SERTRALINE
- 3.13 HEMATOLOGIC
- 3.13.1 SUMMARY
- A. Anterior chamber eye
hemorrhage and purpura have occurred infrequently with sertraline
therapeutic use.
- 3.13.2 CLINICAL EFFECTS
- A. PURPURA
- 1. HEMORRHAGE - Anterior
chamber eye hemorrhage and purpura have occurred infrequently with
sertraline therapeutic use (Prod Info Zoloft(R), 1992).
- 2. A case of prolonged
bleeding time associated with ecchymoses and normal prothrombin and
partial thromboplastin time and normal hepatic enzymes has been
reported which resolved spontaneously with drug cessation (Calhoun
& Calhoun, 1996).
- B. LEUKOCYTOSIS
- 1. CASE REPORT -
Leukocytosis of 24.5 x 10(9)/L was observed nine hours following an
overdose in a pediatric patient. It was likely that the leukocytosis
was not directly related to the overdose as a subsequent urine culture
revealed greater than 100,000 lactose-fermenting Gram-negative rods
(Kaminski et al, 1994).
- 3.14 DERMATOLOGIC
- 3.14.1 SUMMARY
- A. Various types of
dermatitis have been reported with therapeutic use.
- B. Cutaneous vasodilation
has been reported following overdose.
- 3.14.2 CLINICAL EFFECTS
- A. SUMMARY
- 1. Infrequently, rash,
acne, pruritus, alopecia, hypertrichosis, dermatitis, erythema
multiforme, urticaria, and skin discoloration have been reported.
- B. VASODILATATION
- 1. CASE REPORT -
Vasodilation, with flushing, has been reported following a 2 gram
overdose of sertraline in a 42-year-old female with concomitant
alcohol ingestion (Brown & Kerr, 1994).
- 3.15 MUSCULOSKELETAL
- 3.15.1 SUMMARY
- A. Sertraline has been
associated with myalgia, arthralgia, dystonia, and muscle weakness.
- B. Elevated creatine
phosphokinase (CPK) levels may be seen following an acute overdose.
- 3.15.2 CLINICAL EFFECTS
- A. SUMMARY
- 1. Sertraline has been
associated with myalgia, arthralgia, dystonia, and muscle weakness
(Prod Info Zoloft(R), 1992).
- B. CREATINE PHOSPHOKINASE
INCREASED
- 1. CASE REPORT - Elevated
CPK levels were seen in a pediatric overdose of sertraline. CPK levels
rose from 525 U/L on day 1 to 21,285 U/L on day 2, then gradually
decreased over the following day (Kaminski et al, 1994).
- 3.16 ENDOCRINE
- 3.16.1 SUMMARY
- A. Gynecomastia,
galactorrhea, breast pain, and breast enlargement have rarely been
reported with sertraline use.
- 3.16.2 CLINICAL EFFECTS
- A. GYNECOMASTIA
- 1. Gynecomastia,
galactorrhea, breast pain, and breast enlargement have been reported
with sertraline use (Prod Info Zoloft(R), 1992; Bronzo & Stahl,
1993).
- 3.17 METABOLISM
- 3.17.1 SUMMARY
- A. Hypoglycemia,
hypercholesterolemia, hypertriglyceridemia, and a small decrease in
serum uric acid have been occasionally associated with therapeutic
sertraline use.
- 3.17.2 CLINICAL EFFECTS
- A. SUMMARY
- 1. THERAPEUTIC ADVERSE
EFFECTS - Hypoglycemia, hypercholesterolemia, hypertriglyceridemia and
a small decrease in serum uric acid have been occasionally associated
with therapy (Prod Info Zoloft(R), 1992).
- 3.20 REPRODUCTIVE
- 3.20.1 SUMMARY
- A. Sertraline has been
classified as FDA Pregnancy Category B.
