promethazine hydrochloride

(proe meth' a zeen)

Phenergan, PMS-Promethazine (CAN)

Pregnancy Category C

Drug classes
Phenothiazine
Dopaminergic blocking agent
Antihistamine
Antiemetic
Anti-motion sickness drug
Sedative or hypnotic

Therapeutic actions
Selectively blocks H1 receptors, diminishing the effects of histamine on cells of the upper
respiratory tract and eyes and decreasing the sneezing, mucus production, itching, and
tearing that accompany allergic reactions in sensitized people exposed to antigens; blocks
cholinergic receptors in the vomiting center that are believed to mediate the nausea and
vomiting caused by gastric irritation, by input from the vestibular apparatus (motion
sickness, nausea associated with vestibular neuritis), and by input from the
chemoreceptor trigger zone (drug- and radiation-induced emesis); depresses the RAS,
including the parts of the brain involved with wakefulness.

Indications
• Symptomatic relief of perennial and seasonal allergic rhinitis, vasomotor rhinitis,
allergic conjunctivitis; mild, uncomplicated urticaria and angioedema;
amelioration of allergic reactions to blood or plasma; dermatographism,
adjunctive therapy (with epinephrine and other measures) in anaphylactic
reactions
• Treatment and prevention of motion sickness; prevention and control of nausea
and vomiting associated with anesthesia and surgery
• Preoperative, postoperative, or obstetric sedation
• Adjunct to analgesics to control postoperative pain
• Adjunctive IV therapy with reduced amounts of meperidine or other opioid
analgesics in special surgical situations, such as repeated bronchoscopy,
ophthalmic surgery, or in poor-risk patients

Contraindications and cautions

• Contraindicated with hypersensitivity to antihistamines or phenothiazines, coma
or severe CNS depression, bone marrow depression, vomiting of unknown cause,
concomitant therapy with MAOIs, lactation (lactation may be inhibited).
• Use cautiously with lower respiratory tract disorders (may cause thickening of
secretions and impair expectoration), glaucoma, prostatic hypertrophy, CV disease
or hypertension, breast cancer, thyrotoxicosis, pregnancy (jaundice and
extrapyramidal effects in infants; drug may inhibit platelet aggregation in neonate
 if taken by mother within 2 wk of delivery), children (antihistamine overdose may
cause hallucinations, seizures, and death), a child with a history of sleep apnea, a
family history of SIDS, or Reye's syndrome (may mask the symptoms of Reye's
syndrome and contribute to its development), the elderly (more likely to cause
dizziness, sedation, syncope, toxic confusional states, hypotension, and
extrapyramidal effects).

Available forms
Tablets—12.5, 25, 50 mg; syrup—6.25, 25 mg/5 mL; suppositories—12.5, 25, 50 mg;
injection—25, 50 mg/mL

Dosages
ADULTS
• Allergy: Average dose is 25 mg PO or by rectal suppository, preferably hs. If
necessary, 12.5 mg PO before meals and hs; 25 mg IM or IV for serious reactions.
May repeat within 2 hr if necessary.
• Motion sickness: 25 mg PO bid. Initial dose should be scheduled 30–60 min
before travel; repeat in 8–12 hr if necessary. Thereafter, give 25 mg on arising and
before evening meal.
• Nausea and vomiting: 25 mg PO; repeat doses of 12.5–25 mg as needed, q 4–6 hr.
Give rectally or parenterally if oral dosage is not tolerated. 12.5–25 mg IM or IV,
not to be repeated more frequently than q 4–6 hr.
• Sedation: 25–50 mg PO, IM, or IV.
• Preoperative use: 50 mg PO the night before, or 50 mg with an equal dose of
meperidine and the required amount of belladonna alkaloid.
• Postoperative sedation and adjunctive use with analgesics: 25–50 mg PO, IM, or
IV.
• Labor: 50 mg IM or IV in early stages. When labor is established, 25–75 mg with
a reduced dose of opioid. May repeat once or twice at 4-hr intervals. Maximum
dose within 24 hr is 100 mg.
PEDIATRIC PATIENTS > 2 YR
• Allergy: 25 mg PO hs or 6.25–12.5 mg tid.
• Motion sickness: 12.5–25 mg PO or rectally bid.
• Nausea and vomiting: 1 mg/kg IM q 4–6 hr as needed.
• Sedation: 12.5–25 mg PO; 0.25–0.5 mg/kg rectally q 4–6 hr.
• Preoperative use: 1 mg/kg PO in combination with an equal dose of meperidine
and the required amount of an atropine-like drug.
• Postoperative sedation and adjunctive use with analgesics: 1 mg/kg PO, IM, IV,
or PR.

