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This antibody is used with other antineoplastic drugs growth in hormone-dependent tissues dilantin 100 mg cheap treatment plan for anxiety. The goal of therapy is to improve response in women with metastatic breast can- control of tumor growth and palliation of symptoms rather cer cheap dilantin 100mg on line medicine 48 12. Adrenal corticosteroids suppress formation clude alemtuzumab (Campath IH), ibritumomab tiuxetan and function of lymphocytes and therefore are most useful in (Zevalin), gemtuzumab (Mylotarg), and rituximab (Rituxan). They are also used Alemtuzumab binds to molecules on T and B cells in lympho- for complications of cancer (eg, brain metastases, hypercal- cytic leukemia. Major adverse effects include allergic reac- cemia) and with radiation therapy to reduce radiation-related tions, leukopenia, and pancytopenia. Because of the high risk edema in the mediastinum, brain, and spinal cord. Dexa- of infection, patients are treated prophylactically with anti- methasone is commonly used in neurologic disorders. Gemtuzumab, an antibody conjugated with an (eg, anastrozole) that inhibit estrogen synthesis, antiestrogens antitumor antibiotic, is used to treat acute myeloid leukemia. Assess emotional status, coping mechanisms, family relationships, and financial resources. Anxiety and depres- INDIVIDUAL DRUGS sion are common features during cancer diagnosis and treatment. Cytotoxic antineoplastic drugs are listed in Drugs at a Glance: Assess laboratory test results before chemotherapy to es- Cytotoxic Antineoplastic Drugs; hormones and hormone in- tablish baseline data and during chemotherapy to monitor hibitors are listed in Drugs at a Glance: Antineoplastic Hor- drug effects: mones and Hormone Inhibitors. Alpha-fetoprotein is a fetal antigen nor- mally present during intrauterine and early postnatal life CYTOPROTECTANT DRUGS but absent in adulthood. Carcinoembryonic antigen Cytoprotectants reduce the adverse effects of cytotoxic drugs, (CEA) is secreted by several types of malignant cells (eg, which may be severe, debilitating, and life threatening CEA is present in approximately 75% of people with (Box 64–2). A rising level may indicate tumor pro- dosage or frequency of administration, thereby limiting the gression and levels that are elevated before surgery and effectiveness of chemotherapy. Several cytoprotectants are disappear after surgery indicate adequate tumor excision. Other tumor markers are immunoglobulins uling must be precise in relation to administration of the (elevated levels may indicate multiple myeloma) and cytotoxic agent. A cytoprotective agent does not prevent or prostate-specific antigen (elevated levels may indicate treat all adverse effects of a particular cytotoxic agent and it prostatic cancer). A CBC and white blood cell differential are done before Erythropoietin, filgrastim, oprelvekin, and sargramostim each cycle of chemotherapy to determine dosage and fre- are colony-stimulating factors (see Chap. Erythropoietin stim- function so fatal bone marrow depression does not occur, ulates production of red blood cells and is used for anemia; and to assist the nurse in planning care. For example, the oprelvekin stimulates production of platelets and is used to client is very susceptible to infection when the leukocyte prevent thrombocytopenia; filgrastim and sargramostim stim- count is low, and bleeding is likely when the platelet ulate production of white blood cells and are used to reduce count is low. Mesna is used with ifosfamide, tion, serum calcium, uric acid, and others, depending on which produces a metabolite that causes hemorrhagic cysti- the organs affected by the cancer or its treatment. Mesna combines with and inactivates the metabolite and thereby decreases cystitis. Dosages and routes of adminis- Nursing Diagnoses tration for these medications are listed in Drugs at a Glance: • Pain, nausea and vomiting, weakness, and activity intol- Cytoprotective Agents. Useful information includes the nausea, vomiting, and diarrhea type, grade, and stage of the tumor as well as the signs and • Risk for Injury: Infection related to drug-induced neu- symptoms of cancer. General manifestations include ane- tropenia; bleeding related to drug-induced thrombo- 920 SECTION 11 DRUGS USED IN SPECIAL CONDITIONS cytopenia; stomatitis related to damage of GI mucosal • Physiologic care includes pain management, comfort cells measures, and assistance with nutrition, hygiene, ambu- • Deficient Knowledge about cancer chemotherapy and lation, and other activities of daily living as needed. Most cancer treatment involves surgery, radiation, and chemo- • Promote weight control. Optimal regimens maximize effectiveness (eg, attempt development of several cancers, including breast and en- to eradicate tumor cells at primary, regional, and systemic dometrial cancer in women. Surgery is used to excise small, localized tumors, which • Strengthen host defenses by promoting a healthful may be curative; to remove tumors that have been reduced in lifestyle (eg, good nutrition, adequate rest and exercise, size by radiation therapy, chemotherapy, or both; and to treat stress management techniques, avoiding or minimizing complications of cancer, such as bowel obstruction. Passive smoking increases risk of lung cancer in spouses Radiation therapy is used to treat most types of cancer. It may be used with • Minimize exposure to sunlight, use sunscreens liber- surgery to reduce the need for radical surgery (eg, in breast ally, and wear protective clothing to prevent skin cancer. With soft tissue sarcomas of the symptomatic people, especially those at high risk, to detect limbs, wide excision plus radiation therapy can be used in- cancer before signs and symptoms occur. Radiation is also used to eliminate local clude regular examination of breasts, testicles, and skin and or regional malignant cells (eg, positive lymph nodes) that re- tests for colon cancer such as hemoccult tests on stool and main after surgery; with chemotherapy to cure or control sigmoidoscopy.

