Metoprolol tartrate, USP is a selective beta1-adrenoreceptor blocking agent, available as 25, 50 and 100 mg tablets for oral administration.

Hypertension Metoprolol tartrate tablets are indicated for the treatment of hypertension. They may be used alone or in combination with other antihypertensive agents. Angina Pectoris Metoprolol tartrate tablets are indicated in the long-term treatment of angina pectoris. Myocardial Infarction Metoprolol tartrate injection and tablets are indicated in the treatment of hemodynamically stable patients with definite or suspected acute myocardial infarction to reduce cardiovascular mortality. Treatment with intravenous metoprolol tartrate can be initiated as soon as the patients clinical condition allows (see DOSAGE AND ADMINISTRATION, CONTRAINDICATIONS, and WARNINGS). Alternatively, treatment can begin within 3 to 10 days of the acute event (see DOSAGE AND ADMINISTRATION). Classifications: autonomic nervous system agent; beta-adrenergic antagonist (sympatholytic); antihypertensive Prototype: Propranolol Pregnancy Category: C NURSING IMPLICATIONS Assessment & Drug Effects

Take apical pulse and BP before administering drug. Report to physician significant changes in rate, rhythm, or quality of pulse or variations in BP prior to administration. Monitor BP, HR, and ECG carefully during IV administration. Expect maximal effect on BP after 1 wk of therapy. Take several BP readings close to the end of a 12 h dosing interval to evaluate adequacy of dosage for patients with hypertension, particularly in patients on twice daily doses. Some patients require doses 3 times a day to maintain satisfactory control. Observe hypertensive patients with CHF closely for impending heart failure: Dyspnea on exertion, orthopnea, night cough, edema, distended neck veins. Lab tests: Obtain baseline and periodic evaluations of blood cell counts, blood glucose, liver and kidney function. Monitor I&O, daily weight; auscultate daily for pulmonary rales.

Withdraw drug if patient presents symptoms of mental depression because it can progress to catatonia. Possible symptoms of depression: disinterest in people, surroundings, food, personal hygiene; withdrawal, apathy, sadness, difficulty in concentrating, insomnia. Monitor patients with thyrotoxicosis closely since drug masks signs of hyperthyroidism (see Appendix F). Abrupt withdrawal may precipitate thyroid storm.

Patient & Family Education

Learn how to take radial pulse before each dose. Report to physician if pulse is slower than base rate (e.g., 60 bpm) or becomes irregular. Consult physician for parameters. Reduce insomnia or increased dreaming by avoiding late evening doses. Monitor blood glucose (diabetics) for loss of glycemic control. Drug may mask some symptoms of hypoglycemia (e.g., BP and HR changes) and prolong hypoglycemia. Be alert to other possible signs of hypoglycemia not affected by metoprolol and report to physician if present: Sweating, fatigue, hunger, inability to concentrate. Protect extremities from cold and do not smoke. Report cold, painful, or tender feet or hands or other symptoms of Raynauds disease (intermittent pallor, cyanosis or redness, paresthesias). Physician may prescribe a vasodilator. Report immediately to physician the onset of problems with vision. Learn measures to relieve dry mouth; rinse mouth frequently with water, increase noncalorie liquid intake if inadequate, suck sugarless gum or hard candy. Relieve eye dryness by using sterile artificial tears available OTC. Do not drive or engage in potentially hazardous activities until response to drug is known. Do not alter established dosage regimen; compliance is very important. Reduce dosage reduced gradually over a period of 12 wk when drug is discontinued. Sudden withdrawal can result in increase in anginal attacks and MI in patients with angina pectoris and thyroid storm in patients with hyperthyroidism. Do not breast feed while taking this drug without consulting physician. .

