Common Medications Used for Rehabilitation

Common Medications Used for Rehabilitation Pharmacological agents may be useful in a variety of affective and behavioral disturbances associated with neurological injuries. The agents typically used for their direct and indirect pharmacological properties are covered in this module. This self-directed learning module contains information on dosages and side effects you are expected to know to protect our patients, our guests, and you. Carolinas Rehabilitation Target Audience: RN, LPN Recommended: Ancillary caregivers Contents Instructions...2 Learning Objectives...2 Module Content...3 Job Aid...11 Posttest...12-13 Page 1 of 13

INSTRUCTIONS The following module outlines basic drug information on common medications used for patients in the rehabilitation setting. The material in this module is an introduction to general, yet important information. After completing this module, contact your manager to obtain additional information specific to your unit. Read this module. If you have any questions about the material, ask your manager. Complete the online post test for this module. The JOB AID on page 11 may be customized to fit your department and then used as a quick reference guide The drug charts may be customized to fit your department and then be used as a quick reference guide. Completion of this module will be recorded under My Learning in PeopleLink. Learning Objectives When you finish this module you will be able to: State 5 common medications used in patients undergoing rehabilitation. Discuss the basic pharmacologic treatment principles for 5 medications used for the rehabilitation patient population. Identify common side effects associated with 5 of these medications. Page 2 of 13

Commonly Used Medications in the Rehabilitation Patient I. TRAUMATIC BRAIN INJURY (TBI) is broadly defined as an injury resulting from external trauma and includes many different types of head trauma. These injuries often result in significant impairment of one s physical, cognitive, and psychosocial functioning. The pharmacological management of these patients involves using various medications adapted to treat the individual s specific symptoms and needs. Pharmacological agents may be useful in a variety of affective and behavioral disturbances associated with TBI and these agents are typically used for their direct and indirect pharmacological properties. There are numerous indications for some of the drug agents listed below, however the indications listed in the chart below are the most common indications seen in this patient population. TBI medications Methylphenidate (Ritalin, Concerta) Amantadine (Symmetrel) Bromocriptine (Parlodel) Donepezil (Aricept) Modafinil (Provigil) CNS Stimulant Anti-Parkinson s Agent; Antiviral; Dopamine Agonist Anti-Parkinson s Agent; Dopamine Agonist Acetylcholinester ase Inhibitor; Cholinergic Agent CNS stimulant (Nonamphetamine) Arousal, Attention, Responsiveness, Function, Motor recovery, Aphasia Function, Arousal, Responsiveness, Agitation, Emotional lability Arousal, Attention, Responsiveness, Function, Motor recovery, Aphasia, Autonomic storming Memory, Responsiveness Arousal, Attention, Responsiveness, Function 2.5mg to 20mg per dose given twice daily at 8:00 and noon 50mg to 100mg per dose once or twice daily at 8:00 and noon 2.5mg to 15mg per dose given twice daily at 8:00 and noon 5mg/day at bedtime titrated to 10mg/day at bedtime 100-400mg once daily at 8 am Common Side insomnia, decreased appetite, agitation, nausea insomnia, agitation constipation diarrhea nervousness heart rate, CBC-(with prolonged therapy) renal function, mental status, hepatic function, behavior, mood, bowel function blood pressure; levels of sleepiness Page 3 of 13

TBI medications continued Amitriptyline (Elavil) Trazodone (Desyrel) Carbamazepine (Tegretol, Carbatrol) Dantrolene (Dantrium) Tricylcic Antidepressant (TCA) Antidepressant (Serotonin Reuptake Inhibitor) Anticonvulsant Skeletal Muscle Relaxant Sleep Maintenance,, Emotional lability Sleep Initiation Agitation, Emotional lability, Seizure Management, Spasticity, Autonomic Storming 10mg to 100mg daily at bedtime 25mg to 150mg daily at bedtime 800mg to 1200mg daily in 2 divided doses Therapeutic range 4-12 mcg/ml 25mg/day to 400mg/day in divided doses Common Side dry mouth, blurred vision, fatigue, urinary retention sedation, dry mouth, blurred vision sedation, confusion, hypertension, blurred vision, diplopia drowsiness, lightheadedne ss, fatigue, rash, vomiting, muscle weakness pulse, mental status mental status CBC, ophthalmic exams, lipids, serum levels signs and symptoms of intracranial hypertension (papilledema, vomiting), hepatic function, androgenic changes Propranolol (Inderal) Sertraline (Zoloft) Memantine (Namenda) Class II Antiarrythmic; Non-selective Beta Blocker Antidepressant; Selective Serotonin Reuptake Inhibitor (SSRI) Central Nervous System Agent for Alzheimer s Tachycardia, Agitation, Migraine headaches, Autonomic Storming Depression Mild to moderate treatment of dementia in Alzheimer s Page 4 of 13 40mg/day to 180mg/day in divided doses 25mg to 200mg daily 10 mg twice daily at 8am and noon Initial dosing - 10 mg once daily bradycardia, vomiting, fatigue, pruritus, dyspnea insomnia, fatigue, dry mouth, diarrhea, nausea confusion, rash, hypertension, cough heart rate, blood pressure mental status, anxiety, social functioning, akathisia Blood pressure, Improvement in ADL s

