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(klor-PRO-muh-zeen HIGH-droe-KLOR-ide)
Thorazine, Thorazine Spansules,  Largactil
Class: Antipsychotic/phenothiazine;/antiemetic

 Action Effects apparently due to dopamine receptor blockade in CNS.

 Indications Management of psychotic disorders and manic phase of manic-depressive disorder; relief of anxiety and restlessness prior to surgery; adjunct in treatment of tetanus; management of acute intermittent porphyria, severe behavioral and conduct disorders in children; control of nausea and vomiting; relief of intractable hiccoughs. Unlabeled use(s): Treatment of phencyclidine psychosis; treatment of migraine headaches (IM or IV forms).

 Contraindications Comatose or severely depressed states; allergy to product or other phenothiazines; presence of large amounts of other CNS depressants; bone marrow depression; blood dyscrasias; liver damage; cerebral arteriosclerosis; coronary artery disease; severe hypotension or hypertension; subcortical brain damage.

 Route/Dosage

Adults

PSYCHIATRIC (OUTPATIENT): IM 25 mg for prompt control; may repeat in 1 hr. PO 25–50 mg tid after initial regimen. May initiate oral dosing with 10 mg tid-qid and adjust individually; up to 800 mg/day may be needed. PSYCHIATRIC (INPATIENT): PO 25 mg tid; increase as needed; usually 400 mg/day. IM 25 mg initially; may give additional 25–50 mg in 1 hr. Increase gradually until controlled. Up to 2000 mg/day may be needed but generally not for extended periods. ACUTE INTERMITTENT PORPHYRIA: PO 25–50 mg; IM 25–50 mg tid-qid. TETANUS: IM 25 to 50 mg tid-qid; IV 25–50 mg diluted to at least 1 mg/ml and administered at rate of 1 mg/min. NAUSEA AND VOMITING: PO 10–25 mg q 4–6 hr prn. PR 50–100 mg q 6–8 hr prn. IM 25 mg. If no hypotension, may give 25–50 mg q 4–6 hr prn. INTRACTABLE HICCOUGHS: PO 25–50 mg tid-qid. IM May give 25–50 mg if symptoms persist 2–3 days

IV May use slow infusion if hiccoughs persist.

Children > 6 Mo

PSYCHIATRIC (OUTPATIENT): PO 0.5 mg/kg q 4–6 hr prn; PR 1 mg/kg q 6–8 hr prn; IM 0.5 mg/kg q 6–8 hr prn. Psychiatric (INPATIENT): PO Start low and increase gradually; 50–200 mg/day may be needed in severe cases or in older children. IM Up to 5 years: Do not exceed 40 mg/day. 5–12 years: Do not exceed 75 mg/day if possible. TETANUS: IM/IV 0.5 mg/kg q 6–8 hr. When giving IV, dilute to at least 1 mg/ml and administer at rate of 1 mg over 2 minutes. In children £ 23 kg, do not exceed 40 mg/day; 23–45 kg, do not exceed 75 mg/day if possible. NAUSEA AND VOMITING: PO 0.55 mg/kg q 4–6 hr. PR 1.1 mg/kg q 6–8 hr prn. IM 0.55 mg/kg q 6–8 hr prn. Do not exceed 40 mg/day if < 5 yrs or 75 mg/day if 5–12 yrs.

 Interactions

Alcohol: May cause increased CNS depression and may precipitate extrapyramidal reaction. Anticholinergics: May reduce therapeutic effects of and increase anticholinergic effects of chlorpromazine; may lead to tardive dyskinesia. Barbiturate anesthetics: May increase frequency and severity of neuromuscular excitation and hypotension. Beta-blockers: May result in increased plasma levels of beta-blocker and chlorpromazine. Epinephrine, norepinephrine: Actions of these drugs may be decreased or reversed. Lithium: May cause disorienting unconsciousness and extrapyramidal effects. Meperidine: May result in excessive sedation and hypotension. Metrizamide: Risk of seizure may increase.

 Lab Test Interferences Chlorpromazine may discolor urine (pink to red-brown). False-positive pregnancy test results may occur (less likely with a serum test). Increases in protein-bound iodine have been reported. False-positive phenylketonuria test results may occur.

