Level II Pharm Unit 1
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Depression is an _______ disorder.
S/S of depression:
- Low energy level
- Sleep disturbances
- Lack of appetite
- Limited libido
- Inability to perform ADL
- Overwhelming feelings of sadness, despair, hopelessness, and disorganization
Depression can result from deficiencies of:
- Norepinephrine (NE)
- Serotonin (5HT)
This is called Biogenic Amine Theory
MOA stands for what?
Monoamine Oxidase - an enzyme that breaks down NE, dopamine, and 5HT to be recycled or restored in neurons
Name a Tricyclic Antidepressant (TCSs):
- Imipramie (Tofranil)
- Clomipramine (Anafranil)
How do TCAs work?
Reduce the uptake of 5HT(serotonin) & NE (norepinephrine)
This leads to an accumulation in the synaptic cleft and increases stimulation of the postsynaptic receptor
Indications for TCAs:
Depression, sleep disorders, enuresis in children under age 6, chronic pain, migraines, and OCD
What drug is used to treat enuresis in children under 6?
The tricyclic - Imipramine (Trofranil)
What anti-drepressant is used to treat ODC?
Pharmacokinetics of Tricyclic anti-depressants:
- Binds to Plasma proteins & Lipid solubleabsorbed in GI
- Peaks in 2- 4 hours
- Metabolized in liver
- excreted in urine
- T1/2 8-46 hours
What is norepinephrine responsible for:
released by nerves in the sympathetic nervous system
Dopamine is responsible for what?
Coordinates impulses and responses
Serotonin (5TH) is responsible for what?
- Arrosla, alertness
- Promotes motivation
- Mood, appetite
Contraindications of TCAs:
- Recent MI - this drug will increase heart rate
- Myelography (using dye) within 24-48 hrs
Cautions of TCAs:
- CV disease (due to anticholenergic)
- Angle closure glaucoma- increases pressure
- Urinary retention- exacerbated
- Manic-depression-stimulatory into a manic state if previously stable (no paranoid schizophrenic)
Tricyclics will increase what risks in children/adolescents (black box warnings):
Nursing considerations for Tricyclics:
- Sedation - give in evening
- Anticoholenergic effects - bowel support (track BMs, high fiber, liquids, dry mouth)
- no alcohol
- Liver/kidney impairment
- limit access to those already feeling suicidal
Drug/Drug interactions for Tricyclics:
- Oral anti coagulants - will increase bleeding
What should be monitored while taking Tricyclics?
- Liver kidney fxn
- bone marrow suppression (white blood counts)
How do MAOI's work?
What do they treat?
–Irreversibly inhibits MAO from breaking down, norepinephrine, serotonin, and dopamine which allows them to accumulate in the synaptic cleft.
Relief of depression, Hysteria, sadness
Why would you choose to take a MAOI ?
They treat the S/S of depression in patients who can not tolerate or are unresponsive to other SAFER anti-depressants.
Pharmacokinetics of MAOI's:
- –Absorbed from GI tract
- –Peak 2-3 hours
- –Metabolized in the liver, excreted in the urine
- –Cross placenta and enter breast milk
Contraindications for MAOI's :
–pheochromocytoma (tumor on the adrenal gland), CV disease, headaches, renal or hepatic impairment, Myelography (dye), alcohol consumption
Contraindicated foods while on MAOI's:
- Fermented foods containing tyramine
- Pickles, aged cheeses
- Smoked/pickled meats, fish, poultry
- Foods with brewers yeast
- Red wine
Drug-Drug interactions for MAOI's:
- –Other antidepressants, causing Hypertensive crisis, coma
- –Methyldopa-Sympathomimetic effects increase
- –Insulin or oral anti diabetic agents – Additive hypoglycemia
Name a MAOI drug:
Nursing considerations for MAOI's :
- Give in the AM to avoid insomnia
- Discontinue 10 days before surgery or dental procedure
- Monitor Liver fxn
- 2-4 weeks before effective
- decrease environmental stimulus
How do SSRI's work?
