Lecture 4 Flashcards
are any action that occurs other than the desired effect of the drug.
Side Effects
have numerous side effects. This is a result of the action that they have on the:
A) Nervous System
B) Endocrine System
C) Cardiovascular System
D) Exocrine System
E) Miscellaneous Systems
Antipsychotics
Due to:
1. Dopamine antagonism (block dopamine from binding)
2. Blockade of muscarinic cholinergic receptors
3. Blockade of Histamine receptors
4. Blockade of adrenergic receptors
Side Effects
Extrapyramidal Side Effects
Tardive Dyskinesia
Anticholinergic Side Effects
Neuroleptic Malignant Syndrome
Sedation
Confusion
Headaches
Seizures
Sleep Disturbances
Nervous System Side Effects
Akathisia, Akinesia, Pseudo parkinsonism, and Dystonia
- Group of motor disturbances caused by Dopamine being blocked in the Nigrostriatal Pathway
- Typical Antipsychotics are the most likely to cause
- Some symptoms can be controlled with the use of Antiparkinsonian medication
EPS Nervous System
Most common of the EPS
Onset is 5- 60 days from the start of drug therapy
Characterized by motor- restlessness, or an inability to sit still
Condition is completely outside voluntary control (which differentiates it from agitation)
Akathisia
Akathisia usually improves with a reduction in medications or the addition of a _______ or _______
benzodiazepine or propranolol
Immobility or weakness
Complaints of fatigue
Lack of muscle movement
Can be confused with the negative symptoms of Schizophrenia
Increased dose of medication will increase the symptoms
Akinesia/Bradykinesia
Onset is the first week after the initiation of drug therapy
Loss in muscle movement (Akinesia)
Mask like facial expression
Stooped posture
Shuffling gait
Pin rolling movement between finger and thumb,
Muscle rigidity (cogwheel)
Tremors
Pseudo parkinsonism
Onset is very sudden within 1- 5 days of initiation or increase in drug therapy
Characterized by sudden uncoordinated prolonged abnormal tonic contractions of muscle groups
Acute Dystonic Reactions
Torticollis or Retrocollis
Opisthotonos or Pleurthotonus (Pisa Sign)
Oculogyric Crisis
Thickening or protrusion of the tongue
Acute Dystonic Reactions
spasm of the sternocleidomastoid muscle (not looking up)
Torticollis
spasms of the muscles surrounding the spine
Opisthotonos or Pleurthotonus (Pisa Sign)
eyes roll upwards
Severe muscle spasms
Oculogyric Crisis
Thickening or protrusion of the tongue causes
difficulty swallowing
Onset occurs late in psychopharmacological treatment
Most prominent with high potency and high doses of Typical antipsychotics
Believed to be caused by a chronic exposure to dopamine receptor blocking agents in the nigrostriatal pathway
Usually is IRREVERSIBLE and has no effective treatment
Tardive Dyskinesia (TD)
However, monitoring for symptoms of Tardive Dyskinesia can be completed through the
Abnormal Involuntary Movement Scales (AIMS)
Constant chewing
Facial and tongue movements
Facial grimacing
Limb movements
Signs of Tardive Dyskinesia
In the nigrostriatal pathway – dopamine blocks cholinergic receptors
Anticholinergic Side Effects
Dry mouth, constipation, urinary retention, bowel obstruction, dilated pupils, blurred vision, increased heart rate and decreased sweating
Peripheral Anticholinergic Side Effects
Impaired concentration, confusion, attention deficit, disorientation, and memory impairment
Central Anticholinergic Side Effects
Dopamine is blocked at the D2 receptor sites… this causes an increase stimulation of _______ release
acetylcholine
Onset can occur hours to months after the initial start of drug therapy
Hypodopaminergic state (severe low dopamine)
Extremely rare (about 1 % of people) however can be fatal
