Using your drug handbook, answer the following questions:

A. Look for the drug-drug interaction of the following drugs given and give nursing
considerations as you give the drugs together:

1. CELECOXIB WITH ACE INHIBITORS

Drug to Drug Interactions
Celecoxib may diminish the antihypertensive effect of ACE inhibitors.

Nursing Considerations
Before and during therapy, evaluate the range of motion, swelling, and pain in the affected
joints.
Examine the patient for sulfonamide, aspirin, or NSAID allergies. Celecoxib should not be
given to patients who have these allergies.
Throughout therapy, check the patient for skin rashes regularly. Stop taking it as soon as you
notice a rash; it could be fatal. Stevens-Johnson syndrome is possible. Treat
symptomatically; recurrence may occur if treatment is discontinued.
During treatment, keep an eye out for signs and symptoms of DRESS (fever, rash,
lymphadenopathy, facial swelling). If symptoms appear, discontinue therapy.
Monitor blood pressure while taking CELEBREX and an ACE inhibitor at the same time to
ensure that the desired blood pressure is achieved.
Monitor for signs of worsening renal function when using CELEBREX and ACE inhibitors in
patients who are elderly, volume-depleted, or impaired renal function.
Patients should be adequately hydrated when these drugs are administered concurrently.
Assess renal function at the start of the concomitant treatment and regularly after that.

2. AMITRIPTYLINE HYDROCHLORIDE WITH BARBITURATES

Drug to Drug Interactions

Increased response (especially CNS depression) to barbiturates.

Induce metabolism and decrease therapeutic efficacy of amitriptyline. Monitor drug effects
closely.

Nursing Considerations

Restrict drug access for depressed and potentially suicidal patients.

Give IM only when oral therapy is impossible.
Do not administer IV.
Administer a major portion of the dose at bedtime if drowsiness and severe anticholinergic
effects occur (note that the elderly may not tolerate single daily dose therapy).
Reduce dosage if minor side effects develop; discontinue if serious side effects occur.
Arrange for CBC if a patient develops a fever, sore throat, or other signs of infection.

3. ACETYLCYSTEINE WITH ACTIVATED CHARCOAL

Drug to Drug Interactions
Administration of activated charcoal and oral acetylcysteine at the same time may cause a
reduction in acetylcysteine (NAC) absorption.

Nursing Considerations
Monitor signs of angioedema, including rashes, raised patches of red or white skin (welts),
burning/itching skin, swelling in the face, and difficulty breathing. Notify the physician of
these signs immediately.
Monitor other signs of allergic reactions and anaphylaxis, especially after IV administration.
Signs include pulmonary symptoms (tightness in the throat and chest, wheezing, cough,
dyspnea) and skin reactions (rash, pruritus, urticaria). Notify the physician or nursing staff
immediately if these reactions occur.
Monitor signs of bronchospasm and respiratory irritation, including wheezing, cough,
dyspnea, increased secretions, and tightness in the chest and throat. Report excessive or
prolonged respiratory problems to the physician.
When used as a mucolytic, assess the quantity and consistency of sputum to help document
whether this drug is successful in reducing the viscosity of respiratory secretions.

4. Budesonide inhalation with Ketoconazole

Drug to Drug Interactions

Budesonide inhalation will decrease the level or effect of ketoconazole by altering drug
metabolism.

Nursing Considerations
Monitor patients for signs of hypercorticism—acne, bruising, moon face, swollen ankles,
hirsutism, skin striae, buffalo hump—which could indicate a need to decrease the dosage.
Instruct patients to rinse and gargle after each use of a steroid inhaler (budesonide
inhalation) to prevent thrush (candidiasis).
Monitor for an allergic response: patients allergic to other azole antifungals may be allergic
to ketoconazole.

5. CLOBAZAM WITH HORMONAL CONTRACEPTIVES

Drug to Drug Interactions

Hormonal contraceptives may not be reliable when coadministered with clobazam.

Clobazam is a weak CYP3A4 inducer.
As some hormonal contraceptives are metabolized by CYP3A4, their effectiveness may be
diminished when given with Clobazam.

Nursing Considerations
Prescribers should monitor patients for somnolence and sedation, particularly with
concomitant use of other central nervous system depressants.
 Prescribers should caution patients against engaging in hazardous activities requiring mental
alertness, such as operating dangerous machinery or motor vehicles, until the effect of
clobazam is known.

6. ESMOLOL HYDROCHLORIDE WITH ANTIDIABETIC AGENTS

Drug to Drug Interactions

Concomitant use of beta-blockers and antidiabetic agents can increase the effect of the
antidiabetic agents.
Concomitant use of Esmolol hydrochloride 10 mg/ml and insulin or oral antidiabetic drugs
may intensify the blood sugar lowering effect (especially non-selective beta-blockers).

