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phenytoin (Dilantin) hydantoins Why is pt receiving this? Indicated for partial and tonic-clonic seizures. Unlabeled uses for antidysrythmic and neuropathic pain. Selective inhibition of sodium channels. Dose IM not recommended, PO used when possible. Loading dose of 15-20 mg/kg as extended capsules in 3 divided doses given q 2-4 hrs, maintenance dose 5-6 mg/kg/day given in 1-3 divided doses; usual dosing range 200-1200 mg/day SE Nystagmus, sedation, SJS , cognitive impairment GINGIVAL HYPERPLASIA, CV effects, deficiencies in folic acid, vitamins D&K, pancytopenia, suicidal thoughts Med admin Stop tube feeds to administer, wait one hour. T1/2: 8-60 hrs. NARROW THERAPUTIC RANGE: 10 mcg/mL-20 mcg/mL. Decreases effects of oral contraceptives, warfarin, glucocorticoids. Cimetidine, alcohol, valporic acid, diazepam all make worse. Carbemazapine accelerates metabolism. Stimulates CYP450 system. Monitor for s/sx of toxicity: CNS depression, cardiac depression. NO cure for toxicity. Monitor serum levels rigorously. Pregnancy Category D. Administer with or immediately after meals to minimize Gi irritation. Pt education Take as directed, stress importance of adherence to regimen. Dizziness/drowsiness. Avoid ETOH or CNS depressents. Good dental hygiene. Different brands may not be equivalent. Monitor BG carefully. Use an adittional nonhormonal BC method. carbamezapine (Tegretol) Anticonvulsant, mood stabilizer Why is pt receiving this? tonic-clonic, mixed, and complex-partial seizures. Mgmt of trigeminal pain or diabetic neuropathy. Affects sodium channels to decrease synaptic channels. Dose PO anticonvulsant: 200 mg bid or 100 mg qid; increase by 200 mg/day q 7 days until therapeutic levels reached SE nystagmus, ataxia, bone marrow suppression, immune compromise, birth defects, rash, photosensitivity rxns ; LESS CNS DEPRESSION THAN DILANTIN. Med admin Increases CYP450 (oral contraceptives, warfarin), grapefruit juice metabolism: increases plasma value up to 40% Admnister w/ food to minimize GI distress Pt education Coating of Tegretol XR may not be absorbed and appear in stool. Take as directed, stress importance of adherence to regimen. Dizziness/drowsiness. Avoid ETOH or CNS depressents. Good dental hygiene. Use an adittional nonhormonal BC method.valporic acid (Depakote) Anticonvulsant, vascular HA treatment Why is pt receiving this? monotherapy and adj for simple and complex absence seizures, complex partial seizures. Adj for multiple seizures. Combination mechanism, suppresses Na, Ca, and influence on GABA Dose single agent therapy: initial dose of 10-15 mg/kg/day in 1-4 divided doses; incr by 5-10 mg/kg/day weekly until therapeutic response achieved. Polyagent therapy: initial dose of 10-15 mg/kg/day, incr by 5-10 mg/kg/day weekly until therapeutic response achieved; FOR BOTH: when reached 250 mg/day give in multiple doses CAN BE GIVEN IV and rect SE n/v, HEPATOTOXICITY, pancreatitis, teratogenic effects, rash, wt gain, hairloss Med admin Monitor hepatic lab values, therapeutic serum levels, increases risk of bleeding w/warfarin, may be increased by other anticonvulsants, ASA, cimetidine. Addative CNS depression, administer immediately after meals Pt education Take as directed ,dizziness, adverse s/sx, abd sign effects. Pt should carry ID of disease. phenobarbitol Long acting barbiturate Why is pt receiving this? Anticonvulsant in tonic clonic, partial, and febrile seizures in peds. Preoperative sedation alternative. Unlabled use prevention/treatment in hyperbilirubinemia in neonates Dose IV: 15-18 mg/kg in a single or divided dose, maximum loading dose 20 mg/kg. SE hangover, delirium, CNS depression, resp depression, laryngospasm, bronchospasm, hypotension, constipation, d/n/v, hypersensitivity Med Admin Addative CNS depression, may induce hepatic enzymes that metabolize other drugs, including hormonal contraceptives, warfarin, additive hepatotoxicity, Monitor resp status FREQUENTLY, pulse, and BP, signs/symptoms of angioedema. Children and elderly get paradoxical excitation. Pt education Take as directed, do not abruptly discontinue, notify s/sx, use additional nonhormonal bc method ethosuximide (Zarontin) Absence seizures and partial seizures Initial drowsiness wears off over time Less SE in this class Other seizure meds Lamotrigine (Lamictal) Pregabalin (Lyrica): new use in fibromyalgia Toprimate (Topamax): also used in migraine prophylaxis Status Epilepticus IV benzodiazpenes Lorazapam: 0.1 mg/kg infuse at 2mg/hr OR Diazepam: 0.2 mg/kg infuse 5 mg/min Follow up w/ long acting anti-eleptic drug (i.e. Phenytoin or Fosphenytoin) levetiracetam (Keppra) Anticonvulsants, pyrrolidines Why is pt receiving this? Partial, generalized tonic-clonic, and myoclonic seizures. Inhibits burst firing with little to no effect on normal neuronal excitability. Dose Rapid absorption: may be administered anytime. Varies based