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REFERENCES:

Jones & Bartlett Learning., & Jones & Bartlett Publishers. (2015). Nurse's drug     handbook, 14ED. Burlington, MA: Jones and Bartlett Publishers.

Schull, Patricia D. (2013). MCGRAW-HILL NURSE'S DRUG handbook, 7ED. New York: McGraw-Hill Medical.

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Generic Name

Captopril

Brand Name

Capoten

Drug Classification

Chemical class: ACE inhibitor Therapeutic class: Antihypertensive Pregnancy risk category C and D

Mechanism of Action

By inhibiting angiotensin-converting enzyme, captopril prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor that also stimulates the adrenal cortex to secrete aldosterone. Inhibiting aldosterone increases sodium and water excretion, reducing blood pressure. It may inhibit renal and vascular production of angiotensin II. It also decreases serum angiotensin II level and increases renin activity. This decreases aldosterone secretion, slightly increasing serum potassium level and fluid loss.

Stock Dosage

Adult: Acute treatment (within 24 hours of the onset of symptoms): 6.25 mg as test dose, followed by 12.5 mg after 2 hours and 25 mg after 12 hours.

Child: Neonates and infants: 0.15 mg/kg. Children and adolescents: 0.3 mg/kg.

Elderly: Initially, 6.25 mg bid.

Route: Oral

Indication

Ø  To treat left-sided heart failure after MI

Ø  To treat heart failure that’s unresponsive to conventional therapy

Ø  To control accelerated or malignant hypertension when temporary discontinuation of current antihypertensive therapy isn’t practical or when prompt titration of blood pressure is needed

Contraindications

History of angioedema related to ACE treatment, hereditary or idiopathic angioneurotic oedema. Concomitant use with aliskiren especially in patients with diabetes mellitus or renal impairment (GFR <60 mL/min/1.73m²) and neprilysin inhibitor (e.g. sacubitril). Pregnancy.

Side effects/adverse reactions

·         Significant: Hypotension, intestinal or peripheral angioedema, non-productive and persistent cough; cholestatic jaundice, proteinuria, neutropenia, agranulocytosis, thrombocytopenia, renal impairment or failure and hyperkalaemia.

·         Cardiac disorders: Dyspnea

·         Gastrointestinal disorders: Nausea, vomiting, diarrhea, constipation, dry mouth, epigastric discomfort, abdominal pain, peptic ulcer, dyspepsia.

·         General disorders and admin site conditions: Asthenia

·         Metabolism and nutrition disorders: Anorexia, symptomatic hyponatremia, hypoglycaemia.

·         Nervous system disorders: Taste impairment, dizziness.

·         Psychiatric disorders: Sleep disorders, rarely, confusion, depression.

·         Renal and urinary disorders: Rarely, polyuria, oliguria, pollakiuria.

·         Reproductive system and breast disorders: Rarely, gynaecomastia.

·         Skin and subcutaneous tissue disorders: Rash, pruritus with or without rash, alopecia.

·         Potentially Fatal: Angioedema involving the tongue, glottis or larynx; rarely, fulminant hepatic necrosis.

Nursing interventions

ü  Closely monitor patient’s blood pressure, especially when therapy starts and dosage increases. Keep patient supine if hypotension occurs.

ü  Monitor patient’s blood pressure and electrolytes routinely if patient is receiving other drugs that also affect the reninangiotensin system because hypotension and hyperkalemia may occur.

ü  Monitor renal function tests for signs of nephrotic syndrome, such as proteinuria and increased BUN and serum creatinine levels. Also watch for such renal evidence as oliguria, polyuria, and urinary frequency or other signs of impaired renal function, especially in patients who are receiving other drugs that also affect the renin-angiotensin system.

ü  Monitor WBC regularly, as ordered, especially if patient has collagen vascular disease or renal disease. patient teaching

ü  Instruct patient that the medication should be taken on an empty stomach. Take 1 hr before or 2 hr after meals.

