General

Pronunciation
klor-dye-az-e-POX-ide

Trade Name(s)

• Apo-Chlordiazepoxide [Canada]

• Libritabs

• Librium

• Mitran [Canada]

• Novopoxide [Canada]

• Poxi [Canada]

Controlled Substance Schedule
IV

Pregnancy Category
Category D

Ther. class.
antianxiety agents
sedative/hypnotics

Pharm. class.
benzodiazepines

Indications

• Adjunct management of anxiety

• Treatment of alcohol withdrawal

• Adjunct management of anxiety associated with acute myocardial infarction

Action

• Acts at many levels of the CNS to produce anxiolytic effect

• Depresses the CNS, probably by potentiating GABA, an inhibitory neurotransmitter

Therapeutic Effect(s):

• Sedation

• Relief of anxiety

Pharmacokinetics

Absorption: Well absorbed from the GI tract. IM absorption may be slow and unpredictable

Distribution: Widely distributed. Crosses the blood-brain barrier. Crosses the placenta; enters breast milk. Recommend to discontinue drug or bottle feed

Metabolism and Excretion: Highly metabolized by the liver. Some products of metabolism are active as CNS depressants

Half-life: 5–30 hr

TIME/ACTION PROFILE (sedation)

ROUTE	ONSET	PEAK	DURATION
PO	1–2 hr	0.5–4 hr	up to 24 hr
IM	15–30 min	unknown	unknown
IV	1–5 min	unknown	0.25–1 hr

Contraindication/Precautions

Contraindicated in:

• Hypersensitivity

• Some products contain tartrazine and should be avoided in patients with known intolerance

• Cross-sensitivity with other benzodiazepines may occur

• Comatose patients or those with pre-existing CNS depression

• Uncontrolled severe pain

• Pulmonary disease

• Angle-closure glaucoma

• Porphyria

• OB: Lactation: May cause CNS depression, flaccidity, feeding difficulties, and weight loss in infants

• Pedi: Not for use in children <=6 yr

Use Cautiously in:

• Hepatic dysfunction

• Severe renal impairment

• History of suicide attempt or substance abuse

• Geri: Long–acting benzodiazepines cause prolonged sedation in the elderly. Appears on Beers list and is associated with increased risk of falls ( dose required or consider short-acting benzodiazepine)

• Debilitated patients (initial dose reduction required)

Adverse Reactions/Side Effects

CNS: dizziness, drowsiness, hangover, headache, mental depression, paradoxical excitation, sedation.

EENT: blurred vision.

GI: constipation, diarrhea, nausea, vomiting, weight gain.

Derm: rashes.

Local: pain at IM site.

Misc: physical dependence, psychological dependence, tolerance.

*CAPITALS indicates life-threatening.
*italic indicates most frequent.

Interactions

Drug-Drug

• Alcohol, antidepressants, antihistamines, and opioid analgesics —concurrent use results in additive CNS depression

• Cimetidine, oral contraceptives , disulfiram, fluoxetine, isoniazid, ketoconazole, metoprolol, propoxyphene, propranolol, or valproic acid may enhance effects

• May efficacy of levodopa

• Rifampin or barbiturates may effectiveness of chlordiazepoxide

• Sedative effects may be by theophylline

Drug-Natural Products
Concomitant use of kava, valerian, chamomile, or hops can CNS depression

Route/Dosage

• PO (Adults):
Alcohol withdrawal—50–100 mg, repeated until agitation is controlled (up to 400 mg/day).
Anxiety—5–25 mg 3–4 times daily.

• PO (Geriatric Patients or Debilitated Patients):
Anxiety—5 mg 2–4 times daily initially, increased as needed.

• PO (Children >6 yr):
Anxiety—5 mg 2–4 times daily, up to 10 mg 2–3 times daily.

• IM, IV (Adults):
Alcohol withdrawal—50–100 mg initially; may be repeated in 2–4 hr.
Anxiety—50–100 mg initially, then 25–50 mg 3–4 times daily as required (25–50 mg initially in geriatric patients).
Preoperative sedation—50–100 mg 1 hr preop.

• IM, IV (Geriatric Patients or Debilitated Patients):
Anxiety/sedation—25–50 mg/dose.

• IM, IV (Children >12 yr):
Anxiety/sedation—25–50 mg/dose.

