Generic name: chlorpromazine Brand name: Thorazine Preparations: PO 10-25mg 2=4 times daily; may increase every 3-4 days (usual dose is 200ng/day; up to 1g/day) CLASSIFI-CATION: Antipsycho Antipsychotics tics ACTION: • Block dopamine receptors in the brain; also alter dopamine release and turnover. • Prevention of seizures
INDICATION / USES: •Acute and chronic psychoses, particularly when accompanied by increased i ncreased psychomotor activity. Nausea and vomiting. • Also used in the treatment of intractable hiccups. COMMON ADVERSE EFFECTS: •CNS: neuroleptic malignant syndrome, sedation, extrapyramidal reactions, tardive dyskinesia •CV: hypotension (increased with IM, IV) •EENT: blurred vision, dry eyes, eyes, lens opacities • GI: constipation, dry mouth, anorexia, hepatitis, ileus • GU: GU: urinary retention • Hematologic: agranulocytosis, leukopenia • Skin: photosensitivity, pigment changes, rashes CONTRA-INDICATIONS: • Hypersensitivity. •Cross-sensitivity •Cross -sensitivity may exist among phenothiazines. Should not be used in narrow-angle glaucoma. •Should not be used in patients who have CNS depression. NURSING CONSIDERATIO CONSIDERATIONS: NS: • Assess mental status prior to and periodically during therapy. • Monitor BP and pulse prior to and frequently during the period of dosage adjustment. May cause QT interval changes on ECG. • Observe patient carefully when administering medication, to ensure that medication is actually taken and not hoarded. •Monitor I&O ratios and daily eight. Assess patient for signs and symptoms of dehydration.
• Monitor for development of neuroleptic neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control. Report symptoms immediately. May also cause leukocytosis, elevated liver function tests, elevated CPK. • Advise patient to take medication as directed. Take missed doses as soon as remembered, witih remaining doses evenly spaced through out the day. May require several weeks to obtain desired effects. Do not increase dose or discontinue medication without consulting health care professional. Abrupt withdrawal may cause dizziness, nausea, vomiting, GI upset, trembling, or uncontrolled movements of mouth, tongue or jaw.
Stelazine Side Effects Generic Name: trifluoperazine,trifluoperazine hydrochloride
Generic name: haloperidol Brand name: Haldol Preparations: Tablets: 0.5mg, 1mg, 2mg, 5mg, 10mg CLASSIFICATION: Antipsychotics ACTION: • Alters the effects of dopamine in the CNS • Also has anticholinergic and alpha-adrenergic alpha-adrenergic blocking activity. • Diminished signs and symptoms of psychoses INDICATION / USES: •Organic Psychoses • acute psychotic symptoms • Relieve hallucinations, delusions, disorganized thinking • severe anxiety • seizures
COMMON ADVERSE EFFECTS: •CNS: extrapyramidal extrapyramidal symptom such as muscle rigidity or spasm, shuffling gait, posture leaning forward, drooling, masklike facial appearance, dysphagia, akathisia, tardive dyskinesia, headache, seizures. •CV: tachycardia, arrhythmias, hypertension, orthostatic hypertension. hypertens ion.
• Monitor for development of neuroleptic neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control. Report symptoms immediately. May also cause leukocytosis, elevated liver function tests, elevated CPK. • Advise patient to take medication as directed. Take missed doses as soon as remembered, witih remaining doses evenly spaced through out the day. May require several weeks to obtain desired effects. Do not increase dose or discontinue medication without consulting health care professional. Abrupt withdrawal may cause dizziness, nausea, vomiting, GI upset, trembling, or uncontrolled movements of mouth, tongue or jaw.
Stelazine Side Effects Generic Name: trifluoperazine,trifluoperazine hydrochloride
Generic name: haloperidol Brand name: Haldol Preparations: Tablets: 0.5mg, 1mg, 2mg, 5mg, 10mg CLASSIFICATION: Antipsychotics ACTION: • Alters the effects of dopamine in the CNS • Also has anticholinergic and alpha-adrenergic alpha-adrenergic blocking activity. • Diminished signs and symptoms of psychoses INDICATION / USES: •Organic Psychoses • acute psychotic symptoms • Relieve hallucinations, delusions, disorganized thinking • severe anxiety • seizures
COMMON ADVERSE EFFECTS: •CNS: extrapyramidal extrapyramidal symptom such as muscle rigidity or spasm, shuffling gait, posture leaning forward, drooling, masklike facial appearance, dysphagia, akathisia, tardive dyskinesia, headache, seizures. •CV: tachycardia, arrhythmias, hypertension, orthostatic hypertension. hypertens ion.
•EENT: blurred vision, glaucoma • GI: dry mouth, anorexia, nausea, vomiting, constipation, diarrhea, weight gain. • GU: urinary frequency, urine retention, impotence, enuresis, amenorrhea, gynecomastia • Hematologic: anemia, leucopenia, agranulocytosis agranulocytosis • Skin: rash, dermatitis, phtosensitivity
CONTRA-INDICATIONS: • seizure disorder • glaucoma • elderly clients NURSING CONSIDERATIO CONSIDERATIONS: NS: • Assess mental status prior to and periodically during therapy. • Monitor BP and pulse prior to and frequently during the period of dosage adjustment. May cause QT interval changes on ECG. • Observe patient carefully when administering medication, to ensure that medication is actually taken and not hoarded. •Monitor I&O ratios and daily eight. Assess patient for signs and symptoms of dehydration. • Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control. Report symptoms immediately. May also cause leukocytosis, elevated liver function tests, elevated CPK. • Advise patient to take medication as directed. Take missed doses as soon as remembered, witih remaining doses evenly spaced through out the day. May require several weeks to obtain desired effects. Do not increase dose or discontinue medication without consulting health care professional. Abrupt withdrawal may cause dizziness, nausea, vomiting, GI upset, trembling, or uncontrolled movements of mouth, tongue or jaw.
Mellaril Generic Name: thioridazine (THYE oh RID a zeen)
GENERIC NAME: Diazepam BRAND NAME: Valium CLASSIFICATION: Antianxiety agents, anticonvulsants, sedative/hyptonics, skeletal muscle relaxants (centrally acting)
DOSAGE: 10 mg IM MECHANISM OF ACTION: - Depress the CNS, probably by potentiating GABA, an inhibitory neurotransmitter. - Produces skeletal muscle relaxation by inhibiting spinal polysynaptic afferent pathways. - Has anticonvul-sant properties due to enhanced presynaptic inhibi-tion.Therapeutic effects: (1) Relief of Anxiety (2) Sedation (3) Amnesia (4) Skeletal muscle relaxant (5) Decreased seizure activity INDICATION: -Adjunct in the management of: 1) Anxiety 2) Preoperative sedation 3) Conscious sedation - Provides light anesthesia and anterograde amnesia - Treatment of status of status epilepticus/ epilepticus/ uncontrolled seizures - Skeletal muscle relaxant - Management of the symptoms of alcohol withdrawal CONTRAINDICATIONS: - Hypersensitivity - Cross-sensitivity with other benzodiazepines may occurs - Comatose patients - Pre-existing CNS depression - Uncontrolled severe painUse cautiously in: 1) Hepatic dysfunction 2) Severe renal impairment 3) History of suicide attempt or drug dependence SIDE EFFECTS/ ADVERSE EFFECTS: - CNS: 1) dizziness 2) drowsiness 3) lethargy 4) hangover 5) headache 6) depression - EENT: 1) blurred vision - RESP:
1) respiratory depression - CV: 1) hypotension - GI: 1) constipation 2) diarrhea 3) nausea 4) vomiting - DERM: 1) rashes - LOCAL: 1) pain (IM) 2) phlebitis (IV) 3) venous thrombosis - MISC: 1) physical & psychological depen-dence 2)tolerance
NURSING IMPLICATIONS/RESPONSIBILITIES: - Monitor BP, PR,RR prior to periodically throughout therapy and frequently during IV therapy. - Assess IV site frequently during administration, diazepam may cause phlebitis and venous thrombosis. - Prolonged high-dose therapy may lead to psychological or physical dependence. Restrict amount of drug available to patient. Observe depressed patients closely for suicidal tendencies. - Observe and record intensity, duration and location of seizure activity. The initial dose of diazepam offers seizure control for 15-20 min after administration. - IM injections are painful and erratically absorbed. If IM route is used, inject deeply into deltoid muscle for maximum absorption. - Caution patient to avoid taking alcohol or other CNS depressants concurrently with this medication. - Effectiveness of therapy can be demonstrated by decrease anxiety level ; control of seizures; decreased tremulousness tremulousness..
Equanil Generic Name: meprobamate (meh pro BA mate) Brand Names: Equanil, Miltown
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Tofranil Side Effects Generic Name: imipramine,imipramine hydrochloride
Please note - some side effects for Tofranil may not be reported. Always consult your doctor or healthcare specialist for medical advice. You may also report side effects to the FDA. Ads by Google
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Side Effects of Tofranil - for the Consumer Tofranil All medicines may cause side effects, but many people have no, or minor, side effects. Check with your doctor if any of these most COMMON side effects persist or become bothersome when using Tofranil: Dizziness; drowsiness; dry mouth; excitement; headache; impotence; nausea; nightmares; pupil dilation; sensitivity to sunlight; sweating; tiredness; upset stomach; vomiting; weakness; weight loss or gain. Seek medical attention right away if any of these SEVERE side effects occur when us ing Tofranil: Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); blurred vision or other vision changes; changes in sex drive; chest pain; conf usion; constipation; fainting; fast, slow, or irregular heartbeat; fever; frequent or difficult urination; hallucinations; impulsive behavior or other unusual changes in behavior; jaw, neck, or muscle spasms; mental or mood changes (eg, increased anxiety, mood swings, agitation, irritability, nervousness, restlessness); panic attacks; ringing in the ears; seizures; severe dizziness or drowsiness; sore throat; stomach pain; suicidal thinking or behavior; swelling of the testicles; tremor; trouble sleeping; t rouble walking or keeping your balance; twitching of the face or tongue; uncontrolled movements of arms and legs or stiffness; unusual bleeding or bruising; worsening of depression; yellowing of the skin or eyes. This is not a complete list of all side eff ects that may occur. If you have questions about side effects, contact your health care provider. Call your doctor for medical advice about side effects. To report side effects to the appropriate agency, please read the Guide to Reporting Problems to FDA.
Tofranil-PM All medicines may cause side effects, but many people have no, or minor, side effects. Check with your doctor if any of these most COMMON side effects persist or become bothersome when using Tofranil-PM: Dizziness; drowsiness; dry mouth; excitement; headache; impotence; nausea; nightmares; pupil dilation; sensitivity to sunlight; sweating; tiredness; upset stomach; vomiting; weakness; weight loss or gain. Seek medical attention right away if any of these SEVERE side effects occur when using Tofranil -PM: Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); blurred vision or other vision changes; changes in sex drive; chest pain; c onfusion; constipation; fainting; fast, slow, or irregular heartbeat; fever; frequent or difficult urination; hallucinations; impulsive behavior or other unusual changes in behavior; jaw, neck, or muscle spasms; mental or mood changes (eg, increased anxiety, mood swings, agitation, irritability, nervousness, restlessness); panic attacks; ringing in the ears; seizures; severe dizziness or drowsiness; sore throat; stomach pain; suicidal thinking or behavior; swelling of the testicles; tremor; trouble sleeping; trouble walking or keeping your balance; twitching of the face or tongue; uncontrolled movements of arms and legs or stiffness; unusual bleeding or bruising; worsening of depression; yellowing of the skin or eyes.
