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75 Cards in this Set
- Front
- Back
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response to antidepressants wk 1-4
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wk1-red. anxiety, imp. sleep
wk1-3-increased activity, self-care, sex drive, concentration, memory, lower psych motor retardation wks2-4- relief of depressed mood, dec. hopelessness, SI subsides |
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SSRIS
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first line for depression b/c of safety and favorable a.e. profile. no fatality assoc. w/ od.
Approved for depression, panic, ocd,ptsd, bulimia, social phobia -citalopram (celexa) -escitalopram (lexapro) -fluvoxamine (luvox) paroxetine (paxil) fluxetine (prozac) s.e.-mild. Become tolerable w/ time. -gi upset, insomnia, restlessness, sex. dyf.- if bad consider switching to bupropion or nefazondone -EPSE must titrate off-withdrawl synd |
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serotonin syndrome
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rapid onset, too much serotonin
-high doses or not enough wash out between ssri/tca and maoi -confusion, restlessness, hyperreflexia, shivering fever, diarrhea, hypomania, myoclonus, diaphoresis, tremor, elevated BP Tx:d/c med causing increase -supportive measures: cooling blanket, bzds, anticonv, antihypertensives wash out persiod for SSRIs is 5 wks |
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citalopram (celexa)
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SSRI
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fluvoxamine (luvox)
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SSRI
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fluoxetine (prozac)
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SSRI
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paroxetine (paxil)
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SSRI
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sertraline (zoloft)
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SSRI
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TCA's
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have unfavorable s.e. are 2nd line therapy for depression. They block reuptake of serotonin and norepinephrine
TCAs work on other receptors that contribute to s.e.-antihistaminic, anti-cholinergic, effects on cardiac conduction s.e.-dry mouth, blurred vision, gi upset, constipation, urinary retention, confusion. Desipramineand nortriptyline have least intense anticholinergic effects. All TCA's are very sedating, usually take at HS.EKG recommended before start. OH precautions, fatality with od. monitoring therapeutic blood levels is useful to confirm admin dose is maintaining serum drug conc. w/ effective range. Avoid TCAs in elderly |
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Amitriptyline (elavil)
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TCA
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clomipramine (Anafranil)
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TCA
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desipramine (norpramin)
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TCA
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imipramine (tofranil)
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TCA-modification of chlorpromazine (anti-psych)
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Nortriptyline (aventyl)
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TCA
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Protriptyline (vivactil)
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TCA
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trimipramine (surmontil)
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TCA
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Phenelzine (Nardil)
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MAOI
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Tranylcypromine (parnate)
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MAOI
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Selegiline (EMSAM patch)
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MAOI
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MAOIs
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Iproniazid-drug to tx TB in 1950s-was an MAOI. some pts became euphoric-lead to using MAOIs as anti-depressants
use of these is limited because of potency of s.e. and strict dietary modifications needed. mode-norepinephrine, serotonin and dopamine are monoamines. these are synth in presynpactic neuron. Maintenace of cellular homeostatis requires a mechanism to degrade monoamines. Monamine oxidase helps degrade these amines. MAOIs inhibit this enzyme-incr. availability of these neurtransm and results in postsynaptic receptor down-regulation. Used in Tx of atypical depression, MD w/ melancholia or depressive disorders resistant to TCAs. Hypersomnia, hyperphagia,anxiety and absence of vegetative symp characterize atypical dep. contranidications-not good for older ppl, cerebrovascular defects, major CVD, pheochromocytoma. MAOIs sometimes worsen symp of parkinson's disease,induce mania states in bipolar pts, and exacerbate psychotic symp in pts w/ schiz.pts with diabetes req. adjustment of hypoglycemic medications. Contrainindiacted in pregnancy. titrate dose initially s.e.-OH,edema, sex dyf., anticholinergic effects sometimes MAOI induced pyridoxine (vitB6) deficency causes pareshesias-treat with oral pyridoxine |
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MAOIs foods to avoid
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tyramine restricted diet and avoid stim.meds to prevent risk of potentially fatal, hypertensive crisis.
