Chronic Neuro Rx

Including CNS stimulants, CNS sedatives,

ANS medications, antidepressants,
antipsychotics & anti-epileptics
Class: Benzodiazepines Siblings: mizadolam (Versed) for anesthesia
Class: lorazepam (Ativan) Calmers: aprazolam (Xanax), oxazapam (Serax)
aka: Ativan chordiazpoxide (Librium), Librax for IBS
Typical dose: 1—3mg Seizure: clonazepam (Klonopin), diazepam (Valium)
Effect: GABA sustainer (calmers) Sleepers: temazepam (Restoril), triazolam (Halcion)
Ambien dose should not exceed Adopted sleepers: (benzo—like, less addictive)
max 5mg qHS women, 10mg men zolpidem (Ambien) / eszopiclone (Lunesta)

Nurse precautions Related self care instructions

 Monitor vitals, O2 sats  Reliance tolerance > dependence
 Pneumonia risk (shallow resps)  High street value (Hide it)
 Don’t mix with other downers  Promote non-Rx coping: coloring, music, white noise,
 Try complementary therapies aroma therapy, imagery
 Antidote: flumazenil IV  Avoid alcohol and smoking
 C4: Count at shift change  May need surveillance (sleep walking,
 Waste with witness even sleep driving can occur)
 Crush before disposing wastes  Don’t stop abruptly due to seizure risk
 Rax refill to original pharmacy (taper dose to avoid pushback)
Class: Barbituates Antiepileptic Siblings
Name: phenobarbital  primidone (Mysoline) for sleep
aka: Luminal  secobarbital (Seconal) for sleep
Rx range: 10mg tid—60 mg bid  meprobamate (Equanil, Miltown) for sleep
Effect: GABA sustainer (antiepileptic)  chloral hydrate (Noctec) for sleep

Nurse precautions Related self care instructions

 Monitor vitals, O2 sats  Reliance tolerance > dependence
 Pneumonia risk (shallow resps)  Take at bedtime
 Don’t mix with other downers  Don’t take with alcohol or opiates
 Long half life, watch levels Rx is HEPATOTOXIC
 Antidote: only activated charcoal  Avoid driving or smoking under influence
 C4: Count at shift change  Don’t stop abruptly due to seizure risk
C2: Sleeper siblings are C2 (taper dose to avoid pushback)
 Waste with witness  Highly alkaline, IV extravasation or SQ
 Crush before disposing wastes administration can cause tissue injury
 Refill C4 only fax original pharmacy  Class D
Name: Hydroxyzine Siblings: other H1 antihistamines
aka: Vistaril, Atarax class B?? Promethazine (Phenergan) class C
Class: H1 Antihistamines 25mg po, IM, IV given for nausea
used to stop itching Diphenhydramine (Benadryl) class B
used to facilitate sleep 50 mg po IM, IV stop allergic reactions
Safe dose: 50mg po, IM, NOT IV also given to facilitate sleep

Related self care instructions

 Sedative effect. Don’t drive after taking
 Avoid alcohol. Taking with opiates will enhance and prolong sedation
 Anticholinergic side effects (use with caution in glaucoma or BPH)
 Rapid pulse risk in overuse of Unisom for sleep (diphenhydramine)
 All are used as adjuvant medications
Watch for over-sedation if used in combination drugs
 Promethazine is related to neuroleptics. Watch for dykinesias
Generic Name: Tegretol Class: Antiepileptic
Trade name(s): carbamazepine E-Source: rxlist.com/robholland.com

What it does: Blocks Na+, sustains GABA Common Side effects

• Anticonvulsant • Edema
• Adjuvant to stabilizes mood • Nausea/vomiting
• Adjuvant for nerve pain Risks
Contraindications • Steven’s Johnson Syndrome: Flu Sx 
• Hepatic or renal disease red/purple rash blisters possible death
• HTN or Coronary artery disease • Serious blood problems (low WBCs)
• Pregnancy category D
Precautions Safe Dose Range
• Caution with patients who drink • 200-400mg.
Teaching DO NOT EXCEED 1200MG daily
• Abrupt withdrawal  seizures Needed timing
• Avoid hazardous tasks until you know • BID tabs; QID suspension
effects Safe Routes
• Oral- tabs or suspension
Generic Name: Valproic acid  Bipolar mood stabilizer
Trade name(s): Depakote  Antiepileptic
Class: GABA sustainers / Valproates  Nerve pain tranquilizer
 Migraine remedy

