10/30/2019

1

10/30/2019 1

Managing Medication Side Effects

Presented by:Karen Malatestinic BSN, RNDebbie Van Senus BSN, RN

10/30/2019 2

10/30/2019 3 10/30/2019 4

10/30/2019

2

Learning Objectives

10/30/2019 5

1. Identify common medications in a Pediatric Urology setting

2. Provide accurate information/education for management of common urological medication side effects

3. Apply knowledge of medication side effects into daily practice

Most Commonly Used Urologic Medications

• Anticholinergics/Antispasmodics• Alpha Blockers• Antibiotics • Bowel Medication• Antidiuretic Hormone

10/30/2019 6

10/30/2019 7

Anticholinergics/Antispasmodics

Definition:Anticholinergics (Antimuscarinic) Agents-inhibit muscarinic receptors in the detrusor muscle of the urinary bladder, thereby reducing involuntary bladder contraction.

These medications act on the neurotransmitter, acetylcholine. By blocking the action of acetylcholine, anticholinergics prevent impulses from the parasympathetic nervous system from reaching smooth muscle and causing contractions, cramps, or spasms. Therefore, these medications relax the bladder by decreasing the bladder pressure and spasms.

• Ditropan (Oxybutynin)

• Detrol (Tolterodine)

• Vesicare(Solifenacin)

• Oxytrol Patch (Oxybutynin transdermal)

10/30/2019 8

Anticholinergics/Antispasmodics

• Myrbetriq (Mirabegron)

• Sanctura(Trospium)

• Enablex(Darifenacin)

10/30/2019

3

Common Side Effects of Anticholinergics/Antispasmodics

10/30/2019 9

• Facial flushing• Dry mouth, dry eyes• Constipation• Vision Changes/blurred

vision• Headaches• Drowsiness/fatigue• Dizziness• Mood/Behavior changes

• Hallucinations/agitation

• Nightmares

• Upset stomach

• Confusion

• Urinary retention

Ditropan

Generic: Oxybutynin

10/30/2019

Ditropan 5mg/5ml liquid suspensionDitropan 5mg tablet IR

Ditropan 5mg XLDitropan 10mg XLDitropan 15mg XL

Dose: 0.2mg/kg/dose2-3 times/day ages 1-5 years> age 5 give 5mg twice daily up to 5mg 3 times/day

DetrolGeneric: Tolterodine

10/30/2019 11

Detrol suspension 2mg/5ml

Detrol 1mg tablets give 2 x per dayDetrol 2mg tablets give 2 x per day

Detrol LA 2mg capsules give once per dayDetrol LA 4mg capsules give once per day

Dose: 0.1mg/kg/day given Bid

Vesicare/Sanctura/Enablex

10/30/2019 12

Vesicare Generic: Solifenacin5mg and 10mg tablets ER given once daily

Sanctura Generic: Trospium20mg tablets IR BID or 20mg XL given daily60mg ER once daily

Enablex Generic: Darifenacin7.5mg ER tablets and 15mg ER tablets

10/30/2019

4

Myrbetriq

Generic: Mirabegron

10/30/2019 13

25mg tablets ER given once daily50mg tablets ER given once daily

These agents stimulate beta-3 adrenergic receptors in the detrusor muscle of the

bladder, which enhances bladder relaxation, improves bladder capacity.

• Can increase blood pressure

Oxytrol Patch

10/30/2019 14

Side Effects: redness, irritation, itching, swelling at the site.

Transdermal version of Oxybutynin

Oxytrol Patch

• Change patch twice weekly• Apply to areas specified in package labeling• When applying a new patch use a new area of skin,

wait at least 1 week before applying to same location.

