2ND SET OF DRUGS

1. Sertraline (Zoloft)

Generic Name: Sertraline

Brand Name: Zoloft
Classification Name:
 Therapeutic: Antidepressant, anxiolytic, obsessive-compulsive disorder
adjunct
 Pharmacologic: Selective serotonin reuptake inhibitor (SSRIs)

Drug form and Dosage Ordered: 25 – 50 mg/day

Timing: Once a day
Duration: Unknown (Half-life: 62 to 104 hours)
Other drug forms: Oral concentrate, Tablets

Indications:
 Treatment of major depressive disorders, panic disorder, obsessive-
compulsive disorder (OCD), post-traumatic stress disorder (PTSD),
premenstrual dysphoric disorder (PMDD), social anxiety disorder
 Eating disorders, bulimia nervosa, generalized anxiety disorders (GAD)

Pharmacodynamics:
 Mechanism of Action: Blocks reuptake of the neurotransmitter serotonin at
CNS neuronal presynaptic membranes, increasing availability at postsynaptic
receptor sites.
 Therapeutic Effect: Relieves depression, reduces obsessive-compulsive
behavior, decreases anxiety

Side Effects / Adverse Reactions:

 CNS: fatigue, headache, tremor, dizziness, insomnia, somnolence, suicidal
behavior, paresthesia, hypesthesia, nervousness, anxiety, malaise, agitation,
ataxia, coma, confusion, hallucinations, irritability, seizure, hypertonia, pain.
 CV: palpitations, chest pain, hot flashes. edema, HTN, syncope, tachycardia,
vasodilation.
 EENT: visual disturbances, blurred vision, mydriasis.
 GI: dry mouth, nausea, diarrhea, loose stools, dyspepsia, vomiting,
constipation, thirst, flatulence, anorexia, abdominal pain, decreased appetite.
 GU: male sexual dysfunction, decreased libido (both genders).
Musculoskeletal: myalgia.
 Skin: rash, pruritus, diaphoresis, alopecia.

Contraindications:
 Hypersensitivity to sertraline
 MAOI use within 14 days (concurrently or within 14 days of stopping an MAOI
or sertraline).
 Concurrent use of oral concentrate (contains alcohol) with disulfiram
  Concurrent use with pimozide; initiation in patients treated with linezolid or
methylene blue

Nursing Responsibilities:
 Assess appearance, behavior, speech patterns, level of interest, mood
 For patients on long-term therapy, CBC, renal function, LFT should be
performed periodically
 Assess mental status for depression, suicidal ideation (esp. at beginning of
therapy or change in dosage), anxiety, social function, panic attack
 Monitor daily pattern of bowel activity, stool consistency
 Assist with ambulation if dizziness occurs

Patient Teaching:
 Dry mouth may be relieved by sugarless gum, sips of water
 Report headache, fatigue, tremor, sexual dysfunction
 Avoid tasks that require alertness, motor skills until response to drug is
established (may cause dizziness, drowsiness)
 Take with food if nausea occurs
 Inform physician if pregnancy occurs
 Avoid alcohol
 Do not take OTC medications without consulting physician
 Report worsening of depression, suicidal ideation

2. Mirtazapine

Generic Name: Mirtazapine

Brand Name: Remeron, Remeron Soltab
Classification Name:
 Therapeutic: Antidepressant
 Pharmacologic: Alpha-2 antagonist

Drug form and Dosage Ordered: 15 mg/day

Timing: Bedtime daily
Duration: Unknown (Half-lfe: 20 to 40 hours)
Other drug forms: Tablets, Tablets (ODTs)

Indications:
 Treatment of major depressive (MDD)

Pharmacodynamics:
 Mechanism of Action: Acts as antagonist at presynaptic alpha2-adrenergic
receptors, increasing norepinephrine, serotonin neurotransmission. Has low
anticholinergic activity
 Therapeutic Effect: Relieves depression
 Side Effects / Adverse Reactions:
 CNS: somnolence, dizziness, asthenia, abnormal dreams, abnormal thinking,
tremors, confusion, drowsiness, agitation, amnesia, anxiety, apathy,
depression, hypoesthesia, malaise, myasthenia, paresthesia, twitching,
vertigo.
 CV: edema, peripheral edema, HTN, vasodilation.
 EENT: dry mouth.
 GI: increased appetite, dry mouth, constipation, abdominal pain, anorexia,
vomiting, nausea.
 GU: urinary frequency, UTI.
 Metabolic: weight gain.
 Musculoskeletal: myalgia, weakness, back pain.
 Respiratory: dyspnea, cough.
 Skin: pruritus, rash.
 Other: flulike syndrome

