DRUG STUDY

ARTHRITIS

 DRUG
Generic Name: Acetaminophen

Brand Name: Tylenol

Therapeutic Class: Antipyretic, Analgesic (nonopioid)

 DOSAGE, ROUTE AND FREQUENCY

PO or PR
By suppository, 325–650 mg q 4–6 hr or PO, 1,000 mg tid to qid. Do not exceed 4
g/day.

Immediate release

Regular strength: 325-650 mg orally/rectally once every 4 hours as needed; not to

exceed 3250 mg/day; under supervision of healthcare professional, daily doses of up
to 4 g/day may be used
Extra Strength: 1000 mg orally once every 6-8 hours as needed; not to exceed 3000
mg/day; under supervision of healthcare professional, daily doses of up to 4 g/day
may be used

Extended release

2 capsules (1300 mg) orally once every 8 hours as needed; not to exceed 3.9 g/day

 MECHANISM OF ACTION
Acetaminophen, also called N-acetyl para-aminophenol or paracetamol, is one of the
most widely used over-the-counter analgesic and antipyretic agents.[1] Although its
exact mechanism of action remains unclear, it is historically categorized along with
NSAIDs because it inhibits the cyclooxygenase (COX) pathways.[2][3] Like NSAIDs,
acetaminophen has analgesic and antipyretic properties. However, studies have
shown that acetaminophen lacks peripheral anti-inflammatory properties. It may be
that acetaminophen inhibits the COX pathway in the central nervous system but not
peripheral tissues. Additionally, acetaminophen does not appear to bind to the active
site of either the COX-1 or COX-2 enzyme, instead of reducing the activity of COX by
a different mechanism. It also has been theorized that acetaminophen inhibits a
splice variant of COX-1, also called COX-3, but this has not been confirmed to occur
in humans.[4] Regardless, the reduction of the COX pathway activity by
acetaminophen is thought to inhibit the synthesis of prostaglandins in the central
nervous system, leading to its analgesic and antipyretic effects. The analgesic
properties may be due to a stimulating effect on the descending serotonergic
pathways in the central nervous system (CNS). Other studies have suggested that
acetaminophen or one of its metabolites also can activate the cannabinoid system,
contributing to its analgesic action.

 DRUG INTERACTIONS
There are no severe interactions with acetaminophen and other drugs.

There are no serious interactions with acetaminophen and other drugs.

 Moderate Interactions of acetaminophen include:

 Axitinib
 Busulfan
 Daclizumab
 dapsone topical
 eltrombopag
 exenatide injectable solution
 exenatide injectable suspension
 flibanserin
 imatinib
 isoniazid
 ivacaftor
 lixisenatide
 lomitapide
 mipomersen
 tetracaine
 warfarin

 ADVERSE EFFECTS
CNS: Headache
CV: Chest pain, dyspnea, myocardial damage when doses of 5–8 g/day are
ingested daily for several weeks or when doses of 4 g/day are ingested for
1yr
GI: Hepatic toxicity and failure, jaundice
GU: Acute kidney failure, renal tubular necrosis
Hematologic: Methemoglobinemia—cyanosis; hemolytic anemia—hematuria,
anuria; neutropenia, leukopenia, pancytopenia, thrombocytopenia,
hypoglycemia
Hypersensitivity: Rash, fever

 NURSING RESPONSIBILITIES
Before:
 History: Allergy to acetaminophen, impaired hepatic function, chronic alcoholism,
pregnancy, lactation
 Physical: Skin color, lesions; T; liver evaluation; CBC, LFTs, renal function tests.

During:
 Safe administration.
 monitoring for efficacy

After:
 Educate the patient not exceed recommended dose; do not take for longer than 10
days.
 Inform the patientTake the drug only for complaints indicated; it is not an anti-
inflammatory agent.
 Take the drug only for complaints indicated; it is not an anti-inflammatory agent.