• Can get wet in shower, bath, or swimming.-If it falls off, replace

• Available OTC• DO NOT CUT or trim patch• Prep skin with alcohol • Hydrocortisone cream OTC for local reaction

– continued issues, pretreat skin with Benadryl cream and wait 1 hour prior to applying

10/30/2019 15

• Setting Expectations– May take a few weeks to see response– Every patient is different

• Dose Titration– Titrate the dose of the anticholinergic– May need to change to liquid

• Dose Reduction– First line of treatment before d/c– May need to change to liquid

• ER vs IR– Compliance– Tolerance

10/30/2019 16

Side Effect Managementof Anticholinergics

10/30/2019

5

Education

• Oral Care– Chap-stick– Hydration– Oral hygiene– Dental visits

10/30/2019 17

Education

• Overheating– Facial flushing– Hydration– Sports

10/30/2019 18

Education

• Vision– Evaluate headaches– Eye drops– Eye exams

10/30/2019 19

• Assessment• School• Catheterization/Pelvic Floor

Therapy• Additional Medication

10/30/2019 20

Side Effect Management of Anticholinergics

10/30/2019

6

Side Effect Management of Anticholinergics

• Assessment– Based on verbal communication through telehealth/phone triage– For reports of behavioral issues, agitation, or mood changes.

Evaluate for change or stressors in the family, school, or with friends

– If unsure the medication is the cause, stop the medication for 3 days.

– If behavior doesn't resolve have patient see primary care MD

• School– Dose adjustment or altering time may help with drowsiness or

difficulty concentrating– Request 2 labeled bottles so midday dose can be given at school,

school note needed

10/30/2019 21

Side Effect Management of Anticholinergics

• Pelvic floor therapyDysfunctional voiders may benefit from PT in addition to medication

• CatheterizationRetention or difficulty emptying bladder may occur.

For neurogenic bladder or poor emptying, catheterization may be initiated

• Additional MedicationFor patients with overactive bladder and sphincter dyssynergia, Flomax or Cardura may be added

10/30/2019 22

Dysfunctional Bladder

Lack of coordination between bladdercontraction and sphincter relaxation results in incomplete emptying, and overactive bladder.

Definition: These agents block postsynaptic alpha, adrenergic receptors in the bladder neck and prostate. This causes muscle relaxation of the bladder neck and prostatic smooth muscle, and relieves obstructive voiding symptoms.

10/30/2019 24

Alpha Blockers

10/30/2019

7

- Obtain BP reading prior to starting, repeat 3-4 days after, and take an additional 2 more readings in 2-3 weeks.

- Take medication 30 minutes before bed to help minimize lightheadedness

- Upon waking patient should sit at bedside for a couple minutes before getting up.

- Taper when stopping

10/30/2019 25

Alpha Blockers

• Lightheadedness• Hypotension • Headache

Common Side Effects:

- Avoid in patients with Sulfa allergy- Not supposed to be opened

chewed or crushed – need to swallow

- Used to dilate ureters- Stones- Stent discomfort

- Cannot be given via G-tube

Flomax (Tamsulosin)Cardura (Doxazosin)Definition: Inhibits the growth of or destroys

microorganisms – treats bacterial infections.

10/30/2019 26

Antibiotics

• Amoxil• Keflex• Septra• Macrodantin• Cipro

10/30/2019 27

Antibiotics

Common Side Effects:

• Skin Rash/Hives• GI issues

– Upset stomach– Gas– Diarrhea– Decreased appetite

• Yeast Rash

Amoxil

Generic: Amoxicillin

10/30/2019 28

• Used in children less than 2-3months of age

• Suspension 125mg/5ml, 250mg/5ml, 400mg/5ml

• Safe to take when pregnant and breastfeeding

• Can Cause Yeast

Suspension 125mg/5ml, 250mg/5ml, 400mg/5mlChewables 125mg and 250mgCapsules 250mg, 500mgTablets 500mg and 875mg

10/30/2019

8

Keflex

Generic: Cephalexin

10/30/2019 29

• Give with food to avoid GI upset

• Safe to take when pregnant and breastfeeding

• Can cause a severe form of diarrhea called C-diff

Suspension 125mg/5mL and 250mg/5mlCapsules 250mg, 500mg, 750mg

Septra/Bactrim

Generic: Sulfamethoxazole-trimethroprim

10/30/2019 30

• Safe to use 2 months or greater

• Sun Sensitivity

• Rare side effect Steven Johnson's Syndrome

Suspension 200mg/40mg/5mlSeptra SS tablet 400mg/80mgSeptra DS tablet 800mg/160mg

• Can lower white count

• Yearly CBC

Macrodantin

Generic: Nitrofurantoin

10/30/2019 31

• Avoid with patients with chronic lung disease(pulmonary fibrosis)

• Antacids can decrease absorption

Nitrofurantoin 25mg/5ml suspensionMacrodantin 25mg, 50mg and 100mg capsulesMacrobid 100mg ER tablet

• Can take until 38weeks of pregnancy related to hemolytic anemia in neonate, Also do not take while breastfeeding.

