telmisartan
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telmisartan
[tel″mĭ-sahr´tan]telmisartan
MicardisApo-Temazepam, Co Temazepam, Dom-Temazepam, Gen-Temazepam, Novo-Temazepam, Nu-Temazepam, PHL-Temazepam, PMS-Temazepam, Ratio-Temazepam, RestorilTemodal, Temodar
Pharmacologic class: Angiotensin II receptor antagonist
Therapeutic class: Antihypertensive
Pregnancy risk category C (first trimester), D (second and third trimesters)
Pregnancy risk category C (first trimester), D (second and third trimesters)
Pharmacologic class: Benzodiazepine
Therapeutic class: Sedative-hypnotic
Controlled substance schedule IV
Pregnancy risk category X
Pharmacologic class: Alkylating agent
Therapeutic class: Antineoplastic
Pregnancy risk category D
FDA Box Warning
Drugs that act directly on the renin-angiotensin system can cause injury to or death of a developing fetus. Discontinue drug as soon as possible when pregnancy is detected.
Action
Inhibits vasoconstricting effects and blocks aldosterone-producing effects of angiotensin II at various receptor sites, including vascular smooth muscle and adrenal glands
Availability
Tablets: 20 mg, 40 mg, 80 mg
⊘Indications and dosages
➣ Hypertension
Adults: 40 mg P.O. daily, titrated up or down within range of 20 to 80 mg daily based on response and tolerance
➣ Cardiovascular risk reduction
Adults: 80 mg P.O. daily in patients unable to take angiotensin-converting enzyme (ACE) inhibitors
Contraindications
• Hypersensitivity to drug or its components
Precautions
Use cautiously in:
• heart failure, impaired renal function secondary to primary renal disease or renal stenosis, obstructive biliary disorders, hepatic impairment, volume or sodium depletion
• patients receiving high-dose diuretics
• concomitant use of ACE inhibitors and angiotensin receptor blockers (avoid use)
• pregnant or breastfeeding patients
• children younger than age 18 (safety not established).
Administration
• Don't remove tablet from blister pack until just before giving.
• Know that drug may be used alone or with other antihypertensives.
Adverse reactions
CNS: dizziness, headache, fatigue
CV: chest pain, peripheral edema, hypertension, intermittent claudication
EENT: sinusitis, pharyngitis
GI: nausea, vomiting, diarrhea, dyspepsia, abdominal pain
GU: urinary tract infection
Musculoskeletal: myalgia, back and leg pain
Respiratory: cough, upper respiratory infection
Skin: ulcer
Other: pain, flu or flulike symptoms, hypersensitivity
Interactions
Drug-drug. Antihypertensives, diuretics: increased risk of hypotension
Ace inhibitors (ramipril): increased ramipril steady-state Cmax and area under the curve (AUC), decreased telmisartan Cmax and AUC
Digoxin: increased digoxin blood level
Lithium: increased serum lithium concentration and toxicity
Nonsteroidal anti-inflammatory drugs, including selective cyclooxygenase-2 inhibitors): deterioration of renal function, including possible acute renal failure in elderly patients, volume-depleted patients (including those on diuretic therapy), or with compromised renal function; attenuated telmisartan antihypertensive effect
Drug-diagnostic tests. Creatinine: slight elevation
Drug-food. Any food: slightly reduced drug bioavailability
Patient monitoring
• Monitor blood pressure frequently and watch for signs and symptoms of hypotension.
• Closely monitor patient with impaired hepatic or renal function. Correct volume deficits as appropriate before therapy starts. Monitor fluid intake and output and creatinine level during therapy.
Patient teaching
• Tell patient to take 1 hour before or 2 hours after meals.
• Caution patient not to remove tablet from blister pack until just before taking.
• Advise patient to report swelling or chest pain.
• Teach patient to measure blood pressure regularly and report significant changes.
• Tell patient to report suspected pregnancy to prescriber. Caution her not to breastfeed.
