Clorazepate

INTRODUCTION

Indications

Management of simple partial seizures. Anxiety disorder, symptoms of anxiety. Acute alcohol withdrawal. Unlabeled Use: Anxiety associated with acute myocardial infarction.

Action

Acts at many levels in the CNS to produce anxiolytic effect and CNS depression (by stimulating inhibitory amma-aminobutyric acid [GABA] receptors). Produces skeletal muscle relaxation (by inhibiting spinal polysynaptic afferent pathways). Also has anticonvulsant effect (enhances presynaptic inhibition). Therapeutic Effects: Relief of anxiety. Sedation. Prevention of seizures.

Adverse Reactions/Side Effects

CNS: dizziness, drowsiness, lethargy, hangover, headache, mental depression, slurred speech, ataxia, paradoxical excitation. EENT: blurred vision. Resp: respiratory depression. GI: constipation, diarrhea, nausea, vomiting, weight gain (unusual). Derm: rashes. Misc: physical dependence, psychologic dependence, tolerance.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• In patients with seizures, document the number, duration, and severity of seizures to help determine drug efficacy.

• Monitor daytime drowsiness and “hangover,” symptoms such as headache, nausea, irritability, lethargy, dysphoria, and slurred speech. Repeated or excessive symptoms may require change in dose or medication.

• Assess confusion (See Appendix D) or other changes in behavior or cognition (decreased mental acuity, excessive excitation). Report problematic changes in cognitive function.

• Assess symptoms of respiratory depression such as dyspnea and cyanosis. Monitor pulse oximetry and perform pulmonary function tests (See Appendices I, J, K) to quantify suspected changes in ventilation and respiratory function.

• Assess dizziness and ataxia that might affect gait, balance, and other functional activities (See Appendix C). Report balance problems and functional limitations to the physician, and caution the patient and family/caregivers to guard against falls and trauma.

Interventions

• Guard against falls and trauma (hip fractures, head injury, and so forth). Implement fallprevention strategies, especially in older adults or if drowsiness and dizziness carry over into the daytime (See Appendix E).

• Help patient explore nonpharmacologic methods to reduce anxiety such as relaxation techniques, exercise, counseling, support groups, and so forth.

Patient/Client-Related Instruction

• Instruct patients on prolonged treatment not to discontinue medication without consulting their physician. Prolonged use can cause tolerance and dependence, and abrupt withdrawal can cause insomnia, unusual irritability or nervousness, and seizures.

• Advise patient to avoid alcohol and other CNS depressants because of the increased risk of sedation and adverse effects.

• Instruct patient to report other bothersome side effects such as severe or prolonged headache, blurred vision, skin rash, weight gain, or GI problems (nausea, vomiting, diarrhea, constipation).

Pharmacokinetics

Absorption: Well absorbed from the GI tract as desmethyldiazepam.

Distribution: Widely distributed. Crosses the placenta; enters breast milk.