THORAZINE MEDICATION SHEET



THORAZINE MEDICATION SHEET

Drug classes

Phenothiazine

Dopaminergic blocking agent

Antipsychotic

Antiemetic

Antianxiety agent

Therapeutic actions

Mechanism not fully understood; antipsychotic drugs block postsynaptic dopamine receptors in the brain; depress those parts of the brain involved with wakefulness and emesis; anticholinergic, antihistaminic (H 1), and alpha-adrenergic blocking.

Indications

• Management of manifestations of psychotic disorders; control of manic phase of manic-depressive illness

• Relief of preoperative restlessness and apprehension

• Adjunct in treatment of tetanus

• Acute intermittent porphyria therapy

• Severe behavioral problems in children: therapy for combativeness, hyperactivity

• Control of nausea and vomiting and intractable hiccups

• Possibly effective in the treatment of nonpsychotic anxiety (not drug of choice)

Contraindications and cautions

• Allergy to chlorpromazine; comatose or severely depressed states; bone marrow depression; circulatory collapse; subcortical brain damage, Parkinson's disease; liver damage; cerebral or coronary arteriosclerosis; severe hypotension or hypertension; respiratory disorders; glaucoma; epilepsy or history of epilepsy; peptic ulcer or history of peptic ulcer; decreased renal function; prostate hypertrophy; breast cancer; thyrotoxicosis; myelography within 24 hr or scheduled within 48 hr; lactation; exposure to heat, phosphorous insecticides; children with chickenpox, CNS infections (makes children more susceptible to dystonias, confounding the diagnosis of Reye's syndrome or other encephalopathy; antiemetic effects of drug may mask symptoms of Reye's syndrome, encephalopathies)

Available forms

Tablets—10, 25, 50, 100, 200 mg; SR capsules—30, 75, 150 mg; syrup—10 mg/5 mL; concentrate—30, 100 mg/mL; suppositories—25, 100 mg; injection—25 mg/mL

Dosages

Full clinical antipsychotic effects may require 6 wk to 6 mo of therapy.

Adults

•  Excessive anxiety, agitation in psychiatric patients: 25 mg IM; may repeat in 1 hr. Increase dosage gradually in inpatients, up to 400 mg q 4–6 hr. Switch to oral dosage as soon as possible: 25–50 mg PO tid for outpatients; up to 2,000 mg/day PO for inpatients. Initial oral dosage: 10 mg tid–qid PO or 25 mg PO bid–tid; increase daily dosage by 20–50 mg semiweekly until optimum dosage is reached (maximum response may require months); doses of 200–800 mg/day PO are not uncommon in discharged mental patients.

•  Surgery: Preoperatively, 25–50 mg PO 2–3 hr before surgery or 12.5–25 mg IM 1–2 hr before surgery; intraoperatively, 12.5 mg IM, repeated in 30 min or 2 mg IV repeated q 2 min up to 25 mg total to control vomiting (if no hypotension occurs); postoperatively, 10–25 mg PO q 4–6 hr or 12.5–25 mg IM repeated in 1 hr (if no hypotension occurs).

•  Acute intermittent porphyria: 25–50 mg PO or 25 mg IM tid–qid.

•  Tetanus: 25–50 mg IM tid–qid, usually with barbiturates, or 25–50 mg IV diluted and infused at rate of 1 mg/min.

•  Antiemetic: 10–25 mg PO q 4–6 hr; 50–100 mg rectally q 6–8 hr; 25 mg IM. If no hypotension, give 25–50 mg q 3–4 hr. Switch to oral dose when vomiting ends.

•  Intractable hiccups: 25–50 mg PO tid–qid. If symptoms persist for 2–3 days, give 25–50 mg IM; if inadequate response, give 25–50 mg IV in 500–1,000 mL of saline with BP monitoring.

Pediatric patients

Generally not used in children < 6 mo.

•  Psychiatric outpatients: 0.5 mg/kg PO q 4–6 hr; 1 mg/kg rectally q 6–8 hr; 0.5 mg/kg IM q 6–8 hr, not to exceed 40 mg/day (up to 5 yr) or 75 mg/day (5–12 yr).

