Jessem30-1

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jessem30
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132483
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Jessem30-1
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2012-02-02 17:41:15
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mental health pharm
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Mental Health Phamacology
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  1. TYPICAL
    {treats positive sx}
    • High
    • potent- not
    • very sedating, bigger sx:
    • haloperidol, thiothixine(Navane), fluphenazine(prolixin). Come in long acting monthly injections

    Low potent- more sedative; chlorpromazine (thorazine), mezorizidin, thioridazine (off market; mellaril), trifluoperazine (stellazine)

    Medium potent- perphenazine (trilafon) *, Gloxatine, molindone



    OFTEN NEED MEDS TO CONTROL SX. Amantadine (symmetrel), akineton, benztropine (Cogentin), diphenhydramine, trihexyphenadyl (Artane). These work with the psychosis.
  2. ATYPICAL
    • ATYPICAL
    • (med of choice) (works on both
    • positive and negative sx) (fewer EPS and TD and anticholinergic)

    • DONES
    • AND PINES

    • Respiridone (risperdal), ziprasidone (Geodon), paliperidone (invega), pilopuridone = good for psychosis…but with neuro
    • side effects. Good for voices but watered down. Overall less neuro
    • than traditional. Metabolic side effects . ADD aripiprazole (Abilify). Some come in long acting



    • PINES.
    • Quetiapine( Seroquel), onlanzapine(Zyprexa), {clozapine} – Asinapine – generally sedating…more than dones.
    • More metabolic symptoms… than the dones. Don’t need regular bloodwork.
    • http://www.youtube.com/watch?v=rBGG-BD0zF8&feature=related Rob’s story
  3. How do Antipsychotic Drugs
    • Antipsychotic
    • drugs work by blocking receptors of the neurotransmitter dopamine. The typical
    • antipsychotics are good
    • at treating target sx but with many extrapyramidal side effects.. Clozapine has
    • lower incidence of EPSE.
  4. Side
    Effect Profiles
    •Extrapyramidal Side Effects

    •Neuroleptic Malignant Syndrome

    •Tardive Dyskinesia

    •Metabolic Syndrome

    •Agranulocytosis

    •Anticholinergic Side Effects
  5. Extrapyramidal Side
    Effects
    •Acute dystonia

    •Pseudoparkinsonism

    •Akathisia


    •Treatment: discontinue or anticholinergic
  6. Acute dystonia
    • (1st 3 days)acute muscular rigidity and
    • cramping, a stiff or thick tongue with difficulty swallowing and in severe
    • cases, laryngospasm and resp
    • difficulties. Occurs usually in first week of
    • treatment, < 40, males and those receiving high potency drugs. Torticollis, opisthotonus, oculogyric crisis. Painful
    • frightening. IM or IV ANTICHOLINERGIC {Cogentin
    • or Benadryl}
  7. Pseudoparkinsonism
    • (after weeks to months) – stiff stooped posture, mask-like facies;
    • decrease arm swing; shuffling, festinating gait with small steps; cogwheel
    • rigidity (ratchet-like movements of joints); drooling; tremor; bradycardia; and
    • coarse pill-rolling movements of the thumb and fingers at rest. CHANGE MED OR ANTICHOLINERGIC – amantadine
    • which is dopamine agonist.
  8. Akathisia
    • (1st 10
    • days) intense need to move about. Appears restless or anxious and agitated,
    • often with a rigid posture or gait and lack of spontaneous gestures. Internal
    • restlessness and inability to sit still or rest. BETA BLOCKER, ANTICHOLINERGIC;
    • or BENZO
  9. Neuroleptic
    Malignant Syndrome
    •Potentially fatal reaction

    •Rigidity*

    •High fever (sudden)*

    • •Autonomic instability (unstable BP,
    • diaphoresis, pallor)

    •Delirium

    •Elevated CPK levels

    •Confused and mute

    •Agitation to stupor
  10. Neuroleptic
    Malignant Syndrome (CONT)
    • 1st 2 weeks of
    • therapy. TX: immediate DC of meds and supportive medical care
    • Increased CPK, K, leukocytosis, renal failure

    20% mortality rate

    • Can give antipyretics, benzo’s for
    • anxiety, and dantrolene for muscle relaxation
  11. Metabolic
    Syndrome
    •Insulin resistance

    •Hypertension

    •High serum lipids

    •Obesity

    •Coagulation abnormalities
  12. Tardive Dyskinesia
    •Permanent involuntary movements

    –Tongue

    • –Facial
    • and neck muscles

    • –Upper
    • and lower extremities

    • –Tongue
    • thrusting and protruding lip smacking

    • –Blinking,
    • grimacing
  13. Agranulocytosis
    •Most common with Clozaril

    • •Lab value: d/c drug with WBC
    • <2000

    •Symptoms include:

    –Infection

    • –High
    • fever

    –Chills

    • –Sore
    • throat

    –Malaise

    • –Ulceration
    • of mucous membranes



  14. Agranulocytosis (cont)
    • Obtain
    • WBC weekly for 6 months, then every 2 weeks. If baseline WBC is less than 3500
    • don’t’ start on clozaril. If
    • WBC drop less than 200 then take off the
    • med.
  15. Anticholinergic Side
    Effects
    •Orthostatic hypotension

    •Dry mouth

    •Constipation

    •Urinary hesitance or retention

    •Blurred near vision

    •Dry eyes, photophobia

    •Nasal congestion

    •Decreased memory
  16. ANTIDEPRESSANTS
    • SSRI’s
    • are first choice for depression



    • Used
    • in the tx of
    • major depressive illness, anxiety disorders, the depressed phase of bipolar
    • disorder, and psychotic depression…… Meds can also be used for chronic pain,
    • migraine h/a, neuropathies,
    • sleep apnea, dermatologic disorders, panic disorders, eating disorders.



