Ch. 9: CNS problems Flashcards
Sedative Hypnotic medications actions and uses:
relaxes the patient and allows him or her to sleep
Hypnotic agent produces what in the patient?
Sleep
Psychotherapeutic Agents
Antianxiety Medications Antidepressants Antipsychotic Drugs Antimanic Drugs Sedative-Hypnotic Medications
Antianxiety Agents
Anxiety is common, problematic when it interferes with a person’s ability to perform activities of daily living
Action of antianxiety drugs
produce a calming effect
Uses of antianxiety drugs
Relieve anxiety, tension, and fear
May be used to manage alcohol withdrawal symptoms; used preoperatively; used to relieve muscle spasm
Antianxiety agents patient and family teaching
Dosing; appointments and follow-up; adverse reactions; safety with storage; drug and alcohol interactions
Habit-forming: should be used for the shortest time possible
Typical antipsychotic drugs actions and uses
antipsychotic agents act by blocking the action of dopamine in the brain
Used in the treatment of severe mental illness
May be used in combination with major tranquilizers
Expected side effects/adverse reactions of antipsychotic drugs
headache, drowsiness, nausea, constipation and dry mouth/(EPS)–pseudo-Parkinsonism, acute dystonia, akathisia, and tardive dyskinesia
Drug interactions of antipsychotic drugs
acetaminophen, diuretics such as furosemide or hydrochlorothiazide, certain calcium channel blockers, and several antidiabetic agents
Atypical antipsychotic drugs actions and uses
block dopamine 2 or other subtypes of dopamine receptor as well as certain subtypes of serotonin; used primarily for schizophrenia but also can be used for bipolar illnesses and schizoaffective disorder
Atypical antipsychotics side effects/adverse reactions
Insomnia, drowsiness, sexual side effects, dizziness, orthostatic hypotension, constipation and dry mouth
Atypical antipsychotic drug interactions
Drugs that decrease dopamine, alcohol
Antidepressants and Mood stabilizers
Tricyclics MAOIs SSRIs SNRIs Atypical antidepressants
Selective Serotonin Reuptake Inhibitors actions and uses
Act by inhibiting CNS neuronal uptake of serotonin
Used short-term for treatment of outpatients with diagnosis listed as a category of Major Depressive Disorders in the DSM- V
Used long-term for dysthymic and minor depressive disorders
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) actions and uses
inhibit the reuptake of both serotonin and norepinephrine increasing the concentration of both neurotransmitters available to postsynaptic receptors
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) side effects/adverse reactions
nausea, dry mouth, loss of appetite, fatigue, drowsiness, sexual side effects/epistaxis (nosebleeds), gastrointestinal bleeding, and liver damage
SNRIs drug interactions
any drug that affects serotonin or norepinephrine, St. John’s wort
Tricyclic antidepressants actions and uses
Believed to inhibit the reuptake of norepinephrine and or/serotonin
To treat endogenous depression; mild depression due to exogenous causes
Tricyclic antidepressants side effects/adverse reactions
dry mouth, drowsiness, constipation, nausea and orthostatic hypotension/cardiac dysrhythmias, heart failure and seizures
Tricyclic antidepressants drug interactions
sedatives
Monoamine Oxidase Inhibitors actions and uses
Monoamine oxidase: naturally occurring enzyme found in the mitochondria of cells; located in nerve endings, kidneys, liver, and intestines; normally acts as catalyst to inactivate dopamine, norepinephrine, epinephrine, and serotonin MAO inhibitors (MAOIs) block inactivation of these biogenic amines, resulting in increased concentrations at neuronal synapses and antidepressant effects
MAOIs side effects/adverse reactions
constipation, headache, dizziness, drowsiness, dry mouth/liver damage, a variety of blood disorders, thoughts of suicide
MAOIs drug interactions
SSRIs, SNRIs, and St. John’s Wort
Mood stabilizers actions and uses
Exact mechanism of lithium’s action is unknown; alters sodium transport at nerve endings and enhances uptake of serotonin and norepinephrine by the cells (inactivates these neurotransmitters)
