H
halcinonide
Brand Name(s): Halog, Halog-E
Clinical Pharmacology:Mechanism of Action: A topical corticosteroid that has anti-inflammatory, antipruritic, and vasoconstrictive properties. The exact mechanism of the anti-inflammatory process is unclear. Therapeutic Effect: Reduces or prevents tissue response to the inflammatory process.
Pharmacokinetics: Well absorbed systemically. Large variation in absorption among sites. Protein binding: varies. Metabolized in liver. Primarily excreted in urine.
Available Forms:
Indications and Dosages:
Contraindications: History of hypersensitivity to halcinonide or other corticosteroids
Side Effects
Occasional Itching, redness, irritation, burning at site of application, dryness, folliculitis, acneiform eruptions, hypopigmentation
Serious Reactions
Patient/Family Education
Monitoring Parameters
Geriatric side effects at a glance:
U.S. Regulatory Considerations
halobetasol
Brand Name(s): Ultravate
Clinical Pharmacology:Mechanism of Action: A corticosteroid that inhibits accumulation of inflammatory cells at inflammation sites, phagocytosis, lysosomal enzyme release and synthesis or release of mediators of inflammation. Therapeutic Effect: Decreases or prevents tissue response to inflammatory process.
Pharmacokinetics: Variation in absorption among individuals and sites: scrotum 36%, forehead 7%, scalp 4%, forearm 1%.
Available Forms:
Indications and Dosages:
Contraindications: Hypersensitivity to halobetasol or other corticosteroids.
Side Effects
Serious Reactions
Patient/Family Education
Monitoring Parameters
Geriatric side effects at a glance:
U.S. Regulatory Considerations
haloperidol
Brand Name(s): Haldol, Haldol Decanoate
Clinical Pharmacology:Mechanism of Action: An antipsychotic, antiemetic, and antidyskinetic agent that competitively blocks postsynaptic dopamine receptors, interrupts nerve impulse movement, and increases turnover of dopamine in the brain. Has strong extrapyramidal and antiemetic effects; weak anticholinergic and sedative effects. Therapeutic Effect: Produces tranquilizing effect.
Pharmacokinetics: Readily absorbed from the GI tract. Protein binding: 92%. Extensively metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 12-37 hr PO; 10-19 hr IV; 17-25 hr IM.
Available Forms:
Indications and Dosages:Tourette’s disorder: PO 6-15 mg/day. May increase by 2-mg increments as needed. Maintenance: 9 mg/day.
Unlabeled Uses: Treatment of Huntington’s chorea, nausea or vomiting associated with cancer chemotherapy
Contraindications: Angle-closure glaucoma, CNS depression, myelosuppression, Parkinson’s disease, severe cardiac or hepatic disease
Side Effects
Blurred vision, constipation, orthostatic hypotension, dry mouth, swelling or soreness of female breasts, peripheral edema
Serious Reactions
• Extrapyramidal symptoms appear to be dose-related and typically occur in the first few days of therapy. Marked drowsiness and lethargy, excessive salivation, and fixed stare occur frequently. Less common reactions include severe akathisia (motor restlessness) and acute dystonias (such as torticollis, opisthotonos, and oculogyric crisis).
Patient/Family Education
• Avoid tasks that require mental alertness or motor skills until response to the drug has been established
Monitoring Parameters
• Closely supervise suicidal patients during early therapy. As depression lessens, the patient’s energy level improves, which increases the suicide potential
• Assess the patient for evidence of a therapeutic response, including improvement in self-care, increased interest in surroundings and ability to concentrate, and relaxed facial expression
• The therapeutic serum level for haloperidol is 0.2 to 1 mcg/ml, and the toxic serum level is greater than 1 mcg/ml
Geriatric side effects at a glance:
Use with caution in older patients with: Parkinson’s disease (an atypical antipsychotic is recommended), seizure disorders, cardiovascular disease with conduction disturbance, hepatic encephalopathy, narrow-angle glaucoma, congenital prolonged Q-T syndrome or drugs which prolong Q-T interval, drugs which inhibit or utilize 26D substrate of cytochrome P450.
