Drug Profiling PHARMACOLOGY

Drug Profiling
Drug profiles are accurate scientific descriptions of medications that are

presented as "drug profiles." Each profile is presented uniformly and briefly
discusses the chemistry, pharmacology, synthesis, precursors, analysis, physical
form (such as powder, tablet), and mode of use of each chemical (e.g. ingested,
snorted, injected).
In order to try to relate a drug seizure to a synthetic production process or
to a potential precursor, or to look into potential links between other seizures in
order to reveal dealer-user networks, drug profiling attempts to extract
information from the drug sample.
Cardiovascular System
The heart, blood vessels (arteries and veins), and blood flow are all parts
of the cardiovascular system. Blood that is abundant in oxygen (O2), nutrients,
and hormones moves through vessels called arteries, which narrow to arterioles
and then to capillaries. In addition to carrying nutrients to the body's cells,
capillaries also take in wastes such carbon dioxide (CO2), urea, creatinine, and
ammonia. Small venules and larger veins restore the deoxygenated blood to
circulation so that the lungs and kidneys can remove it along with other waste
materials. The energy source for circulating blood to the body's cells is the
heart's pumping motion. Blood flow can be slowed down by vascular obstruction.
AGENTS USED TO TREAT HEART FAILURE

I. Antianginal Drugs
Antianginal medications are used to treat angina pectoris, a condition
characterized by acute heart pain brought on by insufficient blood flow to the
myocardium as a result of coronary artery spasms or plaque occlusions. Pain
occurs from a reduction in oxygen delivery to the myocardium due to decreased
blood flow. Patients who experience anginal discomfort typically describe it as
tightness, pressure in the middle of the chest, and agony that travels down the
left arm. Severe angina pectoris frequently causes referred pain in the left arm
and neck. Anginal assaults could result in MI (heart attack). Anginal pain often
only lasts a few minutes. To assess the degree of coronary artery blockage and
later to treat the problem, it may be necessary to do stress tests,
echocardiograms, cardiac profile laboratory testing, and cardiac catheterization.
AMLODIPINE
Drug Information Amlodipine is a calcium channel blocker used to
treat hypertension and angina. Amlodipine is
frequently used to treat angina and excessive blood
pressure. Nitric oxide (NO), a vital vasodilator that
lowers blood pressure, and antioxidant capabilities
are both present in amlodipine. Amlodipine's
possibility for a single daily dose is one of its
2
appealing qualities.
Mechanism of Action Although the precise method by which amlodipine
reduces angina symptoms has not yet been fully
explained, the mechanism of action is probably two-
fold:
Amlodipine reduces the overall peripheral resistance

(afterload) that the heart muscle must work against
by dilating the peripheral arterioles. Amlodipine is
administered while the heart rate is steady, so the
decreased work of the heart lowers the need for
oxygen and myocardial energy.
Another potential method by which amlodipine

lowers blood pressure is dilatation of the main
coronary arteries and coronary arterioles, both in
healthy and ischemic areas. In patients with coronary
artery spasm (Prinzmetal's or variant angina), the
dilatation increases myocardial oxygen delivery and
lessens coronary vasoconstriction brought on by
smoking.
Clinical Use Management of hypertension, coronary artery
disease (chronic stable angina, vasospastic
[Prinzmetal’s or variant] angina).
Side Effects Frequent (greater than 5%): Peripheral edema,
headache, flushing. Occasional (5%–1%):
Dizziness, palpitations, nausea, unusual fatigue or
weakness (asthenia). Rare (less than 1%): Chest
pain, bradycardia, orthostatic hypotension.
Adverse Reactions Overdose may produce excessive peripheral
vasodilation, marked hypotension with reflex
tachycardia, syncope.
Nursing Considerations BASELINE ASSESSMENT
Assess baseline renal/hepatic function tests, B/P,
apical pulse.
INTERVENTION/EVALUATION
Assess B/P (if systolic B/P is less than 90 mm Hg,
withhold medication, contact physician). Assess for
peripheral edema behind medial malleolus (sacral
area in bedridden pts). Assess skin for flushing.
Question for headache, asthenia.
PATIENT/FAMILY TEACHING
 Do not abruptly discontinue medication.
 Compliance with therapy regimen is essential
3
to control hypertension.
 Avoid tasks that require alertness, motor skills
until response to drug is established. • Do not
ingest grapefruit products.
Table 1. Amlodipine
ATENOLOL
Drug Information Synthetic beta-1 selective blocker atenolol is used to
treat hypertension, chronic angina, and to lower
mortality in individuals with known or suspected
myocardial infarction who are hemodynamically
stable.
Mechanism of Action Atenolol is a beta-blocker with cardioselectivity, so
named because it selectively binds to the β1-
adrenergic receptor as an antagonist up to a
reported 26 fold more than β2 receptors.15 Due to
the higher population of the β1 receptor in cardiac
tissue, selective activity at this receptor results in
cardioselectivity. Therapeutic doses can still cause
some binding to β2 and potentially β3 receptors, but
the effects caused by antagonizing these receptors
are greatly diminished compared to those caused by
non-selective drugs. Due to the Gs coupling between
the β1 and β2 receptors, inhibiting their activation
decreases the activity of adenylyl cyclase and the
downstream signaling that it produces via cyclic
adenosine monophosphate and protein kinase A.
(PKA).
Clinical Use Treatment of hypertension, alone or in combination
with other agents; management of angina pectoris;
management of pts with definite/suspected MI to
reduce CV mortality. OFF-LABEL: Arrhythmia (esp.
supraventricular and ventricular tachycardia),
thyrotoxicosis.
Side Effects Atenolol is generally well tolerated, with mild and
transient side effects. Frequent: Hypotension
manifested as cold extremities, constipation or
diarrhea, diaphoresis, dizziness, fatigue, headache,
nausea. Occasional: Insomnia, flatulence, urinary
frequency, impotence or decreased libido,
depression. Rare: Rash, arthralgia, myalgia,
confusion (esp. in the elderly), altered taste.
Adverse Reactions Overdose may produce profound bradycardia,
hypotension. Abrupt withdrawal may result in
diaphoresis, palpitations, headache, tremors. May
precipitate HF, MI in pts with cardiac disease; thyroid
4
storm in pts with thyrotoxicosis; peripheral ischemia
in pts with existing peripheral vascular disease.
Hypoglycemia may occur in previously controlled
diabetes. Thrombocytopenia (unusual bruising,
bleeding) occurs rarely. Antidote: Glucagon.
Assess B/P, apical pulse immediately beforedrug is
administered (if pulse is 60/min or less, or systolic
B/P is less than 90 mm Hg, withhold medication,
contact physician). Antianginal: Record onset,
quality (sharp, dull, squeezing), radiation, location,
intensity, duration of anginal pain, precipitating
factors (exertion, emotional stress). Assess baseline
renal/hepatic function tests.
Monitor B/P for hypotension, pulse for bradycardia,
respiration for difficulty in breathing, ECG. Monitor
daily pattern of bowel activity, stool consistency.
Assess for evidence of HF: dyspnea (particularly on
exertion or lying down), nocturnal cough, peripheral
edema, distended neck veins. Monitor I&O
(increased weight, decreased urinary output may
indicate HF). Assess extremities for pulse quality,
changes in temperature (may indicate worsening
peripheral vascular disease). Assist with ambulation
if dizziness occurs.
 Compliance with therapy essential to control
hypertension, angina.
 To reduce hypotensive effect, go from lying to
standing slowly.
until response to drug is established. • Advise
diabetic pts to monitor blood glucose carefully
(may mask signs of hypoglycemia).
 Report dizziness, depression, confusion, rash,
unusual bruising/bleeding.
 Outpatients should monitor B/P, pulse before
taking medication, following correct technique.
 Restrict salt, alcohol intake.
 Therapeutic antihypertensive effect noted in
1–2 wks.
Table 2. Atenolol
5
DILTIAZEM
Drug Information A calcium channel blocker called diltiazem is used to
treat hypertension and control chronic stable angina.
A derivative of benzothiazepine having
antihypertensive and vasodilating effects is diltiazem.
It belongs to the group of medicines known as non-
dihydropyridine calcium channel blockers and was
given FDA approval in 1982. It operates by a number
of different methods, but it mostly inhibits calcium
influx into cardiac and vascular smooth muscle
during depolarization. Diltiazem exhibits an
intermediate specificity to target both the cardiac and
vascular smooth muscle in comparison to
dihydropyridine medicines such as nifedipine, which
preferentially acts on vascular smooth muscle, and
verapamil, which directly acts on the heart muscle.
Diltiazem, a powerful vasodilator, is used clinically to
treat cardiovascular disorders such hypertension,
chronic stable angina, atrial fibrillation, and atrial
flutter. It is also used to treat irregular heartbeats and
as an anti-anginal drug.
Mechanism of Action Diltiazem primarily prevents calcium ions from
entering the heart muscle during depolarization.
Reduced intracellular calcium concentrations cause
smooth muscle to relax more, which lowers blood
pressure and dilates the arteries.
Clinical Use PO: Treatment of angina due to coronary artery
spasm (Prinzmetal’s variant angina), chronic stable
angina (effort-associated angina). Treatment of
hypertension. Parenteral: Temporary control of rapid
ventricular rate in atrial fibrillation/flutter. Rapid
conversion of paroxysmal supraventricular
tachycardia (PSVT) to normal sinus rhythm.
Side Effects Frequent (10%–5%): Peripheral edema, dizziness,
light-headedness, headache, bradycardia, asthenia.
Occasional (5%–2%): Nausea, constipation,
flushing, ECG changes. Rare (less than 2%): Rash,
micturition disorder (polyuria, nocturia, dysuria,
frequency of urination), abdominal discomfort,
drowsiness.
Adverse Reactions Abrupt withdrawal may increase frequency, duration
of angina, HF; second- or third-degree AV block
occurs rarely. Overdose produces nausea,
drowsiness, confusion, slurred speech, profound
bradycardia. Antidote: Glucagon, insulin drip with
6
continuous calcium infusion.
Record onset, type (sharp, dull, squeezing),
radiation, location, intensity, duration of anginal pain,
precipitating factors (exertion, emotional stress).
Assess baseline renal/hepatic function tests. Assess
B/P, apical pulse immediately before drug is
administered. Obtain baseline ECG in pts with
history of arrhythmia.
Assist with ambulation if dizziness occurs. Assess for
peripheral edema. Monitor pulse rate for
bradycardia. Assess B/P, renal function, LFT, ECG
with IV therapy. Question for asthenia, headache.
to control anginal pain.
 To avoid postural dizziness, go from lying to
standing slowly.
until response to drug is established.
 Report palpitations, shortness of breath,
pronounced dizziness, nausea, constipation.
 Avoid alcohol (may increase risk of
hypotension or vasodilation).
Table 3. Diltiazem
METOPROLOL
Drug Information Metoprolol is a beta-blocker used to treat
hypertension, angina, and to lower myocardial
infarction mortality.
Mechanism of Action Metoprolol is a beta-1-adrenergic receptor inhibitor
that is only slightly effective on beta-2 receptors and
is only specific for cardiac cells. The negative
chronotropic and inotropic effects of this inhibition
reduce cardiac output without causing any activity
that would contribute to membrane stability or
intrinsic sympathomimetics.
Clinical Use Immediate-Release: Treatment of hemodynamically
stable acute myocardial infarction (AMI) to reduce
CV mortality. Long-term treatment of angina pectoris.
Management of hypertension. Extended- Release:
Long-term treatment of angina pectoris.
7
Management of hypertension. Treatment of stable
symptomatic HF of ischemic, hypertensive, or
cardiomyopathic origin to reduce rate of
hospitalization in pts receiving ACE inhibitors,
diuretics, and/or digoxin. Injection: Treatment of
hemodynamically stable acute myocardial infarction
(AMI) to reduce CV mortality. OFF-LABEL:
Treatment of ventricular arrhythmias, migraine
prophylaxis, essential tremor, aggressive behavior,
prevent reinfarction post-MI, prevent/treat atrial
fibrillation/atrial flutter, hypertrophic cardiomyopathy,
thyrotoxicosis.
Side Effects Metoprolol is generally well tolerated, with transient
and mild side effects. Frequent: Diminished sexual
function, drowsiness, insomnia, unusual fatigue/
weakness. Occasional: Anxiety, diarrhea,
constipation, nausea, vomiting, nasal congestion,
abdominal discomfort, dizziness, difficulty breathing,
cold hands/feet. Rare: Altered taste, dry eyes,
nightmares, paresthesia, allergic reaction (rash,
pruritus).
hypotension, bronchospasm. Abrupt withdrawal may
result in diaphoresis, palpitations, headache,
tremulousness, exacerbation of angina, MI,
ventricular arrhythmias. May precipitate HF, MI in pts
with heart disease, thyroid storm in those with
thyrotoxicosis, peripheral ischemia in those with
existing peripheral vascular disease. Hypoglycemia
may occur in pts with previously controlled diabetes
(may mask signs of hypoglycemia). Antidote:
Glucagon.
Assess baseline renal function, LFT. Assess B/P,
apical pulse immediately before drug administration
(if pulse is 60/min or less or systolic B/P is less than
90 mm Hg, withhold medication, contact physician).
Antianginal: Record onset, type (sharp, dull,
squeezing), radiation, location, intensity, duration of
anginal pain, precipitating factors (exertion,
emotional stress).
Measure B/P near end of dosing interval (determines
whether B/P is controlled throughout day). Monitor
B/P for hypotension, respiration for shortness of
8
breath. Assess pulse for quality, rate, rhythm.
Assess for evidence of HF: dyspnea (esp. on
exertion, lying down), night cough, peripheral edema,
distended neck veins. Monitor I&O (increased
weight, decreased urinary output may indicate HF).
Therapeutic response to hypertension noted in 1–2
wks.
to control hypertension,arrhythmias.
 If dose is missed, take next scheduled dose
(do not double dose).
 Go from lying to standing slowly.
 Report excessive fatigue, dizziness.
 Do not use nasal decongestants, OTC cold
preparations (stimulants) without physician
approval.
 Monitor B/P, pulse before taking medication. •
Restrict salt, alcohol intake.
Table 4. Metropolol
NADOLOL
Drug Information A non-selective beta-adrenergic antagonist called
nadolol is used to treat hypertension, angina
pectoris, and arrhythmias.
Mechanism of Action Despite being referred to as a non-selective beta
blocker, beta 3 adrenal receptors are not affected by
nadolol. By inhibiting cyclic AMP and its signaling
pathway, antagonistic beta-1 and beta-2
adrenoceptors in the heart reduce the strength and
speed of contractions as well as the speed of
relaxation and conduction. Beta-2 adrenoceptor
antagonists prevent the smooth muscle cells in the
vasculature from relaxing, raising peripheral vascular
resistance and lowering the risk of severe
hypotension. The decrease in insulin sensitivity
linked to nadolol use may be a result of the rise in
peripheral vascular resistance. Antagonism of beta-
1 adrenoceptors in the kidney's juxtaglomerular
apparatus prevents the release of renin, which in
turn prevents angiotensin II-mediated
vasoconstriction, aldosterone-mediated water
9
retention, and the release of
epinephrine. Antagonism of beta-2 adrenoceptors in
the liver and skeletal muscle prevents
glycogenolysis, in the lungs.
Clinical Use Nadolol is used to treat high blood pressure either
alone or in conjunction with other drugs. Additionally,
it prevents angina (chest pain). The drug nadolol
belongs to the class of drugs known as beta
blockers. It improves blood flow and lowers blood
pressure by relaxing blood vessels and lowering
heart rate.
Side Effects There could be coughing, sleepiness, dizziness, and
weakness. Notify your doctor or pharmacist as soon
as possible if any of these side effects persist or get
worse. When getting out of a sitting or laying
posture, take it gently to lessen the chance of feeling
lightheaded and dizzy. Your hands and feet may
become cold as a result of this medication's potential
blood flow reduction. Smoking might make this effect
worse. Avoid using smoke and wear warm clothing.
Adverse Reactions In some cases, nadolol may result in cardiac failure.
If you experience chest pain or discomfort, dilated
neck veins, extreme exhaustion, erratic breathing, an
irregular heartbeat, shortness of breath, swelling of
the face, fingers, feet, or lower legs, weight gain,
wheezing, or any other symptoms, consult your
doctor straight once.
Nursing Considerations When helping the patient get out of a supine
position, check for orthostatic hypotension. Keep an
eye on your daily weight and your intake-to-output
ratios. Regularly check the patient for signs of fluid
overload, such as jugular venous distention,
tiredness, peripheral edema, dyspnea, rales or
crackles, and dyspnea with rales.
Table 5. Nadolol
NIFEDIPINE
Drug Information Nifedipine is a dihydropyridine calcium channel
blocker used to treat hypertension and various forms
of angina pectoris.
Mechanism of Action Vascular smooth muscle and cardiac cells' voltage-
gated L-type calcium channels are blocked by
nifedipine. This obstruction lessens peripheral artery
vascular resistance and dilates coronary arteries by
preventing calcium ions from entering cells during
depolarization. Angina is relieved by these
10
movements, which lower blood pressure and boost
the heart's oxygenation.
Clinical Use Immediate-/Extended-Release: Treatment of
angina due to coronary artery spasm (Prinzmetal’s
variant angina), chronic stable angina (effort-
associated angina). Extended-Release: Treatment
of hypertension. OFF-LABEL: Treatment of
Raynaud’s phenomenon, pulmonary hypertension,
preterm labor, prevention/treatment of high-altitude
pulmonary edema.
Side Effects Frequent (30%–11%): Peripheral edema, headache,
flushed skin, dizziness. Occasional (12%–6%):
Nausea, shakiness, muscle cramps/pain,
drowsiness, palpitations, nasal congestion, cough,
dyspnea, wheezing. Rare (5%–3%): Hypotension,
rash, pruritus, urticaria, constipation, abdominal
discomfort, flatulence, sexual dysfunction.
Adverse Reactions May precipitate HF, MI in pts with cardiac disease,
peripheral ischemia. Overdose produces nausea,
drowsiness, confusion, slurred speech. Antidote:
Glucagon.
Concurrent therapy with sublingual nitroglycerin may
be used for relief of anginal pain. Record onset, type
(sharp, dull, squeezing), radiation, location, intensity,
duration of angina pain; precipitating factors
(exertion, emotional stress). Check B/P for
hypotension immediately before giving medication.
Assist with ambulation if light-headedness, dizziness
occurs. Assess for peripheral edema. Assess skin for
flushing. Monitor LFT. Observe for signs/symptoms
of HF.
 Go from lying to standing slowly.
 Report palpitations, shortness of breath,
pronounced dizziness, nausea, exacerbations
of angina.
 Avoid alcohol; concomitant grapefruit product
use
Table 6. Nifedepine
PROPRANOLOL
11
Drug Information A beta blocker is a class of medication that includes
propranolol. Propranolol functions similarly to other
beta blockers by altering how your body reacts to
some nerve impulses, particularly those in the heart.
It lowers your heart rate and facilitates simpler blood
circulation throughout your body for your heart.
Mechanism of Action Competitively blocks both β1 and β2 adrenergic
receptors. When access to β-receptor sites is
blocked by Propranolol HCl, the chronotropic,
inotropic, and vasodilator responses to beta-
adrenergic stimulation are decreased
proportionately.
Clinical Use Treatment of angina pectoris, supraventricular
arrhythmias, essential tremors, hypertension,
ventricular tachycardia, symptomatic treatment of
obstructive hypertrophic cardiomyopathy, treatment
of proliferating infantile hemangioma requiring
systemic therapy, migraine headache prophylaxis,
pheochromocytoma, prevention of MI. Hemangeol:
Treatment of proliferating infantile hemangioma
needing systemic therapy. OFF-LABEL: Treatment
adjunct for anxiety, tremor due to Parkinson’s
disease, alcohol withdrawal, aggressive behavior,
schizophrenia, antipsychotic-induced akathisia,
variceal hemorrhage, acute panic.
Side Effects Frequent: Diminished sexual function, drowsiness,
difficulty sleeping, unusual fatigue/weakness.
Occasional: Bradycardia, depression, sensation of
coldness in extremities, diarrhea, constipation,
anxiety, nasal congestion, nausea, vomiting. Rare:
Altered taste, dry eyes, pruritus, paresthesia.
hypotension. Abrupt withdrawal may result in
diaphoresis, palpitations, headache, tremulousness.
May precipitate HF, MI in pts with cardiac disease,
thyroid storm in pts with thyrotoxicosis, peripheral
ischemia in pts with existing peripheral vascular
disease. Hypoglycemia may occur in pts with
previously controlled diabetes. Antidote: Glucagon.
Assess baseline renal function, LFT. Assess B/P,
apical pulse immediately before administering drug
(if pulse is 60/min or less or systolic B/P is less than
90 mm Hg, withhold medication, contact physician).
Angina: Record onset, quality, radiation, location,
intensity, duration of anginal pain, precipitating
12
factors (exertion, emotional stress).
Assess pulse for quality, regularity, bradycardia.
Monitor ECG for cardiac arrhythmias. Assess fingers
for color, numbness (Raynaud’s). Assess for
evidence of HF (dyspnea [particularly on exertion or
lying down], night cough, peripheral edema,
distended neck veins). Monitor I&O (increase in
weight, decrease in urinary output may indicate HF).
Assess for rash, fatigue, behavioral changes.
Therapeutic response time ranges from a few days
to several wks. Measure B/P near end of dosing
interval (determines if B/P is controlled throughout
day).
to control hypertension, arrhythmia, anginal
pain.
 To avoid hypotensive effect, slowly go from
lying to standing.
 Report excessively slow pulse rate (less than
50 beats/min), peripheral numbness,
dizziness.
 Do not use nasal decongestants, OTC cold
preparations (stimulants) without physician
approval. • Restrict salt, alcohol intake.
Table 7. Propranolol
VERAPAMIL
Drug Information Verapamil is a non-dihydropyridine calcium channel
blocker used in the treatment of angina, arrhythmia,
and hypertension
Mechanism of Action Verapamil prevents calcium (and potentially sodium)
ions from entering conductive and contractile cardiac
cells and vascular smooth muscle cells through slow
channels.
Clinical Use Parenteral: Management of supraventricular
tachyarrhythmias (SVT, rapid
conversion to sinus rhythm), temporary
control of rapid ventricular rate in atrial
flutter/fibrillation. PO: Treatment of
13
angina at rest (e.g., vasospastic angina, unstable
angina, chronic stable angina).
Control of ventricular rate at rest and
during stress in chronic atrial flutter
and/or fibrillation. Management of hypertension.
Prophylaxis of repetitive
paroxysmal supraventricular tachycardia
(PSVT).
Side Effects Frequent (7%): Constipation. Occasional (4%–2%):
Dizziness, light-headedness, headache, asthenia,
nausea, peripheral edema, hypotension. Rare (less
than 1%): Bradycardia, dermatitis, rash.
Adverse Reactions Rapid ventricular rate in atrial flutter/fibrillation,
marked hypotension, extreme bradycardia, HF,
asystole, second- or third-degree AV block occur
rarely.
Obtain baseline ECG. Record onset, type (sharp,
dull, squeezing), radiation, location, intensity,
duration of anginal pain, precipitating factors
(exertion, emotional stress). Check B/P for
hypotension, pulse for bradycardia immediately
before giving medication.
Assess pulse for quality, rate, rhythm. Monitor B/P.
Monitor ECG for cardiac changes, particularly
prolongation of PR interval. Notify physician of any
significant ECG interval changes. Assist with
ambulation if dizziness occurs. Assess for peripheral
edema. For those taking oral form, monitor daily
pattern of bowel activity, stool consistency.
Therapeutic serum level: 0.08– 0.3 mcg/mL; toxic
serum level: N/A.
to control anginal pain.
 Go from lying to standing slowly. • Avoid tasks
that require alertness, motor skills until
response to drug is established.
 Limit caffeine.
 Avoid or limit alcohol.
 Report continued, persistent angina pain,
irregular heartbeats, shortness of breath,
14
swelling, dizziness, constipation, nausea,
hypotension.
 Avoid grapefruit products.
Table 8. Verapamil
II. Anticoagulant Drugs

