L 11
r<lcr? _ _ _ __ __ _ _ __ _~

" the solut io n stable ar1er reconstitution?

syringe the amount of Cefad)'I that

--
---
- ......
..........
{ft ,.,..~(J/-

--- HCl ~t:I

contlffw IN......,..d
1Slng ~ Each tlClttiit

1.S..,.,.. tllrW:llnWdn-
810 S01 $10

~hcu he adminislercd.
What volume of medicauon should be administered
with each dose? _ _ __ __ __ __ _ __
I low can this medic,11ion be ad ministered using a
household measurement when a do><' spoon is not
available!--- - - -- -- -- - -- -
308 SECTION IV Pharmacology for Multisystem Application

Show on the cup the amoum of medication that

should be given 10 the child.

__
nas--:io ...
.....
- 2 S ...

,._,,...
lTSl'-10. .
1~5-
~

REVIEW QUESTIONS .mi

.
I. Why are Jnt1b1otics effecm-e against baeteria but 001 viruS<'S?

2 What i~ acquired antibiotic resistance? Mow does a baaerium become drug resistant/ - - -

1. What spectra .tre used to dassify penicilli ns? Name a commonly used medication in each SfW I

4. What is meant by ,o:e1wmtio11 when discussing penicillin?

5. What is the m.1in indication for the use of sulfonamides? Are these drugs baneriost.11ic or b.l< 1< r 111 Wh,11does
the patient need to be told concerning Ouid intake? - - - - - - - - - - - -

6. Wliat is the difference in use between an antiseptic and a disinfectant! - - - - - - -

7 Wh,11 are the uses of antiseptics in the medical office?

8. I low do disinfectants work? - - -- -- - -- - -- - - - - - - - - --

Antineoplastic Agents

Alter stu 1h1s chapter. you should be C8pable of domg the follow mg
of antoneoplast1c med1ca11ons. Descnbmg how to safety handle and admm1ster
1he difference be tween curative and antineoplast1cs.
~of chemotherapeutic agents Identifying and classifying vanous
t ors by tissues 1n which they chemolherapeuuc med1ca11ons.
orig n Providing patient education for compl ance with
Desc'll 1y tne role of the allied health professional medication used as ant1neoplastic agents.
1n cl 1apy

Jack , sophageal cancer and is undergoing chemotherapy. After chemotherapy treatments. Jack
and anorexia. Hts tongue is red, swollen, and sore.
Is I xpected effect of ant1neoplast1cs? Why or why not?
Wha es!lons do you have to help with his dietary intake?
Can I xpect alopecia from all r.ypes o f chemotherapy? Why or why not?
Ho I you explain to Jack what stage II carcinoma indicates?

Adenocarc1 1oma Biotherapy In situ Neoplasm

Alkylatinq agent Cancer Malignant Nystagmus
Alope<:ia Carcinogenic Metastasis Palliative
Anap la~ Cell cycle phase Mitotic alkaloids Plant alkaloids
Antimetah<>lite Chemotherapy Mitotic inhibitors Proliferation
Antineor.bstic agent Cytotoxic agent Morbidity Radioisotope
Antitumo ~nlibiotics Diffusion Morphology Stomatitis
Aseites Extravasation Mortality Teratogenic
Ataxia Hormone Mutagenic Tumor
Benign immunosuppressant

309
 3 10 SECTIONIV Phermacologyfor Multisystem Applicetion

EASY WORKING KNOWLEDGE OF ANTINEOPLASTICS ,

EGNANCY CATEGORY MAJOR INOICATIONS.ilt-,,;'
DRUG CLASS PRESCRIPTION OTC PR
Alkylaung agents Yes No c.o. x(especially in first Carcinomas. sarcomas. lymphomas.
trimester) leukemias. and polycythem1a l/Cra
No 0 Carcinomas trophoblasuc tUfTlOls. oste()Qerc
Anlimetabohtes Yes sarcomas
No c.o Carcinomas. sarcomas. lymphomas, I~
Ant1tumor ant1bootoC$ Yes
Mitotic mibiun Yes No D Carcinomas leukemias. Hodgkm disease.
(plant alk.'l lotdsl
Ew111g sarcoma
Yes No c.o.x Pros1a1e cancer, breast cane!)( endometria1
Hormone lheraPI'
cancer. adrenal cancer
lmmullOSUllPfessanlS Yes No c.o Kaposi sarcoma. leukemias
Rad101sotopes Yes No c.o Thyroid cancer. polycythcmt r~ metastaic
cancer

EASY WORKING KNOWLEDGE OF INDICATIONS AND SIDE EFFECTS

Seven Warning Signs of C1ncer for Adults Constant rnlectioos
Charige 1n bowel or bladder habits A wh1t1sh color behind the pupil
A sore tha1will not heal Nausea !hat persists or vom11tng without nau
Unusual bleeding or discharge Constanl tiredness or nottceable paleness
Thickening or a lump in the breast or elsewhere Eye or vision changes that occur suddenly an 1st
Indigestion or difficulty swallowing Recurrent and persistent levers of unknown 1
OIMous change 1n a wart or mole
Nagging cough 01hoarseness Common Side Effects of Anhneoplastic 1tions
Stomat1tis
Common Signs ol Childhood Cancer Nausea and vomiting
Con1111ucd unexplained weight loss Otarrhea
Headaches. often with early morning vomiting Alopecia
Increased swelling or persistent parn in bones. 1omts. back. or legs Local tissue IAJUIY
Lump or mass. especially rn the abdomen. necl. chest. pelvis. or Suppression of blood elements
armpits
Devel(Jjlffient of e.iu:ess1ve bru1s1ng. bleeding. or rash

neoplosm (nto-, new, plus Creek silrumll. fonna-

A cells are prone to rapid prollf<r h .,.. clrt 11\0R

tion), also known as a tumor, is a new or unusual
growth of tissue in plants or animals. Ifthe tumor
h as uncontrolled growth and spread or abnormal cells.
it is known as unccr. Neoplasms. named for site or
origin, may be brnlgn or m.dign~nt (Figure 18-1).
Named using originating tissue, benign neoplasms are
named by the sne plus the suffix oma. (Note: Some
ma lignant tumors also end with om11.) Malignant neo-
pl.1;ms arc characierited by the names ending in sarcoma
(Table 18 I) .
Drug treatment of tumors and malignandes, or che-
mother.11>y, is inrreasingly important as an adjunct 10
surgery and r.1dia1ion therapy. Chemotherapy is per-
formed using antlncoplaMk agents that do not direClly
kill cancer cells; rather. Lhey interfere with cell reproduc-
tion and growth, causing death to cells. Because cancer
vulnerable to chemotherapy th.10 h<'.th I 1 nr.i ocerous
cells. Ne,.enheless. many he.thhy ull II the COUl'lf
of chemotherapy, and the indMdu.il .i:omg such
therapy can expect signific.101 sidt fl lrom lhest
toxic drugs. With morhldit) and n lrom cancer
continuing to pose a ma1or health JW>hl , 11 the United
States, research for more effective m.t1rh 1 ",m ongoing
quest and new drug.~ are 1rttrodu1nl tn 1 l!l'ld often.
WHAT IS CANCER?
C'..ancer is not a single disea~c. Wnh 11111 ntrolkd di,1
sion of abnormal cells and wit h 1-.111cN, db rq>roducuig
faster than normal cell s, more than 100 d1ffrrer1t types
of ca ncer have been ide111 ilied C.mCl't, .1 111." s of cells
 --- CHAPTER 18 Antineoplast1c Agents 311

with no useful funcuon, c.m cause dysfunction and stn1c.
iural aherations in surround ing 1issues. A$ 1he 1umor
incn>aw> in si7r, normal cells lack 1he necessary nutri
uon or blood supply and thus decrease in number. This
.iher,111on cJu,es loss of normal body func1ion>. espe.
cially in 1he l.uc s1Jges of the disease.
n1e Original \lie of a IUnlOr is called the primary Slit.
AS ihe mmor undergoes met.astasis to new loca1ions 1n
ihe body. l'Jch nl>w site is referred 10 as a secondary sire.
Hrsl. <Cll; may meta~1asi1,e directly to neighboring
iissue. c.1u"ng ulcera1ion or hemorrhagic masses wi1h
IOGll 111t1hra11on .ind dis1ortion of the struaures.
Bonlgn
Slon
...iace
1 ...:._/~Encap<Ua1ed
"'\ growlh
A to deoscribe 1hc abnormal cells and the l.!l<tem of the
Mahgnan1
Second, detached cells may mow along lymphJ1tc
wsseis or to regional lymph nodes as an embolism
11rns lympha1ic tissue is tlie usual >ite for invasion and
spread of abnormal cells. Cells may also form an
embolus that moves 1hrough blood vessels to org;rns
throughout the body. l mally, cell> may illvdde a body
cavity by diJTu,loo.
Metastatic 1umors mimic the primary tumor. permit
ling d isease diagnosis by cell morphology. C mcers tend
to metastasize to specific secondary sites a1 ;ome dis-
tance from the primary site by trawling through the
cirrnla1ory or lymphatic sys1ems. I he secondary tumors
tend to resemble cells .n the primary si1e .ind are so
named, such lr111p/1onkis for tumors originally found
in the lymphauc system (Stt Table IS. l)
Classifying Tumors
Tumors are classified by stage (invasion) and grade
(dq\rce of metastasis). These are used for overall trc.n
mem plan for a neoplasm The grade and s1age are used
spread of the disease. 1he tumor gr,1de is a system used
to classify cancer cells in 1erms of how abnormal they

~;
Blood
\'e$SI'
Hern<
B wi1h some structural change from normal 11ssue. Grade
neoplasms remain localued. are "'100111 and
local oss..e. and do no1 break the s<n B. Ma'ig-
stsize to now and distant !Issues 1hrough Ille lymph
causing hcrnorrllago They also have an irregular
:ue and olton uterate dwcugh lhe st"'
loo!.. under a microscope. giving some idea of how fast
the tumor will grow and how fast it will spread. Grade
0 is normal tissue. Grade 1 tumor is tl1e most differenti
ated. looking more like the parent tissue. and i the leas1
malignanL Grade 2 i' moderaiely well dilTeremiated
3 is poorly differentiated and has extensive change from
normal tissue. Grade 4 has no r~mblance to the tissue
of origin and h .anapla~llc.
The stages of tumors show the extent oft he spread of
1he cancer. Stage O is cancer lo situ or without invasion

'
Conne n.e. and muscle Site + -oma (11poma. a benign =
Saiwna (hposarcoma malignanJ
~SS neoplasm of adipose ussue) neoplasm of adipose tissuel
Epcthe Adenoma. a ben91 neoplasm Carcmoma{adenocrdnoma =
of glands malignant neoplaSm of glands)
Nevus. a 11eoplasm of Melanoma (malignant neoplasm of
ptgmented cells pigmented cells)
Blood ~5'.u. 1nclud1ng Lymphangioma. a benign L~ (lymphangtOSarcoma -
t1ssue. plasma cells. neoplasm of lymph vessels malignant neoplasm of lymph
arrow vessels. leukemias)
Ne<ve t gang 100 cells Ganghoreullllllil. a benign Blastoma (neuroblastoma =
neoplasm of ntll\le ganghon mafignant neoplasm of ganghon
cells cells)
NO'.e Head ngs ~gn and "Ma, gnanr are not an onciusve but are e.amp1es of naming of tumofl Ennt.,. 111 1ta/Jcs are malrgJ13f1t neoplasms
 312 SECTION IV Pharmacology for Multisystem Application

aJkylaUng agenl5, amibiotics, and horn1ones. are acu,,

of surrounding tissue. St.age I is a tumor limited 10 its
si te of origin Stage 2 is cancer with only local spread. in S<:'.'<eral stages of the cell cycle and ar not SIJi'-
Stage 3 has c..ten;ive local to regional spread. St.age 4 has a single phase. In comb.tnauon . tIicrapy thc goal ~
ii re
widespread meta>tasis throughout the body. destroy cancer cells at \'arious s1,1gc~ of the cell repi:
tion process.

. ANTINEOPLASTIC AGENTS

Ant111eoplas1ic agents. also called climwdrerapeunc agtnlS.

kill iumor cells d1rtttly while imerrupting cell replica-
tion of normal and abnormal cells 10 shrink 1umors and
10 pro\'lde pall1a11on and/or cure (Figure 18-2). When
amineoplastic agents are chosen and administered for F<st o ""' o1
ircaimem of a malignant tumor, its type. size, site grade ~he~
and stage arc considered Chemotherapy may be me
prim,11} trea1men1 or may be used in combination with

(~
surgical removal and radiation. If 1he tumor is extensive Mallgnanl tumo<
chemotherapy may first be used to reduce its size, fol-
lowed by the surgical procedure and then further use of
chemo1herapcu11cs. In other cases the tumor may be Second cours7 of
i:Mmotherapy
f ~uc:ed tumor Ille
ncer ~Is remain
cxci'led, then chemotherapy and radiation may be used.
'rl1e second course of chemotherapy is aimed at destroy-

r1i":'\ .
.
ing cancer cells not destroyed by 1he immune system.
Cancers with fast growth factors and shon cell replica o--Rom 1gcencercda
1ions Me the 1110>1 vulnerable 10 chemotherapeutic
~"'
cells tho ~
agents. tach .mti11eopl.1s1 ic agent has a specific point
of effectiw JC'lion in cell replica1io11 (Figure 183). Anti Destruction of by
mc1.1holltc~ interfere with DNA symhesis, whereas plant body's immune system ~
alka loids, or mitotic inhibi10111, interfere with cell repro-
dunion in 1he me1n1>hase. Some drugs, such as Lhe Figure 182 A cance1 cell's rcsponstJ 1

A nllmetabolltff
MethOtrexalt
5-AUOtOU"1Cll
6-Mercap10p<Jnno
0y1os.,. arabinoslde

tntorphue
Mnosla

Anepllase Plant Alkaloids

Vlncrlsllne
Vinblasllne

Figure 183 Phases of the cell rephcallon Cytfc, showing where chemotherapeuoc medicationsexert their offm 1
 CHAPTER 18 Antineoplasuc Agents 313

BOX 181 DISORDERS ANO SYMPTOMS OF ORGAN TOXICITY FROM ANTINEOPLASTICS

Cardiotox1c Effects Neurotoxic Effects

Congestive heart failure Change 1n cognitive abihues
Changes 1n ST waves Nystagmus
Angina v.ti re rece1vtng medication Ata.ua
smnness ol breath Dllliness. dofficulry chang ng pos1tlOflS lcerebctlar dyslunct1011)
ventricular 6b11llat1on, death T1ngl1ng of face. fingers. toes

Nephrotoxoc Effects Hep1totoxic Effects

Wetght ga Jaundice
Change Vttal signs Nausea and vom1t1ng
Fluid overload A.sc1tes
SWelhng Clay-colored stools
Decreased ne a.tpOt Dark unne
Changes ne co ()( Of COlnponents Bleeding dlSOlders. pruntus

An tine '"c agtnis are most frequently given in
con1bin.11 1 for pdllfatlve effect. Cytotoxic agents are
u,cd f, tam tre.umcnt in 1he hope of eiilwr curing
the di" acing ll in remissio n Because the meta
bol ic r m.11ignan1 tumor cell 1s more rapid than
1h.11 ol 1.11 cell, malignant cells are more sensitive
U> prodo hJt interfere with cell growth.
Side ts of A ntin eoplast ics
l'hc mo 1111u.$ cell d~struction from a ntineoplastics
occurs bone marrow, epithelium of the gamoin-
tl">tin.1 .. "t. nervous system, hair follicles, and
repru<l. dis f,1ch chemotherapeutic agent differs
in thr I ohond to cau~e these adverse effects. Bone
marro 11e>sion may lead to infection. bleeding.
Jnd an 'ic digestiw tract epithelium is especially
\en~ll "10toxic dn1gs. leading to stomUtis and
dimh 11\e loss of epithelial cell~ prevents fluids
from bt . h'orbed in the intestines. Alopeda results
from i , the hair follicles and typically begins 7 to
to dJ' the $1.ln of treatments that cause these
elfcas hormo nal treatments may cause symptoms
simil,u ll O\'nOpallSP, Creating hOI ftashcs. Jn the reprO
ducuv, n. certain teratogenic agents cauw effects
on th > fetus and on the genninal epithelium of
the test >men undergoing chemotherapy should be
advised '' h> become pr~an t because of the danger
of fetal 11lformations. Male patients should be told
thJt an , drug.s might cause irre>'l'rsible Mcrility.
Nel\'O~ , m effects cJn include numbness and tin-
glong in t , xtremitics, he.1daches, di.z.ziness, confusion,
or, in r.11t t l)t'S, sci1urcs. Nausea and von1iting from
chemoth 1py are usually more severe than nausea and
v miung I m most medications. Prcmedication with a
combin.11111n of antiemctics. such as proclrlorperazine,
trlmetlrobenumide, dexaml'lhasane, nU!todopramide,
foraupam, .md serotonin agon ist dn1g.' may reduce
symptoms. Weight loss and resu ltant malnutrition may
occur becau1< of the many Cl symptoms including
anorexia.
Cenain chemotherapeuuc agents have doselirn11ing
adverse re"r1ions Lhat occur when the 111 ,,.xjmu 111 pennis
sible dose has been given to the individual patient
(Box 18-1).
PATIENT ALERT
If ha11 loss 1s Wtpected and the patient desires to wear a
h<lirpiece. this should be selected before treatment 1s begun
so that ha11 colOI and srvle will look as normal as possible.
Hair begins to regrow in 1 to 2 months altei therapy When
haor grows. 11 may not have the same texture or th1d<ness as
before chemotherapy
Patients undergoing chemotherapy should avoid highly sea
soned foods and foods wth strong odors Eating small. fre-
quent meals of C01nplex carbohydrates and cboong liquids
30 to 60 minutes before meals will help manage nausea
Eating tan foods either cold or at room temperature enhances
food intake.
lvrf of the followong should be reported to the physicoan-
rashes. loss of taste; 11ngl1ng on face. fingers. and toes. d1z
ziness. headache. confuston, slurred speech, convulsions:
and unusual bleeding, bru1s1ng, fever. sore throat. mouth
sores
Because of 1111fOOfle system COflllWOOlse. paoents sha.ld
avoid contact wtth communicable diseases and shoold have
limited contact with persons wllo may have a subcilmcal
illness. such as children wll<J have fever or signs of possible
dtsease
312 SECTION IV Pharmacology for Mulusystem Application

alkyl.Hing .tl(l'nl, an1ibio1ics, and hormones, art~

of surrounding tissue. Stage 1 is a tumor hmi1ed 10 iis
si1e of origin. Stage 2 is cancer with onl)' local spread.
Stage 3 hM mensiw local to regional spread Stage 4 has
wid~pr~ meiaswis throughou1 the body.
in several siage> of the c~ll ~de and are 1101 ~
a single phasl!. In comb1~auon therapy the goai 1
destroy cancer cells at vanous s1ages of the ctll !'Pt:;
tion process

ANTINEOPLASTIC AGENTS
Antineoplastic agenis. a lso called cl1emotberape11tic agenrs.
kill 1umor cells direetly while interrup1ing cell repl ica-
1ion of normal and abno rmJI cells IO shrink 1umors a nd
to provide pallia1ion and/or cure (l'igu re 18-2). When First course ot
aniineoplaslic agenl'> are chosen wd admin iMered for
~herapy
1rea1mem of a malignanl tumor. ii) 1ype, Si/-". site, grad e.
and siage are considered. Chemo1herapy may be the
pnmaiy ireaunem or m.1y be used in combina1ion with
surgical removal and radiation If the tumor i l'Xlensive,
Mahgna.n1 tumor
~
chemo1herapy may 6m be used to reduce its size. fol-
lowed by the surgical procedure and then further use of ~
Second cou'; / ~
chemotherapeutia In other cases 1he 1umor may be
excised. then cbernolherapy and rad1a11on may be used.
~ra{ ~.:::
11ie second course of chemotherapy is aimed a1 desuoy-
ing cancer cells not destroyed by the immune sys1em.
~
Ca ncers with fas1 growth faC'lors and )hon cell replica-
1ions are lhe mos1 vulnerable 10 chemotherapeutic
cr-.
(B'\
0-- Remaining canCO<ot11

~
0
agenis. Each a111ineoplas1ic agen1 has a s1>ccific point
of effective action in cell replica1ion (Hi;ure 18-3). Anti- 0es1mcllon of cells by lhe
mclabolitcs imerfere with DNA symhcsis, whereas plant body's immune aya1om \2._,J
alkaloids. or mi101ic inhibi1ors. i111erferc wi1h cell repro-
duc1ion in the me1aphase. Some drugs. such as the Figure 18-2 A cancer cell"s response to cllemo!hera171

AntlmelJlbolltes
Methotrexate
S-FluorouraCll
6--Mercaptopurine
Cy1os1ne arabmostde

G,
' ---RNA synlhes1S

Alkylallng A gents
Nitrogen mustard
lnterphase
Melphalan
Cyclophosphamido Mllools
Chlor&mbucll
'---~ c~--'
Propnase

Plan! Alkalolds
V1nct1st1ne
Vinb4as11ne

Figure 18-3 Ptlases of Ille cell rephca11on cycle showing whe1e ciiemotl"r'peui 1c m
f\i Q
If
t:v1ca11ons exen li11;;1r e ects
 ~~~~~~~~~~~~~~~~~~~~-=:..::..
BOX ti t DISORDERS ANO SYMPTOMS OF ORGAN TOXICITY FROM ANTINEOPLASTICS
Card1otoxic Eltects
Cangestive heart failure
Olangcs in ST waves
Ang111a Mille 1eceiv1ng medication
Shottness ol bteath
Venmcular ~bnllat1on, death
Nephtotoxic Effects
Weight gain
Change in vital signs
Fluid ove1load
Swelluig
Oeaeased urine output
Changes 1n u11ne color or components
Antinl'Qplastic agents are most frequently given in
combinJtions for palllathe effoo. Cytotoxic agents are
u<;ed for long-term ueaunent in the hope of either curing
1he di<e.1se or pla,ing it in remission. Because the meta-
bolic rate of a malignant tumor cell is more rapid th an
that of a normal cell, malignant cells are more sensitive
to produns that Interfere with cell growtl1 .
Side Effect s of Antine oplast ics
The most serious cell desuuaion from antinl'Qplast ics
occurs in the bone marrow, epithelium of the gastroin
te>tinal (Cl) traCI, nervous system, hair follicles. and
reprodunh'I.' cells Each diemotherapeutic agent differs
in the likelihood to cause these adverse effects. Bone
marrow suppression may lead to infection, bleeding.
and anemia. Ille digestive 1rac1 epithelium is especially
sensitive 10 cy101ox.ic drugs, leading 10 stomatllls and
diarrhea because loss of epithelial cells prevents Ouid~
from being absorbed in tlie intestines. Alopcda results
from injury to the hair follicles and typically begins 7 to
10 days after the s1a n o f LreaLments that cause tlws~
effects. Some hormonal treatments may cause symptoms
,imibr 10 menopause. creating hot Oashes. In the repro-
duaive system, certain teratogenic agents c.1usc effens
on the growi ng fetus and on the germinal epithel ium of
the testes. Women undergoing chemotherapy shou ld be
advised not 10 become pregnant because of tile danger
of fetal mJlformations. Male patients should be told
that anticancer dntgs might cause irre"ersible sterilily.
Ner\'ous system effeets can include numbness and tin-
gling in the mrcmilics. headaches. di2Ziness. confusion,
or, in rare cases, sci1.ures. Nausea and vomiting from
chemo1hera11)' arc usually more severe than nausea and
vomiting from most medicaLions. Premedication with a
cornbin.1tion of antlcmeLics, such as proc.hlorpera;r;ir1e,
CHAl'TfR 18 Antineoplastic Agents 313
Neurotox.ic Effects
Change in cogn tr.e abil1nes
~tagmus
Ataxia
01wness. d1ffi<:u Jy changing pos1bons lceretiella1 dysfunct1onl
Tingling of face. fingers, toes
Hepatotoxic Effects
Jaundice
Nausea and vomiting
Asc1tes
Clay-colored stools
Oa1k u11ne
Bleeding disorders. prunrus
trlmethobenzamitk, dexamethasone, metocfopramide,
foraupam, and serotonin agonist dn1gs may reduce
symptoms. Weight loss and resultant malnutrition may
occur because of the many Cl symptoms including
anorexia.
Certain chemotherapeutic agents have dose-limili11g
adverse reactjons that occur \vhcn 1he 1naxl1num pcr111 is...
siblc <lose has been given to the individual patient
(llox 18- 1).
PATIENT ALERT
If hair loss 1s expected and the patient desires to wear a
haupoece. this should be selected before treatment 1s begm
so that ha11 color and style W111 loolt as normal as possible
Hair begms to regrow on I to 2 months after therapy Wilen
hair grows, 11 may not have the same textu1e or thickness as
before chemotherapy.
Patients undergoing chemollletapy should avoid highly sea-
soned foods and foods with suong odors. Eating small. fre-
quent meals of complex carbohydrates and dnnk1ng liquids
30 to 60 minutes before meals will help manage nausea.
Eating tart foods either cold or at room temperature enhances
food intake.
Arry of the following should be reported to the physician:
tashes; loss of taste: tingling in face, fingers. and toes. diz-
ziness, headache. confusion, slurred speech, convulsions;
and unusual bleeding. bruising. fever. SOit throat mouth
sores.
Because of immune system COJ'11)1ormse. patients should
avoid contact wnh amnumcable diseases and should have
hm11ed contact with persons who may have a subchmcal
Illness. such as cl11ldren who have fever or signs of possible
disease.
 3 14 SECTION IV Pharmacology for Mulusystem Application
Ar l neoplastic agents are used most often for mallgnam
7'l'Mhs a llleugh they may be used for olller chronic dis-
. a SUCh as rheumatoid 1rtrir111s
~ treatmc1lt may enta I surgery. radial on therapy
chcmo!hcraPV sing v 111 ui any combonallO(I SUigery
"'"' radiat>on lheraPV 11e the 11ea1ments of dlOICI! for solid
rumors .-ticreas arnineoplastic: agents are the 11eatment of
ce for cancers lhat am louro on seYe<al Sites ttvoughoot
ll body
~.' t anlineoplastic: drugs won: best on lumo<l formed by
c rapidly mulliplytng ralhel than on slow-growing IUmOIS.
AJ ! ancer drog3 il<1l more e ffactive Y.iietl used as combina-
1100 lhctaPV rather than single-drug therapy because the
cancer eels are less I kely to mutate and become drug
rll31Stanl
To.,ceffectson noonal cells rea maior obstacle to success-
ful chemotrierapy
Alltincoplast1cs must have one of three possible benefits to
be uwd cure, pall1a11on. or piolonga11on of life
Because anxiety is an expected response. cancer patients
should be made aware of the need for emotional support for
themselves and tlieir families
2 Good nuu1t1on is essent1al during chemotherapy. The patient
should follow instructions to meet specific nutnt1onal needs
3 lesions in the mouth and bleeding gums are common with
ch<.'fllOtherapy Good oral h'191ene 1s essential
4 Cool, sweetened bev1l1ages ase best tolerated
5 F8\1!r, sore throat. infections. and suppression of blood
counts a1e common side effects of chemotherapy
FACTORS TO CONSIDER
WITH CHEMOTHERAPY
Not all patients or types o( cancer are candidates for
chemotherapy. Ille decision 10 begin medical Lreatmem
is made on an individual basb after informing the
patient of possibll? risks and benefits of therapy and after
informed consent has been obtined. PatienL~ should
not be put al great risk for little to gain. What is unac-
ceptable to one patient might be eagerly pursued by
another, depending on a variety of life factors.
CLASSES OF ANTINEOPLASTIC
AGENTS
Alkylating or Alkylating-Like Agenta
Some of the earlies agents used 10 treat neoplasm.
alkylating agents that poison cancer cells. ~
are based on chemical warfare f~m World War 1~
use of riitrogen nuisrard was introduced Alki
agents were observed 10 inhibit cell growth, Mi""
investigated 10 inhibit the gro"1h of malign.iru al
Because cell reproduction has irreversible bind~
DNA. eventually the cell dies from inab1h1y 10 ~
cell metabolism . This group of chemotheraptUtlQ.,
indudes nitrosoureas and platinum compounJ. ail
aJl.-yla1ing agents {see Figure 18-3)
Alkylating medications arc highly toxic com~
used 10 treat metastatic oV<irian, testicular, and bllddi,
cancer and for pallimivc 1re.umen1 of undesirable 1)1119'
toms of other cancers. such as br.1in tumors (ldblt IS.l,
Antimetabolites
Antimetaboliles arc effective ag,1ins1 cells by im~rfen'
during the symhesis ph,tsc of mcrnbolism, blockingtht
chemical reactions necessary for normal cell growth a
reproduction. Cena in an ti mcrnbolitcs such as mtn4pu
purine (Purinethol) arc also used in immunosupprn11t
therapy (such as for organ transplant.11ion), d! antiviul
med icatic)nS, and in 1rca1men1 of gout (see fabln 18-l
and 18-3).
Mitotic Inhibitors (Plant Alkaloid1)
Ille primary mi lo lie fnhlhilClr\ are deril'cd from pn
winkle and May .1pple plants I hus these mcdica1ic:111111
a group are kno1'11 as planl .dk~lold11 or mhotk ~
loids. l'hey prevent the chro mosomes fnom dl1'1d1ngml
migrating 10 the end of the cells, stopping funha ~
replication or mi1osi,, If l'Alr.iu\Olllon occun 1>ilh thar
medications, tissue iniury i~ expoocd . Alopi.1 1s not a
common as with other cytotoxic drug.o. (ss lablt?S IS:
and 18-3).
Vinca, the penwmkle plant, is an evergreen grO<Jnd Wo1ll
takes more than 6 tons of tile leaves to produce 10tin of
compound.
Hormones and Hormone Antagoni1ts
Horm~n"s and hormo1w antagonist>. the leaM tou;
of anurancer medica1io11s, act on sperifir hornt<lot
fltrt l Q'IUllJl(IJ onr I '
 AUCYlATING AND ALKYLATING-UKE DRUGS
Nausea vom111ng. borle
marrow suppression.
diarrhea. dermat1t1s,
hepatic 01 1enal tox1c1ty.
alopecia, myalgia. fever,
malaise
nitrogen musta1d or 0 4 mg/kg IV Lymphosarcoma. Hodgkin No 1mmun1za11ons.
mechlorethamine disease alcohol
(Mustargool
cyclopllosphamtde 50-100 mg/m'/day PO. Broad spectrum of Ant1gotJt med1ca1tons
ICyto><an) 400-1800 mg/m2 neoplasms
40-50 mg/kg IV
dllorambucll 0 1-0 2 mg/kg/day PO Leukemias. malignancies Antigout medoc:at100S
(l.etJteranJ of lhe lymphatJC and lr.e virus
system vaccines
melphalan (Alkeranl 6 mg daily PO Mulnple myeloma. AntQOtJI medoca11ons
carc10001a of breas1
and ovary. lymphocyuc
leukemia, lymphomas.
mycotic fungus.
polycythemia vera

Platinum Compounds and Alkylating Agents

Asp1nn, NSAIOs.
alcohol,
am1noglycos1des.
loop d1uret1cs
weal platon (Eloxatnl 85 mg!m' BSA IV CA of colon
osplal1n IPlatonoll IV. vanes wllh Metasta!JC tesocular and Antogoul medicatJonS
neoplasm type ovanan cancers.
bladder cancer

NITROSOUREAS
carmustine (81CNU) 75-100 mg/rrr BSA IV Severe nausea and CA of CNS An11coagulants, other
Gliadel wafer 62.6 mg/wafer for vomiting with liver and antinooplasttcs.
brain implant kidney toxicity, bone cime1>dine. d1goxin.
marrow suppression phenytoln
lomust1ne iCCNU) 100-130 mg/m' BSA Hepatotoxicny, 1enal Hodgkin disease and Same as for
PO failure. pulmonary CNS CA carmusttne
fibrosis. anemia
sueptozoctn (Zanosarl 500 mglm' BSA IV Severe nausea and Pancreatic CA Same as for
vom1t1ng, chanocs 1n carmust1ne
glucose le.els. diarrhea.
chllls and lever
BSA. body s..tace area. CA. cancer CNS. central nervous system. GI. gastrl)nQSlinal IM. lllO'""""'larty: IV. ontravencllJSlr; NSAIDs. nons18<0Mlal ant
nftanmatDIY drugs. PCN pen1t1lhn PO. orally, SC. suticutaneOUSly
Medcal>OllS used 11S antoneOlllasbes have highly mdividuabzed doses based on the BSA of the pabent and tile neoplasm being treated The do$e$ on tho.s
table >re provided as l'fll'taI doses only
Because of tho many d1ug intc1act1ons. when adm1nistl!fing all chemotheiapeutot agents. the accompanying literature should always be read and compared
v..ih med1catoons boong ta~en by the pe1soo receivmg oeaunent
Atable wnh more agents wn be found on Evolve. Conrlnrt<tl
 316 SfCTION IV Pharmacology for Mulusystem Application

TABL! 18 7 SELECT ANTINEOPLASTIC AGENTS- cont'd

USUAL ADULT INDICATIONS DRUG J

GENERIC NAME/
TRADE NAME
DOSE, ROUTE.
AND FREQUENCY MAJOR SIDE EFFECTS FOR USE INTERACTIONS I
ANTIMETABOUTES
Severe bone marrow
suppression. mouth and
stomach ulceJS. allllfex1a.
d1armea. nausea.
wmruog. chills and
fever. alopecia
metholre.ate ttoric J J trWJ/~ PO daily Acute lymphocyt1c AlcOOol. NSAIOs,
8Cld analogueL IM.fV leukemia, breast Plobeneclll
amethopte<m cancer. lymphoma, sat cytates. ~
IM.)...1e. ps-011as1s. uterine VltUS l'ilCCIAe,
Rheumatre. MTX, ch-0roocarc1n-0mas. d1goxm. PCN
Trexalll lymph-Osan:omas
mcrcaptopunne 2 5 mg/kg PO qd Acute lymphocy11c Ant1gout medica!O'll
(purine analaguol leukemias; Hodgkin
lf>imne1hol. 6 MP) disease; rumors ol lhe
lymphatic system;
carcinomas or rile
reproductive 1rac1.
liver, pancreas, GI
tracl. and breast
actinic kera1osis
ftuo1ourac1I vanes w11Jl Acute myelocytic Other antmeoplasta
(pyrnnidme admmis1ra11on IV, leukemias
analogue! IAdrucrl, 1op1cal Basal cell carcinomas.
Erudex) actinic kera1oses

MITOTIC INHIBITORS (PLANT ALKALOIDS)

Stomatitis
v1ncris1 ne IOncovrnl 0 S.1 5 mg/m IV Peripheral neurotoxic Acute leukemia Ant1gout medQ
effects live virus \'3Ctll'el.
doxOl\IOOn
Y1nblas11ne {Vetban, 311 mg/m BSA IV Bone marrow suppression, Hodgkin disease,
Velsar) Anllgoul mOOQl~
nausea and wmi11og lymph-Osan:omas. ll\'8vrusvactltll
ch-Onocan:onoma
paclitaxet (Taxoll 135-250 mg/rrr BSA IV Tachycardia, peripheral Ovarian cancer. breast Sarne .is foe
neuropathy, blood cancer, Kaposi vonblastn
dysaasias, tissue sarcoma
necrosis
HORMONE THERAPY
fsuogens
Feminization in males,
blood clots
estramus11ne (EmtY11 14 mg/kg PO qd
Prostate cancer Dairy products
d1athylst1lbestrol 500 mg IV qd 1m11ally,
!DESI iSt1lphos1rolJ increase to I g qd Prostate cancer and
for next 5 days breast cancer
At>dtOgen
Mascuhmzat1on of female$ Breast callCel m 0.al ontlCOilgutants
premenopausal women
auoxvmesterone 10-40 mg PO daily in Metasta!lC bteast cancer Hypoglycermcs.
(HalotestinJ d1v1ded doses cephalospctms.
anticoagulants

Antiestrogens
Hot flashes and weight
gam m females
13mox1fen [Nolvadexl 20-40 mg PO bid Treatment and prevention Estrogens
of breast cancer
anasrrozole 1 mgPOqd Breast cancel Nocie
(Ar1midex)
exemestane 25 mg PO qd Breast and prostate
(Aromasin) cancer
ArrtJandrogens
Impotence mmales
goserefm (Zoladex) 1 implant q28d Metastatic prostate Nocie
cancer

Progestins
megesuol (MegaceJ 40mg PO q1d Endometrial and breast None
cancer
leuprohde 1 mg SC, 25mg IM GI bleeding. myocardial Prostate cancer, None
gonadouop111- 75mg1Mmo; infarction. edema. hot endometriosis
releas ng hormone 22.5 mg IM q3mo; flashes. impotence
(l.upron) 30 mgq4mo

AHTITUMOR ANTIBIOTICS
Nausea. vom111ng. anorexia.
alopecia. detmat111s.
hepatOtOXICll'(,
card1otox1C1l'f,
nephrotoxicitv. blood
dyscras1as
dactinomycin 500 mcg lV x 5 days Testicular cancer. Wilms Antigout medications.
(Actinomycin 0, tumor, lymphoma live virus vaccines
Cosmegen)
doxorub1cm 6().75 mg/m' BSA IV Solid tumors. CA of Antigout med1cattons,
(ttad111ooall lungs, stomach. breast live virus vaccines
(Adnamycm) sarcomas and bfam
doxmlbic1n 20-50. rr'J/rrf BSA tumors
(l1posomal) (Oox1I) Ovarian cancer. Kaposi
sarooma
m1tomye1n 20 rr'Jfnr BSA N Adenocarcmomas. None
(Mutamyc1nl squamous cell
carcinomas. malignant
melanomas
dauoorub1cin 30-60 mg/m2 BSA IV Leukemias Antigout medications.
(CerubidmeJ live virus vaccines
Contlnuctl
 318 SECTION IV Pharmecology for Multisystem Application

I
TABL! 18 7 SELECT ANTINEOPLASTIC AGENTS-<:ont'd

USUAL ADULT
GENERIC NAME/ INDICATIONS DRUG
DOSE. ROUTE.
TRADE NAME AND FREQUENCY MAJOR SIDE EFFECTS FOR USE INnRACTIONS

IMMUNOSUPPRESSANTS AND BIOLOGIC RESPONSE MODIAERS

Hemacuria. gum
hyperplasia. tremOIS.
headaches. nausea.
vomiting. hematologic
dangers
mterferon alf2a Vanous. IM. fV. SC Chronic hepauus C.
IRofeton) malignant melanomas.
Kaposi sarcoma.
leukemias
1nterltlfon alfa2b 2.IXXl.000 IU/m' BSA, leukemia, Kaposi
(lnrronl IM, IV sarcoma

RETINOIC ACID DERIVATIVE

tre11noin (Vesano1d) 45 mg/m' PO daily in Kaposi sarcoma
2 d1v1ded doses
TARGET DRUGS
cetux1mab (Erb11ux) 250 400 mg/m' BSA IV See literature Colorectal cancer. head See drug l11era11te
and neck cancer
1ma11nib IGlee~cl 400 600 mg PO qd CNS symptoms, Heart Myeloid leukemias. See drug l11era1ure
failure. hepatotoxicity. gas1rointes1inal
vomiting. dyspepsia stromal tumo1s
n1lo1in1b (Tas1gna) 400 mg PO bid See drug literature Myeloid leukemias See d1ug literature
dasaunib (Spryccl) 70 100 mg PO qd See drug literature Myleo1d leukemias See drug l11era1.re
ntux1mab (Rnuxanl 375 mglm' BSA IV See drug literature Non-Hodgkin lymphoma See drug I tl!fa:in
(also used for
rheumatoid arthr111sl
MISCEUANEOUS ANTINEOPLASTICS
asparagonase (Elspar) 200 units/kg IM IV Hepatotoxocity. pancreati!Js. Acute lymphocyuc Steroids vmostrf.
thrombocytopenia. leukemias anlJQOllt
anemia medarocm,
methot1wte.
erto11nib ITarceval virus Yac:tft$
150 mg PO qd GI symptoms. rash. eye lung cancer None
pain. fatigue. mouth
ulcers
trastuzumab 2-4 mg/kg fV Paro. lever, chills.
(Hercept1n) Breast. lung, ovarian. CycJ~
headaches. bad pain. pancreatic cancers epuubicii
infection, GI symptoms.
cough, dyspnea

m:ep10B or target lesions. making their action on malig-
nant cells highly selective.
Adrenocorticosteroids- ho rmones {or stero ids} natu-
rally found in the adrenal cortex-produce remission in
certain malignancies by retardi ng pro liferation of lym-
phocytes. such as in trea1ing acute lymphocytic leuke-
mia Often these hormones are used in conjunction
"1th radiation therapy to decrease radiation edema {Stt
Chapter 20 for hormones.)
Sex hormones are used for palliation and for some
cures in carcino mas of the reproductive tract. 1:.trogens
may be administered to relieve symptoms of prostate
cancer and to treat breast cancer in postmenopausal
women. Androgens, male hormones, are used in pre-
menop.lusal women with breast cancers.
Aruiestrogens. such as tamoxif en (Nolvadex). and
antiandrogens are used to inhibit hormone produaion
in advanced stages of hormonally respo nsive cancer.
J:imoxifen, used for breast cancer, may increase the risk
of endometrial cancer, but the benefits greatly outweigh
the known risks (see Table 18-2 and Figure 18-3).
Antitumor Antibiotics
l\ntltumor antibiotics, used only to treat cancer. bi nd
to ONA. inhibiting DNA and RNA synthesis. n,ese medi-
cations l're not used to treat infec1ions. Antitu1nor anti
b1otics are poorly absorbed through the C l traa and
therefore are gi\'en parenterally, usually imra,enously
(Stt Table 18-2).
lmmunosuppressants
lmmunosuppressants may be produced naturally by
whi1r blood cells or synthetkally using recombinant
D1'A techniques. lntnferon exens a variety o( effects on
tumor cells. with an antiproliferative aaion that stops
rapid cell produaion and increases the efficacy o( anti-
ncoplastic drugs. Some immunosuppressants can even
render cancer cells no n malignant. The exaet actio n of
1hese drugs is unknown, but cancer research is explo ring
the po1cntial for immunot herapy to bring abo u1 cures
(Stt Table 18-2).
Radioisotopes
R.ldio.1C1 ive isoto pes. o r radtoi.otopes, are used to treat
many types of cancer. The isotopes may be inscned
locally as pellets, administered as radiation therapy. or
ad ministered systemically as capsules or solutions The
pauent and family must be made aware that these treat-
menis cause e.'<JlOsure to io nizing radiation so that nec:es-
s.1ry precautions can be taken (see Table 18-2).
CHAPTER 18 Anuneoplasnc Agents 319
CLINICAL ALERT
Care must be taken by all persons working with radioisotopes
to keep exposure to radiation to a minimum Exc1etions from
patients being trtrated with radioactive isotopes are considered
rad1oact1ve
NEWER DRUGS AND DRUG
DELIVERY SYSTEMS
Many new drugs are being studied to treat acquired
immunodeficiency syndrome (J\l DS)- assodated cancers
and to improve the treatment and survival of cancer
patients. New medications that have been approved
address different cell-type malignancies occurring in spe-
cific body organs, The use of liposomes as a delivery
system for lipid-soluble drugs. such as liposomal doxo
rub/cln and llerteptin, is food aud Drug Administratio n
(FOA)- approved. By auadling to liposomes, drugs
become sman bombs targeting tumor cells but not
normal cells. Drugs to treat or slow the progression of
breast cancer are another area of intense research inter-
est. The cancer gene ffER-2/neu produces a pro1ein that
alters genes.
A n ew group of drugs. signal tra nsduction inhibito rs,
target specific molecules that drive tumor growth, in the
hope that the targeted eelI is affected while leavi ng
normal cells untouched. Many of these drugs are very
expensive for treaunent. Unfonunately, the responses to
these drugs have been less than impressi\-e. with mo re
severe adverse effeCls than simply their high cost.
Many anticancer drugs are effectMI only mspecific cell cvcle
pliases These medications must be mplace when cells enter
the phase m wludi the med1ca11on works Honnones and
hormone antagonists are not sJlO(tflc to any phase 1n the cell
cycle.
Alkylat1ng agents injure cells by binding to ONA and inhibit
1ng ONA and RNA synthesis.
Ant metabolnes are simtla1 to natural metabolites and a1e
able to d1srup1 metabofic processes by damaging the ONA
temp ate by acting on lhe fol1c acid needed for ce t
metabolism
Antitumor antibiotics are used to treat malignancies. not
inlect1ons Many antitumor an11bio11cs are cardiotoxic
Hormonal anticancer drugs act on target cells through spe
c1fic hormone receptors and are highly selective m their
action.
 320 SECTION IV Pharmacology for Mulusystem Application
...
.. . ANTINEOPLASTIC AGENTS
G . :oconocoids a StJbset of hormonal adrenocort1COstero1ds.
are toit to mallgnancoes of lymphoid organs
Tamo"lun os an antoestrogen used on the ad1uvant treatment
ol b<east Cdncer after surgery and/or rad1~t1on It ts also used
propllyldctocally on cena1n women at high risk for breast
raorer
Pr~ tate cancers ate treated witn gonaclotrop1n-releas1ng
~ lOOO agon1m and androgen suwessants, whtdl reduce
u 1mutaoon ol two:state cells.
N.:w drugs lot ueaung tumois 1a1ge1 specific ceU types. wnh
!he mto noon of affect1ng malignant cells while not harming
"roormal" cells
HANDLING AND ADMINISTERING
ANTINEOPLASTIC AGENTS
In 2004 ll~P 797, a regulation developed by the United
States Pltan11aropoe1a, was initiated 10 provide safety in
preparing >1erile drugs. The FDA has Lhe responsibility
of enforcing Lhe standards of this edict in foci li t ies where
slerile products are prepared or where drug manipula-
tions are performed during compound ing of sterile
products. ProducLS that are covered m.1y be biologics.
diagnosucs, drull-'- nd cytotoxics. The monitoring of the
facility's environment is also included to enhance patient
safety and decttase the chance for cross-contamination
of sterile preparations.
111e drugs to treat cancer are mu~genk, IC'ratogenic,
and carcinogenic when absorbed through skin, lung.~.
or Ct traC1. llccause of these characterisiks. direct con tact
of 1he drug with skin, eyes, and mucou~ membranes can
cause loca l injury 10 the patient or hcal1h care profes-
sional preparing or adm inistering the mcdic.ttion. Per-
sonnel must observt recommendations and regulations
to prevent chronic exposure to cytotoxic drugs. Rox I 8-2
outlines precautions found in written policies and
pnxedures.
Mo>t antineoplastics cause tissue damage if given sub-
CUL1neously or intramuscularly. For medications given
by these routes, the mcdicaiion should be drawn and the
need le should be changed to the smallest possible gauge
to prevent damage 10 normal tissue as drugs are admin-
istered. '111e most reliable and most commonly used
route of administration for very toxic antineoplastics is
the intravenous route.
One goal when administering antineoplastics is to
prewm unwanted exposure of the allied ht>alth profes-
sional to drug.s that disrupt natural biologic processes.
The exact protocol for administering amincoplastic
BOX 18_2 PRECAUTIONS IN HANDLING l
Follow Occupational Safety and Health Ad"'1lls;r.
(OSHA) and United States Pharmacope1a 797 guide 'le
Follow written guidelines for handling a01ineOl)lastu
Protect and secure packages of hazardous drugs
Educate all people who are handling hamdous dror
patient, family, and other heallh care worters-m
dures needed for safely handlmg hazardous drugs Se.
drugs do not escape from containers whrle being ~
and administered
Maintain a register of the staff members wlll
these drugs
use a biologic safety cabinet with a laminar air ftowhlX!i
preparation.
Medications should be prepared in a closed room ~
excellent ventilation and with oqu1pmem for 1mgat1~
and eyes in case of spills. An OSHA spill kit ~~ 11
available
Dispose of biohazard wastes prOIJ8lly
Use personal protective equipment 1nclud~ ~
clothing. a plasuc apron. gloves. safety glasses. all 2 II?
mask when worlcing with chemotherapeutie agenu
Reconstituted medications must not be sprayed ll'lltl '
atmosphere Oiluents must be allowed to slowly 1111 ibn
the sides of containers to prevent back spray A11 ro ~
sy11nge must be expelled into sterile cotton OI galllE ~
prevent spray. Powders must be reconstituted so oo E>t!!!
pressure mthe vial would allow medication to spiav
the needle hole Syringes. intravenous sets anl ie1el
should have locked firungs. and all fillings s!Wdbesmra
All matenals used in prepanng and adrNmsrer~ Ce:;
therapy should be disposed of mleakproof. poncture-ra=
containers marked "BIOHAZARD
Because of the teratogemc1ty of an11ncoplast1cs. health ere
workers who are pregnant. breas1-feod1ng, ortrymg1C1111
ceive a child should not handle cy101ox1c medic.iio11 o
provide direct care for patients who are rece..ing c1100lX
medica11ons These precautions should also be used
patients receiving rad101sotopes. to prevent urnlCess!1
exposure to radiation
medications will vary with each med ica l ~euingandd~
administered, but as a general guideline, stria asqxic
techniqul' should he used, following all safety measum
and one mus1 stay within their scope of practice. Tht
complexity of chemotherapeutics .rnd hazardsasoocialill
with their .1dministration require administr.ation UJldc.
dirt supervi,ion of a speci.1list. Although allial hnkh
professional' would infrequently, if ever. be ilS1td 10
adminiswr antineoplastics, these drugs may bt found J&
their practice selling. Understanding the toxic naturt l
these dt't1g~. pract icing person.ii safety me.isures. in.I
 CHAl'TER I 8 AnMeoplasuc Agents 321

lollowing precautions fo r handling these medications
must be appreciated . Civing suppon to the 1>atien1 and
family is an impon an1 duty of the health professional.
&cause antineoplastic agenlS are toxic, hematologic
testing and blood chemisuy studies may be done to
monuor hematologic. renal, and hepatic function
lcsting is begun before the first treatment and is repeated
1hroughou1 the course of chemotherapy and during
follow-up. Dosage may be based 0 11 ei ther body weight
or body surface are.1 and may be altcrt>d during treatment
b3sro on any toxicities that the patient is exhibiting and
their St'\'l?fity. For many chemotherapeutic agents. use of
.1 nornogram is the best means of dosage calcula1ion
!wcnuse body surface area-weigh t and height- is con
1idercd ror safe administratio n. Too much medicatio n
will cause toxicity, whereas too little will 1101 be
ell'ooo"e
SUMMARY
Rapid changes are occurring in the area of anti o1eoplas
tic~ because of the rapid approval of investig;itional
medications used lO prolong palienlS' lives. New
categories of medications have been sh own 10 be effec.
tive and are bei ng used to alter ONA and RNA lO prevent
abnormal cell mitosis.
Antineoplasllc medications are classified according to
their effect on specific phases on a cell's replication cycle
or based on their ability to target cenain cellular func-
tions. According to their potential mechanism o( action,
the main medicatio n categories include bt11 are not
limited to an1l metaboli1es, alkylating agenlS, mitotic
inhibitors, antitumor antibiotics, hormones, immuno
suppressants. and radioacti\'t agents. Most malignancies
re treated by some combination or surgery. chemother-
apy. and radiation therapy.
Many anti neoplastic agents are no11selective in their
actions, affecting bo1h normal cells and cancerous cells.
Cells that replicate quickly arc more susceptible to the
chemotherapeutic agents than cells with a slower growth
rate. Mos1 side err.as of antineoplastic therapy ocrur in
bone marrow, the Cl trac:t, and hair follicles because
these orga n systems are dominated by cells that grow and
re1lroduce quickly. Patients should be educ;ited about
these side efferu because pa1ienlS who know what
to expect in advance will be more compliant with
treaunent.

!\J'h@i1.'la:11JUilJICii:i4;tdti-
Scenario
Jane has been diagnosed with carcinoma of the breast. She has undergone a mastectomy and is now
scheduled to undergo chemotherapy that will cause alopecia. She tells you she is afraid of hair loss,
nausea, and vommng. Her friends have told her these are rhe worst problems asscciated with
chemotherapy.
1. How do you help Jane prepare for alopecia?
2 How do you help her prepare for nausea and vomiting?
3 What do you tell Jane about her dietary needs whole she is receovong chemotherapy?
4 What should Jane be taught about contact with people with infectious diseases?

DRUG CALCULATIONS
Order: doxorubicin hydrochloride 20 mrfm' for a 2. Order. vinCTisline l.2 mg/m' fo r a person who is 73"
person who is 5'4# tall and weighs 125 lb tall and weighs 185 lb
Dose to be given: - - -- -- - - - - - - Dose 10 be gh-.:n: - -- - - - - - - - - -
322 EC 10N fV Pharmacology for Mulusystem Application

REVIEW QUESTIONS
I , Dc6ne inttneoplasuc medications dnd 1heir general mode of ac1io n. - - - - -- - - - - - -- -

2. Wh.11 is ~n irnmunosuppressaml Why arc these agents beneficial in 1rea1ing malignancies bm harmful 10 ~
p.11icnir _ _ _ __ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ __ _ _ _ _ _ __ _

3 Dncribc lhf' more common side effects 1ha1 patiems receiving chcrno1herapy might expect - - -- - -

4. Lisi the precau1ions necessary when prep.i ri ng and adminis1e1'ing cy1otoxic med icatio ns. - - - - - - -

5. Why should pa1iems expecting .1lopt'cia huy hairpieces before beginning chemo1herapy1 - - - -- - -

6. How c.111 1hc pa1ie111 undergoing clwmo1herapy have some rel ief from nausea and vomiting wi1houi til.mi
medications/ - -- - -- - - - - - - - - - - - - - - - - -- - - - -- - - - - - - - -
Nutritional Supplements and
Alternative Medicines

J CTIVES
After studying this chapter, you should be capable of doing rhe following:
Discussing medical indications for nutrmonal
supplements.
ldenufying fat-soluble and water-soluble v11am1ns
Identifying minerals that are used as supplements
and for electrolyte replacement.
Discussing common home remedies used as
alternative medicinal forms.
Describing use of herbal medicines.
Understanding overthe-<:ounter <OTC) numtional
supplements and their 1nteracuons with
therapeuuc prescription medications.
Describing cultural differences and the use of
herbals and alternative medicines.
Providing patient education for compliance with
medications used as nutritional supplements and
alternative medicines.

Carol has a long history of severe arthm1s m her knees. She has a limited income and cannot afford 10
buy prescnption med1cat1ons for her arthrms. She drinks milk to which vrtamm D has been added.
Why is milk with vitamin D imponant to Carol?
II Carol is allergic to milk, what OTC preparations other than calcium tablets may be used to provide
calcium'
II Carol has a history of epigastnc burning, what OTC preparation could she use to enhance her calcium
intake and also help her epogastnc discomfort?
What are the 1mpl1cat1ons of using glucosamone?

- ---~

Acid Electrolyte Isotonic Salt

Alkaline Folk medicine Micronutrient Solute
Alt ernative medicine Hematuria Mineral Solvent
Avitaminosis Home remedy Nutrient Tetany
Base Hypervitaminosis Osteomalacia Vitamin
Co mplementary Hypovitaminosis Paresthesia
medicine Ion Pellagra

323
 324 SECTION IV Pharmacology for Multlsystem Application
VotanlllS
M11ierals Yes Yes
ALTERNATIVE MEDICINES
Home remedies No Yes
Herbals and plants No Yes (regulated by US.
Department of
Agriculture IUSOAJ)
EASY WORKING KNOWLEDGE OF INDICATIONS AND SIDE EFFECTS
Common Signs and Symptoms ol Nutnt1on1l lmbal1nce
Non$pecific oompta1nts
Abnormal bone formation
Abnormal heartbeat fpalp1ta11ons1
Neurologic damage
fnab1l1ty to build alld repair tissue
Change in energy levels
Intellectual impairment
Muscle wasting
Obesity. emacialloo
Loss of hair
Delayed wound healing
itamins and min.-rals. called mlcronulrlents, are
V essential compounds normally obtained from
plant and animal produru and Ouids we ingest
for body functions such as gTOW1h, maintenance. and
reproduction. Miaoorg;inisms require few raw materials
from their environment, but as life rorms become more
sophisticated with highly s1>ia lized cells and organs,
the ability 10 synthesize necessary nutrients is lost. Thus
the human body is more dcr>cndent on exogenous
sources for nourishmen t, especially for vitamins.
nie OTC marker for nutritiona l and diern ry s upple-
mentS is one of 1he largest in the phannaccutical field,
with more than half of U.S. ci tizens 1.1king vitamins. mi n-
erals, and herbal preparations without a prescription.
A working knowledge of vit.1min~ and minerals. their
sources. symptoms of vitamin deficiencies. .md possible
toxic effects from overdose is necessary for patient safety.
VITAMINS
Vltm.ins art required for metaboli~m of fats, c.1rbo-
hydrates. and proteins. Although vitamins are not
themselves a source of ene'b'Y 1.hcy are essential for
Nooe
None Folk medicine (to~
disease Ir( folkb<ei
None. regulated by USDA under Altemative llledt:ne
the Dietary Supplements (to treat dis~ br
Health Education Act (OSHEA) herbals)
I
Common Side Effects ol V1tllmms, Miner1ls, au HWh
lrritabilrty
Anorexia
Headaches. flushing
Indigestion. nausea. diarrhea. constipation
Abdominal cramping and pain
Discolored stools
Insomnia
Hypotension
energy production and for regulation of n1Nlxm!
pr0<:esses.
These compounds. or nulrfeots, "81Jlate bod) Iva
tions and are necc!.>ary 111 trace amountS for gJOlolh al
health. nu. needed amount varies somewhat Oln lhtllt
cycle. A vi1,1111in deficiency or hypovituninoI
duces ccnain symptoms. just as excessive suppltml!l
tion produces toxir l'ffects. f.Oxaetly how viramini Oii
and ind ica ti ons for tlwir use are not completelyund<r
stood, but we d o know tha t a vitamin deficienq m
resu lt in compromise o f ho meostasis. Some viwm n<
occur in a us,1blc d i!'1.1ry form; others are inarri"" in 100'
natural form hut arc convcr1ed 10 active r.hemical rom
pounds wi1hin the body Bacteria in the gamoin1~1
(GI) tract hdp ac1iva1e vitamin K, vitamin Dis $)11'
sized on <'Xf'lOurc 10 sunlighi, and vitamin 8 is l1M
factured in small amounts in the Cl traCL Viuminuit
imponanr as thl.' crvyme ~)'Stem breaks dOlm b:>l
sources during the mct.1bolic process.
Insufficient int.tkc of vitamins may be caUStd lif
an inadequate dic1 as a r.-sult of cultural. religiou.' or
personal preference~. fad dieting. alcoholism, p<>1"'1\
lack of food av,1il.1b ili1y, or ignora nce. Signs or v111m '
deficiency .trc pri111.1 rily abnorma l tiredness, aches. paiiu.
 CHAPTER 19 Nutm1onal Supplements and Altema11ve Medicines
Jnd general malaise. In the United States. the iw:vere
ltmlnosis !bat produces diseases such as beriberi,
prllagr, rickets, or scurvy is rarely seen. An adequate
diet of proper foods, prepared in ways to retain virn mi ns,
1s the best way to prevent hypovita minosis.
Some experu believe that the average Americn diet
cont.uns adequate vitamins and that vitamin supplements
are not necessary to meet the U.S. Recommended Dietary
lniJkes (RDls) set by the f-ood and Nutrition Board of the
National Academy of Sciences. The RDls should not be
considered t.he minimum daily requirement for persons
"' risk for deficiencies because ROls apply to people in
good healt.h. Ill individuals. the elderly, growing children
Jnd teenagers. pregnant and nursing women, and people
"ho smoke may need supplements to compensate for
d1l1ary deficiencies. Although the practice of taking vita-
mins is widespread, in most cases vitamin supplementJ-
tion is nol necessary and excessive consumption can be
harmful and lead to hypcrvlt.11ninosis.
Classific.a tion of Vitamins
\ namrns are divided inio two major groups fat-soluble
Jnd water-soluble vitamins. fat-roluble vitamins-A. O,
F .rnd K-are stored in the liver and fatty tissues. A de6
cicncy of these vitami ns woul d occur only after a lo ng
period or deprivalion, e ither from lack or food intake or
from a disease prevent ing absorption. Excessive intake,
J>articuldrlyof vitamin A, may lead to toxic efTeC1s because
of prolonged storage time of fat-soluble vitamins.
Water-soluble vitamins, 8 complex vitamins-81 (thia-
mine), 8, (riboflavin), R, (niacin), 85 (pamothenic acid),
U, (pyridoxine), B, (folicacid), a nd B., (cyanocobalamin )-
.ind vitamin Care not ~nored in large arnounLS, 1lnd even
a brief period of deprivation can lead to deficiency. 1oxic
efTcets of water-soluble vitamin' are rare because excess
amounts are excreted from the body.
Successive letters of the alphabet were assigned as new vita
mins were isolated. with some letters being assigned out of
order. Because vitamin Kis necessal)' for blood clotting. tt was
named lor the German wo1d Koagufation Later 1t became
evidefll that v1tam1n B was not a smgle vitamin but actually a
grouc> of ~tamins. Subscnpt numbels were lhen added Missing
nootbell had been assigned to fractions of the groop that were
later foond to be iden11cal to an already named v1tam1n In fact.
all water-soluble vitamins but C are actually groups of related
substonces to which subscript numbers are assigned (e.g., B1.
e,, 0.1
rhc many vitamin prep.lrations on the mar~et today,
both as prescription products and as enc products. vary
from .1 single vitamin to multivitamin capsules and
325
TABLE t9 t FOOO AND DRUG ADMINISTRATION !FOAi
PREGNANCY CATEGORIES FOR VITAMINS
PREGNANCY
CLASSIFICATION VITAMIN
A B tthiam1nel. S. (pyndcwnel e, (folic
ac1dl, 8 (cyanocobalamlll as rmal
spray or POI E, Si (nboftavmJ
c e.,
0. (cyanocobalam1n as iniectable).
C(asco1btc acid). 83 (niacin!. K
x A
Note These cauigones are for Y1tam111S edmmstered 11 the flecommendod
llaily Allowance5 JRDAl Wi111 n:reased anw11s. the ~ category
lllay ~ t0 I h9'ef ieYe!.
tablets. The most popular OTC multivitamin prepara
lio ns co111ain all of t.he vitnmins needed to meet daily
requiremen t wit.haul regard 10 dietary vitamin content.
Extra-strength or high-potency vitamins are rarely netts
sary for the average person
The ll.S food and Drug Administration (FDA) preg
nancy risk classification for the major vitamins is found
in Table 19-1.
.'
V11amms taken m ad<l1llon to d1etaiy sources are called
v1ramm supplemenrs. Specific v1ramm supplements may be
useful at designated t.mes tn the life cycle However. healthy
nonsmok1119. nonpregnan1 adu ts who eat awelJ.munded diet
generally should oot need v1tam1n supplemen1s.
2. Foods with synthetic vnamins added during processing are
lnbeled "for1ifie<I" or "ennched."
3 Vitamins that are purchased over the counter generally haVI!
lower vt1amm content, especially of fat-soluble vitamins and
follc acid. than presctiptJOO med1cat1ons
Fat-Soluble Vitamins
Because storage time of the fatoluble vitamins-A. D.
E, and K- med icaLions containing these vitamins s hould
be used on ly when a medical condit ion has been found
for which a panicular ''itamin is needed. Fat-soluble
vitamins are of clinical imponance because persons
who have diseases t.hat interfere with absorption of fats
will eventually develop fat-soluble vitamin deficiencies
(Table 192).
Water-Soluble Vitamins ~~~~~~~~~
11le Miler-soluble \'itamins-the B complex and C
vitamins-are not stored in fany tissue. The B vitamins,
val)'ing in structure and function, are grouped togeiher
f<.;d totllUUWd on p JJO
 TABLE 19 2 MICRONUTRIENTS-VITAMIN S ~
ORUG NAME. FUNCTION INOICATIONS FOOD ORUG OTHER

~z
OOSAGE, ROUTE IN BODY FOR USE SOURCES HYPOVITAMINOSIS HYPERVITAMINOSIS INTERACTIONS INFORMATION
FAT-SOLUBLE VITAMINS
A
retmol (Aquasol Visual adaptahon. Malabsorphon Fish Oils. Night bl1ndne$$, ~\on Acule cor>IUSIOO. orlis1a1 Pr~ ..,<.,,.
Al._-40CJ0.5<XXJ especially syndrome caused by txmer. lesions. dryness 1m1a11on. d1anllea. C<ltegory x ..3
1nterna11onal unns
PO.IM
night v1s1on;
structural and
GI diseases. acne.
wrinkles
yellow
fruits and
of con1unctiva.
sohemng of cornea
d12zmess. skin
peeling and
..
n
functional
111tegnty of slc111
and mucous
~tables.
milk. cheese.
liver
1n children cracking ,'fOl!llllng
alopecla. headache I0~

membranes; 3::
development of ~
teeth and bones ;..
3
0 .,,>
calc1ferol (Caldero!)-
25 mcg1 5 mg PO.
ergocatc1ferol
Absorption of
calcium.
pilosphOIUS
Maintenance of proper
bone health.
metabolic bone
Fon1fied
cereals.
dairy
Rickets.
oteomalacla,
osteoporosis. bone
fa1/y-diarrtiea,
headache. hrgh thirst
and unnauon. NN
orhstat. 1soueuno1n.
antacids. th1az1de
d1u1et1CS.
Must have 10
minutes of
sunhght per day
..g.
ia..
;;

(Calofeml. Orisdoll- "'

10,0CJ0.80.000 mcg
1n GI ttact
calcification of
dlSOldefs.
hypocalcemia
products.
candy. liver,
and muscle pain.
weakness. tetany
Late--bone and
muscle pain. high
am1noglyrosrdes, Ca
preparations 'synthesis
'propel
PO. IM, bones with dialysis, eggs. fish B/P, pruntus. and active
calc1triol IRocallfol)- hypoparathyroidism. lethargy, mood conversion
0.25 mcg PO topically for diaper sw1ngs, pancreatius.
A and 0 0111tment- rash and chafed skm CVO. renal calcult
topical

E
alpha toc()llherol Antioxidant; Menopause when not Wheat Slows reflexes. Acute-visual Ollistat. oral Tempo1ary reliei
(Aquasol EJ- protects RBCs talong estro0m; germ oil. IOwers muscle disturbances. amicoagutams. uon. IOI mulOf bums.
mdMduahzed PO; from hemolys1s, diaper rash vegetable mass. coo11f1nat1on; headache. nausea. antilipem1cs. mineral chapped skin
IV1ta E Cream)-topical role not clearly oils. leafy anemia; chapped abdominal pam, Oii
understood vegetables skin weakness
Chroo1c-higher
bleeding tendencies.
mpauOd sexuaf
fo1w;11011. ttltPred
U1yro1d 11111r<1hnll.;rn
-
RP ~Wl t"-'""'"' t 'l\n co-v .. 1o,ry d ...., l-VU .,, ,.,_ _,.,,, ., . , , _ O' _ .. , ....,.._,~, M.t .,,,,..,,.__.....,,, ,... i'VI# - .....
'" N
K
phytonadione Synthesis of blood Hypopro1hromb1nem1a. Green Bleeding and Flusll111g. dyspnea. orhstat. antilipem1cs. Malabsorption
1Mephy1on)- clotting factor. prewnt excessive veoeteblas. hemormage chest pain, taste 011 preparauons. syndromo in
25mgPO. ptodoc1ng bleeding 1n newborn; cabbage. alter.mens. b<a1n antiseizure intes11nes Leads
IAquaMEPHYTON)- pt0lh1ombm m warfann toxicity caulrftowef. damage. melfocanons. to deficiency,
O.S-1 mg IM Ml hver fish liver ht'mturla coumarin anubiotic
newborn oils. eggs. anncoagulants. therapy may
milk. meat antiinfectives elrm1nate
bacteria needed
for syiithes1s

WATER-SOLUBLE VITAMINS
8,
thiamine (Betalin, No1111al function of Prevent beriberi. Pork products Peripheral neuritis: Very low tox1c1ty; alcohol large doses
Biamine)-10-20 mg nervous system malabsorption and loss of muscle tone excess excreted warmth,
PO.IM metabolic disorders, and strength: sweating
alcoholism paresthesla; urticaria. GI
depressmn:
memory loss;
tract bleeding
I ~~
B,
dyspnea; anorexia
-"'i:llz
~
ribollavir>-S-30 mg PO f'lomotes Riboftavin defitrency Milk andm1lk Sore tlwoat. swollen None alcohol. probeoecid May tum unne
metabolism of ptodocts. tQlllJUe. anemia. orange 0
carbohydrates. meats. pitching changes in "
!!!.
fats. and grams cornea in children. (I)
c:
proteins. dermatitis of face "'
:!.
svnthesis of and burning "'
3

B,
DNA
-
".,"'
~

"l>
a.
niacin. nicotinic acid Metaoolism of Prevent pellagra. Meats. Skin eruptions. sore Flushing. pruntus. statin medications. More hke a drug
;;:
(Nicobid)-100 mg
PO. IM; {Niaspanl
food. builds
tissue proteins
hypertipoprote1nemia.
lowers choleSterol
legumes.
enriched
grams.
mouth. diarrhea.
headache.
diuiness. insomnia.
diuiness.
dysrllythm1as.
muscle pain. N&V.
probenecid lhan a vitamin
and should be
used with
..
~
;
..
500-2lm mg/day PO
5x daily peanuts dementia. memory
loss
d1an11ea. diy skin medical
supe"'1StOn
..
;::
a.
(~1....N
.."
5
w

w
....N
 ~
"'
TABLE 19 2 MICRONUTRIENTS- VITAMINS-<:ont'd ~z
DRUG NAME. FUNCTION INDICATIONS FOOD DRUG OTHER <
DOSAGE. ROUTE
8,
IN BODY FOR USE SOURCES HYPOVITAMINOSIS HYPERVITAMINOSIS INTERACTIONS INFORMATION
..3
~

pyndaiune---ilose va11es Metabolism of pyridoxine defic1eocy, Chiclcen. fish. Sebonheic-like Very hule tolltity INH. fe.iodopa, alcohol. n
0
amino acids. INH ~otoxicn.y eggs. v.ilole lesions of sbn. except with ctwonic some antfinfect.ves. .,0
fonnatioo grains sore mouth. O'<efUSC oral COOUaceptr<es. <
of blood. penpheral neuntis. 1mmunosuppressan1s ~
~
maintenance of sei21J1es c:
nervoos system =
~ ..
8, 3
folic acid (Folv1te)-use. Synthesis of DNA Megaloblasuc and Green leafy Glossitis. diarrhea Redness of skin. fever. sulfonamides. alcohol. March of Domes ~
PO, IM, SC. IV, vaoies
with age. gender
and RNA macrocytic anemia vegetables.
milk. eggs.
rashes. prurnus methotrexate,
steroids. estrogen.
oral contraceptives
suggests that all
women ol
childbearing age
..s
'.
c;

yeast :::>
take
lohc acid
supplements ol
at least 400 rr'fil/
day to pievent
neural tube
defects in
developmg
fetus.
requuemems
usually increase
in actual
pregnancy, and
most pregnancy
supplements
contain
I mq/day
B,,
cyanocobalamin Promotes normal Pem1c.aus anemia. Fresh shnmp, Nervous system No toxic effects chl0<amp00nicol. Maoy peoplB ta~e
(NTN)---<lose vanes. cell function. B,, deficiency oyste<s, damage. poor alcohol B., m1ect1ons 10
IM.SC; especially in mil~ eggs. OOOrdillatlOO. provide feehng
(Nascobal Nasal Spray) neMlU$ system; cheese memolY loss. of well-being.
topical blood formallOfl. confusion. Meklng
metabolism of demenua. ueatment
carbohydrates. almrmal blood cell maybe
fats. proteins. formallOn necessary for
folates: malabsorp11on
synthesis of diseases.
ONA and ANA cannot be
administered
by IV

c
ascort>ic acid (Ceconf- Building and Prevent scurvy. vitamin Crtrus fruits. Gingivitis. scurvy. Kidney stones. salocylates. prom1done. Prophylact1cally
7().500 mg PO, IM, ma1nta1mng Cdeficiency With tomatoes. anerma. boJ1s1ng. d1uiness. N&V. ll'Oll grvoo for the
SC, IV tissue for boms melons. delayed wound diallhea common co4d. r~
wound healing. cabbage. healmg acfiunct theraPV ~
m
:D
resistance to suawbemes. for cancer. may
infections. bfoa:olo protect aga111St ~

enhanced iron cataracts z

s
abSO<pt1on a
0
::>
B, !!.
pantothenic acid-
found in multiple
vitamins 1n various
Component of
coenzyme A
used in
Virtually all
foods
No deficiency
reported
No reports of toxicity None known No need for
supplementation
bocauso readily
....
"""'
c

3
amounts metabolism of
carbohydrates
and fatty acids
found in most
foods .."
iii
::>
a.

B,
....
~
~
::>
biotin-found Ill Metabolism of In many foods Experimentally. No IOXJC1ty noted None noted lntrons1cally
..=
<
multM1am1ns, dosage
vanes
cart>ohydrates
and fats
dennatrtis, ha~
loss. oonjunctivttis.
rooscle pain.
synthesized by
1ntest1nal
batUlfla
..
:;::
a.
0
paresthesias . w~

w
~
 330 SfCTION IV Pharmacology for Multisystem Application
TABLE t9 J LIFESTYLE CHOICES ANO VITAMIN
SUPPLEMENTS
VITAMIN SUPPlEMENT
UfSTYLE CHOICE NEEDED
RetrlC.ttld diet e.
ExtenSMl eercise B.
0.at c:ontr1Ce1Jl '1lS B,.S...S..B .C
Smolung c cut bade about half of 1he current dosage so 1ltt
Alcohol B. S.. 8 complex
Cafl0100 Bcomplex. C
&ceswe s1ress Bcomplex
because they were fim isolated from the same sources,
ye.1st and liver Because th~ vitamins are rapi~ ly used
or excreted through urine. a daily dictaJy supply 1s neces-
sary to prevent deficiency. Under normal circumsta nces.
hypervit.1minosis do~ no1 occur. The most common
condition causing a deficiency in water-soluble vitamins
In adu1t~ Is alcoholbm because o r the associated anorexia,
decreased rood int.lke, and damage to the d igestive
and meiabolir S)'lltcms. Fasting, 1netabolic d iseases, and
anorexia ncrvosa may also lead to a deficiency, as may
CX(l'S>ivc cooking .111d boil ing o r foods. As a rule, any
conditio n th,11 l)redi~poses a perwn to a water-soluble
vilamin deficiency will reduce levels or rnu lliple B vita
mi ns .1t 1hc same time (sec Table 192).
Some fifoMyle choices are importan t in supplementa-
tion and vitam in .1b~orp1 ion (lable 193).
Uaa of Vitamin Supplements
in the Elderly
The need for dietary supplements increases as people
age becau~ gcnatrk people cannot absorb and store
nuuients as easily as at a )'Ounger age. Jn elderly indi-
viduals who do nol ea1 adequate foods containing suf.
ficient nu1rien15, \'1tamins miglu be indica1ed. The goal
of therapy 15 10 boost energy and strength, provide
nutrition for \\Ctghl gain as appropriate. aid in recowry
from illnesses, .1nd provide extra minerals to maintain
health Many fonnulations of vitamios and supple-
ments are available m liquid and solid fonns for persons
older than 50 ~'l!al'$ or age. Multivitamios designed for
use with )'Olinger Jdults may not contain adequate sup-
plements for geriatric patie111s. Drug companies have
formula1ed many products to m<et specific needs such
as card iovascular health, prost.1te health, and protection
ag.1i nst os1eoporosis in postmenopausaJ women.
Viiamin and mineral supplements may even contai n the
wording 'for age 50+ 10 indicate products for use by
older adults.
For best absorption and ltm11ed gasuointes11nal 1G11
vitamins should no1be taken on an emp1y stomai:11
Vitamin Bu 1s not readily absorbed 1hrough the GI :rtt
2
should be given by m1ec11on or mtranasa Ir b
absorption
3 Some vitamins may change the color of ur111e ~
4 Expens suggest tha1 those who 1ake excessive arrni::i
micront11rient should not s1op taking tt ~elefy
adiust before stopping medication completely
Vitamins are compounds required m minute a
growth and maimenance or health Vitamins are neeaa:
energy transformation and food metabolism
For most people, proper diet alone will supply !ht r1:1<
vitamins.
Vitamins are divided 1n10 two groups fa1soluble v1i.i~
D. E. and Kl and wa1er-soluble vitamins 18 complex al'I)
Fat-soluble vitamins are stored in the body and do notr
daily replenishmen1 Waier-soluble vitamins not 1ntll>l111
used by 1he body are oxcroted 1n urine and need to ber
ished daily
MINERALS I
Minera l, inorganic <olid <ubs1ances sud! a> dXl!1
occurring as pan or the canh"s crust, Me impolUlltPI=
of body composi1ion and arc necessJry in snull1m00
for normal body func11on I lumans obtain m1rwta
eating plants grown in miner.11-rich soil or from ltallll
ary sources of food produC'ls obtained from Wml!i
Like vitamins, minerals have no energy llue IMI
necessary 10 regulate body proce~ and $(!\~.as m
tural components or cell~ while .1ccounung for pp!C'
mately 4% of body wcigh1
As minerals di'ISolve in body fluids. theyaista1 .ia6.
a.llwline' (or ha<c,). and ,,,)(,, 1he d1ssolwd mmm!i
arc c,1lled el,,.trol) k' bcc.1u..c they have lite Jb1ho m
form charged particle' ca lled Ion& that are nmkd
metabolism. Wa ter is the "'''""' and electro~t<>
the solutes. The norm.ti salt rnncentration founJ
body flu id~ is 0.'J% COn('Cll trittl Oll or sodium chJoodt
o r iso1onic. Change< in this concent ration as d ron
q uence o r either raisi ng or lowering the 1>ercenLtgeolth
salt in the sohuion wil l d isrupl bod y horneostJSi~
 CHAPTER 19 Nutritional Supplements and Alternative Medicines
\lost minerals in foods OUr as salrs. which are
soluble in wattr. \iineral supplements may be necessary
during periods of rapid growth and in some dinical
situations-for example. iron for patients with anemia
Prople taking potassium-depleting diuretics may need
p<>iassium supplementation.
Minerals are subdivided into two classes, major min
erals and trace minerals, based on body needs and not
on chemical importance. The major electrolytes in the
body are sodium, chloride, potassium, calcium, phos-
phorus, and magnesium. The most important trace min
erals for homeostasis are iron, zinc, Ouorine. iodine, and
copper (Table 194) .
Use of M ineral Supplements
Mineral supplements should be used with care because
o.cessive supplemental amounts can be hazardous. A
healthy person who eats a balanced diet should obtain
sufficient minerals to counteract normal losses through
perspiration, saliva. urine. and feces. Mineral supple
ments should be taken only on health care provider
advice.
l I I
Minerals are es~llal ror normal body lunctioo.
Minerals called electrolytes are essenttal for homeostasis
Patient Education for Compliance
The patient should pay anent1on to any special labels on
medicine bonles to check exact contents of vnamins and
minerals. Mult1V1tam1n-m1neral combinations can cause tOl
1C1ty or some components
2 M1ne1als not necessary should not be taken because of the
danger or cha1191ng electrolyte balances.
3 L1qu1d Iron preparations should be taken with a dropper
or straw alter dilution to prevent staining or teeth and
mucous membranes. The mouth should be rinsed after each
adm1mstra11on
4 lroo should be taken on an empty stomach. but 11 may be
taken with food 1r GI upset occurs.
5 Iron SUIJl)lemems may cause constJpation.
6 Antacids and ~on should not be taken at the same time
7 Calcium cart>onate (e g . Turns) is a good replacement for
calci\11111 postmenopausal women who have GI upset from
taking other calcium supplements
8 Oral ftuonde dlops should not be taken with milk or dairy
products Fluonde dentill rinses should be used at bedtime
after brushing teeth to ensure nothing is eaten after use.
331
AlTERNATIVE MEDICATIONS
Over the past 20 to 30 years. use of altemati\<e mediane
is an approach to illness that has rapidly increased m the
United States. One of the most rapidly growing types
or alternative therapy is the treatment of osteo.tnhritis
using such drugs as glucosamine or chondroitin, wh1clt
arc nutritional >upplements. Some research suppons the
fact that glucos;imine aids in the repair and formation
of cartilage. Chondroiti n is a protein that allows for
elastkity of the canilagc.
'rhc terms complcrnrntary medicine .rnd altern
11\e medicine describe a group or diverse medical and
health care system practices and products that are gener
ally considered part of conwntional medicine Comple
mentary therapies include diet, exercise. counseling,
biof~back, massage therapy. relalation techniques.
and hypnosis, which generally are not mv.uive. I lome
remedies and folk remedies (Table 19-5) are sull popular
in many cultures and may coaist with modem phanna
cologic therapy.
CULTURAL DIFFERENCES IN USING
-nw
AlTERNATIVE MEDICINE
first alternative medicines were home remedies.
Many folk mcdldne ireatments or horn<' remedies are
used on a daily basis, with each culture having its primary
folk medicine providers. In the United States. most cul
rural groups use some form of complementary or alter
native therapies. using both medicinal treatments nd
social or psychic adjustments.
Among 'ath-e Americans, medicine men and women
used plants and herbs blessed for medicinal use. lllness
was prevented through prayer, charms, and the use of
objects wiLh power to protect the owner. Some of these
forms of healing and health maintenance continue
today.
Certain African and Latin American cul1u res have
auributed d isease to disharmony in relationships
between ht1mans and supernatural forces. Discord may
occur between the person and ancestral spirits, evil
spirits, or living relatives. Treatments arc providl'<I by
Lrai ned, culturally accepted healers, who may be elderly
women healers (grannies). shamans. or root doctors.
I lerbs. roots, and oils are used for healing. Talismans are
worn to ward off evil spirits. Religious rituals such as the
laying on of hands are used to treat disease.
Lit in American populations, including immigrants to
the United Stales, practice a fusion medicine. lllness is
viewed as having a natural caus(', as an act of Cod, as
punishmen~ o r as result of witchcraft or a cur>e. The
lat ut11l1nmI "" p. J J6
 w
:::
~
0
TABLE 19 4 MICRONUTRIENTS- MINERALS :z
<
DRUG NAME.
DOSAGE. ROUTE
FUNCTION
IN BODY
INDICATIONS
FDR USE
FOOD
SOURCES
MINERAL
DEFICIENCY
EXCESSIVE
MINERALS
DRUG
INTERACTIONS
OTHER
INFORMATION ..3
~

MAJOR MINERALS n
0
C1lc1um (Cl/ 0
Ca citrate (C1tncal)- Bone rormation, Nutn11onal Milk, saromes. Bone Confusion. dairy products. May be deposited on ~
varies. PO; contractioo and supplement, cheese. delormit1es. headaches. d1goxin. thyroid joints and solt O'
~

Ca carbonate (Os-Oil relax;mon of hypotalcemoe satmoo. nrkets. N&V,coma hormones, 11ssoe- causmg ~
c
T1tralac. Turns. muscles; blood tetany, green leafy osteomalac1a. tetracycline. pain, hm1tat1on e
Vivactiv)-varies.
PO. chewable,
Ca gluconate (NTN)-
clottmg; nervous
system
transmission to
replacement
lherapy in
vegetables,
whole grains
osteoporosis fluoroqulnolone
anubtotics
of motion.
postmenopausal ..
~
3
menopause. women need Ca ~
vanes. PO. IV and from brain;
secretion of insulin.
antacid;
phosphate
supplements at
1500mg/day
~,..
..
need Vitamin 0 lowering agen1 f0t g
. ::>
metabolism renal failure

Phcs(lhollls (P'J
potassium phosphate Bone and tooth Nutritional Fish. beef, pork, Confusion. Low Ca blood antacids. Phosphorus
(NeutraPhos. formation; energy supplement; cheese. milk, anemia. levels. kidney sevelamer. Ca supplements, K.
K-l'hosphate)--varies. productoo. unnaiy acid1fieis legumes, weakness. stones products, ACE Ca. Na cause GI
I PO, IV;
sodium phosphate (Na
maintenance of
intact cell
carbonated
beverages.
bone
brittleness
inhibitors, K
supplements.
upsets and bone
and joint pain
phoS!iiate)-varies. IV membranes; processed Kspanng
I siorage of fats.
metabolism of
meat. foods
prepared with
diuretics

nutnents phosphonc
acid
ACE. ai1gio1ens1n-<:011Vefting enrime; CNS. cenual ner;ous system: CVO. cardiovascular disease. GI. gastroinoestinal, Kl po1assium iodine; N&V. nausea and vomiting; NSAIOs. nonsteroidal antiinftammatory
dlugs. PO. orally
0
Na< on paretl.- IS die.,.... name. do oge and" lie at ac1m..s1ra11011 follow rrade names
I
Magnesium (Mg I
magnesium chlonde Synthesis of ptote1ns. All but magnesium Green leafy Spasms. Spasms. cefd1toren. Magnesium and
(Slow-Mg)-vanes. stimulates muscle sulfate-used with vegetables. convulsions. convulsions. tetracyclines. calcium
PO; contractions Ca. aluminum. whole grains. tetany. tetany, CNS lluoroqu1nolones interdependent
rnagneStum c1uate and nerve s1meth1cone for legumes diwhea deptession.
(Citromar-varies. PO. transmissions. antacids. laxatives. coma.
magnesium hydroxide activates enzymes. and dietary hypotens1on
tMOMr-vanes. PO: aids in bone supplements.
magnesn.m oxide (Epsom formatton magnesium
saltsr-varies. PO. sulfate-selllJfes
soaks:
magnesium sulfate-
vanes. l'O. IM. rv

Sodium (Na'/
sodium chloride (Saiinex. Necessary for Flushmg. hydrauon. Table salt Nausea. Edema. Table salt is the
Ocean Nasal M SL extracellular fturd. fluid and milk. meat. headadie. 11ypenens1on. prunary source. (")
:r
normal saline. NaCl for body fluid balaooe. electrolyte processed mental cvo intake by diet, )>
=!!
m1ec11on)-SC. IM. rv acrd-base balance; balance. acid-base foods. carrots. confusion. disturbances excretion by "'
ophthalmic, nasal regulates ne1110 balance celery hypotension. kidneys "'
-
solutton. m1ectable transmission. weakness, ""cz
1rntates oell anxiety,
muscle
3.
membrane c;
1mtab1lrty S1l3sms "
!!.
(I)
c
Potassium (K' I 'C
'2.
potassium acetate-40- Intracellular fluid; Vitamin K deficiency; Oraiiges. nssue Lethargy, d1g1talls. NSAIDs. Salt substitutes >
3
100 mEq PO. maintenance of cell ac1dbase balance bananas. breakdown. confusion. dlu1ottcs. sell cause K a>

potassium citrate and structure; 1cgulatcs prunes, red acid-base diarrhea. substttutes inc1eases. main "i;;
potassium bicarbonate muscle function, mea1s. imbalance, N&V. cnuse of d1g1toxin "'
:I
Q.
vegetables. loss of muscle decreased tOXIClty
~
IKLvter-varies. PO. 1nclud1ng cardiac
IV: muscle. protein milk and milk tone. urinary output.
3
muscle
potassium chloride
(K-Lor. K-Our. Klar-Con.
synthesis:
carbohydrate
products.
yams. coffee.
weakness.
paralysis, weakness .."'"'
<

Slow-K. Micro-KJ--<10-
too mg PO. IV;
metabolism soil
subs mutes
cardiac
arrhythmias
..
:;::
Q.

potassium gluconate
(NTN)-40-100 mg
..
;;
5

PO
C.:0"(1"~ ....
....
....
 w
w
TABLE 19 4 MICRONUTRIENTS- MINERALS- cont'd
ORUG NAME. FUNCTION INDICATIONS FOOO MINERAL EXCESSIVE DRUG OTHER
'"
~
DOSAGE. ROUTE IN BOOY FOR USE SOURCES OEACIENCY MINERALS INTERACTIONS INFORMATION
Chloride /Cl )
In combination with other f.xtracellular ftud. Salam of llSSIJe Table salt m'k. Rare except m Noneidltent <
.....
None
el octrolytes buffer: enzyme ftuids meat those taking ::r
activator. processed medications
component of foods that cause ~
n
gastnc: hydrochlonc NaCl loss O'<ef
acid long term f
O'
~

TRACE MINERALS 3:
c
Iron (Ft.-J
ferrous sulfate (Feosol,
Slow FE)-325 mg PO.
Essential component
in hemoglobin.
Iron deficiency
anemia, pregnancy.
Lean red meat.
whole grains.
Anemia Iron poisoning antacids. celd1mr.
tetracyclines.
Men generally
do not need
"'
~;;;
3
ferrous g1ucooate a1111body formation dialysis egg Volks. ftooroqu111olones, supplement >
"O
IFergon)-325-600 mg legumes, mycophenolate. ferrous sulfate 1s
.."'
"O
PO; raisins. thyroid drug ol choice. ~
ferroos fumarate prunes, honnones. iron causes 0
~
IFeostat)-200 mg PO. apricots proton-pump const1pauon:
11on dextran (lmferon, inhibitors injectable iron
INFeO)-IM. should be giwn
iron sucrose (Venofer)- via Ztrack; iron
100 mg/dialysis dextran-shock.
treatment IV se1rures: coffee
I and tea interfere
with absorption

hnc(Zlr)
I Zinc acetate (Galzm)-
25 mg PO.
Component of RNA
and ONA;
Wilson disease,
sexual
Meat, oysters.
eggs, milk.
Skin lesions Poor muscle
coordination.
Huoroqu1nolones.
tetracyclines
Excess zinc inhibits
copper
prenatal vrtam111s- developnent whole grains vomiting,
varies. PO. wound healing, dianflea, renal
zinc oxide-topical skin irritation normal taste and failure
smell. pre.ento0n

I of common cold
Fluorin~ /R I
fluoride. Dental and bone Dietary supptemenl Fluorinated Dental caries Monled tooth Aluminum Fluoride
ftuorine {Fluontab formauoo and osteoporosis. water. stains hydroxide. milk. supplements lor
lundel-vanes. PO; integrity dental canes toothpaste dairy products dl11dren IMng
IPoly.VtAorl dtops. PO and nnses. where water
tea. seafood supply not
ftuOfmated;
experimentally
lor treating
osteoporosis

Iodine WI
fn oomb1nat100 with other Thyroid gland
medications synthes.s. basal
Goiter. cretinism Iodized table
salt. seafood
Physical
deformity,
Aale-li\e lesions thyJOtd hormones. 11
usuig Kl. be alert
I~ m
metabolic rate dwarfism.
mental
to mteractioos
with K-conta1ning
-::D

"'
z
retardation in medicatioos or c
children. those that help 1g_
0
coma. retain Kleg ., "
!!.
hypothermia. ACE Wtibttorsl Cl>
resp1 ra tory ..,..,c
depression in
adults tf"
"1
.,
Copper /Cu'J
In mulhple vrtamins and ..."
prenatal vttamins in
various strengths. f'O
Component ol cell
enzyme. energy
production.
Wilson disease with
zinc intake with
liver and nerve
Organ meats.
sealood.
ntJtS.. seeds.
Found with total
parenteral
lllltritlOO ITPNI
Rare As with other
mmerals in other
oombinaoon
....
~
:;
hemoglobln damage legumes. a
dtugs <
synthesis grams
..
3::
~
.."'
:;

l:l
"'
 336 SECTION I V Pharmacology for MuIusyste rn Application
I'1cd eXlemally o r taken orally to correct ~
TABll 19; EXAMPLES OF HOME ANO FOLK REMEDIES app
orders. lh e goal of Eastern medicine ishealthPllW'
and stabili7.ation. . . . .
REMEDY ANO METHOD In \ .,..,cs tern medici ne' 1n wh ich the sc1enu6c
. .....
-......
OF USE USED FOR d h
1
m of illness a nd trealme nt predommat~
para
. ns 'd " I I h I
lti~y illness as a p 1ys1ca . c cm1ca . orpr,.
Hot chicken soup---ilral fever, cold. flu crn i e1 I . . .
logic <foiurhance in the b oc y. I Oetts 1s on 1 n~el'l'tnli
Lemon in Wdter-oral Cold and conges11on
often i 11vas ivc in son1e inanner, co correcl ~isturt>a,.
Potato iuice-oral Arth11t1S Aggressive treatment o f ~ymptoms. and then_C3U!ts
Orange JU1te alld ArthntlS been the norm; ho wever. a Itemauve_therapl(S -.
gela brt--Otal n 'CllpUncture yoga, and dietary n.,~
1na)~ag..:, " ~
()lions increasingly accepted.
topical to feet fiMlf
Olal Cold
inhaled Congesuon
topical hot packs Earache
topical, raw, on neck or Headache
soles llcrbal s upplem ents (sec 1~1b l c 19-6 ror commonJy 111
oral '
Stomach ontest1nal distress lwrb>) .ue minima lly regu l.ltcd by the FDA Mid
01al Bood clotting disorders Department of Agriculture ll1e FDA regulaia
Olal Heart disease a> d 1ctary ~upplements with l.1beling for COOla'
Vinegar not for medicinal u~. doses, and dangen. la
gargled Sore throat Congress passed the Dietary ~upplement Heallil
J:ducation Act, defining s upplements such as vH..
topical Sunoomed skin
mi ne ra ls, a mino acid s, a nd herbs. Minimal ~
topical Pruntus, contact dermatitis contro l exists, a nd false cla im s arc numerous. Them;.,
oral Chrome fallgue syndrome o f a suppleme nt must o n ly prove that i1 is a "food
Dandelion tea-oral Unnary tract infections s t.incc and label it as a d ic t.iry supplemen~ 50 II..
Gelatin-oral Diarrhea produc1s arc not subject to th e .iringem rules and ~
Garlic before marketing that are re(1uired for phamucmd
topoc:al 01 Olaf Ant1sepl1C -ihe 1 DA mu~t prove th.11 .1 M1pplcmem is unsaf(Mn
Olal it can be legally remowd from the marka. li<a:r
Antob1ot1t, coronary heart
many patients do not have complete knowltdgt
disease. decrease blood
interactions of pharmaccutk.11 produru and ht>
cholesterol, hypertension,
ant1tumor agent p roducts, health profession a ls should inteniew
patient a bo ut a ll m edicatio nb .1 nd su1lplemenu [-(:
1ak<11, w heth er p rescription o r OTC. l' ntients should
encou<Jftcd to discuss herh.il preparations used "1th.
repro.1ch a11d underst.lll<I 1lw physidan is iml'R'.!ltli
disn1"ing supplement use to pr~cnt drug-suppin-::
intcra<li<Jns
healers are cumm/mis (native healers). )'l'ri"ros (herbal- Different pans of an herb blossoms. sttds 'CJ
ists). espmrualuras (spiritualists). or bni1os (those who use and roots- may be Ubed for medicinal purposes.~
wi tchcraft or magic). Hot and cold foods such as herbal leadi ng use~ of supplement products are listtd in
teas are u>ed to treat some conditions Massage may be I'l I. <.:011'L1mers s ho u ld he aw.ire 1ha1 namral" "'
used, and religious medals may be worn. Som e l lispanic not 11cccbs.irily mean ' sa ft'. Some herbal supplellXI
America ns wear an a.wbtlclte, a b lack stone, to ward off ca n b hn1n1ful because of the herb itself1mounta.
the evil eye that causes disease. s umed, pa n of pla n1 used, or contaminants that hJ
In F.astcrn (Asian) medicine, the objective is to keep entered during growi ng or processing stage$. fkC
the body in b.1lance between opposing forces of yin may have m ter.11:1ions with pre'>CT'1bed medicatiom
(cold) and yang (hot) for maintenance of good health, O'IC items. causing toxic or allergic responses. Of
with illness occurring when the body 1s out of balance. c01m~rn 1~ the possibility Lhat the pallt>nt 1sbeingut#l
The Chinese ph)'Sician prescribes a \'aricty of therapies, with herba l supplements and foregoing a medial dot
including herbs. acupuncture.. diet changes, exercise. nosis .md 1re.111ne111 until the d isc.1sc has berolllt
meditatio n. or services o f sp iritua l healers. I lerbs may be adv.111ccd 10 treat effenivel)
 - - - - - -CHAPTER 19
TABLE 19 6 SELECT HERBS USED BY CONSUMERS
Ed#MCea lca.stion IU111g pregnancy
and lactatt0nl
Garlic
Gmlgoloot during pregnancy or
lactation)
Golden seal lnot du11ng pregnancy or
111 yooog ch1len)
Saw pa!meno
Aloe
Panax gmsoog (may cause asthma
attacks. 1ncieased BP. heart
palpitations. postmenopausal
bleedongl
Astratplus
Siberian g1nsong lmay cause asthma.
increased BP, heart palpitations.
postmenopausal bleeding)
B1lber1Y !cannot be used for long
period of time)
Dong (1Jal
St JcM's 'NOil (headaches.
increased BP, photosensitrvity.
multiple drug interactions}
Nutnt1onal Supplements and Ahernative Medicines
: I.
May have am biotic acllCO
Strengthens cardiovascular
system. decreases cholesterol.
decreases BP
Vasodifatat1on. improves blood
circulation. decreases blood
dots. decreases retinal damage
from macular degenerauon
Dries secretions, re00ces
111ftammatoon. mild
antim1C1obiaf. aids 111 digestion
Reduces size of prostate gland.
dries secre11ons. aids with
d1gest1on, sleep, and coughs
Decreases pain of burns and skin
irritations. antihistamine.
laxative
Calms stomach, stimulates vital
organs
StretYJ!hens body, speeds
metabolism. promotes ussue
regeneratoon. 111aeases energy
Stimulates heart, increases
circulation. improves dogesuon.
boosts energy
Increases immune system;
increases resistance to disease.
stress. and fatigue
To treat f!Ve problems such as
glaucoma and cataracts,
decreases plaque 1n arteries,
diarrhea. dOC1eases blood sugar
Genmcidal. antunftammalOl'f.
antidepressant
337
I,
Internal Colds. mfluerua. URls. ear infoc11ons.
sept1Cet11 a. bladdef 1nfect1ons
External Cuts. boils, abscesses. wounds. hrves.
eczema. insect bites. herpes
lntemaf Digestive disorders. d1a11hea. liver and
gallbladder problems. URls. influenza. 1heumato1d
arthritis, bladder infection
Externat Hookworm. roundworm. ringworm, athlete's
foot. swelling. m1oor skin infec11ons
lntemaf Vertigo. Alzheimer disease. tinnitus. phleb1us.
leg ulcers. peripheral vascular disease. cerebral
atheroscleraSIS. headaches. dejnssion. Wakes.
heart attacks. lack of concentration
lntemal Oianhea. 1mtable bowel syndrome. col1t1s.
ulcers, gastritis. gingMllS. vagmal yeast onfect1ons,
Oht1S
Internal Benign prostatic hypertJophy. nasal
congestion. asthma. bronch1us. URls. smus111s.
sedative. diuretic. expectorant, bladder onfecuons
External: Antiseptic
Internal; Digestive disorders. gastric ulcer, laxative
External: Burns. wound infections. Insect bites. skin
1mtations. chickenpox. acne. poison ivy
Internal. Depression. fatigue. stress. UAls. influenza.
inflammation. respiratory tract d1sordeis
'
Internal: General weakness fatigue, loss of
appente. diarrhea. blood abnorrnah11es. URls. AJDS.
cancei. chronic fangue
Internal Poor Clttlllatoon. indigestion. phv$<cal '
mental exhausllon, lowered energy
External: Pain. arthritis. strains. sore muscles and
joints. increases blood flow. stops external bleeding
Internal: Depression. fatigue. siress. UAls. influenza.
respiratory problems. damaged immune system
Internal: Eye strain, cataracts, glaucoma. night
blindness. nearsightedness. diarrhea. constipation.
stomach cramps
External Spider veins. varicose veins. hemorrhoids.
bums. skin disorders
Internal: Menstrual irregulauty, stabbing paon. poor
c1rcula1100. carboocles. palprtat1ons. blurred vision.
li~theadedness
Internal Depression
External Wounds, scar ussue
338 SECTION IV Pharmacology for Mult1system Application

Feverfew (may alter clotung ~mes) BlockS inftammatory substances m

blood
Motion sickness. digestion.
dimness. burns. may prevent
heart disease and suokes by
decreasing BP and internal
clo1t1ng
An11depressam. diuresis.
Kava kilva'
an11sep1ic and antiinflammatory
agent for urinary tract
Bronchial decongestant. CNS
~t1mulant. increases heart rate.
increases BP
Alfa la Nutritional supplement. body
cleanser
Kelp Goiter remedy. th'(roid disorders
(1od1nc-nchl
Parsley Expeclorant. diuretic, laxative
Rose hips Nasal and cheS1 congestion
Tea 1ree 01! Skin disorders
Melatonin Tranqu1hzer. sedatM!
A/OS. acqwod .,..,.,.-ticoency S'jlldrome. BP. blood pressure. CNS, central nervous system. PMS. premenstrual syndlome, Ill/. -
mfecuon
'FDA has 1nd1ca1ed 1ha1 kava kava should not be used because of hver toxicity
Internal Vomning. abdominal cramping. COt4I.
menstrual irregulanties. motion su:kness. ~
sickness. colds. flu. arthritis. increases II' ao'lj
cholesterol
lncemal: Urinary tract disorders. prostate 11~
gout. rheumatism. insomnia. depress100. IT>JSC!e
spasms
Internal fever. coughing. wheezing. nasal or t~~
congestion. indigestion. asthma. obesty
Internal Inflammation of bladder. diuresis ~
consupation. hahtos1s
Internal: Hypoth'(roid1sm. goner
/ntema/ Indigestion. conges11on, asthma, irr~1
menstrual periods. PMS. increases BP; conge..'troe
heart failure
Internet Colds and flu
External: Cuts. abrasions. insect bnes. acne IUOJa
infections, flea shampoo for pe1s
Steep
~

BOX 19-1 COMMON REASONS FOR USE OF DIETARY SUPPLEMENTS 'I

Disorder Herb or Substance Commonly Used
Upper resp1ra10<y mfect1on Echmacea. elderberry. Astragalus
Borns Calendula. lea tree. aloe. lavender od
Headaches Feverlew. black cohosh, willow bait
All!l1g1es Ffeeze-dned nettle leaf. Coleus. grape seed
Rashes Calendula. lea tree. flaxseed oil
Insomnia and S!fess Valerian. passion flower. kava. melatonin
Premenstrual syndrome Vilex. black cohosh, dong quai
Depression St John's wort, SAMe
Diarrhea Blueberry leaf. bilberry
Symptoms associated with menopause Blade cohosh. soy 1soflavones. Vitax. evening pnmrose od
Nausea l'epperm nt. ginger
U11nary tract 1mtabd1ty Cranbeny
Cholesterol and I ptd conlfOI flax seed 011
Prostate health Saw palmeno
Memoiy enhancement Ginseng
Nole: This bo is nor an endorsement of the uses stated
 --~----~-------..:
C..:
HAPTER 19 Nutn11onal Supplements and Alternative Medicines 339

TABLE 19 I EXAMPLES OF HERBS WITH A POTENTIAL FOR TOXIC EFFECTS

lmtnunosupptltSSlon w1m long-tenn use

Ginkgo
Goldenseal. Cumca Oowers. wolfsbane
/Acomtum). mountain tobacco
WotmWOod. absinthe. mugwort. madwort
/A/yssum)
Belladonna, deadly nightshade /Solanum)
Buckeye. horse chestnut (AeSC1J/1JS
/rlppor:Mranuml
Hemlock 1ean;.,r,1 spotted parsley.
St Bennens hefb. spoiled CIM'bane,
roors parsley
Lobeha. Indian tobacco. wild tobacco.
asthma weed. emeuc weed
Ep/iedra Ima huangl
Periwinkle, viiwa
Black cohosh. chaparral, comfrey, kava kava
~love. squ1ll, hconce, hly of the valley
Reacts w11h amicoagulams; hypog~I(; effecrs. so may affect an1id1abell(;
treatments
Reacts with anucoagulants
Affects hean and vascular system; Cunica induces 1ox1c gas1roenteri11s. neNOOs
system d1s1urbances. muscle weakness, and death
Narcolic poison !oil ol wormwood). damage nervous system. cause mental
impairment
Alkaloids of atropine and hyoscyamin-an11cholinerg1c symptoms ranging from
blurred v1s1on. mydnas1s, dry roouth, and inability to urmate 10 unusual behavior
and halluc1nauons
Coomadm glycOSlde-inlerlere with blood dotting
TOXJC a <alood anum and Olher related a'kalo1as
E.xcessive use-sewte vormung, pain. sweating, paralysis, decreased body
temperature. COO'l<l, and death
Contains ephedrine. pseudoephedrine. sympalhomimeuc-lrkely lo m1m1c ac11ons of
epinephrine. increases blood pressure. increases heart rate; used 10 make
methamphe1am1ne
Alkalolds-cy101ox1c, causing h\11lr. kidney, and neurologic damage, base for
an1ineoplas1ic agents
Hepa101oxic11y
Poten11al cardiac effects. such as armythmia

II is d1flicuh 10 evaluate the safety of herbs bause

herbal supplemenlS may contain a mixture of plams and
other materials When potenl herb5 are compared wi1h
equally po1cn1 medications, side effecis of herbs are
compMable or more severe. To date no study h.1s shown
herbs to be more cll'ective than chemicals purified from
them, and s.ife1y of these produC1s cannot be prown
b~c.1use chemicals have not been tested for purity. l're
scrip1ion medications from herbs produce essem ially 1hc
S<1mc aC1ions as quamities of herbs themselves and have
a higher safc1y foC1or because of lhe quality siandards
required for medications. Supplements should always be
usro with caution.
Some serious problems such as toxic ell'eru on
1he liwr and heart. fetal malformations, and produc
uon of abnonnal cells leading to cancer have been
reponed "nh indiscriminate suppll'Dlent use. Ille
actual rate of adverse reactions Lo these supplemenlS
cannot be de1ennined because they are not reponable
by law. l'roducts with potential to cause 1oxic effects
and in1erac1ion> with certain drugs are listetl in
Table 197
Special care should be rakeo Wtth hefbals by patients w1lli
allergies. lhose sensitive 10 medications. those t.Jk1ng med~
cines for chronic illnesses. and those older lhan 65 years of
age or younger than 12 years of age
2 The lowest possible <lose should be taken 10 pio1ect against
adverse reactions. Herbal supplements are bosl absortJed on
an empty stomach, but they should be discontinued of nausea
consistently develops within 2 hours after ingestion.
3 P1egnan1or latlating women are advised no110 take dietary
supplements without a physician's advice.
4 Supplements should be purchased from a reputable source
rather than home grown because 1ox1c contaminants such as
pes11c1des aod heavy metals may be found on some herbal
products Repulable soorres also are more I kety 10 have
some method of qualrty con!JOI duung 1he production of the
product
5 Patients should be careful about 1a\rng prescr1pl1on medica
lions and herbal supplements together
6 Before taking d1elaly supplements. the consumer sllould
acquire as much information as possible aboul the products_
 340 SECTION IV p
harmacology . .
or Mulusystem Application

insufficient vit.1mins or minerols; other di~
as osteoporosi\ and anemias may be impr""
supplemen1ation . . .
JlcmentS are no Vitamin\ are d1v1ded into two groups.111' r.u
Herbs and Olher SUllljj by Ille Food a regulaled as smelly_ as vitdmins- A. I), F.. and K-are absorbed mcf 11, rd
aiiPOV\
ica!JOnS supp1efld
d etatY Dwg Adm1mstrauon
the body. therefore not requiring repl.artment on 1
q)AJ and a<e sold a man"'8'1ts
la< 111 basis Vit.1min n complex and v1tamm C. watn
"emativemedlCUICnthlC
5
~ev1...,....,
, _ 0yculiures include ueat
,, ts for wlllCh sc1e f safely and usefulness vitamin>. arc not stored, and the excess is~
15
urine; ,1 well-b.1lanccd diet provides a continuing ..,~
atkng a dietary suppl1 of tJ1ese vitamins.
Herbs are considered by 1men1and1herefore are
PP1emenlS t1 . Minerals, like vitamins. usually occur adequa1.,,
regulaled as food su h 1e Department of Agn-
1
cuhure, wrlh l1m11ed aul orny given o the FDA foods and arc absorbc~I from suppl eme111sdell(n~ing
body needs. ~omc 01 C supplements are formulat<11
vi tan1in and n1iner.1I con1binations.
compll'mc11t.1ry and a lternative medicine p~
are not univer.ally profe>sionally accepted lltatmrr
uaditional Western mtdical c.are. Folk media...,
S UMMARY home re medics. based on herbs, have been used du
out history. with >Ome cultures having dttper IOCll
Vitamins and mineral' are essenual compounds needed these tradiuo ns 1h.111 others.
'r
10 keep the body m t'omeostasis. adequate diets are Herbal >upplcmcms comain many biologialiy
consumed, most people will not need vitamin and ingredients 10 be used primarily for the lltalJnnil
mineral supplements '11ie I DA coi,~iders vitamin sup- mi ld or chronrc illnesses. Many pharniacrotic.a11
plements to be medications and therefore regulates nating from plants contain these same ingredl!'ll~ 00
their production and use. Young ' hildren and e lderly in a highly p~iri fi<'<l form. 'l11e <la nger with herl>al suw
people, pregnant or lan.11ing women, and patients ments is that tlwy arc no t subject to strict SUP1V111oa
undergoing chem0Lher.1py and dialysis ge11ernll)' need the FD/\ . /\;. well. nrnny o f 1.heir interactions wuh r
10 take vitamin and rn ineral supplemen ts. /\bsorpLion scripti on 111c<lkincs arc unknown o r just coming1oligh1
disorders and irnrnure syi.1e111 deficiencies may also Documentation of a ll herbal supplements beingull'db
necessitate daily ima~e of ,l(Jditio~al vitamins. Some a pa1ie111 b ~cn tial for patiem safety as well ii.It>
diseases, such as scul"\'Y and beriberi, are the result of required by law.

Scenario
Kim. a young adul~ 1s 1n good /1ealth and ears a well-balanced diet. She has heard that rakmg vrtamms
may make her feet better, and she 1s considering taking multivitamins that contain water-soluble and
fat-soluble comporwnts.

1. What do you ten her about excessive water- and fat-soluble vitamins? Should s he need vitamins?
2. What can Kim fixpect to gair' by using these vi tamins?
3. What nsks will she be taking?
4. Kim says that "-hen she wa! pregnant she had to take v1tamrns Why were vitamins rmportant then
and not necesseiry now?
5. What vnam1n d<ies the Marcil of Dimes suggest Kim take ?
 CHAPTER 19 Nutritional Supplements and Ahernabve Medicines 341

DRUG CALCULATIONS
Order: porassium ch loride 80 mLq Dose to be given: 30 m L
A,.ilable medication: How many ounces of medication would be gj'en to
lhe patient/---- - - -- -- - - - - -
Draw the dose to be given on the medicine cup.
NOC 001J.3113-S1

KAON-CL
203
!POTASSIUM
_ .....
2res--30m1.
-->tml

1res __ ,,...
OflDRIDEJ 2TSP-t01ft
' TSfl--.-- .& fl'll
40mEq!S ml
()M[l lY
2. Order: Vi1am in 8 11 1500 mg twice a week
Sul"*'~'"
C..:t. 1S ml C'Zb'n; : 14' Available medication: cyaoocobalamin 1000 mg/ml
~ t ttq Uc:h ol What dose should be administered?- -- - --
~~<hloridc ....
pow,.i..... ~.) '"
uatMitCn vld
'trith
kohol .51'. Show the amount of medication on the syringe below.
CAVTION: f ederal t1w
Pf0hlbit1 dlspt:tulng
wit~! p.-bl:ripcion.

ONE PINT

(#! tlt#\Jllll II l1111J 1111l 1111 !111 11111

REVIEW QUESTIONS
I. N,tme three groups o f people who might need vitamirt supplements. - - -- - -- - -- - -- - --

2. What are vitamins! Minerals? Electrolytes? _____________________ __ _ __

3 Which vitamins are water soluble/ Fat soluble? - - -- - - -- - -- -- - - - -- - - - - - -

4. Why is toxicity with fat-soluble vitamins a pOS$ib ility7 Why is toxicity not as likely wit h water-soluble vita111i1ts?

~. What vitamin is necessary for calcium to be effective? What are two sources of this vitamin? - - - - - - -
SECTION
Endocrine System Disorders

After studying this chapter, you should be capable of doing the following :
Describing hormones and their functions
Explaining how hormones secreted by anterior and
posterior pituitary glands affect diseases and their
treatment
Descnbmg the role of the thyro.d gland and its
replacements and antagon1s11c med1cat1ons
Discussing forms of steroids and corucosteroids
and their role 1n treating disorders.
Describing the role of ant1d1abet1c agents and
ad1unctive agents in treating diabetes me11111Js
(DMI.
Describing role of glucose and glycogen in
maintaining homeostasis.
Prov1d1ng patient education for compfiance w-.n
medications used to treat diseases and cond1:ro.;
o f the endocrine system .

Dianne. age 45, has recently been diagnosed as having T2DM She had no idea she had any medica
problems until she went to her physician and her blood glucose rest result was elevated above 300 arri
the HgA above 15
What symptoms do you thmk may have been present that she might not have reahzed vvere 1mponan1<
What role w ill exercise and diet play m control of glucose levels with this type of diabetes? What is the
role of weight loss with T20M 7
Can Dianne expect to take 1nsuhn for this type o f illness? Why or why not ?
If not insulin, wha t classes o t medications might be used?
Can oral antid1abetic medications be used during pregnancy for gestational diabetes? Why or why notl

Action onset Goiter Lipodystrophy Replacement therapy

Action peak Growth hormone Mineralocorticoid Repository action
Bolus Hormone Negative feedback Steroid
Corticosteroids Hyperglycemie Osteoporosis Target organ
Endogenous Hypoglycemia Polydipsia Tropic hormone
Exogenous Hypothalamus Polyphagia
Glucocorticoid Islets of Langerhans Polyuria

344
a----------------~--------=C:..:.
HAPTER 20 Endocrine System Disorders 345

EASY WORKING KNOWLEDGE OF DRUGS USED IN THE ENDOCRINE SYSTEM

AnterKJr p1tuot.'.lry Yes No B.C Growth stomulams. thyro1d-st1mulat ng loclrmooe.

hormones adrenocortJCotropon, gonadotrop1n
Postenor p11u11ari Yes No c Antid1uretJC hormone. oxytocon
hormones

THYROID HORMONES
Triiodothyron1ne (T1). Yes No AC Hypothyrmdism
Thy1ox1ne (T,)
Calc1tonin Yes No c Ostooporosis
Thyroid-1nh1b111ng Yes No D.Xll-1311 Thyroid malignancies. hypenllyro1d1sm
p!epa1'3tlOOS

STEROIDS/CORTICOSTEROIDS
GIUIXICOlllCOlds Yes Yes-tDplQll c Chronic ii!lamrnations. allergies. exacetbation
of chronoc loog disease
M1neraloconoco1ds Yes No c Ant11nflanvnatDI\'. Addison disease
Cort1costerood10h1bot1ng Yes No C.D Cushing disease. mahgnanc1es of adrenal glands
agents

ANTIDIABETlC AGENTS
Insulin Yes Yes (Regular B. C Tl OM. T20M in some cases
and NPHI
Oral and other injectable Yes No B. C. (should T20M
ant1d1abe1tc agents not be
used in
pregnancy)

HYPERGLYCEMICS
Glucagon Yes No 8 Hypoglyremia

TIOM. T'lll'! t di.iberes me11,tus. TZOM. lj!ll! 2 diabetes meflotus.

EASY WORKING KNOWLEDGE OF INDICATIONS ANO SIDE EFFECTS
Common Symptoms of Endocrine Diseases Common Side Effects of Medications for Endocrine
Mental deviations Diseases
Excepuonal changes in energy levels Corticosteroids: Shortterm-inc1eased appetite and swelling.
Growth aooormalitres long-terrn-cushingoid syndrome. decreased density of miner
Skin. hair. and nail changes als in bones
Weakness and atrophy of muscles Thyroid preparations: palpitations, tremors. ncNOusness. tachy
Emotional disturbances or psychologic disorders card1a, increased blood pressure. headache. exophthalmos.
Edema weight loss. and imtabilily
Changes 1n blood p!essure and heart irregulam1es Ant1d1abet1c agents: hypoglycemia. nausea. heanoom. diarrhea.
Sexual megulanues headache. weight gain
0ianges tn ~!lalY outpUI

he endocrine system is a ne1work ofintemal glands stimulate various tissues to increasetheiractivity. I lonnone

T without ducts chat secrete hormones directly into

the bloodstream to be carried by blood or the lym
phatic system to tis.ues o r other glands throughout the
action is slower in onset and of longer duration when
stimulated by the nervous system. Some honnones ,1re
effooive only in cenain iypes of 1issues o r org;ms. called
1uge1 organs, with specific receptors for 1he specific
body for vital runetions (Figure 20.1). llormones
 346 SECTION v Med1cat1ons Related to Body Systems

may begin activity when recogniud by cell orlitt 11:..

honnone As the honnone attaches to this receptor site it
aru as a key to rde.ise the hormone to produce .its e /Tea
Honnone spe06ciry and cl'llular receptor sites togelh.er
fonn a complex regulJtory '> tt>m to ensure homeostasis.
Only specific ~eptor material bmds lhe hormone so 11
Parathyroid gland
(on posterior .
stHface of rhyrotd
gland)
r. hormones ha\'<? no effect on ussues not hll11t
::~~ receptors for lhe specific hon_none (Fi~ 2C 1
Ole h>pothala mu~, located "' the bri1n, 1
hormone secretions, much.as a lhennosiat regul.a1.,~
rature in .1 heatingcoohng system. lnHuetld by
~y itself and by environmental. faaon, the h)1l<
rnus causes production of releasing .ho~ones th
11
received in the pituitary gland t? mamuim homec,.
With th e hypothalamus responding tO the body'sinte
vironmen t to control hormone release by ntg.i
en
frcdh. . 1bus 1unher
. respon se 11111
i c k, a physiologic ' \ft!
Li ns of hormone. Simi larly, increased hormone.,
ti~ns m.iy cause c~Mation of external Stimuli, endrl\
secretion rl'Sponse internally. This response rs a""'
negative m;ponse much like turning a light off ind
response to light and darkness (Figure 20-3).

Figure 20-1 The major endocrine glands of the body (Ftom APlllegate E:
The anatomyandphysl()logy teaming systl!m. ed 4, Philadelphia. 2011, WB
Saundels)
1111:01;11:r.1;1iw.rn111-.
Hormones are substances from steroids (lipids) o.
nonsteroida l (derived from amino adds) Somt ~
manes regulate the activity of olher hormonesandb
a spe<"ilic physiologic effect on metabolism, indl>.I
substances causing the anterior and posterior pi1U11,
glands to rcll'.rse tropic or s li mu laling hormones. Tht
integr.11cd rcln tionsh ips are between different gland.
the endocrine system (Figure 20-4 ).
I lorrnones are necessary for regulaLion of vit.1l
cesses ~urh as wcretion of gastric en:zymesand fluids

Kidney water
reobSQtplion
+-- oH - - AOH
/ TSH--z,
ACTH I\ OXT

/ FSH LH PAL

" ' liillll'JI

Thyroid
hormones
ThyroOd

Adrenal
Corocal , / gland
h<1 \ Utenne
Lactation

contraction
Breast
nomn..
Testoot0t0ne
JI' I
i'
TestJs
,/ I "
Ovaiy .......
glandular

Sperm Ova i' Progesterone

Estrogen
Figure 20-2 Hormoneraceptor ac~on of hormones rn tl1e body AcrH, adrenomt1co1roprn. ADH. antidiuretic hormone, l'SH. folhcle-snmularn~'
GH. growth hormone; LH, lote1n1Z1ng hormone. OXT. OY1ocrn. PRL prolactin, TSH. thyrordsrurrulating hormone (fiom Applegate E: The anaWftl~arli
ogy learning ~ram. ad 4. PhJfadelph1a. 2011. Saunders.I
 CHAPTER 20 Endocnne System Disorders 3'7

to access tMgct organs. Most honnones have shon half

Envlronmen1al 1actors Body's homeos1aSls
(+ _ , (+1-) lives of 10 to 20 minutes, exerting their effect immedi
ately and reflecting their rapid use or excretion. The
effect.s of other hormones may persist for hours. resulting

Hypothalamus
' 4
in prolonged organ stimulation.
I lormones 1101 used com1>letely must be inactivated
by enzymes in blood, intracellular spaces, li\'er, kidneys,
or target organs or are excreted for the body to stay in
homeostasis l:xcretion is primarily in urine but may be
IJlerease lnl&ibi1 found in bile.
secrelte>nS secretions
Two major therapeutic uses ofhonnones exist. In case
of a deficiency, the needed hormone is ad ministered as
replacement th...-apy. Second, large dOSl'S ofhonnones
Releaslnghormc>neo may be gl\'tn ther.1peuticall)'. such as corllcostttolds
for inflammation or anhritis. Hormones may also be
used for e ndocrine diagnostic testing, such ,is ACfH fo r
f
adrenal insufficiency testing When used either therapeu
Pitu1lary gland tically or diagnostically, as in the situations cited, the
(antenor and posteno<) -+
honnone becomes a phannacologic agent.

Sluoolating Nega1lve leedback-

hormone inhibftlng hormones
PITUITARY GLAND HORMONES

Target gland The pituitary gland, located below the hypothalamus

hormone secreUon
Figure 20-3 The relatiooship between "'gative feedback and
har laS>.S
moior acuvmes o f the digestive tract; produaion of
cnerm" composition and volume of extracellular fluid;
,tdJptation of the body to external environment; growth
,ind developmeni; and reproduaion and lactation.
Stl'roid hormones, secreted by adrenal and sex glands
and manufacturl>d from cholesterol by endocri ne cells,
are lipid soluble to be lf3nsponed in plasma. These
chemicals aa as messengers to regulate the body's inner
fnv1'onment in conjunaion with the nervous system.
Nonsteroid hormones, synthesized fro m amino acids,
.uc charaaerizcd by the followi ng:
Protein honnones such as insulin and glucagons,
parathyTOid honnones (1'11 ls), calcitonin, growth
hormone' (Cl Is), and adrenocorticotropin hormone
(ACTH}
Glycoproteins, including follicle-stimulating hormone
( 1~1 1 ), luicini:ling honnone (1 11 ), thyroid-stimulating
honnone (l'SI I), and chorionic gonadotropin
Peptides such as antidiumic hom1one (ADI I). oxyto-
Clll, and rclmsing honnones
Amino acid derivatives that include epinephrine, norepi
nephrint>. mela1on in, thyroxine. and uiiodoll1yronine
111e endocrine system has extensive Oexibility in
length of aaion, as the honnone leaves the bloodstream
and about the size of a pea, is called ' the master gland:
as it regu lates the endocrine ;ystcm. Pituitary hormo nes
regulate hormone secretions from other endocrine
glands. lhe anterior pituitary lobe secretes tropic hor
mones, named for the affected gland, such as thyro-
tropin. which affect.s the thyroid. Responding to
neurohormo nes or hypothalamic-releasing factors, these
honnones cause other endocrine glands to secrete their
specific hormones.
Anterior Pituitary Gland
'llw anlerior pituitary 1tland with the hypothalamus
communicates by releasing regulating factors delivered
through blood '-essets. The anterior pituitary gland
secretes six major honnones controlled by 1he hypo-
thalamus, with three being used therar>eutically (see
Figure 204) ,
I. CH -stimulates almost a ll tissues and organs for
growth
2. Adrenoconicotropic hormone (ACI II), or
adrenoconicotropin-aas on the adrenal conex to
promote synthesis and release of ilS hormones
3. Thyrotropin ("l'Sli}-aets on the thyroid gland to
promote synthesis and release of hormones
4. Prolaain-stimulates milk production and sttre
Lion in \VOn1e.n
5. FSI I- promotes follicular ovarian growth and tes
ticular spermatogenesis
6. LI I-promotes ovula1ion and the development of
corpus luteum in the female and acts on testes 10
348 SECTION v Med1cauons Related to Body Systems
-

--
PfolaClln
sumu1ates breasts
to secrete milk
Ol<y1ocln
'fhYrotd-stirnulahng Stimulalel ,,...
horm::.on;,;;,.-.. muscle corcrld
lt1U1....
Metanocvte stimulating
hormone-synthesis
ol mela,..ni,..n_ __

Lutetni""9 """"""$
d testosterone
Release ot
9 Formation ot
corpus luteum
and roleose ot
ovoroen lolllcle

FoU1cte~stimu 1 a1 1 ng
honnone

Figure 20-4 The retatoonshp bel'Mleft ll1'l d Development R1pen1ng OI

9 ovar.a n lotl.cte
poturta<yg!Nd and other g ands ol the endocltM of spermatozoa
system

promote androgen production in the male (These
last three hormones are dbcmsed in Chapter 28 in
the seetions on Lht reproduriivc system.)
Somaro1ropi11, or C II, is prod11ccd by the an Leri or pitu-
itary gland 10 help in regu l.uion of growth . Absence o f
this hormone during childhood b the reason for dwarf-
ism in most cases. Main replacement of GI I b with
children who have growth failure because of lack of
produaion or endogenou~ somatotropin. Some people
de--elop antibodies with prolonged treatment, but these
rarely decrease the clTcetiveness of treatment (which ma)
increase growth by as much as 6 inches) Somatotropin
replacement is expensive (approximately $2000 per
year). The efficacy of Cl I replacement therapy declines
as the person grows older. with its therapy becoming
ineffeaive by age 20 to 24 ye,irs. Oetreotide (Sand-
ostatin), a CH inhibitor, is used therapeutically to
lower blood Gii lewis with .1cronwga ly or gigantism
(Ta bk 10 I) I~'<'\\!"" producuon of Gii 11
c,,u..,t...; '" ttH111_..:al>~ 'vlu.:rc.i' .tCis11rur.s1n occun if tlm!
Mimu l.ttio11 o'"'" hdore cpiphyseal lin11111
arc ch_>'>l'tl.
Atlre11owrricotro pic lionno11e (or adrcnoC<~
pi11), llM'tl pnnuri ly for diagnostic tesung.11"'
thc1.1p<'ut1c.1lh lw1.11"c it~ cffccis are h1ghh 1
cannot lw f\IWn or.illy, .111d undesired sidt dlro
lw pmtl11e <'<I hct,rnw 11 stimulates produe1ior
hor1111uw' ('>lt l.thlc 20 I}
Thyroid stimu lat ing hormoM (TSll,
\Umul.11' th}nml i:l.rnd function 11\ 111<1<
upt.lk< ol 1od11w, m< rcasing thyroid hot111<Ak
and 1dt'.l\<". .rnd prommong th)TOld p-001h
20 r,) It " """I d1.111no\t1("1lly to d1fkrcnt""
hyptllh) rrnd"lll loom "'Condary hypoth}'TOOd"
n1<1y .11,0 lw L"cd to u"t for antcnor pimil.1iv~
cil'n< ll's ( , ,., . I.1hk 20 I )
 -~---------~~---..:C;;.:.
HAPTER 20 Endocrine System Disorders 349

ANTERIOR PITUITARY GLAND

Gtowth Hormone
somatotropm Vanes by product Prader.Wrlh Weakness. transie111 insulin
(rerombinant syndrome edema
DNA) IHumatrope. Patients wrth
Genotropin. growth failure
Omnitrope)

Growth Hormone lnhibiror

octreottde lntttally 50 mcg SC. lnhibrts rapid oo Sinus bradycard1a, ant1d1abet1c med1cat1ons,
ISandostattn) IV excessive growth diarrhea, headache. glucagon
(acromegalyJ cardiac dysitlytl1m1as.
changes Ill blood
glucose levels

AdrenocorncI Hormon1s
con1co1ropm (Actharl Varies w1tl1 patient, D1agnost1c testing Insomnia. acne. amphote11cm. insulin,
and Ox IM. SC. IV abdominal distress. oral hypoglycemics.
ACTH Varies with patient. delayed wound d1goxin, d1ure11cs.
and Ox IM, IV healing. increased potassium
suS(eptib1lity to supplements, live
1nfect1on hypertension, virus vaccines
mood changes.
edema. weight gain

ThyroidStimularmo Hormone
lhyrotropm alfa 0 9 mg IM 01agnosnc tes~ng Headache. nausea No maior interactions
(Thyrogen) and treatment of
thyroid ta1-

POSTRIOR PITUITARY GLAND

AnMure11c Hormone (AOH)
vasllpressm Varies. SC. IM. IV Diabetes 1ns1p1dus. Abdorrnnal pain and carbamaiapone, lithium.
(P1t1ess1n) acute massive distress. nausea and chlOIPfopanude,
hemorrhage. vomiting, headache. clofiblate.
abdominal chest pain, C011fusion. norepineph11ne
distention arrhythmias
desmopressin Varies. PO. nasal Diabetes ms1p1dus. abdominal pain, Same as for vasopressin
IDDAVP) spray, IV primary nocturnal headache.change in
enuresis. control BP
bleeding in
hemopllrlia
ACTH. Adrenoconocouopic hormone. BP. blood pressure. CHF. coogeslN8 healt faolufe. Ox. d~s. IM.llltrairuSCdai1 IV. inuavenoostv. PO. orally. SC.
~

Posterior Pituitary Gland
The posterior pi1uiiary gland, with only neuronal s1imu-
la1ion and no direct con1ac1 through blood vessels, pro
duces 1wo hormones: tu-ylocin ( ac1 ive on the reproduc1ive
system) and ADH (uasopreuin; active on the urinary
sys1em). Oxytocin (see Chapu.r 28) and ADM (see
Chap1er 27) are synthesized in the neurosecretory cells
of the hypothalamus. ADI l promo1es renal conserv,uion
of water, whereas oxytocin functions during labor and
 350 ;ECTION V Med1cattons Related to Body Systems

EnvJronmental factors and

body's need for homeostasis

Hypothalamus -
thyrold-releaSlllQ hOmlO"" (TRH)

Ante<'oo< pitu1tal)t gland

Thyr()ICk<imulallflg

-
hoonone (TSH)
Negawe
Neg<lllVe
I-to
loedbaek
Increases
sens.1.1v11y
- IMly toTRH
IOTRH Thyrotd gland (with 10C11ne)

Thyrox.1ne - T4
Tniodothyronine - T3

Increased blood levels

of thyroid hormones

Use of thyroK:t hcumones

Figure 20-5 The negative feedback between the thymid gland hormones and homeostasis

delivery and therefore is not discussed in depth in this

book. flypofunction of the posterior pituitary gland
results in diabetes insipidus. <"ausing profuse voiding of
large amounts of dilute urine. leading to dehydration Release of hormones from the antenor piWitaJy
(see 1:1bl~ 20-1) mftueoced by the hypothalamus and is 1nhsbited bi
feedback.
Growth honnone (GHJ replacement thctll!1Y is~
for children def1t1ent 1n GH. not for children~ in
short.
Elevated blood glucose levels occur in ch ldten lai iv
When usuig somatotropm (growth hormone (GH]) therapy,
1egularly scheduled medical V1s1ts a1e important so that
height and weight e<1n be measured
2 When rete1v1ng 001enocort1tottopm hormone (ACTHJ. notify
the phys1c1an of any signs of infection Oo not stop ACTH
THYROID GLAND HORMONES I
1n1ec11ons abruptly, this drug must be tapered oH
The thyroid gland, loratcd in the anterior necl., !((f;l
3 Patients taking ant1d1uret1c hormone (ADH) should monitor TSH on s timulation hy tht .interior pituit.tl) glJJl
fluid intake and output. as well as weight. as ind1ca11ons of control secretion of r, T,, .111d cakito11i11 (itt J1
dehydration Report shortness of breath, chest pain. or head
20-5). T, and T,, s1im11l.11c protein synthl'sis, inu
aches with AOH therapy
b lood suga r levels, dcnt'asc scrum rholcstcrol 111
increase metabolism for production of heJt and rn<.

and enable normal mental de>Jelopment and normal
gro"1h OietS dt>licient in iodine lead to goiter, as T, and
1, require iodine for production and the thyroid incrt.>ases
1n si>e m an efTon to secrete the needed iodine.
llyposecretion may be caused by glandular destruc-
tion from radiation therapy, lack of iodine, surgical
thyroid removal, or pituitary dysfunction. Oral thyroid
replaceme111s may be ex1r.1cted from endocrine glands of
animals or be synihe1ica lly prepared. Two hormones, T,
and T,, or a combinatio n of the two, may be used, with
1he dose grnclually adjusted for Lifelo ng 1herapy accord-
ing to an indiviclu,1l's needs. Thyroid ho rmo nes are
approved for supplemental or replacement needs of
h)'!>Olhyroidi~m and are not indica1ed or approved for
treatment of obesity, although they do affect me1abo-
Jism. Doses that would be necessary for weight reduction
could produce life-threatening cardiovascular effectS.
Thyroid hormones are usually initiated in small doses
~nd are mdividuali.t.ed until adequate respoll5<' is
reached Ph)'Siologic effectS of o~-erdOS4.' are symptoms of
psychotic behavior, diarrhea, increased blood pressure
and hean me. and angina Long-terrn overuse of thyrox-
ine has been assodated with osteoporosis in post
menopaus.11 women. Thyroxine is contraind icated in
patients who have had a myocardial in farctio n and may
exacerbate d iabetes 111d li1us (DM), leading to an
increased ne(d for anlidiabelic medicatio ns. With esiro
gen 1herapy 1he amount of thyroid ho nnone needed may
increase becau>e estrogens tie up circulating hormones,
1hereby decreasing the amouni available at Lirget tissues.
Jhyroid replacement medications do not readily cross
the placenta, so their needed use in pregnancy does not
affea fetal de>Jelopment ('Ja.ble 20-2).
f;tl '-LtN.-~ P
Patients with diabetes taking lllyr0<d replacements and antodoabetoc
medoca1rons should be watched closely Orscontinumg thyroid medr
canon when taking hypoglycemics may lead to sevllre hypoglycemic
1eact1ons because thyroid medocahons tend to increase blood sugar
levels and 1he need for increased hypoglycemics for control of
glucose levels.
. '
I Litelong thyiood replacement therapy should nol be doscon
tmued wothoot consulting a physician
2 Whencounselongpat1entswhoarebeg1Mingthylo1d replace
ment therapy. mform them that it should be taken on the
fllOmlng fon an empty stomach) to avoid insomnia from
oncre.ned metabohsm
3 PafpitatlOl'ls, neNOUsness. and headaches may be SJgns of
1woc1ty of 1hyro1d medication.
4 lod11ed salt 1s an excellent source of the iodine needed for
proper 1hyio1d function
CHAPTER 20 Endocrine System Disorders 351
ANTITHYROID MEDICATIONS
I Jyperseae11on of thyroid hormones may be the result
of tumors or autoimmune diseases such as Graves
disease. loxcessi-e secretion and circt1lation ofT. and T,
resuh in in<:rl'ased ceU metabolism. \<o"eakness. aru<iety.
and heal production. Treatment for hypenhyroidism is
use of .intithyroid medications, irradiation of the thyroid
gland, or surgical thyroid tissue removal.
Antithyroid medications, such as io11i11c or iodide
ions, radioactive iodine, and thionamide derivatives.
interfere with synthesis of Lhyroid hormones by saturat
ing 1he thyroid gland and decreasing the vascularity of
the thyroid gland 10 decrease secretion~. 1hese agents
will cross the placenta to stop fetal thyroid development
and can cross into breast milk to affea the infant. Radio-
actl1"' lodint', iodine 131 ('"t), may be used to destroy
tissue of thyroid gland (see Table 202).
Propyl1hiouradl should be taken at regular mlclVals
around ll1e clock
2 Iodine solutions should be diluted on hull Juices 01 beverages
to make lllem palatable
3. Boassy taste, burning sensation 1n 1he mouth, and soreness
of gums and teeth are signs of excessive 1od1ne and should
be 1cpor1ed 10 the physician 1mmedia1ely
The thylood gland produces t\\1l atl!Ve hofmooes-
tmodothyronine IT,) and thyroxine ITJ-to stwoolate 8nefDY
productoon. sumulate tile heart. and promote growth and
development
Thyroid replacement therapy is for lrea1men1of hypothyro1d-
1sm. not for treatment of obesity or for weight loss
An11thyio1d medocauons benefit pat1en1s with hyperihyroid
osm by suppressing the secreuon of T; and T,
Calcitonin
C1lcitonin is secreted by the thyroid gland, but blood
calcium levels are regulated by Pll~ and an adequate
dbsorption of vitamin D. These hormonrs work together
to ensure an adequate supply of calcium for neuromus-
cular and endocrine function. Caldtonin Mlmon and
calcium have the same efTectS as human caldtonin and
is safer for lrt.>aunent of osteoporosis in postrnenopausal
women. Calcium and \itam in D intake must be ade
quate for calcitonin salmon to be effective (see Table
202).
 SYNTHETIC THYROID REPLACEMENT
""'L'i;roxinp ' 01-021"QP0qd Hypothyro1d1sm Weight loss. tremors. nervousness. ~
headaches. sweating, . anticoag
(l.evottvoid.
Synthnijd. Un1ttvo1d. exophthalmos. insomnia
Levoxyl)
hothyromne (T,) 0251 mgPOqd Same as for sameas
{Cytomel. Tnostatl levothyroxine levnthl)Ox1ne
hotrix (T,. TJ(Thyrolar) 60 t20 mg PO qd same as llOlll,rr

NATURAL THYROID REPLACEMENT

desiccated thyroid (T. 60-120 mg PO qd Hypothyro1d1sm Same as for synthetic thyroid Same as 111
TJ (Armour Thyroid, replacement synthetct:
Nawre-lhroid.
Westlvood)

ANTITHYROID PREPARATIONS
th1onam1de denva11ves. JOO. 400 mg PO qd Hyperthyroidism Rashes. nausea and vomiting. alllicoaiJUlarn.
propylth1ouracil 1ntt1alty 100150 mg myalg1a. stomach pain. fever. 1od1ne 131
IPropyt-Thyrac1I) PO maintenance increased bleeding tendencies
meth1mazole ITapazole) 1560 mg PO t1d Same as for Same as fo1
1mt1ally, 5-15 mg PO propyllhiouracil propyl lhto iaoJ
ud maintenance
"'I. RAJ (lodotope) 410 1mll1cunes PO qd, Same as for
rv p1opylth101J111
except I

CALCITONIN
calc1tornn salmon 100 UOllS IM. SC Paget di~se. local imtauon. GI upset lithium
!fomcal) elevated Ca
(Mtaealcinl 1 spray in alternating levels.
nostrils osteoporosis

PARATHYROID GLAND MEDICATION

tenparat1de (Forteo) 20 mcg SC Osteoporosis, for Oiuiness. headache, depressron. d1go.icin
those at high hypertension. symptomatic
risk for orthostatic hypotension. arthralg1a,
fractures nausea and vomiting. diarrhea
GI. Gastroimestmal; IM. mtramusculotly; IV. 1m1aV1llltlllSly, PO, orally; RA/, radioactive iodine; SC. subcutaneously

Teach pat ems how to activate a nasal spray of a metered dose
pump of calc111J01n salmon The medication should be refriger
ated between tJSeS
reduced. and old bone is dissolved 10 mamtt1n a'<9l
Calc1to111n salmon has the same merabolic effects as human
calc1tonin and 1s very safe
PARATHYROID HORMONE I
lne parathyroid gland ~ecretes (P'n~) wh1ch. in (l)(f(D
1ion with C'akitoni11, regulates calcium blood ltttO
When blood lcvds or calcium decrease. Pill all
relcaw C'alcium .1~ new bone cell dl.'\-elopm!:l
homco~tasis One l'TI I drug. teriparatld$ (Fon<o
used to trc.tt o.icoporo~is in pos1menopau1al ~' r.
and men who .ire .11 high risk of fractures (stt 1 1~
20-2) .
 --~--~-----------~-~--:C::HAl'TE:..:~ 20 Endocnne System Disorders 353

IQl;iilQfii#;t.11f1?1i#;t.11k- TABLE 20 3 COMMON DRUG INTERACTIONS

ASSOCIATED WITH GLUCOCORTICOIDS
"'e adrenal glands are located directly o''" each kidney INTERACTIVE
,ind are composed of two pans: an ouier portion called MEDICATIONS POSSIBLE RESPONSE
1he ronex, which sc.-reies a number of hormones tha1 are
<'l.>eniial for life, including cortisone. hydroconisone. amphotencin B Potentiates hypokalemia
aldosterone. and deoxycor1icos1erone; and an inner digitalis Possible d1g11ahs tl)J(l(:lly
ponion, called the medul/11 (see Figure 20 I), which d1urencs Potential IOI hypOt.alenua
wcretes epinephrine and norepinephrine and is consid- decreased therapeullt
ered part of 1he sympathe1ic nervous sys1e111. I lormones effect of d1ure11cs
of 1he adrenal cortex a re ac1ivated by ACl'l I from the antibiotics. macrolides Increased clearance of
Jnterior pimi1ary gland. 'lhe most imponani functions comcosteroods from
of adrenal conex hormones are regulation of water and bloodstream decreased
s.1h metabolism, regulation of carbohydraie metabo- metabolism of slelOtd
h~m. and produriion of aruiinnammatory effects. The
anhcoagulants Increases chance of
terms adrenoconirosteroid.<. cortiro>ieroids, and steroids all
thrombosis by inhibilillQ
rl'fer 10 the same natural or synthetic substances, which
anucoagulant ac11ons
ma)' be grouped as mineralocorticoids. glucocorticoids.
or miJ<ed steroids. insulin. oral hypogfyl:ermcs Increased requirements of
med1e<1hon for diabetes
mell11us because of
increased blood glucose
Adre nal Cortex Hormones levels
I he adrenal conex has three levels. The outer level 1somazid Increased doses of
~ccmes mlner~locorticoids, and the midd le level 1somaz1d may be
~ecmes glucocorllcoids (the inner layer secretes small needed
amounts of male and female sex hormones). Like all oral contraceptive. Increase s1ero1d effect.
tropic hom1oncs. ACll-1 is regulated by the hypothala estrogen because drugs inhibit
mus. which is influenced by the sleep-wake cycle neg;i steroid metabolism
1iw feedback. and >1ress. More corticouopin is available pllenobarb1tal. phenytoin. Increase steroid effect
during 1he awake period 10 regulate body 111e1.1bolism, nfampin because of the
and negative feedback inhibits 1he release of conico1ro- enllanced metabolism
rin 10 keep conisol levels rcla1ively constant day 10 day. of steroids
\s body stress rises. cortico1ropin stimulates secretion antacids Decreased s1erOld
of conisol to increase lhc body's ability to cope with abS()(pt1on
siress.
Glurorortiroltls regulate metabolism o f proteins and
carbohydrates. particularly when the body is under stress.
\\'ith therapeutic u>e glucoconicoids cause reten1ion of growth. After long-term or high-dose s1eroid lherapy,
IO<Jiurn, leading 10 water retention and possible hyper- cessation of steroid use rnus1 be tapered off slowly in
lcnsion. Glucocorticoids, po1cn1 agents used in acute small decrements. Ocular use over long periods of time
and chronic inflannnatory rrocesses including organ may lead to glaucoma and ca1amcts.
1ransplants. may be adminis1cred orally. intramuscularly, U'e virus vacci nes may no1 be effective for the patie111
mtraartirularly. intravenous!)'. topical!)\ or by inhala- who is taking steroids and could e\'en pul the patie111 al
uon, for either local or S)'Slemic effect. Preparauons for risk for developing infections that may advance at an
iniramuscular use have repository action' to .1llow the alarming rate because steroids suppress the body's
drug lo be released slowly for a lo nger dura1ion of action. infh11nrnatory response. Drug interactions :tre_ numerous
llwrapeutic doses vary widely and mus1 be adjusted 10 and are lis1ed in 'fable 203.
meet the patient's needs. S1eroids should be used with Mineralocorticoids regula1e blood levels of sodium and
culion with g,1stroin1cstinal ulcers or coliti>. renal potassium by increasing the reabsorption raie ofsodium
d1><,1se, herpes simplex, and emotional ins1ability and by the kidneys. 'lhe mos1im1>0rtant minerJlocorticoid is
.ire contraind ic,ucd in patients with systemic fungal aldos1erone, which acts on disrnl tubules of kidney neph-
111fct1ions, 1uberculosis, and local viral infections. rons. Mineralocorticoids are usually admi11is1ered in
\dverseeffects include joint tissue damage 10 cushingoid conjunriion with glucocorticoids for replaceme111
<;vmp1oms such as fatigue, weakness. edema, moon therapy in adrenoconical insufficiency resulting in
f,1c.,; "1>0t belly: "buffalo hump; and excessive hair Addison disease (Table 204 ).

354 SEC f ON V Medications Related to Body Systems

_r_A~Bl~E~~.:..:.4~S=EU::.:CT.:.:DR:U:G:S~U:S:ED::_:AS::.;,ST~E~R:O:ID:S~O:R~C=O~R~Tl:C=O~ST~E~R~O-ID_s_--~------------------ \

GENE IE/ USUAL ADULT 1NmcATioNs~~o~~utf ": -~=~g;ssme ~RUG I

'~
__ ,... ... a .. ,,,. en1fTS:
TRAD Insomnia. mood
Allergies. body stress.
GlUCOCORTICOIDS replacement therapy, cha11ges.
antiintlammatOfY agents, personality chaAges
leukemia, prur1tus

cortisone ecetate INTNl Varies. ind1v1doahzed

dose$, pO
llydroconisone (Conisol. Vanes. PO. toptcal. IM
Collell rv. enema
hydrocort<SOne sodium Vanes, IM, IV
succ1na1e (Solu-CorteO
prednisolonB (Orapredl Vanes. PO
methylpredn1solone Vanes. PO. IM, IV, IA.
IModrol) Rlenema)
melhylpredntsolone acetare Vanes. IM Same as glucocorucoi and
IOepoMedlolJ bursitis
methylpreOOisolone SOd tl'll Vares. IM. IV. IA
sucmate (SoluMedroll
betamethasone tCelestonel Vanes, PO, IA. IM
dexamethasone (OexPakl Vanes. PO, IM, JV Same as glucocort1co1ds,
bursitis. and before
radiation. chemotherapy
prednisone fNTNI Vanes. PO Same as glucocortico1ds and
multiple sclerosis
mamc1nolooe IAnstocort. PO, toptC<JI, g1ng1val, Same as glucocort1co1ds. oral
KenaconJ 1maled leslOlls, asthma
beclomethasone Uleconase. Intranasal Asthma. bronchms. allergies
OVARI Inhaled
ftuticasooe JFlonase. Nasal topical Rh1nit1s, asthma
FIO\lent, Inhaled
Cut1va1el Topical

MINERALOCORTICOJDS Edema, weakness.

hypertension
deoxycooicosterone Va11es. IM Addison disease d~
acetate IOOCAI
IPercorteol
ftudrocort1sane (AonneO Vanes. PO

INHIBITORS OF Cushing syndrome Nausea. headache, de~

CORTICOSTEROIDS fever. drowsmess,
d1w11ess. muscle
pain, cardiovascular
irregulant1es.
changes in seual
charactens11cs
am1009lu1e1h1mide 250mg PO
(Cytadreo)
tnlostane (Modrastanel 30 mg PO
/A, lntra-amcularty, IM. intramu~ularly; IV. 1n1ravenously, NTN, no trade name l'O
'See C'1apte1 22101dcrmalol091c use of steroid agents oiully, R. 1ec.tal

Adttnal steroul 111l11b11ors suppress adrenal conex func-
uon in adrenal gland malignancies o r other adrenal
hyperplasias. lltese medications are used temporarily
until the radiation thera1>y to the pituitary gland is effec
n't'. Afh't'rse reaetions are cardiovascular irregularities
and liver dysfunction. Precocious sexual development
occurs in males. and females acquire masculine features
(see Table 20-4 ).
ADMINISTRATION TECHNIQUES
WITH STEROID THERAPY
Steroids are given ln lvvo unique 'vays:
I Alternate-day ther.lpy (ADT) is used to reduce o r
eli minate adverse drug reaaions. Shon-acting
medicine is given every o ilier morning. with its
efferu persisting into day 2, when the adrenal
gland funcuons by negative feedback. On the fol
lowing day, the medication is given ag;iin. This
routine allows the adrenal gland to function with
fewer .1dverse reactions.
1. Declining or decreasing dose so that the body
receiws a therapeutic dose rapidly, and the doge is
then t.tpered off. Usually the drug is given in 2-day
increments, althougll this may change with indi-
vidua l dosages for specific conditions. Depend ing
on increments and total dosage. the dosage declines
by a 1able1 per cl.ty or so until the total dosage has
been given.
lable 20-4 lis1s typical steroid and conicostero id med-
ica1ions and 1heir drug forms. Some topical S1eroids used
for various conditions are fo und in Table 20-5. Over-1hc
coumcr (OTC) glucocon icoid preparations contain 0.5%
to 1% h)-droconisone for topical use. l'resaip1ion topical
medica1ions arc listed in Chapter 22.
TABLE 20 5 EXAMPLES OF OVER-THE-COUNTER
STEROIO PREPARATIONS
I '' I I I When "HC" follows a drug name. mosl often 11indica1es 1nclus1on
Corta1d Cream. ointment. lotion, spray
Preparauon H w11h Cream
hydrocoo1sone
Aloe Gel HC (Aloe l'l?fi1 and Gel
hydrccon 1sonel
Caldecon Ointment spray. rectal foam
Gvneccn. Cortef. Feminine Cream
Itch Cream
Bacune HC Cream
CHAPTER 20 Endocnne System Disorders 355
Before medical or dental procedures, the health care proles
sional shoold be inf~ \\lien steroids are being l8len
bet1luse of bleed ng auered healing processes. and a tered
resporises to mfectJOn
2 When 1<1k1ng ster01ds. watch for sogns of salt and water
re1en11on such as weight gain and edema of the feet and
lower legs.
3 Reduce the intake of sod1um-nch foods and increase 1n1ake
of po1ass1um-nch foods IMlen using storo1d preparat1oos
4 Do no1 slop taking s1ero1d med1ca1ions abruplly unless
directed by prescriber
5 Nonpresc11pt1on med1catioos should no1 be 1aken w11h s1e-
ro1ds without consull1ng a phys1c1an or pllarmac1st betause
of numerous drug interact ans
St1110ids may be admm1stered orally. paientera ly topically.
1111ranasally. or by inllalatioo
Glucocort1co1ds influence met<lbohsm of fats, carbol1y\frates.
and proteins as well as affecting the skele1al, musC1Jlar.
cardiovascular. immune. and central ner;ous S\'lilems
Aldos1erone. the major m1neraloconicotd. acls on kidneys to
promote re1en11on of sodiumand waler and allows excretion
of potassium
Excessive doses of sleroids can cause cu~h1ngo1d symp1oms
and Cushing disease
When used in low doses for replacement therapy, s1ero1ds
a1e therapeullC Colwefsely when used chronically for pllar-
macologic needs 111 nonei idocnne diseases. 1hese drugs have
se.1lfe adloerse effects
Gti.cocorticords are used 111 reduce 111flarnma1orv and unnU10
system responses, as 1n anlvms. alle!91C disorders. asf/lma.
cancer and organ traflSl)lant re1ecti<lll
Wllet'I used with nonstero1da an111nfl<Jmma1ory drugs
(NSAIOs). steroids mcrease the nsk of peptic ulcers
S1ero1ds can inc1ease 1he nskof 1ox1c effec1s from digoxin.
lll LEARNING TIP
of hydrocort1sooe.
DRUGS USED AS ANTIDIABETIC
AGENTS
llte pancreas secretes twO ho rmo nes. insulin and gluca
gon, to regula1e metabolism of pro1eins. fats, and espe-
ci.llly carbohydrates. A cluster of pancrea1ic cells known
as the Islets of l.;ingerha.ns produces i nsuJin, which acts
as Lhe key to opening body cells 10 glucose. Insulin and
 356 ;[( T NV Medtcauons Related to Body Systems
glucagon aJIO\, cells 10 recei\-e an adequate supply of
glucose for body fuel and to regulate blood glucose
lewb Insulin has three distinct purposes: (I) it aids in
use of glucose JS energy; (2) i1 prompts liver siorage of
excess glucose Js glyrogen: and (3) 11 is reponsible for
conver~ion of glucose 10 fat. By negative feedback, glu-
cagon sllmulates breakdown of glycogen t0 increase cir-
culating glucot when blood glucose level are 100 low.
Diabetea Mellitus
lhl' most common endoc:rine gland disease involving
the pancreas is diabetes meUitus (DM). the ~ilh leading
cause of dt>ath in the Unhed Swes. OM .1trec1s about 16
million Americans, with 90% to 95% of cases being cype
2 DM ('120M). In persons with OM. rn rbohydra tc
metabolism i1wolves insulin delicicncy, insu lin resis-
tance. or both, leading to hyperglycemia . Most authori
Iles believe that any Jbnonnal lewl of pancreatic function
may lead to DM. either type I OM ( 11 OM) or T20M.
PatientS wnh Tl DM ha'-e wry little or no t:ndogenous
insulin so reqmre exogenous insulm for survival. lllese
ind1v1duals seem to have a genetic ahnom1ality involving
autoimmune destruction of beta cells of the islctS of
Langerhans T20M usuaUy is of maturity onset, ahhough
recent re~earch shows a rise in this dise.1:.c in obese ch il -
dren . Wi th I2DM, the patient has :.omc inulin fu nction,
but production of secretions of the bc1.1 cells is low or
insufficient. The disease may be the resu lt of aging.
improper diet, or genetic factors leading to insulin resis-
tance. Classic signs of Tl OM and 1'2DM arc polydipsia,
pol) ph~g~. and polyurfa (Table 206)
Former name IDOM. 1uvenileonset diabetes. Type 1 OM
Usual age of onset Childhood or adolescence
Onset $peed Rapid
Family htStory Usually negative
Predominance 5%10% of people with diabetes
Etiology Autoimmune process
Pnmary cause loss of insulin secretion
Insulin secreted None in later stages
Ketosis Common
Signs and symptoms Polyuna. polyphag1a. polydipsia. weight loss
Body Thin, undernourished
Blood glucose levels fluctuates m response to body activioes and illness
Treatment Insulin replacement. diet. and exe1cise
/DOM. lnsuht>depei11le111 diabetes melhtus. NIDDM, non- msuhll-de"'""'eni d ,.,..
melhtus
Obese persons with insulin resisllnce art
lic cvndrome. a cluster of conditions-
metabo -, . , 1 d' -
toget her ,,'or increased. . nsk 1or
, iean. 1sease, -~-
diabetes. Four cond1uons 1ound on lhe S)1ldml'lt
o IJes'ty around the wa1M, hypcn . . ens1on,
. hy"'"
-..,r;e-
1rniauon, the lisk b
1 hypcrl ipidemia. In com
\lilt . r
grea" t"r', the person hav111g. 0 11 (' 1JCtor
f.
1s more],..
-
have others. A fam ily h 1stOI')' .o 1'2~M with"
re:.istance or a history of ges1.111.onal d1aba~ ill(Jt
the likclihoo<l of luving the disease. Cbttin.,.
tions increase blood glucose levels and caustlp.,
cemia in the prediabctk person. These drugi
glucocorticoids. prednisonc. thia7ide dilllUtQ.
epincph ine.
'I rcaunent for DM includes medications as ""
dktJry adjust ment 10 limit ingested carbohydri1e5
conistcnt exercise to con trol glucose. The d~ foi
.m: ill three c.11egorics: insulins, oral antidiabe1ic ip
,111 d drugs that affect gluco:.c absorption or plOd~
inrluding new adjunctiw therapy drugs ~ ill:I:,
effcctivene'" of other antid1abetic agenl$. lll!IJIQ
ulfonylurcas de<:l'easc bloo<l gluco~ lt'\'l!ls. ~
medications delay dietary glucose absorption.ind
glucose production in the li"cr to lower blood
lt>vcls, especially po.ipr.111dial blood glUCOlt
l'crso11> with Tl bM mu>t administer exogenous 1
for life .111d must adjust thLir diets and exercise. Plll
,vith 12DM secrete some l'ndogcnous insulin, Jnl
.1 lone may comrol elt'v.1tcd scrum glucose Inti
tho>C persons who do not respond to !he cl;..
trols. or diet alone may hl' m!>ufficien~ ~
or.11 antidiabctic drug.
NIDDM. adult onset diabetes Type2Cl
Usually >40 yr
Gradual
Frequently pos11tve
90%95% of people w1tn d'3be:es
Unknown. strongly fam1h3I
Insulin resistance or dcc1eased ~
levels may bo low. normal. OI hig~ I
Uncommon
May be asymptomauc
Frequently obese
More stable
Exercise and reduced calonc tnUi!.
cases. oral hypoglytemtCS or 1'>1!11
"""" ia.,.,tcs nic'lhtus. TI DM. type 1 d1al~1ts mellitllf. Tl!JM. l'!lll l
 CHAPTfR 20 Endocrine System Disorders 357
---~

When too much insulin or insufficient glucagcm

allows lowering o f serum glucose levels, a hypoglycemic Administration of Insulin in Type 1
reaction (the opposite of OM) may be precipitated. Table Diabetes Mellitus
20-7 compares signs a nd symptoms of hypogly~mla Tl DM requires use of injected insulin because insulin is
and hype1"11lyccmia. inactivated in the digestive traci with oral administra-
tion. The forms of insulin differ with respect to their time
TABLE 2Q 7 COMPARISON Of SIGNS ANO SYMPTOMS and course of action. Insulin is usually giwn by subcu
Of HYPOGLYCEMIA ANO HYPERGLYCEMIA ianeous or intramuscular injection using an insulin
syringe. Regular insulin may be administered imrave-
HYPOGLYCEMIA HYPERGLYCEMIA nously in emergencies or circumstances in which imme
OR INSULIN OR DIABETIC diate insulin a~tion is necessary. Ill nesses, uauma, and
SHOCK COMA suess increase blood glucose levels, and thus higher
doses of insulin may be required to keep the body in
Onset Sudden Gradual homeostasis. Dosage of insulin is individualized and
Sbn Pale. moist Rushed. dry may change over time depending on lifestyle changes
Tongue Moist Ory Commercial insulin preparations produce similar
Breath No change Fruity odor (acetone effeas in the body but vary in time for action onsN,
smell) time to action peak, and dur.111011. 'fhe four groups or
1!11rs1 None Intense insulins that are modified human derivatives are (I)
rapid act ing (lispro IHu malogl, aspart INovoLogl and
Aesp11a11ons Shallow Deep
glulisine IApidral); (2) short aciing (regular. Humulhr,
VonvtJng Rare Ccmmon Nor,-olin R); (3} intermediate acting (lsopluine INPlll
Pulse fast. bounding fast. weak IMumulin N, No"olin NI}; and (4) longacting (gla~ine
Ut1ne No glucose 0t Positive fat glucose. llantu.sl and de1nnir ILn-emirl. and premixed combina-
acetooe acetone or both tions ('fable 20-8 ).
Serum glucose .j, 50 mg/dl f 200mg/dL 'l\vo processes have been used to prolong insulin's
Blood pressure Normal Low effem: (I) add ing a protein to natur.il insulin (NPll)
and (2) removing an amino acid from a natural insulin
Abdominal pain Common, acute None (detemir) by altering DNA. A graph of action has been

TABLE 20 8 COURSE Of ACTION OF INSULIN PREPARATIONS

; I ' ' I ..
RAPID-ACTING INSULINS
insulin hspro (Humalog) H 1530 min Y,-1 hr 3-4 hr
insulin aspart (Novolog) 1020 min 1-3 hr 3-5 hr
glul1sine !Aprdra) 15-30 mm I hr 341v

SHORT-ACTING INSULIN
regular msuhn (Humulin A, Novol1n RI A Xl hr 2 5-5 hr upto6hr

INTERMEDIATE-ACTING INSULIN
1sophane msulm (NPH) IHumuhn N, Novolin N) N 12 hr 4-12 hr up to 24+ hr

LONG-ACTING INSULINS
1nsul111 glatg1ne (Lamus) 1-2 hr No peak 1dentrfied ~41v

insulin detemir (Levemir) 8mmto2hr Unknown up to 24 hr

insulin regular concentrated (Humuhn AU500) Y,I hr up to 24 hr

COMBINATIONS
NPH and m1xrures, (Humuhn, Novohn 70/30. 50/50) 10 20 mm 2-4 hr up to 24 hr
NP\. and hspro (Ht.malog 75/25. 5M>OJ 72 Iv Dual 10-16 hr
NPAJN aoo aspatl (Novol.og 7~) I)' I hr Dual 1().16 tv

!IPA. lsophanc (NPH) and aspart. NPt.. 1soelhane INPH) ard l1spm
 358 SECTION V Medications Related to Body Systems

PeakclAa.al 1 + 1:t1111.1;111;11:0111111&!5~'0'iil'ffi"ililJ
-- ~
I I"" - RoglAot- IA) Antagomstic Effect Potentratlon
l:'
I
I I
1/
.....
........ ., NPH - (N) Ill' acetazolamrde alcohol
j I
,~ .. ................:.........
i . L.anlL"" LeYelTW
human unmunodeficrency angiotenso~
~ virus (HIV) anuvirals (AC8 rillbotO!S
-
I :I \
! f : anabolic s1e101C1s
"'= I : I \
d1azox1de
g f : I . diluazem oral anticoagulants
~
- I .
!
I
I \
,
niacin beta blockers. propra1111e1

:
'I ... sympa1homimo1ics chloroquine
clofibrate
thiazide diuraucs
o 2 e s 10 12 1 1e 18 20 22 2 26 28 :JO 32 3 36 fenffuramine
Hoof'S ahet AdmtnlsUahon lithium
"Lanius hat no t'W:tilrll PtM:. but tn111n4M'l1 ei.vetover24 hOUtS monoam1ne oxtdase
Figure~ Peak '"'"" ol u11cm types of 1nsulon (MAOlsl
Hormones metoprolol
added to assist with understanding how the cypes of comcouopin pentamld1ne
insulin interaa throughout the day (I 1gure 20-6). estrogens and progesttns pyndaxme
Raprd-<icnng insulins include h5pro ( llumalog), aspart oral con1racep11ves sahcytates
(Noval.og), and glulisine (Apidra). w11h effects beginning tetracychnes
glucocor11co1ds
within 8 minutes of adminmrauon and J,1s1ing 2 to 4
hours. Because of rapidiry of aciion and short du ration, growth hormones sulfinpyrazone
Jispro insulin is administered SC JUM before eating. '11ie glucagons fluoroquinolone ant1blat
person must e.11 within 15 minuics or be in danger of a 1hyroid hormones
hypoglycemic reacrion. With ,1spari and glulisine insu- anabolic steroids
lins, medication may be rnkcn 15 minutes before eating epinephrine
o r up to 20 minutes afier Slarting .1 meal. rhese med ica
lions prevent rapid eleva1ion in blood glucose levels
immediately af1er meals. should be adm in istered daily at bedtime, wilh ro
Shon-acting im11lin.1 (regular (R( insulin) are clear solu- li terature Sla ti ng twice-daily dosing may be rl<'<'l!I
tions that may be given intravenously in an emergency Premlnd fi.retl comb11wtion insulins ha\t ~
or subcutaneously or iniramusrularly on J regular basis. amoun" of Nl'l I .md regular or fast-acting irnullll1
have a fast onset (30 to 60 minu1es), and have a short first number in 1he combination is the '!I'll Pft(db;
duration of action {6 to 10 hours). Regular insulin is and the second number is the regular or rapod-
stable for 2 to 4 weeks at room temperature. Exposure insulin perccnt,1ge- for example. Mumulin i'll(ll 1
of medication 10 sunligh1 or heat must be avoided to Nl'I r 70% and rcgul.ir 30%.
prevent deterioration or the drt1g Table 20-? lists the drugs commonly used as illlt
Intermediate-acting i11s11lm (isophane (NrH; insulin NI hetics. Boxc 20 I ,111d 20-2 list drugs intemciiom
insulin I Humulin N, Novolin NI) includes 1he addition insul in a11d o r.11 an tidiabe1ic agents.
of a la rge protamine molecu le 10 dccre.1se solubility of
insulin and 10 prolo ng its absorprion time (I 10 2 hours),
action (6 to 14 hours), and dura1ion ( 16 to 24 hours). ~ l EAnNI NG TIP
This drug is given SC o ne or two times da ily. Because Regular insulin may be administered JV 01 SC. all olhe1 1nsol 'II
protamine is a foreign protein, allergic r<'actions are pos- adminis1ercd SC 111 mos1 cases.
sible. The drug is a suspension, the partkles must be
mixed into the suspension before each administration.
Long-acting insuli11s {glargine (l~ntus( and detemir ~ing Insulins
~~~~~~~~~
ILevemirl) are synthetic, long-aciing (wi1h a 24-hour or
longer duration) agents 1hat do not show an evident lreatmcnt for tl1(' person with diabetes m.1)' r
peak but maintain continuous hypoglycemic action
mixing of two drOercnt insulin preparauons. .udl I
when given SC every 24 hours. rhus providing the less- regular insulin with Nl'l 1 in~ulin for pa1ienr cornfcn.,
ened chance of nocturnal hypoglycem i.1. lnese insulins mixing solution~ in10 one injection rarher thJJl irlfl'(!
should be dear and should be diS<'arded if cloud iness each rype 1>cpar.11cly. !)pedfic guidelines are ustd ~
appears. Neither of these insulins shou ld be mixed with mixing the in su li n.
any other type of insul in. Glargine insulin med ication Regu la. inMr li n ,.,,n
he used with any liktN
insulin Whl'n dr.1wing rwo types ofinsulrn, ,,~I
 Tl OM. and some T2DM w th
lllSIStance to oral hypoglycenucs
RaJ)<dAcMl} Insulins
hspro (Humalogl lnd1v1dualized. SC. IV Not to be used with smokers or
aspart (Novologl lndiv1duahzed. SC. IV people with asthma or COPO
glulis1ne (Apidra) Individualized. SC. IV