This is not a complete list of all side effects that may occur. If you have questions about side effects, contact your health care provider. Call your doctor for medical advice about side effects. To report side effects to the appropriate agency, please read the Guide to Reporting Problems to FDA. Top
Tofranil Side Effects - for the Professional Tofranil Note – Although the listing which follows includes a few adverse reactions which have not been reported with this specific drug, the pharmacological similarities among the tricyclic antidepressant drugs require that each of the reactions be considered when Tofranil is administered. Cardiovascular: Orthostatic hypotension, hypertension, tachycardia, palpitation, myocardial infarction, arrhythmias, heart block, ECG changes, precipitation of congestive heart failure, stroke. Psychiatric: Confusional states (especially in the elderly) with hallucinations, disorientation, delusions; anxiety, restlessness, agitation; insomnia and nightmares; hypomania; exacerbation of psychosis. Neurological: Numbness, tingling, paresthesias of extremities; incoordination, ataxia, tremors; peripheral neuropathy; extrapyramidal symptoms; seizures, alterations in EEG patterns; tinnitus. Anticholinergic: Dry mouth, and, rarely, associated sublingual adenitis; blurred vision, disturbances of accommodation, mydriasis; constipation, paralytic ileus; urinary retention, delayed micturition, dilation of the urinary tract. Allergic: Skin rash, petechiae, urticaria, itching, photosensitization; edema (general or of face and tongue); drug fever; cross-sensitivity with desipramine. Hematologic: Bone marrow depression including agranulocytosis; eosinophilia; purpura; thrombocytopenia. Gastrointestinal: Nausea and vomiting, anorexia, epigastric distress, diarrhea; peculiar taste, stomatitis, abdominal cramps, black tongue. Endocrine: Gynecomastia in the male; breast enlargement and galactorrhea in the female; increased or decreased libido, impotence; testicular swelling; elevation or depression of blood sugar levels; inappropriate antidiuretic hormone (ADH) secretion syndrome. Other: Jaundice (simulating obstructive); altered liver function; weight gain or loss; perspiration; flushing; urinary frequency; drowsiness, dizziness, weakness and fatigue; headache; parotid swelling; alopecia; proneness to falling. Withdrawal Symptoms: Though not indicative of addiction, abrupt ces sation of treatment after prolonged therapy may produce nausea, headache, and malaise. Note – In enuretic children treated with Tofranil the most common adverse reactions have been nervousness, sleep disorders, tiredness, and mild gastrointestinal disturbances. These usually disappear during continued drug administration or when dosage is decreased. Other reactions which have been reported include constipation, convulsions, anxiety, emotional instability, syncope, and collapse. All of the adverse effects reported with adult use should be considered.
Biperiden Hydrochloride CATEGORIES: Extrapyramidal disorder, drug-inducedParkinson's diseasePregnancy Category CFDA Approved 1959 SepWHO Formulary FDS Drug Classes: AnticholinergicsAntiparkinson agents BRAND NAMES: Akineton Akineton Retard Bicamol Biparkin Biperen Biperin Bipiden Dekinet Desiperiden Dyskinon Tasmolin
Antidyskinetics (Systemic) This monograph includes information on the following: 1) Benztropine 2) Biperiden 3) Ethopropazine 4) Procyclidine 5) Trihexyphenidyl
INN: {03} Benztropine—Benzatropine Ethopropazine—Profenamine BAN: {03} Benztropine—Benzatropine Trihexyphenidyl—Benzhexol VA CLASSIFICATION Primary: AU305 2
1
5
5
5
Commonly used brand name(s): Akineton ; Apo-Benztropine ; Apo-Trihex ; Artane ; Artane Sequels ; Cogentin 1; Kemadrin 4 ; PMS Benztropine 1; PMS Procyclidine 4 ; PMS Trihexyphenidyl 5 ; Parsidol 3 ; Parsitan 3 ; 4 5 5 Procyclid ; Trihexane ; Trihexy . Note: For a listing of dosage forms and brand names by country availability, see Dosage Forms section(s).
Category:
Antidyskinetic— Indications Note: Bracketed information in the Indications section refers to uses that are not included in U.S. product labeling. Accepted {06}{07}{08}{09}{10}{11}{12}{13}{15}{17}{21}
—Antidyskinetics are indicated in the treatment of mild Parkinsonism (treatment) {08} {11} {12} {13} {17} {21} cases of postencephalitic, arteriosclerotic, or idiopathic parkinsonism(paralysis agitans) in patients in whom anticholinergic therapy is not contraindicated. Antidyskinetics also are indicated as adjuncts to {06} {07} {09} {10} {13} {15} {16} {19} {21} more potent medications to maximize improvement of symptoms. Procyclidine usually produces a more beneficial effect in conditions of rigidity than in those of tremor. {12} {13}
Extrapyramidal reactions, drug-induced (treatment) —Antidyskinetics are indicated in the control of extrapyramidal disorders(except tardive dyskinesia) due to central nervous system (CNS) drugs such as {06} {07} {08} {09} {10} {11} {12} {13} reserpine, phenothiazines, dibenzoxazepines, thioxanthenes, and butyrophenones. {14} {15} {16} {17} {21} However, concomitant therapy with antipsychotics is not recommended beyond 3 months {19} {26} because extrapyramidal symptoms resulting from antipsychotic therapy usually resolve in 3 to 6 months and because prolonged, routine use of antidyskinetics with antipsychotics may predispose patients to the more serious neurological condition, tardive dyskinesia. 1
[Athetosis, congenital (treatment)] or 1 [Degeneration, hepatolenticular (treatment)] —Ethopropazine is used for the symptomatic treatment of hepatolenticular degeneration and congenital athetosis. 1 Not included in Canadian product labeling.
Pharmacology/Pharmacokinetics Physicochemical characteristics: Molecular weight— Benztropine mesylate: 403.54 Biperiden hydrochloride: 347.93 Biperiden lactate: 401.54 Ethopropazine hydrochloride: 348.93 Procyclidine hydrochloride: 323.91 Trihexyphenidyl hydrochloride: 337.93 Mechanism of action/Effect: Specific mode of action is unknown, but it is though t that these agents partially block central (striatal) {09} cholinergic receptors, thereby helping to balance c holinergic and dopaminergic activity in the basal ganglia; {10} {12} {20} {12} {20} salivation may be decreased , and smooth muscle may be relaxed. Drug-induced {06} {07} {08} {10} {20} extrapyramidal symptoms and those due to parkinsonism may be relieved , but tardive {06} {07} {08} {20} dyskinesia is not alleviated and may be aggravated by anticholinergic effects.
Other actions/effects: Benztropine {06} {07} {21} and ethopropazine {21} also have a slight antihistaminic and local anesthetic effect. {21} {12} Biperiden may have a slight effect on the cardiovascular and respiratory systems. Procyclidine and trihexyphenidyl {14} {15} {16} {21} have a direct antispasmodic effect on smooth muscle. In small doses {21} trihexyphenidyl depresses the CNS, but larger doses may cause cerebral excitation. Absorption: Well-absorbed from gastrointestinal tract.
{10} {20} {21}
Onset of action:
Benztropine: Oral: 1 to 2 hours. Intramuscular or intravenous: Within a few minutes.
Biperiden:
{06}
Intramuscular: Average of 10 to 30 minutes. Intravenous: Within a few minutes.
{10}
{10}
Trihexyphenidyl: Oral: 1 hour.
{20} {21}
Duration of action: Benztropine—Oral, intramuscular, or intravenous: 24 hours. Biperiden—Intravenous: 1 to 8 hours. Ethopropazine—Oral: 4 hours. Procyclidine—Oral: 4 hours.
{10}
{21}
{20}
Trihexyphenidyl—Oral: 6 to 12 hours.
{21}
Precautions to Consider Pregnancy/Reproduction Pregnancy— Problems in humans have not been documented with benztropine, ethopropazine, procyclidine, or trihexyphenidyl. For biperiden—Studies have not been done with biperiden in h umans. {09} Studies have not been done in animals. FDA Pregnancy Category C.
{09}
{09}
Breast-feeding It is not known whether antidyskinetics are distributed into breast milk. lactation. {30}
{09}
However, antidyskinetics may inhibit
Pediatrics No information is available on the relationship of age to the effects of antidyskinetics in pediatric patients. However, it is known that pediatric patients exhibit increased sensitivity to other medications with anticholinergic properties. {30}
Generic name: diphenhydramine Brand name: Benadryl
Preparations: PO 25-50 mg q4-6 hr, 50mg 20-30 mins before bedtime CLASSIFICATION: Antiparkinsonian drug ACTION: • Antagonizes the effect of histamine at H1 receptor sites; does not bind or inactivate histamine INDICATION / USES: •parkinsonism or drug-induced extrapyramidal effects
COMMON ADVERSE EFFECTS: •CNS: headache, fatigue, anxiety, tremors, vertigo, confusion, depression, seizures, hallucinations •CV: tachycardia, palpitations, orthostaic hypotension, heart failure •EENT: blurred vision • GI: dry mouth, nausea, vomiting, constipation, flatulence • GU: urinary hesitancy or frequency, urine retention • Hematologic: leukopenia • Skin: photosensitivity, dermatitis CONTRA-INDICATIONS: • cardiac disease or hypertension • glaucoma • gastric or duodenal ulcers NURSING CONSIDERATIONS: • Caution the client that the medication may cause drowsiness, creating difficulties or hazards or other activities that require alertness. • Tell the client to take the medication with food to decrease GI upset. • Explain to the client that arising quickly form a lying or sitting position may cause orthostatic hypotension. • When taking these medications, the client needs to have blood cells counts, renal function, hepatic function, and blood pressure monitored. • Adverse effects of these drugs occur more commonly in elderly clients. • Explain to the client that use of these drugs in warm weather may increase the likelihood of heatstroke.
GENERIC NAME: phenytoin BRAND NAME: Dilantin, Dilantin-125 DRUG CLASS AND MECHANISM: Phenytoin is an oral and injectable anti-seizure medication first synthesized in 1908. The exact mechanism of action is not k nown, Phenytoin may work by reducing the
sensitivity of nerves in the brain to excessive stimulation and reducing transmission of impulses between nerves. Phenytoin was originally approved by the FDA in 1939. PRESCRIPTION: Yes GENERIC AVAILABLE: Yes PREPARATIONS: Capsules (extended or immediate release): 30, 100, 200, and 300 mg; Chewable Tablet: 50 mg; Suspension: 125 mg/5 mL; Injection: 50 mg/mL. STORAGE: Capsules, tablets, and suspension should be kept at room temperature, 68-77 F (20-25 C). PRESCRIBED FOR: Phenytoin is an anti-seizure medication (anticonvulsant) used for preventing or treating generalized tonic-clonic (grand mal) seizures, complex partial seizures (psychomotor seizures), and seizures occurring during or after neurosurgery. It may be used alone or with phenobarbital or other anticonvulsants. DOSING: The dosing of phenytoin is patient specific. It may be given once, twice, 3, or 4 times daily. Doses are often adjusted to find the optimal dose based on measurement of blood levels. Taking phenytoin with food may reduce some of the side effects. Elderly patients, debilitated persons, and patients with certain kidney or liver diseases may need lower doses. The suspension should not be given at the same time as tube feedings since tube feedings bind to phenytoin and reduce its absorption. The recommended adult dose is 100 mg two to four times daily. Some patients may require 200 mg three times daily. Patients stabilized on 100 mg three times daily may receive 300 mg once daily of the extended release capsules. DRUG INTERACTIONS: There are many potential drug interactions with phenytoin. Phenytoin can increase the metabolism (elimination) of many drugs, reducing their concentrations in the body. Drugs that may be affected include:
digoxin (Lanoxin),
carbamazepine (Tegretol, Tegretol XR, Equetro, Carbatrol),
clonazepam (Klonopin),
corticosteroids (for example, prednisone),
cyclosporine,
disopyramide,
doxycycline,
estrogens,
oral contraceptives,
paroxetine (Paxil, Paxil CR, Pexeva),
quinidine,
tacrolimus (Prograf),
theophylline,
phenobarbital,
valproic acid (Depakote, Depakote ER, Depakene, Depacon, Stavzor), and
warfarin (Coumadin).
phenytoin, Dilantin, Dilantin-125 (cont.) Pharmacy Author: Omudhome Ogbru, PharmD
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Phenytoin can interact with these drugs not only when it is added to therapy but also when it is discontinued. In the latter case, the concentration of the other drugs may increase. Sometimes the effect may be unpredictable. Phenytoin's metabolism may be affected by other drugs. Drugs that increase phenytoin blood levels and toxicity include:
acute alcohol intake,
amiodarone (Coradone),
chlordiazepoxide,
cimetidine (Tagamet),
diazepam (Valium, Diastat),
dicumarol,
disulfiram,
estrogens,
ethosuximide,
fluoxetine (Prozac),
fluorouracil,
fluvoxamine (Luvox),
isoniazid,
methylphenidate (Concerta),
omeprazole (Prilosec),
sertraline (Zoloft),
tolbutamide, and
trazodone (Desyrel).
