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What was the purpose of neuroleptics when they were introduced in the 1950s?
- Intended to relieve physical/behavioral symptoms, not cure disease
- Does not resolve emotional problems
- Intended as an adjunct to individual or group therapy
What are categories of psychopharmacology?
- Anti-manic (mood stabilizers)
- CNS stimulant
Describe pharmacodynamics and pharmacokinetics
- Pharmacodynamics: refers to the actions of the drug on the person
- Pharmacokinetics: refers to the actions of the person on the drug (ADME)
Describe the neurotransmitters Dopamine, Norepinephrine, Serotonin, GABA and acetylcholine
- Dopamine: Increased in Schizophrenia and mania. Decreased in Depression and Parkinson's
- Norepinephrine: increased in mania, anxiety, schizophrenia. Decreased in depression.
- Serotonin: increased in anxiety. Decreased in depression.
- GABA: increased to reduce anxiety. Decreased in anxiety disorders, schizophrenia
- Acetylcholine: increase in depression. Decreased in parkison's, alzheimers, and huntingtons
What is antipsychotic medication used for? What is the method of action? What are the common side effects?
- First gen were used to treat the symptoms of schizophrenia
- MOA: strong antagonist of D2 receptors for dopamine
- Side effects: EPS, drowsiness, sedation, dry mouth
What are the first generation anti-psychotic medications?
- -Chlorpromazine (thorazine)
- -Fluphenazine (Prolixin)
- -Thiothixene (Narvane)
- -Haloperidol (Haldol) (May be given IM to relieve manic, aggressive behavior)
What are the exrapyramidal side effects (EPS) of first gen anti-psychotics?
- Acute dystonic reactions: within minutes, spasms of the face, arms, legs
- Akinesia: muscle weakness
- Akathisia: 1-2 mo of tx leads to continuous restlessness
- Parkinson's syndrome: within 1-5 days. drooling, rigidity, tremor, shuffling gait
- Oculogyric crisis: uncontrolled rolling back of eyes. Prone for young men
- Tardive dyskinesia: long-term use, involuntary movements such as tongue protrusion, lip smacking, grimacing, blinking, chewing. Early recognition is key as this is irreversible with no treatment
What is neuroleptic malignant syndrome (NMS)?
- Onset is within hours to years of treatment
- Life-threatening dysregulation of thermo regulation
- S/S: hyperpyrexis up to 107 degrees, tachycardia, rigidity, labile BP, diaphoresis, rapid deterioration of mental status, photosensitivity
- THIS IS AN EMERGENCY and temperatures should always be assessed for some one on a first gen antipsych
- Bromocriptine (Parlodel is the antidote)
What improvements were made with second gen anti-psychotics? What other things are they used for? What is the method of action? What are the common side effects?
- Produce fewer EPS side effects
- Target both positive and negative symptoms
- Are now the first line treatment. May also be used as an anti-emetic, intractable hiccups, tics, vocal utterance in Tourretes
- MOA is unknown, but thought to bind to the dopamine receptors
- Side effects: weight gain, metabolic side effects such as diabetes and heart disease, occasional nausea
What are examples of atypical anti-psycotic medications?
- Risperidone (Risperidol): best at treating hallucinations
- Quetiapine (Seroquel): sedating, give at hs
- Olanzapine (Zyprexa) and Clozapine (Clozaril): significant weight gain of 100 lbs +
- Aripiprazole (abilify): dopamine stabilizer used as an adjunct also for BPD. Very expensive
- Ziprasidone (Geodon): effective for hallucinations, causes widened Qt interval, bad for cardiac pts
- Paliperidone (Invega): active metabolite of risperdal, no generic and very expensive
- lloperidone (Fanapt)
- Lurasidone (Latuda)
- Asenapine (Saphris)
What is the most significant adverse effect for Clozapine (clozaril)?
- Agranulocytosis- potentially fatal
- Sore throat is the first/main symptom and should never be ignored
- Abrupt onset of fever, malaise, sore throat, leukopenia within the first 3 mo of treatment
- Interventions: stop meds, reverse isolation, antibiotics
- Prevention: weekly CBC, monitor WBC
What side effects come from the dopamine blockage effect of anti-psychotics?
- Movement changes:
- -Tardive dyskinesia
What side effects come from the muscarinic blockage effect of anti-psychotics?
