Lecture 4 Flashcards by Sydney Coopland

are any action that occurs other than the desired effect of the drug.

Side Effects

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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

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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

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Extrapyramidal Side Effects
Tardive Dyskinesia
Anticholinergic Side Effects
Neuroleptic Malignant Syndrome
Sedation
Confusion
Headaches
Seizures
Sleep Disturbances

Nervous System Side Effects

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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

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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

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Akathisia usually improves with a reduction in medications or the addition of a _______ or _______

benzodiazepine or propranolol

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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

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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

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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

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Torticollis or Retrocollis
Opisthotonos or Pleurthotonus (Pisa Sign)
Oculogyric Crisis
Thickening or protrusion of the tongue

Acute Dystonic Reactions

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spasm of the sternocleidomastoid muscle (not looking up)

Torticollis

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spasms of the muscles surrounding the spine

Opisthotonos or Pleurthotonus (Pisa Sign)

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eyes roll upwards
Severe muscle spasms

Oculogyric Crisis

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Thickening or protrusion of the tongue causes

difficulty swallowing

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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)

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However, monitoring for symptoms of Tardive Dyskinesia can be completed through the

Abnormal Involuntary Movement Scales (AIMS)

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Constant chewing
Facial and tongue movements
Facial grimacing
Limb movements

Signs of Tardive Dyskinesia

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In the nigrostriatal pathway – dopamine blocks cholinergic receptors

Anticholinergic Side Effects

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Dry mouth, constipation, urinary retention, bowel obstruction, dilated pupils, blurred vision, increased heart rate and decreased sweating

Peripheral Anticholinergic Side Effects

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Impaired concentration, confusion, attention deficit, disorientation, and memory impairment

Central Anticholinergic Side Effects

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Dopamine is blocked at the D2 receptor sites… this causes an increase stimulation of _______ release

acetylcholine

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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

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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

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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