1368 Unit 11 Additional Drug Classes
and viruses. The skin is very dry, and keratin is a poor Clotrimazole (Lotrimin, Mycelex, others) and miconazole
energy source for microbes. Although perspiration pro- (Micatin) are common antifungals available as creams and
vides a wet environment, its high-salt content discourages lotions that are used for a variety of dermatologic mycoses.
microbial growth. Furthermore, the outer layer is continu- Oral fluconazole (Diflucan) is indicated for more serious
ally being sloughed off, and the microorganisms leave fungal infections of the skin.
with the dead skin.
Certain viral infections can manifest with skin
Bacterial skin diseases may occur when the skin is lesions. Childhood viral infections that affect the skin
punctured or cut, or when the outer layer is abraded include varicella (chickenpox), rubeola (measles), and
through trauma or removed through severe burns. Some rubella (German measles). Usually, these infections are
bacteria also infect hair follicles. The most common bacte- self-limiting and nonspecific, so treatment is directed at
rial infections of the skin are caused by Staphylococcus and controlling the extent of skin lesions. Viral infections with
Streptococcus, which are normal skin inhabitants. Staphylo- skin lesions in adults include herpes zoster (shingles) and
coccus aureus is responsible for furuncles (boils), carbuncles herpes simplex (cold sores and genital lesions). Pharma-
(abscesses), and other pus-containing lesions of the skin. cotherapy of severe or persistent viral skin lesions may
Both S. aureus and Streptococcus pyogenes can cause impe- include topical or PO antiviral therapy with acyclovir
tigo, which is a superficial skin disorder that commonly (Zovirax) or other antivirals.
occurs in school-age children. Cellulitis is an acute skin and
subcutaneous tissue infection caused by Staphylococcus and CONNECTION Checkpoint 73.1
Streptococcus. Folliculitis, an infection of hair follicles usu-
ally caused by S. aureus, is often called a “hot-tub” infection From what you learned in Chapter 52, what is onychomycosis and
because it is acquired when water in these types of tubs is what types of drugs are used to treat it? Answers to Connection
not adequately treated with chlorine. Checkpoint questions are available on the faculty resources site. Please
consult with your instructor.
Although many skin bacterial infections are self-
limiting, some are serious enough to require pharmaco- Scabicides and Pediculicides
therapy. When possible, topical drugs are applied directly
to the infection site. Topical medications offer the advantage 73.4 Scabicides and pediculicides are used
of causing fewer adverse effects, and many are available to treat parasitic skin infestations.
over the counter (OTC) for self-treatment. If the infection is
deep within the skin, affects large regions of the body, or has Common skin parasites include mites and lice. Scabies is
the potential to enter the systemic circulation, oral (PO) or an eruption of the skin caused by the female mite Sarcoptes
parenteral therapy is indicated. Furthermore, the incidence scabiei, which burrows into the skin to lay eggs that hatch
of methicillin-resistant S. aureus (MRSA) skin infections is in about 5 days. Scabies mites are barely visible without
increasing. MRSA often requires pharmacotherapy with magnification. Scabies lesions most commonly occur
two or more antibiotics. Some of the more common topical between the fingers, on the extremities, in axillary and glu-
antibiotics for skin infections include the following: teal folds, around the trunk, and in the genital area. The
major symptom is intense pruritus; vigorous scratching
• Bacitracin ointment may lead to secondary infections. Scabies is easily spread
• Erythromycin ointment (Eryderm, others) through skin-to-skin contact and from mites living in
• Gentamicin cream and ointment upholstery, shared beds, and bath linens. Diagnosis is
• Metronidazole cream and lotion made by visual inspection of the burrows and confirmed
• Mupirocin (Bactroban) by microscopic scrapings of the mite’s ova or fecal pellets.
• Neomycin with polymyxin B (Neosporin), cream and
Over 3 million new cases of lice infestation or pedicu-
ointment losis are treated each year in the United States. Lice are
• Tetracycline. larger than mites, measuring from 1 to 4 mm in length.
They are readily spread by sharing infected hats, hair-
Fungal infections of the skin or nails such as tinea pedis brushes, bedding, or clothes, or by close personal contact.
(athlete’s foot) and tinea cruris (jock itch) commonly occur These parasites require human blood for survival and die
in warm, moist areas covered by clothing. Tinea capitis within 24 hours without the blood of a human host. Lice
(ringworm of the scalp) and tinea unguium (ringworm of (singular: louse) often infest the pubic area or the scalp and
the nails) are also common. These pathogens are responsive lay eggs, referred to as nits, which attach to body hairs.
to therapy with topical OTC antifungals such as undecyle- Head lice are referred to as Pediculus humanus capitis, body
nic acid (Cruex, Desenex, others). More serious fungal infec- lice as Pediculus humanus corporis, and pubic lice as Phthirus
tions of the skin and mucous membranes, such as Candida pubis. The pubic louse is referred to as a “crab louse,”
albicans infections that occur in immunocompromised because it looks like a tiny crab when viewed under the
patients, require systemic antifungals (see Chapter 52).
Chapter 73 Pharmacotherapy of Dermatologic Disorders 1369
microscope. Individuals with pubic lice will sometimes say of the skin by mites causes itching, which lasts up to 2 or
that they have “crabs.” Pubic lice may produce sky-blue 3 weeks even after the parasites have been killed.
macules on the inner thighs or lower abdomen. The bite of
the louse and the release of its saliva into the wound both Successful elimination of parasitic infections should
lead to intense pruritus, followed by vigorous scratching. include removing the nits with a nit comb, washing bed-
Secondary infections can result from scratching. ding, and cleaning or removing objects that have been in
contact with the head or hair.
The treatment of skin parasites consists of using scabi-
cides, which are drugs that kill mites, or pediculicides, Mechanism of Action: Permethrin affects the ner-
which are drugs that kill lice. Some drugs are effective vous system of the parasite, causing paralysis. Because lice
against both mites and lice. The choice of drug depends on are dependent on blood for survival, they die within 24 to
where the infestation is located as well as other factors such 28 hours. It has ectoparasitic and ovicidal activity against
as age, pregnancy, or breastfeeding. P. humanus capitis, P. pubis, S. scabiei (scabies), ticks, mites,
and fleas.
The preferred drug for lice is permethrin, a chemical
derived from chrysanthemum flowers and formulated as a Pharmacokinetics: Topical: 5% and 1% formula-
1% liquid (Nix). This drug is considered the safest agent, Route(s) tions
especially for infants and children. Pyrethrin (RID, others) Less than 2% is absorbed
is a related product that also is obtained from the chrysan- Absorption through intact skin
themum plant. Permethrin and pyrethrin, which are also Stored in body fat
widely used as insecticides on crops and livestock, kill lice Distribution Hepatic
and their eggs on contact. These drugs are effective in 97% Primary metabolism Urine
to 99% of patients, although a repeat application may be Primary excretion 10 min
needed. Adverse effects are generally minor and include Onset of action 14 days
stinging, itching, or tingling. If two treatments of pyrethrin- Duration of action
based medications fail to eliminate the infestation, lindane
or malathion (Ovide) may be prescribed. Resistant lice are Adverse Effects: Permethrin causes few systemic
most likely to appear in patients who have received multi- effects. Local reactions may occur and include pruritus,
ple treatments with pyrethrin-based shampoos. rash, transient tingling, burning, stinging, erythema, and
edema of the affected area.
Permethrin is also a first-line drug for scabies. The 5%
cream (Elimite) is applied to the entire skin surface and Contraindications/Precautions: Contraindications
allowed to remain for 8 to 14 hours before bathing. A single include hypersensitivity to pyrethrins, chrysanthemums,
application cures 95% of patients, although itching may sulfites, or other preservatives. Permethrin should be used
continue for several weeks as the dead mites are eliminated cautiously on inflamed skin, in those with asthma, or in
from the skin. Crotamiton (Eurax) is an alternative scabi- lactating women.
cide that is available by prescription as a 10% cream. If the
scabies is unresponsive to topical medications, the antipar- Drug Interactions: No clinically significant interac-
asitic drug ivermectin (Sklice) may be administered as a tions have been documented.
single oral dose.
Pregnancy: Category B.
All scabicides and pediculicides must be used strictly
as directed, because excessive use can cause serious sys- Treatment of Overdose: No specific treatment for
temic effects and skin irritation. Drugs for the treatment of overdose with permethrin has been reported. Flush eyes
lice or mites must not be applied to the mouth, open skin well with water if the medicine unintentionally gets into
lesions, or eyes, because this will cause severe irritation. the eyes.
PROTOTYPE DRUG Permethrin (Acticin, Elimite, Nix) Nursing Responsibilities: Key nursing implications
for patients receiving permethrin are included in the Nurs-
Classification Therapeutic: Antiparasitic ing Practice Application for Patients Receiving Pharmaco-
Pharmacologic: Scabicide, pediculicide therapy for Lice or Mite Infestation.
Therapeutic Effects and Uses: Nix is marketed as Drugs Similar to Permethrin
a cream, lotion, or shampoo to kill head and crab lice and (Acticin, Elimite, Nix)
mites and to eradicate their ova. A 1% lotion is approved
for lice and a 5% lotion for mites. The medication should Other drugs for parasitic skin infections include crotami-
be allowed to remain on the hair and scalp 10 minutes ton, ivermectin, lindane, malathion, and pyrethrin.
before removal. Patients should be aware that penetration
Crotamiton (Eurax): Crotamiton is a scabicide and anti-
pruritic that is used to eradicate S. scabiei and relieve
1370 Unit 11 Additional Drug Classes
itching. Available as a 10% cream or lotion, this drug include skin infections, abrasions, lactation, and sensitiv-
should not be applied to skin that is acutely inflamed, raw, ity to the solution components. Pyrethrin is usually for-
or has weeping surfaces. It should not be instilled into the mulated with 4% piperonyl butoxide because this
eyes or mouth. If this drug comes in contact with the eyes, combination results in greater parasite killing. Pyrethrin
they must be flushed thoroughly with water. Adverse should be used with caution in ragweed-sensitized
effects may include skin irritation, rash, and erythema. patients, infants, and children. This medication is applied
This drug is pregnancy category C. to infested areas that are wet, allowing it to stay in place
for at least 10 minutes. The areas are then washed and
Ivermectin (Sklice): Ivermectin is a drug first approved rinsed with warm water. For shampoo applications, the
by the U.S. Food and Drug Administration (FDA) to treat hair is shampooed as usual then a fine-toothed comb is
helminthic infections. It is a preferred drug treating river used to remove the lice and eggs from the hair. This drug
blindness, a debilitating infection in many developing is pregnancy category C.
countries. In 2012, ivermectin (Sklice) was approved as a
0.5% lotion for head lice in patients 6 months of age and Pharmacotherapy of Acne
older. Sklice is applied to dry hair and rinsed off with and Rosacea
water after 10 minutes. A single application is usually suf-
ficient. Side effects are minor and include dry scalp and 73.5 The pharmacotherapy of acne includes
eye irritation if the eyes are exposed to the drug. This drug treatment with benzoyl peroxide, retinoids,
is pregnancy category C. and antibiotics; pharmacotherapy for rosacea
includes retinoids and metronidazole.
Lindane: Lindane is a scabicide and pediculicide in a 1%
lotion or shampoo form that is applied directly to the skin Acne vulgaris and rosacea are two disorders that produce
to be absorbed by parasites and ova (nits), resulting in similar appearing lesions on the face. Although the two
their death. This drug is used for treatment of head and conditions have some visual similarities and share a few
crab lice and scabies infestations. Lindane should not be common treatments, the pharmacotherapy of the disorders
applied to skin that has open cuts or to mucous mem- is very different.
branes, eyes, or face. It should be used cautiously in infants
and patients with a history of seizures, human immunode- Acne Vulgaris
ficiency virus (HIV) infections, and alcoholism. Gloves
should be worn when applying the medication to reduce Acne vulgaris, a disorder of the hair follicles and seba-
exposure to the skin. Although effective, this drug pene- ceous glands, is a common condition that affects 80% of
trates the skin and may cause significant adverse effects. adolescents. Although acne occurs most often in teenagers,
Lindane has a black box warning that states that the drug it is not unusual to find patients with acne who are older
is indicated for patients who are unresponsive to safer than 30 years, which is a condition referred to as mature
therapies because seizures and deaths have been reported acne or acne tardive. Acne vulgaris is more common in
with repeated applications. The warning also states that men but tends to persist longer in women. Acne affects
the drug is contraindicated in premature infants and in approximately 17 million people in the United States, mak-
individuals with uncontrolled seizure disorders. Addi- ing it one of the most common skin conditions encoun-
tional adverse effects include dizziness, tremors, seizures, tered by the nurse.
and death. This drug is pregnancy category C.
Although the precise cause of acne is unknown, sev-
Malathion (Ovide): Available as a 0.5% lotion, malathion eral factors that are associated with acne vulgaris include
kills lice and ova by poisoning the nervous system of the abnormal formation of keratin that blocks oil glands and
parasite. It is contraindicated in children under the age of 6. seborrhea, the overproduction of sebum by oil glands.
Care must be taken to keep this drug out of the eyes dur- The bacterium Propionibacterium acnes grows within oil
ing treatment because it can cause conjunctivitis. One gland openings and changes sebum to an acidic and irri-
treatment is all that is needed when using this medication. tating substance. As a result, small inflamed bumps
Because the solution contains alcohol, it is flammable and appear on the surface of the skin. Other factors associated
needs to be kept away from any heat source such as hair with acne include androgens, which stimulate the seba-
dryers or cigarettes. Malathion is very toxic if swallowed. ceous glands to produce more sebum. This is clearly evi-
This drug is pregnancy category B. dent in teenage boys and in patients who are administered
testosterone. Studies have indicated that dietary factors
Pyrethrin (RID): Pyrethrin is a pediculicide solution or do not promote acne. Remissions tend to occur in the
shampoo that poisons the parasite’s nervous system, result- summer, perhaps due to more exposure of the skin to the
ing in paralysis and death. Pyrethrin may require a repeat UV rays from sunlight.
application a week after the first dose. Contraindications
Chapter 73 Pharmacotherapy of Dermatologic Disorders 1371
CONNECTIONS: NURSING PRACTICE APPLICATION
Patients Receiving Pharmacotherapy for Lice or Mite Infestation
Assessment
Baseline assessment prior to administration:
• Obtain a complete health history including dermatologic and social history of recent exposure.
• Obtain a drug history including allergies, current prescription and OTC drugs, herbal preparations, alcohol use, and smoking. Be alert to possible drug
interactions.
• Assess skin areas to be treated for signs of infestation (e.g., lice or nits in hair, reddened track areas between webs of fingers, around belt, or elastic
lines), irritation, excoriation, or drainage.
• Obtain baseline height, weight, and vital signs.
• Assess the patient’s ability to receive and understand instructions. Include family and caregivers as needed.
Assessment throughout administration:
• Assess for desired therapeutic effects (e.g., decreased visible infestation, nits are removed, skin healing is visible).
• Assess for adverse effects: localized tingling, pruritus, stinging, or burning. Promptly report any severe skin reactions or edema.
Interventions and (Rationales) Implementation
Patient-Centered Care
Ensuring therapeutic effects: • Teach the patient, family, or caregiver the appropriate administration
• Monitor the appropriate medication administration for optimal techniques.
results. Monitor the affected area after treatment over the next
1–2 wk to ensure that the infestation has been eliminated.
(Appropriate administration will optimize therapeutic effects
and limit the need for retreatment.)
Minimizing adverse effects: • Instruct the patient, family, or caregiver to continue to assess the area
• Monitor the area of infestation over the next 1–2 wk. Reinfestations will daily for 1–2 wk and contact the healthcare provider for a second
prescription if reinfestation is noted.
usually appear within 1 wk and need to be retreated at that time. (Most
treatments are highly effective when administered correctly. Retreat-
ment may be needed depending on the type of infestation.)
• Monitor family members, caregivers, or sexual contacts for infesta- • Instruct the patient, family, or caregiver to wash bedding, clothing used
tion. Bedding and personal objects should be cleansed before reuse. currently, combs, and brushes in soapy water and dry thoroughly.
(Reinfestation may recur if those in close contact with the patient Vacuum furniture or fabric that cannot be cleaned to remove any errant
are infested. Close contacts should be treated at the same time as vermin. Dry clean hats or caps that cannot be washed. Seal children’s
the patient. Brushes, combs, and bedding should be washed before toys in plastic bags for 2 wk if they cannot be washed.
reuse. Vacuum cloth that cannot be washed. Children’s toys that
cannot be washed may be placed in a plastic bag and sealed for
2 wk. Lice and mites perish quickly once separated from a human
host food source.)
• Monitor skin condition in areas that have been treated. Promptly report • Teach the patient, family, or caregiver to report any redness, swelling,
any irritation, broken skin, erythema, rashes, or edema. (Skin reactions itching, excoriation, or burning to the healthcare provider.
are relatively uncommon but may occur. Allergic reactions should be
reported promptly.)
Patient understanding of drug therapy: • The patient, family, or caregiver should be able to state the reason for
• Use opportunities during administration of medications and during the drug, appropriate dose and scheduling, what adverse effects to
observe for, and when to report them.
assessments to discuss the rationale for the drug therapy, desired
therapeutic outcomes, commonly observed adverse effects,
parameters for when to call the healthcare provider, and any necessary
monitoring or precautions. (Using time during nursing care helps to
optimize and reinforce key teaching areas.)
Patient self-administration of drug therapy: • Teach the patient, family, or caregiver about the drug:
• When administering the medication, instruct the patient, family, or • Wash hair or shower to remove any residual creams or gels before
applying the drug. Dry thoroughly.
caregiver in proper self-administration of the drug, e.g., use exactly • Apply the drug per package directions and allow it to remain in
as directed or per package directions. (Utilizing time during nurse the hair or on the skin for the prescribed length of time (usually
administration of these drugs helps to reinforce teaching.) 10 minutes). Most packages contain enough drug for one
treatment, although a second package may be required if the hair
is long. Do not allow the drug to come in contact with eyes.
• Dry thoroughly after showering or shampooing the drug out of the
hair or skin.
• Comb through the hair with a small-toothed comb to remove any
remaining dead lice, nits, or nit casings.
• If eyelashes are infested, apply a thin coat of petroleum jelly to
eyelashes once a day for 1 wk. Comb through using a small-
toothed comb to remove any dead lice, nits, or nit casings.
• Check hair, webbings of fingers and toes, belt, or elastic waist-
bands for signs of reinfestation over the next week. If needed, a
second application of the drug can be used after 1 wk.
1372 Unit 11 Additional Drug Classes
PharmFACT Many of the medications used for acne and related dis-
orders are available OTC. Mild acne is treated by topical
Although many young people believe that indoor tanning therapy with drugs such as benzoyl peroxide, topical anti-
helps to clear up acne, there is no scientific evidence to biotics, and salicylic acid. Moderate to severe acne is treated
support this claim. Indoor tanning is responsible for about with increasing strengths of tretinoin and the use of sys-
400,000 cases of skin cancer in the United States each year. temic antibiotics. Because of their increased toxicity, pre-
Even one tanning session can increase the risk of developing scription medications are reserved for more severe,
squamous cell carcinoma by 67% and basal cell carcinoma by persistent cases. These drugs are listed in Table 73.2.
29% (American Academy of Dermatology, n.d.).
Benzoyl peroxide (Clearasil, Fostex, others) is the most
Acne lesions are most frequently distributed on the common topical OTC medication for acne. Benzoyl perox-
face, chest, and back and include open and closed ide has a keratolytic effect, which helps to treat acne by
comedones. Blackheads, or open comedones, occur when loosening dry skin and causing an increased shedding of
sebum has plugged the oil gland, causing it to become the outer layer of the epidermis. In addition, this drug sup-
black because of the presence of melanin granules. White- presses sebum production and exhibits antibacterial effects
heads, or closed comedones, develop just beneath the against P. acnes. Benzoyl peroxide is available as a topical
surface of the skin and appear white rather than black. lotion, cream, or gel in various percentage concentrations.
Some closed comedones may rupture, resulting in an Typically the patient applies benzoyl peroxide once daily
inflammatory response. The result is seen as papules, and, in many instances, this is the only treatment needed.
inflammatory pustules, and cysts. Mild papules and cysts The drug is very safe, with local redness, irritation, and dry-
drain on their own without treatment. Deeper lesions can ing being the most common adverse effects. Although the
cause scarring of the skin. Acne is graded as mild, moder- symptoms might worsen during the early weeks of therapy,
ate, or severe, depending on the number and type of the skin usually adjusts quickly to its use. Other keratolytic
lesions present. drugs that are available by prescription are used for severe
acne and include benzoyl peroxide with erythromycin
The goals of acne therapy are to treat existing lesions (Benzamycin) and benzoyl peroxide with sulfur (Sulfoxyl).
and to prevent or lessen the severity of future recurrences.
Severe acne can cause permanent scarring of the face. Treat- In 2014 the FDA issued a drug safety communication
ment for acne is directed toward the pathogenesis of the regarding the use of OTC acne products containing
lesion and there are multiple treatment options. The regi- benzoyl peroxide and salicylic acid. The communication
men used depends on the extent and severity of the acne warns that these drugs may cause rare, but potentially life-
and the response of each individual patient. Mechanisms threatening allergic reactions. Symptoms of this reaction
of action of antiacne medications include the following: include throat tightness; difficulty breathing; feeling faint;
or swelling of the eyes, face, lips, or tongue. The allergic
• Inhibit sebaceous gland overactivity reaction may occur immediately or several days after initi-
• Reduce bacterial colonization ating therapy. New users are urged to test the product on a
• Prevent follicles from becoming plugged with keratin small patch of skin for 3 days. If no discomfort occurs, the
• Reduce inflammation of lesions. drug may be safely applied.
Table 73.2 Drugs for Acne
Drug Remarks
adapalene (Differin) Retinoid-like compound used to treat acne formation
azelaic acid (Azelex, Finacea)
benzoyl peroxide (Clearasil, Fostex, others) For mild to moderate inflammatory acne
clindamycin and tretinoin (Veltin, Ziana) Keratinolytic available OTC: sometimes combined with erythromycin (Benzamycin) or clindamycin
ethinyl estradiol (Estinyl) (BenzaClin) for acne caused by P. acnes
isotretinoin (Accutane) Combination product with an antibiotic and a retinoid in a gel base; for mild to moderate acne
sulfacetamide sodium (Cetamide, Klaron, others)
Oral contraceptives are sometimes used for acne; for example, ethinyl estradiol plus norgestimate
tazarotene (Avage, Tazorac) (Ortho Tri-Cyclen-28)
tetracyclines For severe acne with cysts or acne formed in small, rounded masses; pregnancy category X
tretinoin (Avita, Retin-A, others)
For sensitive skin; sometimes combined with sulfur to promote peeling, as in the condition rosacea; also
used for conjunctivitis
A retinoid drug that may also be used for plaque psoriasis; has antiproliferative and anti-inflammatory
effects
Antibiotics; refer to Chapter 48
To prevent clogging of pore follicles; also used for the treatment of acute promyelocytic leukemia and wrinkles
Chapter 73 Pharmacotherapy of Dermatologic Disorders 1373
Retinoids are a class of drug closely related to vita Rosacea
min A. They are used in the treatment of inflammatory skin
conditions, dermatologic malignancies, and acne. The topi- Rosacea is an inflammatory skin disorder of unknown eti-
cal formulations are often the first-line drugs for mild to ology with lesions affecting mainly the face. Unlike acne,
moderate acne characterized by inflammatory cysts. Drugs which most commonly affects teenagers, rosacea is a pro-
in this class are called comedolytics because they prevent gressive disorder with an onset between 30 and 50 years of
and break up the formation of clogged pores. Tretinoin age. Rosacea is characterized by small papules or inflam-
(Avita, Retin-A, others) is an older drug with comedolytic matory bumps without pus that swell, thicken, and
action that decreases comedone formation and increases become painful. These lesions typically occur in the mid-
extrusion of comedones from the skin. Tretinoin also has dle third of the face, including the forehead, nose, cheeks,
the ability to improve photodamaged skin and is used for and chin. The face takes on a reddened or flushed appear-
wrinkle removal. Other retinoids include isotretinoin ance with accompanying telangiectasia (dilation of small
(Accutane), a PO vitamin A metabolite medication that aids blood vessels). With time the redness becomes more per-
in reducing the size of sebaceous glands, thereby decreas- manent, and lesions resembling acne appear. The soft tis-
ing oil production and the occurrence of clogged pores. sues of the nose may thicken, resulting in a reddened,
Therapy with retinoids may require 8 to 12 weeks to achieve bulbous, irregular swelling called rhinophyma. Disorders
maximum effectiveness. Common reactions to retinoids of the eye frequently accompany rosacea, particularly con-
include burning, stinging, and sensitivity to sunlight. Ada- junctivitis, itching, edema, and keratitis.
palene (Differin) is a third-generation retinoid that causes
less irritation than the older drugs. Epiduo is a topical drug Rosacea is exacerbated by factors such as sunlight,
that contains both adapalene and benzoyl peroxide. Addi- stress, increased temperature, and medications that dilate
tional retinoid-like drugs and the related compounds that facial blood vessels, including alcohol, spicy foods, skin
are used to treat acne are listed in Table 73.2. care products, and hot beverages. Rosacea affects more
women than men, although men more often develop rhino-
Antibiotics are prescribed to lessen the severe redness phyma. Learning and avoiding the environmental triggers
and inflammation associated with moderate to severe acne, that worsen the symptoms of the condition may prevent
especially when the acne is inflammatory and results in cysts rosacea flares.
and pustules. Oral doxycycline (Vibramycin, others), mino-
cycline, and tetracycline, which are administered in small The two most effective treatments for rosacea are topi-
doses over a long period, have been the traditional antibiot- cal metronidazole (MetroGel, MetroCream) and azelaic
ics used in acne therapy. Due to their effects on teeth forma- acid (Azelex, Finacea). Benzoyl peroxide may be applied as
tion, tetracyclines should not be used in children younger needed. Alternative medications include topical tretinoin
than age 8. Erythromycin and clindamycin are frequently (Avita, Retin-A, others), clindamycin (Cleocin-T, Clin-
used topically and have a low incidence of adverse effects. daMax), and sulfacetamide. Tetracycline antibiotics are of
Antibiotics are not comedolytic and resistance can develop benefit to patients with rosacea who have multiple pus-
with continued therapy. Benzamycin is a prescription prod- tules or ocular involvement. Severe, resistant cases may
uct that contains erythromycin and benzoyl peroxide. respond to isotretinoin (Accutane). Newer topical thera-
pies include brimonidine (Mirvaso), oxymetazoline (Rho-
Oral contraceptives (OCs) that contain ethinyl estradiol fade), and ivermectin (Soolantra), which are used to reduce
and norgestimate are also used in pubertal girls to help clear the persistent redness of facial rosacea.
the skin of acne by suppressing sebum production and
reducing skin oiliness. Hormonal therapy is used when anti- PROTOTYPE DRUG Tretinoin (Avita, Retin-A, Others)
biotic therapy has proved ineffective. OCs are most effective
for young women when the acne begins somewhat later Classification Therapeutic: Antiacne drug
than usual and tends to flare up at certain times in the men- Pharmacologic: Retinoid
strual cycle. Estrogen is not administered to male patients
because of undesirable adverse effects, such as breast Therapeutic Effects and Uses: Approved as a topi-
enlargement and decrease in body hair. For the actions and cal drug in 1971, tretinoin is a natural derivative of vitamin
contraindications of oral contraceptives, see Chapter 70. A. This drug is indicated for the early treatment and con-
trol of mild to moderate acne vulgaris. Renova is a topical
CONNECTION Checkpoint 73.2 form of tretinoin that is approved to treat fine facial wrin-
kles and hyperpigmentation associated with photodam-
Retinoids are derivatives of vitamin A. From what you learned in aged skin. Tretinoin has antineoplastic actions; a PO form
Chapter 61, what type of vitamin is vitamin A? What are some signs is approved to treat acute promyelocytic leukemia (APL)
of toxicity due to excess amounts of this vitamin? Answers to Con- and may be prescribed off-label for skin malignancies.
nection Checkpoint questions are available on the faculty resources site. Symptoms take 4 to 8 weeks to improve, and maxi-
mum therapeutic benefit may take 5 to 6 months. Because
Please consult with your instructor.
