Zonalon

doxepin

Silenor

SINEquan

Zonalon

Indications

Action

Pharmacokinetics

Time/action profile (antidepressant activity)

Contraindications/Precautions

Adverse Reactions/Side Effects

Central nervous system

• fatigue (most frequent)
• sedation (most frequent)
• agitation
• confusion
• hallucinations

Ear, Eye, Nose, Throat

• blurred vision (most frequent)
• ↑ intraocular pressure

Cardiovascular

• hypotension (most frequent)
• arrhythmias
• ECG abnormalities

Gastrointestinal

• constipation (most frequent)
• dry mouth (most frequent)
• ↑ appetite
• hepatitis
• nausea
• paralytic ileus
• weight gain

Genitourinary

• ↓ libido
• urinary retention

Dermatologic

• photosensitivity
• rash

Hematologic

• blood dyscrasias

Miscellaneous

• hypersensitivity reactions

Interactions

Drug-Drug interaction

Route/Dosage

Availability (generic available)

Nursing implications

Nursing assessment

• Monitor BP and pulse rate prior to and during initial therapy. Patients taking high doses or with a history of cardiovascular disease should have ECG monitored prior to and periodically during therapy.
• Assess for sexual dysfunction (decreased libido; erectile dysfunction).
• Assess weight and BMI initially and throughout treatment. Obtain FBS and cholesterol levels in overweight/obese individuals.
• Geriatric: Assess falls risk and institute fall prevention strategies. Assess for anticholinergic effects.
• Depression: Assess mental status and mood changes (orientation, mood, behavior) frequently, especially during initial few months of therapy and during dose changes. Confusion, agitation, and hallucinations may occur during initiation of therapy and may require dose reduction. Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. Risk may be increased in children, adolescents, and adults ≤24 yr. Inform health care professional if patient demonstrates significant increase in signs of depression (depressed mood, loss of interest in usual activities, significant change in weight and/or appetite, insomnia or hypersomnia, psychomotor agitation or retardation, increased fatigue, feelings of guilt or worthlessness, slowed thinking or impaired concentration, suicide attempt or suicidal ideation). Restrict amount of drug available to patient.
• Assess for serotonin syndrome (mental changes [agitation, hallucinations, coma], autonomic instability [tachycardia, labile BP, hyperthermia], neuromuscular aberrations [hyperreflexia, incoordination], and/or GI symptoms [nausea, vomiting, diarrhea]), especially in patients taking other serotonergic drugs (SSRIs, SNRIs, triptans).
• Anxiety: Assess degree and manifestations of anxiety prior to and during therapy.
• Pain: Assess the type, location, and severity of pain prior to and periodically during therapy. Use pain scale to assess effectiveness of therapy.
• Topical: Assess pruritic area prior to and periodically during therapy.
• Lab Test Considerations: Monitor WBC and differential blood counts, hepatic function, and serum glucose periodically. May cause ↑ serum bilirubin and alkaline phosphatase levels. May cause bone marrow depression. Serum glucose may be ↑ or ↓.

Potential Nursing Diagnoses

Implementation

• Do not confuse Sinequan with Seroquel, saquinavir, Singulair, or Zonegran.
  • May be given as a single dose 30 min before bedtime to minimize sedation during the day. Dose increases should be made at bedtime because of sedation. Dose titration is a slow process; may take weeks to months.
• To avoid withdrawal, taper by 50% for 3 days, then 50% again for 3 days, then discontinue.
• Oral: Administer medication with or immediately following a meal to minimize gastric irritation. Capsules may be opened and mixed with foods or fluids if patient has difficulty swallowing.
  • Oral concentrate must be diluted in at least 120 mL of water, milk, or fruit juice. Do not mix with carbonated beverages or grape juice. Use calibrated measuring device to ensure accurate amount.
• Topical: Apply thin film of doxepin cream only to affected areas, and rub in gently. Apply only to affected skin; not for ophthalmic, oral, or intravaginal use.

Patient/Family Teaching

• Inform patient that systemic side effects may occur with oral or topical use.
  • May cause drowsiness and blurred vision. Caution patient to avoid driving and other activities requiring alertness until response to the medication is known.
  • Orthostatic hypotension, sedation, and confusion are common during early therapy, especially in geriatric patients. Protect patient from falls. Institute fall precautions. Advise patient to change positions slowly.
  • Advise patient to avoid alcohol or other CNS depressant drugs during and for at least 3–7 days after therapy has been discontinued.
  • Inform patient that doxepin may cause getting up out of bed while not being fully awake and doing an activity that patient does not know he is doing. The next morning, he may not remember that he did anything during the night. May occur more frequently with alcohol or other sedatives. Advise patient to notify health care professional if this occurs.
  • Instruct patient to notify health care professional if urinary retention occurs or if dry mouth or constipation persists. Sugarless candy or gum may diminish dry mouth, and an increase in fluid intake or bulk may prevent constipation. If symptoms persist, dose reduction or discontinuation may be necessary. Consult health care professional if dry mouth persists for more than 2 wk.
  • Advise patient to notify health care professional of medication regimen prior to treatment or surgery.
• Oral: Instruct patient to take medication as directed. Take missed doses as soon as possible unless almost time for next dose; if regimen is a single dose at bedtime, do not take in the morning because of side effects. Advise patient that drug effects may not be noticed for at least 2 wk. Abrupt discontinuation may cause nausea, vomiting, diarrhea, headache, trouble sleeping with vivid dreams, and irritability. Advise patient, family, and caregivers to look for suicidality, especially during early therapy or dose changes. Notify health care professional immediately if thoughts about suicide or dying, attempts to commit suicide, new or worse depression or anxiety, agitation or restlessness, panic attacks, insomnia, new or worse irritability, aggressiveness, acting on dangerous impulses, mania, or other changes in mood or behavior or if symptoms of serotonin syndrome occur.
  • Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions.
  • Inform patient that urine may turn blue-green in color.
  • Inform patient of need to monitor dietary intake. Increase in appetite is possible and may lead to undesired weight gain.
  • Therapy for depression is usually prolonged. Emphasize the importance of follow-up exams to monitor effectiveness and side effects.
• Topical: Instruct patient to apply a thin film of medication exactly as directed; do not use more medication than directed, apply to a larger area than directed, use more often than directed, or use longer than 8 days.
  • Inform patient that topical preparation may cause burning, stinging, swelling, increased itching, or worsening of eczema. Notify health care professional if these symptoms become bothersome.
  • Caution patient not to use occlusive dressings; may increase systemic absorption.
  • Advise patient to notify health care professional if excessive drowsiness occurs with topical application. Number of applications per day, amount of cream applied, or area of application may be reduced. May require discontinuation of therapy.

Evaluation/Desired Outcomes

• Increased sense of well-being.
  • Renewed interest in surroundings.
  • Increased appetite.
  • Improved energy level.
  • Improved sleep.
• Decrease in anxiety.
• Decrease in chronic pain. Patients may require 2–6 wk of oral therapy before full therapeutic effects of medication are evident.
• Decrease in pruritus associated with eczema.