Ruth's Medication Cards

Front 1

metronidazole
(me-troe-ni-da-zole)
Apo-Metronidazole, Flagyl, Flagyl ER, Metric 21, MetroCream, MetroGel, MetroGel-Vaginal, MetroLotion, Metro IV, Metryl, Nidagel, Noritate, Novonidazol, Protostat, Trikacide
Classification
Therapeutic: anti-infectives, antiprotozoals, antiulcer agents

Back 1

Indications: PO IV: Treatment of the following anaerobic infections: Intra-abdominal infections (may be used with a cephalosporin), Gynecologic infections, Skin and skin structure infections, Lower respiratory tract infections, Bone and joint infections, CNS infections, Septicemia, Endocarditis.
IV: Perioperative prophylactic agent in colorectal surgery.
PO: Amebicide in the management of amebic dysentery, amebic liver abscess, and trichomoniasis: Treatment of peptic ulcer disease caused by Helicobacter pylori.
Topical: Treatment of acne rosacea.
Vag: Management of bacterial vaginosis. Unlabelled Use: Treatment of giardiasis. . Treatment of anti-infective associated pseudomembranous colitis.
Route/Dosage: PO (Adults): Anaerobic infections--7.5 mg/kg q 6 hr (not to exceed 4 g/day). Trichomoniasis--250 mg q 8 hr for 7 days or single 2-g dose or 1 g bid for 1 day. Amebiasis--500-750 mg q 8 hr for 5-10 days. H. pylori--250 mg 4 times daily or 500 mg twice daily for 1-2 wk (with other agents). Bacterial vaginoses--750 mg once daily as ER tablets for 7 days.Antibiotic associated pseudomembranous colitis--250-500 mg 3-4 times/day for 10-14 days.
PO (Infantsand Children): Anaerobic infections-30 mg/kg/day divided q 6 hr, maximum dose: 4 g/dayTrichomoniasis--15-30 mg/kg/day divided q 8 hr for 7-10 days. Amebiasis--35-50 mg/kg/day divided q 8 hr for 5-10 days (not to exceed 750 mg/dose). Antibiotic associated pseudomembranous colitis--30 mg/kg/day divided q 6 hr for 7-10 days. H. pylori--15-20 mg/kg/day divided twice daily for 4 weeks.
IV PO (Neonates0-4 weeks, <1200 g): 7.5 mg/kg q 48 hr. Postnatal age <7 days, 1200-2000 g--7.5 mg/kg/day q 24 hr. Postnatal age <7 days, >2000 g--15 mg/kg/day divided q 12 hr.Postnatal age >7 days, 1200-2000 g--15 mg/kg/day divided q 12 hr. Postnatal age >7 days, >2000 g--30 mg/kg/day divided q 12 hr.

Hint 1

IV (Adults): Anaerobic infections--Initial dose 15 mg/kg, then 7.5 mg/kg q 6-8 hr or 500 mg q 6-8 hr (not to exceed 4 g/day). Perioperative prophylaxis--Initial dose 15 mg/kg 1 hr before surgery, then 7.5 mg/kg 6 and 12 hr later. Amebiasis--500-750 mg q 8 hr for 5-10 days.
IV (Children): Anaerobic infections--30 mg/kg/day divided q 6 hr, maximum dose: 4 g/day.
Topical (Adults): Acne rosacea--apply thin film to affected area bid.
Vag (Adults): Bacterial vaginosis--One applicatorful (5 g) 2 times daily for 5 days. Route: PO,IV,Topical,Vaginal (adults) PO (infants and children) IV,PO(neonates 0-4week,<1200g)
Assessment
Assess patient for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and throughout therapy.
Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results.
Monitor neurologic status during and after IV infusions. Inform physician if numbness, paresthesia, weakness, ataxia, or seizures occur.
Monitor intake and output and daily weight, especially for patients on sodium restriction. Each 500 mg of Flagyl IV for dilution contains 5 mEq of sodium; each 500 mg of Flagyl RTU contains 14 mEq of sodium. .
Giardiasis: Monitor three stool samples taken several days apart, beginning 3-4 wk after treatment.
Lab Test Considerations: May alter results of serum AST, ALT, and LDH tests. PO: Administer on an empty stomach, or may administer with food or milk to minimize GI irritation. Tablets may be crushed for patients with difficulty swallowing. IV Administration. Intermittent Infusion: Diluent: Flagyl IV RTU is prediluted and ready to use. Do not refrigerate. Once taken out of overwrap, premixed infusion stable for 30 days at room temperature.Concentration: 5 mg/ml. Rate: Infuse over 30-60 min. Instruct patient to take medication exactly as directed with evenly spaced times between doses, even if feeling better. Do not skip doses or double up on missed doses. Take missed doses as soon as remembered if not almost time for next dose. Adverse Reactions/Side Effects *
*CAPITALS indicate life threatening; underlines indicate most frequent. CNS: SEIZURES, dizziness, headache.
EENT: tearing (topical only).
GI: abdominal pain, anorexia, nausea, diarrhea, dry mouth, furry tongue, glossitis, unpleasant taste, vomiting.
Derm: rashes, urticariatopical only: burning, mild dryness, skin irritation, transient redness.
Hemat: leukopenia. Local: phlebitis at IV site. Neuro: peripheral neuropathy.
Misc: superinfection, disulfiram-type reaction with alcohol.

