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

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

CLINICAL ALERT!

Name confusion has occurred between lorazepam and alprazolam; use caution.

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 Original source at: Nurseslabs

Generic Name: mirtazapine

Brand Name: Remeron, Remeron SolTab

Other Info: Pregnancy Category C

Drug class: Antidepressant (tetracyclic)

Indication

• Relief of symptoms of depression (endogenous depression most responsive)

Contraindications and cautions

• Contraindicated with hypersensitivity to any tricyclic or tetracyclic drug; concomitant therapy with an MAOI; pregnancy (limb reduction abnormalities reported); lactation
• Use cautiously with ECT; preexisting CV disorders (eg, severe coronary heart disease, progressive CHF, angina pectoris, paroxysmal tachycardia [possible increased risk of serious CVS toxicity with TCAs]); angle-closure glaucoma, increased IOP, urinary retention, ureteral or urethral spasm; seizure disorders (TCAs lower the seizure threshold); hyperthyroidism (predisposes to CVS toxicity, including cardiac arrhythmias); impaired hepatic, renal function; psychiatric patients (schizophrenic or paranoid patients may exhibit a worsening of psychosis with TCAs); manic-depressive disorder (may shift to hypomanicor manic phase); elective surgery (TCAs should be discontinued as long as possible before surgery)

Available forms

Tablets—7.5, 15, 30, 45 mg; orally disintegrating tablet—15, 30, 45 mg

Dosages

ADULTS

Initial dose, 15 mg PO daily, as a single dose in evening. May be increased up to 45 mg/day as needed. Change dose only at intervals greater than 1–2 wk. Continue treatment for up to 6 mo for acute episodes.

• Switching from MAOI: Allow at least 14 days between discontinuation of MAOI and beginning of mirtazapine therapy. Allow 14 days after stoppingmirtazapine before starting MAOI.

PEDIATRIC PATIENTS

Not recommended in patients < 18 yr.

GERIATRIC PATIENTS AND PATIENTS WITH RENAL OR HEPATIC IMPAIRMENT

Give lower doses to patients > 60 yr.

Pharmacokinetics

Metabolism: Hepatic; T_1/2: 20–40 hr

Distribution: Crosses placenta; enters breast milk

Excretion: Feces, urine

Adverse effects

• CNS: Sedation and anticholinergic (atropine-like) effects; confusion (especially in elderly), disturbed concentration, hallucinations, disorientation, decreased memory, feelings of unreality, delusions, anxiety, nervousness, restlessness, agitation, panic, insomnia, nightmares, hypomania, mania, exacerbation of psychosis, drowsiness, weakness, fatigue, headache, numbness, agitation (less likely with this drug than with other antidepressants)
• CV: Orthostatic hypotension, hypertension, syncope, tachycardia, palpitations, MI, arrhythmias, heart block, precipitation of CHF, CVA
• Endocrine: Elevated or depressed blood sugar; elevated prolactin levels; inappropriate ADH secretion
• GI: Dry mouth, constipation, paralytic ileus, nausea (less likely with this drug than with other antidepressants), increased appetite, weight gain, vomiting, anorexia, epigastric distress, diarrhea, flatulence, dysphagia, peculiar taste, increased salivation, stomatitis, glossitis, parotid swelling, abdominal cramps, black tongue, liver enzyme elevations
• GU: Urinary retention, delayed micturition, dilation of urinary tract, gynecomastia, testicular swelling in men; breast enlargement, menstrual irregularity,galactorrhea in women; increased or decreased libido; impotence
• Hematologic: Agranulocytosis, neutropenia
• Hypersensitivity: Rash, pruritus, vasculitis, petechiae, photosensitization, edema

Interactions

Drug-drug

• WARNING: Risk of serious, sometimes fatal reactions if combined with MAOIs; do not use this combination or within 14 days of MAOI therapy

Nursing considerations

Assessment

• History: Hypersensitivity to any antidepresssant; concomitant therapy with MAOI; recent MI; myelography within previous 24 hr or scheduled within 48 hr; lactation; ECT; preexisting CV disorders; angle-closure glaucoma; increased IOP, urinary retention, ureteral or urethral spasm; seizure disorders; hyperthyroidism; impaired hepatic, renal function; psychiatric problems; manic-depressive disorders; elective surgery; pregnancy, lactation
• Physical: Body weight; T; skin color, lesions; orientation, affect, reflexes, vision and hearing; P, BP, orthostatic BP, perfusion; bowel sounds, normal output, liver evaluation; urine flow, normal output; usual sexual function, frequency of menses, breast and scrotal examination; LFTs, urinalysis, CBC, ECG

Interventions

• BLACK BOX WARNING: Ensure that depressed and potentially suicidal patients have access only to limited quantities of the drug; increased risk of suicidality in children and adolescents. Monitor accordingly.
• Administer orally disintegrating tablets to patients who have difficulty swallowing: Open blister pack and have patient place tablet on tongue. Do not split tablet.
• Expect clinical response in 3–7 days up to 3 wk (latter is more usual).
• Arrange for CBC if patient develops fever, sore throat, or other sign of infection during therapy.
• Establish safety precautions if CNS changes occur (side rails, accompany patient when ambulating).

