Mosby's 2014 Nursing Drug Reference (245 page)

• Adult:
PO
10-40 mg/day; max 80 mg/day

• Child ≥6 yr:
PO
0.07 mg/kg/day up to 5 mg/day; titrate q1-2wk up to 0.6 mg/kg/day or 40 mg/day

• Geriatric:
PO
2.5-5 mg/day, increase q7days

• Adult:
PO
5 mg initially with diuretics, range 5-40 mg

• Acute myocardial infarction in adults who are hemodynamically stable:
PO
give 5 mg within 24 hr of onset of symptoms, then 5 mg after 24 hr, 10 mg after 48 hr, then 10 mg daily

• Adult:
PO
CCr <30 ml/min, reduce dose by 50%, initially 5 mg/day, max 40 mg/day; CCr <10 ml/min, 2.5 mg/day, max 40 mg/day

• 
Severe hypotension may occur after 1st dose of product; may be prevented by reducing or discontinuing diuretic therapy 3 days before beginning lisinopril therapy

Increase:
hyperkalemia—potassium salt substitutes, potassium-sparing diuretics, potassium supplements, cycloSPORINE

Increase:
possible toxicity—lithium

Increase:
hypotensive effect—diuretics, other antihypertensives, probenecid, phenothiazines, nitrates, acute alcohol ingestion

Increase:
hypersensitivity—allopurinol

Decrease:
lisinopril effects—aspirin, indomethacin, NSAIDs

• 
High-potassium diet (bananas, orange juice, avocados, nuts, spinach) should be avoided; hyperkalemia may occur

Interference:
glucose/insulin tolerance tests, ANA titer

 
Blood studies, platelets; WBC with differential at baseline, periodically q3mo; if neutrophils <1000/mm
³
, discontinue treatment (recommended with collagen-vascular disease)

• 
Baselines of renal, hepatic studies before therapy begins, periodically; LFTs, uric acid, glucose may be increased

• 
Angioedema: anaphylaxis, toxic epidermal necrolysis,
facial swelling, dyspnea, tongue swelling (rare)

Black Box Warning:

Pregnancy before starting treatment; pregnancy (D)

• 
Hypertension:
B/P, pulse q4hr during beginning treatment and periodically thereafter; note rate, rhythm, quality; apical/pedal pulse before administration; notify prescriber of any significant changes

• 
Electrolytes: potassium, sodium, chlorine

• 
CHF:
edema in feet, legs daily; weight daily; dyspnea, wet crackles

• 
Skin turgor, dryness of mucous membranes for hydration status

• 
Therapeutic response: decreased B/P, CHF symptoms

• 
Not to discontinue product abruptly; to taper

• 
To rise slowly to sitting or standing position to minimize orthostatic hypotension

• 
To avoid increasing potassium in the diet

• 
To report dry cough

Black Box Warning:

To report if pregnancy is planned or suspected; pregnancy (D) 2nd/3rd trimesters

Black Box Warning:

Lithium level >1.5 mmol/L

• Adult:
PO
300-600 mg tid, maintenance 300 mg tid or qid;
SLOW REL TABS
q300 mg bid; dose should be individualized to maintain blood levels at 1-1.5 mEq/L

• Geriatric:
PO
300 mg bid, increase q7days by 300 mg to desired dose

• Child:
PO
15-20 mg/kg/day in 3-4 divided doses; increase as needed; do not exceed adult doses; maintain blood levels at 0.4-0.5 mEq/L

• 
Do not break, crush, chew caps, ext rel tabs

• 
Reduced dose to geriatric patients

• 
With meals to avoid GI upset

• 
Adequate fluids (2-3 L/day) to prevent dehydration during initial treatment, 1-2 L/day during maintenance

Increase:
hypothyroid effects—antithyroid agents, calcium iodide, potassium iodide, iodinated glycerol

Increase:
effects of neuromuscular blocking agents, phenothiazines

Increase:
renal clearance—sodium bicarbonate, acetaZOLAMIDE, mannitol, aminophylline

Increase:
masking of lithium toxicity—beta-blockers used for lithium tremor

Increase:
toxicity—indomethacin, diuretics, NSAIDs, losartan

Increase:
lithium effect/toxicity—carBAMazepine, FLUoxetine, methyldopa, thiazide diuretics, probenecid

Decrease:
lithium effects—theophyllines, urea, urinary alkalinizers

• 
Avoid use with kava, St. John’s wort, valerian

Decrease:
lithium levels—black/green tea, guarana

• 
Significant changes in sodium intake alter lithium excretion

Increase:
potassium excretion, urine glucose, blood glucose, protein, BUN

Decrease:
VMA, T
₃
, T
₄
,
¹³¹
I

• 
Mental status:
manic symptoms, mood, behavior before, during treatment

Black Box Warning:

Lithium toxicity:
diarrhea, vomiting, tremor, twitching; serum lithium levels 2×/wk initially then q2mo (therapeutic level: 0.5-1.5 mEq/L); toxic level >1.5 mcg/L

• 
Weight daily; check for, report edema in legs, ankles, wrists

• 
Sodium intake; decreased sodium intake with decreased fluid intake may lead to lithium retention; increased sodium, fluids may decrease lithium retention

• 
Skin turgor at least daily

• 
Urine for albuminuria, glycosuria, uric acid during beginning treatment, q2mo thereafter

• 
Neurologic status: LOC, gait, motor reflexes, hand tremors

• 
ECG in those >50 yr with CV disease, cardiology consult is recommended in those with risk factor

• 
Therapeutic response: decrease in excitement, manic phase

• 
About
the symptoms of minor toxicity:
vomiting, diarrhea, poor coordination, fine motor tremors, weakness, lassitude;
major toxicity:
coarse tremors, severe thirst, tinnitus, diluted urine

• 
To monitor urine specific gravity, emphasize need for follow-up care to determine lithium levels; to monitor lithium levels to ensure effective levels and treatment

• 
That contraception is necessary because lithium may harm fetus (pregnancy [D]); not to breastfeed

• 
Not to operate machinery until lithium levels stable

• 
That beneficial effects may take 1-3 wk

• 
About products that interact with lithium (provide list); about need for adequate, stable intake of salt and fluids; not to use OTC products unless approved by prescriber