tag:blogger.com,1999:blog-35140954371174119922024-03-12T16:59:20.346-07:00drugsdrugsqhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.comBlogger26125tag:blogger.com,1999:blog-3514095437117411992.post-503012312304097602013-04-20T23:16:00.000-07:002013-04-20T23:16:07.177-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
So some people, they have it! All they need to do is pass!<br />
<br />
Some people, they pass, but they don't have it!<br />
<br />
Can you just mix them like juice and then stir with a spoon and then, refreshments, they're now delicious.<br />
<br />
Like here, there's petrol, but then, it's hot.<br />
<br />
Other places, like home, weather is nice, but then, people are poor.<br />
<br />
<br />
It's like you can't have it all!<br />
<br />
But then you do meet people, and you think, gosh, they have it all, and you think, it is attainable!<br />
<br />
Like that co-examinee. OMG the youth, the smarts, the wealth, omg where is your imperfection! You can't be perfect, I'm in denial!<br />
<br />
Like a smile and then wham I'm stunned.<br />
<br />
Stupid attraction protocols signalling me, look at what's in front, such a fine specimen.<br />
<br />
Defense mechanism still successful though, but at the same time, what if? What if I pursued it? Am I going to end up old, alone, full of regrets?<br />
<br />
So to dumb things down, make things simple, yes or no, decision was no.<br />
<br />
Cat photos of johar, hmm I like the cat.<br />
<br />
So maybe it's all in a state of mind. Hot is not so hot. It's not that bad. Sure, it's warm, that's why you need to protect yourself.<br />
<br />
So poor, it's not so poor, we're still happy, instead of being glum, poor already, so smile. </div>
qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-66124240501190572352013-04-17T20:58:00.002-07:002013-04-17T20:58:36.588-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
So my patient was taking Fluoxetine. I took care to spell it correctly, with the u and the the letter o. Just like the word fluoride.<br />
<br />
Now, IELTS. I write my essay, and I use the word flourish. OMG I used uo instead of ou for flourish!<br />
<br />
I attribute this mistake from being so cautious in spelling Fluoxetine that when the time came that I needed to spell flourish, I misspelled it. At times like these, when you are faced with an exam, the tensions are high and I tend to think differently. I proofread my essay, but only when the invigilator said that the time was up did I realize my mistake. I can't touch my pencil!<br />
<br />
So I'm taking a hit for that.<br />
<br />
I researched online, and some website mentioned that a grade of 9 for writing allows for 1 misspelling.<br />
<br />
I honestly don't know what grade they're going to give me. I might be damned in hell for writing the way I did, with a long sentence structure and complex run-on sentences. If they lifted it off my paper and write it in Word, I think red would appear, as Word is imperfect and sometimes gives that.<br />
<br />
Maybe they want the test takers to write easy essays so that they can grade it easily.<br />
<br />
Ah, I see, they will give me a bad grade so that I'll spread the message to everyone, through word of mouth, to avoid creating overly convoluted essays.<br />
<br />
Tomorrow, results. <br />
<br />
<br /></div>
qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-39801053781911441912012-09-29T00:25:00.002-07:002012-09-29T00:25:47.502-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
So six or seven capsules of vitamins in the drawer. I forgot about them. Was spacing them out, didn't want them to be finished quickly. But knew they were there. Just didn't bother taking them. Haven't been feeling the need to take them. Except for vitamin C. Feels like my gums have scurvy. Why are they retreating? And even after an orange, they seem to inch forward again, but after a while, or in no time at all, they feel sparse again. Is that normal? Did gums just grow like that, into adult form, or is it scurvy? Like you could tell where they were once, an arc on the teeth.<br />
<br />
Just not aggressive enough to eat oranges. Hate dirtying fingers, and then touching mouse or keyboard with it. Maybe I could peel it using plastic?<br />
<br />
I do like the taste when it's sweet ^_^<br />
<br />
Apples, yeah, I guess this is the only time I like Apple. It's Ok, can wash them, but sometimes I just want to bite without washing... you look at them, they look fine, they're red, they look healthy, they look fresh, and even after washing them, they look the same. I wish I could see what I was washing off so that there's gratification that washing them actually makes a difference, that the pesticides are actually removed.<br />
<br />
And what about the top and bottom of the apple? You would think that's where all the bad stuff accumulates. Just too lazy to be even bothered to throw it away, so eat it, I do.<br />
<br />
OMG how much pesticides have I consumed?<br />
<br />
Hmm how evil is eat, to eat residue....</div>
qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-57541956584217954042012-09-08T23:09:00.000-07:002012-09-08T23:09:25.403-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
Hi YM, when do you want it open?<br />
<br />
I don't know if the kitchen in the new hospital if there are stoves in there, and then I also have to make sure there's going to be someone who will cook the food... and then the janitor... and then we have to arrange transpo for the staff.<br />
<br />
<br />Was targeting Dec. 1. But then looked at the holidays. So I looked if we can Open Oct. 15. But it's too close, because we have to hire cooks, servers, maintenance people, water trucks... so 1 month might be too close. But I'm thinking, it's doable. I'm just worried if we have to buy beds, that might take a while, I don't know how fast we can get it...<br />
<br />
Was also thinking, I want to open as a gift for you!<br />
<br />
But is it OK if we open Dec.1... I think yes. OK gotta work I love you<br />
<br />
Ok will think of this ^_^<br />
<br />
Dec. 1 sounds like a nice date to start because at least we can measure how much electricity we consume for the whole month, it's like everything starts at day one...<br />
<br />
Nov. 29 is a holiday...</div>
qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-71663756276071105272012-09-05T04:53:00.000-07:002012-09-05T04:53:33.629-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
Mountain Dew<br />
<br />
Checked Sultan Center, they still did not have the new Batman Mountain Dew. Maybe they have it in Carrefour...<br />
<br />
Wonder what needs to be collected.<br />
<br />
They had a new shipment of Mountain Dew today but it's just regular... nothing special... And some of the Pepsi still had Ramadan packaging.<br />
<br />
Maybe the Batman Mountain Dew isn't in this store...<br />
<br />
Saw the logo, the one with the buildings, it's kinda cool, I didn't see that the shape of the sky was a bat ^_^<br />
<br />
Something new and refreshing.<br />
<br />
Diet recall<br />
<br />
2 sandwiches - eggplant, slice of sausage, strips of onions, mayonnaise, chicken liver, french fries, chopped tomatoes, lettuce, scrambled eggs<br />
<br />It's delicious but if had my way, no sausage, fries, mayo... But how to live, these food are delicious...<br />
<br />
Peanuts, banana, cucumber.<br />
<br />
Now gums are receding.<br />
<br />
Scurvy. Need vitamin C...<br />
<br />
Apple!!! I like Apple the fruit not the computer.<br />
<br />
Keep thinking about that iPad for 149.900 in Carrefour. Should have bought it to resell it?<br />
<br />
It was cheap and now, all the prices have gone up. So, strategy for next year, wait for the sale again???<br />
<br />
Pizza, I miss it but gotta make sure it's real...<br />
<br />
Body fat, kinda don't like how it's shaped but it's very stubborn, doesn't want to be shaped the way I like it... very like Grandpa's<br />
<br />
Today is the longest day, waiting for what Nokia will say...<br />
<br />
Who will have this phone? America?<br />
<br />
Maybe I should be diving into pools of water instead, hurtling down at a hundred miles per hour, distorting my lips as wind catches it, to get a buff body.<br />
<br />
Or just give in like everyone else and use steroids :(<br />
<br />
Or be dirt poor and digging ditches to get that Evangelion abs...<br />
<br />
GE, if only families 3 to 5 was level 20... then would have a training card everyday... it's so hard to level it up alone. Should resort to Barrack slots? yeah, that's probably it. So, must continue with the quests... laptop just hums like a mad top, revving loudly and if this goes on for long, fear that the cooling device will die again...<br />
<br />
Need to survive until Windows 8 is here...<br />
<br />
OK play GE!!!<br />
<br /></div>
qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-50410133871418825142012-09-02T23:02:00.000-07:002012-09-02T23:02:58.031-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
So how will Apple respond to all of this?<br />
<br />
Apple sees PureView, they will probably just stick to 8 or 12 megapixels and people will still buy it.<br />
<br />
Apple sees the edge-to-edge screen, Apple will probably... make an edge-to-edge screen too? So this is Google's bargaining tool. They will let Apple copy this, and in return, Google wants to be allowed to continue to use what they copied from Apple.<br />
<br />
So when will Apple make the edge-to-edge screen?<br />
<br />
Maybe they didn't know about it so when they were designing the iPad Mini, it still had bevels. So maybe, the iPhone that's coming out will be iPhone 4G and then next year, iPhone 5, with full screen, no bevels.<br />
<br />
Apple already saw the Galaxy S, S2 and S3, and they still didn't compete in screen size.<br />
<br />
So Apple had that patent where they can upgrade the camera. Maybe they will use that. Maybe it's a stupid idea.<br />
<br />
What other patents does Apple have. Oh, the patent where the screen has cameras the size of pixels! That's exciting. If they can make the whole screen as a camera, that would eliminate the need for a front facing camera.<br />
<br />
And then Samsung is also going to compete in the camera. which phone will have 16MP? Samsung Galaxy S4?<br />
<br />
And Sony... they will also compete...<br />
<br />
Looking back, why did LG announce their phone? Now, no one talks about it.<br />
<br />
Sony too, they announced the XPERIA T. No talk about that too.<br />
<br />
Nokia leaked their phones, now all the talk is about the leak.<br />
<br />
Motorola leaked their secret too, and the talk is about the full screen.<br />
<br />
So LG...it's becoming like that HTC pone where you know it's the best they have but you don't really know what makes it the best.<br />
<br />
So where is HTC's phone? It's missing? Or they announced it an I missed it? The Desire X??<br />
<br />
Oh, the HTC One X+<br />
<br />
OK, we know it, when will it be officially announced? Announce it after Nokia and Motorola presents their phones, no one is going to talk about it...</div>
qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-75634292808503443362012-08-29T14:20:00.000-07:002012-08-29T14:20:10.403-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
Batman!<br />
<br />
I like the trailer where there's a bridge and it's cut.<br />
<br />
So I read Mountain Dew is going to have a promotion. Collect and Win. I wonder what I need to collect. What I don't like about promotions like these is, I'm willing to buy the product but I'm not willing to consume ALL of the food that I'm buying. If I were in a school and I'm in charge of garbage, that would be better.<br />
<br />
I want to win a batmobile!<br />
<br />
Dhofar versus Fanja, why did I know about this now?<br />
<br />
I like how the stadium is fairly near, not like it's as far as the other end of city's linear road. But I've never attended a match. It's always I'm late to know.<br />
<br />
<br />It's OK.<br />
<br />
Listening to Merge.<br />
<br />
Trance around the world, in the most trance-like voice I can make.<br />
<br />
ttytbbiiubllhsa that's what I think is said next<br />
<br />
It's trance! <br />
<br />
Like the rest of the world still has some trance fans and one of them is here.<br />
<br />
<br />
<br /></div>
qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-3820322367795672232012-08-27T00:56:00.000-07:002012-08-27T00:56:02.086-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
So the inspiration now is color. Primary colors.<br />
<br />
Yellows, reds, Pinks.<br />
<br />
Yeah, I saw pinks last night.<br />
<br />
What goes well with pink?<br />
<br />
Pair it with black, and it evokes a feeling, so what, it's pink<br />
<br />
Love it but not brave enough to pink. So maybe light pink, like red that was soaked and washed and the red faded away. Like the red was drained...<br />
<br />
But I want bold, striking colors.<br />
<br />
Use a small flash of bright pink. Yeah, that might work. But what?<br />
<br />
pink watch, pink phone, pink cover, pink hat...<br />
<br />
Don't like pink.<br />
<br />
Maybe I'll stick with Superman blue. Yeah, always loved that.<br />
<br />
Really depends on what's available.<br />
<br />
Let me look at theweek again.<br />
<br />
Saw stripes. And polo shirts.<br />
<br />
How about maroon. Mirror what's seen from the other people.<br />
<br />
Or sea blue.<br />
<br />
Orange... or Red...<br />
<br />
Or stick to what I know, green.<br />
<br />
Or shorts! Maybe should just buy nice, comfy shorts.<br />
<br />
Jeans, when will you get a hole! Would it be frowned upon if sported a hole? Or a rip?<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="http://1.bp.blogspot.com/-M5DUozYgsQA/UDsnmLJZ5yI/AAAAAAAAB4c/ZaJknNMBrX8/s1600/grand+mosque+128.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="http://1.bp.blogspot.com/-M5DUozYgsQA/UDsnmLJZ5yI/AAAAAAAAB4c/ZaJknNMBrX8/s320/grand+mosque+128.JPG" width="320" /></a></div>
<br />
<br />
<br />
<br />
Or this design. I want it on a shirt. To counter the swirls.<br />
<br />
The pixels seen too, like on the e logo, or on the telephone company's wall, I want that. Inspiring. Or the pattern on the carvings. Would it be an issue if that was lifted and placed upon a shirt? Want squares.<br />
<br />
Need to find acid washed jeans and bend and rip it again.<br />
</div>
qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-29677607140495902482012-08-24T23:40:00.001-07:002012-08-24T23:40:48.581-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
Oh my goodness if you want me to keep quiet, you gotta pay to keep me quiet. Like a nice yacht to silence me. Oh my goodness. Exaggeration.<br />
<br />
So yeah, it's not about you, it's about another person.<br />
<br />
So where's Nintendo in all of this? They brought forth the idea of a touchscreen. So Apple sees the DS, touch is good, then joins Moto for the MotoRokr, but then Moto being the asses that they were, just rehashed the e398, but then apparently that gave Apple the connections they needed in AT&T, so, where's Nintendo? Well if they copied Nintendo again... the copycat is Kinect...<br />
<br />
I can't really imagine what the next step will be... Kinect on phones... Wii on phones... 3D on phones...<br />
<br />
Yeah, so put Windows 7 on my phone so that I can play MMO's on it. Invent a wireless power supply. Like solar. I would be happy.<br />
<br />
Or a foldable screen. Doesn't have to fold like a book. Fold it like half-folded paper, so that there's a loop and there's no crease.<br />
<br />Like that bendable, camouflage robot inspired by sea creatures. It could print out a pattern when the ink was introduced through the tubes.<br />
<br />
Like half of the screen is normal, but when you unfold it, the other half's image is injected.<br />
<br />
There's no other way to have a big screen in a small footprint.<br />
<br />
Unless It's paper...<br />
<br />
Or a slider with two screens. Or a flip phone with both clams as screens.<br />
<br />
See, we're going back to Nintendo.<br />
<br />
Nintendo needs to translate that screen to look more like a smartphone's screen, so that when people see it, oh, cool, it looks like a smartphone, now I can use that to show off too when all my friends show off their iPhones.<br />
<br />
Right now, the proportions are still gameboy. That have to make it look like a phone. Please Nintendo, I love you.<br />
<br />
Premium materials please. The grey plastic is not in line with smartphones.<br />
<br />
So what do they need to do? Hire someone from Apple? Or from Samsung? Or Sony? Not HTC or Nokia please... the polycarbonate is not reading well. It tells me, umm, cheap plastic just by looking at it.<br />
<br />
I want it to look like the Razr please. Gorilla glass please. Kevlar please. Metal sides please.<br />
<br />
Hmm I wonder if Nintendo will do that.<br />
<br />
Vita, well... I looked at it, and it's kinda... fat. And the shape kinda doesn't evoke a smartphone... the screen does. Full glass screen, I like it.<br />
<br />
Hmm... yeah... see, you hire Penelope and Nicole Kidman but what I see in their hands, it's still a toy, it's not a swanky, to be coveted celebrity item, it doesn't look good in their hands. So make it like a Razr and then hire Penelope and Nicole again ^_^</div>
qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-12033878043748669592012-08-18T06:22:00.001-07:002012-08-18T07:21:46.779-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
So I'm reading Memoirs of an Arabian Princess and I read the titles of the chapters, and I'm already amazed at how each word is a surprise, it's like I can't believe this was written hundreds of years ago, it's like from the future. Well, it was translated, so whoever translated it, it was good. I'm reading the mango trees, how the cocoanut tree is spelled like that, I'm like, oh, I've lived with coconut trees all my life, why didn't I think of spelling it that way... Oh, not coconut ^_^ It's really cocoa for chocolate ^_^<br />
<br />
But still, it's like if they made up these words, they're like everything is coming from so many different places, it's so fresh to me. Like reading the first chapter makes me read and reread it because I want to savor it, to enjoy it, like I've never read anything like it. I'm not prepared.<br />
<br />
OK I'll continue reading.<br />
<br />
It's like, you have read fiction novels, and what you're reading now, it's more imaginative than fiction, but then you think, it's true, this isn't fiction, it's real life, not imagination. Like a whole different world.<br />
<br />
I'm constantly distracted by reading this because, at a moment, I want to find out the book reviews for this, and then I encounter a word I don't know, perfidy, and I look it up and it means deception, I'm like, whoa, and continue reading the glowing reviews. It's so much fun to read ^_^<br />
<br />
So her Mom was Circassian, so I researched what it was... and the pictures are black and white. The pics of the princess are black and white, and the family pic with the dad and the two children was also in black and white. I'm fascinated by it, like maybe they are beautiful.<br />
<br />
So Circassian is white? But she said her mom had black hair. Authoress' pic, I see her nose, I see her eyes, it's round, and she looks like she has an overbite. Like the nose...<br />
<br />
Where is Northern Caucasus?<br />
<br />
What the heck were they thinking? I think it's a bit far, to get her from Caucasus and then bring her to Zanzibar.<br />
<br />
How the heck did they find Zanzibar?<br />
<br />
I'm thinking, back then, maybe they were thinking they were at the peak of civilization, so it was like, OK, we'll sail on a boat, so they sailed, and they found an island, and so that's how they found Zanzibar, because they were thinking of great things, they had the ambition to sail.<br />
<br />
So the Mom was Circassian... what did she pass on to the Authoress? Light skin... black hair, and from the dad, the nose... well, the nose, they both have strong, nice noses I suppose, so combine them both and it will be nice. It's like, people back then were mixing. So maybe that's why I see a mix here too. Like I'm confused. Just today, I saw the hallmark of a mixed one. He had a mole. I mean, that mole, I noticed that when dark and light mixes... like when they go under the sun and absorb the sunlight, later on, the pigments get collected and form bubble moles ^_^<br />
<br />
So anyway, I think it's hot ^_^ Like your ancestors came from all over the place, so you're a nice mix ^_^ delicious<br />
<br />
Well slavery, that happened a long time ago, it's what's happened, result is beautiful people now ^_^<br />
<br />
@_@<br />
<br />
I mean, yeah, if you're attracted to each other, maybe that's going to produce cute people because of the attraction.<br />
<br />
*_*<br />
<br />
So anyway, continue with the book. It glides so effortlessly in saying a new topic. Wish I had that skill...<br />
<br />
<br /></div>
qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-3378778037814232942012-08-11T06:56:00.000-07:002012-08-11T06:56:33.973-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
So the search result I got for Muscat is wine.<br />
<br />
So I thought, is that a kind of wine, is that a brand, is it a person, what is it?<br />
<br />
So Wiki said it's a grape ^_^<br />
<br />
There's also people whose last name is Muscat<br />
<br />
Hmm so I increased my knowledge ^_^<br />
<br />
In another topic, I'm looking at the Nexus 7.<br />
<br />
The price in Mizado is almost the same as Alatool.<br />
<br />
When I first saw it in Alatool, I was excited, because I thought, ooh, that's a good sign, they have something interesting.<br />
<br />
But then, sticker shock.<br />
<br />
155 is like 400 bucks... umm... too much...<br />
<br />
That's like an iPad already...<br />
<br />
So Mizado, I saw their price, and compared it to Alatool, it's within the same range.<br />
<br />
I wasn't very familiar before with the currencies. I knew AED is Dubai, but there's also Dirham. So I thought, maybe I'm wrong, so there's AED, what is it?<br />
<br />
Oh, it's the same. So Yahoo calls it AED, Mizado calls it Dir<br />
<br />
OK over and out <br />
<br /></div>qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-64839203182692764392012-08-08T06:16:00.001-07:002012-08-08T06:16:51.719-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
Uh it's like blogs leaked and they know it, so yeah, you know what I'm thinking, that's why they stayed away.<br />
<br />
I almost did a medication error<br />
<br />
Underdose<br />
<br />