Anticoagulants are used to prevent the development of clots. They
function differently than thrombolytics because they do not dissolve already-
formed blood clots as a preventative measure to stop new clots from developing.
Patients who have venous and arterial problems that increase their risk of
developing clots are treated with anticoagulants. Deep venous thrombosis (DVT)
and pulmonary embolism (PE) are venous issues, while coronary thrombosis,
also known as myocardial infarction (MI), the existence of artificial heart valves,
and cerebrovascular accidents (CVAs), also known as stroke, are arterial issues.
APIXABAN
Drug Information Apixaban is used to treat people with atrial fibrillation
(a condition in which the heart beats erratically,
raising the risk of blood clots forming in the body and
potentially causing strokes) who are not suffering
from heart valve disease prevent strokes or blood
clots.
Mechanism of Action Apixaban inhibits free and clot-bound FXa, and
prothrombinase activity. Apixaban has no direct
effect on platelet aggregation, but indirectly inhibits
platelet aggregation induced by thrombin. By
inhibiting FXa, apixaban decreases thrombin
generation and thrombus development.
Clinical Use Reduces risk for stroke, systemic embolism in pts
with nonvalvular atrial fibrillation. Prophylaxis of DVT
following hip or knee replacement surgery.
Treatment of DVT and PE. Reduces risk of recurrent
DVT/PE following initial therapy. OFF-LABEL:
Prevention of recurrent stroke or TIA.
Side Effects Rare (3%–1%): Nausea, ecchymosis.
Adverse Reactions Increased risk for bleeding/hemorrhagic events. May
cause serious, potentially fatal bleeding,
accompanied by one or more of the following: a
decrease in Hgb of 2 g/ dL or more; a need for 2 or
more units of packed RBCs; bleeding occurring at
one of the following sites: intracranial, intraspinal,
intraocular, pericardial, intra-articular, intramuscular
with compartment syndrome, retroperitoneal. Serious
reactions include jaundice, cholestasis, cytolytic
hepatitis, Stevens-Johnson syndrome,
15
hypersensitivity reaction, anaphylaxis.
Obtain baseline CBC. Question history of bleeding
disorders, recent surgery, spinal punctures,
intracranial hemorrhage, bleeding ulcers, open
wounds, anemia, hepatic impairment. Obtain full
medication history including herbal products.
Periodically monitor CBC, stool for occult blood. Be
alert for complaints of abdominal/ back pain,
headache, confusion, weakness, vision change (may
indicate hemorrhage). Question for increased
menstrual bleeding/discharge. Assess for any sign of
bleeding: bleeding at surgical site, hematuria, blood
in stool, bleeding from gums, petechiae, ecchymosis.
 Do not take/discontinue any medication
except on advice from physician.
 Avoid alcohol, aspirin, NSAIDs, herbal
supplements, grapefruit products.
 Consult physician before surgery, dental work.
 Use electric razor, soft toothbrush to prevent
bleeding.
 Report blood-tinged mucus from coughing,
heavy menstrual bleeding, headache, vision
problems, weakness, abdominal pain,
frequent bruising, bloody urine or stool, joint
pain or swelling.
Table 9. Apixaban
ARGATROBAN
Drug Information It is recommended as an anticoagulant for
prophylaxis or treatment of thrombosis in individuals
with heparin-induced thrombocytopenia. Argatroban
is a synthetic direct thrombin inhibitor generated from
L-arginine. Direct thrombin inhibitor argatroban binds
reversibly to the thrombin active site.
Mechanism of Action Argatroban inhibits thrombin-catalyzed or -induced
processes, such as the production of fibrin, activation
of coagulation factors V, VIII, and XIII, protein C
synthesis, and platelet aggregation.
Clinical Use Prophylaxis or treatment of thrombosis
in heparin-induced thrombocytopenia
(HIT) in pts with HIT or at risk of developing
16
HIT undergoing percutaneous
coronary procedures. OFF-LABEL: Maintain
extracorporeal circuit patency of
continuous renal replacement therapy
(CRRT) in pts with HIT.
Side Effects Frequent (8%–3%): Dyspnea, hypotension,
fever, diarrhea, nausea, pain, vomiting,
infection, cough.
Adverse Reactions Ventricular tachycardia, atrial fibrillation
occur occasionally. Major bleeding, sepsis
occur rarely.
Obtain CBC, PT, aPTT. Determine initial B/P.
Minimize need for multiple injection sites, blood
draws, catheters.
Assess for any sign of bleeding: bleeding
at surgical site, hematuria, melena,
bleeding from gums, petechiae, ecchymoses,
bleeding from injection sites.
Handle pt carefully and infrequently to
prevent bleeding. Assess for decreased
B/P, increased pulse rate, complaint of
abdominal/back pain, severe headache
(may indicate hemorrhage). Monitor
ACT, PT, aPTT, platelet count, Hgb, Hct.
Question for increase in discharge during
menses. Assess for hematuria. Observe
skin for any occurring ecchymoses, petechiae,
hematoma. Use care in removing
any dressing, tape.
 Use electric razor, soft toothbrush to prevent
cuts, gingival trauma.
 Report any sign of bleeding, including
red/dark urine, black/red stool, coffee-ground
vomitus, blood-tinged mucus from cough.
Table 10. Argatroban
BIVALIRUDIN
Drug Information Patients having percutaneous coronary intervention
for acute myocardial infarction are managed and
treated with bivalirudin. It belongs to the class of
17
medications called direct thrombin inhibitors.
Mechanism of Action Bivalirudin specifically inhibits thrombin by binding
both to the catalytic site and the anion-binding
exosite on thrombin within thrombi and the
circulation.
Clinical Use Anticoagulant in pts undergoing percutaneous
transluminal coronary angioplasty
(PTCA) in conjunction with aspirin and
provisional glycoprotein llb/llla inhibitor.
Pts with heparin-induced thrombocytopenia
(HIT) and thrombosis syndrome
(HITTS) while undergoing percutaneous
coronary intervention (PCI) (in conjunction
with aspirin). OFF-LABEL: HIT; STsegment
elevation MI (STEMI) undergoing
PCI.
Side Effects Frequent (42%): Back pain. Occasional
(15%–12%): Nausea, headache, hypotension,
generalized pain. Rare (8%–4%): Injection
site pain, insomnia, hypertension,
anxiety, vomiting, pelvic or abdominal
pain, bradycardia, nervousness, dyspepsia,
fever, urinary retention.
Adverse Reactions Hemorrhagic events occur rarely, characterized
by significant fall in B/P or Hgb/Hct.
Assess CBC, PT/INR, aPTT, renal function.
Determine initial B/P.
Monitor aPTT, CBC, urine and stool specimen
for occult blood, renal function
studies. Monitor for evidence of bleeding.
Assess for decrease in B/P, increase
in pulse rate. Question for increase in
vaginal bleeding during menses.
Table 11. Bivalidurin
DABIGATRAN
Drug Information When an injectable anticoagulant (also known as a
"blood thinner") has been used to treat deep vein
thrombosis (DVT; a blood clot that typically occurs in
18
the leg) and pulmonary embolism (PE; a blood clot in
the lung), dabigatran is used to treat adults and
children 3 months of age and older.
Mechanism of Action Dabigatran (Pradaxa) blocks the thrombin molecule's
active site from activating coagulation factors by
forming a reversible bond with it. According to the
"Adverse Effects" section, it might not have as strong
of an antagonistic effect on thrombin-mediated
platelet aggregation.
Clinical Use Indicated to reduce risk of stroke, systemic
embolism in pts with nonvalvular
atrial fibrillation. Treatment and reduction
of risk of deep vein thrombosis (DVT) and
pulmonary embolism (PE). Prophylaxis of
DVT and PE in pts who have undergone
hip replacement surgery.
Side Effects Frequent (less than 16%): Dyspepsia (heartburn,
nausea, indigestion), diarrhea, upper
abdominal pain.
Adverse Reactions Severe, sometimes fatal, hemorrhagic events,
including intracranial hemorrhage, hemorrhagic
stroke, Gl bleeding, may occur. Hypersensitivity
reactions, including anaphylaxis,
reported in less than 1% of pts.
Obtain CBC (esp. platelet count), BUN,
serum creatinine; GFR, CrCl. Question
history of mechanical heart valve, recent surgery;
hepatic, renal impairment; recent
spinal, epidural procedures; recent hemorrhagic
events (intracranial hemorrhage,
hemorrhagic stroke, GI/GU bleeding).
Receive full medication history and screen
for interactions. Screen for active bleeding.
Obtain aPTT, platelet count if bleeding
occurs. Assess for any signs of bleeding
(hematuria, melena, bleeding from
gums, petechiae, bruising), hematoma,
hypotension, tachycardia, abdominal
pain. Question for increase in discharge
during menses. Use care when removing
adhesives, tape. Monitor for symptoms of
intracranial hemorrhage (altered mental
status, aphasia, lethargy, hemiparesis,
hemiplegia, seizures, vision changes).
19
• Treatment may increase risk of bleeding.
• Report dark or bloody urine,
black or bloody stool, coffee-ground vomitus,
bloody sputum, nosebleeds. • Strokelike
symptoms may indicate bleeding into
the brain; report difficulty speaking, headache,
numbness, paralysis, vision changes,
seizures. • Do not chew, crush, open, or
divide capsules. • Use electric razor, soft
toothbrush to prevent bleeding. • Do not
take newly prescribed medications, including
OTC medications such as ibuprofen or
naproxen, unless approved by physician
who originally started treatment. • Stopping
therapy may increase the risk of blood
clots or stroke.
Table 12. Dabigatran
DESIRUDIN
Drug Information Deep venous thrombosis is a disorder in which risky
blood clots develop in the blood veins of the legs.
Desirudin is used to avoid this disease. Pulmonary
embolism is a disorder that can result from these
blood clots getting stuck in the blood arteries of the
lungs.
Mechanism of Action The anticoagulant properties of desirudin are
demonstrated by its ability to prolong the clotting
time of human plasma. One molecule of desirudin
binds to one molecule of thrombin and thereby
blocks the thrombogenic activity of thrombin.
Clinical Use Desirudin is used to prevent deep venous
thrombosis, a condition in which harmful blood clots
form in the blood vessels of the legs. These blood
clots can travel to the lungs and can become lodged
in the blood vessels of the lungs, causing a condition
called pulmonary embolism.
Side Effects Serious side effects have been reported
with desirudin. See the "Drug Precautions" section.
Common side effects of desirudin include the
following:
 anemia (blood does not carry enough oxygen
to the rest of the body)
 nausea
 bleeding
 injection site irritation
20
Adverse Reactions 1-10%
 Hemorrhage (1-3%)
 Injection site mass (4%)
 Wound secretion (4%)
 Serious hemorrhage (3%)
 Anemia (3%)
 Deep thrombophlebitis (2%)
 Nausea (2%)
 Allergic reaction (2%)
<1%
 Major hemorrhage
 Hypotension
 Leg edema
 Fever
 Decreased hemoglobin
 Hematuria
 Dizziness
 Epistaxis
 Vomiting
 Impaired healing
 Cerebrovascular disorder
 Leg pain
 Hematemesis
 Hematuria
 Leg edema
Nursing Considerations Nursing assessment
 Assess for signs of bleeding (bleeding
gums, nosebleed, unusual bruising; black,
tarry stools; hematuria; fall in hematocrit
or BP; guaiac-positive stools; bleeding
from surgical site). Notify physician if
these occur.
 Assess patient for evidence of thrombosis.
Symptoms depend on area of involvement.
Notify physician immediately; may require
urgent treatment.
 Monitor patients with epidural catheters
frequently for signs of neurological impairment
(midline back pain, numbness or weakness in
lower limbs, bowel and/or bladder
dysfunction). Notify physician immediately if
these occur.
 Observe injection sites for hematomas,
ecchymosis, or inflammation.
21
 Lab Test Considerations: Monitor activated
partial thromboplastin time (aPTT) daily in
patients with increased risk of bleeding and/or
renal impairment. Monitor serum creatinine
daily in patients with renal impairment. Peak
aPTT should not exceed two times control.
Reduce dose or discontinue desirudin until
aPTT is <2 times control; resume at a lower
dose.
o If a patient is switched from oral
anticoagulants to desirudin or from
desirudin to oral anticoagulants,
measure anticoagulant activity closely.
o Thrombin time is not suitable for
monitoring desirudin.
o Monitor CBC. If hematocrit ↓
unexpectedly, assess patient for
potential bleeding sites.
Implementation
o Reconstitute each vial with 0.5 mL of
diluent provided for a concentration of
15.75 mg of desirudin/0.5 mL. Shake
vial gently until fully reconstituted to a
clear colorless solution. Do not
administer solutions that are
discolored, cloudy, or contain a
particulate matter. Reconstituted
solution should be used immediately,
but is stable for 24 hr at room
temperature and protected from light.
Discard unused solution.
o Subcutaneous: Withdraw all
reconstituted solution into syringe with
a 26- or 27-gauge, 1/2-inch length
needle. Inject entire contents
subcutaneously which will deliver 15
mg. Patient should be sitting or lying
down during administration. Rotate
sites between left and right
anterolateral and left and right
posterolateral thigh or abdominal wall.
Inject entire length of needle while
pinching skin between thumb and
forefinger; continue to pinch skin
throughout injection. Do not rub
injection site following injection to
22
prevent bruising.
o Syringe Incompatibility: Do not mix
with other diluents or medications.
o Patient/Family Teaching
o Advise patient to report symptoms of
unusual bleeding or bruising to health
care professional immediately.
o Instruct patient not to take aspirin,
NSAIDs, or herbal products during
therapy without consulting health care
professional.
o
Table 13. Desirudin
FONDAPARINUX
Drug Information In patients undergoing hip surgery, hip or knee
replacement surgery, or abdominal surgery,
fondaparinux injection is used to avoid deep vein
thrombosis (DVT; a blood clot, typically in the leg),
which can result in pulmonary embolism (PE; a blood
clot in the lung).
Mechanism of Action Fondaparinux enhances the natural neutralization of
activated factor X (Factor Xa) by antithrombin by
binding specifically to antithrombin III. The blood
coagulation cascade is disrupted and Factor Xa
activity is inhibited by neutralization, which stops the
generation of thrombin and the growth of thrombi.
Clinical Use Prevention of venous thromboembolism
in pts undergoing total hip replacement,
hip fracture surgery, knee replacement
surgery, abdominal surgery. Treatment of
acute deep vein thrombosis (DVT), acute
pulmonary embolism in conjunction with
warfarin. OFF-LABEL: Prophylaxis of DVT
in pts with history of heparin-induced
thrombocytopenia (HIT), acute symptomatic
superficial vein thrombosis of the legs.
Side Effects Frequent (19%–11%): Anemia, fever,
nausea. Occasional (10%–4%): Edema,
constipation, rash, vomiting, insomnia,
increased wound drainage, hypokalemia. Rare (less
than 4%): Dizziness, hypotension,
confusion, urinary retention, injection
site hematoma, diarrhea, dyspepsia,
headache.
23
Adverse Reactions Accidental overdose may lead to bleeding
complications ranging from local ecchymoses
to major hemorrhage. Thrombocytopenia
occurs rarely.
Assess CBC, renal function test. Evaluate
potential risk for bleeding. Question
history of recent surgery, trauma,
intracranial hemorrhage, GI bleeding.
Question medical history as listed
in Precautions. Ensure that pt has not
received spinal anesthesia, spinal procedures.
Periodically monitor CBC, esp. platelet
count, stool for occult blood (no need
for daily monitoring in pts with normal
presurgical coagulation parameters).
Assess for any signs of bleeding: bleeding
at surgical site, hematuria, blood in
stool, bleeding from gums, petechiae,
ecchymosis, bleeding from injection
sites. Monitor B/P, pulse; hypotension,
tachycardia may indicate bleeding, hypovolemia.
• Usual length of therapy is 5–9
days. • Do not take any OTC medication
(esp. aspirin, NSAIDs). • Report
swelling of hands/feet, unusual back
pain, unusual bleeding/bruising, weakness.
Treatment may increase risk of
bleeding into the brain; report confusion,
one-sided weakness, trouble
speaking, seizures. Treatment may increase
risk of GI bleeding; report
bloody stool, vomiting up blood; dark,
tarry stools.
Table 14. Fondaparinux
RIVAROXABAN
Drug Information Deep venous thrombosis (DVT), a disorder in which
dangerous blood clots form in the blood veins of the
legs, is treated and prevented with rivaroxaban.
Pulmonary embolism is a disorder brought on by
24
these blood clots stuck in the blood arteries of the
lungs once they have traveled there (PE).
Mechanism of Action An anticoagulant called rivaroxaban binds to factor
Xa directly. After that, it successfully inhibits the
coagulation cascade's amplification to stop thrombus
development.
Clinical Use Prophylaxis of deep vein thrombosis (DVT)
in pts undergoing knee or hip replacement
surgery. Prevents stroke/systemic embolism
in pts with nonvalvular atrial fibrillation.
Treatment of DVT/PE. Reduces risk
of recurrent DVT/PE following 6 mos of treatment. In
combination with aspirin,
reduces risk of major CV events (e.g., MI,
stroke) in pts with chronic coronary artery
disease (CAD) or peripheral artery disease
(PAD).
Side Effects Rare (3%–1%): Wound secretion/oozing,
extremity pain, muscle spasm, syncope,
pruritus.
Adverse Reactions Increased risk of bleeding/hemorrhagic
events including retroperitoneal hemorrhage,
cerebral hemorrhage, subdural
hematoma, epidural/spinal hematoma
(esp. with epidural catheters, spinal
trauma). Serious reactions including
jaundice, cholestasis, cytolytic hepatitis,
Stevens-Johnson syndrome, hypersensitivity
reaction, anaphylaxis reported.
Obtain CBC, serum chemistries, PT/INR,
vital signs, urine pregnancy if applicable.
Obtain ECG for pts with a history of atrial
fibrillation. Question for history of bleeding
disorders, recent surgery, spinal punctures,
intracranial hemorrhage, bleeding
ulcers, open wounds, anemia, renal/hepatic
impairment. Receive full medication
history including herbal products.
Monitor CBC, serum chemistries, renal
function, occult urine/stool. Be alert for
complaints of abdominal/back pain, headache,
confusion, weakness, vision change
(may indicate hemorrhage). Question for
increased menstrual bleeding/discharge.
25
Assess peripheral pulses; skin for ecchymosis,
petechiae. Check for excessive
bleeding from minor cuts, scratches. Assess
urine output for hematuria. Immediately
report suspected pregnancy.
• Do not take/discontinue any medication
except on advice of physician. • Avoid
alcohol, aspirin, NSAIDs. • Consult physician
before surgery, dental work. • Use
electric razor, soft toothbrush to prevent
bleeding. • Report any unusual bleeding/
bruising, spinal/epidural hematomas
(e.g., tingling, numbness, muscular weakness).
• Report if pregnant or planning
to become pregnant. • Avoid grapefruit
products.
Table 15. Rivaroxaban
WARFARIN
Drug Information A prescription drug called warfarin, also known by
the brand name Jantoven, prevents the blood from
clotting normally (coagulation). Another name for it is
an anticoagulant. In some nations, warfarin is offered
under the trade name Coumadin, although the US
and Canada no longer carry this product.
Mechanism of Action Vitamin K epoxide reductase complex in the liver is
blocked by warfarin and other vitamin K antagonists
(VKAs), which causes a depletion of the reduced
form of vitamin K, which is a cofactor for the gamma
carboxylation of vitamin K-dependent coagulation
components.
Clinical Use Prophylaxis, treatment of thromboembolic
disorders and embolic complications
arising from atrial fibrillation or
valve replacement. Risk reduction of
systemic embolism following MI (e.g., recurrent
MI, stroke). OFF-LABEL: Adjunct
treatment in transient ischemic attacks.
Side Effects Occasional: GI distress (nausea, anorexia,
abdominal cramps, diarrhea). Rare: Hypersensitivity
reaction (dermatitis, urticaria),
esp. in those sensitive to aspirin.
Adverse Reactions Bleeding complications ranging from
local ecchymoses to major hemorrhage
(intracranial hemorrhage, GI /GU/nasal /
26
oral /rectal bleeding) may occur. Hepatotoxicity,
blood dyscrasias, necrosis,
vasculitis, local thrombosis occur rarely.
Antidote: Vitamin K. Amount based on
INR, significance of bleeding. Range:
2.5–10 mg given orally or slow IV infusion
(see Appendix J for dosage).
Cross-check dose with co-worker. Obtain
CBC, PT/INR before administration and
daily following therapy initiation. When
stabilized, follow with INR determination
q4–6wks. Obtain genotyping prior to
initiating therapy if available. Screen for
major active bleeding. Question recent
history of bleeding, recent trauma, surgical
procedures, epidural anesthesia.
Monitor INR diligently. Assess CBC for
anemia; urine/stool for occult blood.
Be alert to complaints of abdominal /
back pain, severe headache, confusion,
seizures, hemiparesis, aphasia (may be
sign of hemorrhage). Decrease in B/ P,
increase in pulse rate may be sign of
hemorrhage. Question for increase in
amount of menstrual discharge. Assess
peripheral pulses; skin for ecchymoses,
petechiae. Check for excessive bleeding
from minor cuts, scratches. Assess gums
for erythema, gingival bleeding.
• Take medication at same time each
day. • Blood levels will be monitored
routinely. • Do not take, discontinue any
other medication except on advice of physician.
• Avoid alcohol, aspirin, drastic
dietary changes. • Consult with physician
before surgery, dental work. • Urine
may become red-orange. • Falls, subtle injuries, esp.
head or abdominal trauma,
can be life-threatening. • Report bleeding,
bruising, red or brown urine, black
stools. • Use electric razor, soft toothbrush
to prevent bleeding. • Report
coffee-ground vomitus, blood-tinged mucus
27
from cough. • Do not use any OTC
medication without physician approval
(may interfere with platelet aggregation).
• Seek immediate medical attention
for stroke-like symptoms (confusion,
difficulty speaking, headache, one-sided
weakness); bloody stool or urine.
Table 16. Warfarin
III. Antidysrhythmics Drugs

