Psychopharmacology Flashcards
Signs and Symptoms of Serotonin Syndrome
Mild: Nervousness, insomnia, nausea/diarrhea, tremor, big pupils
Moderate: hyperreflexia, sweating, agitation/restlessness, inducible clonus, side-to-side eye movements
Severe: fever >38.5C/101.3F, confusion/delirium, sustained clonus/rigidity, rhabdomyolysis, Death
Nursing Interventions of Neuroleptic Malignant Syndrome?
life threatening, sent out for clearance…
What are the risks of the following drug interaction:
-SSRIs (i.e. fluoxetine) and warfarin
• MAOIs (phenelzine, tranylcypromine) and tyramine
• Lithium and NSAIDs
• Lorazepam and sertraline
• Serotonin modulators enhance effects of other serotonin modulators
- bleeding
- hypertensive crisis
- lithium toxicity
- sedation?
- serotonin syndrome
Examples of Selective Serotonin Reuptake Inhibitors (SSRIs)
- citalopram (Celexa)
- escitalopram (Cipralex) *
- fluoxetine (Prozac)
- fluvoxamine (Luvox)
- paroxetine (Paxil)
- sertraline (Zoloft) *
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
- desvenlafaxine (Pristiq)
- duloxetine (Cymbalta)
- levomilnacipran (Fetzima)
- venlafaxine (Effexor) *
Tricyclic Antidepressants (TCAs)
- amitriptyline (Elavil)
- clomipramine (Anafranil)
- desipramine (Norpramin)
- doxepin (Sinequan )
- imipramine (Tofranil)
- nortriptyline (Aventyl)
Monoamine Oxidase Inhibitors (MAOIs)
- moclobemide (Manerix) – reversible inhibitor of MAO
- phenelzine (Nardil) – irreversible inhibitor of MAO
- tranylcypromine (Parnate) – irreversible inhibitor of MAO
Mood Stabilizers
- Lithium (Carbolith, Lithmax )
- carbamazepine (Tegretol)
- divalproex (Epival)
- gabapentin (Neurontin)
- lamotrigine (Lamictal)
- valproic acid (Depakene)
What is first line treatment for acute mania, acute depression and maintenance treatment in Bipolar Disorder?
Lithium
Quetiapine
1st line in acute mania, acute depression and maintenance therapy
• Quetiapine, aripiprazole, risperidone, asenapine - used in combination with mood
stabilizers for faster onset in the management of acute mania
• Treat concomitant psychotic symptoms and rapidly help with agitation
First line treatment for most anxiety disorders?
antidepressants
Types of anxiolitics?
buspirone
benzodiazepine
What are signs and symptoms of discontinuation syndrome?
F lu-like symptoms I nsomnia N ausea I mbalance S H yperarousal
Common Side effects of SSRIs?
GI upset, dry mouth, insomnia, somnolence, headache, sexual dysfunction, sweating, agitation, anorexia, increased bleeding risk (with drug interactions), SIADH with hyponatremia, glaucoma, falls risk
(paroxetine is most anticholinergic and caution: discontinuation syndrome)
Common Side effects of SNRIs
Similar to above; sleep disturbances, nausea, agitation, as dose increases: increased BP&HR, caution: discontinuation syndrome especially with venlafaxine)
Common Side effects of NDRI, ex. bupropion (Wellbutrin) - Norepinephrine-Dopamine Reuptake Inhibitor (NDRI)
Insomnia, tremor, sweating, anxiety, decreased appetite, increased risk of seizure
Common Side effects of SARI, ex. trazodone (Desyrel) - Serotonin Antagonist Reuptake Inhibitor (SARI)
Sedation, dizzy, falls/fracture risk; decrease BP (alpha blockade)
Common Side effects of NaSSA, ex. mirtazapine (Remeron)* - Noradrenergic and Specific Serotonin Antidepressant?
Sedation, increased weight, edema, anticholinergic → dry mouth
Common Side effects of TCAs?
Anticholinergic effects (dry mouth, blurred vision, constipation, urinary retention →nortriptyline generally better tolerated), sedation, increase weight, sexual dysfunction, confusion, increase HR, decrease BP, falls risk, cardiac arrhythmias, potentially fatal in overdose
Common Side effects of MAOIs?
Decreased BP, drowsiness, anticholinergic effects, weight gain, sexual dysfunction (less with moclobemide), drug-food interactions (tyramine) → hypertensive crisis
Common side effects of lithium?