Sho1tActm9 Insulins
regular insulin (Humuhn R Individualized, IM, IV,
!human!. Novol1n R!human)) SC

Jntermed11t1Acting Insulins
1sophatle (NPH) 1nsuhn lndiY1dualized. SC
(Huroohn N (humanL Novohn
N !human))

LoogAcong Jnsuhns Tl OM and T20M

91arg1ne 1nsuhn llantusr lnd1vi<fuahzed. SC
detemir msuhn (Levemir) Individualized, SC

F<ed Combmat1ons TlOM

Nl'll/R 70/3U Individualized, SC
fHumulin 70/301
fNovolin 70/301
NPH/A 50/50 lndrvidualized. SC
fHumuhn 50/501
aspart suspens1on/aspart Individualized. SC
solution 70/30 (Novolog
70/301
llSJlfO suspens1on/hspro lndMdual~ SC
solutJon 75125 (Humalog
751251
lispro suspens1on/hspio
solution 50/50 fHumalog
50/50)

Major Side Eff1c1s of Injectable Insulin:

Hypoglytemia

ORAL ANTIOIABETIC MEDICATIONS

Sulfonrtureas T20M See Box 202
SecondGenera11on
grpizi<fe
(Glucouol standard) 5-40 mg PO qd
(Glucotrul XU 5-20 mg PO qd
g1',boode
norr111aon1zed (01a8eta, 1.ZS.20 mg PO qd
Micronasel
micron1zed (Glynase Preslab) 0.75-12 mg PO qd
ACf. Ang1otensin-conver11ng l!fllymo. COPO. chronic obstructive pulmonal'f disease. OPP-4. d1peptidyl pepti<!ase-4. Gl gas1romtes1inal. GLP. gluc39onhke
pepudc IM, 1nuamuscvla1ly, N. intravenously; MAOls, monoam1ne o"dase mh1b1tc<S; NPA. neutral protamine aspart: NP/I, neu11el pro1om1no H39odorn;
PO. Cfally; SC. subcutaneously, TIOM. type 1 diabetes mellitus. TZOM, type 2 thabotes melhtus: TB. tuberculosis
'Glargine insuhn may be Possible cance, risk Gc111i11ued
 TABU ro 9 DRUGS USED AS HYPOGLYCEMICS AND HYPERGLVCEMICS- cont'd -j
~~~:..:.:.::..=..:;~~~~---------------~--- .
USUAL ADULT ]
GENERIC NAME/ DOSE. ROUTE. AND .
FREQUENCY INDICATIONS DRUG INTERACTIONS
TRADE NAME
ghmep1r1de IAmarylJ 1-8mgP0Qd
See Table 2().2
a-G/ucoS1d111 lnh1bltors TD2M
acarbo e (Pieco , so 100 mg PO ud
01goxm, Jl'Ojlfanolol, dul!ll!!.
m gloiol IGlyseU 2!>-100 mg PO trd coucosleroids. oral
contracepirves, Ca~
blockers

T2DM and some Tl OM Iodine dyes. alcohol, atailai!

81gu1n1d11
me1lom11n iGlucQflllageJ w1lh 500-1000 mg PO bid
glyburrde (Glucomancel 1 25/250 mg PO bid

T2DM Ette<:tiveness of oral

Th1e10/1din1d1one1 (G/1lazones)
con1racep11ves reduced ill
30%. With IOSSof
contrac:epllOn
10S19litarone IA.-arodal 4 mg PO qd or bid 1n
dMded doses
plOQhlarone IActosl 1!>-30 mg PO qd
p1ogh1a1one and metformin 15/500 mg 5/850 mg
(ACTOplus Mel) PO qd or bid
Megl1timdes T2DM only Large doses of aspuin arui
ibuprofen, sulfonamides,
warfann. MAOts. prti:e'm:
oral contracepc.~ ~
Jl'eparat1ons. ra~
nateghmoo (Stat11xl 60-120 mg PO 11d
repaghnrde 1Piand1nJ 1-2 mg PO hd

OPP-4 lnh1b11ors T2DM with dle1 and exercise lanoxin, other oral
hypoglycemics eia:ept
metformm and
1h1aiolidmed1ones
s1taglopt1n (Januv1a) 100 mg PO qd
s1taghptin + metform1n 50 mg Sttaghplln and
1Janume11 500 mg metformin
PO bod
saxaghptm l0nglvzal 2.55 mg PO qd Same An11v11 als. macrol des.
anti fungals
metlorm1n (Kombiglvze XR) 5 mg/500 mg.
Smg/100 mg. 2.5
mg/1000 mg 1 lab
POqd

Maior Sidi Effects of Oral Anfldiabeac Medrcll/Ofls:

Su/fonylUtea~I mtallOll. nausea. vorn111ng. weakness. fatigue, d1zzrness. a -Glucosidase inh1birtn-Flatulence. ~
dislentron. dranhea. nguanides-Arorexoa. nausea. meg/ilinides-Hypoglycemra. nausea. vom11Jng, diarrhea. myalg1a
resp1ra1ocv symp1oms. headaches. arthralg1a, back pain; DPP-4 rnh1bt1or.9-Hypoglycemia, nausea, vom111ng, diarrhea. myalg1a
resp11atory symptoms. headaches, arthralg1a. back pain, respiratory symptoms.
-----~~--------~-------.:'..
CH:.:::APTER 20 Endocrine System Disorders 361

AMYUN GLPl ANALOGUES

lncreon Momeucs lmprO'les glycem1c control with acetaminophen. ACE 1nt-1b1t01s.
T20M d1goxm. lovastatn.
erythromycm. estrogens.
MAOls, con1costero1ds
excnat1da IByenal 5-10 mcg SC bid
llraglut1de (V1ctoza) 0.61.8 mg SC qd

Synthetic Human Amvtm Improve glycenuc control with

T10M and T2DM
praml1ntide acetate (Symhnl JO.al mcg SC. with
meals

Ml}4f 5'd fffttts of Amyhn GLPI Analogues:

Nausea. vomiting. diarrhea. 11ttenness. headache. dyspepsia. decreased appe111e

HYPERGLYCEMICS
glucagon 0.5-1 mg SC. IV. IM Hypoglycemia Anncoagulants. d1azox1de
d1arox1de (Proglyceml 1 mg/kg PO q8h; IV Hypoglycemia from hypennsulinism Antiepilep11cs. med1cat1ons used
of pancreatic cancer as hypotens1ves
0-glucose !Glutose) 1025 g PO dosage Acute hypoglycemia con1costeroids
varies. IV

Ml/Of Sid fffBCI$ of Hyperglycemics:

Constipation. anoreioa. nausea. vomiting, abdormnal pain, hean cond1t1011S

insulin should be drawn into the syringe first 10

a''Oid the possibility of contaminating regular
insulin with longer aeting types.
Lispro insulin is made by Eli Lilly Company, a nd
it is recommended to be mixed only witl1 o ther
Lilly products such ns I lumulin LI or l-lumuli11 N.
Lispro i11sulin should be d rawn into the syringe Figure 211-7 Insulin pc"
first. Novolog, manufactured by Novo Nordisk,
should be mixed with 01her like products.
Insulin dc1emir should not be mixed with any
other insulins or solutions. 207), are convenient and ftexible but more expensive
lsophane insulin is compatible with regular insulin than the traditional syringe and vial. Thr pens incorpo-
and with lispro when mixed with other Lill> rate a canridge of insulin and are simple 10 use: dial the
products. d054! for a quick. easy, and accurate amount of insulin.
The disadvantage with this method is that the patient
must take two injections if the needed dosage o f mixed
Insulin Delivery Systems insulin is not available in premixed medications. The
t\ew methods of insulin delivery haw been introduced pen is pressed against skin at the injection site, and
as alternatives to the Lrndilional syringe delivery system. insulin is administered by pressing a bunon on top of
hlulin pens. the siz<? of a large fountain pen (Figure the l'en.
362 SECTION V Med1cauons Related to Body Systems

BOX 10 1 DRUGS THAT INTERACT WITH ORAL ANTI DIABETIC AGENTS '

An11gon1su to SullonylurHs salocylates

beta blOCklllO agents c1metodine
calcium channel blotIJfs steroids
adienergoc.!Jlot>ong agents sympathom1metics
ISOOlazid alcohol
dian:ide sulfonamides
alcohol protienecid
l\'lllp;l!holvtics cklfibrate
p181Cllllaline phenobarbital
~
I fampin Potentiators of Meglilinides
nonste<oidal amllnftammatory drugs (NSAIDs)
Antagon1Sl1 to Carbohydrate lnh1brtors sulfonamides
charcoal warfarin sodium
d1geshve enzvmes probenecid
conicosteroods MAOls
dlcohol beta blockers

Potenti1tors of Sullonylureas Antagonists to Meglitinides (Especially Nateglinide)

insulin lhyroid hormones
monoamine oxodase onh1b11oos (MAOls) thiaz1de diuretics
oral a1111coaqulants conicosteroids
ranot1d1ne sympathomimetics

pancrea tic sccrc1 ions. The pat icn t may alsoselfadmini<'

Figure 20-t lnsut11 ~ IColltesy MniMed. Sy1ma1. Cahfomoa I
Jet mjceto~ delhw msuhn by creating enough pres-
sure to "spray" the in~ulin through skin into subcutane-
ou~ tissue without using a needle. l11cse injectors are
expensive and cause Minging and pain. Bruising may
occur in peoplt with little subcutaneous tissue, such as
children, thin adltl~. and elderly individuals.
f>onable insulin pumps, approximately the size of a
pager or cell phone (Figure 20-8), arc computerized
devices that deliver a continuous. regulated dose of
insulin under the skin through a liny needle or cannula
in 1he abdomen . The needle should be replaced a nd
moved to a new site every I to 3 days. The pump delivers
a continuou; insulin trickle in an amou nt tl1at mimics
bolusc~ o r insul in bcforl' meal;. to cover food IO
eaten. Ex1ernal pumps cos1 ,1bou t S1000 10 $5000,
ano1her SJOO per month for supplies.
Impl antable insul in pumps arc surgically i111Cr
abdominall)'. usually on 1he lcf1 side, 10 dclh'tl in
ei ther in1rapcri1oncally or iniravenously. 1.ikt Lht"
nal pump. tl1c implan1cd pum1> dcliven a omlnt
dose of insulin con1inuously. and bolum maybc "'11.oJ
as needed . 'lne advan1agc of this method is tlut ii
insulin produced naturally in the body, tht insulin
the pump goes dircoly to the livcrto prevent act!&
production . OH~ p.11icnt has less hypogl)'CtllW. b
weight gain, and an lmprowd c.iuality of lift.
Clini<:al research is focusmg on buc<"lll, n.li.llm!
insulins. Craigen, if approved, will be deliwml blr:Iti
and RapidMi'1, which use<; an aerosol dchtl)"
goes directly onto 1hc buccal mucosa Oril 11l>Uli= b
been difficult to produce because msuhn brt.W ~
with digestion. Resc.uch is b.1scd on coaung 1htmnfo
tion to incredsc absorption ,111d provide b1oa~1Uli:
A nasal spray has been on the market but hJ.5 bttn
drawn at time of textbook publica11on ~aUlfoh~
effenivcness.
The insulin patch is .1 delivery method under fll!O
menrntion. Placed topic.1lly, the f>.Jtd1 would pw.111'
a continuous low dose of insuli n 1mnsdermally 11<
pa tieni c.m adjus1 the insu lin to 111ec1 needs .11 mulu
by pull ing a tab to release more insulin. llroblem1w
 - - - -CHAPTER
- 20 Endocrine System 01sorders 363

thi~ ~'Stem are that insulin is not readily absorbed

through the skin and the absorption rate of trnnsdennal TABlE 20 10 DURATION OF ACTION OF THE
medications varies greatly depending on multiple faaors. SULFO NYLUREAS
ONSET
Adverse Reactions to Insulin GENERIC TRADE OF DURATION
NAME NAME ACTION OF ACTION
Insulin is usually well tolerated, although some patients
may have allergic reaaions. Switching to a dilferem SECOND-GENERATION AGENTS
insulin product will usually eliminate this problem. ghplllde
Some ttacttons such as Upodystrophy occur at the injec- standard Glucol/OI 1-1 5 hr 12-24 hr
tion site if the patient does not keep the sites rotated. SUStalllGd Gluc:ouol Xl I I 5 Iv 24 hr
\\eight 8'1'" is a common side effect with insulin admin- release
istration, as are blurred ,.;sion and hypoglycemia (see glybunde
!able 20-7 ) The person with diabetes should be taught
n0<1m1cromzed OiaBeta. 24 hr 12-24 hr
to recognize signs of hypoglycemia and should have
M1cronase
rcadil)' absorbed sugar and a fat product such as peanut
buncr avai Iable. m1cronized Glynase 1 hr 24 hr
PresTab
gl1mep1rido Amaryl 1 hr 24 hr
Pet;i'ilt'IEducatiO'nJ't OijCompliance
Snc\ ng delays absorption of 1nsuhn People needing insuhn
should not smolte for ~ minutes ahet the IOJection Su/fo111111mu. dmvatives of sulfonamide antibiotics
Ptegnancy and illness may dramatocally increase require- but Vithout antibiotic activity, were the first oral hypo-
mPntS for msuhn glycemic agents. 1\vo groups of sulfonyluresas are first-
Sk1pp1ng meals and increased oxeic1se may result 10 generation agents seldom used today and second-
hypoglycemia. genera1io11 agents that en1er bcia cells or the pancreas
Amounts of insulin should not be ad1usted without consulting causing release of insu1in; lncreasc insulin secrelions huL
the physician have no value in treatmen1 of T l OM because no true
PelSOns w11h diabetes should wear medical 1den1tficalion so insulin-like activity exists.
lhat on case of emergency any behavioral changes can be Second-genera1ion agents are 1he mosl potent and
evaluated with regard to hyperglycemia or hypoglytemia produce therapeutic effects in lower doses with a longer
Moo 1tonng blood glucose levels on a regular basis assists duration of action, allowing for once-daily administra-
w1t11 pt8'fflllt1ng reactions. either hypoglycemia or tion ("!Jble 20-10 gh'l'S the onset and durJtion of action
hyperglycemia of these medications). 111ese drugs are absorbed by the
Care should be used when laking OTC prcp.Jratoons because intestines and transponed to the pancreas, causing a
of the sogar c0<1tent found 111 some medications such as delay from administration to action. Sulfonylureas
cough preparations. As OTC drugs are occasionally reformu produce hypoglycemia that is more severe in pacients
lated, labels should be read before each purchase. Reading who nrc elderly, debili tated, or ma lnourished. Bec.1use
labels and checking with the pharmacist are important steps the medications vary in onset and duration of act ion,
m med1cat10<1 safely for the person with diabetes. pa1ients must adhere to a strict diet time and weU-
balanced meals. Hypersensitivity re.mions such as pho-
tosensitivity, jaundice rashes. and blood dyscrasias have
occurred with oral antidiabetic agents. 11\ese medica-
tions are contraindicated in Tl OM with liver and renal
DRUGS USED AS ORAL disease and they should not be used during pregnancy.
ANTIDIABETIC AGENTS After 10 years of use the medications become less effec-
1ive (see 1able 20-9}.
Oral an1idiabetic drugs are in six fami lies: >til fonylureas, C/11Cl/se nllsorprion i11/1ibirors include 1he a.glucosidase
biguanides, a-glucosidase inhibitors. thiazolidinedio- inhibitors acarbose (rrecose) and nrlglirol (Glyse1),
""' meglitinid~ and dipeptidyl iieptidase-4 (OrP-4) which delay absorption of carbohydrates by slowing
inhibi1ors. These agents are used for 1'2DM diabetes absorp1ion of glucose in the small intestines. a-
(biguamdes may be used with n OM) and should be Clucosidase is the enzyme tha1 breaks down carbohy-
~ only after exercise and diet hae nol controlled drates to monosaccharides; thus these drugs "'Ork
elevated blood sugar values. The patient with T2DM who by inhibiting the enzyme and reducing postprandial
loses weight may be able to discontinue use of oral rise in glucose. "tedications in this group can be used
hypOj\lycemic agents. alone or in combination '"ilh insulin, metformin, or
 364 SECTION v Med1cauons Related to Body Systems
\ulfonylurcu lbese medicauons h,l\ e earIY sd e effects
offlatulcnce, diarrhea. and abdominal pain that subside
w11h ronunucd use (see Table 20-9).
81gu111111lts aCI by lowering cellular resistance 10 ~nsuhn.
Me1fon11i11 (Clucophage) decreases producuon of
glucose by the liver while not releasing insulin from the
pancre.u a11d does not cause hypoglycemia. h reduces
blood glucose levels in patienll> who no longer produ.ce
msulm m .1dequate quantities to prl'Vent hype~ycemia.
Metform1111s used for Tl OM and 1'20M but ts not rec-
ommcndl-d for use by older adults or palll'nts with renal
d)")funcuon (S Table 20-9)
l11uu.olkl111t'd1onts, or glitawnes. are a class of antihy-
perglrcem1c medications not related to any o ther ?ral
medication\ for T2DM . These medication> (i.e., ros1gh-
tazone (Avandial) decrease in>ulin resistance and
imp1ovc blood glucose control to be effect ive in persons
with imulin resistance, even LhO>l' who no longer
respond to sulfonylureas. rheir action i~ to incr~ase
insulin 5ens111vity in adipose tissue, muscles, and hwr.
' l'hese agents may be used alone or in combination with
me1form1n or sulfonylureas (see Iable 209)
Megl111111dl"I, also called rapul 111.111/111 rr/1'<1.<erS. are shon-
acting mcd1cauons that may be used alone or with other
med1cauons to stimula1e beta cell> to rell'a~e insulin in an
aClion si111il.1rto that of sulfonylurcas. 'I hcse medications
can be used with injected lo11g JCl i11g insuli n therap)' to
0
provide enhanced blood glucose control. Persons who eat
carbohydmtcs and have a subsequent blood ugar spike
will most like!> benefit from these medica1ions. Repa-
glinille (l'radm) and 1UJ14'81inilh (Starlix) should be
taken 10 to 15 minutes before meals and should not nttd
to be 1aken if the meal is skipped (sec l.tble 20-9).
Dlptplldyl P"PlidJJse-4 Inhibitors (DPP-4), the
newest addition to the oral hnx>gl)'Cem ic agents for
1rea1ing '12DM, may be used alone or in combination
with mctform in or a thiazolidi nedione. Less weight gain
and re"er incidences or hypoglycemi,1 occur with these
drugs (i.e., JIWlgllplin [Onglyza/) a< they work lo
reduce release of glucagon and increase relea<e of insulin
to restore blood gluco<e levels toward normal after eating
(sec Table 20?)
Amy/111 glur11go11-li/1e pcplide (GLP} - 1 analogues,
injectable mediC<ttions, slimula1e secretion of insulin in
beta cells when large amounts of glucose are found in
the bloodstream, thus promoting beta-cell regeneration.
rhese drugs curb the appetite and control blood glucose
levels while minimizing the chance of hypoglycemia by
delaytng gastric emptying to lower high poscprandial
blood glucose levels. These drugs may also be used in
patients who have undergone islet tran<plantation.
1 crt!lin mimeiic:s are given subcutaneouslyio~
. wh:Se diabetes cannot be controlled with OQf ~
medications and may be used for SUnd,i
bellC
. . with TIDM. ' Ib e mcd'1ca11on . 1s . admi1111.
t Iwra Py . d .
n day before the mom 1ng an evening meal --. .
C\v1rc
lid" ( lly('lla), the first dnig 111 this class, an.d liragi.,
(Victo:i.a) are ava ilable as '"~filled pen-1n1ecto~ dr.
to be used in comb1na11on wnh o ther med1cau"'
'lab lc 20-9) .
sy1111ie1lc human a.myli11, used as a,djull(l lfi,
with insulin for uncontrolled Tl OM. a~~ 11DM. ii
able in vials for injection. Ille dose is m1ectedSCbr
. meals and before snacks of 30 g of camohyd1- .
more. Pramli111ide (Symlin) shou~d not be mixed;.
same syringe with insulin prepara11ons: and lheinitc
sites must be at least 2 inches apart. Side effects iod
dccl't1a>e in appetite with re>ultant decrease in c
intake and weight loss.
1 When 1aking insuhn, the person should ra SllOc
mmutes after admmistrat1on because ll1t:Olft
vasoconsmction. which slows the c1rcula11011 ol r.sUi
2. Diet and exercise are important m control of d1a
Persons taking insulin should not skipmeals and ml;S!
else routinely. If a meal is skipped, the insulin dase ilxJ
not be injected
J Blood glucose levels should be morntO<ed 1out1nei'f
4 Persons wilh diabetes should wear medical idem
all umes.
5 When using lispro msuhn. the patient must eat
minutes or medication adm1rustratioo or lljettl);
given 1mmed1ately alter a meal
6. Suspensions of insuhn, mcludmg those used 111 ins
should be gently rolled betwocn the hands bef!l'e a!I"
tration. Vigorous agitation makes tho drug frotlly, ciu.
an inaccurate dose. Insulin pens should be stoied
needle up.
7. Fast-acting and rapid-actmg insulins are clea ~
cloudy as suspensions.
8 lnjecuon sites should be rotated v. tl1 eadl
adm ms1rat1on
9 Unopened vials of msulm should be 1ef11geraied Id
frozen Vials in current use can be stored at roon tBT1l'l
turo for up to 1 month but must be kept out of heat~ ~
sunlight.
IO Persons with diabetes should always read labe~ rJ,
medications or check wnh a pharmacist before lili'r l'IJ
med1ca11ons Sugar content of OTC medications
frequently, so the person should check labels 8ldt
med1ca11on 1s purthased
11 lnfonn patients that reduced food 1m11ke. ~!W'S
excessive alcohol consumption. and exces5M! exer;ll
cause hypoglycemia.
 ----~-------- _ _ _ _ _ _ _ _ _CHAPTER
...,.. 20
12 Teach patoenlS signs ol hypoglytemia-~rd1a, palpo-
tatoons. S'Mlal1ng neNOusoess. headache coolus1on. and
la11gue
13 Persons w11h diabetes should always carry 0tal carliohy
draies 10 counteract a hypoglycemic react100. preferably an
easily synthesized carbohydrate such as sugar. nond1c1
soda. or 1u1ce A carbohydrate that is slower in diges11on.
such as peanut butte1 or fruil should immediately follow
the rapidly digested carbohydrate.
. ..
;
Diabetes mell11us (OMI 1s charactenzed by sustained hyper-
gl;tem a TIOM 1s msuhn dependent wllefeas T20M 1s not
usually 1nsul n dependent but IOSU in may be needed on some
peMnS TIOM. an aut0tmmune disease. reprasents a com-
plete absence of 1nsuhn and must be treated w11h insulin
T2DM results from a cellular resistance 10 insulin and may
be 11ea1ed w11h oral am1d1abet1c agents and/or insulin. but
diet and exercise are also important Patients with T2DM
may not need oral antidiabetic medicatioos alter undergoing
weight roduc11on and exercise programs. T20M requires a
change in hfesl)'le 10 achieve a good qualil)' of life
Four fo1ms ol injectable insulin are used in tile United States
1ap1d acting, last actuig. intermediate acting, and long acting
Premixed comb1na11ons of these types ol insulin are also
ava lable
Rapid-onset onsuhns (8 15 minutes) have a very shon dura
tioo and action
Shon-acting onsuhn has a last onset (aPIJ'OX1mately 30
m11\ltesl and short duration ol action.
lnterrned at1M1tting onsuhn has an intermed ate onset and
dula11on ol acllon
Long-acting insuhn has a prolonged onset and duration ol
action This g1oup includes insulins that provide a contonuous
24-hour supply of insulln. with no plasma peak
All 1nsul1ns should be given subcutaneously. but regula1
insulin mav be administered intramuscularlyor intravenously
11 necessary
Many new insulin delivery systems such as pumps are avail
able Oral and nasal adm1nistrahon and insulin patches a19
being nvesugated
Some classes or anud1abehc agents do not cause hypogly
tefl'la. including a111tx:os1dase inhibitors. btguanides. gll
1azones and amytul/Gll' 1 analogs.
Oral antidoabetoc agents must be evaluated for use on preg-
f1011CY. as lhey cross the placenta and cause hypoglycerma 1n
Ille fetus. and in lactation. because they are found on breast
milk
Alcohol should not be used wnh sulfonylureas.
Endocrine System Disorders 365
HYPERGL YCEMIC AGENTS
I ln>ergl)-cemic medications that elev.lie blood sugar
18'-el and are aniagonislS to insulin may be used to treat
hypogl)-cemic reactions or hypersecretion of insulin
from the pancreas in disea~ such as pancreatic
cancer.
Clucagori, produced in alpha cells of pancreatic islelS,
>1imula1es the breakdown of glycogen and incre,ises the
body's use of glucose. causing blood sugar levels 10 rise.
Clucagon is given parenterally for an insulin overdose
in people with Tl OM diabetes. It is not effective
in starvation-caused hypoglycemia because starvation
fim dc1>letes glrcogen storage. and glucagon must have
gl)-cogen to work. Glucagon may also be used with
barium in gastrointestinal radiography to relaJ< the gas-
uo1ntesonal tract.
DiazDXitk, (l'roglycem) used in patients with inoper-
able pancreatic cancers. is an oral preparauon that pro-
duces a prompt increase in blood glucose 18\"els by
inhibi1ing pancreatic insulin release.
Glucose tablelS and gels in tubes arc av.iilable for use
in persons with hypoglycemic reactions. I hese agenis are
monosa(charides that can be carried for emergency use.
Glucose tableis are especially effective for emergency use
in children (see Table 209).
SUMMARY
l'he endocrine system has no concrete hands-on physiol-
ogy because hormones may be either endogenous or
exogenous. I lonnones are transponcd mainly in the
bloo<lsiream to tatget cells where the response OCCU$,
and their action is inhibited by neg,1tive feedback to the
org;in of origin. Pathologic conditions result from under-
produCtion or overproduction of hormones. i'or under-
production, replacement therapy is usually prescribed.
For overproduction, medications, surgery, or irradiation
may be used .
l'itui1ary gland medications are used for replacement
therapy related 10 specific disorders, such as Cl I for chil-
dren who fail to grow and growth-inhibiting hormone
for children witli gigantism or adu lts wilh acromegaly.
I lormones from the posterior pi tuitary gland are used to
treat diabetes insipidus.
The thyTOid gland secretes three hormones thyroxine
(1,), Lriiodothyronine (T,}. and calcitonin T 1 and 1,
afft'C'I all body cells by increasing metabolism, whereas
calcitonin regulates the body's calcium levels. Replace-
ment therapy is necessary for hypothyroidism, to increase
circulati ng hormones and relieve symptoms Medica
Lions are also used in hypenhyroidism 10 block synthesis
of thyroid hormone.
366 SECTION V Med1ca11ons Related to Body Systems

body rl">1s1.1nce 10 insulin, or both . DM isofn.,,

lhe conicosteroids-glucoconico1ds and mineralo
conicoids-originate in the adrenal conex. These ste
roids haw many pharm.icologic effecis induding
antimtlammatory acuon. me1<1bol~m of cMbohydrates.
fais. and proieins. immunosuppr~ion with organ uans-
plantauon; and effecis rela1ed to physiologic and psy-
chologic response 10 str<!SS ~1ero1ds are given by mouth,
parenterally. topically, .md via other rouies; some are
available arc
rhe primary pancre.11ic hormones Me insulin and
gluc.igon. When insulin cause~ blood glucose levels
to decrease. glucagon i relca;.cd. 111is allows the use o r
glycogen scored in 1he liver, which ag.1in increases blood
glucose ll'\-cls. Neg;uive feedback allows more insu lin co
be released. whim ma1n1ains homco"asis of carbohy-
drate metabolism.
The rela1i"e absence or deficiency of insulin secrelions
IS Lhe ciuse of DM, en.her from insuffiaent ~retions or
Tl OM is imulin dependent. and T2DM is eon~
non - insulin -dependent condition, although
may be needed in some cases of TlDM 1
come 111 several types. depending on their time
and dura1ion of anion. Different 1ypes o( m
insulin 111.1y he mixed to provide adequait ca
ihroughout .1 day, but dosages o f each must btinl
a li?..cd co each p.11ien1's needs and physical Conti
T2DM i;, us~1 all y Ln.-.1.ted wit~ d ietary rnanillit',
weight rcclu c11011, exercise. and 1f necessary oral :tnti
betic agcn 1s.
O ral an 1i d iahe1ic m edications are used by inill;,
American' with T2DM. Some of these drugi aa
increasing pancreatic insulin secretion; othtn
carbohydmte mctaholism . The newer rnedicaiion.
increasing the (unoion ofglucose metabolism in
with insulin resist.111ce.

Scenario
Josie has been taking steroids for a prolonged period of time as treatment for rheumatoid arthntis. She
has gamed weight, especially m her face, and notices that her skm 1s thm and bleeds easily.
1. What do you need to tell Josie about salt and water intake?
2. What about the chance of menstrual 1rregulant1es?
3. WhaSheis concerned about the increased hair on her face and body How can you exPlain this to hell
4 t other symptoms can she expect?
5 Ar~ Y~ talk with her. she says she is going to stop taking the med1c1ne at once because she is
a ra o the side effects What do you tell her about abruptly d1scont1nu1ng these medications>
 CHAPTER 20 Endocrine System Disorders 367
-~-----~~

DRUG CALCULATIONS
I. Order: llum ulin R 25 unils and Humuli n N 30 units
Available medicalion:

r.. .:- ...-..... I

iiiiilJ ... ...,, fI 17m - ....,
liiiliJ " Ill
N
IN11

~R fli
-
1. . . . . ....

=...~
...........

IJ.1ll
l !ll
i%

--
Humullll
,.,,....,,_
,,,...<>\>"I 0
.,.,.
5h<l" the correct amount of insulin on the marked synnges.

V)Olf)O\OOVlOMi.,.o~
--NC\l<'lC'>~ ll)- ~
----=::::i:::J1~~ji~
di~li~i1!Jl~di~il~i1~1il~ii~ii~
,i1~1i!li~ili!lj~jjj~ji~IJ~j'j~"!tl==j Humulln A

2 Ord.r: Synthroid 0.1 mg

Av,1ilable medication:

..
-...
.._.., _
, ...... . . . . lnG.

1111

REVIEW QUESTIONS
What is a hormone and what is its funct io n?- - - - - - - -- - - - -- - -- - - -- - -

2. What are the two major Lheraprutic uses of hormones!---- - -- - - -- - - -- - -- - -

368 SECTION V Med1cat1ons Releted 10 Body Systems

3 Wlm hormones t sccrcted by the thyroid gland! - - - - - - - - - - -- -- -- - -

~~~~~~~~---~-=::-~~~--
. . I n"coidl A steroid 7 - - - - -- - - -- 1
4 What is an adrenocomcood ! A glucocomcood! A monera oco

~~~~~~~~~~~~~-:-:--=-~~---
5. Stt>roids are ordered in what two unique ways that arc specific to th ew mcdicacions? ------~

6. What is the only drug for type I diabetes? How is it adminbtered1 Why can it not be admini5tmd

7. What are the sources for insulin replacement? Which source is most like the bod}l s insulin! - - - --

8. What is the time to on>et, 1)c,1k time, and ti me of duration o r th e di1Tc rc111 insulin t}'\)es? Describe thm 111k
o f lispro, regular, iso1,hanc. and L.1mus insulins. - - - - - - - - - - - - - -- - - - - - -

9. What are some of the ncwcst forms of insulin administration 1cchn1quc\ hemg developed 10 amid tJK
injeaionsl _ _ _ _ _ _ _ _ _ _ _ _ __ __ _ _ _ _ _ _ _ _ __

10. I low do the sulfonylurcas work! Do they produce hypop.lycemiJI - - - - - - - - -- - - - - -

I I. How do the biguanides work! Do they cause bypoglyccmi.1?

-------------~

12. Why would insulin need to be administered to a patient w h o 1s

t.1 k mg .111 oral hypoglycemic1 _ _ __
~~~~~~~~~~~
Eye and Ear Disorders

~--
Af1er swdymg 1h1s chapler, you should be capable of doing 1he followrng:
Explaining the d1flerence between ophthalmic and Descnb1ng how to st0<e ophthalmic and Otte
otic p<eparations. p<eparations to prevent their being 1nadvenently
Recogmz1ng ophthalmic and ot1c medications and interchanged.
their uses Providing pauent education for compliance with
Describing drugs used in the treatment of med1cat1ons used to treat diseases and cond1t1ons
ototox1c1ty and venigo of the eye and ear.

Gene has an mllammarion of the comea of his left eye He has been prescribed an antiinflammarory
solution 10 use tn his eye three times a day. Gene cells you that in the pasL Dr. Merry has prescnbed
the same med1cat1on for use "' his ears for an mfectt0n. The expiration date on the old 011c med1CSt1on
has nor passed
Can Gene use the ot1c solu11on rather than buy the new ophthalmic medicine?
Why can Gene expect some blurring of vision after 1ns11lhng the drops?
Where should Gene instill the drops in his eyes?

Accommodation Cycloplegia Otitis media

Adrenergic agonist Glaucoma Oto toxicity
Anticholinergic agent Hordeolum Paresthesia
Ataxia Keratitis Photophobia
Auralgia Miosis Presbyopia
Blepharitis Miotic Sympathomimetic agent
Cataract Mydriasis Tinnitus
Cerumen Myopia Tonometry
Chalazion Nystagmus Tympanic membrane
Cholinergic agent (or Open-angle glaucoma Uveitis
parasympathomimeticl Ophthalmic preparat ions Vasocongestion
Closed-angle glaucoma Otic preparations Verti go
Conjunctivit is

369
 370 ifCTION V Medicabons Related to Body Systems

Common Srde Effects of Medrcetions

Common Symptoms of Ear .nd Eye Disorders
Ophthalmic
Eyet Changes 10 intraocular pressure
Visual d srurbanccs pain
Eye redness
Bur111ng, Stinging or
. .
on adm1nistrat1on
Blurred vision or d1plop1a
Pain or oomong in or around the eye
Photophobia
Headache
E rs
Increased tears
lw of healing
Vertigo 0t diwness
Tim11us Obc
Earache Ind ncreased llfl!SSUie on lhe eao Tonnnus
Burning or 1tch1ng of ear canal
Dimness

I EASY WORKING KNOWLEDGE OF DRUGS USED FOR EAR ANO EYE DISORDERS I
I .. I I I.

OPHTHALMIC
A11t 1fect1~ Yes Yes {bone acid) B,C Eye tnfectm
Ant11nt..irnmatories and Yes No c Eye mllammatoi
conocos1eto1ds
lrngat1ng solutions Yes Yes B foreign bodies
Antrglaucoma agems Yes No c.x Glaucoma
Myd11at1cs. cycloplegocs Yes No B. C D1agnos11c studies
local anestlie11cs Yes No c Eye 1mta110n
lmmW10010dulatOI$ Yes No c Dry eyes
Attoficia teats. lubncams Yes Yes NIA Replace nm
Ant1alletgcs Yes Yes B Eye allergies
Ooagnostic aids Yes No c 01agnosi.: stulies

one
Ant1infcc11ves. antrbootics Yes No c Middle ear and ei:
canal 1nfect11R1
Antirnftammatones and Yes No c Ear mftammatl(WI
cort1costero1ds
Combination preparations Yes No B. C Infections. r.
Cerumonolyta Yes Yes B Soften ear wai
Ear analg. cs Yes Yes B. C Earacfle
DRUGS FDR VERTIGO Yes Yes B. C Vertigo and m0101
sickness
NIA. Not apphcable

EVE I
T
wo sense organs are discussed in this chapter. The
eye is responsible for vision, and the ear is ne<:es
l'he eye, one of the most del1ca1e yet most ,-Md:i
5'11)' for the senses of hearing and equilibrium . Any
of the <,cnse organs, captun:~ ligh1 and 1ransfona
impairment of these senses causes changes in lifestyle-
into im~gcs in 1he brain . Any disorder results in ollll
eilher temporarily or pennanem ly.
irnpa irmcr11 (Figure 21- 1 ).
 ~~~~~~~~~~~~~
CHAl'ffil 21 Eye and Ear Disorders 371

Clkary body ~
-:=;;;;;;;;;:;;----: Antorle<
- -chamber
tris

""""
AnlerJor
cavliy
flllodw\Jh
Postaoor cavity
8QUOO<lt
humo<
Coniunewa

Ins Figure 212 Aqueous humor l)aSS8$ 11110 anttlf10r chamber l!>rough 1he
Sciera V1tteous humor puprl. where rt rs drained avmy by dle nng shaped canal ol Schlemm (From
Thibodeau GA. Pa non Kf Anrhony's 1ox1book of anatomy and physro/O(ly,
Figure 21-1 Anatomy of the eye !From Young AP. Proctor OB Kifllr'sthe
ed 18, St Louis, 2007, Mosby.)
medical ass1stam: an applied leammo aJJP(oach, ed 11 St Lours, 2011.
Saundals I

The protective outer layer of the eye consists of the t.aMmal

canals
rornca (transparem anterior covering of the eye that
allows the entrance of light) and tl1e sdera (a white
fibrous conLinuaLion of the cornea that maintains tl1e
1ha~ of the eyeball ). The eye surface has a thin layer of
fllithelial cells called the co11111nctil'll that is resistant to
infooion.
l11e mrddle layer of the eye consists of the iris. choroid,
and ciliary body. The iris surrounds the pupil and has
~-- Nasol&erlmal
the ahilily to relax and constrict to conirol the amount duct
of light that enters the eye. Constriction o f the pupil is
mlo<ls; dilalion of the pupil is mydriasls. Dru~ may s
be used to produce either of these condilions for ocular M -'
l
examinations or to treat ere diseases.
The lens lies behind the iris to ensure a clear sharp
foe.II image and sends signab for retinal interpret.11ion.
On each side of the lens is a ci liary body that changes Figure 213 lacrrmal apparatus of the eye JFrom Thibodeau GA. Panon
the sha1>e of the lens for accommodation. Accommo KT: Anth(Jny's textbook of anatomy and plrys10/ogy, od 18. St Louis. 2007.
dation occurs readily in young people, but as 1he lens Mosby )
loses elasticity with age, 1he abili1y to focus on near
objl'CtS is lost, and the point at which an objoo is in
focm recedes-known as pre.b,opla, usually starting
t approxim3tely age 40 to 45 If the lens loses its trans- chamber lies between the lens and mina and is filled
parency and becomes cloudy, the condition is called a with the colorless, transparent, gellike vicreow humor;
c~tarct. t\ paralysis of 1he ciliary muscle is called which holds the retina firmly against the wall of the
cydoplegla. eye to help mai111ain its shape {see Figure 21- 1).
111c third layer of the eye consists of the anierior The eye is protected by eyelashes to catd1 foreign
and pos1erior chambers TI1e a111erior d1ambcr is the ma1erials; bli nking to kee1) 1he corneal surface free of
space between the cornea and tl1e lens. The aq11rous mucus and moisteoed by the lears; and tears that are
humor nows forward between the lens and the iris into bactericidal, preventing infections and draining into the
the an1erior chamber to help maintain the shape and inner comers of the eyelid into the nasolacrimal duets
ptl">'ure in the anterior eye (rigure 21 -2). The J>OSterior {Figure 21.3 ).
 I
372 ;ECTIONv Med1cet1ons Related to e0dySystems

TABLE 212 OPHTHALMIC MEDICATIONS WITH

t
TABLE 11 1OCULAR SIDE EFFECTS FROM ADVERSE SYSTEMIC EFFECTS
SYSTEMIC MEDICATIDNS
DRUG AND CLASS ADVERSE EFfECTs
- Jtf1!:11J1!1!jliu 2
ANTIMICROBIAL
asp1rrn Allergic kerauus and chloraniphenicol Aplasllc anem.a
con1uncuv111s
Barb11u1a1es N)\tdgmu~ ANTI CHOLINERGICS
marr1uana Nyscagmus. con1uncuvitis. a11op1ne Increased t~
double vrsion. m1os1s 1achytardi.;, a:
donidine MIOSlS cyclopentolate CorwlJISIOOS, '-""i:::'l
ConrcostelOlds Cata1acts. increased p$\tllolic r~
mtraocular p!essure scopolam1ne Acute PSycliosis
ethyl alC<Jllol Nyscagmus
ibuprofen Altered color vision. blurred ANTIGLAUCOMA MEDICATIONS
VISIOll Bola-blocking agents Bracfycard1a ~
Mydrras1s decreased blOOd
mdomechacm
pressure, astnm;
1son1a11d Opbc neu1111s
congesto.e liear.
lithium Exophthalmos nausea.ha~
Opiaces MIOSI$ anore..a ~
~tlllalme Cataracts wea\ness. ~
phenyt~1n Nystagrnus Cholrnergic agents Salovatoon, naUS61 llC
Tluamle diuretics Transient myopia. yellow vom1111~. aSl!i!na
color to v1s1on altacks. low blood
pressure
Modified from Solerno X Pharmacology for hea/1/1 protcssronals, Si Louis.
1999. Mosby Carbonic anhydrase Diarrhea. headlcf'e.
1nh1b1tors nervousness. llalUl
andvom111~
anonma. p.amtki
v.e'!#U loss.
Med1ca1ions specifically for use m the eye are called photose= !\
opbthlrnlc prepartions. Medicalions given for S}'S-
temic diS<'ascs may have O<;Ular side cffeas (Table Prostagland1n agonrsts Uppei teS1J1ra17'f n:i
21 I). Conversely, med icatio ns for eye conditions may 1nfect1on. muscle.
1orn~ and chest pait
cause systemic effects and changes in ho meostasis
(Table 212). angrna. rash
Osmotic druretics Nausea and VOIM~
hcadache,;J'C!Ul
av
thirst llllW.
ANTllNFECTIVE AND diarrrea.~
ANTllNFLAMMATORY AGENTS An11chohnergrcs Sweating.~
\3dl)Qnlla
As wich other infcaions, O<;Ular infections should be depressm d\anp
cultured to dc1ennine 1he amibio tic of choice. I n many menial annu:ll
cases. however. treaunem is started before culture results
are av,1i lablc so the severity of infection is limited; in
some CJses. systemic medications a l'C med in conjunc-
tion wi th ocular medicatio ns.
Most aotiinfective agents do no1 read ily penetrate the systemk a111iinfectives .ind 10 discourage drug m$.1
eye. although some topical agents are absorbed when the str.1i11,, .1111ibio1ics for ophth,llmic symp1omut
mucous membrane has been injured or inOamed. Such .1dmrni\ll!red locally Wich oph1halm1c an1nml adt
ocular infections as coojuncthhh, hordeolum, chala-
11011\, for conditions such '" viral conjlJll(U\1m
:<ion, blepharltls, keratltls, and uvelll are treated
by the common cold, both eyes Me trea1td to I"""'
with topical agents. To avoid possible sensitizatio n to
infc1 tion spread (Tab ll' 21 ~) .
 -~~---------------------C;;;H,;;..
Al'TEA21 Eye and Ear Disorders 373

ANTIINFECTANTS AND St1ng1ng, Broad-spectrtJtn an1tbactenal

ANTIINFLAMMATORY m1ta11on. for superficial ocular
AGENTS tearing 1nfect1oos and gram-
pos11ive infections
tnple ant1b1011c tNeosporin Small amount. CS None identified
Ophthalmic ointment,
soluuonl gn" q4h
ciproftoxacin (Clloxan gn II q24h None 1dent1fied
soluuon.
ointment) Small amoum. CS
polymym B(Polysponn
(Ojinhatmicl ointment. Small amounl CS
solutlOOl gtt ;.n m eye qh 111til
favorable response
bac1tractn ointment Small amount. CS None Identified
erytlvomyc1n ointment Small amount. CS BactenostatC. neooatal None identified
coojunct1vitis
gentarntem (Gentak Small amount. CS Gram-positive and gram- Nooe 1dent1fied
ointment, negative oryamsms that
solution) gtt i-ii q2-4h are drug resistant
tobramycm (Tobrex gtt q2h. ointment Ilffi Same as for gentamicin Systemic
solution, qd aminoglycos1des
ointment! with Y. to X inch in CS
dexamethasone gtt j.f Same as for gentamicin
(TobraDex soluuon) gn q4h. ointment
Q4-lih
sulfacetllmide (Bleph-10. Qtl Hi q2-3h Same as for gentamicin Must be insulled
Sulamyd soluuonl JO minutes
after ocular
anesthetlCS
mcooffoxacm (V1gamox) gn i-f tid

ANTISEPTICS Propllylaxis; lJeatment of None 1dent1fied

boric acid (Blinx. Collyt1um
2% solution. S%-10%
omtmentl
s1l\'el muate 1% solution
eye infections; many are
OTC preparations
gtt i-IT to eye,
cs
gtt i both eyes at birth Neonates after birth for
p<ophylaxis of gooococc1

ANTIFUNGALS Fungal blepiarit!S, Not systemocally

con1unctivitis. or kerattt1s absofbed
natamytin (Nawcynl lndlVidualired. usually
grt i q4-6h
CS. Coniunctwal sac
'The 1ou1e ol adm1n1strat1on m this table 1s topical unless otherwise stated
'Ointments are plocod 1n con1unc11val sac; liquids are mst1lled in "18
Note 111e use of the bar ove1lotte1s 10 a dosage indica1cs 1hat the lette1is a roman numeral. The bar is not used cons1sten1ly 10 1he 1ndustl'(
 Viral infections of eye. . ,
ANTIVIRALS herpes simplex. kera1111s

b 1ftuuJi ., (V1ro1mc gtt I q2 4h

t
Allergic Of inftammatOIY May le.oi
CORTICOSTEROIOS Bwmng.
tearing. disorders. used m efffQs
bluned combinations with JJ1tngej
vision. antibiotics and mydnat1cs perujs.
headache. such as lsopto Cetapred. (see dist
pain Medrapred. and Optimyd of ~
mCliav.a Zi
delilmethJIOOe (Maxidex Vanes with patient
susiicmion. solution. and cond111on in eye
omtment)
polyvurvt alcdlol (liqu1fi m gtt I to
Tears. follel with
~lU101d (Poly-Pred git II
t1qu1f1lml
predn1solone sodium Vanes
phosphate (Pred Forte.
Omn1proo as
suspensions and
solutions)

NONSTEROfDAL ANTIINRAMMATORY DRUGS

fturboprofen 10cufen gtt 1q30m1n for a total fnhibns mtraocular m1os1s N!rere:
sofut1onl of 4 gtt before
surgery
ketorolac (Acular. Acuvail Qll I Qld Prophylaxis; trea tment of Nooe 1dertill
soluuon) ocular inflammation

ktJ CLINICAL TIPS

Only Ojlhthalmic preparations should be used in the eye Sliver nitrate, used for gonococcal onfectJonS at~-- m
Ophthalmic preparations are steule and care must be taken to a coltaps1ble capsule containing five drops The ca$
prevent contamination.
used should be tested with ono d1op to BnSlle a I
Be sure sulfa preparations have not darkened from their normal
before administration to prevent damage to eyes dltli
hght yellow color.
nitrate has crystallized.
Action of sulfonamides is inhibited by ophthalmic anesthetics.
When Irrigating eyes. turn patient's head rowarda~
so the two agents should be administered 30 to 60 minutes
to prevent cross-contamination of unaffectoo eia
apan
Ophthalmic cort1costero1ds may hJve a S'ISrei1IC e6sl
A good rule for administration of ophthalmic topical med1ca-
over a prolonged time
t100S IS to allow ume (15 minutes to 1 hour) between adm1ms-
Contact lenses. especially soh tenses. should be~
uatton ol different ophthalmic preparations unless prescnbed
otherv. se adm1n1s1rallon of ophthalmic f)leparatl()f1$ tn ir~.cs;;:
of med1cat1on by the lens
Sulfonamides are iocompat1ble with th1morosal (a mercurial
ant1sep11CI and silver l)feparat1ons
 CHAPTER21 Eye and Ear Disorders 375

The aun of treatment for glaucoma is to decrease IOP.

AGENTS FOR GLAUCOMA
Cbucoma is the name for a group of diseases character-
ized by increased iniraocular pressure (IOP) as a result
of excessi'-e produaion of aqueous humor or dimin-
ished ocular Ouid ou10ow. Several terms are used to
describe glaucoma- primary or secondary. acute or cllro11ic,
,ind open-angle glaucoma or cloed-angle glaucoma .
If pressure is pcrsisten1ly high. blindness may occur sec-
ondary 10 op1 ic nerve damage. rrimary medical ions used
10 1rea1 glaucoma include beta-adrenergic receptor.
blocking agen1s, cholinergics, and sympathomimc1ics.
thus decrea~ing damage to the optic ner\'C.
&ta-atltl'tl"'lJIC m:epror bloctm (bet.1 blocl.ers), when
11-1 for glaucoma. decrease produmon of aqueous
humor 10 reduce IOP (Table 21-4).
Chollnergic ;ogents (or para<ympathomlmetlcs)
or mlotlcs consuict pupils. causing m}opla, opening
spaces for movement of aqueou; humor 8ec.1use the
1>upil o:innot accommodate to changes in illumin.11ion.
cndofday and nighttime activities are particularly haY~
ardous for individuals using these medica1ions. Other
mio1ics are cl10/ir1e;1er11.Se inhibiiors. which inhibi1 de.truc-
tion of ace1ylcholine. Cholines1erase inhibi1or. are

BETA-ADRENERGIC Local-blm1ng, StJngmg eye unlation, Glaucoma Essen11ally

BLOCKING AGENTS visual d&SIUrbatlce. pruntus nooewhen
S~remic-b1adycard1a or used
1achytard1a, confusion. insomnia. 1op1cally
weakness. resp1ra101y symp1oms.
GI disturbances
be1axolol O25% !Be1oplic gn; bid
solution)
carteolol solution Qll I bid
IOcuP1ess soluuon)
llMllxmlol 0 25% 10 gtl TI btd
0.5% tBeiagan solut1011) gn ,.;; qd
meopranolol (Op11Pranolol gn ; bid
O3% soluuon)
limofc4 (Timop11c solution.
TOlllOIJllC XE)

CHOLINERGIC IMIOTIC) Local-blurred v1s1on. myopia. eye

DIRECT-ACTING 1rritaoon. headaches:
AGENTS No systemic side effects
carl>achol (lsopto Carbachol gu 11 lid None idenufied
solution)
pilocarpine (lsopto Carpme gtl n tidqid None 1denufied
solution)
(OctJsenl lnsen disk in CS

CHOLINESTERASE INHIBITORS
ec:OOlhlO!Jhate (Phospholine gn I None Identified
1o011.1e1
CS. Cooiuncti<.11 sac; GI. QaSllOnlllslinal, PO. orally.
"!he 1oute of a<il\1n1suauon 1n 1his iable 1s iopical unless olhe<wlse staled
'Ointments am placed m con1unct1val sac: liquids ai e inslilled m eye
Note Tile use ol the bar CMlr loners m a dosage indicates lllat 111D le1te1 1s a roman numeral. The bar is not used consistemly 1n Ille mdusuv
Umt/nutd

1
; t . ; f f : I I
-
~_;.__..=.:.::.:.:::.:..:.::.:.::.::.:.::::::.::::::.:...::;;;.;;....--------~~~~--- 1
I
TABlf 71 4 DRUGS USED TD TREAT GLAUCOMA-cont'd

USUALROUTE.
DOSE. ADULT INDICATIONS DRUG
GENERIC NAME/ ANO FREOUENCV' ' MAJOR SIDE EFFECTS FOR USE INT
TRADE NAME
Local-same as cholinergic agents;
SYMPATHOMIMETICS Systemll~-see Table 21 2

CARBONIC ANHYORASE INHIBITORS Glaucoma

"'e o_,,I 250.500 mg PO bid. IV Faugue. J. appetite, i urination

dor1olam1de ITrusopt 2% gn 11td

solutionI

PROSTAGLANDIN Local-blurred vision. burning,

INHIBITORS stinging, photophobi.i,
j brown pigmentation;
Systemw-see Table 212
latanoprost IXalatan gn 1qd
soluto0nl
11avoixos1 (Trava1an gn l qd
0 005% solu11onl
b1matoprost llum1gan gtt I qd
0 03% solu11onl

MISCELLANEOUS
811facklntd111e (lop!(fme gtt HI lid Glaucoma. 10 N~ sig!ft:!
O5'11. solutonl reduce ~
aqueous ~
humor
production
brnnon1d1ne (Alphagan gtt I t1d
soluuonl

usually reserved for people who had no response to
other a111iglaucoma agents (see Table 21 -4 ).
l>ymp~thomimetic agents mimic the sympathetic
nerYous S)~tem to dilate pupils in patients with open-
angle glaucoma. Dipivefri11 is convened 10 epinephrine
lowering IOP, decreasing aqueous hum or produnion,
and inrreasing outflow (see Table 21-4).
Oral carlxmic tmliydmse i11ltibi101l ,&rt' diuretics used to
lower 101' by decreasing aqueous production and reduc-
ing aqueous humor volume by more than 50% (see
Table 21-4) Diuretics are discussed in Chapters 26
and 27.
l'roswgla111/rn agonists appro''ed for topical treatment
of glaucoma and ocular hypertension arc as effective a>
bet<\ blockers with fewer side effects. Now considered
the firstline medications for glaucom.1, these agents
reduce IOP by increasing aqueous humor oudlY
.ue u\u,dly well tolerated, with the major ..X
being irreversible brown1ng of the ins ptgl!d
labk 21 -4 ).
0~111011c di11re1ia are ust>d to reduce IOP ~It
or in trl'.ltment of acutl' glaucoma (set labl<>
,1nd21 -4).
MVDRIATICS AND CVCLOPLEGICS
Mydriatics .md cycloplcgic\ arc used for pupil._
for ophthalmologic testing .1nd other oph~
cond111ons.
\tin n.-r k agoni\I\ tn11n1c the sympatlvticl>'I'
ystem to bring about pupill.uy dilation, or ~
 CHAl'TER 21 Eye and Ear Disorders 377

Crri"l'll8" agents Gluse paralysis of ciliary muscles or
pre--ent accommodation and are used primarily in diag-
nosing ophthalmologic disorders, causing dilation of the
iris opening to make the pupil larger. Th<> inherent
danger is that many of these agents are available over the
counter (OTC) to reduce redness in eyes caused by vuo-
congestlon. Prl'SCription medications, used to treat
glaucoma, produce mydriasis for ocular exami nations
and relieve ocular vasoronges1ion (Table 21-5).
Autlcholinerglc agents block the parasympathetic
nc1vous syste1n1 causi ng dilaLion, and are: used to relax
mOamcd imraocular muscles to relit\o't' pain with uveitis.
Other uses are for accurate measurement of refractiw
erTOI'$ and before and afier intraocular surgery Some
medications are administered in combinations to
produce greate1 mydriasis (see Table 21 S ).
Local Ophthalmic Anesthet ic A gents
Ophthalmic anesthetic agents are used to eliminate the
blink reOex and pain associated with opht halmic proce
dures, 1onomelry, removal of foreign objects. suturing

TABLE 21 ~ DRUGS USED AS MYORIATICS OR CYCLOPlEGICS

USUAL ADULT
DOSE, ROUTE. ANO MAJOR SIDE INDICATIONS
GENERIC NAME/TRADE NAME FREQUENCY "' EFFECTS FOR USE DRUG INTERACTIONS

MYDRIATICS DR Burning. llchlllg. Glaucoma. myitiaSIS No S!Jllficant

CYCLOPLEGICS blurred V1S1on for ocular surgety 1nterac11011S Identified
all'lljl1ne llsop10 Auoptne)
solution 1'!lo git j
ointment 1% Small amt CS
cyclopentolate (Cyclogyl 0.5%1% gtt ;.;;
solution)
homatropine llsopto Homatropine git iil
soluuon 2%5%1
scopolam1ne (lsopto Hyoscine gn 1il
solu11on 1%)
uopicamide (Mydral. TrQpicacyl git i-<l
solutlOll 05%1'11.)

AORENERGIC AGONISTS AND Bullllng and Myttiasss, decrease No significant

ANTICHOUNERGICS s11ng1ng on eye redness mteractoons idenufied
1nt11al apphcallon
ep1nephr1ne IEp1fnn. Glaucon' gn i
O5%2% soluuonl
hydroxyamphetam1ne (Paremyd' gU i~I
1% soluuon)
Raphazolinc INaphazollne. gtt j.jj
AK-Con' I% solution. Napll<:on. gtt i
Clea1Eves' solution)
oxymetazohne (Visine' solu11onl gn '
phenylephme (AK01late, Ahafnn. Varies
Neofnn' 2 5% 10% solution)
tetrahydrozohne (Murtne Plus. gn i
ViS1ne' O05% solullon)
cs. CmimttMll sac
"Tl-e roole of adffi,ntSll3llOll 111 UllS !able IS ropical trlless Ottierw>se Sia~
o.,tments ate placed meon1unc11val sac, liquids are insblled 1n O'iC
1
Prescr1pt1m medications
'Ow!rlllecoun1e< med1ca11ons
Note The use of tho bar over le11c1s 1n a dosage indicates that the letter is a roman numeral The bat is not used consistently in tho industry
 378 SECTION v Med1ca11ons Related to Body Systems

'"tered
ad rn1n ~ with oth
. er . topical
. ophthalmic
or remO\'al of sutures and radial keratotomy. The eye . 1a'ore admimstrauon, '"'Tn 5e\-eral Cl.
should ~ proimcd until anc.1h~'S1a "ears off because uom ''" mcdicauon
' . back into an emui,.
ofloss of the bhnk rcRex (I able 21 -6) restore the
1.1blc 21 <>)

IMMUNOMODULATORS
ARTIFICIAL TEARS AND
LUBRICANTS
I
An emulsion to increaSI.' te;ir production. cydosporine
(R1!$tasis). 1s considered an immunomodula1~r or im~rn
nosuppressam A""ilable only J\ ,1 prescnpuon med1ca Anificia l te.ir o lu tio ns o r lubricants are used top,
tion, cyclosporine :.hould not be adminbtcred whe.n an eye lubrica tio n whe n tear p roducuon and blinkr,
individual is wearing con tact lcnw:., nor should ll be are d ecreased. Products a re no rmal saline wub ii,

TABLE Zl -6 MISCEUANEOUS OPHTHALMIC PREPARATIO NS

GENERIC NAME/
TRADE NAME
USUAL ADULT
DOSE. ROUTE. AND MAJOR SIDE INDICATIONS
FOR USE
ORUG I
FREQUENCY"' EFFECTS INTERACTlO!ill
OCULAR ANESTHETICS
tlltratdine ITetca ne gtl Hi Burning on imual Anes1he1mng the eye NoS!g'.itaQ
Altaca ne O5'lli solulion) administration for ophthalmologic mteractJolll
procedures and in 1den111\ea
cases of eye trauma
proparacame (Alcame. Qlt 111 Same as for Same as for tetracaine No s1gnificar1
Ophthe11c. Parcaine O5% 1e1racaine interac11011S
solution) 1dem1fied

IMMUNOMOOULATORS Do no1 usew

COttact lt::i
cyclosponne {Restasis 0 05% One vial lgn i) applied Discard any Increases tear
emulsion) 1opically bid medicauon lefl in production
vial

ARTIACIAl TEARS ANO No ma1or side Amfic1al tears. eye Nos~Ui

LUBRICANTS effects because of lubf1cants mterac~
saline base dent lied
Most of these agents are
OTC medications. wuh a
base of normal saline A
few examples are provided
lacnsert ophthalmic insert One or lWO inserts
topically
lacnlube ointment Om1tnents are instilled
1n cs
Ouratea1s solution. l1qu1ds are 1nst1lled in
HypoTears. Teansol eye

ANTIAu.ERGENIC AGENTS
Ophthalmic allergies No sigtifuJ
and allergic mt~

CfllmOlyn sodium' (Crolom con1unctiv111s lden~lied

gn 11 4-6x/day
solution)

This med1ca1ioo 1s appfled topically unless otherwise ind1ca1ed.

1
0Vllr.lhe-<oun1er !OTC) medica11on
Nole: The use of lhe bar owr louers ma dosage indicates lhal lhe lette1is a roman numoral
fho bm 1s 1101 usrd cons1stenlly in 1he lndustrY
 -----~~---------------.....::C::.:::HAPTtR 21 Eye and Ear Disorders 379

TABLE 21 6 MISCELLANEOUS OPHTHALMIC PREPARATIONS cont'd

USUAL ADULT
GENERIC NAMEJ OOSE. ROUTE. ANO MAJOR SIDE INDICATIONS DRUG
TRADE NAME FREQUENCY"' EFFECTS FOR USE INTERACTIONS
lodoxamode IAlom1de solution) Vanes with age,
usually gtt iii q1d
kerot1fen 0.025%i IZaditor Vanes, usually gn i No cootact lens wear
soluuon) bid
olopatad1ne tPatanot solution) gtl l bid None
pemirolast I% IA lama st 911 iii qdbid No contact lens wear
solu11onl
epinast1ne tElestat solution) gtt i No contact lens wear

OCULAR Ophthalmic vascular

DECONGESTANTS congestJOn
See pheoytephr1ne.
naitwofuie. oxymetazohne
fOtnl 1n adrenergic
agon1sts lsee Table 215)
tetrahydmzoltne' IVisine Relief of symptoms of
Allergy Relief sotut1on) allergies manifest m
eyas

OPHTHALMIC
DIAGNOSTIC AIDS
Huoresce1n Diagnosis of corneal Should oot be used
lftuoresc11e solution) gtl HI eptthelial defects, wuh soh contact
IAu-Olo. 810 Glo. Fluorets Application of strip to fittings of contact lenses
ophthalmic stnp) eye lens. ophthalmic
ang1og~

Mior Side Elf""' Burnong, stinging. staining of contact lens

added 10 ex1end eye contact time to lubricate artificial Decongesta nt agents, weak adrenergic agents that
eyes, moisten contact lenses, and remove debris from 1he reduce eye redness by acting as 10picnl vasoconstrictors,
eyes nie;c products arc usually used th ree or four arc ava il able OTC (see Table 21-6).
times a day. An artificial tear insen (L.acrisert) and oint
ment preparations arc used for a prolonged effect (sec
Table 2t -6).
OPHTHALMIC STAINING AGENTS

.: Fluorrsuln somum, a nontoxic, water-soluble dye. is

! I
Agents for allergic l'YC disorders prevent histamines from
producing allergic reactions and relieve tearing, itching,
and redness related to al lergic eye conditions. Cortico-
steroids may be used for allergic conjunctivitis, including
\'ern,il (spring) conjunctivitis and keracitis,. OTC mcdica
lions should be used only short term (see Table 2 16).
used to diagnose corneal epithelial defects caused by
injury or infection and to locate foreign bodies in the
'>~ When applied to the come.i. Ouorescein stains
comeal lesions shown as green, and foreign bodies
haw a green ring surrounding them. This agent is also
used 10 assess fit of hard contact lens, JS a dye for
retinal studies, and for ophthalmic angiography (see
Table 2 16).
380 >ECl ON V Med1cabons Related to Body Systems
r1P atirni1EducatiO'n"for Compli a nce
Care Should be taken wtien usong ophlhalmic prepara11ons to
JlfeVef t coniam1naoon of medahons by the applicator
looch ng ll1c eye . agents must be used wnh care with glaucoma
2 We.it dark glasses with med1ca11ons thal cause photosens1
llVJty and puptl difauon
3 Consult a pliys1c1an 1f eyes do not show 1mp1ovement after
usong oplltha mic anufungals fOf 7 to 10 days
4 Tre:stmcm w th ant iv rals should continue for 3 ro 5 days
aflel healing or aa:ocdlllQ to physic1ans ordeis
& Cortico!.tetOlds should be used tor only a hm1ted time because
systemie effects may OCXt1r w11h long ierm use Wheo using
COllJCOSteroids in patients v.th diabetes. blood glucose
levels should be monrrored closely for hyperglycemia.
6 Ophthalmic suspensions and emulsions should be placed
back into solution by ag1tat1011 or 1nvers1on before
odmin1stra11on
7 When us1og anuchohnerg1cs. be careful to illuminate dark
areas because of decreased v1s1on 1n dim light With ant1cho-
l1netgics. 11$8 care rn dnving and performing other hazardous
au les because of loss of eye acCOIMlOdauoo. Close-up
vtSUal acuity win be !1e3lfY d1m1111Shed. making reading and
other close up act1V1t1es drfficult
8 Take carbonic anhydrase rnh1b11ors early in the day for
maxtmum benefit
..
Mo.it Qlllltllahmc antllllfectM! agents do not readily pene-
trate eyes lxit are used topically when mucous membranes
are 1nftamed or 1n1ured
Many ophthalmic solutions cause burning or stinging on
appltcat1on and cause headaches
Instill ophthalmic medications in the inner canthus of the eye.
Before admm1strat1on of topical ophthalmic medications.
removal of contact lens rs recommended except when using
wemog solutions and lubncants especially manufac1ured for
conLJtt lenses The lens should not be reinserted foe 15 to
30 minutes after medicatJoo adm1tl1Stration
Ophthalmic medicanOllS cause systemic effects 11 used over
PIOlonged time periods. panicularly conicosterords. beta-
adrenerg1c blockers, and cholinerg1c agents.
Sympathomimetic agents are used to treat open-angle glau
coma by decreasing aqueous humor production and increas-
ing tts outflow
Mylinat1cs and cycloplegics. used as d1agnos11c aids. para
lyze ctf1arv muscles 10 dtfate the pupil conversely m1otics
conwct the pupll
Ant dlol1nerg1c agents are used to treat inflamed rntraocular
m .cles dunng procedures 10 measure refractM! errors and
before and afte1 1ntraocular surgery
'.
Many adrenergic agents available OTC act by taJ
constricuon and optical d1lat1on to reduce eye~
Local ophthalmic anesthetics are used to reduce ~e
reflex and eliminate pain associated with ~
procedures
Anificial tears or lubricants. used with COJ~
basically normal saline solutions to ....tl1ch bdfe:s
added to prolong their eye contact. thus !her
Antrallerg1c agents are used to reduce ~ ..,,_,,
redness associated with allergic reacttOOS
EAR I
!'he cars. 1he sensory o rgan o f hearing and ~
are impo nant organ s c-.urying coumlessclues ;ibcq
ronnw m 10 me brain (l'igurc 214). lhe eustachai
ron ncct' the middle car cavit) to the pha1y0110~
pressure o n bo th sides o f the tympank _..,
llcc.tu~c 1he ear canal is a dark. moist channel Dal
card um. bacteria will travel d own the canal ~
i11fcc1i ons ~uch as swimmer's c.ir. Bacterial and i.;
infections of the ear canal JrC fairly commo11. ~
in children, as the pcdiaLri c ear canal is shon~
straighter than in adults. Li~cwi~. microorg;mi.r
travel up th e eustachian tube fro m the phOll)111
otith m.-dia, especially in children lndi,i du.ah
d iMmkr< m ay have aur.1lgi.1, crtlgo, and .tum
tiOn \ o f the inner ea r cause h earing impainnii-
im bala ncc.
l' .1in, fever, mal.ibe, prcs,urc, and a sensarioo i
fu ll n< s, w ith some he.iring loss nre common!}lllPl
of c,1r disorders. Ex tem,11 c.u- conditions seen in amb;
1o ry CM C <'llings include inlt>ction<, ear wax Kl!l1"
tion .1n<l 1nino r traun1 ,a ~l t1ny eJr disorders au
and eas ily ire,u ed with O I ( mcdrcauons Othm
li miting Somc1imcs h.u r follicles becomt llic
c.1us ing furundes. Scborrhc1c dm nauus. psoM;1
cont,lCt dcmiatitis ma) al w cau!>C ear inOamJ!lllOl
OTIC PREPARATIONS I
''." condi1ions are ofte n 1rc,11cd 1vith S)~temic Ill
t1om such as antibio tics lo p1cal medication<.
<>II< P<'1>ar.. tion~, a rc inmllcd into the t!XICfllollli
tre.1t h.1ctcrial o r fung.1 1 1nfl' tt10 11 or ;is arulp
I )1)111g ''.~<'llL<. u sually comhmauo ns of abW .,..,
add, .1nd 111drogen (H'roxidl!, di) the canal ;and ~
outer Cclr infeclion~ after Jttiv11i~ such as S\'i
ri :1hl1 21-7).
 CHAPTER 21 Eyeend Ear Disorders 381

Extetnal ea1 Middle ear Inner .ar

I I I
I Auricle (Not to scale) 11 11

\=-
Temporal Tympanic
(pinna)

Vestibule
Round windOw
_ AU<htO<Y tube
Meneus lncus Stapes
1 1 s
I L.,. . M
Aud'10ly
~

Figure 21-4 Anatomy of Ille ear. iFrom Thibodeau GA. Patton KT Anthony's textbcolc of anatomy and physiology, ed 18. St Louis. 2007, Mosby I

.~rminftcrit'I! ear preparations. either instillations or BOX 21 1 SOME MEDICATIONS THAT

irrig,11ions. inhibit growth of o r kill bacteria. thus reduc CAUSE OTOTOXICITY
ing swelling, relieving pruritus. and promoting drainage
of external ear infectio ns (see Table 21 7). Antibiotics
umlcosreroids, used to suppress uncom fortable sym1) amikacin (Am1kinl
tot1') associated \\1ith ear inflarn1naLion, also reduce car sueptomyc1n
!'<Irma and pruritus. Corticosteroids should not be u.ro neomycin
to tre.11 viral or fung.11 infections or with a perforated gemamrcm (Garamyc111)
eardrum (stt Table 21 7). erythromycm {EMycm. Eric!
Otic preparations are often found in combinations kanamycin (Kanuex)
10 trl':H 1nore than one symptom or condition at the tobramyc1n (Nebcinl
same 1i1ne. Combinalion medications may contain two vanoomyc1n JVancocinJ
or more antibiotics, an an tibiotic-benz.ocaine combina-
uo n. or an antibiotic-corticosteroid combination (stt Oiuretica
T.1blr 21 7). acetarolamlde ID1amoxl
Cmrminolyric.s soften hardened cerurnen blocking the fu~1de llasixl
external ear cana l, a cond ition commo n with people bumetanide (Bloooxane]
wearing hearing aids. I lardened wax can interfere wi th ethacrymc acid (Edecrinl
hearing and block ae1ions of medications instilled into
the ear canal. A ceruminolytic is often ordered to soften Antineoplesllc Medications
wax before ear irrigations. Many of the:.e preparations cisptatm (Platino~AOJ
r.in be bought OTC (see Table 21 7) . bleomycin IBlenoxanel
&rr arrnlgesic.s, used to relieve pain, may be warmed vmcristine iOncDVtn)
mineral oil, sweet o il, or glycerin. Medications wit h a Many more medications cause ototoxicity but those listed
IH-11U>Caine base may be p rescribed for auraJgia (see are the more damaging.
lable 21-7).

can affect hearing. balance, or both. The most common

VERTIGO AND OTOTOXICITV
Some patients may tl1ink they have ear infections or
wmgo when they are ae1ually experiencing ototoxldty-
a Jctnmemal effect from medication on cranial nct\-e
\ 'Ill (auditory nerve that innervates the ear). Ototoxicity
signs are tinnitus, venigo, and difficulty with equilib
rium . When o totoxicity occurs, the causative medication
should be discontinued. llox 21 I lists some more
common medications that cause ototoxicity.
Patients with Mbtiere's disease have many of the same
symptoms of ototoxicity including venigo. The patient
382 il:CTION v Medicauons Related 10 Body Systems

_r_A_B_LE~Z-l~l~O~R=U=GS:,::US:E:O~A:S~O~T:IC~M=E~O:IC:A~TI~O:N=S:__________________________________~ }
USUAL ADULT INDICATIONS DRUG
DOSE. ROUTE. ANO MAJOR SIDE FOR USE INTERACTIONS
GENERIC NAME/TRADE NAME

DRYING AGENTS
FREQUENCY " EFFECTS
Irritation. swelling,
To treat external
ear infections,
. '
'
urticaria. ' -
overgrowth of and to dry ear
nonsusceptible after contact
microorganisms with water

ace1JC acid sol~tions (Vo-Sol'! gtt 1vV1 instillation.

1mga11on
bouc acid solut100s !Ear Dry. Fill ear with solution
Swim Ear' I
1sopropyl alcohol IAuraDry'I fill ear with solution

Same side effects

ANTIBIOTICS
as drying agents
Nos.~
c1ptonox.....n ottc lCetraxal contamer bid
ntErac:m
solut1001
ofto....:in lflo'l'I Otic solution') on xqd-btd
CORTICOSTEROIDS
gtt ITT-iii No sign bit
dexamethasone solution'
interactions id!!!
Ruoc1nolone IOermOttc'J gtl mrv

COMBINATION PRODUCTS
hydroconisooe-acettc actd 0u m
No s1gndirau
(Acetasol HC soluuon') wtt!ractUll
+ alcchol IEarSol HC solutJ0111) gtt ;; Vi
cohst1n, neomytln, hydrocort1sone. g11 rn
thonzon1um (Coly-Mycm S Otoe
suspension"
1sop1opyl alcohol, glycerin git mIv after
(Sw1mEor Drops'I swimming
acetic acid. bone acid, Vanes with use as
ben1alkon1um. aluminum 1mga11on or
acetate (Burrow's Solution') msullation

CERUMINOLmcs
cart>amtde peroxide (Debrox. gtt vi Softenmg and No~
Mu11ne Ear Drops. Auro Ear removal of ntartlCll~ llir-l
Drops' I cerumen

EAR ANALGESICS
glyce11n. rnineral oil. sweet oil Fill ear canal woth Relieve itching and No s1~1focmll
warm solullOn bumrng rn ear mteractoiS iar.:
benzoca1ne-ant1pynne' IAuralgan solution) Fill ear canal Analgesic
All otc tnldocatoons are lllSUlled 1opcalty in !he external ear canal
'l'\'uscopeoOll medcaoons
'Overlhe<Oliltl!f medtCatJOl\S.
Note The use of the bat over leneis rn a dosage 1nd1ca1es thar 1he lette1 1s a 1oman numi:ial
The bar 1s 1101 used cons1s1enrty on !he indl:Stt'r
 CHAPTER 21 Eye and Ear Disorders 383

TABLE 21 8 DRUGS USED FOR VERTIGO

' I

mecli!llle (Antiven' I
d1phenhyd/am1ne IBenadryl'I
d1menhydnnate lllfamam1ne'I
(Calm-X' chewable tablell
scopolam1ne (Transderm
ScopJ
2>100 mg PO qd 1n divided dos8S Vertigo. mooon sictness CNS depressants
25-50 mg PO. IM. N qS-811 Same as for mech11ne
50-100 mg PO. IM q4-6h Samo as for mecl111ne
As directed by manufacturer
Apply transdermal patch behind ear as Same as for mecliiine
needed qJd

Maj()( Sid Efftte~ of Drugs Used for Venigo: Drowsiness, except with scop<Jlamine
/M, nramuswlatly, /Y, mtravenously, PO. orally.
' l'!esetipuon medications
'()yet ~ ! er med!tallOllS

reels that the room is in motion and has a sensation or
pressure or fullness in the ear f!'able 21-8). The drug of
choice to reduce the symptoms or venigo or 0101oxidty
is medizine (Antivcn).
Iii CLINICAL TIP
To instill medications in a child's ear. gently pull auncle down
and back to straighten external canal; in an adult or older child,
pull auncle up and back (see Chapter 13 for the correct technique
for instilling ouc and ophthalmic medications).
Ear med1ca11ons should be warmed to room temperature before
IOSt1llatlO!l
OtlC med1Cat1ons should never be used ophthalmically Any
medcauons for eye use should be labeled "ophthalmic. In an
emergency. ophthalm!C medications may be used oucally with
1J11tian's penm1ss100
If ear IS draining, med1cat1ons should not be ir1Stilled without
coosuh1ng a phys1c1an.
Never occlude extemal ear with a t1gh1-fimng plug of any type
after 1ns11llation ol a medication because occlusion may cause
eardrum to rupture from increased ear canal pressure Couon
plugs may be used because these do not increase pressure but
allow ail to pass through fibers.
STORAGE OF EYE AND EAR
PREPARATIONS
Ophthalmic medications are sterile and are manufaaured
to be ,,,re when used on a thin eye membrane. whereas
otic medications do not require sterility and are adminis"
tered in a nonsterile ear canal. Opluhalmic and olk liquid
1>re1>ara1io ns are packaged in sirnil:11 comainers and are
easily conrused . The small bottles are similar in shape,
with many o r Lhe same names for o tic and ophthalmic
drugs. Bause of these similarities. ophthalmic and o tic
medic;itions should not be stored in the same area. One
way of preventing this potential medic;ition confusion is
to place ophthalmic medic;itions on one shelf and otic
medirntions on another. Extreme care should be taken 10
return medications 10 their correct place afier use. A good
rule of thumb where ophthalmic and otic preparations
are stored in dose proximity is to check the name or the
medication and route of administration more than the
usual three times to ensure the correa medication has
been chosen. While checking accuracy of the 11reparotion,
make sure the expiration date h..s not passed: this is espe
dally imponant with ophthalm ic preparations b1.'Cause o f
the delicate eye surface tis.~ue.

; .. SUMMARY
Preparations to treat ophthalmic disorders are divided
Pa10. 10\'er, malaise. 1ncieased pressure. aoo feeling of ear
into specific rntegories. Medirntions used in eyes should
lultness with heanng loss are common signs of middle ear
be labeled ophthalmic to ensure proper strength and
111fect1011S
Children often have middle ear 111tections aa:ompauying sterility. Many medications used in the eye cause stinging
or burning on instillation; some are systemically
pllalvng111s because of eustachlan tube angle relatrve 10
absorbed. Patients should be aware of medication effects.
pharynx
Otic medications are agents used 10 treat ear disor-
Ototox1c1ty may occur from systemic medications 1nclud1ng
ders. Medicatio ns are available by prescription and OTC
symptoms of Mnitus. loss of balance. and vertigo
10 treat ear infectio ns and ototoxidty.
384 SECTION V Medica!Jons Releted to Body System::s_ _ _ _ _ _~--~----------~-....J

HINKING EXERCISES ~

Scenario
Jimmy's mother asks why every 1lf1le Jlf1lmy. sge 2. has a sore 1hroa1, he seems to have an earache
1 What do you expect Dr Merry to tell her?
2. She wants to know 11 she should use the ear drops at a cold temperature to relieve the earache
What is the best answer?
3 Can she buy any otic drops OTC to relieve minor pain of an earache and remove excess wax found
in Jimmy's ear? If so. which preparalJons?

DOSAGE CALCULATIONS
I. Order: romocaine Ophth Sol 0.5% gus both eyes stat,
then q4 h until scratching sensation disappear$.
Interpret the order:---- - -- -- - -
What is the indication for this medication?
2. Order. Oebrox gu v AO bid x 4 d
Interpret the order: - - -- - -- - - -- -
What is the indication for this medication!

REVIEW QUESTIONS
I. What does a cycloplegic do? - - -- -- - - -- - - -- - - - - - - -- - - -- -- --

2. Why is it imponam to know systemic medications that may call$<' ophthalmic side efTws? - -- -- - -

I low would this knowledge be used in prescribing optnhalmic medications? - - - -- - -- - -- --

3. Whal kind of systemic reactions can occur from use of ophthalmic medications? What is the role of the allied
health prof~>ssional in watchi ng for these reactions? - - -- -- -- - -- - -- - - - - - - - -

4 Why must any medication used in the eye be labeled ophthalmic? - -- -- - - - -- -- -- --

5. What do miotics do? What is their use in glaucoma? - -- -- - - -- -- - - -- - - - -- -

6. How does Ouorcscein demonstrate corneal defeets from injury and foreign bodies on the cornea?
-----
7. What is a cerurninolytic? - - - -- - -- - - -- - - - - - -- - - -- - - -- -- --
 Drugs for Skin Conditions

Airer studying this chapter. yov should be capable of domg the following:
Oescnblng how topical med1catoons are absorbed De f1n1ng and naming typical topical keratolytocs,
into skin. acne prepara11ons, ectoparas111c1dal agents, and
Explaining why some topical medoca toons may agen ts tor alopec1a.
ha~ systemic effects.
Prov1d1ng patient educauon for compliance With
D scussing vano us classes of medocatoons used to medications used to treat diseases and cond1t1ons
11eat clermatologic conditions of the skin.
Describing general propenies of dermatologic
p1eparat1011S, both legend and over-the-counter
lOTCI, and their 1nd1cations

Johnny fell off his bicycle and skmned h is knee. His mother has cleansed the wound with soap and
wa1er.
Wt'f S this step on treatmentomponant othe r than to remove bactena?
Dr. Merry wants the medocauo n to go onto deeper crevices of the abrast0n. Would you expect hi/Tl to
prescribe an ointment or a cream ? Why would that be the medication of choice?
How often do you think the bandage w ill be changed of a standard schedule for antibiotic dressing is
used?
What should you tell Johnny's mother about keeping the bandage dry?
Why is it omponant to obtain a health history of possible allergies even when applying a topical
medcatoon?
If Dr. Merry orders an occlusive dressing. what would you expect to pla<;e on the abrasion?

KEV TERMS
Acne Disinfectant or Keratin Psoriasis
Actinic keratosis germicidal agent Keratolytic agent Pustule
Antiseptic Eczema Liniment Rubs
Btctericidal agent Edema Lotion Scabiclde
Btcteriostatic Emollient Nits Seborrheic dermatitis
agent Eschar Occlusive dressing Sebum
Bath Furuncle Papule Skin cleanser
Carbuncle Hives Pediculicide Ulceration
Comedones Imp etigo Photosensitivity Vehicle

_ _.__ ___ - -
385
 386 SECTION V Medications Related to Body Systems - - - - - - - _____

EASY WORKING KNOWLEDGE Of INDICATIONS AND SIDE EFFECTS

Common Symptoms of Skin Disorders Common Side Effects of Medic1tions for Skin D1$0rd911
Denna:~ les100S or eruptlOl1S &mng
Prur tU$ and hi'u l'nJmus
lnllammaoon Skin diyness
l:dm~ Rashes
Discomfort Th1nmng of skin
Er;thema
-~--------~~~
lmtauon of skin --------~~---~-'

EASY WORKING KNOWLEDGE Of DRUGS USED FOR SKIN CONDITIONS

DRUG CLASS PRESCRIPTION OTC PREGNANCY CATEGORY MAJOR INDICATIONS

ANTllNFECTIVES
Ant1b10t1CS Yes Yes B. C Skm infections
Ant1v rats Yes Yes B.C Herpetic mfec!JOOs. wa1
mfections
Anl 1nflammarones. corucosteroods Yes Yes c lnflanvnatOJY respooses
Antilungals Yes Yes B.C Candida, tinea infecllons
Acne preparations Yes Yes B. C. O (tetracvclmes). Acne wtgaris
X (tazarocene, 1sotret1nom)
Keratolytics Yes Yes C. X (podophyllum) Hypertceratotic skin lesions
Ant1psoriatic agents Yes No B Plaque psoriasis
Shampoos Yes Yes c Seborrheic dermat11is
Topical anesthetics Yes Yes B, C Pain. itching
Topical antipr1mtics No Yes B Itching
SuHonam1des Yes No B.C Bums and minor bacterial
wound infectJons
Ploteolytic enzymes Yes No Ot!bndement of wounds
PROPHYLACTIC AGENTS
Sunscreens No Yes Prevent soobtms
Protectives No Yes Plotect skin from imtants
Scab1cldes. ped1culicides Yes Yes B Skin parasites
MISCELLANEOUS
m1noxid1I Yes Yes c Alopecia
fluorouracil Yes No 0 Actinic keratosis, superficial
basal cell carcinomas

kin, 1he body's larges1 organ, is J complex suuc-

S 1ure divided into three main layers- the epider-

mis, composed of a 1hin layer of epi1helial cells
that are continuously sloughed and replaced, the dense.
fibrous dermis. containing blood vessels, ne!'-e endings,
and gland openings within connecti\"e 1issue; and the
subcutaneous layer consisting mainly of loose connec-
tive 1issue and adipose (fat) tissue such JS nail beds,
sweat and oil glands, and elas1ic and fibrous 1issues
(Figure 22-1).
Skin has six func1ions: protect ing against dl)ing of
deeper tissues; providing a mechanical barrier against
bacterial infection, regulating body temperature b)
releasing heal through perspiration for a cooling effta.
imeraaing with 1he environment through nerve endings
of pain, touch, pressure. and tempt!rature to ensure pet
sonal safe1y; excreting minerals and water through per-
spiration; and preventing ab>orption of 1oxic substances
while having the abili1y to ah>orb desired subs1ances-
lhe function of phMmacologic importa nce.

Homytaye,
of Op1derm1s
Cellular
layer of
epidermis
Hair Sebaceous Sweat
lollde gland gland
~gurt 221 S1n.c1ure of the $1<in Medocauons are absorbed through tile
ep1ilulmlS to the deim1s and then absorbed imo tho bloodst1eam, as well
111 tor Iola! respon$e 10 pain by nerve tillers (From Young AJ'. Proctor OB
t m sre /.ledic.JImsrant an appliedlei1mlng i1/1(Jroi1Cfl. eo 11. s1LOU>s.
llll I. S..l.flders I
Medications may be absorbed through the skin fo r
ioal dfea or 1hey m.1y be slowly absorbed in sufficient
qu;muues for systemic effect. !>ome rn~lica1ion> may be
in1ccied into upper skin layers (intradermally) or into
!Ubruunrous tissues for release into the blooch1ream for
tranpon throughout the body (see Chapter 14 for par-
enteral medic.1tion administr,llion) .
CLASSIFICATION OF
DERMATOLOGIC PREPARATIONS
Several kinds of medications, such a; .111tiinfcc1ive agents,
nuinOammatory agents, c111.yma1ic prepar.uions, ,111d
1111111.1useant medicauo ns. h .1w S)'tcmic effect when
applied transdermally. Rate of mcdic,1tion absorption
drptnds on drug form, si7e of molecules (sma ller mol
<rulo are more rapidly absor~>d). and medication base
(oil or more readily absorhcd wawr based ehiclc\).
SIJ(h medications a~ hormones, ,111ti.rngina ls, a11tihy1>er-
1m<l\'es, analgesics. and antihistamines may be specifi
rally applied tran\dermally ror prolonged release for
smentic lhera1))'. Ccneral goal' or thrrapy arc Lo rem ove
Cill5n of skin disorders, find meaSUfl'S tO restore and
ma1n1ain normal skin funrnon. and relieve symptoms
such as i1d1ing. dryness, pain, or in O,tmmation. Medica-
tion\. such as transdermal f <'11tanyl fo r analgesia, are
d1!<us~ 111 the appropriate chapter> for their therapcu
tic use (Chapter 13 describe'> proper .1dmin is tration of
uansdermal medicatiom).
Some systemic mcdJCation~ cause \kin d1se.1ses such
as cxfoliatiw dem1atitis and scal ing of ~kin 1ha1 is even-
1wlly sloughed raucnts taking any medications should
be evaluated for pos.,.bility o f adverse skin reactions
Box 22 1 list' types of meditations tha t may p roduce
re<Ktions from erythcma to life-threatening responses.
CHAl'TEA 22 Drugs for Skin Condiuons 387
------
BOX 221 MEDICATIONS THAT CAUSE
SKI N DISORDERS
Erythemes lllpushke Eiythemas
Barbiturates Hydamo1ns
carbamazep1ne hydralazine
furosem1dP 1so01azid
gold p<0cainam1de
griseofulvin 1nme1had1one
penic1 in
Pl1enothiazines
phenytoin
qonidine
Sulfonamides
Tetracychnes
DERMATOLOGIC PREPARATIONS
AND ABSORPTION
Many forms of derma1ologic preparations-such as
liquids, ointments, gels. beads. pastes, plasters, creams.
powders, foams. and sprays-are available 10 treat skin
d isorders. 1he selected fom1 depends on 1he desired
therapeutic effoo and the ability or the person's skin to
absorb medication Skin ker.aUn, when moisturized.
provides a waterproof barrier for the body; therefore skin
must be hydrated for absorption o f water-based drugs.
Some drugs are placed in dressing.s 10 trap perspira
tion and prevent water loss and to assist with hydration
and absorption. Water-soluble drugs nre more readily
absorbed and excreted, whereas fat-soluble drugs in a
lipid base have slower excretion rates. In some body
areas, such as the eyelids or behi nd the ears, the thinness
of skin allows rapid absorption of medicatjon, whereas
areas such .is the palms of the hands and soles of the feet
are th ick. making them almost im penetrable by mcdir;1.
tions. Some products contain lanolin to smooth skin
and apply moisture in a lipid-soluble base. Other prod-
ucts, in alcohol base~, dry skin. Product use dictates the
medication base needed, its method a11d site of applica-
tion, and ability 10 be absorbed.
Just as with medications taken by other routes, the
patient's medical record should be checked for allergies
10 medications 10 prewnt skon irritation or other allergic
reactions. Skin should be dean and dry for optimal
absorpt ion. If medication is fo r a specific site, such as a
topical antiinfeaanl for an infeaed wound, it should be
appl ied 10 the specific site without spreading onto sur-
rounding tissues. If patches are used fo r >-ystemic med ica
1ions. sites should be rotated to avoid skin irritation and
prevent decre.1sed absorption occurring because of skin
sensitization Lo 1nedication.
388 SECTION V Med1cahons Related 10 Body Systems
TYPES OF PREPARATIONS
FOR THE SKIN
Preparations for !he skin come m many different forms.
d~ndent on !he condition being treated Many of lhese
preparations are available OTC
Baths are used Lo dl'.1nse skin, to lower body
temperature, or to apply medicauons such as use of
povidone-iodine as an antiseptic to prepare skin for
surgery; in some skin condidons even \~Jter 1na.y not be
to lerated. 1>ersons with dry ski n should ba the less fre-
quen1ly than those with oily skin and shou ld use an oily
lotion to hydrate the skin rather th.rn one with an alcohol
ba..e. Baths ror soothing irritated skin conditions may
have gelatin. oaaneal (Aveeno), or starch added to water.
Oils. such as AlphaKcri, may be added to a tub of water
to prewnt drying of skin.
A lubricating medication or topical drug product for
hydrauon should be applied immediately after a bath
while ~kin is moist 10 incrl'.1se absorption
Soaps are made by spiriting lats with alkalis. using glycerol and
an alkali sail of the fatty acid. Soaps a1e made from different
oils such as olive oil (lo make e<1st1fo soaps), coconut oil, and
animal fats
Soaps are relatively alkaline and can irritate skin.
Because or friction needed to cleanse skin with soap, it
bomes a mechanical antiseptic, or some may have
medications added to make them chemical antiseptics.
Some products called soaps are actually dlslnfecunt or
germicidal agents. Soap and water promote healthy
skin; however, perfumed or medicated producLS may
cause irritation in a person with hypersensitivities.
llecausc of the drying effeC1, all ~oaps shou ld be ade-
quately rinsed off unless othenvise instruC1ed.
Skin cleansers are usually free of soap or are modi -
fied soap products used by persons who have sensit ive,
dry, o r irritated skin or who have had an allergic reaction
to soap producLS. Cleansers such as Neutrogena bars are
less irritating. may contain an cmoUJent to smooth skin,
and may have a slightly acidic to neutral pl I to be less
irrilating.
Gel.! are found in an alcohol base and arc drying;
therefore gels are appropriate for use on oily skin and
wttpy or vesicular lesions.
Emollierus are fatty or oily substances to smooth or
soften initated skin and mucous membranes and may
be used to apply medications; examples or emoll ients
are lanolin, petroleum jelly, and vitamins A, D, and E
ointments.
Skin prvte<1it111S coat minor ski.n i~~tions and ar,
used to protect ~kin from chern1cal 1mtants such ;is
1>enz,aj11 and benzOlll compounds. Sw~n C~eam is II.std
to protect colostomy and ileostomy pauents skin and to
protect pressure point s.kin of ~ridden persons .
Lotions, liquids with an msoluble powder in ~
suspension, are mildly ,1cidic or alkaline. Others, such
as calarnirni or C.1 ladryl lotion, may be used for thtu
soothing effect in con tact dermatitis, insect bites. or
prickly heat.
Rubs and llnhncnl~ a1c ind icated o n inracr skin, such
as the pain associated with muscle aches, neuralgia,
rheumatism, anhritis, anti spra ins or strains, produdn~
heat for relier of aches and pains. Ingredients may include
counterirritants such as cnrnplror o r rneihyl salicylau or
analgesics such as salicylate substances with potential to
bum or irritate kin llecause of the danger of burning
skin or causing severe irritation, external heat such as a
beating pad or hot water bottle should not be used with
these medications unless so prescribed. Local anesthttia
and antiseptics may also be added for relief of pain
:. .;
Skin preparations used on a daily basis include soaps, gels.
disinfectants, baths. lotions, and sunscreens
Soaps and baths are drying to skin.
Skin protectants should be used to protect skin aroond pre$
sure ulcers or os1om1es to prevent further trauma
Rubs and hmments tend to produce vasodilation and hea
~ernal heat should not be applied to skin after a limmeni
or rub has been apphed because of chance of 1Mnll'l9 skirt
ANTllNFECTIVE AND
ANTllNFLAMMATORY TOPICALS
Skin is subjeC1 to infectio ns by bacteria, fw1gi, and
viruses. 1bpical a11tiinrec1 ives may be used alone as
superficial wound thernpy. Wh ere wounds have deep
infection penetra tion. systemic amiinfectives may be
indicated.
Topical amibimir.s. much like systemic antibiotics. are
used for the two most com mo n organisms found in
skin inreaions- Srreprococw, p11oge11es and S111pli11ococcus
aureu.s-causes of infections such .rs rolliculitis, Imp<
tigo, furunde,, Crbundc, and cellulitis (Figure 221
shows characteriston of various skin lesions).
Antiinfectives may be bact('rlo""lic ;agents, Nett
riddal ;agents, gennicides, disinfectants. or antiseptics
Antiinfeaives such as isopropyl alcohol, hexachloro-
phene. iodine, Lysol, and bcn7~1lkonium chloride are
discussed in Chapter 17. foble 22- 1 lisis typical topiral
antibiot ics, both OTC .i nd legend medications.
....f...---------~---~-------------::c:!1HAPT~~ER~
2~2_D
lJlr~
ugs for Skin Cond111ons 389

pfUllARY LESIONS
SECONDARY LESIONS

MACULE
Flat area of OOlor change (no eteva- _
depression) - ~

Example: Freel<les

PA PULE
CRUST
Solid elevation less than 0.5 cm In Dried exudale on l kln
diameter
Example lmpallgo
Example: Allergic eczema

NODULE
FISSURE
Solid etevation 0 .5 10 1 cm 1n diameter Craci<s ., skin
Extends deeper into dermis ttian papule

ExampiB: Mole

TUMOR ULCER
Solid mass-larger lhan 1 cm Area of destruction of....,.~

Example: Squamous cell carcanoma Example. Decllbltus (pressure sore)

PLAQUE SCAR
Flot elevated surface found on skin or Excess collagen produc11on alter Injury
mucous membrane
Example: Surgical healing
Example: Thrush

WHEAL ATROPHY
Type of plaque. Result Is transtent edema loss of some pott.on of 1l>e llun
in detmls
~ Paratys.a
Example: lntradermal slon test

VESICLE
Small blis1er-ftutd wi1hin or under
epidermis

Example: Herpesvirus 1nteetion

BULLA
Large blister (greater than 0.5 cm)

EJlmp/e: Burn

PUSTULE
VeslCle filled w.lh pus

figure 222 Characieristics of skm lesions (From Young AP. Proctor DB Kuin's lhe Medrcal AsStslant an apPlred leam111g approacll. od 11, St Louis.
1011, SMders t
390 SECTION V Medicauons Related to Body Systems

TABlt l7 t SELECT TOPICAL ANTllNFECTIVES. ANTIVIRALS. ANTllNFLAMMATORY. AND ANTIFUNGAL AGENTS

USUAL ADULT
INDICATIONS FOR USE
GENERIC NAME/TRADE NAME
TOPICAL AHTllNFECTIVES
DOSE ANO ROUTE
. .
,.,..,pirocin iBactroban' olfl1Jllent and crearn, 2%) Apply tllplcally
bac1tracin' 1omunent and cream Apply topically
gemam1cin' cream. omtment Apply topically
neomycin, polymyx1n B. bac111ac1n (Triple Ant1b1ottc', Apply topically
Neosporm' cream. ointment)
Apply topically Burns. ulcers. infections
nitrofurazone' soluble dressing
Soap lor bathing Soap; do not use oo infants
hexachlorophene (Dial soap')

Sldt Elftel$ of Topical Antiinf.clives:

mup1roc1_.ioca1 111itat1on and bum1ng. /lllrofurazooe-prontus. burning. ulcera11on, bacmac1n, gentamicm, neomycin, polymyxin B-
a lflfll c demlauos. rnrrof~untu$. burning ulcerauon. he;cach/orophene-t.ills no1mal bacterial flOfa

1OCJIC8' an~nlectM!S haYe no map ~ug r>t.lfilC1.,,,,

' Prmo:npoon medocaoons.
'OTC medocanons

TOPICAL ANTIVIRALS
acyclov11 (Zovirax 5% ormment. powder! Apply topically Herpet1c lesions and other
w11h hydroconisone (Xerese Cream! denmatolog1c viral cond1uoos
penc1tlov1r (Denavir' ointment, cream) Apply topically Herpetic lesions
docosanol IAbreva' cream 10%1 Apply topically Cold sores. herpes simplex

' Topical antionfeCIM!S have no ma,or drug 1111erac:t1ons

1
Prescnpt1on medJcaoons.
'OTC med1cat1-0ns

TOPICAL ANTllNFLAMMATORY OR CORTICOSTEROID AGENTS'

betamethasone IDi-olene' aeam. 0tntmenl gel Apply topically Inflamed tissue. psonasis.
lotion) (LWOQ. loam) rashes. iosect bnes. ecnma
(0 prosone' cream, Otntmenl lotion. aerosol)
clobetasol ITemovate. C~ Olux' cream. 0tntment. looon. Apply topically
gel. loam. shampoo. solUIJonJ
dcsonide (DesOwen' cream. ointmenl lotion. gelJ Apply topically
d1florasone {Apex1con.' ointment. Max1flor' cream) Apply topically
desoximetasone (Topicon' cream. ointment. gel) Apply topically
ftuocinonide1cream. ointment (l idex' gel. solullon. ointment. Apply topically
cream!
halcmonide (Halog' cream. ointment. solution) Apply topically
tnamcinolone' cream. ointment. lotion. aerosol Apply topically
IKenalog' and others 1n the same f0tms)
hydroc0t11sone (WestCOll' cream, 0tntmen~ Conizone 10' Apply topically
cream. oinunen( Carta d' and other pr91li!'at1011S 1n a eam.
ointment. lotJon. sol011on'J
dexamethasone (Oeca~ aerosol spray; Oecadron' cream] Apply topically
ftuoc1rolone !Denna-Smoothe' aeam. solution. ointment. oil, Apply topically
shampoo)
 CHAPTER 22 Drugs for Skon Cond111ons 391

TABLE 22 1 SELECT TOPICAL ANTllNFECTIVES. ANTIVIRALS. ANTllNFLAMMATORY. ANO ANTIFUNGAl

AGENTS-cont'd

USUAL ADULT
GENERIC NAMEITRAOE NAME
DOSE AND ROUTE INDICATIONS FOR USE
momerasooe (Elocon cream. ointment. lotion. soluuon) Apply topically
~te (Oemiatop' cream, oontmentl Apply topically
'l'ns:rllJIOl "'8dicabOnS
'OTC trtedt<aliOnS
'No...,.. Side ettecu or drug intetactions are IOl.lld with IQP!Cal amnnfta<Mlatory agents.

TOPICAL ANTIAJNGALS'
c ajllll10I tviofonn) Apply tOpteally Anllbactenal
clcll1mazole (Mycelex. Mycelex Troches'. Oeseoex'. Lotumin' Use as topical agems Candid.as1s and tiooa
ropocal cream, solution, lotion) 1nlec1tons
plus beta metnazone (Lo11isone) apply topically
iGyne-lotnmm' vaginal supposnorv and cream) Inserted vaginally
ecooazole (NTN) Apply topically Tmea
uaoonarole (Sporanox' 1OOmg cap) Oral dose vanes Tinea
ketooonazole Tinea cap1t1s and seborrhe1c
IN1zoral' c1eam) Apply topically dermatitis
IXolegel gel) Shampoo
INizoral shampoo) Oral dose varies
IExllna foam) Apply topically
(Nizoral ZOO mg tab)
miconazole (Micatin' . lotrimin topical cream. spray, powder. Apply topically Candidias1s and tinea
omlment) infections
(Momsrat' vaginal suppository) Insert vaginally
(Momstat cream) Apply 1op1cally
ox1conazole (Ox1stat' cream. lotion) Apply 1op1cat1y Cand1d1as1s and tmea
infecuons
sertaconazole (Ertaczo cream) Apply topically Tinea only
Uldecy1enoc acid (Oeseoex. Cruex'. Caldeserle'. Fungoid' 1n Apply top1cally Candidiass and 1111ea
cream. powder. solution. soap. spray, l1qu1d) mlect1oos and d1apet rash
ctcloplox (loprox' gel. topical suspension. toptcal solution. Apply top1tally Tinea only
shampoo, cream)
:Dinaltate (Tinact1n' powder. cream. soluuon. spray. get. Apply 1op1tally
Absabme' solution. Ahate, Nl'27' cream)
li!lbnafine tablet 250mgl'Oqd Tonea only
llamisil cream. gel. sol ut1on') Apply top1tally
naft6re (Naltin' cream. gel) Apply top1tally Tinea only
rtyStattn tNystop1 Cand1d1as1s. doapet rash
tablet 400.000.600.00J llllirs PO
t1d-q1d
suspension Swish and swallow
powde1. croam. ointment Apply topically
vagmal tablets Insert vaginally
C.OruirwrJ
 392 SECTION V Medicanons Related to Body Systems_~-----

terconazole ITerazoll
vag nal cream Apply topically
vaginal SUJJllOSllOIY Insert vaginally
nys1aun + mamcinolono Apply topically Cand1diasis
IMycolog' c1eam. ointment!

Orvg Interactions: H blockers. ant1chohn111g1cs

H histamu>e,. NTN, no oade name, PO. O!alty
'PrOiQ1ption medocauons
'OTC modicabons
'lllo map Side effects oc drug 111teract10t1S are foonl w h topocal anuooftammatorY agents
'No map side effects e loon! with topat ant f~I egents Those fOIRI tndude local untauon. prunros. Mot'11 sensauon. sc:<ihng. ~ 1!1\'11-.
bliste<vig peeling. S111!fong. WIJCa!oa

'lopiClll a11tivimls are applied several times a day 10 skin
lesions such as herpes and herpes zoster. Acyclovir is
applied six Limes a day for 7 days. Multiple CYfC prepara-
tions are available for treating such viral disorders"' cold
sores (herpes simple.x). rable 22 I lists medications used
as topical antivirals.
Topical a11tifungal mMIC4llions. such as clorrimaz.ole
(Deseoex. Cruex) and UJlnaftate (l'inactin), are used to
treat fungal infections of hair, nails. or skin Bec:iuse of
the dampness and warmth of body areas such as feet.
.u<illa. perinea! area. and under brea.is. fungal infections
seem to thrive in these areas. Most antifungals, by chang-
ing the integrity of the fungal cell membrane, a re either
fungistatic or fungicidal. Topical amifungals .tre generally
u;ed to treat Ctmdida and tinea infections. rungal infec-
tions o f nails. or onycho mycosis (tinea unguium), are
difficult to treat and require prolongt'<i therapy with oral
and topical med ications. Topical a111ili.111gal preparations,
sprays. lotions. creams, ointments, and po1,dcrs, are avail-
able as botl1 prescription and OTC medications; some.
such as bet.anethazone and clotrimv.ole (J,otrisone), are
combined with corticosteroids. ~ungal medications
should not come in contact with e)'\'S or delicate mucous
membranes. For topical antifung;ils to be elTUve. skin
burns, seborrheic d ermatitis, psorlals, and eczema.
These med icatio ns contain a drying agent or converscly
an emollien t and are u;u.1lly found in creams, oint
ments, lo tions, and gels to facilitate absorption at thesitt
of action. Absorption is high in areas of thin skin, but
penetration is poor with thick skin.
These preparations vary widely in strength, with thost
3\'llilable OTC being of low potency. Systemic toxicil)
may be a side c1Tec1 with long-tenn therapy using high-
potency topical preparations. Site of application inffu
ences the medication form choice. Gels and lotions art
used in hairy areas Creams rub easily into tissue if
needed for weepy, wet ti~sue lesion s. Lipid-based oim
ments a re more occlusive and moisturizing and are best
for application o n dry o r smly areas. Apply as a thin film
and gent ly rub in to skin (sec Table 22 I and Chapter 20
for systemic corticosteroids.)
k!I CL ~AL

should be dean and dry before application. If no improw-
ment occurs with OTC medications in 2 to 3 weeks, a
physician should be consulted (see Table 22 I).
Topical corriameroid.I are used to relieve inOammation
and pruritus of contact demrntilis, insect bitl'S, minor
Topical med1cattons should be applied with a finger cot or gto.es
to 11<event transfer of the pathogen to other body sites oc people
and to avoid effects to the skin on an undesired locatiOn. fct
patients who are selfmed1cating. hands should lie washed mrne-
diately after applica11on

1 Topical medications should be applied ai regular 1nteivals
2 Cleanse and dry affected area bel0te applying topical medi
cauon. the best time is after a shower. for better absorption.
Skin should be dned belore application
3 Use gloves or otlier protective equipment wtien applyill\I
an11wal medications to herpes lesions to prevent the onfec-
oon lrom spreading.
4 AYOld eye contact with antivirals and cort1costero1ds.
5 ~ a U.n film of corticosteroid medication.
6 Do not cover corticosteroid preparations wotli occlusive
drnslng' OI clothing unless directed Also avoid sunlight
on treated areas.
7 Avoid prolonged use of cort1costero1ds and do not apply to
weeping or denuded areas unless specifically prescribed.
s Do not use tight diapers. diaper covers. or plastic pants when
applying corticosteroids on infants. Occlusion increases
abs0<pt1on of the steroids.
9. Use full ueaunent for fungal infections. even 1f symptoms
ll!lll<OY9. therapy is long term. If cond1t1011 pers1s1s or WCKSenS,
aintacr physician
Acne Preparations
Arnt vulgaris, a skin disease with increased sebum and
oil producrion and incre.1sed fom1a1io n of keratin,
USU.llly on the face. chest. back, and neck. appears as
iupules, pusrules, and comcdones. I reaunent indudes
reduruon of sebum and bacteria with many preparations
.,.,olablt OTC; others require a prescription.
Oral an1ibio1ics such as 1e1racydinc and erythromycin
arc used 10 ireat acne concurrently with to pical
medirations.
1\ dnog specific for acne is lsotrctl11ol11 (Amnesteem,
Clmvis, Sotm), a de rivative of viiamin A, and in preg-
nancy is C-dtegory X, with many teratogenic effects.
l!Juse of severe side effects cdused by isotretino in, it is
rntl\'Cd for se--ere d isfiguring cases of .1cne. Physicians
pmcnb1ng and persons taking the drug must enroll Ul
tile oPl.fDCI program to ensu re 1h.11 no woman begin
ning therapy is pregnant nor becomes pregnant while
taking the dnog. A prescription wri11cn for isoiretinoin
must ha,c a special sticker ~rpl icd by a physician certi-
fioo to prescribe the medicatio n before ii can be fi lled
because of innate neonate dangers.
1\,.o combination o ral contr.1ccp1ivl'S (Estrostep and
Onho Tri-Cyclin) have been .111provcd fo r !feating
women at least 1S years of ,1ge who h.1ve reached men-
Mcht Jnd ha\-e not responded 10 101>ic.1I medications for
ocnt Benefits are from es1roge11, which uppresses and
1nani1"ates sebum production (see Chap1cr 28 for estro-
scn pr11para1io ns).
CHAPTEll 22 Drugs lor Skin Cond1uons 393
/\ few of the available topical preparations for acne
are as follows;
Benuyl per=ide is the ingredient in many prescrip
lion and 01C preparations such as Acnomel, Acne-10,
llenoxyl, Clearasil, D<)'OX. I ostex. Neu1rogena, and
Oxyderm. It pro motes peeli ng of skin and suppresses
growth of bacteria by releasi ng active oxygen.
Ti1pirnl and sysremic t1nlibiorirs a re used 10 treat acne;
the oral antibiotic of choice usu.1lly is teiracycline. The
most commonly prescribed topical antibiotics for mild
10 moderate acne are nythromrnn and dindam,.nn.
which work by decreasing 5ebacrous fatty acid byprod-
ucts and preventing formation of new acne lesions (oral
antibiotics are discussed on Chapter I?).
Trcrlnoin (RetinA Renova). an irritan~ stimulates
r.11>id tu mover of epithelial cells followed by skin peeling.
II reduces fatty acids within comedones, causing them to
be removed while suppressing ro rmation of new plugs.
n. is drug is a pregnancy category x preparation and
should not be used by pregnant women or those who
may become pregnant. 1 retinoin i< applied 10 the face
once a day for pecling; therefore it is also used 10 remove
fine wrinkles caused by aging or sun exposure. Risk of
sunbum is increased with use of this agenL
Adapalene (Differin ) reduces the formation of com-
edo nes and may even ap1>ear 10 exacerbate acne before
becoming effective. Adapalcnc is not systemically
absorbed, but risk of sunburn is also increased wi th Lhis
agent ('fable 22-2).
A.ulaic add (Azelex). dn antiinfcaive, is used for
mild to moderate acne 10 supprm the baaerial growth.
. '
Keep acne preparabollS away from eyes, mouth. and otlier
mucous membfanes
2. Expect dryness and peeling of skin w11h most acne prepara-
tions. discontinue with rash or 1mtat1ons
3 Water-based cosmelics should be used w1tl1 atlle prepara-
tions Do not countertreal des11ed dryness resulting from
these preparauons w11h emollients
4 Wan at least I hoor after apply111g illr'( other topical medica-
tion OI cosmetocs 10 apply topical ery1hnlmyQO
5 T01>ocal te~lines may stain fabf1cs and may tum skin
yellow
6 Persons using 1re11nom are susceptible to sunburn and should
wear sunscreen (SPf 15 or greater) and protective clothing.
If sunburned. do not apply tretinom
7 When tret1noin is used. 1he skin should be washed and dned
15 to 30 minutes belore apphcat1on and hands should be
washed unmediately after application Contact with eyes.
nose. 0< mouth should be i1'1Jlded
8 Cosmeucs should be removed before 11e11no1111s used Treat
ment may be needed fof up to 6 months before a response
is seen
394 SECTION V Med1ca11ons Related to Body Systemc;s_ _ _ _ _ _ __

bef\loyl pero..de 2 5%-10%

IPanO<yi, Desquam Benzac.
&evoql' as soap, eteam,
gel. bquod. lotJOll. mai k
foam. padl
dindarnyttn (Cleotin r Apply topocally Dryness. scaling. peeling of slun,
solutton. gel foam. lot on. st1ng1ng and buming. itching,
swab, [vcclml tendemesS
erythrom~m (so ;itton. gel. Apply topocally Same as above
OlflUncnt. pl~IS)
w11h benroyt perox dQ Apply lllpleally
iBenuimyc1n gel)
cl1ndamycin Apply topically lnflammauon of throat and nose. AbrasNe SOOll$ or
1.2% + tret1no1n IVeh1n gel) dry skin, cleansers. sun
o025'lb gel Iliana) exposure
doxycycline (Oracea 40-mg 40 mgPOqd Pustules. Headaches. diuiness. blurred See dOX'!tYtline 1n
delayed-release capsule) papules of vision: flulike symptoms: loss Chapti!! 17
rosacea of appetite
m1nocyclrne (Solodyn I mg/l<g PO qd lnftammatory Lightheadedness. dizziness: do See minocvchnc
extended rolease tabl lesions of not use before age 12 years 111 Chapter1 7
acne because it will darken teelh
1sotretinoin (Sotret. 0.5 1 mg/kg PO Acne carbamazepine
Amnesteem. Cla1av1s 11 daily m 2 divided
doses
tret1noin (retino1c acid) Apply topically Acne Redness. edematous blisters.
IRet1n-AJ crusting. stinging
(Av11a gel. cream) Apply topically
adapalene (01ffe11n gel, Apply topically Burning, pruntus. erythema.
cream, lot1onl dryness. scaling
azelaic acid (Azelex cream Apply topically Same as adapalene with 110ghng
F1nacea gell and depigmentat1on
PO. orally
Prescr1PtJ011 mecka1m
'OTCmeda11on.
'Pregnancy ca1egory Xcrug

.
. .
. ..
Acne preparations conta1n1ng benzoyf pero.,de are drying
Oil-based creams and cosmeucs should not be used after
aP1Jlicat1on of these medications
Some of the acne p1eparat1ons are OP1Jl1ed to skin to cause
peeling Care should be taken to prevent sun btlmmg
Vitamin Apreparations should not be used during pregnancy
or 11 poss1b1hty of becoming pregnant exists
Keratolytic Agents
Keratolytic o1genL< or keratin di~Ol\ll!rs are UStd to
soften scales and to promote shedding of 1he skin's
horny layer. Effects range from peeli ng to extensiw skrn
desquamation. These prod ucts arc used to treat dandruff
seborrbeic der1natitis, acne, dnd psoriasis, as \i'~ll .u
\varts and corns.
Salicylic acitl, resorcirrol, and sulfiir are the drugs
of cho ice, b ut benzoy/ peroxid1 may be also used with
these conditions. Salicyli c acid. podoi) hyllum rc~in, and

12n1~ridin may be used for common wans, as wcll as
fi>r 'tl1ertal wans.
l'odophyllum, used for g~n ital wans, is 1eratogenic
wuh lhe poten.ual for.systemrc reactions and is noi par.
ticul.Jrly effecuve against common w.irts. These resin~
should be applied and wa~hcd off in I to 4 hours at
weekly intervdls for 4 weeks.
Canlhorldln (Canrharon), used to remove common
wans. is harmful to nonnaJ skin. Norma l skin should be
c:lt~ned immediately with acetone or alcohol in the
t>"111 II tS accidentally touched (fable 22-3).
Kera101'(11c agents are for external use only. A"1>1d contac1
wi1h lace, eyes, mucous membranes. and normal skin.
2 Soaking affected area 1n warm water for 5 minutes before
awhcation may enhance effect of medication.
Kl!t'dlolytrc agents promote shedding or softening of horny. scaly
sk layer S\JCh as warts. calluses. and corns. ranging from
peeling 10 desquamation.
TREATMENTS FOR SEBORRHEIC
DERMATITIS
SllJmpo0$ for seborrheic dermatim. charaaerized by
inll.lnunation and scaling on the face or scalp. under the
arms. on lhe chest, and in 1he anogen ital region, arc
av;iilable a1 OTC and prescription iicms. Seborrheic der
ma1itis begins on the scalp and is characteri,,ed by yel-
lowish. brownish-gray greasy sca les. Kctoco11awle, an
anti(ungal, is used as a shampoo; other medica tions such
as pyrlthlone %inc or sele11i11m s11lfide are avai lable OTC
(&lsun Blue. I lead and Shouldl'r<l) and by prescription
(!>tlsun. L<sel) because of the stronger strength. These
~ts may cause skin irritation, alopecia, and hair dis-
color.11100 (see r.tble 223).
MEDICATIONS FOR PSORIASIS
Newmedica1ionsspecific for psoriasi> h.we been recently
introduced Colcipotriene (Dovoncx) is a foam tha1
is applied topically. Ustehiriumab (Stclara) is injected
subananrously a1 12 week intervals after the first 1wo
~that are administered 4 week~ dJldn 1-lowl'\-er. the
llltd1m1on ,1Jso lowers the body's 1m mune response to
infections incl uding tuberculosis. fungi. b.1cteria, and
VI~ and increases suscep1ibil11y 10 cancers. The
CHAPTER 22 Orugs lor Skrn Conditions 395
dos.lge should not be giwn conrurrently ,.;,h immuni-
J,1t1ons, with immunosuppressiws. and ~i\'t' infections
since this medication le;wes the body's response to infec
tion greatly diminished. Effectiveness is about 7.5% for
clearance of psoriasis in 12 weeks.
C1>11l and pi11e 111r.1 used for psori,tsis (identified by red,
rai~d lesions covered with dry silvery scales), are found
in shampoos. soaps, lo1io11s. and creams In se\'ere cases.
chemotherapeutic agents, such as melhotrexate. may be
~ to treat lesions.
Alefacept (Am<?\i\T), the fir<lt in1ectable immunosup
prcss1ve biologic agent used as therapy for psoriasis,
is expensive (approximately S 1000 per monlh) and
inconvenient because the need for injections weekly
for 12 treaunems but produces prolonged remission
I lowever. long-term use may resu l1 in malignancies.
TOPICAL ANESTHESIA
AND ANTIPRURITICS
lopical anesthetics such as lidocai"" (Solarcaine,
Anbesol) and dibucain" (Nuperc:ainal) are used for
itch ing of skin or mucous membranes and for skin
descnsi1b.11ion to painful s1imuli. '1hcse medications are
av,tilablc as OTC prepara1ions ,Jnd are available for pre
scrip1ion use as t.etramirie (f>omocaine) and lidocaine
(Xylocaine) (see Table 22-3).
Dilute solutions of plumol have also been used for
anesthesia and pruritus. Lo1ion> of calamine or pheno
lated calamine are often used for pruritus. A cream with
diphenhydramine (Benadryl) alone or as a lotion with
calamine (Caladryl) may be bought 0-f'C for relief of
pruritus Cornstarch and oatmeal baths (Mttno) are
also u~d. especially for children with chickenpox (see
T,tble 223).
Ii) CLINICAL TIP
Calamine lotioo should be used with chickenpox The use of
Caladryt lotioo tS not recommended because 11 cootains an
anuhistam1ne.
Ustekrnumab (Stelaral should be administered with a 27-gauge
X inch needle
Topical anesthetics come 1n many forms ID rehe~ pain and
prun tus of insect bites. abrasions. m1no1 bums. wounds. sun-
burns. and l>emorrltoids
Ant1proot1cs are apphed toptCally for nchmg When applying
these medrcauons. the area should not be rubbed as this
action will increase 1tclt ng
TABLE 22 3 MISCEUANEOUS OERMATOLOGIC PREPARATIONS
KERATOLYTICS
:y IC acid I~ W
WanOff.
tMed1plastl plasters. a<llesM!s.
cream. solullons, lo!IOOS. foam.
01mments. gels, shampoo
resorcinol (found m many OTC and
prescription products 1e
shampoos. ointments. lotions.
creams)
sulfur (found 1n many OTC and
prescnptton products 1e. louons,
shampoos. soap)
cantharid1n ICantharone. Ven
Canth' powder!
m1qu1mod (Aldara'. Zyclara c1eaml
podophy11um (Podocon25' hqu1d.
powderI
ammonium lactate (lac-Hydrin
lotion. cream!
DRUG
11~11&1 nnsE.
I I ROUTE.
INDICATIONS FOR USE INTERACTIONS
UENCY
Usually none w.111
Hyperl:eratotic skin
T1nc1ure-apply topica fy
cond1uons. COIMlOO or topical preparaims
plantar wans. psonas1s.
Plas1ers--apply IOPcalfy
calluses. corns. dandruff
Solu1101i. foam,
creams-1op1cally
Shampoo- 1op1cally
Apply 1op1cally Acne, eczema. psoriasis.
seborrheic dermatitis
Apply toPtcally Acne. eczema. psonas1s.
seborrhe1c derma11t1s
Apply topically and covec Common wans and vual
with tape fOf 24 Iv; then induced skin diseases
remove
Apply topically Venereal wans
Apply topically Venereal wans
Apply topically Acne, eczema. psonas1s.
seborrhe1c dermatitis

MEDICATIONS FOR PSORIASIS

calc1potnene [Oovonex solution. Apply topically Plaque psoriasis Flammable
cream. ointment)
ustekmumab (Stelara) 4&-90 mg SC Q4 12 wks Moderate to severe psoriasis BCG vaccine

SELECT TOPICAL ANESTHETICS ANO ANTIPRURETICS

benrocaine tlleruocaine'. Oraiel. Topocalry Anesthesia None noted
Humcaine. Zilactin. Benzodent as
aeam. hqwd. gel. ointment
spray, solution. swab; also
available 1n ot1c drops)
lidoca1ne (Xyloca1ne. Anestacon'. Topically Anesthesia None noted
Solarcaine. ointment. solution,
aerosol spray. cream. lotion)
lidoca1ne wnh prilocaine (EMLA gel) Topically bofore for injection site anesthesia None noted
venipuncture
tctracame solution. cream. ointment Topically Toothache. sunburn, pruritus. None noted
oral pain
d1buca1ne [Nupercaina1 ointment) Topically Sunburn. rectal pain. pruntus None noted
ethyl chl0f1de 2%. ethyl chloride Topcally Freezing before minor Ncine noted
spray surgical procedures.
Sprains. strains
calamine lotion Apply topically Prutrlls
with d1~mine ICaladlvt
cream and lotion)
cleated oatmeal (Aveeno powder! Mix with bath water as None noted
needed for itching
beniyl alcohol (Ulesfial Apply 1op1cally Allergic or irritant derrnat1t1s
 CHAPTER 22 Drugs for Skm Cond111ons 397

TABlf 1l 3 MISCELLANEOUS DERMATOLOGIC PREPARATIONS -cont'd

USUAL DOSE. ROUTE. DRUG

GENERIC NAME/TRADE NAME AND FREQUENCY INDICATIONS FOR USE INTERACTIONS
SCABICIDES AND PEDICULICIDES
hndane' louoo. shampoo As directed topically Sea b1es/ped icul DS1 s
permelfmn !Nix' I One application topically Head lice. scabies
!El mite' shampoo, ointment, One application topically Llce
cream. lott00. liquid)
lllollat!uon (Ovide'. lotion. A-200'. 4-48 oz dependmg on
Rlll-X') length of hair

lkup ln1111c11ons. Usually none wnh topical preparations when used as directed

MEDICATIONS FOR BALDNESS

m1nox1d1l IRogaine topical solution) Apply 1 ml of solution to Baldness
affected area or scalp
~nasteode IPropecia) 1 mg PO qd Baldness
MEDICATIONS FOR MISCELLANEOUS DERMATITIS CONDITIONS
tx'' lvanous OTC prepara!Jons Use to[llcally Psonasis. sebonheic
as stiampoo and soaps derma11t1s
ftuorwrac111Efudex soluuon' cream. Apply topically for Actrrnc keratos1s. superficial
carac. cream) drsintegration of llssues basal cell carcinomas
mexoryt SX (Anthelios SX Apply topically Sunscreen
moisturizing cream'I
BCG bac>lle CalmeneGuerm: PO. orally, SC. subculaneously.
ore l!lldieation
'1.11111 bi lllOdical 1Wofessionals only, not d1spenoed
~ medocatJOn
11o NP 11111 elfecu ate found with tQ!ltCal oestlletJcs and ant11WuntJcs

for prevention of infec1ions and Lo soften and facilitate

TOPICAL TREATMENT OF BURNS
AND CHRONIC WOUNDS
Bum treatment is dependent oil the type and depth of
tilt burn, JS well as the percentage of affected body area.
lypes of bums include therma l, chemica l, and electrical
bums. a~ well <1s inhalation of smoke. Chronic wounds,
including pressure ulcers, diabetic ulcer., and venous
ulcers. Me wounds that " "" not completely healed after
4 10 6 wecks o r treauncnt . llmcrgt'ncy and lo ng-tenn
trtatnirnt may be accomplished by using dressings such
ou DuoDHlM or OpSite as well as antimicrobials. debrid-
ing .1&cnts. dressings. and wound cleansers.
Tu'O 1op1cal sulfonamidt>< arc frt'quemly used with
ittond and third-degree bums becau~e of their broad
'Ptrum of action against gram-positive and gram
n'l!Jt1ve b.1cteria. Silver s11/fatli11zi11e (Si lvadene) is used
c<chu removal. Mafenid' (Sulfamylon). also a broad
spectrum baaerios1<1tic agent, pene1rates esdlar, even in
the presence of pus and scrum. 1'his agent rapidly dif-
fuses through bums and is effective against baaerial
wound invasion. Mafenide is rclati\-cly nontoxic. but
some burning, stinging, or pain may occur on applica-
tion (see Table 22-4).
kt! CLINICAL TIP
Before usrng sifve1 sulladiazrne. be sure !he patient 1s not allergic
to either of the active 1ngred1ents~ silver and sulfa.
Alginate dmsings. made of spun fibers of brown
seaweed, absorb serous drainage or exudates to assist
with debridement and 10 keep a moist wound area.
 398 SECTIONV Med1cauons Related to Body S-'-ys.:...t_em
_s_ _ _ _ _ __

s1"'9< sulfad1anne ISdvadeoe cream! Apply topically Second and

th1rddegree
burns
mafen1de (Sulfamylon cream. powder Apply topically
for solution)
collagenase (Samyl 01nuneml Apply topically D~bride wounds for Cleansing agems
eschar. necrotic
tissue
alginate (spun seaweed) dressing Apply topically
!Alg1DERM, Curasorb, Sorbsant
trypsin (Granulex. Xenademl gel. Apply topically
ointment spray!
fibnnolysin (desoxyriOOnodeaseJ Apply topocally
!Elase ointment!
dextranomer (Oe!risan hydroph1hc Apply topically
beads!
hydrophilic polyurethane foam Apply topically
(81opatch. Curafoam, fleXlanJ
hydrocollmd dressing and granules Apply topically
(OuoDERM, Curaderm)
hydrogel (Curasol. Tegaderm. Vig1lont Apply topically
polyurethane film dressing (B1oclus1ve. Apply topically
CaJTafilm. Tegaderm HP!
becaplermm gel (Regranel\I Apply toptcally
All presmpbon medications

Coll11genrue omrmenrs. are sterile enrymatic debriding

ointments with the ability 10 digest collagen in necrotic
tis.sue. 1. Burns should be cleaned and debnded before sulfonamide$
I l}Ylroplulic polyure1liane {00111, also called ope11 -cel/ foam are applied
tlrl'SSi11g, are sheets of foamed solu1ions containing vari 2. Burns may be continuously covered with sulfonamides 10
able siu d o pen cells 10 hold exudates aw,1y from wounds soften eschar.
whil e maintaining a mois1 enviro nment.
I lydrogels are glycerin-based or wa1erbascd dressing.~
for hydra1ing wounds.
1t/111spare11t film dressings, polyurcihnne ; heets that
. ..
wi11 not adhere to mois1 surfaces, do 1101 have any absor
bent qualities but do allow some transfer of oxygen and Proteolytic eozymes are used to debnde and clean tissues al
'''3ter vapor. debris and exudate
Becaplermin gel (Regranex) i a recombinant formu-
lation of platelet-derived growth factor to promote grao
ulation of 1issue. PROPHYLACTIC AGENTS
Prolro/}1ic ~ are used to clean and debride
1issues of debris and exuda1es by dissolving protein Sunscreens, which absorb or reOect harmful rays from
fou nd in necrotic tissue. Some of these mediG1tions are the s un, arc used when extended sun exposure may lead
combined with amibioucs to add bac1ericidal action (see to premature skin aging or to s unburn during leisure
1'J ble 223 ). activi1ies or occupa1io11s requiring o u1door exposure.

Some chemicals and medicatio ns such as tetracyclines.
wlfonamides, thiazides, phcnmhia,incs, lricyclic antide-
pressants. and antineoplastic agent;, as wel l .1~ cosmetics,
m3Y increase the chance of photo<eMhlit Skin
becomt'S red and painful and bums, with peak reactions
()({UITing 24 to 48 hours after exposure. Skin damage
1Jl3V result in precancerous or cancerous rissues. Absorb-
ing agents. chemicals that absorb harmful rays into the
skin. pre>1'nt erythema, burns. and other harmful cffeas.
lldlecting agents are opaque, like pastes such as %inc
"'1M md 1i1anium dioxide, and must be applied heavily
to bt dfl'Clivt.
The f-ood and Drug Adminis1r.nion (fOA) has classi
fitd sun products by their sun protec11on factor {1.PJ.),
!Mmio belween exposure to uhraviolc1 radiation (UVR)
""'-es and time required to cau..e el)1hema with or
..;thout sunscreen, or minimum erythema dose (MED).
lbebest way 10 choose a ~unscrcen is by type of <kin and
length of time in the sun . nwgeneral recommendation
for use with medkat ions is a minimum Sl'r of 15. In the
uopics. an SPF of 30 is rccommc11Md for ind ividuals
who will be in the sun for even a b1ief 1>criod of ti me.
Efficacy of a sunscreen is rdated to its abili ty to srny o n
the skin through exercise, sweating. and swimming.
Water-resistant sunscre~n ~ ~houlc.l remain on the skin ro r
40 minutes in water; wa terproof sunscreens sho uld
remain on the skin twice as long. Some protectants have
dual SPFs on the label- o ne for dry condi tions and one
for use in water.
Skin protectiws form a fi lm on skin 10 prevent macera-
tion or and dryness or the skin. 11iesc IHOduetS will also
leep out light, air, and dmt. Non.1bsorb.1ble powders
may not be userul as prmcctan l\ hecausc they tend to
stick to wet suifaces and arc difficult to remove. These
powders include 7inc oxide. zinc st~arate, bi~muth prep-
ar.itioru. and talcum powder. Cal/0<lia11 (a mixture or
akobol, ether. and pyroxylin) b .1pplied for protection;
tht ether and alcohol evaporate!>, le.wing a thin, trans-
parrot film on the skin 1lcxiblc collodion i\ collodion
mtxtd "ith camphor and castor oil to make an elastic,
ftaible film. !>typtic collodion contains tannic acid as an
.suingen~ as well as protl'Cl.1nt 11icse agents protect the
skin to allow st11nula11on of healing and prevenr funher
trauma.
MEDICATIONS FOR SCABIES
AND PEDICULOSIS
Sablddes and iwdkuliddc .uc used ag.1inst .anim~l
parasites. Pedicu losis is an inft'station oflicc-pcd1cu los1s
pubis (pubic lice), pcdiru losis cotP?1is (~ody lice)'. ~r
pediculosis capitis (head lie<'). l'cdicu losts corpons is
usually found around the waist, col l.11', or axil_la1y area
btciuse after biting tlw individual the 1,a rasuc hides
in the do~i ing. n1c drug for pcdlcu losis is li11l1111e 111
CHAPTER 22 Orugs for Skin Cond1uons 399
topical creams and lotions applied to affected areas and
left on for 12 hours. then thoroughly removed Shampoo
is worked into scalp for 4 minutes, shampooed. and
then rinsed. finally, nils are combed from hair sharts.
Repeated applications of lindane, a strong insecticide,
may cause central ne1vous system toxicity, espially in
children.
Scabies are small parasites that bore mto the homy
layer of the skin, causing irritation and pruntus A month
after mites burrow under skin, symptoms such as watery
blisters between fingers appear. Infestation then spredds
around wrists and elbo\\-s and onto bunocks With
scabies, lindane lotion is left on the entire body for 8
hours. Other medications such as CTVlamiton ( Lurax),
permethrin (l'ix. Elimite), and malathion (Ovide) are
applied to infested areas. Elimite, a prescription drug for
scabies, is applied from the neck down o"er the body
and is left on for 12 hours before removal Clothing and
bed linens must be treated at the same lime as skin to
destroy mites (see Table 22-3).
1. Do not apply scab1c1des and pedicuhc1des to the lace unless
specifically instructed by a physician
2. Wear gloves for application of 1hese medications
3. Do not apply condiuoners to hair after use of medications for
lice.
4. Treat all household and sexual conlacts fo1 hco
concurrently.
5 Because of flammability, avoid open flames around Ov1de and
other malathion derivatives. Do not use hair dr;ers and do
not smoke.
Med1cat1ons for scabies and pediculosis are fOUlld 1n pre-
scnpt100 and OTC forms
The tnseetlCldes malathJOO and hndane can be absorbed.
taUSJng systemJC ieactlons 11used too olten
OTHER DERMATOLOGIC
PREPARATIONS
Minoxidil (Rogaine) in different strengths may be used
for alopeda in men and women by applying t mL of
solution to thinning areas of the hair twice a day.
Minoxidil was origillally producoo as an an1ihypertens1ve. but
excessive hair growth was seen 10 be a persistent side effect,
and the FDA approved ils use for alopecia.
400 SECTION V Med1ca11ans Related to Body Systems

Another hair stimulam for use in men, finasterith SUMMARY

(Propia), an androgen inhibitor. is a category X medi-
c.11ion in women bccau!i<! handling of the medication or
con1act with semen may be teratogenic to the male
fetus
11uorourtil (Lfudex). ~ for ~ctlnic keratosis
and superficial ba~l cell carcino ma, wo rks by causing a
mild inflammauon that progresses to 5e'"ett inOamma-
uon with burning. sunging. and -esicle formation.
This reactio n 1s followed by u~ue disintegration,
necrosis. erosion, ulcnatlon, and finally healing (see
1.1bl~ 22-3)
Use glows or a cott0<1 tip apphctOf wllen applying fluorouracil.
and apply only to affected are<Js Ptotect surroondmg areas by
enc1rcllng lesion with Vaselme
Many preparations for treating skin disorders exist. Many
of them may be bought 0 re and may be the same med1
cations as prescription drugs but of weaker strength
Many topical preparations such as soaps. baths, and ~Ian
proteaants are used on a daily basis.
Antiinfectives and antiinflammato ries are some of !ht
same medicatio ns -'ith the same indications asdncribftl
in Chapter 17 but are in topical fonms for dermatologic
uses. When used under normal conditions. topKal anu.
infectives d o no t have system ic e ffects or.dangers of drug
resistance that are found with systemic preparalJOnl
Denmatologic therapeutic ,1gents cover a wide ran(lf of
medications. including preparations for acne, psori~
sd>orrheic denmatitis, bums. baldnt?$S. itching. and J>Ma.
sites. Many patients use OTC medications for waru.
contact dermatitis, itch ing, sunburn. or lesions cawed b,
diseases such as chickenpox. Protective agents such as
sunscreens and skin protectants around colostomiet '
pressure sores are important in prophylaxis aga111St
further skin trauma.

THINKING EXERCISES .'.-' ' ,

Scenario
James plays football and has a problem with athlete's foot. He does not want 10 go to the
derma1olog1st with the problem bur wants to use a product that can be bought OTC.
1. Is an OTC product a possible answer for his problem? Explain.
2. What forms of medication can be obtained OTC for fungal infections?
3. What OTC medication would you think that James might try?
4. James also wants to k.now how long he can use this medicine 1f it does not seem to help his funga
infection before he must see a physician. How would you answer?

DRU G C AL C ULATI O N S
1. Order. rctracycline 250 mg qid 2. O rder. Lindane Shampoo, Wash hair hs and rep an
Avail able medication: Tetracycline 0.25 g caps I wk. Com b hair p washing
Dose 10 be administered: - -- - - - - - - - Interpret the o rder: ~~~~~~~~~-
 --------------=C:.:HAl'TER~=2=2=-=D=
rugs for Skin Conditions 401

REVIEW Q UESTIONS

1 !low are Lhe form ,ind s ize of lhe ch emical molecule related 10 absorption of medications through lhe skin?

2 \\'hat is the difference between a soap and a cle a n s e r ? - - - - - - - - - - - - - - - - - - - - - -

3 \'lhat are the modes of action for topical amiinfec1ives used for such conditions 25 impetigo, carbuncles. and
furundes? _ _ _ _ _ _ _ _ _ __ _ __ _ _ _ _ _ _ _ __ _ _ __ _ _ _ _ _ _ _ _ ~

4. Wha1 are indic.11ions for to pical con icosteroids? - - -- -- - - - - - - - - -- - - -- -- - -

s What are the many fonns of a111ifungals? Why are all of these forms necessary! - - - -- - -- - -- -

6 \\'hat is the leading ingredie111 in acne prepar.11ions, and how does 11 act on the skin! - - - -- - -- - -

7 How are topical .1nesthe1ics used I------------------------ ---- -

8. Whal an1i in fec1lve class o f m ed ica tions is used for burns! I low do these prepara1ions facilitale burn lreatment?
Musculoskeletal System Disorders

After studying rh1s chapter. you should be capable of domg rhe following.
Describing causes and symptoms of 101m and Describing how muscle relaxants affect the body
muscle pain and appropriate patient educauon needed f0t
Discussing therapy for osteoporosis. patient safety.
Explaining classes of medications used to treat Identifying medicauons used for arthritis.
musculoskeletal cond111ons. Providing patient education for compliance with
medications used to treat diseases and conditions
of the musculoskeletal system .

Ms. Werner is opproachmg menopause and cannot drink milk because of allergies. She comes to Dr
Merry for a regular office visit and asks tf she needs to be concerned abour her lack of calcium intake
Dr. Merry suggesrs Ms. Werner use Tums as a calcium substitute. As she is leaving the office,
Ms. Werner quesr1ons use of an over-the-counter (OTC) preparation that is md1cared for gastric
disturbances.
What 1s your response concerning the use of Tums?
A few weeks later Ms. Werner calls to say that she has heard of an OTC product for calcium that is
eaten as candy What would be your response if she asks for the product name?
Should she use Tums with this candy-like preparation?

Ankylosing spondylitis Exacerbate Muscle spasticity Osteoporosis

Ankylosis Fibromyalgia Myasthenia gravis Pan nus
Arthritis Fusion Nonsalicylate Purine
Articulate Hyperuricemia Nonsteroidal Salicylat e
Bursitis lmmunomodulator antiinflammatory Tumor necrosis factor
Crepitus lmmunosuppressant drug (NSAIO) (TNF)
Disease-modifying Kyphosis Osteoarthritis
antirheumatic drug Muscle spasm
(OMARO)

402
 CHAPTER 23 Musculoskeletal System Disorders 403
----
EASY WORKING KNOWLEDGE OF INDICATIONS ANO SIDE EFFECTS
Common Symptoms of Musculoskeletal Disorders Common Side Effects of Medications Used
msuffness. pain. 1nllammation. swelling for Musculoskeletel Disorders
Welf/t loss Nausea dOO vom11111g
Bone mass I=. bone defonn1ties Pain 111 abdomen
fatigue. malaise. weakness. fever Drowsiness. dimness. onhosta11c hypotens1on
Tenderness and swelling of 1oints and bones Headache
toss of motion, immobility Const1pat1on and diarrhe<i
Visual changes
-------

EASY WORKING KNOWLEDGE OF DRUGS USED FOR MUSCULOSKELETAL CONDITIONS

I. I I . I.

OSTEOPOROTIC MEDICATIONS l'levenbon and lfeatment of osteopoiosis

B1~tes Yes No c
Bone resorptive mh1b1tors Yes No x
Calcitorn n Yes No c
Ca um cartlonate Yes Yes Not categ0tiied
P"ladlyroid hormone Yes No c
ANTIRHEUMATIC AND ANTIARTHRmc MEDICATIONS
Nonsrero1dal Antii111/Bmmatory Drugs
Salicylates Yes Yes c Ant11nftammatory agents. analgesics
~onsal1Cj1ates Yes Yes B.C.O
O.S1~M11fyrng Anume11mauc Drugs
"1munowppressan1s Yes No 0 Aehea symptoms of rheumatoid arthritis
lmmunomodulators Yes No B
Nf factor blockers Yes No B Moderate to severe rheumatoid arthritis
Gdd salts Yes No C.D
....."'lalanals Yes No B.C.O
OTHER AGENTS FOR MUSCULOSKELETAL CONDITIONS
Anligout medicatrons Yes No C. D Reheve symptoms of gouty anhntis
Skeletal muscle relaxants Yes No B. C Reduce muscle spasms and spasbcity
Anticholinestetase agents Yes No C lncre<iSe muscle tone

he musculoskcle1<1l system i~ really two different connect muscle to bone. whereas ligaments are strong

T systems thJt work closely together for body mobil-

ity and stability. The two sy<tcms indudc a sturdy
collaiion of conowct ivc tissue, muscles, and bones to
fibrous tissues binding bones together to facilitate
motion. Muscles require electrical impulses from nerves
for stimula1ion that cause muscle contra(lion and relax-
ation to produce movement; these actions arc the basis
allow change of po~ition and giw the body height and
on which muscle relaxants work with the pcl'iphcral and
form (Figures 23 I ,incl 23-2). central nervous systems Muscle relaxants relieve me
The muscular )"Item include'I muscles, which are
pain of muscle spasms by relaxing muscle contractions.
<logluly contrJcted at all tim('S. Jnd 5peciaJized conncc-
Sewral disease processes. among !hem myasthenia
ll\'t ussue such as tendon and ligaments. lendons
404 SECTION V Medications Related to Body Systems

gra,.;s. fibromyalgia, muscle spast icity, multiple S(lerosis,

and spinal cord diseases or injuries. result in inability()(
muscles to contract and relax properly.
The skeletal S)'Stem consists of bones that uticubtt
in joints that arc covered with a nilage to allow the bod,,
to be mobile and flexible. lhc capsule surrounding tht
Riis (12) ~~r5'f ~,~ joint. called a but>t1, i~ lined with a syno,<ial membtan(
Coo1al can.lage-/-...!..!;.::.0.::;~':'.""'":'."1--+lt- filled with synovia) lluid. Diseases of the joints are
considered arthrllls or bur,ltls, of which there
are many different types. !lone mass reduction is all~
osteoporosis.

Carpals (8)
Me1acarpaJs (5)
Ptl<llanges ( 14)

Osteoporosis, a metabolic musculoskeletal disease is

Figure 231 The sl:eletal system (f1om f1az1er MS, Orzymkowsk1JW:
sscm1als of huma!1 d1se<ises and cond1t10'1S. ed 4. S1 LOUIS, 2008.
Saundo1S.)
characterized by a porous appearance of bone m.\U
In older adults, especially postmenopausal women, tht
resorption of existing bone begins to exceed formauon
of new bone. causing deterioration in bone mass me!
density. Hrst signs of bone mass loss may be fracture$
\''ilhout causaLive 1r.1urna. Most fractures ocrur in \1.'l'lt
brae, hips, and wrists, es1>ecially dorsal and lumbar wr
tebral fractures and thus leading to height loss. chronic
back pain, and spinal deform ities such as kyphols. To
prevent osteoporosis, adults need to maximize bonf

Tnc:epsbrac:l1ii

Figure 232 Muscles ol lhe body [from Frazier MS. Driymkowsk1 .NI Essenria/s of huma" drseases and eond111ons. e<1 4, St Louis. 2008. SaurO!r> I
 CHAPTER 23 Musculoskeletal System Disorders 405

11 rength by ensuring sufficient intake of calcium and
1.,1,1min D throughout life and by promotillg lifestyle
measures such as regular exercise. Cakium may be
obuined from milk and mi lk products or through
cakium carbonate supplements such as Tums or Viacuv,
Ml OTC chewable supplement in a candy-like form.
Medications include agents to decrease bone r~rp
non and promo te bone formation. Antiresorptives
include bisphosphona1es as preferred treatment ,ind ral-
ciionin for those who cannot tolera1e bisphosphonates.
Estrogen therapy may be added, although this is not a
l'ood and Drug Administration (l'DA) -approved use
(Table 23- 1) and is not recommended for long-term
therapy because of the increased risk of cenam cancers.
blood clots. and cardi0\''1SCUlar disease Bisphospho-
nates are approwd for osteoporosis and are safe for
prevenuon of fraaures Aln1dnnuiu (l<>samax) and
riutlrorrare (Aetonel) Me available in a weekly admin-
istration regimen, whereas ibantlronate (Boniva) is
administered monthly. for these medications to be

TABLE Z3 1 MEDICATIONS USED TO PREVENT AND TREAT OSTEOPOROSIS

USUAL DOSE, ROUTE. INDICATIONS

GENERIC/TRADE NAME AND FREQUENCY FOR USE DRUG INTERACTIONS
RECOMBINANT PARATHYROID Osteoporosis
HORMONE
' ipararnle acetate (Forteol 20mcg SC qd digoxm

/111jor Sidi EH1cts:

Leg cramps. nausea. dizziness. headaches. orthostatic hypotension, tach~ard1a

BISPHOSPllONATES
ietOooate (Fosamax1 510 mg PO daily dose Basically none
with vnamin D (Fosamax 70 + D) 1 tab PO weekly dose
(Fosamax-70) 70 mg PO weekly dose Basically none
nsedronate (Actonel) 5 mg PO daily dose or 35 mg Alltacids. NSAIOs
PO weekly
150 mg PO monthly Dietary supplements. antacids.
NSAIDs
Bornva in1ect1on 3 mg IV q3mo
et1dronate (Didronall 5-15 mg/leg PO qd warfarin. calcium
ram dronate (Ared1a} 15-90 mg IV

M11or Sioe EHte1$:

mooare-lleadaeho. GI symptoms. rrsedrooate-arthralgia. rash; 1bandrooa1~sphagia, bone pain, heartburn. gastne ulcers,
dyspepsia. chest pain, myalg1a, numbness. eridronate and pamidronate-same as with other b1sphosph011ates

CALCIUM PREPARATIONS Osteoporosis

t" llOOlll salmon IM1acalcin) 1 SPfay in nosml qd
w.aJm carbooate ITurns. Viactrv 1000-1 soo ca
mg CJd
chews. Os-tal-D'I

SELECTIVE ESTROGEN RECEPTOR Prevent10n and ueatmenl

of osteoporosis
MODULATORS
60 mg PO qd ampicillin. estrogen replacement
,..,,, fene (Evistal Pfeparauoos. anticoagulants

/111/or Side Elfecll of Selective Estrogen Receptor Modul~tors:

Hot flashes. flul1ke symptoms. arthralg1a, sinusitis. insomma
--- N I N'~/Os oons1er0tdal ant11nnommatory drugs. PO. orally: SC. subcutaneously
61. Ud>Uu1111Ct1$bna1 . intravenous 'f. .,,.. .
~medcatJOn
'OTC -icaUOll
406 SECTION V Med1cat1ons Rela1ed 10 Body Sys1ems
elTeruve. an adequa1e mYke of calcium and viYmin 0
is necessary Bisphosphonates should be tJken on an
empty stomilCh on arising. wnh 6 10 8 ounces of plain
water; lhe patient should not lie down or eat for 30 to
60 minutes after administrauon
Io decrease bone e$0rp1ion, roloJriftM (!,vista), a
selective estrogen receptor modula1or (pregnancy cate
gory X), is prescrib<?d to both prevent and trea1 O>leopo-
rosis in postmenopausal women. 11 can be taken without
reg;ird 10 meals.
Calcit-011i11 salmor1 r1asal spray (Mlacaldn), for 1rea1-
ment of osteoporosis and not a pror>hylactic agen1,
inhibiLS bone resorplion to decrease bone lo~. 11 is safe
when sprayed into ahema1ing nomils daily.
Ttriporallde (Foneo). a parathyroid honnone. has
been appro''ed to stimulate new bone fonnation (see
Chapter 20).
Men are also trea1ed for osteoporosis. Ille decline in
bone mass in men begins at approximately age SO and
occurs at lhe same ra1e as in women An exception in
women is lhe accelerated rate of bone loss during meno-
pause. Ille same dru&' are used for 1reatment of men as
for women, excep1 testosterone is substhmed for esuo-
gcn (see lable 23- 1).
Calcium preparations must have v11am1n 0 (from sunlight or
other sources) to be effecrn1e
2 B1sp/losphonates must be taken on an empty stomach with
a full 8-oz glass of water at least ll to 60 minutes before
breakfast to be eftectrve and may tatl$8 SSOllhag1t1s 1f they
become kldged in the ~us Patient should remain in
an upnght pos11J011 for at least ll to 60 minutes aher
adm1mstraoon
3 Calcium carbonate. p-eferably with vitamin D. should be
taken with or after meals to promo1e absorption
4 Calcium and teuacycl1ne should be taken at least I hour
apart
5 When using intranasal calciton1n salmon. nostnls should be
alternated on a daily basis.
l'lefened OOigs osteoporosis prlM!nt1on are
bt sphosphouate:s.
Cak:1tomn salmon mimics body tl1em cals to mh bit bone
resorption
Calc1tomn is safest drug fOJ osteoporosis but is not as effec-
tlVll as b1sphospllonates or as preventwe as estrogens
JOINT DISEASES AND THEIR
TREATMENT
Anhri1is is characteri?.ed by joinl pain and limitation d
joint movement. lhe most common type of anhritis n
osteo;arthrills, a degenerative noninflammatory disea1(
that causes des1ruction of bones and joints from conS1.1ni
wear and tear. 11 has an insidfous onset in large weight
bearing joinLS. Join1 cartilage gradually becomes thinner
and loses its abif ily 10 keep pace with the need for ii$
replacement. 'lhe disease is characterized by dull, aching
pain with joint SOl'enc;.s and ;.tilTness with little limilation
of movement Wilh disease progression, deformity may
ocrur, wi1h crcpltu~ on movement, progressive loss o(
join1 stabi lity. decreased range of motion. and increased
pain as bone enlarges and deforms the joint, necessitating
joint replacement surgery in some instances (Figure 23-3).
Rhn1111111ou/ 11rtlinris. Jn autoimmune disea~. an
manifest in numerous form). Beginning wilh stiff,_
and fatigue and progressing to a.nkylosls or penmanem
joim fusion, it can be found in all age groups bm usually
peaks be1ween ages 20 and SO. The condition of tht
joints becomes progressively worse; the joints become
red, swollen, tender, and warm, with considerable pain
and limitation of movement. Synovitis with resuhan1
pannus forma lion also occurs, pernlitting tissue OVfr
&>rowth, which eventua lly converts to scar tissue. causing
joint stiffness. Wi1h prolonged illness. scar tissue replacu
bo ny tissue and further ankylosis ocrurs. Replacement
surgery may also be performed when jo ints are suffi.
ciently deformed 10 preven1 movement (Figure 23-4).
Bursitis. an inflammation of the bursa, occurs \\ila!
lhe joint is trauma1ized. overu,,W, o r infected or "'hen
deposits of calcium accumulate. Common siteS ofbuBr
tis are lhe shoulder, knee, and elbow; common signs ~It
tendernes. on movement and inability 10 Oex or extend
lhe joint. With chronic inflammation, calci.6cation may
occur in the affected joint.
No cure for arthrilis currently exists, jus1 allevia1ion
of symptoms. Coals of anhritis therapy are threefold
( 1) 10 relieve pa in, inflammation, and s1iffness; (2) 10
maintain joint function and range of motion; and
(3) to prevent joint deformity. These objectives are
ach ieved through physica l therapy. surgery, and pharma
colherapy. Pa1icn1 educ.11ion must suess lha1 excessi\'t
r~t of a joini causes stilTness and that. conversely, exa:s-
s1ve use causes iniensifkation of inOammation and pain
Medications are only pan of the necessaiy ueaunem
with exercise therapy and surgery as needed.
Antianhritic medications are used 10 treat all rheumil-
LOid condi1ions and may be used for conditions such
:is. ost~anhri1is. inflammatory conditions. and 01her
1omt diseases. Medications such as conicosteroids (Stt
Chaple~ 20) and analgesics (see Chapter 15) have already
been d iscussed. Mo re commonly used salicyla1es and
 --~----'-
CHAPTER 23 Musculoskeletal System Oisorders 407

_..
Bone

Car1iage
Joint

NORMAL OSTEOARniRJTIS OSTEOARTHRms-ADVANCEO

lrregUlar )Cini space Osteoplly1e$
Fragmen1ed carulage PeriatbcUlaJ-
Loss of cartJl&ge Caldfied~
Sclero<ic bone
Cystic change
Figure 23-3 Degene1a11on of 10111ts and can1lage w11h sclerotic and cys11c changes caused by osteoarthnus. (ffom Oam,anov I PathQ/og fot the health
IJO!mllXIS. ed 4. SI Louis. 2012. Saunders) Y

Bono
Ca111lago

