Mosby's 2014 Nursing Drug Reference (129 page)

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dibucaine topical

See
Appendix B

 

diclofenac epolamine (Rx)

(dye-kloe′fen-ak)

Flector

diclofenac potassium (Rx)

Cambia, Cataflam, Rapide
, Zipsor

diclofenac sodium (Rx)

Apo-Dilo
, Novo-Difenac
, Nu-Diclo
, PENNSAID, Sandoz Diclofenac
, Solaraze Topical Gel, Voltaren, Voltaren Topical Gel, Voltaren XR

Func. class.:
Nonsteroidal antiinflammatory products (NSAIDs), nonopioid analgesic

Chem. class.:
Phenylacetic acid

Do not confuse:
Cataflam
/Catapres

ACTION:

Inhibits COX-1, COX-2 by blocking arachidonate resulting in analgesic, antiinflammatory, antipyretic effects

USES:

Acute, chronic RA; osteoarthritis; ankylosing spondylitis; analgesia; primary dysmenorrhea; patch: mild to moderate pain

Unlabeled uses:
Arthralgia, headache, migraine, bone pain, myalgia

CONTRAINDICATIONS:

Hypersensitivity to aspirin, iodides, other NSAIDs, bovine protein, asthma, serious CV disease; eczema, exfoliative dermatitis, skin abrasions (gel, patch)

 

Black Box Warning:

Treatment of perioperative pain (CABG), surgery

Precautions:
Pregnancy (C) (tabs, del rel tab, ext rel tab, top gel), (volteren, ophthalmic sol); pregnancy (B) (top gel)(solaraze); top patch, top sol, cap, powder for oral sol (C <30 wk, D >30 wk); breastfeeding, children, bleeding disorders, GI disorders, cardiac disorders, hypersensitivity to other antiinflammatory agents, CCr <30 ml/min, accidental exposure, acute bronchospasm, hypersensitivity to benzyl alcohol

 

Black Box Warning:

GI bleeding, MI, stroke

DOSAGE AND ROUTES
Calculator
Osteoarthritis


Adult: PO
(Cataflam) 50 mg bid-tid, max 150 mg/day;
DEL REL
(Voltaren) 50 mg bid-tid or 75 mg bid, max 150 mg/day;
EXT REL
(Voltaren-XR) 100 mg daily, max 150 mg/day;
TOP GEL
1% (Voltaren gel) 4 g for each of lower extremities qid, max 16 g/day; 2 g for each of upper extremities qid, max 8 g/day;
TOP SOL
(Pennsaid) apply 40 drops to each affected knee qid; apply 10 drops at a time, spread over entire knee

Rheumatoid arthritis


Adult: PO
(Cataflam) 50 mg tid-qid, max 200 mg/day;
DEL REL
(Voltaren) 50 mg tid-qid or 75 mg bid, max 200 mg/day;
EXT REL
(Voltaren-XR) 100 mg daily, may increase to 200 mg/day, max 200 mg/day

Ankylosing spondylitis


Adult: PO DEL REL
(Voltaren) 25 mg qid and 25 mg at bedtime, max 125 mg/day

Acute migraine with/without aura


Adult: PO
(powder for oral sol) (Cambia) 50 mg as a single dose, mix contents of packet in 1-2 oz water

Mild to moderate pain


Adult: PO
(Zipsor) 25 mg qid

Dysmenorrhea or nonrheumatic inflammatory conditions


Adult: PO
(Cataflam) 50 mg tid or 100 mg initially then 50 mg tid, max 200 mg 1st day then 150 mg/day

Pain of strains/sprains


Adult: TOP PATCH
(Flector) apply patch to area bid

Actinic keratosis


Adult: TOP GEL
(Solaraze) apply to area bid

Prevention of heterotropic ossification (unlabeled)


Adult: PO
50 mg tid × 3 wk

Renal dose

• Avoid:
Use of topical gel, patch, sol, potassium oral tab for advanced renal disease

Available forms:
Epolamine:
topical patch 1.3%;
potassium:
tabs 50 mg; tabs liquid filled 25 mg; oral powder for sol 50 mg;
sodium:
delayed rel tabs (enteric-coated) 25, 50, 75, 100 mg; Pennsaid: top sol 1.5%, ext rel 100 mg; topical gel 1%, 3%

Administer:
PO route

• 
Do not break, crush, or chew enteric products

• 
Take with a full glass of water to enhance absorption, remain upright for 1/2 hr; if dose missed, take as soon as remembered within 2 hr if taking 1-2×/day; do not double doses

• 
Store at room temperature

Topical patch route (Flector)