I looked at the new order, I saw Bisacodyl, I saw it was 5mg... I went to check if we had that available, because I had an experience before that the drug I needed, it wasn't available... so good thing I checked, because it's not there<br />
<br />
And I searched for it<br />
<br />
And when I found it, I lucked out and I got about six tablets. I thought, I only need one, so might as well bring more because tomorrow, it will still be used (unless constipation was relieved)<br />
<br />
So I gave it, one tablet.<br />
<br />
And then, error!<br />
<br />
Two heads are better than one, the second head successfully ran an error check parameter, and I saw it. I should have given more.<br />
<br />
So, end of story, medication error averted ^_^<br />
<br />
I feel I'm getting rusty, like I'm not to 100%<br />
I need food to be alert<br />
Why did I make that mistake...<br />
<br />
I was looking at the computer while standing up. I asked someone, who was sitting in front of the computer, can we check the medication please, and then the window was opened, and I looked at it while standing up, so that's where the error was. My attention wasn't as full as it would have been had I been sitting directly in front of the screen. So how to solve this? Better wait my turn and sit in front of the screen. Or look at the dosage.<br />
<br />
OK I gotta remember this.</div>qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-82572735928293463022012-08-01T20:21:00.001-07:002012-08-01T20:21:24.006-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
So the other day, I was asked, can you get Ibuprofen for me?<br />
<br />
I said yes.<br />
<br />
But really, I don't want to.<br />
<br />
Good thing later on, he said, oh I still have some.<br />
<br />
I didn't want to because it's not mine, I don't want to take it.<br />
<br />
I said yes because he needs it.<br />
<br />
And for smoother interpersonal relations.<br />
<br />
<br />So anyway, I'm thinking of deactivating my facebook again.<br />
The thought got further strengthened when I read they're going to force me to use timeline.<br />
<br />
I hate it.<br />
<br />
Facebook is too meddlesome. Have you ever heard of inertia? I'm not going to move unless a force acts on me. So I'm not moving. Can you do anything? You're not supposed to, but your doing timeline. Leave me alone.<br />
<br />
I just need facebook to communicate.<br />
<br />
Of course, in my advantage.<br />
<br />
So why am I keeping it open?<br />
<br />
It's like a bargaining tool. If I close it, then they would think, aha, hmm... ok, I've got you<br />
<br />
No need to further get you because I've got you<br />
<br />
I have no skills in playing hard to get... I do it and then I overdo it<br />
<br />
So I'm telling, one exit strategy is to take that loan...<br />
<br />
All I need to do is pass the exam.<br />
<br />
And the other me is telling, no, you're going to make a mistake, what if you're better off here than there<br />
<br />
You might have a future here<br />
<br />
Where else do you encounter a new place opening?<br />
<br />
It's like one of those new accounts opening in a call center, the first hires get the boss positions.<br />
<br />
So middle me is saying now, Ok, this is just Plan B, gotta have a plan i case something goes wrong.<br />
<br />
Well, if I continue to save, within 3 years, I don't need to take a loan.<br />
<br />
But I heard it, forget about it.<br />
<br />
So anyway, there's a lot of arguments going on, like many me all talking, like one is saying, oh I'm going there because there, I can marry. Here, you get jail. Another me is saying, are you stupid, this is like chance of a lifetime. Another's saying, nope, you're just imagining things. Looping... like on and on, it repeats.<br />
<br />
So like, in the end, the question is about happiness.<br />
<br />
I would be happy there because I looked at the HP website, and the prices and the one that I want, it's there, I can order it, I'm at the cutting edge of whatever consumer technology I can buy. I looked at other countries, and it's not the same...<br />
<br />
I could buy parts and install it easily, here I can't do that.<br />
<br />
But now, I am thinking, well, you could always go there to visit. Doesn't have to be you live there.<br />
<br />
Omg, it's like, if I'm to complain like this forever, it's going to be a headache. There's no fun, no happiness in this.<br />
<br />
I could not eat, I did it, but when I felt hungry, that's when the thoughts come in, I'm asking, why<br />
<br />
And then when it's time to eat, no appetite<br />
<br />
...<br />
<br />
So uh, what will family say? Yeah, as a natural reaction, they will ask, why... it's not going to be smooth, it's not going to be like, oh, ok, you did that, you're a grown-up, you decided for yourself. That was my idea, I told them that, I think they might use it when they discover, but really, if I move, it will elicit a reaction from them. Up to what degree, I don't know.<br />
<br />
I mean, it's not realistic that they won't make an issue out of it, of course it will be an issue.<br />
<br />
hmm so facebook again, I think it has something to do with that Dream Act, that's why I was contacted.<br />
<br />
I should've just not followed the rules!<br />
<br /></div>qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-66460153334738979882012-07-30T09:00:00.000-07:002012-07-30T09:00:40.545-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
Omg they're in trouble.<br />
<br />
Nothing about them is fun anymore. It's like nothing surprises.<br />
<br />
I don't like their new look.<br />
<br />
The pikachu yellow hair, it's OK, I like it, but the shaved head is kinda not looking cool anymore. I don't know. Maybe one more month and it has to change.<br />
<br />
Give me back the palm tree hair! I loved that, it's so wacky, so unexpected, like if you had that, you would think people will laugh at you but it's so cool, I don't care<br />
<br />
Now the clothes are old... like the inspiration was oldness? I don't like it<br />
<br />
The silk is not working.<br />
<br />
They don't realize, the fans can't wear that... It's ugly!!!!<br />
<br />
OMG they're not listening, they're intoxicated with success<br />
<br />
It's like they thought, ok, our concept will be old chinese, we'll stick to it, it's like they forgot<br />
<br />
they gotta do something fun, the fun doesn't take precedent from the concept, the fun takes center stage<br />
<br />
I want them to be fun again!!!!</div>qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-20867603166510126082012-07-26T02:12:00.000-07:002012-07-26T02:12:00.158-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
So hospital, oh my goodness<br />
<br />
I shouldn't have laughed but I laughed. Dog bit fingertip and I laughed....omg how non therapeutic...<br />
<br />
So you get animal bites... and then you order tetanus shots... and then you get deep wounds, also tetanus shots... and then you get allergies...at first, I thought, OK allergy, but then someone corrected me, yeah allergy, but if the throat is inflamed, they can't breathe...<br />
<br />
And the vehicular accidents omg.. so much blood<br />
<br />
So what looked like a shallow head wound, it turns out to be small but deep, like punctured... <br />
<br />
And then most of the time is waiting... sad is when doctor calls for the ECG machine... at first, I was like, why, and then later, OK, flat line...<br />
<br />
you also get the common cold, I'm like, we're the ER, for emergencies only, please, kindly go to OPD<br />
<br />
And then the people who are dizzy... turns out, high BP... so you tell them to rest... and calm them down.. if they panic, if you scare them, BP goes up again... so you're like, OK, how are you.... like very calm...<br />
<br />
hmmm I'm tired</div>qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-51692912975636395142012-07-12T21:08:00.000-07:002012-07-12T21:18:39.406-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
So prominent was out and then he was back...<br />
<br />
I'm thinking, if you help this guy, you will win his family's favor.<br />
Plus you're a good nurse.<br />
And you helped society.<br />
<br />
It's a win for all!<br />
<br />
Obviously these blogs are leaking... I was thinking, do I tell them face to face or leak it here... I feel like they just want to get rid of him, they don't see the potential... it kinda reaches everyone so I'll say here<br />
<br />
I wasn't the one who was foldered on the face, or the one shouted upon, so if I put myself in their shoes, yeah, it's upsetting, but it's like, I know it's difficult to not take it personally, but these patients have behavioral problems, and they need help from us, it's part of their disease, emphasis on this, so it's like working with these patients, you have to be patient yourself, it's very difficult, I'm telling we should do this, we should do that, I don't know anything, but I know it's a win for all if we help this guy.<br />
<br />
<br />
<br />
<br />
<br />
<br />
So maybe favored one really was telling the truth and he did contact Pikachu. It's great if like something like this was really true, I think it's true. It was his idea, he was the one who said he wanted a big rehab place to live for a long time, I'm just glad I was assigned to him, I'm glad too that Brother Joel said every shift talk to the patients, I'm glad too that I kinda ignored him because he was cute and then he was looking for someone to talk to... it's like if you give attention early on, they will become suspicious or like, why is this guy talking to me, what does he want... OK I want to take credit for convincing him O_o I'm such a blur<br />
<br />
I wonder what he's doing now... I saw him when he was next to the window, a fleeting moment, waving with a smile, and I smiled back, but it's difficult, I'm only allowed to stay where I'm supposed to be... it's like, these guys are thinking, oh you were nice to me when I was there, but how come you never see me now, it's like you're not true<br />
<br />
Sigh I need to work on socialization<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
So yeah I think I didn't show emotion. I did steal a look on a certain spot lol omg and then I shut my eyes. Because why was I looking there. Why am I attracted. Cool too... although the nose was flaring up a bit... why is that? It's like when you get older, things start to get loose and flare<br />
<br />
<br />
<br />
<br />
<br />
So I'm looking forward to being hypoglycemic and just be more concerned with survival than with sex <br />
<br />
<br />
It's ridiculous, one moment you're almost dead and then the next day, balls still make hormones<br />
<br />
<br />
<br />
<br />
<br />
So I get the feeling that, ah, so you're looking at other places huh, so you want to leave, huh, Ok, I'll do this... so I'm thinking, it's like this delusion is getting me nowhere, I have to be realistic, and if salary is this much and the house is this much, it would be faster if I get a bigger salary, so I looked...<br />
I don't want mom to fail there, besides I don't do anything with cash so might as well use it for something good <br />
<br />
But it's like $20 an hour! Or even 40... I have to be realistic and delusion is not reality. Was thinking, oh you can't give me stateside experience<br />
<br />
But reality is also, currently, I haven't found a way for me to go there still<br />
<br />
So I am where I am<br />
<br />
And wait, she's the one who's buying a house, not me<br />
<br />
If budget is 100,000, then it will take two years worth, no eating, no spending for me<br />
<br />
Switch off brain<br />
<br />
So pikachu because I like pikachu<br />
<br />
p.s. kindly click ads for me ^_^</div>qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-61653900383213285892012-07-08T06:04:00.000-07:002012-07-08T06:04:04.697-07:00Opioids<div dir="ltr" style="text-align: left;" trbidi="on">
It's like it's got its hold everywhere. How the heck do you combat it? It's like even the people who come, they are still looking. Just the other day, the cleaner was cleaning, and this patient, he was like, asking if he had any. I was like, dude, I don't understand what your saying but I know you're asking for drugs.<br />
<br />
It's like you catch them ... and then I realized, these dealers, they only started selling so that they can buy drugs hat they will use. It's like, you have no choice, you're addicted, and one way to get the drugs is to sell it, because you need to use the drugs, and even if you know it's bad that you're ruining another person but you're addicted, so I'll sell it...</div>qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-2269481923503903872012-05-22T06:48:00.002-07:002012-05-22T06:48:13.960-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
So diet is chicken, bread, softdrinks...<br />
<br />
Little cuts and bruises, they're leaving marks, and it takes longer for them to disappear... why???<br />
<br />
been letting the blood pump through strongly, still body is sluggish<br />
<br />
I think it's the sleep...<br />
<br />
Today, had a refreshing nap ^_^<br />
<br />
Just my belly, it wouldn't flatten... I think I got my grandpa's belly's gene<br />
<br />
It's the same shape!<br />
<br />
It's like you exercise but muscles are sore, body is tired, hungry, so you eat<br />
<br />
HOW DO THEY DO IT???<br />
<br />
I think I need to keep things simple</div>qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-88336339688208959152012-05-07T23:09:00.000-07:002012-05-07T23:09:28.597-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
So I'm watchig the arabic music videos and they look like so kick ass awesome but the sound is like it doesn't match</div>qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-14302583783201763612012-05-02T07:56:00.001-07:002012-05-02T07:56:50.769-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
So I've been eating roast chicken ^_^ I've noticed that the muscles that would usually be less taut by now, are still tight ^_^ I like it.<br />
<br />
Not much drug news right now. Oh yeah I already mentioned the sheet of Olfen that I forgot was in my pocket.<br />
<br />
I've got mouthwash but I'm too lazy to gargle. Ok I'll use it now!</div>qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-14426869672012460882012-04-29T09:23:00.002-07:002012-04-29T09:23:42.864-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
So today, I got the Mantoux test.<br />
<br />
Now, it's big...<br />
<br />
As soon as I got home, I slept...<br />
<br />
Was wanting to read as I always do, I let myself give in to weakness and dozed off.<br />
<br />
Woke up, felt refreshed. <br />
<br />
So, about drugs...<br />
<br />
Diclofenac is Olfen<br />
<br />
It comes in 100mg tablets<br />
<br />
I saw a new tab today. It's pink.<br />
<br />
...</div>qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-51323029530924536842012-04-27T03:07:00.001-07:002012-04-27T03:07:37.486-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
So I thought, I need to know about Amitriptyline, methadone and so on. It's better to commit things to memory than to always looking up things in a book. Faster.<br />
<br />
I read how one died because his respiration dropped. I want to know when it is appropriate to withhold meds. It's like you talk with your co-workers, and I raised my concern that the patient doesn't look good, and we're trying to get a consensus of whether to give or not to give, and since the medicine is ordered, they say, give it. So we gave it. Sometimes, being too fearful makes me see situations more problematic than it should be. So nothing happened, patient slept, woke up the next day.<br />
I need to know the signs.<br />
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<a href="http://2.bp.blogspot.com/-c9cm5QNRpYs/T5pvf39PJ-I/AAAAAAAAB3Q/poiT4i2lL_M/s1600/grand+mosque+007.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="http://2.bp.blogspot.com/-c9cm5QNRpYs/T5pvf39PJ-I/AAAAAAAAB3Q/poiT4i2lL_M/s320/grand+mosque+007.JPG" width="320" /></a></div>
I need to know the finesse of when not to give it.</div>qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-4925058839708865432010-06-03T23:17:00.000-07:002010-06-03T23:27:24.417-07:00Propranolol decrease in blood pressureWorking...<br />6/3/2010 8:52:15 PM<br />propranolol (HIGH ALERT)(PHARMACOGENETICS)<br /><br />Introduction<br /><br />(proe-pran-oh-lole)<br />[Apo-Propranolol], [Betachron E-R], Inderal, Inderal LA, InnoPran XL, [Novopranol], [pms Propranolol]<br />[] = Available in Canada only.<br /><br />Classification:<br /><br />Therapeutic: antianginalsantiarrhythmics (Class II), antihypertensives, vascular.headache.suppressants<br />Pharmacologic: beta blockers<br /><br />Pregnancy Category C<br /><br />Indications<br /><br />Management of hypertension, angina, arrhythmias, hypertrophic cardiomyopathy, thyrotoxicosis, essential tremors, pheochromocytoma, Also used in the prevention and management of MI, and the prevention of vascular headaches. Unlabeled uses: Also used to manage alcohol withdrawal, aggressive behavior, antipsychotic-associated akathisia, situational anxiety, and esophageal varices, Post-traumatic stress disorder (PTSD)(Ongoing clinical trials at National Institute for Mental Health [NIMH]).<br /><br />Action<br /><br />Blocks stimulation of beta1(myocardial) and beta2 (pulmonary, vascular, and uterine)-adrenergic receptor sites. Therapeutic Effects: Decreased heart rate and blood pressure. Suppression of arrhythmias. Prevention of MI.<br /><br />Pharmacokinetics<br /><br />Absorbtion: Well absorbed but undergoes extensive first-pass hepatic metabolism<br />Distribution: Moderate CNS penetration. Crosses the placenta; enters breast milk<br />Protein Binding: 93%<br />Metabolism and Excretion: Almost completely metabolized by the liver (primarily for CYP2D6 isoenzyme) (the CYP2D6 enzyme system exhibits genetic polymorphism; ~7% of population may be poor metabolizers and may have significantly propranolol concentrations and an risk of adverse effects)<br />Half Life: 3.4-6 hr<br /><br />TIME/ACTION PROFILE (cardiovascular effects)<br /><br />ROUTE<br /> <br />ONSET<br /> <br />PEAK<br /> <br />DURATION<br />PO<br /> <br />30 min<br /> <br />60-90 min+<br /> <br />6-12 hr<br />PO-ER<br /> <br />unknown<br /> <br />6 hr<br /> <br />24 hr<br />IV<br /> <br />immediate<br /> <br />1 min<br /> <br />4-6 hr<br /><br />+Following single dose, full effect not seen until several weeks of therapy<br /><br />Contraindications/Precautions<br /><br />Contraindicated in: Uncompensated CHF. Pulmonary edema. Cardiogenic shock. Bradycardia or heart block.<br />Use Cautiously in: Renal or hepatic impairment. Pulmonary disease (including asthma). Diabetes mellitus (may mask signs of hypoglycemia). Thyrotoxicosis (may mask symptoms). History of severe allergic reactions (may intensity of response). OB: Crosses the placenta and may cause fetal/neonatal bradycardia, hypotension, hypoglycemia, or respiratory depression. May also blood supply to the placenta, increase the risk for premature birth or fetal death, and cause intrauterine growth retardation. May risk of cardiac and pulmonary complications in the infant during the neonatal time frame. Lactation: Appears in breast milk; use formula if propranolol must be taken. Pedi: risk of hypoglycemia, especially during periods of fasting such as before surgery, during prolonged exertion, or with coexisting renal insufficiency. Geri: sensitivity to all beta blockers; initial dose reduction and careful titration recommended.<br /><br />Adverse Reactions/Side Effects*<br />*CAPITALS indicates life-threatening; underlines indicate most frequent.<br /><br />CNS: fatigue, weakness, anxiety, dizziness, drowsiness, insomnia, memory loss, mental depression, mental status changes, nervousness, nightmares.<br />EENT: blurred vision, dry eyes, nasal stuffiness Resp: bronchospasm, wheezing CV: ARRHYTHMIAS, BRADYCARDIA, CHF, PULMONARY EDEMA, orthostatic hypotension, peripheral vasoconstriction GI: constipation, diarrhea, nausea GU: erectile dysfunction, libido Derm: itching, rashes Endo: hyperglycemia, hypoglycemia ( in children) MS: arthralgia, back pain, muscle cramps Neuro: paresthesia Misc: drug-induced lupus syndrome<br /><br />Interactions<br /><br />Drug-Drug: General anesthesia, IV phenytoin, and verapamil may cause additive myocardial depression. Additive bradycardia may occur with digoxin. Additive hypotension may occur with other antihypertensives, acute ingestion of alcohol, or nitrates. Concurrent use with amphetamines, cocaine, ephedrine, epinephrine, norepinephrine, phenylephrine, or pseudoephedrine may result in unopposed alpha-adrenergic stimulation (excessive hypertension, bradycardia). Concurrent thyroid administration may effectiveness. May alter the effectiveness of insulin or oral hypoglycemics (dose adjustments may be necessary). May effectiveness of beta-adrenergic bronchodilators and theophylline. May beneficial beta cardiovascular effects of dopamine or dobutamine. Use cautiously within 14 days of MAO inhibitor therapy (may result in hypertension). Cimetidine may blood levels and toxicity. Concurrent NSAIDs may antihypertensive action. Smoking metabolism and effects; smoking cessation may effects.