- 3.20.2 TERATOGENICITY
- A. LACK OF EFFECT
- 1. ANIMAL STUDIES -
Sertraline is reported to have no teratogenic effects in rats and
rabbits at maternally toxic doses. Similar to other serotonin reuptake
inhibitors, decreased neonatal survival and growth was observed in these
studies (Davies & Klowe, 1998).
- 3.20.3 EFFECTS IN PREGNANCY
§ SERTRALINE
B
§ References: Prod Info Zoloft(R), 1992; Briggs
§ et al, 1998.
- 3.20.4 EFFECTS DURING
BREAST-FEEDING
- A. BREAST MILK
- 1. Sertraline and
norsertraline plasma levels were measured in 3 mother-infant pairs,
with maternal doses ranging from 50 to 100 mg/day. Sertraline plasma
levels in the infants were low, less than 2 ng/mL of either sertraline
or norsertraline. The infants showed no adverse effects (Mammen et al,
1997). Wisner et al (1998) reported sertraline and
N-desmethylsertraline levels in 9 mother-infant pairs. Sertraline
levels were less than 2 ng/mL in 7 of the infants, and the metabolite
levels were also low, less than or equal to 6 ng/mL, in 7 of the
infants.
- 2. Epperson et al (1997)
measured platelet 5-hydroxytryptamine levels in sertraline-treated
mothers and their nursing infants. Marked declines were noted in the
mothers (to 10.2 +/-2.9 percent of baseline), but little or no change
in levels was reported in the infants. This is consistent with low
plasma concentration of sertraline in the nursing infants.
- 3.21 CARCINOGENICITY
- 3.21.2 SUMMARY/HUMAN
- A. Animal studies have
resulted in negative carcinogenicity tests.
- 3.21.3 HUMAN STUDIES
- A. ANIMAL STUDIES
- 1. Two year range finding
studies in the mouse and rat, with dosing at 10, 40, and 80 mg/kg,
revealed negative carcinogenicity tests in rats, while benign liver
tumors, believed secondary to enzyme induction by sertraline, were
reported at an increased rate in male mice (Davies & Klowe, 1998).
- 3.23 OTHER
- 3.23.2 CLINICAL EFFECTS
- A. CONTRAINDICATIONS
- 1. Do not use in
combination with a monoamine oxidase inhibitor or within 14 days of
discontinuing treatment or initiating treatment with a monoamine
oxidase inhibitor due to the risk of serotonin syndrome.
- 2. Use with caution in
patients with preexisting seizure disorders.
- 3. Caution should be used
in agitated or hyperactive patients as sertraline may produce or
activate mania or hypomania.
- 4. Use with caution in
patients taking other psychotropic medications.
- 5. Use with caution in
patients with recent myocardial infarction, unstable heart disease,
hepatic or renal dysfunction.
- B. DRUG INTERACTION
- 1. SUMMARY - Sertraline is
weak inhibitor of hepatic enzymes CYP1A2, CYP2C9/10, CYP2C19, CYP2D6
and CYP3A3/4. Inhibition appears to be dose-dependent, with higher
doses, such as in overdoses, resulting in possible clinical relevance
of drug interactions, particularly with tricyclic antidepressants
(resulting in increased serum levels of TCA and toxicity).
- a. Major pharmacodynamic
drug interactions concern the development of the serotonin syndrome. This
is probably due to activation of 5-HT(1A) receptors in the brain. Drugs
reacting with sertraline to result in serotonin syndrome include
monoamine oxidase inhibitors (MAOI), tryptophan, lithium, and
possibly moclobemide and rifampin (Mitchell, 1997). See DrugReax(R)
for a more detailed list of drugs interacting with sertraline.
- 2. MAOI - Serotonin
syndrome has been reported in patients taking sertraline and MAOI's. Hyperthermia,
rigidity, myoclonus, autonomic instability, respiratory depression,
syncope, incoordination, agitation, impaired memory, delirium, and
coma have been reported when used in combination (Graber et al, 1994;
Bhatara et al, 1993; Prod Info Zoloft(R), 1992).
