Mental Health Exam 3

Is an anticonvulsant with antianxiety properties It has been found to be effective in the treatment of social phobia and moderately effective in the treatment of OCD. It also has been used to augment the antidepressant treatment of PTSD Need to taper See SE/AR o Fuzzy thinking

gabapentin

___________________ tends to be used in an adjunctive role and not as monotherapy. As an adjunctive agent, it is believed to be particularly effective if the patient also experiences anxiety. Similar to lamotrigine, gabapentin upregulates the GABA system, blocks sodium and calcium voltage-gated channels, and inhibits glutamate (glutamate increases cell firing).

gabapentin

o A relative of GABA o Classified as an anticonvulsant, but it is not a particularly good one, especially for monotherapy o Need to taper to prevent risk of seizures o Also, used for nerve pain o May be used to decrease tremor, such as essential tremor o SE/AR: o Somnolence o Fuzzy thinking o Decreased anxiety o Mood changes, including suicidal ideation

gabapentin

Memantine + Donepezil = Namzaric SE/AR: o See individual drugs

combination drug for alzheimers dz

mild to mod lithium toxicity (1.5-2 mEq/L

diarrhea, vomiting, drowsiness, dizziness, hand tremor, muscular weakness, lack of coordination, dry mouth

The two poles of bipolar disorder are ______________________ and __________________.

dysphoria(depression) and euphoria (mania)

Schizophrenia is linked to _______________. Antipsychotic drugs block Da. Blocked Da receptors can cause EPSEs. Antiparkinsonian drugs can be used to treat some of the problems that antipsychotics create. If dopaminergic antiparkinsonian drugs are given, schizophrenia might worsen. Anticholinergic drugs are given to restore ACh balance.

excessive Da

tardive dyskinesia

involuntary movements of the facial muscles, tongue, and limbs; a possible neurotoxic side effect of long-term use of antipsychotic drugs that target certain dopamine receptors, protrusion and rolling of the tongue, lip smacking

__________________ is rare and life-threatening, while _____________ may be under reported and is benign to lethal.

neuroleptic malignant syndrome; serotonin syndrome

Pseudoparkinsonism Treatment

o Anticholinergics o Amantadine

Divalproex/ Valproate (Valproic acid; Depakote; Depakene; Sodium Valproate) has a boxed warning for:

o Boxed: o Hepatotoxicity (can be fatal) - see separate document § Check liver enzymes o Pancreatitis - see separate document o Fetal risk

Akathisia Treatment

o Decrease dose o Beta blocker, such as propranolol o Benzodiazepine o Alpha 2 agonist - clonidine

If hypertensive crisis occurs, the nurse should do the following: with MAO inhibitors

o Discontinue MAOIs and contact the physician. o Know that therapy to reduce blood pressure is warranted (e.g., an alpha-1 blocker). o Monitor vital signs. o Have the patient walk (which decreases blood pressure slightly). o Manage fever by external cooling. o Institute supportive nursing care, as indicated

Lurasidone

o Effect on a serotonin receptor produces antianxiety properties o Overall, good SE profile SGA

Acute Dystonia Treatment

o IV or IM benzodiazepine or anticholinergic o Note: Laryngeal spasm can be life-threatening

Which novel/atypical anti depressant is used to tx depression & insomnia § Similar to TCAs § SE/AR: · Weight gain · Orthostatic hypotension · Antihistamine action

o Mirtazapine

Hypertensive crisis is treated with drugs such as ______________________ or calcium channel blockers

phentolamine (alpha 1 blocker)

A type of dystonia Underlying patho unknown; probably associated with multiple monoamines (serotonin, DA ACh, NE) Probably main cx is imbalance of DA & ACh Lateral flexion of trunk > 10 degrees Resolves when patient is supine Can occur in neurodegenerative diseases and also is associated with being drug-induced Associated with: o Antipsychotics o Antiemetics o Antidepressants o AChE Inhibitors, such as donepezil o Parkinson's disease At least for drug-induced Pisa syndrome, the imbalance of neurotransmitters seems to be a cause Usually reversible when recognized early Anticholinergic drugs can be used to treat but can make cognition worse May also d/c offending medication or decrease dose

pisa syndrome

MAO B inhibitor for PD tx that breaks down into another type of metabolite that does not cause the amphetamine problem that selegiline does.

rasagiline (ras is rad for not cx that amphetamine prob)

_______________ has a mechanism of action similar to that of gabapentin. It increases GABA activity, blocks voltage-gated sodium and calcium channels, and inhibits the excitatory neurotransmitter glutamate. Many patients report weight loss with this drug (the only anticonvulsant known to have this effect). However, whatever positive response this effect has among clinicians and patients is tempered by a cognitive dulling that some patients have reported.

topirimate

what are the SE of divaplex an anticonvulsant used to tx BP?

N/V, sedation, wt gain, hair loss

what are the warnings for topiramate to tx bp

breast-feeding no, cognitive dulling

chlorpromazine has high anticholinergic effects such as:

- sedation, blurred vision, constipation, dry mouth

FDA-approved medications to treat Alzheimer's disease symptoms are:

1. Acetylcholinesterase (AChE) inhibitors; AChE is an enzyme responsible for breaking down ACh and is also known as cholinesterase 2. An N-methyl-D-aspartate (NMDA) receptor antagonist - decreases glutamate

The only 2 antipsychotics (used in the US), in rank order, with clear efficacy advantages over haloperidol

1. Clozapine 2. Olanzapine

Parental route antipsychotics also called decanoate or depot drugs include: (7 of them) (Hally Rode Peppa Pig Over Atlanta Airport)

1. Haloperidol (Haldol LA) (2-4 wks) 2. Risperidone (Risperdal Consta) (2 wks) 3. Paliperidone palmitate (Invega Sustenna) (4 wks) 4. Paliperidone palmitate ( Invega Trinza) (3 months) 5. Olanzapine Pamoate (Zyprexa Relprevv) (2-4 wks) 6. Aripiprazole (Abilify Maintena) (4 wks) 7. Aripiprazole lauroxil (Aristada) (4-6 wks)

long term effects of lithium

1. Thyroid (most common) - anti-thyroid effects & hypothyroidism; check TSH level; hypothyroidism can be treated o Check thyroid fx labs 2. Renal - progressive renal insufficiency; not reversible; need to stop lithium o Can cause nephrogenic diabetes insipidus i. Kidneys have decreased sensitivity to ADH o Renal insufficiency from dehydration should be reversible o IVF & dialysis can help decrease/resolve renal damage o Check renal fx labs 3. Parathyroid - hyperparathyroidism = increased calcium

It is very important with mental health drugs that there is a washout period. What is a washout period?

A period of time between changing meds to ensure that the first med is completely out of the pts system before introducing a new medication.

o Sedation (can be profound depending on drug and dose); decreased mental alertness o Hypotension (benzodiazepines have a vasodilating effect) § A decrease in systolic blood pressure of 20 mm Hg while the patient is standing warrants withholding the drug and notifying the physician. o Tolerance to the drug dosage with continuous use o Psychological dependency o Physical dependency Respiratory depression

AR of benzos

Effective in treating both positive and negative symptoms of schizophrenia Two basic advantages over FGAs 1. Effective in treating negative symptoms 2. Less likely to cause symptoms of EPS, including tardive dyskinesia BOXED WARNING about not giving to elderly dementia patients

ATYPICAL OR SECOND-GENERATION [SGA] ANTIPSYCHOTICS

Introduced in 2002 with aripiprazole being the first Are Da2 partial agonists (restore homeostatic balance to neurochemical circuits) o Decrease Da in areas of the brain where there is too much Da o Increase Da in the areas where there is too little o Exerts little effect on dopamine where Da activity is normal

ATYPICAL OR THIRD-GENERATION [TGA] ANTIPSYCHOTICS

o Donepezil o Galantamine o Rivastigmine o SE/AR: GI distress Hepatotoxicity: monitor routine liver function tests

Acetylcholinesterase/Cholinesterase Inhibitors for Alzheimer dz

acronym for EPS ADAPT

AdAPT over hours, days, weeks, years o Acute dystonia over hours o Akathisia over days o Pseudoparkinsonism over weeks o Tardive dyskinesia over years

First used as an antiviral drug for influenza. It can be used for early treatment of parkinsonism, which could delay the necessity of levodopa. It is effective in treating drug-induced parkinsonism and has fewer side effects than anticholinergics. Can help decrease tremor caused by PD.

