Question

PN 200 Fundamentals of Nursing II Anticoagulants - Coumadin A patient is taking phenytoin, warfarin (Coumadin), promethazine (Phenergan), meperidine (Demerol), and diazepam (Valium) 1. Prepare a patient medication teaching plan for this patient being sure to include specifics about probable drug interactions t o sub oldidentrode 2. During the teaching session, the patient shares that he plans to start taking OTC products to boost his energy. What is the nurse's best response to the patient's comment being sure to explain the rationale for your answer? 3. List four adverse effects of each of the medications this patient is receiving obotell Reviewed 11/18

Answer 1

PATIENT MEDICATION TEACHING:

PHENYTOIN

Phenytoin is an anticonvulsant medication that is used to control seizures. Phenytoin does not treat all types of seizures, and your doctor will determine if it is the right medicine for you.

WHAT ARE THE POSSIBLE SIDE EFFECTS OF PHENYTOIN?

Get emergency medical help if you have signs of an allergic reaction(hives, difficult breathing, swelling in your face or throat) or a severe skin reaction (fever, sore throat, burning in your eyes, skin pain, red or purple skin rash that spreads and causes blistering and peeling).

Seek medical treatment if you have a serious drug reaction that can affect many parts of your body. Symptoms may include: skin rash, fever, swollen glands, muscle aches, severe weakness, unusual bruising, or yellowing of your skin or eyes.

Report any new or worsening symptoms to your doctor, such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Call your doctor at once if you have:

• the first sign of any skin rash, no matter how mild;
• fever, chills, sore throat, swollen glands;
• red or swollen gums, mouth sores;
• easy bruising, unusual bleeding, purple or red spots under your skin; or
• liver problems--loss of appetite, upper stomach pain, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes).

Common side effects may include:

• drowsiness, confusion;
• slurred speech;
• abnormal eye movement; or
• problems with balance or muscle movement.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects.

WHAT IS THE MOST IMPORTANT INFORMATION I SHOULD KNOW ABOUT PHENYTOIN?

You should not use phenytoin if you also take delavirdine (Rescriptor), Since phenytoin decrease delavirdine effects.

WARFARIN(COUMADIN):

Warfarin (brand names Coumadin and Jantoven) is a prescription medication used to prevent harmful blood clots from forming or growing larger. Beneficial blood clots prevent or stop bleeding, but harmful blood clots can cause a heart attack, stroke, deep vein thrombosis or pulmonary embolism. Because warfarin interferes with the formation of blood clots, it is called an anticoagulant . anticoagulants are referred  as *blood thinners; however, warfarin does not thin the blood but instead causes the blood to take longer to form a clot.

How Does Warfarin Work?

The formation of a clot in the body is a complex process that involves multiple substances called clotting factors. Warfarin decreases the body’s ability to form blood clots by blocking the formation of vitamin K–dependent clotting factors. Vitamin K is needed to make clotting factors and prevent bleeding. Therefore, by giving a medication that blocks the clotting factors, your body can stop harmful clots from forming and prevent clots from getting larger.

Monitoring and Dosing

The goal of warfarin therapy is to decrease the clotting tendency of blood, not to prevent clotting completely. Therefore, the effect of warfarin must be monitored carefully with blood testing. On the basis of the results of the blood test, your daily dose of warfarin will be adjusted to keep your clotting time within a target range. The blood test used to measure the time it takes for blood to clot is referred to as a prothrombin time test, or protime (PT). The PT is reported as the International Normalized Ratio (INR).

The INR is a standardized way of expressing the PT value. The INR ensures that PT results obtained by different laboratories can be compared. It is important to monitor the INR (at least once a month and sometimes as often as twice weekly) to make sure that the level of warfarin remains in the effective range. If the INR is too low, blood clots will not be prevented, but if the INR is too high, there is an increased risk of bleeding. This is why those who take warfarin must have their blood tested so frequently.

