Generic Name:

Brand Name: Apo-Clonazepam (CAN), Gen-Clonazepam (CAN), Klonopin, Klonopin Wafers, Nu-Clonazepam (CAN), Rivotril (CAN)

Other Info: Pregnancy Category X, Controlled Substance C-IV

Drug classes: Benzodiazepine, Antiepileptic

Therapeutic actions

Exact mechanisms not understood; benzodiazepines potentiate the effects of GABA, an inhibitory neurotransmitter.

Indications

• Used alone or as adjunct in treatment of Lennox-Gastaut syndrome (petit mal variant), akinetic and myoclonic seizures; may be useful in patients with absence (petit mal) seizures who have not responded to succinimides; up to 30% of patients show loss of effectiveness of drug, often within 3 mo of therapy (may respond to dosage adjustment); treatment of panic disorder with or without agoraphobia
• Unlabeled uses: Periodic leg movements during sleep; hypokinetic dysarthria, acute manic episodes, multifocal tic disorders, neuralgias

Contraindications and cautions

• Contraindicated with hypersensitivity to benzodiazepines, psychoses, acute narrow-angle glaucoma, shock, coma, acute alcoholic intoxication with depression of vital signs; pregnancy (risk of congenital malformations, neonatal withdrawal syndrome), labor and delivery (“floppy infant” syndrome), lactation (infants become lethargic and lose weight).
• Use cautiously with impaired liver or renal function, debilitation.

Available forms: Tablets—0.5, 1, 2 mg; orally disintegrating tablets—0.125, 0.25, 0.5, 1, 2 mg

Dosages

Individualize dosage; increase dosage gradually to avoid adverse effects; drug is available only in oral dosage forms.

ADULTS

Seizure disorders: Initial dose should not exceed 1.5 mg/day PO divided into three doses; increase in increments of 0.5–1 mg PO every 3 days until seizures are adequately controlled or until side effects preclude further increases. Maximum recommended dosage is 20 mg/day.

Panic disorders: Initial dose 0.25 mg PO bid; gradually increase to a target dose of 1 mg/day.

PEDIATRIC PATIENTS > 10 YR OR 30 KG

Initially, 0.01–0.03 mg/kg/day PO; do not exceed 0.05 mg/kg/day PO, given in two or three doses. Increase dosage by not more than 0.25–0.5 mg every third day until a daily maintenance dose of 0.1–0.2 mg/kg has been reached, unless seizures are controlled by lower dosage or side effects preclude increases. Whenever possible, divide daily dose into three equal doses, or give largest dose at bedtime.

Pharmacokinetics

Metabolism: Hepatic; T_1/2: 18–50 hr

Distribution: Crosses placenta; enters breast milk

Excretion: Urine

Adverse effects

• CNS: Transient, mild drowsiness initially; sedation, depression, lethargy, apathy, fatigue, light-headedness, disorientation, anger, hostility,episodes of mania and hypomania, restlessness, confusion, crying, delirium, headache, slurred speech, dysarthria, stupor, rigidity, tremor, dystonia, vertigo, euphoria, nervousness, difficulty in concentration, vivid dreams, psychomotor retardation, extrapyramidal symptoms; mild paradoxical excitatory reactions during first 2 wk of treatment
• CV: Bradycardia, tachycardia, CV collapse, hypertension and hypotension, palpitations, edema
• Dermatologic: Urticaria, pruritus, rash, dermatitis
• EENT: Visual and auditory disturbances, diplopia, nystagmus, depressed hearing, nasal congestion
• GI: Constipation, diarrhea, dry mouth, salivation, nausea, anorexia, vomiting, difficulty in swallowing, gastric disorders, encoporesis
• GU: Incontinence, urinary retention, changes in libido, menstrual irregularities
• Hematologic: Elevations of blood enzymes—LDH, alkaline phosphatase, AST, ALT; blood dyscrasias: agranulocytosis, leukopenia
• Other: Hiccups, fever, diaphoresis, paresthesias, muscular disturbances, gynecomastia. Drug dependence with withdrawal syndrome when drug is discontinued; more common with abrupt discontinuation of higher dosage used for longer than 4 mo

Interactions

Drug-drug

• Increased CNS depression with alcohol
• Increased effect with cimetidine, disulfiram, omeprazole, hormonal contraceptives
• Decreased effect with theophylline
• Risk of increased digoxin levels and toxicity; monitor patient carefully

Nursing considerations

CLINICAL ALERT!