prohibited: aged cheese, ripe avacados, ripe figs, anchovies, bean curd, broad beans(fatal-dopamine), yeast extracts, liver, delicantessan meats, pickled herring, meat extracts,fermented foods, chianti and sherry allowed w/ moderation: beer, ale, white/distilled spirits, cottage chz, cream chz, coffee, chocolates, soy sauce, yogurt, sc, spinach, rasins, tomatoes,eggplant, plums. must maintina dietary restrictions for two wks after d/c MAOI |
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MAOIs hypertensive crisis
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s/s:headache, stiff neck, sweating, N/V
Tx: rifedipine (procadia) 10 mg-watch for stevens-johnson syndrome-very rare a-adren blocker: chlorpromazine (Regitine) |
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MAOIs drugs to avoid
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antihistamines-theophyllaline and inhalers containing epinephrine or B-agonists (albuterol)
antihypertensives-mothyldopa,guanethiaine reserpine anesthetics w/ eminephrine allergy,hay fever, cough and cold products, decongestants, diet pills buspar meperidine (demerol) SSRIs yohimbine |
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duloxetine (cymbalta)
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SNRI approved for tx of MD in adults and diabetic neruopathy
s.e.:fatigue, drowsiness, insomnia, decreased app, constipation,dry mouth |
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venlafaxine
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SNRI.unlike TCAs, doesnt cause a.e. such anticholinergic and antihistamine s.e.-doesnt affect those receptors.pts with less than optimal resp to an ssri use it.
not with mellaril, incr BP,blindness s.e.gi upset, more in older ppl. increased BP-dose related, insomnia,restlessness, headache, irritability |
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trazodone
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SSRI. it blocks serotonin receptors. has sedative effects. used as agent for insomnia.
s.e.-sedation, postural hypotension, priapism |
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bupropion (wellbutrin)
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inhibitory effects on dopamine and norepinephrine reuptake and lesser effect on serotonin reuptake. (NDRI)
s.e.-nervousness, headache,insomnia, seizure risk, dystonia. -useful in reducing cigarette smoking and alcohol/drug detoxification and rehabilitation -zyban |
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mirtazapine (remeron)
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increased both norpinephrine and serotonin in the synapse. also blocks serotonin receptors.
s.e. sedation and wt gain. sedation more prominent w/ lower dose. constipation rare-neutropenia, agranulocytosis, hepattoxicity,get CBC and liver function tests. can be used for presurgical anxiety less sex dysf |
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nefazodone (serzone)
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tx of MD in conjunction w/ psychotherapy
inhibits reuptake of serotonin ane norep, antagonizes alpha1-adrenergic receptors s.e. dizziness, insomnia, somnolence,constipation, dry mouth |
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Tx of Bipolar
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mood stabilizers
may also need anti-anxiety agents, anti-psychotics, anti-depressants, anti-convulsants |
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what can be prescribed for refractory depression?
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lithium
must monitor blood levels |
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ppl with low thyroid function often exhibit symptoms of what?
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depression
evothyroxin(t4) is used and some pts require combo therapy that includes anti-depressants |
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TCAs mode of action
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partially block reuptake of norep &serotonin. Results in increased amt of neurons in synapse, which reduces number of receptors on post-synaptic membrane. This is called down-regulation.
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lithium
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has anti-manic, anti-psych and anti-D activity-but more effective in tx of pure mania and less effective in tx of mixed state mood disorder
usually first choice mood stabilizer. stops 80% of acute manic or hypomanic episodes in 10-21 days, 10% do not resp to lithium initially give antianxiety and antipsych to prevent exhaustion and coronary collapse until lithium starts working (7-14d) serum levels measured q3-4d until therapeutic response then wkly then monthly blood levels must be drawn 12h after last dose or false high readings tx acute mania and dep episodes and prevents recurrence of manic and dep episodes. effective in red elatation,grandiosity, expansiveness, FOI, irritability, manipulativeness, anxiety less eff in treating insomnia, distractibility, psychomotor agitation, hypersexuality, threatening/assaultive behaviors, paranoia must monitor drug level in blood. pts begin lithium in low divided doses to minimize s.e. Dose is titrated according to resp & appearance of s.e. until serum lithium conc is within range 0.5-1.2 Achieve steady state after 5 days other periodic monitoring-renal function, thyroid function, urinalysis, CBC w/ diff, lytes, ECG, & wt. Pregnancy test for women before tx. Renal & thyroid tests. clinical use-effective for acute and prophylactic tx of both manic and dep episodes in pts w/ BI. First line tx is to combine lithium or valproate w/ an anti-psychotic. For less ill pts-monotherapy w/ lithium or valproate. drugs affecting level of drug in body: diuretics, ibuprofen, verapamil |
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for pts w/ rapid cycling bi, what is useful tx?
