ANTIBIOTIC ulcer recurrence

CAPSULES, CHEWABLE TABLETS, ORAL

amoxicillin trihydrate SUSPENSION,
TABLETS
(amoxycillin) Adults. 1 g every 12 hr with 500 mg of
Amoxil, Apo-Amoxi (CAN), Larotid, Moxatag, clarithromycin every 12 hr and 30 mg of
Novamoxin (CAN) lansoprazole every 12 hr for 14 days, or 1 g every
8 hr with 30 mg of
Class and Category lansoprazole every 8 hr for 14 days.
Pharmacologic class: Aminopenicillin To prevent bacterial endocarditis before dental,
Therapeutic class: Antibiotic oral, or upper respiratory
Indications and Dosages tract procedures
To treat ear, nose, throat, GU tract, skin, and CAPSULES, CHEWABLE TABLETS, ORAL
soft-tissue infections SUSPENSION,
CAPSULES, CHEWABLE TABLETS, ORAL TABLETS
SUSPENSION, Adults and children weighing 40 kg (88 lb) or
TABLETS more. 2 g 1 hr before
Adults and children weighing 40 kg (88 lb) or procedure.
more. 250 mg every 8 hr; for Children weighing less than 40 kg. 50 mg/kg 1 hr
severe infections, 500 mg or 875 mg every 12 hr. before the procedure.
Children age 12 wk and over weighing less than 40 DOSAGE ADJUSTMENT For patients with impaired
kg. 20 mg/kg daily in renal function with a
divided doses every 8 hr; for severe infections, 40 glomerular filtration rate less than 30 ml/min,
to 45 mg/kg/day in divided dosage reduced to less than 875
doses every 12 hr. mg; for a glomerular filtration rate of 10 to 30
Children under age 12 wk. Up to 30 mg/kg/day in ml/min dosage reduced to 500 mg
divided doses every 12 hr. or 250 mg every 12 hr; for a glomerular filtration
To treat tonsillitis or pharyngitis caused by rate less than 10 ml/min
Streptococcus pyogenes dosage reduced to 500 mg or 250 mg and
E.R. TABLETS (MOXATAG) frequency reduced to every 24 hr.
Adults and children age 12 and over. 775 mg once Mechanism of Action
daily for 10 days, taken Kills bacteria by binding to and inactivating
within 1 hr of finishing a meal. penicillin-binding proteins on the
To treat lower respiratory tract infections inner bacterial cell wall, weakening the bacterial
CAPSULES, CHEWABLE TABLETS, ORAL cell wall and causing lysis.
SUSPENSION, Contraindications
TABLETS Hypersensitivity including severe reactions
Adults and children weighing 40 kg (88 lb) or (anaphylaxis or Stevens–Johnson
more. 875 mg every 12 hr; for
severe infections, 500 mg every 8 hr. syndrome) to amoxicillin, other beta-lactam
Children age 12 wk and over weighing less than 40 antibiotics, or their components
kg. 40 mg/kg in divided Interactions
doses every 8 hr or 45 mg/kg in divided doses DRUGS
every 12 hr. allopurinol: Increased risk of rash
Children under age 12 wk. Up to 30 mg/kg daily in chloramphenicol, erythromycins, sulfonamides,
divided doses every 12 hr. tetracyclines: Reduced
As adjunct to eradicate Helicobacter pylori to bactericidal effect of amoxicillin
reduce risk of duodenal
methotrexate: Increased risk of methotrexate LACTATION
toxicity
oral anticoagulants: Possible prolonged Drug is present in breast milk and may lead to
prothrombin time (increased sensitization in infant.
international normalized ratio) Patient should check with prescriber before
oral contraceptives with estrogen: Possibly breastfeeding.
reduced effectiveness of Nursing Considerations
contraceptive Know that patients with mononucleosis shouldn’t
probenecid: Increased amoxicillin effects receive amoxicillin because this class of drugs may
Adverse Reactions cause an erythematous rash.
CNS: Agitation, anxiety, behavior changes, Use drug cautiously in patients with hepatic
confusion, dizziness, insomnia, impairment. Monitor hepatic and renal function
reversible hyperactivity, seizures and
CV: Hypersensitivity vasculitis CBC, as ordered, in patients on prolonged therapy.
EENT: Black, hairy tongue; mucocutaneous Also use cautiously in breastfeeding and elderly
candidiasis; tooth discoloration patients.
