aspirin • Advise patient about compliance with product regimen • Advise patient that heat stroke may occur in hot weather; take extra precautions to stay cool • Advise patient to use contraception, inform prescriber if pregnancy is planned or suspected • Advise patient to report suicidal thoughts/ behaviors immediately Evaluation Positive therapeutic outcome • Therapeutic response: decrease in emotional excitement, hallucinations, delusions, paranoia; reorganization of patterns of thought, speech TREATMENT OF OVERDOSE: Lavage if orally ingested; provide airway; do not induce vomiting aspirin (OTC) (as9pir-in) APC-ASA Coated Aspirinâ•— , A.S.A., Ascriptin Enteric, Aspergum, Aspirinâ•— , Aspir-Low, Aspirtrinâ•— , Bayer Aspirin, Bayer Children’s Aspirin, Bufferin, Ecotrin, Equaline, Good Sense Aspirin, Halfprin, PMS-ASAâ•— , St. Joseph Children’s, St. Joseph’s Adult, Walgreens Aspirin Adult Func. class.:╇ ╉Nonopioid analgesic Chem. class.:╇ ╉Salicylate Pregnancy category D (3rd trimester) Do not confuse: Ascendin/Afrin ACTION: Blocks pain impulses in CNS, reduces inflammation by inhibition of prostaglandin synthesis; antipyretic action results from vasodilatation of peripheral vessels; decreases platelet aggregation Therapeutic outcome: Decreased pain, inflammation, fever; absence of MI, transient ischemic attacks, thrombosis USES: Mild to moderate pain or fever including rheumatoid arthritis, osteoarthritis, thromboembolic disorders, transient ischemic attacks, rheumatic fever, post-MI, prophylaxis of MI, ischemic stroke, angina; acute MI ╇ Canada only 81 Unlabeled uses: Prevention of cataracts (long-term use), prevention of pregnancy loss in A women with clotting disorders CONTRAINDICATIONS: Pregnancy D (3rd trimester), breastfeeding, children ,12 yr, children with flulike symptoms, hypersensitivity to salicylates, tartrazine (FDC yellow dye #5), GI bleeding, bleeding disorders, vit K deficiency, peptic ulcer, acute bronchospasm, agranulocytosis, increased intracranial pressure, intracranial bleeding, nasal polyps, urticaria Precautions: Abrupt discontinuation, acetaminophen/NSAIDs hypersensitivity, acid/base imbalance, alcoholism, ascites, asthma, bone marrow suppression, geriatric patients, dehydration, G6PD deficiency, gout, heart failure, anemia, renal/hepatic disease, pre/postoperatively, gastritis, pregnancy C 1st trimester DOSAGE AND ROUTES Arthritis Adult:╇ ╉PO 3 g/day in divided doses q4-6hr Child .25 kg (55 lb):╇ ╉PO or RECT 90-130 mg/ kg/day in divided doses Kawasaki’s disease (unlabeled) Child:╇ ╉PO 80-100 mg/kg/day in 4 divided doses, maintenance 3-5 mg/kg/day MI, stroke prophylaxis Adult:╇ ╉PO 50-325 mg/day Pain/fever Adult:╇ ╉PO/RECT 325-650 mg q4hr prn, max 4 g/day Child 2-11 yr:╇ ╉PO 10-15 mg/kg/dose q4hr, max 4 g/day Thromboembolic disorders Adult:╇ ╉PO 325-650 mg/day or bid Transient ischemic attacks (risk) Adult:╇ ╉PO 50-325 mg/day (grade 1A) Prevention of recurrent MI Adult:╇ ╉PO 75-162 mg/day CABG Adult:╇ ╉PO 325 mg/day starting 6 hr post-procedure, continue for 1 yr PTCA Adult:╇ ╉PO 325 mg 2 hr presurgery Evolving MI with ST segment elevation (STEMI) Adult:╇ ╉PO 160-325 mg nonenteric, chewed and swallowed immediately, maintenance 75-162 mg qd Adverse effects: italics = common; bold = life-threatening 82 aspirin Available forms: Tabs 81, 325, 500, 650, 800 mg; chewable tabs 81 mg; supp 300, 600, mg; gum 227 mg; enteric coated tabs 81, 325, 500, 975 mg; ext rel 800 mg; del rel tabs 325, 500 mg; supp 300, 600 mg Implementation PO route • Do not break, crush, or chew enteric product • Administer to patient crushed or whole; chewable tab should be chewed • Give with food or milk to decrease gastric symptoms; separate by 2 hr of enteric product; absorption may be slowed • Give antacids 1-2 hr after enteric products • Give with 8 oz of water and have patient sit upright for 30 min after dose; discard tabs if vinegar-like smell is present; avoid if allergic to tartrazine • Give ½ hr before planned exercise Rectal route • Place suppository in refrigerator for at least 30 min before removing wrapper ADVERSE EFFECTS CNS: Stimulation, drowsiness, dizziness, confusion, seizures, headache, flushing, hallucinations, coma CV: Rapid pulse, pulmonary edema EENT: Tinnitus, hearing loss ENDO: Hypoglycemia, hyponatremia, hypokalemia GI: Nausea, vomiting, GI bleeding, diarrhea, heartburn, anorexia, hepatitis, GI ulcer HEMA: Thrombocytopenia, agranulocytosis, leukopenia, neutropenia, hemolytic anemia, increased PT, PTT, bleeding time INTEG: Rash, urticaria, bruising RESP: Wheezing, hyperpnea, bronchospasm SYST: Reye’s syndrome (children), ana- phylaxis, laryngeal edema Pharmacokinetics Absorption Well absorbed, small intestine (PO); erratic (enteric); slow (RECT) Distribution Rapidly, widely distributed; crosses placenta, protein binding 90% Metabolism Liver, extensively Excretion Inactive metabolites, kidney; breast milk Half-life 15-20 min (low doses); 9 hr (high doses) ╇ Nurse Alert Pharmacodynamics Onset Peak Duration PO RECT 15-30 min 1-2 hr 4-6 hr Slow 4-5 hr 6-7 hr INTERACTIONS Individual drugs