methocarbamol (Robaxin) Centrally acting skeletal muscle relaxants
Why is pt receiving this? Adjunctive treatment of muscle
assoc. w/ actue painful musculoskeletal contraction. Reduces muscle tone and hyperactivity by unknown mechanism.
Dosage 1.5 g qid for 2-3 days, then 4-4.5 g/day in 3-6 divided doses. IM, IV: 1-3 g/day for not more than
3 day (can be repeated after 48 hr rest period. Direct IV: undiluted, [100 mg/mL], administer at max 180 mg/m^2?min but not more than 3mL/min. IV: dilute in 250 mL NS, 4 mg/mL for infusions.
SE Seizures (IM, IV), dizziness, drowsiness, light headedness, bradycardia/hypotension (IV), Urine color
change: brown/black/or green urine, METALLIC TASTE, ANAPHYLAXIS RXNS,
Med admin concerns. T1/2= 1-2 hrs. Have pt remain recumbent after IV therapy to prevent orthostatic.
B/c drowsiness, common to use @ HS. Addative CNS depression w/ ETOH. Assess for pain, stiffness, and
ROM a/periodically throughout therapy, monitor VS every 15 min during parenteral, assess for allergic rxn/ IV site. LIKE ALL MUSCLE RELAXANTS, INTEDNED FOR SHORT TERM USE; prolonged use assoc. w dependence and potential for abuse
Pt education Take as directed, comply w/ additional therapies, may cause dizziness, drowsiness, and blurred vision, Change positions slowly to minimize orthostatics, Importance of routine follow ups

tubocurarine (Curare): oldest known poison

NONDEPOLARIZING Neuromuscular Blocker 1 : competes w/ Ach for nicotinic receptor, depol never occurs

Creates flaccid paralysis WITH NO EFFECT ON CNS (CONCIOUS!)

Used in emergency intubations, deep anesthetic surgical procedures, reduce O2 requirements, and Electroconvulsive therapy (ECT)

Starts w/ small muscles first, most essential affected the least BUT CAN LEAD TO RESP
PARALYSIS

Hypotension release of histamine (bronchoconstrictor)-> prolonged apnea treated by AChE inhibitor cyclobenzaprine (Flexaril) (Centrally acting skeletal muscle relaxants ) CONTRAINDICATED w/ hyperthyroidism, HF, recent MI

Anticholinergic effect: increased BP

baclofen (Lioresal) Antispasticity agents, central acting skeletal muscle relaxants
Why is pt receiving this? PO: treatment of reversible
due to MS (Most common drug we use for spasticity) or spinal cord lesions. IT: treatment of sever spasticity of cerebral or spinal origin. Structural analog to GABA (inhibitory) which inhibits reflexes @ spinal level. DOES NOT WORK W/ HUNTINGTONS
OR PARKINSON’s
Dose PO: 5mg 3 times daily, may increase q 3 days by 5 mg/dose up to 80 mg/day (can break into 4 doses). Also given IT.
SE Sedation, HA, SEIZURES (IT), edema, hypotension, nausea, constipation, frequency, hyperglycemia, weight gain, ataxia, hypersensitivity rxn
Med admin concerns Increased CNS depression w/ alcohol, antihistamines, opiodis, and sedatives.
high fever, rigidity, hallucinations. Assess spasticity before and periodically during therapy. Observe for s/sx . Administer w/ food or milk to reduce GI irritation.
Pt education Take as prescribed, take missed dose w/in 1 hr. May case dizziness/drowsiness. Instruct to change position slowly to minimize orthostatics. Avoid concurrent use of CNS depressants . adverse s/sx

