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carvedilol (kar-ve-di-lole)
Indications
Hypertension. HF (ischemic or cardiomyopathic) with digoxin, diuretics, and ACE inhibitors. Left ventricular dysfunction after myocardial infarction.
Action
Blocks stimulation of beta1(myocardial) and beta2 (pulmonary, vascular, and uterine)-adrenergic receptor sites. Also has alpha1 blocking activity, which may result in
orthostatic hypotension. Therapeutic Effects: Decreased heart rate and BP. Improved cardiac output, slowing of the progression of HF and decreased risk of death.
Pharmacokinetics
Absorption: Well absorbed but rapidly undergoes extensive first-pass hepatic metabolism, resulting in 25– 35% bioavailability. Food slows absorption.
Distribution: Unknown.
Protein Binding: 98%.
Metabolism and Excretion: Extensively metabolized (primarily by CYP2D6 and
CYP2C9; the CYP2D6 enzyme system exhibits genetic polymorphism); ⬃7% of population may be poor metabolizers and may have significantlyqcarvedilol concentrations and anqrisk of adverse effects); excreted in feces via bile, ⬍2% excreted unchanged in urine.
Half-life: 7– 10 hr.
TIME/ACTION PROFILE (cardiovascular effects)
ONSET
within 1 hr
unknown
PEAK
1–2 hr
5 hr
DURATION
12 hr
24 hr
Contraindications/Precautions
Contraindicated in: History of serious hypersensitivity reaction (Stevens-Johnson syndrome, angioedema, anaphylaxis); Pulmonary edema; Cardiogenic shock;
⫽ Canadian drug name.
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Bradycardia, heart block or sick sinus syndrome (unless a pacemaker is in place);
Uncompensated HF requiring IV inotropic agents (wean before starting carvedilol);
Severe hepatic impairment; Asthma or other bronchospastic disorders.
Use Cautiously in: HF (condition may deteriorate during initial therapy); Renal
impairment; Hepatic impairment; Diabetes mellitus (may mask signs of hypoglycemia); Thyrotoxicosis (may mask symptoms); Peripheral vascular disease; History of
severe allergic reactions (intensity of reactions may be increased); OB: Crosses placenta and may cause fetal/neonatal bradycardia, hypotension, hypoglycemia, or respiratory depression); Lactation, Pedi: Safety not established; Geri:qsensitivity to
beta blockers; initial dose reduction recommended.
Coreg, Coreg CR
Classification
Therapeutic: antihypertensives
Pharmacologic: beta blockers
Pregnancy Category C
ROUTE
PO
PO-CR
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⫽ Genetic Implication.
Adverse Reactions/Side Effects
CNS: dizziness, fatigue, weakness, anxiety, depression, drowsiness, insomnia, memory loss, mental status changes, nervousness, nightmares. EENT: blurred vision, dry
eyes, intraoperative floppy iris syndrome, nasal stuffiness. Resp: bronchospasm,
wheezing. CV: BRADYCARDIA, HF, PULMONARY EDEMA. GI: diarrhea, constipation, nausea. GU: erectile dysfunction,plibido. Derm: STEVENS-JOHNSON SYNDROME, TOXIC
EPIDERMAL NECROLYSIS, itching, rashes, urticaria. Endo: hyperglycemia, hypoglycemia. MS: arthralgia, back pain, muscle cramps. Neuro: paresthesia. Misc: ANAPHYLAXIS, ANGIOEDEMA, drug-induced lupus syndrome.
Interactions
Drug-Drug: General anesthetics, IV phenytoin, diltiazem, and verapamil
may causeqmyocardial depression.qrisk of bradycardia with digoxin. Amiodarone or fluconazole may q levels. q hypotension may occur with other antihypertensives, acute ingestion of alcohol, or nitrates. Concurrent use with clonidine q hypotension and bradycardia. May q withdrawal phenomenon from
clonidine (discontinue carvedilol first). Concurrent administration of thyroid
preparations maypeffectiveness. May alter the effectiveness of insulins or oral
hypoglycemic agents (dose adjustments may be necessary). Maypeffectiveness of
theophylline. Maypbeneficial beta1-cardiovascular effects of dopamine or dobutamine. Use cautiously within 14 days of MAO inhibitor therapy (may result in hypotension/bradycardia). Cimetidine mayq toxicity from carvedilol. Concurrent
NSAIDs maypantihypertensive action. Effectiveness may bepby rifampin. Mayq
serum digoxin levels. Mayqblood levels of cyclosporine (monitor blood levels).
Route/Dosage
PO (Adults): Hypertension— 6.25 mg twice daily, may beqq 7– 14 days up to 25
mg twice daily or extended-release— 20 mg once daily, dose may be doubled every
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.