Alcohol, cefamandole, clopidogrel, eptifibatide, heparin, plicamycin, ticlopidine, tirofiban: increased risk of bleeding Ammonium chloride, nizatidine: increased salicylate level Insulin, methotrexate, phenytoin, valproic acid, warfarin: increased effects of each specific product Nitroglycerin: increased hypotension Probenecid: decreased effects of probenecid Spironolactone, sulfinpyrazone: decreased effects Drug classifications ACE inhibitors: decreased antihypertensive effect Antacids (high doses), corticosteroids, urinary alkalizers: decreased effects of aspirin Anticoagulants, thrombolytics: increased risk of bleeding Diuretics (loop), sulfonylamides, NSAIDs, b-blockers: decreased effect of each specific product NSAIDs, antiinflammatories, steroids: increased gastric ulcers Penicillins, oral hypoglycemics, sulfonamides, thrombolytic agents: increased effects of each specific product Salicylates: decreased blood glucose levels Urinary acidifiers: increased salicylate levels Drug/herb Feverfew, garlic, ginger, ginkgo, ginseng (Panax), horse chestnut: increased risk of bleeding Drug/food Foods acidifying urine may increase aspirin levels Fish oil (omega-3-fatty acids): increased risk of bleeding Drug/lab test Increased: coagulation studies, liver function studies, serum uric acid, amylase, CO2, urinary protein Decreased: serum potassium, cholesterol Interference: VMA, 5-HIAA, xylose tolerance test, TSH, pregnancy test Key NCLEX® Drug atazanavir NURSING CONSIDERATIONS Assessment • Assess for pain: character, location, intensity, ROM before and 1 hr after administration • Monitor liver function studies: AST, ALT, bilirubin, creatinine if patient is on long-term therapy • Monitor renal function studies: BUN, urine creatinine if patient is on long-term therapy • Monitor blood studies: CBC, Hct, Hgb, PT if patient is on long-term therapy • Check I&O ratio; decreasing output may indicate renal failure (long-term therapy) Assess hepatotoxicity: dark urine, claycolored stools, yellowing of the skin and sclera, itching, abdominal pain, fever, diarrhea if patient is on long-term therapy • Assess for allergic reactions: rash, urticaria; if these occur, product may have to be disconÂ�tinued; in patients with asthma, nasal polyps, allergies, severe allergic reactions may occur • Assess for ototoxicity: tinnitus, ringing, roaring in ears; audiometric testing needed before, after long-term therapy • Monitor salicylate level: therapeutic level 150-300 mcg/ml for chronic inflammation • Check edema in feet, ankles, legs • Identify prior product history; there are many product interactions Patient/family education • Teach patient to report any symptoms of renal/hepatic toxicity, visual changes, ototoxicity, allergic reactions, bleeding (long-term therapy) • Instruct patient to take with 8 oz of water and sit upright for 30 min after dose to facilitate product passing into the stomach; to discard tabs if vinegar-like smell is present; to avoid if allergic to tartrazine • Instruct patient not to exceed recommended dosage; acute poisoning may result • Advise patient to read label on other OTC products; many contain aspirin • Inform patient that the therapeutic response takes 2 wk (arthritis) • Teach patient to report tinnitus, confusion, diarrhea, sweating, hyperventilation • Advise patient to avoid alcohol ingestion; GI bleeding may occur • Advise patient with allergies, nasal polyps, asthma, that allergic reactions may develop • Instruct patient to read labels on other OTC products: may contain salicylates • Teach patient not to give to children or teens with flulike symptoms or chicken pox; Reye’s syndrome may develop ╇ Canada only 83 Instruct patient not to use during 3rd trimester of pregnancy (D) • Teach patient to take with a full glass of water Evaluation Positive therapeutic outcome • Decreased pain • Decreased inflammation • Decreased fever • Absence of MI • Absence of transient ischemic attacks, thrombosis TREATMENT OF OVERDOSE: Lavage, activated charcoal; monitor electrolytes, VS atazanavir (Rx) (at-a-za-na9veer) Reyataz Func. class.:╇ ╉Antiretroviral Chem. class.:╇ ╉Protease inhibitor Pregnancy category B ACTION: Inhibits human immunodefi- ciency virus (HIV-1) protease, which prevents maturation of the infectious virus Therapeutic outcome: Decreasing symptoms of HIV USES: HIV-1 infection in combination with other antiretroviral agents CONTRAINDICATIONS: Hypersensitivity Precautions: Pregnancy B, breastfeeding, children, geriatric, liver disease, alcoholism, antimicrobial resistance, AV block, diabetes, dialysis, elderly, women, hemophilia, hypercholesterolemia, immune reconstitution syndrome, lactic acidosis, pancreatitis, cholelithiasis, serious rash DOSAGE AND ROUTES Antiretroviral-naive patients Adult:╇ ╉PO 400 mg daily Child $6 yr/adolescent #40 kg:╇ ╉PO 300 mg with ritonavir 100 mg qd Child $6 yr/adolescent 20 to ,40 kg:╇ ╉PO 200 mg with ritonavir 100 mg qd Child $6 yr/adolescent 15 to ,20 kg:╇ PO 150 mg with ritonavir 80 mg qd Antiretroviral-experienced patients Adult:╇ ╉PO 300 mg daily and ritonavir 100 mg daily Adverse effects: italics = common; bold = life-threatening A