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Transcript
Drug Therapy of Urinary Tract Infections • • • • • • Most common infection More common in females than males In males, they are associated with complications Limited to the urine or invade tissues of the urinary tract Classified according to location • Lower - cystitis • Upper - pyloneph Referred to as • Uncomplicated • Complicated – predisposing factor Treating UTI • Antibiotics • Sulfonamides • Trimethoprim • Sulfonamides and Trimethoprim inhibit bacterial growth by preventing the synthesis of folic acid. Folic acid is essential for the production of DNA, RNA, and proteins. • Penicillins • Aminoglycosides • Cephalosporins • Fluoroquinolones • Urinary Antiseptics • Nitrofurantoin • Methenamine • Nalidixic Acid • Cinoxacin Treating Acute Cystitis (lower UTI) • Three types of oral therapy • Single-dose therapy (least effective, but often used for uncomplicated UTI) • Short-course therapy (uncomplicated UTI, less costly, used for pt that are noncompliant – can help decrease bacterial resistance) • Conventional therapy • First-Line Drugs • Trimethoprim/sulfamethoxazole • Trimethoprim • Ciprofloxacin Treating Acute Uncomplicated Pyelonephritis (upper UTI) • Mild to moderate infection (treated for about 14 days) • Trimethoprim/sulfamethoxazole • Ciprofloxacin • Severe infection (IV antibiotic for 24-48 and then follow with oral antibiotic) • Ciprofloxacin • Ceftriaxone • Ceftazidime • Ampicillin/sulbactam Recurrent UTI • Relapse – recolonization of the original bacteria – shortly after finishing antibiotic – could be a structural abnormality or chronic prostitis – treatment could last up to 4-6wks with oral agent • 20% of recurrent UTI • Progressive drug therapy • Norfloxacin, trimethoprim/sulfamethoxazole • Reinfection – colonization with new organism, commonly related to sexual intercourse or use of contraceptive agents – urine will be collected regularly for culture • 80% of recurrent UTI • Involve lower urinary tract • 3 or more infections a year should be treated prophylactically for 6 months • Trimethoprim/sulfamethoxazole, nitrofurantoin, trimethoprim Trimethoprim (Proloprim) • • • MOA: suppresses synthesis of tetrahydrofolic acid – broad spectrum – used for acute uncomplicated UTI, commonly combined with sulfamethoxazole** Adverse Effects: itching, rash, GI reactions (epigastric, N/V, irritation of epiglottis, stomatitis) Caution in folate deficiency, bone marrow suppression Trimethoprim/Sulfamethoxazole (TMP/SMZ) • • • • • MOA: Inhibits consecutive steps in the synthesis of tetrahydrofolic acid – together they have POWERFUL results, (treat anything from UTI to pneumocystiscarini) Adverse Effects: • N/V • Rash: Stevens-Johnson syndrome (do not administer to clients with allergies to sulfa, thiazide diuretics, sulfonylurea-type oral hypoglycemis, and loop diuretics; Stop at first indication of hypersensitivity such as rash) • blood dyscrasias (agranulytosis, thromocytopenia, leukopenia)(Draw baseline/periodic CBC; observe for any bleeding episodes, sore throat or pallor; If symptoms occur notify Doc) • renal damage • Jaundice/ increased bilirubin lvls* (avoid giving to preggo near term or breastfeeding mother or infants less than 2mnts; monitor liver function) • Photosensitivity* (avoid prolonged exposure to sunlight Maintain hydration to protect the kidneys to prevent crystaluria *(instruct client 8-10 glasses of water a day) TMP-SMZ is the DOC for UTI’s caused by E.coli and other infections caused by Pneummocystiscarni Drug interaction : Warfarin, Dilantin – sulfonamides can increase the effects of the medication Fluoroquinolones • • • Prototype: ciprofloxacin (Cipro) – broad spectrum bactericidal agent that have multiple applications (oral or IV agents) MOA: Inhibit bacterial DNA gyrase so that DNA replication cannot take place Adverse Effects: GI reactions (N/V, diarrhea, abd