Read Mosby's 2014 Nursing Drug Reference Online
Authors: Linda Skidmore-Roth
Mosby's 2014 Nursing Drug Reference (105 page)
(kloz′a-peen)
Clozaril, FazaClo
Func. class.:
Antipsychotic
Chem. class.:
Tricyclic dibenzodiazepine derivative
Do not confuse:
Clozaril
/Clinoril/Colazal
Interferes with dopamine receptor binding with lack of EPS; also acts as an adrenergic, cholinergic, histaminergic, serotonergic antagonist
Management of psychotic symptoms for schizophrenic patients for whom other antipsychotics have failed; recurrent suicidal behavior
Unlabeled uses:
Agitation, bipolar disorder, psychosis in dementia, psychosis in Parkinson’s disease
Hypersensitivity, severe granulocytopenia (WBC <3500 before therapy), coma
Black Box Warning:
Myeloproliferative disorders, severe CNS depression, agranulocytosis, leukopenia, neutropenia, seizure disorder
Precautions:
Pregnancy (B), breastfeeding, children <16 yr, geriatric patients; CV, pulmonary, cardiac, renal, hepatic disease; seizures, prostatic enlargement, closed-angle glaucoma, stroke
Black Box Warning:
Bone marrow suppression, hypotension, myocarditis, orthostatic hypotension, seizures, geriatric patients with dementia-related psychosis
Calculator
• Adult:
PO
12.5 mg daily or bid; may increase by 25-50 mg/day; normal range 300-450 mg/day after 2 wk; do not increase dose more than 2×/wk; max 900 mg/day; use lowest dose to control symptoms
• Geriatric:
PO
12.5 mg daily at bedtime, may increase by 12.5 mg every other day, max 50 mg/day
Available forms:
Tabs 25, 50, 100, 200 mg; orally disintegrating tabs 25, 100 mg (Fazaclo: 12.5, 25, 100, 150, 200 mg)
•
May be taken with or without food
•
Patient-specific registration required before administration; if WBC <3500 cells/mm
3
or ANC <2000 cells/mm
3
, therapy should not be started
•
Check to confirm PO medication swallowed; monitor for hoarding or giving of medication to other patients, if hospitalized; avoid giving patient >7 days’ worth of medication if outpatient
•
Orally disintegrating tab:
do not push through foil; leave in foil blister until ready to take, peel back foil, place tab in mouth; allow to dissolve, swallow; water is not needed
CNS:
Neuroleptic malignant syndrome,
sedation, salivation, dizziness, headache, tremors, sleep problems, akinesia, fever
,
seizures,
sweating, akathisia, confusion, fatigue, insomnia
, depression, slurred speech, anxiety,
agitation
, dystonia, obsessive-compulsive symptoms
CV:
Tachycardia, hypo/hypertension
, chest pain, ECG changes, orthostatic hypotension
EENT:
Blurred vision
GI:
Drooling or excessive salivation, constipation, nausea, abdominal discomfort, vomiting, diarrhea
, anorexia,
weight gain, dry mouth
, heartburn,
dyspepsia, gastroesophageal reflux
GU:
Urinary abnormalities
, incontinence, ejaculation dysfunction; frequency, urgency, retention, dysuria
HEMA:
Leukopenia, agranulocytosis, eosinophilia
MS:
Weakness; pain in back, neck, legs; spasm,
rigidity
OTHER:
Diaphoresis
RESP:
Dyspnea, nasal congestion, lower respiratory tract infection
SYST:
Death among geriatric patients with dementia,
aggravation of diabetes mellitus
Bioavailability 27%-47%; 97% protein bound; completely metabolized by liver enzymes involved in metabolism CYP1A2, 2D6, 3A4; excreted in urine (50%), feces (30%) (metabolites); half-life 8-12 hr
Increase:
CNS depression—CNS depressants, psychoactives, alcohol
Increase:
cloZAPine level—caffeine, citalopram, FLUoxetine, sertraline, ritonavir, risperiDONE, CYP1A2 inhibitors (fluvoxaMINE), CYP3A4 inhibitors (ketoconazole, erythromycin)
Increase:
plasma concentration—warfarin, digoxin, other highly protein-bound products
Increase:
QT prolongation—β blockers, class IA/III antidysrhythmias, and other drugs that increase QT
Increase:
hypotension, respiratory, cardiac arrest, collapse—benzodiazepines
Decrease:
cloZAPine level—CYP1A2 inducers (carBAMazepine, omeprazole, rifampin); PHENobarbital
Increase:
LFTs, cardiac enzymes, cholesterol, blood glucose, bilirubin, PBI, cholinesterase,
131
I
False positive:
pregnancy tests, PKU
False negative:
urinary steroids, 17-OHCS
Black Box Warning
Myocarditis; if suspected, discontinue use; myocarditis usually occurs during 1st month of treatment
Black Box Warning:
Seizures; usually occur with higher doses >600 mg/day or dosage change >100 mg/day; do not use in uncontrolled seizure disorder, use cautiously in those with a predisposition to seizures
•
I&O ratio; obtain baseline before treatment begins; palpate bladder if low urinary output occurs
Black Box Warning:
Bone marrow depression:
bilirubin, CBC, LFTs monthly; discontinue treatment if WBC <3000/mm
3
or ANC <1500/mm
3
; test weekly; may resume when normal; if WBC <2000/mm
3
or ANC <1000/mm
3
, discontinue
•
Urinalysis recommended before, during prolonged therapy
•
Affect, orientation, LOC, reflexes, gait, coordination, sleep pattern disturbances
Black Box Warning:
Hypotension:
B/P standing and lying; take pulse, respirations q4hr during initial treatment; establish baseline before starting treatment; report drops of 30 mm Hg
•
Dizziness, faintness, palpitations, tachycardia on rising
•
EPS
including akathisia (inability to sit still, no pattern to movements), tardive dyskinesia (bizarre movements of the jaw, mouth, tongue, extremities), pseudoparkinsonism (rigidity, tremors, pill rolling, shuffling gait)
Neuroleptic malignant syndrome:
tachycardia, seizures, fever, dyspnea, diaphoresis, increased/decreased B/P; notify prescriber immediately
•
Constipation, urinary retention daily; if these occur, increase bulk, water in diet, especially for geriatric patients; stool softeners, laxatives may be needed
•
If diabetic, check blood glucose levels
•
Supervised ambulation until stabilized on medication; do not involve patient in strenuous exercise program because fainting is possible; patient should not stand still for long periods
•
Storage in tight, light-resistant container
•
Therapeutic response: decrease in emotional excitement, hallucinations, delusions, paranoia, reorganization of patterns of thought, speech
•
About symptoms of agranulocytosis and need for blood tests weekly for 6 mo, then q2wk; to report flulike symptoms
•
That orthostatic hypotension often occurs; to rise gradually from sitting or lying position; to avoid hot tubs, hot showers, tub baths; hypotension may occur
•
To avoid abrupt withdrawal of this product because EPS may result; that product should be withdrawn over 1-2 wk
•
To avoid OTC preparations (cough, hay fever, cold) unless approved by prescriber, since serious product interactions may occur; to avoid use with alcohol or CNS depressants, increased drowsiness may occur
•
About compliance with product regimen
•
About EPS and necessity for meticulous oral hygiene, since oral candidiasis may occur
Black Box Warning:
To report sore throat, malaise, fever, bleeding, mouth sores; if these occur, CBC should be drawn and product discontinued
•
That heat stroke may occur in hot weather; to take extra precautions to stay cool
•
To avoid driving, other hazardous activities; seizures may occur
•
To notify prescriber if pregnant or if pregnancy is intended; not to breastfeed