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The The mechanisms by which HDL cholesterol exerts protective number of LDL receptors on cell membranes determines the amount effects are unknown proven 100 mg dilantin treatment irritable bowel syndrome. Possible mechanisms include clearing choles- of LDL degradation (ie buy cheap dilantin 100 mg line 72210 treatment, the more receptors on cells, the more LDL terol from atheromatous plaque; increasing excretion of cholesterol is broken down). Conditions that decrease the number or function so less is available for reuse in the formation of LDL cholesterol; of receptors (eg, high dietary intake of cholesterol, saturated fat, or and inhibiting cellular uptake of LDL cholesterol. Nonreceptor uptake occurs in various cells, es- tors, smoking, and some medications (eg, steroids and beta block- pecially when levels of circulating LDL cholesterol are high. HDL cholesterol levels are example, macrophage cells in arterial walls can attach LDL, not directly affected by diet. CHAPTER 58 DRUGS FOR DYSLIPIDEMIA 853 Total serum cholesterol (mg/dL) excessive caloric intake (excessive dietary fats are stored Normal or desirable = less than 200 in adipose tissue; excessive proteins and carbohydrates Borderline high = 200 to 239 are converted to triglycerides and also stored in adipose tis- High = 240 or above sue) and obesity. High caloric intake also increases the LDL cholesterol (mg/dL) conversion of VLDL to LDL cholesterol, and high dietary Optimal = less than 100 intake of triglycerides and saturated fat decreases the ac- Near or above optimal = 100–129 tivity of LDL receptors and increases synthesis of choles- Borderline high = 130 to 159 terol. Very high triglyceride levels are associated with High = 160 to 189 acute pancreatitis. Very high = 190 or above Dyslipidemia may be primary (ie, genetic or familial) or HDL cholesterol (mg/dL) secondary to dietary habits, other diseases (eg, diabetes mel- High = more than 60 litus, alcoholism, hypothyroidism, obesity, obstructive liver Low = less than 40 disease), and medications (eg, beta blockers, cyclosporine, Triglycerides (mg/dL) oral estrogens, glucocorticoids, sertraline, thiazide diuretics, Normal or desirable = less than 150 anti–human immunodeficiency virus protease inhibitors). Borderline high = 150 to 199 Types of dyslipidemias (also called hyperlipoproteinemias High = 200 to 499 because increased blood levels of lipoproteins accompany Very high = 500 or above increased blood lipid levels) are described in Box 58–2. Overall, the most effective blood lipid profile for preven- Although hypercholesterolemia is usually emphasized, tion or management of atherosclerosis and its sequelae is high hypertriglyceridemia is also associated with most types of HDL cholesterol, low LDL cholesterol, and low total choles- hyperlipoproteinemia. The National Cholesterol Education Program recommends management of clients according to their blood levels of total DYSLIPIDEMIA and LDL cholesterol and their risk factors for cardiovascular disease (Table 58–1). Note that both dietary and drug therapy Dyslipidemia (also called hyperlipidemia) is associated are recommended at lower serum cholesterol levels in clients with atherosclerosis and its many pathophysiologic effects who already have cardiovascular disease or diabetes mellitus. Ischemic heart disease has a Guidelines include the following: high rate of morbidity and mortality. Elevated total choles- • Assess for, and treat, if present, conditions known to terol and LDL cholesterol and reduced HDL cholesterol are increase blood lipids (eg, diabetes mellitus, hypo- the abnormalities that are major risk factors for coronary thyroidism). Elevated triglycerides also play a role in car- • Stop medications known to increase blood lipids, if diovascular disease. BOX 58–2 TYPES OF DYSLIPIDEMIAS Type I is characterized by elevated or normal serum cholesterol, usually occurs in middle-aged adults (40 to 60 years) and is elevated triglycerides, and chylomicronemia. This rare condition associated with accelerated coronary and peripheral vascular may occur in infancy and childhood. Type IIa (familial hypercholesterolemia) is characterized by a Type IV is characterized by normal or elevated cholesterol lev- high level of low-density lipoprotein (LDL) cholesterol, a normal els, elevated triglycerides, and increased levels of VLDL. This level of very–low-density lipoprotein (VLDL), and a normal or type usually occurs in adults and may be the most common form slightly increased level of triglycerides. Type IV is often secondary to obesity, is a definite risk factor for development of atherosclerosis and excessive intake of alcohol, or other diseases. Type IIb (combined familial hyperlipoproteinemia) is charac- Type V is characterized by elevated cholesterol and triglyc- terized by increased levels of LDL, VLDL, cholesterol, and eride levels with an increased level of VLDL and chylomicrone- triglycerides and lipid deposits (xanthomas) in the feet, knees, and mia. Instead, it is associated Type III is characterized by elevations of cholesterol and with fat and carbohydrate intolerance, abdominal pain, and pan- triglycerides plus abnormal levels of LDL and VLDL. This type creatitis, which are relieved by lowering triglyceride levels. It is essential that diet therapy continue as the 30% of calories from fat, less than 10% of calories from benefits of diet and drug therapy are additive. A Step II diet contains no more than 30% of calories from fat, less than 7% of calo- DRUG THERAPY OF DYSLIPIDEMIA ries from saturated fat, and less than 200 mg of choles- terol per day. The Step II diet is more stringent and may Dyslipidemic drugs are used to decrease blood lipids, to pre- be used initially in clients with more severe dyslipidemia, vent or delay the development of atherosclerotic plaque, pro- cardiovascular disease, or diabetes mellitus. It can de- mote the regression of existing atherosclerotic plaque, and crease LDL cholesterol levels by 8% to 15%.

Halothane and a few norepinephrine rarely used general anesthetics sensitize the myocardium to the effects of catecholamines purchase 100mg dilantin amex medicine used for pink eye. If they are combined cheap dilantin 100mg with amex 714x treatment, ventricular tachy- cardia or ventricular fibrillation may occur. Some are used therapeutically for their barbiturates, opioid analgesics, sedative-hypnotics CNS depressant effects; others are used mainly for other purposes, and CNS depression is a side effect. Any combination of these drugs with each other or with general anesthetic agents produces additive CNS depression. For clients who have been receiving corticosteroids, most physi- cians recommend administration of hydrocortisone before, during, and, in decreasing doses, after surgery. These drugs should be discontinued at isoniazid, procarbazine, tranylcypromine, others least 10 days to 3 weeks before elective surgery. If emergency surgery is required, clients taking MAO inhibitors should not be given general anesthesia. Although they may be given spinal anesthesia, there is increased risk of hypotension. They should not be given local anesthetic solutions to which epinephrine has been added. These drugs are given for this therapeutic effect so that smaller amounts of general anes- thetics may be given. Drugs that decrease effects of general anesthetics: Few drugs actually decrease effects of general anesthetics. When clients are excessively depressed and hypotension, cardiac dys- rhythmias, respiratory depression, and other problems develop, the main treatment is stopping the anesthetic and supporting vital functions rather than giving additional drugs. Effects of general in- halation anesthetics decrease rapidly once administration is dis- continued. With chronic ingestion, however, tolerance to the effects of alcohol and general anesthetics develops; that is, larger amounts of general anesthetic agents are required in clients who have acquired toler- ance to alcohol. Drugs that increase effects of local anesthetics: (1) Cardiovascular depressants—general anesthetics, pro- Additive depression and increased risk of hypotension and pranolol (Inderal) arrhythmias (2) CNS depressants Additive CNS depression with high doses (3) Epinephrine Epinephrine is often used in dental anesthesia to prolong anes- thetic effects by delaying systemic absorption of the local anes- thetic drug. It is contraindicated for this use, however, in clients with hyperthyroidism or severe heart disease or those receiving adrenergic blocking agents for hypertension. Drugs that decrease effects of local anesthetics: These are seldom necessary or desirable. If overdosage of local anesthetics occurs, treatment is mainly symptomatic and supportive. Drugs that increase effects of neuromuscular blocking agents (muscle relaxants): (1) Aminoglycoside antibiotics (eg, gentamicin) These drugs can cause neuromuscular blockade on their own. If given with other blocking agents, additive blockade and increased risk of respiratory depression and apnea occur. Drugs that decrease effects of neuromuscular blocking agents: (1) Anticholinesterase drugs (eg, neostigmine) These drugs often are used to reverse the effects of the non- depolarizing agents. They do not reverse the effects of succinyl- choline and may potentiate them instead. What interventions are needed to ensure client safety during Answer: The risk of administering a drug to the wrong patient is in- recovery from local or regional anesthesia? Other factors that could have contributed ing agent is used in critical care settings? Journal of the American Medical Association, 286(2), Review and Application Exercises 208–216. When assessing a client before, during, or after local or re- Kowalski, S. A post hoc descriptive study of pa- gional anesthesia, what are important factors to consider? Identify risk factors for development of drug drugs and the circumstances indicating dependence.