Drugs that may decrease phenytoin levels and reduce effectiveness include carbamazepine, chronic alcohol abuse, reserpine, and sucralfate (Carafate). The oral absorption of phenytoin can be reduced by any of the following:
antacids containing magnesium,
calcium carbonate, or aluminum;
calcium salts; or enteral feeding products (tube feedings).
Separating the administration of phenytoin and enteral feeding products, antacids, or calcium salts by at least 2 hours will help avoid this interaction. PREGNANCY: There is an increased risk of malformations and birth defects in women taking phenytoin. Thus, phenytoin should be used in pregnancy only if the physician feels that the potential benefit outweighs the risk. NURSING MOTHERS: Phenytoin is secreted into breast milk. Breast feeding is not recommended for persons taking phenytoin. SIDE EFFECTS: Many adverse effects can occur during phenytoin therapy including dizziness, drowsiness, difficulty focusing (vision), unsteady gate, tiredness, abnormal involuntary movements, nausea, vomiting, constipation, abdominal pain, and loss of appetite. Children and young adults can develop overgrowth of the gums during long-term therapy which requires regular treatment by a dentist. Good oral hygiene and gum massage may reduce the risk. R ashes can occur in between 1 in 20 and 1 in 10 persons; some may be severe. Additionally, darkening coloration of the skin may develop (more commonly in women). Phenytoin can produce unusual growth of hair in some patients. This reaction most commonly affects the arms and legs but can also affect the trunk and face; it may be irreversible. Various lymph node reactions have been reported with phenytoin therapy. Lymph nodes may swell, sometimes painfully. Phenytoin causes serum glucose (sugar) to rise. Thus, blood sugar should be monitored closely when phenytoin is administered to patients with diabetes.
Phenytoin can potentially injure the liver although this is an uncommon occurrence. Phenytoin can cause the platelet or white blood cell counts to drop, increasing the risk of bleeding or infection, respectively. Phenytoin also can cause anemia. Because it interferes with vitamin D metabolism, phenytoin can cause weakening of the bones (osteomalacia). Phenytoin can cause sexual dysfunction including decreased libido, impotence, and priapism (painful, prolonged erections). Antiepileptic medications have been associated with an increased risk of suicidal thinking and behavior. Anyone considering the use of antiepileptic drugs must balance this risk of suicide with the clinical need for the antiepileptic drug. Patients who begin antiepileptic therapy should be closely observed for clinical worsening, suicidal thoughts or unusual changes in behavior.
GENERIC NAME: PHENYTOIN SUSPENSION - ORAL (FEN-i-toin; FEN-i-toe-in) BRAND NAME(S): Dilantin Medication Uses | How To Use | Side Effects | Precautions | Drug Interactions | Overdose | Notes | Missed Dose | Storage USES: Phenytoin is used to prevent and control seizures (also called an anticonvulsant or antiepileptic drug). It works by reducing the spread of seizure activity in the brain.OTHER This section contains uses of this drug that are not listed in the approved professional labeling for the drug but that may be prescribed by your health care professional. Use this drug for a condition that is listed in this section only if it has been so prescribed by your health care professional.This drug may also be used to treat certain types of irregular heartbeats. HOW TO USE: Read the Medication Guide provided by your pharmacist before you start taking phenytoin and each time you get a refill. If you have any questions, ask your doctor or pharmacist.Shake this medication well before each dose. Take this medication by mouth usually 2 or 3 times a day, or as directed by your doctor. This product is not recommended for use once a day. You may take it with food if stomach upset occurs.Carefully measure the dose using a special measuring device/spoon/syringe. Do not use a household spoon because you may not get the correct dose.Use this medication regularly in order to get the most benefit from it. It is important to take all doses on time to keep the amount of medicine in your body at a constant level. Remember to use it at the same times each day. Dosage is based on your medical condition and response to therapy.Products that contain calcium (e.g., antacids, calcium supplements) and nutritional tube-feeding (enteral) products may decrease the absorption of phenytoin. Do not take these products at the same time as your phenytoin dose. Separate liquid nutritional products at least 1 hour before and 1 hour after your phen ytoin dose, or as directed by your doctor.Do not stop taking this medication without consulting your doctor. Seizures may become worse when the drug is suddenly stopped. Your dose may need to be gradually decreased.Inform your doctor if your condition does not improve or worsens. SIDE EFFECTS: Headache, nausea, vomiting, constipation, dizziness, drowsiness, trouble sleeping, or nervousness may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly.Phenytoin may cause swelling and bleeding of the gums. Massage your gums and brush and floss your teeth regularly to minimize this problem. See your dentist regularly.Remember that your doctor has
prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.Tell your doctor immediately if any of these unlikely but serious side effects occur: unusual eye movements, loss of coordination, slurred speech, confusion, muscle twitching, double or blurred vision, tingling of the hands/feet, facial changes (e.g., swollen lips, butterfly-shaped rash around the nose/cheeks), excessive hair growth, increased thirst or urination, unusual tiredness, bone or joint pain, easily broken bones.A small number of people who take anticonvulsants for any condition (such as seizure, bipolar disorder, pain) may experience depression, suicidal thoughts/attempts, or other mental/mood problems. Tell your doctor immediately if you or your family/caregiver notice any unusual/sudden changes in your mood, thoughts, or behavior including signs of depression, suicidal thoughts/attempts, thoughts about harming yourself.For males, in the very unlikely event you have a painful or prolonged erection lasting 4 or more hours, stop using this drug and seek immediate medical attention, or permanent problems could occur.Tell your doctor immediately if any of these highly unlikely but very serious side effects occur: uncontrolled muscle movements, swollen glands (lymph nodes), stomach / abdominal pain, persistent nausea/vomiting, yellowing eyes or skin, dark urine, easy bruising/bleeding, signs of infection (e.g., persistent sore throat or fever).A serious allergic reaction to this drug is unlikely, but seek immediate medical attention if it occurs. Symptoms of a serious allergic reaction include: rash, high fever, itching / swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1 -800-FDA-1088.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1 -866234-2345.
Generic Name: thioridazine (THYE oh RID a zeen) Brand Names: Ads by Google Schizophrenia www.earthhouse.orgUnique Mental Health Care Treatment Hope for Mental Health Issues Ask a Doctor Online Now Health.JustAnswer.comA Doctor Will Assist You Now! Questions Answered Every 9 Seconds. Parkinson's disease www.parkinsons-voices.euLearn how one can react to the daily challenges of living with PD What is Mellaril (thioridazine)? Thioridazine is an anti-psychotic medication in a group of drugs called phenothiazines (FEEN-oh-THYE-a-zeens). It works by changing the actions of chemicals in your brain. Thioridazine is used to treat psychotic disorders such as schizophrenia. Thioridazine is usually given after other medications have been tried without successful treatment of schizophrenia.
Thioridazine may also be used for purposes not listed in this medication guide. Mellaril (thioridazine) side effects
Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Stop using thioridazine and call your doctor at once if you have a serious side effect such as: fast or pounding heartbeat; twitching or uncontrollable movements of your eyes, lips, tongue, face, arms, or legs; tremor (uncontrolled shaking), drooling, trouble swallowing, problems with balance or walking; feeling restless, jittery, or agitated; very stiff (rigid) muscles, high fever, sweating, confusion, fast or uneven heartbeats, feeling like you might pass out; seizure (convulsions); decreased night vision, tunnel vision, watery eyes, increased sensitivity to light; pale skin, easy bruising or bleeding, sore throat, flu symptoms; urinating less than usual or not at all; nausea and stomach pain, skin rash, and jaundice (yellowing of the skin or eyes); joint pain or swelling with fever, swollen glands, muscle aches, chest pain, vomiting, unusual thoughts or behavior, and patchy skin color; or slow heart rate, weak pulse, fainting, slow breathing (breathing may stop). Less serious side effects may include: dizziness, drowsiness, anxiety; dry mouth, stuffy nose, constipation; blurred vision, headache; breast swelling or discharge; changes in your menstrual periods; weight gain, swelling in your hands or feet; impotence, trouble having an orgasm; increased or decreased interest in sex; sleep problems (insomnia), strange dreams; or mild itching or skin rash
Adult Dosing & Uses Pediatric Dosing & Uses Drug Interactions Adverse Effects Contraindications & Cautions Pregnancy & Lactation Pharmacology
Pricing & Images Patient Handout
Next Section: Pregnancy & Lactation Previous Next Section: Pregnancy & Lactation Previous Next Section: Pregnancy & Lactation Previous Next Section: Pregnancy & Lactation
Contraindications & Cautions Black Box Warnings Patients with dementia-related psychosis who are treated with antipsychotic drugs are at an increased risk of death as shown in short-term controlled trials. The deaths appeared to be either cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature This drug is not approved for the treatment of patients with dementia-related psychosis
Contraindications Documented hypersensitivity to phenothiazines Coma, severe hypotension, severe CNS depression, concurrency with large amounts of CNS depressants, poorly controlled seizure disorder, myelosuppression, subcortical brain damage Any drugs or conditions that prolong QTc interval Lactation
Cautions Avoid using in children with suspected Reye's syndrome Glaucoma, prostatic hypertrophy, stenosing PUD, tardive dyskinesia, history of NMS, Parkinson's disease, hypocalcemia, renal/hepatic impairment, patients who have exhibited a severe reaction to insulin or ECT, history of seizures, asthma, respiratory tract infections, cardiovascular disease
Risk of EPS, NMS, hypotension Hypotension may be particularly severe in patients with pheochromocytoma or mitral insufficiency Depresses hypothalamic thermoregulatory mechanism; exposure to extreme temperatures may cause hypo- or hyperthermia In case of severe hypotension, use norepinephrine or phenylepinephrine, do NOT use epinephrine or dopamine May need anticholinergic antiparkinsonian agent to counter EPS Sales being discontinued in Canada FDA Warning regarding off-label use for dementia in elderly
Contraindicated (29)
abiraterone
abiraterone increases levels of thioridazine by affecting hepatic enzyme CYP2D6 metabolism. Contraindicated. Avoid coadministration of abiraterone with substrates of CYP2D6. If alternative therapy cannot be used, exercise caution and consider a dose reduction of the CYP2D6 substrate.
amiodarone
thioridazine and amiodarone both increase QTc interval. Contraindicated.
arsenic trioxide
thioridazine and arsenic trioxide both increase QTc interval. Contraindicated.
astemizole
thioridazine and astemizole both increase QTc interval. Contraindicated.
bepridil
thioridazine and bepridil both increase QTc interval. Contraindicated.
cisapride
thioridazine and cisapride both increase QTc interval. Contraindicated.
clomipramine
thioridazine will increase the level or effect of clomipramine by affecting hepatic enzyme CYP2D6 metabolism. Contraindicated.
crizotinib
crizotinib and thioridazine both increase QTc interval. Contraindicated. Thioridazine is contraindicated with drugs that may prolong the QT interval.
desipramine
thioridazine will increase the level or effect of desipramine by affecting hepatic enzyme CYP2D6 metabolism. Contraindicated.
disopyramide
thioridazine and disopyramide both increase QTc interval. Contraindicated.
doxepin
thioridazine will increase the level or effect of doxepin by affecting hepatic enzyme CYP2D6 metabolism. Contraindicated.
fluoxetine
fluoxetine increases levels of thioridazine by decreasing metabolism. Contraindicated. Risk of long QT syndrome.
fluvoxamine
thioridazine will increase the level or effect of fluvoxamine by affecting hepatic enzyme CYP2D6 metabolism. Contraindicated. thioridazine and fluvoxamine both increase QTc interval. Contraindicated. fluvoxamine increases levels of thioridazine by decreasing metabolism. Contraindicated. Risk of long QT syndrome.
ibutilide
thioridazine and ibutilide both increase QTc interval. Contraindicated.
imipramine
thioridazine will increase the level or effect of imipramine by affecting hepatic enzyme CYP2D6 metabolism. Contraindicated.
indapamide
thioridazine and indapamide both increase QTc interval. Contraindicated.
metrizamide
thioridazine, metrizamide. Mechanism: unknown. Contraindicated. Risk of seizure. D/C phenothiazine 24h before admin. of metrizamide.
mifepristone
mifepristone, thioridazine. QTc interval. Contraindicated.
nortriptyline
thioridazine will increase the level or effect of nortriptyline by affecting hepatic enzyme CYP2D6 metabolism. Contraindicated.
paroxetine
paroxetine increases levels of thioridazine by decreasing metabolism. Contraindicated. Risk of long QT syndrome.
pentamidine
thioridazine and pentamidine both increase QTc interval. Contraindicated.
pimozide
thioridazine and pimozide both increase QTc interval. Contraindicated.
procainamide
thioridazine and procainamide both increase QTc interval. Contraindicated.
quinidine
thioridazine and quinidine both increase QTc interval. Contraindicated.
sertraline
sertraline increases levels of thioridazine by decreasing metabolism. Contraindicated. Risk of long QT syndrome.
sorafenib
sorafenib and thioridazine both increase QTc interval. Contraindicated.
sotalol
thioridazine and sotalol both increase QTc interval. Contraindicated.
terfenadine
thioridazine and terfenadine both increase QTc interval. Contraindicated.
toremifene
thioridazine and toremifene both increase QTc interval. Contraindicated. Concurrent use of thioridazine with other agents that prolong QTc interval is contraindicated.