Teaching points

• Take this drug exactly as prescribed; do not stop taking the drug abruptly or without consulting your health care provider.
• Place orally disintegrating tablet on tongue; it can be swallowed without water. Open blister pack with dry hands and use tablet immediately; do not cut or break tablet.
• Avoid using alcohol, other sleep-inducing drugs, or over-the-counter drugs while using this drug.
• Avoid prolonged exposure to sunlight or sunlamps; use a sunscreen or protective garments if long exposure to sunlight is unavoidable.
• You may experience these side effects: Headache, dizziness, drowsiness, weakness, blurred vision (reversible; avoid driving or performing tasks that require alertness); nausea, vomiting, loss of appetite, dry mouth (eat frequent small meals; use frequent mouth care, suck on sugarless candies); nightmares, inability to concentrate, confusion; changes in sexual function.
• Report fever, flulike illness, any infection, dry mouth, difficulty urinating, excessive sedation, suicidal thoughts.

Mirtazapine Original source at: Nurseslabs

Generic Name:

Brand Names: Endep (CAN), Tryptanol (CAN)

Pregnancy Category D

Drug class: TCA; tertiary amine

Therapeutic actions of Amitriptyline

Mechanism of action unknown; TCAs inhibit the reuptake of the neurotransmitters norepinephrine and serotonin, leading to an increase in their effects; anticholinergicat CNS and peripheral receptors; sedative.

Indications of Amitriptyline

• Relief of symptoms of depression (endogenous most responsive); sedative effects may help when depression is associated with anxiety and sleep disturbance.
• Unlabeled uses: Control of chronic pain (eg, intractable pain of cancer, central pain syndromes, peripheral neuropathies, postherpetic neuralgia, ticdouloureux); prevention of onset of cluster and migraine headaches; treatment of pathologic weeping and laughing secondary to forebrain disease (due to MS), insomnia.

Contraindications and cautions of Amitriptyline

• Contraindicated with hypersensitivity to any tricyclic drug; concomitant therapy with an MAOI; recent MI; myelography within previous 24 hr or scheduled within 48 hr; lactation.
• Use cautiously with electroshock therapy; preexisting CV disorders (severe coronary heart disease, progressive CHF, angina pectoris, paroxysmal tachycardia); angle-closure glaucoma, increased IOP, urinary retention, ureteral or urethral spasm; seizure disorders; hyperthyroidism; impaired hepatic, renal function; psychiatric patients (schizophrenic or paranoid patients may exhibit a worsening of psychosis with TCA therapy); manic-depressive patients; elective surgery (discontinue as long as possible before surgery).

Available forms of Amitriptyline

Injection—10 mg/mL; tablets—10, 25, 50, 75, 100, 150 mg

Dosages of Amitriptyline

May be given IM if patients are unable or unwilling to take oral drug. Switch to oral drug as soon as possible.

ADULTS

• Depression, hospitalized patients: Initially, 100 mg/day PO in divided doses: gradually increase to 200–300 mg/day as required. May be given IM 20–30 mg qid, initially only in patients unable or unwilling to take drug PO. Replace with oral medication as soon as possible.
• Depression, outpatients: Initially, 75 mg/day PO, in divided doses; may increase to 150 mg/day. Increases should be made in late afternoon or at bedtime. Total daily dosage may be administered at bedtime. Initiate single daily dose therapy with 50–100 mg at bedtime; increase by 25–50 mg as necessary to a total of 150 mg/day. Maintenance dose is 40–100 mg/day, which may be given as a single bedtime dose. After satisfactory response, reduce to lowest effective dosage. Continue therapy for 3 mo or longer to lessen possibility of relapse.
• Chronic pain: 75–150 mg/day PO.
• Prevention of cluster or migraine headaches: 50–150 mg/day PO.
• Prevention of weeping in MS patients with forebrain disease: 25–75 mg PO.

PEDIATRIC PATIENTS > 12 YR

10 mg tid PO and then 20 mg at bedtime.

PEDIATRIC PATIENTS < 12 YR

Not recommended.

GERIATRIC PATIENTS

10 mg tid PO with 20 mg at bedtime.

Pharmacokinetics

Metabolism: Hepatic; T_1/2: 10–50 hr

Distribution: Crosses placenta; enters breast milk

Excretion: Urine

Adverse effects of Amitriptyline

• CNS: Disturbed concentration, sedation and anticholinergic (atropine-like) effects, confusion (especially in elderly), hallucinations, disorientation, decreased memory, feelings of unreality, delusions, anxiety, nervousness, restlessness, agitation, panic, insomnia, nightmares, hypomania, mania, exacerbation of psychosis, drowsiness, weakness, fatigue, headache, numbness, tingling, paresthesias of extremities, incoordination, motor hyperactivity, akathisia, ataxia, tremors, peripheral neuropathy, extrapyramidal symptoms, seizures, speech blockage, dysarthria, tinnitus, altered EEG
• CV: Orthostatic hypotension, hypertension, syncope, tachycardia, palpitations, MI, arrhythmias, heart block, precipitation of CHF, CVA
• Endocrine: Elevated or depressed blood sugar, elevated prolactin levels, inappropriate ADH secretion
• GI: Dry mouth, constipation, paralytic ileus, nausea, vomiting, anorexia, epigastric distress, diarrhea, flatulence, dysphagia, peculiar taste, increased salivation, stomatitis, glossitis, parotid swelling, abdominal cramps, black tongue, hepatitis, jaundice (rare), elevated transaminase, altered alkalinephosphatase
• GU: Urinary retention, delayed micturition, dilation of the urinary tract, gynecomastia, testicular swelling; breast enlargement, menstrual irregularity andgalactorrhea; increased or decreased libido; impotence
• Hematologic: Bone marrow depression, including agranulocytosis; eosinophilia, purpura, thrombocytopenia, leukopenia
• Hypersensitivity: Rash, pruritus, vasculitis, petechiae, photosensitization, edema (generalized, face, tongue), drug fever
• Withdrawal: Symptoms on abrupt discontinuation of prolonged therapy: Nausea, headache, vertigo, nightmares, malaise
• Other: Nasal congestion, excessive appetite, weight change; sweating, alopecia, lacrimation, hyperthermia, flushing, chills