Drugs designed to prevent aberrant heart rhythms such atrial fibrillation,
atrial flutter, ventricular tachycardia, and ventricular fibrillation are known as
antidysrhythmics, also known as antiarrhythmics. These medications function by
obstructing calcium, sodium, and potassium channels in the heart muscles.
ACEBUTOLOL
Drug Information Acebutolol is a selective β1-receptor antagonist used
for the management of hypertension and ventricular
premature beats in adults.
Mechanism of Action Acebutolol is a selective antagonist of the β1-
receptor. Epinephrine's activation of β1-receptors
causes a rise in heart rate, blood pressure, and
oxygen consumption. Acebutolol inhibits these
receptors, which lowers blood pressure and heart
rate. The medication then has the opposite impact of
epinephrine. In addition, beta blockers stop the
kidneys' production of the hormone renin, which
causes blood vessels to tighten.
Clinical Use High blood pressure is treated with acebutolol. A
dysfunctional heartbeat can also be treated with
acebutolol. Acebutolol belongs to a group of drugs
known as beta blockers. It improves blood flow and
lowers blood pressure by relaxing blood vessels and
lowering heart rate.
Side Effects Acebutolol oral capsule does not cause drowsiness,
but it can cause other side effects.
More common side effects
The more common side effects that can occur with
acebutolol include:
 a slower than normal heart rate
 dizziness
 tiredness
 headache
 constipation
 diarrhea
28
 upset stomach (indigestion)
 muscle aches or pains
If these effects are mild, they may go away within a
few days or a couple of weeks. If they’re more
severe or don’t go away, talk to your doctor or
pharmacist.
Serious side effects
Call your doctor right away if you have serious side
effects. Call 911 if your symptoms feel life-
threatening or if you think you’re having a medical
emergency. Serious side effects and their symptoms
can include the following:
 Very low blood pressure. Symptoms include:
o severe dizziness
o lightheadedness
o fainting
 Very slow heart rate. Symptoms include:
o tiredness
o severe dizziness
o lightheadedness
o fainting
 Poor circulation. Symptoms include:
o cold or blue fingers or toes
 Erectile dysfunction. Symptoms include:
o being unable to get or keep an erection
 Depression
 Pain when urinating
 Liver damage. Symptoms include:
o nausea
o loss of appetite
o dark-colored urine
o tiredness
 Systemic lupus erythematosus (SLE), a
condition where your immune system attacks
parts of your body. Symptoms include:
o severe skin rash, which may look like a
butterfly shape across your nose
o mouth sores
o tiredness
o joint pain
o muscle pain
Adverse Reactions Some patients who use acebutolol may develop

