chlorpromazine

ROUTE	ONSET	PEAK	DURATION
PO	30–60 min	unknown	4–6 hr
IM	unknown	unknown	4–8 hr
IV	rapid	unknown	unknown

Contraindicated in:

Hypersensitivity;
Hypersensitivity to sulfites (injectable);
Cross-sensitivity with other phenothiazines may occur;
Angle-closure glaucoma;
Bone marrow depression;
Severe liver/cardiovascular disease;
Concurrent pimozide use;
Lactation: Lactation.

Use Cautiously in:

Diabetes;
Respiratory disease;
Prostatic hyperplasia;
CNS tumors;
Epilepsy;
Intestinal obstruction;
OB: Neonates at risk for extrapyramidal symptoms and withdrawal after delivery when exposed during the 3rd trimester; use during pregnancy only if potential maternal benefit outweighs potential fetal risk;
Pedi: Children with acute illnesses, infections, gastroenteritis, or dehydration ( risk of extrapyramidal reactions);
Geri: Appears on Beers list. risk of stroke, cognitive decline, and mortality in older adults with dementia. Avoid use in older adults, except for schizophrenia, bipolar disorder, or for short-term use as an antiemetic.

Adv. Reactions/Side Effects ⬆ ⬇

CV: hypotension (↑ with IM, IV), tachycardia

Derm: photosensitivity, pigment changes, rash

EENT: blurred vision, dry eyes, lens opacities

Endo: amenorrhea, galactorrhea

GI: constipation, dry mouth, anorexia, hepatitis, ileus, priapism

GU: urinary retention

Hemat: AGRANULOCYTOSIS, leukopenia

Metab: hyperthermia

Neuro: sedation, extrapyramidal reactions, NEUROLEPTIC MALIGNANT SYNDROME, tardive dyskinesia

Misc: allergic reactions

Interactions ⬆ ⬇

Drug-drug:

Pimozide↑ the risk of potentially serious cardiovascular reactions; concurrent use contraindicated.
May alter serum phenytoin levels.
↓pressor effect of norepinephrine and eliminates bradycardia.
Antagonizes peripheral vasoconstriction from epinephrine and may reverse some of its actions.
May ↓ elimination and ↑ effects of valproic acid.
May ↓ the pharmacologic effects of amphetamine and related compounds.
May ↓ the effectiveness of bromocriptine.
May ↑ blood levels and effects of tricyclic antidepressants.
Antacids or adsorbent antidiarrheals may ↓ adsorption; administer 1 hr before or 2 hr after chlorpromazine.
↑risk of anticholinergic effects with antihistamines, tricyclic antidepressants, quinidine, or disopyramide.
Premedication with chlorpromazine ↑ the risk of neuromuscular excitation and hypotension when followed by barbiturate anesthesia.
Barbiturates may ↑ metabolism and ↓ effectiveness.
Chlorpromazine may ↓ barbiturate levels.
Additive hypotension with antihypertensives.
Additive CNS depression with alcohol, antidepressants, antihistamines, MAO inhibitors, opioid analgesics, sedative/hypnotics, or general anesthetics.
Concurrent use with lithium may produce disorientation, unconsciousness, or extrapyramidal symptoms.
Concurrent use with meperidine may produce excessive sedation and hypotension.
Concurrent use with propranolol↑ blood levels of both drugs.

Drug-Natural Products:

Concomitant use of kava-kava, valerian, chamomile, or hops can ↑ CNS depression.
↑anticholinergic effects with angel’s trumpet, jimson weed, and scopolia.

Route/Dosage ⬆ ⬇

PO (Adults ): Psychoses: 10–25 mg 2–4 times daily; may ↑ by 20–50 mg every 3–4 days (usual dose is 200 mg/day; up to 1 g/day). Bipolar disorder: 10–25 mg 2–4 times daily; may ↑ by 20–50 mg every 3–4 days (usual dose range is 400–800 mg/day). Nausea and vomiting: 10–25 mg every 4 hr as needed. Preoperative sedation: 25–50 mg 2–3 hr before surgery. Hiccups/porphyria: 25–50 mg 3–4 times daily.
PO (Children ): Psychoses/nausea and vomiting: 0.55 mg/kg (15 mg/m²) every 4–6 hr as needed. Preoperative sedation: 0.55 mg/kg (15 mg/m²) 2–3 hr before surgery.
IV (Adults ): Nausea/vomiting during surgery: up to 25 mg. Hiccups/tetanus: 25–50 mg. Porphyria: 25 mg every 8 hr.
IV (Children ): Nausea/vomiting during surgery: 0.275 mg/kg. Tetanus: 0.55 mg/kg.
IM (Adults ): Severe psychoses: 25–50 mg initially, may be repeated in 1 hr; ↑ to maximum of 400 mg every 3–12 hr if needed (up to 1 g/day). Nausea/vomiting: 25 mg initially, may repeat with 25–50 mg every 3–4 hr as needed. Nausea/vomiting during surgery: 12.5 mg, may be repeated in 30 min as needed. Preoperative sedation: 12.5–25 mg 1–2 hr prior to surgery. Hiccups/tetanus: 25–50 mg 3–4 times daily. Porphyria: 25 mg every 6–8 hr until patient can take PO.
IM (Children 6 mo): Psychoses/nausea and vomiting: 0.55 mg/kg (15 mg/m²) every 6–8 hr (not to exceed 40 mg/day in children 6 mo–5 yr, or 75 mg/day in children 5–12 yr). Nausea/vomiting during surgery: 0.275 mg/kg, may repeat in 30 min as needed. Preoperative sedation: 0.55 mg/kg 1–2 hr prior to surgery. Tetanus: 0.55 mg/kg every 6–8 hr.