Risks Dose & Route

 Cognitive harms to unborn (Class D)  250-500mg bid
 Hepatotoxic / Pancreatitis  Oral tablets are large and difficult to swallow
 Thrombocytopenia (never chew)
 Passed on in breastmilk  Oral capsules (open & mix in pudding
 Changes in appetite or applesauce, and give quickly)
 Weakness, tremors, unsteady gait
 Bleeding, bruising, skin reactions Therapeutic Dose Range
 Confusion, sedation  Serum goal: 50-100mcg/mL
 Suicidal thoughts
 Behavior changes
Generic Name: lithium Class: Mood stabilizer
Trade name(s): Lithobid E-Source: drugs.com

What it does Risks

• Controls mania, hyperactivity, rushed • GI erosion
speech, poor judgement, insomnia • Anger / aggression
• Affects flow of Na through nerve & • Toxicity sx: vomiting, sweating, tremors,
muscle cells– Mood stabilizer drunken behavior, seizures, arrhythmias
Precautions Safe Dose Range
• Cardiac monitoring needed if toxic • 900-1200mg/day orally WITH FOOD
• No Diuretics, No KCl, No NSAIDs in divided doses
• See Drugs.com interactions checker • IR version q6h, ER version q12h
Teaching • Never crush or chew!
• Avoid operating heavy machinery
• Drink water but not in excess
• No alcohol (hyponatremia risk)
• Ice chips or hard candy for thirst
• Report skipped beats or falls
Class: Neuroleptics Uses: Subdue wild imagination
1ST GENERATION Risks & implications
 haloperidol (Haldol)
 Fall risk due to drowsiness, dizziness
 chlorpromazine (Thorazine) blurred vision, low BP
 Dyskinesias (EPS) especially is 1st generation
2 GENERATION
ND