Reference:
Gerriets V, Anderson J, Nappe TM. Acetaminophen. [Updated 2020 Aug 11]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK482369/
Acetaminophen (Tylenol): Side Effects, Dosages, Treatment, Interactions, Warnings.
(2017a, April 14). RxList. https://www.rxlist.com/consumer_acetaminophen_tylenol/drugs-
condition.htm#what_other_drugs_interact_with_acetaminophen

DRUG STUDY

ARTHRITIS

 DRUG
Generic Name: Naproxen Sodium

Brand Name: Aleve, Anaprox, Naprosyn

Therapeutic Class: Nonsteroidal anti-inflammatory drug (NSAID)

 DOSAGE, ROUTE AND FREQUENCY

The usual adult dose for pain is 250 every 6 to 8 hours or 500 mg twice daily using
regular naproxen tablets. The usual dose for Naprelan controlled release tablets is
750 to 1000 mg given once daily. For EC-Naprosyn, the usual dose is 375-500 mg
twice daily.

Naproxen should be given with food to reduce upset stomach. The dose for
rheumatoid arthritis, osteoarthritis, or ankylosing spondylitis is 500 to 1000 mg every
12 hours.

 MECHANISM OF ACTION
Naproxen blocks arachidonate binding to competitively inhibit both cyclooxygenase
(COX) isoenzymes, COX-1 and COX-2, resulting in analgesic and anti-inflammatory
effects. COX-1 and COX-2 are catalysts of arachidonic acid conversion to
prostaglandin G (PGG), the first step of the synthesis of prostaglandins and
thromboxanes that are involved in rapid physiological responses. COX-1 is
constitutively expressed in most tissues, while COX-2 is only expressed in the brain,
kidney, bones, reproductive organs, and select tumors such as in colon and prostate
cancers. COX-1 is responsible for prostaglandin synthesis in response to stimulation
by circulating hormones, as well as maintenance of healthy renal function, gastric
mucosal integrity, and hemostasis. COX-2 is inducible in many cells in response to
specific mediators of inflammation (e.g., interleukin-1, tumor necrosis factor,
lipopolysaccharide).

 DRUG INTERACTIONS
Some products that may interact with this drug are: aliskiren, ACE inhibitors (such as
captopril, lisinopril), angiotensin II receptor blockers (such as losartan, valsartan),
cidofovir, corticosteroids (such as prednisone), lithium, "water pills" (diuretics such as
furosemide).

This medication may increase the risk of bleeding when taken with other drugs that
also may cause bleeding. Examples include anti-platelet drugs such as clopidogrel,
"blood thinners" such as dabigatran/enoxaparin/warfarin, among others.

 ADVERSE EFFECTS
The more common side effects that occur with naproxen oral tablet include:
 stomach pain
 constipation
  diarrhea
 gas
 heartburn
 nausea and vomiting
 dizziness

Mild side effects may go away within a few days or a couple of weeks. Talk to your
doctor or pharmacist if they’re more severe or don’t go away.

Serious side effects and their symptoms can include the following:
 chest pain
 shortness of breath or trouble breathing
 weakness in one part or side of your body
 difficulty speaking
 swelling of the face or throat
 high blood pressure
 bleeding and ulcers in your stomach and intestines, with symptoms such as:
 stomach pain
 bloody vomit
 blood in your stool
 black and sticky stool
 asthma attacks in people who have asthma
 low red blood cell count, which can cause fatigue, lethargy, and
weakness
 yellowing of your skin or the whites of your eyes
 unusual weight gain or swelling of your arms, legs, hands, and feet
 skin rash or blisters with fever

 NURSING RESPONSIBILITIES
Before:
Assessment
 History: Allergy to naproxen, salicylates, other NSAIDs; asthma, chronic urticaria,
CV dysfunction; hypertension; GI bleeding; peptic ulcer; impaired hepatic or renal
function; pregnancy; lactation
 Physical: Skin color and lesions; orientation, reflexes, ophthalmologic and
audiometric evaluation, peripheral sensation; P, BP, edema; R, adventitious
sounds; liver evaluation; CBC, clotting times, LFTs, renal function tests; serum
electrolytes; stool guaiac

During:
 Be aware that patient may be at increased risk for CV event, GI bleeding; monitor
accordingly.
 Give with food or after meals if GI upset occurs.
 Arrange for periodic ophthalmologic examination during long-term therapy.
 WARNING: If overdose occurs, institute emergency procedures—gastric lavage,
induction of emesis, supportive therapy.