GENERIC NAME: amiodarone BRAND NAME: Cordarone DRUG CLASS AND MECHANISM: Amiodarone is used to correct abnormal rhythms of the heart. (It is an antiarrhythmic medication.) Amiodarone was discovered in 1961 and approved by the FDA in December of 1985. Although amiodarone has many side effects, some of which are severe and potentially fatal, it has been successful in treating many arrhythmias where other antiarrhythmic drugs have failed. Amiodarone is considered a "broad spectrum" antiarrhythmic medication, that is, it has multiple and complex effects on the electrical activity of the heart which is responsible for the heart's rhythm. Among its most important electrical effects are: 1. a delay in the rate at which the heart's electrical system "recharges" after the heart contracts (repolarization);

2. a prolongation in the electrical phase during which the heart's muscle cells are electrically stimulated (action potential); 3. a slowing of the speed of electrical conduction (how fast each individual impulse is conducted through the heart's electrical system); 4. a reduction in the rapidity of firing of the normal generator of electrical impulses in the heart (the heart's pacemaker); 5. a slowing of conduction through various specialized electrical pathways (called accessory pathways) which can be responsible for arrhythmias. In addition to being an antiarrhythmic medication, amiodarone also causes blood vessels to dilate (enlarge). This effect can result in a drop in blood pressure. Because of this effect, it also may be of benefit in patients with congestive heart failure. PRESCRIBED FOR: Amiodarone is used for many serious arrhythmias of the heart including ventricular fibrillation, ventricular tachycardia, atrial fibrillation, and atrial flutter. DOSING: Amiodarone usually is given in several daily doses to minimize stomach upset which is seen more frequently with higher doses. For this same reason, it is also recommended that amiodarone be taken with meals. DRUG INTERACTIONS: Amiodarone may interact with beta-blockers such as atenolol (Tenormin), propranolol (Inderal), metoprolol (Lopressor), or certain calcium channel blockers, such as verapamil (Calan, Isoptin, Verelan, Covera-HS) or diltiazem (Cardizem, Dilacor, Tiazac), resulting in an excessively slow heart rate or a block in the conduction of the electrical impulse through the heart. Amiodarone increases the blood levels of digoxin (Lanoxin) when the two drugs are given together. It is recommended that the dose of digoxin be cut by 50% when amiodarone therapy is started. Flecainide (Tambocor) blood concentrations increase by more than 50% with amiodarone. Procainamide (Procan-SR, Pronestyl) and quinidine (Quinidex, Quinaglute) concentrations increase by 30%-50% during the first week of amiodarone therapy. Additive electrical effects occurs with these combinations, and worsening arrhythmias may occur as a result. Some experts recommend that the doses of these other drugs be reduced when amiodarone is started. SIDE EFFECTS: Also see Warning section. Constipation, loss of appetite, bitter taste in mouth, nausea, vomiting, dizziness, trouble sleeping, headache, flushing of the face, or decreased sexual interest may occur as your body adjusts to the medication. If any of these effects persist or worsen, notify your doctor promptly. This drug, when used in combination with simvastatin, may infrequently cause muscle damage (which can rarely lead to a very serious condition called rhabdomyolysis). Tell your doctor immediately if you develop: muscle pain/tenderness/weakness (especially with fever or unusual tiredness). Tell your doctor immediately if any of these unlikely but serious side effects occur: coldness, sweating, unexplained weight change, enlarged thyroid gland, nervousness, uncontrolled shaking/tremor, sluggishness, loss of coordination, tingling or numbness of the hands or feet, swelling of the hands or feet, irregular pulse, vision changes (e.g.,

seeing halos, blurred vision, loss of vision), easy bruising/bleeding, persistent sore throat. This drug may cause skin reactions similar to a serious sunburn. Infrequently with long-term amiodarone treatment, you may develop blue-gray discoloring of the skin, particularly of the face and hands. This effect is not harmful and usually reverses, sometimes incompletely, after the drug is stopped. Avoiding prolonged sun exposure may help to prevent this effect. See also Precautions. In the unlikely event you have a serious allergic reaction to this drug, seek immediate medical attention. Symptoms of a serious allergic reaction include: rash, itching, swelling, severe dizziness, trouble breathing. If you notice other effects not listed above, contact your doctor or pharmacist.