- 3. TOLBUTAMIDE - Concurrent
administration produced a 16% decrease in the clearance of tolbutamide
(Prod Info Zoloft(R), 1992).
- 4. WARFARIN - Due to
extensive protein binding, overdose with sertraline may increase the
unbound amounts of warfarin in the serum (Prod Info Zoloft(R), 1992).
- 5. TRAMADOL -
Coadministration of sertraline with tramadol resulted in possible
serotonin syndrome in a 42-year-old female. She had been receiving
sertraline therapy for about 1 yr prior to the addition of tramadol to
her therapy. Within 3 weeks of tramadol dosing, symptoms of serotonin
syndrome developed (Mason & Blackburn, 1997).
- 6. RIFAMPIN - Markowitz
& DeVane (2000) reported rifampin-induced sertraline withdrawal
syndrome in a patient 7 days after starting rifampin while already on
chronic sertraline therapy. It is speculated that rifampin induced the
hepatic CYP3A4 enzyme system, which is thought to metabolize
sertraline.
- C. WITHDRAWAL SYNDROME
- 1. A constellation of
symptoms have been reported following discontinuation of sertraline
therapy. Symptoms have included: fatigue, nausea, abdominal cramps,
diarrhea, shortness of breath, memory impairment, dizziness, insomnia,
chills, headache, eye discomfort, tinnitus, ataxia, abnormal
sensations ("electric shocks", skin tingling sensations, and
involuntary movements). Symptoms typically resolve spontaneously,
generally within 3 weeks, or with reinstatement of sertraline therapy
(Leiter et al, 1995; Louie et al, 1994; Frost & Lal, 1995; Wolfe,
1997; Zajecka et al, 1997).
- 2. CASE REPORT/PEDIATRIC -
Withdrawal symptoms in a neonate after maternal sertraline therapy has
been reported. Symptoms included: agitation, restlessness, poor
feeding, constant crying, insomnia and an enhanced startle reaction. The
child had been well until one day postpartum and symptoms resolved
gradually over the course of a week. The mother remained asymptomatic
(Kent & Laidlaw, 1995).
- 4.0 LABORATORY/MONITORING
- 4.1 MONITORING
PARAMETERS/LEVELS
- 4.1.1 SUMMARY
- A. Asymptomatic elevations
in serum transaminases have been reported within the first 9 weeks of
sertraline treatment and have disappeared promptly upon discontinuation
of sertraline.
- B. Sertraline produces a
mean 7% decrease in serum uric acid concentrations.
- C. A decreased white count
has been seen therapeutically. It has not been reported in overdoses.
- D. The syndrome of
inappropriate secretion of antidiuretic hormone with significant
hyponatremia, elevated urinary sodium, and decreased serum osmolarity
has been reported with sertraline therapy.
- E. Monitor for
signs/symptoms of serotonin syndrome and possible seizures.
- 4.1.2 SERUM/BLOOD
- A. BLOOD/SERUM CHEMISTRY
- 1. LIVER FUNCTION TESTS -
Asymptomatic elevations in serum transaminases have been reported
within the first 9 weeks of sertraline treatment and have disappeared
promptly upon discontinuation of the drug (Cohn et al, 1990; Prod Info
Zoloft(R), 1992).
- 2. URIC ACID - Sertraline
produces a mean 7% decrease in serum uric acid concentrations (Prod
Info Zoloft(R), 1992).
- 3. HYPONATREMIA associated
with SIADH has been reported with sertraline therapy.
- B. HEMATOLOGIC
- 1. WHITE CELL COUNT - A
decreased white blood cell count has been seen therapeutically. It has
not been reported in overdoses.
- 4.1.3 URINE
- A. URINALYSIS
- 1. Increased urinary sodium
excretion associated with SIADH has been reported with sertraline
therapy. Urinalysis may be recommended.
- 4.3 METHODS
- A. CHROMATOGRAPHY
- 1. Sertraline can be
analyzed by gas chromatographic-mass spectrometric analysis (Fouda et
al, 1987).