Adverse Effects Frequency Not Defined EPS (muscle stiffness, dystonia, parkinsonism, tardive dyskinesia, akathisia) (60%) NMS (infrequent but serious) Sedation Anticholinergic effects Weight gain Oligomenorrhea/amenorrhea Erectile dysfunction Insomnia Restlessness Anxiety Euphoria Agitation Depression
Weakness Headache Cerebral edema Poikilothermia Orthostatic hypotension Tachycardia Dizziness Lens opacities (prolonged use) Anorexia Dyspepsia Constipation Ileus Blood dyscrasia ECG changes Photosensitivity Pruritis Diarrhea Galactorrhea Ejaculatory disorder Seizure (rare) Priapism (rare) Cholestatic jaundice (rare)
thioridazine
thye-oh- rid-a-zeen Apo-Thioridazine, Mellaril, Mellaril-S,
Novo-Ridazine,
PMS Thioridazine
Classification Therapeutic: Pharmacologic: Pregnancy Category C Copyright © 2009 by F.A. Davis Company
Indications Treatment of refractory schizophrenia. Considered second line treatment after failure with atypical antipsychotics Alters the effects of dopamine in the CNS Possesses significant anticholinergic and alpha-adrenergic blocking activity
Therapeutic Effects: Diminished signs and symptoms of psychoses
Pharmokinetics Absorption: Absorption from tablets is variable; may be better with oral liquid formulations Distribution: Widely distributed, high concentrations in the CNS. Crosses the placenta and enters breast milk ≥90%Metabolism and Excretion: Highly metabolized by the liver and GI mucosa
Half-life: 21 –24 hr TIME/ACTION PROFILE antipsychotic effects ROUTE
ONSET
PO
unknownunknown8 –12 hr
PEAK
DURATION
Contraindications/Precautions Contraindicated in: Hypersensitivity Cross-sensitivity with other phenothiazines may exist Angle-closure glaucoma Bone marrow depression Severe liver or cardiovascular disease Known alcohol intolerance (concentrate only) Concurrent fluvoxamine, propranolol, pindolol, fluoxetine, other agents known to inhibit the
CYP450 2D6 enzyme, or agents known to prolong the QTc interval (risk of life-threatening arrrhythmias) Hypokalemia (correct prior to use) QTc interval >450 msec
Use Cautiously in: Debilitated patients Glaucoma Urinary retention Diabetes mellitus Patients with risk factors for electrolyte imbalance (dehydration, diuretic therapy) Respiratory disease Prostatic hyperplasia CNS tumors Epilepsy Intestinal obstruction OB, Lactation: Safety not established. Recommend discontinue drug or bottle feed Geri : May be at ↑ risk for extrapyramidal and CNS adverse effects; appears on Beers list; ↑ risk
of mortality in elderly patients treated for dementia-related psychosis
Adverse Reactions/Side Effects* CNS: neuroleptic malignant syndromesedation, extrapyramidal reactions, tardive dyskinesia. EENT: blurred vision, dry eyes, lens opacities, pigmentary retinopathy (high doses). arrhythmiasqtC PROLONGATIONhypotension, tachycardia, GI: constipation, dry mouth, anorexia, drug-induced hepatitis, ileus, weight gain. GU: urinary retention, priapism. Derm: photosensitivity, pigment changes, rashes. Endo: galactorrhea, amenorrhea. agranulocytosis, leukopeniahyperthermiaMisc: allergic reactions.
Interactions Drug –Drug: Concurrent fluvoxamine, propranolol , pindolol , fluoxetine, other agents known to inhibit the CYP450 2D6 enzyme, or agents known to prolong the QTc interval (risk of lifethreatening arrhythmias)
Diuretics increase the risk of electrolyte imbalance and arrhythmias Additive hypotension with other antihypertensives , nitrates, and acute ingestion of alcohol Additive CNS depression with other CNS depressants, including alcohol, antihistamines , opioid
analgesics, sedative/hypnotics, and general anesthetics Additive anticholinergic effects with other drugs possessing anticholinergic properties, including
antihistamines, antidepressants , atropine, haloperidol , other phenothiazines, and disopyramide Lithium decreases blood levels of thioridazine Thioridazine may mask early signs of lithium toxicity and increase the risk of extrapyramidal
reactions Increased risk of agranulocytosis with antithyroid agents Concurrent use with epinephrine may result in severe hypotension and tachycardia May decrease the effectiveness of levodopa
Route/Dosage >12 yr50 –100 mg tid initially; may be gradually increased to a maintenance dose of up to 800 mg/day 0.5 mg/kg/day in divided doses initially; may be gradually increased to a maintenance dose of up to 3 mg/kg/day
Availability (generic available) Tablets: 10 mg, 15 mg, 25 mg, 50 mg, 100 mg, 150 mg, 200 mg Oral suspension10 mg/5 ml, 25 mg/5 ml, 100 mg/5 ml Concentrated oral solution : 30 mg/ml, 100 mg/ml
NURSING IMPLICATIONS Assessment
Assess mental status (orientation, mood, behavior) before and periodically during therapy Assess positive (delusions, hallucinations, agitation) and negative (social withdrawal) symptoms of schizophrenia Assess weight and BMI initially and throughout theerapy Monitor blood pressure (sitting, standing, lying), ECG, pulse, and respiratory rate before and frequently during the period of dose adjustment. May cause Q-wave and T-wave changes in ECG Observe patient carefully when administering medication to ensure that medication is actually taken and not hoarded or cheeked Assess patient for level of sedation after administration. Geri : Geriatric patients are more likely to become oversedated. Monitor intake and output ratios and daily weight. Report significant discrepancies Monitor patient for onset of akathisia (restlessness or desire to keep moving) and extrapyramidal side effects ( parkinsonian—difficulty speaking or swallowing, loss of balance control, pill rolling of hands, mask-like face, shuffling gait, rigidity, tremors; and dystonic—muscle spasms, twisting motions, twitching, inability to move eyes, weakness of arms or legs) every 2 mo during therapy and 8 –12 wk after therapy has been discontinued. Report these symptoms; reduction in dosage or discontinuation of medication may be necessary. Trihexyphenidyl, diphenhydramine, or benztropine may be used to control these symptoms. Benzodiazpines may alleviate akathisia Monitor for tardive dyskinesia (uncontrolled rhythmic movement of mouth, face, and extremities; lip smacking or puckering; puffing of cheeks; uncontrolled chewing; rapid or worm-like movements of tongue, excessive eye blinking). Report
immediately; may be irreversible Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control). Notify health care professional immediately if these symptoms occur Lab Test Considerations : CBC, liver function tests, and ocular examinations should be evaluated periodically during therapy. May cause ↓ hematocrit, hemoglobin, leukocytes, granulocytes, platelets. May cause ↑ bilirubin, AST, ALT, and alkaline phosphatase. Agranulocytosis occurs between 4 –10 wk of therapy with recovery 1 –2 wk after discontinuation. May recur if medication is restarted. Liver function abnormalities may require discontinuation of therapy. May cause false-positive or false-negative pregnancy test results and false-positive urine bilirubin test resultsMay cause ↑ serum prolactin levels
Potential Nursing Diagnoses Implementation
To prevent contact dermatitis, avoid getting liquid preparations on hands, and wash hands thoroughly if spillage occurs. Phenothiazines should be discontinued 48 hr before and not resumed for 24 hr after myelography, as they lower the seizure thresholdPO: Administer with food, milk, or full glass of water to minimize gastric irritation. Dilute concentrate in 120 ml of distilled or acidified tap water or fruit juice just before administration.
Patient/Family Teaching
Advise patient to take medication as directed and not to skip doses or double up on missed doses. Take missed doses as soon as remembered unless almost time for the next dose. If more than 2 doses a day are ordered, the missed dose should be taken within 1 hr of the scheduled time or omitted. Abrupt withdrawal may lead to gastritis, nausea, vomiting, dizziness, headache, tachycardia, and insomnia Inform patient of possibility of extrapyramidal symptoms and tardive dyskinesia. Instruct patient to report these symptoms immediately to health care professional Advise patient to change positions slowly to minimize orthostatic hypotension May cause drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known Advise patient to use sunscreen and protective clothing when exposed to the sun. Exposed surfaces may develop a blue-gray pigmentation, which may fade after discontinuation of the medication. Extremes in temperature should also be avoided, as this drug impairs body temperature regulation Instruct patient to use frequent mouth rinses, good oral hygiene, and sugarless gum or candy to minimize dry mouth. Consult health care professional if dry mouth continues for >2 wk Advise patient that increasing activity and bulk and fluids in the diet helps minimize
the constipating effects of this medication Caution patient to avoid taking alcohol or other CNS depressants concurrently with this medication Advise patient not to take thioridazine within 2 hr of antacids or antidiarrheal medication Inform patient that this medication may turn urine pink to reddish brown Advise patient to notify health care professional of medication regimen before treatment or surgery Refer as appropriate for nutritional/weight management and medical management Instruct patient to notify health care professional promptly if sore throat, fever, unusual bleeding or bruising, rash, weakness, tremors, visual disturbances, darkcolored urine, or clay-colored stools occur Emphasize the importance of routine follow-up exams to monitor response to medication and to detect side effects. Periodic ocular exams are indicated. Encourage continued participation in psychotherapy.
Evaluation/Desired Outcomes
Decrease in positive symptoms (hallucinations, delusions, agitation) of schizophrenia.
GENERIC NAME: diazepam
BRAND NAME: Valium, Diastat DRUG CLASS: Diazepam is an anti-anxiety medication in the benzodiazepine family, the same family that includes alprazolam (Xanax), clonazepam (Klonopin), lorazepam (Ativan), flurazepam (Dalmane), and others. Diazepam and other benzodiazepines act by enhancing the effects of gamma-aminobutyric acid (GABA) in the brain. GABA is a neurotransmitter (a chemical that nerve cells use to communicate with each other) that inhibits activity in the brain. It is believed that excessive activity in the brain may lead to anxiety or other psychiatric disorders. PRESCRIPTION: Yes GENERIC AVAILABLE: Yes PREPARATIONS: Tablets: 2, 5, and 10 mg. Solution: 5 mg/ml. Injection: 5 mg/ml. Rectal Gel: 2.5, 10, and 20 mg. STORAGE: Diazepam should be stored at room temperature, 15-30°C (5986°F). PRESCRIBED FOR: Diazepam is used for the treatment of anxiety disorders. Diazepam also is used for the treatment of agitation, tremors, delirium, seizures, and hallucinations resulting from alcohol withdrawal. It is used for the treatment of seizures and relief of muscle spasms in some neurological diseases.
