nursing considerations in midgut net · impaired skin integrity8,12 focus on impaired skin...

1

The case study presented in this brochure is based on a fictional patient Individual results may vary

Indication for Sandostatinreg LARreg Sandostatinreg LARreg (octreotide) is indicated for the treatment of patients with symptoms associated with functional gastro-entero-pancreatic endocrine tumors (eg carcinoid tumors with features of the carcinoid syndrome) and for the treatment of patients with advanced neuroendocrine tumors of the midgut or of unknown primary origin where non-midgut sites of origin have been excluded

Please see Important Safety Information on pages 8-13

NURSING CONSIDERATIONS IN MIDGUT NET

FOLLOW-UP VISIT OF A PATIENT WITH A FUNCTIONAL MIDGUT NET

Not an actual patient or healthcare provider Copyright BurlinghamShutterstockcom

2

Consider the following patient

MEET MARIA63-YEAR-OLD WOMAN LIVING WITH CARCINOID SYNDROME

Diagnosis

Functional localized midgut NET of the small intestine

Surgical History1

Surgical resection 15 months ago

Ongoing Monitoring1-3dagger

Abdominal imaging (CT or MRI) Biochemical monitoring of CgA and 5-HIAA Echocardiogram as clinically indicated

Current Symptoms24

Diarrhea (~8x daily)

Current Treatment4Dagger

Sandostatinreg LARreg (octreotide) 20 mg every 4 weeks

Important NotesMaria has been on Sandostatinreg LARreg therapy for 3 months While her flushing symptoms are controlled she still has diarrhea up to 8x daily and has been feeling weak Maria did not tell her doctor about the excessive diarrhea during her last visit because she was embarrassed

SANDOSTATINreg LARreg IS OFTEN

PRESCRIBED FOR PATIENTS TO HELP

CONTROL SYMPTOMS ASSOCIATED WITH

CARCINOID SYNDROME4 IN CASES LIKE MARIArsquoS

WHERE SYMPTOMS ARE STILL SIGNIFICANT WITH

TREATMENT A DOSE INCREASE TO 30 MG

EVERY 4 WEEKS MAY BE CONSIDERED4

5-HIAA 5-hydroxyindoleacetic acid CgA chromogranin A CT computed tomography MRI magnetic resonance imaging NET neuroendocrine tumor

The information on this page is a representative patient snapshot not a complete patient profile

dagger Please see recommended monitoring during Sandostatinreg LARreg treatment on page 5

DaggerPlease see important dosing information on page 5


Not an actual patient Copyright pixelheadphoto digitalskillet

Shutterstockcom

3

TALKING TO THE PATIENTIt is important for Maria to understand that she must be open and honest with all members of her healthcare team The amount of diarrhea she is experiencing is taking a toll on her body and leaving her feeling weak5

Let Maria know that by informing the doctor he may recommend increasing her dose of Sandostatinreg LARreg to 30 mg every 4 weeks to help control her diarrhea4

Maria can also benefit from further education regarding nutritional decisions to help with symptom control and ensure she is eating the right foods to maintain adequate nutritional status

NUTRITIONAL INTERVENTIONS FOR CARCINOID SYNDROMEFor a patient like Maria who is having excessive diarrhea nutritional status should be a primary concern Dietary recommendations can be made to help maintain body weight and ensure adequate protein

DAILY NUTRITIONAL

NEEDS

1-15 g of protein per kilo ideal body weight65-10 servings

of carbohydrates6

Fat Intake 25-30 of total calories6

Water Intake 2 quarts daily

(electrolyte beverage replacements if needed)6

Vitamins and Minerals if indicated7


Patients should be encouraged to speak to a nutritionist

about dietary needs

These are general guidelines Patients with carcinoid syndrome may have multiple medical issues and nutritional needs should be assessed on a case-by-case basis

4

DIARRHEA MANAGEMENTMaria withheld important information from the doctor about the frequency of her diarrhea because she was embarrassed Nurses should share information with the physician that was miscommunicated or withheld by the patient

In Mariarsquos case a dose increase of Sandostatinreg LARreg to 30 mg every 4 weeks may help with the frequency of diarrhea that Maria is experiencing4 Education on dietary adjustments should be made as well