Name confusion has occurred between Klonopin (clonazepam) and clonidine; use caution.

Assessment

• History: Hypersensitivity to benzodiazepines; psychoses; acute narrow-angle glaucoma; shock; coma; acute alcoholic intoxication; pregnancy; lactation; liver or renal impairment, debilitation.
• Physical: Skin color, lesions; T; orientation, reflexes, affect, ophthalmologic examination; P, BP; R, adventitious sounds; liver evaluation, abdominal examination, bowel sounds, normal output; CBC, LFTs, renal function tests.

Interventions

• Monitor addiction-prone patients carefully because of their predisposition to habituation and drug dependence.
• Monitor liver function and blood counts periodically in patients on long-term therapy.
• WARNING: Taper dosage gradually after long-term therapy, especially in patients with epilepsy; substitute another antiepileptic.
• Monitor patient for therapeutic drug levels: 20–80 ng/mL.
• If the patient has epilepsy, arrange for patient to wear medical alert identification indicating patient has epilepsy and is receiving drug therapy.

Teaching points

• Take drug exactly as prescribed; do not stop taking drug (long-term therapy) without consulting health care provider.
• Avoid alcohol, sleep-inducing, or over-the-counter drugs.
• Avoid pregnancy; serious adverse effects can occur. Using barrier contraceptives is advised while taking this drug.
• It would be advisable to wear or carry a medical alert identification indicating your diagnosis and drug therapy.
• You may experience these side effects: Drowsiness, dizziness (may become less pronounced; avoid driving or engaging in other dangerous activities); GI upset (take drug with food); fatigue; dreams; crying; nervousness; depression, emotional changes; bed-wetting, urinary incontinence.
• Report severe dizziness, weakness, drowsiness that persists, rash or skin lesions, difficulty voiding, palpitations, swelling in the extremities.

Source and Other References: (1) (2) (3)

Clonazepam (Clonazepam) Drug Study Original source at: Nurseslabs

Brand Names:

Pregnancy Category D

Controlled Substance C-IV

Drug classes: Benzodiazepine, Anxiolytic, Sedative-hypnotic

Therapeutic actions

Exact mechanisms are not understood; acts mainly at subcortical levels of the CNS, leaving the cortex relatively unaffected. Main sites of action may be the limbic system and reticular formation; benzodiazepines potentiate the effects of GABA, an inhibitory neurotransmitter; anxiolytic effects occur at doses well below those needed to cause sedation and ataxia.

Indications

• Oral: Management of anxiety disorders or for short-term relief of symptoms of anxiety or anxiety associated with depression; insomnia due to anxiety of transient situational stress
• Parenteral: Preanesthetic medication in adults to produce sedation, relieve anxiety, and decrease recall of events related to surgery; treatment of status epilepticus
• Unlabeled parenteral use: Management of chemotherapy-induced nausea and vomiting, acute alcohol withdrawal

Contraindications and cautions

• Contraindicated with hypersensitivity to benzodiazepines, propylene glycol, polyethylene glycol or benzyl alcohol (parenteral lorazepam); psychoses; acute narrow-angle glaucoma; shock; coma; acute alcoholic intoxication with depression of vital signs; pregnancy (crosses placenta; risk of congenital malformations and neonatal withdrawal syndrome); labor and delivery (“floppy infant” syndrome); lactation.
• Use cautiously with impaired hepatic or renal function.

Available forms

Injection—2, 4 mg/mL; oral solution—2 mg/mL; tablets—0.5, 1, 2 mg

Dosages

ADULTS

Oral

Usual dose is 2–6 mg/day; range 1–10 mg/day given in divided doses with largest dose hs.

• Insomnia due to transient stress: 2–4 mg given hs.

IM

0.05 mg/kg up to a maximum of 4 mg administered at least 2 hr before operative procedure.

IV

Initial dose is 2 mg total or 0.044 mg/kg, whichever is smaller. Do not exceed this dose in patients older than 50 yr. Doses as high as 0.05 mg/kg up to a total of 4 mg may be given 15–20 min before the procedure to those benefited by a greater lack of recall. Continuous infusion 0.5–1 mg/hr titrated, based on patient response.