heart failure. If you experience chest pain or
discomfort, dilated neck veins, extreme exhaustion,
erratic breathing, an irregular heartbeat, shortness of
29
breath, swelling of the face, fingers, feet, or lower
legs, weight gain, wheezing, or any other symptoms,
consult your doctor straight once.
Nursing Considerations Assessment & Drug Effects
 Monitor BP and cardiac status throughout
therapy. Observe for and report marked
bradycardia or hypotension, especially when
patient is also receiving a catecholamine-
depleting drug (e.g., reserpine).
 Monitor I&O ratio and pattern and report
changes to physician (e.g., dysuria, nocturia,
oliguria, weight change).
 Monitor for S&S of CHF, especially peripheral
edema, dyspnea, activity intolerance.
 Lab tests: Monitor for drug-induced positive
ANA titer during long-term therapy, especially
in women and older adults; periodic CBC with
long-term therapy.
Patient & Family Education
 Know parameters for withholding drug (e.g.,
pulse less than 60).
 Note: Common adverse effects include
insomnia, drowsiness, and confusion.
 Do not drive or engage in potentially
hazardous activities until response to drug is
known.
 Do not increase, decrease, omit, or
discontinue drug regimen without advice from
the physician. Abrupt withdrawal may worsen
angina or precipitate MI in patient with heart
disease.
 Contact physician promptly at the first signs or
symptoms of CHF (see Appendix F).
 Report muscle and joint pain to physician.
Discontinuation of drug therapy usually
reverses these adverse effects.
 Monitor for loss of glycemic control if diabetic.
 Note: Drug may mask symptoms of
hypoglycemia (see Appendix F) and
potentiate insulin-induced hypoglycemia in
diabetics.
 Avoid use of OTC oral cold preparations and
topical nasal decongestants unless approved
by the physician.
 Do not breast feed while taking this drug
without consulting physician.
30
Table 17. Acebutolol
DISOPYRAMIDE
Drug Information Disopyramide is a common anti-arrhythmic
medication. It functions by suppressing specific
electrical signals in the heart that could otherwise
result in an erratic heartbeat. Your risk of having a
heart attack or stroke can be decreased by treating
an irregular heartbeat because doing so lowers the
likelihood of blood clots.
Mechanism of Action Disopyramide inhibits the cardiac myocyte's increase
in sodium permeability during Phase 0 of the
ventricular action potential, which in turn reduces the
inward sodium current. As a result, the excitation
threshold is raised and the upstroke velocity is
decreased.
Clinical Use Disopyramide is a drug used to treat irregularities in
cardiac rhythm that can be fatal, like ventricular
tachycardia/fibrillation, or that are linked to higher
rates of morbidity and death, like atrial fibrillation and
hypertrophic cardiomyopathy.
Side Effects Disopyramide may cause side effects. Tell your
doctor if any of these symptoms are severe or do
not go away:
 dizziness or lightheadedness
 difficult urination
 frequent urination
 dry mouth
 constipation
 blurred vision
 nausea
 fatigue
 headache
 weakness
 stomach pain or bloating
 fatigue
 weakness
 headache
 rash
Some side effects can be serious. If you
experience any of the following symptoms, call
your doctor immediately:
 chest pain
 swelling of the feet or hands
 unusual weight gain
31
 irregular heartbeat
 shortness of breath
 sudden changes in mental status
Adverse Reactions Dry mouth, constipation, nausea, abdominal

pain/gas/bloating, blurred vision, dizziness, dry
nose/eyes/throat, and urination problems (such as
difficulty urinating or unusual frequent urge to
urinate) may occur. If any of these effects persist or
worsen, tell your doctor or pharmacist promptly.
 Check apical pulse before administering drug.
Withhold drug and notify physician if pulse
rate is slower than 60 bpm, faster than 120
bpm, or if there is any unusual change in rate,
rhythm, or quality.
 Monitor ECG closely. The following signs are
indications for drug withdrawal: Prolongation
of QT interval and worsening of arrhythmia
interval, QRS widening (>25%).
 Monitor for rapid weight gain or other signs of
fluid retention.
 Lab tests: Baseline and periodic hepatic and
renal function tests, blood glucose, and serum
potassium. Correct hypokalemia or other
imbalances before initiation of therapy.
 Monitor BP closely in all patients during
periods of dosage adjustment and in those
receiving high dosages.
 Monitor I&O, particularly in older adults and
patients with impaired renal function or
prostatic hypertrophy. Persistent urinary
hesitancy or retention may necessitate lower
dosage or discontinuation of drug.
 Report S&S of hyperkalemia (see Appendix
F); it enhances drug's toxic effects.
 Measure IOP before treatment begins in
patients with a family history of glaucoma.
 Monitor for S&S of CHF.
 Discontinue promptly if S&S of
agranulocytosis, peripheral neuritis, or
jaundice appear (see Appendix F).
 Take drug precisely as prescribed to maintain
regularity of heartbeat. Do not skip or stop
medication or change dose without consulting
32
physician.
 Weigh daily under standard conditions and
check ankles for edema. Report to physician a
weekly weight gain of 1–2 kg (2–4 lb).
 Make position changes slowly, particularly
when getting up from lying down because of
the possibility of hypotension; dangle legs for
a few minutes before walking, and do not
stand still for prolonged periods. If you feel
light-headed, lie down or sit down.
 Do not take OTC medications unless
approved by physician.
 Avoid exposure to sunlight or ultraviolet light;
drug may cause photosensitivity.
 Do not drive or engage in other potentially
hazardous activities until response to drug is
known.
 Do not drink alcoholic beverages while taking
disopyramide.
Table 18. Disopyramide phosphate
ESMOLOL
Drug Information Esmolol is used to treat irregular heart rhythms or
fast heartbeats. This medication is also used to treat
high blood pressure and a rapid heartbeat before,
during, and after surgery.
Mechanism of Action Esmolol lowers myocardial oxygen demand,
shortens atrioventricular conduction, and lengthens
atrioventricular refractory time. High intravenous
infusion doses have been observed to cause a little
beta-2-adrenergic blockage.
Clinical Use Rapid, short-term control of ventricular
rate in supraventricular tachycardia (SVT),
atrial fibrillation or flutter; treatment of
tachycardia and/or hypertension (esp.
intraop or postop). Treatment of noncompensatory
sinus tachycardia. OFF-LABEL:
Postoperative hypertension or SVT in children.
Arrhythmia and/or rate control in
ACS, intubation, thyroid storm, pheochromocytoma,
electroconvulsive therapy.
Side Effects Generally well tolerated, with transient,
mild side effects. Frequent: Hypotension
33
(systolic B/P less than 90 mm Hg)
manifested as dizziness, nausea, diaphoresis,
headache, cold extremities, fatigue.
Occasional: Anxiety, drowsiness, flushed
skin, vomiting, confusion, inflammation
at injection site, fever.
Adverse Reactions Overdose may produce profound hypotension,
bradycardia, dizziness, syncope,
drowsiness, breathing difficulty, bluish
fingernails or palms of hands, seizures.
May potentiate insulin-induced hypoglycemia
in diabetic pts.
Assess B/P, apical pulse immediately
before drug is administered (if pulse is
60 or less/min or systolic B/P is 90 mm
Hg or less, withhold medication, contact
physician).
Monitor B/P for hypotension, ECG, heart
rate, respiratory rate, development of
diaphoresis, dizziness (usually first sign
of impending hypotension). Assess pulse
for quality, irregular rate, bradycardia,
extremities for coldness. Assist with ambulation
if dizziness occurs. Assess for
nausea, diaphoresis, headache, fatigue.
Table 19. Esmolol
FLECAINIDE
Drug Information Paroxysmal supraventricular tachycardia (PSVT) and
paroxysmal atrial fibrillation/flutter are two
arrhythmias that can be prevented or treated with
flocainide (PAF). Additionally, flocainide is utilized to
stop potentially fatal prolonged ventricular
tachycardia (sustained VT).
Mechanism of Action Flecainide acts on the fast-inward Na+ ion channel
and has a high affinity to activated or open Na+
channels. It prolongs depolarization and increases
refractoriness due to slow release from its binding
site. It potently acts on the His-Purkinje system.
Clinical Use Flecainide is used to prevent or treat irregular
heartbeats (arrhythmias) such as paroxysmal
supraventricular tachycardia (PSVT) and paroxysmal
atrial fibrillation/flutter (PAF). Flecainide is also used
to prevent life-threatening sustained ventricular
34
tachycardia (sustained VT).
Side Effects It's possible to have lightheadedness, vision issues
(such as blurred vision, difficulty focusing, or seeing
spots), headache, nausea, shaking, fatigue, or
weakness. Inform your doctor or pharmacist as soon
as possible if any of these side effects persist or get
worse. Keep in mind that your doctor has
recommended this medication because they believe
it will benefit you more than it will harm you. Many
users of this medicine report no significant negative
effects. Inform your doctor right away if you
experience any severe side effects, including as new
or worsening heart failure symptoms (such as
shortness of breath, swelling in the ankles or feet,
extreme fatigue, or rapid or unexpected weight gain).
If you have any extremely serious adverse effects,
including as a quicker or more irregular heartbeat,
severe dizziness, or fainting, seek medical attention
right away.
Adverse Reactions  Difficult or labored breathing.
 dizziness, fainting, or lightheadedness.
 fast, irregular, pounding, or racing heartbeat or
pulse.
 shortness of breath.
 wheezing.
 Correct preexisting hypokalemia or
hyperkalemia before treatment is initiated.
 Note: ECG monitoring, including Holter
monitor for ambulating patients, is essential
because of the possibility of drug-induced
arrhythmias.
 Determine pacing threshold for patients with
pacemakers before initiation of therapy, after
1 wk of therapy, and at regular intervals
thereafter.
 Monitor plasma level recommended,
especially in patients with severe CHF or
renal failure because drug elimination may be
delayed in these patients.
 Note: Effective trough plasma levels are
between 0.7–1 mcg/mL. The probability of
adverse reactions increases when trough
levels exceed 1 mcg/mL.
 Attempt dosage reduction with caution after
arrhythmia is controlled.
35
 Note: It is VERY important to take this drug at
the prescribed times.
 Report visual disturbances to physician.
Table 20. Flecainide
LIDOCAINE
Drug Information A chemical that reduces pain by suppressing signals
at skin nerve endings. To stop heart arrhythmias, it
can also be administered intravenously. It is both an
antiarrhythmic and a form of local anesthetic.
Mechanism of Action Lidocaine controls intracellular and extracellular
calcium concentrations through additional ligand-
gated ion channels in addition to blocking Na+ and
K+ ion channels. The first sodium channel blocker to
be discovered was lidocaine. Its primary mode of
action is the blockage of VGSC/NaVs, or voltage-
gated Na+ channels.
Clinical Use Antiarrhythmic: Rapid control of acute
ventricular arrhythmias following MI,
cardiac catheterization, cardiac surgery.
Local anesthetic: Infiltration/nerve
block for dental/surgical procedures,
childbirth. Topical anesthetic: Local
skin disorders (minor burns, insect bites, prickly
heat, skin manifestations
of chickenpox, abrasions). Mucous
membranes (local anesthesia of oral,
nasal, laryngeal mucous membranes;
local anesthesia of respiratory, urinary
tracts; relief of discomfort of pruritus
ani, hemorrhoids, pruritus vulvae).
Dermal patch: Relief of chronic pain in
postherpetic neuralgia, allodynia (painful
hypersensitivity).
Side Effects CNS effects generally dose-related and
of short duration. Occasional: Infiltration/
nerve block: Pain at injection site.
Topical: Burning, stinging, tenderness at
application site. Rare: Generally associated
with high dose: Drowsiness, dizziness,
disorientation, light-headedness,
tremors, apprehension, euphoria, sensation
36
of heat, cold, numbness; blurred or
double vision, tinnitus, nausea.
Adverse Reactions Serious adverse reactions to lidocaine
are uncommon, but high dosage by any
route may produce cardiovascular depression,
bradycardia, hypotension, arrhythmias,
heart block, cardiovascular collapse, cardiac arrest.
Potential for
malignant hyperthermia, CNS toxicity
may occur, esp. with regional anesthesia
use, progressing rapidly from mild side
effects to tremors, drowsiness, seizures,
vomiting, respiratory depression.
Methemoglobinemia
(evidenced by cyanosis)
has occurred following topical application
of lidocaine for teething discomfort
and laryngeal anesthetic spray.
Question for hypersensitivity to lidocaine,
amide anesthetics. Obtain baseline B/P,
pulse, respiratory rate, ECG, serum electrolytes.
Monitor ECG, vital signs closely during and
following drug administration for cardiac
performance. If ECG shows arrhythmias,
prolongation of PR interval or QRS complex,
inform physician immediately. Assess
pulse for rhythm, rate, quality. Assess B/P
for evidence of hypotension. Monitor for
therapeutic serum level (1.5–6 mcg/mL).
For lidocaine given by all routes, monitor
vital signs, LOC. Drowsiness should be
considered a warning sign of high serum
levels of lidocaine. Therapeutic serum
level: 1.5–6 mcg/mL; toxic serum level:
greater than 6 mcg/mL.
PATIENT/ FAMILY TEACHING
• Local anesthesia: Due to loss of feeling/
sensation, protective measures may be
needed until anesthetic wears off (no ambulation,
including special positions for
some regional anesthesia). • Oral mucous
membrane anesthesia: Do not
eat, drink, chew gum for 1 hr after application
(swallowing reflex may be impaired,
37
increasing risk of aspiration; numbness of
tongue, buccal mucosa may lead to bite
trauma). • IV infusions: Report dizziness,
numbness, double vision, nausea,
pain/burning, respiratory difficulty.
• Topical: Report irritation, pain, numbness,
swelling, blurred vision, tinnitus, respiratory
difficulty.
Table 21. Lidocaine
MEXILETINE HYDROCHLORIDE
Drug Information Mexiletine Hydrochloride is the hydrochloride salt
form of mexiletine, a local anesthetic and
antiarrhythmic (Class IB) agent structurally related to
lidocaine.
Mechanism of Action As a member of the class Ib antiarrhythmic drugs
mexiletine's primary mechanism of action is blocking
fast sodium channels, reducing the phase 0 maximal
upstroke velocity of the action potential. It increases
the ratio of effective refractory period to action
potential duration, but has little effect on conductivity.
Clinical Use Mexiletine is used to treat certain types of ventricular
arrhythmias (abnormal heart rhythms). Mexiletine is
in a class of medications called antiarrhythmics. It
works by blocking certain electrical signals in the
heart to stabilize the heart rhythm.
Side Effects Check with your doctor as soon as possible if any of
the following side effects occur:
Less common
 Chest pain
 fast or irregular heartbeat
 shortness of breath
Rare
 Convulsions (seizures)
 fever or chills
 unusual bleeding or bruising
Some side effects may occur that usually do not
need medical attention. These side effects may go
away during treatment as your body adjusts to the
medicine. Also, your health care professional may be
able to tell you about ways to prevent or reduce
some of these side effects. Check with your health
care professional if any of the following side effects
continue or are bothersome or if you have any
questions about them:
More common
38
 Dizziness or lightheadedness
 heartburn
 nausea and vomiting
 nervousness
 trembling or shaking of the hands
 unsteadiness or difficulty in walking
Less common
 Blurred vision
 confusion
 constipation or diarrhea
 headache
 numbness or tingling of fingers and toes
 ringing in the ears
 skin rash
 slurred speech
 trouble in sleeping
 unusual tiredness or weakness
Adverse Reactions A very serious allergic reaction to this drug is rare.