Interactions of Amitriptyline

Drug-drug

• Increased TCA levels and pharmacologic (especially anticholinergic) effects with cimetidine, fluoxetine
• Increased TCA levels with methylphenidate, phenothiazines, hormonal contraceptives, disulfiram
• Hyperpyretic crises, severe seizures, hypertensive episodes and deaths with MAOIs, furazolidone
• Increased antidepressant response and cardiac arrhythmias with thyroid medication
• Increased or decreased effects with estrogens
• Delirium with disulfiram
• Sympathetic hyperactivity, sinus tachycardia, hypertension, agitation with levodopa
• Increased biotransformation of TCAs in patients who smoke cigarettes
• Increased sympathomimetic (especially beta-adrenergic) effects of direct-acting sympathomimetic drugs (norepinephrine, epinephrine)
• Increased anticholinergic effects of anticholinergic drugs (including anticholinergic antiparkisonians)
• Increased response (especially CNS depression) to barbiturates
• Decreased antihypertensive effect of guanethidine, clonidine, other antihypertensives
• Decreased effects of indirect-acting sympathomimetic drugs (ephedrine)

Nursing considerations of Amitriptyline

Assessment

• History: Hypersensitivity to any tricyclic drug; concomitant therapy with an MAOI; recent MI; myelography within previous 24 hr or scheduled within 48 hr; lactation; EST; preexisting CV disorders; angle-closure glaucoma, increased IOP, urinary retention, ureteral or urethral spasm; seizure disorders; hyperthyroidism; impaired hepatic, renal function; psychiatric patients; manic-depressive patients; elective surgery
• Physical: Weight; T; skin color, lesions; orientation, affect, reflexes, vision and hearing; P, BP, orthostatic BP, perfusion; bowel sounds, normal output, liver evaluation; urine flow, normal output; usual sexual function, frequency of menses, breast and scrotal examination; LFTs, urinalysis, CBC, ECG

Interventions

• Restrict drug access for depressed and potentially suicidal patients.
• Give IM only when oral therapy is impossible.
• Do not administer IV.
• Administer major portion of dose at bedtime if drowsiness, severe anticholinergic effects occur (note that the elderly may not tolerate single-daily-dose therapy).
• Reduce dosage if minor side effects develop; discontinue if serious side effects occur.
• Arrange for CBC if patient develops fever, sore throat, or other sign of infection.

Teaching points 

• Take drug exactly as prescribed; do not stop abruptly or without consulting health care provider.
• Avoid using alcohol, other sleep-inducing drugs, over-the-counter drugs.
• Avoid prolonged exposure to sunlight or sunlamps; use a sunscreen or protective garments.
• You may experience these side effects: Headache, dizziness, drowsiness, weakness, blurred vision (reversible; if severe, avoid driving and tasks requiring alertness while these persist); nausea, vomiting, loss of appetite, dry mouth (eat frequent small meals; use frequent mouth care and suck on sugarless candies); nightmares, inability to concentrate, confusion; changes in sexual function.
• Report dry mouth, difficulty in urination, excessive sedation during amitriptyline therapy.

Amitriptyline HCl Drug Study Original source at: Nurseslabs

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

Image Via: Pharmacy Technician

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

CLINICAL ALERT!: Name confusion has occurred among Xanax (alprazolam), Celexa (citalopram), and Cerebyx (fosphenytoin), and between alprazolamand lorazepam; use caution.

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.

Sources: (1) (2) (3) (4) (5)

Alprazolam Original source at: Nurseslabs

Generic Name: fluoxetine hydrochloride

Brand Name: Apo-Fluoxetine (CAN), Co-Fluoxetine (CAN), Novo-Fluoxetine (CAN), PMS-Fluoxetine (CAN), Prozac, Prozac Pulvules, Prozac Weekly, ratio-Fluoxetine (CAN), Sarafem

Other Info: Pregnancy Category C

Drug class: Antidepressant, SSRI

Indications

• Treatment of depression; most effective in patients with major depressive disorder
• Treatment of OCD
• Treatment of bulimia
• Treatment of PMDD (Sarafem)
• Treatment of panic disorder with or without agoraphobia
• Unlabeled use: Treatment of obesity, alcoholism, numerous psychiatric disorders, chronic pain, various neuropathies

Contraindications and cautions

• Contraindicated with hypersensitivity to fluoxetine, pregnancy.
• Use cautiously with impaired hepatic or renal function, diabetes mellitus, lactation, seizures; history of suicide attempts.

Available forms

Tablets—10, 20 mg; capsules—10, 20, 40 mg; liquid—20 mg/5 mL; DR capsules—90 mg

Dosages

Individualize dosage; same for oral or IV routes because of rapid and almost complete absorption.

ADULTS

• Antidepressant: The full antidepressant effect may not be seen for up to 4–6 wk. Initially, 20 mg/day PO in the morning. If no clinical improvement is seen, increase dose after several weeks. Administer doses > 20 mg/day on a bid schedule. Do not exceed 80 mg/day. Once stabilized, may switch to 90-mg DR capsules once a week.
• OCD: Initially, 20 mg/day PO. If no clinical improvement is seen, increase dose after several weeks. Usual dosage range, 20–60 mg/day PO; may require up to 5 wk for effectiveness. Do not exceed 80 mg/day.
• Bulimia: 60 mg/day PO in the morning.
• PMDD (Sarafem): 20 mg/day PO or 20 mg/day PO starting 14 days before the anticipated beginning of menses and continuing through the first full day of menses, then no drug until 14 days before next menses; do not exceed 80 mg/day.
• Panic disorder (Prozac): 10 mg/day PO for the first week; increase to 20 mg/day if needed. Maximum dose, 60 mg/day.

