This document provides information on the use and side effects of diazepam, paracetamol, tramadol, and phenobarbital. It notes that diazepam dose reduction is recommended in the elderly and debilitated. Paracetamol poses risks of toxicity in those under 50kg or with liver issues. Tramadol use can lead to dependence and side effects include nausea and dizziness. Phenobarbital use requires caution in the elderly, children, and those with liver or kidney issues due to risk of adverse reactions.

1. REFERENCE:BNF 73 1
I. Diazepam
* dose reduction recommended in elderly (confusion & ataxia) & debilitated
pt.
* injections containing benzyl alcohol should be avoided in neonates
* intravenous administration require immideate availablility mechanical
ventilation facilities for reversing respiratory depression
* contrindicated in marked neuromuscular respiratory weakness, acute
pulmonary insufficiency, sleep apnoea syndrome, chronic psychosis, phobic/
obssessional state & hyperkinesis
* can precipitate coma if used with hepatic impairment while renal
impairment pt. have increased cerebral sensitivity to drug so it is used in small
doses
* regular use should be avoided in pregnancy (risk of withdrawal symptoms),
neonatal hypothermia, hypotonia & respiratory depressionreported following
administration during late pregnancy/labour
* associated with drowsiness & lightheadedness in next day, amnesia, vertigo,
dizziness, slurred speech, salivation changes, visual disturbance, dysarthria,
tremor, gynecomastia, incontinence, also it affect performance ofskilled tasks
like driving
* rarely associated with jaundice, skin reactions & thrombophelbites

2. REFERENCE:BNF 73 2
II. Paracetamol
* pt. at risk for toxicity with therapeutic doses invlove those weighed under
50kg & those with risk factors of hepatotoxicity
*large doses should be avoided with hepatic impairment (dose related
toxicity) while ifusion dosageinterval should beincreased with GFR less than
30ml/min/1.73m2 in renal impairment
* not harmful neither in pregnancy nor with breast-feeding
* rarely associated with malasie, skin reaction, blood disorder, hypotension,
tachcardia & flushing
III. Tramadol
* dose reduction recommended in elderly & debilitated pt
* repeated use is associated with psychological & physical dependence
(specially in pt. with history of drug dependence) while long term use can
cause dose-related hypogonadism, leading to amenorrhoea, infirtility,
depression, reduced lipido & erectile dysfunction, also causes hyperalgesia so
dose reduction & using alternative therpay is recommended
* contraindicated with condition of raised intracranial pressure & head injury
(interferee with pupillary responses vital for neurologic assessment),
uncontrolled epilepsy & acute aclohol intoxication
* should be avoided/ reduce dosein hepatic impairment (precipitate coma) &
in renal impairment (incrased cerebral sensitivity to opioid, effect is
prolonged)
* should be avoided in pregnancy (emberyotoxic in animal studies, associated
nonatal respiratory depression & withdrawal effect) beside maternal gastric
stasis & inhalation pneumonia reported when used during delivery, also
avoided in breast feeding (despite amount is too small to be harmful)
* associated with vomiting, dry mouth, biliary spasm, malasie, muscle
rigidity, brady- & tachy-cardia, hypertension, syncope, wheezing, dilirium,
nightmares, dys- & eu-phoria, apetite change, tremor, hypoglycemia &
drowsiness (affect performance of skilled tasks), sleep disturbance, urinary
retension, visual disturbance, sweating, flushing, rash, urticaria & pruritus

3. REFERENCE:BNF 73 3
IV. Phenobarbital
* used with caution in elderly & children (causes hyperactivity)
* consider vit. D supplement is advised in immobilized pt.
* avoided in severe hepatic impairment (may precipitate coma) while used in
caution with renal impairment
* in pregnancy there is increased risk of teratogenicity, used in caution with
close monitoring of infant for feeding, sedation, adequate weight gain &
development milestone advised in breast feeding (established risk of
drowsiness)
* associated with hepatitis, cholestasis, impaired memory & cognition,
osteomalacia, megaloplastic anemia & allergic skin reaction