However, get medical help right away if you notice
any symptoms of a serious allergic reaction,
including: fever, swollen lymph nodes, rash,
itching/swelling (especially of the face/tongue/throat),
severe dizziness, trouble breathing.
 Check pulse and BP before administration;
make sure both are stabilized.
 Effective serum concentration range is 0.5–2
mcg/mL.
 Lab tests: Baseline and periodic liver function
tests.
 Supervise ambulation in the weak, debilitated
patient or the older adult during drug
stabilization period. CNS adverse reactions
predominate (e.g., intention tremors,
nystagmus, blurred vision, dizziness, ataxia,
confusion, nausea).
 Encourage drug compliance; affected
particularly by the distressing adverse effects
of tremor, ataxia, and eye symptoms.
 Check frequently with patient about
adherence to drug regimen. If adverse effects
are increasing, consult physician. Dose
adjustment or discontinuation may be needed.
 Learn about pulse parameters to be reported:
39
Changes in rhythm and rate (bradycardia =
pulse below 60); symptomatic bradycardia
(light-headedness, syncope, dizziness), and
postural hypotension.
 Do not breast feed while taking this drug.
Table 22. Mexiletine hydrochloride
PROPAFENONE HYDROCHLORIDE
Drug Information Propafenone Hydrochloride is the hydrochloride salt
form of propafenone with class 1C antiarrhythmic
effects. Propafenone hydrochloride stabilizes the
neuronal membrane by binding to and inhibiting
voltage-gated sodium channels, thereby reducing
sodium influx required for the initiation and
conduction of impulses in Purkinje and myocardial
cells. This agent produces a marked depression of
phase 0 and prolonged effective refractory period in
the atrio-ventricular nodal and His-Purkinje tissue,
resulting in a profound decrease in excitability,
conduction velocity and automaticity, thereby
counteracting atrial and ventricular arrythmias.
Mechanism of Action In order to reduce the excitability of the cardiac
muscle cells, propafenone slows the entry of sodium
ions into the cells. Propafenone blocks normal cells
more than class Ia or class Ib anti-arrhythmic drugs
while being more selective for cells with a high rate.
Clinical Use Immediate-Release: Treatment of lifethreatening
ventricular arrhythmias (e.g.,
sustained ventricular tachycardias). To
prolong time to recurrence of paroxysmal
atrial fibrillation/flutter (PAF) or
(PSVT) in pts with disabling symptoms
and without structural heart disease.
Extended-Release: Prolong the time to
recurrence of atrial fibrillation/flutter or
in pts with disabling symptoms without
structural heart disease. OFF-LABEL:
Treatment following cardioversion of
recent-onset atrial fibrillation; supraventricular
tachycardia in pts with Wolff-
Parkinson-White syndrome.
Side Effects Frequent (13%–7%): Dizziness, nausea,
vomiting, altered taste, constipation. Occasional
40
(6%–3%): Headache, dyspnea,
blurred vision, dyspepsia. Rare (less than
2%): Rash, weakness, dry mouth, diarrhea,
edema, hot flashes.
Adverse Reactions May produce, worsen arrhythmias, HF.
Overdose may produce hypotension,
drowsiness, bradycardia, atrioventricular
conduction disturbances.
Correct electrolyte imbalance before administering
medication. Obtain baseline
ECG. Screen for cardiac contraindications.
Assess pulse for quality, rhythm, rate.
Monitor ECG for cardiac performance
or changes, particularly widening of
QRS, prolongation of PR interval. Question
for visual disturbances, headache,
GI upset. Monitor fluid, serum electrolyte
levels. Monitor daily pattern of
bowel activity, stool consistency. Assess
for dizziness, unsteadiness. Monitor
LFT. Monitor for therapeutic serum level
(0.06–1 mcg/mL).
• Compliance with therapy regimen is
essential to control arrhythmias. • Altered
taste sensation may occur. • Report
headache, blurred vision. • Avoid
tasks that require alertness, motor skills
• Report chest pain, difficulty
breathing, palpitations.
Table 23. Propafenone hydrochloride
SOTALOL HYDROCHLORIDE
Drug Information Sotalol Hydrochloride is the hydrochloride salt form
of sotalol, an ethanolamine derivative with Class III
antiarrhythmic and antihypertensive properties.
Sotalol hydrochloride is a nonselective beta-
adrenergic receptor and potassium channel
antagonist. In the heart, this agent inhibits
chronotropic and inotropic effects thereby slowing
the heart rate and decreasing myocardial
41
contractility. This agent also reduces sinus rate,
slows conduction in the atria and in the
atrioventricular (AV) node and increases the
functional refractory period of the AV node. In the
lungs, sotalol inhibits vasodilation and
bronchodilation. In addition, this agent inhibits renin
release.
Mechanism of Action Sotalol helps to prevent or slow supraventricular
arrhythmias involving the atrioventricular node as
part of a reentrant pathway and also helps to control
the ventricular rate during supraventricular
arrhythmias conducted to the ventricles over the
normal atrioventricular pathway.
Clinical Use Treatment of documented, life-threatening
ventricular arrhythmias. Maintain
normal sinus rhythm in pts with
symptomatic atrial fibrillation/flutter.
OFF-LABEL: Fetal tachycardia, treatment
of atrial fibrillation with hypertrophic
cardiomyopathy.
Side Effects Frequent: Diminished sexual function,
drowsiness, insomnia, asthenia.
Occasional: Depression, cold hands/
feet, diarrhea, constipation, anxiety,
nasal congestion, nausea, vomiting.
Rare: Altered taste, dry eyes, pruritus,
paresthesia of fingers, toes, scalp.
Adverse Reactions Bradycardia, HF, hypotension, bronchospasm,
hypoglycemia, prolonged QT interval,
torsades de pointes, ventricular tachycardia,
premature ventricular complexes may occur.
Baseline QTc interval and CrCl must be
determined prior to initiation. Pt must be
on continuous cardiac monitoring upon
initiation of therapy. Do not administer
without consulting physician if pulse is
60 beats/min or less. Question medical
history as listed in Precautions.
Diligently monitor for arrhythmias. Assess
B/P for hypotension, pulse for bradycardia.
Assess for HF: dyspnea, peripheral edema,
jugular vein distention, increased weight,
rales in lungs, decreased urinary output.
42
• Do not discontinue, change dose without
physician approval. • Avoid tasks
requiring alertness, motor skills until response to
drug is established (may cause
drowsiness). • Periodic lab tests, ECGs
are essential part of therapy. • Report
rapid heartbeat, chest pain, swelling of
ankles/legs, difficulty breathing.
Table 24. Sotalol Hydrochloride
Reproductive System
The reproductive system is made up of a number of organs and a network
of hormone-producing cells that collaborate to produce life. The testes (which
make sperm), penis, epididymis, vas deferens, ejaculatory ducts, and urethra are
all parts of the male reproductive system. The ovaries, which create eggs or
oocytes, the fallopian tubes, the uterus, the cervix, the vagina, and the vulva
make up the female reproductive system.
For a couple to conceive naturally, both the male and female reproductive
systems must be in good health. Infertility can be brought on by issues with either
reproductive system's structure or operation.
I. Pregnancy and Preterm Labor
PYRIDOXINE
Drug Information Pyridoxine: One of the vitamin B6 group (which also
includes pyridoxal and pyridoxamine) that is
transformed in the body to pyridoxal phosphate,
which functions as a coenzyme, a substance that
enhances the action of an enzyme and thereby helps
catalyze and speed a biochemical reaction.
Mechanism of Action Pyridoxine has multiple mechanisms of action in
responsive PH1 patients. Pyridoxine works via PLP
as a chemical chaperone and a prosthetic group.
Pyridoxine increases the expression, activity and
peroxisomal targeting of AGT-170. Pyridoxine
enhances the functionality of AGT-170, AGT-152
and AGT-244 in CHO cells.
Clinical Use It is used to treat and prevent vitamin B6 deficiency
resulting from poor diet, certain medications, and
some medical conditions. This medication is
sometimes prescribed for other uses; ask your
doctor or pharmacist for more information.
Side Effects Pyridoxine usually has no side effects when used in
recommended doses.
If your doctor has prescribed this medication,
43
remember that your doctor has judged that the
benefit to you is greater than the risk of side effects.
Many people using this medication do not have
serious side effects.
Pyridoxine can cause side effects when taken in

large doses for a long time. Tell your doctor right
away if you have any serious side effects, including:
headache, nausea, drowsiness, numbness/tingling of
arms/legs.
Adverse Reactions Pyridoxine may cause effects. Tell your doctor if
any of these symptoms are severe or do not go
away:
 upset stomach
 headache
 sleepiness
 tingling, prickling, burning, or sensation of
tightness of the hands and feet

 Monitor neurologic status to determine
therapeutic effect in deficiency states.
 Record a complete dietary history so poor
eating habits can be identified and corrected
(a single vitamin deficiency is rare; patient can
be expected to have multiple vitamin
deficiencies).
 Lab tests: Periodic Hct and Hgb, and serum
iron.
 Learn rich dietary sources of vitamin B 6:
Yeast, wheat germ, whole grain cereals,
muscle and glandular meats (especially liver),
legumes, green vegetables, bananas.
 Do not self-medicate with vitamin
combinations (OTC) without first consulting
physician.
Table 25. PYRIDOXINE
DOXYLAMINE
Drug Information Doxylamine is a medication used to manage and
treat nausea and vomiting of pregnancy (NVP),
allergic rhinitis, and insomnia. It is in the first-
44
generation histamine receptor H1 antagonist class of
medications. In the USA, it is available as an over-
the-counter medication.
Mechanism of Action Doxylamine is in a class of medications called
antihistamines. It works by blocking the action of
certain natural substances in the body that may
contribute to nausea and vomiting.
Clinical Use Doxylamine is used in the short-term treatment of
insomnia (difficulty falling asleep or staying asleep).
Doxylamine is also used in combination with
decongestants and other medications to relieve
sneezing, runny nose, and nasal congestion caused
by the common cold.
Side Effects Drowsiness, dizziness, headache, constipation,
stomach upset, blurred vision, decreased
coordination, or dry mouth/nose/throat may occur. If
any of these effects last or get worse, contact your
doctor or pharmacist promptly.
If your doctor has directed you to use this