<br /><br />Route/Dosage<br /><br />PO (Adults): Antianginal—80-320 mg/day in 2-4 divided doses or once daily as extended/sustained-release capsules. Antihypertensive—40 mg twice daily initially; may be as needed (usual range 120-240 mg/day; doses up to 1 g/day have been used); or 80 mg once daily as extended/sustained-release capsules, as needed up to 120 mg. InnoPran XL dosing form is designed to be given once daily at bedtime. Antiarrhythmic—10-30 mg 3-4 times daily. Prevention of MI—180-240 mg/day in divided doses. Hypertrophic cardiomyopathy—20-40 mg 3-4 times daily. Adjunct therapy of pheochromocytoma—20 mg 3 times daily to 40 mg 3-4 times daily concurrently with alpha-blocking therapy, started 3 days before surgery is planned. Vascular headache prevention—20 mg 4 times daily or 80 mg/day as extended/sustained-release capsules; may be as needed up to 240 mg/day. Management of tremor—40 mg twice daily; may be up to 120 mg/day (up to 320 mg have been used)<br />PO (Children): Antihypertensive/antiarrhythmic—0.5-1 mg/kg/day in 2-4 divided doses; may be as needed (usual range for maintenance dose is 2-4 mg/kg/day in 2 divided doses)<br />IV (Adults): Antiarrhythmic—1-3 mg; may be repeated after 2 min and again in 4 hr if needed<br />IV (Children): Antiarrhythmic—10-100 mcg (0.01-0.1 mg)/kg (up to 1 mg/dose); may be repeated q 6-8 hr if needed<br /><br />Availability (generic available)<br /><br />Oral solution: 4 mg/mL, 8 mg/mL Cost: Generic4 mg/mL $38.54/480 mL Tablets: 10 mg, 20 mg, 40 mg, 60 mg, 80 mg Cost: Generic10 mg $8.99/100, 20 mg $7.99/100, 40 mg $12.22/100, 60 mg $86.65/100, 80 mg $15.59/100 Sustained-release capsules (Inderal LA): 60 mg, 80 mg, 120 mg, 160 mg Cost: 60 mg $132.98/90, 80 mg $141.97/90, 120 mg $176.80/90, 120 mg $230.05/90 Extended-release capsules: 60 mg, 80 mg, 120 mg, 160 mg Cost: Generic60 mg $99.99/90, 80 mg $141.97/90, 120 mg $176.80/90, 160 mg $230.05/90 Injection: 1 mg/mL In combination with: hydrochlorothiazide (Inderide). See Appendix B: Combination Drugs<br /><br />NURSING IMPLICATIONS<br /><br />Assessment<br /><br />• Monitor blood pressure and pulse frequently during dose adjustment period and periodically during therapy<br />• Abrupt withdrawal of propranolol may precipitate life-threatening arrhythmias, hypertension, or myocardial ischemia. Drug should be tapered over a 2-week period before discontinuation. Assess patient carefully during tapering and after medication is discontinued. Consider that patients taking propranolol for non-cardiac indications may have undiagnosed cardiac disease. Abrupt discontinuation or withdrawal over too-short a period of time (less than 9 days) should be avoided<br />• Pedi: Assess pediatric patients for signs and symptoms of hypoglycemia, particularly when oral foods and fluids are restricted<br />• Patients receiving propranolol IV must have continuous ECG monitoring and may have pulmonary capillary wedge pressure (PCWP) or central venous pressure (CVP) monitoring during and for several hours after administration.<br />• Assess for orthostatic hypotension when assisting patient up from supine position.<br />• 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).<br />• Angina: Assess frequency and characteristics of anginal attacks periodically during therapy.<br />• Vascular Headache Prophylaxis: Assess frequency, severity, characteristics, and location of vascular headaches periodically during therapy.<br />• PTSD: Assess frequency of symptoms (flashbacks, nightmares, efforts to avoid thoughts or activities that may trigger memories of the trauma, and hypervigilance) periodically throughout therapy.<br />• Lab Test Considerations: May cause BUN, serum lipoprotein, potassium, triglyceride, and uric acid levels<br />• May cause ANA titers<br />• May cause or in blood glucose levels. In labile diabetic patients, hypoglycemia may be accompanied by precipitous of blood pressure.<br />• 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<br />• Hypotension may be treated with modified Trendelenburg position and IV fluids unless contraindicated. Vasopressors (epinephrine, norepinephrine, dopamine, dobutamine) may also be used. Hypotension does not respond to beta agonists<br />• Glucagon has been used to treat bradycardia and hypotension.<br /><br />Potential Nursing Diagnoses<br /><br />Decreased cardiac output (Side Effects).<br />Noncompliance (Patient/Family Teachings).<br /><br />Implementation<br /><br />• High Alert: IV vasoactive medications are inherently dangerous. Before administering intravenously, have second practitioner independently check the original order, dose calculations, and infusion pump settings. Also, patient harm or fatalities have occurred when switching from oral to IV propranolol; oral and parenteral doses are not interchangeable. IV dose is 1/10 of the oral dose. Change to oral therapy as soon as possible. Do not confuse propranolol with pravachol. Do not confuse Inderal (a brand name of propranolol) with Adderall (an amphetamine/dextroamphetamine combination drug).<br />• PO: Take apical pulse prior to administering. If <50 bpm or if arrhythmia occurs, withhold medication and notify physician or other health care professional<br />• Administer with meals or directly after eating to enhance absorption<br />• Extended-release capsules should be swallowed whole; do not crush, open, or chew. Propranolol tablets may be crushed and mixed with food<br />• Mix propranolol oral solution with liquid or semisolid food (water, juices, applesauce, puddings). To ensure entire dose is taken, rinse glass with more liquid or have patient consume all of the applesauce or pudding. Do not store after mixing.<br /><br />IV Administration<br /><br />• Direct IV: Diluent: Administer undiluted or dilute each 1 mg in 10 mL of D5W for injectionConcentration: Undiluted: 1 mg/mL. Diluted in 10 mL of D5W: 0.1 mg/mL. Rate: Administer at 0.5 mg/ min for adults to avoid hypotension and cardiac arrest; do not exceed 1 mg/min. Pedi: Administer over 10 min.<br />• Intermittent Infusion: Diluent: May be diluted in 50 mL of 0.9% NaCl, D5W, D5/0.45% NaCl, D5/0.9% NaCl, or lactated Ringer's injectionConcentration: Depends on dose. Rate: Infuse over 10-15 min.<br />• Y-Site Compatibility: acyclovir, alfentanil, alteplase, amikacin, aminophylline, anidulafungin, ascorbic acid, atracurium, atroppine, azathioprine, aztreonam, benztropine, bivalirudin, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium gluconate, carboplatin, caspofungin, cefazolin, cefonocid, cefoperazone, cefotetan, ceftazidime, ceftizoxime, ceftriaxone, cefuroxime, chloramphenicol, chlorpromazine, cimetidine, cisplatin, clindamycin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmedetomidine, digoxin, diltiazem, diphenhydramine, dobutamine, docetaxel, dopamine, doxacurium, doxorubicin, doxycycline, enalaprilat, ephedrine, epinephrine, epirubicin, epoetin alfa, eptifibatide, ertapenem, erythromycin, esmolol, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, fluconazole, fludarabine, fluorouracil, folic acid, furosemide, ganciclovir, gemcitabine, gentamicin, glycopyrrolate, granisetron, heparin, hetastarch, hydrocortisone, hydromorphone, idarubicin, ifosfamide, imipenem/cilastatin, inamrinone, isoproterenol, ketorolac, labetalol, levofloxacin, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, meperidine, metaraminol, methotrexate, methoxamine, methyldopate, methylprednisolone, metoclopramide, metoprolol, metronidazole, midazolam, milrinone, mitoxantrone, morphine, multivitamins, nafcillin, nalbuphine, naloxone, nesiritide, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, palonosetron, pancuronium, papaverine, pemetrexed, penicillin G, pentamidine, pentazocine, pentobarbital, phenobarbital, phentolamine, phenylephrine, phytonadione, potassium chloride, procainamide, prochlorperazine, promethazine, propofol, protamine, pyridoxime, quinupristin/dalfopristin, ranitidine, rocuronium, sodium acetate, sodium bicarbonate, streptokinase, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thiamine, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, tolazoline, trimetaphan, urokinase, vancomycin, vasopressin, vecuronium, verapamil, vincristine, vinorelbine, vitamin B complex with C, voriconazole.<br />• Y-Site Incompatibility: amphotericin B cholesteryl, amphotericin B colloidal, amphotericin B liposome, dantrolene, diazepam, diazoxide, indomethacin, insulin, paclitaxel, pantoprazole, phenytoin, piperacillin/tazobactam, trimethoprim/sulfamethoxazole.<br /><br />Patient/Family Teaching<br /><br />• Instruct patient to take medication as directed, at the same time each day, even if 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 (8 hr with extended-release propranolol). Inform patient that abrupt withdrawal can cause life-threatening arrhythmias, hypertension, or myocardial ischemia.<br />• 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.<br />• Teach patient and family how to check pulse daily and blood pressure biweekly. Advise patient to hold dose and contact health care professional if pulse is <50 bpm or blood pressure changes significantly.<br />• May cause drowsiness or dizziness. Caution patients to avoid driving or other activities that require alertness until response to the drug is known.<br />• Advise patients to change positions slowly to minimize orthostatic hypotension, especially during initiation of therapy or when dose is increased.<br />• Caution patient that this medication may increase sensitivity to cold.<br />• Instruct patient to ask a health care professional before taking any OTC medications or herbal products, especially cold preparations, when taking this medication.<br />• Diabetic patients should closely monitor blood glucose, especially if weakness, malaise, irritability, or fatigue occurs. May mask tachycardia and increased blood pressure as signs of hypoglycemia, but dizziness and sweating may still occur.<br />• Advise patient to notify health care professional if slow pulse, difficulty breathing, wheezing, cold hands and feet, dizziness, light-headedness, confusion, depression, rash, fever, sore throat, unusual bleeding, or bruising occurs.<br />• Instruct patient to inform health care professional of medication regimen prior to treatment or surgery.<br />• Advise patient to carry identification describing disease process and medication regimen at all times.<br />• Hypertension: Reinforce the need to continue additional therapies for hypertension (weight loss, sodium restriction, stress reduction, regular exercise, moderation of alcohol consumption, and smoking cessation). Medication controls but does not cure hypertension.<br />• Angina: Caution patient to avoid overexertion with decrease in chest pain.<br />• Vascular Headache Prophylaxis: Caution patient that sharing this medication may be dangerous.<br />• PTSD: Advise patient that medication may relieve distressing symptoms but that psychotherapy is the primary treatment for the disorder. Refer patient and family to a PTSD support group.<br /><br />Evaluation/desired Outcomes<br /><br />• Decrease in blood pressure.<br />• Control of arrhythmias without appearance of detrimental side effects.<br />• Reduction in frequency of anginal attacks.<br />• Increase in activity tolerance.<br />• Prevention of MI.<br />• Prevention of vascular headaches.<br />• Management of thyrotoxicosis.<br />• Management of pheochromocytoma.<br />• Decrease in tremors.<br />• Management of hypertrophic cardiomyopathy.<br />• Decrease in symptoms associated with PTSD.<br />0<br />Copyright © 2009 by F.A. Davis Company. All rights reserved.<br />(+/-) Show / Hide Bibliography<br />Bibliographic Citations Bibliographic Citations<br /><br />Export a citation for this title:<br /><br /><br />Or highlight and copy (Ctrl-C) the plain text citation below<br />............................................................<br />APRIL HAZARD VALLERAND, PhD, RN, FAAN, JUDITH HOPFER DEGLIN, PharmD, eds. 2009. Davis's Drug Guide for Nurses. Philadelphia, PA. F. A. Davis Company. ISBN-10: 0-8036-1912-X, ISBN-13: 978-0-8036-1912-8. STAT!Ref Online Electronic Medical Library. http://online.statref.com/document.aspx?fxid=58&docid=476. 6/4/2010 1:18:47 AM CDT (UTC -05:00).<br /><br /> * Copyright:<br /> o Copyright © 2009 by F.A. Davis Company. All rights reserved.<br /> * Database Title:<br /> o STAT!Ref Online Electronic Medical Library<br /> * Editor:<br /> o APRIL HAZARD VALLERAND, PhD, RN, FAAN<br /> o JUDITH HOPFER DEGLIN, PharmD<br /> * ISBN:<br /> o ISBN-10: 0-8036-1912-X<br /> o ISBN-13: 978-0-8036-1912-8<br /> * Publication City:<br /> o Philadelphia, PA<br /> * Publication Year:<br /> o 2008<br /> * Publisher:<br /> o F. A. Davis Company<br /> * Title:<br /> o Davis's Drug Guide for Nurses - 11th Ed. (2009) <br /> * Date Posted:<br /> o 6/3/2010 8:52:15 PM CDT (UTC -05:00) <br /> * Electronic Address:<br /> o http://online.statref.com/document.aspx?fxid=58&docid=476 <br /> * Date Accessed:<br /> o 6/4/2010 1:18:47 AM CDT (UTC -05:00) <br /> * Location In Title:<br /> o DAVIS'S DRUG GUIDE FOR NURSES - 12th Ed. (2011)<br /> "P" Monographs<br /> propranolol (HIGH ALERT)(PHARMACOGENETICS)<br /><br />Send Feedback<br />Customer Service<br />800.901.5494<br />Title Updates<br />User Responsibilities<br />Training Center<br />What's New<br />Teton Server (6.8.1) - ©2009 Teton Data Systems<br />Send Us Your Comments<br /> <br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br />5/11/2010 6:32:36 PM<br />Propranolol (Systemic)<br /><br />Introduction<br /><br />Nonselective β-adrenergic blocking agent.b,c<br /><br />Class: beta-Adrenergic Blocking Agents 24:24; CV100 (VA)<br /><br />Synonyms: Hydrochlorothiazide and Propranolol Hydrochloride<br /><br />Uses<br /><br />Hypertension<br /><br />Management of hypertension, alone or in combination with other antihypertensive agents.b,c Not indicated for the treatment of hypertensive emergencies.b,c<br /><br />Angina<br /><br />Management of chronic stable angina pectoris.b,c<br /><br />A component of the standard therapeutic measures in the management of unstable angina or non-ST-segment elevation/non-Q-wave MI+.a<br /><br />Supraventricular Tachyarrhythmias<br /><br />β-Adrenergic blocking agents, including propranolol, are one of several preferred antiarrhythmic agents for the treatment of stable, narrow-complex supraventricular tachycardias (e.g., paroxysmal supraventricular tachycardia [reentry supraventricular tachycardia], ectopic or multifocal atrial tachycardia, junctional tachycardia) if the rhythm is not controlled by vagal maneuvers or adenosine in patients with preserved left ventricular function and for rate control in atrial fibrillation or flutter in patients with preserved left ventricular function.352<br /><br />Paroxysmal atrial tachycardias, especially those caused by catecholamines or cardiac glycosides, or those associated with the Wolff-Parkinson-White syndrome.a<br /><br />Treatment of persistent atrial extrasystoles and noncompensatory sinus tachycardia that impair the well-being of the patient and do not respond to conventional therapy.a<br /><br />May be especially useful in conjunction with a cardiac glycoside to slow ventricular rates in the treatment of atrial flutter and fibrillation in patients whose arrhythmia is not controlled by adequate doses of a cardiac glycoside alone.a<br /><br />Ventricular Arrhythmias<br /><br />Treatment of tachyarrhythmias during cardiovascular surgery+, including decreasing ventricular fibrillation time during cardiopulmonary bypass surgery+.a<br /><br />Treatment of persistent ventricular premature contractions that impair the well-being of the patient and do not respond to conventional therapy.a<br /><br />Tachyarrhythmias Associated with Cardiac Glycoside Intoxication or Catecholamine Excess<br /><br />Management of supraventricular or ventricular tachyarrhythmias associated with cardiac glycoside toxicity when AV block is not present.b<br /><br />Management of resistant tachyarrhythmias associated with catecholamine excess during anesthesia; use with extreme caution and constant ECG and central venous pressure monitoring.a,b More effective and less hazardous therapy, such as lessening the depth of anesthesia or improving ventilation, is preferred.a<br /><br />Hypertrophic Subaortic Stenosis<br /><br />Management of exertional or other stress-induced angina, vertigo, syncope, and palpitation in patients with hypertrophic subaortic stenosis; clinical improvement may be temporary.b<br /><br />Pheochromocytoma<br /><br />Management of symptoms resulting from excessive β-receptor stimulation in patients with inoperable or metastatic pheochromocytoma, as an adjunct to α-adrenergic blocking agents.b Initiate therapy with an α-adrenergic blocking agent prior to treatment of pheochromocytoma.b (See Pheochromocytoma under Cautions.)<br /><br />Management of tachycardia prior to or during surgery in patients with pheochromocytoma, as an adjunct to α-adrenergic blocking agents.a,b Initiate therapy with an α-adrenergic blocking agent prior to treatment of pheochromocytoma.b (See Pheochromocytoma under Cautions.)<br /><br />Thyrotoxicosis<br /><br />Short-term (2-4 weeks) adjunctive therapy of tachycardia and supraventricular arrhythmias in patients with thyrotoxicosis when these symptoms are distressful or hazardous, or when immediate therapy is necessary.a<br /><br />Vascular Headache<br /><br />Prophylaxis of common migraine headache; not recommended for the treatment of a migraine attack that has already started.b<br /><br />AMI<br /><br />Secondary prevention following AMI to reduce the risk of reinfarction+ and mortality.a,b,352<br /><br />Management of ventricular arrhythmias complicating AMI.352<br /><br />Essential Tremor<br /><br />Management of essential (familial, hereditary) tremor.201,202,203,204,205,206,207,208,209,210,211,212,213,214,215,216,217,218,219,220,221,222,223,224,225,226,227,228,229<br /><br />Not indicated for tremor associated with Parkinsonism.b<br /><br />Dosage and Administration<br /><br />General<br /><br />Hypertension<br /><br />• In patients with hypertension, monitor BP during initial titration or subsequent upward dosage adjustment;289 large or abrupt reductions in BP should generally be avoided.289 Full hypotensive effect may require weeks of therapy, especially when low initial doses are used.a<br />• Adjust antihypertensive dosage at 1-2 month intervals (more aggressively in high-risk patients) if response is inadequate.289 Larger doses or 3 divided doses daily may be required to maintain effective response throughout the day.201<br />• Propranolol hydrochloride/hydrochlorothiazide fixed combination is not recommended for initial combination therapy;a,d adjust initial and subsequent dosages by administering each drug separately.a<br /><br />AMI<br /><br />• In patients with AMI, administer therapy in 2, 3, or 4 divided doses daily.201 Continue therapy for at least 1-3 years unless contraindicated;246,248,260 some experts recommend that therapy be continued indefinitely unless contraindicated.292<br /><br />Angina<br /><br />• Periodically reevaluate chronic therapy for angina to determine the need for dosage adjustment or continued therapy.a<br />• In patients with unstable angina or non-ST-segment elevation/non-Q-wave MI, the ACC and the AHA suggest initiation with IV loading dose of a β-blocker (in patients who tolerate IV therapy), followed by oral therapy.321<br />• If long-term therapy is to be discontinued, reduce dosage gradually over a period of about 2 weeks.a (See Abrupt Withdrawal of Therapy under Cautions.)<br /><br />Vascular Headache<br /><br />• If an adequate response for prophylaxis of migraine is not obtained within 4-6 weeks after reaching the maximum dose, discontinue therapy gradually over several weeks.201,314,315<br /><br />Administration<br /><br />Administer orally or IV.b<br /><br />Individualize dosage according to patient response.a<br /><br />Oral Administration<br /><br />Administer conventional tablets in divided doses before meals and at bedtime.a<br /><br />Administer extended-release capsules once daily.a,c<br /><br />Extended-release capsules produce lower blood concentrations than conventional tablets; do not substitute on a mg-for-mg basis.c Consider dosage retitration when switching from conventional tablets to extended-release capsules, especially to maintain effectiveness at the end of the dosing interval.c<br /><br />Dilute oral concentrate solution with water, juice, or carbonated beverages or mix with semisolid foods (e.g., applesauce, puddings) just prior to administration.a<br /><br />IV Administration<br /><br />For solution and drug compatibility information, see Compatibility under Stability.<br /><br />Monitor ECG and central venous pressure carefully during IV administration.201<br /><br />Replace IV therapy with oral therapy as soon as possible.b<br /><br />Rate of Administration<br /><br />Administer by slow IV injection at a rate not >1 mg/minute.b<br /><br />Dosage<br /><br />Pediatric Patients<br /><br />Usual Dosage<br /><br />>Oral<br /><br />Conventional tablets: 2-4 mg/kg daily in 2 equally divided doses.b Weight-adjusted initial dosage is approximate; adjust dosage according to response, up to 16 mg/kg daily.201,231,b<br /><br />Do not calculate dosage based on body surface area; may result in excessive plasma concentrations.a<br /><br />If propranolol is to be discontinued, decrease dosage gradually over 7-14 days.b<br /><br />Hypertension<br /><br />>Oral<br /><br />Conventional tablets: initially, 1 mg/kg daily in 2 equally divided doses.201,240,243 Adjust according to response and tolerance.a, 240,241<br /><br />Usual maintenance dosage is 2-4 mg/kg daily in 2 equally divided doses, up to 16 mg/kg daily.201<br /><br />Alternatively, some experts recommend a usual initial dosage of 1-2 mg/kg daily given in 2 or 3 divided doses.335 Increase dosage as necessary up to a maximum dosage of 4 mg/kg (up to 640 mg) daily given in 2 or 3 divided doses.335<br /><br />Cardiac Arrhythmias<br /><br />>Oral<br /><br />Initially, 1.5-2 mg/kg daily; titrate upward as necessary to 16 mg/kg daily in 4 divided doses to control the arrhythmia.231,232<br /><br />Dosages >4 mg/kg daily may be necessary for the management of supraventricular tachyarrhythmias.231,232<br /><br />>IV<br /><br />10-20 mcg/kg infused over 10 minutes has been recommended.a<br /><br />Thyrotoxicosis<br /><br />>Treatment of Tachyarrhythmias in Neonates with Thyrotoxicosis<br /><br />Oral:<br /><br />2 mg/kg daily in 2-4 divided doses has been used.a Higher dosages occasionally may be needed.a<br /><br />Adults<br /><br />Hypertension<br /><br />>Monotherapy<br /><br />Oral:<br /><br />Conventional tablets or oral solution: initially, 40 mg twice daily.201 Usual effective dosage is 120-240 mg daily.201<br /><br />Extended-release capsules: initially, 80 mg once daily.314 Usual effective dosage is 120-160 mg once daily.314<br /><br />Increase dosage gradually at 3- to 7-day intervals until optimum affect is achieved;a some patients may require doses of 640 mg daily.201,314<br /><br />>Fixed Combination Therapy<br /><br />Oral:<br /><br />Propranolol in fixed combination with hydrochlorothiazide: administer in 2 divided doses daily (up to 160 mg of propranolol and 50 mg of hydrochlorothiazide total daily dosage).c<br /><br />Combination preparation is inappropriate with propranolol dosages >160 mg daily due to excessive dosage of the thiazide component.323 May gradually add another antihypertensive agent when necessary using half of the usual initial dosage to avoid an excessive decrease in BP.323<br /><br />Initial use of fixed-combination preparations is not recommended; adjust by administering each drug separately, then use the fixed combination if the optimum maintenance dosage corresponds to the drug dosages in the combination preparation.a Administer separately for subsequent dosage adjustment.a<br /><br />Angina<br /><br />>Chronic Stable Angina<br /><br />Oral:<br /><br />Conventional tablets or oral solution: usual dosage is 80-320 mg daily in 2-4 divided doses.201,315 More than 320 mg daily has been recommended when there is only a partial response to usual dosage.a<br /><br />Extended-release capsules: initially, 80 mg daily.314 Gradually increase dosage at 3- to 7-day intervals as needed to control symptoms.314 Optimum response usually occurs at 160 mg daily, but there is wide variation in response.314<br /><br />>Unstable Angina or Non-ST-Segment Elevation/Non-Q-Wave MI<br /><br />IV:<br /><br />Initial dose of 0.5-1 mg, followed in 1-2 hours by oral therapy.321<br /><br />Oral:<br /><br />Conventional tablets or oral solution: initially, 40-80 mg every 6-8 hours; thereafter, maintain on 20-80 mg twice daily.321 Titrate to target heart rate of 50-60 bpm in patients with unstable angina in the absence of dose-limiting adverse effects.321<br /><br />Cardiac Arrhythmias<br /><br />>Oral<br /><br />Conventional tablets or oral solution: usually 10-30 mg 3 or 4 times daily.b<br /><br />>Life-threatening Arrhythmias or Those Occurring during Anesthesia<br /><br />IV:<br /><br />1-3 mg by slow IV injection.201 If necessary, repeat dose after 2 minutes.201 May administer additional doses at intervals of ≥4 hours until desired response is obtained.201<br /><br />>Supraventricular Tachyarrhythmias<br /><br />IV:<br /><br />Initial dosage: 0.1 mg/kg (divided in 3 equal doses) by slow IV injection (≤1 mg/minute) at 2- to 3-minute intervals has been recommended.352 May repeat total dose in 2 minutes if needed.352<br /><br />>Rate Control in Atrial Fibrillation and Flutter<br /><br />IV:<br /><br />Initial dosage: 0.1 mg/kg (divided in 3 equal doses) by slow IV injection (≤1 mg/minute) at 2- to 3-minute intervals has been recommended.352 May repeat total dose in 2 minutes if needed.352<br /><br />>Slowing of Ventricular Response during Acute Atrial Fibrillation<br /><br />IV:<br /><br />Loading dose: 0.15 mg.319<br /><br />Oral:<br /><br />Maintenance dosage for persistent atrial fibrillation: 80-240 mg daily in divided doses.319<br /><br />Hypertrophic Subaortic Stenosis<br /><br />>Oral<br /><br />Conventional tablets or oral solution: 20-40 mg 3 or 4 times daily.201,314,315<br /><br />Extended-release capsules: 80-160 mg once daily.201,314,315<br /><br />Pheochromocytoma<br /><br />>Prior to Surgery<br /><br />Oral:<br /><br />Conventional tablets or oral solution: 60 mg daily in divided doses (in conjunction with an α-adrenergic blocking agent) for 3 days prior to surgery.201,315 (See Pheochromocytoma under Cautions.)