Mosby's 2014 Nursing Drug Reference (406 page)

Black Box Warning:

Suicidal ideation in children/adolescents

• Adult:
PO
150 mg/day in divided doses, may increase by 50 mg/day q3-4days, max 400 mg/day (outpatient), 600 mg/day (inpatients);
EXT REL
150 mg in
PM
, may increase gradually by 75 mg/day q3days, max 375 mg/day

• Child 6-18 yr (unlabeled):
PO
1.5-2 mg/kg/day in divided doses, may increase q3-4days up to 6 mg/kg/day or 400 mg/day, whichever is less

• Geriatric:
PO
25-50 mg at bedtime, increase by 25-50 mg q3-7days to desired dose, usually 75-150 mg/day

• Adult:
PO
50-100 mg/day

• Adult:
PO
150 mg in divided doses, may increase by 50 mg/day q3-4days

• Adult:
PO
50 mg at bedtime

• 
Increased fluids, bulk in diet if constipation occurs, especially in geriatric patients

• 
With food, milk for GI symptoms

• 
Dosage at bedtime for oversedation during day; may take entire dose at bedtime; geriatric patients may not tolerate daily dosing

• 
Avoid use of CNS depressants

• 
Do not crush, break, chew ext rel product

Increase:
toxicity, serotonin syndrome—FLUoxetine, nefazodone, other SSRIs, SNRIs, linezolid; methylene blue (IV)

Increase:
effects of direct-acting sympathomimetics (EPINEPHrine), alcohol, barbiturates, benzodiazepines, CNS depressants, digoxin, phenytoin, carBAMazepine

Increase:
effects of traZODone—CYP3A4, 2D6 inhibitors (phenothiazines, protease inhibitors, azole antifungals)

Increase or decrease:
effects of warfarin

Decrease:
effects of guanethidine, cloNIDine, indirect-acting sympathomimetics (ePHEDrine)

Increase:
serotonin syndrome—SAM-e, St. John’s wort

Increase:
CNS depression—hops, kava, lavender, valerian

Increase:
LFTs

Decrease:
Hgb

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

• 
Blood studies: CBC, leukocytes, differential, cardiac enzymes if patient is receiving long-term therapy

• 
Hepatic studies: AST, ALT, bilirubin

• 
Weight weekly; appetite may increase with product

• 
ECG for flattening of T wave, bundle branch block, AV block, dysrhythmias in cardiac patients

• 
EPS, primarily in geriatric patients: rigidity, dystonia, akathisia

Black Box Warning:

Mental status changes: mood, sensorium, affect, suicidal tendencies, increase in psychiatric symptoms, depression, panic; observe for suicidal behaviors in children/adolescents, not approved for children

• 
Urinary retention, constipation; constipation most likely in children

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

• 
Alcohol consumption; hold dose until morning

 
Serotonin syndrome, neuroleptic malignant syndrome:
increased heart rate, shivering, sweating, dilated pupils, tremors, high B/P, hyperthermia, headache, confusion; if these occur, stop product, administer serotonin antagonist if needed

• 
Storage in tight, light-resistant container at room temp

• 
Assistance with ambulation during beginning therapy for drowsiness, dizziness

• 
Therapeutic response: decreased depression

• 
That therapeutic effects may take 2-3 wk; to take product before bedtime, not to crush, chew ext rel product

• 
To use caution when driving, performing other activities requiring alertness because of drowsiness, dizziness, blurred vision

• 
To avoid alcohol ingestion

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

• 
To report urinary retention, priapism >4 hr immediately

• 
To wear sunscreen or large hat because photosensitivity occurs

Black Box Warning:

That suicidal thoughts/behaviors may occur (adolescents/children)

• 
To notify prescriber if pregnancy is planned or suspected, pregnancy (C), avoid breastfeeding