DOSING: Diazepam may be taken with or without food. Diazepam is metabolized by the liver and excreted mainly by the kidney. Dosages of diazepam may need to be lowered in patients with abnormal kidney function. The usual oral diazepam dose is 2-10 mg given 2-4 times daily. The usual rectal dose is 0.2-0.5 mg/kg and depends on the age of the patient. DRUG INTERACTIONS: Alcohol or medications that cause sedation may add to the sedative effects of diazepam. Patients taking benzodiazepines should avoid such combinations. Cimetidine (Tagamet), ketoconazole (Nizoral), omeprazole (Prilosec, Rapinex), fluvoxamine (Luvox), and fluoxetine (Prozac) may prolong the effects of diazepam by inhibiting liver enzymes that break down diazepam. Dosages may need to be decreased when these drugs are used with diazepam. PREGNANCY: Benzodiazepines, such as diazepam, can cause fetal abnormalities and should not be used during pregnancy. NURSING MOTHERS: Diazepam is excreted in breast milk and can affect nursing infants. Therefore, diazepam should not be used by women who are nursing. SIDE EFFECTS: The most frequent side effects of diazepam are drowsiness, fatigue, and ataxia (loss of balance). Rarely, diazepam causes a paradoxical reaction with excitability, muscle spasm, lack of sleep, and rage. Confusion, depression, speech problems, and double vision are also rare side effects of diazepam. Diazepam can lead to addiction (dependency), especially when higher dosages are used over prolonged periods of time. In patients addicted to diazepam or after prolonged use, abrupt discontinuation of the medicine may cause symptoms of withdrawal (insomnia, headaches, nausea, vomiting, lightheadedness, sweating, anxiety, and fatigue). Seizures can occur in more severe cases of withdrawal. Therefore, after extended use, diazepam should be slowly tapered under a doctor's supervision rather than abruptly stopping the medication. Nursing Considerations • Use diazepam with extreme caution in patients with a history of alcohol or drug abuse because it can cause physical and psychological dependence, and in patients with hepatic disorders such as hepatic fibrosis and hepatitis because of potentially significant increase in drug’s half -life. • Use diazepam cautiously in patients with hepatic or renal impairment. Severe hepatic impairment is a contraindication to use. • Expect to give a lower diazepam dose to patient with chronic respiratory insufficiency because of the risk of respiratory
depression. •Mix concentrated oral solution (Intensol) with liquid or semisolid food. Use supplied calibrated dropper to measure doses. • Protect diazepam injection from light. Don’t use solution that’s more than slightly yellow or that contains precipitate. • Give I.M. injection into deltoid muscle for rapid, complete absorption. Using other sites may cause slow, erratic absorption. • Before administering emulsion form, ask if patient is allergic to soybeans because this form contains soybean oil. • For an infant or a child, administer I.V. injection slowly over 3 minutes in a dose not to exceed 0.25 mg/kg. • Give emulsion form within 6 hours of opening ampule because it contains no preservatives and allows rapid microbial growth. Use polyethylene-lined or glass infusion sets and polyethylene or polypropylene plastic syringes for administration. Don’t use a filter with a pore size less than 5 microns because a smaller size may break down the emulsion. • Don’t mix emulsion form with anything other than its emulsion base. Otherwise, it may become unstable and increase the risk of serious adverse reactions. •Monitor patient for adverse reactions, especially if she has hypoalbuminemia, which increases the risk of sedation. WARNING Watch for signs of physical and psychological dependence (strong desire or need to continue taking diazepam, need to increase dose to maintain drug effects, and posttherapy withdrawal symptoms, such as abdominal cramps, insomnia, irritability, nervousness, and tremor). •Monitor patient closely for increase in frequency or severity of grand mal seizures when diazepam is used with standard anticonvulsant therapy. Dosage of other anticonvulsants may need to be increased.
• Avoid abrupt withdrawal of diazepam, as ordered, when used as part of the patient’s seizure control regimen because a transient increase in frequency or severity of seizures may occur. •Monitor severely depressed patient or one with depression-related anxiety for suicidal tendencies, particularly when therapy starts and dosage changes; depression may worsen temporarily during these times. •Watch for psychiatric and paradoxical reactions to diazepam, especially in children and the elderly. If reations occur, notify prescriber and expect drug to be discontinued. •Monitor patient for decreased drug effectiveness, especially with prolonged use. • Check patient’s blood counts and liver function periodically, as ordered, because prolonged diazepam therapy rarely causes neutropenia and jaundice. PATIENT TEACHING • Instruct patient not to take more drug, more often, or for a longer time than prescribed. Warn her that physical and psychological dependence can occur, and teach her to recognize the signs. • Advise patient not to take drug to relieve everyday stress. • Advise patient to avoid hazardous activities until drug’s CNS effects are known. • Advise patient to avoid CNS depressants and alcohol during therapy. • Instruct patient not to stop taking drug abruptly without prescriber’s supervision. If patient has a history of seizures, warn that abrupt withdrawal may trigger them. • Instruct patient to mix Diazepam Intensol with water, soda, or a similar beverage; applesauce; or pudding just before taking it. Caution her not to save the mixture for later. Tell her to use calibrated dropper that’s provided to measure each dose. • Teach patient how to self -administer a rectal
form, if prescribed. • Instruct female patient of childbearing age to notify prescriber immediately if she is or could be pregnant because diazepam therapy will need to be discontinued. • Urge family or caregiver to watch patient closely for suicidal tendencies, especially when therapy starts or dosage changes.
GENERIC NAME: CHLORDIAZEPOXIDE - ORAL (KLOR-dye-AZ-e-POX-ide) BRAND NAME(S): Librium Medication Uses | How To Use | Side Effects | Precautions | Drug Interactions | Overdose | Notes | Missed Dose | Storage
USES: Chlordiazepoxide is used to treat anxiety and acute alcohol withdrawal. It is also used to relieve fear and anxiety before surgery. This medication belongs to a class of drugs called benzodiazepines which act on the brain and nerves (central nervous system) to produce a calming effect. It works by enhancing the effects of a certain natural chemical in the body (GABA). HOW TO USE: Take this medication by mouth as directed by your doctor. The dosage is based on your medical condition and response to therapy.Use this medication exactly as prescribed. Do not increase your dose, take it more frequently or use it for a longer period of time than prescribed because this drug can be habit-forming. Also, if used for an extended period of time, do not suddenly stop using this drug without your doctor's approval. Some conditions may become worse when the drug is abruptly stopped. Your dose may need to be gradually decreased to avoid side effects such as seizures.When used for an extended period, this medication may not work as well and may require different dosing. Talk with your doctor if this medication stops working well. SIDE EFFECTS: Drowsiness, dizziness, nausea, constipation, blurred vision, or headache may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly.Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.Tell your doctor immediately if any of these unlikely but serious side effects occur: mental/mood changes, slurred speech, clumsiness, trouble walking, decreased/increased interest in sex, tremor, uncontrollable movements, facial or muscle twitching, trouble urinating, sleep disturbances.Tell your doctor immediately if any of these highly unlikely but very serious side effects occur:
fainting, stomach / abdominal pain, persistent nausea, vomiting, fatigue, yellowing eyes or skin, dark urine, persistent sore throat or fever.A serious allergic reaction to this drug is unlikely, but seek immediate medical attention if it occurs. Symptoms of a serious allergic reaction include: rash, itching / swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.
Generic Name chlordiazepoxide TradeName Librium Classification Benzodiazepinesantianxiety agents Dose 5 mg Route PO/NG tube Time/frequency BID PRN Peak 0.5-4 hr Onset 1-2 hr Duration up to 24 hr Normal dosage range 5 mg 2-4 times daily initially Why is your patient getting this medication anxiety For IV meds, compatibility with IV drips and/orsolutions n/a Mechanism of action and indications (Why med ordered) Depresses the CNS, probably by potentiatingGABA, an inhibitory neurotransmitter Nursing Implications (what to focus on) Contraindications/warnings/interactions Hypersensitivity, those with pre-existing CNS depression,Long--acting benzodiazepines cause prolonged sedation inthe elderly. Appears on Beers list and is associated withincreased risk of falls (↓ dose required or consider short -acting benzodiazepine.) Common side effects Dizziness, drowsiness
EQUANIL® Tablets EQUANIL® L.A. Tablets SCHEDULING STATUS: S5 PROPRIETARY NAME (and dosage form): ®
EQUANIL Tablets ® EQUANIL L.A. Tablets COMPOSITION: Each EQUANIL tablet contains meprobamate 400 mg. Each EQUANIL L.A. tablet contains meprobamate 400 mg as a slow release tablet. Chemically, meprobamate is 2,2-di-(carbamoyl-oxymethyl)-pentane EQUANIL L.A. tablets contain TARTRAZINE.
PHARMACOLOGICAL CLASSIFICATION: Category A, 2.6 Tranquillizers PHARMACOLOGICAL ACTION: EQUANIL (meprobamate) is a carbamate derivative which has been shown to have effects at multiple sites in the central nervous system including the thalamus and limbic system. Pharmacokinetics: Meprobamate is well absorbed from the gastrointestinal tract. The drug is widely distributed in the body; there is little binding to plasma protein. Meprobamate undergoes extensive metabolism in the liver with 10 to 20% of the drug eliminated unchanged via the kidneys; the remainder is excreted as hydroxymeprobamate and as the glucoronide. Meprobamate can induce some hepatic microsomal enzymes, but is not clear whether the drug induces the enzymes responsible for its own metabolism. INDICATIONS: For the relief of anxiety and tension; as an adjunct in the treatment of various disease states in which anxiety and tension are manifested. The effectiveness of EQUANIL and EQUANIL L.A. in long-term use, that is, more than 4 months, has not been assessed by systematic clinical studies. The physician should reassess periodically the usefulness of the drug for the individual patient. CONTRA-INDICATIONS:
Acute intermittent porphyria and allergic or idiosyncratic reactions to meprobamate or related compounds, such as carisoprodol, mebutamate or carbromal.
WARNINGS: Addiction potential: Physical dependence, psychological dependence, and abuse have occurred. Chronic intoxication from prolonged ingestion of, usually, greater than recommended doses is manifested by ataxia, slurred speech, and vertigo. Therefore, careful supervision of dose and amounts prescribed is advised, as well as avoidance of prolonged administration, especially for alcoholics and other patients with a known propensity for taking excessive quantities of drugs. Sudden withdrawal of the drug after prolonged and excessive use may precipitate recurrence of pre-existing symptoms such as anxiety, anorexia, or insomnia, or withdrawal reactions such as vomiting, ataxia, tremors, muscle twitching, confusional states, hallucinosis, and rarely, convulsive seizures. Such seizures are more likely to occur in persons with central nervous system damage or pre-existent or latent convulsive disorders. Onset of withdrawal symptoms occurs usually within 12 to 48 hours after discontinuation of meprobamate; symptoms usually cease within the next 12 to 48 hour period. To avoid withdrawal symptoms, it is recommended that meprobamate not be abruptly discontinued in these situations; rather, a gradual tapering of the dose be attempted. Alternatively, a short-acting barbiturate may be substituted then gradually withdrawn. Usage in Pregnancy and Lactation: An increased risk of congenital malformations associated with the use of minor tranquillizers (meprobamate, chlordiazepoxide, and diazepam) during the first trimester of pregnancy has been suggested in several studies. Because use of these drugs is rarely a matter of urgency, their use during this period should almost always be avoided. The possibility that a woman of childbearing potential may be pregnant at the time of institution of therapy should be considered. Patients should be advised that if they become pregnant during therapy or intend to become pregnant they should communicate with their physicians about the desirability of discontinuing the drug. Meprobamate passes the placental barrier. It i s present both in umbilical-cord blood at or near maternal plasma levels and in breast milk of lactating mothers at concentrations two to four times that of maternal plasma. When use of meprobamate is contemplated in breastfeeding patients, the drug’s higher concentration in breast milk as compared to maternal plasma levels should be considered. Usage in Children: Meprobamate should not be administered to children under 6 years of age since there is a lack of documented evidence of safety and effectiveness. EQUANIL L.A. tablets contains F D and C Yellow No. 5 (tartrazine) which may cause allergic-type reactions (including bronchial asthma) in certain susceptible individuals. Although the overall incidence of tartrazine sensitivity in the general population is currently thought to be low, it is frequently seen in patients who have aspirin sensitivity. DOSAGE AND DIRECTIONS FOR USE:
EQUANIL tablets: Usual adult dose is 1 200-1 600 mg/day in divided doses. Doses greater than 2
400 mg/day are not recommended. The usual dose of children ages 6 -12 years is 100-200 mg two to three times daily. Not recommended for children under 6 years. EQUANIL L.A. tablets: Usual adult dose is 1 tablet twice daily.