1374 Unit 11 Additional Drug Classes
of potentially serious adverse effects, this drug is most insufficiency, and pneumonia. About 40% of patients
often reserved for cystic acne or severe keratinization develop a rapidly evolving leukocytosis, which is associ-
disorders. ated with a high risk of life-threatening complications.
There is a high risk that infants will be severely deformed if
Mechanism of Action: The principal action of treti- this drug is administered during pregnancy.
noin is regulation of skin growth and turnover. As cells
from the stratum germinativum grow toward the surface, Contraindications/Precautions: Contraindications
skin cells are lost from the stratum pore openings, and for topical administration include eczema, exposure to
their replacement is slowed. Tretinoin reverses retention sunlight or UV rays, sunburn, hypersensitivity to this
hyperkeratosis and comedone formation, which are the drug or vitamin A preparation, and children less than
primary events in acne pathology. The drug increases the 12 years of age. This drug should be used cautiously in
permeability of the skin and supports conversion of fol- patients who are in an occupation necessitating consider-
licular epithelium into a less sturdy and almost fragile con- able sun exposure or weather extremes or in patients with
dition. Tretinoin also decreases oil production by reducing hepatic disease. This drug may cause birth defects and is
the size and number of oil glands. contraindicated during lactation, pregnancy, or suspected
pregnancy. Pregnancy testing is advised before start-
Pharmacokinetics: Topical, PO ing therapy in female patients of childbearing age. Oral
Route(s) tretinoin is contraindicated in patients who have hepatic
Absorption Minimally absorbed from intact disease, leukopenia or neutropenia, or who are hypersen-
skin; well absorbed PO sitive to the drug.
Distribution
Secreted in breast milk; more Drug Interactions: Topical acne keratinolytics (sul-
Primary metabolism than 95% bound to plasma fur, resorcinol, benzoyl peroxide, and salicylic acid) may
Primary excretion protein increase inflammation and peeling; topical products that
Onset of action contain alcohol or menthol may cause stinging. Additive
Duration of action Hepatic phototoxicity can occur if tretinoin is used concurrently
with other phototoxic drugs such as tetracyclines, fluoro-
Renal; small amounts in feces quinolone, or sulfonamides. Use of this medication with
hypoglycemic drugs may lead to a loss of glycemic con-
Unknown trol and cardiovascular risk, because tretinoin raises serum
triglyceride levels. Hepatotoxic drugs may cause additive
Half-life: 0.5–2 h liver impairment if used concurrently with PO tretinoin.
Herbal/Food: The PO absorption of tretinoin is increased if
Adverse Effects: Nearly all patients who use topi- taken with a high-fat meal.
cal tretinoin will experience local effects such as redness,
scaling, erythema, crusting, and peeling of the skin with Pregnancy: Category C (topical) and D (PO).
temporary hypopigmentation or hyperpigmentation. Skin
irritation can be severe and cause discontinuation of ther- Treatment of Overdose: Overuse of the topical drug
apy; a lower strength solution may be necessary to limit will lead to excessive skin drying and peeling. Symptoms
the severity of these adverse effects. Dermatologic adverse of PO overdose are nonspecific and resolve with symptom-
effects resolve once therapy is discontinued. Oral therapy atic treatment.
can also cause adverse skin effects.
Nursing Responsibilities: Key nursing implications
For treatment of APL, very high oral doses are used for patients receiving tretinoin are included in the Nursing
and adverse effects are more serious than with topical ther- Practice Application for Patients Receiving Pharmacother-
apy. The most common effects with PO therapy include apy for Acne and Related Skin Conditions.
bone pain, fever, headache, nausea, vomiting, rash, stoma-
titis, pruritus, sweating, and ocular disorders. Other Drugs Similar to Tretinoin
adverse effects may include hyperlipidemia, shivering, (Avita, Retin-A, Others)
hemorrhage, pain, dizziness, paresthesias, anxiety, insom-
nia, depression, cerebral hemorrhage, intracranial hyper- Other antiacne drugs include adapalene, azelaic acid,
tension (HTN), hallucinations, dysrhythmias, flushing, isotretinoin, and tazarotene.
hypotension or HTN, heart failure, visual disturbances,
abdominal pain, diarrhea, constipation, dyspepsia, gastro- Adapalene (Differin): Approved in 1996, adapalene is a
intestinal (GI) hemorrhage, kidney impairment, dysuria, topical acne drug that modulates the inflammation, epithe-
and acute kidney failure. Black Box Warning: Patients with lial keratinization, and differentiation of follicular cells. It
APL are at high risk for serious adverse effects. About 25% is very similar to the retinoids but is reported to produce
of patients develop retinoic acid-APL syndrome, which is a less skin irritation. Optimal results may take up to
serious condition characterized by fever, weakness, fatigue,
dyspnea, weight gain, peripheral edema, respiratory
Chapter 73 Pharmacotherapy of Dermatologic Disorders 1375
12 weeks of therapy. Patients must be cautious with sun occur after even short courses of therapy. The warning fur-
exposure because this drug can increase the potential for ther states that the drug has special requirements for dis-
sunburn. Other adverse effects include local burning, tribution that require patients, healthcare providers, and
pruritus, scaling, and peeling. Only minimal amounts of pharmacists to register and adhere to the iPledge Program,
adapalene are absorbed through the skin. Safety of this a pregnancy risk management program. Before starting
drug in patients under age 12 has not been established. therapy, the patient must submit to two negative preg-
This drug is pregnancy category C. nancy tests and sign a statement of understanding about
the drug’s adverse effects. Each subsequent month, the
Azelaic acid (Azelex, Finacea): Approved in 1995, aze- pharmacist must document receipt of a negative preg-
laic acid is a natural product found in wheat, rye, and nancy test and verify that two forms of effective contracep-
barley. Azelaic acid is a topical therapy that is effective tion are being utilized by the patient. Males must also
for the treatment of mild to moderate acne by suppress- register with the iPledge Program because small amounts
ing the growth of P. acnes and decreasing the prolifera- of isotretinoin are found in semen and could potentially
tion of keratinocytes. It is also approved for the topical cause birth defects in a pregnant partner. Other common
treatment of inflammatory pustules associated with adverse effects include cheilitis, epistaxis, xerostomia, hair
rosacea. Only 4% is absorbed systemically. Adverse loss, eczema, elevated serum lipid levels, myalgia, and
effects are typical of other topical antiacne drugs: local arthralgia. Clinical depression, psychosis, and aggression
burning, pruritus, scaling, and peeling. Safety of this have been reported.
drug in patients under age 12 has not been established.
This drug is pregnancy category B. Tazarotene (Avage, Tazorac): Approved in 1997, tazaro-
tene is a topical retinoid derivative of vitamin A that is
Isotretinoin (Accutane): Approved in 1982, isotretinoin is used for the treatment of acne, fine facial wrinkles, and
a PO retinoid that is the most effective drug for severe, psoriasis. Patients become sensitive to the sun’s UV light
inflammatory acne. Therapy may require several months and need to wear protective sunscreen and clothing when
for optimal benefit. Off-label uses include rosacea, psoria- using this drug. Adverse effects are similar to those of topi-
sis, and the treatment of squamous cell carcinoma of the cal tretinoin: local burning, stinging, erythema, and gen-
skin. Because of potentially serious adverse effects, this eral skin irritation. This drug is metabolized in the skin to
drug is usually used when other therapies fail to produce an active metabolite; small amounts are absorbed systemi-
satisfactory results. Isotretinoin carries a black box warn- cally. Safety of this drug in patients under age 12 has not
ing that it causes birth defects (category X), which can been established. Tazarotene is pregnancy category X.
CONNECTIONS: NURSING PRACTICE APPLICATION
Patients Receiving Pharmacotherapy for Acne and Related Skin Conditions
Assessment
Baseline assessment prior to administration:
• Obtain a complete health history including dermatologic, hepatic, or kidney disease; psychiatric disorders; pregnancy; or breastfeeding.
• Obtain a drug history including allergies, current prescription and OTC drugs, herbal preparations, alcohol use, and smoking. Be alert to possible drug
interactions.
• Evaluate appropriate laboratory findings (e.g., complete blood count [CBC], lipid profiles, hepatic or renal function laboratory tests).
• Obtain baseline vital signs.
• Assess the patient’s ability to receive and understand instructions. Include the family or caregiver as needed.
Assessment throughout administration:
• Assess for desired therapeutic effects (e.g., skin is clearing of acne lesions).
• Continue periodic monitoring of CBC, lipid profiles, glucose, and hepatic function tests if on a PO drug.
• Monitor vital signs at each healthcare visit.
• Monitor eye health periodically with eye examinations every 6 months while on PO drug therapy.
• Assess for adverse effects: localized skin irritation, erythema, pruritus, dry or peeling skin; dry mouth, eyes, or nose may occur if on the PO drug.
Immediately report any sudden or significant changes in mood, especially depression or suicidal thoughts in patients on PO isotretinoin.
Implementation
Interventions and (Rationales) Patient-Centered Care
Ensuring therapeutic effects: • Teach the patient appropriate administration techniques.
• Monitor appropriate medication administration for optimal results. • Advise the patient that significant improvement may take several weeks
(Topical treatment areas should show signs of improvement within but some improvement should be noticed within a few days of treat-
2–4 wk but may require up to 3–4 months of treatment. PO treatment ment.
is usually successful within one course and a second course may be
delayed for several weeks to monitor continuing improvement.) (continued )
1376 Unit 11 Additional Drug Classes
CONNECTIONS: NURSING PRACTICE APPLICATION (continued)
Implementation
Interventions and (Rationales) Patient-Centered Care
Minimizing adverse effects: • Teach the patient to gently cleanse the skin using a non-oily soap and
• Monitor the area under topical treatment for excessive dryness and avoiding vigorous scrubbing. If excessive dryness occurs, use a non-
oily lotion to areas of dryness.
irritation. (Overcleansing or overdrying of the skin may make the condi-
tion worse. If other drying products such as benzoyl peroxide were
used before treatment, a brief recovery period may be needed to avoid
excessive skin irritation.)
• Monitor patients on isotretinoin for emotional health or changes in • Instruct the patient, family, or caregiver to immediately report any signs
mood. (Depression, including with suicidal ideations, has been noted of decreased mood, affect, depression, or expressed suicidal thoughts
as an adverse effect.) to the healthcare provider.
• Monitor CBC, lipid levels, and hepatic function laboratory values peri- • Instruct the patient to return periodically for laboratory tests.
odically for patients on PO medication. (Lipid levels may increase in up • Teach the patient to report any symptoms of abdominal or right upper
to 70% of patients on PO acne therapy. Hepatic toxicity is an adverse
effect of PO drugs.) quadrant discomfort or pain, yellowing of the skin or sclera, fatigue,
anorexia, darkened urine, or clay-colored stools immediately.
• Monitor for vision changes. (Corneal opacities or cataracts are an ad- • Instruct the patient to maintain regular eye examinations and to report
verse effect of PO antiacne medications. Dryness of eyes during treat- any changes in visual acuity, especially with night driving.
ment is common. Night vision may be diminished during treatment.)
• Teach the patient that artificial tear solutions may assist in relieving
eye dryness. Consult the healthcare provider if dryness is severe or
increases.
• Monitor the patient’s exposure to sun and UV light. Use oil-free • Teach the patient to use sunscreens of SPF 15 or higher and to wear
sunscreen of SPF 15 or higher prior to any sun exposure. (Drying, skin protective clothing and hats to avoid sun exposure to areas under
sensitivity, and peeling skin are possible adverse effects of antiacne treatment for acne or wrinkles.
and antiwrinkle medications, especially for patients on tretinoin. Protec-
tion from sun exposure is essential to prevent increasing skin damage.) • Teach the patient that UV light therapy from a healthcare provider is
monitored, and tanning beds are not a substitute. Tanning beds should
be avoided unless specifically ordered by the healthcare provider.
• Monitor adherence with iPledge requirements for patients on isotreti- • Instruct the patient on isotretinoin of the requirements of the iPledge
noin. (iPledge is required of all patients on isotretinoin before receiving mandatory program to ensure continued prescriptions, including:
a prescription or refills of the drug. It includes educational information • Women of childbearing age must use two methods of birth control
and requires the patient to ensure that all requirements to prevent while on the drug.
teratogenic effects have been met.) • Women of childbearing age must have two negative pregnancy
tests 1 month before, during, and after drug therapy, conducted
at certified laboratories. The results of these tests are submitted by
the healthcare provider, along with a description of the two types
of birth control used by the patient.
• Male patients must verify that they will use a barrier method of birth
control and will not donate blood while on the drug.
Patient understanding of drug therapy: • The patient should be able to state the reason for the drug, appropriate
• Use opportunities during administration of medications and during dose and scheduling, what adverse effects to observe for, and when to
report them.
assessments to discuss the rationale for drug therapy, desired thera-
peutic outcomes, commonly observed adverse effects, parameters
for when to call the healthcare provider, and any necessary monitoring
or precautions. (Using time during nursing care helps to optimize and
reinforce key teaching areas.)
Patient self-administration of drug therapy: • Teach the patient to take the drug following appropriate guidelines:
• When administering the medication, instruct the patient, family, or • Gently cleanse the affected skin twice daily with non-oily soap,
avoiding excessive or vigorous scrubbing.
caregiver in proper self-administration of the drug, e.g., topical drug • Apply a thin layer of topical cream or lotion to the affected area
used appropriately, iPledge program is followed. (Utilizing time during after cleansing the skin. Keep the drug out of the eyes. Allow to dry
nurse administration of these drugs helps to reinforce teaching.) and avoid contact with clothing, towels, or bedding to avoid stain-
ing or bleaching.
• For PO medications, take in the morning, and if twice-a-day dosing
is ordered, take the second dose approximately 8 h after the first.
Pharmacotherapy of Dermatitis may lead to excoriation, which are scratches that break
the skin surface and fill with blood or serous fluid to
73.6 The most effective treatment for dermatitis form crusty scales. A wide variety of factors can cause
is topical corticosteroids, which are classified by dermatitis, with different types of symptoms occurring
their potency. depending on the causative agent. The three most com-
mon types that respond to topical pharmacotherapy are
Dermatitis is a general term that refers to superficial atopic, contact, and seborrheic. Dermatitis may be acute
inflammatory disorders of the skin. General symptoms or chronic.
include local redness, pain, and pruritus. Intense scratching
Chapter 73 Pharmacotherapy of Dermatologic Disorders 1377
PharmFACT
About 37% of young children with severe eczema also have
a food allergy. Many children no longer have eczema by the
time they enter grade school (American College of Allergy,
Asthma and Immunology, n.d.).
Atopic dermatitis, or eczema, is a chronic, inflamma- Figure 73.2 Dermatitis.
tory skin disorder with a genetic predisposition. Patients
who present with eczema often have a family history of Courtesy of Librakv/Fotolia.
asthma and hay fever as well as allergies to a variety of
irritants such as cosmetics, lotions, soaps, pollens, food, pet potency, as listed in Table 73.3. The high-potency medica-
dander, and dust. About 75% of patients with atopic der- tions are used to treat acute flare-ups and are limited to 2 to
matitis have had an initial onset before 1 year of age. In 3 weeks of therapy. The medium-potency formulations are
those babies predisposed to eczema, breastfeeding seems for more prolonged therapy of chronic dermatitis. The low-
to offer protection, because it is rare for a breastfed child to potency corticosteroids are prescribed for children.
develop eczema before the introduction of other foods. In
infants and small children, lesions usually begin on the face Long-term corticosteroid use may lead to irritation,
and scalp, and then progress to other parts of the body. A redness, hypopigmentation, and thinning of the skin. High-
frequent and prominent symptom in infants is the appear- potency formulations are not advised for the head or neck
ance of red cheeks. regions because of potential adverse effects. If absorption
occurs, topical corticosteroids may produce undesirable
Contact dermatitis can be caused by a hypersensitivity systemic effects, including adrenal insufficiency, mood
response, resulting from exposure to specific natural or changes, serum imbalances, and loss of bone mass, as dis-
synthetic allergens such as plants, chemicals, latex, drugs, cussed in Chapter 68. To avoid serious adverse effects, care-
metals, or foreign proteins. Accompanying the allergic ful attention must be given to the amount of corticosteroid
reaction may be various degrees of cracking, bleeding, or applied, the frequency of application, and how long it
small blisters. See Figure 73.2. should be used. For most patients with dermatitis, topical
corticosteroids have minimal adverse effects.
Seborrheic dermatitis is a form of eczema that can
affect patients at any age. The exact cause of seborrheic der- Patients with persistent atopic dermatitis that does not
matitis is unknown, but hormone levels, coexisting fungal respond to corticosteroids may benefit from PO immuno-
infections, nutritional deficiencies, and immunodeficiency suppressants, such as cyclosporine. This drug is generally
states are associated with the disease. Seborrheic dermatitis used for the short-term treatment of severe disease. The
presents as greasy, not dry, scales that affect the scalp, cen- topical calcineurin inhibitors pimecrolimus 1% (Elidel) and
tral face, and anterior chest, often presenting as scalp scal- tacrolimus 0.03%, 0.1% (Protopic) are available for patients
ing, or dandruff. Other symptoms may include redness of older than 2 years of age. These medications may be used
the nasolabial fold, particularly during times of stress; on all skin surfaces (including the face and neck) because
blepharitis; otitis externa; and acne vulgaris. In infants, they have fewer adverse effects than the topical corticoste-
thick, greasy scales on the vertex of the scalp, commonly roids. Adverse effects include burning and stinging on bro-
known as cradle cap, are seen. These scales can become ken skin. Pimecrolimus and tacrolimus are not approved
more widespread, with the central face, forehead, and ears for long-term therapy because of a small risk of skin cancer
being affected. and lymphoma. They are reserved for patients who have
not responded to topical corticosteroids. When using these
Pharmacotherapy of dermatitis is symptomatic and
involves lotions and ointments to control itching and skin
flaking. Antihistamines may be used to control inflamma-
tion and reduce itching, and analgesics or topical anesthet-
ics may be prescribed for pain relief. Atopic dermatitis can
be controlled, but not cured, by medications. Part of the
management plan must include the identification and
elimination of allergic triggers that cause flare-ups.
Topical corticosteroids are the most effective treatment
for controlling the inflammation and itching of dermatitis.
Creams, lotions, solutions, gels, and pads that contain cor-
ticosteroids are specially formulated to penetrate deep into
the skin layers. These dermatologic drugs are classified by
1378 Unit 11 Additional Drug Classes
Table 73.3 Selected Topical Corticosteroids CONNECTIONS: Treating the
Diverse Patient
for Dermatitis and Related Symptoms
The Role of Genetics in Dermatitis
Generic Name Strength (%) Trade Name and Psoriasis
Very High Potency
betamethasone dipropionate, 0.05 Diprolene As more is learned about the role genetics plays in the
augmented, cream response to drug therapy, it is clear that genetics also influ-
clobetasol propionate 0.05 Temovate ences skin reactions such as atopic dermatitis, psoriasis,
diflorasone diacetate 0.05 Maxiflor and drug-induced skin reactions (Borroni, 2015; Dhingra et
halobetasol 0.05 Ultravate al., 2014; Sukasem, Puangpetch, Medhasi, & Tassa-
High Potency neeyakul, 2014). Activated T cells and cytokines such as
amcinonide 0.1 Cyclocort interleukins have been shown to play a role in skin defenses
fluocinonide 0.025 Lidex and skin reactions. Differences have also been shown to
halcinonide 0.1 Halog exist in the numbers and activation of cytokines between
Medium Potency children and adults, and between racial groups (Leung,
betamethasone benzoate 0.025 Uticort 2015). Gaining a better understanding of the role genetic
betamethasone valerate 0.1 Valisone factors play in the development of skin conditions will help to
clocortolone pivalate 0.1 Cloderm refine treatment options, particularly with the biologic
desoximetasone, cream 0.025 Topicort response modifiers, and to develop new approaches to ther-
fluocinolone acetonide 0.025 Synalar apy (Miyagaki & Sugaya, 2015).
flurandrenolide, cream 0.025 Cordran
fluticasone propionate, cream 0.05 Cutivate route every other week. The most common adverse effects
hydrocortisone valerate 0.2 Westcort are injection-site reactions and conjunctivitis.
mometasone furoate 0.1 Elocon
prednicarbate 0.1 Dermatop Topical therapy for seborrheic dermatitis primarily
triamcinolone acetonide 0.025–0.1 Aristocort, consists of antifungals and low-dose topical corticoste-
Kenalog roids, depending on the location affected. The first-line
Low Potency 0.05 therapy for seborrheic dermatitis that affects the scalp
alclometasone dipropionate 0.05 Aclovate should be topical corticosteroids. These may be adminis-
desonide Desonate, tered as a shampoo, topical solution, or a lotion applied to
0.1 DesOwen, the scalp. A typical regimen for an adult would be to use a
dexamethasone 0.25–1 Verdeso topical corticosteroid once or twice daily with the use of a
hydrocortisone — medicated shampoo 2 to 3 times per week. Shampoos that
Cortizone, Hycort contain selenium sulfide (Selsun), salicylic acid, zinc pyri-
thione, or an antifungal azole are most often used. Once-
drugs, occlusive dressings should not be used because this daily antifungal medication with fluconazole (Diflucan),
promotes absorption of the drug and can increase the risk ketoconazole (Nizoral), or ciclopirox (Loprox) combined
of systemic toxicity. The immunosuppressants are pre- with 2 weeks of once-daily desonide (DesOwen) is recom-
sented in Chapter 42. mended for seborrheic dermatitis of the face and ears.
Other alternatives to corticosteroids for atopic derma- CONNECTION Checkpoint 73.3
titis include doxepin (Zonalon), crisaborole (Eucrisa), and
dupilumab (Dupixent). When given PO doxepin is used to Topical applications of corticosteroids are used for a variety of
treat depression; however, Zonalon cream is indicated for conditions. What are some indications for corticosteroids given
atopic dermatitis. Some of the drug is absorbed across the by the following routes of administration: aerosol inhalation (see
skin, causing drowsiness in about 20% of patients. Applied Chapter 44), intranasal (see Chapter 45), and intra-articular (see
topically, crisaborole is an anti-inflammatory drug Chapter 72)? Answers to Connection Checkpoint questions are avail-
approved in 2016 to treat atopic dermatitis. able on the faculty resources site. Please consult with your instructor.