Contraindications:
 Hypersensitivity to mirtazapine
 Use of MAOIs to treat psychiatric disorders (concurrently or within 14 days of
discontinuing either MAOI or mirtazapine), initiation of mirtazapine in pts
receiving linezolid or IV methylene blue

Nursing Responsibilities:
 Assess mental status, appearance, behavior, speech pattern, level of interest,
mood
 Obtain baseline weight
 For pts on long-term therapy, renal function, LFT, CPC should be performed
periodically
 Supervise suicidal-risk pt closely during early therapy (as depression lessens,
energy level improves, increasing suicide potential)
 Children, adolescents are increased risk for suicidal thoughts/behavior and
worsening of depression, esp. during first few months of therapy.
 Assess appearance, behavior, speech pattern, level of interest, mood
 Monitor for hypotension, arrythmias

Patient Teaching:
 Take as single bedtime dose
 Avoid alcohol, depressant/sedating medications
 Avoid tasks requiring alertness, motor skills until response to drug established
 Report worsening depression, suicidal ideation, unusual changes in behavior

3. Sodium valproate

Generic Name: Sodium valproate / Valproate sodium / Valproic acid

Brand Name: Depakote, Depakene, Depacon, Stavzor, Epival
Classification Name:
 Therapeutic: Anticonvulsants
 Pharmacologic: Carboxylic acid derivatives

Drug form and Dosage Ordered:

 Minimum: 15 mg/kg/day
 Maximum: 60 mg/kg/day

Timing: Once a day

Duration: Unknown (Half-life: Adults, 9 to 16 hours; children, 3 ½ to 67 hours

based on age)

Other drug forms: Capsules, Tablets (delayed and extended-release), Injection,

Syrup

Indications:
 Used in the treatment of bipolar disorder, cluster-tic syndrome, epilepsy,
hyperekplexia, mania, migraine prevention, schizoaffective disorder, seizure
prevention, seizures
 Mania
 To prevent migraine headache

Pharmacodynamics:
 Mechanism of Action: It acts on Gamma Amino Butyrate (GABA) levels in
the brain, blocks voltage gated ion channels and also acts as HDAC inhibitor
(HDACi). Besides elevation of the GABA levels, VPA may also have
antiepileptic activity by reducing the high frequency timing of neurons by
blocking voltage-gated sodium-potassium and calcium channels.
 Therapeutic Effect: Works in the brain tissue to stop seizures

Side Effects / Adverse Reactions:

 CNS: asthenia, dizziness, drowsiness, headache, insomnia, nervousness,
somnolence, tremor, abnormal thinking, amnesia, ataxia, depression,
emotional upset, fever, abnormal dreams.
 CV: chest pain, edema, HTN, hypotension, tachycardia, palpitations.
 EENT: blurred vision, diplopia, nystagmus, pharyngitis, rhinitis, tinnitus.
 GI: abdominal pain, anorexia, diarrhea, dyspepsia, nausea, vomiting,
pancreatitis, constipation, increased appetite.
 GU: UTI, vaginitis, dysmenorrhea, dysuria, urinary frequency, urinary
incontinence.
 Hematologic: bone marrow suppression, hemorrhage, thrombocytopenia,
bruising, petechiae.
 Hepatic: hepatotoxicity.
 Metabolic: hyperammonemia, weight gain or loss.
 Musculoskeletal: back and neck pain, arthralgia.
 Respiratory: bronchitis, dyspnea.
 Skin: alopecia, erythema multiforme, hypersensitivity reactions, SJS, rash,
photosensitivity reactions, pruritus.
 Other: flulike syndrome, infection, chills.

Contraindications:
 Pre-existing acute or chronic liver dysfunction or family history of severe liver
inflammation (hepatitis) particularly medicine related
 Hypersensitivity to valproate or any of the ingredients used in the preparation
 Urea cycle disorders
 Hepatic porphyria
 Hepatotoxicity
 Mitochondrial disease
 Pancreatitis
 Porphyria
 Contraindicated in patients hypersensitive to drug and in those with hepatic
disease or significant hepatic dysfunction, and in patients with a urea cycle
disorder (UCD).

