ATI Templates

• Gentamicin can injure cells of the proximal renal tubules (nephrotoxicity).
• Gentamicin is ototoxic — can cause permanent hearing loss and vestibular damage.
• Naproxen and other NSAIDs can independently cause renal insufficiency.
• The glomerular filtration rate of the kidneys decreases with advanced age, ↑ risk for nephrotoxicity.
• Combining gentamicin with naproxen significantly increases the risk of acute kidney injury.

• Hypersensitivity to aminoglycosides
• Pre-existing renal impairment — requires dose adjustment
• Pre-existing hearing or vestibular impairment
• Myasthenia gravis — can worsen neuromuscular weakness
• Pregnancy Category D — fetal ototoxicity reported
• Caution in elderly (age-related ↓ renal function) and dehydrated clients
• Avoid concurrent nephrotoxic or ototoxic drugs when possible

• Loop diuretics (furosemide, bumetanide) → ↑ ototoxicity
• Nephrotoxic drugs (vancomycin, NSAIDs, amphotericin B, cisplatin) → ↑ nephrotoxicity
• Neuromuscular blockers (succinylcholine, vecuronium) → potentiated blockade → respiratory paralysis risk
• Cephalosporins → additive nephrotoxicity
• IV magnesium → ↑ neuromuscular blockade
• Penicillins — NEVER mix in same syringe/IV line (mutual inactivation); space doses 1 hr apart

• ↓ fever, ↓ WBC count toward normal
• Negative blood, urine, or wound cultures post-therapy
• Resolution of infection-specific signs (↓ purulent drainage, ↓ pain at infection site, improved oxygenation in pneumonia)
• Therapeutic drug levels:
  • Peak 5-10 mcg/mL
  • Trough < 2 mcg/mL
• No nephrotoxicity: BUN/creatinine stable, urine output > 30 mL/hr
• No ototoxicity: hearing and balance intact, no tinnitus or vertigo

• Bleeding — most common; ranges from minor (gum, nose, bruising) to major (GI, intracranial, retroperitoneal)
• Warfarin-induced skin necrosis — rare; days into therapy, often in protein C-deficient clients
• Purple toe syndrome — cholesterol microembolization
• Hair loss (alopecia)
• Hypersensitivity reactions
• Hepatic injury (rare)
• Teratogenicity (Category X) — fetal warfarin syndrome, fetal bleeding

• Pregnancy Category X — teratogenic (fetal warfarin syndrome)
• Active bleeding or recent major surgery
• Severe hypertension or thrombocytopenia
• Hemorrhagic stroke, peptic ulcer disease, esophageal varices
• Vitamin K deficiency
• Caution with falls risk (elderly), alcohol abuse, hepatic disease

• St. John's wort is a CYP450 inducer (CYP3A4 and others)
• It will ↓ warfarin levels → ↓ anticoagulation effect → ↑ risk of thrombosis/stroke
• St. John's wort also interacts with: OCPs, antiretrovirals, digoxin, antidepressants (serotonin syndrome)

• INR within therapeutic range (2.0-3.0 standard; 2.5-3.5 mechanical valves)
• No new thrombotic events (stroke, DVT, PE, MI)
• Resolution of existing clot (per imaging or clinical findings)
• No bleeding complications: stable Hgb/Hct, no bruising or unexplained bleeding

• GI: nausea (most common), diarrhea, dry mouth, weight gain (more than other SSRIs)
• Sexual dysfunction: ↓ libido, erectile dysfunction, anorgasmia (very common, often persistent)
• Suicidal ideation (FDA boxed warning, especially age < 25)
• Hyponatremia / SIADH (especially elderly)
• Bleeding (antiplatelet effect)
• Discontinuation syndrome — worst of all SSRIs (flu-like, dizziness, "brain zaps")
• Serotonin syndrome (with other serotonergic agents)
• Activation of mania in bipolar clients
• Insomnia or drowsiness, headache, dizziness, sweating, tremor

• Hypersensitivity to paroxetine or other SSRIs
• Concurrent MAOIs or within 14 days of stopping MAOI (serotonin syndrome risk)
• Concurrent thioridazine, pimozide (QT prolongation)
• Pregnancy Category D (cardiac defects in first trimester) — strongest concern of SSRIs
• Caution: bipolar disorder (can trigger mania), suicidal ideation (esp. age < 25), bleeding disorders, hyponatremia/SIADH, seizure disorder, hepatic/renal impairment
• Caution: elderly (↑ falls, hyponatremia risk)

• MAOIs, linezolid, methylene blue → serotonin syndrome (life-threatening)
• Other serotonergic drugs (SSRIs, SNRIs, TCAs, triptans, tramadol, St. John's wort) → ↑ serotonin syndrome risk
• Warfarin, NSAIDs, aspirin, antiplatelets → ↑ bleeding risk
• Tamoxifen → paroxetine inhibits CYP2D6 → ↓ tamoxifen efficacy (avoid combo)
• Phenytoin, carbamazepine → ↓ paroxetine levels
• Alcohol → additive CNS depression

• ↓ anxiety symptoms (worry, restlessness, irritability, muscle tension)
• ↓ panic attack frequency and severity
• ↓ PTSD symptoms (flashbacks, hypervigilance, avoidance)
• ↓ OCD symptoms (intrusive thoughts, compulsions)
• Improved daily functioning, sleep, concentration, social engagement
• No suicidal ideation (esp. monitor in first 4-12 weeks and when changing dose)
• No serotonin syndrome signs

• GI: nausea (very common), diarrhea, dyspepsia, dry mouth
• Sexual dysfunction: ↓ libido, ejaculatory dysfunction, anorgasmia
• Suicidal ideation (FDA boxed warning, especially age < 25)
• Hyponatremia / SIADH (especially elderly)
• Bleeding risk (antiplatelet effect, GI bleeding with NSAIDs)
• Insomnia or somnolence, headache, dizziness, tremor, sweating
• Weight changes (less than paroxetine)
• Serotonin syndrome (with other serotonergic agents)
• Activation of mania in bipolar clients
• Discontinuation syndrome (less severe than paroxetine)

• Hypersensitivity to sertraline or other SSRIs
• Concurrent MAOIs or within 14 days of stopping MAOI (serotonin syndrome)
• Concurrent pimozide (QT prolongation)
• Pregnancy Category C (preferred SSRI in pregnancy after risk-benefit; less risk than paroxetine)
• Caution: bipolar disorder (can trigger mania), suicidal ideation (esp. age < 25), bleeding disorders, hyponatremia, seizure disorder, hepatic impairment
• Caution: elderly (↑ falls, hyponatremia)

• MAOIs, linezolid, methylene blue → serotonin syndrome (life-threatening)
• Other serotonergic drugs (SSRIs, SNRIs, TCAs, triptans, tramadol, St. John's wort, ondansetron) → ↑ serotonin syndrome
• Warfarin, NSAIDs, aspirin → ↑ bleeding risk
• Pimozide → QT prolongation
• Alcohol → additive CNS depression (avoid)
• Highly protein-bound — may displace other protein-bound drugs (warfarin, digoxin)

• ↓ depressive symptoms: ↓ sadness, hopelessness, anhedonia
• ↑ energy, ↑ interest in activities
• Improved sleep, appetite, concentration
• Restored social and occupational functioning
• No suicidal ideation (especially monitor in first 4-12 weeks and during dose changes)
• No serotonin syndrome

• New onset of diabetes mellitus or loss of glucose control in clients who have diabetes
• Weight gain
• Hypercholesterolemia
• Orthostatic hypotension
• Anticholinergic effects (urinary hesitancy or retention, dry mouth)
• Agitation
• Dizziness
• Sedation
• Sleep disruption
• Tremors
• Agranulocytosis, neutropenia
• Hyperprolactinemia