Front 2

acetaminophen
(a-seet-a-min-oh-fen)
Abenol, Acephen, Aceta, Aminofen, Apacet, APAP, Apo-Acetaminophen, Aspirin Free Anacin, Aspirin Free Pain Relief, Children's Pain Reliever, Dapacin, Feverall, Extra Strength Dynafed E.X., Extra Strength Dynafed (Billups, P.J.), Genapap, Genebs, Halenol, Infant's Pain Reliever, Liquiprin, Mapap, Maranox, Meda, Neopap, Novo-Gesic, Oraphen-PD, Panadol, paracetamol, Redutemp, Ridenol, Silapap, Tapanol, Tempra, Tylenol, Uni-Ace

Classification
Therapeutic: antipyretics, nonopioid analgesics

Back 2

Indications: Mild pain. Fever.
Route/Dosage Children ≤12 yr should not receive >5 doses/24 hr without notifying physician or other health care professional. PO (Adults and Children > 12 yr): 325-650 mg q 4-6 hr or 1 g 3-4 times daily or 1300 mg q 8 hr (not to exceed 4 g or 2.5 g/24 hr in patients with hepatic/renal impairment).
PO (Children 1-12 yr): 10-15 mg/kg/dose q 4-6 hr as needed (not to exceed 5 doses/24 hr). PO (Infants): 10-15 mg/kg/dose q 4-6 hr as needed (not to exceed 5 doses/24 hr). PO (Neonates): 10-15 mg/kg/dose q 6-8 hr as needed.
Rect (Adults and Children > 12 yr): 325-650 mg q 4-6 hr as needed or 1 g 3-4 times/day (not to exceed 4 g/24 hr).
Rect (Children 1-12 yr): 10-20 mg/kg/dose q 4-6 hr as needed. Rect (Infants): 10-20 mg/kg/dose q 4-6 hr as needed.
Rect (Neonates): 10-15 mg/kg/dose q 6-8 hr as needed.
Contraindications/Precautions Contraindicated in:
Previous hypersensitivity. Products containing alcohol, aspartame, saccharin, sugar, or tartrazine (FDC yellow dye #5) should be avoided in patients who have hypersensitivity or intolerance to these compounds. Use Cautiously in:
Hepatic disease/renal disease (lower chronic doses recommended) Chronic alcohol use/abuse, Malnutrition.

Hint 2

Adverse Reactions/Side Effects *CAPITALS* indicate life threatening; underlines indicate most frequent.
GI: HEPATIC FAILURE, HEPATOTOXICITY(OVERDOSE).
GU: renal failure (high doses/chronic use).
Hemat: neutropenia, pancytopenia, leukopenia. Derm: rash, urticaria. Assess overall health status and alcohol usage before administering acetaminophen. Patients who are malnourished or chronically abuse alcohol are at higher risk of developing hepatotoxicity with chronic use of usual doses of this drug. Assess amount, frequency, and type of drugs taken in patients self-medicating, especially with OTC drugs. Prolonged use of acetaminophen increases the risk of adverse renal effects. For short-term use, combined doses of acetaminophen and salicylates should not exceed the recommended dose of either drug given alone. .
Pain: Assess type, location, and intensity prior to and 30-60 min following administration. Fever: Assess fever; note presence of associated signs (diaphoresis, tachycardia, and malaise). Lab Test Considerations: Evaluate hepatic, hematologic, and renal function periodically during prolonged, high-dose therapy. May alter results of blood glucose monitoring. May cause falsely ↓ values when measured with glucose oxidase/peroxidase method, but probably not with hexokinase/G6PD method. May also cause falsely ↑ values with certain instruments; see manufacturer's instruction manual. Increased serum bilirubin, LDH, AST, ALT, and prothrombin time may indicate hepatotoxicity. .
Toxicity and Overdose: If overdose occurs, acetylcysteine (Acetadote) is the antidote. When combined with opioids do not exceed the maximum recommended daily dose of acetaminophen. PO: Administer with a full glass of water.
May be taken with food or on an empty stomach. .Pedi: Advise parents or caregivers to check concentrations of liquid preparations. Errors have resulted in serious liver damage. Have parents or caregivers determine the correct formulation and dose for their child (based on the child's age/weight), and demonstrate how to measure it using an appropriate measuring device Inform patients with diabetes that acetaminophen may alter results of blood glucose monitoring. Advise patient to notify health care professional if changes are noted. Caution patient to check labels on all OTC products. Advise patients to avoid taking more than one product containing acetaminophen at a time to prevent toxicity.

