Neuropsych drugs Flashcards
chlorpromazine (Thorazine)
Class: Low potency 1st gen antipsychotic (FGA, typical)
MoA: Blocks many receptors in CNS and PNS: dopamine, AcH, H1, NE & Alpha 1 & 2
Uses: Mainly schizophrenia, schizoaffective disorder, manic BPD episodes, intractable hiccups, emesis, behavioral problems in kids, delirium
Admin: PO, IM, IV.
Considerations: incr r/f CNS depression w benzos, benadryl, ETOH, opioids, barbiturates, some antidepressants. Incr r/f hypotension w/ antihypertensives d/t effect on NE.
AEs: Extrapyramidal symptoms: Acute dystonia. Parkinsonism. Akathisia. Tardive dyskinesia.
NMS.
Anticholinergic effects.
Orthostatic hypotension d/t blockade of Alpha receptors causing vasodilation.
Cardiac dysrhythmias.
Sedation (1st week).
Agranulocytosis.
Sexual dysfunction, gynecomastia, galactorrhea, menstrual irregularity, incr. sensitivity to sunlight, sunburns, seizures, r/f death in elderly.
Parkinsonism symptoms
bradykinesia, drooling, rigidity, shuffling gait, stooped posture
Akathisia
uncontrollable need to move
Tardive dyskinesia
twisting/worm-like
movements of the tongue/face, lip smacking
& tongue darting. Can interfere with chewing which can result in malnutrition/ weight loss. Sometimes irreversible even after stopping treatment.
NMS
(Neuroleptic Malignant Syndrome)
“lead pipe” rigidity, sweating, dysrhythmias, fever,
confusion & restlessness. Rare but can be fatal.
Anticholinergic effects of chlorpromazine (Thorazine)
Due to blockade of AcH: dry mouth, constipation, urinary frequency/retention, tachycardia & blurred vision
Cardiac dysrhythmias side effect of chlorpromazine (Thorazine) considerations
prolong QT interval. Check ECG and check K+ before starting drug.
Agranulocytosis SE of chlorpromazine (Thorazine)
rare but serious AE
characterized by ↓ WBC ct. → ↑’d R/F infx. Check WBC ct. before starting treatment
Acute dystonia
severe muscle spasms of the tongue, face, neck & back. Medical emergency; can affect breathing. Requires immediate admin of Benadryl.
Extrapyramidal symptoms (EPS)
likely d/t blockage of DA receptor sites in the EPS of the brain:
Acute Dystonia
Parkinsonism
Akathisia
Tardive dyskinesia
haloperidol (Haldol)
Class: High potency FGA (typical)
MoA: Same as thorazine
Uses: Schizophrenia, acute psychosis, Tourette’s, severe behavioral issues in kids. The most often used drug of the FGA’s.
Admin: PO, IV, IM
Considerations: incr. r/f dysrhythmias with amiodarone, erythromycin & quinidine. Check ECG & K+ before starting. Use caution in pts w/ hx of dysrhythmias, K+ imbalance, heart disease & elderly
AEs: Early EPS reactions. More likely to occur w/ high potency than low potency FGAs.
Sedation, hypotension & anticholinergic effects uncommon
Gynecomastia, galactorrhea & menstrual irregularity
Fatal arrhythmias
risperidone (Risperdal)
Class: Second generation antipsychotic (SGA, atypical)
MoA: Blocks 5-HT2 (serotonin), DA, H1 & Alpha-adrenergic receptors
Uses: Schizophrenia & bipolar mania. Approved for autistic kids w/ severe behavioral problems.
Admin: PO & IM. Rapidly absorbed and long lasting. Decrease dose w/ renal or hepatic impairment.
Considerations: ↑ R/F CNS depression w/ benzo’s, 1st gen. antihistamines, ETOH, opioids, barbiturates, FGA’s & some antidepressants.
↑ R/F hypotension w/antihypertensives
AEs: Metabolic Symptoms: Wt. gain, diabetes & dyslipidemia. Check fasting blood glucose and lipid panel before starting therapy.
EPS risk very low with low doses
May cause agitation, tremors, dizziness, sedation, fatigue
↑ R/F death in elderly
clozapine (Clozaril) or aripiprazole (Abilify)
Class: Second generation antipsychotic (SGA, atypical)
MoA: Same as risperidone.
Uses: Schizophrenia, bipolar mania, major depressive disorder, agitation & irritability a/w autism. Adjunctive Tx for OCD. Safest SGA.
