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These drugs have involving the skin purchase coreg 25 mg visa blood pressure normal low pulse rate, muscles buy cheap coreg 6.25 mg on line prehypertension 30 years old, joints, and other connective tis- strong anti-inflammatory effects and more severe adverse sue. It is useful in inflammatory disorders, such as arthritis, effects than the propionic acid derivatives. Potentially serious but many people prefer drugs that cause less gastric irritation. These effects are especially associated with in- in 1 to 2 hours, and lasts 4 to 6 hours. Taking aspirin with domethacin; the other drugs were developed in an effort to find food slows absorption, but also decreases gastric irritation. Absorption of enteric-coated aspirin and rectal suppositories Although adverse reactions occur less often with sulindac and is slower and less complete. Aspirin is distributed to all body tissues and fluids, in- In addition to other uses, intravenous (IV) indomethacin cluding fetal tissues, breast milk, and the central nervous is approved for treatment of patent ductus arteriosus in pre- system (CNS). In plasma, aspirin binds to artery to the aorta in the fetal circulation. Aspirin has a short half-life of 15– close, blood is shunted from the aorta to the pulmonary 20 minutes because it is rapidly converted to salicylic acid, artery, causing severe cardiopulmonary problems. Salicylic acid has a half-life of 2 to Other drugs related to this group are etodolac (Lodine), 3 hours at low doses and 6 to 12 hours at therapeutic anti- ketorolac (Toradol), and nabumetone (Relafen). It undergoes oxidation and conjugation portedly causes less gastric irritation, especially in older in the liver and its metabolites are excreted through the kidneys. Ketorolac is used only for In alkaline urine (eg, pH of 8), renal excretion of salicylate is pain, and although it can be given orally, its unique charac- greatly increased. Parenteral ketoro- Aspirin is a home remedy for headaches, colds, influenza lac reportedly compares with morphine and other opioids in and other respiratory infections, muscular aches, and fever. How- can be purchased in plain, chewable, enteric-coated, and ef- ever, its use is limited to 5 days because it increases the risk fervescent tablets and rectal suppositories. Hematomas and wound bleeding have been re- in liquid form because it is unstable in solution. Diflunisal (Dolobid) is a salicylic acid derivative that dif- Oxicam drugs include meloxicam (Mobic) and piroxicam fers chemically from aspirin. Meloxicam has a serum half-life of 15 to 20 hours rior to aspirin in mild to moderate pain, rheumatoid arthritis, (text continues on page 108) CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 105 Drugs at a Glance: Analgesic, Antipyretic, Anti-inflammatory Drugs Routes and Dosage Ranges Generic/Trade Name Indications for Use Adults Children Comments Acetaminophen Pain PO 325–650 mg q4–6h, PO 10 mg/kg or accord- Warning: Overdoses may (Tylenol, others) Fever or 1000 mg three or ing to age as follows: cause fatal liver dam- four times per day; 0–3 mo, 40 mg; age. Maximum recom- maximum 4 g/d 4–11 mo, 80 mg; mended dose for adults 1–2 y, 120 mg; 2–3 y, is 4 g/d, from all 160 mg; 4–5 y, 240 mg; sources. Parents and 6–8 y, 320 mg; 9–10 y, caregivers should ask 400 mg; 11 y, 480 mg. Rectal suppository 650 mg Rectal suppository: age q4–6h, maximum of under 3 