Psychopharmacology Flashcards
Mode of Action
What the drug does to the body
Mechanism of Action
How the drug works in terms of symptoms, cure of disease and the symptoms the drug does.
Most important neurotransmitters
Acetylcholine
Dopamine
Serotonin
Glutamate
Acetylcholine: 2 important subdivisions and important receptor
2 Subdivisions:
nicotinic and muscarinic cholinergic receptors
Important:
M1 postsynaptic receptor for mediating effect in memory function
Dopamine
Controls movement
Involved in pleasurable sensation, euphoria, delusions and hallucinations
Intervenes positive and negative psychotic symptoms
Release of prolactin, promotes breastmilk
What is the relationship between dopamine and acetylcholine?
Reciprocal relationship
Serotonin
Inhibitory catecholamine
Receptors start with “5-HT”
Intervenes with cognitive effects, emotions, pains, memory, anxiety, sleep-wake cycles and inhibits dopamine release.
Glutamate
Major excitatory neurotransmitter
Remission phase
Focuses on the return of baseline functions and no symptoms.
Maintenance phase
Prevents recurrence of illness
Increases pt functioning while decreasing symptoms
Recovery phase
Emphasizes individual growth and achievement despite having a mental illness.
Psychosis: 5 symptoms dimensions
Positive Negative Cognitive Function Impairment Aggressive and Hostile Depressive and Anxious
Conventional (1st generation) vs atypical antipsychotics (2nd generation)
1st generation: block D2 receptors
2nd generation: lower potential for EPS (extrapyramidal effects), does not affect negative and cognitive symptoms.
Antipsychotic Meds Indication
Schizophrenia & schizoaffective disorders
Delusional disorders
Adjunct therapy for Bipolar disorder
Antipsychotic Meds Goal of Therapy
Pt needs to follow through with long term care
What habit affects the absorption of antipsychotic meds?
Cigarette smoking increases drug metabolization and pts would require higher doses.
Antipsychotic Meds Clinical Use and Efficacy
Use the lowest dose for shortest time.
Positive symptoms are relieved within hours while affective symptoms takes 2-4 weeks to be relieved.
Cognitive and Perceptual symptoms take 2-8 weeks for response.
Negative symptoms take longer to respond.
Always start with 3-4 divided dose/day and wean down to 1-2 dose/day.
Serum level of monitoring indications
No response after 6 weeks
Severe or unusual adverse reaction
Physically ill, older adults and young children
Extrapyramidal Effects (EPS): 4 symptoms
Dystonia
Pseudoparkinsonism
Akathisia
Tardive Dyskinesia
Dystonia: when does it normally occur, what reverses it and what does it look like.
Occur in the initial treatment regimen
Reversed with IM diphenhydramine ( Benadryl) or benztropine (Cogentin)
Spasms of eye, neck, back, tongue or other muscles.
Pseudoparkinsonism: what reverses it and what does it look like.
Tx: reduce antipsychotic dose or change med, or oral antiparkinsonian agent
Decreased movements. muscle rigidity, resting hand tremor, drooling and masklike face and shuffling gait.
Akathisia: How does it look like and Tx.
Restlessness. pacing, rocking and inability to sit still.
Tx: Propranolol and benzodiazepam.
What do you monitor if the pt takes propranolol?
Monitor BP
Tardive dyskinesia and Tx
Severe abnormal movements of any voluntary muscle group that occurs after a long dopamine blockade
No effective Tx.
Tardive dyskinesia and EMS
When tardive dyskinesia occurs, decreasing the med dose worsens tardive dyskinesia but improves EMS.
Increasing dose improves tardive dyskinesia but worsens EPS.
Neuroleptic Malignant Syndrome (NMS)
MEDICAL EMERGENCY Decreased LOC, increased muscle tone and autonomic dysfunction (hyperreflexia, labile HTN, tachycardia, tachypnea, diaphoresis, and drooling) , Fever myoglobinuria, leukocytosis elevated creatine phosphokinase levels.
Neuroleptic Malignant Syndrome (NMS) Tx:
Discontinue antipsychotic meds
Hydrate with IV fluids
Give Tylenol and cooling blankets for Hyperthermia
IV Heparin for PE if PRN
Manage arrythmias
Monitor Renal Function
Give IV dantrolene (Dantrium), muscle relaxant
Possible dopaminergic drugs (Bromocriptine, amantadine)
Wait 1-2 weeks before restarting antipsych meds
Cardiovascular Side Effects
Postural hypotension, esp. older adults
Arrhythmias and Palpitations
Changes in QT intervals - monitor with EKG.