Nursing Considerations
Monitor BP, pulse, and ECG, during esmolol infusion. Hypotension may have its onset during
the initial titration phase; thereafter the risk increases with increasing doses. Usually, the
hypotension experienced during esmolol infusion is resolved within 30 min after the infusion
is reduced or discontinued.
Change injection site if a local reaction occurs. IV site reactions (burning, erythema) or
diaphoresis may develop during infusion. Both reactions are temporary. Blood chemistry
abnormalities have not been reported.
Overdose symptoms: Discontinue administration if the following symptoms occur:
bradycardia, severe dizziness or drowsiness, dyspnea, bluish-colored fingernails or palms of
hands, seizures.

7. INDOMETHACIN WITH AMINOGLYCOSIDES

Drug to Drug Interactions

When indomethacin is used in combination with aminoglycosides (for example, gentamicin)

the blood levels of the methotrexate or aminoglycoside may increase, presumably because
their elimination from the body is reduced.

Nursing Considerations

Be aware that patients may be at increased risk for CV events, and GI bleeding; monitor
accordingly.
Do not give SR tablets for gouty arthritis.
Give drugs with food or after meals if GI upset occurs.
Arrange for periodic ophthalmologic examination during long-term therapy.
Discontinue drugs if eye changes or symptoms of hepatic or renal impairment occur.
For overdose, use emergency procedures—gastric lavage, induction of emesis, support.
Test renal function between doses. If severe renal impairment is noted, do not give the next
dose.
8. ISONIAZID WITH ACETAMINOPHEN

Drug to Drug Interactions

Using acetaminophen together with isoniazid may alter the effects of acetaminophen and
cause serious side effects that may affect your liver.
The combination of isoniazid and acetaminophen has caused severe hepatotoxicity in at
least one patient; studies in rats have demonstrated that pre-treatment with isoniazid
potentiates acetaminophen hepatotoxicity.

Nursing Considerations
Be alert for signs of drug-induced hepatitis, including anorexia, abdominal pain, severe
nausea and vomiting, yellow skin or eyes, fever, sore throat, malaise, weakness, facial
edema, lethargy, and unusual bleeding or bruising.

9. MESALAMINE WITH WARFARIN

Drug to Drug Interactions

This combination has the potential to alter the effects of warfarin through an unknown
mechanism.

Nursing Considerations
Advise patient about the likelihood of GI problems such as nausea, diarrhea, vomiting,
belching, flatulence, and anal irritation. Instruct patients to report severe or prolonged GI
reactions, or signs of pancreatitis such as upper abdominal pain (especially after eating),
indigestion, weight loss, and oily stools.
Watch for signs of bleeding and hemorrhage, including bleeding gums, nosebleeds, unusual
bruising, coughing up blood, black/tarry stools, hematuria, or a fall in hematocrit or blood
pressure.

10. RIFAMPICIN WITH PROBENECID

Drug to Drug Interactions

Concomitant use with probenecid increases the concentration of rifampicin (rifampin) which
may increase the risk of rifampin toxicities.

Nursing Considerations
Monitor for adverse reactions during co-administration.
Advise patients about possible discoloration of tears, saliva, urine, and other body fluids.
Instruct the patient to notify the physician if discoloration becomes troublesome. Advise
patients about the likelihood of GI reactions (nausea, vomiting, diarrhea, flatulence,
abdominal pain, heartburn).

Give the adverse reactions of the following drugs on the systems indicated:
1.CIMETIDINE – Gastrointestinal

Common (1% to 10%): Constipation, diarrhea, flatulence, nausea, vomiting.

Rare (0.01% to 0.1%): Acute pancreatitis/pancreatitis.

2. ESTERIFIED ESTROGEN – Central Nervous System

Frequency not reported: Migraine, dizziness, headache, exacerbation of epilepsy, dementia,

chorea.

3. GENTAMICIN SULFATE – Respiratory

Frequency not reported: Laryngeal edema, postoperative respiratory distress, pulmonary
fibrosis, respiratory depression.

4. ILOPERIDONE – EENT
Common (1% to 10%): Blurred vision, conjunctivitis, nasopharyngitis, nasal congestion.

5. MEROPENEM – Central Nervous System

Common (1% to 10%): Headache.
Uncommon (0.1% to 1%): Dizziness, seizure, paresthesia, somnolence, syncope, asthenia.
Frequency not reported: Hearing loss, other adverse central nervous system (CNS)
experiences.

6. SIMVASTATIN – Respiratory
Common (1% to 10%): Respiratory tract infection, bronchitis, sinusitis
Post-marketing reports: Interstitial lung disease

7. TROSPIUM CHLORIDE – EENT

More common: Blurred vision, dry mouth, sleepiness, or unusual drowsiness.
Less common: Dry eyes, sore throat.
Incidence not known: Dry throat, changes in vision, red, irritated eyes.

8. DESMOPRESSIN ACETATE – Gastrointestinal

Mild abdominal cramps and nausea in 2% of patients.
Dyspepsia and vomiting have rarely been associated with DDAVP nasal spray.

9. ETHAMBUTOL HYDROCHLORIDE – Musculoskeletal

 Very rare (less than 0.01%): Joint pain.

10. PROMETHAZINE HYDROCHLORIDE – Metabolic

Frequency not reported: Anorexia, loss of appetite, appetite stimulation.