Neuroleptic Malignant Syndrome
Risk Factors
Initiation or increase of antipsychotic medication
Dehydration, physical exhaustion, malnutrition
Clients with underlying brain damage and dementia
Higher doses of antipsychotics or use of multiple antipsychotics
Neuroleptic Malignant Syndrome
Symptoms:
Extrapyramidal side effects (muscle rigidity)
Increased body temperature (diaphoresis)
Change in consciousness (delirium, confusion, coma)
Fluctuating BP, Tachycardia, decrease respirations
Elevated CPK and myoglobin (causes damage to the liver and kidneys)
Tremor
Progresses over days to weeks if untreated
Neuroleptic Malignant Syndrome
Treatment is:
Immediate discontinuation of drug
Physician may prescribe a dopamine AGONIST (Bromocriptine)
Supportive treatment is required (fluids, electrolytes)
Neuroleptic Malignant Syndrome
5) Sedation - usually related to anti- histaminic action of antipsychotics
6) Confusion – difficulty with concentration, disorientation
7) Headache
8) Seizures – Caution with clients that have a history of seizure disorder and disorders such as dementia
9) Sleep Difficulties – vivid dreams and nightmares
Other Nervous System Side Effects
Antipsychotic medications _____ the seizure threshold – All can but Clozapine (unless dose above 600 mg) – worst, Seroquel and Risperidone lower risk
lower
Metabolism
Sexual Hormone Dysregulation
Endocrine System Side Effects
Antipsychotics can cause weight gain and increased appetite
There is also a risk for diabetes (T2DM) and metabolic syndrome with antipsychotics.
Metabolism side effects
which includes:
Weight
Fasting bloodwork [Blood sugar, triglycerides, cholesterol],
Waist circumference
Vital Signs
Olanzapine and Clozapine have a higher risk for metabolic side effects than other drugs
Metabolic monitoring
Younger age at treatment initiation
First exposure to antipsychotics
Non-smoking status
Female sex
Family history of high BMI
Use of specific antipsychotics
Predictors of Increased Weight Gain
Include:
Cardiovascular Disease
Gall bladder disease
Type 2 Diabetes
Cerebrovascular disease
Hypertension
Sleep Apnea
Health Risks Associated with Increased Weight
Blocking dopamine in the Tuberoinfundibular Dopamine pathway causes an increase in prolactin concentrations
This leads to hyperprolactinemia
Sexual Hormone Dysregulation
Side Effects are:
Disturbances in menstruation – delayed or amenorrhea
Lactation in women (galactorrhea)
Gynecomastia (male breast enlargement) in men and women
Rapid demineralization of bones (in post menopausal women not on estrogen therapy)
Sexual dysfunction
Sexual Hormone Dysregulation
increases prolactin – good to do a baseline measure and monitor
Risperidone
Orthostatic Hypotension
QT Interval
Agranulocytosis
Cardiovascular System side effects
Caused by blocking the adrenergic receptors
Most common side effect of antipsychotics (Typical and Atypical)
Orthostatic hypotension (postural hypotension) the sudden drop of blood pressure from lying to sitting, lying to standing or sitting to standing
Causes: Tachycardia and Dizziness
Orthostatic Hypotension
Antipsychotics can prolong the QT interval
This is a marker for arrhythmic risk
Can lead to cardiac arrest or transient loss of consciousness
QT Intervals
Serious side effect
Failure of bone marrow to make enough granulocytes (specifically neutrophils)
Leaves the body susceptible to serious infections
Agranulocytosis
Symptoms include:
Fatigue for more than 3 days
Sore throat
Ulcers in mouth or throat
Fever and severe chills
Signs of infection
Hyperthermia
Treatment is: blood test to determine current white blood cell count; discontinuation of drug that is causing the problem; infection control procedures.