~~~~~~~~
Jolnl
capsule

fitm 23-4 Pa111oiogic changes 1n lfleumatOld anhnus The rust pm ustrates a rypecal pnt The smnl pnt ~ SlflO"llJ$ and Joos of arucutar
SllDcaosed by pamus fotmation The third pnt IS ankyfoSed "lllg (l) rheumatoid artfv1(1$ and OSUllJ!lDIOS&S. (Fmm Damianov I Pathology lot theheall/I
pe'mois. ed 4 S1 LDulS 2012. 5.1undefs I

oonsteroid;al antllnOamnMtorv drug' (NSAIDs),
w!ucb are no1 used prim.1rily fo r a1Mlgcsic e ffects, are
brieffydiscussed here to assbt in understanding 1heir use
as musculoskeleta l agents. Antia11hritk medications,
used for long-tenn syrnpto ma1ic re lief. may produce
shon-term disease remissi o n. ltlrcly docs remission con-
tinue. and eventually the disc.1w becomes r.tcrrbated,
with funher progression of sym 1)tom~ and increased
debilitation.
Amianhritic medications usually fall into 1hrce major
categories: NSAfDs. disHse modifylng antlrheuni.tic
drugs (DMARDs), and glucoconicosteroids. NSAJDs
may be funher subdivided into ulicylate and non
salicylate medications. Safer than the 01her types of
medications, these drugs give relief of symptoms but do
not prevent disease progression . DMARDs, more toxic
and with a slower onset of action, necessitate regular
moni1ori ng. but they do delay disease progression .
408 SECTION V Med1ca11ons Related to Body System:.::s_ _ _ _~~-
BOX 231 TYPICAL PROGRESSION Of MEDICATIONS
FOR ARTHRITIS
Mild Symptoms
1 $a!icy1ate NSAJOs laspmn)
!
2 Nonsahcy!ate NSAIDs (ibuprofen. naproenl
.!.
Modenile Symptoms
3 Add DMARDs
J. T
May be prescribed together
4 Glucocorticosterords (short term)
C lucoco rticosteroids provide rapid sympto m relief. do
no t prevent disease progression, and ar~ toxic with lo ng-
term U'il'. Therefore steroids are indicated o nly for sho n -
1erm, acme therapy. Progressio n of therapeutic agents
is found in Box 23-1. In some instances, NSAIDs and
OMAROs are used together in an effo n 10 delay joint
dcgcnerarion.
Salicyl111e NSAID.1 are effenive, fos t-aning, and, con-
s ideri ng their ability to relieve sym ptoms, i nexpensive.
Their actions are generally a1Hiinflammatory, b ut they
also provide analgesia. E11teric-coa1ed medicatio ns m ay
reduce the diance of gastric symptoms and gastric b leed-
ing. Medication compliance may be difficu lt to achieve
bttause the pa1ient may not believe aspirin and o ther
arc salicylates can be effectiVI: for arthritic symptoms
(Table 23-2).
Norua/1cylate NSAJD>. effective as antiinflammatory
and analgesic agents. are more expensive and acL basi-
cally as salicylate medications do. Patients who do not
respond to salicylates may respond 10 nonsalicylates
and may respond better 10 one nonsalicylatc than to
another. Short-term rherapy witl1 these medications has
less o f a tendency 10 cause gastrointeslinal (Cl) upset;
ho wever, when used long-term, nonsalicylarc NSAIDs
m ay cause C l ulceratio n and should be taken with m eals
or food. At presen~ m any of Lhese medicatio ns a re o n
the market to treat not o nly arthritis but bursitis and
tendonitis. PatienLs who are hypersensitive to aspirin
may be hypersensitive to these aspirin-like medications.
Contrary to some patients' beliefs. au1arnl nophen
(Tylenol), an analgesic. is nor e.ffectwe for mnammatory
or arthritis-like symptoms. Melt>Klcam ( Mobic), an anLi
inflammatory, analgesic. and antipyretic, is specific for
os1eoanhritis and should not be taken with other
NSAIDs (see Table 23-2).
Late i n 2010, a new group of drugs 10 relie\'e os1eoar-
thriris, rheumato id arthritis. and 01her m usculoskeleLal
diseases such as ankyloslng spondylltls, while
Figure 23. 5 lntraart1cular 1n1ect1ons of glucocorticosteroids maybe
"''th pallents with inftammatorv 101n1 d1Sease
decr~ing the risk o f de\'elopmeni of gastric ulcers from
NSAIDs, wa> mtrodured by combining medications for
anhriti> '"ith pro ton pump inhibitors. Tue first media.
uon in the g roup, available in two strengths, is nap'""'
combi ned with csomepraz.olc, a protein pump inhibi101
(see Chapter 24 and T.1blc 23 2) .
Cyclooxyge11nsr2 (COX-2) i11/J ibi1ors are used to sup.
press joint inna m matio n while caus ing minimal side
effects. Celccoxlb (Celcbrex) is indicated for osteoanhfi.
tis and rheumatoid arthri tis but s ho uld not be used by
people with sulfa allergies (sec Table 23-2). The other
COX2 inhibitors have been removed from the maikt
because o f the toxic cardio vascular dfeas.
Clurocorru:osreroul.s (Chapter 16), powerful media
rions that reduce inflammato ry responses. are useful in
treating joint disease. f hcse medications palliate arthntJs
but do not provide remissio n or hah disease progressJOn
For people with several joints invohed, oral sLeroids m.iy
be prescribed: Lhose with o nly o ne or 1wo joints im-oh'l:d
may be given i ntraanicular mcdic.~1 io ns with lower IOXK
ity and greater effe( tiveness and that allo w more d11-
matic increases in m obi lit)' ( Fig ure 23-5). With s1eroidt
joims tha t wcr.- previously immo bile may becomt
mobile; h owever. 1hcsc m ed icati o ns sho uld be resencd
fo r sh ort-term therapy in those who have not responded
10 other medicatio ns o r for treaLmem of an exacerbauon
of the disease.
DMARDs are used with moderaLe 10 severe rheum~
Loid arthritis when t-.:SAIDs have not been efTll'"!.
These include gold s.1lts. lmmunosuppresunt agents,
immunomodul~to" and antimalarials. Many of thae
medications have black box wamin~.
Cold snits are expensive but seem 10 reduce syn0\1US
seen with rheumato id diseases. Used since 193-0 to
relieve joint s 1i ffne>S and pain, these medications may
even h alt progressio n o f joi111 degeneratio n. l l wy do not
 CHAPTER 23 Musculoskeletal System Disorders 409
---

Ant11nflammalllfY. analgesoc Antacids. COftlCOSternids. ACE

351)M1Etollln. Bayer, ButtennJ
d>Olre magnesium salicytate
iNTNI
mapsr1111 sahcylate (Magan.
Mobrdin. Ooan's P11ls'I
sa salate (NTNI
agen1s fOf osteo- and inlubrlllfs. beta blockers
rheumatoid artllntis melhouexate. anticoagulants
pobeuec:id. sulf~.
su fonyturea. alcohol penoc:11l n.
naproxen. valprooc acid. oral
h'jpogl~ buprofen
650 mg PO Q4h
3000 mg PO daily
d1V1ded m 23 doses
tab I PO q4h
1000 1500 mg
b1d/q1d

NONSALICVLATES Analgesic. antiarthnt1s.

antoinflammatory
ddofenac (Volta1en. Cataflaml 2550 mg PO bid/q1d ACE mh1b1tors. ltth1um. wartann,
with m1S-Ojlrostol (Arthrotec) 50/200 mg PO tid am1noglycos1des
1Munosal (Oolob1d) 125-500 mg PO bid digoxln. furosem1do.
methotrexate. warfann
etodolac (NTN) 1200 mg PO d1vidod
bid/lid
fenoprofen (Nalfon) 300600 mg PO trd/qid
flurb1profen [Allsa1d) 200300 mg PO in 24
d1v1ded doses
1b\J!Jofen(Motnn1 Auten. 200800 mg tJd/q1d (max
Advil''I 3200 mg/d)
Rkxnethacm (lndocrnJ 25-50 mg PO b1d/11d Gout and arthrotoc Not for use by children younger
conditions than age 14 years Of pregnant
' lactating Wllf!len
inlprofen (OrudlS. plain and SQ. I00 mg PO trd Analgesic. anti- See all above
exmnded-releasel 111flammatory, arthritis
Ml>cam (Mobtcl 1Smg PO qd
nalunetone INTNI 1000-2000 mg PO qd
naproxen INatyOSVR') 250-500 mg PO btd
RllJIOllM sodium IAnaprox. 275550 mg PO bod
A1ew1 220440 mg PO brd
~111 IOayprol 600 1200 mg PO qd
IMOitam (Feldenel 1020 mg PO bod/qd
sulllldac lChnonll 1SO 200 mg PO bod
tolmetin INTNI 200-400 mg PO 11d
ACl. Angootensm-wwt111ing eivyme; COX. cyclooxygenase; ER. extended . release; IA, inttaatticularly; IM. mttamuscularly, IV, 1ntravooously;
NSAIOs. ncnsteroidal an111nflamma1ory drugs, PO, orally. PP/, protein pump mh1b110<, RA. meumatoid anhnt1s; SC. subcutaneously
ore med1oa11on
'Presa1pt1on mechcauon <- onttnut."tl
41 O SECTION V Medications Related 10 Body Svs:::
ie:.::m:::s:___~-----

COX-2 INHIBITORS Anmnflammatory. analgeslC

celeco" b (Celelnxl
for arthnt1s
lithium. cannot be used by
100-200 mg PO bod
persons allergic to sulfa
medications

IMMUNOSUPPRESSANTS
RA Vaccines. NSAIDs. probenec1d.
metho1rexate (Aheumatrex) 7 5-20 mg PO. IM, IA.
sulfinpyrazone.
IVqwk
111methopnm-sulfamethoxazoie
Allopurinol
a2ath1opnne (lmuran) 1-2 5 mg/kg PO qd

TUMOR NECROSIS FACTOR INHIBITORS

adalomut'lab (Hum ra) 40 mg SC qlv.k Moderate to severe RA LMI virus vaccines
111ftix1mab (Remicade) 3-5 mg/kg rv Q4-8w\: live vtrus vaccines
ceitoltrunab pegol (Cimzoa) 200-400 mg SC q2-4wfi etanercept
gohmunab (S.mpooi) SO mg SCqmo etanercept

INTERLEUKIN-& INHIBITOR
1ocih2umab (Actemra) 4 8 mg/kg IV q4wk etanercept

IMMUNOMODULATORS
abatacept (Orencia) 5001000 mg IV q2-4wk Antirheumatic agent Vaccines. corticosteroids
1hen qmo
anakinra (Kineret) 100 mg SC qd Moderate to severe RA None
etanercepl (Enbtel) 50 mg SCqwk Osteoarthnus. RA None
leftunom1de (Arava) 20 mg POqd RA me1hotrexa1e, rifampm
gold sod um tluomafate 10.50 mg IM qM Ant1meumat1c. None noted
anuinftammatory
auranofin (Rtdaura) 6mgP0Qd RA See literature

ANTIMALARIAL
hydroxychloroqu1ne (Plaquenol) 400-600 mg PO qd RA None noted

COMBINED NSAIDS AND PPIS

naproxen + esomeprarole 375 mg/20 mg bid Dsteoarthnus, RA Similar 10 naproxen.
(Vimovo) esomeprazole separately
(VimovoERJ 500 mg/20 mg bid

MISCELLANEOUS
glucosamme ch-Olldromn 1200-1500 mg PO Natural supplemen1 for Possibly heparin
arthritis
hyaluronate (Hyalgan) WeeJdy x 3 Of 5 IA Osteoarthnt1s of knee No other medications 1n knee

reverse any previous joint damage. Oral gold prepara-
tions cause fewer toxic effecis. but when taken orally,
gold preparations can cause Cl distress (see lable 23-2).
/111mu11osuptm?S5<mt1. also used as antineoplastics, may
be used therapeutically for rheumatoid cond itions by
reducing Lhe autoimmune response 10 the body's own
1issues. These agents have 10 be taken for several weeks
to be effective. Metl1otruau (RheumatreX), .ibo
a chemotherapeutic agen1 (sec Chapter 18), 1s !Ix
fastest aeting of the DMARl)s and is first choice in thi
group.
lrmnu110111odu/11ro1~ .ire used to a her immune responst
10 inhibit p roduction of ant ibodies in response to .in
ant igen an d the refore have ma ny b lack box wamingl

...inst
...,... . such. diseases
( fV)as tuberculosis human 1mmuno-
Jdioen<y vtrus I I , and fungal disorders. Abatace r
(Oreno.J), el4n~pl (Enbrel), and adalimu ".,
(llum1rJ) are typical of these drug.;.
Tumor .
necrosis f
factor {1Nr) inhibitors are
d' .
increasing group o me 1cnt1ons that are used to bl k
the immune response in au to immune disease
'd h . . B
rheuma101 art nus. ecause the immu 11.. ' syst
em 1s sup.
pres~. the d anger o f use .nof, these drugs is inf<>ct'
ellheracu.teor. ch . ronic.
d . '"JIX111111b (Remicade) a typ1ca
drug. is ad m1mstere intravenously with methot
..._. .d nh . . th
form<umato1 a n us cranv ,,.,.. (C'lffiLl3
YI ' C..rtolizu--b
and gollmumab (Sunpon1) may be administered b th
. . th
p.iuent using e ro ute established by the physician.
rllese drugs may be administered with DMAROs ancI
methotrexate (see Table 23-2).
tll LEARNING TIP
""" TNF mbttors end '" mab"
ktJ CLINICAL TIP
Patients stanmg most immunomodulators and TFN inhibitors should
halt a tuberculin skin test as a base-line before treatment.
Anumalarials. such as hydroxychloroquine (Plaque-
nil). may produce remission of rheumatoid anhritis but
are usually reserved for patiems who have not responded
tO other amianhritic treatment. S.."Vcral months may be
required to produce a thera1>cutic effect, and NSAIDs
should be used during this interval.
Other miscell aneo us medicatio ns u;,ed for joint con-
ditions ;uch as arthritis include pc11kill11mirre (Cupri-
mint), which can produce remission of rheu mato id
anhrius It should not be used unless arthri tis does not
respond 10 more conventional therapy. With a slow
onsn of aaion, the drug may not produce therapeutic
f/feru for ~l!ral months. Cluco111111ine chondroitin, a
combioJtion of glucosaminc (.1 form of amino sugar)
and chondroitin (a large protein molecu le), is no t avail-
able by prescription but rather is considered a nuuitio nal
supplement. Glucosamine is cxtranccl from crab, lobster,
and shrim1J shells, whereas cho ndroi1i11 is fro m an imal
ranilage. CfTecti\eness has not been determined, although
studies ha"c shown pain relief al NSAIO level, but carti-
bgr damage from osteoarthritis may be slowed. Because
glU<osamine is an amino sugar. pc>ns with diabetes
melhtusshould check blood ;ug.lr levels more frequently.
Combined with anticoagulant .igcnts, chond roitin may
cause bleeding because th i~ supplement is similar in
chemical sm1crnre to l1eparirr (;,cc r.1ble 23-2).
_ _C_H_APTER 23 Musculoskeletal System Disorders 411
I In susceptible pesoos. salicy1tes may cause astllna anac<s
ma
2 Many nonsahcy1ata ro mero1dal ant11nftammatoiy drugs
a rap1"diy (NSAIOsi may not be tak~n with asp111n because of the s1m1-
lar1ty of tile drug aher metabohsm The pauent should be told
cl oc which drugs may or may no1 be taken together.
s SU 1 as
3 Pauents taking 1/lclt1fl'n11c (Voltarenl should undergo liver
, ions, function tests r1!9ufarty and $hould report any signs of jaun
1 dice, nausea. or fatigue
4 Because of the~ aruun.ammatorv or analgesic i-oper1res
rexate
) NSAfOs may mast signs of in!ecuon.
5 Ibuprofen (Momn! may ta\1$G Vlsual problems rnclud ng
Y e
d1m1mshed v1s1on and change$ n visual oolor
6 NSAIDs should be 1aken with food. milk. or a full glass of
water to reduce gasuic upset Alcohol should not be con
sumed with NSAIOs because of the increased risk of gastro
intestinal bleeding.
Three obiectrves of arthritis therapy are to reduce pain.
inflammation. and stiffness, to prevent joint deformity; and
to maintain joint !unction
Three classes of drugs are used to treat rheumatoid cond1
tions nonsteroidal ant11nflammatory drugstNSAIOsl. d1sease-
mod1!y1ng annrheumahc drugs IDMARDs). and
glucoeoltJcOSte<OtdS
NSAIDs stWess inftammation and re ieve mdd to moderate
pain found wnh rhe1J111atold disease
NSAIDs and steroids qu1tkly rehlM! symptnmS of arthnus.
whereas OMAROs take longer
NSAIOs and steroids do not slow progression of rheumatoid
diseases. but OMAAOs slow p1ogress1on.
Aspmn 1s the least expens1va treatment for arthritis. but u is
associated with gastrointestinal distress when taken over a
prolonged period of ume
Nonsalicylate NSA!Ds are more expenSNe than sal1cylates
GOUTY ARTHRITIS
Couty arthritis, or gout, is associated with an inbo m
erro r in uric acid me1abo lism, a byproduct of purine
metabolism, causing hyperurlccmla. With gout, uric
add accumulates and ays1als are deposited in tissues
and joints. producing acute pain, swelling, redness.
wanmth, and tenderness of joints. especially of the big
toe. ankle. instep, knee. and elbow. Treatment goals are
to end the attack as soon as possible, prevent recurrence
of the acute condition, and decrease the possibil ity of
 41 2 SECTIONV Med1cat1ons Related to Body Systems

A
Deposits
of urate _,__.......
Joint space + --'Ir.-

B Uric acid crys1a1s

Figure 23-6 A. Gou1 B. Gouty anhrius. Uric attd crystals are depos11ed in tile oonnec1ive 11ssue and jo1n1s. It is most ohen found in lhe ioint ol 1he
groa1100.lA fromfra1ie1 MS. Or1yinkowskiJW Essoo11afsofhumandiseasesandcondi11oris. ed4, St Louis. 2008. Saunders; B frotn Oamjanovl l'ar/1fJilogi
for t/lf1 Ilea/th professions. Eid 4, St Louis. 2012. Saunders.)

cornplica1io ns. l'a1iem education includes giving speci fic
informarion abou1 avoidi ng foods high in purines, such
as oatmeal, cheese, red mra1, to matoes, alcohol, shell-
fish. and fa ll)' foods (figure 23-6).
Medica1ions used 10 treat aru1e gout include colchi-
cine. NSAIOs, roniros1eroids. and febuxostat (Uloric),
approwd in 2009 A derivative of the autumn crocus.
colt hltine is 1101 an analgesic bu1 an antiinflarnmatory
agem specific for gout. 11 is ineffective for any other
disease and is used 10 treat acute attacks. 10 reduce inci-
dence of chrome gout attacks. and 10 abon a possible
attack It should be usetl with care by older patients
because of dangers of CJ, renal, hepatic, and cardiac
diseases. for chronic gout symptoms. allopurinol
{Aloprim or Lyloprim), probenttid (Benernid), and sul-
finpyraume (Amurane) decrease uric acid production
and arc indicated in prophylaxis and treatment of chronic
gouty anhritis. Probenecid has no antiinOammatory o r
.malgesic cffcru and cannot be given during an acute
gout auack and may even precipiiate an acute auack
at initidtion of medica1ion therapy. Sul6npyrazone
(Anturanc) is used for chronic gout .macks. Febuxostat
(Uro lic) is specific for hyperuricemia, with majo r side
effecrs bei ng liver functio n abnormalities. nausea, jo int
pttin, and rashes. llrolic, "1 %ar1thine oxiduse inhi bitor, is
used for chro nic managcmc111 of hyperu ricemia of gout
Thjs drug acts by lowering scrum uric acid levels bu1 may
initially increase gout flares. These flares may requirt the
initial concurrent use of NSAIDs or colchiclne. A new
medication, pegloticase ( Krys1exxa). is a biological agem
for the treatment of chronic goU1 for persons who h;M
not responded 10 conventional gou t medications It mar
produce a gout Oare in some persons so use of cokhiont
or an NSAJ D should be given for 7 days before tre~tmen1
(Table 233 ).
COlchicme is a gout-specific antunllammatOI)' and is 11Jt an
analgesic. so 1t does not relifl'le pain of gout
Allopurinol reduces blood uric acid lfl'lels and may be used
as prophylaxis fOf gout.
Probenecid is used for relief of symptoms from chron" Q1'Utv
arthritis cond1hons
Febuxostat and peglo11case are specific d1ugs fo1 chlonit
gout.
Peglo11case is the firs1 biological agent specific 101 gou1

0.5-0 6 mg/day PO
p1ophylact1cally;
0.51.2 mg PO q2h for
acute attack
a ~ronol IZ)'lopnm) 2Q0.800 mg PO Qd
plllJl!neCld !NTN) 250-500 mg PO btd
febuxostat (Ulo1ic) 40-80 mg PO qd
peglOtrease ll(rystexxal 8 mg 1Vq2wfc
l.s4ofls. Nonsieroodal ilfltunftammatory drugs. TNT, no Uade name. PO. orally
DISEASES INVOLVING MUSCLES
When the central nervous system neuromuscular junc-
tion hJs interruptions in normal transmission of nerve
stimuli, skeletal muscl.- 'Pa,ms and mu,clc spasticlty
occur.
S~tlecal muscle spasms cause pain with a decreased
it>'l'I of funetioning \.lost muscle spasms are caused
by loc,11 injury, but others may result from mineral
deficiencies or diseases that cause seizures. Each spasm
must be treated according to its cause. Skeletal mu,dc
injuries are usually self limiting and arc treated with
rtst physicil therapy, and possibly antiinflammatory
mnlicJt1ons. Centrally .icting skeletal muscle relaxants
art used for spasms that do not respond quickly
to other therapy. but these agent> .He not always
effective.
The exaet way central ly acting skeletal muscle relax-
ants such as carisoprlJilol (Soma), rnrlhocarbamol
(Robuin), and tiurnidinr (Zanaflex), work is not com -
pletely understood. l11cy are used to treat locali1cd
spasms resulting from muscle injury by decreasi ng local
pain and tenderness, increasing range of motion, and
causing sedation. No studi.s have shown that o ne nwdi
cation is better than o thers or whether these muscle
rtl.lll.1nts are more effccti\'e than NSAI Os .ind o ther anal
ge.1r .1ntiinOammatory agents. Choice of a medication
is usually determined by physicia n's preference and
patient response to medication.
Oinupam (Valium) and baclofen (1ioresal) are the
only medications that .uc effective .1s central muscle
rdAUntS and for muscle sp.ISlici ty caused by neuromus
rular d150rders (Table 2 3 4 ).
CHAPTER 23 Musculoskeletal System Disorders 41 3
Gout None noted
Anticoag1dams
1ndometllaan am Oll!ef
NSAIOS. aspirin ood other
sahcylates, heparin
Hyperuricemia azathioprine, mercaptOlllJnne,
or theophyllme
Chroruc gout None noted
Skeletal mu'1Cle relaxants cause centra neMJUS system
depression. so hazardous act1v1t1es such as drMng should be
avoided until \he patient can evaluate the effects of the
medication.
2. Effects of opio1ds a00 other analgesics are 1ntens1fied by
skeletal muscle relaxants
3 Alcollol should be avoided IMlen ta<mg sketet.1I muscle
relaxants because of syner91st1c actions
~fetal muscle relaxants give rehef for muscle 1n1urres. but
a side effect is depression of the central nervous system.
Skeletal muscle relaxants are chosen according to physi-
cian's preference and patient response. as effectiveness of
drugs seems to be the same
Oiazepam l\lahum) and baclofen flroresall are the only cen-
trnlly ac11ng muscle relaxants useful Wl1h spast1t1ty from
neuromusC1Jlar diseases and other muscular CQnd111ons stM:h
as localized muscle spasms
Diseases with Muscle Spasticity
Musde spasticity is caused by muscle stimulation from
either the spinal cord or the bmin in patients with
central nervous system injuries or st rokes, as ,..,ell as in
diseases such as multiple sclerosis and cerebral palsy.
Centrally acting and direct-acting muscle relaxants,
accompanied by physical therapy, are the drugs of choice
 414 SECTION V Med1ca11ons Related 10 Body System::;
s _ _ _ _ _ _ _ __

TABLE Z3 4 MEDICATIONS USED TO TREAT MUSCLE DISORDERS AND MISCELLANEOUS DISORDERS

CENTRAUY ACTING Muscle spasms aod muscle Other CNS depi essar11:;
MUSCl RELAXANTS spas11cuy and MAOls
bacloren (lKl<esal) tS-20 mg PO lid
cansoprodol IS-Oma) 350 mg PO 11d-qhs
chloooxarone (Paraflex. 2505001119 PO lidqrd
Parafon Forte. Remular-SJ
cyclollenzaprme fFlexeril) 10 mg PO 11d
d1azepam !Valium, Ze1ran) 2 10 mg PO, IM, IV May also be used as a
peripheral muscle relaxanl
metaxalone fSketaxin) 800 mg PO 11d q1d
melhocart>amol (Robaxin) 1CXXJ mg PO q1d
11zanid1ne flanaflexl 4-6 mg PO bod lid CNS dep.-essants.
phenytoin, alaJhol.
ant1hypertensrves
01phenadt1ne fNOlffex) 60 mg IM qt2h. 100 mg PO btd
dan1rolene (OBntnum) 25-100 mg PO. IV q1d

CHOLINESTERASE INHIBITORS
ambenonium (Mytelase) 5-25 mg PO 11d-q1d Myaslhenia grav1s
neost1gmine (Prostigmm) 150 mg PO m divided doses
pyndosligmine (Mestinonl 600 mg PO daily in divded
doses. i mg IM, IV q2-3h
ER tabs 180!>40 mg PO qd bid

MISCELLANEOUS MEDICATIONS
mdnac1pran iSallO!fa) 50-100 mg PO bid fibromyalgia SNRls and SSRls. cloMme

Mior Side EH.ctr constrpaoon. hot flashes. hyperhidros1s. 11on1111ng. palpitanons. increased hean raie. dry moulh, hypenenslllfl.
suicKlal tendencies. increased depresst00

CNS. central fll!MJUS system; ER. mended - JM 10UamUSQJlatty: fV. IOOa.eoously. MAO/, monoom1ne ox1dase mh1bttor: PO. 0tally; SNR1. "'""""'
noreponephMereuptail! 1nt.bltor: SSRl select1'4 serotonin reuptake 1nh1btt0t.

ror relier or muscle spastidry. Di1iup11m (V.1 lium} and

d11111role11e {Dantrium) arc drugs of choice .is periphera l
or direct-acting skeletal muscle relaxants (see Table 1. For evaluauon of drug offecllveness as treatment progresses.
23-4 ). patients taking med1cat1ons for myasthenia gravis shout!
Myasthenia gr;wts, d1aracteri1ed by skeleta l muscle record 11me medications are taken and when signs and SVITI!'
weakness and fatigue. is a progressive. inrurabfe auto- toms recur after med1ca11on administration.
immune disease caused by loss or acetylcholine recep- 2. Cholinesterase 1nh1b1t01 dosage !or myastherua gm s ~
tors that block spinal cord nerve stimulation to prevent vanabfe and hfcloog Paucnts must be taugll1 10 real!JllZE
muscles rrom 0\1'rresponding to s11muli. Cholinesterase- the need !or more OI less medicallon and 10 ad~ dosa;a
inhibiting agents such as neostigmin~ (Prosligmine) as needed
and pyrido.ftigmine {Mestinon) block cholinesterase
and allow aceiylcholine to accumulate, increasing
muscle strength and function. Dosages or these
medications vary greatly based on disea>e severity
(see Table 23-4).

- .
Spastocrty 1s treated wrth four medrcatrons badofen (Liore-
sall. drazepam (Vahuml. tizanidine (Zanaftexl. or dantrolene
(Oantnuml
Myasthenia gravis is treated with cholinesterase inhibitors
10 increase muscle strength.
fibromyalgia
n bromyilgi is a painful, d ebilitating ~-yndrorne that
causes chronic pain in muscles and sort tissues surrou nd-
ingjoirus. Symptoms include aching of muscles th rough-
out the body, stiffness, fa1igue, d isturbed s leep,
depression, and specific tender points tliat are indicative
ortht syndrome Excessive stimu lation by bright lights,
odors. and loud noises makes symptoms worse Trea1-
mtnl includes NSAIDs (see Table 23-2), analgesics such
u ptrtabalin {Lyrica), and physical therapy.
SUMMARY
The musculoskeletal system is composed o f two d istinc1
S)1tems that are o ften disc1.1ssed together because of their
interdependency, which allows the body to remain
upright and provides mobility. Daily wear and tear on
that systems takes its toll, and disease processes such as
rnhrius and muscle injuries become more prevalem
wrth aging. Also, softening and d ecrease in bone rna..s
(osteoporosis) may occur, especially in postmenopausal
women. 'lhe 1rea1 ment of ostcoporosi~ centers on increas
ing bone mass. Bisphosphonatcs arc drugs speci fic fo r
0$tCOporosis. For therapy to be successful, vitamin 0 a nd
calcium must also be present .
ITICAL THINKING EXERCISES
Scenario
Mr Quan has been diagnosed with osteoarthritis and has been taking aspinn, but he belleves there
must be a better product for his condition and the pain.
1 What do you tell him about aspirin the rapy for osteoarthritis?
2 Mr Quan returns to the office 2 months later complainrng of ringing in his ears and stomach pain.
What suspicions come to mrnd?
3 What suggestions can you grve Mr. Quan to reheve the stomach discomfons caused by the NSAID
now prescribed?
4 If he wants to take asp111n now that the ringrng has stopped, what type of aspmn would you expect
the phys1c1an to suggest?
CHAPTER 23 Musculoskeletal System Otsorders 41 5
Pam, a common symp1om of all musculoskeletal con-
duions. 1s treated on a shon-term b.1sis for acute condi
tions o r on a long-term basis for the person witb chronic
lifelong anhrilic condilions N!)AIDs and DMARDs are
used to ireat anhriticconditions NSAIDs maybe changed
based on patiem tolerance. DMARDs are more toxic and
ar~ used as rheumatoid symptoms increase, although
some therapeutic protocols suggest using these medica-
1lo ns early in tbe disease process 10 pre\oent defomlities
o f jo ints. A new group of drug~ n N inhibitors. are used
for moderate 10 se\'ere rheumatoid anhritis by blocking
1he immune response to prewm inOammatory responses
in jo ints. The natural OTC supplements gJucosamine
and chondroilin are used for osteoarthritis.
Cout ls a painful joim inOamma1orycondition caused
by hyperuricemia. Cokhicine is ;pecific for ac1.11e gou 1
altacks; o ther medications may be given long 1erm 10
decrease uric acid production All antigout medica1ions
1cnd lo cause Cl disuess. 11w firs1 biological agen1 10
1reat chronic gout is peglo1icase.
Skeletal muscle spasms and spasticity may occur from
muscle injury or from such diseases as multiple sclerosis.
strokes, o r cerebral palsy These conditions may be
ireated wilh centrally acting or peripherally acting muscle
relaxants, which 1end to decrease pain and tenderness
and increase range of motion. Patients taking muscle
relaxants should be warned ng.1inst engaging in hazard
ous activities because of possible central nervous sys1ern
depression.
Myasthenia gravis, a progressive. incurable disease
related to the diminished release of acetylcholine or the
exces>h'e release of cholines1ernse. is treated with neuro-
muscular blocking agents or cholines1erase inhibitors to
increase muscle strength and reduce muscle Oaccidi1y.
Dosage of these dno~ varies greatly and depends on level
or 1he disease
l'ibromyalgia, a painful disease that causes lethargy
a11d fatigue, is treaied with physical 1herapy, NSAIDs, and
ana lgesics such as preg.1balin.
416 SECTION V Medications Related to Body Systems
r
DRUG CALCULATIONS
Order daamethasone 6 mg IM 2. Order: indomethaci n 50 mg
Available mediation Available medicauo n

--- -
IJ(lAMllHAiDll;t
l601UM l"MOS....aTf

rt111#1' 1r l
r~t H:; i, .-.
-= lndocln9 25 mg
BL
LOT
11P1,fiii.' nf I
w:..:----.:; iit11'1I !ni1.i:1H1
EXP

Dose to be given: - - - - - - - - - - -
25 VlllS =
. . 100

Cafl!U=-* ~
.r--.....,

Dose 10 be given: - - - -- - - -- --
Show the amouni on the syringe below.

II 111il1111!1111h111l1111I

REVIEW QUESTIONS
I What are the specific preferred druwi for osteoporosis? Gouty arthritis! - - - - - - - - -- - -- - -

2. What are the three typeS of medications used 10 treat arthritic symptoms? Which are usually used first? Which m
fast acting! Which are the slowest' - - -- - - - -- -- - -- - - - - -- - - - - - -- -

3. What are some of the side errec1s of.1spiri 11 or sa licylate therapy ? - - -- - - - -- - - -- - -- -

4. Why is it safer to use steroid prepa rations imraanicularly than systemically! - - - - - - -- - -- -

S. I low do immunosuppressan~ work in the 1rca1men1 of arthritis? What arc their dangers? - - - - - -- -

6. How do gold preparations have therapeutic effect in anhritis therapy! - - - - - - - -- - - - - --

 CHAPTER 23 Musculoskeletal System Disorders 417

i Why would a medication for hyperuricemia be imponam in the treatment or gout! - - - -- -- -- -

8 What symptoms do skeletal muscle relaxants relit?\e? - - - - -- - -- - - -- - -- -- - -

Gastrointestinal System Disorders

After studymg this chapter. you should be capable of doing the followmg:
Describing how medications move through the
gastro1ntest1nal !GU tract to be absorbed for the
body's use
Discussing med1cat1ons used for prophylaxis m
mouth and tooth disorders and as therapeutics for
mouth diseases.
Explaining actions of medications used for
stomach and gallbladder conditions.
Describing agents used for treatment of hepatitis
Band C.
Describing acuons of pancreatic enzymes.
anuflatulents, ant1d1arrheals, carmmauves,
cathartics. and laxatives.
Describing how ant1mflammatory agents are used
with large bowel conditions
Discussing preparations used for anorectal
disorders.
Explaining proper choice and use of medications
for intestinal parasites. including the needed
prophylaxis to prevent recurrence.
Discussing drugs used for appe tite suppression
and their side effects.
Providing patient education for compliance with
medications used to treat diseases and conditions
of the gastrointestinal system.

Kim is f/ymg to Europe m 2 weeks. She has had motion sickness on previous Blf trips and does nor
want robe nauseared on rhis long f/1ghr. She asks Dr. Merry if there is a medication she can take to
prevent nausea
What medications could Dr Merry prescribe?
Can Kim expect these drugs to make her sleepy?
Are all these medications taken by mouth. or are other methods available? (Do not consider miections I

Acid rebound Antispasmodics Effervescence Masticate

Adsorbent Antiviral Emesis Palliative
Anorectal Astringent Expectorate Peristalsis
Anthelmintics Caries Gastroesophageal Proklnetic agent
Anticholinergics Carminative reflux disease Proton pump
Antidiarrheal Cathartics (GERO) Regurgitation
Anti emetic Cholelithiasis Gingivitis Stom atltis
Antiflatulent Defecation Halitosis U lcer
Antisecretory agent Dentifrice Laxative Viscosity
Antiseptic Diaphoresis M agaldrate

418
 - - -CHAPTER
- 24 Gastrointestinal System Disorders 419

EASY WORKING KNOWLEDGE OF INOICATIONS AND SIDE EFFECTS

c.nion Symptoms of Gastrointestinal Disorders
UXllNIS
..:ss of appet te ard weight loss Elecuolyte imbalances
~lpa1n
Habttuati0'1
\ausea and ...or111t1ng
CJ!ari98 1n bowel habits (diarrhea. constipation) Othtr Gasrromres&nal Medicaoons
flatulence Headache. d1wness. confusion. Vl!rtigo, d1owsiness
Blood 01 mucus in feces Rash
fever Abdominal pain or cramping
Hea~burn. md1gest1on. difficulty swallowing D1a1rhea or const1pat1on
Oiphor.d Blurred v1s1on
Ory mouth
C4mmon Side Effects of Gastrointestinal Medications
Antwds
Coost1pat1011 01 diarrhea
Eiee:rolyte imbalances

EASY WORKING KNOWLEDGE OF ORUGS USEO FOR GASTROINTESTINAL CDNOITJONS

Oral pieparauons
Mouthwashes. gargles Yes Yes Antiseptic and anesthetic
Fluoride preparations Yes Yes fluoridating agents
O!al ant1fungals Yes No B. C Oropharyngeal cand1d1as1s
Sa""' substitutes No Yes Replace sahvary secretions
Oral antiviral agents Yes Yes B.C Hetpes Stmplex 10fect1ons
O!al topaf anesthetics Yes Yes c Mooth 1es1ons and 11ntat1ons
t.mactds aroJ related drugs Yes Yes B (suetalfate). C Reduce gastnc acids
Aitt1ulcef and GERO agents
Ant1b1oucs Yes No B Treat Helicobacter py/011
Ant1chohnerg1c egents Yes No c Treat ulcers by reducing secretions
H,receptor antagonists Yes Yes B.C Treat ulcers and GERO by blocking
histamine
Proton or gas111c pump inhibitors Yes Yes B,C Inhibit gastric secretions and protect
gastric mucosa
Prostaglandin analogues Yes No x Inhibit gastric secreltons and protect
gastric mucosa
AntispasmodH:S Yes No B.C Reduce gastnc spasm and slow gasuic
motility
l'tol:onetc agents Yes No c GI stimulant
liepa~llS B and C agents Yes No c Treat hepa11t1s Band C
Pancrtatic eruymes Yes No c Pancreatic enzyme replacement
Ga'lstone solubtlt11ng agents Yes No B (ursod1oll Dissolve gallsl1llltlS
Ant1eme11cs Yes Yes B.C Stop Ylll11 iting
Con11nuN
Gffjf). Gastroesophagcat rcftux disease GI, gastro1ntes11nal
420 SECTION V Med1cat1ons Related to Body System.:_s________

~ASY WORKING KNOWLEDGE OF DRUGS USED FOR GASTROINTESTINAL CONDITIONS- cont'd

PREGNANCY
MAJOR INDICATIONS
DRUG ClASS PRESCRIPTION OTC CATEGORY

Agents lor large 1nres11nes

Yes c !Wlief of GI gas
Ant1ftatolents No
Yes C, X(castor 011) Relief of constipation and 1n
Laxauves. catllamcs Yes
preparation for gastric diagnost~
testing
.An11d1arrheals Yes Yes B,C, D Relieve symptoms of diarrhea
(Pepto-B1smol)
No B.C Inflammatory and irritative colon
GI ant11nflammatones Yes
disorders
.Anocectal ptepa1a11ons Yes Yes c Rectal fissures and hemorrhoids
.Ant11nfect1ves. anthelmmttes Yes Yes c Intestinal parasites
Ano<exiants Yes Yes B.C. X Appetite suppression and we9>t kis1

ome medications discussed in this chapter are

S easily recognized over-the-counter (OTC) drugs

used daily for such common disorders as gastritis,
indigestion, and constipation. M.lll)' drug1> relieve symp- Mouth
(oral cavily) &--- l ---Pa101id gland
toms rather than contro l o r cure g.1s1rointcstinal (C l) r---+..--Pllarynx
tract d iseases or disorders. These same medications
may cause electrolyte imbalances when absorbed Subtingual gland
systemically.

GASTROINTESTINAL SYSTEM
AND HOW DRUGS ACT

The process or convening food into chemical substances

that can be used by the body. primary digestion, begins Gallbladder
with intake oflarge rood partides to be chewed {or mas-
Llcated} then broken down by saliva in the mouth to
complex molecules that can be absorbed and used by the
body. Once swallowed, tl1e bolus of food mixes witl1
enzymes and other fluids fro m the gas1ric mucosa 10 be
n,={,,lL-1-ReClum
funher bro ken down and diges1ed by churning action
into a semisolid mixture called chyme. Peristalsis moves ""---+Anus
chyme tluough the stomach toward tile pyloric sphinc-
1er. If the mixture passes th rough tl1e stomach too slowly, figure 24-1 The <119estive system
the rate at which nutrients are digested and absorbed is
diminished; ir the mixture passes too rapidly, gastric
juices are not allowed to mix and the food's absorbabil-
ity may be decreased. Passage of chrrne into Ll1e small electrolytes and excess Ouids 10 maintain Ouid bilance
intestine is the first step in nutlrienl absorption by villi. Remaining residue becomes fecal material and is puslMd
Accessory organs- gaJJbladder, liver, and pancreas-add to the rectum for expulsion from the body. The digestion
secretions of mucus and enzymes to funhcr aid in the process is ,olso import.mt for breakdown and absorption
breakdown or rood substances for use. Residue from of medications (ligure 24- 1).
digest io n passes into the large in1estine. where digest ion Many drugs for Cl d isorders work in three wa)1 on
does not continue; rather. the large i111cs1i ne absorbs muscula r tissue and glandular tissue either directly or

--" the inRuence of the .autonomi' nnrvou
th,._. ~ s system:
(1) 1ncreaseordecrease funcuon of the Ct traa by chang-
ing muscl~ tone. and change secretions of or into the Ct
uact. (2) increase or decrease emptying time as food
p.tSSeS through the stomach, or cha nge the rate of peri-
stalsis; or (3) ~ep~ace enzyme deficiencies. T hro ugh these
llCllons, medtcauons cou nteract hypcracidity or flatu-
lence. indu~ or prevent vomiting, a nd help ihe Cl tract
diagi_iose disorders (e.g.. agents used in radiology). Oral
med1cauons and age.nts, 111dudmg anesthetics, are also
t.old for the GI tract. including drugs for parasites and
vmb1olics.
DRUGS USED IN THE MOUTH
Good oral hygiene is essential in maintain ing homeosrn-
si~ Trauma. nutritiona l dcticicncies. chemotherapy,
inkctions, and dental disorders may cause mouth disor-
dtn. and sy:.temic diseases may cause 'tomalilis. Symp-
toms such as blistering of the tongue and mucous
mrnibr.ines of the mouth and gums, as well as mouth
p.iin and inRammation, may occur Most systemic medi-
ations generally have little oral efTect, but systemic
<lru;i may be administered huccally or through oral
av11y mucous membranes.
Agents Used for Mouth Conditions
MO't oral agents are 01'C prepa1ations used to relieve
sort gums and remove plaque (e.g .. mou1hwashes), lip
llms. and agenis 10 trea11oothaches. glngh Ills, or gum
1m1.11ioo from dental appliance irri1ation. These prod-
uct> should be used only as adjunaive care to proper
brushing and flossing of teeth.
The American Dental A<sociation classifies mouth
rinses as follows:
I Anesthetics, such as C hlorascptic. or antibacterials,
such as Peridex, 10 be used twice a day.
2. Cosme1ics, such as Lavoris and &ope. used as oflen
as needed to mask mou1h odors
3 nuorides. such as Reach wilh fluoride. used daily
10 prevent c~riei>.
4 Oxygena1ing agents, such as Permax and Peroxyl,
uwd to loosen debris in inaccessible mouth areas.
5 Phenolic compounds. such as Listerine, are anti-
b;1c1eri;1 I, and p rebrushing rin;es, such as Plax, aid
in the removal of plaque.
Moutliwrulll's, s uch as those containing a lcol1ol
(C'.cpacol and Llstermin1 ), are u<cd ror h.tllto~is and as
gargles for sore throa1s. Cum and mouth diseases. the
most common cause of halitosis, cannot be treated with
mouthwashes Sore throats ar~ usually caused by bacte-
nal or viral infections, and g.,rgling with mouthwash
cannot reach the infection site, hich most often is deep
in the throat.
CHAPTER 24 Gastromtes1mal System Disorders 421
!ill CLINICAL TIP
Mouthwashes have high alalhol cootent, up to 27'J.. and should
not be used by young children, who tend 10 swallow these products
Alcoliol-<:onta1ning mou!hwashes should not be used by persons
taking disu lfiram for alcoholism.
1opirnl anC>t!U?til: agent< may be used for 1emporary
relief of oral lesions while proper treatment for a sys-
1cm1c disease or condition becomes effeah-e Adults who
haw gum irritation caused by dental appliances and
1cethmg infants may u"' these phmal or topical anes-
thetic preparations for relief. Topical anesthetics come in
gels, ointments. aerosol sprays. and rinses. Lozenges,
pas1cs, and film-forming gels are fom1ula1ed for pro-
longed pain relief. Ol'C lo1enges ,md sprays such as
be1w.cxaine-containing anesthetics (cg.. Chloraseptic o r
Spec-T) may also be used for om l pain and sore throats.
llytlrogen perorlde, an oxygena1ing agem and a weak
antibanerial agenl, works by errennct'Dtt to loosen
tis.sue debris and reduce baeteria orally. Rinses such as
OxyCel are a\'ailable for oral irritations, and a gel
(Peroxyl), available for minor mouth irritation, is
applied. allowed to work. and 1hen expectorated ar1er
use. These agents should 1101 be swallowed.
l'/11ori1/e prod11e1s are av.1il,tblc in the fonn of mou1h-
wa;h cs, 1001hpasw. tablets, nd solutions to prevcm
denial Clries by hardening 1001h enamel Mouthwashes
should be used fora I-minute gargle daily after brushing
1eeth. Nothing should be taken by mouth for30 minutes
after use. Fluoride produm, as 1ablets and drops, are
used by children for the prevention of dental caries in
areas where waler is not adequa1ely fluorinated.
Dentifrices, or 1oothpastes. are mild abrasives wi1h a
foaming agent and Ravorin~ in paste. gel, or powder
form, to clean teeth and reduce most plaque buildup
with daily use. Many types of 1001 hpaste have fluoride
added for da ily fluorine contact. Some dentifrices for
hypersensitive teeth con1ain potassium nitrate as a
desensiti7ing ingredient to reduce the pain associated
with heat or cold.
\\fl111ming agents con1.1ining wrbamlde peroxith are
O'I C produas used 10 bleach 1eeth discolored bj tobacco,
cofTee, tea, alcohol, and the like. These agents should be
used according to manufacturers' direaions to prevent
permanent tooth damage.
Om/ antif1111gals (see Chapter 17) such as clotrimazole
(Mycclex lo7.enges) and ketoco1rnwle (Nizoral) are used
fo r oropharyngeal candidiasis (1hn.ish). Lozenges should
be dissolved, not chewed, 10 ensure coverage of 1he
afTooed area during a 15- to 30-minute period. These
medications bind to the oral mucosa and remain for
therapeutic action for up 10 3 hours.
Sttlmt replacemenu are natural therapeutics to be used
when saliva is absent or secretions are minimal. Wa1er is
422 SECTION V Med1ca11ons Related to B.:.od:.ly:.. :S:.y.:.
frequently used but is a poor subst11u1e bause 11 lacks
ions and lubricants needed Anificial sahva products
haw chemical and physical properues that are similar 10
those of salJ\"a and are cellulose dmvau~ with llaV'Or-
ing agents and an1jbacterials included to mcrea5e hcos-
lly. Mos1 saliva products come m sprays. although
loanges are available. Agents must be administered
repeatedly throughou1 the day 10 be prophylactically
effec1ive; they may also be used 1herapeutkally in chron-
ic.illy ill persons who need mou1h mois1ure.
Antlvlrab may be prescribed for either systemic or
loral use for oral viral infections. Trea1111e11t is palllatlve
for herpes zoster and herpes simplex infections, varirella,
and I IJV lesions. One 1opical medica1ion, docosat1ol
{Abreva), has been appro-ed by 1he IOod and Drug
Adrninisuation (FDA) for OTC US<' Ac)dovlr (Zovirax)
1s used for symptomatic rehef of oral mucosa I shedding.
local pain. and encrusted lesions caused by these dis-
e;ises (see Chapter 17). To prewnt d1se.ase spread, care
should be taken 10 aV'Oid contact wnh lesions while 11ea1-
111en1 is 1n progress (Table 24 I)
I
Local 1op1cal anesthetics are only iemporary reltaf agents for
1001haches. lesions from 1llfin1ng dcniures. or disease. Care
should be taken with oral topical anes1hc11cs to prevent
m1urv to local ussues because of loss of sensation Patients
using topteal oial anesthetics should not eat or dnnk while
rnoutll and throat are desensJ111ed
2 If stored m a glass comaner. ftuonde drops may cause
etdtmg of glass
3 FolloY;ing use of ftuonde p.-oductS. lood and drink should be
aYOtded lor 30 minutes
4 Denufnces. ff used once a day, should be used at night to
reduce buildup of plaque Oent1fr1ces w'th ftuonde added are
helplul mcaries prevention
5 Directions on whitening agents should be followed to prevent
toollt damage
; ' :
Mariy oral preparauons are OTC m00icat1ons used to relieve
mouth lesions caused b'( local or sys1emic diseases Good
0<al hyg- 1s essential to preven1 Ola lesions and maintain
homeostasis.
Fluoride products are used 1n areas wtiere water ftuondabon
1s not adequate 10 protect teeth
! st:e::
: m.:.
s_______ ----------~--
DRUGS USED FOR GASTRIC
CONDITIONS
As food enters the stomach, it is mixed with hydroctiio.;..
acid and the e1t1ymes pepsin, rennin, aod Ii~ iii
the stomach's ,1cidic environment. Sometimes !ht Jod
becomes so strong 1ha1 it actually eats away the s1om;icb
wall. Stress and anxiety seem 10 increase the SIOm;ich
secre1ions, causing ulcers and sloughing of gasuiclilSUt
Ami ulcer medications fall in10 five djstinct categon11
antacids, mucosal protectal1ls (forming barriers 1o
ulcers), a n1 ibio1 ics. an1 icholi nergic ( anUsec"tI)')
agents, and ;rntl>p.tMnodlcs 10 reduc~ ~ai.n and pJO.
gression of gastric ulcers. However. anub1oucs 1ogeihef
with antisecre1ory agents and proton pump inhibi1or1
(PPls) work 10 eradicate the microorganism Htlir<>Natr
fT)Wri while also reestablishing an intaa stomach lini,.
through neutrali..a1ion of hydrochloric acid.
Because of ready availability, OTC medicatJom.
induding antisecre1ory medica1ions. are often tht fini.
used therapeu1ic agents for gastric conditions. That
agents relieve the burning sensation (heanbum) 1h.i1
occurs with acid renux into the esophagus. lf1herapy ~
not staried during 1.he early stages of g;istric discomfon,
peptic ulcers may occur, making trea1men1 mort
d ifficu lt.
Anracids, alkal ine compounds used 10 neutrnli1~
hydrochloric acid, are ma insrnys of peptic ulcer 1herapy
Newer medica1 ions are available as prophylaxis for
siress-induced ulcers and 10 relieve symptoms of gastro-
esophageal r4'0ux di"'JW {GliRO} by oeull'3lil1ng
acid to protect the intestinal mucosa. With the excq>non
of sodium bicarbot1ate (baking soda), these aget>IS m
poorly absorbed and do not alter systemic pH when Ultd
as directed. I lowcver, 0\-eruse of antacids may actwlly
interfere with proper digestion. To be most efftttnt.
antacids should be 1aken on a regular basis, no1 just IO
relieve pain when discomfor1 occurs; howevet etTtttivt-
ness is limited by 1he shor1 duration of action, approxi
ma1ely 30 minu tes on an empty stomach. Food aas as
a buffer for antacids, coniinuing ac1ivi1y for 2 10 3 homs.
Chronic use of a111acids produces acid rebound, 1hu1
neutra lizing the eifec1s of th~ d rug. Usual dosage isse-tn
times a day: before mea ls. I to 2 hours after meals. ~nd
a1 bedtime. Because these medications are inconvenim1
10 take so frequenlly and 1end 10 have an unpltasan1
taste, adminis1ra1ion usually occurs with the onset of
pain rather than on a dos..1ge schedule. Antacids come 1n
liquids (which must be placed back into a suspmsioe
before adminis1ra1ion) and che\vable tablets (.,fudl
should be followed by a glass of vater after chtl-1~
thoroughly).
Families of amacids are dassified by chemical formu-
la1ion as aluminum, m,1gnesium, calcium, and sodium
compounds. Each family has a different effect on bowe~
-

Mouth lesions and Usually none

1mtauons
tenZocame
(Humcaine aerosol) 1 spray topically
(Oraiel. Num-Zot gel) Apply gel topically
tCepacol lozengesJ 01ssotve I lozenge PO q2h
fChlaaseptlC spray) I Sj)lay tOptcally
IBefwdenl. Anbesol ointment) Apply Ointment topically
1
<kleame (Xyloca111e ointment or spray) Apply or Sj)lay topically

ORAL AHTISEPTICS Ant1seplJC, anesthelJC,

canes preve11tion
~'4.olhwa$hes' leg. Cepacol, Swish as directed or des11ed
tisteme. Scope. Lavor1s)
rogen peroxide (Paramax, Pendex1 Apply or swish bid Relieves mouth 1rmation Usually none
as mouthwash) and removes debris
(Peroxyl' mouthwash or gell

FLUORIDE PREPARATIONS' Prevent dental canes Usually none

Auora-day tablets (luride) 5-10 ml solution PO apply
(lheraFlur. Gel Kam) topically qd

ANTIFUNGALS Orophal)'Ogeal calldidiasis Nooe indicated

clotrimazole (Mycelex lozenges. Dissolve 10 mg PO q1d
uochesl
ketoconazole 200400 mg PO qd astemizole, terfenadine
nystatin (Mycostatin. Nilstal) None 1nd1cated
lozflf'lglls/troches Dissolve 1 or 2
lozenges PO qid
suspension 4 ml suspension. swish and
swallow

ORAL ANTIVIRALS Herpes lesions and vancella Usua ly none

lesions of mouth
ao:ytlovlr {Zov1rax')
tablet 200mg P0q4h
Odllll81t Apply topically
percdovir tllenavir1) Apply toptcally
ltmsanol tAbreva" I Apply topically

SALIVA SUBSITTUTES Replace saliva Nooe

Selected saliva substitutes NQrle
&11e11a1ner's Secret, Spray topically
Salovan, Sahx. Lozenges topically
Mo1Stir. Swabsucks) Swabs
Chahnerg1c Agomst
cl!Vlmehne' (Evoxac) 30 mg PO t1d Increases saliva output None

PO, Ora ly
'Overlhe-counter medication
'l'rescnp11on med1ca1100
Note Ap1escnption 1s rcqu11ed for all 01al an1tlungnls exccpl docosanol.
424 SECTION V Med1cauons Related to Body Systems
TABLE 74 7 CAUSATIVE PROPERTIES OF ANTACID
COMPOUNOS
ANTACID CONSTIPATION OIARRHEA
Alum num compounds Yes No
Magnesium compounds No Yes
Calcium compounds Yes No
Sodium compounds' No No
' Should not be used roounely because rou11oe use changes systemic pH
of body
and syi.1emic pH . Sodium bicarbonate. a household
chemical used indiscriminately as an amadd. is very
dangerous because of systemic absorption. changing the
entire body's add-base balance. Calcium preparations.
ouch as Tums. are frequently used for gastric symptoms
and as calcium supplements for pm-em ion of bone mass
loss with osteoporosis. Aluminum and magnesium salts
are mixed to form magaldrace compounds. used to
prevent diarrhea and constipation occurring with use of
the chemical compounds alone. Added ingredients
include simerhicone (an antlflatulent), mineral oil, sac-
ch.uin, o r sorbitol (an osmotic laxative) p;1ble 24-2).
Other uses of antacids include replnccmen L therapy
for some needed minern ls. Aluminum compounds may
be used for hyperphosphatemia. Magnesium deficiency
from alcoholism and other medical conditions may be
treated with magnesi11m hydro.ritk
111us antacids must be chosen with c-are to suit each
patienc's needs and should not be t.1ken for prolonged
periods of time. The indication for contrnucd use is relief
of acute symptoms of GERO, heanburn, and hyperactiv-
ity (Table 24-3).
Alcohol consumptron exacerbates ulcer symptoms Certain
foods such as colas, acid juices. coffee, chocolate. and spices
aggravate stomach and gallbladder cond1t1ons.
2 Chewable antacids should be taken seven t11nes a day and
followed by a glass of water 01 milk to 1mp1ove absorption.
3 Liquid suspens1oos need shaking before lldm1111strallon and
should not be followed by any hQurds that will dilute the
med1catmn.
4 Antacids and h1starnme (H 1-recep!Of blockl!Is should be
taken at least an hoof apart with antaOds taken first
S Antacids shoold nm be taken rou1rnety with other medica-
llons because the stomach's acrd content may be necessary
for absorpuon of sorne drugs
6 Pauents should be aware that dark. tarry stools and cottee-
ground" vooutus are signs of 9astrorntes11nal bleeding
BOX l4-1 LIFESTYLE TIPS TO IMPROVE
GASTROINTESTINAL CONOITIONS
Cena n foods will increase the seaehons ol stOIT'a:h aads.
among them tomato. Ofange. and grapefruit JUJCeS. a1cato.
colas. coffee. lried 'tally foods. chocolate. peppenruni; mi
sprees
Diet 11sell plays only a minor role m ulcer uealment, eating fi"'
or six small meals wrll be helpful in treatment by redu. '1lg
nuctuations 1n stomach acidity to lacih1a1e healing
Oo not overeat Watch weight. Weight gain contributes 10
stomach problems
Avoid eaung w1th1n 2 hours of bedtime.
Do not smoke.
Elevate head of bed 6 to 8 inches so gravity helps in emptylllg
stomach
..
Because antacids interfere wrth absoiption of nmy nela-
tions, especially ant1b1ot1cs, other medications should no1 be
given with antacids
The ideal time to give antacids is 2 hours aftlll meals v.ten
acid rebound occurs
Other Medications for Peptic Ulcers
Optimal antiulcer therapy requires drug therapy and
changes in lifestyle {Box 24-1). The goal ofulctr unt
ment should be to allC\iate symptoms, promote healing
of the ulcer, prC\ent complications, and pre.'ellt rttut
rence. H. (1)/on has been found in 85% of cases of duo-
denal ulcer diseaw and 70% of gastric ulws and "
believed to be an opponunistic infection at the uketsitt
Mucosa/ pro1ec1t111u, u~ed to protect the mucosa from
acid secretions and irritating medications, should bt
taken on an empty stomach to be effective. Sucra/fari
(Carafate), a nonsystemk complex of alum inum hydrox-
ide and su lfa ted sucrose with a loca l soothing effect
in the Cl tract, promotes healing of peptic ulcers by
adhering to the g.m1 ic ulcer, form ing a mechanical
protectant ag.1i11M hydrochloric acid and digesti1t
enzymes. llnlike antacids, no potential for altering pH
is usually seen. When used over prolonged periods al
time. sucralfate may cause deficiencies in fatsolul>fc, iu-
mins (Table 24 -4)
Histamine, (111 )-rietptor 1111rago11isu (antiseml<ll\
agents) decrease ga"ric Ou1d secretions. Gastric muc~
histamine receptors mediate secretion of gastric acid and
pepsin with ulcers and CERD. The 11,-receptor antag<>-
nrsts dtneti1li11e ('1;1ga11wt) and ranitidine (Zamac)
inh ibit interaction of 111 .11 its receptors and are ava1lablt
 ______ _ _ :C:H APTER 24 Gasuomtestinal System Disorders
: .:: 425

TABLl 74 3 ANTACIDS AND RELATED DRUGS

USUAL DOSE ROUTE

GENERIC/TRADE NAME AND FREQUENCY INDICATIONS
FDR USE DRUG INTERACTIONS
SELECTED ANTACIDS Reduce stomach acid re1racytr111es. Q1J1ntd1ne, rnorplo ne.
Sodium CampoUlldS penocdhn. pseudoephednne.
~"" botafbooate or batong Not advised. but 1ndiscnmlll8tely INH. asp nn. docurnarol, dogo.ii n.
si:lla used at home allopunncl. antochol"11!fgocs
w:ll acetarmnophen 1 packet on w.iter PO Q4h comcosteroods. Hr recep!OI
11an~ (Bromo-Seltzerl antagoosts. lhyrOld hormones.
Wltll aspinn as effeivescent 1 tab m water PO Q4h sa qlates. conicosteroods
tablets IAll<a-Seltzerl chlorpromanne

AAl8Wllll1I Compounds
allln 'IUITI h)llroiude
IAltemaGEl. Amphoiell 10-30 ml PO q36h

/Ja9nes1um Compounds
ma91es1um hydroxide 1 or 2 tablets PO q1d
1Phlllips chewable tabletsl
IM1 k of Magoosia, Maalox) 10 30 ml PO q1d
magaldrate + s1meth1cone 1030 ml PO qid
!Maalox Plus. R1opan)
magnesium +aluminium
iGaviscon.Gelus1f) 1 01 2 chowabla tabs PO qid
Calcium Compounds Also used with
prevention of
osteoporosis
calcium carbonate ITurns, 1or 2 chewable tabs PO q3-6h
Rota ds)
II,. lflst<lm1ne, /NH. 1son1az1d, PO, orally
' \1edica!JOIS .. this table are ore products
"" l.!edtcaoons under drug ontcractoons appty to the eni.re table

OTC and by prescnpuo n at different s trengths. Not
affected by food , these med oca11o ns may be take n with
meals. Well toleratt'.<I fo r sh o n -tcrm and chro nic main-
tenance therapy, antacids and I t,. rcccptor antago nists
should not be take n at the ~amc time (sec table 24-4 ).
Ill LEARNING TIP
Many antisecretory agents end 1n "dine
l'roum pump inhibirors (PPls) (also called gastric pump
inhibirors) work by inhibiting chemicals essentiI for pro
duction of hydrochloric acid. Omepr1UDle (Prilose<"),
lansoprazole (Prevacid), esonupr4ZDle (Nexium), and
rabepra:wle (AcipHex), chief medications in the dass.
are used for the shon-term treatment of benign gastric
ulcers and GERO. When used in combination with anti
biotjcs for H. pylori, these drugs promote ulcer healing
and prevent recurrence. All l'Pls are used for etive duo
denal ulcers, eroshe csophagitis, o r pathologic hyper.
secretory conditions. Prolonged use of PPls for benign
426 SECTION V Med1cat1ons Related to Body Systems -~--

PROTECTIVE BARRIERS magnesium antacids. cafferie

er f IC a1 lgl'Oqid Protect against ulcer
formation. protect antacids. calcium chante
gastnC rnocosa blockers. c1sapride.
carl>amazepine. at1d many
others

ANTISECRETORY OR Hr Reduce histamine

RECEPTOR ANTAGONISTS secreuons in stomach
Clnl"I r (l.. t l.qdtn' t 200-400 mg PO qd
HB')
famot1d ne iPepc1d Pepc1d AC') 20-<10 mg PO bid
with anliKd (Pepcid 1 0t 2 tabs PO qd
Complete)
ran111d1ne flantdc I 150-300 mg PO bid
nizat1d1ne (Ax1d 11 150-300 mg PO qd

PROTON PUMP INHIBITORS Short-term trealJllent of

ulcers and GERO; reduce
gastric acid production
and lower esophagitis
omepra1ole(Pnlosec"'I 1040 mg PO qd Same as for PPls Oral anticoagulanis. d1a1epam,
phenvtoin
lansoprazole IP1evacid') 1S.30 mg/day PO qd ketoconazole. iron salts.
amp1cill1n. d1goxin. sucralfate
rabeprazole (Ac1pHex) 20mg PO' qd
esomeprazole (Nexiumt 20-<10 mg PO' qd amp1c1lhn. clanthromycm
pamoprazo101Proton1x"J 20-40 mg PO qd No significant interactions no~
dexlansoprazole (Kapidex. 60 mg PO qd
Dex1lant)

COMBINATION PROTON PUMP INHIBITORS AND ALKAUNES

sodium blearbonate with 1100 mg/20 to 40-mg
omepraiole IZ89"1id 1 cap packet muted m
water. POqd

PROSTAGlANDIN ANALOGUE
m1SO!JfOSlol ' (Cytotecl 100-200 mcg PO q d Prfl\'elltion of NSAID magnesium amac1ds. caffeine.
induced gasmc ulcers antacids. calcium chamel
blockers. c1sapride,
carbamazep1ne. and many
others
GERO. Gastrocsopllageal reftux disease. N. intravenously: IM. intramuscular. NSAID. nonstero1dal antiinflammatory drug, PO. orally
Prescnp11on medica11on
'Over-lhe-coun1e1 medica11on
'Must be swallowed whole
 CHAPTER 24 Gasttoonteslmal System Disorders 427

SELECTED
ANTICHOUNERGICS Peptic ulceis. spasms, Usually none
belladonna intestinal and bohary cohc
witll phenobarbital (Oonnatal) 1 or 2 tabs PO t1d-q1d
~ 0125-025 mg PO
Q4hpm
(Anaspill. L!Nb.d. levsm)
0 375 mg PO (timed
release I q12h
glyc0pvrrolate (Robinul, Robinul I2 mg PO tid/qid
Fmel
J1J11111818entyl) 10..20 mg PO q1d None llldicated
fllli Side Ellw:ts:
01wness. headache, insomnia. drowsiness. visual disturbances. changes on heart rhythm

PROKINETIC AGENT
tocloprarr1de" (Reglan) 5-10 mg PO, IV, IM GERO. also may be used alcohol
q1dac for llOl!lottng with
chemotherapy for cancer
MetOlOIV) 5- 10 mg po dissolving
tab qid ac
M1/0< Side Effects:
11' irrhea. abdoo11nal pain. headache, restlessness, drowsiness. fatigue. insomnia. headaches. dimness

disease will lead 10 a decrease in body Ouids (sec r,1ble ulcerative coli 1is, diver1iculilis, ulcers, and biliary spasm
24-4). by blocking ace1ylcholi11e al muscarinic reccp1ors. TI1ese
agents shou ld be taken 30 minuLes before meals and al

tll LEARNING TIP
Many Pf'ls end in zole
l't-oslilglandtn mwlogues, indica1cd for nons1eroidal
inumllamma1ory drug (NSAID)- onduced gastric ulct'rs.
hJ\-. as a typical ag~n1 misoprosrol (Cytotec) 10 inhibit
ga$lric secre1ions and protect agains1 irritant effects of
ml'dications. Aspirin a nd other NS1\ll)s may irrirn1e the
s1omach. Taken with food 10 suppress acid secretions
ind increase cyiopro1ooive mucu> in the Cl 1rae1, this
medication is for me with tJ1osc who Me suscep1ible 10
mfdicdtion-induced gas1ric irri1a11on h must be used
with c.tre in women of ch ildbearing age because of cat
egory X pregna ncy classifica1io 11.
Mu.1C11rinic t1nt11go11ists (anlidwllncrgics), such as
dkydomine (llcn1yl), are al ~o c.tlled a111ispnsmodics
hu.e they decreaw secreLion~ and slow peristalsis
.00 spasms thal occur with irri1ahlc bowcl syndrome.
bedtime to reduce heanbum frequency and allow healing
of irritated tissue. n.ese medications may cause visual
dismrbanc~. increaS<'d confusion in demenced patients.
and changes in hean rhy1hrn; therefore they should no1
be used by patients wi1h glaurnma, urinary Mention. o r
obmuctive bowel syndrome (see 'fable 244). Anticho-
linergics .ue also uS<'d for urinary incominence (see
Chapter 27).
Anribrotics are common therapy for II. pylori. Treal
mem includes two an1ibio1ics (10 reduce the risk of drug
resista nce), usually in combi nation wi1h bismuth salts
(Pepto-llismol) to prevent the bacteria from anacking
the s1omach wall. Amibio1ics of choice are amoricillin,
Ulraqdlne, -rronidazol (rlagyl), and clarllhromy-
dn (Biaxin) ('fable 245) (see Chaplet 17 for antibiotics
and an1ifungals). Some physicians prefer 10 add .1 PPI or
an an1isccretory agent to the regimen. Some medications
come in blister packs concain ing medications such as
bismu1h salicylate tablets, metronida7.ole tablets, and
antibiotics. for a dos.1ge of one or 1wo blisltr packs per
day for 2 wttks (see Table 24 -4) .
428 SECTION V Med1ce11ons Related to Body System..:s_ _~---- ----------~---
TABLE 74 ~ COMBINATION OF MEDICATIONS
FOR H PYLORI
SHORT TERM THERAPY DOSE
M. IC h ' :y ,, (Pepto- 1 i:-uck PO qtd
e. ..,, t I .agyl) and
t 11 ~
LONG TERM THERAPY DOSE
"""'l
"""t: ?f~<JUUI :.>mg PO bod
at!IOCtl mflrimoI 2000 mg PO bid
clarillwomvtm IBia.<ml 500 mg PO bid
a- medQroons come 11 a Pkl.1oe lha1 rs a 5"lgle dose All medica-
lJCIRS should be WI.en at Oll8 ,.,..
Proklnetk agent\, such as rr1~1ocloprarr1ide (Regla.n).
are used 10 sumulatt Cl moult 1y by lowering esophageal
~phincter prl'S\ltrC. acccleraiing g;isuic emptying a nd
movement of food through intestines. ' I hese agenis a.re
used to 1rea1symp10111s of CERD when lifestyle changes
and diet have not been effective (sec Table 244 ).
Sucralfate. a protective ba111er. should be taken on an empty
stomach 1 houo bef0<e meals and not w1lh1n 2 hours of any
other med1caton
2 Patents with peptic ulcer disease should ea1 five or six small
meals a dav 10 docreaso fluctuauon of gastric ac1d11y
J Hreceptor an1agon1s1s 01 blockers may be taken once a day
fat bedumel. 01 tw~ a day wrthout regard 10 meals.
Acid sec:ret1oos peak during sleeping hours. so Hr receptor
blockets should a ways be adm nrstl!fed at bedlfme
4 Cigarette smokng decreases tJie effects of H receptor
antagon1~u and mcreases the amoool of acid the stomach
P1oduce
Goals of peploc ulcer disease therapy are to alleviate symp-
toms. P1omole ulcer hea ng. Pll!\'ent compiocalKJflS. and
prl!\'cnt dsease process recurrente
lifestyle changes related 10 smoking alcohol and carbon-
ated 00-.erages may be required for treatment of gastro1n-
1es11nal symptoms Stress relief and d1e1ary changes are
essential 1n u1ce1 treatment
Hrrecep1or antagonists block gaswc H1 to suppress gastric
acid sec1et1on
Proton pump mh1brtors. or gastric pump mh1b1tors. 1nh1b11 H'
and K' ions, needed for production of gastnc acids
l~WUH1tS\N-
Vtral hepatitis is the most commo n li~er _di~ase, " lb
millions of Americans affected. lmmun1za11on with 11tp.
atitis 6 vaccine is the best resource for pre\'enoon o1
ht.'!>"titis B disease. Acute hepatitis last~ fo~ abou1 ,
months or less and is characterized by hver tnfl.imm~
uon and jaundice. Chronic hepa1 i1is is caused by h~
tit is B and C. llepat itis C is treated with inrnf.,..
alfa2a (Pegasys), P"glyted imnferon (pegmttrfero11~
and ,,.,ginmferon alfa2b ( Pl:G-lntio n) for 12 momk
unfonunately, ha.If of the ~pie rela pse after 1~a1m.m
is stopped. Adverse reactions include flulike sympt""1.
depression. fatigue, alo pecia, a nd Cl >)'m~t~ms lnsonw
cases. oral ribavirin (Rcbeiro l), a n an11v1ral, mJ}' bf
combi ned with parenteral (subct1ianeous) 1merfaoo
alfa for mo re inte nse trea tment.
Acute hepa titis ll is decreasing owing 10 im mun1L1.
tion with he pa1i1is B virus (II BV) vacci ne. I lowew> a.
chronic he pati1is B develops, cirrhosis, hepatitis failuie.
and hepa1ocellular carcino m,1 occur. Tre.11melll is mU<h
like that for ch ron ic hepa1ilis C wit hout the use of pegin
ierfero n alfo-2b. The medic<11io ns arc more e1Tcc1ivi:
when used with nucleosidc analogues such as lam/1111
di11e (Epivir I IBV), ntlfotrlr (1 lcpscra). nnd enterca<ir
(Baraclud e), also antivin1ls, which are administered bj
mouth. Side effects are basica lly the same as with drtJ&I
for chro nic he pa1i1is C (Table 246).
DRUGS USED AS PANCREATIC
ENZYME REPLACEMENTS
nie pancreas produces fou r main digestive enzytnt>-
lipase. amylase. chymotrypsi n, a nd uypsin- to aid m
digestion o f fats, carboh ydraics, and proteins. PancmtK
enzyme replacements must be taken with "'ti)' food
intake a nd are available in l\VO basic preparaiiotu-
pancreatin (Pancrca1in) and panCn!lipau (Cow<m.
Pancrecase MT)-from .mimal sou rces. Th( capstolt>
contain e nte ric-coa1cd microspheres and anlOIO<h to
proiect inactivatio n of the medication by gastric JUK<>
The dosage is individualized d ue 10 patient nttds ff.ablt
24-7).
DRUGS USED WITH GALLBLADDER
DISEASE
'lhe gallbladder is the o nly si1e fo r excre1ion of cho-
lesterol from the bod y. Most cholellthlasls is from
cholesterol stones alo ne that canno1 be seen on radro-
graphs, whe reas ca lcium s1ones are o bservable. When
symptoms o f cholclithiasi< ocrur. o r.1 1r.tdiopaquedn.lg)
 -----~-=-
CHA
.::..::P..:T::
ER 24 Gastrointestinal System Disorders 429

TABLE 11 6 DRUGS FOR HEPATITIS B ANO C

GENERIC NAME/ USUAL DOSE, ROUTE.

INDICATIONS
TRADE NAME ANO FREQUENCY
FOR USE DRUG INTERACTIONS
INTERFERON-LIKE DRUGS
1nterleron alfa-2b (lntron Al Varies with patient. SC Hepat1t1s B and c aminophylllne, warla11n. z1dovudone
peg1nterferon alfa2a IPegasys) 180 mcg SC once wkly Hepautos Band c lithium
111telfaron allacoo-1 llnfergen) 9 mcg SC 3></wlc Hepat1t1s C None ndcated
peginterleron alfa-2b 1 mcg/kg SC once wkly Hepattus C Same as peg1merleron allH
1PEG-1ntron)
rm.im IRebetol. Copegus) Bas00 on body weight PO Used with peg10tetfeton Other antiwa s
varies alfa foi hepat1t1s C
ANTIVITALS
1am1vudone (Ep1vir HBVI 100 mg PO qd Hepat111s B TMP-SMZ. 11dovud1ne
adefo\111 (Hepseral 10mg P0qd Hepatitis 8 Multiple ln1eract1ons. see literature
entecav1r IBaracludel Based on renal function. PO Hepautts 8 None mdicated
varies
1elbWl ne (Tyzekal 600mg PO qd Hepa11t1s 8 antMrals, HMG-coA reOOclase
1nh1bltois. penoc:1llam111e.
cyclosponne, erytlwomycin. 111acin.
oonicostero1ds. hydro.ychkJtoquone
PO orally, SC. subcumneousty; TMP-SMZ. tnmcthopnm-sulfamethoxarole

TABLE 14 1 DRUGS FOR PANCREATIC ANO GALLBLADDER DISEASE

PANCREATIC ENZVM ES antacids. oron supplements

pr eatn IPancreatml lndovodualized, PO varies
pa0".rel1pase !Creon. Pancrease, Zenpep) Individualized. PO vanes

DRUGS FOR GALLBLADDER DISEASE Dissolve gallstones

chenod1ol (Chenodal) 250 mg, PO tid Usually none
ursod1ol IAct1gatl. Urso. Urso Forte) 8-10 mg/kg. PO aluminum antacids, cholestyramine,
divided qd colestipol, 01al contracepuves.
estrogens

MojM Side Effects:

Ab!->fr of ta.te. bohary pain, dianhea. nausea. vomiting with chenodlOI
PO. orally
Nooo All of the drugs listed in this table require a presc;i1puon.

to aid in visu.1 li,dng the stones. ~uch as 'lelep.oque o r
8ilopaque may be given to the patient before radio-
guphic gallbladder studies are performed. The dose is
b.wd on patient weight. After a low-fat l?\'ening meal.
W>ltts arc taken at 5-minute intervals until all ordered
tablets haw been taken; then notlu ng including water
should be taken by mouth until the test has been
performed.
In pa tient> who are asymptomatic but have been
shown to have gallstones. medications to dissolve gall-
stones may be used. with best results occurring in women
'"ith small stones. Therapj may take as long as 2 years.
The preferred medication for reducing cholesterol in bile
is urs-Odlo/ (Actigall) be<;:iu..- it is well tolerated. Usual
prolonged treatment is one tablet in the morning and
evening. 12 hours apan (see Table 24-7).
430 SECTION V Med1cabons Releted to Body Systems

Seroro 11111 a111ago11ists are the most effecti\e dru~ ~ ~

BOX 24 2 VOMffiNG FROM CHEMOTHERAPY
Chemell ~apy May ca- <e s."""' r t ig; these
side effects mav e'll!ll be the remon wtrt patents discontinue
~tlierapy Vorrutmg may be antopa0ty ~s (oa:umng
before receipt ol anticancer drugs and triggered by memones of
previous severe nallSl!a and vom111ogl acute emestS foa:umng
shortly after chemotherapy 1s adm1mstetedl. or delayed emes1s
(occurring aday or two after chemotherapyI for emes1s p!even-
t1on. a med1cat1on may be administered befOle chemotherapy
For the patient rece1v1ng chemotheiapy that causes emes1s, a
combination of med1cauons may be required. using drugs from
seve1al ant emetic drug classes 10 be elfecuve
DRUGS FOR EMESIS
Antiemetlcs are used to suppress nauS<'a and vomiting.
I mesis, or regurgiutJon, may activate the ~-omiting
rcllex via either (I) signals from the stomach or ~mall
intesunes or (2) direct acuon of compounds that cause
vomiting. such as anticancer medications or opiates used
for pain (see Box 24-2 for an explanation of emesis
occurring with chemotherapy). Antiemetic drugs are
~eparated into several d'>CS, depending on how they
act on the body (Table 24-8).
suppressing nausea and vomiting ca~ by ntlllfo.
plastic medications. 11w side effects mdude diant>Q
and headache l'he two typical drugs are
(Zofran) and gra11ise1ro11 (K)~ril, Cranisol). .
"""""'"'
0op.1111i11 m11ago11is1.1. ,1 ma1or category of anue~
are divided into three groups: phenothiazines. bu~
phenones. and a group of other medications. lhew
medication' suppress vomiting by b locking dopamint-l
receptors. l'heno1hiazines such ns promethazine (Phm.
ergan) arc used orally. p<1re111eral ly. o r rectally fornausti
and vomiting of chemotherapy. surgery, and toxic po 1
saning. These medications a re also used with psychiatoc
disorders (see Chapter 30).
Benwdit1upi11es such as loriueparn (Ativan) and dit:-
epam (Valium) arc also given for chemotherapy paueim
Both provide sedation and suppress anticipation ci
emesis while produdng some amnesia of emesis (set
Chapter 30).
t\111iciloli11ergiu, used to treat motion sickness, blod
acetylcholine and lustamine. Scopolamine is a cholma
gic amagon ist used for prevention and treatment o(
motion sickness through oral, subcutaneous. or tr;11u.
dermal administration. Transdermal patches are changed
every 3 days. IJox 24 -3 has an explanation of vomiting
from motion sickness.

TABLE 24 8 MEDICATIONS FOR EMESJS

GENERIC NAME/ USUAL OOSE, ROUTE. INDICATIONS MAJOR SIOE
TRAOE NAME AND FREQUENCY FOR USE EFFECTS DRUG INTERACTIONS
SEROTONIN Postchemot!ierapy D1anhea. headache Usually none
ANTAGONISTS oausea
ondansetJon (ZofranJ 4-8 mg PO bid. IV
g.anrseuon (Kytril. I mg PO. IV I Iv before
Grarnsoll chemotherapy
(Sancuso patch) T patch uansdermal q3-4d
dolasetron (Anzemel) 1DO mg PO, IV I hr before
chemotherapy
palonosetron (Aloxif 0.5 rng PO 1 hr befo1e
chemotherapy, 0.25 mg IV
1 hr before chemotherapy

DOPAMINE Nausea and alcohol, lithrum. trqtlc

ANTAGONISTS vomiting from anhdepressants.
various causes. monoanune Qitidase
including motion mhib<IOIS,
siclcness hypotensive agentS.
anbthyroid agents
chlorf)lomaiine 10-25 mg PO Q46h,
25-50 mg IM. IV q4-Sh
CNS. Cenual nervous_sy.;tem; IM, intramuscula1ly, N. 1n1ravenously: PO. orally; SC. subcuianeousl
' Prescnp11on medication y
 -----~C=H
- APTER 24 Gastrointesnnal System Disorders 431

TABLE 24 8 MEDICATIONS FDR EMESIS- cont'd

GENERIC NAME/ USUAL DOSE, ROUTE, INDICATIONS MAJOR SIDE

TRADE NAME AND FREQUENCY FDR USE EFFECTS DRUG INTERACTIONS
~ne IJ.16 mg PD. IM. IV qd in
divided doses
1131cJperalllle 5-10 mg PD q12h, IM. IV
~nel
lf.olllOI 25 mg rectal suppository
IJIJN!thaMe ll'henerganl 12 5-25 mg PD q4-6h. IM.
IV. rectal suppository

~
~IHaldoll 12 mg PD qd, IM. IV alcohol. CNS
depressants. hth1um

Olber Oop1mine Nausea and 01zzmess. headache.

A/IUIJOftlSts VOlnlttng With restlessness. dry
chemotherapy mouth. hypotension
metoelopram1de IReglanl 10-15 mg PO qid. 12 mg/ alcohol
kg IV 30 mm belore
chemotherapy

ANTICHDUNERGICS
Aftrmisrammes Motion sickness. No significant
nausea and 1nteract1Qns noted
vomiting from
various causes
d1menhydrmate 1 50 1OD mg PO q4-6h, IM.
(Olamaminel IV
d1ph~ram1ne'' 12 5-50 mg PO lldq1d, IM.
(Benadryll IV
l)odroxy11ne (Ataru 25100 mg PO smgle dose.
Vistanll IM
medi!ine"' (Bomne.' 25-50 mg PO Qd
Armven"I
(llramamtne Less 25 mg PO 1hr befOfe uavel
ll<Uwsy')
!QlllOlam1ne 0 4-0.8 mg PD. 0 6-1 mg SC.
IM.IV
'Transdeml Scopl o5-mg transdennal patch
MISCEUANEOUS Nausea and wmitmg from various causes
AGEHTS
~IOiall!d 15-30 ml PD single dose
cartmydrate solution'
(Emetrol and others I
300 mg PD ud-q1d. 200 mg CNS depressants
v1methobefl1amlde
(Tiganl IM
125 mg PO on morning of Nausea and terfenadme. c1sapnde,
aprep1lant (Emend)
chemotherapy, 80 mg PO vomiting with astem11ole. warfarm
on days 2 and 3 after chemotherapy
chemotherapy
oremedication
432 SECTION V Med1cat1ons Aela1ed to Body Systems
BO~ 24 J VOMITING FROM MOTION SICKNESS
MollOll ic~ , r '' ocr w11h v rav -i1V o;.,a, a r or au10-
mobile, aro even in space Symp10ms rnclude nausea. vommnq.
pa IOf, andcoldswea1s Drugs fllf mollOllsrcknessare best given
prOpllylaclically bcfOle 11lMll rather than as treatment after
symptoms ate occumng Persons y,o!Jo ti;r;e motion sKkness are
usua ly 1Mara of lhc prglllem and use the nece$Sil!Y medrcat1ons
pr0pllylac1ic:ally
PlrosphoaUd ' "'bohyfrau solution (Fmetrol), a
dextrose, fructose. ind phosphoric acid combination,
works by reducing hyperac1ivny of smooth g;istric wall
muscles llttause of 11s su1;.u base and its availability
arc.. pauent education for per.sons wilh diabetes mel-
li1us should include the danger of medication use and
increased blood glucose levels
Another popular anuemeuc. trlmethobe,,....mide
( ng.1n), may be adm1111s1ered by mouth, injection, or
rec1al suppos11ory. llecause parenteral administration is
painful, the Z-1rack method is the preferred route (see
Chapter 14 for methodology for Z.track injection).
Med1ca11ons for motion sickness should be taken 30 10 60
m1nu1es belo1e uavel
2 Transdermal scopolamme 1s a 72-hour patch Iha! 1s placed
behind the ea 101 con11nual ielease of med1cat1on for mo11on
sickness 0< nausea
.. .
A comb1nal1011 of med1ca11ons may be necessary to prevent
emes1s from chemolhet'apy
DRUGS USED FOR INTESTINAL
CONDITIONS
Drugs for intestinal conditions include antifiatulents
and laxatives or c;ub.utlcs. lloth groups of drugs ar~
often uwd with ore preparations and have names that
arc commonly recogni"ed.
Antiflatulents
Some people have excess gas production and requfre
relief of gastric and intestinal distention. Medications,
including some amacids used as an1i0atulents or carml-
natlvcs, are bought OTC, with 1i111etl1icone being the
most cornmon active ingrcdien1 (e.g., l'hazyme, c~x.
Mylan ta) . Sirnethicone disperses ?nd prt>venu gas r>odct
formation in the Cl tract. Ant10J1ulen1S are u5((! lo
relie--e gas; however, patients w ith exchs gas shOtJ.d
avoid gas-forming foods such as cabbage. onioru, illd
beans and avoid u<ing straws when drinking liqu4
(Table 24-9).
Laxatives and Cath artics
Bowel function is a major concern in the elderl> (COOl!i-
pation) and young children (diarrhea). Constip.111on a
related to the hardness of stools rather than to lh u
frequency. Laxatives should be used for consupa11on ;ii~
hard, dry stools, not for sofi, hydrated stools Ifa lau1nt
is necessary. it should be used for only a shon l1lnt
in conjunction with dietary changes and \'Xercisc Tbt
elderly have increased constipation leading to boiod
obstruction or habituation of laxatives because o( mul
tiple chronic illnesses, polypharmacy, and dtdint 111
body Function. Constipation is rommon in children,
with con tributing facto rs such as emotio ns, newe111iron.
men ts, d ietary changes, and fever. Glycerin supposilonn
for chi ldren are the most appropriate ireatmen1 for con.
s tipation in ch ildren age 10 years and younger. Diarrhea
in ch il dren may cause rapid clcc1ro lytc imbalances. and
early Lreaun en L ls necessary Lo 1nnin1ain horneost,lsis,
Laxati ves and cathartics a rc used to induce ckfm.
Uoo. Laxatives resu lt in leisurely production of a~
formed stool over a period of I to 2 days. Thew
medications may be abused and/or rau~e der>endency
especially in the e lderly, because of preconceived 1de!j
concerning daily bowel evacuation. Cathanics product~
prompt. fast, intense Ouid e-acua1ion from the bowcl
and are used most often for diagnostic testing. Somt o1
these medications may alter the color of stools fbblt
24-10).
The advertising for OTC laxatives tends to encotJnlt
habitual self-medication when these agenu are no1.x111-
ally needed. Unnecessary use of a laxali\'e may paptlll-
ate the patient's perception that a laxatt\'I! is "I'll
no:cessary. After purging the intestinal tract. lht p.111<111
''."" need 2 to 5 days to refill the bowel, during ..ilidl
ume the habitual laxative user will take another I.wt~
because a daily bowel movement has not occurred
a period of time the body becomes reliant on tht Lu.t
'"
live for a bow~I movement, leading to pathologic chJ~
such as heart irregularities. C.udiar arrest may C-'tll oroir
from loss of pmassiu m.
Laxatives may be used with pa1icnt5 who ha\T a l<Jl.1
o.r abdominal and gastric muscle 1onc. With anlhthnio
uc therapy, laxatives are used 10 obtJi n stool specimen\
empty the C l tract before med ication administration.
and. to expel dead parasiles. '1lwse medications art .1lio
111d1ca1ed before diagnostic and surgical 1HocedurtS
 CHAPTER24 Gastrointestinal System Disorders 433

TABLE 24 9 DRUGS USED FOR INTESTINAL CONDITIONS

GENERIC NAME/ USUAL DOSE, ROUTE,

TRADE NAME AND FREQUENCY
INDICATIONS FOR USE DRUG INTERACTIONS
Flatulence. mclud1ng that
caused by radiographic
studies
~ fMyhcon. Phazyme} 00.160 mg PO ud Usually none
OSMOTIC LAXATIVES' Relieve oonst1patron
~glycol fM11alAX) 1 Tbsp PO 1n 8 oz water PO
qd
latlulOS8 (Constulose. Enulose. 15-60 ml PO Qd
Knstalosel
sodlllll phosphate {fleet hquld,
enemaI
ix oz 1n 8 oz water PO Qd
1 bonlo rectal

Magnesium Compounds
rnagnesum hydroxide
(Milk of Magnesia) 3060 ml PO qd
(Phillip's chewable) 300 600 mg qd
magnesiumcitrate
(Citrate of Magnesia) 1 8oz glass PO as a single
dose
(Cttr11fllil) 5 10ozPO qd
magnesiumsulfate (Epsom saltsl 24 g in 8 Ol waler PO qd

BULKFORMING LAXATIVES'
melhylcellulose (C11rucel) 1 tbsp in B oz water PO K-spanng d1ure11cs. saltcylates.
Qdtld digox1n
polycarbo?Jd (F1berCon. 2 tabs PO qd qid
M1trolan. F1beralll
psy11llm lrtdrophthc IKonsyl I tsp 1n 8 oz w.1ter PO
l'eid1em. Metamucil. Serutanl Qd t1d

STIMULANT LAXATIVES
~ (OulcolaxJ 10.15 mg PO or I rectal F0t diagnostic tesung
SIJPllOS1tory
cascara sagada (NTNJ I tab or 1 ISP PO qd, dose
mayvaiy
sema ISenoko~ Exlax. Black 10.15 ml 0t t or 2 tabs PO
Orauijlt Fletcher's Castor.al bod
.JSttw ' I !HiO ml PO qd

WBRICANT LAXATIVES'
mneral oil (Kondremul, tSmLPOqd Reheve constipation
Aeet Enemal I bottle rectally
0 ive 011 15mLPOqd
CllS. Central nervous svstom. MAO/. monoammo oxrdase inh1b11or, PO. orally
me mllilrcat1on Cor11wur1I
 TABLE 24 9 DRUGS USED FOR INTESTINAL CONDITIONS- cont'd

GENERIC NAME/ USUAL DOSE. ROUTE. INDICATIONS FOR USE DRUG INTERACTIONS
TRADE NAME ANO FREQUENCY
STOOL somNERS AND MOISTENING AGENTS
doc .au .,, C with 1 OI 2 VE' caps PO pm Relieve cons11pauon. ease
defincat1on
" r ~
Seoc Ct.SI
clocusate~ 1 or 2 tabs PO prn
1 recial SIJppositllfV pm

CATHARTICS ANO BOWEL Bloabng. nausea.

EVACUANTS abdonunal fullness.
diagnostic tesbllQ
po""'" Y O"r electrolyte 4 l PO 124il Iii every
sol~t1on (l'EG-ESI IGolvtetv. tO mn until all
Colytt N1 ytt y M ralaxl consumed!

Mior S1d1 Elftcll:

OsmotK. laat1"1~enerally none except abdominal cramping. sodium Jl'losp/Jate--abdominal cramping, bulkformmg /axat1>e>-
ftatulenr:e and oolky stools. abd111ninal cramping. sttmulant /<l,l'ative~bdominal cramping. nausea. diarrhea. flatulence

ANTIOIARRHEALS Relieve symptoms of

cholestyram1ne' lOueS1ran)
bismuth subsahcylate'
(Pepto-B1smol)
ac1tva1ed cha1coal' (CllarcoCaps)
loperam1de (lmod1um AD,'
lmod1um1)
diaO'hea
Anticoagulants, d1go.ion.
thiazides. pen1c1lhns
tetracyclines. propranolol.
thy1oid replacement. fol1c ~
15 ml PO or 2 tabs PO prn Anlicoagulants. oral
hypoglycemics
2 caps PO prn
2-4 mg PO t1d prn

SYNTHETIC OPIOIDS
d1phenoxyla1e and atropine 2 tab stat then 1 tab PO alcohol. CNS depressants.
ILomouU l&hedule VI pm q MAO ls

M1ior Sid Elftcts of Synthetic Opioidr.

/op8ram"'8-{)111in. ss, dry mouth. depresses CNS; d11iltmoxylate and atropine-same as loperamide plus ag1tat1on. tachycardla
numbness ol l\iJrlos and feet drowsiness

GASTROINTESTINAL Irritable and mftamrnatory

ANTIINFLAMMATORY AND bowel disease
ANTllRRITANT AGENTS " Crohn disease
UtcerattVe cohtis
mesalamine lRowasal Enema. rectal suppository digoxrn. mesalamine
Im-mg mg PO t1d
controlled release lPentasal
sutfasalaz1ne (Azulfid1ne) lgPOq8h oral hypoglycemics. warfa11n
olsalaz1ne (01pentuml 500mg PO bid None
balsalaz1de (Colazal) 225g PO lid warfarin, vancella vaccine
alosetron !Louonex) 05 mg PO bid fluvoxamme
' Prescnp1ion modic<1t1on
'Anlldiarrheals aro ldmuustored as d11ec1cd until cessahon of diarrhea.
 CHAPTER 24 Gastrointestinal System Disorders 435

TABLE Z4 9 DRUGS USED FDR INTESTINAL CONDITIONS-cont'd

GENERIC NAME/ USUAL DOSE, ROUTE,

TRADE NAME AND FREQUENCY INDICATIONS FOR USE DRUG INTERACTIONS
/111jor SiH ElfectJ:
n-es.i1amire-abdom1nal pain, crampmg, headache. weakness dill! .
dsJiam-abdormnal cramping diarrhea ...,._ ness. sulfasal~usea. fever. JOtnt pa n, rashes;
nausea and vom1t1ng . .,.,..,ps1a. 101nt pa111, anorexia a/C1Selnlf>-<onsUpat1on. bloody diarrhea. '-tburn.

AHORECTAl PREPARATI ONS

..w;aioe (NIJ!ll!fC31nal ointment Apply topically, rectally Hemorrhoids. rectal None noted
or SllRJOSllonesJ with hd/qid fissures
cort!SO'le (Nupeita1nal HCI
'll)Ie OTC medrcall(Jll Cortisone suppositories and ointments may also be used. some require a p.-escnptlOO. and othels do no1

ANTHELMINTICS
ireOendalole 100 mg PO bid Roundworms. prnworrns None
pyramel' (P1nX'I PO based on body weight Roundworms. pinworrns.
hookworms
pra11quanter (81ltnc1del PO based on body weight Tapeworms. flukes
t111abendazo1e PO based on body weight Threadworms.
roundworms
albendazole' lAlbenzat PO based on body weight Pork and dog tapewonns

Major Side Effects:

mebendazole and pyramel-abdominal cramping. diarrhea: prsziquantel-headaches. drowsiness. abdominal discomfort
thtabendazo/e and albendazo/e-abnormal cramping. anorexia. nausea and vomiting. dizziness. drowsiness

MISCELLANEOUS INTESTINAL MEDICATIONS

kib prostone (Am1t1zal 824 mcg PO bid Idiopathic, chronic
constipation

MISCELLANEOUS
iegaserod IZelnorml 26 mg PO bid Increased GI moulity; None
peristalic agent

lrlajo< Sih Elfocrs:

reoaserorl maleat&-headaches. diarrhea. lubiprostone occasional diarrhea

Types of Laxatives hy)><'nension. heart failurt?. or edema because of possible

Uutives. mostly 01C preparations. are classified by electrolyte changes. Milk of magnesia as the mildest of
thrir sourct?. site of action. degree of action. or mecha saline laxatives and the preferred laxative in this category
ni~m ofaction (Hgure 24 2) for children. Cephulac; another osmotic saline laxative
Os111D1rc Jalml' laxm11.,,; inNcasc the amount of water contains fructose and lactose; thus it should be used with
in large intestine so the fecal m.l\~ swell,, sirctching the care in people with diabetes mcllitus.
intestinal wall and incrca,ini: pcri~talsis. I.ow doses of
ill~ medications work in 6 to 12 hours; large doses
work in 2 to 6 hours, hut a Ja1gc dose c.in c.1usc consider-
able abdominal cramping. Osmotic sa li ne laxatives
can rause a subsccintia l watl'r lo~s. and its rcplac-c111cnt is Milk of magnesia {MOMI may be used as an antacid in low
necessary to keep the bc>dy in homcosiais. Therefore doses.
these drugs shou ld not lw used with pat ients with
436 SECTION V Med1cauons Related to Body Systems

Stimulant laxari1'<!s are f~orn boiani~al source$ nc'T>I

8ulkformr11g /1J.1,1/1t~~. among the lea~ harmful of for 1tisac0dyl [Dulcolax}. 11wse laxauves, absorbed to
lax.111ve\, \11mulatr pcmwls1s by ,welling. increasing stimulate peristalsis, aa in 6 to 8 hours and are hhn
bulk. .ind modifying conmtency of stools to stimulate fonning. When intestinal motility is increased, waterhai
the intcmnal iract Natural or sem1synthe11c cellulo~ less time for absorption in large intestines, resulting 111
Mrh-ativ..-s \uch .is ml!t/1ylullulose (Citrucel) and poly-
watery stools. Se1111a, c11scnr11 sa.~mdll, and alot in ir.,
carltophil (I 1b<:rCon) Mt acme mgred1ents in bulking
gTOup cross into breast milk Risacodyl, a relatively non
agents Bulkfonmng agents are l3JC.1U\'es of choice with
toxic agent that aru by stimulJting peristalsis in thr
pregnanC) rauenis must take sufficient Ouids for these
colon, is often used before diagnostic testing. ll.lUS< cl
medteauon' to work On.\Ct of amon occurs in t 2 hours
possible stomach irritation. these tablets should not bo
to 3 da)-. rrun~ and bran haw s1m1lar effects as these
crushed or chew<:<!. nor should they be taken with mill
laxauvn (see Iable 24 9)
or antacids because of interference with absorpuon \tit.
rwsull'S such as Ex-Lax are the mildest of these laulr<ft
and may discolor urine to pink, red, or brown <Ait etl,
TABLE 74 10 MEDICATIONS THAT MAY CHANGE THE obtained from the seeds of castor beans. passes rpidh
COLOR OF STOOLS through the stomach unchanged, causingsmall 1nte>ti
I I I I
irritation. Rapid rnovemem into the small intouna
and colon is the basis for effectiveness. Cmor oil 15 ""'
Antacids w'th alum1nom sa ts Wl111e specks 'white recommended for pregnam or lactating women (!t<
{e g. Maal()J(. Mylan1al d1scolora11on of stools Table 24-9).
Anticoagulants. such as tllose Red-orange to black due to Lubric11t11 hmtives (mineral o il and olive 011) allo.
containing warfa11n intestinal bleeding water to penetrate the fec,1' mass. usually acling in 6 to
Bismuth or iron salts (including Black 8 hours. laxatives do not increase bu lk. but oily agtnu
Pepto B1smol) coat the stool surface and soften stool 10 e.1se defec.iuon
laxatMJS with phenolphthalein Red 1.arge doses of these laxatives tend to cause le.tk.ige or
oi l from the rectum . Clyccrin suppositories. another
laxatMIScoota1ning senna Yellow to orange to brown
lubricant laxative that is usua lly cffcrtive in 15 mi11u1es
phcnazopy11d1no iPynd1uml Ora"IJO to red to an hour. increase peristalsis in all age groups (itt
nfampin Red to orange or brown Table 24 9).

Drug type 1 Mool tof'ltNI Orvg rype. 3- stimulant Drug type 5; lvbricen1
Mtchlnl1m wttbng agent UMd M(tChanlsm: increases periS&al$i$ Mechamsm COf.tl &ut111~ ol 1.oe1 nd
to tof*1 llClll fNA via nefV8 stimulation ., OOIOn cdon to ease pus119t ot tool. alto

e'*"ct 3 dlys Onse4 of acbOn: 6 to 12 h0ul'$ soltens f:al NM.

..,,.,.. tlCllOl'I.
-...'..10CCOloctJ Example: ...,,.. JCUcata $89-) Onset of action 810 a houf'I
Example mlMfal Oii

Figure 24-2 Site of ac1ion for lypes of laxatives


Srool softenm, or fecal moistening agents, decrease the
consistency of stools by reduci ng surface tension. Stool
softeners with a wide margi n of safety and few potential
.id''"~ reaetions work by absorbing water imo the stool,
lubricating the rectum, and increasing stool bulk. Docu
,.,1, (Colace) acts as a detergent, pennining water and
rauysubstances 10 penetrate and mile with fecal material
1llese medications usual ly take 1 10 3 days 10 be effective,
especially for pa1 ien1s who should avoid straining for
bo\;tl movements. They may be combined with laxatives
wnh such medications as Peri-Colace and Doxidan to
soften Stools while enhancing stool evacuation (Stt
l~blt 24-9).
&m'tl emcunlll.! (cathartics) such as polye1/1yle11e
gll"I (G0Ly1ely) arc bowel-cleansing solutions of mix-
tul'l'S similar to body Ouids so 1hat water and electrolytes
llt not absorbed. These agents are safer for patients who
~ sensiti\'\' to electrolyte imbalance because water is
not lost and elcrtrolyte balance is more likely main-
uined. \~en thew agcnL~ are used before diagnostic
1esiing. the pa1ien1 must d rink la'lle amounts of 1hcsc
fluids (about a gallon) within 2 10 3 hours; bowel move~
mcms begin about an hour after administration is
<Wttd If rectal excretions become clear. the laxati-e may
bc<topped. Oral mcdkations should no1 be given within
an hour of starting solutions because medicine may be
flushed from the Cl 1rnct (see Table 24 9}.
Misalla11eousagc111s, including lublprostone (Amic iza),
1ncrease imestinal fluid secretions to soften stools.
1nmase motility in the intestines, and promote sponla-
MOUS bo\\'cl movements. reducing bloating and wain-
ing associa1ed with duonic idiopathic constipation.
Ami1iz:1 produces resu lts within I week. Tcgtuerod
{l.elnorm), another miscell aneous agc_n.1, is indi~ai_cd 10
mgger peristalic reflex in such rond111ons as irmable
00..d S)Tidrome and chronic consupacion.
Heallll care p<0less1onals should obtain a full history of laxa
IM! use and possible misuse because these med1cat1ons
llU!lfero with absorption and metabohsm of olhef medicinal
items
2 Patient edocation should include the need for dietary change
by avoiding such constipating foods as chee~e and sugar.
ha'ving adequ;ne Hu1d intake. and eating h19h-fibor d1e1.
Patients should avoid 111discr1m111ate use of laxauves but
rolher should try adding dietary fruits. vegetables. and fluids
tor an ages
l Use of laxatMlS to force eva<:uauon may initiate laxative
abuse . .
4 lai14tives shoold not be used by patients with abdominal
pain, nausea. and abdominal cramping or known mtesunal
disease unless specifically ordefed by a physlClan
-----
CHAPTER 24 GastrOllltesunal System 01so1der$ '37
5 Coost1pat1on refers to cons1s1encv of stools. net flequency,
an mponant fact with gei.auic pauenis
6 Bol\fonm ng laxanves and sutfactanis s!Wd be taen with
a full glass of water
7 Castor 011should be mixed with 1u1ce to 1mp1ove taste and
should not be adm1n1ste1ed at night Of to someone who has
difficulty swallowmg
8 When given 1n sma I doses. osmotJC lax;ll!WS soften StOOIS
~t tallSe watery e'<aCUallClll with la1ge doses
9 Glycerin supposnones a1e the safest treatment IOI coosnpa-
t1on 1n all age groups
laxatives prnmo1e defe<:auon
Laxall\llJS and stool sof1eners should be used for leg111mate
reasons Ollly. such as IOf diagnostic tests. beloie su1g1cal
procedures. or for medical cond1bOllS that prevent straining
requued for evacuatlClll ol bowel movements
Elderly patients should be taught 10 avoid consl patong foods
such as cheese and suga1 and to have adequate ftu1d intake
with a high-fiber diet
Bulkform1ng laxatives should be given with water
Stimulant laxauves shoo d be used with d1scnm1nat1on
OsmollC laJl.8t1ves require an increased intake ol ft1J1ds to
prevent deltydratl()n
Stunulaung laxallves and osmotic laxatives should not be
given al bedtime because ol rapid onset ol acuon
DRUGS USED FOR RELIEF
OF DIARRHEA
Antldlarrhul agents are used 10 treat diarrhea, a
symptom of bowel disorders and 1101 a disorder its~Jf.
Diarrhea consists of stools of excessive volume and fluid-
ity with increased frequenq of defecation and is associ-
ated with cramping pain because of rapid passage of
intestinal contents. Management of diarrhea depends on
finding the u nderlying cause. repladng water and elec-
1rolytes as needed, reducing 7ramp mg. and ~ed~1c1ng the
number of stools. Diarrhea 1s usually self-hm11mg and
resolves without funher effects. Chronic diarrhea needs
evaluation for cause and treatmenL Diarrhea in children
may become a medical emergency in as liule as 24 hours
because of loss of elearolytcs. Antidiarrheal agents may
be dassificd as adsorben is and opioid or synthetic opioid
medications.
Adorbents act by coating the walls of the Cl tract.
absorbing toxins or bacteria that are causing diarrhea.
438 SECTION V Med1cebons Releled to Body Systems
and excreting 1h~ agents wnh stool~ Med1cauons given
while adsorbents are being u~ may not be absorbed at
expttled le\-ds. OTC med1cauons include acuva1ed char-
coal. bimuth salts. kaolin, pectin. an.apulgne. and 1he
prescription drug droln1yramine (Ques1ran). are usually
taken af1tt each loose bowel movement until the diar-
rhea 1s comrolled. Constipation may follow use of large
amoums of th~ produru. Peplo-Bismol may be u<ed
a~ an antidiarrheal, antacid. or amiulcer medication; ii
absorbs irrilants of the Cl Ir.lei (set 1,1ble 24-9).
Symhrric opioid metlicarioru are prci.cription drugs that
inhibit Cl motility. decrease hyrerpcrlstalsis. and slow
pa;sage of intestinal contents lo allow for rcabsorption
of water and electrolytes, thu> slowing s1ool frequencies.
Lo~ramlde {lmodium) is a prescription medication bu1
is also found as lmodium /\D, an O'IC preparation for
acute nonspecific and chronic diarrhea Diphenoxylate
with atropine {Lomotil) isa Schedule V synthetic opioid
1ha1 inhibits 1he propulsion of food through the Cl tract
(see Table 24-9).
[!fati~~omplince
1 Anud1armeals are available OTC and by IJ(esc11puon
2 Pepto-81smol. !he drug of choice for diarrhea. acls as an
nu,~plk and ant1d1arrheal 10 soothe the gasuointestinal
tract.
LOWER GI ANTllNFLAMMATORY
AGENTS
AmiinOamma1ory medica1ions for ulcttali\"l' colitis are
available as rectal suppositories. enemas. and oral 1able1S.
Mrsalamine (Rowasa), specifically for management of
ulcerati\"l' colitis and Crohn disease, is administered as
oral tablets three limes a day, supposilories 1wice a day,
or an 8-hour mention enema al bedtime.
Su/fasalazine {Azulfidine). a member of the sulfon-
am ide family, is indicaled only for irriiable bowel ;yn-
dro111e. Olsalazine (Oipemum) is a salicylale derivative
used for ulcerative colitis and o ther chl'on ic inflamma-
tory bowel diseases; ba.lsalazide (Cola1.1I), also a salicy-
late, has the same indications for chronic inflammatory
bo"'"<'I disease (see Table 24-9).
MedicatJOOS for lower gastroi01est1nal 1rac1 are pr manly
used to resto1e a normal bowel pattern
Inflammatory bowel disease mav be treated with sahcylates.
sulfasalazine. glucocort1co1ds. alld 1mmuroosuppressants
''fll;l44i''4;14kJ;P!\itfrP
Anorect..I preparations are used 10 provi_desymPlomo.
relief from the discomfort ofanor~I dosorders.sudu1
hemorrhoids. Some contain topical anC$1hetiC1-lor
mple. 11e11wc11i11e and dibucaine, found in ~
~n H and Nupercaina l ointment-whereas olber Jlff
parations con1,1in l11tlrocortisone .' ~educe swelh"I.
suppress inOamma11on. an<~ rel ieve 11ebmg and stinging.
Aciing as cmo//i1111> 10 lubnca1e the rectum and r~uet
irritations. so rne prcparauons conlam lanolm or mmer~I
oil. Astr lngl'nts >ttCh as tvitc/1 /111u/ are used to re.duet
swel ling. inOammatiorr. and irri~ation. Nupercai1.
Prepara1ion 11. and Anusol are nwd1cauons tha1 comton
several forms: ~uppositories, creams. ointments, foam\
and pads. In Jabk 24-9, Nupercainal is shown as i
l}'Pical anorectal medication.
: ..
Anorectal preparations containing topical anesthetics are fourd
as OTC prepara11ons. When hydrocort1sones are added. m n1
lhen become presc11ption medications.
DRUGS USED FOR
INTESTINAL PARASITES
Anrlrelminriu are used t<> 1reat commonly found ime.u-
nal parasitic worms. Early infes1a1ions are asymptonulJ<
but severe medical prohlems arise as t.he infection pro-
gresses. Most common types of parasitic worms are pin
worms, nukes. roundworms. and rnpeworms. Dosages of
medic:Hions for parasites .ire based on weigh~ wilh mo1t
of the dose excreted in feces. Mebe11dtu:ole (Verrnox) is
relatively slow act ing for the trcaunen t of roundworms
and pinworons. l'yr1111te l (found in Anliminth, J>in.X.
and o ther anlhelmirr1ics), an OTC preparation, acts b)
killing t.he para>ile; therefore the eniire dose must bt
taken at one time. l'raziq1111111e l (Biltricide) is absort>cd
by the helmint.h, cau~ing the worms 10 detach from !ht
host's body tissues TI1iabendauile (Minierol} bas irW-
gesic, amipyretic, and amiinOamma1ory actions. plO\id
ing relief of the abdominal cramping that cornt'S mth
treatment of parasites. Many of the anthelm1ntic agtnb
are enhanced when given with fany food 10 slow drug
dis1ribu1ion. Also, tabl ets may be cJ1ewed or crushe.d 10
increase their absorption (sec 1able 24-9).
 --~--,;;...
CHAPTER 24 Gastrointesunal System Disorders 439

d1etllylp1op1on (Schedule IV) 25 mg PO t1d Weight loss, obesity

pt.entcnmna
(AdlpexPl !Schedule IV) 37.5 mg PO qd
111siat 1xen1call (OTC) 120 mg PO tid p1avastaun.
iAI ii 60 mg PO tid Vitamins A. D.
E.K
de>~ne 5-10 mg PO lid MAOls
10e>ed11neJ !Schedule HJ
benzphetamine (01drex) 25-50 mg PO qd
!Schedule lllJ
CN5. Central neM>US system; MAO/. monoam1ne oxidase i11h1b1tor; PO. by mourn
Note All of IN d1ugs listed in this table requiro a p1escnp11on except All!

Mos1 of these prescription medications are controlled

When treating for intestinal parasites. the entire household
should be treated Stnct hygiene 1s essential to prevent
reinfec1101>- d1s1nfec1 toilets, launder undergarments and
linens, wash hands before and after earing and after using toilet.
ard tal e showe1s instead of baths
kt! CLINICAi T P
.lilied health professionals should obtain an accurate body weight
ro1 all family members when anr1hehmn11c medication is
11.iicared
DRUGS USED TO
SUPPRESS APPETITE
About 50% of Americans are obese. a .i.ue in which
an 1nd1v1dual's total body weight ronsists of a greater
amount of fat than normal (2S% over the ideal weight
for men, and 15% for wo men). Obesity in children and
teeM is considered o ne of the leadi ng he.11th problems
in the l lnirc<I Stt"1> today. Genetic~. amcie1y, stress, and
poor self image are some of thf most common reasons
for this cond ition. Obese persons tend 10 have a greater
anciden of cardiovascular disease and a higher inci-
tknce of type 2 diabe1es mt>lli1us (T2DM).
l\norcxiant drugs, or appetite 'uppress.ints, include a
"l<k vari~y of medications tht act on the brain as weak
11imula1ors 10 suppress the appetite center in the hypo-
thalamus and to mimic the sympatlw tic nervous system .
sub~1ance5. ~ubje(t 10 regula1ions governing scheduled
dn1gs ( Iable 24-tt).
Amphetamines and amphe1;iminc-like substances
'uch as tlextroamphetamlrre (Dexadrine) are Schedu le II
drugs because of the danger of habituation. Other pre-
scri p1ion drugs that are used as anorcxiants are either
Schedule Ill, such as ben.tplretamine (Oidrex), or Sched
ule IV medica1ions. such as dlethylpropion (Tenua1e)
and phemermiM {Fas1in, AdipexI') Bulking agents
such ~ methylcellulose (Fiber I nm) and psyllium
hydrophilic mucilloid (Melamucil) may be used to gi'"
a feeling of fullness and reduce craving for food.
/\norcxiants have a number oflimitations and should
be used o nly shon 1erm as an adjunct to behavior
mod ification, diet, and exercise, because medication 10 1
erance n1ay occur in jusL a fc\.Y "'eek.-t. Short-actj11g
anorexiants usually work for 3 to 4 hours and should
be taken about 30 to 60 minules before meals. Long
acting medications las1 for about t 2 houts and should
be taken 12 hours before sleep 10 pm."ni insomnia (see
'lable 24 IO).
; .'
Anorex1ants are for short-1e1m treatm(lllt of obesity because
or danger of habituation. Behavior mod1fica11on, diet. and
exercise should be added to drug therapy for long-term tseat
ment of obesity
Anorexants that sumulate central neMllJS system m<rf
cause msomrua. neMltJSlleSS, and related side effects
f'lesc11p11on anoteXJants are scheduled drugs controllsd by
the Drug Enlorcem1!11t Admrnrstraoon
 440 SECTION V Med1cauons Related to Bodv Systems
SUMMARY
Many products used for the Cl tract are available OfC
Jnd ha,.., t'asily recogmuble names Mouthwashes.
g.trgles. and dentifrices contain Ouondes for tooth care
and dental canes preven11on fluoride replacement is
especially imponam in children who do not live where
Ouorine has been added to watt>r Dental therapeutics are
important 10 retain teeth for chewing food and to prevent
gu 111 diseases.
Saliva is necessary for lubrkation of food as it passes
through the mouth into the Cl trart llcplacement of
s;iJiva requires multiple application~ daily for needed
mo is Lure.
Oral amifungals are used for thrush by coating
the mouth
Anuvirals. used for symptomatic relief of herpes
simplex, '-aricella. and HIV infecuons of the mouth,
should be appLied using techniques that will not spread
lesions during ueaunenL Viral lesions and l..sions from
dental work, amineoplastics. or disease processes may be
relieved with topical anesthetics
Gastric conditions are treated w1tl1 many types of
medications to relieve hyper;1cidity, ulcers, spasms,
nause.l, and vomiting. Diges1ants are used to a:.sist with
food digestion. Amacids arc used either to decre.1se acid
secretions or to neutralize the secreted hydrochloric acid
in tl1e stomach when hyperacidity ocnors. Antacids have
alu 1ninu1n and magnesium as bases, with each having
the opposite clfea on bowels; magnesium causes diar-
rhea. aluminum causes COn$tipation fo prevent side
effects. some antacids. known as 11111galdr.i1a, contain
both compounds. Calcium rarbonate an antacid. is also
cffectiw as a calcium substiture on osteoporosis preven
uon. Sodium bicarbon.ue should be a\'01ded as a routine
antacid because it interacts with body Ouids to change
electrolyte 11?''\'ls.
Optimal antiulcer therapy requires drug and lifestyle
changt'S. Antibiotic therapy, using at least two antibiotics
10 prevent the chance of forming drugresistalll strains
of microorganisms. is used fo r 11. pylori bacterial u lcers.
111-receptor amagonistS are effoctive in inh ib iting hista-
mine secretions of the gastric mucosa to decrease acid
secretions. When antacids and anrisecretory agenL~ are to
be used therapeutically, agents should be given al least
I hour apan to be effective. PPls decrease hydrogen and
potassium. chemicals essential for formation or hydro
chloric add in the stomach. Some antiulcer medications
protect the gastric wall by mating i1 to reduce gastric
irritations.
Symptoms of CERD may be reduced by using
antispasmodics 10 decrease secretions and slow gastric
motility. Prokinetic medications stimulate gasoic motil.
ity and lo" er esophageal sphincter pressure. Thesea!:ttlts
are also used for rhc ueaumenl of nausea caused by <lit
motherapy and ma)' be u>ed for Cl disorders whm lift
style chang..s ha\'<' not been effective..
Viral hepatiti~ 8 and C. the mam caust'S or&"'
diseaSt', may be acute ?r chronic. Bo~ typeS of chron~
hepatitis arc treated w1tl1 parrntera l '?teC:eron alfa .ind
pegimerferon a lfo-2b for 12 months With hm11ed succ..,
after treaLment is stopped.
Digesrive enzyme supplements .re spe~ifically for(.11
digestio n in persons who produce onsuffiaenr pancreitic
enzymes. Ch olesterol gallstones may be dissol,-ed by
m edica1ions. but this b a long process, taking up to
2 )'ears.
Amiemctks work in several ways to suppress \'Omot
ing. Some drugs are used with chemotherapyandsulJl!!J.
whereas others are used to treat motion sidaiess 111
hyperactivity of the stomach associated with inge111d
toxins. Some ,mtiemetics for nausea oftra\'elsicknt>'t
av-ailable OIC and should be taken 30 to 60 minu1<>
before the beginning of a trip, whereas oth<'n "'
av-ailable by preS<"ripLion for prolonged transdennil
application.
Because of case of obtaining laxatives. these d111gs
may be the m ost misused o( all medications, especially
by the elderly. Rebound constipa1ion occurs whm a
person d epends o n laxatives for bowel action. Laxathts
work several ways. so the chosen type should be matcOOI
to the const ipation cause.
Antid iarrhcals classified as synthetic opioids are avail
able either by prescription or OTC and should be tlitn
with care. One o( the most effective ueaunems for dW
rhea is Pepto-Bismol, which coats the intestinal uaa.alld
is bacteriostatic in the stomach.
lrrirable bowel S) ndrome is treated with saliC)u1<>
and antibiotics Some preparations for the disast nt
retention enemas that are used at bedtime.
Anorectal preparations, most being OTC prepar.t
lions, are topical anesrhetics, hydrocortisone. or a
combinati on of both agen ts for anal discomfons m.iy
requi re a prescript ion . Emoll ients a re used to lubnate
the rectum, whereas ~stringents are used to decrease
s'"elling, lnna rn1nntion, and irritation.
An1helmintics. used to treat intestinal parasites, arr
enhanced when given with fatty foods. When ooi
member of a fam ily is treated for intestinal parasites. tht
entire household should be weighed and treated.
Anorexiants, used for uea1men1 of obesity, should bt
used only shon rerm, wnh behavioral modification ml
diet used in the long term. fhese drugs, whidl aU!t
central nervous system irritability, are scheduled m(<fia
tions because of their habit-forming nature.
 _ _____
, __:__:
CHAPTER 24 Gastrointesbnal System Disorders 441

Sc&nario
Sally comes to the medical setting stating she has heartburn on a daily basis Sile states that she has
also oeen constipated.
1 What formula tor an antacid should she take?
2 How often and at what time of day should she take the antacid?
3 How should she space her routine medications with the antac1d7
4 What suggestions would you make 1f Sally begins to have diarrhea7
5 What lifestyle changes might help Sally's bowel and gastric condrt100s?

DRUG C ALCULATIONS
Order: Surfak 100 mg PO hs
Available medication:

..........,_,,,_
. . . . i. . . - .. ........

.. _..,.......-, ... ...

::="":.. ............ .
....-.-
_... -...-..--.
---..
Surtak
........... YIP
SlOOl IOfltl ll

-h-
~-
C - t ......... _ _

-'--"''-
,._
,...~.:,c::.....
--
a...- - ,,...
11tt:CM11111---.
~
M lftf'\1"1
I0110 2'H
--...._""
100 CAPSULES
50 MG EACH

Dose to be given: _ _ __

_
2 Order Zantac 37.5 mg IM ~t.lt
Available medication:

_..
a.tll!'I--
Zantac
I ~
hydl- l
~ijectlou

25mg/ml"
l:=:==-,........1

Dosr 10 be given:
---
:..,....... ..........

. vded
11111111
Show the volume of medic.uion on the syr111ge pro ' .
442 SECTION V Med1caMns Related to Body System_
s ~-----

REVIEW QUESTIONS
I What is the indication for using fluo ride produas? Jn what forms are they available? -- - - - - - --

2. What are the indications for antacids1 - - - -- - - -- - - - - - - - -- - - - - - - --

3. What bacterium has been found to cause peptic ulcers! What a re two antibiotics used in the Lreaunent of bacterial

peptic ulcer$?------------ - -- -- - -------- - --------

4 \\!hat is an antiemeticl What are the classes of antiemetics! I low do medications for motion sickness wadi

5. What two special groups of patients must be watched closely with the use of laxatives! Why do these populations
need special considerations! - - - - - - - -- - - -- -- - - - - - -- - - - - -- - -

6. Why are laxatives and cathartics usedr Wh,11 is the difference between laxatives a11d c.1thartics? - -- - -

7 I low do adsorbent antidiarrheals workf Opioid and synthetic opioid antidiarrhc,llsl - - - -- - - - --

8. What is the purpose ofanthelminiksr What are some oflheir side effects?
-------------
Respiratory System Disorders

Att111 srudylng this chapter, you should be capable of domg the following:
Briefly discussing the respiratory tract as a source
for internal and external respirations
Descnbing the effects of ant1h1stammes and
decongeS1ants and the use of nasal preparauons
w th respiratory cond1uons.
Bnefly expla1n1ng the need for corticosteroids in
;ICUte and chronic resp11atory tract diseases and
associated side effects of long-term therapy
D1scuss1ng mucolytics, expectorants, and
ant1tuss111es and thetr effects on respiratory
secretions.
Explaining medicinal inhibition of influenza.
Describing medicatt0ns for respiratory syncytial
virus
Providing patient educatton tor compliance with
medications used to treat diseases and cond1t1ons
of the respiratory system.

Mac, age 2, has a cough and congestion because of an upper respiratoty infection (URI). Mac visits
Or Merry because he has begun to wheeze. Mac's mother is concerned that Mac might have asthma
and might need cort1costero1ds. Or. Merry checks Mac and fmds that he also has 011t1s media.
Would you expect Mac to have an earache with a URI?
01 Meny prescribes a decongestant. What side effects would Dr Merry tell Mac's mother may occur?
Why would Dr Merry prescribe a decongestant rather than an an11h1stam1ne?

Anomaly Oyspho nia Leukotriene Rale

Anosmia Oyspnea Mucokinetic agent Rebound congestion
Antihistamine Emphysema Mucolytic Rhinitis
Antitussive Epistaxis Mucus Rhinorrhea
Asthma Expectorant Nebulizer Sputum
Atelectasis Expectoration Nonproductive cough Stomatitis
Btonchiectasis Extra pyramidal Palliative Tenacious
Coryia symptoms Patent Tenacious cough
Decongestant Hemoptysis Productive cough