- Blurred vision
- Dry mouth (watch for H20) toxicity
- Urinary difficulty
What are the anticholinergic symptoms from anti-psychotic use?
- Dry mouth
- Urinary hesitancy/retention
- Blurred Vision
- Dry eyes
What are anticholinergics used for in relation to antipsychotics?
- Used to counteract the side effects/adverse effects of antipsychotics
- MOA: blocks central acetylcholine receptors
- -Trihexyphenidyl (Artane)
- -Diphenhydramine (Benadryl)
- -Benztropine (Cogentin)
- *one of these should always be ordered when an antipsych med is prescribed
Describe TCAs. Name some commonly used TCAs. Why are they not the first line drug?
- Use: Major Depressive Disorder (MDD)
- MOA: blocks reuptake of norepi & to small degree sertonin; also blocks receptors for acetylcholine
- Side effects: blurry vision, dry mouth, constipation, tachycardia**
- Do not give freq due to cardiac SE
- -Amitriptyline (Elavil)
- -Imipramine (Tofranil)
- -Nortriptyline (Pamelor)
Describe MAOIs. Name commonly used MAOIs
- Monoamine Oxidase Inhibitors (MOAI)
- Use: MDD, GAD, PTSD
- MOA: inactivates MAO, a chemical that inactivates norepi, serotonin, dopamine, tyramine
- Side effects: orthostatic hypotension, weight gain, change in cardiac rate/rhythm, sexual dysfunction, mania
- -Isocarboxazid (Marplan)
- -Phenelzine (Nardil)
- -Selegiline (EMSAM)
- -Tranylcypromine (Parnate)
What special considerations need to be taken for clients on MAOIs?
- Special diet low in tyramine due to risk of HTN crisis and CVA
- -smoke meats
- -pepperoni, salami
Describe the MOA, use, and side effects for SSRIs
- Selective Serotonin Reuptake Inhibitors
- MOA: blocks the reuptake of serotonin
- Uses: MDD, OCD, social phobia, Anxiety D/O
- SE: lower incidence of anti-cholinergic effects, abd discomfort, diarrhea, irritability, insomnia, sexual side effects (dysfunction, decreased libido)
- *dose at same time each day, take with meals to decrease n/v/d
- *do not take with grapefruit juice, limit to 6 oz/day
- *4-6 wks to reach therapeutic levels
Name the common SSRIs
- Citalopram (Celexa)
- Fluoxetine (Prozac)
- Fluvoxamine (Luvox)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
- Escitalopram (Lexapro)
What are SNRIs? What is their method of action and side effects? Give some examples
- Serotonin-norepinephrine reuptake inhibitors
- Uses: depression, smoking cesstion
- MOA: blocks the reuptake of serotonin and norepi
- SE: nausea, dry mouth, dizziness, constipation, seizures
- -Bupropion (Wellbutrin, Zybran): low dose used for smoking cessation
- -Venlaxafine (Effexor)
- - Desvenlafaxine (Pristiq): active metabolite of Effexor, no generic, very expensive
- -Trazodone (Oleptro): sedation, give at hs
- -Duloxetine (Cymbalta): more energy
What are SNDI? Give and example
- Serotonin-Norepinephrine Disinhibitors
- Antagonizes (blocks) apha 2 receptors
- Antidepressant + antianxiety + antiemetic effects
- Example: Mirtazapine (Remeron)
Describe patient teaching for clients on antidepressants
- Takes weeks to months to reach therapeutic blood level
- 1. SE that can be noticed within days
- 2. Do not stop taking your meds- notify your provider
What medications are categorized as mood stabilizers?
- Anticonvulsant drugs (slow down the firing in the brain)
- -Valproate (Depakote, depakene)
- -Carbamazepine (Tegretol)
- -Lamotrigine (lamictal)
- -Gabapentin (Neurontin)
- -Oxcarbazepine (Trileptal)
- -Topiramate (Topamax)
Describe Lithium, the MOA, and side effects
- Mood Stabilizer
- Uses: antimania, BPD
- MOA: may alter the Na and K+ across the cell membrane, may balance serotonin and norepi.
- *competes with sodium, dehydration can lead to toxicity
- Side effects: dry mouth, diarrhea, dizziness, slurred speech, slight tremors
What is the therapeutic range for lithium? What are the s/s of toxicity?