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valproate plus anti-psychotic is sometimes preferred over lithium
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side effects of lithium
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lowering dose may help, correlated to peak levels- tremors
hypothyrodism-give levothyroxine transient and mild toxicity: -fine hand tremor (give beta-blocker) -GI upset (give slow-rel cap w/ meals) -mild polyuria, polydipsia (diuretic) muscle weakness, lethargy persistent effects: fine tremor, mild polyuria, polydipsia, inc WBC, nontoxic goiter, hypothyroidism, exacerbation of psoriasis, acna, alopecia, wt gain effective acute tx and prophylaxis 0.5-1.2 mod toxicity: level >1.5 coarsening of tremor, reappearance of GI symp, confusion, sedation, lethargy as level inc: ataxia, dysarthria, mental status deterioration sever toxicity: >2.5 seizures, coma, death, cardiovascular collapse hemodialysis is the only reliable method to rapidly dec serum level, esp in acute poisoning or when pt deteriorates rapidly and is showing clinical signs of intoxication-coma, convulsions, cardiovas collapse |
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lithium baseline monitoring
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VS, wt, lytes, BUN, crt, CBC w/ diff, UA, TFT, ECG, pregnancy test
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valporate (Depakote) Valproic acid
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anti-conv-tx of manic episodes and first line tx for rapid cycling of bi. More effective than lithium in tx bi w/ prominent dep symptoms. good as adjunct for schizaff disorder
dose related s.e.: sedation, gi upset, n/v, diarrhea, dyspepsia, anorexia, benign transaminase elevation, osteoporosis, tremor, hair loss, inc app, wt gain, mild asymp leukopenia & thrombocytopenia sometimes occur but usually return to normal when pt d/c therapy. transient and mild elev of liver enzymes, up to 3x upper limits of normal do not require d/c, inc ammonia levels is common for persistent gi stress-take withfood if pt vomits and sev abd pain-monitor pts amylase level and carefully evaluate pt for pancreatits tremor-low dose, admin beta-blocker(propranolol) sedation-use at HS hematologic effects-mild leukopenia usually is reversible on dose reduction severe a.e. Rare: fatal hepatic failure, pancreatitis, thrombocytopenia CBC q 6 months drug-drug int: valporate displaces high protein-bound drugs from their binding sites, resulting in inc blood levels of the drugs displaced. An example of this is lamotrigine-inc lamo blood level twofold. valproate interfers w/ met of drug lamotrigine therapeutic levels 50-125 micrograms/ml fatal at 800-1000mcg/ml -resp depress (hold if RR<12) wt gain and mild alopecia is common check platelets-thrombocytopenia liver function tests |
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tx of bi
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lithium
valproate carbamazepine (tegretol) oxcarbazepine (trileptal) lamotrigine (lamictyl) topiramate (topomax) FDA not approved: Tiagabine (gabatril) zonisamide (zonegran) levetiracetam (kepra) |
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side effects of lithium
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lowering dose may help, correlated to peak levels- tremors
hypothyrodism-give levothyroxine transient and mild toxicity: -fine hand tremor (give beta-blocker) -GI upset (give slow-rel cap w/ meals) -mild polyuria, polydipsia (diuretic) muscle weakness, lethargy persistent effects: fine tremor, mild polyuria, polydipsia, inc WBC, nontoxic goiter, hypothyroidism, exacerbation of psoriasis, acna, alopecia, wt gain effective acute tx and prophylaxis 0.5-1.2 mod toxicity: level >1.5 coarsening of tremor, reappearance of GI symp, confusion, sedation, lethargy as level inc: ataxia, dysarthria, mental status deterioration sever toxicity: >2.5 seizures, coma, death, cardiovascular collapse hemodialysis is the only reliable method to rapidly dec serum level, esp in acute poisoning or when pt deteriorates rapidly and is showing clinical signs of intoxication-coma, convulsions, cardiovas collapse |
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lithium baseline monitoring
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VS, wt, lytes, BUN, crt, CBC w/ diff, UA, TFT, ECG, pregnancy test
