Diclofenac Na

INDICATIONS

     • PO: Management of inflammatory disorders

including:
     ○ Rheumatoid arthritis
     ○ Osteoarthritis
     ○ Ankylosing spondylitis
     • Relief of mild to moderate pain of dysmenorrhea
     • Acute pain
     • Topical: Treatment of actinic
keratoses

ACTION

     • Inhibits prostaglandin synthesis

     • Therapeutic Effects:
     ○ Suppression of pain and inflammation

PHARMACOKINETICS

Absorption: Well absorbed after oral administration. Oral diclofenac sodium is a delayed-release dosage form. Diclofenac
potassium is an immediate-release dosage form. 10% of topically applied diclofenac is systemically absorbed
Distribution: Crosses the placenta; enters breast milk
Protein Binding: >99%
Metabolism and Excretion: >50% metabolized on first pass through the liver
Half-life: 1.2-2 hr

TIME OF ACTION

 ROUTE   ONSET   PEAK   DURATION 

 PO   few days-1  2 wk or
 unknown 
(inflammation)  wk  more 
 PO (pain)   30 min   unknown   up to 8 hr 
 Topical   unknown   30 days*    unknown 
*Complete healing of lesions following cessation of therapy

CONTRAINDICATIONS/PRECAUTIONS

Contraindicated in:
     • Hypersensitivity to diclofenac or other components of formulation
     • Cross-sensitivity may occur with other NSAIDs including aspirin
     • Active GI bleeding/ulcer disease
Use Cautiously in:
     • Severe renal/hepatic disease
     • Cardiovascular disease or risk factors for cardiovascular disease (may ↑ risk of serious cardiovascular thrombotic events,
myocardial infarction, and stroke, especially with prolonged use)
     • History of porphyria
     • History of ulcer
disease
     • Geri: Geriatric patients (dosage reduction recommended; more susceptible to adverse reactions, including GI
bleeding)
     • Bleeding tendency or concurrent anticoagulant therapy
     • Pedi: Pregnancy, lactation, and children (safety not established; not recommended for use during second half of
pregnancy)

ADVERSE REACTIONS/SIDE EFFECTS*

*CAPITALS indicate life threatening; underlines indicate most frequent.

For oral diclofenac unless noted

CNS: dizziness, drowsiness, headache,

CV: hypertension,
GI: GI BLEEDING, abdominal pain, dyspepsia, heartburn, diarrhea, hepatotoxicity,
GU: acute renal failure, dysuria, frequency, hematuria, nephritis, proteinuria,
Derm: EXFOLIATIVE DERMATITIS, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, eczema,
photosensitivity, rashes,
F and E: edema,
Hemat: prolonged bleeding time,
Local: Topical only: contact dermatitis, dry skin, exfoliation, rash,
Misc: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS,

INTERACTIONS

Primarily noted for oral administration

Drug-Drug:
     • Concurrent use with aspirin may ↓
effectiveness
     • ↑ adverse GI effects with aspirin , other NSAIDs , colchicine , corticosteroids , or
alcohol
     • Chronic use with acetaminophen may ↑ risk of adverse renal reactions
     • May ↓ effectiveness of diuretics , antihypertensives , insulins , or hypoglycemic
agents
     • ↑ serum digoxin levels (dosage adjustment may be necessary)
     • May ↑ levels/risk of toxicity from cyclosporine , lithium , or methotrexate
     • Probenecid ↑ risk of toxicity from diclofenac
     • ↑ risk of bleeding with some cephalosporins , thrombolytic agents , antiplatelet agents , or
anticoagulants
     • ↑ risk of adverse hematologic reactions with antineoplastics or radiation therapy
     • Concurrent use with potassium-sparing diuretics ↑ risk of hyperkalemia
     • Concurrent use with gold compounds may ↑ risk of adverse renal reactions
     • Concurrent use of oral NSAIDs during topical diclofenac therapy should be minimized
Drug-Natural:
     • ↑ bleeding risk with arnica , chamomile , clove , dong quai , feverfew , garlic , ginger , ginkgo , Panax ginseng , and
others

ROUTE AND DOSAGE

Diclofenac Potassium
     • PO (Adults ): Analgesic/antidysmenorrheal--100 mg initially, then 50 mg 3 times daily as needed; rheumatoid arthritis --50 mg
3-4 times daily, after initial resopnse reduce to lowest dose that controls symptoms (usual maintenance dose 25 mg 3 times
daily);osteoarthritis--50 mg 2-3 times daily, after initial response reduce to lowest dose that controls symptoms; ankylosing
spondylitis--25 mg 4-5 times daily, after initial response reduce to lowest dose that controls symptoms

