W5_Pharmaco_Somatic Flashcards
Classifications of Psychopharmacological Agents
1) Anti-psychotics (1st-gen, 2nd-gen), (typ, Atyp.)
2) Anti-depressants (TCA, MAOIs, SSRIs)
3) Mood Stabilizers (Lithium, Anticonvulsants, SSRI)
4) Anxiolytics & Hypnotics (BZD, non-BZD)
**1) Anti-psychotics **
- 1st Gen (Low Potency, High Potency)
- 2nd Gen (Atypical)
1st Gen Typical Anti-psychotics
- Works on blocking the Dopamine (D2) receptor antagonists
- Once administered, they travel to the brain and block dopamine D2 receptors in the mesolimbic pathway, thereby helping alleviate psychotic symptoms
Chloropromazine (CPZ), Largactil
Administering 1st-Gen anti-psychotics, typical,
low potency drugs.
What’s the drug name & considerations
- Low Potency, hence require a larger dose
Drugs: Chlorpromazine (CPZ) / Largactil
Highly sedating
Postural hypotension, dizziness, dry mouth, blurred vision, & difficulty in urinating.
(can cause water toxicity, advise patients to suck on ice cubes or drinks sips of water)
Note: Not commonly used these days as it is 1st Gen, but some doctors will still prescribe this in the hospital to make use of its sedating effect.
Name some of the commonly used 1st-Gen typical anti-psychotics
Chloropromazine (CPZ): Largactil
List some of the typical 1st-gen anti-psychotics (high potency drugs)
Haloperidol: Haldol
Trifluoperazine: Stelazine
Pipothiazine Palmitate : IM Piportil
Zuclopenthixol Acetate/Decanoate:** IM Clopixol**
Fluphenazine Decanoate: IM Modecate
Flupentixol Decanoate : IM Fluanxol
Administering 1st-Gen anti-psychotics, typical,
**high potency ** drugs.
What are the benefits over low potency drugs
High Potency, small amount to reach therapeutic effect.
Haloperidol
Trifluoperazine / Stelazine
Fluphenazine / Modecate
These groups produce least sedative & anticholinergic effects but
most Extrapyramidal Side Effects (EPSE)
Common side effects of anti-psychotics
**1) Anticholinergics **(blurred vision, dry mouth, constipation, urinary retention, increased ocular pressure)
**2) Sedation **(blockade of histamine receptors)
**3) CVS **
(orthostatic hypotension, arrhythmias, tachycardia)
4) Extra Pyramidal Side Effects (EPSE)
- Acute Dystonia
- Akathisia
- Dystonia
- Tardive Dyskinesia
- Parkinsonism
- Neuroleptic Malignant Syndrome (NMS), most severe form of EPSE
Treatment for EPSE
1) Congentine (IM) : Benztropine
- Given in acute condition, symptoms will improve after 15-20mins
2) Artane (Trihexyphenidyl)
- 1st occurence, inform doctor asap. Most commonly prescribed drugs.
3) Diphenhydramine (Benadryl)
- For cough, but also effective in treating EPSE side effects.
2nd-Gen Atypical Anti-psychotics
vs
1st Gen Typical anti-psychotics
what’s the difference in MOA?
1st Gen blocks Dopamine D2 receptor
2nd Gen Blocks both Dopamine & Serotonin (5HT2) receptor
2nd gen is more effective in treating the negative symptoms of Schizophrenia (5As)
What are the dosing considerations for 2nd-gen / Atypical anti-psychotics?
Start at a low dose. (atypical)
- if we start a high dose, it will have lots of side effects. - If the drugs does not work, doctor will switch to another drug.
What is the main benefit for switching over from 1st-gen anti-psychotics to 2nd-gen anti-psychotics?
**Improves positive symptoms **of schizophrenia patients.
Reduce the risk of Extrapyramidal side effects (EPSE) & Neuroleptic Malignant syndrome **(NMS) **
Contraindications for using 2nd-gen atypical anti-psychotics
CNS depression
Seizures
QT Prolongation
Fatal Myocarditis
Bradycardia
Cardiac Arrest
Avoid Alcohol
Severe Neutropenia
Side effects from 2nd Gen Atypical Anti-psychotics
Not totally free from side effects
Majority are dose-related
High dose = similar EPSE
Clozapine may develop agranulocytosis
Olanzapine may develop 100%** weight gain** or even Type 2 DM
Metabolic side effects: weight gain, increased blood glucose level, dyslipidemia, (scientist can’t explain why)
e.g., Patient gained 2x weight, in a few months.
Name the 3 Classes of anti-depressants, explain which is the 1st line of drugs given
1st line of treatment: SSRI
Selective Serontonin Reuptake Inhibitors
Fluoxetine (Prozac),
Sertraline Hydrochloride** (Zoloft)**
- Used for mood disturbances, altered cognition, anxiety, aggressiveness.
- SNRI are hardly used.
TCA are hardly used
Monoamine Oxidase Inhibitors (MAOIs) requires strict restriction of tyramine rich foods such as cheese, and fermented soy products.
When will MAOIs be considered?
When patient is not responding to TCAs, SSRIs and ECT
What is the MOA for anti-depressants
Anti-depressants help to increase
Helps to increase NE and SE in the brain.
Depression
- Decreased Norepinephrine (NE) &
- Decreased Serotonin (SE) levels in the brain
Treatment lag of 2-3 weeks
Some medications might take 4-6 weeks to reach its peak effect.
Different between typical and atypical depression
In typical major depression, your depressed mood is usually constant.
