INFLIXIMAB
GENERIC NAME: INFLIXIMAB - INJECTION (in-FLICKS-ih-mab)
BRAND NAME(S): Remicade
Warning | Medication Uses | How To Use | Side Effects | Precautions | Drug Interactions | Overdose | Notes | Missed Dose | Storage
WARNING: Infliximab decreases immune system function (immunosuppression), which can result in serious infections (e.g., tuberculosis or fungal infections), or a worsening of an existing infection. Before starting treatment with infliximab, you should have a TB skin test done to check for tuberculosis that may not be causing any symptoms (latent TB). If you are diagnosed with TB, anti-tuberculosis medicines must be started before you start infliximab therapy. This will prevent a serious TB infection. Tell your doctor immediately if you develop signs of infection while using this drug, such as: fever, persistent sore throat, unusual vaginal discharge, painful or frequent urination.
USES: Infliximab inhibits a protein called TNF. This action results in decreased swelling (inflammation) and decreased immune system function (immunosuppression). Infliximab is effective in treating rheumatoid arthritis and certain bowel diseases (Crohn’s disease), since swelling and an overactive immune system likely play a role in these diseases.
HOW TO USE: This medication is given by vein (IV) over at least 2 hours. Follow all instructions for proper mixing and dilution with the correct IV fluids. Consult your pharmacist. This medication should be checked visually for particles or discoloration before use. The liquid should be colorless to light yellow and translucent particles may be present (this is normal). Do not use the liquid if whitish/opaque particles or discoloration are present.
SIDE EFFECTS: Nausea or pain at the injection site may occur. If these effects persist or worsen, notify your doctor. Report promptly: signs of infection (e.g., persistent sore throat, fever), chills, severe headache, chest pain, cough, extreme fatigue, stomach pain, unusual vaginal discharge, white patches in the mouth (fungal infection). Unlikely but report promptly: diarrhea, joint/muscle pain, mental/mood changes, vision changes, unexplained muscle weakness, numbness/tingling, changes in skin appearance, painful urination, increased urgency/frequency of urination, unusual bruising or bleeding, sudden weight gain. Very unlikely but report promptly: fast or irregular pulse, unusual lumps/growths, night sweats, unexplained weight loss, swollen glands. In the unlikely event you have an allergic reaction to this medication, seek medical attention immediately. Symptoms of an allergic reaction include: rash, itching, swelling, dizziness, trouble breathing.
PRECAUTIONS: Tell your doctor your medical history, especially of: any allergies, current infections, seizures, certain brain/spinal cord disorders (demyelinating disorders such as multiple sclerosis), history of cancer (e.g., lymphoma), decreased bone marrow function. This medication is not recommended for use if you have the following medical condition: congestive heart failure (CHF). Infliximab may worsen CHF; some deaths have occurred in patients with CHF. Consult your doctor or pharmacist for more details. Use of this medication may result in a secondary infection (e.g., oral, bladder or vaginal yeast infection). Caution is advised when this drug is used in the elderly, as this group may be more sensitive to drug side effects. This medication should be used only when clearly needed during pregnancy. Discuss the risks and benefits with your doctor. It is not known whether this drug is excreted into breast milk. Because of the potential risk to the infant, breast-feeding while using this medication is not recommended. Consult your doctor before breast-feeding.
DRUG INTERACTIONS: Tell your doctor of all nonprescription and prescription medication you may use, especially: . immune system suppressing drugs (e.g., prednisone, cyclosporine), anakinra.
OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US national poison hotline at 1-800-222-1222. Canadian residents should call their local poison control center directly.
NOTES: Do not share this medication with others. Laboratory and/or medical tests may be performed to monitor your response to therapy.
MISSED DOSE: If the dose is interrupted, contact your doctor immediately to establish a new dosing schedule.
STORAGE: Store in a refrigerator between 36 and 46 degrees F (2 to 8 degrees C) away from light and moisture. Do not freeze. After mixing and dilution in correct IV fluids (consult your pharmacist for details), the drug should be used immediately. Discard any unused liquid.
CELECOXIB
GENERIC NAME: celecoxib
BRAND NAME: Celebrex
DRUG CLASS AND MECHANISM: Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID) that is used to treat arthritis, pain, menstrual cramps, and colonic polyps. Prostaglandins are chemicals that are important contributors to the inflammation of arthritis that causes the pain, fever, swelling and tenderness. Celecoxib blocks the enzyme that makes prostaglandins (cyclooxygenase 2), resulting in lower concentrations of prostaglandins. As a consequence, inflammation and its accompanying pain, fever, swelling and tenderness are reduced. Celecoxib differs from other NSAIDs in that it causes less inflammation and ulceration of the stomach and intestine (at least with short-term treatment) and does not interfere with the clotting of blood. NSAIDs have been found to prevent the formation and reduce the size of polyps in patients with the genetic disease, familial adenomatous polyposis (FAP). In FAP, patients develop large numbers of polyps in their colons, and the polyps invariably become malignant. The only cure of FAP requires removal of the entire colon. Celecoxib is approved as an adjunctive (secondary) treatment among patients with FAP. The cramping and pain during menstrual periods is due to prostaglandins, and blocking the production of prostaglandins with celecoxib reduces the cramps and pain.
