Midazolam Hydrochloride and Paromomycin Sulfate

• Generic Name: midazolam
• Dosage Forms: n.a.
• Other Brand Names: Versed, Nayzilam

Used preoperatively to produce sedation, anxiolysis, and anterograde amnesia.

Particularly useful when relief of anxiety and diminished recall of events associated with the surgical procedure are desired.

Some clinicians consider midazolam the benzodiazepine of choice for preoperative use for short surgical procedures because of its relatively rapid onset and short duration of effect and improved local tolerance at the site of injection compared with other currently available parenteral benzodiazepines.

Use only in monitored settings. (See Boxed Warning.)

Used alone or in combination with other CNS depressants for procedural sedation, anxiolysis, and amnesia. Has been administered prior to dental or other minor surgical procedures; diagnostic, therapeutic, or endoscopic procedures such as upper GI endoscopy, bronchoscopy, or cystoscopy; cardiac catheterization; coronary angiography; oncology procedures; radiologic procedures (e.g., computerized tomography); and suture of lacerations.

Particularly useful when relief of anxiety and diminished recall of events associated with the procedure are desired.

Produces amnestic and sedative effects, but no analgesia; therefore, usually administered in conjunction with an analgesic agent.

Some clinicians consider midazolam the benzodiazepine of choice for moderate sedation (formerly known as conscious sedation) prior to short procedures because of its relatively rapid onset, short duration of action, pronounced amnesic effect, and improved local tolerance at the site of injection compared with other currently available IV benzodiazepines.

Use only in monitored settings. (See Boxed Warning.)

Used IV for induction of general anesthesia prior to administration of other anesthetic agents.

Induction with midazolam provides anxiolysis, anterograde amnesia, and dose-related hypnotic effects (progressing from sedation to loss of consciousness), but not analgesia.

Also may be used for maintenance of anesthesia during short surgical procedures, usually in conjunction with inhalation anesthetic agents, balanced anesthesia (e.g., nitrous oxide and oxygen), and/or opiate agonists (e.g., fentanyl). Should not be used alone for maintenance of anesthesia.

Used as a continuous IV infusion for sedation of intubated and mechanically ventilated patients in critical care settings (e.g., ICU).

Nonbenzodiazepine sedatives (dexmedetomidine or propofol) are generally preferred to benzodiazepines in mechanically ventilated critically ill adults because of some modest clinical benefits that have been demonstrated (e.g., reduced duration of mechanical ventilation, shorter time to extubation, reduced risk of delirium).

When selecting an appropriate sedative agent, consider patient's individual sedation goals in addition to specific drug-related (e.g., pharmacology, pharmacokinetics, adverse effects, availability, cost) and patient-related (e.g., comorbid conditions such as anxiety, seizures, or alcohol withdrawal) factors.

Used IM for treatment of status epilepticus.

Benzodiazepines are considered initial drugs of choice for management of status epilepticus because of their rapid onset of action, demonstrated efficacy, safety, and tolerability. Evidence supports use of IV lorazepam, IV diazepam, or IM midazolam. Individualize choice of therapy based on local availability, route of administration, pharmacokinetics, cost, and other factors (e.g., treatment setting).

IM midazolam may be useful when IV administration of a benzodiazepine is not possible (e.g., in a prehospital setting).

Used intranasally for acute treatment of intermittent, stereotypic episodes of frequent seizure activity (i.e., seizure clusters, acute repetitive seizures) that are distinct from the patient's usual seizure pattern.

Has been used for management of acute agitation.

• Generic Name: paromomycin
• Dosage Forms: n.a.
• Other Brand Names: Humatin, Paromycin

Treatment of acute and chronic intestinal amebiasis caused by Entamoeba histolytica.

Treatment of asymptomatic cyst passers (intraluminal infections), especially in children and pregnant women.

Not effective for and should not be used alone for treatment of extraintestinal amebiasis (including amebic liver abscess) caused by E. histolytica. Used to eradicate encysted E. histolytica in the intestinal lumen as follow-up after treatment with a tissue amebicide (metronidazole or tinidazole).