DIETARY ADJUSTMENTS CAN HELP CONTROL DIARRHEA

WHAT TO AVOID6 WHAT CAN HELP89

Foodsdrinks high in amines

mdash Aged cheeses (cheddar Camembert Stilton)

mdash Alcoholic beverages

mdash Smoked salted or pickled fish and meat (herring salami sausage corned beef)

mdash Yeast extracts and Brewerrsquos yeast

mdash Broad beans sauerkraut shrimp paste some soybean products miso soup soy sauce tofu

mdash Chocolate (in large amounts)

mdash Peanuts coconuts brazil nuts

mdash Some types of pizza

mdash Raspberries bananas avocados

mdash Caffeinated beverages (coffee soda)

Large meals

Fatty or spicy foods

High-fiber foods

mdash Raw fruits and vegetables

Starchy easily digestible carbohydrates

mdash Potatoes with skin removed

mdash White carbohydrates (ie white bread pasta rice)

mdash Cornflour tapioca croissants

Low-fiber foods

mdash Cooked fruits and vegetables

mdash Remove skin seeds and stalks from vegetables

Healthy low-fat sources of protein

Smaller more frequent meals

Room temperature beverages

PATIENTS SHOULD BE ADVISED TO TALK WITH

THEIR DOCTOR BEFORE MAKING ANY

SIGNIFICANT CHANGES TO THEIR DIET


The foods listed here may trigger a reaction and therefore it may be beneficial to avoid or eat sparingly

5

TREATMENT WITH SANDOSTATINreg LARreg

HOW IT WORKSSandostatinreg LARreg is a somatostatin analogue Somatostatin is the hormone in the brain that inhibits secretion of peptides and serotonin produced within the gastroenteropancreatic endocrine system

Somatostatin also inhibits increased secretion of growth hormone4

Administration of Sandostatinreg LARreg in patients with carcinoid syndrome may result in improvement of symptoms particularly of flushing and diarrhea In many cases this is accompanied by a fall in plasma serotonin and reduced urinary excretion of 5-HIAA Administration of Sandostatinreg LARreg also works at the tumor site to inhibit growth in advanced NET of midgut or unknown primary tumor location4

IMPORTANT DOSING INFORMATIONIt is recommended to start treatment with the administration of 20-mg Sandostatinreg LARreg at 4-week intervals Patients on treatment with subcutaneous Sandostatinreg (octreotide acetate) should continue at the previously effective dosage for 2 weeks after the first injection of Sandostatinreg LARreg4

For patients in whom symptoms and biological markers are well controlled after 3 months of treatment the dose may be reduced to 10-mg Sandostatinreg LARreg every 4 weeks4

For patients in whom symptoms are only partially controlled after 3 months of treatment the dose may be increased to 30-mg Sandostatinreg LARreg every 4 weeks4

The recommended dose of Sandostatinreg LARreg for patients with advanced NET of the midgut or unknown primary tumor location is 30 mg every 4 weeks Treatment with Sandostatinreg LARreg for tumor control should be continued in the absence of tumor progression4

RECOMMENDED MONITORING DURING SANDOSTATIN reg LAR reg THERAPYThyroid function hepatic function glucose tolerance and antidiabetic treatment should be monitored during treatment with Sandostatinreg LARreg4

Ultrasonic examination of the gallbladder should occur prior to therapy initiation and at 6-month intervals to check for gallstones4

Patients with a history of vitamin B12 deprivation should have B12 levels monitored during therapy4

LEARN MORE ABOUT SANDOSTATINreg LARreg AT WWWSANDOSTATINCOM


6

NURSING CONSIDERATIONSIf patients are still experiencing diarrhea the following should be reviewed with them during their Sandostatinreg LARreg follow-up visit

Current symptoms4 - Frequency and severity

Reasons for Sandostatinreg LARreg dose changes if any4

Treatment schedule4 - Sandostatinreg LARreg injection by a healthcare professional every 4 weeks

Goals of treatment4

- Nutritional interventions6

Current medication list

Additional Issues to Address With Patients

Chronic diarrhea can put patients at risk for other problems Assess for

Electrolyte imbalances10

Altered nutritional status10

Dehydration11

Impaired skin integrity812

Focus on impaired skin integrity

Frequent loose stools can cause skin breakdown around the anus and patients with poor nutritional status are at an increased risk of having impaired skin integrity812