GENERIC AVAILABLE: No
PRESCRIPTION: Yes
PREPARATIONS: Capsules: 100 mg (white with a blue band), 200 mg (white with a gold band), 400 mg (white with a green band)
STORAGE: Capsules should be stored at 25캜 (77캟). It is okay for brief periods in temperatures between 15-30캜 (59-86캟).
PRESCRIBED FOR: Celecoxib is used for the relief of pain, fever, swelling, and tenderness caused by osteoarthritis,? rheumatoid arthritis, and ankylosing spondylitis? Celecoxib does not prevent the progression of either type of arthritis. It reduces only the symptoms and signs of arthritis. Celecoxib has been approved for patients with familial FAP who have not had their colons removed. Celebrex also is approved for the relief of acute pain and the pain of menstrual cramps (primary dysmenorrhea).
DOSING: The lowest effective dose should be used for each patient. For the management of osteoarthritis, the dose usually is 100 mg twice daily or 200 mg as a single dose. For rheumatoid arthritis, the dose usually is 100 or 200 mg twice daily. For acute pain or menstrual cramps, the dose is 400 mg as a single dose on the first day followed by an additional 200 mg if needed, then 200mg twice daily as needed. For FAP, the recommended dose is 400 mg twice daily.
DRUG INTERACTIONS: Concomitant use of celecoxib with aspirin or other NSAIDs (e.g., ibuprofen, naproxen, etc.) may increase the occurrence of stomach and intestinal ulcers.
Fluconazole (Diflucan) increases the concentration of celecoxib in the body by inhibiting the breakdown of celecoxib in the liver. Therefore, treatment with celecoxib should be initiated at the lowest recommended doses in patients who are taking fluconazole.
Celecoxib increases the concentration of lithium (Eskalith) in the blood by 17%. Therefore, lithium therapy should be closely monitored during and after therapy with celecoxib.
Persons taking the anticoagulant (blood thinner) warfarin (Coumadin) should have their blood tested when initiating or changing celecoxib treatment, particularly in the first few days, for any changes in the effects of the anticoagulant.
Persons who drink more than 3 alcoholic beverages per day may be at increased risk of developing stomach ulcers when taking NSAIDs, and this also may be true with celecoxib.
PREGNANCY: Celecoxib has not been studied in pregnant women. In animal studies, doses that were twice the maximally recommended dose were harmful to the fetus. Celecoxib should only be used in pregnant women when the benefits outweigh the potential risk to the fetus.
NURSING MOTHERS: The use of celecoxib in nursing mothers has not been evaluated.
SIDE EFFECTS: Although stomach and intestinal ulcers occur with the use of celecoxib, their incidence is less than with other NSAIDs in short-term studies.
Celecoxib does not interfere with the function of the blood platelets and, as a result, does not reduce clotting and lead to increased bleeding like other NSAIDs.
The most common adverse effects are headache, abdominal pain, dyspepsia, diarrhea, nausea, flatulence and insomnia. Other side effects include fainting, kidney failure, heart failure, aggravation of hypertension, chest pain, ringing in the ears, deafness, stomach and intestinal ulcers, bleeding, blurred vision, anxiety, photosensitivity, weight gain, water retention, flu-like symptoms, drowsiness and weakness.
Allergic reactions can occur with celecoxib. Individuals who have developed allergic reactions (rash, itching, difficulty breathing) from sulfonamides (e.g., Bactrim), aspirin or other NSAIDs may experience an allergic reaction to celecoxib and should not take celecoxib.
ibuprofen
GENERIC NAME: ibuprofen
BRAND NAME: Advil, Children’s Advil/Motrin, Medipren, Motrin, Nuprin, PediaCare Fever etc.
DRUG CLASS AND MECHANISM: Ibuprofen belongs to a class of drugs called non–steroidal anti–inflammatory drugs (NSAIDs). Other members of this class include aspirin, naproxen (Aleve), indomethacin (Indocin), nabumetone (Relafen) and several others. These drugs are used for the management of mild to moderate pain, fever, and inflammation. Pain, fever, and inflammation are promoted by the release in the body of chemicals called prostaglandins. Ibuprofen blocks the enzyme that makes prostaglandins (cyclooxygenase), resulting in lower levels of prostaglandins. As a consequence, inflammation, pain and fever are reduced. The FDA approved ibuprofen in 1974.
PRESCRIPTION: Yes
GENERIC AVAILABLE: Yes
PREPARATIONS: Tablets of 200, 400, 600, and 800 mg; Chewable tablets of 50 and 100 mg; Capsules of 200 mg; Suspension of 100 mg/2.5 ml and 100 mg/5 ml; Oral drops of 40 mg/ml.
STORAGE: Ibuprofen should be stored at room temperature, between 15–30°C (59–86°F).
PRESCRIBED FOR: Ibuprofen is used for the treatment of mild to moderate pain, inflammation and fever caused by many and diverse diseases.
DOSING: For minor aches, mild to moderate pain, menstrual cramps, and fever, the usual adult dose is 200 or 400 mg every 4 to 6 hours.
Arthritis is treated with 300 to 800 mg 3 or 4 times daily.