<br /><br />>Adjunctive Treatment for Inoperable Pheochromocytoma.<br /><br />Oral:<br /><br />30 mg daily in divided doses (in conjunction with an α-adrenergic blocker).201,315 (See Pheochromocytoma under Cautions.)<br /><br />Vascular Headache<br /><br />>Prevention of Common Migraine<br /><br />Oral:<br /><br />Conventional tablets or oral solution: initially, 80 mg daily in divided doses.201,314,315<br /><br />Extended-release capsules: 80 mg once daily.201,314,315<br /><br />Gradually increase dosage to achieve optimum response; usual effective dosage is 80-240 mg daily.201,314,315,326<br /><br />Discontinue if response is inadequate after 4-6 weeks; gradual withdrawal over several weeks may be advisable.201,314,315<br /><br />AMI<br /><br />>Mortality Reduction after AMI<br /><br />Oral:<br /><br />Conventional tablets or oral solution: 180-240 mg daily in divided doses, beginning 5-21 days after infarction.201,315 Higher dosage may be necessary for patients with coexisting conditions (e.g., angina, hypertension).201,315<br /><br />Administered in 3-4 divided doses daily in clinical studies, but twice-daily dosing also may be adequate.201<br /><br />Optimum benefit may be achieved when oral therapy with β-adrenergic blocking agent is continued for at least 1-3 years after infarction (when not contraindicated);246,248,260 some experts recommend continuing therapy indefinitely unless contraindicated.292<br /><br />Essential Tremor<br /><br />>Routine Therapy<br /><br />Oral:<br /><br />Conventional tablets: initially, 40 mg twice daily.201,229<br /><br />Response is variable and dosage must be individualized; optimal suppression of tremor usually occurs with 120-320 mg daily in 3 divided doses.201,202,203,204,205,207,208,211,213,214,215,216,219,220,221,228,229<br /><br />Complete suppression of tremor rarely is achieved;205,206,207,214,215,220,225,226 dosages exceeding 320 mg daily may not provide substantial added benefit but are associated with an increased risk of adverse effects.205,209,221<br /><br />Extended-release capsules: usual dosages administered once daily each morning appear to be at least as effective as equivalent dosages of conventional tablets administered in divided doses daily.216<br /><br />>Intermittent Therapy<br /><br />Oral:<br /><br />Conventional tablets: 80-120 mg as a single dose 1-3 hours before planned activity or anticipated stress associated with tremor.202,208,211,227<br /><br />Prescribing Limits<br /><br />Pediatric Patients<br /><br />Hypertension<br /><br />>Oral<br /><br />Maximum 16 mg/kg daily;201,231,232,240,241 however, some experts recommend a maximum dosage of 4 mg/kg (up to 640 mg) daily.335<br /><br />Adults<br /><br />Angina<br /><br />>Oral<br /><br />320 mg daily; some clinicians recommend higher dosage if there is only a partial response to usual dosage.317,a<br /><br />AMI<br /><br />>Oral<br /><br />240 mg daily.201,315<br /><br />Essential Tremor<br /><br />>Oral<br /><br />320 mg daily; higher dosages do not provide substantial added benefit and are associated with an increased risk of adverse effects.205,209,221<br /><br />Special Populations<br /><br />Hepatic Impairment<br /><br />Use with caution.b<br /><br />Renal Impairment<br /><br />Dosage adjustments not required.a Use with caution.b<br /><br />Geriatric Patients<br /><br />Use caution in dosage selection; initiate therapy at low end of dosage range.b<br /><br />Cautions<br /><br />Contraindications<br /><br />• Sinus bradycardia.b<br />• Heart block greater than first degree.b<br />• Cardiogenic shock.b<br />• CHF (unless secondary to a tachyarrhythmia treatable with propranolol).b (See Cardiac Failure under Cautions.)<br />• Raynaud's syndrome.a<br />• Malignant hypertension.a<br />• Bronchial asthma.a (See Bronchospastic Disease under Cautions.)<br />• Concomitant thioridazine therapy.310 (See Specific Drugs under Interactions.)<br />• Pre-excited atrial fibrillation or flutter.313<br /><br />Warnings/Precautions<br /><br />Warnings<br /><br />Cardiac Failure<br /><br />Possible precipitation of CHF.b Avoid use in patients with overt CHF;b may use cautiously in patients with inadequate myocardial function and, if necessary, in patients with well-compensated heart failure (e.g., those controlled with cardiac glycosides and/or diuretics).b,a Adequate treatment (e.g., with a cardiac glycoside and/or diuretic) and close observation recommended if signs or symptoms of impending cardiac failure occur; if cardiac failure continues, discontinue therapy, gradually if possible.b Possible decreased exercise tolerance in patients with left ventricular dysfunction.a<br /><br />Abrupt Withdrawal of Therapy<br /><br />Abrupt withdrawal of propranolol is not recommended as it may exacerbate angina symptoms or precipitate MI in patients with CAD.a, b Gradually decrease dosage over about 2 weeks and monitor patients carefully.b,a If exacerbation of angina occurs or acute coronary insufficiency develops, reinstitute therapy promptly, at least temporarily, and initiate appropriate measures for the management of unstable angina.b<br /><br />Bronchospastic Disease<br /><br />Possible inhibition of bronchodilation produced by endogenous catecholamines.b Possible increased airway resistance and bronchospasm, particularly in patients with a history of asthma.a Use with caution in patients with a history of nonallergic bronchospasm (e.g., chronic bronchitis, emphysema).b Use not recommended in patients with bronchial asthma.b (See Contraindications under Cautions.)<br /><br />Major Surgery<br /><br />Possible increased risks associated with general anesthesia (e.g., severe hypotension, difficulty restarting or maintaining heart beat) due to decreased ability of the heart to respond to reflex β-adrenergic stimuli.b,a Use with extreme caution for management of arrhythmias occurring during anesthesia with myocardial depressant anesthetics.a (See Specific Drugs under Interactions.)<br /><br />Diabetes and Hypoglycemia<br /><br />Possible decreased signs and symptoms of hypoglycemia (e.g., tachycardia, palpitation, BP changes, tremor).200,305,b Possible hypoglycemia, especially in those undergoing dialysis, prolonged fasting, or severe exercise regimens.305,314 Use with caution in patients with diabetes mellitus.a<br /><br />Thyrotoxicosis<br /><br />Signs of hyperthyroidism may be masked.b Possible thyroid storm if therapy is abruptly withdrawn; carefully monitor patients having or suspected of developing thyrotoxicosis.b,a Possible altered thyroid function test results.b,a<br /><br />Bradycardia<br /><br />Possible bradycardia, occasionally severe and accompanied by hypotension, syncope, shock, or angina.b,a Severe bradycardia requiring a demand pacemaker has occurred in patients with Wolff-Parkinson-White syndrome.b Treat severe bradycardia with IM or IV atropine sulfate.a If response is inadequate, consider cautious administration of IV isoproterenol.a,352 Possible depressed SA node automaticity; use with caution in patients with sinus node dysfunction.a<br /><br />AV Block<br /><br />Possible intensification of AV block, AV dissociation, AV conduction delays,352 complete heart block, or cardiac arrest, especially in patients with preexisting heart block caused by digitalis or other factors.a<br /><br />Pheochromocytoma<br /><br />To prevent severe hypertension, institute α-adrenergic blocking agent therapy prior to the use of propranolol and continue during propranolol therapy.b<br /><br />General Precautions<br /><br />History of Anaphylactic Reactions<br /><br />Possible increased reactivity to a variety of allergens; patients may be unresponsive to usual doses of epinephrine used to treat anaphylactic reactions.201,314<br /><br />Ocular Effects<br /><br />Possible dry eyes, generalized hyperemia of the conjunctivae, decreased tear production, and eye pain.a<br /><br />Myasthenia Gravis<br /><br />Myasthenic condition (e.g., ptosis, weakness of limbs, and double vision) reported rarely with propranolol; use may be contraindicated in patients with myasthenia gravis.a<br /><br />Other Precautions<br /><br />Shares the toxic potentials of β-adrenergic blocking agents; observe usual precautions of these agents.a<br /><br />When used in fixed combination with hydrochlorothiazide, consider the cautions, precautions, and contraindications associated with thiazide diuretics.a<br /><br />Specific Populations<br /><br />Pregnancy<br /><br />Category C.b,c,d<br /><br />Lactation<br /><br />Distributed into milk.b,c,d Use with caution.b,c,d<br /><br />Pediatric Use<br /><br />Efficacy and adverse effect profiles in children generally similar to such profiles in adults.201 Bioavailability may be increased in children with Down's syndrome.201 Safety and efficacy of extended-release capsules, oral solution, and injection not established in children.317,a<br /><br />Geriatric Use<br /><br />Insufficient evidence in patients ≥65 years of age to determine whether geriatric patients respond differently than younger patients.a Select dosage with caution, usually initiating therapy at the low end of the dosage range because of age-related decreases in hepatic, renal, and/or cardiac function and potential for concomitant disease and drug therapy.a<br /><br />Hepatic Impairment<br /><br />Use with caution;b assess hepatic function prior to and periodically during prolonged therapy.a<br /><br />Renal Impairment<br /><br />Use with caution;b assess renal function prior to and periodically during prolonged therapy.a<br /><br />Common Adverse Effects<br /><br />Bradycardia, nausea, vomiting, diarrhea, epigastric distress, abdominal cramping, constipation, flatulence.b,a<br /><br />Interactions<br /><br />Specific Drugs<br />Drug Interaction Comments Antipsychotic agents Potential pharmacodynamic interaction (additive (e.g., phenothiazines) hypotensive effect), especially with large doses of phenothiazines [a] Chlorpromazine Potential pharmacokinetic interaction (decreased propranolol clearance) [a] Thioridazine Potential pharmacokinetic interaction (decreased Concomitant use contraindicated [310] thioridazine metabolism). [310] Possible increased risk of serious, potentially fatal cardiac arrhythmias (e.g., torsades de pointes) [310] Haloperidol Potential pharmacodynamic interactions (hypotension and cardiac arrest) [a] Fluoxetine Potential pharmacokinetic interaction (decreased Caution recommended with concomitant propranolol metabolism); [272,273] complete heart use and in those with impaired block reported [272,273] cardiac conduction [272] Sympathomimetics Potential pharmacodynamic interaction (antagonism of Administer epinephrine with caution; β-adrenergic stimulating effects). [a] Very large decreased pulse rate with first- and doses of isoproterenol may be needed to overcome β- second-degree heart block may occur adrenergic blocking effects [a] [a] Drugs with Potential pharmacodynamic interaction (antagonism of anticholinergic cardiac β-adrenergic blocking effects) [a] effects Diuretics Potential pharmacodynamic interaction (increased Careful dosage adjustments recommended hypotensive effect) [a] [a] Reserpine Potential pharmacodynamic interaction (additive effects) [a] Antiarrhythmic drugs Potential pharmacodynamic interaction (additive or (lidocaine, phenytoin, antagonistic cardiac effects and additive toxic procainamide, effects) [a] quinidine, verapamil) Verapamil Serious adverse reactions reported rarely with concomitant IV verapamil, especially in patients with severe cardiomyopathy, CHF, or recent MI [a] Other cardiovascular Potential pharmacodynamic interaction (additive drugs (e.g., cardiac negative effects on SA or AV nodal conduction) [a] glycosides, nondihydropyridine calcium-channel blocking agents) Neuromuscular blocking Potential pharmacodynamic interaction (increased Administer with caution to patients agents effects of neuromuscular blocking agents) [a] receiving or recovering from the effects of neuromuscular blocking agents [a] Antidiabetic agents Potential pharmacologic interaction (altered Close monitoring recommended [a] antidiabetic response) [a] Ergot alkaloids Potential pharmacokinetic interaction (additive Use concomitantly with caution [a] peripheral vasoconstriction) [a] Cimetidine Potential pharmacokinetic interaction (decreased Monitor for signs and symptoms of propranolol clearance) [a] increased β-adrenergic blocking activity [a] Antacids Potential pharmacokinetic interaction (decreased Need to avoid concomitant use or propranolol absorption) [201,235,236,237] stagger dosing of an aluminum hydroxide antacid has not been fully elucidated; [237,238] consider increasing propranolol dosage if interaction suspected [235,237] Levodopa Potential pharmacodynamic interaction (decreased hypotensive and positive inotropic effects of levodopa) [a] Nonsteroidal anti- Potential pharmacodynamic interaction (decreased inflammatory agents hypotensive effects of propranolol) [a] Theophylline Potential pharmacokinetic interaction (decreased theophylline clearance). [a] Potential pharmacologic interaction (decreased theophylline- induced bronchodilation) [a] Myocardial depressant Potential pharmacodynamic interaction (increased risk general anesthetics of myocardial depression, bradycardia, hypotension) [a]<br /><br />Pharmacokinetics<br /><br />Absorption<br /><br />Bioavailability<br /><br />Oral absorption almost complete.a<br /><br />Bioavailabilities of conventional tablet and oral solution reportedly equivalent in adults.a<br /><br />Oral bioavailability may be increased in children with Down's syndrome.a<br /><br />Onset<br /><br />Conventional oral tablets: peak effect in 1-1.5 hours.b<br /><br />Plasma Concentrations<br /><br />100-150 ng/mL with considerable interpatient variation; 100 ng/mL generally represents high degree of β-blockade.a<br /><br />Distribution<br /><br />Extent<br /><br />Widely distributed into body tissues, including lungs, liver, kidneys, and heart.a Portion of orally administered dose immediately bound by liver.b<br /><br />Crosses blood-brain barrier.a<br /><br />Crosses placenta and is distributed into milk.a<br /><br />Plasma Protein Binding<br /><br />>90% over a wide range of blood concentrations.a<br /><br />Elimination<br /><br />Metabolism<br /><br />Almost completely metabolized in the liver.a<br /><br />Elimination Route<br /><br />Excreted principally in urine; at least 8 metabolites have been identified.a<br /><br />1-4% of an oral or IV dose of the drug appears in feces as unchanged drug and metabolites.a<br /><br />Half-life<br /><br />IV: 10 minutes (initial phase), 2.3 hours (terminal phase).b<br /><br />Conventional oral tablets: about 4 hours.b<br /><br />3.4-6 hours with chronic administration of usual therapeutic doses; 2-3 hours after single dose.a<br /><br />Extended-release capsules: apparent half-life about 10 hours.c<br /><br />Special Populations<br /><br />In patients with severely impaired renal function, a compensatory increase in fecal excretion of propranolol occurs.a Propranolol apparently not substantially removed by hemodialysis.a<br /><br />Stability<br /><br />Storage<br /><br />Oral<br /><br />Capsules<br /><br />Tight, light-resistant containers at 20-25°C; protect from moisture, freezing or excessive heat.c<br /><br />Tablets<br /><br />10, 60, and 80 mg: Tight containers at 20-25°C.b<br /><br />20 and 40 mg: Tight, light-resistant containers at 20-25°C.b<br /><br />Tablets (Propranolol Hydrochloride and Hydrochlorothiazide)<br /><br />Tight containers at about 25°C; protect from moisture, freezing or excessive heat.d<br /><br />Solution and Solution Concentrate<br /><br />Tight, light-resistant containers at 20-25°C.a<br /><br />Maximum stability at pH 3, rapidly decomposes at alkaline pH.a<br /><br />Decomposition in aqueous solution is accompanied by lowered pH and discoloration.a<br /><br />Parenteral<br /><br />Injection<br /><br />20-25°C; Protect from freezing or excessive heat.b<br /><br />Compatibility<br /><br />For information on systemic interactions resulting from concomitant use, see Interactions.<br /><br />Parenteral<br /><br />Solution CompatibilityHID<br />Compatible Dextrose 5% in sodium chloride 0.45 or 0.9% Dextrose 5% in water Ringer's injection, lactated Sodium chloride 0.45 or 0.9%<br /><br />Drug Compatibility<br /><br />>Admixture Compatibility [HID]<br />Compatible Dobutamine HCl Verapamil HCl<br /><br />>Y-Site Compatibility [HID]<br />Compatible Alteplase Fenoldopam mesylate Heparin sodium Hydrocortisone sodium succinate Inamrinone lactate Linezolid Meperidine HCl Milrinone lactate Morphine sulfate Potassium chloride Propofol Tacrolimus Tirofiban HCl Vitamin B complex with C Incompatible Amphotericin B cholesteryl sulfate complex Diazoxide Lansoprazole<br /><br />Actions<br /><br />• Inhibits response to adrenergic stimuli by competitively blocking β-adrenergic receptors within the myocardium and within bronchial and vascular smooth muscle; no intrinsic sympathomimetic activity.a<br />• Decreases resting and exercise-stimulated heart rate, myocardial contractility, and cardiac output; increases systolic ejection time and cardiac volume; decreases conduction velocity through the sinoatrial (SA) and atrioventricular (AV) nodes; and decreases myocardial automaticity.a<br />• Initially increases peripheral resistance; however, peripheral resistance decreases with chronic administration.a<br />• Decreases renal blood flow, glomerular filtration rate, and hepatic blood flow.a<br />• Membrane-stabilizing effect on the heart occurs at high dosages.a<br />• Reduces BP by decreasing cardiac output, decreasing sympathetic outflow from the CNS, and/or by suppressing renin release.a<br />• Reduces the frequency of anginal attacks and increases exercise tolerance by decreasing myocardial oxygen consumption and coronary blood flow.a May reduce myocardial oxygen requirements.a<br />• Antimigraine effect results from inhibition of vasodilation, the presence of β-adrenergic receptors in pial vessels of the brain, and inhibition of arteriolar spasms over the cortex.a<br />• Increases airway resistance (especially in asthmatic patients), inhibits glycogenolysis in the skeletal and cardiac muscles, blocks the release of free fatty acids and insulin, increases the number of circulating eosinophils, and increases uterine activity.a<br /><br />Advice to Patients<br /><br />• Importance of taking medication exactly as prescribed.a<br />• Importance of not interrupting or discontinuing therapy without consulting clinician; importance of temporarily limiting physical activity when discontinuing therapy.a<br />• Importance of immediately informing clinician at the first sign or symptom of impending cardiac failure or if any difficulty in breathing occurs.a<br />• Importance of patient informing anesthesiologist or dentist about propranolol therapy before undergoing major surgery.a<br />• Importance of informing patients that propranolol may interfere with glaucoma screening test.b<br />• Importance of informing clinicians of existing or contemplated therapy, including prescription and OTC drugs.a<br />• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.a<br />• Importance of informing patients of other important precautionary information. (See Cautions.)<br /><br />Preparations<br /><br />Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.