chapter 16

Central Nervous System Stimulants

Objectives
AFTER STUDYING THIS CHAPTER, THE STUDENT WILL BE ABLE TO:

1. Describe general characteristics of central 4. Identify effects and sources of caffeine.

nervous system (CNS) stimulant drugs. 5. Identify nursing interventions to prevent,
2. Discuss reasons for decreased use of amphet- recognize, and treat stimulant overdose.
amines for therapeutic purposes.
3. Discuss the rationale for treating attention
deficit-hyperactivity disorder with CNS
stimulant drugs.

Critical Thinking Scenario

Mrs. Williams comes to your office with her 6-year-old son. She complains that he is a very active child who
always seems to be getting into mischief. She likes a clean, orderly house and he likes to make messes. He
seems to be doing OK in school, although she would like to see his grades improve. She was talking to a
neighbor, who encouraged her to talk with a physician about prescribing Ritalin, because her son may have
attention deficit-hyperactivity disorder (ADHD).

Reflect on:
 What advice you would have for Mrs. Williams.

 Possible therapeutic effects if the boy has ADHD.

 Possible negative effects if the boy does not have ADHD.

USES known; sleep studies are required for an accurate diagnosis.

M any drugs stimulate the CNS, but only a few are used
therapeutically, and their indications for use are limited. Two
disorders treated with CNS stimulants are narcolepsy and
attention deficit-hyperactivity disorder (ADHD).
In addition to drug therapy, prevention of sleep deprivation,
regular sleeping and waking times, avoiding shift work, and
short naps may be helpful in reducing daytime sleepiness.
Attention Deficit-Hyperactivity Disorder