on type of seizure but can be given PO or IV. Renal impairment adjustments. SE Suicidal thoughts, aggression, agitation, anger, anxiety, apathy, depersonalization, depression, dizziness, hostility, irritability, personality disorder, weakness, coordination difficulties, SJS, TENS, renal impairment, muscle weaknessMed Admin No concerns regarding meal time or feeds . Few drug-drug interactions.Pt education Take as directed. Do not discontinue suddenly. Carry identification of disorder at all times. Mag Sulfate in eclampsia Anti-convulsant in eclampsia pts Inhibits seizures without resp. depression IV (IM use painful) Loading dose neededCalcium gluconate should be kept in proximity: treatment for OD Assess DTR frequently; monitor EKG (will prolong QRS and PQ intervals) diazepam (Valium) Benzodiazepine Why is pt receiving this? adjunct in mgmt. of anxiety disorder, anthetosis, anxiety relief prior to cardioversion, stiffman syndrome, preoperative sedation, conscious sedation, treatment of SE/uncontrolled seizures. Skeletal muscle relaxant. Mgmt. of sysmptoms of ETOH withdrawl. Acts at BZ1 in cerebellum to mediate anxiety and BZ2 located in basal ganglia/hippocampus to impact musle relaxation and cognition. Dose PO: 2-10 mg 204 times daily. IM,IV: 2-10 mg, may repeat in 3-4 hrs as needed. SE dizziness,drowsiness, hiccups (vagal stimulation may be more serious than thought), blurred vision, more moderate resp depression than others, hypotension and cardiovascular collapse (IV), rashes, local rxns Med admin additive CNS depression, cimetidine, hormonal contraceptives, metorpolol or valporic acid inhibit metabolism,Pt education Take as directed, do not increase dose unsupervised. May caused drowsiness, clumsiness, or unsteadiness. Avoid taking ETOH or other CNS depressents. Importance of follow up exams. Smoking may decrease effectiveness Do not d/c suddenly (Benzo withdrawal) lorazepam (Ativan)Benzodiazepines Why is pt receiving this? Anxiety disorder. Preoperative sedation. Unlabeled antiemetic prior to chemo. Insomnia, panic disorder, as an adjunct w/ acute mania or acute psychosis. Acts at BZ1 in cerebellum to mediate anxiety and BZ2 located in basal ganglia/hippocampus to impact musle relaxation and cognition.Dose Given PO, IM, IV (dilutent required); BEWARE OF RAPID INFUSION-> CARDIAC ARREST PO: 1-3 mg 2-3 times daily (up to 10 mg/day) SE dizziness, drowsiness, lethargy, hangover, headache, ataxia, slurred speech, myoclonic jerking in preterm infnats, paradoxical excitation, constipation, diarrhea, n/v, weight gain. Med admin additive CNS depression, cimetidine, hormonal contraceptives, metorpolol or valporic acid inhibit metabolism,Take as directed, do not increase dose unsupervised. May caused drowsiness, clumsiness, or unsteadiness. Avoid taking ETOH or other CNS depressents. Importance of follow up exams. Smoking may decrease effectiveness Do not d/c suddenly (Benzo withdrawal)flumazenil (Romazicon) AntidoteWhy is pt receiving this? Benzo antagonist. Stops Ativan depression. No effect no CNS depression from other agnets. Dose IV 0.2 mg. Additional doses given at 1 min intervals until desire results are obtained. Up to total dose of 1 mg. If resedation occurs, regimen may be repeated at 20 min intervals, not to exceed 3 mg/hr. Benzo OD: 0.2 mg w/ additional 0.3 mg given 30 sec later. Further doses of 0.5 mg may be given at 1 min intervals to a total dose of 3 mg. May be administered undiluted or diluted up to [0.1 mg/mL]. Administer each dose over 15-30 sec into free flowing IV in large vein. Do not exceed 0.2 mg/min in children or 0.5 in adults. SE Benzo withdrawl symptoms, SEIZURES (if benzo given for seizure control), irregularities in behaviorMed admin Institute seizure precautions. Assess IV site frequently Benzo like drugs Zolpidem (Ambien): helps to stay asleep Zalelplon (Sonata): helps get to sleep Eszopiclone (Lunesta): increases length of sleep ramelteon (Rozerem) Melatonin receptor agonist Why is pt receiving this? treatment of insomnia characterized by difficulty sleep onset.Dose PO: 8 mg w/in 30 min hs SE abnormal thinking, behavior changes, dizziness, fatigue, HA, worsened insomnia, sleep driving, nausa, ANGIOEDEMA Med admin concerns serum levels increased by fluvoxamine. Addative CNS depression. Do not administer w/ or immediately following high fat meal. Pt educationsleepiness, drowsiness, sleep health, avoid ETOH. Sumatriptan (-triptan)Serotonin 1B/1D Receptor agonist Binds to receptors on intracranial blood vessels and causes vasodilation. Diminishes perivascular inflammation. ABORTS ongoing attack. Oral or nasal spray Heavy arms or chest pressure, coronary vasopasm, teratogenesis, vertigo, malaise, bad taste (intranasal) Triptans and Ergot alkaloids cause vasoconstriction resulting in addative vasopsam. Serotonin syndrome w/ SSRI and SNRIs, addative toxicities w/ MAOIs ................
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