Chapter 22 Psychotherapeutic agents Flashcards
Antipsychotics MEDS
Typical Antipsychotics: Chlorpromazine, Fluphenazine, Haloperidol, Loxapine, Perphenazine, Pimozide, Prochlorperazine, Thiothixene, Trifluoperazine.
Atypical Antipsychotics: Aripiprazole, Asenapine, Brexpiprazole, Cariprazine, Clozapine, Iloperidone, Lumateperone, Lurasidone, Olanzapine, Paliperidone, Quetiapine, Risperidone, Ziprasidone
Antipsychotic MOA
Typical Antipsychotics:
Block dopamine (D2) receptors, preventing dopamine from stimulating postsynaptic neurons.
Depress the Reticular Activating System (RAS), limiting brain stimuli.
Have anticholinergic, antihistamine, and alpha- adrenergic blocking effects.
Atypical Antipsychotics:
Block both dopamine and serotonin (5HT) receptors, reducing neurological side effects compared to typical antipsychotics.
Indications of Antipsychotic
Schizophrenia and psychotic disorders.
Hyperactivity, severe behavioral problems in children (short- term).
Bipolar disorder, major depressive disorder (MDD) (some atypical antipsychotics).
Adjunctive therapy for depression (Brexpiprazole).
Irritability in Autism Spectrum Disorder (Risperidone, Aripiprazole)
Tourette’s syndrome
(Aripiprazole).
Nausea and vomiting control (Prochlorperazine).
Acute psychiatric episodes (Haloperidol, Aripiprazole, Olanzapine).
Pharmacokinetics Antipsych
Erratic GI absorption, depending on the drug and formulation.
Intramuscular (IM) doses provide 4-5 times the active dose compared to oral administration.
Widely distributed in tissues, stored for up to 6 months after discontinuation.
Metabolized in the liver, excreted via bile and urine.
Children metabolize faster, older adults metabolize slower (dose adjustments required).
Crosses the placenta and enters breast milk.
CI antipsych
Parkinson’s disease (dopamine blockade worsens symptoms).
QTc prolongation risk, leading to serious arrhythmias.
Older adults with dementia
(increased cardiovascular mortality; boxed warning).
Cautions:
- Anticholinergic effects (caution in glaucoma, peptic ulcer, GI obstruction, urinary retention).
- Seizure disorders (may lower seizure threshold).
- Alcohol use disorder (risk of CNS depression).
- Pregnancy (risk of neonatal extrapyramidal effects and withdrawal symptoms).
- Immunosuppressed patients (risk of bone marrow suppression and blood dyscrasias)
AE antipsych
Neurological Effects:
- Extrapyramidal symptoms
(EPS): Dystonia (spasms), Akathisia (restlessness), Pseudoparkinsonism (tremors, rigidity), Tardive Dyskinesia (involuntary facial and limb movements).
- Neuroleptic Malignant Syndrome (NMS): Fever, muscle rigidity, autonomic instability (potentially fatal).
Cardiovascular: QTc prolongation, risk of fatal arrhythmias (Haloperidol, Ziprasidone).
Metabolic Effects: Atypical antipsychotics linked to diabetes mellitus and weight gain.
Other:
- Orthostatic hypotension,
sedation, sexual dysfunction, anticholinergic effects (dry mouth, constipation).
- Ziprasidone: Risk of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), a potentially fatal skin reaction.
DDI antipsych
CNS Depressants (alcohol, sedatives, opioids): Increased sedation, respiratory depression.
Dopamine agonists (e.g., Levodopa): Reduced effectiveness due to dopamine blockade.
QTc-prolonging drugs (antiarrhythmics, fluoroquinolones): Increased risk of fatal arrhythmias.
Antihypertensives:
Increased risk of hypotension.
Metabolic Interactions: - Clozapine requires routine monitoring for agranulocytosis (low white blood cells).
- Risperidone and Olanzapine increase weight gain and diabetes risk.
Nursing consideration antipsych
Baseline ECG for QTc monitoring in high-risk patients.
Monitor for extrapyramidal symptoms (EPS) and neuroleptic malignant syndrome (NMS).
Assess for metabolic effects (weight, glucose levels, lipid profile) in atypical antipsychotic use.
Educate patients:
- Report sudden weakness, tremors, fever, or severe
restlessness.
- Avoid alcohol and OTC sedatives.
- Do not abruptly stop medication (risk of withdrawal
symptoms).