Pharmacokinetics
Route Onset Duration
Oral 20 min 12 hr
IM 20 min 12 hr
IV 3–5 min 12 hr
Metabolism: Hepatic; T1/2: Unknown
Distribution: Crosses placenta; enters breast milk
Excretion: Urine

IV facts
Preparation: Dilute to a concentration no greater than 25 mg/mL.
Infusion: Infuse no faster than 25 mg/min.
Incompatibilities: Do not combine with aminophylline, chloramphenicol, heparin,
hydrocortisone, methicillin, pentobarbital, thiopental.
Y-site incompatibilities: Do not give with cefoperazone, foscarnet, heparin,
hydrocortisone, potassium chloride.

Adverse effects
• CNS: Dizziness, drowsiness, poor coordination, confusion, restlessness,
excitation, seizures, tremors, headache, blurred vision, diplopia, vertigo, tinnitus
• CV: Hypotension, palpitations, bradycardia, tachycardia, extrasystoles
• Dermatologic: Urticaria, rash, photosensitivity, chills
• GI: Epigastric distress, nausea, vomiting, diarrhea, constipation
• GU: Urinary frequency, dysuria, urinary retention, decreased libido, impotence
• Hematologic: Hemolytic anemia, hypoplastic anemia, thrombocytopenia,
leukopenia, agranulocytosis, pancytopenia
• Respiratory: Thickening of bronchial secretions; chest tightness; dry mouth,
nose, and throat; respiratory depression; suppression of cough reflex, potential for
aspiration
• Other: Tingling, heaviness and wetness of the hands

Interactions
• Additive anticholinergic effects with anticholinergic drugs
• Increased frequency and severity of neuromuscular excitation and hypotension
with methohexital, thiamylal, phenobarbital anesthetic, thiopental
• Enhanced CNS depression with alcohol

Nursing considerations
Assessment
• History: Hypersensitivity to antihistamines or phenothiazines, severe CNS
depression, bone marrow depression, vomiting of unknown cause, concomitant
therapy with MAOIs, lactation, lower respiratory tract disorders, glaucoma,
prostatic hypertrophy, CV disease or hypertension, breast cancer, thyrotoxicosis,
pregnancy, history of sleep apnea or a family history of SIDS, child with Reye's
syndrome
• Physical: Weight, T; reflexes, orientation, IOP; P, BP, orthostatic BP; R,
adventitious sounds; bowel sounds and normal output, liver evaluation; urinary
output, prostate size; CBC; urinalysis; thyroid, liver, and kidney function tests

Interventions
 • Do not give tablets, rectal suppositories to children < 2 yr.
• Give IM injections deep into muscle.
• Do not administer SC; tissue necrosis may occur.
• Do not administer intra-arterially; arteriospasm and gangrene of the limb may
result.
• Reduce dosage of barbiturates given concurrently with promethazine by at least
half; arrange for dosage reduction of narcotic analgesics given concomitantly by
one-fourth to one-half.

Teaching points
• Take drug exactly as prescribed.
• Avoid using alcohol.
• Avoid driving or engaging in other dangerous activities if CNS, vision changes
occur.
• Avoid prolonged exposure to sun, or use a sunscreen or covering garments.
• Maintain fluid intake, and use precautions against heat stroke in hot weather.
• Report sore throat, fever, unusual bleeding or bruising, rash, weakness, tremors,
impaired vision, dark urine, pale stools, yellowing of the skin or eyes.

Adverse effects in Italic are most common; those in Bold are life-threatening.