Low Potency Typical Antipsychotics
Sedation / Drowsiness Weight gain Photosensitivity Poikilothermic Galactorrhea and Gynecomastia
Haloperidol as a short-acting typical (Conventional) Antipsychotics
Used for short term symptoms of agitation.
Given IV and IM
Caution with elderly pts
Fluphenazine Deconate Injection
Long-Acting Injectible Typical Antipsychotics
Given IM or subQ
Feel effects within 48-96 hours
Haloperidol Decanoate Injection
Long-Acting Injectible Typical Antipsychotics
Deep IM
Given every 4 weeks
Clozapine: Drug Class, Mechanism of Action, Clinical Use
Atypical Antipsychotics
Not a first-line therapy due to agranulocytosis
High receptor affinity for D4 and 5-HT2
Used for refractory illness
Clozapine: Risks and Side Effect
Risk for Agranulocytosis- decrease or lack of agranulocytic WBCs. Side Effects: Sedation, Anticholinergic effects, orthostatic hypotension, weight gain, hypersalivation and risk for seizures.
Anticholinergic effects
Dry mouth Blurry vision Constipation Urinary retention Ejaculatory inhibition
Risperidone: Drug Class, Receptor, Clinical Use, Side Effects
Atypical Antipsychotics
Blocks dopamine (D2) receptors
Treats both positive and negative symptoms
Used for older pts and has few anticholinergic effects
Side Effects: insomnia, hypotension, agitation, headache and hyperthermia
Olanzapine: Drug Class, Receptor, Clinical Use, Side Effects
Atypical Antipsychotics
Greater D2 blocker and weaker D4 and a-adrenergic blockade
Treats both positive and negative symptoms of schizophrenia, monotherapy for bipolar
Side Effects: Sedation, anticholinergic effects, weight gain, adult onset DM, risk for seizures and hyperprolactinemia
Quetiapine: Drug Class, Receptor, Clinical Use, Safety
Atypical Antipsychotics
Multiple receptors
Treatment of schizophrenia
Monitor cholesterol and triglycerides for elevation
Ziprasidone: Drug Class, Receptor, Clinical Use
Atypical Antipsychotics
5HT and D2 antagonist, protects against EPS and inhibits norepinephrine reuptake
Treatment of acute agitation of schizophrenia
Ziprasidone: Contraindication, Side Effects
Contraindicated pts with heart problems
Increased risk of death with dementia-related psychosis
Take with food
Side Effects: GI discomfort, drowsiness, EPS, akathisia, dizziness, dystonia, hypertonia, tachycardia and postural hypotension, rash, fungal dermatitis, and abnormal vision and upper respiratory function.
Antidepressants: Indications
Major Depression Anxiety OCD Panic Bulimia Anorexia PTSD Bipolar Social Phobia IBS Enuresis Neuropathic pain Migraine headache ADHD Smoking cessation Autism
Downregulation of Antidepressants
Increased neurotransmitter in synapse but less neurotransmitter in synapse
Major Classes of Antidepressants
Selective Serotonin Reuptake Inhibitor (SSRIs)
Tricyclic Antidepressants (TCAs)
Monoamine Oxidase Inhibitors (MAOIs)
Selective Serotonin Reuptake Inhibitor (SSRIs): Receptor and efficacy
First-line treatment of antidepressants
Inhibiting reuptake of 5HT
Efficacy depends on pt’s tolerance to adverse effects and cost
Serotonin Syndrome
Life threatening due to interactions with other drugs Confusion Hypomania Restlessness Myoclonus Hyperreflexia Diaphoresis Shivering Tremor Diarrhea
Serotonin Syndrome Tx
Discontinue med that increases serotonin
Suppoertive measures
Selective Serotonin Reuptake Inhibitor (SSRIs): Side Effects
Side effects are most severe beginning of tx GI upset Insomnia restlessness irritability headache Sexual dysfunction EPS Not lethal with overdose
Tricyclic Antidepressants (TCAs): Receptor, Side Effects
Second-line therapy
Blocks reuptake of 5-HT and norepinephrine
Anticholinergic side effects, Orthostatic hypotension
Tricyclic Antidepressants (TCAs): Monitoring parameters
Take at bedtime because of sedative effect
Use EKG before therapy - possible cardiotoxicity
Risk of fatality with overdose
Avoid with elderly pts
Monoamine Oxidase Inhibitors (MAOIs): Mode of Action, Efficacy
Block enzyme for degrades norepinephrine, serotonin and dopamine.