II. STROKE occurs when there is an acute loss in circulation to an area of the brain that results in ischemia and a corresponding loss of neurological function. Various pharmacological agents are used in the management of patients following a stroke in order to treat the associated comorbidities, as well as for secondary prevention. The medications used for stroke patients are the same as those used in traumatic brain injury patients except Propranolol (Inderal) is not used often, Phenytoin (Dilantin) is generally used in place of Carbamazepine (Tegretol, Carbitrol), and ACE inhibitors are often used. The chart below summarizes these additional medications. Stroke Medications Phenytoin (Dilantin) Trandolapril (Mavik) Lisinopril (Prinvil, Zestril) Tizanidine (Zanaflex) Enoxaparin (Lovenox) Gabapentin (Neurontin) Anticonvulsant Angiotensin- Converting Enzyme (ACE) Inhibitor Angiotensin- Converting Enzyme (ACE) Inhibitor Alpha2- Adrenergic Agonist Anticoagulant; Low Molecular Weight Heparin (LMWH) Anticonvulsant Seizure Management Hypertension Hypertension Spasticity Anticoagulant for: prophylaxis; treatment; PE treatment Neuropathic 15-20mg/kg based on serum concentrations and recent dosing history 1-4mg/day once daily 10-40mg/day 2-8mg 3 to 4 times daily Prophylaxis: 30mg SQ BID Or 40mg SQ daily (often needs to be corrected for renal impairment) Treatment: 1mg/kg/dose every 12 hours 300mg/day to 3600mg/day in 3-4 divided doses Page 5 of 13 Common Side pruritus, gingival hyperplasia, headache cough cough dry mouth, fever, confusion, pain at the injection site, bruising, bleeding, hemorrhage ataxia, fatigue plasma phenytoin level, blood pressure, CBC, liver function tests serum potassium, renal function, serum creatinine, BUN serum potassium, renal function, serum creatinine, BUN ophthalmic function, liver function platelets, occult blood, signs and symptoms of bleeding, plasma anti-factor Xa (in patients with significant renal impairment) pain assessments

III. SPINAL CORD INJURIES often result in neurological deficits and disability, with specific symptoms varying depending on the location of the injury. Patients with this type of injury are also at a high risk for certain types of morbidity including: thromboembolic disease, autonomic dysfunction, neuropathic pain, neurogenic bladder dysfunction, neurogenic bowel management, pressure ulceration, and spasticity. Various pharmacologic agents are used in the treatment of the morbidities seen in this patient population. There are numerous indications for some of the drug agents listed below, however the indications listed in the chart below are the most common indications seen in this patient population. Spinal Cord Injury Medications Oxybutynin (Ditropan) Baclofen (Lioresal) Enoxaparin (Lovenox) Warfarin (Coumadin) Urinary Antispasmodic Agent Skeletal Muscle Relaxant Anticoagulant; Low Molecular Weight Heparin (LMWH) Anticoagulant Coumarin derivative Neurogenic Bladder Spasticity Anticoagula nt for: prophylaxis; treatment; PE treatment Anticoagula nt for: prophylaxis; treatment; PE treatment 5mg 2-4 times a day Extended Release: 5mg to 30mg once daily 15mg/day to 80mg/day in 3-4 divided doses Prophylaxis: 30mg SQ BID Or 40mg SQ daily (often needs to be corrected for renal impairment) /PE Treatment: 1mg/kg/dose every 12 hours Per Pharmacy Protocol based on INR results Common Side dry mouth, impaired urination drowsiness, vertigo, psychiatric disturbances, insomnia, slurred speech, ataxia, weakness fever, confusion, pain at the injection site, bruising, bleeding, hemorrhage bleeding, hemorrhage incontinence episodes, post void residuals (PVR) reduction in muscle spasms, passive limb movement, pain relief platelets, occult blood, signs and symptoms of bleeding, plasma anti-factor Xa (in patients with significant renal impairment) prothrombin time, hematocrit, INR, platelets, signs and symptoms of bleeding Page 6 of 13

