1. zolpidem
    (Ambien, Edluar)
    Class: Sedative/Hypnotics
    Preg. Cat C
    • Indications: short term management for insomnia
    • Administration: for rapid sleep onset, drug should not be taken with or immediately after meals
    • Adv. Reaction:
    • cns- headache amnesia daytime drowsiness depression dizziness hangover lethargy sleep disorder
    • cv- palpitations
    • eent: pharyngitis, sinusitis
    • gi- abdominal pain, constipation, diarrhea, dyspepsia, n/v
    • other - anaphylaxis angioedema back or chest pain flu like syndrome
    • Interactions:
    • d-d: may cause cns depression
    • Rifampin- may decrease effects of zolpidem avoid using together if possible consider another hypnotic
    • d-lifestyle: avoid alcohol use
    • Overdose S/S
    • impaired conciousness, somnolence, coma, cv or resp compromise death
    • Nx Consideration:
    • warn pt may cause allergic reactions, facial swelling & complex sleep related behaviors such as driving eating & making phone calls while asleep. advise pt to report the adverse effects
    • avoid alcohol use while taking drugs
    • instruct pt to take the drug immediately before going to bed, onset action is rapid
    • take drugs wit or immediately after meals
  2. lorazepam
    Class: Anticonvulsants/Antianxiety. Antianxiolytics, Benzodiazepines
    Preg Cat: D
    • Indications:
    • anxiety, insomnia from anxietypreoperative sedation, status epilepticus
    • Administration:
    • monitor respirations every 5-15 mins & before each i.v. dose
    • avoid use in neonates
    • keep emergency resuscitation equip & oxygent available
    • Incompatibilities:
    • aldesleukin astreonam, buprenorphine, caffeine nitrate
    • Action: may potentiate effects of GABA, depress the cns & supress the spread of zeisure activity
    • Adverse reaction:
    • cns - drowsiness sedation amnesia, insomnia, agitation dizziness, weakness
    • cv - hypotension
    • eent - visual disturbances, nasal congestions
    • gi - abdominal discompfort , nausea change in appetite
    • Interactions:
    • d-d - cns depressants may increase cns depression
    • digoxin - may increase digoxin level & risk for toxicity, monitor digoxin level closely
    • d-herb - kava may increase sedation
    • d-lifestyle - alcohol use
    • smoking - may decrease effectiveness of drugs. monitor pt closely
    • Lab Test - monitor LFT VALUES
    • Contraindications and cautions
    • contraindicated in pt hypersensitivity to drug benzodiazepines
    • pt with acute angle-closure glaucoma
    • pregnant women in first trimester
    • pulmonary renal or hepatic impairment or hx of substance abuse
    • Overdose S/S
    • drowsiness confusion lethargy ataxia, hypotonia, hypotension , hypnotic state , stage 1-3 coma, death
    • Nx Consideration
    • monitor hepatic renal & hematopoietic function periodically in pt rcvng repeated and prolonged therapy
    • alert: drug may lead to abuse & addiction don't stop abruptly withdrawal symptoms may occur
    • Pt Teaching:
    • Avoid use of alcohol, women to avoid becoming pregnant while taking drug, smoking will derease effectiveness, avoid hazardous activities that requires alertness until effects of drugs is known.
  3. quetiapine
    Class: Antipsychotics, 2nd Generation; Dibenzothiazepine Dervative
    Preg. Cat: C
    • Indications - schizophrenia, monotherapy & adjucnt therapy with lithium or divalproex for the short-term tx of acute manic episode associated with bipolar 1 disorder; adjucnt maintenance therapy with lithium or divalproex. depression associated with bipolar disorder
    • Administration:
    • do not crush xr
    • give drug without regard for food. give xr without food or light meal 300 calories
    • Action:
    • Blocks dopamine & serotonin5-ht receptors. Its action may be mediated through this antagonism
    • Adverse reaction:
    • cns - dizziness, headache, somnolence, neuroleptic malignant syndrome seizures, hypertonia, dysarthria, asthenia
    • cv - orthostatic hypotension, tachycardia, palpitations, peripheral edema
    • eent - ear pain, pharyngitis, rhinitis
    • gi - dry mouth dyspepsia, abd pain, constipation, anorexia
    • hematologic - leukopenia
    • metabolic - wt gain, hyperglycemia
    • musculoskeletal - back pain
    • respiratory - increased cough dyspnea
    • skin - rash, diaphoresis
    • Interactions
    • d-d: antihypertensives , monitor b/p; carbamazepines, glucocorticoids, phenobarbital, phenytoin, rifampin
    • cns depressants may increase cns effects
    • dopamine agonists levodopa - may antagonize effects monitor pt
    • erythromycin fluconazole, itraconazole, ketoconazole
    • avoid alcohol use
    • Lab Tests Results -
    • may increase liver enzyme cholesterol triglyceride & glucose levels, may decrease T4 & thyroid stimulating hormone levels
    • may decrease wbc
    • Contraindications & Cautions
    • Pt at risk for aspiration PNA
    • BBW: not approved for use in children
    • Overdose S/S
    • drowsiness hypotension, sedation, tachycardia, hypokalemia first-degree heart block
    • Nx Considerations
    • dispense lowest qty to avoid drug overdose
    • watch for evidence of neuroleptic malignant syndrome
    • monitor pt for tardive dyskinesia w/c may occur after prolonged use
    • monitor wt gain
    • hyperglycemia may occur, monitor pt with diabetes
    • drug may cause cataract formation obtain baseline opthalmologic examination & reassess every 6 mos.