When under the care of a physician, the maximum dose of ibuprofen is 3.2 g daily. Otherwise, the maximum dose is 1.2 g daily. Individuals should not use ibuprofen for more than 10 days for the treatment of pain or more than 3 days for the treatment of a fever unless directed by a physician.
Children 6 months to 12 years of age usually are given 5–10 mg/kg of ibuprofen every 6–8 hours for the treatment of fever and pain. The maximum dose is 40 mg/kg daily.
Juvenile arthritis is treated with 20 to 40 mg/kg/day in 3–4 divided doses.
Ibuprofen should be taken with meals to prevent stomach upset.
DRUG INTERACTIONS: Ibuprofen is associated with several suspected or probable interactions that can affect the action of other drugs. Ibuprofen may increase the blood levels of lithium (Eskalith) by reducing the excretion of lithium by the kidneys. Increased levels of lithium may lead to lithium toxicity. Ibuprofen may reduce the blood pressure–lowering effects of drugs that are given to reduce blood pressure. This may occur because prostaglandins play a role in the regulation of blood pressure. When ibuprofen is used in combination with aminoglycosides [for example, gentamicin (Garamycin)] the blood levels of the aminoglycoside may increase, presumably because the elimination of aminoglycosides from the body is reduced. This may lead to aminoglycoside–related side effects. Individuals taking oral blood thinners or anticoagulants [for example, warfarin (Coumadin)] should avoid ibuprofen because ibuprofen also thins the blood, and excessive blood thinning may lead to bleeding.
PREGNANCY: There are no adequate studies of ibuprofen in pregnant women. Therefore, ibuprofen is not recommended during pregnancy. Ibuprofen should be avoided in late pregnancy due to the risk of premature closure of the ductus arteriosus in the fetal heart..
NURSING MOTHERS: Ibuprofen is not excreted in breast milk. Use of ibuprofen while breastfeeding, poses little risk to the infant.
SIDE EFFECTS: The most common side effects from ibuprofen are rash, ringing in the ears, headaches, dizziness, drowsiness, abdominal pain, nausea, diarrhea, constipation and heartburn. NSAIDs reduce the ability of blood to clot and therefore increase bleeding after an injury. Ibuprofen may cause ulceration of the stomach or intestine, and the ulcers may bleed. Sometimes, ulceration can occur without abdominal pain, and black, tarry stools, weakness, and dizziness upon standing (orthostatic hypotension) due to bleeding may be the only signs of an ulcer. NSAIDs reduce the flow of blood to the kidneys and impair function of the kidneys. The impairment is most likely to occur in patients who already have impaired function of the kidney or congestive heart failure, and use of NSAIDs in these patients should be cautious. People who are allergic to other NSAIDs, including aspirin, should not use ibuprofen. Individuals with asthma are more likely to experience allergic reactions to ibuprofen and other NSAIDs. Fluid retention (edema), blood clots, heart attacks, hypertension and heart failure have also been associated with the use of NSAIDs.
ketoprofen
GENERIC NAME: ketoprofen
BRAND NAMES: Orudis, Oruvail
DRUG CLASS AND MECHANISM: Ketoprofen is a nonsteroidal anti-inflammatory drug (NSAID) effective in treating fever, pain, and inflammation in the body. As a group, NSAIDs are non-narcotic relievers of mild to moderate pain of many causes, including injury, menstrual cramps, arthritis, and other musculoskeletal conditions. Since the response to different NSAIDs varies from patient to patient, it is not unusual for a doctor to try different NSAIDs for any given condition.
PRESCRIPTION: yes; except for 12.5mg dose
GENERIC AVAILABLE: yes
PREPARATIONS: capsules: 12.5mg, 25mg, 50mg, 75mg; Oruvail (extended-release capsules): 100mg, 150mg, 200mg
STORAGE: Store at room temperature, sealed container, avoid moisture. Protect from excessive heat.
PRESCRIBED FOR: Ketoprofen is used for the treatment of inflammation and pain caused by rheumatoid arthritis and osteoarthritis, as well as soft tissue injuries, such as tendinitis and bursitis. Orudis is immediately released into the blood and is also used for rapid relief of mild to moderate pain and menstrual cramps. Oruvail is slowly released into the blood and is generally not useful in situations where prompt pain relief is desired.
DOSING: Should be taken with food.
DRUG INTERACTIONS: Ketoprofen should be avoided by patients with a history of asthma attacks, hives, or other allergic reactions to aspirin or other NSAIDs. Rare but severe allergic reactions have been reported in such individuals. It also should be avoided by patients with peptic ulcer disease or poor kidney function, since this medication can aggravate both conditions.
Ketoprofen is generally used with caution in patients taking blood thinning medications (anticoagulants), such as warfarin (Coumadin), because of an increased risk of bleeding. Patients taking cyclosporine (Sandimmune) can develop kidney toxicity. Probenecid (Benemid), used to reduce elevated uric acid levels, can cause ketoprofen blood levels to elevate. Simultaneous use is therefore avoided.
Ketoprofen is not recommended in children as it has not been adequately studied in younger patients. Ketoprofen is not habit forming. NSAIDs should be discontinued prior to elective surgery because of a mild tendency to interfere with blood clotting. Ketoprofen is best discontinued at least two days in advance of the procedure.