- 5.0 ABSTRACTS
- 5.1 CASE REPORTS
- A. ADULT
- 1. A 23-year-old female with
depression took an overdose of 750 to 1000 milligrams. She was lavaged,
observed, and treated symptomatically. She recovered without sequelae
(Prod Info Zoloft(R), 1992).
- 2. A 43-year-old female took
1400 milligrams with unknown amounts of alcohol, temazepam, and
mefenamic acid. She was observed overnight and discharged without
sequelae the next day (Prod Info Zoloft(R), 1992).
- B. PEDIATRIC
- 1. A 9-year-old ingested an
unknown quantity of sertraline and presented to the emergency
department with tachycardia, hypertension, hallucinations,
hyperthermia, vasodilation, and tremors in all extremities. The patient
was extremely agitated and delirious. His pupils became fixed and
dilated and tonic shaking activity became more intense over the next
several hours (Kaminski et al, 1994).
- a. Laboratory tests
revealed increased levels of liver enzymes, CPK, and leukocytes.
- b. Activated charcoal with
sorbitol was administered in the ED. Since the child was exhibiting an
anticholinergic reaction, physostigmine was administered by slow
intravenous infusion in a dose of 0.5 mg every 10 minutes for a total
of 2 mg. An appropriate reduction in heart rate and temperature
resulted. By the fourth hospital day, a mild tremor was still present,
and the child was subsequently discharged to home.
- 2. Meier & Lam (1998)
report a sertraline overdose of 4000 mg and naproxen 7700 mg in a
14-year-old girl. Decontamination with activated charcoal was given 3
hours post-ingestion. Mild sedation was noted. Treatment included
prochlorperazine for mild nausea and vomiting, lactated ringer's
solution and repeated activated charcoal.
- a. The girl sustained a
grand mal seizure at 4.5 hours post-ingestion followed by sinus
tachycardia (102-108 bpm). Approximately 5.5 hours post-ingestion she
experienced a second seizure. No anticonvulsants were given. No anion
gap was noted on laboratory reports. Serum sertraline level was
reported to be >1000 ng/mL. Urine toxicology was negative for other
drugs. The patient was discharged to psychiatric care 2 days later.
- 6.0 TREATMENT
- 6.1 LIFE SUPPORT
- A. Support respiratory and
cardiovascular function.
- 6.3 PATIENT DISPOSITION
- 6.3.1 DISPOSITION/ORAL EXPOSURE
- 6.3.1.5 OBSERVATION
CRITERIA/ORAL
- A. A minimum observation
period of 6 hours is recommended in cases of massive sertraline
overdoses in order to prevent complications associated with
sertraline-induced seizures. When serotonin syndrome is suspected,
longer observation periods may be necessary.
- 6.4 MONITORING
- A. Asymptomatic elevations in serum
transaminases have been reported within the first 9 weeks of sertraline
treatment and have disappeared promptly upon discontinuation of
sertraline.
- B. Sertraline produces a mean 7%
decrease in serum uric acid concentrations.
- C. A decreased white count has been seen
therapeutically. It has not been reported in overdoses.
- D. The syndrome of inappropriate
secretion of antidiuretic hormone with significant hyponatremia,
elevated urinary sodium, and decreased serum osmolarity has been
reported with sertraline therapy.
- E. Monitor for signs/symptoms of
serotonin syndrome and possible seizures.
- 6.5 ORAL
EXPOSURE
- 6.5.1
PREVENTION OF ABSORPTION/PREHOSPITAL
- A. EMESIS/NOT
RECOMMENDED -
- 1. EMESIS:
Ipecac-induced emesis is not recommended because of the potential for
CNS depression and seizures.
- B. ACTIVATED
CHARCOAL -
- 1. PREHOSPITAL
ACTIVATED CHARCOAL ADMINISTRATION
- a. Consider
prehospital administration of activated charcoal as an aqueous slurry
in patients with a potentially toxic ingestion who are awake and able
to protect their airway. Activated charcoal is most effective when
administered within one hour of ingestion.