• Hypersensitivity to risperidone
• Boxed warning: elderly clients with dementia-related psychosis — ↑ mortality risk
• Caution: cardiovascular disease, cerebrovascular disease, seizure disorder
• Caution: Parkinson disease, dementia with Lewy bodies (extreme sensitivity)
• Caution: diabetes mellitus (atypicals ↑ glucose, lipids, weight)
• Caution: hyperprolactinemia, breast cancer history
• Pregnancy Cat C; possible neonatal extrapyramidal/withdrawal symptoms in 3rd trimester

• CNS depressants (alcohol, benzodiazepines, opioids) → additive sedation
• Antihypertensives → additive hypotension
• Levodopa, dopamine agonists → antagonized by risperidone (avoid in Parkinson)
• Carbamazepine, phenytoin, rifampin → ↓ risperidone levels
• Fluoxetine, paroxetine → ↑ risperidone levels
• QT-prolonging drugs (amiodarone, methadone) → ↑ arrhythmia risk

• ↓ positive symptoms: ↓ hallucinations, delusions, disorganized thinking
• ↓ negative symptoms: ↑ motivation, ↑ emotional expression, ↑ social engagement
• ↓ agitation and aggression
• Improved functioning and quality of life
• No extrapyramidal symptoms (rigidity, tremor, akathisia, tardive dyskinesia)
• No neuroleptic malignant syndrome
• Stable weight, glucose, lipids

• New-onset hypertension
• Loss of glycemic control in clients who have diabetes mellitus
• Nausea
• Vomiting
• Insomnia
• New-onset depression
• Suicidal thoughts

• Hypersensitivity to varenicline
• Severe renal impairment (CrCl < 30) — dose adjust
• End-stage renal disease on dialysis — reduce dose
• Caution: history of psychiatric illness (depression, suicidal ideation, bipolar) — although FDA removed boxed warning in 2016, monitor closely
• Caution: cardiovascular disease (slight ↑ MI risk vs placebo in trials)
• Caution: seizure disorder
• Pregnancy Cat C; breastfeeding

• Nicotine replacement therapy (patch, gum) → ↑ adverse effects (nausea, dizziness); not recommended together
• Cimetidine → ↑ varenicline levels (only with severe renal impairment)
• Alcohol → ↑ neuropsychiatric effects, intoxication
• Few other clinically significant drug interactions (renal excretion, not metabolized by CYP enzymes)

• The client will maintain smoking cessation.
• The client will report reduced cravings for nicotine.

• CNS effects
• Gingival hyperplasia
• Teratogenic birth defects
• Decreases effectiveness of oral contraceptives, warfarin, and glucocorticoids
• Causes stimulation of hepatic medication-metabolizing enzymes
• Alcohol (acute use), diazepam, cimetidine, and valproic acid increase phenytoin levels.
• Carbamazepine, phenobarbital, and chronic alcohol use decrease phenytoin levels.
• Additive CNS depressant effects can occur with concurrent use of CNS depressants.

• Hypersensitivity to phenytoin or other hydantoins
• Sinus bradycardia, second/third-degree heart block, Adams-Stokes syndrome (IV use)
• Pregnancy Category D — fetal hydantoin syndrome (cleft lip/palate, cardiac defects, growth deficiency)
• Caution: hepatic impairment, hypoalbuminemia (↑ free drug)
• Caution: diabetes (↑ glucose), porphyria, suicidal ideation
• Caution: Asian ancestry with HLA-B*1502 allele (↑ Stevens-Johnson syndrome risk)

• Phenytoin is a potent CYP enzyme inducer → ↓ levels of many drugs:
  • Warfarin (effect variable: initially ↑ INR, then ↓ — close monitoring)
  • Oral contraceptives → contraceptive failure
  • Carbamazepine, valproate (variable)
  • Corticosteroids, theophylline, doxycycline, quinidine, digoxin
• Drugs that ↑ phenytoin levels (toxicity): cimetidine, fluconazole, isoniazid, amiodarone, omeprazole
• Drugs that ↓ phenytoin levels: rifampin, chronic alcohol, antacids, sucralfate, enteral feeds (hold feed 1 hr before/after)
• Alcohol (acute) → ↑ levels; alcohol (chronic) → ↓ levels

• ↓ seizure frequency and severity
• Therapeutic drug level: 10-20 mcg/mL (total)
• No status epilepticus episodes
• Improved quality of life and functioning
• No signs of toxicity: nystagmus (lateral gaze first), ataxia, slurred speech, confusion, drowsiness
• No serious adverse effects (rash, blood dyscrasias)

• Rash
• Dizziness, lightheadedness, tremors, restlessness, and convulsions

• Perforated tympanic membrane (caution; use products approved for this)
• Hypersensitivity to fluoroquinolones or corticosteroids
• Viral or fungal ear infections (steroid may worsen)
• Caution in pregnancy and breastfeeding (limited topical absorption)

• Minimal systemic interactions due to topical use
• If used concurrently with systemic fluoroquinolones, consider total exposure
• Other topical ear drops — space administration if multiple are prescribed

• ↓ ear pain
• ↓ ear drainage and discharge
• ↓ swelling and erythema of ear canal
• Hearing returns to baseline (was muffled due to inflammation/exudate)
• No new symptoms suggesting otitis media or spread

• Malignant hyperthermia — life-threatening; severe hyperthermia, muscle rigidity (esp. masseter), tachycardia, hypercarbia, metabolic acidosis, hyperkalemia, rhabdomyolysis, dark urine; treat with dantrolene
• Hyperkalemia — normally mild; MASSIVE and fatal in burns, crush injuries, denervation, prolonged immobility
• Prolonged apnea in pseudocholinesterase deficiency
• Bradycardia (vagal stimulation, esp. with repeated doses, especially in children)
• Cardiac arrest (esp. children with undiagnosed muscular dystrophy)
• ↑ intraocular pressure (avoid in open eye injury)
• ↑ intragastric pressure → aspiration risk
• ↑ ICP (caution in head injury)
• Muscle pain post-procedure (myalgia from fasciculations)
• Hypersensitivity reactions

• Personal or family history of malignant hyperthermia — life-threatening reaction
• Severe burns, crush injuries, denervation injuries (24-72 hr post-injury) — massive K+ release → fatal hyperkalemia
• Skeletal muscle myopathies (Duchenne muscular dystrophy, etc.)
• Acute narrow-angle glaucoma, penetrating eye injuries (↑ intraocular pressure)
• Pseudocholinesterase deficiency (genetic or acquired) — prolonged paralysis
• Pre-existing hyperkalemia
• Major nerve damage, paraplegia (chronic) — hyperkalemia risk
• Caution: children (rare cardiac arrest reported), pregnancy Cat C

• Anesthetics (halothane, sevoflurane, isoflurane) → ↑ malignant hyperthermia risk
• Aminoglycosides, polymyxins, clindamycin → potentiate neuromuscular blockade
• Magnesium → enhanced and prolonged blockade
• Lithium → prolonged blockade
• Calcium channel blockers → enhanced blockade
• Anticholinesterases (neostigmine) → DO NOT REVERSE succinylcholine (different mechanism); may prolong
• Cyclosporine, oral contraceptives, MAOIs → ↓ pseudocholinesterase activity → prolonged effect
• Digoxin → arrhythmia risk (esp. with fasciculations releasing K+)

• Successful endotracheal intubation
• Adequate muscle relaxation for procedure (ECT, endoscopy, surgery)
• Return of spontaneous respiration and movement within 5-10 minutes after dose
• No malignant hyperthermia (no severe hyperthermia, muscle rigidity, dark urine, hypercarbia)
• No prolonged paralysis (suspect pseudocholinesterase deficiency if > 20 min)
• No serious hyperkalemia or cardiac arrhythmias
• Full neurologic recovery

