Pharm Exam 1

Benzodiazepines

Benzodiazepines

Prototypes: diazepam (Valium) and alprazolam (Xanax)

EPA: Enhance inhibitory effects of gamma- aminobutyric acid (GABA)

Admin: Alprazolam Oral only; Diazepam PO/IV: Admin IV slowly/Monitor IV site

Therapeutic use: Generalized anxiety disorder (GAD) & panic disorder; emergency management seizure disorders

ADRs: CNS/Resp depression, Hypotension, Tolerance and physical dependence (especially with alprazolam)

*Overdose/toxicity: possibly life-threatening sedation, hypotension, respiratory depression, cardiac arrest

Contraindications/Interactions: Pregnancy – teratogenic • Glaucoma • Respiratory and/or CNS depression • Concurrent use of CNS depressants

RN intervention/client education: Monitor for withdrawal symptoms: insomnia, anxiety, tremors, diaphoresis, hypertension, seizures • Monitor for phlebitis • Assess/Monitor Falls • Regular Vital Signs • Do not stop abruptly • Assess CNS and Resp depression

Antidote: Flumazenil (Anexate, Romazicon)

Non-benzo/misc. anxiolytic

Prototype: buspirone (BuSpar)

EPA: Binds to serotonin & dopamine receptors; agonistic action on dopamine*

Admin: PO; give 2-4 weeks before tapering Benzodiazepines. Can take 2-4 weeks to take effect

Therapeutic use: Short term treatment of Generalized anxiety disorder (GAD)

ADRs: Paradoxical effects: insomnia, anxiety, restlessness. GENERALLY well tolerated

Contraindications/interactions: MAO inhibitors → (HTN) • Grapefruit juice, Ketoconazole, erythromycin → inc. blood levels • Avoid CNS depressants

RN intervention/client education: Monitor for paradoxical effects • Avoid contraindicated meds/grapefruit juice

TCA

prototype: amitriptyline (Elavil)

EPA: Block norepinephrine reuptake pump & serotonin reuptake pump in synaptic space → boosts availability of serotonin, norepinephrine, acetylcholine, dopamine

Admin: PO at bedtime due to sedative effects. Takes several weeks to take effect

Therapeutic use: Treatment of major depression. 2nd line drug

ADRs: MANY. Anticholinergic effects (dry mouth, dizziness, urinary retention), sedation, inc risk for suicide (child/adolescent)

**abrupt discontinuation can cause withdrawal (anxiety, headache, muscle pain, nausea)

**high risk for overdose (life threatening dysrhythmias, confusion, seizure)

contraindications/interactions: Avoid use of MAOIs  Avoid Anticholinergics (Why?)  Avoid CNS depressants  Cardiac dysrhythmias  Seizure d/o  Recent myocardial infarction (MI)

RN intervention/client education: Give @ bedtime  Monitor orthostatic vital signs.  Monitor for increases in depression and suicidal ideation.  Taper the drug over 2 weeks to prevent or minimize withdrawal.

SSRI

prototype: fluoxetine (Prozac)

EPA: Block reuptake of serotonin → strengthened transmission of serotonin at serotonergic synapses

Admin: PO in morning due to CNS excitation. Takes 4-6 weeks to take effect

Therapeutic use: Many indications! Depression, anxiety, OCD, bulimia nervosa, premenstrual dysphoric disorder

ADRs: Insomnia, Sexual dysfunction, Weight gain, Serotonin syndrome **Increase risk for suicidal ideation (especially children, young adults) Serotonin syndrome; hyperpyrexia, agitation → coma, muscle rigidity, seizure

contraindications/interactions: MAOIs  St. John’s wort  Ibuprofen

RN intervention/client education: Monitor for insomnia, anxiety  Monitor for dec. libido and/or impotence  Monitor weight gain  Monitor for inc. depression or suicidal ideation  Monitor for s/sx serotonin syndrome  Do not stop abruptly

SNRI

prototype: vanlafaxine (Effexor XR)

EPA: Block neuronal reuptake of serotonin AND norepinephrine → increased amt of serotonin/norepinephrine available

Admin: PO. Start with low dose and gradually titrate up.

Therapeutic use: Major depression, social anxiety disorder, generalized anxiety disorder (GAD)

ADRs: Very similar to SSRI. Sexual dysfunction less common than w/SSRI and can cause hypertension

Contraindications/interactions: MAOIs  First Generation Antipsychotics/Typicals  Ibuprofen

RN intervention/client education: Take in the morning w/food  Monitor for insomnia  Monitor for dec. libido and/or impotence  Monitor weight gain  Monitor for inc. depression or suicidal ideation  Monitor for s/sx serotonin syndrome  Do not stop abruptly  Monitor BP periodically

MOAI (monamine oxidase inhibitors)

prototype: phenelzine (Nardil)

EPA: Blocks monoamine oxidase-A and Monoamine Oxidase – B

Admin: PO. Start with low dose possible

Therapeutic use: Depression that hasn’t responded to other medications, Depression in Bipolar

ADRs: CNS stimulation, Constipation, weight gain, sexual dysfunction, orthostatic hypotension

**Hypertensive crisis when eating foods containing tyramine (aged cheeses,/meat, yeast, chocolate, alcohol)

Contraindications/interactions: Cardiac disease  Clients > 60  SSRIs  Glaucoma

RN intervention/client education:  Monitor Vital signs and BP  Provide client a list of foods to avoid  Instruct client to report severe anxiety, insomnia and agitation to provider

Atypical Antidepressant

prototype: BUPROPION (Wellbutrin)

EPA: Inhibits dopamine reuptake thereby inc dopamine availability

Admin: PO

Therapeutic use: Depression, Seasonal affective d/o; adjunctive to smoking cessation

ADRs: weight loss, appetite suppression, inc risk for seizure. CNS stimulation: insomnia, agitation, tremor.