Nursing Responsibilities:
 Lab tests: perform baseline platelet counts, bleeding time, and serum
ammonia, then repeat at least q2mo, especially during the first 6 mo of
therapy
 Monitor any changes of patient in the following: weight, skin color, lesions,
orientation, affect, reflexes, bowel sounds, normal output; CBC and
differential, bleeding time tests, LFTs, serum ammonia level, exocrine
pancreatic function tests, EEG
 Avoid rapid infusion
 Notify physician promptly if spontaneous bleeding or bruising occurs
 Monitor patient carefully for clotting defects (bruising, blood-tinged
toothbrush)

Patient Teaching:
 Tell patient and caregivers that drug may increase risk of suicidal thoughts
and behavior and to immediately report the emergence or worsening of
depression, unusual changes in mood or behavior, or emergence of suicidal
thoughts, behavior, or thoughts about self-harm.
 Tell patient to take drug with food or milk to reduce adverse GI effects.
 Advise patient not to chew capsules; irritation of mouth and throat may result.
 Tell patient that sprinkle capsules may be either swallowed whole or carefully
opened and contents sprinkled on a teaspoonful of soft food. Tell patient to
swallow immediately without chewing.
  Tell patient and parents that syrup shouldn't be mixed with carbonated
beverages; mixture may be irritating to mouth and throat.
 Tell patient and parents to keep drug out of children's reach.
 Warn patient and parents not to stop drug therapy abruptly.
 Tell patient to immediately report rash (with or without blisters), fever, swollen
lymph nodes, mouth ulcers, or skin shedding.
 Warn patients and caregivers that abdominal pain, nausea, vomiting, and
anorexia can be symptoms of pancreatitis that require prompt medical
evaluation.
 Advise patient to avoid driving and other potentially hazardous activities that
require mental alertness until drug's CNS effects are known.
 Instruct patient or parents to call prescriber if malaise, weakness, lethargy,
facial swelling, loss of appetite, or vomiting occurs.
 Tell female patient to call prescriber if she becomes pregnant or plans to
become pregnant during therapy.

4. Carbamazepine

Generic Name: Carbamazepine

Brand Name: Carbatrol, Epitol, Equetro, TEGretol, TEGretol XR
Classification Name:
 Therapeutic: Anticonvulsant
 Pharmacologic: Iminostilbene derivative

Drug form and Dosage Ordered: 200 mg (adults and children >12 y/o)

Timing: Twice a day

Duration: Unknown (Half-life 25-65 hours with single dose; 8-29 hours with long-
term use

Other drug forms: Capsules (extended-release), Oral suspension, Tablets,

Tablets (chewable), Tablets (extended-release

Indications:
 Carbatrol, Epitol, TEGretol, TEGretol XR: treatment of partial seizures with
seizures with complex symptomatology, generalized tonic-clonic seizures,
mixed seizure patterns, pain relief of trigeminal, glossopharyngeal neuralgia
 Equetro: Acute manic and mixed episodes associated with bipolar disorder
 Neurophathic pain in critically ill patients

Pharmacodynamics:
 Mechanism of Action: Decreases sodium ion influx into neuronal
membranes (may depress activity in thalamus, decreasing synaptic
transmission or decreasing temporal stimulation, leading to neural discharge
 Therapeutic Effect: Produces anticonvulsant effect

Side Effects / Adverse Reactions:

 CNS: ataxia, dizziness, drowsiness, somnolence, vertigo, worsening of
seizures, confusion, fatigue, fever, headache, syncope, pain, depression
including suicidal ideation, speech disorder.
 CV: arrhythmias, AV block, HF, aggravation of CAD, HTN, hypotension.
 EENT: blurred vision, conjunctivitis, diplopia, nystagmus, dry pharynx.
 GI: nausea, vomiting, abdominal pain, anorexia, diarrhea, dry mouth,
dyspepsia, glossitis, stomatitis.
 GU: albuminuria, glycosuria, erectile dysfunction, urinary frequency, urine
retention.
 Hematologic: agranulocytosis, aplastic anemia, thrombocytopenia,
eosinophilia, leukocytosis. Hepatic: hepatitis.
 Metabolic: hyponatremia.
 Musculoskeletal: leg cramps. Respiratory: pulmonary hypersensitivity.
 Skin: erythema multiforme, SJS, excessive diaphoresis, rash, urticaria,
pruritus.
 Other: SIADH, chills