AmanTadinE ( T for tremor relief; E for early tx; aman oh man you fixed my drug induced pd)

Need to distinguish between depression/anxiety relapse and antidepressant discontinuation syndrome May need to restart antidepressant & taper more slowly May begin fluoxetine, which has a long ½ life and taper other drug Onset usually begins within 1 week (average 2 days) Duration - 1 day - 3 weeks after onset of symptoms???? (some people believe symptoms can still be present 1 year after d/cing drug)

Antidepressant Discontinuation Syndrome [SSRIs & SNRIs]

Pregabalin is molecularly similar to GABA. It is used for the treatment of anxiety spectrum disorders, neuropathic pain, and seizures. It is related to gabapentin in that it inhibits neuronal excitability. It is a second-line agent but has been found to be effective. It is a schedule IV drug. Levetiracetam (Keppra) increases the release of GABA, and thus has an antianxiety effect.

Antiepileptics: Pregabalin (Lyrica) & Levetiracetam (Keppra)

______________________are metabolized by the CYP-450 system, liver dysfunction extends half-life. Remember, cigarette smoking can decrease serum level of the drugs.

Antipsychotics

Rescue drug for advanced PD to tx severe "off" episodes (bradykinesia & rigidity). Administered SQ & has a short ½ life (about 40 minutes). Works within minutes. Bridges gap between doses if levodopa. B/c of nausea effects in the first few weeks of use, need to pre-medicate with trimethobenzamide (Tigan). Do not take Apo with 5HT3 antagonists (Odansetron) - causes hypotension & loss of consciousness.

Apomorphine (Apokyn injection) (Apo the ape man to the rescue)

_______________________ is a third-generation agent. It has been shown to be effective in the treatment of bipolar disorder.

Aripiprazole (Abilify)

o Aproved in 2002 o Da system stabilizer o See above explanation of Da effects - contrast with Da2 blockade of traditional drugs o An antagonist at one serotonin receptor and a partial agonist at another - a serotonin modulator o Good SE profile Patent has expired TGA

Aripiprazole (Abilify) - one of the most used drugs in U.S.

Atypical or Third-Generation Antipsychotics (TGAs)

Aripiprazole (Abilify) - one of the most used drugs in U.S. Brexpiprazole (Rexulti) Cariprazine

o Only sublingual o Approved for schizophrenia and bipolar disorder SGA

Asenapine

________________________ is a newer antipsychotic approved for bipolar disorder. It is given sublingually, providing rapid absorption. It is approved by the FDA for treating acute mania and mixed episodes.

Asenapine (Saphris)

atypical second gen antipsychotics

Asenapine (Saphris) Clozapine (Clozaril) Iloperidone (Fanapt) Lurasidone (Latuda) Olanzapine (Zyprexa) Paliperidone (Invega) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon)

social phobia

BBs: in combination with antidepressants or benzos, propranolol benzos alone or in combo with antidepressants clonazepam SSRIs

what do you assess for with serotonin syndrome?

Assess for: Ø Deep tendon hyperreflexia (common) Ø Inducible or spontaneous muscle clonus (common) Ø Neuromuscular findings are typically more pronounced in the lower extremities Ø Tachycardia Ø Hypertension Ø Hyperthermia Ø Swings in HR & BP Ø Agitation Ø Ocular clonus (slow, continuous, horizontal eye movements) Ø Dilated pupils Ø Tremor Ø Akathisia Ø Flushed skin Ø Hyperactive bowel sounds

what are the types of combination therapy for BP?

Atypical approach: atypical antipsychotic (olanzapine) plus lithium or valproate. Benzodiazepine approach: benzos plus lithium or valproate. Typical approach: typical antipsychotic (haloperidol) plus lithium or a valproate. Mood stabilizers:two or more

oApproved in 2015; made by same pharmaceutical company as aripiprazole oFDA approved to tx schizophrenia but the company is trying to get it approved for other indications oSE profile even better TGA

Brexpiprazole

what are the warnings of carbamazepine an anticonvulsant used to tx BP?

Blood dyscrasias, teratogenicity

________________________ is one of two drugs considered most effective for OCD (the other is the SSRI fluvoxamine)

Clomipramine (Anafranil)

Two COMT inhibitors used to tx PD

Entacapone Tolcapone (rarely used b/c of heptotoxicity) CAPONE come on in and get COMTforble

A serotonin partial agonist; GABA not believed to be involved Good safety profile Does not have abuse potential; not scheduled drug Need to take daily Takes about 4 - 8 weeks to work Generally, does not depress the CNS unless at high doses No cross-tolerance with sedatives or alcohol No withdrawal symptoms Generally, does not cause sexual dysfunction Do not use with MAOI; [ask me about SSRIs & SNRIs] Not necessarily an efficacious drug for anxiety SE/AR o H/A o Nervousness o Nausea

Buspirone (Buspar)

These inhibit the COMT enzyme and increase the concentration of levodopa and are used in combination with levodopa-carbidopa. With COMT inhibitors, a smaller dose of levodopa is needed. Extend benefit of levodopa. Not given alone (would have no effect. Drug: entacapone - carbidopa - levodopa = Stalevo. Do not split, crush or chew.

COMT inhibitors

____________________________ is effective for most patients who do not respond to lithium or to the valproates; it also has a faster onset of action compared with lithium. Patients with a rapidly cycling bipolar episode are more likely to be unresponsive to lithium and to respond to this drug. This drug sometimes might be given in combination with lithium. Although generally well tolerated, side effects include nausea, anorexia, and occasional vomiting. Sedation and drowsiness are other common side effects. The most serious potential side effect is agranulocytosis. Complete blood counts should be obtained weekly when this drug treatment is initiated.

Carbamazepine Carbamazepine (Tegretol)

Third line approach for monotherapy tx of BP?

Carbamazepine or lamotrigine, or gabapentin, or topiramate

__________________, a decarboxylase inhibitor, permits more levodopa to reach the brain, where levodopa is converted to dopamine. With the use of this, less levadopa is needed.

Carbidopa

Which drug would you teach the patient about possible discolored body fluids from catecholamine oxidation, which is harmless (urine dark)?

Carbidopa-Levadopa

Which drug is a dopaminergic (da replacement) drug used to tx PD?

Carbidopa-Levodopa

o Newer than those above (late 2015) o Partial agonist at both Da2 and Da3 receptors o Da3 partial agonist activity is believed it may mediate behavioral abnormalities that might be caused by glutamate system irregularities TGA

Cariprazine

Drug and food interactions of ENZYME INHIBITING AGENTS OR MONOAMINE OXIDASE INHIBITORS [MAOIs]

Certain drug and food interactions with MAOIs can be fatal Tyrosine is found in some foods o Tyramine is an amine derived from tyrosine o MAO normally breaks down tyramine o MAOI's make people unable to inactivate tyramine o Tyramine is a catecholamine precursor/releasing agent (causes release from neurons) Any drugs that are CNS stimulants or sympathomimetics, such as vasoconstrictors and cold medicines that contain phenylephrine and pseudoephedrine can cause a hypertensive crisis when taken with an MAOI Should not receive meperidine (Demerol) with MAOIs Ginseng, ephedra (ma huang), & St. John's wort may lead to palpitations, MI, and hypertensive crisis when taken with an MAOI An increased intake of brewer's yeast with MAOIs can increase blood pressure o Found in beer o Found in nutritional supplements In addition, certain foods that contain tyramine have sympathomimetic-like effects and can cause a hypertensive crisis Foods that must be avoided include: o Aged cheeses o Bananas o Salami o Sauerkraut o Soy sauce o All beers on tap o Coffee o However, other foods also carry a risk; see list copied from textbook

what is the only first generation antipsychotic that is low potency?