Increases postsynaptic downregulation
Used as last resort, resistant to TCAs
Rapidly absorbed and half-life is 24 hours
Monoamine Oxidase Inhibitors (MAOIs): Contraindication
Cerebrovascular defects Cardiovascular disease Pheochromocytoma - tumor in adrenal medulla Pregnancy Older than 65yrs old
Monoamine Oxidase Inhibitors (MAOIs): Hypertensive Crisis, Symptoms and Tx
MAOIs inhibit monoamine oxidase, they decrease the breakdown of tyramine from ingested food, thus increasing the level of tyramine in the body. Excessive tyramine can elevate blood pressure and cause a hypertensive crisis
Symptoms include: Headache, Stiff neck, Sweating, Nausea and vomiting,
Treatment: Nifedipine, and Monitor vital signsq10-15 min
Monoamine Oxidase Inhibitors (MAOIs): Dietary Restrictions - Prohibited
Aged cheese, ripe avocados
- Ripe figs, anchovies, bean curd
- Broad beans, yeast, liver
- Deli meats, pickled herring
- Meat extracts, fermented foods
- Chianti and sherry
Monoamine Oxidase Inhibitors (MAOIs): Dietary Restrictions - Moderate Use:
Cottage cheese, cream cheese
- Yogurt, sour cream
- Coffee, chocolate
- Spinach, raisins, tomatoes, eggplant
Monoamine Oxidase Inhibitors (MAOIs): Restricted Use
Anti-asthmatics Antihypertensives Epinephrine Allergy, hay fever decongestants Cough and cold products Buspirone Meperidine SSRIs Yohimbine
Monoamine Oxidase Inhibitors (MAOIs): Side Effects and Toxicity
Orthostatic hypotension Edema Sexual dysfunction Weight gain Insomnia Confusion and feeling drunk is excessive dose
Monoamine Oxidase Inhibitors (MAOIs): Pt Teaching and Nursing Responsibilities
Teach pt and family about foods to avoid, - give handouts
Teach pts not to take any additional medication without consulting HCP, Dentist and Pharmacist
Teach pt about hypertensive crisis and toxicity
Wait 5 weeks before starting MAOI after discontinuing fluoxetine.
Must be tapered, do not stop abruptly
Other Antidepressants
Venlafaxine (Effexor) – Serotonin-norepinephrine reupdate inhibitor (SNRI)
Nefazodone -
Trazodone – Serotonin modulator
Bupropion – Aminoketone (related to tricyclic, tetracyclic and SSNRI)
Mirtazapine - Noradrenergic and specific serotonergic antidepressant
Saint John’s Wort
Time Course of Antidepressants
1st wk: decreased anxiety, improved sleep, pt unaware of changes
1-3 wk: increased activity, sex drive, and self-care abilities, improved concentration and memory and psychomotor retardation resolves
2-4wks: relief of depressed mood, less hopeless, and suicidal ideation subsides
Antidepressants with kids
Can increase suicidal thinking and behavior
Can happen in adults as well but monitor the kids
Mood Stabillizers
Lithium Valproate Carbamazepine Oxcarbazepine Lamotrigine Topiramate Gabapentin Tiagabine Zonisamide Levetiracetam
Lithium: Indication and Risks
Treatment for bipolar mania and depressed episodes
Narrow therapeutic range
Risk for toxicity in older pts
Combine with valproate as first line tx
Lithium: Pt Teaching and Nursing Responsibilities
Monitor blood serum level to avoid adverse effects
Monitor renal function, thyroid function, urinalysis, CBC with differentials, serum electrolytes, ECG and weight.