y, consult 6 in 24 h physician; age 3–6 y, 120 mg q4–6h, maxi- mum, 720 mg in 24 h; age 6–12 y, 325 mg q4–6h, maximum 2. RA: PO 150–200 mg/d in two, three or four divided doses (continued) 106 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Drugs at a Glance: Analgesic, Antipyretic, Anti-inflammatory Drugs (continued) Routes and Dosage Ranges Generic/Trade Name Indications for Use Adults Children Comments Ankylosing spondylitis AS: PO 100–125 mg/d in Diclofenac sodium is (AS) four or five divided available in 25-, 50-, Pain, dysmenorrhea doses (eg, 25 mg four and 75-mg delayed- or five times daily) release tablets and a Pain, dysmenorrhea: 100-mg extended- (diclofenac potassium release (XR) tablet. It only) PO 50 mg three is not recommended times daily for acute pain or dys- menorrhea. Diflunisal (Dolobid) Osteoarthritis OA, RA: PO 500– Not recommended for use Rheumatoid arthritis 1000 mg/d, in two in children <12 years of Pain divided doses, in- age creased to a maximum of 1500 mg/d if necessary Pain: PO 500–1000 mg initially, then 250– 500 mg q8–12h Etodolac (Lodine, Osteoarthritis OA, RA: PO 600– Dosage not established Available in immediate- Lodine XL) Rheumatoid arthritis 1200 mg/d in two to release and extended- Pain four divided doses release (XL) tablets of Pain: PO 200–400 mg various strengths. The q6–8h immediate-release Maximum according to forms should be used weight: 1200 mg/d for to treat acute pain. Bursitis to a maximum of three doses Acute painful shoulder 150–200 mg/d, if Acute gout necessary Closure of patent ductus arteriosus (IV only) CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 107 Drugs at a Glance: Analgesic, Antipyretic, Anti-inflammatory Drugs (continued) Routes and Dosage Ranges Generic/Trade Name Indications for Use Adults Children Comments Acute gouty arthritis, acute painful shoulder, PO 75–150 mg/d in three or four divided doses until pain and inflammation are con- trolled (eg, 3–5 d for gout; 7–14 d for painful shoulder), then discon- tinued Ketoprofen (Orudis, Pain Pain, dysmenorrhea: PO Do not give to children Extended-release cap- Oruvail) Dysmenorrhea 25–50 mg q6–8h PRN <16 years unless di- sules are available as Osteoarthritis OA, RA: PO 150–300 mg/d rected by a physician. Note that the doses names do not contain Sustained-release (Oruvail any letters (eg, SR, XL) SR), 200 mg once daily that indicate long-acting Maximum, 300 mg/d for dosage forms. IM 15 mg q6h to a maximum of 60 mg/d Meloxicam (Mobic) Osteoarthritis PO 7. Oral sion, and in immediate- Ankylosing spondylitis symptoms subside suspension (125 mg/ and delayed-release Pain Maximum, 1250 mg/d 5 mL) twice daily ac- formulations Dysmenorrhea Naproxen sodium: Pain, cording to weight: Bursitis dysmenorrhea, acute 13 kg (29 lb), 2. Pirox- ative safety of these drugs, there have been a few cases re- icam has a half-life of about 50 hours. The long half-lives ported in which hypertension was acutely worsened by the allow the drugs to be given once daily, but optimal efficacy drugs (blood pressure returned to previous levels when the may not occur for 1 to 2 weeks. Formulations a COX-2 inhibitor had a small increase in the incidence of are delayed or extended-release and onset of action is there- myocardial infarction and stroke due to thrombosis, compared fore delayed. Peak action occurs in about 2 hours and effects with clients receiving a nonselective NSAID (naproxen) or last 12 to 15 hours.