atracurium (Tracrium) (-curium, -nium) Nondepolarizing neuromuscular blocker II HIGH ALERT
Why is pt receiving this? Induction of skeletal muscle paralysis and facilitation of intubation after induction of anesthesia in surgical procedures; facilitation of compliance during mechanical ventilation.
Does not cross BBB. Competes for Ach @ motor end plate which results in FLACCID PARALYSIS w/ no
anxiolytic/analgesic properties
Dose IV: .4-.5 mg/kg initially ; may repeat w/ .08-.1 mg/kg 20-45 min after initial dose as needed or by continuous infusion at
5-9 mcg/kg/min. Direct: can be undiluted. Rate: bolus over 1 min. Intermittent: Maintatnence dose required 20-45 min following initial dose. Dilute w/ D5W, NS, D5NS, administer every 15 min or by continuous infusion (titrate to pt response)
SE bronchospasm, hypotension, tachycardia, flushing, rash, HYPERSENSITIVIT RXN
Med concerns: Intensity duration prolonged by succinylcholine, general inhaled anesthesia, aminoglycosides, vancomycin, tetarcylcins, quinidine, beta blockers, potassium losing diureticts, or Mg; higher infusion rates may be needed w/ long term use of carbamezpine or phenytoin. Assess resp status, monitor neuromuscular response w/ TRAIN OF FOUR (4 electric stimuli, looking for 1-2 twitches, 4 not enough, no is too much) ,
Pt education Explain procedure IF NOT USED W/ ANESTHESIA B/C DOES NOT AFFECT CONCIOUSNESS ,
REASSURE COMMUNICATION WILL RETURN AS MED WEARS OFF

succinylcholine Depolarizing Neuromuscular Blocker HIGH ALERT
Why is pt receiving this? Use during surgical procedures to produce skeletal muscle paralysis after induction of anesthesia and provision of opioid analgesia. Encourages rapid use of Ach to create sustained depolarization resulting in shorter acting paralysis
Dose IV test dose using 5-10 mg (assess resp function) followed by .6 mg/kg up to 150 mg total dose.
Can give IM
SE
(arrhythmias accompanying K+ release) in those w/ genetic predisposition! , prolonged apnea, muscle pain
Med admin concerns potentiation w/ general anesthesia, aminoglycosides, lidocaine, quinidine, betablockers, potassium losing diuretics and mag salts. Assess resp status (SHOULD ONLY BE USED BY
INDICIAULS EXPERIENCED IN ENDOTRACHEAL INTUBATION), monitor nerumosuclar respone (TRAIN OF
4), ECG, HR< BP, Assess pt history of malignant hypothermia
Pt education Explain procedure IF NOT USED W/ ANESTHESIA B/C DOES NOT AFFECT CONCIOUSNESS ,
REASSURE COMMUNICATION WILL RETURN AS MED WEARS OFF

Botulinum Toxin Type A

Designer drug for wrinkles, also covered for hyperhidrosis, and (dep on insurance) migraine prophylaxis

Photosensitivity rxns common

Decreased spastcity could take up to 2 weeks

Can DEVELOP ANTIBODIES ->> Cardiovascular collapse

Aldendronate (Fosamax) (-dronate) Biphsophonates, bone resorption inhibitors
Why pt receiving this? Treatemnt and prevention of postmenopausal osteoporosis and osteoporosis in men. Treatment of Paget’s disease. Treatment of corticosteroid induced osteoporosis in pts. Inhibits osteoclast activity.
Dose PO: Treatment 10 mg once daily or 70 mg once weekly. Prevention 5 mg once daily or 35 mg once weekly. Paget’s 40 mg once daily for 6 mo. Corticosteroid: 5 mg once daily (10 for women not receiving estrogen)
SE heartburn, SEVERE ESOPHOGEAL IRRITATION , OSTEONECROSIS OF THE JAW (ONJ), Renal failure, atypical femur fracture , photosensitivity
Med admin concerns MUST BE ABLE TO SIT OR STAND >30 min AFTER TAKING DRUG (esophagus), ONLY
TAKEN w/ WATER, OTHER MEDICATIONS DECREASE ABSORPTION, PAIN FOR WEEKS/MONTHS AFTER
BEGINNING THERAPY,
Pt education Importance of taking as directed, first thing in morning, 30 min before taking anything else, eat a balanced diet, participate in regular exercise and modify lifestyle, use sunscreen/protection