Front 3

propranolol
(proe-pran-oh-lole)
Apo-Propranolol, Betachron E-R, Inderal, Inderal LA, InnoPran XL, Novopranol, pms Propranolol

Classification
Therapeutic: antianginals, antiarrhythmics (Class II), antihypertensives, vascular headache suppressants
Pharmacologic: beta blockers

Back 3

Indications

Management of hypertension, angina, arrhythmias, hypertrophic cardiomyopathy, thyrotoxicosis, essential tremors, pheochromocytoma.
Also used in the prevention and management of MI, and the prevention of vascular headaches. Unlabelled Use: Also used to manage alcohol withdrawal, aggressive behavior, antipsychotic-associated akathisia, situational anxiety, and esophageal varices. Post-traumatic stress disorder (PTSD)(Ongoing clinical trials at National Institute for Mental Health [NIMH].). Contraindications/Precautions
Contraindicated in:
Uncompensated CHF
Pulmonary edema
Cardiogenic shock
Bradycardia or heart block.
Use Cautiously in:
Renal or hepatic impairment
pulmonary disease (including asthma)
diabetes mellitus (may mask signs of hypoglycemia)
thyrotoxicosis (may mask symptoms)
history of severe allergic reactions (may ↑ intensity of response)
OB: Crosses the placenta and may cause fetal/neonatal bradycardia, hypotension, hypoglycemia, or respiratory depression. May also ↓ blood supply to the placenta, increase the risk for premature birth or fetal death, and cause intrauterine growth retardation. May ↑ risk of cardiac and pulmonary complications in the infant during the neonatal time frame.Lactation: Appears in breast milk; use formula if propranolol must be taken
Pedi: ↑ risk of hypoglycemia, especially during periods of fasting such as before surgery, during prolonged exertion, or with coexisting renal insufficiency
Geri: ↑ sensitivity to all beta blockers; initial dose reduction and careful titration recommended.

Adverse Reactions/Side Effects *
*CAPITALS indicate life threatening; underlines indicate most frequent.

CNS: fatigue, weakness, anxiety, dizziness, drowsiness, insomnia, memory loss, mental depression, mental status changes, nervousness, nightmares.
EENT: blurred vision, dry eyes, nasal stuffiness.
Resp: bronchospasm, wheezing.
CV: ARRHYTHMIAS, BRADYCARDIA, CHF, PULMONARY EDEMA, orthostatic hypotension, peripheral vasoconstriction.
GI: constipation, diarrhea, nausea.
GU: erectile dysfunction, decreased libido.
Derm: itching, rashes.
Endo: hyperglycemia, hypoglycemia (increased in children). MS: arthralgia, back pain, muscle cramps.
Neuro: paresthesia.
Misc: drug-induced lupus syndrome. Route/Dosage

PO (Adults): Antianginal--80-320 mg/day in 2-4 divided doses or once daily as extended/sustained-release capsules.Antihypertensive--40 mg twice daily initially; may be increased as needed (usual range 120-240 mg/day; doses up to 1 g/day have been used); or 80 mg once daily as extended/sustained-release capsules, increased as needed up to 120 mg. InnoPran XL dosing form is designed to be given once daily at bedtime.Antiarrhythmic--10-30 mg 3-4 times daily. Prevention of MI--180-240 mg/day in divided doses. Hypertrophic cardiomyopathy--20-40 mg 3-4 times daily. Adjunct therapy of pheochromocytoma--20 mg 3 times daily to 40 mg 3-4 times daily concurrently with alpha-blocking therapy, started 3 days before surgery is planned. Vascular headache prevention--20 mg 4 times daily or 80 mg/day as extended/sustained-release capsules; may be increased as needed up to 240 mg/day. Management of tremor--40 mg twice daily; may be increased up to 120 mg/day (up to 320 mg have been used).
PO (Children): Antihypertensive/antiarrhythmic--0.5-1 mg/kg/day in 2-4 divided doses; may be increased as needed (usual range for maintenance dose is 2-4 mg/kg/day in 2 divided doses).
IV (Adults): Antiarrhythmic--1-3 mg; may be repeated after 2 min and again in 4 hr if needed.
IV (Children): Antiarrhythmic--10-100 mcg (0.01-0.1 mg)/kg (up to 1 mg/dose); may be repeated q 6-8 hr if needed. Monitor blood pressure and pulse frequently during dose adjustment period and periodically during therapy.
Abrupt withdrawal of propranolol may precipitate life-threatening arrhythmias, hypertension, or myocardial ischemia. Drug should be tapered over a 2 week period before discontinuation. Assess patient carefully during tapering and after medication is discontinued. Consider that patients taking propranolol for non-cardiac indications may have undiagnosed cardiac disease. Abrupt discontinuation or withdrawal over too-short a period of time (less than 9 days) should be avoided.
Pedi: Assess pediatric patients for signs and symptoms of hypoglycemia, particularly when oral foods and fluids are restricted. .

