Mosby's 2014 Nursing Drug Reference (104 page)

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clopidogrel (Rx)

(klo-pid′oh-grel)

Plavix

Func. class.:
Platelet aggregation inhibitor

Chem. class.:
Thienopyridine derivative

Do not confuse:
Plavix
/Paxil/Elavil

ACTION:

Inhibits ADP-induced platelet aggregation

USES:

Reducing the risk of stroke, MI, vascular death, peripheral arterial disease in high-risk patients, acute coronary syndrome, transient ischemic attack (TIA), unstable angina

Unlabeled uses:
Cardiac surgery (infant and child), Kawasaki disease

CONTRAINDICATIONS:

Hypersensitivity, active bleeding

Precautions:
Pregnancy (B), breastfeeding, children, previous hepatic disease, increased bleeding risk, neutropenia, agranulocytosis, renal disease, Asian/Black/Caucasian patients

 

Black Box Warning:

CYP2C19 allele (poor metabolizers)

DOSAGE AND ROUTES
Calculator
Recent MI, stroke, peripheral arterial disease

• Adult:
PO
75 mg/day with/without aspirin

Acute coronary syndrome

• Adult:
PO
loading dose 300 mg then 75 mg/day with aspirin

Cardiac surgery/other cardiac conditions (unlabeled)

• Child ≤2 yr, infant, neonate:
PO
0.2 mg/kg/day for platelet inhibition

Available forms:
Tabs 75, 300 mg

Administer:

• 
Without regard to food

• 
Should be discontinued 5 days before elective surgery if an antiplatelet action is not desired

SIDE EFFECTS

CNS:
Headache, dizziness, depression, syncope, hypesthesia, neuralgia

CV:
Edema, hypertension, chest pain

GI:
Nausea, vomiting, diarrhea, constipation, GI discomfort,
GI bleeding, pancreatitis, hepatic failure

GU:
Glomerulonephritis

HEMA:
Epistaxis, purpura,
bleeding, neutropenia, aplastic anemia, agranulocytosis, thrombotic thrombocytopenic purpura

INTEG:
Rash, pruritus,
anaphylaxis

MISC:
UTI, hypercholesterolemia, chest pain, fatigue,
intracranial hemorrhage, toxic epidermal necrolysis, Stevens-Johnson syndrome,
flulike syndrome

MS:
Arthralgia, back pain

RESP:
Upper respiratory tract infection, dyspnea, rhinitis, bronchitis, cough,
bronchospasm

PHARMACOKINETICS

Rapidly absorbed; peak 1-3 hr; metabolized by liver (CYP3A4); excreted in urine, feces; half-life 8 hr; plasma protein binding 95%; effect on platelets after 3-7 days

INTERACTIONS

 

Black Box Warning:

Avoid use with CYP2C19 inhibitors (omeprazole, esomeprazole)

Increase:
bleeding risk—anticoagulants, aspirin, NSAIDs, abciximab, eptifibatide, tirofiban, thrombolytics, ticlopidine, SSRIs, treprostinil, rifampin

Increase:
action of some NSAIDs, phenytoin, TOLBUTamide, tamoxifen, torsemide, fluvastatin, warfarin

Decrease:
clopidogrel effect—proton pump inhibitor (PPIs)

Decrease:
CYP3A4 inhibitors/substrates —atorvastatin, simvastatin, cerivastatin

Drug/Herb

Increase:
clopidogrel effect—feverfew, fish oil, omega-3 fatty acid, garlic, ginger, ginkgo biloba, green tea, horse chestnut

Decrease:
clopidogrel effect—bilberry, saw palmetto

Drug/Lab Test

Increase:
AST, ALT, bilirubin, uric acid, total cholesterol, nonprotein nitrogen (NPN)

NURSING CONSIDERATIONS
Assess:

 
Thrombotic/thrombocytic purpura,
fever, thrombocytopenia, neurolytic anemia

 

Black Box Warning:

CYP2C19 Allele (poor metabolizers): Consider using another antiplatelet product, higher CV reaction occurs after acute coronary syndrome or PCI, tests are available to determine CYP2C19 allele