Mood-stabilizing drug
Used to treat patients with bipolar disorder who are in acute manic phase; prevents recurrent manic episodes
Mood stabilizers side effects/adverse reactions
mild weight gain, increased thirst, increased urine output, dry skin/hypothyroidism, renal failure and diabetes insipidus
Mood stabilizers drug interactions
Diuretics, NSAIDS, antidepressants, and antipsychotic drugs
Excitatory neurotransmitters
ACh, epinephrine, and norepinephrine
Inhibitory neurotransmitters
Dopamine, types of serotonin, and GABA
Parkinson’s Disease
imbalance of excitatory and inhibitory neurotransmitters
Alzheimer’s and Parkinson’s Disease
result from degenerative changes that occur within nerves
PD is a CNS disorder
not enough dopamine, imbalance between excitatory and inhibitory reduced
PD symptoms
tremors, stooped posture, difficulty stopping motion, difficulty chewing, swallowing, and drooling
PD complications
Depression, anxiety, hallucinations, and delusions
PD drugs increase dopamine levels
to improve motor symptoms
Increased dopamine supply results in
hallucinations/delusions
Most common neurodegenerative disease
Parkinson’s
PD drugs
COMT inhibitors and Monoamine Oxidase type B (MAO-B)
Dopamine Agonists
increased levels of dopamine to restore balance between ACh and dopamine action
Carbidopa/Levidopa
Sinemet, Rytary; 1st line treatment for PD patients older than 70 years
Parmipexole, roprinrol, and rotigotine
Mirapex, Mirapex ER, Requip, Neupro; 1st line treatment for PD patients between 50 and 70 years
Levodopa
is synthesized in the brain and converted to natural dopamine
COMT inhibitors
Entacapone (Comtan), tolcapone (Tasmar)
Selective MAO-B
breaks down dopamine; rasagiline (Azilect), safinamide (Xadago), selegiline (Eldepryl, Ensam, Zelapan)
Dyskinesia
involuntary muscle movements common in patients on long-term carbidopa/levidopa therapy
Delirium
psychosis and hallucinations, caused by dopamine agonists
Neuroleptic Malignant Syndrome
symptoms of agitation, coma, muscle rigidity, tremors, high fever, and an unstable BP
COMT and MAO-B inhibitors
added to the regimen of dopamine agonists, further complications of dopamine will preciptate
Take carbidopa/levidopa
on an empty stomach
Antihypertensive agents with dopamine agonists
can cause severe hypotension
Phenelzine (MAO inhibitors) with dopamine agonists
can cause hypertensive crisis
Iron decreases the effects of
carbidopa/levodopa
B6 increases metabolism of
levodopa
Reglan decreases effectiveness of
dopamine agonists
Dopamine agonists with sedatives
worsen drowsiness
Akinesia
loss of movement
Tardive Dyskinesia
abnormal and involuntary body movements
Dystonia
impairment of muscle tone
Monitor all patients closely for behaviors of
psychosis and depression
COMT is metabolized by
the liver
Epinephrine or methyldopa may increase
heart rate, dysrhythmias, BP
MAO-Bs, selegiline and rasagililne are safe to take with
COMT drugs
MAO-B inhibitors
an enzyme made in many body areas that breaks down many substances, neurotransmitters; suppresses the actions of MAO-B, allows dopamine levels to increase and decrease symptoms of PD
Side effects of MAO-B inhibitors
dry mouth, nausea, constipation and lightheadedness. Confusion and hallucinations in older adults
Tyramine rich foods
should be avoided e.g., avocados, aged cheese, beer, soy sauce, red wine, sauerkraut
MAO-B drug interactions
opiates and methadone=hypertensive crisis
tricyclic antidepressants=hyperthermia, tremors, seizures, or delirium
amphetamines, decongestants and cough medicines=hypertensive crisis
ginseng, ephedra, ma huang, St Johns Wort= hypertensive crisis
N-methyl-D-asparate (NMDA) blockers
Early onset of AD are memory issues, progressive diseases with memory problems, medication may offer a temporary improvement in symptoms
Cholinesterase inhibitors
increased ACh levels, reduced ACh in AD, binds to ACh-esterase, delays memory loss, increases ADLs
Donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne)
cholinesterase inhibitor drugs
Side effects of cholinesterase inhibitor drugs