PEDIATRIC PATIENTS 8–18 YR

• Major depressive disorder: 10 mg/day PO; may be increased to 20 mg/day after several weeks.

PEDIATRIC PATIENTS 7–17 YR

• OCD: Initially, 10 mg/day PO. After 2 wk increase to 20 mg/day. Suggested range, 20–60 mg/day PO.

PEDIATRIC PATIENTS < 7 YR

• Safety and efficacy not established.

GERIATRIC PATIENTS OR PATIENTS WITH HEPATIC OR RENAL IMPAIRMENT

Give a lower or less frequent dose. Monitor response to guide dosage.

Pharmacokinetics

Metabolism: Hepatic; T_1/2: 9 days

Distribution: Crosses placenta; enters breast milk

Excretion: Feces, urine

Adverse effects

• CNS: Headache, nervousness, insomnia, drowsiness, anxiety, tremor, dizziness, light-headedness, agitation, sedation, abnormal gait, seizures
• CV: Hot flashes, palpitations
• Dermatologic: Sweating, rash, pruritus, acne, alopecia, contact dermatitis
• GI: Nausea, vomiting, diarrhea, dry mouth, anorexia, dyspepsia, constipation, taste changes, flatulence, gastroenteritis, dysphagia, gingivitis
• GU: Painful menstruation, sexual dysfunction, frequency, cystitis, impotence, urgency, vaginitis
• Respiratory: URIs, pharyngitis, cough, dyspnea, bronchitis, rhinitis
• Other: weight changes, asthenia, fever

Interactions

Drug-drug

• WARNING: Possible fatal reactions with MAOIs; do not administer together; 2-wk washout period needed.
• Increased therapeutic and toxic effects of TCAs
• Do not use with thioridazine (increased levels of thioridazine)
• Decreased effectiveness if taken while smoking
• Increased toxicity of lithium; avoid this combination
• Additive CNS effects if combined with benzodiazepines, alcohol; avoid these combinations
• Avoid administration with other serotonergic drugs; may lead to serotonin syndrome

Drug-alternative therapy

• Increased risk of severe reaction if combined with St. John’s wort therapy

Nursing considerations

CLINICAL ALERT! Name confusion has occurred between Sarafem (fluoxetine) and Serophene (clomiphene); use caution.

Assessment

• History: Hypersensitivity to fluoxetine, impaired hepatic or renal function, diabetes mellitus, lactation, pregnancy, seizures
• Physical: Weight, T; skin rash, lesions; reflexes, affect; bowel sounds, liver evaluation; P, peripheral perfusion; urinary output, LFTs, renal function tests

Interventions

• Arrange for lower or less frequent doses in elderly patients and patients with hepatic or renal impairment.
• BLACK BOX WARNING: Establish suicide precautions for severely depressed patients. Limit quantity of capsules dispensed; high risk in children and adolescents.
• Administer drug in the morning.
• Monitor patient for response to therapy for up to 4 wk before increasing dose.
• Switch to once a week therapy by starting weekly dose 7 days after last 20 mg/day dose. If response is not satisfactory, reconsider daily dosing.

Teaching points

• It may take up to 4 weeks before the full effect occurs. Take in the morning. If you feel sleepy or tired, you may take it at night. If you are taking the once-weekly capsule, mark calendar with reminders of drug day.
• Do not take this drug during pregnancy. If you think that you are pregnant or wish to become pregnant, consult your health care provider.
• Keep this drug, and all medications, out of the reach of children.
• You may experience these side effects: Dizziness, drowsiness, nervousness, insomnia (avoid driving or performing hazardous tasks); nausea, vomiting, weight loss (eat small frequent meals; monitor your weight loss); sexual dysfunction; flulike symptoms.
• Report rash, mania, seizures, severe weight loss.

Fluoxentine HCl (Prozac) Original source at: Nurseslabs

Brand Names:

Carbolith (CAN), Duralith (CAN), Eskalith, Eskalith CR, Lithane (CAN),

Pregnancy Category D

Drug class

Antimanic drug

Indications of Lithium

• Treatment of manic episodes of manic-depressive illness; maintenance therapy to prevent or diminish frequency and intensity of subsequent manic episodes
• Unlabeled use: Improvement of neutrophil counts in patients with cancer chemotherapy–induced neutropenia and in children with chronic neutropenia and HIV patients on zidovudine therapy (doses of 300–1,000 mg/day, serum levels of 0.5 and 1 mEq/L); prophylaxis of cluster headache and cyclic migraine headache, treatment of SIADH, hypothyroidism (doses of 600–900 mg/day)

Contraindications and cautions of Lithium

• Contraindicated with hypersensitivity to tartrazine; significant renal or CV disease; severe debilitation, dehydration; sodium depletion, patients on diuretics (lithium decreases sodium reabsorption, and hyponatremia increases lithium retention); use of ACE inhibitors; pregnancy; lactation.
• Use cautiously with protracted sweating and diarrhea; suicidal or impulsive patients; infection with fever.