denosumab (Prolia) Bone resorption inhibitors, monoclonal antibodies
Why is pt receiving this? Treatment of osteoporosis in post menopausal women @ high risk for hip f/x, increase bone mass in men w/ osteoporosis who are at high risk, increase bone mass n men receiving androgen deprivation therapy, increase bone mass in women receiving adjuvant aromatase inhibitor therapy for br ca Inhibits osteoclast formation
Dosage Sub Q 60 mg q 6 months.
SE HA, pancreatitis, cystitis, hypocalcemia, hypophosphatemia, hypercholesterolemia, back pain, extremity pain, msk pain,
dyspnea, cough, hypersensitivity rxn
Med admin concerns Assess pts via bone density studies, perform oral exam prior to initiation of therapy, monitor for s/sx of hypersensitivity. Use w/ immmunosupressent drugs increases risk of infection
Pt education Explain purpose, if dose missed administer as soon as possible. Advise balanced diet, notify hcp immediately for s/sx of hypersensitivity, hypocalcemia, infection or skin rxns, participate in regular exercise, modify lifestyle, take good care of teeth and gums. Females use highly effective contraception

teriparatide (Forteo) Parathyroid hormones
Why is pt receiving this ONLY DRUG THAT ACTIVELY BUILDS BONE INSTEAD OF PREVENTING LOSS, treatment of osteoporosis in postmenopausal women, increase bone mass, most useful for those who have failed or intolerant to other therapies. Regulates calcium and phosphate metabolism in bone by binding to specific receptors and stimulating osteoblastic activity.
Dose Sub Q 20 mcg once daily
SE orthostatic hypotension, muscle spasms
Med admin conerns: hypercalcemia may increase risk of digoxin toxicity, Boxed warning of osteosarcoma
Pt education Administer same time each day. Instruc proper injection technique. Importance of other treatments. Administer first few doses in sitting position to determine response. Notify persistent symptoms. Emphasize importance of follow up tests

raloxifene (Evista) Bone resporption inhibitors, selective estrogen receptor modulators (SERM)
Why is pt receiving this? Treatment/prevention of osteoporosis in postmenopausal women, reduction of risk of breast cancer in postmenopausal women w/ osteoporosis and those at risk for breast cancer.
Binds to estrogen receptors, producing estrogen like effects at some recepotrs, anti estrogen at others.
(cousin to Tamoxifen)
Dose PO 60 mg once daily ; or 30 mg daily and MUST BE TAKING CALCIUM
SE
Med admin conern: hx of clot, sedentary or immobility and use in men are all contraindicated.
Concurrent estrogen therapy not recommended. May potentiate warfarin. Assess bone mineral density.
Pt education take as directed, importance of calcium and diet, importance of weight bearing exercise, lifestyle modifications, will not reduce hot flashes (may cause them), discontinue smoking/drinking, may have teratogenic effects

pramipexole (Mirapex) Antiparkinson’s agents
Why is pt receiving this? IR indicated for Restless Leg Syndrome (RLS). Stimualtes dopamine recepotrs in striatum of brain
Dosage PO: .125 mg daily 1-3 hr before bedtime. May be increased at 4-7 day intervals to .25 mg daily, then up to .5 mg.
SE SLEEP ATTACKS , amnesia, dizziness/drowsiness, orthostatic hypotension, may activate melanoma,
SIADH, constipation , dry mouth, dyspepsia, nausea, urinary frequency, leg cramps. Hypertonia
Med admin concerns Take with meals to minimize GI effects. Assess sleep patterns and frequency of symptoms
Pt education Take as directed. Take missed doses as soon as remembered if not almost time for next dose. MAY CAUSE SLEEP ATTACKS, change position slowly to minimize orthostatic, have periodic skin checks, advise if new or increased gambling, sexual or other intense urges.