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valporate
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anti-conv-tx of manic episodes and first line tx for rapid cycling of bi. More effective than lithium in tx bi w/ prominent dep symptoms. good as adjunct for schizaff disorder
dose related s.e.: sedation, gi upset, n/v, diarrhea, dyspepsia, anorexia, benign transaminase elevation, osteoporosis, tremor, hair loss, inc app, wt gain, mild asymp leukopenia & thrombocytopenia sometimes occur but usually return to normal when pt d/c therapy. transient and mild elev of liver enzymes, up to 3x upper limits of normal do not require d/c, inc ammonia levels is common for persistent gi stress-take withfood if pt vomits and sev abd pain-monitor pts amylase level and carefully evaluate pt for pancreatits tremor-low dose, admin beta-blocker(propranolol) sedation-use at HS hematologic effects-mild leukopenia usually is reversible on dose reduction severe a.e. Rare: fatal hepatic failure, pancreatitis, thrombocytopenia CBC q 6 months drug-drug int: valporate displaces high protein-bound drugs from their binding sites, resulting in inc blood levels of the drugs displaced. An example of this is lamotrigine-inc lamo blood level twofold. valproate interfers w/ met of drug lamotrigine |
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carbamazepine (tegretol)
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anti-conv
alternative tx for acute bi mania in place of lithium enhances gaba activity in brain and inhibits glutamate and aspartate activity psychotropic effects and is less sedating, elevates mood in some dep pts-second line therapy for bi does not reach steady state until 4 wks give w/ food incr bioavailability check CBC,hepatic panel drug interactions: erythromycin, ca channel blockers and SSRIs ince carba. levels. lower carb. level w/ anti-psych, bzd, tcas and anticonv, some steroids, thyroid hormones when used with clozapine-incr risk of aplastic anemia when used with lithium- can cause acute confusion common s.e. drowsiness,dizziness first 3-4d, oh therapeutic serum levels 4-12mcg agranulocytosis/thrombocytopenia -check platelets and CBC, assess sore throat, malaise, mouth ulcers, easy bruising or bleeding toxicity usually occurs in children under 18 yrs -nystagmus, dystonic rxns, resp depression |
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tx of bi
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lithium
valproate carbamazepine (tegretol) oxcarbazepine (trileptal) lamotrigine (lamictyl) topiramate (topomax) FDA not approved: Tiagabine (gabatril) zonisamide (zonegran) levetiracetam (kepra) |
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oxcarbazepine (trileptal)
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anti-conv; as effective as carbmazepine in pts w/ bi and pts tolerate it better
risks: hyponatremia major concern, most cases asymptomatic. some pts: confusion, inc seizure frequency have occured. s.e. headache, drowsiness, dizziness, ataxia, tremor, fatigue, sedation, encephalopathy. hyperlipidemia, antiduretic hormone effects, alt reproductive hormones, wt gain, eff on thyroid functions. |
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lamotrigine (lamictyl)
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anti-conv effective for bi dep and bi rapid cyclic
s.e.-headache, dizziness, gi distress, blurred vision drug int w/ valproate (lower dose by half) life threatening rash-very rare |
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topiramte (topomax)
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anti-conv
used to tx epilepsy. Helpful in adjunct therapy for bi risks-use w/ caution in pts w/ renal impairment, adjust the dose. may cause acute myopia and sec. closed angle glaucoma and should be avoided by pts w/ glaucoma. slowly taper. s.e.-anemia, cv effects:HTN, postural hypotension, vasodilation, arrhythmias, palpitations, atrioventricular block and bundle block common-drowsiness, pyschomotor slowing, nystagmus, fatigue, confusion, language problems, anxiety, cognitive problems, possible auditory hallucination no wt gain, no blood monitoring |
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tx of mania
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first step-use mood stabilizer such as lithium or valproate. anti-psych helpful.