GI: Clostridium difficile-associated diarrhea, Expect to start therapy before culture and
diarrhea, elevated liver enzymes, sensitivity test results are known.
hemorrhagic or pseudomembranous colitis, Be aware that chewable tablets and tablets for oral
hepatic dysfunction, jaundice, suspension contain phenylalanine.
nausea, vomiting WARNING Stop amoxicillin immediately and
GU: Crystalluria, vaginal mycosis provide emergency care as indicated
HEME: Agranulocytosis, anemia (including and ordered if an allergic reaction occurs.
hemolytic anemia), eosinophilia, Monitor patient closely for diarrhea, which may
granulocytosis, leukopenia, thrombocytopenia, indicate pseudomembranous colitis caused by
thrombocytopenic purpura Clostridium difficile. If diarrhea occurs, notify
SKIN: Erythema multiforme, erythematous prescriber, expect to withhold amoxicillin, and
maculopapular rash, generalized treat
exanthematous pustulosis, Stevens–Johnson with fluids, electrolytes, protein, and an antibiotic
syndrome, toxic epidermal effective against C. difficile.
necrolysis, urticaria Expect treatment that lasts at least 10 days for
Other: Allergic reactions, anaphylaxis, serum hemolytic streptococcal infections.
sickness-like reaction (such as Monitor patient for superinfection. If it occurs,
arthralgia, arthritis, fever, myalgia, rash, and expect to discontinue drug and provide treatment
urticaria) as
Childbearing Considerations ordered.
PATIENT TEACHING
PREGNANCY
Tell patient to refrigerate reconstituted
It is not known if drug can cause fetal harm. suspension and to shake well before each use.
Use with caution only if benefit to mother Know that when amoxicillin suspension is
outweighs potential risk to fetus. prescribed for a child, instruct parents to place it
LABOR & DELIVERY directly
on child’s tongue to swallow. If this does not work,
It is not known if drug given to mother during tell parents to mix dose of suspension with
labor has immediate or delayed adverse effects on formula or cold drink (milk, fruit juice, ginger ale,
the water) and have child drink it immediately.
fetus.
Tell patient to chew or crush chewable tablets and patients receiving hemodialysis, dosage
not to swallow them whole. interval changed to every 7 days
Urge patient to take amoxicillin for full length of following dialysis.
time prescribed, even if he feels better. Mechanism of Action
Teach patient to report adverse reactions and
Inhibits hepatitis B virus (HBV) by competing
notify prescriber if infection worsens or doesn’t
with the natural substrate
improve after 72 hours.
Urge patient to tell prescriber about diarrhea deoxyadenosine triphosphate and by causing
that’s severe or lasts longer than 3 days. Remind DNA chain termination after its
patient incorporation into viral DNA, which prevents
that watery or bloody stools can occur 2 or more replication.
months after antibiotic therapy and may be Contraindications
serious, Hypersensitivity to adefovir dipivoxil or its
requiring prompt treatment. components
Inform patient with diabetes who is using glucose Interactions
tests based on the Benedict’s copper reduction
DRUGS
reaction that false-positive reactions may occur
drugs that are excreted renally or known to
when testing for glucose in urine. Advise patient to
use glucose tests based on enzymatic glucose affect renal function, such as
oxidase reaction instead. aminoglycosides, cyclosporine, NSAIDs,
tacrolimus, and vancomycin: Possibly
ANTIVIRAL increased serum concentrations of adefovir or
these drugs or both, increasing
adefovir dipivoxil risk of adverse reactions
Hepsera
Adverse Reactions
Class and Category CNS: Asthenia, headache
Pharmacologic class: Nucleotide analogue GI: Abdominal pain, diarrhea, dyspepsia,
Therapeutic class: Antiviral flatulence, nausea, pancreatitis,
Indications and Dosages severe acute exacerbations of hepatitis,
To treat chronic hepatitis B in patients with severe hepatomegaly with steatosis,
evidence of active viral vomiting
replication and either evidence of persistent GU: Abnormal renal function, elevated
elevations in serum creatinine level, Fanconi syndrome,
aminotransferases (ALT or AST) or nephrotoxicity, proximal renal tubulopathy,
histologically active disease renal failure
TABLETS MS: Bone pain, myopathy, osteomalacia
Adults and children age 12 and over. 10 mg SKIN: Pruritus, rash
once daily. Other: HIV resistance, hypophosphatemia,
DOSAGE ADJUSTMENT For patients with a lactic acidosis
creatinine clearance between 30 and 49 Childbearing Considerations
ml/min, dosage interval changed to every 48 PREGNANCY
hr. For patients with a creatinine
clearance between 10 and 29 ml/min, dosage Pregnancy exposure registry:
interval changed to 72 hr. For 1-800-258-4263.