Persons who have more than 3 alcoholic beverages per day are at increased risk of developing stomach ulcers when taking ketoprofen or other NSAIDs.
PREGNANCY: Ketoprofen is generally avoided during pregnancy.
NURSING MOTHERS: Ketoprofen is generally avoided in nursing mothers.
SIDE EFFECTS: Most patients benefit from ketoprofen and other NSAIDs with few side effects. However, serious side effects can occur, and generally tend to be dose related. Therefore, it is often desirable to use the lowest effective dose to minimize side effects. The most common side effects of ketoprofen involve the gastrointestinal system. It can cause ulcerations, abdominal burning, pain, cramping, nausea, gastritis, and even serious gastrointestinal bleeding and liver toxicity. Sometimes, stomach ulceration and bleeding can occur without any abdominal pain. Black tarry stools, weakness, and dizziness upon standing may be the only signs of internal bleeding. Rash, kidney impairment, ringing in the ears, and lightheadedness can also occur.
warfarin
GENERIC NAME: warfarin
BRAND NAME: Coumadin
DRUG CLASS AND MECHANISM: Coumadin is an oral anticoagulant that inhibits the synthesis of clotting factors, thus preventing blood clot formation. Blood clots can occur in the veins of the lower extremities, usually after periods of immobility. These clots can break off and become lodged in the blood vessels of the lung (pulmonary embolism), causing shortness of breath, chest pain, and even life-threatening shock. Blood clots can also occur in the atria of the heart during atrial fibrillation (see Atrial Fibrillation article), and around artificial heart valves. One of these clots can also break off and obstruct a blood vessel in the brain, causing an embolic stroke with paralysis. Coumadin is important in preventing the formation of blood clots. It is also important to prevent extension of clots already formed, and to minimize the risk of blood clot embolization to other vital organs such as the lungs and brain.
PRESCRIPTION: yes
GENERIC AVAILABLE: yes
PREPARATIONS: tablets (1mg, 2mg, 2.5mg, 5mg, 7.5mg, 10mg)
STORAGE: Store at room temperature in tight, light resistant container.
PRESCRIBED FOR: Coumadin is used in treating patients with blood clots in the lower extremities to prevent extension of the clot, and to reduce the risk of pulmonary embolism. Patients with pulmonary embolism are treated with Coumadin to prevent further blood clot emboli. Coumadin is also used in patients with atrial fibrillation and artificial heart valves to reduce the risk of strokes. It is also helpful in preventing blood clot formation in certain orthopedic surgeries such as knee or hip replacements. Coumadin is also used in preventing blood clot closure of coronary artery stents.
DOSING: Coumadin may be taken with or without food. Since Coumadin is metabolized by the liver and excreted by the kidneys, dosages need to be lowered in patients with liver and kidney dysfunction. Frequent blood tests are performed to measure blood clotting time (protime) during Coumadin treatment. Protime results help doctors adjust medication dose to avoid excessive blood thinning and risk of bleeding.
DRUG INTERACTIONS: Many drugs, both prescription and nonprescription (OTC), can affect the anticoagulant action of Coumadin. Some medications can enhance the action of Coumadin and cause excessive blood thinning and life-threatening bleeding. A few examples of such medications include Aspirin, Tylenol, alcohol, ibuprofen (Motrin), cimetidine (Tagamet), oxandrolone (Oxandrin), certain vitamins, and antibiotics. Patients on Coumadin should regularly consult their doctor before instituting any medications on their own. It is also advisable for patients on Coumadin to carry identifications to alert other health professionals.
PREGNANCY: Coumadin should be avoided by pregnant women or women who may become pregnant. Birth defects and fetal bleeding have been reported.
SIDE EFFECTS: The two most serious side effects are bleeding and necrosis (gangrene) of the skin. Bleeding can occur in any organ or tissue. Bleeding around the brain can cause severe headache and paralysis. Bleeding in the joints can cause joint pain and swelling. Bleeding in the stomach or intestines can cause weakness, fainting spells, black tarry stools, vomiting of blood, or coffee ground material. Bleeding in the kidneys can cause back pain and blood in urine. Other side effects include purple, painful toes, rash, hair loss, bloating, diarrhea, and jaundice (yellowing of eyes and skin). Signs of overdose include bleeding gums, bruising, nosebleeds, heavy menstrual bleeding, and prolonged bleeding from cuts.
cimetidine
GENERIC NAME: cimetidine
BRAND NAME: Tagamet
DRUG CLASS AND MECHANISM: Cimetidine belongs to a class of medications called histamine H2-antagonists. Histamine is a natural chemical that stimulates stomach cells to produce acid. Histamine H2-antagonists inhibit the action of histamine on the acid-producing cells of the stomach and reduce stomach acid. Cimetidine was approved by the FDA in 1977.
PRESCRIPTION: Yes
GENERIC AVAILABLE: Yes
PREPARATIONS: Tablets: 200, 300, 400, and 800 mg. Liquid: 300 mg/5 mL. Injection: 150 mg/mL.
STORAGE: Store at room temperature 15-30캜 (59-86캟).