Chlorpromazine

o Excellent effectiveness o DOC for refractory schizophrenia o Problem is agranulocytosis (BOXED) SGA

Clozapine

· SGA no longer used as often Tx of tardive dyskinesia · Boxed: o agranulocytosis

Clozapine

__________________________, although not approved, is very effective for the treatment and prophylaxis of acute mania; however, the same concern associated with its more conventional antipsychotic use remains problematic, that is, agranulocytosis. Hematologic monitoring is required.

Clozapine (Clozaril)

serious lithium toxicity

Serious Toxicity: Person needs dialysis o Cerebellar Dysfunction § Ataxia § Dysarthria (slurred speech) § Dysmetria (lack of coordination) o Seizures

SE/AR of carbidopa-levadopa?

N/V/Anorexia Levodopa induced dyskinesia (LID) (involuntary movements) - happens during peak effect of drug "On/Off" effects (motor fluctuations; immobility "off" effect), especially with long-term use (after 3 - 5 years) Hypotension Hallucinations/CNS effects Discolored body fluids from catecholamine oxidation, which is harmless (urine dark) Increased risk of melanoma Peripheral edema

· Vesicular Monoamine Transporter-2 (VMAT-2) Inhibitor · Used to tx Huntington's Chorea as well as TD tardive dyskinesia · Boxed: o Suicide o Depression

Deutetrabenazine

o Primarily classified as an anticonvulsant o Sometimes used to tx migraine o Need to monitor therapeutic serum range mood stabilizer

Divalproex/ Valproate (Valproic acid; Depakote; Depakene; Sodium Valproate)

Which drugs are used as mood stabilizers?

Divalproex/ Valproate (Valproic acid; Depakote; Depakene; Sodium Valproate),Carbamazepine, Oxcarbazepine,lamotrigine, gabapentin, topirimate, olanzapine + fluoxetine, and antipsychotics: aripiprazole, asenapine, clozapine, olanzapine, quetiapine, risperidone, ziprasidone

what are the common SE of lithium a drug used to tx BP

N/V/D, polyuria, polydipsia, wt gain, tremor, fatigue

Which drugs can cause compulsive behaviors?

Dopamine agonists Pramipexole (Mirapex), Ropinirole (Requip), Rotigotine (Neupro patch).

What types of drugs are used to tx PD?

Dopaminergics (Da replacement), Dopamine Agonists, Monoamine Oxidase B Inhibitors, Catechol-O-Methyltransferase (COMT) Inhibitors, and anticholinergics

Which version of carbidopa-levadopa may help decrease motor fluctuations in advanced PD as well as decrease on/off effects, i.e., immobility?

Duopa

___________________ is enteral solution of carbidopa-levadopa admin via jejunostomy tube; is delivered by continuous J-tube infusion over 14 - 16 hours; patient may take a pill at night.

Duopa

SE/AR of dopamine agonist drugs Pramipexole (Mirapex), Ropinirole (Requip), Rotigotine (Neupro patch)?

Dyskinesia during peak time but less than with levodopa Compulsive behaviors - impulse control disorders (ICDs); can happen with levodopa, too, but less risk with levodopa Excessive daytime sleepiness - higher than with levodopa Visual hallucinations - higher than with levodopa Confusion - higher than with levodopa Edema of legs - higher than with levodopa Orthostatic hypotension

Relevant to treating depression - Inhibit enzymes that break down Da, NE, and serotonin As effective as TCAs, but because of adverse reactions and dietary restrictions, only about 1% of patients who take antidepressants take an MAOI Usually only prescribed for refractory depression Overdose is only 6 - 10 times a normal dose and can be fatal o Cheeking or hoarding pills can be a catastrophe

ENZYME INHIBITING AGENTS OR MONOAMINE OXIDASE INHIBITORS [MAOIs]

o Akathisia o Akinesia & Bradykinesia o Dystonia § Torticollis. - contracted positioning of the neck § Oculogyric Crisis - contracted positioning of the eyes upward § Laryngeal - pharyngeal constriction (potentially life-threatening) o Drug-induced Parkinsonism o Tardive Dyskinesia o Neurologic Malignant Syndrome o Pisa Syndrome SE of???

EPS

who is at increased risk of lithium toxicity?

Elderly Renal disease Sodium loss o Taking thiazide diuretics o Vomiting or diarrhea (V/D) o Dehydration o Excessive sweating Taking an ACE inhibitor o ACEI causes potassium (K) retention and sodium (Na) excretion Taking an NSAID (except ASA) - can double lithium level - mechanism UK; does not occur with everyone o Acetaminophen okay Low sodium intake

Mnemonic: FINISH for SE of antidepressants

Flu-like Insomnia Nausea Imbalance Sensory Hyperarousal

Acute on chronic toxicity of lithium

GI and neuro

o Effect on a serotonin receptor produces antianxiety properties o Overall, good SE profile SGA

Iloperidone

_____________________ and _____________________, while not officially approved, have proven to be effective for panic-anxiety attacks

Imipramine (Tofranil) and desipramine (Norpramin)

Another top-selling herbal preparation in the United States. It has been the subject of at least 18 clinical trials evaluating the effects of (its bioactive derivative product) EGb-761 in cognition and memory Many of these studies focused on potential therapeutic uses in Alzheimer's disease Evidence gathered indicates that a daily regimen of 240 mg of EGb-761 may be efficacious in stabilizing or slowing cognitive decline in persons with dementia Concerns about the safety of it were raised when it induced tumors in animal models and also when a higher incidence of colon and breast cancer among trial participants receiving its derivatives was demonstrated. Additionally, a study involving a large Veterans Administration population found an increased risk of adverse bleeding events when warfarin is taken in conjunction with it o Due to its anticoagulant properties, caution should be advised when taking ginkgo with other drugs sharing anticoagulant properties it also has antihypertensive properties and caution should be exerted when combining ginkgo with antihypertensive drugs. Finally, increased clearance of insulin and oral hypoglycemics by ginkgo has been demonstrated, potentially raising blood sugar levels, particularly among diabetics taking insulin or oral hypoglycemics.

Ginkgo biloba

what are the SE for lamotrigine used to tx BP?

HA, sedation, cognitive dulling, insomnia, ataxia, N/V, dizziness, diplopia

what are the two high potenct FGAs?

Haloperidol (Haldol) Fluphenazine (Prolixin)

what are the warnings for divaplex an anticonvulsant used to tx BP?

Hepatotoxicity, teratogenicity, and pancreatitis

Da2 antagonist FDA approved to tx psychotic disorders o Reduces positive symptoms o Treats violent or aggressive behavior o Treats motor & autonomic hyperactivity o Can take several weeks for full effects of tx Not FDA approved but sometimes used to treat bipolar disorder o Sometimes used for acute mania § Not for bipolar maintenance Higher risk of EPS than lower potency drugs and atypicals Oral and long acting

High Potency - FLUPHENAZINE & Medium - PERPHENAZINE

chlorpromazine SE

High hypotension with both PO and IM administration o Has alpha 1 blocking effects o Dizziness/orthostatic hypotension Moderate weight gain May raise triglycerides Diabetes mellitus Galactorrhea, amenorrhea, gynecomastia Priapism Can lower seizure threshold o Most antipsychotics can lower seizure threshold, especially low potency FGAs & clozapine Life-threatening effects o Rare NMS o Rare agranulocytosis o Long QT

H1 antagonist Rx It is an older agent and was used infrequently for many years, but it has experienced a "comeback" of sorts. It is an antihistamine (first generation); thus, it blocks histamine and cholinergic receptors. However, it also increase serotonin and NE in the area of the brain that results in decreased anxiety Produces a metabolite similar to trazadone May be as effective buspirone, & some benzodiazepines It has few significant side effects when given in appropriate doses, is inexpensive, is not typically habit forming, and has many dosage forms.