    • SSRI’s,
    • TCA’s, MAOI’s



    • SSRI,
    • TCA, atypical antidepressants; maoi;
    • other forms
  17. Antidepressant Drugs
    •SSRI

    •TCA

    •MAOI

    • •NRI
    • – bupropion

    •SNRI

    •Heterocyclics

  18. What do antidepressants drugs iteract with?
    • Antidepressants interact with norepinephrine and serotonin (reg
    • mood, arousal, attention, sensory processing and appetite.
  19. SSRI
    fluoxetine(prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro)
  20. TCA
    mine, line, and pine…. Imipramine (tofranil); desipramine (norpramin); amitriptyline (Elavil); Nortriptyline (pamelor); Doxepin, trimipramine, protriptyline, maprotiline, Mirtazapine (Remeron); amoxapine, clomipramine (Anafranil)
  21. MAOI
    nardil, parnate, marplan
  22. TCA side effects
    • sedation, orthostatic, anticholinergic side effects. Lethal with OD. TCA’s may
    • take 4-6 weeks to be effective. Block cholinergic receptors causing anitcholinergic effects like dry mouth, constipation,
    • urinary hesitancy or retention, dry nasal passages, blurred near vision. Sex
    • dysfunction and wt gain are common reasons for noncompliance. Anticholinergic effects on the CV system restricts the
    • use in elderly. Terrifying nightmares.
  23. MAOI’s side effects
    • low incidence of sedation and anticholinergic, and in general causes hypotension
    • leading to HF BUT… htn
    • crisis with tyramine… dangerous combined with other drugs….
    • And lethal OD. May need 2-4 weeks. Daytime sedation, ninsomnia, st
    • gain, dry mouth, orhtosypo, sex dysfunction. HTN crisis is biggest
    • thing. (htn,
    • hyperpyrexia, tachy, diaph,
    • tremulousness, cardiac dysrhythmias. Also buspirone, dextromethorphan, opiate derivatives.
  24. SSRI’s side effects
    • SSRI’s now DOC… fewer SE’s. Prozac weekly…. May
    • take 2-3 weeks. Enhanced serotonin transmission can lead to several common side
    • effects such as anxiety, agitation, akathisia (beta blocker), n, insomnia (sedative/
    • hypnotic), sex dysfunction*, wt gain, GI complaints, h/a, dizziness
  25. Tyramine foods
    •Aged cheeses

    •Aged meats

    •Fava beans, tofu, banana peel, overripe fruit, avocado

    •Tap beer and microbrewery beer

    •Sauerkraut, anything soy

    • •Yogurt, sour cream, peanuts,
    • Brewer’s yeast, and MSG

    • •Caffeinated coffee, colas, tea,
    • chocolate

  26. HYPERTENSIVE CRISIS
    • CRISIS
    • (explosive occipital headache, nausea, increased HR and BP,
    • head or face flushed and feel “full”,
    • palpitations, chest pain, sweating, fever, nausea, vomiting, dilated pupils,
    • photophobia)

    Do not lie down. IM chlorporamazine 100mg, repeat (blocks norepinephrine); IV phentoloamine 5mg, repeat (binds with norepinephrine receptor sites, blocking norepi.
  27. Serotonin syndrome
    • •Results from taking MAOI and SSRI
    • at the same time

    •Symptoms include

    –Agitation

    –Sweating

    –Fever

    –Tachycardia

    –Hypotension

    –Rigidity

    –Hyperreflexia
  28. MOOD
    STABILIZERS
    • Two
    • first-line medications most often used for long-term treatment of bipolar
    • disorder are lithium and valproic acid (Depakote)

    Lithium

    Anti-convulsants

    • Lithium normalizes the reuptake of certain
    • neurotransmitters such as serotonin, norepinephrine, acetylcholine, and dopamine. Also
    • reduces the release of norepinephrine thru competition with calcium and produces its effects intracellulary rather than within neuronal synapses.
    • Acts directly on G proteins and certain enzyme subsystems.

    Valproic acid and topiramate increase GABA. VA and Carbamazepine stablize mood by inhibiting the kindling process
  29. Mood-Stabilizing Drugs
    •Lithium

    •Anticonvulsants
  30. Lithium
    • Lithium
    • was discovered in 1817 by Arfwedson, who named the drug agter the
    • Greek word for stone. It was initially used in the US as a salt substitute for
    • heart patients but quickly removed 2nd toxicity. Then finally back in 1970.