It is should be treated in pregnant women because of its associa- especially important that sufficient insulin is given to tion with cystitis and pyelonephritis order 12.5 mg coreg free shipping heart attack 23 years old. Uncontrolled acidosis is uria and UTIs are also associated with increased preterm likely to interfere with neurologic development of the deliveries and low birth weights discount coreg 25 mg without a prescription hypertension bench. At the same time, careful dietary control and other and nitrofurantoin are commonly used drugs. Poor asthma control time, termination of the pregnancy reverses the diabeto- during pregnancy is considered more detrimental to a fetus genic hormonal changes and decreases insulin require- than treatment with available drugs. Commonly used drugs include orally inhaled beta2 ag- on frequent measurements of blood glucose. Once the onists (eg, albuterol or metaproterenol) and anti-inflammatory insulin requirement is stabilized, the client may be able agents (eg, cromolyn or beclomethasone). CHAPTER 67 DRUG USE DURING PREGNANCY AND LACTATION 973 Hypertension Nursing Notes: Ethical/Legal Dilemma Chronic hypertension (hypertension beginning before con- ception or up to 20 weeks of pregnancy) is associated with increased maternal and fetal risks. Thus, appropriate manage- As a nursing student, you are assigned to a unit where abortions ment is mandatory. Your religious and family upbringing has taught avoiding excessive weight gain, sodium restriction, increased you that abortion is an immoral act. Do you have a right to refuse to participate in an experience involving abortion as a student? If drug therapy is required, so, how might you approach your instructor about this issue? Alternatives include labetalol and other beta blockers, cloni- dine, hydralazine, isradipine, nifedipine, and prazosin. With beta blockers, fetal and neonatal bradycardia, hypotension, hypoglycemia, and respiratory depression have been re- ABORTIFACIENTS ported. As a result, some authorities recommend avoiding the drugs during the first trimester and stopping them 2 to 3 days Abortion is the termination of pregnancy before 20 weeks. Medical Opinions seem divided on the use of angiotensin-converting abortion may be induced by prostaglandins and an antiproges- enzyme (ACE) inhibitors. Some sources say the drugs are tin (Drugs at a Glance: Abortifacients, Prostaglandins, To- contraindicated during pregnancy; others say they can be colytics, and Oxytocics). Prostaglandins may be used to used during the first trimester but should then be discontin- terminate pregnancy during the second trimester. The reproductive system, prostaglandins E and F are found in same effects would probably occur with angiotensin II the ovaries, myometrium, and menstrual fluid. They stimulate receptor blockers (ARBs), because they also act on the uterine contraction and are probably important in initiating and renin–angiotensin system. Drug preparations of Although diuretics are commonly used in the treatment of prostaglandins are capable of inducing labor at any time dur- hypertension, they should not be given during pregnancy. Misoprostol, a prostaglandin developed to They decrease blood volume, cardiac output, and blood pres- prevent nonsteroidal anti-inflammatory drug–induced gastric sure and may cause fluid and electrolyte imbalances, all of ulcers (see Chap. Mifepristone is a progesterone antagonist used to termi- Seizure Disorders nate pregnancy during the first trimester. A prostaglandin is given approximately 48 hours after the mifepristone to Although antiepileptic drugs (AEDs) are known teratogens, augment uterine contractions and ensure expulsion of the they must often be taken during pregnancy because seizures conceptus. Despite the usually good outcomes, the incidence of birth defects is 2 to TOCOLYTICS 3 times higher in fetuses exposed to AEDs than in those not exposed. If an AED is required, monotherapy with the low- Drugs given to inhibit labor and maintain the pregnancy are est dose that stops seizures should be used and plasma drug called tocolytics. Uterine contractions with cervical changes levels should be checked monthly. Women with epilepsy between 20 and 37 weeks of gestation are considered prema- should take a folic acid supplement (at least 400 mcg daily) ture labor. Nonpharmacologic treatment includes bed rest, all the time and 800 mcg or more during pregnancy. Drug therapy is most effective when plemental vitamin K is usually needed during the last the cervix is dilated less than 4 cm and membranes are intact. An Ritodrine, terbutaline, magnesium sulfate, and nifedipine injection of vitamin K is also given to the infant immedi- are used as tocolytics (see Drugs at a Glance: Abortifacients, ately after birth. Ritodrine and There has been controversy as to whether teratogenic terbutaline are beta-adrenergic agents that relax uterine smooth effects stemmed from epilepsy or AEDs.