PRESCRIBED FOR: Cimetidine is used for the treatment of duodenal ulcers, active gastric ulcers, gastroesophageal reflux disease (GERD), pathological hypersecretory conditions (e.g., Zollinger Ellison syndrome), heartburn and the prevention of gastrointestinal bleeding.
DOSING:
- Duodenal ulcers are treated with 800 mg at bedtime, 300 mg 4 times a day at meal times and bedtime, or 400 mg twice a day for 4-6 weeks. Maintenance therapy is 400 mg at bedtime.
- Active gastric ulcers are treated with 800 mg at bedtime or 300 mg 4 times a day at meal times and bedtime for up to 8 weeks.
- The regimen for GERD is 800 mg twice a day or 400 mg 4 times a day for 12 weeks.
- Pathological hypersecretory conditions are treated with 300 mg 4 times daily up to 2400 mg daily.
- Heartburn, indigestion and sour stomach may be treated with 200 mg once or twice daily and may be administered up to 30 minutes before ingestion of food or beverages that may cause heart burn.
- For hospitalized patients who cannot take oral medications, 300 mg of cimetidine may be administered by intravenous or intramuscular injection every 6-8 hours. A continuous intravenous infusion of 37.5 to 50 mg/hour also may be used.
DRUG INTERACTIONS: Cimetidine may increase the blood levels of several drugs by reducing their elimination by the liver. This interaction may occur between cimetidine and warfarin (Coumadin), a commonly used blood thinning agent. Patients taking both medications should have frequent blood monitoring to avoid accumulation of high levels of warfarin leading to excessive blood thinning and bleeding. Cimetidine also may increase the blood levels phenytoin, theophylline, lidocaine, amiodarone, metronidazole, loratadine, calcium channel blockers (e.g., diltiazem, felodipine, nifedipine), bupropion, carbamazepine and fluvastatin. Because cimetidine reduces stomach acid, it may reduce the absorption of drugs (e.g., ketoconazole) that are best absorbed in acidic conditions. Such drugs should be administered at least 2 hours before the administration of cimetidine.
PREGNANCY: There are no adequate studies of cimetidine in pregnant women.
NURSING MOTHERS: Cimetidine is excreted in breast milk.
SIDE EFFECTS: Side effects due to cimetidine are rare and generally reversible once the medication is stopped. Minor side effects include constipation, diarrhea, fatigue, headache, insomnia, muscle pain, nausea, and vomiting. Major side effects include confusion and hallucinations (usually in elderly or critically ill patients); enlargement of the breasts; impotence (usually seen in patients on high doses for prolonged periods); decreased white blood cell counts. Other side effects include irregular heartbeat, impotence, rash, visual changes, allergic reactions, and hepatitis.
ketoconazole
GENERIC NAME: ketoconazole
BRAND NAME: Nizoral
DRUG CLASS AND MECHANISM: Ketoconazole is an antifungal medication. Fungi are organisms normally found on the skin and in moist areas of the body. When the skin is injured or chronically moistened, or normal bacteria flora of the body are altered due to prolonged antibiotic treatment, fungus can proliferate to cause inflammation of the skin or moist body areas. Fungus organisms can also infect the lungs and other body tissues especially in patients with weakened immune systems.
PRESCRIPTION: yes
GENERIC AVAILABLE: yes
PREPARATIONS: Tablets: 200 mg; Shampoo: 2%; Cream:2%.
STORAGE: Ketoconazole tablets: store at 59-86degrees F, protect from moisture. Ketaconazole shampoo: store at a temperature not above 77 degrees F, protect from light.
PRESCRIBED FOR: Ketoconazole is used to treat a variety of fungal infections. Examples of these fungal infections include candida infections of the skin or mouth (thrush), blastomycosis, histoplasmosis, coccidiomycosis, and others. Ketoconazole is also used to treat fungal infections that have not responded to griseofulvin, another antifungal medication.
DOSING: Ketoconazole may be taken with or without food. Ketoconazole tablets need the acidity of the stomach to dissolve. Therefore, ketoconazole should be administered at least two hours before taking antacids or acid-inhibiting medications (such as Tagamet or Zantac).
Ketoconazole should be avoided by patients with liver dysfunction. Signs of liver problems include unusual fatigue, loss of appetite, nausea and vomiting, yellowing of the skin (jaundice), dark urine, and pale stools. Development of these symptoms while taking ketoconazole should be reported to the physician.
DRUG INTERACTIONS: Ketoconazole should not be administered together with antihistamines terfenadine (Seldane) and astemizole (Hismanal), or with cisapride (Propulsid), because of increased risk of serious heart side effects. Ketoconazole should not be taken with the sedative triazolam (Halcion), because of risk of excessive sedation. Digoxin (Lanoxin) and phenytoin (Dilantin) levels should be monitored when taking ketoconazole. Tuberculosis medications INH and rifampin lower the blood levels of ketoconazole. Ketoconazole taken with alcohol can cause flushing, rash, swelling, headache, and nausea. Ketoconazole shampoo can irritate the eyes, and should be used with caution. Ketoconazole is avoided in children.
PREGNANCY: Ketoconazole is avoided during pregnancy.
NURSING MOTHERS: Ketoconazole is avoided in nursing mothers.