Hint 3

Patients receiving propranolol IV must have continuous ECG monitoring and may have pulmonary capillary wedge pressure (PCWP) or central venous pressure (CVP) monitoring during and for several hours after administration. .
Assess for orthostatic hypotension when assisting patient up from supine position.
Monitor intake and output ratios and daily weight. Assess patient routinely for evidence of fluid overload (peripheral edema, dyspnea, rales/crackles, fatigue, weight gain, jugular venous distention).
Angina: Assess frequency and characteristics of anginal attacks periodically during therapy.
Vascular Headache Prophylaxis: Assess frequency, severity, characteristics, and location of vascular headaches periodically during therapy.
PTSD: Assess frequency of symptoms (flashbacks, nightmares, efforts to avoid thoughts or activities that may trigger memories of the trauma, and hypervigilance) periodically throughout therapy.
Lab Test Considerations: May cause ↑ BUN, serum lipoprotein, potassium, triglyceride, and uric acid levels.
May cause ↑ ANA titers.
May cause ↓ or ↑ in blood glucose levels. In labile diabetic patients, hypoglycemia may be accompanied by precipitous ↑ of blood pressure. .
Toxicity and Overdose: Monitor patients receiving beta blockers for signs of overdose (bradycardia, severe dizziness or fainting, severe drowsiness, dyspnea, bluish fingernails or palms, seizures). Notify physician or other health care professional immediately if these signs occur.
Hypotension may be treated with modified Trendelenburg position and IV fluids unless contraindicated. Vasopressors (epinephrine, norepinephrine, dopamine, dobutamine) may also be used. Hypotension does not respond to beta agonists.
Glucagon has been used to treat bradycardia and hypotension. .
High Alert: IV vasoactive medications are inherently dangerous. Before administering intravenously, have second practitioner independently check the original order, dose calculations, and infusion pump settings. Also, patient harm or fatalities have occurred when switching from oral to IV propranolol; oral and parenteral doses are not interchangeable. IV dose is 1/10 of the oral dose. Change to oral therapy as soon as possible. Do not confuse propranolol with pravachol. Do not confuse Inderal (a brand name of propranolol) with Adderall (an amphetamine/dextroamphetamine combination drug).
PO: Take apical pulse prior to administering. If <50 bpm or if arrhythmia occurs, withhold medication and notify physician or other health care professional.
Administer with meals or directly after eating to enhance absorption.
Extended-release capsules should be swallowed who≤ do not crush, open, or chewPropranolol tablets may be crushed and mixed with food.
Mix propranolol oral solution with liquid or semisolid food (water, juices, applesauce, puddings). To ensure entire dose is taken, rinse glass with more liquid or have patient consume all of the applesauce or pudding. Do not store after mixing. . IV Administration

Direct IV: Diluent: Administer undiluted or dilute each 1 mg in 10 ml of D5W for injection.Concentration: Undiluted: 1mg/ml. Diluted in 10 ml of D5W: 0.1 mg/ml. Rate: Administer at 0.5 mg/ min for adults to avoid hypotension and cardiac arrest; do not exceed 1 mg/min. Pedi: Administer over 10 min.
Intermittent Infusion: Diluent: May be diluted in 50 ml of 0.9% NaCl, D5W, D5/0.45% NaCl, D5/0.9% NaCl, or lactated Ringer's injection.Concentration: Depends on dose. Rate: Infuse over 10-15 min.
Syringe Compatibility: inamrinone, milrinone.
Syringe Incompatibility:
pantoprazole. .
Y-Site Compatibility: alteplase, fenoldopam, heparin, hydrocortisone sodium succinate, inamrinone, linezolid, meperidine, milrinone, morphine, potassium chloride, propofol, tacrolimus, vitamin B complex with C.
Y-Site Incompatibility: amphotericin B cholesteryl sulfate complex, diazoxide, lansoprazole. Instruct patient to take medication as directed, at the same time each day, even if feeling well; do not skip or double up on missed doses. Take missed doses as soon as possible up to 4 hr before next dose (8 hr with extended-release propranolol).Inform patient that abrupt withdrawal can cause life-threatening arrhythmias, hypertension, or myocardial ischemia