• CNS depression: drowsiness, sedation, fatigue, ataxia, confusion (especially elderly)
• Respiratory depression (esp. with opioids — fatal combination; FDA boxed warning)
• Dependence and tolerance with long-term use; withdrawal syndrome (seizures, anxiety, insomnia, tremor) on abrupt discontinuation
• Paradoxical reactions: agitation, hostility, hallucinations (especially elderly, children)
• Anterograde amnesia
• Falls and fractures (especially elderly)
• Cognitive impairment with chronic use
• Phlebitis with IV use; tissue necrosis with extravasation
• Bradycardia, hypotension (IV use, especially rapid)
• Teratogenic — cleft lip/palate, neonatal floppy infant syndrome / withdrawal
• Suicide risk (especially in overdose with other CNS depressants)

• Pregnancy: Benzodiazepines are Pregnancy Risk Category D (a high risk to the fetus)
• Sleep apnea
• Respiratory depression
• Organic brain disease
• Lactation
• Cautious use in clients who have a history of substance use disorders, liver dysfunction, and kidney failure

• CNS depressants (alcohol, opioids, antihistamines, antipsychotics, anticonvulsants, sedatives) → additive respiratory depression — potentially fatal
• Opioids — FDA black box warning for concurrent use
• CYP3A4 inhibitors (cimetidine, erythromycin, fluoxetine, ketoconazole) → ↑ diazepam levels
• CYP3A4 inducers (rifampin, carbamazepine, phenytoin) → ↓ diazepam levels
• Grapefruit juice → ↑ levels
• Probenecid → ↑ levels

• Anxiety: ↓ anxiety symptoms, ↑ ability to function
• Seizures: ↓ frequency, termination of status epilepticus
• Alcohol withdrawal: ↓ tremors, anxiety, autonomic hyperactivity; prevention of seizures and DTs
• Insomnia: improved sleep latency and duration
• Muscle spasms: ↓ muscle tension and discomfort
• No excessive sedation, respiratory depression, or paradoxical agitation
• No development of dependence (with appropriate short-term use)

• Oral agents can cause tachycardia and angina due to activation of alpha1 receptors in the heart.
• Activation of beta2 receptors in skeletal muscle causes tremors.

• Hypersensitivity to albuterol or other sympathomimetics
• Caution: cardiovascular disease (CAD, arrhythmias, HTN)
• Caution: hyperthyroidism, diabetes mellitus (may ↑ glucose)
• Caution: seizure disorder
• Caution: hypokalemia (albuterol can lower K+ further)
• Pregnancy Cat C (benefit usually outweighs risk in acute asthma)

• Beta-blockers (esp. non-selective like propranolol) → antagonize albuterol effect; can trigger bronchospasm
• MAO inhibitors, tricyclic antidepressants → ↑ cardiovascular effects
• Other sympathomimetics → additive effects, ↑ adverse effects
• Loop and thiazide diuretics → additive hypokalemia
• Digoxin → ↓ digoxin levels (theoretical)

• ↓ wheezing, coughing, dyspnea
• ↑ peak expiratory flow rate (PEFR)
• ↑ oxygen saturation (SpO₂)
• ↑ ability to speak in full sentences
• ↓ accessory muscle use
• Improved tolerance to activity/exercise
• Use frequency < 2 days/week (well-controlled asthma)

• GI upset
• Drowsiness
• Dizziness
• Rash

• Hypersensitivity to guaifenesin
• Persistent cough > 1 week — needs evaluation, NOT continued OTC use
• Productive cough caused by chronic conditions (asthma, smoking, emphysema) — only use under provider guidance
• Children < 4 years (avoid all OTC cough/cold products)
• Caution in pregnancy and breastfeeding

• Few clinically significant interactions (low protein binding, minimal metabolism)
• May interfere with urine 5-HIAA test (false positive)
• Often combined with other ingredients in OTC products (decongestants, antihistamines, dextromethorphan) — read labels to avoid duplication

• Cough is more productive, mucous is easier to expectorate.
• Chest congestion is decreased.

• Dehydration
• Hypotension
• Ototoxicity
• Hypokalemia

• Anuria
• Hypersensitivity to furosemide or sulfonamides (cross-reactivity possible)
• Severe hypovolemia, dehydration
• Severe electrolyte imbalances (esp. hypokalemia)
• Hepatic coma (precipitate by hypokalemia)
• Caution: gout, diabetes (↑ glucose), SLE, renal impairment
• Caution: ototoxicity risk with rapid IV push or high doses
• Pregnancy Cat C; breastfeeding (suppresses lactation)

• Aminoglycosides, vancomycin → additive ototoxicity and nephrotoxicity
• Digoxin → hypokalemia ↑ digoxin toxicity
• Lithium → ↓ lithium clearance → ↑ toxicity
• NSAIDs → ↓ diuretic effect, ↑ nephrotoxicity
• Antihypertensives → additive hypotension
• Corticosteroids → ↑ hypokalemia
• Antidiabetics → ↓ effect (furosemide ↑ glucose)
• Probenecid → ↓ diuretic effect

• ↑ urine output (target depends on indication)
• Weight loss appropriate to goal (e.g., 1-2 lb/day for HF)
• ↓ peripheral edema, ↓ ascites, ↓ JVD
• ↑ ease of breathing, ↓ crackles, ↓ orthopnea (HF, pulmonary edema)
• BP at goal (HTN indication)
• Electrolytes stable: K+ 3.5-5.0, Mg++ 1.5-2.5, Na+ 135-145
• No signs of dehydration (BP, HR, mucous membranes, skin turgor)
• No ototoxicity (hearing intact, no tinnitus)

• Diarrhea: dose-related, occurs most frequently in females and older adult clients
• Risk for angioedema and rash caused by allergy to the medication
• Hyperkalemia
• Hypotension

• Pregnancy — fetal injury/death possible (Cat D in 2nd/3rd trimesters)
• Concurrent use with ACE inhibitors or ARBs in clients with diabetes or moderate-severe renal impairment (contraindicated — ↑ hyperkalemia, hypotension, renal impairment)
• Hypersensitivity to aliskiren or history of angioedema
• Caution: renal artery stenosis (bilateral or in solitary kidney)
• Caution: hyperkalemia, hyponatremia, volume depletion
• Caution: severe hepatic impairment

• ACE inhibitors, ARBs in diabetics or those with renal impairment → contraindicated
• Potassium-sparing diuretics (spironolactone), K supplements, salt substitutes → hyperkalemia
• NSAIDs → ↓ antihypertensive effect, ↑ renal impairment
• Cyclosporine, itraconazole → ↑ aliskiren levels — avoid combination
• High-fat meals → ↓ absorption by 70% — take consistently with or without food
• Other antihypertensives → additive hypotension

• BP at target range (typically < 130/80 for most adults)
• ↓ symptoms of hypertension (headache, dizziness, blurred vision)
• No hyperkalemia (K+ < 5.5 mEq/L)
• Stable renal function (BUN, creatinine)
• No angioedema or severe hypotension

The client should monitor for manifestations of digoxin toxicity, which include GI effects (nausea, vomiting, diarrhea), CNS effects (fatigue, weakness), visual effects (yellow-tinged vision, halos around lights, diplopia), heart rate less than 60/ min in adults, or skipped beats when checking the pulse.

