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Diabetes.

Adults, initial: 100 mg/day if fasting blood sugar is less than 200 mg/100 mL, or 250 mg/day if fasting blood sugar is greater than 200 mg/100 mL. Adjust dose to response, not to exceed 1 g/day. If more than 500 mg/day is required, it should be given in two divided doses, usually before the morning and evening meals. Elderly, malnourished, underweight clients or those not eating properly: 100 mg once daily with breakfast, adjusting dose by increments of 50 mg/day each week. Doses greater than 1

TOLAZAMIDE

g/day will probably not improve control.

DENTAL CONCERNS

See also Dental Concerns for Antidiabetic Agents: Hypoglycemic Agents and Glipizide.

Tolbutamide

[toll-BYOU-tah-myd] Pregnancy Category: C

APO-Tolbutamide M, Novo-Butamide M, Orinase [Rx]

Tolbutamide sodium

[toll-BYOU-tah-myd] Pregnancy Category: C

Orinase Diagnostic [Rx] Classification: Sulfonylurea, first-generation

See also Antidiabetic Agents, Hypogly-cemic Agents.

Action/Kinetics: Onset: 1 hr. tv2: 4.5-6.5 hr. Time to peak levels: 3-4

hr. Duration: 6-12 hr. Changed in liver to inactive metabolites. Excreted through the kidney (75%) and feces

Additional Uses: Most useful for clients with poor general physical status who should receive a short-acting compound.

Tolbutamide sodium is used to diagnose pancreatic islet cell tumors. It causes blood glucose, in the presence of a tumor, to drop quickly after IV administration and remain low for 3 hr.

Additional Side Effects: Melena (dark, bloody stools) in some clients with a history of peptic ulcer. Relapse or secondary failure may occur a few months after therapy has been started. May cause hyponatremia and a mild goiter.

Additional Drug Interactions

Alcohol / Photosensitivity reactions Sulfinpyrazone / T Effect of tolbutamide due to l breakdown by liver How Supplied: Tolbutamide: Tablet: 500 mg. Tolbutamide sodium: Powder for injection: 1 g

Dosage-

Diabetes mellitus. Adults, initial: 0.25-3 g/day (usually 1-2 g). Adjust dosage depending on response. Usual maintenance:

0.25-2 g/day). A daily dose greater than 2 g is rarely needed; maximum daily dose should not exceed 3 g.

DENTAL CONCERNS

See also Dental Concerns for Antidi-abetic Agents, Oral.

Tolmetin sodium

[TOLL-met-in] Pregnancy Category: C

Novo-Tolmetin M, Tolectin M, Tolectin 200, Tolectin 600, Tolectin DS [Rx] Classification: Nonsteroidal, antiinflammatory, analgesic

See also Nonsteroidal Antiinflammatory Drugs.

Action/Kinetics: Peak plasma levels: 30-60 min. t1/2: 1 hr. Therapeutic plasma levels: 40 mcg/mL. Onset, anti-inflammatory effect: within 1 week; duration, anti-inflammatory effect: 1-2 weeks. Inactivated in liver and excreted in urine. Uses: Acute and chronic treatment of rheumatoid arthritis and osteoarthri-tis. Juvenile rheumatoid arthritis. Non-FDA Approved Uses: Sunburn. Special Concerns: Use with caution during lactation. Dosage has not been determined in children less than 2 years of age. How Supplied: Capsule: 400 mg; Tablet: 200 mg, 600 mg

Dosage-

• Capsules, Tablets

Rheumatoid arthritis, osteoarthritis. Adults: 400 mg t.i.d. (one dose on arising and one at bedtime); adjust dosage according to client response. Maintenance: rheumatoid arthritis, 600-1,800 mg/day in three to four divided doses; osteoarthritis, 600-1,600 mg/day in three to four divided doses. Doses larger than 1,800 mg/day for rheumatoid arthritis and osteoarthritis are not recommended.

Juvenile rheumatoid arthritis.

TOPIRAMATE 415

2 years and older, initial: 20

mg/kg/day in three to four divided doses to start; then, 15-30 mg/kg/day. Doses higher than 30 mg/kg/day are not recommended. Beneficial effects may not be observed for several days to a week.

DENTAL CONCERNS

See also Dental Concerns for Non-steroidal Anti-Inflammatory Drugs.

Topiramate

[toh-PYRE-ah-mayt] Pregnancy Category: C Topamax [Rx]

Classification: Anticonvulsant, miscellaneous

See also Anticonvulsants. Action/Kinetics: Precise mechanism not known. The following effects may contribute to the anticonvulsant activity. (1) Blocks repetitive action potentials. (2) Increases the frequency at which GABA activates GABAA receptors. (3) Antagonizes the ability of kainate, thus reducing the excitatory effect. Rapidly absorbed; peak plasma levels: About 2 hr. tV2, elimination: 21 hr. Steady state is reached in about 4 days in those with normal renal function. Excreted mostly unchanged in the urine. Uses: Adjunct to treat partial onset seizures in adults.