Available forms of Lithium

Capsules—150, 300, 600 mg; tablets—300 mg; SR tablets—300 mg; CR tablets—450 mg; syrup—300 mg/5 mL

Dosages of Lithium

Individualize dosage according to serum levels and clinical response.

ADULTS

• Acute mania: 600 mg PO tid or 900 mg slow-release form PO bid to produce effective serum levels between 1 and 1.5 mEq/L. Serum levels should be determined twice per wk in samples drawn immediately before a dose (at least 8–12 hr after previous dose).
• Long-term use: 300 mg PO tid–qid to produce a serum level of 0.6–1.2 mEq/L. Serum levels should be determined at least every 2 mo in samples drawn immediately before a dose (at least 8–12 hr after previous dose).
• Conversion from conventional to slow-release dosage forms: Give the same total daily dose divided into two or three doses.

PEDIATRIC PATIENTS

Safety and efficacy for children < 12 yr not established.

GERIATRIC PATIENTS AND PATIENTS WITH RENAL IMPAIRMENT

Reduced dosage may be necessary. Elderly patients often respond to reduced dosage and may exhibit signs of toxicity at serum levels tolerated by other patients. Plasma half-life is prolonged in renal impairment.

Pharmacokinetics

Metabolism: Hepatic; T_1/2: 17–24 hr

Distribution: Crosses placenta; enters breast milk

Excretion: Urine

Adverse effects of Lithium

Reactions are related to serum lithium levels. (Toxic lithium levels are close to therapeutic levels. Therapeutic levels in acute mania range between 1 and 1.5 mEq/L; therapeutic levels for maintenance are 0.6–1.2 mEq/L)

< 1.5 mEq/L

• CNS: Lethargy, slurred speech, muscle weakness, fine hand tremor
• GI: Nausea, vomiting, diarrhea, thirst
• GU: Polyuria

1.5–2 mEq/L (mild to moderate toxic reactions)

• CNS: Coarse hand tremor, mental confusion, hyperirritability of muscles, drowsiness, incoordination
• CV: ECG changes
• GI: Persistent GI upset, gastritis, salivary gland swelling, abdominal pain, excessive salivation, flatulence, indigestion

2–2.5 mEq/L (moderate to severe toxic reactions)

• CNS: Ataxia, giddiness, fasciculations, tinnitus, blurred vision, clonic movements, seizures, stupor, coma
• CV: Serious ECG changes, severe hypotension with cardiac arrythmias
• GU: Large output of dilute urine
• Respiratory: Fatalities secondary to pulmonary complications

> 2.5 mEq/L (life-threatening toxicity)

• General: Complex involvement of multiple organ systems, including seizures, arrythmias, CV collapse, stupor, coma

Reactions unrelated to serum levels

• CNS: Headache, worsening of organic brain syndromes, fever, reversible short-term memory impairment, dyspraxia
• CV: ECG changes; hyperkalemia associated with ECG changes; syncope; tachycardia-bradycardia syndrome; rarely, arrhythmias, CHF, diffuse myocarditis,death
• Dermatologic: Pruritus with or without rash; maculopapular, acneiform, and follicular eruptions; cutaneous ulcers; edema of ankles or wrists
• Endocrine: Diffuse nontoxic goiter; hypothyroidism; hypercalcemia associated with hyperparathyroidism; transient hyperglycemia; irreversible nephrogenicdiabetes insipidus, which improves with diuretic therapy; impotence or sexual dysfunction
• GI: Dysgeusia (taste distortion), salty taste; swollen lips; dental caries
• Other: Weight gain (5–10 kg); chest tightness; swollen or painful joints, eye irritation, worsening of cataracts, disturbance of visual accommodation,leukocytosis

Interactions of Lithium

Drug-drug

• Increased risk of toxicity with thiazide diuretics due to decreased renal clearance of lithium—reduced lithium dosage may be necessary
• Increased plasma lithium levels with indomethacin and some other NSAIDs—phenylbutazone, piroxicam, ibuprofen and fluoxetine, methyldopa, and metronidazole
• Increased CNS toxicity with carbamazepine
• Encephalopathic syndrome (weakness, lethargy, fever, tremulousness, confusion, extrapyramidal symptoms, leukocytosis, elevated serum enzymes) with irreversible brain damage when taken with haloperidol
• Greater risk of hypothyroidism with iodide salts
• Decreased effectiveness due to increased excretion of lithium with urinary alkalinizers, including antacids, tromethamine
• Risk of increased adverse effect with SSRIs

Drug-alternative therapy

• Increased effects and toxicity with juniper, dandelion

Nursing considerations of Lithium

Assessment

• History: Hypersensitivity to tartrazine; significant renal or CV disease; severe debilitation, dehydration; sodium depletion, patients on diuretics; protracted sweating, diarrhea; suicidal or impulsive patients; infection with fever; pregnancy; lactation
• Physical: Weight and T; skin color, lesions; orientation, affect, reflexes; ophthalmic examination; P, BP, R, adventitious sounds; bowel sounds, normal output; normal fluid intake, normal output, voiding pattern; thyroid, renal glomerular and tubular function tests, urinalysis, CBC and differential, baseline ECG

Interventions

• Give with caution and daily monitoring of serum lithium levels to patients with renal or CV disease, debilitation, or dehydration or life-threatening psychiatric disorders.
• Give drug with food or milk or after meals.
• BLACK BOX WARNING: Monitor clinical status closely, especially during initial stages of therapy; monitor for therapeutic serum levels of 0.6–1.2 mEq/L; toxicity is closely related to serum levels.
• Individuals vary in their reponse to this drug; some patients may exhibit toxic signs at serum lithium levels considered within the therapeutic range.
• Advise patient that this drug may cause serious fetal harm and cannot be used during pregnancy; urge use of barrier contraceptives.
• Decrease dosage after the acute manic episode is controlled; lithium tolerance is greater during the acute manic phase and decreases when manic symptoms subside.
• WARNING: Ensure that patient maintains adequate intake of salt and adequate intake of fluid (2,500–3,000 mL/day).