443
~~~~~
SECTION V Medications Related to Body Systems ~~~

EASY WORKING KNOWLEDGE OF INDICATIONS ANO SIDE EFFECTS

Common SymptoGs of Resporetory Srstm 01sord1rs Common Side Effects of Med1cat1ons for Respt181ary
Pa11 m resporaray traCI lllduding ~t po n and sore tlltOat System Conditions
IMi:l1ea. w!leeMg. rain le;idng lO cyanostS Ckymoultt
Aa.te ot chronic co.qi. pnidoc!Ml or nonprtiductJw coogh Tachycardia
l)ysphon a Sleeplessness and nervousness
Fat19ue and malaise Nausea. vom1t1ng, and anorexia
Chills. fever, and headaches Stornat1t1s
Hemoptys1s and epistax1s Drowsiness
Hypotension
Decreased coordination
Hoarseness

EA SY WORKING KN OWLEDGE OF DRUGS USED TO TREAT RESPIRATORY SYSTEM DISORDERS

PREGNANCY
DRUG CLASS PRESCRIPTION OTC CATEGORY MAJOR INDICATIONS
Anhhlstamules Yes Yes B. C Treatment of h1stam1ne-iA!used allergies SUC!t as
rh1mus
Decongestams Yes Yes c Reltef of nasal and upper respiratoty !Xlligestio\
1nclud1ng colds and inffuenza
Nas.al sprays and drops Yes Yes c Aeltef of nasal membrane edema. as
decongestants. and for seasonal allergic
rhinitis
Combination deooogestant Yes Yes c Common cold
products
An11iuss1ves Yes Yes B.C Relief of cough, especially nonproductive COi1Jfi
Mucolyt1cs Yes Yes B Decrease v1scos11y of respiratory secreuons
Expec10<ants Yes Yes c Promote coughing and expectoration of truaJs
and sputum
Broochodijators Yes Yes B.C Dilate bronchial tree to increase o,.ro, exdmJe
GIUCOCottteoids Yes No C.D Re 1eve acute and chrome astlvna
AslhrnatJc: ~actic agents Yes Yes B Prevenuon of an astlvna a11ack
Agents for ueatlllQ mffuenza Yes No c Prevention of inffuenza symptoms
A and B and prOphytac(lc
agents
Agents for treating resporatory Yes No X (ribavinn). C Treatment of RSV infection
syncytial virus (RSV)

T
he respiratory traa carries OX)'gCn to and removes
carbon <tioxide from the lungs- external respira- HOW RESPIRATION CONTROLS
tion. The circulatory system carries oxygen to BODY FUNCTIONS
body cells. wheie it is exchanged with carbon dioxide at
the cellular le>-el or cellular (internal) respiration. 1ltese
two components of oxygen exchangt> maintain body pl I
The respiratory tract is divided into upper and '""'
respiratory tracts and is re hant on accessory organs such
and homeostasis. with any change in the respiratory as chest wall skeletal muscles and the diaphragm to func.
system affecting all body systems Other disease pro- tion (Figure 2 5- l) In cardiopulmonary resuscitation.\
c~ increase the work of the respirato ry system, and
or ai rway, and /l, o r bre.uhing. are the fim steps for
impaired oxygen-carl>on d ioxide exchange must be
maintena nee ofl i fc, followed by C, or ci rculation (card1~c
treated before other S)'1item disorde"' can be addressed.
function), Lo send needed oxygen Lo body cells for

---~---
Nasopha~nx----1.---~
Oropha~nx ------'~,,!,
U>we<
l8SPf310IY
tract
A B
Figure 25-1 A. A resporatocy system. sflow,ng upper. llllddle. aRI lowef tracts B, AnalDITI'/ of bnnllooles llld .......
homeostasis. Respirations regulate the fuHctionalitv of
body sy$1ems. adjusting to any changes in a 1>e,.,,on's
IJl(labolic state.
Keeping the respiratory 1raa p.l\ent with the presence
of needed secret ions and their tenacity determine respi-
ratory tract efficiency. When annmJlie~, diseases, or
aniuries occur.. medications are us..>d as treatnlent to
msure Oowof air through respiratory passages into body
cells for a constant supply of oxyg~n and co ntinuous
removal of carbon dioxide.
Respiratory tract secretions produce thick mucus that
b.tlhes the upper tract to protea ag..11nst toxins. These
$t\'retions. together with cilia, prevent pathogens from
entering the lower respi 1-;uory tract. Watery n uid~ in the
lcn."tr respiratory traa m.H lung epithelium as protec-
wns. If thl'$e secretions b~'Come ll'nulous, the cilia are
ineffective and have difficulty removing secretions for
expulsion. Moistu re in the respiratory traa then can no t
keep secretions 1.hin, rc<ulung in difficulty hrcathing.
Xcretionscollect becauw of excessive amounts of mucus.
The tracheobronchial tree, inncrv,11ed by the auto-
nomic nervous system. allows smooth muscles to work
to improve V('ntilation . Basic respiratory rhythm aHd
conuol come from the hrain's medulla . Chemorcceptors
ind baroreccplors in carotid and aortic blood vessels
leJd to respiratory center stimulatoon when control of
brtathing is necessary. Thus respiratory cemers control
blood pl I, and vice vcrna. Fear, pain, stress, exercise.
blood pressure. body tcmperaturl', and blood oxygen
CHAJ'TER 25 Respiratory System Disorders 445
Smoot!> muscle
BRONCHIOLES ANO
Al.VEOU
levels modify Lhe respiratory centers and control of the
rh)'lhm and depth of respiration. Although the respira-
tory system may be affected by \'Oluntary controls. final
control is involuntary.
OXYGEN THERAPY
Oxygw therapy is used to treat inadequate oxygen intake
resulting from pathologic respiratory conditions thaL
decrease pulmonary gas exchanges, such as found with
chronic obstructi-e pulmonaJY disease (COPD). Oxygen
is ordered by prescription and administered by inh.1Ja.
1ion through v.irious delivery systems. Oxygen should be
av;iilable in medical se11ings such as physicians' offices
for emergency use. Allied health professionals should
know proper and competent use of available equipment
and should ensure it is always in working condition.
In disease processes such a. COPD, low doses of
oxygen are administered to promote respiratory gas
exchange. Effectiveness of oxygen therapy depends
on blood carbon dioxide content and response by
involuntary respirations. Because oxygen-carbon dioxide
cxdlange is impaired in individuals with cluonic rc>pira
tory diseases. carbon dioxide content of the blood tends
to rise. Also, because cirbon dioxide le."tls are chron1cally
increased with decreased blood oxygen levels as seen with
COPD. the respiratory center of the brain is relatively
insensiuvc to carbon dioxide stimulation. decreasing
"6 ~ECllON V Medications Related to Body Systems
involuntary rr-;p1ra1ory r'-"'flO'' Jllercfore these patients
are usually prescribed very low d~ of oxygen (I to 2 I./
min) 10 s11mula1e re>ptrations l..arger doses of oxygen
wall funhcr supprN involuntary respirations.
Recogniimg oxygen 1ox1cny as difficult. Some early
signs of high oxygen levels arc menul confusion, sternal
aching or burning. and dry, hacking cough Respiratory
distress. naust'a. \'Orn111ng. restlessness, twitching, loss of
feeling. and tremo rs in any order may follow. Excessive
oxy-gen intake for a long period o f time can lead to con-
vulsions and dta1h
IP8t10iii'! EClucatiO!!f!O!lCompllance
Q, /gell should not be U$cd near an apcn llame or v.ten there IS
a possibi ty of spaiU bealuse of the daoge< of explOS1on
UPPER RESPIRATORY
TRACT CONDITIONS
1 he u pper rc<1piratory tr,oct consists of the nasal cavity.
sinuses. 1>harynx, larynx, trarlwa, and mouth. The sym p-
to ms o f 1hc upper rl'~pi ra 1ory tract conditio ns such as
rhlnills are s1we1ing. cpls t.u h, runny nose, dy~pho
nla, itching. and congestion. Allergic rhinitis is caused
by histu ninc rcle,1;,e, where,1> nonallergic rhinitis is
o ften a symptom of the common cold. llistam ine, a
chemical found in body tissue, protects from environ-
mental faetors that produce allergic .md inOammatory
rcaetions. TI1e prind1>al action of histamine is vascu lar
dilation and contraetion of smooth muscles of the bron-
chial tree and gasuointcsunal traet. I-or the person who
as sensi1 i'ed to histami ne release in the respiratory tract.
snee,ing. increased nasal Sretion~ itching and watery
eyes, and bronchoconstriction may resul~ leading to
d)Spnu and airwai obstruction
TREATMENT OF NASAL
CONGESTION
St-veral med1cauon dasse are used to treat rhinitis,
among them antihistamines, decongestants. cromolyn,
and intranasal gluroconiroids All may be used to treat
allergic rhinitis, dteongestants are used 10 treat nonal-
lergic rhinitis. cory.t, or the common cold.
Antih istamin es
I lypersecre1ion of nasal Ouid> because of allergies may
necessitate use of nllhlst.amlne~ to block histamine,
(11 1)-rccepior sites and to prevent histamine from
causing edema, inOammJtio n. and itching. Amihista-
mincs have their greatest therapeutic effeet o n nasal
a llergic reaetions. Hrst-gcnern tio n drugs ~~eh
diphe11 1rydramirw (Benadryl) a nd bro111pl1*1!tronti..
(Dimetane) have been a~a1lable for many )'tars; ""'"
second-generation druSI> include ce1lri%/rre (Lynl'C) ...i
loratadine (Claritin) (fable 25- 1} .
Antihistamines are not cffecu ve a~mst h1s~r,..
that have already attached to receptor _sues, so drt.og1 a:r
most effective if taken before contact wnh allt>rgy-Qllllllg
compounds. llle<e medications are palllll' ' ~
they do not provide proteC11on o~r a long penod ol 11111t
and are more likely to he e1Tect1ve at the begann111o(
allergy season. t\ntihi.iamines fail to reduct !hf ..lb...,
that frequently accompanies seasonal allergic r~
such as hay fever.
first-generation antihistamines a~e ~onse~mn~ 10
their elTects on peripher.11and systemic htstamme rl.'Up-
tors, although these agents produce the same dqrtt of
therapeutic response to histam ine. 1he main drffftmcr
in specific medications is in the ir variable degree or K<U
tion and their antih istam ine activity.
Chlorplrc11/ra111i11e (Chlor-Tnmeton) may cause insomnia'"
the elderly. In acute conditions. diphenhydramrne (Benadryll
still the medication of choice for allerglos
The second-generatio n antihista mines. with equal 01
better anti allergic e ffects, are no t as sedating or drying
and seem to aa mo re sclc<"ti vcly o n the peripheral h11
tamine receptors. '11iese med ica tio ns do not cross thr
blood-brain barrier easily a nd so dre safer for U!f with
cen tral nervous system (CNS) depressants.
Dozens of anti h istam ines are ava ilable for use. and
tolerance to them can develop. An tihistamines may bt
used interchangeably to find the most efTooi\ogmt to
relieve the symptoms, matching dnog 10 patient and hr>
or her tolerance. When choosing from among ''i1iblllr
antihistamine p roduas, evaluation must indudt faaon
such as potency, duration of action. and mcidmct of
side effects such as drowsiness. Often sewral ~
lions may be tried before the appropriate drug for thr
person is found.
Because histamine also cauo;es motion ~1cl.nn>.
over-the-counter (OTC) antih istamines may be u.>ed ID
relieve these symptoms, a. well as venigo. hay fflTI
allergic coughs, allergic rhinitis, and a llergies to 1m1
bites and contact dermatitis. T h ese produru are al<O
used as sedatives be<"ausc o f the major side effoo of
sedation. Many OTC d nrgs con tain antihistamines~
sleeping aid s (e.g . Nytol) . Oral absorption of thnf
agems is good, w i1h most h avi ng an onset of ction
within 15 in 60 minutes.
When a ntih ista mi nes are given fo r 11.1sal secmio111 of
a commo n cold, the rcsulrn111 thickening of bronchial
 - - - ---~_ __;:C:.;;
H:_:APTER 25 Resp111tory System Disorders 447

Acute and ch!lll!IC ai<:ohol. antich0f1nerg1CS.

allergic reactions MAOls
1nclud1ng allergic
rhinitis, dermatitis.
and hay few1
~ramrne (Btomax) 11 mgPObtd
..,llJrptei ram1ne (Chlor- 4 mg PO Q46h
T111neton. and others) SA 8-12mgPOq812h
d1menhydrinate' (Dramamine) 50-100 mg PO q46h
1phenhydramine 1(Benadryl) 25' 50' mg PO q4-Sh
mectwne(Antive11: 1Bonine . 25-100 mg PO daily
Dramamine Noodrowsy) in divided doses

SECONDGENERATION DRUGS Same as for Same as for first

first-generation generation drugs
drugs
cttlll!ll1e' fZyr1ecJ 5-10 mg PO Qd
k.afenadrne' ' (Allegra) 60-180 mg PO Qd
loratad ne (Clamin. Alave11) lOmgPOqd
desloratadine' (Clannex) 5 mg PO qd

SECOND-GENERATION DRUGS Same as for Same as for first

WITH DECONGESTANT" first-generauon geoerauon drugs
drugs
cetmnne + pseudoephedrrne t 20 mg PO qd
(Zynec-0)
texofenadine + pseudoephedrine 60 mg/120 mg PO Qd
Allegra-DI
bioaoone + pseudoephednne 5mg/120 mg-
(ClarrurH>, AlavellO) 10 mg/240 mg PO Qd

NASAL SPRAY ANTIHISTAMINE

azelastine' (Astelin. Astepro) 12 sprays each Environmental None indicated
nostril twice daily irritants and
seasmal allergic
rh1mt1s
D. dealrlgestant. MAO/, monoamine ox1dase 1nh1b11or; NO, non-drowsy. PO. orally
"OTC medication
'flte1Upuon medication

secretions may cause airway o bs tructi on. especia lly in
patienlS with COP!). More antihistam ines and an tih is-
umine-decongest.mt combinations are being sold OTC
w11h reduced do~age r.1ther than on a prescription.only
bJ$iS. Care shou ld he taken wi1h patienl.S who have
glauco ma, ulcers, or u rine retentio n because of the
drying effectSof amil1istamines and the resultalll buildup
of pressure in the eye. Drtrpynmldal symptoms such
as tremors. dystonia. and Parkinsonlike symp1oms
should be reponed immediately.
 448 StCllON V Med1cauons Related to Body Systems
Care li0Uld be talen when using ant1h1~1am nes and opera I
111g machincly because of the sedat ng effects. The pa11em
should evaluate tus or her Slate of alertness before operating
madnnerv or driVVlQ a car
7 Ant hi tammes 111e drying frequent sips of water. a poece of
hard candy or chew ng gum may temporal ly provide re 1ef
3 When an11liSl3mlnllS 819 taken for motJOn SIC <oess. the dose
should be raken llPIJl1l"mately ~ llllllli:es to 1 hour before
uavel depanure
4 Pat er ts v. th bcncgn prostatoc hypettrO!irf or card10Vascular
disease e:pecaa y h-jperlensaon should not use an11tusia-
mmes w thou! a ~ian's SIJPOMSICJll
5 Ak:ohol should not be used with 6rst-gene<at1011 anWUsta-
m1nes because of synerg1st.c elfects
6 When using medicatlOllS for a lergic th1rut1s. a ergens such
as pol utton nd SlllQke sholild be aVOoded
7 Because many cold and coogh prepara!IOl1S contain ant1h1s
tamines. pa11en1s should not mix cold and cough preparations
without professional ad.ice
...
Allergic rh1ni11s. most common of all allergic disorders. is
1rea1od with ant1h1stam111es
Ant1h1stam1nes decrease histamine secretions throughout
the body and may cause d1wness, drows111ess. photosensi
tlVlty, and headaches
A1111h1stam1nes relieve coughs and colds as well as mouon
sickness
Ant1h1stam1nes relieve rh1northea. sneezing, and 11ch1ng but
do not relieve nasal or chest congestoon
Sedation. a common side effect of first~ration anllh1sta
mines. has been reduced to basically no probletn 1n second
generatlOll ag..~ts
Decongestants ~~~~~~~~~-
Deco ng e~tnt~. u~ to relie\'l' nasal congestion. ate
vaso<onstriamg agents that shrink the swolll'n mucous
membranes o( nas.11 pass.1ges. with a resultant decrease
in nasal drainage (111ble 252) These agrnts come as
both oral and nasal preparations. Most oral agents are
adrenergic medications or medications that mimic th.-
effects o( the sympathetic nervous system. Label warn.
ing. on OTC preparations instruct patil'llts with hyper
tension, hypenhyroidism. diabe11'S mellitus, or ischemic
heart disease to use these drug.s with care.
Decongestants and antihistamines are often com
bine<I, but care should be taken 10 keep the dosage
within a s,1(e r.1nge. 'J\o agents. phenylephrine and pseu
doephcd ri ne. arc considered safe as decongestants when
used as th<' label indicates. Medica tions containing thtx
agents .;ause vasoconstriction and shrinking of swolkn
membran<'s. l'henylephrine. the most widely u5'(! ri
decongestants. is administered topically in the no,.
alone or as an active ingredient in combination "'th
other preparations. \.\lhl'n decongestants such
naz.olirie (Afrin) and pheriylephririe (Neo-Synqihnn.)
as..,..
are used topically. aaion is rapid, wherl'Js oral ~.
lions such as P"'"doephedririe (Sudafed and Coni.}
have delayed and prolonged response<;. l'sl'ud'l'hal.
rine has a high inddence o( CNS stimulation and u l!1ll
as widely used as phenylephrine. Persons talong ~
as an herbal supplement should be extremely ardtj
when using decongestants because o( synergistic acuon.
Decongestants, topical and oral. are for shont"11f
use. with rebound congestion occurring with jia1 a fn.
days of constant use. The patient may dewlap habinu.
tion with use on a prolonged regular basis. With IOPICI
nasal agents. the possibility of rebound congauon
becomes greater as the effect o( nasal spray wears off lo
overcome this, patients tend 10 use larger medicauon
doses more frequently. This cycle of escalJting con~
tion followed by increased doses of medication will
become progressively worse unless the l)atient $IOps
using topical decongesrnms completely. Disco111inua11on
of topical sprays of1cn produces severe congestion for
several days until mucous membranes adjust 10 lark o(
medication. Therefore to picil l decongestants are inap.
propriate for patients with chron ic rh initis symptoms.
Because of the danger of rebound congestion. the time
limit for using topical decongestants on a regular bas~
should be 5 days.
Because of abuse potential and use with 1lllc1t drug ma<llacM
1ng, pseudoephednne now 1s a med1cauon that has aresi1t1~
on the amount that may be purchased at a t111l8
[lmponiiilt ]FiiCti8iiO'i.iiTDecongesta
Decongestants should be used only on advice ol phy-11!
patients W1th heart disease. glaucoma and prosti:a caur
Self-med1ca1ion using OTC preparahons should be Mide1
as these may cause tachycardia. nervousness. resuessm::.
insomnia. blurred vision. and nausea and vomiting
Overuse_ or con11nued use or nasal sprays causes lel:Qn!
congestion. making symptoms worse and hawig 1nherenl
danger of side effects rrom 111creas111g medica11on use
Topical decongestants (e.g., nasal sprays} act 1apidly and
produce minimal systemic effects. although oral dcconget
tams work slowly. producing central neNOUS system $t1mula-
t1on. no rebound congestion occurs. so these should be used
for therapy lasting longer
 --~-----=
C:.::..:HAPTfR 25 Resp1tatory System Disorders 449

Nonallergic rhirllt1s, such MAOls

as common cold
ep nephnne 0.1 'lb {AsthmaHaler Mist, 1 or 2 inhalations
8rookaid Mist Primatene Mist)
(Adienalinl
naitoarofine 0 05% {Allerest. Privine) 2 drops or sprays tOpically in
nosuil
..,,ootarohne 0 OS'lb (Afnn, Onstan) 2 sprays topically on nostril
bid
j:ilenyleptuine 0 125%1% (Neo Several drops in nostril. 1 or 2
Synephnne. Sonex) nasal sprays q4h
~ine O05-01 % (Tyzine) 2-4 drops m topically on
nostril q4-8h
<1lometazohne 0 I% (Ouivin, 2-3 drops topically in nostril.
T11am1mcl 2 or 3 nasal sprays q8-10h
ORAL DECONGESTANTS
~ine (Sudafed) 60 mg PO q4-6h
SOOaled 12 lfVSudaled 24 HR) 120 mg (sus1a1ned-release)
/240 mg PO q12h

COMBINATION DECONGESTANTS
oua1fenesin + pseudoephedrine 60 mg/120 mg PO ql 2h
iGua1fenex PSE. Mucmex.
lrrammic. Robitussm PE)
cl! !1pheniramine + pseudoephednne 1 tab PO q12h
ISudafed Plus. Chlor-Tnmeton 0)
dexvomethorphan 1 I tabPOQ12h
pseudoephedrine (m combination
With aceiam nophen) (Allerest
Cmtac. many OTC combinations)
ZlNCPREPARATIONS
111oonium glucosa1mn0 (Zicam. I dose as nasal spray or Common cold Usually none
ColdEeze) nasal gel applied locally
~ Mouanmie oudase mhrbtOC PO. mlly
rJtanl available mseve<al dofferent fom-..los and forms.
t>Jte- All Ille dnlgs hsted in thos wb!e are avalab!e OTC

rhinitis. If nasal congestion is present, a topical nasal

Cromolyn Sodium
lnuanasal cromolyn sodium ("'a\akrom) relieves aller-
gic rhmitis by prcvcnung rclcao;e of hbtamine atter al ler-
gen exposure, so iL is more effective if used before the
oni.et orallergic symptoms caused by hista mines. A1>1,,ox-
ima1ely a week is nccd<"d for cromolyn 10 be effeciive, so
lhJS lll<'dication should be u!.ed throughout allergy
ic.ison Ctomolyn provides no relief for nonallergic
decongestant may be used before cromolyn.
Glucocorticoids
Nasal glucoconicoids, such asjl111icaso11e (Honase) and
triornclnolo11e (Nasacon), should be used at times when
prolonged effectiveness for seasonal and perennial
rhini1is is needed. These agents suppress symptoms
450 SECTION V Medicabons Related to Body Systems -~-----

I nasal spray q4.Ql

Allergic rtunrus Usually none

INTRANASAL GLUCOCORTICOIOS
beclomethasone !Beainasel 1 puff in nosu1I bid
budesonide !Rh1nocort aqua) 2-4 nasal puffs qd
nun1sohde 2 nasal puffs bid
Outicasone fflonase. Veramystl 2 nasal puffs qd
mamc1nolone tNasacon AO) 1 or 2 nasal pt1ffs qd
mometasone tNasonex) I spray in nostril qd
c1cleso111de !Omnansl 2 sprays in each nosll1I bid
"All of Ille dtugs 111lhaslableare10p1Cat al>lfic.ition to nasal ca>1ty
Noto AJI Ille drugs lisli!d m dllS table are ?'estriptJOll dtugs

TABLE 25 4 DIFFERENCES AMONG ALLERGIC RHINITIS. COLDS. AND INFLUENZA

I I I I

Feve1 No Occasionally Common, with temperatures of 102"-104 Fwith

sudden onset
Aching. pain No Very occasionally May be severe
Sneezing Yes Yes Infrequent
Itching Yes No No
Cough Oce<Js1onally Usually Yes
Occurrence Seasonal Anytime Any11me
Headache Maybe Infrequent Usually
Cause Alie.gens Vital Viral

of allergic rhinitis-congestion. rhlnorrhu, sneezing. common ly pu rchased OTC medications. as shown in

itching. and erythema. Unlike corticosteroids used for
ot her conditions. these drugs have minimal systemic
effects with topical nasal use. but their use should be
limited to I month at a time (Table 253).
Tables 25 1 a nd 252. Some Me combinations of decon
gestants o r a ntihi.iamincs with dntitussive$ or analgt-
sics. In most cases. th e OTC medication dosage has been
reduced from that found in prescription medications.
Othe~ newer ore med icati ons such as Cold-Leu

OTC Products for Upper and homeop.11hic med ications such as Airborne h.-t
Respiratory Conditions zinc bases.

u_s_citizens spend billions of dollal'$ yearly on OTC

medications. with approximately one third being used
for upper respiratory tract conditions. such as colds.
cough, ~llergies. and related symptoms Table 25-4 com-
pares signs and symptoms of allergies. influen7-a, and the
common cold_
Many forms of OTC medications arc available for
upper respiratory conditions; these agents are the most
Combination OTC Products
Combinatio n OTC products should be careful!)' sdtctid
beca'' multidrug formulas have some drugs unntaS-
sary for specific diw rders. Decongestants, antitussl\"'
and analgesics are used to relieve obvious cold symi>
toms of rhinorrhea. cough, sneezing. sore throa~ he.id
ache, malaise. and aching. whereas antihistamines will

.uwress sretion of. mucus
I
through
. .
anticholinh~rgic
,cuon Beause no singe med1ca11on relieves all Id
11111ptoml. th~ p~annaceutical industry has fonnul~~ed
\'3rious comb1.nauon .Products to relieve multiple symp-
tom~ A cold 1s self-hm1ting because of it> viral nat
but symptoms sho uld be addressed fo r patient comf~r~:
Disadv,1ntJges of combmauon medications are subther-
apet11ic levels fou11d with some do;ages and excessive
lt1'tlS of chemical agents that arc not needed. If the
pJtle1lt h~ only one symptom to relieve, then a single-
tnlll)' preparation should be US<!d. If an ad.-erse reaaion
occurs with use of combination medications. the offend
1ng medication may not be identified. For safety, if an
~OJlg<Sic-.mtipyretic is necessary. it i.hou ld be selected
and given separately. These combinatio ns should be
avoided in most viral infections to prevent missing a
diagnosis of a secondary bacterial infect ion that may be
present.
Under Food and Drug Administration (FDA) regula-
tions. a brand-name product may be reformulated
1nd sold under the previous name l11us. unless they
1tt mremely careful to read medication labels with
t.JCh purchase. patients may buy a product that lacks
agml5 contained in the same product purchased
previously
Zinc-Based OTC Product s
In recent )'l'ars, ,inc-based products such as Cold-Ee1,.e
and /.icam ha'C been used for common cold symptoms.
Some produas are available as zinc gluron,11e lozenges
that hil\'I' an unpleasant taste. Other items are available
as zinc i luwnau glycine (Zic,un) in the form of dose
spoons, nasal sprays, swabs, gels. and tJblets 1ha1 melt
tn the momh and may cause loss of smel l and taste.
Zincba>ed chemica ls are also found in rombination
with dc(Ongestants and anti histamines for relief or
symptoms (s~-c Table 252 ).
Herbal Cold Prophylactic Product s
Airborne 1s a unique blend of herb,ll CJ<lraas. vitamins.
electrolytes. and amino acids for ,1 boost to the immune
.l}~tem. It is to be used for prophylaxis against the
cornmon cold. Th is product is available as .1n efferves
<e111 t:tblet nnd a lozenge.
A.ctlome was created by a teacher who was c:onstantly exposed
to geims 111 the classroom and wanted some agent fOf
!JUPhylax is
CHAPTER 25 Respiratory System Disorders 451
Nasal st ng ng and burning may OCCIJf w th ropical nasal
products Ztncbased Sll'll\'$ may cause .anosmia
2 Applicatos for top cal Msal decoogesiants !nose drops and
nasal sprays) should be cleaned alter ei!Ch use.
3 Nasal spray up should not touch M$al mucosa. and container
of med1catton should not be shared with anyone
4 Na!ial di0ps shoold be administered tn a lateral head-low
pos111on to allow spread over nasal mucosa
DRUGS USED FOR COUGHS
Coughing is a reflex beneficial for removing foreign
matter from the respiratory tract, dear airways, and
remove exce secretions from the bronchial tree. Cough
preparations are used 10 suppress cough intensity and
frequenC) while allowing secretions to be eliminated
Coughs that prevent sleep or cau~ d1scomfon related to
upper respiratory tract infections (llRJs) should be
treated. A dry nonproductive cough should be created
because it can be exhausting. painful, and detrimental to
1he cirmlatory system and the elast icity of the respiratory
system. When coughing is prolonged or spastic. hcmo
pt)'''" may occur. However, a 1>roduc1lve cough from
COl'D should not be suppressed
Antitu ssives
fhc two major groups of antitussivcs are opioid and
nonopioid. The opioid cough suppres.ants. Schedule Ill
medirations, that contain hydrocodone require a pre-
scription. Codeine cough su1>1>ressants are Schedule V
medications and may not require a pre~cription, depend
ing o n the laws of each s1a1c. Nonopioid antitussives
may require a prescription, but some are available OTC
fl:lble 255 ).
Opioid Cough Suppressants
Codeine and codeine-like products are the most effective
prescription cough suppressants ror routine prescription
use. Codeine suppresses hot h cough frequency and
intensity by elevating the cough th reshold. Given ora lly,
doses remain low (approximMely one tenth of tha1
needed to relieve pain), so the chance of physical depen-
dence is low when taken as directed. Most cough mix
tures are Schedule Ill, IV, or V medications. In some
states, Schedule V medications may be bought OTC
if the patient signs a roS1er showing receipt of the
medication.
452 SECTION V Medicauons Related to Body Systems

OPIOIOS
1().20 mg l'O q3-81 Suwession of dfY, 1mtaung coughs See under Anaiges.a m
co1' v QJS prepara11ons in various Chapter 15
of upper resporatOI'( diseases
"'d ' alcohol
lr,lllococbie t~omet Tussignon) S-10 mg l'O q4-91
w1th cf lclrt 1 -.une tTUSSlOreXI 12 tsp l'O q

NONOPIOIOS Cough suwess1on

1().30 mg PO q4-9I MAOls
ooxtrOI"' rp1 n w.th goa1fenesm
tSW\ltS, lk.<V:.n OM one lozenge q4-91
Rot.tussin OM. Romotar Cf) 10 ml q4-6h
(llenylin OMI 1().20 mg PO q4h
d1phen/1ydram1ne' t8enad1YIJ 25 mg PO q4-lih Basically none
benzonatate ITessalooJ 100 mg cap PO ud Basically none

f'l'escnpt1on med1<a11on

cough Pll!ll<llations ooe by prescnpt1on. although some preparations that are Schedule vdrugs. may be bought OTC. depending on the lll'llunl cl
'OTC medico11on.
'Codeine
codeine present ond s1a1e regula11oos Customer must sign fo1 OTC medications 10 _show proof of r~cipt.
'When 'OM' follows cough prnpara11ons. In most aiscs dextromethorpan 1s found in the med1C<itoo

medications, has an antitussivc dose of25 mg every4 to

BOX 25 t COMMON OTC PREPARATIONS CONTAINING 6 hours. 111e cough suppression comes with sedation .as
DEXTROMETHORPHAN
a side effect.
Ch1ld111n's Nyqu1I Berrumatate (Tcssalon), re l,u cd to tctrataln (a local
Cheracol 0 anesthetic), relieves coughing by peripherally ancsthetlb
Mul11symptom Tyleool Cold ing cough receptors. 1lwse gelca ps should I": sw<1llOl>td
Naldocon OX intact to p revent anesthesia in the mouth. Jl11s drug m~
Novah1st1ne OMX affect the gag reflex but has no major ~trmic effcm or
Nyquol Noghttir!IB Cold Fonmula interactions with o ther medications. Onset of action~
Rob1tuss1n CF about I 5 to 20 minutes, with a duration of action o1
Tylenol Cold approximately 8 hour< (see T.1ble 25-S)
Voeks formula 440 and 44M

Nonopioid Cough Suppressants If a rough produces significant amounts of s;iut an

Nonadd1aing nonop101d cough suppressants do not
should be taken on using cough suppressants betdUSI! rm/>
have the gastromtesunal side efToos found with codeine
1ng may be needed to expel sputum
preparations.
2. All OTC labels should be read carefully bcfOl'e OTC ttugsn
/k.<1ro11U'rlwrpl11111, one of the most effective nonopi- taken.
oid cough medicines, does not suppress respirations.
3 If a cough persists for mllfe than I0 days w11h hili1 IMJ IJ
Used in recommended doses, it is just as effective as
chest pain. consult a health care provider
codeine except for severe acute coughs. Dextrometho-
4 Antituss1ves should be taken only in specified dosage$
rphJn should not be taken with monoamine oxidase
5 Avoid initants such as smoking and du~I to decrease thrtll!
inhibitolll (MAOls) because of the chance of excitability.
irritauon
sedation, and severe hyJ>('nension (see Box 25-1 for
6. Chew gum. dnnk frequent sips of water. or suck on sugarless
common dex11omethorphan OTC prep.irations).
hard candy to diminish coughing However, sugarless proo
Olpl1e11hydra111lne (Benadryl), an active ingred ient
in many OTC preparations and in some prescription
ucts may produce flatulence
 ------------~CH~A~
PITR 25 Respiratory System Disorders
, Coughing is necessary to clear respiratory tract secretions
Ant11u,s1ves should be used when coughing 1s nonproductive
interrupts daily activities. or is excessive.
Cough preparations containing codeme or codeine-like medi-
cauons cause drowsiness and should be taken with care
v."en machinery is being operated.
Codeoeand codeine-like preparations are the most effective
axqi suppressants Only small doses are necessary for
al'"'t~ treatment Many an11tussives are Schedule 111
.,
l)pxtr~thorpllan 1s the most effective nonopoord cough
r;pptessant avarlable
The IO\\er respiratory traC1 consists of the bronchial tree
ml tun~ which must be kept patent for the How of air.
Smooth muscles regulate the size of the passage lumen,
and canilage gives suppon 10 keep the passages open.
When lower respiratory tract diseases occur, exchange of
ox)'llen and carbon d ioxide canno1 occur in th e single-
layeroo capillaries of a lveoli, resulting in serious altera-
tions of blood gases. Acute condit ions may include
pneumonia and acute asthmatic anacks. Chronic condi-
tions such asCOl'D (an irreversible disease) and emphy
kllU may lead to bronchiccUI and atclecusis.
S)'rnptoms of lower respiratory disea'CS mclude dyspnea.
>11lttZing. tenacious spurum, and che~1 congestion and
d1scomfon Coro and emphysema eventually lead 10 a
g.is exchange problem with a re~ul t,1111 chronic cough,
susccp1lbili1y to infection, and diflicuhy in engaging in
physic.ii activhy. llronch od ila1ors .md mucolytic agents
arc us<.'d, along wi th breathing exercises and oxygen
therapy, 10 assist in palliatively rel ievl ng the respiralOI)'
S)mp1oms. but the damage 10 the lungs is irreversible.
Trutment or these diseases includes maimenance of
i~'S wing bronchodilators, mucokinetic agents, and
apmoranl$. Chronic conditions may be treated using
comcos1cro1ds 10 reduce the swelling of the bronchial
Lrtt and sympathomimetics 10 reduce the edema and 10
slimuldtc vasodilation and bronchod il ation. Cigarene
smoking and toxic fumes lead 10 chronic bronchia l tree
irri1a1io11, c..1using increased and thickened pul n1onary
stem ions
Asthma is a condition cauwd by an antigen-an tibody
reacuon resulung in wheezing. shonm:ss of breath, and
fttlingof suffoc:aiion from con\trinion of bronchioles.
Th" disorder may be caused by nl.ln)' fanors such as
im1ants, enrcise. infections of the rc<>pirntory tract. aller-
gies, gastroesophageal renux d1sea<e, and s,1licylates. The
453
ain<ay becomes inflamed with edema and mucow.
plugs. wnh bronchial Utt hYJ't'r.ICUvity adding 10
symptoms During asthmatic anack>. when bronchiole
constriction and increased secrcuons are presen~ bron
chodilators are used for relief Abo used for chronic and
acute relief are antiinflamma1ory agents such as gluco-
conicoids and cromolyn. Most nwdicaiions for asthma
arc administered by inhala1ion to achieve more rapid
therapeutic effects in an acute attack and to deliver the
medication directly 10 the site where n is needed and
with minimized systemic effoo
DRUGS FOR CONDITIONS OF THE
LOWER RES Pl RA TORY TRACT
Mucokinetic Agents
Patients with chronic re\pira1ory diseases have exces-
sively thick. tenacious sputum that must be thinned for
pectoratlon. Mucoklnetlc agents, or mucolytics,
are drugs that react with mucus 10 make 11 more watery
'"1us the cough is more producu"e sputum is easier 10
expectorate. and mucus re1en11on is pre--emed. When
using these drugs. the patient must increase fluid intake.
Mucus is a normal secretion from the mucous mem-
brnes o r the respiratory tract. whereas sputum is an
;ibnorma l secretion originating in 1he lower respi ratory
Lr.1Cl. Sputum may contain pa1hologic microorganisms
because thick mucus 1ends 10 remain in place longer.
allowing normal flora 10 become pathologic.
I lypenonic saline solution and acetylC)'l'teine are used
for their mucolytic actions tlyptttonic saline (1.8"6
Mdium chloride) stimulates a cough by irritating the
respiratory mucosa while anmeting water 10 the secre-
tions 10 assist with expulsion. Acetylcysteine (Muco-
myst), a prescription mucoly1ic, is used as an inhalation
agent to make mucus less viscous, bui as an undesireable
cffeet this drug has an unpleasant, mus1y odor (Table
256).
ktJ C NICAL TIP
Hyperton1c saline may be used fat relief as a home remed'( by using
table salt and water as a gargle' as an inhalation 1hrough mists
or 10 a room humidifier. If a hum1d1fier os not available. table salt 1n
boiling water for inhalation as a vapOr will assist with removal of
thick. 1enacious mucus of respiratory diseases
Expec torants
l:x-pcctorants, which render coughs more productive
by stimulating respiratory tract sretions 10 decrease
the viscosity of mucus. are relatively safe drug-;. The
dnig with greatest evidence of safety and effectiveness is
454 SECTION V Medications Related to Body Systems
35 nt of 201(, SOIVllon. 6-10 ml
of lO"lt solutoo. inhaled
pfenesin' (Rob.tuSSlll.. l~mgPOq4h
M..w:~'I
(gua fenesm XR Orgarot11 Nill 600-1200 mg PO q12h
doma38 affa' (Pulmolyme) 2 5 mg lrllaled qd
ore IN!dlcallell
'Prescnpt1011 mcCcalicn
Nola Gua 'enesin IS l>"lllable '" -11 lonnulas based .., p-esent111g symptoms and use. such as Roboluss1n
lhe~I
gualfene1ln. l.xp1oran1> are often combined with other
medic;11ions for resp1ra1ory condi1ions such dS an 1ihisia-
mines. decongestant>, Jnd antilussives 10 help remove
mucus Mos1 have no ~ign1firan1 contraindications.
A specific expectorant for cystic fibrosis, dorntUe alfa
(Pul mo~yme), digests extracellular DNA to improve pul-
mo n,1ry funr1ion and reduces risk of respiratory infec-
tions. The drug work< within 3 to 7 clay:. after the paLienl
s1ans 1aking i1 (see l'J blc 256 ).
Inhalation Medications Used
As Bronchodilators ~~~~~~~~~~~
llirec devices for in halation ad ministra1ion are merered
dose 111/inlm (MDls), 11elmliu1l, and dry pou.ter inltalers
(Orts), each of which provides a differen1 medication
form 10 gi~ a more rapid response. Using 1hese
me1hods of delivery provides local effects, minimizing
sys1emic absorp1ion (see Chapter 13 for inhalation
administralion)
MDls deliver J fine mist of medication that is usually
acrompli~hed with one or 1wo puffs from a hand-held
pressurized device Medicauons delivered by this method
include alburnol (Ventolin) and rrrburaline {Breth
aire) Approximateli IO'l'o of medkations administered
by an MDI reach the lungs Lighty percent is swallowed
in the mouth and phar)'nX. possibly causing stom.Atitis
with longttnn use. Patients must be taught 10 use this
device correctly with hand-lung coordination. Correct
administraiion is diffiruh, but use of a spacer will aid
wi1h appropria1e administration.
01'1 medi<a1ions. such as rlorropium (Spiriva). deliver
a given amouni of medica1ion into the lungs in the form
of dry powder. Dl'ls arc breath activated and easier 10
use than MOls Some medications are available in both
OPI and MDI adm inistration forms.
A nebulbcr uses a s mall machine to conven a solu-
tio n imo a mis~ usi ng sud1 medications as epirrcpl1rine
Thin viscous mucus
Increases outpUt of respiratory
tract ft111ds
Expectorant for cystic fibrosis
OM wti ch con1a.ns 1 c1ecoc,.....
. ' 4
(Prima1ene) and isoethariue (Bronkome1er). Mistdr0y
lets are inhaled either through a fore mask or through~
mouihpiece. Not used as frequ c111ly today, nebuliuti
have a degree of effectiveness th at depends on 1he ""
of med ication d roplets as 1hey reach 1he lungs and Oft
the responsiveness of the pati ent's respira1ory $)~tein
1. When medicallon 1s administered via MDI in tl'<\l pulls. afu
minute should elapse between puffs
2. Patients should ga1gle after use or med1C<Jt1011s dehV1:r
by MDls and DPls to prevent throat 1rn1a11on and pos~
stomatit1s.
Epinephrine, Ephedra, and
Betar Adrenergic Drugs
The major drug.s used to treat asthma and other con!I!'
1jve obstructions of aitwa)"l include S)'lllp.lthomuMJC
medications and xamhine dcrivati"es (1'1ble 25-7)
Nonselective adrenergic mcdicauons such ~s epuvph
rine and ephedrine stimulate body cells to product
vasoconstriction and reduce edema, whereas Othtt
medications stimulate vasodilation and bronchodill-
tion. Epinepl1rine (Adrenalin) and ephedrlnt, with I
rapid onse1 of action, are indicated to pre\'enl broncho-
spasm and for treatment of bronchial asthma nd bro&
chitis. Duration of action is I to 3 hours when u>ed bi
inhalation or I to 4 hours when gi'l?n partntcrallv
Ephedrine, noi "potent a~ epineph rine, is W<!ful when
taken orally, with a longcrdura1ion of action. butr1u!6
n ervousness a nd stimu lai ion o f the hean and nervou1
sys1em.
Be1a-adren ergic ( beta,) d rugs s uch as 111ernprortm1ol
(Alu pcm ) a nd alburerol (Provent ii) work as both wd1.ir
 -----~--=C:.:H::.:A:PTER
..; 25 Respiratory System Disorders '55

~ (Adrenal111. 0 3 mg by injection. 2 25%

erortatd.' Med1haler Ep: Dila t on of bronchia I tree Anesthe!JCS, trlC'ltllC
in NEB inhaled. 10 dr0ps depressants. beta blockers.
P11matene') ol 1% solution by d;g1tahs, cardiac
inhalation
glycosides. ergotamme and
its denYatM)S
iedr111e (Viclcs inhaler) Inhaled topically Same as for eponephnne
~ Sih Effects of Epinephrine and Ephedrine:
weased heart rate. tachycardia, palp1tat1ons, muscle tremors, CNS stimulation, nervousness. anorexia

BETAADRENERGIC AGENTS
'1Jlrooterol (Foradll)
(Xopenex HFll
abuteiol' Nentolin)
\l'rlMlrltil HFA . Ventolin HFA)
ptrtxlterol' fMaxa1rl
terbutaline
meiaproieienol" (Alupentl
sa!meteror (Serl!'IOOt D1skusl
arl0<rooterol (BrDYana)
Same as for epinephrine Same as lor epinephrine
1 cap DPI inhaled in
aerolizer bid
0 63 mg-1.25 mg inhaled in
NEB q612h MDI
45 mcg as MDI q612h
2-4 mg tab PO tidq1d Beta blockers. am1tr1ptyline.
2 puffs inhaled (DPI) q4.oll MAOls
1-2 puffs mhaled (OPIJ q4.oll
2 puffs inhaled (MDI) q4-6h None indicated
2.55 mg PO tid albuterol
025mgSC
2 or 3 inhalations NEB. Q4h Same as for albuterol
aerosol
1 inhalation (DPll btd None ind cated
2 NEB doses q12h COPO. including bronchitis aminophylline. theophylline.
and emphysema diuretics

Major Side Effects of BetaAdrenergic Agenrs:

':ti...ed heart rate. tachycardia. palp11at1ons. muscle tremors. CNS sumulat1on. nervousness. anorexia. neM>Usness
!dd111orr formoterol-tremors, muscle cramps, insomnia. headache: eformoterol-pa1n. headache, neM>Usness. hypotalelllla

METHYLXANTHINES Caffeine. c1me11d1ne.

fluoroquinolone,
am1b1011cs. r1famp1n,
phenobartinat, phenytoin
lileoplyfl1ne. am1nophylhne Vanes by immediate and
IEhxophylhnl sustained-release !actors
dyphylhne fOylix, Lufyllinl 15 mg/kg PO q6h
lhjor Side Effects of Methylxantltinu:
11.usea. anxiety restlessness. gast11c upset. GERO. headache. insomnia. tachycardia. neMJUsness
CNS. central nervous system. COPO. c1>ron1c obstructive pulmonaty disease; OPt. dty powder iMa er: GERO, gas~ reffux disease.
MAOls. monoam1ne oxidaso 1nh1bito1s. MDI. metered dose inhaler; NEB. nebulizer. PO, orally, tm. urinary uact 1nfect1on.
'l'rescnption mcdicahlll>
'OTC ..itC<Jtion Qmrim1ed
456 ECTION V Med1caoons Related to Body SySterns

I AHLI 7, I BRONCHODILATORS cont'd

GENERIC NAME/
TRADE NAME ~ It '
. --- --UTE.
I I . INDICATIONS FOR USE DRUG INTERACTIONS j
Basically none
ANTICHOUNERGIC AGENTS None
~ a II .,,. (Al IV II 2-4 puffs inhaled !MDI) qd
t tn ,_ val 1 puff inhaled IOPIJ qd

M/Of S1"'1 EllKb of Anticllo/1. .tJ1U:

Ory,... ,u 1 UT ~. tt01IOl]lum with rhin1ns

None
COMBINATION
BRONCHODILATORS '
f 11 on Sd odlerr Used 1n chrome asthma.
(Adva1r OuwJ l powder dose inhaled (01'1) emphysema
qlZh
(Advau HfA aerosol) I dose inhaled (MDI) q12h
1prauop1um + albuwol' 2 or 3 puffs inhaled IMOIJ
(Comb1Vllf1t. Ouooebs) q12h

M1jor Sidi EH1c11 of Combin11jon Bronchodilators:

Dry rnou1h w11h Rut1casone + salrnete101

and rcspira1ory agonis1s. Their main adion is on !he
smoo1h muscle of 1he bronchia l lt'ee and on !he hean.
lle1a,.recep1or medica1ion~. the most effooive medica-
l ions 10 reduce acute and exercise-induced broncho-
spasms. su1>press Jung histamine release, provide
bronchodila1io11, and increase dliary mobility to move
mucus. llecause beta, agents are selective, 1hese medica-
1ions have replaced older. less selective sympathomimet-
ies such as epinephrine in 1rea1ing asthma and other
chronic conges1h'I! conditions. Beta, agonists relieve
ongoing asthmatic anacks and may be used prophylaai-
cally and for nttess.11y relief of breakthrough symptoms.
Shon-acting agents begtn 10 work almos1 immediately~
their effoo peaks 111 30 to 60 minutes and Iasis 3 to 5
hours tong-lasting preparations have a slow onset of
adion, but their effects persist for 12 hours. Salmeterol
(Serevent) is preferred for prophylaxis but it is not effec-
tive in aboning an attack because of aaion slowness.
These drugs may be adminis1ered by inhalation and may
also be given orally or by injection.
Xanthine Derivat ives
Xanth ine derivatives relax the smooth muscles of the
bronchial iree and s1imula1e cardiac muscle and the
CNS. '111ese drugs indudc tl1eopliylli11e and arninopliyl-
llrte (Slo-Phylli n, Elixophyllin), used for prevention and
1reat mcn1 of bronchial asthm a and for treatme nt of
emphysema, COPD, a nd bronchicis. Some sc,nes do 001
allow generic product subs1i1u1ions because release 1imc
fo r aetion varies be1ween generic and 1rade name dru&1
Tiwophyl li ne, the basic adive ingredicn1 ofxanthina is
available in oral standard or sustaincd-relea11e formuli~
with fonns effective for up to 24 hours. Because 1heorh
ylline has a narrow therapeucic rnnge and broiuse ~
agonists are safer and more effective. x;inthines ~rt 11<11
used as frequently 1oday. Patien1s with ron~ti\'l' hun
failure. coronary hean dieasc. hypo1hyroidisrn. C00\'11~
si,-e disorders, and acllle pulmonary edema canno1 wot
these derivatives (see Table 25-7).
An t icholinergic Medications
Anlicholinergic (airopine-like) medicatioM. uStd lof
asthma, ad by drying mucous membranes in pa1iam
who cannot use other bronchodilators Wi1h a>lhnu.
anticholinergic medications offer some relief of ;ulhru
symptoms. lpratropiurn (Airovcnt) is used in p.111rn1>
with chronic asthma, has a rapid onset of adion (111
seconds), and reaches maximum effect in 3 minutes. and
effects last for 6 hours (sec 1 ~1ble 25-7) .
Glucocorticoids
Glucoconico ids, effec1ivc . , a11tias1hma1ic mcdic~iloru.
are usually administered by inha l.11ion with cith~ra OPI
or an MDI but may be given oral ly or by injee1ion.'lliest
 CHAPTER 25 Respiratory System Disorders 457
---~

mtdlC3ti<>ns are saf~ and hi_ghly e!fective with gtucocor-

ucoid ;ad'"rse rearuons ~mg n11nor when used for a
,hon pmod of time with anite pulmonary diseases.
Patients using inhaled g ucocortJCOitls should r llS1l the r mou"Uls
f10'eVl!t long-term systemic use has ~ere adverse
afte1 onhahng medications to pie-ent poss1bll ty ()f Otal
dfccts (see Chapter 20). With asthma. these medications cand1d1as1s
suppress inRammatio n an d reduce bronchial tree hyper-
!(Crctions. Prophylactic adm inistration in chron ic
~sthma is preferably given by inhalation 10 prevent sys-
temic side elTectS, whereas o ra l use is effective in severe Prophylactic Medications for Asthma
nthma. Inhaled doses are given on a daily basis, at a Crorroolyn {lntal and 1'asalcrom) and nedocromil
~" dose. and not on an as-needed basis ~cause (lilade) are used to prewnt asthma attacks but are not
of sl0\\1lCSS in development of therapeutic effeas useful for ongoing auacks (Table 259). Cromol)1l sup-
(Tible 25-3). presses mOammation but does not dilate the bronchial

beclomethasono (lleclovent. 2 putts (MDI) bid Chronic or acute asthma attacks See Chapter 20
Vancerll, OVAR)
bl.deson tkl Same as for beclomethasone Same as tor
iPulm1cor1 Flexhaler) 1-4 puffs (MDI) For ages 12 and younger beclome1hasone
iPulllllCOll Respules) NEB Inhaled bid
IUasone lfkM!nt HFA) 2-4 puffs iMOI)
~ 5-60 mg tab PO qod
IQdni30lone iPrelone) 40.60 mg PO qd
Mii. me1e1ed dose onhaler. PO. orally
Note All tile dlugs llSled m this table are prescnp11on medications.

c1omolyn nasal spray Prophylaxis in

(Nasalcroml nebuhzer chronic asthma
zafiilukast (Accolate) 20 mg PO btd aspirin. warfann. glucocOlticoids. phenytoin.
cyclosponne. astem12ole. theopliytline
!>-10mgPOqd Nooe

/0. Olllly d I
Nota All 11'1 drugs listed on t111s table are prescnp11on me ica ions.
458 SECTION V Med1cauons Related to Body Systems
1r<><>; rather, 11 inh1b1tli releas<! of h1st.1mines, acting as
an anuallergenic C:romolyn 1s the prophylactic d rug of
choice for modcfdle Jllergic asthma. especially in chi l-
dren. bt-cau~ of 1t\ y fcty .ind efficacy ILhas no thera-
peuuc effect in acu1t as1hma amids The most common
side effects are whce.t1ng and coughing on adminis-
tr.lllon Ncdocmmil. also anuinflammatory and an1i-
allergic, has an unple.ornt taste.
l.tukotrlnn contnbu1e 10 inflammation associated
with asthma 1.1.'ukouicne antdgomstl> block broocho-
conmi('IJon. producuon of mucus. and inOammation
occurring wnh asthma Zafirluluut (Accolate), the 6rst
medication m tlus nt-w anumflammatory dass. is used
as maintenance therapy for paucms w11h chronic asthma.
II has few side effects bu1 has muluple drug interactions.
Zlleuton (/.yflo) is rapidly absorbed, but its place in
asthma therapy is not completely under111ood. ah hough
n is used for prophylaius and treatmen1 of chronic
as1hma in persons older than l 2 years Mor11"1uka.s1
(Smgulair), a bronchodilator. respira1ory stimulant. and
leukotnene rC<Cptor antago nist.. should be given at night
for maximum effectiveness for prophylactic u>e. If shon-
acting bronchodlla1ors are needed more frequently while
1he 1>a1ien1 is on 111on1eluka>1, 1he physician should be
nmified.
Patient EducetiOril.f OrlCompliance
Crnmolyn 1s for prophylaxis of asthma end should be admm
1stered 30 minutes bcfo10 oxe1c1se.
7 Beta agomsts 10kcn fOI long-term therapy should be taken
011 a 1cgula1 schedule and not only as needed but may be
used for short te1m therapy as needed
3 If symptoms of aslhma become Wl!lse. patients should not
change doses' selfmed1cate w11hoot phys1cran's direction
4 Apahent W>th thick lung secrehons should dnnk six to eight
glas.~es ol water Jl8I dav 10 dec1ease V1SC0S1ty of brnodtial
secret.ans
5 OTC and preso;11pt1on medicatlOlls fOf 1esp1ratD1Y disorders
should not be m"ild because ol the chance of multiple doses
of similar drugs. espeaally svmpathomimetc drugs
6 Colas coffee. chocolate. and chaibroded foods should be
IM>lded wtien taking xamhme preparations sud! as lheophyl-
l1ne and IS denvatr;QS
- .
Many beta. agon sts a1e 1nhalt'<I forms to be deh~ered by
metered d0$e inhaler IMOI) dry i)O'Mle1 nhaler (OPI). or
nebuh1e1. 1a1ely causing systemic side effects.
Asthma and chronc obs1tuct1Ye IJlllmonary disease ICOPD)
are ch1on1c d seases causing inflammation of a11wavs. hyper
act1v1ty of bronchial secretions, and broochospasm. Allergies
mav be the unde1ly1ng cause al asthma
COPO and asthma are treated with an111nflammatOl'f agero
and bronthodilators Correct use of MDls. DPls. and ~
ern rs mcty, and patient education 1s essential
nhaled beta. antagonists a1e the most etfect"e ~ca
to rehew acute bronehospasm and exercl'~1ncb:ed btn-
choSP3sm attac*s
lmaled salmeterol. used to prewnt COPO and as:!ma Jai
a delayed onset and extended durahon of actoi
G1ucocorucoids. are used orally for acute asthma an.acts
prevenuve shoftterm lherapy in respiratory Iran ~
drugs suppress 1nftammat1on of blooch1al asthma
Inhaled glUCOCOlliroids used for long-term prD!Jhv~ s
relanvely safe. with oropharyngeal candld1as1s and~
being ma1or side effects .
Ctomolvn. a nebulized an111nnamma1ory meditatoo is USl'd
for prophylaxis.
Theophylilne and xanth1nes rei'eve COPO and asthlllil i:.,
blonchodilat1on. although xanth1nes have been 1eplacedY11
newer drugs because of narrow therapeutic range anddartJet
of use with some diseases
INFLUENZA A AND B
Influenza, a serious disease causing morbidity and mor.
ia lity throughout the world, is caused b) inOuen1J
viruses. of which two types arc more prevalent: iMj111<>1i:a
A vinis and i11fl111mw R vims. lnfluen1,1 A virus cau;,n
mo re infections than 1ypc B, but these viruses are Con
stantly undergoing evo lutio n and changes 'lhe \'ill!>
enters Lhe body 1hro ugh highly contagio us droplets from
sneezing and coughing, but its replication takes plact
within Lhe respiratory tract.
Influenza is bes1 managed by yeJrly prophyl.ank
influenza vacci nes that change fro m r ear to ycardcpmd-
ing on the e.xpected virus of the current year llO\\'t\tr.
drugs are available for secondary 11eatme111 of the illnes>
These drugs fall in10 two distinct categories a<Umm-
tanes are acti\e agains1 o nly influenza A, wherus !ht
newer drugs, neur mi nidase inhibi1ors. ca n be~ ,.ilfl
either influenza A or B virus
Medications for Inhibition of lnfluen11
Some newer medicatio ns are used to lessen or inh1b1t
signs and sympto ms of mflucnza, bu1 these producu
are no1 substi1u1es for influen/,a vaccine administt1td
to prevent o r attcnua1e symp1o ms. Rather, they art fo1
patients who, fo r med ica l reasons (such as eloolv
patients with severe chronic med ical condilioru) or P"I
sonal reasons, need pro phylaxis ag.1ins1 the disease ~ht1
e.xposure 10 lhe vi rus. These medications are relatiwh
e.xpensive and arc not widely used (Thble 25-10)

TABll l~ 10 DRUGS USED FDR INHIBITION OF INFLUENZA VIRUS
GENERIC NAME/ USUAL DOSE. ROUTE.
TRADE NAME
ANO FREQUENCY
ADAMANTANES
nmantadine (Rumadine) 100 mg PO bid
amantad100 100-200 mg PO bid
HEURAMINIDASE INHIBITORS
-mMr 1Tam1ftu) 75 mg PO bid
JaB!lr. r 11\lenza) 2 lllhalat1ons 15 mg) bod for
treatment. qd lor prophytaic1s
N!e All Iha drugs fisted in this table are p<eSC11pt1on medica11ons.
IABLl 7~ t t DRUGS USED FOR RESPIRATORY SYNCYTIAL VIRUS
nbf1 M IV-aiole) 20 mg inhaled NEB cmr qdl2-18h
pa!~ilulnab lSynag1s) rv
15 mg/l<g once monthly
The ndaman tanes, no t recommended by the Centers
for Disease Control and Prevention (CDC} because of
the fast devdopment of re<istancc. are rirnantadin"
(Flumadine) and a rnantadin" (~ymmetrel), used in the
prophylaxis and treatment of influenza A infections.
~should be used only in the documented presence
of an influenza A virus epidemic
Tht ntwer medications, neuramm1dase inhibitors, are
fairly expensive but are more effe<tivc and better toler-
ated. Oselramiuir (Tam iflu) is ind ic,1ted for the treat
ment of uncomplicated inlluc1w,1 infections (includi ng
avian and swine Ou) with symptoms lll'~Sen l for less tha n
2 days. Z<111am ivir (Relen7A1) is fo1 patients who have
had symptoms for more than 2 da)'ll. ' ll1b medica1ion is
.dmimsttrcd by using a Diskhalcr and a 5-mg blister
fl'd that is inhaled twice a day for S dd)'S, with the doses
Approiumately 12 hours apan. Inhaled bronchodilators
hould be used to open the airways befor" use of zana-
m1vir Safety m patients with COP!) has not been estab
h1hetl, and .1 quest ion has ari,cn concerning safety in
coronary ~aticnts.
NP.w lll!Mral onftuenza medications must be used within 2 days
ol 1t11 cnse1 of svmptoms 10 be effec11ve
CHAPTER 25 Respiratory System Disorders 459
INDICATIONS
FDR USE DRUG INTERACTIONS
Prophylaxis of mfiuenza acetaminophen. aspmn. c1met1d1ne
ant1chohnerg1cs
Nooe
RSV Nudeoside analogues
RSV None
Vaccination against nfluenza A and B slloold be me first hne
of defense. Disease treatment should be used only v.hen
necessaiy
Amantad1nes are used With care 1n lhe elderly for prophylaxis
and 1reo1men1 of 1nftuerua A 111fecll00$
Neuram1nidase inh1bilors are used w1111 influenza A and B
inrec11ons.
MEDICATIONS FOR RE SPIRATORY
SYNCYTIAL VIRUS INFECTION
Respiratory syncytial \inus (RSV) is a major lower respira-
tory tract infection in the young. the elderly, and those
with cardiac, respiratory, or immune system diseases.
Uke innuenza it is seasonal. l\vo drugs are approved for
use against this disease, although neither is really effec
live: ribavirin is in inhaled or o r.ii form, and palivi-
zumab is injectable. Ribalriri (Virazole), also used for
hep,1titis C. is a broad-specuum vinustatic antiviral drug.
Expense (over $1300 per day) with minimal benefits
necessitates selectiw use of the medication. Palivi.wmab
(Synagis) is used with children and those with chronic
r~piraiory diseases. This medication, which should be
given before and through RSV season, is given intramus-
cularly .ind costs about $7000 sesonally (Table 25- 11).
460 ;ECTIONV Med1caoons Related 10 Body Systems

be used prophylactically for asth ma over a long llerJOd

SUMMARY
I ffecll\'elll'SS of the resp1ra1ory S)'Stcm affectS the body's
.1bilny to funcuon in homeostasis lhe respiratory iraa
is neccuary for inspirauon of oxygen and expiration
of c.irbon diolOdt Oxygen 1> l'Ssential to sustain life
llttatlS(' of Hammab1lny, the nttd for safety with thera-
peutic oxygen around names should be explained during
pauent teaching
Anuhistammn are used to relie\'e allergic reactions
and are also used frequently 10 relieve rhinorrltea and
allergic bronchttis Allied ht'alth professionals must
know '.l)'Olptoms of allergic conduions "ersus common
colds versus onOurn1.1 to be sure that an antihistamine
is the correct medicauon for use. If congestion is from
colds, a decongcstJnt 1s more appropriate, to relieve
thickened mucus
Cough-suppre<;ing preparations are indicated for dry,
nonproduoi"e coughs that interrupt daily activities. If a
cough is producuv~. suppression is not appropriate and
an expectoram may be administered to help ex:pel secre-
tions For thick phlC!lm or sputum, mucolytics may be
prescribed to decrc,1se the secretions' viscosity. Many
preparations are .1v.1ilJble OTC, so a working knowledge
of indications for each is important.
llccausc topical na,al prep.irations are readily avail-
able. ,111 explanation of the d,111gers of rebound conges-
1io n when used for more Lha 11 shon-1erm 1herapy, usually
no longrr 1han n week, is imponant. Cromo lyn may
of time.
Bronchodilators for smooth muscle relax.ition ,,,
used tO ease breathing in the 1rea1me111 or a!lhm.
COPD. and chronic bronchitis. Some agems. sudi ~
epinephrine and be1a,_agonists, are usi;d in acuttmpo11
tory attacks. Others include leukoinene agonisu. for
long-term therapy; albuterol, for exerti~indU<ftl
asthma; and cromolyn. Clucoconicoi<h. rtlath'tl> sat
for shon term use with bronchoconstriction and ..,
liquefy thick mucous secredo~s. are admoniSlm.t bi
inhalation to achie"e local respiratory tract tfTtct~
corD and asthma should be treated on in 1ndm~
alized basis, as should allergic condi1ions In t~lJ!Wlll
of these conditions. especially with antihistamines, drug
tolerance occurs and medica1ions may nttd changi"
regularly. For persons with seasonal allergies, prophi
taxis by avoiding allergens is indicated; for chronic Min
gic reaaions, cromolyn may be indica ted for long-ltrm
prophylaxis.
Two groups of medications to prevent or reduct
symptoms of inOuenza A and ll arc available as na$dl or
oral preparations. llecause of the expense. thesedrugure
not u sed routinely. The best p rophylaxis for infturnz.i
remains Lhe a nnua l immunization wi th inftu<'n u
vaccine.
RSV is a m ajor disease in the elderly and children. rwo
d rugs are ava il able to treat this d isease, bu11rea1mem ~
very expens ive and s hould begin before and continue
throughout th e dise;isc season .

Scenario
Smokey has COPO. and hs brea1hmg has become progressively more d1fficut1. Hts physician has
prescflbed sympa1hom1metic bronchod1lators for his condition. Smokey wants to know how these w'!
help his cond1t10n when he is admmistenng the medica1ions by breaching them through the mouth
rather than taking a tablet.
1 How would you explain the actt0ns. safety. and prolonged use of the medicines to Smoke ?
2. He also tells you that the prescribed low dose of oxygen does not seem to help him al all,Yand he
wants to increase the flow to 6 lJm1n, rather than the prescribed 2 LJmin as order d H Id
you explain the dangers of this change? e ow wou
3. What questions should the allied health professional ask about bronch'al
1 secretions d
expel these secretions? an the ab1h1y 10
 --~--- CHAPTER 25 Respiratory System Disorders 461

DRUG CA L C ULATION S
1 Order guaifenesin ER 600 mg q 12h
2. Order. diphenh>'llrnmrne 60 mg
1wJilable medication:

--- Available medication.

_...,
l..,ott2010t~

__
I "
~-'i51"'9 .............
,.,....~
....
.
=CUl;IOidlt.iWf\5~ AICorlol
Benadryl
...
0. ., ..
~o-. tl0 2~
...... w..__.,
2I04~(H..

-----
c ...........

4 FllJIX)lN::ES
fl'ARt<l OAVIS
DN., w.,~ co
"'"*
-............,...,
. . . . . - . . . . CM! atr.IMICI\

............c ...IJ}.,....... .....

MOl',lt ........ M..101950 USA

l Ofjl-1 \YI I( 1.\1\l I I' nose to be adminis1ercd. - - - -- - - -- -

What amount of medication would be administered

using household utensils! - - - -- -- - - -

LOT31...08-I .G

Dose 10 be administered: - - - - - -- - - -- -

REVIEW QUESTIONS

I Why do we use antihistamin es? Decongestants?---- - - - -- - - -- -- - - -- -- -- -

2 What is the indica tion for to pical nasal glucocon icoids? What is the safety factor in using these medications?

l \\'hen would >'OU expect the phy.1d an to order a cough suppress.1nt? A mucol}>tid An expectorant! - - - - -

4 What is tlie com mon mcdic.uio n found in no no pioid cough suppressants? What arc the expected side effect.~?

5 What do bronchodilato rs do ! - - - -- - - -- - - - -- -- -- -- - - -- -- - - -
462 SECTION V Med1c1uons Related to Body Systems

6 What are the three inhalauon devices used to deliver medications as topical bronchodi lators1 I low d~s each Ont
wurkl

7 C.lucoconico1J\ are gener.tlly discouraged for long-term oral therapy. Why are the to1>ical agents for asthn~ ron
~idered r.-asonably i.afl' for long-term use! - --- - - - --- --- ------------
8 What mt.'(hcauons are available for the prophylaxis of influenza! - - -- - - - - - - - - - - - -

'). Why must the proph)lacuc agents for asthma be taken on a regular basis rather than pm? - -- -- - -
Circulatory System and Blood Disorders

After studying this chapter, you should be capable of doing the following
Discussing how medications are used for
Clfculatory and blood disorders and the need for
patient compliance through educauon.
Describing use of medications to relieve stable
1exerttonal) angina and variant (vasospasucl angina.
Explaining how card1oton1cs are used in coronary
disease.
Explaining how medications are used to maintain
regular and adequate cardiac rhythm
Explaining objectives of ant1hypertensive therapy,
medications used, and the need for
1ndividualizat1on for patient compliance.
Descnbong prevention of atherosclerouc heart
disease through use of hypohp1dem1cs and
peripheral vasodolators.
Discussing role of anticoagulants and their
antagonists. thrombolyt1cs. and anuplatelet agents
on heart disease.
Describing use of hematop01etics and
erythropoieucs for building blood components.
Providing patient education for comphance with
medications used to treat diseases and conditions
of the circulatory system.

Ms. El/ory, age 67, has a history of angina pectoris for which Dr. Merry has prescflbed nitroglycerin
patches. Ms Ellary knows she should change the patch daily, leaving It off for several hours dunng
the day
What else does Ms Ellory need to know about the placement of patches?
What does she need to know about administration of the nitroglycerin tablets that Dr. Merry has also
p<escrobed?
After the con tamer has been opened. how long will these subhngual tablets main ta on their strength?
Should Ms. Ellery carry this med1cat1on with her at all tomes? Why or why not?
Can she put some tablets in another clear medicine bonle wrth other medocauons? Why or why not?

Ectopic beat s Low-density Point of maximum

Aggregation
Embolus lipoprotein (LOLI impulse (PMI)
Angina pectoris
Glyco side Myocardial infarction Sympatholytic agent
Arrhythmia
Hem ostasi s (Mil Thromboembolism
Arteriosclerosis
High-density Necrosis Thrombus
Atherosclerosis
lipop rotei n (HOL) Orthostatic Tr iglycerides
Automaticity
Hypertension hypotension Vasoconstrictors
Chronotropic
lnotropic effect Paresthesia Vasodilators
effect
Peripheral vascular Very-low-density
Digitalization Intermittent
resistance lipoprotein (VLOL)
Dromotropic effect claudication
Dysrhythmia lschemia

463
464 SECTIONV Med1ce11ons Related 10 Body Systems

EASY WORKING KNOWLEDGE OF INOICATIONS ANO SIDE EFFECTS

Common Side Effects of Circulatory Medications
Common Symptoms of C1rcul11orv Disorders
Chest Pfl!ll Onhos1at1c hypotensioo
Oyspnea ladr,.pnea Unnarv frequency
Headaches. dizziness. hghtheadedness
fatigue and weakness
Pa P.latOOS tachy!:ard a Anorexia
Biadycardia Nausea. diarrhea. 0< constipa11on
Pa !or cyarcsis Faugue and weakneSS
Edema Bradycard<a
Syncope
Unusual sweating
Natne3 vorNting. anore"a
He3!laclle
Anxiety

EASY WORKING KNOWLEDGE Of DRUGS USED TO TREAT CIRCULATORY DISORDERS

An11ang1nal agents Yes No B. C. X(amyl nnrate) Relieve angina pec1or1s

Cardiac glycos1dos Yes No c Treat congesove hean laiure
Ant1arrhy1hm1c agents Yes No B. c. D Treal dysrhythm1as and
disorders of cardiac rhythm
D1u1e11cs Yes Yes (e.g., caffeine) B.C Treat edema of congestive
heart lailure and
hypertension
Am1hypenens1ves Yes No B. C. 0 {ACE inhrbilors) Treat hypenens100
Peripheral vasod1lators Yes No C{cilostazol) Treat perrpheral vascular
disease
HVPOhp1demtts Yes No B, C, X{slatins) Treal elevated serum
llpoproto1ns
An11coagulants Yes No B, C. X{oral Prevent venous thrombi
anticoagulants)
Thrombolyl<CS Yes No B.C Dissolve lhrombt
Anllplatelel med!C<lttons Yes Yes C. D(aspirin in the Prevent aggregation of
thud 111mester) pta1ele1s and prewni
anerial lhrombi
Topecal hetnos!attCS Yes No Provide lopocal l8nos1.lsls
HemalQPO!ellCS. Yes No c Increase proclJctol o1 bbl!
e<yth<opoiellcs cells

ccordmg to American I lean /\ssoc:iation statistics.

A cardiovasC\llar dise.1se is the leading cause of death

in the United Stat~ with one out of every five
deaths directly related lo such diseases. More than 60
million Americans have ~ome type of heart condition.
Major advances have b~-.,n made in knowledge and treat-
ment of heart disease, and with this knowledge have come
major changes in phannacologic treatment of heart
conditions.
FUNCTION OF THE
CIRCULATORY SYSTEM
The circu latory system, composo:d of the hean and blooJ
vessels, has two pri mary function~: ( 1) dcliveryofoX)'8""
nutrients, hormones, :md other essential body iul>
stances i ll blood to cells th roughout body and (l)
removal of waste products from cells. l'ulrnon;uv

Superior vena c-ava
Pulmonary valve
Pulmonary artery _ __..,__,,._.
Ascending aorta 7"":t-..-.,_-I-
Pulmonary \leins
TrlCUSj)ld valve
Fi9u11 26-1 lncernal view ol heon (From Young AP. P1oc101 DB. Kmn's tile med1~/ oss1stil/IL an applied leam1~ approach, ed 11, St Louis. 2011,
Saunders I
dmJIJuon is responsible for oxygen and carbon dioxide
ochJngr by carrying blood 10 lungs 10 receive inhaled
~-gen and removing carbon dioxide by cxhal,uion.
Coronary circulation pro motes nutrition and health of
hear1 muscle itself. System ic ci rculation dcl iv~rs b lood
and its componen l\ to all tissues except lungs :ind
nt)'OC'~rdiwn.
\ \trOng muscle about the size of a fist, 1he heart is in
the thoraA between the lungs 'I\'() thin-walled .llria are
f''fntiJfl) receiving and holding chamber< for blood
before 11 enters two thick-w,1lled venuiclcs to be pumped
10 lungs o r l>ody. Pumping of the hean forces b lood from
the he.1rt imo ei1her pu lmo11.1ry or systemic ci rculation.
nw pulse cre;itcd by 1hc hcan can be feh beating at the
point of muimum lrnpuh<' (PMI); this landmark is
ui<!d 10 take an apical pulse before cardiac medications
Mt administered (rigure 26 I).
How Drugs Affect th e Cardi ac
Electr ical C o nduc t ion System
Blood flow through coro1ury arteries (Figure 26-2) and
l)'tcm1cally depends on th<> heart contraction's force.
When rn)'ocardial function is decreased, the ht>art's
~hilny to contract is al'o dc<rcased. Drugs that work on
-----
CHAPTER 26 Circulatoiy System and Blood Disorders 465
,..::::==~-- - ""'
F'Ulmonlty artery
lnlOMlnlnctllar wplum Apex
the heart's contraction force. ,in action referred to as
inotroplc cffe, are the cardiac gl}cosldes.
The heart's elearical conduction system consists of
specia lized tissues. The heart sets its own rhythm at the
sinoatrial (SA) n0<le, the pacemaker of the heart, found
on the po.ierior wall of the right atrium near the entra nce
of the vcna cava. The airioventricular (AV) node. 0 11 the
floor of the right atrium near the interauial septum, con-
tinues impulses 10 the bundle of Mis. or AV bundle. I rom
this point, conduction spreads LO the left and right sides
of the hcaJt through bundle branches to Purkinje fibers,
or rnnductlon myofibers ( l'igure 26-3). Conduction of
tl1c regu larly spaced electrica I impulses tliro ugh 1he
cardiac muscle produces normal rhythm. When the heart
does not beat in a regular rhythm, antidysrhythmics, or
drugs that have a dromotroplc effect, may be ordered.
If the heart rate is too fast or 100 slO\\\ medications may
be prescribed to either increase or decrease the me or 10
convert the rhythm to normal sinus rhythm (i.e.. drugs
with a chronotropic effect ). Calcium channel blockers
and antiang.i nal m edications act on coronary arteries to
lessen heart work. Table 26-1 summarizes the phannaro-
logic effect> of cardiac medications on bean action.
Coronary artery disease (CAD) caused b)' arterioscle-
rosis occurs when insufficient blood flows through
hardened and narrowed coronary arteries. causing
466 SECllON V Med1cat1ons Related to Body Systems

Right
coronaJY 8'18<)'
Grea1
Left

-
coronary ane<y cardiac: vein
C.tCtJrnftex
,fj~Au-~x
Left
0()<()08ty
anery

Figure 26-2 ear,.,., 1<1Al<

St LOUIS. 2011, Sao.<>dnl

Bundle of His
Slnoelrlol
(SA) node Left anterior
bundle branch

Left posterior
bundle branch

Purkinje fibers
A1heroscterosis

Figure 263 The hean's conduc11on system affected by anuarrhythmic

agen1s (from Young Af'. Proc1or DB Kinn 's r/le medical assistant an Figure 264 Alherosclerosis and 11arrow1ng ot anery lu""'
app/1811 leam1ng appr~ ad 11. S1 tou1s. 201 t. Saunde<s I

TABLE 16 t HOW CARDIAC MEDICATIONS AFFECT HEART ACTION

I . , I I I

Myocardium Positive inotropic !increases force of myocardial cootrac1JOOI

C-talc1.-n chamel bloctell
Ant1ang1nal med c.1t1ons
Cardiac conduction
Coronary a11enes
Coronary a11er1es
Positive and negatrve dromotropoc !increases and decreases
conduction of electncal impulses through heart mu$Clel
Positive and negatrve chronotropoc !Increases and decr8il$8$ W.
rate to conve11 to normal sinus rhythm)
Vasodilatoon of coronary a11eroes
lessens work of heart

decreased blood Row to lhe hean itself. Narrowing of
ancrics may also occur when plaque from fatty deposits
develo ps in the .incries-atbero6clerosls, a form of
arteriosclerosis (rigure 264).
The first symptom of a myoc.Jrdial lnfarctloo (Ml),
or he.irt auack, is often dnglna pcctoris or spasms of
the cardiac muscle caused by hchcmla. When a OOrt
area is deprived of blood supply, the result is myomdi.il
cell necro~i s or an Ml occurs. llecause damaged cell>
of lhe myocard ium will noL regcncra1e, conir.tetihl} b
perm anently reduced; depending on the infarct sue
lhc condu.-1ion sys1em may also be afTected, rn1>11lg
 CHAPTER 26 C11culatory Sys1em and Blood Disorders 467

...rmanent damage. Medications are dire~--

.- ffi . ~= toward
r;tabl11htng SU Clent myocardtaJ COn tractility to ror TABLE 26 2 ONSET ANO DURATION OF ACTION
blood through the body. Ce OF NITRATES

TIME TO ONSET DURATION

N;11t;111;e.1 1a 1~nua;c.1;1s . . DRUG ANO FORM OF ACTION OF ACTION
Nrtroglytenn
'Jlgina pectoris, o r cardiac muscle spasms, is temporMy Subllngual 13 min (R) 3060mm (B)
interference with Lhe Oow or blood. oxygen, or nutrients
Transl1ngual spray 23m1n (R) 3060 min (Bl
to the hean. rt>Suh 111~ in coronary ischcmia. Drug th erai>y
is b.ls<'d on relaxa11011 of coronary smooth muscl
--~i . e to
Oral capsules ' 2(}45 min !SI 3 8 hr Ill
bnng aboot va,.,..1 auon and therefore improve blood iablets. SR
f1o1> 10 the hean, using nitrates to produce temporary Transdermal palthes X lhrlSI 24 hr (l)'
rtlie[ Top1cal ointment Xl hr !SJ 212hr(l)'
Slllbl". or exertlorwl, "'!8i11a is often triggered by physi- lsosorb1de monomtrate
calacuvny or stress and 1s related to a11eriosderosis. The Oral tablets Y, 1h1 (S) 610hr(l)
goal or therap)' for stable angiM is to reduce inten~ity
ind frequency of angina! attacks to decrease cardiac
Oral iablelS. SR Xl hr (SI 712 hr (l)
O')'gefl demand. Three types of medications are used for
lsosorbtde d nitrate
1mtingstableangina. nitrates, beta blockers, and calcium Subl1ngual 0< 25 mm (RI 13hr(lJ
channel blockers. "111ese dnigs on ly relieve symptoms; chewable tableis
they do not affect underlying diseases. Oral tablets 20-40 min (S) 46 hr Ill
\arinn~ or l'tlsospa.<ric, a11gi1111 is caused by coronary Oral tablets 0< 30 min ISi 6-8 hr (l)
.inny spasms restricting myoc:ardial blood Oow. nw goal capsules. SR
of ire.i1ment of vasospastic angina is 10 reduce the Amyl mtnte 30 sec (ultra RI 3-5 mm(B)
number and severily of attacks by increasing c..rdiac
oygen. Calcium channel blockers and nitrate.< are used B. brief acting; L long actJllQ. R. 1ap1d onset. S. slow onsel SR. sustained
LO dilate hean vessels. release.
' Should not be used for more than 12 hours. 10 prevent 1olctance.
Ille third type or angina is 1mswble angin11. 111is
medical emergency is treated in a hospital situation and
only rarely in an ambulatory care selling. nitroglyccnn or those who have continuous therapy over
a length of time may develop drug tolerance. lo prevent
Nitrates tolerance, the lowest effective doses or daily nitroglycerin
preparnt io ns should be given. Longaaing formulas
Ni1ra1es. the oldest and most frequen1ly used amianginal should be used on an intermittent basis, allowing the
mtdiGttioos. are not true coronary anery dilators as pre- patient 10 be drug free al some time during the day
1iously thought because coronary .meries are already (usually at night). N'.quired tolerance is rO!\'t!rsible when
dilated by aneriosclerotic vascular d1se.1Se. Nitrates dilate nitrates are withheld for shon periods or 1ime. Nitroglyc
S),temic vessels to reduce card iac work and oxygen con- erin preparations are available in a variety of routes to
su1nption and relax v;"tscular sn1001h n1uscle \''hen con- produce si milar responses; time of onset and duration
1med 10 nitric oxide. A decrease in venous return 10 the of action differ. Some prepa rations are rapidly effeaive
htan causes a decrease in blood pressure, reducing the (I to 5 minutes) and last for about an hour. whereas for
htan's workload Nitrates are used during attaCM of others the effect is slO\"Cr in onset but lasts for several
angina to relil'\.-c intense pain and arc used prophylacti- hours (see Table 26-2).
cally to prevent attacks. 111e most common route or The most commonly used form of nitroglycerin is
.1dminis1ra1ion is suhlingual. wi th "lmost immediate subli11gmll 11ltroglyceri11 (Nitrostat), an ideal prepara-
onset of adion (within minutes) bu1 shon duration or tion for acute a ngina! pain that works rapidly and lasts
ilCtion (<30 minu1e<>) {'lable 262) . for about an hour. Medication administration should
1'1tro&~'<trin {Nl'G), the most widely used nitrate, is bq:in as soon as pain begins and should not be delayed
dTttti1-e fast acting. and inexpensive; ii acts directly on until pain is se1ere, or medication may be gi1"n prophy-
vascular smooth muscle to dilate blood vessels. Nitrale lactically when exenion is anticipated. If one tablet is not
preparations decrc.1w cardiac oxygen demand in stable sufficient, one or two addi1ional tablets should be taken
angina, \\thereas in vc1riant angina they relax the spas1ns at 5-minute in1erva1s. l'or per.;istem pain, emergency
and increase oxygen supply. Initial us<' produces a severe medical allention should be obtained 10 rule oul Ml.
ht~ache that can be relieved with mild ana lge>ics Transdermal nitroglycnin (Transderm Nitro), av-ailable
such as aatAmlnoplien. Patients on high doses of as a patch, contains a resen'Oir of drug that is slO\'lY
468 SECTION V Med1cat1ons Related to Body Systems
relea,ed for ,,b~l'j)llOn daily tlirough skin The site
'hould be MJll'd daily to 1>revent loca l imtation. To
avoid dl"elopmcnt of tolcra nee to nmoglyccrin. tlw
patch should not be wom for more than JO to 12 hours
per day. uuall) 1t 1Hpplu:d m the morning and removed
in the evening. Patches result in a slow onset and are not
e<recll\e for an ongom11 angmal ana<:k. Topical niu-o-
&lycmn olntmrnt must be measured on a papt>r pro-
vided wnh medicauon to ensure proper dosage. Topical
omtmeni sues should ;also be rotated. Nilroglyurin
spray (~nrohngu..I) 1s eptt1ally useful 1n patients who
ha'" decreal<!d dextcnty 1.1ch container holds 200
1mmed1atcl) ab~rbed sprays providing quicker relief
than o ther forms of nnrogl)-cerm 'Ille mist may be
sprared mto the mouth nery 5 minutes for three doses;
each dose contains mtroglycenn 04 mg. This medica-
tion form is more stable and not M!nsuive to heal. lighl.
or mo1.s1u~
If nnroglyceri n is disconu nued, this action should
take 1>l.1Ce over a period of ume. Abrupt d iscontinuation
o rJong arttng prepJr.1tio n;, may cauM! angina and vaso
spasm~ ( Iable 26 3).
..
Pauem education lor using nitroglycerin spray should include
pnm1ng of container by polntmg noulo awav and depressing
until a click 1s 11-0ard This should be repeated every 6 weeks if
container 1s not used To use SJllav, remove cap and do not
shake Hold bonle as close to mouth as possible to release spray
into mouth (under tooguc is not necessary) Do not rnhale spray.
No food or d11nk should he taken for 5 to 10 minutes after
administration
kt] CLINICAL TIP
Sublongual tablet is to remain under tongue until u dissolves
Because notrogljcenn is chemically 11\Stable and loses rts effectJve.
ness OW< a penod of time. the medicatlOll botde should not be
opened unul 1-'ed Shelfhfe 1s fongei in a dartc. tightly closed
container Mer oontauter 1s opened. ~ug is effective for apprOJti
mately 6 months. and the date on YA!idl 1t was opened should be
wrmen on container Six month$ aher ll!ll!flll19. med1cat1on should
be discarded and repl<IQ!d with a new bottle
Beta-Adrenergic Blockers
'---~~~~~~~~~~
Used for several cardiovascular disorders, beta-
adrcnergic blocker (beta blockers) reverse sympathetic
he.in stim ulation caused by exercise. stress. or physical
exertion, including increased hean rate, increased fo rce
of contractio n. a nd increased o xygen use. Th~ d111r;
decrease the hean's rate and force o f contraction. IOI\.,
ing oxygen use to prcven1 myocardial ischem1a nd
pain . Beta blockers are used for chronic managemmt ~
angina by lessening frequency of anacks, dela)-ing
of pain during exercise, allowing increased hun ~DJ\
""'
capacity. and allowing incrcacd exercise toltr~ >c<
(Other uses for beta blockers. such as Jntihypen~
and antidysrhythmic applications. are discussed lata 111
this chapter.)
Propranolol (lnderal) is used alone or 111 comb~
uon with nitrates for angina control. The goal of~
isuation is to reduce the pulse to 50 to 60 beats/mm
rest and 100 beats/ min during exercise. Beta blodt!i
should be avoided with anhma and may mask h)-pogly
cemia in patients with diabetes mell itus (-Tablt26-J~
Calcium Channel Blockers
Calcium channel blocke rs interfere with m~mcnt or
calcium io ns through cell me mbranes to treat angirul
pai n. Because v,lScular smooth muscle contraction ~
depende nt o n ca leium move ment fro m extracrllul,u to
intracellular Siles, inh ibitio n o r calcium prewms th~
contraction. all owing vasodilation to occur. Calcium
blockers also dilate la rger coronary arteries to incrtJ!f
blood flow to the heart. These med ications .ire indicatfd
for vasospastic angina.
Verapamil (Calan) and 1lllt/aze111 (Cardizem) hau
primary use as a ntidysrhythmics bu t are um! fo1 1hnr
vasodilating prope11ies in the treating o f angina J1lae
medica ti o ns also decrease heaM rJte. lhu> decre.isingtlw
hean's work. Nifedipinr (Ad,1lat) , rticardlplne (Cardcn~).
amlodipine (Norvasc). f elodipine (r lendil), and ura-
dipine (DynaCirc), used a;, antihypenensi'-es (Stt lata
in this chapte r), are also used for a ngina becaust their
properties cause vasodilation a nd relaxation or cororwi
a nery spasms with mi no r effect o n decreasing hein mt
Ill LEARNING TIP
Many of the calcium channel bloclcers have names that ..i ~
"pine
Combining the Medications for Angina
Combin ations of nitrates, beta blockers. and raloum
chan~el blockers may be used for angin,11 treatment lb<
goal is lo '"duce frequency a nd intensity of angin.i
auac!'5. w11ho ut o verly supprcssi ng cardi.1c .1ction. &for<
~dmin1sten ng calcium channel o r be t.1 bloc~eB. lt ~
impo rtan t to take blood pressu re and pu l~ to enU"
both are within no rma l range.
 -~_CHAPTEll
_ 26 Circulatory System and Blood Disorders 469

Angina pectons. Headache. hypotension. Use w lh care wilh

Ml, CHF tachycardia llypotsnsr;es, beta
hghlheadedness. block81s, verapam1I,
d1umess. burning d1lt1a1em. s1ldenafil,
sensation m mouth alcohol
With spray
iroglyrefln (N1trostat) 0.30.6 mg SL q5m1n
x 3 doses
IN,troMistl 1 or 2 translmgual
sprays q5min x
3 doses
1N1troglycerin SR. Nitro- 2.5-6.5 mg PO bid
Time)
!Transdefm Nitro. Nitro- 1 patch qd, remove
Our. N1tro01sc. after 1214 hr
M1mtran)
(N1tro-81d IV) 5 mcg/min IV to
desired response
IN tro-e.cl. N1trol ointment) 1-2 inches tOplcally
qd
isosorbide mononitrate 20 mg PO qid
IMonoket)
llllWSRl J0.120 mg PO bid
'sosorblde dm11.mte 2.5-10 mg SL. PO q1d
(lsordil T1tradose) 540 mg PO q8-12h
!Dtlatrata-SRI 40mgq812h
iyt nitme 0.18-03 ml inhaled

BETA-ADRENERGIC Insomnia, deprnssion.

BLOCKERS b11arre dreams
r lJlarolal (lode<all 20-BO mg PO bid-qid In comblnat1on theopliythne. calcium
!See Table 268 for other wnh mtrates lor chamel blockers.
beta blockers) angina pectons reserpine. cimehdme.
plienytoin, alcohol

CALCIUM CHANNEL Angina pectOllS Faugue. headache.

BLOCKERS flushing, d1wness.
(See Table 26 5 for class Ill hypotens1on. GI
agents and Table 26-11 for disturbances.
olher calcrum chamel constipation
blockers used with angina)

MISCELLANEOUS ANTIANGINAL MEDICATIONS

'n..iame IAanexal 500-1000 mg PO bid Antianginal. GI symptoms. quinid1ne. sotalol.
antil$dlem1c headadle. d1ZZ111eS$. tetoconazole. HIV
nausea. weakness. medications. macrohde.
indigestion an11bio11cs. diltiazem,
verapam1I. grapefruit
CH Ur'!11'51Ne heart failure. GI. gas1romtes11nal. HIV human unmunodeficierq Yirus. IV. intr<Mll'IOU$ly: AA: Myocardial infarttllln PO. orally: Sl. subl~
9'"'1~.
Sit sustained 1elease
'lo 1M>1d tolerance. the doses should allow the pollen! to be medication free at some rime during the day.
470 SECTION V Medocauons Related to Body Systems
Rn11olad11 (R.1nex.1) os a medication specified as an
anuanllmal wnh an unknown mode of acuon. Used with
chronic s1.1ble angma, this med1o uon should be used in
comhonat1on with other antianginals such as nitrates
and beta-blockers
IP ii'iient 1Education for Compliance
N uoglytenn subhngua lableu shootd be carr ed at all
tJll1eS "' an tasdy accessible. dart ainla!flef
2 Transdemiaf ~ is for ~is of angina To
tJll!'ll'lt tolctance to rutrogf;wrin patches. 11iey should be
roiated on a daily OOSIS and should not be worn more than
I0 to 12 hours per day
3 A n 11oc;tvi:e11n slJbl ngual tablet shootd not be swallowed
but should be placed under the tongue unttl ot has fully dos
solved The mooth should be moist for absorptton of wblon-
gu~I rntrO<J~eion tablets
4 Med cal e-;alu.111on IOl possible myocardial inlarctoon (Mii
1s necessary 11 acute ang1nal pain has not been relieved
after thrtlil sublongual mtroglycenn tablets have been
taken
5 long-actonq nitroqlyccrrn should not be discontinued
ab<uptly but must be tapered off because vasospasm may
occur
6 N111oglyce11n ointment should be measured on paper sup-
plred by manufacturer and applied 1n I 10 Z1nch strips as
directed by physician but should be removed at some point.
usually at night. to pievent tolerance
7 Changes on lifestyle -<J1e1, smokrng cessa11on, and weight
cootrol - are 1mpoi1an1 with use al med1ca11ons for angina
pectoris
8 Headaches cau~od by nitroglycerin will gradually diminish
with long term uso and may be relieved by nonsteroodal
ant11nftammatory drugs
9 Pat1oob using n1uogtycenn should il\'Oid alcohol and med~
catrons for e<ectole dysfunctlOO
10 Pat1ents taking lhcse mecfreat1ons should move slowly from
a lying positton to a s1tt1ng or stanlfjng posrhon because of
the charce of or1ho11atk hpotcnslon.
. .. . .
Angina pectons occurs when the heart's oxygen S1Jpply rs
1nsufficren1 to meet its oxygen demands
Three types of angina exist (I} chrooc stable. or exertiooal,
angina, caused by coronary allleroscleros1s, 121 varoant. or
vasospashc. angina. caused by coronary artery spasm. and
l3l uns1able angina. which requires immediate medical care.
I ortant Facts about Me dic ations ~,
-'-< Pectoris-co
mpAngina
,for nt' d
1
Drugs that increase myocardial oxygen flow will decteaie
angrnal pain Cardiac oxygen needs are determined b'f )JCll1
rate. heart cootrac:trllty, venous return to the ~
pressure. and heart pressure
Drugs for stable angina rehew pain by decreasrig
retum 10lowerthe11eans oxygen demand. not by~
oxygen supply.
Drugs for vanant angina increase oxygen SUllPY bit O:i
decrease oxygen demand N1troglyrorrn further d1 aos
eroscle1ot1c verns to rehew stable angrna
Three common side effects of mtroglytenn are ~
orthostat1c hypotensoon. and tachycardia
Continuous use of mtrogtvce11n rewlts an toletan:e.
prevent tolerance. lhe lowest possible cflectl'/9 dole sl'O.t1
be used and admrnos11a11on should be on an inlermrtt;:
schedule, with the pauent being drug free for at lea>t81Qn
a day
Nitroglycerin with a rapid onset should be used IOI aog I
attacks or for prophylaxis before exertion Niuog yr.etm
IJ'eparat1ons with a long duration or effect are for IJQ!J)ct~o
against angina! attacks and should be administered GO a
fixed schedule.
Beta blockers prevent stable angina by decreasmg hean ra e
and heart contractihty, thus reducing cardiac oxygen need.
Calcium channel blockers relieve pain of stable angina bi
reducing heart's oxygen demand.
CONGESTIVE HEART FAILURE
AND ITS TREATMENT
Congestive heart failure (Cl IF) affects more than~
million Americans. with almost half a million QlC\
primarily in elderly individuals, added each )'t'Ar S)inp-
1oms such as tiredn~ fatigue. shortness of breath. r.pid
heart rate, and peripheral edema occur when h<!an coo-
traailiiy is decreased and less blood is pumptd tNn ~
receives. With blood accumulating in hean chambtr\
less blood circulates. leading 10 retention of elecuolmi.
including sodium, 10 allow Ouids to remain in intr.lCfl
lular spaces, a condition called e1/cm<1.
Cl IF is a progressive disease charaeteri.ud by mluctd
cardiac ou1put, vcmrides that d o not contract ellicicni~
and accumulation of fluids or congestion in tissues and
lungs. Of all fac1ors, depressed hean contractility 11 a
major cause of heart failure. Principal drugs for hun
failure cl1angc the force of co ntmetion and the hean ra1t
Overall therapeutic goa ls arc 10 correct the under~i"8
cause and gain the pa1icn t's compliance in pharmaco
logic treatments and nonpharrnacologic care surh ai
 --~C_H_
APTER 26 Circulatory System and Blood Disorders 471

Congestive heart failure, See Bo ZS-I

a1rhythm1as, and to control
ventricular rate

&ataSing dietary sodium, limiting alcohol, increasing

!'Xl'l(ise. and lowering suess levels. BOX 26-1 DRUGS THAT INTERACT WITH OIGOXIN

Drugs Thll Decrease Oigox1n levels

cholestyram1ne
Medications for Treating Co n gest iv e kaolin/pectin (aluminum salts)
Heart Failure neomycin land other aminoglycos1des)
sulfasala11ne
Three major classes of dnigs for Cl IF are (I) vasodilators, antacids
to ttduce symptoms; (2) diuretics, to redu<"e edema in
tht peripheral \'1?$SCIS and to reduce blood volume over- Drugs Th1t lncrt1se Oigoxin l evels
load; and (3) cardiac glyoosides, to reduce the symptoms amtroglycosideS
in chronic hean failure. e<ythromyon
The carJuu glycosules (digitalis group or digoxin) are omeprazole
the oldest medicinal agents for C l IF and Mc obtained tetracychne
liom digitJlis plant leaves. After treatment with cardiac alpra1olam
gl)'COsides. hearthe.11s are more forceful wi th in a s honer arniodaronc
period of ti me 10 increase the volume of blood pumped d11tiazom
from the hean, improving circulat ion and de<'reasing n1fed1pine
congestion without increasing oygcn conumption. propafenone
Wuh edema redunion , weight is lost and blood volume qu1ntd1ne
is reduced Normal blood circulation i restored VErapamtl
and kidney funnion is increased. Digoxin produces
1mpr0\-ement of exercise tolerance and reduces fatigue. Drugs That Increase the Incidence of DV$rhythmiH
llowever, even with improvement of symptoms, this Th1az1de and loop d1uret1cs
medication does not alter the dis<'asc 1uocess and does amphotoricin
not prolong life. Glucocort1co1ds
Because cardiac glycosides slow lw.111 rate, patients
must be might to count the pulse before taking medi- Drugs That Decrease Hean Rate and Contractility
C4tion, being sure lhe pulse rat<' i; above 60. If the Beta blockers
pu~ is below 60, the medication should 1101 be tak<'Jl verapamtl
"1thom a physician's p<'mtission ( 1.1ble 26-4 and dluazcm
Box26-t).
Drugs Thi! Increase Heart Rate and Con1r1cllhty
Sympathom11t1cs

0191tahs works much like a spark plug in an automobile-it

makes the heart wo1k on all cylinders.
Digltalb.atlon is administration of therapeu~
glycosides al a rapid rate to produce a blood d1g11ahs
ln'l!I that subsequently is maintained Dosages. of
digoxin are high ly ind ividualizcd, ,rnd e.1d1 paucm
should be carefully evaluated until an effective dose
has been established, afier '"hich monitoring is gener-
ally not n~ry. The difference between therapeutic
and toxic levels ";th digitalis is slim. and patients
mu~t be watched dosely for signs of toxicity
(Box 26 2) .
472 SECTION V Med1cabons Related to Body Systems
BOX 2& 2 SIGNS AND SYMPTOMS OF DIGITALIS
TOXICITY
Cm nn
loss of appe~te
Headaches. mala!Se, lalJQOO
Nausea. vom.tn,i. diarrhea
Pa pilall!JnS DI bradytan:lia
lneg:Jlar pulse
v; ' ige: lcnisual)-halos DI rlll!js ol IVit around obfects
lg liglts DI bught $1Xl!S
1Qe3 In color percepbon
81 'Cl EPOlS DI blurred YlSIOl1
I) ff . J unnary OU!put
Ex ......... ioctumal urmaclDll
Swel 1ng
01eas00 consciousness
01ffi(ulty b<8JCh ng ....tien lying down
lP ati8r\il.EducatiO]lfor Compliance
Pac1ellls should be warned noc co double up on missed doses
of d1goxm
2 Sw11ch1ng nmong blends and formulauons or d1gox1n may
lead co ahe1ed 10sponses. as b1oavailab1hl'f differs wich dif
re1enc brands
3 Pa11ems ~hould mom1or JllJISe for race and rhythm daily
befoie taking d1goxm Pulse race should be above 60 and
below 90 befa<e medication is taken
Therapy for heart failure relieves pulmonary and penpheral
edema. 1ncrea~s qualol'f of life. and prolongs hie
expectancy
Card&aC glytosicje$ 1naease heart 1T11JSCle contractoon l0tte
to increase cardiac Ol/lput
Oral card&aC gi';cosldes are relatrvefy safe for long-term use
v.11h congestrve heart la turn ICHF) However. drgoxm has a
narrow therape1;tre dose range before causing side effects
and aMrse reactrons
By increasing cardiac output. drgox n can reverse the man~
f8$tat1ons of heart failure by mcreasrng cardiac output.
decreasing hea<t rate. and decreasing heart s12e while
dec1easrng Vilsotons111cuon. blood volume. and pulmonary
and per11lheral edema and reversing v.ater 1etentroo to
decrease weight and increase exen:1se cole1ance
01g1tah1ac1on 1s done when quick cherapellllc levels are
necessary
01ureucs. ang1ocensinconvert1ng enzyme (ACE) mhib11ors,
and beta bloc:kers are used w111l cardiac glycos1des to treat
CHF
CARDIAC DVSRHVTHMIAS
AND THEIR TREATMENT
Medications used to treat di<orders of cardiac rhythlll. lll
arrhythmias, are called 11nridysr/1)'rJi111ics or antaanfriii
mitt Although 11rrltyr/1111ia, meaning loss of rh)1hm, ii
most ofien used. perhaps d) ~rhythml is a better ~
Lo denote abnonmal hean rhythm . Dysrhythmia,. .aa.
ally a deviation from nonmal rti>:hm that may~ 6om
CAD. eJearolyte imbalances. cardiac conduction ~llCl
malities. or even thyroid disease as well as chromed"'
therapy. Some dysrhythmias may ha-e only a mild dfut
on cardiac output, whereas ochers may cause ~'ttt 0>11-
promise of cardiac pumping. . .
Dysrhythmia is caused by an elear1cal impulse '111<r1-
tion and is ueated with medication to regulate rhyctu L
Any change in the normal. aucomatically-conuollcd
heartbeat may be caused by electrical impulses no11n1Cr
preted into nonmal hcan rhythm by Lht he.in etU..
producing ecwpic be111s. When scv;!re dY$rhythm1;
occurs, especially in ventricu lar disorders. patients m;-.
be experiencing a medical emergency and ne>?d hospn.11
care. This section focuses on medic;uions used on
ambula tory care.
Therapeut ic effeccs of an1idys1hythmics lie in the
ability to restore the ions of the hca11 co normal orco
improve the heart's abilily to pump blood. Antidysrhylh
mic medications, found in folll' discinct grou1is by effen
do noL cu re dysrhythmia, bu1 they do ancmpl co rtscort
nonnal cardiac funcc ion.
Class I drugs bind to sodium channels and interim
with sodium ion movement during heart excitation, fo,..
ering hean excitability. Medicacions also slow conduc-
tion velocity. prolong the hean's refractory period. ~nd
decrease mlomalicil> of the hean's action. Quimdint
is used 10 ueat supraventricular arrhythmias. such
atrial Outter and fibrillation and some vencncular d\-.
mythmias. The myocardium's conduction S)1tem
depressed, decrea,ing concractile heart for and slowq
hean rate. Procainamitle (l'ronescyl or Procan SR~
related 10 procaine (an anesthetic), depressn rudYc
muscle excitability and slows conduciion to inat.U( dw
refractory period. Disopyramlde (Norpace), a ur~
depressant, is another medication to decrease urdr
excitability. 1\"o medications chemically and chmpcu-
tically related to lidocaine. me.rileline (Mexitil) ;and
tocainide (Tonocard), have been modified for orM
administration for ambulatory care with '"nuiotl
arrhythm ias (Table 26-5).
Class II antidysrhythmic medications are ~
adrenergic blockers Lhac decrease heart rate. hean not-
ability, conduccion velocity, and autornnicity, particulMiJ
of the ventricles lo mimic the sympathetic nerwus
system , l'ropr11rro/o/ (lndcr.11 ), meloprolol (Toprol SL).
and ate11olol (Tenormin) are common beta blodtn
 cl.ASS I AGENTS
.,--e polygalacturonate 300-600 mg PO q6h
Treatment of Nausea. YOm tong. diarrhea. beta blocJ<en. digttahs.
l~TN) 200-400 mg IV SUPJavenu1cular and faOQ1Je. IM!akllt!'s. potassium,
gluconate (Ournaglute [SR)) 324-648 mg PO ventricular dysrllythm1as tmn11us. hypotens1on, mfed1p1nc,
Q812h severe headache. blurred procamam1de
su~ate IOuimdex ISAJ) 30!l-600 mg PO v1s1on, d1wness
Q812h
pi:ca1namide INTNJ IV dose vanes with Same as for qu1n1d1ne pomozido.
dysry1hm1a
neu1omuscular
blockers. qum1dine.
alcohol. c11ne11dine
1i41J171tarmde (Norpace ICR, 40CJ.800 mg PO
Ory mouth. coostopatoon. punozode. othel
SRP q12h Visual d sturbances. anuclyslllytlvnics
urinary re1ent1or
mexilet1ne (NTN! 200 mg P0q8h GI distress, dizzme~s. unnary ac1d1fiers.
ltghtheadedness. tremors metoclop1em1de.
phenytoin, rifampin
rreiY10tn tD1lanunJ 50100 mg IV every
HJ.15 mrns as
needed
fleca1n1de (TambocorJ 100.400 mg PO bid Same as for
diS()pyram1de
prqiafenone (AythmoH 150-300 mg PO q8h PfOpranolol. d1goxin,
walfaun

ClASS II AGENTS
popranolol (lnderal. lnderal 1030 mg PO t1dqid Depress depolanza11on Rashes. mental confusion d1ureucs. NSAIOs.
LAI 60100 mg PO qd hypo1ens1ves.
xanthines
awtolol (Sec1ralJ 6001200 mg PO in
dMded doses
daily

CLASS Ill AGENTS

Depress depolarization. Otzzmess. nausea.
aerial fibr1lla1ton vomiting. aoorex1a, bitter
taste. weight ~.
paresthesie of hands
and feet. IM!alcness
MlOdarone (Cordarone, 20!l-400 mg PO qd. Life threatening cardiac glycos1des.
PaceroneI IV venu1cular arrhythmia aniicoagulants
dllle1tbde (filosyn) lnd1v1duah1ed PO fOf None 1dent1fied
the elderly, dose
vanes based on
response

CLASS IV AGENTS
(see Table 26111
0( ~ re1Nstt. GI. QdSll0<ntestinat. IV. onu......iooslv. LA IOng acting; NSA/Ds. ~ anLinllanrnitory drugs. NTN no uade name: PO.
nllr. SR. sustained refuJ>IJ
 474 SECTION V Med1c111ons Related to Body Systems
used as amidysrhythm1cs ResidtS haV1ng beta-blocking
effea. they also cause quinodine-like dtpression of
C"ardiac muscle excuab1l11y 10 delay wntricular repolar
1zation. The most common urd1ovMCUlar adverse
reacuons are hypo1ension and decreased heartbeat (see
f,1ble 265).
lll LEARNING TIP
Most or the beta blockers have names tl\at end 1n 101"
Class Ill antidysrhythmic medications interfere with
ouinow of poiassium during repolarizauon. prolonging
the potential contraction durallon of Purkinje fibers
and ventricular muscle fibers 10 decrease the hean
failure frequency. Amiodarone (Cordarone) decreases
au1oma1idty. prolongs AV conducuon. and blocks
exchange of sodium and potassium J11is acuoo can
cau.e serious side effects. and amiodarone is used only
for life-threatening dysrhythmias not r~ponding 10
other medications (see 1:1ble 26-5).
Class IV agents, referred to as c11trium clrmmel block
im. decrease entry of calcium lnio hean cells and blood
v~sels. The SA and AV nodes require calcium for
normal activity and normal sinus rhythm. lleducing
calcium decreases SA node rate and AV node conduc
tion velocity to treat supravemricular tachycardia. These
calcium amagonists may also decrease the hean's ability
10 produce forceful contranions. leading to Cl II; Useful
wilh angina and for h},,ertenslon, these medications
also relax smooth muscles and cause vasodilation_
v....apamil (Calan. lsopiin) decreases SA node activity
10 decrease hean ra1e and AV node conduction. Vera-
pamil is contraindicated with known SJ\ or AV node
disorders or with CHE Diltiaum (Clrdi1~m) is less
potent in decreasing hean rate bul has greater potency
as a v.1sodila1or; lhereforc ii is used 111Jinly as an an1i-
hypenensivc agent (see 'J:1ble 26- 11 for rakium channel
blockers.)
[ii8il8rii1Ed uca~O!J.Compliance
Anudysthytfvmc medocato(lllS must be taken at Jlfl!SCflbed
levels ~ must not be skipped tllless instructed by a
phystoan.
2 Patoeats should ta~e no OTC medocatoons with ant1dysrhyth-
m1cs wllllout obtaining perm1ss100 from a phys1c1an.
3 Avoid alcohol and nicotine with ant1dysrhythm1cs
0ysthythm1as result from electncal 1111f)Ulse alterallQn
mng at SA node Antodysshythmics control cardiac
cooecung or compensating !or altered rhythm
All ant1dysthythm1c meditations can worsen ers!JR,I ~
uons and generate new rhythm d1sorders
Class I aot1dysrhythm1c medications block card ac SOfom
channels. slowing impulse conduction. Oum1d1ne bi0tti
sodium channels and delays vent11cular repolanzatoon
Class 11 medications are beta blockers, which decreases~
automatic1ty. AV velocity, and myocardial contracllli!V
Class Ill anltdysrhythmics block potassium chaMels. prolo11t
1ng ventricular repolanzat1on.
Class IV ant1dys1hythmics are calcium cllannel b~
which reduce SA node automatoc1ty AV oode ctrductirL
and myocardial contraculoty
HYPERTENSION AND ITS
TREATMENT
Hypenension is a chronic cardiovascular disorderaffen.
ing millions of Americans: 25% of the U.S. population
has hypertension. flffec\$ of hypenension kill 2500
Americans every day, and two of every five deatl1s in the
United States arc related to hyperiension and cardiol';u..
cular disease. In approximately 90% of cases, no cause
is apparen t, and, more imponanl, over one third ol
those affened have no idea they have hypertension
making the disease a silent killer. t-lypenension withm
unknown etiology is referred 10 as es.senriaJ or pn-,
hYP<-r1e11sio11. Generally in adullS, blood pressure .iv,.,
120/80 is considered prehypenensiw. .,;ch 140 90
being hyperiensive. When either systolic or dias1olic
pressure or both are above baseline for an ext~
period of time. hypcnension should be suspected. Di.Jg
nosis of hypertension should not be made based on
single blood pressure reJd ing. Unless blood pressure
poses an immediate d.111ger. readings should be 1.1km
on a1 least two subsequent visits, a week 10 sewral
weeks apart. "J\vo readings should be taken a1 each vi111
and averaged .
Risk fae1ors for hy1>cncnsion incl ude family histol\'.
stress, obesity, smoking. sedentary lifestyle. diabetes mt~
litus. and excessive lipid blood levels. When hyptnft'-
sion is no1 properly treated, risk of stroke. cerebnl
hemorrhage. coronary hean disease. and Cllf incr~
Renal failure is incre.1scd during hypenension btalll<
blood now through kidneys is reduced.
Blood pressure is controlled by complex imer.icnon<
among nervous. hormonal. and renal systems. Whro
blood pressure drors. informalion aCTivates 1he sym)lJ
the1ic nervous sys1em. Epinepnrine increases hean rate
 CHAPTER 26 Circulatory Sys1em and Blood Disorders
and force of heart contractions to elevalc cardiac output
and blood presstcre. Al the SJmc tinw, the renin
;uigiotensin-aldosterone ( RAA) mechanism helps rcgu-
1.ne blood pressure _by increasing or decreasing renal
blood How. Increase in blood volume from retention of
~-attr and sodium cause,, blood pressure increase. The
RN\ mechanism therefore functions in maintenance of
blood \'Olume and blood prc.\Sure (see llox 26-3 for a
(t'rie> of RAA mechanism)
Blood pressure respond> to changes in ,inerial blood
lo>-- Peripheral ns<:ulu rc,ht~nce in blood vessels
wdl as blood volume .tnd visco>ny arc factors 1n ane-
nal "-all pressure exerted Atherosclerosis, with reduced
Mterfal diameter, will neces.itate more force whc1\ blood
is p115hed through vessels to i ncrcase blood pressure.
finall); cardiac output and tlie hean's ability to pump
blood proficiently affect blood pressure.
BOX 16 3 REVIEW OF RENIN ANGIOTENSIN-
ALDOSTERONE MECHANISM
1 Oeaeased blood pressure stimulates kidneys to secrete
renin
2 Renin changes plasma protein ang1otens1nogen (synthesized
by the liver) to angiotenson I
3 An91otens111 I 1s convened to ang101ensin 11 by enzymes found
primarily in lung tissue.
& Angiotensm 11 causes vasoconstric11on and stimulates
adrenal conex to secrete aldosterono 10 increase blood
pressure
Conuol weoght by
diel and exercrse
Stop mok"'ll
andoeeroau
alCOhol Intake
. F t of 1i~rtans1on striving for multidiscip11naoy lifestyle modifications 1s necessaoy
Figure 26 5 or 11eatmcn '""
475
Antihypertensive Therapy
Antihypertensive therapy is often a difficult area for
obtaining patient compliance because the patient is
asked to comply with therapy for a disease that is bas
cally asymptomatic. Long-tenn therapy is necessary to
prevent the morbidity and monality associated with
uncontrolled hypertension; noncompliance leads to a
poor prognosis, whereas compliance with an indl\idual
ized regimen is associated with a good prognosis.
Antihypertensive Therapy
and Lifestyle Changes
The basic approach for antihypenensi"e therapy begms
with changes in lifestyle (Figure 26-5). If desired efftC'IS
are not produced, medication may be staned to lower
blood pressure. Treatment begins with one drug. If this
drug fails to produce desired effects. another medication
may be added. Before a second medication is added,
evaluation of patient's compliance in taking the first
medication and with lifestyle changes should be under
taken to detennine whether an adequate dosage of tl1c
first medication was prescribed. If treaunent with two
med ications is not successful. after funher dose cva lua
tion, a lhird medication may be added (l"igure 26-6).
Adding Medications for Treatment
of Hypertension
Initial drugs used in t.reatment of hypertensio1~ are
usually either diuretics or beta blockers. Altemauvely,
angiotensin-convening enzyme (ACE} inhibitori;. Glkium
Rest and
mm to
avoid
stress
476 SECTION V Medocauons Related to Body Systems

Srool<lnQ oessalion or
other ldostyle d'langes

Evaluale rospon$0
and add medicallon d
changeS are inadequalo

y T

Increased dosage of Substitute another Add another medication

1><esent medication medleation from another class

Inadequate response

Reevaluate therapy

Add 2"" 0< 3fd medocation

Figure 26-6 Typical treatmen1 of hypenensioo

channel blockers. alpha adrenerg1c blockers, or alpha-
bcla adrmcrgk blockers may be used for inilial therapy
if needed
When medica11ons are added. each medication is
chosen from a different dn1g dm wi1h a different mech-
anism of action Multidrug therapy incn>ases the chance
of uccess. wuh several receptor sues being anacked at
the same time. When medications are given together, a
lower dose of each is possible than if one drug were used
alone. Using multiple mediations may have the posi-
tive effect of reducing side effects and adverse reactions
that occur with higher doses of one medicine. Finally,
medications .ire usually started at low doses, with the
dose then gradually increased "' needed for blood pres-
sure control. Medicinal treatment for concurrent ill-
nesses and diseases may have synergistic aetion for
treatment of both diseases; for example, hypertensive
patients with angina may u<c c.1kium channcl blod.m
to ueat both conditions. I lowcver, anuhypertcn>ot
medications may alo;o ha,e antagonistic effms on~
condiLions.
Patients from some ethnic and cultural groups fM'
reaa in unexpected w,1)~ to medicines for h)'Pf'kll'
sion, with rcspono;es different from routinely exp1td
responses. African American patients are at incrwtd
risk for hypenension and generally have a brtttt
response to diuretics and c:.1kium channel blodm
than to ACE inhibitors and beta bl0<ker>. llypcrln>
sion is rnore co1nmon in \\fOnicn \Vho have 1.1ke:n oral
contracepLivcs for 5 years than in those who havt not
Age, smoking. ,md cstrogm replacement therapy ~lso
increase hypenension risk. In 1he elderly, lowl!r doses
of medicaLions should be st,lfled a1 less fret1U(1lt
interva ls because of 1he agini: body's sensi1ivit)' to

Huid deplclion and because of impaired cardiovascular
rtflexes.
Jf 11ypcnension has been controlled for a year, the
!lll'dic.ltt0n dose m~y be decreased, but all lifestyle mod.
tftcations mll5t conunue. Ifd'.'1g dosage is lowered slowly,
dl5<3Sf control may be achieved with less medication
In reducing dosage, the patient must continue to fol low
dtt prescribed regimen faithfully and must continue to
undergo regular follow-up evaluations to detect any
renirn of elev,11ed blood pressure.
CATEGORIES OF
-
ANTIHVPERTENSIVE MEDICATIONS
Ant1hypenensive medications are classified into five
majorategories: (1) diuretics, (2) centrally and periph
mlly acting adrenergic inhibiting agents, (3) ACF inhib
itoo and angiotensin 11 receptor antagonists, ( 4) calcium
dunnel blocker$, and (5) vasodilators. The adrenergic
inhibiting ag;-nts include such groups of medications as
bet.t-adrenergic blockers. Ri1111m/fia derivatives, ,1nd
alpha.adrenergk blockers. Types of medication u.ed to
ueat hypenension arc found in Box 26 4. Each medica
lion has a specific indica tion, with treatment becoming
more aggressive with each level.
Diuretics
Diuretics block rcabsorption of sodium and chloride,
allowing more water to b" excreted. Increase in urinary
output is directly related 10 blocking of resorption
BOX 21i 4 TYPES OF MEDICATIO NS USEO TO TREAT
HYPERTENSION
Anglotens1n-con~rt1ng enzyme (ACE) inhib1t0<s act by dilating
arterial blood vessels and decreasing blood volume
ill>g101ens1n II receptor antagonists act by blocking ang1otens1n
II, causing vasoconstnctton.
Alpl\abeta adrenero1c blockers dilate blood vessels by working
Oil alpha and bota cells to decrease norepinephnne
formation
Antoadrenerg1c drugs (centrally acting) wor1c on alpha and beta
receptors ot sympathettc nervous system 10 dilate blood
~!!IS
Beta-adtenergic blockers cause hean to beat Jess frequently and
~1!nts blood vessel constnc\lort
Ca!cium chaMel blockers relax smooth muscle of blood vessels
io cause d1lat1on
Vasodilating agents blod< calcium movement imo smooth
tnUSCle or blood vessels to cause relaxation and dilation
0 uretics cause excretion of sodium and wa1er to decrease blood
~lume and blood pressure
CHAPTER 26 Circulatory System and Blood Disorders 477
of sodium and chloride. Diureiics work early m the
nephron to block the greatest amouni of sodium and
chloride solutes and produce the greatest diuresis with
resultant acid-base imbalance and eltttrolyte le-.YI
disturbances.
Diuretics are mainstays of hypenensive therapy and
may be used alone or in combination with other anti
hypenensives. The four major categories of diuretics are
(I} high-ceiling (loop) diuretics, (2) thiMide diuretics,
(3) osmolic diuretics, and {4) potassium spJring agents.
Hig/t-ceiling (loop) diuretics, the most effcc1ive diumics
available, produce greater loss of Ouids and electrolytes
by acting o n tl1e loop of I lenle (Figure 26-7). Not used
routinely fo r hypertension, these medication> are used
when diuresis is necessary 10 reduce blood volume lo
decrease blood pressure and to promote vasodilation.
llecause of electrolyte Joss, potassium rtplacemenLS are
necessary with these drugs. Furoumlde (~ix) is the
most frequently prescribed loop diuretic, acung on the
ascending loop of Henle. Stt Table 266 for the loop
diuretics.
Thia.;;ide diuretia, most commonly used as antihyper-
tensive agents, reduce blood volume, produce initial
reduction in blood pressure, and reduce anerial resi>-
rnncc for long-term antihypenensive effects. 'I hesc agents
incr~asc excretion of sodium, chloride. poiassium, and
water while raising uric acid and glucose levels but have
lower diure.~is capability 1han loop diuretics. Powssium
may be replaced by medication or by ea1ing po1assium
rich foods such as bananas, greens, meatS. and apricots.
J lydrochlorothiazide is the mos widely used thiazide
diur.,Lic. These agents work in the early segmcm of distal
PIOXJmal __,.ed
tubule (A. B, C, E)
GlomerulJs
Collecllng duct
Distal oonl.'Cluted tubule
(A, 8, 0 , E)
A Thiazlde dlureta
B loo!>dourtOct
Loopol c PYoiomel tubule douretJcs
Henle(A.B)-- DDlstal~
spanng douft1ICI
E Osmooc 00.otica
Figure 26-7 Action of kidney nephron ond its reta11onsh1p to diuretics
 478 SECTION V Med1cauons Related 10 Body Systems

LOOP OIURETICS Loss of potassium.

dehydrauon.
elevated blood
sugar and uric acid
levels. hearmg loss
drgox111. NSAIOs,
lurosermde (lastaJ 20-00 mg l'O qd. IM, HypeflenslOfl.
am1nogi\ltosQs,
rv congestive hean
fa lure. renal potass1iin-~

disease d1U1et1CS. l1t1111111

totsemode lllernadexl
bumetan1de (NTNI
5-20 mg ro Cid. rv Other ameflllies.
NSAIDs. dogo1 n.
anucoagutants
l1 1h1um. amphoter!Cll
heparin
0 5-2 mg PO qd, IV Same as for elflacrrolc
acid

THIAZIDE DIURETICS Hypertension, Loss of potassium, d1g1tahs. lithium,

edema. diabetes dehydration cholestyram1ne,
insipidus coles11pol
chioroth1a11de ID1uril) 500 mg PO b1d-qd
hydrochlorolh1a11de 25-50 mg PO qd
(Hydrodiunl, Micro11de)

THIAZIDELIKE Same as for thiazide Same as for thiazide

DIURETICS diuretics diureucs
chlonhahdone (Til<lhtanel 25-100 mg PO qd
mctolazone (Zaroxotyn) 5-20 mg PO qd
indapam1de (Lozoll 1 25-5 mg PO qd
methycloth1az1de INTNJ 5mgl'Oqd

DISTAL TUBULE DR Congesnve hean Nausea. vomiting, antocoagulants.1.sAA>s.

POTASSIUM-SPARING failure. diumess lithium. ACE
DIURETICS hypertension mh bot<n. flOI=
con1a1rong duet.a.
po ta~
supplements
amolonde (Mldamclfl 5-20 mg PO qd
sporonotactone 25-100 mg PO qd
(Aldactonel
mamterene (()yreo1uml 50-100 mg PO bid
ACE. ang1otens11W011Vetting enzvme. IM. 1nttamU$Cufarly; N. rntravenously; NSAIOs. noostero1dal ant11nftammatory drugs. NTN. no uade name. PO. oiiti
Note All d1ure11cs may cauoe onlloslatic hypotet1s1on and dry mouth
"!' comb1na1>on d10<et1cs and an1>11ypertensives. see Table 26-7
 CHAPTER 26 Circulatory System and Blood Disorders 479

con"oluted tubules (see Figure 267) and are not effcc-

d\'f in patients with impaired renal function . Also
in<luded in this group of medications u'>Cd for hypcnen-
sjon dftfour drugs that are thiazidc-likc. being similar
Ill funcu~n and mucture: cl1lorthalidone (1 lygroton),
inUpamule (Lozo!), metolau m e (Zaroxolyn). and qui-
~ne (H>'<iromox) (see rable 266).
/'tJIJJ.S!1um-spari11g dwrelics produce a modest increase
in urinal}' output and decrease in potassium excretion. HC12 spuooolactone
n- diuretics are seldom used alone with hypcnen- HClZ tnamtell!Oe
sion but are frequently added to primary agents, because
DIURETIC ANTIHYPERTENSIVE
Joss of potasSium with thiazidC$ and loop diuretics is
counteracted. Potassium replacement is not indicated Micatd1s HCl HCTZ telllllsal10f1
md porusiurn rich foods should be 3\'0ided. Spirono: VaseretJC HCTZ tmla!inl
lodon (Aldaaone), typical of potassium-paring Diovan HCl HCTZ valsartan
diuretics. blocks aldostcrone use in the distal nephron.
lopressor HCT HCTZ metoprolol
causing retention of potassium and excretion of sodium
(stt Figure 26-7). Care should be taken with ACC inhib- Z1ac HCTZ btSOJDol
iton (see discussion of ACE inhibitors later in this lotensm HCl HCTZ benaze~d
chapter). Avahde HCTZ 1rbesartan
Qlmbinariori 1li11re1ics include thiazidc diuretics com Hyzaar HCTZ losanan
bined in single-dose medirations whh potassium-sparing Zes1oret1c HCTZ lisinopril
diuretics as wel l as calcium channel blockers and ACE Pnni1de HCTZ lisinopnl
inhibitors. l'ixed-doc combinations may provide clon1d1ne
Comb1pres chlorthalidone
diuretic activity and decrease pmassium dcplc1ion. In
addition, diuretics may be combined wi th 01her antihy- Tenoreiic chlorthalldone atenolol
penensives 10 provide simple compliance after hypcncn- ACE CALCIUM CHANNEL
sion has been stabi lized through medication and lifc.~tyle INHIBITOR BLOCKER
changes (Table 267 ).
lotrel benarepril amlod1pine
Tarka tiandolapnl verapam1I
lexxel enalapnl felod1p1ne
HCTZ Hydroclllorotl11azide.

Pailent'i Educat~lience
frequents1ps of water or chewing gum may relieve dry mouth
OCt1>1ring with d1uret1ts
2 011retics should be taken m mornings for oncea-day reg
mens and at 8 AM and 2 PM for twice-a-day regunens 10
preYent interference with sleep
3 fwosemtde should be iaken with food 11 gast101n1es11nal
upset octUIS
4 Postural hypotens1011 may octUr with d1u1e1ics
5 Pat.ants record weight on a regular basis. we1gh1ng at same
llme of day
.. ..
6 Patients taking th1azlde or loop diuretics should avoid eXlleSS
e.q>O$Ure 10 sunlight and ultraviolet hght Some vasod lators woB: on artenal blood ftow. some on
7 Patients with diabetes mell1tus who take loop d1uret1cs venous blood flow, and some on both typeS of vessels
should test blood glocoso levels more frequently Hypertension is systolic pressure above 140 mm Hg 01 d1a
8 Pauents 1ak1ng potassium-sparing d1ureucs should avoid stohc pressure above 90 mm Hg. whereas a prehypertens1ve
foods high in potassium and salt subs11tutcs containing state is blood pressure of 120/80 01 above
potassium Primary hypenoosion. most common type ol hypenens1on,
9 Pauents taking d1uret1cs. especially elderly patients, should has no identifiable cause.
(.ilt11Hlll(l/
dnnk adequate fluids ~-----
480 SfCllON V Med1ca~ons Related to Body Systems
Important Fact about Diuretics arid_.1lil!
Hypertension-cont'd - ~';_~
Management of prehypertenSJon and flypeneflSlon begins
Wth !estyfe changes
Tt- 11ide d<uretics and loop diuretics reduce blood volume
I lower arteflal resistance
M t diuretJCS 8C1 by blor. ng active 193b$orp11011 of sod um
' : chloride thus preventmg reabsOlp!JOn of v.ater to reduce
bowd~
n.- s BC!mg earty on neitirons creae ivealllst d uresrs by
t hng great!lll amount of water reabsor)ltlOI\
Li :o d<urellCS block absorplllln of sod um and chlonde 111
ol Henle to produce g<eotcst d uresis. cauSlllQ dehydta-
t tllroug-i fCessi\'ll ftuid loss
oop d<uretics lllilV taU$! heanng loss
111 llule d uret1cs prme less do11resis than loop d1uretrcs
PotassumHpanng diuretoes produce only modest d1uresrs
Adrenergic-lnhibiting Agent
Ad renergir-inhiblt ing agents or sympatholylic agents
include groups of medications such as be1a b lockers,
Raurrolfili derivative~. and alpha-adrenergic agen ts. The
heart, blood vessels, a nd kidneys in Ouence arterial blood
pressu re by increasing the heart rate and force o f myo-
cardial contractions, by arteri ole and w nule constriction,
and by release of renin in the kidneys. Adrenergic-
inhibi1ing agems are effective to lower blood pressure
and prcwnl serious ra rdiovascular complications by
acti ng as ,,,.oconstrlC1ors. Some of these medications
arc also u~ for migraine headaches as seen in Chapter
29 p :1blc 26-8).
Be111 blockm such as natlolol (Corg;ird) and propra110-
lol (lnderal) decrease cardiac output. inhibit renin secre-
1ion, and interfere with the RAA mechanism, 1hereby
lowering blood pressure (see Rox 26-3). These medica-
tions are also used with angina and acute Ml .
/llt/ostmme rraptor amagonuu, such as eplerenone
(lnspra), block binding of aldos1erone in RM mecha-
nism absorpuon to lower blood pressure and may be
used separaiely or may be gh-en with thiuide diuretics.
/l/pl1a-ll<'ra blockm such as la,,.,ta/ol (Nonnodyne) are
similar to beia blockers and are used for S<?\-'t're hypenen-
sion. Alpha recep1or block.1de causes ""sodilation and
decrt'<lsed peripheral vascular r-esistance when added to
beta-blocking mechanisms.
Omrally acting tU/mu,rgrc inhibiron such as clonidine
(Catapres) are e!Tcclivc. especially when given with a
diuretic. With sympathetic nerves functioning at a higher
than no rmal level. these medications reduce blood pres-
sure. pulse rate, and cardiac output.
Prriplrm1lly actilrg 11dnmergic inhibitors such as doxazo.
si11 (Cirdura) and praz.osln (M inipress) are powerful
ant ihypenensives that either interfere with re lease of
norepinephrine from neivc e ndings o r block recept011
in vasrular smooth muscle. 111ese agents nr1 by dee~
ing vasrular ione, primarily in veins, followed by efrt<11
in aneries.
ILJ LEARNING TIP -
Many of the peripherally acting adrenerg1c rnlub1t1ng agents e!lll
With sm
11ngiorensi11 II rl'Cepror 11111ago~ists are used alo"" x
with diuretics to treat hypenensron Th~ me<l1all(Q
such as irfH,sartan (Avapro) and olmtsart"" (llmlQlj
are also used in treatment of Ml and Cl I~ in J>tOplcldio
cannot tolera11. AC L inhibitors. fhe action is 10 inlubti
binding of angiotensin II in vascular smooth musclt !O
blood pressure cannot be raised. Because vnsoconscnc
tion is blocked, side c!Tec1s sim ilar to those ofACEinhib-
itors, such as onhostatic hypo1cnsion, occur (Set Tabk
26-8).
ILJ LEARNING TIP
Angiotensin II receptor antagonists in most cases have namesthat
end in "ian_"
ACE in/ribi1ors such as be1111:wpri/ (Lotensin) and
c11alapril (Vasotcc) slow angio tcnsi n II formation, lo.-
ering blood volume and blood pressure. Most fr,.
quemly u sed w ith C l IF and d iabetes. AC& inhibitors
are used for treauncn1 of severe hypertension. Thi!(
drugs resuh in peripheral vasod il atio n, renal vasod1la
tion, and suppression of aldos1cronc-mediated \'lllumt
expansion . ACE inhibitors arc usually associated wuh
the desirable effect of increased rena l blood Oow whllt
having less interference w ith mental and physial pn-
forrnance. Conscqucn1ly, the ben er qualily or tilt
afforded by ACF. inhibi1ors should lead to bencr com
pliance (Table 26.C>).
lll LEARNING T' P
Are inhibitors tend to have names that end with "pr1I "
Vasodilators
Vasodilators relax or dilate vessels throughout tilt
body-veins or aneries or both. These drug.1 relax !ht
smooth muscle of peripheral arierioles, thus decrc~ng
peripheral resistance to s timu late 1he symp;1thdrc
neivous system LO incrca~e heari ra1e and cardiac out(llll.
Because of this effect, a be1a blocker may also be gh~n
lo inh ibit sympa1he1ic response, and a d iuretic may b<
used to al leviate sod ium and w~ tcr re1e111ion. Mino.rid/I
(Loni1en) is usually given w i1h a beta b locker 10 P'"'"'"'
reflux tachycardia p :1hlc 26 10) .
 CHAPTER26 Circulatory System and Blood Disorders 481

Hypenens100. angina Diuretics. xan1h1nes. hypoglycemics.

cardiac arrhythmias. NSA!Os. amiodarone. ampecilhn
acute myocardial antaeids, digoxon, epineplw1ne. tacnne
mfartt100 phenylephone. svrr4)iltncmlmBtlCS
.JC1DitOOl ISec11all 200-800 mg PO qd
a:irolol (Tenormml 25-100 mg PO qd
t11:.unlol (Kerlonel 520mgPOqd
llsoPtJlol IZebetal 2.5-10 mg PO qd
metO!JOIOl llopressor. ToprolXll 25-200 mg PO Qd
nai)iol (Corgardl 40-80 mg PO/day every
214 days
peobutolol llevatol) 1080 mg PO qd
pondolol 1030 mg/day PO in
d1v1ded doses
ptlll1ClOOIOI (lnderall I60480 mg PO/day in
d1v1ded doses
sotalol IBetapace) 80 mg PO bid
tiioolol 1030 mg PO bid

ALDOSTERONE RECEPTOR ANTAGONISTS

eplerenone Unspra) 2550 mg PO qd Hypenension NSAIOs. lithium. ACE inhibitors

ALPHA-BETA BLOCKERS
lalietalol ITrandatel I00-400 mg PO bid. IV Severe hypenensioo Same as beta blockers plus MAOls
taf\led1lol (C-Oreg CR) 3 125-50 mg PO bid Hypenension Same as beta blockers plus MAOls

CENTRAUY ACTING AORENERGIC INHIBITORS

clonid 'll! ICatapres) OIO 8 mg PO Qd. Hypenension beta blocl(ers. tricychc antidepressants
transdermal patch
pilacme ITenexl I 52 mg PO qd None
me1ttyldopa 5002000 mg PO daily m MAOls. sympathom1mel1CS
dwl<led doses. IV

PERlPHERAUY ACTING AORENERGIC INHIBITORS

"""'10.ln ICardura) 1 16 mg PO qd Hypenension NSA!Os. estrogen
NSA!Os. verapamil. beta blodefs
pa10S111 IM nipressl 120 mg PO qd
reserpine ISerpalan) 0 10 25 mg PO qd MAOls
ACE inh1b1tors. NSAJDs. prl)Pl'anolOI
OJilllSIO (Hyuin) 120 mg PO qd
cimeudme. phenobartl1tal. nfampm,
ANGIOTENSIN II RECEPTOR Hypenension.
ANTAGONISTS vasodilation lithium. ketocooazole. uoleandomycm
losanan IC01aar) 25100 mg PO qd
valsanan ID1ovanl 80320 mg PO qd
1rbesanan IAvaprol 150-300 mg PO qd
2040 mg PO qd herbal supplements
olmesanan medoxom1l !Benicarl
400800 mg PO qd hertial supplements
eprosanan ITevetenl warfarin. digoxin
telm1sanan (M1card1sl 2080 mg PO qd
ACE. angiotcnsin converting enl'/111e: JV. 1mmvenuusly: MAO!. rnonoam1ne oxidase 1111libi10<: NSA/Os. nonsteroidal antiinflammotory drugs: PO. oially
 482 SECTION V Medications Rela1ed 10 Body Systems

TABlE 16 9 ANGIOTENSIN -CONVERTI NG ENZYME IACEI INHIBITORS USED FOR HYPERTENSION

INDICATIONS DRUG '
GENERIC NAME/
TRADE NAME
UIUAL DOSE. ROUTE.
AND FflEOUENCY FOR USE INTERACTIONS l
benazepnl flotensin) >eomg POqd Hypenens1on fll I ' I' - ..

captopr1I (Capoll!nl 25-100 mg PO btd-rid

enalapnl (Vasotecl 5-40 mg PO daily 1n dMded doses
fosmopnl (Moooprill 10-40 mg PO qd
lis1nopnt IPnnivil, Zestnl) 10-40 mg PO qd
moex1{lfll (Un1vasc) 7.5-30 mg PO qd
qumapnl IAccupnl) IOBD mg PO qd
ram1pnl (Altacel 252'0mgPOqd
trandolapnl (Mavikl 1-4 mg PO qd alcohol and di"'eta
penndopnt fAceonl 2-8 mg PO qd For use wnh thiaz1des None iden~fied

Majot Sido EHectr . .

DfV nonprodUCINe cough. headaches. diarrhea. oonst1pation. loss of taste. weakoess. d1wness. 1oint pam. upper reS?Ji!lllly
1nlecb0ns. /ratldolapfl>-dyspep$ia. coiq,. syncope. myalga

hydralazine 10-50 mg PO bid-q1d, IM, IV Hypertension diuretics

minoxidil 5-80 mg PO qd NSAIDs. nit1ates. guaneth~~e

Major Sidi Effects:

Headaches. anorexia, cons11pa11on, d1wness. nasal congestion
/M, 111tramlllCUlarly; N. onl11MlflOUSly. NSA/0$. nons1eri>idal am11nftaJTmatary drugs; PO. orally

BOX 26 5 SPECIAL CONSIDERATIONS FOR USE OF

A side effect of mnomol 1s meteased body hair growth, leading
to 1ts primary use in treating baldness
lll LEARNING T IP
Many of rhe calcium channel blockers end in pine" or ii"
Calcium Channel Blockers
Calcium channcl blockers nre used 10 tre.11 angina.
cardiac dysrhyth mia, and hypenension by interfering
with inOux of calcium in vascular and smooth muscles.
Of most concern in blood pressure tre;11men1 is action
on the rnusde of peripheral anerioles bause peripheral
vasodilation or decreased peripheral vascular resistance
lowers blood pn:ssure during res1 and exercise. Calcium
channel blockers approved by the f-ood and Drug Admin-
istration (FDA) for treatment of hypenension are listed
in Table 26 LI. Special considerations for use in the
elderly are described in Box 265.
CALCIUM CHANNEL BLOCKERS IN THE ELDERLY
Elderly pat1e01s are more susceptible to calcium cllannel bb:i
ing agents and have an increased occurrence of side effeas
such as weakness, d1wness. fainting, and falls
Smoking and nicotine should be avoided; they reduce effect-e-
ness of those medications.
Use of alcohol may lead to hypotensive episodes.
Gradual withdrawal 1s recommended when stopping calc1u~
channel blocking agents.
.
Antihypenensrves are hfelong medications to aintrol !XJ!d
cure hypenensoon
2 Panents should repon signs of penpheral edema11llenl.Jl
calcium channel blockers
3 An11hypertens1ves may cause drowsiness. dizmess. 11
lightheadedness
 CHAPTER 26 Circulatory System and Blood Disorders 483

TABLE Z6 1t CALC IUM CHANNEL BLOCKERS USED TD TREAT HYPERTENSION

l(HERIC NAME/TRADE NAME USUAL DOSE. ROUTE, INDICATIONS

AND FREQUENCY FOR USE
,, , I : I "
DRUG INTERACTIONS
2510 mg PO qd Hypertension and
1 ' I t ' beta blockers (both systemic
2 5/105/20 mg PO Qd anqona pectons and apirhalmolog I dig11al1s.
di arem !Carthzem. T1azac) varies by product d sopyramide. pora "\-
lelodip1ne !Plend1IJ 510 mg PO qd depleting medications.
nocadipne (Cardene) qu1rndJne proca1111t'"l1de
20-40 mg PO Ud
n.fed1p1ne (Procard1a, Adalat) 3090 mg PO qd
nisoldipine (Sular) 8 5-40 mg PO qd
verapamil (Calan. lsoptin, 80-120 mg PO q8h
Catan SR. lsopDn SA. Verelan)
180-480 mg PO qd

eilher atherosclerosis or hyperlipidemia, ancriosclerosi>

lack of patient compliance is the major cause ol ueatment
t ure on antlhypertcnsive theraJJV because theraJJV often
c.uses negatM! feelings as the body ad1usts to the medica-
tion. Medication and lifestyle compliance is d1ff1cult to
1Ch eve because hypertension 1s a silent disease that pro-
!P..SSS slowly but rnquires lifelong. expensM! treatment
Seta blockers and diuretics are the preferred drugs for the
n tial therapy of hypertension
8 .la bkJci< W$ reduce blood pressure pnmarily by reducing
penpl1eral vascular resistance and cardiac ouiput
Duretics 1ooease urinary output to decrease blood volume
Illus loY.1llng blood ptessu1e
Vasod1lators and calcium channel blockers reduce blood
pressure by promoting dilation of arterioles.
l'l1lell a Cllll'lbtnauon of drugs is used for hypenens1on. each
drug should have a different mechanism of action.
Ang1otens1n-converting enzyme (ACEI inhibitors aro used to
treat hypertenSIOf1, congestive heart failure. and myocardial
mfart11on
Calcium channel blockers cause vasodilation. which is useful
11 hypertens100 and angina
Calollll channel blockers and beta blockers have s1m1lar
therapeutic effects
DISEASES OF THE BLOOD VESSELS
reduces blood Dow 10 1issues. blood viS<Osity is elevated
because or fat content, and blood flow to tissues is
diminished Red blood cells are less flexible. and lack or
oxygen causo limitation of blood Oow and oxygen and
carbon dioxide cell exchange with exercise. resulting m
ischemia and pain. Peripheral vasodila1ors are used 10
smooth skelcul muscles of the periphml anerial walls
while having little effect on cutaneous blood Oow. Isox-
supriroe (V,1sodila11) may relieve these >)'mptoms (Table
26 12).
1lemorrheologic agents are also used to improve
blood Oow and lower blood viscosity in peripheral
tissues Ptntoxi/ylline (Trental) is a hemorrheologic
agent use<I to imp~ blood flow through rigid blood
vessels to improve miaocirculniion. Cilosrazol (rleta l)
is the second medication in 1his ca1egoiy, used 10 reduce
the intermittent claudication that comes whh walking
dis1,1 nces by pla1ele1 aggregation (set> T.lble 2G t 2).
HVPERLIPIDEMIA AND
ITS TREATMENT
Some cholesterol and triglycerides, necessary in fonna
lion of cell membrane and neive tissue. are found in
plasma pro1eins. Excessi'"' dietary iniake of lipids is
stored as fat in adipose tissue to be reserved for energy
use. Cholcs1erol is also stored in the gallbladder a> a pan

-
AND THEIR TREATMENT

Pmphml \'ascular disease. with exircmities becoming

cold or numb, with Intermittent dau<liutlon and
ulCt'rs, is common among elderly. Usually caused by
of bile acids. Lipids do nor circulate freely in the blood
srrcam bu1 instead bind to plasma pro1eins (albumin
and globulin) 10 form lipoproteins. Excessi,e circulation
of lipids leads to hyperlipidemia, which is associated
wi1h alhcrosclerosis, leading I() Obslruction or blood
 484 SECTION V Med1ca11ons Related to Body System:.
s------
TARL E 76 12 DRUGS USED WITH PERIPHERAL VASCULAR DISEASES
GENERIC NAME/ USUAL DOSE. ROUTE.
TRADE NAME AND FREQUENCY
PERIPHERAL VASODILATORS
1 supr1ne 1O20 mg PO tid-<i d
bo er tan (TracleerJ 62 5 mg PO t d
M1ior Side Effectt ol Peripheral VHodilotors:
Orthosu1t1c hypotens1on, ftush1ng, d1wncss. weakness. nausea. palpitauons. tachycardia
HEMORRHEOLOGIC AGENTS
pentox1ly1hne (TremalJ 400 mg PO !Id
cilostazol (Pletall 100 mg PO btd
M1jor Side Effectt ol HomotrlHHJIOflC A,.111r:
Dlllllll!SS. headacl1e, abc!M> nat d lrt n..usea. vomrbng
110\v and CAO. The large- and medium-oi.<ed arteries
are usually the ones involved with lhese degenerative
changes.
I ipoproteins are classified by their densi ty. 'lhe three
primary groups are very-low-density llpoproteins
(VLDLs), low-density lipoprotelns (LDLs), Jnd hlgh-
denslty lipoprotclns (1101.s). VI OL part icles al'e
secreted by the liver. becoming smaller as lhe triglycer-
ides are removed. LOI.$, considered to be mo>t harmful,
contain the major ponion of blood cholesterol. HDLs,
the smallest and most dense of the lipoproteins, trans-
pon cholestttal from the peripheral rells 10 li-er for
metabolism and excretion. Because I IOL is a transpon
aid to rid the body of lipoproteins. the higher the llDL
level, the more beneficial with r~ud to pre...enting accu-
mulation of lipids in anerial walls.
Adults should undergo periodic cholesterol testing
becau.e of the dear relationship between I OL and ath-
erosclerosis. An HDL level below 35 mgfd L is considered
to put a person at risk for CAD. 'l11e decision to provide
medicatio ns to lower blood cholesterol is based o n LOL
levels, with levels below 130 111g/dL considered desir-
able. When the level is above 110 111g/dl .. the person
should be treated therapeutically, especially when other
risk faaors such as hypenension, diabetes, and low HOL
levels ha'-e been found. Familial history and aging may
necessitate interventions such as medications when
dietaiy and lifestyle change are not adequate.
Treatment of Hyperlipidemia
------
Medications are used only if diet modifications, weight
loss, smoking cessation, and exercise programs fai l to
reduce LDL 10 acceptable levels. When these lifelong
INDICATIONS FDR USE DRUG INTERACTIONS
Penl)heral vascular disease None
cyclospoone. glyburlde
Oecrease blood viscosity Other antihypertensives
Platelet aggregatron erythromycin, d1ltiazem
omeprazole, kl!tOCOllalfAe
medications are initiated, diet therapy must continur.
For optimum therapy, LDL levels are reduced withoot
reducing 11DL levels. LDL will return to high le>tb
if th ese drugs are d iscontinued. The treatmem is
prophylactic-preventing and retard ing ancriosder0<1i1
rather than musing regressio n of a disease process tha1
has occurrc<l .
Hypolipitlemics or ""'ill)'Per/ipidemii;s are used as a<ljt>
vant therapy to reduce elevated cho lesterol levels wrtlt
hypercholcsteremia and high l.DL levels. T\\o majoH.11
egories are bile acid scquestrants and HMC-CoA redJK
tase inhibitors or stati ns. Other combination medication!
are used for v.irious effects on lipoproteins, indudr,.
combinations of medications to treat more than ont
condition (Table 26- 13).
Bile t1cul <11111es1r11111s such as cholestyramine (Questr~n)
are nonabsorbablc, cholesterol-lowering medications
effective becau>c d1olesterol is the major bile acid pit
cursor. To reduce LOI. ,md seru m cho lesterol level, 1hest
medica tions bind bile acids in the intestine to prl'\<tnl
their absorptio n a11d fo r excretio n in feces. Bile add
sequestran1 medication;, used for primary hypercholes-
terolem ia, must he med with care b)' patien~
with pancreatitis. hy1>0thyroidism, gallstones, C/\D, or
hemorrhoids. llec.1use of 1he binding and loss rl.
fats, defidencic in fat-soluble vitamins A. D, K. and [
may occur.
l-IMC:CoA retl11c111.w 111/11/mors. or statins. are the lllO"
effeaivc agents for lowenng LOI. and cholesterol lc\tls
and cause few adverse re.1nions. Agents such as 01,,,..,..
latin (Li pitor) .1nd sinwastalin (Zocor) are wide!} ustd
Statins reduce the liver cnqrne I IMC-CoA reduct.isr.
necessary in cholesterol riroduction. Respon~ for 1"-
enng elcv.11cd levels of LDL cholesterol are dose
 --~-----~CHAPT~ER 26 Circulatory System end Blood Disorders 485

TABLE 1ti 13 HYPOLIPIOEMICS

GENERIC NAME/ USUAL DOSE, ROUTE,

TllADE NAME ANO FREQUENCY
INDICATIONS FOR USE DRUG INTERACTIONS
Bil ACID
Hypertll)ldcm1a; reduction
SEOUESTRANT
of LDL and cholesterol
d'OestVJamne 46 g powder in water-
[Ouestran. Prevahte) anticoagulants, d190Jun, d11azides.
based liquid PO 1-2x daily
penicillin, prnprallOlol. aspinn.
tetracyclines. fohc acid. thyroid
honnooes
olSlll)Ol IColestldJ 15-30 g Ofllnules PO bid-qld

Mai Side fftects ol Bile Acid-$equestranr:

Coostipallon. ind1gestion. abdominal pain, nausea and vomiting, dizziness. headache. gallstones

HMG-CoA REDUCTASE INHIBITORS STATINS

..msiann (Lpitor) 10-llO mg PO qd alcohol. niaan. cyclospo11ne.
I v~tabO ltescoll 20-40 mg PO qd dig1tahs. etythromycon. nfamp111,
IO'lastarin IMevacor) 2080 mg PO qd anticoagulants. oral
p1tavasta11n llivalol 1-4 mg PO qd contraceptives. propronolol
p1avastatin (Pravachol) 10-40 mg PO qd
-"1lln IZote1) 10-40 mg PO qd
rt. rl8Slabn ICtestorJ 5-10 mg PO Qd

ltl1jor Sid CHects of Stalins:

lleadache. ftaluleoce. constipation. abdominal pain, cramping, dyspepsia

MISCEUANEOUS Elevated cholesterol

HYPOUPIDEMICS or triglycende levels
r :otinic acid. niacin 1-2 g PO qd 1n 23 d1v1ded statins, alcohol
ISl0-N1acinl doses
gemfib1oz11(Lop1dl 600 mg PO bid statins, anttccagulants
ei 1m1be fletia) 10 mg PO qd cyclosponne, bile acid <equestrants
~tellncor. 48-145mg qd warlar on. bile aad sf)QUestrants.
loflbra) cyclosponne
lenofibnc acid (Tnl1p1x) 135 mg PO qd cyclosponne. warfann. d1u1et1cs,
hormones. beta blockers

Major Sid CHBCts of M iscellaneous Hypo/ipidemics:

t'!IC acid-ftush1ng, 1tch1ng. nausea. vonut1ng, diarrhea, gemfibtOzil-61 ~toms. dizziness. blurred vision. muscle pain and
v...aness. cloliltrate-headache. d1armea. skin rash; e1ct1mlbe-fat1gue. arthralgoa. myalgia. dimness. headache diarrhea.
lenofiOO!te-fa11gue. arthralg1a, headache. insomnia, dyspepsia, rash, pruntus. fenolibnc acid-stomach patn related 10 ga !bladder
disease. nausea, vom1t1ng, jaundice. pain or swelling of legs. chest pain, sudden cough, wheeimg, rapid breathing and heart rate

COMBINATION HYPOLIPIOEMICS
be .. sunva~taun
IVytamJ
amlod1p1ne + atoNastatin
(Caduetl
10/10-10/40mgPOqd
5/10-10/80 mg PO qd
Familial hyperl1pidem1a
Hypecl1p1dem1a.
hypenension
Ant1fungals. eiythromyctn,
clanthrornyan. amiodarone.
verapamol

.,,,.,Side EHBCts of Combintian Hypolipidemics:

H..lache. gallstones. myalg1a
G1 Ga.tro1n1esuna1, tot low densuy hpopiotem. PO. orally
486 SECTION V Med1ca11ons Related to Body Systems
dependem I.ow doses provide a ;,maller decrease; large
doses may reduce production of the enzyme up to 60%.
l11cse medicauons mu.i be continued for life to reduce
progrffiion of CAO, dccrea>e number of cardiac prob-
lems. and decrta~ momlity {see Table 26-13).
Ill LEARNING TIP
Because 1Ndoea11011S t11 th$ family have sta/111 m the genenc
names. they a1111eferred 10 as s1aWlS
Nicoll11lc 11d d (N1cobid) redurn WL and VLDL
levels and raises 1101 ll'\-els. but use is limited by side
effcctS such as nushing and ungling sensations. Side
effl'ClS d11nin1sh after several weeks of use and can be
lessened by taking aspirin 30 minutes before nicotinic
acid adminimation . Triple therapy consisting of nico
tinic acid plus a bile acid- binding resin and a statin may
decrease LOI cholesterol levels by 70% or more (see
r.1blc 26- 13).
l'i/Jrir 11dtl tleii11<1ti1'l!s are used to lower triglycerides
.rnd raise I ll)L lt'Vels. Ccmfibroz il (Lopid) inhibits
breakdown of fats into triglycerides and decreases hepatic
production of triglycerides. nils drug, preferred for
patients with hypertriglyceridemia when triglyceride
levels exceed 1000 mg/dL (normal is 10 10 190 mg/dL).
may be used togellwr with otl1er hypolipidemic drugs
(sec 'Iable 26- 13).
With all hypolipidemics and associated medications,
patiem compliance is eS!>ential. For long-term benefit of
cholesterol and I DL reduction and prevention of CAD.
dosage calculation and scheduling of medications
should be individuali.<ed to each patient because of
possible adverse effects. Serum levels of lipoproteins
and liver enzymes should be asses.ed regularly to be
$Ure the desired effect is being obtained without adverse
effects.
~atient\.Education forCompliance
1 Chet mod1ficallOl1$ should be carefully followed before usuig
hypolipidemcs Onlg therapy alone will 1101 significantly
lower blood lipopro1e1n levels
2 Cholestyram1ne (Ouestran or Preval11e) powder must be
mixed w111l 4 to 6 ounces of water or a noncarbonated bever-
age. The p0Wde1 should not be ingested in doy form.
3 Coles11pol (Colestid) g1anules will not dissolve in thin
liquids and so should be mixed with thick liquids for
ingestion
c lmportani FactSiabout Hyp olipidenii'Cil
Low-density lipoprotems ILDLs) transport cholesterol
penpheral 11ssue; h1gh-dens1ty hpoprotems IHDLsJ tra111PJJ1
cholesterol to liver
Dtet modification 1s primary method for reduc1~ llll l!ll
chofesterol levels 0fll9S are used only 1f diet mod~
unsuccessful
Statins. the moSt effec11ve drugs for lowern.i LI). ~
lesterol levels. cause the fewest side effects
Bile acid sequestrams prevent bile acid reabsorp1ion 1111:e1-
tines. causrng const1pat1on and other gasuom1estn11 ~
Other oral medocauons should be given I hour bebe ~
acid sequestrants OI 4 hours ah8f, to allow for absr:rlllJl
wtthout interference by hypohptdemlt$
MEDICATIONS THAT AFFECT
COAGULATION
Clot formation to prevent further loss of blood from
wounds is necessary for surviva l with injuries or suige~
Hemoslasis is necessary for homeostasis. OccasionJlfy
the body wil l form dots or thrombi tlm jam blood
vessels, causing a thrombocmbolls m. A thrombus isa
blood clot wi thin a blood vessel, whereas an ~mbolus
is a mass o f undissolved matter in a vessel IDOl'ing
tl1rough tl1e ci rculatory syste m (Figure 268). AntkO<lgll
!ants arc used to prevent venous cloni ng in patienuwith
thrombohemol)'l ic disorders. An ticoagulants disrupt tht
coagulatio n process and suppress fibrin fonnation
Thrombolytic medic11ions promote dissolution o(
thrombi.
Antiplatelet drugs are used to keep platelets from
dumping (or aggregating). Anti platelet medication.arr
most effective in preventing arterial thrombi fomuu~
whereas anticoagulants arc used to p~I \ tllOUI
thrombi fonnation.
Anti c oagulants
Anticoagulants may be given parenterally, as hepann. Of
orally, as warf arin (Coumadin). 1r not givm 1ntn1t-
nously, heparin must be given by suba1tanrous injtxll
because administration into muscle will cause musdr
bleeding. Safe for use in pregnancy because II doo
not cross the placenta, heparin has an al mo~t imm<
diate onset but a short duration of ae1ion lhmfort
it is usually used in inpatient situations or ir
intravenous tubing where blood cloning is a possib1li~
~uch as during dialysis. O ther injectable a111ico.igulan11
111_dud1~g e11ox11pari11 (Lovcnox) and dalltjlllri
(Fragmm), arc simi lar to heparin and are used moor
often in ambula tory care.
 Endothelial damage-
oells and lipid
ICCUmulate
Tunica
"1tlma
____C_
H_

__
APTER 26 Circulatory System and Blood Disorders

3. E-.s _,,
487

Tunoca ~ol
media lib<Olany matenal
...... and i pods

8. Plaque
Total occlusion
or artery
M ery partially by thrombus
Obstructed

r-t#-.4- Thrombus
Atheromatous
plaque

C. - o1 Uvombus O. Compllcatoe>ns E. Embolus

~ 11l'onQis and embolus lfrom Young M', Proct0t OB K.,,,,.,
I/le medical il$$lstant .,, BJfiied UMf1l(J(Xldl.ed11. St lOlls 2011.

TABLE Z6 14 ANTICOAGULANTS

hepa11n Individualized IV. deep SC Prophylaxis ol antiplatelet medications. NSAIOs. diuretics.

venous thrombi thromboly1ics. antacids. allopurinol.
c1metidine. tricychc anudepiessants.
an11b1oucs. estmgen. oral h\'lloglycemics.
barb1tura1es
W!rlar111 ICoumad1nl 0.25-10 mg PO. individualized
depeode111 on prothrombin time
Individualized SC
Individualized SC
61. Gast-inal, IV. 1ntrlM!flously: NSAIOs. nonstero1dal anti nftammatory drug$. PO. orally: SC. Sltlcutaneousty

Oral anticoagulant. used to p revent Lh rombi, have a is treated with vitamin K. A long list of interactions is
delayed onset of action; therefore they a re not appropri shown in Table 26-14.
ate in emergency i1t1.11i ons. Rather. these agents arc u~cd
prophylac1 lcally for deep vein thrombosis or IO prevent
thrombus formation in such conditions as atrial fibri ll a
tion, to prevent pulmonary embolus, and in hcan valve
replacement urgcry. Warfarm was first found rn spooled silage that caused cattle to
bleed When first developed tt was used to kill rats. and rt 1s still
Warlarin one of the lllOSt W1dely used products for elrm1nat1ng rodents.
The oldest and most used anticoagulant medication is
warfann, an antago m st to vitamin K. which is needed for
dourng facto11 to wo rk /\ledicauo n lewls peak a few
dJ\'S after initiatio n o f treatment. and the dmg remains
1n the body for 2 to 5 days after discontinuatio n Pro-
thrombrn times arc neces~ary to evaluate dosage safety. llJ LEARNING TIP
Patients must be carefully watched for bruising, b loody Anticoagulants tend to end in on
stools, bleeding gums, and blood in urine. An overdose
488 SECTION V Med1callons Related to Body Systems
II . I
aspmn' IBavet and otllersl 81-325 mg l'O daily'"
divided doses
er
11clopodine. oc:lidl 250 mg l'O bid
d pyrldamole' (Pssantonel 50-100 mg l'O qod
clopodogrel' lf'lav,.) 75 mg l'O once da ly
ACE l'lg10t~1<1ing lfll'f'lllr. NSA/Os. nonsteroodal antiflllammatotV drugs. PO. orally
ore medication
'l'lff:r1p11on medication
Antiplatelet Medications
Antiplatelet drugs arc used to $uppress ggregalion of
platelets. The moM frequently used antiplatelet medica-
tion is aspirin, proven effective in preventing Mis and
strokes. Oosage is low, with increilsed doses offering no
further therapeutic advantage. Clopidogrel (Plavix), used
in patients who have rercntly had an M l, a stroke. or have
established periphera l vascular disease is also used as
secondary 1>1-evcn1io n o f further disease processes, com-
plications, or deaths with atherosclerosis. Dentists o r
surgeons should be informed if a person is taking this
medication. to prevent excessive bleed ing. Ticlopidi11e
(llclid), which is more expensive l11an aspirin, is no
more prophylaetic. Dif1Yrltlarnolc (Persantine) also
decreases platelet aggn.11aLion and is used in combina-
tion with aspirin in hean valve replacement surgery
(Table 26-15).
Thrombolytic M edications
'lllrombolytic medications. used to dissol\'e already
formed blood dots. or thrombi, are effective for ueating
Mis if gi'-en within 6 hours of chest pain onset. Five
lhrombolytic drug.s are available: strep1okinase {Strep-
tase), altqlase (ACli\'ase), uroltinase (Abbokinase),
reuplase (Retavase), and a11istreplau {Eminase). These
medications arc gi"en m a hospital selling by heallh
care proviMrs experienced in caring for patients with
thrombi.
ll! LEARNING TIP
Note that the names of thrombolytic med1caoons tend to end in
ase," mdica1mg that these are enzymes
Prevention of anenal oral an11coagulanu, ACE
1nh1b1tors. d tia1e111
womboses by
prevennng platelet
aggregauon
None indicated
NSAJOs. pheny1oo,
warfann. tamoxrlen
tolbutamode. tDfleC:;(le
Topical Hemostatics
Topical hemostatics arc gelatin or cell ulose sponges
employed to absorb excess b lood and fluids and to
comrol bleeding during ora l, ophthalmir, or prmtate
surgery. 1'hese agents expand o n contact with wounds 10
absorb large amounts of b lood and permit clouing 10
occur a long surfaces. These hemostatics are ultimately
absorbed. Oxidized cel lulose canno t be used for permJ
nent implants because it inte rfe res with bone regen(ld
Lion an d may produce cyst forma tion. Absor1Mbl1
gelatin foam (Cclfoam), 11bsorl111ble gelatin film
(Celfilm). and absorb11blc g clat/11 powder (C<'lfoam
powder) are specially prepared no nanLigcnic prep.ira
Lions available in either strips or powders for cornplct,
absorption in 2 to 5 days when applied to skin and 4
weeks to 5 monlhs when applied to surgical wounds.
These agents should be moiMened with isotonic salmr
solutions or thrombin solutions before being ipplitd to
a wound. Oxidized u ll11lose {OX)cel, Surgicel) u swgi-
ca.I gauze or con on that exerts a hemostauc effect. 011tf
uses are in removal of nas.11 polyps and other mmor
swgical procedurC$. 'Ille agem should not be used "' i
surface dressing because 11 inhib11s growth of ep1thrhil
tissue and d ressing material is not premoisttntd
Thrombin ('lllrombinar. 11uombostat), a <1111k
powder obtained from bovine p rothrombin, is wed
topically to treat capillary bleeding.
1. Patients taking anticoagulants and anttplatclet dru!J1 m\51
be careful to avoid injury, including usuig a S(llt br111!ell
toothbrush and an elecmc razor
2. Prothrombin levels should be regularly evaluated when us.ng
anticoagulant therapy
 CHAPTER 26 C1rcula1ory System and Blood Disorders 489

TABLE 26 lb HEMATOPOIETIC AN O ERVTHROPOIETIC STIMULANTS

GENERIC NAME/ USUAL DOSE, ROUTE,
DRUG
f.A~~'1E~""'
mADE N ANO FREOUENCV INDICATIONS FOR USE INTERACTIONS
I .~1 ,
1
. , ... 5 mcg/)(g SC. IV once daily
Stomulate newo1inl prob.toon
Coocom1tantly with
pegfilgrastim(NeulasLa) ant1neoplast1cs
6 mg SC with chemotherapy loth1um
Mljot Side Elfecrs of Hematopoietic A11nts:
..,.., nausea and vom1t1ng, skeletal paon

ERVTlfROPOIETIC AGENTS
Stimulate e0Vthrupo1es1s.
an1oanemics
dartiepoetmalfa (Aranesp) 045 mg/)(g SC androgens
;.0ei.n (Epogen, Procfl!) 100 150 units/leg SC None of 51g111ficance
Ml( SiH Elf..rs of Erythropoietic Agents:
diJdJepoerin a/fr-se11.Ure. stroke, CHF, Ml, diarrhea, nausea, fahgue, fever, bone parn. myalgra, dy>Jll1ea. epoe11n-se11u1e,
coklness, swea!lllg, hypertension, bone pain. headache
CHf Congesuve hean lailure; Ill, intravenously, Ml myocardtal mfarc11on. SC. subcutaneously

protein produced by kidneys. fltese medic.11ions arc

Heniosras1s occurs with formation of platelet plug followed
y coagulatoon
Attenal lhrolTlbt are best prevented with anuplatelet dr!J9$,
~s thrombi are prevented wi1h anticoagulants
Heparrn rs admrn1stered subcutaneatrsly and intravenously
Warfarrn. pr0Lo1ypes for oral anticoagulants. act by block111g
b1Csynthes1s of vuamon K
Asr.<ron and otl>er antJplatelet drugs suppress thromoos
. ~.atJon
Iapo;al hemostats have no s1gnofrcant drug interactions
MEDICATIONS USED AS
HEMATOPOIETICS AND
ERYTHROPOIETICS
l le1na1opoie1 ic ~ti rnuldnts arc Riven to inc1casc \.Vh itc
blood cell levels by stim ulating bone marrow to
produce more leukocytes, espeially neutrophils. lly
tn<rruing neutroplul levels, the body is be11er able
to fight infection< Jfter administration of chcmo1her-
apy or with disease< or therapy c.1using decreased cell
formation. On the other hand, c1y1hropoietin s1imu la-
1ors ca~ bone marrow to produce more eryth rocytes
ind reduce the need for blood transfusions after
hcmodi.tlysis or therapy chat produc"" anemia. Anemia
Illa) be the result of decreaS<' of erythropoiecin, a
admi nistered paremerally and are expen<ivt' treatmem
options. Doses can be adjusted as needed to meet
patient needs (Table 26 16).
SUMMARY
Cardiovasrular disease is the lead ing cause of death in
the United S~11es. Some med ications are elTcctive on the
myocardium itself, whereas others are elTective on blood.
The three actions of medications on cardiac muscle
are motrop" (force of m)'ocardial contraction), dromo-
tropic (conduction of elemiol impulses through heart
muscle), nnd dirouorropi< (heart rate). Ot her medica-
tions cause vasodilation, co lessen the hean's work. As
CAD occurs (e.g., aneriosclerosis o r atherosclerosis),
medications are used to inm?ase circulation by increas-
ing myocardial contractions to adequately pump blood
through the body.
Vasodi lators such as nilrates increase blood vessel size
to improve blood circulation. Nitrates are used as anti-
anginal agents. 8eca blocker.i and calcium ch.lllnel block-
ers are also used for long-term management of angina,
by slO\\fing the hean and onterfering with calcium move-
ment through cell membranes of va.'ICUlar smooth
muscle. The therapeutic goal of angina 1re.1tment is to
reduce frequency and intensity of auacks.
Card iac glyrosides, or digitalis preparations, are used
to increase force of myocardial contractions in CHF.
increa.<e strength of contractions, slow he.trt rate. and
490 SECTION V Medications Related to Body Systems

leading to obs1ruction of blood Oow, hypolipidenuci.

slow conduction of eleoncal 1mpul~ to 1he heart. Heart
efficiency 1s increased wnhou1 1ncreasmg oxygen con
sumption. Gl)'t:0Si~ tend to decrcaS( hcan rate; there-
fore patient educauon should include 1<1king the pulse
d.uly before taking digttalis prtparauons If the pulse is
belo" 60. lhe physician should decide 1f the patient's
med1cauon should be taken
An1id)'srhyihmics are us;:d to tre.11 di~orders of
cardiac rhyihm occurring from CAO, electrolyte imbal-
ances, cardiac conduction abnormalities, or even endo-
crine diseases such as 1hyroid diorder~. Dysrhylhmias
may have little effea on cardi.1c output or may cause
severe compromise of cardiac pumping action. Medica-
tions change hean eleorophysiologic properties by reg-
ula1ing calcium, sodium, and pot.mium ions flowing
11110 hean muscle
Antihypenensive medication~ mcludmg diuretics,
ACI: inhibitors. beta blockers. sympa1holytic agents. and
vasodilators. are used only when lifestyle changes have
not adequately lowered elevated blood pressure. Combi-
nations of medicines may be required, and each new
drug should come from a different ther.1peutic category.
l'auents must be aware that treatment for hypertension
is lifelong. induding lifestyle changes. medications,
or bolh.
For peripheral vascular diseases, vasodilators have a
relaxing effect o n the smooth muscles of peripheral ane-
rial walls to alleviate symp1oms of a1herosclerosis o r
hyperlipidemia. I lemorrheologic agent.\ are u>ed 10
improve blood Oow lhrough rigid arirriosclerotic blood
vessels and lhrough microcircula1ion of arterioles,
wnules. and capillaries. To reduce lhe circulating
lipoproteins and to allevia1e hypercholesterolemia
along with lifestyle changes are used for long-lttnt
therapy
Anticoagulants are used to treat deep \t'nOUS Ihm..,.
bosis by disrupting the coagulation process and f-
tion of fibrin Ant'.pl_atelet med!cations. such asfreq11en1~
used aspirin, 1nh1b1t aggregauon of pla1elets to P'""'
anerial thrombi formation.
J fema1opoietic ,ind eryth ropoietic agents are used 1o
increase circula ting b lood cells when disease proces.i.,
or disease Lre,unienl cause a drop in \Yhite or rtd
blood cells. Trc:ument reduces the need for blood
lransfusion~ in persons undergoing chemotherapy,
hemodia lysis, or with in fections such as human immu
nodeficiency virus.
Many medica1ions affect lhe cardiovascular S)'llan
and thrombus-fonning blood disorders-major arai
in medical ireatment today. Cardiac glycosicks ini1
nitrates are medkines that have been in use for mm,
years. /\ntihyperlipidemks are more recent addition!
for cardiac disease prophylaxis. Nitrates. paniaWity
ni1rogl)'Cerin, now come in various forms. Somt att
used as needed. whereas 01her forms are used on 1
daily basis, but 1he patien1 must be nitrate free al somt
point during 1he day to prevent development of 1oler
ance to lhe med icalion .
As more in formation is gathered aboui lhe le.1ding
cause of sickness and dealh-cardiovascular disease-
medications are cha nging rapidl y. The lifelong need fr
treating hyperiension cominues. Vessel disease is still
present, but preven1ion through lifestyle changes and
medication will continue 10 improve qualiry oflifdOI
!hose prone to cardiovascular disease.

THINKING EXERCISES . -.-;.;,.,..~!,,,~"\.

Scenario
Mr Jon~s has been diagnosed with essential hypertension. He asks how long he will need to take
med1ca11ons.
1. What do you tell him?
2 He also wants to know if there are any l1festyte changes that will help. Name several of these for
Mr. Jones.
J Given diuretics as his first med1call0n, Mr. Jones needs to eat what foods 10 h I k
at acceptable levels? e P eep poiassun
4 How often does Mr. Jones need to check his blood pressure?
5. Can other medications be added to help bnng hos blood pressure to th
diuretics alone do not accompltsh this? Explain your answer. Wt in an acceptable range rt
 CHAPTER 26 Circulatory System and Blood Disorders 491

DRU G C ALCULATIONS
1. order: captopril 50 mg PO qam
2. Order: l..anoxin 375 mcg PO qam if P f60
t.vailable medicaoion:
Available medication:

ifitl

---=-==--
I -
HOC 017;Hl24!H6
i ===
I iii
111
i
'l!Y
-
25mg
IOCtm 111'141
100Tal>le1$
( 10 b'51erpadcs ol 10 IOlllels each)

h jii
U !:
CAPOTEN UNIT DOSE PACK

fjtls Captopril Tablets

1 ~,.._._....._ LANOXIN. (digoxin)
t,.
j, , - - . .".,..
...... - Tablets
Each scored tablet con1a1ns
Dose to be administered - - - - - - - - - - 250 mcg {0.25 mg)
See package instft fer OOSoge ..0 AOmm
trltlon
Store 31 25"C (7rf): mul$ion$ pemlltl!d IO
1S 10 30"C (59 to 86"f) jsee USP Cooliolled
Room Temperature! In a1;t11.llla<>'---

Dose to be administered: - - - -- - - - -

REVIEW QUESTIONS
I. llow do cardiac glyt:osidts work on hc.rn tissuc1 - - - - - -- - -- - - - -- - -- --

2. What chemical classificauon o ( medicines is used for angina! pain? - - - - - -- - - -- -- -

3. llowdo the cardiacglycosodes work on the hean muscle in congestive hean failure? _ _ __ _ _ __ __

4 \\lha1 are the side effc<"t~ of .1ntid)'Srhythmics1 - - -- -- - -- - -- -- - - - -- - -

5 What are the five catcgo1 ies of nwdica tions used 10 treat hypenensionl - -- - -- - - -- - - -
492 SECTION V Med1ceoons Related 10 Body Sys1ems

6 What 1....o categories or metl1Cat1on\ are used for the initial treatment of hypertt>nsion? - - - -- - -

1
7. What is hypatipidemia' What are 1he classifications or Jipoproteins - - - - - - -- - - - - --

8 I low do the statins decrea~e li poprotein levels? - - - - - - - - - - - - - - - - -- - - - -

9 I low do anticoagulants a~t! Ihrombolytics? - - - - - - - - - - - - - - - -- - - -- - -

10. I low do antiplatelet metl1cauons MOP thro m b i ? - - - - - - - - - - - - - - - - - - - - - -

Urinary System Disorders

After srudymg this chapter. you should be capable of domg the following:
01scuss1ng spec1f1c electrolytes needed 10 achieve Discussing enuresis and med1cat1ons used for
homeostasis and to balance extracellular and treatment.
ntracellular fluids. Discussing medications used for treating an
Oesc11b1ng how and what an111nfec11ves and overactive bladder (OAB).
ant1sept1cs are used for urinary tract infecuons Providing patient education for compliance with
Explaining the role of urinary tract analgesics and medications used to treat diseases and conditions
antispasmodics in treatment of urinary tract of the urinary system.
conditions.

Mrs Smith calls to tell you that her 7-year-old son. James. is having a problem with bedwerttng and
she has tfled w1thholdmg l1qu1ds ar bedtime. This action does nor seem 10 help James, and Or Merry
orders OOAVP
What is the form of this medication?
What side ettects would be expected with this med1cat1on?
What is the youngest age the Food and Drug Administration considers to be safe for taking this
medication?
What other suggestions may be made to assist with the control of enuresis?

Enuresis Malaise Solute

Anorex.ia
Hematuria Nocturia Solvent
Ascites
Incontinence Oliguria Urgency
Diuresis
Ion Pyuria Urinary frequency
Dysuria
Lethargy Replacement therapy
Electrolyte

493
4!M SECTION V Med1ca11ons Related to Body Systems

EASY WORKING KNOWLEDGE OF INOICATIONS ANO SIOE EFFECTS

Common Side Effects of Medications for Urinary Syst..
Common Symptoms of U11n1ry System 01sorders
Aootex1a nausea. \'Om ling Disorders
Malaise fatigue lelharllY Drying of secreuons
Noctu11a. hematuna pyuria, protemuna
Drowsiness and dizziness
Oysuria urneni;y frequency 1ncontmence Rash and umcana
Pam m lumbal reg>011 or ftari radiatng lll!O medial th91S. ranging Gastromtestinal symptOms (nausea. vom1t1ng d1arlheal
from slqn teudemess to tnlense pam Headaches
ffVl:I Bradycarda. tachycardia
Edema llld asc1tei Discolored urine
SVmi>UllllS ol resiiiratory and cardiomcutar disease including
hvPenension and shortness of breat~

EASY WORKING KNOWLEDGE OF DRUGS FOR URINARY SYSTEM DISORDERS

Diuretics (also see Yes Yes B.C Hypertension and edema

Chapter 26)
Ant11nfect1ves !also see Yes No B. C. D(sulfamethoxizole Urinary tracl infections including
Chapter 17) at term! pyelonephr1tis. cyst111s. ureuv11s
Urinary tracl an11sept1cs Yes Yes 8 Urinary 1iac1 irnta1ion
Ur1nary tract Yes No 8 Geni1ourinary muscle relaxant
antispasmodics
Med1ca11ons for Yes No c Trea1men1 of DAB symploms
overacllve bladde1
(OABI
Med1ca11ons for enu1es1s Yes No B Enuresis 1n children older lhJn 6

--
rine is fom1cd in kidney nephrons and 1hen

U passes th rough two ureters into the urinary

bladder for storage before excretion (Vigures
27 I and 272) Ilic kidneys regulate homeostasis. main-
;:=:~r- Ra
glJll'd
tain fluid and cloorolyte balance. and eliminate body Renal
fluid wastes throug)i urine. When the bladder is suffi- vem ~~-.....,.
ciently filled (approximately 250 ml. of urine), the -+--4--KOllJ
person feels the urge to void, and urine \'Olumarily passes ~
throug)i the urethra from the body. When urine is ~-'----"~-
retained for prolonged periods of time. urimuy tract

--.- -
9-- - - + - U . .
infec1ions (lnls) are more prevalent.
In males the urethra is surrounded by the prostate
gland If the prostate becomes enlarged. urine may be ~
retained in the bladder because of urethral constriction.
llowever. tms are more prevalent in women owing to Urinary
bladder -f--~"''__)::::"{ -
proximity of the ureth ra, vagina. and anus. and the short
length of the urethra. When medications have been
ordered, patients should be aware that urine can change
Prostate
gland +-~B=-=tTngoot llt- - - - + - " " " '
u.-

color with ingestion of certain dntgs, an important figure 27-1 C-Omponents of the u11na1y system !From Frazier MS. Dll'I"'
ele111cn1 in 1>.iticnL educnion in the use of urinary tract kowst1 JW: Essenrta/s of human diseases and ccnd1110t1s. ad 4. St lllll~
medications (Table 27- 1). 2008. Saunders J
 CHAPrER 27 Unnary SyS1em Ois0<ders 495

TABLE 27 1 MEDICATIONS THAT MAY ALTER

URINE COLOR
I . I I I'

am1tnptyhr>a IElavill 81ue111een

Cotlect1ng Anticoagulants contammg Ptnk, red, or dark brO'M1
vbule warfarin (mdocatove of systemic
with urine
bleeding)
cascara sagrada In acidic unne. brown
In allcahne unne.11 low 10 pool:
In standing urine. black
iron salts BtOWll to black
Laxatives containmg Pink 10 red to brown
senna
To renal
pelvis laxatives coma nrng Pink lo red
phenotphlhale1n
levodopa Oarltens unne and sweat
methyldopa Pink or amber to da1k urine
Figure 27 2 Anatomy of a nephron.
me1ron1dazole Dark urine
nitrofuranto1n Yellow to rusty brown
phenazopyndone O<ange-red unne that may
FLUID AND ELECTROLYTE Slain clotlung
BALANCE phe11yto1n Redbrown or darkened urine
phenoth1a11ne Pink, red, or orange urine
Diuretics (see Chapter 26 fo r use wilh cardiova&cu lar
rilampin Red. orange, or brown urine.
diseaSl'S) modify kidney runction 10 increase diureI.
sahva. sweat. or tears
Diuretics are also used to treat edt>rna from cirrhosis.
ntphrollc disea~ renal failure, hypenension, and car.
diov.lscular disease. When body fluid> are excreted,
excessiV\' sodium, powssium, and chlorides are also
excreted, which resu lts in possible electrolyte
imbalances. Electrolytes are substances dissolved in body Ouids.
1ht amount or water excreted in urine is under the called solutl.'s, and are panicles that dewlop an electri-
dum influence of antidiuretic horrnonc (ADH) and the cal charge when dissoh'ed in water; examples are sodium,
roncemra1ion of waste products found in urine. Approxi potassium. and chloride. t:lectrolytes, or ions, are found
matcly 60% of body weight is water. in the form of inside and outside of cells. Fluids and electrolytes are
intracellular and extracellular fluids. ' lhree fourths of acquired through food and water. Normally fluid gain is
body fluid is iniraccllular Ouid, which is absolutely approximately equal 10 flu id loss. Abnormal physical
tssenllal for metabolic reactions. fhc largest ponion of conditions can result in loss of fluids or elearol)'les or
cnracellulM Ouid is interstitial fluid Intracellular fluid both. When electrol)'les or fluids are not present in
mJinuins the proper environment for homeostasis by normal amounts. replacement therapy is used 10 return
supplying nutrients, oxygen, \<ilam ins, and elenrolytes the body 10 homeostasis.
and arrying off waste p1od~1cts.
Wawr is the solcnt in which body substances arc Replacement Therapy
dissolved In infant<. up 10 75% of body weight may be
"~ltr. this percentage decreases with age. Infants and Fluids and electrol)'les are interdependent because as the
Ytl)' )'Oung children are ,11 greater risk for dehydration amount of water in a body increases. the concentration
than older children and adults because or the high ratio of electrolytes decreases, and vice versa. Replacement
of body smface area 10 body weigh t and immaturity of therapy may also be accomplished by o ral or intravenous
kidneys. Obese persons also nave less Ouid because fat adminis tration, but the oral l'Oule takes longer and is less
conuons little water. Elderly and obese individuals are at efficient. Oral replacement is used in milder. chronic
lllk for dehydration in situations in which Ouid loss cases of imbalances such as diarrhea or excessh-e perspi-
OUB ration not requiring urgent and immediate tttatmenl in
496 SECllON V Mod1cat1ons Related to Body Systems
TABLI /I I SIGNS OF ELECTROLYTE IMBALANCES
. I
SODIUM
c p ' " letha1gy hypotension. uomach crampuig.
vom ttng. diarrhea
Excess Edema tiwenorncotv red ftushed skin. my
mucous memblanes. t111rS1. elevated
wmpeiature
POTASSIUM
D'I) I lmpa red skeletal rrusde functJm.
weakness. paralysis
Abdominal distenbon, weakness diarrhea.
paralysis
CALCIUM
Oepl.1t100 Muscle cramping and 1W1tch1ng, numbness
and unghng of fingeis, roes. and lips
Excess Anore.ia nausea weakness. vomiting.
coma, const1pat1on, apathy, depression.
stupo1, cardiac contracuhrv
MAGNESIUM
Depletion C<11dlat dysrhythm1as, neurotoxic1ty
Excess Flushing, sweating, hypothermia, paralysis.
muscle exc11abtlity. cardiac depression
adulrs. Huid and electrolyte imbalances usua lly occur at
the same time and arc corrected by giving fluids with
proper elmrolytcs and nutrients such a, glucose. potas-
sium, sodium, and chlorides. When oral rehydrat ion is
not pranic,11 or not efficient for the needs. intravenous
fluids may be used 10 replace lost eloorolytes and glucose
because glucose aids in absorption of electrolytes (see
Cha11ter 19 for a discussion of vitamins and minerals
and their replaament for homeostasis).
Llectrolyte loss usually is a result of nausea. vomiting.
renal disease diarrhea, exccss1w sweating. bums, trauma,
and O\'cruse of diureucs F.ach eloorolyte has some spe-
cific signs of imbalance ( rable 27-2) Various Ouid bases.
such as water and saline. may be used for the addition
of fluids. nutrients. or electrolytes.
When electrolytes are lost during diuresis or disease
conditions. fluid balance will also be affected. Sodium is
the primary cation in interstitial fluids; thus when its
concentration is reduced, Ouid transfers from extracel-
lular sources to maintain i111racellulJr fluids.
So<liw11 loss will cause a patient to experience nausea,
mlalse, weakness. headaches. and drowsiness. The
usual repl .1cemcnt is oral ad ministration of sodium o r
sodium chloride compounds. An increase in p ulse mte
blood pressure a re good indicati ons of the approri
w d response. In pat ients. w 'llh . nepIH~tlC
ate ' d'~bean
fai lure. or cirrhosis, a nd on pa t 1ent_s using druJ!$ SUCh 11
corticosteroids and ora l contracep_uves, the plasm~ '"di
of sodium may be excessive, causmg edema and d11Qw
conditions such as congestive hean failurt. Rtstnoq
intake of salt and water is required with these do~
and diuretics are given 10 increase excretion of ac""'-
sodium and fluids
PotJJSSium may be lost in urine when diureuo ~
used, but more commonly loss results from disord<n af
the ga.stroin1es1inal (Cl) t~CI such a~ vomning. dWtbtt
or excessiw use of Jaxauves. Respiratory or mfl.lbolic
acidosis, conicos1eroid therapy. and renal duasa m.,
also lead 10 potassium depletion. When JlOUMIUlll 1
Jost, cardiac mu<;Cle conduaion and nerve impu11f cuo.
duaion are interrupted . As a regulator in many Jll<U.
bolic aaivities. potassium replacement is nccm.uy to
maintai n homeostasis. Signs of potassium loss indUO:.
apathy, weakness. menta l disturbances, cardiac arrhyth
m ias. a nd thirst. Potassiu m may be given through inui
venous replacemen t therapy. but oral replacemenr "
preferred. Preparatio ns com e in s low-release tabl(IS
effervescent tablets, and liquid prcpar;itions. PerhaJl$lht
easiest way 10 replace sma ll potassi um IOSS<!S is through
dietary intake.
Calcium d efici ts arc associated with excessive Jo11a
fro m th e G I tract, pa ncreatic diseases. and other dist~
such as parathyroid d iseases. Defici t s igns are tingling of
extre mities, m uscle cramps, 1e rnny, and l)OSsibly ronwl
s io ns. Dietary c.1lcium is incrc.1scd d uring replamenl
and o ral c.1Jciu m s uppl ements may be added Vltamin D
therapy is frequenoly added to enha nce Cl tract absorp
tio n of ca lcium. A good source of calcium for elderly
women is Tums or other calcium antacids. Lxca""
amounts of calcium cause lethargy, decreasro musdt
tone. and deep bone pa in. Cancer and trawna p.1tim1>
with multiple fractures may also have an 1ncrwt 111
calcium absorption with the s.1nw effoos. 'lau~ -
iring. aoorufa, wn1ipa1ion, and kidney stones ml)'
result from excess calcium intake. A sign of alcium
depletion is muscle cramping for what Sttms to bt
unknown reason.
Magnesium deficits are usually dietary in natwt bal
may be cauS<XI by severe malnutrition. alcohol~m. pro-
longed diarrhea, or intestinal malabsorpuon l'toplt
with magnesium deficits have neu romuscular exoub
ity. Mild deficits are treated with the addiuon of
magn esium-rich foods p lus magnesium .based anoodl
Excessive m agnesi um absorption is usually found wolh
renal insufficiency. Signs of excessive magnesium are an
increased sense of warmth, d ecreased deep tend<lfl
reflexes. low blood pressure. d r<>winess, and lethargy
An eleo roca rcl iogram m,1y s how a rrhythmias lreaunrnt
is a imed a t the cuse o f exces absorption, but mu!
dia lysis m ay he required .

TREATING URINARY
TRACT INFECTIONS
IJfls are the most common bacterial infection; reported
in lhe United States. 1cn percent to 20% of women
eq><rien' a lnl during their lifetime. An upper Ull
(tidne)"1 and ureters) may cause lower back. Oank. or
stomach !"lin with fever, sweating. headache, "cal..ness.
ind naUS<'a and \'Om1ting. lower trns. in the bl.1ddcr
ind urethra. are associated "ith urln~I"} fr.-quenC),
~<l dy<url~. lnconlinl'nce, hcmaturi~, and 0 11.
gu:riL Thne inft>Ctions may be from cross-contamination
from lh<! Cl lraC1 with Ls<l1rnc/11n coli, which causes
~t 90'lo of all Ul1s. Orug therapy for lower lflls may
be suned before cuhurc and ;ensitivity resuhs are a"ail
.hie be(ause of the strong likelihood of Cl contamina
uon.When symptoms of lower LI n .ire related to dietary
factors. stria adherence to a dirt eliminating irritating
foods should bring significant 1clicf in a week to 10 days
(Box 271 lists common foods that irritate the bladder) .
As symptoms subside, su,riciou~ food~ may be added
bad< to the diet, one al a time. If the symp1oms return,
identification of the irri t.11 ing food can be made and
lha1 food avoided. As foods .ire return ed to the diet,
significant amoums of w .ll<'f should he consumed to
Rush kidneys of i rritams.
BOX 27 1 FOODS THAT IRRITATE THE BLADDER
The loUOW1119 foods are ac1d1c and are considered 1m1ams to
ll'e ~ tllal should be avoided by persons who are prooe 10
lower i.mary uact inlecuons
l\lalhollC beverag!!S
Guava
Apples aod apple 1u1ce
l'ea:hes
Ca;lablpe
r.lleaAJle
Cartxlnated beverages
P'i."TLS
OW and olhel spicy foods
Suawlieriies
Ouola1e
Ci!IUS fru ts
Tea
Coffee (1nclud1ng decaffell\atedl
Tamai~
CrarA>emes and cranbe1 IV JUtte
Vnegar
Grapes
Vitam n Bcomplex
CHAl'rER 27 Urinaiy System Disorders 497
---
Drugs to Treat Urinary Tract Infections
f'osfomycin (Monaural) is a unique amibiotic approved
for use with uncomplicated lJlls in women and compli
caled infections in men caused by E. co/1 or (ntfnKi>c<W
faeca/U. fhe dose is in a water-soluble powder pad<et at
3 g/dose. Women receive one dose of the medication
only, as further administralion will not 1mpr0\T symp
loms. Men receh-e t\>'O or three doses of the med1ca11on.
Side effects are diarrhea. vaginilis. headache. and na~a
ff.lble 27-3).
Other drugs used to ueat Ulls and pyuri~ indude
antibacteriali., antiseptics. and analgesics Sulfonamides
(see Chapter 17), the most commonly presc:nbed anfr
bacterial agents for uns. \\'Ork by suppressing the syn
thesis of folic acid. They have a high solubility m urine.
achieve effective concenuations in the urinaiy uaa. and
are less expensive than the other antiinfectivcs. 1lowever,
with recurrent infections. sulfonamides alone may not
be adequate.
Short and intermediate-acting sulfonamides indud
ing 1 MP SMZ (trimethopri111-sulfametl1oxazole) may be
used 10 treat arute q>stitis, acute urethral disease, arute
pyelonephritis, and acute bacterial prostatitis, as well
as for long-term prophylaxis for recurrent llTls. Sulfon.
am ides are used as first-line drugs in lrefltntent of U"l ls
because o f lower cost. Sho n -acting sulfonamides (sulfa
medicatio ns), including sulfism1awle (Cantri;in) .md
sulfadlazine (Microsulfon), are also included in the
shon-acting sulfa medications. Intermediate-acting sul
fo nam ides may also be used as needed, depending 0 11
the ex1cm of infection. The only intermediate-acting
sulfonamide is sulfametJ10JU1r.ole (Cantanol), which has
the same urinaiy indication> for use as short-acting
medications. Because of i1s prolonged duration of
action, ii can be adminislered less frequemly {s 1:1ble
178).
Trimethoprim \fMP} and sulfametho.uuole (SMZ}
are marketed together as a fixed-dose combination
known as TMP.SMZ ( co-trimoxazole. Septra, B;icuim)
"Ibis combination is a powerful antimicrobial and is
used for uncomplicated lnls. It is pankularly useful
for prophylaxis and for chronic or recurrent lflh (see
Table 273).
Antiinfectives
Penicillin, cephalosporins. tetracyclines. and Ouoroqui
nolones may be added or used in conjunction with sul
fonamides for bacterial infections (see Chapter 17 for
specific discussion of antimicrobials). Penicillins arc
also used against enteric-caused baaerial infeaions, but
their usefulness is decreasing as E. coli strains become
resistam to penicillin. Cephalosporins are used for lrrls
resistant to penicillin and TM PSMZ. Telracyd ine m ay
be used to treat initial infections and d1lamydial infec
Lions, but resistance 10 telracycli nes develops rapid ly.
498 SECTION V Med1cet1ons Related to Body Systems

I ABLE 11 3 DRUGS USED TD TREAT URINARY TRACT DISORDERS

USUAL DOSE. ROUTE. DRUG 1

GENERIC NAME/ INTERACTIONS
INDICATIONS FDR USE
TRADE NAME AND FREQUENCY
ANTllNFECTIVES' Usually none
3 g powder packet PO smgle Cystitis
fo: f0'11y ~ 1Mon (Bil
dose
Unnaiy tract mfect111ns
SHORT-ACTING
SULFONAMIDES '
lli.o 250-500 mg PO 4-Sx qd Usua ly none

M1jor Side fleer. of Shon nd lntermedi1te-Actin11 Suffonamiffs:

Nll ~..., 1ng ra.I

SULFONAMIDE Unnaiy uact infecuons

COMBINATIONS'
tnnl' 1tho11nm-suIfamethoxarole 00/400 mg PO bid Usually none
!TMP-SMZltSe!itra.
Bactrim.
Septra OS. Bactrim OSI 160/800 mg PO bid

Ma/or Side Effec11 of Sulfonamide Combinations:

Nausea. vom111ng, rashes

URINARY TRACT ANTllNFECTIONS'

n1trofu1antoin (furadantm, 50-100 mg PO bid therapeutically Urinaiy tract infections No significant
and p1ophylactically qhs
Macrodantm, Macrob1d) 50 I00 mg PO qid
p1ophylactically qhs

Major Side Eiieen of Urinry Tract Antiinfectives:

nttrofuranrorf!-(jl disturbances, headaches. verugo. drowsiness

URINARY TRACT ANALGESICS

phena1opynd1ne U11naiy tract 1rntallon Usually none
fPy11d um') 100-200 mg PO 11d
(Aro'I 100 mg PO tid
pentosan polyslJlfate 100 mg PO t1d Interstitial cysllus hellann. ot'lel
(Elm1ron1 anticoagutaus

Major Sid EW.Ctt of Drup for Uria111 Tr1ct An1fgesics:

pentosan po/'ysulfate-GI discomfort. hair lo:ss. insomma. headache

DRUGS FOROVERACTIVE BLAOOER'

toltefOd ne (Oetrol.' 1-2 mg PO bid Overactive bladder None
Oetrol LA) 2-4 mg PO qd
trospium (Sanctura. 20 mg PO bod alcohol
Sanctura XA) 60 mg PO qd
sohfenacm (VESlcare) 5-10 mg PO qd
darifenac1n (Enablexl 7.5-15 mg PO qd
fesoterodme (Tov1az) 4-ll mg PO qd
IM, Intramuscular. 1Y, intravenously, PO. orally: SC. subcutaneously, XR, extended release
'Prescripuon medicauon
'OTC medication
 CHAPTER 27 Unnaiy System Disorders 499

TABLE 21 J DRUGS USED TD TREAT URINARY TRACT DISORDERS- cont'd

GENERIC NAME/ USUAL DOSE, ROUTE.

TRADE NAME DRUG
ANO FREQUENCY
INDICATIONS FOR USE INTERACTIONS
'
1~
' I ' I . .'
:
U I I I f t t. f ,

URINARY TRACT ANTISPASMODICS

~a\IOxate (Unspasl 100200 mg PO tid qid Genitourinary muscle None
relaxant
oqOJtvnin 5 mg PO bld-q1d Unnary annspasmodoe.
llJ<uopan XI., S.15 mg PO qd 0Ye1act1ve bladder
Oxytroll 3.9 mg/day patch 2x/wk
Oxytrol Transde11mal Transdermal gel 10%
Gelnique apply 1 pkg topically qd

"'''Side Elfecrs ol Urinary TnJct Antispasmodi cs;

o.i~l)'ntn-<lry mouth, conStJpallon

DRUGS TO TREAT ENURESIS '

m11am ne (Tofranill 612 yr: 25 mg PO >12 yr. Enuresis in persons older alcohol, phenoth1azine,
75 mg PO at bedtime than 6 yr c1met1d1ne.
donod1ne, phenytoin
.smc11essJn (OOAVP, 14 sprays qd 1n d1v1ded dose carbamazep.ne,
St1matel chlorpropam1de
demeclocycline

"'ior Sidt EHtcts of Drugs to Trear Enuresis :

~ drowsiness. fatigue. dry mouth. blurred v1s1on, consupanon. impaired concentrauon ~
oosebleeds. increased blood pressure. sore throat

c.rndidal overgrowth occurs most frcquemly wi th tetra

cyclines. Fluoroqu inolo nes are hro.1dspectrum agents
and are active aga in~t mos t o rganisms causing Lrrls, but
the cost of most agents is prohibitiwly high for some Escherichia cali is the most common cause of unC001plica1ed
patients. UTls
Most Ulls can be treated on outpatient ba$1S with oral
medtcallOOS.
Sulfonamides are drugs of choice with Ulls, with TMPSMZ
being preferred med1ca11on.
1 Sullonam1des i hould be taken on empty stomach with full Sulfonamides should be discontinued at first sign of hyper-
sens1t1V1ty reaction
glass of water
2. Er. re course of treatment for urinary uact infection shOOtd Sulfonamides may JllCI- effects of warta11n and oral
hypoglycemtCS, and reduction in their dosage may be
Ile completed. tl'<t!tl though symptom~ may have improved
3 Care should be taken to avoid prolonged exposure to sunlight necessary
when taking sulfonamides If it 1s necessary to be in sun, Prophylaxis for UTI may be achieved with low doses of trun
ethoprun, TMPSMZ. 01 urinary antiseptics
llln.'l:reens should be worn.
4 Drllllt eight to ten Soz glasses of water a day while taking
su!'onarrudes
500 SECTION V Med1catrons Related to Body Systems
Urinary Tract Antis eptics
The most commonl)' ~ unnary tract antiseptic is
ni1ro/uran1oin (Fur.idantin, Macrob1d, and \iacrodan-
11n) lhlS agent may be u~ for prophylaxis and for
treatment of upper lfTis but 1> pnmarily ~ in the
lower urinary traCL Urinary tract an11sep11cs exen anti-
bacterial aaivity in urine but hae liule or no systemic
antibacterial effects (Stt lable 27-3)
MISCELLANEOUS URINARY
TRACT MEDICATIONS
Urinary Tract Analgesics
Urinary tract analgesia may be accomplished through
topical analgesia or local anesth~ia on urinary traa
mucosa. Phena.zopyrldine (Pyrid1um), an oral agent. is
a dye that exens topical anestheuc effect on the urinary
traa lining. It has no an11infectl\e effect but relieves pain
and burning on urination and urinary frequency found
with tms. With the possibility of masking infection
symptoms. phenazopyridine h.u minim.ii side effects
and is forshon-term use. Pe,,rosa" polysulfate (Elmiron)
is a drug specific for prevention of irritation of the
bladder wall found with in tl'rstitial cystitis. The drug
has a blood thinning effect and m.1y cause increased
bleeding.
IPBiliiiitTEducation for Compliance
Pyyid um may change unne to orange-red color and may per-
manently stain clolhlllQ
2 for unnary antrsep-ucs to be most effectrve, unne should be
acidic laige doses of v1tam n C. cranbemes. and prunes will
p<omote acidic unne
3 Carbonated beverages and citrus fru11s should be avoided
with urinary antiseptics because !hey 1end to make urine
alkaline.
4. When lakniq pentosan polysulfa1e, the physician or dentist
pertOfming procedures needs to be informed of 1he adminis-
lering of the medica11on
' Important Facu ' a bout Urinary~Ti&Ctl
Antiseptics and Analgesics~
Unnary tract antiseptics are S8tOnd lone drug chooces for
uonary tract on'ectJons
l'y11d1um os a dye used as an analgeSJC or local anesthe11c on
urinary tract mucosa and for symptornallc relief of burning.
pain. discomfort. or urgency
Urinary Trac t Antispasmodics and
Drugs for Ove ra c tive Bladder
overactive bladder C?AR)_syndrome is a fonn of un111ty
incontinence found 111 pa11e1\ls of all ages, butsympi
increase with age Classic sympto ms a"' U<getl(\ fit
quency, and nocturla. Medications for treallll<nt 1111
aimed at increasing the volume of urine in the blidder
reducing the frequcncy of urination, and d('(Je.,,1
pressure and urgency, which c.10se the n~d to unnatt
by relaxing bladder smooth muscles (see Table 27-l)
Flavwcate (Urispas). a urinary anllspasmodic and gL'llJ.
tou rinary muscle relaxant, is used to treat d)'1uni
urgency, nocturia, and the incontinence of C)'$titi1 ~lld
prostatiti). It may ;1lso be used for nocturnal tnu,.
in children o lder than 6 years of age. Patients ...,1
glaucoma must be closely monitored be<:ause ofth<pi.
sibility of increased intraocular pressure n.yw1,_
(Ditropan) reli~~ urinary symptoms associated..,
neurogenic bladder conditions. Oxybutynin is nouai:t
forneurogenic bladder or OAR but is a means for ~llt1t:i
to live a relatiwly symprom -free life. To/terodiM (Ddiol
LA). trospiHm (Sanctura), and darifenacin (Enabla)Mt
used 10 relieve urin,try frequency and urgency, pr01idin~
relief of OAll ,ymp1oms. 111e medications relax smooth
muscles o f th e bladder. Fc.foterodine (Toviaz) inhibits
urinary bladder con tractions to rel ieve symptoms of
urgency .111d frequency.
IP8tieni1 Educat1on for Complianc;;m
Unnaiy an11spasmodics may cause drowsiness ~
nnachinery may pose a danger
' ..
Urmaiy ant1spasmod1cs reduce the strength and frequency al
unnary bladder contractions
Drugs for Enuresis
.c:.;.,;...:....:..:.;;_~~~~~~~~
Bedweuing, or enuresis, is fa irly common in child!l'fl.
with the percc11t.1ge of bcdweuers gradually decrm1ng
by age 21. Some behavioral techniques may be ustd ~
achieve temporary improvement for those with a sm
or spastic-like bladder that seems to empty autom.iualh-
when it contain~ a cenain volume of urine /mi,,.
(Tofra~il). an .1ntidcpre<>s.1nt, improws symptOlll> d
em~res1~ ~ some children Desmoprnsin (ODA\l') D
an11d1urctoc: hormone (ADI I), increases reabsorptK>~"
water. Tins nasal spray may be used in children 6 )~.111
of ~ge or older and in elderly individuals who h~I
enuresis (sec "l:1blc 27-3 ).
- CHAPTER 2 7 Urinary System Disorders 501

use with Ln Is caused by emeric bacteria. lTll symp1oms-

W!!fto01d1ng ftuids at bedtime is not effective in 11eating enure-
sis ei<.Cl!PI in cases of
a small bladder
~ mav be used to reduce 1nconunence. frequency. and
~ by reducmg spasms of bladder smooth muscles
SUMMARY
Urinary organs excrete nuid body wastes l,,e urinary
rract is aho a major component of mainiaining homeo-
susis and in Ouid and eloorolytc balance. l!dcma may
be caused by sewral medical conditions but is most
trequemly associated with cardiovascular diseasci. (see
Chapter 26). Diuretics are grou1>cd by sites of action to
incmse excretion of Ouids, thereby reducing swelling.
Howe-er, diuretics may cause ~xcretiOll of clcc1 rolytes,
and their loss may result in specific sig11> and symptoms,
with replacement necessary. Chron ic elcarolyte imbal-
ances may be treated as an ambulatory cond ition as well
as in an inpatient selling.
trns arc tre.ued with i.ulfonamidcs and their dcriva
1ives as first choice. TMPSM;t; b 1he hest medication to
urgency, frequency, dysuria.. o liguri;i, and bumlng on
urination-are relieved by both sulfonamides and TMP
SMZ. Some foods {cranberries and cranberry juice) are
indicated to ueat infections. to keep urine more addic
for better effecti\-.:ness of urinary antiseptics. but they
should be avoided for routine ingestion by tho5" prone
10 frequem tJTis because they tend 10 irritate the bladder
Fosfomycin, in a single dose for uncomplicated mfec.
tions in women and two or three doses for complic.ated
infeaions in men. is specific for infections caused by
enteric cross-infection.
Urinary traa antiseptics are the second-choice medi
cations for pm-.:ntion and 1reaunent of I.Ills. These
medications have little or no systemic effect. as they an~
urinary tract specific. and may be used for prophylaxis
or long-term therapy.
Phenazopyridine is a local analgesic for lflls. woth no
antiinOammatory properties. This agent relieves pain
and burning associated with I.Ills.
Urinary tract antispasmodics are ui.ed to relax genilO
urinary muscles to relieve incontinence. nocturia, and
dysuria. Some ne-ver medicatio11s are indicated to relieve
the frequency and wgency of an OAB.
enuresis is treated with medications in children older
than age 7. liehavioral Lherapies may not be indicated,
and withholding fluids at bedtl1J1e in children is not an
effcClive treatment for small bladder or OAB in some
d 1ildren.

Scenario
Mary comes to see Dr Merry complaining of urinary frequency, burning, and dysuria.
1 Should you expect to get a urine sample from Mary? Why or why not?
2. If the sample shows bacteria and Or Merry orders sulfonamides for Mary. what side effects should
she be aware of 7
3. How long should she take sulfonamide med1cat1011s?
4 What food should Mary avoid to prevent 1mtatton of the bladder?
5 Could Mary expect 10 take sulfonamides on a daily basis for chronic UTls? Why or why not?
502 SECTION V Med1cet1ons Related to Body Systems_ _ _ _ _~

DRUG CALCULATIONS
Ordtt Dttrol U\ 4 mg ro qm 2 . Order trimethoprim-sulfamethoxazole 160/80.
tab i qd x 14 da)'S
Available medication
Availabk mcdic.11ion

NOC 00095191-01

SEPTRA n ..
DetrdZA .......
.... sr1 ca
(.iMt I Ill

w.-.
)

__ ul-""'
tolterodlne tartrate Eacl'l 1eo<ed tablet contJinl
160 mg
extended release 600 mo ...
capsules CAlfllOll: Fodllll Ii'#~
....
d90lnlinO wilhocd. ptesc:iCA*:lll.
u - i.. ~.,_

4mg X. ~ r,....M..:: mae

...
L01'
StS4 tl

Dose to be administered : - -- -- -- - -
30 C4PSUles

Dose 10 be administered: - - - - - - - - -

REVIEW QUESTION S
I. \\lhat is an elecuol)'le! What are the four chief clecuolyies! - -- - - - - -- - - - - - - --

2. What is replacement Lherapyl - - - - -- - - - -- - -- - - - - -- - - - - - -- -

J. What are the mosLcommo nly ordered med icatio ns for Lrrls? - -- - - - - - - - -- -- -- -

4 . What isTMP-SMZ! What are the indications for this combination of mcdirations/
-------- --
5. How are the four urinary traCI antiseptics effective in lllls! - - - - - - - - -- -- - -- -- -
Reproductive System Disorders

OBJECTIVES . o" " _ JIJ..' - . ,

After srvdymg this chapter, you should be capable of doing rhe following:
01SCUss1ng sex hormones and their func11on 1n
human reproduction .
Oescnbing medications used in treating diseases
specific to the male and female reproducuve
systems.
Describing pros and co11s of different forms of
contraceptive medications .
Discussing medications used lo treat in fertility and
their effectiveness.
Providing information on medications for
piemenstrual syndrome and dysmenorrhea.
lden11fymg med1cat1ons for endometrios1s
Discussing medications for erectile dysfuncuon
and the dangers when used with nitrate
medications.
Discussing categories of med1cattons that impair
sexual funcuon as a side effect.
Providing patient education for compliance with
medications used to treat diseases and condittons
of the reproductive system.

Mr. Husain. age 65, comes 10 Dr. Merry womed about an inability to void that has become
progressively worse. At this time, he has not voided for about 8 hours. Dr. Merry examines Mr. Husain
and prescnbes Proscar
For what disease process is Proscar indicated?
What mechcat1ons for hypertension should not be used with Proscar?
If Mr Husain were a younger man. would an enlarged prostate be as likely as 111s after age 60?
Mr. Husain tells you that his l1b1do has d1m1n1shed since he started taking diphenhydramine for
allergies. He wants to know 1f there 1s any connection between his diminished hb1do and the allergy
medteabon. What 1s your response?

KEY TERMS
Cryptorchidism Galactorrhea Ovum
Anabolic steroids
Depot form of Hirsutism Priapism
Anabolism Progesterone
medication Hypogonadism
Androgen Progestin
Dyspareunia Negative feedback
Chloasma Spermatogenesis
Estrogen Oogenesis
Coitus Testosterone
Exogenous Ovulation
Contraoeption

503
504 SECllON V Med1cat1ons Related to Body Systems

EASY WORKING KNOWLEDGE Of DRUGS USED FOR REPRODUCTIVE SYSTEM DISORDERS

DRUG CLASS PRESCRIPTION OTC

PREGNANCY
CATEGORY MAJOR INDICATIONS
Hormone replacement
I
Androgens Yes fanabofic androgens- No c. x
Schedule Ill)
No B. D. X(finastendel Reduce symptoms of berugii
Benign IJIO$Ul1IC Yes
prostauc hypenrOIJhy
hypertrophy agents
htrogens. progestons No C. D. X Menopause, r~ ~
Yes
cancers 1n males aid ferntti
Oral and long acting Yes No x Prevenuon of pregoa1':\'
parenllll'al contraceptrves
Othef contrar:ept!Ve$ Y8$ ld1aphragm) Yes Nooapplicable Prevenuon of pregiarcy
Postcoita contracepuves Yes No x Prevention of pregnancy a!air
unprotected se.wal 1ntetl:Qlle
Med1cat1oos for PMS and Yes Yes B. D Rehef of symptoms of PMS ..i
dysmenotrllea menstrual cramping
Medications for 1nlert1hty Yes No x Trearment of male and femal
inlert1l1 tv
Med1cat1ons for erectile Yes No N/A Treatment of erectile dy1fur-:tj)d
dysfunction
PMS. Promons11ual svndrome.

EASY WORl<ING l<NOWLEDGE OF INDICATIONS ANO SIDE EFFECTS

Common Symptoms of Reproductive System Oisordel$ Found with Reproductive Tract in Both Ganders
Sexuelty Transmmed Dist1ses (STDsJ Genital lesions
Pelvic or genital pain Breast changes (growths (benign and malignant!. mas11,
Dysuna. hematuna. pu1ulent d1scha1ge discharge I
Burning or 11ch1ng on urination Psychologic response to hormone changes
Urinary frequency 0< 1nconunence
Dyspareuma Specific to Male Reproductive System
Fever, malaise Frequency, urgency, pain. 01 burning on unnahon; ohg1111
Lesions in gcflltal area Sexual dysfunction. including impotence or erect r dysfu~
Pain. swelling, or lesions of any reproduct1~e organ
lnl rohry
Allnolmal prognanoes Common Side Effects of Medications for the Reprodutl!ft
System
Endomel!lOSls or othef reproduttrve tract d1sordefs, 1ncludmg
bloclied fallopan tubes or tumors Edema and weight gain
Congenital malformations Acre and skin discolorauon. especially of face (e g chlo.i
Decrea100 spenn count lnaeased or deaeased sexual stimulation or libido
Enlarged breast tissue in both sexes
Hlrsutim . deepening of voice. and amenoohea in 'Mll!el
Specific ro F.male Reproducave Sy>tem Nausea and vomiting
Fever Arouetv. depression
'
Abnormal vaginal discharge 1t1:h1ng Headaches
Pam 1n lower abdomen or peiVlc region Increased risk of thromboembolic disorders
Dyspareun1a or sexual dysfunction Hypertension. myocardial rnfarcuon. stroke
Dysmenorrhea, amenorrhea. metrorrtiag1a, menorrhagia. or Increased risk of cerv1citis
oligomenorrtiea Increased risk of gallbladder disease
Menstrual irregularities
Visual disturbances

teause the reproducrive S)"tcm has been doaked
B in secrecy :'"d cultural inhibuions for centuries,
many pauems. arc uncomfonable dbcussing
stXUJI matters. cspeaally when the patient is of one
gender ,mcl the . physician is of the o tlwr. Because
of l()Cial P_Crcepuons about reprod11ctiw organs and
their funcuons, health care professionals face chal.
lengt>S obtaining information concerning repro ductive
<)~tem dysfunctions, m~king an open, trusting patient
professional rdauonsh1p necessary. Mcdkations used
require teaching and coun.scling in pcNQnal and sensi
0,,. areas; therefore patient inform,11ion must be prc-
!(llted and dtSCUssed with an understanding but positive
approach
In review, the major structures of the female repro-
duetive sy>tcm M C the ovaries, fallopian tuhes, uterus,
and v.1gina (Figure 28-l ). In the ma le, th e urinary and
reproductive systems arc inte rrelawcl con>is ting of the
tes1es. vas dcfcrens, pros1ate gland, urcthr.1, ~cminal ves
ides. cpididymis, ejacu latory duct, .1nd penis (Figure
28-2) The male ,tnd female sex hormones are necessary
for de\"tlopmcnt and mai men a nee of ~ondary sex
characttristtcs and for reproduction ' l he reproducti\1'
proc~ begins '"ith secretion of gonadotropic hor-
mones from the anterior pituitary gland, stimulating
de1'tlopment o f sex organs. Foll iclcs timulaling hor
moue (ISi 1) stimu lates oogenes ls in o varies and
spermalogenesls in testes. l..utcinlzing hormone (LH)
stimulates release of an egg and form,1tion of corpus
luteum In the testes, spermatogcncsis and secretio n of
androgens occur. The male <ex hormones are called
mdrogens; the female sex hormones arc .-~trogen and
progttteront' (see rigure 28 l) ~ Chapter 20 for
more informauon on these hormone$.
Falo!Joln lube
UttNI
Unnary bladder
Urethra
l.Abla mlnO<a
l.Abla majofa
Figu11 23-1 The female reproclJclr.e svstem !From Fm1e1 MS. O.iym-
lnwJ<, J.V EssenMls of hum;m diseases and CDfld1t10t1S. ed 4. St lours.
2008. Saunders )
----'CHAPTER
--- 28 Reproductive System Disorders 505
INFLUENCE OF HORMONES ON
THE REPRODUCTIVE SYSTEM
FSI l a nd interstitial cell-stimulating hormone (lCSH) in
males stimulate production of testosterone. Testosterone
promotes adult male sexual charaCteristics, essential for
regulating metabolism and growth of bone and skeletal
muscle>.
In females, f'SH sti mulates growth of a graafian folli-
cle and production of estrogen During the prolifera-
tive menstrual cyde pha.se. "' estrogen mcreases. FSI f
decreases, preparing the uterus to rece"" and nourish
a fertih1.ed o~-um. During the proliferatM! phase, the
endometrium grows and enclocervical glands secrete
viscous mucus to nourish sperm before fenilization
(Figure 283).
With ovulaUon at midcydc, 111 i110uences formation
of the rorpus luteum, releasing cstrog~n and progester-
one during the menstrual cycle secretory phase. If the
ovum is fenilized. the increased endometrial lining will
suppon growth and nourishment of the ovum. If fenil
iz.11ion docs not occur, increased e<;trogen and progester-
one decrease the release of FSl l and LI I by a negaUve
feedb,1ck me.:hanism.
1he chier ,1gents affecting the reproductive system
are hormones, \vith son'e agents stimul;iting secre1 ions
and o th ers blocking these same secretion~. Medication
therapy for conditions of the reprodunive system can
be complicated, even with drugs witl1 familiar names.
Although hormones are naturally produced, some
di-orders are indications for use of exogenous male or
female hormones. Such symptoms and diseases as defi-
ciendes m hormone secretions. hypogonadism. and
Ovary
Rocwm
Cerv"'
Efacutatory duct
Rectum
Cowpers gland
vagina Anus
Urelhra Scrotal sac
Anus
Epididymls
p.,., Testes
Figure 28-2 The male reproductM! system JfnJ111 Frana MS. Oriym-
Mlw1kr ;r.N ES5t!tlbals of /xJman dise<lses illd CCtld1tms. ed 4. SI LOUIS.
2008. SaundlllS.I
506 SECTION V Med1cat1ons Related to Body Systems

supp Iemenl low levels of testosterone. 10 correct b,.,.

.-
gonadlsm or cryptorc~1~di,m; to increase SjX'rm l"l>
duction in cases of 1nfemh1y; and ~o sumulate prodUOIClll
d blood cells An increase...m. red blood cells~

~
-~ ..Y' ..... lnhblS
of re

50
1
in proiein synthesis causes m..,...e ~ass to ma.__
athletes may use androgens to 1mpl'Ol't ~dlkiii
petformance.



Testosterone - - - - -- - - - -- -



Testosterone brings abou t a sense of ".'ell -being. restorti
men tal equi librium and energy, and increases the resii
tance of the central nervous S)'Slem to fatigue.1wo 1y~1
FSH of testosterone are available for replacement ther~P'i
StJmu:lates
natural testosterone from testes of bulls._ and synth"'
androgens. Anaholl~m, the consrruruve meuboi
process for convening substances mto other chm1<1I
compounds that are rt'quired for cell repair and grOW!li,
is stimulated by 1es1os1erone. Testosterone funcuons 0
build new body tissue and 10 increase muscle sumg111
and endurance. r-.a1ural types are preferred. to ach..,.
adequale blood drug levels. Adminisuation by intrami.
cular injection is necessaiy because oral testosterone ~
highly metabolized in the intestines a nd the li,'tr~o1r

reaching the b loodstream. which lowers its erfeai\'enas
Medication is available in aqueous bases forshon action
in oi l bases. or in the depot form of m"<licaUon

Estrogen fo r actio n up 10 4 weeks. Testosterone pellets are .tvaiJ.
IProgeswone I able for subcurnncous implantation, with extendld
Oevefepment and maintenance Prej)8r.. endome1rium duration of ~ct ion of 2 10 6 months. Methyltes1os1eroo.
of f&male reproductive s1ructures 10< lmplanlll uon may be administt'rcd by the buccal route. whereas 1)1'
Dewtopmoot ol lemale Prepares mammary gland thetic androgens may be effectively adminis1ertd or~~
secondary M eharactensllCS for 1aeta1oon
Fat depo<ited in b<eesls, (Table 28 I ).
butlocks, and lhqls Transdermal t~'Stosterone preparations are appltal 11
Alcilary and ~ hair
Mammary glands begin 10 different ways. Ihe tcs1osterone patch, Testodl'fll\ "
developonbreasls applied to S<ro1al ~kin for absorption at a high ralt fM
PelYls broadens times greater than at other dermal si1es. The patch i!ldt
Figure 28-3 Hormone regulatJOn of 1he menstrual cycle and ovarra on the scrotal .uea for 24 hours and is changed d.tih
function (Fmm Applegate EJ. Anatomy and {ilys1ology loaming system, When used for treating ciyptorchidism to encouragi
ed 4, St Louis. 2010. Saunders) descem of IC.O.ll'S in 10 the scrota I sac an 8 week couM o1
therapy s recommc11ded. Tiw second 1estos1erone patch.
Androderm, is appl ied 10 the back, abdomen, arm~ 01
carcinomas of male and female reproductive organs may thigh~ daily, wi1 l1 the applicati on s ite changed evel)' 24
be reason for this treatment. 1lormoncs arc also indi hours so 1ha t no site is used more frequently than ontt
ca1ed for treatment of symptoms of menopause and for in 7 days. Both of 1hcsc patches should be applied mgh~i
contraception. al about 10:00 l'M so that maximum serum levels art
adtit:Ved in thl.' morning. to stimula te normal dm1dUJ1
rhythm in young boys AndroGel, a gel preparallon.
DRUGS THAT AFFECT THE MALE applied daily to a clean, diy area on the shouldm. uppn
REPRODUCTIVE SYSTEM anns, or abdomen a1 bedtime. Buccal tes1osteront D
placed on the gum at the incisor eveiy I 2 hours ID dw
Androgens morning and at bedtime.
Dosage and length of therapy depend on didgJIOI>
Ille male sex hom1ones are called androgens; the major patient's age and gender. and side effeClS or ad\'er!e re.i<
hormone is testoslerooe. Androgens are given 1hera- ions that occur. In males with delayed pubeny, lhedoot
peu1ically 10 men for various conditio ns, such as 10 may be low initially then gradua lly increased according
 _ _ _ _ _...,:C:.;.H::_:A:_:
PTER 28 Reproductive System Disorders 507

2-0 pellets SC q3-6mo Pa al()ll of ,...tastat.c

breast can-:ei
Replacement therapy
Postpartal br t pa n
lllelatesuyt. Oepo-Testosterone. 50-400 mg IM q2-4wks
IJepotcsL Duratest) (long-acting
fl,"'ttable)
(Androderm) (transdermal) 1 patch q24h
(AndroGel 1%. Testim) 5 mg topically qd
{Str1~t)
1 buccal apphca11on bid
Huol()'rll9Slerone (Androxy) 520 mg PO'' qd
irelhy!testosterone (Adroid. Methitest. 10-50 mg PO qd
T~.Vmlon)
danazol 200 400 mg PO daily in Endometriosis lovastatin, oral anllcoagulants
d1v1ded doses
Androgen 111l11bitor 1000 mg PO qd Advanced metastatic CYP206
abiraterone (Zyt1ga) EPrednisone 5 mg P1ostate cance1
M1jo< Sit/II EffeC#: Fema/es-<J1ly skin, acne. 1ocreased hair growth, 1ocreased libido. irregular menses. deepening .01ce. mat~
utinaiy urgency, swelling or tendemess ol breasts, frequent erections. priapism; both gender.1'--change of skin color. abdominal
pa , insomrna. mouth soreness. diarrhea. constipation. diumess. headaches. confusion. depression. edema of legs
IM ln1ra1MCular. PO. orally; SC. subcutaneous
'Used as replacement therapy
!U.i for pos!llarlllll breast paon
'Used ID palhate merastalac breast cancer

to need and response. l'rca tment ma)' last for several
months or may continue throughout puberty. 111ese
drugs ar~ Jlso used for antineoplastic therapy in men
and women: a 3 111onth pe1'iod i> nccessory to evaluate
utatment effeoiveness. Women should receive a shon-
acung androgen because they m> occasionally increase
the extent of brca~l ca ncer. llecausc of drug interactions
111th an11cwgulants, an increase in bleeding episodes
may occur and an unusual increase or decrease in libido
may occur.
Anabolic Steroids
A1Hbollc steroid,, which are used 10 bring about a
fmmg of \\"ell-being. are acrnally natural or synthetically
produced androgens. In tl1c male, ,111drogcns function to
butld new body 1issue and to greatly increase muscle
strength and endurance (the obuse of anabolic steroids
is discussed in Chapters 20 and 31 ). Anabolic steroids.
or 17-alpha-alkylated androgens. are classified as Sched-
ule Ill medicat ions because of the potential for abuse
or misuse and their serious side cffectS. Men who 1hlnk
the anabolic action will maintain suength, especially in
spOrtS, and virility into the older adult years, are those
who usually use these drugs. Mood, libido, and choles-
terol le-oels may be improved. and muscle mass may
increase, but the dangers far outweigh the benefits. Ther-
apeutically these drugs administered o rally, intra musru-
larty, and topically, may be used to treat anemias from
renal disease in both genders. For conditions character-
i,,ed by a breakdown in protein metabolism. anabolic
steroids may be used to promote weight gain. These
medications are hepatotoxic. and irreversible liver
damage can occur [fable 28-2).
 508 SECTION V Medtcattons Related 10 Body Systems
nandrolone Uleca 50-tOOmg M
Dlnabol nl
M1for Sid Effects: Rash, hematuria. elevated blood pressure. amenorrhea. nausea. vom1ung. changes in ltbldo, headaches, ins~
increased aggression and 1rn1ablhty
IM. lnuamuscularty; PO. oranv
[PitientEdUC'iiirOriltorJ.Com pli 11 nee
Pat1e<lts using Testoderm should shave sc1otum before apply-
mg patth
2 Sodium and water 1eter111on mav otaJI with use of 1estoster
one. v. th resultant we.gilt ga111 and f'trcm tv edema
3 Buccal tesu>stemne should be pbced with rounded surface
against gum at 111C1sor Me and held 1n place IOI 30 seconds
with finger 0\'111' ~P Do not cllew DI swallow bucxal appl1-
cat1on of 1es1osterone Ac:italtl placement with each
adm n1stra1ron
4 Signs of hepal!c toXJc1ty such as 1aund1ce, chalky stools, and
pain m right shoolder should be reported 1mmed1ately when
using androgens
5 Oral androgens should be taken w11h food 10 avoid gastro1n
testinal upset
...
: .. ! :
Tes1osterone os pnoopal 811drogen.
Andtogens sttmutate productlOll of red blood cells and
increase muscle mass Andiogens are used lherapeullcally
as repfacemem lherapy for anemias from renal disease, to
treat female breast engorgement. and palhatY11ly 1n meta
static breast e<1ncer
Testosterone taken orally is metabol11ed by lhe ltver before
absorption. so tesrosterone 1s usually given by 1n1ect1on or
lransdermally. Testos1erone gel and buccal tablets are also
available for ease of administration.
Two llansdermal forms of 1es1osterone are available. One is
applied to scrotum, other 1s applied LO extremities or back.
and sites should be rotated
Anabolic steroids have 1ox1c effects on hve1 and are Schedule
Ill drugs because of potential IOI abuse
Medications for Benign
Prostatic Hypertrophy
Benign prosiatic hypenrophy (BPI I) is an increase in
glandular and connective 1issue mass of 1he prostate sur-
rounding 1he m~le ure1hra. Development of BPH is
BteaSt cancer and anemias AnlJCOagllianlS. arit1diabetc.
caused by renal disease 1mmunosuppressaiu
considered ,1 norma l age-rela1ed change in me11 af1era&\'
of 40, with 71% of men by age 70 having syn1p1omso1
BPI I requiring medica l intervention. BPH obsuuru lht
bladder neck and compresses the urethra, resulting in
urinary reten1ion and an increased risk of urina1y Ina
infections. Symptoms ofllPI I are hesitancy on urinalice,
decrease in s1ream and force of urine. posl\'Oiding dnb-
bling, and sens.1tion of incomplete bladder ClnPl)ii
resuhing in frequency and noe1uria.
The goal of treatment of BPI I is to relie;e bothmooir
sympto ms. Alpha-adrenergic blockers such as 1411.
su/osit1 (Flomax), lera:ws iro (Hy1rin), and .i-io
(Cardura) are preferred for BPI I tream1eni in pa1icnu
with relatively small prostates. These medica1ions relax
the smooth muscles of the bladder neck and pros1a1efor
ease of voiding whi le ac1ing as hypotensives; thus 1heie
med ications are usefu l for both prosta1e disease and
hypenensi<rn.
Fit1asteride (l' roscar) .rnd dutasteriM (A\'Odan)
5-alpha-reduelasc inhibitors, are appropriate forpatitnb
with large prosta1c glands to promote prostattshrini:.
Benefils develop slowly, laking up to 12 monlhs 10
appear. 111 is medication prevents testosterone comw
sion 10 dihydrotes1osterone (DI-IT), the androgm found
in prosta1c gland. llw powdered DI IT dooea5e5 pltJi!UI
growth 10 relieve llPI I symptoms. Women of chil<lbQI
ing age should not handle this medication, because all\'
amount absorbed through the skin may cause binh
defects. Women of childbearing age with partnel'l undtr
going finastcridc 1hcrapy should use contraception
(Table 28-3 ) . II 1ww group of androgen inhibitors useJ
for advanced mctaMal ic pros1a1e cancer had been imro-
duced. Abirat.,ro11e (Zytlga) is a pregnancy catei,'01') X
drug 1ha1 is 1akcn concurren1ly with prednisone.
lll LEARNING TOP
Adrenergoc antagonists used for BPH usually end UI sin '11
5-alpha 1educ11on 111h1bttors used for BPH usually end 111 "nde
Finasteride is marketed as P!oscar 5 mg tablets f01 BPH iJld as
Propecia 1 mg tablets for alopecia.
 _ _ _C
_HAPTEA 28 Reproductive System Disorders 509

ADREHERG1C ANTAGONISTS
(BLOCKERS)
~~ (Rapaftol 8mgPOqd rtraconarole or
ntonavit CYP3A4 1nlubttor,
ketoconalole
rl1!all)Sltl 1-10 mg PO qd ACE 1nhbtlOIS. NSAIOs.
Pl opi aoolol
~(Aomax) 04mgPOqd Beta blockets. other
adrenergoc antag0n1sts
~n(Cardural 1-8 mg PO qd Hypertension ACE 1nhb<tors. onOomethacon,
verapam1I, noledop1ne
al'U11JS1n (Uroxauall 10 mg PO qd alcohol

s.Al.PHA REDUCTASE INHIBITORS

dutastende (Avodart) O5 mg PO qd None
finastende tProscar) 5 mg PO qd No s1gmficant interactions but
should not be handled by
WOO\efl of ch1ldbeanng age

ACE. An;iLOtensinccxwe"'ng 0<11vm-0: NSAIDs. nonstero1dal a11111nftamma1oiy drugs. PO. orally

. '
1 Patients taking alphaadrenerg1c blockers should take medi
cations at bedtune because of rirstdose" orthostatic hypo
1e11s1on and d1w ness
2 Treatment for benign pros1at1c hypertrophy is suppressive
rather than curative, and symptoms may return 1f medication
is wtlldraWTI
3 ~lpha reductase onh1b1tors may be teratogenic 10 male
tetuses. so all women of childbearing age should not handle
~ Seual panner should not become pregnant while
pal1ner IS taking drug
Benign prostate hypertrophy tBPHI occurs in 73'lf> of men by
age 70. C3US!ng sufficient symptoms to require medical 1nter-
'll!lltl0n with drugs
S;~torns of BPH result from meochanocal obstruction of
<e" a from overgrowth of epithelial 0< smooth muscle cells
Alphaadrenerg1c blockers. which are also used as an11hyper-
teo-rves. ielax the smooth muscles of the bladder and prns
tate to relieve BPH symptoms
!>alpha reductase inh1b1tors promote regression of prostate
ep1thehal tissue and reduce mechaniC<il obstructoon. being
more effective in men whose prostate 1s sogmficantly
enlarged
1;n~it!lr1111111ew
Med ications used 10 treat conditions of the female repro-
ductive system are similar to the hormones naturally
produced by females but also includes use of androgens
in some cases. The medi<:ations-provided a> the fem~le
hormones estrogen and progesterone (or progestin. the
synthetic equivalent)-are prescribt to supplement low
levels of nacural hormones. to correct hormone imbal
ances that <:ause abnormal uterine bleeding. to reverse
abnormal ovulation. to enhance fettility, and to be used
for oral contraception.
. ?ccasionally women are treated with androgens pal
loauvely for metas1;1tic breast cancer and as therapy for
postpanum breast engorgement. endometriosis. and
6brocystic breast disease. Women receiving androgen
preparations may haoe irreversible ''Oice deepening.
Estrogens
l:strogens suppon development and maintenance of
reproductive o rgans and secondary sex charaeteristics in
females. These hormones al~o have profound influences
on reproducthe physiology. from their actions during
the menstrual C)d e to stimulation of uterine growth and
blood flow du ringpregnancy. In premenopau>al women.
the ovary is the principal organ of estrogen production
in estradio l form.
 510 SECTION V Med1cat1ons Related to Body Systems
Lstrogens haw a positiw effect for blod<lng bone
mass resorption and promoting mineral deposits. During
pubeny. estrogens promote growth of long bones. In
postmenop;Jusal women. estrogen replacement helps to
mamtam bone mass
Estrogens are the domin.mt form of medidnal therapy
for female reproducth-e system cond1uons as well as
having a direct effect on bone and card1~lar func-
tion and insulin sensiuvity estrogens reduce levels of
low-density lipoproteins (I Ol.s) and increase levels of
high-density Jipoproteins (I IDL.s), thought to reduce risk
of hean anacks in premenopaus.11 women. A' estrogen
levels begin to fall during mcnopau;e, the incidence of
hean attacks in females ri.es. l.wogens al>o increase
bile's cholesterol coment, explaming why women taking
estrogens may dC\'l.'lop gallstones
J,strogens haw Se\'eral uses m both genders. including
ad1uvant therapy for cenain cancers- male prostate
cancer and non~trogen-dependcni breast cancers in
both genders. llonmone replacement therapy (MR'f)
using estrogen prepara1ions is prescribed for women
who had their ovaries removed during the reproductive
years and in older women for prevcniion and treaimem
of osteoporosis. A f.1mily or personal h istory of breast
cancer may be a contraindka1ion for use of I IRT.
Use of estrogen '~ithou1 added progcllJJs in post-
mcnopausal women increases risk of endome1rial hyper-
plasia and of endometrial and b1cast c.mcer; estrogens
alone cause endometrial lining prol ifera1lon. /\ woman
with an intaet u1erus who receives replacemen t therapy
should be followed closely with physical examinations
and Pap smears to ensure early detection of disease.
Addition of progestins reduces endometrial cancer risk
by down-regulating estrogen receptors
Recent studies have shown that with HRT therapy in
postmenopausal women who took conjugated estrogens
for tO years. the risk of death from any cause was
decreased by 37%. Risk of death from hean disease was
decreased by 53% and from stroke \"<JS decreased by
32%. However some scientists are of the opin ion that
I lRT may be more hilm1ful than helpfu l bernuse of the
increased risk o f reproductive tract cancer. Some women
who are given prescriptions for estrogen replacement
therapy never fill the 1>rescrip1ion out of fear of develop-
ing endometrial or brcas1 cancer. Women who had an
early menarche and a la1e menopause .ind who take J l RT
appear to have a greater incidence of breast r,,ncer.
Whether incidence is higher because of an aetual disease
increase or because of earlier detection of breast cancer
in women who ha'oe regular, frequent ex;iminations is
unknown.
Estrogens are available in conjugated doses from
natural sources. including the urine of pregnant mares,
and are alsosymhetically fonnulated. 1:$triol and estrone
are naturally occurri ng estrogens that occur when esua-
diol secreted by the ovaries is convened. Conjugated
estrogens (Premarin) are available in mixtu"'5 of e 1r.,
genie medications in oral, parenteral, transdemui Ind
percutaneous fonns. rransdennal patches, vagJn~ nllgl,
percutaneous creams. and emulsions of esuogm prqi.
rations are most often used for urogenital aun-q.
Estrndiol used by women with estrogen deficiency 1111!
be delivered transdermally to provide its conhnw 1
release. Inc lowest ei.1rogen dose needed to produet u1
desired effect ohou ld be adminis tered over the $hon. i
period of 1imc 10 reduce the potential for seriou11;.i.
effects.
Estrogens shou ld be used wim caution in p.11it11ii
wi th endomcirio>i, gallbladder and liver diseaS(, pan.
cre.ititis, and elevated lipopro tein levels. Women 1vilbi
history of c:.trogen hypersensitivity, hypercalcemi~ and
thrombophlebitis or 1hromboembolic disease shoulJ
avoid estrogens unless the benefit outweighs !ht 11\\
Glucose tolerance is decrc3S(.'<1 wim estrogen thmpy.
occasionally leading to symptoms of diabetes mdl11111.
Estrogens tend to cause retention of sodium and " lift
and therefore may aggravate asthma, epilepsy, mignlll(
headachC'o, hean disease, and kidney disease. Ptopl-
who wear con1,1et lenses may note intolerance for iftll
wear became edema changes the corneal shape an.'
results in improper Jen fit.
Forms of Estrogen Preparations
Estrogens arc ,1vaila ble in severa l forms with uniqu1
means of adm inistra1ion. Estrogen and proges1eronc
products arc available ora lly, paremerally (inuamll!a>
Jarly). vaginal ly, topically, and as intradermal implams
To lengthen the onset and duration of action, honno111>
may be administered parenterally in an oil base-tht
depot form- for slower absorption from musdtllllUt
Transdermal estrogen patches, applied to a diy sun.n
on me abdomen or buttocks, bypass hepatic met.Ibo>
lism . Administration of transdennal mediation" I a.-
2 times a week. rather th.1n dJily. An innovati"' fonn ol
estrogen therapy for menopausal hot Rashes is an eslrJ
diol emulsion to be rubbed on each leg daily in momt!l
much like a lotion. r'he lower dose of esiradiol ii
absorbed th rough the skin into 1he bloods1ream. Another
un ique delivery 1>y.icm is a drug-laden vaginal ring
pressed i1110 the v.1ginal mnal for continuous releal( of
medica1ion into local tissues. Vaginal insens and m~m1
are formu lated 10 rclo?ae hormones into the vagin1 on
contaa.
New oral forms arc most commonly used, w11h lht
trend toward longJCting produets mat are taken cbih
for up to 3 months before stoppage to allow for 1
menstrual period. 01c U.S. Food and Drug AdmonlStl>
tion (FDA) now allowi. indefinite use of some !Mlic.
tions for prevention of menses, as "-ell ~s for onl
contraception .
lmpla11ts containing contraceptives are surgic.1111
placed under upper arm skin to prevent pregnancy OldfC
 CHAPTER 28 Reproduc~ve System Disorders 511

impl~nt fonns ~ontained ~ultiple rods that were changed

ewry s years.1he newest implant, consisting of one rod
for a 3-)0?ar duration, is expected to stop menstruation
tn most "omen.
Oral esrrogen may be prescribed in cyclic dost>s, m
,.hieh 3 weeks of estrogen are followed by a week off, or
b) p!Oge$tln addition for the last 10 to 13 days of the
ryde. Newer low-dose oral contraceptives rarely include
more than 50 mcg of estrogen; in most cases, the use of
10 to JO mcg of cmogcn is adequate for binh con trol.
IP-'trdoses with effective coverage improve oral contra-
ccptl"I' safety (fable 284 ).
Progesterone
rrogesterone. stimulated by LI I and produced by the
O\'lllc<. is a
naturally occurring but also may be synthetic
progestln with similar pharmacologic effects. Advantages
of progest in over progesterone ate that a lower dose of
progestin is necessary 10 produce the desired response,
progcstill has a longer duration of action thall progester-
one. and progestin is available in oral and sublingual
forms for easier adminmmion. Progestin is used for
ueating amenorrhea and abnormal uterine bleeding
from hormone imbalances. for contraception or in com
bi nation with estrogen for postmenopausal I IR'I. and as
adjuv,1111 or palliative therapy for renal or cndonwtrial
cancer. When in combination with progesterone. the
estrogen component is mO>l often stated in micrograms
with the progestin component stated in milligrams. A
combined-continuous rqpmen for HRT i~ estrogen and
progestin combined in a single tablet for daily ,1dminis-
tra1ion sec 1.1ble 28-4 ).
Patients with a history of migraines, dial>Ctes mellitus.
hyperlipidemia, thrombophlebitis. and undiagnosed
bleeding from the reproducti'" tract should be atched
closely when taking progestin

TABLE ZB-4 SELECT ESTROGENS ANO PROGESTINS

RNERIC NAME/ USUAL ADULT DOSE.

TRADE NAME ROUTE. ANO FREQUENCY INDICATIONS FOR USE DRUG INTERACTIONS
ESTROGENS
Htrad1ol (EstraceJ 0.52 mg PO daily 1n cycles Menopausal symptoms. bromocnptino.
hypogonad1sm hepatotOKiC drugs
(Estraderm. 11 ......i e. Chmara) 0 025-0 1 mg patcll
!Est11ng) 2 mg vaginal nng every 3 mo
(Estrasorb} 2 5 mg applied onto each leg qd
(omulsion)
IEvamist) 153 mg spray on inner surface
of f0<earm qd
IVagifeml lvag nal tablet) 10 mg topically in vag na
IElestnn) (gel) O87 g topically to upper arm qd
es1rad1ol cyp1onate \Oepo- 15 mg lM every 3-4 wks
Estradiol. OuraEstnn}
est' ad1ol valerate 1020 mg IM every 3-4 wits Menopausal symptoms tobacco
lllelestrogenl Hypogonad1srn. and prostallC
cancer
ewadiol. eth1nyl 12 mg PO bidUd Prostat1c cancer
esterified estrogen (Monest} 03125 mg PO qd
0.75-3 mg PO Qd Same as other estrogens and None noted
Htrop1pa1e
osrnoporosis

II.( '1rrM1USCUlarty PO orally "'""""'

512 SECTION V Med1cauons Related to Body Systems

TABLl 18 4 SELECT ESTROGENS AND PROGESTINS-<:ont'd

GENERIC NAME/ USUAL ADULT DOSE. J

TRADE NAME ROUTE. AND FREQUENCY INDICATIONS FOR USE DRUG INTERACTIONS
PROGESTINS
Amef10rrllea, abnormal utertne None noted
P'"O'~t111 5-lOmg IM
bleeding, 1nfert1hty
!Cr1noool Vaginal geVsuppoSllOI)' topically
IPromttnuml 200 mg PO qd xi 7/day
210 mg PO qd Endomerrial hypefplas1a. None noted
medrc 'Y!l'ogesTe<one iPrCM!fal
secondary amenorrhea,
abnormal utenne bleeding
(Oepo-Prove1a) 150 mg M q 3 months Cootraception
4(X).1000 mg IM wldy Eodometnal carcinoma
17 g/wk Eodometrial cancer
megcstrol IMegacel 40 mg PO q1d Breast cancer None noted
40-320 mg PO qd Endometrial cancer
800 mg PO qd Anorexia, cachexia
oorethmdrone 0 5-20 mg PO qd Amenorrhea, abnormal uterine None noted
bleeding
!Camila. Ernn, NorOO, 0.35 mg PO qd Contraception
Johvet1e) 5mgPOqd Prevention of endometrtal
hyperplasia with estrogen
therapy
noreth1ndrone acetate IAygestin) 2.5 mg POqd HAT replacement. abnormal
bleeding. ondometriosis

COMBINATION ESTROGEN AND PROGESTERONE MEDICATIONS

este11fied estrogen with 1 25 ff11j/2.5 mg PO qd Menopausal symptoms. None noted
methyltestosterone (Covaryx, hypogonadism. and breas1
EEMTI cancer
esterthed esuogen w11h 0.625 mg/2.5 mg PO qd Same as other esuogens None noted
medroxyprngesterone
!PREMPRO, Premphasel 0 625 mg/5 mg PO qd
esuad1ol, noreth1ndrone dose vanes with drug HAT replacement None noted
(Combipatch, Act.vella)
1M11nvey)
estradlOI. norges11mate IPrefestl 1 tab qd 1n cycles HAT replacement
1 mg/O 09 mg PO qd
esirad ol. OO'ethmdrone lfemlvtJ 5 mcg/1 mg PO qd HAT replacement
estrad1ol, d1osporenone (Angeltql 5 mcg/1 mg PO qd HAT replacement
COOJugated esuogens !Premann) 0.3-2 5 mg l'O qd Menopausal symptoms. None noted
!Premann vaginal cream) 2-4 g lop1Cally qd osteoporns1s preven11on.
con1ugated ll$ttogen. synthetic 03-1 2S mg l'O qd m cycles prostate cancer, breast cancer.
A ICenes11nJ hypogonadism. and atropluc
con1ugated esuogen. synthetic B 0.3-1.25 mg PO qd in cycles vaginitis
IEn1uv1a)

, Befolestarting any estrogen therapy, a female pauent should
~rgo full physical exarn1nat1on 111ctud1ng bfeast and pelvic
wimnatl(llls. Pap smear. blood pressure. and lipid profile.
folioY<td by yearly reexaminations and monthly breast self
eJll'Tl nabons for women older than age 40, a mammogram
rnav be indicated
2. Esuugens can cause genotal abnormalities in male fetus and
vaginal cancer in female fetus Estrogens should be d1scon-
tRJl!d as soon as pregnancy 1s suspected
3 To rb:e side effects of estrogen and progesterone. take
n!dica!JOll with load
' H p&1S1stent vaginal bleeding develops 111 menopausal
women. the itiysic1an should be notified
5 f$UOQen and progestin may cause a sunbumhke reaction on
eqlOSIJfe to sunlight or ultraviolet hght
s BIOOd glucose l!lVllls should be checked more frequently 1n
people with diabetes metl1tus taking estrogens
7 Esnad1ot transdermal patches should be applied to a clean.
dry a<ea ot intact skm on the abdomen 01 trunk. pressing 11
firmly in place with palmof hand for 10 seconds If patch falls
off. reapplysame patch Application site should be changed
with each new patch. Avoid applying estrad1ol transdermat
patches at waist or breasts. or in places where clothing will
loosen edges of patch.
a lntravaginal estrogen preparations should be positioned high
1n vagina. Arecumbent position for 30 minutes is necessary
after applicauon to allow medications to remain m place 101
etfect1veness If patient is in upright position, medications
will be expelled by gravity
9 Patient should avoid sunsc1eens when using estrogen
~ls1on
Esuachol 1s the p11nc1pal endogenous esuogeo with a rote in
l"" l"lenstrual cycle and is req1ured for growth and matura
!lit of reproductrve organs
f.-igens raise levels of high-density I PQ1110te1ns (HOll 800
ri.;..;e levels of low-1Jensrty hpoprotein (lDll. which may
e~ n ~ premenopausal women may not be as suscep.
tible to coronary heart d1se<1se
i.ausea 1s the most common side effect of estrogen
p.-eparat1ons
Prolooged use of esuogens afQ!1e 1s associated with an
n1eased nsk ol endometrial carcinoma. when used wrth
progesterone. there 1s little or no osk of urnnne cancer
Estrogens taken for less than 5 years pose a smaller nsk for
breast cancer and
, Progesuns may cause breakthrough bleeding. spomng.
amenorrhea
CHAPTER 28 Reproducuve System Disorders 513
-Important Facts about Es trogen
Progesterone Preparations- cont' d
Natural estrogen losses 1n menopause may cause hot fta~s
loss of booe mass. and an increased nsk of coronary heart
d sease
Honnone replacement lherapy rn poscmenop3US31 women
usually consists of estrogen combu'.ed with pn>ge$t l\ Estro-
gens and prog8SIJRS are contraindicated durong pregnancy
and m women wllh es;rogen-dependl cart1nomas. undiag
nosed abnonnal vag111at bleed ng and ttitomboembohc
d1soolets
FORMS OF CONTRACEPTION
Chief factors to consider when c:hoosmg a method of
birth control are effectiveness, safety, and personal prefer-
ence. Contraception denores prevenrion of ovum fenil
izarion and subsequent onset of pregnancy Binh control
may be accomplished using pharmacologlc methods
such as oral conrraceptives, medication-laden implants,
injectable hormones, and intrauterine devices (IUDs).
Nonpharmacologic methods include surgic,11 stcril i1.1-
tion. mechanical devices, and the rhythm method. The
best form o r co ntraceprion will be inelTective if im prop-
erly practiced.
Safety of birth control me;isures is a complex area: Of
contracepuve methods available, oral contraceptives
have the largest spectrum of adverse effects- from nau~J
10 menstrual abnorrnaliLies to rare thromboemboly11c
disorders. The lowest monality rate is seen with barrier
methods, but oral contraceptives are relatively safe
in nonsmoking women with normal cardiow>rular
function.
Oral Contraceptives
Oral comracepti\'t'S are the most elTeaive form of easily
reversible binh control presently available. Hrst made
available in the late 1950s. these medic.uions have had
a large impact on socioeconomic conditio ns . in the
United States because their use has reduced family siu.
Early dosages of contraceptives were much stro~~ with
greater side effeas than those found today. Millions of
women ha\'I'.' used these medications; through this expe
rience. risk factors. dosages, and elTecth'eness hJve bttn
evaluated and modified. Newer low-dose oral contracep
tives are associated with lower risk of adverse elTects.
The first oral oomraceptrves contained from tO to 20 mg of estro
gen per tablet compared to 0.5 to 1 mcg per tablet currently.
514 SECTION V Medications Related to Body Systems
Combination oral contraceptl\~ which consist of
some estrOgen and progestin formulation, inhibit ovula-
tion by increasing hormone lewis and increasing the cer-
vical mucus ''boosiry. thus crtaung a bamer to spenn. T""'O
main categories of oral contraceptwes that are nearly
100% elfenn"e are (I) those con1.11nmg estrogen and pro-
ges1m, known as combinatw11 om/ 1011tr<1up11t'I'>, and (2)
those containing only progesuns. or mini pills. Combi-
nation oral contraceptiVt>S are manufactured in monopha-
sir, biphasic, lriphasic, and estroph.isic formulations. In
monophasic regimens, daily doses of es1rogen and pro-
gestin remain constant throughou1the menMrual cycle. In
hiphasic regimens. the estrogen dose remains constant
but the progestin dose is increased during the second half
of the cycle. Triphasic regimens divide tlw men>trual cycle
into three phases. with the proges1in amow11 changing in
each phase of cycle. In estrophasic regunens, the amount
of progestin remains constant and the esuogen dose is
gradually increased throughout the cycle.
Lstrogen components ha~ bttn associated with
venous and arterial thrombocmbohsm, causing myocar-
dial infarctions and strokes ASsocialed risJ.. of hrpenen-
sion increases with prolonged oral contr,1cep1ive use
and increasing age. Risk of adverse card1ovasC11tar reac-
tions and breast cancer is grea1ly increased in women
who smoke while taking ora l contraceptives. C1ncer risk
is low, especially when compared with the endometrial
ca ncer risk found with po111nenopausal estrogen
therapy. Oral contraceptives con1aining progestins ca n
e.leva1e blood sugar levels and c.,use ga.llbladder disease.
The efficacy of oral contraccp1ive> can be affected by
medications, and oral contraceptives in turn can affect
the dosage of some medications (Box 28- I).
BOX 28-1 MEDICATIONS THAT CHANGE THE
EFFECTIVENESS OF ORAL CONTRACEPTIVES
Orugs that Reduce Effects of Oral Contrueptivea
nfamp1n (tuberculosis)
phenobarbital. pheny101n. and pnm1done (an11se1iure)
tel1acychne and penic1tl1n denva11ves lant11nfcct1ve}
St John's Wort (hertlall
ritonav1r (antiviral}
Drugs Whose Effects ere Reduced by
Oral Contraceptives
warfann (anucoagulant}
insulin and othe1 hypoglycenuc agents (fOf diabetes mellitusl
Drugs Whose Effects are lncnued by Oral
Contraceptives
theophylhne lfOf asthma}
tncyclic antidepressants (fOf depress~)
d1aiepam tanb-anx1el'{)
chlordiazepoxide (anti-anxiety)
~---
Taking Oral Contraceptives Effectively
Most oral comracepti\es are taken in a S('(juence oi 21
da)'s. followed br 7 days of no pill, an inen pill, or~
iron-containing pill Some oral comracepti\-esare<tanal
on the fifth day of the menstrual cyde to be taken at u,,
same time daily Succe!.Sive cydes begin C\'Cr)' 28 ~
Other oral contraceptives are started on the fim <1.iy ,
the menstrua l cycle and are continued daily lhrougheo
the cycle. 111ese medications may contain iron suppl(.
men ts or placebos during the last 7 days. During the firit
cycle of use. other birth con trol forms should be used II
a single dose of oral con traceptive is missed, the chance
of ovulation is small. I lowever. risk of ovulation becom<1
greater with each consecutive pill omitted. If one dost
missed, it should be taken the next day. If two d~ a.rt
missed, two table1s should be taken o n the next 1 lb\,
If three doses arc missed, a new medication cycle shOOtd
be started 7 days after the last pill was taken. Addiuon.it
birth control should be used during the fim 2 "'ttb o(
the new cyde. If this routine is not followed, pr~M'
due 10 ovulation may occur {Table 28-5).
Breakthrough bleeding, spotting. amenorrhea, and lmu
1eoderness are possible with es11ogen and prog(
preparations
2 Oral ooniracep11ves should be taken at same nme dl!!y
beginning at the appropnate time dunng menstrual eiat
Monophas1c med1ca11ons are taken for 21 days. folkMed t'j
no drug for 7 days Other foonulatioos may PfO'lde Ulle:s
con1a1mng 11on Of placebos so tablets are taten CJl
basis
3 Shonness of breath, leg tenderness, chest pain. tieadac!:es.
or visual disturbances while takmg oral coo11acept1ves m
be reported to physician 1mmed1ately. Yearly physical elJl!l1
nations are necessary
4. If two consecutive menstrual periods are missed, Ille pos
bility of pregnancy must be evaluated.
5. Menses may be irregular for several months alter d1sco~1
ation of oral contracepllves
6 Oral contraceptives cannot be used dunng breasriri'lg
because hormones will enter bfeast milk and pass 10 ant
7. Persons w11h diabetes mclhtus taking oral con.'raCl!ftllt!
should moo11oi blood glucose levels closely
8. Incidence of mult pie births is meteased 11 concepoon ocan
shortly after oial oonuaceptrves are stQWed To recb:e
chance, 01her forms of birth control should be llsed k:r 3
months alter termination of oral cootracept1ve use
9 Add1t1onal forms of contraception should be used dut"'9
mmal cycle of oral contraceptive use
 CHAPTER 28 Reproductive System Disorders 515

MONOPHASIC COMBINATION Ptevenuoo 01 See Box 2&1 lor dr11g mtetat11ons

MEDICATIONS pregiancy IMth this Q'llllP of drll{IS
eM estrad ol/noreth1ndrooe (in various 1 lllb PO qd (the
;:rangthsltloestr1n, Loestnn 24 FE. eslfllgen component
Oicxlrl 35. l!levlt:oo. Mod1con. Nomrit. is in moaograms.
~. Juoel. Microges11nl the progesun
component 1s m
milligrams)
~ es!radiol/drospirenone (Yasmin, I tab PO qd m cycles
Yazl
etti'1jl estrad1oVnorelgestrom1n (Ortho APflly patch topically
&'rill ooce wkly
ethinyl estrad1ol/levonorgestrel (Alesse. 1 tab PO qd in cycles
~ette, Altavera)
e:h1nyl estrad101/norgestrel (Lo/Ovral. I tab PO qd 1n cycles
Ovrall
e1lonyl estrad101/desogestrel (Oesogen. 1 tab PO qd in cycles
Onho-CepO
etn1nyl estrad101/norgestimate (Prev1fein. I tab PO qd in cycles
OnhoCyclenl
eth1nyl estrad1ol/e1hynodiol diacetate 1 tab PO qd tn cycles
1Zov1al
mestranol/norethindrone (Norinyl, I tab PO qd in cycles
OrthoNovum 1/50. Necon 1/501
esuogen/progestm (Necon 1/35. Alesse 1 1ab PO qd m cycles
ZS. Ortho-Novum 1/351
81PHASIC COMBINATION MEDICATIONS
et.flt'1)' esuad1ol/noreth1ndrone (Ortho 1 tab PO qd in cycles
Novum t0/11. Necon 10/111
e" nyt estadt01/desogestrel (M1rceuel I tab PO qd 111 cycles

TlllPHASIC COMBINATION MEDICATIONS

e..,., ~trad ol/noreth1ndrone (lnNonnyl. I lllb PO qd on cycles
fXro.NrMxn 7fl{II
mll)I estradiol/leVOflOrgesuel (lnphasil. 1 tab PO qd in cycles
Tri-.oral
e~ estradtOl/norgesumate (Onho I lllb PO qd in cycles
To-Otden'I
ESTROPHASIC COMBINATION MEDICATIONS
eth ny1 estradiol/noreth1ndrone !Estrostepl 1 tab PO qd m cycles
ff. Iron. /I.I intramuscularly, IUD. 1nuaul111'l dev.ce: PO. orally
'frt drugs separated by a slash. tile Inst d1ug hsled 1s an estrogen component and the second drug is a progest1n component
'food ard 01119 Adm1msuat1on app1oved fo1 use with acne
516 SECTION V Med1cauons Related to Body Systems

PROGESTIN-ONLY MEDICATIONS
noreth1ndrone f0ttho-M1cro11orl 1 tab PO qd in cycles

LONG-ACTING CONTRACEPTIVES
ethyl estrad1ol/levon0<gesuel fSeasonale. 1 tab PO for 91 days
Seasoo1que, LoSeason1que) 1 tablet PO for 84 days
flybrell 1 tab PO illdefinnely
medroxyprogeslerone fDepo-Provera, 150 mg q3mo IM
Oepo-subOI 104 mg q 3 mo SC
levmorgesuel flmplanon) 1 rod subdermal q3yr

INTRAUTERINE PROGESTERONE CONTRACEPTIVE SYSTEM

.M>OOtgestrel fM1renal IUD q5yr None noted

Other Forms of Contraception

Implants and Transdermal Patches
Two mam categories ol oral oootraceptives are comb1nall0ns
of esuogen plus progestm and proges1 n-only med1ca11oos
(m nip;lls)
Combmauon oral con1racep11ves primar ly iM1bi1 0V1Jlallon.
Senoos adverse reactions from oral con1racept1w use are
rare. although side effects and some comphcatons oocur.
Ad1us11ng estrogen and progcs11r content may mm1m1ze
problems.
low-estrogen combination oral con1racep11ves pose only
minimal lhromboembohsm risk except 1n women wnh
past history of thromboembolic disease or 1n those who
smoke
Oral contraceptives are 1era1ogcmc and may cause cance1 in
female offsp11ng; therefore t~ev are contraindicated during
pregnancy
Progestins are slightly saler than combmauon oral contracep-
wes but are less effectlVI! and cause more menstrual
uregulanty.
ProgesnlKlllly oral conuacep11ves increase viscosity of
cef\'lcal mucus. creating a bamef to spenn and suppress-
ing growth of endometnum to prtlV9'1t fllf11lued OVIJOI
1mplanta11on
Combination oral contraceptions protect against ovarian and
endometnal cancer They do 001 cause breast cancer
O ther medicatio ns Me used for lo ng-acting con1r.1<q>
tion. A subdcm1al ~ystem, Jmplanon, provides S)1lthetir
progcstin, /e11011orges1rel, as the most effeai\'e lorig-t~
revt>rsible method of contraceptio n. The six tiny cipstilei
containing synthetic progestin are surgically impbniol
inside the upper arm. Levonorgestrel dilfuses sl"iy .nl
continuously .tt ,1 rate of about 80 mcg/day 10 pro1idt
contraceptio n for up to 5 years. The implant must t.
surgically rem oved when no longer desired or dftttn
A monophasic transderma l patch holds a combinJ
tion of et/1/nyl estmdiol and norelgestrom/11 (Onho-
Evra) 10 providccon tr.1ception much Iike oral prepara1ion1
with the same indications .ind contraindications. Pa1che1
are a pp lied to the upper a rms, back, abdomen, or but
tocks and arc worn in d1 her weekly or biweekly cydel.
The patch is ~ppl ied o n the same day of theweeUorl
weeks, with the fo urth week being patch free Wirh
correct use. effectiveness of contraception is tqual to th
of oral medications without the need to rernembtr to
take daily medicauon doses. Jh is medication has ~
less effective in women weighing 198 lb or mOfl\ indi-
cating the nt>ed for other means of comraception
obese women. Women using 1his mt>dication shoulJ not
be without a patch for lo nger than 7 days in a row. or
pregnancy is possible If a patch becomes loose or fllh
off for less th.111 I d.ty, eith er the patch should bt
 CHAPTER 28 Reproductive System Disorders 517

re;1pplied or~ a new

h
patch

s hould be "PJllid
' < an
d 1h e
iegula~ day or c angmg shou ld remain the s.imc. If the TABLE 28 6 COMMON SPERMICIOALS
pa.id> is off for more thirn I day or if the lime off is
unkJJown, a new 4-week cycle should begin immcdiaiel MEDICATION ACTIVE
<ind a backup method of con1raccp1ion should be use~ TYPE INGREDIENT" TRADE NAME
tht tmi week of the cycle (>ec 1~1ble 285). Foam nonoxynot-9 Dellen. Koromex
Jelly nonoxynol9 Gynol H
Contraception by Injection Gel nonoxynol-9 lntceptrot
,\ single injecti~n of metlroxyprogesltrone ( Depo- Advantage 24 .1
flo\"ff3. 150 mg mdepot form or OeposubQ 104 m Advantage-$.
in subamaneous form) provides contraception S<lfel~ AQoJa lube Plus.
<ind dfert":eJY for 3 months or more. Injections prcvem KY Plus.' Gynol
pr.gnaocy tn ihree ways: (I} by suppressing ovula11on n: Koromex'
(2) by thickening the c_eivkal mucus, and (3) by alterin~ octoxynol-9 ()nho-Oynol'
lherodometn~~ io_dscourage fertilia<l ovum implan
Suppository nonoxyool-9 Encare Semicid
uuoo. When 1~11ecuo1~s are discominued. an average
of 12 mondls is required for fertility 10 return, with Vagrnal flm nonoxyno1.9 VCF. Ol1ho Op11ons
sorotwomen remaining infenile for 2 or more years (see
M ajor Side Effects: Nausea. voo11ung.1nten1l1ty, breast
Table 285).
tenderness. ectopic pregnancy. blood clot fonnat1on
Intrauterine Devices Side effecis minimal.
IUDs. another relatively long-term effective reversible 'lo be used only in combina(J()n w11h a diaph1agm
fonn of birth control, are inserted 11sing minor su rgical
procedures. The principa l problem with 11IO use is pelvic
inflammatory disease. nw major side effcc1 is cra mping.
The IUD should be used by women al low risk for sexu
ally uansm iued diseases (STDs) . 'l11rec IUDs arc avail
able: the Copper T 380A (PnraCnrd) Ill L) and the
intrauterine progest~rone contr.lrcn1ivc syst~n1 (Progcs-
1asert) and levonorges1rcl (Mi rc na) . IUD l'arnCard may
remain in place for 8 year> nnd is more widely uscd .11ie Barrier Devices
Progestasert musl be replaced annllally. and Mirena is Barrier devices, nonpham1acologic methods of hinh
effecm-e for 5 years (see 'l.1ble 285 ). control, inducle male and female condom, diaphragms,
and ceivical caps. The most commonly usl barrier con
S,,.rmicides tmcepiive device is the male condom.
With minimal adverse re.1ction>. spermicides come in Condoms are made from three materials-latex, poly-
foams, gels, creams, and suppositories 1ha1 may be pur- urethane. and lamb intestine. Most condom in the
dwed without a prescription Spermicides, """~ol-9 United States are made from latex. which is impene
(Delfen, Ensure} and oc10..ry1101-9 (Onho-Gynol, Koro trable by baCleria and viruses. In addition to use for
mex cream), provide effective ron1r.1ception when used contraception, the latex condom protects .gains! sros.
u directed, with an creased e1Tcc11-e1w when u<;ed "~th Lubricants containing mineral oil can decrease the
a diaphragm or condom . 'I he .imve ingn>dient, a chemi barrier strength of latex by as much as 90% and should
al wrfaaant. kills sperm by destroying their cell mem- therefore be avoided. Polyurethane condoms are thinner.
braMS. The adverse reactions .ire minimal /I spermicide are possibly stronger, and do not cause allergies (a pos
must be applied before <nil us bu1 no more than I hour sibili1y witb la1ex), while still prO\-iding prolect.ion
in advan if used alone. 1>pcnnicidt>s must be reapplied
against SfOS. lamb intestine condoms allO\Y viral tranS-
miSSiOn and so do not protea against viral STUs. Male
t;tch time intercourse h a111icipa1cd loams musl be
condoms have a 12% failure rate in preventing
lhoroughly shaken hefore <>.ich u"" 10 ensure dispersal
of acti-e ingredients. Supposiwrics or 1able1s should be pregnancy.
The female condom, Real ity, is a loose-fitting tubular
msened inio 1hc vagina a rnonimum of 10 10 15 minuu.s
polyurethane pouch with Oexible rings at bo1h ends. The
before imercourse ro allow 1imc for 1hco;e fonns of con-
ring a1 the closed end anchors 1he pouch on 1he cervix.
1racrp1io11 to dissolw. Oo11ch1ng should be posiponed On 1he open end, the pouch has a larger ring to be
for al least 6 hours ,1ftcr roilu> with any >1wrmicidal use.
placed over the labia as an exremal anchor. 'l11is mecha
Recent da1a indicale 1h,11 u>c of nonoxyno19, the ingre-
nism provides some protection against STDs. The Reality
dienl in mosl 81,ermicitks. can increase 1he risk of 111\/ condo m is prelubrica1ed, available over 1he cou n1er
transmission (Table 28-6 ).
 518 SECTIONV Med1cauons Related to Body Systems

(OJ'(,}, and cannot be combmed with a male condom. pregna1,cy teq and~ pelvic examination
. should~-
....,.
Jf pregnancy occurs, an abor11011 should be consod< ~
ldilure raie for prt.-gnancy 1s about 21% . because of the 1era1ogcniciry of escrogen_io lhe f'1u; let
111e diaphragm is d ;oft rubber cap with a metal spnng
Table 2 s . 7 for a list of ora l con1racepuves lha1 Cin ht
10 reinforce the nm . I or proper sizmg the device must
be filled by a health c.ue provider and is bought with a used as ECPs.
prnmpuon Before msemon. the diaphragm should be
filled wnh spcnnic1de 10 completely block the cervix. A
diaphragm ma) he msened up to 6 hours before inter-
courw but must remam m place for at least 6 hours after.
ra1lure raie for pr'-'8/lancy 1s about 18%.
Ille ct-iv1cal cap 1s a small, pliant. cup-shaped device
Long-lasting methods of birlh con1rol, such a;
that fit.s directly over the cervix. where 11 1s held in place
implants. onrrauierine devices (IUDs). and stei l11a1r.:111111:~
by sucuon I 1ke the d1~phrawn . the cap 1s not available
be used when comphance mav be aproblem. Olaf
CYTC but must be filled by a health care professional, and
sperm1cidn muse be used as a barrier. rhe failure rate for 11ves are a close second for elfecuveoess ol birth
Noqilant, which acts s milarly 10 progestan IS eff
women who have previously gJ\'en binh is around 40%,
whereas the failure rate 1s about 20% for women who s years and is the most effective method of coo~
have not gi'-en birth Medroxyprogesterone (Depo-Provera) is g l llll ~w:;;;.,
larly, works for 3 mon1hs, and is highly effectr.~
Postcoita/ Contraception Morning-after polls are noi to be used as rou11ne 11'3
Medications used JS pos1coital contraceplives may be cootracept1on These drugs are for emergeocy s1
either *morning.after pi lls or *abonion pills to prevent only These medications may be a combination of es:r
fHegnancy after intercourse. 11wsc drugs are not to be and progest1n or a proges11n-only med1cat1on
used routinely because of the dangers from potential
side effcm; rather. emergency con1r.1ception pills ( ECPs)
are meam 10 provide one-time emergency protection
fro m unplanned and unw,111tcd pregnancies occurri ng TABLE 28-7 SELECT MEDICATIONS THAT MAY BEUSED
from unprotected >cxual intercourse resulting from
AS EMERGENCY CONTRACEPTIVES
sexual a11.1ck, co111race1l1 io n fa ilure. and the like.
The morn ing-after pill has th ree possible modes of TYPE OF USUAL DOSE. ROUT!.
ace ion: ( I) inhibiting ovulation, {2} altering the men- MEDICATION TRAOE NAME AND FREQUENCY
strua l cycle 10 [>rl>vent ovula1ion, and (3) irritating the
uterine lining so rejl'<:tion of a possible fenilized egg proges1in--0nly Plan a I pall within 72 hr ar.i
occurs. A high-dose oral contraceptive. the pill is formu- ECP' anoth r 12 hr la
lated of either p1ogcMln alone. estrogen alone. or both Combined ECP Preven 2 polls w1th1n 72118111
of these anificial steroids together. Medications with 2 1110< e polls 12 tr
combined honnones are called comb111cd ECPs. A spe latl!f
dally pack.1ged combination of high doses of estrogen Combined oral Owal 2 pills willun n 1r n
and prngestin, Prl'\-en, has a dose of two pills. The only contraceptive 2 pills t 2Ir la:
drug packaged for I CP 1s Plan 8, the remainder of the
Nordette. 4 pills wi!M n 1r
medications are contraceptions that are used as ECP.
Levien, levora 4 pr s 12 Ir la:t:
Combined I CPs are 75'1b effecuve in women who would
lo/Ovral,
otherwise bome pregnant from unprotected sex. The
Low-Oges1rel
other t)'llt' of LCI~ or progestin-only (Plan B) ECP,
with a dose of one tablet. is l'\l!TI more effective, at an Alesse. lellh1e 5 polls V; trun n IJ' rd
85% rate. 5 pills 12 Ir later
The pill may be taken immediately after the unpro- m1fepristone M1feprex 3 polls (600 mg! w
tected intercourse. but the first pill must be taken within (RU-486) 63 d.lys of LM~
the first 72-hour period. A second pill must be taken 2 tabmiso~
12 hours after the first dose. 2 days l.lter
Danger signals for a few weeks after use of morning-
af1er pills are severe pain in the legs, severe abdominal Major Side Effects: Excessivebleeding. cramping. nausea.
pain, chest pJin, ;hortness of breath, blurred vision, vomiting, fatigue, weakness. headache. d1aorhea
trouble speaking. loss of vision, or jaundice. The next
ECP. Emergency comracep11on pall, LMP. Last menstrual penod
men.irual period mJy be earlier or later than usual. If
As of February 2007, Plan Bas available OTC In somo stales
the mcns1nial lleriod does not begin for 3 weeks, a 'Only med1ca1ion spcc1tic as ECP

---~--
RU-'86 (Abortion Pill)
\ttfepristone (Rll:486) is approved by the FDA 3 , a post-
rortal contracepuve agent to stop gestation. Similar in
!1J11Cfure to progesterone. mifeprisrone (Mifeprcr) is the
6111 of i new generation of birth control pills called
,,,.~ins. h works only in the first 9 weeks of preg.
iun<Y or up to 63 days from the stan of the 1,151 men-
stni.tl period, to produce a medical-chemical abonion
bptimulating uterine c~ntractions and preventing tht>
fertilized egg from atlachmg to the uterus. After the first
7 weeks of pregnancy, the natural progesterone found In
the pregnant woman is too great to allow medicat ion to
IJ<> effective. lllced ing and cramping that typically occur
aher administrat ion a re si milarto or greaten han a heavy
mensrrual period and last for 9 lo 16 days. Efficacy is
92%t0 95%.
Women using this medication must be carefully
!(ltt1led, and medicine must be administered by spe.
(Ullytrained heahh care providt>rs who have the capabil-
11)' of surgical intel"\ention if needed for an incomplete
~ion or for excessive bleeding. Mifepristone should
not be used with the following conditions: confirmed
or suspected mbal pregnancies; ll!D in place; chronic
adrenal gland disease; curr~nt long-term therapy with
conicosteroid;; history of .tllergy to mifepristonc. mho
prostol, or ot her prostaglandins; and bleeding d isorders
or curre111 ant icoagu lant therapy.
Eligible women will need to sec the health care pro
vider three times for completion of en tire procedure:
(1) initially. to receive ,1 three-pill dose by mouth; (2) to
uke a dOSt' of misoprostol, a prostaglandin, 2 days later
to complete the abonion; and (3) finally. a return visit
wroximately 2 weeks later 10 be cenain the abonion
"'1S complete. If abonion is not complete. a surgical
prottdu"' may be necessary to tenninate the pregnancy.
HOl\!Vn, methotrcxate (an .ullimetabolite) and an intra
\'agmal insenion of m1soprostol is a safe and effeoive
alternative to surgica I 1nten1eniion.
The medical community has identified RU-486 as having promis
1ng effects In treatment of some breast cancers, endometrial
cancer brain tumors, endometnos1s, uterine fibroid tumors.
adrenal cancer. glaucoma. and in inducing labor.
Forms of Contraception on the Horizon
Rttfarthers are pursuing new vaccines for both men and
"'Omen A male vaccine has been shown to be 99% effec
t1w m suppressing sperm production. 'Olis vaccine
requires weekly inject ions of testosterone at pres~nt,
but scientists .ire looking at implants or longer-actmg
injections.
CHAPTER 28 Reproducuve System Disorders 5 19
Ban oe< cor111aceptoves used by women should remain 111 place
for jll1!$Ct1bed 111ne after seual dltefaltJ<S8 and should be
used "'th ljlem1IClde as suggested by m;n;f.J(;t!lfers
2 lubricants contallllng mineral od should not be used \\1tn
latex coodoms because strenglll of latex may be detreased
by as much as 0084.
3 Barner contra<:ept1on dev1Clls such as d1Jptiragms and cer.it
cal caps must be fitted professionally
4. "Morning-after conuacept1on must be acton1phshed w1th1n
72 hours of unprotected sex and should be used only as
emergency means of contracepuon, not as rootme means of
conuacept1on
5 Abomon pill" must be adm1mste1ed by ilealth ca1e profes-
sional w1th1n 7weeks of the last menstrual penod Ptegnaf1CV
should be confirmed before use of RU-486
DRUGS FOR PREMENSTRUAL
SYNDROME AND DYSMENORRHEA
l'remenstrUal syndrome (PMS) is a group of physical and
psychologic symptoms that occur just before menstrua
tion and resolve a few days after onset of menses. See Box
28-2 for common PMS symptoms. For PMS to be diag-
nosed. sympto ms must be intense and rd.ned to a
woman's menstrual cycle. l'or mild sym1>1oms. lifestyle
changes i11duding dietary supplements. exercise, eating
rarbohydrate-rich foods. and reducing sail intake are the
BOX 28-2 CO MMON SYMPTOMS OF PREMENSTRUAL
SVNORO ME
Psycholog1c ind Behavioral Symptoms
lmtablhty and cryrng
Depression. sadness. feeling of helplessness
Alternating sadness and lll19Cf
HypersensttMty 10 mvial events
Social withdrawal
Allx1ety and tension
Difficulty concentrating
Reduced efficiency in woik performance
Restlessness and agitation
Physical Symptoms
Acoo
Bteast tenderness
Abdominal bloatlng. ankle edema
Weight ga n from water ratenhon
food aavmgs
Faugue
Headache
Backache.101nt and muscle pain
Nausea. vom1tmg. const1patton, or diarrhea
 520 SECTION V Med1cauons Related to Body Systems
first hne of treaunent I-or more severe symptoms. two
t)~ of drug therapy using d11Ter.nt agents are indicated.
llie most prescribed medicauons are mood-altering drugs
and those used to suppress O\'Ula11o n. although other
medications may be used to relic-~ sPific symptoms.
Mood-altering drugs (disrusscd m Chapter 30) that
are often used are ( 1) selecuve serotonin reuptake inhib-
itors {SSRls) such as flu Oltine (Proac) and urtraline
(/.oloft), the 6rst drugs of choice ro relieve psychologic
PMS symptoms; (2) alprnzoltim (XanitX). a member of
the benzodiazepine family, used 10 reduce irritability,
anJCiety, and tension of PMS; (3) ovulation suppressants.
including two dasse< of drugs- oral contraceptives
and gonadotropin-releasing hom1one (CnRI I) agents-
helpful with primarily ph)'Sical symproms. and (4) /eu
pro/ilk (Lupron), used to reduce brea!>t tenderness.
bloating. anxiety, and nen'Ous tension
Some other medications for sPific symptoms
includespironolaa one (Aldacto ne). a potassium-sparing
diuretic. used to treat bloating and urine retention;
calcium to decrease mood swings and deprosion, aches.
pains. food cravings. and water retenuon. and analgesics
such as aspirin, aataminophn1, naproxe11 (Naprosyn),
and ibuprofen, which may relieve cramps. headaches.
dysmenorrhea, and muscle and joint pain. Ibuprofen is
considered superior medication for relief of primary dys
menorrhea. Aspirin and naproxcn relieve primary dys
menorrhea because 1hey suppress prosraglandins that
cause smooth muscle cramping. Dn1gs known not to
work for dysmenorrhea are progesierone, pyridoxine.
tamoxifen, Uthium, and magnesium.
MEDICATIONS FOR INFERTILITY
lnfmi/11y is the decreased ability to reproduce; sterility is
the absence of reproductive ability. lnfenility is experi-
enced by 15% of couples trying to conceiv~ children, and
it may be the resul1 of reproducuve dysfunction in either
partner or both. With medic.ii care, apfMOxima1ely half
o f the couples are able to achieve fcn ility when medica
1ion is matched to the cause.
Pertility depends on secret ing proper a 111 ounts of hor-
mones by the endocrine system. l)eficiencies in hor-
mones responsible for produc1ion of ova or sperm may
lead to infertility. Cysts, tumors, or infec1ions of repro
duetive organs o r obstruction of tubal structures that
transpon ova or sperm may cause difficulty in concep
tion. Some conditions can be trea1ed medicinally; others
require surgical inten'l?'ntion.
Treatment by Follicular Stimulation
Anovulation, a cause of infenility, fre.:1uently can be
corrected by pharmaceutical means 10 promote follicle
maturation and produce ovulation. Clomipherre
(Clomid) and gotwdorelin (Practal, Lutrep~I~) It
antiestrogenic e!Tect s to <:a use ovanan sumulauon, '
ration of ovarian follicles. and development of COIJlas
luteurn Merrotroplrr (Pergonal, Humegon), a hom.. 11111
preparation with LI I and ~SH activity in. equal .~
is used to prO\'ide adequate ovarian stunulauon "'has
pituitary hormones .ue insufficient. 'Ille cost for a si"ll
medication treatment can be as high as S1500, bur l1
rate of ovu l.1tion approaches 100%. Human chor;.,.,.
goiuulo1ropl11 (hCC) is also gi.ven after 4. days of mtnc
iropin 10 stimulate nvuJau on. Of interest, thest
medications are ,1lso used to treat infertility in mall'\
Urofollitropl11 (MeLrodi n), similar lo menotropin,
obtained frorn the urine of postmenopausal womtn,
contains FSI l. hCC is administered afier urofollitropin
to stimulate natural ovulation.
Treatme nt of Amenorrhea
Bromocriptinr (Parlodel) is used to correct amenO!Tha
and infenility associated with excessive prolarun S<m
tion. In some persons, a cornmon first-dose side effra
the phenomenon of diMiness or syncope on change ol
position . Some conditions of 1he female reproducu1t
tract Mich ~ polycyMic ovaries, endometriosi~ and
uterine fibroid rumors may be ei<acerbated; medication
is then con1rn inclic.1tcd flable 288).
Male Infertility
~~~~~~~~~~~~~
Male reproductive syi.tem dysfunaion is the cause of
30% of cases of infenility, which frequently are unrc
sponsive to medications. This failure may be caustd bl
decreased density o r motility of sperm or to abOOlll"
quality or volume o f semen. In men who do notpiodi.r
spenn because of insufficient secretion of hormonn
drug therapy may bt> helpful. Sperm counts m;ii ~
increased with the use of hCC alone or in comb1nau..
wi th menotropin . Combination therapy is expenshund
may require prolonged tre.11111ent for 3 10 4 year1 If
hormone deficiency is severe, androgens may be used for
drug therapy.
Infertility is deCleased ability to reproduce. sterili G
absence of ab1hty to reproduce
lnfertihty may occur in etlher partner or both
Clom1phene promotes follicular matura!JOO and (l';Wl!ln
Menotropin 1s a 50 :50 mixture of lutein1z1ng hormone anl
folliclest1mulating hormone that promotes follicular maw
t1on and ovulation
 ---~--::.
CH'..'.'.:APTER 28 Reproducwe System Disorders 521