SIDE EFFECTS: Ketoconazole is generally well tolerated. Ketoconazole can cause rash, itching, nausea and/or vomiting, abdominal pain, headache, dizziness, fatigue, impotence, and blood count abnormalities. Rarely, ketoconazole has caused a reaction resulting in serious lowering of the blood pressure and shock (anaphylaxis). Also rarely, ketoconazole has caused severe depression, hair loss, and tingling sensations. Ketoconazole shampoo has been reported to result in loss of curl of permanently waved hair.
phenytoin
GENERIC NAME: phenytoin
BRAND NAME: Dilantin
DRUG CLASS AND MECHANISM: Phenytoin is an oral and injectable anti-seizure medication first synthesized in 1908. Phenytoin was originally approved by the FDA in 1939.
PRESCRIPTION: yes
GENERIC AVAILABLE: yes, but not recommended.
PREPARATIONS: Tablets (triangular; yellow), 50mg; capsules (white with colored band): 30mg (pink band); 100mg (red band). It also is available as a suspension (125mg per 5mL).
STORAGE: Tablets, capsules, and suspension should be kept at room temperature, 15-30캜 (59-86캟).
PRESCRIBED FOR: Although it has been used in many conditions, phenytoin’s only approved use is as an anti-seizure medication (anticonvulsant), especially to prevent tonic-clonic (grand mal) seizures and complex partial seizures (psychomotor seizures). It may be used alone or with phenobarbital or other anticonvulsants.
DOSING: The dosing of phenytoin is very patient- specific. It may be given once, twice, or three times daily. Doses are often adjusted to find the optimal dose, based on measurement of blood levels. Taking phenytoin with food may reduce some of the side effects. Elderly patients, debilitated persons, and patients with certain kidney or liver diseases may need lower doses. The suspension should not be given at the same time as tube feedings.
DRUG INTERACTIONS: There are many potential drug interactions with phenytoin. Phenytoin can increase the metabolism (elimination) of many drugs, reducing their concentrations in the body. Drugs that may be affected include: digoxin, carbamazepine, clonazepam, corticosteroids (e.g. prednisone), cyclosporine, disopyramide, doxycycline, estrogens, felodipine, levodopa, lidocaine, methadone, mexiletine, oral contraceptives, paroxetine, quinidine, tacrolimus, theophylline, phenobarbital, and warfarin. Phenytoin can interact with these drugs not only when it is added to therapy but also when it is discontinued. In the latter case, the concentration of the other drugs may increase.
Phenytoin’s metabolism may be affected by other drugs. Drugs that can reduce the amount of phenytoin in the body include rifampin and phenobarbital. Drugs that increase phenytoin concentrations include amiodarone, chloramphenicol, cimetidine, disulfiram, fluconazole, fluoxetine, isoniazid (INH), omeprazole, and paroxetine. Thus, measuring levels of phenytoin in the blood may be necessary when patients begin or discontinue other medications.
The oral absorption of phenytoin can be reduced by any of the following: antacids containing magnesium, calcium carbonate, or aluminum; calcium salts; or enteral feeding products (tube feedings). Separating the administration of phenytoin and enteral feeding products, antacids, or calcium salts by at least 2 hours will help avoid this interaction.
PREGNANCY: There appears to an increased risk of malformations and birth defects in women taking phenytoin. Thus phenytoin should be used in pregnancy only if the physician feels that the potential benefit outweighs the risk.
NURSING MOTHERS: Phenytoin is secreted into breast milk. Nursing is not recommended for persons taking phenytoin.
SIDE EFFECTS: Many varied adverse effects can occur during phenytoin therapy including dizziness, drowsiness, difficulty focusing (vision), unsteady gate, tiredness, abnormal involuntary movements, nausea, vomiting, constipation, abdominal pain, and loss of appetite. Children and young adults can develop overgrowth of the gums during long-term therapy which requires regular treatment by a dentist. Good oral hygiene and gum massage may reduce the risk. Rashes can occur in between 1 in 20 and 1 in 10 persons; some may be severe. Additionally, darkening coloration of the skin may develop (more commonly in women). Phenytoin can produce unusual growth of hair in some patients. This reaction most commonly affects the arms and legs but can also affect the trunk and face; it may be irreversible.
Various lymph node reactions have been reported with phenytoin therapy. Lymph nodes may swell up, sometimes painfully. Phenytoin cause serum glucose to rise. Thus, blood sugar should be monitored closely when phenytoin is administered to patients with diabetes. Phenytoin can potentially injure the liver although this is an uncommon occurrence. Phenytoin can cause the platelet or white blood cell counts to drop, increasing the risk of bleeding or infection, respectively. Phenytoin also can cause anemia. Because it interferes with vitamin D metabolism, phenytoin can cause weakening of the bones (osteomalacia). Phenytoin can cause sexual dysfunction including decreased libido, impotence, and priapism (painful, prolonged erections).