Contraindications: Lactation. Special Concerns: Use with caution in impaired hepatic and renal function. Safety and efficacy have not been determined in children. Side Effects: Note: Side effects with an incidence of 0.1% or greater are listed. CNS: Psychomotor slowing, including difficulty with concentration and speech or language problems. Somnolence, fatigue, dizziness, ataxia, nystagmus, paresthesia, nervousness, difficulty with memory, tremor, confusion, depression, abnormal coordination, agitation, mood problems, aggressive reaction, hypoes-thesia, apathy, emotional lability, de-

personalization, hypokinesia, vertIgo, stupor, clonic/tonic seizures, hy-

perkinesia, hypertonia, insomnia, personality disorder, impotence, hallucinations, euphoria, psychosis, decreased libido, suicide attempt, hypo-reflexia, neuropathy, migraine, apraxia, hyperesthesia, dyskinesia, hyperreflexia, dysphonia, scotoma, dystonia, coma, encephalopathy, upper motor neuron lesion, paranoid reaction, delusion, paranoia, delirium, abnormal dreaming, neuroses. Oral: Dry mouth, gingivitis, halitosis, gum hyperplasia, tooth caries, stomatitis, gingival bleeding, increased saliva, tongue edema. GI: Nausea, dyspepsia, anorexia, abdominal pain, constipation, diarrhea, vomiting, fecal incontinence, flatulence, gastroenteritis, hemorrhoids, increased appetite, dysphagia, melena, gastritis, hiccough, gastroesopha-geal reflux, esophagitis, gall bladder disorder. CV: Palpitation, hypertension, hypotension, postural hypotension, AV block, bradycardia, bundle branch block, angina pectoris, vasodilation. Body as a whole: Asthenia, back pain, chest pain, flulike symptoms, leg pain, hot flashes, body odor, edema, rigors, fever, malaise, syncope, enlarged abdomen. Respiratory: URI, pharyngitis, sinusitis, dyspnea, coughing, bronchitis, asthma, bronchospasm, pulmonary embolism. Dermatologie: Acne, alopecia, dermatitis, nail disorder, fol-liculitis, dry skin, urticaria, skin discoloration, eczema, photosensi-tivity reaction, erythematous rash, seborrhea, decreased sweating, abnormal hair texture, facial edema. GU: Breast pain, renal stone formation, dysmenorrhea, menstrual disorder, hematuria, intermenstrual bleeding, leukorrhea, menorrhagia, vaginitis, amenorrhea, UTI, micturition frequency, urinary incontinence, dysuria, renal calculus, ejaculation disorder, breast discharge, urinary retention, renal pain, nocturia, albuminuria, polyuria, oliguria. Musculoskeletal: Arthralgia, muscle weak

TOPIRAMATE

ness, arthrosis, osteoporosis, myalgia, leg cramps. Metabolic: Increased weight, decreased weight, dehydration, xeropthalmia. Hematologic: Anemia, leukopenia, lym-phadenopathy, eosinophilia, lym-phopenia, granulocytopenia, lym-phocytosis, thrombocytothemia, purpura, thrombocytopenia. Der-matologic: Rash, pruritus, increased sweating, flushing. Ophthalmic: Diplopia, abnormal vision, eye pain, conjunctivitis, abnormal accommodation, photophobia, abnormal lacri-mation, strabismus, color blindness, myopia, mydriasis, ptosis, visual field defect. Miscellaneous: Decreased hearing, epistaxis, taste perversion, tinnitus, taste loss, paros-mia, goiter, basal cell carcinoma. Drug Interactions Alcohol / CNS depression and cognitive and neuropsychiatric side effects

Carbamazepine / l Plasma levels of topiramate

CNS depressants / CNS depression and cognitive and neuropsychiatric side effects

How Supplied: Tablets: 25 mg, 100 mg, 200 mg.

Dosage-

Adjunctive therapy for treatment of partial onset seizures. Initial: 50 mg/day; then, titrate to an effective dose of 400 mg/day in 2 divided doses. Titrate by adding 50 mg each week for 8 weeks, until the dose is 400 mg/day. Doses greater than 400 mg/day have not been shown to improve the response. If CCR < 70 mL/1.73 m2, use one half of the usual adult dose.

DENTAL CONCERNS

See also Dental Concerns for Anticon-vulsants.

1. Can cause photosensitivity. The patient may require dark glasses when the dental light is on.

Tramadol hydrochloride

Pregnancy Category: C Ultram (Rx)

Classification: Analgesic, centrally acting

Action/Kinetics: A centrally acting analgesic not related chemically to opiates. Precise mechanism is not known. It may bind to mu-opioid receptors and inhibit reuptake of norepi-nephrine and serotonin. Rapidly absorbed after PO administration. Food does not affect the rate or extent of absorption. Onset: 1 hr. Peak effect: 2-3 hr. Peak plasma levels: 2 hr. tV2, plasma: Approximately 7 hr after multiple doses. Extensively metabolized by one of the P-450 isoenzymes. Excreted in the urine, with about 30% excreted unchanged and 60% as metabolites. The M-metabolite is active.

Uses: Management of moderate to moderately severe pain. Contraindications: Hypersensitiv-ity to tramadol. In acute intoxication with alcohol, hypnotics, centrally acting analgesics, opiates, or psy-chotropic drugs. Use in clients with past or present addiction or opiate dependence or in those with a prior history of allergy to codeine or opiates. Use for obstetric preoperative medication or for postdelivery analgesia in nursing mothers. Use in children less than 16 years of age, as safety and efficacy have not been determined. Special Concerns: Use with great caution in those taking MAO inhibitors, as tramadol inhibits norepi-nephrine and serotonin uptake. Dosage reduction is recommended with impaired hepatic or renal function and in clients over 75 years of age. Use with caution in increased intracranial pressure or head injury, in epilepsy, or in clients with an increased risk for seizures, including head trauma, metabolic disorders, alcohol or drug withdrawal, and CNS infections. Tramadol may complicate the assessment of acute abdominal conditions.