The approval of dupilumab in 2017 has led to a new Pharmacotherapy of Psoriasis
approach to treating persistent atopic dermatitis that has
not responded to other therapies. This drug is a monoclo- 73.7 Psoriasis is a chronic, inflammatory
nal antibody that targets the interleukin-4 (IL-4) receptor disease that is treated with topical and systemic
pathway. By blocking the binding of IL-4 (and to some medications.
extent IL-13), the drug prevents the release of inflamma-
tory cytokines. It is administered by the subcutaneous Psoriasis is a chronic, inflammatory skin disorder that
affects 1% to 2% of the population and appears with
Chapter 73 Pharmacotherapy of Dermatologic Disorders 1379
greater frequency in people of European ancestry. The Figure 73.3 Psoriasis.
onset of psoriasis is generally established by 20 years of
age, although it may occur throughout the lifespan. Courtesy of Casi/Fotolia.
Although the etiology of psoriasis is incompletely base of the lesion is exposed, producing multiple bleeding
understood, it appears to have both genetic and autoim- points. Lesions vary in size and are usually present on the
mune components. About 33% to 50% of the cases have a scalp, elbows, knees, extensor surfaces of the arms and
genetic basis, with a close family member also having the legs, sacrum, hands, and occasionally around the nails
disorder. When one identical twin presents with psoriasis, (Figure 73.3). The face is rarely affected. When psoriasis
the other twin has a 70% probability of also acquiring the affects the nails, a yellow or brown discoloration may
disease. The immune nature of psoriasis is supported by result, and the nail itself may separate from the nail bed,
the discovery that activated T lymphocytes (T cells) migrate thicken, and crumble. The various forms of psoriasis are
to the dermis and release cytokines such as tumor necrosis described in Table 73.4.
factor (TNF) that increase the production of skin cells and
cause inflammation. Furthermore, suppressing T-cell func- The goal of psoriasis pharmacotherapy is to reduce
tion through the use of immunosuppressants or biologic erythema, plaques, and scales to improve the cosmetic
therapies improves symptoms of psoriasis. appearance of the patient, leading to the ability to perform
normal lifestyle activities. This is accomplished by reduc-
Specific environmental triggers worsen psoriasis, ing epidermal cell turnover and promoting healing of the
including stress, smoking, alcohol, climate changes, and psoriatic lesions. The choice of therapy depends on the
infections. In addition, certain drugs, including angiotensin- type and extent of the disease and the history of response
converting enzyme (ACE) inhibitors, beta-adrenergic to a previous treatment of psoriasis. A number of prescrip-
blockers, tetracyclines, and nonsteroidal anti-inflammatory tion and OTC drugs are available for the treatment of pso-
drugs (NSAIDs), act as triggers. People with psoriasis seem riasis and are listed in Table 73.5. Therapy is often conducted
to improve in warmer climates, where there is more expo-
sure to sunlight.
When psoriasis occurs, both the dermis and epidermis
become thickened from an extremely fast skin turnover
rate, with skin cells reaching the surface in 4 to 7 days
instead of the normal 2 to 3 weeks. This rapid proliferation
time does not allow for cell maturation and keratinization
to occur, giving the skin lesions their characteristic appear-
ance. The typical psoriatic lesions are characterized by red,
raised patches of skin covered with flaky, thick, silver
scales called plaques. Plaques are ultimately shed from
the surface while the underlying skin becomes inflamed
and irritated. If the scales are scraped away, the dark-red
Table 73.4 Types of Psoriasis
Form of Psoriasis Description Most Common Location Comments
of Lesions
Guttate (droplike) or eruptive Lesions smaller than those of psoriasis Upper trunk and extremities More common in early-onset
psoriasis vulgaris psoriasis; can appear and resolve
Skin over scalp, elbows, and knees; spontaneously a few weeks following
Psoriasis vulgaris Lesions are papules that form into lesions possible anywhere on the a streptococcal respiratory infection
Psoriatic arthritis erythematous plaques with thick, silver or body
gray plaques that bleed when removed; Most common form; requires long-
plaques in dark-skinned individuals often term specialized management
appear purple
Fingers and toes at the distal About 20% of patients with psoriasis
Resembles rheumatoid arthritis interphalangeal joints; can affect the also have arthritis
skin and nails
Psoriatic erythroderma or Generalized scaling; erythema without Least common form
exfoliative dermatitis lesions All body surfaces
Pustular psoriasis Eruption of pustules; presence of fever Trunk and extremities; can appear on Average age of onset is 50 years
the palms, soles, and nail beds
1380 Unit 11 Additional Drug Classes
Table 73.5 Selected Drugs for Psoriasis and Related Disorders
Drug Route and Adult Dose Adverse Effects
Topical Medications (Maximum Dose Where Indicated)
Burning, stinging, folliculitis, itching, dry skin, hyperpigmentation
calcipotriene (Dovonex) Topical: Apply a thin layer to the lesions 1–2 times/day up
to 8 wk No serious adverse effects
Folliculitis, irritation, photosensitivity
coal tar (Balnetar, Cutar, Topical: Apply to affected areas 1–4 times/day
others) No serious adverse effects
Erythema, pruritus, stinging of the skin
salicylic acid (Neutrogena, Topical: Apply to affected areas tid–qid in concentrations
No serious adverse effects
Salex, others) ranging from 2% to 10% Pruritus, burning, stinging, skin irritation, transient worsening of
psoriasis, skin peeling, photosensitivity
tazarotene (Tazorac) Acne: Apply a thin film to the clean, dry area daily
Plaque psoriasis: Apply thin film daily in the evening Hypertriglyceridemia, teratogenicity
Systemic Medications PO: 25–50 mg/day with the main meal Dry mouth, alopecia, cheilitis, dry skin, dry mucous membranes
acitretin (Soriatane)
Increased triglycerides and cholesterol, paresthesias, rigors,
adalimumab (Humira) Subcutaneous: 40 mg every other week arthralgia, skin peeling, pseudotumor cerebri, depression,
elevated liver function tests, teratogenicity
alefacept (Amevive) IM: 15 mg once weekly for 12 wk Upper respiratory infection, local reactions at the injection site
(pain, erythema, myalgia)
apremilast (Otezla) PO: Begin with 10 mg/day and increase over a 6-day
period to 30 mg bid Malignancies, serious infections, worsening heart failure
brodalumab (Siliq) Nausea, vomiting, diarrhea, pharyngitis, dizziness, cough, pruritus
Subcutaneous: 210 mg at wk 0, 2, and 4 followed
cyclosporine (Gengraf, by 210 mg q2wk Malignancies, serious infection, hepatotoxicity, lymphopenia
Neoral, Sandimmune) Diarrhea, nausea, headache
PO: 1.25 mg/kg bid (max: 4 mg/kg/day)
Depression, weight loss
etanercept (Enbrel) Subcutaneous: 50 mg twice weekly (given 3–4 days apart) Arthralgia, headache, fatigue, diarrhea, injection site reactions
Maintenance dose: 50 mg/wk
Neutropenia, serious infections, suicidal ideation
guselkumab (Tremfya) Subcutaneous: 100 mg at wk 0 and 4 followed by 100 mg Hirsutism, tremor, vomiting, headache, pruritus, nausea, diarrhea
q8wk
HTN, myocardial infarction (MI), nephrotoxicity, hyperkalemia,
infliximab (Remicade) IV: 5 mg/kg given as an induction dose at 0, 2, and 6 wk gingival enlargement, paresthesias, hepatotoxicity, infection
ixekizumab (Taltz) followed by a maintenance dose of 5 mg/kg q8wk Local reactions at the injection site (pain, erythema, myalgia),
thereafter abdominal pain, vomiting, nasopharyngitis
Subcutaneous: 160 mg at wk 0, followed by 80 mg at wk Serious infections, lupus-like syndrome, positive antinuclear
2, 4, 6, 8, 10, and 12 followed by 80 mg q4wk antibodies, heart failure exacerbations
Upper respiratory infection, headache, arthralgia, diarrhea,
methotrexate (Otrexup, PO: 2.5–5 mg bid for 3 doses each week injection-site reactions
Rheumatrex, Trexall) (max: 25–30 mg/wk)
Serious infections
Subcutaneous (Otrexup): 10–25 mg once weekly Infections, headache, abdominal pain
secukinumab (Cosentyx) Subcutaneous: 150–300 mg at wk 0, 1, 2, 3, and 4 Infusion-related reactions, invasive fungal infections,
followed by 300 mg q4wk malignancies, hepatotoxicity, lupus-like syndrome
Local reactions at the injection site, upper respiratory infections,
ustekinumab (Stelara) Subcutaneous: 45–90 mg initially and 4 wk later, followed nausea
by 45–90 mg q12wk
Serious infections, hypersensitivity, worsening of inflammatory
bowel disease
Headache, glossitis, gingivitis, mild leukopenia, nausea
Ulcerative stomatitis, myelosuppression, aplastic anemia, hepatic
cirrhosis, nephrotoxicity, sudden death, pulmonary fibrosis, acute
renal failure, teratogenicity
Nasopharyngitis, diarrhea, upper respiratory tract infection
Serious infections, hypersensitivity reactions
Nasopharyngitis, upper respiratory tract infection, headache, and
fatigue
Malignancies, serious infections
Note: Italics indicate common adverse effects. Underline indicates serious adverse effects.
Chapter 73 Pharmacotherapy of Dermatologic Disorders 1381
in a stepwise manner. Psoriasis is a lifelong disease and inhibits deoxyribonucleic acid (DNA) synthesis, arrests
there is no pharmacologic cure. abnormal cell growth, and reduces inflammation. Coal tar
is inexpensive and available as a solution, gel, lotion, and
PharmFACT shampoo. Coal tar preparations, however, are messy, stain-
ing, and have a foul odor. The use of coal tar is considered
Psoriasis affects more than 8 million Americans. More than a second-line therapy except for shampoos, which can
30% of these patients will experience their first episode treat scalp lesions.
before age 20 (National Psoriasis Foundation, n.d.).
Calcipotriene (Dovonex): Approved in 1993, calcipotriene
Topical Drugs is a derivative of vitamin D that is available as a cream for
use on the body and as a solution for the scalp. The drug
Corticosteroids: Topical corticosteroids are a first-line binds to vitamin D receptors in the skin, suppresses cellular
therapy for the initial treatment of psoriasis. These drugs proliferation, and decreases cellular turnover in the psori-
are effective, inexpensive, and relatively safe. When they atic plaques. Symptomatic improvement is seen in 2 to
are applied to psoriatic lesions, topical corticosteroids sup- 3 weeks. Calcipotriene is an effective alternative to topical
press cell division, reduce inflammation, relieve pruritus, corticosteroids. Only about 6% of a topical dose is absorbed
and delay the movement of keratinocytes that are associ- systemically. Its most common adverse effect is local irrita-
ated with fast skin turnover. Choosing the correct strength tion. It is not recommended for use by patients over age 65,
of corticosteroid and the most effective vehicle base are who have an increased incidence of adverse effects with the
important aspects of treatment because the effectiveness of drug, or by pregnant and lactating women (category C). Its
a topical steroid depends on its potency and ability to be use may produce hypercalcemia if applied over large areas
absorbed into the skin. Initial therapy may begin with a of the body or if used in higher than recommended doses.
high-potency drug to obtain rapid clearing of the lesions. Phototherapy of excessive exposure to UV light should be
High-potency medications are also used for acute flare-ups avoided due to the potential for increased tumor incidence.
for 2 to 3 weeks. The high-potency formulations are best This drug is pregnancy category C.
applied to the areas thickest with plaque, such as the hands
or feet, and should not be used on the face and genital Salicylic acid: Salicylic acid is a keratinolytic that has been
areas. For chronic maintenance therapy, the patient is used as an OTC remedy to treat various skin conditions,
switched to moderate- and low-potency corticosteroids including psoriasis, acne, dandruff, warts, and dermatitis.
because they have a lower potential for adverse effects. It is the active metabolite of aspirin and has been available
for over 100 years. Salicylic acid removes the outer layers of
Occlusive dressings may be applied to increase the skin, allowing improved penetration of other dermatologic
effectiveness of the corticosteroid. A simple way to enhance drugs. The drug is pregnancy category C.
drug penetration is to apply the steroid directly to the skin
followed by warm, moist dressings and an occlusive outer Tazarotene (Tazorac): Approved in 1997, tazarotene
wrap. Wraps may be large plastic bags, vinyl jogging suits, (Tazorac) is a vitamin A retinoid that causes sloughing of
or rolls of tubular plastic. Care should be taken that the the scales covering the psoriatic plaques. Available as an
wraps not be left in place longer than 8 hours. The skin ointment or gel, this drug is applied once daily in the eve-
should be inspected for atrophy, striae, hypopigmentation, ning. Tazarotene is also approved for facial wrinkles and
and telangiectasias, which are all adverse effects of topical acne. Because this drug is pregnancy category X, its use is
corticosteroid therapy. contraindicated during pregnancy.
Repeated use of topical corticosteroids will result in Systemic Drugs
tolerance. To delay tolerance, doses of the high-potency
drugs are kept as low as possible. Some healthcare provid- Some patients have severe psoriasis that is resistant to top-
ers discontinue corticosteroids after an adequate response ical therapy. Because systemic drugs have the potential to
has been obtained and switch to a different therapy such as cause serious adverse effects, they are generally used when
coal tar for several weeks. topical drugs and phototherapy fail to produce an ade-
quate response. In some cases, they may be used for a few
When large areas of the body have psoriatic lesions, weeks to produce a rapid improvement in symptoms
topical corticosteroid therapy can be expensive and involve before beginning topical therapy.
some systemic risk. The larger the area treated, the greater
the absorbed doses. The student should refer to Chapter 68 Acitretin (Soriatane): Acitretin is a PO retinoid that is
for a discussion of the adverse effects of systemic cortico- approved for severe, resistant psoriasis. Two to three
steroid therapy. months of therapy may be required for significant symp-
tomatic improvement. Approved in 1997, acitretin acts like
Coal tar: Coal tar may be used as monotherapy or in com- other retinoids to inhibit keratin formation and skin
bination with other psoriasis medications. The drug
1382 Unit 11 Additional Drug Classes
inflammation. This drug is very effective at eliminating Biologic therapies: An understanding of the role of the
psoriatic lesions. However, the lesions return soon after immune system in the pathogenesis of psoriasis has led to
therapy is discontinued. The most serious adverse effect is the use of biologic therapies to treat patients with moderate
teratogenicity (category X). At least two negative preg- to severe disease. Biologic drugs suppress the hyperactive
nancy tests should be obtained before beginning therapy, inflammatory and immune responses characteristic of
and the patient should use effective birth control for psoriasis by several different mechanisms. Adalimumab
3 years after discontinuing the drug. Many adverse effects (Humira), etanercept (Enbrel), and infliximab (Remicade)
occur frequently during therapy, including cheilitis, hair inhibit TNF. Apremilast (Otezla) produces an anti-inflam-
loss, dry skin, pruritus, rash, epistaxis, bleeding gums, and matory effect by blocking the enzyme phosphodiesterase-4.
joint pain. The active metabolite of acitretin, etretinate Ixekizumab (Taltz), secukinumab (Cosentyx), ustekinumab
(Tegison), was withdrawn from the market in 1998 due to (Stelara), guselkumab (Tremfya), and brodalumab (Siliq)
high toxicity. The patient should refrain from drinking are newer drugs that inhibit interleukins. Alefacept
alcohol during acitretin therapy because this converts (Amevive) inhibits T-cell activation.
more of the drug to its toxic metabolite.
The biologic therapy medications induce general
Apremilast (Otezla): Approved in 2014, apremilast is immunosuppression, and patients are at an increased risk
used to treat psoriatic arthritis and plaque psoriasis. The for infection, including reactivation of latent infections
drug inhibits the enzyme phosphodiesterase-4, which such as tuberculosis. In addition brodalumab, one of the
results in a reduction in several different proinflammatory newest biologic therapies, has a black box warning regard-
mediators. It is the first drug approved for psoriasis that ing the potential for suicidal ideation. Healthcare providers
acts by this mechanism. Apremilast is considered an option and pharmacies must receive special certification to dis-
for patients who have not responded to phototherapy or pense brodalumab. Major disadvantages of biologic drugs
systemic therapy with other drugs. Patients with a history are that they are not available in PO formulations and their
of depression, suicidal behavior, or weight loss should be annual costs may exceed $20,000 per year.
monitored regularly while on apremilast therapy. This
drug is pregnancy category C. Nonpharmacologic therapy: Phototherapy with ultravio-
let-A (UVA) and ultraviolet-B (UVB) light is used in cases
Cyclosporine (Gengraf, Neoral, Sandimmune): Cyclospo- of severe debilitating psoriasis. Phototherapy with UVA is
rine is an immunosuppressant that is presented as a proto- combined with methoxsalen, a drug from a chemical fam-
type drug in Chapter 42. The drug acts by suppressing ily known as the psoralens. The concurrent use of UVA
T-cell functions. It is effective at providing rapid relief from and the drug is called PUVA therapy. Psoralens are PO or
the symptoms of psoriasis and is often combined with topical drugs that produce a photosensitive reaction when
other drugs, such as calcipotriene, to provide for a lower exposed to UV light. This reaction reduces the number of
dose and reduced toxicity. Due to the potential for serious psoriatic lesions, but unpleasant adverse effects such as
adverse effects such as nephrotoxicity, hepatotoxicity, and headache, nausea, and skin sensitivity occur that may limit
increased risk for infections and neoplasia, cyclosporine is the effectiveness of PUVA therapy. Treatments are limited
used for extensive psoriasis when other treatment meth- to 2 to 3 times per week, and an interim period of 48 hours
ods have failed. between treatments is necessary. Because of the strong
photosensitizing properties of the psoralens, patients must
Methotrexate (Otrexup, Rheumatrex, Trexall): Methotrex- wear dark glasses during treatment and for the remainder
ate is one of the most frequently prescribed systemic drugs of the day. The use of PUVA has been associated with an
for severe psoriasis. An older drug approved in 1953, increased risk for cataract development.
methotrexate is used in the treatment of a variety of disor-
ders, including carcinomas and rheumatoid arthritis, in The second type of phototherapy is with narrow-band
addition to being prescribed for psoriasis. For psoriasis, UVB light, which is less hazardous than UVA therapy. The
methotrexate inhibits the rapid proliferation of cells in the wavelength of UVB is similar to that of sunlight, and it
skin. It is administered either once weekly or twice daily reduces the lesions that cover a large area of the body that
for 3 days each week. In 2013 a new formulation of the normally resist topical treatments. It is usually used in con-
drug, Otrexup, was approved that permits a once-weekly junction with topical coal tar. If access to a light treatment
subcutaneous injection for patients with severe psoriasis. unit is not feasible, natural sunlight may be used. The use
Improvement is noted after several weeks of therapy but of commercial tanning beds is not recommended for the
maximum effects may take 2 to 3 months. For resistant patient with psoriasis.
lesions, methotrexate may be combined with phototherapy
or alternated with other systemic drugs. Methotrexate is All UV treatments may cause acute sunburn reactions,
discussed as a prototype drug in Chapter 57. including generalized redness with edema and tenderness
as well as the development of long-term effects of actinic
keratosis, premature aging of the skin, and skin cancers.
Chapter 73 Pharmacotherapy of Dermatologic Disorders 1383
Immunosuppressant drugs such as cyclosporine are not The best treatment for sunburn is prevention. Sun-
used in conjunction with PUVA therapy, because they screens are liquids or lotions applied for chemical or physi-
increase the risk of skin cancer. cal protection. Chemical sunscreens absorb the spectrum of
UV light that is responsible for most sunburns. Chemical
Pharmacotherapy of Minor sunscreens include those that contain benzophenone for
Skin Burns protection against UVA rays, and those that work against
UVB rays such as cinnamates, para-aminobenzoic acid
73.8 The pharmacotherapy of sunburn includes (PABA), and salicylates. Physical sunscreens such as zinc
prevention with sunscreens and treatment with oxide, talc, and titanium dioxide reflect or scatter light to
lotions, topical anesthetics, and analgesics. prevent the penetration of both UVA and UVB rays. Parsol
is another sunscreen product that is being used more fre-
Sunburn results from overexposure of the skin to UV light quently as a key ingredient in lip balm.
and is associated with light skin complexions, prolonged
exposure to the sun during the more hazardous hours of The effectiveness of a sunscreen is indicated by its SPF.
the day (10 a.m. until 3 p.m.), and lack of protective cloth- An SPF of 8 means the product offers 8 times more protec-
ing when outdoors. Chronic sun exposure can result in tion than using no sunscreen. Patients with skin that sun-
serious conditions, including eye injury, cataracts, and skin burns easily should use products with an SPF of 15 or
cancer. greater. Waterproof sunscreens are meant to withstand
8 minutes of exposure to water. People tend to apply sun-
Minor, first-degree burns affect only the outer layers of screen too infrequently and in layers that are too thin. To be
the epidermis. Excessive exposure to UV light, however, effective, sunscreen must be applied generously and often
injures the dermis and dilates the capillaries, leading to during the exposure period.
redness, tenderness, edema, and occasional blister forma-
tion. In addition to producing local skin damage, sun over- Treatment for sunburn consists of addressing symp-
exposure releases toxins that may produce systemic effects. toms with soothing lotions, rest, prevention of dehydra-
The signs and symptoms of sunburn include erythema, tion, and topical anesthetics, if needed. Treatment is usually
intense pain, nausea, vomiting, chills, edema, and head- done on an outpatient basis. Topical anesthetics for minor
ache. These symptoms usually resolve within a matter of burns include benzocaine (Solarcaine), dibucaine (Nuper-
hours or days, depending on the severity of the exposure. cainal), lidocaine (Xylocaine), and tetracaine HCl (Ponto-
Once sunburn has occurred, medications can only alleviate caine). Aloe vera is a popular natural therapy for minor
the symptoms; they do not speed recovery time. skin irritations and burns. Hydrocortisone cream may
decrease pain and swelling and assist in the healing of
CONNECTIONS: Complementary and Alternative Therapies
Aloe Vera
Description Standardization
Numerous products on the market, including soaps, lotions, Aloe vera has not been evaluated by the FDA for safety, effec-
creams, and sunscreens, are aimed at the consumer who is tiveness, or purity.
seeking the healing properties of aloe vera gel. Healthcare pro-
viders have also recommended aloe vera gel to treat dermatitis, Evidence
burns, and a variety of skin disorders.
Like other herbal products, controlled research studies demon-
History and Claims strating the effectiveness of aloe vera are lacking. The gel is most
often used topically, although it may be taken orally. The yellow
Aloe vera is derived from the gel inside the leaf of the aloe latex component of aloe produces a strong laxative effect and
plant, which is a member of the lily family. Aloe vera contains intense cramping may occur; the drug is not recommended to be
over 70 active substances, including antioxidants, minerals, taken orally for this reason (National Center for Complementary
vitamins, and enzymes. These substances are supposed to kill and Integrative Health, 2016). The antimicrobial actions of aloe
a variety of microorganisms, decrease pain, and reduce local- vera extracts have been clearly demonstrated (Stanley, Ifeanyi, &
ized inflammation. Aloe vera also has value for its moisturizing Eziokwu, 2014). While it is known that whole-leaf aloe vera extract
and wound healing properties. It has been used medicinally for has demonstrated carcinogenic outcomes, less is known about
thousands of years. Early mention is made of aloe’s use in the long-term effects of the gel, used topically or orally (Guo & Mei,
ancient Sumer in 2200 BC, where it was proclaimed a plant of 2016). Until more rigorous clinical trials have been conducted,
great healing power. nurses should advise patients wanting to use aloe vera, particu-
larly the PO form, to discuss it with their healthcare provider.
1384 Unit 11 Additional Drug Classes
damaged tissue. These same drugs may also provide relief Nursing Responsibilities:
from minor pain due to insect bites and pruritus. In more
severe cases, PO analgesics and anti-inflammatory medica- • Assess the sunburn, including the location, portion of
tions such as aspirin or ibuprofen may be indicated. body surface area, edema, erythema, and blistering.
PROTOTYPE DRUG Benzocaine (Americaine, • Assess for systemic symptoms such as fever, chills,
Anbesol, Others) weakness, and shock. These may occur following
severe exposure, or when the sunburn affects a large
Classification Therapeutic: Topical anesthetic portion of the body surface area.
Pharmacologic: Local anesthetic
• Obtain a thorough history, including sunburn and tan-
(ester type), antipruritic ning history, the amount of time the patient usually
spends in the sun, how easily the patient burns, and
Therapeutic Effects and Uses: Approved in 1938, the type of sun protection used. If the patient uses a
benzocaine inhibits the conduction of nerve impulses sunscreen, obtain the SPF rating.
from sensory nerve endings, producing surface anesthe-
sia. It is indicated for the temporary relief of pain and • Obtain an allergy history and use of OTC products or
discomfort in patients with pruritic skin problems, minor home remedies to treat the sunburn.
burns and wounds, and insect bites. It is available in a
variety of delivery forms, including sprays, lotions, gels, • If topical anesthetics or ointments are ordered, assess
and lozenges. Several products are available OTC to treat the skin for secondary infections for which these med-
pain due to toothaches, dentures, or canker sores. Because ications are contraindicated.
of its short duration of action, it must be applied 3 to
4 times a day. • For patients using the medication for the first time,
conduct a trial application on a small area of skin to
Mechanism of Action: Benzocaine produces surface assess for an allergic reaction. If no adverse effects
anesthesia by inhibiting the conduction of nerve endings. occur within 30 to 60 minutes, the medication may be
applied to the entire area of sunburn.
Pharmacokinetics:
• Report any serious sunburn in children under age 6 to
Route(s) Topical the healthcare provider.
