PHARM 1 EXAM #4 Flashcards
Differentiate between the two groups of drugs: antipsychotics and anxiolytics
Antipsychotics = shh’s the brain from being/having it out of touch with reality
Anxiolytics = lysis anxiety
Two types of FGAs: Phenothiazines + Nonphenothiazines
Subtypes of Phenothiazines
chlorpromazine (Thorazine)
Side effects: strong sedation, severe orthostatic hypotension, moderate EPS, some antiemetic effect
fluphenazine (Prolixin)
Side effects: low sedation, strong antiemetic effect, severe EPS
Thioridazine HCl (Mellaril)
Side effects: sedation, few EPS, low risk of orthostatic hypotension, no antiemetic effect
Differences between treating psychosis vs. treating depression/anxiety
— When treating psychosis we block or antagonize the action of neurotransmitters.
— When treating depression (chapter 23) or anxiety we enhance the action of neurotransmitters.
What are the MAJOR side effects when taking Phenothiazines?
— Sedation
— Orthostatic HoTN
— EPS
— Antiemetic
these drugs lower seizure threshold = bad for epileptics
Thorazine used to tx persistent hiccups
Name the 4 neurotransmitters (NTs) targeted by psychopharmacologies agents are
- GABA — inhibitory; calms; lack —> anxiety
- Serotonin — sleep/wake cycles, mood, delusions & hallucinations; lack —> depression
- Dopamine — cognition, movement, emotion; lack —> Parkinson’s
- Norepinephrine — arousal, attention, vigilance, mood affect
Contrast the action, uses, side effects, and adverse effects of traditional/typical and atypical antipsychotics
What is depression?
A mood d/o that involves: A mood disorder that involves
— Depressed mood, despair, insomnia, hypersomnia
— Loss of interest in normal activities
— Fatigue, decreased ability to think
— Suicidal thoughts
___________________
Pathophysiology
— Insufficient amount of monamine neurotransmitters (norepinephrine, serotonin, dopamine) | want to INCREASE amount of NTs
________________
Other etiology
— Genetic predisposition
— Social and environmental factors
Types of Depression
Reactive
— Usually sudden onset resulting from precipitating event (e.g., death of a loved one)
Major
— Characterized by loss of interest in work or home
— Inability to complete tasks
— Deep depression
Bipolar
— most difficult to tx
— Mood swings between manic (euphoric) and depressive (dysphoria)
Herbal Supplements for Depression
Useful for _mild _depression
St. John’s wort
— Can decrease reuptake of the neurotransmitters serotonin, norepinephrine, and dopamine
Gingko biloba
— The use of these and many herbal products should be discontinued 1 to 2 weeks before surgery.
— The patient should check with the health care provider regarding herbal treatments.
Major Depression
— May be primary or secondary to a health problem
— Difficulty sleeping or excess sleeping
— Feelings of fatigue and worthlessness
Major Antidepressant Agents
Tricyclic antidepressants (TCAs)
Selective serotonin reuptake inhibitors (SSRIs) & Serotonin norepinephrine reuptake inhibitors (SNRIs)
— If we inhibit reuptake (stopping the reabsorption process), we actually INCREASE the availability NT in that synapse
Atypical antidepressants
Monoamine oxidase inhibitors (MAOIs)
— MAO = enzyme that breaks down the NTs (includes norepinephrine); increase amount of NT available by DECREASING its breakdown
TCA’s Action + Use
Action
— Blocks uptake of neurotransmitters norepinephrine and serotonin in brain
— Blocks histamine receptors
— Elevates mood, increases interest in ADLs, decreases insomnia
Use
Major depression and agitated depression
Examples
amitriptyline (Elavil)
iImipramine (Tofranil)
trimipramine (Surmontil)
doxepin (Sinequan)
desipramine (Norpramin)
nortriptyline (Pamelor, Aventyl)
protriptyline (Vivactil)
fluphenazine (Prolixin)
Action: Blocks dopamine receptors in brain
Use: Manages symptoms of schizophrenia
Interactions
— Increase depression when taken with alcohol or other CNS depressants; kava kava may increase EPS.