Side Effects: CNS: Dizziness, vertigo, headache, somnolence, CNS stimulation, anxiety, confusion, incoordination, euphoria, nervousness, sleep

TRANDOLAPRIL

disorders, seizures, paresthesia, cognitive dysfunction, hallucinations, tremor, amnesia, concentration difficulty, abnormal gait, migraine, development of drug dependence. Oral: Dry mouth, stomatitis, dysgeu-sia. GI: Nausea, constipation, vomiting, dyspepsia, diarrhea, abdominal pain, anorexia, flatulence, GI bleeding, hepatitis. CV: Vasodilation, syncope, orthostatic hypotension, tachycardia, abnormal ECG, hypertension, myocardial ischemia, palpitations. Dermatologic: Pruritus, sweating, rash, urticaria, vesicles. Body as a whole: Asthenia, malaise, allergic reaction, accidental injury, weight loss, suicidal tendency. GU: Urinary retention, urinary frequency, menopausal symptoms, dysuria, menstrual disorder. Miscellaneous: Anaphylaxis, visual disturbances, cataracts, deafness, tinnitus, hyperto-nia, dyspnea.

Drug Interactions

Alcohol / Enhanced respiratory depression

Anesthetics, general / Enhanced respiratory depression Carbamazepine / I Effect of trama-dol due to T metabolism induced by carbamazepine CNS depressants / Additive CNS depression

MAO Inhibitors / Tramadol may T the risk of seizures in those taking MAO inhibitors

Naloxone / Use of naloxone for tramadol overdose may T risk of seizures.

How Supplied: Tablet: 50 mg

Dosage-

Management of pain. Adults: 50-100 mg q 4-6 hr as needed, but not to exceed 400 mg/day. For moderate pain, 50 mg, initially, may be adequate, and for severe pain, 100 mg, initially, is often more effective. For clients over 75 years of age, the recommended dose is no more than 300 mg/day in divided doses. In impaired renal function with a CCR less than 30 mL/min, the dosing interval should be increased to 12 hr, with a maximum daily dose of 200 mg. The recommended dose for clients with cirrhosis is 50 mg q 12 hr.

DENTAL CONCERNS

See also Dental Concerns for Opioid Analgesics.

Trandolapril

[tran-DOHL-ah-pril] Pregnancy Category: C (first trimester); D (second and third trimesters) Mavik [Rx]

Classification: Antihypertensive

See also Angiotensin Converting Enzyme (ACE) Inhibitors. Action/Kinetics: Rapidly absorbed; food slows rate, but not amount absorbed. Peak plasma levels, trandol-april: 30-60 min; trandolaprilat: 4-10 hr. t1/, trandoprilat: 15-24 hr. Metabolized in liver to active trando-laprilat. About !/3 trandolaprilat is excreted in urine and 2/3 in feces. Uses: Hypertension, alone or in combination with other antihyper-tensives such as hydrochlorothia-zide.

Contraindications: In those with history of angioedema with ACE inhibitors.

Special Concerns: Safety and efficacy have not been determined in children.

Side Effects: See also ACE Inhibitors. Hypersensitivity: Angioedema. CNS: Dizziness, headache, fatigue. Oral: Angioedema (lips, mucous membranes, tongue). GI: Diarrhea, dyspepsia, gastritis. CV: Hypotension, bradycardia, cardiogenic shock, intermittent claudication, stroke. Pulmonary: Cough, Hepatic: Hepatic failure, including cholestatic jaundice, fulminant hepatic necrosis, death. Miscellaneous: Neutropenia, syncope, myalgia, asthenia. Drug Interactions See also Angiotensin-Converting Enzyme Inhibitors.

418 TRANDOLAPRIL

Tetracyclines / l Absorption of tet-racycline due to high magnesium content of quinapril tablets How Supplied: Tablet: 1 mg, 2 mg, 4 mg

Dosage-

Hypertension. Initial: 1 mg once daily in nonblack clients and 2 mg once daily in black clients. Adjust dosage according to response; usually, adjustments are made at intervals of 1 week. Maintenance, usual: 2-4 mg once daily. Those inadequately treated with once-daily dosing can be treated with twice-daily dosing. If BP is still not adequately controlled, diuretic may be added. If CCR is less than 30 mL/min or if there is hepatic cirrhosis, initial dose is 0.5 mg daily.

DENTAL CONCERNS

See also Dental Concerns for An-giotensin-Converting Enzyme Inhibitors and Antihypertensive Agents.

Tranylcypromine sulfate

[tran-ill-SIP-roh-meen] Parnate (Rx)

Classification: Antidepressant, monoamine oxidase inhibitor

Action/Kinetics: An MAO inhibitor with a rapid onset of activity. Due to inhibition of MAO, the concentration of epinephrine, norepinephrine, and serotonin increases in storage sites throughout the nervous system. This increase has been alleged to be the basis for the antidepressant effects. MAO activity recovers in 3-5 days after drug withdrawal. Uses: Treatment of major depressive episode without melancholia. Not a first line of therapy; is used when clients have failed to respond to other drug therapy. Non-FDA Approved Uses: Alone or as an adjunct to treat bulimia, obsessive compulsive disorder, and manifestations of psychotic disorders. Also, treatment of social phobia, seasonal affective disorders, adjunct to treat multiple sclerosis, and to treat idiopathic orthostatic hypotension (e.g., Shy-Drager syndrome), refractory to conventional therapy.

Contraindications: Use in those with a confirmed or suspected CV defect or in anyone with CV disease, hypertension, or history of headache. In the presence of pheoch-romocytoma. History of liver disease or in those with abnormal liver function. Use in combination with a large number of other drugs, especially other MAO inhibitors, tricyclic antidepressants, serotonin-reuptake inhibitors, buspirone, sympathomi-metics, meperidine, CNS depressants (e.g., alcohol and narcotics), hypoten-sive drugs, excessive caffeine, and dextromethorphan (see Drug Interactions). Use with tyramine-contain-ing foods (see Drug Interactions). Special Concerns: Assess benefits versus risks before using during pregnancy and lactation. Use with caution in clients taking antiparkinson drugs, in impaired renal function, in those with seizure disorders, in diabetics, in hyperthyroid clients, and in those taking disulfiram. Geriatric clients may be more sensitive to the drug.