- (1) In
patients who are at risk for the abrupt onset of seizures or mental
status depression, activated charcoal should be administered by
medical or paramedical personnel capable of airway management to
prevent aspiration in the event of spontaneous emesis.
- 2. CHARCOAL
DOSE
- a. Use a
minimum of 240 milliliters of water per 30 grams charcoal (FDA,
1985). Optimum dose not established; usual dose is 25 to 100 grams in
adults and adolescents; 25 to 50 grams in children aged 1 to 12
years; and 1 gram/kilogram in infants up to 1 year old (USP DI, 2000;
Chyka & Seger, 1997).
- (1) Routine
use of a cathartic with activated charcoal is NOT recommended as
there is no evidence that cathartics reduce drug absorption and
cathartics are known to cause adverse effects such as nausea,
vomiting, abdominal cramps, electrolyte imbalances and occasionally
hypotension (Barceloux et al, 1997).
- b. ADVERSE
EFFECTS/CONTRAINDICATIONS
- (1)
Complications: emesis, aspiration (Chyka & Seger, 1997). Refer
to the ACTIVATED CHARCOAL/TREATMENT management for further
information.
- (2)
Contraindications: unprotected airway, gastrointestinal tract not
anatomically intact, therapy may increase the risk or severity of
aspiration; ingestion of most hydrocarbons (Chyka & Seger,
1997).
- 6.5.2
PREVENTION OF ABSORPTION
- A.
GASTRIC LAVAGE
- 1. INDICATIONS:
Consider gastric lavage with a large-bore orogastric tube (ADULT: 36
to 40 French or 30 English gauge tube {external diameter 12 to 13.3
mm}; CHILD: 24 to 28 French {diameter 7.8 to 9.3 mm}) after a
potentially life threatening ingestion if it can be performed soon
after ingestion (generally within 60 minutes).
- a. Consider
lavage more than 60 minutes after ingestion of sustained-release
formulations and substances known to form bezoars or concretions.
- 2. PRECAUTIONS:
- a. SEIZURE
CONTROL: Is mandatory prior to gastric lavage.
- b. AIRWAY
PROTECTION: Alert patients - place in Trendelenburg and left lateral
decubitus position, with suction available. Obtunded or unconscious
patients - cuffed endotracheal intubation.
- 3. LAVAGE
FLUID:
- a. Use small
aliquots of liquid. Lavage with 150 to 200 milliliters warm tap water
(preferably 38 degrees Celsius) or saline per wash (in children over
5 or adults) and 10 milliliters/kilogram body weight of normal saline
in young children. Continue until lavage return is clear.
- b. The volume
of lavage return should approximate amount of fluid given to avoid
fluid-electrolyte imbalance.
- c. CAUTION:
Water should be avoided in young children because of the risk of
electrolyte imbalance and water intoxication. Warm fluids avoid the
risk of hypothermia in very young children and the elderly.
- 4.
COMPLICATIONS:
- a.
Complications of gastric lavage have included: aspiration pneumonia,
hypoxia, hypercapnia, mechanical injury to the throat, esophagus, or
stomach, fluid and electrolyte imbalance (Vale, 1997). Combative
patients may be at greater risk for complications.
- b. Gastric
lavage can cause significant morbidity; it should NOT be performed
routinely in all poisoned patients (Vale, 1997).
- 5.
CONTRAINDICATIONS:
- a. Loss of
airway protective reflexes or decreased level of consciousness if
patient is not intubated, following ingestion of corrosive substances,
hydrocarbons (high aspiration potential), patients at risk of
hemorrhage or gastrointestinal perforation, or trivial or non-toxic
ingestion.
- B.
ACTIVATED CHARCOAL
- 1.
CHARCOAL ADMINISTRATION
- a. Consider
administration of activated charcoal after a potentially toxic
ingestion (Chyka & Seger, 1997). Administer charcoal as an
aqueous slurry; most effective when administered within one hour of
ingestion.