Diclofenac Sodium
     • PO (Adults ): Rheumatoid arthritis--50 mg 3-4 times daily, after initial resopnse reduce to lowest dose that controls symptoms
(usual maintenance dose 25 mg 3 times daily)
     • Topical (Adults ): Apply to lesions twice daily for 60-90 days

AVAILABILITY
     • Diclofenac potassium immediate-release tablets: 50 mg, 75 mg
     • Cost: Cataflam — 50 mg $183.82/100
     • Diclofenac sodium delayed-release (enteric-coated) tablets: 25 mg, 50 mg, 75 mg
     • Cost: Voltaren — 25 mg $68.82/100, 50 mg $134.23/100, 75 mg $154.44/100
     • Diclofenac sodium extended-release tablets: 75 mg, 100 mg
     • Suppositories: 50 mg, 100 mg
     • Gel: 3% in 25- and 50-g tubes
     • In combination with: 200 mcg misoprostol (Arthrotec). See Appendix B

NURSING IMPLICATIONS

ASSESSMENT

     • Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity
reactions
     • Pain: Assess pain and limitation of movement; note type, location, and intensity before and 30-60 min after
administration
     • Arthritis: Assess arthritic pain (note type, location, intensity) and limitation of movement before and periodically during
therapy
     • Actinic Keratosis: Assess lesions prior to and periodically during therapy
     • Lab Test Considerations: Diclofenac has minimal effect on bleeding time and platelet aggregation
      ○ May cause ↓ hemoglobin, hematocrit, leukocyte, and platelet counts
     ○ Monitor liver function tests within 8 wk of initiating diclofenac therapy and periodically during therapy. May cause ↑ serum
alkaline phosphatase, LDH, AST, and ALT concentrations
     ○ Monitor BUN, serum creatinine, and electrolytes periodically during therapy. May cause ↑ BUN, serum creatinine, and
electrolyte concentrations and ↓ urine electrolyte concentrations
     ○ May cause ↓ serum and ↑ urine uric acid concentrations

POTENTIAL NURSING DIAGNOSES

     • Acute pain (Indications).

     • Impaired physical mobility (Indications).

IMPLEMENTATION

     • Do not confuse Cataflam (diclofenac) with Catapres (clonidine)

     ○ Administration in higher than recommended doses does not provide increased effectiveness but may cause increased side
effects. Use lowest effective dose for shortest period of time
     • PO: Administer after meals, with food, or with an antacid containing aluminum or magnesium to minimize gastric irritation May
take first 1-2 doses on an empty stomach for more rapid onset. Do not crush or chew enteric-coated or sustained-release
tablets
     • Dysmenorrhea: Administer as soon as possible after the onset of menses. Prophylactic treatment has not been shown to be
effective
     • Topical: Gel should be applied to intact skin; do not use on open wounds

PATIENT/FAMILY TEACHING

     • PO: Instruct patient to take diclofenac with a full glass of water and to remain in an upright position for 15-30 min after
administration. Take missed doses as soon as possible within 1-2 hr if taking once or twice a day or unless almost time for next
dose if taking more than twice a day. Do not double doses
     ○ Caution patient to avoid concurrent use of alcohol, aspirin, acetaminophen, other NSAIDs, or other OTC medications
without consulting health care professional
     ○ May cause drowsiness or dizziness. Caution patient to avoid driving or other activities requiring alertness until response to
medication is known
     ○ Instruct patient to notify health care professional of medication regimen before treatment or
surgery
     ○ Caution patient to wear sunscreen and protective clothing to prevent photosensitivity
reactions
     ○ Advise patient to consult health care professional if rash, itching, visual disturbances, tinnitus, weight gain, edema, black
stools, persistent headache, or influenza-like syndrome (chills, fever, muscle aches, pain) occurs
     • Topical: Advise patient to minimize use of concurrent NSAIDs during topical therapy

EVALUATION/DESIRED OUTCOMES

     • Decrease in severity of mild-to-moderate pain

     ○ Increased ease of joint movement. Patients who do not respond to one NSAID may respond to another. May require 2 wk
or more for maximum effects
     • Decrease in or healing of lesions in actinic keratosis. Optimal effect may not be seen until 30 days after discontinuation of
therapy. Lesions that do not heal should be re-evaluated

Acetazolamide(diamox)
Acetazolamide is used to treat glaucoma, a condition in which increased pressure in the eye can lead to gradual loss of vision.
Acetazolamide decreases the pressure in the eye. Acetazolamide is also used to reduce the severity and duration of symptoms
(upset stomach, headache, shortness of breath, dizziness, drowsiness, and fatigue) of altitude (mountain) sickness. Acetazolamide
is used with other medicines to reduce edema (excess water retention) and to help control seizures in certain types of epilepsy.

