Mosby's 2014 Nursing Drug Reference (102 page)

Black Box Warning:

Children, suicidal ideation

• Adult:
PO
25 mg at bedtime, increase gradually over 4 wk to 75-250 mg/day in divided doses

• Child 10-18 yr:
PO
25 mg/day gradually increase over 2 wk; max 3 mg/kg/day or 200 mg/day, whichever is smaller

• Adult:
PO
25 mg/day, may increase to 75-100 mg/day, max 250 mg/day

• Child:
PO
25 mg/day, may increase if needed

• Adult:
PO
25-50 mg/day

• Adult:
PO
25 mg at bedtime and increase gradually over 4 wk to 75-250 mg/day in divided doses

• Child 10-18 yr:
PO
25-50 mg/day gradually increased; max 3 mg/kg/day or 200 mg/day, whichever is smaller

• 
Do not break, crush, or chew caps

• 
Increased fluids, bulk in diet for constipation, especially for geriatric patients

• 
Without regard to food, during initial dosing and titration give with meals

• 
After titration, may be given as a single dose at bedtime to reduce daytime sedation

Increase:
hypertensive crisis, seizures, hypertensive episode—MAOIs

Increase:
Serotonin syndrome-SSRIs, SNRIs serotonin syndrome, linezolid, methylene blue IV

Increase:
clomiPRAMINE levels—cimetidine, FLUoxetine, fluvoxaMINE, sertraline; do not use together

Increase:
hypertensive effect—cloNIDine, EPINEPHrine, norepinephrine

Increase:
clomiPRAMINE level—CYP1A2, CYP2D6

Increase:
CNS depression—alcohol, CNS depressants, general anesthetics

Increase:
QT prolongation—other tricyclics, phenothiazines, quinolones

Decrease:
effect of cloNIDine, levodopa, skeletal muscle relaxants, haloperidol, opiates

Decrease:
clomiPRAMINE levels—barbiturates, carBAMazepine, phenytoin

Increase:
serotonin syndrome—St. John’s wort; do not use concurrently

Increase:
CNS depression—hops, kava, valerian

Increase:
prolactin, TBG, AST, ALT, blood glucose

Decrease:
serum thyroid hormone (T
₃
, T
₄
)

• 
B/P lying, standing; pulse q4hr; if systolic B/P drops 20 mm Hg, withhold product, notify prescriber; take VS q4hr in patients with CV disease

• 
Serotonin syndrome:
hyperpyrexia, rigidity, irregular pulse, diaphoresis

• 
ECG
for flattening of T wave, QTc prolongation, bundle branch block, AV block, dysrhythmias in cardiac patients, may lead to cardiac collapse

• 
Blood studies: CBC, leukocytes, differential, cardiac enzymes if patient is receiving long-term therapy and signs of blood dyscrasias

• 
Hepatic studies: AST, ALT, bilirubin

Black Box Warning:

Mental status: mood, sensorium, affect, suicidal tendencies; increase in psychiatric symptoms: depression, panic, frequency of obsessive-compulsive behaviors; watch closely for evidence of suicidal thoughts in children, adolescents; seizure disorders

• 
Urinary retention, constipation; constipation more likely in children

• 
Withdrawal symptoms:
headache, nausea, vomiting, muscle pain, weakness; not usual unless product discontinued abruptly

• 
Alcohol consumption; if alcohol consumed, withhold dose until
AM

• 
Storage in tight container at room temp; do not freeze

• 
Assistance with ambulation during beginning therapy, since drowsiness, dizziness occurs

• 
Gum, hard candy, or frequent sips of water for dry mouth

• 
Therapeutic response: decreased anxiety, depression

• 
That the effects may take 4-6 wk to appear

• 
About risk for seizures

• 
To use caution when driving, performing other activities that require alertness because drowsiness, dizziness, blurred vision may occur

• 
To avoid alcohol, other CNS depressants

• 
Not to discontinue medication quickly
after long-term use because this may cause nausea, headache, malaise

Black Box Warning:

That suicidal thoughts/behaviors may occur in children, young adults, report immediately

• 
To wear sunscreen, protective clothing to prevent photosensitivity

• 
To notify prescriber if pregnancy is planned, suspected

• 
That men may experience a high incidence of sexual dysfunction

• 
Serotonin syndrome:
report immediately sweating, diarrhea, twitching

• 
Abrupt discontinuation:
do not stop abruptly

• Adult:
PO
up to 1.5 mg/day in 3 divided doses; may be increased 0.5-1 mg q3days until desired response, max 20 mg/day

• Geriatric:
PO
0.25 daily-bid initially, increase by 0.25/day q7-14days as needed

• Child <10 yr or <30 kg:
PO
0.01-0.03 mg/kg/day in divided doses q8hr, max 0.05 mg/kg/day; may be increased 0.25-0.5 mg q3days until desired response, max 0.1-0.2 mg/kg/day

• Adult:
PO
0.25 mg bid increase to 1 m daily after 3 days, max 4 mg/day

• Adult:
PO
0.5 mg tid or 0.5 mg in the evening and 30 min before bedtime

• Adult:
PO
0.125-0.25 mg at bedtime, titrate up q3-4days as needed

Increase:
clonazePAM effects—CYP3A4 inhibitors (azoles, cimetidine, clarithromycin, diltiazem, erythromycin, FLUoxetine), oral contraceptives

Increase:
CNS depression—alcohol, barbiturates, opiates, antidepressants, other anticonvulsants, general anesthetics, hypnotics, sedatives

Decrease:
clonazePAM effect—CYP3A4 inducers (carBAMazepine, PHENobarbital, phenytoin)

Increase:
CNS depression—kava, chamomile, valerian

Increase:
clonazePAM effect—ginkgo, melatonin

Decrease:
clonazePAM effect—ginseng, St. John’s wort

Increase:
AST, alk phos, bilirubin

Decrease:
Platelets, WBC

• 
Seizures:
duration, type, intensity, with/without aura

• 
Blood studies: RBC, Hct, Hgb, reticulocyte counts every wk for 4 wk then monthly

• 
Hepatic studies: ALT, AST, bilirubin, creatinine

• 
Abrupt discontinuation:
Do not discontinue abruptly, seizures may increase

• 
Signs of physical withdrawal if medication suddenly discontinued

 
Mental status:
mood, sensorium, affect, oversedation, behavioral changes,
suicidal thoughts/behaviors;
if mental status changes, notify prescriber

• 
Eye problems: need for ophthalmic exam before, during, after treatment (slit lamp, funduscopy, tonometry)

• 
Allergic reaction: red, raised rash; product should be discontinued

 
Blood dyscrasias:
fever, sore throat, bruising, rash, jaundice

• 
Toxicity:
bone marrow depression, nausea, vomiting, ataxia, diplopia, CV collapse; drug levels during initial treatment (therapeutic 20-80 ng/ml)

• 
Assistance with ambulation during early part of treatment; dizziness occurs, especially among geriatric patients

• 
Therapeutic response: decreased seizure activity

• 
To carry emergency ID bracelet stating name, products taken, condition; prescriber’s name, phone number

• 
To avoid driving, other activities that require alertness

• 
To avoid alcohol, other CNS depressants; increased sedation may occur

• 
Not to discontinue medication quickly after long-term use; to taper off over several wk

• 
To notify prescriber of yellowing of skin/eyes, clay-colored stools, bleeding, fever, extreme fatigue, sore throat, suicidal thoughts/behaviors

• 
To notify prescriber immediately if suicidal thoughts, behaviors occur