- 2.
CHARCOAL DOSE
- a. Use a
minimum of 240 milliliters of water per 30 grams charcoal (FDA,
1985). Optimum dose not established; usual dose is 25 to 100 grams in
adults and adolescents; 25 to 50 grams in children aged 1 to 12
years; and 1 gram/kilogram in infants up to 1 year old (USP DI, 2000;
Chyka & Seger, 1997).
- (1) Routine
use of a cathartic with activated charcoal is NOT recommended as
there is no evidence that cathartics reduce drug absorption and
cathartics are known to cause adverse effects such as nausea,
vomiting, abdominal cramps, electrolyte imbalances and occasionally
hypotension (Barceloux et al, 1997).
- b.
ADVERSE EFFECTS/CONTRAINDICATIONS
- (1)
Complications: emesis, aspiration (Chyka & Seger, 1997). Refer
to the ACTIVATED CHARCOAL/TREATMENT management for further
information.
- (2) Contraindications:
unprotected airway, gastrointestinal tract not anatomically intact,
therapy may increase the risk or severity of aspiration; ingestion
of most hydrocarbons (Chyka & Seger, 1997).
- 6.5.3
TREATMENT
- A.
SYMPTOMATIC/SUPPORTIVE CARE
- 1. Good supportive
care should be available for these cases. The patient's airway should
be maintained and oxygen administered as required. Monitor cardiac and
other vital signs. There is no specific antidote.
- B.
PHYSOSTIGMINE
- 1. In a case of
a pure sertraline overdose (no mixed ingestion) physostigmine was
given to counteract anticholinergic signs. A diagnosis of serotonin
syndrome was made and the patient responded favorably to the
physostigmine intravenous injection (Kaminski et al, 1994). It is NOT
recommended to administer physostigmine in any mixed or unknown
ingestions.
- 2.
PHYSOSTIGMINE/INDICATIONS
- a.
Physostigmine is primarily used as a diagnostic agent to distinguish
anticholinergic delirium from other causes of altered mental status.
Long lasting reversal of anticholinergic signs and symptoms is
generally not achieved because of the relatively short duration of
action of physostigmine (20 to 60 minutes).
- b.
Physostigmine has also been used to treat seizures, severe agitation,
coma with hypoventilation, and hypotension with dysrhythmias in the
setting of severe anticholinergic overdose. Safety and efficacy for
these indications has not been established.
- c. Coma may be
reversed dramatically in some cases, but physostigmine should not be
used just to keep a patient awake.
- d.
Physostigmine should not be used in patients with suspected tricyclic
antidepressant overdose, or an ECG suggestive of tricyclic
antidepressant overdose (QRS widening, R wave in aVR). In the setting
of tricyclic antidepressant overdose, use of physostigmine has
precipitated seizures and intractable cardiac arrest (Stewart, 1979;
Newton, 1975; Pentel, 1980).
- 3. DOSE
- a.
ADMINISTRATION: Dilute dose of physostigmine in 10 milliliters of
dextrose 5% in water or normal saline. Give over 5 minutes.
- b. PEDIATRIC
THERAPEUTIC TRIAL: 0.02 milligram/kilogram, up to 0.5 milligram of
physostigmine intravenously over several minutes to reverse acute
anticholinergic crisis. If the toxic effects persist and no
cholinergic effects are produced, the drug should be readministered
at five-minute intervals until a maximum dose of 2 milligrams is
given.
- c. PEDIATRIC
THERAPEUTIC DOSE: The lowest total effective trial dose of
physostigmine should be repeated if life-threatening symptoms recur. Physostigmine
is metabolized in 30 to 60 minutes. DO NOT USE AS A CONTINUOUS DRIP.
- d. ADOLESCENT
AND ADULT DOSE TRIAL: 1 to 2 milligrams of physostigmine
intravenously slowly, over 5 minutes. A second dose of 1 to 2
milligrams may be attempted in 20 minutes if no reversal has
occurred.