Specifically block the uptake of 5HT, with little to NO effect on the NE
Indications for SSRI's:
- Newest group of antidepressant drugs
- Fewer adverse reactions than with TCA or MAOI drugs
- Compulsive activities
- Social phobia/anxiety
Pharmacokinetics for SSRI's:
- Associated with congenital abnormalities
- Absorbed in GI
- Metabolized in liver
- Excreted in urine
Contraindications for SSRI's:
- Pregnancy, lactation
- impaired liver/renal
- young children / adolescents may become more suicidal
- exacerbates diabetes
Adverse/ drug-drug reactions SSRI's:
- TCA's increase of therapeutic & toxic effect (if not transitioned properly)
- St. John's Wort
- insomnia, anxiety, tremor
- Weight loss with Prozac
Name a SSRI drug:
- Fluoxetine (Prozac)
- duloxetine (Cymbalta)
- escitalopram (Lexapro)
Nursing considerations for SSRI's:
- Give in AM to avoid insomnia
- Use contraception
- decrease dose for elderly to avoid insomnia
- lower dose for liver/hepatic impaired fxn
What is Bupropion (Wellbutrin, Zyban) used to treat?
______ is a collection of different syndromes characterized by the same features, sudden discharge of excessive electrical energy from nerve cells located within the brain, which leads to a seizure.
Patients of these ethnic groups may metabolize anti-seizure agents differently due to differing liver enzyme function:
- Arab Americans & Asian AMericans
- they may require lower doses and frequent adjustments
Newborns (1-10 days) respond to _____ if a anti-epileptic is needed.
Children from 2 months- 10 years old metabolize ________ drugs quicker than adults. How do you adjust to this?
Larger dose to maintain therapeutic levels
Describe a toni-clonic seizure:
Involuntary muscle contraction followed by relaxation appearing as an aggressive spasm.
Loss of consciousness, followed by recovery including confusion and exhaustion
Describe a Jacksonian seizure :
begin in one area of the brain (one body part) and then spread to other parts - may develop into generalized toni-clonic seizures.
Describe Myoclonic seizures:
- Short, sporadic periods of muscle contractions that last for several minutes.
- They are relatively rare and are often secondary seizures.
____ seizures are caused by abnormal cells/neurons with no underlying cause.
_____ seizures are caused by outside factors.
- caused by fever, head injury, drugs, preeclamsia, CO2 poisoning ...
Partial seizures have what 2 classifications?
Simple (no loss of consciousness)
Complex (consciousness impaired)
Generalized seizures involve what in the brain?
Both hemispheres and loss of consciousness
Absence seizures are most common in what age group?
children at age 3 - Disappear by puberty
Rapidly reocurring seizures without periods of recovery are called _______.
Partial seizures are also called _____ seizures.
GABA modulators work to do what?
inhibit nerve activity / help prevent over excitability
Name a Hydantoin drug:
Hydantoins used to treat what?
- Prevention of status epilepticus
- Treatment following neuro surgery
What is the therapeutic level of Phenytoin (Dilantin)?
What makes Hydantoins more desirable than other, less toxic anti-seizure drugs?
How do hydantoins work?
Stabilize the nerve membrane and limit spread of excitability from the initiating focus
Contraindications for Phenytoin (Dialantin) & Phenobarbital :
- Hepatic/renal impairment
- Coma, depression, psychoses, elderly/ debilitated patients who may respond adversely to CNS depression
Adverse effects for phenytoin (Dialanton)
- Bone Marrow suppression
- Gingival hyperplasia
- Excessive hair growth
- Steven Johnson's syndrome
- Dry mouth
Drug/drug interactions for phenytoin:
- Herbals - evening primrose, ginkgo
Name a barbiturate used to treat seizures:
Phenobarnital ( Solfoton, Luminal)
Adverse Effects for barbituates:
- CNS depression
- Low BP
- Paradoxical excitement and exacerbation of hyperkinetic behavior in children
What drug is given in an emergent situation to treat status epilepticus, tetanus, eclampsia, or meningitis:
Benzodiazepines prototype :
What is Diazepam used for?