ü  Tell patient to rise slowly from sitting or lying to minimize orthostatic hypotension.

ü  Tell patient to avoid sunlight or wear sunscreen in direct sunlight because photosensitivity may occur.

ü  Warn patient not to stop taking drug abruptly.

ü  Urge patient not to use salt substitutes that contain potassium and to consult prescriber before increasing potassium intake to avoid increasing risk of hyperkalemia.

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Generic Name

Atorvastatin Calcium

Brand Name

Lipitor

Drug Classification

Chemical class: Synthetically derived fermentation product Therapeutic class: Antihyperlipidemic, HMG-CoA reductase inhibitor Pregnancy category X

Mechanism of Action

Reduces plasma cholesterol and lipoprotein levels by inhibiting HMG-CoA reductase and cholesterol synthesis in the liver and by increasing the number of LDL receptors on liver cells to enhance LDL uptake and breakdown.

Stock Dosage

Adults. Initial: 10 or 20 mg once daily; then increased according to lipid level. Maintenance: 10 to 80 mg once daily. dosage adjustment Initial dose may be increased to 40 mg once daily for patients who need cholesterol level reduced more than 45%.

Route: Oral

Indication

Ø  To control lipid levels as adjunct to diet in primary (heterozygous familial and nonfamilial) hypercholesterolemia and mixed dyslipidemia

Ø  To reduce debilitating cardiovascular events such as stroke and MI in patients with multiple risk factors but without known coronary artery disease

Contraindications

Active hepatic disease, breastfeeding, hypersensitivity to atorvastatin or its components, pregnancy, unexplained persistent rise in serum transaminase level

Side effects/adverse reactions

·         CNS: Abnormal dreams, amnesia, asthenia, cognitive impairment, depression, dizziness, emotional lability, facial paralysis, fatigue, fever, headache, hyperkinesia, lack of coordination, malaise, paresthesia, peripheral neuropathy, somnolence, syncope, weakness

·         CV: Arrhythmias, elevated serum CK level, orthostatic hypotension, palpitations, phlebitis, vasodilation

·         ENDO: Hyperglycemia or hypoglycemia

·         GI: Abdominal or biliary pain, anorexia, colitis, constipation, diarrhea, duodenal or stomach ulcers, dysphagia

·         GU: Abnormal ejaculation; cystitis; decreased libido; dysuria; epididymitis; hematuria; impotence

·         HEME: Anemia, thrombocytopenia

·         MS: Arthralgia, back or muscle pain, bursitis, gout, immune-mediated necrotizing myopathy, leg cramps, myalgia

·         RESP: Dyspnea, pneumonia

·         SKIN: Acne, alopecia, contact dermatitis, diaphoresis, dry skin, ecchymosis, eczema, erythema multiforme, petechiae, photosensitivity, pruritus, rash, seborrhea, Stevens-Johnson syndrome, toxic epidermal necrolysis, ulceration, urticaria

·         Other: Anaphylaxis, angioneurotic edema, flulike symptoms, infection, lymphadenopathy, weight gain

Nursing interventions

ü  Know that atorvastatin should not be used in patients taking cyclosporine, gemfibrozil, tipranavir plus ritonavir, or telaprevir because of high risk for rhabdomyolysis with acute renal failure.

ü  Use atorvastatin cautiously in patients who consume substantial quantities of alcohol or have a history of liver disease because atorvastatin use increases risk of liver dysfunction.

ü  Expect liver function tests to be performed before atorvastatin therapy starts and then thereafter as clinically necessary.

ü  Notify prescriber immediately and expect to withhold atorvastatin therapy if patient develops an acute condition suggestive of complications

ü  Tell patient to take drug at the same time each day to maintain its effects.

ü  Instruct patient to take a missed dose as soon as possible. If it’s almost time for his next dose, he should skip the missed dose. Tell him not to double the dose.

ü  Advise patient with diabetes to monitor blood glucose levels closely because atorvastatin therapy can affect blood glucose control.