Unlike most medications that are administered as a fixed dose, warfarin dosing is adjusted according to the INR blood test results; therefore, the dose usually changes over time. Coumadin/ warfarin pills come in different colors, and each color corresponds to a different dose (see graphic below).

.

Warfarin must be taken exactly as prescribed.

Never increase or decrease your dose unless instructed to do so by your healthcare provider. If a dose is missed or forgotten, call your healthcare provider for advice.

Other counselling points about taking warfarin can include:

• Warfarin should be taken at the same time each day.
• The strength of tablets come in different colours for ease of recognition (0.5mg white; 1mg brown; 3mg blue; 5mg pink).
• Never double up on doses: If a dose is accidentally missed, they should continue with the regimen as prescribed, and never take a double dose (unless specifically advised).
• Let healthcare professionals such as community pharmacies know that you are taking warfarin (due to drug interactions and contraindications etc).
• Inform anticoagulant clinic if any other medication has been started (by GP, over the counter, herbal, hospital) since it may mean patient needs more frequent drug monitoring. This includes consumption of any vitamins/multivitamins since vitamin E can enhance the effects of warfarin and vitamin K can antagonise the effects of warfarin.
• Inform the patient of the duration of treatment, since in some cases treatment is only required for a set period (e.g. certain cases of DVT will need treatment for 6 months).
• warfarin cannot be used during pregnancy therefore if necessary discuss this with the patient and consider contraceptive options for women of a child-bearing age. Also for women with regular menses, heavy periods whilst on warfarin should be reported to the physiciansince the dose may need to reviewed or alternative options considered (change of drug, initiation of iron etc.)

PROMETHAZINE:

Promethazine is used to prevent and treat nausea and vomiting related to certain conditions (such as motion sickness, or before/after surgery). It is also used to treat allergy symptoms such as rash, itching, and runny nose. It may be used to help you feel sleepy/relaxed before and after surgery or to help certain narcotic pain relievers (such as meperidine) work better. The suppository form is used when medications cannot be taken by mouth.

Promethazine is an antihistamine and works by blocking a certain natural substance (histamine) that your body makes during an allergic reaction. Its other effects (such as anti-nausea, calming, pain relief) may work by affecting other natural substances (such as acetylcholine) and by acting directly on certain parts of the brain.

Promethazine is available under the following different brand names: Phenergan, and Phenadoz.

Dosage of Promethazine:

Adult Dosage Forms and Strengths

Tablet

• 12.5 mg
• 25 mg
• 50 mg

• Suppository

• 12.5 mg
• 25 mg
• 50 mg

• Injectable solution

• 25 mg/mL
• 50 mg/mL

• Syrup

• 6.25 mg/5 mL

• Dosing Considerations – Should be Given as Follows:

  Allergic Conditions

• Taken orally or rectally: 25 mg at bedtime or 12.5 mg before meals and at bedtime (dosage range, 6.25-12.5 mg once every 8 hours)
• Intravenously (IV)/intramuscularly (IM): 25 mg; may be repeated in2 hours when necessary; switch to oral dosing as soon as possible

• Nausea and Vomiting

• Taken orally or rectally: 12.5-25 mg once every 4-6 hours as needed
• Intravenously (IV)/intramuscularly (IM): 12.5-25 mg once every 4-6 hours as needed

• Motion Sickness

• 25 mg taken orally or rectally 30-60 minutes before departure and once every 8-12 hours as needed; on succeeding travel days, 25 mg orally or rectally every morning and every evening

• Preoperative Sedation

• 50 mg taken orally or rectally on night before procedure or 25-50 mg intravenously (IV)/intramuscularly (IM) combined with reduced doses of analgesics and atropine-like drugs

• Postoperative Sedation

• 25-50 mg intravenously/intramuscularly/orally/rectally combined with reduced doses of analgesics and atropine-like drugs