TABLE 18 8 DRUGS USED TO TREAT INFERTILITY

GENE.RIC NAMEJ USUAL ADULT DOSE.

TRADE NAME DRUG

' '
;.. 11 ~
.' ROUTE, ANO FREQUENCY
50 mg PO qd x 5 days, stanmg 00
INDICATIONS FOR USE
Female 1nfen1hty
INTERACTIONS
None noted
the fifth day of menstrual cycle,
may be used for 3 or 4 cycles
an<! then increased to
75-100 mg/day
75 units each of FSH and LH IM Stimulates follocles ta mature None noted
SQ
by acting on FSH and lH
tME!flOllUII 75 units each of FSH and LH IM
SC '
urofolliUopon (Bravelle) 75 mg/day x 1 week IM/SO or St11!1\Jla1es lollrcle matunty tn Nooe noted
more, followed by 5<m to males and lemales
10,000 units of hCG on day
after last dose of urofolhtropin
brorrocnpt1ne (Parlode1) 2 57.5 mg PO qd None noted
lunaR d'oorl(lflOC gonadotropm. 5000-10,000 unns IM on day 1 St mulates productJ<Jn of None noted
llCG IA PLPregnyt, after last dose of tropins progesterone frOfl the
Novarel) corpus luteum
fSH. Riricle-s11mula11ng hormone; hCG, human chonooic gooadouopin; /M. onuamuscularly, UI, lutein0ng ho!mone. PO. D1ally. SC. subcu1llnl!OU$ly

MEDICATIONS FOR
MISCELLANEOUS REPRODUCTIVE
CONDITIONS
0.MZOI (Oanocrine), used to treat cndometriosis and
associated inren ility, may temporarily impair 1he abili ty
ortheendorneuium 10 suppon i\ pregnancy, so attempts
it roncepuon should be postponed for 3 momhs after
completion or treatment lhe medicauon causes atrophy
of endometrial tissue and is weakly androgenic (see
Table 28-1 ).
Gosntlln (Zoladex). an injectable implan1 adminis-
ctrtd imo the abdominal w.111e\>ery4 weeks for 6 months
to 1re.11 endometriosis. h pregnancy category X. Cosere-
lin is also used as an ant ineoplas1k ,1gent in breas1 and
prosme cancer.
Two CnRI I agents arc u>t'<I for endometriosis- leup-
rvliU (Lupron) and nafarelin (Synarel). Nararelin, the
drug of choice for trc.11ing endome1riosis if future
renility is an issue. is a gonadotropi11 used Lo trc.11 endo
meuiosis in females and precocious pubeny in both
'0($. Booiuse the route or administration is nas.11, rhi-
nous may occur. (This drug may also be used to 1rea1
prostate cancer.) Leuprolide, sin1i1<1r to goscrelin in
.iction and side effeclS. is also used for uterine fibroids
(Table 28-9)
..
Women taking dana2ol fat ondome1nos1s should refrain from
becoming pregnant for 3 months after treatment because of
possible mascuhn!lalJ<Jn of fews
MEDICATIONS FOR ERECTILE
DYSFUNCTION
Slldenafil (Viagra), the first medication for treatmem of
impotency, was 6rst released as a card1()V3jQ!Jar agent 10
lower b lood pressure; today it is used for ereclile dys
runction in men. Newer drugs such as tadalafil (Cialis)
and varM11afil (Levi1ra) have rapidly joined this group
for use wi1h erectile d)'$funaion. Th~ medications aa
to increase blood Oow 10 produce penile rigidity when
associa1ed with sexual st imu lation. Sildenilfil and v,irde
nafil should be 1akeJ\ one hour before sexual aoivity and
not more 1han once a day. Mowe\oer, tadalalil has a more
rapid onset and prolonged effects. providing effective-
ness for up 10 thirty-six hours with a new lower dose 1ha1
may be oaken daily. hwes1igations are being conducted
to evalua1e potential effectiveness for use io women.
522 SECTION V Med1cauons Relaied to Body Systems

TABL~ 28 9 MISCELLANEOUS MEDICATIONS USED FOR REPRODUCTIVE TRACT CONDITIONS

GENERIC NAME/ USUAL ADULT DOSE, DRUG INTf.RAcnoJ
ROUTE. AND FREDUENCY INDICATIONS FOR USE
TRADE NAME
DRUGS FOR ENDOMETRIOSIS None roted
daralol 200-800 ~ PO da 1y 1n d1v1ded EndometnOSIS

oo....
goserehn IZoladex) 3 6 mg SC mon1hly

GnRH Agomsts
Endometnosis and uterine fibroids None noted
leuprollde (lupron) 375 mg/dose IM monthly
Endometrios1s and precocious puberty Nasal topical
nafarel1n (Synarel) 200-400 mcg as nasal spray bod
decongestants

Mior Side Effecrs ol Orllfl lor Endoml1rio1is:

Anxiety, headaches. CVA. hot flash bo'wkthrough bleeding. breast tenderness

DRUGS FOR ERECTILE DYSFUNCTION

d'naf !Viagra) 50 mg PO 1 Iv Ii" fOf~ sexual Erectile <1ystoocuon in male nitrate prep;ra11Ql1
activity
tadalafil IC1ahs) 5-20 mg PO before sexual actMty nitrates, sane attMrts
or5mgPOqd
vardenafil llev1tra) 520 mg PO before sexual octovity nitrates. alpha bloder1
IStaxyn) oral d1sm1egrat1ng tab before
sexual act1v1ty

M1jor Side Effects of Drug for Ereclilt Oysf11ncrion:

Headache. flushing. GI upset. nasal congestion. diarrhea. rash. visual disturbances
CVA. Cerebrovascular accident GI. 93suo111test1nat, IM, intramuswtarly; PO. orally. SC, wtx:utaneously

These medications have not been associated with
priapism, but these drugs should be used with care in
the patient who is predisposed to the cond ition. An erec-
tion lasting longer than 4 hours should be immediately
reponed to the physician (tt T.1ble 23-9),
Ii] CLINICAL TIP
Drugs lot erectile dysfunchon should not be given with nitrates
because of severe hypotension and danger ol myocardial
mfarc1100
Ill LEARNING TIP
The genenc names for medica11ons for erectile dysfunction end
1n afiL"
MEDICATIONS THAT IMPAIR
OR ENHANCE LIBIDO
AS A SIDE EFFECT
Some medicatio ns can have side effeas or adw' rue
!ions that decrca;e libido in both genders. A demal(d
level of tes1oste1onc in either gender lowers the sexdriw
Centrally acting alpha, agonists ( tnethyldopa IAldomn~
clor1idi11e ICataprcs l, and grranfacirre (TencxJ) forh)'P""
tension have been associatt:d with impotency and sC'11al
dysfunction. Crrarretl1idirre (lsmelin) and reurpirw
have been reponcd 10 cause difficulty with male ejJcull
!ion. Anticho linergi c agents used for hypenension OU\
Jlso cause impotence. Thiazide diuretiC$ may indutt
sexual dysfunnion and decrease libido. with impot('O(V
and breast changes. Spironolaaone (Aldactont) -
to be the chief age111 of this group to cause lOllli
dysfunction.
Continuous use of antihistamines will also interfl'lt
with sexual anivity Some well-known medication~ sudl
as diplum/1ydramlrrc (llenadryl), pron1etJ11uiM (Phm
ergan), and cl1/orp/1c11iramine (Chlor-1'rimet0n), are
- CHAPTER 28 Reproducnve System Disorders
ustd as anuemetics and sedatives and to control allergy
1>11lptoms. ~owever, these drugs also block parasympa-
thttOC nerve impulses Lo sex glands and organs.
~!any of. th~ cenu:ally acting antianxiety and psycho-
uopic med1ca11o ns, mclud1ng benzoclia~.cpines such as
dimpam (~al lu."l affect s~xual in terest and capabi lity.
ll'hlle a paue111 !s undergoing thcr.tpy, phe nothiazi nes
decrease sexual 1111eres1 by inhibiting sexua l funet.ion
causing drcreased libido and the inability to ejaculat~
Jmpocence and prolonged amenorrhc.1 are also possible.
flay/ lcohol ls a sexual depressant, although moderate
amounts may enhance sexual activity by decreasing
inh1b11ions
Histamine, {1 1, )-receptor antagonists cirnetidine
{Tagamet) and ranitidine {Zantac) lead to impotency
when used for long periods of 1ime. Sonie calciu m
channel blockers cause erectile dysfunctio n. and beta
blo<kcr1, espcciall) propranolol ( lnderal), have been
associated with decre:isecl libido and cr1cti le dysfunc-
tion. The tricydic antidepressant t/onripramine (Anafra-
nil) may induc<' a spontaneous orgasm as a side
dftct
Opioids and psychotic agenl\ \uch as LSD, cocaine.
mariiuana, and amphl'tamines arc comidered aphrodi
si.lCS in contemporary society. More commonly, sexual
beh,wior is decreased. Th e user's siatc of mind and the
amounl of mcdicaLion consumed coniribute Lo sexual
effect of medication.
Some elderly patienL taking k1101/opa (Dopar) have
obse"-ed a Sl'Xual rejuvenation . Am1l nitrate, a vasodila-
torustd for angina pectoris, has been .1lleged to enhance
!CXUJI act1Vit) and to intensify orgasmic experiences for
men; howe,-er. loss of erection .md dclJ)'Cd ejaculation
~ abo result.
Many medications, both legal and il legal. may affect
sexuality ,uid sexual behavior. For rMtiems taking Lhera-
pcuiic doses of medications in1crfcring with sexual
behavior, allied health care profession,1ls s hould take an
acruraie hb1ory to develop awareness of the patient's
needs and provide th is information 10 the physician so
ueatment may be altered as needed 10 ensure medication
<ompliance 1Js1ening to patients' concerns about medi
cations and sexual function is an imponan1 role of the
allied health professional.
Some drugs cause 1mpa1rment of sexual function. The~e con-
cerns should be discussed with the health ca1e professional to
llilw Changes m med1caL1ons ii possible
523
SUMMARY
Androgens. necessary for normal development of male
sex characteristics and for Spl'rma1ogenesis. may be used
therapeutically as hormonal repl.lcemenL therapy in
males or for brrast cancer uea1ment
~i n astcride is a drug specific for llPI I, a common
reproductive system disorder in older mall'S.
Tl'Stos1erone. the primary male hormone or androgen,
coml'S 1n se...eral forms for trea1ml'nt of cenain t}'Pl'S of
cancer Patches must bl' applil'd to the proper sites,
whereas inieaable forms may be shon or long acting.
An.1bolic steroids a.re synthetic androgens often used by
athlc1es 10 enhance performance. Although steroids have
po1ential, the risks tha1accomp.my1heir use are substan-
tial, making thl'Se medkationsSchedu le Ill drugs bl'C3use
of 1he dJnger of abuse.
l's1roge11s and proges1ins arc necl'SSary for develop-
ment of female sex charac1eristlcs and reproduction
Esirogens and progestins are used for contraception and
for noncomraceptive applications such as llRT and
treatment ofbrl'aSt and prosta1e cancer fatrogens rl'duce
the inddence of osteoporosis and coronary anery
diseaw; therefore pos1menopausal women should be
evaluated for prophylactic use. Progeslins are indicated
for 11 lff and also for treaLmenl of endomctriosis and
carcinomas, as well as to prcven1 pregnancy. Estrogen$,
proges1ins, .md androgens arc 1cra1ogcnic. All oral con-
1rnceptivcs containing combinat ions of estrogens and
progcstins are an effecti\e form of binh control. Thl'Sc
medications are widely used because of ease of admin
istration. Thromboembol)'lic disease is a dangerous
ad\-erse reanjon.
Medications are a\'3ilabll' for trl'allnl'nt of infenility
and sexual dysfunction and should be used with care
because of their possible side effects Orngs for female
infenil ity must be taken exact ly .is ordered, with coitus
occurring at a specific Lime in relat ion to drng admin
istra1 ion 10 encourage pregnancy. Products available
for erectile dysfunction should no1 be uSl'd with
ni1ra1~.
l"he morning-after pill for postcoital contracl'ption
must be taken within 72 hours after unprotected intl'r
course and should not be used as a means of routine
contraception. The abonion pill' must be adminis
tcrcd by a Spl'cially trained health care professional
requiring a Spl'cific regimen of three office visiL~.
The use of medicaLions for any reproducti"e conditio n
is n scnsiLive are.1 for most patients. Allied health profes
sionals should be empath ic and d iscreet when discussing
reproductive tract condi1ions and their treatments with
clients
524 SECTION V Med1ca11ons Related to Body Systems

Scenario
Erin ~ 11rl 1ng an 0<al conrracepwe bur states that when she had the flu. she forgot ro take her pills 101
3 days Also, the physician gave her a prescflpt1on for amp1cillm tor a bacterial mfecr1on.
1 Does the ampect l1n have any beanng on the efficacy of the oral contraceptive 7 If so, what?
2 What should Erin do to resume her schedule of oral contracepuve use7
3 ShOuld she use additional means of oontracepr1on at any point? Explain your answer.
4 Enn wants to know why 21 tab ets in the prescnption for the contraceptive look alike and seven
look different What is your response'

DRUG CALCULATIONS
Order medroxyprogescerone acetate 0 .2 g stat Show the volume of medication on the 5)'ringe!h01o-u,

_____
---_...... --
Available med1cauon

......... --
--
...

___ _..____
-...._~-
Ota6oProvtra
=.-.....,_. wi;;:i--
,_ mg per ml =--
--~ ..
- -- ----
-~.:_.

----
400 r=t===-~
........

Volume to l'le ad 111i11 iscered:

---------
2. Order: J>remarin 1.25 ms 1'0 qd
/\v.lilablc medication: Premarin 0.625 mg per tablet
Amount to be administered with each dose: _ __

REVIEW QUESTIONS
I . What is the collective name for male sex hormones! ~~~~~~~~~~~~

l What hormone 1s primarily responsible for the d~opment of secondary sex rharacteristics '" the rruftl

3 What is the goal of phanmaceuuc,,I treatment for benign pros ta tic hypenrophy1

4 . What are some of the nsl.s associated with female hormone replacement therapy! - - - - - - - - -

~. What docs co111uga1ed "'"'8'" meanl - - -- -- - -- - -- -- -- - - - - - - - - - -

G. What are some of the side effects of esLtogen therapy' ~~~~~~~~~~~~

7. Why are combination o ral comraceptives so effective? ~~~~~~~~~~

 CHAPTER 28 Reproductive System Disorders 525
-------
s. \Vhat is the main component of the min ip ill? - - - - -- - - - - - - - - - -- - -- - - - -

9. l:.Xplain the di fferences among monophasic, biphasic, uiphasic. and estropha;ic oral con1racep1ives.

JO. Miat medications reduce the effcoiveness of oral cont racepth>es! - - - - - - - - - -- - -- - - -

11. Whal medicatio n category is most effective for dysmcnorrhea? - - - - -- - -- - - - - - - - - -

12 Wh.n medications are considered dangerous for u;c with sildenafill - - -- -- - - - - - - - - - -

Drugs for Neurologic System Disorders

OBJECTIVES
Afcer srudymg chis chapter. you should be capable of doing Che following
Bnefly descnb1ng how analgesics and general
anesthe!JCS work.
Explaining actions of local anesthetics
01scussong how hypnotics and sedatives affect the
body
Descnb1ng antise1zure medications and theor
actions.
Explaining how medications can be used 10 relieve
Parkinson's disease symptoms
Oescnb1ng how medications are used for
headaches and m1gra1nos.
Discussing how drugs are used to relieve
spastic1ty
Identifying central nervous system stimulants a"CI
theor actions
Explaining action of m edications on autonomic ard
penpheral nervous system.
Providing pauent education for compliance woth
m edications used to treat diseases and cond1t1ons
o f the neurolog1c system.

Kacheflne. age 32. has a family h1scory of migraine headaches with auras In che past few months.
Kachenne has had two ml(}ra1ne headaches related to menstruation. She thinks these may have been
caused by tension and fatigue from her new JOb.
What nondrug measures might Katherine try for early relief of headaches?
What are causes of nonmogra ne headaches?
What group of medications spec1f1c is for migraine headaches?

KEY TERMS
Absence or petit mal Blood-brain b arrier Hypnotic Seizure
seizures Cataplexy Narcol epsy Spasticity
Acetylcholine (AChl Catecholamines Neurohormones Sympathetic nervous
Adrenergic Centr al nervous system Neuron system
(sympathomimetic) Cholinesterase Parasympathetic Sympatholytic (or
agonists Clonic nervous system adrenergic blocldngl
Amyloid blockers Convulsion Parasympatholytic agent
Analeptics Oiaphoresis (cholinergic) agent Sympathomimetic
Analgesic Oyskinesia Peripheral nervous (adrenergic or
Anesthesia Oyston la system adrenergic-acting
A norexfant Euphoria Physical depen dence agents)
Aura Focal (partial ) seizure Restless legs Tolerance
Autonomic nervous Generalized seizure syndrome Tonic
system (ANSI Grand mal seizure Sedative Xerostomia

526
 CHAPTER2!> Drugs for Neurolog1c System Disorders 527

AneSt11et1cs Yes
pain
Sed;OW$. hypnotics Yes Yes (alcohol) D (many not categoruedl SedatJOn and treatment of
insomnia RlS
~llUfe medicatlOOS Yes No C.D Epilepsy and assocrted seimre
chsoolefs. Rl.S
~lflSOOJsm Yes No B.C Part nsm's disease and
inedlcallOllS Par\inson's syndrome. RLS
MedicatlCllS for Yes Yes B. C. X!ergot p-eparaoons Headaches. especral!y m1gra1ne
Nladadles and sumamptanl headaches
Medcat1oos for spast1c1ty Yes Yes c Muscle spastic1ly
CNS S'"mulants Yes Yes B.C ADD.ADHD.anorexan~.
fatrgue
Olol1nergics (amylo1d Yes No C. X(isoflurophares) Glaocoma. myaslhenia grav1s,
blockers) Alz11e1mer disease
Ant1cholmerg1cs Yes No B,C Gastric an11spasmod1c and
ant1ulcer treatment,
mydnat1c. Parkmson1sm
Yes Yes B. C. D Cardiovascular and respiratory
cond1t1ons, shock
Adrenergrc blockers Yes Yes B. C Hypertension. angina. glaucoma
AOO. Anent1ondefic1t d1so1dcr. ADHD. a11cn11on-dol1c1llhype1ac1ivity disorder. CNS. central ncivous system; RLS. restless legs synd1ome.

EASY WORKING KNOWLEDGE OF INDICATIONS AND SYMPTOMS

Common Signs and Symptoms of Neurologic Disorders Common Side Effects of Medications for Neurologic
~cadaches and fever Disorders
Nauiea and 1;om11mg Visual disturbances
.,.,eainess and motor disturbances Lack of muscular coordina6on
Mood swr>gs and memory impairment Skm rashes
C.V..SttSS. stupor. coma Drowsiness
Sel2ures. paralysis. corrvuls1ons, numbness Anorel<la
Muscle n9ad1ly (JI nacc1d1ty lrmabehty
0 ::irbances 1n speech. vts1on. heanng. taste Heada(hes
Trerras ~tence
~Ung pain Ory mouth
Nightmares

be nervous S)'l>t~m is composed of the brain and performed by neurotransmiucrs such as ~cet)'lchollne

T spinal cord (1hc cl'nlr.al ncr.ou <yUn> ICl"SJ)

and the ncmts (p<'riph<'' ner.ou sy.iem
IP\SI) (rigure 2? l) . Nl'uron,, the IM'ic cells of 1he
nm'Ous sysiein, carry nerw impul'"' from one
of ,an
(ACh), which stimulates 1he nerve ending. and cholln
csler.ase, which enzymatically breaks down ACh to
inhibit its aaions (Figure 293 ). Other ncurotransmi1
1e~ or neurohormones, indude the ct1tecbolamlner;,

the body 10 another. Axons carry nerve information away serotoni n, and peptides such as endorphins.
from the nerve cell hotly, .rnd dcndri1cs carry infor
Incoming messages are received and passed 1hro ugh
dend rites. processed in lhc cell body, and Lranspon ed
ma1ion to the nerve cell hody (Fi11urc 292). Al 1hc ju nc
10 the axon. Messages exit by an axon 1erminal and
uon of neuron~. the co111i11u1 io11 of 1hc messages is
528 SECTION V Med1cauons Related to Body Systems

Ne<VOUS System

Penpt>eral
Nervous System

~ xedNetveS
SenSOtY-
(AHerent)
(IJ!e<ent and
Ellerent)

lnvolunUlry "'
Autonomic Nerves

Sympalhebe or ParasympathellC
Adrene<gic or ChoUnerglc

figure 29 1 Components or the nervous system

Movement of variations in ACh transmission and inhibition by cho.

electrical impulse
Synap4ic-
oonlUWlg Ne<ve
ecet)1cholll .. terminals
Figure 29-2 Componenis or a neuron
continue by either electrical or chemical transport across
the synapse to form electrical impulses for moving the
impulse through the nerve trac~ allowing nerves to react.
Onigs can act directly on impulses and their receptors to
induce or reduce nerve lfansmission.
As a neurotransmitter, ACh has various parasympa-
thetic effects such ,ts peristalsis, vasodilation, and cardiac
inhibition. Voluntary mu;.cles are conlfacted by release
of J\Ch at the neuromuscular junction, causing muscle
fibers 10 contract simultaneously for body movemen1.
linesterase cause diseases related to body movemem
Catecholamines, sto red in the brain, are auached to
sympathetic effector cells of the autonomlc nmoui
system (ANS) to depl'ess bra in stimulation. An incrme
in ca techolam ines and serotonin causes cerebral s1imu
lation, allowing drugs 10 have a depressing effect to
the brain.
Neuroactive peptides such as endorphins or en~cpha
lins affect neuron activity by either increasingordmr
ing synthesis, release, or breakdown of neurotransmmm
at the synapse. Endorphins arc peptides that $Uppins
pain and are tllC basis for acupuncture and tranSCUWX
ous electrical nerve stimulation ( mNS) for p.tin rd!((
Enkephalins decrease perception and emotional lSPftU
of pain by blocking spinal cord receptors (Rtswditht
nervous system and its anatomy and physiology for 111ort
in-depth information about nerve transmissions.)
The brain is covered by nerve cells that m<irdt ID
capillary walls to form the hloodbrln buri<r. 11ul
barrier prevents passage of many dru~ and l.ug.e mok-
cules inio the brain but allows substances with $1'-
molecules (such as w.ucr, alcohol, oxygen. and wboa
dioxide, as well .1s glucose and lipid-soluble matuwbl
to pass for absorption and is a type of security S)'Slllll
against toxic effects of some druw; on 1he CNS foJ.r, 1
pharmacemical research involves ways to increaseblood-
brain barrier permcabilily so specific medirationsnt<J<J
for treatmen t of brain discacs can be absorbed d1recd!.
Dn1g actio ns requiring brain ue are directly rebted w
the section of the bra in affected by medications. Figu~
2?-4 shows brai n areas and thcspecifoc func1ionofe3di
 CHAPTER 29 Drugs for Neurologic System Disorders 529

Synaptic deft 0<

neuromuscular

)UnCllOn

\ SodUn-
pola...um
_ .. , gate"'-
_,~~~

/
Aootyteholne racepl0<$

figure 29-3 The coo11nuauon of neNe mess.ages by neurouansm1nas

Cen1tal sulcua
Preceniral gyrus Postoentrnl gyrus
Sometomotor conex Somatosansoty oonex
Longitudinal fissure
PARIETAL LOBE
FRONTAL LOBE Sensat10n
Pesonallty OCCIPITAL LOBE
Behavior Vision
Emolloo
Intellectual tunctioos Gnostic area
Stores complex
&JlctJs -J.-r'" ' memory patterns
Gustatory area
Taste
RIGHT CEREBRAL
HEMISPHERE Wernicke's area
_..;.~:._.r._ language
comprehen5100
LEFT CEREBRAL
HS!ISPHERE / /

TEMPORAL LOBE Figure 29-4 The areas ol lhe brain and thoil
Broce'sarea
(_ Motor speech
Hearing.smell
INSut.A .,._..-,i;....,.
hn:tion 11 homeostasis. (F1orn ~te EJ The
....1117>Y snd physiology lean1lllQ ~em. ed 4,
Vo$C8tal effects St I.Duos. 2011. Salllde<s.)

When neurons arc over acll\c or hypcrcxcited. too
m.my messages are tr.111smitttxl at d rapid, irregular rate,
ltadmg to distonion and mcorrect interpretations of
llimul~ which resuh in ,c11un\. If neuron~ are not
rtttiving sufficien1 ~tin1ulation, neurons c,111not detect
netW lransmissiom. cauoing a decrease in body func
uon.111us nervous yolcm 111cdicat1ons arc dependent on
nairon stimulation, .is well "' the ability to cross the
brain-blood barrier and twuro111ucular junnions.
The ANS is also dependent o n 1wuro11,1 I actions. 111e
l)'!llpalhe11c nerves, al;,o c.illcd 11dr111e1;~ir nerves, are
responsible for body safety through lhe '6gl11-0r-Oigl11'
mechanism by stimulating 1wo neurohom1ones-
cpinephrine or adrenaline. and norepinephrine or nor-
adrenaline. This mechanism supplies funC1ions vital 10
body survival when the person must either reaCI (fight)
or run away (Right). When lhe ANS responds lo stimuli,
blood and nerw stimulation bypasses body pans and
organs no viul for suNival, causing extrn blood and
nerve supply to be sent to areas of stress.
The parasympathetic n ervou s system or c/10/111rrgic
system conserves energy through tl1e neurohormone ACh
530 SECTION v Medica11ons Related to Body Systems
and 1he eivyme cholmes1erase. The para;-ymi:'athetic
sys1cm comrol1 the reed-or-breed body funcuons by
slowing 1he hean, digl>Sllng food, eliminating waste. and
producing sex hormones
EFFECTS OF LONG-TERM DRUG
USE ON THE CENTRAL
NERVOUS SYSTEM
When Cl'S med1cauons are taken chronicall>' the effects
from the long course may differ from those seen w~en
the agcm "as first u'4:d. as 1he brain adapts to ':"ed!~-
1ions O\er ume When lhe adap1a1ion 1s beneficial. n LS
con1idered thcrap.?Uuc; demmenta) adaptation is con-
sidered a side effect Wi1h ~me a-;s medications taken
for a long umc. side effect mtensny may diminish while
desired lherapcu1ic effect remains the s.1me (e.g.. pheno-
barbi1al for epilepsy). 111e undesired sed.11ive effect of
phcnobarb11al i1 decreased over 1ime whi le 1he desired
an1iconvuls.tn1 thr,tpy 1s retained.
(",enain dntgs, 1ypically anti psychotics and antidepres-
sants, mu11 be t.1ken for ~evera l weeks before full thera-
peutic effect~ appear or un1il the CNS responds ;u1d
modifies its respon>c 10 dnig exposure, although side
effects may occur immedi.uely. In ll1e meant ime, Lhese
drugs have an increased 1herapeutic effect 1hat is not
readily dC!l'(led. l'olcranc.,, an adaplation of the brain
10 a medica1ion. and phy&lc.tl dependence, in which
the dn1g-adap1ed brain require~ 1he medicatio n or wi1h-
drawal symp1oms occur when 1he medica1ion is stopped,
are also manifes1.11ions ofllw CNS and its adap1ive abili-
1ics. These respon'es are seen wi1h medications used over
prolonged periods (S Chap1ers 2 and 31).
ANALGESICS
A11nlguics are used 10 relieve pain-a unique and sub-
jective srmp1om tha1 IS a highly individualized response.
l)'pes. signs. and symptoms of pain and in1em:ntions
for controlling or preventing pain are different for each
person. A feared symptom, pain is imponam because ii
""'ms lha1 the body is malfunnioning or is ou1 of
homeos1asis Only lhe person experiencing pain can
describe 1he symp1oms. m1ens11y, and sile.
Analgesics are 1he subject of Chap1er IS. but a shon
review is included here because of their interactions with
the nervous sysiem. The ph)-i;ical discomfon of pain may
cause ANS responses such as hypenension, dfapboresis,
pallor. restlessness, anxiety. lensed muscles, and inabili1y
10 concemra1e. Pain impu lses are transmitted on affer-
em. or sensory, nerve fibers to the CNS for in lerpretation.
The brain releases 1he na1ural paln relievers enkephalins
and endorphins 10 comrol pain . When these are not fully
effec1ive. analgesics arc ordered for pain relief.
Cl as ses of Analgesics:
. Narcotics
and Nonnarcotics
cs come in ''"o main groups-narcolin ln4
Ana Iges1 'th
nonnarcotics. Narco1ic analgesics are eth1 e~ op1y10tdi-.
II occurring-or op 1a1 e~-syn et1ca1 ~
dnarura y
ed-medications. 'd s an d some nonop1<>1..,1a
Op101 -
uc t -" by the Drug Enforcemem Adminislritq
regu 1a= . . . .h
(Dl:.A), oihers are prescnpuon nems wn ou1 ~
and some with less abuse po1enual may e<.'l!n be ~
over the coumer (0 re).
1_ Opioids are given 1nspec1ficdosesmedlha1s1toudid not be
or abruptly disconunued without ca1 l1tllCln.
2. Oie1ary fiber and fluid in1ake should be lncreasel
taking analgesics. especially with op101ds. It ~
occurs. a 1axa11Ve may be 111d1ca1ed
3. Initial doses of op1oids may cause nausea and >0m
which can be minimized w11h an anueme11c and byre~
calm. Side effects usually subside wl!h each adm1m~
dose
4. Analgesics may cause drowsiness. decreased men1.1 l!C:
ness. and decreased physical coordina1ion. ha2ardoosikllV
ties should be stopped while evalua1ing drowsiness
5. Orthos1atic hypotension may occur w11h analgesics. esoe
cially opioids. Care should be taken w11h pos1Mn cha1'9"l
Opioid medications may increase effec1s of anllhyp!ln
sives. especially causing or1hos1a11c hypo1cns100
6. Severe or recurrent pain for more Ulan 10 days 01 hqi n
tinuous fever lot more lhan 3 days should be repo11Bd u
health care provider.
7 Potential for physical and psycholog1c dependence~IDllJ
ance w11h op101ds. sedauves. analgeslCS. and I\!X:o!CI
exists. These drugs should be la ken on a limited bass b
shon periods of time e.xcepr by terminally Ill patienit
nally ill panents should be kepi as pa1n-ftee as possi!te
Analgesics are used 10 relieve pain wirnoot loss d 111-
sciousness Some types of pain such as~ paoril
pa111 from inflammatory processes may nol re;ipond ID
medicauons
Opto1ds are 1he most elfect1ve analges1C$. wilh nmmi 1
being the pro1otype for analgesic 1eliel
Respiratory dep<ess1on is a senous adverse reacton 11
opioids, as are cons11pa11on. urinary re1entt011 Oltt.Oltt
hypo1ension, and wmitmg
Because prolonged op101d use loads 10 physical deperiderte
and abrupt sroppage will lead 10 w11hchawal ~
lhese drugs should be gradually w11hd1awn
 --~ CHAPTER 29 Drugs for Neurolog1c System Disorders
Important Fac_t~.[a bout
Analgesics-cont'd
, Patiefll$ should avoid alcohol. ant1h1stam1ns llicycl 1c anu-
~ .
Jepressants. and atropme-hke ant1chohnergic medications
and other CNS depressants when taking opioid analge 1
, Opioi-0 dosage must be ind1viduali1ed Patients with : ~~w
pain tole1ance or with extremely painful conditions need
higher doses Patients with sharp, stabbing pain need higher
doseS than those with dull pain Lower opioid doses are
needed with the elderly 10 be effective Term nally rn patients
slxlufd be given as much medication as needed to relieve
l'Slll
ANESTHETICS
Tu'O rypes of anesthesia arc genera l and local. Anesthc-
siJ b) de~nition is used to produce a loss of sensation.
rauems arc often. fearful when anticipating surgery
b(auscof 5urgery nself or fear offccling pain during the
proctdurr 'Ille allied health profes~ional should anempt
to dLSpel fear by assuring the patient that anesthesia
pl'0\'1des sleep throughout w ith arnnesi,1 about the expe-
rience This educational step is important because exces-
si'~ fear may disrupt surgica l proc~dur~s. T herefore this
section on anesthesia is p resented to assist with pat ient
education.
General Anesthetics
Gmeul anesthe11cs produce their desired elTeas by
bloc~ing all sensory impulses to the brain, causing
unconJCiousness. Stages of anc\lhCSia are controlled and
passed through during induction and .ire reversed during
recoveiy. l'dlients undergoing su rgery a re usually taken
to stage 3 to allow muscula r relax.Ilion.
Sw.~" I. /\11nlgtsin starrs \vith .1dmlnis1ration of a nes-
thetic and Jasrs 10 Joss of consciousness. Charaaer-
istics are euphoria, distonion' of perceptions, and
amnesia Sorne surgery c.1n be performed at rhis
le-~I
~Wtt 1 De/mum begins wnh lo5s of consciousness
and extends to the beginning of surgical anesthesia.
During this s tage, through which induction is
rapid, involumary muscles .ire acrive, breathing is
irregular. and hypcn ension and t.1r hycardia may
occur because of muscle cxcitahility.
Stage 3: Surgical m1estl1esi11 ocCt1r;,, w ith musde relax
ation and respiratory dcprc"ion, lasting until
spontaneous repirations ce41~
\t.1gt 4 Mrt/Jilldf)' deprm11>11 is u5u,1lly caused by anes-
thesia overdose. beginning wnh rcss.1tion of respi-
ra1101\S and encling with circulatory collapse causing
death.
531
The most common route of administration for
general anesthesia is inhalation. although some general
anesthetics are giwn intrawnously {I\') The main intra-
venous drugs are 1hlopn11a/ (Pcntothal). lrelaminfl
(Kctalar), and mida.w/arr1 (Versed). Diaupam (Valiu m)
may he used to aid induetion of anesthesia or as a pre-
OJ>crativc medication.
Preanesthetic Medications
Preanesthetic medications are g"-en to reduce anxieiy, to
produce preoperati\'t! amnesia and to reliC'~ preopera-
tive and )l05toperative pain. Med1cauons are also often
used prophylaaically to reduce adverse reactions such as
excessive salivation, coughing. vomiring. and increased
bronchial secretions. Ben20dia1.cpines such as diazepam
and barbiturates such as secob11rbluil or pemobarbital
are given to reduce anxiety and produce amnesia by
producing mild sedation. Anticholinergk medications
~uch as alropirlfl decrease the bradyc.irdia risk during
surgery while also diying secretions.
Midazolam for Conscious Sedation
Intravenous rnid37,.olam may be used for induction of
anesthesia or for conscious sedJtion. The patient is
llllf>Crtutbed and passive but is ca1>Jblc of responding 10
comma nds needed for minor surgery or endoscopic pro
ccdures. Versed does cause res1>ira1ory and ca rdiac
depression.
Local Anesthetics
J'ain perception is the 6rst sensation los~ followed by
cold, warmth. touch, and deep prb5ure, in that order.
l..ocal anesthetics work by interfering with nerve conduc
Lion and pain percepcion fro m the body to CNS. The
great advamage over genera l anesthesia is that pain is
suppressed without loss of consciousness and nervous
system depression, allowing medical and surgical proce-
dures to be performed with less risk and pain.
111e duration of aaion of local ane.thetics with rapid
onset in most cases is longer than necessary, whereas
prolonged procedures may necessitate repeated admin-
istration. Vasoconsuiaors-usually epinephrine-are
often added to local anesthetics to prolong anesthesia
and reduce risk of toxicity. Systemic reactions such as
pa lpitations, tachycardia, nervousness. and hypenension
1nay occur ,.,..iLh vasocons1rictor use.
In the a nesthetized area. blood flow is imponant in
determ ining how Jong anest hesia will last. In areas with
many blood \'CSsels. the ancsthetic effect is quickly
carried away; in areas where few blood \'l?SS<'ls are found
or blood flow is resuicred, a prolonged duration will
occur. If local anesthetics are absorbed into the blood-
stream, adverse reactions such as bradycardia and
 532 SECTIONV Med1cat1ons Related 10 Body Systems

symptoms related LO the hean conducuon impulses may TABLE 291 TOPICAL LOCAL ANESTHETICS
occur c-:s excttability followed by depression and
TIME TO
drowsiness may occur if large doses are given; allergic
GENERIC PEAK DURATleli'
reactions are not common but may occur
Local anesthetics may be admtn1stercd euher topically NAMEJ SITES OF EFFECT OFAtn>i
as surface anestheucs applied 10 the skm or a mucous TRAOE NAME APPLICATION (MINI IMINJ ]
membrane or by infihratton as in1cc11ons Therapeutic Skin <5 l&-45
d1bucame
uses for topically applit'tl ancsthettcs are 10 relieve pain, (Nuperca1nal)
nching. and soreness from infections, burns. sunbums, 2-5
lidocame Skin, mucous 15-45
diaper rash, wound<, bruises, ,1brasion>, plant poisoning,
(Xylocaine) membranes
.ind insect bites and neuropathlc-type pd in. Applica1ions
to mucous membranes include those in 1he nose. mouth, benzocacne Skin. mucous <5 30-00
pharynx. larynx. trachea, vagina, and urethra. Local anes- (many trade membranes
the1ics may also be used for hemorrhoids, a na l fissu res. names)
and anal pruri1us. Infiltration anl'S1hesia stops conduc- cocaine Mucous 3-8 30.s:J
tion of nerve impulses and blocks motor neurons by membranes
iniecting local anesthetics, such as procaine and lido- tetraca1ne Skin. mucous 3-ll ~
c:aine. imo specific areas for surgery or onhopedic (Pontocaine) membranes
manipulation.

Procaine
Proca ine (Novocain), a local anesthettc agent first made
in 1905, is not effective topically and so mu>t be admin- TABLE 292 INJECTABLE LOCAL ANESTHETICS
istered by injection, often given in cornbina1ion with
epinephrine 10 slow 1he absorp1ion. f'rocaine is available
in 1%, 2%, and 10% solutions fo r injec1ion and with
epinephrine added in ra1ios of I : 1000, I: 10,000, a nd procaine (Novocain) 2-5 1&-ro
I : 50,000. TI1e allied health profes.ioM I should care- tetracaine $ 15 12!1180
fully read labels to ensure sclcc1ion of the correct medi- (Pontocaine)
cation as ordered by percentage of procaine and correct lidocaine (Xylocaine <2 30-81
ratio or epinephrine.
and others)
Lidocaine mep1vacaine 3-5 45-9)
Udoc<Jine (Xylocaine), introduced 111 I ?48, is one of (Carbocaine.
the most widely used local anestheucs because it may
Poloca111e)
be administered topically or by injection willi rare aller- buptVaCame 5 120-240
gic reactions. This agent produces anesthesia more (Marcaine,
rapidly, more intensely, and w11h a more prolonged Sensorcaine)
effect than procaine. The effects may be prolonged Epmephnne may 1naease anestlles1a du1a1ion by rwo 10 lhtee"""
further by addi ng epinephrine. Injectable lidocaine
comes in concentrations ra nging from 0.5% lo 200k.
Forms o f Lidocai ne include creams, oi ntm ents. gels,
aerosols, and solutio ns. Schedu le II contro lled m ed icatio n, cocaine causes v;uo.
constrict io n and so s ho uld no t be given with epineph
rine because of an increased risk o r cardi0\11sruli1
toxicity. 111c medication is avai lable as soluble uhlru
Because hdocaine supprasses cardiac muscle exc1tab1hty by powder, and 4% solution. the usual form used (Tabl1>
29-1 and 29-2).
blockmg sod um channels. 11 1s also used to treat cardiac
arrhyUv111as

Cocaine
. .

Cocaine, an excellent topical anesthetic that am rapidly

Pattems who have received local aoesthetics should tals C3ll
and has a d ura1io n of effect of abou1 an hour. is used to avoid act1v111es that might 1n1ure anesthetized areas
primarily for anesthesia of the car, nose, a11d throat. A
cannot respond 10 pain signals.
 CHAPTER 29 Drugs for Neurolog1c System Disorders 533

3
TABll ?'l EFFECTS OF SEDATIVES ANO HYPNOTICS ON THE CENTRAL NERVOUS SYSTEM tCNSI
INCREASED DOSE
Of MEDICATION PSYCHOLDGIC AND
EFFECTS OF DRUG
t 11 :
. '
PHYSICAL RESPONSE CNS STIMULATION

TABLE 29-4 ACTION TIMES OF BARBITURATES

General anesthetics produce unconsciousness and insensi- DURATION TYPICAL
llVl1Y to pa1ntul stimuli CLASSIFICATION OF ACTION MEDICATIONS
lucat analgesrcs reduce sens1t1V1ty to pain without loss of
ta1SCIOUSll8SS Some local anesthe11cs may be maxed with Ultra-sho<t-actmg 20 m nutes th1opental (Pentothall
epineplvioe to cause vasoconsuict1on and prolong anesthetlC agent or less
el!ecls. Short-acting agents 3-4"' secobarbital (Seconal)
pentoba1b1ta'
(NembutalI
Intermediate-acting &8 hr amobarb11al (Amytall
agents
SEDATIVES AND HYPNOTICS aprobarb11al (Alurate)
butabarb1tal (Butisol)
.~I body ac1ivities are influenced by the CNS. Depression long-acting agents 10-16 Iv phenobart>atal (lum1nall
o( the CNS reduces physical and mcnt.11 activity and is mepOObartiotal (Mebaral)
of1en rtlated to use of barbiturates and alcohol (see
Olaptl.'f 10) Sedatives and h) pnotlc' such as pen10-
barbi1al (Nembutal) and plrenoborbital (Luminal) are
usro 1hcrapeutically to decrease CNS .tetivity. The major
difference between drugs being used as hypnotics a nd
BOX 29-1 GENERAL GUIDELINES FOR DRUG THERAPY
!<!da1ive; Is the amou nt nf depression and sedatio n
FOR TRANSIENT INSOMNIA
induced Smal l doses of medication may be tL~ed for
da)iime wdation, whereas larger doses of the same drug Use shortterm therapy WTlh loweSt effective dose for shortest
may be used to produce hypnotic effects and produce 11me period
slttp induciion (lables 29-3 and 2'.l-4 ) . Assess pallent regutally to ensure need for cor.tinued therapy
Stdatr\'t'S. used to reduce ncr\'Qusn~, excitability, and that underfyrng pathology is not a cause
~nd 1mtab1li1y, produce calming effects When various lmenupt therapy to allow tolerance to decline
emotional or medical condi1ions rJusc anxiety or Use hypnotacs cautioosly w1!11 tllose wf1o Sl'oOl'e heaVlly. are m
letrnon, sleep may be interrup1cd .111d sedation may be respiratory distress. or are pregnant Of suicidal
indica1rd flcn~odiazepincs such as tlioz.epanr (Valium)
Jnd lorauip111n (Ativan) a re used for their sedative effects
as well as for controlling stress 1cla1ed to hypertension
flltble 29 s).
ll>'l>notics. used to induce and maintain sleep, should use, hypnotic use should be li mited to 2 to 4 weeks.
bt used intermiuently only when needed for transient Beruodiazepines are frequently used over barl>iturates as
in<amnia Some drug.s more frequently used as hypnot- sedatives or hypnotics because of their safety. Other CNS
K>are chloral h yd rate ( octcc) .md uma.upam (Resto- depressants such as alcohol should not be used with
nl) Rccause tolerance to hypnotics develops and antianxiet>' drugs and hypnotics and sedative$. Box 29-1
effec1iveness decreases after sevcr11I \\fC~ks of continuous lists general rules for treatmem of transient insomnia.
534 SECTION V Medications Releted to Body Systems
TABLE 2'J 5 SELECT SEDATIVES AND HYPNOTICS
GENERIC NAME/TRADE
NAME ISCHEDULEI
BARBITURATES
amobafbttal (II) (Amytall
mephoba1b1tal (IVJ' (Mebaral)
penl!lbarbttal (Ill' (Nembutal)
seoobafbttal fllf (Seconal)
phenobatllfral (IVJ' (Lummall
BENZODIAZEPINES
alprazolam'' (1111 (Xanax)
chlord1azepox1de' (IV) (L1bnum)
clonaiepam.. (IVJ (Klonoptn)
clOtaZepate' (Ill) (Tranxenel
diazepam' (Ill) (Varuml
estazolam.. (IVJ (ProSom)
flurazepam 11 (IVJ
lorazepam' (Ill) (At1van)
midarolam' (Ill (Versed!
CNS. een11111neMJUS system. IM. W1tramusailarty
"lntermediata acting.
'tong acting.
'Short ac;ting.
10angerous in okler adults
Note The Roman numerals in parenthesis behind the gcner1< name is the indication of U>e DEA schodule thm applies to that medicaoon
USUAL ADULT DOSE. INDICATIONS
DRUG INTERACTIONS
ROUTE. AND FREQUENCY FOR USE
alcohol. analgesa. MAOs,
~I '
other sedatives.
theophylhne. COllJCoS~
oral conttacepl!ves. Ofai
anticoagulants
Hypnotic. 65200 mg IM 12 hr
before surgcl'(
Sed<lt1ve 32-100 mg PO tid-qid Also used wi1h epilepsy
Epilepsy 400-600 mg PO qd or
d1v1ded
Sedattve 30 120 mg PO qd, IM.
rv
Hypnotoe 100-200 mg PO hs
Precperative use 100-200 mg IM
Hypnotte I00-200 mg PO qd, IM
Hypnotte 100320 mg IM. IV. PO
hs
o251 mg PO tod Sedative. anxiety, cimeudine. digoxin,
alcohol withdrawal macrolides. ethanol,
grapefruit 1uice. phenyto1n.
carbamaiepme
525 mg PO tid-q1d ethanol. cimetid1ne,
50-100 mg IM, IV fluconazole. levodopa
O!'>-1 mg PO ttd Also used fOf seizures valp..oic acid. disul!iram
30 mg/day PO bld-ttd Also used fOf seizures c1metidine. ethanol. ~
d1Sulfiram
210 mg PO tld-q1d. IM. rv Also used with skeletal See alprazolam
muscle relaxants and
101 seizures
1-2 mg PO hs Insomnia ethanol, c1me11cf1ne, di~~
macrolides. rifampt11
I5-30 mg PO hs Insomnia beta blockers. 1soniwd (INHI,
cimetidine. clozapme.
disulfiram, loxapine.
macrolides, nfampin.
omeprazole
I10 mg PO b1d-tid in dtvtded Anxiety. insomnia. ethanol, ftuconazole.
doses alcohol withdrawal 1traoonazole
IM. IV, va11es with level of Sedation calcium channel blockll~.
sedation macrohdes. lofazepam. all
ethanol
N. intr.1VOOOUSly; MAO{ monoamone oxldase 1nh1t>.1or. ore. over tile comter: PO. arally
 ~--C_
HAPT
...:: ER 29 Drugs for Neurolog1c System Disorders 535

rGl!ll8"1"' 1111)
Aruoetv. alcohol
pra1epam' (IV) fCentrax) withdrawal
20-40 mg PO qd
Anxiety, alcohcl See estazolam
iema1'PiJl'l uvi IRestooll withdrawal
15-30 mg PO hs Sedat,,18, hypnotic
tnazolam' llVJ IHalc1on) alcohol CNS depr8SSallts
0. 125-0 5 mg PO hs Hypnotic, insomnia
lllleplon flVI (Sonata I alcohol, CNS depressants
510 mg PO hs Insomnia
esr<>Mle llV) (Lunesta) alcohol
1-3 mg PO hs Insomnia
rameheon fRozerem) alcohol
SmgPOhs Insomnia 11fampin
chl01al hydrate flVI 250 mg-1 g PO hs Sedative, hypnotic alcohol. anticoagula11ts
rolpodefn llV) IAmb1enJ 5-10 mg PO hs Hypootoc CNS ~pressants. lcdlol
11uS?rone' f&SparJ 15-30 mg PO btd-tid Hypnotit. sedatrve MAOts
hydlW(line1 fAtarax) 5 I00 mg PO q1d, IM Antianx1e1y, anbemcuc alcohol
IV~taroll 25-100 mg PO qid, IM Sedattve. hypnotic
INSOMNIA MEDICATIONS
di(toenhydram1ne (OTCJ (Nytol. According to package instructions alcohol
Sominex. Sleep-Eze.
aeiw,tl
imytamine IOTCJ (Umsoml According to package 1nstrt1Ctions
1Nlt lllW!ed 1n Controlled Substances Act-no evidence f0< abuse

Treatment of Sleep D isorders

Some medication cla~es, such .ts barbiturates and ben.
zodiaupinl'S as well as some OTC medications, arc u>ed
for treaung sleep disorders.
Barbiturates
Baibiturates. some of the oldl">t drugs. produce dose-
de!J('ndent depression of CN~. Most of these medica-
lionsareclassified as either Sclwllule II or 11 1medica tions,
<1lthough phenobarbital is ,, Schedu le IV drug in mo>t
\I.lies (Stt table 29-5) Depending on the amount given.
these medications produce CNS llepression and mood
alteration from rcducl'd excit.ttion to scdalion followed
bihypnosis and deep coma After 2 weeks of continuous
ow. th~ desired efTcets at the s.1me do\e .ire not pro-
duced. The tendency is then to increase the dose to
produce d<-sired effects, lead ing 10 physica l and psyrho-
logJC dependence. After prolonged use of barbiturates,
withdra1al symptoms may occur when medication is
stopped. These medications must be used 1ith care in
tltc elderly, in debilitated persons, in those with severe
renal and liver disease and in those who lta1't' suicidal
tendencies. Barbiturates should be avoided in geriatric
pa1ients because CNS depression, confusion, and ataxfa
arc often reported (Box 29-2). 111c shon-acting benzodi
azepines are safer agents than barbiturates and so are
used more often.
Elderly individuals consume one third to one half of
the sedatives and hypnotics prescribed because most,
especially women, have changes in sleep panems that
come with age. The most common reasons the elderly
give for being unable to sleep include respiratory prob
!ems. pain, and cramping of leg musdes. Of concern is
the susceptibility to many side elToos occurring with
sedatives and hypnotics Elderly patients nttd to be
watched for increased excitability, hostility, confusion,
and hallucinations.
536 SECTION V Med1ca11ons Related to Body Systems

BOX 2<J 2 IMPLICATIONS Of SEDATIVE ANO HYPNOTIC

USE IN THE ELDERLY
S >ep d'ST rbana!s rt 11MlO!l 111 elderly because pree,osting
conditJOnS. such as a<thr1t1s. ~. and cardiac a!lhyth-
mtas. 11teml1Jt s eep
Hypnotics should be used fllf short duration to treat acute insom- Relatrve safe1)' High Low
nia and should not be givoo long enough fllf tolerance or Low High
Depression of
dependency to develop
central
Daytime sedation may occur when long-acung hypnotics are
nervous
piescnbed
system
Use of relaxa11on techniques. establishment or regular bedtimes.
function
and av1ndance of caffeine should be anempted before use or
Respiratory Low High
hypnotic medications
OTC sleeping aids often conLJ1n ant1h1stamines. wluch may depression
cause duzmess. tinnitus. blurred vision. gastrointestinal dis- Potential for Low HljJll
tur!Jances. and dry mooch suicide
Chance of Low Hi(#l
causing
physical

lll LEAR NIN G TI P

dependency
Potenual for Low High
Most generic names for balbfturates end 1n "barbital. and the trade abuse
names end in a1. Tolerance Low High
potential

Benzodiazepines
Jlenzod iazepines. or anxiolytks, arc among the most
widely prescribed medications bcc.iuse of many advan-
tages over older medicines such as barbiturates, 1nepro-
bama1r, and alcohol. Diaupam (Valium), the prototype
of this dass of medications, is ind1ca1cd for anxiety dis-
orders, alcohol withdrawal, preoperative medications.
insomnia, seizures, and neuromu5Clllar diseases such as
skeleul muscle spasms or nruron dysfunction. Like bar-
bi1urates, benzodiazepines are Schedules Ill and IV med-
ications with shon- 10 long-acting effects. Th= drugs
have fewer deaths from toxicity and O\'erdose. a lower
polential for abuse and side elfer1s, and fewer drug inter-
actions. These drugs have mu~le relaxa nt, antiarudery,
anLiconvulsant. and sedating and hypnot ic effects (see
Table 29-5 ). See Chap1er 30 for more information on
benzodiazepines as anxio ly1ics.
Other Medic ations Used as Sedatives
and Hypno ti cs
A number of .m1ianxie1y drugs and sedati\'es and ~
notics do not fall in10 1he categories previously lo<tcd
Their action; are similar, causing sedation and h'l'OOlll.
agents such as ;w/pitlem (Ambien) are therefore 'idwd-
ules Ill and IV medications, with a potential for ltlllllSt
and abuse especially by 1he elderly. Buspironr (lluSpM
does no1 cause scda1 ion, has no abuse po1entW, ~nd
does not inlcnsify CNS depressants and its amianxie11
effects take an extended time to develop; it is 1he drug
of choice because of these propenies (see 'Iable 295)
Other Produc ts Available OTC
for Ins omnia
Antihistamine; 111.1y cause excessive drowsiness when

lll LEAR NING T I P

Many of the generic names for benzod19lePmes end m "pam"
Of "lam:
When comparing barbiturates and benzodia7,epines
for uses or abuses, these medications are at opposite
1>0les. Whereas barbiturates are dangerous, bcnzodiaze-
pi nes are much safer (Table 296) .
given with seda1 ivcs and hypnotics and may even produce
a "hangover, or sedative effect, the next day. The rood
and Drug Administration (lDA) has apprO\-ed t"'o..nt>
histamines for use wuh insomnia-d iphmhyd'"*
(Nytol. SominCA. llenadryl) and doxylaminr (lllll!OCll~
These medicauons are not as effecthe as benzodlllt-
pines, and tolerance 10 1he hypno1ic effect de\-clopo
quickly, often in les than 2 weeks (see Table 29S)
Alternative products that do not require a pre5CllpllOCI
such Is v~ l crian root (an herbal supplement) ~nJ

,.,...1a1onin (a dietary su'.'plement) have been emploi-'ed
to promote sleep. Valenan root can assist with falling
~ttfl but does not help maintain sl~p and must be
1.1ktn for a week o r more to be effeniw. Melatonin is
secreted by the pineal gland with an action th at is stirnu-
la1ed with darkness. Trials have indic;Hed that melatonin
supplemcms can promote sleep. l.arge doses have side
effOCIS such as hea.daches, hangover, nighimares, hypo-
lhcrmia. and trans1en1 depression.
1 Potl!<ll1al for <M!rdose with elderly using sedatives is always
presenl. and signs of confusion, ag1tat1on. halluc1nallons. and
11yperexc1tab1hty may show that this reaction is occumng.
i Withdrawal from analgesics. hypnoucs, and sedatives after
prolonged use may lead to nightmares. hallucrnations. insom
nia. or a comb1nat1on of these
3 W1UI sodat~ and hypnotics. daytime sedation 1s possible.
..i ird lOOals takrng these dlllgs should avotd hazardous
aclMllllS
4 At.:datlOOS for sedation and sleep should be taken at lowest
dcse possible f0t shortest period of lime
5 Altohol and all other CNS depressants such as antihista-
m.,es (cg , OTC cold. cough, or allorgy medicauonsl should
be avoided when sedatives are being taken. Some medica
lions coota1n antihistamines a11d acoontuate drowsiness.
whe1eas others contain CNS s11mulants and defeat the
IUJlOSB of sada uves.
6 Patier ~ hav1J19 difficulty sleepmg should try to identify
Iha cause Ideally. the cause rathe< than sleep disturbance
slwld be ueated
...
110 that piomote sleep are called hypnotics. with daytime
< 1.ion and amnesia being ch el side effect
1J 111ates. regulated by Drug Enforcement Admmistration
DcAI. havo high potential for abuse and cause significant
, lllte and physical dependence
& !llod1J1epones are safer with low allllse potential and
cau'f! less tolerance and dependence. therefore these med1-
ca11ons aro preferred to barbiturates and other general CNS
dcpcessants
P11nc1pal 111d1cations for benzod1azop1nes are msomnia,
an>1ety, and seizure disorders Ben1od1azcp111es are dru_gs of
ctOce for transtent msomnia Adm1111s1ra11on should be mte1-
ttent and ll1e drugs should be given f0t only 2 to 3 weeks
because of physical dependence. but withdrawal syndrome
IS llSUollly mild With longer use. drugs should be decreased
11\tlf ~ral weeks to months to prevent seizures
-------'
CHAPTER 29 Drugs lor Neurolog1c System Disorders 537
ANTISEIZURE MEDICATIONS
Epilepsy. a group of disorders ch.uacterized by hyperex-
citJhi Iity within the CNS, is presem in approximately
2.5 million Americans. Abnorm~l stimuli can produce
111~ny symptoms from short periods or w1conscious11ess
to viole111 conmlsions. Seiwrt is a term for all epileptic
cvcms, whereas rom'Ulsio11 relates to abnonnal motor
movements such as the 1er~mg mO\emenL'l of grand
m~I seiL.ures. Seizures are or two broad types; focal
(putl~I) $<!IJ:Ures and gener~liLW ttlzures. Box 29-3
comp.ires d11Terem typeS of seizures
Epilepsy may be controlled but cannot be cured. Early
epilep~y control began in the mid-nineteenth centurr.
when bromide> were used to rcdure seizures. In 19t 2
phcnob.irbital was fou nd to produce depression of the
br.1in's nioLOr conex to reduce lh<! number of seizures;
how<'Wr. the drug had the unpleasant side effect of
depressing sensorr and motor areas
BOX 29-3 TYPES OF SEIZURES
Focal or pamal seirures (hmllcd spiead)
A Simple se1wres. Convulsion of single hmb or muscle
group with no loss of consciousness
B Complex partial seizures Confused. bizarre behavior with
impaired consciousness
II Geoerahzed se1ZUres (generally pioduce loss of
consciousness)
A Nonconvulsrve
I Absence Cf pelll mal selZUtes loss ol consciousness
for a short ume (I 0 to 30 seconds) with mild symmetric
motor act1v1ty to no motOI ac11v1ty at all-may be as
mild as only eye blinking
B Convulsive
1. Tomc-clomc or grand mal seizu1os. Major convulsions
with muscle ng1d1ty and synch1onous muscle jerks.
marked 11nJl8irment of consciousness
2 Ton1c-ps}'dlrxno1or se1111res Tonic muscle con-
tractoons
a Uncontrolled se1ZU1es Usua 1Y children; mul11ple
seizures per day (up to 1001
b. Atoo1c or ak1net1c se1111res Sudden loss of muscle
tone causing collapse of the body or body part
without muscular contractions
c. Myoclonic seizures: Sudden, rapid muscle
co11tractions
d Febrile seizures Ton1c-clomc seizures of shon
duration. usually seen 1n children with moderate to
rugi lempefature levels (children more likely to
dewlop eprlepsy laterl
J Status epilepurus Unconuolled seizures lasmg 30
minutes Cf mcra. may be ~le threatening
 538 SECTION V Med1cauons Related to Body Systems

AntiSetZUre medicauons llow ind1v1duals to have
greater self-control by suppremg neuronal malfunction
at the seizure focus Reduction in brain cell eiicitability
reduces the incidence and seo.'t?rny of seizures. Medica
uonsconuol 40%ofab<encr or JK'llt m;al seizures and
reduce the frequency of ano1her 35%. Tonlc-donic
(grand ma!) seiLures are beuer comrolled. with complete
control achieved in 50% of the pauems and greatly
reduced frequency in another 35%. Tonic (psychomO
1or) seizures, charaeterif.ed by 1ense movemenlS, a re con-
1rollcd in only 35% of pa1 icn1s. but frequency is reduced
in another 500Ai of paticms. Aniiseizure medicines
require dosage adjus1mc111s during 1imes of stress or
severe illness or wi1h the addi1ion of medications taken
for other medical condnions
Medications for seizures include barbiturates (dis-
cussed earlier). with phenobarbnal being most fre-
quently used for its antiepileptk propen1es. Sedathe and
hypnotic effects are undesired side effects; however, 101-
erance to sedation dl'\-elops as J posilM.' effect when
barbiturates are used chronically Sudden withdrawal
of barbi1urates in seizure-prone paucnts can produce
sei.mres. Therefore if wnhdrawal of barbiturates is
desired, the dose should be gradually reduced (see
'lable 295).
111e benzodiazepi nes tllaup11111 (Valium), clonaze-
pa111 (Klonopin), and ltiraupam (A1hr.111 ) ;ire also used
as antiseizure drugs. Diazepam and lorazcpam are used
10 hall seizur~s i_n p~ress. Clonazepam. is U!rd b
myoclonic. akineuc-atonoc, and absence seizures (T
29-5).
flydantoins include pl1enytoin (Dilantin), 1 l'Olllil
broad-spectrum antiseizure medication for palll.ll Jtld
tonic-donic seitures. 1hese dru~ change the lla'>t ed
excitabili1y by decreasing the SO<hum effeet in !ht~
Because hypercxcilability is decreased. seizure reduct
occurs in most patie111S: Good _dental hygiene and gui
care are imporia nt w11h pa11en1s laking hydanioin
because of gum hyperplasia (Table 29-7). '
Ftlspl"myto/11 ( Ct.'re byx ), used paren1erally, is used r.,
s1atus ep ilcp1icus a nd wh en s ubs1i1ution for oral amllt'
zure medica tions is necessaiy, su ch as with surgical pm
cedures (see .fable 29-7).
lll LFARl\llNG TIP
Most hydamo1ns have names that end m "nytOin.
Succini m idl'S, used exclusively for the treaun~nt '
absence or pc1i1 mal seizures, decrease calcium C\Jrrtn
in 1he brain 10 pl,1y an impon am role in treating lhtv
seizures. T he most com monly used succinimideistthe-
suximitle (7.aron1 in), with 111etlisuximi1le (Ctlontin)
a nd p/1e11suxi111/tlc (M ilo nlin) being two other medira
lions in the group (S<'e Tab le 29-7 ).

