ANALGESICS, NONOPIOID

Acetaminophen

• Mild pain, headache

• Severe liver damage, neutropenia, thrombocytopenia

• Monitor total daily intake of acetaminophen because of risk of liver toxicity. Use with caution in elderly patients and those with liver disease.

ANALGESICS, OPIOID

Codeine

• Mild to moderate pain

• Respiratory depression, bradycardia, sedation, constipation

• Monitor for respiratory depression. Use with caution in elderly patients and those with head injury, seizures, or increased ICP.

Morphine

• Severe pain

• Respiratory depression, apnea, bradycardia, seizures, sedation

• Monitor for respiratory depression. Use with caution in elderly patients and those with head injury, seizures, or increased ICP. Contraindicated in patients with acute bronchial asthma.

ANTICONVULSANTS

Carbamazepine

• Generalized tonicclonic seizures, complex partial seizures, mixed seizures

• Heart failure, worsening of seizure, atrioventricular block, hepatitis, thrombocytopenia, Stevens-Johnson syndrome

• Use cautiously in patients with mixed seizure disorders because it can increase the risk of seizure. Use cautiously in patients with hepatic dysfunction. Obtain baseline liver function studies, complete blood count, and blood urea nitrogen level. Monitor blood levels of the drug; therapeutic level is 4 to 12 mcg/ml.

Fosphenytoin

• Status epilepticus, seizures during neurosurgery

• Increased ICP, cerebral edema, somnolence, bradycardia, QT prolongation, heart block

• Stop drug with acute hepatotoxicity. May cause hyperglycemia; monitor blood glucose in diabetic patients. Fosphenytoin should be prescribed and dispensed in PE units. Monitor for cardiac arrhythmias and QT prolongation.

Phenytoin

• Generalized tonicclonic seizures, status epilepticus, nonepileptic seizures after head trauma

• Agranulocytosis, thrombocytopenia, toxic hepatitis, slurred speech, Stevens-Johnson syndrome

• Abrupt withdrawal can trigger status epilepticus. Contraindicated in patients with heart block. Use cautiously in patients with hepatic disease and myocardial insufficiency. Monitor blood levels of the drug; therapeutic range is 10 to 20 mcg/ml. If rash appears, stop the drug.

Primidone

• Generalized tonicclonic seizures, focal seizures, and complex partial seizures

• Thrombocytopenia, drowsiness, ataxia

• Abrupt withdrawal can cause status epilepticus. Reduce dosage in elderly patients.

Valproic acid, valproate

• Complex partial seizures, simple and complex absence seizures

• Thrombocytopenia, pancreatitis, toxic hepatitis, sedation, ataxia

• Obtain baseline liver function tests. Avoid use in patients at high risk for hepatotoxicity. Abrupt withdrawal may worsen seizures. Monitor blood levels of the drug; therapeutic range is 50 to 100 mcg/ml.

ANTICOAGULANTS

Heparin

• Embolism prophylaxis after cerebral thrombosis in evolving stroke

• Hemorrhage, thrombocytopenia

• Monitor for bleeding. Obtain baseline prothrombin time/International Normalized Ratio (PT/INR), and partial thromboplastin time (PTT). Monitor PTT at regular intervals. Protamine sulfate reverses the effects of heparin.

ANTIPLATELETS

Aspirin

• Transient ischemic attacks, thromboembolic disorders

• GI bleeding, acute renal insufficiency, thrombocytopenia, liver dysfunction

• Monitor for bleeding. Avoid use in patients with active peptic ulcer and GI inflammation.

Sulfinpyrazone

• Thrombotic stroke prophylaxis

• Blood dyscrasia, thrombocytopenia, bronchoconstriction

• Monitor for bleeding. Avoid use in patients with active peptic ulcer and GI inflammation.

Ticlopidine

• Thrombotic stroke prophylaxis

• Thrombocytopenia, agranulocytosis

• Monitor for bleeding. Avoid use in patients with hepatic impairment and peptic ulcer disease.

BARBITURATES

Phenobarbital

• All types of seizures except absence seizures and febrile seizures in children; also used for status epilepticus, sedation, and drug withdrawal

• Respiratory depression, apnea, bradycardia, angioedema, Stevens-Johnson syndrome

• Monitor for respiratory depression and bradycardia. Keep resuscitation equipment on hand when administering I.V. dose; monitor respirations.

BENZODIAZEPINES

Clonazepam

• Absence and atypical seizures, generalized tonic-clonic seizures, status epilepticus, panic disorders

• Respiratory depression, thrombocytopenia, leukopenia, drowsiness, ataxia

• Abrupt withdrawal may precipitate status epilepticus. Elderly patients are at a greater risk for central nervous system (CNS) depression and may require a lower dose.

Diazepam

• Status epilepticus, anxiety, acute alcohol withdrawal, muscle spasm

• Respiratory depression, bradycardia, cardiovascular collapse, drowsiness, acute withdrawal syndrome

• Monitor for respiratory depression and cardiac arrhythmia. Don’t stop suddenly; can cause acute withdrawal in physically dependent persons.

Lorazepam

• Status epilepticus, anxiety, agitation

• Drowsiness, acute withdrawal syndrome

• Don’t stop abruptly; can cause withdrawal. Monitor for CNS depressant effects in elderly patients.

CALCIUM CHANNEL BLOCKERS

Nimodipine

• Neurologic deficits caused by cerebral vasospasm after congenital aneurysm rupture

• Decreased blood pressure, tachycardia, edema

• Use cautiously in hepatic failure. Monitor for hypotension and tachycardia.

CORTICOSTEROIDS

Dexamethasone, methylprednisolone

• Cerebral edema, severe inflammation

• Heart failure, cardiac arrhythmias, edema, circulatory collapse, thromboembolism, pancreatitis, peptic ulceration

• Use cautiously in patients with recent myocardial infarction, hypertension, renal disease, and GI ulcer. Monitor blood pressure and blood glucose levels.

DIURETICS

Furosemide (loop)

• Edema, hypertension

• Renal failure, thrombocytopenia, agranulocytosis, volume depletion, dehydration

• Monitor blood pressure, pulse, and intake and output. Monitor serum electrolyte levels, especially potassium levels. Monitor for cardiac arrhythmias.

Mannitol (osmotic)

• Cerebral edema, increased intracranial pressure (ICP)

• Heart failure, seizures, fluid and electrolyte imbalance

• Contraindicated in severe pulmonary congestion and heart failure. Monitor blood pressure, heart rate, and intake and output. Monitor serum electrolyte levels. Use with caution in patients with renal dysfunction.

THROMBOLYTICS

Alteplase (recombinant tissue plasminogen activator)

• Acute ischemic stroke

• Cerebral hemorrhage, spontaneous bleeding, allergic reaction

• Contraindicated in patients with intracranial or subarachnoid hemorrhage. The patient must meet criteria for thrombolytic therapy before initiation of therapy. Monitor baseline laboratory values: hemoglobin level, hematocrit, PTT, PT/INR. Monitor vital signs. Monitor for signs of bleeding. Monitor puncture sites for bleeding.

Streptokinase

• Acute ischemic stroke

• Cerebral hemorrhage, spontaneous bleeding, allergic reaction

• Contraindicated in patients with intracranial or subarachnoid hemorrhage. The patient must meet criteria for thrombolytic therapy before initiation of therapy. Monitor baseline laboratory values: hemoglobin level, hematocrit, PTT, PT/INR. Monitor vital signs. Monitor for signs of bleeding. Monitor puncture sites for bleeding.