Narcolepsy ADHD is reportedly the most common psychiatric or neu-

Narcolepsy is a sleep disorder characterized by daytime sleep
attacks in which the victim goes to sleep at any place or any
time. Signs and symptoms also include excessive daytime
drowsiness, fatigue, muscle weakness and hallucinations at
onset of sleep, and disturbances of nighttime sleep patterns. The
hazards of drowsiness during normal waking hours and sud-
denly going to sleep in unsafe environments restrict activities
of daily living.
Narcolepsy affects men and women equally and usually
starts during teenage or young adult years. Its cause is un-
robehavioral disorder in children. It occurs before 7 years of
age and is characterized by persistent hyperactivity, a short at-
tention span, difficulty completing assigned tasks or school-
work, restlessness, and impulsiveness. Such behaviors make
it difficult for the child to get along with others (eg, family
members, peer groups, teachers) and to function in situations
requiring more controlled behavior (eg, classrooms).
Formerly thought to disappear with adolescence, ADHD
is now thought to continue into adolescence and adulthood in
one third to two thirds of clients. In adolescents and adults,
impulsiveness and inattention continue but hyperactivity is
251
 252 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM
not a prominent feature. A major criterion for diagnosing later
ADHD is a previous diagnosis of childhood ADHD. Some
studies indicate that children with ADHD are more likely to
have learning disabilities, mood disorders, and substance abuse
disorders as adolescents and adults as well as continuing diffi-
culties in structured settings such as school or work.
TYPES OF STIMULANTS
Most CNS stimulants act by facilitating initiation and trans-
mission of nerve impulses that excite other cells. The drugs are
somewhat selective in their actions at lower doses but tend to
involve the entire CNS at higher doses. The major groups are
amphetamines and related drugs, analeptics, and xanthines.
Amphetamines increase the amounts of norepinephrine,
dopamine, and possibly serotonin in the brain, thereby pro-
ducing mood elevation or euphoria, increasing mental alert-
ness and capacity for work, decreasing fatigue and drowsiness,
and prolonging wakefulness. Larger doses, however, produce
signs of excessive CNS stimulation, such as restlessness,
hyperactivity, agitation, nervousness, difficulty concentrating
on a task, and confusion. Overdoses can produce convulsions
and psychotic behavior. Amphetamines also stimulate the
sympathetic nervous system, resulting in increased heart
rate and blood pressure, pupil dilation (mydriasis), slowed
gastrointestinal motility, and other symptoms. In ADHD, the
drugs reduce behavioral symptoms and may improve cognitive
performance.
Amphetamines are Schedule II drugs under the Controlled
Substances Act and have a high potential for drug abuse and
dependence. Prescriptions for them are nonrefillable. These
drugs are widely sold on the street and commonly abused (see
Chap. 15).
Amphetamine-related drugs (methylphenidate and dexme-
thylphenidate) have essentially the same effects as the amphet-
amines and are also Schedule II drugs.
Analeptics are infrequently used (see doxapram and
modafinil, below).
Xanthines stimulate the cerebral cortex, increasing mental
alertness and decreasing drowsiness and fatigue. Other effects
include myocardial stimulation with increased cardiac output
and heart rate, diuresis, and increased secretion of pepsin and
hydrochloric acid. Large doses can impair mental and physi-
cal functions by producing restlessness, nervousness, anxiety,
agitation, insomnia, cardiac dysrhythmias, and gastritis.
Indications for Use
Amphetamines and methylphenidate are used in the treatment
of narcolepsy and ADHD. Dexmethylphenidate is indicated
only for ADHD. One analeptic is used occasionally to treat
respiratory depression; the other one is approved only for
treatment of narcolepsy. Caffeine (a xanthine) is an ingredient
in nonprescription analgesics and stimulants that promote
wakefulness (eg, No-Doz). A combination of caffeine and
sodium benzoate is occasionally used as a respiratory stimulant
in neonates.
Contraindications to Use
Central nervous system stimulants cause cardiac stimulation
and thus are contraindicated in clients with cardiovascular dis-
orders (eg, angina, dysrhythmias, hypertension) that are likely
to be aggravated by the drugs. They also are contraindicated
in clients with anxiety or agitation, glaucoma, or hyper-
thyroidism. They are usually contraindicated in clients with a
history of drug abuse.
INDIVIDUAL CENTRAL NERVOUS
SYSTEM STIMULANTS
Individual drugs are described below; dosages are listed in
Drugs at a Glance: Central Nervous System Stimulants.
Amphetamines and Related Drugs
Amphetamine, dextroamphetamine (Dexedrine), and meth-
amphetamine (Desoxyn) are closely related drugs that share
characteristics of the amphetamines as a group. They are more
important as drugs of abuse than as therapeutic agents.
Methylphenidate (Ritalin) is chemically related to am-
phetamines and produces similar actions and adverse effects.
It is well absorbed with oral administration. In children, peak
plasma levels occur in about 2 hours with immediate-release
tablets and about 5 hours with extended-release tablets. Half-
life is 1 to 3 hours, but pharmacologic effects last 4 to 6 hours.
Most of a dose is metabolized in the liver and excreted in urine.
Dexmethylphenidate (Focalin) is very similar to methyl-
phenidate and the amphetamines. It is well absorbed with
oral administration and reaches peak plasma levels in 1 to
1.5 hours. It is metabolized in the liver and excreted in urine.
Analeptics
Doxapram (Dopram) is occasionally used by anesthesiolo-
gists and pulmonary specialists as a respiratory stimulant.
Although it increases tidal volume and respiratory rate, it also
increases oxygen consumption and carbon dioxide production.
Limitations include a short duration of action (5 to 10 minutes
after a single intravenous [IV] dose) and therapeutic dosages
near or overlapping those that produce convulsions. Endotra-
cheal intubation and mechanical ventilation are safer and more
effective in relieving respiratory depression from depressant
drugs or other causes.
Modafinil (Provigil) is a newer drug for treatment of nar-
colepsy. Its ability to promote wakefulness is similar to that
of amphetamines and methylphenidate, but its mechanism of
action is unknown. Like other CNS stimulants, it also has
 CHAPTER 16 CENTRAL NERVOUS SYSTEM STIMULANTS 253