Patients may be embarrassed to talk about this topic so it is important for the nurse to address this information To help ease discomfort and avoid skin breakdown offer patients the following advice8

Use unscented wet wipes instead of toilet paper

Take a warm bath daily

Wear loose-fitting cotton underwear Nylon can further irritate the area

Consider using a barrier cream or ointment to help soothe the area and prevent further irritation


7

PATIENT SUPPORT GROUPS Encourage your patients to find a support group with other patients with NET either online or in their area if they havenrsquot done so already A support group is a place where they can share their feelings and concerns hear othersrsquo stories and even help those who are just beginning their own journey

It may be harder for patients to find live support groups specific to NET Support groups dedicated to cancer in general should also be considered for the patient and their loved ones

Not an actual patient or healthcare provider Copyright RawpixelcomShutterstockcom


8

SANDOSTATINreg LARreg IMPORTANT SAFETY INFORMATION

Contraindications

Known hypersensitivity to octreotide or to any of the excipients (see list of excipients)

Special warnings and precautions for use

General

As GH-secreting pituitary tumors may sometimes expand causing serious complications (eg visual field defects) it is essential that all patients be carefully monitored If evidence of tumor expansion appears alternative procedures may be advisable

Thyroid function should be monitored in patients receiving prolonged treatment with octreotide

Hepatic function should be monitored during octreotide therapy

Cardiovascular related events

Common cases of bradycardia have been reported Dose adjustment of medicinal products such as beta blockers calcium channel blockers or agents to control fluid and electrolyte balance may be necessary (see section Interaction with other medicinal products and other forms of interaction)

Gallbladder and related events

Octreotide inhibits secretion of cholecystokinin resulting in reduced contractility of the gallbladder and an increased risk of sludge and stone formation Development of gallstones has been reported in 15 to 30 of long-term recipients of sc Sandostatinreg The prevalence in the general population (aged 40 to 60 years) is about 5 to 20 Long-term exposure to Sandostatinreg LARreg of patients with acromegaly or gastro-entero-pancreatic tumors suggests that treatment with Sandostatinreg LARreg does not increase the incidence of gallstone formation compared with sc treatment Ultrasonic examination of the gallbladder before and at about 6-monthly intervals during Sandostatinreg LARreg therapy is however recommended If gallstones do occur they are usually asymptomatic symptomatic stones should be treated either by dissolution therapy with bile acids or by surgery

Glucose metabolism

Because of its inhibitory action on growth hormone glucagon and insulin release Sandostatinreg LARreg may affect glucose regulation Post-prandial glucose tolerance may be impaired As reported for patients treated with sc Sandostatinreg in some instances the state of persistent hyperglycemia may be induced as a result of chronic administration Hypoglycemia has also been reported

In patients with concomitant Type I diabetes mellitus Sandostatinreg LARreg is likely to affect glucose regulation and insulin requirements may be reduced In non-diabetics and type II diabetics with partially intact insulin reserves Sandostatinreg sc administration may result in increases in post-prandial glycaemia It is therefore recommended to monitor glucose tolerance and antidiabetic treatment

In patients with insulinomas octreotide because of its greater relative potency in inhibiting the secretion of GH and glucagon than that of insulin and because of the shorter duration of its inhibitory action on insulin may increase the depth and prolong the duration of hypoglycemia These patients should be closely monitored


9

Nutrition

Octreotide may alter absorption of dietary fats in some patients

Depressed vitamin B12 levels and abnormal Schillingrsquos tests have been observed in some patients receiving octreotide therapy Monitoring of vitamin B12 levels is recommended during therapy with Sandostatinreg LARreg in patients who have a history of vitamin B12 deprivation

Sodium content

Sandostatinreg LARreg contains less than 1 mmol (23 mg) sodium per dose ie is essentially ldquosodium-freerdquo

Interaction with other medicinal products and other forms of interactionDose adjustment of medicinal products such as beta blockers calcium channel blockers or agents to control fluid and electrolyte balance may be necessary when Sandostatinreg LARreg is administered concomitantly (see Special warnings and precautions for use)

Dose adjustments of insulin and antidiabetic medicinal products may be required when Sandostatinreg LARreg is administered concomitantly (see Special warnings and precautions for use)