• Digoxin toxicity (active or recent)
• Ventricular fibrillation, ventricular tachycardia
• Second/third-degree heart block (without pacemaker)
• Hypokalemia ↑ toxicity risk substantially
• Hypercalcemia, hypomagnesemia, hypothyroidism
• Acute MI (caution)
• Renal impairment — dose-adjust (digoxin renally cleared)
• Caution: elderly (↓ renal function), pregnancy Cat C

• Thiazide and loop diuretics → cause hypokalemia → ↑ digoxin toxicity
• Quinidine, verapamil, amiodarone, dronedarone → ↑ digoxin levels
• Antacids, cholestyramine, kaolin-pectin → ↓ digoxin absorption
• ACE inhibitors, ARBs → ↑ digoxin levels (renal effect)
• NSAIDs → ↑ digoxin levels
• St. John's wort → ↓ digoxin levels
• Hawthorn, licorice, ginseng → potentiated effects

• Improved cardiac output: ↑ urine output, ↓ peripheral edema, ↓ dyspnea, ↓ fatigue
• HR within target range (typically 60-100; provider sets parameters)
• ↓ symptoms of heart failure (clear lungs, ↓ JVD, ↓ S3)
• For atrial fibrillation: rate control achieved
• Digoxin level 0.5-2.0 ng/mL
• No signs of toxicity (nausea, vomiting, visual changes, dysrhythmias)

Major adverse effects include headache, dizziness caused by hypotension, and rebound tachycardia.

• Concurrent PDE-5 inhibitors (sildenafil, tadalafil, vardenafil) — severe hypotension, MI, death
• Concurrent riociguat
• Severe hypotension or hypovolemia
• Increased intracranial pressure
• Severe anemia
• Constrictive pericarditis, cardiac tamponade
• Right ventricular MI (preload-dependent)
• Hypertrophic obstructive cardiomyopathy (worsens obstruction)
• Hypersensitivity to nitrates

• Phosphodiesterase-5 inhibitors (sildenafil/Viagra, tadalafil/Cialis, vardenafil/Levitra) — life-threatening hypotension; wait 24 hours after sildenafil/vardenafil and 48 hours after tadalafil before nitroglycerin
• Antihypertensives, beta-blockers, calcium channel blockers → additive hypotension
• Alcohol → additive hypotension
• TCAs, phenothiazines → additive hypotension
• Heparin → ↓ heparin effect with concurrent IV NTG

• Acute angina: chest pain relieved within 5 minutes of sublingual dose
• Chronic angina prevention: ↓ frequency and severity of attacks
• ↑ exercise tolerance
• No serious hypotension (SBP > 90, no orthostatic symptoms)
• No medication overuse (using > 3x in 15 min indicates emergency)
• No serious headaches (usually improves with continued use)

• Bradycardia
• Hypotension
• Heart failure
• Constipation

• Severe hypotension (SBP < 90 mmHg)
• Cardiogenic shock
• Second/third-degree AV block (without pacemaker)
• Sick sinus syndrome
• Severe heart failure with ↓ EF (negative inotrope worsens HF)
• Wolff-Parkinson-White (WPW) syndrome with atrial fib (paradoxical ventricular response)
• Concurrent IV beta-blocker (additive cardiac depression)
• Hepatic impairment — dose adjust
• Pregnancy Cat C

• Beta-blockers → additive bradycardia, AV block, HF → AVOID combination (esp. IV)
• Digoxin → ↑ digoxin levels → toxicity risk
• Statins (esp. simvastatin) → ↑ statin levels → rhabdomyolysis risk
• Grapefruit juice → ↑ verapamil levels (CYP3A4 inhibition)
• Amiodarone → ↑ bradycardia, AV block
• Antihypertensives → additive hypotension
• Carbamazepine → ↑ carbamazepine levels (toxicity)

• Angina: ↓ frequency and severity of chest pain, ↑ exercise tolerance
• HTN: BP within target range
• SVT: conversion to sinus rhythm; ↓ ventricular rate in afib/aflutter
• HR within target (typically 60-100)
• No signs of HF worsening (no new dyspnea, edema, weight gain)

• Muscle pain/tenderness (myopathy)
• Liver toxicity with findings (jaundice, upper abdominal pain, anorexia, and nausea)

• Active liver disease or unexplained persistent ↑ liver enzymes
• Pregnancy Category X — fetal harm (cholesterol needed for fetal development)
• Breastfeeding
• Caution: history of liver disease, heavy alcohol use, renal impairment, hypothyroidism (treat first), elderly
• Caution with concurrent fibrates, niacin, cyclosporine, certain antifungals/antibiotics (↑ rhabdomyolysis risk)

• Grapefruit juice → ↑ statin levels → ↑ rhabdomyolysis risk (esp. simvastatin, atorvastatin)
• Fibrates (gemfibrozil) → ↑ myopathy/rhabdomyolysis
• Niacin (high-dose) → ↑ myopathy
• Cyclosporine, erythromycin, clarithromycin, itraconazole, ketoconazole → ↑ statin levels
• Warfarin → ↑ INR (monitor closely)
• Digoxin → ↑ digoxin levels (atorvastatin specifically)
• St. John's wort → ↓ statin effect

• LDL reduction to target (varies by ASCVD risk; commonly < 100, or < 70 if high risk)
• ↓ total cholesterol and triglycerides
• ↑ or stable HDL
• No new cardiovascular events (MI, stroke, revascularization)
• No hepatotoxicity (stable LFTs)
• No myopathy (no muscle pain or weakness, CK within normal)

Like other platelet inhibitors, clopidogrel can cause bleeding due to thrombocytopenia. It can also cause GI effects (abdominal pain, nausea, diarrhea).

• Active pathologic bleeding (peptic ulcer, intracranial hemorrhage)
• Severe hepatic impairment
• Hypersensitivity to clopidogrel
• CYP2C19 poor metabolizers — reduced efficacy (genetic testing available)
• Caution: recent surgery, history of GI bleed, thrombotic thrombocytopenic purpura (TTP) — rare but serious
• Discontinue 5-7 days before elective surgery

• NSAIDs, aspirin, warfarin, heparin → ↑ bleeding risk (sometimes combined intentionally for ACS; otherwise caution)
• Proton pump inhibitors (especially omeprazole and esomeprazole) → ↓ clopidogrel activation via CYP2C19 inhibition → ↓ antiplatelet effect; pantoprazole or H2 blockers are preferred for GI protection
• SSRIs/SNRIs → ↑ bleeding risk
• Ginkgo, garlic, ginger → ↑ bleeding risk
• St. John's wort, rifampin → ↑ clopidogrel activation (theoretical ↑ effect/bleeding)

• Prevention of thrombotic events: no new MI, stroke, or stent thrombosis
• Patency of coronary stents (per imaging/clinical)
• ↓ recurrent ischemic events in ACS, PAD
• No bleeding complications: stable Hgb/Hct, no bruising, no GI bleeding

• Headaches and myalgia (body aches)
• Thrombotic events, such as myocardial infarction and stroke
• Hypertension (common, sometimes serious)
• A too-rapid increase (hgb greater than 1 g/dL over 2 weeks, or hgb greater than 10 g/dL) can worsen hypertension, increase risk of thrombosis, and cause seizures.

