General

Pronunciation
klor-PROE-ma-zeen

Trade Name(s)

• Chlorpromanyl [Canada]

• Largactil [Canada]

• Novo-Chlorpromazine [Canada]

• Thorazine

• Thor-Prom

Pregnancy Category
Category Unknown

Ther. class.
antiemetics
antipsychotics

Pharm. class.
phenothiazines

Indications

• Second-line treatment for schizophrenia and psychoses after failure with atypical antipsychotics

• Hyperexcitable, combative behavior in children

• Nausea and vomiting

• Intractable hiccups

• Preoperative sedation

• Acute intermittent porphyria

Unlabelled Use(s):

• Vascular headache

• Bipolar disorder

Action

• Alters the effects of dopamine in the CNS

• Has significant anticholinergic/alpha-adrenergic blocking activity

Therapeutic Effect(s):

• Diminished signs/symptoms of psychosis

• Relief of nausea/vomiting/intractable hiccups

• Decreased symptoms of porphyria

Pharmacokinetics

Absorption: Variable absorption from tablets/suppositories; better with oral liquid formulations. Well absorbed following IM administration

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

Protein Binding: >= 90%

Metabolism and Excretion: Highly metabolized by the liver and GI mucosa. Some metabolites are active

Half-life: 30 hr

TIME/ACTION PROFILE (antipsychotic activity, antiemetic activity, sedation)

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

Contraindication/Precautions

Contraindicated in:

• Hypersensitivity

• Hypersensitivity to sulfites (injectable) or benzyl alcohol (sustained-release capsules)

• Cross-sensitivity with other phenothiazines may occur

• Angle-closure glaucoma

• Bone marrow depression

• Severe liver/cardiovascular disease

• Concurrent pimozide use

Use Cautiously in:

• Geriatric/debilitated patients ( initial dose)

• Diabetes

• Respiratory disease

• Prostatic hyperplasia

• CNS tumors

• Epilepsy

• Intestinal obstruction

• OB: Lactation: Safety not established. Discontinue drug or bottle feed.

• Pedi: Children with acute illnesses, infections, gastroenteritis, or dehydration (increased risk of extrapyramidal reactions)

• Geri: risk of mortality in elderly patients treated for dementia-related psychosis

Adverse Reactions/Side Effects

CNS: NEUROLEPTIC MALIGNANT SYNDROME, sedation, extrapyramidal reactions, tardive dyskinesia.

EENT: blurred vision, dry eyes, lens opacities.

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

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

GU: urinary retention.

Derm: photosensitivity, pigment changes, rashes.

Endo: galactorrhea, amenorrhea.

Hemat: AGRANULOCYTOSIS, leukopenia.

Metabolic: hyperthermia.

Misc: allergic reactions.

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

Interactions

Drug-Drug

• Concurrent use with pimozide the risk of potentially serious cardiovascular reactions

• 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

• Activated charcoal absorption

• 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 blood 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

• May the risk of seizures with subarachnoid metrizamide

• Concurrent use with propranolol blood levels of both drugs

Drug-Natural Products

• Concomitant use of 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 increase every 3–4 days (usual dose is 200 mg/day; up to 1 g/day).
Nausea and vomiting—10–25 mg q 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) q 4–6 hr as needed.
Preoperative sedation—0.55 mg/kg (15 mg/m²) 2–3 hr before surgery.

• IM (Adults):
Severe psychoses—25–50 mg initially, may be repeated in 1 hr; increase to maximum of 400 mg q 3–12 hr if needed (up to 1 g/day).
Nausea/vomiting —25 mg initially, may repeat with 25–50 mg q 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 q 6–8 hr until patient can take PO.

• IM (Children >6 mo):
Psychoses/nausea and vomiting—0.55 mg/kg (15 mg/m²) q 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 q 6–8 hr.

• IV (Adults):
Nausea/vomiting during surgery—up to 25 mg.
Hiccups/tetanus—25–50 mg.
Porphyria—25 mg q 8 hr.

• IV (Children):
Nausea/vomiting during surgery—0.275 mg/kg.
Tetanus—0.55 mg/kg.

Availability

• Tablets: 10 mg, 25 mg, 50 mg, 100 mg, 200 mg

• 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

» Asses fasting blood glucose and cholesterol levels initially and periodically throughout therapy. Refer as appropriate for nutritional/weight and medical management

» Assess positive (hallucinations, delusions, agitation) and negative (social withdrawal) symptoms of schizophrenia

» Monitor blood pressure (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 benzotropine 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

Preoperative Sedation

• Assess level of anxiety prior to and following administration

Vascular Headache

• Assess type, location, intensity, and duration of pain and accompanying symptoms

Lab Test Considerations

• Monitor CBC, liver function tests, and ocular exams periodically throughout therapy. May cause hematocrit, hemoglobin, leukocytes, granulocytes, platelets. May cause bilirubin, AST, ALT, and alkaline phosphatase. Agranulocytosis occurs 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

Potential Nursing Diagnoses

• Disturbed thought process (Indications)

• Imbalanced nutrition: risk for more than body requirements (Side Effects)

Implementation

• Do not confuse chlorpromazine with chlorpropamide or prochlorperazine

» Keep patient recumbent for at least 30 min following parenteral administration to minimize hypotensive effects

» Phenothiazines should be discontinued 48 hr before and not resumed for 24 hr following metrizamide myelography, because they lower the seizure threshold

• 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.

• IM: Do not inject subcut. 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 Adminstration:

• Direct IV:

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

• Continuous Infusion:

Diluent: May further dilute 25–50 mg in 500–1000 ml of D5W, D10W, 0.45% NaCl, 0.9% NaCl, Ringer's or lactated Ringer's injection, dextrose/Ringer's or dextrose/lactated Ringer's combinations

• Syringe Compatibility:

» atropine

» benztropine

» butorphanol

» diphenhydramine

» doxapram

» droperidol

» fentanyl

» glycopyrrolate

» hydromorphone

» hydroxyzine

» meperidine

» metoclopramide

» midazolam

» morphine

» pentazocine

» scopolamine

• Syringe Incompatibility:

» cimetidine

» heparin

» pantoprazole

» pentobarbital

» thiopental

• Y-Site Compatibility:

» amsacrine

» cisatracurium

» cisplatin

» cladribine

» cyclophosphamide

» cytarabine

» dexmedetomidine

» docetaxel

» doxorubicin

» doxorubicin liposome

» famotidine

» fenoldopam

» filgrastim

» fluconazole

» gemcitabine

» granisetron

» heparin

» hydrocortisone sodium succinate

» ondansetron

» oxaliplatin

» potassium chloride

» propofol

» teniposide

» thiotepa

» vinorelbine

» vitamin B complex with C

• Y-Site Incompatibility:

» allopurinol

» amifostine

» amphotericin B cholesteryl sulfate complex

» aztreonam

» bivalirudin

» cefepime

» etoposide phosphate

» fludarabine

» furosemide

» linezolid

» melphalan

» methotrexate

» paclitaxel

» pemetrexed

» piperacillin/tazobactam

» sargramostim

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

• Medication 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

• 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 since symptoms can recur after discontinuation of medication

Evaluation/Desired Outcomes

• Decrease in excitable, manic behavior. Therapeutic effects may not be seen for 7–8 wk

• Relief of nausea and vomiting

• Relief of hiccups

• Preoperative sedation

• Management of porphyria

• Relief of vascular headache

• Decrease in positive (hallucinations, delusions, agitation) symptoms of schizophrenia

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