After:
Teaching points
 Take drug with food or meals if GI upset occurs; take only the prescribed dosage.
 Dizziness, drowsiness can occur (avoid driving or the use of dangerous
machinery).
  Report sore throat; fever; rash; itching; weight gain; swelling in ankles or fingers;
changes in vision; black, tarry stools.

Reference:
University of Illinois. (2018, October 9). Naproxen, Oral Tablet. Healthline.
https://www.healthline.com/health/naproxen-oral-tablet#interactions

L., R. (2019, February 13). naproxen Nursing Considerations & Management. RNpedia.
https://www.rnpedia.com/nursing-notes/pharmacology-drug-study-notes/naproxen/

DRUG STUDY

ARTHRITIS

 DRUG
Generic Name: Ibuprofen

Brand Name: Advil, Motrin, Nuprin

Therapeutic Class: Nonsteroidal anti-inflammatory drugs (NSAIDs), Analgesic (nonopioid)

 DOSAGE, ROUTE AND FREQUENCY

ADULTS
Do not exceed 3,200 mg/day.

 Mild to moderate pain: 400 mg q 4–6 hr PO.

 Osteoarthritis or rheumatoid arthritis: 1,200–3,200 mg/day PO (300 mg qid or
400, 600, 800 mg tid or qid; individualize dosage. Therapeutic response may
occur in a few days, but often takes 2 wk).
 Primary dysmenorrhea: 400 mg q 4 hr PO.
 OTC use: 200–400 mg q 4–6 hr PO while symptoms persist; do not exceed
1,200 mg/day. Do not take for more than 10 days for pain or 3 days for fever,
unless so directed by health care provider.

 MECHANISM OF ACTION
Ibuprofen is a traditional non-steroidal anti-inflammatory drug (NSAID) widely used
for its analgesic, anti-inflammatory, and antipyretic properties. The main mechanism
of action of ibuprofen is the non-selective, reversible inhibition of the cyclooxygenase
enzymes COX-1 and COX-2 (coded for by PTGS1 and PTGS2, respectively). Of the
two enantiomers, S-ibuprofen is a more potent inhibitor of COX enzymes than R-
ibuprofen, with a stronger inhibitory activity at COX-1 than COX-2 in vitro. COX-1 and
COX-2 catalyze the first committed step in the synthesis of prostanoids -
prostaglandin (PG) E2, PGD2, PGF2alpha, PGI2 (also known as prostacyclin), and
thromboxane (Tx) A2 - from arachidonic acid. Arachidonic acid is released from the
cell membrane phospholipids by phospholipase A2, PLA2, encoded by PLA2G4A
(cytosolic, calcium-dependent) and PLA2G2A (in platelets and synovial fluid).
Arachidonic acid is converted to the unstable intermediate prostaglandin H2 by
cytosolic prostaglandin G/H synthases, termed cyclooxygenases, COX, that exist in
two forms, COX-1 and COX-2, and are encoded by PTGS1 and PTGS2,
respectively. PGH2 is converted by tissue-specific synthases to various prostanoids,
i.e. PGE2, PGD2, PGF2alpha, PGI2, and TxA2. These bioactive lipids act through
their corresponding receptors to trigger a series of biological effects.
 DRUG INTERACTIONS
Some products that may interact with this drug include: aliskiren, ACE inhibitors
(such as captopril, lisinopril), angiotensin II receptor blockers (such as losartan,
valsartan), cidofovir, corticosteroids (such as prednisone), lithium, "water pills"
(diuretics such as furosemide).