PEDIATRIC PATIENTS

Drug should not be used in children < 12 yr.

GERIATRIC PATIENTS OR PATIENTS WITH HEPATIC DISEASE

Initially, 1–2 mg/day in divided doses. Adjust as needed and tolerated.

Pharmacokinetics

Metabolism: Hepatic; T_1/2: 10–20 hr

Distribution: Crosses placenta; enters breast milk

Excretion: Urine

IV facts

Preparation: Dilute lorazepam immediately before IV use. For direct IV injection or injection into IV line, dilute with an equal volume of compatible solution (sterile water for injection, sodium chloride injection, or 5% dextrose injection); do not use if solution is discolored or contains a precipitate. Protect from light.

Infusion: Direct inject slowly, or infuse at maximum rate of 2 mg/min.

Y-site incompatibilities: Do not mix with foscarnet, ondansetron.

Adverse effects

• CNS: Transient, mild drowsiness initially; sedation, depression, lethargy, apathy, fatigue, light-headedness, disorientation, anger, hostility,episodes of mania and hypomania, restlessness, confusion, crying, delirium, headache, slurred speech, dysarthria, stupor, rigidity, tremor, dystonia, vertigo, euphoria, nervousness, difficulty concentrating, vivid dreams, psychomotor retardation, extrapyramidal symptoms; mild paradoxical excitatory reactions during first 2 wk of treatment
• CV: Bradycardia, tachycardia, CV collapse, hypertension and hypotension, palpitations, edema
• Dermatologic: Urticaria, pruritus, rash, dermatitis
• EENT: Visual and auditory disturbances, diplopia, nystagmus, depressed hearing, nasal congestion
• GI: Constipation, diarrhea, dry mouth, salivation, nausea, anorexia, vomiting, difficulty in swallowing, gastric disorders, hepatic dysfunction
• GU: Incontinence, urinary retention, changes in libido, menstrual irregularities
• Hematologic: Elevations of blood enzymes: LDH, alkaline phosphatase, AST, ALT; blood dyscrasias—agranulocytosis, leukopenia
• Other: Hiccups, fever, diaphoresis, paresthesias, muscular disturbances, gynecomastia. Drug dependence with withdrawal syndrome when drug is discontinued; more common with abrupt discontinuation of higher dosage used for > 4 mo

Interactions

Drug-drug

• Increased CNS depression with alcohol and other sedating medications, such as barbiturates and opioids
• Decreased effectiveness with theophyllines
• Risk of toxicity if combined with probenecid, valproate; reduce lorazepam dose by 50%

Drug-herb

• Kava kava increases the sedative effects of benzodiazepines; coma has been reported with concurrent use

Nursing considerations

[sws_red_box box_size="630"]

CLINICAL ALERT!

Name confusion has occurred between lorazepam and alprazolam; use caution.[/sws_red_box]

Assessment

• History: Hypersensitivity to benzodiazepines, propylene glycol, polyethylene glycol or benzyl alcohol; psychoses; acute narrow-angle glaucoma; shock; coma; acute alcoholic intoxication with depression of vital signs; pregnancy; lactation; impaired liver or renal function, debilitation
• Physical: Skin color, lesions; T; orientation, reflexes, affect, ophthalmologic examination; P, BP; R, adventitious sounds; liver evaluation, abdominal examination, bowel sounds, normal output; CBC, LFTs, renal function tests

Interventions

• Sublingual administration has more rapid absorption than PO, and bioavailability compares to IM use.
• Do not administer intra-arterially; arteriospasm or gangrene may result.
• Give IM injections of undiluted drug deep into muscle mass, monitor injection sites.
• Do not use solutions that are discolored or contain a precipitate. Protect drug from light, and refrigerate oral solution.
• Intensol is a concentrated solution; it is recommended it be mixed with water, juice, soda, applesauce, or pudding.
• WARNING: Keep equipment to maintain a patent airway readily available when drug is given IV.
• Refrigerate injection and oral solution (36° to 46° F).
• Reduce dose of opioid analgesics by at least half in patients who have received parenteral lorazepam.
• Keep patients who have received parenteral doses under close observation, preferably in bed, up to 3 hr. Do not permit ambulatory patients to drive following an injection.
• WARNING: Taper dosage gradually after long-term therapy, especially in patients with epilepsy.

