Warning patients

Some ophthalmic drugs produce blurring of vision, which can result in falls and other injuries. The nurse warns patients to exercise care when getting out of bed when the vision is impaired by these drugp. Patients using the pilocarpine ocular therapeutic system must have the system replaced every 7 days (see Chap. 24). The system is inserted at bedtime because myopia (nearsightedness) occurs for several hours after insertion. 

Because of the potential for postural hypotension, warn patients that dizziness, presyncope, and even syncope may result from abrupt changes in body position during initiation or up-titration of drugs with a-blocking effects. 

In 2002, the Supreme Judicial Court of Massachusetts joined a growing number of state courts that have recognized a responsibility of pharmacists to warn patients of possible side effects from prescribed medications. In the case of Cottam v. CVS Pharmacy (764 N.E.2d 814), that court affirmed a jury verdict in favor of a patient who had not been warned of the risk of priapism by the pharmacist who dispensed trazodone to him. The facts of the case disclosed that the pharmacy provided a short list of warnings to the patient but priapism was not included on the list. The court ruled that when a patient can reasonably conclude that a list of side effects is a complete and comprehensive list, the pharmacy has undertaken a legal duty to provide complete warnings and information. 

Side effects, warning patients of, 210 Single-nucleotide polymorphism (SNP) maps, 83-84... 

Warn patients of the risk of hepatic injury and advise them to stop the use of naltrexone and seek medical attention if they experience symptoms of acute hepatitis. 

Hematologic effects Aspirin interferes with hemostasis. Avoid use if patients have severe anemia, history of blood coagulation defects, or take anticoagulants. Long-term therapy To avoid potentially toxic concentrations, warn patients on long-term therapy not to take other salicylates (nonprescription analgesics, etc). Salicylism Salicylism may require dosage adjustment. 

Potentially hazardous tasks May produce drowsiness, disorientation, and confusion. Warn patients against engaging in activities that reguire mental alertness, such as driving a motor vehicle or operating dangerous machinery. 

Hazardous tasks Because of its profound effects on mental status, warn patients... 

Pancreatitis Cases of life-threatening pancreatitis have been reported in children and adults receiving valproate. Some of the cases have been described as hemorrhagic with rapid progression from initial symptoms to death. Some cases have occurred shortly after initial use as well as after several years of use. Warn patients and guardians that abdominal pain, nausea, vomiting, or anorexia can be symptoms of pancreatitis that require prompt medical evaluation. 

Hepatic - Pretreatment serum transaminase (ALT and AST) tests are advised for all patients before taking terbinafine. Warn patients to immediately report to their physician any symptoms of persistent nausea, anorexia, fatigue, vomiting, right upper abdominal pain or jaundice, dark urine, or pale stools. Discontinue treatment in patients with these symptoms taking oral terbinafine, and immediately evaluate the patient s liver function. 

Dosage adjustment Discontinue nevirapine if patients experience severe rash or a rash accompanied by constitutional findings (see Warnings). Patients experiencing rash during the 14-day lead-in period of 200 mg/day (4 mg/kg/day in children) should not have their nevirapine dose increased until the rash has resolved. 

Levonorgestrel is used in the form of intrauterine devices, both as a contraceptive and to treat menorrhagia. They are effective, but critical reviewers continue to point to the need to be alert to the possible development of pain and hypermenorrhea, and to warn patients of the possibility of expulsion or perforation (46). 

Another factor that may hinder compliance is the sleep loss experienced early in treatment. SRT initially produces a mild sleep deprivation, with associated daytime fatigue and drowsiness experienced in midaftemoon and evening hours. Sometimes, patients worry that they will not be able to tolerate these effects (5,30). Education, reassurance, and support are important to alleviate fears, increase treatment compliance, and help reduce dropouts. Warning patients about this potential short-term effect is important, especially when full alertness at work or for other tasks is a concern (30). 

Allergies and any other medicines should be enquired about before explaining that Mrs WL should take one tablet three times a day. Explain what side-effects she may experience as above and inform her that she can take the tablets with food if the side-effects are troublesome. It is very important to warn patients that their stools may be darkened (almost black). Compliance is often an issue with iron tablets and good counselling can aid this. 

Inhaled corticosteroids should be prescribed for patients with an FEVi of 50% predicted or less, who have two or more exacerbations needing treatment with antibiotics or oral corticosteroids a year. Warn patients about the possible risk of osteoporosis and other side effects of high-dose inhaled corticosteroids. None of the inhaled corticosteroids currently available is licensed alone for use in COPD. 

Withdrawal symptoms in the 2 weeks after sudden discontinuation of citalopram have been examined in a double-blind, placebo-controlled study (24). Withdrawal symptoms were overall mild, but neurological and psychiatric disturbances were 2-3 times as common in patients randomized to placebo than in those randomized to continue with citalopram. The authors pointed out that withdrawal symptoms were particularly common in patients who were randomized to placebo who also had depressive relapses. This shows the difficulty of disentangling the effects of depressive relapse from those of pure treatment withdrawal. However, it is also possible that acute withdrawal of medication induces an abnormal neu-robiological state, in which both depression and abstinence symptoms are more likely to occur. It would be wise to warn patients about the possible effects of missing doses of the shorter-acting SSRIs. 

AMIODARONE GRAPEFRUIT JUICE Possibly 1 effect of amiodarone Inhibition of CYP3A4-mediated metabolism of amiodarone to its active metabolite Warn patients to avoid grapefruit juice if amiodarone becomes less effective, ask the patient about grapefruit juice ingestion... 

AMIODARONE H2 RECEPTOR BLOCKERS Cimetidine may t amiodarone levels Uncertain Monitor PR and BP at least weekly until stable. Warn patients to report symptoms of hypotension (lightheadedness, dizziness on standing, etc.). Consider alternative acid suppression therapy... 

DISOPYRAMIDE ANALGESICS Disopyramide may slow the onset of action of intermittent dose paracetamol These drugs have anticholinergic effects that include delayed gastric emptying. This will delay absorption Warn patients that the action of paracetamol may be delayed. This will not be the case when paracetamol is taken regularly... 

CENTRALLY ACTING ANTIHYPERTENSIVES ALCOHOL Clonidine and moxonidine may exacerbate the sedative effects of alcohol, particularly during initiation of therapy Uncertain Warn patients of this effect and advise them to avoid driving or operating machinery if they suffer from sedation... 

VASODILATOR ANTIHYPERTENSIVES CICLOSPORIN 1. Co-administration of bosentan and cidosporin leads to t bosentan and 1 cidosporin levels 2. Risk of hypertrichosis when minoxidil given with cidosporin 3. t sitaxentan levels 1. Additive effect both drugs inhibit the bile sodium export pump, which is associated with hepatotoxicity 2. Additive effect 3. Uncertain 1. Avoid co-administration of bosentan and cidosporin 2. Warn patients of the potential interaction 3. Avoid co-administration... 

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