Side Effects: CNS: Anxiety, agitation, headaches (without elevation of BP), manic symptoms, restlessness, insomnia, weakness, drowsiness, dizziness, significant anorexia. Oral: Dry mouth. GI: Nausea, diarrhea, abdominal pain, constipation. CV: Tachycardia, edema, palpitation. GU: Impotence, urinary retention, impaired ejaculation. Musculoskeletal: Muscle spasm, tremors, myo-clonic jerks, numbness, paresthesia. Hematologic: Anemia, leukopenia, agranulocytosis, thrombocytopenia. Miscellaneous: Blurred vision, chills, impotence, hepatitis, skin rash, impaired water excretion, tinnitus.

Drug Interactions

Alcohol / Possibility of excitation, seizures, delirium, hyperpyrexia, circulatory collapse, coma, death Anesthetics, general / Hypotensive effect; use together with caution. Phenelzine should be discontinued at least 10 days before elective surgery

Anticholinergic drugs, atropine / MAO inhibitors effect of anticholi-nergic drugs

Antidepressants, tricyclic / Co-mcomitant use may result in excitation, sweating, tachycardia, tachyp-nea, hyperpyrexia, disseminated intravascular coagulation, delirium, tremors, convulsions, death. At least 7-10 days should elapse between discontinuing an MAO inhibitor and initiating a new drug. However, such combinations have been used together successfully Fluoxetine / Possibility of hyper-thermia, rigidity, myoclonic movements, death. At least 10 days should elapse between discontinuation of phenelzine and initiation of fluoxetine; and, at least 5 weeks should elapse between discontinuing fluoxetine and beginning phe-nelzine

MAO inhibitors / Concomitant use of tranylcypromine with other MAO inhibitors may cause a hypertensive crisis or severe seizures Meperidine / See Opioid Analgesics Opioid Analgesics / Possibility of excitation, seizures, delirium, hyper-pyrexia, circulatory collapse, coma, death

Selective serotonin reuptake inhibitors /See Fluoxetine Sympathomimetic drugs—amphetamine, cocaine, dopa, ephedrine, epi-nephrine, metaraminol, methyldo-pa, methylphenidate, norepineph-rine, phenylephrine, phenylpropanolamine. Many OTC cold products, hay fever medications, and nasal decongestants contain one or more of these drugs / All peripheral, metabolic, cardiac, and central effects are potentiated for up to 2 weeks after termination of MAO inhibitor therapy. Symptoms include acute hypertensive crisis with possible intracranial hemorrhage, hyperthermia, coma, and possibly death

How Supplied: Tablets: 10 mg

Dosage-

Major depressive syndrome without melancholia.

Individualize the dose. Usual effective dose: 30 mg/day given in divided doses. If there are no signs of improvement in 2 weeks, the dose can be increased by 10 mg/day at intervals of 1-3 weeks, up to a maximum of 60 mg/day.

DENTAL CONCERNS

See also Dental Concerns for Antide-

pressants, Tricyclic.

General

1. Possibility of hypertensive episode with vasoconstrictors.

2. Patient should not be prescribed prescription or over-the-counter products that contain aspirin.

Trazodone hydrochloride

[TRAYZ-oh-dohn] Pregnancy Category: C

Alti-Trazodone M, Alti-Trazodone Di-vidose M, Apo-Trazodone M, Apo-Trazodone D M, Desyrel, Desyrel Di-vidose, Dom-Trazodone M, Novo-Trazodone M, Nu-Trazodone M, Nu-Trazodone-D M, PMS-Trazodone M, Trazon, Trialodine [Rx] Classification: Antidepressant, miscellaneous

Action/Kinetics: A novel antide-pressant that does not inhibit MAO and is also devoid of amphetaminelike effects. Response usually occurs after 2 weeks (75% of clients), with the remainder responding after 2-4 weeks. May inhibit serotonin uptake by brain cells, therefore increasing serotonin concentrations in the synapse. May also cause changes in binding of serotonin to receptors. Causes moderate sedative and or-thostatic hypotensive effects and slight anticholinergic effects. Peak plasma levels: 1 hr (empty stomach) or 2 hr (when taken with food). ti/2, initial: 3-6 hr; final: 5-9 hr. Effective plasma levels: 800-1,600 ng/mL. Time to reach steady state:

3—7 days. Three-fourths of those with a therapeutic effect respond by the end of the second week of therapy. Metabolized in liver and excreted through both the urine and feces. Uses: Depression with or without accompanying anxiety. Non-FDA Approved Uses: In combination with tryptophan for treating aggressive behavior. Panic disorder or agoraphobia with panic attacks. Treatment of cocaine withdrawal. Chronic pain including diabetic neuropathy. Contraindications: During the initial recovery period following MI. Concurrently with electroshock therapy.

Special Concerns: Use with caution during lactation. Safety and efficacy in children less than 18 years of age have not been established. Geriatric clients are more prone to the sedative and hypotensive effects. Side Effects: General: Dermatitis, edema, blurred vision, constipation, dry mouth, nasal congestion, skeletal muscle aches and pains. CV: Hypertension or hypotension, syncope, palpitations, tachycardia, SOB, chest pain. Oral: Bad taste in mouth, dry mouth, hypersalivation. GI: Diarrhea, N&V, bad taste in mouth, flatulence. GU: Delayed urine flow, pria-pism, hematuria, increased urinary frequency. CNS: Nightmares, confusion, anger, excitement, decreased ability to concentrate, dizziness, disorientation, drowsiness, lighthead-edness, fatigue, insomnia, nervousness, impaired memory. Rarely, hallucinations, impaired speech, hypomania. Other: Incoordination, tremors, paresthesias, decreased libido, appetite disturbances, red eyes, sweating or clamminess, tinnitus, weight gain or loss, anemia. Rarely, akathisia, muscle twitching, increased libido, impotence, retrograde ejaculation, early menses, missed periods.