Front 4

HISTAMINE H2 ANTAGONISTS
famotidine
(fa-moe-ti-deen)
Acid Control, Apo-Famotidine, Gen-Famotidine, Maximum Strength Pepcid, Mylanta AR, Novo-Famotidine, Nu-Famotidine, Pepcid, Pepcid AC, Pepcid AC Acid Controller, Pepcid RPD, UlcidineClassification
Therapeutic: antiulcer agents
Pharmacologic: histamine H2 antagonists

Back 4

Indications

Short-term treatment of active duodenal ulcers and benign gastric ulcers.
Maintenance therapy for duodenal and gastric ulcers after healing of active ulcers.
Management of GERD.
Treatment of heartburn, acid indigestion, and sour stomach (OTC use).
Cimetidine, famotidine, ranitidine: Management of gastric hypersecretory states (Zollinger-Ellison syndrome).
Cimetidine, famotidine, ranitidine IV: Prevention and treatment of stress-induced upper GI bleeding in critically ill patients.
Ranitidine: Treatment of and maintenance therapy for erosive esophagitis. Unlabelled Use: Management of GI symptoms associated with the use of NSAIDs. Prevention of acid inactivation of supplemental pancreatic enzymes in patients with pancreatic insufficiency. Management of urticaria. Contraindications/Precautions
Contraindicated in:
Hypersensitivity
Some products contain alcohol and should be avoided in patients with known intolerance
Some products contain aspartame and should be avoided in patients with phenylketonuria.
Use Cautiously in:
Renal impairment (more susceptible to adverse CNS reactions; increased dosage interval recommended for cimetidine and nizatidine if CCr ≤ 50 ml/min, and for famotidine and ranitidine if CCr <50 ml/min
Hepatic impairment (for ranitidine)
Acute porphyria (for ranitidine)
Geri: Geriatric patients (more susceptible to adverse CNS reactions; dosage reduction recommended)
OB: Lactation: Pregnancy or lactation.

Adverse Reactions/Side Effects *
*CAPITALS indicate life threatening; underlines indicate most frequent.

CNS: confusion, dizziness, drowsiness, hallucinations, headache.
CV: ARRHYTHMIAS.
GI: constipation, diarrhea, drug-induced hepatitis (nizatidine, cimetidine), nausea.
GU: decreased sperm count, erectile dysfunction (cimetidine).
Endo: gynecomastia. Hemat: AGRANULOCYTOSIS, APLASTIC ANEMIA, anemia, neutropenia, thrombocytopenia. Local: pain at IM site. Misc: hypersensivity reactions, vasculitis. Route/Dosage


Cimetidine
PO (Adults): Short-term treatment of active ulcers--300 mg 4 times daily or 800 mg at bedtime or 400-600 mg twice daily (not to exceed 2.4 g/day) for up to 8 wk. Duodenal ulcer prophylaxis--300 mg twice daily or 400 mg at bedtime. GERD--400 mg q 6 hr or 800 mg twice daily for 12 wk. Gastric hypersecretory conditions--300-600 mg q 6 hr (up to 2400 mg/day). OTC use--up to 200 mg may be taken twice daily (for not more than 2 wk).
PO (Children): Short-term treatment of active ulcers--5-10 mg/kg q 6 hr.
IM IV (Adults): Short-term treatment of active ulcers--300 mg q 6 hr (not to exceed 2.4 g/day). Continuous IV infusion--900 mg infused over 24 hr (37.5 mg/hr); may be preceded by a 150-mg bolus dose. Gastric hypersecretory conditions--300-600 mg q 6 hr (not to exceed 2.4 g/day). Prevention of upper GI bleeding in critically ill patients--50 mg/hr.
IM IV (Children): Short-term treatment of active ulcers--5-10 mg/kg q 6 hr.

Renal Impairment
IV PO (Adults): CCr 10-50 ml/min--Administer 50% of normal dose; CCr <10 ml/min--Administer 25% of normal dose;prevention of upper GI bleeding in critically ill patients if CCr <30 ml/min--25 mg/hr.

Renal Impairment
PO (Children): 10-15 mg/kg/day.