- Rise slowly from sitting/lying positions to prevent
dizziness.
Monitor for suicidality, especially in young adults with depression or mood disorders.
Encourage adherence: Therapeutic effects may take several weeks.
Bipolar Disorder MEDS
Traditional Mood Stabilizer: Lithium (Lithobid)
Atypical Antipsychotics: Aripiprazole (Abilify) Cariprazine (Vraylar) Lurasidone (Latuda) Olanzapine (Zyprexa, Zyprexa Zydis) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon)
Antiepileptic agents
Lithium MOA
Alters sodium transport in nerve and muscle cells.
Inhibits norepinephrine and dopamine release but does not affect serotonin.
Increases intraneuronal stores of norepinephrine and dopamine while decreasing second messengers, which may modulate hyperactive neurons involved in mania.
The exact mechanism of action for mania control is not fully understood.
Lithium and atypical antipsych indications
Lithium:
Management of acute manic episodes and prevention of future episodes.
Atypical Antipsychotics:
Used as monotherapy or adjunctive therapy for bipolar disorder to help stabilize mood and manage symptoms of mania or depression.
Pharmacokinetics Lithium
Lithium:
Absorbed in the GI tract, peak levels in 30 minutes to 3 hours.
Slowly crosses the blood-brain barrier (delayed toxic effects).
Excreted through the kidneys, with 80% being reabsorbed.
Dehydration or sodium depletion leads to higher lithium reabsorption, increasing toxicity risk.
Crosses the placenta and enters breast milk, leading to potential congenital abnormalities.
CI lithium
Renal disease (risk of toxicity due to decreased excretion).
Cardiovascular disease (risk of arrhythmias and complications).
Dehydration, sodium depletion, or diuretic use (increases lithium reabsorption and toxicity).
Severe depression or suicidal ideation (lithium can cause lethargy and worsen symptoms).
Pregnancy and lactation (associated with congenital abnormalities).
Atypical Antipsychotics:
Elderly patients with dementia
(increased risk of death).
Risk of metabolic syndrome (weight gain, diabetes, hyperlipidemia).
QTc prolongation (Ziprasidone and others require cardiac monitoring).
AE lithium and atypical antipsych
Mild Toxicity (Serum levels 1.2- 1.5 mEq/L): Lethargy, slurred speech, muscle weakness, fine tremors, polyuria, nausea, vomiting, and diarrhea.
Moderate Toxicity (1.5-2.5 mEq/L): Worsening tremors, GI upset, confusion.
Severe Toxicity (>2.5 mEq/L):
Multi-organ toxicity, cardiovascular collapse, coma, and death.
Atypical Antipsychotics:
Sedation, weight gain, metabolic syndrome, QT prolongation, extrapyramidal symptoms (EPS), tardive dyskinesia.
DDI lithium and atypical antipsych
Lithium Interactions:
Diuretics, ACE inhibitors, NSAIDs: Increase lithium levels, causing toxicity.
Psyllium (herbal supplement): Reduces lithium absorption, decreasing effectiveness.
Haloperidol + Lithium: Risk of irreversible brain damage with encephalopathic syndrome (weakness, tremors, confusion, extrapyramidal symptoms).
Serotonergic drugs (SSRIs, SNRIs, triptans, tramadol, MAOIs): Increased risk of serotonin syndrome.
Atypical Antipsychotics Interactions:
CNS depressants (alcohol, sedatives): Increased sedation and respiratory depression.
Drugs that prolong QT interval: Increased risk of fatal arrhythmias.
Nursing interventions lithium and atypical antipsych
Monitor serum lithium levels frequently:
- Therapeutic range: 0.6–1.2 mEq/L.
- Toxic levels >1.5 mEq/L require immediate intervention.
Encourage adequate hydration and sodium intake to prevent toxicity.
Monitor renal function (creatinine, BUN) and thyroid function (risk of hypothyroidism).
Assess for suicidal ideation in patients starting therapy.
Educate patients:
- Avoid dehydration and excessive sweating (risk of lithium
toxicity).
- Take lithium with food to reduce GI distress.
- Do not abruptly stop medication; taper gradually.
Atypical Antipsychotics:
- Monitor for weight gain, metabolic effects, and QT prolongation.
- Assess for extrapyramidal symptoms (EPS) and tardive dyskinesia.
- Caution with concurrent CNS depressants.