Teaching points

• Take drug exactly as prescribed; do not stop taking drug (in long-term therapy) without consulting health care provider.
• You may experience these side effects: Drowsiness, dizziness (may be transient; avoid driving or engaging in dangerous activities); GI upset (take drug with food); nocturnal sleep disturbances for several nights after discontinuing the drug if used as a sedative and hypnotic; depression, dreams, emotional upset, crying.
• Report severe dizziness, weakness, drowsiness that persists, rash or skin lesions, palpitations, edema of the extremities; visual changes; difficulty voiding.

Sources: (1), (2), (3), (4),

Lorazepam (Ativan) Drug Study Original source at: Nurseslabs

Generic Name:

Brand Name: Alprazolam Intensol, Apo-Alpraz (CAN), Niravam, Novo-Alprazol (CAN), Nu-Alpraz (CAN), Xanax, Xanax TS (CAN), Xanax XR

Other Info: Pregnancy Category D, Controlled Substance C-IV

Drug classes: Benzodiazepine, Anxiolytic

Therapeutic actions

Exact mechanisms of action not understood; main sites of action may be the limbic system and reticular formation; increases the effects of GABA, an inhibitory neurotransmitter; anxiety blocking effects occur at doses well below those necessary to cause sedation, ataxia.

Indications

• Management of anxiety disorders, short-term relief of symptoms of anxiety; anxiety associated with depression.
• Treatment of panic attacks with or without agoraphobia
• Unlabeled uses: Social phobia, premenstrual syndrome, depression

Contraindications and cautions

• Contraindicated with hypersensitivity to benzodiazepines, psychoses, acute narrow-angle glaucoma, shock, coma, acute alcoholic intoxication with depression of vital signs, pregnancy (crosses the placenta; risk of congenital malformations, neonatal withdrawal syndrome), labor and delivery (“floppy infant” syndrome), lactation (secreted in breast milk; infants become lethargic and lose weight).
• Use cautiously with impaired liver or kidney function, debilitation.

Available forms

Tablets—0.25, 0.5, 1, 2 mg; XR tablets—0.5, 1, 2, 3 mg; oral solution—1 mg/mL; rapidly disintegrating tablets—0.25, 0.5, 1, 2 mg

Dosages

Individualize dosage; increase dosage gradually to avoid adverse effects.

ADULTS

• Anxiety disorders: Initially, 0.25–0.5 mg PO tid; adjust to maximum daily dose of 4 mg/day in divided doses or extended-release form once per day in theAM once dosage is established (immediate release, intensol solution).
• Panic disorder: Initially, 0.5 mg PO tid; increase dose at 3- to 4-day intervals in increments of no more than 1 mg/day; ranges of 1–10 mg/day have been needed; extended-release form once per day in AM once dosage is established (Xanax products, Niravam).

UNLABELED USES

• Social phobia: 2–8 mg/day PO.
• PMS: 0.25 mg PO tid.

GERIATRIC PATIENTS OR PATIENTS WITH ADVANCED HEPATIC OR DEBILITATING DISEASE

Initially, 0.25 mg bid–tid PO; gradually increase if needed and tolerated; ER tablets—0.5 mg PO once each day

Pharmacokinetics

Metabolism: Hepatic; T_1/2: 6.3–26.9 hr

Distribution: Crosses placenta; enters breast milk

Excretion: Urine

Adverse effects

• CNS: Transient, mild drowsiness initially; sedation, depression, lethargy, apathy, fatigue, light-headedness, disorientation, anger, hostility,episodes of mania and hypomania, restlessness, confusion, crying, delirium, headache, slurred speech, dysarthria, stupor, rigidity, tremor, dystonia, vertigo, euphoria, nervousness, difficulty in concentration, vivid dreams, psychomotor retardation, extrapyramidal symptoms; mild paradoxical excitatory reactions during first 2 wk of treatment
• CV: Bradycardia, tachycardia, CV collapse, hypertension, hypotension, palpitations, edema
• Dermatologic: Urticaria, pruritus, rash, dermatitis
• EENT: Visual and auditory disturbances, diplopia, nystagmus, depressed hearing, nasal congestion
• GI: Constipation, diarrhea, dry mouth, salivation, nausea, anorexia, vomiting, difficulty in swallowing, gastric disorders, hepatic impairment
• GU: Incontinence, changes in libido, urinary retention, menstrual irregularities
• Hematologic: Elevations of blood enzymes—LDH, alkaline phosphatase, AST, ALT; blood dyscrasias—agranulocytosis, leukopenia
• Other: Hiccups, fever, diaphoresis, paresthesias, muscular disturbances, gynecomastia. Drug dependence with withdrawal syndrome when drug is discontinued; more common with abrupt discontinuation of higher dosage used for longer than 4 mo