TABLE 29 7 ANTISEIZURE MEDICATIONS

GENERIC NAME/
TRADE NAME
8AR81TURATES
USUAL AOULT DOSE.
ROUTE. AND FREQUENCY
INDICATIONS
FOR USE DRUG INTERACTIONS t
phenobarbital. Epilepsy-partial See Table zs.s
mephobarbital. and so tonic-clonic seizures
on (see Table 29-5)

BENZODIAZPINES
diazepam. clonazeparn.
lorazepam. clorazepare
(see Table 295)
HYDANTOINS
phenytojn I011antin)
fosphenytom (Cerel1fxl
G( Gasuointestinal; JM, in11amuscula11v. N. in1ravenousrv. PO. orally; TB. tuberculosis
Myoclonic. absence. See Table 295
and akinetic seizures
and status ep1lep1icus
All are highly 1ndiv1dual1Zed Panial and ton1c-clonic Oral contracepwes for all
seizuies
50200 mg PO bodtd
glucoconiQ>ids. ~ ~
drazepam. amantalfire
phenobatlxtal. a!cdtol
lrd1111duahzed, IM. IV For use when oral
med1cat1ons cannot
be used
 CHAPTER 29 Drugs tor Neurolog1c System Disorders 539

Mil Si# Effects of /lrdantoins;

Sk rashes. husut1sm. overgrowth of mouth
gums. gong1v1t1s. d1niness, Visual d1 .turbances. postural imbalance
SUCCINIMIDES
elhosux1m1de (Zarontin) Absence seizures None mcllcated
500 mg/dav PO qd-tid
~mide (Mdonun) 13 g PO tod-qid
'IUlUlllide (Celonton) 300-1200 mg PO tid-q1d

'111ja1 Sid EHtcts of Succinimides:

Gt svmptoms, drowsiness. diarrhea. dimness. blood dyscrasias
MISCELLANEOUS
ANTISEIZUREAGENTS
carbamazepme (Tegretol)
lll!i:iooc acid (Oepakeoe)
valproate (Depakote)
p11r111done (Mysohne)
gabapentin (Neuron11n)
imomgme !Lam1ctal)
lel1'toraa!lam IKeppra)
KewaXR)
a<artiazejltne {lnleptal)
top1ramate (Topamax)
!lagabme (Gabitnl)
1tnsam1de (Zcnegran)
Pama! and generalized
IOIUCclOfllC seiZures
and mixed se.zures
Varies
100.200 mg PO vanes All generalized sem.res
and partial se.zures
125250 mg PO (as sprinkle or As w11h valpro1c acid
tablctl
250 mg-500 PO tid-qid Psychomotor seizures
100-800 mg PO t1d Pama! seizures
Varies Partial seizures
500-1000 mg PO. IV bid Pama! selleis
500-1000 mg bod PO
300-1200 mg PO bid Pama! seiwres
25-400 mg PO in divided doses Panial seiiures
4 qd56 mg PO in divided doses Partial tonrcclonic
seizures. migraine
headaches. alolhol
treatment
100500 mg PO qd Partial seizures and
others as needed
steroids. cimet1dme.
~lants. l11Mrn
acetammophen.
an11depressan1s. oral
contracepuves, calcium
channel blockers
Other armseinl:e dl"ugs.
medications for TB.
sahcytares. macro des
Same as valpro1c acid
d1goxin, alcohol. oral
antieoagulants. vatproic
acid. carbamalllpine
antacids
carbimazole. valprorc acid.
phenytoin. phenobarbital
Basically none
Same
Same
Same. oral contraceptives
Ant1furlgals

Mljor Side EHecU of M iscellaneous Anr/S1iwr Agents:

~ltOl'I, GI symptoms. valproic acid and vatiroate--nausea. 1111mrtmg. diarrhea. tremors. primidone-GI
l'lffiP!OfnS. anorexia. drowsiness. gabapentm- sleep1ness. auvua. fat1g~e. nausea. severe dtwness. lamotngme--Oniness.
senous rash. drplop1a. headache. ataxia. somnolence. /evot1mcetam-<lrows1ness. asthenra. oxca1balep1ile-diwness.
nausea. headache. d1arrhaa, ataxia. nervousness; top1ramate-dizziness. asthenia. somnolence, confusion. headache. tremo1s;
11agab1n&-SOmnolence, dizziness. ataxia. diplop1a, nystagmus. nervousness. nausea, tremor: zonisom1de-drowsrness.
d1111ness. headaches. nausea. impa11ed speech
540 SECTION V Med1ca11ons Related 10 Body Systems
Ill LEARNING TIP
The geiierte names of SUCCJlltll'odes end on mide.and uade names
end Ill 1Jn.-
0 4 OTC medrcat1ons should not be used wrth antJsewe
Other antiscizure mcd1calions include new dru~ as
well as dru~ that have been around for a long time:
Carbamaupine [l'egretol). similar to tricyclic anti-
depressants, blocks sodium ion chan nels, much
like 1>heny1oin. 111is medkJ1ion also po~..esses
analgesic properties for neuralgia and is used to
ueat bipolar disorders.
Oxcarbaupirui {1 rileptal), a derivative of carbam-
azeJ>ine. is beuer tolerated and may be used for
panial seizures in adults and children.
Valproic acid (Depakene) and valproate (Depak-
ote) can be used with all types of S<>1zures. as well
as for migraine headache prophylaxis. by inhi-
biting neurouansm111ers 10 the C"S. These medi-
cations ha,.., the potenual 10 cause fatal liver
1oxici1y.
l'rimido"" (Mysoline), rt'la1<.>d chemica lly 10 barbi-
turates, is metaboli7cd and convened into
phenobarbital.
Gabaperrtin (Neurontin) SUJlpresS<>s neuron excit-
ability, which inil iates epileptic >ci,,urcs much like
brain neurons excitabilily.
Several new drugs such > lamotrigi11e (Lamicral).
tiaga&ine (Cabi1ril), and zorrlsorrrltle (7.onegran)
for control of partial sdwres have been introduced.
Topiramate flbpamax) has been introduced for
partial seizures and tonic-clonic sei-.urcs, as well as
ueatment of alcoholism and prevention of migraine
headaches.
ILWtirautam (Keppra) is used in adults for
adjuncti\' therapy in panral seizures. with the
advantage of not interacting with o ther medica-
1ions (see Table 29-7).
Neurontin. first introduced as an antiseizure medication. is being
used for se\/1l1e neur09enic pain
lPati8rit' Education for Compliance
Persms takmg an11se1zure medrca11oos sllould not omit
'
increase. deaease medrcat1ons without penn SStOll of the
heallh care provider
2 AntJsetMe medrcatJons shoold no1 be d1scont>0ued abruptly
3 Anuseuure medrcatoos may cause drtl'M1ness or dlZllness.
therefl)(e avoid hazardous tasks until side effects are
evaluated.
catoos wolhout phystCran's permisstOn
5 No alcohOI should be consumed wlllle lalung ar.
medications
6 Use good denial hygiene after each meal, especialJy
hydan101ns. beeause of gum tissue overgrowth.
1. Keep a record of all seizures-<late, time. leoglh. &r.d
forth
' .
The goal of ant1se1zure med1ca11on is to reduce sewes
the extent that !he pauem can hve a normal I fe:: ~
complete seizure ehm1na11on may not be poss ble M;:t
seizure medications are selective for pa11.icuta1 setz1n
Successful treatment depends on finding the llOSI 1f
drug for each 1nd1v1dual pauent Noncompbance rs hi
reason for ueatrnenl failure
Antiset1u1e med1cat1on must be tapered and not ~
withdrawn
Most ant1se1zure med1cat1on causes ceniral neMJus svste111
!CNS) depression: other CNS depressants such as alctllol
op1oids. and antihistamines should not be used
concurrently
Phenytoin. phenobarbital, and carbamazep1ne are actM!
against partial and tornc-clonic seizures but not abserl:e
seizures
Phenyto1n causes gtnglV3f hyperplasia
DRUGS FOR PARKINSON'S DISEASE
Parkinson's di~easc is 1hough1 to be caused bydop.imint
deficiency and an ACh excess within Lhe CNS. Whtn
regulati ng vo lu nt,1ry m usclc movements, ACh is n eJl(it
atory neuro1ransmi1tcr. wi1h dopamine inhibiting, 01
stopping, the ACh ncuro1r.msmi1ters LO decrease musclt
movem ents. Norma lly ACh and dopamine are balnctd.
providing smooth, bcuer-comrolled muscle mowmem
A decrease in dopamine produces exc~ in ACh.
causing tremors and muscle rigidity typical ofp.irl<iruoo-
ism. Drug treatment i~ effective in reducing symptoM
but patients bcconw progressively disabled md rM
become immobile in la1er stages. Depression or ckmm
tia may occur. causing memory impairment and ~lttl
lions in thinking. Medications for parkinsonism tn'OI\~
increasing doparn ine levels by administering le>'Odop.i-1
prerursor of dopamine-or administering medic.i1iot11
that st imul a1e dOJlarninc receptors. Reduction of ACh
 CHAPTER 29 Drugs for Neurologic System Disorders 541

BOX 19 4 NOMENCLATURE FOR DRUGS ACTIVE ON THE AUTONOMIC NERVOUS SYSTEM

oriision of the Drugs That Promote or
Autonomic Nervous Important Neuroactive Reproduce Effects of This Drugs That Reduce or Block
System Substances System Effects of This System
Paras'i"'1131het1C acetylchollne P.ir')mpathomJmetic P.ins) mpatholytlc
(cnoltnergicl cholinesterase !d1olln<"rglc agent<; also lanticbolinttgk or
called cholmergic aga11stsl cholln<"Tgl< blocking
aR<"Dt: also ca led cho/tf11!!91C
aniagomst>1
$o,padletlC ladrenerg cl eponeplmne S)mp.ithomlmelic S}mp.atholytk
noreponeplvine !.idrenttgic or !anti.adrenni;ic or
dopamine adrt'nergic-acting adttnerglc-blocklng
&t'nts; also cal ed adrenergc agmts; also ca led ~IC
agooists1 anragon1sts1
Agi:rrtst lagon1st1cl Entity that activates. in pharmacology, a drug that stimulates the actMty of cell receptOfS nonnally 1esponsive to
no..1a 1y occurnng chemical substanc;es Anragonisrtantagomst1cl Enuty that counteracts the action of another substance. in INfmacol
ogv. a drug that p1events stimulation of a receptor site

Activity may also be used for dn1g therapy with parkin
sonism (Box 294 ).
Ln'Odopa (Dopar) converts in10 dopamine to
lessen 1>y1111>10111s of parki11,011 isrn and 10 provide
significant i111proveme111 in physical activity. allow-
ing niany pa1icnts to rcsu 1n1,._ normal f\Ctivi1y.
Levo<lopa ca n cross the blood-brain b.uricr (dopa
mine does not luve 1hb cap.1bili1y) 10 be mciabo
lizl:'d into dopamine.
Carbidopa (1.odosyn) is given with lcvodopa to
prevent periphera l conver.ion of lcvodopa 10
dopamine. m,1king more lcvodopa avai lable
10 enter the brain. Carbidop.i h,,_ no therapeutic
effect and no side effect> when given alone;
howeo.-er, the combination of rarbidopa and
/tlNHlopa (Sineme1) 1mprov.~ mobility by decrea
mg tremors
EntJJcapont (Comt,1n) and 10/wf!one (Tasmar)
are used with kvodopa-carbi<lopa 10 improoe the
ability of patient> w11h p.irkinsonism 10 accom
plish activities of daily hvmg
AmanlJJdinr (~ymmctrcl) promote> dopamine
release from brain storage >itCS lffettS were found
by accident while the drug ""is being ued ~ri
marily as an an1iviral l~'VOdopa and am.rntadmc
are used lo treat drug indutcd d> ''-inc,la. Some
pauents experienced ,km discolor.uion that disap
pe;irs on drug discon1111ua11on . Paoonsonrsm is treated by actJVallng dopamine receptors and
Selegiline (Eldcpryl, Cortex), a mo1~oam~ne
oxida.e inhibilor (MAOl), reduces the w~armg
out' effect of levodo 1~.1 and is neuropro1cc11vc 10
delay dbe.1se progrc>,ion. . .
BromOl'rifJlirre ( 1'.irlmlel). ,, dircct-acrnig dopa
mine agonlst, is often uctl with lcvodopa 10
decrease dyskincsi"
l'ergolide (Permax), similar 10 bromocriptine, can
prolong control ofparki nsonism symptoms. reduce
fluctuations in mo1or response. and reduce dyski-
nesia induced by l~o0dopa.
l'Tamlpexole (Mirapex) and r11pi11/role (Requip)
may be used alone in early Parkinson's di.ease
o r may be used with levodopa as the disease
progresses and greater dmg Lhernpy is required
(Table 29-8 ).
. .
Anupall:insomsm medications may cause d1wness. drows1
ness, and bluried v1s1on. No alcohol sllould be consumed
With these drugs
2. Medicatrons for pall:inson1sm should be taken with food to
prevent gastroin:;esillla1disturbances that may occur
3 Avoid "'ta1111n 8. With lewdopa. as n accelerates breal<down
of cloPamine to decrease lewdopa ellec1S
... ..
use of acetylcholine IAChl blocking drugs
Levodopa 1s the most effective treatment for Par1onson's
disease.
Levodopa and monoamine ox1dase 1nh1b11ors (MAOlsl ta~en
together can cause a hypenens1ve cns1s
Amantadine relieves symptoms of ea1Jy pa11onsonism
 542 SECTION V Med1cauons Related to Bodv Systems

TABLE Z9 8 MEDICATIONS USED FOR PARKINSONISM

GENERIC NAMEJ
TRAOENAME
USUAL AOULT OOSE.
ROUTE. ANO FREQUENCY INDICATIONS FOR USE DRUG INTERACTIONS ..
DRUGS TO INCREASE PartCJnSOlllSlll v1tamm Bs. anllpS'/l:hotics
DOPAMINE carbidopa, antichol ~
amantadrne. pergohde
MAOls
levodopa, IL.<f-Opa Dopar OS 1g PO qd, mcrease to
larodopa) 48g
carb1dopa-levodopa (S1nemet lnd1v1dualized but usuallv
10/100. S1nemet 25/100, 11ab PO t1d
Sineme1 251250)
amantad1ne' (Symmetrel) 100 200 mg PO bid alcohol
seleg1hne IEldepryl, Zelaparl Smg PO bid Increases response to mependme. tricyclic
Orally d ssolv ng tablet levodopa-carb1dopa antidepressants
12525mgqd
rasag1hne (Azrlectl OSmg-1mg POqd Same as for seleg1l111e mependine. MADls.
antid0PfessantS,
dextr~

Major Side EHem of Drugs to Increase Oopemine:

levrxJopaandcarb1dopa-leVOlk!f-d>lonl~ nausea, vomrt1ng, abdommal pain, dysphag1a. drv mouth, mental changes,
headache. dizziness. hand tremors. dyskmes1a, amancadine-f!rv mouth. GI disturbances. CHF. visual disturbances. d1121ness.
confusion. selegi/ine-nausea, halluc111at1ons. confusion, depression, loss of balance, dimness: rasagilm~sual disturbances.
headaches. se12ures, nausea and vom111ng

DOPAMINE AGONISTS
bromocnptrne (Parlodel) 125mg PO bid neuroleptics, erythromyc1n
entacapooe !Corntanl 200 mg with each dose of methyldopa, dOOutarmne.
cart>tdopalevodopa isoproterellOI
P'3ffi pexole IM rapex) 15-45mgl'Oqd Early or late parlonsomsm c1meud1ne. dopamni
and restless legs antagonists, ~
syndrome ciprofloxacin. estlOgef\I
rop1nuole (Requip) 0 25 mg PO ud (11nmedia1e
release)
tolcapooe ITasmar) 100..200 mg PO t1d levodopa, dopamine antil!1l'l m
Major Sid EHects of Oop1mino Agonists:
bromocriptine and pergoltde-nausea. psycho11c reactions. confusion. nightmares. agitation. hallucinations. paraooia;
entacapone-nausea and vomiting, dvsk111esias. orthostatic hypotens1on. hallucinations. sleep disturbances; pramipexole,
ropimrole, tolcapone. pramipexolfl-flausea. dimness. somnolence. hallucina1ions. 011hostatic hypotension. agitation. conlusioo
ANTICHOUNERGIC Adjunctive treatment for
MEDICATIONS alcohol. amantadine. ~'"''
parkinsonism p1ocamam1de
benztropine mesytare ICoQentinl 1-6 mg PO qd, IM, IV

ANTIHISTAMINES
d1phenhydramine (~) 25-50 mg PO Ud-qid, IM. IV Reduce drugnduced alcohol
extrapyram1dal effects
a!F. Congestrie heart failure: GI. gasuo1n1es1111a1. JM. 1n1ramuscularly; N. 1111ravenoosly; MA(}(. monoomuie oxidase inllibttoc PO 0tally
A~ used with in6uenza 10 relieve acf1ing end roosde shaklflg

DRUGS FOR RESTLESS
LEGS SYNDROME
Rtl~ss le~ syndro~e (RLS), affening two o ut of IO
Amencans, 1s characte~1zed by an uncom rol lable urge 10
move 1he legs whe1~ s1~ung or lying d o wn. 11le person
sim1>ly can1101 sit sul l. 111~ cau~e is unknown, although
the syndrome may be familia l. l'rea tment includes using
ml'dicauons for parkinsonism, such as pramif>U{lle
(Mirapex) (s.:e Table 298 ), opioids. muscle relaxants
(stt Table 143), and medications for epilepsy (see Table
197) rhe only FDA-approved drug for RLS is rapinirole
(Rtquip), a dopamine agonist (see l'able 298).
llradarhcs are common symptoms caused by a variety
of rmoM including fatigue, illness, alcohol, and stress.
\Uny headaches are relieved by OTC medications. but
some p.ltoems have debilitating. se"ere, recurrent head
xhn requiring frequent medical attention (Figure 295).
Snl'rt head,1ches may be further subdivided into those
with identifiable causes such as infenions. hypertension,
or mmor and those with no identifiable cause such as
migraine or duster headaches. When the cause of head
aches is known, that cause is the center of treatment.
Migraine Headaches
\11gra1ne headaches are characteri.ted by unilateral,
throbbing or nonthrobbing pain of1en accompanied by
11.1u<a, vomiling. and sensitiv11y to noise and light.
Some migraines have an aura (formerly known as classic
m1gr<1111es), and >Orne have no aura (formerly known as
common mi,~raines), the type m ost commonly fo und.
Migraine auacks may be prcci 1,iw1ed by hormones
because the headaches seem 10 be won;~ duri11g men-
suuation and women seem to cc.1se having migraines
Hyperte11S1ve
Allergic ...::::l::- - -- -
(slnus)
Figure 29-5 01fferenuatl()C1 of he<Klachos bv Jocaton of pain
CHAPTER 29 Drugs for Neurolog1c System Disorders 543
with menopause. Familial tendencies are another
common cause of migraine headaches Some medical
professionals belia-e tha1 m1gr.11ne headaches are vascu-
lar in origin.
Treatment of Migraines
Dn111s for m igrnines have two methods of action: to treat
an ongoing headache and 10 prevent attacks. Medication
individualization is necessary because some medica1ions
can cause dependency. Treatrnems for migraines include
use of nonsteroidal antiinflamma1ory drugs (NSAIOs),
opioid analgesics. and ergot alkaloid$. Aspirin, aceiamin
ophen, ibuprofen, and other asp1nn-like NSl\IDs can
relieve mild to moderate migraine headaches and may be
combi ned wi1h rnetoclopranoltlc (Rglan) for enhanced
aspirin absorption. Fiorinal contains aspirin, caffeine,
and b111albital; Fioriur is si111 ilar to l'iorinal but con1ains
ace1am inophen rather 1han aspirin. Another popular
combination is Mitlrln (acetam inophen, a sedative. and
a sympatl1omimetic) for pain relief. Midrin is contrain
dicated with glaucoma. severe renal disease. and severe
lier and hean diseases caused by vasoronstriction.
Opioid analgesic:s are used with 5e\1're headaches that
do no1 respand to nonopioids. The most frequently used
arc meptt'idine (Demerol) and l1111orphanol "'""'spray
(S1adol NS) (see analgesic:s in Chapter 15).
Medications specific for migraine headaches are in the
tri1>1an family, such as eletrlpta11 (Relpax). Jly reduci ng
1he sw11ing of blood vessels surrou11ding tbe brain, ii
has a fairly rapid 001se~ with relief for most people in 2
hours. Persons with vascular or coronary diseases should
noi use this medica1ion. Sumatrlptan (lmiirex), related
to serotonin and available for oral and subcutalleous
administration, relievt$ botl1 headadles and accompa
nying )'mptom$. Sumatripian is teratogenic and should
no1 be used in pregnancy. O ther triptans include zolmi
1ript11r1 (7.ornig) and rizatrlptan (Maxalt), whirh are
s imilar to sumatriptan, with similar effects and side
effects (Table 29-9).
Prevention of Migraine Headaches
Nondrug measures such as biofeedback and other relax
a1ion techniques aie hdpful in controlling or diminating
causath1' factors of migraine head.lches. Rest in a quiet.
dark atmosphere is often indicated as early prophylaxis.
Some medications are given prophylactically to reduce
frequency and intensiiy of auacks. including beta blockers
such as anoitriptyline (Elavil ), calcium channel blockers,
mell1y..,rgltle (Sansen), and v11/proic acid (Depakcnc)
among others. Prophylaxis is indicated for 1hose who
ha"e frequen1 or severe migraines or for those who do
no1 respond adequately 10 other therapy. Propmnolo/
(lnderal), a beta blocke~ is the drug of choice for prophy
lax1$. Ph"""Wne (Naidil), an MAOliype antidepressant,
is UM!ful against migraines but 1s po1entially dangerous,
so ii is not used routinely (see Chapter 30).
 5 SECTION V Medications Related to Body Systems

TABLE Z'l 9 MEDICATIONS SPECIFIC FDR USE WITH HEADACHES

GENERIC NAME/TRADE NAME

(SCHEDULEI
USUAL ADULT DOSE.
ROUTE. AND FREQUENCY
INDICATIONS
FDR USE DRUGINTERACTIONS I
NONDPIOID ANALGESICS
ospmn 325 mg - buta botal 50 Mg 1 or 2 tabs PO q3-4h Tension headache Same as the 111grro1en11
+caffeine 40 mg (F1onna11fl , included
acetaminophen 325 mg + 1 or 2 tabs PO q3-4h Tension headache Same as for Fionnal
caffeine 40 mg + butalb1tal
50 mg (Fioricet'I (Ill)
acetaminophen 325 mg + 1 or 2 caps POup to 8 per day Tension, vascular bromocriptine
d1chloralphenazone 100 mg + headache
sometheptene 65 mg (M1dnnJ
llV)

TRIPTANS
narauiptan fAmelgeJ 12 5 mg PO pm q4h. max M1gra1ne headaches ergot preparatJOOS. oire
Smwdav S.HT agonisu. l.4M$
almotnptan !Axenl 6 25-125 mg PO Qd. max Migraine headaches Same asAmerge
2511l!Vday
rizatnptan (Maxaltl 5-10 mg PO. max 30 mg q24h Migraine headaches Same as Amelge
eletriptan (Relpaxl 20-40 mg PO qd M1gra1ne headaches ergotamine anbfungals.
nefazodone. macrolides.
ant1v1rals
frovatriptan (FrovaJ 2 5 mg PO; max 7.5 mg PO q24h Migraine headaches ergotamine, oral
contraceptives, pr01lfano~I
sumau1ptan (lmitiexl 25100 mg PO. 6 mg SC; 520 mg Severe migraine or ergotamine,
11111anasal q2h cluster headaches dihydroergotamine
1ofm1triptan (Zomig) 2 5-5 mg PO/nasal spray topically Migraine headaches MAOls, SSRls. oral
contiaceptives
Major Side Effects of Tript.tns:
eletnptan-;JllZJlleSS. nausea. we<i<ness. fahgue, prBSSIJle sensation in chest or throa~ frova111ptan-hot or cokl sensatlORS,
douiness. faugue, cheSl pain. ~keletal pain, dry mouth. dyspepsia, flushing. suma111ptan. .rolm1tnptan-angina-lile pa.i. paf1111
necic or tlvoat. venigo. malaise. fatigue
MAOI. Monoamlne OJodase 1"'11~11ors: PO. orally SC. subcutaneously
'May h<lve codeine added 1n gr X: gr X. or gr X

Treatment of Additional T ypes

More common he.1daches that cause pain and often
=- ;
llrugs for migraine headaches are used for either tieatment
of e~s~ng lleadaches or prophylaxis
The goal of rreatmeot for m19ra1ne headaches IS to eliminate
the pa n. nausea. and \'00111 ng asscc1ated with headaches
The goal of prophytactic therapy IS to reduce the 1nc1dence
of migrallle attads
Aspmnfike ana gesics are effeciNe for ueat1ng mild to mod
erate migraines
OplOlds may be used for severe mgra1ne headaches not
re51JOnd1ng to other med1ca11ons
of Headaches
inabil ity to co ncentrate and perform needed tasl.i
include cluster headaches and tensio n headaches. Rdiel
of the pain may be o btained fro m prescription medlO
tions, or o ft en 0 re drugs are used. As with other l)'Jl!S
of headaches, the causathe factor should be idenuficd
whether this be allergies, tension, or o ther precipn~u~
mauers.
Cluster Headaches
Cluster headache O<cur in a series o r dustet with ah
au ack lasting 15 minutes to 2 hours. Symptoms indudt
severe, no nthro bbing. uni l.1teral pain usually loca1id
 - ---
CHAPTER 29 Drugs for Neurolog1c System Disorders
1>3clofen 10-20 mg PO qid
dantrolene !Dantrium) 25 mg PO qd: up to 100 mg PO
in divided doses
(Ji'S raiual nel\'OllS system: PO. orally
around the eye that is not preceded by an aum, does not
include nauscd and vomiting. is not familial in nature,
and OCCU!$ more often in males. TI1esc anacks consist of
one headache or more every day for 4 10 t 2 weeks. with
an inierval of months 10 years of sep.1mtion in each
incident Vempnmil (Calan), a calcium channel b locker:
li1hium (:.ee Chapter 30); and glucocorticoids (see
Chapier 20) are used for clusier headaches.
Tension Headaches
f(flSion or muscle contraction he.1daches, the most
rommon type of headaches, are characterl/-ed by moder-
att, nonthrobbing pain distributed in the head, neck,
and 5CJlp with tightness and pressure-like pain. Tension
headache may occur wi1h migraines. l'recipi1a1ing factors
aresircss and eye strain. AJl acu te a11.1ck is treated with
combination medica iions such as but11//1itnl (Fiorinal or
norrcet) and muscle relaxants such as cydobenzaprirre
(lltxenl) (see Table 29-9). Amitriptylirre (Elavil), a tricy-
dic antidepressant. is the drug of cl1oicc for prophylaxis.
Possible causes of headaches such as eye diseases. sinus
1!tl. or 1nfect1ons should be ident1f1ed and treated. Patients
tr\i1f be able to find ways to avoid, control, 01 eliminate the
faL101s tha1precipitate headaches
1 Resting to a quiet. dark room for 2 to 3 hours after taking
medcatlons will usually ease headache pain.
J Medications for headaches should be taken at the onset
of symptoms unless prophylactic therapy is prescribed f()(
f)iltietits with frequent m1graone headaches
DRUGS FOR SPASTICITY
Loss of dexterity. spasm, and incr<1scd muscle tone d 1ar-
ac1erize s11~tlcity, as found with mu lt iple sclerosis ?r
mu!Cular dystrophy. Spas1ici1y is a phenomenon 111
wh1Ch uncoordinated movement< .ire caused by CNS
O\'mllmulation rr.1uma 10 the'""'" I cord or stroke may
llO uuw muscle spasms. Drugs .rnd physical therapy
re trtatments of choice. Muscle rd.1Aants are not effec-
h\'e in ueaung spasticity. Bacloftrr (Uores:ill is used 10
l!tlucupa~ticity cau>ed by multiple sclerosis. spmal cord
545
Muscle spasticrty of CNS ongm alcohol, msuhn
calcium channel blockers.
alcohol, estrogens
in1ury, and cerebral palsy but not by strokes. h decreases
nexor and extensor muscle spasm. rlucing spasticity
discomforL If medication is stopped, withdrawal should
be accomplish! slowly over I 10 2 weeks. Diaupam
(Valium) has simi lar aaions but docs 1101 affect skeletal
muscles directly. Da111role11e (l)antrium) is related 10
pheny1oin and direnly relaxes skeletal muscles by i1uer-
fering with release of calcium, thus decreasing the skel
e1al muscles' ability to contract tnis mlicine is used
with multiple sclerosis. cerebral palsy, and spinal cord
injuries The medication may take as long as 45 days 10
dt'>-elop effectiveness. Unfonunately, Dantrium causes
dow-rclatl liver toxicity (Table 29 10)
CENTRAL NERVOUS
SYSTEM STIMULANTS
me CNS processes infonnation to and from the l'NS and
i~ the coordination control center for the entire body.
Stimulants increase CNS neuron aalvity. \1any medica-
tions stimulate the C.'IS, but their therapeutic usefulness
is limited by side effeas. Chronic use and misuse may
occttr, leading 10 drug 1olerance. drug dependence. and
dntg misuse or abuse.
CNS stimulanl<, also called analeptks, are used to
fogh1 fatigue. alleviate mild 1iain, .mcl counteract side
efferu of depressing medications 10 relieve respiratol)'
distress (ee Chapter 25). 111e most common analcptic
is caffeine, found in many foods, drinks. and drugs such
as l:Xccdrin. Anacin, and arc decongestants. Caffeine. a
stimulant that gh'l'S a quick picker-upper, may produce
habituation and psychologic dependence causing with-
drawal signs such as headaches, irritation, nervousness.
anxiety, and dizziness on abn1pt discon1inua1ion. Caf-
feine shou ld be used with care during pregnancy because
it crosses the placenta to the fetus and is passed from
mot her to d1ild in breast milk.
Olocolate oontans caffeone with theollromtne that are CNS stimu-
lates Large amotlllS of chocolate ngestion may cause selZIJleS
and can be lethal Chocolate truly IS a quttl: pd:er'\JllPllf.
 546 SECTION V Med1ca11ons Related to Body Systems
CNS sumulant.s, uch a' ampheumines. have been
prescribed for exogenous obe<.ny, but this use is consid-
ered obsolete and dangerous These mt>dic.-.tions depress
appetite by stimulating the cerebral conex to produce
euphoria and wakefulness. but tolerance usually occurs
wnhin 2 weeks-less ume th.1n required to achieve the
weight reduction goal Because or the high abuse poten-
ual and dange:rs of addiction. amphet.1mines are dassi -
fied DEA Schedule JI drugs 'lheir many side effects
cJuse these drugs to have liu le use. llicse medkations
should be avoided in patient~ with hyp;?rthyroidism,
hypenension, glaucoma, a histo1y or drug abus" and
swere aneriosderosis (1~1bl e 29- 11)
Anorexiants, used (or shon-tenn I real mel1l ofobesity,
suppress appetite by directly stimulating the satiety
center or the hypothalamus Some agents work on sym
p.1thetk nervous system pathwa}">. whereas others
work with adrenergic and dopamine pathways. These
Schedule II through Schedule IV agenlS have a high
potential for abuse. Cauuon must be used when anorexi
.tnlS are prescribed for people wnh hypene11s1on, cardiac
disease. and a history of seizures (see Chapter 24 and
lable 29- t I for further informauon on anorexiants).
Stimulants are al:;o u~d (or nucolepsy, catapll'Jt)',
sleep apnea, shift work sleep disorders, and auditory
or vt.ual hal lucinations at sleep onset and 10 control
daytime drowsiness and excessive sleep pauems. Stimu-
lation results in an increase in 11101or function and
mental alermess and a decre,1se in sense ()(fatigue and
produce a euphoric state (see Thblc 29 ll ).
Psychomotor stimulants also haw uses similar to
those of CNS stimulants in inhibition of impulsive
behaviors associated with anention.<feficit disorder
(ADD) and auention-deficn/ hyperactivity disorder
(ADHD). These medications ar~ beliewd to activate por
lions of the CNS that inhibit 1mpulm-e behavion. (see
1Jble 29-11 and Chapter 30).
Individuals taking central nervous system (CNS} st1mulants
should be aware of dangers of abuse and dependence.
Abrupt withdrawal may result n depress100. 1rntab1hty.
fatogue, ag11at100, and disturbed sleep
2 CNS suroolants shoold be taken early m the day to prevent
tnsc:xrwua
3 CMdim t.aiong CNS Sllmulants should be observed for
t1CS. gasmc do.stlllbances. wequ loss neiwusness. and
msoointa
4 Other stimulants such as catfeme and chocolate should be
a'V01ded when taking prascribed CNS stimulants
Important Fac ts .at>out Centra l Ne.Vous
[ System (CNS) Stimulants ....
Amphetamines produce most of the11 effect by re1easaa;i
ep1nephnne from neurons m CNS and its per1Jlheri
Amphetamines increase wakefulness and a~
fatigue. elev.lie mood. stimulate resporat1ons. and
appellte
The principal 1nd1cauons for amphetamines are ane..
defic1t/hyperncuv1ty disorder (AOHO} and narco ePSY
AUTONOMIC NERVOUS
SYSTEM DRUGS
The ANS can be thought of as a self-governing. an ill\IJ~
umary, or an automatic nervous system. Persons lu.'t
control owr ANS, which is divided into sympathnic >tld
parasympathetic divisions. These systems keqi intm~
body organs in homeostasis or at their highest ltwl ar
function to control ~mooth muscle. cardiac musde. ~nd
glandu lar secretions (Figure 29-6).
Parasympathetic and ~ympatheLic systems simultane-
ously innervate many oft he same organs, opposingeich
o ther to ba lann innervations or p rovide negative foed
back (Figure 29 7 ) . The parasympat hetic syste111 has the
primary function t)f i-onservi ng energy and restoring
body resources ror rest and digestion. or "feed-0r-brool'
responses. I he sympathetic system mobilizes dun~
emergency or stress situations, or fight-or-flight" action
lliese responses raise energy expenditures and increa
body functions for response to eneigy ttquim"ltlll>
while decreasing digesth't' functions.
Medications affecting the ANS may mimic, imtruili-
or block effectS or the sympathetic or par.uymp;11bmc
divisions. Cholincrgic med ications mimic the pUil!)M-
pathetic system and so are called parasytnparhamtrtttr
drugs. Amicholincrgic or dlolinergic blocking agenu
also ca lled p11riisy111pt11/rol1rics, block transmissions of1ht
parasympathet ic nervous system. Adrenergic drugs. or
sympathomimetic .1gcnts, act 10 facilitate anions o(
Autonomoc N&NOUS System
Parasympa1hetlCICt10l!nergic
(Acetytchohne)
Figure 296 Oovisoons ol the autooom1c nervous system and the rti.tld
neurotransmitters
 CHAPTER 2!> Drugs for Neurologic System Disorders 547

TABLE 29 11 CENTRAL NERVOUS SYSTEM STIMULANTS

GENERIC NAME/
TRADE NAME USUAL ADULT DOSE, INDICATIONS
!SCHEDULE) ROUTE, AND FREQUENCY FOR USE DRUG INTERACTIONS
ca'Wne INoDoz (OTC). IOQ.200 mg PO q34h P!omoie mental ftuornqu nolone antibiotics,
v;,ann [OTCL
alertness. decrease filJCOllalOle
Caffedme (OTCll respualllly depniss1on
11.;ot Sift EJrecrs:
1$0IMl3. nef\'Ollsness. trefllOfS

AMPHETAMINES
ntetamire and 530 mg PO bod Narcolepsy, ADO. antaeods. MAOls,
deltl0a~tam1ne obeSlty gua<1ethid ne. caril ac
iAdderall) Ill) glyooS1deS, beta blocket5
dexl!Oarretam1ne 5-20 mg PO Qdttd Same as for MAOls. antaods.
1Dexe00nel till amphetamine anudefi'essan1s
inethylpllemdate 1060 mg PO daily on 23 d1Vided ADD. narcolepsy MAOls. tncycltc.
1R11al nl(llJ doses antidepressants.
vasopreSSOls
methampheta mme 2025 mg PO/day in 2 d1v1ded AOHO and obesJty same as 10< amphetamine
tDesoxyn) 1111 doses

M1jor Side Effects of Ampheramines:

amphetaminir rnsomnia. weight loss. restlessness. euphoria, irritability. visual disturbances. excessive sweating,
div mouth, nausea and vomiting, anorexia, tachycardia, chest pain. impotence; dex1roamphe1amine-oncreased inorab1hty.
neM>usness. insomnia. headaches. nausea and vomiting. sweating, tachycardia

CENTRALNERVOUS Exogenous obesity

SYSTEMSTIMULANTS
USED AS
ANOREXIANTS
Jtientenn1ne (Ad1pexPI 15-37 5 mg PO qd None
IV)
bEnzjiletam1ne 25-50 mg PO ud Nooe
IOodreJrl llVl
jilendimeu~ine 17 5-35 mg PO b1dttd. 0< None
l!cJTU1 l(IV) 105 mg extended release qd

OlliEll CNS STIMULANTS

rmfn (Pru.ig11) IM 200 mg PO qd Narcolepsy. sleep apnea Oral contracepuves.
~
a:nodafild (NUV1g11) (IV) 150250 mg PO qd Narcolepsy. sleep apnea

lajot Side Effects of CNS Srimu/1nrs: .

iaeased 1mtablhty. eupllona. neovousncss. insomnia, headache. nausea and 'IOITl1t1ng, sweating. tachycardia
ADO. Al"cenoor>defocrt disordci. ADHD. aurntion oofici!/hyperactM!y disorder. CNS. central nervous system. MAOf. rnonoam1ne oxodase 1nll1b1tor. PO. orally
 548 SECTIONV Med1cet1ons Related to Body Systems

-Paruympett>ehc
-SympalhetJC Terminal lia Constrict

frlCl'ease saliva
Decrease salfva

Dilate bfonchioleS
increase hear1 rate

Secrete a<lrenab,,.

Release glucose in lrve

Decrease digeslion

Iner....,
lnteetonal ectMty
Oectease intestinaf achVt

Sympalhetlc
Close sphincters of chain
bladder and colon ganglia

Co11a1em1
ganglia

Figure 29-7 Comparison of !he sympathetic and parasympa1he1ic nervous sys1cms

1he sympa1hc1 ic nervous system. Adrenergic blockers, o r
sympa1holytic drugs, block sympathetic responses. Ter-
minology for substances active on the ANS is su mma-
ri1ed in llox 29 -4.
121 LEARNING TIP
M1me11c means 10 1m1tate or mlfllrc. so parasympathcmtmetic
means 10 m1mrc parasympathetic neMJUS system. or acetylcholine
IAChl atllOfl Sympat/lomllnetJc means to m1m1c sympathetrc
neMlUS system transm1nl!fs such as norepmephnne and epineph-
rine Lys1s means to reheve or reduce action of; lyric comes from
the tetm /ysts. so para~tholytrcs act as cholinesterase to
decrease ACh ac11on Sympathofytics are used to block the sympa-
thetic nef'IOUS system. they are also called adronergic blockers
Cholinergic or Parasympathomimetic
Medications
nie 1>arnsympa1he1ic nerve fibers liberate ACh as tbe
facilim1or 10 1ransrni1 nerve impulses in bo1h phases of
the ANS. Cholinergk or parasympatho rnimetic agents,
also called muscarin ic agon is ts, are obtained from plant
or syn thetic source hec,1usc n,uural ACh's duration b
100 shon 10 be pharmacologically effocti,e. SymhtUc
medications are more stable, being subdivided into c..o
groups: direct-acting and indirecl-aCling dni&' Dir!
acting medications such as bt 1ha11tchol (Uredlohnt)
auach 10 recep10,... to mimic or increase /ICh lndmct
acting medications such a' neoj ligmine (Pros11gm1n]
inhibit 1he enryme ace1ylcholincs1erasc or duml) ~low
ACh to accumulate a1 receptor si 1es.
Cholinergic medical ions ( parasymp<nhomimtllC
agents} produce actions similar 10 1hose of /101 .indMf
used in condition. tha1 require (1) stimulJUng !ht
intestines 10 increase pcri.ialsis or the bL!Jda ID
increase urination, (2) lowering in1raocula1 p<o<att
with glaucoma bccau~ of ophthalmic m1ouc mpon-e
(3) increasingsaliv.uion and swca11 ng. and {4) mm~
effects of curare-like mcdica1ions used for rel.u.iuon
during anesthesia. These mcclica1ions are comrimJ1
ca1ed. in ben ign pros1a1ic hypcnrophy, gas1ric ulcm.
mtesunal obstn1C1ions, asthma, and cardiac d1sor.kn
(Table 29-12).
Som e p hysicfa ns use cho lincrgic agent> or imyloid
blocke rs Lo increase the br.1in's ACh lewis .11 nem~5)11-
apses for trea1ing Alzhei rrwr d isease. Memory Ins\
 --~---~-.::C~HAPT~ER 29 Drugs for Neurolog1c System Disorders 549

DIAECTACTING MEDICATIONS
IC81\'lcholine tsee Chapter
21 fOf ophthalmic
prepaia11onsJ
~tllanechOI (Urecholine. 1().50 mg PO lld-qid
(M<Jidl Urinary retent10n ambenonotrn. neos19111ne
atropine quonidine.
proca namide.
epmephnne
cevimchne {Evoxac) 30 mg PO lid Xerostornl.1 Beta blockers.
antihistamines. 111cycloc
anudepressants.
pheooth&azine:i
Ml/or Sido Effects of DirectAcfing Medicat/oni:
Nausea and vomiting. diarrhea. r~uscle cramps, muscle weakness. slowing of heart, hypotensioo, resp1raiory depression,
bronchospasm. flushing, sweating, excessive saliva, tearing

fHDIRECTACTING MEDICATIONS
~ Cll<l!Jter 21 fOf
C!ll>thalmic preparauonsJ
ambenonium (MytelascJ 5.75 mg PO t1dqid Myastl1ema grav1s uic11ne
edrQIOOn1um (EnlonJ 12 mg IM, IV, followed by Testing for mvastherna gravis procamam1de and tacrine
antichohnesterase PO
1 hr later
15-375 mg PO. IM in Also used w1tl1 treaiment of succ1ny1cllol1ne. same as
divided doses myasthema grav1s f(){ bethanechol
I.I( IMramuscularly; JV. m11avenously; PO, 01ally; SC. subcutaneously.

demenm. and dctcrior.1tion of mental funetion are
thought to occur be;ausc of lack of ACh in synapses. Use
of th(>w medications in Alzheimer dise.1se is discussed
in Chapter JO.
Malathion. an insecticide. acts as a cholinerg1c agenl on insecls
Ant icholinergic or Parasympatholytic
Medi cations
Cholinergic blocking ;igcnts such as /1yoscyam lr1e
(1.n~m) and uopolam in~ are referred 10 as a11ticholi11,.,..
&kJ 01 p.m1.1)'171p<t1/Jol111t ".~ems or 11111Slln111c anra.~0111sts.
These medica1ions do not allow adequa1e ACh to bind
to receptor sites, prevemingACh ac1ion-1he opposite of
the effe<"l found with cho lincrgic agents. n1ese drugs
r.ause mydriasis (dilation) of 1he eye pupil; drying of the
mouth, nose, throat. and brondiial secretions; decreased
secretions and motili1y in the gasuoimes1inaf 1ract;
increa<ed hean rate; and decreased sweating. Medica-
tions used arc (I) antispasmodic and antisecretory agents
in the gasirointestinal and genitourinary 1rncts, (2) neu-
romuscular blo.-kers with spastic disorders. ('l} antidotes
for insecticide and mushroom poisoning. (4) for emer
gency care for bradycardia and auiO\."muicular hean
block, (5) for dilation of pupils, and (6) for prewntion
and Lreatmcnt of bronchospasm. Contraindications are
ch ro nic obsiructive pulmonary disease (COPD), .1sthma,
closed-angle glauroma, gastrointestinal and geni1ouri
nary obstruction. cardiac arrhythmias, hypenension,
hypothyroidism, and liver and renal disease (Table
29-13).
550 SECTION V Med1cauons Related to Body Systems

TABLI 79 t3 ANTICHOLINERGIC IPARASYMPATHOLYTIC) AGENTS"

GENERIC NAME/ USUAL ADULT DOSE. DRUG INTERACTIONS

TRADE NAME ROUTl AND FREQUENCY INDICATIONS FOR USE

"
......
If ;
I *f I ' t Bradycard1a, GI and GU
hypermot1hty. preoperat1vely
amantad1ne. Qu nid1ne,
d1sopyram1de. levodopa,
to decrease secrettOOS proca1namide
Peptic ulcers. imtable bowel None
0 125-0 2S mg l'O q4h. IM,
syndrome. vemgo. enuresis.
SC. Sl
partinsornsm. urinary uact
spasms
Motion sickness None
scopobmine 1 patch iransderma ly q72h
(11ansdeml-Sccp]
lrntable bowel syndrome, amantad1ne. lewdopa, bcitfic
dqtlomioo IBentyl,
Anlispas) infant colic. antispasmodic ant1depressan1s. MAOls. H
anuh1s1am1nes. phenot~
ketoconazole

M101 Sid Eff.ctJ: a1rop1,__flush1ng. blurred v1s1on. dry mouth. constipation. urinary retention, headaches. conlus1on. lacliycria
61. Gasuomtest1oal. Gt/ gen1tounnJry; tM, intramuscularly; MAO/, moooamine wodase inh1b1tor, PO, orally; SC. subcutaneously; SI. subl1ngually
see Chapter 21 for ophthalmic uses and Chaplet 27 for unoal'( tract uses.

Belladonna alkaloids, oflen used as anticholinergic agents, are
foond 1n OTC prcpa1a11ons and 1n many common plants and
111-0diblc berries, caus111g danger for young children and pets.
OTC preparauons arn used for mfant colic. gastrointestinal
spasms. and diarrhea
~etion 'for Compliance
Patients taking chohnerg1c med1cat1ons or those exposed to
1nsectic1des such as mala1h1on should report such symptoms
as decreased heart rale. decreased respuaoons. gastromtes
1111al d1Slless, and excessive pe!Splralton 10 a physician.
2 Cholmetgic mOOICallOllS should nol be comboned wrth heart
medications Cf ant1bio1tcs
3 MedicAlell iags should be worn when using chohnergic
medtcatlOllS
4 Per100S taking chohnerg1c blodwrs should practJce f~nt
mouth care and good dental hygiene
5 flue such as water should be available "tlen taking chol111-
ergic blod<e~ 10 combat dry mouih effects. Chl!Wlng gum
and hard cardy may be useful
6 Report rapod heart rale Cf palpi1at1ons and blurred Y1S1on
wllen raking anuchol111erg1cs
7 Avoid oral antichohnerg1cs with chronic obstructive ptJlmo
nary disease !COPOJ or aslhma and use only prescribed ml\al
ants. No OTC products should be used
8. An11chohnerg1cs may cause pho1ophob1a. so sunglasses
outside and reduced light indoors may be necessary
' l
Cholinergic medications. or parasympa1hom1met1cs mime
ACh effects and act either directly on chohnergic recc o~
or indirettly by mh1b11ing cholinesterase achoo
Cholinergic medicauons sumulaie penstals1s and uona
lower intraocular pressure with glaucoma, ard 1rea1 11'\11-
thenia gravis by innervating skeletal muscles. much as AQi
does.
Cholinerg1c blocking agents (parasympatllolywl do i.x
allow binding of ACh at receptor sites. Consequen:fy
medications produce mydnas1s. drying of secra:
decreased moulrty of gastro1mes11nal 11ac1. and
heart rate.
Chohnerg1c blocking agents. especially al/Qplne.11e a
antispasnnodtCS and anuseaetory agen1s and as ;,il4J!es b
msect1cide potsoning
Adrenergi c Agonists or
Sympathomimetic Drugs
The sympathetic nervous system is considerl'<i tht en><I
gency.system 10 mobilize the body for a quick rcspon<t
to fngh tening si1uations-"figh1-or-Oight" rnpo"
Blood pressure, pulse, and respirations increase; pciirh
era! blood vessels constrict to allow nowofbloo<l 1011ul
organs; pupi ls dilate; and bronchioles dilate to iupph
more oxygen. Adrenergic Agonis1s have a broad spUUm
 ___ CHAPTER 29 Drugs for Neurolog1c System Disorders
BOX 1'l 5 USES OF SYMPATHOMIMETICS
sriia1horrllmet1cs are used to restore cardiac rhythm and
e1.,.,ate blood pressure m shock and emergency situatiOllS.
In the medical office. adrenerg1c agoms1s may be used
10
constrict capillaries to control bleeding from nosebleeds or
10 allev1a1e nasal congestion.
Add1t1on or these agents to local anesthetics to control
bleed ng is commonly found in medical and dental practice.
Epine!fi1ne type medications are used to dilate bronchioles
a$11VT1a attacks, bronchospasm, or with anaphytacllc
I tOllS
, YI"<" 1agents are used on lacerations found m penfiieral
t su tS such as nose, fingers. or toes. tissue necrosis may
occur
Because of side effects. adrenerg1cs should be used with
ext1eme caution in patients with angma. coronary insufficien
c1es, hypenension. cardiac arrhythmias. angle-closure gfau-
cana. 01gamc brain damage, and hypenhyro1dism.
o( clinical appliG11ions in many specialty areas from
obstetrics 10 cardiovascular medicine.
Medirations found wiLhin the 111/mrergic >')'lnpathomi
merii 11go11ist o r classification n1c c;:nech<Jlamines and
noncatecholamines. 111e catcchola1nines such as epi-
ntjJhrl11e (adrenalin) and tlop11111/11e ( levodopa), found
naturally, are M'creted at ner"c term inals. Epinephrine is
found tn lhe adrenal medulla, whereas dopamine is
from sites in the brain, kidneys. ,md gastrointEStinal
tnct. These agents are available synthetically lo produce
~ samt effects as naturally secreted neurotransmitters
(Box 295). Noncatecholamines including e phedrine
and phenylepltrine (Sudafed) have actions somewhat
similar 10 those of catecholamines, being more selective
ofreceptorsitcs and having a longer dur.u ion but slower
anions f lab le 29-14 ).
Adrenergic Blocking Agents
or Sympatholytic Drugs_ _ _ _ __ _
Adrcnergic blockers are composed of two grou~
alpha and beta-adrenergic blocking Jgeuts-dependtng
on the blocked receptors. These .1gcnts plug or block
receptors, preventing o thc1 agents fro m stimul?Ling .h.e
rccep10r sites. 11ie alpha blockers suth as prazo.~111 (M.nt
press) and 14!1'azosin (1 lytrin) rm:vcnt norepmephnnc
from producing a sympathetic rcsponC. 11le maior
dTtttS of alpha blockade are lowering of blood pressure
and isodilation (amih)'pcnen;1vc effect!> of alpha
blcxkm arc disctJssed in Chapter 26) 11wse agenLS are
al<o used to treat peripheral vaS<ulM conditions such as
Ray1m1d di>case and to di,1gnow phco<hromocytoma, 3
551
tumor or lhe adrenal medulla (I able 29-15). See chapter
1able1 related to use in specific body systems.
Beta-Adrenergic Receptor Blockers
(Beta Blockers)
Hern b lockers, such as 111e1oprolol (Lopressor) and
1111110/ol (Corgard), bind 10 bctaadrenergic receptors,
~peci,llly in lhe hean. Clinical use of beta blockers is 10
decrease cardiac activity-hean rate. force of cardiac con-
tractions, and impulse conductton Reduction in hean
\\Ork causes a drease in oxygen need llause clinical
beta blockers h<n-e cardi<><'aSCUlar action. these agents are
discussed in Chapter 26 Another use for beta blockers
is for migraine headaches and prophylactically for ncu-
rologic conditions as discussed earlier in this chapter
(see Table 29 I5).
IL] LEARNING TIP
Many beta blockers have names that end 1n o1o1; and seveial of
the alfiia blockers have names that end in os111
Adrenergic medicauons may produce anorexia. Orets high
1n carbohydrates and proteans and low an fats wadi small
meals are better tolerated
2 Because 1nsornn.a and ner.ousness accompany adrenergte
medteat1ons. caffe1na1ed producu should be avOOed. espe
caalty after soo PM AlternatMl sleep aids such as relax-
auon teclvt1ques may be med to reduce insomnia
3 Patients taking beta-adrenerg1c blocke1s should be aware
or possible posrural hypotons1on and should use care when
changing post11ons.
4 Pulse should be taken 10 assess br&dycard1a that occurs
w11h adrenergic blockers
5 Alcohol. antihistamrnes, muscle relaJ<ants. tranquilizers
and sedall\leS may potenua1e CNS dep'ess10rt and sedation
that oa:urs wim adrene<g c blockers
6 Sexual dysfunc11cn may result with beta blockers. neces
st1altng dosage regu1a11on or medication change
7 Beta blockers may increase serum ltp1d 18'/els. these levels
should be tested on regular basis with prolonged therapy
8. Patients with diabetes should watch glucose levels for
hypoglycemia when taking beta-adrenergic blockers
because these med1ca11ons reduce blood glucose levels
9 Beta blockers may cause headaches. mental confusion.
and n1ghLmares. which should be repotted to health
profeSStOnal
1O Wealcness. faogue. dimness. and sedaoon are common
side effects of beta blockers
552 SECTION V Med1caoons Related to Body Systems

TABLE 29 14 ADRENERGIC AGONISTS ISYMPATHOMIMETIC AGENTS)

GENERIC NAME/
TRADE NAME
USUAL ADULT OOSE.
ROUTE. AND FREOUENCY INDICATIONS FOR USE DRUG INTERACTIONS I
ALPHAAORENERGIC AGONISTS MAOls, tncyclic
llronchospasm. asthma.
epoflelllv>/18 !Adrenahn. O001 If. as topical hemostatic anudepressants.
anaphytax1s, cardiac arrest.
Pnmatene: Bronka1d 1 with local anestheucs anesthetics. ooia bloc!
Inhalation O3.0 5 ml 1% IM elevate BP. prolong local
anesthesia sympathomimet1cs

ln1ec1 as needed for allergies Anaphylaxis prevention

Ep1-Pen
ephednne IEfedronl
IPreu-0 and others!
methoxam ne (Vasoxyll
noreponephme (levophedl
plelylepvine(Neo-
Synei:ilfone.'
Sonex.
Sma1est Nasal, Neo-
svneinone J
INeo-Synephnne gelJ
pseudoephedrme ISudafed.
Novafed. PediaCare, others')
Bronchodilators. nasal Same as epmephrine illld
25-50 mg PO qd-qid norepinepllrine
decongestion. increase BP.
12.550 mg IM, IV. SC
ep1stax1s, myasthema
24 dtops or sm<1ll amount of gel grav1s. urinary 1nconunence
in nosttol
Same as metaraminol Same as ephednne
5-20mg IM
8-12 mcg/mon IV Same as metaram1nol Same as ephednne
Increase BP. nasal Same as ephednne
HO mg IV
decongestant,
10mg PO vasocoostnctton. mydnasis
2 or 3 drops of sp<ay in
nostnl--0 25-0 5% solution
Small amount into each nostril
60 mg PO q46h Nasal decongestant Other sympathomrmetics,
MAOls, oota blockeis

Major Side Effects of A/pha-Adrtnerg/c Agonlsts:

Palp11a11ons, tachycardia. neMJusness. tremors. cardiac arrhythmias, angmal pain, hypertension, hyperglycemia. headaches.
insomnia; irritation of nasal sinuses end eyes when used as decongestants

BETAADRENERGIC AGONISTS
eponephnne (see under Bronchodilator
Alpha-Adrenetgic Agon1stsJ
albuterot t!'rv<erml VemolonJ 2-4 mg PO q6-8h Bronchodilator epmephnne. MAOls. ;qdt
1 or 2 1nhalat1ons q4-6h pm anlldepressants. beta
blocicers
1SOjlCOtereooJ ltsuprel) 0 02.Q 06 mg ri/ Also used as cardiac Same as for alooterol
O15-02 mg SC stimulator
1015 mg SL
metaproterenol 2 01 3 111halatmns Bronchodilator Same as for alooterol
20 mg PO tid-qid
terbutalme IBrethine. Bretha1re) 2 5-5 mg PO tid Also used as muscle relaxant Same as for alooteml
0.25mg SC 1n premature labor
salmeterol ISerevent) 2 inhafa11ons bid Bronchodilator beta blockers
Prevent exercise-induced
bronchospasm
dopamine llntllllJinl IV based on body weight Vasopressor for shock Same as for albliterOI
BP. Blood pressura IM. onuamusailarty, N inuavenousty MAOl m<mlllWlB oxJdase mhihtor PO. orally. SC. subcuraneoosly: st ~
01c medlta!IOO.
'PreSCJ ptJOn r!QU~ed
Note: See Oiapter 21 for opimatmic uses of these medications
 CHAPTER 2? Drugs for Neurolog1c System Disorders 553

AU'HA BLOCKERS
d.;.l4llJSln (Cardura) 116mgPOQd Bemgn prosta~c hypertlOIJhy. ACE .nhibitors. iOOomethaon.
1carc1u1a XU 18 mg PO Qd hypertension ve<apamd. nofed pme
ft91t.llalrune IRegrtooe) 25 mg IM. IV Penpheral vascular disease Same ~ tor do.azosin
~ 1M101pressl 1 SmgPOqd Hypenens1on ACE mh bilOO. NSAJDs.
'1!1apalllll. beta blotlters
tera!OS'n (Hytnn) 1-20 mg PO Qd Hypertensoon ACE inhibitors. NSAJOs.
prooranolol
1'qx Sile E/fects of Alpha Blockel'$:
MlostS. nasal congestion. increased GI acuv1ty. tachycardia. onhostat1c hypotens1on, fainting

BETA BLOCKERS
!a!Jetalol (Normodyne)
nadolol (Corgard)
porodolol (V1sken)
~anolol (lndeial)
tJIOOlol (T1mopt1c)
~bulolol (Sectral)
a:endol ITenormrn)
~IZebetaJ
meqrolol tartrato
lllJPlessor)
lft!toprolol succ1nate
flropol Xll
100-400 mg PO bod Hypertension and angina c1meud1ne, NSAIDs.
pectons epmephnne
80 240 mg PO qd bid adenosme. ampicrlhn. antacids.
calcium channel blockers.
clonodine. lidocame.
neostigmme. NSAIDs.
prazosin. tacrine. vcrapam1I
15-40 mg PO/day in Hypertension Same as nadolol and multiple
3-4 d1v1ded doses others
160-480 mg PO IV/day Also used with angina NSAIDs. antrdiabetic agents,
in 23 divided doses pectoris, an11ythmias. barb1t1Jrates. calcium
migraines channel blockers, d1goxm.
epinephrine
10-60 mg PO bod, Hypertension diuretics. NSAIDs
ophthalmic as Glaucoma
directed
200-000 mg PO qd bid Hypertension. ventricular amp<crlhn, antacids. klc<rl
arrhythmias anestbellcs. d1goxon.
epinepllnne. NSAJDs
25-100 mg PO qd Hypertension, angina neurolepbcs (see hterature for
pectoris othersl
25-lOmgPOqd Hypertension Same as for acetiutolol and
atenolol
loo.450 mg PO ud Hypertension. angina Same as for acebutolol and
pectoos. myocardial aieoolol
mlarc!lon
25-100 mg PO qd

Major Side Effects of Bot Blockers:

ltr'po1ens1on. bradytardia. fatigue. lethargy. nausea and vomi1ing. hypoglycemia, confusioo
AC( Angiotenson-convorting enl'/mo. GI, gasuoimostinal. IM. m11amusculally, N. intravenously: NSA!Ds. nonst~oodal antionflammatory drugs, PO. orally
NDIB' Please see appropriate chaprnrs by body system for more 1nforma11on on alpha and beta blockers including: Chapter 21. Ophthatmo<: Prepa1a11ons.
CMiite 26. Cardovascular Con<11t1ons: and Chnptor 27. U11nnry Tract Cond111ons.
554 SECTION V Medications Related to Body Systems
'
Adreoorgoc agorusts s~pathomimetocs are c ass1fied as
catedlolammes or noncatedlolam nes 10 m mic fight-or
ft t" ICtlOllS oc:curnng w th sympathttic neMlOS system
1 lation Natora ty OC<Ufring adrene<gic agomsts are eJM
. inne narepmcjilr111e and dopamine
. ;iathormnew Biil useo ID restore cardiac rflythm.
.aie blood pressuie and control bleed.rig by vaso-
;tntUOn
Epinephnne rs added to loca anesthetics for vasocoristr octlOll
ID proloog anesthesia effects
r pathomimetics ere used IOI mydnasis n oplllha mology
A . ia-adrenergic blotless or s-,mpatholytoc agents. are
d ID reduce hyl)CftenslOfl and for benign prostatoc
t.y..,rtroCihv
Ma or ed\<erse effects ol a plia blockers are orthostat1c
hypoteos1on. nosal congestion, tachy'Cilrd1a. and sexual
dyfuncllOn
The firs1 dose of alplia blocker may cause ramung because
of orthos1at1c hypotens1on called "firstdose effect
Bet1 blockers ha'lll many drug interactions mat should be
cl1ecked before any othe1 med1cauons are added OTC non-
s1ero1dal an111nflammatory drugs (NSAIOs) have strong in1er
acuons with be1a blockers
Pl1nc1pal md1cat1011s ror beta blockers-hypertension, angina
pec1oris, and dysrhy1hm1as from tachycardia {see Chapter
26kause postural hypo1cns1on.
Beta blockers must be used with caution in patients w11h
chronic obstrucuve pulmonary disease {COPD) and asthma
because ol lxonchoconstnct1on
Beta blockers reduce conversion of glycogen to glucose 1n
hver or muscles 10 reduce blood glucose levels-a problem
for people with d1abe1es
Beta blorkers are adm1n1stered once or twice a day and
c;;nnot be discontinued alxuptly
DRUGS SPECIFIC FOR
STROKE PREVENTION
AnliplJtelet medication> (Stt Chapter 26) are indicated
in the prevention of arterial thrombi and are used in
cerebral thrombi or stroke prevention. Aspirin is used
for prophylaxis of thrombi. as is tlipyridanwle (Persan
tine), by preventing platelet aggregiltion. A combination
product of aspirirr 25 mg and tlipyritlamole 200 mg
{Aggrcnox) is used for prevention of recurrent strokes in
people who have experienced transient ischemic attacks
or who have had ischemic anacks from thrombosis.
Combi ned agents reduce stroke risk by a greater margin
than either agent used alone but may rau>e headarh.i
as a side effeet.
SUMMARY
The nervous sysrem is composed of two divisions th.
CNS (the brain and spinal cord) and the l'NS (nmu
outside the CNS). The ANS, composed of S)'Dl~tht,>C
and parasympathetic nervous systems. conuob bod,.
funetions wirhout specific conscious effon by tht
viduaJ. fhe CNS receives infonnation from periphml
nerves for interpretation and then returns stimuh to tbt
peripheral system for response. The ANS has ~
fight-or-flight responses or feed-or-breed funa.-.
needed for maintenance of homeostasis Med1ar01
are used to assist with functions of these S)'Stenis ~lit.II
secretions responding to stimuli are either 100 $pal'lt ..
too great.
Analgesics are used for pain, a worldwide hfahl
symp1om that disables and distresses people on ad.Ji~
basis. Important is the fact thm pain therapy should ii(
available to all people at a level needed for rtlid If
opioids or potem analgesics are used for prolonged
periods. abuse. misuse. and tolerance are possible. Shon
term pain relief until 1hc cause is treated does not cau~
1hese effects. Terminally ill persons should be given lo~
term methods of pa in relief and should be kept u paill
free as possible. Everyone has a right to be pai11 frtt.
Anesthetics arc used to in tcrfere with conduetion oC
nerve impulses to the CNS. General anesthesia is ulfd
in surgical procedures and may be give11IV0rbyinlula
Lion. Local or regional anesthesia is achil!\ed by topial
application or through infiltration of a selected ~110
Local anesthesia is used to render a body pan in1tn<itht
to pain. Additives such as epinephrine are includro "'th
local anesthetic agents to prolong effects and 10 c.aw
vasoconsuiaion to reduce bleeding. but these mtdlt!-
Lions may also cause nervousness. palpitations. .md
other stimulations to body funciions. lliese sidt tfftt11
are expected, but patients should be awart that that"'
a normal reaction
Benzodiaupines are commonly used to trtat irwt11
and insomnia. 1hese agents, bcc..1use of theu giata
effectiveness and safety, have replaced man)' of tht ~
Lives of the barbiturate family that were used in !ht fM>t
Ceriatric patients arc often persons needingmediullODt
therefore care should be taken because of their incfUl<lf
sensitivity lo medications, Shortacung medicatMllll
should be used in the elderly because of dtt~
metabolism and excretion abilities.
Refore medications arc prescribed for insomni.i. tht
cause should be considered .111d a1>propriate acuoro
taken to reduce th is factor. Medications prl'Seribed !or
i~somnia are habit forming when used for proloni:<J
li mes; therefore :1 lim ited prescription "ith dos-:

ro0nitoring o f use is recommended to reduce a risk.
Allltd health professionals should 1,1ke a comi)lcte
history toattempl to find the underlying cau,c of inom-
nia. possibly preventing medication need.
Seizures are symptoms showing disorgani1cd electric
impul~ in brain. Classification of sci,ures 1s by caus-
;iti\" factors and symptom, produced. Several drug
groups are used to treat seizur~barbiturates, hydamo.
ins. succinimides. benzodia7cpines. ,1nd some m1scclla-
11(()11$ medications. Th~ drug.s produce vJrious ide
df<CIS !hat necessitate lifestyle changes for the person
with epilepsy. P.atients must be taught the imponance
oi ulang medications as prl'\Crilx.>d and the ncce.it)
oi f<POning seizure activity that occurs while taking
medications.
Medications are used with diseases uch as parki n-on-
iw. RLS, and m)'3Sthenia gravis to treat typical progres-
sil'l' S)mptoms. Muscle spa,ucity, in,1bility to ambulate
safely. and tremors associated with lhC'C di'Ca'es arc
uuted to allow patients to func1ion as independently as
possible for as long as pos>ihlc.
With parkinsonism, the idc.11 b to co1rcct the d iease-
causing imbalance of dopamine Jnd ACh . Mcdica1ions
such as anticholinergics and .1111ihi>1a111incs arc used for
central effect, and medications th,11 inCl'casc dopami ne
IMls in the brain may be pre>rrihcd.
M)'35Lhenia gravis is a dcbi li tJting dis~asc character
iud by skeletal muscle we,1lmcss .111d fa1iiwc. 1 ~cat111e11t
is to control sympu.>m' u>ing medications 1ha1 inhibit
cholinesterase to provide the AC:h ncn"ary for muscle
con uaai Ii1y.
Medications that affect cholincrgic rcc('plor sites,
rttd-or-breed medicatiom .trc used 10 mimic, inten-
sify, or inhibit p.Hasymp.llhctic ncrvou' SY'lcm effects.
Scenario
Joseph, age 25 hes had three tomc-clomc seizures 1n the past month. Until now. he has been seizure
fr~ for 2 years.
h Id ask Joseph about taking his medications?
1 What questions shou h y~us not had the money to btJY his medicaMns for 2 weeks. Would this be
2 Joseph tells you t at e a h t?
important to tell thoe lphys1cf1oa~~:r:Y,~~nW,ri' ;:ars. What does Joseph need to know about mouth
3 Joseph has taken 1antin
and gum prophylactic care? Why?
CHAPTER 29 Drugs for Neurologic System Disorders 555
Medications that affect ACh rtteptOl"I a/feel smooth
muscle glands, and cardiac muscles that are essenti.ll
body functions. Choliaergic medications are used LO
stimulate the intestinal uact and urinary bladder, lo"er
intraocular pressure dilate peripheral blood \ti>els.
stimulate muscle contrac:tiluy, and promote sahv.nion
and sweating. Anticholinergic medications are used
to treat other illn~ that haw spa~ticity as a symp-
tom uch as irriiable bowel S)1ldrome and urinal)
disorders.
The sympathetic nervous S)'Stem, or adrenergic S)'Slem,
is responsible for !he bod>' "fight-or-flight" response.
\lcdications affecting alpha or betA receptors are used to
mimic the S)mpathetic nervous system (sympalhomi
metic or adrenergic drugs) with direct or indirect action
or both.
Other mcdications-adrenergic blockers or sympa-
thol)1ic drugs-block receptor sites and inhibit sympa
thetic response. Blocking agents are discussed in chapters
that cover the systems where the ~peciftc action occurs,
such as hypen.ensives in Chapter 26. Adrenergic blockers
(sympatholytics) may be alpha, beta, or alpha-beta
blockers and are used for treatment of hypenension a~
well as other conditions such as benign pro>t.nir hyper
trophy a nd glaucoma.
Epinephrine, an importa nt sympatho111ime1ic drug
th11t st imulates alpha and beta receptors, is used to kre1}
the body in homeostasis with treJtment of asthma, in
emergency conditions such as anaphylaxis and cardiac
emergencies, to achieve local hemost,1sis. and in treat
ment or open-angle glaucoma.
Norepinephrine is used for peripheral vascular con-
striction to raise both systolic and diastolic blood pres-
sure and for vasodilation to treat circulatory shock
556 SECTION V Med1cat1ons Related to Body Systems

DRUG CALCULATIONS
2. Order: Dilantin 60 mg PO
Order phenobarbual 97.S mg IM stat
Available medication:
A~.1ilable medicauon

CICm"'l't . . ........ 1 ... ICllC . .. OC7725

PHENOBARBITAL::.:-...=:.:
......"*'"'*-UIP .................. ~
-
=
I

130 1119'
-.........
~ ---
.... ., .. _ ,.. . I
........... , , , . . . . . .
=== I

=
........
'"FVL-
aaaow w-..
111
.......,,.,.
- .-. -----
- _. ~ '4"

-
....... - . - , - .....-c ........
.,.9'
.., ~

- Dose to be administered: - - - - - - - - -
Dose to be admimstered - -- - -- - -- - -
Show the amount to be administered on the syringe
shown

~~-c=:J1noc,~~.:;:;;.~'t:.~.~.:,~~.:.i111)~~===========:iO

REVIEW QUESTIONS
I. What is tlw blood,Jiruin barrier! Why is this impona nt in pharmacology? - - - - - - - - - - - - -

2. What are the two groups of local anesthetics? What are typical e)(amplcs of each? - - - - - - - - - - -

3. Wh)' is epinephrine added to local anesthetics? - - - -- - - - -- - - - - - - - - - - - -

4. What are the actions of barbiturates?--------------- - - - - - - - - - - - -

S I low do hydantoins (Oilantin) work for seizure control?----- - - - - - - - - - - - - - - -

6. What .ire the three pharmacologic categories used Lo treat Parkinson's disease? - - - - - - - - - - - -

7. What medication is used prophylactically for cluster headaches? - - - - - - - - - - - - - - - - -

 CHAPTER 29 Drugs for Neurologic System Disorders 557

s. \\lhat diseases with spasticity CM be trea ted with badofen? What medications are not effective m treating skeletal
muscle spasticity? - - - - - - - - - - - - - - - - -- - -- - - - - - - - - -- - - - -

9. llow do cholinergic medications work! Anticholinergics1 Adrenergicsl Adrenergic blockers!-- - - - - -

JO. Oiolinergics are used for what medical rnndilions1 What are their side effeasl - - - - - - - - - - - -

11 What are the side efTcct~ of a111icholincrgic agc1us? - - - - - -- - - - - - - -- - - - - - - -

12. Can anticholinergic mcd ica1io11s be bough t OTC? If so, which ones? - - - - -- - - - -- - - - - -
Drugs for Mental Health and
Behavioral Disorders

After slUdymg this chapter. you should be capable of domg the followmg
Descnblng mental health and deviations diagnosed
as mental illness
Identifying med1ca11ons used to treat anxiety.
Recognizing medications used to treat psychottc
diseases.
Identifying principal signs of depression and drugs
used as treatment.
Recognizing agents used as antimanics and
medications for bipolar disorder.
Describing behavioral disorders found in adults~
children and drugs indicated 1n treatment
Understanding role of medications in trea~ng
Alzheimer's disease.
Iden ti tying drugs for attention-deficit disorder and
attention-def1cil/hyperactivity disorder.
Providing patient education for compliance with
m edications used to treat conditions and diseases
of men tal health and behavioral disorders.

Mrs Jones. age 76, has become more and more disoriented and confused. Or. Merry has made a
tentative diagnosis of Alzheimer's disease. Betty. Mrs. Jones's daughter. wants Dr. Merry to give her
mother a medication to cure the disease
Is this possible? Explain your answer
If not, why are medications given for Alzheimer's disease?
If Ancept is prescnbed. what side effects should Betty be told to look for while caring tor her mother>
What are the 1nd1ca11ons for memant1ne (Namenda)?

KEY TERMS
- -----
Affect Bipolar disorder Neuroleptic Psychotherapy
Affective disorders Compulsions Neurosis Sch izophrenia
Akathisia Delirium tremens Obsession Tardive dyskinesia
Alzheimer's disease Delusion Psychoanalysis Tourette' s syndroma
Anxiolytic Drug holiday Psychologic drug T ranquilization
Attention-deficit/ Dystonia dependence o r
hyperactivity Extrapyramidal effects habituation
disorder IADHDJ Hallucinations Psychosi s

558
 CHAPTER 30 Drugs for Men1111 Health and Beh1v1oral Disorders 559

common Signs and Symptoms ol Mental Disorders

Stn ' anK1ety, depression Common Side Effects of Medications for Menlll
w .;awal lrom society Disorders
~ ttimng. halluc1nat1011S llypotensoon. rest~
~oa!e or violent behavior Tachycardia
Coying mood swings Ory mouth
Sleep disturbances. fatigue, agitation Decreased motor and cogn111ve ab1h11es
toss of conce11tration Alterations 1n sleep patterns
!nab ry 10 expeltellce pleasure Hangover effect
lrueased or dooeased hbodo
~ Impotence
tJli IV to place self m environment. person. place
Para101a 01woess, drowsmess. confusion
Extrapyram1dal symptoms
Tardi11e dyskines1a

Ar.uoly!IC$, ant1anx1ety, minor tranquilizers

An"cty
kllps\dlotics. oeuroleptics. ma1or tranquilizers Yes No ~hotc disorders
Antidellrassants
Un polar Yes No 8, c. [) Depression
Bpolar Yes No 0 Mania, depression
Medications fOI' cognitive ability Yes No c.x Alzheimer's disease
Cerllral neowus system s11mulanls Yes No B.C Anentoon-deficitlhyperactMIY
d1sordel

T
he ability to cope wit h different types of stressors
dunnga lifetime is pan ofnorrnal living or mental
health. Defining normal is difficult because the
tnms normal and nbnor11111/ are relative 10 th e local envi-
ronment What is considered normal c.111 and does
vary from culture 10 culture, country to country. town
to town, and even within towns. Daily stressors may
tl'tll chJnge normal to abnonroal within short periods
oftim(
individuality by integration of the physkal, cognitive.
and affecti\'e domains. lo the social dimension the ability
to interaa with family or community members effec-
tively is dominant. Environmental faaors are ewry1hing
outside o f the person . These components interaa to
form a continuum for menial health throughout life.
Mental health is not a concrete achievable goal; rather.
a lifelong process forms a senS<.' of personal harmony
and balance.

WHAT IS MENTAL HEALTH? WHAT IS A MENTALLY

M<'ntal health is a person's interaction among physical,
<ogn1uw 1ffeaive behavioral, and social realms as well
as m1metoons with the environment 10 choose and act
wuh rrg.1rd 10 a purpose in life. The physical d imension
i11Cludes physiologic a:.pccts, whereas the cognitive
dimenlion involves forrn11 l.1tio n of th oughts, processing
of information, and problem solving. n1e affective
donuon onvolves the ability to experience and express
fttlings and emotions llw behavioral dimension is
HEALTHY PERSON?
Mentally healthy people are able 10 percei\'e reality accu-
rately and control the manner in which emotions are
experienced and expressed. Clear and logical 1hinking
allows effec1 ivc communica1 io n while anticipating events
and solving problems. Persons ca n then initiate and
maintain meaningful relationships, develop a positive
self-concept, and beha"e in ways to promote personal
growth and dev'elOpment.
560 S[CTION V Med1cauons Related to Bodv Systems
Mental disorder. afrect almO>t l?Vt'ryone at some time
during li fe, either personally or by association with a
friend or family member I actors that produce mental
111;1ab1lily mclude congenital deficiencies, hereditary
facto!'\, auidents. traumatic t'\en1s on one's life. or drug-
rela1ed toxicity In many case1. the exact cause of instabil-
ity i~ unknown, but most mental disorders are related to
mess and prn~ures imposed by modem society. The
pain or ment~I illness is real md intense. altering a per-
son's ~b1l11y to ad1us110 S<Xietal stress When self-esteem
is decreased. coping skills are reduced. affecting behav-
ior \tental disorders may result in mild to severe dis-
ruption of the ab1hty to funcuon in interpersonal
rela11onsh1ps. self-care. and abiluy 10 main1.1in a job to
be self-sufficient When a person is able to cope and
adapt to the stresses of everyday life. he or she is consid-
ered 10 be ment.illy healthy.
ANXIETY AND DAILY LIVING
Anxiety, a lifelong emotion from infancy 10 older adult-
hood, is the major factor in motivating one's emotional
life. A person usu,tlly takes ,1 course of action 10 reduce
stre~s, apprehension, tension, <ind uneasiness Lhat
thre.11en one's well -bdng or sense of control in a given
situ:uion . '11lc \Y-.1y in \vhich a person confronts anxiety-
rnusing hua1io ns, from mild anxio usness Lo states of
panic, is an ultimate sign of mental hea lth. Nol all
anxiety is harmful; mild anxiety increases alertness and
lncreao;es 1>rodu<tlvi1y. Moderate anxiety diminishes cog-
nitive abilities and m;ikes leaming and decision making
difficult. When a 1>erson is unable to adapt 10 anxiety or
stress, homeostasi may be affected, causing changes in
mechanisms of pro1ec1 ion .tnd defense in an effort 10
main1ain equilibrium. When stress presents a crisis with
.1dapta1ion and function being affected, medications
may be prescribed to decrease stress and anxiecy to allow
needed adaptation.
Prolonged anxiety, tension, and nervousness result in
behavioral and emouonal changes or neurosis. '"hile
allowing psychosomatic cond1Uons and panic disorders
to occur Anlolylle11, formerly called minor mmquili.um,
are u5ed as trealment to calm the individual and reduce
unpleasant symptoms of severe anxiety.
ROLE OF MEDICATION THERAPY
IN PSYCHOTHERAPY
Medications in modern ps)chotherapeutic care are used
10 reduce or alleviate symptoms of stress and allow tense
or psychotic persons an opportunity Lo participate in
other psychotherapeulic ue,11ment. Drugs temporarily
modify behavior. whereas psychotherapy may perma-
nently change behavior. Psyd101herapeutic medications
are chosen by diagnos.is (e.g., m~d ica1ions are Specilicfor
cbiLophreoia, manic depression, psychosis, or other
mental illness} because drugs have additi\'t. poten11.1
ing. or an1agonis1ic effects on one another. SelttUon
based on behavioral actions, pharmacologic efTt<. llld
potential adverse reactions, as well as individ~ llld
environmental factors present. rlderly patients Mtolttio
inappropriately prCKribed psychotropic agents. In fI,
about 10% of all medic.11 visits by elderly patienu la.It
in prescriptions for psychotropic agents. le.ldi11 IO
increased risk of adverse or serious drug rt'<lCllons ~
interfering with cogniti'e and functional siatus.
Treatment of mental health has taken giant sttpt
the United States in the past 60 year<i with the introd..:
tion of tranquilizers. The first antipsychotic agen~ dolor
promaz.ine (Thorazine), was released in the early 19;oi
and remains typical of phenoihiazines u~ to aim\?-
Lated or anxious patients. Rather than being insutut1<J~
alized for years, as in the past, many psychouc ~
are today treated at community me111.1I health ctnltn
outpatients. For those who are hospitJli1.ed, the ho.pi
talization course is usual ly s hon term-only for dl,
length of time necessary 10 s tabi lize the condition and
medications.
Newer medications that are more ~elective in 1heu
action on the brain tend 10 resu lt in traoqulliLUon
without causing seda tion or depressing the entire ctnual
nervous system (CNS). Medications are used fo11reati11
both basic categories of menial disordcrs-neuro~is and
psyd1osi~.
NEUROSIS VERSUS PSYCHOSIS
Both basic categories-neurosis and psych~is-i!t
treated with tranquilizers in individuals who display~
tation, hyperactivity, and inappropriate and somtll1116
violent behavior. 111e mentally 111 individual is uiubltto
communicate with others and 10 function in noniul
activities.
Neurosis is found in the fearful individual who ud
in contaa with rcalicy but cannot adjust fa\Vr.ibk to
surroundings or life situations Many situauons on lilt
produce fear or anxiety from eilher real or un""'""
danger with stimulation of the fight-or-Hight' mpom<
of the sympathetic nervous 5)'$tem, resulting in slttpim-
ness and either an increasc or a decrease in appeult ~
accumulation of anxiousness and tension mJy Cilllt
neurosis Lo occur. Treatment involves pS}chon.al) ~ to
determine the cause of chc anxiety and drug lhtrapf
using anxiolytics to alleviate symptoms lypes ohruutn
related conditions arc generali-1ed anxiety disonl<t
(CAO), social a 1ixie1y disorder. and obsessive-compuls11~
disorder.
CAD, a chronic cond ition cllar.1e1crized by unconiml
lable worrying for 6 months or more. is accompanied bl'
 CHAPTER 30 Orugs for Mentel Health and Behavioral Disorders 561

depression with insomnia,

. .
tremblino appr"h
OI (
.
~ ens1on, and
paor concentration. Physical symptoms incl d relaxants for chronic muscle pain, <'Specially back p.1111
.. -; d I . u c tachy. and/or muscle spasms. Occasionally, minor tranquili'c"
""u1a. sweaung. an .__ pa p11ations
. 1he most commonly
used drul!-' are .,.,nzodoa~.epines such as 1 are also used for seizures 10 reduce the number of con
. ) d d' {" . oraupani vulsions and as adjunetiw medication m alcohol with
{All\'.111 an 1aupani va1mm), busplrone (ll S )
drawal. These medications. dassified as Schedules Ill and
l'fti"'Jo.rtrie uexor , an sclccuvc wrotonin reu park
'' , (E" ) d .
onhibi10JS (SSRls) ~uch as parOJteline {Paxil CR) upta e IV drugs. are for shonterm use and are contraindicated
for long-term use and carry the poss1bih1y of toler.ance
SocLtl aOlCJety
' . .
disorder
.
has chuaneristics of .intense,
and physical or psycbologic drug dependencr or
l(li}UOna
.
I 1ear on s11ua11ons where
. scru1ini1inn
- a 0 r h UITII1I habituation, especially in larger doses Sudden with
.ilJOO .ma)' OC~r. Srmptoms include blushing. stuttering. dr~\"31 of minor tranquilizers may result in sei.mres. agt
S~tmg. palp11a11ons.. muscle tension, and dry throat ~auon, psychosis. insomnia, and gastric distress rhi~
SSRls such as paroxeune
. d arc drug.-; of choice "'or 1reat ~formation is an imponam "'aming in patient educa
mmt ofth ese d1sor en. uon. Some of these drugs may be undassified under the
O~ive<ompulsive d~sorde~ is ch,iraeteri?ed by Controlled Substances Aa (Table 30-1 ).
obS"SSODS and compuh1ons mterferin<> with d 1
. . p , a1y
l~1ng. auerots may penorm ~uch act ion\ as excessive
hlod washing. placement of objects, or hoarding rre.11. Benzodiazepines
meot indud~ us~ of SSRls such as fluo.reline (Pro7-ac) Benzodiazepines, first introduced in the 1960>. are the
and sntraline (Zoloft) and tricyclic antidepressants drugs of choice in treatiJ1g anxiety and msomnia loday
(JCAs) such as clomipramine (Anafr.mil). bcnzodiazepines are among the most widely prescribed
In psyc.hosis. the ~e.r.on has lo\I con ta<"t with rea lity, medications in the United States, with diauparn
resuJung m .he maboloty to rnmmunicatc saiisfoctorily. (Valium) being the most familiar. B~u!.t! these medica
lbe personality break> d<:>wn, with thought pa11erns and tions have few aoions outside the CNS, thus having
ri:sponses to lhc environnw111 unrelated 10 real-life situ lower potential for abuse and producing less tolerance
ations. Treatmcm fur 1his severe men tal il lness may a nd physical dependence, they are safer 1h,111 some CNS
require hospi1aliz.1Lion. depressants. With benzodiazepines, ca lmnes> occurs
without excessive sedation. Increasing doses c,ouse scda
tion that may progress to hypnosis and stupor.
Taken via the oral route of administration, benzodi
f>kn1al health is difficult 10 define and may change from a,.epines are readily absorbed from the gastrointest in.tl
pe1son 10 person. culture lo culture. and tome to tome Mental trad. Dia.epam and lorazeparn (Ativan) may also be
health os ab1h1y 10 love wnh daily s1ressors given by injection when more rapid action is desired or
Psychotherapeutic agents are among the most frequently required. Duration of anion is the m.1jor difference in
pre1t11bed med1cat1ons benzodiazepines. wngacting agents have half.Jives of
NaruraJ. temporary situations p1omotong sadness. anxiety. or more than 29 hours, whereas shonading drul!-' have
11l$tlessness do not always need to be treated with ps~ho half.lives of5 to 20 hours. Tremors and extupyramldal
tnerapeutoc agents effects may occur with persistent use of these drugs.
Proper diet. el0lrc1se. dnd a pleasant ef1Vlrooment are ompot especially in the elderly. Excessh-e use of b<!nzodiue
ta. 111 ueat ng emotional d1sordefs
pines may lead 10 interference with memory and 10
N ro5IS IS found in the 1ndovldual who IS in contact With
psychotic behavior. Aggressi't! behaVlor could become
'~olent with prolonged drug use. l'atients who operate
11 but is 1J11able to ad1ust favorably to sunoundings or
machinery induding driving a c.u should be careful of
...1uons All!l etv os maJor ~ptom of neurosis sedating adions.
. CS1S occurs when a person os out of touch with reality
Patients must realize that anxiolytics only reliew
symptoms wd do no1 cure anxieiy. The rC"ason for anxiety
must be found and eliminated for symptoms to I><! allevi
ated. Drug dependency wi1h antianxieiy agents comes
more from habituation than from physical dependence;
1hus care should be taken that the medication does not
Drugs used for the rdief of anxiety m.1y .1lso be used as become a crutch for relieving stress and unhappiness.
hypnotics or sedatives to promot<' sleep (sec Chapter Abuse of benzodia>.epines is more likely 10 ocrur with
29). The difference bc1wccn u'ing nwdications a< anxio 1>atients who take larger than therapeutic do~ llen1.o-
l}1ics and as hypnotics i> hascd on dose- a lower dose d iazepines should be avoided during pregnancy and
to 1elieve anxiety and high<'r dose' for hypnotic cfTeCtS; used 'vith extreme caution in patients \\ ho are suicidal,
1

are severely depressed, or h ave depress('<! vital signs

a single medication m,1y he 1>1c>crihcd for bo1h uses.
These medications may .11, 0 he uM'd for s keletal muscle (Box 30 I).
562 SECTION V Med1cauons Related to Body Systems

Aruoety. panic disorders Other CNS depressants. alcd'd,

SHORT-ACTI NG c1me1id1ne. antcoagulanu,
BENZOOIAZEPINES con1cos1er0tds. dog11a 1$
pheny101n. oral contraceiit ~
a prlllOlam I l txanax. Xanax 0 2!>-1 mg PO lld
XR. Nra-.'3111)
lorazeparn I I (Atr.'311) 0 >I mg PO. 1M. IV
IJod.tid
q zt, n(IV) IOnra I 7).15 mg PO qhs

M1j0f Sidt Efftcts of ShortActin1 Benzodi1upines:

Orowsill"'~. conf 11 sion. dtaia. nausea. consupauon. dry mouth. GI disturbances. rashes. photosensmv1rv. mens11ual irregu at:.es,
loss of hbodo

LONGACTING Same as shon-act1ng

BENZODIAZEPI NES
chlord1a1epox1de (Ill)
clonazepam 11111 (Klooop1nl
clorazepa1e (Ill) (Tranxene
d1awpam 11111 IValiuml
oxazepam 11111
Benzodiazephines
5-10 mg PO 11d-q1d .Mx1olytic. alcohol withdrawal
Ant1seizure
05 mg PO bid An11seizure. other anx1olyt1cs. alcctd
withdrawal
n 7515 mg PO in
d1v1ded doses
210 mg PObid-q1d. Same as for clorazepate. muscie
IM. IV relaxant and preope1a1ove
mod1cation
30120 mg PO in Same as for clorazepate. alcohol.
d1v1ded doses CNS depressants. MAOls

MISCEUANEOUS Same as for sholl-act1ng

ANXIOLYTICS
oospirone l&Sparl
hydroxvnne IVstanll
paroetll'l8 (Pax I)
Vlllllalaxone (Ettexor XRI
S.10 mg PO qd
25-100 mg PO. IM qid
1().50 mg PO qd
37 >225 mg PO qd
Benzod1azep1nes
Aruoety
.Mxiety. emesis. anupruritJc.
f)(eope<ative medicauons
.Mxte!y. def)(ess1on. MAOls. c1meudlne phenyton.
obsessive-compulsive nspendone
disorder. pamc disorder
.Mxiety. depression MAOls

M1j' Sid Efftcrs of Miscel/1neous Amriolytics:

buspirone-dlll\ness. um1tus, ghtheadedness. rashes. fatigue, nausea. chest pain. nasal congestion, sore th1oa1. CNS
disturbance. hydroxyzme. paroxetme. lr8l00otte-<frowsiness. dry mouth. pain at 1nject1on site. 1n add1t1on d1aphoresis, trernin
vom111ng with paroxeune. unpleasant taste. headache with 11arodone
CNS. Central neM>us system. GI. gaslrointesonal; INH. 1soniaz1d. IM. intramuscularly. IV. intravenously. MAOls. monoamine ox1dase 1nh1bi101t PO di
 CHAPTER 30 Drugs for Mental Health and Behev1oral Disorders
SOX JO 1 OTHER COMMON ANXIOL YTICS
, Busplnme IBuSpar) ts solely an an11anxie1y medication.
,.,,ng oo ant1convulsant or muscle-relaxing properties or
<edahve effect Not substantially 1mpamng psYthomotor
ft11Ct1on. 1t 1s more effective for cognitive and interpersonal
rela11onsh1p issues such as anger and hostility, whereas ben
zod1a~p111-0s are more effective for soma1tc symptoms
SuSpar, not a controlled substance. 1s well tolerated. and
""$age may be increased progressively as needed because
~ po1en11al for tolerance and drug dependency is low
, uydrozyr.iru 11/istaril. Ataraxl has many uses as an ann-
lil'111118. anxrolyttc. antiemettc. or sedauve. This medtca-
1,,. may be gM!ll by mouth or by 1n1ectton. When given by
ir11ec~on. 11 must be given deep intramuscularly 10 prevent
1rri1a11on 10 tissue.
, Three medications introduced as miscellaneous anxiolytics
and for 1rea1ment of hypertension-p11roxe1irre (Paxil) and
1,..11fo/axine (Elfexor)-vre not Drug Enforcement Adm1n-
11>tra11on IDEAi-scheduied drugs and are all used for anxiety
and ~;:1e.sion Paroxenne is also used for obsesstve-
ampulstv1 and panic disorders Venlafaiune ts used for gen-
eralized eruuety disorder (see Table 30-11
~ LEARNING T IP
Nol? that many of the benzod1azep1nes have generic names that
1111111 pam or "lam
8en1od1a1cp1nes should be taken with food 11 gastrointestinal
r,mpioms occur
2 Patte11ts should take anxiolyttc med cattons as ordered and
s!nJld 001 maease dosage or discontinue medicallons
wilholit consulhng a physician Relaxatton techmques may
also help reduce stress. _.
3 Transient insomnia usually will be relteved once the prec1fll-
1a11ng stress0< has been eltmrnated _ drawal from the social environment with hiillucina-
4 ll!ows1ness occurs with benzod1azep1nes. so hazardous ac1JY-
111es soould be avoided until effects of the med1ca1ion can
be evaluated by the patient .
S. ~oeal dependence is rare with most ben1od1a1ep1nes, but
pe1SOOS using alprazolam IXanaxl have reparted substanltal
depcudmtee factors
6. Benrodiarepones should not be used with pregnancy.
1 AlrlJIJ( d1scont1nuatron of aruuolyt1cs may lead to seuures.
all talion. psychosis. insomnia. and gastnc upset
---
563
llmportaiifjFacts a b o u t Anxiolytics ;
Oru<J used to treat ar ery are cal ed anliaflolY agerrrs.
an..olytics. or mll)()r rraoqu ftlefS and mos1 may also be used
as hypnotics
Elderly persons generally require lower doses of psycho-
1Wrapeu1ic agents and may experience excessive sedanon
when given the usual adult dose
OTC med!Qltions such as an11h1S1am1nes and coogh prepara-
tions may cause excess ,,, sedal on wflcn combtned w th
mrnor tranqudizess
Alcchol should not be combined ...., th any II' <1olytoe.
The potential for abuse and additl on is hqi ~ tranqU1i-
1zers are used for a prolonged perrod of time
The pnnc1pal md1ca11ons for benzod1azep nes are anxiety,
insomnia. and possibly seizure disorders. These drugs are
safer 1han barbiturates, have a lower abuse potenttal. and
cause less tolerance and dependence
Ben1od1azep1nes may cause severe resp1ra1ory depression
when m"ed willl other central llelVOOS system
depressants
All benlod1azepines ha.e essentially the same phannaco-
logte action; lllerefore selection 11 based on !Ile d1lferences
1n action time Ben.rodiaiepioes, the drugs of choice f0< tran-
sient 1nsomn1a, should be adm n ~tt.,ed 1n1erm1t1en1ly la< only
2 to 3 weeks
Benzodiazepines should not be usod dunng pregnancy or
by persons with sleep apriea Scltcdule IV under the Con
trolled Substances Ac1, these drugs have a possibility of
dependence
care shoold be taken Y.ilen using any &nllolytoc OI psycho-
therapeutic medication 1n persons willl suicidal tendencies
NEUROLEPTICS OR DRUGS
FOR PSYCHOSIS (MAJOR
TRANQUILIZERS)
Psychosis does not have a single dingno~is but ~s clini-
cally described as being our of touch wrth reahty. 'Ille
two major fonns of psychosis are schizophrenia and
severe depression, althoug)l other conditions are classi-
fied as psychosis. _
r~rsons with schizophrenia have symptoms of w11h-
tion s, deluions, and inappropriaie or unpredictable
behavior. Psychotic symptoms may be c~used by med1c.1-
1ions used 10 1rea1 illnesses. causi ng the patient to lose
contact with reality. The patien1 with schizophrenia has
dctcriora1ion in social functioning. with disorganized
1houghts. changes in affect, and inability to perform
tasks needed for daily living. Speech may be mcoheren~
repeti1iw. and reOective of wan~e~ng thoug)115. :n
gems, or inability to get to the pomt tn commu_mcauon,
are not uncommon. With persecution delusions, the
564 SECTION v Med1ca11ons Related to Body Systems

agents and are considered. al)-pical a.niipsychotir d'llp

individual feels lhreatened and that olhen. are uying to
cause personal harm in wme "ay Wilh delusions of
grandeur an exaggerated feeling of imponance. knowl-
edge, or identity is present -1reatment for bolh delusions
and hallucinauons in\'Ohon JX>'<hotherapy and use of
anupsydiotic medicauons, alw called neuroleptics or
ma1or iranquilizers.
111e patient with severe depression has strong feeling.<
of hopelessness and is often suicidal and should be eval-
uated regularly when taking a111ipsychotics.
Uses for Antipsychotics
or Neuroleptics
In general, antipsychotks are effective in three major
areas. (I) to relieve ll1e symptoms of psychosis or se\'ere
neurosis such as delusion"- hallucinations. agitation, and
combativeness; (2) to therapeutic-ally reliev-e naUS<'a and
\'Omiting (see Chapter 14 ); and (3) to potentiate analge-
SJts, for example. as promethume does (see Chapter IS).
Dosage of amipsychotics is regulated to modify dis-
turbed behavior and to relieve symptoms of severe
anxiety without profound impairment of consciousness.
Antipsychotic medications. also called 11e11roleptics (for-
merly called major trt1nt/11ilacr;), do not cure acute or
chronic psychosis but are used to control the related
symptoms. The most impor1am clabses of antipsychotic
medications-phenothia..dncs, butyro~>henones, and
thioxanthenes-are used to suppress symptoms of
schizophrenia and other psychotic conditions. 111e exact
mechanism of action is not well understood, bu t it is
thought that these agents act on dopamine. a neurotrans-
mitter in lhe brain. Serotonin, another neurotransmiuer.
is also invol\'ed in the control of psrchotic bel>avior.
Some drug.< block serotonin to act antipsychotic
because their main .1cuon 1s not against dopanunt bq
rather on -.erotonin (Table 30..2}.
Potency and Neuroleptics
Amipsychotics can also be classified by P"'L'lll)'-not IO
be confused with drug effectiveness. Effectwr~ 1111
sures therap<?utoc response to individual medim100,
Potmcy refers to drug quantity necessary to product in
equ iv.tlent effect when compared wit h a mediation of
the same drug classifica tion. An ti psychotics are da~ilitd
by their potency- low potency, intermediate potcnC)
and high potency. An example is cl1/orpromazine(Tho11
zine), a low-potency drug. lnorazine 100 mg is mn\Jd
ered to be the equivalent of mesoriAaz.ine (Seren~)
SO mg (an intcmwdiate-potency drug) or ltaJOjltrU,/
(llaldol) 2 mg (a high-poumcy agent} (SeeTablt 30.~
Side Effects of Neuroleptics
As patients t.ike a111ipS}'Chotic medications from months
to a prolonged J)('riod of time. medications tend 10 0 111
extrapyramidal effects by blocking dopamine repton.
l'ardilie dy~klncI~. a more serious condition, indudn
invo lunta ry movements s uch as tics; movements of the
I ips, jaws. a nd tongue; and jerking movemems or exuem.
ities that cause postura l imbalance. Often, tardivtd)'!i
nesia appears when the medicaLion is discontinut'd, and
either restarting the drug or increasing the dosagt> nuy
s uppress ~ymptoms, but with f~unher prolonged ust !ht
dyskinesia worsens and becomes unresponsive 10 utn
mem. These symptoms may then become pemunt111
and irreversible; therefore frequent office visits to"""'
progression of dyskine..ia are imponam (Hgure JO.I)

t
TABLE JO 2 SELECT DRUGS USED TD TREAT PSYCHOSIS

GENERIC NAME/
TRADE NAME !POTENCY!
TRADITIONAL ANTIPSYCHOTICS
PHENOTHIAZINES
ftuphenaione HCI
ftuphenazine decanoate lHPI
USUAL ADULT
DOSE, ROUTE,
AND FREQUENCY ' INDICATIONS FOR USE DRUG INTERACTIONS
Psychosis antihistamines, alcohol.
artalgesics. tranqu1h1ers.
MCOltcs. guaneth1d1ne beta
blockers. barb<turates. llSUllr.
ornl hypoglycemoc:s.
anticholtllllfQICS. leWOOpl
epmephnne
2S-50 mg PO bld-qod. Psychosis. emests, and
M. rv hiccups
May be up to 1000 mg
2 S. 1Omg PO qd-qod
12 5-25 mg IM as depot
ql4wk
 CHAPTER 30 Drugs for Mental Health and Behavioral Disorders 565

824 mg PO tid. f's/chos1s. emes1s

5-10 mg IM. IV
poctibperanne 5-10 mg PO t1d-q1d. Psychosis. emesis
1().20 mg IM. IV
1Can1JOHIPI 25 mg rectal supposrtcwy
tllU'lla!ine (I.Pl SG-800 mg PO qd
tnfkallielalire IHPI 5-40 mg PO 1n drv1ded
doses

/llljor SiH Effects of PhenolhillinH:

l'ostural hypo1eos1on.
.,,,,, tachycardia
bradycard1a vert 190, drv mooth bl uned vision.
fever, oonstipatton unnary retention anorexia
rashes. ,.~tosel1$tllVlty, insomnia. agitauon. restlessness. depression. headaches. confus100. dr0\~1ness. weaknes~

BUTYROPHENONE
halope11dol IHaldol) IHP) 0 52 mg PO b1dhd Psychosis. mania. alcohol. lithium. CNS
2.5 mg IM schizophrenic depressants. levodopa.
epinephrine

T!llOXANTHENE Psythosis Same as for haloPendol

th1othixeoe INavanel IHPI 2 mg PO tid
OIBENZODIAZEPINES Same as for haloperidol
DERIVATIVES
clozapme iClozanl Fazaclo) 75 450 mg PO qd Psychosis. schizophrenia
IAn mania. dep!ession
loxapine ILoxatme) 60100 mg PO qdbid

ATYPICAL ANTIPSYCHOTIS
BENZISOXAZOLE Same as for hak1pendol
rspendooe (A1sperdal) (AT) 16 mg PO. IM md1v1ded Psythosis. irritab1lny of
doses autism; bipolar disorder

T!llENOBENZODIAZEPINE carbamai:ep1ne. levodopa.

antihypeftensl'l'es
10 mg PO Qd Sch1rophrema

MISCEUANEOUS
.ras.me llatuda) 40-80 mg PO qd Schizophrenia
112 mg PO bad Scl11l0jlhrenia paroxeune and ketoconazole
o<O!*dooe (Fanaptl IATI
Schizophrenia. bipolar Annfungals. carbamazepme.
a'lpii-azole IAhthfy) 15-30 mg PO. IM
disease paroxetine. Huoxetne. alcohol
1Abc 1fy 01smell) IAT) 1520 mg (ocal
d1smtegrauon tablet)
20 160 mg PO bid. IM Schizophrenia. bipolar Same as anp1prazole
11pras done iGeodon) IATI
mania
PSythosis. depression, alcohol. op101ds. lorazepam,
que11ap111e ISeroquel) (AT) 2550 mg PO qd
mania dopamine

AT, AIV!ltCal agent. CNS. cenual nervous sys1cm. /IP. 111oh po1cncy. IM. innamuscularlv: IP, imermediate po19'1C'(; IV. 1ntravenou~y. IP. low potency;
PO. Olally; SL. sublmgually
'Given in diviood doses unless 01horw1so no11X1
566 SECTION V Medications Related to Body Systems
PHOdoperk1n11011l1m
StOQPld posture
Shvllilng glll
R.gOty
~
Tremors I rnl
P...-.U mol.<ln Cl the hand
Akath.11'8
A-
Trctblo standing still
Paces the floor
F..1n constant mooon,
roclong back and r<><1h
figure 30-1 EJCuapyram1dal adverse eHeclS of neu1olepuc medications. (f rom Kee JL. Hayes ER. McCurstron LE Pharmacology a nursing /XfJ!1
approx/I, ad 6. St l ours. 2009. Saunders)
Elcl~rly patients taking neuroleptics seem more prone
LO pllrkillso11it111 sym/itoms such as tremors, drooling.
tongue prmrusion, mu:.culnr rigidity, and dysphagia.
Antiparkinsonism medic.u ions used prophylactically,
such as anticholinergic drugs with an ti psychotic medica-
tions, will not prevent extra1>yramidal symptoms, and
symptoms only continue to worsen. Although seen in
adults. dystonic reactions including muscle spasms of
the head with twitching. facial grimacing. to nicollis o r
wryncck. and twisting or the face. neck. and back are
more prone to occur in children.
Dy.ion!~ usually appears early in treatment and sub-
sides rapidly with medication discontinuation. Anticho-
linergics are used for treating dys1onia. Ablhisia, or
motor res1lessness, also more common in children, is
manifes1!.'d by continuous body movement wilh reslless-
ness. pacing. and insomnia.
i\ntipsycho1ics, contraindicall.'d with seizure <fisor-
ders. sewre depression, parkinsonism, and pregnancy,
mus1 be used with caution in children and 1he elderly,
patiems with hcpalic or renal disease. men with prostatic
hypenrophy, and palienis wi1h glaucoma. Boxes 30-2
and 30-3 list implications in elderly patients and chil-
dren. Box 30-4 lim the classes of drugs used as
antipsychotics.
Ill LEARNING TIP
Gene11c names for mosl phenothiazines end m "zine."
Acute dyatonlo
Facial gromaelng
Involuntary upward eye,,,......,,.,..
Muscle spasms of the t'9J0. lace,'*'<
and t>ac1<(bad<....-_,._
trunk to arch IO<Ward)
Laryngeal sp&SIM
Terdlve dy&klnffle
Protrusion and roll!ng ol " IOr9'I
Suclong lllld ameclong ...........
or the ~ps
Chewing motion
Feela! dys~lnffla
lnVOluntary fTlOll9ments ol Ille bo"1
and ox1temltlM
BOX 302 PEOIATRIC IMPLICATIONS FOR USE
OF PSYCHOTHERAPEUTIC AGENTS
Children are at greater risk of developing extrapyramrdal s1je
effects, especially dystonra.
Pedia1ric patients with chickenpox, central nefVOUS r1s1e~
infections, measles. dehydra1ron, gastroontent s. or o'lv
acute illnesses are more at risk of devctopmg severe advw..e
reactJons and even Raye's syndrome
Tricyclic antidepressants are usually not recommended ltr
depression rn chrld1en younger than age 12 Some 8glil1l3
such as amrtriptyfine (Elavrl). desrpram ne tNo!ptamtnl rd
imipramine (Tofranrl) may be used tn chrldten oldel lhii 6
who have ma1or depressron
Chtldren are sensnMJ to acu1e oveidosage. vAuch cay lie
serious and even fatal
Increased neM>usness. sleeplessness. COf!'4llainU of benJ
ured, hypenensron. and stomach distress are loon! 11 dll-
dren taking tncyclrc antrdepressants
lithrum may decrease bone density and bone formatr01v;
used with chtldren
SSRI agents have been aPIJfO'Jlld for children and adol8sUrU
SSRls ha'Jll black box warnrngs for surcrdal rcleatoi
children
Ar.ypietrl n111ipsyc/101ic medicariorrs are agents blodl!1
serotonin and dopamine receptors. Cfoznpi11t (Clo-
zaril ), a typical drug. causes sedatio n, hypo1ension. ~nd
anticholinergic effects, bu t cx1rapyramidal effect! 0(!1ll
only with large doses. Alypic:il agen ts have the advanlJ~
 CHAPTER 30 Drugs for Mental Heahh and 8eh1v1011f Disorders
9(JX JO J GERIATRIC IMPLICATIONS FOR USE
Of PSYCHOTHERAPEUTIC AGENTS
, Old persons tend to have higher serum levels of antipsy-
chOtic and anudepressant drugs because of changes in drug
d1su1bu11on from a decrease in lean body mass. less total
bcxty water. tower serum albumin. and usually an increase in
bcxty fat These patients need lower doses.
, Geriauic patients are more likely to have orthostat1c hypoten-
11(111. antichohnergic side effects. extrapyramrdal effects. and
sedatioo.
, Ellertv pa~ents should receive half the recommended adult
mse, When cl meal rmprovemen1 is noted. attcmpt.S 10 taper
OI discontinue med1ca11ons should be instituted
, rrrychc antidepressants may cause increased anxiety in
ge11atr1c patients. The tncyclic antidepressant increases the
nsk of inducing dysrhythmias. tachycardia. stroke. congestive
heart failure. and myocardial Infarction m persons with car-
diovascular disease.
, l IMlll is more toxic for geriamc patients The elderly are
me prone to central neMJ1.1S system toxicity. lithrum-
rWcad goiter. and dinical hypothyrood1sm
BOX 30 4 CLASSES OF DRUGS USED
AS ANTIPSYCHOTICS
C11forpror11azlrre !Thorazine). the first anti psychotic agem.
1ema ns typical of phenoth1a2rnes that possess anticholiner
gi.. ant emetic. ant1histamm1c. and alpha-adrenergic blotk-
rr;i elfetlS and ant1psythot1c actions These drugs are also
usal for treatment ol nausea. vomiting, piurrtus. and allergic
oiatt1G11s. although they are not the drugs of first choice
Phenothiazone denvatives may also be used as adJuvant
""!raw with tetanus and 1ntrac1able hiccups. as well as for
,11,, fAr I ,order. agitation. and delirium tremens.
Bu1yrophenone derivatives. chemically different from pheno
1h1a11nos. haVli the same antipsychot1c effects. Halopendol
fHaldol). the main drug in 1his group. is used as an antipsy-
chot1c and ant1eme11c and for severe behavioral problems on
chiklren lour~ne' syndrouu, a CNS disease with
~ rnvoluntary repehtrve motor movement.S of muscles
n U!VOloo1ary vocal toes or nooses. can also be con1rolled
by lhl$ drug Low doses of halopendol have been used to
treat severe agitation. combativeness, and psychosis on
demented persons. Because butyrophenones cause greater
m!Mlmcnt disturbances than phenothiazmes. elderly pauems
ahould receive lowered doses (see Table 30-2). . .
Thioxanthenes are chemically similar 10 pheno1h1azones.
l1tlorl1w ne INavane). the typical drug in this group. exerts
an~psychotoc effects by blocking dopamine on the brain but
1$ men se llttrve on causing extrapyramidal effects.
, trwJpine (Loxitanel a dibenzodiazepme and similar 10 phe-
lllthial1nes. causes ~ moderate degree of sedation with a
h1!/l 1nc1dence of ex1rapyram1dal symptoms
567
of not causing tardi\~ d)-skinesia ~nd so .tre well suited
for patients who prl'\ious experienced exuapyramidal
symp1oms. Olan.zapine {Zyprex.1), a typical thienoben
zodi;vcpine. is usro 10 1re.11 ~hl/,ophrenia by blocking
serotonin and dopamine. Newer miscellaneous atypiGll
anripsychotic agents, such J> arlpiprazole (Abilify)
and i.lprasidone (Ceodon), have fewer side effeas, such
a$ sedation, extrapyramidal eff=s. and hypo1ension,
making them more patient friendly (seelable 30-2).
Treatment of Psychosis
w ith Pa renteral M edicat ions
For long~term maintenance therapy of schizopb.renia,
depot injeaable antipsychotics with long-acting e1pa-
bilit ies are used for patients who may not be compliam
on .1 daily basis or tend to be g('nerally noncompliant.
l'arcnteral medication prcve1m relapses and maintains
th<' highest possible level of functioning with no greater
risk of side effeas than found wuh oral preparations.
Risk of tardive dyskinesia is actually reduced. The mos1
commonly used medications for depot adminis1tation
are hnloperidol (Haldol) and Jluphmazine (Prolixin)
Wirh long-term therapy, the depol method may be "'?re
effective, with fewer withdrawal symptoms, fewer side
effect>. and beuer compliance.
Treatment of Schi zophrenia
Treatment for schizophrenia is chronic and prolonged
and has three major objectives (I) suppress aane epi-
sod<.>S of ps)'Chosis. (2) pr.,.-em acute disease exacerba-
tions. and (3) maintain the highest possible funaional
level.
Unless contraindicated, high polency traditional
agenis are used. The exact drug depends on patient
response, as some patients respond more successfully
to a specific medication. Selection may ~>ven reqmre a
mcdk.uion trial to determine rhe drug wuh fewest side
cffcas. maximum comfon. and greal""t promotion of
compliance.
ratients should be allowed an a11emp1 al treatment
discontinuation after a )'e<lr of therapy; approximately
25% of patients will not need drug continuation. The
rime chosen for auempted tapered disconunuauon
should not be a stressful time.
Anllpsydlotocs are effective an three ma1or areas 10 relieve
psydlos1s or se.ere neu10s1s, to relieve nausea and vomrtmg.
and to p01en11ate analgeSJts
Um11"wd
568 SECTION v Med1ca11ons Related to Body Systems
AP! !IS)'tllai.t medicatJOnS la I 111to rwo groups,
trad oonal
alld atypieal Trad :JCnal drugs aie thought to relieve
ymptilmS by blcchig neurotransm1uer recep!Ols such as
dopamine Atypical medications block other oeurutransm1t
ters such as seroton n
Maior 1nd1cation fer ant1psycl11mcs is sch1rophrema. a cllron1c
illness marked by hallucinations. delusions. and agitation
along with d1sorgam1ed thoughts and loss of reahty Social
withdrawal 1s often seen
low-potency to high-potency trad1t1onal anupsychot1cs have
equal therapeultc effect
low-potency agents produce more sedation, orthostauc
hypotens1on, alld antochohnergic eflects than high-potency
ageflts
Therapeo:ic effects of antipsythotc med cations develop
s..mfy. often taking several "1!t!<S to be effect111e
Trad1tJOnal antipsydioltC medicattOnS may cause three types
of e>IIapyramidal effects tard ""dyskines1a. acute dyston1a.
and atath1s1a
At\'P!C<ll ant1psycllotics cause few er no extrapyramtdal
effects.
Depot parenteral ant1psychot1c agents are used for long-term
schi1ophrooia maintenance therapy and for those who lend
to be noncompliant
Chlorproma1me (Thoraltne) was the rirst low-potency agent
and Is the prototype for anupsychot1c med1cat1ons Haloperi-
dol (lialdoll is the prototype fer high-potency agents
[PatientEducati"1.for Compliance
Patients should be aware of the psychologic and physical
dependence potential with prolonged use of psychotropic
medications MedlClnes should be taken at prescnbed
dosage for the time set
2 No CNS dep1essams-anatges1cs. alcohol. muscle relax-
ants. anuhistamines. ant1emeucs. cardiac med1ca11ons. and
ant1hypertensives-should be taken with psychotropics
unless ordered by a physician
3. Be careful when laking any medications w11h antipsychotics
because of many drug interactJons. especially with OTC
antih1stam1nes and sleeping aids
4. Patients taking psychotropic med1cat1ons should be edu
cated about orthostauc hypotens1on and the dange1s of
changmg pos111ons rapidly
5 A.old sun exposu1e with ant1psychoucs because of sunburn
~ with prolonged sun exposure
6 Report restlessness. muscle spasms. ng1d1ty, tremois.
drooling. V1Sual d sturbante$, weakness. and faintness
when taking ant1psychot1cs
7. Oral amipsycllotic liquid med cations sllould be protected
from light
[Patient Education for
[Complianc-cont'd
8. 01luuon of oral hqutd ant1sycho1JCS should be 8Cll
using fr11tt iu1ce to lllCl'ease palatability
g Oral anltpsychottC hqu1ds may cause contaet ~
avoid skin contact
10 Patients should have writteo and verbal insll'IJCtal:
dosage and urning of medications. Ha-e family "'"'il1:
assist with med1cauon compliance.
11 Educate patients about early signs of extrapyramtdal ,,
toms such as spasticity in the face. neck. and to1"9Je a'1!1
restlessness
12. Dry mouth. blurred vision. photophob1a. unnal'I hcs1ln't
and const1pat1on are possible and should be ll!llOr.td
symptoms become severe. medication may have tG it
stopped or a reduced dosage anempted MDVIII tr'i
may be rel 1eved by chewmg gum Of sucking on hard ta!l'/
J3. Sexual dysfunction rs possible with anopsythoocs
should be rep0<1ed for reduction of dasage or ~ 1
med1ca11on
14 Patients should attend all psychotlleral)ell!IC Sl!SSIOllS
taking med1cauons for psychotic conditions.
15. Ant1psychot1es cause drowsiness. Taslts lhatrequ 1e mer.:i:
alertness should not be attempted until med1ca1ion ~
are known.
16. High-fiber diets are important and a stool roftellef may fie
needed when taking an ti psychotics because ol theircons1
paung effects.
DEPRESSION AND ITS TREATMENT
Depres.~ion, one of the most common J>S}'Chiauic cfuor.
ders, is characterized by feelings ofintense 5.ldnm, ~
lessness, and worthlessness causing impaired funcuon"'
Appetite disturbances such as anorexia or O\~u~
sleep disturbanrl"., and loss of interest in pm.i<lu!~
enjoyed anivitic~. including family and worl<. are pl\)>1
cal and p~ychologic symptoms of depression. Diagn01~
of depressio n gencr.1lly includes psychologic symptoms
of mood chnngc~ wilh despondency, anxiety, self.piir
low self-es1eem, hopelessness, and helplessness Ph)"
ologic manifc&tations include either insomnia or hyptr
somnia, headaches, loss of energy, and complamts of
fatigue. and lhought alterations, induding dl'Cmldl
concentration, poor memory, confusion, and del~o""
Mood swings arc often diurnal or related to <plbC
times of day and arc often worse in mornings.
Mood disorders, also called ..trectln disordm
include depression as well as mania or elation \ll
factors including genetics, psychosocial evenl5. ~ct>
l~c stress, and personality traits precipitate afftnt
disorders such a~ depression. Major depression is pit!
en tly referred to .is 1111ipolar affective disorder. Disonl<11
 CHAPTER 30 Drugs for Mental Health and Behavioral Disorders
BOX J{) 5 RECOGNIZING DEPRESSION
Signs of depression include the following
M1n<X ftuclua11ons 1n mood, becoming an overall "d
leellflQ own
Feeling overwhelmed by rcspoos1b1ht1es
Fvturn seems dismal
NegatM! opinion of self
Cnt1C1Z"10 and blamuig self 1epeatedly
Smallest incidents of hie are bothersome
that ioclude mixed-type reaoions or mood changes from
ebtion 10 depression arc called l11pol11r rlrsoriler (previ-
OU$1y known as m1111ir-tll'f!l"t'SS11.'" d1sortler). Dysthymia,
a milder form of depression. rs typical of those who
are sad or 'down in the dumps. l11is person is chroni
cally depres;ed, finding li11lr joy or CJ<citemcnt in life
aod having had more days of dc1m<~ion 1h.1n not for
al lrast 2 years. Dys1hymia is a common condi1ion-
approxlmn1ely 6% of the entire 1>opula1ion cxpc1icnce,
dysthymia in their life. wi th .1hout 1% ,1ffeeted ~1 any
gJ\re:Jl 1in1e. ~l'hese proct.'sses h~1vc no ~i ng1e causr, but it
is belie"ed th,ll .iressf11 I <'WIH o r menta l conflicts
precede depression (llox J0-5 ).
Antidepressant Medications
Major antidepressant drug classes include monoamine
oxidase inhibitors (MAO!;), l'(J\>, SSIUs. and selective
oorepinephrine uptake inhibitors (SNIUs) . Some herbal
supplements. called rrt1111r11/ m1/1Mke 111l11b11ors (NRls ),
hJ\-e also been indicated as ,in1ide1>rc>s.ints. I he thera-
peutic response rate with all .mtidcprcs.sant> is similar.
so agent selection is dependent nn drug side effects asso-
ci..urd with patient drug e~1>erienc'1' in the past . Selec-
tion must be based on potenti.11 side cffe<ts compared
nth the individual's medical cond11ion Some patients
will nttd sedation for agilation, so a sedating an1ideprcs
uni is ordered rhe L>cprl.'SSion Cuidehne P.mcl in I ')?3
esublished medic.uion sclcc11on m.mncr (Box 30-6).
Tricyclic Antidepressants
TO.s. so named because of their 1nplc-ring structure. arc
used with major deprcssron tx-cauc they art.' incxpen
sive. effccti'~ e.1sy to .idmint>ICr. .md relatively safe.
TCi\s block u1>take of scro1omn and norcpincphrine to
lfSUlt in stimulauon . l11c first tricrdic agent, imipra-
.,;1141 {lofranil), was irmoduccd in the 1950s, leading to
a group of medications to relieve dcprcs,ivc symptoms
by blocking reuplakc of endogenous ncurohormones.
TC4.s may also as;is1 with p.1i11 cnn1ml. chronic insom
nia, and a11en1ion clefirit/hypcrallivi1y disorder (ADI ID)
569
BOX 306 SELECTION OF ANTIDEPRESSANT
MEDICATIONS FOR DEPRESSED PATIENTS
A frrst- ar.d second- ne choices
1 Secondary al!llne llql:lic antidepressants
2 blJpropioo (We lbtnM. Zybanl
3 fluoxenne (Prozacf-SSRI
4 paroxenne (Paulf-SSRI
5 sema 1ne (Zofoltf-SSRI
6 lralOdone (!Jesvrell
B Altematrie agents lor pat.enU w th Sj)OOill medlC81
consrdelauoos
1 Teruary amine TCAs for the followmg
a Absence of senous medical nass nlud111g cardiac
disease
b Need for rapid sedation
2 MAOls
a Unresponsrveness or 1ntoleiance to at least ooe TCA
b. family or personal hrstO<)' ol response to MAOI
c. Atypical depresSJon symptoms
3. Select an<rOl\fllc med1cat1ons
a. Medical con1ta1nd1ca11ons to FDA-approved anllde
pressant med1cat1ons
b. No adlll!rse cardiovascular effects
c. Low s1de-etfect profile
d. No history of substance abllse
e. Need for quick action
f. Short. limited exposure time needed 101 med1ca11on
FDA, Food and Drug Adminis1ra11on: MADI. morwmme ox1dase 1nh1bltor.
SSRl selective serotonin reuprake inhibitor. TCA. 1ncychc an11d(lpressan1
and are also used for obsessive-compulsive disorders and
enuresis in children.
TCAs are equally effective. Geriatric pa1ienLS are
usually staned on one third to one half of the usual aduh
do~ followed by dosage evaluation and adjustment
based on therapeutic response and presence or absence
of undesirable side effects (Table 303 ).
Atypiul Antidepressants
Atypical antidepressanLS arc second-generation antide-
pressanLS; first available in the 1980s. they are used with
major depression. reactive depression. and anxiety. lllese
medications affect one or two of the neuro1ran>mit1ers-
sero1onin. norcpinephrine. and dopamine-and should
not be taken with MAOls (Box 30 7).
Monoamine Oxidase Inhibitors
MAO ls, such as phrne/zi11e (Nardil), are antidepressanlS
used only for atypical depression when 01her medica
Lions ha,e not been effecthe. These medic"tions have
nu merous interactions with prescription and OTC medi
calion.s as \veil as caffeine- and tyran1ine-containing
 Depressron alcohol, amphetamines.
TRI CYCLIC
anhchohnergics. antih1S1a1n:>es.
ANTIDEPRESSANTS (TSIU)
an11se12ure med1ca:,ons.
barbtturates. MAOls.
pheno1h1a1ioes. an11dy~
~JOOmgPOqd
~250mgqdPO ObsessMHomf)OISM!
disorder. depression
des1pramme IN'JfPlllmm) 100-300 mg PO qd Depression
dceptll ID-JOO mg PO qd
ll!llpramone ITolranill 50-150 mg PO qd
mapr0t1hne 100-150 mg PO tid
noonpty1 ne IPamelo<) 25 mg !Id to 150 mg PO
qd
prompty11ne (VM1ctt1) 15-40 mg PO tid
111m1pram11Y1 ISurmont1ll 100-200 mg PO ud

Mjor Sidi EHtcll of Tricyclic Antidprtssanll: .

Ory mouth. const1pal1on, urinary re1cn11on. 1achycard1a. onhostatic hypotension. blurred v1s1on. drowsiness. restlessness. tremo.-s.
mania. sexual dysfunc11on

ATYPICAL Depression an1icholinerg1cs. guane1h1d ne.

ANTIDEPRESSANTS pheno1h1azines
amoxapine 50 100 mg PO tid
buprop1on IWellbutr111, Zyban) l 00450 mg PO qd
m1na1ap1ne (Remeronl 15-30 mg PO oral
dissolving tablet qhs
traiodone 100-400 mg PO qd in and 1erfenad1ne, estemllOle
dMdcd doses
IOlepuoJ 150300 mg PO qhs
Major Sid EHtcll of Atypical Antidprtssan/3:
amoxaplfl9-EPSs. tardrw dyskines1a /)uproplon-same as for tricycfic antidepressants plus ag1ta11on. insomnia. m1rwapme-
somnolence Wth unusual dreams. increased appetite. weight gain. elevated cholesterol. ftulike symptoms. nefillOdone-
sormolence. sexual dysfuoctJon. ~edatt0n, nausea. vom111og. venlafaxme-diastohc hypenens1on

MONOAMINE OXIOASE Neurosis Of atypical See Table 30-5

INHIBITORS (MAOls) depression
phenelz1ne INatd1ll 45-00 mg PO tid
tranylcyprom1ne (Pamatel ID-40 mg PO 1id

M1jor Sid Efltcll of MAOfs:

Postural hypotens1on. dry mouth. consupalJOn. Ul1118ry retenuon, blurred vision. impotence. insomnia, tremors. COIMI s!OflS

SELECTIVE SEROTONIN Depression, obsess1ve- alcohol, d1g1tahs. a<11ichol~

REUPTAKE INHIBITORS compuls1ve disorder MAOls. phenytoin. tryptophiri
ISSRls)
cualopram !Celexal ZD-40 mg PO qd and c1me11dine
duloxetine (Cymbalta) 60mg PO qd and th1011dazine
esc1talopram (lexaproJ ZD-60 mg PO qd
fluoxetine (Prozac. S-0rafem) lD-80 mg PO Qd
Oii. Oelaved release. EPSs. exuapyram1dal symploms. Gl gastrointesiinal. IM. 1n11amuscularly; MAOls. monoamine oxidase inhibitors. NSAIOs. nom:e~
antiinflammatory drug~ PO. orally.
 CHAPTER 30 Drugs for Mental Health and Behavioral Disorders 571

paroioetioe tpax1l Paxil CR.

Peieval
seroa.-ne (Zoloftl 56-100 mg PO qd

1111 SiH Elfects of Selective Serotonin Reuptk Inhibitors:

A. eJ1!f}I lbbxelllle-sexual dysfunction. nausea. headache
.J111!lia. diaproresis. du/oxer11-oausea dry ... neNOUsness. ill$OIM1a. aiwety. dJUiness. fatigue. diarthea
moum conS11pa11011. decreased appeute. s~

SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR (SNRlsl

oelazodone 50300 mg PO bid t1d Benzod1az panes, prOllfanolol,
d1goxm. stat ns. MAOls

IA/Of Siltt EHects of Selective Norepi nephrlne Reuprake Inhibitors:

Orv mouth. 1rem01S, hypotension. constipa11on, decreased libido, urinary reten110n. diuiness. headache. msomma. d1aphores1s

MEDICATIONS FOR BIPOLAR DISORDER

anp111azole IAbihfyl 15-30 mg PO qd
carbamazep1ne (Tegretoll 200-400 mg PO bid
in11ially, up to
1200 mg PO qd
1th1um carbClnate (Lithob1d) 300600 mg PO dose
vanes by formulation
nrnum citrate (syrup} Varies with ind1v1dual
dva'proex sodium (Oepakotel 500 1000 mg PO qd
val;:rOtC acid IDepakenel 500 t000 mg PO qd
!Stavrofl IDR 750 mg PO qd
Mame depression
disorder. agitation.
major depressioo
Mania
Manic schizophrenia.
aggression in children.
epilerpsv. m1granes
Sch1zophrema, epilepsy
See 1n Table 30-2 also mul11ple
01hers
diuretics. ftuoxetine, anhthyro1d.
halopendol. ant1chohnergics,
phenytoin. NSAIOs
alcohol. aspmn. warfarin.
c1metid1ne, clonazepam
erythromye1n

Mljor Side EHecu of Bipolar 011order Medications:

..n carbooate-flausea ttemors. vomiting. diarrhea. drOWS1ness. loss of equ1hbrn.rn. timitus. frequency ol unna11on.
~edat1on. GI distuibances. tremotS. leukopen1a. va/prOtC ~non. nausea. tremors. hau loss

those with panic attacks or when phobic symp1oms art

foods and be\-erage,; ( IJbles 304 ,1nd lO 5). rood prod
UCI$ GI.USC sudden and severe hypertension tha1 may
progress to vascular collapse if untrca1cd
MAOls inhibit bre,1kdown of norepinephrinc and
1iCTOton1n to pern1it an inc-rca~e of 1he,se ncurotransmil
ters. allowing stimulation of the <.NS for clinical depres-
sion improvement lni1i,1lly, after 2 " 'eeks of 1herap)'
these drugs cau'e dccrca'c in appetite and insomnia 1ha1
continues for approxim,11cly l weeks ,1ftcr disconiinua
tion of therapy. MAO ls .ire indicated primarily for rcsis
tant depression .ind a nxiom hosti le depression. especially
in\'olved. In general, MAOls are most effective in f\'\'CJ'S
ing dysphoric states. but bulimia and obsessive
compulsive disorders may also oc 1reated with 1hese
medications (see Table 30-3).
Selective Serotonin Reuptake Inhibitors
SSlUs are newer antidepressants that block reuprnke of
serotonin 10 inactiva1e its brain act ion, rausing siimula
tion to reverse depressio n. But unlike TC.As. SSRls
have little aciion to block cholinergic, adrenergic, or
572 SECTION V Med1ca11ons Aela1ed 10 Body SyStems

BOX JO. 7 COMMON ATYPICAL ANTIDEPRESSANTS TABLE 30 S MEDICAL REACTIONS OF MAOIS

WITH DRUGS AND FOODS
Bupropion Wt 1> r r Zy1> ( dN;I of C IOICI!
I. I
f!lf illl0k1119 cessaoon tfleral!V Ml:' iy blocs reup1ake of
neuiotr.l0$lllltteu 111 people MIO are unresponsive ID othe< alcohol. CNS depressants Erllaoced CNS dep;ess,..,
anlldeinssaois Severe hypertensive reattcn
local anesthettcs
l\lirtazapinr IRemeronl. a drug en a welHolera1ed class of
antidepressants Elevated temperatures.
medica11ons. increases release of serolon n and norepineph
hypertens1w C11S1s. se 11.
nne to relieve depression. anxicl'(. and insomnia
death
Traz.odorw (Oesyrell a second line agenl for depression.
can be helplul lor pat1en1s w11h an11dcpressanl induced hypoglycemic agents Enhancement of hypoglycern1c1
insomnia A ma1or side effect rs p11ap1sm bupropion Increased risk of to11c11y
V11lafaxinr (EffexcxJ. used for anxiety and depression. buspirone Hypertension
blocksnorep11ieph11ne and serotonin and weakly blocks dopa Cardiac dysrflythrnias.
caffeine
mine. w11h pOlenual 10 produce a ccxnplele remission hypertension
An agent lhat has both antidepressant and ant1psychot1c
dex1rome1horphan Increased excttab1lr1y. tmmeJ
properoes 1samoxap;rrr (Asend1nl Because of s1deeffec1S.
fever. hypertensroo
UUs rnedtCalJOll should be used only fill psychouc depress100
fsee Table ~31 ftuoxe11ne Agitation. restlessness.
gawointesllllal d!suess.
seizures. hypertflllSI\'! D'lSIS
guanadrel. guaneth1dine. Severe hypertension
TABLE 30 4 FOODS THAT ARE UNSAFE AND SAFE TD Rauwolfia alkaloids
CONSUME WHEN TAKING MONDAMINE OXIDASE
levodopa Severe. sudden hypert!rltv~
INHIBITORS
crisis
CATEGORY UNSAFE SAFE meperidine and olher Severe hypertension, increased
opioids excitability, sweating, and
Cheeses, milk Practically all Milk, cottage rigidity
products cheeses. sour cheese. cream
cream, yogurt melhyldopa Severe headaches, hypertenSlO!\
cheese
halluconat1ons
Meals. fresh Beef and chrcl<en Fresh meats,
sausage lr.'l!I; fermented. methylphenidate Hypertensive cnsas
fresh fish
smoked. aged systemoc sympa1hom11nettcs Severe hypertensNB cnsis.
meats. bologna. increased temperat..e.
pepperonr. salami. cardiac asrhythrnias.
dned or CU!ed fish headache, '<Ol1l l"'!I
Fruits and Avocado. lava beans. Most fruits and
FOOD !See Box 3081 POSSIBLE EFFECTS
vegetables figs. raisins. vegetables
bananas, tryptophan and Hyperven11lat1on, increased
sauerkrau1 1ranylcypromine temperature, disonl!l'tat IJl
Foods wrth yeast Yeast ex1ract Baked goods mania
w11h yeast 1yramine or foods Sudden, sewre hypertensr;e
Beer. wine Imported beer. Domestic beers containing large amounts crisis
Chianti wine. ale and wines of pressors
Other foods Protein d1e1al'( Most other CNS. Central norvous svstem; MAOls. monoarnine oxodase inh1bl10rl
supplemems. foods
soups, shnmp histamine 1crep1ors. 'l11erefore SSRls haw fewer <idt
paste. soy sauce effects and arc lhe mos1 widely used amidepRSSJlll
Caffeonated Colas. tea. coffee. Noncaffe1nated dru&< (Box 30 8) SS Rls should be orally admim>tmd
bewrages chocolate dnnks be>e<ages in lhe morning because oft he chance of nel\oosnesund
Chocolate /llri chocola1e Nonchocolate i nsomnia. Used primarily 10 1reat major depression tht
product products SSRls are also approved for obsessive-compulsivt dlWI
Ginseng Herbal produets Nongmseng ders. Care should be taken with panicipation in hwrd-
containing ginseng herbals ous activities un ti l symptoms of dizziness as a sideelft11
can be eva luaied (see flo x J0-8).
 CHAPTER 30 Drugs for Mental Health and Behavioral Disorders
BOX JO 8 SELECTIVE SEROTONIN REUPTAKE
INHIBITORS
, fluo.ttlin !Prozac) 1s often prescribed for this class
because 11 is as effective as tricychc antidepressants with
fewef side effects and is less dangerous when taken in
o;e1dose Although not approve<! for these uses by the Food
and Drug Administration, Prozac is the preferre<I agent for
p.l!I c disorders and premenstrual syndrome Other uses
n:lude buhmoa. alcoholism, anention-defic1t/hyperactivi1y
disclrdef. bopolar d1SOfder. premenstnual migraine headaches,
-<! obesity It should be used wo!h ca1e m patients with
tes melhtus and those with suicidal tendencies.
, Strtmline IZoloft) 1s also frequently used for posnraumatic
ues.! syndrome, obsessive compulsive disorder. panic disor.
de. p1emenstrual syndrome disorder. and seasonal affective
disorder
Clrnfoprnm ICelexa) is a medication used only with
depression This agent does not produce a sympathomimet1c
re.;ponse or anticholmerg1c act1v1ty and thus have fewer side
er.eCIS This me<location can be used wrth monoamine
c:xiilale mil botors (MAOls) and should not be given oot I
2..wei.1 aftllf MAOls have been stopped (see Table 30-31
Selective Norepinephrine Reuptake Inhibitors
SNRl1 are nor related 10 TCAs, M/\0 1;., or SSRls; rather.
the 11\'0 medica1ions in 1his Clegory, reboX<!liue (Vestra)
and aromOX>?tlru. (Stra11era), enhance transmission of
norqimephrine. These medicdtions induce remission
"""" used for shon-tenn therapy and prevent relapses
Ill long-term use. The chief 1nd1cation for these drugs is
for paumu with severe depression who also have difli-
rulty with social funcLioning (sec 1.1ble 30-3).
Natural Reuptake Inhibitors
In fl'CCOI rears, increased interest in herba l supplements
aaing as NRls for trea1ment of dcpre,sion by stabilizing
srnnonin and norepinephrinc h,15 developed. Studies
hal-e shown !hat S1 Johns won is helpful for mild to
modm1e depression but not for "'-"'-ere depression
ll011e-1!1', herbals do interaa adw~I) wi1h many drugs.
Other na1Ural produas, induding Si\M-e and 5-H'ffi
ina~ production of serotonin 10 r<1;ulatc mood and
fmouon Ginseng and Ginkgo have also been lned 10
uea1 depression.
Antimanic Medications
1\ntimanic medica1ions are used for the patient 'vi'."
b1rolu disorder. 111 which ahcrnating episodes of mania
ind ckprosion typically ocrur In the m~oc suue. _a
h<igl11entd mood, with hyperactivity, excessive enlhus
'11m. O\'eracuvity al work or play, nd a reduced need ~or
ilttp, is .lpparcnL Extreme self.confidence. excess"."
aoc:iabilny. and extreme 1.1lkativencss arc charactensuc
573
BOX JO 9 ANTIMANIC MEDICATIONS
llt/1lum, ll1e most COOYl1C<1 v ~ .d ..,.dteatJOn fO' mama.
ac1. as a mood stab1hzer Used Pltlllhylactallv to reduce the
frequency and seve111y of mania. htti1um appears to reduce
hyperac11v1ty and excucment while allowing organ1iat1on ol
thought patterns Indicated for treatment of 1nd1v1duals wllo
expeneoce large shifts mmood, mania.' alternating cycles
of depression and man a. lithium can conuol svmpwms 1n
both phases jn the acute manic ~la\B, i1hium reduces hyper
atUV1ty w thoot sedallOll and may be comhr>ed W th benlo-
d1azep1nes ' armpsj'dlollc ac,ietits that SU!ll'fess symptomS
until h!h1um can be effective If depressroo occurs. an anti-
depressant. such as a mcyclic aniodepreU<W. mus1 be goven
because lithium does not prevent episodes of depression,
although early symptoms may be controlled
Cnrf1amaupi11e ITegretol), 1alprolr adtl IDepakenel,
and dlvalproex sodium IDcpakotel, ong1nally marketed
fo1 se11ure disorders. have recently been used to treat bipolar
disorder Carbama1epone reduces symptoms during manic
and depresslVI! attacks and 1s used prophy1acoca ly fOI
repeated anar:ts Valprooc acid. ant1psydlotJcs, and dnial
proe.< sodium are prtJmtS ng a terna1r;es IOI bthlooi few those
who have not responded to hth1um or cannot tolerate its stde
effects Both of ttiese med1cauons control acute manic epi-
sodes and may prevent recurrent episodes of mania and
depression while being especially useful with rapidly cycling
bipolar disorder. For more 1nforma11on about carbama1epine.
valpro1c acid and d1valproeK sodium, sea Chapter 29 under
ant1se1zure medicahons
signs. Thoughts and idea1ions are unrealistic in Lhe
manic phase.
Ideally, bipolar disorder is trea1ed with a combination
of medications and psychotherapy because drug therapy
alone Is 1101 opLimal (Box 30?). Poor patien1 compli-
ance is often found during 111ank episodes because the
pa1ient sees nothing wrong with his or her thinki ng or
behavior. rurthermore, the manic episode may not be an
unpka>alll experience. Family is an imponam factor 10
ensure pa1ienL compliance with medication administra-
tion during mania and depression
..
Patients laking monoam1ne ox1dase inh1b11ors IMAOls)
should keep a list of foods and OTC medications mat contain
caffeine or tyramine so these can be avoided lsee Table
30-41
2. MAOls cause d1umess. low blood pressure. diy mouth, con-
st1pat1on. and blurred vision, and unpotence on males
J Pauents should repon feelings of faintness. doffirulty w1tti
unnation. agrtanon. or iaundoee wlleo taking MAOls.
CM!nrtwd
574 SECTION V Med1ca11ons Related to Body Systems
I
Patient eilucation"for
~~~--
-
1.,C omplianc"e-cont'd
4 PatJelll.l should morutor blood 1RSSU1e and pulse vAlen
ra<mg IJJC'jtlic an!Jdepressants
5 Atryooe talang tncytfoc ao!Jdeprezsants should not take arrf
medocatJons. espeoa 1y OlC mooicauons. without permis-
sion from tile phys1c1an
6 lnsomma, nausea. loss of appeute. headaches. and ner
vousness are common side effec1s of SSRls
7 Because of noncompliance. common wllh any psychotropic
or antidepressant med1cat1on, pallents should be encour-
aged 10 take med1cat1ons as prescribed
8 Theiapeuuc effects of psychotropic med1ca11oos may not
occur for SS'Jeral weeks
9 Patients should inform a health care professJOOals of
cunent antldepressan llierapy
10 Antidepressants should be taken oo a daily baSls, not as
needed
11 A Iselec!Ne seroton111 reutxake mlubitors (SSRlsl should be
adm1111stered with food
12 Patients tak no l1th1um should be mon11ored for
hyperglycemia
13 Patients must mamtain adequate sodium intake when
taking lithium, a reduced sodium lovel causes an increased
lithium level
14 Pauents taking lithium should drink at least 10 glasses of
Huid a day
Antidepressants are slow to provide therapeu11c responses
fnmal responses dew op m 1 to 3 weol<s. but maximum
response develops 1n 1 to 2 months Therapy should con11nue
for 6 to 12 months alter reltef of symp1oms
Tncyclic antidepressants (TCAs) cause sedation, orthostat1c
hypo1ens1on. dry mouth, alld coos11pat1on.
TCAs and moooamine ox1dase inh1b11ors (MAOlsl cannot be
combined because of the danger of h\'l)llrtensive crisis.
Selective serotonin reuptake 1nh1b1tors (SSRls) have fewer
side effects and are safer moverdose than TCAs.
SSRls may cause insomnia and nervousness. TCAs may
cause sedation
Serual dysfunction is more common with SSRls than with
othef antidepressants
TCAs 300 MAOls may cause orth0stat11; hypote11S1on,
wllereas SSRls do not
Suicidal tendeocies should be evaluated 1n all depressed
patients. espeoally ~ medcat1ons are being prescnbed
and taken.
L1th1um, used for bipolar disorder. 1s teratogenic
I,] ;iit&J 4' ;(ii'): I4fol 4;(jIMfUI
AJ7belm.,r'~ dl~e.ue is a deva_statin~ illn~ char
ized by progressive memory fa1lu~ 1mpautd thin \
confusion. disoriemation. personality ~anges. rCll),,,.
ness, speech disrurbances. and mab~hty to l'ftfocll
routine tasks. rragically. the disease 1s mcurablt ~
affects about 250,000 new i1~dividuals per }'eai Qin
cally, progressive decline of intellectual functions nd
redu~tion or de1criora1ion of neive pathwa)~ haw
recently been shown 10 respond ~o therapy wi~t cholin.
esterase inhibitors and 1111m1atttrne (Namenda) {lablt
J0-6). Most pharmacotherap~ ~s foo1sed on imprO\'tng
cogn itive functioning or l1m1tmg disease progmsion
and control of symptoms. In Alzheimer's d~ase. act!).
choline (ACh) is decreased (ACh is necessary for ll<U!1>
uansmission and for fanning memories) IDd Lltui
cholinesterase inhibitors are used. With tnetnOI) Ion
comes confusion, wandering. agitation. and ~'l
which seem to intensify in the early t'\~ning~ phmo.
menon called sundowning. No specific test for
Alzheimer's disease exists; therefore a definitive di~
sis i~ possible o nly on autopsy and possibly with bram
tissue ch.111ges as seen o n computed tomography KJnS
When all o ther causes of dementia have been roled ow.
Alzheimei's disease is a probable diagnosis (8ox 3010),
Investigation is being done into the use of NSAIO!
and vitamin E to decrease the risk of the disea$e and to
prevent and trea t early )'mptoms. Evidence indicata
that a fink exist between the disease and inRammauon
Estrogens Jppear to reduce disease risk in postJtJmr
pausal women because estrogens seem Lo unpt""
memory. If needed, medications for delusions. agiu:ioo.
depression, o r anxiety may be used in pauems wilh
Alzheimer' disease; however, TCAs must be usnl "D
care because of significant anticholinergic aetions.
Razadyne. a medication for slowing of Alzheime(s d1seaie is
derived from daffodil bulbs.
. .. . .
Alzheimer's disease 1s a relentless illness characterized
progressive memory loss. impa red th1nl"rg Pl!l1IN
changes, and progressive mab1hty to perform rw111e td1
Tacnne causes modest unprovement m 30% ol Al~ s
disease patients. the other 70% do not respond
Several med1cat1on categories are being invest.gated tu
to slow the disease in Alzheimer's patients
 CHAPTER30 Drugs for Mental Health and Behavioral Disorders
lfOOepelll (Ancept) 5-10 mg PO qd
eryllloid mesylates 1 mg PO tld
,,,as1igm1ne (Exelon) 15-3 mg PO bid
4 6-9 6 mg patch qd
~ne (Namenda) 5-20 mg PO bid
~ ne (Razadynel 4-12 mg PO bid
JWaityne ER) 8-16 mg PO bod
IH~iH Ctr.ct.. donepez1/-flausea. d1armea; memanrme-d1zzoness. headache. confusion. oonsttpa!IOn. hypertenst00.
liS/llDS. i'lonsteroodal antnnftammatoiy drugs, PO. orally
BOX 30-10 DRUGS FOR AUHEIMER'S DISEASE
Da11epnil (Aricept) is similar m mechanism of action to
tacnne and has lhe same effectiveness. Approved by Food
and Drug Adm1nistrat1on (FDA) for Alzheimer's disease. done-
pei1Idoes not affect the underlying disease p<ocess Unlike
tactine. donepez1I does not cause liver damage.
Cala111a m iroe (Razadyne). ant1dementia medication.
ele-.ates brain's acetylcholine concentrations to slow
degeneration
Menumtiroe (Namenda), recent medication approved as
anu-Alzhe1mers agent. 1s used to reduce detenoratoon of
chohnerg.: nerve pathways with moderate to severe
Allhe1mer's disease (see Table 30-6)
Ril'fUfigmin" (Ekelon) 1s a chohnesterase 1nh1b1tor that
atts much like Razadyne
DRUGS USED FOR ATTENTION-
DEFICIT/HYPERACTIVITY DISORDER
~ttentlon dcficll /h)pHdctlity dl,ordr {AOllO) is a
common behavioral di~order in children. with an average
of one ADllD chi ld in each classroom. Symptoms of
manention, h)'Peract1vily. and impulsivity begin be1ween
the ages of 3 to 7 and persi~t int o the teenage years. Roys
aie four to eigh t times more likely to lrnve ADI I P than
girls. Children with Al)l 11) arc fidgety and unable to
575
Alzheimer's disease an!Jcholi11er91CS
Alzhe met"s disease N'lfll!
Alzheimers disease None
carbonic artrydrase iM1b1ton
Alzheimer s disease
Alzheimer s disease Cmetidine. kl!roconazote.
paro1et111e. ervtrvnmvt1n
complete tasks, jumping from one activity to another
with an inability to concentrate o n schoolwork; they
tend to be impatient in class, never \Yaiting their 1urn.
Diagnosis is made when symptoms occur before 7 ye.i rs
of age and last for 6 months.
Th e exact underlying pathology for AO HD is unknown,
but sympto ms do respond to stimulant medications (see
Chapter 29). CNS stimulants should be used for a year
or less with an interruption because growth suppression
caused by these medications occurs. More impona111,
continued treatment should be assessed yearly. Summer
break is a good time for long-term interruption. and
weekends and holidays are good times for shon-tenn
interruption.
The mainstay drugs for ADHD are methylphmidall!
(Ritalin, Concena). dalroamphetamiM (Dexedrine).
amplretamine sulfau (AdderaJI), atomautine (Strat
tera). and li&dtJ<OmfetamiM (Vyvanse) (Table 30-7).
These drugs will haw increased warnings for children
because of hean disease and psychiatric effects found to
happen in later life {Box 30-11 ).
Child1en taking medications for ADHD who require more than
one dose per day shoold take morning dose alte1 lxeakfast and
last dose by 4:00 PM to prevent insomnia.
 576 SECTION V Medicauons Related lo Body Systems

TABLE 30 7 DRUGS USED FOR ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

USUAL ADULT DOSE.

INDICATIONS DRUG
GENERIC NAME/ ROUTE. AND FREQUENCY
FOR USE INTERACTIONS
TRADE NAME (SCHEDULE I Of ADMINISTRATION
I I I ,-
! '"'
nartolepsy 1 t

amphetamine sulfate 5-30 mg PO qd 1n AM to bid

(Adderall) 1111
atomoxe11ne (Suattera) 40 mg PO qd
dextroamphetamme 515mg PO bid
(Oexednne) (II)
hsdexamfetam1ne 30 mg- 70 mg PO qd
(Vyvanse) (II)
melhylfilen1da1e IR11alm) (II) :Z0.30 mg PO" qd m 23 d1v1ded
doses
10 mg uansdoonal patch di
daily
20-40 mg PO daily m cfolided
doses
(Coo:ertai 18-36 PO qd

Majo1 Side Ett.crs: insomnia. resllessncss. tachycardia, anorexia. dry mou1h, diarrhea. talkativeness; m~thylphenidale--iRSOfMia,
growth suppression. headache. abdominal pain. lell1argy, listlessness. weighl loss. dry mou1h. 1rntab1ilty; atomoxetme-fleadache
dyspepsia. nausea and vom111ng, fa11guo. decreased appetite. dizziness. al1ered mood
AOHO, Attent1on-delici1/hype1ac11v11y d1s0<der. CNS. cootral nervous system; MAO/s. monoamine oxidase inhibitors; PO. orally
"May be grven iwice a day in morning and mdafternooo

BOX 30-11 MEDICATIONS FOR ATTENTION -DEFICIT/HYPERACTIVITY DISORDER (AOHD) AND ATTENTION-DEFICIT
DISORDER (ADD)

Mnhylphenidate IRrlalon). Schedule II med1cat1011. rs the
most commonly prescribed drug Cognotrve functions of
memory, read ng, and anthme11c improve S19nrficantly Use of
a stimulant would seem 10 be the opposite of the expected_
Children respond drama!lcally to this drug wrth an increased
attention span and wellfocused behavior. with decreased dis-
1rac11bili1y, hyperactivity, restlessness. and impulsiveness.
Because the child can concemrate on the task at hand. impul-
siveness and hyperact1v1ty decline. Melhylphenidate does not
suppress rowdy behavior but improves attention and focus_
The drug comes in susta1ned1elease tablets that are adminis
1ered once a day in the morning Also available are slandard
tablets. taken two or three umes per day in the morning and
at noon bu1 may be given at 4 00 PM rf behav10< 1s 1mpulsrve
at home after school_ Dosage is 1nc1Mduah1ed according to
JfllP'Oemeni <1 symptoms and appearance of sKle effects If
possible. the medica!JOO 1s 001 given on weekends and dU1ing
the summer. known as a drug hollct..
Dutroamphetamine IDexed11ne and others). also a Sched-
ule II drug, is as effective as methytphemdate. on fact some
children who do not respond to Ritalin will respond to
dextroamphe1am1ne Dexednne has a rapid hrne of actllll "'
adm1nis1ta11on occumng al 8 00 NA and 4-00 FM.
Another amphetamine-based central neMJuS system ICi
s11mulan1 is li1duamf"tamine (Vyvanse). wh1dl IJIJ''des
consistent 12-hour ADHD control Only ooe dose per d<l, 11
needed for therapeutic effects.
Tri cyclic anlldopressants may be used to decrease hyperac11
ity but have lillle effect on impulsivity and ina1tent1on Toi~
ance frequently dovelops within a few monms. and pauel\ls
taking these medications should have a drug holiday lell
effective and more dangerous than CNS stomulants, 11lele
medications are the second choice for treaunem
Clmridin" (Ca1apresJ. a med1cauon for hypeltB'IS
reduces hyperactivity and impulsiveness Sedanon and llf,0-
1ens1on that occur with this medication make nan a
med1cauon to be used only rf absoWtely neede:l ~
Chapter 26)
A new med1cauon used for AOHO. atomoutine (StrJlt!ftl
not a Drug Enforcement Administration (DEA) scl~JJled i!l!lf>
cation. sclec1rvely inhibits uptake of norepmephnne. caus ng1
calming effect (see Table 30-7)
 CHAPTER 30 Drugs for Mentlll Health end Behavioral Disorders
Mosl medlCallOllS IOI ADHD, Drug Enforcemem Administra.
.,..,. 10EAI Schedule II medications should be trealed with
proper prataUllOOS
Gcals of AOHD med1cat1ons are 10 reduce symptoms of
hyperactMty and reduce steep attacks in patien1s with
narcolepsy
.oovnon side effects of amphe1amones are insomnia and
'!#II loss
SUMMARY
Ole ability 10 cope with life's sircssors at different life
s~igcs is the basis for mental health. "No rmal " can be
difficult to define; ii varies from lime to time culture
111 culture and person 10 person \.lental illness affoos
~lm<t evel}-one <lunng life stages, either themselves
or their family members. Causes of mental ii Ines; mJy
be congenital deficiencies, heredit,1ry facmrs, or trnu
matic evems. Trca11n ent o f nwnta l il lness has made
g)Jnt steps in the past 60 ycaN with introduetion
o{ new psychiatric medication~ Today, most mentally
all pmons are lrcated as outp.uicnts rather than
m1mutionalized
'l\\'O main 1nental ;11ness caicgories are neurosis
and psychosis, both o f which 1)roducc such symptoms
;o, agitation, hyper,ac1ivi1y, and inappropriate behavior.
\rurosis produces fear or anxic1y from either real or
unknown dangt>rs. with respom<'\ producing many
symptoms; drng therapy involve< anxiolytics, or minor
tranquilizers. Anxiolytics, us('d to treat prolonged
anxie1y, may " lso be used as hypnot ics and sed.11ives.
mu~le relaxants, adjuvant medical ions for convulsions,
nd treaunent ror alcohol abuse withdrawal. Antianxi
ft) medications c.rnnot be used ror prolonged periods
of time because tolerance, habatuJtaon, and physical
nd psycholog1c dcrcndence onay occur. Benzod iaLe
piowi. Wl're int roduced in the 1960s and continue
10 bt some of 1hc most widely pocscribed anxiolytic
medications
l'sychosis occurs when a rerson as out of control. out
of touch with rt>ahty, .md wlable 10 communicate. rreat
ment for psychosi< iucludes p'l)'chotherapy and ,rnti
f'\)'Cho1ic medic.11ions, ,1lso called neuroleptirs or nwjor
1ran1[11ilizers. 111c h rM ant ipychol ic ,agents, introduced
on the 1950s, chang('d mental health treatment bccau~e
of lheit ability 10 >uppres.s sdu,ophrenic symploms
nd other psychouc condition< by ac:ting on the
577
neurotransmouer dopamine in the braon Major side
effe<;ts with these drngs are extrapyram1d.1l >ymptoms,
ta rd 1vt> dyskinesia, parkinsonism-like symptoms. akatlli
~aa, a~d dystonic reacuons that art' more likely to occur
tn children In general, anupsychotics are used to reliew
psychotic symptoms or 5"'ere neurosis, 10 rehew nausea
and vomiting, and for potentiation of analgesics. Chil
dren and geriatric patients require special c.ire when
using the>e drngs.
Depot antips)'Chotics are used for longterm mainte
nance therapy. With these injectable medications, patient
compliance is enhanced and the patient ~ maintained
at the highest possible level of functioning.
Antidepressants are used for both endogenous
and cxogt>no us depres<ion. In many depressed people,
neuro1ransmi11ers-ser01onin and norepinephrine-are
in shon supply, keeping nerve cells from functioning.
Drugs are used to increase lewls of these monoamines
to elevate moods. Croups of medications used fordeprcs
sion include TCAs, MAOls. SSRls, and SNRls The TCAs
are th e usual firs t line of medication, followed by SSR!s
o r SNRls. MAOls have mauy side effeca., , have many drug
interactions. and require severe dietary rcslrioion.s;
therefore they are used only when other antidepressants
do not provide relief In recent )-eatS. herbal supplements
haw been studied and used 10 relieve mild 10 moderate
depres:>ion.
I ithium, a slow-acti ng drug. is tl1e medication of
choice for bipolar or manic-depressive disorder espe-
cially in acute manic auaw and may be used prophy
lactically to prl.'\-ent these atlaclcs. 8enLod1azepines or
other ,mtipsychotic agents may be used until lithium
become> effective.
Al7hcimer's disease, a progressive illness, causes a
decli ne in in1ellec1ual and physical funrtions. Medica
tions for use to slow advance of the disease have been
speciflcally approved but are not cures for the progl'essiw
devastation caused by brain changes. ln""tig;ition is
being do1ie to stlldy use of NSAIDs, vitamin[, .md estro-
gens with Al;;heimer's dbe.ise.
Mei hyll' henidate is 1he d mg of choice fo r AD HD, but
amphetamine sulfate. dl')ltroamphetamine. or lisdexam
fetamine may be used. Olese drugs increase children's
anention span and enable goal-0rimted behavior but
require drug holidays, on weekends and during summer
10 overcome growth su1>pression, a major >ide effect.
One of the newest dn1g.~ for this condition, aiomoxeti ne
(Stra11era), does no1 have an amphetamine base and
causes calming by inhibiting uptake of norepinephrine.
Within the past half.century, with the introduction
of anxiolytics and antipsychotics, use of mental health
medicatio ns has incre.i sed rapidly and hJs changed
health care in many ways: perhaps the grea1es1 of these
is Lhat now most mentally imbalanced persons are
able 10 live work, and contribute in their home
commun1lies.
578 SECTION V Medications Related to Body Systems

Scenario
Lakeesha is a 10-year-<Jld who has been diagnosed wrrh ADHD and is treated with me1hylphenida1e
lhree tmes a day Her mother calls to tell you rhat she is givmg the med1cme m the mommg, a1 school,
and al supper Lakeesha has been unable to sleep.
1 At what umes do you think Dr Merry intended Lakeesha to take the medica tion?
2 Her mother also wants to know why Lakeesha cannot take the med1cat1ons on weekends and
during the summer to help with her hyperactivity. What reasons do you think Dr. Merry would give
Lakeesha's mother'
3. What side effects from the drug can Lakeesha and her mother expect?
4 In what class of controlled substances is methylphenidate?
5 What does that mean to her family when prescriptions for Lakeesha are necessary?
6 How 1s the drug effective against ADHD?

DRUG CALCULATIONS
I . Order: Ativan I mg stat then bid 2. Mt>llari l 15 ml.
Available medication: Ava ilable m edication:
HOC001'-00013 1
4 1loz(11 8ml)
()QNCENTAATf_

MELLARIL: zw
(thloridazine) HCI ::;
0<al solution, USP
30 mg/m1 ....."'
0

Dose to bt' given: - - - - - - - - -- - -

Dost> to be given: - - - -- - -- - --

How should this m edicatio n be diluted l>eforeadmin

istration ? - - - - - - -- - - -- --

Show the amou nt o f medication for di lution and the

amount of di luent on the utensil pro\ided.
 CHAPTER 30 Drugs for Mental Health and Bah1V1oral Disorders 579

REVIEW QUESTIONS
Wha1dasses of d rugs a re used 10 1rca1 neu rosis? rsydiosis?
--------------~

2 Whal are other nanws used for anxiolytics?

~~~~~~~~~~~~~~~~-

l Wh~t are three use for anxiolytics other 1han reduction of anxieiy? - - - - - - - -- - -- - -- -

5 \\1iat are the uses of n euroleptics? I low are they effect ive in the 1rcatment of schi1,ophrenial - - - - - - -

6 Wha1 is meant by a low-potency antipsyd1otic? ln1crmediate-po1cncy1 1ligh-potencyl - - - - -- -- -

1 Whal is an a1ypic.1I amipsycho1ic medication? I low are these effective?---- - - - - -- - - -- -

8 What is a depo1 .rntip~ychotic agen t! What is the main indication for use of a depol an1ipsychotic 7 - - -- -

9. Wlm are the three cl.tsses of ma1o r antidepressants'-- -- -- -- - -- - - - - -- -- - --

10. Wha1 is the use of lith ium, and whal condition dOt'l> ii treat?-- -- - -- - - -- - - -- -- -

11 Why are medic.iiions effeoive only in slowing signs a nd symp1oms of Altheimer's disease?-- - - - - -
Misused, Abused, and Addictive Drugs

After studying this ch4pter. you should be capable of domg the fo/lowmg
D1scuss1ng dangers of drug abuse Describing actions leading to misuse or abuse of
Recognizing med1cauons used ror treatment of prescription and nonprescription medications and
alcohol abuse identifying factors of possible misuse and ablJse.
Discussing illegal abused drugs and their effects. Providing patient educauon ror compliance with
ldent1rying misused or abused prescription medications used to treat diseases and eood1tl0f\s
medications in the m isuse, abuse, and addiction to drugs

Mr Godd10, age 45, has lower back pain and early emphysema. You find Mr. Goddio's blood pressure
ro be elevated, and laboratory tests show an elevated lipid profile. He is known to smoke one to two
packs of crga1ettes per day.
How does this habit increase Mr. Godd1o's chance of cardiovascular disease?
What would you tell Mr Goddio it he asks why it is imponant for him to stop smoking?
What types or products are available for prescribing to help Mr Godd10 stop smoking? What are their
side effects?
How would you answer Mr. Godd10 1t he wants to know why the dosage of medication is gradually
decreased throughout the program?
Will the med1catoon be effective 11 he does not want to stop smoking? Why or why not?

