N
nabumetone
Brand Name(s): RelafenChemical Class: Acetic acid derivative
Clinical Pharmacology:Mechanism of Action: An NSAID that produces analgesic and anti-inflammatory effects by inhibiting prostaglandin synthesis. Therapeutic Effect: Reduces the inflammatory response and intensity of pain.
Pharmacokinetics: Readily absorbed from the GI tract. Protein binding: 99%. Widely distributed. Metabolized in the liver to active metabolite. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 22–30 hr.
Available Forms:
Indications and Dosages:Acute or chronic rheumatoid arthritis and osteoarthritis: PO Initially, 1,000 mg as a single dose or in 2 divided doses. May increase up to 2,000 mg/day as a single or in 2 divided doses.
Contraindications: Active peptic ulcer disease, chronic inflammation of GI tract, GI bleeding or ulceration, history of hypersensitivity to aspirin or NSAIDs, history of significant renal impairment
Side Effects
Diarrhea, abdominal cramps or pain, dyspepsia
Nausea, constipation, flatulence, dizziness, headache
Serious Reactions
Patient/Family Education
• Nabumetone may cause serious GI bleeding with or without pain; avoid aspirin during nabumetone therapy because it increases the risk of GI bleeding
Monitoring Parameters
• Initial hematocrit and fecal occult blood test within 3 months of starting regular chronic therapy; repeat every 6-12 months (more frequently in high-risk patients (>65 years, peptic ulcer disease, concurrent steroids or anticoagulants); electrolytes, creatinine, and BUN within 3 months of starting regular chronic therapy; repeat every 6-12 months
• Therapeutic response, such as improved grip strength, increased joint mobility, and decreased pain, tenderness, stiffness, and swelling
Geriatric side effects at a glance:
Use with caution in older patients with: Renal impairment, Hepatic impairment, CHF, HTN, PUD, History of GI bleeding, GERD, Bleeding and platelet disorders, History of aspirin sensitivity reaction. Also use with caution in patients taking Anticoagulants, Aspirin, and Antihypertensive agents.
U.S. Regulatory Considerations
Other Uses in Geriatric Patient: Acute gout
Side Effects:
Geriatric Considerations – Summary: A preferred agent in older adults due to its association with fewer GI adverse effects. Use of NSAIDs in older adults increases the risk of GI complications including gastric ulceration, bleeding, and perforation. These complications are not necessarily preceded by less severe GI symptoms. Concomitant use of a proton pump inhibitor or misoprostol reduces the risk for gastric ulceration and bleeding, but may not prevent long-term GI toxicity. No clinical data exist to support reduced GI toxicity with the use of nabumetone.nadolol
Brand Name(s): CorgardRx: with Bendroflumethiazide (Corzide)
Chemical Class: β-Adrenergic blocker, nonselective
Clinical Pharmacology:Mechanism of Action: A nonselective beta-blocker that blocks beta1– and beta2-ad-renergic receptors. Large doses increase airway resistance. Therapeutic Effect: Slows sinus heart rate, decreases cardiac output and BP. Decreases myocardial ischemia severity by decreasing oxygen requirements.
Pharmacokinetics: Variable absorption after PO administration. Protein binding: 28%-30%. Not metabolized. Excreted unchanged in feces. Half-life: 20-24 hr.
Available Forms:
Indications and Dosages:Mild to moderate hypertension, angina: PO Initially, 20 mg/day. May increase gradually. Range: 20–240 mg/day.
Unlabeled Uses: Treatment of arrhythmias, hypertrophic cardiomyopathy, MI, mitral valve prolapse syndrome, neuroleptic-induced akathisia, pheochromocytoma, tremors, thyrotoxicosis, vascular headaches
Contraindications: Bronchial asthma, cardiogenic shock, CHF secondary to tachyarrhythmias, chronic obstructive pulmonary disease (COPD), patients receiving MAOI therapy, second- or third-degree heart block, sinus bradycardia, uncontrolled cardiac failure
Side Effects
Nadolol is generally well tolerated, with transient and mild side effects. Diminished sexual ability, drowsiness, unusual fatigue or weakness
Bradycardia, difficulty breathing, depression, cold hands or feet, diarrhea, constipation, anxiety, nasal congestion, nausea, vomiting
Serious Reactions
• Abrupt withdrawal of nadolol may result in diaphoresis, palpitations, headache, tremors, exacerbation of angina, MI, and ventricular arrhythmias.