Interactions

Drug-drug

• Increased CNS depression with alcohol, other CNS depressants, propoxyphene
• Increased effect with cimetidine, disulfiram, omeprazole, isoniazid, hormonal contraceptives, valproic acid
• Decreased effect with carbamazepine, rifampin, theophylline
• Possible increased risk of digitalis toxicity with digoxin
• Decreased antiparkinson effectiveness of levodopa with benzodiazepines
• Contraindicated with ketoconazole, itraconazole; serious toxicity can occur

Drug-food

• Decreased metabolism and risk of toxic effects if combined with grapefruit juice; avoid this combination

Drug-alternative therapy

• Risk of coma if combined with kava therapy
• Additive sedative effects with valerian root

Nursing considerations

Assessment

• History: Hypersensitivity to benzodiazepines; psychoses; acute narrow-angle glaucoma; shock; coma; acute alcoholic intoxication with depression of vital signs; labor and delivery; lactation; impaired liver or kidney function; debilitation
• Physical: Skin color, lesions; T; orientation, reflexes, affect, ophthalmologic examination; P, BP; liver evaluation, abdominal examination, bowel sounds, normal output; CBC, LFTs, renal function tests

Interventions

• Arrange to taper dosage gradually after long-term therapy, especially in epileptic patients.
• Do not administer with grapefruit juice.
• Taper drug slowly; decrease by no more than 0.5 mg every 3 days.

Teaching points

• Take this drug exactly as prescribed; take extended-release form once a day in the morning; place rapidly disintegrating tablet on top of tongue, where it will disintegrate and can be swallowed with saliva.
• Do not drink grapefruit juice while on this drug.
• Do not stop taking drug (in long-term therapy) without consulting health care provider; drug should not be stopped suddenly.
• Avoid alcohol, sleep-inducing, or over-the-counter drugs.
• You may experience these side effects: Drowsiness, dizziness (these effects will be less pronounced after a few days, avoid driving a car or engaging in other dangerous activities if these occur); GI upset (take drug with food); fatigue; depression; dreams; crying; nervousness.
• Report severe dizziness, weakness, drowsiness that persists, rash or skin lesions, difficulty voiding, palpitations, swelling in the extremities.

Alprazolam (Xanax) Drug Study Original source at: Nurseslabs

Generic Name:

Brand Names:  Valium

Pregnancy Category D

Controlled Substance C-IV

Drug classes:

• Benzodiazepine
• Anxiolytic
• Antiepileptic
• Skeletal muscle relaxant (centrally acting)

Therapeutic actions of Valium

Exact mechanisms of action not understood; acts mainly at the limbic system and reticular formation; may act in spinal cord and at supraspinal sites to produce skeletal muscle relaxation; potentiates the effects of GABA, an inhibitory neurotransmitter; anxiolytic effects occur at doses well below those necessary to cause sedation, ataxia; has little effect on cortical function.

Indications

• Management of anxiety disorders or for short-term relief of symptoms of anxiety
• Acute alcohol withdrawal; may be useful in symptomatic relief of acute agitation, tremor, delirium tremens, hallucinosis
• Muscle relaxant: Adjunct for relief of reflex skeletal muscle spasm due to local pathology (inflammation of muscles or joints) or secondary to trauma;spasticity caused by upper motoneuron disorders (cerebral palsy and paraplegia); athetosis, stiff-man syndrome
• Parenteral: Treatment of tetanus
• Antiepileptic: Adjunct in status epilepticus and severe recurrent convulsive seizures (parenteral); adjunct in seizure disorders (oral)
• Preoperative (parenteral): Relief of anxiety and tension and to lessen recall in patients prior to surgical procedures, cardioversion, and endoscopic procedures
• Rectal: Management of selected, refractory patients with epilepsy who require intermittent use to control bouts of increased seizure activity
• Unlabeled use: Treatment of panic attacks

Contraindications and cautions

• Contraindicated with hypersensitivity to benzodiazepines; psychoses, acute narrow-angle glaucoma, shock, coma, acute alcoholic intoxication; pregnancy (cleft lip or palate, inguinal hernia, cardiac defects, microcephaly, pyloric stenosis when used in first trimester; neonatal withdrawal syndrome reported in newborns); lactation.
• Use cautiously with elderly or debilitated patients; impaired liver or renal function; and in patients with a history of substance abuse.