Spinal Cord Medications Continued Tizanidine (Zanaflex) Gabapentin (Neurontin) Pregabalin (Lyrica) Bisacodyl (Dulcolax) Docusate (Colace) Senna (Senokot, Ex- Lax) Amitriptyline (Elavil) Alpha2- Adrenergic Agonist Anticonvulsant, Anticonvulsant Stimulant Laxative Stool Softener Stimulant Laxative Tricylcic Antidepressant (TCA) Spasticity Neuropathic Neuropathic Bowel Movements Bowel Movements Bowel Movements Sleep Maintenance 2 to 8 mg per dose 3 times to 4 times a day 300mg/day to 3600mg/day in 3-4 divided doses 150mg/day to 300mg/day in 2-3 divided doses Oral: 5mg to 30mg as a single dose Rectal Suppository: 10mg 50mg/day to 500mg/day in 1-4 divided doses 8.6mg to 17.2mg daily at noon Oral: 10mg to 100mg daily at bedtime Common Side dry mouth, ataxia, fatigue peripheral edema, ataxia, dry mouth, tremor, blurred vision, diplopia mild abdominal cramps, fluid and electrolyte imbalance diarrhea, abdominal cramping diarrhea, abdominal cramps, nausea dry mouth, blurred vision, fatigue ophthalmic function, liver function pain assessments pain assessments, degree of sedation, symptoms of myopathy and ocular disturbance, weight gain/edema, CPK levels bowel movements; fluid intake bowel movements bowel movements pulse, mental status Page 7 of 13

IV. ORTHOPEDIC/ONCOLOGY Orthopedic patients are often admitted due to fractures, most commonly of the knee and hip, and are treated with pharmacologic agents based on their condition. Most often, these patients will need pain management and thromboembolism prevention. Oncology patients are often admitted due to a decline in functional status due to disease progression or chemotherapy. Various pharmacological agents are used in managing the associated symptoms in this patient population. The medications used for these patients are similar to all previous listed medications but also include the pain management medications summarized in the chart below. Orthopedic/Oncology Medications Oxycodone (Oxycontin) Morphine (MS Contin) Tramadol (Ultram) Oxycodone/ Acetaminophen (Percocet) Opioid Opioid Non-Opioid Opioid Chronic (Moderate to Severe) Chronic (Moderate to Severe) (Moderate to Severe) (Moderate to Severe) Oral: 10-160mg every 12 hours Oral: 15-30mg every 8-12 hours 50-100mg every 4-6 hours (not to exceed 400mg/day) Based on Oxycodone content: 5-30mg every 4 to 6 hours titrated to appropriate analgesic effect (MAX Acetaminophen dose= 4g/day) Common Side pruritus, vomiting bradycardia, drowsiness, pruritus, dry mouth, weakness flushing, insomnia, tremor, seizure, pruritus, weakness pruritus, respiratory depression, sedation pain relief, respiratory status, mental status, blood pressure pain relief, respiratory status, mental status, blood pressure pain relief, respiratory rate, pulse pain relief, respiratory status, mental status, constipation Page 8 of 13

V. PEDIATRICS Many of the same drugs used for traumatic brain injury and spinal cord injury are also used in pediatric patients. The following are additional drugs that are used in the pediatric patient population, for the indications listed in the chart. Pediatric Medications Divalproex (Depakote) Desipramine (Norpramin) Hydrocodone/ Acetaminophen (Lortab) Anticonvulsant Antidepressant (Tricyclic) Opioid Combination Irritability Arousal, Attention (Moderate to Severe) 10-60mg/kg/day in 2-3 divided doses 1-3 mg/kg/day in divided doses Based on Hydrocodone Content: 2.5-10mg every 4 to 6 hours titrated to appropriate analgesic effect (MAX Acetaminophen = 4grams/day) Common Side drowsiness, dizziness loss of appetite, dry mouth, blurred vision pruritus, vomiting liver enzymes, bilirubin, serum ammonia, CBC heart rate, mental status, weight pain relief, respiratory status, mental status, blood pressure Diazepam (Valium) Lidocaine (Lidoderm) Antianxiety, Anticonvulsant, Benzodiazepine, Hypnotic, Sedative Topical Spasticity Oral: 0.12-0.8 mg/kg/day in divided doses every 6-8 hours IM/IV: 0.04-0.3 mg/kg/dose every 2-4 hours to a maximum of 0.6 mg/kg within an 8- hour period if needed Apply patch topically to painful area for up to 12 hours; up to 3 patches per application (Max dose 3mg/kg/dose) bradycardia, drowsiness, confusion, fatigue, blurred vision, decrease in respiratory rate skin irritation, decreased sensation heart rate, respiratory rate, blood pressure pain assessments Page 9 of 13