U.S. Regulatory Considerations
Other Uses in Geriatric Patient: Behavior disturbances in the setting of dementia
Side Effects:Of particular importance in the geriatric patient: Tardive dyskinesia, akathisia (may appear to exacerbate behavioral disturbances), anticholinergic effects, may increase risk of sudden death
Geriatric Considerations – Summary: Sink and colleagues’ systematic review showed statistically significant improvements on neuropsychiatric and behavioral scales for some drugs, but improvements were small and unlikely to be clinically important. Because of documented risks, and uncertain benefits, these agents should be used with caution in demented elderly persons, with frequent monitoring for side effects and a low threshold for discontinuing use.1 Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs. J Am Geriatr Soc. 1999;47:30-39.
2 Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. JAMA. 2005;293:596-608.
3 Ray WA, Meredith S, Thapa PB, Meador KG, Hall K, Murray KT. Antipsychotics and the risk of sudden cardiac death. Arch Gen Psychiatry. 2001;58:1161-1167.
heparin sodium
Brand Name(s): Hep-Lock, Hep-Pak CVC
Chemical Class: Glycosaminoglycan, sulfated
Clinical Pharmacology:Mechanism of Action: A blood modifier that interferes with blood coagulation by blocking conversion of prothrombin to thrombin and fibrinogen to fibrin. Therapeutic Effect: Prevents further extension of existing thrombi or new clot formation. Has no effect on existing clots.
Pharmacokinetics: Well absorbed following subcutaneous administration. Protein binding: Very high. Metabolized in the liver. Removed from the circulation via uptake by the reticuloendothelial system. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 1-6 hr.
Available Forms:• Injection (Hep-Lock): 10 units/ml, 100 units/ml, 1000 units/ml, 2500 units/ml, 5000 units/ml, 7500 units/ml, 10,000 units/ml, 20,000 units/ml, 25,000 units/500 ml infusion.
Indications and Dosages:Treatment of venous thrombosis, pulmonary embolism, peripheral arterial embolism, atrial fibrillation with embolism: Intermittent IV Initially, 10,000 units, then 50-70 units/kg (5000–10,000 units) q4-6h. IV Infusion Loading dose: 80 units/kg, then 18 units/kg/hr, with adjustments based on aPTT. Range: 10-30 units/kg/hr.
Prevention of venous thrombosis, pulmonary embolism, peripheral arterial embolism, atrial fibrillation with embolism: Subcutaneous 5000 units q8-12h.
Contraindications: Intracranial hemorrhage, severe hypotension, severe thrombocytopenia, subacute bacterial endocarditis, uncontrolled bleeding
Side Effects
Serious Reactions
• Bleeding complications ranging from local ecchymoses to major hemorrhage occur more frequently in high-dose therapy, intermittent IV infusion, and in women 60 years of age and older.
• Antidote: Protamine sulfate 1-1.5 mg, IV, for every 100 units heparin subcutaneous within 30 min of overdose, 0.5-0.75 mg for every 100 units heparin subcutaneous if within 30-60 min of overdose, 0.25-0.375 mg for every 100 units heparin subcutaneous if 2 hr have elapsed since overdose, 25-50 mg if heparin was given by IV infusion.