pain), CNS effects (dizziness, HA, confusion et restlessness), candida, seizure, tendon rupture • • • Monitor IV site, it can cause extravagation This med can also cause tendon rupture – avoid giving to pt under the age of 18. (tendon injury is reversible if identified early) This medication can increase serum warafin levels, monitor PT/INR Urinary Tract Antiseptics • Nitrofurantoin (Macrodantin, Macrobid) (broad spectrum – in low doses it is bacteriostatic, high doses - bacteriocidal) – only used for UTI • MOA: Injures bacteria by causing damage to DNA • Adverse Effects: • GI (N/V, anorexia) (take with milk or food – may also reduce dosage • pulmonary (dyspnea, chest pain, cough and fever)(STOP medication) • Hematologic (penia’s) Blood dyscrasias • Peripheral neuropathy (tingles, numbness, muscle weakness, restless leg) Nitrofurantoin is contraindicated in clients with renal dysfunction and creatinine clearance less than 40mL/min Inform client that urine will have a brownish tint • • • • • Methenamine (Mandelamine, Urex) – treatment for chronic UTI MOA: Breaks down into ammonia and formaldehyde and formaldehyde denatures bacterial proteins to cause cell death Adverse Effects: GI distress, bladder irritation (mimic the symptoms of UTI), may also see hemuteria and proteinuria Contraindicated in liver dysfunction (due to ammonia break down) and renal impairment (due to crystaluria) Available in enteric preparation to decrease GI effects of the drug • • • • Nalidixic Acid (NegGram) used to treat acute UTI and used prophylactically • • • Cinoxacin (Cinobac) – very similar to nalidixic but fewer side effects MOA: Inhibits replication of bacterial DNA causing DNA degradation and cell death Adverse Effects: GI disturbances, visual disturbances, rash, photosensitivity Drug Interaction: warfarin MOA: Inhibits replication of bacterial DNA causing DNA degradation and cell death Adverse Effects: GI disturbances, visual disturbances, rash, photosensitivity Analgesic • • • Pyridium (Azostandard) Used for symptomatic relief of urinary burning, itching, frequency, and urgency Patient education: • May discolor urine (orange) which will stain fabric – this is normal • Discontinue drug use if skin or sclera develop a yellow color Drugs for Erectile Dysfunction and Benign Prostatic hyperplasia Erectile Dysfunction (Also known as impotence) Persistent inability to achieve or sustain an erection suitable for satisfactory sexual performance Commonly associated with chronic illness Risk increases with advancing age Causes of Erectile Dysfunction Chronic illnesses (DM, CVD,PVD….) Lifestyle choices (smoking, obesity) Surgery Medication Psychological factors Treatment for Erectile Dysfunction Psychotherapy Vacuum Devices Surgery-penile implant Drug Therapy PDE5 Inhibitors I Prototype: Sildenafil (Viagra) MOA: Causes selective inhibition of PDE5 which in turn increases and preserves cGMP levels in the penis Adverse Effects: hypotension, priapism(notify doc if erection last more than 4hrs), headache, flushing, dyspepsia Contraindications: nitrates, alpha blockers, inhibitors of CYP3A4 (med would not metabolize properly) Oral doses of 25 mg, 50 mg, 100 mg Drug Interactions Nitrates Alpha Blockers Inhibitors of CYP34A PDE5 Inhibitors II Prototype: Vardenafil (Levitra) and Tadalafil (Cialis) MOA: Causes selective inhibition of PDE5 which in turn increases and preserves cGMP levels in the penis Adverse Effects: headache is the most common Dosing Medication Dosage Viagra 25 mg 50 mg 100 mg Affected by high fat meals Peak Duration Yes (increased effects) 1 hour fasting 4 hours Levitra 2.5 mg 5 mg 10 mg 20 mg Cialis 5 mg 10 mg 20 mg Yes (increased effects) 1 hour 4 hours No 2 hours 36 hours Injectable Prototype: Papaverine Plus Phentolamine and alprostadil (Prostaglandin E 1) – 10min – 2-4 hrs MOA: increase arterial inflow to the penis and decrease venous outflow to produce erection