Hydroxyzine (Vistaril, Atarax)

PTSD

SSRIs tx of choice, antipsychotics if psychotic sx occur, mood stabilizers if irritable

Caffeine and methylxanthines increase excretion of lithium, possibly by 20 - 30% Keep intake level If decrease caffeine, can increase lithium significantly

Increased Risk of Subtherapeutic Lithium Level

o Not a great anticonvulsant o Risk of SJS Also, can develop itchy rash that is not SJS, but need to monitor

Lamotrigine

what are the warnings of using the drug lithium to tx BP

Lithium toxicity, and teratogenicity

SE/AR of haloperidol

Lower sedation (sedation very low) and is usually transient Very low anticholinergic effects Very high EPS risk Very low hypotensive effects Galactorrhea, amenorrhea, gynecomastia Weight gain in significant minority Monitor triglycerides Monitor for diabetes For motor SEs/ARs use: o Benztropine o Trihexyphenidyl o Diphenhydramine o Amantidine o Benzodiazepines for akathisia

_____________ is the enzyme that inactivates monoamines (serotonin, Da, norepinephrine, & epinephrine) and non-catecholamines, such as ephedrine and phenylephrine. It is located in the liver, intestinal wall, and CNS (neurons and synapses).

MOA

mild lithium toxicity

Mild Toxicity: Stop lithium o Weakness o Worsening tremor o Mild ataxia o Poor concentration o Diarrhea

Nursing interventions for TRICYCLIC ANTIDEPRESSANTS [TCAs] overdose.

Monitor BP, HR and rhythm, and respirations. Maintain patent airway. ECG reccomended. Use cathartics or gastric lavage with charcoal to prevent further absorption. The antidote for severe TCA toxicity (anticholinergic toxicity) is physostigmine, an acetylcholinesterase inhibitor, inhibits the breakdown of ACh. Should only be given to severe life threatening situations.

More specific for dopamine (rather than norepinephrine) so not as much risk of "wine & cheese"effect but still need to be cautious and not combine with other antidepressant. MAO breaks down catecholamines, including dopamine. Provide modest symptom control as monotherapy in early PD or in combination with other meds to reduce "off" time and extend "on" time. Have anticholinergic effects and some other side effects similar other PD drugs.

Monoamine Oxidase B Inhibitors

o Blocks glutamate o Memantine SE/AR: Confusion Hallucinations (memantine is a relative of ketamine) CNS depression

N-methyl-D-aspartate (NMDA) Receptor Antagonist

what are SE of carbamazepine an anticonvulsant used to tx BP?

N/V, dizziness, sedation, rash, HA

Bupropion (Wellbutrin) Used for: o Depression o Nicotine addiction (smoking cessation) o ADHD o Augmenting agent General considerations o Not particularly effective as an antidepressant o Good to try if want to avoid sexual dysfunction o Can use with SSRI to try to reverse sexual dysfunction o Do not use if patient has seizure or eating disorder o Used as augmenting agent with mood stabilizers and/or atypical antipsychotic drugs when treating bipolar depression o Should taper to d/c unless person has a seizure o Combined with naltrexone to treat obesity (Contrave)

NOREPINEPHRINE-DOPAMINE REUPTAKE INHIBITOR [NDRI]

what is Bupropion (Wellbutrin)?

NOREPINEPHRINE-DOPAMINE REUPTAKE INHIBITOR [NDRI]

which novel/atypical antidepressant has an AR of hepatotoxicity?

Nefazodone

What three things happen to neurotransmitters?

Neurotransmitters are inactivated by enzymes, taken back into neurons (reuptake), or drift away

o Obesity - weight gain SGA

Olanzapine

__________________________ is approved as monotherapy for acute and maintenance treatment of bipolar disorder. Its particular pharmacologic profile might reduce the risk of precipitating a depression after treatment for acute mania. Olanzapine is associated with significant weight gain in some patients.

Olanzapine (Zyprexa)

How is chlorpromazine administered?

Oral, injectable, suppository o IM for emergency use

haloperidol May take several weeks to reach full effects in treating psychosis and may be administered?

Oral, injection, decanoate

o An anticonvulsant related to carbamazepine & seems to be better tolerated than carbamazepine o Tablet, ER, suspension o SE/AR § Nystagmus § Rash § SJS/TEN

Oxcarbazepine

_____________________ is becoming a commonly prescribed agent for bipolar disorder. It is structurally related to carbamazepine and has similar pharmacologic activity. However, it does not cause some of the more serious adverse reactions associated with carbamazepine.

Oxcarbazepine (Trileptal)

o Active metabolite of risperidone o Similar to lithium & valproate so good mood stabilizer SGA

Paliperidone

_____________________ is oral disintegrating form of carbidopa-levadopa.

Parcopa

Antipsychotic used to tx hallucinations and delusions in PD pimavanserin has SE of?

Peripheral edema and confusion (p in pima for puffy extremities; v for very confused)

which FGA is med/high potency?

Perphenazine

· An atypical antipsychotic indicated for the treatment of hallucinations and delusions associated with PD psychosis · Boxed warning: Using with elderly patients with dementia-related psychosis increases the risk of death, so not approved for this use unless for PD · Warning: Increases QT interval

PimavanSERin (SERiously getting rid of those bugs I just saw crawling on the wall)

Other Atypical Antipsychotic

Pimavanserin (Nuplazid) - To decrease hallucinations with Parkinson's

panic disorder tx (discrete and intense period of anxiety apprehension and distress, including palpitations sweating, trembling, and dyspnea)

SSRIs: safefst for long-term and prophylactic doses; gradual titration to sertraline or paroxetine Benzos: clonazepam and alprazolam can provide immediate relief TCAs: same dose as used in tx depression but level should be carefully titrated to prevent risk of paradoxical effect

These D2- and D3-dopamine receptor agonists may be used in combination with carbidopa-levodopa and will reduce need for as high dose of levodopa. Have longer ½ lives than levodopa so can help decrease intensity of "wearing off" reactions. They are not converted to dopamine. They less potent than levodopa. They may be used as monotherapy early.

Pramipexole (mirapex), Ropinirole (Requip), Rotigotine (Neupro patch)

A non-selective β-blocker that effectively interrupts the physiologic responses of anxiety related to social phobia Autonomic dysregulation is a factor in anxiety. It makes sense that a drug that blocks these receptors could be effective. Propranolol is less effective than benzodiazepines but is safe and has little abuse potential Taper

Propranolol (Inderal)

________________ is used to treat bipolar disorder. It can control acute mania and rapidly cycling mania and is used prophylactically.

Quetiapine (Seroquel)

o Increased prolactin § Decreased libido § Impotence § Gynecomastia § Amenorrhea/change in menses § Galactorrhea § Long-term - osteoporosis o Long QT

Risperidone

______________________ has been established as an effective agent for acute bipolar disorder. It does not cause as much weight gain as other mood stabilizers.

Risperidone (Risperdal)

___________________ is extended release capsules with beads version of carbidopa-levadopa - can sprinkle on 1 - 2 tblsp of applesauce if cannot swallow well.