 Adverse Reactions

CV: Orthostatic hypotension; hypertension; tachycardia; bradycardia; syncope; cardiac arrest; circulatory collapse; ECG changes. CNS: Faintness; dizziness; extrapyramidal side effects (eg, pseudoparkinsonism; tardive dyskinesia); muscle spasms; motor restlessness; headache; weakness; tremor; fatigue; slurring; insomnia; vertigo; seizures; sedation; neuroleptic malignant syndrome. DERM: Photosensitivity; skin pigmentation; dry skin; exfoliative dermatitis; urticarial rash; maculopapular hypersensitivity reaction; seborrhea; eczema. EENT: Pigmentary retinopathy; glaucoma; photophobia; blurred vision; increased IOP; mydriasis. GI: Dry mouth; dyspepsia; constipation; adynamic ileus (with possible complications resulting in death). GU: Urinary retention and hesitancy; impotence; sexual dysfunction; menstrual irregularities. HEMA: Agranulocytosis; eosinophilia; leukopenia; hemolytic anemia; thrombocytopenic purpura. HEPA: Jaundice. META: Altered cholesterol levels. RESP: Laryngospasm; bronchospasm; dyspnea, aspiration pneumonia. OTHER: Increased appetite and weight; polydipsia; breast enlargement; galactorrhea; heat stroke/hyperpyrexia; sudden death.

 Precautions

Pregnancy: Safety not established. Lactation: Excreted in breast milk. Children: Do not use in children < 6 mo unless considered lifesaving. Do not use in conditions for which specific children’s dosage not established. Elderly: More susceptible to enhanced effects; consider lower dose. Special risk patients: Use caution in patients with cardiovascular disease or mitral insufficiency, history of glaucoma, EEG abnormalities or seizure disorders, prior brain damage, hepatic or renal impairment.

PATIENT CARE CONSIDERATIONS

 Administration/Storage

  • Store all forms at room temperature and avoid exposure to direct sunlight, excessive heat, or cold. Keep liquid concentrate in amber or opaque bottle.
  • Give with food to avoid gastric irritation. Tablets may be crushed, but capsules should not be opened, crushed or chewed.
  • Make certain that patient swallows oral preparations.
  • Mix concentrate with juice, soft drink or semisolid food immediately prior to administration.
  • If concentrate is spilled on skin or clothing, rinse area immediately with water to prevent or reduce skin irritation.
  • Give deep IM injection. Solution may be slightly yellow without affecting potency. If skin irritation is a problem, dilute with normal saline or 2% procaine.
  • Caution patient to remain recumbent for approximately 30 min following IM injection.
  • Monitor BP frequently during IV infusion.

 Assessment/Interventions

  • Obtain patient history, including drug history and any known allergies.
  • Identify last day of menses, and assess for possible pregnancy, use of contraceptives and whether patient is currently breastfeeding.
  • Assess daily for changes in mental status.
  • Notify physician of any signs or symptoms of possible adverse reactions.
  • Assess lying and standing BP, vital signs, and weight and compare to baseline values.
  • Document orthostatic hypotension by routinely recording lying and standing BP.
  • Document signs of anticholinergic-related effects such as dry mouth, blurred vision, constipation and urinary retention. Offer sugarless hard candy or gum and sips of water if dry mouth is a problem.
  • Weigh patient weekly and monitor intake and output.
OVERDOSAGE: SIGNS & SYMPTOMS
  CNS depression, hypotension, extrapyramidal symptoms, agitation, restlessness, convulsions, fever, hypothermia, hyperthermia, coma, autonomic reactions, ECG changes, cardiac arrhythmias

 Patient/Family Education

  • Instruct patient to report these symptoms to physician immediately: sore throat, fever, easy bruising, unusual bleeding, muscular rigidity, breathing difficulty, rapid heart beat, yellow skin or sclera, skin rash.
  • Remind patient to continue medication even if symptoms subside because symptoms may recur if medication is discontinued. Caution patient not to stop taking medication abruptly.
  • Explain that drug may cause drowsiness and to avoid intake of alcoholic beverages as well as any otc medications that also may cause drowsiness. Remind patient to use caution when driving or performing other tasks that require mental alertness.
  • Instruct patient to consult physician before taking other medications including nonprescription drugs.
  • Explain that dry mouth may be relieved by rinsing mouth with warm water, sucking on sugarless hard candy or gum and taking frequent sips of water.
  • Remind patient to dress warmly in cold weather and avoid extended exposure to either very hot or very cold temperatures, as body temperature is harder to maintain with this drug.
  • Explain that medication may cause increased sensitivity to sunlight and that sunscreen and/or protective clothing should be worn until sun tolerance is known.
  • Inform patient that dizziness or lightheadedness may be experienced when rising to a sitting or standing position.
  • Tell patient that a pink or red-brown urine discoloration is a harmless effect of the medication.
  • Tell patient to carry a card or Medi-Alert bracelet at all times that lists the name and dosage of this medication.

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