Best for patients who is effected by neurological effects Adverse Effects: priapism, fibrotic nodules, burning sensation Do not use more than 3 times a week, only once in a 24hr period Dosage: patient dependent Benign Prostatic Hyperplasia Signs and Symptoms Hesitancy Urgency Frequency Dysuria Nocturia Straining Post-void dribbling Decreased force and caliber of stream Sensation of incomplete bladder emptying BPH Long-term Complications Obstructive nephropathy Bladder stones Recurrent urinary tract infections Treatment Modalities Surgery Drug Therapy 5-alpha-reductase inhibitors Alpha1-adrenergic antagonists Combination of both Watchful waiting 5-Alpha-Reductase Inhibitors Finasteride (Proscar) MOA: Inhibits type II 5-alpha-reductase, interfering with conversion of testosterone to 5-alphadihydrotestosterone Adverse Effects: decreased ejaculate volume and libido, gynecomastia Dosage: 1 mg, 5 mg Dutasteride (Avodart) 3 differences More complete reduction in circulating DHT Harmful to developing male fetus Extremely long half-life Inhibits 5-alpha-reductase in reproductive tissues and skin and liver Can be absorbed through the skin Pregnancy Risk Category X Alpha1-Adrenergic Antagonists Terazosin (Hytrin) Doxazosin (Cardura) Tamsulosin (Flomax) Alfuzosin (Uroxatral) MOA: Relaxes smooth muscle in the bladder neck, prostate capsule, and prostatic urethra, to decrease dynamic obstruction of the urethra Adverse Effects: for terazosin and doxazosin is hypotension, fainting, dizziness, somnolence, nasal congestion; for tamsulosin – abnormal ejaculation Drug Interactions Antihypertensive Organic nitrates PDE5 inhibitors Strong inhibitors of CYP3A4 Herbal Preparation Saw palmetto Available as a dietary supplement From berries of the American dwarf saw palmetto Active ingredient not identified Once thought to reduce PSA levels Hematopoietic Growth Factors Accelerate neutrophil and platelet repopulation after chemotherapy Accelerate bone marrow recovery after autologous bone marrow transplant Stimulate erythrocyte production in chronic renal failure (due to lack of production of erythropoietin) Erythropoiesis Production of erythrocytes, or RBCs Largely regulated by cellular oxygen requirements Stimulated by hypoxia & controlled hormonally by erythropoietin Influenced by nutrients Epoetin Alfa (Epogen, Procrit) Stimulates erythrocyte production (also mimics the bodies erythropoietin) Uses Chronic renal failure Anemia secondary to chemotherapy Anemia in HIV-infected clients Epogen Administration Subcutaneous (stings, given in abdomen) or intravenous Do not shake vial Adverse effects Hypertension (directly related to the rate of hematocrit rise – if this occurs, the dosage should be reduced) Cardiovascular events (greatest when hemoglobin exceed 12mg/dL – MI, stroke) Nursing Interventions for Epogen Monitor for signs of anemia (pallor, fatigue, SOB, tachycardia) Assess levels of consciousness (facial drooping, slurred speech, HA) Monitor blood pressure before and during therapy (contraindicated in pts with uncontrolled HTN) Monitor lab values (CBC, reticulocytes, hemoglobin) Monitor for signs/symptoms of blood clots (swelling, pain, heat at site) Monitor dietary intake (iron, folic acid, Vit B12 replacement may need to be given…if levels are decreased the Epogen may not work well enough to fix anemia) (Darbepoetin Alfa) Aranesp Longer half life Administered less frequently (once weekly versus 3 times per week Generally well tolerated Hemoglobin levels should be monitored weekly until patient has stabilized, then monitor monthly Adverse Effect: hypertension Leukopoiesis Control of white blood cell production Colony-stimulating factors Granulocyte Colony-Stimulating Factor: Filgrastim (Neupogen) Granulocyte Colony-Stimulating Factor, Long Acting: Pegfilgrastim (Neulasta) Granulocyte-Macrophage Colony-Stimulating Factor: Sargramostim (Leukine) Filgrastim (Neupogen) G-CSF