for agitation-bzd w/ initial tx- lorazepam, clonazepam; Alprazolam not used b/c of its anti-d effects precipitates mania. atypical antipsych for mania: olanzapine (zyprexa), clozapine (clozaril), quetiapine (seroquel), risperidone (risperidal), ziprasidone combo:lithium sometimes combined w/ valproate for effective tx of bi disorder in manic phase |
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symbyax
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fixed dose combination of olanzepine (zyprexa) and fluoxetine (prozac)
-combines an atypical antipsychotic med w/ an SSRI take in evening b/c zyprexa is sedating |
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bipolar maintenance
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atypical antipsych
olanzepine (zyprexa) and aripiprazole (abilify) to tx mania and maintain stabile mood |
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lithium therapeutic levels
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local standards
tx 0.5-1.5 acute mania 1-1.5 elderly 0.3-0.8 toxicity can occur at 1.5 and above |
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baseline assessment before lithium
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renal function, thyroid function, lytes
eval dementia/neuro disorders (poor lithium resp if dementia) -EKG long term risks w/ lithium hypothyroidism kidney impairment |
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lithium expected nuisance side effects
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fine hand tremor, polyuria, mild thirst, usually persist
mild nausea, taste changes usually subsides wt gain (10-20 common) muscle weakness inc urine output diarrhea |
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lithium toxicity
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early/mild1.5 or less
n/v, diarrhea, thirst, polyuria, slurred speech, muscle weakness, hold meds gi upset, lethargy advanced 1.5-2.0 coarse hand tremor, gi upset, mental confusion, eeg changes, muscle hyperirritability severe2.0-2.5 ataxia, marked eeg changes,blurred vision, clonic movements, lg dilute urine, seizures,stupor, sev hypotension, coma, death due to pulmonary comps no antidote,stop lithium, excretion(emetics, urea mannitol, aminophylline(resp drug) >2.5 incontinenc,confusion, cardiac issues, circulation collapse, oliguria, proteinuria add hemodialysis or peritoneal dialysis |
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common causes of elevated lithium levels
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dec na intake, diuretic therapy, dec renal function, fluid/lyte loss, fever/vomitting, medical illness, lithium overdose
can loose salt through exercise, sunbathing, vomitting |
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lithium nursing indications
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monitor for glycosuria, monitor glucose levels in diabetics
can cause hypothyroidism, can cause diabetes insipidous,give w/ meals to dec stomach upset, normal salt intake never double a dose if u miss one drink 2.5 quarts of water each day report diarrhea, fever, sweating to prescriber use contraceptives, notify prescriber if pregnant water pills are contraindicated |
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antiepileptics for bi disease
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indications-give w/ LIO3 or to nonlithium responders, no family hx of bipolar, bipolars who abuse substances, rapid cyclers, EEG changes, schizoaffective pts with affective swings, bi pts that are impulsive/aggressive pts
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escitalopram (lexapro)
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SSRI
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meds for psychosis
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believed that + symp result of overactivity of dopamine neurons in mesolimbic dopamine pathway (inc brain activity)
- symp result of cortical dopamine deficiency in mesocortical pathway of brain (low brain activity) anti-psychotics are tx for psychosis, schizaff and delusional disorders pts w/ psychosis from secondary causes such as lyte/hormonal imbalances, drug abuse, brain tumors, mania or dep w/ psychotic features benefit from short-term antipsych med until underlying cause is treated. |
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typical antipsychotics
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high affinity antagonists of dopamine receptors. most effective for reducing positive symptoms
high potency -low dose, more EPS, less sedation, less cholinergic s.e. -(Haldol)Haloperidol, (Proloxin) fluphenazine, navane, (trilafon)perphenazine, trifluperazine (stelazine) low potency -high dose, less EPS, more sedating, more anticholinergic s.e. -(Thorazine)thioridazine, Thioridazine (mellaril) reduce positive symp, cause movement disorders, block D2 receptors in limbic region inc prolactin |
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antipsychotic: absorption and distribution