Contraindications:
 Concomitant use or within 14 days of use of MAOIs, myelosuppression
 Concomitant use of delavirdine or other NNRT inhibitors that are substrates of
CYP3A4
 Hypersensitivity to Carbamazepine, tricyclic antidepressants

Nursing Responsibilities:
 CBC, serum iron determination, urinalysis, BUN should be performed before
therapy begins and periodically during therapy
 Seizures: Review history of seizure disorder (intensity, frequency, duration,
level of consciousness. Initiate seizure precautions.
 Neuralgia: Assess facial pain, stimuli that may cause facial pain
 Bipolar: Assess mental status, cognitive abilities
 Observe frequently for recurrence of seizure activity.
 Monitor therapeutic levels
 Assess for clinical improvement (decrease in intensity, frequency of seizures)
 Assess for clinical evidence of early toxicity (fever, sore throat, mouth
ulcerations, unusual bruising/bleeding, joint pain)
 Avoid triggering tic douloureux (draft, talking, washing face, jarring bed,
hot/warm/cold food or liquids)
 Monitor for suicidal ideation, behavioral changes.
 Observe for excessive sedation
 Patient Teaching:
 Do not abruptly discontinue medication after long-term use (may precipitate
seizures)
 Strict maintenance of therapy is essential for seizure control
 Avoid tasks that require alertness, motor skills until response to drug is
established
 Blood tests should be repeated frequently during first 3 months of therapy and
at monthly intervals thereafter for 2-3 years
 Do not take oral suspension simultaneously with other liquid medicine
 Do not ingest grapefruit products
 Report serious skin reactions

3RD SET OF DRUGS

1. Lorazepam (Ativan)

Generic Name: LORAZEPAM

Brand Name: ATIVAN, LORAZEPAM INTENSOL
Classification Name:
 Therapeutic: Benzodiazepine (Schedule IV)
 Pharmacologic: Antianxiety, sedative-hypnotic, antiemetic, skeletal muscle
relaxant, amnesiac, anticonvulsant, anti-tremor

Drug form and Dosage Ordered:

Timing:
Duration: Unknown; Half-Life: 18 hours (adults), 15 hours (children)
Other drug forms: Tablets

Indications:
 Management of anxiety disorders, short-term relief of symptoms of anxiety,
anxiety associated with depressive symptoms.
 Insomnia due to anxiety or transient stress
 Status epilepticus, pre-anesthesia for amnesia, sedation
 Treatment of alcohol withdrawal, psychogenic catatonia, partial complex
seizures, agitation (IV administration only), antiemetic for chemotherapy
 Rapid tranquilization of agitated pt, status epilepticus in children

Pharmacodynamics:
 Mechanism of Action: Enhances action of inhibitory neurotransmitter
gamma-aminobutyric acid (GABA) in CNS, affecting memory, motor, sensory,
cognitive function
 Therapeutic Effect: Produces anxiolytic, anticonvulsant, sedative, muscle
relaxant, anti-emetic effects

Side Effects / Adverse Reactions:

 CNS: cerebral hemorrhage, fatigue, headache, pyrexia, weakness,
depression, dizziness, insomnia, anxiety.
 CV: edema.
 EENT: epistaxis, nasopharyngitis.
 GI: GI hemorrhage, abdominal pain, anorexia, constipation, diarrhea,
dyspepsia, nausea, vomiting.
 Hematologic: hemorrhage, neutropenia, thrombocytopenia, anemia.
Metabolic: hypokalemia, weight increase.
 Musculoskeletal: arthralgia, myalgia, muscle cramps, musculoskeletal pain,
growth suppression in children.
 Respiratory: cough, dyspnea, pneumonia.
 Skin: petechiae, rash, pruritus.
 Other: night sweats.

Contraindications:
 Contraindicated in patients hypersensitive to drug or its components.
 Use cautiously in elderly patients and in those with hepatic or renal
impairment.
 Severe HF and left ventricular dysfunction have occurred in patients taking
imatinib. Use cautiously in patients with cardiac disease or risk factors for HF.
 Growth retardation has occurred in children and preadolescents receiving
imatinib; long-term effects of prolonged treatment are unknown.
 Safety and effectiveness in children younger than age 1 haven't been
established.