Rytary

SE/AR of MAO inhibitors

SE/AR o CNS stimulation (agitation, restlessness, & insomnia) o Orthostatic hypotension o Anticholinergic effects

Block the reuptake of serotonin Fewer SE/AR than with TCAs and far Far less dangerous than MAOIs Fluoxetine weekly - long half-life GI effects usually are transient Cx sexual dysfunction serotonin syndrome may cx withdrawal Drugs: o Citalopram o Fluoxetine o Paroxetine o Escitalopram o Fluvoxamine o Sertraline

SELECTIVE SEROTONIN REUPTAKE INHIBITORS [SSRIs]

Inhibit reuptake of serotonin and NE Duloxetine (Cymbalta) may relieve nerve pain May have some adrenergic effects Drugs o Venlafaxine o Desvenlafaxine o Duloxetine § Approved to tx · Diabetic peripheral neuropathy · Chronic musculoskeletal pain · General anxiety disorder · Major depression o Levomilnacipran

SELECTIVE SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS [SNRIs]

General SGA SE/AR (remember, there are varying degrees for different drugs) o Weight gain § Blocking of H1 receptors and effects on serotonin receptors § Insulin resistance occurs § Carbohydrate craving is common o Drowsiness/sedation o Postural hypotension (orthostatic) o Unsteady gait o Insomnia o Depression o Diabetes mellitus o Dylipidemia o Increased prolactin - gynecomastia & galactorrhea; with long-term use can cause osteoporosis o EPS o NMS o Anticholinergic effects o Sexual dysfunction Metabolic syndrome (see S/Sx above) o SGAs are more likely to cause this than FGAs and TGAs o Boxed warnings o Truncal obesity (belly fat) o High cholesterol levels o Elevated blood pressure or treatment for same - but note, drugs may cause hypotension o High fasting glucose

SGAs

Primarily used as treatment for mild-to-moderate depression St. John's wort (Hypericum perforatum) preparations are available as capsules, tea leaves, or tinctures, being among the top-selling botanical products in the United States. Three recent meta-analyses investigating the effectiveness of St. John's wort for depression found that it might be as efficacious and better tolerated than conventional antidepressants for mild-to-moderate depression St. John's wort is also commonly used to treat seasonal affective disorder, sleep disorders, anxiety disorders, and even ADHD, though evidence of the efficacy of St. John's wort for these conditions is still lacking The precise mechanism of action of St. John's wort is still a matter of scrutiny and debate; however, it is accepted that a broad range of different, biologically active components present in the plant act synergistically on different brain neurotransmitter systems to produce its antidepressant effects There have been, however, case reports of St. John's wort exacerbating mania and increasing the risk for serotonin syndrome; thus, it should not be taken with other antidepressants

St. John's Wort

Non-selective - block reuptake of both serotonin and norepinephrine (NE) Have a complex neurotransmitter profile "Dirty drugs" Not often 1st line drugs Significant risk of toxicity and overdose - overdose can be fatal Need to monitor serum levels - has narrow therapeutic range/index Alcohol, hypnotics, sedatives, and barbiturates potentiate CNS depression Imipramine is used to tx enuresis in children Dose should be decreased for elderly patients

TRICYCLIC ANTIDEPRESSANTS [TCAs]

SE/AR o Orthostatic hypotension o Sedation (may be helpful) o Antihistamine effects o Cardiotoxicity § Can be significant § Long QT § This is the most serious reaction o Seizures - they lower seizure threshold o Weight gain (can be a benefit if weight loss due to depression) o Anticholinergic effects - see MH book and pharmacology class information o Erectile dysfunction o Amenorrhea o Blood dyscrasias (leukopenia, thrombocytopenia, & agranulocytosis) o Liver problems - check liver fx o Amitriptyline may cause EPS o Clomipramine can cause NMS

TRICYCLIC ANTIDEPRESSANTS [TCAs]

Toxicity - 3 C's o Cardiotoxicity o Convulsions o Coma

TRICYCLIC ANTIDEPRESSANTS [TCAs]

o Amitriptyline o Clomipramine o Desipramine o Imipramine o Maprotiline Nortriptyline

TRICYCLIC ANTIDEPRESSANTS [TCAs] drugs:

o Tardive means "late appearing" o D/c offending drug - change to one less risky for TD o Not directly associated by Da - Ach imbalance, so anticholinergics aren't used to treat o Believed to be associated with change in Da receptors o May not be reversible or may last days or years after drug d/c'd § Need to identify early o Stigmatizing

Tardive Dyskinesia Treatment

Nursing interventions for a pt taking carbidopa levadopa?

Tell pt to report any immobility or motor fluctuations that could be associated with levadopa induced dyskinesia (LID) (involuntary movements) - happens during peak effect of drug or "On/Off" effects (motor fluctuations; immobility "off" effect), especially with long-term use (after 3 - 5 years). Moniter blood pressure due to hypotension being a SE. Warn pt that they may experience hallucinations or other CNS effects. Assess pt and be aware of SE of peripheral edema. Warn pt to limit sun exposure due to increased risk of melanoma.

o An anticonvulsant o Also, used to treat migraines, but SE/AR limit its use o Used to treat neuropathic pain o SE/AR: § Sedation § Mental dulling § Weight loss o Remember, combined with phentermine for weight loss

Topirimate

_________________________ has a highly sedative quality and is often prescribed for individuals who are experiencing anxiety (particularly older adults) to facilitate sleep Taper

Trazodone (Desyrel, Oleptro)

True or False Nurses make decisions about administering prn drugs.

True

True or False: Finding the right drug regimen is often a trial and error.

True.

· Vesicular Monoamine Transporter-2 (VMAT-2) Inhibitor · Regulates monoamines · SE/AR o Somnolence o QT prolongation o Maybe anticholinergic SE used in tx of tardive dyskinesia.

Valbenazine

Drugs used to treat Tardive Dyskinesia?

Valbenazine, Deutetrabenazine, Clozapine, Baclofen ( Val doesn't clean bears)

which novel/ atypical antidepressant is an SSRI + Partial agonist at a 5HT receptor?

Vilazodone

which novel/ atypical antidepressant is an SSRI + 5HT agonism + 5HT antagonism @ various receptors?

Vortioxetine

withdrawal of benzos

Withdrawal S/Sx § Agitation & nervousness § Tremor § Insomnia § Sweating § Muscle cramps § Anorexia o More Serious Withdrawal S/Sx § Paranoia § Delirium § Hypertension § Status epilepticus § Suicide

worsening lithium toxicity

Worsening Toxicity: IVF & gastric lavage if soon after lithium taken by patient o Vomiting o Gross tremor o Slurred speech o Confusion o Lethargy

o Because of effects on serotonin and norepinephrine helps with anxiety and depression o Fairly good SE profile except for risk for cardiac problems o Long QT/cardiac SGA

Ziprasidone

_____________________ has also received approval to be used for treatment of acute bipolar disorder. It causes little or no weight gain

Ziprasidone (Geodon)

dystonia

a condition of abnormal muscle tone that causes the impairment of voluntary muscle movement, facial grimacing, involuntary upward eye movement, muscle spasms of the tongue, neck, face, and back, laryngeal spasms

1. Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs):

a. Bupropion

1. Selective Serotonin Reuptake Inhibitors (SSRIs):

a. Citalopram b. Fluoxetine c. Paroxetine d. Escitalopram e. Fluvoxamine f. Sertraline

1. Tricyclic Antidepressants (TCAs)

a. Non-selective - block reuptake of both serotonin and norepinephrine (NE) b. Amitriptyline c. Clomipramine d. Desipramine e. Imipramine f. Maprotiline Nortriptyline

1. Novel Antidepressants:

a. Noradrenergic/specific serotonergic agent i. Mirtazapine b. Serotonin-1A agonist/serotonin reuptake inhibitor i. Vilazodone c. Serotonin stimulator/serotonin modulator i. Vortioxetine d. Serotonin-2 antagonist/serotonin reuptake inhibitors (SARI) i. Trazadone ii. Nefazodone

Non-selective MAOIs: block both A & B monoamine oxidase

a. Phenelzine b. Tranylcypromine c. Isocarboxazid

1. Selective MAOIs

a. Selegiline - MAO-B inhibitor i. Used in PD, but higher dose used to tx depression ii. Breaks down into amphetamine metabolite

1. Selective Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):

a. Venlafaxine b. Desvenlafaxine c. Duloxetine d. Levomilnacipran

_____________________ of the valproates are that they have a rapid onset, can be used initially without attempting lithium, and are well tolerated with little effect on cognition

advantages

chlorpromazine has Low EPS, but can cause ___________.

akathisia

withdrawal from what cx anxiety

alcohol, social drinking, nicotine, benzos

phobic disorder (fear of being away from home or in situation that you can not escape)

alprazolam at high doses, TCAs, SSRIs, like clomipramine, amitriptyline, trazodone

what is the second line of defense for monotherapy tx of bipolar?