It is not known if drug can cause fetal harm. discontinued.
Use with caution only if benefit to mother Be aware that immune reconstitution
outweighs potential risk to fetus. syndrome has occurred in patients treated
LACTATION with combination
antiretroviral therapy, including adefovir. The
It is not known if drug is present in breast inflammatory response predisposes
milk. renal dysfunction and patients taking susceptible patients
concomitant nephrotoxic agents such as to opportunistic infections such as
aminoglycosides, cytomegalovirus infection, Mycobacterium
cyclosporine, NSAIDs, tacrolimus, and avium infection,
vancomycin. Pneumocystis jiroveci pneumonia, or
Use caution when administering adefovir to tuberculosis. Autoimmune disorders such as
patient with liver dysfunction or known risk Graves’ disease,
factors for Guillain–Barré syndrome, or polymyositis
liver disease. have also occurred. Report sudden or unusual
WARNING Know that lactic acidosis and adverse
severe hepatomegaly with steatosis have reactions to prescriber.
occurred with adefovir therapy and death has Expect patient to be closely monitored for at
occurred in some patients. least several months after adefovir has been
Risk factors include presence of obesity, discontinued, because exacerbation of
prolonged nucleoside exposure, hepatitis may occur, some cases of which have
and being a woman. However, know that been severe.
lactic acidosis and severe PATIENT TEACHING
hepatomegaly with steatosis have also
occurred in patients with no known Instruct patient to take adefovir once daily. If
risk factors. Expect drug to be discontinued in he misses a dose, tell him to take it as soon as
any patient who develops he
clinical or laboratory findings suggestive of remembers but not to double the next dose or
lactic acidosis or pronounced take more than the prescribed dose.
hepatotoxicity, even in the absence of marked Advise patient that treatment with adefovir
transaminase elevations. does not reduce the risk of transmission of
Monitor patient throughout treatment for HBV to
evidence of loss of therapeutic response. others.
Indicators include Tell patient to report any new or worsening
increasing levels of HBV DNA over time after symptoms to prescriber immediately, because
an initial decline below assay limit, emergence
progression of of resistant hepatitis B virus may occur or
clinical signs or symptoms of hepatic disease disease may worsen during treatment.
and/or worsening of hepatic Instruct patient with hepatitis B on the
necroinflammatory importance of testing for HIV before therapy
findings, or return of persistently elevated begins and then
ALT levels. These findings may require drug periodically throughout therapy to avoid
to be development of resistance to HIV treatment.
Warn patient with hepatitis B that acute clearance is known before adefovir therapy
severe exacerbations of hepatitis B may occur begins and then rechecked periodically
following throughout
discontinuation of adefovir. He should not therapy, because adefovir may cause a
discontinue drug without prescriber delayed nephrotoxicity that may require
knowledge. Tell dosage interval to be
patient to report any reappearance of signs lengthened or drug discontinued. Know that
and symptoms of hepatitis B. patients at higher risk include those having
underlying
Instruct mother not to breastfeed while she is
receiving adefovir therapy, as drug is present
in human ANTIFUNGAL
milk.
Tell women of childbearing age to report a amphotericin B
known or suspected pregnancy.
WARNING Alert patient that severe conditions Fungizone Intravenous
may develop while taking adefovir. amphotericin B lipid complex
Encourage him to stop taking drug and seek Abelcet
medical attention immediately amphotericin B liposomal complex
if he experiences any persistent, severe, or AmBisome
unusual symptoms; especially
abdominal pain, change in urine Class and Category
characteristics or urination pattern, loss of Pharmacologic class: Amphoteric polyene
appetite, pale stools, muscle pain, or Therapeutic class: Antifungal
yellowing of the eyes. Indications and Dosages
To treat severe fungal infections
A decision should be made to discontinue I.V. INFUSION (FUNGIZONE)
breastfeeding or the drug to avoid potential Adults and adolescents. Initial: 1-mg test dose
serious adverse in 20 ml of D5W infused over
reactions in the breastfed infant. 20 to 30 min; if test dose is tolerated, then
Nursing Considerations 0.25 to 0.3 mg/kg daily prepared as a
Check to be sure HIV antibody testing has 0.1 mg/ml infusion, given over 2 to 6 hr.
been done prior to starting adefovir therapy Increased in 5- to 10-mg increments,
because based on patient tolerance and infection
treatment with anti-hepatitis B therapies, severity, to a final daily dose of 0.5 to
such as adefovir, may cause an emergence of 0.7 mg/kg but not to exceed a total daily dose
HIV of 1.5 mg/kg.
resistance. Usual range: Up to 1 mg/kg daily or 1.5
Use with extreme caution in patients with mg/kg every other day.
renal dysfunction. Check to ensure that To provide empirical therapy for presumed
patient’s creatinine fungal infection in febrile,
neutropenic patients
I.V. INFUSION (AMBISOME)
Adults and children. 3 mg/kg daily infused permeability and allows loss of potassium
over 2 hr. Infusion time may be and small molecules from cells. This
decreased to 1 hr if tolerated or increased if action results in fungal cell impairment or
patient experiences discomfort. death.