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In hypotension and gic drugs are also contraindicated for persons with narrow- shock buy 12.5 mg coreg with visa heart attack and vine cover, they may be given to increase blood pressure generic coreg 6.25mg with amex blood pressure medication names starting with a. In hem- angle glaucoma because they result in mydriasis, closure of the orrhagic or hypovolemic shock, the drugs are second-line filtration angle of the eye, and increased intraocular pressure. Adren- In bronchial asthma and other obstructive pulmonary dis- ergic drugs are contraindicated with local anesthesia of dis- eases, the drugs are given as bronchodilators to relieve bron- tal areas with a single blood supply (e. In upper respiratory ears) because of potential tissue damage and sloughing from infections, including the common cold and sinusitis, they vasoconstriction. They should not be given during the sec- may be given orally or applied topically to the nasal mucosa ond stage of labor because they may delay progression. Thus, they may be used older adults because of their cardiac- and CNS-stimulating to treat allergic rhinitis, acute hypersensitivity (anaphylac- effects. Other clinical uses include relaxation of uterine mus- INDIVIDUAL ADRENERGIC DRUGS culature and inhibition of uterine contractions in preterm labor. They also may be added to intraspinal and local anes- Epinephrine (Adrenalin) is the prototype of adrenergic drugs. Topical uses include application When it is given systemically, the effects may be therapeutic to skin and mucous membranes for vasoconstriction and he- or adverse, depending on the reason for use and route of mostatic effects, and to the eyes for vasoconstriction and administration. Increased systolic blood pressure, due primarily to in- creased force of myocardial contraction and vasocon- striction in skin, mucous membranes, and kidneys Contraindications to Use 2. Vasodilation and increased blood flow to skeletal muscles, heart, and brain Contraindications to using adrenergic drugs include cardiac 3. This al- dysrhythmias, angina pectoris, hypertension, hyperthyroidism, lows shunting of blood to the heart and brain, with in- and cerebrovascular disease because stimulation of the sym- creased perfusion pressure in the coronary and cerebral CHAPTER 18 ADRENERGIC DRUGS 273 circulations. They must be used correctly to avoid potentially eficial effect in cardiac arrest and cardiopulmonary serious hazards. When given by injection, it acts rapidly but has a short stimulation of conducting tissues in the heart. When given intravenously, epinephrine acts bradycardia may occur when blood pressure is raised. Relaxation of GI smooth muscle a positive inotropic and positive chronotropic effect on the myo- 6. Relaxation or dilation of bronchial smooth muscle cardium, hyperglycemia, bronchodilation, and vasoconstric- 7. Increased glucose, lactate, and fatty acids in the blood tion of arterioles in the skin, mucosa, and most viscera. For due to metabolic effects acute asthma attacks, subcutaneous (SC) administration usu- 8. Inhibition of insulin secretion ally produces bronchodilation within 5 to 10 minutes; maximal 9. Miscellaneous effects, including increased total leuko- effects may occur within 20 minutes. Most epinephrine is cyte count, increased rate of blood coagulation, and de- rapidly metabolized in the liver to inactive metabolites, which creased intraocular pressure in wide-angle glaucoma. The remaining epinephrine is de- When given locally, the main effect is vasoconstriction. However, at high stimulating alpha and beta receptors and causing release of doses, alpha-adrenergic effects (eg, vasoconstriction) pre- norepinephrine. The effects and clinical indications for epineph- than those of epinephrine. Ephedrine produces more CNS rine, the prototype of adrenergic drugs, are the same as for stimulation than other adrenergic drugs. In addition, epinephrine is the adren- treatment of bronchial asthma to prevent bronchospasm, but ergic drug of choice for relieving the acute bronchospasm and it is less effective than epinephrine for acute bronchospasm laryngeal edema of anaphylactic shock, the most serious al- and respiratory distress. Epinephrine is used in cardiac arrest for its Ephedrine can be given orally or parenterally. It given orally, therapeutic effects occur within 1 hour and last also is added to local anesthetics for vasoconstrictive effects, 3 to 5 hours. When given SC, it acts in approximately 20 min- which prolong the action of the local anesthetic drug, prevent utes and effects last approximately 60 minutes; with intramus- systemic absorption, and minimize bleeding. Ephedrine is excreted un- children; syncope has occurred with use in asthmatic chil- changed in the urine.