Famotidine
PO (Adults): Short-term treatment of active duodenal ulcers--40 mg/day at bedtime or 20 mg twice daily for up to 8 wk. Treatment of benign gastric ulcers--40 mg/day at bedtime. Maintenance treatment of duodenal ulcers--20 mg once daily at bedtime. GERD--20 mg twice daily for up to 6 wk; up to 40 mg twice daily for up to 12 wk for esophagitis with erosions, ulcerations, and continuing symptoms. Gastric hypersecretory conditions--20 mg q 6 hr initially, up to 160 mg q 6 hr. OTC use--10 mg for relief of symptoms; for prevention--10 mg 60 min before eating or take 10 mg as chewable tablet 15 minutes before heartburn-inducing foods or beverages (not to exceed 20 mg/24 hr for up to 2 wk).
PO IV (Children 1-16 yr): Peptic ulcer--0.5 mg/kg/day as a single bedtime dose or in 2 divided doses(up to 40 mg daily); GERD--1 mg/kg/day in 2 divided doses(up to 80 mg twice daily).
PO (Infants >3 mo-1 yr): GERD--0.5 mg/kg/dose twice daily.
PO (Infants and neonates <3 mo): GERD--0.5 mg/kg/dose once daily.
IV (Adults): 20 mg q 12 hr.

Hint 4

Renal Impairment
PO (Adults): CCr <50 ml/min--administer normal dose q 36-48 hr or 50% of normal dose at normal dosing interval. CCr <10 ml/min--dosing interval may need to be ↑ to q 36-48 hr.

Nizatidine
PO (Adults): Short-term treatment of active duodenal or benign gastric ulcers--300 mg once daily at bedtime. Maintenance treatment of duodenal ulcers--150 mg once daily at bedtime. GERD--150 mg twice daily. OTC use--75 mg twice daily given 30-60 min before foods or beverages expected to cause symptoms.

Renal Impairment
PO (Adults): Short-term treatment of active ulcers-- CCr 20-50 ml/min--150 mg once daily; CCr <20 ml/min--150 mg every other day. Maintenance treatment of duodenal ulcers--CCr 20-50 ml/min--150 mg every other day; CCr <20 ml/min--150 mg every 3 days.

Ranitidine
PO (Adults): Short-term treatment of active duodenal of benign gastric ulcers--150 mg twice daily or 300 mg once daily at bedtime. Maintenance treatment of duodenal or gastric ulcers --150 mg once daily at bedtime. GERD--150 mg twice daily. Erosive esophagitis--150 mg 4 times daily initially, then 150 mg twice daily as maintenance. Gastric hypersecretory conditions--150 mg twice daily initially; up to 6 g/day have been used. OTC use--75 mg 30-60 min before foods or beverages expected to cause symptoms (up to twice daily) (not to be used for more than 2 wk).
PO (Children1 mo-16 yr): Treatment of gastric/duodenal ulcers2-4 mg/kg/day in 2 divided doses (up to 300 mg/day)Maintenance treatment of ulcers2-4 mg/kg once daily (up to 150 mg/day);GERD/erosive esophagitis5-10 mg/kg/day in 2 divided doses (up to 300 mg/day for GERD or 600 mg/day for erosive esophagitis).
PO (Neonates): 2 mg/kg/day in 2 divided doses.
IV, IM (Adults): 50 mg q 6-8 hr. Continuous IV infusion--6.25 mg/hr. Gastric hypersecretory conditions--1 mg/kg/hr; may be ↑ by 0.5 mg/kg/hr (not to exceed 2.5 mg/kg/hr).
IV, IM (Children1 mo-16 yr): Treatment of gastric/duodenal ulcers--2-4 mg/kg/day divided q 6-8 hr (up to 200 mg/day). Continuous infusion--1 mg/kg/dose followed by 0.08-0.17 mg/kg/hr.
IV (Neonates): 1.5 mg/kg/dose load, then in 12 hr start maintenance of 1.5-2 mg/kg/day divided q 12 hr Continuous IV infusion--1.5 mg/kg/dose load followed by 0.04-0.08 mg/kg/hr infusion.

Renal Impairment
PO (Adults): CCr<50 ml/min--150 mg q 24 hr.