Drugs for ADHD and Narcolepsy
CNS Stimulants: Methamphetamine hydrochloride (Desoxyn) Amphetamine formulations (Adderall XR, Adzenys ER, Dyanavel XR, Evekeo ODT, Mydayis) Methylphenidate (Ritalin, Concerta, and others)
Dexmethylphenidate
(Focalin)
Dextroamphetamine
(Dexedrine)
Lisdexamfetamine
(Vyvanse)
Modafinil (Provigil) Armodafinil (Nuvigil)
Selective Norepinephrine Reuptake Inhibitor (SNRI): Atomoxetine (Strattera)
Alpha-2 Adrenergic Agonists: Guanfacine (Intuniv) Clonidine hydrochloride (Kapvay)
MOA CNS stimulants, SNRI, alpha -2
CNS Stimulants:
Increase the release of
catecholamines (dopamine, norepinephrine) from presynaptic neurons.
Block reuptake of norepinephrine and dopamine, increasing synaptic availability.
The paradoxical effect in ADHD: reduces hyperactivity and improves focus.
Modafinil and Armodafinil act through dopaminergic pathways without major cardiac stimulation.
SNRIs (Atomoxetine):
Blocks norepinephrine reuptake without significant stimulant effects.
Lacks cardiovascular and systemic stimulant effects, making it preferable for patients who cannot tolerate CNS stimulants.
Alpha-2 Adrenergic Agonists:
Reduce sympathetic outflow, calming hyperactivity and impulsivity.
Work through the prefrontal cortex to improve attention regulation.
Indications for ADHD and narcolepsy
CNS Stimulants:
ADHD treatment in children and adults.
Narcolepsy and other sleep disorders (modafinil, armodafinil).
Lisdexamfetamine is also approved for binge-eating disorder but not for weight loss due to addiction risk
Pharmacokinetics of ADHD/ narcolepsy drugs
Rapidly absorbed from the GI tract. (Peak levels in 2-4 hours)
Metabolized in the liver, excreted in the urine.
Half-life varies (2-15 hours depending on the drug).
Stimulants cross the placenta and enter breast milk, increasing risks of
premature birth and low birth weight.
CI to ADHD/narcolepsy drugs
Allergy to CNS stimulants (risk of hypersensitivity reactions).
Marked anxiety, agitation, tension, severe fatigue (CNS stimulation may worsen symptoms).
Glaucoma (due to increased intraocular pressure).
Cardiac disease, congenital heart defects (risk of arrhythmias, sudden death).
Uncontrolled hypertension (stimulants increase blood pressure and heart rate).
Pregnancy and lactation (risks to fetal growth, potential neonatal withdrawal).
AE of ADHD/narcolepsy
CNS Effects:
- Nervousness, insomnia,
dizziness, headache,
tremors.
- Restlessness, increased
anxiety, agitation.
Cardiovascular Effects:
- Tachycardia, increased
blood pressure,
palpitations.
- High doses: Risk of
arrhythmias and sudden cardiac death.
GI Effects:
- Loss of appetite, nausea, vomiting, abdominal pain.
- Weight loss and growth suppression in children.
Other Effects:
- Priapism (rare but serious)
(methylphenidate).
- Risk of physical and psychological dependence with amphetamines.
- Skin rash with modafinil and armodafinil (risk of Stevens-Johnson syndrome).
DDI ADHD/narcolepsy
CNS Depressants (alcohol, sedatives): Reduce stimulant efficacy.
Other CNS Stimulants:
Increased risk of
hypertension, tachycardia, arrhythmias.
MAOIs: Risk of hypertensive crisis (avoid within 14 days of stimulant use).
Tricyclic Antidepressants (TCAs): Increased sympathomimetic effects.
Antihypertensives: Stimulants may reduce efficacy, leading to uncontrolled hypertension
nursing interventions ADHD/narcolepsy
Ensure proper ADHD or narcolepsy diagnosis before prescribing.
Monitor blood pressure, heart rate, weight, and height in children.
Screen for cardiac history before initiating stimulant therapy. Educate families about potential for abuse (controlled
substances).
Encourage taking medications early in the day to minimize insomnia.
Assess for psychological dependence and misuse.
Periodically interrupt stimulant use in children to assess continued need.
Monitor for psychiatric symptoms (aggression, paranoia, suicidal ideation).
Avoid abrupt discontinuation (risk of withdrawal symptoms).