• 
Wash hands before handling patch

• 
Remove and release liner before administration

• 
Use only on normal, intact skin

• 
Remove before bath, shower, swimming

• 
Discard removed patch in trash away from children, pets

• 
Store at room temperature

Topical gel route

• 
Apply to intact skin

• 
Use only for osteoarthritis, mild to moderate pain

• 
Store at room temperature, avoid heat, do not freeze

Topical solution route

• 
Apply to clean, dry skin

• 
Wait until dry before applying clothing, other creams/lotions

• 
Wait ≥30 min after use before bathing, swimming

• 
Store at room temperature

SIDE EFFECTS

CNS:
Dizziness, headache
, drowsiness, fatigue, tremors, confusion, insomnia, anxiety, depression, nervousness, paresthesia, muscle weakness

CV:
CHF,
tachycardia, peripheral edema, palpitations,
dysrhythmias,
hypo/hypertension, fluid retention,
MI, stroke

EENT:
Tinnitus, hearing loss, blurred vision,
laryngeal edema

GI:
Nausea, anorexia, vomiting, diarrhea,
jaundice, cholestatic hepatitis,
constipation, flatulence, cramps, dry mouth, peptic ulcer,
GI bleeding, hepatotoxicity

GU:
Nephrotoxicity: dysuria, hematuria, oliguria, azotemia, cystitis, UTI

HEMA:
Blood dyscrasias,
epistaxis, bruising

INTEG:
Purpura, rash, pruritus, sweating, erythema, petechiae, photosensitivity, alopecia

META:
Hyperglycemia, hypoglycemia

RESP:
Dyspnea, hemoptysis, pharyngitis,
bronchospasm,
rhinitis, SOB

SYST:
Anaphylaxis

PHARMACOKINETICS

PO:
Peak 2-3 hr;
TOP Patch:
peak 12 hr; elimination half-life 2.5 hr, 99% bound to plasma proteins, metabolized in liver to metabolite, excreted in urine

INTERACTIONS

• 
Need for dosage adjustment: antidiabetics

Increase:
hyperkalemia—potassium-sparing diuretics

Increase:
anticoagulant effect—anticoagulants, NSAIDs, platelet inhibitors, salicylates, thrombolytics, SSRIs

Increase:
toxicity—phenytoin, lithium, cycloSPORINE, methotrexate, digoxin, lithium

Increase:
GI side effects—aspirin, other NSAIDs, bisphosphonates, corticosteroids

Decrease:
antihypertensive effect—β-blockers, diuretics, ACE inhibitors

Decrease:
effect of diuretics

Drug/Herb

Increase:
bleeding risk—garlic, ginger, ginkgo; monitor for bleeding

NURSING CONSIDERATIONS
Assess:

 

Black Box Warning:

CABG:
do not use oral, top, gel, patch, in perioperative pain in coronary artery bypass graft surgery for 10-14 days

 

Black Box Warning:

Stroke/MI:
may increase CHF and hypertension, increased CV thrombotic events that may be fatal; those with CV disease may be at greater risk

• 
Pain:
location, character, aggravating/alleviating factors, ROM before and 1 hr after dose

• 
Patients with asthma, aspirin hypersensitivity, nasal polyps; may develop hypersensitivity

• 
LFTs (may be elevated), uric acid (may be decreased—serum; increased—urine) periodically; also BUN, creatinine, electrolytes (may be elevated)

 
Blood dyscrasias (thrombocytopenia):
bruising, fatigue, bleeding, poor healing; blood counts during therapy; watch for decreasing platelets; if low, therapy may need to be discontinued, restarted after hematologic recovery; stool guaiac

Evaluate:

• 
Therapeutic response: decreased inflammation in joints, after cataract surgery

Teach patient/family:

• 
That product must be continued for prescribed time to be effective; to contact prescriber before surgery regarding when to discontinue this product


 
To report bleeding, bruising, fatigue, malaise;
blood dyscrasias
do occur

• 
To avoid aspirin, alcoholic beverages, NSAIDs, or other OTC medications unless approved by prescriber

• 
To take with food, milk, or antacids to avoid GI upset; to swallow whole

• 
To use caution when driving; drowsiness, dizziness may occur


 
To report
hepatotoxicity:
flulike symptoms, nausea, vomiting, jaundice, pruritus, lethargy

• 
To use sunscreen to prevent photosensitivity

• 
To notify all providers of product use

• 
To notify prescriber if pregnancy is planned or suspected (C, tabs) (C, <30 wk, D, >30 wk caps, topical patch/solution, powder for oral solution)

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