Cirrhosis Dysphoria Inebriation

Delirium tremens Euphoria leukoplakia

EAS Y WORKI NG KN OWLE DG E OF MEDICATIONS USED TO TREAT SUBSTANCE ABUSE

I. .. '.
' '.
Substance abuse deterrents Yes Yes c. o.x Cessation of alcohol ard
nicotine use
Narcotic antagonists Yes No 8, C Dctox1r1ca11on 1n narco1c
abstlllcnce

580

c.o-n Signs and Symptoms of Drug Abuse end Misuse
(llanOeS mweight and sleep habtts
1mpa1ted memol'(
I liJ9<311hlnk1ng
Mood swings. lmtab11ity, depression. angor
Defensiveness
ArelY and overreaction to difficult s1tuat1ons
~ 1n l'ltal signs
lll'llY riose. nasal stuffiness, bloodshot eyes, sweating
~ 111 f"ends and appearance
ll drug_s. prescription or over 1he coumer (OTC),
A 111clud1ng those used for self-medication, have
thr po1ential for abuse and misuse. Each patient's
"1UJI needs should be evaluated, and only appropriate
mcdic.iuons should be prescribed. Physicians who indis-
cnm1n.itl)' prescribe medications wi1hout looking into
ph)~ial complaints and the pa1icnt's medic.ti conditions
arr misusing medication. Prolonged and unsupervised
taking or medications is also drug misuse. Drug abuse,
llOwl!'<'Cr, is self-medication on a chronic basis in quan-
tities causing physical or psychologic dependence and
inabilily to func1ion within socially acceptable norms.
Takingan1ihistamines or analgesics cilher too frequently
or'" doses no1 recognized as acce1>tablc is an example
<i rmy day drug abuse. Some patiems jus1 enjoy feeling
higli and w11l 1ake medications to achieve this feeling.
Drug abuse and misuse arc no1 new phenomena; they
h~-e occurred throughout history as a way to relieve
~rsonal , physic.ii. psychologic, soci.11, and/or economic
problem'!. Since the dawn or civiliz.11ion, mind-alteri ng
drug.\ have held fascination as a me.Ills 10 el ~va1e mood,
induce hallucinations, and modify lilinking. Abuse is
n01 related 10 any certain socioeconomic, cul1ural, or
tlhnic group bu1 is found al all societal levels.
Mn! aher1ng med1cat1oos. s11ll used in some cullures today
during religious ceremonies, may come from sources considered
socially or 1ellg1ously accep1able. such as herbals.
fr!itilti';tUMt1t1:tii=iit1i abuse also has degrees or severity from occasional use 10
Drug abuse m.1y be described as usmg a drug incon~is
rentlywilh medicI, social, and/ or nihural norms '"hale,
drug misuse relJles to using a medication in an
CHAPTER 3 1 Misused, Abused, and Add1ct1vt Drugs 581
Common Side Effects of Abused ind M11used Orugs
Dr~1ness. const1pa1ton
Hallucma11ons
ligh1headedness. dizziness, headache
lmpo1ence
Cardiac a1rhythm1as
Nausea. sore mouth and throa1. diarrhea
RespiralOIY d1s1ress
Elvthcma prur11us. local edema. rash
Mental tonf1J1ion
BOX 31 -I DEFINITIONS OF TERMS USED IN DRUG
ABUSE ANO MISUSE
Drug m ..-Nonspecific or md1sairnmate use of drugs
Drug abuse-Orug use not preswbed by a physician, or
improper or excessive use of any drug
Drug h.1011-frequent md1scnm.na1e drug use. causing a
problem when anempang 10 s1op use
Drug dependency-Physical or PSYtholog1c need 10 use a
drug to achieve a sense of well-be mg or 10 avoid withdrawal
symptoms, not the same as add1c11on
Drug habituation-Drug use so frequem that 11 1s part of
dally 8CllVltl8S
Drug add1caon-tompols1ve, excessive. or consiam use of
drugs 10 achieve a desired stale .,.,,th resulls being harmful
10 1he petSOI\ sooery, or both
Drug tole<ance--tond1t100 rn which an increased amotl'lt of
a drug 1s necessary 10 p<0d1Jce the orig nal effect because
the drug produces less elfec1 than when prev101Jsly takllfl
Withdrawal-Effect eXl)Einenced when drugs of physical or
psychologic depend!lflce have been d1scont1nued
inappropriate manner Each ins1ance of drug use musl
be evalua1ed for potential drug misuse and abuse. Large
dosages of psycho1herapemic med1cations may be neces-
sary in certain populations, whereas these dosages could
very well be abused in another population. An instance
or acceptable medicinal use versus abuse would be use
of opioids for relier of acu1e or chronic pain found wi1h
cancer and other painful conditions, which is an accepl
able use. versus use of il1e same drugs by healiliy persons
to ge1 high. which would be considered abuse. Drug
habimal, compulsi"e and romine use. Box 31-1 shows
1he 1crminology of subsrance abuse.
Drug and alcohol misuse. abuse, and addiction are
major social problems in 1he United S1a1es today. One
 582 SECTIONV Med1cat1ons Related to Body Systems
can pick up any newspaper and find arucles concerning
abused drugs. from stimulants to depressants. from
agents causing a high to those bringing abusers d0\"'1.
One major social concern today 1s theft of medicatiom
such as analgesics and anlidepressants by children,
usually from famil) members. for personal use or illicit
s.ile Drug abuse is defined as use of a drug for purposes
other than therapeutic Drug misuse or abuse is indis-
criminate Ul>e of a drug.
nie most frequently misu~d and abused chemical
substances are xanthines and caffeine. found in coffee.
tea, caffeine-cont~iningsofl drinks, and chocolate, which
produce mild stimulation, t>uphoric effeets. and physical
dependence- that is, the substance is necessary for per
fonnance of daily tasks witho ut experiencing symptoms
such as headaches, sleepines\ and lethargy. This abuse
1s shown in the person who must ha,e a caffeine-laden
be\-erage in midaftemoon to be able to complete the
day's work.
Drug or substance abuse 1s a mult1b1ll1on-<1ollar-a-year problem
with a significant impact on all aspects of society and affecting
people of all cultural and economic backgrounds Substance
misuse or abuse affects every person in tho United States. either
d11ecdy or indirectly, in social, economic, medical. or interper-
sonal ways. Assaults. rape. and child abuse are often related to
substance abuse. whereas traffic accidents and fatah11es often
involve alcohol and drug impairment
Factors that Contribute to Drug
Misuse and Abuse
Se\-eral faaors conuibute to drug abuse or progressive
use of drugs. Curiosity concerning medicinal effectS
often leads to psychoaaive drug use. Orug abuse may
begin with occasional misuse for feeling good and then
lead to a compulsive need for drug.- or progression
from experimentat io n with dn1gs to compulsive need for
and use of substances (I.lox 31 2).
Different abused drugs can be detected m the unne over differ-
ent lengths of trme. For certain drugs. prolonged use can extend
these times !Table 31-1)
BEHAVIORS FOUND
WITH DRUG ABUSE
Drug misuse or abuse is often unplanned, beginning
with experimentation and steadily increasing from there.
rhe person who starts with '~eekend use may start to rely
BOX 312 FACTORS IN ORUG ABUSE AND MISUSE
People m1gh1 first uy a drug out of curiosity0t peep
but feeling good" leads to ronMued use If lhe ckug
caused negatM! feelings. drug use would SIOP
Physical dependence is based on Ille size of the dose aii
length of 11me used The more physically deperrjern tile
v1dual is. the more likely withdrawal symptoms.,
Physical dependence plays an important role when ll!r
son's need is to alleviate symptoms. although other 1ea
may lead to dependencies. When withdrawal symp1~
begin. another dose ol drug is taken for relief of sympill'1il
resulting 1n ongoing drug abuse.
Psychologic dependence. a craving for Ille drug wnh aSlrll'.fl
need tor a feeling of well-being. leads to addiction. U.nexi
step past abuse
Social status and social approval. related to peei fJtru!
may cause continued use of medications t!Y!l!I
the drug causes an unpleasant result This is tr. h
reason for contmoed expenmentaoon with
of abuse
Drug availabl/1ry allows drug abuse development and~
ued use of agents
Vu/nerab1hty to drugs allows some people to be more
10 become drug abusers or misusers. Individual d1ffurerte1
lead some people to experiment with a drug ooce and n!l'I'
try 11 again; others will try a drug one time and imJ1'E(i 01>1~
develop a compulsive desire. Once an abuser of one arug.
the more likely a person will abuse other drugs
Psychosocial disorders such as depression and anxiety IBlll
to cause persons who are 1mpuls1ve with little tolerance
frustrallon to become rebellious toward social expecta'.
leading to abuse.
GenetJCS. especially with alcohol use. have been llDl!ll
play a role m drug abuse and misuse. Alcoholism n
abuse are seen as diseases with familial tendencies
Tolerance 10 otherwise mtolerable Stlua/JOl1S 0CC1Jrs
drug use allows a person to alter his or her stale ol ~
sciousness. with a rapid onset of desired effecl$ rut d
wnhdrawal symptoms 1f the drug is d1scontmued abr
Feelings of shame and inadequacy, personal cooft1cts. ard
predlsposnion to depression are avoided wnh drug abus~.
with the abuser bel ieving he or she can Junction aCte11ta~~
in society.
on drugs to assist with difficult situations during tht
week. Weekend use becomes insufficient and incm..,
to seve~I times a week or daily, until dru~ becomt J
~tch many uncomfortable or tensionproducing sit
auon. Often, fami ly members become awart of tht
problem on ly when d.1ily dn1g use becomes the lll<fl
mode of survivi11g. or the norm (Box 313).
 _ ._...:C...:
HAPTE
...:: R3 1 Misused, Abused. and Add1ct1Ve Drugs 583

TABLE 31 I LENGTH OF TIME FOR WHICH A DRUG

CAN BE DETECTED IN THE URIN E
Drug abuse 1s using a drug 1n a way that ts oncons1stent
DRUG DURATION With medical cuotural and SOClal norms witr>in a gNen
~ <I day population
rnplllwn<nes Drug abuse 1s not a new pllcnome1m bu1 has OCtlltred
Up to I day
t1a1b1Males throughout h1s1<Wy 1ll\lolv1ng herbals and presc11bed 01 OTC
Up to t day med1ca11ons as well as sir~et drugs
benrodiazepines Up to 2 days Drugs used lor self-med1ca1100 are often Utose most abused
CllCl ne Up to 2 days or misused because chtoruc use aod excesS<ve dosages are
~ngleuse Up to6days not delccted
,.. ;ana-mul11ple uses Cu11os1ty IS a lead ng reason IOI begnlUlQ dlUg use A deslr
Up to I mo
~ ids lsl1ort-actingJ
able leehng elte< drug use is usually a rea~ IOI cnnt1nued
Up to t day drug abuse or misuse
jtlencyclid1ne lPCP) Up to 6 days Physical dependence has built in cond1t1ons such as taler
it"'noba1bllal Up to 6 days ance levels and withdrawal symptoms when che drug is
Stopped
Psycllologoc depeuder ice leads to add1Ction because of
craving for lhe medicaMn tll agr11
Drug ava1lab1hty. sooal status. and social acceptance are
1easons for continued use of drugs
BOX JI 3 SIGNS OF DRUG ABUSE Parents shouldwatch for loss ol prescription medications, as
this may be a sign of !heh by cM01en IOI use 0t 1lhc1t sate.
Pllyi1c1I Signs
iianges in sleeping habits and 1n weight and vital signs
lack of muscle coord1nat1on. with slurring of words
le1hargy and illnesses on a more frequent basis

Psychologic Signs DRUGS OF ABUSE NOT REQUIRING

D111ession and apathy
Ari!l\' and overreaction
Concentration 1mpa11men1 and shortened memory
lo 1b<l11y 10 organ1ie ond 1nflexibillty to changes in planned
1ehedules
I .og cal thinking and confusion
Social Signs
Mood swings. 1mtab1l1ty, anger
Defensiveness and overreaction to social situations
Decreased school or work performance and absenteeism
fa. hogs of inadequacy
() respect IOI authority and dist:iplmo
~ lhe casting aside of old fnends
Drug withdrawal symptoms indude nervousness.
ninny nose and sturtine!ll>. sweating, bloodshot or puffy
t)e<, lnbility 10 s1.1y still, ,rnd ch,1nges in vital signs
including variation in blood pressure and pulse with
rapid r\'Spiralions. l)cath fro m rapid wi thdrawal is 1>os-
sible. Withdrawal symptoms cau;c 1lw abuser to become
d~te for the next dose and willing to engage in any
.ictf\ lly to obtain the needed drug.
A PRESCRIPTION
Some dn1gs are easily obtJined legally in society.
Often 1101 considered drugs. nicotine and alcohol are
read ily available for person> or legal age. llecause or
the ease or procuring these leg.'ll substances. dangers
are often ignored until abuse ocrurs and 1rea1me111 is
indicated
Nicotine
The chief source of nicotine. a liquid alkaloid, is tobacco.
Nicotine has only one therapeu1ic use: to provide pro-
duas for smoking cessation assistance (\vhich seems
ironic). 1lowewr. nicotine is or great phannacologic and
toxicologic interest. Readily .1bsorbed through the skin
and the g;1stroi111es1.inal and respiratoty tracts, compo-
ne111s of IObdCCO smoke include potelllially dangerous
materials. such as carbon monoxide. hydrogen cyallide.
ammonia. and coal l3I, which are known carcinogens.
Smoking cigarmes. pipe tobacco, or cigars is the great
est single cause of prevc111.1ble illnesses and premature
death, produdng complex and unpredictable 1>harmaco-
logic effects. Secondhand smoking-inhalation or ciga-
rene smoke b) nonsmokers- has been shown by I.he
Food and Drug Administration (lDA) to lead 10 as many
health risks and harmful rfftttS (or more than) as
584 SECTION v Medications Related to Body Systems
: ..
I ABLE 31 2 EFFECTS OF NICOTINE ON THE BODY
lnitlil ty slo;o'1 heat1 rate but later
causos acceleration
Per ptieral blood vessels oonstrict
but latet dilate. causing drop rn
blood pressure
Causes coronaiy hean disease.
myocardial tnlarcuons,
arte11oscleros1s
Nervous system Affects vital organ funcuon
regulated by CNS
Causes tolerance and physical
dependence
Increases levels of comsol am
catecholamines
Urinary system Atts as antid1uretic
Gastr0cntest1nal Increases gasmc acids
system Increases gastnc muscle tooe and
mouhry
Causes gas111c ulcers and chronic
dyspepsia
Causes loss of appetite
Immune system Decreases immunity
Causes mutation of cells leading
to precancerous cells
Respiratory system Decreases lung volume
Decreases air now
Causes pulmonary emphysema.
acute and chronic lxonchitis
lntl1!ases nsk or sodden infant
death ~(SIDS)
Reproduc!M! system Results 111 low bltth wetgllts of
111fants born 10 smokers
Increases chance of congenrtal
abnormal111es
Increases nsk ol piernatunty
smoking itself. Nicotine may c.1use acme toxicil)' in chil-
dren who ingest or inhale tobacco products, or chronic
toxicity may occur from long-term use or association
with products. Use or chewing tohacco and snuJT leads
to leukoplakb and cancer of oral cavity mucous mem-
branes. a traumatic disease. See Table 3t-2 for cffeas of
nicotine on body systems.
Nicotine interacts with other dru~. ~moking increases
metabolism of acdaminophen (1)'1cnol), caffeine,
oxaupam (Serax), penrauidne [lalwin), propranolol
(lnderal), and theophylline, requiring higher or more
frequent doses. Cessation of smoking may result in
BOX 31 -4 DRUGS SPECIFIC FOR SMOKING CESSATIOH
B upropion IZyban). which has the same actJ-e 1-
as the antidepressant Wellbutnn. reduces aaving lcr
une and reduces nicotine withdrawal symi:ccms To be ef.t
tM!. treatment takes about a week wh11e the pe!Stl'I ~
smoking. so an anempt to stop smolung should not be_
until the second week of treatment This medication ltot:1
be taken for 7 to 12 weeks II the smokmg has not Sll.WeJ
by the seventh week. it rs unlikely this med1cab011 w 1 ~
effective
Va re uic/111e IChantix) partially activates bfarn's AICotJre
receptors to reduce craving for and withdrawal symptoms of
nrcotme. The medication reduces the urge to smo(e arll
blocks the ellects of nicotine ii smoking resumes T~l1'.1!
takes 12 weeks and may be repeated for a second 12-llllGI
penod This med1cat1on shoold also be taken for 7 dais IJ
to an anempt to stop srnolcang is made
increased insulin effect, so insul in dosage may nctd ID
be decreased 10 prevent hypoglycemia.
Early signs of nicotine overdose are nausea and vomit
ing. severe abdominal 1>ai n, diarrhea, cold swea~ ~nd
severe headaches. Disturbed hearing and vision; confu
sion; hypotcnsion; and fast. weak, or irregulJr pulse m
found with advanced overdose.
Smoking Cessati on Products
Nicotine tnoking cessation products come as ublcu.
gums, lozenges. nasal sprays, and transdcrmal S)'Sltml
to prevent the experience of acute nicotine witl>Jn,.
Products are available as prescription and O'J'C 1~
Tablets, LO assist with absti nence.. are taken owr ~
months (for at least 3 months but no longer tlun 6
months). with reduced dosage as the person adiusis IO
nonsmoking. Bucra l absorption of nicotine is slowfl
th an inhalation, so ins1e.1d or smoking. nicotine ~urn u
chewed, with the number o f pieces per day decrmed
over a peri od of 2 10 3 mo nths. Transdennal patcherne
worn for I G to 24 hours dai ly to mimic daily use or cig.i
re1tes wi th lowering of scrum nicotine at nighL Nicoune
nasal spray, which more closely simulates smoking. t<
faster than gum or patches and has the same effic.m
Patien ts should not smoke while using spray, nouhould
it be used with other nicotine produru, Tht Liltt
smoking deterrent is a vaccine (NicVAX) used to mlaxt
pleasurable effects of smoking (Box 31-4}.
Smoking ress.111011 agems should not bt uS<d br
patients who ha,e angina pectoris, cardiacdysrhythmw.
insulin-dependent diabetes mellitus. hypenvu1on.
peripheral vaS<"u lar di,casc, peptic ulce~ or a historyol
myocard ial infamion ('l~1ble 3t-3).
 CHAPTER 3 1 Misused, Abused, and Add1cuve Drugs 585

Use of mcotme
products

I mg a 2 Sllfavs per
nostnl (I or 2 doses
per hour up to 40
doses per day)
I transdermal patch
per day (16 hr)
oral inhaler 4 mg
INICO'ene NICORehel. 912 pieces ol gum at
Thmoe) (OTC) 1 to 2hr mtervals
(up to 30 pieces
per day)
(Commit) Dissolve lozenges 1n
mouth
(N~ollerm CO) I transdermal patch
per day (24 hr)
(N~VAXJ lniectable
,areniclme (Chan\lx) 0.5 mgI mg tab PO
bid
lxlprop1on (Zyban. as well 150 mg PO qdbid alcohol. TCA. ntonavir.
asothersl tramadol

M1jor Sid Effects of Nicotine Deterrents:

All-Nausea. tachycardia. headaches. dimness. increased appetite. 1nd1gestion. insomnia; gums and Jozenges-<lamage to mouth.
tseth. and dental work: transdermal patches-local rash or pruritus

ALCOHOL AND OPIOID DITTRRENTS

acamprosate (Campral) 666 mg PO t1d Alcoholism
L.nn (Antabusel 125-500 mg PO qd Alcoholism alcohol. 1soo1az1d. warfann
~ (Oolophnel 20-120 mg PO qd. SC, Opioid abuse alcohol. warfann. cometidone.
IM selegdllll!. furazohdone
0 42 mg SC. IM, IV Opioid abuse Decrease effect of opioods
!JO mg PO qd Alcoholism. opioid analgesics. cough preparations.
' :re.une (Revoa. Depade) 'f preparauon wilh alcohol
380 mg IM q4wtc misuse
!'{~troll
base

Mljft Sift fleets of Alcohof nd Opioid Deteffents:

J1S1Jl>lram--<1rows1ness. side effects such as nausea and vom111ng are desired; acamp'OS8te-1lrarrhea. gas. loss of appetite.
dumess. weakness. 1tch1ng, naloxone-tachycardra. drowsiness, nervousness
.M. lnlralllU!ICUla.ly; IV, intravenously PO. 0<allv. SC. sullC1J1BOOOusly. TCA. mcyclc ant1depressams
586 SECTION V Med1cauons Related to Body Systems

Important Facts about Medications . ,

for Nicotine Abuse ' : ...' . ""--': .: 1
r.. Ul6 Iran agarene smol.ing 1s absctbed 11 lhe lungs.
...eas rucotine from cigars am smokeless tobacco 1$
dLJS.>'bed in the moo ui Both are caftlnogerut
N:cot ne 1J11nally 111Creases a ertness lac1htates melllOf'(.
improves coqn t1ve IU11Ct1on and suppiesses apperne.
bot loog-rerm use causes mul!1ple hfe-threaien1ng
diseases
N1cot1ne causes tolerance and physical dependence. with
craving. nervousness, restlessness. 1rnwb1hty, rmpat1ence.
host1hty, insomnia increased appetite. weight gain, and
unpaired concentra11on
few peop e achieve long term success wh0<1 anempung
10 Quot smoking. even Y.1th noco11ne 1eplacement therapy
Only when Ille person desires 10 cease noco1111e use will
medotatoans f~ smoting cessation assrst rn break ng the
habit
N oo:.ne replacement therapy is eva1 ble 11 sut forms
tablets, uansdennal pa1ches chewing gum. lozenges. oral
1 hall!f, and nasal spra\11. wtllCh are available by pieSC11p1000
and OTC
Smoking cessauon agents cause belching. tachyca1d1a, head
aches. increased appellle, S-Ofeness of 1h~ mouth and lhroat.
dimness. and 1nsomn1a
The lastes1-working n1co11ne subs111ute 1s the nasal spray
having the same efficacy as palches
Transdenmal patches mav cause local ormat1on
According to the U S Department of Heailh, a1atc:tis:i
the third most senoos pubhc health problem, folloormg ~
disease and cancer
The mouthwash Cepacol contains 14.5% alcohol 129
whereas Listerine coniaons approximately 27% a~ IS!
proofl. Vicks 44 and Vicks Nyquil conta n 1004 alCQld
proof). The liquid appeute stimulants Allerton1c, Elder.
and Hadacol are actually multivitamins rn alcohol base$
Physical dependence causing use of larger and largn
amoums of alcohol with denia l and tolerance iscommoo
with chronic use. 'lllose with physical dependenct 1o
alcohol tend to have cross-dependence on olh<t C\\
depressants such as barbiturates and benrodimpton
When alcohol is discontinued after physical d~
delirium lrt'mens may occur. With chronic uw d
alcohol, detrimental efrccts 10 body systems will ,Ilona
life expectancy ("IJblc 31 4 ).
Drug Interactions with Alcohol
Drug inter.1C1ions of alcohol with o ther medicaiionsm11
be add it ive, or alcohol may jus1 change the effec1ivelle\i
of medications, causi ng many detrimemal symfl(om1
even li fc-1hrea1cning ones (Table 31 5). For pa1ien1 safety,
a general ru le to be followed with medications is dut
alcohol should be avoided when taking prescription'
OTC medications unless the physician is aware oftht
patient' alcohol consumption.

ETHYL ALCOHOL OR ETHANOL

TABLE 31-4 EFFECTS OF ALCOHOL ON THE BODY
Alcohol, one of the oldest and most abused drugs in
the United States, is a central nervous system (CNS)
BODY SYSTEM EFFECTS 1
depressant. Alrohol does have some medicinal uses- Gastrointestinal liver damage by
for example, as a vehicle for cough suppressants and as system accumulauon ol lats
a germicidal in mou1hwashcs. 1\lcohol is often m isused and proteins, leadll'IJ Ill
or abu;ed 1.hrough use of OTC medica1 ions such as cirrhosis and hepa1111s
nighttime cough and cold prc1>ara ti ons containing Erosion of gas1nc mi.o:nsa
antihislamines; some have as much as 25% alcohol (or with gastnc bleed1rg
50 proof). Elderly individuals may u* ~thyl alcohol- Esophageal vances
based medications as appetite stimulants during Pancreatins
periods of disability or convalescence or may use Nervous system HepallC encepha~
alcohol preparations for mt when other hypnotics Urinary system
cannot be tolerated. Effects are dose dependent, with
Acts as diuretc br
high doses causing depression of the medulla and thus stWesslllQ~
basic life funaions. The most common concern is non- hormone
medical chronic use by heavy drinker$. ausmg atrophy Resporatory sys1em Depresses resporato"O
of the cerebrum and loss of intellectual functions. Jn Nervous sys1em Produces toletaoce
extreme doses. alcohol may produce a11esthesia that Central nervous SY$~
could be lethal. depressant
 CHAPTER 31 Misused. Abused, and Add1cbve Drugs 587

TABLE 31 5 INTERACTIONS BETWEEN MEDICATIONS education with disulfiram ls ex1.rcmely 1mporwni.

AND ALCOHOL as any alcohol consumption (e.g., cough ~yru~.
A1.COHOL COMBINED cooking sauces; mouthwa!.ho, products applied to
the skin such as liniments. afttrsha'e lotions. per
WITH MAY CAUSE fumes; and any product containing .ilcohol) may
L~tiOn too- sleep, Increased physical and produce 5"'-ere and potentially faul reJct1011;
tralQllifaers 11SYtholog1c dependence i\camprosate is used along "1th coun~ling and
~ts Rapid 1ntoxicatoon social suppon to help persons a\-01d cravmg for
l.lliOlil S1Ciness medicauons and drinking of large amoun~ of alcohol A
Excessow drowsiness delayed-release tablei must be admmistered thrl'e
Pairl rel,_s. muscle Mental confusion times a day but does not caUS<! alcohol aw~1on ~
rela.ants. ant1allerg1cs. found with disulfinm and does not CJUS<! reac
~ $lalllilleS
tion when alcohol is ingested Ho"'"'"r. this m<'<ll
~.ais too- angina 01wness. fa1ntmg cation does increase suicidal tendencies
pedlll'IS
Aot'1\'P"tensr.oes lack of skeletal muscle Othe r Alcoho l Preparation s
coordmatoon
Agents such as aspmn, Increased gastric 1mta11on Toxic alcohols include isopropyl alcohol and methyl or
~SAIDs. anticoagulants, and bleeding wood alcohol. When unable to purchase ethyl alcohol
potassiumsupplements o r ethanol, some alcoholics will substitute isopropyl
(rubbing) alcohol or methyl alcohol (antifreeze) for
Some ant1bootics. Nausea, vom111ng, and consumption. Either of thCS<! will prevent alcohol
metronidazol e ftush1ng withdrawal symptoms but potemially cause poisoning
01al hypoglycemics Tachycardia, dyspnea o r death.
Aoucoagulants. seizure Changes in effectiveness or
medications. hypoglycemics medications rn controlling
specific illness
NSAIOs. Noostero1dal ant1inflammatory d1ugs
..
1. Disulfiram should not be administered un111 at least 12 hours
have passed since the last ingesuoo of alcohol Patients
should avoid all alcohol products. oo matterwtial form, while
Drugs Used to Treat Al coh o lis m taking Antabuse
2 Many OTC and home remedies contammg alcohol cause
For those who have chron ic alcohol intake with dcpen sedation and hypnosis without the person takmg 1he med1ca
dtnctoralcoholism. certain med ications m.1y .1s.ist with 11on being aware or this content
withdrawal symptoms. lkn,odia,cpincs (tr.rnquilizer<; 3 People may beCOOle less self-conscious when dnnk1ng
1tt Chapter 30), at"11olol fl~normin; sec Chapter 26 ), alcohol and may oot reahze the dangers of e>Cessive
md ultrttane (Revia) arc used to ~urpre~ these symp drinkrng
toms. Rat>arch has shown dccreas<>d craving for alcohol, 4 Some states require a witness for adm111istratm of
btt drinks consumed, and fewer instances of relapse disulfiram m patients with a history of dr"' ng under the
"1th use of naluexone Once .tbsuncnce has been rnftuence.
Krolllplished, conunued abstinence may be maintained
If nttded by the use of disulfiran1 (AntabuS<!) or
"""'8sale (C1mpral)
Disul6ram's only use 1s 1ts l..nown interactions with
alcohol. discouraging per.on> from drinking and
causingS<"-ere side cfferts when micd with alcohol. Alcohol is a depressant drug
Desired side effects include nausea. copious \'Omit Alcohol increases blood Jlfl!Ssure n duect correlatron to tile
ing. nushi ng, palp11a tio11>, headache. thirst. swe.1t amount of alcohol coosumed Alcohol depresses respirations
ing. chest pain, blurred vh1on, wcaknc'>S, and and leads to hepatitis. crrrhos1s of 1he liver, and erosrve
hypotension that may I"' <ever~ and may last from gastntis.
30 minutes to severa l hours wit h even the smallest Chronic use of alcohol produces tolerance to many of alto
absorptio n of alcoho l (a' liulc .1; 7 ml.}. The hol's effects aJld to central nervous system !CNS} depres
person who docs not have 1hcdcsirc to MOP alcoho l sams except op1oids.
use should not he trc.11cd wi1h disulfiram because (r1"tt11unt
ofi1s ever~ auverse effects (sec 1;1blc Jl 3). Patient
588 SECTION V Med1cat1ons Related to Body Systems
Important Feet about Medications ;'l
for Alcoholism-cont'd . ''
Petsons who arc~ to use alcohol as a medicinal agent
need to be caretu Iv screened for addactrve htstOIY Cauuon
IS alsomdica' lld for people with strong family h1s1orres of
alcohohsm and for 1tme w :II diabetes and peptic ulcer
dlSeaSe
Alaml acts a an additm to CNS depressants.
Alcollol is cardooprotett "when used 111 moderanon and low
volumes lxlt may be add tive If abused
Acampros:ite may be used to il$Sl$t wr!h avoiding alc:Oho4
~
OISuffiram IS gr;en to alcohofocs to a3SIS1 1n refrarnong from
alcohol corwnp1oon. Patient educatoon concerning alcohol is
very important w th this medacat1on.
Only pa11cnts ~nng to withdraw from chrome use of
a' "'1ol should be preswlled drsulfiram because of danger-
"" Side elfllCIS
Ra'<!Jrth II.ls shown that alcohclrsm tends to be familial
Alr.ohcltcs to obtain desired alcohol, may use OTC medica-
llons and agents contJ1ntng aloollol When alcohol is ne<:es-
sary to prevent dofu1um tremens. even toxic preparations
such as rubbing alcohol and an11freeze may be used.
PRESCRIPTION DRUG ABUSE
Use of presrription medications for pain, such as opio ids
and opiates, and Mimu lants uch as amphetamfoes and
use of anabolic steroids, for example. by body builders.
may lead to misuse or abuse when directions for pre-
scripuon are not followed. Person> with tendencies
toward drug dependence often fall victim to misuse and
abuse and finally addiction. lllerefore careful screening
including a familial history is imponant before pain or
stimulam medications are prescribed. The allied health
professional should also be aware of the dangers of per-
sonal use of easily available prescrip1ion medications. as
well as the abusers' needs for these drugs. Indications of
the abuser's drug seeking should also be evaluated in the
medical office.
Opiates and Opioids
Drugs that are frequently misused and abused are syn-
thetic opioids (such as hydrocodone. methadone. oxyco-
done), opiates from natural sources (such as opium
alkaloids of heroin and morphine), and semisynthetic
drugs (hydromorphone, oxymorphone) (see Chapter 15
for more informa1ion as analgesics) . These medications
may be 1aken by mouth, by percutaneous means for
absorption through mucous membra ne$ or skin, by
1eaion. by direct admi nistration into "eins (or ma
J , 'f'h
II
fining), or by sniffing and. snoru~1g. e most frtqlle!>o~
abused prescription pain relievers are '"'Ptrldi.,
(Demerol), oxyrodor1e (OxyCon tin, Percodan, Olnd l'ti.
cocet ), and morpJ1i11~. The .nost fr~uemly abu!td llr<11
drugs are marijuana, heroin. cocaine. and OX)'ccdortt
Oxycodone and meperidinc are prescription dru8' "Iott
frequently abused by health care professional$ ber-.
of ease of availability.
In 1896 the Bayer Company advemsed a rtlNi drug co be
as a cure lor morphine (a wtdely abused drug at ~
wnhdrawaf The new agent was thought 10 be nonaddicti.e ~
new sate drug was heroirt--a drug that 'M! now Mo.. a
a nonadd1cttng cure but a powerful. add1c11ng DEAldtetldel
central nervous system dep<essanl that 1s class fied a:i 1
narcotic
The beginning of opioid use that may lead to m11w
occurs either socia lly or for pain management i11 1
med ical seuing. whereas m ost abuse Stans with illegij
use of a street d rug or inappropriate use ofpre!Oiption
pain medications. Opioids relieve pain; ek>Vdle mood,
rel ieve tension. fear, and anxiety; and produce tranquilify
and peace with euphoria. O ther effects include suppres.
sion of cough and appetite. Al l these effects can le.id 10
psycho logic and physical dcpendenrc. tong.term oonu1>
ued use is based on feelings of 'al l is well' rather lhan1
rush that occurs with earlier administration. The uscrOI
abuser has the perception that the world is roiy ind
bright with no problems. Researchers beli~ that Jiil"
chologic dependence continues throughout life althouglt
desire may be controlled with strong will11oweund po
sonal desire to remain drug free.
Toxicicy lcvels. often found with abuse of these ID<\.>
cations, cause signs such as slow, shallow bre.ih J
leading to cyanosis and hy1>0xia; cold, damm" !hi!.
pinpoint pupils; depressed blood pressure; anddepmord
sensory perceprion. Because rhese agents also ttnd to
decrease gastric motility and reduce perisulsis. 1ncruMll
amounts of medication may be absorbed
Signs and Symptoms of Opioid
and Opiate Withdrawal
Withdrawal from dependency on opioids oralroholwi11
produce symptoms tha t smn approximately 2 to 4'
hours after the last dose. depending on the abu!l'<I drug
Peel ings of restlessness. chills, hot Oashes. restless ll<'tl'>
pilocrection (goose bumps), rhinorrhea (runny n()>().
tearing. and dilation of eye pupil~ occur during lint

H hours. Sneezing. ya,~ning. leg cr. m p ing. vom iti ng.
diarrhea. loss of appetite, swea11 ng. m u~de twiiches.
jn.sOmnia, elevated vital s ig ns, and drug craving follow
.ilen these early sym ptoms subside. In ~omc ca~cs. wiih-
dfaWal sympto ms m ay progre~ to cardiovascular
collapse.
Withdrawal programs provide therapeutic mc~ns for
bJndling symptoms of abmpt. or cold turkey. with-
dnwal by upering the dn1g dos.1ge over a period of days.
u;ing a substitution of methadone for the opioid or
opiate. Methadone. a synthetic opioid analgesic. permits
wbslitution by cross-tolerance. stalls the euphoric cffoos
o(beroinand other opioids. and reduces craving without
physiul and mental effects. Methadone treatment pro-
grims change dependence to methadone, but withdrawal
simptoms for methadone arc less severe (see Table ll -3)
. ..
drawal, chewing or teeth grinding. photophobia, and
, One of the most misused and abused groups of drugs is
the op101ds and opiates. used as pain relievers Morphine.
QxyCon1in. mependme. and hydromorphonc are prescription
nems abused most frequently.
, Opio1ds and opiates. depressant drugs. produce mental
dep<ession and analgesia. as well as cough and appe11te
deprnss1on. The abuser likes the feelings of well being and
e11p00na rather than the rush occurring 1mmed1ately aher
adm nisuauon
Withdrawal symptoms such as restlessness. cramping of the
1egs. vomiting. diarrhea. insomnia, and craving occur with
JJOlonged use of op101ds
Me1hadone ts used in withdrawal piograms for op101d abuse
ABUSED CENTRAL NERVOUS
SYSTEM STIMULANTS
Some CNS stimulants have spific medical uses but are
mo used illegally and ilhcitly. including manufacture of
these drugs in the person's home cnvtronmcn1 . Th?se
most commonly seen arc di!>Cll,se<I so 1ha1 the alhed
btalth professional h.1> knowledge of 1hc dangers and
signs and >ymp1oms of the user nr abuser.
Amphetamines
.~phetamines. c.1lku ~- uppc~ or ,.wed
.-- . have both
medical and illegal "'es. Medkal ly presn1bcd .u.n~hel
.
anuncs are cIc1ss111UJ
L. a~ l)rt1g Fnforccmcnl
Adm 1111stra-.
tion (01:.A) Scheduk II drugs, used 10 ire'.11 chroni.c
fatigue syndrom e, obcMly,. narco Icp.sy au e n uo rl dcficn
CHAPTER 3 1 Misused, Abused, and Add1ct1ve Drugs 589
d isorder, and mental depression. and to tombat side
effects of narcotics in terminally ill patients ("'e Cha~
ters 29 and 30). When used illegally. they increa!oe ph~'St
cal performance and provide ps)'Cllologic stimulus lne
most frequently abused amphetanunes are methamphet-
amine cice or "crystal meth"). which may be smoked
or taken orally or inlra\'l't\ously. A rapid rue rn metham
phetamine use and manufaaure using OTC medications
such as cold and allergy products containmg pseudo-
ephedrine has caused the FDA to placr hmrts on Ol'C
s.1les of produru containing pseudoephedrine. Stores
have m'~ these drugs into the pharmacy or bdlind the
checkout area for safekeeping. with a ltmtt on purchases
per person 10 once in 48 hours.
Amphetamines provide more confidence alertnes\,
and talkativeness. with hyperactivity and a fttling of
euphoria and a sense of arousal. Amphetamines are also
anorexics, so the person feels no need for food and
therefore weight loss occurs. Other symptoms of poss1
ble il licit use include irritability, confusion. social with
parano ia. Compulsive behaviors drive users to repeat
drug use again and again lO maintain euphoria. Physical
depe ndence is moderate. but psychologic dependence
m ay be intense. . .
Sig ns o f 1oxicity with a mphetammes are Ous~11ng or
pallo r, palpilatiOnS, tremo~, extreme 0uctu,l lt0 11S Of
pulse and blood pressure, c.hest pain, sweating. dllaled
pupils. and m ental disturbances. Treaunent is symp-
to m atic, as no antido1e is '"-ilable for am1>he1a 111mcs.
Abrupt withdrawal will produce a disagreea~le nn~
depressed mood-an experience known as a cr,1sh.
These m anifestations, especial ly 1he depression. m.iy
persist for m o nths, causing resum ption use of
amphetami nes.
Cocaine
Cocaine has been used for years by native Indians of
South Americ.1 to ward off fatigue and hunger. In the
nineteenth century cocaine was considered a ~wonder
drug for numerous medical conditions. but m 1914
legislation restriaed its use. ll''t'\"", tts ~.as a recre-
ational drug dramatically in~eased begjnnrng m the
1970s. causing numerous SOC1al and m~rc:a~ problems.
The only approved medicinal use of coca.me ts as a local
anesthetic applied topically. usually f~r ~asal procedures,
because of anesthetic and vasoconsunruve propemes.
Coca-Cola originally contained cocaine from the coca plant-
hence the name and nickname Coke.
590 SECTIONV Med1cauons Related to Body Systems

I ffem of cocauw arc Mm1lar to tho~ of amphet

amin~. wnh the lntcnsi1y and duration of the effeas
lx'ing dependcni on purity of preparauon and n;'ethod
of admin1mauon Cocaine. because of itS denvauon Cardiovascular system Tachycard1a
from coca lea"cs. can be converted to a water-soluble Hypertension
hydrochlonde <>.lit in a powder form for oral, intranasal. Myocardial intarctJOo a:.i
and intra\'enous adminmrAtion When it is used as a thrombo
drug of abu~ the usual route is intranasal-snoned- RespiratOIV system Lung nfecttoos and ~
for rapid nasal mucosa! absorption Pulmonary edema
Coca1nt base, which 1s a CJ}'S"11hne rock form. gets th_e Pneumon1t1$
name cr.lCk from the cracking sound it makes as 11 Atrophy of nasal 111UC0$1 ~
bums Powdered. pure cocaine is cut by adding such snorted cocaine v.>lh 1 Jos:s
substances as comstArch or b.lking soda to raise drug of smell
,olume. thus increasing 1ts street value. Unfonunatcly, Necrosis and perloratm ol
drug purny or 1he amount or cocaine is not predictable, nasal passages with
and potency will vary greatly from one dose to the next. intranasal use
When cocaine base ("crack") is smoked (or freebased). Severe resp1raoory sys1er.1
rapid absorption occurs 1hrough the lungs. Euphoria damage occurs when ot'l!r
(high") received from smoking crack cocaine is rapidly subs1ances of abuse arv Uled
replaced by d}sphorl, ("down), and the cocaine user mcon1unct1on with coca ne
repeats d05e$ 10 n1.1u11.1in euphoria.
' I he half-life of cocaine is shor~ with symptoms sub Urinary system Acute renal fa1lu1e
siding in I 10 2 hours, leading 10 acute intoxication. As Nervous system Seizures
a llCrson uses cocai ne. tolerance develops. causing an Strokes and increased
incre,1se in need forihe drug or in amount used to obtain intracranial pressure
1ltc same euphoria. For this reason cocaine addiction is Reproductive system Leads to stillbirths and pieh
difficult to tre.11, and no antidote is available for toxicity labor
("1ble 316). Congenital deform111es
Acute withdrawal symptoms n
the infant. with behavior
... '. Psycholog1c health
delays throughout life
Paranoia and dep1ess1on
Psychosis
Amphetamines, nicoone, and cocaine are CNS stimulants Su1c1de
that are of1en abused Dependence with severe si
Amphetamines are called "uppers or speed" and have both and aud11ory. vtSUal, irld
medicinal and 1llrc1t mphcat1oos tacule hallucma1oons
Amphetamines pioduce oompuls ve behav10rs. causing usetS
to repeat drug u~e again and again
Treatmeflt lor amphetamine or cocaine tOXJC1ty must be
$V'11!l0fn<ll< as no antidote ts b'oO'Ml
Barbiturates
Barbiturates (see Chapter 2?) 1ypify the CNS depr'1Wl'll
u-i for illicit purposes Depressant clfcru m dolt
ABUSED CENTRAL NERVOUS dependent and range from mild sedation to *'P
SYSTEM DEPRESSANTS or coma.
Used indiscriminately, barbiturates art al!ef
R.1rbiturates and benwdhu.epines (as well as alcohol. downers. They produce symptoms including dr<!"
discussed earlier) are often abused CNS depressanis. ness. confusion, impaired judgment, slurred spttd1. l!rd
These agents have many safe therapeutic applications lack or facial expression. Route of administration iso<J;.
when used as designed by the manufacturer and pre- or intravenous injection in a liquid form. Acute tol<id~
scribed by a physici,111. I lowever. because of the potential produces three expected signs: respira1ory deprt\<IOn
for abuse. tolerance, and physical dependence, these coma, and constriction or pupi ls 10 pinpoints Symr
medica1ions are regulated under the Controlled Sub- to ms include nausea and loss of appetite. llfboonJ
siances /\ct. rapid-eye-movement sleep and nightm.ircs occur oa

,.1thdfawal of medications. No specific a ntidote is avail-
Jblt for b.lrbiturate intoxication.
eenzodiazepines
litllZ')(liazepincs. commonly prescribed fo r anxieiy and
in!Omnia (see Chapter 30), .ire safer than barbiturate<>
Mid ate rarely lethal whe n taken alo ne. Da nger comes
when dru~ are combined with o ther CNS depressants
!UCh as alcohol. Benzod iazepines are generally no t con-
!idl'fed street drugs, but misuse, abuse, and d ependen-
cies have been rcpo n cd, ~specially with diazep11111
(Valium), afpra.wl11111 (Xa nax), and lorazepam (Ativan ).
-~a rule. 1olcmnce a nd physical de pendence a re only
minimal when these dn1gs are taken fo r medici nal indi
auons, but a substantial problem can occur with mbuse
cw abuse..
J<>r the patient w ho has built a tolerance and abu-e
It.el. gradual withdrawal by changing to a long-acting
btnWC!iazepine is recommended. Symptoms of with-
dml-al uidude increased an><iety and irritability, twitch
ing. aching. muscle weal.ness. tremors, headaches.
nause~ anorexia, depression, lethargy, hypersensitivity
1ostimuli, blurred vision, and sleep dismrban ces. J Jealth
care professionals s ho uld be aware that pro lo nged use
of benzodiuepines is d ,rngerous even for the rapeutic
rt.isons. especially in elderly patients who use these
medications for insomnia and daily anxieties. Plumau-
nll (Romazicon) is specific as an antagonist for bcnzo-
di.v.epine toxicity a nd seda tio11 reversal.
'' ' . - .;. . 1injiOrtiilt1 Fai:iSl'About Marijua_~~UsliJI
Balbitlllates and benzod1azepmes are cOllVllOllly abused prn-
""!'1100 medications because of lhe1r use for anxiety rnl1ef
mws
Tolerance. a ton1rnon ellecl of barbiturate and benzod1aze-
use, leads to physical dependence.
Wl'"drawal from barbiturates and benzod1azepines should
lit gradual when tho drugs have been used for prolongc<I
engths of ume
Marijuana and .:H
:..:..::
a.:: s.:.:
h;:is
:.;h
:..;__ _ _ __ _ _
ltarijuana and hash ish, cla>sified as C NS depressams,
Clase euphoria, sedation, and halluci na_tion~- Drug
potmcy of tetrahydrocann.1binol (THC) van es wnh con-
diUOIU under which the hemp plants. Camu1bis saru<1.
""' grown Resin from female plants is kn?"'ll as
/uilmh, whereas the dried plant (seed. Hower. C\"1gs. and
la."tS) is the basis for m,on 0uana. These d rugs. known as
lllllMblno1ds, ha-e street names such as grass, weetl, hemp,
1\fary /ant, pot, and tlope; rnttrijuan(1 cigarenes are knO\ Vll
:ossrogil'$, joi11u, or re1'f,rs.
CHAPTER 31 Misused, Abused, and Add1ctove Drugs 591
When smoked, marijuana has its dim in 5 to t 5
minutes. peaking at 30 to 90 minut.- wnh a durauon
of 3 to 4 hours. Because of fat solub1J11,. 111c; " tak...n
up m fatty body tissues and thus met.ibolw.-. ,fowl>
with 30% 10 50% of the drug remammg \\ccJ.. later
When smoked, hashish is rapidly absorb..-J through the
lung.' A maior side effect of mari1uana 1s lung damage.
with a greater risk of cancers Mari1uan.1 produc'S a
greater amount of tar than its eqmvalem weigh t m
tobacco and contains more carcinogens th.in 1nbMco
s mo ke.
Marijuana produces three subjective effens: sedation,
~u phoria, and someti mes hallucinations No other dnig
produces a ll three responses, placing mariju.rna 111 J class
by itself. When the drug is taken orally, practically dll the
n IC is absorbed but is inactiva1ed by fir;t pa~~ through
the liver, so three to 10 times as much marijuana or
hash"h is required to obtain the same effeo ;as found
with smoking. When ingested, marijwna may hJ'e
some effecti\'eness for up to 12 hours (Tablt> 31 7) .
lolerance occurs with marijuana use, with rapid rever-
s.ti after product cessation. Abrupt cessauon af1er pro-
longed use is associated with psychologic \)'rnptom~
from the phy.ical dependence. Symptoms include d)"
phoria, anxiety, tremors, eating and sleeping distur-
ba nces, and increased sweating. Psychntic rcaetions and
;icut~ p'-111icanxiety reactions occur with inexperienced
users who are not familiar with the effects or with those
who h ave taken high doses or have experienced pro-
longed marijuana use.
Maniuana 1s considered 10 be a central neMJUs system
depressant. a though 1t causes euphona before sedation and
halluc1na111ins
Maniuana 1s fat soluble, leading to absorpt on in fatty body
11ssues. providing proklnged effects
Maniuana produces throo effects-euphoria w11h gaiety and
heightened sense of humor. sedation with lethargy and
memory toss. and sometimes halluc1na11ons caused by per-
cep1ual inadequacies and increased sensory s11mul1
Tolerance occurs w11h marijuana and is rapidly reversed w11h
cessa11on of use.
HALLUCINOGENS, PSYCHEDELICS,
AND PSVCHOTOMIMETICS
llallucinogens and psychedelics (m10d-ah~ring d";'l!S)
are agents that produce auditory and visual halluc10a-
tions. or a "psychedelic" state. l'sychoactM? efTectS occur
J to 2 hou rs after administration and may range fro m
eupho ria to panic and severe depression. l'cll!Ons often
592 SECTION V Med1cauons Related to Body Systems
rABl I 31 I EFFECTS Of MARIJUANA ON THE BOOY
: I I
CardlO'lillCulal sy;1em Taclr;card1a
Increased appetJte
6astrOU1le$I nal system
ReSl)lrarorv S'f.>tem 8ronchod1lahon
ll.W"G umauons and cough
Sensory sysfl'!n Coojunctrval redness
lncteased sense of taste.
touch. and smell
Dmoruon ol t1me perceptJon
Pertep1 ual ll'laCXWllClflS
Ner;ous system ShorHerm mel110I'( loss
lmpa "ed leammg w11h
decreased mtellectual
performa11Ces
lmpa red reftex reaction with
mab1hty to mull1taslc
RepioduCllve syslem Oecreased sperm counts and
reduced lestosterOlle levels
lrrElllular menses and sporadic
ovulauon
Reduced es1rogen levels
Tera1ogenic to ferus. lower
birth weights
Psvcholog1c hcal1h Euphoria and relaxalion wilh
gaiety and heightened sense
of humor
Apalhy, dullness. lelllargy,
poor grooming
Reduced interest 1n
achievement {amotrvational
syndromeI
Paranoia and deJ)fession
Psychosis
Suicide
Oependence w11h severe
anxiety and audrtCJIY, visual.
and 1ae1rle halluc.nauons
do no1 realize the difference in self and nonself, have an
increased awareness or sensory stimuli, and often believe
the world is hmno nious and beau1iful. Psychedelics
have the ability to bring aboul the types or alterations in
though~ perception, nd feeling that otherwise occur in
dreams, or psychedelics can c.1use dreaming without loss
or consciousness, effects not seen with other drugs. Lyser-
gic add die1hyl3mide (LSD). dimethyluypiamine (DMT),
phencyclicline (PCP), mescaline, p~ilocybin, and MD1\.IA
(ecstasy) arc examples or these agents. with LSD consid-
ered the pro101ype.
LSD is a poten1 hallucinogenic street drug. io wh ~
tolerance de-relops . rapidly. As wi1h most s1ret1 d11Jl\I.
trengths vary, causing many user problems. llnptfd"'
:ble effeos take place in 20 minut~ indud1ng hiM
tension, dilated pupils, hypenhennra, tachycardll ~
enhanced awareness or activities llnpleaS.lnt ~
ences are frequent, such as altered stales or COlllCl<.a.
ness that cause psychosis to develop, or the d11.1g "I
trigger latent psychosis to become ob~rvablt. Ho~
thoughts may be a result o( acute pamcor J><ltanot.1 Nan
alternating and altering le--els or consdousnas, i oci.
plete state or exhaustion results as drug's dfms "Qr
off-a time when suicide is a risk. Signi6ant llllMl<r
able reactions induced by I.SD may ~ prolon~ ~
or delayed with recurrent flashbacks (bad tnp). Lndioj.
ing paranoia, depression, and schizophren1c P!ld>.xic
reactions.
Mesailine, from Rower heads or the peyott <M1lll
produces effects similar to those or LSD. The ffown m.t
be dried and smoked. or a soluble crys1allint (lOllda
may be ingested either as a tea or capsule Hfl'CU of
mescaline include vivid, colorful hallucinauons ~1th
physical effects or abdominal pain, nausea, vomll1Jl
and diarrhea. Anxiety, stimulation of reflexes, llemon
aJld psych ic disturbances occur wi1h drug use.
Psilocybin, from Mexican mush rooms, produm luJ.
lucinogenic dysphoria simil ar to that from nmcalintbut
o( shorter duration . Mood may be pleasant for lOmt
people. but a pprehension may be produced in others
'J'he capacity 10 make crit kal judgmc111s is poor, perfor.
mance abil ities are impaired, and compulsive h)]ltl\i
netic movemen ts, laughter, dila1ion or 1mpil~ \tfll8"
ataxia, paresthesia, muscle weakness. drowi;ines1. no
sleep occur.
MDMA (3,4-methyknedioxyme1hamphetam1n(j, or
'ecstasy: became prominen1 in the midl980s. Al fol l
was not a regulated drug, bu1 i1 soon became dass11icd
as a Schedule I controlled substance. mdicaung no
medicinal use. Ecstasy ans as both a J>S>'Chcddiond a
psychostimulam agent. Taken orally, this amphtunuoc
derivative produces CNS s1imulation, euphoN. ml
visual disturbances. lhose who use MOMA rtplll a
sense or closeness wi1h peo ple, lowering or ddtn!t\
reduced anxie1y, enhanced commun1ca11on s~lls. IDll
increased sociability. With large d~ panic, ~
paranoia, and signs of sympa1hetic ner\'OU5 S)~tem !IJllo
ulation such as increased hean ra1e. irregular pulw alW
respirations, dilated pupils, and, caused by deataocd
body temperature, v.1soconstrictio n or the blood \'t!ol<ll
in 1he skin are seen.
PCP, or "angel dust: ' acid: or "purplehil.le wasfint
s1udied for use as a gcner.11 anesthetic. Human tJ.I( ""'
subsequently d ropped because or a high incidenct"
delirium, but the drug is s1 ill used in veierinJI)' pr;iclice
Use and cheapness of the age1ll's production al the !Utd
level have led 10 abuse. Effects of l'CI' make ii oneoflbt

1!1(1$td0111gerous and mo>i unpreclictable of abused screet
substances. rcr may be administered ora lly, ini rana .
s.illy. intravt'no~sly, ~nd by smoking. Because of its high
solubility, PCP is rapidly absorbed from all sites. Absoq).
OOCl begins in the stomach, followed by recirculation of
dw blood back to the acid environment of the stomach,
where the drug reenters the intestines for reabsorption
~111 into the blood. This constant recycling through the
body le;tcls to prolonged drug action.
I.ow PCP doses cause CNS stimu lat ion, euphoria, and
!1111~1hetic nel\'Ous system stimulation, ~imilar to the
drtcU of amphetamines or alcohol. With increased
do.es. disorientation, motor incoordination, and slurred
ipeh occur. Euphoria leads to rapid rcle3se of inhibi
tionsand emotiona l swings. llizarre hehavior may occur
with high doses, progressing to dysphoria, caiatonia,
muscle rigidity, hypertensive crisis, coma, and death
Jrr.iment for PCP use includes protection by removing
thf pmon from external stimuli because anti psychotics
dnd JIS}'(hotherapy arc rnrcly effective. Symptoms of
withdrawal must be treated lo provide life support.
!
, f Iucin~s and psychedelics produce auditory and visual
h lloc1nat1ons ow1119 to mcreased awareness of sensory
stmuh
t14ic acid d1ethytam1de (LSD) 1s a potent hallucinogen that
causes Ulljlledoctable ri.. .ponses, some pleasant and some
~t
LSD may produce prolonged, delayed, and recurrent reactions
ol depression and sch11ophrenic and psychotic reactions.
w1h rapid tolerarice developing
Mesta ne rs similar to LSD. causmg vivid, colorful
halhJanatooos
l'srloc)tin produces halluc1110geo1C effects that are less pro-
~ than those of lSD or mescaline
MOMA or ecstasy. a derivative of amphotamme. acts as a
psychedelic and psychostrmulant
Phcncychd1ne (PCP) produces stimulat10'1 and euphona,
to alcohol or amphetamines. Euphona leads to release
al irllibtlons and produces emouonal changes on a raprd
basis
INHALANTS
Benzine (used in dyes .rncl drug production), acet~ne
(nail polish and paint removers), carbon tetrachlomle
(diy cl~aning Ouid), gasoline, trichlorocthylene (anes
thetic), and toluene ar(' volatile hydrocarbo_11s used for
i.nifhng Many of these chemicals are fou 11 d 111 common
housthold products using h)-drocarbons _as propcllan.IS.
Th~ products are relatively mexpcns1ve and easily
CHAPTER 31 Misused, Abused. end Add1ctJVe Drugs 593
bought legally-for example, g.\SOllne, kerosene, ink cor
renion fluids, gas found in aerosol containers, and ..ven
helium found in balloons lhercfore these agents have
become more popular with )Oung people and those
who cannot afford illicit sult~ncn. Although children
and teens are most likely 10 use h)-dl'OGlrh<>ns for smfT.
ing. adults are also abusers.
Bagging. huffing. and sniffing processes are used for
inhalation. Ragging is perfortned by pouring solvents in
.1 plastic bag and inhaling vapors I luffing is pounng the
solvent on a rag to inhale vapors ~nilling is inh~ling the
solvent from its original container AU three means of
inhalation produce rapid general CNS depression wuh
marked Inebriation, dizziness, lightheadedncss. and
intense feelings of wellbeing similarto alcohol intoxica-
tion. Euphoria and hallucinations usually lasting for 15
to 45 minutes are the desired and expected results '>ome
users experience feelings of reckless abandonment and
increased po"er, with resultant aggressiveness, hc~d
.1ches, vertigo, and ataxia. I ligh doses lead to confusion,
brain damag~. and coma, causing perrnanent disabi lity
or death. Sudden death is possible. caused by anoxia,
respiratory depression, increased heart mes, and dys
rhythmias, I-or persons in poverty or economic depriva
tion, glue sniffing may be the drug of choice. Tolerance
to inhalants commonly occurs, those starting with a
single tube of glue per day may progress to three, four.
()r 1nore rubes 10 111aint-ain the sanH? effect.
...
Commonly found 1nloalants such as cleansing products, glue.
hairsptays, lacquers. and paints are abused. especially by
young people and economically depressed 111d1v1duals
Inhalants provide euphoria and hallucmauons
ANABOLIC STEROIDS
Many anabolicadrenergic steroidal preparations a1:e
available for oral or parenteral use. '111ey are thcrapeutt-
cally prescribed, especially for males with low testoster-
one levels and specifically for undenoeig/11 individuals,
but are also used nontherapeutically by individuals who
want an athletic edge. Misuse and .1buse of th~se drug:.,
a growing problem, incl udes the use of anabolic (adren
ergic) steroids by athletes to enhance. athleti~ perfor-
rnance and inrrease their chances of '''1nn1ng 1n sports
e>oenlS. to g;iin strength, and simply to 1ook good."
Steroids refers to a class of drugs, adrenergic refers to increased
masculine characteristics; and anabolic refers to muscle
bu11d1ng.
594 SE< TION V Medications Related to Body Systems
Many org;iniz.iuons. such as the National Collegiate
Athletic Assoc1auons. the lmemational Olympic Com-
mmee, and major league sports. have banned the use of
1hese drugs nie U.S. Congress has even had hearings
because of the increased use of lhcse produru. Misuse
led to the addition of anabolic steroids to the DEA's
con1rolled substance list in 1982.
Readily available on the Internet, anabolic steroids are
known by names such as D-bol, Sten, Deca, and Anadrol.
Some pm.ons use these drugs by c)'chng. involving
taking multiple doses of drug O\"er a period of time. stop-
ping for a ume. and then staning ag;un to increase effec-
tiveness stacking of steroids. or tJking multiple
metabolic steroids at one time. is still a practice used
illegally and unethically by some athletes. Coinciding
wit h thesicroid use. a program of strenuous exercise and
a high-protein diet are used to increa>e muscle mass and
stamina Shon-term efTeru include increased aggressive
behavior and masculinization in females Long-term use
lads to aggression, extr<'l'lle mood swings. and other
J>S>'Chiatric effects, such as paranoia, depression, delu-
sions. and tmpall'ed judgmenL llttausc of misuse and
abuse. steroids are Schedule Ill drugs 1n all states. with
some states making these drugs Schedule II agents with
a high potential for misuse o r abuse (see 1:1ble 28-2) .
~ ..
Anabolic sterOlds are misused by a1hle1es to mcrease body
wetghl and strength
Anabolic steroids are prepared lrom the male hoonone tes-
tosterone. Illus telld ng to mascuhnize U$1lrs
CARING FOR PATIENTS WITH DRUG
MISUSE AND ABUSE PROBLEMS
1lealth care professio nals need knowledge of psichotro-
pic drugs. their actions, and their side effects. When
giving care to persons with drug misuse or abuse prob-
lems. professionals should be nonjudgmental but willing
to worl.. with the patient. family, and members of the
community to provide suppon needed for treatment.
Through education and recognition of signs and symp-
toms of drug abuse. proper referr,1ls for care may be
made. Some of the more common signs of drug 111 isuse
or abuse include the following:
Abrupt changes in work or school attendance.
quality of work, work output, grades, and
discipline
Unusual Oare-ups or outbreaks of rage or temper
Withdrawal from responsibility
Ceneral changes in '"rail attitude
Deterioration in phyi;ical appcamnce
Wearing sunglas.'les at inappropriate times
Contin!Jal wearing of long-sl~'ed gannenu, JIU.
ticularly in hot weather, or relurunce to ""21 i
short-sleeved garment
Asocialion wilh known drug abusers
Secretive behavior about actions and behal'iori.
poorly concealed au e1n pis to ev;ide auemion and
suspicion, such as freq uent trips to restrooms. base-
ments, and like a reas
Stealing items induding prescription mcdicatioQ,
from home. work. or school
Glazed appearance in eyes
Odor on breath
Changes in health habits
Asking for panirular medicaiions for pain and
accepting only those m edica1 ions
Knowledge of sym p to m s of d rug use will eiuble
the hea I1h care professiona I to assess drug usage {Table
31-8). Through asking q uesti ons, assistance with inter-
vention may break the drug abuse cyde. uncomfon.ablt
withdrawal symptoms may be cased, and sevett or lift.
threatening effects may be avoided. Remember th.tt sub-
stance abuse is not limited to street drugs but Illa\' bt
found with use of prescription medications also. '
Low self-esteem, a feeling of not belonging in 500m
a strong need for social approVill, and inadequa~
TABLE 31 8 SYMPTOMS SPECIFIC TO ABUSED DRUGS
SUBSTANCE SYMPTOMS ;
inhalants Nausea. dtwness. headaches iaci. li
coordinallon, odol of subsine oo
breath
heroin and Euphoria. drowsiness. nausea.
narcoucs vomiting. pinpoint pupils, needle
tracks on arms
cocaine and Talkativeness. ltyporalert state.
amphetamines increased blood pressure. h SIDI'! iJf
weight loss. hyperact1vily. ulcers m
nose and throat ltallOCtllalDlS all
paranoia
barbiturates and Slow pulse and resp11at11V rares,
benzod1azepines docte<-hopprng w11h vague
compla1ms. slurred speech
hallucinogens (PCP, Mood/mind altera11on. panic. extreme
LSD) focus on details. symptoms of fear
and paranoia. unp1ed1ctable violent
behavior
marijuana Red eyes, d1la1ed pupils. di'( IJQJ1h.
altered perceptoons of~";;!.
euphooa, 1nappropr1ate la~
and manner. smell of bt1nt l(ll'e.
panic reactions. impaired rner.m
LSD. Lvsoruic acid d1ethylamide, PCP. phencychdrne
 CHAPTER 31 Misused. Abu$ed. and Add1clJVe Drug$ 595

communicnion skills are risk faaors that increa d

~and abuse. lnabilicy to feel gratification an~ rug
bonding with families and friends predispose an ~od~:
,;dual to substance abuse. A person with a family hist
of alcoholism ordn.1gabuse is also more likdy to beco':nry
an abuS<'r as a way of avoiding personal confrontation~
Patient Educati ont"tor . com i>llance
1he be$! pa11001 education is teaching PfeveRt1on ot misuse and
itaise ol 111bslalees. including therapeutic medicines such as
ralQellC$ and s1ero1ds
SUMMARY
Drug abuse is :.elf-medication on a ch ronic basis, using
e:xcessive quamilics tha1 may cause physical and/or psy-
chologinl depwdence. Drugs, from thcr.1peutically prc-
l(Jlbtd medications to sueet dru~ may be misused or
.ibttsed Before a medication is prescribed, a definite
nttd for the drug should be cstablihed
Not a new phenomenon, drug abuse b using a medi-
cation in a way inconsistent with medical, social. and
n1hural norms o f a certain population. It is important
10 note that 1he defini tion of drug ahu~c is related to
social and cultura l norms and to specific situat ions in
which medications arc pres.-rihed . No socioeconomic,
tthnic. and cultural dasses are exempt from drug and
subsunce buse.
Ph)~ical and psychologic dependence occurs with
ml>USC or abuse of drugs, with 1oler.1nce leading 10
gmttr doses On.1g availability is another factor leading
to dependency and con1 inued use; abu\e c,1n occur on ly
if drug.scan be obtained. Vu lnerability to abuse can be
a familial 1cnclmcy; dependence rnn lw ,, crutch to cope
with everyday tensions.
rhysical signs of drug abuse include weight loss.
changes in sleep habits that cause lc1ha1!,'}'. and frequent
illnesses. Psychologk signs include inability to concen-
tnlt, lack of memory. apathy, and in.1b1lity to function
Q\lstd by illogical thought processes. ~ially. mood
swings, 1mubili1y. anger. and isolauon from the envi
ronment mduding manges of surroundings nd friends
are . apparent. Drug abuse" may bcrome arutious in
social s ituations and my overreact, for mstance, wnh
defcn,ivenei;.,, and unexplained anger.
The two most abused drug,~ are readily avail.1ble
and legally purdlai.ed by adults- nicoune and alcohol
Dar~~ers from addiction 10 these dru~ far outweigh any
pos111vee1Teas loleranceocrurs wnh both drugs.Alcohol
has interacuoru. with many other drugs. uusmg severe
ph)"liolog.ic elTectS. Disulliram and acamprosate are spe-
cific therapeuuc ueaunent for alcohol abuse. Patient
education is absolutely necessary when these medica
tion are prescribed.
Use o f ill icit drugs is a societal and personal major
prohlem in the United States 1od.1y. Some abused sub
stances .ire easily obtained, such as glue. household
chemicals, or acetaminophen. whereas others are more
diffirult to obtain. such as narcouoo and amphetamines,
making these agents expcnsi\e at streei level. Some prob-
lems o f misuse arise from patient admmisuation of
medicauons or "'1!n from unimenuo nal misuSI! of pre-
scribed medicines.
The theft of prescription dn.1gs for illeg,11 street use is
one of today's social concerns
O ne of the main dangers of illicit drugs consists of
variabi lity in drug strength caused by manufacture a1
street level-culling drugs for increJ>ed profits. Because
each dose is different and there is no control of these
illegal substances. users are at risk for ovl'rdose. The
health care professional must be aware of and recognize
the many schemes used 10 obtain prescription medica-
tions sudl as opiates and opioid; for illicit use. A physi-
cal diwase may be replaced by p~chologic dependence
with medicmion tolerance. in whkh more and more
drug use is needed 10 adlievc the same results.
Of great importance for the health care professional
10 remember is that all medicinal agents have potential
fo1 misu~e and abuse. Innocently u;ing medications
when there are insufficient symptoms is abusing drogs-
that is. using drugs too frequemly or using excessive
dos.1gcs These misuse and abuse problems are frequently
seen in health care facilities today.

CRITICA ~
Mrs. Svansdottlf comes to tha phvs1cian's office becausa of a migraine headacha. Dr Marry prescribes
a narcotic medication for pain. Mrs. Svensdotrir mentions that sha has been drinking wma nightly with
her d1nnar and has anothar glass of wine before bedt1ma when she feats she will nor sleep well
I Does Dr Merry need 1h1s information? Why or why not?
2 Could the use of wine at night be a kmd of drug misuse? Why or why not?
3 Mrs Svensdottir denies that she has an alcohol abuse problem and states that she has everything
under control. How is this a typical response from someone who is alcohol dependent?
596 SECTION V Med1ca11ons Related to Body Systems

REVIEW QUESTIONS
I What IS drug abuse! Drug m1SUse! Why are th~ so prevalent! - - - - - - -- - -- - - - -- -

2. I low can a drug be used 1herapeu1ically and abused by the same person I - - -- -- - - - - -- -

3. I low does drug availability affm drug abuse? - - -- - - - - - - - - - -- - - - - -- -

4. What are the psrchologic sympto ms of drug abuse! Physical signs? Social effects! -- -- - -- -- -

5. What is the effect of alcohol on 1he body? What groups should avoid the us.: of alcohol? - - -- - - -

6. What distinct patient education must occur wi1h disulfiram1 - - - - - - - -- - - - - - -- - -

7. Explain what tolerance 10 medications means and how this increases the dangers of drug abuse. _ _ __

8. Wha1 is a hallucinogen/psychedelic? Why are these age111s d"ngerousl - - - - - -- - - - - -- -

9. lla,e anabolic steroids been placed on the DEA's list of scheduled drugs! If so. which schedule. and whyl

10. What are the implications for 1he medical assistant when confronted by a drug abuser or misuser? _ _ _
Check Your Understanding Answers

6-4
Chapter 6
I. Y,. 11. l ,Y.
6-1 3. Y. 13. 4 y,
I. E 5. 'Y.. 15. I%
3. I 7. Y.. 17. .v.
5. E 9. y, 19. l':V.,
1. r I I . 12 Y.
9. E 13. sx. 6-8
I I. Y,, y., Y,, -Y,,, Y,,, r,"' 'Y., 15. 11ri. I. I
13. r...x,. r.. 17. IX 3. 1
15. y., Y.. y,. 19, iy;CI 5. 68
7. 56.8
6-2 6-5 9. 121.3
I. 4.Yi I. y, 11. 233.33
3. 6Y, 3. Y. 13. 88.89
5. 7% 5. y,. IS. 100.06
7. 4Y. 7. Yo 17. 234.557
9 6Y, 9. JI, 19. 357.975
II . X 11. Y,,
l3 y, 13. % 6-9
IS o/. 15. 12 I. 0.625
Ii.~ 17. }(, 3. 0. 167
19. "..<. 19 13X 5. 0.3 7 5
21 sx 6-6
7. 1.9
9. 2.7
2.l 4.V.
25 3Y, I. :x 11. 3.5
17. IY, 3 x 13. 4.75
15. 2.64
29 4 Y. s. 'X
7 II
6-3 '). 2Y, 6- 10
I 40 II 4 Y, l. 125.72
3 12 n . 1'K 3. 1345. 151
15. SY,, 5. 655.541
5 42
76 7 . 912.29
6 -7 9. 782.454
9 35
I. ;.< 1 1. 6.24 2
II l.Y.
13 Y. 3. v.. y, 13. 39.94
15. 'Yi, s. y, I 5. 3.37
17. 90.038
17. y,, 7. 3Y,
19. 0. 14
19. r,, <J . 6X
597
598 APPENDIX A Check Your Understanding Answers

I5. 2 tablets
6-11 6-18
17 Y.
I 269 07 I 10
19. 900 mg
3 770.76 3 25
S 521 II s so
7. 0.01 7. 125 Chapter 7
9 6874 47 9 30
7-1
I. less than
6-12 6- 19
3. grea1cr than
I. 2.3 l 0.005
3 0.0144 S. grea1er than
3. 6 I 7. less than
s. 3 s. 0.3333 9. gram
7. 2.2 7. 7234%
I I. 1.001
9. 6.2 9. 5%
11. 0.5 13. 0.0011
15. 0. 10101
6-13 13. 32.7
15. 16.8 I 7. length; 120 on
I. 32'%.,.
17. 34% I 9. length; 3000.75 m
3. 33
19. 67% 21 solid (weight); IOOO mcg
S. I
7 3.7 21 60 23 solid (weight); S kg
23. so 25. length; 750 km
9. 0.38
11 68.247 25 3
13. 1047.322 27 32 7-2
IS. 17.4 29. 48 I. 6.9 m
17. 100.39 3. 0.043 m
19. 204.1 6-20 5. 9 cm
21. 1491 I. x = 25 7. 88 mm
23. 1.1 83 3. x= 22 9. 120 cm
25. 2.882 S. x = 150 ll . 425 mm
7. x= 7 13. SO cm
6-14 9. x = 16 I S. 100 cm
I. 0.01 II. x = G
3. 0.05 13. x = 9 7-3
s. 0.31 15. x = 2 I . 0.00 1 L
7. 0.08 17 x= 125 3. 6400 ml
9. 0.18 19. x = 400 s 0.5 I.
7. 1.45 L
6-15 6-21 9. 0. 1 L
I. 359% I. 60 11 2000 ml,
3. 6% 3. 9 1'3. I I.
5. 4.7% s. 20 15. 3 L
7. 11 7% 7. 188
9. S.5% 9. 27 7. 4
11. 64 I. 1.5 mg
6-16 13. 12S 3. 6500 mg
I. 3.92 15. 19 5. 34 0 g
3. 5.34 17. 47 7. 90 mg
5. 14.25 19. 80 9. 30 s
7. 48 11. 2200 g
9. 15.58 622 13. 0.5 mg
I. .t = 4 I 5. I tab = 0.088 mg
6-17 3 .t= 20
I. 83.3% s. .t = 0.04 7-5
3. 18.2% 7. 56 tablets I. tablespoon
5. 42.9% 9. IY, 1ablets 3. cup
7. 15.4% 11. 0.2 ml S. tablespoon
9. 9.1% 13. 95 kg 7. grca1cr 1han
 ---~
A_,
PP..:::
ENDIX A Check Your UnderstJtndtng Answers 599

9. Jess than 5. 0 .3 g
9-5
11. DissolV<.' 2 leve l teaspoons of 7. 6 gr
magnesium sulfate i nto I cup of I two 500 mg tablci. by mouth
? . 160 mg
"'Her and take by mouth. twice a day
11. 3 lb
13 Take I teaspoon of Benylin elixir J. two 50 mg tablets by mouth 4
11. 4250 mg
evel)' 4 hours. Do not exceed 6 times a day
15. 75 g
S. four 250 mg 1.1blets by mouth
doses daily.
daily
15 lnStill 2 drops of liquifilm tears 8-6 7. one half or one O OS mg 1.1bk1
in each eye as needed. I. 20 cm by mouth daily
1 10 ft 9. one 300 mg tablet by mou1h
Chapter 8 5. 2 ft lwtce a day
7 2m
8-1 ?. I m
I. 0-140 11 . 25 mm (2.5 <:'m); yes 9-6
3 1102 13. 45 nn I. 1200 mg
5 224S 15. 0 .6 in 3. 30 ml
1. 0033 5. Yes. I teaspoon S ml. uSt' dose
9. 1533 syringe for accuracy
Chapter 9
I). 9:21 PM 7 200 mg
13. 12:45 AM 9- 1 9. 6 days
15 midnight I. 3 tsp 11. 87 ml
17. 2:10 AM 3. (, mL
19. 3:1S PM 5. 5 ml. 9-7
I. 0.35 BSA
82 9 -2 3. 1.0 BSA
I. 37.6 C=99.6 F I. y, S. 1.2 BSA
3. 39.4 ' C = 103 F l. Yo...
s. 26.7 c =so F 5. JI, 9-8
7. 100' C= 212" F 7. 1:250 I. 0.92 m'; 135 mg; 2.7 ml or
9. - 17.8' C= 0 F ') .I: 1000 y, tsp
11. 57.2' F = 14' C l I. IY, tabs 3. 1.36 m' ; 4 mg or 4 ml
13. 41 ' F = 5' C 11. 2 tabs 5. 1.08 m1; 318 ms; 64 m l. or
15 204.8 ' F = % C 15. 4 tabs lY, tsp
17. I08.I ' F= 42.3 C
19. 51.8' F =II ' C 9 -3 9.9
I. a. 500 mg I 250 mg; 5 ml
8-3 b. 1000 mg 3. 380 mg/day; 127 mg/dose or
1. 1:s = K c. ml 125 mg/dose; 1 m I~ Y, tsp
12.S=K d 25 ml 5. 500 mg/dose; 10 ml/ dose; 2 tsp
s. 910= r.. 1. a 160 mg
7.)1 =1:2 b. 120 mg Chapter 10
9 > =1: 100 c tablets
d . Y, tablet 10-1
8-4 ~ a 400 mg I. 2.3 mL
I 3 tbsp b. 200 mg 3. 0.7 ml
c. ml 5. 2.8 ml
3 IS (16)' gu
d . 10 ml 7. draw a line at 0.9 ml
5 90 ml
7.IY,tabs 9. draw a line at I.I ml
7 Ic
9. 20 ml; 4 ISP 11. draw a line at 0.3 ml
9 500 ml.
13. draw a line al 1.9 ml
II. 2T
9-4 15. draw a line al 2.9 ml
13 2 q1 o r 64 07
15. I oz I . 1000 mg/I S
1. 10 mJ../200 mg 10-2
8-5 s. 1 g/ 1000 ms 1. 2.5rnl.
7. IY, tabs 3. 0.5 ml.
I 45 mg
'), 20 111 I.; 4 IS fl 5. 3 ml
3. 900 mg
800 APl'NOIX A Check Your Understandmg Answers

10-5
10-3 10-4
I 35 units
I. 0.5 m l
I 52 unus 3. 1.5 ml.
3 14 unus 3. 84 uniis
S. 15 uniis 5. 2 ml.
5 26 units
7 . I mL IM four times a day (every 7 . 0.9 mL
7 show 46 un its insulin 9 0.2 ml.
9 . show O.S mL 6 hours)
9. 1.8 mL
Drug-Nutrient and Drug-Drug
Interactions
DRUG-NUTRIENT INTERACTIONS
calcium C<1rbona1c (Turns): dairy products, bran and
01her whole grains
e1)1hromydn, 1>enicillins: acidic juices, citnis fruits, soft
drinks
all st.11ins (Mcvacor, Zocor): gr.1pcfrui1 juke
1ctracydines: calciu rn-con tai ning foods such as ice cream,
dt<<eSC :ind milk
warfarin sodium: beef liver, spinach, cabbage, Brussels
sprouts, broccoli
Monoamine oxidasc inhibitors {MAO ls): foods high in
l)T.lmine such as cheese, sour cream, yogurt, meat
tenderi1.us, beer and wine, aged meals
CLINICALL V SIGNIFICANT
DRUG-DRUG INTERACTIONS
carb.tmU(J>ine fregretol ): charcoal, crythromycin,
dozapine
chlorpropamide (Diabincse): ethyl alcohol
doruJone (C11apres): propranolol (lnderal)
do1..ipone (Oozaril) carbamazepine (Tegretol)
digi1ax1n rifampin (Rif.1din)
d1goxm (1.<lnoxin) amiodarone (Cordarone), erythro-
mycin base quinidine. 1etracycline, verapamil (Calan)
dJhlazcm (CardiU'm): cyclosporine (Neoral)
0)1hromycin cyclosporine (Nooral)
rth)i alcohol: disuUiram (Antabuse)
gcni.imicin (Caramycin) carbcnicillin (Ceocillin), ceph-
aloihin (KeOin)
Sot.net for dn1g drug in1craclion": Pocket guide lO evaluations
o( drug inicractlons, cd 4 , Washing1on. DC, 2002, American
Ph.armaceuLlc.ll Associa1ion.
heparin: aspirin
insulin: propranolol (lnderal)
keioconazole (Nizoral): cyclosporine (Ncoral)
lidocaine (Xylocaine) : cimetidine (l:lg.1me1)
lincomycin (Lincocin): kaolin
lithium carbonate (Lithobid): ace1:11~lamide (Diamox),
ch lorothiazide (Diuri l)
mepcridine (Demerol): phencl~i11c (Nardi l)
methotrexa ce (Folex): aspirin, probcnecid (Uencmld),
s ulfome1 hoxawleirime1hciprim (Se1>1ra, llnetrim)
phenelzine (Nardil ): levodopa (I-dopa)
phenytoin (Dilantin): cimetidine ("1:1gamel), disulfiram
(An1.1buse), dopamine (Dopast.11. l;ncropion), nuco-
na7..ole ( Diflucan)
propranolol (lnderal): cimetidine (T,lj!Jmet), epinephrine
pyridoxine (vitamin B. ): levodopa (I dopa)
quinidine: amiodarone (Cordarone), veraparnil (Calan)
rifampin (Rifadin) : cydosporinc (Neoral), oral comra-
ceptive agents
spironolactone (Aldactone): potassium chloride (K-T,1bs)
1etracydine: aluminum hydroxide (Ampho1cl). ferrous
sulfate
lheophylline (Elixophyllin, lheo-Dur) charcoal, cimeti-
dine (Tagamet), erythromycin, tobacco
triazolam (Halcion): ketocon<v~le (NilOral)
warfarin (Coumadin ): amiodarone (Cordaronc), aspirin,
cimetidine (Tagame1), dofibratc (Acromid -S), d1sulfi-
ram (Antabuse), erythromycin, glucago n, methyhes
1os1erone. nalidixic acid (1'-egC ram), phenobarbital,
phenylbuU1ZOne (Alka Butawlidin), phyto nadione
(vitamin K), rifampin (Rifadin), sulfomethoxaw le
(Can1.1nol), sulfinpyrazone (Amurane), thyroid
(Synlhroid)
601
Glossary
Abs ence or ~tit mal seJ2u 1ts l.o>s of con>dousness
for a shon period of tune caused by setture aetivity
Ab sorption Uptake of medications for di>tribution in
the body through or across ussues
Accommodation Change on sha~ of the lens of the eye
to adjust to viewing objects at different distances
AcelylchoUne (Ach) Chemical neurotransmiuer in the
parasympathetic nervous system
Acid Any substance with a hydrogen ion that is released
in a solmion and reacts with metals 10 form sa lts; pH
below 7
Acid rebound Increase in g_,s1ric acid sccrelions lOneu-
tralize antacids that have been taken for a prolonged
period of lime
Acne Inflammation of the hair follicles and sebacoous
glands charaaerized by comedones, pustules. and
papules (raised areas)
Acquired immunity Immunity tha1 1s the result of
exposure to a disease antigen, the onjection ofimmune
globulins. or immunizations
Actinic keratos is Horny, premalignant lesions of the
skin caused by excessive exposure to sunlight
Action onset Time at which the desired funetion begins
to produce an effea, such as with medications
Action peak Time at which 1he desired function reaches
the highest potemial, such as the highest level of med-
itat ion in 1he blood stream during drug administra-
tion cycle
Active Immunity Immunity resulting from the develop-
ment of antibodies wi1hin a person's body that renders
the person immune; mayocmr from exposure 1hrough
a disease process or from immunizations
Active ingredient Medicinal ingredient in a pure, undi-
luted form of the chemical that has elfros on body
funaions
Addiction Compulsi""- uncontrollable dependence on
a chemical substance, habi~ or praoice 10 such a degree
that either the means of obtaining or ceasing may cause
emotional, mental, or psychologic reJctions
Adenocarcinoma A malignant 1umor arising from glan-
dular 1issue
602
Adjuvant m edicatio n Medication used to incr~ ,.
has1en the action of the principal medications
Admlnis ter To give to or apply medication on a pm.,n
Adre.nerg ic agonlst Also called sympalhom11'1ftlc
agen1 or agonist. agent that stimula1es the acuon o(
1he sympa1hctic nervous system or mimic. the acuo.-
of the sympathetic nervous system
Ads orbent Liquid or gas subs1ance tha1 readily adhrns
the surface of a solid ma1erial to the surface of anolhn
subs1ance
Advers e reaction Unintended, undesirable, and often
unprcclicrnhlc cffec1 of a medicatio n that cause pain
discomfort, o r unwanted symptoms; more severe than
a s ide effect
Aerobic bacteria llacteria that live in an environmrn1
comaining oxygen
Aeroc hambe r A hollow, dosed tube added to 1nhb
lion medications to increase the availabiliiy of !ht
medica1ion
Aerosol Liquid in a pressurized containertha1 dHptma
medication 10 s11es of absorption
Ae rosol foam Water-in-oil emulsion tha1 disptruts
into a foam when mixed with air
Affect Emo1ion or emotio nal respnnse
Affective disorders C roup of disorders characteriuJ
by disturbances in mood, from partial to full mama
or depre~siou
Aggregation C lustering or clumping of subs1ancei.
such as b lood cells
Agitate 1b shake a conrniner vigorously
Agonis t Medica1ion tlial binds to the recep1or ~ile ~nd
s1imulatcs the func1ion of that site; drug that mimn
a function of 1he body
Akathis la Restlessness, inability to sit still, urgm1 ~
to move
Alkaline A substance having a pM below 7; a subounct
that combines with ~cids to form salts
Alkaloid Organic compound that is alkahnt Ill
nature and is combined with acids to make saltl; i
group of alkaline org.1n ic subs tances obrained from
plants

,Ukylting_gen t Substance_ 1ha1 interferes with cel l
metabolism and growth by mttndud ng an a lkyl ai:wnt
orrompouod; agent used 10 treat ma lignancies
AIJ~C reactlon 1lypersensitivity 10 a <lrug that may
O((llf after only one dose has been Liken (see 1,,,,...,.
ft!U11111!y rtactrot1)
,Uoped Loss of hair
,Uternative med icine Practice of usi ng product., ~
which scientific evidence of safety a nd effir.cy ~~
lcking (eg., most herbal preparations, copper brace-
ltls for anhritis)
~ disease Disease charactcri1:ed by progre..sive
1mp.11nnent m mem?ry and cogn 1t1ve function that
may lead to a vegc1.111ve state and death
Ampule Small glass container that is sealed an<l
holds a single dose of medication, usually for
iniecti<>n
Anl}iold Aboonnal neuronal lipoprotein; starchhke
complathat is deposited in tissues. such as the bram,
possible cause of Alzheimer disease
Amrloid blockers Drugs that prevent the forma tion of
amyloids
Anbolk steroid s Synthetica lly produced androgens
wboDsm Constructive metabolic process by which
511bstances are converted by an organism into other
componentS of the organism's chemical struc1urc; in
the example of anabolic steroids such as testosterone,
the result is grea1cr muscle mass
Anaerobic bacteria llacteria that live in an environ-
mtnt free of oxygen
Anakptia Drugs that stimulate the central nervous
5)'$1em
Analgesic Medicatio n with pain-relieving p ropen y
Anaphyluis Severe allergic reaction. possibly fatal, to
~ drug that occurs a shon time after the drug has
~ administered to a person who is hypersensi1ive
lO it
Anplastic Characteri;i;ed by loss of cell differentiation
Anatomy Branch of science that de ab with structure of
organis1ns
Androgen Any male sex hormone
AMsthesi Lo~ of sensation. either of the entire body
or of certain body area>
Angina !'('ctorls Insufficient hlood now to the he.trt,
with resultant spa;m of 1he cMdiac muscle. causing
ches1 pain
Ankylosing spon dylllls Change in spi ne, sim il ar
10 rheumatoid arthritis, that cau>e> stiffening of
tht back
Ankylosls lmmob1hty of joints, c.tused by congenital
conditions, surgery, trauma, or dheases
Anomaly Any devia1 ion from no rn1al
AnorL'Ctal Perta ining to the anus and rectu m
A.norul;a Loss of appetite
Anorman l Medicauon med 10 suppress appetite
Anosmla Lack of sense of smell
Glouary
Antagonism Cancellauon or reduruon of one drug'>
effect by another drug
Antagonist Medication that binds at recq'ltor sites to
prevent other medicauons from binding to those
same sues
Anlhelmlntlcs Agents used for treatment of tntesunal
worm.\
AnUbactc rlal drugs Dn.1&.' w11h the ability for dcstruc
tton or inhibition of growth of bacten.1
Antlb'.ollc "latural or ~ntheuc substance. originally
denved from plant or ;1n1mal source<. that kills or
inhibit> the growth of microorganisms
Anllbody l'rotein that develops in rcspon~ to the
presence of an antigen an the body and reacts with
the antigen on the next exposure; may he formed
from infenions. immuniT,;it1ons. transfer from the
mother to a child, or from no known anugen
stin1ulat1on
Antibody titer Quanmy of viable anubod1es requtred
to respond to a given quanmy of antigen as deter-
m ined by a labonuory (scrologic) test
Antlclrnllnergic agents Also called ll1tl11 laoltnerg1CS;
agents that block the parasympathetic nerve impulse
(e.g., causing dilation of the pupil)
Anlicho llnerglcs See lln11d1ol111trgic asnu
Antldlarrheal Agent or substance that prevents or treats
d iarrhtJ
Antidote Drug or substance given 10 SIO!l a toxic
effect
Antlemellc Agent that prC\.-ents or relieves nausea or
\'Omiting
Antiflatulc nl Agem that decreases excessive gas in the
s to rnach or intestines
Antigen Substa nce 1ha1 is either introduce<! imo the
body or formed by the body to induce the fonnation
of antihodies specific 10 that antigen
Antigen-antibody response Neutralization or destruc
tion of antigen by an1ibodies
Anllhlstamlne Agent tha1 decreases histamine release
Antllnflammatory Medicaiion with i11 nan1 ma1ion
reducing 1>roperty
Anlimeubollte Agent that disrupts essential cell meta
bolic processes and is used 10 treat malignancies by
opposing the actions of or replacing a metabolite
nec:essary fo r cell growth by interfering with DNA
metabolism
Antimicrobial Penaining to destruction or inh ibition
of growth of microorg.1nbms; when said of drugs.
includes both those of org.1nic origin (a1111bw11a) and
those of nonorganic origin (e.g., silver, sulfur, and
mercury)
An tln eo1>las Uc agent Dn.1g used to prcven1 develop
ment, growth, or prolifcra1io11 of ma lignont cells
Anllpyretlc Medication with fever-reducing 1iropeny
Antisttretory agent Agent that inhibits Srctions of a
gland or org.,n
Antlseplic Agent that reduces. prevents, or inhibits
the growth of microbial flora of the skin and
mucous membranes wnhou1 necessarily killing
them
Anliserum Serum containing an11bod1cs 10 a specific
antigen; usually of human or animal ongin
Anllipas modia Agen~s 1ha1 P""~"' or decrease in1es-
1inal spasms
Antitoxin Agent 1ha1 provides antibodi~ produced in
response to a specific 1oxin 1ha1 has the ability 10
neu1ralize that same 1oxi n in .1no1her person (e.g.,
1e1anus antitoxi n)
Anthumor anlibiotlcs On1gs that hold 10 DNA to
inhibi1 synthesis of DNA and RNA
Anlituss i>'e Agen1 that relieves or suppresses cough ing
Antiviral Agen11ha1 opposes the anion of a virus; medi-
cation specifically for trea1ing viral rondnions
Anxlolytic Medication 10 rclie\'e anxiety; minor
tranquilizer
Aperture An opening or hole in an ob100
Apothecary Pharmacist or druggist
Apothecary system One of the oldest measuremem
systems used to calculate drug orders; based on grains
and drams
Aqueous Llke \Yater, watery
Aqueous solulion WaLer-soluhle solut ion; when refer-
ring 10 injections, the aqueous solution is considered
to be thin or watery
Arrhythmia Irregular rhythm (i.e.. irregul.ir heartbea1)
Arteriosderosis Thickening of walls of anerioles
causing loss of elas1ici1y and loss of ability 10
comraa
Arthritis Inflammation of join~ accompanied by pain,
swelling. and bony dianges in the jo1111
Anlculate To join bones in joints
Arllfidal acti.-e immunity tong-ienn immunity pro-
vided by immuni2ation with a specific agent to
develop antibodies to a SPific disease process
Artlfidal passive immunity Shon-term immunity pro-
vided from other persons or animals that have the
antibodies for a specific disease (e.g.. immune globu-
lins, antitoxins}
Ascites Accumulation of serous fluid in peritoneal
cavity
Aspirate Drawn in or out by suciion; to pull o n plu11ger
of syringe to withdraw air
Asthma Disease of 1racheobronchial tree with paroxys-
mal constriction of bronchial airways
Astringent Agent that ouses shrinking or constricting
actio~ usually applied topically or IOCillly
Ataxia Difficulty with balance
Atdtuis An airless condi1ion in the nonexpanded
lung
Atherosderosis Form of arteriosclermis characterized
by buildup of fatty plaques on the walls of aneries
and anerioles
AUenllon -d c lidtfbyperactivity dfaorder (ADHO)
Disease found most frequently in children ~
charaeteri1.ed by inauemion, hypenaivity,
impulsiveness
Attenuated Lessened, abbrevia1ed; in referenct '>
immuniiy, lessened virulence of a pathogen
Aura t-.eurologic vi~uaJ phenomena (e.g., ligh1 ft~
blank areas in the field of vision) tha1 may~
epileptic seizures and migraine headaches
Au ralgla Ear pain; a lso call ed otalgia or otodyn111
Automatlcl ty Automa1ic spon taneous initiation of 1
hean imru lsc
Au ton omic n ervous system Self-governing. il\volun.
Lary nervous system
Auxiliary labe l L.ibel added LO prescription bot~t IO
provide addi1io11al information
Avirulent lndbilily 10 1>roduce disease or path~iot}
Avitaminosis Any disease caused by lack of iunun
production or intake
Bacteria (s in gular, bacurium) One<elled OJgani>rll
tha1 can synthesize D~A. RNA. or other ewrrua1
produns and can reproduct>, but live on foodsupplitd
by a host or by a supponive environment
Bactericidal l'en.1i n ing 10 destruction of baaeria; diugs
or chemicals wi1h this ability
Bacte riocl dal agent Subs1ance wi1h the ability 10
desiroy baeteri a
Bactcrlos tatlc Inhibiting o r retarding the grow1h o!
bac1eria; d rugs or dwmicals with this ability
8actcriostatlc agent Substance with 1he ability 10
inhibit or retard growth of bacteria
Base Any substance that combines with hydr~ 10
form a salt; pl I above 7 or alkaline in nature
Bath Method of cle.rnsing the bod)' or its pans or llnl
ing 1hc body thcrnpcutically with a deansing agnn
Ben ign Nonmalignant
Bevel Slan1cd surface on 1he end of a hypodnmic
needle, including the point and the lumen
Biocqu lvale n ce St.nc or property of having !ht iamt
strength and av.iilability for absorption in the body
as the same dosage of another available source of
th at dn1g
Biot11era1>y System of cancer 1herapy that uses intnfet
ons and 111i1ogcn s1imu la1cd lymph ocy1es
Biotransformatlon Chemica l d1anges a subst~nre
undergoes in the body
Bipola r disorder l'syrhiatric conctition charaamud
by alterna1ing periods of mania and depressive Wit<
previously called mt1nic-depressiue disorder
Bleb Irregularly raised elevation of the epidermis
Blepha rltis lnflamm.nion of the eyelids from b.cttNI
infeetions or allergies
Blood -brain barrier Capillary walls of the brain. .. hidl
can an 10 prcvc111 potentially hamiful submn<"
from moving out of lhe bloodstream and enteringlht
meninges in the brain or cerebral spinal fluid

llodrsurf ~e ( BSA) i:otal body surface area based
on th<' relauonsh1p of height 10 weight
llod1 surface area (BSA) calculallon Process of ca)cu.
)Ating dosages based on weigh1 and height using a
nomogram
(lolus Co1.icenLrated amount of medication given
rapidly 1n1ravenously
Brnd-name drug Proprietary drug with a trademark
(such drugs are marked with QI>)
aroad-sptttrum a ntibiot ic Antibiotic effective against
\'3riety of gram-positive and gram-negative
mlCJOOfl!ilnisms
arondll<Ctasis Abnormal condition of bronchial tree
ch.tncmi.red by irreversible dil,11ion and destruction
of bronchial walls
Buccal Inside of cheek, surface of tooth , or gum
BucCAI tblet Tablet p laced in the mou th between
dleek and gum (buccal area) for absorption
BufTertd tablet Medicat ion combined with an antacid
to reduce irritation to the stomach when ingested
Bureu of Narcotics a nd Dangerous Drugs (BNOD)
Col=men1 agency that exiMed from I ?68 to 1973
and h<ld responsibilities for regulation of controlled
wbstances
Bursitis lnOammation of the bursa of joints
Cn<er Malignant neoplasm; uncontrolled growth and
spread of abnormal cells
Cplel J.ong, oblong tablet with a s mooth fi lm-coated
cove1ing for ese of swallowing
Capsult Small gelatin container filled with medication
in powder or granule form
Carbunde Lesion of the skin with inOarnrnation of the
<Ian and deeper tissues 1ha1 produces 1uppuration
and sloughing of the tissue; similar to a boil or
furuncle
Cudnogenlc Potential 10 produce cancer or increase
the risk of cancer; agent with cardnogenic potential
Carles c,whies in teeth
C.irmlnallvc Agent 1hat helps prcwn t formation of gas
in the g.rnrointestinal tract
C.l lpluy A condition charaaeri1ed by sudden muscu
lir \\\'al.ness and hypotonia causecl by .1nger, fear, or
SUIJl05e
Cator<Kt Opacity (loss of tran<parcncy) on or in the
lens or ca1>Sule of the eye
C.tttholaml nes Epinephrine. 11orc1>inephrine. and
do1>amine. derived from tyros.11ni ne
r..1hartlcs Active agents Lhat cause n bowel moveme111
Ctlllng effecl Dose beyond which no further response
occurs (e.g., an analgesic cei ling cffcr1)
Ctll cyde pbase Steps 1ha1 occur in the growth and
dtwlopmem of a cell
Ctlslus remperature scale in which O is freezing and
100 1s boil mg point of water at sea level
Ctntral nervou s system llrain and spmal cord
Ctrumen har wax
GloSSllry 605
Ch.a lulon ~~ard eyelid (')'SI re<>ulung from chronic
mn.1mmauon of a me1bomian gland
Chela to r Agent used to treat m(ta) po1wnmgs
Che motherapy Treatment of d1se.1sc usmg chemical
agents
C hewable tablet Tablet wuh a 1ugar or Oavored base,
d<'signed to be chewed
Chloasm.1 Darkening of the skm Mound 1he eyes
Cholellthlasis Formation or presence of calculi or bile
stones in the gallbladder
Chollnergic agent (or puasympalhomimelic
agent) Drug that m1m1c:s thC' parasympatheuc
nervous system; agent 1ha1 actS to transmu nei--e sum-
ul.111ons m the parasympathetic ncf\'OUS system (e.g ,
c.1us1ng constriction of 1he pupil 1n the eye)
Chollne5terase Enzyme 10 mhihi1 the action of
.1cetylcholine
Chronotroplc 4'ffect lncreae or decrease in the he;irt
r.1tc
Cirrh osis Chronic liver diseaw frequently found m
pcrwns with long-term alcohol abu~
Cli nic.ti ph armacology Study of drug effects in
humans
Clu nie Pertaining to alternating contracung and relax
ing of muscles
Clos ed-a ngle glaucoma Elevated pressure in eye caused
by obstruction of ou1now of aqli<'Ous humor tl1a1
OC'C'll~ \\ ilh a narrO\\ling of angle bei\veen the iris and
1
cornea 10 b lo<k exit of aqueous humor
Coan algesia Adminis1ra1ion of l\VO or more medica ..
lions (analgesics) together for synergistic effect
Coitus Sexual union of 1wo people of the opposite sex
in which the penis is mtroduced 10 the \'agina
Colloid suspension/solution Suspension wnh
alcohol, water, or ether as a soJ,..,nc a thin la}U of
mcdic.iiion is left on 1he skin when the solvent
evaporates
Co med ones (singular, co111ed11) Skin lesions found
with acne vulgaris; commonly c.11led whiwhead or
blrlckhead
Compatible Suitable for mixing without unfa,'Orable
actions; in pharmacology, refers to mixing l"'O or
more medications
Complementary medicine Ahematiw medical tech
niques that have been proved cffecti'" by scientific
research as a basis for use and 1ha1 are accepted as pan
of good medical practice (e.g. acupuncture, mass.1ge
therapy)
ComJ)oundlng Mixing a prescri1nion according to the
physician's order
Compuls ion An irresistible, rcpe11t1ve. irrational.
impulse to perform an act that results in overt anxiety
if ac1 is not done
Concenlra lio n Ratio of mass or volume of a
solu1e 10 the mass or ,'O)umc of the solution or
solvent
 606 Glossary
Conjunclirilis Acute mOammauon of the conjunctiva
from bacterial or'"''' infccuon. usually self-limiting;
also called pr~
Contrattplion l're.-ention of fentll7.1t1on of the ovum
and the subsequent onSl't of pregnancy
Contnind icalion Condiuon m whKh use of given
medication should be avoided
Controlled substance Medicauon that 1s controlled by
the Drug Enforcement Adminl\trJtion because of its
potential for abuse and mis use
Convers ion factor Known equiv.tlcncy of two values in
different measurement sysiems; may be wriuen as a
rraction or a ratio
Convert Change from one form to another
Convulsion Abnormal motor mowments. such as the
jerking movement of a grand mal seizure
Corticos teroids Any one of the hormones (except the
sex hormones) from the adrenal cortex that control
body processes
Coryu Inflammation of the mucous membranes of the
nose with a prof115e nasal discharge; commonly called
a "head cold
Cream Semisolid preparauon in a base that is absorbed
into the tissue for slow, sustained rele.tse
Crepitus Crackling sounds 111 JOints resulting from
arthritis
Cryptorchidism Develo 11mc111n l dcfert in wh id1 one or
both tes1 icles fa il 10 descend in 10 the ocrotum
Cumulation (accumulation) Increasing storage of a
medication in the body cau'<I by the hody's inability
to mctaboli7,eorexcrete the mcdicaiion beforeanoLher
dose is taken
Curative {healing) mediation Medkation prescribed
to kill or remove the causativr agent of a disease
Cydoplegia Paralysis of the ciliary muscle
Cytotoxic agent Compound that <auses cell
destruction
Dangerous drug Orug that can cause addiction or that
is detrimental to Lite body
DEA number Identification number supplied to
medical professionals, pharmncies, and the like by
the Dmg Enforcement Agency to allow the agency
to enforce regul atio ns rom rolli ng schedu led
substances
Decimal J\ fractional pan of a number
Decongestant Agent Lhat reduces swelling and conges-
tion in the respiratory tract
Defeat.ion Passage of fe<"e;. from the body; bowel
rnO\--en1en1
Odayed-acllon caps ule Capsule prepared to release
drug at a panicular site or lo provide a steady release
of mediation o't'r a period of time
Delirium tremens Restlessness. confusion, insomnia,
and iaitabilicy, with visual. tactile. and auditory
hallucinaLions, caused by Jbstinence of alcohol
consumption in an alcohol abuser
Delusion raise belief that cannot be changtd "llh
reason
Dem ulcent l)nig used lO soothe a body ~ er IO
relieve symptoms of irritation
Denominator lerm for number below or to the r-.1:1
of the line on a fraction indicating the numbn of
equal p.ms into which the while is divided
De n tlfrlce ~ub$tance for deaning teeth
Dentillo n Development and eruption of teeth; arran11r
ment. number, .ind kind of teeth as they appear in tht
mouth
Dependence ' lbta I psychophysical state o f addiction 10
drug.~ or a lcohol; st.He in which a n increasingamouni
of a substa nee is needed IO preven t the onset of with.
drawa l symptoms
Depot fo rm of medication Drug injected or implanttd
to be slowly ab;orbed into cirrulation, usu.illy 10
a fatty tissue area where the drug is sloral >lid
di'1ributed
De p o t injectable Medication gh'ell parenterally ~t
stored in the fatty tissue for slow release in the bod.
Depressa nt L)nig that acts lo lo~r or lessen the il(IMt\'
of a body part
Des ired the rapeutic effect or des ittd effect lntend<d
re~ponsc co a 1ncdication
Des tructive agenl Substance that destroys cells and
ti!<Sucs. from bactericidals lo chemo therapy
D iagnos tic agent Medica tion used to assist in diagno;
ing diseases
Dlapho rc s ls !;xce;.sivc perspiration
Diffus ion Process in which panides in a fluid ''"'
from an area of higher concentration 10 an art~ of
lower concentration, resulting in an even disuibu11on
of the pankles in the fluid
Dig itallzalion Rapid administration of dig;uhs to
reach a therapeutic level
Diluent Agent LlJJl dilutes j substance; in pharmxcl-
ogy. the liquid added 10 a powder to chan~ t~
powder 10 a liquid form for parenteral administrauoo
or for unstable oral preparations
Oime n s lo nal analys is l'.xlcnded rates used 10 calculatt
doses for medications when two medication measurt
mcn t system' are used
Disease-m o di fying anlirheumallc drug
( OMARD) Drug that modifies rheumatic diseases
Ols lnfectant or ge rmicid al agent Agent that dearill6
the number of microorganisms on inanimate objtn
and prNCnts infooion by killing baaeria on 1n.1n1
mate surfaces
Dis pe ns e To give medications 10 a patient to be uLrn
at a later lime
Dispers ion Sc.mering of medication panicles throuf
out the body or throughout a liquid
Dis tribution Dispersion of medication to sites in tht
body
Diu resis Loss of w.u~r in tht> body
()ilid<nd Number o r quantity to be divided
()!risor Number or quantity by which the dividend 15
di>id<d 10 produce Lhe quo1iem
IJO<UID4'nlalion Wriuen no1ation in a medical rec d
of information ob1ained from a pa1 iem and p ro'::.
du1es 1ha1 have been performed in !he m edical seiL
Dosage Reg11nen ng individua l doses1118
o r ad mm1s1en of
mtdica1io11, expressed in quan1i1y per unii of time
r>osag< strength (weight) Strcng1h or weigh1 or medi-
wion in the dose(s) of ad_minis1ercd medication(s)
Dose Exact amoum of a med1ca11on to be ghen or taken
at ont un1e
Do<e spoon A spoon-like device tlS<'d to adminisier
d~ ofliquid medications orally
Dost< syringe A )'Tinge-like device used 10 adminis1er
liquid doses of oral m edications
Douche A procedure in whi ch .1 li quid medica1io n or
solution is introduced into Lhc vagin,1
Dram Unit of measure for liquid volume in the apoth-
JI)' system
Dromotroplc ~erect Increase or dc<"rt>a!>t" in the conduc-
uon of cardiac electrical impulses
Dnig Any chemic-di that has an elTl'CI on living
pfOC($!<?$
Drug abuse Misuse o r overuse of drugs in a m anner
1ha1 devia1es from the prescribed m.mner, which
mighl le.id 10 physical or psychologic dependence,
usually by self-medication
Drug addiction Compulsive u<e of drugs or sub-
stances that resu lts in physical. pS)'Chologic, o r social
lunn
Drug blood le.d Amount of a drug circulating in the
bloodstrum; also known as the rifm11ce "''""in lab-
oratory reports
Drug de~ndence Compulsion 10 take a drug. e ither
rontinuously o r periodically, to relieve a real or imag-
ined physical or psychologic need
Drug efficacy Ability of a drui: 10 produce the desired
chemical change in Lhe body
Drug Enforttm c nt Administration (DEA) Agency in
1he Depanmem or Justice with the legal r"sponsibility
10 enforce the statutes of the Comprehensive Drug
~and Prevention Act of 1970
Dnlg Faas and Compariso11s Publication updated
monthly by Facts and Comp.uiwn giving in-depth
inform,nion concerning medica1ions; usually used by
phannacists
Dnig habituation Ta king of mcdic;Hion as a mauer of
course. not out of need
Drug halr-llfc f'ime in which half of 1hc available drug
"metaboliu:d by 1he body for excretion
Drug hollday Period during which drug doses are with-
held to allow reversal of side effcet or adverse
(fJCUOllS
Drug lnteractlon EffectS of mcdic.11ions taken
together
Drug misuse :->onspecific or m1h>cr1mmatr use of
drugs, the use of drugs for pUfJ'OM."> other than thera
r>eut1c intentions
Drug ~omendature S)"tem of nammg drugs (t e ,
chem ical, generic. and brand nme.)
Drug llUrlty Quality or \late of h.wmg the type and
conccn iration of substances ~t forth by I DA stan-
dards for production o( a drug
Drug quality State or cond111on of ensuring that each
tune a medication is taken as ordcrcJ or in comph
ancc wi1h the manufacturer's dirttuon!., 11 meets the
Qme drug standards
Drug s;ample Medicauon left hy a manufacturer's rep
rc"'-'lllative in a physician's office tu be gi'en, not sold.
to ,, patient with the main purpose of ensuring the
paticn1 can effectively t.1ke the mt>dication
Drug Sla ndardization ProCt\s in wh ith a pharmafell
tk;i l prcpamtion or d1enikJI subMance of know
qua11ti1y. ingredients. and ;trc11g1h ,. 1he same quan-
ti1y, ingredients. and >trength in a comparable phar
mac-eutical prcparauon
Drug standards Rules and fl'llulauons to assure con-
~umers that they are receiving medicauons with thera-
peuuc consistency
Drug strength or potency Conlclllration of active
ingrcdient(s) in a medicin.11 prcp.ir.uion
Drug tole.ranee Accus10111iz.uion to .l 1nf!dication
1c:,ult ing in a decreased responSt" to the usual do~
Dry powder inhaler (DPI } Orug delivery sysiem Lha1
dispenses a given amount of medication as a dry
powder directly to the mucous membranes of 1he
r~p1r.1tory tract
Oysklnes la Excessive involuntary body mo-ements
Oyspareunla Painful sexual in1errour-1e
Oysphonla Difficulty speaking or hoarseness
Dysphorla Exaggerated feeling of depression or
ll l,fCSl
Oyspnea Difficulty brea1h ing; ,, subjective sensation of
s iresfu l breatl1ing due to respirawry and cardiac exer-
ci~e or aruciety
Dysrbythmla A disturbance or abnormality in normal
rhythmic pauem as with hean rhythm
Oysto nla Weak. slow body movemenl5 caused by lack
of muscle coordination or impaired muscle tone
Dysurla 1'.1inful urination
Ectopic beats An event of hean heat~ occurring a1 the
wrong Lime. such as prema1urc be,1"
1!<7ma Acute or chronic skin irritatio n that has ery
thc m,t, papu les. vesicles, pustules, scales, crusts, or
scabs, either alone o r in combilMLion
Edema Excel>sive amount of ti<sue fluid; swelling
Effervesce.nee Formation of gas bubbles on tl1e surface
of a liquid
Effervescent powder Coar-1ely ground medicinal agent
that has been mind with an effervescent salt to release
carbon dioxide when a liquid is added
608 Glossary
-------
Electrolyte Substance tha1 uncouples 11110 ions in solu-
tion and can then conduct an electrical charge; in
human physiology. an 1on11ed SJh such as .odium
and chloride found in blood. tissue fluids. and cells
Elixir Oe..r, sweetened, fla-'Ored med1ca11on containing
;ikohol and water
Embolus Obsuuction of a blood vessel by a foreign
substance or a blood do1
f.mesls Act of vomiting
Emollient /\gene that sofcens and soothes the surface 10
which ii is applied, usually 1he ~kin
Emphysema Abnormal condi1io11of1espiratory sysiem
charaaerized by overinOa1ion and destructive changes
in alveolar w.ill> m.uhing in loss of Jung elas1ici1y and
decreased gas exchange
Empiric Method of rreacing dise.lSt' based on observa-
tions and experience without an understanding of the
cause or mechanism of the disorder or the way thera-
peutic agent affec15 implO\ement or rure
Emulsion Wacer-and-oil mixture containing medica-
tion in phannacology
Endemic Penaining to concinuous or cyclic prdence of
disease in a given geographic area
Endogenous Arising fron1 within a celt an organ, or an
o rganism i1Self
Endorphlo Naturally occurring opioid-like subsiance.
produced by the body, tha1 blocks p.1i n stimuli
En<'ma lnstilla1ion of a li quid 11110 the rectum
Enteral Pertaining 10 gas1roi111cs1ina l tract route of
medication adminisuation (i.e.. oral or rectal); the
medicu ion is absorbed from the gaslrointestina l tract
llnteric-<10at.c d tablet Tablet coacl'd with a film, formu-
lated to pass through the stomach into the small
intes1ines for absorption; pre-'l?nlS irritation of the
gastric mucosa
Enur esis Involuntary discharge of urine after an age
when bladder control should be achieved; usually
called bedu'l!lling because the pcrM>n does no1
wake up al night
Epistaxis Nosebleed
llquin lent fractions Fractions of 1he same value
llscbar Sloughing o f ski n after a burn
lltrogen Female sex hormone
Euphoria Exaggerated feeling of well-being
Exacerbate To aggravace sympcoms or cause increased
symptomatology of a disease
Excoriation Abrasion of 1he skin
Excretion Elimination of medication from the body
through respiration, perspiration. urination, or
defecation
Exogenous Origina1ing ou1Side an organ or organism
itself
Expectorant Agent that assislS wilh the removal of
mucous secretions from 1he lower respimtory 1ract
Expectorallon The act of spining out s.1liva or cough
materials from 1he air pa'IS.tges
Extract a nd Ould exuact Highlyconcemratedp~
tion of liquid medication achieved through n-apor._
tion of a solution
E.rtrapynmldal symptoms (dfects) ln!mon, "'""'
nia, or slow 1rregulM. involuntary movemen1> o( lbr
upper exircmi1ies, especially hands and fi~ ..,,.
toms of motor imbalance and lack of musdt lont
Extravas allon ~rape of fluid fro m vessels imo IUI
rounding 1issues; in pharrnac~logy, . refers 10 drup
thai escape from blood vessels into tissues
factors Num bcrs being m u ltiplied; any of lwo or moti
quanti 1ies wh ich fonn a p roduct when multiplied
1ogc1hcr
facultatlve bacteria l'ertaining to baaeria wilh mt
abili1y 10 1hrive in dissimi lar environmems; baom.,
tha1 are able 10 Jive in ei1her aerobic or nacrob~
conditions
Fahrenhe it Scale of measuremenl of tempemwt 11
which the boiling poim is 212 and the f1tt2ingl'Ollll
is 32 at sea level
fibromyalgla Debili1a1ing disease with chronic pa1nol
muscles and soft tissues surrounding the join1>
filter needle I lypodcrmic needle that coniains a snul
filler system to prevelll aspiration of small glJ11
particles from ampules into the syringe: should ht
re mewed from the syri nge and replaced with 3 hypo.
dermic needle befo re injectio n
first pllSS effect R,1pld in activation o f soone oral medi
cations as 1hey pass 1hrough the liver for the fi~t time
before entering tht' S)'Slemic circulation
Focal (pardal) seizure Seizure with limited spread tn
1he brain, usually affl'<'ting a single musde group
Folk medicine Remedies for illnesses passtd down
from generation 10 genemtion in families Ot 1n 1
ruhurc for the treat men I of specific symptoms (tg..
cobwebs to stop blttding. meat tenderiur 10 rdim
the itching of insoo bites)
food and Drug Admlnls uatlon (FDA) i\gency"'P<""
siblc for the safety, efficacy, and purity of drogs m.u
ke1cd in the United St.ues
formula method Substitution of inform3tion into a
form ul .1
f ree drug Drug that has reached 1he bloodstream and
is ready for use in 1he body; synonym for 1111/Jounddn.1
Fungicida l Drug wi th ability tO kill fungi
funglsta tic Drug with abilily to inhibi1 gro\\1h of
fungi
Fungus (plural, f uugi) Spore-fanning. plandikt. 11n-
gle-cellcd microorganism that 1hrives on dl'ad OtP11JC
matter; usually part of normal body Rora
Furunde Anltl', dttp-seated inflammation of 1ht WI
that begins in a hair follicle or sweat gland and pn>
duces suppuration and necrosis; boil
Fusio n Joining 1ogethcr of two lines, such as bont
fusion, in which two seccions of bone are perml
nently joined together
c.IJ<lorrhea Excessive se("retion of milk
eisirotsophageal reffux disease (CERD) Condition
in which acidic contents of the stomach flow back-
ward in10 the esophagus
Gaug SrandJrd of measurement indkating the diam-
eter of the lumen o f a hypodermic needle
Gtl Semisolid in a wate r base w il h a th ickening agent
for absorption through the skin
GtiaP Soft gelatin shell filled \vith liquid medication
eenerillzed scizme Seizure with loss of con$dousness
Ctntfk drug Drug not protected by a trademark but
ttgUlaied by the FDA
Ctnftlc Immunity (inborn or natural immunity)
Mort orless permanent immuni1y pre:.ent from birth
;u a result of genetic factors
Gtrmldde Agent with the abili 1y 10 destroy germs or
microorganisms
Gtrmlstatlc agent Agent that prevents growth of
microorganisms
Cinglltls Inflammation of the gums
Gbucoma Disease of the eye chara~teri.wd by increased
in1raocular pressure
Clu<ocortlcoid 1lonnone secreted by the adrenal conex
1ha1 protect> against stress and is u>ed in protein and
carbob)'drate metabolism
Glycoslde Active plant substance 1hat yields a sug.-ir
(gl)(O) plus an active ingredient
Goller Enlargement of the thyroid gland
Crain llasic un it of measu re for solid wdgh1 in the
apothecary system; compared with one grain of wheat
or rice
en. Basic unit of measure for solid weight in the
mttric S)'Stem
Cnnd mal seizure CeneraliLed tonic-clonic seizure
Cranule a small partide of dry mass capable of free-
Oowing movemen 1
Growth hormone I lormone secreted by the anterio r
pituitary that regu lates cell division .111d protei n syn-
thesis needed for growth
Cum Siicky substance that driN to ,1 solid mass that is
ioluble in water
Hbllullon psychologic and emotional dependence
on a drug, tobacco, or alcohol that results from
rrptated use of the substanc<' but without the addic
hve need to increase dosage
Halitosis llad breath
lfallud nallon Perception that has no basis in real ity;
may be visual, auditory, rnctilc, or olf.mory
llelmlnths Worms
llt111aturla Blood in urine
lttmoptysls Cough that contain~ blood expectorated
from tither the oral cavity or another pan of the respi-
ratory t12<1
Unnostub Arrest of bleeding
lligh-dens lty Upoprotein ( llDL) Simple protein thal
1s combined with lipids-cholesterol, phospholipids,
and lrigl>"Crndes; a higll lewl of 11 DL lipoproieins is
desirable
lllr~ullsm l.xcessive body hair 111 m.llt"llline distribu
tion p.mern as a result of hen'dny, dru~ hormonal
dysfunction, or the like
lllves Vascular skin condition char.mcri1ed by papules
and wheals, producing inten<c itrhmg
llo~e remedy Treaunent devised and applied at home
wnhout professional medical advice; may or may not
have therapeutic value ( e g., prl'parauons from plan"
grown m herb gardens to treat toothache. itching from
poison "'Y nausea, and the hl.e)
Ho~eostasl s Equilibrium of the body tha1 is main
tamed by ever-changing feedb.lCk and regulation pro-
rc~scs in response to external or iniemal changes,
Stall' of equilibrium in the internal environment of
the body
llordcolum Localized, pumlent, lnOammatory bacte
rial infenion of sebaceou< glands of the eyelids,
usually with small abS<esses, also c.illed a sr)"'
llo rmone Substance originating 111 an organ, gland, or
hod> pan that is secreted d1rl'Clly into the blood
stream and carried to another pan of the body 10
begin a chemical action, to increasc the activity of that
pan, or to increase another secretion
Hos l Organism that provides nourishmenl for a
par~lSile
Household system System of 111casu rement that uses
common kitchen measuring d<'Vices
llyperglycemla Elevated blood glucose level
Hypers ens itivity reaction I lcightcned immune reac-
tion or allergic reaction to a medication
llyper1en s lon Clevation of blood pressure abo-e
normal limits
1-lyperurlcemia Excessive arnounts o( uric acid in
blood
Hypervllamlnosls Condition resu lting from the excess
in take of vitamins, usua lly viiamin compounds;
usua lly found wit h lipi<l Olublc vitamins
HypnotJc Medication used 10 induce or maintain sleep
Hypoglycemia Decreased blood glucose level
Hyp ogonadism Deficiency in secretions from ovary or
testes
llypolhalamus Portion of the brain that lies directly
under the 1halamus; it has many functions including
secr~tion of. releasing. and inhibiting hormones
Hypovltamlnosls Condition resulting from a dcliciency
or lack o f absorpt ion or use of one or more dietary
vif.,n1ins
Ideal drug Drug that is both cffcnive and safe, produc-
ing no side effectS or adverse reactions; only a 1heo-
re1ical construct
ldiosyncntic drug reaction Unexpected. unusual
response to a drug
I mmune serum Serum from dn animal immunl"
against a specific pathogen for injl'Clion into a patient
610 Glossary
.;_~~~~~~~~
with the disease from the same organism; a blood
component
Im munity Antibody proteoion ag.i1nst a disease espe-
cially infectious disu...s
Immunodeficiency Decreased or compromised ability
of the body to respond to an anugen with an appro
priate immune response
lmmunoglobulins o r Immu ne globu Uns Blood prod
uctsthat contain disease-specific anubodies for passive
immunity
lmmunomodulato r /\substance that alters the immune
resp0nse by augmenting or reducing tlw ability of the
immune system to produce antibtldies that recognize
and reaa with the antigen that caused the reaction
lmmunos timulant /\gent that stimulates the activiry of
the immune system
lmmunos uppressant /\gent that 111terfercs wilh the
normal reactions of the immune system 10 an antigen;
used in anhritis treatment and o rg.1n transplantation
to prevent the production of anubod1es to foreign
an11gens
Impetigo lnOammatory skin disease with isolated pus
tl~es that become cruted .ind break down; usually
caused by streptococci or staphylococci
Implant Fonn of medication placed under the skin for
longtemi, controlled release; also called < pellet
Improper fraction Fract io n with the numerator equal
to or greater than the denominator
In s itu Loca lized. in place
IJJactivated vacdnes Suspension in which the virus or
microorganisms have been trc.11ed so they arc no
longer capable of reproduetion
lnconUncnce Inability to hold or reta111 urine
Indication Reason to use a panicular dmg for a panku-
lar disorder
Ineb riation State of intoxication or drunkenness
Inert Ingredient Ingredient that has little or no effect
on body funaions; used to provide substance lo active
ingredient
lnotropic effect Increase or decrea;e in the force of
rny0<ardial contraction
Inscription Pan of the 1ncscription th.It ind icates the
name of a drug and the dosage prescribed
Ins tillation Procedure by which Ou id is introduced into
a body cavity to expose tis<uc of tJw are.1 to the Ouid
or medicaLion
Insulin pen Device for administering insulin using a
cartridge containing insulin that inserts into a pen Like
container for ease of administration
lnterrnincn t d au dlcatio n Se\'ere pam in the calf
muscles that occurs during exercise beca~ of inad
equate blood supply to the lower extrcnuties
International Standard ISO 860 1 Internationally
accepted standard date and time notation; yyyymm
dd and hhmmss
lntraa.r ticular within a joint
ln tra dc rm a l Into or within the dermis of the skin
In tram us cular Into or within a muscle
lntra~nous Into or within a vein
Ion /\to m o r mo lecule bearing a positi\'I? (calion) ff
negative (anion) electric charge; in aqueoussolutlOftl
and in body Ouids. ions are charged clearof)1t'>
Irritant Drug applied to produce inOammation .11 tht
site of admin1str.11ion
ls cbcmla Decreased supply of oxygenated blood to j
body pan causing p.1in and organ dysfunction
Is lets o f Lan ge rha n s C lusters of cells in the panani
that produce in~u lin
Isotonic ncfcrri11g LO so luLi ons with the same tonkily.
in rhysiology. solutions that are compatible wnh
normal body tis;ue on the basis of having the <amt
concentration of 'olutes as is found in that ~
tissue (e.g.. physiologic salt solution and nooi.i
saline)
Keratin 1bugh protein substance in the luir, nail\ and
stratu1n corneu1n
Kcratitis lnOammation of the cornea
Keratolytlc agen t Agent that causes or promotes tht
shedding of skin
KiUed vaccines Vaccines made from whole k1ll<d
m icrobes and their components
Kyphosls Abnormal condition of spine charactenud
by increased rnnvexity (outward curve) in thecurva
ture of the thomck sp ine as viewed from the side
Laxative Subsiante that acts to promote and faciliratt
the evacuation of bowel contents, thus aJJC\ating
constipation
Legend drug Drug that requires an order from a liceni<d
health c.ire provider for dispensing (synonym prr-
scription drug)
Lethargy I l'<!ling of sluggishness
Lcukopla kia Fo nnJtion of white spots or patdics tm
mucous membrane of the tongue or cheek
Lcukotrien es Croup of metabolites that fuooion 1>
chemic.ii mediators of allergic reactions and 1nftam-
mation that are implicated in the inflammatoty
responses in ,1;Lhma
Linhne 11l Medic;ition that combines oil, soap, 'A'3tcr,or
a lcohol and is placed on the s kin to produce heat
Lipodystro1>hy Abnormal ity in the distribution and
metabolism of fats
Liter Basic mea;urcment unit of volume (liquid or ~)
in the metric system
Uve vaccin es o r live a ttenu ated Vaccines compostdol
live microbt'S that have been rendered avirulem
Local actio n Drug action of a medication at the SJtcol
.1dministration o r in the surrounding tissues
Lotio n Frec Oow1ng liquid or formulation wuh u~
dients suspended in w.1ter for application to tl>t
skin
Low-d ens ity llp oprote ln ( LOL) Simple protein that d
combined with lipids-cholesterol. phospholipi<b, anJ

