pharmacology 1 Flashcards
Antidepressant Administration Notes
can be taken with food to avoid GI distress
will need to be tapered to avoid withdrawals
– someone switching from a TCA to an MAOI will need two weeks washout (no TCA for two weeks), SSRIs have a low potential for overdose so can be prescribed in normal quantities
What is the usual first line antidepressant?
SSRIs
Antidepressant Assessment
blood pressure (hypotension), 1-2 weeks to start taking effect, 4-6 weeks for full effect (educate patient to be patient), usually sedating so be careful with driving and alcohol until you know how you handle it
SSRI suicide risk
lowest risk for suicide so they are dispensed in normal quantities
can cause an increased suicide risk in some patients, often they will be happy about it
slight increase in teens and young adults however its not statistically significant
Examples of SSRIs
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Sertraline (Zoloft)
Paroxetine (Paxil)
Fluvoxamine (Luvox)
SSRI adverse effects that affect compliance
sexual dysfunction and weight gain
SSRI adverse effects to monitor
withdrawal can occur, must taper drug to avoid syndrome
hyponatremia risk with thiazide diuretics
can alter bleeding avoid NSAIDs and aspirin
SNRI (serotonin norepinephrine reuptake inhibitors) Examples
Duloxetine (Cymbalta)
Venlafaxine (Effexor)
NASSAs Mechanism and Example
Increase norepinephrine and serotonin neurotransmission by blocking presynaptic alpha-2 adrenergic receptors & minimizing serotonin related side-effects by blocking certain serotonin receptors.
Mirtazapine (Remeron)
NDRIs
Inhibit the re-uptake of dopamine and norepinephrine
Bupropion (Wellbutrin, Zyban)
Bupropion (Wellbutrin, Zyban) Considerations and Other Uses
Hx of seizures - don’t exceed 300 mg
Seizure risk greatly increases if dose execeds 450 mg day
Also used for: smoking cessation, ADHD, alternative to stimulants
SARIs
Serotonin receptor antagonists and reuptake inhibitors:
Trazodone (Desyrel)
Higher does to treat depression (watch for hypotension) and lower doses for insomnia
Auvelity
Dextromethorphan/bupropion(DXM/BUP)
TCA Examples
Increases norepinephrine and serotonin levels but have more side effects than SSRI’s
Amitriptyline (Elavil)
Clomipramine (Anafranil)
Desipramine (Norpramin)
Imipramine (Tofranil)
Nortriptyline (Pamelor, Aventyl)
Trimipramine (Surmontil)
Doxepin (Sinequan)
Protriptyline (Vivactil)
TCA Side Effects
Orthostatic hypotension, cardiac dysrhythmias, contraindicated in recovery of MI
Anticholinergic effects not as severe as antipsychotics
Decreased seizure threshold
Tapered withdrawal
TCA Withdrawal Symptoms
nightmares, N&V, cold sweats, anxiety, akathisia
TCA Interactions
Do not use with MAOI: hypertensive crisis
Do not use with SSRIs: ↑ Serotonin syndrome
Take at night - sedating effect, best for insomnia/agitation
Generally not used for older adults due to increased fall risk
MAOIs Examples
Inhibit monoamine oxidase breakdown of serotonin and norepinephrine
Phenelzine (Nardil)
Tranylcypromine (Parnate)
Isocarboxazid (Marplan)
Selegiline (EMSAM0) transdermal patch
Generally reserved for non-responders to other antidepressants
MAOI Side Effects
Risk for hypertensive crises with TCA’s (2 week washout)
food containing tyramine cheese
Risk for serotonin syndrome with SSRIs
Hypotension
Taper dose to prevent withdrawal
Foods Containing Tyramine
to avoid cheese effect
Dairy: aged cheese and cultured products
Fruit & Veg: avocado, banana, fava
Meat: lunch meat, pickled or potted meat, dried fish
Any high-protein food that has been aged, fermented, pickled or smoked
Other: chocolate, licorice, sauerkraut, soy, yeast
Hypertensive Crisis S/S
Obviously – high BP
Sudden onset
Stiff neck, headache
Palpitations
Dilated pupils, photophobia
N & V
Diaphoresis
Chest pain
Drugs for Hypertensive Crisis
Phentolamine IV
Nifedipine S/L in ER
Trazadone (Desyrel)
is classified as an antidepressant but is commonly used to treat insomnia (18 and older)
Escitalopram (Lexapro) Off Label Use
generalized anxiety disorder
Fluoxetine (Prozac) Off Label Use
Obsessive-Compulsive Disorder (OCD)
Venlafaxine (Effexor) Is Approved For
FDA approved to treat GAD, Panic Disorder, and Social Anxiety Disorder
Serotonin Syndrome - Why Though
Caused by increased serotonin when things are combined, particularly with an SSRI
Other antidepressants
Lithium
Opioids
Other: copious caffeine, St. John’s Wort, migraine medication
Serotonin Syndrome - What Do
s/s: sudden onset of confusion, agitation, myoclonus muscle spasms, rigidity, diarrhea, increased HR, hyperthermia, changes in BP
Untreated – seizures, apnea, death
Interventions: inform PCP and stop meds
Treat symptoms: i.e., propranolol, anticonvulsants, induce paralysis
Cooling blankets
Anticholinergic Side Effects
Dry mouth
Blurred vision, photophobia
Tachycardia
Constipation: may need immediate medical attention
Urinary retention: may need immediate medical attention
Benzodiazepines administration
sublingual, PO or IV are used to prevent severe withdrawal, elevated VS, seizures, or DTs.