This medication may increase the risk of bleeding when taken with other drugs that
also may cause bleeding. Examples include anti-platelet drugs such as clopidogrel,
"blood thinners" such as dabigatran/enoxaparin/warfarin, among others.

Check all prescription and nonprescription medicine labels carefully since many
medications contain pain relievers/fever reducers (including aspirin, NSAIDs such as
celecoxib, ketorolac, or naproxen). These drugs are similar to ibuprofen and may
increase your risk of side effects if taken together. However, if your doctor has
directed you to take low-dose aspirin for heart attack or stroke prevention (usually at
dosages of 81-325 milligrams a day), you should continue taking the aspirin unless
your doctor instructs you otherwise. Daily use of ibuprofen may decrease aspirin's
ability to prevent heart attack/stroke. Talk to your doctor about using a different
medication (such as acetaminophen) to treat pain/fever. If you must take ibuprofen,
talk to your doctor about taking immediate-release aspirin (not enteric-coated/EC)
while taking ibuprofen. Take ibuprofen at least 8 hours before or at least 2 hours after
your aspirin dose. Do not increase your daily dose of aspirin or change the way you
take aspirin/other medications without your doctor's approval.

 ADVERSE EFFECTS
 Oral: Dyspepsia, vomiting, abdominal pain, heartburn, nausea, diarrhoea,
epigastric pain, oedema, fluid retention, dizziness, rash, tinnitus. Parenteral:
Intraventricular haemorrhage, skin irritation, hypocalcaemia, hypoglycaemia,
GI disorders, anaemia, apnoea, respiratory infection, sepsis.
 Potentially Fatal: Severe CV thrombotic events. Severe GI bleeding,
ulceration and perforation.

 NURSING RESPONSIBILITIES
Before:
Assessment
 History: Allergy to ibuprofen, salicylates or other NSAIDs; CV dysfunction,
hypertension; peptic ulceration, GI bleeding; impaired hepatic or renal function;
pregnancy; lactation
 Physical: Skin color, lesions; T; orientation, reflexes, ophthalmologic evaluation,
audiometric evaluation, peripheral sensation; P, BP, edema; R, adventitious sounds;
liver evaluation, bowel sounds; CBC, clotting times, urinalysis, LFTs, renal function
tests, serum electrolytes, stool guaiac

During:
 Be aware that patient may be at increased risk of CV event, GI bleeding, monitor
accordingly.
 Administer drug with food or after meals if GI upset occurs.
 Arrange for periodic ophthalmologic examination during long-term therapy.
 Discontinue drug if eye changes, symptoms of hepatic impairment, or renal
impairment occur.
 WARNING: Institute emergency procedures if overdose occurs: Gastric lavage,
induction of emesis, and supportive therapy.

After:
 Teaching points
 Use drug only as suggested; avoid overdose. Take the drug with food or after meals
if GI upset occurs. Do not exceed the prescribed dosage.
 Avoid over-the-counter drugs. Many of these drugs contain similar medications, and
serious overdosage can occur.
 You may experience these side effects: Nausea, GI upset, dyspepsia (take drug with
food); diarrhea or constipation; drowsiness, dizziness, vertigo, insomnia (use caution
when driving or operating dangerous machinery).
 Report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers,
changes in vision, black or tarry stools.