 quetiapine (Seroquel)  Anticholinergic effects (UTIs, constipation

 clozapine (Clozaril) worse if taking Cogentin for dyskinesia
 Neuroleptic syndrome
3RD GENERATION ~ ATYPICALS   WBC risk
 olanzapine (Zyprexa) especially with National Institute of Mental
Health. (2016). Mental Health
 risperdone (Risperdal) Clozaril use
Medications. Retrieved from
 aripiprozole (Abilify)- NDRI  Dyslipidemia www.nimh.nih.gov/health/topics
& weight gain /mental-health-medications/inde
x.shtml
Class: SSRI Uses: Anxiety & OCD
Siblings
Depression
Risks & implications
 paroxetine (Paxil)
 Headache & High BP
 citalopram (Celexa)
 Nausea
 escitalopram (Lexapro)  Lethargy & Fatigue
 fluoxetine (Prozac)  Suicidal thoughts
 sertraline (Zoloft)  Insomnia
 Sexual dysfunction
Herbal relatives  Weight Gain
 St. John’s Wort  Do Not take with MAOIs
 Do Not abruptly stop taking Rx
Related antidepressants Uses: Anxiety & Depression
HETEROCYCLICS (SLEEPERS)  use cautiously in cardiovascular disease
 trazodone (Desyrel) hypertension and MI may follow use
 mirtapazine (Remeron)  caution in hx of drug abuse, mania & seizures
can trigger recurrent episodes
SNRIS FOR ANXIETY DEPRESSION can cause hepatic or renal impairment
 venlafaxine (Effexor)
 can cause dizziness / drowsiness
 duloxetine (Cymbalta)
 can increase glucose
 desvenlafaxine (Pristiq)
 vortioxetine (Brintellix)  can worsen glaucoma
Atypical  can cause dizziness, muscle tension & mood
swings & nausea in 1st week of use or when
NDRI FOR ADDICTION withdrawing from the medication
 bupropion  suicidal ideations can become worse
(Wellbutrin, Zyban)
Class: Tricyclics Depression & Anxiety
Siblings Risks
☑ amitriptyline (Endep) ☒ Blurred Vision (low lights)
☑ imipramine (Tofranil) ☒ Urinary Retention (toilet q2h)
☑ nortriptyline (Aventyl) ☒ GI shutdown (remedies)
☑ protriptyline (Vivactil) ☒ Dry mouth (ice chips)
☑ amoxapine (Asendin) ☒ Tachycardia (watch lung sounds)
(behavioral Rx)
☒ Orthostatic BP (fall precautions)
☑ clomipramine (Anafranil)
☒ Weight Gain/Loss
used to treat OCD
☒ Can Worsen Seizures.
☒ Suicidal Thoughts (assess mood)
☒ Sedation (give @ HS)
Class: MAOIs Uses: Depression / Parkinsons
Siblings Risks & implications
 Marplan (isocarboxacid)  Contraindicated in elders, poor liver
 Parnate (tranylcypromine) function, seizures or headaches
 Nardil (phenelzine)  Risk of suicidal behavior
 Hypertensive crisis when
eating high tyramine foods
MAOI-B for parkinsons avoid comfort foods)
 Eldepryl (selegeline)  Orthostatic hypotension-
(rise slowly)
Source: Roach, S. S., Ford, S. M., (2010)  Don’t take with other anti-depressants,
Clinical Pharmacology, Antidepressant alcohol, decongestants
Drugs, 9th Edition, pg. 195, Philadelphia,
PA
 Class: Dopaminergics Uses: Parkinsonism
 Carbadopa / Levodopa Risks & implications
(Sinemet)
 Increased risk for MI, and stroke
 Carbidopa only (Lodosyn)
 Dyskinesias may not resolve if
 Entacapone (Comtan) dose is too low
 Sinemet + Comtan=Stalevo  May decrease platelet and WBC
 Mirapex hemoglobin and hematocrit
 May cause hallucinations if dose is
Drugs.com. (2017). Carbidopa, entacapone, and too high
levodopa medical facts from Drugs.com. Retrieved
on April 18, 2017 from
 May cause dizziness
https://www.drugs.com/mtm/carbidopa-  2 week washout between
entacapone-and-levodopa.html selegeline & Sinemet
Generic Name: rivastigmine patch Class: ACh—ase inhibitor (cholinergic)
Trade name(s): Exelon E-Source: Davis drug guide
What it does  Risk for cholinergic side effects
 Enhances cholinergic function by  Bradycardia
reversible inhibition of cholinesterase  Nausea/vomiting
 Treats dementia  Bowel or bladder urgency

Precautions Safe Dose Range

 History of asthma or COPD  4.6mg/24hr transdermal patch
(wheezes can become worse)  Oral 3-6mg q12h titrate from 1.5mg
 Watch for urinary urgency causing fall risk if higher dose > higher patch dose
used in Parkinsonian dementia (used in severe alzheimers)
Teaching Needed timing
 Apply patch to clean, dry, hairless area that  Change patch daily
will not be rubbed by tight clothing
 Avoid exposure to heat sources for long Safe Routes
periods of time (avoid hot tubs)  Transdermal
 Rotate sites  Oral
Generic Name: phenytoin Class: Antiepileptic
Trade name(s): Dilantin Class 1 antiarrhythmic (sodium blocker)
Loading doses Common Side effects
• Cardiac Monitor when toxic • Gingivitis is a primary adverse effect
or when giving a loading dose • Hyperglycemia
• Adult: 10—20 mg/kg = loading dose • Sudden arrhythmias / hypotension
Dilute loading dose om 250 mL NS • Severe allergic reactions
• Rate shouldn’t exceed 25—50mg/min • Bone marrow depression
or 1—3mg/kg/min infants & children • Suicidal thoughts

Precautions Safe Routes

• Watch for rash • IM is not recommended
• Watch for CNS depression • Oral should be used when possible
• Frequent oral cares due to gingivitis • 100mg q6-8h PO=typical adult dose
• Watch glucose
• Watch CBC, especially if bruising or
infections emerge