Teaching points

• Take this drug exactly as prescribed, after meals or with food or milk. Swallow extended- or controlled-release tablets whole; do not chew or crush.
• Eat a normal diet with normal salt intake; maintain adequate fluid intake (at least 2.5 quarts/day).
• Arrange for frequent checkups, including blood tests. Keep all appointments for checkups to get the most benefits with the least toxicity.
• Use contraception to avoid pregnancy. If you wish to become pregnant or believe that you have become pregnant, consult your health care provider.
• Discontinue drug, and notify your health care provider if toxicity occurs—diarrhea, vomiting, ataxia, tremor, drowsiness, lack of coordination or muscular weakness.
• You may experience these side effects: Drowsiness, dizziness (avoid driving or performing tasks that require alertness); GI upset (eat frequent small meals); mild thirst, greater than usual urine volume, fine hand tremor (may persist throughout therapy; notify your health care provider if severe).
• Report diarrhea or fever.

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

Lithium Original source at: Nurseslabs

Brand Name: Apo-Methylphenidate (CAN), Concerta, Daytrana, Metadate CD, Metadate ER, Methylin, Methylin ER, PMS-Methylphenidate (CAN), Ritalin, Ritalin LA, Ritalin SR

Other Info: Pregnancy Category C, Controlled Substance C-II

Drug class: CNS stimulant

Therapeutic actions

Mild cortical stimulant with CNS actions similar to those of the amphetamines; efficacy in hyperkinetic syndrome, attention-deficit disorders in children appearsparadoxical and is not understood

Indications

• Ritalin, Ritalin SR, Metadate ER, Methylin: Narcolepsy
• Attention-deficit disorders, hyperkinetic syndrome, minimal brain dysfunction in children or adults with a behavioral syndrome characterized by the following symptoms: Moderate to severe distractibility, short attention span, hyperactivity, emotional lability, and impulsivity, not secondary to environmental factors or psychiatric disorders
• Unlabeled use: Treatment of depression in the elderly, cancer and CVA patients; alleviation of neurobehavioral symptoms after traumatic brain injury; improvement in pain control and sedation in patients receiving opiates

Contraindications and cautions

• Contraindicated with hypersensitivity to methylphenidate; marked anxiety, tension, and agitation; glaucoma; motor tics, family history or diagnosis of Tourettesyndrome; severe depression of endogenous or exogenous origin; normal fatigue states.
• Use cautiously with seizure disorders; hypertension; drug dependence, alcoholism; emotional instability; lactation, pregnancy.

Available forms: Tablets—5, 10, 20 mg; chewable tablets—2.5, 5, 10 mg; SR tablets—20 mg; ER tablets—10, 18, 20, 27, 36, 54 mg; ER capsules—20, 30 mg (Metadate CD); and 20, 30, 40 mg (Ritalin LA); transdermal patch—1, 1.6, 2.2, 3.3 mg/hr

Dosages

ADULTS

Individualize dosage. Give orally in divided doses bid or tid, preferably 30–45 min before meals; dosage ranges from 10–60 mg/day PO. If insomnia is a problem, drug should be taken before 6 PM. Timed-release tablets have a duration of 8 hr and may be used when timing and dosage are adjusted to the 8-hr daily regimen. ER forms: 18 mg PO daily in the morning; may be increased by 18 mg/day at 1-wk intervals to a maximum of 54 mg/day (Concerta); 20 mg/day to a maximum 60 mg/day (Metadate CD, Ritalin LA).

PEDIATRIC PATIENTS 13-17 YR

Initially 18 mg/day PO taken in the morning without regard to food; titrate to a maximum 72 mg/day PO. Do not exceed 2 mg/kg/day. Tablets must be swallowed whole and should not be cut, crushed, or chewed (Concerta).

PEDIATRIC PATIENTS > 6 YR

Start with small oral doses (5 mg PO before breakfast and lunch with gradual increments of 5–10 mg weekly). Daily dosage > 60 mg not recommended. Discontinue use after 1 mo if no improvement. Discontinue periodically to assess condition; usually discontinued after puberty. ER forms: Use adult dosage. Or, 10-30 mg/day by transdermal patch; apply patch 2 hr before effect needed and remove after 9 hr.

PEDIATRIC PATIENTS < 6 YR

Not recommended.

Pharmacokinetics

Metabolism: Hepatic; T_1/2: 1–3 hr (6.8 hr ER)

Distribution: Crosses placenta; may enter breast milk

Excretion: Urine

Adverse effects

• CNS: Nervousness, insomnia, dizziness, headache, dyskinesia, chorea, drowsiness, Tourette syndrome, toxic psychosis, blurred vision, accommodation difficulties
• CV: Increased or decreased pulse and BP; tachycardia, angina, cardiac arrhythmias, palpitations
• Dermatologic: Rash, urticaria, fever, arthralgia, exfoliative dermatitis, erythema multiforme with necrotizing vasculitis and thrombocytopenic purpura, loss of scalp hair
• GI: Anorexia, nausea, abdominal pain, weight loss
• Hematologic: Leukopenia, anemia
• Other: Tolerance, psychological dependence, abnormal behavior with abuse