To treat oral candidiasis amphotericin B Incompatibilities
Don’t reconstitute amphotericin B with
Fungizone Intravenous diluents other than those recommended
amphotericin B lipid complex because solutions with sodium chloride or
Abelcet bacteriostatic agents (such as benzyl
amphotericin B liposomal complex alcohol) may cause drug precipitation.
AmBisome Contraindications
Hypersensitivity to amphotericin B or its
Class and Category components
Pharmacologic class: Amphoteric polyene Interactions
Therapeutic class: Antifungal DRUGS
Indications and Dosages antineoplastics: Increased risk of
To treat severe fungal infections bronchospasm, hypotension, and
I.V. INFUSION (FUNGIZONE) nephrotoxicity
Adults and adolescents. Initial: 1-mg test dose corticosteroids, corticotropin: Increased risk
in 20 ml of D5W infused over of hypokalemia and cardiac
20 to 30 min; if test dose is tolerated, then dysfunction
0.25 to 0.3 mg/kg daily prepared as a cyclosporine, nephrotoxic drugs: Increased
0.1 mg/ml infusion, given over 2 to 6 hr. risk of nephrotoxicity
Increased in 5- to 10-mg increments, digitalis glycosides: Possibly hypokalemia and
based on patient tolerance and infection more severe digitalis toxicity
severity, to a final daily dose of 0.5 to flucytosine: Possibly increased flucytosine
0.7 mg/kg but not to exceed a total daily dose toxicity
of 1.5 mg/kg. imidazoles such as cloyrimazole, fluconazole,
Usual range: Up to 1 mg/kg daily or 1.5 ketoconazole, miconazole:
mg/kg every other day. Possibly induced resistance to amphotericin
To provide empirical therapy for presumed leukocyte transfusion: Possibly acute
fungal infection in febrile, pulmonary toxicity
neutropenic patients skeletal muscle relaxants: Possibly
I.V. INFUSION (AMBISOME) hypo-kalemia and increased muscle
Adults and children. 3 mg/kg daily infused relaxation
over 2 hr. Infusion time may be Adverse Reactions
decreased to 1 hr if tolerated or increased if CNS: Fever, headache, shaking chills,
patient experiences discomfort. tiredness, weakness
To treat oral candidiasis CV: Chest pain, hypotension, irregular
Mechanism of Action heartbeat
Binds to sterols in fungal cell plasma EENT: Difficulty swallowing, pharyngitis
membranes, which changes membrane GI: Abdominal pain, anorexia, diarrhea,
hepatic failure, indigestion, jaundice,
nausea, vomiting Know that before using D5W to dilute
amphotericin B solution, determine the
GU: Decreased or increased urine output, injection’s pH
hemorrhagic cystitis, impaired renal aseptically. If pH is below 4.2, follow
function manufacturer’s instructions for buffering it.
HEME: Agranulocytosis, anemia, leukopenia, Avoid using in-line membrane filter or use
thrombocytopenia, unusual one with a mean pore diameter of more than
bleeding or bruising 1 micron to
MS: Arthralgia, muscle spasms, myalgia, prevent significant drug removal because
rhabdomyolysis reconstituted amphotericin B is a colloidal
RESP: Apnea, bronchospasm, cyanosis, suspension.
dyspnea, hypoventilation, hypoxia, Prepare amphotericin B cholesteryl sulfate
pulmonary edema, tachypnea complex by reconstituting with sterile water
SKIN: Erythemia, flushing, maculopapular for injection.
rash, pruritus and redness especially
around ears, urticaria Using a sterile syringe and 20G needle,
Other: Anaphylaxis, angioedema, rapidly add 10- or 20-ml sterile water for
hypocalcemia, hypokalemia, injection to a 50- or
hypomagnesemia, infusion-site pain, and 100-mg vial, respectively, to obtain a solution
thrombophlebitis containing 5 mg of amphotericin B per
Childbearing Considerations milliliter.
Shake gently by hand, rotating vial until solids
PREGNANCY are dissolved; fluid may be clear or
opalescent. For
It is not known if drug can cause fetal harm.