Nursing Responsibilities:
 Offer emotional support to anxious pt.
 Pt must remain recumbent following parenteral administration to reduce
hypotensive effect.
 Assess motor responses (agitation, trembling, tension), autonomic responses
(cold or clammy hands, diaphoresis).
 Monitor B/P, respiratory rate, heart rate.
 For those on long-term therapy, hepatic/ renal function tests, CBC should be
performed periodically.
 Assess for paradoxical reaction, particularly during early therapy.
 Evaluate for therapeutic response: calm facial expression, decreased
restlessness, insomnia, decrease in seizure-related symptoms

Patient Teaching:
  Tell patient to take drug with food and a large glass of water.
 Advise patient unable to swallow tablets to mix them uncrushed in water or
apple juice (50 mL for 100-mg tablet and 200 mL for 400-mg tablet) and to stir
and drink immediately.
 Advise patient to report adverse effects, such as fluid retention and sudden
weight gain.
 Advise patient that periodic laboratory tests will be needed to monitor therapy.
 Inform patient and caregivers that growth retardation has occurred in children
and preadolescents receiving imatinib, and that long-term effects of prolonged
treatment are unknown. Monitor growth closely.
 Advise patient of the risk of dizziness, blurred vision, or somnolence during
treatment and to use caution when driving a car or operating machinery.
 Advise female patient that drug may cause fetal harm. Caution her to avoid
pregnancy during therapy and for 14 days after therapy ends and to inform
the prescriber if she suspects pregnancy.
 Advise female patient not to breastfeed during therapy and for 1 month after
final dose.

2. Diazepam (Valium)

Generic Name: DIAZEPAM

Brand Name: VALIUM, APO-DIAZEPAM, DIASTAT, DIAZEPAM INTENSOL,
NOVO-DIPAM
Classification Name:
 Therapeutic: Benzodiazepine (Schedule IV)
 Pharmacologic: Antianxiety, skeletal muscle relaxant, anticonvulsant

Drug form and Dosage Ordered:

Timing:
Duration: 20-80 hr. (PO); 15-60 min (IV); Half Life: 1 to 12 days
Other drug forms: Injection, Oral solution, Rectal gel twin packs, tablets

Indications:
 Short-term relief of anxiety symptoms
 Relief of acute alcohol withdrawal
 Adjunct for relief of acute musculoskeletal conditions
 Treatment of seizures
 Control of increased seizure activity in refractory epilepsy in pts on stable
regimens.
 Treatment of panic disorder
 Short-term treatment of spasticity in children with cerebral palsy
 Sedation for mechanically vented pts in ICU
 Tetanus

Pharmacodynamics:
 Mechanism of Action: Depresses all levels of CNS by enhancing action of
gamma-aminobutyric acid (GABA), a major inhibitory neurotransmitter in the
brain
 Therapeutic Effect: Produces anxiolytic effect, elevates seizure threshold,
produces skeletal muscle relaxation.

Side Effects / Adverse Reactions:

 CNS: drowsiness, dysarthria, slurred speech, tremor, transient amnesia,
fatigue, ataxia, headache, insomnia, paradoxical anxiety, hallucinations,
minor changes in EEG patterns, pain, vertigo, confusion, depression.
 CV: CV collapse, bradycardia, hypotension.
 EENT: diplopia, blurred vision, nystagmus.
 GI: nausea, constipation, diarrhea with rectal form, dry mouth.
 GU: incontinence, urine retention.
 Hematologic: neutropenia.
 Hepatic: jaundice.
 Respiratory: respiratory depression, apnea, hiccups.
 Skin: rash, phlebitis at injection site.
 Other: altered libido, physical or psychological dependence

Contraindications:
 Hypersensitivity to diazepam
 Acute narrow-angle glaucoma, untreated open-angle glaucoma, severe
respiratory depression, severe hepatic insufficiency, sleep apnea syndrome,
myasthenia gravis
 Children younger than 6 mos (oral)
 Pts receiving other CNS depressants or psychoactive agents, depression,
history of drug and alcohol abuse, renal/hepatic impairment, respiratory
disease, impaired gag reflex, concurrent use of strong CYP3A4 inhibitors or
inducer

Nursing Responsibilities:
 Assess B/P, pulse, respirations immediately before administration
 Monitor heart rate, respiratory rate, B/P, mental status.
 Assess children, elderly for paradoxical reaction, particularly during early
therapy.
 Evaluate for therapeutic response (decrease in intensity/frequency of
seizures; calm facial expression, decreased restlessness; decreased intensity
of skeletal muscle pain).
 Periodically monitor LFTs, CBC, and renal function in patients receiving
repeated or prolonged therapy
 Don't withdraw drug abruptly after long-term use because withdrawal
symptoms may occur; taper gradually

Patient Teaching:
  Avoid alcohol.
 Limit caffeine.
 May cause drowsiness; avoid tasks that require alertness, motor skills until
response to drug is established.
 May be habit forming.
 Avoid abrupt discontinuation after prolonged use.
 Advise female patient to avoid use during pregnancy; inform her of the
potential hazard to the fetus if drug is used during pregnancy or if patient
becomes pregnant while taking drug.
 Instruct patient's caregiver on the proper use of Diastat rectal gel.