Often ordered on a ‘sliding scale’ based on CIWA scores/VS
benzodiazepines and opioids at the same time – high risk of respiratory depression
must be tapered to avoid withdrawals
antidote for benzodiazepine overdose
Flumazenil IV
Alcohol Withdrawal Medications
decreased ICU admissions phenobarbital used with benzodiazpines
phenobarbital use decreased readmissionin the first 3 days after discharged
phenobarbital instead of benzodiazepines shortened LOS length of stay on inpatient services
Carbamazepine (Tegretol)
(alcohol withdrawal) decrease risk for seizures
Clonidine (Catapres)
(alcohol withdrawal) reduces high HR and BP
Sedative and Hypotensive used to manage opioid withdrawal symptoms
Also used for chronic pain
DOES NOT REDUCE CRAVINGS
Taper dose at end of treatment to prevent withdrawal
Propranolol (Inderal)
(alcohol withdrawal) reduces high HR and BP and decreases cravings
Atenolol (Tenormin)
(alcohol withdrawal) reduces high HR and BP and decreases cravings
Acamprosate (Campral)
“relief cravers” (minimize withdrawal discomfort first few months), FDA approved specifically for alcohol use disorder treatment; alternative to off label use of Gabapentin (Neurontin)
Naltrexone(Revia)
Reduces effects and craving for alcohol
Used for Alcohol and Opioid Use Disorders
Disulfiram (Antabuse)
cause AcetaldehydeSyndrome when combined with alcohol use (aversion therapy), check liver function to avoid hepatotoxicity, effects can linger for 2 weeks after last dose
AcetaldehydeSyndrome
can cause death - wear a medical alert bracelet
Cardinal - facial flushing
nausea & severe vomiting (and thirst)
headache (throbbing)
tachycardia and cardiac palpations
Diaphoresis
Weakness and Vertigo
Can occur in people (Asian) who lack aldehyde dehydrogenase (breaks down alcohol)
Opioid Notes
Heroin is made from Morphine but is 3x stronger and is faster
Oxycodone (Percocet, Oxycontin) much stronger than hydrocodone (Vicodin, Norco)
Fentanyl is 50x more potent than heroin, cheaper to manufacture for illegal drug trade
Reverse opioid overdose
Naloxone(Narcan)
Methadone
Opioid Agonist, synthetic similar to morphine – long half life
Heroin/Opioid Replacement - has less euphoria and sedation, used in approved rehabilitation centers for manage opioid withdrawal symptoms and decrease cravings
taper at the end of treatment to avoid withdrawals
some people are methadone lifers
Buprenorphine (Buprenex)
Opioid partial agonist
Higher doses for detox, then maintenance dose of 4-24mg/day, prevents withdrawal and decreases cravings
Lower respiratory depression than methadone
Be aware of sound alike/look alike: Bupropion (Wellbutrin, Zyban) – different med
Suboxone
combines naloxone (Narcan) and buprenorphine
Naltrexone(Revia)
Blocks euphoria
Suppresses cravings
Used for Alcohol and Opioid Use Disorders
Bupropion (Wellbutrin, Zyban)
An antidepressant used to decrease S/S withdrawal
Decreases seizure threshold, avoid use in pts with seizure Dos
Varenicline (Chantix)
Increases dopamine (reword neurotransmitter)
Reduces cravings
Blocks nicotine effects
Decreases S&S withdrawal
Lithium effective for
Effective for symptoms of hypomania and mania: elation, grandiosity, flight of ideas, irritability, manipulation, anxiety – may take 7-14 days for full effect
lithium acts like
Acts like sodium – dehydration, diaphoresis, diuretics (hydrochlorothiazide), low sodium, and NSAIDS can cause lithium toxicity
lithium dosage
Dosage 300-600mg. BID-TID
Narrow therapeutic Index 0.6-1.5 mEq/L (some say 0.8 to 1.2)
Ideally – medication nurse documents daily on presence or absence of side effects and toxic effects (story geri-psych unit)
Titrate up to blood, higher end to control mania, lower end for maintenance
Need to obtain trough level (before AM dose)
maintain water intake
Lithium side effects
Reassure pts that these side effects usually resolve in time
Fine hand tremor
Polyuria
Mild thirst
Mild nausea – TAKE WITH FOOD to minimize GI irritation
Weight gain - because its acts like a salt
early lithium toxicity
Nausea
Vomiting
Diarrhea
Increased thirst
Increased polyuria
Lethargy
Slurred speech
Muscle weakness
advanced lithium toxicity (time to admit)
Coarse hand tremor
Persistent GI, Nausea and Vomiting
Confusion
Muscle irritability
EEG changes
Sedation
Poor coordination
severe lithium toxicity
“drunk sailor”
Worsening lack of coordination – ataxia, clonic movements
Increased EEG changes - seizures
Blurred vision
Giddiness and or stupor
Increased polyuria – dilute urine
Hypotension
Death secondary to pulmonary complications
lithium toxicity so bad you need dialysis
Oliguria (opposite of polyuria)
Seizures
Death
Anticonvulsants as Mood Stabilizers
Valproic acid (Depakene) & Valproate semisodium (Depakote)
Carbamazepine (Tegretol)
Lamotrigine (Lamictal)
Valproic acid (Depakene) & Valproate semisodium (Depakote) administration
BBW liver damage
regularly do ammonia level and valproic acid levels
Lamotrigine (Lamictal)
administration
Report rashes - usually benign - BUT Black Box Warning for Stevens-Johnson and other rash reactions that can cause death
