General

1. Determine etiology of respiratory depression. Opioid antagonists do not relieve the toxicity of nonnarcot-ic CNS depressants.

2. This drug is intended for acute use only. However, patients may experience side effects.

3. Dose should be carefully titrated to avoid serious cardiovascular adverse effects.

4. Note agent being reversed. If opi-oid is long acting or sustained release, repeated doses will be required in order to continue to counteract drug effects. Monitor VS and respirations closely after duration of action of antagonist; additional doses may be necessary.

5. Observe for symptoms of airway obstruction; if comatose, turn frequently and position on side to prevent aspiration.

6. Maintain a safe, protective environment. Use side rails, supervise ambulation, and use soft supports as needed.

7. Significant opioid depression that occurs in the dental office may require transportation of the patient to a hospital.

ORAL

CONTRACEPTIVES: ESTROGEN-PROGESTERONE COMBINATIONS_

See Table 1.

Action/Kinetics: The combination oral contraceptives act by inhibiting ovulation due to an inhibition (through negative-feedback mechanism) of LH and FSH, which are required for development of ova. These products also alter the cervical mucus so that it is not conducive to sperm penetration, render the endo-metrium less suitable for implantation of the blastocyst should fertilization occur, and inhibit enzymes required by sperm to enter the ovum.

The estrogen used in combination oral contraceptives is either ethinyl estradiol or mestranol. Mestranol is de-methylated to ethinyl estradiol in the liver. tV2: 6—20 hr. The progestin used in combination oral contraceptives is either desogestrel, ethynodiol diacetate, levonorgestrel, norethin-drone, norethindrone acetate, nor-gestimate, or norgestrel.

The progestin-only products do not consistently inhibit ovulation. However, these products also alter the cervical mucus and render the endometrium unsuitable for implantation. These products contain either norethindrone or norgestrel. This method of contraception is less reliable than combination therapy.

Although oral contraceptives may be associated with serious side effects, a number of noncontraceptive health benefits have been confirmed. These include increased regularity of the menstrual cycle, decreased incidence of dysmenorrhea, decreased blood loss, decreased incidence of functional ovarian cysts and ectopic pregnancies, and decreased incidence of diseases such as fibroadenomas, fibrocystic dis-

Table 1 Combination Oral Contraceptive Preparations Available in the United States

Trade Name

Estrogen

Progestin

MONOPHASIC

T

Alesse 21-Day and 28-Day

Ethinyl estradiol (20

mcg)

Levonorgestrel (0.1 mg)

R

Brevicon 21-Day and 28-Day

Ethinyl estradiol (35

mcg)

Norethindrone (0.5 mg)

P

Demulen 1/35-21 and 1/35-28

Ethinyl estradiol (35

mcg)

Ethynodiol diacetate (1 mg)

E

Demulen 1/50-21 and 1/50-28

Ethinyl estradiol (50

mcg)

Ethynodiol diacetate (1 mg)

n D

Desogen (28 day)

Ethinyl estradiol (30

mcg)

Desogestrel (0.15 mg)

Genora 0.5/35 21 Day and 28 Day

Ethinyl estradiol (35

mcg)

Norethindrone (0.5 mg)

Genora 1/35 21 Day and 28 Day

Ethinyl estradiol (35

mcg)

U G

Genora 1/50 21 Day and 28 Day

Mestranol (50 mcg)

Norethindrone (1 mg)

Levlen 21 and 28

Ethinyl estradiol (30

mcg)

Levonorgestrel (0.15 mg)

C A

Levora 0.15/30-21 and -28

Ethinyl estradiol (30

mcg)

Levonorgestrel (0.15 mg)

ryi

Loestrin 21 1/20

Ethinyl estradiol (20

mcg)

Norethindrone acetate (1 mg)

I C

Loestrin 21 1.5/30

Ethinyl estradiol (30

mcg)

Norethindrone acetate (1.5 mg)

Loestrin Fe 1/20 (28 day)

Ethinyl estradiol (20

mcg)

Norethindrone acetate (1 mg)

I

Loestrin Fe 1.5/30 (28 day)

Ethinyl estradiol (30

mcg)

Norethindrone acetate (1.5 mg)

O N

Lo/Ovral-21 and -28

Ethinyl estradiol (30

mcg)

Norgestrel (0.3 mg)

tyj

Modicon 21 and 28

Ethinyl estradiol (35

mcg)

Norethindrone (0.5 mg)

Necon 0.5/35-21 Day and 28 Day

Ethinyl estradiol (35

mcg)

Norethindrone (0.5 mg)