Available forms

Tablets—2, 5, 10 mg; SR capsule—15 mg; oral solution—1 mg/mL, 5 mg/5 mL; rectal pediatric gel—2.5, 5, 10 mg; rectal adult gel—10, 15, 20 mg; injection—5 mg/mL

Dosages

Individualize dosage; increase dosage cautiously to avoid adverse effects.

ADULTS

Oral

• Anxiety disorders, skeletal muscle spasm, seizure disorders: 2–10 mg bid–qid.
• Alcohol withdrawal: 10 mg tid–qid first 24 hr; reduce to 5 mg tid–qid, as needed.

Oral sustained-release

• Anxiety disorders: 15–30 mg/day.
• Alcohol withdrawal: 30 mg first 24 hr; reduce to 15 mg/day as needed.

Rectal

• 0.2 mg/kg PR; treat no more than one episode q 5 days. May give a second dose in 4–12 hr.

Parenteral

• Usual dose is 2–20 mg IM or IV. Larger doses may be required for some indications (tetanus). Injection may be repeated in 1 hr.
• Anxiety: 2–10 mg IM or IV; repeat in 3–4 hr if necessary.
• Alcohol withdrawal: 10 mg IM or IV initially, then 5–10 mg in 3–4 hr if necessary.
• Endoscopic procedures: 10 mg or less, up to 20 mg IV just before procedure or 5–10 mg IM 30 min prior to procedure. Reduce or omit dosage of opioids.
• Muscle spasm: 5–10 mg IM or IV initially, then 5–10 mg in 3–4 hr if necessary.
• Status epilepticus: 5–10 mg, preferably by slow IV. May repeat q 5–10 min up to total dose of 30 mg. If necessary, repeat therapy in 2–4 hr; other drugs are preferable for long-term control.
• Preoperative: 10 mg IM.
• Cardioversion: 5–15 mg IV 5–10 min before procedure.

PEDIATRIC PATIENTS

• Oral

> 6 mo: 1–2.5 mg PO tid–qid initially. Gradually increase as needed and tolerated. Can be given rectally if needed.

• Rectal

< 2 yr: Not recommended.

2–5 yr: 0.5 mg/kg.

6–11 yr: 0.3 mg/kg.

>12 yr: Use adult dose; may give a second dose in 4–12 hr.

• Parenteral

Maximum dose of 0.25 mg/kg IV administered over 3 min; may repeat after 15–30 min. If no relief of symptoms after three doses, adjunctive therapy is recommended.

• Tetanus (> 1 mo): 1–2 mg IM or IV slowly q 3–4 hr as necessary.
• Tetanus (> 5 yr): 5–10 mg q 3–4 hr.
• Status epilepticus (> 1 mo–< 5 yr): 0.2–0.5 mg slowly IV q 2–5 min up to a maximum of 5 mg.
• Status epilepticus (> 5 yr): 1 mg IV q 2–5 min up to a maximum of 10 mg; repeat in 2–4 hr if necessary.

GERIATRIC PATIENTS OR PATIENTS WITH DEBILITATING DISEASE

2–2.5 mg PO daily–bid or 2–5 mg parenteral initially; reduce rectal dose. Gradually increase as needed and tolerated; use cautiously.

Pharmacokinetics

• Metabolism: Hepatic; T_1/2: 20–80 hr
• Distribution: Crosses placenta; enters breast milk
• Excretion: Urine
• IV facts
• Preparation: Do not mix with other solutions; do not mix in plastic bags or tubing.
• Infusion: Inject slowly into large vein, 1 mL/min at most; for children do not exceed 3 min; do not inject intra-arterially; if injected into IV tubing, inject as close to vein insertion as possible.
• Incompatibilities: Do not mix with other solutions; do not mix with any other drugs.
• Y-site Incompatibilities: Atracurium, heparin, foscarnet, pancuronium, potassium, vecuronium.