- Adjunct in status epilepticcus or reoccurring Seizures
- Delirium tremors in alcohol with drawl
- Sedative before surgery
- Muscle spasms
Adverse effects for Diazepam:
CNS depression - drowsiness, sedation, fatigue, lethargy, disorientation, urinary retention, loss of libido, physical dependence and withdrawal syndrome
Reversal agent for Diazepam:
Name a succinimide:
- Ethosuximide (Zarontin)
- Methsuximide (Celontin)
What are Succinimides indicated for:
- Suppression of abnormal activity in the brain
- Absence seizures (formerly petit-mal)
- Sometimes migraine prevention
Contraindication for use of Ethosuximide :
- Intermittent porphyria (metabolic disorder)
- Hepatic/renal impairment
- Pregnancy & lactation
Adverse effects when taking Ethosuximide:
- Bone marrow depression (fever may indicate)
- Dermatologic reactions
Drug/Drug interactions with Ethosuximide:
Primidone (barbituate) for treating migraines - may cause decreased serum levels
What is Valproic acid (Depakene) used to treat?
- Myoclonic seizures
- 2nd drug of chose for absence seizures
- Reduces abnormal electric activity on the brain and may INCREASE GABA activity at the inhibitory receptors
- PSYCH patients for mania
Valproic acid is contraindicated for those patient with what?
- Suicidal ideations
- Pregnant/ lactation
- Impaired hepatic/renal fxn
Adverse effects for Valproic acid (Depakene):
- Liver toxicity
- CNS depression
Carbamazepine (Tegretol, Atretol) is used to treat what?
- Partial seizures (simple or complex)
- Tonic seizures
- Trigeminal Neuralgia
- Bi-polar disorder
Carbamazepine (Tegretol, Atretol) should not be used in patients with what issues?
- Bone marrow suppression
- Severe hepatic dysfunction
Adverse effects associated with taking Carbamazepine (Tegretol, Atretol):
Do not take Carbamazepine (Tegretol, Atretol) with what other substances?
- other CNS depressants
_____ is a progressive neurological disorder.
- symptoms of Parkinson's with out having a diagnosis - may be the result of a brain injury or side effect of drugs .
- may exhibit tremors or bradykinesia
Levodopa (Dopar) is used to treat what?
Parkinson's & Parkinsonism
Parkinson disease is caused by what?
Degeneration of dopamine-releasing neurons
Name an anticholinergic used to treat Parkinson's disease:
Benztropine (Cogentin) - 6th edition
Diphenhydtamine (Benadryl) used in children/elderly -earlry in disease process - or if its drug induced
How do anticholinergics work to treat Parkinson's?
Block the action of acetylcholine-dopamine imbalance
Do not give anticholinergics to patients who have what contraindications?
- Narrow Angle Glaucoma
- GI/GU obstruction
- Myasthenia gravis (neuro-muscular disorder)
- Prostatic hypertrophy
When using anticholinergics in Parkinson's, do not mix with what other drugs?
Tricyclic antidepressants and the phenothiazines, because they also have anticholinergic affects.
What is unique about the anticholinergic Bentropine from others?
Patients are not able to sweat as readily. May be at greater risk for heat exhaustion
Name a domaminergic agent:
Levadopa may be used in combination with what other drug?
Dopaminergic agents are contraindicated for patients with a history of what?
- History of the presence of suspicious skin lesion or malignant melanoma
- Angle closure glaucoma
Use domamergic agents with caution in patients with ...
- Psych disorders
- Cardiovascular diseases
Drug/drug interactions with Levodopa :
- Vitamin B6 (from supplements/ multi vitamins / bran)
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