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CHAPTER 66 DRUGS USED IN DERMATOLOGIC CONDITIONS 961 External Otitis on other aspects (eg order dilantin 100mg without a prescription medicine x topol 2015, erythema quality 100mg dilantin atlas genius - symptoms, telangiectasia, hyperplasia of connective tissue and sebaceous glands). Hydrocortisone is the corticosteroid most often in- cluded in topical otic preparations. It relieves pruritus and in- Urticaria flammation in chronic external otitis. Systemic analgesics are Systemic drug therapy with antihistamines (H1 receptor an- usually required. In addition, an epinephrine injection may be used initially and topical Pressure Ulcers medications may be applied to relieve itching. With chronic urticaria, the goal of treatment is symptom In pressure ulcers, the only clear-cut guideline for treatment relief. Antihistamines are most effective when given before is avoiding further pressure on the affected area. Many topi- histamine-induced urticaria occurs and should be given cal agents are used, most often with specific procedures for around the clock, not just when lesions appear. Consistent implementation of a protocol (ie, position changes, inspection of current or po- Dosage Forms tential pressure areas, dressing changes, use of alternating, pressure-relieving mattresses) may be more effective than The choice of dosage form for topical drug therapy de- drug therapy. Guidelines include the following: Psoriasis • Ointments are oil-based substances that usually con- tain a medication in an emollient vehicle, such as Localized lesions are usually treated by a combination of petrolatum or lanolin. Ointments occlude the skin and topical agents, such as a corticosteroid during daytime promote retention of moisture. Coal tar preparations cially useful in chronic skin disorders characterized by work slowly but produce longer remissions. Ointments should usually be avoided in psoriasis drugs such as calcipotriene or tazarotene may also hairy, moist, and intertriginous areas of the body be- be used. Calcipotriene is reportedly as effective as topical cause of potential maceration, irritation, and secondary fluocinonide. However, its onset of action is slower than that of a topical corticosteroid. Tazarotene is a topical retinoid that which dry and leave a film over the area) retain mois- may cause cutaneous irritation. Generalized psoriasis, which requires systemic treatment These preparations are cosmetically acceptable for use or body light therapy, should be managed mainly by derma- on the face and other visible areas of the body. Systemic therapy often involves oral retinoids or also may be used in hairy, moist, intertriginous areas. Acitretin has replaced etretinate as the oral Creams and gels are especially useful in subacute der- retinoid of choice for treatment of severe psoriasis. Sprays bearing potential who take acitretin should be instructed to and aerosols are similar to lotions. Powders usually should not be applied in acute, Methotrexate is an antineoplastic drug that may cause signif- exudative disorders or on denuded areas because they icant adverse effects. Phototherapy can involve natural sunlight, which is highly Also, some powders (eg, cornstarch) may lead to sec- effective. Most clients with psoriasis notice some remission ondary infections by promoting growth of bacteria and during summer months. However, creams or ointments may be used for dry, crusted le- sions, and powders may be used for drying effects. Rosacea • Topical vaginal medications may be applied as douche Mild skin cleansers (eg, Cetaphil), oral tetracycline, and top- solutions, vaginal tablets, or vaginal creams used with ical metronidazole are commonly used; oral isotretinoin and an applicator. These medications • Anorectal medications may be applied as ointments, prevent or treat acneiform lesions; they have little to no effect creams, foams, and rectal suppositories. Few guidelines have been developed for Principles of topical drug therapy are generally the same as drug therapy of these disorders. In addition, topical corticosteroids should children, have more permeable skin and are more likely to ab- be used with caution on thinned or atrophic skin.

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