SIDE-EFFECTS AND SPECIAL PRECAUTIONS: SIDE-EFFECTS: Central nervous system: Drowsiness, ataxia, dizziness, slurred speech, headache, vertigo, weakness, paresthesias, impairment of visual accommodation, euphoria, overstimulation, paradoxical excitement, fast EEG activity. Gastrointestinal: Nausea, vomiting, diarrhoea. Cardiovascular: Palpitation, tachycardia, various forms of arrhythmia, transient ECG changes, syncope, hypotensive crises. Allergic or Idiosyncratic: Milder reactions are characterized by an itchy, urticarial, or erythematous maculopapular rash which may be generalized or confined to the groin. Other reactions have included leukopaenia, acute nonthrombocytopaenic purpura, petechiae, ecchymoses, eosinophilia, peripheral oedema, adenopathy, fever, fixed drug eruption with cross reaction to carisoprodol, and cross sensitivity between meprobamate/mebutamate and meprobamate/carbromal. More severe hypersensitivity reactions, rarely reported, include hyperpyrexia, chills, angioneurotic oedema, bronchospasm, oliguria, and anuria. Also, anaphylaxis, exfoliative dermatitis, stomatitis and proctitis. Stevens-Johnson syndrome and bullous dermatitis have occurred. Haematologic (See also “Allergic or Idiosyncratic”): Agranulocytosis, aplastic anaemia have been reported, although no casual relationship has been established, and thrombocytopaenic purpura.
Other: Exacerbation of porphyric symptoms. SPECIAL PRECAUTIONS: The least effective dose should be administered, particularly to elderly and/or debilitated patients in order to preclude oversedation. Meprobamate is metabolized in the liver and excreted by the kidney; to avoid its excess accumulation, caution should be exercised in the administration to patients with compromised liver or kidney function.
Meprobamate occasionally may precipitate seizures in epileptic patients. The drug should be prescribed cautiously and in small quantities to patients with suicidal tendencies.
Potentially Hazardous Tasks: Patients should be warned that meprobamate may impair the mental or physical abilities required for performance of potentially hazardous tasks such as driving or operating machinery. Additive Effects: Since CNS-suppressant effects of meprobamate and alcohol or meprobamate and other psychotropic drugs may be additive, appropriate caution should be exercised with patients who take more than one of these agents simultaneously. Medicine Interactions: The enzyme-inducing effect of meprobamate may decrease the activity of some drugs which are metabolized by the liver, including digitoxin and endogenous and exogenous estrogens. The risk of breakthrough bleeding, spotting, or pregnancy in women taking oral contraceptives, is therefore increased when such women are also taking meprobamate. Laboratory Test Interactions: Meprobamate may cause falsely high urinary 17-ketosteroid and 17-ketogenic steroid levels in the Zimmerman reaction and 17-hydroxycorticosteroid levels in the modified Glenn-Nelson technique. Addiction potential: See “WARNINGS”. Usage in Pregnancy and Lactation: See “WARNINGS”. Usage in children: See “WARNINGS”. KNOWN SYMPTOMS OF OVERDOSAGE AND PARTICULARS OF ITS TREATMENT: Suicidal attempts with meprobamate have resulted in drowsiness, lethargy, stupor, ataxia, coma, shock, vasomotor, and respiratory collapse. Some suicidal attempts have been fatal. General supportive measures should be employed along with gastric lavage, I.V. fluids should be administered, and an adequate airway maintained. Diuresis, osmotic (mannitol) diuresis, peritoneal dialysis, and haemodialysis have been used successfully. Careful monitoring of urinary output is necessary and caution should be taken to avoid overhydration. Relapse and death, after initial recovery, have been attributed to incomplete gastric emptying and delayed absorption. IDENTIFICATION: EQUANIL tablets are white, flat tablets with bevelled edges containing not more than a slight characteristic odour, having the word “WYETH’ impressed on both halves of the scored face and the letter “W”within a shield impressed on the other face.
EQUANIL L.A. tablets are yellow with the letter “W’within a shield imprinted on both sides.
PRESENTATION: EQUANIL tablets: Bottles of 100 and 250 tablets. EQUANIL L.A. tablets: Bottles of 25 tablets. STORAGE DIRECTIONS: Store in a cool (below 25 °C), dry place. Keep out of reach of children. REFERENCE NUMBERS: EQUANIL tablets B1340 (Act 101/1965) EQUANIL L.A. tablets B1341 (Act 101/1965) NAME AND BUSINESS ADDRESS OF APPLICANT: AKROMED PRODUCTS Electron Avenue ISANDO 1600 Trademark and product, under licence from WYETH-AYERST LABORATORIES. U.S.A.
DATE OF PUBLICATION OF THIS PACKAGE INSERT: 6 December 1984 24460 IG608 Davbar Dbn.
ranil (Imipramine Hydrochloride) - Indications and Dosage
INDICATIONS AND USAGE Depression - For the relief of symptoms of depression. Endogenous depression is more likely to be alleviated than other depressive states. One to three weeks of treatment may be needed before optimal therapeutic effects are evident. Childhood Enuresis - May be useful as temporary adjunctive therapy in reducing enuresis in children aged 6 years and older, after possible organic causes have been excluded by appropriate tests. In patients having daytime symptoms of frequency and urgency, examination should include voiding cystourethrography and cystoscopy, as
necessary. The effectiveness of treatment may decrease with continued drug administration. imipramine
im-ip-ra-meen Apo-Imipramine,
Impril, Norfranil,
Novopramine, Tipramine, Tofranil, Tofranil PM
Classification Therapeutic: Pharmacologic: Pregnancy Category C Copyright © 2009 by F.A. Davis Company
Indications Various forms of depression Enuresis in children
Unlabelled Uses: Adjunct in the management of chronic pain, incontinence (in adults), vascular headache prophylaxis, cluster headache, insomnia
Action Potentiates the effect of serotonin and norepinephrine Has significant anticholinergic properties
Therapeutic Effects: Antidepressant action that develops slowly over several weeks
Pharmokinetics Absorption: Well absorbed from the GI tract Distribution: Widely distributed. Probably crosses the placenta and enters breast milk Protein Binding: 89 –95% Metabolism and Excretion: Extensively metabolized by the liver, mostly on first pass; some conversion to active compounds. Undergoes enterohepatic recirculation and secretion into gastric juices
Half-life: 8 –16 hr TIME/ACTION PROFILE antidepressant effect ROUTE
ONSET
PO, IM
hours2 –6 wkweeks
PEAK
DURATION
Contraindications/Precautions Contraindicated in: Hypersensitivity Cross-sensitivity with other antidepressants may occur Angle-closure glaucoma Hypersensitivity to tartrazine or sulfites (in some preparations) Recent MI, known history of QTc prolongation, heart failure
Use Cautiously in: Pre-existing cardiovascular disease Seizures or history of seizure disorder May ↑ risk of suicide attempt/ideation especially during early treatment or dose adjustment OB: Drug is present in breast milk; discontinue imipramine or bottle feed Pedi : Suicide risk may be greater in children or adolescents. Safety not established in children
<6 yr Geri : Geriatric patients (more susceptible to adverse reactions). Geriatric males with prostatic
hyperplasia are more susceptible to urinary retention
Adverse Reactions/Side Effects* * CAPITALS indicate life threatening; underlines indicate most frequent. CNS: drowsiness, fatigue, agitation, confusion, hallucinations, insomnia. EENT: blurred vision, dry eyes. CV: ARRHYTHMIAS, hypotension, ECG changes. GI: constipation, dry mouth, nausea, paralytic ileus, weight gain. GU: urinary retention, decreased libido. Derm: photosensitivity.
Endo: gynecomastia. Hemat: blood dyscrasias.
Interactions Drug –Drug: May cause hypotension, tachycardia, and potentially fatal reactions when used with MAO inhibitors (avoid concurrent use—discontinue 2 wk prior to imipramine) Concurrent use with SSRI antidepressants may result in increased toxicity and should be avoided (fluoxetine should be stopped 5 wk before) Concurrent use with clonidine may result in hypertensive crisis and should be avoided Imipramine is metabolized in the liver by the cytochrome P450 2D6 enzyme and its action may be affected by drugs that compete for metabolism by this enzyme including other
antidepressants, phenothiazines, carbamazepine, class 1C antiarrhythmics (propafenone, flecainide); when used concurrently, dose reduction of one or the other or both may be necessary. Concurrent use of other drugs that inhibit the activity of the enzyme, including
cimetidine, quinidine, amiodarone , and ritonavir, may result in ↑ effects of imipramine Concurrent use with levodopa may result in delayed/↓ absorption of levodopa or hypertension Blood levels and effects may be ↓ by rifamycins ↑ CNS depression with other CNS depressants including alcohol, antihistamines , clonidine,
opioids, and sedative/hypnotics
Barbiturates may alter blood levels and effects Adrenergic and anticholinergic side ef fects may be ↑ with other agents having these properties Phenothiazines or hormonal contraceptives ↑ levels and may cause toxicity Cigarette smoking (nicotine) may increase metabolism and alter effects Drug –Natural: Concomitant use of kava, valerian, or chamomile can increase CNS depression ↑ anticholinergic effects with jimson weed and scopolia
Route/Dosage PO (Adults): 25 –50 mg 3 –4 times daily (not to exceed 300 mg/day); total daily dose may be given at bedtime 25 mg at bedtime initially, up to 100 mg/day in divided doses
PO (Children >12 yr): Antidepressant —25 –50 mg/day in divided doses (not to exceed 100 mg/day)
PO (Children 6 –12 yr): Antidepressant —10 –30 mg/day in 2 divided doses PO (Children ≥6 yr): Enuresis—25 mg once daily 1 hr before bedtime; increase if necessary by
25 mg at weekly intervals to 50 mg in children <12 yr, up to 75 mg in children >12 yr
IM (Adults): Up to 100 mg/day in divided doses (not to exceed 300 mg/day)
Availability (generic available) Tablets: 10 mg, 25 mg , 50 mg75 mg Capsules: 75 mg, 100 mg, 125 mg, 150 mg Injection: 12.5 mg/ml
NURSING IMPLICATIONS Assessment
Monitor blood pressure and pulse rate prior to and during initial therapy Monitor Plasma levels in treatment-resisant patients Monitor weight and BMI initially and periodically throughout therapy For overweight/obese individuals, obtain FBS and cholesterol levels Refer as appropriate for nutrition/weight management and medical management Obtain weight and BMI initially and regularly throughout therapy Assess for sexual dysfunction (decreased libido; erectile dysfunction) Pedi, Geri : Monitor baseline and periodic ECGs in elderly patients or patients with heart disease and before increasing dose with children treated for enuresis. May cause prolonged PR and QT intervals and may flatten T waves DepressionAssess mental status (orientation, mood, behavior) frequently. Confusion, agitation, and hallucinations may occur during initiation of therapy and may require dosage reduction. Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient
Enuresis Assess frequency of bedwetting during therapy. Ask patient or caretaker to maintain diary PainAssess location, duration, and severity of pain periodically during therapy. Use pain scale to monitor effectiveness of therapy Lab Test Considerations : Assess leukocyte and differential blood counts and renal and hepatic functions prior to and periodically during prolonged or high-dose therapy. Serum levels may be monitored in patients who fail to respond to usual therapeutic dose. Therapeutic plasma concentration range for depression is 150 –300 ng/mlMay cause alterations in blood glucose levels Toxicity and Overdose : Symptoms of acute overdose include disturbed concentration, confusion, restlessness, agitation, seizures, drowsiness, mydriasis, arrhythmias, fever, hallucinations, vomiting, and dyspnea. Treatment of overdose includes gastric lavage, activated charcoal, and a stimulant cathartic. Maintain respiratory and cardiac function (monitor ECG for at least 5 days) and temperature. Medications may include digoxin for CHF, antiarrhythmics, and anticonvulsants
Potential Nursing Diagnoses Ineffective coping (Indications) Chronic pain (Indications)
Implementation
Do not confuse imipramine with desipramine. Dose increases should be made at bedtime because of sedation. Dose titration is a slow process; may take weeks to months. May be given as a single dose at bedtime to minimize sedation during the dayTaper to avoid withdrawal effects. Reduce by 50% for 3 days, then reduce by 50% for 3 days, then discontinuePO: Administer medication with or immediately following a meal to minimize gastric irritation IM: May be slightly yellow or red in color. Crystals may develop if solution is cool; place ampule under warm running water for 1 min to dissolve Patient/Family Teaching Instruct patient to take medication as directed. Take missed doses as soon as possible unless almost time for next dose; if regimen is a single dose at bedtime, do not take in the morning because of side effects. Advise patient that drug effects may not be noticed for at least 2 wk. Abrupt discontinuation may cause nausea, vomiting, diarrhea, headache, trouble sleeping with vivid dreams, and irritability. May cause drowsiness and blurred vision. Caution patient to avoid driving and other activities requiring alertness until response to drug is knownInstruct patient to notify health care professional if visual changes occur. Inform patient that periodic glaucoma testing may be needed during long-term therapyCaution patient to change positions slowly to minimize orthostatic hypotensionAdvise patient to avoid alcohol or other
CNS depressant drugs during therapy and for at least 3 –7 days after therapy has been discontinuedInstruct patient to notify health care professional if urinary retention, dry mouth, or constipation persists. Sugarless candy or gum may diminish dry mouth and an increase in fluid intake or bulk may prevent constipation. If symptoms persist, dose reduction or discontinuation may be necessary. Consult health care professional if dry mouth persists for more than 2 wkCaution patient to use sunscreen and protective clothing to prevent photosensitivity reactionsAlert patient that urine may turn blue-green in colorInform patient of need to monitor dietary intake, as possible increase in appetite may lead to undesired weight gain. Inform patient that increased amounts of riboflavin in the diet may be required; consult health care professionalAdvise patient to notify health care professional of medication regimen prior to treatment or surgeryTherapy for depression is usually prolonged. Emphasize the importance of follow-up exams to evaluate progress and improve coping skills Pedi : Inform parents that the side effects most likely to occur include nervousness, insomnia, unusual tiredness, and mild nausea and vomiting. Notify health care professional if these symptoms become pronounced. Advise parents to keep medication out of reach of children to prevent inadvertent overdoseRefer to local support group.