Interactions

Drug-drug

• Decreased effects of guanethidine; avoid this combination
• Increased effects and toxicity of methylphenidate with MAOIs
• Increased serum levels of phenytoin, TCAs, oral anticoagulants, SSRIs with methylphenidate; monitor for toxicity

Drug-lab test

• Methylphenidate may increase the urinary excretion of epinephrine

Nursing considerations

Assessment

• History: Hypersensitivity to methylphenidate; marked anxiety, tension, and agitation; glaucoma; motor tics, Tourette syndrome; severe depression; normal fatigue state; seizure disorders; hypertension; drug dependence, alcoholism, emotional instability; pregnancy, lactation
• Physical: Weight; T; skin color, lesions; orientation, affect, ophthalmologic examination (tonometry); P, BP, auscultation; R, adventitious sounds; bowel sounds, normal output; CBC with differential, platelet count, baseline ECG

Interventions

• BLACK BOX WARNING: Be aware that drug has potential for abuse, use caution with emotionally unstable patients.
• Ensure proper diagnosis before administering to children for behavioral syndromes; drug should not be used until other causes or concomitants of abnormal behavior (learning disability, EEG abnormalities, neurologic deficits) are ruled out.
• Apply transdermal patch to clean, dry area of the hip approximately 2 hr before effect needed. Remove after 9 hr. Alternate hips.
• Interrupt drug dosage periodically in children to determine if symptoms warrant continued drug therapy.
• Monitor growth of children on long-term methylphenidate therapy.
• Ensure that all timed-release tablets and capsules are swallowed whole, not chewed or crushed.
• Dispense the smallest feasible dose to minimize risk of overdose.
• Give before 6 PM to prevent insomnia.
• Monitor CBC and platelet counts periodically in patients on long-term therapy.
• Monitor BP frequently early in treatment.

Teaching points

• Take this drug exactly as prescribed. Timed-release tablets and capsules must be swallowed whole, not chewed or crushed. Metadate CD capsules may be opened and entire contents sprinkled on soft food—do not chew or crush granules. Transdermal patch should be applied to clean, dry area of the hip. Remove after 9 hr. Alternate hips.
• Take drug before 6 PM to avoid nighttime sleep disturbance.
• Avoid alcohol and over-the-counter drugs, including nose drops, cold remedies; some over-the-counter drugs could cause dangerous effects.
• You may experience these side effects: Nervousness, restlessness, dizziness, insomnia, impaired thinking (may lessen; avoid driving or engaging in activities that require alertness); headache, loss of appetite, dry mouth.
• Keep drug in secure place; do not share with others.
• Report nervousness, insomnia, palpitations, vomiting, rash, fever.

Methylphenidate Original source at: Nurseslabs

Generic Name:

Brand Name: Apo-Gabapentin (CAN), Gen-Gabapentin (CAN), Neurontin

Other Info: Pregnancy Category C

Drug class: Antiepileptic

Therapeutic actions

Mechanism of action not understood; antiepileptic activity may be related to its ability to inhibit polysynaptic responses and block posttetanic potentiation.

Indications

• Adjunctive therapy in the treatment of partial seizures with and without secondary generalization in adults and children 3–12 yr with epilepsy
• Orphan drug use: Treatment of amyotrophic lateral sclerosis
• Management of postherpetic neuralgia or pain in the area affected by herpes zoster after the disease has been treated
• Unlabeled uses: Tremors of MS, neuropathic pain, bipolar disorder, migraine prophylaxis

Contraindications and cautions

• Contraindicated with hypersensitivity to gabapentin.
• Use cautiously with pregnancy, lactation.

Available forms

Capsules—100, 300, 400 mg; tablets—100, 300, 400, 600, 800 mg; oral solution—250 mg/5 mL

Dosages

ADULTS

• Epilepsy: Starting dose is 300 mg PO tid, then titrated up as needed. Maintenance: 900–1,800 mg/day PO in divided doses tid PO; maximum interval between doses should not exceed 12 hr. Up to 2,400–3,600 mg/day has been used.
• Postherpetic neuralgia: Initial dose of 300 mg/day PO; 300 mg bid PO on day 2; 300 mg tid PO on day 3.

PEDIATRIC PATIENTS 3–12 YR

Initially, 10–15 mg/kg/day PO in three divided doses; adjust upward over about 3 days to 25–35 mg/kg daily in three divided doses in children > 5 yr, and up to 40 mg/kg/day in three divided doses in children 3–4 yr.

GERIATRIC PATIENTS OR PATIENTS WITH RENAL IMPAIRMENT

Postdialysis supplemental dosing, 125–350 mg PO following each 4 hr of dialysis.

Pharmacokinetics

Metabolism: Hepatic; T_1/2: 5–7 hr

Distribution: Crosses placenta; enters breast milk

Excretion: Urine, unchanged

Adverse effects

• CNS: Dizziness, insomnia, nervousness, fatigue, somnolence, ataxia, diplopia, tremor
• Dermatologic: Pruritus, abrasion
• GI: Dyspepsia, vomiting, nausea, constipation, dry mouth
• Respiratory: Rhinitis, pharyngitis
• Other: Weight gain, facial edema, cancer, impotence

Interactions

Drug-drug

• Decreased serum levels with antacids

Drug-lab test

• False positives may occur with Ames N-Multistix SG dipstick test for protein in the urine

Nursing considerations

Assessment

• History: Hypersensitivity to gabapentin; lactation, pregnancy
• Physical: Weight; T; skin color, lesions; orientation, affect, reflexes; P; R, adventitious sounds; bowel sounds, normal output

Interventions

• Give drug with food to prevent GI upset.
• Arrange for consultation with support groups for people with epilepsy.
• WARNING: If overdose occurs, hemodialysis may be an option.

