promethazine

ROUTE	ONSET	PEAK	DURATION
PO, IM	20 min	unknown	4–12 hr
Rectal	20 min	unknown	4–12 hr
IV	3–5 min	unknown	4–12 hr

Contraindicated in:

Hypersensitivity;
Comatose patients;
Prostatic hypertrophy;
Bladder-neck obstruction;
Some products contain alcohol or bisulfites and should be avoided in patients with known intolerance;
Angle-closure glaucoma;
Pedi: Children <2 yr (may cause fatal respiratory depression).

Use Cautiously in:

Hypertension;
Cardiovascular disease;
Hepatic impairment;
Prostatic hypertrophy;
Glaucoma;
Asthma;
Sleep apnea;
Epilepsy;
Underlying bone marrow depression;
OB: Avoid chronic use during pregnancy;
Lactation: Safety not established in breastfeeding;
Pedi: Children >2 yr (use lowest effective dose and avoid concurrent respiratory depressants);
Geri: Appears on Beers list. ↑ risk of anticholinergic adverse reactions in older adults, including falls, delirium, and dementia. Avoid use in older adults.

Adv. Reactions/Side Effects ⬆ ⬇

CV: bradycardia, hypertension, hypotension, tachycardia

Derm: photosensitivity, rash, severe tissue necrosis upon infiltration at IV site

EENT: blurred vision, diplopia, tinnitus

GI: constipation, dry mouth, hepatitis

Hemat: blood dyscrasias

Neuro: confusion, disorientation, sedation, dizziness, extrapyramidal reactions, fatigue, insomnia, nervousness, NEUROLEPTIC MALIGNANT SYNDROME

Interactions ⬆ ⬇

Drug-drug:

Additive CNS depression with other CNS depressants, including alcohol, other antihistamines, opioid analgesics, and other sedative/hypnotics.
Neuroleptic malignant syndrome can occur when used with antipsychotics.
Additive anticholinergic effects with other drugs possessing anticholinergic properties, including other antihistamines, antidepressants, atropine, haloperidol, other phenothiazines, quinidine, and disopyramide.
May precipitate seizures when used with drugs that lower seizure threshold.
MAO inhibitors may ↑ risk of sedation and anticholinergic side effects.

Route/Dosage ⬆ ⬇

Antihistamine

PO (Adults ): 6.25–12.5 mg 3 times/day and 25 mg at bedtime.
PO (Children ≥2 yr): 0.1 mg/kg/dose (not to exceed 12.5 mg) every 6 hr during the day and 0.5 mg/kg/dose (not to exceed 25 mg) at bedtime.
IM IV Rect (Adults ): 25 mg; may repeat in 2 hr.
Rect (Children ≥2 yr): 0.125 mg/kg every 4–6 hr or 0.5 mg/kg at bedtime.

Antivertigo (Motion Sickness)

PO (Adults ): 25 mg 30–60 min before departure; may be repeated in 8–12 hr.
PO Rect (Children ≥2 yr): 0.5 mg/kg (not to exceed 25 mg) 30–60 min before departure; may be given every 12 hr as needed.

Sedation

PO Rect IM IV (Adults ): 25–50 mg; may repeat every 4–6 hr if needed.
PO Rect IM (Children >2 yr): 0.5–1 mg/kg (not to exceed 50 mg) every 6 hr as needed.

Nausea/Vomiting

PO Rect IM IV (Adults ): 12.5–25 mg every 4 hr as needed; initial PO dose should be 25 mg.
PO Rect IM IV (Children ≥2 yr): 0.25–1 mg/kg (not to exceed 25 mg) every 4–6 hr.

Availability ⬆ ⬇

(Generic available)

Tablets: 12.5 mg; 25 mg; 50 mg
Oral solution cherry flavor: 6.25 mg/5 mL
Solution for injection: 25 mg/mL; 50 mg/mL
Suppositories: 12.5 mg; 25 mg; 50 mg
In combination with: codeine, dextromethorphan, and/or phenylephrine in a variety of cough and cold preparations.