an atypical antipsychotic

Several studies have attributed neuroprotective properties to its derivatives via antiapoptotic, antioxidative, and anti-inflammatory mechanisms, indicating a promising role of angelica preparations in the treatment of neurodegenerative disorders. it has also been shown to cause significant muscle relaxation without changes in level of consciousness. Studies on the use of angelica for anxiety disorders remain insufficient, but it remains a promising anxiolytic herb for treating anxiety because of its potential to facilitate relaxation without also impairing cognition and motor behavior. There is insufficient evidence of efficacy and safety for the use of angelica at the present time.

angelica

The first group of drugs used to treat Parkinson's disease before levodopa and dopamine agonists were introduced. Used to treat tremor with PD. Also used to tx drug induced parkinsonism, such as with antipsychotic drugs. Older adults are more susceptible to the many side effects, and patients with memory loss or dementia should not be on this therapy.

anticholinergics

in addition to lithium, _____________ and ______________ are also used as antimanics.

anticonvulsants and antipsychotics

_______________ drugs are also called mood stabilizers.

antimanic

Used to tx schizophrenia, schizoaffective disorder, bipolar disorder, psychotic depression and other psychiatric disorders. Off-label uses such as insomnia, tics, delirium, stuttering, hiccups.

antipsychotics

Drugs o Mirtazapine o Vilazodone (Viibryd) o Vortioxetine (Trintellix in U.S.; Brintellix in Europe) o Trazadone o Nefazodone Fit into which category?

atypical or novel antidepressants

medications that cx anxiety

asthma meds like albuterol, B-agonists (isoproterenol), herbal drugs (Ma Huang and ginseng), coricosteriods, antidepressants

what are some tyramine rich foods that are good to avoid when taking MAO inhibitors?

beer, wine, chz, sour cream, yogurt, avocado, bananas, fava beans, canned figs, bologna, chk liver, fish, liver, meat tenderizer, pickled herring, salami, sausage, coffee, cola, tea, chocolate, licorice, seurkraut, soy sauce, yeast

· GABA Agonist but actual MOA unknown · Taper Tx of TD tardive dyskinesia · SE/AR o CNS sedation o Tolerance o Respiratory depression CV depression

baclofen

One adverse effect closely associated with _______________ is anterograde amnesia, an impaired ability to recall events that occur after dosing.

benzos

Teach patients that __________________should be gradually withdrawn, especially if they have been taken for several weeks or more or short-term at high doses. Cause withdrawal symptoms if abruptly stopped; when symptoms appear depend on the drug's half-life

benzos

These drugs are classified as Schedule IV drugs according to the Controlled Substances Act. They are highly protein bound. The normal recommended dose may be too much for the older adult, so half the dose is recommended initially to prevent overdosing. Patients with renal or hepatic dysfunction should take only small doses.

benzos

_____________________________ increase the action of/availability of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). Neuron excitability is reduced.

benzos

____________________are anxiolytics, but they cause dependence and are drugs of abuse. They can be used to control a person's anxiety before another drug is working, since most of the other antianxiety drugs take a period of time to work. They can be taken prn.

benzos

Three anticholinergic drugs used to tx PD?

benztropine, trihexphenidyl, biperiden (Anticholinergic Aunties drugs benz tri and bip been trying bippy hard to tx the PD)

General point - must be cautious about giving anti-depressants to a person with ____________________.

bipolar disorder

o An anticonvulsant also used to tx psychiatric disorders (e.g., bipolar disorder) as well as trigeminal neuralgia (as an analgesic), and alcohol withdrawal o Need to monitor therapeutic serum range o Increased risk of SJS/TEN among Asian people o Weight gain

carbamazepine

It is important with _____________________ that you do not arbitrarily interchange forms of drug or from generic to trade and vice versa.

carbidopa-levadopa

Patient should not take medication with a high protein meal - take 30 min - 1 hr before meals. Usually better absorbed on empty stomach but can be taken with meals if N/V are a problem; just do not take with a high protein meal. Which drug is this important to remember?

carbidopa-levadopa

With the drug ________________ the patient will need to adjust timing of meds to try to manage levodopa induced dyskinesia LID and on/off effects.

carbidopa-levadopa

Several therapeutic properties have been attributed to chamomile, including sedation and anxiolysis. Although there is no firmly established scientific evidence supporting these claims, one randomized clinical trial found chamomile to significantly reduce moderate-to-severe symptoms of generalized anxiety disorder (GAD), whereas another, open-label, randomized control trial using chamomile extracts for treatment of GAD found anxiolytic responses significantly greater than placebo treatment lasting for up to 8 weeks Interestingly, isolated bioactive components of chamomile have been found to produce arterial vasodilation, which may explain the sedative properties commonly attributed to chamomile

chammomile

Antipsychotics discovered accidentally around 1950 when a drug was developed as an antihistamine; it was used to calm pts before surgery but was found to have antipsychotic properties; this drug is considered to be the first antipsychotic drug.

chlorPROmazine (PRO means first like procreate)

FGA that was originally developed as an antihistamine?

chlorpromazine, low potency

OCD

clomipramine fluvoxamine, other SSRIs or gabapentin,

SSRIs for anxiety

clomipramine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine, duloxetine

Is an α-2 agonist Because agonistic stimulation of auto-receptors, such as α-2, causes a decrease in neurotransmitter production, it follows that this drug, which is typically indicated for hypertension, could have antianxiety effects, and it does. Clonidine has also been used successfully in treating nightmares associated with PTSD Will probably decrease BP so check it Taper

clonidine

illegal drugs that cx anxiety

cocaine, meth, methlyphenidate, ecstacy

Parkinson's dz is ____________ dopamine in the brain.

decreased

anxiety is

decreased GABA

______________________ include transient hair loss, weight gain, tremors, gastrointestinal upset, and dose-related thrombocytopenia. Polycystic ovary syndrome and general menstrual disturbances in women and reduction in intelligence in children exposed to valproates in utero are major concerns that should be considered. Therapeutic serum levels should be slightly higher than for their antiepileptic effects.

disadvantages

Levadopa is a _______________, which is decarboxylated in the periphery.

dopamine precursor

What are the SE of Oxcarbazepine (Trileptal)?

fatigue, N/V, dizziness, sedation, diplopia, hyponatremia

Atypicals have _____________ EPSs than typical antipsychotics.

fewer

Therapeutic serum levels of lithium (0.6-1.0 mEq/L)

hand tremor, memory problems, goiter, hypothyroidism, mild diarrhea, anorexia, nausea, edema, weight gain, polydipsia, polyuria

chlorpromazine is __________ sedating.

highly

disorders that cx anxiety

hypothyriodism, asthma, cardiac arrhythmias

MAO- B does what?

inactivates Da

MAO- A does what?

inactivates norepinephrine and serotonin

Tx of PD is to?

increase Da and decrease ACh

Parkinson's dz is _____________ acetylcholine in the brain.

increased

increased cortisol cx

increased anxiety

Various theories exist as to the cause of Alzheimer's disease, with neuritic plaques (__________________ glutamate), degeneration of the cholinergic neurons, and a _________________in acetylcholine

increased glutamate, decrease in ACh

Antipsychotic used to tx hallucinations and delusions in PD PIMAVANSERIN has a risk of?

increasing QT interval (Pima you breaking my heart)

__________________is a root derivative from a subspecies of the pepper plant (Piper methysticum) that is ubiquitous to many Pacific Island cultures, being prized for its purported "ability to soothe the worried mind." It is widely incorporated into traditional religious and social ceremonies of those cultures. Precise mechanism of action is not completely understood There is, however, indication that kava, like benzodiazepines, acts on gamma-aminobutyric acid (GABA) receptors to enhance their intrinsic activity There have been, however, reports of severe hepatotoxicity caused by concentrated kava extracts manufactured in Germany and Switzerland and also from traditional beverages prepared in Pacific Island locations, with some patients needing liver transplantations and even dying. These unfortunate events ultimately caused the retraction of kava-containing products from the market by regulatory authorities in Germany, Canada, Switzerland, and France; kava preparations are still available in the United States. Although those often represent extreme cases resulting from excessive consumption, prior history of liver failure, concomitant use of hepatotoxic drugs, or contamination of preparations, kava should still be used with caution—liver tests should be performed on those using it daily, and it should not be used daily for more than 4 months Individuals with liver problems, those who use medications extensively metabolized by the liver, and persons that consume alcohol on a daily basis should not use kava preparations. Patients using kava should also be warned about signs and symptoms of hepatotoxicity, such as jaundice, malaise, and nausea.