<br /><br />Propranolol Hydrochloride<br />Routes Dosage Forms Strengths Brand Names Manufacturer Oral Capsules, 60 mg Inderal® LA Wyeth extended- release 80 mg Inderal® LA Wyeth Innopran® XL Reliant 120 mg Inderal® LA Wyeth Innopran® XL Reliant 160 mg Inderal® LA Wyeth Solution 20 mg/5 mL* Propranolol Hydrochloride Solution (with Roxane parabens) 40 mg/5 mL* Propranolol Hydrochloride Solution (with Roxane parabens) Solution, 80 mg/mL* Propranolol Hydrochloride Intensol® (with Roxane concentrate calibrated dropper) Tablets 10 mg* Inderal® (scored) Wyeth Propranolol Hydrochloride Tablets IVAX, Mylan, Pliva, UDL, Watson 20 mg* Inderal® (scored) Wyeth Propranolol Hydrochloride Tablets IVAX, Mylan, Pliva, UDL, Watson 40 mg* Inderal® (scored) Wyeth Propranolol Hydrochloride Tablets IVAX, Mylan, Pliva, UDL, Watson 60 mg* Inderal® (scored) Wyeth Propranolol Hydrochloride Tablets Pliva 80 mg* Inderal® (scored) Wyeth Propranolol Hydrochloride Tablets IVAX, Mylan, Pliva, UDL, Watson Parenteral Injection 1 mg/mL* Inderal® Wyeth Propranolol Hydrochloride Injection Bedford -----------------------------------------------------------------------------------------------------------<br />* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name<br /><br />Propranolol Hydrochloride and Hydrochlorothiazide<br />Routes Dosage Strengths Brand Names Manufacturer Forms Oral Tablets 40 mg Propranolol Hydrochloride Inderide® (scored) Wyeth and Hydrochlorothiazide 25 mg* Propranolol Hydrochloride and Mylan, Pliva, Hydrochlorothiazide Tablets Purepac 80 mg Propranolol Hydrochloride Inderide® (scored) Wyeth and Hydrochlorothiazide 25 mg* Propranolol Hydrochloride and Mylan, Pliva, Hydrochlorothiazide Tablets Purepac ----------------------------------------------------------------------------------------------------<br />* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name<br /><br />Comparative Pricing<br /><br />This pricing information is subject to change at the sole discretion of DS Pharmacy. This pricing information was updated 03/2010. For the most current and up-to-date pricing information, please visit www.drugstore.com. Actual costs to patients will vary depending on the use of specific retail or mail-order locations and health insurance copays.<br /><br />Inderal LA 120MG 24-hr Capsules (AKRIMAX PHARMACEUTICALS): 30/$157.4 or 90/$441.99<br /><br />Inderal LA 160MG 24-hr Capsules (AKRIMAX PHARMACEUTICALS): 30/$194.99 or 90/$564.93<br /><br />Inderal LA 60MG 24-hr Capsules (AKRIMAX PHARMACEUTICALS): 30/$143.84 or 90/$398.59<br /><br />Inderal LA 80MG 24-hr Capsules (AKRIMAX PHARMACEUTICALS): 30/$132.48 or 90/$354.9<br /><br />Inderide 40-25MG Tablets (WYETH): 60/$96.92 or 180/$277.47<br /><br />InnoPran XL 120MG 24-hr Capsules (GLAXO SMITH KLINE): 30/$73.85 or 90/$200.45<br /><br />InnoPran XL 80MG 24-hr Capsules (GLAXO SMITH KLINE): 30/$71.75 or 90/$202.53<br /><br />Propranolol HCl 10MG Tablets (PLIVA): 100/$12.99 or 200/$16.98<br /><br />Propranolol HCl 20MG/5ML Solution (ROXANE): 240/$25.99 or 480/$45.98<br /><br />Propranolol HCl 20MG Tablets (PLIVA): 100/$13.99 or 200/$21.98<br /><br />Propranolol HCl 40MG Tablets (PLIVA): 30/$12.99 or 90/$12.99<br /><br />Propranolol HCl 60MG Tablets (PLIVA): 60/$55.99 or 180/$139.97<br /><br />Propranolol HCl 80MG Tablets (PLIVA): 90/$15.99 or 270/$35.96<br /><br />Propranolol HCl CR 120MG 24-hr Capsules (PAR): 30/$59.99 or 60/$105.97<br /><br />Propranolol HCl CR 160MG 24-hr Capsules (PAR): 100/$219.99 or 300/$619.92<br /><br />Propranolol HCl CR 60MG 24-hr Capsules (PAR): 100/$115.97 or 300/$319.98<br /><br />Propranolol HCl CR 80MG 24-hr Capsules (PAR): 100/$134.99 or 300/$375.99<br /><br />--------------------------<br /><br />AHFS Drug Information. © Copyright, 1959-2010, Selected Revisions September 2009. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.<br />+ Use is not currently included in the labeling approved by the US Food and Drug Administration.<br /><br />References<br /><br />200. Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The 1984 report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1984; 144:1045-57. [IDIS 184763] [PubMed 6143542]<br /><br />201. Ayerst Laboratories Inc. Inderal® (propranolol hydrochloride) tablets prescribing information. Philadelphia, PA; 2002 Jan.<br /><br />202. Findley LJ. The pharmacological management of essential tremor. Clin Neuropharmacol. 1986; 9:S61-75. [PubMed 2885088]<br /><br />203. Larsen AT, Teravainen H. β1 versus nonselective blockade in therapy of essential tremor. Adv Neurol. 1983; 37:247-51. [PubMed 6344590]<br /><br />204. Calzetti S, Findley LJ, Perucca E et al. 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Metoprolol in essential tremor. Lancet. 1981; 2:1227. [IDIS 140990] [PubMed 6118649]<br /><br />224. Calzetti S, Findley LJ, Perucca S et al. The response of essential tremor to propranolol: evaluation of clinical variables governing its efficacy on prolonged administration. J Neurol Neurosurg Psychiatry. 1983; 46:393-8. [PubMed 6101174] [Free Fulltext PMC]<br /><br />225. Findley LJ, Calzetti S, Gresty MA et al. Amplitude of benign essential tremor and response to propranolol. Lancet. 1981; 2:479-80. [IDIS 136446] [PubMed 6115243]<br /><br />226. Koller WC. Propranolol in essential tremor. Neurology. 1985; 35:446. [PubMed 3974912]<br /><br />227. Calzetti S, Findley LJ, Gresty MA et al. Effect of a single oral dose of propranolol on essential tremor: a double-blind controlled study. Ann Neurol. 1983; 13:165-71. [IDIS 165922] [PubMed 6338809]<br /><br />228. Huttunen J, Teravainen H, Larsen TA. Beta adrenoreceptor antagonists in essential tremor. Lancet. 1984; 1:57.<br /><br />229. Wilson JF, Marshall RW, Richens A. Essential tremor: treatment with beta-adrenoceptor blocking drugs. In: Findley LJ, Capildea R. Movement disorders: tremor. London: Macmillan; 1984:245-60.<br /><br />230. National Heart, Lung, and Blood Institute Task Force on Blood Pressure Control in Children. Report of the Second Task Force on Blood Pressure Control in Children—1987. Pediatrics. 1987; 79:1-25. [IDIS 224856] [PubMed 3797155]<br /><br />231. Gillette PC. Advances in the diagnosis and treatment of tachydysrhythmias in children. Am Heart J. 1981; 102:111-20. [IDIS 134545] [PubMed 7246397]<br /><br />232. Pickoff AS, Zies L, Ferrer PL et al. High-dose propranolol therapy in the management of supraventricular tachycardia. J Pediatr. 1979; 94:144-6. [IDIS 107683] [PubMed 758396]<br /><br />233. Cohen SN, Kauffman RE, Strebel L. Appendix: Drugs. In: Behrman RE, Vaughan VC, eds. Nelson textbook of pediatrics. 13th ed. Philadelphia: W. B. Saunders Company; 1987: 1520-34.<br /><br />234. Cleeves L, Findley LJ. Beta-adrenoreceptor mechanisms in essential tremor: a comparative single dose study of the effect of non-selective and a beta-2 selective adrenoreceptor antagonist. J Neurol Neurosurg Psychiatry. 1984; 47:976-82. [PubMed 6148382] [Free Fulltext PMC]<br /><br />235. Dobbs JH, Skoutakis VA, Acchiardo SR et al. Effects of aluminum hydroxide on the absorption of propranolol. Curr Ther Res. 1977; 21:887-92.<br /><br />236. Remon JP, Belpaire F, Van Severen R et al. Interaction of antacids with antiarrhythmics. V. Effect of aluminum hydroxide and magnesium oxide on the bioavailability of quinidine, procainamide and propranolol in dogs. Arzneimittelforschung. 1983; 33:117-20. [PubMed 6681962]<br /><br />237. Mangini RJ, ed. Drug interactions facts. St. Louis: JB Lippincott Co; 1986(Apr):105.<br /><br />238. Hong CY, Hu SC, Lin SJ et al. Lack of influence of aluminum hydroxide on the bioavailability and beta-adrenoceptor blocking activity of propranolol. 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Philadelphia, PA; 2003 Nov.<br /><br />Copyright © 2010 by the American Society of Health-System Pharmacists, Inc. All rights reserved.<br /><br />0.0156251<br />Copyright © 2010 by the American College of Physicians. All rights reserved.<br />The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP. Because all PIER modules are updated regularly, printed web pages or PDFs may rapidly become obsolete. Therefore, PIER users should compare the date of the last update on the website with any printout to ensure that the information being referred to is the most current available.<br />(+/-) Show / Hide Bibliography<br />Bibliographic Citations Bibliographic Citations<br /><br />Export a citation for this title:<br /><br /><br />Or highlight and copy (Ctrl-C) the plain text citation below<br />............................................................<br />2010. ACP PIER & AHFS DI® Essentials™. 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Therefore, PIER users should compare the date of the last update on the website with any printout to ensure that the information being referred to is the most current available.<br /> * Database Title:<br /> o STAT!Ref Online Electronic Medical Library<br /> * Publication City:<br /> o Philadelphia, PA<br /> * Publication Year:<br /> o 2010<br /> * Publisher:<br /> o American College of Physicians<br /> * Title:<br /> o ACP PIER & AHFS DI® Essentials™ <br /> * Date Posted:<br /> o 5/11/2010 6:32:36 PM CDT (UTC -05:00) <br /> * Electronic Address:<br /> o http://online.statref.com/document.aspx?fxid=92&docid=5394 <br /> * Date Accessed:<br /> o 6/4/2010 1:17:34 AM CDT (UTC -05:00) <br /> * Location In Title:<br /> o ACP PIER & AHFS DI® Essentials™<br /> AHFS DI® ESSENTIALS™ (2010)<br /> "P" Monographs<br /> Propranolol (Systemic)<br /><br />Send Feedback<br />Customer Service<br />800.901.5494<br />Title Updates<br />User Responsibilities<br />Training Center<br />What's New<br />Teton Server (6.8.1) - ©2009 Teton Data Systems<br />Send Us Your Commentsqhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-63355853936538725372010-06-03T23:11:00.000-07:002010-06-03T23:17:37.332-07:00Norepinephrine vasoconstrictorWorking...<br />5/11/2010 6:32:36 PM<br />Norepinephrine (Systemic)<br /><br />Introduction<br /><br />Norepinephrine is identical to the endogenous catecholamine that is synthesized in the adrenal medulla and in sympathetic nervous tissue; norepinephrine predominantly acts by a direct effect on α-adrenergic receptors.b<br /><br />Class: alpha- and beta-Adrenergic Agonists 12:12.12; AU100 (VA)<br /><br />Synonyms: l-Arterenol Bitartrate; l-Arterenol Bitartrate; Levarterenol Bitartrate; Noradrenaline Acid Tartrate; (-)-Noradrenaline Acid Tartrate; (-)-Noradrenaline Bitartrate; l-Noradrenaline Bitartrate; l-Noradrenaline Bitartrate; Levophed; Norepinephrine<br /><br />Uses<br /><br />Shock<br /><br />Used to produce vasoconstriction and cardiac stimulation as an adjunct to correct hemodynamic imbalances in the treatment of shock that persists after adequate fluid volume replacement.b (See Hypovolemia under Cautions.)<br /><br />If severe peripheral vasoconstriction exists, norepinephrine may be ineffective and may have a deleterious effect by causing further reductions in plasma volume and blood flow to vital organs.b<br /><br />Value of pressor therapy in shock, especially when due to septicemia, burns, trauma, or drug overdosage, is questionable, either because the effectiveness has not been proved or because vasoconstriction caused by the drug may adversely affect the patient.b<br /><br />May be indicated if patient fails to respond to administration of fluids, a change in position, or other measures directed to the specific cause of shock such as anti-infectives in septicemia, epinephrine in anaphylactic shock, or specific antidotes and/or removal of the drug in cases of drug overdosage.b<br /><br />Pressor therapy in overdosage of barbiturates or other sedatives is especially controversial; some clinicians have stated that the incidence of mortality may actually be increased when a pressor is given.b<br /><br />May be useful to control shock following pheochromocytomectomy, but shock generally can be prevented by maintenance of adequate blood volume and/or preoperative administration of an α-adrenergic blocking agent.b<br /><br />May be used as an adjunct in the management of shock resulting from sympathectomy or poliomyelitis.b<br /><br />Anaphylactic Shock<br /><br />Epinephrine is the drug of choice in the emergency treatment of severe acute anaphylactic reactions, including anaphylactic shock.b<br /><br />Once adequate ventilation is assured, maintenance of blood pressure in patients with anaphylactic shock may be achieved with other pressor agents, such as norepinephrine.b<br /><br />MI<br /><br />In hypotension associated with MI, cautious administration of norepinephrine may be of value and some clinicians consider it to be the pressor drug of choice.b<br /><br />This type of shock generally has a poor prognosis even when pressor agents are used, and norepinephrine-induced increases in myocardial oxygen demand and the work of the heart may outweigh the beneficial effects of the drug.b<br /><br />Cardiac arrhythmias due to norepinephrine are more likely to occur in patients with MI.b<br /><br />CPR<br /><br />May be used for ACLS as an adjunct to maintain adequate BP when severe hypotension (e.g., SBP <70 mm Hg) and low total peripheral resistance persist and renal and cerebral perfusion remain inadequate after an effective heartbeat, palpable pulse, and ventilation have been established by other means.b<br /><br />Exhibits both positive inotropic and vasoconstrictive activity; therefore, may be particularly useful in elevating systolic arterial pressures to 70-100 mm Hg.b Once such elevations are achieved, dopamine therapy can be initiated.b<br /><br />Relatively contraindicated in patients with hypovolemia.b<br /><br />Use cautiously in patients with ischemic heart disease because it may increase myocardial oxygen requirements.b<br /><br />Hypotension during Anesthesia<br /><br />May be used to treat hypotension occurring during spinal anesthesia, but other vasopressors having a longer duration of action and which can be administered IM such as metaraminol, methoxamine, or phenylephrine are more commonly used.b<br /><br />May be used to treat hypotension occurring during general anesthesia; however, the possibility of cardiac arrhythmias should be considered.b (See Anesthetics, general under Interactions.)<br /><br />If a vasopressor is required, norepinephrine should not be used in obstetric patients (see Pregnancy under Cautions); ephedrine usually is preferred.b<br /><br />Adjunct to Local Anesthesia<br /><br />May be added to solutions of some local anesthetics to decrease the rate of vascular absorption of the anesthetic, thereby localizing anesthesia and prolonging the duration of anesthesia.b<br /><br />Decreases risk of systemic toxicity due to the local anesthetic.b<br /><br />Not as potent as epinephrine and must be used in higher concentrations to prolong local anesthetic effects; epinephrine is more commonly used for this purpose.b<br /><br />GI Hemorrhage<br /><br />Has been used with some success intraperitoneally+ or via a nasogastric tube+ as a hemostatic agent for severe upper GI bleeding+.b<br /><br />Pericardial Tamponade<br /><br />Has been used to increase cardiac output by increasing ventricular emptying and temporarily increasing cardiac filling pressure in pericardial tamponade+.b<br /><br />Dosage and Administration<br /><br />General<br /><br />• Observe the effect of the initial dose on BP carefully and adjust the rate of flow to establish and maintain the desired BP.b<br />• Do not leave the patient unattended; must closely monitor the infusion flow rate.b<br />• Check BP every 2 minutes from the time the norepinephrine infusion is started until the desired effect is achieved, then every 5 minutes while the drug is being infused.b<br />• Elevate BP to slightly less than the patient's normal BP.b<br />• In previously normotensive patients, maintain SBP at 80-100 mm Hg; in previously hypertensive patients, maintain SBP at 30-40 mm Hg below their preexisting BP.b<br />• Very severe hypotension: Maintenance of even lower BP may be desirable if blood or fluid volume replacement has not been completed.b<br />• Continue therapy until adequate BP and tissue perfusion are maintained.b<br />• Discontinuing therapy: Slow infusion rate gradually and avoid abrupt withdrawal; observe patient carefully so that therapy may be resumed if the BP falls too rapidly.b<br />• In some patients, additional administration of IV fluids may be necessary before norepinephrine can be discontinued.<br />• Do not reinstate pressor therapy until the SBP falls to 70-80 mm Hg.b<br /><br />Administration<br /><br />Administer by IV infusion.b<br /><br />IV Administration<br /><br />For solution and drug compatibility information, see Compatibility under Stability.<br /><br />Administer by IV infusion using an infusion pump or other apparatus to control the rate of flow.b<br /><br />Infuse into the antecubital vein of the arm if possible, although the femoral vein may also be used.b (See Extravasation under Cautions.)<br /><br />Administer through a plastic catheter inserted deep into the vein.b<br /><br />A catheter tie-in technique should be avoided if possible because obstruction of blood flow around the tubing may cause stasis and increased local concentration of the drug.b<br /><br />Care must be taken to avoid extravasation because local necrosis may result.b (See Extravasation and also Extravasation Treatment under Cautions for discussion on the prevention and treatment of the adverse effects of extravasation.)<br /><br />In prolonged therapy, change the injection site periodically.b<br /><br />Dilution<br /><br />Prior to administration, dilute the commercially available concentrate for injection with 5% dextrose injection, with or without sodium chloride.b<br /><br />Concentration of norepinephrine and the infusion rate depend on the drug and fluid requirements of the individual patient.b<br /><br />Infusion solution usually prepared by adding 4 mg of norepinephrine (4 mL of the commercially available injection) to 1 L of 5% dextrose injection creating a resultant solution containing 4 mcg/mL;<<011>>a more dilute or concentrated solution may be prepared depending on the fluid volume requirements of the patient.b<br /><br />Dosage<br /><br />Available as norepinephrine bitartrate; dosage expressed in terms of norepinephrine (2 mg of norepinephrine bitartrate is equivalent to 1 mg of norepinephrine).b<br /><br />Pediatric Patients<br /><br />Shock<br /><br />Administer in the lowest effective dosage for the shortest possible time.b<br /><br />>IV<br /><br />Usually administered at a rate of 2 mcg/minute; alternatively, 2 mcg/m2 per minute.b<br /><br />Pediatric Advanced Life Support (PALS) during CPR<br /><br />>IV<br /><br />Initial infusion rate: 0.1 mcg/kg per minute; ranges up to 2 mcg/kg per minute and should be adjusted to achieve the desired change in BP and perfusion.b<br /><br />Adults<br /><br />Shock<br /><br />Administer in the lowest effective dosage for the shortest possible time.b<br /><br />>IV<br /><br />Usual initial dosage: 8-12 mcg/minute; alternatively, some clinicians suggest initiating norepinephrine therapy at a dosage of 0.5-1 mcg/minute titrated to effect.b<br /><br />Average adult maintenance dosage: 2-4 mcg/minute.b<br /><br />>Refractory Shock<br /><br />IV:<br /><br />May require 8-30 mcg/minute.b<br /><br />GI Hemorrhage<br /><br />>Intraperitoneal<br /><br />8 mg of norepinephrine in 250 mL of 0.9% sodium chloride injection has been administered intraperitoneally+ to control upper GI bleeding+.b<br /><br />>Nasogastric<br /><br />8 mg of norepinephrine in 100 mL of 0.9% sodium chloride solution has been instilled through a nasogastric tube+ every hour for 6-8 hours, then every 2 hours for 4-6 hours to control upper GI bleeding+; frequency of administration was then gradually reduced until the drug was discontinued.b<br /><br />Special Populations<br /><br />Geriatric Patients<br /><br />Has not been evaluated systematically in those 65 years of age and older, but the manufacturers currently do not make specific dosage recommendations for geriatric patients.b<br /><br />If used in geriatric patients, initial dosage usually should be at the low end of the dosage range and caution should be exercised since renal, hepatic, and cardiovascular dysfunction and concomitant disease or other drug therapy are more common in this age group than in younger patients.b<br /><br />Cautions<br /><br />Contraindications<br /><br />• Generally considered contraindicated to use during anesthesia with cyclopropane or halogenated hydrocarbon general anesthetics because of the risk of inducing cardiac arrhythmias.b (See Anesthetics, general under Interactions.)<br />• Use in patients with profound hypoxia or hypercapnia may be contraindicated for risk of inducing cardiac arrhythmias.b<br />• In conjunction with local anesthetics, norepinephrine is contraindicated for use in fingers, toes, ears, nose, or genitalia.b<br /><br />Warnings/Precautions<br /><br />Warnings<br /><br />Hypovolemia<br /><br />Pressor therapy is not a substitute for replacement of blood, plasma, fluids, and/or electrolytes.b<br /><br />Correct blood volume depletion as fully as possible before administration.b<br /><br />May be used in an emergency as an adjunct to fluid volume replacement or as a temporary supportive measure to maintain coronary and cerebral artery perfusion until volume replacement therapy can be completed, but norepinephrine must not be used as sole therapy in hypovolemic patients.b<br /><br />Additional volume replacement also may be required during or after administration of norepinephrine, especially if hypotension recurs.b<br /><br />Monitoring of central venous pressure or left ventricular filling pressure may be helpful in detecting and treating hypovolemia; in addition, monitoring of central venous or pulmonary arterial diastolic pressure is necessary to avoid overloading the cardiovascular system and precipitating CHF.b<br /><br />Hypoxia, Hypercapnia, and Acidosis<br /><br />Hypoxia, hypercapnia, and acidosis, may reduce the effectiveness and/or increase the incidence of adverse effects of norepinephrine, and must be identified and corrected prior to or concurrently with administration of the drug.b<br /><br />Extravasation<br /><br />Because severe local adverse effects may occur, extravasation of norepinephrine must be avoided.b<br /><br />The site of infusion should be checked frequently for free flow and the infused vein should be observed for blanching.b<br /><br />Risk of tissue damage is apparently very slight if infused through a plastic catheter deep into an antecubital vein.b<br /><br />Avoid injection into leg veins, especially in geriatric patients or those with occlusive vascular diseases, arteriosclerosis, diabetes mellitus, or Buerger's disease.b<br /><br />If blanching is observed in the infused vein or if therapy is to be prolonged, changing the injection site periodically may be advisable.b<br /><br />Extravasation Treatment<br /><br />If extravasation occurs, 10-15 mL of sodium chloride solution containing 5-10 mg of phentolamine mesylate should be infiltrated (using a syringe with a fine hypodermic needle) liberally throughout the affected area, which is identified by a cold, hard, and pallid appearance.b<br /><br />Immediate and conspicuous local hyperemic changes occur if the area is infiltrated within 12 hours, but such treatment is ineffective when given >12 hours after extravasation; therefore, phentolamine should be administered as soon as possible after extravasation is noted.b<br /><br />Addition of 5-10 mg of phentolamine to each L of infusion fluid containing norepinephrine may prevent sloughing of tissue, if extravasation occurs, without altering the pressor effects of norepinephrine; however, IV injection of phentolamine is not an effective antidote after extravasation has occurred.b<br /><br />In severe hypotension after MI: Thrombosis in the infused vein and perivenous reactions and necrosis may be prevented by adding enough heparin to the norepinephrine infusion to supply 100-200 units of heparin per hour.b<br /><br />Hypertensive or Hypothryroid Patients<br /><br />Administer with caution to hypertensive or hyperthyroid patients since adverse reactions are most likely to occur.b<br /><br />Peripheral or Mesenteric Vascular Thrombosis<br /><br />Unless necessary as a life-saving procedure, do not use in patients with peripheral or mesenteric vascular thrombosis because ischemia may be increased and the area of infarction extended.b<br /><br />Sensitivity Reactions<br /><br />Sulfite Sensitivity<br /><br />Formulations of norepinephrine bitartrate injection contain sulfites, which may cause allergic-type reactions (including anaphylaxis and life-threatening or less severe asthmatic episodes) in certain susceptible individuals.b<br /><br />General Precautions<br /><br />Extravasation and Localized Vasoconstriction<br /><br />Can cause tissue necrosis and sloughing at the site of injection as a result of local vasoconstriction. (See Extravasation under Warnings.)