Adverse effects
• CNS: Transient, mild drowsiness initially; sedation, depression, lethargy, apathy, fatigue, light-headedness, disorientation, anger, hostility, episodes of mania and hypomania, restlessness, confusion, crying, delirium, headache, slurred speech, dysarthria, stupor, rigidity, tremor, dystonia, vertigo, euphoria, nervousness, difficulty in concentration, vivid dreams, psychomotor retardation, extrapyramidal symptoms; mild paradoxical excitatory reactions during first 2 weeks of treatment
• CV: Bradycardia, tachycardia, cardiovascular collapse, hypertension, hypotension, palpitations, edema
• Dermatologic: Urticaria, pruritus, rash, dermatitis
• EENT: Visual and auditory disturbances, diplopia, nystagmus, depressed hearing, nasal congestion
• GI: Constipation, diarrhea, dry mouth, salivation, nausea, anorexia, vomiting, difficulty in swallowing, gastric disorders, hepatic dysfunction
• GU: Incontinence, urinary retention, changes in libido, menstrual irregularities
• Hematologic: Elevations of blood enzymes—LDH, alkaline phosphatase, AST, ALT; blood dyscrasias—agranulocytosis, leukopenia
• Other: Hiccups, fever, diaphoresis, paresthesias, muscular disturbances, gynecomastia. Drug dependence with withdrawal syndrome when drug is discontinued; more common with abrupt discontinuation of higher dosage used for longer than 4 mo
Interactions
Drug-drug
• Increased CNS depression with alcohol, other CNS depressants, propoxyphene
• Increased effect with cimetidine, disulfiram, omeprazole, isoniazid, hormonal contraceptives, valproic acid
• Decreased effect with carbamazepine, rifampin, theophylline
• Possible increased risk of digitalis toxicity with digoxin
• Decreased antiparkinson effectiveness of levodopa with benzodiazepines
• Contraindicated with ketoconazole, itraconazole; serious toxicity can occur
Drug-food
• Decreased metabolism and risk of toxic effects if combined with grapefruit juice; avoid this combination.
Drug-alternative therapy
• Risk of coma if combined with kava therapy
• Additive sedative effects with valerian root
Nursing considerations
CLINICAL ALERT!
Name confusion has occurred among Xanax (alprazolam), Celexa (citalopram), and Cerebyx (fosphenytoin), and between alprazolam and lorazepam; use caution.
Assessment
• History: Hypersensitivity to benzodiazepines; psychoses; acute narrow-angle glaucoma; shock; coma; acute alcoholic intoxication with depression of vital signs; labor and delivery; lactation; impaired liver or kidney function; debilitation
• Physical: Skin color, lesions; T; orientation, reflexes, affect, ophthalmologic examination; P, BP; liver evaluation, abdominal examination, bowel sounds, normal output; CBC, liver and renal function tests
Interventions
• Arrange to taper dosage gradually after long-term therapy, especially in epileptic patients.
• Do not administer with grapefruit juice.
Teaching points
• Take this drug exactly as prescribed; take ER form once daily in the AM.
• Do not drink grapefruit juice while on this drug.
• Do not stop taking drug (in long-term therapy) without consulting health care provider.
• Avoid alcohol, sleep-inducing, or OTC drugs.
• You may experience these side effects: Drowsiness, dizziness (these effects will be less pronounced after a few days, avoid driving a car or engaging in other dangerous activities if these occur); GI upset (take drug with food); fatigue; depression; dreams; crying; nervousness.
• Report severe dizziness, weakness, drowsiness that persists, rash or skin lesions, difficulty voiding, palpitations, swelling in the extremities.