Teaching points

• Take this drug exactly as prescribed; do not discontinue abruptly or change dosage, except on the advice of your health care provider.
• Wear a medical alert ID at all times so that any emergency medical personnel will know that you have epilepsy and are taking antiepileptic medication.
• You may experience these side effects: Dizziness, blurred vision (avoid driving or performing other tasks requiring alertness or visual acuity); GI upset (take drug with food or milk, eat frequent small meals); headache, nervousness, insomnia; fatigue (periodic rest periods may help).
• Report severe headache, sleepwalking, rash, severe vomiting, chills, fever, difficulty breathing.

Gabapentin Original source at: Nurseslabs

Brand Name: Lexapro

Other Info: Pregnancy Category C

Drug classes: Antidepressant, SSRI

Therapeutic actions

Potentiates serotonergic activitity in the CNS by inhibiting reuptake of serotonin resulting in antidepressant effect with little effect on norepinephrine or dopamine; an isomer of citalopram.

Indications

• Treatment of major depressive disorder
• Maintenance treatment for patients with major depressive disorder
• Treatment of generalized anxiety disorder
• Unlabeled use: Panic disorder

Contraindications and cautions

• Contraindicated with MAOI use; with allergy to drug or to citalopram or any component of the drug.
• Use cautiously in the elderly, and with renal or hepatic impairment, illnesses of metabolism or hemodynamic response, pregnancy, lactation, suicidal patients, patients with mania or seizure disorders.

Available forms

Tablets—5, 10, 20 mg; oral solution—5 mg/5 mL

Dosages

ADULTS

• Major depressive disorder: Initially, 10 mg/day PO as a single daily dose; if needed, may be increased to 20 mg/day after a minimum of 1-wk trial period. For maintenance, 10–20 mg/day PO; reassess periodically.
• Generalized anxiety disorder: 10 mg/day PO; may be increased to 20 mg/day after 1 wk if needed. Treatment beyond 8 wk not tested.

PEDIATRIC PATIENTS

Safety and efficacy not established.

GERIATRIC PATIENTS OR ADULTS WITH HEPATIC IMPAIRMENT

10 mg/day PO as a single dose, do not increase dose.

Pharmacokinetics

Metabolism: Hepatic metabolism; T_1/2: 27–32 hour

Distribution: Crosses placenta; enters breast milk

Excretion: Urine

Adverse effects

• CNS: Somnolence, dizziness, insomnia, fatigue
• Dermatologic: Sweating
• GI: Nausea, dry mouth, constipation, diarrhea, indigestion, abdominal pain, decreased appetite
• GU: Ejaculatory disorders, impotence, anorgasmia in females, decreased libido
• Respiratory: Rhinitis, sinusitis, flulike symptoms

Interactions

Drug-drug

• Risk of serious toxic effects if combined with citalopram; do not use these drugs concomitantly
• Increased escitalopram levels and toxicity if taken with MAOIs; ensure that patient has been off the MAOI for at least 14 days before administeringescitalpram
• Risk of serotonin syndrome—a syndrome characterized by increased BP, T, severe anxiety, agitation, rigidity, and can occur when multiple serotonin elevating drugs are used. Monitor patient carefully
• Possible severe adverse effects if combined with other centrally acting CNS drugs including alcohol; use caution
• Possible decreased effects of escitalopram if combined with carbamazepine, lithium; monitor patient closely

Drug-alternative therapy

• Increased risk of severe reaction if combined with St. John’s wort; avoid this combination

Nursing considerations

CLINICAL ALERT!

There is potential for name confusion between escitalopram and citalopram and Lexapro (escitalopram) and Loxitane (loxapine); use caution.

Assessment

• History: MAOI use; allergy to drug, citalopram, or any component of the drug; renal or hepatic impairment; the elderly; pregnancy; lactation; suicidal tendencies; metabolic illnesses or problems with hemodynamic response; alcoholism
• Physical: Orientation, reflexes; P, BP, perfusion; R, bowel sounds, normal output; urinary output; liver evaluation; LFTs, renal function tests

Interventions

• BLACK BOX WARNING: Monitor patient for risk of suicidality, especially when starting or altering dosage; children and adolescents at increased risk.
• Administer once a day, in the morning or the evening; may be taken with food if desired.
• Encourage patient to continue use for 4–6 weeks, as directed, to ensure adequate levels to affect depression.
• WARNING: Limit amount of drug given in prescription to potentially suicidal patients.
• Advise any depressed patients to avoid the use of alcohol while being treated with antidepressive drugs.
• Establish appropriate safety precautions if patient experiences adverse CNS effects.
• Institute appropriate therapy for patient suffering from depression.

Teaching points

• Take this drug exactly as directed, and as long as directed; it may take several weeks to realize the benefits of the drug. The drug may be taken with food if desired.
• Avoid the use of alcohol while you are taking this drug.
• This drug should not be taken during pregnancy or when nursing a baby; using barrier contraceptive is suggested.
• You may experience these side effects: Drowsiness, dizziness, tremor (use caution and avoid driving a car or performing other tasks that require alertness if you experience daytime drowsiness); GI upset (frequent small meals, frequent mouth care may help); alterations in sexual function (this is a drug effect and will pass when drug therapy is ended).
• Report severe nausea, vomiting; blurred vision; excessive sweating, suicidal ideation, sexual dysfunction, insomnia.

Escitalopram Original source at: Nurseslabs