• As appropriate, review all other significant adverse reactions and interactions, especially those related to the drugs, tests, and foods mentioned above.
temazepam
Pharmacologic class: Benzodiazepine
Therapeutic class: Sedative-hypnotic
Controlled substance schedule IV
Pregnancy risk category X
Action
Depresses CNS at limbic, thalamic, and hypothalamic levels. Enhances effects of gamma-aminobutyric acid, resulting in sedation, hypnosis, skeletal muscle relaxation, and anticonvulsant and anxiolytic activity.
Availability
Capsules: 7.5 mg, 15 mg, 22.5 mg, 30 mg
⊘Indications and dosages
➣ Insomnia
Adults: 15 mg P.O. at bedtime p.r.n. Range is 7.5 to 30 mg.
Dosage adjustment
• Elderly or debilitated patients
Contraindications
• Hypersensitivity to drug or other benzodiazepines
• Pregnancy
Precautions
Use cautiously in:
• chronic pulmonary insufficiency, hepatic dysfunction, renal disease, psychoses, drug abuse
• history of suicide attempt or drug abuse
• elderly or debilitated patients
• breastfeeding patients
• children younger than age 15.
Administration
• Give at bedtime with or without food.
Adverse reactions
CNS: hangover, headache, dizziness, drowsiness, lethargy, fatigue, paradoxical stimulation, light-headedness, talkativeness, irritability, nervousness, confusion, euphoria, relaxed feeling, tremor, incoordination, impaired memory, nightmares, paresthesia
CV: chest pain, palpitations, tachycardia
EENT: eye irritation, pain, and swelling; photophobia; tinnitus
GI: nausea, vomiting, constipation, diarrhea, heartburn, abdominal pain, dry mouth, anorexia
Musculoskeletal: joint pain
Other: altered taste, body pain, physical or psychological drug dependence, drug tolerance
Interactions
Drug-drug. Antidepressants, antihistamines, opioid analgesics, other sedative-hypnotics: additive CNS depression
Digoxin: increased digoxin blood level, greater risk of toxicity
Probenecid: faster temazepam onset and prolonged effects
Theophylline: antagonism of temazepam's sedative effects
Drug-herbs. Chamomile, hops, kava, skullcap, valerian: increased CNS depression
Drug-behaviors. Alcohol use: additive CNS depression
Smoking: increased drug metabolism
Patient monitoring
• Monitor neurologic status carefully. Check for paradoxical reactions, especially in elderly patient.
• Watch for signs and symptoms of physical and psychological drug dependence. Stay alert for drug hoarding.
Patient teaching
• Advise patient to establish effective bedtime routine, to minimize insomnia.
• Inform patient (and significant other if appropriate) that drug may cause psychological and physical dependence and should be used only as prescribed and needed.
• Caution patient to avoid driving and other hazardous activities on day after taking drug, until he knows how it affects concentration and alertness.
• Instruct patient not to drink alcohol.
• Advise patient not to smoke or use herbs without consulting prescriber.
• Instruct patient to report suspected pregnancy.
• As appropriate, review all other significant adverse reactions and interactions, especially those related to the drugs, herbs, and behaviors mentioned above.
temozolomide
Pharmacologic class: Alkylating agent
Therapeutic class: Antineoplastic
Pregnancy risk category D
Action
Rapidly converts to monomethyl triazeno imidazole carboxamide, an active compound that prevents DNA transcription
Availability
Capsules: 5 mg, 20 mg, 100 mg, 140 mg, 180 mg, 250 mg
Injection (powder for solution, lyophilized): 100 mg
⊘Indications and dosages
➣ Refractory anaplastic astrocytoma
Adults: 150 mg/m2 P.O. or by 90-minute I.V. infusion daily for 5 consecutive days of each 28-day treatment cycle. Adjust dosage as appropriate based on absolute neutrophil count.