Admin: PO & IM,
Considerations: ↓ drug levels w/ barbiturates, rifampin, Tegretol & Dilantin
↑ drug levels w/ many antifungals, erythromycin, quinidine, Paxil & Prozac
AEs: HA, agitation, nervousness, anxiety, insomnia, n/v, dizziness & somnolence
Incidence of wt. gain, diabetes & dyslipidemia lowest of all SGA’s
R/F EPS & orthostatic hypotension low
NMS (Neuroleptic Malignant Syndrome) very rare
↑ R/F death in elderly same as other antipsychotics
Serotonin syndrome
a serious and can be fatal reaction with hypertensive crisis, hyperpyrexia, extreme agitation progressing to delirium and coma, muscle rigidity and seizures. (Altered mental status, dyscoordination, myoclonus hyperreflexia, overactive sweating, tremors & fever)
fluoxetine (Prozac)
Class: SSRI
MoA: Blocks reuptake of serotonin (5-HT) resulting in increased serotonin availability at synapses
Uses: MDD, BPD, OCD, panic disorder, bulimia, PMDD
Off label: PTSD, social phobia, alcoholism, ADHD, migraines, obesity, tourette’s
Admin: PO.
Considerations: Use w/ MAOIs increases r/f serotonin syndrome. Increases TCAs and Lithium drug levels. Incr. r/f bleeding w antiplatelets & anticoags
AEs: Sexual dysfunction, nausea, diarrhea, HA, excessive sweating, weight gain, & insomnia most common
Serotonin syndrome.
Withdrawal syndrome w/ abrupt DC (dizziness, HA, n/v sensory disturbances, tremors, anxiety & dysphoria)
If taken during last part of pregnancy, may cause AE’s in the newborn
Bruxism- clenching/grinding of teeth
Hyponatremia in older pts taking diuretics
Bleeding Disorders- R/F GI bleed increased 3-fold. Teach to avoid ASA/NSAIDS
As w/ all antidepressants, initially ↑ r/f suicide
venlafaxine (Effexor)
Class: SNRI
MoA: Blocks reuptake of 5-HT & NE + weak block of DA reuptake, resulting in increased availability at synapses
Uses: MDD, GAD, social phobia, panic disorder
Admin: PO, should be taken w food.
Considerations: Inrc. r/f serotonin syndrome w/ other antidepressants. Contraindicated w/ MAOIs.
AEs: Nausea, HA, anorexia, nervousness, excessive sweating, somnolence, insomnia & sexual dysfunction most common
Dose-Dependent Wt. Loss & HTN
Hyponatremia in older pts on diuretics
If used late in pregnancy, can cause neonatal withdrawal syndrome
Withdrawal syndrome with abrupt DC- Avoid by slowly tapering over several weeks
As w/ all antidepressants, initially ↑’d r/f suicide
imipramine/amitriptyline (Elavil)
Class: Tricyclic Antidepressant (TCA)
MoA: Blocks reuptake of 5-HT and NE resulting in increased availability at synapses
Also causes blockade of H1 and Alpha 1 and AcH receptors
Uses: Depression, BPD depressive symptoms, fibromyalgia, neuropathic pain, chronic insomnia, ADHD, panic disorder, OCD
Admin: PO at bedtime. Therapeutic effect in 1-3 weeks, mac effect in 1-2 months.
Considerations: Use w/ MAOIs = incr. risk for severe HTN.
Inhibition of Indirect-Acting Sympathomimetics (e.g. amphetamines, cocaine, tyramine)
Potentiation of Direct-Acting Sympathomimetics (e.g. epinephrine/NE, dopamine)
Potentiation of Anticholinergics
Potentiation of CNS Depressants
AEs: Sedation & orthostatic hypotension most common
Anticholinergic effects: dry mouth, constipation, tachycardia, blurred vision
Excessive sweating & hypomania
Dysrhythmias: obtain ECG before starting therapy
Seizures
As w/ all antidepressants, initially ↑’d r/f suicide
Monoamine oxidase inhibitor (MAOI)
Class: MAOI
MoA: Blocks enzyme that breaks down NE, 5-HT and DA to inactive substances, resulting in increased availability at synapses
Uses: Depression when all else has failed
Admin: PO & transdermal.
Considerations: Interacts w/ Most Meds & Tyramine-rich Foods & Drinks (most fermented foods, cheeses, cured meats, figs, avocados, soy & ETOH)
AEs: CNS Stimulation (anxiety, insomnia, agitation & mania)—d/t more availability of NE
Orthostatic Hypotension
Hypertensive Crises from Dietary Tyramine… severe HA, tachycardia, n/v, confusion, sweating—medical emergency!
bupropion (Wellbutrin)
Class: atypical antidepressant
MoA: Possibly blocks DA and/or NE reuptake resulting in increased availability at synapses
Does not affect serotonin, AcH or H1
Uses: MDD, SAD & smoking cessation
Off label: Neuropathic pain, BPD depressive symptoms & ADHD
Admin: PO.