Drug Interactions

Alcohol / T Depressant effects of alcohol

Antihypertensives / Additive hypo-

Barbiturates / T Depressant effects of barbiturates

CNS depressants / T CNS depression MAO inhibitors / Initiate therapy cautiously if trazodone is to be used together with MAO inhibitors Phenytoin / Trazodone may T serum phenytoin levels How Supplied: Tablet: 50 mg, 100 mg, 150 mg, 300 mg

Dosage-

Antidepressant. Adults and adolescents, initial:

150 mg/day; then, increase by 50 mg/day every 3—4 days to maximum of 400 mg/day in divided doses (outpatients). Inpatients may require up to, but not exceeding, 600 mg/day in divided doses. Maintenance: Use lowest effective dose. Geriatric clients: 75 mg/day in divided doses; dose can then be increased, as needed and tolerated, at 3- to 4-day intervals.

Treat aggressive behavior. Trazodone, 50 mg b.i.d., with trypto-phan, 500 mg b.i.d. Dosage adjustments may be required to reach a therapeutic response or if side effects develop.

Panic disorder or agoraphobia with panic attacks. 300 mg/day.

DENTAL CONCERNS

See also Dental Concerns for Antide-pressants, Tricyclic. Client/Family Teaching

1. Use caution when driving or when performing other hazardous tasks; may cause drowsiness or dizziness.

Triamcinolone

[try-am-SIN-oh-lohn] Pregnancy Category: C Dental Paste: Kenalog in Orabase, Oracort, Oralone (RxJ. Tablets: Aristo-cort, Atolone, Kenacort [Rx]

Triamcinolone acetonide

[try-am-SIN-oh-lohn] Pregnancy Category: C

TRIAMCINOLONE

Dental Paste: Oracort M. Inhalation Aerosol: Azmacort, Nasacort, Nasacort AQ [Rx]. Parenteral: Kenaject-40, Kenalog-10 and -40, Schein-pharm Triamcine-A M, Tac-3 and -40, Triam-A, Triamonide 40, Tri-Kort, Trilog [Rx]. Topical Aerosol: Kenalog [Rx]. Topical Cream: Aristocort, Aristocort A, Delta-Tritex, Flutex, Kenac, Kenalog, Kenalog-H, Kenonel, Triacet, Tri-aderm M, Trianide Mild, Trianide Regular, Triderm, Trymex [Rx]. Topical Lotion: Kenalog, Kenonel [Rx]. Topical Ointment: Aristocort, Aristocort A, Ke-nac, Kenalog, Kenonel, Triaderm M, Trymex, Topical Spray: Nasacort AQ [Rx]

Triamcinolone diacetate

[try-am-SIN-oh-lohn] Pregnancy Category: C Parenteral: Amcort, Aristocort Forte, Aristocort Intralesional, Aristocort Parenteral M, Articulose L.A., Kenacort Diacetate, Triam-Forte, Triamolone 40, Trilone, Tristoject. Syrup: Aristocort Syrup M [Rx]

Triamcinolone hexacetonide

[try-am-SIN-oh-lohn] Pregnancy Category: C

Aristospan Intra-Articular, Aristospan Intralesional [Rx]

Classification: Corticosteroid, synthetic

See also Corticosteroids. Action/Kinetics: More potent than prednisone. Intermediate-acting. Has no mineralocorticoid activity. Onset: Several hours. Duration: One or more weeks. tV2: Over 200 min.

Additional Uses: Pulmonary emphysema accompanied by broncho-spasm or bronchial edema. Diffuse interstitial pulmonary fibrosis. With diuretics to treat refractory CHF or cirrhosis of the liver with ascites. Multiple sclerosis. Inflammation following dental procedures. Triamcin-olone acetonide for PO inhalation is used for maintenance treatment of asthma. Triamcinolone hexaceto-nide is restricted to intra-articular or intralesional treatment of rheumatoid arthritis and osteoarthritis. Special Concerns: Use during pregnancy only if benefits clearly outweigh risks. Use with special caution with decreased renal function or renal disease. Dose must be highly individualized. Additional Side Effects: Intra-artic-ular, intrasynovial, or intrabursal administration may cause transient flushing, dizziness, local depigmenta-tion, and rarely, local irritation. Exacerbation of symptoms has also been reported. A marked increase in swelling and pain and further restricted joint movement may indicate septic arthritis. Intradermal injection may cause local vesicular ulceration and persistent scarring. Syncope and anaphylactoid reactions have been reported with triamcinolone regardless of route of administration. How Supplied: Triamcinolone: Tablet: 1 mg, 2 mg, 4 mg, 8 mg. Tri-amcinolone acetonide: Metered dose inhaler (nasal): 55 mcg/inh; Metered dose inhaler (oral) 100 mcg/inh; Cream: 0.025%, 0.1%, 0.5%; Nasal spray: 55 mcg/inh; Injection: 3 mg/mL, 10 mg/mL, 40 mg/mL; Lotion: 0.025%, 0.1%; Ointment: 0.025%, 0.05%, 0.1%, 0.5%; Paste: 0.1%; Topical spray: 0.147 mg/g. Triamcinolone diacetate: Injection: 25 mg/mL, 40 mg/mL. Tri-amcinolone hexacetonide: Injection: 5 mg/mL, 20 mg/mL.