Mild diarrhea, drowsiness, headache, loss of appetite, GI discomfort, joint pain, muscle cramping
Adverse reactions of cholinesterase inhibitor drugs
Hallucinations, dysrhythmias, GI bleeding, infection, incontinence
Cholinesterase drug interactions
Drugs that prolong the QT interval=torsade de pointes(ventricular tachycardia, fatal)
Cholinesterase with dextromethorphan, quinidine, fluconazole and Tensilon
increase risk for adverse effects
Before administering cholinesterase inhibitor drugs
obtain baseline weight, decreases appetite
With cholinesterase inhibitor drugs, observe for
decrease in hematocrit and hemoglobin
Monitor blood levels on cholinesterase drugs
BUN and liver function
Alzheimer’s Disease Assessment Scale
cognitive testing for AD
Take Donepezil (Aricept)
at bedtime
Take galantamine (Razadyne) and rivastigamine (Exelon)
at the same time everyday, 2x daily with food
NMDA
block entrance of calcium into neurons, Memantine (Namenda, Ebixa)
can be taken with Aricept, Exelon, and Razadyne to increase cholinergic agoinsts
Side Effects of NMDA
Headaches, dizziness, constipation
Adverse Reactions of NMDA
Somnolence, shortness of breath, incontinence, weight loss
Drug Interactions with NMDA
drugs that increase urine pH, increase side effects/adverse reactions eg., carbonic anhydrase inhibitors (acetazolamide, quinidine, and dextromethorphan)
Memantine increases risk for
renal impairment
Obtain baseline before administering Memantine
creatine and BUN, liver enzymes
UTIs can increase levels of
Memantine
Monitor vitals for AD patients with
heart disease
For AD patients, report
ataxia, dizziness
Epilepsy
neurons of the brain become hyperexcitable, trigger electrical signals when not needed
Seziures
body’s response to inappropriate brain signals
Covulsion
sudden contraction of many muscle groups without conscious control
Subtypes of seizures
partial or generalized
Traditional AEDs
phenytoin, carbamazepine, ethosuximide, phenobarbital, and valproic acid
Phenytoin
prevent the spread of neuron excitation by binding to sodium channels
Phenytoin prodrug
Fosphenytoin (Cerebyx), converted to phenytoin in the body
Carbamazepine
limits the spread of neuron excitation by altering sodium channels to prevent or slow refiring or neurons
controls epilepsy in children, mood stabilizer
Ethosuximide
increases seizure threshold by altering calcium channels on the neuron membranes
for absent seizures, likely to cause birth defects
Phenobarbital
barbituate class, increases seizure threshold, ehances action of GABA, CNS depression
oldest drug to control seizures, sedative agent, longest duration, not for absent seizures
Phenobarbital can also be used short-term for
insomnia and anxiety
Phenobarbital Prodrug
Primidone
Valproic Acid
increases seizure threshold by increasing activity of GABA
combined with divalproex sodium to increased duration, decreases dosing frequency
Side effects of Phenytoin
gum hyperplasia, abdominal discomfort
Side effects of Carbamazepine
constipation, nausea, vomiting, ataxia, itching, burning, rash, muscle weakness
Side effects of Ethosuximide
dyspepsia, nausea, vomiting, dizziness, drowsiness and fatigue
Side effects of Phenobarbital and Primidone
drowsiness, ataxia, blurred vision, dizziness, mental status changes
-more apparent in the beginning of medication therapy
Side effects of Valproic Acid
drowsiness, muscle weakness, nausea, diarrhea and menstural irregularities. Anorexia, double vision, blurred vision and sometimes insomnia
Adverse reactions of Phenytoin
teratogen (birth defects), blood cell problems of anemia, decreased WBC counts, increased risk for infection
Adverse reactions of Carbamazepine
Anemia, decreased WBC count, increased risk for infection, decreased platelet counts with increased risk for bleeding, tachycardia, A-fib, and severe hypertension
Adverse reactions of Phenobarbital
severe CNS depression, can cause respiratory depression, bone marrow depression, cognitive impairment, exfoliative dermatitis, liver impairment and coma
Adverse reactions of Valproic Acid