Renal Impairment
IV (Adults): CCr<50 ml/min--50 mg q 24 hr. Assess for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate.
Geri: Assess geriatric and debilitated patients routinely for confusion. Report promptly.
Lab Test Considerations: Monitor CBC with differential periodically during therapy.
Antagonize effects of pentagastrin and histamine during gastric acid secretion testing. Avoid administration for 24 hr before the test.
May cause false-negative results in skin tests using allergenic extracts. Histamine H2 antagonists should be discontinued 24 hr before the test.
May cause ↑ in serum transaminases and serum creatinine.
Serum prolactin concentration may be ↑ after IV bolus of cimetidine. May also cause ↓ parathyroid concentrations.
Nizatidine may cause ↑ alkaline phosphatase concentrations.
Ranitidine and famotidine may cause false-positive results for urine protein; test with sulfosalicylic acid. Instruct patient to take medication as directed for the full course of therapy, even if feeling better. Take missed doses as soon as remembered but not if almost time for next dose. Do not double doses.
Advise patients taking OTC preparations not to take the maximum dose continuously for more than 2 wk without consulting health care professional. Notify health care professional if difficulty swallowing occurs or abdominal pain persists..
Inform patient that smoking interferes with the action of histamine antagonists. Encourage patient to quit smoking or at least not to smoke after last dose of the day.
May cause drowsiness or dizziness. Caution patient to avoid driving or other activities requiring alertness until response to the drug is known.
Advise patient to avoid alcohol, products containing aspirin or NSAIDs, and foods that may cause an increase in GI irritation.
Inform patient that increased fluid and fiber intake and exercise may minimize constipation.
Advise patient to report onset of black, tarry stools; fever; sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health care professional promptly. .
.

Front 5

levofloxacin
(le-voe-flox-a-sin)
Levaquin , Novo-Levofloxacin
Classification
Therapeutic: anti-infectives
Pharmacologic: fluoroquinolones

Back 5

Indications

PO IV: Treatment of the following bacterial infections: Urinary tract infections including cystitis and prostatitis (ciprofloxacin, levofloxacin, norfloxacin, ofloxacin), Gonorrhea (may not be considered first-line agents due to increasing resistance), Gynecologic infections (ciprofloxacin, norfloxacin, ofloxacin), Respiratory tract infections including acute sinusitis, acute exacerbations of chronic bronchitis, and pneumonia (not norfloxacin), Skin and skin structure infections (levofloxacin, moxifloxacin, ciprofloxacin, ofloxacin), Bone and joint infections (ciprofloxacin), Infectious diarrhea (ciprofloxacin), Intra-abdominal infections (ciprofloxacin, moxifloxacin).
Febrile neutropenia (ciprofloxacin).
Post-exposure treatment of inhalational anthrax (ciprofloxacin, levofloxacin). Contraindications/Precautions
Contraindicated in:
Hypersensitivity. Cross-sensitivity among agents within class may occur
Gemifloxacin and moxifloxacin: Concurrent use of amiodarone, disopyramide, erythromycin, pentamidine, phenothiazines, procainamide, quinidine, sotalol, or tricyclic antidepressants
Known QT prolongation or concurrent use of agents causing prolongation
OB: Pregnancy (do not use unless potential benefit outweighs potential fetal risk)
Pedi: Use only for treatment of anthrax and complicated UTIs in children 1-17 yrs due to possible arthropathy.
Use Cautiously in:
Known or suspected CNS disorder
Renal impairment (dosage reduction if CCr ≤50 ml/min for ciprofloxacin, levofloxacin, ofloxacin; ≤30 ml/min for norfloxacin; <40 ml/min for gemifloxacin)
Cirrhosis (levofloxacin or norfloxacin)
Geri: Geriatric patients (↑ risk of adverse reactions)
Lactation: Lactation (safety not established except for treatment of anthrax).

Adverse Reactions/Side Effects *
*CAPITALS indicate life threatening; underlines indicate most frequent.

CNS: SEIZURES, dizziness, headache, insomnia, acute psychoses, agitation, confusion, drowsiness.
CV: gemifloxacin, levofloxacin, moxifloxacin: ARRHYTHMIAS, QT prolongation, vasodilation.
GI: PSEUDOMEMBRANOUS COLITIS, diarrhea, nausea, abdominal pain, increased liver function tests (ciprofloxacin, moxifloxacin), vomiting.
GU: vaginitis.
Derm: photosensitivity, rash.
Endo: hyperglycemia, hypoglycemia. Local: phlebitis at IV site. MS: tendinitis, tendon rupture.
Misc: HYPERSENSITIVITY REACTIONS INCLUDING ANAPHYLAXIS, STEVENS-JOHNSON SYNDROME.