Agranulocytosis
Benefits:
Extremely good effectiveness compared to other antipsychotics
Effective in decreasing hallucinations and delusions
FDA- Approved for the treatment of recurring suicidal behaviour
Can diminish symptoms of aggression and violence
Low incidence of EPS and akathisia
Almost no tardive dyskinesia
Clozaril Benefits
Risks:
May cause agranulocytosis
Can interact with other drugs that decrease WBC Count
Some deaths have been reported from myocarditis (inflammation of the heart muscle)
Over sedation
Weight gain and risk for other metabolic issues
Can cause urinary incontinence
Can cause constipation
Seizures at higher doses (above 600mg/day are common)
Clozaril Risks
needs to be titrated up slowly.
If a client is non-compliant for a period of time, titration (and monitoring) needs to start again requires weekly blood levels (WBC) within the first 6 month of treatment
After the first 6 months of treatment biweekly blood work occurs
Client prescriptions/blood work levels are monitoring through National Data Bases
Clients need to stay on the specific brand of___ that the doctor has prescribed in order to keep up to date with mandatory blood work.
Clozapine protocol
Photosensitivity
Dermatological/ Temperature Regulation Effects
Exocrine System Effects
Sensitivity to the sun
Can cause redness, blisters and abnormal skin pigmentation
Photosensitivity
Hyperthermia
Polydipsia - Water Intoxication
Dermatitis
Steven Johnson Syndrome – beings with flu-like symptoms and is followed by painful red or purplish rash
Temperature Regulation Effects
Change in appetite
Antiemetic
Gastric irritation (nausea/vomiting)
Hypersalivation
Glossitis (inflammation of the tongue)
Dysphagia (choking)
Gastrointestinal
Granular deposits
Retinopathy
Blurred Vision
Ocular
Increases the clearance of:
Haloperidol
Perphenazine
Thiothixene
Chlorpromazine
Fluphenazine
Clozapine
Olanzapine
Smoking
Approx. ___ of ppl diagnosed w schizophrenia smoke
60%
Smoking (nicotine) enhances ______ (increases)
Smoking can help alleviate EPSE but may increase other side effects
dopamine
All _______ are possible with all antipsychotics. However, the severity of the risk of the symptoms increases with different types of antipsychotics.
side effects
The ______ of risk also increases when dosages reach their upper limit or surpass their recommended dosages.
severity
Known hypersensitivity
Acute myocardial infarction (MI)
History of myeloproliferative diseases
Uncontrolled epilepsy
CNS depression , stroke or comatose states
Significant liver or renal diseases
Hx severe side effects
Contraindications
means that the drug should not be used with these conditions because it could be extremely harmful to the person.
CONTRAINDICATION
means that risk versus benefit should be considered prior to initiation of the drug.
Caution
may also be described as an allergy (ex Haldol allergy)
Hypersensitivity
Parkinson’s Disease
Medical conditions such as glaucoma, peptic ulcers, and urinary or intestinal obstructions
Seizure disorders
Alcohol misuse
Cautions
_______ (alcohol, barbiturates, benzodiazepines, narcotics, antihistamines, anesthetics and pain medication)
CNS Depressants (Drug Interactions)
Antidepressants (MAOIs and Tricyclic Antidepressants)
(Drug Interactions)
Dopamine Agonists (levodopa carbidopa)
Drug Interactions w/ Antipsychotics
Antihypertensive
Drug Interaction w/ Antipsychotics
______ and Lithium - Encephalopathy
Haldol
Many antipsychotics react poorly with:
Kava Kava Root
Gotu Kola-
St. Johns Wort
Valerian
Evening Primrose
Herbal Contraindications w/ Antipsychotics
causes liver damage (is currently banned in Canada)
Kava Kava Root
increase the effect of numerous antipsychotics
Gotu Kola
increase the effect of numerous antipsychotics
St. Johns Wort
acts like a sedative – increases the effect of numerous antipsychotics
Valerian
increases the symptoms of schizophrenia
Evening Primrose
spasm of the sternocleidomastoid muscle (looking up)
Retrocollis