Stimulates neutrophil production – identical to human G-CSF (granulocyte-colony stimulating factor) Decreases risk of infection Uses Chemotherapy-induced neutropenia Severe chronic neutropenia May also be used in patient with bone marrow transplant Do not administer within 24 hours before or after chemotherapy Given subQ or IV Adverse Effects Bone pain (most common- directly related to dose – Tylenol will help relieve the pain) Leukocytosis (monitor CBC 2xweek during treatment; decrease dose or stop treatment if WBC >50,000) Splenomegaly (long term) Pegfilgrastim (Neulasta) G-CSF with sustained duration of action, similar to Neupogen (can increase uric acid level, alkaline phosph) Sargramostim (Leukine) Increases production of neutrophils, monocytes, macrophages, and eosinophils Administered IV infusion Adverse Effects: Leukocytosis and thrombocytosis, diarrhea, weakness, rash, malaise, bone pain Used for bone marrow transplants Nursing interventions Monitor vital signs, heart rate and rhythm Monitor CBC (can cause increase in platelet count) Assess for bone pain Monitor for s/s of infection clients are more susceptible to infection until WBC response is achieved Thrombocytopoiesis Production of platelets controlled by hormone thrombopoietin Oprelvekin (Neumega, Interleukin-11) Used for thrombocytopenia caused by cancer chemotherapy Given subQ Adverse effect Fluid retention (retention of Na and H20) will see peripheral edema Cardiac Dysrhythmia (caution in HF due to fluid retention) – tachycardia Afib, Aflutter, most likely related to plasma volume increase It can cause plasma volume to increase, which causes hgt, hct to decrease leading to anemia – pt will start getting dyspnic Use with caution in clients with cardiac disease Teach client to avoid activities that could cause bleeding Reach client to immediately report edema and difficulty breathing Weigh daily Report bruising or hematuria Contraindicated in clients allergic to yeast products Drug Therapy for Renal Dysfunction Drugs Associated with Renal Toxicity Aminoglycosides Amphotericin B IV contrast Allopurinal, NSAIDs, PCNs, Sulfonamides Gold salts, heroin, lithium High dose acyclovir ACE-inhibitors, ARBS, excessive diuretic use can cause renal ischemia Special Needs for Renal Failure Clients Restricted fluid intake Decreased protein, phosphate and sodium K+, Mg+ and phosphorus restricted Hyperphosphatemia can lead to hypocalcemia Vitamin D and calcium supplements Iron supplements Calcium Acetate (Phoslo) Binds to dietary phosphate in the gut to form calcium phosphate MUST be taken with meals to bind phosphate Adverse Effects: constipation Food/Drug interaction Glucocorticoids (give meds at least 1 hr apart) Tetracyclines et thyroid hormones (give meds at least 1hr apart) Thiazide diuretics (assess for s/s of hypercalcemia ; tachycardia, elevated BP, muscle wkness, constipation, lethargy) Spinach, rhubarb, bran et whole grain (will decrease calcium absorption) Phosphates, carbonates, sulfates et tartrates (IVCa precipitates with these compounds) Dig and parenteral Ca (can lead to severe bradycardia Do not use if patient is hypercalcemic Will see med is effective if phosp levels are down in blood work Sevelamer (Renagel) Binds phosphate in the GI tract Recommended for clients with calcium and phosphate levels Must take with food** in order to be effective Adverse Effects: diarrhea, nausea, vomiting, dyspepsia, abdominal pain, and constipation Calcitrol (Rocaltrol) Vitamin D analog serum calcium levels by promoting calcium absorption to manage hypocalcemia Indicated for treatment of hypocalcemia in renal failure Administer by mouth or IV Cinacalcet (Sensipar) Calcimimetic Treats hyperparathyroidism Increases sensitivity of calcium-sparing receptors on cells of the parathyroid gland Administer by mouth – absorption increased by food Adverse Effects: Nausea, vomiting, diarrhea, hypocalcemia