Absorption Minimally absorbed from intact Lifespan and Diversity Considerations:
skin • The drug should not be used for children under 1 year
of age except on direction of the healthcare provider.
Distribution Unknown
Patient and Family Education:
Primary metabolism Hepatic
• Avoid applying the medication to open or infected
Primary excretion Renal areas of skin.
Onset of action 1 min • Report severe, persistent pain.
• Avoid additional sun exposure while receiving
Duration of action 15–20 min
treatment.
Adverse Effects: Adverse effects include sensitiza- • Prevent sunburn in the future by wearing protective
tion in susceptible individuals, allergic reactions, and ana-
phylaxis. Because it is poorly absorbed, systemic adverse clothing such as long-sleeved shirts and large-brim
effects are rarely observed. hats, and by using sunscreen with an SPF of 15 or
greater.
Contraindications/Precautions: Contraindications • Follow the directions regarding use and reapplication
include hypersensitivity to benzocaine or other PABA of sunscreen after swimming or sweating.
derivatives or to any of the components in the formula- • Refrigerate topical lotions so they will provide a sooth-
tion. Caution should be used in patients with a history of ing, cooling effect when applied.
drug sensitivity to ester-type anesthetics, denuded skin, • Increase hydration after sunburning to aid in cooling
or severely traumatized mucosa, and in children under the skin. Avoid excessive cool bathing, which may dry
6 years. the skin further.
• Do not apply benzocaine to infants and young
Drug Interactions: Benzocaine may antagonize the children.
antibacterial activity of sulfonamides.
Drugs Similar to Benzocaine
Pregnancy: Category C. (Americaine, Anbesol, Others)
Treatment of Overdose: Overdose with topical ben- Benzocaine is the only drug in its class that is used for
zocaine is unlikely. minor burns.
Chapter 73 Pharmacotherapy of Dermatologic Disorders 1385
Pharmacotherapy of Alopecia anti-inflammatory medications are used to decrease the
destruction of the hair follicles.
73.9 Several drugs are able to stimulate
moderate hair regrowth in patients with male- Minoxidil (Rogaine): Oral minoxidil (Loniten) was first
and female-pattern alopecia. approved for HTN in 1979. Approval to market the topical
solution for hair loss occurred in 1996. The drug is rubbed
Alopecia is the loss of hair, resulting in baldness. Male- onto the scalp twice daily. Although minoxidil is a potent
pattern baldness is the most common cause of hair loss in vasodilator, this mechanism is likely not involved in its
men and is genetically determined. Men affected by this effectiveness as a hair regrowth agent. The exact mecha-
type of alopecia typically experience a loss of hair at the nism of action is unknown. Only 2% of a topical dose is
temples, followed by a recession of the hairline and absorbed systemically; therefore, this route does not affect
baldness at the crown. blood pressure. Various brands of minoxidil include 2%
Rogaine for Women, 2% Rogaine for Men Regular Strength,
Two drugs are currently available to promote hair and 5% Rogaine for Men Extra Strength. An off-label use is
regrowth in patients with male-pattern baldness: topical to treat chemotherapy-induced alopecia. In patients who
minoxidil (Rogaine) and PO finasteride (Propecia, Proscar). are receiving chemotherapy, hair regrowth occurs at a
Neither drug was originally developed for baldness. faster rate with minoxidil use. Response rates vary how-
Although their exact mechanisms of action are unknown, it ever, and over half of patients treated do not experience
is thought that these drugs work by stimulating the epithe- significant regrowth. The drug has no significant adverse
lial cells within the hair follicle. They are most successful in effects. This drug is pregnancy category C. Caution should
patients with recent onset of symptoms or who are less be taken to keep the solution out of the reach of children.
than 50 years of age. About 40% of patients who are treated One teaspoon of the solution contains the amount of a
2 to 3 times daily for a year will experience moderate daily adult antihypertensive dose.
regrowth of hair. For both drugs, hair regrowth stops when
the drug is discontinued. Finasteride (Propecia, Proscar): Proscar was approved for
benign prostatic hyperplasia (BPH) in 1992. Propecia was
Hair loss in women differs from hair loss in men and later approved to treat male-pattern baldness in 1997. The
varies by ethnicity. A common type of alopecia in Cauca- dose used for treating BPH is 5 times higher than that used
sian women, female-pattern hair loss, typically begins in for baldness. Unlike minoxidil, finasteride is a PO medica-
the early 20s and 30s, with progressive thinning and loss of tion. This drug is thought to act by reducing the amounts
hair on the top of the scalp but not the back. These women of dihydroxytestosterone (DHT) in hair follicles, thus
typically do not have a receding hairline. The hair also slowing hair loss. It is less effective than minoxidil at pro-
becomes finer as individual hairs become smaller, resulting moting hair regrowth. At the low doses used for hair
in less dense hair. Some women with this pattern of hair regrowth, adverse effects are uncommon. It is not
loss may have elevated androgen levels or diabetes that approved for use in women. This drug is pregnancy cate-
requires treatment. Topical minoxidil is currently the only gory X. Pregnant women should not touch this drug
hair regrowth treatment approved for women by the FDA. because it may harm a male fetus if absorbed.
Applied to the scalp twice daily, it stimulates hairs that are
actively growing to have more robust growth. CONNECTION Checkpoint 73.4
Women of African descent have a different type of alo- From what you learned in Chapter 71, describe the mechanism by
pecia called central centrifugal alopecia. This type also which finasteride reduces symptoms of BPH. Answers to Connection
results in hair loss on the top of the scalp, but it is different Checkpoint questions are available on the faculty resources site. Please
from the female-pattern hair loss in that the hair follicles consult with your instructor.
are destroyed. Topical minoxidil is used in this group to
stimulate growth in the unaffected hair follicles, whereas
Understanding Chapter 73
Key Concepts Summary 73.2 The etiology of skin disorders may be classified as
infectious, inflammatory, or neoplastic.
73.1 Three layers of skin, known as the epidermis,
dermis, and subcutaneous layers, provide effective
barrier defenses for the body.
1386 Unit 11 Additional Drug Classes 73.6 The most effective treatment for dermatitis is topical
corticosteroids, which are classified by their potency.
73.3 When the integrity of the skin is compromised,
microbes can gain entrance and cause infections 73.7 Psoriasis is a chronic, inflammatory disease that is
that require anti-infective therapy. treated with topical and systemic medications.
73.4 Scabicides and pediculicides are used to treat 73.8 The pharmacotherapy of sunburn includes
parasitic skin infestations. prevention with sunscreens and treatment with
lotions, topical anesthetics, and analgesics.
73.5 The pharmacotherapy of acne includes treatment
with benzoyl peroxide, retinoids, and antibiotics; 73.9 Several drugs are able to stimulate moderate hair
pharmacotherapy for rosacea includes retinoids regrowth in patients with male- and female-pattern
and metronidazole. alopecia.
CASE STUDY: Making the Patient Connection
Remember the patient “Danny provider diagnoses Danny’s skin condition as acne vul-
McBride” at the beginning of garis and prescribes tretinoin (Retin-A).
the chapter? Now read the
remainder of the case study. Critical Thinking Questions
Based on the information pre- 1. What would you tell Danny about his condition? Include
sented within this chapter,
respond to the critical thinking what acne is, who is prone to develop it, and what meth-
questions that follow. ods of treatment have been found to be beneficial.
2. What are some reasons why Danny’s acne outbreaks
Danny McBride is a 17-year-old high school student in his may have increased at this time?
senior year. He is active in lacrosse and baseball but is find- 3. What will you teach Danny about the application
ing that his skin is breaking out more often lately and is of tretinoin and adverse effects that may occur?
becoming discouraged at the frequency. He feels it has
started to affect his social life, so his parents make an Answers to Critical Thinking Questions are available on the
appointment with a dermatologist. The healthcare faculty resources site. Please consult with your instructor.
Additional Case Study 3. Stephanie’s psoriasis has not been responsive to
betamethasone and she is prescribed calcipotriene
Stephanie Caldera, age 36, is seen by her healthcare pro- (Dovonex). What teaching does Stephanie receive
vider for scaling patches on her forearms, elbows, and about this new prescription?
lower legs. She is diagnosed with psoriasis vulgaris and the
provider prescribes betamethasone cream (Diprosone). Answers to Additional Case Study questions are available on
Stephanie asks the nurse, “What is psoriasis? I look so the faculty resources site. Please consult with your instructor.
awful! Is it contagious?”
1. How should the nurse respond?
2. What specific instructions should Stephanie be given
about the application of the betamethasone cream?
Chapter Review 2. A patient is being treated with a course of topical des-
oximetasone (Topicort) for atopic dermatitis. In plan-
1. An important inclusion in a teaching plan prepared ning teaching for this patient, which adverse effects
for the patient who is taking permethrin (Nix) is: would the nurse anticipate?
1. Nix can be applied after body lotion is applied. 1. Burning and stinging of the skin in the affected area
2. All body hair, including eyelashes and eyebrows,
2. Development of localized pruritus and hives
can be treated with lindane.
3. Lice cannot live outside the body. 3. Hair loss in the application area
4. In addition to hair shafts, examine the inner thigh
4. Worsening of acne vulgaris
areas, gluteal folds, and pubic areas for lice.
Chapter 73 Pharmacotherapy of Dermatologic Disorders 1387
3. The patient reports using benzoyl peroxide (Benzac) 5. Benzocaine (Americaine) has been recommended to a
for treatment of acne. The nurse notes that the action 17-year-old patient for treatment of a mild sunburn.
of this drug includes which of the following? (Select What should the patient be taught about using this
all that apply.) product?
1. Sebum suppression 1. It may be used on superficial and partial-thickness
sunburns.
2. Antimicrobial effect
2. Warming the lotion under warm water will prevent
3. Keratolytic effect a chilled sensation when applied.
4. Microdermal abrasion 3. A small test area should be used if the drug has not
been used before to assess for allergy.
5. Sunscreen activity
4. Cover the treated area with a light dressing
4. A patient has been prescribed topical tretinoin (Retin-A) wrapped in plastic wrap to keep it from
for treatment of acne unresponsive to over-the-counter rubbing off.
products. What essential information should the nurse
include in the patient’s teaching? 6. A patient who has been prescribed isotretinoin (Accu-
tane) must comply with the iPledge Program because
1. Wash the face thoroughly 3 times a day with an of the risk of __________________ effects.
antiacne soap while using this medication.
See Answers to Chapter Review in Appendix A.
2. Plan to expose the involved skin areas to sunlight
for a minimum of 15 minutes each day.
3. Use only mild soaps, warm water, and pat the skin
dry to avoid excessive irritation.
4. Alternate the topical tretinoin (Retin-A) with
benzoyl peroxide on an every-other-day rotation
for best results.
References Miyagaki, T., & Sugaya, M. (2015). Recent advances in
atopic dermatitis and psoriasis: Genetic background,
American Academy of Dermatology (n.d.). Indoor tanning. barrier function, and therapeutic targets. Journal of
Retrieved from https://www.aad.org/media/stats/ Dermatological Science, 78, 89–94. doi:10.1016/j.
prevention-and-care dermsci.2015.02.010
American College of Allergy, Asthma and Immunology. National Center for Complementary and Integrative
(n.d.). Eczema (atopic dermatitis). Retrieved from http:// Health. (2016). Aloe vera. Retrieved from https://nccih.
acaai.org/allergies/types-allergies/skin-allergy/ nih.gov/health/aloevera
eczema
National Psoriasis Foundation. (n.d.). Facts about psoriasis.
Borroni, R. G. (2015). Role of dermatology in Retrieved from https://www.psoriasis.org/teens/
pharmacogenomics: Drug-induced skin injury. about-psoriasis
Pharmacogenomics, 16, 401–412. doi:10.2217/pgs.15.4
Stanley, M. C., Ifeanyi, O. E., & Eziokwu, O. G. (2014).
Dhingra, N., Shemer, A., Correa de Rosa, J., Rozenbilt, M., Antimicrobial effects of aloe vera on some human
Fuentes-Duculan, J., Gittler, J. K., . . . Guttman-Yassky, pathogens. International Journal of Current Microbiology
E. (2014). Molecular profiling of contact dermatitis skin and Applied Science, 3, 1022–1028.
identifies allergen-dependent differences in immune
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01.2016.1166826 safety communication: FDA warns of rare but serious
hypersensitivity reactions with certain over-the-counter
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136, 1265–1267. doi:10.1016/j.jaci.2015.09.011
1388 Unit 11 Additional Drug Classes
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Journal of Drugs in Dermatology, 13(3), 235–238.
“I just cannot see clearly while
driving at nighttime anymore.
All I see are halos around the
other cars’ headlights.”
Patient “Therese Duclos”
Chapter 74
Pharmacotherapy of
Eye and Ear Disorders
Chapter Outline Learning Outcomes
cc Anatomy of the Eye After reading this chapter, the student should be able to:
cc Pathophysiology of Glaucoma
cc Pharmacotherapy of Glaucoma 1. Identify the major anatomic structures of the eye.
Prostaglandins 2. Identify the primary risk factors associated with
PROTOTYPE Latanoprost (Xalatan), p. 1393 glaucoma.
Autonomic Drugs
PROTOTYPE Timolol (Betimol, Timoptic, Others), p. 1396 3. Compare and contrast open-angle and closed-angle
Carbonic Anhydrase Inhibitors glaucoma.
Osmotic Diuretics
cc Pharmacotherapy for Eye Examinations 4. Explain the two major mechanisms by which drugs
Anticholinergics reduce intraocular pressure.
Sympathomimetics
cc Pharmacotherapy for Other Eye Conditions 5. Identify examples of drugs that dilate or constrict
Lubricants pupils, relax ciliary muscles, constrict ocular blood
Vasoconstrictors vessels, or moisten eye membranes.
cc Anatomy of the Ear
cc Pharmacotherapy with Otic Preparations 6. Identify the types of ear conditions that could
Antibiotics benefit from pharmacotherapy.
Cerumenolytics
7. Describe the nurse’s role in the nonpharmacologic
and pharmacologic management of eye and ear
disorders.
8. For each of the classes shown in the chapter outline,
identify the prototype and representative drugs and
explain the mechanism(s) of drug action, primary
indications, contraindications, significant drug
interactions, pregnancy category, and important
adverse effects.
9. Apply the nursing process to the care of patients
receiving pharmacotherapy for eye and ear
disorders.
1389
1390 Unit 11 Additional Drug Classes
Key Terms mastoiditis, 1405 otitis externa, 1402
miosis, 1396 otitis interna, 1405
aqueous humor, 1391 mydriasis, 1396 otitis media, 1403
cerumenolytics, 1405 mydriatics, 1400 tonometry, 1392
closed-angle glaucoma, 1392 open-angle glaucoma, 1393
cycloplegics, 1400
glaucoma, 1392
The senses of vision and hearing are the primary means for Anatomy of the Eye
us to communicate with the world around us. Disorders
that affect the eye and ear can result in problems with self- 74.1 Knowledge of basic eye anatomy is
care, mobility, safety, and communication. The eye is vul- fundamental to understanding eye disorders
nerable to a variety of conditions, many of which can be and their pharmacotherapy.
prevented, controlled, or reversed with proper pharmaco-
therapy. The first part of this chapter covers drugs that are Knowledge of basic ocular anatomy is key to understanding
used for the treatment of glaucoma and those used rou- eye disorders and their pharmacotherapy. The important
tinely by ophthalmic healthcare providers. The remaining structures of the eye are shown in Figures 74.1 and 74.2.
part of this chapter presents drugs that are used for the
treatment of common ear disorders, including infections, The wall of the eye contains three layers, known as
inflammation, and the buildup of earwax. tunics. The outermost fibrous tunic is composed of the
cornea and the sclera. The cornea is the transparent layer
that covers the anterior portion of the eye. It has no blood
Anterior Fovea
chamber
Cornea Central artery
Edge of and vein
pupil
Optic
Visual nerve
axis Orbital
Lens fat
Iris Posterior
Conjunctiva chamber
Figure 74.1 Anatomy of the interior of the eye. Retina
Sclera
Bony orbit
.GPU Chapter 74 Pharmacotherapy of Eye and Ear Disorders 1391
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Figure 74.2 (a) In a healthy eye, aqueous humor is formed in the ciliary process and drains through the canal of Schlemm. (b) In chronic
open-angle glaucoma, the anterior chamber angle remains open, but drainage of aqueous humor through the canal of Schlemm is impaired.
(c) In acute closed-angle glaucoma, the angle of the iris and anterior chamber narrows, obstructing the drainage of aqueous humor through
the canal of Schlemm.
vessels and receives nutrients from the fluid lying behind that change the diameter of the pupil. The pupil is the cen-
the cornea, or aqueous humor. It is continuous with the tral opening that allows light to enter. These muscle fibers
sclera, which is the thick, white, opaque portion covering are under control of the sympathetic nervous system. Pupil
the posterior portion of the eye. The vascular tunic is the constriction is the result of parasympathetic stimulation,
middle layer of the eye, which is rich in blood vessels. and its dilation is a sympathetic response.
The vascular tunic contains specialized structures that
include the iris and ciliary body. The innermost layer is The anterior cavity is filled with aqueous humor, a
the neural tunic or retina, which contains the photorecep- thin fluid that slowly circulates to bring nutrients to the
tors for vision. area and remove wastes. The aqueous humor is secreted by
cells in a muscular structure called the ciliary body. Once
The interior of the eye is divided into two cavities. The secreted, the aqueous humor flows from the posterior
largest portion of the interior of the eye is the posterior cav- chamber through the pupil and into the anterior chamber.
ity, which is filled with a gel-like substance called vitreous Within the anterior chamber and around the periphery is a
humor that helps the eyeball to maintain its shape and network of spongy connective tissue, or trabecular mesh-
keep the retina in place. work, that contains an opening called the canal of Schlemm
(scleral venous sinus). The aqueous humor drains into the
The anterior cavity is smaller but is very important canal of Schlemm and out of the anterior chamber into the
from a pharmacologic perspective. This cavity is separated venous system, thus completing its circulation. Under nor-
into two chambers by the lens. The anterior chamber mal circumstances, the rate of aqueous humor production
extends from the cornea to the iris; the posterior chamber is equal to its outflow, maintaining intraocular pressure
lies between the iris and the lens. In front of the lens is the (IOP) within a normal range. Interference with either the
pigmented iris, which is made up of smooth muscle fibers
1392 Unit 11 Additional Drug Classes
production or outflow of aqueous humor, however, can Diagnosis of glaucoma can be difficult because it some-
lead to an increase in IOP. times occurs so gradually that patients do not experience
symptoms or seek medical attention until late in the dis-
The conjunctiva, eyebrows, eyelashes, eyelids, and lac- ease process. Tonometry is a primary ophthalmic tech-
rimal apparatus that produce tears all serve to protect the nique that tests for glaucoma by measuring IOP. Patients
eye. Infection and inflammatory responses are common with unusually thick or thin corneas may have false nega-
conditions in these supporting structures. Redness, edema, tives or false positives during tonometry. Patients who
and itching are common symptoms. have had Lasik surgery, which removes corneal tissue to
correct myopia, may appear to have normal IOPs, yet have
Pathophysiology of Glaucoma glaucoma. Gonioscopy uses a gonioscope to measure the
angle in the eye where the iris meets the cornea and is use-
74.2 The two principal types of glaucoma, ful in distinguishing between open-angle and closed-angle
closed-angle glaucoma and open-angle glaucoma. Visual field testing (perimetry) assesses the
glaucoma, are characterized by increased degree of central visual field narrowing and peripheral
intraocular pressure. vision loss. Funduscopic examinations look at retinal field
changes that accompany glaucoma.
Glaucoma is a condition that is characterized by gradual
loss of peripheral vision, usually accompanied by The two major types of primary glaucoma are closed-
increased IOP. Glaucoma occurs when the IOP becomes angle glaucoma and open-angle glaucoma, as shown in
high enough to cause optic nerve damage, leading to Figure 74.2. Both disorders result from the same problem: a
visual field loss and possible progression to blindness. buildup of aqueous humor in the anterior cavity. This
Although the median IOP in the population is 15 to buildup is caused either by an excessive production of
16 mmHg, this pressure varies greatly with age, daily aqueous humor or by a blockage of its outflow. In either
activities, and even time of day. As a rule, IOPs that are case, IOP increases, leading to progressive damage to the
consistently above 21 mmHg are considered abnormal. optic nerve. As the optic nerve degenerates, the patient will
Many patients, however, tolerate IOPs in the mid to high first notice a loss of visual field, then a loss of central visual
20s without damage to the optic nerve. IOPs that are above acuity, and eventually total blindness. The major differ-
30 mmHg require treatment because they are associated ences between closed-angle glaucoma and open-angle
with a high risk for permanent vision changes. Some glaucoma include how quickly the IOP develops and
patients of Asian descent may experience glaucoma at whether there is narrowing of the anterior chamber angle
“normal” IOP values, below 21 mmHg. between the iris and cornea.
PharmFACT Closed-angle glaucoma, also called acute- or narrow-
angle glaucoma, accounts for only 5% of all primary glau-
Blindness from glaucoma is 6 to 8 times higher in African coma. The incidence is higher in older adults and in
Americans than Caucasians. After cataracts, it is the leading individuals of Asian descent. It is typically caused by the
cause of blindness among African Americans (Glaucoma normal thickening of the lens and may develop gradually
Research Foundation, 2017). over several years. This type of glaucoma is usually unilat-
eral and is often associated with conditions that result in
Glaucoma affects more than 3 million people over the dilation of the pupil, such as stress, impact injury, or medi-
age of 40 in the United States. It is the leading cause of cations. Closed-angle glaucoma occurs when the pressure
preventable blindness worldwide. Primary glaucoma usu- inside the anterior chamber increases suddenly because the
ally occurs without an identifiable cause and is most fre- iris is being pushed over the area where the aqueous humor
quently found in people older than 60 years of age. In normally drains into the trabecular network and the canal
some cases, glaucoma is associated with genetic factors; it of Schlemm. The displacement of the iris is due in part to
can be congenital in infants and children. Glaucoma can the dilation of the pupil or accommodation of the lens,
also be secondary to eye trauma, infection, diabetes, causing the angle between the posterior cornea and the
inflammation, hemorrhage, tumor, or cataracts. Some anterior iris to narrow or close.
medications may contribute to the development or pro-
gression of glaucoma, including the long-term use of corti- Signs and symptoms of closed-angle glaucoma are
costeroids, some antihypertensives, antihistamines, and caused by acute obstruction of the outflow of aqueous
antidepressants. Other major risk factors associated with humor from the eye and include dull to severe eye and
glaucoma include hypertension (HTN), migraines, refrac- facial pain, headaches, seeing colored halos around bright
tive disorders with high degrees of nearsightedness or far- lights, a bulging iris, and a sudden change in visual acu-
sightedness, and normal aging. ity. The affected eye may appear reddened and the pupil
may be nonreactive. Ocular pain may be so severe that it
causes nausea and vomiting. Once the outflow is totally
Chapter 74 Pharmacotherapy of Eye and Ear Disorders 1393
closed, closed-angle glaucoma constitutes a medical teaching for the patient and family or caregiver should be
emergency and laser or conventional surgery is indicated directed at how the disease can be managed with the cor-
for the preservation of sight. Surgical options include iri- rect use of the medications.
dectomy, laser trabeculoplasty, trabeculectomy, and
drainage implants. Many drugs are available to treat glaucoma. These
medications work by one of two mechanisms: increasing
Open-angle glaucoma is the most common type of the outflow of aqueous humor at the canal of Schlemm or
glaucoma, accounting for more than 90% of the cases. Its decreasing the formation of aqueous humor at the ciliary
cause is unknown and many patients are asymptomatic. It body. Many antiglaucoma drugs produce these effects by
is usually bilateral, with the elevated IOP developing over modifying actions of the autonomic nervous system.
years. Open-angle glaucoma is named as such because the
anterior chamber angle is normal; the iris does not com- Although topical drugs are most commonly pre-
pletely cover the trabecular meshwork and canal of Sch- scribed, oral (PO) medications may be used for severe glau-
lemm. They remain open with their flow being partially coma. Drugs for glaucoma, which are listed in Table 74.1,
obstructed. This leads to the gradual development of include the following classes:
increased IOP with slow degeneration of the optic nerve,
resulting in a gradual loss of vision. Most patients with • Prostaglandins
open-angle glaucoma can be successfully treated with • Autonomic drugs, including beta-adrenergic blockers,
medications.
alpha2-adrenergic agonists, cholinergic agonists, and
Pharmacotherapy of Glaucoma nonselective sympathomimetics
• Carbonic anhydrase inhibitors
74.3 The primary goal of glaucoma • Osmotic diuretics.
pharmacotherapy is to prevent damage to the
optic nerve by lowering intraocular pressure. 74.4 Prostaglandin analogs are the first-line
drugs for treating high intraocular pressure
When glaucoma is diagnosed and treated early in the because of their long durations of action and
course of the disease, permanent vision disability can usu- high safety profiles.
ally be prevented. Some healthcare providers initiate phar-
macotherapy in all patients with an IOP greater than Prostaglandin analogs are often the preferred drugs for
21 mmHg. Because of the expense of pharmacotherapy glaucoma because they have long durations of action,
and potential adverse drug effects, other healthcare pro- allowing for once-daily dosing, and produce fewer adverse
viders will instead carefully monitor the patient through effects than the beta-adrenergic blockers. They may be
regular follow-up examinations and wait until the IOP used as monotherapy or combined with drugs from other
rises to 28 to 30 mmHg before initiating treatment. If signs classes to produce an additive reduction in IOP in patients
of optic nerve damage or visual field changes are evident, with resistant glaucoma.
the patient is treated regardless of the IOP.