Dosage-

Triamcinolone • Tablets

Adrenocortical insufficiency (with mineralocorticoid therapy). 4-12 mg/day.

Acute leukemias (children). 1-2 mg/kg.

Acute leukemia or lymphoma (adults).

16-40 mg/day (up to 100 mg/day may be necessary for leukemia).

Edema.

16-20 mg (up to 48 mg may be required until diuresis occurs).

422 TRIAMCINOLONE

Tuberculosis meningitis. 32-48 mg/day.

Rheumatic disease, dermatologic disorders, bronchial asthma. 8-16 mg/day.

Allergies. 8-12 mg/day.

Hematologic disorders. 16-60 mg/day.

Ophthalmologic diseases. 12-40 mg daily.

Respiratory diseases. 16-48 mg/day. Triamcinolone acetonide

• IM Only (Not for IV Use) 2.5-60 mg/day, depending on the disease and its severity.

• Intra-articular, Intrabursal, Tendon Sheaths

2.5-5 mg for smaller joints and 5-15 mg for larger joints, although up to 40 mg has been used.

• Intradermal

1 mg/injection site (use 3 mg/mL or 10 mg/mL suspension only).

• Topical: 0.025%, 0.1%, 0.5% Ointment or Cream; 0.025%, 0.1% Lotion; Paste: 0.1%; Aerosol—to deliver 0.2 mg)

Apply sparingly to affected area b.i.d.-q.i.d. and rub in lightly.

• Metered Dose Inhaler (Azma-cort)

Adults, usual: 2 inhalations (200 mcg) t.i.d.-q.i.d. or 4 inhalations (400 mcg) b.i.d., not to exceed 1,600 mcg/day. High initial doses (1,200-1,600 mcg/day) may be needed in some clients with severe asthma. Pediatric, 6-12 years: 1-2 inhalations (100-200 mcg) t.i.d.-q.i.d. or 2-4 inhalations b.i.d., not to exceed 1,200 mcg/day. Use in children less than 6 years of age has not been determined.

• Intranasal Spray (Nasacort)

Seasonal and perennial allergic rhinitis.

Adults and children over 12 years of age: 2 sprays (110 mcg) into each nostril once a day (i.e., for a total dose of 220 mcg/day). The dose may be increased to 440 mcg/day given either once daily or q.i.d. (1

spray/nostril).

Triamcinolone diacetate

40 mg/week.

• Intra-articular, Intrasynovial

• Intralesional, Sublesional

5-48 mg (no more than 12.5 mg/in-jection site and 25 mg/lesion). Triamcinolone hexacetonide Not for IV use.

• Intra-articular

2-6 mg for small joints and 10-20 mg for large joints.

• Intralesional/Sublesional

DENTAL CONCERNS

See also Dental Concerns for Corticos-

teroids.

General

1. Monitor vital signs at every appointment because of cardiovascular and respiratory side effects.

2. The patient may require a semisu-pine position for the dental chair to help with breathing.

3. Dental procedures may cause the patient anxiety, which could result in an asthma attack. Make sure that the patient has his or her sympa-thomimetic inhaler present or have the inhaler from the office emergency kit present.

4. Morning and shorter appointments, as well as methods for addressing anxiety levels in the patient, can help reduce the amount of stress the patient is experiencing.

5. Sulfites present in vasoconstrictors can precipitate an asthma attack.

Client/Family Teaching

1. Daily home fluoride treatments for persistent dry mouth.

2. Avoid alcohol-containing mouth rinses and beverages.

3. Avoid caffeine-containing beverages.

4. Dry mouth can be treated with tart, sugarless gum or candy, water, sugar-free beverages, or with saliva substitutes if dry mouth persists.

5. Review use, care, and storage of in-

haler. Rinse out mouth and wash the mouth piece, spacer, sprayer and dry after each use. 6. Review technique for use and care of prescribed inhalers and respiratory equipment. Rinsing of equipment and of mouth after use is imperative in preventing oral fungal infections.

Triamterene

[try-AM-ter-een] Pregnancy Category: B Dyrenium (Rx)

Classification: Diuretic, potassium-sparing

See also Diuretics.

Action/Kinetics: A mild diuretic that acts on the collecting tubule and collecting ducts to inhibit the reabsorption of sodium, chloride, and increases potassium retention. It promotes the excretion of sodium— which is exchanged for potassium or hydrogen ions—bicarbonate, chloride, and fluid. It increases urinary pH and is a weak folic acid antagonist. Onset: 2-4 hr. Peak effect: 6-8 hr. Duration: 7-9 hr. tVi: 3 hr. From one-half to two-thirds of the drug is bound to plasma protein. Metabolized to hydroxytriamterene sulfate, which is also active. About 20% is excreted unchanged through the urine.

Uses: Edema due to CHF, hepatic cirrhosis, nephrotic syndrome, steroid therapy, secondary hyperaldos-teronism, and idiopathic edema. May be used alone or with other diuretics. Non-FDA Approved Uses: Prophylaxis and treatment of hypoka-lemia, adjunct in the treatment of hypertension.

Contraindications: Hypersensitiv-ity to drug, severe or progressive renal insufficiency, severe hepatic disease, anuria, hyperkalemia, hyper-uricemia, gout, history of nephrolithiasis. Lactation. Special Concerns: Safety and efficacy have not been determined in children.

Side Effects: Electrolyte: Hyperkale-mia, electrolyte imbalance. Oral: Dry mouth. GI: Nausea, vomiting (may also be indicative of electrolyte imbalance), diarrhea. CNS: Dizziness, drowsiness, fatigue, weakness, headache. Hematologic: Megaloblas-tic anemia, thrombocytopenia. Renal: Azotemia, interstitial nephritis. Miscellaneous: Anaphylaxis, photo-sensitivity, hypokalemia, jaundice, muscle cramps, rash.