    • Pt Teaching
    • Warn pt about risk for dizziness when standing up quickly . the risk is greatest during the 3-5 day period of first dosage adjustment when resuming tx or adjusting
    • Tell pt to avoid becoming overheated or dehydrated
    • Avoid alcohol maybe taken w/ or w/o food.
    • not to breasfeed while taking this drug
    • BBW: may increase the risk of suicidal thinking & behavior in children adolescents
  4. ziprasidone
    Class: Antipsychotics, 2nd generation, Benzisoxazole derivative
    Preg Cat: C
    • Indications:
    • Symptomatic Tx of Schizophrenia, Rapid control of acute agitation in Schizo pts, Acute bipolar mania including manic & mixed episodes w/ or w/o psychotic features
    • Administrations:
    • always give drug with food for optimal effects
    • dont mix inj with other drugs
    • Action:
    • may inhibit dopamine & serotonin 2 receptors causing reduction in schizo symptoms
    • Adverse Reactions:
    • cns - dizziness, suicide attempts, h/a, somnolence, akathisia
    • cv - bradycardia, qt interval prolongation, orthostatic hypotension
    • eent - abnormal vision, rhinitis
    • gi - n/v, constipation, rectal hemmorage, anorexia dyspepsia
    • gu - dysmenorrhea, priapism
    • metabolic - hyperglycemia
    • muscoloskeletal - back pain, myalgia
    • resp - cough
    • skin - rash
    • Interactions:
    • d-d: antiarrhytmics (amiodaronedofetilide, procainamide, quinidine, sotalol) - may incease arrhythmias
    • antihypertensives - may increase hypotensive effects. monitor b/p
    • carbamazepine - may decrease ziprasidone levels
    • drugs that decrease potassium or magnesium such as diuretics. monitor K & Mg level
    • Contraindications & Cautions
    • contraindicated in pt hypersensitive to drug and in those with recent MI or uncompensated heart failure
    • Overdose S/S:
    • sedation slurred speech transitory htn, somnolenceanxiety, extrapyramidal symptoms, tremor
    • Pt Teaching
    • Advise pt that symptoms may not improve for 4-6 weeks
    • to report any recent episodes of diarrhea, abnormal movement, sudden fever, muscle rigidity or change in mental status
  5. benztropine
    Class: Antiparkinsons Agents, Anticholinergics
    Preg Cat: C
    • Indications:
    • drug induced extrapyramidal disorders (except tradive dyskinesia)
    • acute dystonic reaction
    • parkinsonism
    • Administration
    • drug may be given before & after meals depending on pt reaction
    • Adv Reaction
    • cns - ion, memory impairment, hallucinatons toxic psychosis
    • cv - tachycardia
    • eent - dilated pupils blurred vision
    • gi - dry mouth constipation, nausea
    • gu - urine retention, dysuria
    • skin - decreased sweating
    • Interactions
    • d-d: amantadine, phenothiazines tricyclic antidepressants cholinergics may antagonize the therapeutic effects of these drugs
    • Contraindications and Cautions
    • use cautiously in pts with prostatic hyperplasia arrhytmias or seizure disorders
    • Nx Considerations
    • monitor v/s carefully watch closely for adverse reactions
    • watch for intermittent constipation
    • Pt Teaching
    • If pt takes a single daily dose, take at bedtime
    • relieve dry mouth with cool drinks, ice chips sugarless gum or hard candy
    • limit hot weather activities because drug induced lack of sweating may cause overheating
  6. topiramate
    Class: Anticonvulsants
    Preg Cat: C/D
    • Indications
    • Initial monotherapy for partial-onset or primary generalized tonic-clonic seizures
    • Adjunct Tx for partial onset
    • Lennox-Gastaut syndrome
    • to prevent migraine headache
    • Adjust a dose if creatinine clearance is less than 70 ml/minute
    • Administration:
    • give drug without regard for food
    • crushed or broken tablets have a bitter taste
    • capsules may be opened & contents sprinkled on a teaspoon of soft food. Pt should swallow immediately without chewing
    • Action:
    • unknown may block a sodium channel potentiate the activity of Gaba, & inhibits kainate's ability to activate an amino acid receptor
    • Adverse reactions
    • cns: ataxia confusion difficulty with memory dizziness fatigue nervousness paresthesia psychomotor slowing somnolence speech disorders, tremors, generalized tonic-clonic seizures, suicide attempts abnormal coordination, aggresive reaction, agitation, apathy, asthenia,
    • cv- chest pain edema palpitations vasodilation
    • eent - abnormal vision
    • gi - anorexia
    • gu - amenorrhea, dysuria dysmenorrhea, hematuria
    • hematologic - leukopenia, anemia
    • metabolic - decreased weight increased weight
    • muscoloskeletal - athralgia, back or leg pain
    • resp - upper resp tract infection, bronchitis, coughing, dyspnea
    • skin - acne alopecia increased sweating pruritus
    • other - body odor breast pain decreased libido
    • Interactions
    • d-d: carbamazepine may decrease topiramate level. monitor pt carbonic anhydrase inhibitors, may cause renal calculus formation
    • hormonal contraceptives - may decrease efficacy. report changes in menstrual pattern advise to use another contraceptive method
    • Phenytoin/Valproic - may decrease topiramate & increase phenytoin/valproic level monitors levels & pt
    • d- lifestyle - alcohol use may cause cns depression & other psychiatric events
    • Lab Results
    • may increase liver enzyme levels, may decrease bicarbonate & hgb & hct levels
    • may decrease wbc count
    • Contraindications & cautions
    • use caution to drugs predispose pts to heat related disorder including carbonic anhydrase inhibitors & anticholinergics
    • Nx Considerations
    • taper to minimize risk of increased seizure activity
    • may cause hyperchloremic non-anion gap metabolic acidosis from renal bicarbonate loss
    • measure baseline and periodic bicarbonate levels if metabolic acidosis develops and gradually persists consider reducing the dose
    • Pt Teaching
    • Tell pt to drink plenty of fluids durinh therapy to minimize risk of forming kidney stones
  7. metformin
    Class: Antidiabetics, Biguanides
    Preg Cat. B
    see page 1040-1043
    • Administration
    • give drugs with meals maximum doses may be better tolerated if total dose is divided
    • Action:
    • decrease hepatic glucose production & intestinal absorption of glucose & improves insulin sensitivity
    • Adv Reaction:
    • cns - asthenia headache
    • gi - d/n/v abdominal bloating flatulence, anorecia taste per version
    • hematologic - megaloblastic anemia
    • metabolic - lactic acidosis, hypoglycemia
    • other - accidental injury, infection
    • Interactions
    • d-d: betablockers hypoglycemia, calcium channel blockers
  8. valproic acid
    (Depakote / Depakene)
    Class: Anticonvulsants, carboxylic acid derivative
    Preg. Cat. D
    • Indications:
    • Simple & complex absence seizures mixed seizures including absence seizures, to prevent migraine headache
    • Administration:
    • Give drug with food or milk to reduce adverse GI effects
    • Adverse reactions:
    • cns- asthenia , dzness, headache, insomnia, nervousness, somnolence, tremor
    • cv- chest pain, edema, htn, tachycardia, hypotension
    • eent - blurred vision, diplopia, nystagmus, pharyngitis, rhinitis, tniitus
    • gi- abd pain, anorexia, diarrhea, dyspepsia, N/V, pancreatitis, constipation
    • musculoskeletal - back & neck pain
    • respiratory - bronchitis, dyspnea
    • Interactions:
    • D-D: aspirin, chlorpromazine, cimetidine use cautiously and monitor drug level
    • D- Lifestyle: no alcohol use
    • Effects on Lab:
    • may increase ammonia, alt ast & bilirubin levels. may decrease platelet rbc & wbc counts
    • Contraindaications & Cautions:
    • hepatic disease or hepatic dysfunction & in pts with urea cyccle disorder
    • bbw: avoid
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