<br /><br />Impairment of circulation and sloughing of tissue may also occur without obvious extravasation.b<br /><br />Prolonged Administration<br /><br />Has caused decreased cardiac output, edema, hemorrhage, focal myocarditis, subpericardial hemorrhage, necrosis of the intestine, or hepatic and renal necrosis.b<br /><br />Generally occurs in patients with severe shock and it is not clear if the drug or the shock state itself was the cause.b<br /><br />Cardiovascular and Renal Effects<br /><br />Can cause severe peripheral and visceral vasoconstriction, reduced blood flow to vital organs, decreased renal perfusion and therefore decreased urine output, tissue hypoxia, and metabolic acidosis; these effects are most likely to occur in hypovolemic patients.b<br /><br />May cause plasma volume depletion which may result in perpetuation of the shock state or recurrence of hypotension when the drug is discontinued.b<br /><br />Increases myocardial oxygen consumption and the work of the heart.b<br /><br />Cardiac output may be decreased following prolonged use of the drug or administration of large doses because venous return to the heart may be diminished because of increased peripheral vascular resistance; decreased cardiac output may be especially harmful to elderly patients or those with initially poor cerebral or coronary circulation.b<br /><br />Arrhythmias<br /><br />May cause palpitation and bradycardia as well as potentially fatal cardiac arrhythmias, including ventricular tachycardia, bigeminal rhythm, nodal rhythm, AV dissociation, and fibrillation.b<br /><br />Arrhythmias are especially likely to occur in patients with AMI, hypoxia, or hypercapnia, or those receiving other drugs that may increase cardiac irritability such as cyclopropane or halogenated hydrocarbon general anesthetics. (See Anesthetics, general under Cautions.)<br /><br />Specific Populations<br /><br />Pregnancy<br /><br />Category C.c<br /><br />Lactation<br /><br />Unknown whether norepinephrine is distributed into human milk.b,c Because of norepinephrine's indications, use during breast-feeding is unlikely.c<br /><br />Pediatric Use<br /><br />Safety and efficacy not established.b<br /><br />Geriatric Use<br /><br />Has not been evaluated systematically in those ≥65 years of age, but the manufacturers currently do not make specific dosage recommendations for geriatric patients.b<br /><br />If used in geriatric patients, the initial dosage usually should be at the low end of the dosage range and caution should be exercised since renal, hepatic, and cardiovascular dysfunction and concomitant disease or other drug therapy are more common in this age group than in younger patients.b<br /><br />Norepinephrine infusions should not be administered into leg veins in geriatric patients. (See Extravasation under Cautions.)<br /><br />Common Adverse Effects<br /><br />May cause headache, weakness, dizziness, tremor, pallor, respiratory difficulty or apnea, and precordial pain.b<br /><br />Overdosage or administration of usual doses to patients who are hypersensitive to the effects of norepinephrine (e.g., hyperthyroid patients) may result in photophobia, pallor, intense sweating, vomiting, retrosternal or pharyngeal pain, severe hypertension, cerebral hemorrhage, seizures, and severe headache. Headache may be a symptom of hypertension.<br /><br />Interactions<br /><br />Specific Drugs<br />Drug Interaction Comments α-Adrenergic blocking agents Despite animal evidence of interaction (decreased pressor response), interaction appears unlikely in humans [b] β-Adrenergic blocking agents Possibility that concomitant use might result in Propranolol may be used to treat cardiac higher elevations of BP because of blockade of any arrhythmias occurring during administration of β-mediated arteriolar dilation should be kept in norepinephrine [b] mind [b] In animals, preadministration of a β-adrenergic blocking drug such as propranolol blocks the cardiac stimulating effects of norepinephrine [b] Anesthetics, general Concomitant use with cyclopropane or halogenated If a pressor drug is required when these general (cyclopropane or halogenated hydrocarbon general anesthetics, which increase anesthetics are used, give one with minimal hydrocarbons) cardiac irritability, may result in arrhythmias [b] cardiac stimulating effects such as methoxamine or phenylephrine [b] Antidepressants, tricyclic May potentiate the pressor effects of norepinephrine, Norepinephrine should be given cautiously and in resulting in severe, prolonged hypertension small doses to patients receiving these drugs Antidepressants, MAO Potentiation may result from inhibition of tissue MAO is one of the enzymes responsible for inhibitors uptake of norepinephrine or by increased norepinephrine metabolism; although some adrenoreceptor sensitivity to the drug [b] clinicians have reported that MAO inhibitors do not appear to potentiate the effects ofnorepinephrine to a clinically important extent, the manufacturer states that norepinephrine should be administered with extreme caution to patients receiving an MAO inhibitor because severe, prolonged hypertension may result Antihistamines (especially May potentiate pressor effects, resulting in severe, Use cautiously and in small doses with these drugs diphenhydramine, prolonged hypertension tripelennamine, and dexchlorpheniramine) Atropine Atropine sulfate blocks the reflex bradycardia caused by norepinephrine and enhances the pressor response to norepinephrine Diuretics (furosemide, other Concomitant use may decrease arterial responsiveness diuretics) to pressor drugs such as norepinephrine Ergot alkaloids, parenteral May potentiate the pressor effects of norepinephrine, Use cautiously and in small doses with these drugs resulting in severe, prolonged hypertension Guanethidine May potentiate the pressor effects of norepinephrine, Use cautiously and in small doses with these drugs resulting in severe, prolonged hypertension Methyldopa May potentiate the pressor effects of norepinephrine, Use cautiously and in small doses with these drugs resulting in severe, prolonged hypertension<br /><br />Pharmacokinetics<br /><br />Absorption<br /><br />Bioavailability<br /><br />Oral: Destroyed in the GI tract.b<br /><br />Sub-Q: Poorly absorbed.b<br /><br />Onset<br /><br />IV: Pressor response occurs rapidly.b<br /><br />Duration<br /><br />Short; pressor action stops within 1-2 minutes after the infusion is discontinued.b<br /><br />Distribution<br /><br />Extent<br /><br />Localizes mainly in sympathetic nervous tissue.b<br /><br />Crosses the placenta.b,c<br /><br />Not known if distributes into milk.b,c<br /><br />Does not cross the blood-brain barrier.b<br /><br />Elimination<br /><br />Metabolism<br /><br />Via the liver and other tissues by a combination of reactions involving the enzymes catechol-O-methyltransferase (COMT) and MAO.b<br /><br />Pharmacologic actions are terminated mainly by uptake and metabolism in sympathetic nerve endings.b<br /><br />Major metabolites are normetanephrine and 3-methoxy-4-hydroxy mandelic acid (vanillylmandelic acid, VMA), both of which are inactive.b<br /><br />Elimination Route<br /><br />Metabolites are excreted in urine mainly as the sulfate conjugates and, to a lesser extent, as the glucuronide conjugates; only small quantities of norepinephrine are excreted unchanged.b<br /><br />Stability<br /><br />Storage<br /><br />Parenteral<br /><br />Injection<br /><br />Tight, light-resistant containers.b<br /><br />Protect from light and air at 25°C (may be exposed to 15-30°C).b<br /><br />Compatibility<br /><br />For information on systemic interactions resulting from concomitant use, see Interactions.<br /><br />Parenteral<br /><br />IV infusion: Dilute norepinephrine with 5% dextrose injection with or without sodium chloride to protect against loss of potency caused by oxidation during IV infusion; do not use sodium chloride injection alone.b<br /><br />Following dilution with 5% dextrose, IV infusions containing norepinephrine 2.5 or 4 mcg/mL have been reported to be stable for at least 24 hours at room temperature if the pH is approximately 5.6.b<br /><br />Norepinephrine solutions containing 2.5 mcg/mL in 5% dextrose have been reported to lose 5% of their potency in 6 hours at pH 6.5 and in 4 hours at pH 7.5.b<br /><br />Use caution if diluted with 5% dextrose injections with a pH of >5.5-6 or if the drug is mixed with alkaline additives such as sodium bicarbonate, barbiturates, or alkaline buffered antibiotics which will result in pH >6; these solutions should be used immediately after preparation.b<br /><br />Administer whole blood or plasma, if indicated during therapy with norepinephrine, separately or via a Y-tube.b<br /><br />Solution CompatibilityHID<br />Compatible Amino acids 4.25%, dextrose 25% Dextrose 5% in sodium chloride 0.9% Dextrose 5% in water Ringer's injection, lactated Sodium chloride 0.9%<br /><br />Drug Compatibility<br /><br />>Admixture Compatibility [HID]<br />Compatible Amikacin sulfate Calcium chloride Calcium gluconate Cimetidine HCl Ciprofloxacin Corticotropin Dimenhydrinate Dobutamine HCl Heparin sodium Hydrocortisone sodium succinate Magnesium sulfate Meropenem Methylprednisolone sodium succinate Multivitamins Potassium chloride Succinylcholine chloride Verapamil HCl Vitamin B complex with C Incompatible Aminophylline Amobarbital sodium Blood, whole Chlorothiazide sodium Chlorpheniramine maleate Pentobarbital sodium Phenobarbital sodium Phenytoin sodium Sodium bicarbonate Streptomycin sulfate Thiopental sodium Variable Ranitidine HCl<br /><br />>Y-site Compatibility [HID]<br />Compatible Alcohol 10% in dextrose 5% Amiodarone HCl Argatroban Bivalirudin Dexmedetomidine HCl Diltiazem HCl Dobutamine HCl Dopamine HCl Epinephrine HCl Esmolol HCl Famotidine Fenoldopam mesylate Fentanyl citrate Furosemide Haloperidol lactate Heparin sodium Hetastarch in lactated electrolyte injection (Hextend) Hydrocortisone sodium succinate Hydromorphone HCl Inamrinone lactate Labetalol HCl Lorazepam Meropenem Midazolam HCl Milrinone lactate Morphine sulfate Nicardipine HCl Nitroglycerin Pantoprazole sodium Potassium chloride Propofol Ranitidine HCl Remifentanil HCl Sodium nitroprusside Vasopressin Vecuronium bromide Vitamin B complex with C Incompatible Drotrecogin alfa (activated) Thiopental sodium<br /><br />Actions<br /><br />• Acts predominantly by a direct effect on α-adrenergic receptors.b<br />• Directly stimulates β-adrenergic receptors of the heart (β1-adrenergic receptors) but not those of the bronchi or peripheral blood vessels (β2-adrenergic receptors).b<br />• Believed that α-adrenergic effects result from inhibition of the production of cyclic adenosine-3´,5´-monophosphate (AMP) by inhibition of the enzyme adenyl cyclase, whereas β-adrenergic effects result from stimulation of adenyl cyclase activity.b<br />• Main effects of therapeutic doses are vasoconstriction and cardiac stimulation.b<br />• Constricts both capacitance and resistance blood vessels by its effect on α-adrenergic receptors.b<br />• Total peripheral resistance is increased, resulting in increased SBP and DBP.b Blood flow to vital organs, skin, and skeletal muscle is reduced.b<br />• Local vasoconstriction caused by the drug may result in hemostasis and/or necrosis.b<br />• May reduce circulating plasma volume (especially with prolonged use) as a result of loss of fluid into extracellular spaces caused by postcapillary vasoconstriction.b<br />• Acts on β1-adrenergic receptors in the heart, producing a positive inotropic effect on the myocardium.b<br />• Although norepinephrine has fewer CNS effects than does epinephrine, restlessness, headache, and tremor may occur.<br />• Can increase glycogenolysis and inhibit insulin release in the pancreas, resulting in hyperglycemia.b<br />• Increased oxygen consumption and elevation of body temperature may occur.b<br />• As a result of its effect on α-adrenergic receptors, norepinephrine may cause contraction of the pregnant uterus and constriction of uterine blood vessels; however, the vasoconstrictor effects may be overcome by an increase in maternal blood pressure.<br /><br />Advice to Patients<br /><br />• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs as well as any concomitant illnesses.<br />• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.<br />• Importance of informing patients of other important precautionary information. (See Cautions.)<br /><br />Preparations<br /><br />Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.<br /><br />Norepinephrine Bitartrate<br />Routes Dosage Forms Strengths Brand Names Manufacturer Parenteral For injection, 1 mg (of Levophed® Bitartrate (with sodium Hospira concentrate, for norepinephrine) metabisulfite and sodium chloride) IV infusion per mL* Norepinephrine Bitartrate Injection (with Bedford, sodium metabisulfite and sodium PharmaForce, chloride) Sicor -----------------------------------------------------------------------------------------------------------------<br />* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name<br /><br />--------------------------<br /><br />AHFS Drug Information. © Copyright, 1959-2010, Selected Revisions August 2007. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.<br />+ Use is not currently included in the labeling approved by the US Food and Drug Administration.<br /><br />References<br /><br />b. AHFS drug information 2004. McEvoy GK, ed. Norepinephrine. Bethesda, MD: American Society of Health-System Pharmacists; 2004:1270-3.<br /><br />c. Briggs GG, Freeman RK, Yaffe SJ. Drug in pregnancy and lactation: a reference guide to fetal and neonatal risk. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2002:1014.<br /><br />pdh. Schilling McCann JA, Publisher. Pharmacists drug handbook. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins and American Society of Health-System Pharmacists; 2003.<br /><br />HID. Trissel LA. Handbook on injectable drugs. 14th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2007:1231-7.<br /><br />Copyright © 2010 by the American Society of Health-System Pharmacists, Inc. All rights reserved.<br /><br />0.0156251<br />Copyright © 2010 by the American College of Physicians. All rights reserved.<br />The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP. Because all PIER modules are updated regularly, printed web pages or PDFs may rapidly become obsolete. Therefore, PIER users should compare the date of the last update on the website with any printout to ensure that the information being referred to is the most current available.<br />(+/-) Show / Hide Bibliography<br />Bibliographic Citations Bibliographic Citations<br /><br />Export a citation for this title:<br /><br /><br />Or highlight and copy (Ctrl-C) the plain text citation below<br />............................................................<br />2010. ACP PIER & AHFS DI® Essentials™. Philadelphia, PA. American College of Physicians. STAT!Ref Online Electronic Medical Library. http://online.statref.com/document.aspx?fxid=92&docid=5268. 6/4/2010 1:11:07 AM CDT (UTC -05:00).<br /><br /> * Copyright:<br /> o Copyright © 2010 by the American College of Physicians. All rights reserved.<br /> The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP. Because all PIER modules are updated regularly, printed web pages or PDFs may rapidly become obsolete. Therefore, PIER users should compare the date of the last update on the website with any printout to ensure that the information being referred to is the most current available.<br /> * Database Title:<br /> o STAT!Ref Online Electronic Medical Library<br /> * Publication City:<br /> o Philadelphia, PA<br /> * Publication Year:<br /> o 2010<br /> * Publisher:<br /> o American College of Physicians<br /> * Title:<br /> o ACP PIER & AHFS DI® Essentials™ <br /> * Date Posted:<br /> o 5/11/2010 6:32:36 PM CDT (UTC -05:00) <br /> * Electronic Address:<br /> o http://online.statref.com/document.aspx?fxid=92&docid=5268 <br /> * Date Accessed:<br /> o 6/4/2010 1:11:07 AM CDT (UTC -05:00) <br /> * Location In Title:<br /> o ACP PIER & AHFS DI® Essentials™<br /> AHFS DI® ESSENTIALS™ (2010)<br /> "N" Monographs<br /> Norepinephrine (Systemic)<br /><br />Send Feedback<br />Customer Service<br />800.901.5494<br />Title Updates<br />User Responsibilities<br />Training Center<br />What's New<br />Teton Server (6.8.1) - ©2009 Teton Data Systems<br />Send Us Your Commentsqhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0tag:blogger.com,1999:blog-3514095437117411992.post-21565500396510589372010-06-03T23:08:00.000-07:002010-06-03T23:09:44.650-07:00Phenylephrine vasoconstrictionWorking...<br />5/11/2010 6:32:36 PM<br />Phenylephrine (Systemic)<br /><br />Introduction<br /><br />Sympathomimetic amine that predominantly acts by a direct effect on α-adrenergic receptors.<br /><br />Class: alpha-Adrenergic Agonists 12:12.04; AU100 (VA)<br /><br />Synonyms: Phenylephrine<br /><br />Uses<br /><br />Shock<br /><br />Used to produce vasoconstriction as an adjunct to correct hemodynamic imbalances in the treatment of shock that persists after adequate fluid volume replacement.b (See Contraindications and also see Warnings under Cautions.)<br /><br />Individual hemodynamic abnormalities must be identified and monitored so that therapy can be adjusted as necessary.b<br /><br />May be ineffective if severe peripheral vasoconstriction exists and may have a deleterious effect by causing further reductions in plasma volume and blood flow to vital organs.b<br /><br />Value of pressor therapy in shock, especially when due to septicemia, burns, trauma, or drug overdosage, is questionable;b may be indicated if patient fails to respond to administration of fluids, a change in position or other measures directed to the specific cause of shock, such as anti-infectives in septicemia, epinephrine in anaphylactic shock, or specific antidotes and/or removal of the drug in cases of overdosage. Drugs which also stimulate the myocardium (e.g., norepinephrine, metaraminol) are usually preferred to phenylephrine, especially in shock caused by myocardial infarction, septicemia, or surgical complications.b<br /><br />Pressor therapy in overdosage of barbiturates or other sedatives is especially controversial; some clinicians have stated that the incidence of mortality may actually be increased when a pressor is given.b<br /><br />May be useful when cardiac stimulation is undesirable (as in the treatment of hypotension occurring during general anesthesia with cyclopropane, halothane, or other agents that sensitize the myocardium to arrhythmias).b<br /><br />May be used to treat hypotension or shock resulting from overdosage of or idiosyncratic reactions to certain drugs (e.g., adrenergic and ganglionic blocking agents, rauwolfia and veratrum alkaloids, phenothiazines).b<br /><br />May be useful to control shock following pheochromocytomectomy, but shock generally can be prevented by maintenance of adequate blood volume and/or preoperative administration of an α-adrenergic blocking agent.b<br /><br />Hypotension During Spinal Anesthesia<br /><br />Has been used both for the prevention and treatment of hypotension resulting from spinal anesthesia, but some clinicians state that pure α-adrenergic agonists should not be used because they may further reduce cardiac output.b<br /><br />Routine prophylactic use of any vasopressor in spinal anesthesia has been questioned because hypotension does not always occur during spinal anesthesia and treatment can readily be instituted if necessary; it has been suggested that vasopressors be administered prophylactically only in those cases in which a substantial decrease in BP is expected.b<br /><br />Use of vasopressors to correct hypotension occurring during anesthesia in obstetrical patients is controversial; hypotension can usually be minimized by adequate hydration and changing the position of the patient so that the uterus does not compress the inferior vena cava; if a vasopressor is required, ephedrine is usually preferred.b<br /><br />Prolongation of Local Anesthesia<br /><br />May be added to solutions of some local anesthetics to decrease the rate of vascular absorption of the anesthetic, thereby localizing anesthesia and prolonging the duration of anesthesia.b<br /><br />Decreases risk of systemic toxicity due to the local anesthetic.b<br /><br />Not as effective as epinephrine in prolonging local anesthesia but may be preferred when cardiostimulation is undesirable.b<br /><br />Paroxysmal Supraventricular Tachycardia<br /><br />Administered IV to raise BP in order to terminate some attacks of paroxysmal supraventricular tachycardia, especially in patients who are also hypotensive or in shock.b<br /><br />Administration of an anticholinesterase drug having a short duration of action (e.g., edrophonium chloride) may be safer.b<br /><br />Nasal Congestion<br /><br />Self-medication for temporary relief of nasal congestion associated with upper respiratory allergy (e.g., hay fever) or the common cold.114,124 However, efficacy of oral phenylephrine for