Patient/Family Education
• Do not take other medications, including OTC drugs, especially aspirin and NSAIDs, without physician approval
Monitoring Parameters
• aPTT (usual goal is to prolong aPTT to a value that corresponds to a plasma heparin level of 0.2-0.4 U/ml by protamine titration or to an antifactor Xa level of about 0.3-0.6 U/ml; this range must be determined for each individual laboratory), usually measure 6-8 hr after initiation of IV and 6-8 hr after INF rate changes; increase or decrease INF by 2-4 U/kg/hr dependent on aPTT
• Platelet counts, signs of bleeding, Hgb, Hct, AST (SGOT) and ALT (SGPT) levels, and stool and urine cultures for occult blood
• Assess the patient’s gums for erythema and gingival bleeding, skin for ecchymosis or petechiae, and urine for hematuria
• Evaluate the patient for abdominal or back pain, a decrease in blood pressure, an increase in pulse rate, and severe headache, which may be evidence of hemorrhage
• When converting to warfarin therapy, monitor the patient’s PT/INR results, as ordered. PT/INR will be 10%-20% higher while heparin is being given concurrently
Geriatric side effects at a glance:
U.S. Regulatory Considerations
• Increased risk of spinal/epidural hematomas with neuraxial anesthesia or spinal puncture. Risk is further increased by use of indwelling spinal catheters, repeated/traumatic epidural/spinal puncture, or use of drugs affecting hemostasis (NSAIDs, anticoagulants, platelet inhibitors).
hydralazine hydrochloride
(hye-dral’-a-zeen hye-droe-klor’-ide)
Brand Name(s): Apresoline
Clinical Pharmacology:Mechanism of Action: An antihypertensive with direct vasodilating effects on arterioles. Therapeutic Effect: Decreases BP and systemic resistance.
Available Forms:
Indications and Dosages:Moderate to severe hypertension: PO Initially, 10 mg 2-3 times a day. May increase by 10-25 mg q2-3days. IV, IM Initially, 10-20 mg/dose q4-6h. May increase to 40 mg/dose.
Dosage in renal impairment: Dosage interval is based on creatinine clearance.
| Creatinine Clearance | Dosage Interval |
|---|---|
| 10-50 ml/min | q8h |
| less than 10 ml/min | q8-24h |
Unlabeled Uses: Treatment of CHF, hypertension secondary to eclampsia and pre-eclampsia, primary pulmonary hypertension.
Contraindications: Coronary artery disease, lupus erythematosus, rheumatic heart disease
Side Effects
Serious Reactions
• High dosage may produce lupus erythematosus–like reaction, including fever, facial rash, muscle and joint aches, and splenomegaly.
• Severe orthostatic hypotension, skin flushing, severe headache, myocardial ischemia, and cardiac arrhythmias may develop.
Patient/Family Education
• Notify clinician of any unexplained prolonged general tiredness or fever, muscle or joint aching, or chest pain
Monitoring Parameters
Geriatric side effects at a glance:
U.S. Regulatory Considerations
hydrochlorothiazide
(hye-droe-klor-oh-thye’-a-zide)
Brand Name(s): Aquazide H, Esidrix, HydroDIURIL, Microzide, Oretic
Rx: with ACE inhibitors: quinapril (Accuretic); captopril (Acediur, Capozide); lisinopril (Prinzide, Zestoretic); benazepril (Lotensin HCT); moexipril (Uniretic); enalapril (Vaseretic); with spironolactone (Aldactazide, Spirozide); with methyldopa (Aldoril); with hydralazine (Apresazide); with reserpine (Aqwesine, Hydropres, Hydroserpine, Hydrotensin, Mallopres, Marpres, Unipres); with angiotensin II receptor blockers: irbesartan (Avalide), valsartan (Diovan HCT), losartan (Hyzaar); with hydralazine and reserpine (Cam-ap-es, H.H.R., Hyserp, Lo-Ten, Ser-A-Gen, Seralazide, Ser-Ap-Es, Serpex, Uni-Serp); with triamterene (Dyazide, Maxzide); with potassium (Esidrix-K); with guanethidine (Esimil); with β-blockers: propranolol (Inderide); metoprolol (Lopressor HCT); labetalol (Normazide, Trandate-HCT); timolol (Timolide); bisoprolol (Ziac); with amiloride (Moduretic)
Clinical Pharmacology:Mechanism of Action: A sulfonamide derivative that acts as a thiazide diuretic and antihypertensive. As a diuretic, blocks reabsorption of water, sodium, and potassium at the cortical diluting segment of the distal tubule. As an antihypertensive, reduces plasma, extracellular fluid volume, and peripheral vascular resistance by direct effect on blood vessels. Therapeutic Effect: Promotes diuresis; reduces BP.