• Obstetric Sedation

• 25-50 mg intravenously (IV)/intramuscularly (IM) in early labor; may be increased to 25-75 mg once every 2-4 hours after labor established; not to exceed two doses or up to 100 mg/day during labor

• Allergic Conditions (Off-label)

• Children under 2 years old: Contraindicated
• Children 2 years and older: 25 mg taken orally or rectally at bedtime or 12.5 mg once every 6 hours; alternatively, 6.25-12.5 mg orally/rectally once every 8 hours

• Nausea & Vomiting

• Children under 2 years old: Contraindicated
• Children 2 years and older: 0.25-1 mg/kg orally/rectally once every 4-6 hours as needed; not to exceed 25 mg

• Motion Sickness

• Children under 2 years: Contraindicated
• Children 2 years and older: 12.5-25 mg orally/rectally administered 30-60 minutes before departure and once every 8-12 hours as needed or 0.5 mg/kg orally once every 12 hours as needed
• Succeeding days of travel: 12.5-25 mg twice daily (upon arising or before evening meals)

• Sedation

• Children under 2 years: Contraindicated
• Children 2 years and older: 12.5-25 mg orally/intramuscularly/rectally at bedtime

• Preoperative Sedation

• Children under 2 years: Contraindicated
• Children 2 years and older: 1 mg/kg orally or rectally with reduced dose of analgesic and appropriate dose of atropine-like drug

• Postoperative Sedation

• Children under 2 years: Contraindicated
• Children 2 years and older: 12.5-25 mg with reduced dose of analgesic and appropriate dose of atropine-like drug
• SIDE EFFECTS ASSOCIATED WITH USING PROMETHAZINE

• Common Side effects of Promethazine include:

• Sedation
• Confusion
• Disorientation
• Blurred vision
• Hallucinations
• Muscle spasms
• Catatonic states
• Euphoria
• Excitation
• Extrapyramidal symptoms (tremors, jerky movements, musclerigidity)
• Fast or slow heart rate
• Photosensitivity
• Obstructive jaundice
• Dry mouth
• Skin swelling (angioneurotic edema)
• Involuntary movements (tardive dyskinesia)
• Hives
• Angioneurotic edema
• Impotence
• Urinary retention

• Rare side effects of promethazine include

• Leukopenia
• AgranulocytosiS

• OTHER DRUGS INTERACT WITH PROMETHAZINE:

• If your doctor has directed you to use this medication, your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with your doctor, health care provider or pharmacist first.

  Severe Interactions of promethazine include:

• astemizole
• cisapride
• disopyramide
• ibutilide
• indapamide
• metrizamide
• pentamidine
• pimozide
• procainamide
• quinidine
• sotalol
• terfenadine

• Promethazine has serious interactions with at least 59 different drugs.

  Promethazine has moderate interactions with at least 290 different drugs.

  Promethazine has mild interactions with at least 69 different drugs.

  This information does not contain all possible interactions or adverse effects. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you, and share this information with your doctor and pharmacist. Check with your health care professional or doctor for additional medical advice, or if you have health questions, concerns or for more information about this medicine.

  WHAT ARE WARNINGS AND PRECAUTIONS FOR PROMETHAZINE?

  IV administration can cause severe tissue injury, including burning, gangrene, or thrombophlebitis, necessitating fasciotomy, skin graft, or amputation

• Severe tissue injury can occur from perivascular extravasation, unintentional intra-arterial injection, and intraneuronal or perineuronal infiltration
• Deep IM injection is the preferred the method of administration
• Intra-arterial and SC administration are contraindicated
• 25 mg/mL product may be administered by deep IM injection or IV infusion (at rate not to exceed 25 mg/min through flowing IV tubing)
• Monitor for signs and symptoms of potential tissue injury including burning or pain at site of injection, phlebitis, swelling, and blistering
• Discontinue IV infusion immediately if patient complains of pain during injection
• Respiratory fatalities reported with use in children less than 2 years (use contraindicated); use lowest effective dose in children 2 years and older; avoid other drugs with respiratory depressant effects
• This medication contains promethazine
• Do not take Phenergan or Phenadoz if you are allergic to promethazine or any ingredients contained in this drug
• Keep out of reach of children
• In case of overdose, get medical help or contact a Poison Control Center immediately