this use has been questioned.115,125,126,127<br /><br />Self-medication for temporary relief of sinus congestion and pressure.114,124<br /><br />Used in fixed combination with other agents (e.g., acetaminophen, chlorpheniramine, dextromethorphan, diphenhydramine, guaifenesin, pheniramine) for temporary relief of nasal/sinus congestion and/or other symptoms (e.g., rhinorrhea, sneezing, lacrimation, itching eyes, oronasopharyngeal itching, cough) associated with seasonal or perennial allergic rhinitis, other upper respiratory allergies, or the common cold.133,134,135,136,137,138,139<br /><br />Because of recent state and federal actions restricting OTC sale and purchase of preparations containing pseudoephedrine, ephedrine, or phenylpropanolamine (no longer commercially available in the US),109,110,111,112 some manufacturers have reformulated various OTC preparations by substituting phenylephrine for pseudoephedrine that was previously contained in these preparations.113,116<br /><br />Labeled and has been used for self-medication for temporary relief of nasal congestion associated with sinusitis;114,117 however, efficacy data are lacking and/or controversial.117,118,119 In October 2005, FDA issued a final rule to remove this indication from labeling of OTC nasal decongestants.117 Compliance date for preparations with annual sales <$25,000 was October 11, 2007; compliance date for all other preparations was April 11, 2007.117<br /><br />Hemorrhoids<br /><br />Anorectal preparations (e.g., creams, gels, ointments, suppositories) containing phenylephrine hydrochloride are used topically or rectally to provide temporary symptomatic relief of external or internal hemorrhoids.101,102,103,104,105,106,107,108<br /><br />When applied topically or rectally to the anorectal area, vasoconstrictors such as phenylephrine stimulate α-adrenergic receptors in the vascular beds102 with a resultant temporary constriction of arterioles and a modest and transient reduction in congestion (swelling) of hemorrhoidal tissues.101,102,108<br /><br />May relieve anorectal pruritus, discomfort, and irritation, possibly in part secondary to some weak local anesthetic action; the mechanism of this local anesthetic effect is unknown.102,108<br /><br />May relieve pruritus associated with histamine release.102,108<br /><br />If minor bleeding is present, a clinician should be consulted promptly for advice since anorectal bleeding may be a sign of conditions ranging in seriousness from simple abrasions to cancer.108<br /><br />Diagnosis of Heart Murmurs<br /><br />IV phenylephrine has been used to increase BP as an aid in the diagnosis of heart murmurs+.b<br /><br />Dosage and Administration<br /><br />General<br /><br />• Vasopressor therapy: Elevate BP to slightly less than the patient's normal BP.b<br />• Previously normotensive patients: SBP should be maintained at 80-100 mm Hg.b<br />• Previously hypertensive patients: SBP should be maintained at 30-40 mm Hg below their usual BP.b<br />• Very severe hypotension: Maintenance of even lower BP may be desirable if blood or fluid volume replacement has not been completed.b<br />• Do not leave patients receiving the drug by IV infusion unattended; the infusion flow rate must be closely monitored; check BP frequently, especially during IV administration.b<br />• Continue therapy until adequate BP and tissue perfusion are maintained.b<br />• IV infusion discontinuance: Gradually slow the infusion rate and avoid abrupt withdrawal.b<br />• Observe patient carefully so that therapy may be resumed if the BP falls too rapidly.b<br />• Do not reinstate pressor therapy until the SBP falls to 70-80 mm Hg; some patients may require additional administration of IV fluids before discontinuation.b<br /><br />Administration<br /><br />Parenteral Administration<br /><br />Vasopressor therapy: Administer by IM, sub-Q, or slow IV injection or IV infusion; route of administration determined by the needs of the individual patient.b<br /><br />Patients who are in shock may require IV administration to ensure absorption.b Usually administered by IV infusion as a dilute solution.b<br /><br />Direct IV injections are administered in treating paroxysmal atrial or nodal tachycardia or in emergencies requiring a strong, immediate pressor effect.b<br /><br />Emergencies: May be administered by direct IV injection.b<br /><br />Dilution<br /><br />For convenience in administration by direct IV injection, 1 mL of the commercially available phenylephrine hydrochloride injection containing 10 mg/mL may be diluted with 9 mL of sterile water for injection to prepare a solution containing 1 mg/mL.b<br /><br />For IV infusion, phenylephrine may be diluted with 5% dextrose or 0.9% sodium chloride injection.b<br /><br />The concentration of phenylephrine and the infusion rate depend on the drug and fluid requirements of the individual patient. Infusion solutions are usually prepared by adding 10 mg of phenylephrine hydrochloride to 500 mL of diluent.<br /><br />Oral Administration<br /><br />Vasoconstrictor for nasal congestion: Administer orally alone114,124 or as a fixed-combination decongestant preparation.b<br /><br />Place orally dissolving strip(s) on the tongue, where it rapidly dissolves and then can be swallowed.124<br /><br />Topical and Rectal Administration<br /><br />Vasoconstrictor for hemorrhoidal symptoms: Topical preparations are administered externally to the affected perianal area, and rectal preparations are administered externally to the affected perianal area and/or intrarectally.101,102,103,104,105,106,107,108<br /><br />Apply topical preparations labeled for external use only externally to the affected area and do not administer inside the rectum by either using fingers or any mechanical device or applicator.101,102,103,105,107<br /><br />Rectal preparations are labeled either for rectal use only (e.g., suppositories) or for external and/or intrarectal use only.101,102,104,106,107<br /><br />When a special applicator such as a pile pipe or other mechanical device is used to administer the drug intrarectally, attach the applicator to the tube of drug and then lubricate the applicator well and gently insert into the rectum;101,102,104 cleanse the applicator thoroughly after each use and store according to the manufacturer's instructions.104<br /><br />Do not use such preparations if introduction of the applicator or device into the rectum causes additional pain; advise patients to consult a clinician promptly in such cases.101,102,104,107<br /><br />Remove wrapper from suppositories prior to insertion into the rectum.101,102,106,107<br /><br />Advise patients receiving the drug for the local management of hemorrhoids to cleanse the affected perianal area by patting with warm water and mild soap and rinsing thoroughly or with an appropriate cleansing wipe whenever practical.101,102,103,104,105,106,107<br /><br />Dry the area by patting or blotting with toilet tissue or a soft cloth before application of the drug.101,102,103,104,105,106,107<br /><br />Dosage<br /><br />Because combinations and dosage strengths vary for fixed-combination preparations, consult manufacturer's product labeling for appropriate dosage of the specific preparation.<br /><br />Pediatric Patients<br /><br />Administer the lowest effective dosage for the shortest possible time; when possible, small doses should be injected initially and subsequent doses determined by pressor response.b<br /><br />Hypotension<br /><br />>Mild or Moderate<br /><br />IM or Sub-Q:<br /><br />Children: 0.1 mg/kg or 3 mg/m2 IM or sub-Q; may give additional IM or sub-Q doses in 1-2 hours if needed.b<br /><br />Hypotension During Spinal Anesthesia<br /><br />>Treatment<br /><br />IM or Sub-Q:<br /><br />Children: 0.044-0.088 mg/kg IM or sub-Q to treat hypotension during spinal anesthesia.b<br /><br />Nasal Congestion<br /><br />>Oral<br /><br />Self-medication in children 2-5 years of age: 2.5 mg every 4 hours.124<br /><br />Self-medication in children 6-11 years of age: 5 mg every 4 hours.124<br /><br />Self-medication in children ≥12 years of age: Usually, 10 mg every 4 hours.114,b<br /><br />May be administered in fixed combination with other drugs.b<br /><br />Discontinue therapy if symptoms persist for >7 days or are accompanied by fever or if nervousness, dizziness, or insomnia occurs.114,124<br /><br />Hemorrhoids<br /><br />>Temporary Relief<br /><br />Topical or Rectal:<br /><br />Children ≥12 years of age: Self-medication with a cream, gel, ointment, or suppository containing 0.25% of the drug alone or in combination with other anorectal agents (e.g., protectants, local anesthetics, astringents, antipruritics, analgesics).101,102,103,104,105,106,107,108<br /><br />Administer at bedtime, in the morning, and after bowel movements102,103,104,105,106 up to 4 times daily.101,102,103,104,105,106,107,108<br /><br />Do not exceed the recommended dosage unless otherwise directed by a clinician.101,102,103,104,105,106,107,108<br /><br />Anorectal dosage for self-medication of hemorrhoids should not exceed 2 mg daily (i.e., 0.5 mg 4 times daily).108<br /><br />Adults<br /><br />Administer the lowest effective dosage for the shortest possible time; when possible, small doses should be injected initially and subsequent doses determined by pressor response.b<br /><br />Hypotension<br /><br />>Mild or Moderate<br /><br />IM or Sub-Q:<br /><br />Usually, 2-5 mg; doses range from 1-10 mg.b<br /><br />Initially, do not exceed 5 mg.b<br /><br />IV<br /><br />Usually, 0.2 mg by slow IV injection; doses range from 0.1-0.5 mg.b<br /><br />Initial dose should not exceed 0.5 mg; doses may be given no more frequently than every 10-15 minutes.b<br /><br />Severe Hypotension or Shock<br /><br />>IV<br /><br />Administer as a dilute solution.b (See Parenteral Administration under Dosage and Administration.)<br /><br />Usually administer at an initial rate of 0.1-0.18 mg/minute; after the BP stabilizes, 0.04-0.06 mg/minute is usually adequate.b<br /><br />Rate of infusion is adjusted to maintain the BP at the desired level.b<br /><br />To produce the desired pressor response, additional drug in increments of 10 mg or more may be added to the infusion solution and the rate of flow adjusted according to the response of the patient.b<br /><br />Hypotensive emergencies: May be given IV in an initial dose of 0.2 mg; any subsequent dose should not exceed the previous dose by 0.1-0.2 mg and a single dose should not exceed 0.5 mg.b<br /><br />Hypotension During Spinal Anesthesia<br /><br />>Prevention<br /><br />IM or Sub-Q:<br /><br />Low spinal anesthesia: Usually, 2 mg.b<br /><br />High spinal anesthesia: 3 mg may be necessary.b<br /><br />Administer 3-4 minutes prior to the spinal anesthetic.b<br /><br />Prolongation of Spinal Anesthesia<br /><br />>IV<br /><br />Usually, 2-5 mg are added to the anesthetic solution.b<br /><br />Vasoconstriction for Regional Anesthesia<br /><br />>IV<br /><br />Optimally, the concentration of phenylephrine hydrochloride is 0.05 mg/mL (1:20,000).b<br /><br />Solutions may be prepared for regional anesthesia by adding 1 mg of phenylephrine hydrochloride to each 20 mL of local anesthetic solution.b<br /><br />Some pressor response can be expected when at least 2 mg is injected.b<br /><br />Paroxysmal Supraventricular Tachycardia<br /><br />>IV<br /><br />Initially, administer rapidly (within 20-30 seconds) by direct IV injection with a dose not exceeding 0.5 mg; increase subsequent doses in increments of 0.1-0.2 mg, depending on the BP response of the patient. b<br /><br />Do not raise SBP above 160 mm Hg.b<br /><br />Maximum single dose is 1 mg.b<br /><br />Nasal Congestion<br /><br />>Oral<br /><br />Self-medication: Usually, 10 mg every 4 hours.114,b May be administered in fixed combination with other drugs.b<br /><br />Discontinue therapy if symptoms persist for >7 days or are accompanied by fever or if nervousness, dizziness, or insomnia occurs.114<br /><br />Hemorrhoids<br /><br />>Temporary Relief<br /><br />Topical or Rectal:<br /><br />Self-medication as a cream, gel, ointment, or suppository containing 0.25% of the drug alone or in combination with other anorectal agents (e.g., protectants, local anesthetics, astringents, antipruritics, analgesics).101,102,103,104,105,106,107,108<br /><br />Administer at bedtime, in the morning, and after bowel movements102,103,104,105,106 up to 4 times daily.101,102,103,104,105,106,107,108<br /><br />Do not to exceed the recommended dosage unless otherwise directed by a clinician.101,102,103,104,105,106,107,108<br /><br />Anorectal dosage for self-medication of hemorrhoids should not exceed 2 mg daily (i.e., 0.5 mg 4 times daily).108<br /><br />Prescribing Limits<br /><br />Pediatric Patients<br /><br />Nasal Congestion<br /><br />>Oral<br /><br />Self-medication in children 2-5 years of age: Maximum 15 mg in any 24-hour period.124<br /><br />Self-medication in children 6-11 years of age: Maximum 30 mg in any 24-hour period.124<br /><br />Self-medication in children ≥12 years of age: Maximum 60 mg in any 24-hour period.114<br /><br />Hemorrhoids (Temporary Relief)<br /><br />>Topical or Rectal<br /><br />Children ≥12 years of age: Anorectal dosage for self-medication of hemorrhoids should not exceed 2 mg daily (i.e., 0.5 mg 4 times daily).108<br /><br />Adults<br /><br />Hypotension<br /><br />>Mild or Moderate<br /><br />Sub-Q or IM:<br /><br />Initially, do not exceed 5 mg.b<br /><br />IV<br /><br />Initial dose should not exceed 0.5 mg; repeat doses no more frequently than every 10-15 minutes.b<br /><br />Hypotension during Spinal Anesthesia (Prevention)<br /><br />>IM or Sub-Q<br /><br />Hypotensive emergencies: May be given IV in an initial dose of 0.2 mg; any subsequent dose should not exceed the previous dose by 0.1-0.2 mg and a single dose should not exceed 0.5 mg.b<br /><br />Paroxysmal Supraventricular Tachycardia<br /><br />>IV<br /><br />Maximum single dose is 1 mg.b<br /><br />Do not raise SBP above 160 mm Hg.b<br /><br />Nasal Congestion<br /><br />>Oral<br /><br />Self-medication: Maximum 60 mg in any 24-hour period.114<br /><br />Hemorrhoids (Temporary Relief)<br /><br />>Topical or Rectal<br /><br />Anorectal dosage for self-medication of hemorrhoids should not exceed 2 mg daily (i.e., 0.5 mg 4 times daily).108<br /><br />Cautions<br /><br />Contraindications<br /><br />• Severe hypertension or ventricular tachycardia.b<br />• Peripheral or mesenteric vascular thrombosis, because ischemia may be increased and the area of infarction extended.b<br />• For use in fingers, toes, ears, nose, or genitalia in conjunction with local anesthetics.b<br />• Severe coronary disease or cardiovascular disease (including MI) in the view of some clinicians.b<br />• For self-medication of hemorrhoidal symptoms unless otherwise directed by a clinician: Cardiac disease, high BP, thyroid disease, diabetes mellitus, or difficulty in urination secondary to prostatic hyperplasia.101,102,103,104,105,106,107,108<br />• Known hypersensitivity to phenylephrine or to any ingredient in the respective formulation.b<br /><br />Warnings/Precautions<br /><br />Warnings<br /><br />Hypovolemia<br /><br />Pressor therapy is not a substitute for replacement of blood, plasma, fluids, and/or electrolytes.b<br /><br />Correct blood volume depletion as fully as possible before administration.b<br /><br />May be used in an emergency as an adjunct to fluid volume replacement or as a temporary supportive measure to maintain coronary and cerebral artery perfusion until volume replacement therapy can be completed, but phenylephrine must not be used as sole therapy in hypovolemic patients.b<br /><br />Additional volume replacement also may be necessary during or after administration of epinephrine, especially if hypotension recurs.b<br /><br />Monitoring of central venous pressure or left ventricular filling pressure may be helpful in detecting and treating hypovolemia; in addition, monitoring of central venous or pulmonary arterial diastolic pressure is necessary to avoid overloading the cardiovascular system and precipitating CHF.b<br /><br />Severe vasoconstrictive effects may be most likely to occur in hypovolemic patients.b<br /><br />Hypoxia and Acidosis<br /><br />Hypoxia and acidosis may reduce the effectiveness of phenylephrine and must be identified and corrected prior to or concurrently with administration of the drug.b<br /><br />Concomitant Diseases<br /><br />Administer with extreme caution to geriatric or hyperthyroid patients or those with bradycardia, partial heart block, myocardial disease, or severe arteriosclerosis.b<br /><br />Administer parenterally with extreme caution if at all to hypertensive patients.b<br /><br />If administered to patients with acute pancreatitis or hepatitis, the drug may increase ischemia in the liver or pancreas.b<br /><br />Do not use for self-medication for nasal congestion in patients with thyroid disease, diabetes mellitus, hypertension, heart disease, or difficulty urinating because of prostatic hypertrophy without consulting a clinician.114,124<br /><br />MAO Inhibitors and Antihypertensive Agents<br /><br />Avoid use for self-medication for nasal congestion if currently receiving or have recently received (i.e., within 2 weeks) an MAO inhibitor.114,124<br /><br />Consult a clinician before initiating self-medication with an anorectal preparation of the drug if they currently are receiving an antihypertensive agent or antidepressant (e.g., MAO inhibitor).101,102,103,104,105,106,107,108<br /><br />Sensitivity Reactions<br /><br />Sulfite Reactions<br /><br />Some formulations of phenylephrine hydrochloride injection contain sulfites which may cause allergic-type reactions (including anaphylaxis and life-threatening or less severe asthmatic episodes) in certain susceptible individuals.b<br /><br />Major Toxicities<br /><br />Overdosage<br /><br />Overdosage may cause hypertension, headache, seizures, cerebral hemorrhage, palpitation, paresthesia, or vomiting; headache may be a symptom of hypertension.b<br /><br />Hypertension may be relieved by administration of an α-adrenergic blocking agent (e.g., phentolamine).b<br /><br />General Precautions<br /><br />Prolonged Administration<br /><br />Prolonged administration of vasopressors has caused edema, hemorrhage, focal myocarditis, subpericardial hemorrhage, necrosis of the intestine, or hepatic and renal necrosis; these effects have generally occurred in patients with severe shock and it is not clear if the drug or the shock state itself was the cause.b<br /><br />Combination Preparations<br /><br />When used in combination with other drugs (e.g., acetaminophen, chlorpheniramine, dextromethorphan, diphenhydramine, guaifenesin, pheniramine), consider the cautions, precautions, and contraindications associated with all ingredients in the formulation.133,134,135,136,137,138,139,b<br /><br />Prolonged use of the drug may result in plasma volume depletion which may result in perpetuation of the shock state or the recurrence of hypotension when phenylephrine is discontinued.b<br /><br />Systemic Effects<br /><br />Injections may be followed by paresthesia in the extremities or a feeling of coolness in the skin.b<br /><br />Cardiac Effects<br /><br />When ≥2 mg is injected during regional local anesthesia, a pressor response may occur.b<br /><br />Administration by rapid IV injection in the treatment of paroxysmal supraventricular tachycardia may result in overdosage with short paroxysms of ventricular tachycardia, ventricular extrasystoles, or a sensation of fullness in the head.b<br /><br />Can cause severe bradycardia and decreased cardiac output.b<br /><br />Decreased cardiac output may be especially harmful to elderly patients and/or those with initially poor cerebral or coronary circulation.b<br /><br />Reduced Vital Organ Blood Flow<br /><br />Can cause severe peripheral and visceral vasoconstriction, reduced blood flow to vital organs, decreased renal perfusion, and probably reduced urine output and metabolic acidosis.<br /><br />Extravasation<br /><br />May cause necrosis or sloughing of tissue if extravasation occurs during IV administration or following sub-Q administration.b<br /><br />Anorectal Use<br /><br />Based on observations with local use for nasal congestion, prolonged local use of excessive anorectal dosages of vasoconstrictors will likely lead to rebound vasodilation and congestion.108<br /><br />Less commonly, prolonged local use of excessive anorectal dosages of vasoconstrictors can lead to anxiety and paranoia.108<br /><br />Contact dermatitis has been reported following topical application of certain formulations of vasoconstrictors.108<br /><br />Possibility that topical anorectal application of vasoconstrictors if absorbed systemically in adequate amounts could interact with MAO inhibitors resulting in potentiated hypertensive effects should be considered.108<br /><br />For additional precautions associated with anorectal phenylephrine therapy, see Topical and Rectal Administration under Dosage and Administration.<br /><br />Specific Populations<br /><br />Pregnancy<br /><br />Category C.132<br /><br />Administration in late pregnancy or labor may cause fetal anoxia and bradycardia by increasing contractility of the uterus and decreasing uterine blood flow.132,b<br /><br />If a vasopressor is used in conjunction with oxytocic drugs, the vasopressor effect is potentiated and may result in potentially serious adverse effects.b (See Oxytocic Drugs under Interactions.)<br /><br />Use during pregnancy only when clearly needed.b Other pressors (e.g., ephedrine) usually preferred.132<br /><br />Lactation<br /><br />Does not appear to be distributed to any great extent into breast milk.121 However, caution if used in nursing women.b<br /><br />Pediatric Use<br /><br />Risk of overdosage and toxicity (including death) in children <2 years of age receiving OTC preparations containing antihistamines, cough suppressants, expectorants, and nasal decongestants alone or in combination for relief of symptoms of upper respiratory tract infection.128,129 Limited evidence of efficacy for these preparations in this age group; appropriate dosages not established.128 Therefore, FDA recommends not to use such preparations in children <2 years of age; safety and efficacy in older children currently under evaluation. Because children 2-3 years of age also are at increased risk of overdosage and toxicity, some manufacturers of oral nonprescription cough and cold preparations recently agreed to voluntarily revise the product labeling to state that such preparations should not be used in children <4 years of age. During the transition period, some preparations on pharmacy shelves will have the new recommendation ("do not use in children <4 years of age"), while others will have the previous recommendation ("do not use in children <2 years of age"). FDA recommends that parents and caregivers adhere to dosage instructions and warnings on the product labeling that accompanies the preparation and consult a clinician about any concerns.