PRECAUTIONS: Before taking amiodarone, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies. This medication should not be used if you have certain medical conditions. Before using this medicine, consult your doctor or pharmacist if you have: certain types of irregular heartbeats or heart rhythms (e.g., severe sinus node dysfunction resulting in marked sinus bradycardia, second or third degree atrioventricular block, bradycardia with associated syncope except when a pacemaker is used). Before using this medication, tell your doctor or pharmacist your medical history, especially of: liver disease, heart problems (e.g., congestive heart failure, low blood pressure), lung diseases, thyroid problems, upcoming major surgery, electrolyte problems such as low potassium or low magnesium. This drug may make you dizzy; use caution engaging in activities requiring alertness such as driving or using machinery. Limit alcoholic beverages. This medication may make you more sensitive to the sun. Avoid prolonged sun exposure, tanning booths or sunlamps. Use a sunscreen and wear protective clothing when outdoors. This medication is not recommended for use during pregnancy due to the potential for fetal harm. Consult your doctor for more details. Amiodarone passes into breast milk. Breastfeeding is not recommended while using this drug. (a-meeoh-da-rone) Cordarone, Amio-Aqueous, Pacerone Classifications: cardiovascular agent; antiarrhythmic, class iii Pregnancy Category: D NURSING IMPLICATIONS Assessment & Drug Effects

Monitor BP carefully during infusion and slow the infusion if significant hypotension occurs; bradycardia should be treated by slowing the infusion or discontinuing if necessary. Monitor heart rate and rhythm and BP until drug response has stabilized; report promptly symptomatic bradycardia. Sustained monitoring is essential because drug has an unusually long half-life. Monitor for S&S of: Adverse effects, particularly conduction disturbances and exacerbation of arrhythmias, in patients receiving concomitant antiarrhythmic therapy (reduce dosage of previous agent by 30%50% several days after amiodarone therapy is started); drug-induced hypothyroidism or hyperthyroidism (see Appendix F), especially

during early treatment period; pulmonary toxicity (progressive dyspnea, fatigue, cough, pleuritic pain, fever) throughout therapy. Lab tests: Baseline and periodic assessments should be made of liver, lung, thyroid, neurologic, and GI function. Drug may cause thyroid function test abnormalities in the absence of thyroid function impairment. Monitor for elevations of AST and ALT. If elevations persist or if they are 23 times above normal baseline readings, reduce dosage or withdraw drug promptly to prevent hepatotoxicity and liver damage. Auscultate chest periodically or when patient complains of respiratory symptoms. Check for diminished breath sounds, rales, pleuritic friction rub; observe breathing pattern. Druginduced pulmonary function problems must be distinguished from CHF or pneumonia. Keep physician informed. Anticipate possible CNS symptoms within a week after amiodarone therapy begins. Proximal muscle weakness, a common side effect, intensified by tremors presents a great hazard to the ambulating patient. Assess severity of symptoms. Supervision of ambulation may be indicated.

Patient & Family Education

Check pulse daily once stabilized, or as prescribed. Report a pulse <60. Take oral drug consistently with respect to meals. Become familiar with potential adverse reactions and report those that are bothersome to the physician. Use dark glasses to ease photophobia; some patients may not be able to go outdoors in the daytime even with such protection. Follow recommendation for regular ophthalmic exams, including funduscopy and slit-lamp exam. Wear protective clothing and a barrier-type sunscreen that physically blocks penetration of skin by ultraviolet light (e.g., titanium oxide or zinc formulations) to prevent a photosensitivity reaction (erythema, pruritus); avoid exposure to sun and sunlamps.

Do not breast feed while taking this drug without consulting physician