• Contraindications

• Hypersensitivity
• Newborn/premature infants less than 2 years old (risk of potentially fatal respiratory depression)
• SC or intra-arterial administration
• Coma
• Treatment of lower respiratory tract symptoms, including asthma
• Use caution in asthma, hepatic impairment, peptic ulcer disease, respiratory impairment, bone marrow suppression, anaphylaxis in susceptible individuals
• May impair ability to drive or perform hazardous tasks
• May impair core body temperature regulation; caution when taking medications with anticholinergic effects, heat exposure, or strenuous exercise
• Depresses hypothalamic thermoregulatory mechanism; exposure to extreme temperatures may cause hypo- or hyperthermia
• May alter cardiac conduction (life-threatening arrhythmias reported)
• Antiemetic effect may obscure toxicity of chemotherapeutic drugs
• Monitor closely in patients with cardiovascular disease, hepatic impairment, Reye syndrome, or history of sleep apnea
• Has anticholinergic effects; use with caution in patients with decreased gastrointestinal motility or obstructions (partial or complete), urinary retention, urinary obstructions, xerostomia, BPH, or visual problems
• May cause extrapyramidal symptoms including pseudoparkinsonism, acute dystonic reactions, tardive dyskinesia, and akathisia
• Neuroleptic malignant syndrome reported with use; monitor for fever, muscle rigidity and/or autonomic instability, or mental status changes
• May cause orthostatic hypotension; use caution in patients at risk of experiencing hypotensive episodes (cardiovascular disease, cerebrovascular disease, hypovolemia or taking medications that may predispose to bradycardia or hypotension)
• May cause photosensitivity
• Pyloroduodenal obstruction, stenosing peptic ulcer disease, or bladder neck obstruction
• Anticholinergic effects of promethazine may exacerbate conditionin patients with narrow-angle glaucoma or myasthenia gravis

• Pregnancy and Lactation

• Use promethazine with caution if benefits outweigh risks
• Animal studies show risk and human studies not available or neither animal nor human studies done
• It is not known whether promethazine crosses into breast milk; discontinue drug, or do not nurse while using promethazine
• MEPERIDINE (DEMEROL HCL)

• Meperidine is an opioid pain medication used to treat moderate-to-severe pain.

  Meperidine may also be used for purposes not listed in this medication guide.

  WHAT ARE THE POSSIBLE SIDE EFFECTS OF MEPERIDINE (DEMEROL HCL)?

  Get emergency medical help if you have signs of an allergic reaction: hives; difficult breathing; swelling of your face, lips, tongue, or throat.

  Opioid medicine can slow or stop your breathing, and death may occur. A person caring for you should seek emergency medical attention if you have slow breathing with long pauses, blue colored lips, or if you are hard to wake up.

  Stop using meperidine and call your doctor at once if you have:

• weak or shallow breathing, slow heartbeat;
• severe drowsiness, feeling like you might pass out;
• confusion, mood changes;
• tremors, muscle movements you cannot control, or a seizure(convulsions);
• low cortisol levels--nausea, vomiting, loss of appetite, dizziness, worsening tiredness or weakness.

• Seek medical attention right away if you have symptoms of serotonin syndrome, such as: agitation, hallucinations, fever, sweating, shivering, fast heart rate, muscle stiffness, twitching, loss of coordination, nausea, vomiting, or diarrhea.

  Serious side effects may be more likely in older adults and those who are malnourished or debilitated.

  Long-term use of opioid medication may affect fertility (ability to have children) in men or women. It is not known whether opioid effects on fertility are permanent.

  Common side effects may include:

• dizziness, drowsiness;
• headache;
• nausea, vomiting; or
• sweating.

• This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects.

