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(sigh-MET-ih-deen)
Tagamet, Tagamet HB,  Apo-Cimetidine, Novocimetine, Nu-Cimet, Peptol
Class: Histamine H2 antagonist

 Action Reversibly and competitively blocks histamine at H2 receptors, particularly those in gastric parietal cells, leading to inhibition of gastric acid secretion.

 Indications Management of duodenal ulcer; treatment of gastroesophageal reflux disease, including erosive esophagitis; therapy for benign gastric ulcer; treatment of pathologic hypersecretory conditions; prevention of upper GI bleeding. Unlabeled use(s): Prevention of aspiration pneumonia and stress ulcers; herpes virus infection; chronic idiopathic urticaria; anaphylaxis (relieves dermatologic symptoms only); dyspepsia; used before anesthesia to prevent aspiration pneumonitis; to treat hyperparathyroidism and to control secondary hyperparathyroidism in chronic hemodialysis patient; treatment of chronic viral warts in children.

 Contraindications Hypersensitivity to cimetidine or other H2 antagonists.

 Route/Dosage

Duodenal Ulcer (Active)

ADULTS: PO 800 mg at bedtime for 4 to 6 weeks. ALTERNATE REGIMENS PO 300 mg qid w/meals and at bedtime or 400 mg bid. MAINTENANCE THERAPY PO 400 mg at bedtime.

Active Benign Gastric Ulcer

ADULTS: PO 800 mg at bedtime.

Gastroesophageal Reflux Disease

ADULTS: PO 1600 mg daily in divided doses (800 mg or 400 mg) for 12 weeks, although some patients may require chronic therapy.

Pathologic Hypersecretory Conditions

ADULTS: PO 300 mg qid w/meals and at bedtime. If needed, 300 mg doses may be given more often (maximum 2400 mg/day).

Prevention of Upper GI Bleeding

ADULTS: Continuous IV infusion of 50 mg/hr. For hospitalized patients with pathologic hypersecretory conditions or intractable ulcers, or patients unable to take PO medication. USUAL DOSE: IM/IV 300 mg q 6 h to 8 h (maximum 2400 mg/day).

 Interactions

Antacids, anticholinergics, metoclopramide: May decrease absorption of cimetidine. Benzodiazepines, caffeine, calcium channel blockers, carbamazepine, chloroquine, labetalol, lidocaine, metoprolol, metronidazole, moricizine, pentoxifylline, phenytoin, propranolol, quinidine, quinine, sulfonylureas, theophyllines, triamterene, tricyclic antidepressants, warfarin: Cimetidine may reduce metabolism and increase serum concentration and pharmacologic/toxic effects of these drugs. Carmustine: Bone marrow toxicity may be enhanced. Cigarette smoking: Reversed cimetidine’s effects on suppression of nocturnal gastric secretion. Ferrous salts, indomethacin, fluconazole, ketoconazole, tetracyclines: Cimetidine may decrease absorption of these drugs. Hydantoins: Hydantoin levels may increase. Narcotic analgesics: Toxic effects (eg, respiratory depression) may be increased. Procainamide: Levels of procainamide and its active metabolite may increase. Tocainide: Cimetidine may decrease the pharmacologic effects of tocainide.

 Lab Test Interferences None well documented.

 Adverse Reactions

CV: Cardiac arrhythmias. CNS: Headache; somnolence; fatigue; dizziness; confusional states; hallucinations. DERM: Exfoliative dermatitis or erythroderma; alopecia; rash; erythema multiforme; epidermal necrolysis. GI: Diarrhea. GU: Impotence; loss of libido. RESP: Bronchospasm. OTHER: Gynecomastia; hypersensitivity reactions; transient pain at injection site; reversible exacerbation of joint symptoms with preexisting arthritis, including gouty arthritis.

 Precautions

Pregnancy: Category B. Lactation: Excreted in breast milk. Children: Safety and efficacy not established. Elderly: May have reduced renal function; decreased clearance may occur. Renal function impairment: Decreased clearance may occur; reduced dosage may be needed. Hepatic function impairment: Use caution; decreased clearance may occur. Hypersensitivity: Rare cases of anaphylaxis have occurred as well as rare episodes of hypersensitivity. Gastric malignancy: Symptomatic relief with cimetidine does not preclude gastric malignancy. Antiandrogenic effect: Gynecomastia, especially in patients treated for pathologic hypersecretory states may occur. Rapid IV administration: Has been followed by rare instances of cardiac arrhythmias and hypotension. Reversible CNS effects: Mental confusion, agitation, psychosis, depression, anxiety, hallucinations and disorientation have occurred, predominantly in severely ill patients. Advanced age and pre-existing liver or renal disease appear to be contributing factors.

PATIENT CARE CONSIDERATIONS

 Administration/Storage

  • Administer medication with or before meals and at bedtime for maximum effect.
  • Administer IM dose undiluted. Dilute IV dose (300 mg) in 0.9% normal saline, D5W or other compatible solution to a total of 20 ml. Inject slowly over no less than 5 min.
  • For intermittent IV infusion, dilute 300 mg in at least 50 ml of compatible solution; infuse over at least 20 min. (Continuous IV infusion is usually preceded by a loading dose.)
  • Do not add drugs or additives to mixture. Stop other in-line drugs while administering, and flush lines before and after administration.
  • Do not allow equipment containing aluminum to come in contact with the solution.
  • Use only compatible solutions for admixture: 0.9% normal saline, 5% and 10% Dextrose in Water, lactated Ringer’s solution, 5% sodium bicarbonate.
  • Product may be added to standard TPN solutions.
  • Store premixed products at room temperature. Discard any unused mixed solutions after 48 hr.

 Assessment/Interventions

  • Obtain patient history, including drug history and any known allergies.
  • Establish baseline vital signs.
  • Avoid administering antacids within 1 hr of medication.
  • Review periodic monitoring of serum concentrations and clinical effects for other drugs affected by cimetidine.
  • Renal/liver function studies and blood counts are all especially important in elderly.
  • Assess patient for abdominal pain, confusion and GI bleeding (blood in stools or emesis).
  • Assess gastric pH q 8 hr, when possible.

 Patient/Family Education

  • Counsel patients to stop smoking, since smoking reduces ulcer-healing efficacy of cimetidine.
  • Instruct patients to keep appointments for laboratory testing and physician follow-up.
  • Advise patients not to take otc medications without consulting physician.
  • Instruct patients to report to physician immediately any black tarry stools, coffee-ground emesis, abdominal pain or confusion.
  • Counsel patients regarding need for lifestyle changes, stress reduction programs and dietary modifications (eg, avoid spicy foods and alcohol).

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