Necon 1/35-21 Day and 28 Day

Ethinyl estradiol (35

mcg)

Norethindrone (1 mg)

Necon 1/50-21 Day and 28 Day

Mestranol (50 mcg)

Norethindrone (1 mg)

N.E.E. 1/35 21 Day and 28 Day

Ethinyl estradiol (35

mcg)

Norethindrone (1 mg)

Nelova 0.5/35E 21 Day and 28 Day

Ethinyl estradiol (35

mcg)

Norethindrone (0.5 mg)

Nelova 1/35E 21 Day and 28 Day

Ethinyl estradiol (35

mcg)

Norethindrone (1 mg)

Nelova 1/50M 21 Day and 28 Day

Mestranol (50 mcg)

Norethindrone (1 mg)

Neocon 0.5/35-21 Day and -28 Day

Ethinyl estradiol (35

mcg)

Norethindrone (0.5 mg)

Neocon 1/35-21 Day and -28 Day

Ethinyl estradiol (35

mcg)

Norethindrone (1 mg)

Neocon 1/50-21 Day and -28 Day

Ethinyl estradiol (50

mcg)

Norethindrone (1 mg)

Nordette-21 and -28

Ethinyl estradiol (30

mcg)

Levonorgestrel (0.15 mg)

Trade Name

Estrogen

Progestin

MONOPHASIC

Norethin 1/35E 21 Day and 28 Day

Ethinyl estradiol (35

mcg)

Norethindrone (1 mg)

Norethin 1/50M 21 Day and 28 Day

Mestranol (50 mcg)

Norethindrone (1 mg)

Norinyl 1 + 35 21-Day and 28-Day

Ethinyl estradiol (35

mcg)

Norethindrone (1 mg)

Norinyl 1 + 50 21-Day and 28-Day

Mestranol (50 mcg)

Norethindrone (1 mg)

Norlestrin 1/50 21 Day and 28 Day

Ethinyl estradiol (50

mcg)

Norethindrone (1 mg)

Norlestrin 2.5/50 21 Day and 28 Day

Ethinyl estradiol (50

mcg)

Norethindrone (2.5 mg)

Ortho-Cept 21 Day and 28 Day

Ethinyl estradiol (30

mcg)

Desogestrel (0.15 mg)

Ortho-Cyclen-21 and -28

Ethinyl estradiol (35

mcg)

Norgestimate (0.25 mg)

Ortho Novum 1/35-21 and -28

Ethinyl estradiol (35

mcg)

Norethindrone (1 mg)

Ortho Novum 1/50-21 and -28

Mestranol (50 mcg)

Norethindrone (1 mg)

Ovcon-35 21 Day and 28 Day

Ethinyl estradiol (35

mcg)

Norethindrone (0.4 mg)

Ovcon-50 21 Day and 28 Day

Ethinyl estradiol (50

mcg)

Norethindrone (1 mg)

Ovral 21 Day and 28 Day

Ethinyl estradiol (50

mcg)

Norgestrel (0.5 mg)

Zovia 1/35E-21 and -28

Ethinyl estradiol (35

mcg)

Ethynodiol diacetate (1 mg)

Zovia 1/50E-21 and -28

Ethinyl estradiol (50

mcg)

Ethynodiol diacetate (1 mg)

BIPHASIC

s 1

Jenest-28

Ethinyl

estradiol

(35

mcg

in

each

tablet)

Norethindrone (10 tablets by 11 tablets of 1 mg)

of 0.5

mg

followed

=

Necon 10/11 21 Day and 28 Day

Ethinyl

estradiol

(35

mcg

in

each

tablet)

Norethindrone (10 tablets

of 0.5

mg

followed

t

by 11 tablets of 1 mg)

e

Nelova 10/11-21 and -28

Ethinyl

estradiol

(35

mcg

in

each

tablet)

Norethindrone (10 tablets

of 0.5

mg

followed

i

by 11 tablets of 1 mg)

i

Necon 10/11-21 and -28

Ethinyl

estradiol

(35

mcg

in

each

tablet)

Norethindrone (10 tablets

of 0.5

mg

followed

e

by 11 tablets of 1 mg)

t

Ortho-Novum 10/11-21 and -28

Ethinyl

estradiol

(35

mcg

in

each

tablet)

Norethindrone (10 tablets by 11 tablets of 1 mg)

of 0.5

mg

followed

Table 1 (continued)

Trade Name

Estrogen

Progestin

Estrostep (21 or 28 days) Ortho-Novum 7/7/7 (21 or 28 days)

Ortho-Tri-Cyclen (21 or 28 days)