• Nadolol administration may precipitate CHF and MI in patients with cardiac disease; thyroid storm in those with thyrotoxicosis; and peripheral ischemia in those with existing peripheral vascular disease.
Patient/Family Education
• Do not discontinue abruptly; may require taper; rapid withdrawal may produce rebound hypertension or angina
• Notify the physician if confusion, depression, difficulty breathing, dizziness, fever, night cough, rash, slow pulse, sore throat, swelling of arms and legs, or unusual bleeding or bruising occurs
Monitoring Parameters
• Angina: reduction in nitroglycerin usage; frequency, severity, onset, and duration of angina pain; heart rate
• Congestive heart failure: functional status, cough, dyspnea on exertion, paroxysmal nocturnal dyspnea, exercise tolerance, and ventricular function
• Toxicity: blood glucose, bronchospasm, hypotension, bradycardia, depression, confusion, hallucination, sexual dysfunction
Geriatric side effects at a glance:
U.S. Regulatory Considerations
FDA Black Box In patients using 
nafcillin sodium
Brand Name(s): Nafcil, Nallpen, Unipen
Chemical Class: Penicillin derivative, penicillinase-resistant
Clinical Pharmacology:Mechanism of Action: A penicillin that acts as a bactericidal in susceptible microorganisms. Therapeutic Effect: Inhibits bacterial cell wall synthesis. Bactericidal.
Pharmacokinetics: Poorly absorbed from gastrointestinal (GI) tract. Protein binding: 87%-90%. Metabolized in liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 10.5-1 hr (half-life increased with imparied renal function).
Available Forms:
Indications and Dosages:
Unlabeled Uses: Surgical prophylaxis
Contraindications: Hypersensitivity to any penicillin
Side Effects
Mild hypersensitivity reaction (fever, rash, pruritus), GI effects (nausea, vomiting, diarrhea) more frequent w/oral administration
Serious Reactions
• Superinfections, potentially fatal antibacterial-associated colitis may result from altered bacterial balance.
Patient/Family Education
Monitoring Parameters
• Oral nafcillin absorption is erratic (consider alternate oral penicillinase-resistant penicillins)
• Daily bowel activity and stool consistency. Although mild GI effects may be tolerable, severe symptoms may indicate the onset of antibiotic-associated colitis.
• Signs and symptoms of superinfection include abdominal pain or cramping, anal or genital pruritus or discharge, moderate to severe diarrhea, severe mouth or tongue soreness, and new or increased fever.
Geriatric side effects at a glance:
U.S. Regulatory Considerations
naftifine hydrochloride
(naf’-ti-feen hye-droe-klor’-ide)
Brand Name(s): NaftinChemical Class: Allylamine derivative
Clinical Pharmacology:Mechanism of Action: An antifungal that selectively inhibits the enzyme squalene epoxidase in a dose-dependent manner, which results in the primary sterol, ergosterol, within the fungal membrane not being synthesized. Therapeutic Effect: Results in fungal cell death. Fungistatic and fungicidal.
Pharmacokinetics: Minimal systemic absorption. Metabolized in the liver. Excreted in the urine as well as the feces and bile. Half-life: 48-72 hr.
Available Forms:
Indications and Dosages:Tinea pedis, T. cruris, T. corporis: Topical Apply cream 1 time a day for 4 weeks or until signs and symptoms significantly improve. Apply gel 2 times a day for 4 weeks or until signs and symptoms significantly improve.