Typical depression often causes a loss of appetite and insomnia (difficulty falling and/or staying asleep)
Whereas atypical depression usually causes an increase in appetite & feeling sleepy despite sleeping enough or too much.
Side effects of Anti-depressants
(significant ones for each class)
MAOI: Avoid tyramine rich products, orthostatic
hypotension,
SSRI: Weight Loss, Loss of libido, insomnia,
TCA: Weight Gain & tachy, urinary retention, constipation)
Mood stabiliser
Helps in maintaining frequency of manic behaviour, mood swings and aggressive behaviour (more for bipolar patients)
Different Types of mood stabiliser:
- Lithium carbonate
Balance the serotogenic neurotransmission
- Carbamazepine (Anti-convulsant)
Blocks the nero-sodium channel (calms neurons) - Sodium Valporate (Anti-convulsant)
Enhancing serotogenic and reducing dopaminergic actions
Mood stabilizers,
Side effects
LITHIUM (0.8 to 1.2mEq/L)
Neurological: Slurred speech, hand tremor, poor memory, mental slowness
G.I. Effects – severe nausea, polyuria & thirst
Endocrine: Risk of hypothyroidism
Cardiovascular: ECG changes
Haematological Disorders – Leucocytosis
Patients can experience toxic effects with levels above 1.5 mEq/L such as marked tremor, nausea, muscle weakness and diarrhea, or blurred vision;
Levels above 2.0 mEq/L are have been associated with life-threatening side effects, such as neurotoxicity, delirium and encephalopathy
Dangerous levels of Lithium
Patients can experience toxic effects with levels above 1.5 mEq/L such as marked tremor, nausea, muscle weakness and diarrhea, or blurred vision;
Levels above 2.0 mEq/L are have been associated with life-threatening side effects, such as neurotoxicity, delirium and encephalopathy
First line treatment for mood stabilizers
Lithium is the first line treatment for mood stabilisers. Followed by sodium valproate (commonly used as well)
Carbamazepine not commonly used.
Any special considerations for the use of Anxiolytics and Hypnotics?
Which of the above to administer during AM and PM
Hypnotics should be administered at night.
Anxiolytics in the morning.
Both share many characteristics
Anxiolytics treats daytime tension but hypnotics relieve insomnia
Initially barbiturates were major hypnotic choice
In the 1970s replaced by benzodiazepine (BZP) Lesser adverse effects in overdoses
Concerns on rebound insomnia, withdrawal symptoms and abuse
Pharmacological treatment options for Insomnia
- Short acting BZP: Triazolam (Halicon)
- Intermediate acting BZP: Lorazepam (Ativan) (IV & IM for aggressive patients)
- Long acting BZP: Diazepam (Valium) (IV, PO etc.)
- Novel non-BZP: Buspirone (BuSpar)
- Sedating antihistamine:
Hydroxyzine Hydrochloride (Atarax) (Z drugs, Hypnotics)
The need should be reviewed at 2 to 4 months interval. (normally given to patients in 2 months interval to prevent dependence and abuse)
Name the 3 Different drug classes for Anxiolytics & Hypnotics
1) Antidepressants
- Usually SSRI
– Exert anxiolytic and sedative effects
– Insomnia or relieve anxiety
2) BZD
- Phobiam, sleep disorders, alcohol & drug withdrawl
3) Beta Blockers
- If anxiety is a/w somatic symptoms
What are the nursing implications for administering Anxiolytics & Hypnotics?
Nursing Implications
Give daily dose during bedtime (unless patients work during nighttime)
- promote more daytime activities.
- Observe for therapeutic effects
- Observe for adverse effects
- Over-sedation, hypotension, paradoxica excitement, e.g., hostility, confusion or hyperactivity.
- Monitor adverse effects from beta blockers
- Hypotension, bronchospasm, bradycardia
- Know that lorazepam can be given sublingually for rapid effect
- Instruct client not to use anxiolytics together with alcohol
- (minimally, wait for 2hours, or interval with 2hrs, avoid caffeine as well.)
Safety Precautions when administering atypical antipsychotics
Atypical Antipsychotics (Clozapine)
WBC monitoring (Once /week x 6 months),
risk of agranulocytosis
(Advice doctor to order FBC)
(Monitor, 1st 18 weeks in IMH)
When do we need to monitor their weight?
Patient is taking atypical antipsychotics such as Olanzepine, Clozapine, Quetiapine.
Significant weight can.
When do we need to start a fit chart?
Patient is taking:
Atypical antipsychotics: Clozapine
- dose related to seizure risk
Anxiolytics: Clonazepam
- Abrupt withdrawal precipitate status epilepticus.
Serotonin Syndrome
Also known as serotonin toxicity
May be a consequence of therapeutic medication use, accidental interactions between medications and recreational drugs, or an intentional overdose.
Usually caused by combing medications, e.g., an SSRI in combination with another medicine (or substance) that also raises serotonin levels, such as another antidepressant or St John’s wort.
Uncommon, range from mild to fatal, potentially life-threatening
Symptoms such as diarrhea hyperreflexia (greater in lower extremities), clonus (greater in lower extremities), autonomic instability (often hypertensive), diaphoresis, mydriasis, tachycardia, and agitation
Treatment for Serotonin Syndrome
Treatment:
1) discontinue serotonergic agents
2) supportive care to normalizing vital signs (including IV fluids & oxygen therapy)
3) sedation: chemical restraint (benzodiazepines) for delirious agitation
4) antidote only when supportive measures, and sedation are not adequate