Pregnancy test to women on child bearing age
Teach pt the side effects of lithium and potential drug interactions
Monitor fluid intake
Avoid salt-restricting diet
Lithium: Side effects within therapeutic range
Fine tremor Nausea, vomiting, diarrhea Mild polydipsia, polyuria Lethargy, muscle weakness Weight gain Increased WBC Acne, alopecia Hypothyroidism
Lithium: Side effects and range of Moderate toxicity
Lithium level >1.5 mEq/L
- Coarsening of tremor
- Worsening GI symptoms
- Confusion, slurred speech
- Sedation, lethargy
Lithium: Side effects and range of Severe toxicity
Lithium level >2.5 mEq/L RISK FOR PERMANENT NEUROLOGIC IMPAIRMENT - Arrhythmias - Bradycardia - Myocarditis - Seizures - Coma - Death
Rapid cycling bipolar
4 or more mood disorder episodes within 12 months
Valproate: Drug class, indication and compare to lithium
Anticonvulsant med
First line tx of rapid cycling bipolar
Minor side effects and wider therapeutic range than lithium
Valproate: side Effects
Sedation GI distress Benign transaminase elevation Osteoporosis Tremor Hair loss Increased appetite Weight gain
Valproate: Pt teaching and nursing responsibilities
Monitor baseline liver functions and signs of hepatoxicity
Severe vomit, monitor serum amylase level and evaluate for pancreatitits
Take at bedtime
Anticoagulation therapy, monitor for clotting function
Monitor hepatic function and CBC every 6 months
Teach pt side effects, risks and what to look for
Carbamezepine: Drug class, Indication
Anticonvulsants
Tx of acute bipolar mania
second-line treatment for bipolar disorder
Does not reach steady state until 4 weeks after initial therapy
Carbamezepine: toxicity
Dizziness Ataxia Sedation Diplopia Stupor Coma Tx: gastric lavage and symptom management
Carbamezepine: Pt teaching and Nursing responsbilities
Effects does not show until 4 weeks after initial dose
Monitor CBC and liver function test every 2 weeks
Teach pts to monitor for signs and symptoms of hematologic and hepatic abnormalities
Teach pt to call HCP when rash occurs
Oxcarbazepine
Treatment for bipolar disorder
Alternate tx to carbamazepine
Risks for hyponatremia esp with older adults
Decreases T4 hormone in thyroid
Lamotrigine
Treatment for rapid cycling bipolar disorder
Reduce the dose of lamotrigine by half if taken with valproate
risks for steven johnson syndrome
Topiramate
Adjunctive therapy for seizures
Treatment for binge eating, bulimia, cluster headache, Tourette’s syndrome and trigeminal neuralgia
Risk for acute myopia and glaucoma
Caution with renal impairment pts and avoid pts with glaucoma
Risk for anemia
Tx of Mania
Use of mood stabilizer
For agitation, benzodiazepine can be added to initial tx
Bipolar pt with depression
Avoid TCAs
Monitor pt because antidepressant can cause pt to have mania
Tx of Generalized Anxiety Disorder
Antidepressant
Benzodiazepine - rapid onset
Buspirone - longer onset
Benzodiazepine Advantages
Rapid onset
Benzodiazepine Disadvantages
Cognitive impairment
Decreased coordination
Potential Drug Abuse
Withdrawal symptoms
Benzodiazepine Drug Names
Clonazepam
Lorazepam
Alprazolam
OCD meaning
Persistent and recurrent thoughts, images, impulses and behaviors that are distressing to the individual and impair daily function
OCD Tx
Antidepressants: SSRIs and clomipramine Cognitive Behavioral Therapy Dopamine-blocking agents: Haloperidol Busipirone Lithium Clonazepam
PTSD
Recurrent life symtoms in response to very serious life events
PTSD Tx:
Antidepressants: SSRIs
Benzodiazepines: Clonazepam
Mood stabilizers
Social Phobia
Most common anxiety disorder
Strong persistent anxiety that results from fear of scrutiny by others, embarrassment or humiliation
High incidence with alcohol abuse and depression
Social Phobia Tx:
Antidepressant: SSRIs Benzodiazepine: Clonazepam and alprazolam Gabapentin Kava Kava Valerian
Pt Education for Anxiety
Educate pt that anxiety is a treatable illness
Educate about different types of medications, side effects, precautions and contraindications
Encourage pt to be part of decision making
Meds take several weeks to achieve maximum effects
Advise pt regarding drug-drug and drug-herb interactions
Encourage nonpharmacologic interventions
Caution pts with mixing alcohol with drinks, avoid driving or operating machinery
Insomnia Medication
Hypnotics: benzodiazepine Nonbenzodiazepine hypnotics Trazadone - avoid alcohol Chloral Hydrate - avoid alcohol Diphenhydramine - tolerance in 2 weeks and avoid in older adults Melatonin - Avoid with other CNS drugs Barbituates Kava Kava Valerian
benzodiazepine for insomnia
Triazolam - Difficulty falling asleep
Temazepam - awakens early who cannot stay asleep
Flurazepam - difficulty falling asleep and staying asleep. Possible rebound insomnia
Nonbenzodiazepine for insomnia
Zolpidem - limit to 7-10 days and reevaluate pt
Zaleplon - For middle night to early morning, dizziness and headache
Eszopiclone -
Rozarem
Trazodone insomonia
SSRI
For pts undergoing drug and alcohol detox
Side effects: sedation, orthostatic hypotension and priapism.
Aggressive and Violent Behaviors
Sedate and calm pts and prevent self-harm or harm to others
Treat chronic aggressive behaviors
Acute Agitation and Aggression
Antipsychotics: Haloperidol Ziprasidone Quetiapine Risperidone Olanzapine
Benzodiazepines
Traozodone
Chronic Aggression
Schizophrenia: Antipsychotics
Mania: Lithium & Valproate
Seizure disorder: Carbamazepine & Valproate
Older adults: Trazodone