    • Lithium
    • levels should be about 1.0. greater than 1.5 is toxic. Level every 2-3 days
    • then weekly, then monthly. Tight therapeutic
    • index (0.6 – 1.5) Stuart and Laraia say renal and thyroid test also. Every 3
    • months lithium level for 1st 6 months then every 6 months. Keltner .6 - 1.2.

    • Regular
    • se – n,d,anorexia,
    • fine hand tremor, polydipsia, polyuria, metallic taste, fatigue, lethargy, wt
    • gain, acne

    • Toxic effects of lithium are severe diarrhea,
    • vomiting, drowsiness, muscle weakness, and lack of coordination….renal failure,
    • coma, and death.

    • Anticonvulsants – drowsiness,
    • sedation, dry mouth, blurred vision. Rashes, ortho hypo, WA wt gain, alopecia, hand tremor,
    • liver failure
  31. Lithium Toxicity
    • •Fine hand tremors progressing to
    • coarse tremors

    • •Mild GI upset progressing to
    • persistent upset

    • •Slurred speech, muscle weakness to
    • mental confusion, muscle hyperirritability, poor coordination, and EEG changes

    • •SEVERE: decreasing LOC to stupor to coma, seizures, severe hypotension,
    • severe polyuria
  32. Kindling Effect
    • •Process by which seizure activity
    • in an specific area of the brain is initially stimulated by reaching a
    • threshold of the cumulative effects of stress, low amounts of electric
    • impulses, or chemicals such as cocaine that sensitize nerve cells and pathways.
  33. ANTI ANXIETY DRUGS
    • Also
    • called anxiolyticsBenzo’s vs.
    • non benzo’s

    • Hypnotics,
    • benzo and
    • hypnotics, nonbenzo and hypnotic; antihistamines; betablocker;
    • SSRI and Atypical antidepressants

    • Used to treat anxiety, anxiety
    • disorders, insomnia, OCD, depression, PTSD, alcohol withdrawal. Most widely
    • prescribed med today.

    • Mediate the actions of the amino
    • acid GABA, the major inhibitory neurotransmitter in the brain. Powerful potentiators of the inhibitory neurotransmitter GABA.

    • What sociocultural factors may help to explain why
    • benzodiazepines are the most commonly prescribed medications in the US?
  34. Antianxiety Drugs
    •Benzodiazepines

    •Non-benzodiazepines

    •Half-life

    •Antidote
  35. sTIMULANTS
    • All
    • stimulant medications release norepinephrine and
    • dopamine into the CNS and inhibit the reuptake of norepinephrine and
    • dopamine

    • Amphetamines:
    • potential for abuse is high. Weight loss,
    • attention. Now used mostly for ADHD.

    • Methylphenidate (ritalin);
    • amphetamine (adderall) and dextroamphetamine (dexedrine). Atomoxetine (strattera) a selective norepinephrine reuptake inhibitor was first nonstimulant med for ADHD

    • Act
    • by causing release of the neurotransmitters (norepi, dop, and
    • serotonin) from presynaptic nerve terminals as opposed to having
    • direct agonist effects on the postsynaptic receptors. Block reuptake of these
    • NT’s.

    • Mood
    • elevators

    • Drug
    • Holidays….growth suppression
    • Addicting…abstinence syndrome. Mild overdose – restlessness,
    • insomnia, nervousness. Severe overdose – panic, hallucinations, circulatory
    • collapse, and seizures.
  36. Cognitive
    Medications
    • Pharmacotherapeutics is based on the theory that Alzheimer’s
    • disease is a result of depleted levels of the enzyme acetyltransferase, which is necessary to produce the
    • neurotransmitter acetylcholine
  37. Cholinesterase inhibitors
    •Aricept

    •Exelon

    •Reminyl

    •Cognex

    •Namenda
  38. What do Cholinesterase inhibitors
    Temporarily slow the progress of dementia.

    • Levels of numerous
    • neurotransmitters (acetylcholine, dopamine, norepinephrine, and serotonin) are decreased.

    • Cognex –
    • liver problems…not med of choice

    • Namenda – an
    • NMDA receptor antagonist. NMDA is a substance that contributes to degeneration
    • of brain cells. Blocks the entry of calcium into nerve cells and thus slows
    • down brain cell death.
  39. Disulfiram (Antabuse)
    • •Sensitizing agent that causes an
    • adverse reaction when mixed with alcohol in the body.

    Useful for those motivated to stop drinking.

    • 5-10 minutes after alcohol: facial
    • and body flushing from vasodilation, throbbing headache, tachycardia,
    • decreased bp,
    • sweating, dry mouth, n,v,d,
    • weakness. Last for 30 min to 2 hours.

    • Inhibits the enzyme aldehyde hehydrognase which is involved in the metabolism of
    • ethanol. Acetaldehyde levels are then increased from 5-10 times higher than
    • normal…

    • Other items with alcohol…. shaving
    • cream, aftershave lotion, cologne, deodorant and otc meds like cough syrup….
  40. Methadone
    •Maintains abstinence from heroin

    •Teaching

    •Outpatient clinics

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