Drugs at a Glance: Central Nervous System Stimulants

Routes and Dosage Ranges

Generic/Trade Name Indications for Use Adults Children

Amphetamines
Amphetamine
Dextroamphetamine (Dexedrine)
Methamphetamine (Desoxyn)
Amphetamine mixture (Adderall)
Amphetamine-Related Drugs
Dexmethylphenidate (Focalin)
Methylphenidate (Ritalin, Ritalin
SR, Concerta, Metadate)
Analeptics
Doxapram (Dopram)
Modafinil (Provigil)
Narcolepsy Narcolepsy: PO 560 mg/d in divided Narcolepsy: >6 y: PO 5 mg/d initially,
ADHD doses increase by 5 mg/wk to effective
dose
ADHD: 35 y: PO 2.5 mg/d initially, in-
crease by 2.5 mg/d at weekly inter-
vals until response; >6 y: PO 5 mg
once or twice daily initially, increase
by 5 mg/d at weekly intervals until
optimal response (usually no more
than 40 mg/d)
Narcolepsy Narcolepsy: PO 560 mg in divided doses Narcolepsy: >6 y: PO 5 mg/d initially, in-
ADHD crease by 5 mg/wk to effective dose
ADHD: 35 y: PO 2.5 mg/d initially, in-
crease by 2.5 mg/d at weekly inter-
vals until optimal response; >6 y:
PO 5 mg once or twice daily initially,
increase by 5 mg/d at weekly inter-
vals until optimal response (usually
no more than 40 mg/d)
ADHD in children PO 510 mg daily initially. Usual dose,
1525 mg daily, in 2 divided doses
ADHD Narcolepsy: PO 10 mg daily initially, >6y: ADHD, PO 5 mg 12 times daily,
Narcolepsy increase if necessary increased if necessary
ADHD PO 2.510 mg twice daily
ADHD Narcolepsy: PO 1060 mg/d in 2 or 6 y: ADHD, PO 5 mg twice a day ini-
Narcolepsy 3 divided doses tially, increase by 510 mg at weekly
intervals to a maximum of 60 mg/d if
necessary
IV 0.51.5 mg/kg in single or divided
doses; IV continuous infusion
5 mg/min initially, decreased to
2.5 mg/min or more. Dose by infusion
should not exceed 3 g.
Narcolepsy PO 200 mg once daily, in the morning. Dosage not established for children
Dosage should be reduced by 50% <16 years of age
with severe hepatic impairment.

psychoactive and euphoric effects that alter mood, percep-
tion, and thinking. It is a Schedule IV drug. It is rapidly ab-
sorbed (food may delay absorption), reaches peak plasma
levels in 2 to 4 hours, is 60% bound to plasma proteins, and
is 90% metabolized by the liver to metabolites that are then
excreted in urine. Steady-state concentrations are reached in
2 to 4 days and half-life with chronic use is about 15 hours.
Modafinil is not recommended for patients with a history of
left ventricular hypertrophy or ischemic changes on electro-
cardiograms. Adverse effects include anxiety, chest pain,
dizziness, dyspnea, dysrhythmias, headache, nausea, nervous-
ness, and palpitations. Interactions with other drugs include
decreased effects of cyclosporine and oral contraceptives and
increased effects of phenytoin, tricyclic antidepressants,
and warfarin. Dosage should be reduced by 50% with se-
vere hepatic impairment; effects of severe renal impairment
are unknown.
Xanthines
Caffeine has numerous pharmacologic actions, including CNS
stimulation, diuresis, hyperglycemia, cardiac stimulation,
coronary and peripheral vasodilation, cerebrovascular vascon-
striction, skeletal muscle stimulation, increased secretion of
gastric acid and pepsin, and bronchodilation from relaxation of
smooth muscle. In low to moderate amounts, caffeine in-
creases alertness and capacity for work and decreases fatigue.
Large amounts cause excessive CNS stimulation with anxiety,
agitation, diarrhea, insomnia, irritability, nausea, nervousness,
 254 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM

premature ventricular contractions, hyperactivity and restless-
ness, tachycardia, tremors, and vomiting. Toxic amounts may
cause delirium and seizures. With large amounts or chronic
use, caffeine has been implicated as a causative or aggravating
factor in cardiovascular disease (hypertension, dysrhythmias),
gastrointestinal disorders (esophageal reflux, peptic ulcers),
reproductive disorders, osteoporosis (may increase loss of
calcium in urine), carcinogenicity, psychiatric disturbances,
and drug abuse liability. Caffeine produces tolerance to its
stimulating effects, and psychological dependence or habitu-
ation occurs.
Pharmaceutical preparations include an oral preparation
and a solution for injection. Caffeine is usually prescribed
as caffeine citrate for oral use and caffeine and sodium ben-
zoate for parenteral use because these forms are more soluble
than caffeine itself. It is an ingredient in some nonprescription
analgesic preparations and may increase analgesia. It is
combined with an ergot alkaloid to treat migraine headaches
(eg, Cafergot) and is the active ingredient in nonprescrip-
tion stimulant (antisleep) preparations. A combination of
caffeine and sodium benzoate is used as a respiratory stim-
ulant in neonatal apnea unresponsive to other therapies.
Caffeine is a frequently consumed CNS stimulant world-
wide, and most is consumed from dietary sources (eg, coffee,
tea, and cola drinks). The caffeine content of coffee and tea
beverages is determined by the particular coffee bean or tea
leaf and the method of preparation. Because of the wide-
spread ingestion of caffeine-containing beverages and the
wide availability of over-the-counter products that contain
caffeine, toxicity may result from concomitant consumption
of caffeine from several sources. Some authorities recom-
mend that normal, healthy, nonpregnant adults consume no
more than 250 mg of caffeine daily. Sources and amounts of
caffeine are summarized in Table 161.
Theophylline preparations are xanthines used in the
treatment of respiratory disorders, such as asthma and bron-
chitis. In these conditions, the desired effect is bronchodila-
tion and improvement of breathing; CNS stimulation is then
an adverse effect (see Chap. 47).
Herbal and Dietary Supplements
Guarana is made from the seeds of a South American shrub.
The main active ingredient is caffeine, which is present in
greater amounts than in coffee beans or dried tea leaves.
Guarana is widely used as a source of caffeine by soft drink
manufacturers. It is also used as a flavoring agent and an in-
gredient in herbal stimulant and weight-loss products, usually
in combination with ephedra (ma huang), energy drinks, vit-

TABLE 161 Sources of Caffeine

Source Amount (oz) Caffeine (mg) Remarks

Coffee
Brewed, regular 58 40180 Caffeine content varies with product and preparation
Instant 58 30120
Espresso 2 120
Tea
Brewed, leaf or bag 8 80 Caffeine content varies with product and preparation
Instant 8 50
Iced 12 70
Soft Drinks
Coke, Diet Coke 12 45 Most other cola drinks contain 3545 mg/12 oz
Pepsi, Diet Pepsi 12 38
Mountain Dew 12 54
Mr. Pibb, Diet 12 57
OTC Analgesics
Anacin, Vanquish 1 tablet or caplet 3233
APAP-Plus, Excedrin, Midol 1 tablet, caplet or geltab 6065
OTC Antisleep Products
Caffedrine, NoDoz, Vivarin 1 tablet or capsule 200
OTC Diuretic
Aqua-Ban 1 tablet 100 Recommended dose 2 tablets 3 times daily (600 mg/d)
Prescription Drugs
Cafergot 1 tablet 100 Recommended dose 2 tabs at onset of migraine, then 1 tab
every hour if needed, up to 6 tabs (600 mg/attack)
Fiorinal 1 capsule 40 Recommended dose 12 cap every 4 hours, up to 6/d (240 mg/d)
Also contains butalbital, a barbiturate, and is a Schedule III
controlled drug