Side effects:
— Sedation, dizziness, headache, seizures
— Dry mouth, nasal congestion, blurred vision,
photosensitivity, urinary retention
— GI distress, peripheral edema, tachycardia, EPS
*Dopamine involved in regulation of cognition, emotional responses, and motivation
Administration:
— given IM in a slow release formulation q2-4 wks; very thick so Z-track in deep muscle to help prevent soreness/inflammation at injection site
— Oral liquid = cause contact dermatitis, so avoid contact with skin
Interactions + Side Effects +Drug Examples for taking TCA’s
Amitriptyline (Elavil)
Interactions
— Increased CNS effects with alcohol and other CNS depressants
— Increased sedation and anticholinergic effects with phenothiazines, haloperidol
Side effects/adverse reactions
— Sedation, dizziness, blurred vision, dry mouth and eyes, urinary retention, constipation, weight gain, GI distress, sexual dysfunction, seizures
— Orthostatic hypotension, dysrhythmias, EPS, blood dyscrasias
Greatest fear is the patient can now act on and is focused enough to carry out their suicide ideations
Use + Contraindications for Phenothiazines vs. Nonphenothiazines for Antipsychotics
Phenothiazines = fluphenazine (Prolixin)
Use: manages S/Sx of schizophrenia
Side effects:
— Sedation, dizziness, headache, seizures
Dry mouth, nasal congestion, blurred vision,
photosensitivity, urinary retention
GI distress, peripheral edema, tachycardia, EPS
Nonphenothiazines = Haloperidol (Haldol)
Use:
Treats acute and chronic psychoses, dementia
Treats schizophrenia
Treats Tourette’s syndrome
Contraindications:
Narrow-angle glaucoma
Sedation
Severe liver, kidney, and cardiovascular disease
Blood dyscrasias: High dosing or long-term use of some antipsychotics can cause or worsen blood dyscrasias
Extrapyramidal Syndrome (EPS)
Antipsychotic drugs are well known for evoking EPS in patients
Pseudoparkinsonism symptoms
— Stooped posture
— Masklike features
— Rigidity
— Tremors at rest
— Shuffling gait
— Bradykinesia
— Pill-rolling motion of the hand
Adverse Effects when taking TCA’s
Seizure threshold is decreased with TCAs
Most common adverse effects: orthostatic hypotension, sedation, anticholinergic effects anticholinergic (dry mouth, blurry vision, constipation); sedation; orthostatic hypotension; EPS.
Most dangerous adverse effect: cardiac toxicity; dysrhythmias; may increase risk of suicide early in treatment
SSRI’s Action + Uses + Drug Examples
Action
— Block uptake of neurotransmitter serotonin
Uses
— Major depression
— Anxiety disorders
—Obsessive-compulsiveness
— Panic
— Phobias
— Prevention of migraine headaches
Examples
fluvoxamine (Luvox)
fluoxetine (Prozac)
sertraline (Zoloft)
paroxetine (Paxil)
citalopram (Celexa)
escitalopram (Lexapro)
Anything that changes the brain chemistry, may now have multiple uses
Foods HIGH in K+
Lima beans, strawberries, potatoes
What are the advantages of taking an SSRI compared to taking TCA’s?
— SSRIs do not cause as much sedation, HoTN, anticholinergic S/Eff, not as cardio toxic compared to TCAs
— They also aren’t as harmful regarding overdosing when dealing with a suicide ideations patient
— Most SSRIs have stimulant properties, and hence can cause insomnia and agitation
— TCAs cause sedation
SSRIs Interactions + Side Effects
Interactions
— Increased CNS effects with alcohol and other CNS depressants
Side effects/adverse reactions
— Headache, nervousness, restlessness
— Insomnia, tremors, seizures
— GI distress
— Sexual dysfunction
— Suicidal ideation
Side effects often decrease over 1 to 4 weeks, so let the patient’s know this
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) Action + Use + Drug Examples
Norepinephrine is associated with control of arousal, attention, vigilance, mood, affect, and anxiety.
This transmitter is involved with thinking, planning, and interpreting
Action: Inhibit the reuptake of serotonin and norepinephrine, increasing these substances in nerve fibers
Use: Major depression as well as generalized anxiety disorder and social anxiety disorder
Examples
venlafaxine (Effexor)
duloxetine (Cymbalta)
desvenlafaxine (Pristiq)
SNRI Venlafaxine (Effexor): Side Effect + Adverse + Interactions
Venlafaxine (Effexor)
Side effects: drowsiness, dizziness, insomnia, headache, euphoria, amnesia, blurred vision, photosensitivity, and ejaculation dysfunction
Adverse effects: hyponatremia, bleeding, hypertension, angioedema, blood dyscrasias, suicidal ideation, and Stevens-Johnson syndrome
Interactions: concurrent interaction of venlafaxine and St. John’s wort may increase the risk of serotonin syndrome and neuroleptic malignant syndrome
Atypical Antidepressant Drug Examples
Primary use: major depression, reactive depression, and anxiety
Examples: amoxapine (Asendin), maprotiline (Ludiomil), nefazodone (Serazone), trazodone (Desyrel)
Action: affect one or two of the three neurotransmitters: serotonin, norepinephrine, and dopamine.