Drug-Drug:
↑ risk of QTc prolongation and life-threatening arrhythmias with concurrent use of gemifloxacin and moxifloxacin and amiodarone, disopyramide, erythromycin, pentamidine, phenothiazines,procainamide, quinidine, sotalol, and tricyclic antidepressants (concurrent use should be avoided).
↑ serum theophylline levels and may lead to toxicity.
Administration with magnesium and aluminum-containing antacids, iron salts, bismuth subsalicylate, sucralfate, didanosine, and zinc salts ↓ absorption of fluoroquinolones.
May ↑ the effects of warfarin.
Ciprofloxacin may ↓ blood levels and effectiveness of phenytoin.
Serum levels of fluoroquinolones may be ↓ by antineoplastics.
Cimetidine may interfere with elimination of fluoroquinolones.
Beneficial effects of ciprofloxacin may be antagonized by nitrofurantoin.
Probenecid ↓ renal elimination of fluoroquinolones.
May ↑ risk of nephrotoxicity from cyclosporine.
Concurrent use of ciprofloxacin with foscarnet may ↑ risk of seizures.
Concurrent therapy with corticosteroids may ↑ the risk of tendon rupture.
May ↑ risk of hypoglycemia when used with antidiabetic agents.
Drug-Natural: Fennel ↓ the absorption of ciprofloxacin.
Drug-Food:
Absorption is impaired by concurrent tube feeding (because of metal cations).
Absorption is ↓ if taken with dairy products or calcium-fortified juices.
Route/DosageLevofloxacin
PO IV (Adults): Most infections--250-750 mg q 24 hr; inhalational anthrax (post-exposure)--500 mg once daily for 60 days.

Hint 5

Renal Impairment
PO IV (Adults): Normal renal function dosing of 750 mg/day:-CCr 20-49 ml/min--750 mg q 48 hr; CCr 10-19 ml/min--750 mg initially, then 500 mg q 48 hr;Normal renal function dosing of 500 mg/day: CCr 20-49 ml/min--500 mg initially then 250 mg q 24 hr; CCr 10-19 ml/min--500 mg initially then 250 mg q 48 hr. Normal renal function dosing of 250 mg/day: CCr 10-19 ml/min--250 mg q 48 hr. Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC; urinalysis; frequency and urgency of urination; cloudy or foul-smelling urine) prior to and during therapy.
Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results..
Observe for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue drug and notify physician or other health care professional immediately if these problems occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in case of an anaphylactic reaction. Patients takinggemifloxacinwho are at greater risk for rash are those receiving gemifloxacin for >7 days, <40 yrs of age, females, and postmenopausal females receiving hormone replacement therapy.
Lab Test Considerations: May cause ↑ serum AST, ALT, LDH, bilirubin, and alkaline phosphatase.
May also cause ↑ or ↓ serum glucose.
Moxifloxacin may cause hyperglycemia, hyperlipidemia, and altered prothrombin time. It may also cause ↑ WBC; ↑ serum calcium, chloride, albumin, and globulin; and ↓ glucose, hemoglobin, RBCs, neutrophils, eosinophils, and basophils.
Monitor prothrombin time closely in patients receiving fluoroquinolones and warfarin; may enhance the anticoagulant effects of warfarin. .
Instruct patient to take medication as directed at evenly spaced times and to finish drug completely, even if feeling better. Take missed doses as soon as possible, unless almost time for next dose. Do not double doses. Advise patient that sharing of this medication may be dangerous.
Instruct patient to notify health care professional if fever and diarrhea develop, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional.
Instruct patient to notify health care professional immediately if rash, jaundice, signs of hypersensitivity, or tendon (shoulder, hand, Achilles, and other) pain or inflammation occur. Increased risk in >65 yrs old, taking corticosteroids concurrently, and taking ciprofloxacin, ofloxacin, and levofloxacin. Therapy should be discontinued. Advise patient to notify health care professional of any personal or family history of QTc prolongation or proarrhythmic conditions such as recent hypokalemia, significant bradycardia, or recent myocardial ischemia. Patients with this history should not receive fluoroquinolones.
Advise patient that antacids or medications containing iron or zinc will decrease absorption. Ciprofloxacin,levofloxacin,norfloxacin, and ofloxacin should be taken at least 2 hr before (3 hr for gemifloxacin, 4 hr for moxifloxacin) or 2 hr after (8 hr for moxifloxacin) these products.
May cause dizziness and drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known. Do confuse norfloxacin with Norflex (orphenadrine).
PO: Administer norfloxacin and ofloxacin on an empty stomach 1 hr before or 2 hr after meals, with a full glass of water. Moxifloxacin,levofloxacin, and gemifloxacin may be administered without regard to meals. Should be taken at least 2 hr (3 hr for gemifloxacin, 4 hr for moxifloxacin) before or 2 hr (8 hr for moxifloxacin) after antacids or other products containing calcium, iron, zinc, magnesium, or aluminum.