Octreotide has been found to reduce the intestinal absorption of ciclosporin and to delay that of cimetidine

Concomitant administration of octreotide and bromocriptine increases the bioavailability of bromocriptine

Limited published data indicate that somatostatin analogs might decrease the metabolic clearance of compounds known to be metabolized by cytochrome P450 enzymes which may be due to the suppression of growth hormone Since it cannot be excluded that octreotide may have this effect other drugs mainly metabolized by CYP3A4 and which have a low therapeutic index (eg quinidine terfenadine) should therefore be used with caution

Pregnancy breastfeeding and fertilityPregnancy

There is a limited amount of data (less than 300 pregnancy outcomes) from the use of octreotide in pregnant women and in approximately one third of the cases the pregnancy outcomes are unknown The majority of reports were received after postmarketing use of octreotide and more than 50 of exposed pregnancies were reported in patients with acromegaly Most women were exposed to octreotide during the first trimester of pregnancy at doses ranging from 100-1200 microgramsday of Sandostatinreg sc or 10-40 mgmonth of Sandostatinreg LARreg Congenital anomalies were reported in about 4 of pregnancy cases for which the outcome is known No causal relationship to octreotide is suspected for these cases

Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity (see Preclinical safety data)

As a precautionary measure it is preferable to avoid the use of Sandostatinreg LARreg during pregnancy (see Special warnings and precautions for use)

SANDOSTATINreg LARreg IMPORTANT SAFETY INFORMATION (cont)


10

Breastfeeding

It is unknown whether octreotide is excreted in human breast milk Animal studies have shown excretion of octreotide in breast milk Patients should not breastfeed during Sandostatin reg LARreg treatment

Fertility

It is not known whether octreotide has an effect on human fertility Late descent of the testes was found for male offsprings of dams treated during pregnancy and lactation Octreotide however did not impair fertility in male and female rats at doses of up to 1 mgkg body weight per day (see Preclinical safety data)

Effects on ability to drive and use machinesSandostatinreg LARreg has no or negligible influence on the ability to drive and use machines Patients should be advised to be cautious when driving or using machines if they experience dizziness astheniafatigue or headache during treatment with Sandostatinreg LARreg

Undesirable effects and adverse drug reactionsSummary of the safety profile

The most frequent adverse reactions reported during octreotide therapy include gastrointestinal disorders nervous system disorders hepatobiliary disorders and metabolism and nutritional disorders

The most commonly reported adverse reactions in clinical trials with octreotide administration were diarrhea abdominal pain nausea flatulence headache cholelithiasis hyperglycemia and constipation Other commonly reported adverse reactions were dizziness localized pain biliary sludge thyroid dysfunction (eg decreased thyroid stimulating hormone [TSH] decreased total T4 and decreased free T4) loose stools impaired glucose tolerance vomiting asthenia and hypoglycemia

Tabulated list of adverse reactions

The following adverse drug reactions listed in Table 1 have been accumulated from clinical studies with octreotide

Adverse drug reactions (Table 1) are ranked under heading of frequency the most frequent first using the following convention very common (ge110) common (ge1100 lt110) uncommon (ge11000 lt1100) rare (ge110000 lt11000) very rare (lt110000) including isolated reports Within each frequency grouping adverse reactions are ranked in order of decreasing seriousness



11

Table 1 Adverse drug reactions reported in clinical studies

Gastrointestinal disorders

Very common Diarrhea abdominal pain nausea constipation flatulence

Common Dyspepsia vomiting abdominal bloating steatorrhea loose stools discoloration of feces

Nervous system disorders

Very common Headache

Common Dizziness

Endocrine disorders

Common Hypothyroidism thyroid dysfunction (eg decreased TSH decreased total T4 and decreased free T4)

Hepatobiliary disorders

Very common Cholelithiasis

Common Cholecystitis biliary sludge hyperbilirubinemia

Metabolism and nutrition disorders

Very common Hyperglycemia

Common Hypoglycemia impaired glucose tolerance anorexia

Uncommon Dehydration

General disorders and administration site conditions

Very common Injection site reactions

Common Asthenia

Investigations

Common Elevated transaminase levels

Skin and subcutaneous tissue disorders

Common Pruritus rash alopecia

Respiratory disorders

Common Dyspnea

Cardiac disorders

Common Bradycardia

Uncommon Tachycardia



12

Table 2 Adverse drug reactions derived from spontaneous reports

Post-marketing

Spontaneously reported adverse reactions presented in Table 2 are reported voluntarily and it is not always possible to reliably establish frequency or a causal relationship to drug exposure