Use with caution only if benefit to mother infusion, further dilute reconstituted solution
outweighs potential risk to fetus. to about 0.6 mg/ml. Don’t filter solution or
use an in-
LACTATION line filter. Flush existing line with D5W or use
a separate line.
It is not known if drug is present in breast
milk. Prepare amphotericin B lipid complex by
Breastfeeding should be discontinued during shaking vial gently until no yellow sediment is
drug therapy. seen. Using
Nursing Considerations an 18G needle, withdraw prescribed dose
Prepare amphotericin B by adding 10 ml of from required number of vials into one or
sterile water for injection without a more 20-ml
bacteriostatic agent syringes. Replace needle with 5-micron filter
to vial containing 50 mg of amphotericin B. needle supplied with each vial. Empty syringe
For I.V. infusion, dilute solution containing 5 contents
mg/ml to into bag of D5W so that final concentration is
0.1 mg/ml by adding 1 ml (5 mg) of solution 1 mg/ml. Expect to use a concentration of 2
to 49 ml of D5W with a pH above 4.2. mg/ml for
children and patients with cardiovascular Give amphotericin B oral suspension between
disease. Before infusion, shake bag until meals to permit prolonged contact with oral
contents are mixed lesions.
thoroughly. Flush existing line with D5W, or Assess I.V. insertion site regularly to detect
use a separate line. Don’t use an in-line filter. extravasation of amphotericin B, which may
If infusion cause severe
exceeds 2 hours, shake infusion bag every 2 local irritation. To minimize local
hours. thrombophlebitis, plan to add heparin to
Prepare amphotericin B liposomal complex infusion or expect to
by adding 12 ml sterile water for injection administer amphotericin on alternate days,
(without which also may help prevent anorexia.
bacteriostatic agent) to each 50-mg vial to Alternate-day dose
achieve a concentration of 4 mg amphotericin shouldn’t exceed 1.5 mg/kg.
B per Monitor renal function because of the risk of
milliliter. Immediately shake vial vigorously renal impairment. Plan to obtain serum
for at least 30 seconds until all particles creatinine level
completely every other day while amphotericin B dosage
disperse. Withdraw prescribed dose of is increasing and then at least twice weekly
amphotericin B liposomal complex during
suspension. Then use a 5- therapy. If serum creatinine or BUN level
micron filter to inject it into D5W to provide a increases significantly, expect to stop
final concentration of 1 to 2 mg/ml. Expect to amphotericin B until
use a renal function improves. Know that a
lower concentration (0.2 to 0.5 mg/ml) for cumulative dose of more than 4 g may cause
infants and young children. Flush existing line irreversible renal
with D5W, dysfunction.
or use a separate line. An in-line filter with a Expect to monitor CBC and platelet count
mean pore diameter of at least 1 micron may weekly during therapy to detect adverse
be used. hematologic
Expect to give an antihistamine, antipyretic, effects. Also monitor serum calcium,
or corticosteroid just before infusing magnesium, and potassium levels twice
amphotericin B to weekly to detect
help minimize fever and shaking chills. abnormalities.
Shake well before giving amphotericin B oral Use reconstituted amphotericin B within 24
suspension. Drop suspension on tongue with hours if stored at room temperature, 1 week if
calibrated refrigerated. Use reconstituted amphotericin
dropper. Then tell patient to swish B cholesteryl sulfate complex within 24 hours.
suspension in mouth for as long as possible Use
before swallowing. If amphotericin B lipid complex within 6 hours
drug must be swabbed on, use a if stored at room temperature, 48 hours if
nonabsorbent swab. refrigerated.
Use diluted amphotericin B liposomal To treat mild to moderate P. jiroveci
complex within 24 hours if refrigerated, but pneumonia in patients who can’t
begin infusion tolerate trimethoprim-sulfamethoxazole
within 6 hours. SUSPENSION, TABLETS
Be aware that false elevations of serum Adults and adolescents. 750 mg (5 ml) twice
phosphate may occur when samples are daily with meals for 21 days.
analyzed using the Maximum: 1,500 mg/day.
PHOSm assay.