  WHAT IS THE MOST IMPORTANT INFORMATION I SHOULD KNOW ABOUT MEPERIDINE (DEMEROL HCL)?

  MISUSE OF OPIOID MEDICINE CAN CAUSE ADDICTION, OVERDOSE, OR DEATH. Keep the medication in a place where others cannot get to it.

  Taking opioid medicine during pregnancy may cause life-threatening withdrawal symptoms in the newborn.

  Fatal side effects can occur if you use opioid medicine with alcohol, or with other drugs that cause drowsiness or slow your breathing.

  WHAT SHOULD I DISCUSS WITH MY HEALTHCARE PROVIDER BEFORE TAKING MEPERIDINE (DEMEROL HCL)?

  You should not use meperidine if you are allergic to it, or if you have:

• severe asthma or breathing problems; or
• a blockage in your stomach or intestines.

• Do not use meperidine if you have used an MAO inhibitor in the past 14 days. A dangerous drug interaction could occur. MAO inhibitors include isocarboxazid, linezolid, methylene blue injection, phenelzine, rasagiline, selegiline, tranylcypromine, and others.

  Tell your doctor if you have ever had:

• a head injury, brain tumor, or seizures;
• any type of breathing problem or lung disease;
• drug or alcohol addiction, or mental illness;
• a blockage in your stomach or intestines;
• urination problems;
• liver or kidney disease;
• problems with your gallbladder, adrenal gland, or thyroid;
• sickle cell anemia; or
• abnormal curvature of the spine that affects breathing.

• If you use opioid medicine while you are pregnant, your baby could become dependent on the drug. This can cause life-threatening withdrawal symptoms in the baby after it is born. Babies born dependent on opioids may need medical treatment for several weeks.

  Do not breast-feed while using meperidine. This medicine can pass into breast milk and cause drowsiness, breathing problems, or death in a nursing baby.

  HOW SHOULD I TAKE MEPERIDINE (DEMEROL HCL)?

  Follow the directions on your prescription label and read all medication guides. Never use meperidine in larger amounts, or for longer than prescribed. Tell your doctor if you feel an increased urge to take more of this medicine.

  Never share opioid medicine with another person, especially someone with a history of drug abuse or addiction. MISUSE CAN CAUSE ADDICTION, OVERDOSE, OR DEATH. Keep the medication in a place where others cannot get to it. Selling or giving away opioid medicine is against the law.

  Measure liquid medicine carefully. Use the dosing syringe provided, or use a medicine dose-measuring device (not a kitchen spoon).

  Do not stop using this medicine suddenly after long-term use, or you could have unpleasant withdrawal symptoms. Ask your doctor how to safely stop using meperidine.

  Never crush or break a meperidine pill to inhale the powder or mix it into a liquid to inject the drug into your vein. This practice has resulted in death with the misuse of prescription drugs.

  Store at room temperature away from moisture and heat. Keep track of your medicine. You should be aware if anyone is using it improperly or without a prescription.

  Do not keep leftover opioid medication. Just one dose can cause death in someone using this medicine accidentally or improperly. Ask your pharmacist where to locate a drug take-back disposal program. If there is no take-back program, flush the unused medicine down the toilet.

  WHAT HAPPENS IF I MISS A DOSE (DEMEROL HCL)?

  Since meperidine is used for pain, you are not likely to miss a dose. Skip any missed dose if it is almost time for your next dose. Do not use two doses at one time.

  WHAT HAPPENS IF I OVERDOSE (DEMEROL HCL)?

  A meperidine overdose can be fatal, especially in a child or other person using the medicine without a prescription. Overdose symptoms may include slow breathing and heart rate, severe drowsiness, muscle weakness, cold and clammy skin, blue-colored skin or lips, fainting, or coma.

  WHAT SHOULD I AVOID WHILE TAKING MEPERIDINE (DEMEROL HCL)?

  Do not drink alcohol. Dangerous side effects or death can occur when alcohol is combined with meperidine.