Description of selected adverse reactionsGastrointestinal disorders

In rare instances gastrointestinal side effects may resemble acute intestinal obstruction with progressive abdominal distension severe epigastric pain abdominal tenderness and guarding

The frequency of gastrointestinal adverse events is known to decrease over time with continued treatment

Injection site reactions

Injection site related reactions including pain burning redness hematoma hemorrhage pruritus or swelling were commonly reported in patients receiving Sandostatinreg LARreg however these events did not require any clinical intervention in the majority of the cases


Although measured fecal fat excretion may increase there is no evidence to date that long-term treatment with octreotide has led to nutritional deficiency due to malabsorption

Pancreatic enzymes

In very rare instances acute pancreatitis has been reported within the first hours or days of Sandostatinreg sc treatment and resolved on withdrawal of the drug In addition cholelithiasis induced pancreatitis has been reported for patients on long term Sandostatinreg sc treatment

Immune system disorders Anaphylaxis allergyhypersensitivity reactions


Urticaria

Hepatobiliary disorders Acute pancreatitis acute hepatitis without cholestasis cholestatic hepatitis cholestasis jaundice cholestatic jaundice

Cardiac disorders Arrhythmias

Investigations Increased alkaline phosphatase levels increased gamma glutamyl transferase levels



13

Cardiac disorders

In both acromegalic and carcinoid syndrome patients ECG changes were observed such as QT prolongation axis shifts early repolarization low voltage RS transition early R wave progression and nonspecific ST-T wave changes The relationship of these events to octreotide acetate is not established because many of these patients have underlying cardiac diseases (see Special warnings and precautions)

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorization of the medicinal product is important It allows continued monitoring of the benefitrisk balance of the medicinal product Healthcare professionals are asked to report any suspected adverse reactions via the national reporting system

Overdose

A limited number of accidental overdoses of Sandostatinreg LARreg have been reported The doses ranged from 100 mg to 163 mgmonth of Sandostatinreg LARreg The only adverse event reported was hot flushes

Cancer patients receiving doses of Sandostatinreg LARreg up to 60 mgmonth and up to 90 mg2 weeks have been reported These doses were in general well tolerated however the following adverse events have been reported frequent urination fatigue depression anxiety and lack of concentration

The management of overdosage is symptomatic

List of excipients

Vial

Poly (DL-lactide-co-glycolide) 7835 of nominal1048790ll weight sterile mannitol 170 of nominal fill weight

Prefilled syringe

Kit without vial adaptersafety needle

One prefilled syringe (solvent for parenteral use) containing sodium carboxymethylcellulose 125 mg mannitol 15 mg water for injection qs ad 25 mL

Kit with vial adaptersafety needle

One prefilled syringe (solvent for parenteral use) containing sodium carboxymethylcellulose (14 mg) mannitol (12 mg) poloxamer 188 (4 mg) water for injection qs ad 2 mL