•  Surgery: Preoperatively, 0.5 mg/kg PO 2–3 hr before surgery or 0.5 mg/kg IM 1–2 hr before surgery; intraoperatively, 0.25 mg/kg IM or 1 mg (diluted) IV, repeated at 2-min intervals up to total IM dose; postoperatively, 0.5 mg/kg PO q 4–6 hr or 0.5 mg/kg IM, repeated in 1 hr if no hypotension.

•  Psychiatric inpatients: 50–100 mg/day PO; maximum of 40 mg/day IM for children up to 5 yr; maximum of 75 mg/day IM for children 5–12 yr.

•  Tetanus: 0.5 mg/kg IM q 6–8 hr or 0.5 mg/min IV, not to exceed 40 mg/day for children up to 23 kg; 75 mg/day for children 23–45 kg.

•  Antiemetic: 0.55 mg/kg PO q 4–6 hr; 1.1 mg/kg rectally q 6–8 hr or 0.55 mg/kg IM q 6–8 hr. Maximum IM dosage 40 mg/day for children up to 5 yr or 75 mg/day for children 5–12 yr.

Geriatric patients

Start dosage at one-fourth to one-third that given in younger adults and increase more gradually.

Pharmacokinetics

|Route |Onset |Peak |Duration |

|[pic] |

|Oral |30–60 min |2–4 hr |4–6 hr |

|IM |10–15 min |15–20 min |4–6 hr |

|[pic] |

Metabolism: Hepatic, T ½: 2 hr, then 30 hr

Distribution: Crosses placenta; enters breast milk

Excretion: Urine

|IV facts |

|Preparation: Dilute drug for IV injection to a concentration of 1 mg/mL or less. |

|Infusion: Reserve IV injections for hiccups, tetanus, or use during surgery. Administer at a rate of 1 |

|mg/2 min. |

|Incompatibilities: Precipitate or discoloration may occur when mixed with morphine, meperidine, cresols. |

Adverse effects

Adverse effects in Italics are most common; those in Bold are life-threatening.

•  CNS: Drowsiness, insomnia, vertigo, headache, weakness, tremors, ataxia, slurring, cerebral edema, seizures, exacerbation of psychotic symptoms, extrapyramidal syndromes, neuroleptic malignant syndrome

•  CV: Hypotension, orthostatic hypotension, hypertension, tachycardia, bradycardia, cardiac arrest, CHF, cardiomegaly, refractory arrhythmias, pulmonary edema

•  EENT: Nasal congestion, glaucoma, photophobia, blurred vision, miosis, mydriasis, deposits in the cornea and lens, pigmentary retinopathy

•  Endocrine: Lactation, breast engorgement in females, galactorrhea, SIADH, amenorrhea, menstrual irregularities, gynecomastia, changes in libido, hyperglycemia, inhibition of ovulation, infertility, pseudopregnancy, reduced urinary levels of gonadotropins, estrogens, and progestins

•  GI: Dry mouth, salivation, nausea, vomiting, anorexia, constipation, paralytic ileus, incontinence

•  GU: Urinary retention, polyuria, incontinence, priapism, ejaculation inhibition, male impotence, urine discolored pink to red-brown

•  Hematologic: Eosinophilia, leukopenia, leukocytosis, anemia, aplastic anemia, hemolytic anemia, thrombocytopenic or nonthrombocytopenic purpura, pancytopenia, elevated serum cholesterol

•  Hypersensitivity: Jaundice, urticaria, angioneurotic edema, laryngeal edema, photosensitivity, eczema, asthma, anaphylactoid reactions, exfoliative dermatitis, contact dermatitis

•  Respiratory: Bronchospasm, laryngospasm, dyspnea, suppression of cough reflex and potential aspiration

•  Other: Fever, heat stroke, pallor, flushed facies, sweating, photosensitivity

Interactions

[pic]Drug-drug

• Additive anticholinergic effects and possibly decreased antipsychotic efficacy with anticholinergic drugs

• Additive CNS depression, hypotension if given preoperatively with barbiturate anesthetics, alcohol, meperidine