prednisone
GENERIC NAME: prednisone
BRAND NAME: Deltasone, Orasone, Prednicen-M, Liquid Pred
DRUG CLASS AND MECHANISM: Prednisone is an oral, synthetic (man-made) corticosteroid used for suppressing the immune system and inflammation. It has effects similar to other corticosteroids such as triamcinolone (Kenacort), methylprednisolone (Medrol), prednisolone (Prelone) and dexamethasone (Decadron). These synthetic corticosteroids mimic the action of cortisol (hydrocortisone), the naturally-occurring corticosteroid produced in the body by the adrenal glands. Corticosteroids have many effects on the body, but they most often are used for their potent anti-inflammatory effects, particularly in those conditions in which the immune system plays an important role. Such conditions include arthritis, colitis, asthma, bronchitis, certain skin rashes, and allergic or inflammatory conditions of the nose and eyes. Prednisone is inactive in the body and, in order to be effective, first must be converted to prednisolone by enzymes in the liver. Therefore, prednisone may not work as effectively in people with liver disease whose ability to convert prednisone to prednisolone is impaired
PRESCRIPTION: yes
GENERIC AVAILABLE: yes
PREPARATIONS: Tablets of 2.5, 5, 10, 20, and 50 mg. Oral solution or syrup of 5mg/5ml
STORAGE: Store at room temperature 20-25캜 (68-77캟), and keep away from moisture.
PRESCRIBED FOR: Prednisone is used in the management of inflammatory conditions or diseases in which the immune system plays an important role. Since prednisone is used in so many conditions, only the most common or established uses are mentioned here. Prednisone most often is used for treating several types of arthritis, ulcerative colitis, Crohn’s disease, systemic lupus, allergic reactions, asthma and severe psoriasis. It also is used for treating leukemias, lymphomas, idiopathic thrombocytopenic purpura and autoimmune hemolytic anemia. Corticosteroids, including prednisone, are commonly used to suppress the immune system and prevent the body from rejecting transplanted organs. Prednisone is used as replacement therapy in patients whose adrenal glands are unable to produce sufficient amounts of cortisol.
DOSING: The initial dose of prednisone varies depending on the condition being treated and the age of the patient. The starting dose may be from 5 to 60 mg per day and often is adjusted based on the response of the condition being treated. Corticosteroids typically do not produce immediate effects and must be used for several days before maximal effects are seen. It may take much longer before conditions respond to treatment. Prolonged therapy with prednisone causes the adrenal glands to atrophy and stop producing cortisol. When prednisone is discontinued after a period of prolonged therapy, the dose of prednisone must be tapered (lowered gradually) to allow the adrenal glands time to recover. (See side effects.) It is recommended that prednisone be taken with food.
DRUG INTERACTIONS: Prednisone may interact with estrogens and phenytoin (Dilantin). Estrogens may reduce the action of enzymes in the liver that break down (eliminate) the active form of prednisone, prednisolone. As a result, the levels of prednisolone in the body may increase and lead to more frequent side effects. Phenytoin increases the activity of enzymes in the liver that break down (eliminate) prednisone and thereby may reduce the effectiveness of prednisone. Thus, if phenytoin is being taken, an increased dose of prednisone may be required.
PREGNANCY: Corticosteroids cross the placenta into the fetus. Compared to other corticosteroids, however, prednisone is less likely to cross the placenta. Chronic use of corticosteroids during the first trimester of pregnancy may cause cleft palate.
NURSING MOTHERS: Corticosteroids are secreted in breast milk and can cause side effects in the nursing infant. Prednisone is less likely than other corticosteroids to be secreted in breast milk, but it may still pose a risk to the infant.
SIDE EFFECTS: Side effects of prednisone and other corticosteroids range from mild annoyances to serious, irreversible damage, and they occur more frequently with higher doses and more prolonged treatment. Side effects include retention of sodium (salt) and fluid, weight gain, high blood pressure, loss of potassium, headache and muscle weakness. Prednisone also causes puffiness of the face (moon face), growth of facial hair, thinning and easy bruising of the skin, impaired wound healing, glaucoma, cataracts, ulcers in the stomach and duodenum, worsening of diabetes, irregular menses, rounding of the upper back (”buffalo hump”), obesity, retardation of growth in children, convulsions, and psychiatric disturbances. The psychiatric disturbances include depression, euphoria, insomnia, mood swings, personality changes, and even psychotic behavior.
Prednisone suppresses the immune system and, therefore, increases the frequency or severity of infections and decreases the effectiveness of vaccines and antibiotics. Prednisone may cause osteoporosis that results in fractures of bones. Patients taking long-term prednisone often receive supplements of calcium and vitamin D to counteract the effects on bones. Calcium and vitamin D probably are not enough, however, and treatment with bisphosphonates such as alendronate (Fosamax) and risedronate (Actonel) may be necessary. Calcitonin (Miacalcin) also is effective. The development of osteoporosis and the need for treatment can be monitored using bone density scans.
Prolonged use of prednisone and other corticosteroids causes the adrenal glands to atrophy (shrink) and stop producing the body’s natural corticosteroid, cortisol. If prednisone is abruptly withdrawn after prolonged use, the adrenal glands are unable to produce enough cortisol to compensate for the withdrawal, and symptoms of corticosteroid insufficiency (adrenal crisis) may occur. These symptoms include nausea, vomiting and shock. Therefore, prednisone should be discontinued gradually so that the adrenal glands have time to recover and resume production of cortisol. Until the glands fully recover, it may be necessary to treat patients who have recently discontinued corticosteroids with a short course of corticosteroids during times of stress (infection, surgery, etc.), times when corticosteroids are particularly important to the body.