Pharmaceutical formulations may vary between countries

Please see the Summary of Product Characteristics



14G-SAS-1157175317copy Novartis 2017

Novartis Pharma AG CH-4002 Basel Switzerland

References 1 Kunz PL Reidy-Lagunes D Anthony LB et al Consensus guidelines for the management and treatment of neuroendocrine tumors Pancreas 201342(4)557-577 2 Vinik AI Woltering EA OrsquoDorisio TM Go VLW Mamikunian G Diagnosing and treating gastroenteropancreatic tumors including ICD-9 codes In Neuroendocrine Tumors A Comprehensive Guide to Diagnosis and Management 5th ed Inglewood CA Inter Science Institute 20121-56 3 Grozinsky-Glasberg S Grossman AB Gross DJ Carcinoid heart disease from pathophysiology to treatmentndashlsquoSomething in the way it movesrsquo Neuroendocrinology 2015101(4)263-273 4 Sandostatin LAR [Summary of Product Characteristics] Novartis 2016 5 US National Library of Medicine MedlinePlus Diarrhea httpswwwmedlineplusgovencyarticle003126htm Accessed January 30 2017 6 Warner ME The Carcinoid Cancer Foundation Nutritional concerns for the carcinoid patient developing nutritional guidelines for persons with carcinoid disease httpwwwcarcinoidorgfor-patientsgeneral -informationnutritionnutritional-concerns-for-the-carcinoid-patient-developing-nutrition-guidelines-for -persons-with-carcinoid-disease Accessed January 30 2017 7 The Carcinoid Cancer Foundation Nutrition and diet for carcinoid patients an interview with Jeffrey I Mechanick MD httpwwwcarcinoidorgfor-patients general-informationnutritionnutrition-and-diet-for-carcinoid-patients-an-interview-with-jeffrey-i-mechanick -m-d Accessed January 30 2017 8 Cancer Research UK Tips on coping with diarrhea httpwww cancerresearchukorgabout-cancercoping-with-cancercoping-physicallyboweltypesdiarrhoeamanaging tips-on-how-to-cope-with-diarrhoea Accessed January 30 2017 9 Whyand T Davies P Caplin M Food and Neuroendocrine Tumours (NETs) ENETS Centre of Excellence 2014 10 Greenberger NJ Merck Manual Diarrhea httpwwwmerckmanualscomprofessional gastrointestinal-disorderssymptoms-of-gi-disordersdiarrhea Accessed January 30 2017 11 Anthony L Freda PU From somatostatin to octreotide LAR evolution of a somatostatin analogue Curr Med Res Opin 200925(12)2989-2999 12 Litchford MD Dorner B Posthauer ME Malnutrition as a precursor of pressure ulcers Adv Wound Care 20143(1)54-63


2

Consider the following patient

MEET MARIA63-YEAR-OLD WOMAN LIVING WITH CARCINOID SYNDROME

Diagnosis

Functional localized midgut NET of the small intestine

Surgical History1

Surgical resection 15 months ago

Ongoing Monitoring1-3dagger

Abdominal imaging (CT or MRI) Biochemical monitoring of CgA and 5-HIAA Echocardiogram as clinically indicated

Current Symptoms24

Diarrhea (~8x daily)

Current Treatment4Dagger

Sandostatinreg LARreg (octreotide) 20 mg every 4 weeks

Important NotesMaria has been on Sandostatinreg LARreg therapy for 3 months While her flushing symptoms are controlled she still has diarrhea up to 8x daily and has been feeling weak Maria did not tell her doctor about the excessive diarrhea during her last visit because she was embarrassed

SANDOSTATINreg LARreg IS OFTEN

PRESCRIBED FOR PATIENTS TO HELP

CONTROL SYMPTOMS ASSOCIATED WITH

CARCINOID SYNDROME4 IN CASES LIKE MARIArsquoS

WHERE SYMPTOMS ARE STILL SIGNIFICANT WITH

TREATMENT A DOSE INCREASE TO 30 MG

EVERY 4 WEEKS MAY BE CONSIDERED4

5-HIAA 5-hydroxyindoleacetic acid CgA chromogranin A CT computed tomography MRI magnetic resonance imaging NET neuroendocrine tumor

The information on this page is a representative patient snapshot not a complete patient profile

dagger Please see recommended monitoring during Sandostatinreg LARreg treatment on page 5