• Additive effects of both drugs if taken concurrently with beta-blockers

• Increased risk of tachycardia, hypotension with epinephrine, norepinephrine

• Decreased hypotension effect with guanethidine

[pic]Drug-lab test

• False-positive pregnancy tests (less likely if serum test is used)

• Increase in protein-bound iodine, not attributable to an increase in thyroxine

[pic]Nursing considerations

|CLINICAL ALERT! |

|Name confusion has occurred between chlorpromazine and chlorpropamide; use caution. |

Assessment

•  History: Allergy to chlorpromazine; comatose or severely depressed states; bone marrow depression; circulatory collapse; subcortical brain damage, Parkinson's disease; liver damage; cerebral or coronary arteriosclerosis; severe hypotension or hypertension; respiratory disorders; glaucoma; epilepsy or history of epilepsy; peptic ulcer or history of peptic ulcer; decreased renal function; prostate hypertrophy; breast cancer; thyrotoxicosis; myelography within 24 hr or scheduled within 48 hr; lactation; exposure to heat, phosphorous insecticides; children with chickenpox; CNS infections

•  Physical: T, weight; skin color, turgor; reflexes, orientation, intraocular pressure, ophthalmologic exam; P, BP, orthostatic BP, ECG; R, adventitious sounds; bowel sounds, normal output, liver evaluation; prostate palpation, normal urine output; CBC; urinalysis; thyroid, liver, and kidney function tests; EEG

Interventions

• Do not change brand names of oral dosage forms or rectal suppositories; bioavailability differs.

• Dilute the oral concentrate just before administration in 60 mL or more of tomato or fruit juice, milk, simple syrup, orange syrup, carbonated beverage, coffee, tea, or water, or in semisolid foods (soup, puddings).

• Protect oral concentrate from light.

• Do not allow the patient to crush or chew the sustained-release capsules.

• Do not give by SC injection; give slowly by deep IM injection into upper outer quadrant of buttock.

• Keep recumbent for 30 min after injection to avoid orthostatic hypotension.

• Avoid skin contact with oral concentrates and parenteral drug solutions due to possible contact dermatitis.

• Patient or the patient's guardian should be advised about the possibility of tardive dyskinesias.

• Be alert to potential for aspiration because of suppressed cough reflex.

• Monitor renal function tests, discontinue if serum creatinine, BUN become abnormal.

• Monitor CBC, discontinue if WBC count is depressed.

• Consult with physician about dosage reduction or use of anticholinergic antiparkinsonian drugs (controversial) if extrapyramidal effects occur.

• Withdraw drug gradually after high-dose therapy; possible gastritis, nausea, dizziness, headache, tachycardia, insomnia after abrupt withdrawal.

• Monitor elderly patients for dehydration; sedation and decreased sensation of thirst; CNS effects can lead to dehydration, hemoconcentration, and reduced pulmonary ventilation; promptly institute remedial measures.

• Avoid epinephrine as vasopressor if drug-induced hypotension occurs.

Teaching points

• Take drug exactly as prescribed. Avoid OTC drugs and alcohol unless you have consulted your health care provider.

• Do not cut, crush, or chew sustained-release capsules.

• Do not change brand names without consulting your health care provider.

• Learn how to dilute oral drug concentrate; how to use rectal suppository.

• Do not get oral concentrate on your skin or clothes; contact dermatitis can occur.

• These side effects may occur: drowsiness (avoid driving or operating dangerous machinery; avoid alcohol, increases drowsiness); sensitivity to the sun (avoid prolonged sun exposure, wear protective garments or use a sunscreen); pink or reddish-brown urine (expected effect); faintness, dizziness (change position slowly; use caution climbing stairs; usually transient).

• Use caution in hot weather; risk of heat stroke; keep up fluid intake, and do not overexercise in a hot climate.

• Report sore throat, fever, unusual bleeding or bruising, rash, weakness, tremors, impaired vision, dark urine, pale stools, yellowing of the skin and eyes.

Copyright © 2004 Lippincott Williams & Wilkins

Amy M. Karch

2004 Lippincott's Nursing Drug Guide

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