Unlabeled Uses: Trichomycosis
Contraindications: Hypersensitivity to naftifine or any of its components
Side Effects
Serious Reactions
Patient/Family Education
Monitoring Parameters
Geriatric side effects at a glance:
U.S. Regulatory Considerations
nalbuphine hydrochloride
(nal’-byoo-feen hye-droe-klor’-ide)
Brand Name(s): NubainChemical Class: Opiate derivative; phenanthrene derivative
Clinical Pharmacology:Mechanism of Action: A narcotic agonist-antagonist that binds with opioid receptors in the CNS. May displace opioid agonists and competitively inhibit their action; may precipitate withdrawal symptoms. Therapeutic Effect: Alters the perception of and emotional response to pain.
Available Forms:
Indications and Dosages:Analgesia: IV, IM, Subcutaneous 10 mg q3-6h as needed. Don’t exceed maximum single dose of 20 mg or daily dose of 160 mg. For patients receiving long-term narcotic analgesics of similar duration of action, give 25% of usual dose.
Supplement to anesthesia: IV Induction: 0.3-3 mg/kg over 10-15 min. Maintenance: 0.25-0.5 mg/kg as needed.
Contraindications: Respiratory rate less than 12 breaths/minute
Side Effects
Serious Reactions
• Abrupt withdrawal after prolonged use may produce symptoms of narcotic withdrawal, such as abdominal cramping, rhinorrhea, lacrimation, anxiety, fever, and piloerection (goose bumps).
• Overdose results in severe respiratory depression, skeletal muscle flaccidity, cyanosis, and extreme somnolence progressing to seizures, stupor, and coma.
Patient/Family Education
• The patient should alert you as soon as pain occurs and should not wait until the pain is unbearable because nalbuphine is more effective when given at the onset of pain
• Avoid tasks that require mental alertness or motor skills until response to the drug has been established
Monitoring Parameters
Geriatric side effects at a glance:
U.S. Regulatory Considerations
nalmefene hydrochloride
(nal’-me-feen hye-droe-klor’-ide)
Brand Name(s): RevexChemical Class: Thebaine derivative
Clinical Pharmacology:Mechanism of Action: A narcotic antagonist that binds to opioid receptors. Therapeutic Effect: Prevents and reverses effects of opioids (respiratory depression, sedation, hypotension).
Pharmacokinetics: Well absorbed. Protein binding: 45%. Metabolized primarily via glucuronidation. Excreted in urine and feces. Half-life: 8.5-10.8 hr.
Available Forms:
Indications and Dosages:Solution for Injection: 100 mcg/ml ([blue label] Revex), 1,000 mcg/ml ([green label] Revex): IV, IM, Subcutaneous Initially, 0.25 mcg/kg followed by additional 0.25 mcg doses at 2- to 5-min intervals until desired response. Cumulative doses >1 mcg/kg do not provide additional therapeutic effect.
Known or suspected opioid overdose: IV, IM, Subcutaneous Initially, 0.5 mg/70 kg. May give 1 mg/70 kg in 2-5 min. If physical opioid dependence suspected, initial dose is 0.1 mg/70 kg.
Contraindications: Hypersensitivity to nalmefene
Side Effects
Serious ReactionsSpecial Considerations
• Longer duration of action than naloxone at fully reversing doses; agent of choice in instances where prolonged opioid effects are predicted, including overdose with longer-acting opioids (e.g., methadone, propoxyphene), patients given large doses of opioids, and those with liver disease or renal failure (eliminating the need for continuous infusions of naloxone and prolonged observation periods after outpatient procedures)
Patient/Family Education
Monitoring Parameters
Geriatric side effects at a glance:
U.S. Regulatory Considerations
naloxone hydrochloride
(nal-oks’-one hye-droe-klor’-ide)
Brand Name(s): NarcanRx: with pentazocine (Talwin NX); with buprenorphine (Suboxone)
Chemical Class: Thebaine derivative
Clinical Pharmacology:Mechanism of Action: A narcotic antagonist that displaces opioids at opioid-occupied receptor sites in the CNS. Therapeutic Effect: Reverses opioid-induced sleep or sedation, increases respiratory rate, raises BP to normal range.
Available Forms:
Indications and Dosages:
Unlabeled Uses: Treatment of ethanol ingestion, Pneumocystitis carinii pneumonia (PCP)
Contraindications: Respiratory depression due to nonopioid drugs
Side Effects