Lavage, activated charcoal; provide an airway; do not induce vomiting
Canada only Side effects:
italics
= common;
bold
= life-threatening Nurse Alert
(koe′deen)
Func. class.:
Opiate analgesic, antitussive
Chem. class.:
Opiate, phenathrene derivative
Do not confuse:
codeine
/Lodine/iodine/Cardene
Depresses pain impulse transmission at the spinal cord level by interacting with opioid receptors; decreases cough reflex, GI motility
Moderate to severe pain
Unlabeled uses:
Diarrhea, arthralgia, bone/dental pain, headache, migraine, myalgia, nonproductive cough
Breastfeeding, hypersensitivity to opiates, respiratory depression, increased intracranial pressure, seizure disorders, severe respiratory disorders
Precautions:
Pregnancy (C), geriatric patients, cardiac dysrhythmias, prostatic hypertrophy, bowel impaction
Calculator
• Adult:
PO
15-60 mg q4hr prn
• Child 6-17 yr:
PO
3 mg/kg/day in divided doses q4hr prn
• Adult:
PO
10-20 mg q4-6hr, max 120 mg/day
• Adult:
PO
CCr 10-50 ml/min, 75% of dose; CCr <10 ml/min, 50% of dose
• Adult:
PO
30 mg; may repeat qid prn
• Adult:
PO
15-60 mg q4-6hr
• Child ≥3 yr:
PO
0.5-1 mg/kg or 15 mg/m
2
(max 60 mg/dose) q4-6hr
Available forms:
Tabs 15, 30, 60 mg; inj 15, 30 mg/ml; oral sol 30 mg/5 ml, 30 mg/5 ml sol
Discontinue gradually after long-term us
CNS:
Drowsiness, sedation
, dizziness, agitation, dependency, lethargy, restlessness, euphoria,
seizures,
hallucinations, headache, confusion
CV:
Bradycardia, palpitations, orthostatic hypotension, tachycardia,
circulatory collapse
GI:
Nausea, vomiting, anorexia, constipation
, dry mouth
GU:
Urinary retention
INTEG:
Flushing, rash, urticaria, pruritus
RESP:
Respiratory depression, respiratory paralysis,
dyspnea
SYST:
Anaphylaxis
Bioavailability 60%-90%; peak 1/2-1 hr; duration 4-6 hr; metabolized by liver (CYP3A4 to morphine); excreted by kidneys, in breast milk; crosses placenta; half-life 3 hr; protein binding 7%; altered codeine metabolism occurs in different ethnic groups
PO:
Onset 30-60 min
Increase:
CNS depression—CYP2D6, alcohol, opiates, sedative/hypnotics, antipsychotics, skeletal muscle relaxants
Increase:
toxicity—MAOIs; use cautiously
Increase:
lipase, amylase
•
Pain:
intensity, type, location, aggravating, alleviating factors; need for pain medication, tolerance; use pain scoring
•
I&O ratio; check for decreasing output; may indicate urinary retention, especially among geriatric patients
•
GI function: nausea, vomiting, constipation
•
Cough:
type, duration, ability to raise secretion for productive cough; do not use to suppress productive cough
•
CNS changes, dizziness, drowsiness, hallucinations, euphoria, LOC, pupil reaction
•
Allergic reactions: rash, urticaria
Respiratory dysfunction:
respiratory depression, character, rate, rhythm; notify prescriber if respirations are <10/min, shallow; obstructive sleep apnea (children) (tonsillectomy/adenoidectomy)
•
Storage in light-resistant container at room temp
•
Therapeutic response: decrease in pain, absence of grimacing, decreased cough, decreased diarrhea
•
Not to breastfeed
•
To report any symptoms of CNS changes, allergic reactions
•
That physical dependency may result after extended periods
•
To decrease dry mouth use sugarless gum, rinse mouth often
•
To change position slowly; orthostatic hypotension may occur
•
To avoid hazardous activities if drowsiness, dizziness occurs
•
To avoid alcohol, other CNS depressants unless directed by prescriber
Naloxone 0.4-mg ampule diluted in 10 ml 0.9% NaCl and given by direct IV push, 0.02 mg q2min (adult)