methotrexate (abr. MTX) (Rheumatrex) Disease Modifying Antirheumatic Drug (DMARD) HIGH ALERT
Why is pt receiving this? Alone or w/ other modalities in treatment of RA and juvenile idiopathic arthritis unresponsive to conventional therapy. Immunosupressive function ALSO USED IN CA
Dose PO/Sub Q: 7.5 mg weekly, not to exceed 20 mg/wk. When response obtained, dose should decrease.
SE dizziness, drowsiness, HA, malaise, seizures, blurred vision, Pulmonary fibrosis , PENUMONITIS,
HEPATOTOXICITY , anorexia, diarrhea, stomatitis, n/v, TENS< SJS, painful plaque erosions, Aplastic anemia, anemia, leukopenia, thrombocytopenia, hypouricemia, nephropathy
Med admin concerns PREG CATEGORY X . Most rapid acting, but still takes up to 3-6 weeks for effect to be seen. Monitor resp function, bone marrow suppression, assess nutritional status, assess for rash.
Assess for pain and ROM prior to and throughout therapy.
Pt education Take as directed , if dose is missed, omit. Notify promptly for s/sx, inspect oral mucosa for ulceration, protect against photosensitivity, instruct technique for subq

hydroxychloroquine (Plaquenil) Antirheumatics/antimalarials
Why is pt receiving this? Treatment of severe RA/SLE, unknown MOA
DosePO 400-600 mg once daily initially, maintenance 200-400 mg/day divided 1-2 times daily.
SE
Med admin Take w/ milk or meals to reduce GI SE, may be crushed and added to empty capsules or to jello/pudding. Addative risk of hepatoxicity. Urinary acidification may increase excretion. May increase levels of digoxin.
Pt education Take as directed. Avoid use of alcohol, explain need for periodic ophthalmic exams, notify for adverse s/sx, contact if no improvement noticed after few days of tx

etanerept (Enbrel) Biologic DMARD
Why is pt receiving this? Decrease progression, s/sx of rheumatoid arthritis and other conditions. May be used with other agents. Inactivates TNF, a mediator of the inflammatory response . Used in moderate to severe RA
Dose SubQ 50 mg once weekly.
SE HA, rhinitis, Upper RTI, abd pain, dyspepsia, injection site reaction, INFECTIONS (due to decreased immunofunction), MALIGNANCY, SARCOIDOSIS
Med admin Administer TB test before use (positive PPD should be referred before therapy), assess for latex allergies (needle cover), do not administer w/in 1 inch of an old site or into area tender/red/hard/bruised .
Pt education Instruct self administration technique, not tor ecievie live vaccines during therapy, methotrexate, NSAIDS, corticosteroids MAY be continued during therapy, notify for infections, adverse s/sx

Synvisc: elastic mixture inected by orthopedist directly into joint to replace lost lubricating fluids

indomethacin (Indocin) NSAID
Why is pt receiving this? Inflammatory disorders incl Gout, osteoarthritis, generally reseved for pts who do not respond to less toxic treatments ; also given to infants w/ PDA to close
Dose 100 mg initially followed by 50 mg 3 times daily for relief of pain, then decrease further.
SE dizziness, drowsiness, HA, psychic disturbances, blurred vision, hypertension, HEPATITIS, GI BLEED, hyperkalemia, hypoglycemia, ANAPHYLAXIS
Med admin Can have cross allergy to ASA. W/ prolonged therapy, doses should be reduced to lowest level that controls symptoms. Adminsiter after meals, with food, or w/ antacids to decrease GI irritation.
DO NOT CRUSH, BREAK or CHEW Sustained release . concurrent with ASA may decrease effectiveness, addative adverse GI effects, chornic use of acetaminophen (Tylenol) may increase risk of adverse renal rxns, may decrease effectiveness of antihypertensives, may increase hypoglycemia, increase risk of toxicity form lithium, addative risk of bleeding, risk of adverse hematologic rxns w/ antineoplastics or radiation therapy, hyperkalemia w/ potassium sparing diuretics,
Pt education Take w/ full glass of water, sit upright for 15-30 min, take as directed (take missed dose asap), avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen or other OTCs w/out contacting