Drug Interactions

Indomethacin and other NSAIDs / T Risk of nephrotoxicity and acute renal failure

Indomethacin and other NSAIDs /1 Antihypertensive effects How Supplied: Capsule: 50 mg, 100 mg

Dosage-

Diuretic.

Adults, initial: 100 mg b.i.d. after meals; maximum daily dose: 300

DENTAL CONCERNS

See also Dental Concerns for Diuretics.

General

1. Patients on chronic drug therapy may develop blood dyscrasias. Symptoms include fever, sore throat, bleeding, and poor wound healing.

Consultation with Primary Care Provider

1. Patients with symptoms of blood dyscrasias should be referred to their primary care provider for complete blood counts. Treatment should be postponed until the results are known.

-COMBINATION DRUG-

Triamterene and

Hydrochlorothiazide

Capsules

(try-AM-ter-een, hy-droh-klor-oh-THIGH-ah-zyd] Pregnancy Category: C Dyazide (Rx)

Triamterene and

Hydrochlorothiazide

Tablets

[try-AM-teh-reen, hy-droh-kloh-roh-THIGH-ah-zyd] Pregnancy Category: C Apo-Triazide M, Dyazide, Maxzide, Maxide-25 MG, Novo-Triamzide M, Nu-Triazide M, Pro-Triazide M [Rx] Classification: Diuretic, antihypertensive

See also Hydrochlorothiazide and Triamterene.

Content: Capsules. Diuretic: Hydrochlorothiazide, 25 or 50 mg. Diuretic: Triamterene, 50 or 100 mg. Tablets. Diuretic: Hydrochlorothia-zide, 25 or 50 mg. Diuretic: Triamterene, 37.5 or 75 mg. (In Canada the tablets contain 25 mg of hydrochloro-thiazide and 50 mg triamterene.) Uses: To treat hypertension or edema in clients who manifest hypokalemia on hydrochlorothiazide alone. In clients requiring a diuretic and in whom hypokalemia cannot be risked (i.e., clients with cardiac arrhythmias or those taking digitalis). Usually not the first line of therapy, except for clients in whom hypokale-mia should be avoided. Contraindications: Clients receiving other potassium-sparing drugs such as amiloride and spironolac-tone. Use in anuria, acute or chronic renal insufficiency, significant renal impairment, preexisting elevated serum potassium.

Special Concerns: Use with caution during lactation. Geriatric clients may be more sensitive to the hypotensive and electrolyte effects of this combination; also, age-related decreases in renal function may require a decrease in dosage. Side Effects: See also Hydrochlorothiazide and Triamterene. Drug Interactions: See also Hydro-chlorothiazide and Triamterene. How Supplied: See Content

Dosage-

Hypertension or edema. Adults: Triamterene/hydrochlorothi-

azide: 37.5 mg/25 mg—1-2 capsules given once daily with monitoring of serum potassium and clinical effect. Triamterene/hydrochlorothiazide: 50 mg/25 mg—1-2 capsules b.i.d. after meals. Some clients may be controlled using 1 capsule every day or every other day. No more than 4 capsules should be taken daily.

Hypertension or edema. Adults: Triamterene/hydrochlorothi-azide: 37.5 mg/25 mg—1-2 tablets/day (determined by individual titration with the components). Or, triamterene/hydrochlorothiazide: 75 mg/50 mg—1 tablet daily.

DENTAL CONCERNS

See also Dental Concerns for Antihypertensive Agents, Triamterene, and Hydrochlorothiazide. General

1. Patients on chronic drug therapy may develop blood dyscrasias. Symptoms include fever, sore throat, bleeding, and poor wound healing. Consultation with Primary Care Provider

1. Patients with symptoms of blood dyscrasias should be referred to their primary care provider for complete blood counts. Treatment should be postponed until the results are known.

Trihexyphenidyl hydrochloride

[try-hex-ee-FEN-ih-dill] Pregnancy Category: C

Aparkane M, Apo-Trihex M, Artane, Artane Sequels, Novo-Hexidyl M, PMS-Trihexyphenidyl M, Trihexy-2 and -5, Trihexyphen M [Rx] Classification: Antiparkinson agent, anticholinergic

See also Cholinergic Blocking Agents and Antiparkinson Drugs. Action/Kinetics: Synthetic anti-cholinergic, which relieves rigidity but has little effect on tremors. Causes a direct antispasmodic effect on smooth muscle. High incidence of side effects. Small doses cause CNS

TROGLITAZONE

depression, whereas larger doses may result in CNS excitation. Onset, PO: 60 min. Duration, PO: 6-12 hr. Uses: Adjunct in the treatment of all types of parkinsonism (often used as adjunct with levodopa). Drug-induced extrapyramidal symptoms. Sustained-release medication is for maintenance dosage only. Additional Contraindications: Arteriosclerosis and hypersensitivity to drug.

Additional Side Effects: Serious CNS stimulation (restlessness, insomnia, delirium, agitation) and psychotic manifestations. Additional Drug Interactions: T Effectiveness of levodopa if used together; such combined use not recommended in clients with psychoses. How Supplied: Elixir: 2 mg/5 mL; Tablet: 2 mg, 5 mg

Dosage-

Parkinsonism. Initial (day 1): 1-2 mg; then, increase by 2 mg q 3-5 days until daily dose is 6-10 mg given in divided doses. Some clients may require 12-15 mg/day (especially those with postencephalitic parkinsonism).