Interaction:
— Do not take with MAOIs and do not use within 14 days after discontinuing MAOIs
— Trazodone may have a potential drug interaction with ketoconazole, ritonavir, and indinavir that may lead to increased trazodone levels and adverse effects.
Monoamine Oxidase Inhibitors (MAOIs) Use + Action + Drug Examples
Make the NTs more available in the brain because will inhibit breakdown by inhibiting MAO
Big problem with these drug are the interactions therefore NEVER a 1st line option
Examples: tranylcypromine sulfate (Parnate), isocarboxazid (Marplan), selegiline (Emsam), phenelzine sulfate (Nardil)
Action: monamine oxidase enzyme inactivates norepinephrine, dopamine, epinephrine, and serotonin.
Use: depression not controlled by TCAs and second-generation antidepressants
The go drug IF suffering refractory depression, not being controlled with other medications
MAOIs Interactions
Drug interactions:
Vasoconstrictors and cold medications containing phenylephrine and pseudoephedrine can cause a hypertensive crisis when taken with an MAOI.
Food interactions:
Foods that contain tyramine
Some cheeses, cream, bananas, avocados, raisins, Italian green beans, liver, pickled foods, sausage, soy sauce, yeast, beer, and red wines, can cause a hypertensive crisis.
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Coffee (caffeine) does not contain tyramine, but intake should be limited to 2- 8 oz. beverages, because it can increase BP significantly when combined with MAO-Is.
Overripe fruits are higher in tyramine.
MAOIs Side/Adverse Effects
— Agitation, restlessness, insomnia
— Anticholinergic effects
— Orthostatic hypotension
Hypertensive crisis from fatal tyramine or drug interaction
Plan nursing interventions, including patient teaching, for the patient taking antipsychotics
and anxiolytics
Antidepressant Agents RN Interventions
— Monitor vital signs.
— Monitor mood for drug effectiveness.
— Monitor for suicidal tendencies, seizures.
— Warn that foods that contain tyramine can cause a hypertensive crisis with MAOIs.
— Encourage taking drug as prescribed.
— Encourage avoiding alcohol, CNS depressants, and cold medicines.
— Teach to take drug with food if GI distress occurs.
— Warn patient against driving or using dangerous mechanical equipment until drug effect is known.
— Warn patient against abruptly stopping drug
— Instruct patient to take drug at bedtime (may make you drowsy)
— Advise patient that a therapeutic response usually occurs in 2 to 4 weeks (but chemistry changes are effected immediately)
— Inform patient that herbs (e.g., St. John’s wort, ginseng) may interact with antidepressants.
Mood Stabilizers Drug Examples
Used to tx bipolar d/o for the switching of euphoria —> dysphoria, making it difficult to treat
Lithium (Lithibid)
Carbamazepine (Tegretol)
Divalproex (Depakote, Valproate)
Lamotrigine (Lamictal)
Olanzapine (Zyprexa)
Ziprasidone (Geodon)
Aripiprazole (Abilify)
Normally used in conjunction with an antidepressant
What is Bipolar Disorder?
Bipolar affective disorder was formerly known as manic-depressive illness.
Definition of bipolar disorder (BPD)
— Cyclic disorder
— Recurrent fluctuations in mood
— Episodes of mania and depression persist for months without treatment
In patients with bipolar depression, using an antidepressant alone may induce mania—although the risk appears lower than previously believed. Nonetheless, to minimize any risk mania, antidepressants should not be used alone; rather, they should be combined with a mood-stabilizing drug.
Mood Stabilizer: LITHIUM
LITHIUM (ESKALITH)
also known as an antimania drug, was the first drug used to manage bipolar affective disorder
Therapeutic serum range: 0.5 to 1.5 mEq/L
— Serum lithium levels greater than 1.5 to 2 mEq/L are toxic.
— Changes in fluid balance will alter these levels, making it hard to manage; Li+ follows Na+
Action
— Alteration of ion transport in muscle and nerve cells
— Increased receptor sensitivity to serotonin
Use
— Treat manic episodes in bipolar psychosis
Overhydrated = Lithium will be flushed = below therapeutic range = drug failure
Dehydrated = Lithium will be saved = will enter toxic ranges