Availability ⬆ ⬇

(Generic available)

Tablets: 10 mg; 25 mg; 50 mg; 100 mg; 200 mg
Oral solution: 30 mg/mL; 100 mg/mL
Solution for injection: 25 mg/mL

Assessment ⬆ ⬇

Assess mental status (orientation, mood, behavior) prior to and periodically during therapy.
- Assess weight and BMI initially and throughout therapy. Refer as appropriate for nutritional/weight and medical management.
- Assess positive (hallucinations, delusions, agitation) and negative (social withdrawal) symptoms of schizophrenia.
- Monitor BP (sitting, standing, lying), pulse, and respiratory rate prior to and frequently during the period of dose adjustment.
- Observe patient carefully when administering medication to ensure medication is actually taken and not hoarded.
- Assess fluid intake and bowel function. Increased bulk and fluids in the diet may help minimize constipation.
- Monitor patient for onset of akathisia (restlessness or desire to keep moving) and extrapyramidal side effects (parkinsonian: difficulty speaking or swallowing, loss of balance control, pill rolling of hands, mask-like face, shuffling gait, rigidity, tremors; and dystonic: muscle spasms, twisting motions, twitching, inability to move eyes, weakness of arms or legs) every 2 mo during therapy and 8–12 wk after therapy has been discontinued. Notify health care professional if these symptoms occur; reduction in dose or discontinuation may be necessary. Trihexyphenidyl, diphenhydramine, or benztropine may be used to control these symptoms. Benzodiazepines may alleviate symptoms of akathisia.
- Monitor for tardive dyskinesia (uncontrolled rhythmic movement of mouth, face, and extremities; lip smacking or puckering; puffing of cheeks; uncontrolled chewing; rapid or worm-like movements of tongue, excessive eye blinking). Report these symptoms immediately; may be irreversible.
- Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, convulsions, diaphoresis, hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control). Report these symptoms immediately.
- Monitor for symptoms related to hyperprolactinemia (menstrual abnormalities, galactorrhea, sexual dysfunction).
Assess for falls risk. Drowsiness, orthostatic hypotension, and motor and sensory instability increase risk. Institute prevention if indicated.
Preoperative Sedation: Assess level of anxiety prior to and following administration.

Lab Test Considerations:

Monitor CBC, liver function tests, and ocular exams periodically during therapy. May cause ↓ hematocrit, hemoglobin, leukocytes, granulocytes, platelets. May cause ↑ bilirubin, AST, ALT, and alkaline phosphatase. Agranulocytosis may occur 4–10 wk after initiation of therapy, with recovery 1–2 wk following discontinuation. May recur if medication is restarted. Liver function abnormalities may require discontinuation of therapy. May cause false-positive or false-negative pregnancy tests and false-positive urine bilirubin test results.
- Assess fasting blood glucose and cholesterol levels initially and periodically throughout therapy.
- May cause ↑ serum prolactin levels.

Implementation ⬆ ⬇

Do not confuse chlorpromazine with chlordiazepoxide.
- Keep patient recumbent for at least 30 min following parenteral administration to minimize hypotensive effects.
Hiccups: Initial treatment is with oral doses. If hiccups persist 2–3 days, IM injection may be used, followed by IV infusion.
PO: Administer oral doses with food, milk, or a full glass of water to minimize gastric irritation. Tablets may be crushed.
- Mix oral solution with ≥60 mL of a carbonated beverage, coffee, fruit or tomato juice, milk, orange syrup, simple syrup, tea, or water; may also add to semisolid food (pudding, soup).
IM: Do not inject SUBQ. Inject slowly into deep, well-developed muscle. May be diluted with 0.9% NaCl or 2% procaine. Lemon-yellow color does not alter potency of solution. Do not administer solution that is markedly discolored or contains a precipitate.

IV Administration:

Diluent: Dilute with 0.9% NaCl.Concentration: Do not exceed 1 mg/mL.
Rate: Inject slowly at a rate of at least 1 mg/min for adults and 0.5 mg/min for children.
Rate: 1 mg/min.

Patient/Family Teaching ⬆ ⬇

Advise patient to take medication as directed and not to skip doses or double up on missed doses. If a dose is missed, take within 1 hr or omit dose and return to regular schedule. Abrupt withdrawal may lead to gastritis, nausea, vomiting, dizziness, headache, tachycardia, and insomnia.
Inform patient of possibility of extrapyramidal symptoms and tardive dyskinesia. Instruct patient to report these symptoms immediately to health care professional.
Advise patient to change positions slowly to minimize orthostatic hypotension. Protect from falls.
May cause drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to the medication is known.
Caution patient to avoid taking alcohol or other CNS depressants concurrently with this medication.
Advise patient to use sunscreen and protective clothing when exposed to the sun. Exposed surfaces may develop a temporary pigment change (ranging from yellow-brown to grayish purple). Extremes of temperature (exercise, hot weather, hot baths or showers) should also be avoided, because this drug impairs body temperature regulation.
Instruct patient to use frequent mouth rinses, good oral hygiene, and sugarless gum or candy to minimize dry mouth. Consult health care professional if dry mouth continues for 2 wk.
Advise patient not to take chlorpromazine within 2 hr of antacids or antidiarrheal medication.
Inform patient that this medication may turn urine a pink-to-reddish-brown color.
Advise patient to notify health care professional of medication regimen prior to treatment or surgery.
Instruct patient to notify health care professional promptly if sore throat, fever, unusual bleeding or bruising, rash, weakness, tremors, visual disturbances, dark-colored urine, or clay-colored stools occur.
Rep: Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding.
Emphasize the importance of routine follow-up exams to monitor response to medication and detect side effects. Encourage continued participation in psychotherapy as indicated.
Treatment is not a cure; symptoms may recur after discontinuation of medication.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