tn;)'Cffldes; a h igl\ le--el or LDL lipoproteins is
undesirable
l.Al~"rst co~on denom~nator (LCD) rhe lowe.i
number or integer th at, is exactly divisible by each
fractional denominator 111 a Set o r fract ions
l.Al~'est common multJple {LCM) The lowest number
that is a multiple or rwo or more numbers
I.OWi&" Hard. dry medication held in the mouth to
d1ssoh-e
1.uJD<D A tabular space within a hypodermic needle
Macrophage Phagocytic cell o r reticuloendothelial
S)~tClll
Magaldratc Mixture or a lu mi num a nd magnesium
compound
)Ugm Suspension or fine 1>anides in small amount or
.... tff
Malnttnance mediatlon Medication prescribed to
mainwin a condition or health: usually used with a
chronic disease p rocess
Malaise Discon1fon o r a non~peci fic reeling of u neasi-
nes~ of1en a sign of i ll nc~s
Mallgnant Cancerous
Mastlcaie To chew, tear, or grind food with teeth
,lkdlcated enema Enema that provides medication for
absorpuon in the reeturn
Mtdlcallon administration Introduction or a medica-
tion into the body or its application to the body; the
giving of a dose of medicine
Mtdlc.llon error Mistake made in prescribing. admin-
l~tmng. or dispensing ,1 medication; may indude
administering the wrong medicine or the incorrect
dole. using the incorreet route, failing to administer a
mf<licine that has been ordered, giving the medicine
at the incorreo time, or givi ng the medicine lo the
wrong patient
Moolcatlon order Wri ucn or verba l (ora l) order fo r
administration or a mcdic.ition in a health care
setting
Mtdlcallon(s) A drug or other substance that is used as
rMdicine
Menlsrus Concave rurv.iture made by a solution when
poured into a cont.tincr; in pharmacology. the liqui d
is poured imo a calib rated measuring cup
Meubollsm Physical or chemical processes in the body
that inaaivate a drug for excretion from the bodr;
biotnnsformation
Mttmasls Change in the location of a disease or its
manifestations from one body organ or area to
another; a secondary growth of malignant cel ls in a
OfW location
Mett r ijasic measuremen t unit of length in th e metric
system
Mttred dose inhaler (MDI) Breatl1-aoiv.11cd device
that dell\'t'rs a given amount of a fine mist of mcdica-
uon directly to the mucous membranes or the respira-
toiy tract
~~~~~~::_:_:~
Glossary 611
Metric system Measuceml'nt S)">tcm based on pO\\cri of
10, c~nsidered to be the mternauonal standard for
s~1cnt 16c and industrial measurements; uses warns.
li ters, and meters
Microbe Unicellular or small multicellular organism
M~croblology Study of microscopic organisms
M1cronu1rlent Dietary ekment essential m minute
"'."ounts for normal ph)'li1ologic function. such as
vnanuns and minerals or chcm1als
Milllequlvalent Weight of .1 drug (usually 111 m1lli
grams) in a volwne (usually liters) of solullOn
Mineral Inorganic (neither p lant nor animal) solid ;ub-
stance, usually a component of the eanh's crust
Mlneralocorticoid 1-tormonc ~eted by the adren~I
conex tl1at is primarily invohed in the regula11on or
fluid and electrolytes througl\ acuons on 1011 transpon
and the renal tubules
Minim l>mallest unit of volume (liquid) in the apothe-
cary syMern; approximately a drop in houehold
1ne11sure
Miosls Constriction of the pupil
Miotlc Agent that causes the pupil to constnet
(contract)
Mit otJc alkaJoids Group or alkalme materials obtained
from plants that interfere with cell division
MltotJc Inhibitors Drug. that decrease all d1v1sion by
preventing division and migration of cell chromo-
somes or cell mitosis
Mixed number Nwnbcr containing a whole number
and a fraction
Morbidity Illness or disease state
Morphology Study or the strueture and form of 0'!1-ln-
isms without regard to the runction
Mortality Death
Mucokln eUc agent Medicac ion LhaL removes cxCCS)ive
or ,1bnormal secretions from the respiratory 1r.1ct
Mucolytlc Agent that decrea..cs the viscosity or thick-
ness of sputum or other secretions of the respiratory
tract
Mucos a ! Penaining to mucous membrane
Mucus Viscid nuid secreted by mucous membr.mes and
glands containing mucin, white cells, epithelial cells,
and waterand salts, such as the nu ids from the murous
glan ds or the mouth
Muse.le spasm Sudden in,'Oluntary muscular contraction
Muscle s pastldty lncrea..00 tone or contractions of
muscle causing stiff and awkward movements
Mutagen le Causing a change in genetic structure
Myast henla graris Disease with symptoms or gre.u
musnilar weakness (without muscle arrophy) and
pmgressive fatigue o n exert ion
Mydrias ls Dilation of the pupil
Myocardial Infarction (Ml ) Deprivation of the myo-
cardium or blood supply to the hean caused by block
age of the coronaiy aneries with resultant necrosis of
the myoc.udium: hean anack
 612 Glossary
~-~----
Myopia Visual refracti\oe error; nearsightedness
Narcolepsy Syndrome charae11'ri1.ed by sudden sleep
attacks. cataplexy, and v1sual/ aud1tory hallucinations
at the onset of sleep
Narcotic Older tenn for a co ntrolled drug that
depresses the central nen.'OUs system to reliaoe pain
and has the potential to cause habituation or
add1etion
Narrow-spectrum a ntibiotic Antibiotic effective
against only a few or specific microorg.111isms
Na tional Drug Code (NOC) Number on drug label
that identifies the manufacturer. product substances.
and size of container
N11tior1al Formulary (NP) List of officially recognized
names of drug.< that ha'" an ~tablished usefulness
Natural active immunity lmmuruty tl1Jt is more or less
permanent by species or results from the fonnation
of antibodies after dise<ise processes
Natural immunity Immunity that 1s genetically deter-
mined by species. families. o r populations
Natural passin Immunity Immunity passro from
mother to child, either in utrro or in breast milk;
immunity from natural inherent factors
Nebullur Breatl1-ae1ivated device tliat delivers a fine
;pray of micronizecl powder into the mucous mem-
branes of the respiratory tr.lCl
Necrosis Death of tissue o r bone in areas that are sur-
rounded by healthy tissue
Negative feedback Cont rol mechan ism in whid1 a
stimulus produces a response that reverses or reduces
a previous stimul ation, thereby >topping the initial
response
Neoplasm New and abnonnal fonnation of tissue
Neurobormones I lonnones found in portions of the
neivous system, such as the catttholamines
Neur oleptic Another name for medication used to treat
psychosis
Neuron Nerve cell
Neurosis Abnormal behavior from increased anxiety,
tension, or emotional imbalance
Nits ~of lice
Nocturia Excessive urination at night
Norncoclatu re A system of naming used in scientific
d isciplines, the m eans providing system.uic and con-
sistent scientific or technical names
Nomogram Measuring device used to show relation-
ships among numerical va lues; set up as a grapb, it is
the most accurate means of calculating the dose of
medication based on weight and height; usually used
with pediatric and geriatric patients
Nooopioid medications Analgnics that contains no
opium, opium derivatives. or synthetic opioid
medications
Nonpar e.oteral medlcatlons Medications taken by
mouth or through mucous membranes or skin, such
as ears, eyes, nose, or rectum
Nonproductive cough Cough in which no exudatt"
expelled
Non s<tlicylate Antiinflammatory agent that do.s .,
contain salicylic add (e.g. Tylenol, naproXtn)
Nons te roldal antllnOammatory drug (NSAJO) illt
inflammatory medication that does not con~
steroid preparation
Norm al flora Racteria and microorganisms norma ,
found on or within the body; may be potential~
pathogenic when the body is not in homeostasis
Novolln pen Prefilled. multi use cartridge of insulin thill
al lows a dosage to be d ialed for adm inistration of
correct dose
Numerator Term of fraction that shows how many sp;
cific part~ of a unit are taken, nu mber wriuen allO\,
or to left of line in a fraction
Nutrient Food or substance that supplies the bodi'with
the necessary clements for metabolism and body
nourishment
Nystagmus Constant involuntary m()\c'l'ltle.nt oftht ')t
in any directio n
Obsessi on Persistent and rerurrent thought or idta
with which the mind is continuously preoccupied anJ
cannot be expunged volu n tarily
Occlusive dressing Dressing that does no t allow a1r to
enter under the d ressing (e.g., plastic wrap)
Off-label use l lsc of d rug 10 treat a condition for which
the FDA has not approved treatment
OU T hick, greasy liquid th at is e ither volatile (having an
aroma) or foxed
OinLmcnt Semisolid in g reasy base that is not absoibfd
into the skin, but the medication is absorbed fromtht
greasy base
Ollgurla Diminished ability to fonn and pass urint
Oogenesis 1-orrnation of female gametes or Ol'a
Open-angle gla ucom a Increased pressure in ~" m
which the angle permits the drainage of aqueous
humor but the function of drainage is inadeqwtt dut
to overproduction of "queous humor or outft""'
obstn.1ction
Opbtlialmlc prep aration s Medicatio ns used in theeit
O piate Drug conta in ing or d erived from opium, a
na rcoli c
Opioid analgesic l) rug Lhat is a )'11theLic pain mcdka
tion with the >trcngth of a morphine-like substance
but is no t derived from opium
Oppo rtunis tic Infectio n Infection that is prtnt
becau~ the immune system cannot fight the nomul
flora found on the body or in the environmen~ mi
dent flora proliferat<? and infect the body
Ortbostatlc hypotcns lon Drop in blood pressurt tltJI
a person cxpcncncei, when changing from a sup1nt11>
an upright 1>osition
Osteoarthrllls Chronic noninOarnmatory amoim
m~me dise.1se of Lhe joints, epecial ly weight-beanng
101ms, that cau'"' destruction o f the joints

Ostromalacl~ .~isease in which softening of the bones
causes flo1b1hty and bnttleness, learung to deformi
on; the adult form of rickets in children
Ost<0Porosls Disease involving reduction of bone
m.us 1hat tends to occur in older adults; bones become
porous I d. .
Otic prtparat ons Me 1cauons used in the ear
Otitis mediJ Infection of the middle ear; a lso called
cympani1is
Ototo.ddty Detrimental effect from medications on the
tighth crnnial nerve or the organ of hearing
om.ihe-counler (OTC) d rug Drug that does no t
require a prescription; nonlegend drug
o11daUon Release of ovum from ovary
o.11m f:gg; female reproductive cell
Plckage lnse.r1 Comprehensive concise description of
a medication developed by the manufacturer that
xcomp.mies any legend drug; required by the Food
ind Drug Administration for all pharmaceutics
Pain ptrcepllon Point at whicl'I a person becomes
~'3tt of a p.1inful stimulus
Pain threshold Point at which a person acknowledge
thJt the sumulus is painful
hin toler.nce Person's abil ity to tolerate pain
Palliative Alleviating a symptom without curing the
rondition ciusi ng 1h e symptom
Pannus Inflamed synovial granulation tissue of joints
found in rheu matoid anl1ri lis
Papule Small, red, elevated nrea on skin that precedes
pustules; pimple
Parasite Organism 1hat liws within, on, or at the
t:Xjl<'nse of another without contributing to survival
hrasympathellc nervous system Pon ion of the au10-
nomic nm"Ous system that conserves energy and
ltSIOres body resources in rest and digestion ("feed
0
orbtted action)
Pmsympalhomlmellc ( cholinergic) agent Agent
that blods the action of the parasympathetic nervous
S)~ltm
Parenteral route Route by wh ich medications arc given
through the skin by injection, such as intramuscular,
intradennal.. subcut._tneo us, and intravenous
Paruthesla Sensatio n o f numbness, prickling, or
1ingling
Parkinson disease C hro nic nervous system disease
tharaacrfaed by fine, >lowly spreading uemors and
mu5CU1ar weakn!'S!J and rigidi ty, accompa nied by a
charaaeristic shuffling gait
Push"<' Immunity lmmuniiy acquired from the injec
uon or p.usage o( anubodies from an immune person
or animal to another or shon-term immunity or
immunity p.1Ssed from mother to child
Putt Stiff, thick, semisolid medicated preparation that
adhem to the skin
Patent State in which an objea is open. as in an open
airway
Glosstrv 613
--~------'
Pathogen Organism capable of causing d1s.:ue, usually
a microorganism
Pathology Study of the causes of d1sea- '"'"<>l,ing
struaure or function; condition produc<d by disease
Pedlculidde Agent that kills lice
Pellagra Disease resulting from deficitncy of niacin
l'ellel See lmplam
Percent In. 10, or for every hundred
l'ercut;tneous Route tl'trough the skin. in pharmacol-
ogy, refers to medications absorbed through the skin
or mucous membranes such a~ to1>1cal, buccal, or
trtlnsde:rmal medications
Peripheral nervous system Ponion> or the nervous
system outside the brain and ~p111.ll cord
Periph eral vascular resistance lll:sist.1nce of blood
flow through the anerial vascular S)'l>tcm, especially
anerioles and capillaries
Peristalsis Progressive wa,-elike 111voluntarl movement
that occurs in a hollow tubular hod) organ. for
moving food and waste material~ 1hrough the g;uuo-
inteslinal traa
Pham1acodynamic agent Subs1.1nce 1hat alters normal
body function in some way
Pbarmacodynamlcs Interactions of drugs and ltving
tissues
Pharmacogno1' Branch of pharmacology cle.11ing with
the origins of drugs (natural o r manufactured sources)
Ph armacoklnellcs Processing of drugs by 1he body
l>harmacology Study of drug.~ their uses, and their
inleracaions with living sy~te1ns
Pharmacotherapeutics Effeas of drugs in the ucat
ment of rusease
Photophobia Abnonnal intolerance of light
Photosensitivity Abnonnal response to cxpoure to
light. specifically on exposure to sunlight or its
equivalent
Physical dependence Craving for dru~ because of
extended use, so the drugs hae taken over the indi
vidu.11' life and have affeaed normal body function
ing; discontinuatio n of use of the drug typically results
in withdrawal symptoms
1'/1ysicia11s' Desh Refenmce (POR) llook, published
y~arly, that is a compilation of drug package inserts
t>hyslology Study of normal physical body functions
Placebo Medication with no pharmarologic or thera-
p~utic effect that is used to sati>fy a patient'> psycho-
logic need for medication
Plant alkaloids Group of organic alkaline subst.mces
obtained from plants for medicinal purposes
Plaster Solid or semisolid, medicated or unmedicated
preparation that adheres LO the skin
Point of maximum impulse (PMI) l.1ndmark in the
fifth intercostal space 2 inches to the left of m1dline
where the pulse of the hean can be felt mo~t suongly
Polydips la Excessive thirst
Polyph agia Excessive uncontrolled ea1ing or hunger
61 4 Glossary
Polyphannacy lndlSCflminate use, whether intentional
or unintentional. of multiple dru~ at the same time
(commonly found w11h older adults)
Polyuria Excessi'" urinauon
l'otency Strength of a medic.iuon
Potentbtioo Prolong;iuon of or increase in the effect
of a drug by another drug
l'owder Medication in fine panide form, may be recon-
stituted into other forms or medication or used as a
powder
l'recaulion Specific warning to consider when prescrib-
ing or administering medications
Precipitate Insoluble granules or solid panicles that
separate from a solution
l'remeasured cartridge Premeasured, one-dose amount
of medication in a disposable canridge
Presbyopia Inability of the lens to accommodate to
near objeas because of the rigidity of the lens caused
by aging
Prescribe To indicate, euher 111 writing or orally, a
medication to be given
Prescription Wriuen order for dispensing or adminis-
tering medications, usually by a physician, dentist. or
other licensed health care provider as allowed by law
Preventive (propbylactk) medication Medication
prescribed to prevent a disease or illness or to lessen
its severity
Prlapfsm l'requem or continuous erections in the male
Product Result of multiplying
Productive cough Cough in which mucus or an exudate
is expelled
Progeslln Female sex hormone secreted by the corpus
luteum
Progesterone Natural female hormone
Proklnetic agent Agent used to stimulate gastrointesti-
nal motility by reducing esophageI sphincter pres-
sure and accelerating g;istric and intt'Stinal emptying
Proliferation Rapid and repeated reproduction by cell
division
Proper fraction Fraction in which the numerator is less
than denominator
Pr<>1>hylactic agent Drug used to prcwn t pregna ncy o r
illness
Proportion Equality between ratios; relationship
bet\veen four quantities on l\\ 0 ratios
1
Proportional method Process of setting up dosage
problems by comparing the relationships between
two ratios that are considered equivalent
Proteolytic enzyme Enzyme that helps break down
proteins imo usable peptides
Proton pump inhibitors (PPls ) Located in stomach,
parietal cells that excretes hydrogen in exchange for
potassium to form g;istric acids
Protozoa (singular, protowa11) Single-celled parasitic
organisms
PSO Packaging. storage. and distribution
Pseudoaddlctlon A syndrome of abnormal beh..ior
developed as a direct consequence ofinadtquatt !Miii
man.1gement
Psoriasis Chronic disease of the skin "ith sih'tl) !"-
low-while lesions that form plaques with dlllJnQ
borders
Psyclioanalysls Method of ob~aining mental and (Ill(>
tional history of past experlences that are runnu'
affecting menial disorders
Psychologlc drug d ependence o r habitualioo Arrui
tomization to a drug through frequent use or exro-
sure or repeated adm inistration of medications fortht
palient's mental sense of well-being; Lhe craving for i
drug becau>e of frequent use
Psychosis Menta l illness accompanied by biu11t
beh.wior and altered personality with failwe 10 J><I
ceive reality
Psycho therapy f'reatmem of mental illness th~
mental means rather than physical orchemicalthtt'P!
Purine Group of nitrogenous components that m Cid
product of ccnain proteins while some are S)lltht
sized within the body
Pustule Small e levation of the skin filled with l)'l'llph or
pus
Pyurla Pus in the urine
Quality assurance (QA) Estab lished standardsofexcd
lence in paticn l care and tailoring care to tho;e
srnndards
Quotient Number obtained when one quantil)' or
number is divided by another quantity or numbn
Radioisotope Radioactive form of an elemen~ wtd t0
diagnose or treat neoplasms
Rafe Common abnormal respiratory sound COMllllt
of discontinuous babbling noises heard oo
inspiration
Ratio Expression that compares two quantities; acoloo
usually separates the two quantities
Rebound co ngestion Reflex response of nasal congr>-
tion that occurs after the prolonged daily ust ol
decongestants; nasal congestion caused by lhe body'1
respon~~ to prolonged depression of the mucous
m embranes' secretions by m edication
Receptor s ite Cel l componem that combines with a
dn1g 10 alter cell function; in pharmacology, the pJ.11
of a cell that imcracts with drugs
Redproca.I Fract ion obtained when invtrtil\g
fraction
Recomblnanl ONA technology Genetic enginttnng
technology used LO create new drugs
Reconstitution Proc('SS of adding a Ouid such as w.ll<'
or saline to a powdered form of a drug. tNbng
specific dosage s1rcngtl1
Refill Additional medication or treatment to bt dD-
pensed if prescribed
Regurgitation llackward flow; the return of siomidt
contents lo ihe 111ou1h, as in vo 111itus
11tPlcemcnt thuapy Medication therapy used 1
rrplace missing chemicals in the body, includin;
tioonones. electrolytes, and Ouids
RtpOSltory action Medica1ion insened and s1ored for
skl<- release a1 body temperature
lftSpoDde.at s upulor Legal premise by which ihe
empl~-er is held responsible or liable for the wrong-
ful acuons of an em ployee that may cause injury or
dJmage as lo ng as the employee works w ith itl ihe
s<:ope of praClice; Ii terally, "I.et the master answer"
ReSlkss legs syndrome Condi1io n of unknown cau~c
marked by in1olerable creeping sensatio n in lower
I~ causing irresistible urge 10 move legs
Rhinltls lnflam111 a1ion of the nasa l 1nucous
membranes
Rhinorrbea Runny nose
tubs Subs1ance applied 1opically to relieve a sympiom,
such as muscle ache or rash
Sift drug Drug 1ha1 causes no harmful effeos when
~n in high doses over a long period of time
Silkylale Amiinflammatory drug compound comain
ing s.1licylic acid (e.g., aspirin)
s.JI Chemical compound resul1ing from the imerac1ion
of an acid and a base
Sa.nitlzatlon Process o f deani ng and removi ng d in
from objects
Scabidde Age111 1hn1 kills scabies
Schizophrenia Croup of me ntal disorders o f u nknown
cause 1hni affeet tl1inking. affect. and behav'ior
StborrheJc dum atltls lnO amma1ory skin disease of
unknown cause that causes yellow or brown-gray
grea~ scales
Stbum lauy secretion from the sebaceous glands of 1he
~n
Stdatm Medicauon used to reduce the desire for physi-
cal Clivity and produce a calming effeet
Sdzutt Epileptic event
Stmisynthetlc A natural substance that has been par
tially ahered by chemical man ipulation
Strum Serous fl uid that moistens the surfaces o f serous
membrJnes; clea r watery lluid 1na t has been sepu ;11cd
from more solid eleme11ts
Shelfllfc Storage time fo r medicatio n LO mai nta in d 1ug
po1ency and 10 e nsu re drug safety
Side effce1 Mild or an noying bu t expected a nd fairl)
common u11desirab lc resp0nse 10 a medi~11tion
Slgnture (Sig or S ig n a) l'art of prescription that indi
cat'5 1he proper dos.1ge of medication to be iaken
Skln dean~r Agent used as soap to remove debris.
bacteria. and was1e produas from the skin
Solubility Abilily of particles 10 be dissolved
Solute Subs1ance di$.Solved in a solution or body lluids
Solutlon Medica1ion dissolved in a liqu id vehicle
Solvent l.iquid i11 which substances are dissolved (e.g..
water in 1he body)
Spacer Aerochamber used wi1h metered d ose inhalers
Spas tldty Phenomenon in which uncoorJmtl'<I mO\T
ments are caused b) C.'IS '~~umuluon
Spermatogen esis Process of dewlopmrnt of
spermatozoa
S pi rits Alcoholic or hydroakohohc soluuon\ con1;11n
ing volaule aromatic ingredienL\
S pore Reproduction uni1 of some fungi and protozoa
S pray Set of fine medic.ited vapor applied 10 a diseasru
IMrt or discharged into the air
Sp~1um Substance obtained and ('Xpclled from cough
111g <>'. cle.tnng of the throa t co111,11ning ,1 v.irlety of
matenals from the respira1ory 1ra<1
Standardization See Drug s1and.trds
Standard p rotocol Wriucn de:1erip11on of one or more
.icp~ to be taken in ueaung spilic methcal prob-
lems; lhis should be signed by 1he .1ppropriatc health
care provider
Standing order Request for a procedure th11s rouune
for cenain medical trea1men1s under cerum
conditions
Sterili7.ation Process of desiropng all m1croorg.imsms
and spores
Steroid Hormone produced by the .1drrnal cortex
Sti mulant Drug that aets 10 increase the funetion or
activity of a body pan
Stomatltls lnllamma1io n of the mouth
Subcuta n eous Beneath the skin; injected inm 1he ~ub
culancous tjssue
Subllngual Under the tongue
Subllngual tablet Table1designed10 dis;olve under the
tongue
Sub scription Part of the prcscrip1ion containing the
direetions for the pharmacist wi1h 1he mformauon for
compounding ingredien1s if necessar)'
Summation Combining ofdrugs to ach1C\e the expected
effect of each drug
Supuinfection New infeetion that appears dunng the
course of treatment for a primary mfeCtlon
S uperscription Ponion of a prescnpuon designated
with the symbol R,
Su1,plemcntal medication Medica1ion used to avoid
deficiencies o r to achieve necessary lewh of existing
body chemicals
Su1,portlve medication Medicat io n 1>rescribed to a""is1
with ma in1enance of homeos1asis un1il a dise"e
process can be resolved
Su ppository Medication carried in rocoa buucr, hydro
genated vegetable oil, or glycerina1ed gelatin to form
a solid dose for insenion into a body orifice su(h as
1he \'agina. urethra, or reetum
Suspensio n Medication in the form of und1ssoh-ed par
1icles dispersed in a liquid vehicle
Sustained-release (controlled -release) ublel Tablet
form of medication in which the medicauon 1s
released over a period of time; also called co111rolld
rrleme 1<1blet
 616 Glossary
SunaJned-release capsule C,;ipsule fonn of media
uon in which lhe med1callon 1s released O\'l!'r a desired
period of known durauon
Sympathetic nervous ~tem Poruon of autonomic
nCIVOUS system that mobilius a person in an emer-
gency situa1ion cfight-or-01gh1 rtacuon)
Sympatholytic (or adrcnerglc blodcl ng) agent Agent
that blocks the action of 1he sympathetic nervous
system
Sym pathomimetic (adrcn crglc or adrcnerglc-acLing)
agent Agent that acis 10 simulaie or mimic the sym-
pathetic nervous system
Synergism Working together of two or more drugs to
produce a stronger effeci than could be achieved with
each drug taken alone
Synthetic Subsiance produced by artificial ra1her than
natural process or material
Synthetic or manufactured drug Drug that has been
created chemically in the laboratory w1thou1 the use
of plan1 or ammal produru
Syrup Aqueous soluuon sweeiened wnh sugar or a
sugar substitute 10 digu1se taste
Systemic action Drug action found al more than the
site of administration, usually tissue throughout
the body
Tablet Dried powder form of mcdkntion that has been
compressed into a small disk
Tampon Packed conon sponge o r other material for
dlCcking bleeding to an o rg.111 or pan of the body by
pressure
Tardin dysldnesla Slow, rhythmic, involuntary move-
mem as a result of the use of l>l>)'chouopic drugs
Target o rgan Site to which the effe<'I> of a drug,
honnone. or therapeutic agent are pnmarily directed
Tenacious Thick. viscous
Tenacious cough Stubborn, retentive, or pt!rsistent
cough with thick. viscous exudates
Ter-atogen Agent that adversely afTeru the development
of an embryo or fetus
Tera togenic Capable of causing abnormal cellular
uevelopmem of an embryo or fetus
Testosterone A na turally occurring J ndrogenic
hormone
Tetany Hyperexcitability of nerves and muscles charac-
terized by spasms. cramps, and twitching
Tberapeutic(s) Pertaining to beneficial treatment
Therapeutic med_icatlon/ agent Medication used in the
treatment of a condition or disease to relieve symp-
toms or effect a cure
Thromboembolism Embolism; the blocking of a blood
vessel by a detached embolus
Thrombus Blood dot that obstructs the lumen of a
blood vessel
Tinclllre Alcohol-based liquid used as a skin
disinfectant
l'lnnltus Ringing in the ears
Tolerance Decreased response to a medication 1 rt,,
prolonged use
Too.ic Penaaning to muscular tension or conlQ(tioq
Tonometry Measurement of intraocular pressure; US(d
to diagnos~ glaucoma
Topical Adjecti-e denoting surface; in pharmilCOJogy,
refers to medications applied to a surface a1t1 tr
locally 10 the skin or mucous membrane
Tourellc syndrome Rare d isease of unknown calllf
characterized by lack of muscle conuol, tics, PU!]JO!f.
less movement>. and incoherent grunts and barks
Toxic Po isonous
Toxicology ~1udy of poisonous effects of drugs
Toxoid Uacterial toxins that have been changed 10 a
nomoxic state for immunization
Trade n ame Brand name given to a drug by 1u
manufacturer
Tran quillzalion State of reduced mental tension dw-
actcrized by calmness but without significamRdiuon
or ment.11 confusion
Transdermal 11lrough the skin; in pharmacologi; refm
to mcdic.11ions th.11 are applied to the skin for loc.11
or systemic effect
Tra n sdermal p atd1 or dis k Drug-containing patch or
disk th at is applied to the skin, through which tht
drug is absorbed
Triglycerides Simple fot compou 1Jd consistingofthret
molecules of f,111y acid and glycerol
Troch e I lard disk of medication designed to dissoll>t in
the mouth for local effect; similar to lozenge
Tropic hormone I lormone secreted by the pilWtal)
gland that stimulates the production of anothn
honnone; also known as a srimulating lwrmcnt (ei
thyroid-stimulating hormone)
Tumor Swelling or enlargement; new growth
formation
Tumor necrosis factor (TFN) A protein productd b!
white b lood rclls to provide signals for regulation oi
cell growth and function during an immune rcspollll
and inna1111n;Hion
Tympanic membrane Eardnim
Ulcer Open sore includi ng sores of mucous membrane>
as in the s tomach and duodenum
Ulceration l..esion of th e ski n or mucous membrant
accompanied by ;,loughing of the inJlamed nccrouc
tissue
Unit Basic quantity used when calculating desirtd
dosages to indicate the strength of a panicular mtdt
cation; the unu is unique for each drug, based on tht
drug's s1reng1h in a basic measurement S)'Slml (t!
grain, gram, milligram)
United S 1a1es Pl1an1111copocia (USP) Official guidt
prepared by a national group of pharmaceutical pro-
fessionals and iS5ued every s years (with periodic
supplements) by the ll.S. government giving the
approved formulas and info rmation on tht

preparacion and dispensing of medications found in
ihe Uni1ed States
Unlttd State Pliar111111:opooia/ Dispensing Infonnation
(USP/ 0 1) Compendium of practical informa1ion
ab<>UI medications approved by USP
Uniltd SloUI Plrannaa>pooia/Narional Fonnulary
(USr/NF) Official drug reference book for medica
lions approved in 1hc Llni1ed S1,ues; combination of
USP and NF
urgncr Sudden, uncontrollable need 10 urina1e
Uri~I)' frequency frequent urination or urgency while
not increasing daily urinary ou1pu1
Us& Application or administra1ior1 of a medicJ1ion
for a given purpose
0 ,.,.uis 1nflamma1io n of 1he uvcJI m1ct {iris. choroid,
and ciliary body)
\.itt1na1ioo Process of immuniu1ion for prevention of
d~ises
l'.iln Preparation containing a suspension of whole
or fractiona1ed microorganisms 1h.11 o n adminiMra-
lion causes the recipient 10 fo rm an 1ibodies 10 a
di.we
\'uocoogution Conges1ion of 1he blood vessels
\'uoCOnstrlctor Agem chat narrows or constricts blood
,meis
\'sodila1or Agenl 1ha1 increases s i1A' o r dilates b lood
-essels by relaxa1ion of vascular smooch muscl es
\'tttor Carrier. usua lly an insect, 111.11 transmits patho-
gms (disease-causing organisms) from infected to
unmfeaed individuals wi1hou1 1hc carrier itself
Mquiring the disease
\'ehld Inactive agcn1 that carries an active medici nal
ingredient
\'erb1I order Requcs1 for medica1ions or procedures
tha1 is given orally rlher 1han in wri1ing
Glossary 617
Verligo !>ense that the cnvironmem or on~lf is
revolving
Vtty-low-denslty Upoproteln (VLOL) ~1mple protein
tha1 i~ combined with hp1d-choles1erol. ph<>Spho-
Upids, and lrigl)"Cerides. a high le--el of th<"><'. proteins
is unde<>irable
Vial Cl.1,s or plastic container with a mc1al mclosro
rubber ~cal for inj~'CtJble medica1io11,, may hold
single or mul1iple do><!s
Virule nce Dr...,ase-producing strength of a m1cro-
org;mism
Virus Bundle of genetic ma1erial in a pro1crn coot that
requirt>s .1 hosi for 11u1rnion and reprodunron, some-
times con,idcred Lo be a one-celled mrm>organism
Visco sl ly Abi liiy or i11.1bil 11y of a fluid 10 flow easily,
fluid 1h,11 rs 1hick and flows slowly
Vis cous lh1ckness of a subs1ance
Viscous solut.i on Thick. oft<>n oil-based solu11un; when
referring 10 injection,., a <;0lu1ion with a v"cous baw
is, 111 uch thicker than .1n aqueous soluti<ln and is
therefor~ !liven intramuscularly
Viscous s uspension 'I hick, gummy or gel,11rnous com-
p0u11d made up of solid panicles mix.'tl bu1 not dis
sol\'cd, Ill a fluid
Vitamln General tenn for a number of Olll'lllic sub-
st-.nces necessary in Lr Jee 1111\ounts for norinal growth,
devclopmcm, metaboli;m, and rele.1'e of!'rwrgy from
food; exclusive of pro1eiM, carbohydr.ues. foes, and
organic s.1hs
Volume Space occupied by a gas or liqurd
Wheal Round or elonga1~d clev.uion of the skrn, which
can be produced by iniradermal injcrtmn>
Xeros to rnla Dry mouth
Index
Plf' oumbtts followed by <. figures; 1.
ubln-
A Aaion onset, 35 7
.\b>IJ<tlll (Orencia), 4 091-410~ 410411
,\bbokinase. Srt Urokinasc
.lllbrrvilions
nirttnl 1rends for, 123
for modifying d rug fonns. 70b
in 1nescri1>dons and 111cdication
orders. 12-73, 721
Abilify S... Aripiprawle
Abre"J Sfr Ooros,1nol
Ablorbable gcl;uln film (Cclfilm). 488
Ablorbablc gcl.iin foa m ( Ctlfoa rn ),
488
/\biorb.1ble gel.iin powder (Celfoam
powder), 488
Ablorp1io1~ 24 27, 25b, 251-261, 187
/\bust. Srr Drug abuse and dependence
Aampros;ilt (Campral), 5851, 587
,\urboot (Precose), JS91-3611. 363-364
Aaolait. ~ ZafirlukJSI
Aaommoda1ion. 371
ACE inhibitors &t Angio1ensin-
con\'tfting enryme inhibitors
Awn1nophen ffylenol). 246-247,
N7~ SS-I
""nhniit. 408, 4091-4101
"l'tnn compared wuh. 246247
rodtint and 243
coonb1nauons with, 2491
\<tl)'lchohnt (ACh), 527-528. 529f
Act'l)'k)1tt111t (Mucomys1). 453, 4541
lt)b.lhcylic acid Stt Aspirin
!.Cll \tt llcetylcholine
Arid rebound 422
AcJrlla. ~ R.llM'pra7..ole
Acnt prrpara1ion>. 3?3-394, 3941
A<qu11td immun11y, 256. 257f. 2571
inborn immunh)' v .. 258-260, 258h.
259(
.\cromeg;ily, 348
AClll. S"1 Adrenocor1ico1ropic
honnone
Acthar. Su Adre:nocorticotrop1n
Actig;ill. Stt Ursodiol
Actinir keratosis. 400
Action peak. 357
ACt.ivase. See Aheplase
Active immuni1y. 256. 257f. 2571
artificial, 259-260. 263-269,
2641-2661
na1ural. 258-259, 259f
Actonel. See Ris('drona1e
Acme pain, 242-243
Acydovir (7,ovirax). 300, 301 t-3021,
3901-3921. 392, 422. 423l
J\dalat. See N ifedi pine
Adalimumab ( 1-lum ira), 409<-4101,
41041 1
Adamanlanes, 459, 4591
Adapale ne (Differin), 393. 3941
ADD. See Attentiondefici1 d isordor
Adderall. See Ampheta1ninc sulf.1l(>
Addiction, 8, 341, 241. See also Drug
abuse and dependence
Addition
of d'1Cimals. 98-99
of fractions. 89-91
ADH. See A.nfidiuretic honnone
ADHD. Stt Anen1ion-de6cil/
hyperactivity disorder
J\dipexP. Stt Phentermine
Adjuvam medica1ions. 243. 250.
lSOt-2511
Adminis1ration. SN Drug
administration
Adrenal com"' honnones. Stt
C.Ortirosteroids
Adrenal steroid inhibi1ors. 354~ 355
Adrenalin. Stt f.pinepluine
Adrenergic agonisis, 550-551, 5511>.
5521
ophthalmic. 376-377, 3771
Adrenergic blocking agents. 55 1-554.
553l
Adrenergic-inhibiting agents, 475b.
480, 48 11-4821, 55 1-554, 553l
Adrenoconteostennd\ \tt
Con icos1cro1ds
Adrenocon1<01mpic honnont (AC:IH).
347 l48. H?t. l~l
Adrenocor11rotr<>prn (A<1hr). 14?1
Ad.011><>01>. 43ll-4\5t. 437 4 IR
Adverse re;aalons, l , 22 23. 30
in thildu,n, 60t
idenrlfi11ion of, II, lib
10 insulin. l61
10 1oxo1ds, 262-261, 263b
to v.1ccinolion, 262 263, 26lb
Advil. ~--Ibuprofen
A~robic hJtteri.1, 182
Acr()(_h,unhl'r~. 214
Mro>Ols. 208, 2 14
Mf1n. %1-%4
Affrflivc di>orde". 568569
Afric.1n n'edicinc. Jlt
Afrin, Sr-t Oxymt'tJJ:olinc
Agt. dOJJIC c.1kul,111on< ba."'<l on,
54 SS
AjQl<11<llion of pl,ucleis. 246, 488
AgitJ1ion. o( rccons1ituted powcJe"
170
i\g(lni\m, 341
Agonhl, 12
Airbomc. 451
AJ.a1h15i., S66. %6f
Albu1erol (l'ro>enul). 4SI 156.
45514561
Alcohol, 586 588. S861
as Olntascptic. 10-I , l06t
<lncnen. 58~l. 587
drug 1ntcraoions with. 'i86. 587l
i.opropyl. 104
dunng pregnancy. 57
for san11a1ion, 304
Aldildone. 5rr Sprronol0e1one
Aldosteronc recep1or .1ntagonifot~. 4t\O,
481 1
Alcfarep1 (Amevivc). 195
Alendrono1~ (1-o,.ml.lx), 40~-406. 4051
Alt-Vl\ St.c Naproxtn
A1f.1lf.i. 3171-3381
619
 Alginate dressings. 397, 398t
Al~ylaung agents. 312, 3121 314
315Ul8t
Alkylaung-lih agm15, 314 315t 318t
Al ltrgi< reactJOn, 30. 34 t. 338b
Allied htalth professional
tthia of. 17 18. 17b
phJnnacology and, 3.5
rea.>0ns for studying. 3-1, 41
role of hrahh profes.<ionals in
drug administration, 4 -5,
4f-5f. 16- 18, 17b
sare1y in medication ad1ninistrarlon
1ierformed by, 190 191, 191b
Allopurinol (Aloprim, l)'loprim), 412,
413l
Aloe. 337t-J38t
Alop<eia, 313
Aloprim. Stt Allopurinol
l\fph.a tocopherol. 326l 329t
Jlfph.-i beL> blocktrs. 480. 4811
JlfprdZOlam (X.11uJ<), 520, 591
Altrplase (Acti\'d!e). 488
Ahematiw medicine,. 324t. HI, ))(It
c:ultural difference$ in using. 331 33<>
AlupenL Stt Muproierenol
Al1hcirnd di5"3.e, 574, 575b, 575t
AlllJntJdine (Symmeirel), 459, 4591,
541. 542l
A1nbitn. See Zolpidenl
Antcnorrhea. 520, 5211
Anlevivt. Str AJefacept
Aminogl)'rosides. 292, 292t
Aminophylline. 455t-456t. 456
Am1odaronr (Cordarone), 473t. 4 74
Amitiz.a Stt Lubiprostone
Amitriptytine (Elavil), 543-545
Amlodipinr (Non.....:), 468, 48lt
Amnestttm Ste lsotretinoin
Amoxidllin. 426t-428t. 427
Amphetamine sulfate (Adderall).
57S.577, 576t
Amphetamines. 546, 547l, 589
Amphotericin B (Fungizone), 299-100.
299t
A1npule. 49, 49f. 220, 222223, 223(,
224b
lunylin glucagon-lik(' dnalogues,
359l3611, 364
Amyloid blod<ers, 548-549
Anabolic steroids. 507-508, 508t.
593-594
Anabolic Steroids Control Ao of 1990,
10
AouerobK bacteria. 282
Anafr.mil. Stt Clomipramine
Analrptio, 545
AnalgC$ic, 29. 240.254, 530531
adjuvant medications. 250, 2501-2511
children and, 250.251. 2521
classes of, 530-531
Anlgcsic (Coruinud)
=nglesia, 243
combination. with, 248-249, 249t
defined. 243
for Nr. 181 , 3821
lderly and, 252
nonop101ds, 246-248, 246b, 24 7t,
452t
non-&1licyla1cs, 246 24 7, 24 7l
NMIDs. 245. 247-248, 2471
for arthritis, 406-408, 408b.
409t-4101
for gout, 412, 4 131
for headaches, 543, 544t
ophthalmic, 373t-374t
opioid and opiates. 14, 243 245.
244l
abuse of. 588
cough suppr...ants. 451 . 452t
defined. 243
d<'terrents. 585t
precutions for. 245, 24 Sb
synthetic, 438
U;<.'> Of. 245
withdrJwal from, 585t, 588589
r<'CIJI v. oral, 251t
s.licylJlC, 246, 247t
>ide effects of, 241 b
types of. 243-249
urinary Lrtlct. 498t499t, 500
l\11JphyJ,1x.is. 31
AnaplJstit. 311
Anatomy and physiology in
plMnnarology. 3
Anbc>ol St-. Lldocaine
Androdenn. 506, 507t
l\ndrogcl, 506, 507t
Androgcns, 315t-318~ 506. 507t
Alll~thetia, 531 -533
~neral , 531
loc~I. 377378, 3781-379~ 531 -531
nlid.uolam, 531
mouth, 421
prtJnesthetic medic.:nions, 531
lOpic.11, 395, 396t-397l
AnginJ pectoris. 466-470, 467t, 469t
AnKiOtensin 11 rt~c ptor an1agonis1~.
480, 48 1l
Angiotensin-<om-.ning enzyme (ACI')
inhibitors. 480. 4821
Anos1rrplase (rminase), 488
Ankylosing spondylitis. 408
Ankylosis. 406
Anore<tal preparations. 4331435~ 418
Anorexia. 496
Anorexiants, 439. 439t. 546, 547t
ANS. Sa Au1onomic nervous S)"\tcrn
AntJbuse. Su Disulfiram
Antacids. 422-424, 4241-425t
nonopioids and, 248
AntJgonism, 32, 33f. 341
Antagonist. 32
Anterior pituitary gland hol'1tl0tlft.
345t. 347348, 348( 349t. 31()(
Anlhelmintia. 433t-435~ 438-43'
Antiallergic senu. 378t-379t 37'
Anllandrogens. 315t3181
Anubacterial drugs. 285-295
Jminoglycosides. 292, 2921
c.ubJpenems, 288, 290!
cepha looporins, 281. 288, 288b, 289t
chlommphenicol, 293. 2941
ketolides. 29 11, 294t, 295
linco1nycin, 28 1, 293, 294t
m.1crolides. 288-290, 291 t
metronidazole. 294t, 295, 4261427l
427
ox.uolidinones, 293-295, 2941
penicillins. 23b. 123, 285-286, 287\
288b
qumolona. 292-293, 2931
sulfonamides. 295-296, 2961. 4'7
498t-499t
tttrq'Cline. 57, 290, 291t, 426Hl7l
427
1igecycline, 294t, 295
for tuberculosis. 297, 298t
VJ.ncon1ycin, 294t, 295
Amibiotics. See also Antibacterial dfllll'
::nlli!nicrobials 11., 282-283
.m 1i neoplastic, 312, 3J2( 3151-318\
3 19
bactericidal v. bacteriosta1ic, 283
broad-.pec1rum, 282, 284
defined, 281 282
implications with. 285b
misuw of. 284-285, 285b
narrow-spectrum, 282
OIOIOJ<icity of. 381 b
'"""he-counter. 295
for peptic ulc- 426t427l 427
prophylactic use or. 284
rcsi~cance to, 284
sclcnion or. 283-284
drug sensi1iviry, 283
p,11 ie 111 factors, 283284
superinfcc1ion and, 284
An 1ibodics, 257258
Alli ibo<ly titer. 26 1
Amibody-media100 immunity, 258
Antlcholinergic agents. 426t42h 427.
HO, 430t431t. 4J2b, 455t456L
456, 549-550. 550!
ophthJlmic, 172\ 377, 377t
Anticoogulanu. 486-487, 487f
Anudepressants. 569-574, 569b.
570t-5nt
:intin1.t.nic medicatiom. S10t-57lt.
573-574, 573b
.11ypical, 569, 570t-5711, 572b
MAOls, 569-571, 570t5721
n<1tural reuptake inhibitors, 573

~munts (Omtinu<'tl)
~'Ill~ 5i'Ol571 l. S73
~RI< S70t 5711. 571572, 573b
lV\.~ S69, S70t571t
i\JIUJiab<tic ag<!nts. 345t, 355-363. ~er
id!D Insulin
0)1Jnd. 356-357, 356t357t
cril medications, 359t3611. 362b.
J6).J64, 363t
o<J><r 1nl(<Llbles. 364365
~""'""' "&"ntS. 433t-435t,
07-438
,widiumlC ltonmOr'tC (AOll ), 349 350,
~91
~nudot~ JO, 32
AntlCtnrtic:<, 430432, 430b. 430t-4Jlt.
Hlb
Anticoirogens. 315t318t
Ant10.iulrt11s, 432. 433t-435t
.\nufungill drugs, 298-300 . 299t
ophth.llntic, 373t-374t
.. ~ 421. 42ll
S)>1<m1C, 299300, 2991
"""""" .!99, 390t392l. 392
i\111'8"'-inubody response 258
Anhl!C"'- 257258
Anttgluroma medications. 3 72t,
375-176, 37St-3761
Anuhi.i~mincs. 446448. 4471
Anuhyperlipidemics, 484, 48St
Muhype:nensh"t therapy, 4 75,
47Sl-476f
\nlllllftttivr agents. Su alw Spt< /i<
fll"S
ophdulmic. 372-374, 3721-374t
oCK 181, J82t
topKll, 188-395, 389{, 390t3921
lo< lflls. 497-499, 49814991
An111nnamma1ory agems. 29, 243
for g.uiroin1es1in.1l tracl. 433t-4l5t,
418
oph1halmic, 372-374, 373t374 t
topical. 388395, 389f, 390t-392l
~Llrials. l03, 3031. 409t-4 IOt. 411
-~"""' mt<hu1ions. 5701-5711,
S7H74, 573b
MUm<ubolnt!. 32, 312, 312f, 114,
3151-ll 81
.\nt1m1(fobial<
an11b1otic:< 11., 282283
dthn~, 282-283
Anunooplasllc ngents, 312314, 3 12(
8.'i/\ doage ralcula1ions ror, 160
162. 161f
Cll>!nof, )14-319, 3 1513181
1k)-lung or alkylaiinglike. 314,
31513181
1nub1oucs. 312. 312f. 3151-1181,
319
mimnabolites, 32. 312, 312f.
314, 3151-3181
~---------~~"
ln~d~
Anunroplastic ai;ents (um11nueJ)
hormones and honnont>
antagonists. 314 119.
3151-3181
inimunosuppres~ants. Jl St318t.
3 19
mitotic inhibilOfli, 112. 3 12f, 3 14,
3151-3 181
radioisoto!l<', 3151- l l Si. 119
handli ng and admimstenng.
320-321, 320b
newer drugs .nd drug del""'Y
systems, 319-320
0 101oxiciiy of, 381b
side effects of, 311-114, JI lb
A111i plaielet medka1ions. 488, 4881
A111ipruritics, 395, 3%1 39?t
Antip'fyeho tics. SPe Neu rohqll irs
An1ipyretics, 29, 240-254
An1irctroviral dru8-'. 300-302, 1011302t
Antirheumatic medir.11ions, 4011
Anti.seizure medicallon.s. S l4t4> JSt.
537-540, 53?b. 538151?1
Anuseptics. 303305, JO-If, 188
alcohol. 304, 3061
dh~infectants and germirides 11., l04,
304 f
hcxachlorophene, 105, 1061
hydrogen peroxid. 305, 1061
iod ine preparations. 104, 1061
ophthalmic, 1731-3741
silver prepara1ion1. lQS, 1061
urinary tract. 4981-4991, 500
Antiserum, 260, 260(
Anli-snakebite seru1n, 260b
Antispasmodics, 426t-127t. 427,
4981-4991, 500
An 1is1Jphylococcal penicillin~1 286,
28?t
Antithyro id nledir.1tions, 3Sl352,
3521
Ami1oxins, 260-26 1, 260b, 271
1>01ul ism, 260b
diphtheria, 26-0b
Ami1uberculosis drug.;. 297, 2981
Amitu!>Si'"' 451-453, 4521
Anttulcer me<liutions, 422428, 424b,
4241-4271
Anti\'Cn. See Mcdi1inr
Antiviral drugs, 300-102, 30 11302
rlassifica1io n of, 300
11 IV, 300-302, 301lJ021
OlOUlh, 422, 4231
uon-1llV. 300. 10113011
ophthalmic, 3711-1741
topical, 39013921, 192
Aruurane. Stt Sulfinpyrnonc
Anx1ecy
anxiolytics for. 560-561, S621,
S63b
daily living a nd. 560
ex 621
Anxioh'tlo. ~~6) 5621
btnzodtu.q>m< 561-563 5621.
56)b
Ap1dr.i. ,.,,.,. (;lult\fnc
Aphgraf, 2l24
Apothecary )'>tern, 121, 1211
length conwrilon., 140-141,
1401
volurne con\trHons, 132 l 34
1121. I Hf
weight com-.nte>n'- 135 139. 1351.
ll61
APP<'lll uppr.won 4 l9. 091
Aqueous 1n1m1on~ 4950. 222
Aripiprarol (Ab1hfy). 5641-5651,
566-567
AriSlOCOrt. ~('(! I rl.illlC'inolo11t
Arrhythmia> /.<"Cardi>< d)'>rhythmiJS
Anrriost"lcr~1s. 16S.466
Arthrili,, 40 I
osteoanhr11111. IO(l. 407f
rhrumdlOid .1nhnus. 406, 40'if
therapy for 4011. 406-411 , 408b.
40914101
Artificial ~1\'t 1mmun11y, 259260
agent> for. 2<> l 269. 2641-2661
ch i ckenpo~. 262, 2641-266t
D'l,11', I dap, and Id, 263,
2Mll661
hcp,uilh A .uul n, 2M t2661.
161
I hb, 264t266t. 267
111'11. 2(>412C>6t 268-269
inHucn/a 2641 2661. 268
II'\/ 01'\ 2641 2661. 267
menmg1u" 2641-2661. 268
M\11\, 264t-2661. 267
pneumonia, 26412661, 268
rabies, 2642661, 269
ro1aviru>. 2<>41266t. 268
safety with, 26?, 2701, 271 b
shingles. 2Ml2661, 269
suJ"'r sh<>t<". 264 266t. 269
tet.inu) lO~oi<l. 264t266t. 267
LUb<'fCUILI'i' 2641-2661. 268
Anifici.il p.iss1ve immunity, 260. 260b.
260f
agent> for. 271-272
antitoxin-.,:, 271
immune globuhns, 272. 272f.
2731
J\rtifid,11 ICOl'll, 178-379, 3781-3791
Ascorbic .1cid. 126d29t
Asian 1nedirin{', 116
J\spM1 (Novo! og). 3591-3611
Aspirctlion. b<'fort 1n1ecuon. 23 l
Aspirin (c"'yl"ltcylic <id). 29. 63
246, 2471
acetJ1ninophrn compared v.'ith.
246-247
for Jr1hm1s, 408, 4091-4101
 622 Index

l\Klofen (Lioraal), 413, 4141, 545. Bilberry. 33713381, 338b

Aspmn (acnylsaliq.iic ocid) (Con11n~I)
combuuuons w11h. 2491 5451 Bile acid ~ues1ranlS, 484, 4851
for~... SO. 5441 sac1m 81 hricide. Stt Pruiquan1d
tourtts of, 13 aff0b1c, 282 1l1oun, 3261329t
Aslhrru. 453. 45514561, 456 an.ierobic, 282 ll1otr.iMfonnation. Stt Metabolism
gJuconicoids for. 456-457, 4571 dauifiation of. 282 nipolar disorder, 567b. Srot-snl
prophylactic mro1auon for. f.t(Uliati-e. 282 573,574_ S73b
457-458. 4571 Bac1tricidal agents Bi>Jcodyl (Oukolax), 433t435l 416
Mlr.11!3lus. 319b320b, 33713381 bacierios1atic agems v., 283 llisphosphonates, 405406, 4051
ALlr.ix. Stt I lydroxyzine 1opical, 388 llleach. See Sodium h11'0Chlori1e
ALl.'lia, 380 UJttcriosl;nic agenlS lllepharitiS. 372-374
AtelecLlsis, 453 b.1c1cricidal agems v. 283 Blood
Atenolol (Tenormin), 472-474, 4711, topical. 388 coagulatio n, 486-489, 487(
587 llaldnCM n1edications, 29. 39, hypet li pidemia, 483-486, 4851
A1heroscleros1S, 4 65-4 66, 4 66f 3961-3971 pr<Mure and hypenension, 474-475
A1ivan Stt Lorazepam Bal>alvide (Colazal). 4331-4351, 438 v.,,sel diseases. 483, 4841
A1omi.zm. Stt Nebuliun Balb11ura1es. 5341-5351, 535-536, S36b, lllood level, of drug>. 27
A1omoxetine (Sinner>), 573. S7S-S77. 538 lllood-brain barrier. 528
S76b. 5761 abUS<> of. 590-591 BNDD. Sn Bureau of Narcotia nd
AtolV.ULltin (Upi1or), 484-486. 4851 ~iv.epines v. 536. 5361 DangerotJS Drugs
Atropine. 10, 70f 8.irntr con11aception d<"ices. SI 7 518 Body surface area (BSA), 55
Alro\"'"1 Stt lpr.uropium l!Jths. 388 dosage calculations using. 160-161
Allen11on-de6ci1 disorder {AOO). 546 BCC vaccine. Stt Bacille CJlmene- 161(
Auenllon-defici1/hyperacuviiy d1<0rder Cu~rin v-oiccine llolus. J62
(ADllO), 546, 575577, 576b. llaplcrmin gel, 398, 3981 llones. See Musculoskdeul S}~ltm
5761 Behavioral disorders. See Mental health BonivJ, See lbandronate
Alypical an1idepressan1S, 569, 5701 Bcnadryl. 5< Diphenhydramine lloric acid. 305, 3061
5711, 572b Bc1u!n'li<l. Su Probenecid Hotu lism anti toxin, 260b
Aur.ilgia. 380 Benic~,r. Se" Oln1esar1an Bowel evncuants. See Cathartics
Autonomic neivous S!"'lem (ANS), Ucnlgii neoplasm, 310, Jllf, 3111 fl Pl I. Src lle nign pros1a1ic hypenrophy
528-529, 54 1b. 546-554, 546f. Benign pros1a1ic hypenrophy (lll'l I), 1Jr.1i11, 528, 529f
548( 508-509. 5091 Brand-name drugs. 1011, lib, ~O
adrenrrgic agonis:ts or lle111yl. Sfr Dicyclomine medica1ion label. 69, 69f-70f
sympathomimeiic drugs. llenl.-1lkonium chloride. 304 llre.1s1feeding. Sn Laaa1ion
SS0-551, 551b, 5521 llen.tiso.w>le. 5641-5651 llroad-s1>1rum antibiotics, 282. 284
OM!rencigic blocking agenlS or llenM>diaupines. 538, 561 563, 5621, Broad-specuum penicillins. 286 2&71
sympalhol)iic drugs. 551-554, S63b Bromocriptine (Parlodel). 520. 521~
5531 abllSC of. 591 541, 5421
anllcholineigic or pat<lS)'tllp1holytlf barbuumes v. 536, 5361 Bromphenir.imine (Dimeianr).
;agenlS, 549-550, 550t for gastroin1.,.tinal disorders. 430. 446-448. 44 71
cholinergk or parasympathomim~ic 430t-431l llronchiect.uis. 453
agents. 548-549, 5491 for neurologic sysiem disorders. sn. lJronchodilators. 454458. 4S51-4S61
Auxiliary labels. 71, 71( 5341-535t, 536 llSA. See llody surface area
Avapro. 5te Jrbesartan llenzon,llJte (Tt'SSalon), 452-453, 4521 Bucc.11 medica1ions. 205-206, 209-210.
Avi1aminosis. 324-325 llenwyl peroxide. 393-395, 3941 210f
Avoclan. See Ducasteride llenzphc1..1mine (Didrex), 439, 4391 Bu lk-form ing laxatives, 4331435l
J\zathioprine (lnlur.u"'I), 275 Beriberi, 324-325 436
A.<elaic acid (Azelex), 393-394, lle1.1-adrenergic (be1a,) d 1ugs, 454-456, llu1>ropion (Zyban ). 584b
394l 4551-4561 Bun!.1u of Narcotics and Dangttrous
Azdex. s...Azelaic acid 8eia-adrenergic recep1or blockers. Drugs (BNOO). 9
Azithromycin (Zithromax), 1S8 I59, 551-554. 5531 Bums. 338b, 397-398, 3981
158f, 15~ 290. 291( for cardiovascular disorders. 468, llursiti,,, 404, 406
Azm.icon. Ste Triamcinolone 4691, 472-474. 472b, 4731, llusporone ( BuSpar), S341535l S.16.
Azole antifungals. 2991 47Sb. 480 560-561. 5621, 563b
Azulfidine. Stt Sulfasalv;ne oph1halmic. 375, 3751-3761 Bu1alb11al ( Fiorinal). 543. 5441, s.i;
ll<cadme. Stt l'<Mdone iodine Bu1yrophenone, 564t-56Sl S67b
B lkthanechol (Urecholine), 548 Byc11a. See l:xcnatide
8 cells. 258 Bevel. 221-222
S.cille Calmette-Cuerin (BCC) vaccine.
2641-2661, 268
Bextra, I 2b
6iaxin. Ste CJarithro1nydn
c
Ca. ~ce C.lcium
llaci1rndn. 295 Biguanidcs. 3591-361 t. 364
CAD. i.,,,, Coronary anery diseiie

c,iTtln< S4S. 5471, 584
,,.noplC>i<h nd. 248. 2491
()ll.lnnt lotion. 2f17, 388, 395,
J96'3971
c,.l.in 5tt Verapamil
c.Jnf<rol. 32613291
c;.lnpo1riene (Dovonex), 395,
3?61397
c.1o1onin, 351352, 352t
CIJolOnln SJlmon (Fonical), 351352,
lS2t
Qlaron SJlmon nasal s pray
(Moolcin), 4051, 406
()lolnol. 3261 J291
c;a1oum (Cl), 32613291, 496. 4961
c.lauon channel blockers, fo r
cardiovascular disorders, 468,
4731, 474, 482483, 482b. 4 831
c.mp<al Sr< Acamprosa1e
C.ncer. 310312, J iit. See also
.\ntJneopl<titic agents
(.aod>,lriJon (Contharone), 395,
39613971
~ 44, 451, I 98b, 200b
c.nf.i1t Stt Sucralfa1e
C&oWmvtpln (Tegre1ol), 53815391,
l40
c.!Nmide 1>rroxld e. 42 1, 4231
C.rbJptn<m~ 288, 2901
C.rb1dopa (todosyn). 541 , 5421
C.rboh)'<ira1e Inhibitors. 362b
c.irbonic anh)'dme inhibitors.
1;st.J761, 376
c.d>unci J88
c.ronorirnlC substances. 320
Unkn< Sit 1'icardipine
Card"' dys~lythmias. 472474,
4731
C.rdaac gl)'cosides, 4 71-4 72.
471b472b. 47 11
C.rdio1001la1 sysieni. Su CirculJltlry
l)'lttm
Cudaem .I Dih iaum
Cudun. SN Oo:uzosin
Caniop<odol (Soma). 413, 414t
C:..Wa ~ (Exl.a>C). 433t-4351,
06
Ca1or otl. 43 lt-4351. 436
c.url<Xy. 546, 5471
C.i.prrs. Stt Clonidine
Cataran. 371
Catttholamlncs. 527-528, 551
Ca1hank~ 436t, 437
c.itnnc. Jl7t338t
. \ft Clrbic cemimeter
Cahng dl'm 245
Cdttonb (Celebrex), 408. 4091-410t
CdiCepl Sit M)wphenolate mofetol
Cdlmedia1td ommuniry, 257258
Cdonun. Stt Methsuximide
Ctlsiui. 127, 129- 130, 129t
Central nervous sysiem (C"IS), 527
528(
depress..nts. 590-591, 592t
long.term drug u~ and, SlO
sedatives and hypnotics Jnd,
533.537, S33b, SlJt, 516i
sti m u lants, 545546, 547t, 5895?0
5901
Centrally acting drenerg1c inhibitors.
480, 481t
Cephalosporins. 281, 288. 28?I
genecations of. 288b
Cerebyx. Stt Fo>phenytorn
Cenoli.rumab, 4091-4 IOL 411
Cen1men, 381
Ceruminol)'liC>. 381. 182t
(;etvarix. Stt Human pa1, illo111,tvin1s
Cervica l cap, 51 8
Cctirizine (Zyrtec), 446-448, 447t
Cha lazion, 372.374
Chantix. See Vareniclioe
Cheltor, 32
Chemotherapy. Stt also Amineoplastic
agents
faaors 10 <On$idcr "'ith, JI 4
hemaiopoietic. and. 489, 48?t
vomiting from, 430b
Cl m See Congestive hc;irt failure
Ch ickc 11 p0x vacci ne. 262. 264 t 266t
Child ren
analgesics fo r. 250-25 1, 252t
BSA dosage calculations for. 160-
162, l61f
medic.-uion use in, 58~60. 60t
milligrams per kilogJm dosa~
calculations for. 16 l
ncuroleptics in, 566b
oral medication safety with. 200
Chloral h ydrate (Nocll'C). 511.
534t535t
Ch loramphenicol, 293, 2911t
Ch loride (Ci-). 326t329t
Chloroquine, 303, 303t
Chlorpheniramine (Chlor.'lrimeion),
446448. 44n 522.523
Chlorpromazine (Thor.woe), 560,
564, 5641-S6SL 567b
Chlonhalidone. 477-47?, 411(. 478t
C hlorTrime1on. Sci' Chloophcniramine
Cholelithiasis, 428-429
Chol<Slerol, 3381>
Cholcs1y ramine (Q ucstr.rn), 431t435t,
437-438. 484, 485t
Choline rgic agents. 375176. 3751
376L 548-549, 549t
Cholinesterase. 527, 529r
Cholinesterase inhibiton. 175376,
375t-376t
Chondroi1in. 331, 409t-410t, 411
Chronic obs1run.ive puhnonary di$e3..St
(COPD). 445, 453
Index 623
ChronK ~m. 24120
Chrome "'Wnd.. 1?7398, 398t
Chronouop1c dlen. 465
CiaUs s,.,. hdalahl
Cilostawl (rl<tI), 483, 484t
Cimetidln ( l.tg.1met). 424--US,
426t-4271, 511
Circulatory 5>'1trm. 463-492. 46-lb.
464t
ngma pn tons 4"6 410 467L 4691
canliac d)>rhythm1a\, 472-174 47l1
CllF. 470-472. Hlb-472b. nu
drug rff<CU on 465 467, 466(. 4<>6t
funcuon of. 164 467, 465f
hypenension. 474 H7, 475b,
475f.477f, 477b. 478t-4791.
4811411 It, 482b
Citrucel ~.... Mtthylcollulose
Cl . See Chloride
Claravis. ~< IM>lrccinoin
Clarithrom)'<'in (llrn). 2?0. 2911
for pep11c ulc""' U61-1281. 427
Clanun_ W l.1nJ1ad1ne
Cleansers. skrn, 188
Oindanl)'OO (Clt'UCrn), 293. 294L J?J
394t
Clinical phannacology. 22b
Clorniphcne (Clon11d), 520
Clomipramlnc (Atufranil), 523, 561
Clonazep.1111 (Klonopin). 534t535~
538
Clonidine (C~U.tJ'""'). 480. 481t
Clop1dogrd (Plavix). 488, 4881
Closed-angle (!lau.oma 375
Clounmazole (~no. Crua. Mycel""
loungn). 390t 3921, 392. 421
4l3t
Cloz.aprne ((.101,aril), 564t56S1,
566567
Cluster hcJdJthos, 544545
CNS. See CcntrJI l1Cf\10us sysLem
CoagulJtion, 486489, 487f
Coal tar, 395, 396tl97o
Coanaglr<i,, 24 I
Cocaine. 589590. 590t
as an<'Sth<toc. 532-533. 5321
during pr<gnn<)'. 57
Codeine 8. 244t
acetaminophen and. 24'\
in cough !)uppr~sanl.). 451. 452l
Colace. See Docu\.1te
Colaz.al. S11 Halsa1"1idc
Colchicinc, 412. 413t
Colds
combma11on O'I C products for.
450-451
il<'rbal medicine for. 451
zinc-based products for, 451
Coll.igen.ose orntments. 398. 39St
Comedonr<, 193
Conlmunicauon. cornpliance and, 65
624 Index
Compauble media1iom. 228
Complementary medione 331
Compliance
communtation andr 65
culwr>I d1fferencn nd, 63-65, 64(,
641
dos.1ge calcula1ions and, 56-57
m old<r adul!S, 62
paclGlgmg for. 50, 50(
questions LO asstSI wnh, 54b
in special popula1lons. 62-63
Co1npreheosive Drug Abuse Prewntion
and Control /\ct of 1970, 9, 12
Compress. 206
Compulsion, 561
Comtan Ste Entacapone
Concentration. of drug actm:
ingrtdient 70
Concffl.l !> Mnhyl1>ht:ruda1<
Condoms. 517518
Conges1ion, 446-451 S ~/Jo
Ottongestants
Conges1i't bean C.ilw<t (CM~) .
470-472, 471 b-472b. 4711
Con1uga1ed <Str<Jg\'nS (Premarin),
5IO
C'.onjunctivi1is, 372-374
Conscious seda1ion, 531
C'.ons1ipa1ion, 432437, H61
Contac. See Pseudoephedrine
Container. Stt !\4cdication con1Ji11cr!
Contmcep1ion, 513-519
barrier devices, 517-518
fu1urt, 519
implams and transdermal p.11ehes.
5151-516t 516-517
injection. 5151-516t 517
inuauterine 515t-516t 517
oral, 513-514, 514b, 5151-5161
postcoital, 518, 5181
RU-486, 519
sprnnicides. 517, 5171
Contraindications
for immunization, 262
for speci6c populo1ions, 57-62
d1ildren, 58-60, 601
older aduhs. 60-62, 61b
pregnancy and lac1a1ion, 57-58,
58b60b
Conuolled subsiances, 9
analgesics. 244t
DEA regulation of. 12-14, llt 14(
d ispooal of. I 5-16
medication label on, 69(-10(, 71
ordering and SOOJring of. 14
prC$<'1'iptions for. 74-76
record keeping and in,-e111ory rontrol
for. 14, 14f
schedules of. 13t
Controlled Substances Act of 1970, 9,
12, 13t
Con"\TtSion
dn:1mals. 97-98, 102
fractions. 9798
lmgth, 116-117, 140-141. 1401
bel"ttn measuremmt systtins. 127
length. 140 14 I, 1401
with ~cios and prop<>nions. 131
temper.uure conversions. 1 29 130.
129t
1ime oonversions, 127- 129, 128b,
128f
volume, 132-134, 132t, 134f
weigh!, 135-139, 1351, 136f
percenrs, 102
volumt, 118. 132-134, 1321, l34f
weight, 119120, 135 139. 1351, 116'
Conversion factors. 132, 152
COPO. Stt Chronic obstructive
pulmonary disease
Copper (Cu' ), 326t-3 29t
Cotdarone.. Stt Amiodarone
Corgard. Stt l'adolol
Coronary anery disease (CAD),
465-466
Conex. ~ Selegiline
Co11icos1eroids. 345t 347, 351-355,
35313541
ad1ninis1rn1ion techniques ror.
3541355 .355
for gout, 412, 4131
for inln1unosuppression, 275
ophtha lmic, 3731-3741
Olic, 381 , 3821
topical, 390!392~ 392
Cola.<ym Su Panmlipase
Coughs. 451-453, 4521
Coumadin Stt Warfarin sodium
COX2 inhibi1ors. Stt
C)'dooxygenase-2 inhibi1ors
Crea1ns
application of, 206-207
rectal, 197- 198
Crepitus, 406
Cromolyn (lnral. Nasalcrom). 449,
457458, 4571
Cross-resistance. 284
Crotamiton (f.umx), 399
Cruex. See Clmrimazole
Cryp1orchidism, 506
Cu-_ S.e Copper
Cubic cenrimeter (cc), 115
Cultural differences, compliance and,
63-65. 64(, 64t
Cumulation. J4t
Customary System of ~1~asuremeru.
U.S. Stt Mousebold S)'litem
Cyanocobalamia, 3261329t
C)'Cloben1.aprine (~1exeril), 545
C)-dooxygenaS<'-2 (COX-2) inhibi1ors,
12b, 408, 409t-410t
Cydoplegia, 371
Cydoplegics, 376-378, 3171
Cydosporine (Re.Iasis. s.ndimm.nr~
275, 378
c;ys1ic fibrosis. 454, 454t
Cytotec. Stt ~lisoprostol
Cyto1oxi< medications, 313
0
Oakin sohuion, 305, 306t
D.1heparin (Fragmin), 486, 4871
l)ana1.ol (Oanocrine), 507t. 521
l).mgcrous drugs, 8
Danocrinc. See Dana1..ol
Oanuolene (Damrium), 413414, 414i.
545, 545t
l)arifenadn (Enablex), 4981499!, SOo
Uarvon Stt l'ropoxyphene
ODAVP. Stt Desmopressin
OrA Stt Drug Enforcemem
Administration
Decimals. 96-97
.lddition and subtraaion o(, 98-"
changing bctw- pm:en .. .acl m
convening fractions to, 97.9g
division of, 100
muhi 1>lication of, 99
rounding of, 9697
OC<'onges1an1s, 210, 448, 4491
01>h1ho Imic, 3 781-3791, 379
Del fen . Sre Nonoxynol-9
Delirium tremens, 567b, 586
J)elivery, of medications, QA in,
189-190
Oelivcry >)'Siems. See DosJge fornu
Deltoid sil<. for l.\i injection. 23}
234f
Delusion, 563-564
Demerol. S \leperidine
!Hmulcent 28t 29b
Denominator, 86
Denial caries, 421, 4231
Dcnrifrice<. 421 , 4231
l)en1i1ion, 6J
Ocrakene. See Valproic acid
Dcrako1e. Srr Valproa1e
Dependence. See Drug abuse and
depc11dcnce
l)cpo Provera. See
Meclroxyprogesterone
Ocpo <ubQ. Stt Medroxyprognieront
Oeprc<sants. 28t 29b
CNS, 590-591. 5921
!Hpr.,.sion. 338b, 568-574. 569b
an1idepres>an1S for. 569-574. 56"'-
~7015721, 572b-573b
Demia1ologic preparauons
ab,,.,rption and, 387
acne prc1>arations. 393-394, 3941
antiin(ective .and antiinflamma:torr
lopicals, 388-395, 389(,
390392l

""'""logic prrp;iracions (Corrrinued)
tor !>oms ind chronic wounds.
)97-398. 3981
dll<lli<1ion of, 387
li<Rlol)11C ilg(lll.S. 194-395,
)961-3971
.,1hm. 399 lOO
prorh}l;KliC g<nlS. 398-399
psonJ!i mtdica1ions, 392. 395,
3961-3971
sobiddes ond pediC\Jliddes,
39613?71, 399
srborrheic dermatitis n1ct1icalions,
394.395, 1%13971
toptull an~1hesia and andpruri1ics.
395, 39613971
~!"' of.388
Ol> s.. Oiahyls1ilbesuol
~ Stt Clo<rimawle
Otllttd ~pn111c effects. 23, 28-29,
J,.11
~n (Ol)AVP), 349~
49St ~99~ 500-501
[)r<UU<li"' drug. 30t
'1t11li1 (L<vt-mir). 35 7 358. 357~
J59t-l611
Otuol lA. S.-C 'lollcrodine
Ot\lopment. See New drug
d<\-cloprnent
Do11oam1>he1Jm i11c (l)rxedrine), 439,
439~ 575-577. 576b, 5761
0o110rnahorphan. 452. 452b, 4521
Oialxus mellitu1 (PM), 356357,
3561-3571
mlllhn ildmi111s1mion in. 357-358.
357~ 3581>. l58f. 3591361~
362b
anl inud1ilbft1c ml1cAtions for.
3S91-361 ~ 362b, 363-364, 3631
Olhn- miUbln for. 364 165
Dubetic com Stt I l~rglycemi.1
Diagnostic drug, JOI
Di.lphoresi~ 510
Oi'pbragm, SI 8
Oianhea, 3l8b, 43314351, 437-438
lha:r.tpam (V,1llu111). 40, 523, 545,
545~ 560-561, '621
abus. of, 591
forg;1SLrolmes1lnal di>0rders. 410.
4301-4311
for mu.0. disease<. 413-414, 4141
for Dftlrologic 5)'51tm di>0rders. 5ll,
5341-5351, HS
lllbmzodiutponn. 5641-5(>51, 567b
Diiua111t (1'upcrca1nJI), 395.
3%1 397t
llic-!domont (Beruyl), 4161-4271,
417
Didra. Str lle111phe1.1rnme
Diet. doSJ~ ckulJlions b.lsed o n,
S556
~-----~~---.::'":.:d.::
ex 625
Dietary Sup1>lemr111 I ltlth and
D1uR'tia
i:ducuion Act. J 36
combnuuon. 479 480 4791
D~ethylprop1on (Tenuie), 439 4391
h1gll<eiling. ~77, 4T.'L 4781
D1e1hylsulbes1rol (DIS). S7b
for hypcrtms1un 477 '480. 477f
Differin. Stt Maplene
478H791
Diffusion. of cance-r. 111
osmotic.. 376
Digitalis, s. Sf, 471-472, 471b472b. OIOIOJOOl) ol, )81b
4711
po1ass1um-spanng. 4771 1761 47?
Digitaliza1io11, 471-472, 472b
1hiatide, 477 179, n11, ns1
Digoxin {l.anox111. tanoxicaps), 5. 355, Dividend, 100
47 1-472, 47 1h-472b, 4711 Division
l)ilantin. Se, PhC'nytoin or decimals. 100
Dilaudid. Sr; I lydromoqihone I ICI of frat'CiOrl'~. 94
Dihi a&m (Cmli1em). 468. 474. or mixed numl><."n. 94 95
4831 of percents, 104
Dilueni. 223 Divisor. 100
Dimensional anal).,is. 138 OM &.e Di.1beu."S 1nt. lll1Ul
hepllrin dosage c.alrulauons usi~ DMARDs 'iN p,..,.,1tk>Jli)1ng
179 an1irhnan1.1uc dn1p
nonparentenl dosage' calculouions D1'A 1edmology. 2l 24 HI 241
using. 149, 151 I 56 Do t-:01 ll>e l.s1 72-71 72t II>. 121
parenreral tlm..1ge- cJlcul.it1ons using. Docosanol (AbrC\-.). 412. 42l1
174-175, 178 Documentation
Dime1anr St"t" Kromphen1roun1ne for conuolled ~ulxt.utcC". 14, l4f
Dip("Olu1n. Sf'l! 01$.0llJ.line of drug order>. 71
Dipep1idyl pep1ida;e.4 (Dl'P-4) of im muniz.111011 lb l
inhibilors. lS91-J6ll. 16<1 of medication ;tdn'l11U\U.H1nn, 1cJ1,
Diphenhydramiow (llc11.1diyl, Ny1ol. 192[, 193b
Sominex), 28. 10. 19'>, 3961-3971, Docusa1e (Colace), 41 J1.4J51, 4 l7
446-448, 4471, 452. 45lt, Doloph ine. ~" Mc1h.1don(
522-523, 514153'>1, 536 Dong quai, 3371 1381, I 18b
Diphcnoxylate wi1h atropine Dopan1ine, 551, SSlt
(Lomo1il), 4331 41St, 437-438 Dopamine anlagon1,I\, 1 lO, 4 \01+-1 \t t
Oiph1heria Dopar. Stt l.vodo1
1e1anu*" and a(cllular pertussis Domase alfa (Pulmo1ynw). H4, 4541
(!YfaP) vac<ine. 261, 2641-2661 Dorsoglute.1.1 ~llc, for l\i lnJt"C.Uon.
vaccines for, 26l, 264t-2661 233-234. l 141
Diphtheria antilo:inn, l60b Dosage calrul.uion
Dipj'Tidamole (Pe,..n1ine). 488, 4881, for nonpa.r!lnltr.il n1W1r.iuon~
554 147-150. 147b. 150b. t64
Dis.-ase, dos.>ge calculauon> b.15'/d on. BSA m<thod. IC>-01<>2, l&H
56 dimen\ion.11 .1n.ll)')1S. l49.
Disease-drug i111cr.1c1ions. 35 154 1>6
DiS(";ise-modifyinK antirhcumalic dn1gs formuld method, 149, 151 15l
(DMA llOs), 407408, 408b. method sele<'cion, 156
4091-4 101 milligr.uns per kilol{r,1rn 111i!LhoU,
Disinfecta111S. 101- 'OS, J04f. 3061 163
an1isep1ics 11., 104, 304f po\.\l'der ri..'Constilulion, l c;s I ~'J,
for skin. 388 158f, 1ss1
Disks. applic"1ion of. 207. 209b. ratios and proponion\ n1<:thoJ.
209f 149 I so. I 50b
Disopyr.1mide (Norp;ice). 472, 4731 for parenterJI medicauon" 170--171
DisJ)<'r<ions. 44, 461 with metric ~)"'item, 174 11c;
Oisp<>s;Jhle injeuion unil>. 123, 223f. wi1h unil'>. 176. 178 179
226b \-ariables affecting. H-~7.
administration rouh. 56
''f
Disposal
of dru&'< 15-16 adminisu.uion umt. 56
of needles. 188-189, l 88f-189f age 54.55
Distribu1ion, 24 25, 25b, 27 con'lplian<.t>, 5657
diel, >5-56
Disulfiram (Ant.1bue), 5851. 587
Di1ro1)an. Se Oxyb111y11ln diseJSe 56
626 Index
~ alrufaoon (Cormnu"1)
drug depmdenc._ S6
mviroomeni. 56
g<nda 56
gtnrua, 56
mediation hisrory. 56
menial slat.. S6
wrighi. SS
Dos~ forms. 41-50. Sn also Drug
administration
fo r .1mineoplastic agents. 319 llO
insulin, 361363, 361f162f
o n medication label, 70, 70h
nonparenu~rnl. 148
oral, 261. 44, 44b, 4St-4Gt, 47b
other, 4 9f. SO
~g for complianc~. SO, ~Of
p.irentral. 251-261. 49-SO, SO(
pvnlWleOtJS. 2S1-261. 41. 47f. 481.
49b
safny .md. 193-19~
005<' sp0on. 201 b
Douche>. so
Do\'Onex. Stt Calcrpolriene
Ooxaiosin (Cardura). 480, 4811, S08.
S09t
Ooxycydine, 2911
Doxylamine (Unisom), S34 15351. SJ6
DPls. .'lee Dry powder inhalers
Dl' 1'4 inhibi1ors S Dipeplidyl
pepLidase-4 inhibitors
Dram, 121, 1211
Oromorropic effect. 465
Drugs. Stt a/5o Dosage calrula11on
~ons of. 23, 28-29, 281. 29b
addiction to. 8
body's processing of. 23-28, 2Sb.
25(, 25t26t
dassioouion of. 39
ruhural differences and, 63-6S. 64f,
641
defined. 2223, 22b
disposal or. 1516
forms nd deli\'\'ry S)'Slems of, 41 SO
for dlltineoplastic Jgenls, 319320
insulin, 361363, 361f362f
on medic;11ion label, 70, ?Ob
nonparentcral medications. 148
ornl, 261. 44, 44b, 451461. 47b
other. 49f. 50
pack<lging for compliance, SO, 50f
paremeral, 2Stl61. 49SO, SO(
percutaneous. 2St261. 47. 47f.
481. 49b
safctyand, 193 I 94
healrh professional~ o(, 18
identification of undesirable effects
of. 31, lib
indjcations for, 23, 29, 30t
infonnaLion sources for, 4041.
42f-43f. 43t
Drugs (Qmrinutd)
introduction of. FDA and, 10 I 6,
llb. lit
l~beltngof
ore drugs. 11 . n. nb. nf
stock medications. 6912. 69r-11f.
?Ob
no1nenclature of, 39--40
off-label uses for. 39
ordenng of. 72.77
abbreviations used in. 12 13, 721
mcdicarion orders, 72-74, 721, 7Jh
prcscrip 1ions, 72-77, 72t. 74f. 76b
sranding orders. 73.74
V/O. 73
poisonous elTecu of. 23, 30-31
QA in deli'"'Y of. 189-190
rtteptor sires for. 32. 32f
s.c_nsi1ivity~ 283
se:nsitiution to, 284b
50\JR:es of. 23-24. 24f. 241
for spttfal populations. 57-62
children. 58-60, 60t
compliance in, 6263
olderadults, 60-62, 61 b
pf'('gnant or lactating pJ ti en 1 ~.
51-58, S8b-60b
in urine., 5831
Drug .1buse and depende nce, 9, 141,
5801, 581. 581b
a lcohol. 57. 5851-5871, 586 588
a nabolic sreroids, S93-594
behaviors found wirh, S82-583,
583b
caring for parientS wirh, 594-595,
5941
with C.'IS depressants. 590-591 , 5921
with C.'IS stimulants. 589590. 5901
definitions and cem1s, 581 582, 581 b
dosage calculations and, 56
factors contributing to, 582, 582b
hallurinogens, psychedelia. and
PS)'(Chotornimetics, 59 1S93
by heallh prores.io nals, 18
inhalants, 593
i.vith no nprescription dn1gs, 'l81586
nicotine, 583~586, 584h,
S84t585t
with pl"C$0"iptio n drug.<. 585t.
588S89
prnention of, 16
Drug .1d1ninirualion. Stt also
Nonparenteral drug
.ldn1inisualion. ~renteral drug
.1dminis1nlion
bsorp1ion and. 251-261. 26
dosage calculations and, 56
imulin. 171. 171f-172f. 174. 1741.
176, 179
in DM. 357-358, 357t, 358b, 1ssr.
359t361l, 362b
Drug administration (Con11nloQ/}
on medication labd. 70. )'()(
role of health professioruls u\ 4 s,
4f.5f, 16-18. 17b
safety in. 186-188
allied heahh profession>!
administration. 190-191 1'1b
documentation, 192, 192( "1b
error sources. 193. I 93b
with o ral medic.atjons. 200b
O~ l IA >1andards, 188-189,
188fl89f
pacient administra1ion, 187188.
187b
route of delivery and, 193 I94
J + 7 for reducing medicallon
errors, 191193, 192(, 19lb
steroids. 3541-35S1. 3SS
Drug cards. 41
Drug lnforcemem AdminiuritlOft
(DEA). 4. 9
controlled sub.stances rtgul>tlO!l b,
12-14, 13t. 14(, 530-531
drug S<1mples and, 17b
number, 75-76
surveilla nce by, lit
D1ux lticts tAnd Compari.son.1, 41
Drug ho liday, 576b
l)rug infornlation sheets, 41, 43f
t)rug intcr,1c1ions
with alcoho l, 586, 5871
disease-drug. 35
drug-drug. 3132. 31b. 33(. 341
mechanisms of. 3235, 3lb. 3lf. 141
nutrient-drug. 333S, 33b
Drug listing ACl of 1972. 9
Dmg rrice Competition nd PittN
Term RA:>s1onuion llCt. 10
Drug regulJtiOn
01:1\ regula1ion of conuollfd
ubsunces, 12-14, 13t 14(
drug S1andards and patient saf1\'
7-10
FOA Jnd introduaion of new drug1.
10 I 6, 11b, 111
federnl legislar io n, 8 10
herb a I s upplements, 336
1n1en1aLional, federal, and state
~tJlu te:s, 8
ntcd for. 7
Drug llegulation and Reform i\Ct ol
1978. 9
Drug s.imples. 17-18. 17b
!)rug-drug interaction$, 3132. lib \l(
34t
Ory po"der inhalers (DPls). 214
Drying .tgents. 380, 3821
LYl.11' vJccine. Su Diphtheria. ttt10U5,
Jnd acellular penussis va<cilll?
Dulcolax See 6isacodyl
l)urham-1lumph rey Amendmenl, ~

E .
IA !6(). 181 (, Stt allD Ouc
m<d1G1lt00$
CllOloOOll' >nd. 381-383. 381 b
miigo ~nd, 3701. 380-383, 3831
f.duN<t.. 317t-3391. 338b
t,tl'>. Stt 1:mergency comraceplion
pills
f.atnl' 392
lffll''dCl'nt powders. 44
1.fft,<or Su Vtnlfaxine
UllUCJ' of drugi. 7
u.idc1 Stt lluorouracil
[I.iii!. '>tt Amnriptyline
lldqicli Stt Stlegiline
lld<rlJ ~ Older adults
[J<ClflC,ll ronducdon system, 465-467,
466f, 466t
l1110l)'ltt. 110, 331 b
balanre or. 495-496, 496t
Elt1rip1.111 (Rclpax), 543, 5 44t
Elimlniuon. Stt Excretion
Elinlt<. Su r.rmeihri n
~ron Stt !Tntosan polysulfate
IJocqm(Y contractption pills (~Cl's),
SIS. 51111
lnloi> 430-432, 4JOb. 430t-431 I.
02b
lm<lrol SN rhosphora1ed
.,tbohydr>te solution
Cntl~se 541 Anis1replase
Emollients, 388
lmouonJt responses and pain,
241242, 242b
lllpll)'l(m.\. 45 l
Wblet la Ouifencin
IJlllcd Stt fianerctpt
Utdomnts)'St<m, 345-346, 345b.
J.151. 1461 Stt also liormone>
ntglll\~ feedback in, 346, 347f.
J50(
l:Jidogcttou homones, 348
Endommlols, 507t, 521. 522t
ltwlo<phius, l41 242, 528
!Jl<m.u, 197-200, 200f-20l f. 203b
m"11uted, ~
Utgmx-8. Stt llepatitis B vaccine
l.a&IM ~..urement S)"Stem. Stt
Housd>old S)'Stttn
~n (l.ownox). 486, 4871
lmu1<. SN Nonoxynol-9
1.n~"ponc (Comrnn), 541, 542t
Fn1erat drug admin1str.ition, 194.
196-204
.1bsorption and, 251-261
oral medications. 44, 197,
l98b-201b
absorption of. 26t
liquid p reparatio ns, 44, 46t, 47b,
197, I 99b201 I>
sarcty in, 200b
solid prepar.tions, 44, 44b. 45t.
197. I 98b. 200b
rectal medications. 197-200.
200f-201 (, 202b-20Jb
I nuresis, 4981-499t, 500501
1nvironn1ent. dosag~ calcula11ons and,
56
Enzyne replacemenls, 1>anrrr.tic, 428,
429t
Fphcdra, 337t-339t. 454-456,
455t-456t
Ephedrine, 551, 5521
I pilepsy, 537
lpinephrine (Adrenalin), 454-456,
455t-156t. 551, 552t
fplerenone (lnspra). 480. 4811
l;quivalent fraaions. 87
I rectilc dysfw,ction, 521 522, 522t
r rgocalcifcrol, 32Gt329t
l~rro rs, in n1edication
sources of. 193, 193b
3 + 7 for reducing. 191 I91, I ?2f.
193b
l .rythromycin, 290, 291t, 191, l94t
r.rythrop<>ietics. 489. 489t
Lschar, 397
l'iOmeprazole (Nexium), 425-427.
426t-427t
1.stradiol. 509. 5 11 t-512t
llstradiol dots, 209
Estrogens, 509-511. 5 11tS12t
rnuineoplastic agent'!, Jl.5t-318t
in contraception, 5135 14, 515t-516t
for os1ooporosis, 4051. 406
I tanercep1 (Enbrel), 409t 410t, 410-411
I thambu1ol, 297, 298t
1 thanol. Stt Alcohol
rthi. in pharmacology, 17 18. I 7b
Lthinyl e<tradiol, 5151-516t, 51<>-517
I 1hosuximide (Zarontin), 518-540,
5381539t
Fthyl alcohol. See Alcohol
l'.thyl chloride, 208
l:u phoria, 588
I ur.1x. See Crotamiton
fvi)ot.1. See Raloxifene
I .xcoriation. 208
lxcretion. 2425, 251>. 27-28
r-'cnatide (B)'etu), 359t36H. JM
r.-1.1x. Sre Cascara sagrada
l.xogenous hormones. 356
l.<pcctorants, 453-454, 454 t
f.xp1rauon .Utt, on rnediauon bbd
70{, 71
Extended >ptttrum pm1C1lhns. 286.
287t
Extrapyran11dal rfrtt1>. 561
Extravasa1ion, 31 t
Ey. 370-172, 371(, 172t &also
Oph1h.1l1nic n1t.-d1C.ltions
syst\'mic mt>J1c..1uons cuuing sidt
ffccu in. 3?2t
Eye drops. 211b-212b
E)'eomtmcnt 211b 212b
F
factor, in d1mtn\ionJ.I analysis. 15..
Facuhativt" banen.a. 282
lahrenhclt. 127, 1n 130, 129t
Fastin. Sf'4' PhClll('OHine
Fat-solul>lc vlt.1m1n<, 115, 326t-329t
FDA. St.- lood and Dnig
Adm1n1\tr,1t1on
Fe'. 5tt Iron
fd>uxosut {lllonc) 412 413t
Federal drug h'f\Ulation. 8-IO
Federal ...,,ucoll( Drug An of 1914, 8
Felodipme (l'lcnd1I). -168. 483t
Femorii. she. for l~t 1njce1ion, 234,
23Gf
Fentanyl, 55, 244 t, 24Sb
lransdern1JI .1c.Jn1lni'i.cr,11ion of, I <1.
209
Fesoterodinc ( l0viaz), 4981-4991. 500
m't'rfl'W, Jl7t 338t, JJ8b
Fiber Trim \tv \t<th)lcellulose
Fiber Con "" rol)urbophil
t1bric acid dc11v.1lt\'"-"' 4~'it, 486
Fibromyalgia, 4Vi
Filter needle. JJl 222
Finasterid\' (Pro1xc l;l, Proscar)1 400,
508-509, SMt
l~i o ricel, 543, 'i44t
Fiorinal. 5rt H111,,lbit.ll
Fimprn d 1ce1 n
Fl . s,, rluorutt
Flagyl S.... \lt'1ron 1d.uole
~hvox.11e (llr"P"l 498t499t. 500
Flexeril. s,-, C)dol>eru.lpnne
Flomax.. ~,. 1,,n1,ulosin
Flonase. Ser 1lutk.tsone
Fluid balan<e, 1?~496, 4%t
f1urn.H:linc. 5tr Rin):lncadinc
Flurnnenil ( llom.uicon ), ~91
FluMist, lG4t2r.6t, 268
Huoride produm, 421, 42.lt
Fluorine (ti ), l16t329t
Fluoroquinolonts Stt Quinoloncs
Fluorouraol (rfudl"). 396t-397t. 4()(J
Fluoxetim ( l'ro/..>C). 520. 561
Fluphen;vmc (rrohin). 564t-565t
567
Fluticaso11' (1 lona'iC), 449450. 450t
 628 Index
111QJ sctZWes, 537, 537b
folic Kid. 326t329t
folk remedies, 331 -336, 3361
folhcul.u sumuuuon. 520
food. Drua. illld Cosmetic Act of 1938.
8-9
Food and Drug Adm1mstra11on (fDA),
1 \.astrointes1inal S)'"Sttm. 418-442
drug 1nfonnauon requirements of
54
herbal supplemem regula1ion by.
336
introduction of new dn1gs and,
10-16, lib, Ill
labeling guidelines for OJC
medications.. 72b
pregnancy categories of. 57, 58b
sum.>illance by. 11 t
lood and Drug Adminoslration
Modemi.iation Act. 10
food-drug inunaions. 33 35, Hb
fonnaldehyde. 304
lorrns of drug>. Stt Dosage forms
I orrnula method
heparin dosage cal cul~1ions usmg.
179
nonparenteral d0$41gt' calcul,Hions
using. 149. 151-153
pdrtnteral dosage calcul;HiClrl, using.
174, 178
Forteo. See Terlparatide
1ortical. Stt CaJdlonin saln1on
Fosatnax. See Alendrona1e
1-o>fornydn (Monural). 497, 4981-4991
l~phenytoin (Cuebyx), 538,
5381539t
Fraetal. S Conadorelin
fraction>, 86-87
addition of. 8991
COO\'efSiOn to decimal~ 97-98
division o(. 94
equivalenl. 87
figuring peittnts from, 104 105
improper. 86-88
1nixed nuo1be:rs and, 88-95
n1uhiplicalion of, 92
proper. 86
simplifying. 87
sub1maion of. 91-92
I rdgmin. Su Dalteparin
I rec drug. 27
lungi, 282. 298-300, 299L 5-;r aw
Antifungal drugs
F\J.ngi.to1>e 5-;r Amphotericin B
Furosemide (Lasix), 477, 477f, 4781
forundes, 388
G C largine (Lmtus). 357-358, 357~
CJbJpeniin (Neurontin), 5381 5391.
540
Cobio-ii. Stt Tiagabine
Callbldder disease 428-429, 4291
Canunol. 5-;r Sulfamt'thoxazole
<.anlrisin. 5-;r Sulfisoxa.wle
C..rcbsil 5-;r Human papilloma"rus
Culoc 3371-3391
Ca.lrO<!SOphageal reOux disease
(CLRD), 422. 424-42S. 4261-4271
anorectal preparations. 4331-4351,
438
.ulliinArunn1atorles, 433t435t, 438
appetite suppression, 439. 4391
diarrhea. 4331-4351, 437-438
drug activity and, 420-421. 420f
emesis. 430-432, 430b, 43014311,
432b
gallbldder disease. 428-429. 4291
gaslric condilions. 422-428,
424t-425t
hepauus Band hepa1ins C 428,
4291
1ntes11nal conditions,. 432-437
u11esunal parasites. 4331-4351.
438-439
mou1h, 421-422, 423t
pancreatic enzyme replaccn1en1s,
428, 4291
C:augcs. of needles, 221-222, 2361
eel. 206-207. 388
C:ckaps. 44, 461, 47b
Cd film.~-- Absorbable gela1in film
Cclfoom. Stt Absorbablc gelatin foam
Celfoam powder. See Absorbablc
gelaiin powder
Gemfibroul (Lopid). 4851. 486
Ccnder, dosag<> calculations based on.
56
GenerI antsth<'lics. 531
C.enerli,.ed seizures. 537, 537b
Genenc drug>. 10, lib. 40
medicalion label. 69-70, 69f-70f
Generic imrnuni1y, 256, 257f, 2571
Cenetits. dosage catculations b.1.:;a.I on.
56
Cl'Odon. See Ziprasidone
C lmD. See Camoesophagcal rcOux
disease
Ccriauic patients. See Ol<lcr adults
Germicides, 303-305, 304(
an 1ise.ptics 11., 304, 304(
skin. 388
c~rmistatic agen1s.. 304
Cl I S Growth hormone
Cig.i.nlism. 348
Ginga. 3371-3381
Cingko. 3371-3391
Ginseng, 3371-3381, 338b
3591-3611
Glaucoma medicalions, 3721, 375-376,
3751-3761
Clnazones. Stt 'llliazolidinedi""
Clucagon, 355-356
ClucororlJcoids. 353, 35313>1~ ll5
Glucoconkosteroids, 407-408. 4Qeb.
4091-410
<.;lucophage. Stt M.Uormin
(;luconicoids. 449-450, 450!, 456..151
4S7t
C lucosaminc. 331. 409141()(. 411
Glucose absorplion inhibi1on. 359t-
J6 1t, 363364
cx-C lucosidose inhibi1ors, 3591-3611,
363-364
Clulis ine (Apidra), 357358, 3571.
3~913611
C lutaraldehrde. 304
C:lysei. S..'1" Migli1ol
Cold salt>. 408-410, 409t-410I
Goldenseal, 337t-339t
Colimumab. 409t-4IOI. 411
Golytely &~ Polyethylene gl)'rot
Conadorelin (rraoal. t.uirepui..i SlO
C:oserelin (Zoladex), 521
Comy arthritis. 411-412, 412(. 41lt
Grade. of 1umors, 311-312
Cr,,i11, 121, 1211
Cram, 114-115, 114(, IJ51
nle.isurement and conversion or,
119- 120
Crtllll s1ain, 282
Cran<l mat seizures. 537, 537b
Cranisetron ( Kytril ), 430, 430!4311
Cranules, 44
C:rowth horrnone (CM). 347-348, 34!1.
C:uifcnesin, 188. 453-454, 4541
Cua.nethidine (lsmelin), 522
Guanfaone (Tenex), 522
(.um, 451
H
11, receplor antagonisl$. Sa 1lisumu'l(
recep1or antagonists
I l.1hirn.11ion, 16, 34~ 561
I l.1cmophilus inOuen2ae type 8 (~hb)
vaccine. 2641-2661, 267
l IJldol. Se< I lalo1Wri.dol
11,df-life. 27
llalilosis. 421, 4231
I lallueinJtion, 563-564
llalluci nogens. 591-593
I laloperidol (I laldol), 564, S641 -565~
567
1larnson Narcotic Aa.. 8
lldShish. 591, 5921
11,wrix. Stt I lepatilis A ..a:i~
hCC. s..., I luman chorionic
gonJdotropin
1leadaches, 338b. 543-S45. 543{
rlusicr. 544-545
n1 igr.iine. 543-544, 544t
lcnsion. 544t, 545

H<Allh prof<>Sionab
(tbl<>Of. 17 18, 17b
~log)' nd. JS
"'.dOll> for studying. 3-4, 4f
roltofh<lth profts<ionals in
drug ~m inistration_, 4 5.
fSf. 16-18. 17b
~ftt)' ln mtdtCJtion admini~tration
performed by. 190 191, 191 b
~
an.itomy or. 464465, 46Sf
electrical condunlon system of,
465-467, 466'. 4661
ll<flltopoietiCll. 489, 4891
1tonmria, 497
lkmOIWi>. 486, 487f
HftllOIUUC>. top1G1I, 488489
tl<plnll. 486. 4871
1111J1Sof. IB, 176. 178179
llqMlltnA >-accin< (llavrix), 264t
2661. 267
ikl>'btis B. 428. U9t
il<p>IJUI 8 \'il(Cllle ( Rttombivax HB,
l.,U B), 264t266t, 267
lltpilltil C, 428, 429t
Htrbol m<dicin<. S. J24t
for colds. 451
ror in1omnla, 536517
l.lrety and r<11ul,ulo11 of. -116340,
J37t-139t, 338b
de efl'em 0 r. 12 4
ww1<menl$, 336140, 137t338t
llrrt<ptin, JI 9
llnom. 243
H<uchlorophene J0~ 105, l06t
Hihxon<. 'in llaomophilu'
"'lk.mu< type B vacdnt'
Hlgl>iling d1uretiN. 477, 477f, 4781
Hiluaunt. (II,) f<"C'1'tor antagonitS.
m-125. 426t H7t
lliOI)'
dos.\gt calculations based on, 56
olphnnacol<>llY, 57, Sf. Gb
HJV, antivirals. 100302, 301t-302t
Hom<remedics. 65, 124 t, 111316,
316t
llomeosta1is, l. no
llO!drolum, l72174
llonoon.,, 3453-17, J46f, 348f
anud1b<tic ;igtnl$ affecting. 345t,
355-361
0\1 and. J56l57, l56tl57t
0<al mdicuons. J59t361t, 362b.
363 16~ 16 Jt
v<hn m1,.ble" 161365
111tmeOplnllc 'llfl'IS. 314 319,
315t318t
rort1<0>1cro1d> 345t, 347, J';l.)55,
35lt354t
admini.)1ra11on 1rrhnlques for,
354t IS5t. 355
Honnones (Con11nul'tl)
for goui. 412. 41lt
for imnlunos.uppr~1on. 275
ophthalmic, 173tl74t
OllC, 381. l82t
topical, 390t 392t, 192
h)'p<'rglycemir agent\ and, l45t.
3591-161 ~ 365
insulin, 2124, 35~356
adminimalion of, 171 , 171 f 112r.
174, 174t, 176, 17'), 357358,
357t, 3581>, 358f, l5~t%ll,
J62b
adverse re.l<tion.; lO, 163
delivery )'Stems for, 161 163,
361 f 362f
in DM, 356357, 356t-357t
mixing of, 229, 2291. 358 l61
units of. 121, 174 174t. 176, 179
pituitary gland honmone-.
anterior lobe. 345t. 147148, 348f,
349t, 350f
posterior lobe. 34 5t. 148(.
349-350, H9t
PTH, 352, H2t, 405~ 406
reprodunivc "tcm and, 505506,
506f
thyroid gland honnonc.. H5t,
350351, l'lOf, lS2t
ancilhyroicl nll'dic.u ion.,:, 151~3 52,
l52t
l lorn1on\' antJgoni~ts, J l 4 3 19,
315t318t
Hormone repl.1ccment thcr.lpy ( 11R'I ),
510
llousehold system, 114. 121122, 121t
length conwrs1on'>. 140141. 140t
volume rom1!rs1ons. 132 134, I 32t,
IHI
\\'ciglu <Oll\.'t'~ions, l lS 139. t35t..
136f
I IPV vaccine. 6" I lu1nan
papillo1nJvi1\1'l
1urr. Srr I lorn1one replacc111c111
therapy
I lum alog. Sec I bpro
I h unan chorio11ic KOn:'ldo1ropin
(hCc:), 520
f-lw..-i.1n hep.llil1s H hn1nune globulins,
260b
flum,m pdpillon1.1v1ru1 (I ll'V) vaccine
(Gard.sil, U:rv.irix), 264t266t,
268269
I lumegon Stv \tn101ropin
llumir.l. &e Adahmumab
Humoral immunity, 258
J lumulin N Ser lso1>hant insulin
I lornulin R ,S.,~ Hegular in~ulin
Hydanioins. H8. 518t '\l?t
I lydrochlorothi&iJ<. 477.479, 477f.
478t
Inde x 629
I l)drogds. 198, l?Ai
ll)dr<>g<n ptroxkk. J05 'I06t, 421
423t
ll)dromorphon~ llCl (lloludiJ)
69-10. 69f10f
liydromo~ '>tt Qumnhuon<
H\'drophihc r<>lvu1ctl111w f.,.m H~
1981
Hydrox\'chloroqum, ( Pl111ucn1I ),
409t410t. 411
Hydroxyzine (Vostdf1I, AtJrax). 5621.
563b
1-lyos<yminc (1 t'Vl<ln), >I'> S<;o, 550t
1lyperglyccmia. 157. IS71
Hypergly<em1c .1g<1m. H "lt l>9t lr.1 t
365
Hypttlip1dem .. 481 481>. IK'>I
l-lyperse-nsiu...11)- ft"..k uon lO
H)-pmt>nsion. 47..a t 1; 17\b
475f-l76f
liftst)k rhnltl"' 1nJ 47>. 47'>1 4761
medic.luorl lor, 4 7'1 4 Rl ~ 17h
adren<'f}tic 1nh1h111ng aJ;'-n1~ 47'ib
480, 4811 4821
ca1ciunl <hJ111n_I hl<l<ltf,, 481
48 l, 482b. 48 It
diumar,, 477 180. 47if, 17Kt 17?t
vasoclil;Hor~. 4HO 48.2, 1K21
Lherapy fo1, 4 7 i;
Hype-nonic ....11i1H', l'i \, l'llt
Hyperu1ict>1n i.1, 4 ll U ..Z
llypervll.unino\i,. 11,. l Hl
Hypnotic~. 5 ll'l \7. i \ \h 'l l lt. i l6t
~leep d1sordt.r, .tntl l \ ll "; l t.
5155 I(
li}'Jl(lgi)H'ml.l 157, l'i7t
I l)'J'O&l)llli<". l'i?t \(>I l
I 1}1"'8"1l.ldi\m, o;f)(,
ll)'f>Olip1d.-mi" ~h~ 48'it
H~-pothalA111tL\, H!
l-fypovila.n1ino\1~, l.24
1-tytrin .~,. le1.110\1n
r. Srr Iodine
"'I. Sct Iodine I 'I
lA injections. ~'-'t' fntr.1.1r1in1l~r
i11jcclions
lbandro11.11e (Konl\.t). tO'i 406, 4ll'>t
Ibuprofen (Advil, \1011111) 29, < l
247 248. 247t
br.1nd n.a1n("\ of t lh
comb1n.nion~ \ ..uh 2491
safety w11h. 188
ID injtion!> V.. lntr.ttlfnn.ll
injections
Ideal drug. 222l
ldiosrrHratic drug rc.u.uun~. n. llh.
34t
li\1 inJCetions. ~4~.~ ln1r.tnlU\ct1l.1r
injt:clions
 630 Index
fm1pramme (foframl). 4%1 49?t
500-501, 569. 570!-5711
fm1ua. Stt Sumatripun
lmmuM globubns. 261, 271, 271(.
2731
humn hepatitis 8. 260b
respiratoiy syncytial virtl>. 271, 11 ll
for J>ific conduions. 271. 271(
manus. 260b
Immunity. 255-279
~cquired, 256, 257r. 2571
,1r1i ~. 256, 257f, 2571
anificial, 259-260
na1uraf, 258259, 259(
anllbody-n1ediated. 258
ctll-med1a1ed. 257-258
mbom, 256, 251r. 2571
inborn t. acquir<d, 258-260. 258b.
l59f
lpnphocytes in. 257-258
mliations in. 256t
p;mn-.. 256. 257f. 2571
amficial. 260, 260b. 260f
natural, 258
types of. 256, 257f. 2571
hnmunizalions. 255279 ~tt llho
VJccinations
Jdvcrse reactions 10, 256b, 262 263,
263b
agents for, 260261, 263269,
26412661
;lnthoxins, 261
chickenpox. 262, 264 t266t
DTaP, Tdap, and Td, 261,
2641-2661
hepd111i A and B. 264t266t. 267
llib, 2641-2661. 267
HPV, 264t-266t. 268-269
immune globulins. 261
mftuenza, 264t266t. 268
rrv. orv. 2641-2661, 267
meningitis. 2641-2661, 268
MMR. 57, 2641-2661, 267
pneumonia, 2641-2661, 268
rabies. 264 1-2661, 269
rotavirus, 264t266t, 268
safely wi1h, 269, 2701, 27 1b
shingles. 264t2661, 269
"super shots', 2641-2661, 269
lrtanus 1oxoid, 2641-2661, 267
1oxoids. 261
1uberculosis. 2641-2661. 268
'OKrines. 26(}.261
contraindications for. 262
documentation of. 263
eduuuon concerning. 272-274 2741
indiuioons for. 256b, 262
popula1ion seleciion for. 261
for navel to foreign rouniries. 274,
2741
lmm<U10dtficiency, 275
lmmunomodulatocs
for anhnus. 409t-410t. 410-411
ophthnmic. J78, 3781-3791
Jmmunootimulants. 256b. 27S, 276t
Jmmunosuppressants, 274-275
a.n11nroplas1ic. 315t-318l. 319
for anhntis. 409<-4101. 410
1nd1cations and side effects of, 2S6b
lrnod1um. See Loperamide
lmf)(;ligo. 388
lmplaniable contracepcion, 5 1515 16t,
5 16-517
fmplan1s. 50
Improper fractions. 86-88
lnluran Se~ Azathioprine
lnaetivated poliovirus vaccine (fl'\/),
2641-2661, 267
lnaruva1ed \'accioes, 261
lnbom immunity, 256, 251(, 2S7t
acquired immunity'" 258-260,
258b, 259f
Incontinence 497
lncrrun mimrtics, 359l-361l, 364
lndapamid< {Lozol), 477-479, 477f,
478t
fnderal. Stt Propranolol
lndicaLions
fo r drug use 23. 29, 301
for injcc1ion rou1es, 230l
I ncbriJlion, 593
Jncrt ingredienLS. 22
Infants
BSA dosage calculacions for, 160
162, 16Jf
medica1ion use in. S860
lnfooions. Stt aha spific in/ttrat>ru
chain of. 304f
opponuni$tic. 299300
fnfenility. 520
follicular stimulation, 520
male, 520
I nfliximab ( Remicade), 40914101, 411
I nfluena
v;1ccines, 264t2661, 268
virus. 458459, 4591
INI I. S"' lsoniazid
fnhulan1s, 593
In haled medications. 214, 2 14(, 21Sb
Injec1ions. See Parenteral drog
ad1ninis.tration
fnoiropic effect. 465
Inscription, 74-75, 14(
Insomnia. 338b, 534<-535t. 536-537.
See also Sleep disorders
lr"pr.t. Stt Eplerenone
Insulin, 2324, 355-356
adminismuion of. 171, 171f.f72(,
174, 1741, 176, 179
in DM, 357-358, 3571. 35Sb, 35sr.
3591-36Jt, 362b
adverse reactions lo, 363
Insulin (Contm-'J
deliveiy systems for. 361363,
36Jf.J62f
m OM, 356-357, 356t3571
mixing of, ll9. ll9f. 358-361
UOILS Of. 123, 174, 17~1. 176. )~
Insulin P"" 50, SOf, 221, 221f. 361,
36Jf
Insulin pump, 362, 362(
Insulin s hock. Su I lypogl)'(emia
f11sufin syringe, 171 , 171f-172f. t74,
' 74t, 176, 179, 220221, 220f
1111.11. See Cromolyn
fmcrferon alfa, 275, 27Gt
l111crferon alfa2a (PegaS)). 428, 42?1
lnierlcukin-2 (Proleukin). 275, 2761
ln1em1edia1e-acting insulins, 357-358.
J57t. 359361t
fn1em1ed.iateaeting sulfonamides, o;,
498t-499t
ln1ema1ional drug regulation, g
fmemal.ional Standard ISO 8601
127-129. 128b, 128f
lnleslinal rondi1fons. 432-437
an1ifla1ulen1s. 432, 433t4351
lax.11ives an d cathartics, 432-437
4161
ln1esLi11a l 11arnsi1es. 4331-435~ 438-4J9
fnLr.1artku lar ( IA) injec1io11s. 218-219,
219(
lniradermal (ID) injections. 171,
2 18-2 19, 229231. 230b. 230f231f
2301. 2361
ln1ramuscular (JM) injections, 171,
218219
adntinistration of. 230(, 2.30t.
231-234, 233f. 235b. 236t
i1es for. 233.234
dchoid. 233. 234f
dorsogluteal site. 233-234, 234f
vastus lateraJis and femon.s sue
234. 236(
ventroglu1eal si1e. 234. 234f
tn1rau1erinc devices ( IUDs), 5JS1-Sl6L
517
lnu-ownous ( IV) injedions. 218219
lntron. See l)eginterferon alfa-2b
lnvento1y (Ollll'OI, for con1101led
substances. 14, 14f
Incline (I ). 326t3291
preprations. 304, 3061
tincture of. 304, 3061
Iodine 131 ('I), 351, 3521
Ions. 495
fprairopium (Aum-en1), 4551-456< ~~
ff'V. Sll lnactiva1ed polio>irus VJllV
lrbesnan (Avapro), 480. 4811
Iron ( le'). 326<-329L
Irritant. 28t. 29b
lslels or Langerhans. 355356
l~1ncli n. See Cuanethidine
.,.,.,....i (1!'111, Loniazid),
~n< insulin (NPH, Humulin N,
,.,,,lin NJ, 357-358, 3571,
J59t-J61 t
1
>pto!l)'I akohol, 304
li<)IOlllC solution, 330
i.oittiinoin (Anrnesteem, Clamvis,
SoU<t). 393, 394t
..,.,uptin< (Vasodilan), 483, 484t
1 Longactmg insulin~ 357358. 3571,
bJipcn< (OynaCirc), 468
Rll)I. w ln1nuterine devices
11 iojc(UOt1S. Stt Intravenous
111t'iom
IJoin1d11t.s<S. 406-411, 407f-408f,
4()')1-4 101
K
r "" l'o1assium
i;..a l.Jv;i, 3371-339t
Mfaii1ttllmis /.mendment. 9
K<!p.ll71J381
llU<Ofl. Stt lh.tmcinolone
MW" ~ '"'"'iracetam
MrUll. l87
M<l1US. 172-374
t.<fIOl)1k llS<"IS, 394-395, 396t-3971
i'l((k S. Telhhromydn
l'ltoconazole (Nizoral). 395, 421.
4lll
~,i.oo 291~ 2941, 295
M""'I"" w Clon32epam
lorOal<Jtmam SttOetoxynol-9
l'fllow' 404-405
L,W. S.. Cran...,ron
L
labrls
r.. orc dmg~ 11-12. 72b, nr
fooiock 111edko1ions, 69-72,
69f.n r. ?Ob
Llbculol (Normodyne), 480. 4811
lo1e1.uiion. medication use durin&
SHi. 58b60b
VJ\ S ll\oe 111enuared influenza
,JCCirw
1"""'1gin (L.amiaal), 538t-539t.
540
U.Uuid !>tr lsoniazid
L'lnoxic.1~ St'<r Digoxin
Llnoxin Se Digoxin
lanwp1ill.OI< (l'revacid), 425-427,
42614271
lanlllS 1'<t Clargine
law. S.. Fu~ide
LilinAmman medicine. 331-336
~ 43207, 4331-4361. 436(
LO> 1tt Low<S1common
ddK>mina1or
Lat 5" 1.Q\\'esl common multiple
297. 298t l.q;;tl aspeas of pharmacology
Dt:A regulation of controlled
subs1<1nces. 12-14, n1. 14f
drug regulatio n need, 7
drug standards and patient sarety,
7-IO
FDA and inuoduc1ion of new dni~.
10 16, llb, 111
federal legislation relJted 10 drugs.
8-10
international federal. <1nd 5t.ilte drug
regulation, 8
l..egend drugs. 4. 40
Legislation related 10 drugs. 8- 10
herbal suppleme1m, 336
l.cngth
conversion ben'ecn 1nensurc1nen1
systems, 140 14 1, 140t
i '' 1nctric sys\c1n, IJ 64 JI?
I e1hargy, 496
I eukoplakia. 583584
Leukoirienes. 458
l~uprolide (Lupron). 520-521, S22t
1-e\.-crnir. Su Dec.emir
t.e-"ttiracetam (Keppra). 538t-519t. 540
l..eviira. S..e Vardenafil
L<vodopa (OopJr), 523. 54 1, 542t
1.('Vonorgestrel (Mirena). 5 I St5161,
516517
L.evsin. See I lyoscya1ninc
Libido, 522-523
J.idocaine (Solarcainc, Anb<!$0l.
Xylocaine), 170, 395, 396" 1971.
532, 5321
Lifes1yle choices
an1ihypenensiw 11,.r1'Y nd, 475,
475f-476f
viuunin supplements and, 330, 330t
Lincomycin, 281, 293, 294 1
I inear equation, 154
I inczolid (Zyvox), 2932?5, 2')41
l.Jnirnents, 388
Lioresal. See Baclofen
l.ipiror. Stt Atorvast.Jtin
I ipod)~<rophy. 363
Lipoproteins. 484
l.iposome products. ll 5t- l 181. 319
Liquid oral preparation~ 44, 461. 47b,
197. 200b
medicine cup adn'linistra1ion o(,
199b
syringe or dose !tpoon ridn1inistration
of. 2otb
I iraglutide (Victoza). 3591-36 1~ 364
I isdex.imretamine (Vyvanse). 575-577,
576b, 576t
I ispro (1 lumalog. No"olog), 357358.
3571. 3591-3611
1.i1cr, 114 11 5. 114f. 1151. 118
Lhe auenuated inOucni.a V.lC'Ciru.
( 1.AIV), 2641-266t, 268
Li\~ ~lh:'Ou.Jlcd \:ill'.(1ftn. 261
l.iV< \';&CCIM<, 261
Local anathC11cs. 531.533
oph1hln11c 377178. 378t-3791
Local drug ><lion, 28
Lodosyn. ~.... Carbldopa
Lomotil .\., ll1phenoX)la1e wilh
~urupinc
3591 J<>11
lonitt-n ~ \t1noxad1I
l,operamid~ (lmod1um). H3l-4 35l
417438
Lopid . \ct
. t:cmhbro"I
l.opress<u .\fV M<1oprulol
1.oratadine (t laruln), 446-418, 4471
1.orazepam (A11v,m), 430, 430,.4311
533, H4,.5 l5t 538. 560-561 '
5621, 59 1
1.otions. 206-207, 188
LO\lenox_ \ti" r OOlCJ(>.1nn
l..o,Qt con1n1on dmon11na1or (l t O)
90
Lowes1 common muluplt (LCM) 9tl
Lo""pme (l.011.me). 5641-565l 567h
Loangcs, 44
l.owl. !>er lndapJ1n1de
Lubiproi:.tonC' (A1ni1i1a) 1 4331....i l5t.
437
Lubricanl, for eye, 178379, 3781- l7<J1
LubricJ.nl l .ix.Jliv\'"' 413t4"l5t.. 416
Lumm, 222
LuminJ.I . .\n- l'henohJrbital
Lupron. &.- lt~1prohde
Lutrepulse \ov (;ondorelin
LymphOC)o1<>. 257-258
Lynea.. ~f'-l' Ptcg.1bal1n
M
Macrolidc. lSR-2'>0, 291!
tvldc:rophJ.K~~. 2'i72'l8
MJfenidc (Sulf.unylon). 197. 3981
~1ag.aJdr,nc cornpounds., 4ll-l24.
425t
Magne>mm (Mg'). 126" 1191, 496.
496t
Magnesium h)Jnmde. 4H, 4231
f\iajor tranquilil'C'D SN' NeurolepU<.!.
MalaiS<', 496
Malaria, 103, 3011
Malatl1ion (Ov1dc), 399
Male infcr1ilily. 520
Maligna111 neopJ .,rn. 110, 311 ( l II 1
Manufactured drugs, 21. 241
Manufacturer's label. h9-7l
parts of (>?f.71f 70b
\.\anufJcturtft; n.imr-, on medi'-'uon
label. 71, 71 f
~tAOls. ~ \to110..lm1ne o~da.se
inhibitor\
Mariju<lna, 59 1, 5921

\tath review
decimili, 96-97
>ddiuon and subtr.lCtlon o(. 9899
changing i.....ttn poe<nu md.
102
con'trung l'ranions to, 97.93
dovision of. 100
multiplication of. 99
rounding of, 96-97
fraaions. 8681
addilion of. 89-9 1
conversion LO decin1;ils. 97~98
division of. 94
equivalenl, 87
figuring percenl$ from. 104- IOS
imprope<. 86-88
mixtd numbers and. 88-9~
muJtipliation or 92
proper. 86
<implifying. 87
subtraction of. 91-92
ml.IM numbers
dMsion of. 94-95
framons and. 88-95
muhipHcarion of, 93
percents. 101-102
changing bet"-een dedn1als ~nd,
102
division or. 104
equations, use of, 106
fractions. use of, 104- 105
multiplication of. 103
r.itios and proponions, Ust: of,
108-109
ratios and proponions. 107-108
6gunng percems. 108- 109
practical applications. 110.111
solving for x. 107-108
\1axalL Stt ltizauiptan
MOls. Stt Metered dose inhalers
Measles vaccines. 57, 264t-266t, 267
Measles-mumps-rubella (MMR)
vaccine. 57, 264t266t, 267
~teas:urenlen1 sys-tenls
apothe<:aiy system, 121, 1211
length conversions, 140- 141, 140t
vohune co nversion~ 132134,
1321, 134f
weight comoersions, I 35-139. I 35t,
136f
con\-ersions between. 127
length. 140.141, 1401
ratios and proponions. 131
tempera1ure com-enions. 129130.
129t
timecoO\'ersions, 127- 129. 1281>,
128(
volume. 132 134, 132L 134(
weighL 135-139, 135L 136(
current trends for symbols and
abbreviaLions. 123
Measurement $)'Stell)$ (Conunu<!J}
household$}'Slem, 114, 121-122.
1211
length con'Ol'Sions. 140141, 140t
\"Olume convusio~ 132 114.
132t, 134f
we1gt11 com'<'rsions. 135139. 135~
136f
m"ric system, l14-115, II 4f. 1I5t
length measurement and
conversion in, 116... JI 7,
140-14 1. I 40t
parenteral dosage calculations
using. 174-175
volume measurement and
convasion i<L ll8, 132- 134.
132L 134'
weighl measurtmmt and
COO\USion in. 119 120,
115-139, 135L 136f
unns. 122-123
o(hepari<L 123, 176. 178 179
of insulin, 123, 174, 1741, 176.
179
parente-ral dosage caJcula1ion.s
using. 170, 176, 178-179
Mcbendazole (Vennox), 433 t-435t,
438-439
Meclizine (An1iven), 381-383, 383 t
Medical office. DEA regub1io n o(
controlled substances 11nd, 1214,
14f
Medicated enemas, 50
Medica1ions. S.. Drugs
i\1ediation containers
(0< injectable medicauons. 222223
ampules. 49. 49[ 220, 222223,
223(. 224b
di4iposable injection uni1s. 223,
223f. 226b
pre611ed syringe. 223
seleaion o(, 220-222
vi,1ls, 49. 49(, 220. U3, 223(.
225b
to tal ,unount of medication in,
70(.71(, 71
Medicatio n orders, 73-74, 73b
.abbreviaLions used in, 72-73, 7lt
Medicine cup. 199b
Medroxyprogesterone ( Depo-Prowra,
Depo-subQ), 515t-516L 517
Meglitinides, 359t-361 ~ 362b, 164
Melatonin, 337t-338L 338b. 516-537
Meloxicam (Mobic), 408, 409t-410t
Memmine (Namenda). 574, 575t
Memory. 3 38b
Meningitis vaccine. 264 t-266L 268
Meniscus. 199
Menopause. 33Bb
Menotropin (l'ergonal, llumegon).
520
Mental disordetS, 559b. 559t
AOllD, S46, 575-577, 5761>. 5761
Alzheimer's disease 574, 5751> 1;.11
anxiety
nxiOlytics (or. 560-563, 5621.
563b
daily living and, 560
dcpre<sion, 568574, 569b
ant idcpressams for. S69-574,
569b. 570t-572t, 572b.573b
fl('UfO<is, 56056)
psycho<is, 560-561
neuroleptics for. 563-568, S64t
565L 566b-567b, 566f
psychothernpy and medication
therapy role in. 560
Memal heahh, 559
Mental state, dosage calcul1tions od.
56
\/lentally healthy person, 559560
'leperidine (Demerol). 40. 243. 2~t
543. 588
Mer<ap1opurine (Purinethol), 314.
3151-318t
Mesalamine (Rowasa), 4331,,.35L O&
Mesoridazine (Serentil), 564, 564156>1
Mcstinon. Se-e Pyridostigmine
Metabolism, 24-25. 25b, 25(. 27
Mcrnmudl. See J'syllium hydrophili<
1n ucilloicl
Metapro tercno l (Alupem), 454-456.
455t456t
~h.~1as1asis. o( cancer, 31 l
Meter. 114-117, 114f. 1151
Metered dose inhalers (MOls). 214
214(, 215b
Metforrnin (Clucophage). 3591361l
364
Methadone (Dolophine). 2441
Methocarbamol (Robaxin), 413. 414t
Methotrexaie (Rheumatrex), 409!-410!.
410
Methsuxi mide (Celomin), 538540.
518t-5391
Mcthylcellu lose (Citrucel, Fiber Trim).
433t 435t, 436, 439, 4391
Methylph e nida1e (Ritalin, Conceiu).
20?, 575-577, 576b, 576t
Mcthylxanthines. 455t-456L 456
Methysergide (Sansen), 543-544
\1ecoclopramide (~an), 4261-ll7L
428
MctolJLOne (ZarOltolyn), 477-479
477(, 478t
\lecoprolol froprol SI. l.opresw<).
472-474, 473L 551-554, 553t
Metric system, 114-115, 114f. 115t
length measure1nen1 and con\'t'TSlOn
in, 116-117. 140-141. 140!
parenu?ral dosage calculalions usuig
174. 175

).ldl1( !)1WI' {Cotllmutd)
.,...... mt.iwmnent and
(00\\'fSIOll in. 118, 132 134,
1)21. 134(
.;;ii mt.ow~ and conversion
in. 119-120, 135-139, 1351. 136(
~n Ste urofollilropin
MtlfOllidUOI< (f1Agy1), 2941. 295
for prpek ulcrs. 4261-42n 427
l!Oll<llnr (Mexhil), 472, 4 731
MOiul. Stt M<'X ile1lnc
Mg'. 5,. MagJll.'llhun
Ml St< M)ocardial infarclion
\li.IG&lcin Stt C.1lciloni11 saln1on nasal
spray
)!J<robi-OI08)'. 282
*10ftulriaus. Stf M ineral.s; Vitamins
)4iaoOlpllUmS
~"" of, 282
,..,SUIOS. 282
""""firUOn ol 282
Cl"1"' nttds o<. 282
th.1pe ol. 282
}olJ(JOSUlron. 5"' Sulfadiazine
~1dw>Ltm. 531
~idnn. SO, 5441
Mif<pr1S1on (ltll-486, Mifeprex), 519
lli~ilol (C:l)1<1), 3591-3611, 3 63-364
.1tigninc headaches, 543-544, 5441
1tilt or mgnesia (MOM), 4331-4351.
m 409 t410t
1111li<quivalenl!I, f 23
111I1pilm! per kilogrom dosage
alcuJtioM 163
llilonun Sa l'hensuximide
11111ao1o<o<1icoids. 353, 3541, 355
~ 3241. 330-lll. 3321-3351
llllrdl<as o( 324
lllflll<mmu. 331
Mr ... 121. 1211
llin press Stt Pr.m,.in
liJJlol t1'nquillurs. Srr Anxiolytics
llJonlOdil (Rogainr. to11i1cn ), 29, 39,
m, 480-482, 4821
M1111ciol. Sec 'lh iobcndazole
MIOSu. 371
M1oors, 375J76, 3751-3761
Minpex. Scc Pr;unlpexole
M""1a. Stt 1.evonorgesirel
"1110pcostol (Cytotec), 4 261-4271. 427
ltilux. ltt Drug buse and
ckpmdrncr
11*'1ir mh1b1tors. 312, 312(, 314,
Jl51 118t
\lll<d numbm
drvi!ion or, 94 95
fnoions Id.88 9 5
mulupllCllOn or, 93
llu:i11g mrdicatlons
tor injwions, 228-229, 228b, 229f
iruulin, 229, 229f. 358361
MM R v...ccinc :X. Measles mumps.
rubella v;acrine
Mobic. &. Melox1<am
MOM. Stt Milk of magnesia
MOnO..\fnine OXJdaw 1nhibilors
(MAOls), 569571, 570t-5?2t
Mo nteluka>1 (~mgulaar), 4571, 458
Monural. Se~ I osfon'l)'<'in
Mo rph ine, 8, 243, 2441, 588
Mo1io11 sickness. 412b
Mo lrin. Sre Ibupro fe n
Mou1h, 4 21 -422, 4231
Mouthwashes, 42 1, 4211
Mucokine tic :igcncs. 4'i3, 4541
lvtucolytiC"&. 5t~ 1\1ucokinelic agenL'i
Mucomysl. See Acelylcysteinc
MucOSdJ drug ad1 ninis1r~u1011, 25t 26t
MucoS<ll proll'Clanu. 424, 4261-4271
Multiphca1ion
of decimals. 99
or frJctions. 92
of mixed numb<.'rs. 93
of percenu. 103
Mumps vaccines, 57, 264 t 266~ 267
i\i.uscarin ic antagonisls, 426t 4 271., 427
Musculoskelct.11 S)'\tcm, 402-4 17
ana10my o f, 403404, 404f
fi b romyJlgia, 415
gou1y arlhrilis, 411 4 I 2, 4 I 2 r, 4 l 31
join t d isc.1s-s. 4064 I I, 407f40Sf,
muscle d iseases. 411-41 5, 41 41
oSleoporosis, 4031. 404-406, 4051
spasticil)'. 413-4 15, 4141
MWldflleII. Stt Nnrogcn mustard
~1utage:n1c s.ubs101nces. 320
Myas1he111.1 gr.wi" 414-415, 4141
M)'<'clex loanges SN Clouimazole
MycophenOIJte mofetil (CellCept), 275
Myrnphenolic acid (Myfonic), 275
Mydria<is, 171, 176-377
MydriatiCS. 376- 178, J 771
Myfonic. Sr.c Myco1>hcno lic acid
Myocardial inf.m1io n (Ml), 466-467
f\.tysolinc. Sc~ Pri 1nidonc
N 548r
Na". See Sodium
Nado lol (CorgJrd), 472b, 4 75b, 480,
551-554, S5lt
Nafarelin (Synard), 521. 5221
Nah rexone (~'ViJ), 58 7
Namendd ~~ l\1eman1ine
Naprosyn, II b
Naproxen (Ale>..,), 2471
for arthn11s. 408, 40?t-4101
brand nan1cs of, 11b
safe1y with, 188
Narcolcp;y, 546, 547t
Narcotic., 8, 243, 249~ 530-531. See
tJ/so C',,onuolled subs1anc<:s
Index 633
-----~
Nard1I Stt l'""ntv,~
Narro\\ ~sPlnJm .1n11bt0hc,. 182
Na.Iro\oo-spenrum P't"flt0lhm. 286 :!tt;"1
Nuacon \tt I n~ m<nlnlonr
N05al cong..uon. 446-151
Nasal mt-dic uom., 210 112 n 2f
Na>alcro m . w C romolyn
Nat<'g)inode (~ldrh). \5'h l~ll ](,.!
National 011ldhond Vt<1n< lniury An
of 1986, 2(oJ
National Drug Cool' (NIK ). 70(. 71
Nation.ii lormulJry (NI). 7, IU
Native A1111;.'nC.ln nu_llid nc. '11
Natural ac1ive lmmun11y, H~ 2sq 15?1
Natural po:t"iw 1m111u1uty, l'l K
NaturJI r..-upld~1.. 1nh1h110" 'ii'\
Nausea H 8b
Navant! .\tv Ih101hLAcll<'
NOC. Stt 1'allonal llrug <:...k
Nebuhu" 214
Nerol ..
..feiy wnh, 18H 11<9, IKMJ lb)t
selection of, 111 122 2111. nib.
2161
Neg.uiw fl'<.-dba< k, H e.. \ 471, 1'111
Nembutal. ~re l)t.111oh.11b11.1l
Neon1yc.in. 2?5
Neoplasm, 310, lll f, 111 t
benign v. n1.llign.1n1, \JO, 111 1 111 1
dassific.ation o l, ll 1 ll l
Neosporin, 2cJ 5
Nrostigmine (Pro ... 11~1n 111 t). tl 4 l l5.
4141, 548
Nro-Synephn111.. \i't' Pthn~ftphnnt
Neurdm1n1d.&M> 1nh1b1tor' l 1 1, 4 ; 1Jt
Neurolepti<'\. 5b l Shtl i;<h t;(, ll
p.aren1er.al. ';(17
poiency of % 4
for schirophr,1u.1. 1i(17 1bri
side ('fl"-"CU of. S<,1 'i(17, )(,.11 i;c,51
5 661> 56 7b, %"1
US<'S fo" 56 4
Neurologic ~~1eo1, 'il(, 557, 'i27h,
5271
anes1he1 ics, 531 '>J \
ANS, 528-529. 5<Jlh, 5<Jl,.551, 546f.
antis..:iturc.> n1cd1cJuo11,_, 'i l4t ~ 15t.
537-540, 517b, S IKI '1J1
CNS, 527, 5l8f
depreM..tHI~. 5?0 591 '.1 1)lt
long-tenn drug u-.c Jnd 510
St-d.U1\'t":S JnJ h)'f'OOUC\ ~nd
513 537. 5131> Hll HM
.stin1ulanu. s.itJ.S-1 6 1-471
589-590, 5901
hcadacht..,, 541>45. 5411
OVl'rYIO'Y Of, 527 'i\(l 5J$f51'1J
Parkinson'~ d1sc.i)t". S-10 511 54 1b.
542t
restle>S lclll' ; yndro mf. 5ll1, 54 l
634 Index
-.;<urologic $)'SUTO (Con11niuJ)
$b1nb and hypnotia. 533-537,
53Jb. 5331. 5361
po.sucity. 545. 5451
srrokr. 554
'curo~ 527, 528(
Ncuromin Stt Caba~ton
Neurosl$. 560-561
New drug developmcni. FDA and,
10-1 6. lib, Ill
Newborns, medication u~ in1 5860
Nexium Su Esomepr.,.ole
NI. Stt N1ional Formulary
Niacin, 326t3291
Nicrdipin< (C3.rdene). 468, 4831
Nicobid. 1>tt Nicotinic Mid
Nicoune 583-586, S84b. 5841-5851
detenenu, 584-586, 584b. 5851
N1ro1ine pau:hes. 20?
Nt<otrnic acid ("icob1d). 3261 l291
4851, 486
Nfhpme (Adal.11). 468. 4831
"!mates. 467-468. 4671
Nitrogen mustard (Mu.<iargen), 31 4,
315t-3181
Nitroglycerin (NTC), 132, 209, <167,
4671. 469L Stt a/Jo Sublingual
nitroglycerin: Tr.1nsdermal
nitroglycerin
application of. 206, 208b. 209
Nitrolingual, 467-468, 467 1, 469t
Nitrosourea.s, 3151-3181
NitrosraL Stt Sublingual mlrogl)'Cerin
Niis, 399
Nix. Stt Pmnetbrin
Nizoral. Stt Kaoconuole
NN'lls. Stt Nonnucleoside "''Tf'W
transcriptase inhibi1ors
Noctec. Stt Chloral h)'tlrale
Nocturia. 500
Nomenclatwe, of dru~ 39 40
Nomogram, 16-0, 16Jf
Non-lllV antivirals. 300, 30ll302t
Nonnucleoside reverse uanscripH1w
inhibitors (NNTls), JOI t-3021, 302
Nonopioids, 246-248, 246b, 2471
con1binat.ion, 248
cough suppressan1s. 452-453, 452t
defin<d, 243
salicyfate analgesics, 246, 2471
Nonoxynol-9 (Delfen. Ensure), SI 7,
5171
l'onparmtenl drug admmil>tmion Stt
also r:.nteral drug adminiSlrtlliOn~
Pttcuuneous drug admini.stntion
dosage calcula1ion for, 14 7- JSO,
150b, 164
BSA method. 160-162, 161(
dimensionaJ anal)~is. l49,
154- 156
ronnula method, 149, 151 - 153
NonJ>JI"nltral drug administrauon
(Contmiwd)
method ..tection. 156
powder reconsti1u1ion. 158-159,
158t J58t
m1os ..nd proponions. 149 I SO.
150b
dosag focms for, 148
Non-salicyla1e analgesics, 246-247, 247t
Noiualicylale NSAIDs, 408. 408b.
409t-4 101
Nonsce:roidal anLii nflammo.uory drugs
(NSAIOs), 245, 247-248, 2471
for arthri1is, 406-408. 408b,
409t-4IOI
for gout. 41 2, 413t
for headaches. 543, 544 1
ophthalmic. 3731-3741
"lorelgesuomin. 515t-516t, 516-517
"lormal Oora. 282
ormodyne. Stt Labetalol
1'iorpace. Stt DiSOp)'r.lmide
Norvasc. Stt Amlodipine
NOVOC-din. Stt Procaine
Novolin N. Stt lsophane insulin
Novolin R. Stt Rgular in<ulin
Novolin.Pen, 50
NovoLog. See Aspan; Llspro
NPI I. S" Jsophane insulin
NRTis. SeP Nur,Jeo.side reverse
ua nscrip1ase inhibitors
NSAIDs. See Nons1eroidal
anliinOammarory drugs
NTC Stt Nitroglycerin
Nucleoside m-erse uanscrip1a.<e
inhibitors (NRTis). 301 1-1021, 302
~umerator, 86
Nuperrainal. Stt Dibucaine
Nuprin, Jib
Nutrient-drug imeraaions. 33-35, 33b
Nutrients. See Vitamins
Nutritional imbalance. 324
Nutritio nal supplements. See "/so
ViLa1nins
herbal, 336-340, 3371-338<
n1inerals. 33 1
Nys1agmus. 372t
Nytol. Sre Dipbenhydramine
0 immunomodulatoJ>. 378, 378131'1
OAB Stt Overaaive bladder
OBRA 1990. Stt Omnibus 8udge1
Reconcilia1ion Act of 1990
ob....ion, 561
Occlusi'" dreuings. 393
Ocrupa1ional Safety and 1lealth
Adminitration (OSI IA)
medication administration s1.lndard>
of. 188-189, 188fJ89f
or.11 n1edication s1andards, 197
rec-1al rnedication Slandards, 19 7
Oetoxynol-9 (Onho-Cynol, ""'-
cream). 517, 5171
0ctr<01ide (Sandostuin), 348. 34411
Off-lab<>I use 39
Oil-bas'-'<I parentaal m<dicationt. o,
222
Oils, 46t
Ointnlents
application of, 206-207
collagenase. 398. 398t
eye. 211 b-212b
rectal, 197-1 98
0 1.mzapine (Zyprexa), 5641565t,
566-567
O lder adullS
analgesic and, 252
BSA dosage calculations for. J6().
162. 161f
compliance in. 62
n1ediGJtion use ~ 60-61
neuroleptics in. 567b
oral mediouion safety with. 200
polypharmacy in, 6162. 61b
1op1cal medications in, 208
vitamin supplementation in, 330
O liguria, 497
Ohnesanan (llenicar). 480, 4811
Olalazine (Dipentwn), 4331-435~ 418
Omcpmzole ( Prilosec), 425-421,
426t-427t
Omnibus 8udge1 Reconciliation .1(1 of
J990 (OBRA 1990), JO
Ondansetron (Zofran), 430, 430!-4311
Open-angle glaucoma. 375
O pen-cell foam dreuing. Stt
Hydrophilic poli'\ll\'lh.,,. foon
Ophthalmic medicatio" 371lb. l?Ot
adminis1ra1ion or. 210. 211b-212b
adverse $)'Slemic elfecu of, 3121
anti.Ulergic and decon~ant ..,..
378t3791. 379
antiglaucoma medications,. 3121,
375-376. 3751-3761
a111iinfective agenis. 312-314,
372t-3741
antiinfJa1nn1a1ory agents, 372-374,
3731-3741
anificial tears and lubricam~
378379, 378t-379t
local anesthetic agenis. 377-378,
378t3791
mydrialics and cydopl<gia.. 376-3;
3771
SIAining ag..nu, 3781-3791. 379-JMI
siorage or. 383
Opioids and opiates. 14, 243-245. 244t
.1buse of. 588
cough suppressanu, 451, 452t
defined, 243
deterre nts, 585l

Opioid> .,id op1.its (Continued}
p"'llO' fat: 245. 245b
~ndl<IJC. 08
Ill(> o( 245
w>lhd,.wal from, 5851, 588-589
Ol'um. 8
O!JllO"unisiic infections, 299-300
OPI' IN Oral poliovirus vaccine
(Jill drug administration, 44, 197.
1%1>-lOlb. Stt abo Nonparenteral
dnC ;odmini51ration
~ nd.26
bquld P"l""'ions. 44, 461, 47b,
197, 200b
m<did1l<' cup fo r, I 99b
iyringt or dose spoon
adminisl'ation of, 201 b
t.tfcty in, 200b
t()lid prep;ira1ions. 44. 44b, 45t. 197,
198b. 200b
()sol lll(dl('.JtlOOS
~2Sh
...,Jubttic mtdirntions. 359t-361t.
162b. 363364, 3631
azrulunpls. 421, 423t
(OlllJl(tpUV<5, 513 514, 514 b,
51StSt6t
Or~ pollovints vaccine ( Ol'V),
264t266t, 267
Otdm. drug. n. 17
Jbbrl\'i.Jtions used in, 72-73, 72t
mcd1r.1tion orders. 72-74 , 72L 73b
pta<nptions. 72-77, 72L 74( 76b
......i.. O<ckn. 7 3. 74
\ '(), 7)
"""" w Abati<ept
Olphon Drug of 1983, 9- 10, IOb
i\Ct
Onho-C)'llOI Sn Ocioxynol-9
O!dtlmivir (TamiOu), 459, 459t
OSILI. SH Occupational Safety and
ll<hh lldminisiracion
O<n'li< diuretics. 376
Owoli<1.1hne lilLlti,..., 433t435t.
m ParaCard, 515 1-5161. 517
Olltoinhtll1$. 406, 407f
*"""""!$, 351. 4031, 404406, 4051
Olt dnip. ii.. O\-er-the-<0unter drug.\
.,,, n>N1utions. 370b, 3701, 380-381.
382t
admmimation of. 210, 213b
oi<gt or, 383
O.itio mtdia. 380
Olotoxkity. 381381, 381b
"''""~bladder (OAB), 4 98t-499t,
500
0...tht-<ountor (Ul'C) drugs. 3-4, 40
labtlof. 11-n n b. nr
..i.iy ..,lh. 186-188. 187b
AnOid preparitions. 355t
'"" Sr.Malathion
Ow.tp.1m ($mx), 584
Ou2olid inones. 293-295. 294 t
OxcarbaUpine (Trilept.al), ~38t 5391
540
Oxidi'-"<l cellulose (Oxy<"el. Surgtrel),
488
Oxybu1y nin (Ditropan), 4981499t, 500
Oxyccl. See Oxidized celluloc
Oxycod o ne (OxyCon1in, l'ercod n,
r ercocet), 2441, 588
OxyContin. See Oxvcodone
OX)'llen needs. of ~icroorg;ml\ms 282
Oxygen 1herapy, 445-446
Oxym etazoline (Afrin), 210, 448. 4491
Oxytocin, 349-350
p IA. 2111-219, l l ?f
I''. See rhosphorus
r.tckage insert, 40. 42( 4Jt
Packaging, for patient co1nplian("c, 50,
50 f
rain
cu1e, 242243
chro n ic. 24 2-243
defined, 24 1-243. 242b-243b
emotio nal resp0nses and. 241 242,
24 2b
1nedica1ions and, 24 2243
perception. 24 1-242, 2421>
severity of, 245
threshold, 241
to lerance. 241
l'aliviw mab (Synagi$), 45?. 4591
ralliali\'e drugs. 313
l'anax ginseng. 3371-3381, l38b
l'ncrease MT. Stt Pancrehpase
Potnaeatic enzyme replace:1nen1s, 4 28,
4 291
r .111rreatin, 428, 4291
r a ncrclipase (Cotazym, l'ancocase MT),
428,. 42!.>t
Pa nnus. 406
r .11110 1he nic acid. 326t -i291
l'a pule. 393
rarasito
1111estin al, 433t-4351. 418-439
microorganism s, 282
Par.a~yn1pathetic nervou!; S)'Stcn1,
529530, 54 1b, 546-554. 5 46f.
548 f
Par<t)y111pa1holytic agenls, 549..sso.
550t
Parasympathomimetics S~e <:holi ne-rgi<'
agcntS
P.lfa1hyroid hom>one ( 1'111 ). 35 2,
3521
recombinani, 405t, 406
rartnteral drug administrdtion. 19-1 .
218-238
,,bsorption a nd, 25t 261
.id'"n1ages of, 219
Index 635
Parmteral drug odmin1wuon
(Omun.,..I)
contracept1o n lllJttltOns. 515 t-51 61
51 7 .
d 1sadvantagl' o r. 21 9
dosage calcul>uon> for. 170- l ? I
WiLh n1etric .S)'tl'm. t 74- 17S
with unm 176. 176- 179
dosage fo m" 25t 26c 49.50, sof
equopmeni M'le<1100 for 120-222
med1cauon cont.u~ 110-212
nttdle., 221 222. 221(. l22b. 236I
5ynns 220221 llOf-2211. 22lh
2 l 6t
injection ro ul"'- 22?-234
ID. 171 , 218219, 229 231, 230b,
lJOf 2 111, 2301. 236t
IM, 171, 2 11\.!1 9, 2 101. 230t
231 214, 2Hf-2l41. 235b.
236f 2161
IV. 21 821?
SC. 171. 1711 112r. 2111-219
230( 2111. HOt, HI , 232b
2361
injmion rull"\ .ind ftUtdehn~ 222h
22?, 229b
n1ec.licJlion root.liners for, 222-22 -~
dm pule>. 49, 491, 220, l2 2-221.
22Jf, 224b
dispos.1blt injl'(tio n unns. 221,
2211, 12<>h
prefilleJ '>""!>"'
223
selectio n o f 210 122
\'ials. 19, 491. no 123. 2nr.
21 Sb
for ncurolcpucs. ';67
oi l -ba~4..xl. SO
precaution.; wi1h, 219
preparadon for, 223 229
mixing two medic;uio ns. 228-.22t>.
228b, 229f
powc..lt!r n."<'On\111u11on. 123. 2.27h
reading \)'ringc\ fnr. l71 1i'2.
17lr- 112r 174 t
safety durinJI. 188 Iii?, 1&8flt!'ll
water-b.u<'<l. 49-SO
Parkinson' d1Se3'r, 540-541 541b
5421
Parlodcl. Slt BronH>Clip1ine
l'aroxetinc (1'.1xil (.;R), 560-561
Parsley, H 71 1l8t
Partial seizure\, 'i l 7, S_l 7b
Passive in1n1unity, 256, lli7f, 257t
arti6d.ll. 260. 260b. 160[. 2;1.1-!
natural, 2 58
Pa1ch. 207. 20?1:>. 209f
Pathogen. 2a2
Pathology. 3
P.ttient co 1npli.1nrc '''
Compli.ince
ra1ient s3fel)' .St~ ~Jf('t)'

r.wl <.R. Stt Pro""'""
l'CV ~ Pneumococcal con1u~1ed
\'XciM
PDR. ~ 1'11)1Jt1Jru" ~ Rlftrma
redm1~ 269
Pedia1nc p.IU"1llS. ~. Ouldr(tl
Ped1culicida, 3961-3971. 399
l'egasys Stt Interferon alfa-2
l'egimerferon alfa-21> (ln1ron). 428,
4291
Pegyla1ed interferon. 428. 4291
l'ellagu, 324-325
l'ellel!, SO
ren_.w ln~ulin pen
l'enicillmine, 4091-4 JOI, 411
l'enialhn. 23b. 285-286
nllsuphylococcal, 286, 2871
broadsptt\IUm. 286. 28 71
txl~ptttrum, 286. 2871
~auons of. 288b
nanow->ptttrum. 286. 28 71
l'enirillon C, 123
Penicillin V. I 23
PenlACel. 269
l'enl.lZOCine (Talwin), 2441, 252, 584
Pcntobarbital (Nembutal), 511. ~n1
l'entos.Jn polysulfate (Glmiron),
4981-4991. 500
l'entoxifyllinc (Trcntal), 481, 484 1
l'eptic ulcers. 422-428. 424b, 424t-427t
Per.univir, IOb
Perrems, 101-102
changing between decimal~ and, 102
division of. H)4
f<!Uations. use of. 106
fractions. use of. 104-105
mult1plicuion of. 103
r.tios and proponions. use of.
108-109
rercocet. Stt Oxycoclone
Percodan. Su Oxycodone
Percu1.1neous dn1g adn1inis1ra11on, 194,
205-217. Su 11/$() Ophth.ilmic
n1edicuions; Topical 1nedic.11ion)
nbsorp1ion and. 25t-26t
buccal medicat ions, 205-206,
209.210. 21or
dosage forms. 25t-26~ 47, 47f, 48~
49b
inhaled medications. 214. 2t4r,
2151>
nasal medications. 210212, 212f
otic m<diations. 210, 2131>. Jrob.
370t. 3$0.381, 382t
administration of. 210, 21 Jb
stor.ge of. 383
sublingwl m<dications, 205206,
209-210, 2tof
vaginal medic;uions. 212
Pergolid<(l'l:nnax). 54 1, 5421
l'ergona1. See f\1enotropin
Pen.K'l n. 39
l'mpltcral nen'OUS sy>tem (P"IS), 527.
528f
r..nplter-al vasculor resistance. 475
Penpherally acting adrenergic
mh1bi1ors. 480. 4811
Pennax. Stt l'ergolide
Permethnn (Nix, Elimiie), 199
Pers<1ntme Set Dipyridamole
Pertussis vaccines, 263, 264t266t
11ethe mnl seizures, 537b, 538
f'h,1nuacist
drug adminisua1ion role of, 4 5,
4f-5f
ethics of, 17 18. 171>
Phannacodynamk drug. 30t
Pharmacod)'llamic:s. 23, 28 29. 28t,
29b
PharmacogoOS)'. 23-24. 24f. 241
PharmK<>kinetic:s. 2328, 25b
absorption. 24-27, 25b. 251 26t
distnbution, 24-25. 25b, 27
excretion, 24-25. 25b, 2728
meiabolism, 24-25, 251>, 25f, 27
Pharmacology, 3
basic terms in, 22b
categories of. 2331
phar1nacodynamics, 23, 28 ~ 29,
28. 29b
phannacognosy, 23-24, 24(, 24 t
pharmacokinciic:s. 23-28, 25b, 25f.
2St-26t
pharmacotherapcu1ie<, 23, 29, 30t
toxicology, 23. 30-31
defined. 22-23. 22b
drug interaaion mechani.sn1s. 3 23S,
33b, 33f, 34t
drugs defined, 22-23, 22b
ethics in, 17-18, 17b
health sciences and, 3-5
reasons ror swdying. 3-4, 4f
role of heallh professio11.1ls in
drug adn1inis1ralion, 4~ 5,
4(.5(, 16 18, 17b
hi>tory o(, 5-7, Sf. 6b
i<lrntification of undesirable dn1g
effects,3 1, J i b
leg.ii aspects of
DEA regula1ion or controlled
substances. 12- 14, 131, 14(
drug regulation need, 7
drug standards and paiient safety,
7-10
l'DA and introduriion of new
drug>. 10-16, lib. lit
federal legislation related 10 drui;~
8-10
int~rnationaJ. federal, and state
drug regulation, 8
receptor sites ror drug.<, J2, 32f
Pharrnacotherapcutics, 23, 29, 30t
Phenampyridine (Pyridium), 498t-
4?9i. 500
l'henelzine (Nardil), 543-54~ ~-Sll
5701-5711
Phenergan. Stt Prometha:ziM
Phenobarbital (Luminal), 69-lO, 11l(,
533, S33t. 538
Phenol, 395
r henothiazines, 564t-565t, 567b
l' hensuximide (Milontin), 538-54-0.
538t-539t
Phcn termine ( Fasti n, Adipex-P), 439.
439t
Phenylephri nc (Neo-Synephrinr). 448
449t. 551, 5521
Phenytoin (Dilanlin), 538, 538t5)91
l'ho>pho~.ced catboh)'<lrate solu00n
(Emetrol). 430t-431i. 432
Phosphorus (P-), 326t-329t
Photosensitivity, 398-399
Physical dq>endence 16, 341, 530
582b
Physician
drug adminisuation role o( 4-S.
4 r-sr. t 6-18, 11b
ethics of. 17-18, t7b
Ph)"ici111u' Desk Reference ( l'DR), 40-41
l'hytonndio ne, 326t-329t
l'iLre~in. See Vasopressin
l'ituitary gland hormones
anterior lobe. 3451. 347-348, 148f
34?t, 350f
posterior lobe, 3451, 348f, 349.350
349t
l'lacebo, 7
Plant alkaloids. Stt Mitotic inh1b1ton
l'laquenil. Stt H)'drOX)-dlloroqumr
Plt<let at!St<g;lliOn, 246
Platinum compounds and alkylaung
agents, 315t-318t
Plavix. s.. Clopidogrel
Plendil. s...., Fdodipine
l'letI. See Cilostazol
PMI. ~ee Poi nt of maxi1num impulst
l'~IS. S1'r Prt>menstn1<ll syndrome
Pneu111oooccaJ conjugated vaccine
(PCV), 264t-266l, 268
1ncu1nococca1 polysaccharide vacrint
(Pl'V), 264t-266t. 268
Pneumonia vaccine 264t-266i. 168
P'IS. &.. Peripheral ner.'OUS S)'<ll'lll
Podophjllum, 395, 396t-397t
Point of maximum impulse (P\11). 40
Poison. Stt Toxicology
Poison Prevention Pack.lging j\(t o(
1970, 9
Poliomyelitis Y.lccines. 256-257.
264t 266~ 267
roly<Mboph il (Fiber-Con), 43lt-4lll
436
rolydipsia, 356, 356t
 lndu 637
~i<nf gl)'<Ol (CoL)1ely), Premeasured canridge. 49
~1lc-ll5~ 437 Premenstrual syndrome {l'MS), J38b, Proton pump inh1h11on. (l'f'li)
!d)111l''" 8. 295 519-520, SI 9b 3011-1021, 425-427, 421>1-4171
Protozo.t. 2 82
~JS6.JS6c Premixed fixed co1nb1ndUOn insulins.
~.icy. ~. 61-62, 61b 357-358, 357t. lS9t-361t PrO\-enlJI Stt Albutnul
l'ol!""" }56. }561 Presbyopia, 371 Prozac Stt J luoxnuw
Presqi ptions. 7 4 1'$aidoaddicuon Ht. H 1
Pb0'''1nt. Stt 1etrK.i1nt
""""''"! concr.icep1ion. 518, 5181 abbrevia1iom u<1I on, 7273, 721 1'$aidoephednn~ (\uJJfcJ <~>nt.1<)
pans of, 7476, 711f 448. 1491
"""- p11ui1ary gland hom1ones.
145~ 348( 149-350, 3491 preparation or. 74 Psori.si<. 192, 39>. 1%1 l'l7l
Psychedelia1, 591-591
l\>IJSSiUm (~"), J26tJ291, 496, 4961 refills of. 75-77, 76b
Psycho.1nJl)''h. sc,o
l\)lil!llUOlSPalill& diure1ics, 4 77f, 4781, S<lfeguarding 1>ads for. 77
Psychological dn11! Jciwndi nc., 1c..
479 Prescription drug .1buse. 58~1, 588589 341, 561, 582h
l\'ldl<J' Prescriprion Drug An1end1n cnts or l'sycho<is, sc,o s1.1
ol drug>. 7 1992, IO
neurolep1ic~ for, 'lU l ,C,H \C,4t \h5t.
o1 iwrolrp1ks. 564 Prescription drugs. 4
,..,.....io.. 12. 341 Prevacid. S<Y L.1nsopruole
566b-567h. >11c.t
l's)chother.11l). %0
l'lloidont ood1"' (Beudioe), 304 PriloStt. & Omepra>.ole Psrchotomin1ei1<,, \)1 S'> l
~H Primidone (M)'SOline), S38t-5l9~ 540 l's)11ium hrdrophrhc moolloiJ
...,i;aoon of. 206 Probenecid (llenemid), 412, 413t {MetJmucrl) H1. 4 Nt
llll)m(JIUllOP ol 170 I 71 Procainamide {l'ronestyl, PrOC'..i.n SR). PO I ~t Par.uh) rote.I hornn>or
.io.. alruluon.s for. 15S-I 59, 472, 4731
158(. 1581 Procaine (Novocain), 532. 5Jlt PulmoZ) me "'" Do "'"' II
Pump. Stt 1n,ul1n punJl
~ ini11on. 223, 227b Procan SR. s~~ Proc.1inan1ide P'llre Food .1nd On1g .;\( t ul I '>Of,. K 10
l'PI .'itt Pro1on pump inhibiiors Produo, in proponions. 107 Purinethol. Srr 1\1t!t(.l(llopurinl
l'f'\. Stt f'ncumococt.11 polysaccharide l'roges1ascr1, Sl5t516t. 517 Purity of dr11~' 7
\'M'tine Progesterone, 51 1 511, 511 t512t Pustule. 391
Pr"11n S"' Rl>p.1glinlde ProgeMins, 511-5 11, 511t512t Pyrnntel, 4ll1435t, 4 lK 4 I<)
rrwipexok {~limpcx), 541, 5421 an1inooplastic 1ll{C1Hs, 315t 3 181 Pyrazinalllidc (l'/J\). J'>7, l'lttt
Prl.lllllntick> (Symlin), JS9t-361~ in cont.racepcion, 5115 14, 51515 16t Pyridiu1n. See l 1 hl.'n.a/,~1,vrid1111.
J64-J65 rrokinecic agents. 42614271, 428 Pyrido,tigmme ( ~11,11111111) 414 .115
l'caliqu>ntel (Biltricidc), 4J1t-435t. Prolcuki11. S..e lntcrlcuki112 4141
438-419 Prolixin. s,., Huphena1ine Pyridaxine, 32C1t l..' 1h
l'nolw1 (\linipcm), 480. 4811. 551, rrome1hazine (Phcnerg.1n), 430. Pyrithione 7-n< l'l \
mi 43014311, 522-523 l'yuria, 497
,.,.,..,..
f!oontlwlic mcdiauon" 531 Pronestyl. Sre PrOC'.ainamide
Propecia. Sre I rnttride
P'/A. S.-.. l')T'1linm1Jc

iDr pirmttnl drug adm111is1ratio1~ Proper fractions. 86 Q

219
fol\pttLll populations. 57-62
dulJr<n. 58 60, 601
older .idulL<. 6()..62, 61b
pttgnan<y and l.icrntion. 57-58,
S8b-60b
s.,.
Preroo<. Acarbosc
l'!tfilled syringe. 223
i't!pbalin (Lyrica), 2441
Pngnancynd lactation, 57-58,
58b-60b
lloohol US< during. 57
(l)Qjnr US< during. 57
mocmnd1Cations during. 57-58,
5Sb-60b
llMatqonn for. 57, 58b
llldiuoon US< dunng. 57-58.
>8b-60b
l"'Outions dunng. 57-58, 58b-60b
<1110kingduring. 57
"'1.IC)tlme during. 57
11cam1ns during. 325, 1251
l'ltmrin, S.t Conjug.11td estrogens
Prophylactic agem" 30t
antibiotics. 284
fo r asthma, 457458, 457t
for skin, 398-399
Proportional rncthod, 107
Proportions a nd r.nios See ltnios .1nd
propon i o n ~
Propoxyphcnc (Da1von), S84. 588
Propranolo l (Indcral ), 4 ~8. 4691.
472-474, 472b, 47'1, 475b. 480.
523. 543-544, 584
Propriei.uy drug. Set Brand-name drug.<
Prol')'lthiouracil, 151
rroQuad, 269
Prosur. Stt I masteride
l'rostaglandm nalogucs. 4261 4271,
427
Prostaglandrn inh1b11ors. 3751-376~
376
Prosta1e. 338b
Proslig1nint. St.c Noos1igrnine
Protectants, kin, 388, 399
Proteolytic enzynws. 1?8
QA. Stt Qu.l111y ''\lU.U\C4.'
Quality J'lnJn ((},\) I~? 1'10
Quality of dnig' 7
Questran. Sn (,holt\tyr.111111\l'
()uinethazone (I lyJro1nox), 477 l7'J,
477f, 4781
Quinolone<. 292-291, illl
Quo1im1, 100
R
Rabeprazolr (Acipl k). 12~ u;
4261 4271
Rabies .1ntisen11n 2(~c)h
Rabies vaccine 2'1412bhl 26 J
Radioactive iod1n4..*. l'il l5.lc
RadioLSOto~ .1nuntopl.uuc ll ,1
3181. 319
Raloxifene (hi<t.l), Hl~t 4116
R..lnexa Si'1" R.1nol,uint:
Ranitidinc (Z.1nt.1C) 4.? i 41~. l26l
427c, 521
Ranol37ine (R.rnex.1). IC~t 47tl
Ra~lid in.:,ulin n.~lc.1 .....:r' ~ i\tl'}tlltinul,ti

lt.ipid.xttng insulins. 357-358. 157t
359t36h
R.isha, 3381>
lt.itios and propomons. 107. lOll
1n COD\'Uting bei"een mr~rcmtru
S)'S<em!, 131
fii;unng petctf\1$ from 108-100
hepann dosagt calculation using.
178-179
nonparenteral dosagt ralculatlon
using. 149-150, lSOb
parenteral dosage calculations using.
174, 178
practical applications, 110-111
solving for x, 107108
RDls Stt Recommended Dietary
Inukes
R.ebetol Stt Ribavirin
Rd>ound rongesuon. 210, 448
Reboxetine (\'estra), S'IOl571t, 571
Receptor sites, for dru8'- 32. 32f
Reciprocal of fnaion. 94
Recombinant DNA technolOt!)', 2124,
24(, 24t
Recombinant paralhyroid hormone.
405t, 406
Rl'Combivax HB. See I lepa1ilis B
vaccine
R<commrnded Dietary lnrnkes (ltllls),
325
Reconstitution, 49
on medication label, 71. 71 f
of powders. 170 171
do.;ige calrulations for, 158 159,
IS8t 158t
for injection, 223, 227b
Record l<ttping. Stt Oocumem ...on
Rrttal analgesia;. 251 t
Rectal drug adminisuation, 197200,
2oor-201r. 2021>-203b
R<ftlli, of prescriptions. 7577, 76b
Rcglan. Stt Metodopramide
R<gular insul in ( 1lumulin It Novohn
R), 357358. 357~ 359t36h
Regul.tion. s.,., Drug regulation
Rcle1tta. See Zananlivir
Rclpax. Stt Ektriptan
Re1nicade. See ln!lix.in1ab
R(nova. 5" Tretinoin
Rcpaglinide (Pradin), 359t361~ 364
IU!plattment therapy, 347. 510 Stt 11/so
Honnones
for Ouids and elearoli1es. 495-496.
496t
Rq>ositooy aaions. 353
Rq>roduaiw ')'Stern, 503-525, S().lb.
5041
ana1omy of, SOS, 50Sf
contraception, SI 3-SI 9
endometriosis. S07t. 521, S22t
erectile dysfua ction, 52 1-522, 522t
Reproducti'"' S)'Sletn (Conrrnue.I)
fern.ale. 509.513, 511 t512t
esuogens. 509.511, Sllt-512t
progesterone. 511.511. 5111 512t
hormones and, SOS-506, 506f
inferuhty. 520
libido. 522523
male 506-509, 507tS091
Jnabolic steroids. 50750R, 5081
androgens. 506. 5071
t<Stosterone, 506-507, 5071
PMS Jnd dysmenorrhea, 519-520,
519b
J.oquip. See Ropinirole
Resistance, lO antibiotics, 284
Resoranol, 394-395, 3961-3971
Respiratory syncytial vinos (RSV), 459,
459t
immune globulins. 272. 273t
RA.'$1>iratory S}'>l<lll, -143-462. 444b,
444t
body functions and. 444445, 445f
coughs. 451453
infection. 338b
inOuenza virus and, 458459, 4 59t
lower, 453458, 4541
nJsal congestion, 446-45 1
oxygen 1herapy, 445-446
IIBV, 459. 459t
UPP"" 446
Respondent superior. 16- 17
Restasis. See Cydosporine
Restl<-.s ll'K> syndrome (Rl.S), 542t,
543
Re.tori I. Stt Temaupam
Reteplase (Ret.wase). 488
Reun-A. Stt Tretinoin
Retinol, 326t329t
Revia. Stt N.duexone
Rheumatoid arthritis, 406, 407(
Rheumatrex. Stt f\.1ethocrcx..'11e
RhoCMI. See Rho(D) immune hu11lon
globulin
Rho(O) immune huma n globulin
(RhoCAM), 23, 272. 272f
llibavirin ( Hebe1ol, Virazolc). 428,
429t, 459. 4591
Riboflavin, 3261-3291
IUckm, 324-325
Rifampin (Rimactane. Rifadin), 297,
298t
Rimant.ldine (Flumadine), 459, 4591
Ris<dronate (/lctonel), 405-406,
405t
Risperidone. 564t565t
Rnalin. Stt Methylphcnidate
Rizatriptan (Maxalt). 543, 544t
RLS. Stt Restless legs syndrome
Robaxin. Stt Methocarbamol
Rogc1ine. See Minoxidjl
Ro1nazicon. See Flu1uazenil
Ro1>inirole (Requip). 541, 542~ ; 0
Ro>(' hips. 337t338t
Rowdisk. 214
Rota req. Stt Ro1avirus V>cci..
R.otavirus vaccine (RouT"I). 26"1.2~
268
Round mg decimals, 96-97
Route> of administration Stt Drug
adrninistration
Rowas..1. See Mesalamine
ll1.V. Sec Respiratory syncy1ial vin15
llll -486. See Mifepristo ne
llubel la vaccines, 57, 2641-266~ 267
llubs. 388
s
S.1bi11 v-tirdne. Stt Oral polio\inis
vaccine
S..fe drug. 23
1>.lfet)'
drug standards for. 7-10
of herbal medicine. 336-340.
337t339~ 338b
in rncdication administration,
186-188
.111ied health professional
administration, 190-191, 191b
docun1enta1jon, l 92, 192(, 19lb
error sou rces. 193, l 93b
with oraJ rnedications. 200b
OSllA swndards. 188-189,
l88f- 189f
pdtient administration, 187188
187b
route of delivery and. 193-194
J + 7 for reducing medlGllioo
errors. 191-193. 192f 193b
with vaccines, 269, 271b
Salicylate analgesics. 246, 247t
S.tlicylate NSAIOs, 408, 408b,
409t410t
~Jlicy li c acid, 394-395, 396t3971
~Jliva replacemems, 421-422, 4231
!-.al k v.1cci ne. Ste I r13Clivat00 poliQl.iM
v,u.:cine
SJl metero l (Serevent), 454-456,
455t-456t
Salt;, 130
Samples. ethics and, 17 18, 171>
Sdnctura. See 'frospium
Sndimmune. Stt Cydosporine
l>ndost.ltin. &e Octr<otidt
~nitiutio~ 304
&rnwn Stt Me1h}'S<f&ide
SJw paimeuo. 337t-338t
SC onjeoions. Stt SubcutantoUS
injl"'Clions
Sc.1hicides, 396t397t, 399
Schedule drugs. See Comrolltd
s ubstances
Scho~ophreni". 560, 567-568

""powmnt. 200 430. 430t
021>. s.19550. 550!
''"'" }24 125
~ d <fl1UOllS. 394.395,
J'lf.C.1'71
...iium. l'll
'Ii"'"" 5n.537, 5131>. 5331, 5361
slC't'P disordm and. 534 1535~
535.5}6
....,.,,... 529
s.fccui'!' norepinephrine reup1ake
inhibitor> (SNRls), 5701-5711, 573
'icl<ctw< Sl'rolonln rcupiake Inhibitors
(SSRls). 5701-5711, 571 572. 573b
\<lcphn< (Udepl')'I. Conex), 541, 5421
l<ltmum wind<. J95
<dlnxda<UOO. 187 188, i87b
o;.m..,11th<tJ<>, anubiolics. 282
"""""" drug. 283
1mwuution. drug. 284b
l<lu w o..aup.m
ltm>UI Stt \ttj()ndaztr><
"""""' Stt ~hn<tcrol
1<roion1n ani.igonis!J. 430, 430r-431t
5tru<1]in< (/.olof1), 520. 561
Stnim kknm. 260
Seven rights. for reducing medicaiion
(rrors. 191 193, inf. 193b
Shpt of microorganisms. 282
Sht lrllfe 49
~hmgln voccin<. 26412661, 269
q,1ppi~ Stt Dtlivery
q,irley Amtndmtni of 1912, 8
q,,,n..icung 1nwlins. 357358, 3571,
lS913611
Sboru c11ng sulfonam1~ 497,
4,,,t-4991
SI "'"m Stt M<lric i)~lem
~ ~ 33 713381
Sidt dlttts. 3, 2223. 2829
ohnunroplas1ic agon1~ 313314,
313b
'"eye 3721
ol nroroltpli<!. 564567, 564!565t,
566b-S67b. SG6f
ofvu1mins. 1nlnerals and herbs,
1 20Jb
324
Sig. Stt Signaturt
Sign> Sa Signamre
Signal uansduction inhibilon;.
)J'l.J20
S...wrt (S111o Sign). 74-75, 74(
Sildmofil (V~). 521 522. 5221
lolndmt. Stt Stt-.'l'I' sulfadiuint
s.hu nnn1e !05. 3061
Sihu prqi.ralions. 305, 3061
s.1.., sulfadiuJn< (Sil\'aden). 296~
305. 306~ }97. 3981
SIJll<tbacone 432, 41314351
~imphfying fractions, 87
~1mv"l1in (ZOcor), 484-486, 4851
Singulair. Stt Mon1eluk.ui
Skin. 386-387, 386b-387b, 386 ~ 387(
Stt also Drona1o logoc prep.1ra1to ns
lesions of. 388, 389f
Sleep di>0rden;, 5l4t535 ~ 535-536
Smallpox vacones. 256-257
Smoking
cessa1ion products. 584 586, 5 84b,
585t
during pregnoncy, 57
SMZ. See Sulfamc1hox.1zole
SNIUs. Sec SeletLiw norcpincphrinc
reuptake inhibhors
Soaks, application of, 206
Soaps. 388
Sodium (Na' ), 32613291, 496, 496t
Sodium bicarbonate, 4 22-4 24 , 4 251
Sodium bypochlorite (bleach), 305,
3061
Solarcaine. Stt Lidocaine
Solid oral prepratio ns. 44, 44b, 4 51,
I 97, I 98b. 200h
Solubility, 2526
Solu1es. 495
Soltuions. 44, 461
Solvent, 495
Soma. See Carisoprodol
Son1alot.ropin. See Crowlh honnonc
Son1inex. See Diphenhydra1nin<'
SoLret See lsotrrlinoin
Spastici1y, 545. 5451
muscle. 41341 5, 4 141
Special populations. 5762
children. 58 60, 60t
compliance in, 6263
ruhurI difTerontes ir~ 6365, 64f.
64!
drug dosing for. 54.57, SSf
older adul!J. 60-62. 6 1b
prqpian1 or laet 1ing pa1ien1s. 57-58.
58b-60b
SJXrmicidts. 517, 5171
Spironolaetone (Aldanone), 4 77f,
4781, 479, 520. 522
Spoon. oral drug .ldniinistra1ion \'lith,
Sprays. appficaiion of, 208
SSRJs.. See Selective s.cro1onin reuptake
inhibitors
St John'5 won, 33713381, 338b
Stage. of 1umon;, 311 31 2
Staining agents. fo r C}Y. 37813791,
379-380
Standard proioco l, 73.74
Standardw1ion o f drugs. 7
patient .. reiy and, 7 10
Standing orders. 7374
Siarlix. See Na1eglinide
Staie drug regola1 ion, 8
Sta tins. 484 486, 4851
Stelara. See llstckinun1.1b
S1eror<h Stt An.1hol oc llnoido.
Con1c0\.lnoJ,
S~mul~t '"""'"" Hl1 41~1 436
Sumul~is. 2 81 , l'Jb
c ... s. 545-54(> '>47l ~8') '>'JO
590!
Su>ck mcditdtlon' IJhithJlR of 69t 711
70b
Stom ati1i&, ll \
't
Stool softener\, 4 l 1 l'il l ~i'
Storage, of ophth.1h111t .lnd ouc
rntd kdtion~. lt( l
Strauera Ste A1on1oxt1int
Sirengtb o l drul!, 7
on med 1r.111011 IJb..J. h')f i"Ot .0
Streptokin.t~l (\thpt.i,..:) 188
Streptom)Tin . .ZHI 2')7 :'>St
Stre..s. Hhb
Stroke. 554
Subruian..uu, (\!) lntr<lton.. 171
171(.1721 11811'1
admin1~trJllon of 2\0l 2111 Jl01
lll. 21lh )ll11
Sublingu.il mtd1l.U1on' io... l1l6
2()<) 210. 2101
Sublingua) n 1trogl)tt:n11 ("-11r11'1 U)
467~4(,tl, 4b7t, H1'll
SubM'ripl ion, 747'1. :'41
Subst<tnc..l' Jbust .'It'( I >111K .1ht1 .. l .uul
dt:pendt"n<t'
S:uhtrattion
or decin1.ll~. 1>H ?'>
of fr.1c-1ion'. '>I '>~
Succininlic.h.~ l lR 5 $< 'i 1s1 5 91
Sucraflatc (W,.flh) ~24 4l<>t .i2 1
Sud.afeJ ~ l)\ol'UJCH pht-dnne
Sulfacetam1<k (\ulJonvJ) 1% 2'16!
Sulfadi.vrn. ( \hoosulfon) 4?
4?8H9'lr
Sulf..unct.hox..uolc (\\t/ c..in1..i11t>I}
296, 497 4'lXl .a>>t ~. itlf.<I
1nn1e1hopnn1 'ull.unt thc1x I/Oh.
Sulfan1ylon .\1,~ \t,, ltnld~
Sulranila1nid1.., i)h
Sulfas.ilaz.it1~ (A1ulluli1u), 2')ht.
4331435 !, ~ \ij
Sulfinpyra1o ne (i\n1u1.11w). 11 l
41) 1
Sulfi.5-oxJ.L.oh; (C.uur1 .. ul). 1'L
Sulfo na mid~ l9~-2J)h
in comb1n.iuon,. ;iJ ' 1'>6
topical prepJrJtHJJ\\ of 2?l1
for un . 497 4981 4)91
SulfonylurcJ' l~'ll 1611 l&lb
3631
Sulfur, 394.19-; 1%1 3'>.,
Sum;uriptJn (lmi1h \), ;.f\ c;.i.i1
Sum1nalion, 14 t
super sho~ . 164t ir'<'' ~" J
Superinfecuon, JR.i
Superscription. 7-1.7<;, 711

C\uppltmrnti \tt Sulnllon.al
"'f'rl<"menu
'"l'l""'tonn. 48t. SO. SOI. 197-200.
2001 202b
'>ulJI d w Orid11<d <dlul(JO('
~Uipt"l\ll()l\\o, -1.t, -'6t 4ib
S1mhol rum-nt '"'""'for. 111
~)i-nlan W PrJmllnudc
\)Tllmt1rd \N AmntMl1ne
\\'lllp.lth<'IK nm""' <J)~tnn S41b
546 H~ >t6f '~Sf
\1mp.ithol)1IC ~"n" w t\drcne11t><
1nh1l>itmg :ig.-nt>
!.)-mp.11hom1mnoc g,;nt< SW-SSI,
SSll>. H2t
ophthalmt<, l7'>1 176t. 176
~)'OJSI' \ r,ill\'l./Unab
\ynarel W N,1fJ1<hn
'yn<rgism. l2. HI. l-lt
~yn1he11c drug>. 2l, 241
.lntob1otlcs. 282
op1olds. ns
~ymheu< ht111Mn ,unylin, 3591 1611,
164 365
Syringes
insulin. 171, 17tf 1721, 174, 1741,
116, 1n. 220 221. 22or
or;\I drug .1dnlinblration wilh. 201 b
prcfillcd, 223
rcadongol. 171172,17 1r112f, 174t
.,1fr1y with, 188 189, 1881 1891
;cle<11011 ot 220-221, 220f-221f,
222h, 2l(1l
tubcrruhn, 174, 1741, 176, 220-221.
2201
S)"trrmc drug action, 28
T Iluenobenzodiazepine, S64t>6St
I cells, 257-258
T 'w lrioodoohyronm
1, SH lhj-TOxme
Tbleu. 44, 45~ 198b. 200b
TJdbfil (Ciah5), S21S22. S22t
T"l!'lrnel w C11ne11d1ne
T.ilwtn W Pen1v:oc1nt
T.in1iHu W 0Sth.11n1vtr
TJmpon>. SO
TJm<ulosm (MomJx). 508. W9t
Trd1w d)~~me<i.i, S64, 566f
T.ub't!I org;rns. ofhormon<-.. llS-146
TCAs Stt TriC)~hr an11d~prcss.mt
Td vaccine Mt>'l1..1Jnu,+c.hphtheria
vacc1nt'
ldaP vaccine. Sn I CtJnu~. d1phthcriJ,
and ar.ellul.u l)('rlU~si~ v.tcr1nt?
lea t...., oil, J37t3381. JJ8b
l'cgrctol. Str CMbamaM:pinc
Tclithromydn (Ketck), 294 1, 29S
Tcm0/c1iaon (~1oril), 533, S34t-S35t
1C1n1>i.:rJ1urr conversion~. 129 130.
129t
Tenex. Sll Cuanfacine
Tcnonn1n Set' A1enolol
Ten<ion headaches. S44 t, 54 5
Tcnw1e. Stt Dieihylpropion
lcwogen. 5758. 320
T"'uosm (llytrin). 508. SO?L 55!,
553t
lcn~ode (foneo). 352, J52t. 4051,
406
TCSPlon Stt &-nzonatate
r._...oderm. 506. so;1
Tntosteronc. S06--.507. SOIL
patches. 209
letnw. diphtheria. and acellular
pmtwis (l<LIP) \'accine. 263.
264t266t
Tei>nus immune globulin, 260b
Tei.mus 1oxoid (IT), 261. 264t266t,
267
lc1anus \'aCCincs. 263, 264t266t
lcrnnus diphtheria (Td) vaccine, 263,
26412661
1Ccr<tc.1ine (Poncocaine), 395,
3961-3971
Tetracycline. 290. 29 1t
for peptic ulcers. 426t427t, 427
<luring pregnancy, 57
'Ilia Iidomide. 9b- 10b, 58
ll>eophylline, 200, 455t456t, 456, 584
'l1>er.1peutic drug. 301
'11ierapeutics, 22b
'Il>iabendazole (Min1ezol). 433H15t,
438439
lnimine, 326t329t
Thiazide diuretics. 477--479, 477f,
478t
lniazolidinediones. 3591-361 t, 364
lbiothixene (Navane), 564lS6St.
567b
lbiounthene. 56~t-565L 567b
lhoraz.1ne. &~ Chlorprom.uine
lhrce befores. for reducing medic.a1ion
enors. 191
3 + 7. for reducing medi<a1ion errors,
191-193, 192( 193b
lnrombin (11-.rombinar, Thrombostat),
488--489
lluomboembolism, 486, 487f
lbrombol)1ic medic.iions. 488
lbrombosut Stt Thrombin
lh>Toid gland honnones. 345t,
350.351, 350f. 3521
anti1hyroid rnedications. 351-352.
3521
lhyroid-s1i mulating hormone (TSI I,
1hymtropin), 348, 349~ 350-351,
350f
lhyroxinc (T,). 350-351. 352t
riagahinc (Cabitril), 5381539t. 540
ridopidine (Tidid), 488. 488t
ng;in. Ser I rinw1hob<?num1dt
ngC}-clinc ( fygocil). 294~ 295
lime conversions. 127 129, 128b. l!SI
11nadin. Sn 1olnaftatt
1 mflurc of iodine. 304, l06t
Tinnitus. 381
r.,.midine (7.. nafttx), 413, 414t
I \IP S\l/_ 5"'
1rimcthoprim sulr.~
TNI inhibitors "n Tumor nea"'
(a(tor inhibilors
rocainidc {lonocard). 472. 47lt
Tofranil S.-t lm1pr>mine
TolerJnce. 32. 34t, 530. 561
rolnaftat (linoctin). 390tJ92~ m
loltcrodinc {l>eirol LA), 4981-4?9!.
soo
Tonocard See Tocainidt
Tonometry, 177-378
top~un01x Set lopira1nat'
lopical medications, 47, 205208
acne prcpamion>. 393-394, J9ll
anesthesia, 395, 396tJ97t
,1nt ifu ngal drugs, 299
01111 iinfcrtivc :uuJ antiinOanunatory
1opicals. 388395, 1891,
39011?21
.tp1>lication of. 206208, 207h-208b
cr('(tlllS, o intrncnts. gel~ ct11d
lotions, 206-207
pacch~, disks, and 1ransdcrm1I
do1<. 207, 209b, 2091
1>owders, 206
soaks. ron1prrssn. and \\'l"t
dre<sin~ 206
I"'">" and aerosols. 208
(or burn~ ,lnd chronic- wou1ld,
397 398, 398t
hemostllcs. 488 189
kcrn1oly11c agents. 394.395
196tl97t
mouth, 421
in older duhs. 208
Topiramate ( lopamu), 53~1 539~ ~
Toprol St.. !-..-. Mctoprolol
Tourette's syndrome S67b
loviJ> ~ I eso1erod1ne
loxicology, 2l, 10-11
10,oid'- 161
adverw reaf!ions to. 262-261. 2lb
1eldnU\, 261, 261l266~ 267
Ir.ldc oa1ne. Sei' Rr.tnd ~ namt drugs
rradcmarkcd drugs ~t Brand nam<
dnig
TramMIOI ( llltr.un). 244t
Ir.lnt.1uili1n.1ion, 560
rr,lnquili1crs. i.,rt Anxiolytics,
Ncurolc1)tics
1'ransdrnn Ni1ro. ~,rr.u1~de:rmal
nitroglycerin
'l'1.11tsderm.1I doh. 207, 209b.109f

~ ...,i;oiiont. 4i 47( 48~
_ : . :~ ~ mr
~SIS! ~16c. 516-517
191 :09
~tnn pransderm
b!ll"""'i~ 4bB. 467~ 4691
,;;ao 6lm Jn~'"~ 398, 3981
i-: rtnio.ifvlhnt
..,.,.,in (l!tlln .._ RtllO\'a). 393,
J!ll K on
'loot (An~ocon. enac ,
\:JllXl'rl l>.llJCOll). 3S41,
~,..w. IOI
"""'""'"""''t1onidt. 164
~nts (ICM). 569,
sm
"""''1!1!"'111"< cr.i 1~351, 3521
5# <Jiarlwtl"M
~flill"'I OOt-431~
m antispasmodics. 4981499t, 500
;ordlo!M..ulfamttho'11.0k
(IMl'\lll). 295296. 296~ 497,
4$4~'11
!!xMU
tftip< tiormona 347
111 ISincturJ), 49814??1.
wJ111roidsilmulatlng
fo,.irmc~nt
Sor T.unus toxoid
~1\llngt. 174, 1741, 176,
221).221. l10f
t.'n::lbis
u=- loc 297. 2981
...... roc 1 2~ 268
1-S. ~
.,_,, "'""' r.ctor [NF) inhibitors.
trl!l-410l. 411
f)p:ll w r~ine
J)bil v o1<mm1nophn1
,.,.., mcmbran~ 380
111< I dubr1cs melli1us. Sre Diabetes
mdl11us
Ti]l< l d1"1t1es mellitus. Sre l) iabc1cs
ritlhws
u I lib, 2641-2661. 267
l.lbraoo. 400
llkm I l'>ptic ulars
Ubic i<o Fdlwosut
l b Ill' Tomudol
Olob:.nd dnig. 27
Set Oox)imuv
... "'"""""'!\ 122123
lllkl"nn. Ill, 176, 178 179
1111'111hn.123, 174, 1 74~ 176,
17~
of "''""1<mtn~ 147
"""11doi.il!" c.lcula1ion using.
170. 176, 178.179
United States PhMmacopoeia (USP). 7
official drug list of. 40
Pictogram Library, S4
Upper respiratory i)"tem
inrection, 338b
arc products for. 450. 45-0l
combination. 450451
zinc-based, 4491, 451
Upper respir.11ory tract, 446
Uredioline. Srr lkthanechol
Urgency, 497
Urinary freq uency, 497
Urinary syi;tem, 494, 494f 495f. 4951
Urinary system disorders. 494b, 4941
enuresis, 498t-499t. 50050I
Ouid and electrolyte balance and,
495-496, 4961
OAIJ. 498t-499t, 500
Urinry traet. 338b
analgesics, 498t 499~ 500
antiseptics. 498t-499t. 500
Urinary 1rac1 infections (lnls),
497-500, 497b, 498t499t
Urine
color aheratio ns of, 4 95t
500 drug de1ection in, 5831
Urispas. &e Flavox,uc
Urofoll itropin (Me1rodin), 520
Urokinase {AbbokinJse), <188
Ursodiol (Adig.111), 429, 4 291
Usage. 29
USP. See United SlJI<> Pharmacopoeia
Unekinumab (StelarJ), 395, 3961-1971
lnls. Stt Urinary trJCI 111ft'(;lion>
U'ei1is, 372-174
v Verapamil {C..lan), 468, HI, 41111,
Vaccinations. 260 2<1
ad'ITSe readions to, 262-261,
263b
chickenpox, 262. 264 t 266t
developmen1 of v,1tci11e<, 256257
diphtheria, 261, 264 t2661
hepatitis A, 2M t266t, 267
hepatiti> B, 264t 2661, 267
inactivated. 261
inftuen7.<l, 264t-266t, 268
Ii\'\! or live auenu.i1.I, 26 1
measles. 57, 264t 266t, 267
meningitis. 264 266~ l68
mumps, 57, 261t266t. 267
National Childhood V.lCdnc Injury
Ad or 1986, 2<>1
pen us.is. 263, 264 t 2661
pneumonia, 26412661, 268
poliomrclitis, 256-257, 2641-2661.
267
rabies, 264t-2661, 269
rotavirus, 2641 266t, 268
Index 64 1
Vaccinations (Cmuinu&I}
rubella. 57, 2641-2661, 267
safery with, 269, 271 b
shingles, 264t-266t. 269
smallpox, 256-257
super shois, 264t2661, 269
tetanus, 263, 264t266t
tube rculosis, 264 t-2661, 268
Vaccine Adverse Event Rc1>0rting
Sysiem (VAERS), 262
Vaccine In formation Statcme1m (VISs),
263
VAf.RS. See Vaccine Adverse Eve111
Reporting S)'lllem
Vaginal medication>, 212
Valerian, 337t338t. 338b, SJ<>-537
Valium. Stt DiazepJm
Valproate {Depako1e). 538t-5l9t,
540
Valproic acid (Ocpakenc), 200.
5381-5391. 540, 543.544
Vancomycin. 294t, 295
Vardenafil {l..evitra), 5]1 522, 5221
Varenicline {Chamix). 5841>
Varicella vaccine (VJriv..,.), 262,
264t-266t
Vasocongcstio11, 376 177
Vasodilan. Sie lsoX>uprlnr
Vasodila1ors, 480-482, 4821
Vasopressin (Pitresin), 14? 3'10,
3491
Vastus lateralis site for 1\1 1n1Mion.
234, 23M
Vehicle. for mro1ca11on' 75, l87
Venlafaxine (EfTc.xor). 560 >61
\'entroglute.al \ite. for l\1 1njt."Cl1on.
234, 23-lf
544-545
Verbal order (V/ O), 71
Vennox. Ser Mebcnduok
Vertigo, 370L 380 381, 1811
Veslt3. See Rcboxct i1w
Viagra. SrP Sildcn.1til
Vial, 49, 49f. 220, 22l. 221f. 215b
Victou. See Li r~lglut iclr
Vioxx, 12b
Virazole. See RibJv1 ri11
Virus. 282
Viscous drugs, 50
Viscous injections. 50. l l l
VISs. Stt VJccine lnlonnauon
Stau.~_1nenb
Vistaril. S.-e ll1drol<)'Lim
Vitamins. 324-330. 1241
classification of1 12:;, l2St
in elderly, 310
fa1-solublr, 3H, 32(>t ll9t
fu nction of. 124
intake or. 124 32'>
life;tyle rhoires Jnd. 110, HO
 642 Index

/.iCc"lnl Srr l.1nc g luCOOd1t

V11mm\ (C,,.ntm-1)
P'1CIUl1<} nJ. 125 1251
.,dt <flu of. 124
Unll Of 123
Wl<r<t<>luhlt, 325 )JO. J251 3291
\ umm "- 125. 3251 1291
\ iumm 8 HS. J26t JJO<
\iumm C. 125. 3261 HOt
\nmm I>, l25, 3251 1291
\ 1umm I , J15. 1251 J29I
\"iumm I(. l2S. 12.S1. J29t 48?
\", 0 'W \'<rbI ordtt
\Olum~
con .. l'"rs1on bt.1-wttn mt"'..1\Urtment
<>~ems. 112 134. lllt ll4f
of m<'d1011on. 10
in mtln( S)"m. 118, 1121
Vom111ng
from chrmo1hrr.1py, 430b
from molion "' ~'"""' 4J2b
V)'Van~e. ~ I J.Klcxa rnfel.lrn ine
w Z-irMk 1crhnlq ur. 230L lll. lJ.I(
WMfari n >Odium (CoumJdi n), J2, 63.
486487, 4871
W.ll<r St. I luid b.1i.111cc
W,Hcr ba~ed parenteral rnrdica1ions.
49 so.222
W.u er SOiubie viLarnin~ 325 3l0,
1251-3291
Weigh I
conversion betv.een measurernent
systems. 135-139. 1351. 136'
dosage calculations based on. 55
m metric system. 119 I 20, 135 ll'>.
1351. 136f
We1gb1 of drug. See Suengt h of drug
Wes1em medicine 336
Wet dressings. 206
Wheal, 230b, 231. 231 f
Wlutening agents. 4 21 , 4231
Wuhdrawaf. 583
from opioids and opia1e<. 5851,
588-589
Wounds, 397-398, 3981
x Zontig S,'tt /.ol mllripr.1n
XandX. 5tt Alprazolam
X.lllthine derivatives. 4 55t 456t, 456
Xan1hine oxid ase inhibito r, 4J 2.
4 131
Xylo<Jinc. Sre Lidoca in e
z 2161
/.afirlukast (Accofa te ), 4 571, 4 58
Zana flex. See ~Jizani dine
Z.anamivir (Re lenza), 4 59, 4 5!.>I
La ntaC'. .~e Ranilidine
Zaro ncin . Sre E1hosu.xirnicle
i'..aroxolyn. See Melolazonc
/ ilcu1on (/.yflo). 4571. 458
/inc (/n ), 32(1 3291
Zinc g luconalt g)yont (/-"Jlll
)'inc oxide. 207
)'jnc-IM\t..J dl'COllg<'<Urtl~ 40t
Zipr.t\ldOllC (Cl'Odon) S6C 56
51>6 - ~67
/.i thrOtn3JC Stt A>nhroltl)'Oll
Ln St /inc
Z()('Or. ..Vt' "iimvasl.lUn
/.of r.i 11 !irt' Ondansetron
/.OIJdcx Srr C05<'.rclon
Zohnnrip1an (/.om1g) 54 ), Si
l.ofof1 S<r Scnral1nt
/.olpidem (Ambitn), .IJ41 SJ5c.
Zo111<,1midc (7.onegran). 5l8H
540
/.osier vaccine (Zostav.lll). 26'1
26?
zovirax. ~.,. Acyclovir
/.yb .111. Sre Uupropion
ZyOo. S1r l ilcuwn
Zyfo p rim . '"' Aflopurinol
Zypr('Xi"l. St1 O lanzapint
Zyn cc. Sr C:t-1irizi11e
/.yvox. S11 Unezofld

DATE DUE

- ~ 1
'
I'-

RM 300 . F79 201 2

Ph armacology : prlociplu a
applica t ions
DE.MCO 3'2i8

Fulc he r , Eugenia H.

oint ointment
O.S. OS left eye
!'Ml OTC over -the-counter
itvee OU.OU both eyes
Ive oz. ! oonce
ien
ji alter
II
pc. pc alter meals
of eadl by. with
pe!
befld meats afternoon
pm
IS~ po by mouth
pm. PRN as needed
ll1IJ1q pnt
pt
~wale! patient
tN(l! aday Pl
putv powder
licdv~.- a1ea every
wtn q
qam every morning
capsule($)
qd every day
ab( centimeter
qh every hour
day
q2h every 2 hours
diS1XJnt11>ue
q4h every 4 hours
dilute
q6h every 6 hours
dram
q12h every 12 hours
doctoi
dextrose 1n water qid four times a day
qns quantity not sufficient
diagnosis
eye, ear. nose, and th1oat qod every other day
ehx1r qs quantity sufficient
emulsion rep repeat
~tract &. Rx prescription
"uid s without
gauge SC. SO. sc. subq subcutaneous
gallon Sig directions. wnte on label
gram sol solution
gra n ss one-half
c;~sl stat. STAT immediately, at once
hou< subhng, SL subhngual. under tongue
1t bed1Mne/t.iui of sleep supp suppository
111trniscular stN saline in water
lllflCll()l1 syr syyup
lnlematl()flal lb! tab tablet
Mf1CU$ Tbsp. tbsp. T tablespoon
jX)laSSllln tid dvee times a day
logam t.,.;, tr bncture
~ TO telephcoe order
~ top topically
1111!lim up, t teaspoon
microgram u unit
m hequ1valent ung ointment
mlligram VO verbal order
m lhter wt, Wt weight
mill meter x times
~ sodium > greater than
night < less than
do not 1epea1 = equal to
nothing by mouth r increase
no1mal saline J, decrease
right eye