3. Haloperidol (Haldol)

Generic Name: HALOPERIDOL

Brand Name: HALDOL, HALDOL DECONAOATE, NOVO-PERIDOL
Classification Name:
 Therapeutic: First-generation (typical) antipsychotic
 Pharmacologic: Butyrophenone derivatives

Drug form and Dosage Ordered:

Timing:
Duration: Unknown; Half-life: 14-17 hours (PO)
Other drug forms: Tablets, Injection, Oral Solution

Indications:
 Treatment of schizophrenia, Tourette’s disorder (controls tics and vocal
utterances), severe behavioral problems in children with combative explosive
hyperexcitability without immediate provocation.
 Management of psychotic disorder, short-term treatment of hyperactive
children
 Treatment of non-schizophrenic psychosis, alcohol dependence,
psychosis/agitation related to Alzheimer’s dementia, emergency sedation of
severely agitated/ psychotic pts

Pharmacodynamics:
 Mechanism of Action: Nonselectively blocks postsynaptic dopamine
receptors in brain
 Therapeutic Effect: Produces tranquilizing effect. Strong extrapyramidal,
antiemetic effects; weak anticholinergic, sedative effects.

Side Effects / Adverse Reactions:

 CNS: severe extrapyramidal reactions, dystonia, tardive dyskinesia, NMS,
seizures, sedation, drowsiness, lethargy, headache, insomnia, confusion,
vertigo, agitation, anxiety, depression, euphoria, restlessness, tonic-clonic
seizures, hallucinations, parkinsonian-like syndrome.
  CV: tachycardia, hypotension, HTN, prolonged QT interval and other ECG
changes
 EENT: blurred vision, cataracts, retinopathy, oculogyric crisis.
 GI: dry mouth, anorexia, constipation, diarrhea, nausea, vomiting, dyspepsia.
 GU: urine retention, menstrual irregularities, priapism.
 Hematologic: leukopenia, leukocytosis.
 Hepatic: jaundice.
 Metabolic: hyperglycemia, hypoglycemia, hyponatremia.
 Skin: rash, other skin reactions, diaphoresis.
 Other: gynecomastia

Contraindications:
 Contraindicated in patients hypersensitive to drug and in those with dementia
with Lewy bodies, Parkinson disease, coma, or CNS depression.

Nursing Responsibilities:
 Assess behavior, appearance, emotional status, response to environment,
speech pattern, thought content.
 Assess mental status.
 Screen for co-morbidities as listed in Precautions (esp. seizure disorder, long
QT syndrome).
 Monitor B/P, heart rate/rhythm.
 Monitor ECG, QT interval.
 Supervise suicidal-risk pts closely during early therapy (as depression
lessens, energy level improves, increasing suicide potential).
 Monitor for rigidity, tremor, mask-like facial expression, fine tongue
movement.
 Assess for therapeutic response (interest in surroundings, improvement in
self-care, increased ability to concentrate, relaxed facial expression).

Patient Teaching:
 Full therapeutic effect may take up to 6 wks.
 Do not abruptly withdraw from long-term drug therapy.
 Sugarless gum, sips of water may relieve dry mouth.
 Drowsiness generally subsides during continued therapy.
 Avoid tasks that require alertness and motor skills until response to drug is
established.
 Avoid alcohol.
 Report muscle stiffness, lip puckering, tongue protrusion, restlessness.
 Avoid overheating, dehydration, exposure to sunlight (increased risk of
heatstroke).

