When is Compazine (prochlorperazine) contraindicated?

Contraindications for Prochlorperazine (Compazine)

Prochlorperazine is contraindicated in patients with bone marrow depression, history of hypersensitivity reactions to phenothiazines, concurrent use of central nervous system depressants, history of neuroleptic malignant syndrome, pregnancy, and in patients with dementia, glaucoma, or seizure disorders. 1

Absolute Contraindications

• Hypersensitivity reactions: Patients who have previously demonstrated hypersensitivity reactions (e.g., blood dyscrasias, jaundice) to any phenothiazine should not receive prochlorperazine 1

• Bone marrow depression: Prochlorperazine should be avoided in patients with existing bone marrow suppression 1

• History of neuroleptic malignant syndrome (NMS): Patients with a history of NMS from any antipsychotic medication are at increased risk of recurrence with prochlorperazine 2

• Concurrent use with lithium: The combination can cause an encephalopathic syndrome that may lead to irreversible brain damage 1

• Untreated or inadequately treated extrapyramidal symptoms: Prochlorperazine can worsen existing movement disorders 1

Relative Contraindications/Use with Caution

• Pregnancy: Prochlorperazine is not recommended during pregnancy except in cases of severe, intractable nausea and vomiting where potential benefits outweigh possible hazards 1

• Breastfeeding: Phenothiazines are excreted in breast milk; caution should be exercised 1

• History of leukopenia or neutropenia: Prochlorperazine should be used with caution due to risk of drug-induced leukopenia 3

• Dementia: Increased risk of adverse effects in patients with dementia 3

• Glaucoma: Anticholinergic effects may worsen narrow-angle glaucoma 3, 4

• Seizure disorders: May lower seizure threshold 3, 4

• Concurrent use with CNS depressants: Phenothiazines may intensify or prolong the action of central nervous system depressants including alcohol, anesthetics, and narcotics 1

• Fall risk: May cause somnolence, postural hypotension, and motor/sensory instability leading to falls 1

Special Populations at Risk

• Young adults: Higher risk of acute dystonic reactions 5

• Patients with viral infections: May have increased susceptibility to dystonic reactions 5

• Elderly patients: Higher risk of adverse effects due to decreased metabolism and increased sensitivity 4

Common Adverse Reactions to Monitor

1. Extrapyramidal symptoms:

   • Acute dystonic reactions (4% incidence in ED settings) 6
   • Akathisia (44% incidence within 1 hour of IV administration) 7
   • Tardive dyskinesia with long-term use 8

2. Neuroleptic malignant syndrome: Characterized by hyperthermia, muscle rigidity, altered mental status, and autonomic instability 2

3. CNS depression: Somnolence and impaired mental/physical abilities 1

Alternative Medications

When prochlorperazine is contraindicated, consider these alternatives:

• Ondansetron 8 mg PO twice daily or 8 mg IV 4
• Granisetron 1-2 mg PO daily 4
• Dexamethasone 4-8 mg PO/IV daily 4
• Metoclopramide 10-40 mg PO or IV every 4-6 hours (note: also has risk of extrapyramidal symptoms but different mechanism) 4

Clinical Decision Making

When considering prochlorperazine use:

1. Review patient's medical history for contraindications
2. Assess risk factors for extrapyramidal symptoms
3. Consider alternative antiemetics in high-risk patients
4. If prochlorperazine must be used in patients with history of dystonic reactions, premedicate with diphenhydramine 25-50 mg 4
5. Use the lowest effective dose in at-risk populations

Remember that prochlorperazine-induced adverse reactions are common (16% akathisia, 4% dystonia in ED settings) and can significantly impact patient comfort and safety 6.