Prostaglandin analogs lower IOP by increasing the
Once pharmacotherapy has been initiated, reevalua- outflow of aqueous humor. Latanoprost (Xalatan), which
tion is performed after 2 to 4 months to assess for therapeu- is available as a 0.005% eyedrop solution, is one of the
tic effectiveness. Some of the antiglaucoma drugs take 6 to most commonly used prostaglandin analogs. Other ocu-
8 weeks to reach peak effect. If the therapeutic goals are not lar prostaglandins include bimatoprost (Lumigan) and
achieved with a single drug, it is common to add a second travoprost (Travatan Z). An occasional adverse effect of
medication from a different class to the regimen to produce these medications is heightened pigmentation, which
an additive decrease in IOP. Some of the drugs may con- turns a blue iris to a more brown color. Many patients
tinue to have effects on the eye for 2 to 4 weeks after being experience thicker and longer eyelashes. These drugs
discontinued. cause local irritation, stinging of the eyes, and redness
during the first month of therapy. Because of these
Maintaining patient adherence with the medication effects, prostaglandins are normally administered just
regimen is a key factor in preventing progressive vision before bedtime.
impairment. It is essential for the nurse to determine any
factors that could decrease adherence, such as insufficient PROTOTYPE DRUG Latanoprost (Xalatan)
financial resources, lack of knowledge about the disease,
inability to properly instill the medication, or difficulty Classification Therapeutic: Drug for glaucoma
remembering the dosing schedule. The patient diagnosed Pharmacologic: Prostaglandin analog
with glaucoma may experience fear and anxiety about
potential blindness and disability. Accurate and thorough Therapeutic Effects and Uses: Approved by the
U.S. Food and Drug Administration in 1996, latanoprost
is a prostaglandin analog believed to reduce IOP by
increasing the outflow of aqueous humor for patients with
1394 Unit 11 Additional Drug Classes
Table 74.1 Selected Drugs for Glaucoma
Drug Route and Adult Dose Adverse Effects
Prostaglandins (Maximum Dose Where Indicated)
bimatoprost (Lumigan)
latanoprost (Xalatan) 1 drop of 0.03% solution daily in the evening Increased length and thickness of eyelashes,
tafluprost (Zioptan) 1 drop of 0.005% solution daily in the evening darkening of the iris, stinging, sensation of
travoprost (Travatan Z) 1 drop of 0.0015% solution daily in the evening foreign body in the eye
Beta-Adrenergic Blockers 1 drop of 0.004% solution daily in the evening
betaxolol (Betoptic) Respiratory infection, flu, angina, muscle or
carteolol (Ocupress) joint pain
levobunolol (Betagan)
metipranolol (OptiPranolol) 1 drop of 0.5% solution bid Local burning and stinging, blurred vision,
timolol (Betimol, Timoptic, others) 1 drop of 1% solution bid headache
1–2 drops of 0.25–0.5% solution 1–2 times/day
Alpha2-Adrenergic Agonists 1 drop of 0.3% solution bid Conjunctival hyperemia, angina, anxiety,
apraclonidine (Iopidine) 1–2 drops of 0.25–0.5% solution 1–2 times/day bronchoconstriction, hypotension,
brimonidine (Alphagan P) Gel (salve): apply daily dysrhythmias
Cholinergic Agonists 1 drop of 0.5% solution bid Local itching and burning, blurred vision, dry
carbachol (Isopto Carbachol) 1 drop of 0.1–0.15% solution in the affected eye tid, 8 h apart mouth, headache, eye discharge
echothiophate iodide (Phospholine Iodide) Allergic conjunctivitis, conjunctival hyperemia,
pilocarpine (Isopto Carpine, Pilopine) hypotension, bulbar conjunctival follicles
Sympathomimetics 1–2 drops of 0.75–3% solution in the lower conjunctival sac Induced myopia, reduced visual acuity in low
dipivefrin (Propine) up to 3 times/day light, eye redness, headache
1 drop of 0.03–0.25% solution 1–2 times/day Salivation, tachycardia, hypotension,
bronchospasm, sweating, nausea, vomiting,
Acute glaucoma: 1 drop of 1–2% solution every 5–10 min for retinal detachment (pilocarpine)
3–6 doses
Chronic glaucoma: 1 drop of 0.5–4% solution q4–12h
1 drop of 0.1% solution q12h Local burning and stinging, blurred vision,
headache, photosensitivity
Carbonic Anhydrase Inhibitors PO: 250 mg 1–4 times/day Tachycardia, HTN
acetazolamide (Diamox) 1 drop of 1% solution tid
brinzolamide (Azopt) 1 drop of 2% solution in the affected eye(s) tid For topical medications: blurred vision, bitter
dorzolamide (Trusopt) PO: 50–100 mg bid–tid taste, dry eye, blepharitis, local itching,
methazolamide (Neptazane) sensation of foreign body in the eye,
headache
Osmotic Diuretics PO: 1–3 g/kg 1–2 times/day
isosorbide (Ismotic) IV: 1.5–2 mg/kg as a 15–25% solution over 30–60 min For PO medications: diuresis, electrolyte
mannitol (Osmitrol) imbalances, blood dyscrasias, flaccid
paralysis, hepatic impairment
Orthostatic hypotension, facial flushing,
headache, palpitations, anxiety, nausea
Severe headache, electrolyte imbalances,
edema
Note: Italics indicate common adverse effects. Underline indicates serious adverse effects.
open-angle glaucoma and ocular HTN. The recommended Pharmacokinetics:
dose is one drop in the affected eye(s) in the evening. It is
used to treat open-angle glaucoma. Route(s) Ophthalmic solution
Mechanism of Action: Latanoprost reduces elevated Absorption Through the cornea
IOP in patients with open-angle glaucoma. Latanoprost is
a prodrug that is metabolized to its active form in the cor- Distribution Enters systemic distribution in
nea, reaching its peak effect in about 12 hours.
small amounts
Primary metabolism Metabolized in the aqueous
humor to its active form
Chapter 74 Pharmacotherapy of Eye and Ear Disorders 1395
Primary excretion Renal free of preservatives. Preservatives sometimes cause aller-
Onset of action 3–4 h with peak effect at 8–12 h gic reactions in susceptible patients and may worsen ocu-
Duration of action Unknown lar surface disorders such as dry eye syndrome. The
actions, effectiveness, and side effects of tafluprost are
Adverse Effects: Adverse effects include ocular symp- equivalent to those of other prostaglandins.
toms such as conjunctival edema, tearing, dryness, burn-
ing, pain, irritation, itching, sensation of a foreign body in Travoprost (Travatan Z): Approved in 2001, travoprost is
the eye, photophobia, or visual disturbances. The eyelashes approved for the treatment of open-angle glaucoma. Tra-
on the treated eye may grow thicker or darker. Changes voprost has been found to be more effective in African
may occur in the pigmentation of the iris of the treated eye Americans than in non–African Americans. Like bimato-
and in the periocular skin. Rare, systemic adverse effects prost, travoprost is used when other drugs have failed to
include headaches, rashes, flulike symptoms, and abnor- produce a satisfactory response. Use of this drug can cause
mal liver function tests. a gradual increase in the development of brown pigmenta-
tion in the iris, which may be irreversible, and includes an
Contraindications/Precautions: Contraindications increase in pigmentation of the eyelid and growth of the
include hypersensitivity to the drug or another component eyelashes. Conjunctival hyperemia has been reported in
in the solution, pregnancy, lactation, intraocular infection, 35% to 50% of patients treated with travoprost. Some other
or conjunctivitis. It should not be administered to patients adverse effects include blurred vision, eye discomfort, ocu-
with closed-angle glaucoma. The safety of this drug has lar pruritus, dry eye, light intolerance, and tearing. It is
not been demonstrated in children. available as a 0.004% solution, applied once daily in the
evening. This drug is pregnancy category C.
Drug Interactions: Latanoprost interacts with the
preservative thimerosal: If used concurrently with other CONNECTION Checkpoint 74.1
eyedrops that contain thimerosal, precipitation may occur.
Herbal/Food: Unknown. Several prostaglandins are used for their actions on uterine smooth
muscle. From what you learned in Chapter 70, what are the primary
Pregnancy: Category C. indications for the prostaglandins carboprost (Hemabate), dinopro-
stone (Cervidil), and mifepristone (Mifeprex)? Answers to Connection
Treatment of Overdose: Overdose with the ophthal- Checkpoint questions are available on the faculty resources site. Please
mic solution is unlikely. consult with your instructor.
Nursing Responsibilities: Key nursing implications 74.5 Drugs that affect the autonomic nervous
for patients receiving latanoprost are included in the Nurs- system are sometimes prescribed to treat
ing Practice Application for Patients Receiving Pharmaco- glaucoma.
therapy for Glaucoma.
Several structures within the eye are activated by the sym-
Drugs Similar to Latanoprost (Xalatan) pathetic and parasympathetic divisions of the autonomic
nervous system. As such, a significant number of auto-
Bimatoprost, tafluprost, and travoprost are other prosta- nomic drugs have been used to treat glaucoma and to aid
glandin analogs used for glaucoma. in ophthalmic examinations of the eyeball.
Bimatoprost (Lumigan): Approved in 2001, bimatoprost • Sympathetic activation (or parasympathetic division
is a synthetic prostaglandin analog indicated for the treat- blockade): Muscles of the iris contract to dilate the
ment of open-angle glaucoma. It is usually used when the pupil; the ciliary muscle relaxes to enhance distance
patient has not responded adequately to other antiglau- vision.
coma drugs. In 2008, a newer formulation of this drug,
Latisse, was approved to treat hypotrichosis, a condition of • Parasympathetic activation (or sympathetic division
having too few eyelashes. Use of bimatoprost can cause a blockade): Muscles of the iris contract to constrict the
gradual increase in the development of brown pigmenta- pupil; the ciliary muscle contracts to enhance near
tion in the iris, which may be irreversible, and includes an vision.
increase in pigmentation of the eyelid. Other adverse
effects include blurred vision, eye discomfort, ocular pruri- The most frequently used autonomic drugs are the
tus, conjunctivitis, dry eye, light intolerance, and tearing. It beta-adrenergic antagonists or blockers. Alpha2-adrenergic
is available as a 0.01% or 0.03% solution applied once daily agonists, cholinergic agonists, and nonselective sympatho-
in the evening. This drug is pregnancy category C. mimetics play minor roles, as discussed next. Prior to read-
ing this section, the student may want to review Chapter 12
Tafluprost (Zioptan): When approved in 2012, tafluprost to brush up on the terminology and anatomy of the auto-
became the first antiglaucoma prostaglandin completely nomic nervous system.
1396 Unit 11 Additional Drug Classes
Beta-adrenergic blockers: Before the discovery of the meshwork to allow greater outflow of aqueous humor and
prostaglandin analogs, beta-adrenergic blockers were the a lowering of IOP. Pilocarpine (Isopto Carpine, Pilopine) is
preferred drugs for open-angle glaucoma. These drugs the most commonly prescribed antiglaucoma drug in this
decrease the production of aqueous humor by the ciliary class. The cholinergic agonists are applied topically to the
body in the affected eye and can lower IOP by 20% to 30%. eye 4 times daily. Because of their greater toxicity and fre-
Five beta-adrenergic blockers are available as ophthalmic quent dosing, these drugs are normally used only in
solutions: betaxolol (Betoptic), carteolol (Ocupress), patients with open-angle glaucoma who do not respond to
levobunolol (Betagan), metipranolol (OptiPranolol), and other drugs. Local effects include headache, induced myo-
timolol (Betimol, Timoptic, others). These drugs generally pia, and decreased vision in low light. Systemic absorption
produce fewer adverse ocular effects than cholinergic ago- can result in hypotension, vomiting, diuresis, bronchocon-
nists or sympathomimetics. In most patients, the topical striction, diaphoresis, and abdominal pain with diarrhea.
administration of beta blockers does not result in signifi- Toxic effects include vertigo, bradycardia, tremors, syn-
cant systemic absorption. Should absorption occur, however, cope, and cardiac dysrhythmias. Other actions of the cho-
adverse systemic effects may include bronchoconstriction, linergic agonists are presented in Chapter 13.
dysrhythmias, and hypotension. Because of the potential for
adverse systemic effects, these drugs should be used with A second group of cholinergic agonists, the cholines-
caution in patients with asthma, bradycardia, or heart fail- terase inhibitors, act indirectly to lower IOP. They produce
ure. Tolerance will develop with long-term use in about 25% essentially the same actions as the direct-acting drugs but
of patients who take these drugs. exhibit a higher incidence of adverse effects. Cholinester-
ase inhibitors such as echothiophate cause cataracts in a
Alpha2-adrenergic agonists: Alpha2-adrenergic ago- significant percentage of patients and are used only in
nists lower IOP by decreasing the production of aqueous those who are resistant to therapy with other drugs.
humor and increasing its absorption. Only two alpha2-
adrenergic agonists are currently approved: apraclonidine CONNECTION Checkpoint 74.2
and brimonidine. Apraclonidine (Iopidine) is infrequently
used but may be prescribed for the prevention or short- Cholinergic agonists such as pilocarpine activate muscarinic recep-
term therapy of postoperative increases in IOP. Brimoni- tors. From what you learned in Chapter 13, what effect do muscarinic
dine (Alphagan P) is more commonly prescribed, either as agonists have on lacrimation and how is this used therapeutically?
monotherapy or as an adjunct in combination with a beta- Answers to Connection Checkpoint questions are available on the faculty
adrenergic blocker, for the long-term treatment of open- resources site. Please consult with your instructor.
angle glaucoma or glaucoma secondary to uveitis, which
is an inflammation of the middle layer of the eyeball. Nonselective sympathomimetics: Nonselective sym-
Alpha2-adrenergic agonists may be used in combination pathomimetics activate the sympathetic nervous system to
with other antiglaucoma drugs to cause additive reduction produce mydriasis (pupil dilation) and increase the out-
in IOP. Combigan is an ophthalmic solution that consists of flow of aqueous humor, resulting in a lower IOP. They are
brimonidine and timolol. not as effective as the beta-adrenergic blockers or the pros-
taglandin analogs. Medications in this class include
Alpha2-adrenergic agonists are contraindicated in epinephrine and dipivefrin, which are converted to epi-
closed-angle glaucoma because the pupil dilation that nephrine in the eye. Both are administered topically for
results would worsen the condition. The most significant open-angle glaucoma and are contraindicated in closed-
adverse effect, and one that is a frequent cause for discon- angle glaucoma. Epinephrine will increase blood pressure
tinuation of therapy, is an allergic-type reaction that causes and the heart rate if it reaches the systemic circulation;
sensation of a foreign body, itching, and hyperemia. Other thus the drug is contraindicated in patients with unstable
adverse effects include headache, drowsiness, dry mucosal cardiovascular disease. Sympathomimetics also produce a
membranes, blurred vision, and irritated eyelids. These high frequency of ocular adverse effects, including tearing,
drugs produce few cardiovascular or pulmonary adverse burning, hyperemia, and stenosis of the nasolacrimal duct.
effects. Rare systemic adverse effects may occur, including Because of the potential for systemic adverse effects, these
nervousness, anxiety, and muscle tremors. Patients should medications are third-choice drugs for glaucoma.
immediately notify their healthcare provider if they experi-
ence acute eye pain, because this may signal the onset of PROTOTYPE DRUG Timolol (Betimol, Timoptic, Others)
closed-angle glaucoma.
Classification Therapeutic: Drug for glaucoma
Cholinergic agonists (miotics): Drugs that directly Pharmacologic: Miotic, beta-adrenergic
activate cholinergic receptors in the eye produce miosis, or
constriction of the pupil, and contraction of the ciliary antagonist
muscle. These actions physically stretch the trabecular
Therapeutic Effects and Uses: Approved in 1978,
timolol is a nonselective beta-adrenergic blocker available
Chapter 74 Pharmacotherapy of Eye and Ear Disorders 1397
as a 0.25% or 0.5% ophthalmic solution. Its primary indica- bradycardia. When given by the ocular route, timolol will
tion is chronic open-angle glaucoma. It may also be used produce additive lowering of IOP when given concur-
for aphakic glaucoma (high IOP in patients with no lens), rently with other antiglaucoma drugs. Herbal/Food: There
secondary glaucoma, and ocular HTN. The usual dose is are no known herbal or food interactions with this drug.
one drop in the affected eye(s) twice a day. Timoptic XE
allows for once-daily dosing. Treatment may require 2 to Pregnancy: Category C.
4 weeks to reach the maximum therapeutic effect.
Treatment of Overdose: Overdose with ophthalmic
Timolol is available in several formulations. Cosopt is solution is unlikely but could result in systemic symptoms
an antiglaucoma drug that combines timolol with such as reduced heart rate and bronchospasm.
dorzolamide, a topical carbonic anhydrase inhibitor. Combi-
gan is an ophthalmic solution of timolol with brimonidine, Nursing Responsibilities: Key nursing implications
an alpha-adrenergic agonist. Timolol is also available in tab- for patients receiving timolol are included in the Nursing
lets (Blocadren), which are prescribed to treat mild HTN. Practice Application for Patients Receiving Pharmacother-
apy for Glaucoma.
Mechanism of Action: Timolol topically lowers the
elevated and normal IOP by reducing the formation of Drugs Similar to Timolol (Betimol,
aqueous humor and possibly increasing outflow. It affects Timoptic, Others)
both beta1 and beta2 receptors.
Other beta-adrenergic blockers with ophthalmic indica-
Pharmacokinetics: Eye solution or gel tions include betaxolol, carteolol, levobunolol, and metip-
Route(s) ranolol. Levobetaxolol (Betaxon) is an ophthalmic beta
Absorption Small amounts reach the blocker that has been discontinued in the United States.
systemic circulation from
Distribution topical application Betaxolol (Betoptic): Approved in 1985, betaxolol is a
Primary metabolism selective beta1-adrenergic receptor blocker. This drug
Secreted in breast milk reduces IOP by decreasing the production of aqueous
Primary excretion humor. Betaxolol is indicated for intraocular HTN and
Onset of action 80% metabolized in the chronic open-angle glaucoma. A tablet form of this drug
Duration of action liver to inactive metabolites (Kerlone) is available to treat HTN. Although only small
amounts are absorbed from ophthalmic administration,
Renal this drug should be used cautiously in patients with heart
failure and if used concurrently with a systemic beta-
30 min adrenergic blocker. Ocular irritation and tearing are fre-
quent adverse effects. This drug is pregnancy category C.
12–24 h
Carteolol (Ocupress): Carteolol is a nonselective beta-
Adverse Effects: The most common adverse effects adrenergic blocker that competes for available beta recep-
from ophthalmic administration are local burning and tor sites and is used for the treatment of chronic open-angle
stinging on instillation. Vision may become temporar- glaucoma. Both beta1 and beta2 receptors are inhibited.
ily blurred. In most patients absorption is not significant Adverse effects and contraindications are the same as
enough to cause adverse systemic effects as long as timolol those of other ophthalmic beta blockers. This drug is preg-
is applied correctly. If absorption occurs, hypotension or nancy category C.
dysrhythmias are possible.
Levobunolol (Betagan): Approved in 1985, levobunolol is
Contraindications/Precautions: Although little a nonselective beta-adrenergic blocker that is indicated for
is absorbed through ocular administration, this drug the treatment of intraocular HTN and chronic open-angle
should be used with caution in certain patients. Timolol glaucoma. Because small amounts may reach the systemic
is contraindicated in patients with asthma, severe chronic circulation, caution needs to be practiced when using this
obstructive pulmonary disease (COPD), sinus bradycar- drug in patients with asthma, COPD, bradycardia, thyroid
dia, second- or third-degree atrioventricular block, heart conditions, diabetes, and abnormal blood glucose levels.
failure, cardiogenic shock, or hypersensitivity to the drug. Tolerance can develop with long-term use. Ocular irrita-
Safety in children has not been established. tion is a frequent, transient adverse effect. This drug is
pregnancy category C.
Drug Interactions: Drug interactions may result if
significant systemic absorption occurs. Timolol should be Metipranolol (OptiPranolol): Approved in 1989, this drug
used with caution in patients who are taking other beta is a nonselective beta-adrenergic blocker used for the treat-
blockers owing to additive cardiac effects. Concurrent use ment of elevated IOP and chronic open-angle glaucoma. It
with anticholinergics, nitrates, reserpine, methyldopa, or
verapamil could lead to hypotension and bradycardia.
Epinephrine use could lead to HTN followed by severe
1398 Unit 11 Additional Drug Classes
is available as a 0.3% solution that is applied to the affected (Azopt), are well tolerated and produce few significant
eye(s) twice daily. Small amounts may be absorbed sys- adverse effects other than photosensitivity. PO formulations
temically. Contraindications are the same as those of other such as acetazolamide (Diamox) are very effective at lower-
ophthalmic beta blockers. Ocular irritation is a frequent, ing IOP in both open-angle and closed-angle glaucoma but
transient adverse effect. Although rare, uveitis has been are rarely used because they produce more adverse sys-
associated with metipranolol use. If this occurs, this drug temic effects than drugs from other classes. These adverse
should be discontinued because uveitis can cause an effects include lethargy, nausea, vomiting, depression, par-
increase in IOP. This drug is pregnancy category C. esthesias, and drowsiness. Patients must be cautioned when
taking these medications because they contain sulfur and
Miscellaneous Drugs for Treating may cause allergic reactions. Because the oral formulations
Glaucoma are diuretics and can reduce IOP quickly, serum electrolytes
should be monitored during treatment. A prototype feature
74.6 Carbonic anhydrase inhibitors and osmotic for acetazolamide is presented in Chapter 32.
diuretics are occasionally used for treating
glaucoma. Osmotic diuretics: Osmotic diuretics are occasionally
used preoperatively and postoperatively with ocular sur-
Although prostaglandin analogs and beta-adrenergic gery or as emergency treatment of acute closed-angle glau-
blockers are the two most frequently prescribed classes for coma attacks. Examples include isosorbide (Ismotic), urea,
lowering IOP, some patients may experience adverse effects and mannitol (Osmitrol). Because they have the ability to
from these drugs or have particularly resistant glaucoma. quickly reduce plasma volume, these drugs are effective in
Two additional classes, the carbonic anhydrase inhibitors reducing the formation of aqueous humor, thereby reduc-
and the osmotic diuretics, are not routinely prescribed. ing IOP. Adverse effects include headache, tremors, dizzi-
ness, dry mouth, fluid and electrolyte imbalances, and
Carbonic anhydrase inhibitors: Carbonic anhydrase thrombophlebitis or venous clot formation near the site of
inhibitors interfere with the synthesis of carbonic acid, which intravenous (IV) administration. A prototype feature for
decreases the production of aqueous humor and reduces IOP. mannitol is presented in Chapter 32.
They are used as long-term therapy in patients with open-
angle glaucoma when prostaglandin inhibitors, beta block- CONNECTION Checkpoint 74.3
ers, and other autonomic drugs have not been effective.
Mannitol is given by the IV route under controlled conditions. From
Drugs in this class are divided into topical or oral for- what you learned in Chapter 32, describe the mechanism of ac-
mulations. Dorzolamide (Trusopt) is used topically to treat tion of osmotic diuretics. Answers to Connection Checkpoint ques-
open-angle glaucoma, either as monotherapy or in combi- tions are available on the faculty resources site. Please consult with your
nation with other medications. Dorzolamide and other topi- instructor.
cal carbonic anhydrase inhibitors, including brinzolamide
CONNECTIONS: NURSING PRACTICE APPLICATION
Patients Receiving Pharmacotherapy for Glaucoma
Assessment
Baseline assessment prior to administration:
• Obtain a complete health history including ophthalmologic, respiratory, cardiovascular, and endocrine disease.
• Assess visual acuity and visual fields. Assess for the presence of eye pain, visual disturbances such as halos around lights, diminished foggy vision, or
loss of peripheral vision.
• Assess for history of recent eye trauma or infection.
• Obtain a drug history including allergies, current prescription and OTC drugs, herbal preparations, alcohol use, and smoking. Be alert to possible drug
interactions.
• Obtain baseline vital signs.
• Assess the patient’s ability to receive and understand instructions. Include family and caregivers as needed.
Assessment throughout administration:
• Assess for desired therapeutic effects (e.g., IOP remains below 21 mmHg, no changes in visual acuity or fields).
• Assess for adverse effects: conjunctival edema, tearing, dryness, burning, pain, irritation, itching, sensation of foreign body in the eye, or photophobia.
Severe visual disturbances or eye pain should be reported to the healthcare provider.
Implementation
Interventions and (Rationales) Patient-Centered Care
Ensuring therapeutic effects: • Instruct the patient to immediately report changes in vision, eye pain,
• Monitor visual acuity, vision fields, and IOP. (IOP should remain less light sensitivity, halos around lights, or headache to the healthcare
provider.
than 21 mmHg or per parameters set by healthcare provider. Visual
acuity and fields remain intact.)
Chapter 74 Pharmacotherapy of Eye and Ear Disorders 1399
CONNECTIONS: NURSING PRACTICE APPLICATION (continued)
Implementation
Interventions and (Rationales) Patient-Centered Care
Minimizing adverse effects: • Teach the patient the proper administration techniques for eyedrops.