metabolism, excretion and serum level monitoring |
absorption-well absorbed by GI tract influenced by: food, antacids, anticholinergics, smoking
distribution-depends on route of administration IM: greater bioavailability metabolism half-life: 20-40H met in liver excretion via kidneys serum level monitoring is not routinely useful |
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atypical antipsychotics
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block serotonin receptors reducing negative symptoms, do not affect movement, influence
glutamte therapy improving cognition, improve TD, have few anticholinergic effects, differ in mode of action, s.e., potency, fewer EPS, greater efficacy w/ negative symp, cognitive symp, refractory illness -lower potential to increase prolactin First line: olanzapine (zyprexa) risperidone (risperdal) quetiapine (seroquel) aripirazole (abilify) ziprasidone (Geodon) clozapine (clorazil)- good 4 med resistant pts have a lower affinity for dopamine D2 receptors and higher affinities for sero and norep- more effec for neg symp |
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aripirazole (abilify)
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atypical antipsych
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clozapine (clozaril)
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atypical antipsych-good for med resistant pts-can develop agranulocytosis.
higher receptor affinity for D4 and serotonin -reserved for refractory illness risk: agranulocytosis in 1-3% of pts -wkly WBC, fever, malaise, flu like symp side effects: anticholinergic, EPSE, NMS not a risk, tachycardia, oh, wt gain, hypersalivation, fever, seizures, sedation is common |
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olanzapine (zyprexa)
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atypical antipsych
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quetiapine (seroquel)
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atypical antipsych
NMS > in |
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risperidone (risperdal)
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atypical antipsych
EPSE > with high dose |
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ziprasidone (geodone)
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atypical antipsych
using too long may prolong QRST irreg EKG |
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other side effects of antipsychotic use
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skin discoloration such as blue/gray skin is associated with antipsychotic use. low potency conventional antipsychotics such as chlorpromazine and thioridazine are asoc. w/ skin pigmentation.
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antipsychotics assoc. w/ wt gain
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clozapine, olanzapine, low-potency conventional anipsych, quetiapine, risperidone, high-potency conventional antipsychotics, ziprasidone and molindone
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NMS
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it is a medical emergency
sypm: dec loc, incr muscle rigidity, autonomic dysfunction(hyperoyrexia, labile htn, tachycardia, tachypnea, diaphoresis, drooling) muscle necrosis(rhabomyolysis) causing kidney failure leukocytes 15,000-30,000 crt phosphokinase over 3000 can occur first wk of tx or anytime and rapidly progresses 1% can occur w/ most antipsych meds, 10% fatal older females, younger males in first 2 wks of tx, rapid dose titration of high potency antipsych, dehydration tx: d/c med, STAT transfer to ICU, IV fluids, correct lyte imbalances, parlodel and dantrium, tx cardiac arrhythmias, ice blankets, sm heparin doses decrease pulmonary embolus risk, amantadine (symmetrel) |
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postural hypotension assoc. w/ antipsych use
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dizziness assoc. w/ sudden changes in position. the use of low potency antipsych such as chlorpromazine and thioridazine presents a greater risk for postural hypotension as a result of adrenergic receptor blockade
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side effects assoc. w/ receptor blockade
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dopamine2
EPSE prolactin histamine sedation wt gain cholinergic dry mouth blurred vision sinus tachycardia constipation imp memory/cognition alpha oh reflex tachycardia serotonin wt gain gi upset sex dyf |
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adjucnt meds used to tx EPSE
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anticholinergic -cogentin, artane
antihistamine-benadryl dopamine agonist-symmetrel |
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depot medication
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typicals
fluphenazine decanoate (prolixin d) haloperidol decanoate (haldol d) atypical long lasting resperidone (consta) administration pointers inspect sol'n use dry syringe and needle do not exceed 3 ml per site |