medication, remember that your doctor has judged
that the benefit to you is greater than the risk of side
effects. Many people using this medication do not
have serious side effects.
Adverse Reactions  Drowsiness
 Dizziness
Nursing Considerations This drug is not recommended for women who are
breastfeeding. Both doxylamine and pyridoxine are
excreted in breast milk and irritability and sedation
have been documented in infants exposed to
doxylamine via breastfeeding
Table 26. DOXYLAMINE
PROMETHAZINE
Drug Information an antihistamine drug used to treat allergies and to
prevent vomiting, esp in motion sickness.
Mechanism of Action Alpha adrenergic, muscarinic, NMDA, post-synaptic
mesolimbic dopamine, and histamine H1 receptors
are all antagonists of promethazine. Treatment for
allergic responses uses the antihistamine effect. Its
use as a sleep aid, as well as a treatment for anxiety
and tension, is influenced by antagonistic effects on
muscarinic and NMDA receptors.
45
Clinical Use Promethazine is used in combination with other
drugs to treat anaphylaxis (sudden, severe allergic
responses) and cold-related symptoms as runny
nose, coughing, and sneezing. Additionally, during
delivery, before and after surgery, and in other
situations, promethazine is used to calm and sedate
patients.
Side Effects Common side effects of promethazine include
drowsiness, headaches, nightmares and feeling
dizzy, restless or confused.
Adverse Reactions The most common side effects include sedation,
confusion, and disorientation, which may impair
physical and mental abilities. However, in some
cases, promethazine may paradoxically cause
excitability, restlessness, or rare seizures.
 Supervise ambulation. Promethazine
sometimes produces marked sedation and
dizziness.
 Be aware that antiemetic action may mask
symptoms of unrecognized disease and signs
of drug overdosage as well as dizziness,
vertigo, or tinnitus associated with toxic doses
of aspirin or other ototoxic drugs.
 Patients in pain may develop involuntary
(athetoid) movements of upper extremities
following parenteral administration. These
symptoms usually disappear after pain is
controlled.
 Monitor respiratory function in patients with
respiratory problems, particularly children.
Drug may suppress cough reflex and cause
thickening of bronchial secretions.
 For motion sickness: Take initial dose 30–60
min before anticipated travel and repeat at 8–
12 h intervals if necessary. For duration of
journey, repeat dose on arising and again at
evening meal.
 Do not drive or engage in other potentially
hazardous activities requiring mental
alertness and normal reaction time until
response to drug is known.
 Avoid sunlamps or prolonged exposure to
sunlight. Use sunscreen lotion during initial
drug therapy.
46
 Do not take OTC medications without
physician's approval.
 Avoid alcohol and other CNS depressants.
 Relieve dry mouth by frequent rinses with
water or by increasing noncaloric fluid intake
(if allowed), chewing sugarless gum, or
sucking hard candy. If these measures fail,
add a saliva substitute (e.g., Moi-Stir, Orex,
Xero-Lube).
 Do not breast feed while taking this drug.
Table 27. PROMETHAZINE
METOCLOPRAMIDE
Drug Information Metoclopramide is a drug used to treat esophageal
and stomach issues. In addition to helping those with
delayed stomach emptying and gastric reflux
disease, it is frequently used to treat and prevent
nausea and vomiting. It is additionally used to treat
migraines.
Mechanism of Action Metoclopramide stimulates presynaptic excitatory 5-
HT4 receptors, inhibits presynaptic and postsynaptic
D2 receptors, and antagonizes presynaptic inhibition
of muscarinic receptors in order to increase
gastrointestinal motility.
Clinical Use PO: Symptomatic treatment of diabetic
gastroparesis, gastroesophageal reflux. IV/IM:
Symptomatic treatment of diabetic
gastroparesis, prevent/treat nausea/vomiting
with chemotherapy or after surgery.
Side Effects ALERT! Doses of 2 mg/kg or greater,
or increased length of therapy, may result
in a greater incidence of side effects.
Frequent (10%): Drowsiness, restlessness,
fatigue, lethargy. Occasional (3%): Dizziness,
anxiety, headache, insomnia, breast
tenderness, altered menstruation, constipation,
rash, dry mouth, galactorrhea,
gynecomastia. Rare (less than 3%): Hypotension,
hypertension, tachycardia.
Adverse Reactions Extrapyramidal reactions occur most
frequently in children, young adults
(18–30 yrs) receiving large doses (2
mg/kg) during chemotherapy and usually
are limited to akathisia (involuntary
limb movement, facial grimacing, motor
restlessness). Neuroleptic malignant
47
syndrome (diaphoresis, fever, unstable
B/P, muscular rigidity) has been
reported.
Antiemetic: Assess for dehydration (poor
skin turgor, dry mucous membranes,
longitudinal
furrows in tongue). Assess
for nausea, vomiting, abdominal distention,
bowel sounds.
Monitor for anxiety, restlessness, extrapyramidal
symptoms (EPS) during IV
administration. Monitor daily pattern of
bowel activity, stool consistency. Assess
skin for rash. Evaluate for therapeutic response
from gastroparesis (nausea, vomiting,
bloating). Monitor renal function, B/P,
heart rate.
• Avoid tasks that require alertness, motor
skills until response to drug is established.
• Report involuntary eye, facial,
limb movement (extrapyramidal reaction).
• Avoid alcohol.
Table 28. METOCLOPRAMIDE
ONDANSETRON
Drug Information an antiemetic drug administered orally or
parenterally in the form of its hydrated hydrochloride
C18H19N3O·HCl·2H2O to prevent nausea and vomiting
occurring especially as a consequence of cancer
chemotherapy or surgery.
Mechanism of Action Ondansetron is a selective antagonist of the 5-HT3
subtype of serotonin receptors (8,9,10).
Serotonin (5-HT) is released by enterochromaffin
cells of the small intestine in response to cytotoxic
chemotherapy and radiotherapy. This release is
thought to trigger the vomiting reflex by activating 5-
HT3 receptors on vagal afferents 8, 9, and 10.
Ondansetron may prevent the reflex from starting.
The chemoreceptor trigger zone of the region
postrema, which is situated on the floor of the fourth
ventricle, may also release serotonin centrally in
response to vagal afferent activation 8,9,10.
48
Ondansetron's antiemetic effect is thus likely brought
on by the specific inhibition of 5-HT3 receptors on
neurons found in the peripheral, central, or maybe
both nervous systems.
Clinical Use Prevention/treatment of nausea/vomiting
due to cancer chemotherapy (including
high-dose CISplatin). Prevention and
treatment of postop nausea, vomiting. Prevention
of radiation-induced nausea, vomiting.
OFF-LABEL: Breakthrough treatment
of nausea and vomiting associated with
chemotherapy, hyperemesis gravidarum.
Side Effects Frequent (13%–5%): Anxiety, dizziness,
drowsiness, headache, fatigue, constipation,
diarrhea, hypoxia, urinary retention.
Occasional (4%–2%): Abdominal pain, xerostomia,
fever, feeling of cold,
redness/pain at injection site, paresthesia,
asthenia (loss of strength, energy).
Rare (1%): Hypersensitivity reaction
(rash, pruritus), blurred vision.
Adverse Reactions Hypertension, acute renal failure, GI
bleeding, respiratory depression, coma,
extrapyramidal effects occur rarely. QT
interval prolongation, torsades de
pointes may occur.
Assess degree of nausea, vomiting. Assess
for dehydration if excessive vomiting
occurs (poor skin turgor, dry mucous
membranes, longitudinal furrows in
tongue). Provide emotional support.
Monitor ECG in pts with electrolyte abnormalities
(e.g., hypokalemia, hypomagnesemia),
HF, bradyarrhythmias, concurrent
use of other medications that may
cause QT prolongation, pts receiving high
doses or frequent doses. Provide supportive
measures. Assess mental status. Assess
bowel sounds for peristalsis. Monitor
daily pattern of bowel activity, stool consistency.
Record time of evacuation.
• Relief from nausea/vomiting generally
occurs shortly after drug administration.
49
• Avoid alcohol, barbiturates. •
Report persistent vomiting. • Avoid tasks
that require alertness, motor skills until
response to drug is established (may cause
drowsiness, dizziness).
Table 29. ONDANSETRON
ALUMINUM HYDROXIDE
Drug Information An inorganic salt called aluminum hydroxide is used
as an antacid. It is an elementary substance that
works by balancing the hydrochloric acid in
gastrointestinal secretions. The action of pepsin may
be inhibited by subsequent pH increases. Increases
in prostaglandins and bicarbonate ions may also
have cytoprotective effects.
Mechanism of Action Aluminum hydroxide is a basic inorganic salt that
acts by neutralizing hydrochloric acid in gastric
secretions. Aluminum hydroxide is slowly solubilized
in the stomach and reacts with hydrochloric acid to
form aluminum chloride and water. It also inhibits the
action of pepsin by increasing the pH and via
adsorption.
Clinical Use Heartburn, sour stomach, and peptic ulcer discomfort
are all relieved with aluminum hydroxide, and peptic
ulcer recovery is accelerated.
Side Effects The medicine may cause serious side effects. Stop
using the medicine and call your doctor at once if
you have:
 severe stomach pain or constipation, loss of
appetite;
 pain when you urinate;
 muscle weakness, tiredness;
 extreme drowsiness; or
 bloody or tarry stools, coughing up blood or
vomit that looks like coffee grounds.
Adverse Reactions  GI: Constipation, fecal impaction, intestinal
obstruction.
 CNS: Dialysis dementia (thought to be due to
aluminum intoxication). Metabolic:
Hypophosphatemia, hypomagnesemia.
 Note number and consistency of stools.
Constipation is common and dose related.
Intestinal obstruction from fecal concretions
has been reported.
 Lab tests: Monitor periodic serum calcium and
50
phosphorus levels with prolonged high-dose
therapy or impaired renal function.
 Patient & Family Education
 Increase phosphorus in diet when taking large
doses of these antacids for prolonged periods;
hypophosphatemia can develop within 2 wk of
continuous use of these antacids. The older
adult in a poor nutritional state is at high risk.
 Note: Antacid may cause stools to appear
speckled or whitish.
 Report epigastric or abdominal pain; it is a
clinical guide for adjusting dosage. Keep
physician informed. Pain that persists beyond
72 h may signify serious complications.
 Seek medical help if indigestion is
accompanied by shortness of breath,
sweating, or chest pain, if stools are dark or
tarry, or if symptoms are recurrent when
taking this medication.
 Seek medical advice and supervision if self-
prescribed antacid use exceeds 2 wk
Table 30. ALUMINUM HYDROXIDE
TERBUTALINE
Drug Information Terbutaline is approved to prevent and treat
bronchospasm (narrowing of airways) associated
with asthma, bronchitis, and emphysema. The drug
is sometimes used off-label (an unapproved use) for
acute obstetric uses, including treating preterm labor
and treating uterine hyperstimulation.
Mechanism of Action Terbutaline is a selective beta-2 adrenergic receptor
agonist. Agonism of these receptors in bronchioles
activates adenylyl cyclase, increasing intracellular
cyclic adenosine monophosphate (cAMP).
Clinical Use Terbutaline is used to both prevent and treat the
wheezing, chest tightness, and shortness of breath
brought on by emphysema, chronic bronchitis, and
asthma. Beta agonists are a group of drugs that
includes terbutaline. It facilitates breathing by
calming down and widening the airways.
Side Effects Nervousness, shaking (tremor), dizziness,
drowsiness or headache may occur. If any of these
effects last or get worse, notify your doctor or
pharmacist promptly.
Adverse Reactions Be aware that death and serious adverse reactions,
51
including increased heart rate, transient
hyperglycemia, hypokalemia, cardiac arrhythmias,
pulmonary edema, and myocardial ischemia have
been reported after prolonged administration of oral
or injectable terbutaline to pregnant women.
Nursing Considerations  may cause nervousness, restlessness,
tremors
 beta blockers can reduce effect
 assess respiratory status
 monitor maternal/fetal vital signs if using for
preterm labor
 monitor for hypoglycemia
 may cause decreased potassium level
Table 31. TERBUTALINE
MAGNESIUM SULFATE
Drug Information Magnesium sulfate is a magnesium salt having
sulfate as the counterion. It has a role as an
anticonvulsant, a cardiovascular drug, a calcium
channel blocker, an anaesthetic, a tocolytic agent, an
anti-arrhythmia drug, an analgesic and a fertilizer. It
is a magnesium salt, a metal sulfate and an organic
magnesium salt.
Mechanism of Action The mechanism of action of magnesium sulfate is
thought to trigger cerebral vasodilation, thus
reducing ischemia generated by cerebral vasospasm
during an eclamptic event. The substance also acts
competitively in blocking the entry of calcium into
synaptic endings, thereby altering neuromuscular
transmission.
Clinical Use In order to treat and prevent low blood magnesium
levels and seizures in eclamptic women, magnesium
sulfate is a medicine. Additionally, it is used to treat
barium poisoning, severe asthma exacerbations,
torsades de pointes, and constipation. It is
administered orally as well as through injection into a
vein or muscle.
Side Effects Side effects of magnesium sulfate injection include:
 heart disturbances,
 breathing difficulties,
 poor reflexes,
 confusion,
 weakness,
 flushing (warmth, redness, or tingly feeling),
 sweating,
 lowered blood pressure,
52
 feeling like you might pass out,
 anxiety,
 cold feeling,
 extreme drowsiness,
 muscle tightness or contraction, or
 headache.
Adverse Reactions maternal administration of magnesium sulfate for
longer than 5–7 days in pregnancy may be
associated with adverse effects in the foetus,
including hypocalcaemia, skeletal demineralisation,
osteopenia, and other skeletal adverse effects.
Nursing Considerations  use caution with renal insufficiency
 may cause decreased respiratory rate,
arrythmias, hypotension, muscle weakness
 monitor EKG and respiratory status
 monitor Mg levels
 ensure dosage with secondary practitioner
 Calcium gluconate is the antidote
o Magnesium toxicity results in
respiratory depression and loss of deep
tendon reflexes.
Table 32. MAGNESIUM SULFATE
II. Labor, Delivery, and Postpartum
PENTOBARBITAL
Drug Information a narcotic and sedative barbiturate drug formerly
used to relieve insomnia.
Mechanism of Action Pentobarbital works in the central nervous system by
binding to gamma-aminobutyric acid (GABA) A
subtype receptors. This action induces a change in
the chloride transport receptor, leading to an
increase in the duration that the chloride channels
remain open, hence potentiating GABA effects.
Clinical Use Pentobarbital is a medication used to manage and
treat several medical conditions, including seizures,
intracranial pressure control, insomnia, and as a pre-
anesthetic in the operating room.
Side Effects Common side effects of pentobarbital may
include:
 drowsiness, dizziness;
 loss of balance or coordination;
 nausea, vomiting, constipation;
 overactive reflexes;
 sleep problems (insomnia), nightmares; or
53
 feeling restless or excited (especially in
children or older adults).
Adverse Reactions Pentobarbital may cause serious side effects.
Call your doctor at once if you have:
 confusion, agitation, hallucinations;
 weak or shallow breathing;
 slow heart rate, weak pulse; or
 a light-headed feeling, like you might pass
out.
Side effects such as confusion, depression, or
excitement may be more likely in older adults and
those who are ill or debilitated.
Nursing Considerations  High doses can cause death
 Contraindicated
o Hypersensitivity
o Porphyria
 Monitor
o Hemodynamics
 Respiratory status
 Mechanical ventilation
 Avoid use in geriatric patients
 Use caution
o Depression
o Hepatic impairment
o Renal impairment
Table 33. PENTOBARBITAL
HYDROXYZINE
Drug Information Hydroxyzine is in a class of medications called
antihistamines. It works by blocking the action of
histamine a substance in the body that causes
allergic symptoms. It also works by decreasing
activity in the brain.
Mechanism of Action Hydroxyzine's predominant mechanism of action is
as a potent H1 receptor inverse agonist. Hydroxyzine
acts to block the action of endogenous histamine at
the histamine H1 receptor. The sedative action of the
drug may be due to central anticholinergic activity,
but this is less clearly understood.
Clinical Use Hydroxyzine is used to help control anxiety and
tension caused by nervous and emotional conditions.
It can also be used to help control anxiety and
produce sleep before surgery. This medicine is also
used to relieve symptoms of allergic conditions (eg,
chronic urticaria and atopic and contact dermatoses).
54
Side Effects Drowsiness, dizziness, blurred vision, constipation,
or dry mouth may occur. If any of these effects last
or get worse, tell your doctor or pharmacist promptly.
To relieve dry mouth, suck (sugarless) hard candy or
ice chips, chew (sugarless) gum, drink water, or use
a saliva substitute.
Adverse Reactions A very serious allergic reaction to this drug is rare.
However, get medical help right away if you notice
any symptoms of a serious allergic reaction,
including: rash, itching/swelling (especially of the
face/tongue/throat), severe dizziness, trouble
breathing.
Nursing Considerations Advise patient to avoid alcohol and other CNS
depressants because of the increased risk of
sedation and adverse effects. Instruct patient to
report other troublesome side effects such as severe
or prolonged headache, urinary retention, skin
redness/warmth, or GI problems (constipation,
nausea, dry mouth, bitter taste).
Table 34. HYDROXYZINE
FENTANYL CITRATE
Drug Information The citrate salt of fentanyl, a synthetic opioid related
to the phenylpiperidines with analgesic and
anesthetic properties. Fentanyl exerts its analgesic
effect by selectively binding to the mu-opioid
receptor in the central nervous system (CNS),
thereby mimicking the effects of endogenous
opiates. Additional pharmacological effects of
fentanyl include anxiolysis, euphoria, feelings of
relaxation, respiratory depression, constipation,
miosis, and cough suppression.
Mechanism of Action Fentanyl binds to opioid receptors, especially the mu
opioid receptor, which are coupled to G-proteins.
Activation of opioid receptors causes GTP to be
exchanged for GDP on the G-proteins which in turn
down regulates adenylate cyclase, reducing
concentrations of cAMP.
Clinical Use A drug used to treat severe cancer pain that occurs
even though the patient is already taking opioids. It is
also used during anesthesia for surgery. Fentanyl
citrate binds to opioid receptors in the central
nervous system.
Side Effects As with other narcotic analgesics, the most common
serious adverse reactions reported to occur with
SUBLIMAZE (fentanyl citrate) are respiratory
55
depression, apnea, rigidity, and bradycardia; if these
remain untreated, respiratory arrest, circulatory
depression or cardiac arrest could occur. Other
adverse reactions that have been reported are
hypertension, hypotension, dizziness, blurred vision,
nausea, emesis, diaphoresis, pruritus, urticaria,
laryngospasm and anaphylaxis.
Adverse Reactions As with opioid agonists, the most common serious
adverse reactions reported to occur with fentanyl are
respiratory depression, apnea, rigidity, and
bradycardia; if these remain untreated, respiratory
arrest, circulatory depression or cardiac arrest could
occur.
Nursing Considerations Assessment
 History: Hypersensitivity to fentanyl or opioids,
physical dependence on an opioid analgesic,
pregnancy, labor, lactation, COPD, respiratory
depression, anoxia, increased intracranial
pressure, acute MI, ventricular failure,
coronary insufficiency, hypertension, biliary
tract surgery, renal or hepatic impairment
 Physical: Orientation, reflexes, bilateral grip
strength, affect; pupil size, vision; P,
auscultation, BP; R, adventitious sounds;
bowel sounds, normal output; LFTs, renal
function tests
Interventions
 Administer to women who are nursing a baby
4–6 hr before the next scheduled feeding to
minimize the amount in milk.
 BLACK BOX WARNING: Keep opioid
antagonist and facilities for assisted or
controlled respiration readily available during
parenteral administration.
 Prepare site for transdermal form by clipping
(not shaving) hair at site; do not use soap,
oils, lotions, alcohol; allow skin to dry
completely before application. Apply
immediately after removal from the sealed
package; firmly press the transdermal system
in place with the palm of the hand for 10–20
sec, making sure the contact is complete.
Must be worn continually for 72 hr. Do not use
any system that has been torn or damaged.
Remove old patch before applying a new one.
 Note that the patch does not work quickly. It
56
may take up to 12 hr to get the full therapeutic
effect. Breakthrough medications need to be
used.
 Do not use Actiq in patients who never
received narcotics before; should be used
only in opioid tolerant patients.
 Use caution with Actiq form to keep this drug
out of the reach of children (it looks like a
lollipop) and follow the distribution restrictions
in place with this drug very carefully.
 Use Ionsys only for hospitalized adults. Apply
to intact, nonirritated skin on chest or upper
arm. Patient presses button twice, firmly.
System will deliver dose over 10 min. Up to 3
units may be used sequentially, if needed.
Teaching points
 Do not drink grapefruit juice while using this
drug. If using the patch, do not use any patch
that has been torn or damaged. Remove old
patch before applying a new one.
 You may experience these side effects:
Dizziness, sedation, drowsiness, impaired
visual acuity (ask for assistance if you need to
move); nausea, loss of appetite (lie quietly,
eat frequent small meals); constipation (a
laxative may help).
 Report severe nausea, vomiting, palpitations,
shortness of breath, or difficulty breathing.
Table 35. FENTANYL CITRATE
MORPHINE SULFATE
Drug Information Morphine sulfate is an alkaloid sulfate salt. It
contains a morphine. ChEBI. The principal alkaloid in
opium and the prototype opiate analgesic and
narcotic. Morphine has widespread effects in the
central nervous system and on smooth muscle.
Mechanism of Action Morphine sulfate produces respiratory depression by
direct action on brain stem respiratory centers. The
respiratory depression involves a reduction in the
responsiveness of the brain stem respiratory centers
to both increases in carbon dioxide tension and
electrical stimulation.
57
Clinical Use Morphine sulfate is an opioid agonist indicated for
the relief of moderate to severe acute and chronic
pain where use of an opioid analgesic is appropriate.
Side Effects agitation, hallucinations (seeing things or hearing
voices that do not exist), fever, sweating, confusion,
fast heartbeat, shivering, severe muscle stiffness or
twitching, loss of coordination, nausea, vomiting, or
diarrhea. nausea, vomiting, loss of appetite,
weakness, or dizziness.
Adverse Reactions The most frequently observed adverse reactions
include sedation, lightheadedness, dizziness,
nausea, vomiting, constipation, and diaphoresis.
These effects seem to be more prominent in
ambulatory patients and in those who are not
experiencing severe pain.
Nursing Considerations  Monitor blood pressure prior to
administration. Hold if systolic BP < 100 mm
Hg or 30 mm Hg below baseline.
 Monitor patient's respiratory rate prior to
administration.
 Reassess pain after administration of
morphine.
 Monitor for respiratory depression and
hypotension frequently up to 24 hours after
administration of morphine.
 Place call light signal close to patient.
Accompany patient if need to get out of bed to
minimize risk of falls.
Table 36. MORPHINE SULFATE
BUTORPHANOL TARTRATE
Drug Information Butorphanol tartrate is a synthetically derived opioid
agonist-antagonist analgesic of the phenanthrene
series. The chemical name is (-)-17-
(cyclobutylmethyl)morphinan-3,14-diol D-(-)-tartrate
(1:1) salt. The molecular formula is C21H29NO2
•C4H6O6, which corresponds to a molecular weight
of 477.6.
Mechanism of Action Butorphanol is a partial opioid agonist at the mu
opioid receptor and a full agonist at the kappa opioid
receptor. The principal therapeutic action of
butorphanol is analgesia.
58
Clinical Use This medication is used to treat moderate to severe
pain, including pain from surgery, muscle pain, and
migraine headaches. Butorphanol is an opioid pain
reliever similar to morphine. It acts on certain centers
in the brain to give you pain relief.
Side Effects Drowsiness, dizziness, blurred vision, flushing,
headache, nausea, vomiting, constipation, nasal
irritation/congestion, trouble sleeping, dry mouth, and
sweating may occur. If any of these effects persist or
worsen, tell your doctor or pharmacist promptly.
Adverse Reactions The most serious symptoms are hypoventilation,
cardiovascular insufficiency, coma, and death.
Butorphanol overdose may be associated with
ingestion of multiple drugs
Nursing Considerations Assessment
 History: Hypersensitivity to butorphanol,
physical dependence on a narcotic analgesic,
pregnancy, lactation, bronchial asthma,
COPD, increased intracranial pressure, acute
MI, ventricular failure, coronary insufficiency,
hypertension, biliary tract surgery, renal or
hepatic impairment
 Physical: Orientation, reflexes, bilateral grip
strength, affect; pupil size, vision; pulse,
auscultation, BP; R, adventitious sounds;
bowel sounds, normal output; LFTs, renal
function tests
Interventions
 Ensure that opioid antagonist facilities for
assisted or controlled respiration is readily
available during parenteral administration.
Teaching points
 You may experience these side effects:
Dizziness, sedation, drowsiness, impaired
visual acuity (avoid driving, performing other
tasks that require alertness); nausea, loss of
appetite (lie quietly, eat frequent small meals).
 Report severe nausea, vomiting, palpitations,
shortness of breath or difficulty breathing,
nasal lesions or discomfort (nasal spray).
Table 37. BUTORPANOL TARTRATE
NALBUPHINE HYDROCHLORIDE
Drug Information Nubain is a prescription medicine used to treat the
symptoms of Pain and as an Anesthesia
Supplement. Nubain may be used alone or with
59
other medications.
Nubain belongs to a class of drugs called Opioid
Analgesics.
It is not known if Nubain is safe and effective in