Mechanism of Action
PATIENT TEACHING May destroy P. jiroveci organisms by
inhibiting the enzymes needed to
Instruct patient to shake bottle of oral synthesize nucleic acid and adenosine
suspension well before each dose; to drop triphosphate.
suspension directly Contraindications
on his tongue using calibrated dropper; and Hypersensitivity to atovaquone or its
then to swish suspension in his mouth for as components
long as Interactions
possible before swallowing. If prescriber DRUGS
orders drug to be swabbed onto oral lesions, indinavir: Possible loss of efficacy of indinavir
tell patient to metoclopramide, rifabutin, rifampin,
use nonabsorbent swab. Instruct him to take tetracycline: Possibly decreased blood
drug four times a day (between meals and at atovaquone level
bedtime). Adverse Reactions
Tell patient to notify prescriber if he develops CNS: Fever, headache, insomnia
local irritation, if existing symptoms worsen EENT: Rhinitis, throat tightness, vortex
or return, keratopathy
or if new symptoms arise. GI: Abdominal pain, diarrhea, elevated liver
enzymes, hepatic failure,
ANTIPROTOZOAL hepatitis, nausea, pancreatitis, vomiting
GU: Acute renal dysfunction
atovaquone HEME: Anemia, thrombocytopenia
Mepron RESP: Bronchospasm, cough, dyspnea
SKIN: Desquamation, erythema multiforme,
Class and Category Stevens–Johnson syndrome,
Pharmacologic class: Ubiquinone analogue rash, urticaria
Therapeutic class: Antiprotozoal Other: Allergic reaction, angioedema,
Indications and Dosages methemoglobinemia
To prevent Pneumocystis jiroveci pneumonia Childbearing Considerations
in patients who can’t tolerate PREGNANCY
trimethoprim-sulfamethoxazole
SUSPENSION, TABLETS It is not known if drug can cause fetal harm.
Adults and adolescents. 1,500 mg (10 ml) Use with caution only if benefit to mother
once daily with meals. outweighs potential risk to fetus.
LACTATION ANTINEOPLACTIC

It is not known if drug is present in breast cladribine

milk. Mavenclad
Centers for Disease Control and Prevention
recommend women infected with HIV-1 not Class and Category
breastfeed Pharmacologic class: Purine antimetabolite
their infant to avoid risking postnatal Therapeutic class: Antineoplastic
transmission of HIV-1. Indications and Dosages
Nursing Considerations
Use atovaquone cautiously in patient with To treat relapsing forms of multiple sclerosis
severe hepatic impairment because, although (MS), to include relapsing-
rare, serious remitting disease and active secondary
adverse reactions affecting liver function may progressive disease, in patients
occur.
Monitor blood test results because who have had an inadequate response to, or
atovaquone may decrease serum sodium, are unable to tolerate, an alternate drug
hemoglobin levels, and indicated for the treatment of MS
neutrophil count; and may increase AST, ALT, TABLETS
alkaline phosphatase, and serum amylase Adults. 3.5 mg/kg divided into 2 yearly
levels. treatment courses (1.75 mg/kg/treatment
Crush atovaquone tablets, if needed. course with each treatment course further
Don’t use tablets and oral suspension divided into 2 treatment cycles). First
interchangeably; they aren’t bioequivalent. course/first cycle is begun at any time,
PATIENT TEACHING followed by first course/second cycle
administered 23 to 27 days after last dose of
Instruct patient to take atovaquone with first course/first cycle. Second
meals for maximum effectiveness. course/first cycle administered at least 43 wk
Remind patient taking suspension form to after last dose of first
shake the suspension gently before using each course/second cycle. Second course/second
time. cycle administered 23 to 27 days
Instruct patient to take a missed dose as soon after last dose of second course/first cycle.
as possible. If it’s almost time for the next Administer each cycle dosage as 1 or
dose, tell 2 10-mg tablets once daily, with dosage
him to skip the missed dose. Tell him not to divided and given over 4 or 5
double the next dose. consecutive days. Do not administer more
Tell patient to notify prescriber if his than 20 mg once daily. Dosage based
condition doesn’t improve in a few days or if on weight as follows:
he develops signs For adults weighing 110 kg and above (242
of an allergic reaction, such as fever or rash. lb). 100 mg for cycle one and 100
mg for cycle two.