- Therapeutic range: 0.5-1.5 mEq/L
- -fine hand tremor, mild thirst
- Early toxicity: 1.5 mEq/L
- -n/v/d, slurred speech
- Advanced: 1.5-2.0 mEq/L
- -course tremors, confusion
- Severe: 2.0 mEq/L and above
- -confusion, abd pain, seizures, hypotension, incontinence, ekg changes
- * must draw levels 8-12 hrs after last dose prior to admin
- *there is no antidote for toxicity, although hemodialysis and hydrating may be helpful if caught early
What patient teaching should be done for a client on lithium?
- Know the side effects of toxicity and when to call provider
- Do not change your dosage without speaking with provider
- Stay well hydrated, dehydration can lead to toxicity
- Follow up blood work will be necessary
Describe Lamotrigine (lamictal)
- Useful for maintenance phase of BPD
- Not used for acute mania
- Cautions: steven johnson syndrome can occur at any time! (usually within first 3 mo)
- Report ANY skin changes and do not change any personal care items/laundry detergent during therapy
What kinds of medications are commonly used for anxiety disorders?
- Benzodiazepines- potentiates actions of GABA
- SSRIs- inhibit actions of serotonin
- Beta Blockers- treats somatic manifestations of anxiety- tremors, palpitations
Uses: anxiety, sleep induction, acute alcohol withdrawal, phobias, pre-med for surgery
Describe s/e of Benzodiazepines and give examples
- Side effects: sedation, dizziness, drowsiness, blurry vision, physical dependence, tolerance, withdrawal if stopped
- Do not stop abruptly for risk of rebound seizures
- Flumazenil (romazicon) is antidote
- BZD + ETOH is deadly!
- -Diazepam (valium)
- -Clonazepam (klonopin)
- -Alprazolam (Xanax)
- -Lorazepam (Ativan)
What are z-hypnotics? Give examples
- Short acting sedative-hypnotic agents
- Do not dose after midnight
- Same antidote as BZD
- Zolpidem (ambien)
- Zaleplon (sonata)
- Eszopiclone (Lunesta)
What medication are used for obsessive disorders? What are their MOA and side effects?
- -fluoxetine (Prozac)- works well for OCD behaviors
- -fluvoxamine (Luvox)
- -Clomipramine (anafranil)
- MOA: regulation of serotonin
- SE: drowsiness, n/v/d, stomach upset, sexual side effects
What medications are used as CNS stimulants?
- *Dextroamphetamine (Adderal, Vyvanse)
- *Atomoxetine (strattera)- only drug approved for kids under 6 y/o
- *Methyphenidate (Ritalin, daytrana)
- used: for ADHD
- SE: loss of appetite, tachycardia, GI upset
- *dose before noon, treat like narcotic in pyxis
What medications are commonly used for substance abuse? What is most successful?
- Disulifram (Antabuse)
- naltrexone (Revia)
- Buprenorphine (subutrex)
- Methadone (Dolophine)
- *Subutrex and LAAM most effective, therapy combo needed
Describe Disfulfiram (Antabuse) and Naltrexone (Revia)
- Disulfiram (Antabuse)
- use: chronic alcoholism
- MOA: blocks oxidation of alcohol at acetaldehyde stage, producing a reaction including HA, flusing, n/v, sweating, chest pain
- naltrexone (revia)
- Use: narcotic abuse
- MOA: blocks opiate receptors, blocking mechanism of Reinforcement, lasts 72hrs
Describe Buprenorphine (Subutrex) and Methadone (dolophine)
- Buprenorphine (Subutrex)
- use: effective for heroine
- MOA: opioid agonist. Blocks effects of opiod withdrawal.
- Given SL
- Methadone (dolophine)
- Use: opioid treatment, esp for heroine but end up addicted to the methadone instead
- MOA: synthetic opioid (synthetic morphine) that blocks craving but is highly addictive
- SE: drowsiness, confusion, HA, n/v. HR for resp depression
What is LAAM?
- Methadone alternative
- Dose every 3 days
- Properties similar to morphine, addictive
What acetylcholinesterase inhibitors are used for Alzheimers?
- Tacrine (Cognex)
- Donepezil (Aricept)
- Galantamine (Razadyne)
- Revastigmine (Exelon)
- Mematine (Namenda, Namenda XR *for mod to severe)