➣ Newly diagnosed glioblastoma multiforme with radiotherapy
Adults: 75 mg/m2 P.O. or by 90-minute I.V. infusion for 42 days with focal radiotherapy (RT), followed by initial maintenance dose of 150 mg/m2 P.O. or by 90-minute I.V. infusion daily for days 1 to 5 of a 28-day cycle for six cycles. Four weeks after completing the drug plus RT phase, administer drug for an additional six cycles of maintenance treatment. Dosage in maintenance cycle 1 is 150 mg/m2 P.O. or by 90-minute I.V. infusion daily for 5 days, followed by 23 days without treatment. At start of maintenance cycle 2, dosage may be escalated to 200 mg/m2 based on absolute neutrophil and platelet counts. Continue dosage at 200 mg/m2 daily for first 5 days of each subsequent cycle except if toxicity occurs. If dosage wasn't escalated at maintenance cycle 2, escalation shouldn't be done in subsequent cycles.
Dosage adjustment
• Neutropenia, thrombocytopenia
Contraindications
• Hypersensitivity to drug, its components, or dacarbazine
Precautions
Use cautiously in:
• severe hepatic or renal impairment, active infection, decreased bone marrow reserve, other chronic debilitating illness
• elderly patients
• pregnant or breastfeeding patients
• children (safety not established).
Administration
• Follow facility policy for handling and disposing of chemotherapeutic drugs.
• Give capsules whole daily with a full glass of water, consistently either with or without food.
• Bring powder for injection to room temperature before reconstituting with 41 ml sterile water for injection that results in a 2.5-mg/ml solution. Gently swirl but don't shake vials. Don't further dilute reconstituted solution. Use reconstituted solution within 14 hours, including infusion time. Withdraw prescribed dose and transfer into empty 250-ml infusion bag. Give reconstituted solution only by I.V. infusion using infusion pump over 90 minutes. Flush lines before and after each infusion.
• Know that drug may be given in same I.V. line with normal saline solution for injection only.
• Be aware that dosages in 28-day cycle depend on nadir neutrophil and platelet counts.
Adverse reactions
CNS: fatigue, headache, dysphasia, poor coordination, ataxia, anxiety, depression, dizziness, drowsiness, confusion, amnesia, insomnia, mental status changes, weakness, paresis, hemiparesis, paresthesias, seizures
CV: peripheral edema
EENT: abnormal vision, diplopia, pharyngitis, sinusitis
GI: nausea, vomiting, constipation, diarrhea, abdominal pain, anorexia
GU: urinary incontinence or frequency, urinary tract infection, breast pain (in women)
Hematologic: anemia, leukopenia, thrombocytopenia
Metabolic: adrenal hypercorticism
Musculoskeletal: abnormal gait, back pain, myalgia
Respiratory: cough, upper respiratory infection
Skin: pruritus, rash
Other: fever, viral infection, weight gain
Interactions
Drug-drug. Antineoplastics: additive bone marrow depression
Live-virus vaccines: decreased antibody response to vaccine, greater risk of adverse reactions
Valproic acid: decreased oral clearance of temozolomide
Drug-diagnostic tests. Neutrophils, platelets: decreased counts
Drug-food. Any food: reduced rate and extent of temozolomide absorption
Patient monitoring
Monitor CBC with white cell differential. Stay alert for evidence of bone marrow depression.
• Assess neurologic status carefully.
• Monitor fluid intake and output, and weigh patient regularly.
• Be aware that Pneumocystis jiroveci pneumonia prophylaxis is required during concomitant administration of RT and should be continued in patients who develop lymphocytopenia until recovery from lymphocytopenia (circulating tumor cells Grade 1 or less).
Patient teaching
• Tell patient to take capsules consistently with or without food, and with a full glass of water.
• Instruct patient to swallow capsules whole without opening or chewing them and if capsules are accidentally opened or damaged, to avoid inhalation or contact with the skin or mucous membranes.
• If drug causes nausea or vomiting, advise patient to take it 1 hour before or 2 hours after a meal.
• Inform patient that drug may cause abnormal gait and dizziness.
Instruct patient to immediately report unusual bleeding or bruising.
• Advise patient to avoid live-virus vaccines.
• Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration, alertness, and vision.
• Instruct patient to report suspected pregnancy. Caution her not to breastfeed.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.