Adjunct with levodopa. Adults: 3-6 mg/day in divided doses.

Drug-induced extrapyramidal reactions.

Initial: 1 mg/day; then, increase as needed to total daily dose of 5-15 mg.

DENTAL CONCERNS

See also Dental Concerns for Choli-nergic Blocking Agents and Antiparkinson Drugs.

Trimipramine maleate

[try-MIP-rah-meen] Pregnancy Category: C

Apo-Trimip M, Novo-Tripramine M, Nu-Trimipramine M, Rhotrimine M, Surmontil (Rx)

Classification: Antidepressant, tricyclic

See also Antidepressants, Tricyclic. Action/Kinetics: Causes moderate anticholinergic and orthostatic hypo-tensive effects and significant sedative effects. Effective plasma levels: 180 ng/mL. Time to reach steady state: 2-6 days. t12: 7-30 hr. Uses: Treatment of symptoms of depression. PUD. Seems more effective in endogenous depression than in other types of depression. Contraindications: Use in children less than 12 years of age. How Supplied: Capsule: 25 mg, 50 mg, 100 mg

Dosage-

Antidepressant. Adults, outpatients, initial: 75 mg/

day in divided doses up to 150 mg/day. Daily dosage should not exceed 200 mg; maintenance: 50-150 mg/day. Total dose can be given at bedtime. Adults, hospitalized, initial: 100 mg/day in divided doses up to 200 mg/day. If no improvement in 2-3 weeks, increase to 250-300 mg/ day. Adolescent/geriatric clients, initial: 50 mg/day up to 100 mg/day. Not recommended for children.

DENTAL CONCERNS

See also Dental Concerns for Antide-pressants, Tricyclic.

Troglitazone

[troh-GLIH-tah-zohn] Pregnancy Category: B Rezulin (Rx)

Classification: Oral hypoglycemic

See also Antidiabetic Agents: Hypogly-cemic Agents.

Action/Kinetics: Decreases hepatic glucose output and increases insulin-dependent glucose disposal in skeletal muscle and perhaps liver and adipose tissue. Troglitazone is not an insulin secretagogue. Rapidly absorbed; maximum plasma levels: 2-3 hr. Steady-state plasma levels are reached in 3-5 days. Food increases the rate of absorption. t1/2 , elimina

426 TROGLITAZONE

tion: 16-34 hr. Metabolized in the liver and excreted mainly in the feces. Uses: Alone or in combination with a sulfonylurea for treatment of type II diabetes with poor glucose control despite insulin therapy. Non-FDA Approved Uses: Use in the productive and metabolic consequences of polycystic ovary syndrome. Contraindications: Lactation. Use for type I diabetes or for the treatment of diabetic ketoacidosis. Special Concerns: Use with caution in those with liver disease. Ovulation may resume in premenopausal anovulatory clients, leading to an increased risk of pregnancy. Safety and efficacy have not been determined in children.

Side Effects: GI: Nausea, diarrhea. CNS: Headache, dizziness. Metabolic: Hypoglycemia. Hematologic: Decreased hemoglobin, hematocrit, and white blood cell counts. Nose/throat: Rhinitis, pharyngitis. Miscellaneous: Infection, pain, accidental injury, asthenia, back pain, UTI, peripheral edema.

Drug Interactions Terfenadine / l Plasma levels of terfenadine ^ l effect How Supplied: Tablets: 200 mg, 400 mg

Dosage-

With insulin in type II diabetes mellitus.

Adults: 200 mg daily while continuing the insulin dosage. If the response is inadequate, the dose may be increased after 2-4 weeks. Usual daily dose: 400 mg/day. Maximum daily dose: 600 mg/day. The insulin dose should be decreased by 10%-25% when fasting plasma glucose levels decrease to less than 120 mg/dL in clients receiving both insulin and troglitazone.

Polycystic ovary syndrome. Adults: 400 mg/day.

DENTAL CONCERNS

See also Dental Concerns for Antidi-abetic Agents, Hypoglycemic Agents.

1. Place dental chair in semisupine position to help eliminate or minimize GI adverse effects of the drug.

-COMBINATION DRUG-

Tylenol with Codeine Elixir or Tablets

[TIE-leh-noll, KOH-deen] Pregnancy Category: C (Tablets are C-III and Elixir is C-V) [Rx] Classification: Analgesic

See also Acetaminophen and Opioid Analgesics.

Content: Nonopioid analgesic: Acetaminophen, 300 mg in each tablet, and 120 mg/5 mL elixir. Opioid analgesic: Codeine phosphate, 15 mg (No. 2 Tablets), 30 mg (No. 3 Tablets), 60 mg (No. 4 Tablets), and 12 mg/5 mL (Elixir).

Uses: Tablets: Mild to moderately severe pain. Elixir: Mild to moderate pain.

Special Concerns: Use with caution during lactation. Safety has not been determined in children less than 3 years of age. May be habit-forming due to the codeine component.

How Supplied: See Content

Dosage-

• Tablets, Capsules

Analgesia. Adults, individualized, usual: 1-2

No. 2 or No. 3 Tablets or No. 3 Capsules q 2-4 hr as needed for pain. Or, 1 No. 4 Tablet or Capsule q 4 hr as required. Maximum 24-hr dose is 360 mg codeine phosphate and 4,000 mg acetaminophen. Pediatric: Dosage equivalent to 0.5 mg/kg codeine.

Analgesia. Adults, individualized, usual: 15 mL q 4 hr as needed; pediatric, 7-12 years: 10 mL t.i.d.-q.i.d.; 3-6 years: 5 mL t.i.d.-q.i.d.

DENTAL CONCERNS

See also Dental Concerns for Opioid Analgesics.

VALPROIC ACID 427

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