Impril

imipramine

Impril

Tofranil

Tofranil PM

Indications

Action

Pharmacokinetics

Time/action profile (antidepressant effect)

Contraindications/Precautions

Adverse Reactions/Side Effects

Central nervous system

• suicidal thoughts (life-threatening)
• drowsiness (most frequent)
• fatigue (most frequent)
• agitation
• confusion
• hallucinations
• insomnia

Ear, Eye, Nose, Throat

• blurred vision (most frequent)
• dry eyes (most frequent)

Cardiovascular

• arrhythmias (life-threatening)
• hypotension (most frequent)
• ECG changes

Gastrointestinal

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

Genitourinary

• urinary retention
• ↓ libido

Dermatologic

• photosensitivity

Endocrinologic

• gynecomastia

Hematologic

• blood dyscrasias

Interactions

Drug-Drug interaction

Route/Dosage

Availability (generic available)

Nursing implications

Nursing assessment

• Monitor BP and pulse rate prior to and during initial therapy.
• Monitor plasma levels in treatment-resisant patients.
• Monitor weight and BMI initially and periodically throughout therapy.
• For overweight/obese individuals, obtain FBS and cholesterol levels. Refer as appropriate for nutrition/weight management and medical management.
• Obtain weight and BMI initially and regularly throughout therapy.
• Assess for sexual dysfunction (decreased libido; erectile dysfunction).
• 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 yrs. After starting therapy, children, adolescents, and young adults should be seen by health care professional at least weekly for 4 wk, every 3 wk for next 4 wk, and on advice of health care professional thereafter.
• Pediatric / Geriatric: Monitor baseline and periodic ECGs in elderly patients or patients with heart disease and before increasing dose with children treated for enuresis. May cause prolonged PR and QT intervals and may flatten T waves.
• Depression: Assess mental status (orientation, mood, behavior) frequently. Confusion, agitation, and hallucinations may occur during initiation of therapy and may require dosage reduction. Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient.
• Enuresis: Assess frequency of bedwetting during therapy. Ask patient or caretaker to maintain diary.
• Pain: Assess location, duration, and severity of pain periodically during therapy. Use pain scale to monitor effectiveness of therapy.
• Lab Test Considerations: Assess leukocyte and differential blood counts and renal and hepatic functions prior to and periodically during prolonged or high-dose therapy.
  • Serum levels may be monitored in patients who fail to respond to usual therapeutic dose. Therapeutic plasma concentration range for depression is 150–300 ng/mL.
  • May cause alterations in blood glucose levels.
Symptoms of acute overdose include disturbed concentration, confusion, restlessness, agitation, seizures, drowsiness, mydriasis, arrhythmias, fever, hallucinations, vomiting, and dyspnea.
• Treatment of overdose includes gastric lavage, activated charcoal, and a stimulant cathartic. Maintain respiratory and cardiac function (monitor ECG for at least 5 days) and temperature. Medications may include digoxin for HF, antiarrhythmics, and anticonvulsants.

Potential Nursing Diagnoses

Implementation

• Dose increases should be made at bedtime because of sedation. Dose titration is a slow process; may take weeks to months. May be given as a single dose at bedtime to minimize sedation during the day.
  • Taper to avoid withdrawal effects. Reduce by 50% for 3 days, then reduce by 50% for 3 days, then discontinue.
• Oral: Administer medication with or immediately following a meal to minimize gastric irritation.
• Intramuscular: May be slightly yellow or red in color. Crystals may develop if solution is cool; place ampule under warm running water for 1 min to dissolve.

Patient/Family Teaching

• 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.
  • May cause drowsiness and blurred vision. Caution patient to avoid driving and other activities requiring alertness until response to drug is known.
  • Instruct patient to notify health care professional if visual changes occur. Inform patient that periodic glaucoma testing may be needed during long-term therapy.
  • Caution patient to change positions slowly to minimize orthostatic hypotension.
  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.
  • Advise patient to avoid alcohol or other CNS depressant drugs during therapy and for at least 3–7 days after therapy has been discontinued.
  • Instruct patient to notify health care professional if urinary retention, 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.
  • Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions.
  • Alert patient that urine may turn blue-green in color.
  • Inform patient of need to monitor dietary intake, as possible increase in appetite may lead to undesired weight gain. Inform patient that increased amounts of riboflavin in the diet may be required; consult health care professional.
  • Advise patient to notify health care professional of medication regimen prior to treatment or surgery.
  • Therapy for depression is usually prolonged. Emphasize the importance of follow-up exams to evaluate progress and improve coping skills.
• Instruct female patients to notify health care professional if pregnancy is planned or suspected, or if breast feeding.
• Pediatric: Inform parents that the side effects most likely to occur include nervousness, insomnia, unusual tiredness, and mild nausea and vomiting. Notify health care professional if these symptoms become pronounced.
  • Advise parents to keep medication out of reach of children to prevent inadvertent overdose.

Evaluation/Desired Outcomes

• Increased sense of well-being.
  • Renewed interest in surroundings.
  • Increased appetite.
  • Improved energy level.
  • Pain relief.
  • Diminished incidence of enuresis.
  • Improved sleep in patients treated for depression. Patient may require 2–6 wk of therapy before full therapeutic effects of medication are noticeable.
• Control of bedwetting in children >6 yr.
• Decrease in chronic neurogenic pain.