• Uncontrolled hypertension
• Pure red cell aplasia following ESA therapy
• Hypersensitivity to epoetin or albumin (human or other components)
• Boxed warning: ↑ mortality, MI, stroke, VTE, tumor progression — use lowest dose to avoid transfusion
• Caution: cardiovascular disease, stroke history, thrombosis history, seizure disorder
• Caution: cancer (avoid in clients with anticipated cure if non-myeloid)
• Pregnancy Cat C

• Iron, folate, B12 deficiency → must be corrected for response; check and supplement
• ACE inhibitors, ARBs → may potentiate hypertensive effects in dialysis
• Antihypertensives — may need adjustment as Hgb rises (↑ BP common)
• Heparin requirements may ↑ during hemodialysis (↑ blood viscosity)

• Hgb rising at appropriate rate: 1-2 g/dL per 2-4 weeks (target 10-11 g/dL)
• ↑ reticulocyte count within 7-10 days
• ↓ fatigue, ↑ exercise tolerance, improved quality of life
• ↓ need for blood transfusions
• BP controlled (no hypertensive crisis)
• No thrombotic events (DVT, MI, stroke)
• Adequate iron stores maintained

• Constipation (most common) — encourage fiber and fluids
• Hypercalcemia with chronic high-dose use — nausea, vomiting, lethargy, confusion, polyuria, polydipsia
• Acid rebound — paradoxical hyperacidity after calcium effect ends
• Gas, belching, flatulence (CO₂ released during gastric acid neutralization)
• Kidney stones (calcium-containing) in predisposed clients
• Milk-alkali syndrome — hypercalcemia + metabolic alkalosis + renal impairment
• ↓ absorption of certain medications (tetracyclines, fluoroquinolones, iron, levothyroxine, bisphosphonates)
• Allergic reactions (rare)

• Hypercalcemia (cancer, hyperparathyroidism, milk-alkali syndrome)
• Renal calculi (calcium-containing stones)
• Severe renal impairment (↑ calcium retention)
• Caution: heart failure (sodium load in chewables), hypertension
• Caution: digoxin therapy (hypercalcemia ↑ digoxin toxicity)
• Caution: pregnancy (limit total calcium intake; Cat C)

• ↓ absorption of many drugs when given concurrently — separate by at least 1-2 hours:
  • Tetracyclines, fluoroquinolones (chelation)
  • Iron, levothyroxine, bisphosphonates
  • Digoxin, phenytoin
• Thiazide diuretics → ↑ calcium retention → hypercalcemia
• Other antacids — usually given alone
• Excessive milk + calcium = milk-alkali syndrome (hypercalcemia, alkalosis, renal impairment)

• Relief of heartburn, indigestion within 5-15 min
• ↓ epigastric pain in peptic ulcer disease
• No constipation (common side effect)
• No signs of hypercalcemia (nausea, vomiting, lethargy, confusion, polyuria)
• No acid rebound (paradoxical hyperacidity with excessive use)

Complications that occur with the use of sulfasalazine include agranulocytosis, and hemolytic and macrocytic anemia.

• Hypersensitivity to sulfa drugs, salicylates, or aspirin
• G6PD deficiency (hemolytic anemia risk)
• Intestinal or urinary obstruction
• Severe hepatic or renal impairment
• Porphyria
• Pregnancy Cat B; caution in third trimester (kernicterus risk)
• Breastfeeding (transferred in breast milk)
• Infants < 2 yr

• Folate antagonist — supplement with folic acid 1 mg/day
• Digoxin → ↓ digoxin absorption
• Methotrexate → ↑ adverse effects (additive folate antagonism, hepatotoxicity)
• Warfarin → ↑ INR / bleeding risk
• Sulfonylureas → ↑ hypoglycemia
• Other hepatotoxic or bone marrow-suppressing drugs → additive toxicity

• UC: ↓ stool frequency, ↓ blood/mucus in stool, ↓ abdominal pain; mucosal healing on endoscopy
• RA: ↓ joint pain, swelling, stiffness; ↑ function; ↓ ESR/CRP
• No hematologic toxicity (CBC stable)
• No hepatic toxicity (LFTs stable)
• No serious hypersensitivity reactions

• Hypokalemia during initial treatment of severe deficiency (rapid RBC production drives K+ into cells)
• Anaphylaxis (rare; more often with parenteral)
• Injection site pain, itching, swelling (parenteral)
• Mild diarrhea, itching, rash
• Peripheral edema
• Headache
• Hyperuricemia (rare)
• Fluid overload from rapid erythropoiesis (in cardiac clients)
• Mild hyperglycemia
• Polycythemia rebound if overdosed

• Hypersensitivity to cobalt or vitamin B12
• Optic nerve damage (Leber's hereditary optic neuropathy) — rare
• Hypokalemia (correction of megaloblastic anemia → rapid cellular K uptake → hypokalemia)
• Caution: cardiac disease (volume changes with rapid erythropoiesis)
• Caution: iron, folate deficiency (often coexists)
• Pregnancy Cat A (oral); Cat C (parenteral)

• Drugs that ↓ absorption: PPIs, H2 blockers, metformin, colchicine, neomycin, cholestyramine
• Alcohol (chronic) → impaired absorption
• Chloramphenicol → ↓ response to B12 therapy
• Iron, folate deficiency may coexist — treat all
• Nitrous oxide (chronic exposure) → inactivates B12

• Review laboratory values for increased reticulocyte count and macrocytes and hgb and hct levels within the expected reference range.
• Assess for improvement of neurologic manifestations (numbness, tingling of hands and feet).

• Decreased libido
• Decreased ejaculate volume
• Gynecomastia
• Orthostatic hypotension

• Pregnancy and women of childbearing age — causes feminization of male fetuses (genital abnormalities)
• Crushed/broken tablets must NOT be handled by pregnant women
• Hypersensitivity to finasteride
• Caution: hepatic impairment (extensively metabolized)
• Caution: clients with risk of prostate cancer (drug ↓ PSA — interpret PSA cautiously; may mask cancer)

• Few clinically significant drug-drug interactions
• Alpha-blockers (tamsulosin, doxazosin) → often combined for BPH (additive symptom relief)
• St. John's wort → may ↓ levels (CYP3A4 induction)
• Effect on PSA — informs lab teams; multiply measured PSA by 2 for cancer screening

• BPH: ↓ urinary frequency, urgency, nocturia, hesitancy, weak stream; ↓ post-void residual; ↑ urinary flow rate
• ↓ prostate volume on exam/imaging (over months)
• Hair loss: stabilization, then gradual regrowth (most visible 3-12 months)
• ↓ PSA (approximately 50% reduction)
• No serious adverse events (depression, suicidal thoughts, breast changes, severe sexual dysfunction)

Hypertensive crisis

Hypertension, preeclampsia, cardiac disease: Use with caution with maternal history of severe renal or hepatic disease, and sepsis.

• Vasoconstrictors, other sympathomimetics → severe HTN
• CYP3A4 inhibitors (erythromycin, clarithromycin, azole antifungals, HIV protease inhibitors) → ↑ ergot toxicity (vasospasm, ischemia)
• Beta-blockers (esp. propranolol) → ↑ vasoconstriction → peripheral ischemia
• Triptans, other ergots → additive vasoconstriction (avoid)
• Tobacco → ↑ vasoconstriction

• Firm, contracted uterus on palpation (no boggy uterus)
• ↓ uterine bleeding, normal lochia rubra → serosa progression
• Stable vital signs (BP, HR, no signs of shock)
• Adequate uterine involution (descending fundal height postpartum)
• No signs of ergot toxicity: chest pain, severe HA, vision changes, peripheral coldness/numbness

• Severe infections, including tuberculosis or reactivation of hepatitis B
• Heart failure
• Severe skin reactions, such as Stevens-Johnson syndrome
• Hematologic disorders

• Active infection (sepsis, TB, opportunistic infections) — TNF inhibition impairs defense
• Latent TB — screen with PPD or IGRA before initiation; treat if positive
• Hepatitis B carrier status — risk of reactivation
• Demyelinating disease (MS) — may worsen
• Heart failure (NYHA III-IV) — TNF inhibitors may worsen HF
• Hypersensitivity to etanercept
• Live vaccines (during therapy and prior) — avoid; complete vaccinations BEFORE starting
• Caution: history of malignancy, especially lymphoma
• Pregnancy Cat B (limited data, but generally avoided unless benefit clearly outweighs)

• Live vaccines (MMR, varicella, zoster, intranasal flu, yellow fever) — AVOID
• Other biologics, anakinra, abatacept → ↑ infection risk; do not combine
• Cyclophosphamide → ↑ malignancy risk
• Methotrexate — often combined intentionally for RA (safe)
• Inactivated vaccines (e.g., flu shot) — give before therapy if possible; may be less effective during

• RA: ↓ joint pain, stiffness, swelling, fatigue; ↑ function; ↓ ESR/CRP; slowed radiographic progression
• Psoriasis: clearer skin, ↓ plaque coverage and severity (PASI score improvement)
• Ankylosing spondylitis: ↓ back pain and stiffness, ↑ spinal mobility
• No serious infections (sepsis, opportunistic, TB reactivation)
• No new malignancies
• No worsening of HF or demyelinating disease

Alendronate can cause esophagitis and esophageal ulceration; other GI effects (nausea, diarrhea, and constipation); muscle pain; and visual disturbances. Rarely, it can cause atraumatic femoral fracture.

