10/30/2019
1
10/30/2019 1
Managing Medication Side Effects
Presented by:Karen Malatestinic BSN, RNDebbie Van Senus BSN, RN
10/30/2019 2
10/30/2019 3 10/30/2019 4
10/30/2019
2
Learning Objectives
10/30/2019 5
1. Identify common medications in a Pediatric Urology setting
2. Provide accurate information/education for management of common urological medication side effects
3. Apply knowledge of medication side effects into daily practice
Most Commonly Used Urologic Medications
• Anticholinergics/Antispasmodics• Alpha Blockers• Antibiotics • Bowel Medication• Antidiuretic Hormone
10/30/2019 6
10/30/2019 7
Anticholinergics/Antispasmodics
Definition:Anticholinergics (Antimuscarinic) Agents-inhibit muscarinic receptors in the detrusor muscle of the urinary bladder, thereby reducing involuntary bladder contraction.
These medications act on the neurotransmitter, acetylcholine. By blocking the action of acetylcholine, anticholinergics prevent impulses from the parasympathetic nervous system from reaching smooth muscle and causing contractions, cramps, or spasms. Therefore, these medications relax the bladder by decreasing the bladder pressure and spasms.
• Ditropan (Oxybutynin)
• Detrol (Tolterodine)
• Vesicare(Solifenacin)
• Oxytrol Patch (Oxybutynin transdermal)
10/30/2019 8
Anticholinergics/Antispasmodics
• Myrbetriq (Mirabegron)
• Sanctura(Trospium)
• Enablex(Darifenacin)
10/30/2019
3
Common Side Effects of Anticholinergics/Antispasmodics
10/30/2019 9
• Facial flushing• Dry mouth, dry eyes• Constipation• Vision Changes/blurred
vision• Headaches• Drowsiness/fatigue• Dizziness• Mood/Behavior changes
• Hallucinations/agitation
• Nightmares
• Upset stomach
• Confusion
• Urinary retention
Ditropan
Generic: Oxybutynin
10/30/2019
Ditropan 5mg/5ml liquid suspensionDitropan 5mg tablet IR
Ditropan 5mg XLDitropan 10mg XLDitropan 15mg XL
Dose: 0.2mg/kg/dose2-3 times/day ages 1-5 years> age 5 give 5mg twice daily up to 5mg 3 times/day
DetrolGeneric: Tolterodine
10/30/2019 11
Detrol suspension 2mg/5ml
Detrol 1mg tablets give 2 x per dayDetrol 2mg tablets give 2 x per day
Detrol LA 2mg capsules give once per dayDetrol LA 4mg capsules give once per day
Dose: 0.1mg/kg/day given Bid
Vesicare/Sanctura/Enablex
10/30/2019 12
Vesicare Generic: Solifenacin5mg and 10mg tablets ER given once daily
Sanctura Generic: Trospium20mg tablets IR BID or 20mg XL given daily60mg ER once daily
Enablex Generic: Darifenacin7.5mg ER tablets and 15mg ER tablets
10/30/2019
4
Myrbetriq
Generic: Mirabegron
10/30/2019 13
25mg tablets ER given once daily50mg tablets ER given once daily
These agents stimulate beta-3 adrenergic receptors in the detrusor muscle of the
bladder, which enhances bladder relaxation, improves bladder capacity.
• Can increase blood pressure
Oxytrol Patch
10/30/2019 14
Side Effects: redness, irritation, itching, swelling at the site.
Transdermal version of Oxybutynin
Oxytrol Patch
• Change patch twice weekly• Apply to areas specified in package labeling• When applying a new patch use a new area of skin,
wait at least 1 week before applying to same location.