• Monitor appropriate administration of the drug to avoid extraocular effects. PO medications should be taken as regularly throughout the day as
possible and with consistent dosing.
(Eyedrops should be instilled into the conjunctival sac and the lacrimal
duct area held with gentle pressure for one full minute to prevent drug
leakage into the nasopharynx with possible systemic effects. PO drugs
should be taken consistently throughout the day with no doses omitted.)
• Monitor IOP periodically. (Consistent readings above 21 mmHg may • Instruct the patient about the importance of returning for and
indicate worsening disease or improper use of drug therapy.) maintaining regular eye examinations.
• Monitor for increasing eye redness, pain, light sensitivity, or changes in • Instruct the patient to avoid touching the eyedrop tip to the conjunctival
visual acuity. (Eye changes or pain may indicate worsening disease, sac when instilling eyedrops. Immediately report any increasing
infection, or adverse drug effects.) redness, eye pain, eye drainage, or changes in vision.
• Remove contact lenses before administering ophthalmic solutions. • Instruct the patient to remove contact lenses prior to administering
Avoid use of other eyedrops or ointments unless approved by the eyedrops and wait at least 15 min before reinserting them.
healthcare provider. (Contact lenses may hinder eye solution from fully
reaching all eye surfaces or may absorb solution, resulting in higher • Instruct the patient to seek the healthcare provider’s advice before
than expected amounts in the eye over time. Other eye solutions may using any other eye solution.
interact with or counteract the effects of the prescribed solution.)
• Monitor vital signs periodically for signs of systemic absorption of • Teach the patient to return to the healthcare provider periodically for
ophthalmic preparations. (Ophthalmic drugs such as beta blockers or monitoring. Assess blood pressure once per week (e.g., at
cholinergic drugs may result in hypotension, bradycardia, or respiratory supermarket pharmacy counter sphygmomanometer) and report any
distress due to bronchospasm if the drug is absorbed systemically. blood pressure less than 90/60 mmHg or per parameters set by the
Ensure that the patient is administering drops appropriately if changes healthcare provider. Immediately report any dizziness, lightheadedness,
in blood pressure are noted. Lifespan: Monitor older adults frequently headache, palpitations, syncope, or difficulty breathing.
for hypotension related to systemic absorption to prevent falls.)
• Provide for eye comfort such as an adequately lighted room. • Caution the patient about driving or other activities in low-light
(Ophthalmic drugs such as beta blockers used in the treatment of conditions or at night until the effects of the drug are known.
glaucoma can cause miosis and difficulty seeing in low light levels.)
• Monitor adherence to the treatment regimen. (Nonadherence with drug • Teach the patient the importance of adhering to the medication
therapy may result in the total loss of vision.) schedule as prescribed.
• Address any concerns the patient may have about cost or discomfort
related to drug therapy, and provide appropriate referrals (e.g., social
service agency) as needed.
Patient understanding of drug therapy: • The patient should be able to state the reason for the drug, appropriate
• Use opportunities during administration of medications and during dose and scheduling, what adverse effects to observe for, and when to
report them.
assessments to discuss the rationale for the drug therapy, desired
therapeutic outcomes, commonly observed adverse effects,
parameters for when to call the healthcare provider, and any necessary
monitoring or precautions. (Using time during nursing care helps to
optimize and reinforce key teaching areas.)
Patient self-administration of drug therapy: • Teach the patient to take the drug following appropriate guidelines:
• When administering the medication, instruct the patient, family, or • Remove contact lenses if worn.
• Gently pull down on the lower eyelid, anchoring the hand against
caregiver in proper self-administration of the drug, e.g., appropriate the cheekbone.
instillation of eyedrops followed by teach-back. (Utilizing time during • Tilt the head back; steadying the hand on the forehead as needed,
nurse administration of these drugs helps to reinforce teaching.) drop prescribed numbers of drops into the conjunctival sac. Do not
drop solution directly onto the eye surface.
• Close the eye gently. Hold light pressure on the tear duct for one
full minute to retain the solution.
• Do not reinsert contact lenses for a minimum of 15 min after
eyedrop instillation, or as directed.
Pharmacotherapy cause sympathetic activation that relaxes the ciliary mus-
for Eye Examinations cle, causing dilation of the pupil and thus allowing for
better visualization of retinal structures. Cycloplegic
74.7 Drugs that are routinely used for eye drugs not only dilate the pupil but also paralyze the cili-
examinations include mydriatics, cycloplegics, ary muscle and prevent the lens from moving during
diagnostic dyes, and local anesthetics. assessment. Mydriatics and cycloplegics are often used in
combination to achieve the maximum pupil dilation
Various drugs are used to enhance diagnostic eye exami- needed for surgery or during funduscopic examinations.
nations and during ophthalmic surgery. Mydriatic drugs Examples of drugs used for eye examinations include
1400 Unit 11 Additional Drug Classes
anticholinergics, such as atropine (Isopto Atropine) and Diagnostic drugs are used to help locate lesions or for-
tropicamide (Mydriacyl, Tropicacyl), and sympathomi- eign bodies within the eye and to provide some local anes-
metics, such as phenylephrine (Mydfrin, Neo-Synephrine). thesia. Fluorescein sodium is a dye used in assessing the
Mydriatic, cycloplegic, and other drugs for eye conditions cornea and fitting contact lenses. Scratches may turn bright
are listed in Table 74.2. green; foreign bodies are surrounded by a green halo. Areas
where the conjunctiva is damaged show an orange-yellow
Mydriatics cause intense photophobia and pain in discoloration. Fluorescein sodium with benoxinate (Fluress)
response to bright light. Mydriatics can worsen glaucoma adds local anesthesia, making it useful for the identification
by impairing aqueous humor outflow and thereby increas- and removal of foreign bodies from the cornea.
ing IOP. In addition, strong concentrations of anticholiner-
gics have the potential to have systemic effects on the Local anesthetics are used to prevent the pain associated
central nervous system (CNS) and cause confusion, with diagnostic and surgical procedures, suturing and
unsteadiness, or drowsiness. Cycloplegics can cause severe removal of foreign bodies, and ocular injections. The drugs
blurred vision and loss of near vision. Scopolamine, an used include proparacaine (Alcaine, Ophthaine) and tetra-
anticholinergic often used to prevent motion sickness, can caine. Application consists of one to two drops applied to the
cause blurred vision due to cycloplegia, as well as angle- affected eye. Anesthesia typically occurs within 20 seconds
closure glaucoma attacks. The response to mydriatics and and lasts for 10 to 20 minutes. Adverse effects of their use
cycloplegics can last from 3 hours up to several days. The include local irritation, including conjunctivitis. Systemic
patient should be taught to wear sunglasses and that the effects are rarer, but CNS excitation has been known to occur.
ability to drive, read, and perform visual tasks may be The nurse must be careful to protect the patient’s eye from
affected during treatment. injury while anesthetized, or corneal damage may occur.
Table 74.2 Miscellaneous Drugs Used for the Eye
Drug Route and Adult Dose Adverse Effects
(Maximum Dose Where Indicated)
Mydriatics: Sympathomimetics Eye pain, photosensitivity, eye irritation,
1 drop of 2.5% or 10% solution before eye examination headache
phenylephrine (Mydfrin,
Neo-Synephrine)
Cycloplegics: Anticholinergics Uveitis: 1–2 drops of 1% solution up to 4 times daily; HTN, tremor, dysrhythmias
atropine (Isopto Atropine, others) also give 1–2 drops 1 h prior to eye examination
1 drop of 0.5–2% solution 40–50 min before eye examination Eye irritation and redness, dry mouth, local
cyclopentolate (Cyclogyl, Pentolair) 1–2 drops of 2% or 5% solution before eye examination burning or stinging, headache, blurred vision,
homatropine (Isopto Homatropine, Uveitis: 1–2 drops of 2–5% solution bid–tid up to q3–4h as needed photosensitivity, eczematoid dermatitis
others) 1–2 drops of 0.25% solution 1 h before eye examination (scopolamine and tropicamide)
scopolamine (Isopto Hyoscine) 1–2 drops of 0.5–1% solution before eye examination Somnolence, tachycardia, convulsions,
tropicamide (Mydriacyl, Tropicacyl) mental changes, keratitis, increased IOP
Anesthetics 2 drops of 3.5% gel in affected eye, reapplied as needed (homatropine)
lidocaine (Akten) 1 drop of 0.5% solution in affected eye q5–10min for 5–7 doses
proparacaine (Alcaine, Ophthaine) 1–2 drops of a 0.5% solution or 1.25–2.5 cm of ointment in the lower Stinging, corneal erosion, headache, slowed
tetracaine conjunctival sac healing of corneal abrasions
Anaphylactic reactions
Lubricants Apply a thin film to the inside of the eyelid
lanolin alcohol (Lacri-lube) 1–2 drops tid–qid prn Temporary burning or stinging, eye itching or
polyvinyl alcohol (Liquifilm, others) redness, headache
No serious adverse effects
Vasoconstrictors
Temporary burning or stinging, eye itching or
naphazoline (Albalon Allerest, Clear 1–3 drops of 0.1% solution q3–4h prn redness, headache
Eyes, others) No serious adverse effects
oxymetazoline (OcuClear, Visine LR) 1–2 drops of 0.025% solution qid
phenylephrine (Neo-Synephrine) 1–2 drops of 0.12% solution up to 4 times/day
tetrahydrozoline (Murine Plus, 1–2 drops of 0.05% solution bid–tid
Visine, others)
Note: Italics indicate common adverse effects. Underline indicates serious adverse effects.
Chapter 74 Pharmacotherapy of Eye and Ear Disorders 1401
CONNECTIONS: Community- discomfort. It is administered as one drop daily in each eye.
Oriented Practice Side effects are minor and include local irritation, dysgeu-
sia (distorted sense of taste), and decreased visual acuity.
Improper Eyedrop Administration
Minor eye irritation is a frequent condition that is often
Most adults will use eyedrops occasionally to treat dry eyes, treated with vasoconstrictors. Common vasoconstrictors
allergy conditions, or as a prescribed treatment for more seri- include phenylephrine (Neo-Synephrine), naphazoline
ous eye conditions. In a study of post–cataract surgery (Clear Eyes, others), and tetrahydrozoline (Murine Plus,
patients who did not regularly use eyedrops, An, Kasner, Visine, others). The adverse effects of the vasoconstrictors
Samek, and Lévesque (2014) found that less than 8% of are usually minor and include blurred vision, tearing,
patients self-administered eyedrops correctly. Despite only headache, and rebound vasodilation with redness.
31% of patients reporting difficulty with self-administration, the
most common problems observed were failure to wash hands Infection and inflammatory responses are common
before self-administration (78%), contaminating the bottle tip conditions in the supporting structures of the eye and may
(57.4%), missing the eye (31.5%), and instilling an incorrect result from foreign bodies, bacteria, or viruses. Allergies
number of drops (64%). The authors also found that self- and irritants such as tobacco smoke are also common
administration improved significantly after the patients were sources of inflammation. Redness, edema, and itching are
provided instruction in the proper instillation techniques. To common symptoms. The anti-infectives used to treat eye
improve therapeutic outcomes and patient safety, adequate infections are the same drugs used to treat infections in
patient education is vital. other areas of the body. Applied topically they carry the
common adverse effects of conjunctivitis and local skin and
Pharmacotherapy for Other eye irritation. Examples of eye infections that are treated
Eye Conditions with anti-infective medications include:
74.8 Numerous pharmacologic drugs are used • Blepharitis. Inflammation of the edges of the eyelids
to treat minor eye irritation and redness. that is commonly seen in older adults and those with
dry eyes.
Drugs for minor eye irritation and dryness come from a
broad range of classes. Some drugs lubricate only the eye’s • Conjunctivitis. Inflammation or infection of the lining
surface, whereas others are designed to penetrate and of the eyelids. Bacterial conjunctivitis is often caused
affect a specific area of the eye. by Staphylococcus aureus, Streptococcus pneumoniae, and
Haemophilus inf luenzae. Viral conjunctivitis is highly
Dry eye disease (or syndrome) is a condition in which contagious and treatment is symptomatic.
the patient secretes either an insufficient amount of tears or
poor quality tears. Common in older adults, this condition • Chalazion and styes. A chalazion is a lump or cyst
is worsened by certain medications such as decongestants along the edge of an eyelid. Hordeolum, or an external
or antihistamines, or by environmental conditions such as stye, is a blockage of the sebaceous glands at the base of
wind or dry climate. Long-term use of contact lenses and the eyelashes. A chalazion or hordeolum may become
refractive surgeries (Lasik) can decrease tear production. infected and require the use of ocular antibiotics.
Minor dry eye disease is treated with lubricants such • Keratitis. An inflammation of the cornea that may
as artificial tears. Artificial tear drugs are topical prepara- also be caused by trauma or dryness of the cornea
tions of methyl or vinyl cellulose. These drops can be from decreased lubrication. If left untreated, corneal
instilled as often as every hour. A wide variety of over-the- scarring with impaired vision may result.
counter (OTC) preparations are available, including eye-
drop solutions, ointments, and inserts. Nonsteroidal anti-inflammatory drugs (NSAIDs), such
as ketorolac (Acular, Acuvail), can be used to treat conjuncti-
Two prescription drugs are available to treat dry eye vitis and other inflammatory conditions. They are also used
disease. Cyclosporine ophthalmic emulsion (Restasis) to reduce inflammation postoperatively and the symptoms
stimulates the production of tears in patients whose tear associated with seasonal allergies. Topical corticosteroids are
production is suppressed by ocular inflammation. It is also very effective at reducing inflammation in the eye,
most effective when used in combination with artificial tear although they should not be administered if an infection is
replacement and is administered as one drop in the affected suspected. The most common adverse effects of topical cor-
eye(s) twice daily. Cyclosporine is presented as a prototype ticosteroids are cataracts, glaucoma, mydriasis, and ptosis.
immunosuppressant in Chapter 42. Cycloplegics can also be used to treat ocular pain caused by
almost any inflammatory condition, except glaucoma.
Approved in 2016, lifitegrast (Xiidra) is an ophthalmic
solution that blocks certain inflammatory cytokine interac- Several medications, including antihistamines, mast cell
tions on the surface of the eye. This reduces dry eye stabilizers, and combination antihistamine–mast cell stabi-
lizers, are used to decrease the redness and itching associ-
ated with allergic conjunctivitis. Systemic antihistamines
1402 Unit 11 Additional Drug Classes
Table 74.3 Drugs for the Treatment of Allergic Conjunctivitis
Drug Route and Adult Dose (Maximum Dose Where Indicated) Adverse Effects
Mast Cell Stabilizers
cromolyn (Crolom) 1–2 drops of 4% solution q4–6h Dry mouth, headache, nausea, sneezing, nasal
lodoxamide (Alomide) 1–2 drops of 0.1% solution qid symptoms, and transient eye stinging and burning
nedocromil (Alocril) 1–2 drops of 2% solution bid Bronchospasm, angioedema, anaphylaxis
Antihistamines
alcaftadine (Lastacaft) 1 drop of 0.25% solution once daily Fatigue, dizziness, dry mouth, headache,
azelastine (Optivar) 1 drop of 0.05% solution bid pharyngitis, cough, bitter taste, rhinitis
bepotastine (Bepreve) 1 drop of 1.5% solution bid No serious adverse effects
cetirizine (Zerviate) 1 drop of 0.24% solution bid
emedastine (Emadine) 1 drop of 0.05% solution qid
epinastine (Elestat) 1 drop of 0.05% solution bid
ketotifen (Alaway, Zaditor) 1 drop of 0.025% solution q8–12h
olopatadine (Patanol) 1 drop of 0.1% solution bid
Note: Italics indicate common adverse effects. Underline indicates serious adverse effects.
may be used but they may cause ocular dryness, which is the main organ of hearing, whereas the semicircular canals
could aggravate symptoms. Topical mast cell stabilizers, and vestibule are responsible for balance and equilibrium.
with or without an antihistamine, are the preferred treat-
ment for allergic conjunctivitis because they do not cause Pharmacotherapy with Otic
further drying of the eyes. Olopatadine (Patanol) and ketoti- Preparations
fen (Alaway, Zaditor) are combination antihistamine–mast
cell stabilizers. Ketotifen is available OTC. Drugs for the 74.10 Otic preparations treat infections,
treatment of allergic conjunctivitis are listed in Table 74.3. inflammation, and earwax buildup.
Anatomy of the Ear Otic medications commonly used to treat ear infections,
inflammation, and wax buildup are shown in Table 74.4.
74.9 Knowledge of basic ear anatomy is Otitis, or inflammation of the ear, is a common indication
fundamental to understanding ear disorders for pharmacotherapy. Otitis externa, commonly called
and pharmacotherapy. swimmer’s ear, is an inflammation with or without infec-
tion of the skin in the external auditory canal. The acute
The ear has two major sensory functions: hearing and form is bacterial in origin and most often due to Pseudomo-
maintenance of equilibrium and balance. The three struc- nas aeruginosa or S. aureus. It is associated with water expo-
tural areas of the ear—the external, middle, and inner sure, high humidity, and a history of ear trauma generally
ear—carry out these functions, as shown in Figure 74.3. from sharp or small objects. Chronic otitis externa is most
often caused by a fungal infection or an allergic response
The external ear consists of the pinna, which is the visible usually associated with cosmetics, hair products, or
portion of the ear, and the external auditory canal. The exter- devices placed within the ear canal. The typical presenta-
nal auditory canal transmits sound waves to the tympanic tion is that of acute-onset ear pain associated with pruri-
membrane, or eardrum. This canal is lined with numerous tus, swelling, and tenderness to the touch or with
ceruminous glands that protect the canal and help keep the movement. A greenish white drainage may accompany
tympanic membrane pliable. The tympanic membrane sepa- symptoms. Hearing impairment may result if the swelling
rates the external ear from the middle ear. The middle ear con- is sufficient to obstruct the auditory canal.
sists of a bony cavity containing the three ossicles, called the
malleus, incus, and stapes, that transmit sound waves to the Treatment of otitis externa focuses on reducing pain and
inner ear. The eustachian tube provides a connection between inflammation, usually with topical corticosteroids, antibiot-
the middle ear and the nasopharynx. It permits equalization ics, and analgesics, as needed. Neomycin, gentamicin, and
of pressure in the middle ear by allowing air to enter or leave ciprofloxacin (Cipro otic) are the most commonly used topi-
the middle ear cavity and for the drainage of secretions. Its cal otic antibiotics. Mild fungal infections can be treated with
mucosa is continuous with the mucosal lining of the throat, a 90% to 95% alcohol solution; more advanced disease may
providing a means for infectious organisms to enter the mid- be treated with topical 1% clotrimazole (Lotrimin) or tolnaf-
dle ear from the nose and throat. The inner ear consists of the tate (Tinactin). If swelling obstructs the external canal, an ear
semicircular canals, the vestibule, and the cochlea. The cochlea
Chapter 74 Pharmacotherapy of Eye and Ear Disorders 1403
External ear Middle ear Inner ear
Auricle
Semicircular
Malleus Vestibule canals
Incus
Cranial
nerve VIII
External Stapes Cochlea
auditory in oval
canal Tympanic window Round
window
membrane Eustachian
tube
Figure 74.3 Anatomy of the ear.
wick may be placed past the blockage and the drops applied Otitis media, which is inflammation of the middle ear,
to the end. The use of systemic antibiotics may be necessary is a common disorder that affects infants and young chil-
in cases when outer ear infections are extensive, such as with dren, although people of any age may be affected. Among
cellulitis or lymph node involvement. children 75% experience at least one episode of otitis media
by their third birthday, and almost half of these children will
PharmFACT have three or more ear infections during that time.
Otitis externa has a peak incidence of 7 to 12 years of age and There are three common types of otitis media: acute,
occurs most commonly in the summer months. Although chronic, and serous. Acute otitis media and chronic otitis
called swimmer’s ear, the condition may also be caused by media are similar. An infectious agent, most often a viral
cleaning and scratching the ear canal with cotton swabs or upper respiratory infection, results in pathogens being
paper clips (Waltzman, 2017). introduced into the middle ear through the eustachian
tube, leading to swelling and inflammation of the ossicles
Table 74.4 Otic Preparations
Drug Route and Adult Dose (Maximum Dose Where Indicated) Adverse Effects
3–5 drops q4h–qid for 24 h, then 5 drops tid–qid
acetic acid and hydrocortisone (Acetasol HC, Ear irritation, local stinging or
VoSoL HC) 1–5 drops of 6.5% solution bid for 4 days burning, dizziness
4 drops in the affected ear bid for 7 days
carbamide peroxide (Debrox) 3 drops of the suspension instilled into the affected ear bid for 7 days Allergic reactions (antibiotics)
5–10 drops in the affected ear once daily for 7 days
ciprofloxacin-dexamethasone (Ciprodex) 3–5 drops in the affected ear tid–qid
ciprofloxacin-hydrocortisone (Cipro HC)
ofloxacin (Floxin otic)
polymyxin B, neomycin, and hydrocortisone
(Cortisporin)
colistin, neomycin, thonzonium bromide and
hydrocortisone (Cortisporin TC)
Note: Italics indicate common adverse effects. Underline indicates serious adverse effects.
1404 Unit 11 Additional Drug Classes
of the middle ear. Bacterial infection with S. pneumoniae, Otitis media is treated with a course of systemic, rather
H. inf luenzae, and Streptococcus pyogenes causes most than topical, antibiotics. Amoxicillin, at a dose of 80 to
cases. Otitis media may also be associated with allergies 90 mg/kg/day, is prescribed for most children. For patients
or eustachian tube dysfunction. Acute otitis has a dura- who have symptoms of a more severe illness and in those
tion of less than 3 weeks; chronic otitis follows repeated for whom additional coverage for b-lactamase–positive
episodes and has a longer duration of symptoms. Some- H. influenzae and Moraxella catarrhalis is desired, therapy is
times the eardrum ruptures, and pus drains out of the initiated with high-dose amoxicillin-clavulanate. For
ear. More commonly, the pus and mucus remain in the patients with mild penicillin allergy, a cephalosporin may
middle ear due to the swollen and inflamed eustachian be considered. If the penicillin allergy is more severe,
tube. This is called middle ear effusion or serous otitis azithromycin or clarithromycin can be used. In the patient
media. After the acute infection has passed, the effusion who is vomiting or cannot otherwise tolerate oral medica-
may remain and become chronic, lasting for weeks, tion, a single dose of parenteral ceftriaxone has been shown
months, or even years. to be effective.
CONNECTIONS: Preparing for Advanced Practice
Otitis Media
Case • Tugging or pulling at one or both ears
• Fever
Aadila, a 3-year-old, is brought to the clinic by her mother • Purulent or bloody drainage from the ear
because she has been experiencing a low-grade fever of 38°C • Loss of balance
(100.5°F) for 2 days. The fever is accompanied by reports of left • Unresponsiveness to quiet sounds, or other signs of hearing
ear pain that has been awakening her. Both Aadila and her mom
look exhausted, and Aadila has been extremely fussy during the difficulty such as sitting too close to the television or being
visit. Mom tells you that Aadila has had upper respiratory infec- inattentive.
tion symptoms including rhinorrhea, nasal congestion, and a
nonproductive cough for 1 week, although the symptoms have The American Academy of Pediatrics and the American
started to resolve. She did not have any fever before the ear Academy of Family Physicians released an updated clinical
pain started. The child has had no changes in eating or elimina- practice guideline for the treatment of AOM in 2013 that high-
tion patterns. Mom has not tried any medications, but has been lights the causes of and treatment options for AOM (Lieberthal
putting warm compresses over the ear, which seems to relieve et al., 2013). The decision to place a patient on antibiotics or to
some pain. Aadila has no significant medical history and has observe is based on the child’s age, diagnostic certainty, and
had only one other ear infection when she was 9 months old. illness severity, remembering that viruses are the most common
She is fully immunized. Her temperature is 37.7°C (100°F). The cause of upper respiratory tract infection in children. Deferring
physical examination revealed the only abnormalities to be slight antibacterial treatment for children over 6 months of age with
redness of the throat, a nose full of thick green mucus, a pearly nonsevere illness for 48 to 72 hours and limiting management
gray right tympanic membrane with positive light reflex and visi- to symptomatic relief is appropriate. All children under 6 months
ble bony landmarks; an erythematous and bulging left tympanic of age should receive antibiotic therapy regardless of illness
membrane with diminished light reflex and bony landmarks not severity. Amoxicillin remains first-line therapy for children who
visualized. No drainage was observed and no pain on palpation have not received amoxicillin within the past 30 days.
of the mastoid bone was noted. Should Aadila be treated with Amoxicillin/clavulanate is recommended if amoxicillin has been
antibiotics? Should she be treated for pain management? taken within the past 30 days, if concurrent conjunctivitis is
present, or if the child has a history of recurrent AOM unrespon-
Discussion sive to amoxicillin.
The chief symptom of otitis media is ear pain with an accompa- Symptomatic pain management, especially during the first
nying sense of fullness in the ear. Headaches are common, 24 hours of an episode of AOM, should be part of the care plan,
along with malaise and nausea. The patient may experience tin- regardless of the use of antibiotics. Symptomatic relief involves
nitus or popping sounds when yawning or swallowing. Acute the use of analgesics, such as acetaminophen, or NSAIDs, such
otitis media (AOM) is often difficult to detect because most chil- as ibuprofen (for children over 6 months of age), to relieve pain
dren affected by this disorder do not yet have sufficient speech and reduce fever. Patients with severe pain may require therapy
and language skills to tell someone what is bothering them. with opioid analgesics such as codeine. A 7-day course of a cor-
Common signs include the following: ticosteroid is often combined with antibiotics when severe inflam-
mation is present. Antihistamines or decongestants may be used
• Unusual irritability to decrease mucus production and fluid levels in the middle ear
• Difficulty sleeping (Lieberthal et al., 2013).