4. Divalproex sodium (Depakote)

Generic Name: DIVALPROEX SODIUM

Brand Name: DEPAKOTE, DEPAKOTE ER, DEPAKOTE SPRINKLE, EPIVAL
Classification Name:
 Therapeutic: Anticonvulsants
 Pharmacologic: Carboxylic acid derivatives

Drug form and Dosage Ordered:

Timing:
Duration: Unknown (Half-life: Adults, 9 to 16 hours; children, 3 ½ to 67 hours
based on age)
Other drug forms: Capsules (sprinkle), Tablets (delayed-release), Tablets
(extended-release)

Indications:
 Used in the treatment of bipolar disorder, cluster-tic syndrome, epilepsy,
hyperekplexia, mania, migraine prevention, schizoaffective disorder, seizure
prevention, seizures
 Mania
 To prevent migraine headache

Pharmacodynamics:
 Mechanism of Action: It acts on Gamma Amino Butyrate (GABA) levels in
the brain, blocks voltage gated ion channels and also acts as HDAC inhibitor
(HDACi). Besides elevation of the GABA levels, VPA may also have
antiepileptic activity by reducing the high frequency timing of neurons by
blocking voltage-gated sodium-potassium and calcium channels.
 Therapeutic Effect: Works in the brain tissue to stop seizures

Side Effects / Adverse Reactions:

 CNS: asthenia, dizziness, drowsiness, headache, insomnia, nervousness,
somnolence, tremor, abnormal thinking, amnesia, ataxia, depression,
emotional upset, fever, abnormal dreams.
 CV: chest pain, edema, HTN, hypotension, tachycardia, palpitations.
 EENT: blurred vision, diplopia, nystagmus, pharyngitis, rhinitis, tinnitus.
 GI: abdominal pain, anorexia, diarrhea, dyspepsia, nausea, vomiting,
pancreatitis, constipation, increased appetite.
 GU: UTI, vaginitis, dysmenorrhea, dysuria, urinary frequency, urinary
incontinence.
 Hematologic: bone marrow suppression, hemorrhage, thrombocytopenia,
bruising, petechiae.
 Hepatic: hepatotoxicity.
 Metabolic: hyperammonemia, weight gain or loss.
 Musculoskeletal: back and neck pain, arthralgia.
 Respiratory: bronchitis, dyspnea.
 Skin: alopecia, erythema multiforme, hypersensitivity reactions, SJS, rash,
photosensitivity reactions, pruritus.
 Other: flulike syndrome, infection, chills.

Contraindications:
 Contraindicated in patients hypersensitive to drug and in those with hepatic
disease or significant hepatic dysfunction, and in patients with a urea cycle
disorder (UCD).

Nursing Responsibilities:
 Lab tests: perform baseline platelet counts, bleeding time, and serum
ammonia, then repeat at least q2mo, especially during the first 6 mo of
therapy
 Monitor any changes of patient in the following: weight, skin color, lesions,
orientation, affect, reflexes, bowel sounds, normal output; CBC and
differential, bleeding time tests, LFTs, serum ammonia level, exocrine
pancreatic function tests, EEG
 Avoid rapid infusion
 Notify physician promptly if spontaneous bleeding or bruising occurs
 Monitor patient carefully for clotting defects (bruising, blood-tinged
toothbrush)

Patient Teaching:
 Tell patient and caregivers that drug may increase risk of suicidal thoughts
and behavior and to immediately report the emergence or worsening of
depression, unusual changes in mood or behavior, or emergence of suicidal
thoughts, behavior, or thoughts about self-harm.
 Tell patient to take drug with food or milk to reduce adverse GI effects.
 Advise patient not to chew capsules; irritation of mouth and throat may result.
 Tell patient that sprinkle capsules may be either swallowed whole or carefully
opened and contents sprinkled on a teaspoonful of soft food. Tell patient to
swallow immediately without chewing.
 Tell patient and parents that syrup shouldn't be mixed with carbonated
beverages; mixture may be irritating to mouth and throat.
 Tell patient and parents to keep drug out of children's reach.
 Warn patient and parents not to stop drug therapy abruptly.
 Tell patient to immediately report rash (with or without blisters), fever, swollen
lymph nodes, mouth ulcers, or skin shedding.
 Warn patients and caregivers that abdominal pain, nausea, vomiting, and
anorexia can be symptoms of pancreatitis that require prompt medical
evaluation.
 Advise patient to avoid driving and other potentially hazardous activities that
require mental alertness until drug's CNS effects are known.
 Instruct patient or parents to call prescriber if malaise, weakness, lethargy,
facial swelling, loss of appetite, or vomiting occurs.
 Tell female patient to call prescriber if she becomes pregnant or plans to
become pregnant during therapy.