• Can get wet in shower, bath, or swimming.-If it falls off, replace
• Available OTC• DO NOT CUT or trim patch• Prep skin with alcohol • Hydrocortisone cream OTC for local reaction
– continued issues, pretreat skin with Benadryl cream and wait 1 hour prior to applying
10/30/2019 15
• Setting Expectations– May take a few weeks to see response– Every patient is different
• Dose Titration– Titrate the dose of the anticholinergic– May need to change to liquid
• Dose Reduction– First line of treatment before d/c– May need to change to liquid
• ER vs IR– Compliance– Tolerance
10/30/2019 16
Side Effect Managementof Anticholinergics
10/30/2019
5
Education
• Oral Care– Chap-stick– Hydration– Oral hygiene– Dental visits
10/30/2019 17
Education
• Overheating– Facial flushing– Hydration– Sports
10/30/2019 18
Education
• Vision– Evaluate headaches– Eye drops– Eye exams
10/30/2019 19
• Assessment• School• Catheterization/Pelvic Floor
Therapy• Additional Medication
10/30/2019 20
Side Effect Management of Anticholinergics
10/30/2019
6
Side Effect Management of Anticholinergics
• Assessment– Based on verbal communication through telehealth/phone triage– For reports of behavioral issues, agitation, or mood changes.
Evaluate for change or stressors in the family, school, or with friends
– If unsure the medication is the cause, stop the medication for 3 days.
– If behavior doesn't resolve have patient see primary care MD
• School– Dose adjustment or altering time may help with drowsiness or
difficulty concentrating– Request 2 labeled bottles so midday dose can be given at school,
school note needed
10/30/2019 21
Side Effect Management of Anticholinergics
• Pelvic floor therapyDysfunctional voiders may benefit from PT in addition to medication
• CatheterizationRetention or difficulty emptying bladder may occur.
For neurogenic bladder or poor emptying, catheterization may be initiated
• Additional MedicationFor patients with overactive bladder and sphincter dyssynergia, Flomax or Cardura may be added
10/30/2019 22
Dysfunctional Bladder
Lack of coordination between bladdercontraction and sphincter relaxation results in incomplete emptying, and overactive bladder.
Definition: These agents block postsynaptic alpha, adrenergic receptors in the bladder neck and prostate. This causes muscle relaxation of the bladder neck and prostatic smooth muscle, and relieves obstructive voiding symptoms.
10/30/2019 24
Alpha Blockers
10/30/2019
7
- Obtain BP reading prior to starting, repeat 3-4 days after, and take an additional 2 more readings in 2-3 weeks.
- Take medication 30 minutes before bed to help minimize lightheadedness
- Upon waking patient should sit at bedside for a couple minutes before getting up.
- Taper when stopping
10/30/2019 25
Alpha Blockers
• Lightheadedness• Hypotension • Headache
Common Side Effects:
- Avoid in patients with Sulfa allergy- Not supposed to be opened
chewed or crushed – need to swallow
- Used to dilate ureters- Stones- Stent discomfort
- Cannot be given via G-tube
Flomax (Tamsulosin)Cardura (Doxazosin)Definition: Inhibits the growth of or destroys
microorganisms – treats bacterial infections.
10/30/2019 26
Antibiotics
• Amoxil• Keflex• Septra• Macrodantin• Cipro
10/30/2019 27
Antibiotics
Common Side Effects:
• Skin Rash/Hives• GI issues
– Upset stomach– Gas– Diarrhea– Decreased appetite
• Yeast Rash
Amoxil
Generic: Amoxicillin
10/30/2019 28
• Used in children less than 2-3months of age
• Suspension 125mg/5ml, 250mg/5ml, 400mg/5ml
• Safe to take when pregnant and breastfeeding
• Can Cause Yeast
Suspension 125mg/5ml, 250mg/5ml, 400mg/5mlChewables 125mg and 250mgCapsules 250mg, 500mgTablets 500mg and 875mg
10/30/2019
8
Keflex
Generic: Cephalexin
10/30/2019 29
• Give with food to avoid GI upset
• Safe to take when pregnant and breastfeeding
• Can cause a severe form of diarrhea called C-diff
Suspension 125mg/5mL and 250mg/5mlCapsules 250mg, 500mg, 750mg
Septra/Bactrim
Generic: Sulfamethoxazole-trimethroprim
10/30/2019 30
• Safe to use 2 months or greater
• Sun Sensitivity
• Rare side effect Steven Johnson's Syndrome
Suspension 200mg/40mg/5mlSeptra SS tablet 400mg/80mgSeptra DS tablet 800mg/160mg
• Can lower white count
• Yearly CBC
Macrodantin
Generic: Nitrofurantoin
10/30/2019 31
• Avoid with patients with chronic lung disease(pulmonary fibrosis)
• Antacids can decrease absorption
Nitrofurantoin 25mg/5ml suspensionMacrodantin 25mg, 50mg and 100mg capsulesMacrobid 100mg ER tablet
• Can take until 38weeks of pregnancy related to hemolytic anemia in neonate, Also do not take while breastfeeding.