<br /><br />Geriatric Use<br /><br />Administer with extreme caution to geriatric patients.b<br /><br />Common Adverse Effects<br /><br />Systemic use: May cause restlessness, anxiety, nervousness, weakness, dizziness, precordial pain or discomfort, tremor, respiratory distress, pallor or blanching of the skin, or a pilomotor response.b<br /><br />Anorectal use: In recommended dosages for local effect in anorectal disorders (e.g., hemorrhoids), adverse systemic effects of vasoconstrictors such as phenylephrine generally are minimal.108<br /><br />Interactions<br /><br />Specific Drugs<br />Drug Interaction Comments α-Adrenergic blocking Vasopressor response to phenylephrine is decreased by agents (phentolamine prior administration of an α-adrenergic blocking agent mesylate, [b] phenothiazine) β-Adrenergic blocking Cardiostimulating effects of phenylephrine are blocked by agents prior administration of β-adrenergic blocking drugs [b] Anesthetics, general Cyclopropane or halogenated hydrocarbon general Use only with extreme caution or not at all (cyclopropane or anesthetics increase cardiac irritability, may with these general anesthetics [b] halogenated sensitize the myocardium to phenylephrine, and may hydrocarbon) result in arrhythmias [b] Antidepressants, May potentiate the vasopressor effects of phenylephrine tricyclic [b] Atropine Blocks the reflex bradycardia caused by phenylephrine and enhances the pressor response to phenylephrine [b] Digoxin Possibility that digoxin can sensitize the myocardium to the effects of sympathomimetic drugs should be considered [b] Ergot alkaloids Excessive rise in BP may occur if phenylephrine is administered to patients receiving a parenteral injection of an ergot alkaloid such as ergonovine maleate [132,b] Guanethidine May potentiate the vasopressor effects of phenylephrine [b] MAO inhibitors Cardiac and pressor effects of phenylephrine are Avoid oral administration of phenylephrine in potentiated by prior administration of MAO inhibitors patients receiving an MAO inhibitor. because metabolism of phenylephrine is reduced [b] Parenteral administration of phenylephrine to The potentiation is greater following oral administration these patients, if unavoidable, should be of phenylephrine than after parenteral administration undertaken with extreme caution and initial of the drug because reduction of the metabolism of doses should be small phenylephrine in the intestine results in increased Patients should consult a clinician before absorption of the drug [b] initiating anorectal phenylephrine therapy if they are receiving an MAO inhibitor [b] Oxytocic drugs The pressor effect of phenylephrine is potentiated [132, If phenylephrine is used during labor and b] delivery to correct hypotension or is added to a local anesthetic solution, the obstetrician should be cautioned that some oxytocic drugs may cause severe persistent hypertension and that rupture of a cerebral blood vessel may occur during the postpartum period [132,b] Phenothiazines Phenothiazines have some α-adrenergic blocking effects; therefore, prior administration of a phenothiazine may reduce the pressor effect and duration of action of phenylephrine [b] Sympathomimetic agents Combination products containing phenylephrine and a (epinephrine) bronchodilator sympathomimetic agent should not be used concomitantly with epinephrine or other sympathomimetic agents because tachycardia or other serious arrhythmias may occur [b]<br /><br />Pharmacokinetics<br /><br />Absorption<br /><br />Bioavailability<br /><br />Completely absorbed following oral administration; undergoes extensive first-pass metabolism in the intestinal wall.121,122<br /><br />Bioavailability following oral administration is approximately 38% relative to IV administration.121,122 Because of extensive first-pass metabolism, considerable interindividual and possibly intraindividual variation in oral bioavailability exists.121<br /><br />Peak serum concentrations occur at 0.75-2 hours following oral administration of 1- or 7.8-mg dose.121,122<br /><br />Given parenterally to achieve cardiovascular effects.b<br /><br />Onset<br /><br />IV administration: Pressor effect occurs almost immediately.b<br /><br />IM administration: Pressor effect occurs within 10-15 minutes.b<br /><br />Oral administration: Nasal decongestion may occur within 15 or 20 minutes.b<br /><br />Duration<br /><br />IV administration: Pressor effect persists for 15-20 minutes.b<br /><br />IM administration: Pressor effect persists for 30 minutes to 1-2 hours.b<br /><br />Oral administration: Nasal decongestion may persist for 2-4 hours.b<br /><br />Distribution<br /><br />Extent<br /><br />Undergoes rapid distribution into peripheral tissues; may be stored in certain organ compartments.121 Pharmacologic effects are terminated at least partially by uptake into tissues.b<br /><br />Penetration into the brain appears to be minimal.121<br /><br />Not known if phenylephrine crosses the placenta.132<br /><br />Does not appear to be distributed to any great extent into breast milk.121<br /><br />Elimination<br /><br />Metabolism<br /><br />Undergoes extensive metabolism in the intestinal wall (first-pass) and in the liver.121,122<br /><br />Principal routes of metabolism involve sulfate conjugation (principally in the intestinal wall) and oxidative deamination (by the enzyme MAO); glucuronidation also occurs to a lesser extent.121,122<br /><br />Elimination Route<br /><br />Excreted in urine (80-86%) mainly as metabolites; unchanged drug accounts for 2.6 or 16% of an oral or IV dose, respectively.121,122<br /><br />Half-life<br /><br />2-3 hours following oral or IV administration.121,122<br /><br />Special Populations<br /><br />Clinical data regarding effects of renal or hepatic impairment on phenylephrine pharmacokinetics are limited.121<br /><br />Because of extensive first-pass metabolism in the intestinal wall, hepatic impairment unlikely to result in major changes following oral administration; however, phenylephrine pharmacokinetics may be substantially altered following IV administration.121<br /><br />Stability<br /><br />Storage<br /><br />Oral<br /><br />Strips, orally dissolving<br /><br />20-25°C.124<br /><br />Tablets<br /><br />15-25°C in a dry place.114<br /><br />Parenteral<br /><br />Injection<br /><br />Tight, light-resistant containers.b<br /><br />Up to 30°C protected from light.b<br /><br />Solutions diluted in 5% dextrose injection are stable for at least 48 hours at pH 3.5-7.5.b<br /><br />Stable for at least 48 hours when diluted to 0.02 mg/mL with 5% sodium bicarbonate injection.b<br /><br />Compatibility<br /><br />For information on systemic interactions resulting from concomitant use, see Interactions.<br /><br />Parenteral<br /><br />Solution CompatibilityHID<br />Compatible Dextran 6% in dextrose 5% Dextran 6% in sodium chloride 0.9% Dextrose-Ringer's injection combinations Dextrose-Ringer's injection, lactated, combinations Dextrose-saline combinations Dextrose 2.5, 5 or, 10% in water Fructose 10% in sodium chloride 0.9% Fructose 10% in water Invert sugar 5 and 10% in sodium chloride 0.9% Invert sugar 5 and 10% in water Ionosol products Ringer's injection Ringer's injection, lactated Sodium bicarbonate 5% Sodium chloride 0.45 or 0.9% Sodium lactate (1/6) M<br /><br />Drug Compatibility<br /><br />>Admixture Compatibility [HID]<br />Compatible Chloramphenicol sodium succinate Chloramphenicol sodium succinate with sodium bicarbonate Dobutamine HCl Lidocaine HCl Potassium chloride Sodium bicarbonate Sodium bicarbonate with chloramphenicol sodium succinate<br /><br />>Y-site Compatibility [HID]<br />Compatible Alcohol 10% in dextrose 5% Amiodarone HCl Argatroban Bivalirudin Etomidate Famotidine Fenoldopam mesylate Haloperidol lactate Hetastarch in lactated electrolyte injection (Hextend) Inamrinone lactate Levofloxacin Remifentanil HCl Vasopressin Zidovudine Incompatible Lansoprazole Thiopental sodium Variable Propofol<br /><br />Actions<br /><br />• Acts predominantly by a direct effect on α-adrenergic receptors; in therapeutic doses, the drug has no substantial stimulant effect on the β-adrenergic receptors of the heart (β1-adrenergic receptors) but substantial activation of these receptors may occur when larger doses are given.b<br />• Believed that α-adrenergic effects result from the inhibition of the production of cyclic adenosine-3´,5´-monophosphate (cAMP) by inhibition of the enzyme adenyl cyclase, whereas β-adrenergic effects result from stimulation of adenyl cyclase activity.b<br />• Does not stimulate β-adrenergic receptors of the bronchi or peripheral blood vessels (β2-adrenergic receptors).b<br />• Main effect of therapeutic doses of phenylephrine is vasoconstriction.b<br />• Constricts resistance and, to a lesser degree, capacitance blood vessels by its effects on α-adrenergic receptors.<br />• Total peripheral resistance is increased, resulting in increased SBP and DBP.b<br />• Venous return to the heart may be decreased; however, phenylephrine increases venous pressure slightly.b<br />• Blood flow to vital organs, skin, and probably skeletal muscle is reduced.b<br />• May reduce circulating plasma volume (especially with prolonged use) as a result of loss of fluid into the extracellular spaces caused by postcapillary vasoconstriction.b<br />• Constriction of renal blood vessels by phenylephrine decreases renal blood flow.b<br />• Local vasoconstriction and hemostasis also occur following topical application or infiltration of phenylephrine into tissues.b<br />• Following oral administration, constriction of blood vessels in the nasal mucosa may relieve nasal congestion.b<br />• Main effect on the heart is bradycardia, which results from increased vagal activity occurring as a reflex to increased arterial BP.b<br />• Bradycardia occurs after parenteral administration of usual therapeutic doses and may also result from overdosage via oral inhalation.b<br />• Attacks of paroxysmal atrial or nodal tachycardia may be ended by the decrease in sympathetic cardioaccelerator tone and increase in parasympathomimetic cardiodecelerator tone.b<br />• Constricts coronary blood vessels but increases coronary blood flow, probably as a result of increased systemic BP.b<br />• In therapeutic doses, causes little if any CNS stimulation but may cause nervousness, restlessness, anxiety, dizziness, and tremor in some patients, especially after overdosage.b<br />• As a result of its effects on α-adrenergic receptors, may cause contraction of the pregnant uterus and constriction of uterine blood vessels; however, the vasoconstrictor effect may be overcome by an increase in maternal BP.b<br /><br />Advice to Patients<br /><br />• Importance of advising patients not to exceed the recommended dosage unless otherwise directed by a clinician.101,102,103,104,105,106,107, 108<br />• Importance of informing patient to consult a clinician before using for self-medication of nasal congestion if they have been diagnosed with thyroid disease, diabetes mellitus, hypertension, heart disease, or difficulty urinating because of prostatic hypertrophy.114,124<br />• Importance of discontinuing self-medication of nasal congestion and consulting a clinician if symptoms persist >7 days or are accompanied by fever or if nervousness, dizziness, or insomnia develops during therapy.114,124<br />• Importance of informing patients not to exceed 2 mg daily (i.e., 0.5 mg 4 times daily) for the anorectal dosage for self-medication of hemorrhoids.108<br />• Importance of informing patients to consult a clinician if the anorectal condition worsens or does not improve within 7 days or if bleeding occurs.101,102,103,104,105,106,107<br />• Importance of informing patients that when a special applicator such as a pile pipe or other mechanical devise is used to administer the drug intrarectally, the applicator should be attached to the tube of drug and then the applicator should be lubricated well and gently inserted into the rectum;101,102,104 cleanse the applicator thoroughly after each use and store according to the manufacturer's instructions.104<br />• Importance of advising patients to not use and to consult a clinician promptly if introduction of the applicator or device into the rectum causes additional pain.101,102,104,107<br />• Importance of informing patients to remove wrapper from suppositories prior to insertion into the rectum.101,102,106,107<br />• Importance of informing patients receiving the drug for the local management of hemorrhoids to cleanse the affected perianal area by patting with warm water and mild soap and rinsing thoroughly or with an appropriate cleansing wipe whenever practical;101,102,103,104,105,106,107 dry the area by patting or blotting with toilet tissue or a soft cloth before application of the drug.101,102,103,104,105,106,107<br />• Importance of informing patients to consult a clinician promptly for advice if minor bleeding is present since anorectal bleeding may be a sign of conditions ranging in seriousness from simple abrasions to cancer.108<br />• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs as well as any concomitant illnesses.131<br />• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.131<br />• Importance of informing patients of other important precautionary information.131 (See Cautions.)<br /><br />Preparations<br /><br />Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.<br /><br />In response to concerns regarding the safety and efficacy of cough/cold preparations in young children, many OTC cough/cold preparations specifically formulated for infants have been voluntarily withdrawn from the US market.130 Therefore, some of the preparations described below may no longer be commercially available in the US.<br /><br />Phenylephrine Hydrochloride<br />Routes Dosage Forms Strengths Brand Names Manufacturer Oral Strips, 2.5 mg Triaminic® Thin Strips® Cold Novartis orally with Stuffy Nose dissolving 10 mg Sudafed PE® McNeil Tablets, 10 mg Sudafed PE® McNeil film-coated Parenteral Injection 10 mg/mL* Neo-Synephrine® Hydrochloride Hospira Phenylephrine Hydrochloride Injection Topical Cream 0.25% with Glycerin 14.4%, Preparation H® Wyeth Pramoxine Hydrochloride 1%, and White Petrolatum 15% Gel 0.25% with Witch Hazel 50% Preparation H® Wyeth Nasal Spray 0.5% Vicks® Sinex® Nasal Spray Procter & Gamble Vicks® Sinex® Ultra Fine Mist Procter & Gamble Ointment 0.25% with Mineral Oil 14%, Preparation H® Wyeth Petrolatum 71.9%, and Shark Liver Oil 3% Suppository 0.25% with Cocoa Butter 85.5% Preparation H® Wyeth and Shark Liver Oil 3% ----------------------------------------------------------------------------------------------------------<br />* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name<br /><br />Phenylephrine Hydrochloride Combinations<br />Routes Dosage Forms Strengths Brand Names Manufacturer Oral Capsules, 5 mg with Acetaminophen 325 mg Vicks® DayQuil® Sinus LiquiCaps Procter & (liquid- Gamble filled) 5 mg with Acetaminophen 325 mg and Vicks® DayQuil® Cold/Flu LiquiCaps Procter & Dextromethorphan Hydrobromide 10 mg Gamble Gelcaps 5 mg with Acetaminophen 325 mg Tylenol® Sinus Congestion & Pain McNeil Daytime 5 mg with Acetaminophen 325 mg and Tylenol®Cold Multi-Symptom Daytime McNeil Dextromethorphan Hydrobromide 10 mg Gelcaps, 5 mg with Acetaminophen 325 mg Tylenol® Sinus Congestion & Pain McNeil rapid Daytime release 5 mg with Acetaminophen 325 mg and Tylenol® Allergy Multi-Symptom McNeil Chlorpheniramine Maleate 2 mg 5 mg with Acetaminophen 325 mg and Tylenol® Cold Multi-Symptom McNeil Dextromethorphan Hydrobromide 10 mg Daytime For Solution 10 mg/packet with Acetaminophen 325 mg/ Theraflu® Cold & Sore Throat Novartis packet and Pheniramine Maleate 20 mg/ packet 10 mg/packet with Acetaminophen 650 mg/ Theraflu® Daytime Severe Cold Novartis packet 10 mg/packet with Acetaminophen 650 mg/ Theraflu® Flu & Sore Throat Novartis packet and Pheniramine Maleate 20 mg/ packet Theraflu® Nighttime Severe Cold Novartis 10 mg/packet with Dextromethorphan Theraflu® Cold & Cough Novartis Hydrobromide 20 mg/packet and Pheniramine Maleate 20 mg/packet Solution 5 mg/15 mL with Acetaminophen 325 mg/15 mL Theraflu® Daytime Warming Relief Novartis and Dextromethorphan Hydrobromide 10 mg/ Syrup 15 mL Tylenol® Cold Multi-Symptom McNeil Daytime Citrus Burst® Liquid Vicks® DayQuil® Cold/Flu Relief Procter & Gamble 5 mg/15 mL with Acetaminophen 325 mg/15 Tylenol® Cold Multi-Symptom Citrus McNeil mL, Dextromethorphan Hydrobromide 10 mg/ Burst® Liquid 15 mL, and Guaifenesin 200 mg/15 mL 5 mg/15 mL with Acetaminophen 325 mg/15 mL Theraflu® Flu & Sore Throat Relief Novartis and Diphenhydramine Hydrochloride 12.5 Syrup mg/15 mL Theraflu®Nighttime Warming Relief Novartis Syrup 2.5 mg/5 mL with Acetaminophen 160 mg/5 mL Children's Tylenol® Plus Cold McNeil and Chlorpheniramine Maleate 1 mg/5 mL 2.5 mg/5 mL with Acetaminophen 160 mg/5 mL Children's Tylenol® Plus Multi- McNeil and Chlorpheniramine Maleate 1 mg/5 mL, Symptom Cold and Dextromethorphan Hydrobromide 5 mg/ 5mL 2.5 mg/5 mL with Acetaminophen 160 mg/5 mL Children's Tylenol® Plus Cold & McNeil and Diphenhydramine Hydrochloride 12.5 Allergy mg/5 mL 2.5 mg/5 mL with Chlorpheniramine Maleate Triaminic® Cold & Allergy Novartis 1 mg/5 mL 2.5 mg/5 mL with Dextromethorphan Children's Sudafed PE® Cold & McNeil Hydrobromide 5 mg/5mL Cough Triaminic® Day Time Cold & Cough Novartis 2.5 mg/5mL with Diphenhydramine Triaminic® Night Time Cough & Cold Novartis Hydrochloride 6.25 mg/5 mL 2.5 mg/5 mL with Guaifenesin 50 mg/5mL Triaminic® Chest & Nasal Novartis Congestion 10 mg/15 mL with Dextromethorphan Vicks® Formula 44D Cough & Head Proctor & Hydrobromide 20 mg/15 mL Congestion Relief Gamble 5 mg/5 mL with Diphenhydramine Children's Benadryl-D® Allergy & Pfizer Hydrochloride 12.5 mg/5 mL Sinus Strips, 2.5 mg with Dextromethorphan 3.67 mg Day Time Triaminic® Thin Strips® Novartis orally (equivalent to Dextromethorphan Cold & Cough dissolving Hydrobromide 5 mg) 5 mg with Diphenhydramine Hydrochloride Night Time Triaminic® Thin Strips® Novartis 12.5 mg Cold & Cough 10 mg with Dextromethorphan 14.8 mg Theraflu® Thin Strips® Daytime Novartis (equivalent to Dextromethorphan Cold & Cough Hydrobromide 20 mg) 10 mg with Diphenhydramine Hydrochloride Theraflu® Thin Strips® Nighttime Novartis 25 mg Cold & Cough Tablets 5 mg with Acetaminophen 325 mg, Theraflu® Nighttime Severe Cold Novartis Chlorpheniramine Maleate 2 mg, and Caplets Dextromethorphan Hydrobromide 15 mg 5 mg with Acetaminophen 325 mg and Theraflu® Daytime Severe Cold Novartis Dextromethorphan Hydrobromide 15 mg Caplets 10 mg with Chlorpheniramine Maleate 4 mg Sudafed PE® Sinus & Allergy McNeil Tablets, 5 mg with Acetaminophen 325 mg Excedrin® Sinus Headache Novartis film- coated Sudafed PE® Sinus Headache Caplets McNeil Tylenol® Sinus Congestion & Pain McNeil Daytime Caplets 5 mg with Acetaminophen 325 mg and Tylenol® Allergy Multi-Symptom McNeil Chlorpheniramine Maleate 2 mg Cool Burst® Caplets Tylenol® Sinus Congestion & Pain McNeil Nighttime Caplets 5 mg with Acetaminophen 325 mg, Tylenol® Cold Multi-Symptom McNeil Chlorpheniramine Maleate 2 mg, and Nighttime Cool Burst® Caplets Dextromethorphan Hydrobromide 10 mg Tylenol® Cold Head Congestion McNeil Nighttime Cool Burst® Caplets 5 mg with Acetaminophen 325 mg and Tylenol® Cold Multi-Symptom McNeil Dextromethorphan Hydrobromide 10 mg Daytime Cool Burst® Caplets Tylenol® Cold Head Congestion McNeil Daytime Cool Burst® Caplets 5 mg with Acetaminophen 325 mg, Sudafed PE® Cold & Cough Caplets McNeil Dextromethorphan Hydrobromide 10 mg, and Guaifenesin 100 mg 5 mg with Acetaminophen 325 mg, Tylenol® Cold Multi-Symptom Severe McNeil Dextromethorphan Hydrobromide 10 mg, and Cool Burst® Caplets Guaifenesin 200 mg Tylenol® Cold Head Congestion McNeil Severe Cool Burst® Caplets 5 mg with Acetaminophen 325 mg and Benadryl® Allergy & Cold Caplets Pfizer Diphenhydramine Hydrochloride 12.5 mg Benadryl® Allergy & Sinus Headache Pfizer Caplets Sudafed PE® Multi-Symptom Severe McNeil Cold Caplets 5 mg with Acetaminophen 325 mg and Benadryl® Severe Allergy & Sinus Pfizer Diphenhydramine Hydrochloride 25 mg Headache Caplets Maximum Strength Sudafed PE® Nighttime Cold Caplets McNeil Tylenol® Allergy Multi-Symptom McNeil Nighttime Cool Burst® Caplets 5 mg with Acetaminophen 325 mg and Tylenol® Sinus Congestion & Pain McNeil Guaifenesin 200 mg Severe Caplets 5 mg with Guaifenesin 200 mg Sudafed PE® Non-Drying Sinus McNeil Caplets 10 mg with Diphenhydramine Hydrochloride Benadryl-D® Allergy & Sinus Pfizer 25 mg Sudafed PE® Nighttime Nasal McNeil Decongestant<br /><br />Comparative Pricing<br /><br />This pricing information is subject to change at the sole discretion of DS Pharmacy. This pricing information was updated 03/2010. For the most current and up-to-date pricing information, please visit www.drugstore.com. Actual costs to patients will vary depending on the use of specific retail or mail-order locations and health insurance copays.<br /><br />AlleRx 3-7.5MG/5ML Suspension (CORNERSTONE BIOPHARMA): 473/$206.28 or 1419/$573.13<br /><br />Bromfed-PD 6-7.5MG 12-hr Capsules (VICTORY PHARMA): 30/$70.99 or 90/$192.98<br /><br />Duraphen 1000 30-1000MG 12-hr Tablets (KOWA PHARMACEUTICALS AMERICA): 100/$99.99 or 300/$271.86<br /><br />Duraphen Forte 30-30-1200MG 12-hr Tablets (KOWA PHARMACEUTICALS AMERICA): 100/$132.57 or 300/$375.84<br /><br />Duraphen II DM 20-20-800MG 12-hr Tablets (KOWA PHARMACEUTICALS AMERICA): 30/$41.76 or 90/$125.02<br /><br />Duratuss AC 12 15-12.5-15MG/5ML Suspension (VICTORY PHARMA): 473/$215.97 or 1419/$610.03<br /><br />Duratuss GP 25-1200MG 12-hr Tablets (VICTORY PHARMA): 30/$59.99 or 90/$159.99<br /><br />Guaphen Forte 30-30-1200MG 12-hr Tablets (RIVER'S EDGE PHARMACEUTICALS): 30/$31.52 or 90/$85.1<br /><br />Promethazine VC Plain 6.25-5MG/5ML Syrup (QUALITEST): 473/$39.97 or 1419/$109.97<br /><br />R-Tanna 9-25MG Tablets (PRASCO LABORATORIES): 30/$39.99 or 90/$102.97<br /><br />Rynatan 9-25MG Tablets (MEDA PHARMACEUTICALS): 30/$109.98 or 90/$307.96<br /><br />Rynatan Pediatric 4.5-5MG/5ML Suspension (MEDA PHARMACEUTICALS): 120/$87.11 or 360/$254.05<br /><br />Sitrex 30-1200MG 12-hr Tablets (VINDEX PHARMACEUTICALS INC.): 30/$19.94 or 90/$58.76qhttp://www.blogger.com/profile/08913095420873132710noreply@blogger.com0