Evaluation/Desired Outcomes
Increased sense of well-being. Renewed interest in surroundingsIncreased appetiteImproved energy levelPain reliefDiminished incidence of enuresisImproved sleep in patients treated for depression. Patient may require 2 –6 wk of therapy before full therapeutic effects of medication are noticeableControl of bedwetting in children >6 yr Decrease in chronic neurogenic pain.
Drug Information The following information is obtained from various newswires, published medical journal articles, and medical conference presentations. Drug Name: Marplan Tablets Company: Roche Approval Status: Approved August 1998 Treatment Area: Depression
General Information Marplan is indicated for the treatment of depression. Because of its potentially serious side effects, it is not recommended as an anti-depressant of first choice in the treatment of newly diagnosed depressed patients. The effectiveness of Marplan for long-term use, meaning longer than 6 weeks, has not been fully evaluated by trials. Side Effects Marplan can cause serious side effects. It is not recommended as initial therapy but should be reserved for patients who have not responded satisfactorily to other anti-depressants. Some side effects include: headaches, palpitation, neck stiffness, nausea or vomiting, sweating (fevers or clammy skin), photophobia, tachycardia, bradycardia, constricting chest pain, dilated pupils, intracranial bleeding and increased blood pressure.
INDICATIONS AND USAGE Marplan is indicated for the treatment of depression. Because of its potentially serious side effects, Marplan is not an antidepressant of first choice in the treatment of newly diagnosed depressed patients. The efficacy of Marplan in the treatment of depression was established in 6-week controlled trials of depressed outpatients. These patients had symptoms that corresponded to the DSM-IV category of major depressive disorder; however, they often also had signs and symptoms of anxiety (anxious mood, panic, and/or phobic symptoms) (See CLINICAL PHARMACOLOGY). A major depressive episode (DSM-IV) implies a prominent and relatively persistent (nearly every day for at least 2 weeks) depressed or dysphoric mood that usually interferes with daily functioning, and includes at least five of the following nine symptoms: depressed mood, loss of interest in usual activities, significant change in weight and/or appetite, insomnia or hypersomnia, psychomotor agitation or retardation, increased fatigue, feelings of guilt or worthlessness, slowed thinking or impaired concentration, and a suicide attempt or suicidal ideation. The antidepressant effectiveness of Marplan in hospitalized depressed patients, or in endogenomorphically retarded and delusionally depressed patients, has not been adequately studied. The effectiveness of Marplan in long-term use, that is, for more than 6 weeks, has not been systematically evaluated in controlled trials. Therefore, the physician who elects
to use Marplan for extended periods should periodically evaluate the long-term usefulness of the drug for the individual patient. DOSAGE AND ADMINISTRATION For maximum therapeutic effect, the dosage of Marplan must be individually adjusted on the basis of careful observation of the patient. Dosage should be started with one tablet (10 mg) of Marplan twice daily. If tolerated, dosage may be increased by increments of one tablet (10 mg) every 2 to 4 days to achieve a dosage of four tablets daily (40 mg) by the end of the first week of treatment. Dosage can then be increased by increments of up to 20 mg/week, if needed and tolerated, to a maximum recommended dosage of 60 mg/day. Daily dosage should be divided into two to four dosages. After maximum clinical response is achieved, an attempt should be made to reduce the dosage slowly over a period of several weeks without jeopardizing the therapeutic response. Beneficial effect may not be seen in some patients for 3 to 6 weeks. If no response is obtained by then, continued administration is unlikely to help. Because of the limited experience with systematically monitored patients receiving Marplan at the higher end of the currently recommended dose range of up to 60 mg/day, caution is indicated in patients for whom a dose of 40 mg/day is exceeded (see ADVERSE REACTIONS). isocarboxazid
eye-soe-kar- boks-a-zid Marplan Classification Therapeutic: Pharmacologic: Pregnancy Category C Copyright © 2009 by F.A. Davis Company
Indications Treatment of depression (usually reserved for patients who do not tolerate or respond to other modes of therapy [e.g. tricyclic antidepressants, SSRIs, SSNRIs or electroconvulsive therapy])
Action Inhibits the enzyme monoamine oxidase, resulting in an accumulation of various neurotransmitters (dopamine, epinephrine, norepinephrine, and serotonin) in the body
Therapeutic Effects: Improved mood in depressed patients
Pharmokinetics Absorption: Unknown Distribution: Unknown Metabolism and Excretion: Unknown Half-life: Unknown TIME/ACTION PROFILE antidepressant effect ROUTE
ONSET
PO
unknown3 –6 wkunknown
PEAK
DURATION
Contraindications/Precautions Contraindicated in: Hypersensitivity Liver disease Severe renal disease Cerebrovascular disease Cardiovascular disease Uncontrolled hypertension Pheochromocytoma History of severe or frequent headaches Patients undergoing elective surgery requiring general anesthesia (should be discontinued at least 10 days before surgery) Excessive consumption of caffeine Concurrent use of meperidine, SSRI antidepressants, SSNRI antidepressants, tricyclic antidepressants, tetracyclic antidepressants, nefazodone, trazodone, procarbazine, selegiline, linezolid, carbamazepine, cyclobenzaprine, bupropion, buspirone, sympathomimetics, other MAO inhibitors, dextromethorphan, narcotics, alcohol, general anesthetics, diuretics, tryptophan, or antihistamines Concurrent use of foods containing high concentrations of tyramine (see ) Lactation Children <16 yr (safety and effectiveness not established)
Use Cautiously in: Patients who may be suicidal or have a history of drug dependency Pedi : May ↑ risk of suicide attempt/ideation especially during first 1–2 months of treatment or
with dose adjustments (approved for use in children ≥16 yr) Hyperthyroidism Schizophrenia Bipolar disorder
Seizure disorders Diabetes (↑ risk of hypoglycemia) Geri : Geriatric patients (↑ risk of adverse reactions)
Pregnancy (safety not established)
Adverse Reactions/Side Effects* * CAPITALS indicate life threatening; underlines indicate most frequent. CNS: SEIZURES, dizziness, headache, akathisia, anxiety, ataxia, drowsiness, euphoria, insomnia, restlessness, weakness. EENT: blurred vision. CV: HYPERTENSIVE CRISIS, orthostatic hypotension. GI: nausea, black tongue, constipation, diarrhea, dry mouth. GU: dysuria, sexual dysfunction, urinary incontinence, urinary retention. Derm: photosensitivity.
Interactions Drug –Drug: Serious, potentially fatal adverse reactions may occur with concurrent use of other antidepressants (SSRIs, SSNRIs, bupropion, tricyclics, tetracyclics, nefazodone, trazodone), carbamazepine, cyclobenzaprine, sibutramineprocarbazine, or selegiline. Avoid using within 2 wk of each other (wait 5 wk from end of fluoxetine therapy) Hypertensive crisis may occur with amphetamines , methyldopa, levodopa, dopamine,
epinephrine, norepinephrine, reserpine, methylphenidate, or vasoconstrictors Hypertension or hypotension, coma, seizures, respiratory depression, and death may occur with meperidine (avoid using within 2 –3 wk of MAO inhibitor therapy) Concurrent use with dextromethorphan may produce psychosis or bizarre behavior Hypertension may occur with concurrent use of buspirone; avoid using within 10 days of each other Additive hypotension may occur with antihypertensives, spinal anesthesia, opioids, or
barbiturates Additive hypoglycemia may occur with insulins or oral hypoglycemic agents Risk of seizures may be ↑ with tramadol
Drug –Natural: Serious, potentially fatal adverse effects (serotonin syndrome) may occur with concomitant use of St. John's wort and SAMe Hypertensive crises may occur with large amounts of caffeine-containing herbs (cola nut,
guarana, or malt) Insomnia, headache, tremor, hypomania may occur with ginseng Hypertensive crises, disorientation, and memory impairment may occur with tryptophan or supplements containing tyrosine or phenylalanine
Drug –Food: Hypertensive crisis may occur with ingestion of foods containing high concentrations of tyramine (see )
Consumption of foods or beverages with high caffeine content increases the risk of hypertension and arrhythmias
Route/Dosage PO (Adults): 10 mg twice daily; may be increased every 2 –4 days by 10 mg, up to 40 mg/day by the end of the first wk, then may increase by up to 20 mg every wk, up to 60 mg/day in 2 –4 divided doses. After optimal response is obtained, dose should be slowly decreased to lowest effective amount (40 mg/day or less) Tablets: 10 mgRx
NURSING IMPLICATIONS Assessment
Assess mental status, mood changes, and anxiety level frequently. Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient Monitor blood pressure and pulse rate before and frequently during therapy. Report significant changes promptly Monitor intake and output ratios and daily weight. Assess patient for urinary retention Lab Test Considerations : Assess hepatic function periodically during prolonged or high-dose therapy. Monitor serum glucose closely in diabetic patients; hypoglycemia may occur Toxicity and Overdose : Concurrent ingestion of tyramine-rich foods and many medications may result in a life-threatening hypertensive crisis. Signs and symptoms of hypertensive crisis include chest pain, tachycardia or bradycardia, severe headache, nausea, vomiting, photosensitivity, neck stiffness, sweating, and enlarged pupils. Treatment includes IV phentolamine. Symptoms of overdose include anxiety, irritability, tachycardia, hypertension or hypotension, respiratory distress, dizziness, drowsiness, hallucinations, confusion, seizures, sluggish reflexes, fever, and diaphoresis. Treatment includes induction of vomiting or gastric lavage and supportive therapy as symptoms arise
Potential Nursing Diagnoses Ineffective coping (Indications) Implementation
Do not administer this medication in the evening because the psychomotor stimulating effects may cause insomnia or other sleep disturbances PO: Tablets may be crushed and mixed with food or fluids for patients with difficulty swallowing Patient/Family Teaching Instruct patient to take medication as directed. Take missed doses if remembered within 2 hr; otherwise, omit and return to regular dosage
schedule. Do not discontinue abruptly as withdrawal symptoms (nausea, vomiting, malaise, nightmares, agitation, psychosis, seizures) may occur Caution patient to avoid alcohol, CNS depressants, OTC drugs, and foods or beverages containing tyramine (see ) or excessive caffeine during and for at least 2 wk after therapy has been discontinued; they may precipitate a hypertensive crisis. Instruct patient to notify health care professional immediately if symptoms of hypertensive crisis (e.g. severe headache, palpitations, chest or throat tightness, sweating, dizziness, neck stiffness, nausea, or vomiting) develop Instruct parents or guardians of children to contact health care professional immediately if child exhibits any suicidal thoughts or behaviors (e.g. worsening depression, new or worsening anxiety, agitation, panic attacks, insomnia, new or worsening irritability, violent behavior, impulsive actions, excessive talking, unusual changes in mood or behavior) May cause dizziness or drowsiness. Caution patient to avoid driving and other activities requiring alertness until response to medication is known Caution patient to change positions slowly to minimize orthostatic hypotension. Geriatric patients are at increased risk for this side effect Instruct patient to consult with health care professional before taking any new prescription, OTC, or herbal product Advise patient to notify health care professional if dry mouth, urinary retention, or constipation occurs. Frequent rinses, good oral hygiene, and sugarless candy or gum may diminish dry mouth. An increase in fluid intake, fiber, and exercise may prevent constipation Advise patient to notify health care professional of medication regimen before surgery. If possible, therapy should be discontinued at least 2 wk before surgery Instruct patient to carry identification describing medication regimen at all times Emphasize the importance of participation in psychotherapy if recommended by health care professional and follow-up exams to evaluate progress.