• Can elevate liver enzymes, yearly CMP
Cipro
Generic: Ciprofloxacin
10/30/2019 32
BLACK BOX WARNING• Can cause tendon rupture,
tendinitis, and peripheral neuropathy
• Educate family to call for any potential side effects or adverse reaction
• Give 2 hours before or 6 hours after any dairy products or mineral supplements to avoid decrease absorption
• Clogs GT
• Give 2 hours after meals
Suspension 250mg/5ml and 500mg/5ml Tablets 250mg and 500mg
10/30/2019
9
Bowel Medication
MiralaxGeneric: Polyethylene Glycol
We use Miralax for a variety of patients including dysfunctional voiders, neurogenic bowels, and post op patients.
Because the bowel directly effects bladder behavior we need to address bowel activity.
Miralax is titrated to obtain the desired effect
10/30/2019 33
Side effects: diarrhea or loose stools, gas, bloating, nausea, stomach pain
Bowel Medication
10/30/2019 34
Miralax: • Stress importance of using fluid amount recommended to
achieve desired effect. • Titrate dose
- Start with a lower dose and increase accordingly or start with higher dose then lower the dose with the goal of daily soft bowel movements
• It usually takes 1-4 days to see results
• Fiber Gummies:• Patients and families commonly stop miralax due to stools
getting too loose. • When scheduling surgery, educate patients prior to surgery on
ways to help prevent post op constipation. • -Diet, fluids, Miralax, fiber, probiotics
Constipation• Infrequent BM
• Frequent >2x day
• Hard small stools
• Abnormally large stool
• Painful, blood streaks
• Stool accidents (streaks, smears)
• Retentive behavior (hides)
• Sits, strains for a long time
Prevent and Treat Constipation
• Make sure your child drinks plenty of fluid-mostly water-during the day– Follow Elimination Diet
• Eat a high fiber diet– Fruits, vegetables, grains
• Establish a routine– Timed sitting (5-10) minutes after a meal– Sit with feet supported, pants down around ankles and in a
relaxed position• May need a toilet insert
10/30/2019
10
Antidiuretic Hormone
10/30/2019 38
Definition: Antidiuretic hormone, a man- made hormone that regulates how the body uses water.
DDAVP-Desmopressin
• Anti-diuretic hormone
• Taken at bedtime with a sip of water
• Stop fluids 2 hours before and 8 hours after
• Maximum dose is 3 tabs(0.6mg) usually start at 0.4mg and increase after one week if wetting persists. Decrease to 0.2mg if dry at one week
• Works in 50-60% patients
• Water toxication
10/30/2019 39
Common Side Effects of DDAVP
10/30/2019 40
Common side effects related to excess fluid intake resulting in water toxicity (hyponatremia).
Common Side Effects:• Headache• Nausea• Vomiting • Seizures.
DO NOT take if vomiting or diarrhea. With decreased NA levels=confusion, muscle cramping, hallucinations, feeling
restless or unsteady
Fluid Shifting
• Not enough to drink less at night• Drink 6-8 oz. every 2 hours (day)• Eliminate bladder irritants after 4pm
(caffeine, carbonation, citric acid, chocolate, red and purple dyes, and dairy products)
• From 4pm to dinner – 12 oz. total• Sips at bedtime if medications taken
10/30/2019 41
10/30/2019
11
Conclusion
• Listen to your patients and parents• Be proactive vs reactive
10/30/2019 42
References
• https: //online.lexi.com/lco/action/doc/retrieve/docid/iuhealthsystem
• Kidney Disease Program Kidney Disease Program https: //Kdpnet.Kdp.Louisville.edu/drug book/pediatric
• Medications (2019)http://www.epocrates.com/mobile/iphone/essentials
• Guide to Urological Medications. (2016). A supplement to the SUNa core curriculum fro urologic nursing (pg 1-50). Pitman, NJ:Mary Lee, Pharm D, BCPS , FCC P. Nicole A. Rozette, Pharm D, BCPS
10/30/2019 43