• Esophageal abnormalities (strictures, achalasia) that delay esophageal emptying
• Inability to stand/sit upright for at least 30 minutes
• Hypocalcemia (correct before initiating)
• Severe renal impairment (CrCl < 35)
• Pregnancy Cat C
• Caution: GI disease (gastritis, ulcers, dysphagia)
• Caution: invasive dental procedures planned (osteonecrosis of jaw risk)

• Calcium, iron, magnesium, antacids, food → significantly ↓ absorption — separate by at least 30 min (preferably take alendronate first, on empty stomach)
• Coffee, juice, milk → ↓ absorption — water only
• NSAIDs → ↑ GI ulcer/erosion risk
• Aspirin → ↑ GI adverse effects
• Aminoglycosides → additive hypocalcemia
• Other bisphosphonates → not used concurrently

• ↑ bone mineral density on DEXA scan (every 1-2 years)
• ↓ risk of vertebral, hip, and non-vertebral fractures
• Resolution of bone pain (if Paget disease)
• No serious adverse events: no atypical femoral fractures, no osteonecrosis of jaw, no severe esophageal injury

• Gastrointestinal effects can occur, including anorexia, abdominal pain, nausea, vomiting, and heartburn.
• GI bleeding can occur because NSAIDs affect platelet function.
• Nephrotoxicity can occur.
• NSAIDs can cause CNS effects (dizziness, headache, blurred vision, and tinnitus).
• Allergy can occur, including cross allergy with other NSAIDs (aspirin).

• Hypersensitivity to NSAIDs (cross-reactivity within class)
• Aspirin-sensitive asthma (Samter triad: asthma + nasal polyps + NSAID sensitivity)
• Active or history of GI bleeding, peptic ulcer disease
• Severe heart failure, recent CABG (FDA boxed warning — ↑ MI, stroke, HF risk)
• Severe renal impairment (CrCl < 30)
• Severe hepatic impairment
• Pregnancy 3rd trimester (Cat D) — premature closure of fetal ductus arteriosus, fetal renal effects
• Caution: HTN (may ↑ BP, ↓ effect of antihypertensives), elderly (↑ GI, renal, CV risk), bleeding disorders, dehydration
• Caution: concurrent anticoagulants, corticosteroids, SSRIs

• Anticoagulants (warfarin, heparin, DOACs) → ↑ bleeding risk
• Antiplatelets (aspirin, clopidogrel) → ↑ bleeding risk
• Other NSAIDs → additive toxicity (do not combine)
• SSRIs/SNRIs → ↑ GI bleeding risk
• Corticosteroids → ↑ GI ulcer/bleeding risk
• ACE inhibitors, ARBs, diuretics → ↓ antihypertensive effect; ↑ renal toxicity ("triple whammy" of NSAID + diuretic + ACE/ARB)
• Lithium → ↑ lithium levels (toxicity)
• Methotrexate → ↑ methotrexate toxicity
• Aspirin (low-dose for CV protection) → ibuprofen can block antiplatelet effect; take aspirin ≥ 2 hr BEFORE ibuprofen, or ≥ 8 hr after
• Alcohol → ↑ GI bleeding

• ↓ pain to acceptable level
• ↓ inflammation (↓ joint swelling, warmth, redness)
• ↓ fever (return toward normal)
• ↑ joint mobility and function (in arthritis)
• No GI bleeding (stable Hgb, no melena/hematemesis)
• No renal impairment (stable BUN/creatinine, normal UO)
• BP remains controlled

• Sedation
• Nausea/vomiting
• Constipation
• Orthostatic hypotension
• Urinary retention

• Hypersensitivity to hydromorphone or opioids
• Severe respiratory depression, acute asthma, paralytic ileus
• Head injury with ↑ ICP
• Suspected acute abdominal condition
• Concurrent MAOI use
• Caution: elderly, debilitated, hepatic/renal impairment, prostatic hyperplasia, hypothyroidism
• Caution: history of substance use disorder
• Pregnancy Cat C; chronic use → neonatal abstinence syndrome

• Other CNS depressants (benzodiazepines, alcohol, barbiturates, sleep aids, antihistamines, gabapentin) → additive respiratory depression — FDA black box warning
• Other opioids → additive sedation, respiratory depression
• MAOIs → severe and potentially fatal reactions (hypertension or hypotension, hyperpyrexia, coma); avoid within 14 days
• SSRIs, SNRIs, TCAs, triptans, tramadol, St. John's wort → serotonin syndrome risk
• Anticholinergics → ↑ constipation, urinary retention
• Antihypertensives → additive hypotension
• Diuretics → ↑ hypotension; opioids cause ADH release → urinary retention
• Cimetidine → ↑ CNS effects
• Mixed agonist-antagonists (buprenorphine, butorphanol, pentazocine) → may precipitate withdrawal; reduced analgesia
• Naloxone — reverses effects (use for overdose)

• ↓ pain to acceptable level
• ↑ functional ability and quality of life
• No respiratory depression (RR ≥ 12)
• Maintained bowel function
• No signs of overdose (pinpoint pupils, respiratory depression, ↓ LOC)

Adverse effects of carbamazepine include GI manifestations (abdominal pain, nausea, and vomiting). It also can cause bone marrow suppression, affecting all blood cell types.

• Hypersensitivity to morphine or opioids
• Severe respiratory depression, acute asthma, paralytic ileus
• Head injury with ↑ ICP (opioids ↑ ICP)
• Suspected acute abdominal condition (masks symptoms)
• Concurrent MAOIs or within 14 days
• Caution: elderly, debilitated, hepatic/renal impairment, hypothyroidism, prostatic hyperplasia
• Caution: history of substance use disorder
• Pregnancy Cat C; chronic use → neonatal abstinence syndrome
• Breastfeeding (excreted in breast milk)

• The medication can cause hypertensive crisis if taken within 14 days of an mAOI antidepressant.
• Toxicity can result if the client drinks grapefruit juice while taking carbamazepine.

• ↓ pain to client's acceptable level (typically < 4/10 or per goal)
• Improved ability to perform ADLs and breathing exercises
• ↓ pain-related distress, improved sleep, restored appetite
• No respiratory depression (RR ≥ 12, SpO₂ stable, no excessive sedation)
• Bowel function maintained (no severe constipation/ileus)
• No signs of overdose: pinpoint pupils + respiratory depression + ↓ LOC

The nurse should monitor for chest and arm heaviness/pressure, angina caused by coronary vasospasm, dizziness, and vertigo.

• Cardiovascular disease: history of MI, ischemic heart disease, coronary vasospasm (Prinzmetal angina), peripheral vascular disease
• Cerebrovascular disease: history of stroke or TIA
• Uncontrolled hypertension
• Hemiplegic or basilar migraine
• Use of another triptan or ergot within 24 hr (vasoconstriction additive)
• Use of MAOI within 14 days (oral and nasal forms)
• Severe hepatic impairment
• Caution: risk factors for CAD (HTN, hyperlipidemia, smoking, DM, family history, obesity, men > 40, post-menopausal women) — ECG screen if multiple risks
• Pregnancy Cat C

Toxicity can result if sumatriptan is given concurrently or within 2 weeks of an mAOI antidepressant. Sumatriptan should not be given concurrently with other triptan medications or within 24 hr of ergotamine or dihydroergotamine.