- e. ADOLESCENT
AND ADULT THERAPEUTIC DOSE: 1 to 4 milligrams intravenously slowly,
over 5 to 10 minutes, should be repeated if life-threatening symptoms
recur. It is metabolized within 30 to 60 minutes. DO NOT USE AS A
CONTINUOUS DRIP.
- 4.
CAUTIONS
- a. Relative
contraindications to the use of physostigmine are asthma, gangrene,
peripheral vascular disease, obstruction of the gastrointestinal
tract or urogenital tract, cardiac conduction defects, and
atrioventricular block.
- b. Too rapid
IV administration of physostigmine has resulted in seizures and
asystole.
- 5.
ATROPINE FOR PHYSOSTIGMINE TOXICITY
- a. Atropine at
a dose of one-half milligram per 1 milligram of physostigmine (of the
last dose administered) should be available to reverse
life-threatening physostigmine induced, toxic cholinergic effects
such as bronchoconstriction.
- C.
SEIZURES
- 1.
SUMMARY
- a. Attempt
initial control with a benzodiazepine (diazepam or lorazepam). If
seizures persist or recur administer phenobarbital. Benzodiazepines
and barbiturates are generally preferred over phenytoin for the
control of overdose or withdrawal related seizures.
- b. Monitor for
respiratory depression, hypotension, dysrhythmias, and the need for
endotracheal intubation.
- c. Evaluate
for hypoxia, electrolyte disturbances, and hypoglycemia (or treat
with intravenous dextrose ADULT: 50 milliliters IV, CHILD: 2
milliliters/kilogram 25% dextrose).
- 2.
DIAZEPAM
- a. MAXIMUM
RATE: Administer diazepam intravenously over 2 to 3 minutes (maximum
rate = 5 milligrams/minute).
- b. ADULT
DIAZEPAM DOSE: 5 to 10 milligrams initially, repeat every 5 to 10
minutes as needed. Monitor for hypotension, respiratory depression
and the need for endotracheal intubation. Consider a second agent if
seizures persist or recur after diazepam 30 milligrams.
- c. PEDIATRIC DIAZEPAM
DOSE: 0.2 to 0.5 milligram per kilogram repeat every 5 minutes as
needed. Monitor for hypotension, respiratory depression and
the need for endotracheal intubation. Consider a second agent if
seizures persist or recur after diazepam 10 milligrams in children
over 5 years or 5 milligrams in children under 5 years of age.
- d. RECTAL USE:
If an intravenous line cannot be established, diazepam may be given
per rectum (generally use twice the usual initial dose because of
decreased absorption), or lorazepam may be given intramuscularly.
- e. MIDAZOLAM:
has been used intramuscularly and intranasally, particularly in
children when intravenous access has not been established. PEDIATRIC
MIDAZOLAM DOSE: INTRAMUSCULAR: 0.2 milligram/kilogram (maximum 7
milligrams) (Chamberlain et al, 1997); INTRANASAL: 0.2
milligram/kilogram (Lahat et al, 2000). Buccal midazolam, 10
milligrams, has been used in adolescents and older children
(5-years-old or more) to control seizures when intravenous access was
not established (Scott et al, 1999).
- 3.
LORAZEPAM
- a. MAXIMUM
RATE: The rate of intravenous administration of lorazepam should not
exceed 2 milligrams/minute (Prod Info Ativan(R), 1999).
- b. ADULT
LORAZEPAM DOSE: 2 to 8 milligrams intravenously. Initial doses may be
repeated in 10 to 15 minutes if seizures persist (Prod Info,
Ativan(R), 1999; AMA, 1991).
- c. PEDIATRIC LORAZEPAM
DOSE: 0.05 to 0.1 milligram/kilogram intravenously, (maximum 4
milligrams/dose) repeated twice at intervals of 10 to 15 minutes
(Benitz & Tatro, 1995).