Read Mosby's 2014 Nursing Drug Reference Online
Authors: Linda Skidmore-Roth
Mosby's 2014 Nursing Drug Reference (112 page)
Canada only Side effects:
italics
= common;
bold
= life-threatening 
Nurse Alert
(sye′kloe-spor-een)
Cyclosporine, modified Gengraf, Neoral, Pulminiq, Sandimmune
Func. class.:
Immunosuppressant
Chem. class.:
Fungus-derived peptide
Do not confuse:
cycloSPORINE
/cycloSERINE/cyclophosphamide
SandIMMUNE
/SandoSTATIN
Produces immunosuppression by inhibiting lymphocytes (T)
Organ transplants (liver, kidney, heart) to prevent rejection, rheumatoid arthritis, psoriasis
Unlabeled uses:
Recalcitrant ulcerative colitis, aplastic anemia, Crohn’s disease, GVHD, thrombocytopenia purpura, lupus, nephritis, myasthenia gravis, psoriatic arthritis, atopic dermatitis
Breastfeeding, hypersensitivity to polyxyethylated castor oil (inj only); psoriasis or RA in renal disease (Neoral/Gengraf); Gengraf/Neoral used with PUVA/UVB, methotrexate, coal tar; ocular infections
Black Box Warning:
Uncontrolled, malignant hypertension; radiation in psoriasis, neoplastic disease, sunlight (UV) exposure, renal disease/failure
Precautions:
Pregnancy (C), geriatric patients, severe hepatic disease
Calculator
• Adult and child:
PO
15 mg/kg several hr before surgery, daily for 2 wk, reduce dosage by 2.5 mg/kg/wk to 5-10 mg/kg/day;
IV
5-6 mg/kg several hr before surgery, daily, switch to PO form as soon as possible
• Adult and child:
PO
4-12 mg/kg/day divided q12hr, depends on organ transplanted
• Adult:
PO
2.5 mg/kg/day divided bid, may increase 0.5-0.75 mg/kg/day after 8-12 wk, max 4 mg/kg/day
• Adult:
PO
2.5 mg/kg/day divided bid, × 4 wk, then increase by 0.5 mg/kg/day q2wk, max 4 mg/kg/day
• Adult:
PO
1.25-2.5 mg/kg bid
• Adult and child:
PO
12 mg/kg/day or 15 mg/kg/day (child) with antithymocyte globulin (ATG)
• Adult/adolescent/child ≥2 yr:
PO
5 mg/kg/day
• Adult:
PO
2.5-15 mg/kg/day (nonmodified)
Available forms:
Oral sol 100 mg/ml; soft gel cap 25, 50, 100 mg; inj 50 mg/ml; sol for inh 300 mg/4.8 ml
•
Do not break, crush, or chew caps
•
Use pipette provided to draw up oral sol; may mix with milk or juice; wipe pipette, do not wash (Neoral)
•
For several days before transplant surgery; give at same time of day
•
With corticosteroids
•
With meals for GI upset or in chocolate milk, milk, or orange juice (SandIMMUNE)
•
With oral antifungal for candida infections
•
Give Neoral or Gengraf 2.5 mg/kg/day divided bid; may use with salicylates, NSAIDs, PO corticosteroids
•
Always give the daily dose of Neoral/Gengraf in 2 divided doses on consistent schedule
•
Give initial SandIMMUNE PO dose 4-12 hr prior to transplantation as a single dose of 15 mg/kg, continue the single daily dose for 1-2 wk, then taper 5%/wk to a maintenance dose of 5-10 mg/kg/day
•
After diluting each 50 mg/20-100 ml of 0.9% NaCl or D
5
W; run over 2-6 hr, use an inf pump, glass inf bottles only
•
May run over 24 hr
•
For SandIMMUNE parenteral,
give 1/3 of PO dose, initial dose 4-12 hr before transplantation as a single IV dose 5-6 mg/kg/day, continue the single daily dose until PO can be used
Solution compatibilities:
D
5
W, NaCl 0.9%
Y-site compatibilities:
Abciximab, alatrofloxacin, alfentanil, amikacin, aminocaproic acid, aminophylline, amphotericin B lipid complex, anidulafungin, argatroban, ascorbic acid injection, atenolol, atracurium, atropine, azaTHIOprine, aztreonam, benztropine, bivalirudin, bleomycin, bretylium, bumetanide, buprenorphine, butorphanol, calcium chloride/gluconate, CARBOplatin, carmustine, caspofungin, cefamandole, ceFAZolin, cefmetazole, cefonicid, cefoperazone, cefotaxime, cefoTEtan, cefOXitin, ceftaroline, cefTAZidime, ceftizoxime, ceftobiprole, cefTRIAXone, cefuroxime, cephalothin, cephapirin, chloramphenicol, chlorproMAZINE, cimetidine, ciprofloxacin, CISplatin, clindamycin, codeine, cyanocobalamin, cyclophosphamide, cytarabine, DACTINomycin, DAPTOmycin, DAUNOrubicin, dexamethasone, dexmedetomidine, digoxin, diltiazem, diphenhydrAMINE, DOBUTamine, DOCEtaxel, DOPamine, doripenem, doxacurium, DOXOrubicin, doxycycline, enalaprilat, ePHEDrine, EPINEPHrine, epirubicin, epoetin alfa, eptifibatide, ertapenem, erythromycin, esmolol, etoposide, famotidine, fenoldopam, fentaNYL, fluconazole, fludarabine, fluorouracil, folic