• Relief of migraine within 1-2 hr (pain ↓ to mild or no pain)
• Resolution of associated symptoms: nausea, photophobia, phonophobia
• Return to normal function within 2-4 hr
• No serious cardiovascular adverse events (chest pain, MI, stroke)
• No serotonin syndrome

• Gi effects (nausea and vomiting)
• Pancreatitis manifested by acute abdominal pain and possibly severe vomiting
• Hypoglycemia, especially when taken concurrently with a sulfonylurea medication (glipizide)

• Boxed warning: risk of thyroid C-cell tumors (medullary thyroid carcinoma) — avoid with personal/family history of MTC or MEN2
• Hypersensitivity to exenatide
• Severe gastrointestinal disease, gastroparesis
• History of pancreatitis (caution)
• Severe renal impairment (CrCl < 30) — exenatide contraindicated; Bydureon caution
• Type 1 diabetes (does not replace insulin)
• Diabetic ketoacidosis
• Pregnancy Cat C

• Insulin, sulfonylureas, meglitinides → ↑ hypoglycemia risk (reduce insulin/sulfonylurea dose)
• Delayed gastric emptying → may affect absorption of oral medications
• Take oral antibiotics, contraceptives at least 1 hr BEFORE exenatide
• Warfarin → may ↑ INR (monitor closely)

• ↓ HbA1c (target individualized, typically < 7%)
• ↓ fasting and post-prandial glucose
• Weight loss (often 2-5 kg)
• ↓ insulin or sulfonylurea requirements
• No serious adverse events: no pancreatitis, no thyroid mass, no severe hypoglycemia

Adverse effects are essentially the same as manifestations of hyperthyroidism: cardiac manifestations (hypertension and angina pectoris); insomnia; anxiety; weight loss; heat intolerance; increased body temperature; tremors; and menstrual irregularities.

• Untreated thyrotoxicosis
• Acute MI
• Uncorrected adrenal insufficiency (treat adrenal first)
• Hypersensitivity to levothyroxine
• Caution: cardiovascular disease (start low, titrate slowly — ↑ cardiac workload)
• Caution: elderly (↑ cardiac sensitivity, osteoporosis risk with overreplacement)
• Caution: diabetes (may worsen control), osteoporosis
• Pregnancy Cat A; dose typically increases during pregnancy

• ↓ absorption: calcium, iron, antacids (Al/Mg), sucralfate, cholestyramine, bile acid sequestrants, PPIs — separate by 4 hours
• Soy, walnuts, high-fiber foods → ↓ absorption (consistent timing matters)
• Espresso/coffee → can ↓ absorption (separate by 1 hour)
• Warfarin → ↑ INR (levothyroxine ↑ catabolism of clotting factors)
• Insulin and oral hypoglycemics → may need dose adjustment (changing metabolism)
• Digoxin → ↓ digoxin effect
• Estrogens, oral contraceptives → ↑ thyroid-binding globulin → may need ↑ levothyroxine dose
• Phenytoin, carbamazepine, rifampin → ↑ metabolism → may need ↑ levothyroxine dose

• TSH within target range (typically 0.5-4.5 mIU/L; tighter for pregnancy or thyroid cancer)
• ↓ symptoms of hypothyroidism: ↓ fatigue, cold intolerance, constipation, weight gain, dry skin, hair loss
• ↑ energy, ↑ mental clarity, ↑ activity tolerance
• Normal heart rate, no chest pain
• No signs of overreplacement (hyperthyroidism): palpitations, heat intolerance, weight loss, tremor, insomnia, diarrhea

• The 9vHPV vaccine can cause redness, tenderness, and swelling at the injection site.
• It has caused fainting in some clients shortly after the vaccine is administered.
• Headache and mild to moderate fever are also possible adverse effects the client should monitor for.

Contraindications to receiving the 9vHPV vaccine include pregnancy and a severe allergy to yeast.

• Other vaccines — can be given concurrently at separate injection sites
• Immunosuppressants → may ↓ vaccine response (still recommended)
• Recent immunoglobulin or blood product → may interfere with response (less concern with subunit vaccines)

• Completion of full vaccine series
• No serious adverse events (anaphylaxis, severe injection reaction)
• Continued routine cervical cancer screening (Pap/HPV testing) per age guidelines — vaccine does NOT replace screening
• Population-level: ↓ HPV prevalence, ↓ precancerous lesions, ↓ HPV-related cancers

• Hot flashes (or flashes), decreased libido, gynecomastia
• Cardiac manifestations (dysrhythmias) and increased edema, which can lead
• Decreased bone density, which can lead to fractures
• Disease flare, which means manifestations of the client's prostate cancer can

• Hypersensitivity to leuprolide or other GnRH analogs
• Pregnancy (Cat X) — fetal harm
• Undiagnosed vaginal bleeding
• Caution: history of QT prolongation, congenital long QT
• Caution: history of mental health disorders
• Caution: cardiovascular disease, diabetes (worsens with androgen deprivation)
• Caution: existing osteoporosis (worsens with sex steroid loss)
• Initial flare can cause: bone pain, spinal cord compression, urinary obstruction in metastatic prostate cancer (pretreat with antiandrogen)

• Antiandrogens (bicalutamide, flutamide) — combined to prevent flare in prostate cancer
• QT-prolonging drugs (amiodarone, methadone, certain antibiotics) — additive QT risk
• Diabetes medications — leuprolide may worsen glycemic control
• Hormone replacement therapy → defeats the purpose
• Drugs causing bone loss (steroids, PPIs) → additive osteoporosis risk

• Prostate cancer: testosterone at castrate levels (< 50 ng/dL); ↓ PSA; symptom relief
• Endometriosis: ↓ pelvic pain, ↓ dysmenorrhea, amenorrhea, ↓ lesion size on imaging
• Fibroids: ↓ size on imaging, ↓ menorrhagia
• Precocious puberty: regression of pubertal signs, ↓ rate of skeletal maturation
• No flare-related complications (cord compression, bone pain crisis)
• Bone density preserved (with concurrent therapy if appropriate)

• Infusion reactions (red man syndrome: rashes, flushing, tachycardia, and hypotension)
• Ototoxicity (rare and reversible)
• Renal toxicity
• Thrombophlebitis at the IV site
• Im and IV injection-site pain

• Hypersensitivity to vancomycin
• Renal impairment — dose-adjust based on CrCl and serum trough levels
• Caution: hearing loss or ototoxicity history
• Caution: elderly, dehydration
• Pregnancy Cat C (IV); oral form not absorbed → no fetal exposure
• Caution in concurrent nephrotoxic or ototoxic drug use

• Aminoglycosides (gentamicin, tobramycin) → ↑ nephrotoxicity and ototoxicity
• Loop diuretics (furosemide) → ↑ ototoxicity
• NSAIDs, amphotericin B, cisplatin, polymyxin B → ↑ nephrotoxicity
• Neuromuscular blockers → ↑ neuromuscular blockade
• Anesthetics → ↑ infusion reactions, hypotension

• Resolution of infection signs: ↓ fever, ↓ WBC, negative cultures
• Trough levels within therapeutic range (10-20 mcg/mL)
• For CDAD: ↓ diarrhea frequency, resolution of abdominal pain, normal stool form
• No nephrotoxicity (stable BUN/creatinine, UO ≥ 30 mL/hr)
• No ototoxicity (hearing intact, no tinnitus)
• No infusion reactions

• The most common adverse effects of erythromycin are GI manifestations, including abdominal pain, nausea, vomiting, and diarrhea.
• Hepatotoxicity with abdominal pain, anorexia, fatigue, and possibly jaundice can occur after 1 to 2 weeks of erythromycin therapy.
• Erythromycin can cause a prolonged QT interval on ECG, which can lead to potentially fatal tachydysrhythmias.
• Ototoxicity can occur with high doses, especially after prolonged periods.