amin supplements, candies, and chewing gums. The product,
which may also contain theophylline and theobromine, is also
available in teas, extracts, elixirs, capsules, and tablets of var-
ious strengths. In general, the caffeine content of a guarana
product is unknown and guarana may not be listed as an in-
gredient. As a result, consumers may not know how much
caffeine they are ingesting in products containing guarana.
As with caffeine from other sources, guarana may cause
excessive nervousness and insomnia. It is contraindicated
during pregnancy and lactation and should be used cau-
tiously, if at all, in people who are sensitive to the effects of
caffeine or who have cardiovascular disease. Overall, the use
of guarana as a CNS stimulant and weight-loss aid is not rec-
ommended and should be discouraged.
Nursing Process
Assessment
Assess use of stimulant and depressant drugs (prescribed,
over-the-counter, or street drugs).
Assess caffeine intake as a possible cause of nervousness,
insomia, or tachycardia, alone or in combination with
other central nervous system (CNS) stimulants.
Try to identify potentially significant sources of caffeine.
Assess for conditions that are aggravated by CNS stim-
ulants.
For a child with possible attention deficit hyperactivity dis-
order (ADHD), assess behavior as specifically and thor-
oughly as possible.
For any client receiving amphetamines or methylphenidate,
assess behavior for signs of tolerance and abuse.
Nursing Diagnoses
Sleep Pattern Disturbance related to hyperactivity, ner-
vousness, insomnia
Risk for Injury: Adverse drug effects (excessive cardiac
and CNS stimulation, drug dependence)
Deficient Knowledge: Drug effects on children and adults
Noncompliance: Overuse of drug
Planning/Goals
The client will:
Take drugs safely and accurately
Improve attention span and task performance (children and
adults with ADHD) and decrease hyperactivity (children
with ADHD)
Have fewer sleep episodes during normal waking hours
(for clients with narcolepsy)
Interventions
For a child receiving CNS stimulants, assist parents
in scheduling drug administration and drug holidays
(eg, weekends, summers) to increase beneficial effects
and help prevent drug dependence and stunted growth.
CHAPTER 16 CENTRAL NERVOUS SYSTEM STIMULANTS 255
Record weight at least weekly.
Promote nutrition to avoid excessive weight loss.
Provide information about the condition for which a stim-
ulant drug is being given and the potential consequences
of overusing the drug.
Evaluation
Reports of improved behavior and academic performance
from parents and teachers of children with ADHD
Self- or family reports of improved ability to function in
work, school, or social environments for adolescents and
adults with ADHD
Reports of decreased inappropriate sleep episodes with
narcolepsy
PRINCIPLES OF THERAPY
Appropriate Use
Stimulant drugs are often misused and abused by people who
want to combat fatigue and delay sleep, such as long-distance
drivers, students, and athletes. Use of amphetamines or other
stimulants for this purpose is not justified. These drugs are
dangerous for drivers and those involved in similar activities,
and they have no legitimate use in athletics.
When a CNS stimulant is prescribed, giving the smallest
effective dose and limiting the number of doses obtained
with one prescription decrease the likelihood of drug depen-
dence or diversion (drug use by people for whom the drug is
not prescribed).
Toxicity of CNS Stimulants:
Recognition and Management
Overdoses may occur with acute or chronic ingestion of large
amounts of a single stimulant, combinations of stimulants, or
concurrent ingestion of a stimulant and another drug that slows
the metabolism of the stimulant. Signs of toxicity may include
severe agitation, cardiac dysrhythmias, combativeness, con-
fusion, delirium, hallucinations, high body temperature,
hyperactivity, hypertension, insomnia, irritability, nervousness,
panic states, restlessness, tremors, seizures, coma, circulatory
collapse, and death.
Treatment is largely symptomatic and supportive. In gen-
eral, place the client in a cool room, monitor cardiac function
and temperature, and minimize external stimulation. Gastric
lavage may be helpful if done within 4 hours of ingestion of
the stimulant. After emptying the stomach, activated charcoal
(1 g/kg) may be given. With amphetamines, urinary acidifi-
cation, IV fluids, and IV diuretics (eg, furosemide or manni-
tol) hasten drug excretion. IV diazepam or lorazepam can be
given to calm agitation, hyperactivity, or seizures; haloperi-
dol may be given for symptoms of psychosis. If cardiovascu-
lar collapse occurs, fluid replacement and vasopressors may
 256 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM
CLIENT TEACHING GUIDELINES
Methylphenidate and Dexmethylphenidate
General Considerations
These drugs may mask symptoms of fatigue, impair phys-
ical coordination, and cause dizziness or drowsiness.
Use caution while driving or performing other tasks re-
quiring alertness.
Notify a health care provider of nervousness, insomnia,
heart palpitations, vomiting, fever, or skin rash. These are
adverse drug effects and dosage may need to be reduced.
Avoid other central nervous system stimulants, including
caffeine.
Record weight at least weekly; report excessive losses.
The drugs may cause weight loss; caloric intake (of nu-
tritional foods) may need to be increased, especially in
children.
Take these drugs only as prescribed by a physician.
These drugs have a high potential for abuse. The risks of
drug dependence are lessened if they are taken correctly.
Get adequate rest and sleep. Do not take stimulant drugs
to delay fatigue and sleep; these are normal, necessary
resting mechanisms for the body.
be used. If a long-acting form of the stimulant drug has been in-
gested, saline cathartics may be useful to remove undissolved
drug granules.
With caffeine, ingestion of 15 to 30 mg/kg (1 to 2 g for a
person of 70 kg or 150 lbs) may cause myocardial irritability,
muscle tremors or spasms, and vomiting. Oral doses of 5 g or
more may cause death. Signs of toxicity are correlated with
serum levels of caffeine. Several cups of coffee may produce
levels of 5 to 10 mcg/mL and symptoms of agitation and
tremors. Cardiac dysrhythmias and seizures occur at higher
levels. Additional manifestations of caffeine toxicity include
opisthotonus, decerebrate posturing, muscle hypertonicity,
rhabdomyolysis with subsequent renal failure, pulmonary
edema, hyperglycemia, hypokalemia, leukocytosis, ketosis,
and metabolic acidosis.
Treatment is symptomatic and supportive, with gastric
lavage and activated charcoal if indicated. IV diazepam or
lorazepam may be used to control seizures. Hemodialysis is
indicated if the serum caffeine concentration is >100 mcg/mL
or if life-threatening seizures or cardiac dysrhythmias occur.
Effects of CNS Stimulants
on Other Drugs
Caffeine may increase adverse effects of clozapine and theo-
phylline by decreasing their metabolism and increasing their
blood levels. It may increase effects of aspirin by increasing
aspirin absorption. It may decrease effects of lithium by
increasing lithium clearance. Dexmethylphenidate and meth-
Prevent nervousness, anxiety, tremors, and insomnia
from excessive caffeine intake by decreasing consump-
tion of coffee and other caffeine-containing beverages or
by drinking decaffeinated coffee, tea, and cola. Sprite
and 7-Up have no caffeine.
Self-Administration and Administration to Children
Take regular tablets approximately 30 to 45 minutes be-
fore meals.
Take the last dose of the day in the afternoon, before
6 PM, to avoid interference with sleep.
Ritalin SR, Concerta, Medadate CD, and Medadate ER are
long-acting forms of methylphenidate. They should be
swallowed whole, without crushing or chewing.
If excessive weight loss, nervousness, or insomnia de-
velops, ask the prescribing physician if the dose can
be reduced or taken on a different schedule to relieve
these adverse effects.
ylphenidate may increase effects of phenytoin and anti-
depressants (selective serotinin reuptake inhibitors and tri-
cyclics), and they may decrease effects of antihypertensive
drugs. Modafinil may increase effects of clomipramine,
phenytoin, tricyclic antidepressants, and warfarin. It may de-
crease effects of cyclosporine and oral contraceptives.
Use in Children
Central nervous system stimulants are not recommended for
ADHD in children younger than 6 years of age. When used,
dosage should be carefully titrated and monitored to avoid
excessive CNS stimulation, anorexia, and insomnia. Sup-
pression of weight and height have been reported, and growth
should be monitored at regular intervals during drug therapy.
In children with psychosis or Tourette syndrome, CNS stim-
ulants may exacerbate symptoms.
In ADHD, careful documentation of baseline symptoms
over approximately 1 month is necessary to establish the diag-
nosis and evaluate outcomes of treatment. This can be done by
videotapes of behavior; observations and ratings by clinicians
familiar with ADHD; and by interviewing the child, parents, or
caretakers. Some authorities believe that this condition is over-
diagnosed and that stimulant drugs are prescribed unnecessar-
ily. Guidelines for treatment of ADHD include the following:
1. Counseling and psychotherapy (eg, parental counsel-
ing or family therapy) are recommended along with
drug therapy for effective treatment and realistic ex-
pectations of outcomes.