DaggerPlease see important dosing information on page 5


Not an actual patient Copyright pixelheadphoto digitalskillet

Shutterstockcom

3





DAILY NUTRITIONAL

NEEDS


of carbohydrates6







about dietary needs


4
















Large meals


High-fiber foods






Low-fiber foods











5














6





Goals of treatment4







Dehydration11










7





8


Contraindications



General








Glucose metabolism





9

Nutrition



Sodium content













10

Breastfeeding


Fertility











11







Common Dizziness

Endocrine disorders











Common Asthenia

Investigations





Common Dyspnea

Cardiac disorders

Common Bradycardia




12


Post-marketing









Pancreatic enzymes




Urticaria






13

Cardiac disorders




Overdose




List of excipients

Vial


Prefilled syringe













3





DAILY NUTRITIONAL

NEEDS


of carbohydrates6







about dietary needs


4
















Large meals


High-fiber foods






Low-fiber foods











5














6





Goals of treatment4







Dehydration11










7





8


Contraindications



General








Glucose metabolism





9

Nutrition



Sodium content













10

Breastfeeding


Fertility











11







Common Dizziness

Endocrine disorders











Common Asthenia

Investigations





Common Dyspnea

Cardiac disorders

Common Bradycardia




12


Post-marketing









Pancreatic enzymes




Urticaria






13

Cardiac disorders




Overdose




List of excipients

Vial


Prefilled syringe













4
















Large meals


High-fiber foods






Low-fiber foods











5














6





Goals of treatment4







Dehydration11










7





8


Contraindications



General








Glucose metabolism





9

Nutrition



Sodium content













10

Breastfeeding


Fertility











11







Common Dizziness

Endocrine disorders











Common Asthenia

Investigations





Common Dyspnea

Cardiac disorders

Common Bradycardia




12


Post-marketing









Pancreatic enzymes




Urticaria






13

Cardiac disorders




Overdose




List of excipients

Vial


Prefilled syringe













5














6





Goals of treatment4







Dehydration11










7





8


Contraindications



General








Glucose metabolism





9

Nutrition



Sodium content













10

Breastfeeding


Fertility











11







Common Dizziness

Endocrine disorders











Common Asthenia

Investigations





Common Dyspnea

Cardiac disorders

Common Bradycardia




12


Post-marketing









Pancreatic enzymes




Urticaria






13

Cardiac disorders




Overdose




List of excipients

Vial


Prefilled syringe













6





Goals of treatment4







Dehydration11










7





8


Contraindications



General








Glucose metabolism





9

Nutrition



Sodium content













10

Breastfeeding


Fertility











11







Common Dizziness

Endocrine disorders











Common Asthenia

Investigations





Common Dyspnea

Cardiac disorders

Common Bradycardia




12


Post-marketing









Pancreatic enzymes




Urticaria






13

Cardiac disorders




Overdose




List of excipients

Vial


Prefilled syringe













7





8


Contraindications



General








Glucose metabolism





9

Nutrition



Sodium content













10

Breastfeeding


Fertility











11







Common Dizziness

Endocrine disorders











Common Asthenia

Investigations





Common Dyspnea

Cardiac disorders

Common Bradycardia




12


Post-marketing









Pancreatic enzymes




Urticaria






13

Cardiac disorders




Overdose




List of excipients

Vial


Prefilled syringe













8


Contraindications



General








Glucose metabolism





9

Nutrition



Sodium content













10

Breastfeeding


Fertility











11







Common Dizziness

Endocrine disorders











Common Asthenia

Investigations





Common Dyspnea

Cardiac disorders

Common Bradycardia




12


Post-marketing









Pancreatic enzymes




Urticaria






13

Cardiac disorders




Overdose




List of excipients

Vial


Prefilled syringe













9

Nutrition



Sodium content













10

Breastfeeding


Fertility











11







Common Dizziness

Endocrine disorders











Common Asthenia

Investigations





Common Dyspnea

Cardiac disorders

Common Bradycardia




12


Post-marketing









Pancreatic enzymes




Urticaria






13

Cardiac disorders




Overdose




List of excipients

Vial


Prefilled syringe













10

Breastfeeding


Fertility











11







Common Dizziness

Endocrine disorders











Common Asthenia

Investigations





Common Dyspnea

Cardiac disorders

Common Bradycardia




12


Post-marketing









Pancreatic enzymes




Urticaria






13

Cardiac disorders




Overdose




List of excipients

Vial


Prefilled syringe













11







Common Dizziness

Endocrine disorders











Common Asthenia

Investigations





Common Dyspnea

Cardiac disorders

Common Bradycardia




12


Post-marketing









Pancreatic enzymes




Urticaria






13

Cardiac disorders




Overdose




List of excipients

Vial


Prefilled syringe













12


Post-marketing









Pancreatic enzymes




Urticaria






13

Cardiac disorders




Overdose




List of excipients

Vial


Prefilled syringe













13

Cardiac disorders




Overdose




List of excipients

Vial


Prefilled syringe













nursing considerations in midgut net · impaired skin integrity8,12 focus on impaired skin...

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