**Inc risk for psychosis/hallucination

contraindications/interactions: History of an eating disorder  Seizure disorder  MAOI  Head trauma or tumor in the CNS (why?)  Interacts with many medications

RN intervention/client education: Weekly weights  Assess for ADRs  Assess for inc. depression symptoms or suicidal ideation

Mood Stabilizer

Prototype: lithium carbonate (Lithobid)

EPA: Not well understood. Changes to transport of sodium ions in nerve cells and alters metabolism of catecholamines (fight or flight) in response to stress. This is thought to dec. mania assoc w/bipolar.

Administration: PO; give w/milk or food to reduce GI upset

Therapeutic Use: Controls acute mania and acute manic episodes assoc. w/bipolar disorder. Used prophylactically to prevent recurrence of mania or depression

ADRs: Therapeutic levels: GI distress, confusion, muscle weakness, memory impairment. Polyuria, dec. secretion of thyroid hormone àgoiter or hypothyroidism. Fine hand tremors.

Toxicity due to narrow therapeutic range (muscle weakness, fine tremor progressing to coarse tremor, ataxia, confusion, seizures, coma, and death)

Contraindications/Interactions:

•Pregnancy/Lactation

•Moderate-Severe cardiac disorders

•Dehydration

•Hyponatremia

•MANY DRUG INTERACTIONS

•AVOID NSAIDS

RN Intervention/Client Education

­NARROW therapeutic range

­Monitor Lithium levels. Desired serum plasma levels = 0.6-0.8 mEq/L

­Regular Bloodwork:

­Electrolytes (sodium) and CBC

­thyroid function - hypothyroidism

­renal function

­Monitor for signs/symptoms of toxicity and other ADRs

­Drink 2-3L of fluid per day

­Avoid caffeine and stressors

­Consume foods with sodium

FIRST GENERATION ANTIPSYCHOTICS (FGA)/TRADITIONAL

Prototype: chlorpromazine

Other Drugs: haloperidol (Haldol)

EPA: Block several receptors: norepinephrine, acetylcholine, dopamine, histamine.

Administration: PO, IV, IM, Rectal

Therapeutic Use: Suppresses symptoms of schizophrenia. Acute manic phase of bipolar disorder

ADRs:

Extrapyramidal symptoms (EPS): Abnormal muscle contraction/posturing and Acute dystonia

Neuroleptic malignant syndrome: Fever, stiffness of muscles, altered mental status, change in BP resp. failure

Akathisia (inability to sit still)

Anticholinergic Symptoms (dry mouth, dizziness, urinary retention, etc)

Parkinsonism

Orthostatic hypotension

Cardiac arrhythmias à prolonged QT interval

Liver failure

Contraindications/Interactions

­alcohol/other CNS depressants

­Caution with meds that activate dopamine receptors (levodopa)

­SSRIs àincrease levels of serotonin à serotonin syndrome

­Hyponatremia

­Antihypertensives

­Pregnancy/Lactation

­Parkinsons disease, bone marrow depression

RN Intervention/Client Education

•Monitor for ADRs

•wear gloves when handling

•Have client report:

•muscle rigidity, tremors, and sluggish movements, drooling, and shuffling gait

•severe spasms of the neck and body

•involuntary movements of tongue, face, limbs, trunk

•palpitations, fainting spells, other cardiac symptoms

•avoid sun exposure, use sunscreen, wear protective clothing, wear sunglasses

•sudden fever immediately to provider

SECOND GENERATION ANTIPSYCHOTICS (SGA)/ATYPICALS

Prototype: risperidone (Risperdal)

Other Drugs: olanzapine (Zyprexa), quetiapine (Seroquel), apriprazole(Abilify), clozapine (Clozaril)

EPA: Block receptors for dopamine and serotonin. Dopamine blockade is less than conventional antipsychotics thus fewer EPS occur

Administration: PO – instructions vary by drug

Therapeutic Use: Treat symptoms of Schizophrenia and Bipolar disorder

ADRs: sedation, hypotension (blockade of alpha-adrenergic receptors); Metabolic syndrome: wtgain, diabetes, dyslipidemia; Arrhythmias; Agranulocytosis (Clozapine); Extrapyramidal symptoms when given high doses

Contraindications/Interactions

•Prolonged QT (EKG)

•Severe CNS depression

•Psychosis related to dementia in older adults

•Pregnancy/Lactation

•Drugs to treat parkinsons disease

•MANY drug interactions

RN Intervention/Client Education

­Very similar to FGAs/Typicals

­Weekly blood tests (CBC)

­Periodic blood glucose monitoring

­Report lethargy/flu like symptoms

­Notify provider if you become pregnant

­Notify provider if you have increased HR

WARNING:

administration of clozapine and other second-generation antipsychotics to elderly patients with dementia can increase risk of death. The FDA has not approved the drug for use in dementia-related psychosis.

Centrally Acting Muscle Relaxants

(p)

Traditional AEDs (2)

Traditional AED (3)

Newer AEDs 2