Considerations: ↑ R/F Seizures w/ some SSRI’s: Zoloft, Prozac & Paxil
MAOI’s can ↑ r/f Wellbutrin toxicity
AEs: Agitation, HA, dry mouth, GI symptoms, dizziness, tremor, insomnia, blurred vision, tachycardia most common
Don’t use in pts w/psychotic disorders-can cause hallucinations & delusions
IMPROVES sexual function for many pts
In high doses → seizures
As w/ all antidepressants, initially ↑ r/f suicide
lithium (Lithobid)
Class: heavy metal & in-organic ion found naturally in body
MoA: Possibly helps prevent neuronal atrophy and/or promote neuronal growth
Uses: BPD: drug of choice to control acute mania & provide long-term prevention against recurrence
Admin: PO in 3-4 doses daily d/t short half life.
Considerations: Lithium excretion is ↓’d when serum NA is Low: teach importance of avoiding NA loss & staying well hydrated
Very Low Therapeutic Index (narrow therapeutic range) makes Toxicity a Big Concern: keep Plasma Drug levels within Therapeutic Range of 0.4-1 Not to Exceed 1.5
Interactions:
* ↑ R/F Lithium Toxicity w/ Diuretics
* ↑ R/F Lithium Toxicity w/ NSAIDS x ASA
* Avoid Anticholinergics d/t → urinary hesitancy & ↑↑ discomfort
AEs: When Lithium Levels WNL:
GI Effects (nausea, diarrhea, abd bloating & anorexia)
Transient fatigue, muscle weakness HA, confusion & ↓ memory
Tremors
Polyuria & thirst- Avoid excessive activity that would result in fluid loss.
Renal Injury
Goiter & Hypothyroidism
Teratogenesis
when Lithium Levels > 1.5:
Persistent GI upset, course hand tremors, ECG changes, confusion, muscle hyperirritability, tinnitus, blurred vision, seizures, ↓ BP, coma → death
valproate (Depakote)
Class: antiepeleptic/anticonvulsant
MoA: Unknown how it helps BPD. Possibly neuroprotective effects. Similar effectiveness as lithium with less AEs.
Uses: BPD: controls symptoms in acute manic episodes & prevents relapse of mania
Also used to treat migraines and seizures
Admin: PO & IV
Considerations: Incr. levels of dilantin and phenobarbital
AEs: GI upset (n/v/d & indigestion) & weight gain most common
Thrombocytopenia, pancreatitis, liver failure
Teratogenic: do not use in pregnancy
lorazepam (Ativan)
Class: benzo - anxiolytic, hypnotic
MoA: Potentiates action of GABA (the main inhibitory NT in the brain). Endogenous GABA causes decreased neuron firing resulting in decreased anxiety, increased sleep and muscle relaxation
Uses: Anxiety, insomnia, seizures, preop sedation, ETOH withdrawal, panic disorder, GAD
Valium (diazepam) often prescribed for muscle spasms
Admin: PO, IM, IV (be v cautious w/ IV admin). High lipid solubility–crosses BBB.
Considerations:
Tolerance Develops to Some but Not All Effects
Physical Dependence is Possible but Low
Interactions: ↑ R/F CNS Depression W/ CNS Depressants
AEs: CNS depression
Anterograde amnesia if not desired
Sleep driving/walking/talking
Paradoxical effects
Respiratory depression
Low Abuse Potential- Schedule IV of the CSA
Avoid in pregnancy & Nursing Moms
Withdrawal Syndrome often Mild (Anxiety, insomnia, sweating & tremors), but more Severe w/ Prolonged Use at High Doses (Panic attacks, paranoia, delirium, HTN & convulsions). Best to taper slowly
zolpidem (Ambien)
Class: benzo-like drug - hypnotic
MoA: Same as benzo
Uses: Short term tx of insomnia
Admin: PO & sublingual. Peaks in 2 hrs.
Considerations: Avoid taking w/ ETOH or other CNS depressants
AEs: Daytime drowsiness & dizziness most common
Sleep driving/talking/walking
Safety in pregnancy not established
Low abuse potential- Schedule IV of the CSA
zaleplon (Sonata)
Class: Benzodiazepine-like drug–Hypnotic
MoA: Same as benzo
Uses: Same as Ambien
Admin: PO - peak in 1 hour
Considerations: Avoid taking w/ ETOH or other CNS depressants
↑ R/F Toxicity w/ Tagamet
AEs: HA, Nausea, drowsiness, dizziness, myalgia & abd pain most common
Sleep driving/talking/walking
Low abuse potential- Schedule IV of the CSA