2. Young children may not require treatment until start-
ing school. Then, the goal of drug therapy is to con-
trol symptoms, facilitate learning, and promote social
development.
3. Drug therapy is indicated when symptoms are moderate
to severe; are present for several months; and interfere
in social, academic, or behavioral functioning. When
possible, drug therapy should be omitted or reduced in
dosage when children are not in school.
4. Methylphenidate is the most commonly used drug. It is
usually given daily, including weekends, for the first 3
to 4 weeks to allow caregivers to assess beneficial and
adverse effects. Desirable effects may include im-
provement in behavior, attention span, and quality and
quantity of school work, and better relationships with
other children and family members. Adverse effects in-
clude appetite suppression and weight loss, which may
be worse during the first 6 months of therapy.
5. Drug holidays (stopping drug administration) are con-
troversial. Some clinicians say they are indicated only if
no significant problems occur during the drug-free pe-
NURSING
ACTIONS Central Nervous System Stimulants
NURSING ACTIONS
1. Administer accurately
a. Give amphetamines and methylphenidate early in the day,
at least 6 hours before bedtime.
b. For children with attention deficit-hyperactivity disorder
(ADHD), give amphetamines and methylphenidate about
30 minutes before meals.
c. Do not crush or open and instruct clients not to bite or chew
long-acting forms of methylphenidate (Concerta, Metadate
CD, Metadate ER, Ritalin SR).
2. Observe for therapeutic effects
a. Fewer sleep attacks with narcolepsy
b. Improved behavior and performance of cognitive and psy-
chomotor tasks with ADHD
c. Increased mental alertness and decreased fatigue
3. Observe for adverse effects
a. Excessive central nervous system (CNS) stimulation
hyperactivity, nervousness, insomnia, anxiety, tremors, con-
vulsions, psychotic behavior
b. Cardiovascular effectstachycardia, other dysrhythmias,
hypertension
c. Gastrointestinal effectsanorexia, gastritis, weight loss,
nausea, diarrhea, constipation
CHAPTER 16 CENTRAL NERVOUS SYSTEM STIMULANTS 257
riod and are not recommended for most children. Other
clinicians believe they are desirable when children are
not in school (eg, summer) and necessary periodically to
re-evaluate the childs condition. Dosage adjustments
are often needed at least annually as the child grows and
hepatic metabolism slows. In addition, the drug-free
periods decrease weight loss and growth suppression.
Use in Older Adults
CNS stimulants should be used cautiously in older adults.
As with most other drugs, slowed metabolism and excretion
increase the risks of accumulation and toxicity. Older adults
are likely to experience anxiety, nervousness, insomnia,
and mental confusion from excessive CNS stimulation. In
addition, older adults often have cardiovascular disorders
(eg, angina, dysrhythmias, hypertension) that may be ag-
gravated by the cardiac-stimulating effects of the drugs, in-
cluding dietary caffeine. In general, reduced doses are safer
in older adults.
RATIONALE/EXPLANATION
To avoid interference with sleep. If insomnia occurs, give the last
dose of the day at an earlier time or decrease the dose.
To minimize the drugs appetite-suppressing effects and risks of
interference with nutrition and growth.
Breaking the tablets or capsules destroys the extended-release