ANTINEOPLASTIC For adults weighing 100 kg (220 lb) to less
than 110 kg (242 lb). 100 mg for
cycle one and 90 mg for cycle two. hematotoxic drugs: Increased risk of serious
For adults weighing 90 kg (198 lb) to less adverse reactions because of
than 100 kg (220 lb). 90 mg for additive hematological effects
cycle one and 80 mg for cycle two. immunomodulatory, immunosuppressive,
For adults weighing 80 kg (176 lb) to less myelosuppressive drugs: Increased risk
than 90 kg (198 lb). 80 mg for cycle of serious adverse reactions because of
one and 70 mg for cycle two. additive effects on immune system
For adults weighing 70 kg (154 lb) to less interferon-beta: Possibly increased
than 80 kg (176 lb). 70 mg for cycle lymphopenia risk
one and 70 mg for cycle two. potent BCRP CNT, ENT transporter inhibitors
For adults weighing 60 kg (132 lb) to less such as cilostazol, curcumin,
than 70 kg (154 lb). 60 mg for cycle cyclosporine, dilazep, dipyridamole,
one and 60 mg for cycle two. eltrombopag, nifedipine, reserpine,
For adults weighing 50 kg (110 lb) to less ritonavir, sulindac: Possible alteration of
than 60 kg (132 lb). 50 mg for cycle bioavailability, intracellular
one and 50 mg for cycle two. distribution, and renal elimination of
For adults weighing 40 kg (88 lb) to less than cladribine potent BCRP and P-gp
50 kg (110 lb). 40 mg for cycle transporter inducers: Possible decreased
one and 40 mg for cycle two. exposure of cladribine, decreasing
Mechanism of Action effectiveness
May involve cytotoxic effects on B and T Adverse Reactions
lymphocytes through impairment of CNS: Depression, fever, headache, insomnia,
DNA synthesis, resulting in depletion of seizures, vertigo
lymphocytes. CV: Cardiac failure, hypertension
EENT: Diplopia, mucous membrane
Contraindications ulceration, oral herpes, throat swelling
Active chronic infections such as hepatitis or GI: Activation of latent hepatitis infections,
tuberculosis, breastfeeding (avoid anorexia, elevated bilirubin and
for 10 days following last dose), HIV infection, liver enzymes, fulminant hepatitis, jaundice,
hypersensitivity to cladribine or nausea
its components, current malignancy, patient GU: Pyelonephritis
of reproductive potential who does
not plan to use effective contraception during HEME: Anemia, decreased platelet count,
cladribine therapy and for 6 lymphopenia, neutropenia,
months after last dose in each treatment pancytopenia, thrombocytopenia
course, pregnancy MS: Arthralgia, back pain
Interactions RESP: Bronchitis, upper respiratory infection
DRUGS SKIN: Alopecia, dermatitis, pruritus, rash
antiviral and antiretroviral drugs such as Other: Bacterial, fungal, herpes viral,
lamivudine, ribavirin, stavudine, opportunistic, tuberculosis infections;
zalcitabine, zidovudine: Possible interference hypersensitivity reactions; malignancies
with cladribine effectiveness Childbearing Considerations
PREGNANCY
 to be screened for cancer before cladribine
A negative pregnancy test must be obtained therapy begins and follow
before drug therapy begins. standard cancer screening guidelines during
Drug causes fetal harm. and after drug therapy.
Drug is contraindicated during pregnancy. Ensure that all women of childbearing age
If pregnancy occurs during treatment, drug is have had a negative pregnancy test prior to
discontinued. cladribine
LACTATION therapy, because drug can cause fetal harm.
Obtain a complete blood count, including
It is not known if drug is present in breast lymphocyte count, before cladribine therapy
milk. begins.
Drug is contraindicated in breastfeeding Lymphocytes must be within normal limits
women. before initiating first treatment course and at
REPRODUCTION least 800
cells/microliter before initiating second
Patients of reproductive potential must use treatment course. Second treatment course
effective contraception during cladribine may have to be
therapy and for delayed for up to 6 months to allow for
6 months after last dose in each treatment recovery of lymphocytes to at least 800
course. cells/microliter.
Instruct female patients of childbearing age to However, if recovery takes longer than 6
immediately report suspected or confirmed months, expect drug to be discontinued.
pregnancy Assess patient for the presence of infection
to prescriber. prior to starting cladribine therapy. This
Women using systemically acting hormonal includes
contraceptives need to add a barrier method evaluating patient for acute infection
during (cladribine therapy may have to be delayed
cladribine therapy and for at least 4 weeks until infection is
after last dose in each treatment course, under control), excluding presence of
because it is hepatitis B and C and HIV infections (screen
unknown if drug may reduce effectiveness of for hepatitis B
hormonal contraceptives. and C before first and second treatment
Nursing Considerations courses), tuberculosis screening (before first
and second
Know that cladribine is not recommended for
patients with clinically isolated syndrome, treatment courses), and varicella zoster virus
because screening (vaccination for patients who are
drug is deemed unsafe. antibody-
WARNING Be aware that cladribine may negative).
increase the risk of malignancy and is
contraindicated in patients who currently Expect to obtain a baseline (within 3 months)
have a malignancy. Expect patient magnetic resonance imaging prior to first
treatment
course because of risk of progressive treatment in each treatment course (if
multifocal leukoencephalopathy (PML) and lymphocyte count at month 2 is below 200
assess alkaline cells/microliter,
phosphatase, total bilirubin, and serum expect monthly monitoring until month 6),
aminotransferase levels prior to starting and periodically thereafter and when
cladribine therapy. clinically indicated.