children younger than 1 year of age.
Mechanism of Action Nalbuphine produces respiratory depression by
direct action on brain stem respiratory centers. The
respiratory depression involves a reduction in the
responsiveness of the brain stem respiratory centers
to both increases in carbon dioxide tension and
electrical stimulation.
Clinical Use Relief of moderate to severe pain. OFFLABEL:
Opioid-induced pruritus.
Side Effects Frequent (36%): Sedation. Occasional (9%–3%):
Diaphoresis, cold/clammy skin, nausea, vomiting,
dizziness, vertigo, dry mouth, headache. Rare (less
than 1%): Restlessness, emotional lability,
paresthesia, flushing, paradoxical reaction.
Adverse Reactions Abrupt withdrawal after prolonged use may produce
symptoms of narcotic withdrawal (abdominal
cramping, rhinorrhea, lacrimation,
anxiety, fever, piloerection [goose
bumps]). Overdose results in severe
respiratory depression, skeletal muscle
flaccidity, cyanosis, extreme drowsiness
progressing to seizures, stupor, coma. Tolerance
to analgesic effect, physical dependence
may occur with chronic use.
Question medical history as listed in
Precautions. Obtain vital signs before
giving medication. If respirations are 12/
min or less (20/min or less in children),
withhold medication, contact physician.
Assess onset, type, location, duration of
pain. Effect of medication is reduced if
full pain recurs before next dose.
Monitor for change in respirations, B/P,
rate/quality of pulse. Monitor daily pattern
of bowel activity, stool consistency.
Initiate deep breathing, coughing exercises,
particularly in pts with pulmonary
impairment. Assess for clinical improvement,
record onset of relief of pain.
60
Consult physician if pain relief is not
adequate.
• Avoid alcohol. • Avoid tasks that require
alertness, motor skills until response
to drug is established. • May
cause dry mouth. • May be habit
forming.
Table 38. NALBUPHRINE HYDROCHLORIDE
BENZOCAINE
Drug Information a white, odorless, crystalline powder used in
ointments as a local anesthetic and to protect
against sunburn.
Mechanism of Action Benzocaine diffuses into nerve cells where it binds to
sodium channels, preventing the channels from
opening, and blocking the influx of sodium ions.
Nerve cells unable to allow sodium into cells cannot
depolarize and conduct nerve impulses.
Clinical Use Benzocaine is used to relieve pain and itching
caused by conditions such as sunburn or other minor
burns, insect bites or stings, poison ivy, poison oak,
poison sumac, minor cuts, or scratches.
Side Effects Check with your doctor immediately if any of the
following side effects occur:
Rare
 Bluish color of the fingernails, lips, skin,
palms, or nail beds
Incidence not known
 Blistering, burning, crusting, dryness, or
flaking of the skin
 cracking, itching, redness, or stinging of the
skin
 dark urine
 difficulty with breathing
 difficulty with walking
 dizziness or lightheadedness
 fainting
 fever
 headache
 inability to feel hands and feet
 irritability
 irritation of the nose
 itching, scaling, severe redness, soreness, or
swelling of the skin
 pale skin
61
rapid heart rate

red, sore eyes

shortness of breath

sore throat

unusual bleeding or bruising

unusual drowsiness, dullness, tiredness,

weakness, or feeling of sluggishness
Adverse Reactions The topical anesthetic benzocaine is linked to a
number of minor side effects, ranging from dry skin
to allergies. A serious but rare side effect of this
over-the-counter medication is a blood condition
called methemoglobinemia.
 Assess swallowing when used on oral
mucosa, as benzocaine may interfere with
second (pharyngeal) stage of swallowing; hold
food and liquids accordingly.
 Assess for sensitivity. Local anesthetics are
potentially sensitizing to susceptible
individuals when applied repeatedly or over
extensive areas.
 Use specific benzocaine preparation ONLY as
prescribed or recommended by manufacturer.
 Discontinue medication if the condition
persists, worsens, or if signs of sensitivity,
irritation, or infection occur.
Table 39. BENZOCAINE
III. Neonatal and Newborn
ERYTHROMYCIN
Drug Information an antibiotic used in the treatment of infections
caused by Gram-positive bacteria. It is similar in its
effects to penicillin.
Mechanism of Action Erythromycin acts by inhibition of protein synthesis
by binding to the 23S ribosomal RNA molecule in the
50S subunit of ribosomes in susceptible bacterial
organisms.
Clinical Use Treatment of susceptible infections due to
S. pyogenes, S. pneumoniae, S. aureus,
M. pneumoniae, Legionella, Chlamydia,
N. gonorrhoeae, E. histolytica,
including syphilis, nongonococcal urethritis,
diphtheria, pertussis, chancroid,
62
Campylobacter gastroenteritis. Topical:
Treatment of acne vulgaris. Ophthalmic:
Prevention of gonococcal ophthalmia
neonatorum, superficial ocular infections.
OFF-LABEL: Systemic: Treatment
of acne vulgaris, chancroid, Campylobacter
enteritis, gastroparesis, Lyme
disease, preoperative gut sterilization.
Topical: Treatment of minor bacterial
skin infections. Ophthalmic: Treatment
of blepharitis, conjunctivitis, keratitis,
chlamydial trachoma.
Side Effects Frequent: IV: Abdominal cramping/ discomfort,
phlebitis/thrombophlebitis. Topical: Dry skin (50%).
Occasional: Nausea, vomiting, diarrhea, rash,
urticaria. Rare: Ophthalmic: Sensitivity reaction with
increased irritation, burning, itching, inflammation.
Topical: Urticaria.
Adverse Reactions Antibiotic-associated colitis, other superinfections
(abdominal cramps, severe watery diarrhea, fever),
reversible cholestatic hepatitis may occur. High
dosage in pts with renal impairment may lead
to reversible hearing loss. Anaphylaxis
occurs rarely. Ventricular arrhythmias,
prolonged QT interval occur rarely with
IV form.
Question for history of allergies (particularly
erythromycins), hepatitis. Receive full medication
history and screen for interactions.
Monitor daily pattern of bowel activity, stool
consistency. Assess skin for rash. Assess for
hepatotoxicity (malaise, fever, abdominal
pain, GI disturbances). Be alert for superinfection:
fever, vomiting, diarrhea, anal/
genital pruritus, oral mucosal changes (ulceration,
pain, erythema). Check for phlebitis
(heat, pain, red streaking over vein).
Monitor for high-dose hearing loss.
• Continue therapy for full length of treatment.
• Doses should be evenly
spaced. • Take medication with 8 oz
water 1 hr before or 2 hrs following food
or beverage. • Ophthalmic: Report
63
burning, itching, inflammation. • Topical:
Report excessive skin dryness, itching,
burning. • Improvement of acne
may not occur for 1–2 mos; maximum
benefit may take 3 mos; therapy may last
mos or yrs. • Use caution if using other
topical acne preparations containing peeling
or abrasive agents, medicated or abrasive
soaps, cosmetics containing alcohol
(e.g., astringents, aftershave lotion).
Table 40. ERYTHROMYCIN
PHYTONADIONE
Drug Information Phytonadione is a man-made form of vitamin K,
which occurs naturally in the body. It treats and
prevents low levels of blood clotting factors needed
to help your blood to thicken and stop bleeding
normally. This medicine is available only with your
doctor's prescription.
Mechanism of Action Phytonadione catalyzes the hepatic synthesis of
blood-clotting factors including active prothrombin
(Factor II), Factor VII, Factor IX, and Factor X.
Clinical Use Phytonadione (vitamin K) is used to prevent bleeding
in people with blood clotting problems or too little
vitamin K in the body. Phytonadione is in a class of
medications called vitamins. It works by providing
vitamin K that is needed for blood to clot normally in
the body.
Side Effects Pain, swelling, or soreness at the injection site may
occur. Temporary flushing, taste changes, dizziness,
rapid heartbeat, sweating, shortness of breath, or
bluish lips/skin/nails may also rarely occur. If any of
these effects persist or worsen, tell your doctor or
Adverse Reactions This medicine may cause a serious allergic reaction
called anaphylaxis, when it is given as a shot into
your muscle or vein. This can be life-threatening and
requires immediate medical attention
 Monitor patient constantly. Severe reactions,
including fatalities, have occurred during and
immediately after IV injection (see ADVERSE
EFFECTS).
 Lab tests: Baseline and frequent PT/INR.
 Frequency, dose, and therapy duration are
guided by PT/INR clinical response.
64
 Monitor therpeutic effectiveness which is
indicated by shortened PT, INR, bleeding, and
clotting times, as well as decreased
hemorrhagic tendencies.
 Be aware that patients on large doses may
develop temporary resistance to coumarin-
type anticoagulants. If oral anticoagulant is
reinstituted, larger than former doses may be
needed. Some patients may require change to
heparin.
 Maintain consistency in diet and avoid
significant increases in daily intake of vitamin
K–rich foods when drug regimen is stabilized.
Know sources rich in vitamin K: Asparagus,
broccoli, cabbage, lettuce, turnip greens, pork
or beef liver, green tea, spinach, watercress,
and tomatoes.
Table 41. PHYTONADIONE
HEPATITIS B IMMUNE GLOBULIN