feature and allows the drug to be absorbed faster. An overdose
may result.
Therapeutic effects depend on the reason for use.
Adverse effects may occur with acute or chronic ingestion of any
CNS stimulant drugs.
These reactions are more likely to occur with large doses.
These reactions are caused by the sympathomimetic effects of the
drugs.
(continued )
258 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM
NURSING ACTIONS
4. Observe for drug interactions
a. Drugs that increase the effects of CNS stimulants:
(1) Other CNS stimulant drugs
(2) Albuterol and related antiasthmatic drugs, pseudo-
ephedrine
b. Drugs that decrease effects of CNS stimulants:
(1) CNS depressants
c. Drugs that increase effects of amphetamines:
(1) Alkalinizing agents (eg, antacids)
(2) Monoamine oxidase (MAO) inhibitors
d. Drugs that decrease effects of amphetamines:
(1) Acidifying agents
(2) Antipsychotic agents
e. Drugs that increase effects of modafinil:
(1) Itraconazole, ketoconazole
f. Drugs that decrease effects of modafinil:
(1) Carbamazepine, phenytoin, rifampin
g. Drugs that increase effects of caffeine:
(1) Enoxacin, fluvoxamine, mexilitene, theophylline
(2) Cimetidine, oral contraceptives
h. Drugs that decrease effects of caffeine:
(1) Carbamazepine, phenytoin, rifampin
RATIONALE/EXPLANATION
Such combinations are potentially dangerous and should be avoided
or minimized.
These drugs cause CNS and cardiac stimulating effects.
IV diazepam or lorazepam may be used to decrease agitation, hyper-
activity, and seizures occurring with stimulant overdose.
Drugs that increase the alkalinity of the gastrointestinal tract in-
crease intestinal absorption of amphetamines, and urinary alkalin-
izers decrease urinary excretion. Increased absorption and decreased
excretion serve to potentiate drug effects.
Potentiate amphetamines by slowing drug metabolism. These
drugs thereby increase the risks of headache, subarachnoid hem-
orrhage, and other signs of a hypertensive crisis. The combination
may cause death and should be avoided.
Urinary acidifying agents (eg, ammonium chloride) increase uri-
nary excretion and lower blood levels of amphetamines. De-
creased absorption and increased excretion serve to decrease
drug effects.
Decrease or antagonize the excessive CNS stimulation produced
by amphetamines. Chlorpromazine (Thorazine) or haloperidol
(Haldol) is sometimes used in treating amphetamine overdose.
These drugs inhibit cytochrome P450 3A4 enzymes that partly
metabolize modafinil.
These drugs induce cytochrome P450 3A4 enzymes that partly
metabolize modafinil.
These drugs inhibit the cytochrome P450 1A2 enzymes that par-
ticipate in the metabolism of caffeine. Decreased metabolism
may increase adverse effects.
May impair caffeine metabolism.
These drugs induce drug-metabolizing enzymes, thereby decreas-
ing blood levels and increasing clearance of caffeine.

Review and Application Exercises
1. What kinds of behaviors may indicate narcolepsy?
2. What kinds of behaviors may indicate ADHD?
3. What is the rationale for treating narcolepsy and ADHD
with CNS stimulants?
4. What are the major adverse effects of CNS stimulants, and
how may they be minimized?
5. Do you think children taking CNS stimulants for ADHD
should have drug-free periods? Justify your answer.
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CHAPTER 16 CENTRAL NERVOUS SYSTEM STIMULANTS 259
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