  Avoid driving or hazardous activity until you know how this medicine will affect you. Dizziness or drowsiness can cause falls, accidents, or severe injuries.

  WHAT OTHER DRUGS WILL AFFECT MEPERIDINE (DEMEROL HCL)?

  You may have breathing problems or withdrawal symptoms if you start or stop taking certain other medicines. Tell your doctor if you also use an antibiotic, antifungal medication, heart or blood pressure medication, seizure medication, or medicine to treat HIV or hepatitis C.

  Opioid medication can interact with many other drugs and cause dangerous side effects or death. Be sure your doctor knows if you also use:

• other narcotic medications--opioid pain medicine or prescription cough medicine;
• a sedative like Valium--diazepam, alprazolam, lorazepam, Ativan, Klonopin, Restoril, Tranxene, Versed, Xanax, and others;
• drugs that make you sleepy or slow your breathing--a sleeping pill, muscle relaxer, tranquilizer, antidepressant, or antipsychoticmedicine; or
• drugs that affect serotonin levels in your body--a stimulant, or medicine for depression, Parkinson's disease, migraine headaches, serious infections, or prevention of nausea and vomiting.

DIAZEPAM

Diazepam is a benzodiazepine .Diazepam affects chemicals in the brain that may be unbalanced in people with anxiety.

Diazepam is used to treat anxiety disorders, alcohol withdrawal symptoms, or muscle spasms. Diazepam is sometimes used with other medications to treat seizures.

Diazepam may also be used for purposes not listed in this medication guide.

WHAT ARE THE POSSIBLE SIDE EFFECTS OF DIAZEPAM?

Get emergency medical help if you have signs of an allergic reaction: hives; difficult breathing; swelling of your face, lips, tongue, or throat.

A person caring for you should seek emergency medical attention if you have slow breathing with long pauses, blue colored lips, or if you are hard to wake up.

Call your doctor at once if you have:

• weak or shallow breathing;
• severe drowsiness, feeling like you might pass out;
• depressed mood, thoughts of suicide or hurting yourself;
• confusion, hallucinations;
• anxiety, panic attacks, trouble sleeping;
• hyperactivity, agitation, aggression, hostility;
• unusual risk-taking behavior; or
• new or worsening seizures.

The sedative effects of diazepam may last longer in older adults. Accidental falls are common in elderly patients who take benzodiazepines. Use caution to avoid falling or accidental injury while you are taking diazepam.

Common side effects may include:

• drowsiness;
• tired feeling;
• muscle weakness; or
• loss of coordination.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

WHAT IS THE MOST IMPORTANT INFORMATION I SHOULD KNOW ABOUT DIAZEPAM?

You should not use this medicine if you are allergic to diazepam or similar medicines (Klonopin, Xanax, and others), or if you have myasthenia gravis, severe liver disease, narrow-angle glaucoma, a severe breathing problem, or sleep apnea.

MISUSE OF THIS MEDICINE CAN CAUSE ADDICTION, OVERDOSE, OR DEATH, especially in a child or other person using the medicine without a prescription.

Fatal side effects can occur if you use this medicine with opioid medicine, alcohol, or other drugs that cause drowsiness or slow your breathing.

Do not give this medication to a child younger than 6 months old.

WHAT SHOULD I DISCUSS WITH MY HEALTHCARE PROVIDER BEFORE TAKING DIAZEPAM?

You should not use this medicine if you are allergic to diazepam or similar drugs (Klonopin, Xanax, and others), or if you have:

• myasthenia gravis (a muscle weakness disorder);
• severe liver disease;
• a severe breathing problem;
• sleep apnea (breathing stops during sleep); or
• alcoholism, or addiction to drugs similar to diazepam.

To make sure diazepam is safe for you, tell your doctor if you have ever had:

• glaucoma;
• asthma, emphysema, bronchitis, chronic obstructive pulmonary disorder (COPD), or other breathing problems;
• kidney or liver disease;
• epilepsy or other seizure disorder;
• a drug or alcohol addiction; or
• mental illness, depression, or suicidal thoughts or behavior.