Chapter 74 Pharmacotherapy of Eye and Ear Disorders 1405
Otitis interna, or labyrinthitis, is an inner ear infection Cerumen (earwax) softeners are also used for proper
that may occur as the result of chronic otitis media or as part ear health. When cerumen accumulates, it narrows the ear
of a viral systemic infection, including mononucleosis or an canal and may interfere with hearing. Cerumenolytics may
upper respiratory infection. Of all ear infections, otitis be needed to loosen and remove impacted cerumen from
interna is the most difficult to treat because the blood– the ear canal. Use of these agents usually involves the instil-
labyrinth barrier makes it difficult for systemic medications lation of an earwax softener and then a gentle lavage of the
to reach the affected areas. Mastoiditis, or inflammation of wax-impacted ear with tepid water using an irrigating
the mastoid sinus, is frequently the result of chronic or inad- syringe to gently insert the water. An instrument called an
equately treated bacterial otitis media or an otitis interna ear loop may be used to help remove earwax but should be
infection. The infection moves into the bone and surround- used only by healthcare providers who are skilled in using
ing structures of the ear. Symptoms of pain, hearing loss, it. There are three types of cerumen-softening preparations:
and tenderness typically appear 2 to 3 weeks after an epi- water based, oil based, and nonwater oil based. Water-
sode of otitis media. Mastoiditis can be a serious problem. If based preparations include solutions of triethanolamine,
left untreated, it can result in hearing loss. 3% hydrogen peroxide, 10% sodium bicarbonate, and saline
or water. The nonwater oil-based preparation available in
The treatment of acute mastoiditis involves aggressive the United States includes the OTC drug carbamide perox-
antibiotic therapy. IV gentamicin or ticarcillin may be used ide (Debrox). Oil-based preparations include household
initially. Therapy may be adjusted once culture and sensi- olive, mineral, and almond oils and commercially prepared
tivity results have been obtained. Therapy is continued for combinations, such as Cerumol, Earex, and Otocerol.
at least 14 days. If the antibiotics are not effective and Research has shown that the water-based and nonwater oil-
symptoms persist, surgery such as a mastoidectomy or based agents have equal effectiveness.
meatoplasty may be indicated.
CONNECTION: NURSING PRACTICE APPLICATION
Patients Receiving Pharmacotherapy for Otitis
Assessment
Baseline assessment prior to administration:
• Obtain a complete health history including neurologic disease.
• Assess hearing and balance. Obtain audiology screening as needed.
• Assess for history of recent infections, swimming, condition of external ear canal, presence of drainage, and tympanic membrane assessment.
• Obtain a drug history including allergies, current prescription and OTC drugs, herbal preparations, alcohol use, and smoking. Be alert to possible drug
interactions.
• Obtain baseline vital signs.
• Assess the patient’s ability to receive and understand instructions. Include family and caregivers as needed.
Assessment throughout administration:
• Assess for desired therapeutic effects (e.g., infection is clearing, or hearing is maintained).
• Assess for adverse effects: localized irritation or burning, dizziness, vertigo, nausea, or vomiting. Severe ear pain, increased drainage, fever, increasing
dizziness, vertigo, nausea, and vomiting should be immediately reported to the healthcare provider.
Implementation
Interventions and (Rationales) Patient-Centered Care
Ensuring therapeutic effects: • Instruct the patient to immediately report severe ear pain, increased
• Monitor hearing and balance. Obtain audiology screening periodically drainage, fever, increasing dizziness, vertigo, nausea, vomiting, or
tenderness in or around the ear to the healthcare provider.
as needed. (Hearing remains within the patient’s baseline assessment
parameters, no dizziness or vertigo is noted.)
Minimizing adverse effects: • Teach the patient the proper administration techniques for eardrops.
• Monitor appropriate administration of the drug to avoid adverse effects.
(Eardrops should be administered into the ear canal without dropping
the solution directly on the tympanic membrane, which may induce
vertigo.)
• Monitor hearing periodically in patients with chronic otitis with effusion. • Instruct the patient, family, or caregiver on the importance of returning
(Otitis media with effusion may lead to hearing loss and speech or for and maintaining regular hearing examinations.
language impairment, especially in young children.)
• Monitor balance and for changes in gait or ambulation. (Dizziness • Instruct the patient to immediately report any increasing dizziness or
or vertigo may cause intolerance to activity and increase the risk for vertigo. Assist the patient with ambulation if dizziness is present to
falls. Lifespan: Monitor older adults more frequently for dizziness prevent falls. If dizziness occurs at home, the patient should sit or lie
to prevent falls.) down and not attempt to stand or walk, until the sensation passes.
• Provide for ear comfort such as warm, moist compresses to the outer • Teach the patient to apply warm but not hot compresses to the
ear. (Warm, moist compresses to the outer ear may increase circulation external ear for approximately 15–20 min as needed for discomfort.
to the local area and ease ear discomfort.)
(continued )
1406 Unit 11 Additional Drug Classes
CONNECTIONS: NURSING PRACTICE APPLICATION (continued)
Implementation
Interventions and (Rationales) Patient-Centered Care
Patient understanding of drug therapy: • The patient should be able to state the reason for the drug, appropriate
• Use opportunities during administration of medications and during dose and scheduling, what adverse effects to observe for, and when to
report them.
assessments to discuss the rationale for the drug therapy, desired
therapeutic outcomes, commonly observed adverse effects,
parameters for when to call the healthcare provider, and any necessary
monitoring or precautions. (Using time during nursing care helps to
optimize and reinforce key teaching areas.)
Patient self-administration of drug therapy: • Teach the patient to take the drug following appropriate guidelines:
• When administering the medication, instruct the patient, family, or • Warm eardrop solution by placing in or under warm but not hot
water. The bottle may be placed in a plastic bag to protect the label
caregiver in proper self-administration, e.g., appropriate instillation of before warming. Never warm eardrops in the microwave.
eardrops, followed by teach-back. (Utilizing time during nurse • Have the patient lie supine with the ear to be treated uppermost.
administration of these drugs helps to reinforce teaching.) Gently pull the pinna down and back for children under age 3, up
and back for children over age 3, adolescents, and adults.
• Instill the number of drops ordered into the ear canal, taking care
not to drop the solution directly onto the eardrum but allowing it to
slide down the side of the ear canal.
• Gently massage the area in front of the ear (tragus) to promote
thorough administration of the drop unless pain is severe.
• Have the patient continue lying down for 5–10 min to ensure complete
absorption of the eardrop. A small piece of cotton may be placed at
the entrance to the ear canal if any solution returns upon arising.
Understanding Chapter 74
Key Concepts Summary 74.6 Carbonic anhydrase inhibitors and osmotic diuretics
are occasionally used for treating glaucoma.
74.1 Knowledge of basic eye anatomy is fundamental
to understanding eye disorders and their 74.7 Drugs that are routinely used for eye
pharmacotherapy. examinations include mydriatics, cycloplegics,
diagnostic dyes, and local anesthetics.
74.2 The two principal types of glaucoma, closed-
angle glaucoma and open-angle glaucoma, are 74.8 Numerous pharmacologic drugs are used to treat
characterized by increased intraocular pressure. minor eye irritation and redness.
74.3 The primary goal of glaucoma pharmacotherapy 74.9 Knowledge of basic ear anatomy is fundamental
is to prevent damage to the optic nerve by to understanding ear disorders and
lowering intraocular pressure. pharmacotherapy.
74.4 Prostaglandin analogs are the first-line drugs for 74.10 Otic preparations treat infections, inflammation,
treating high intraocular pressure because of their and earwax buildup.
long durations of action and high safety profiles.
74.5 Drugs that affect the autonomic nervous system
are sometimes prescribed to treat glaucoma.
CASE STUDY: Making the Patient Connection
Remember the patient “Therese Therese Duclos, a 65-year-old African American woman, vis-
Duclos” from the beginning of the its her ophthalmologist with reports of blurry vision and not
chapter? Now read the remainder being able to see well at night while driving. Her health his-
of the case study. Based on the tory includes adult-onset diabetes for the past 10 years and
information presented within this osteoporosis since age 55. Her medical regimen includes diet
chapter, respond to the critical control for the diabetes and Boniva monthly. She denies any
thinking questions that follow. injury to her eyes and last had an eye checkup 1 year ago.
Critical Thinking Questions Chapter 74 Pharmacotherapy of Eye and Ear Disorders 1407
1. What factors are present in Mrs. Duclos’s health his- 3. What would be possible effects from systemic absorp-
tory that you identify as predisposing conditions for tion if the patient were taking beta-adrenergic drops
the development of primary open-angle glaucoma? (e.g., timolol, carteolol)? Prostaglandin drops (e.g.,
latanoprost, bimatoprost)? Cholinergic agonists (e.g.,
2. Therese needs to learn the proper administration of carbachol, pilocarpine)?
eyedrops. What teaching would you provide to ensure
that the skill will be performed correctly? Answers to Critical Thinking Questions are available on the
faculty resources site. Please consult with your instructor.
Additional Case Study
Zachary, a 4-year-old boy, is experiencing pain in his right administration, the nurse will teach her about the proper
ear. His mother takes him to the healthcare provider and he technique. Create a patient information sheet for a parent
is diagnosed with otitis media. Zachary is prescribed cipro- who needs to administer eardrops.
floxacin with dexamethasone (Ciprodex) otic drops to be
instilled in his right ear twice a day for a week. To ensure Answers to Additional Case Study questions are available on
that the mother is knowledgeable in this form of the faculty resources site. Please consult with your instructor.
Chapter Review trabecular meshwork, allowing a greater outflow of
aqueous humor and lowering intraocular pressure.
1. The nurse is teaching a patient about a new eyedrop
prescription for timolol (Timoptic) for treatment of 4. The nurse is teaching a 25-year-old patient about the
open-angle glaucoma. The patient has a history of administration of ciprofloxacin with hydrocortisone
seasonal allergies and hypertension. What is an impor- (Cipro) for otitis. In which order will the nurse
tant administration technique to stress for this patient? instruct the patient to use the drug?
1. Take any eyedrops for allergies 5 minutes before 1. Gently massage the area in front of the ear.
administering the timolol drops. 2. Pull the earlobe upward and back.
3. Allow the drop to fall into the ear canal flowing
2. Do not use the timolol drops while concurrently
taking allergy medication. down the side.
4. Remain with the treated ear in an uppermost
3. The timolol drops may temporarily worsen
seasonal allergies. position for 5 minutes.
4. Gently put pressure on the inner canthus (tear 5. The nurse is teaching a patient with otitis about a pre-
duct) for 1 minute after instilling the timolol drop. scription for polymyxin B, neomycin, with hydrocor-
tisone (Cortisporin). The patient should be instructed
2. The nurse is providing health teaching to a patient to immediately report which symptom?
who has been prescribed latanoprost (Xalatan) for
open-angle glaucoma. While harmless, the nurse 1. Mild itching in the outer ear canal
would caution the patient about which potential 2. Gradually decreasing pain
nonocular effects of the drug? (Select all that apply.) 3. Slight dizziness after instilling the eardrop
4. Increasing pain, particularly in the area around the ear
1. Darkening and thickening of the upper eyelid
6. The nurse is instilling drops of phenylephrine (Neo-
2. Darkening and thickening of eyelashes Synephrine) into the patient’s eye before cataract sur-
gery. Phenylephrine is used prior to cataract surgery
3. A lightening of iris color and a slight darkening because it causes ________________, allowing visual-
of the sclera ization of the operative area.
4. A slight darkening of the iris color See Answers to Chapter Review in Appendix A.
5. A permanent bluish tint to the conjunctiva
3. Pilocarpine (Isopto Carpine) has been ordered for a
patient with closed-angle glaucoma who has not
responded well to other drugs. Pilocarpine causes
__________________________, which stretches the
1408 Unit 11 Additional Drug Classes
References Lieberthal, A. S., Carroll, A. E., Chonmaitree, T., Ganiats,
T. G., Hoberman, A., Jackson, M. A., . . . Tunkel, D. E.
An, J. A., Kasner, O., Samek, D. A., & Lévesque, V. (2014). (2013). The diagnosis and management of acute otitis
Evaluation of eyedrop administration by inexperienced media. Pediatrics, 131(3), e964–e999. doi:10.1542/
patients after cataract surgery. Journal of Cataract and peds.2012-3488
Refractive Surgery, 40, 1857–1861. doi:10.1016/j.
jcrs.2014.02.037 Waltzman, A. A. (2017). Otitis externa. Retrieved from
http://emedicine.medscape.com/article/
Glaucoma Research Foundation. (2017). Glaucoma facts and 994550-overview#a5
stats. Retrieved from http://www.glaucoma.org/
glaucoma/glaucoma-facts-and-stats.php
Selected Bibliography Schwartz, S. R., Magit, A. E., Rosenfeld, R. M.,
Ballachanda, B. B., Hackell, J. M., Krouse, H. J., . . .
Greco, A., Rizzo, M. I., De Virgilio, A., Gallo, A., Fusconi, Cunningham, E. R. (2017). Clinical practice guideline
M., & de Vincentiis, M. (2016). Emerging concepts in (update) earwax (cerumen impaction). Otolaryngology–
glaucoma and review of the literature. The American Head and Neck Surgery, 156(Suppl. 1), S1–S29.
Journal of Medicine, 129(9), 1000.e7–1000e13. doi:10.1177/0194599816671491
doi:10.1016/j.amjmed.2016.03.038
Stainsby, H. (2016). Management of patients with chronic
Harasymowycz, P., Birt, C., Gooi, P., Heckler, L., Hutnik, open angle glaucoma. Nursing Standard, 30(37), 52–60.
C., Jinapriya, D., . . . Day, R. (2016). Medical doi:10.7748/ns.30.37.52.s42
management of glaucoma in the 21st century from a
Canadian perspective. Journal of Ophthalmology, 2016, Ventocilla, M. (2017). Allergic conjunctivitis. Retrieved from
Art. ID 6509809. doi:10.1155/2016/6509809 http://emedicine.medscape.com/article/1191467-
overview#a4
Hayter, K. L. (2016). Listen up for safe ear irrigation.
Nursing2016, 46(6), 62–65. doi:10.1097/01.NURSE.
0000481437.02178.3b
“I don’t know if you can ever be
completely prepared, but that’s
why we keep practicing and
running drills. If something
occurs, we’ll be ready.”
Emergency department nurse “Carol Boler”
Chapter 75
Emergency Preparedness:
Bioterrorism and Management
of Poisoning
Chapter Outline Learning Outcomes
cc Emergency Preparedness, Bioterrorism, and Nursing After reading this chapter, the student should be able to:
cc Biologic Agents
1. Discuss the role of professional nursing in
Anthrax emergency preparedness and the management of
Botulism poisoning.
Pneumonic Plague
Tularemia 2. Discuss the purpose, function, and components of
Viruses the Strategic National Stockpile.
cc Chemical and Physical Agents
Chemical Toxins 3. Identify the types of agents that might be used for a
Ionizing Radiation bioterrorist attack.
cc Management of Poisoning
Drugs Used in the Management of Poisoning 4. Compare and contrast the various chemical agents
PROTOTYPE Activated Charcoal (CharcoAid), p. 1418 that can be used as poisons.
Ion Trapping
Chelating Drugs 5. Explain the risks associated with ionizing radiation
PROTOTYPE Edetate Calcium Disodium emitted from a nuclear terrorist attack.
(Calcium EDTA), p. 1419
PROTOTYPE Dimercaprol (BAL in Oil), p. 1419 6. Describe the five general principles of treating acute
poisoning.
7. Identify the drugs important in emergency
preparedness and management of poisoning.
8. Compare the pharmacologic management of
biologic, chemical, radiologic, nuclear, and explosive
agents in emergency preparedness.
9. Discuss the management of poisoning by the poison
control center, including minimizing poison
absorption and enhancing poison removal.
10. Apply the nursing process to the care of patients
receiving pharmacotherapy for poisoning or
overdose.
1409
1410 Unit 11 Additional Drug Classes
Key Terms emergency preparedness, 1410 Strategic National Stockpile
pneumonic plague, 1413 (SNS), 1412
anthrax, 1412 radiation sickness, 1415
bioterrorism, 1410 smallpox, 1414 tularemia, 1413
botulism, 1413
chelation therapy, 1419
Emergency preparedness is the ability to respond swiftly at an all-time high. Healthcare providers must continually
and effectively to an unexpected event that may impact update their knowledge of emergency management and
human health. The unexpected event may be a natural think more globally in dealing with patients whose illness
disaster caused by severe weather, an unintentional chemi- presents in a less typical way. Knowledge of treatment
cal spill, or a purposeful terrorist attack on the public. modalities related to bioterrorism has become a basic com-
Nurses have an essential role in assessing and recognizing petency required of all healthcare providers.
poisoning and taking appropriate interventions to save
lives. Sometimes, specific drugs are necessary to counter 75.2 Bioterrorism is the intentional release of a
the effects of biologic hazards and minimize the loss of life virus or microorganism to cause human harm.
in emergency situations. This chapter focuses on the role of
pharmacology in emergency preparedness as related to The past two decades have brought the acts and effects of
bioterrorism and management of poisoning. terrorism to the forefront of discussion in this and other
countries. Terrorism is generally defined as the systematic
Emergency Preparedness, use of terror, violence, or intimidation to achieve a desired
Bioterrorism, and Nursing purpose or end. The U.S. Federal Criminal Code describes
terrorism as activities that involve life-threatening acts
75.1 Emergency preparedness has become intended to coerce or intimidate a given population. Ter-
an essential competency for all healthcare rorists use chemical, nuclear, radiologic, explosive, or bio-
professionals. logic hazards to commit violent and intimidating crimes
against general and special targeted populations.
Emergency preparedness has been an emerging role of
professional nursing for many years. In the past, however, Bioterrorism is the intentional release of an infectious
most training focused on emergency management for nat- agent for the purpose of causing harm to a large number of
ural disasters, catastrophic incidents, or infectious epidem- people. In the United States, governmental agencies such
ics. Often nurses responded to victims at the location of the as the Centers for Disease Control and Prevention (CDC)
disaster or incident. Today, nurses must learn how to and the Department of Defense provide education to pre-
respond to mass casualty incidents and potential disasters pare the general public for possible bioterrorism events. In
that can result from agents that are biologic, chemical, the wrong hands, simple and easily obtained toxic agents
radiologic, nuclear, or explosive in nature. Standard emer- could be disseminated for public harm. However, of great-
gency triage may be reversed, focusing on patients with est concern is the use of highly infectious diseases such as
the best chance to live. anthrax, smallpox, hemorrhagic viruses, and plague, or
toxic agents such as nerve gas, cyanide, and chlorinated
Nurses may be among the first responders to victims agents as well as nuclear and radiation threats. Table 75.1
who arrive at emergency departments (EDs), clinics, provides the CDC list of biologic threats and their potential
healthcare provider offices, or school health settings. They impact on the health of the general public.
must be prepared to assess and recognize when someone
has been exposed to potential hazards and to take appro- 75.3 Nurses may have the first opportunity to
priate actions. Failure to do so could lead to an epidemic or recognize and initiate a response to bioterrorism.
major loss of life. Examples include patients who present to
the healthcare setting with symptoms of anthrax, avian flu, Nursing has a rich history in emergency preparedness. Flor-
or severe acute respiratory syndrome (SARS). ence Nightingale began defining the role of nursing in
emergency preparedness as early as the Crimean War.
Since the terrorist attacks of September 11, 2001, Amer- Throughout many wars and disasters, nurses have honed
icans are more concerned with threats of terrorism and are their assessment and critical care skills to support people in
more aware of emergency preparedness than ever before. need and improve healthcare outcomes. The Civil War was
Increased efforts to safeguard the general populace remain a time when nurses worked together with leaders like Clara
Chapter 75 Emergency Preparedness: Bioterrorism and Management of Poisoning 1411
Table 75.1 Categories of Infectious Agents
Category Description Examples
A Agents that pose a significant risk to national security because Anthrax (Bacillus anthracis)
they Botulism (Clostridium botulinum toxin)
• can easily be disseminated or transmitted person to person; Plague (Yersinia pestis)
• r esult in high mortality rates with potential for major public Smallpox (Variola major)
health impact; Tularemia (Francisella tularensis)
Viral hemorrhagic fevers such as Marburg, Ebola, Lassa, and Machupo
• might cause public panic and social disruption; and
• require special action for public health preparedness.
B Second highest priority agents include those that Brucellosis (Brucella species)
• are moderately easy to disseminate; Epsilon toxin of Clostridium perfringens
• result in moderate morbidity and low mortality rates; and Food safety threats such as salmonella, Shigella, and Escherichia coli
• require specific enhancements of CDC’s diagnostic capacity Glanders (Burkholderia mallei)
and enhanced disease surveillance. Melioidosis (Burkholderia pseudomallei)
Psittacosis (Chlamydia psittaci)
Q fever (Coxiella burnetii)
Ricin toxin from Ricinus communis
Staphylococcal enterotoxin B
Typhus fever (Rickettsia prowazekii)
Viral encephalitis
Water safety threats such as Vibrio cholerae and Cryptosporidium parvum
C Third highest priority agents include emerging pathogens that could Hantaviruses
be engineered for mass dissemination in the future because of Nipah virus (NiV)
• availability;
• ease of production and dissemination; and
• potential for high morbidity and high mortality rates and major
health impact.
From Emergency Preparedness & Response: Bioterrorism Agents/Diseases, CDC, n.d. Retrieved from https://fas.org/biosecurity/resource/documents/CDC_Bioterrorism_Agents.pdf.