Evaluation/Desired Outcomes
trihexyphenidyl
Improved mood in depressed patients. Decreased anxietyIncreased appetiteImproved energy level Improved sleepPatients may require 3 –6 wk of therapy before therapeutic effects of medication are seen
(trye-hex-ee- fen-i-dill) Apo-Trihex, Artane,
PMS-Trihexyphenidyl, Trihexane, Trihexy
Classification Therapeutic: antiparkinson agents Pharmacologic: anticholinergics Pregnancy Category C Copyright © 2009 by F.A. Davis Company
ARTANE Indications Adjunct in the management of parkinsonian syndrome of many causes, including drug-induced parkinsonism.
Action Inhibits the action of acetylcholine, resulting in: Decreased sweating and salivation, Mydriasis (pupillary dilation), Increased heart rate. Also has spasmolytic action on smooth muscle. Inhibits cerebral motor centers and blocks efferent impulses.
Therapeutic Effects: Diminished signs and symptoms of parkinsonian syndrome (tremors, rigidity).
Pharmokinetics Absorption: Well absorbed following oral administration. Distribution: Unknown. Metabolism and Excretion: Excreted mostly in urine. Half-life: 3.7 hr. TIME/ACTION PROFILE (antiparkinson effects) ROUTE
ONSET
PEAK
DURATION
PO
1 hr
2 –3 hr
6 –12 hr
PO-ER
unknown
unknown
12 –24 hr
Contraindications/Precautions Contraindicated in: Hypersensitivity; Angle-closure glaucoma; Acute hemorrhage; Tachycardia secondary to cardiac insufficiency; Thyrotoxicosis; Known alcohol intolerance (elixir only).
Use Cautiously in: Geriatric and very young patients (increased risk of adverse reactions); Intestinal obstruction or infection; Prostatic hyperplasia; Chronic renal, hepatic, pulmonary, or cardiac disease; Pregnancy, lactation, or children (safety not established).
Adverse Reactions/Side Effects* * CAPITALS indicate life threatening; underlines indicate most frequent. CNS: dizziness, nervousness, confusion, drowsiness, headache, psychoses, weakness. EENT: blurred vision, mydriasis. CV: orthostatic hypotension, tachycardia. GI: dry mouth, nausea, constipation, vomiting. GU: urinary hesitancy, urinary retention. Derm: decreased sweating.
Interactions Drug –Drug: Additive anticholinergic effects with other drugs having anticholinergic properties, including phenothiazines , tricyclic antidepressants , quinidine, and disopyramide . May increase the efficacy of levodopa but may increase the risk of psychoses. Additive CNS depression with other CNS depressants, including alcohol, antihistamines , opioids, and sedative/hypnotics. Anticholinergics may alter the absorption of other orally administered drugs by slowing motility of the GI tract. Antacids may decrease absorption. May increase GI mucosal lesions in patients taking oral solid oral potassium chloride preparations .
Drug –Natural Products: Increased anticholinergic effects with angel’s trumpet and jimson weed and scopolia.
Route/Dosage PO (Adults): 1 –2 mg/day initially; increase by 2 mg q 3 –5 days. Usual maintenance dose is 6 –10 mg/day in 3 divided doses (up to 15 mg/day). Extended-release (Artane Sequels) preparations may be given q 12 hr after daily dose has been determined using conventional tablets or liquid.
Availability Tablets: 2 mg, 5 mg. Elixir (lime-mint flavor): 2 mg/5 ml. Extended-release capsules: 5 mg.
NURSING IMPLICATIONS Assessment
Assess parkinsonian and extrapyramidal symptoms (restlessness or desire to keep moving, rigidity, tremors, pill rolling, mask-like face, shuffling gait, muscle spasms, twisting motions, difficulty speaking or swallowing, loss of balance control) prior to and throughout therapy.
Monitor intake and output ratios and assess patient for urinary retention (dysuria, distended abdomen, infrequent voiding of small amounts, overflow incontinence). Patients with mental illness are at risk of developing exaggerated symptoms of their disorder during early therapy with this medication. Withhold drug and report significant behavioral changes.
Potential Nursing Diagnoses
Impaired physical mobility (Indications) Risk for injury (Indications) Deficient knowledge related to medication regimen (Patient/Family Teaching)
Implementation
Do not confuse Artane (trihexyphenidyl) with Altace (ramapril). Extended-release capsules are not used until dosage is established with shorteracting forms. PO:Usually administered after meals. May be administered before meals if patient suffers from dry mouth or with meals if gastric distress is a problem. Extendedrelease capsules should be swallowed whole; do not break, crush, or chew. Use calibrated measuring device to ensure accurate dosage of elixir.
Patient/Family Teaching
Instruct patient to take this drug exactly as directed. If a dose is missed, take as soon as remembered, unless next scheduled dose is within 2 hr; do not double doses. Medication should be tapered gradually when discontinuing or a withdrawal reaction may occur (anxiety, tachycardia, insomnia, return of parkinsonian or extrapyramidal symptoms). May cause drowsiness or dizziness. Advise patient to avoid driving or other activitie s that require alertness until response to medication is known. Caution patient to change positions slowly to minimize orthostatic hypotension. Instruct patient that frequent rinsing of mouth, good oral hygiene, and sugarless gum or candy may decrease dry mouth. Patient should notify health care professional if dryness persists (saliva substitutes may be used). Also, notify the dentist if dryness interferes with use of dentures. Advise patient to confer with health care professional prior to taking OTC medications, especially cold remedies, or drinking alcoholic beverages. Caution patient that this medication decreases perspiration. Overheating may occur during hot weather. Patient should remain indoors, in an air-conditioned environment, during hot weather. Advise patient to increase activity and bulk and fluid in diet to minimize constipating effects of medication.
Advise patient to avoid taking antacids or antidiarrheals within 1 –2 hr of this medication. Advise patient to notify health care professional if confusion, rash, urinary retention, severe constipation, or visual changes occur. Emphasize the importance of routine follow-up exams.
Evaluation/Desired Outcomes
Decrease in tremors and rigidity and an improvement in gait and balance. Therapeutic effects are usually seen 2 –3 days after the initiation of therapy. Resolution of drug-induced extrapyramidal symptoms.
benztropine benz-troe-peen Apo-Benztropine, Cogentin Classification Therapeutic: Pharmacologic: Pregnancy Category C Copyright © 2009 by F.A. Davis Company
CONGENTIN Indications Adjunctive treatment of all forms of Parkinson’s disease, including drug-induced extrapyramidal effects and acute dystonic reactions Blocks cholinergic activity in the CNS, which is partially responsible for the symptoms of Parkinson’s disease Restores the natural balance of neurotransmitters in the CNS
Therapeutic Effects: Reduction of rigidity and tremors
Pharmokinetics Absorption: Well absorbed following PO and IM administration Distribution: Unknown Metabolism and Excretion: Unknown Half-life: Unknown TIME/ACTION PROFILE antidyskinetic activity
ROUTE
ONSET
PEAK
DURATION
PO
1 –2 hr
several days
24 hr
IM, IV
within min
unknown
24 hr
Contraindications/Precautions Contraindicated in: Hypersensitivity Children <3 yr Angle-closure glaucoma Tardive dyskinesia
Use Cautiously in: Prostatic hyperplasia Seizure disorders Cardiac arrhythmias OB, Lactation: Safety not established Geri : ↑ risk of adverse reactions
Adverse Reactions/Side Effects* CNS: confusion, depression, dizziness, hallucinations, headache, sedation, weakness. EENT: blurred vision, dry eyes, mydriasis, . arrhythmias, hypotension, palpitations, tachycardiaGI: constipation, dry mouth, ileus, nausea. GU: hesitancy, urinary retention. Misc: decreased sweating.
Interactions Drug –Drug: Additive anticholinergic effects with drugs sharing anticholinergic properties, such as antihistamines , phenothiazines, quinidine, disopyramide , and tricyclic antidepressants Counteracts the cholinergic effects of bethanechol Antacids and antidiarrheals may ↓ absorption
Drug –Natural: ↑ anticholinergic effect with angel's trumpet, jimson weed, and scopolia
Route/Dosage ParkinsonismPO (Adults): 1 –2 mg/day in 1 –2 divided doses (range 0.5 –6 mg/day) Acute Dystonic Reactions 1 –2 mg, then 1 –2 mg PO twice daily Drug-Induced Extrapyramidal Reactions 1 –4 mg given once or twice daily (1 –2 mg 2 –3 times daily may also be used PO)
Availability (generic available) Tablets: 0.5 mg, 1 mg, 2 mg Injection: 1 mg/ml
NURSING IMPLICATIONS Assessment
Assess parkinsonian and extrapyramidal symptoms (restlessness or desire to keep moving, rigidity, tremors, pill rolling, mask-like face, shuffling gait, muscle spasms, twisting motions, difficulty speaking or swallowing, loss of balance control) before and throughout therapy. Assess bowel function daily. Monitor for constipation, abdominal pain, distention, or absence of bowel soundsMonitor intake and output ratios and assess patient for urinary retention (dysuria, distended abdomen, infrequent voiding of small amounts, overflow incontinence)Patients with mental illness are at risk of developing exaggerated symptoms of their disorder during early therapy with benztropine. Withhold drug and notify physician or other health care professional if significant behavioral changes occur IM/IVMonitor pulse and blood pressure closely and maintain bedrest for 1 hr after administration. Advise patients to change positions slowly to minimize orthostatic hypotension
Potential Nursing Diagnoses PO: Administer with food or immediately after meals to minimize gastric irritation. May be crushed and administered with food if patient has difficulty swallowing Parenteral route is used only for dystonic reactions IV route is rarely used because onset is same as with IM route Administer at a rate of 1 mg over 1 min metoclopramideperphenazine fluconazole tacrolimus Patient/Family Teaching
Encourage patient to take benztropine as directed. Take missed doses as soon as possible, up to 2 hr before the next dose. Taper gradually when discontinuing or a withdrawal reaction may occur (anxiety, tachycardia, insomnia, return of parkinsonian or extrapyramidal symptoms) May cause drowsiness or dizziness. Advise patient to avoid driving or other activities that require alertness until response to the drug is known Instruct patient that frequent rinsing of mouth, good oral hygiene, and sugarless gum or candy may decrease dry mouth. Patient should notify health care professional if dryness persists (saliva substitutes may be used). Also, notify the dentist if dryness interferes with use of dentures Caution patient to change positions slowly to minimize orthostatic hypotension Instruct patient to notify health care professional if difficulty with urination, constipation, abdominal discomfort, rapid or pounding heartbeat, confusion, eye pain, or rash occurs Advise patient to confer with health care professional before taking OTC medications, especially cold remedies, or drinking alcoholic beverages Caution patient that this medication decreases perspiration. Overheating may occur