kava

_______________________ is approved for the treatment of bipolar disorder, including bipolar depression. This drug works by manipulating the GABA system and inhibiting neuronal firing. Other mechanisms of action include blocking of voltage-gated sodium and calcium channels, further inhibiting neuronal conduction. Finally, lamotrigine is believed to inhibit the excitatory neurotransmitter glutamate. § One particular adverse reaction that is especially noteworthy is lamotrigine-induced rash. Lamotrigine can cause moderate skin rashes (about 10% of patients) and potentially fatal Stevens-Johnson syndrome. Predictors of rash include high initial dose, rapid increase in dosage, and young age

lamotrigine

Has one of the most narrow therapeutic ranges among drugs o Exact levels shown below may vary depending on where you are seeing them o Maintenance: 0.8 - 1.2 mEq.L or 0.6 - 1.2 mEq/L o When patient is manic: 1.0 - 1.5 mEq/L o Level of 1.5 - 2.0 may cause early signs of toxicity o People who are very sensitive to lithium may show signs of toxicity at 1.0 - 1.5 § May need to keep level at 0.4 - 0.8 for these people o Level should be monitored every 2 weeks until a therapeutic level has been obtained, and then it must be monitored at least every 1 - 2 months on the maintenance dose o Draw level immediately before/close to time for next dose? (varies - check with lab) o At about 4.0, will need dialysis to lower level o Toxicity can be fatal Monitor drug level more frequently when dosage changed or brand of drug changed Serum sodium levels also need to be monitored, b/c lithium tends to deplete sodium o Used with caution, if at all, with people who take diuretics, especially thiazide diuretics o Increased sodium intake increases renal excretion of lithium, so the sodium intake needs to be consistent Take with meals to decrease GI effects o GI distress should decrease over time

lithium

Mechanism of action is not absolutely known (see hypotheses in textbook). Has some serotonergic activity; need to monitor for serotonin syndrome if give with other serotonergic drugs. Has a calming effect but may cause some memory loss and confusion. Decreases suicide even when the person is depressed. Caution: patient may stop drug when he/she feels better Should not be D/C'd abruptly; taper o Can cause mania o Stopping & starting decreases effectiveness

lithium

_____________ is the oldest antimanic drug.

lithium

drug used to tx bp that Is a metallic salt on periodic table

lithium

For severe acute mania, use

lithium or a valproate plus an atypical antipsychotic

for bipolar depression, tx with

lithium or lamotrigine, or fluoxetine + olanzapine, or electroconvulsive therapy

what is the first line of defense for monotherapy tx of bipolar disorder?

lithium, a valproate, or medication used for acute stage

Acute lithium toxicity

mostly GI

What can cross the BBB?

nicotine, ethanol, heroin, caffeine, and benzodiazepines cross; remember levodopa can cross, but it is mostly changed to dopamine before it crosses; dopamine does not readily cross - however, remember that dopamine is a brain neurotransmitter

what accounts for 50% of relapse?

non-adherance

Some drugs inhibit both MAO-A and MAO-B; they are _______________. Some drugs are selective for inhibiting either MAO-A or MAO-B.

nonselective MAO inhibitors

high potency FGA haloperidol is FDA approved for?

o Psychotic disorders § Positive symptoms o Tics & vocal utterances in Tourette's syndrome o 2nd line tx for behavior disorders in children (combative, explosive, hyperexcitability) o 2nd line short-term tx of hyperactive children Not FDA approved for, but may be used for: o Bipolar disorder o May help with mania but is not a mood stabilizer o Delirium o Behavioral disturbances in dementia o However, is contraindicated with a BOXED WARNING - causes increased mortality

SE/AR of Divalproex/ Valproate (Valproic acid; Depakote; Depakene; Sodium Valproate)

o SE/AR o Tremor o Weight gain o Alopecia o Drowsiness Thrombocytopenia

what are the FDA approved uses for the FGA low potency drug chlorpromazine?

o Schizophrenia - takes several weeks for full effects § Reduces positive symptoms o Psychosis o N/V - immediate relief o Restlessness & apprehension before surgery o Mania o Intractable hiccups o Combative/hyperexcitable behavior in children o Hyperactive children with conduct disorder Sometimes used to tx bipolar but not FDA approved

which novel/atypical antidepressant is used to treat depression & insomnia § Similar to TCAs § SE/AR: · Priapism not necessarily associated with sexual activity · Orthostatic hypotension · Cardiac arrhythmias

o Trazadone

SE/AR of High Potency - FLUPHENAZINE & Medium - PERPHENAZINE

o Weight gain - not as much as with chlorpromazine o Sedation (low) in a significant minority so not as much as chlorpromazine o Elevated triglycerides o Pre-diabetes/diabetes with weight gain o Akathisia o Priapism o EPS, tardive dyskinesia o Galactorrhea, amenorrhea, gynecomastia o Dizziness o Anticholinergic effects - see book and pharmacology book & notes o Sexual dysfunction o Hypotension, tachycardia, syncope o Susceptibility to hyperthermia § Decreased sweating o Depression o Photosensitivity o Phenothiazines can cause reddish - pink urine Life Threatening o Rare NMS o Rare agranulocytosis o Rare seizures o Increased risk of death & CV events in elderly patients with dementia-related psychosis [BLACK BOX - SEE HALOPERIDOL] o Long QT - Torsades de pointes (type of V-tach), either spontaneously resolves or causes cardiac arrest; treat symptomatically [Haloperidol & chlorpromazine, too] For motor SEs/ARs use: o Benztropine o Trihexyphenidyl o Diphenhydramine o Amantidine o Benzodiazepines for akathisia

severe toxicity (>3mEq/L)

previous symptoms plus seizures, organ failure, renal failure, coma, death

moderate to severe toxicity (2-3 mEq/L)

previous symptoms, ataxia, giddiness, tinnitus, blurred vision, large output of dilute urine, delirium nystagmus

chronic lithium toxicity

primarily neuro

What is down regulation?

receptors change with chronic exposure to a drug; This occurs with antidepressants - with fewer receptors there is likely to be increased effects· Also, downregulation may have something to do with the fact that antidepressants do not work in treating depression for a number of weeks - effects seem to develop around the same time that downregulation occurs, so there may be a connection. However, there are implications if drugs are started and stopped

akathisia

restlessness

MAO B inhibitor for PD tx that is not effective as monotherapy - use as adjunct with carbidopa-levodopa to treat "off" episodes. Most common SE/AR are: dyskinesia, fall, nausea, insomnia.

saFinaMide (M for no good as monotherapy and MAO inhibitor, F for tx of oFF episodes)

Quetiapine

sedating, SGA

what are the SE topiramate used to tx bp

sedation, cognitive blunting, anxiety, termors, wt loss, dizziness

what are the SE of gabapentin used to tx bipolar

sedation, fatigue, tremors, nausea, dry mouth, dizziness, diplopia, hyperthermia

A MAO B inhibitor for tx of PD that breaks down into an amphetamine metabolite that can cause problems (especially insomnia) for some people.

selegiline (inSomnia, sele is silly and hyper)

What are the three monoamine oxidase B inhibitors?

selegiline, rasagiline, safinamide (MAO B inhibitors sel ras and saf)

what are the warnings for lamotrigine used to tx bp?

serious rash, SJS, no breast feeding

GI effects - especially early in treatment or if increase dose Fine tremor (trembling hands) o Tx'd with beta blocker but check for depression as SE/AR of beta blocker o Note: gross hand tremor is a sign of toxicity Dry mouth Polydipsia Polyuria Weight gain Metallic taste Teratogenic N/V Dermatological effects o Acne o Psoriasis o Alopecia o Worsening of wounds Unmasks Brugada syndrome o Cardiac electrophysiology problem o Check EKG if > 50 y/o o Can cx sudden death See below LMNOPP LMNOPP L = Lithium M = Movement N = Nephropathy O = HypOthyroidism P = Pregnancy - avoid, if possible P = hyperParathyroidism = increased calcium

side effects/adverse reactions of lithium

what are the warnings for gabapentin used to tx bp

teratogenicity no breast feeding

what are the warnings for oxcarbazepine used to tx bp?