Availability

• Capsules: 5 mg, 10 mg, 25 mg

• Tablets: 5 mg, 10 mg, 25 mg

• Injection: 100-mg ampule

• In combination with: amitriptyline (Limbitrol DS), clidinium (Librax). See combination drugs

Assessment

• Assess for anxiety and level of sedation (ataxia, dizziness, slurred speech) periodically during therapy

» Assess degree and manifestations of anxiety and mental status (orientation, mood, behavior) prior to and periodically during therapy

» Monitor blood pressure, heart rate, and respiratory rate frequently when administering parenterally. Report significant changes immediately

» Prolonged high-dose therapy may lead to psychological or physical dependence. Restrict the amount of drug available to patient

» Geri: Assess risk of falls and institute fall prevention strategies.

Alcohol Withdrawal

• Assess for tremors, agitation, delirium, and hallucinations. Protect patient from injury. Institute seizure precautions

• Geri: Assess risk of falls and institute fall prevention strategies

Lab Test Considerations

• Patients on prolonged therapy should have CBC and liver function tests evaluated periodically. May cause in serum bilirubin, AST, and ALT

» May alter results of urine 17-ketosteroids and 17-ketogenic steroids. May cause response on metyrapone tests and decreased thyroidal uptake of ¹²³I and ¹³¹I

Toxicity and Overdose

• Flumazenil reverses sedation caused by chlordiazepoxide toxicity or overdose (flumazenil may induce seizures in patients with a history of seizures disorder or who are on tricyclic antidepressants.)

Potential Nursing Diagnoses

• Anxiety (Indications)

• Risk for injury (Side Effects)

• Ineffective coping

• Dysfunctional family processes: alcoholism

Implementation

• Do not confuse Librium with Librax

» IV administration is usually the preferred route for parenteral administration because of the slow, erratic absorption after IM administration

» After parenteral administration, have patient remain recumbent and observe for 3–8 hr or longer, depending on patient's response

» Equipment to maintain a patent airway should be immediately available when chlordiazepoxide is administered intravenously

» Use parenteral solution immediately after reconstitution and discard any unused portion

• PO: Administer after meals or with milk to minimize GI irritation. Tablets may be crushed and taken with food or fluids if patient has difficulty swallowing. Administer greater dose at bedtime to avoid daytime sedation. Do not discontinue abruptly; taper by 10 mg every 3 days to reduce chance of withdrawal effects. Some patients may require longer taper period (months). Monitor patients closely with seizure disorder as abrupt withdrawal may precipitate seizures

• IM: Reconstitute only with 2 ml of diluent provided by manufacturer. Do not use solution if opalescent or hazy. Agitate gently to minimize bubbling. Administer slowly, deep into a well-developed muscle mass to minimize pain at injection site. Solution reconstituted with IM diluent should not be given IV

IV Adminstration:

• Direct IV:
Diluent: Reconstitute 100 mg in 5 ml of 0.9% NaCl or sterile water for injection. Do not use IM diluent.
Concentration: 20 mg/ml

• Rate:
Administer prescribed dose slowly over at least 1 min. Rapid administration may cause apnea, hypotension, bradycardia, or cardiac arrest

• Y-Site Compatibility:

» heparin

» hydrocortisone sodium succinate

» potassium chloride

» vitamin B complex with C

Patient/Family Teaching

• Instruct patient to take chlordiazepoxide as directed. If medication is less effective after a few weeks, check with health care professional; do not increase dose. Medication should be tapered at the completion of long-term therapy. Sudden cessation of medication may lead to withdrawal (insomnia, irritability, nervousness, tremors)

• May cause drowsiness or dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known. Geri: Instruct patient and family how to reduce falls risk at home.

• Advise patient to avoid the use of alcohol and other CNS depressants concurrently with this medication

• Instruct patient to consult health care professional before taking OTC medications

• Instruct patient to notify health care professional if pregnancy is planned or suspected

• Advise patient that benzodiazepines do not cure underlying problems. Psychotherapy is beneficial in addressing source of anxiety and improve coping skills

• Teach other methods to decrease anxiety, such as; exercise, use of support group (eg, Alcoholics Anonymous), or relaxation techniques

• Teach patient not to share medication with anyone

Evaluation/Desired Outcomes

• Decreased sense of anxiety

» Increased ability to cope

• Decreased delirium tremens and more rational ideation when used for alcohol withdrawal

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