When treating seizures, do not start or stop taking diazepam during pregnancy without your doctor's advice. Diazepam may cause harm to an unborn baby, but having a seizure during pregnancy could harm both the mother and the baby. Tell your doctor right away if you become pregnant while taking diazepam for seizures.

When treating anxiety, alcohol withdrawal, or muscle spasms: If you take diazepam while you are pregnant, your baby could become dependent on the drug. This can cause life-threatening withdrawal symptoms in the baby after it is born. Babies born dependent on habit-forming medicine may need medical treatment for several weeks. Tell your doctor if you are pregnant or plan to become pregnant.

Diazepam can pass into breast milk and may harm a nursing baby. You should not breast-feed while using this medicine.

Diazepam is not approved for use by anyone younger than 6 months old.Do not give this medicine to a child without a doctor's advice.

HOW SHOULD I TAKE DIAZEPAM?

Follow all directions on your prescription label. Your doctor may occasionally change your dose. Do not take this medicine in larger or smaller amounts or for longer than recommended.

Diazepam may be habit-forming. Misuse of habit-forming medicine can cause addiction, overdose, or death. Selling or giving away this medicine is against the law.

Measure liquid medicine with the dosing syringe provided, or with a special dose-measuring spoon or medicine cup. If you do not have a dose-measuring device, ask your pharmacist for one.

Diazepam should be used for only a short time. Do not take this medicine for longer than 4 months without your doctor's advice.

Do not stop using diazepam suddenly, or you could have increased seizures or unpleasant withdrawal symptoms. Ask your doctor how to safely stop using diazepam.

Call your doctor at once if you feel that this medicine is not working as well as usual, or if you think you need to use more than usual.

While using diazepam, you may need frequent blood tests at your doctor's office.

Store at room temperature away from moisture, heat, and light. Keep track of your medicine. Diazepam is a drug of abuse and you should be aware if anyone is using your medicine improperly or without a prescription.

Do not keep leftover diltiazem. Just one dose can cause death in someone using this medicine accidentally or improperly. Ask your pharmacist where to locate a drug take-back disposal program. If there is no take-back program, flush the unused medicine down the toilet.

WHAT HAPPENS IF I MISS A DOSE?

Take the missed dose as soon as you remember. Skip the missed dose if it is almost time for your next scheduled dose. Do not take extra medicine to make up the missed dose.

WHAT HAPPENS IF I OVERDOSE?

An overdose of diazepam can be fatal.

Overdose symptoms may include extreme drowsiness, loss of balance or coordination, limp or weak muscles, or fainting.

WHAT SHOULD I AVOID WHILE TAKING DIAZEPAM?

Do not drink alcohol. Dangerous side effects could occur.

This medication may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be alert.

Grapefruit and grapefruit juice may interact with diazepam and lead to unwanted side effects. Discuss the use of grapefruit products with your doctor.

WHAT OTHER DRUGS WILL AFFECT DIAZEPAM?

Taking diazepam with other drugs that make you sleepy or slow your breathing can cause dangerous side effects or death. Ask your doctor before taking a sleeping pill, opioid pain medicine, prescription cough medicine, a muscle relaxer, or medicine for anxiety, depression, or seizures.

Other drugs may interact with diazepam, including prescription and over-the-counter medicines, vitamins, and herbal products. Tell your doctor about all your current medicines and any medicine you start or stop using.

WHERE CAN I GET MORE INFORMATION?

Your pharmacist can provide more information about diazepam.

REMEMBER, KEEP THIS AND ALL OTHER MEDICINES OUT OF THE REACH OF CHILDREN, NEVER SHARE YOUR MEDICINES WITH OTHERS, AND USE THIS MEDICATION ONLY FOR THE INDICATION PRESCRIBED.