Barton to establish the American Red Cross, with nursing situation and victims of an MCI and to have the technical
becoming a special service in 1909. In World War II, nurses and communication skills required to function as an effec-
became a defined group within the military, and the Cadet tive member of the response team. Under technical skills,
Nurse Corps was established. These wartime nurses learned nurses must demonstrate safe administration of medications
triage, provided trauma care, and administered penicillin to and immunizations and have knowledge of nursing inter-
save many lives. Nurses have played a major role in provid- ventions for adverse medication events. This is but one area
ing emergency assistance in natural disasters such as earth- of professional nursing practice where knowledge of phar-
quakes, tornados, hurricanes, floods, and tsunamis. The macology is important to nursing emergency preparedness.
challenges have now expanded to include bioterrorism, tox-
ins, radiation, and mass casualty emergencies. For more than 30 years The Joint Commission has
required accredited hospitals to meet standards in disaster
Today emergency preparedness has come to the fore- planning. In the late 1990s, The Joint Commission added
front of professional nursing practice. Established through standards that address possible bioterrorism and emer-
a grant in 2004 in collaboration with the U.S. Department of gency management. State and federal agencies have devel-
Homeland Security, the National Nurse Emergency Pre- oped updated emergency preparedness plans that include
paredness Initiative (NNEPI) advances the education and bioterrorism. Nurses are part of the collaborative devel-
policy related to emergency preparedness for professional oped by healthcare professionals to respond immediately
nurses. to a community emergency. Key roles for nurses include
education, resources, referrals, diagnosis, treatment, and
In 2001, the International Nursing Coalition for Mass planning. Pharmacology for emergency preparedness has a
Casualty Education was established, defining emergency role in each of these.
preparedness competencies for registered nurses respond-
ing to mass casualty incidents (MCIs). Now known as the 75.4 The Strategic National Stockpile has large
Nursing Emergency Preparedness Education Coalition quantities of medicine to protect the public if a
(NEPEC), the coalition identified a set of general core com- health emergency arises.
petencies that provides guidelines for the role of profes-
sional nurses in responding to MCIs. Competencies When a health emergency such as a biologic or chemical
identified included the ability to adequately assess the attack, flu outbreak, or earthquake occurs, the response
1412 Unit 11 Additional Drug Classes
must be rapid to minimize health consequences and pro- Although microbiologist Robert Koch confirmed the bacte-
tect the American public. Due to the unexpected nature of rial nature of anthrax in 1876, anthrax has plagued the
such an incident, shortages in medical supplies, equip- world for many centuries, even in biblical times. Anthrax
ment, and drugs may occur. The Strategic National Stock- infection is found among hoofed animals such as cattle,
pile (SNS) is a national repository of antibiotics, chemical sheep, goats, pigs, bison, antelopes, and elephants. It was
antidotes, antitoxins, antiviral drugs, life support medica- recognized as a potential biologic weapon in World War I,
tions, intravenous (IV) administration equipment, airway and several countries were suspected of experimenting
maintenance supplies, and surgical material for use in a with its use as a weapon in World War II. In 1995, Iraq
declared biologic or terrorism incident or other major admitted producing anthrax as a biologic weapon. U.S.
health emergency. The CDC manages the SNS to ensure military personnel were vaccinated before deployment to
immediate availability and deployment of essentials to the Gulf War areas.
any state. These antibiotics, vaccines, and medical supplies
are free to the population affected by the adverse event. In the fall of 2001, following the terrorist attacks on the
World Trade Center, five people died from exposure to
One of the two components of the SNS is a Push Pack- anthrax in what most believe were purposeful acts of bio-
age, which includes preassembled caches of drugs, anti- terrorism. In total, 19 confirmed and 4 suspected cases
dotes, and medical supplies that broadly cover a nonspecific occurred across the United States in Connecticut, Florida,
emergency for use in early hours. Stored strategically, Maryland, New Jersey, New York, Pennsylvania, Virginia,
deployment can be accomplished within 12 hours. The SNS and the District of Columbia. Over 32,000 people were
program ensures that the medical materials stock is rotated treated for possible exposure, many of whom were postal
and kept within potency shelf-life limits. The second com- workers, between October 8 and November 9, 2001. Lives
ponent is vendor-managed inventory (VMI) packages that were lost, government workers and U.S. citizens were criti-
contain additional supplies that can be more event specific cally threatened, and agency operations such as the U.S.
and ship within 24 to 36 hours. This plan is designed to Postal Service were interrupted for weeks.
minimize local hospital stockpiling of bioterrorism phar-
maceuticals that have expiration dates and can be costly. Anthrax poisoning can occur by ingestion, absorption
through an open wound on the skin, or inhalation, which is
Parts of the SNS were deployed for relatively recent the most dangerous route. The method of transmission
health threats. In 2005, SNS response teams were sent to affects the symptoms demonstrated. Table 75.2 summa-
support state efforts in responding to hurricanes Rita and rizes the clinical picture of anthrax. Anthrax infects by
Katrina on the Gulf Coast. Part of the SNS antiviral inven- releasing two toxins, edema toxin and lethal toxin. Both
tory was used to help state efforts to control the H1N1 cause necrosis and exudate accumulation and symptoms
swine influenza outbreak in 2009. such as pain, edema, and restricted activity. The anthrax-
binding receptor binds with a human cell, allowing the
Biologic Agents bacterial toxins to enter. Anthrax produces heat and chemi-
cally resistant spores, which can remain viable in soil for
75.5 Highly infectious bacteria or viruses could many years. These are dangerous because they have the
be used as bioterrorist threats. potential for inhalation infection for humans. Left
untreated, inhalation anthrax is usually deadly. In the
The U.S. government takes the threat of bioterrorism seri- anthrax attacks in the United States in fall 2001, anthrax
ously and has implemented a program to prepare the pub- was delivered as a fine powder. This form of anthrax is eas-
lic for such catastrophes. Six biologic agents are considered ily inhaled and adheres to almost any surface.
category A threats (see Table 75.1), meaning they could
cause enough mortality and morbidity damage to interfere Several drugs can be used to treat anthrax. Ciprofloxa-
with the social functioning of a large city or populated cin (Cipro) is the primary antibiotic used with a prophy-
area. These six threats are anthrax, botulism toxin, pneu- laxis oral (PO) dose of 500 mg every 12 hours for 60 days. If
monic plague, smallpox, tularemia, and viral hemorrhagic anthrax exposure is confirmed, the patient is immediately
fevers. Knowing the agents most likely to be used in a ter- administered IV treatment with 400 mg every 12 hours.
rorist event allows the professional nurse to plan and to Anthrax can also be treated with other antibiotics such as
prepare for emergencies of this nature. The nurse can be an penicillin, ampicillin, vancomycin, erythromycin, tetracy-
effective member of the emergency team who is respond- cline, and doxycycline. Inhalation anthrax exposure may
ing to the widespread panic and life-threatening illnesses necessitate the combined use of ciprofloxacin and doxycy-
caused by an attack of bioterrorism. cline but must be done immediately to avoid death. The
public should be discouraged from seeking the prophylac-
Anthrax is an acute infectious disease that results from tic use of antibiotics in cases where anthrax exposure has
exposure to the spore-forming bacterium Bacillus anthracis. not been confirmed. Indiscriminate, unnecessary use of
The spore produces a toxin that can be fatal to the host. antibiotics can be expensive, can cause significant adverse
Chapter 75 Emergency Preparedness: Bioterrorism and Management of Poisoning 1413
Table 75.2 Clinical Manifestations of Anthrax
Type Description Symptoms
Cutaneous anthrax Most common but least complicated form of anthrax; almost always Small skin lesions develop and turn into black scabs;
curable if treated within the first few weeks of exposure; results from inoculation takes less than 1 wk; cannot be spread by
Gastrointestinal anthrax direct contact of contaminated products with an open wound or cut person-to-person contact
Inhalation anthrax
Rare form of anthrax; without treatment, can be lethal in up to 50% of Sore throat, difficulty swallowing, cramping, diarrhea,
cases; results from eating anthrax-contaminated food, usually meat and abdominal swelling
Least common but the most dangerous form of anthrax; can be Initially, fatigue and fever for several days, followed by
successfully treated if identified within the first few days after exposure; persistent cough and shortness of breath; without
results from inhaling anthrax spores treatment, death can result within 4–6 days
effects, and can promote the appearance of resistant bacte- preventing the disease. Until these issues are resolved, the
rial strains. A prototype feature for ciprofloxacin can be use of anthrax immunization will likely remain limited to
found in Chapter 49. select groups. Vaccines and the immune response are dis-
cussed in more detail in Chapter 43.
Two newer medications have been developed to treat
inhalation anthrax. In 2015, the U.S. Food and Drug Admin- Botulism is caused by Clostridium botulinum, an organ-
istration (FDA) approved Anthrasil, an immune globulin ism that secretes a potent toxin that paralyzes the muscles
preparation prepared from the plasma of people vacci- after an individual is poisoned. Respiratory failure and
nated against anthrax. The globulin preparation contains paralysis may force a patient to be on a ventilator for weeks
antibodies that neutralize toxins produced by the anthrax or months. As a biologic weapon, botulism could be trans-
bacteria. Anthrasil carries a black box warning that throm- mitted in air, food, or water. Treatment includes immediate
bosis may occur when using immune globulin products. In administration of an antitoxin and assisted ventilation until
2016, the FDA approved obiltoxaximab (Anthim), the first patients are able to function independently. The antitoxin
monoclonal antibody for treating anthrax. Obiltoxaximab should be given as soon as possible and never delayed
neutralizes toxins secreted by the anthrax bacteria. The pending the microbiologic testing. Trivalent botulinum
drug carries a black box warning that it may cause hyper- antitoxin is available through state departments of health
sensitivity reactions, including anaphylaxis. Neither or the CDC. A pentavalent toxoid vaccine for botulism pro-
Anthrasil nor Anthim have antibacterial activity; therefore, phylaxis is available as an investigation drug through the
they must be used in combination with antibacterial drugs. Department of Defense.
CONNECTION Checkpoint 75.1 Pneumonic plague is a life-threatening infectious lung
disease that occurs after breathing Yersinia pestis, a bacte-
From what you learned in Chapter 49, name the antibiotic class to rium found on rodents and their fleas that is responsible for
which ciprofloxacin belongs and describe its mechanism of bacte- the bubonic plague. It is highly contagious and can be
riocidal action. Answers to Connection Checkpoint questions are deadly if untreated within 24 hours of contact. As a biologic
available on the faculty resources site. Please consult with your agent, Y. pestis could be spread by aerosol over the popula-
instructor. tion. Within 1 to 6 days of exposure, the patient would be
infectious to everyone he or she has come in contact with
Although anthrax immunization was approved by the during that time. This makes the plague difficult to contain.
FDA 30 years ago, it has not been widely used because of Symptoms include fever and weakness, rapid develop-
the extremely low incidence of this disease in the United ment of pneumonia, chest pain with shortness of breath,
States. The vaccine is effective only if given prior to expo- cough, and bloody sputum. Without immediate treatment,
sure. The anthrax vaccine causes the body to make protec- respiratory failure will result followed by shock and death.
tive antibodies, thus preventing the onset of disease and its Treatment with antibiotics must occur within 24 hours and
symptoms. Immunization for anthrax consists of 5 subcu- last for at least 7 days to prevent death from the infection.
taneous doses given over 18 months. Annual booster injec- The primary antibiotic for Y. pestis infection is doxycycline
tions of the vaccine are recommended. At this time, the 100 mg twice a day or ciprofloxacin 500 mg twice a day for
CDC recommends vaccination for only select populations 7 days. There is no vaccine approved in the United States
who might be exposed to large amounts of anthrax on the for this bacterium at the present time.
job. This includes certain laboratory or remediation work-
ers, some military personnel, and those handling animals Caused by the organism Francisella tularensis, tulare-
or animal products (CDC, 2017). mia is a serious infectious disease found in rodents, rabbits,
and hares. Cases have been reported in almost every state,
Controversy is ongoing regarding the safety of the although overall the infection is rare in the United States.
anthrax vaccine and whether it is truly effective in F. tularensis is one of the most infectious bacteria known
1414 Unit 11 Additional Drug Classes
and survives at low temperatures for weeks in hay, straw, work with these hemorrhagic fever viruses, which are con-
moist soil, or in the bodies of decaying animals. As a bio- sidered a biosafety level 4. This class consists of exotic
logic weapon the most casualties would be with aerosol agents that can be transmitted by aerosol and pose a high
release in an area of high population, causing hemorrhagic risk of life-threatening disease.
inflammation of the respiratory airway. Treatment includes
IV therapy with streptomycin as the preferred drug, with Chemical and Physical Agents
parenteral gentamicin being an alternative. Aminoglyco-
sides should be used for 10 days. Tetracyclines and chlor- 75.6 There are 13 categories of toxic chemicals
amphenicol can be used for at least 14 days but have a that could cause mass casualties if released into
higher rate of relapse and treatment failure. In mass casu- the environment.
alty incidents, oral doxycycline for 14 to 21 days and cipro-
floxacin for 10 days are preferred for adults and children. Chemical warfare agents have been used since World War I,
Antibiotics for treating tularemia are included in the SNS. but few drug antidotes exist today. Many treatments pro-
An attenuated (live) vaccine is available as an investiga- vide minimal help other than to relieve some symptoms
tional drug and is under review by the FDA. and provide comfort following exposure. Whether a chemi-
cal is released by terrorists, enemy military, or by industry
A major viral biologic threat is the variola virus, better in a chemical release accident the result is the same: A haz-
known as smallpox. This serious, contagious disease is ardous chemical is released into the environment that may
fatal in up to 30% of cases. Although believed to be eradi- harm the health of the public. The CDC has classified haz-
cated, with the last case in the United States occurring in ardous chemicals into the following categories:
1949 and in Somalia in 1977, the virus may still be stock-
piled in laboratories across the world for use as a biologic • Biotoxins. Poisons from plants or animals
weapon. Generally, personal contact is needed to spread • Vesicants and blister agents. Agents that severely
this disease, but only a few viral droplets spread through
the air or on contaminated objects are needed to produce blister the skin, respiratory tract, or eyes on contact
the disease. Humans are the only carriers. Unvaccinated • Blood agents. Poisons that are absorbed into the
populations are at risk.
circulation
Vaccination is the only known treatment for smallpox. • Acids and caustics. Chemicals that burn the eyes,
The vaccination gives immunity for 3 to 5 years and is
effective if given prior to exposure to the virus or up to skin, or lining of the respiratory tract on contact
3 days postexposure. Smallpox vaccinations are contraindi- • Pulmonary and choking agents. Chemicals that irri-
cated for certain groups such as pregnant or lactating
women; children under 1 year old; people with impaired tate the lungs and cause swelling and choking
immune systems, such as those with human immunodefi- • Incapacitating agents. Chemicals that alter conscious-
ciency virus (HIV) or leukemia; people with atopic derma-
titis or eczema; or anyone with an allergy to a component ness, making it difficult for the patient to think clearly
in the vaccine. Although serious adverse effects are very • Long-acting anticoagulants. Chemicals that produce
rare, vaccines can cause death. A mutation in the virus
would render the vaccine ineffective, so mass vaccinations uncontrolled bleeding by preventing clotting
for smallpox are not considered prudent at this time. Peo- • Metals. Agents that are metallic poisons
ple at risk such as law enforcement, healthcare profession- • Nerve agents. Poisons that impair nervous system
als, or military personnel might need vaccination if exposed
to the virus. The U.S. government maintains enough vac- functioning
cinations for the public in the event of an outbreak. • Organic solvents. Chemicals that damage living tis-
Viral hemorrhagic fevers, which are caused by a num- sue by dissolving fats and oils
ber of virus families, can cause severe physical damage • Tear gas or mace. Agents used for riot or crowd
affecting multiple organ systems. Usually these viruses
damage the circulatory system, resulting in hemorrhage. control by law enforcement or for self-defense;
The host can be the cotton rat and deer mouse but some, irritate the eyes and the respiratory tract, resulting in
such as Ebola or Marburg, have unknown hosts. There is incapacitation
no cure or vaccine for these viruses and patients are treated • Toxic alcohols. Chemicals that damage vital organs
with supportive therapy, such as fluid and electrolytes, and such as the heart, kidneys, and nervous system
management of complications. Ribavirin is an antiviral • Vomiting agents. Chemicals that induce nausea and
drug that has shown some success in treating Lassa fever. vomiting.
CDC researchers in the Viral Special Pathogens Branch
Table 75.3 lists well-known chemical agents and their
symptoms and treatments. The primary chemical hazards
related to pharmacology are nerve agents. Individuals who
breathe nerve gas experience convulsions and loss of con-
sciousness, which result in respiratory failure within min-
utes. The antidote for nerve gas is the anticholinergic drug
atropine.
Chapter 75 Emergency Preparedness: Bioterrorism and Management of Poisoning 1415
Table 75.3 Chemical Agents and Treatments
Agent Signs and Symptoms Decontamination Persistence
Nerve Agents
Tabun (GA) Salivation Remove contaminated clothing. 1–2 days if heavy concentration
Sarin (GB) Lacrimation
Soman (GD) Urination Flush with a soap and water solution for 1–2 days will evaporate with water
V agents (VX) Defecation patients.
Gastric disturbances Moderate, 1–2 days
Emesis Flush with large amounts of a 5% bleach
and water solution for objects. High, 1 wk if heavy concentration; as
volatile as motor oil
Vesicants (Blister Agents)
Sulfur mustard (H) Acts first as a cell irritant, then as a Remove contaminated clothing. Very high, days to weeks
Distilled mustard (HD) cell poison. Conjunctivitis, reddened
Nitrogen mustard (HN 1,3) skin, blisters, nasal irritation, Flush with soap and water solution for Moderate
Mustargen (HN 2) inflammation of throat and lungs. patients. Days, rapid hydrolysis with humidity
Lewisite (L)
Immediate pain with blisters later. Flush with large amounts of a 5% bleach
and water solution for objects.
Phosgene oxime (CX) Immediate pain with blisters later— Low, 2 h in soil
necrosis equivalent to second- and
third-degree burns.
Chemical Asphyxiants (Blood Agents)
Hydrogen cyanide (AC) Cherry red skin or ~30% cyanosis. Remove contaminated clothing. Extremely volatile, 1–2 days
Cyanogen chloride (CK) Patients may appear to be gasping Rapidly evaporates and disperses
Arsine (SA) for air. Seizures prior to death. Effect Flush with a soap and water solution for Low
is similar to asphyxiation but is more patients.
sudden.
Flush with large amounts of 5% bleach
and water solution for objects.
From Biological and Chemical Agent Quick Reference Tables, Edgewood Chemical Biological Center, n.d. Retrieved from http://www.ecbc.army.mil/hld/ip/bca_qr.htm.
75.7 Ionizing radiation produces immediate 4 to 6 cases per million people to 45 cases per million. If
and long-term effects on human tissue. taken prior to, or immediately following, a nuclear inci-
dent, KI can prevent up to 100% of the radioactive iodine
Bioterrorists may use nuclear bombs or attack nuclear from entering the thyroid gland. It is effective even if taken
facilities that could cause mass casualty deaths at the point 3 to 4 hours after radiation exposure. Generally, a single
of impact and create residual ionizing radiation for miles 130-mg dose is necessary for adults.
around the site. Some radioisotopes emit radiation for
decades and even centuries. Smaller scale radiation could Unfortunately, KI protects only the thyroid gland from
occur with the release of solid or liquid nuclear material 131I. It has no protective effects on other body tissues, and it
into public areas or a dirty bomb, which explodes with offers no protection against the dozens of other harmful
radioactive powder or pellets, contaminating the area. radioisotopes generated by a nuclear explosion. As with
vaccines and antibiotics, the stockpiling of KI by local
Radiation sickness occurs after exposure to ionizing healthcare agencies or individuals is not recommended.
radiation and can last from hours to days. Initial symp-
toms include nausea, vomiting, and diarrhea with later CONNECTION Checkpoint 75.2
symptoms of weight loss, anorexia, fatigue, and suppres-
sion of the bone marrow. When exposed to large amounts From what you learned in Chapter 67, describe the therapeutic use
of radiation or to small amounts over many decades, of 131I in treating thyroid disease. Answers to Connection Checkpoint
patients tend to develop certain malignancies such as leu- questions are available on the faculty resources site. Please consult with
kemia or thyroid cancer. your instructor.
Except for supportive therapies, the only recognized PharmFACT
treatment available to counter the thyroid uptake of radia-
tion is ingestion of potassium iodine (KI) before or immedi- The most serious nuclear incident in the United States
ately after exposure. One of the radioisotopes produced by occurred at the Three Mile Island nuclear plant in Pennsylvania
a nuclear explosion is iodine-131 (131I). Because iodine is in 1979. No injuries or deaths occurred and the average
naturally concentrated in the thyroid gland, 131I will imme- estimated dose of radiation to the public around the plant was
diately enter the thyroid and damage thyroid cells. For 1 millirem, which is an amount equivalent to one sixth of a
example, following the Chernobyl nuclear disaster, the chest x-ray (U.S. Nuclear Regulatory Commission, 2014).
incidence of thyroid cancer in the Ukraine jumped from
1416 Unit 11 Additional Drug Classes
Management of Poisoning curious minds who put strange substances into their
mouths. Most poisonings present with low levels of toxic-
75.8 The general management of poisoning ity, but some can result in fatalities, such as the ingestion of
includes contacting the poison control center or gun-bluing agents used to maintain the color of gun bar-
emergency medical services as soon as possible. rels. Signs and symptoms of ingested poisons include
abdominal cramping or stomach pain, nausea, vomiting,
Virtually any chemical may cause poisoning if taken in diarrhea, sleepiness or loss of consciousness, bottles or con-
excessive amounts. The body has a remarkable capacity to tainers of poisons close by, or odor, stains, or burns around
tolerate a wide variety of chemicals and has physiologic the mouth.
mechanisms to detoxify and rapidly eliminate many of
them. Toxicity results when the body’s detoxification and Poisoning from medications may be unintentional or
excretion abilities are exceeded. Toxic effects may appear intentional (suicide). Acetaminophen is a common toxin
immediately or they may appear decades after the initial because so many analgesic medications contain this drug.
exposure. Although legal for adults, alcohol is a potential poison and
its abuse is a major health problem in the United States.
PharmFACT Ingestion of alcohol, along with certain prescribed medica-
tions, amphetamines, hallucinogens, or inhaled substances
During the past decade, as the death rates for the top leading such as solvents or glue can create life-threatening situa-
causes of death, such as heart disease and cancer, have tions. Symptoms of drug overdose include confusion, ele-
substantially decreased, the death rate associated with opioid vated heart rate, drowsiness, enlarged or dilated pupils,
pain medication has increased. From 1999 to 2014, more and hallucinations. Other medications that cause frequent
than 165,000 people in the United States have died from poisonings include iron, calcium channel blockers, and tri-
overdoses related to opioid pain medication (Dowell, cyclic antidepressants.
Hagerich, & Chou, 2016).
When a specific antidote is available, it is administered
Medications are the most frequently involved sub- as soon as the poisoning is diagnosed (Table 75.4). In the
stances in poisonings for all age groups. Household clean- vast majority of poisoning cases, there is no specific anti-
ing compounds comprise a second large group of dote. General therapies such as activated charcoal, perito-
poisonings, with cosmetics being close behind. Although neal dialysis, hemodialysis, and gastric lavage have only
exposure to poisons may occur by any route, ingestion limited effectiveness. In some cases, they are totally ineffec-
accounts for over 75% of all poisoning cases. Swallowing tive. Emergency physicians and nurses are generally faced
dangerous substances is common among children with with treating individual symptoms either because the poi-
son is unknown or because there is no antidote. The
Table 75.4 Specific Antidotes Antidote
Poison acetylcysteine (Cetylev, Mucomyst)
physostigmine (Antilirium)
acetaminophen flumazenil (Romazicon)
anticholinergic drugs glucagon
benzodiazepines calcium, IV insulin in high doses with IV glucose
beta-adrenergic blockers atropine, pralidoxime (Protopam)
calcium channel blockers digoxin immune Fab (Digibind)
carbamates ethanol, fomepizole (Antizol)
digoxin (Lanoxin) chelating drugs
ethylene glycol (antifreeze, brake fluid, coolants) deferoxamine (Desferal)
heavy metals pyridoxine (vitamin B6)
iron ethanol, fomepizole (Antizol)
isoniazid (INH) methylene blue
methanol
methemoglobin-forming drugs (some local anesthetics, nitrates, nitrites, naloxone (Narcan)
phenacetin, sulfonamides) atropine, pralidoxime (Protopam)
opioids sodium bicarbonate
organophosphates
tricyclic antidepressants
Chapter 75 Emergency Preparedness: Bioterrorism and Management of Poisoning 1417
strategy for treatment of acute poisoning consists of five • Provide fresh air to the individual if the poison was
general principles: inhaled.
• Topical decontamination. Removal of contaminated • Remove contaminated clothes if the poison came in
clothing, flushing of the skin or eyes contact with the individual’s skin. Take care not to
spread contamination from the poisoned clothes to the
• Prevention of absorption. Administration of adsor- surrounding environment. Flush the skin with water
bents (activated charcoal), whole-bowel irrigation, for 15 to 20 minutes to dilute or remove the poison.
induction of vomiting, and gastric lavage
• Rinse the eyes with running water for 15 to 20 minutes
• Neutralization. Administration of acids or bases if contacted by poison.
• Increase in the rate of excretion. Administration of
• Do not induce vomiting by gagging or tickling the
diuretics, peritoneal or hemodialysis, and ion back of the throat.
trapping
• Antidotes and symptomatic therapy. Administration • Do not give ipecac syrup. Though once considered a
of specific antidotes and support of vital functions. routine procedure, this method of poison management
is now considered ineffective. Discourage parents
Treatment for ingested poisons depends on the age from keeping ipecac syrup in the home. There is no
and physical size of the patient and the time between swal- evidence that syrup of ipecac actually helps improve
lowing and presenting for medical intervention. Any infor- the outcome in poisoning cases. Furthermore, the
mation about the poisoning that can be obtained from the administration of syrup of ipecac can delay the admin-
patient, family, or caregiver can be helpful, such as the type istration of more effective treatments, such as acti-
of poison that was swallowed, when it was ingested, and vated charcoal or antidotes.
how much was swallowed. Following are some specific
interventions for managing the patient poisoned by • Do not give milk or water unless directed to do so by
ingestion: the poison center. Though once thought to dilute the
poison, fluids can liquefy dry poison and send it more
• Do not implement the package instructions for poi- rapidly to the small intestine. The exception to this is
soning without consulting the American Association caustic or corrosive poisons.
of Poison Control Centers or an appropriate health-
care provider. Preferred therapy may have changed CONNECTION Checkpoint 75.3
since the packaging was printed.
From what you learned in Chapter 43, which of the following vaccines
• Contact the poison control center if the poisoning is would be considered a subunit vaccine: polio, HBV, MMR, varicella,
the result of taking too much or the wrong medication tetanus, HPV. Answers to Connection Checkpoint questions are avail-
was taken. able on the faculty resources site. Please consult with your instructor.
CONNECTIONS: Using Research in Practice
Emerging Strategies to Combat Bioterrorism
Antibiotics and vaccinations have long been the mainstay of demonstrated activity against Francisella, a causative agent in
treating bioterrorism where infectious agents are weaponized tularemia (Dean & van Hoek, 2015). Although existing drugs may
and released. As antibiotic resistance becomes an increasing not be found useful for treating a biologic agent directly, what is
global crisis, different drugs will be needed to treat the highly being learned about the chemical compounds that they include
infectious agents used in a bioterrorism attack. The use of pre- and their anti-infectant properties may lead to new treatments.
and postexposure vaccinations may also be problematic if suffi-
cient quantities of the vaccine cannot be made quickly. Should a biologic agent be released, developing sufficient
quantities of vaccine to protect the population is also a concern.
Two recent areas of research seek to provide newer strate- Traditional methods of producing vaccines to meet a growing
gies to combat the release of biologic agents. Current research demand based on reemergence and spread of infectious dis-
is investigating the use of existing FDA-approved drugs, and eases are hindered by the amount of time needed to produce
what is known about their chemical structures, to treat bioterror- the vaccine, safety concerns, and limited scalability. Recent
ism agents. For example, chloroquine, a drug that has been research has begun to focus on the viability of using plant prod-
used to treat malaria, appears to have efficacy against viral bio- ucts to produce subunit vaccines (those developed through
logic agents such as dengue and chikungunya (Madrid et al., recombinant DNA technology) to provide rapid scalability of vac-
2013). Drugs without anti-infective properties are also being cine production (Streatfield, Kushnir, & Yusibov, 2015). Further
studied. Chlorpromazine, a phenothiazine antipsychotic and study of such products is needed, but this line of research
antiemetic, has been shown to have activity against some strains stands to benefit both the ability to fight bioterrorism agents and
of Salmonella, and the tetracyclic antidepressant maprotiline has to increase the availability of common vaccines.
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