Tri-Levlen 21 Day and

Tri-Levlen 28 Day Tri-Norinyl (21 or 28 day) Triphasil 21 (21 or 28 day)

TRIPHASIC

Ethinyl estradiol (20, 30, and 35 mcg) Ethinyl estradiol (35 mcg in each tablet)

Ethinyl estradiol (35 mcg in each tablet)

First 6 days: Ethinyl estradiol

Next 5 days: Ethinyl estradiol (40 mcg) Last 10 days: Ethinyl estradiol (30 mcg) Ethinyl estradiol (35 mcg in each tablet)

First 6 days: Ethinyl estradiol (30 mcg) Next 5 days: Ethinyl estradiol (40 mcg) Last 10 days: Ethinyl estradiol (30 mcg)

Norethindrone (1 mg in each tablet) Norethindrone (0.5 mg the first 7 days, 0.75 the next 7 days, and 1 mg the last 7 days) Norgestimate (0.18 mg the first 7 days, 0.215 mg the next 7 days, and 0.25 mg the last seven days)

Levonogestrel (0.05 mg)

Levonorgestrel (0.075 mg) Levonorgestrel (0.125 mg) Norethindrone (0.5 mg the first 7 days, 1 mg the next 9 days, and 0.5 mg the last 5 days) Levonorgestrel (0.05 mg) Levonorgestrel (0.075 mg) Levonorgestrel (0.125 mg)

THERAPEUTIC DRUG CLASSIFICATIONS

All combination oral contraceptives are Rx and Pregnancy category: X.

ease, acute pelvic inflammatory disease, endometrial cancer, and ovarian cancer.

Uses: Contraception, menstrual irregularities, menopausal symptoms. High doses are used for endometrio-sis and hypermenorrhea. Non-FDA Approved Uses: High doses of Ovral (ethinyl estradiol and norgestrel) have been used as a postcoital contraceptive.

Contraindications: Thrombophlebitis, history of deep-vein thrombophlebitis, thromboembolic disorders, cerebral vascular disease, CAD, MI, current or past angina, known or suspected breast cancer or estrogen-dependent neoplasm, endometrial carcinoma, hepatic adenoma or carcinoma, undiagnosed abnormal genital bleeding, known or suspected pregnancy, cholestatic jaundice of pregnancy. Smoking.

Special Concerns: Cigarette smoking increases the risk of cardiovascular side effects from use of oral contraceptives. Low estrogen-containing oral contraceptives do not increase the risk of stroke in women. Use with caution in clients with a history of hypertension, preexisting renal disease, hypertension-related diseases during pregnancy, familial tendency to hypertension or its consequences, a history of excessive weight gain or fluid retention during the menstrual cycle; these individuals are more likely to develop elevated BP. Use with caution in clients with asthma, epilepsy, migraine, diabetes, metabolic bone disease, renal or cardiac disease, and a history of mental depression. Use with drugs (e.g., barbiturates, hydantoins, rifampin) that increase the hepatic metabolism of oral contraceptives may result in breakthrough bleeding and an increased risk of pregnancy. Use combination products during lactation only if absolutely necessary; pro-gestin-only products do not appear to have any adverse effects on breastfeeding performance or on the health, growth, or development of the infant.

Side Effects: CV: MI, thrombophlebitis, venous thrombosis with or without embolism, pulmonary embolism, coronary thrombosis, cerebral thrombosis, arterial thromboembolism, mesenteric thrombosis, thrombotic and hemor-rhagic strokes, postsurgical throm-boembolism, subarachnoid hemorrhage, elevated BP, hypertension. CNS: Onset or exacerbation of migraine headaches, depression. Oral: Hyperplasia, bleeding gums. GI: N&V, bloating, abdominal cramps. Ophthalmic: Optic neuritis, retinal thrombosis, steepening of the corneal curvature, contact lens intolerance. Hepatic: Benign and malignant hepatic adenomas, focal nodular hyper-plasia, hepatocellular carcinoma, gallbladder disease, cholestatic jaundice. GU: Breakthrough bleeding, spotting, amenorrhea, change in menstrual flow, change in cervical erosion and cervical secretions, invasive cervical cancer, bleeding irregularities (more common with pro-gestin-only products), vaginal candi-diasis, ectopic pregnancies in contraceptive failures, breast tenderness, breast enlargement. Miscellaneous: Acute intermittent porphyria, photo-sensitivity, congenital anomalies, melasma, skin rash, edema, increase or decrease in weight, decreased carbohydrate tolerance, increased incidence of cervical Chlamydia trachomatis, decrease in the quantity and quality of breast milk.

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