colchicine Anti gout agents; HIGH ALERT
Why is pt receiving this? Prophylaxis and treatment of acute attacks of gouty arthritis. Prevents mobility of granulocytes decreasing inflammatory response.
Dosage Treatment of attacks, PO: 1.2 mg initially then .6 mg 1 hr later; Prevention: .6 mg once or twice daily. Dose adjustments for Renal impairment and concurrent use w/ CYP3A4 inhibitors.
SE AGRANULOCYTOSIS, APLASTIC ANEMIA, GI DISTRESS, PERIPHERAL NEURITIS
Med admin concerns Intermittent therapy w/ 3 days between courses can decrease risk of toxicity.
Concurrent use w/ strong CYP3A4 inhibiotrs (-ivir, -mycin) may increase levels of toxicity, addative bone marrow depression, increased risk of rhabdo w/ Statins, addative GI effects w/ NSAIDs
Pt education Review admin schedule, taked missed dose ASAP (do not double doses). When taking prophylactic doses, DO NOT increase to therapeutic doses (use NSAID or corticosteroid instead). Avoid grapefruit/grapefruit juice.

allopurinol (Zyloprim) Antigout agents, antihyperuricemic
Why is pt receiving this? Prevention of gouty arthritis and nephropathy, treatment of secondary hyperuricemia (PO or IV). Inhibits production of uric acid
Dose PO Initially 100 mg/day, increase at weekly intervals. Doses over 300 mg/day SHOULD be given in divided doses. Mainteance dose of 100-200 mg 2-3 times daily.
SE hypotension, hypertension, bradycardia, HF (w/ IV0, drowsiness, diarrhea, hepatitis, nausea, renal failure, hematuria, rash (DISCONTINUE AT FIRST SIGN OF RASH) bone marrow depression,
Hypersensitivity
Med admin conerns administerd after milk or meals to minimize GI irritation, give w/ plenty of fluid.
Increased effects of warfarin and oral hypoglycemic agents. Use w/ thiazides or ACE increases hypersensitivity rxns.
Pt education Take as directed. Take missed doses as soon as remembered. Do not double up on doses. IF dose is more than once a day, take up to 300 mg of missed dose the next day. Containue taking w/ and NSAID or colchicine during acute attacks (does not alleviate gout attacks). Alkaline diet may be ordered (acidification via vitamin c or citric acd may increase kidney stone formation). May cause drowsiness, report adverse s/x, importance of follow up

probenecid antigout
Why is pt receiving this? prevention of recurrence of gouty attacks, treatment of hyperuricemia secondary to thiazide, also used in combination to decrease excretion (and increase length of effectiveness) of anti-infectives. Inhitibs renal tubular resorption of uric acid, promoting renal excretion.
Dose PO 250 mg twice daily for 1 wk, up to 500 mg twice daily, then may increase by 500 mg/day every 4 wk (not to exceed 3 g/day)
SE HA, dizziness, n/v, abd, pain, diarrhea, hepatitis, sore gums, uric stones, urinary frequency, aplastic an
Med admin concerns Does not treat gouty arthritis, but prevents it, so should be used w/ NSAID or corticosteroid. Administer w/ food or antacid to minimize gastric irritation. Increases levels of antifinfectives, benzodiazepines, NSAIDs, and sulfonylureas (diabetes drugs). Salicylates may decrease urosuric activity.
Take as directed, don’t discontinue w/out consulting. Irregular dosing may elevate uric acid. Follow reccomendations of lifestyle modification (weight loss, alcohol consumption), diet. Avoid aspirin or other salicilates. Report s/sx