How to use
Acetazolamide comes as a tablet and capsule to take by mouth. Follow the directions on your prescription label carefully, and ask
your doctor or pharmacist to explain any part you do not understand. Take acetazolamide exactly as directed. Do not take more or
less of it or take it more often than prescribed by your doctor.

If you are taking the extended-release (long-acting) form of acetazolamide (Diamox Sequels), do not crush or chew the capsules.

before taking acetazolamide,

  tell your doctor and pharmacist if you are allergic to acetazolamide, sulfa drugs, diuretics ('water pills'), or any other drugs.
 tell your doctor and pharmacist what prescription and nonprescription medications you are taking, especially
amphetamines, aspirin, cyclosporine (Neoral, Sandimmune), medications for depression or irregular heartbeat, diflunisal
(Dolobid), digoxin (Lanoxin), diuretics ('water pills'), lithium (Eskalith, Lithobid), phenobarbital, primidone (Mysoline), and
vitamins.
 tell your doctor if you have or have ever had heart, liver, or kidney disease; or diabetes.
 tell your doctor if you are pregnant, plan to become pregnant, or are breast-feeding. If you become pregnant while taking
acetazolamide, call your doctor immediately.
 if you are having surgery, including dental surgery, tell the doctor or dentist that you are taking acetazolamide.
 you should know that this drug may make you drowsy. Do not drive a car or operate machinery until you know how this
drug affects you.
 remember that alcohol can add to the drowsiness caused by this drug.
 plan to avoid unnecessary or prolonged exposure to sunlight and to wear protective clothing, sunglasses, and sunscreen.
Acetazolamide may make your skin sensitive to sunlight.

Adverse effect

 numbness and tingling

 increased thirst and urination
 drowsiness
 headache
 confusion
 fever
 rash
 blood in urine
 painful urination
 yellowing of the skin or eyes
 seizures
 sore throat
 unusual bleeding or bruising

Acetazolamide may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away:

 upset stomach
 vomiting
 loss of appetite

brominidine (alphagan)
Alphagan has been approved for the treatment of open-angle glaucoma and ocular hypertension.

Mechanism of Action

Alphagan is a selective alpha-2 agonist, which significantly lowers intraocular pressure with minimal effects on cardiovascular and
pulmonary parameters. Its unique dual mechanism of action lowers intraocular pressure by reducing aqueous humor production and
increasing uveoscleral outflow.

dosage

Brimonidine ophthalmic comes as a solution (liquid) to instill in the eyes. It is usually instilled in the affected eye(s) three times a day.
Use brimonidine eye drops at around the same times every day, and try to space your 3 daily doses about 8 hours apart. Follow the
directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Use
brimonidine eye drops exactly as directed. Do not use more or less of them or use them more often than prescribed by your doctor.

Before using brimonidine eye drops,

 tell your doctor or pharmacist if you are allergic to brimonidine eye drops or any other medications.
 do not use brimonidine eye drops if you are taking a monoamine oxidase (MAO) inhibitor such as isocarboxazid
(Marplan), phenelzine (Nardil), selegiline (Eldepryl), or tranylcypromine (Parnate).
  tell your doctor and pharmacist what prescription and nonprescription medications, vitamins, nutritional supplements, and
herbal products you are taking or plan to take. Be sure to mention any of the following: antidepressants such as
amitriptyline (Elavil), amoxapine (Asendin), clomipramine (Anafranil), desipramine (Norpramin), doxepin (Adapin,
Sinequan), imipramine (Tofranil), nortriptyline (Aventyl, Pamelor), protriptyline (Vivactil), and trimipramine (Surmontil);
barbiturates such as phenobarbital and secobarbital (Seconal); digoxin (Lanoxin); medications for anxiety, high blood
pressure, mental illness, pain, or seizures; sedatives; sleeping pills; and tranquilizers. Your doctor may need to change
the doses of your medications or monitor you carefully for side effects.
 if you are using any other eye drops, instill them 5 minutes before or 5 minutes after you instill brimonidine eye drops.
 tell your doctor if you often feel dizzy when you sit or stand from a lying position and if you have or have ever had
depression; conditions that affect your blood circulation including Raynaud's disease (a condition that causes attacks of
low blood circulation to the fingers and toes), thromboangiitis obliterans (a condition that causes poor blood circulation in
the hands and feet), and problems with blood flow to your heart or brain; or heart, kidney, or liver disease.
 tell your doctor if you are pregnant or plan to become pregnant. If you become pregnant while you are using brimonidine
eye drops, call your doctor. Do not breast-feed while you are using brimonidine eye drops.
 if you are having surgery, including dental surgery, tell your doctor or dentist that you are using brimonidine eye drops.
 you should know that brimonidine eye drops may make you drowsy. Your vision may be blurry for a few minutes after you
instill the eye drops. Do not drive a car or operate machinery until you know how this medication affects you.
 ask your doctor about the safe use of alcohol while you are using brimonidine eye drops. Alcohol can make the
drowsiness caused by brimonidine eye drops worse.
 tell your doctor if you wear soft contact lenses. Remove your soft contact lenses before instilling brimonidine eye drops
and wait at least 15 minutes after using the medication to replace your lenses.