Pediatric Medications Continued Ibuprofen (Advil, Motrin) Methadone (Methadose) ; Non-steroidal antiinflammatory Narcotic Used as a taper after extended period of intubation 4-10mg/kg/dose every 6-8 hours; Maximum daily dose: 40mg/kg/day Variable per MD Common Side rash, dyspepsia, abdominal pain, tinnitus, fluid retention vomiting, sedation pain assessments, CBC, liver enzymes respiratory function, mental status, blood pressure, bowel movements Page 10 of 13

JOB AID The pharmacologic management of the TBI, stroke, SCI, Ortho patients involves using medications adapted to treat the individuals specific symptoms Pharmacologic agents have multiple uses and can be used in varying doses according to diagnosis Medications such as Coumadin or Lovenox are often used as a prophylactic to prevent the complication of s Many drugs used for pediatric patients can be the same used for the adult patient however different dose requirements must be noted. Sleep medications or seizure medications may cause the patient to be very lethargic during the day, if this does not resolve the MD should be notified- a dosage change may be warranted. Complaints of dry mouth while taking Ditropan are common, fluids should be encouraged. References Drug facts and comparisons. www.efacts.com. Lexi-Comp online. www.lexicomponline.com. Micromedex online. www.micromedex.com. Up to date 18.3- on line educational resources. CHS synapse Page 11 of 13

Posttest Name: Date: Circle the correct answer. 1. A patient who is currently taking Oxybutynin (Ditropan) for neurogenic bladder complains of having a very dry mouth. What is the BEST thing you should do? a. Tell them this is a common side effect of the medication, and try to increase their fluid intake b. Tell them they should not complain, and focus on their therapy c. Page the doctor immediately because this is a serious adverse drug reaction 2. You are working with a patient who was just started on propranolol (Inderal) for tachycardia. The patient is getting fatigued more quickly then normal, and when you take their pulse, their heart rate is low. Which of the following statements is true? a. The patient needs a Mt Dew to stimulate them and increase their heart rate b. This is a common side effect of this medication that the patient is experiencing, but you will notify the physician c. The patient needs a stat EKG 3. A patient on methylphenidate (Ritalin) for arousal may have an increased appetite a. True b. False 4. A common side effect a patient on Amitriptyline (Elavil) and Bromocriptine (Parlodel) may experience is dizziness. a. True b. False 5. A patient arrives at therapy after receiving a dose of oxycodone (Oxycontin) for chronic pain management. Which of the following is a common side effect of this medication that you may see? a. Drowsiness b. Diplopia c. Fever (Continue next page) Page 12 of 13

6. Your patient complains that they are not moving their bowels regularly. You look at their current medications which include: Enoxaparin (Lovenox) 30mg SQ Daily Warfarin (Coumadin) 5mg PO Daily Propanolol (Inderal) 40mg PO Daily Oxycodone/Acetaminophen (Percocet) 5/325mg PO Q6H Which medication is the most likely cause of this side effect? a. Enoxaparin (Lovenox) b. Warfarin (Coumadin) c. Propanolol (Inderal) d. Oxycodone/Acetaminophen (Percocet) 7. Patients being treated with warfarin (Coumadin) for prophylaxis are at a greater risk for bleeding then normal. a. True b. False 8. You are working with a patient who is currently taking pregabalin (Lyrica) for neuropathic pain following a spinal cord injury and they appear to have some mild peripheral edema present. Is this a common side effect of this medication? a. Yes, mild peripheral edema may occur in patients on this medication b. No, mild peripheral edema has never occurred in patients on this medication c. This drug is not used for neuropathic pain. 9. A patient who has been started on lisinopril (Prinvil, Zestril) for hypertension may experience a dry cough a. True b. False 10. A pediatric patient who is receiving a lidocaine patch (Lidoderm) topically for pain relief may experience minor skin irritation and a decrease in sensation around the area where the patch is applied. a. True b. False 11. You arrive in a patient s room to initiate therapy and they are very lethargic. You review their MAR for possible medication causes. Which of the following combinations would most likely be the cause? a. Oxycodone (Oxycontin) 20mg po QAM and Gabapentin (Neurontin) 600mg po TID b. Modafinil (Provigil) 100mg po QAM and Donepezil (Aricept) 10mg PO QHS c. Lovenox 40mg SQ BID and Warfarin 5mg PO Qday. Page 13 of 13