amnesia and heart rhythm irregularities, hearing loss and GI bleeding
Drug interactions of traditional AEDs
Aspirin, acetaminophen, oral contraceptives, proton pump inhibitors, and drugs for diabetes
drugs used to manage psychiatric problems and warfarin
Newer AEDs
Oxcarbazapine, Lamotrigine, Lacosamide, and Topiramate
Adjuvant therapy
“added on” therapy
Oxcarbazapine
blocks sodium channels increase seizure threshold, controls partial seizures
Expected Side Effects/Adverse reactions of newer AEDs
Drowsiness, dizziness, headache, nausea
Double vision and blurred vision
Hyponatremia
Drug interactions of newer AEDs
aspirin, acetaminophen, oral contraceptives, proton pump inhibitors, drugs for psychiatric problems, HIV and diabetes
Lamotrigine
thought to block sodium channels on neuron membranes
partial seizures, tonic-clonic seizures, and seizures associated with Lennox-Gastaut syndrome
Side Effects of Lamotrigine
Drowsiness, abdominal pain, and usual disturbances
Ataxia, dry mouth, dizziness
-clearance rate is lower among black patients
Adverse Reactions of Lamotrigine
Stevens-Johnson syndrome and toxic epidermal necrolysis
interacts with folic acid formation
not recommended during pregnancy
Drug Interactions of Lamotrigine
Aspirin, acetaminophen, oral contraceptives, proton pump inhibitors, cardiac drugs, drugs for psychiatric problems, drugs for HIV disease, drugs for tuberculosis and drugs for diabetes
Lamotrigine has 3 different
“starter kits”
Lacosamide
amino acid with an unknown mechanism of action, appears to control seizures by acting at sodium channels
- monotherapy
- partial seizures
- “add on” drug
Side effects of Lacosamide
headaches, dizziness, blurred vision, fatigue, nausea and ataxia
Adverse reactions of Lacosamide
due to euphoria, can cause psychological dependence
pain at injection site rapid lowering of blood pressure, and heart rhythm problems
Drug interactions of Lacosamide
cardiac drugs, antihypertensive drugs, drugs f or psychiatric problems, drugs for HIV disease, antifungal drugs, and drugs for tuberculosis
Before giving Lacosamide, assess patient’s
blood pressure, can cause severe hypotension
Topiramate
appears to reduce seizures by preventing the spread of excitation in the brain
- acts at sodium channels
- enhances GABA
- Monotherapy for partial seizures, tonic-clonic seizures and seizures associated with Lennox-Gaustaut syndrome
- “add on” drug
Side effects of Topiramate
abdominal pain, nausea, dizziness, drowsiness, fatigue, taste changes, anorexia, and paresthesias
Adverse Reactions of Topiramate
memory impairment, electrolyte imbalances, decreases levels of phosphorus and calcium
metabolic problem, acidosis and elevated ammonia concentrations
encephalopathy from too high ammonia levels
Unexplained lethargy, vomiting, changes in mental status, and low core body temperature manifest from
encephalopathy from toxic ammonia levels in blood
Drug Interactions with Topiramate
Aspirin, acetaminophen, oral contraceptives, cardiac drugs, diuretics, antihypertensives, antifungals, drugs for psychiatric problems, drugs for HIV disease, drugs for tuberculosis, drugs that affect blood clotting, and drugs for diabetes
MS
occurs 2x as often in women than men
Corticosteroids for MS
may help symptoms, but do not alter the course of the disease
Biological Response Modifiers (BRMs)
used to RRMS, modify the patient’s immune response to abnormal trigger for immunity, and inflammation
Sub Q Beta inferon:
Avonex, Betaseron, Extaria, Plegridy, Rebif, glatiramer(Copaxone, Glatopa)
Oral Beta inferon:
Fingolimod (Gilenya), teriflunomide (Aubagio)
Monoclonal Antibodies for MS
antibodies attack and inactivate or destroy lymphocytes that destroy myelin or that produce cytokines that trigger the immune system to destroy myelin
- risk for infection, increase in WBCs
- Given on IV infusions
Specific Neurologic Drugs for MS
Dimethyl fumarate (Tecfidera) and dalfaprimide (Ampyra) -must be taken daily
Tecfidera
reduces inflammation in the CNS
Ampyra
blocks potassium channels in affected nerves
What vitamin should you avoid while taking Antiparkinsonian agents?
B6, pyroxamine
