Applications of lorazepam in the hospice setting kjohnson

Ppt for advanced pharmacology

1. Applications of Lorazepam in the Hospice Setting Kamryn Johnson Lamar University College of Arts and Sciences Joanne Gay Dishman Department of Nursing Graduate Nursing Studies

2. Lorazepam Lorazepam is a benzodiazepine (BZD) A study conducted by the International Association of Hospice and Palliative Care identified lorazepam as on of the six most essential drugs used in hospice (Sera, McPherson, & Holmes, 2013).

3. Lorazepam: Treatment for Anxiety Anxiety is the triggering of the fight-or-flight response by which epinephrine, nor-epinephrine, and cortisol enter the blood stream and set off a chain of physiologic responses in the body ( Mandos and Reinhold, 2017). Energy needs of the fight-or-flight response are met by: a release of sugar from the liver into the bloodstream a shift in circulation to the brain and extremities increase in respiratory rate, heart rate and blood pressure to meet increasing oxygen needs perspiration as a means of cooling the body pupils dilate the muscles become tense all the senses become keener (Mandos & Reinhold, 2017).

4. Expected Response to Lorazepam Mild to moderate sedation Muscle relaxation Mild amnesiac Anticonvulsant effect Reduction or elimination of anxiousness (Mandos & Reinhold, 2017).

5. Potential Interactions to Lorazepam Lorazepam and BZDs in general can become less effective when taken in conjunction with antacids, phenytoin, rifampin, theophylline, and carbamazepine (Mandos & Reinhold, 2017). An increase in side effects are seen in patients who combine lorazepam with alcohol, carisoprodol, clozapine, probenecid, CYP3A4 inhibitors such as cimetidine, and protease inhibitors (Mandos & Reinhold, 2017).

6. Adverse Reactions to Lorazepam Reported severe adverse reactions or allergic reactions include: Extreme dizziness Syncope Hives Shortness of breath Swelling around the eyes Swelling to the feet (Cheema, personal communication, November 27, 2017).

7. Common Side Effects of Lorazepam Sedation Psychomotor impairment Cognitive and memory impairment Confusion Elderly patients tend to experience greater side effects from lorazepam than other patient populations, with drowsiness, dizziness, and loss of appetite being common complaints (Cheema, personal communication, November 27, 2017).

8. Pharmacokinetics of Lorazepam Short half-life Rapid absorption Highly bound to plasma protein Lipid-soluble Metabolized in the liver (Mandos & Reinhold, 2017).

9. Drug Binding Issues with Lorazepam Binding issues have been found when lorazepam is administered in conjunction with barbiturates. Drugs such as Fioricet and Fiorinal , commonly prescribed to treat migraines, contain butalbital and should be used with caution in patients taking BZDs as the side effects may be increased ( Ogbru , 2017).

10. Improving Communication Thorough review of the patient’s medical history, allergies, and complete list of current medications Recognition that this information is not always relayed to retail pharmacies, leaving the potential for drug interactions and allergic reactions (Cheema, personal communication, November 27, 2017). Collaboration with the interdisciplinary team to evaluate the patient response to lorazepam, including the potential to maintain therapeutic levels at the lowest dose possible to reduce the risk of side effects. Routine review by the care team of lorazepam and its dosing, side effects, drug interactions, contraindications, and special considerations to prevent complacency of use of this commonly prescribed drug.

11. How the Use of Lorazepam Can be Applied in the Hospice Care Setting In the hospice setting, a large patient population consists of the elderly, cancer patients, those with cardiovascular or pulmonary diseases, neurologic disorders, and often various combinations of these illnesses which all can be causes of anxiety. Age related changes and end-stage disease processes contribute not only to the patients’ mental state but to how they respond to medication. Though there is a risk of drug interactions and adverse or even allergic reactions, most of the side effects such as drowsiness and loss of appetite are also consistent with symptoms that are experienced by many patients in the end-stages of illness. The benefits of reducing anxiety and allowing the patient to be alleviated of worry or fear can improve quality of life, despite the side effects associated with lorazepam.

12. With a knowledgeable care team, educated patients and caregivers, communication among all members, and monitoring of symptoms, lorazepam can be a safe and effective drug for the treatment of anxiety in many hospice patients. Education + C ommunication = Patient Safety and Better Patient Outcomes!

13. References Mandos, L.A. & Reinhold, J.A. (2017). Anxiety Disorders. In V.P. Arcangelo, A.M. Peterson, V. Wilber & J.A. Reinhold (Eds.), Pharmacotherapeutics for Advanced Practice: A practical approach (4 th ed.).(pp 701-703). Philadelphia: Wolters Kluwer. Ogbru , O. (February 6, 2017). Barbituates. retrieved from https://www.medicinenet.com/barbiturates-oral/article.htm#for_what_conditions_are_barbiturates_prescribed? Sera, L., McPherson, M.L., Holmes, H.M. (February 12, 2013). Commonly Prescribed Medications in a Population of Hospice Patients. American Journal of Hospice and Palliative Care. Doi.10.1177/1049909113476132 Special thanks to Dr. Gary Cheema, PharmD for his collaboration.