Assessment ⬆ ⬇

Monitor BP, HR, and respiratory rate frequently in patients receiving IV doses.
- Assess level of sedation after administration. Risk of sedation and respiratory depression are ↑ when administered concurrently with other drugs that cause CNS depression.
- Monitor patient for onset of extrapyramidal side effects (akathisia: restlessness; dystonia: muscle spasms and twisting motions; pseudoparkinsonism: masklike face, rigidity, tremors, drooling, shuffling gait, dysphagia). Notify health care provider if these symptoms occur.
- Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control). Notify health care provider immediately if these symptoms occur.
Assess for falls risk. Drowsiness, orthostatic hypotension, and motor and sensory instability ↑ risk. Institute prevention if indicated.
Geri: Assess for adverse anticholinergic effects (delirium, acute confusion, dizziness, dry mouth, blurred vision, urinary retention, constipation, tachycardia).
Allergy: Assess allergy symptoms (rhinitis, conjunctivitis, hives) before and periodically throughout course of therapy.
Antiemetic: Assess for nausea and vomiting before and after administration.

Lab Test Considerations:

May cause false-positive or false-negative pregnancy test results.
- Evaluate CBC periodically during chronic therapy; blood dyscrasias may occur.
- May ↑ serum glucose.
- May cause false-negative results in skin tests using allergen extracts. Promethazine should be discontinued 72 hr before the test.

Implementation ⬆ ⬇

When administering promethazine concurrently with opioid analgesics, supervise ambulation closely to prevent injury from ↑ sedation.
PO: Administer with food, water, or milk to minimize GI irritation. Tablets may be crushed and mixed with food or fluids for patients with difficulty swallowing.
IM: Administer deep into well-developed muscle. SUBQ or inadvertent intra-arterial administration may cause severe tissue necrosis and is contraindicated.

IV Administration:

IV: High Alert: If administered IV, assess for burning and pain at IV site; may cause severe tissue injury. Avoid IV administration, if possible. Administer IV only if IM injection not possible. If pain occurs after IV administration, discontinue administration immediately and evaluate for possible arterial injection or perivascular extravasation, and initiate appropriate medical management.
IV promethazine is a vesicant. Dilution is required before administering IV. Administer into a large vein or preferably through a central venous catheter. If extravasation occurs, immediately stop infusion. Leave needle/cannula in place temporarily but do not flush the line. Gently aspirate extravasated solution; then remove needle/cannula. Elevate patient's extremity and apply dry warm or dry cold compresses. Initiate hyaluronidase antidote for refractory cases in addition to supportive management. For hyaluronidase, inject a total of 1 mL (15 units/mL) intradermally or SUBQ as five separate 0.2-mL injections (using a tuberculin syringe) around the site of extravasation; if IV catheter remains in place, administer IV through the infiltrated catheter; may repeat in 30–60 min if no resolution.
IV Push: Diluent: Dilute with 0.9% NaCl or D5W. Concentration: 1 mg/mL.
Rate: Administer each 25 mg slowly, over ≥10–15 min (max rate = 25 mg/min). Rapid administration may ↓ BP.
Y-Site Compatibility:
- alemtuzumab
- amikacin
- aminocaproic acid
- amiodarone
- anidulafungin
- argatroban
- arsenic trioxide
- ascorbic acid
- atracurium
- atropine
- azithromycin
- benztropine
- bleomycin
- bumetanide
- buprenorphine
- butorphanol
- calcium chloride
- calcium gluconate
- carboplatin
- caspofungin
- ceftaroline
- chlorpromazine
- ciprofloxacin
- cisatracurium
- cisplatin
- cladribine
- cyanocobalamin
- cyclophosphamide
- cyclosporine
- cytarabine
- dacarbazine
- dactinomycin
- daptomycin
- daunorubicin
- dexmedetomidine
- dexrazoxane
- digoxin
- diltiazem
- diphenhydramine
- dobutamine
- docetaxel
- dopamine
- doxorubicin hydrochloride
- doxycycline
- edetate calcium disodium
- enalaprilat
- ephedrine
- epinephrine
- epirubicin
- epoetin alfa
- eptifibatide
- ergonovine
- erythromycin
- esmolol
- etoposide
- etoposide phosphate
- famotidine
- fentanyl
- filgrastim
- fluconazole
- fludarabine
- gemcitabine
- gentamicin
- glycopyrrolate
- granisetron
- hydromorphone
- idarubicin
- ifosfamide
- insulin, regular
- irinotecan
- isoproterenol
- ketamine
- labetalol
- leucovorin
- levofloxacin
- lidocaine
- linezolid
- lorazepam
- magnesium sulfate
- mannitol
- melphalan
- meperidine
- mesna
- methadone
- metoclopramide
- metoprolol
- metronidazole
- midazolam
- milrinone
- mitoxantrone
- morphine
- moxifloxacin
- mycophenolate
- nalbuphine
- naloxone
- nicardipine
- nitroglycerin
- norepinephrine
- octreotide
- ondansetron
- oxaliplatin
- oxytocin
- paclitaxel
- palonosetron
- pamidronate
- pemetrexed
- pentamidine
- phentolamine
- phenylephrine
- potassium acetate
- procainamide
- prochlorperazine
- propranolol
- protamine
- pyridoxine
- remifentanil
- rituximab
- rocuronium
- sargramostim
- sodium acetate
- succinylcholine
- sufentanil
- tacrolimus
- theophylline
- thiamine
- thiotepa
- tigecycline
- tirofiban
- tobramycin
- topotecan
- trastuzumab
- vancomycin
- vasopressin
- vecuronium
- verapamil
- vinblastine
- vincristine
- vinorelbine
- voriconazole
- zoledronic acid
Y-Site Incompatibility:
- acyclovir
- aldesleukin
- allopurinol
- aminophylline
- amphotericin B deoxycholate
- amphotericin B liposomal
- ampicillin/sulbactam
- azathioprine
- cangrelor
- carmustine
- cefepime
- cefotaxime
- cefotetan
- cefoxitin
- ceftazidime
- ceftobiprole
- ceftriaxone
- cefuroxime
- chlorothiazide
- clindamycin
- dantrolene
- diazepam
- diazoxide
- dimenhydrinate
- doxorubicin liposomal
- ertapenem
- fluorouracil
- folic acid
- foscarnet
- ganciclovir
- gemtuzumab ozogamicin
- indomethacin
- ketorolac
- methohexital
- methylprednisolone
- minocycline
- mitomycin
- morphine
- nafcillin
- nitroprusside
- oxacillin
- pantoprazole
- pentobarbital
- phenobarbital
- phenytoin
- piperacillin/tazobactam
- sodium bicarbonate
- trimethoprim/sulfamethoxazole

Patient/Family Teaching ⬆ ⬇

Explain purpose and side effects of medication. Advise patient to read Patient Information before starting therapy. Review dose schedule with patient. If medication is ordered regularly and a dose is missed, take as soon as remembered unless time for next dose. Pedi: Caution caregivers to use only the measuring device accompanying the liquid medication and not to use household measuring devices.
Advise patient to notify health care provider of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care provider before taking other medications.
May cause drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
Advise patient that frequent mouth rinses, good oral hygiene, and sugarless gum or candy may ↓ dry mouth. Health care provider should be notified if dry mouth persists >2 wk.
Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions.
Advise patient to change positions slowly to ↓ orthostatic hypotension. Protect from falls. Geri: Older adults are at ↑ risk.
Caution patient to avoid concurrent use of alcohol and other CNS depressants with this medication.
Instruct patient to notify health care provider if sore throat, fever, jaundice, or uncontrolled movements are noted.
Motion Sickness: When used as prophylaxis for motion sickness, advise patient to take medication ≥30 min and preferably 1–2 hr before exposure to conditions that may cause motion sickness.
Rep: Advise women of reproductive potential to notify health care provider if pregnancy is planned or suspected or if breastfeeding.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