Adverse effects

• CNS: Transient, mild drowsiness initially; sedation, depression, lethargy, apathy, fatigue, light-headedness, disorientation, restlessness, confusion,crying, delirium, headache, slurred speech, dysarthria, stupor, rigidity, tremor, dystonia, vertigo, euphoria, nervousness, difficulty in concentration, vivid dreams, psychomotor retardation, extrapyramidal symptoms; mild paradoxical excitatory reactions, during first 2 wk of treatment, visual and auditory disturbances, diplopia, nystagmus, depressed hearing, nasal congestion
• CV: Bradycardia, tachycardia, CV collapse, hypertension and hypotension, palpitations, edema
• Dependence: Drug dependence with withdrawal syndrome when drug is discontinued (common with abrupt discontinuation of higher dosage used for longer than 4 mo); IV diazepam: 1.7% incidence of fatalities; oral benzodiazepines ingested alone; no well-documented fatal overdoses
• Dermatologic: Urticaria, pruritus, skin rash, dermatitis
• GI: Constipation; diarrhea, dry mouth; salivation; nausea; anorexia; vomiting; difficulty in swallowing; gastric disorders; elevations of blood enzymes—LDH, alkaline phosphatase, AST, ALT; hepatic impairment; jaundice
• GU: Incontinence, urinary retention, changes in libido, menstrual irregularities
• Hematologic: Decreased hematocrit, blood dyscrasias
• Other: Phlebitis and thrombosis at IV injection sites, hiccups, fever, diaphoresis, paresthesias, muscular disturbances, gynecomastia; pain, burning, and redness after IM injection

Interactions

Drug-drug

• Increased CNS depression with alcohol, omeprazole
• Increased pharmacologic effects of diazepam if combined with cimetidine, disulfiram, hormonal contraceptives
• Decreased effects of diazepam with theophyllines, ranitidine

Nursing considerations

Assessment

• History: Hypersensitivity to benzodiazepines; psychoses, acute narrow-angle glaucoma, shock, coma, acute alcoholic intoxication; elderly or debilitated patients; impaired liver or renal function; pregnancy, lactation
• Physical: Weight; skin color, lesions; orientation, affect, reflexes, sensory nerve function, ophthalmologic examination; P, BP; R, adventitious sounds; bowel sounds, normal output, liver evaluation; normal output; LFTs, renal function tests, CBC

Interventions

[sws_red_box box_size="630"]

• WARNING: Do not administer intra-arterially; may produce arteriospasm, gangrene.[/sws_red_box]
• Change from IV therapy to oral therapy as soon as possible.
• Do not use small veins (dorsum of hand or wrist) for IV injection.
• Reduce dose of opioid analgesics with IV diazepam; dose should be reduced by at least one-third or eliminated.
• Carefully monitor P, BP, respiration during IV administration.

[sws_red_box box_size="630"]WARNING: Maintain patients receiving parenteral benzodiazepines in bed for 3 hr; do not permit ambulatory patients to operate a vehicle following an injection.[/sws_red_box]

• Monitor EEG in patients treated for status epilepticus; seizures may recur after initial control, presumably because of short duration of drug effect.
• Monitor liver and renal function, CBC during long-term therapy.
• Taper dosage gradually after long-term therapy, especially in epileptic patients.
• Arrange for epileptic patients to wear medical alert ID indicating that they are epileptics taking this medication.
• Discuss risk of fetal abnormalities with patients desiring to become pregnant.

Teaching points

• Take this drug exactly as prescribed. Do not stop taking this drug (long-term therapy, antiepileptic therapy) without consulting your health care provider.
• Caregiver should learn to assess seizures, administer rectal form, and monitor patient.
• Use of barrier contraceptives is advised while using this drug; if you become or wish to become pregnant, consult with your health care provider.
• It is advisable to wear a medical alert ID indicating your diagnosis and treatment (as antiepileptic).
• You may experience these side effects: Drowsiness, dizziness (may lessen; avoid driving or engaging in other dangerous activities); GI upset (take drug with food); dreams, difficulty concentrating, fatigue, nervousness, crying (reversible).
• Report se

Diazepam (Valium) Drug Study Original source at: Nurseslabs