• Hypersensitivity to erythromycin or other macrolides
• Concurrent pimozide, cisapride, terfenadine — fatal arrhythmias (QT prolongation)
• Concurrent simvastatin, lovastatin (high doses) — rhabdomyolysis risk
• Severe hepatic impairment
• History of QT prolongation, torsades, hypokalemia
• Caution: myasthenia gravis (may worsen)
• Pregnancy Cat B (estolate form is Cat D — hepatotoxic in pregnancy; avoid)
• Breastfeeding (small amounts in milk)

• Potent CYP3A4 inhibitor → ↑ levels of many drugs:
  • Warfarin → ↑ INR
  • Digoxin → ↑ digoxin levels
  • Statins (simvastatin, lovastatin) → rhabdomyolysis
  • Carbamazepine, theophylline → toxicity
  • Cyclosporine, tacrolimus → ↑ levels
  • Benzodiazepines (esp. midazolam, triazolam) → ↑ sedation
• QT-prolonging drugs (amiodarone, methadone, certain antipsychotics) → torsades risk
• Ergot alkaloids → severe vasospasm
• Antacids → may ↓ absorption (separate)

• Resolution of infection symptoms: ↓ fever, ↓ pain, improved appearance of infected site
• Negative cultures (when applicable)
• For gastroparesis: ↑ gastric emptying, ↓ nausea/early satiety
• For acne: ↓ inflammatory lesions
• Completion of course without relapse
• No serious adverse events: no QT prolongation, no hepatic injury, no severe GI symptoms

• Orange-red discoloration of urine, sweat, tears, skin, sclera (expected; harmless but stains fabrics and contact lenses)
• GI: nausea, vomiting, abdominal cramps, dyspepsia (take with food)
• Headache, dizziness, vertigo
• Rash, pruritus (allergic reaction)
• Hemolytic anemia in G6PD-deficient clients
• Methemoglobinemia (rare but serious; blue-gray skin, dyspnea, headache)
• Hepatotoxicity with prolonged use or in hepatic impairment
• Nephrotoxicity with prolonged use, especially in renal impairment
• Anaphylaxis (rare)

• Hypersensitivity to phenazopyridine
• Severe renal impairment (CrCl < 50)
• Severe hepatic impairment
• G6PD deficiency (hemolytic anemia risk)
• Caution: pregnancy Cat B; breastfeeding
• Use limited to 2 days when combined with antibiotic (no longer needed by then)

• Few drug-drug interactions of significance
• May discolor body fluids (urine, sweat, tears) → can stain clothes, soft contact lenses
• May interfere with urine tests (color-based readings: glucose, ketones, bilirubin, urobilinogen)
• Antacids → ↓ absorption (separate)

• Relief of burning, urgency, and frequency within 1-2 days
• ↑ comfort during voiding
• Antibiotic therapy continues to address infection (this is symptom relief only)
• Resolution of UTI symptoms after antibiotic completes
• No hemolytic anemia (CBC stable)
• No hepatotoxicity (skin/sclera not yellowing)

• Paresthesias in the extremities caused by vitamin B6 deficiency
• Hepatotoxicity
• Hyperglycemia (if client has diabetes mellitus)

• Severe hepatic disease, history of INH-induced hepatitis
• Hypersensitivity to INH
• Caution: chronic alcohol use (↑ hepatotoxicity)
• Caution: peripheral neuropathy (give pyridoxine/B6 to prevent)
• Caution: diabetes, malnutrition (↑ neuropathy risk)
• Caution: pregnancy (Cat C; benefit usually outweighs risk for active TB)
• Caution: HIV (may need higher doses; drug interactions)

• Rifampin → ↑ hepatotoxicity risk (but combination usually necessary)
• Acetaminophen, alcohol → ↑ hepatotoxicity
• Phenytoin, carbamazepine, valproate → INH inhibits metabolism → ↑ levels of these drugs → toxicity
• Antacids (Al-containing) → ↓ INH absorption; separate by 1-2 hr
• Tyramine-rich foods (aged cheese, smoked meats) → can cause hypertensive reaction (MAO-A inhibition)
• Disulfiram → psychosis, ataxia

• Active TB: negative sputum cultures after 2-3 months, ↓ symptoms (cough, fever, night sweats, weight loss), improved chest X-ray
• Latent TB: no progression to active disease
• No hepatotoxicity (stable LFTs)
• No peripheral neuropathy
• Adherence verified (DOT or pill count)

• Minor discomforts (fever, headache, and nausea)
• Suppresses the bone marrow, causing a decrease in WBcs, especially granulocytes
• Causes thrombocytopenia frequently
• The client should report any discomforts and be sure to report new onset of fatigue, easy bruising, or sore throat.
• Advise the client to report manifestations of infection or bleeding, and to avoid crowds or individuals who have respiratory infections.

• Severe neutropenia (ANC < 500/mm³) — drug is bone marrow toxic
• Severe thrombocytopenia (platelets < 25,000/mm³)
• Hypersensitivity to ganciclovir or acyclovir
• Pregnancy Cat C — teratogenic, carcinogenic, gonadotoxic in animals; use only if benefit outweighs risk
• Caution: renal impairment — dose-adjust based on CrCl
• Caution: severe hepatic impairment
• Caution: history of cytopenias or bone marrow disease

• Zidovudine → additive bone marrow toxicity → severe neutropenia
• Other myelosuppressive drugs (chemotherapy, trimethoprim/sulfa) → additive cytopenias
• Nephrotoxic drugs (cyclosporine, tacrolimus, aminoglycosides, amphotericin B) → ↑ renal toxicity
• Probenecid → ↑ ganciclovir levels
• Imipenem-cilastatin → ↑ seizure risk (avoid combination)
• Mycophenolate → ↑ levels of both drugs
• Didanosine → ↑ didanosine levels

• CMV retinitis: stabilization or improvement of retinal lesions on serial ophthalmologic exams
• ↓ CMV viral load (PCR)
• Resolution of CMV-associated symptoms (colitis, pneumonitis)
• Successful prevention of CMV disease (transplant prophylaxis)
• No significant cytopenias: ANC > 500, platelets > 25,000
• Stable renal function

• Mild adverse effects, including dry mouth, lightheadedness, constipation, GI discomfort
• Skin rash with client exposure to sunlight

• Hypersensitivity to St. John's wort
• Severe (major) depression — efficacy unclear; risks of delaying effective treatment
• Bipolar disorder (can trigger mania)
• Concurrent use with prescription antidepressants — serotonin syndrome risk
• Concurrent use with many critical medications (see Interactions) — DOZENS of significant interactions
• Pregnancy and breastfeeding (insufficient data)
• Surgery — discontinue at least 5 days before (anesthetic interactions)
• Photosensitivity in fair-skinned clients

• Can cause serotonin syndrome when combined with other antidepressants, amphetamine, and cocaine
• Decreases effectiveness of oral contraceptives, cyclosporine, warfarin, digoxin, calcium channel blockers, steroids, HIV protease inhibitors, and some anticancer medications

• ↓ mild-to-moderate depressive symptoms (questionable benefit; many studies show limited efficacy)
• ↑ mood, ↑ energy, improved sleep
• No serotonin syndrome
• No suicidal ideation worsening
• No drug interaction-related problems (contraceptive failure, transplant rejection, etc.)
• For severe depression: assess for inadequate response — refer for evidence-based treatment