teratogenicity, breastfeeding no

1. Administer an emetic and follow with activated charcoal if the patient is conscious; use gastric lavage if the patient is unconscious. 2. Administer the benzodiazepine antagonist flumazenil intravenously if required. o Flumazenil (Romazicon) is used for overdose o Flumazenil blocks the benzodiazepine-binding site on the GABA receptor o Flumazenil can cause adverse effects, too, so need to use caution when administering it and need to closely monitor the patient; flumazenil can cause: § Seizures, especially if patient mixed drugs or if dependent on benzodiazepines § N/V § Agitation o Can cause withdrawal symptoms if patient has been using benzodiazepines over time § Need good history for others o If patient hasn't responded after 5 minutes & 5 mg, look for another cause o 5 mg is not ideal; 3 mg is safer o Assess for returning respiratory depression; flumazenil has short ½ life; may need to repeat dose o Should be okay after about 2 hours 3. Maintain an airway, give oxygen as needed for decreased respirations, and monitor vital signs. 4. Give intravenous vasopressors for severe hypotension. 5. Request a mental health consultation for the patient.

tx of benzo od

In the liver, MAO inactivates __________________, which is in many foods, and the amines in some drugs. When liver MAO is inhibited, serious sympathetic effects can occur.

tyramine

More than 250 different species of valerian are native to Europe and Asia. The variety used for anxiety comes from the plant Valeriana officinalis. Considerable difference exists in the potency of valerian, depending on the manufacturing process. Most studies evaluating the therapeutic properties of valerian have focused on the treatment of sleep disturbances—it has been shown to be effective in decreasing sleep latency, nocturnal awakening, and to promote a subjective sense of "good sleep" Another study compared the sedative properties of valerian, triazolam, temazepam, and diphenhydramine, with valerian providing sedation equivalent to that of the other drugs studied, with a slightly better side-effect profile Fewer studies exist that evaluate the use of valerian to treat anxiety disorders, with mixed results reported; in fact, a rigorous, systematic review of available studies found just one well-designed randomized clinical trial, with no evidence supporting anxiolytic properties of valerian One study where valerian was used in combination with St. John's wort found the combination to be superior to placebo and comparable to diazepam for treating anxiety. Like kava, valerian appears to exert its sedative effects via modulation of GABA receptor activity (a property shared with benzodiazepines). Valerian is not effective for short-term treatment of anxiety and insomnia, as it may take several weeks for it to become effective

valerian

Tranquilizing effects of antipsychotics occur roughly within about an hour (PO) but antipsychotic effects takes _______________________.

weeks (roughly 3 - 8)

When does Serotonin syndrome occur?

within 24 hours of exposure

what are the affective side effects of antidepressants?

§ Anxiety § Irritability § Agitation § Anger § Low mood Tearfulness

what are the general somatic side effects of antidepressants?

§ H/A § Lethargy § Tremor § Sweating § Anorexia § Flu-like syndrome

what are the sleep disturbance side effects of antidepressants?

§ Insomnia § Nightmares § Excessive dreaming

GI SE of antidepressants?

§ N/V/D

what are the sensory side effects of antidepressants?

§ Paresthesias § Rushing noise in head § Palinopsia ("visual trails") § Electric shock feeling

o Non-selective MAOIs: block both A & B monoamine oxidase drugs

§ Phenelzine § Tranylcypromine § Isocarboxazid

o Selective MAOIs

§ Selegiline - MAO-B inhibitor · Used to treat PD · At higher doses can be used to tx depression

what are the disequilibrium side effects of antidepressants?

§ Vertigo § Dizziness § Lightheadedness

Cigarette smoking can cause induction of the CYP-450 system. What does this mean in regards to medications?

· Pts who smoke half a pack or more per day require more medication · Depending on the drug, this could lead to toxic levels if the medication is not decreased if the pt stops smoking

What are the four cardinal symptoms of PD?

· Tremors · Bradykinesia · Rigidity · Postural instability & gait disturbances

when does neuroleptic malignant happen?

Ø After beginning neuroleptics Ø After dose increase Ø Average onset is 4 - 14 days after start of tx Ø 90% of cases occur within 10 days Ø Can occur years after beginning tx Ø Usually evolves over 24 - 72 hrs

how do you dx serotonin syndrome?

Ø Clinical grounds Ø Need thorough history Ø Need thorough physical exam Ø Need thorough neuro exam Ø No good labs to check except patient may end up developing rhabdo, renal failure, DIC, and acute respiratory distress syndrome Ø Problems with missed diagnosis Differential diagnosis from NMS: Ø NMS develops over longer time; serotonin syndrome develops within 24 hours Ø NMS involves sluggish muscles and rigidity; serotonin syndrome involves hyperreflexia and myoclonus (though some rigidity can be present with severe toxicity) Resolution of NMS may take 9 days; serotonin syndrome is usually resolved within 24 hours

how do you manage a pt with serotonin syndrome?

Ø D/C serotonergic agents Ø Supportive care: o Normalize vital signs; ay need drugs to lower BP & HR but need to check for labile V/S o Oxygen o IV fluids o Hypothermia blanket but antipyretics are NOT effective and should not be used Ø Sedate with benzodiazepines (diazepam) - will lower BP, help decrease muscle hyper-reflexia, and decrease agitation Ø May administer cyproheptadine - serotonin antagonist (only available in oral form - can administer through N/G tube) Ø May administer anti-psychotic drug to lower serotonin Do NOT use dantrolene (no effect) or bromocriptine (serotonin agonist properties)

What are the the causes of neuroleptic malignant syndrome?

Ø D2 receptor blockade Ø Antipsychotics

What factors increase risk of neuroleptic malignant syndrome?

Ø Dehydration Ø Exhaustion Ø Malnutrition Ø Agitation Ø High-potency antipsychotic drugs Ø Warm/humid environment Ø Organic brain syndromes Ø Genetic factors?

how do you dx neuroleptic malignant syndrome?

Ø Good history (primary) Ø Lab abnormalities o Example check myoglobinuria & myoglobinemia

cardinal features in serotonin syndrome?

Ø Mental status changes Ø Autonomic hyperactivity/instability Ø Neuromuscular abnormalities/myoclonus [myoclonus = muscle jerks; hiccups & jerking muscles when falling asleep are myoclonus] Hyperthermia

what factors increase the risk of serotonin syndrome?

Ø OTC drugs Ø Dietary intake Ø CAM Ø Illicit drugs Ø Changes in dose & schedule MAOI's

what are the cx of serotonin syndrome?

Ø Serotonin toxicity Ø Increased serotonin activity in CNS Ø Therapeutic medication Ø Drug interactions Ø Intentional self-poisoning

cardinal features of neuroleptic malignant syndrome?

Ø Severe muscular rigidity ("lead pipe") Ø Hyperthermia (> 38 C) Ø Autonomic instability Ø Changes in level of consciousness Autonomic dysregulation includes: Ø Diaphoresis Ø Sialorrhea (excessive salivation) Ø Tachycardia Ø Tachypnea (respiratory distress in 31% of cases) Ø Increased or labile BP Ø Hypoxemia Ø Other symptoms, which may be related to the above or not: o Seizures o Incontinence o Shuffling gait o Dysphagia o Tremor o Rhabdomyolysis and then renal failure (éCPK) o Disseminated intravascular coagulation (DIC)

how do you manage a pt with neuroleptic malignant syndrome?

Ø Supportive o Respirations o Hyperthermia - use hypothermia blanket; antipyretics o Renal failure Ø Dantrolene (Dantrium) may help - muscle relaxer Ø Bromocriptine - dopamine agonist Ø Benzodiazepines D/C causative drugs