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(kloe-NAY-ze-pam)
Klonopin,  Rivotril
Class: Anticonvulsant/Benzodiazepine

 Action Potentiates action of GABA, inhibitory neurotransmitter, resulting in increased neuronal inhibition and CNS depression, especially in limbic system and reticular formation.

 Indications Treatment of Lennox-Gastaut syndrome; management of akinetic and myoclonic seizures and absence seizures unresponsive to succinimides. Unlabeled use(s): Treatment of restless legs syndrome, parkinsonian dysarthria, acute manic episodes of bipolar affective disorder, multifocal tic disorders and neuralgias; adjunctive therapy for schizophrenia.

 Contraindications Hypersensitivity to benzodiazepines; psychoses; acute narrow-angle glaucoma; significant liver disease; shock; coma; acute alcohol intoxication.

 Route/Dosage

ADULTS: Initial dose: PO 1.5 mg/day in 3 divided doses. Increase by 0.5–1 mg q 3 days until seizures are adequately controlled (maximum 20 mg/day). INFANTS & CHILDREN (£ 10 yr Or 30 Kg): Initial dose: PO 0.01–0.03 mg/kg/day in 2–3 divided doses. Increase by 0.25–0.5 mg q 3 days until maintenance dose of 0.1–0.2 mg/kg has been reached.

 Interactions

Alcohol and CNS depressants: May cause additive CNS depressant effects. Cimetidine, oral contraceptives, disulfiram: May cause effects of clonazepam to increase, with excessive sedation and impaired psychomotor function. Digoxin: May increase serum digoxin concentrations. Omeprazole: May increase Theophyllines: May antagonize sedative effects.

 Lab Test Interferences None well documented.

 Adverse Reactions

CV: Cardiovascular collapse; hypotension; phlebitis or thrombosis at intravenous sites. CNS: Drowsiness; confusion; ataxia; dizziness; lethargy; fatigue; apathy; memory impairment; disorientation; anterograde amnesia; restlessness; headache; slurred speech; aphonia; stupor; coma; euphoria; irritability; vivid dreams; psychomotor retardation; paradoxic reactions (eg, anger, hostility, mania, insomnia, muscle spasms). DERM: Rash. EENT: Visual and auditory disturbances; depressed hearing. GI: Constipation; diarrhea; dry mouth; coated tongue; excessive salivation; nausea; anorexia; vomiting. GU: Dysuria; enuresis; nocturia; urinary retention. HEMA: Blood dyscrasias including agranulocytosis; anemia; thrombocytopenia; leukopenia; neutropenia. HEPA: Hepatic dysfunction, including hepatitis and jaundice; elevated LDH, ALT, AST and alkaline phosphatase. OTHER: Dependence/withdrawal syndrome (eg, confusion, abnormal perception of movement, depersonalization, muscle twitching, psychosis, paranoid delusions, seizures).

 Precautions

Pregnancy: Safety not established. Avoid drug, especially during first trimester, because of possible increased risk of congenital malformation. Not recommended during labor and delivery. Lactation: Excreted in breast milk. Children: Initial dose should be small and gradually increased. Longterm use may cause adverse effects such as possibly delayed mental or physical development. Elderly or debilitated patients: Initial dose should be small and gradually increased. Give drug with extreme care to elderly or very ill patients with limited respiratory reserve. Psychiatric disorders: Not intended for use in patients with primary depressive disorder, psychosis or disorders in which anxiety is not prominent. Renal or hepatic impairment: Use drug with caution to avoid accumulation. Seizure: In patients with multiple seizure types, drug may increase incidence or precipitate onset of grand mal seizures. Suicide: Use drug with caution in patients with suicidal tendencies; do not allow patient access to large quantities.

PATIENT CARE CONSIDERATIONS

 Administration/Storage

  • Give with food or milk to decrease GI upset.
  • Do not administer with antacid; give at least 1 hr apart.
  • If possible, divide daily dose into three equal doses. If doses are unequal, give largest dose at bedtime.
  • Parenteral administration should be reserved primarily for acute states.
  • Observe patient for up to 3 hr after parenteral administration.
  • Do not inject drug intra-arterially; intra-arterial injection may produce arteriospasm that can lead to gangrene.
  • Store at room temperature.

 Assessment/Interventions

  • Obtain patient history, including drug history and any known allergies.
  • Assess renal studies: urinalysis, BUN, urine creatinine.
  • Assess blood studies (CBC and platelets) prior to and regularly throughout therapy.
  • Evaluate hepatic studies: ALT, AST, bilirubin, creatinine, alkaline phosphatase.
  • Patient should undergo ophthalmic examination before, during and after therapy.
  • Observe for drowsiness, ataxia, confusion, especially in elderly or debilitated patient.
  • Drowsiness and dizziness may occur early in therapy; assist with ambulation, use siderails.
  • Provide gum, hard candy and frequent sips of water to relieve dry mouth.
  • Because of risk of apnea and cardiac arrest, resuscitative facilities should be available.
  • Monitor drug levels during therapy. Therapeutic level is 20–80 mg/ml.
  • Monitor for blood dyscrasias: observe for fever, sore throat, bruising, rash, jaundice.
  • Monitor mental status: mood, sensorium, affect, oversedation, sleep pattern, drowsiness, behavioral changes (especially in children; eg, inattention in school). Report changes to physician.
  • Monitor seizure activity and record. Take seizure precautions as needed.
  • Abrupt withdrawal, particularly in long-term, high-dose therapy, may cause status epilepticus, vomiting, diarrhea, and sweating; monitor patient carefully.
OVERDOSAGE: SIGNS & SYMPTOMS
  Somnolence, confusion, diminished reflexes, coma

 Patient/Family Education

  • Instruct patient to take drug with food or milk to decrease GI upset.
  • Tell patient not to take drug within 1 hr of antacid.
  • Instruct patient to keep record of seizure activity and report to physician.
  • Encourage patient to carry identification card or Medi-Alert bracelet that indicates diagnosis and drug dosage.
  • If patient is child, advise parents to supervise child’s play and watch for inattention.
  • Caution patient not to stop taking medication abruptly.
  • Advise patient to contact physician immediately if serious side effects (eg, changes in mental status) occur.
  • Instruct patient to rise slowly or fainting may occur, especially in elderly patients.
  • Advise patient to avoid intake of alcoholic beverages or other CNS depressants.
  • Advise patient that drug may cause drowsiness and to use caution while driving or performing other tasks requiring mental alertness.

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