• Can elevate liver enzymes, yearly CMP

Cipro

Generic: Ciprofloxacin

10/30/2019 32

BLACK BOX WARNING• Can cause tendon rupture,

tendinitis, and peripheral neuropathy

• Educate family to call for any potential side effects or adverse reaction

• Give 2 hours before or 6 hours after any dairy products or mineral supplements to avoid decrease absorption

• Clogs GT

• Give 2 hours after meals

Suspension 250mg/5ml and 500mg/5ml Tablets 250mg and 500mg

10/30/2019

9

Bowel Medication

MiralaxGeneric: Polyethylene Glycol

We use Miralax for a variety of patients including dysfunctional voiders, neurogenic bowels, and post op patients.

Because the bowel directly effects bladder behavior we need to address bowel activity.

Miralax is titrated to obtain the desired effect

10/30/2019 33

Side effects: diarrhea or loose stools, gas, bloating, nausea, stomach pain

Bowel Medication

10/30/2019 34

Miralax: • Stress importance of using fluid amount recommended to

achieve desired effect. • Titrate dose

- Start with a lower dose and increase accordingly or start with higher dose then lower the dose with the goal of daily soft bowel movements

• It usually takes 1-4 days to see results

• Fiber Gummies:• Patients and families commonly stop miralax due to stools

getting too loose. • When scheduling surgery, educate patients prior to surgery on

ways to help prevent post op constipation. • -Diet, fluids, Miralax, fiber, probiotics

Constipation• Infrequent BM

• Frequent >2x day

• Hard small stools

• Abnormally large stool

• Painful, blood streaks

• Stool accidents (streaks, smears)

• Retentive behavior (hides)

• Sits, strains for a long time

Prevent and Treat Constipation

• Make sure your child drinks plenty of fluid-mostly water-during the day– Follow Elimination Diet

• Eat a high fiber diet– Fruits, vegetables, grains

• Establish a routine– Timed sitting (5-10) minutes after a meal– Sit with feet supported, pants down around ankles and in a

relaxed position• May need a toilet insert

10/30/2019

10

Antidiuretic Hormone

10/30/2019 38

Definition: Antidiuretic hormone, a man- made hormone that regulates how the body uses water.

DDAVP-Desmopressin

• Anti-diuretic hormone

• Taken at bedtime with a sip of water

• Stop fluids 2 hours before and 8 hours after

• Maximum dose is 3 tabs(0.6mg) usually start at 0.4mg and increase after one week if wetting persists. Decrease to 0.2mg if dry at one week

• Works in 50-60% patients

• Water toxication

10/30/2019 39

Common Side Effects of DDAVP

10/30/2019 40

Common side effects related to excess fluid intake resulting in water toxicity (hyponatremia).

Common Side Effects:• Headache• Nausea• Vomiting • Seizures.

DO NOT take if vomiting or diarrhea. With decreased NA levels=confusion, muscle cramping, hallucinations, feeling

restless or unsteady

Fluid Shifting

• Not enough to drink less at night• Drink 6-8 oz. every 2 hours (day)• Eliminate bladder irritants after 4pm

(caffeine, carbonation, citric acid, chocolate, red and purple dyes, and dairy products)

• From 4pm to dinner – 12 oz. total• Sips at bedtime if medications taken

10/30/2019 41

10/30/2019

11

Conclusion

• Listen to your patients and parents• Be proactive vs reactive

10/30/2019 42

References

• https: //online.lexi.com/lco/action/doc/retrieve/docid/iuhealthsystem

• Kidney Disease Program Kidney Disease Program https: //Kdpnet.Kdp.Louisville.edu/drug book/pediatric

• Medications (2019)http://www.epocrates.com/mobile/iphone/essentials

• Guide to Urological Medications. (2016). A supplement to the SUNa core curriculum fro urologic nursing (pg 1-50). Pitman, NJ:Mary Lee, Pharm D, BCPS , FCC P. Nicole A. Rozette, Pharm D, BCPS

10/30/2019 43