Administer all immunizations, as ordered,
according to immunization guidelines prior to Withhold drug after consulting with
starting prescriber if lymphocyte count is below 200
cladribine therapy. Expect to administer cells/microliter.
live-attenuated or live vaccines at least 4 to 6 Monitor patient for signs and symptoms of
weeks prior to infection throughout drug therapy, especially
starting drug therapy. if
Be aware that following the administration of lymphocyte count is below 500
two treatment courses, drug should not be cells/microliter. Know that infections occur in
administered about half of patients,
during the next two years because of risk of with the most serious being herpes zoster
malignancy. and pyelonephritis. At first sign of infection,
Administer all oral drugs at least 3 hours notify
before or after administering cladribine to prescriber, because drug therapy may have to
prevent drug be delayed or interrupted. Institute infection
interactions. control
Know that cladribine is a cytotoxic drug and measures.
requires special handling and disposal Monitor patient for liver dysfunction such as
procedures. Once abdominal pain, anorexia, dark urine, fatigue,
removed from the blister, tablet must be jaundice,
swallowed immediately. If tablet is left on a unexplained nausea, or vomiting. If present,
surface or if a notify prescriber and expect liver enzymes to
broken or fragmented tablet is released from be
the blister, area must be thoroughly washed obtained. If elevated, expect drug to be
with water. interrupted or discontinued.
Avoid contact with skin. Follow protocol if Monitor patient for hypersensitivity reactions
contact occurs. such as dermatitis and pruritus. Serious
Expect to administer antiherpes prophylaxis reactions can
in patients with lymphocyte counts less than occur involving diplopia, headache, rash, and
200 throat swelling. Stop cladribine immediately
cells/microliter, as ordered. and notify
Ensure that complete blood counts with prescriber. Provide supportive emergency
differential, including lymphocyte count, are care according to protocol, as prescribed.
performed as Monitor patient for heart failure such as
follows: before initiating first course, before edema, irregular or rapid heartbeat, or
initiating second course, 2 to 3 months after shortness of breath,
starting because cladribine may induce heart failure.
WARNING Monitor patient for signs and Tell patient to separate taking cladribine from
symptoms of progressive multifocal ingestion of all other oral drugs by at least 3
leukoencephalopathy (PML), such as changes hours
in memory, orientation, or during the 4- or 5-day treatment cycles.
thinking leading to confusion and personality Instruct patient that once tablet is removed
changes, as well as from the blister, tablet must be swallowed
clumsiness of limbs, progressive weakness on immediately. If
one side of the body, and
visual disturbances. Although no reports of tablet is left on a surface or if a broken or
PML have occurred with fragmented tablet is released from the blister,
cladribine for treating relapsing forms of MS, area must be
it is a possibility. At first sign thoroughly washed with water. Patient must
of PML, notify prescriber, expect cladribine to have dry hands when handling tablets and
be withheld, and ensure that hands must be
appropriate diagnostic evaluation is done. washed thoroughly afterward. Tell patient to
Know that MRI findings may avoid contact with skin.
reveal problems before clinical signs or Tell patient to notify prescriber immediately if
symptoms appear. edema, irregular or rapid heartbeat, or
Be aware that if patient requires a blood shortness of
transfusion, irradiation of cellular blood breath occurs.
components is WARNING Tell men and women of
recommended, prior to administration, to reproductive potential to use effective
decrease risk of transfusion-related contraception during cladribine therapy and
graft-versus-host for 6 months after the last dose
disease. Expect a hematologist to be in each treatment course. Stress importance
consulted. of informing prescriber
PATIENT TEACHING immediately if pregnancy is suspected or
confirmed, as drug must be
Stress importance of taking cladribine exactly discontinued.
as prescribed. If a dose is missed, tell patient
not to Inform women using systemically acting
double next dose or take extra doses. Instead, hormonal contraceptives to add a barrier
the patient should take the missed dose on method during
the cladribine therapy and for at least 4 weeks
following day and extend the number of days after the last dose in each treatment course,
in that treatment cycle. If two consecutive because it is
doses are unknown if drug may reduce effectiveness of
missed, treatment cycle is extended by 2 days. hormonal contraceptives.
Instruct patient to take tablets with water and
swallow them whole without chewing or
crushing
them. Inform patient that drug may be taken
with or without food.