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Pharmacologic class: Tricyclic dibenzoxazepine derivative
Therapeutic class: Antipsychotic
Pregnancy risk category C
Unknown. Thought to block neurotransmission of postsynaptic dopamine receptors in brain, alleviating psychotic symptoms.
Capsules: 5 mg, 10 mg, 25 mg, 50 mg
Indications and dosages
Adults: 10 mg P.O. b.i.d. Dosage may be increased over first 7 to 10 days, up to 100 mg/day P.O. in two to four divided doses. Maximum dosage is 250 mg/day.
• Elderly patients
• Hypersensitivity to drug or other dibenzoxazepines
• Coma or severe drug-induced CNS depression
Use cautiously in:
• seizures, cerebral arteriosclerosis, severe hypotension, hypertension, glaucoma, breast cancer, hepatic disease, bone marrow depression, Parkinson's disease, blood dyscrasias, urinary retention, concurrent use of other CNS active drugs or anticholinergics
• pregnant or breastfeeding patients
• children younger than age 16.
• Give with or without food.
CNS: drowsiness, insomnia, vertigo, headache, dizziness, weakness, akinesia, staggering or shuffling gait, slurred speech, agitation, extrapyramidal reactions, sedation, syncope, tardive dyskinesia, numbness, confusion, pseudoparkinsonism, EEG changes, seizures, neuroleptic malignant syndrome
CV: orthostatic hypotension, hypertension, ECG changes
EENT: blurred vision, ptosis, nasal congestion
GI: nausea, vomiting, constipation, dry mouth, paralytic ileus
GU: urinary retention
Hematologic: leukopenia, agranulocytosis, thrombocytopenia
Hepatic: hepatocellular injury with hepatic enzyme elevations
Musculoskeletal: muscle twitching
Skin: rash, pruritus, seborrhea, photosensitivity, alopecia
Other: weight gain or loss, hyperpyrexia, facial edema, hypersensitivity reactions
Drug-drug. Anticholinergics, CNS depressants: additive effects
Epinephrine: severe hypotension, tachycardia, decreased epinephrine effects
Drug-diagnostic tests. Granulocytes, platelets, white blood cells: decreased counts
Liver function tests: increased values
Drug-behaviors. Alcohol use: increased CNS depression
• Measure blood pressure before and periodically during therapy.
• Monitor hematologic studies and liver function tests.
☞ Stay alert for evidence of neuroleptic malignant syndrome (extrapyramidal symptoms, hyperpyrexia, muscle rigidity, altered mental status, irregular pulse or blood pressure, tachycardia, arrhythmias, diaphoresis).
• Assess for tardive dyskinesia (involuntary jerky movements of face, tongue, jaws, trunk, arms, and legs), especially in elderly women.
• Tell patient to take with or without food.
• Inform patient that drug may cause tardive dyskinesia. Describe symptoms.
• Caution patient to avoid activities requiring mental concentration until drug's effects are known.
☞ Teach patient to immediately report sore throat, fever, rash, impaired vision, tremors, involuntary muscle twitching, muscle stiffness, or yellowing of eyes or skin.
• Instruct patient to move slowly when sitting up or standing, to avoid dizziness from sudden blood pressure decrease.
• Caution patient to avoid alcohol use.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, and behaviors mentioned above.
Time/action profile (antipsychotic effect)
|PO||30 min||1.5–3 hr||12 hr|
Adverse Reactions/Side Effects
Central nervous system
- neuroleptic malignant syndrome (life-threatening)
- confusion (most frequent)
- dizziness (most frequent)
- drowsiness (most frequent)
- extrapyramidal reactions
- tardive dyskinesia
Ear, Eye, Nose, Throat
- blurred vision (most frequent)
- lens opacities
- nasal congestion
- orthostatic hypotension (most frequent)
- drug-induced hepatitis
- dry mouth
- urinary retention
- facial photosensitivity
- pigment changes
- agranulocytosis (life-threatening)
- allergic reactions
Drug-Drug interactionBlocks the alpha-adrenergic effects of epinephrine (may result in hypotension and tachycardia).Additive CNS depression with other CNS depressants, including alcohol, antihistamines, opioid analgesics, and sedative/hypnotics.Antacids or adsorbent antidiarrheals may ↓ absorption.Use with antidepressants or MAO inhibitors may result in prolonged CNS depression and ↑ anticholinergic effects.Concomitant use of kava, valerian, skullcap, chamomile, or hops can ↑ CNS depression.
Availability (generic available)
- Monitor patient’s mental status (orientation, mood, behavior) before and periodically during therapy.
- Assess positive (delusions, hallucinations, agitation) and negative (social withdrawal) symptoms of schizophrenia.
- Assess weight and BMI initially and throughout therapy. Refer as appropriate for nutritional/weight management and medical management.
- Monitor BP (sitting, standing, lying) and pulse rate before and frequently during.dose adjustment.
- Observe patient carefully when administering medication to ensure that medication is actually taken and not hoarded or cheeked.
- 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. Report these symptoms; reduction in dosage or discontinuation of medication may be necessary. Trihexyphenidyl, diphenhydramine, or benzotropine may be used to control symptoms. Benzodiazepines may alleviate 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). Tardive dyskinesia is dose related initially but may increase with cumulative dose. Report immediately; may be irreversible.
- Monitor frequency and consistency of bowel movements. Increasing bulk and fluids in the diet may help minimize constipation.
- Loxapine lowers the seizure threshold. Institute seizure precautions for patients with history of seizures.
- 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 symptoms immediately.
- Lab Test Considerations: Monitor CBC and differential before and periodically throughout therapy.
- Obtain fasting blood glucose and cholesterol levels initially and periodically during therapy.
Antiemetic effects of loxapine may block the action of ipecac. Overdose is treated by gastric lavage, barbiturates to control seizures, and supportive care for fluctuations in body temperature. Hypotension may be corrected by use of IV fluids, norepinephrine, or phenylephrine. Avoid use of epinephrine, as it may worsen hypotension.
- Monitor liver function studies and urine bilirubin and bile concentrations if patient develops jaundice.
Potential Nursing DiagnosesDisturbed thought process (Indications)
Disturbed sensory perception(specify: visual, auditory, kinesthetic, gustatory, tactile, or olfactory) (Indications)
- Do not confuse loxapine (Loxitane) with acetretin (Soriatane), Lexapro (escitalopram), or fluoxetine (Prozac).
- Oral: Administer tablets and capsules with food or milk to decrease gastric irritation.
- Do not administer antacids or antidiarrheals within 2 hr of loxapine.
- Instruct patient on need to take loxapine as directed. Take missed doses as soon as remembered, up to 1 hr before next scheduled dose. Patients on long-term high-dose therapy may need to discontinue gradually to avoid withdrawal symptoms (dyskinesia, tremors, dizziness, nausea, and vomiting).
- 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.
- May cause drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to the medication is known.
- Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions.
- Caution patient to avoid concurrent use of alcohol, other CNS depressants, and OTC medications without consulting health care professional.
- 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 to notify health care professional of medication regimen before 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.
- Advise patient of need for continued medical follow-up for psychotherapy, eye exams, and laboratory tests, and to detect side effects.
- Decrease in positive symptoms of schizophrenia (hallucinations, delusions, agitation).
- Decrease in excitable, manic behavior.