Brimonidine eye drops may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away:

 itchy, irritated, red, stinging, or burning eyes

 dry eyes
 watery or runny eyes
 red or swollen eyelids
 sensitivity to light
 blurred vision
 headache
 drowsiness
 difficulty falling asleep or staying asleep
 dry mouth
 runny nose and other cold symptoms
 cough
 sore throat
 flu-like symptoms
 pain or pressure in the face
 heartburn

Some side effects can be serious. If you experience any of the following symptoms, call your doctor immediately:

 rash
 difficulty breathing
 seeing specks or flashes of light
 blind spots
 fainting
 dizziness
 nausea
Hydroxypropyl Methylcellulose (Ophthalmic)

INN:
Hypromellose {10}

VA CLASSIFICATION
Primary: OP500

Commonly used brand name(s): Artificial Tears; Bion Tears; Eyelube; Gonak; Goniosoft; Goniosol; Isopto Alkaline; Isopto Plain;
Isopto Tears; Just Tears; Lacril; Methocel; Moisture Drops; Nature's Tears; Ocucoat; Ocucoat PF; Ocutears; Tearisol; Tears
Naturale; Tears Naturale Free; Tears Naturale II; Tears Renewed; Ultra Tears.

Note: For a listing of dosage forms and brand names by country availability, see Dosage Formssection(s).

Category:

Protectant (ophthalmic)—

tears (artificial)—

lubricant (ophthalmic)—

diagnostic aid (contact lens procedures; gonioscopy)—

Indications

Note: Bracketed information in the Indications section refers to uses that are not included in U.S. product labeling.

Accepted

Keratitis, exposure (treatment)

Keratitis, neuroparalytic (treatment) or
Keratoconjunctivitis sicca (treatment)—Hydroxypropyl methylcellulose is indicated for the relief of dry eyes and eye irritation
associated with deficient tear production in order to prevent corneal damage. {02} {03} {04} {05} {06} {08} {09} {14} {16} {21} {23} {24}

[Corneal erosions, recurrent (treatment)]1or{21}

[Corneal sensitivity, decreased (treatment)]1{21}—Hydroxypropyl methylcellulose is used in the treatment of recurrent corneal
erosions and decreased corneal sensitivity. {01} {21}

Ocular lubrication1{21}—Hydroxypropyl methylcellulose is indicated as an ocular lubricant for hard contact lenses {02} {03} {08} and
artificial eyes and to protect the cornea during gonioscopy {07}{17} {33} {34} {36} {37} and procedures involving use of a diagnostic contact
lens, such as laser photocoagulation of the retina, laser gonioplasty, and laser iridectomy.
1
 Not included in Canadian product labeling.

Pharmacology/Pharmacokinetics
Mechanism of action/Effect:

Promotes corneal wetting by stabilizing and thickening the precorneal tear film and prolonging the tear film breakup time, which is
usually shortened in dry eye conditions. Also acts to lubricate and protect the eye.

Precautions to Consider

Pregnancy/Reproduction

Problems in humans have not been documented.

Breast-feeding

Problems in humans have not been documented.

Pediatrics

Appropriate studies on the relationship of age to the effects of hydroxypropyl methylcellulose have not been performed in the
pediatric population. However, pediatrics-specific problems that would limit the usefulness of this medication in children are not
expected.

Geriatrics

Appropriate studies on the relationship of age to the effects of hydroxypropyl methylcellulose have not been performed in the
geriatric population. However, geriatrics-specific problems that would limit the usefulness of this medication in the elderly are not
expected.

Medical considerations/Contraindications
The medical considerations/contraindications included have been selected on the basis of their potential clinical significance
(reasons given in parentheses where appropriate)— not necessarily inclusive (» = major clinical significance).

Risk-benefit should be considered when the following medical problem exists

Sensitivity to hydroxypropyl methylcellulose