acid, furosemide, gallium, ganciclovir, gatifloxacin, gemcitabine, gentamicin, glycopyrrolate, granisetron, heparin, hydrocortisone, HYDROmorphone, hydrOXYzine, ifosfamide, imipenem-cilastatin, indomethacin, irinotecan, isoproterenol, ketorolac, labetalol, lansoprazole, levofloxacin, lidocaine, linezolid, LORazepam, mannitol, mechlorethamine, meperidine, meropenem, methicillin, methotrexate, methoxamine, methyldopate, methylPREDNISolone, metoclopramide, metoprolol, metroNIDAZOLE, mezlocillin, micafungin, miconazole, midazolam, milrinone, minocycline, mitoXANtrone, morphine, moxalactam, multiple vitamins injection, nafcillin, naloxone, nesiritide, netilmicin, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, PACLitaxel, palonosetron, pamidronate, pancuronium, pantoprazole, papaverine, PEMEtrexed, penicillin G potassium/sodium, pentamidine, pentazocine, phentolamine, phenylephrine, phytonadione, piperacillin, piperacillin-tazobactam, polymyxin B, potassium acetate/chloride, procainamide, prochlorperazine, promethazine, propofol, propranolol, protamine, pyridoxine, quiNIDine, quinupristin-dalfopristin, ranitidine, ritodrine, sargramostim, sodium acetate/bicarbonate, succinylcholine, SUFentanil, tacrolimus, teniposide, theophylline, thiamine, thiotepa, ticarcillin, ticarcillin-clavulanate, tigecycline, tirofiban, tobramycin, trimetaphan, urokinase, vancomycin, vasopressin, vecuronium, verapamil, vinCRIStine, vinorelbine, zoledronic acid
CNS:
Tremors, headache
,
seizures, confusion, encephalopathy,
migraine
GI:
Nausea, vomiting, diarrhea,
oral candida, gum hyperplasia
,
hepatotoxicity, pancreatitis
GU:
Albuminuria, hematuria, proteinuria, renal failure, hemolytic uremic syndrome, nephrotoxicity
INTEG:
Rash, acne,
hirsutism
, pruritus
META:
Hyperkalemia, hypomagnesemia, hyperlipidemia, hyperuricemia
MISC:
Infection, hypertension
Peak 4 hr; highly protein bound; half-life (biphasic) 1.2 hr, 25 hr; metabolized in liver; excreted in feces, 6% in urine; crosses placenta; excreted in breast milk
Increase:
action, toxicity of cycloSPORINE—allopurinol, amiodarone, amphotericin B, androgens, azole antifungals, β-blockers, bromocriptine, calcium channel blockers, carvedilol, cimetidine, colchicine, corticosteroids, fluoroquinolones, foscarnet, imipenem-cilastatin, macrolides, metoclopramide, oral contraceptives, NSAIDs, melphalan, SSRIs
Increase:
effects of aliskiren, digoxin, etoposide, HMG-CoA reductase inhibitors, methotrexate, potassium-sparing diuretics, sirolimus, tacrolimus
Increase:
action toxicity of—digoxin, colchicine
Decrease:
cycloSPORINE action—anticonvulsants, nafcillin, orlistat, PHENobarbital, phenytoin, rifamycins, sulfamethoxazole-trimethoprim, terbinafine, ticlopidine
Decrease:
antibody reaction—live virus vaccines
•
Slowed metabolism of product: grapefruit juice, food
•
Renal studies: BUN, creatinine at least monthly during treatment, 3 mo after treatment
•
Product blood level during treatment 12 hr after dose, toxic >400 ng/ml
•
Hepatic studies: alk phos, AST, ALT, bilirubin; hepatotoxicity:
dark urine, jaundice, itching, light-colored stools; product should be discontinued
•
Serum lipids, magnesium, potassium, cycloSPORINE blood concentrations
Encephalopathy:
impaired cognition, seizures, visual changes including blindness, loss of motor function, movement disorders and psychiatric changes; dosage reduction or discontinuation may be needed in severe cases
Nephrotoxicity:
6 wk after surgery, acute tubular necrosis, CyA trough level >200 ng/ml, gradual rise in creatinine (0.15 mg/dl/day), creatinine plateau <25% above baseline, intracapsular pressure <40 mm Hg
Signs/symptoms of encephalopathy, lymphoma
•
Therapeutic response: absence of rejection
•
To report fever, chills, sore throat, fatigue, since serious infections may occur; tremors, bleeding gums, increased B/P
•
To use contraceptive measures during treatment, for 12 wk after ending therapy; to notify prescriber if pregnancy is planned or suspected
•
To take at same time of day, every day; not to skip doses or double dose; not to use with grapefruit juice or receive vaccines; that there are many drug interactions; not to add new or discontinued products without approval of prescriber
Black Box Warning:
To limit UV exposure
•
That treatment is lifelong to prevent rejection; to identify signs of rejection
•
To report severe diarrhea because drug loss may result
•
About the signs of nephrotoxicity: increased B/P, tremors of the hands, changes in gums, increased hair on body, face
•
To continue with all lab work and follow-up appointments
•
That types of products are not interchangeable
•
Not to wash syringe/container with water, variation in dose may result