Drug Information Hepatitis B immune globulin (Human) injection is
used to prevent hepatitis B from occurring again in
HBsAg-positive liver transplant patients who have
had liver transplants. This medicine also helps keep
you from getting sick if you have been exposed to
hepatitis B virus.
Mechanism of Action HepaGam B provides passive immunization for
individuals exposed to the hepatitis B virus, by
binding to the surface antigen and reducing the rate
of hepatitis B infection.
Clinical Use Hepatitis B immune globulin (Human) injection is
used to prevent hepatitis B from occurring again in
HBsAg-positive liver transplant patients who have
had liver transplants. This medicine also helps keep
you from getting sick if you have been exposed to
hepatitis B virus.
Side Effects Redness, pain, or tenderness at the injection site
may occur. Nausea, vomiting, fever, chills, dizziness,
headache, or back/joint pain may also occur. If any
of these effects last or get worse, tell your doctor or
Adverse Reactions  Blurred vision
 confusion
 dizziness, faintness, or lightheadedness when
getting up suddenly from a lying or sitting
65
position
 sweating
 Have epinephrine 1:1000 readily available;
hypersensitivity reactions are most likely to
occur in patients receiving large doses or
repeated injections.
 Learn potential adverse reactions.
 Do not breast feed after taking this drug
Table 42. HEPATITIS B IMMUNE GLOBULIN
RECOMBINANT HEPATITIS B
Drug Information Recombinant hepatitis B vaccine Engerix B((R))
[Hep-B(Eng)] is a noninfectious subunit hepatitis B
viral vaccine indicated for the active immunisation of
adults, children and infants against hepatitis B virus
infection.
Mechanism of Action The vaccine works by causing your body to produce
its own protection (antibodies) against the disease.
Clinical Use RECOMBIVAX HB® [Hepatitis B Vaccine,
Recombinant] is indicated for prevention of infection
caused by all known subtypes of hepatitis B virus.
RECOMBIVAX HB is approved for use in individuals
of all ages.
Side Effects Common Side Effects
 Soreness, redness, or swelling in the arm
where the shot was given.
 Headache.
 Fever.
Adverse Reactions The most frequently reported systemic adverse
reactions ( > 1% injections), in decreasing order of
frequency, were irritability, fever ( ≥ 101°F oral
equivalent), diarrhea, fatigue/weakness, diminished
appetite, and rhinitis.
 Note: The ACIP recommends serologic
confirmation of postvaccination immunity in
patients undergoing dialysis and in
immunodeficient patients.
 Monitor temperature. Some patients develop
a temperature elevation of 38.3° C (101° F)
following vaccination that may last 1 or 2 d.
66
 Learn potential adverse reaction.
Table 43. RECOMBINANT HEPATITIS B
BERACTANT
Drug Information In addition to phospholipids, neutral lipids, fatty
acids, and bovine surfactant proteins, Beractant—
also marketed under the name Survanta—contains
synthetic DPPC, tripalmitin, and palmitic acid. It is a
modified bovine pulmonary surfactant.
Mechanism of Action Beractant replenishes lung surfactant and restores
surface activity to the lungs by lowering surface
tension on alveolar surfaces during respiration and
stabilizing the alveoli against collapse at resting
transpulmonary pressures.
Clinical Use BERACTANT is a lung surfactant. Our bodies need
lung surfactant to keep the lungs open during
breathing. This medicine is used to prevent and to
treat Respiratory Distress Syndrome (RDS) in babies
who are born early.
Side Effects The most common side effects of Survanta include:
 noisy breathing,
 feeding or bowel problems, and
 bleeding around the endotracheal tube
Adverse Reactions Transient bradycardia, oxygen desaturation,
endotracheal tube reflux, pallor, vasoconstriction,
hypotension, endotracheal tube blockage,
hypertension, hypocarbia, hypercarbia, apnea.
 Monitor heart rate, color, chest expansion,
facial expressions, oximeter, and
endotracheal tube patency and position,
during administration. Most adverse effects
occur during dosing.
 Monitor frequently with arterial or
transcutaneous measurement of systemic
oxygen and CO2.
 Note: Rales and moist breath sounds may
occur transiently following drug administration.
These do not necessarily indicate a need for
suctioning.
Table 44. BERACTANT
PORACTANT
Drug Information Poractant alfa is a pulmonary surfactant marketed as
67
Curosurf in the United States and Canada. It is used to
treat Respiratory Distress Syndrome (RDS) in
premature infants with an endogenous pulmonary
surfactant deficiency. Poractant alfa is an extract of
natural porcine lung surfactant consisting of 99% polar
lipids (mainly phospholipids) and 1% hydrophobic low
molecular weight proteins (surfactant associated
proteins SP-B and SP-C). The phospholipid content of
the extract consists primarily of phosphatidylcholine
and dipaImitoylphosphatidylcholine. Poractant alfa is a
creamy white suspension of this extract in 0.9% sodium
chloride solution. It contains no preservatives.
Mechanism of Action Endogenous pulmonary surfactant reduces surface
tension at the air-liquid interface of the alveoli in the
lungs, thus stabilizing them against collapse under
transpulmonary pressures. A deficiency of pulmonary
surfactant in premature infants allows surface tension
to increase to the point where sections of lung collapse
and respiratory distress syndrome (RDS) develops.
Poractant alfa lowers minimum surface tension to less
than or equal to 4 mN/m. This compensates for the lack
of endogenous surfactant and restores adequate
surface activity to the lungs.
Clinical Use PORACTANT ALFA is a lung surfactant. Our bodies
need lung surfactant to keep the lungs open during
breathing. This medicine is used to treat Respiratory
Distress Syndrome (RDS) in babies who are born
early. This medicine may be used for other purposes;
ask your health care provider or pharmacist if you have
questions.
Side Effects  hives,
 difficulty breathing,
 swelling of your face, lips, tongue, or throat,
 endotracheal tube blockage,
 chocking,
 breathing that slows or stops,
 slow heart rate, and
 low blood pressure
Adverse Reactions Because clinical studies are conducted under widely
varying conditions, adverse reaction rates observed
in the clinical studies of a drug cannot be directly
compared to rates in the clinical studies of another
drug and may not reflect the rates observed in
practice.
Adverse Reactions in Studies in Premature Infants
with Respiratory Distress Syndrome
The safety data described below reflect exposure to
68
CUROSURF at a single dose of 2.5 mL/kg (200
mg/kg), in 78 infants of 700-2000 grams birth weight
with RDS requiring mechanical ventilation and a
FiO2 ≥ 0.60 (Study 1) [see Clinical Studies (14.1)]. A
total of 144 infants were studied after RDS
developed and before 15 hours of age; 78 infants
received CUROSURF 2.5 mL/kg single dose (200
mg/kg), and 66 infants received control treatment
(disconnection from the ventilator and manual
ventilation for 2 minutes).
Transient adverse reactions seen with the
administration of CUROSURF included bradycardia,
hypotension, endotracheal tube blockage, and
oxygen desaturation
 Stop administration of poractant alfa and take
appropriate measures if any of the following
occur: Transient episodes of bradycardia,
decreased oxygen saturation, reflux of
poractant alfa into endotracheal tube, or
airway obstruction. Dosing may resume after
stabilization.
 Do not suction airway for 1 h after poractant
alfa instillation unless there is significant
airway obstruction.
Table 45. PORACTANT
69
REFERENCES
Acebutolol: Uses, Interactions, Mechanism of Action. (n.d.). DrugBank. Retrieved
October 27, 2022, from https://go.drugbank.com/drugs/DB01193
Amlodipine: Uses, Interactions, Mechanism of Action. (n.d.). DrugBank. Retrieved
Antiplatelet Drugs: Types, Uses & Side Effects. (2022, May 5). Cleveland Clinic.
Retrieved October 27, 2022, from
https://my.clevelandclinic.org/health/drugs/22955-antiplatelet-drugs
Apixaban. (2020, June 15). MedlinePlus. Retrieved October 27, 2022, from
https://medlineplus.gov/druginfo/meds/a613032.html
Argatroban: Uses, Interactions, Mechanism of Action. (n.d.). DrugBank. Retrieved
Bivalirudin - StatPearls. (2022, September 21). NCBI. Retrieved October 27, 2022, from
https://www.ncbi.nlm.nih.gov/books/NBK557823/
Cheung, J. (n.d.). Cardiac Glycosides: What Are They, What Are They Used For, How
Do They Work, Side Effects, and More. Osmosis. Retrieved October 27, 2022,
from https://www.osmosis.org/answers/cardiac-glycosides
Dabigatran. (2021, August 15). MedlinePlus. Retrieved October 27, 2022, from
Desirudin (Subcutaneous Route) Description and Brand Names. (n.d.). Mayo Clinic.
Retrieved October 27, 2022, from https://www.mayoclinic.org/drugs-
supplements/desirudin-subcutaneous-route/description/drg-20074071
Diltiazem - StatPearls. (2022, September 3). NCBI. Retrieved October 27, 2022, from
https://www.ncbi.nlm.nih.gov/books/NBK532937/
70
Diuretics. (n.d.). Mayo Clinic. Retrieved October 27, 2022, from
https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-
depth/diuretics/art-20048129
Diuretics. (n.d.). Mayo Clinic. Retrieved October 27, 2022, from
https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-
depth/diuretics/art-20048129
Drug profiles. (n.d.). emcdda. Retrieved October 27, 2022, from
https://www.emcdda.europa.eu/publications/drug-profiles_en
Drug profiling. (n.d.). FutureLearn. Retrieved October 27, 2022, from
https://www.futurelearn.com/info/courses/introduction-to-forensic-
science/0/steps/10573
Eliquis (apixaban). (n.d.). CenterWatch. Retrieved October 27, 2022, from
https://www.centerwatch.com/directories/1067-fda-approved-drugs/listing/3442-
eliquis-apixaban
Fondaparinux | C31H53N3O49S8. (n.d.). PubChem. Retrieved October 27, 2022, from
https://pubchem.ncbi.nlm.nih.gov/compound/Fondaparinux
How Do Class IA Antidysrhythmics Work? - Uses, Side Effects, Drug Names. (2021,
May 18). RxList. Retrieved October 27, 2022, from
https://www.rxlist.com/how_do_class_ia_antidysrhythmics_work/drug-class.htm
Kizior, R., & Hodgson, K. (2021). Saunders Nursing Drug Handbook 2021. Saunders.
List of Antihyperlipidemic agents - Generics Only. (n.d.). Drugs.com. Retrieved October
27, 2022, from https://www.drugs.com/drug-class/antihyperlipidemic-agents.html
Metoprolol: Uses, Interactions, Mechanism of Action. (n.d.). DrugBank. Retrieved
Nadolol. (2017, August 15). MedlinePlus. Retrieved October 27, 2022, from
71
Nadolol (Corgard) | Davis's Drug Guide. (n.d.). Nursing Central. Retrieved October 27,
2022, from https://nursing.unboundmedicine.com/nursingcentral/view/Davis-
Drug-Guide/51524/all/nadolol
Propranolol: medicine for heart problems, anxiety and migraine. (n.d.). NHS. Retrieved
October 27, 2022, from https://www.nhs.uk/medicines/propranolol/
propranolol [TUSOM | Pharmwiki]. (2022, January 20). TMedWeb. Retrieved October
27, 2022, from https://tmedweb.tulane.edu/pharmwiki/doku.php/propranolol
The Reproductive System | Loma Linda University Fertility. (n.d.). Loma Linda Fertility.
Retrieved October 27, 2022, from
https://lomalindafertility.com/pregnancy/reproductive-system/
Rivaroxaban: Uses, Interactions, Mechanism of Action. (n.d.). DrugBank. Retrieved
Thrombolytic Therapy - StatPearls. (2022, September 8). NCBI. Retrieved October 27,
2022, from https://www.ncbi.nlm.nih.gov/books/NBK557411/
Types of Blood Pressure Medication (Antihypertensives). (2022, April 29). Cleveland
Clinic. Retrieved October 27, 2022, from
https://my.clevelandclinic.org/health/treatments/21811-antihypertensives
Verapamil. (n.d.). Accessdata.fda.gov. Retrieved October 27, 2022, from
https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/018925s010lbl.pdf
72

Drug Profiling PHARMACOLOGY

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Drug Profiling PHARMACOLOGY

Uploaded by

Copyright:

Available Formats

Drug Profiling

Drug profiles are accurate scientific descriptions of medications that are

AGENTS USED TO TREAT HEART FAILURE

Amlodipine reduces the overall peripheral resistance

Another potential method by which amlodipine

II. Anticoagulant Drugs

Table 13. Desirudin

III. Antidysrhythmics Drugs

Adverse Reactions Some patients who use acebutolol may develop

Adverse Reactions Dry mouth, constipation, nausea, abdominal

Table 18. Disopyramide phosphate

Table 20. Flecainide

Adverse Reactions A very serious allergic reaction to this drug is rare.

Table 22. Mexiletine hydrochloride

I. Pregnancy and Preterm Labor

If your doctor has prescribed this medication,

Pyridoxine can cause side effects when taken in

Nursing Considerations Assessment & Drug Effects

Table 25. PYRIDOXINE

If your doctor has directed you to use this

Table 30. ALUMINUM HYDROXIDE

II. Labor, Delivery, and Postpartum

Table 33. PENTOBARBITAL

It is not known if Nubain is safe and effective in

III. Neonatal and Newborn

HEPATITIS B IMMUNE GLOBULIN

Acebutolol: Uses, Interactions, Mechanism of Action. (n.d.). DrugBank. Retrieved

October 27, 2022, from https://go.drugbank.com/drugs/DB01193

Amlodipine: Uses, Interactions, Mechanism of Action. (n.d.). DrugBank. Retrieved

October 27, 2022, from https://go.drugbank.com/drugs/DB00381

Retrieved October 27, 2022, from

Argatroban: Uses, Interactions, Mechanism of Action. (n.d.). DrugBank. Retrieved

October 27, 2022, from https://go.drugbank.com/drugs/DB00278

Retrieved October 27, 2022, from https://www.mayoclinic.org/drugs-

Diuretics. (n.d.). Mayo Clinic. Retrieved October 27, 2022, from

Drug profiles. (n.d.). emcdda. Retrieved October 27, 2022, from

Drug profiling. (n.d.). FutureLearn. Retrieved October 27, 2022, from

Eliquis (apixaban). (n.d.). CenterWatch. Retrieved October 27, 2022, from

Fondaparinux | C31H53N3O49S8. (n.d.). PubChem. Retrieved October 27, 2022, from

May 18). RxList. Retrieved October 27, 2022, from

List of Antihyperlipidemic agents - Generics Only. (n.d.). Drugs.com. Retrieved October

27, 2022, from https://www.drugs.com/drug-class/antihyperlipidemic-agents.html

Metoprolol: Uses, Interactions, Mechanism of Action. (n.d.). DrugBank. Retrieved

October 27, 2022, from https://go.drugbank.com/drugs/DB00264

2022, from https://nursing.unboundmedicine.com/nursingcentral/view/Davis-

October 27, 2022, from https://www.nhs.uk/medicines/propranolol/

propranolol [TUSOM | Pharmwiki]. (2022, January 20). TMedWeb. Retrieved October

27, 2022, from https://tmedweb.tulane.edu/pharmwiki/doku.php/propranolol

Retrieved October 27, 2022, from

Rivaroxaban: Uses, Interactions, Mechanism of Action. (n.d.). DrugBank. Retrieved

October 27, 2022, from https://go.drugbank.com/drugs/DB06228

2022, from https://www.ncbi.nlm.nih.gov/books/NBK557411/

Types of Blood Pressure Medication (Antihypertensives). (2022, April 29). Cleveland

Clinic. Retrieved October 27, 2022, from

Verapamil. (n.d.). Accessdata.fda.gov. Retrieved October 27, 2022, from

You might also like