- N/V/D
- polyuria, polydipsia
- fatigue
- weight gain
- hand tremor
- alopecia
- acne, psoriasis
- hypothyroidism
- hyperparathyroidism, increased calcium
- increased potassium
- increased SCr, renal impairment
- cardiac effects
- leukocytosis
What and when to monitor when taking lithium?
- SCr
- CBC
- weight
- TSH
- ECG
- lytes
- Ca++
- 12-hour post dose serum levels (5 days after initiating therapy or change in therapy)
What are signs and symptoms of mild, moderate and severe lithium toxicity?
➢ Mild: GI upset (diarrhea, vomiting), confusion, agitation,
muscle weakness, fatigue, fine hand tremor, slurred speech
➢ Moderate: lethargy, nystagmus, course hand tremors, fluctuating LOC
➢ Severe: seizures, organ failure, coma, death
What factors effect lithium concentration?
- hydration status
- salt intake
- renal function
- drug interactions
Common side effects of carbamazepine (Tegretol)?
N/V, drowsiness, blurred vision, menstrual irregularities Rare: aplastic anemia, severe skin reactions (esp. in Asian population)
LOTS of drug interactions!
Common side effects of divalproex (Epival) & valproic acid (Depakene)?
Prodrug of valproic acid, divalproex usually less GI issues than valproic acid
N/D, weight gain, dizzy, ataxia, alopecia, menstrual disturbances
Rare: pancreatitis, decreased platelets, decreased WBC, teratogenic defects
Common side effects of gabapentin (Neurontin)?
N/V, Dizzy, ataxia, nystagmus, blurred vision, weight gain
Common side effects of lamotrigine (Lamictal)?
N/V, dizzy, ataxia, diplopia,
Rare: Stevens-Johnsons rash and toxic epidermal necrolysis)
Common side effects of benzodiazepine?
- headaches
- confusion
- ataxia
- daytime drowsiness
- risk of falls
- withdrawal upon discontinuation
- “Rebound” phenomenon
Nursing management of Serotonin Syndrome?
- Stop presumptive causative agent(s)
- Refer patient to hospital
- Provide supportive care
- Control agitation, hyperthermia, HR, BP
- Use 5-HT2A antagonists (i.e. cyproheptadine)
First generation (typical) antipsychotics?
haloperidol, chlorpromazine
Second generation (atypical) antipsychotic?
risperidone, olanzapine
Third generation anti
aripiprazole, brexpiprazole
What antipsychotics can be used for acute agitation?
haloperidol, loxapine, olanzapine, risperidone, zuclopenthixol acetate (Acuphase)-not a chemical restraint
Key differences between side effect profile of typical and atypical antipsychotics?
Typical (D2 antagonism): more EPS, edocrine effects
Atypical: Metabolic S/E, depression, anxiety
Acute dystonic crisis treatment?
anticholinergics: benztropine, diphenhydramine
benzos
Akathisia treatment?
Reduce dose
Stop/switch antipsychotics Anticholinergic ?
Propranolol
Benzodiazepines
Tardive dyskinesia treatment?
stop anticholinergic, discontinue antipsychotic
switch to atypical or clozapine
Pseudoparkinsonism (Resting tremor (pill-rolling) Cogwheel rigidity Bradykinesia
Salivation
Stooped posture Shuffling gait) treatment?
Reduce dose
Stop/switch antipsychotics Anticholinergic for rigidity
daily Propranolol
Signs and symptoms of NMS?
muscle rigidity, fever and acute change in mental status – Autonomic Dysfunction (tachycardia, tachypenia, incontinence )
– Altered consciousness
Treatment-resistant schizophrenia?
failure of an adequate trial of at least 2 different APs
Clozapine monitoring guidelines?
Bloodwork:q weekly, q14 days, q28days
Bowel monitoring: 1st line lactulose, PEG, 2nd line stimulants (sennosides, bisacodyl)
caution: – Fiber and bulk-forming products (i.e. psyllium, inulin fiber, etc.) -Can worsen constipation/cause impaction in patients with underlying dehydration
– Use with caution
Signs and symptoms of clozapine-induced myocarditis?
chest pain, rapid or abnormal HR, dyspnea, fluid retention/ fatigues, s/s of viral infection (headache, joint pain, fever, sore throat, diarrhea)
Life-threatening side effects of clozapine?
agranulocytosis, constipation, myocarditis
What medication is used to reduce alcohol consumption…
naltrexone