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● PO: Take apical pulse before administering. If ⬍50 bpm or if arrhythmia
7– 14 days up to 80 mg once daily; HF— 3.125 mg twice daily for 2 wk; may beqto
6.25 mg twice daily. Dose may be doubled q 2 wk as tolerated (not to exceed 25 mg
twice daily in patients ⬍85 kg or 50 mg twice daily in patients ⬎85 kg) or extendedrelease— 10 mg once daily, dose may be doubled every 2 wk as tolerated up to 80
mg once daily; Left ventricular dysfunction after MI— 6.25 mg twice daily,qafter
3– 10 days to 12.5 twice daily then to target dose of 25 mg twice daily; some patients
may require lower initial doses and slower titration or extended-release— 20 mg
once daily, dose may be doubled every 3– 10 days up to 80 mg once daily.
● Administer with food to minimize orthostatic hypotension.
● Administer extended-release capsulesin the morning. Swallow whole; do not
NURSING IMPLICATIONS
Assessment
Patient/Family Teaching
occurs, withhold medication and notify health care professional.
● Monitor BP and pulse frequently during dose adjustment period and pe●
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riodically during therapy. Assess for orthostatic hypotension when assisting
patient up from supine position.
Monitor intake and output ratios and daily weight. Assess patient routinely for evidence of fluid overload (peripheral edema, dyspnea, rales/
crackles, fatigue, weight gain, jugular venous distention). Patients may
experience worsening of symptoms during initiation of therapy for HF.
Hypertension: Check frequency of refills to determine adherence.
Lab Test Considerations: May causeqBUN, serum lipoprotein, potassium,
triglyceride, and uric acid levels.
May causeqANA titers.
May causeqin blood glucose levels.
Toxicity and Overdose: Monitor patients receiving beta blockers for signs of
overdose (bradycardia, severe dizziness or fainting, severe drowsiness, dyspnea,
bluish fingernails or palms, seizures). Notify health care professional immediately
if these signs occur.
crush, break, or chew. Extended-release capsules may be opened and sprinkled
on cold applesauce and taken immediately; do not store mixture.
● To convert from immediate-release to extended-release product, doses of 3.125
mg twice daily can be converted to 10 mg daily; doses of 6.25 mg twice daily can be
converted to 20 mg daily; doses of 12.5 mg twice daily can be converted to 40 mg
daily; and doses of 25 mg twice daily can be converted to 80 mg daily.
● Instruct patient to take medication as directed, at the same time each day, even if
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Potential Nursing Diagnoses
Decreased cardiac output (Side Effects)
Noncompliance (Patient/Family Teaching)
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Implementation
● Do not confuse carvedilol with captopril.
● Discontinuation of concurrent clonidine should be gradual, with carvedilol dis-
continued first over 1-2 wk with limitation of physical activity; then, after several
days, discontinue clonidine.
●
feeling well. Do not skip or double up on missed doses. Take missed doses as soon
as possible up to 4 hr before next dose. Abrupt withdrawal may precipitate
life-threatening arrhythmias, hypertension, or myocardial ischemia.
Advise patient to make sure enough medication is available for weekends, holidays, and vacations. A written prescription may be kept in wallet in case of emergency.
Teach patient and family how to check pulse and BP. Instruct them to check pulse
daily and BP biweekly. Advise patient to hold dose and contact health care professional if pulse is ⬍50 bpm or BP changes significantly.
May cause drowsiness or dizziness. Caution patients to avoid driving or other activities that require alertness until response to the drug is known.
Advise patient to change positions slowly to minimize orthostatic hypotension, especially during initiation of therapy or when dose is increased.
Caution patient that this medication may increase sensitivity to cold.
Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking other Rx, OTC, or herbal products, especially cold preparations, concurrently with this medication.
Patients with diabetes should closely monitor blood glucose, especially if weakness, malaise, irritability, or fatigue occurs. Medication may mask some signs of
hypoglycemia, but dizziness and sweating may still occur.
Advise patient to notify health care professional if slow pulse, difficulty
breathing, wheezing, cold hands and feet, dizziness, confusion, depression, rash, fever, sore throat, unusual bleeding, or bruising occurs.
䉷 2015 F.A. Davis Company
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carvedilol
● Instruct patient to inform health care professional of medication regimen before
treatment or surgery.
● Advise patient to carry identification describing disease process and medication
regimen at all times.
● Hypertension: Reinforce the need to continue additional therapies for hyperten-
sion (weight loss, sodium restriction, stress reduction, regular exercise, moderation of alcohol consumption, and smoking cessation). Medication controls but
does not cure hypertension.
Evaluation/Desired Outcomes
● Decrease in BP without appearance of detrimental side effects.
● Decrease in severity of HF.
Why was this drug prescribed for your patient?
⫽ Canadian drug name.
⫽ Genetic Implication.
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.