• 
Symptoms of stroke, MI during treatment

• 
Hepatic studies: AST, ALT, bilirubin, creatinine (long-term therapy)

• 
Blood studies: CBC, differential, Hct, Hgb, PT, cholesterol (long-term therapy)

Evaluate:

• 
Therapeutic response: absence of stroke, MI

Teach patient/family:

• 
That blood work will be necessary during treatment

• 
To report any unusual bruising, bleeding to prescriber; that it may take longer to stop bleeding

• 
To take without regard to food

• 
To report diarrhea, skin rashes, subcutaneous bleeding, chills, fever, sore throat

• 
To tell all health care providers that clopidogrel is being used; may be held for 5 days before surgery

Canada only   Side effects:
italics
= common;
bold
= life-threatening   
Nurse Alert

clotrimazole (topical, vaginal, oral)

(kloe-trim′a-zole)

Cruex, Gyne-Lotrimin, Lotrimin, Lotrimin AF, MyCelex, MyCelex-7, Trivagizole 3, Desenex

Func. class.:
Topical antifungal

Chem. class.:
Imidazole derivative

Do not confuse:
clotrimazole
/miconazole/clobetasol

ACTION:

Antifungal activity results from altering cell wall permeability

USES:

Vulvovaginal, oropharyngeal candidiasis; topical fungal infections

CONTRAINDICATIONS:

Hypersensitivity, ophthalmic use

Precautions:
Hepatic impairment (oral)

DOSAGE AND ROUTES
Calculator
Tinea corporis, cruris, pedis, versicolor; candidiasis

• Adult/child ≥2 yr:
Apply to affected area and rub into area
AM
/
PM
× 2-4 wk

Vulvovaginal candidiasis

• Adult/child

12 yr:
Vag cream
1 applicator at bedtime × 3 days (2%) or 7 days (1%)

Oropharyngeal candidiasis

• Adult/child

3 yr:
Lozenge
1 PO dissolved 5 × /day × 2 wk or adults 1 lozenge dissolved tid (prevention)

Available forms:
Topical cream, solution, 1%; vaginal cream 1%, 2%; Lozenges, troches 10 mg

Administer:
Topical route

• 
Topical skin products are not for intravaginal therapy and are for external use only; do not use skin products near the eyes, nose, or mouth

• 
Wash hands before and after use; wash affected area and gently pat dry

• 
Cream/solution:
Apply to the cleansed affected area; massage gently into affected areas

• 
Troches:
Allow to dissolve, do not chew or swallow whole

Intravaginal route

• 
Only use dosage formulations specified for intravaginal use; intravaginal dosage forms are not for topical therapy; do not ingest

• 
Cream:
Use applicator(s) supplied by the manufacturer

SIDE EFFECTS

GI:
Nausea, vomiting

GU:
Vaginal burning, irritation

INTEG:
Burning, peeling, rash, pruritus

PHARMACOKINETICS

PO duration 3 hr

INTERACTIONS
Drug/Lab Test

Increase:
LFTs

NURSING CONSIDERATIONS
Assess:

• 
Allergic reaction:
Assess for hypersensitivity, product might need to be discontinued

• 
Infection:
Assess for severity of infection, itching

Evaluate:

• 
Decreased infection, itching

Teach patient/family:
Topical route:

• 
That topical skin products are not for intravaginal therapy and are for external use only; do not use skin products near the eyes, nose, or mouth

• 
To wash hands before and after use; wash affected area and gently pat dry

• 
Cream:
To shake well before use, apply a thin film to the cleansed affected area, massage gently into affected areas

PO route:

• 
Troches
: Allow to dissolve, do not chew or swallow whole

Intravaginal route:
To use only dosage formulations specified for intravaginal use; intravaginal dosage forms are not for topical therapy; do not ingest

• 
Cream:
To use applicator(s) supplied by the manufacturer

Canada only   Side effects:
italics
= common;
bold
= life-threatening   
Nurse Alert

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