A serious complication of long-term use of corticosteroids is aseptic necrosis of the hip joints. Aseptic necrosis is a condition in which there is death and degeneration of the hip bone. It is a painful condition that ultimately can lead to the need for surgical replacement of the hip. Aseptic necrosis also has been reported in the knee joints. The estimated incidence of aseptic necrosis among long-term users of corticosteroids is 3-4%. Patients taking corticosteroids who develop pain in the hips or knees should report the pain to their doctors promptly.
dexamethasone, oral
GENERIC NAME: dexamethasone, oral
BRAND NAME: Decadron
DRUG CLASS AND MECHANISM: Dexamethasone is a synthetic adrenal corticosteroid. Corticosteroids are natural substances produced by the adrenal glands located adjacent to the kidneys. Corticosteroids have potent anti-inflammatory properties, and are used in a wide variety of inflammatory conditions such as arthritis, colitis, asthma, bronchitis, certain skin rashes, and allergic or inflammatory conditions of the nose and eyes. There are numerous preparations of corticosteroids, including oral tablets, capsules, liquids, topical creams and gels, inhalers and eye drops, and injectable and intravenous solutions. Dexamethasone that is prescribed in oral tablet form is addressed in this article.
Dosage requirements of corticosteroids vary among individuals and diseases being treated. In general, the lowest possible effective dose is used. Corticosteroids given in multiple doses throughout the day are more effective, but also more toxic, than if the same total dose is given once daily, or every other day.
PRESCRIPTION: yes
GENERIC AVAILABLE: yes
PREPARATIONS: tablets: .25mg, .5mg, .75mg, 1.5mg, 4mg, 6mg
STORAGE: Store at room temperature, sealed container.
PRESCRIBED FOR: Dexamethasone is used to achieve prompt suppression of inflammation in many conditions. Some examples include rheumatoid arthritis, systemic lupus, acute gouty arthritis, psoriatic arthritis, ulcerative colitis, and Crohn’s disease. Severe allergic conditions that fail conventional treatment may also respond to dexamethasone. Examples include bronchial asthma, allergic rhinitis, drug-induced dermatitis, and contact and atopic dermatitis. Chronic skin conditions treated with dexamethasone include dermatitis herpetiformis, pemphigus, severe psoriasis and severe seborrheic dermatitis. Chronic allergic and inflammatory conditions of the uvea, iris, conjunctiva and optic nerves of the eyes are also treated with dexamethasone.
Dexamethasone is also used in the treatment of blood cell cancers (leukemias), and lymph gland cancers (lymphomas). Blood diseases involving destruction of platelets by the body’s own immune cells (idiopathic thrombocytopenia purpura), and destruction of red blood cells by immune cells (autoimmune hemolytic anemia) can also be treated with dexamethasone. Other miscellaneous conditions treated with this medication include thyroiditis and sarcoidosis. Finally, dexamethasone is used as a hormone replacement in patients whose adrenal glands are unable to produce sufficient amounts of corticosteroids.
DOSING: Should be taken with food.
DRUG INTERACTIONS: Prolonged use of dexamethasone can depress the ability of body’s adrenal glands to produce corticosteroids. Abruptly stopping dexamethasone in these individuals can cause symptoms of corticosteroid insufficiency, with accompanying nausea, vomiting and even shock. Therefore, withdrawal of dexamethasone is usually accomplished by gradual tapering. Gradually tapering dexamethasone not only minimizes the symptoms of corticosteroid insufficiency, it also reduces the risk of an abrupt flare of the disease under treatment.
Dexamethasone and other corticosteroids can mask signs of infection and impair the body’s natural immune response to infection. Patients on corticosteroids are more susceptible to infections, and can develop more serious infections than healthy individuals. For instance, chicken pox and measles viruses can produce serious and even fatal illnesses in patients on high doses of dexamethasone. Live virus vaccines, such as small pox vaccine, should be avoided in patients taking high doses of dexamethasone, since even vaccine viruses may cause disease in these patients. Some infectious organisms, such as tuberculosis (TB) and malaria, can remain dormant in a patient for years. Dexamethasone and other corticosteroids can reactivate dormant infections in these patients and cause serious illnesses. Patients with dormant tuberculosis may require anti- TB medications while undergoing prolonged corticosteroid treatment.
By interfering with the patient’s immune response, dexamethasone can impede the effectiveness of vaccinations. Dexamethasone can also interfere with the tuberculin (TB) skin test and cause false negative results in patients with dormant tuberculosis infection.
Dexamethasone impairs calcium absorption and new bone formation. Patients on prolonged treatment with dexamethasone and other corticosteroids can develop osteoporosis and an increased risk of bone fractures. Supplemental calcium and vitamin D are encouraged to slow this process of bone thinning. In rare individuals, destruction of large joints can occur while undergoing treatment with dexamethasone or other corticosteroids. These patients experience severe pain in the involved joints, and can require joint replacements. The reason behind such destruction is not clear.
PREGNANCY: Dexamethasone can be used in pregnancy, but is generally avoided.