Reference:
Ibuprofen Nursing Considerations & Management. (2019, February 13). RNpedia.
https://www.rnpedia.com/nursing-notes/pharmacology-drug-study-notes/ibuprofen/

Drugs & Medications. (n.d.). WebMD. https://www.webmd.com/drugs/2/drug-5166-

9368/ibuprofen-oral/ibuprofen-oral/details

DRUG STUDY

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

 DRUG
Generic Name: Levalbuterol Hcl

Brand Name: Xopenex

Therapeutic Class: Bronchodilators

 DOSAGE, ROUTE AND FREQUENCY

ADULT
Nebulizer solution: 0.63 mg 3 times daily at intervals of 6-8 hr; may increase dose to
1.25 mg 3 times daily with close monitoring for adverse effects

Aerosol: 90 mcg (2 actuations of metered-dose inhaler) q4-6hr; 1 actuation q4hr may

be sufficient; not to exceed 2 actuations q4hr

 MECHANISM OF ACTION
Levalbuterol binds to beta-2 adrenergic receptors in bronchial smooth muscle and
activates intracellular adenyl cyclase, an enzyme that catalyzes the conversion of
adenosine triphosphate (ATP) to cyclic-3',5'-adenosine monophosphate (cAMP).

 DRUG INTERACTIONS
Concurrent use or use within 2 weeks of tricyclic antidepressants or MAO inhibitors may ↑
risk of adverse cardiovascular reactions (use with extreme caution).Beta blockers block
the beneficial pulmonary effects of adrenergic bronchodilators (choose cardioselective
beta blockers if necessary and with caution).May ↑ risk of hypokalemia from
potassium- losing diuretics.May ↓ serum digoxin levels.May ↑ risk of arrhythmias with
hydrocarbon inhalationanesthetics or cocaine.Use with caffeine-containing herbs
(guarana, tea, coffee) ↑ stimulant effect.

 ADVERSE EFFECT
 CNS: anxiety, dizziness, headache ,nervousness
Respiratory: paradoxical bronchospasm (excessive use of inhalers) (life-threatening),
increased cough, turbinate edema
Cardiovascular: tachycardia
Gastrointestinal: dyspepsia, vomiting
Endocrinologic: hyperglycemia
Fluid and Electrolyte: hypokalemia
Neurologic: tremor

 NURSING RESPONSIBILITIES
Before:
Assessment:
 Assess lung sounds, pulse, and BP before administration and during peak of
medication. Note amount, color, and character of sputum produced. Closely monitor
patients on higher dose for adverse effects.
 Monitor pulmonary function tests before initiating therapy and periodically during
course to determine effectiveness of medication.
 Observe for paradoxical bronchospasm (wheezing, dyspnea, tightness in chest). If
condition occurs, withhold medication and notify health care provider immediately.
 Lab Test Considerations: May cause ↑ serum glucose and ↓ serum potassium.

During:
 Allow at least 1 min between inhalations of aerosol medication.
 For nebulization, levalbuterol solution does not require dilution prior to administration.
Once the foil pouch is opened, vials must be used within 2 weeks; open vials may be
stored for 1 week. Discard vial if solution is not clear or colorless.
After:
 Instruct patient in the proper use of metered-dose inhaler and nebulizer (see ) and to
take levalbuterol as directed. Caution patient not to exceed recommended dose; may
cause adverse effects, paradoxical bronchospasm, or loss of effectiveness of
medication.
 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 any OTC medications or alcoholic beverages concurrently with this
therapy. Caution patient also to avoid smoking and other respiratory irritants.
 Instruct patient to contact health care professional immediately if shortness of breath
is not relieved by medication or is accompanied by diaphoresis, dizziness,
palpitations, or chest pain.
 Advise patients to use levalbuterol first if using other inhalation medications, and
allow 5 min to elapse before administering other inhalant medications unless
otherwise directed.
 Advise patient to rinse mouth with water after each inhalation dose to minimize dry
mouth.
 Instruct patient to notify health care professional if no response to the usual dose of
levalbuterol.

Reference:
Xopenex (Levalbuterol): Uses, Dosage, Side Effects, Interactions, Warning. (2019, January
14). RxList. https://www.rxlist.com/xopenex-drug.htm#description
Levalbuterol (Inhalation Route) Precautions - Mayo Clinic. (n.d.). MayoClinic.
https://www.mayoclinic.org/drugs-supplements/levalbuterol-inhalation-route/precautions/drg-
20067232?p=1