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Afterwards order 6.25 mg coreg mastercard blood pressure low diastolic, the doctor used the method of transverse rubbing on the lower back region until the back became hot discount coreg 6.25 mg with mastercard hypertension facts. Press seeds were also attached over the following ear points: Bladder Kidney Urinary Tract Brain The points were pressed on one side each time. One treatment was given per day, and one week equaled one course of treat- ment. Tuina combined with moxibustion From The Treatment of 15 Cases of Pediatric Enuresis with Tuina & Moxibustion by Song Zhan-lin, Shi Yong Zhong Yi Nei Ke Za Zhi (Clinical Journal of Chinese Medicine Internal Medicine), 1993, #1, p. Ten cases were between 7-10 years old, three cases were 11-14 years old, and two cases were 15-18 years old. Nocturnal enuresis in these patients ranged from slight (one time per night) to severe (multiple times per night). Most children in this study did not have any other obvious symptoms, but five cases had frequent urination during the day. Treatment method: Tuina consisted of supplementing Shen Jing (Kidney Channel) on the pinky 500 times, supplementing Pi Jing (Spleen Channel) on the thumb 300 times, supplementing Fei Jing (Lung Channel) on the ring finger 300 times, transporting Nei Ba Gua (Inner Eight Trigrams), i. Moxibustion was then applied to the following acupoints: Dan Tian (CV 4-6) Shen Shu (Bl 23) Bai Hui (GV 20) These patients were treated one time per day, and five days equaled one course of treatment. In general, patients received 1-2 courses of treatment, although stubborn cases received three courses. Chinese Research on the Treatment of Pediatric Enuresis 161 Study outcomes: Ten cases (67%) were cured, four cases were markedly improved, and one case improved. Tuina combined with internal medicine From The Treatment of 60 Cases of Pediatric Enuresis Combining Chinese Medicinals & Spinal Pinch Pull Technique by Wu Xiao-ju, Huai Hai Zhong Yao (Huaihai Chinese Medicine), 2002, #4, p. Forty-eight of these patients (80%) were between 5-8 years old and 12 cases (20%) between 9-15 years old. All the children were more than three years old, and their course of disease was less than one year. Treatment method: External treatment consisted of the spinal pinch-pull technique. In other words, the practitioner pushed and pinch-rolled up the spine five times and then rubbed with their palm in a circular manner from the top to the bottom of the spine two times. Ten days equaled one course of treatment, and, after a three day interval, the patient continued with the next course of treatment. Internal treatment consisted of the oral administration of Bu Shen Suo Niao Tang (Supplement the Kidneys & Reduce Urination Decoction) which was composed of: Huang Qi (Radix Astragali), 30g Dang Shen (Radix Codonopsitis), 10g Shan Yao (Radix Dioscoreae), 10g Tu Si Zi (Semen Cuscutae), 10g Yi Zhi Ren (Fructus Alpiniae Oxyphyllae), 10g Sang Piao Xiao (Ootheca Mantidis), 10g Wu Wei Zi (Fructus Schisandrae), 6g Jin Ying Zi (Fructus Rosae Laevigatae), 10g 162 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine Fu Pen Zi (Fructus Rubi), 10g Ma Huang (Herba Ephedrae), 6g One packet of these medicinals was decocted per day in water until 300 milliliters of medicinal liquid remained. Ten days equaled one course of treatment, and the treatment was continued for three successive courses of treatment. From The Treatment of 32 Cases of Pediatric Enuresis with Spinal Pinch Pull, Moxibustion & Cupping by Li Qiang-hua, An Mo Yu Dao Yin (Massage & Dao Yin), 2000, #4, p. The course of disease was less than three years in 19 cases and more than three years in 13 cases. The enuresis occurred one or more times per night in 16 cases, 1-3 times per week in nine cases, and 1-2 times per month in seven cases. Also in seven cases, the enuresis was increased in amount on cold, rainy days. Treatment method: First, spinal pinch-pull was performed five times from Chang Qiang (GV 1) to Da Zhui (GV 14). During the fifth time, the area was pinched three times (instead of one time) and pulled. One treat- ment was given every day, and 10 days equaled one course of treatment. This treatment was done every other day, and five treatments equaled one course of treatment. In addition, Chinese Research on the Treatment of Pediatric Enuresis 163 moxibustion for approximately 10 minutes was done at Guan Yuan (CV 4) and San Yin Jiao (Sp 6) until the skin was slightly red. One treatment was given every day, and 10 days equaled one course of treatment.

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