Treatment of mild to moderate or severe symptomatic intestinal amebiasis or extraintestinal disease (including amebic liver abscess) involves the use of both a tissue and a luminal amebicide to ensure eradication of tissue-invading trophozoites as well as cysts in the intestinal lumen.

Regimen of choice for symptomatic intestinal amebiasis or extraintestinal disease (including liver abscess) is a nitroimidazole derivative (oral metronidazole or oral tinidazole) followed by a luminal amebicide (oral iodoquinol or oral paromomycin).

Some strains of Entamoeba are nonpathogenic (e.g., E. dispar, E. hartmanni) and asymptomatic intraluminal infections with these organisms generally do not require treatment.

Has been used for treatment of balantidiasis caused by Balantidium coli.

Not a drug of choice. Tetracycline is the drug of choice and metronidazole and iodoquinol are alternatives for treatment of balantidiasis.

Has been used for treatment of cestodiasis (tapeworm infection) caused by certain cestodes pathogenic to humans including Diphyllobothrium latum (fish tapeworm), Dipylidium caninum (dog and cat tapeworm), Hymenolepis nana (dwarf tapeworm), Taenia saginata (beef tapeworm), and T. solium (pork tapeworm).

Not a drug of choice. Praziquantel, niclosamide (not commercially available in the US), and nitazoxanide usually recommended for treatment of these tapeworm infections.

Treatment of cryptosporidiosis caused by Cryptosporidium parvum in patients with HIV infection; used alone or in conjunction with azithromycin.

No anti-infective has been found to reliably eradicate Cryptosporidium, although several drugs (e.g., paromomycin, azithromycin, nitazoxanide) appear to suppress the infection.

CDC, NIH, IDSA, and others state that the most appropriate treatment for cryptosporidiosis in HIV-infected individuals is the use of potent antiretroviral agents (to restore immune function) and symptomatic treatment of diarrhea.

Treatment of infections caused by Dientamoeba fragilis.

Iodoquinol, paromomycin, tetracycline, or metronidazole are drugs of choice for treatment of D. fragilis infections.

Treatment of giardiasis caused by Giardia duodenalis (also known as G. lamblia or G. intestinalis).

Drugs of choice are metronidazole, tinidazole, or nitazoxanide; alternatives are paromomycin (especially in pregnant women), furazolidone (not commercially available in the US), or quinacrine (not commercially available in the US).

Although paromomycin may be less effective than the other agents, it is poorly absorbed from the GI tract and may be useful for treatment of giardiasis in pregnant women.

Has been used in the management of hepatic coma as an adjunct to protein restriction and supportive therapy to inhibit nitrogen-forming bacteria in the GI tract.

Not a preferred or alternative treatment; nonabsorbable disaccharides (lactulose) or certain other anti-infectives (neomycin or metronidazole) usually recommended.

Has been used topically (in conjunction with topical methylbenzethonium chloride) for treatment of cutaneous leishmaniasis, including infections caused by Leishmania major, L. braziliensis, and L. mexicana.

Has been used IM for treatment of visceral leishmaniasis (kala azar) caused by L. donovani.

For treatment of cutaneous leishmaniasis, pentavalent antimony compounds (IM or IV sodium stibogluconate or meglumine antimonate [drugs not commercially available in the US]) are drugs of choice; topical paromomycin or IM or IV pentamidine are alternatives.

For treatment of visceral leishmaniasis, pentavalent antimony compounds (e.g., IM or IV sodium stibogluconate or meglumine antimonate [drugs not commercially available in the US]) or IV amphotericin B (conventional or liposomal) are drugs of choice; IM or IV pentamidine or IM paromomycin are alternatives.

Topical paromomycin should be used only in geographic regions where cutaneous Leishmania species have low potential for mucosal spread. Topical treatment cannot cure lymph node infection or protect against mucosal disease if metastasis has already started.