Exam 4

SSRIs - Fluoxetine

therapeutic use: major depression, BPD, anxiety/panic disorders, bulimia, PMDD

adverse effects: nausea, sexual dysfunction, insomnia (pt ed to take early in the day), weight gain, serotonin syndrome (increased risk with MAOIs, linezolid, other serotonergic drugs), withdrawal syndrome, neonatal effects, suicidal ideation (warn pt)

nursing implications: strong inhibitor CYP2D6

SNRIs - Venlafaxine

therapeutic use: major depression, anxiety/panic disorders, pain disorders

adverse effects: nausea, anorexia/weight loss, HTN, tachycardia, sexual dysfxn, HA, insomnia, serotonin syndrome (increased risk with MAOIs, linezolid, other serotonergic drugs), bronchitis/dyspnea, CNS effects (DDI w CNS depressants), neonatal effects, suicidal ideation

atypical antidepressants - Bupropion

therapeutic use: major depression, prevention of seasonal affective disorder, smoking cessation (Zyban), neuropathic pain

adverse effects: insomnia, appetite suppression, seizures (increased risk in pt w hx of seizure or eating disorders, DDI w 2D6 inhibitors increases seizure risk), HTN, tachycardia

TCAs - Amitriptyline

therapeutic use: depression, BPD, ADHD, anxiety, panic disorders. other - neuropathic pain disorders, insomnia

adverse effects: anticholinergic AEs, orthostatic hypotension, sedation, weight gain, arrhythmias and seizures (lethal in OD), suicide risk

nursing implications: narrow therapeutic index - lethal dose is only 8x avg therapeutic dose. many DDIs - w MAOIs can have SS or HTN crisis, also w other serotonergic drugs

MAOIs - Phenelzine

therapeutic use: major depression, bulimia, panic and anxiety disorders

adverse effects: CNS stimulation (insomnia), orthostatic hypotension, risk of suicidal ideation

nursing implications: MANY DDIs (pt should tell everyone they’re taking it) - linezolid, other serotonergic drugs (inc risk of SS), DFI with foods high in tyramine (hypertensive crisis). wash out period req before pt starts another serotonergic drug, effects last

CAM - St. John’s Wort

therapeutic use: depression (but no more effective than use of placebo for major depressive disorder)

adverse effects: CNS effects, photosensitivity w high doses, SS w other antidepressants

nursing implications: CYP450 enzyme inducer (tell pts). look for USP verified products

Disulfiram

MOA: disrupts alcohol metabolism by causing irreversible inhibition of aldehyde dehydrogenase

therapeutic use: AUD (maintenance)

adverse effects: WITH concurrent alcohol use: acetaldehyde syndrome → mild symptoms are N, V, flushing, palpitations, HA, sweating, thirst, chest pain, weakness, blurred vision, hypotension; severe symptoms are respiratory depression, CV collapse, dysrhythmias, seizures, death. WITHOUT concurrent alcohol use: rash, drowsiness, liver dysfxn (rare), peripheral/optic neuritis (rare)

nursing implications: DDI w alcohol (avoid products containing alc), metronidazole, warfarin. admin at least 12 hr after last drink, effects persist for 2 wk after stopping med. pt wear medic alert bracelet.

Naltrexone

MOA: pure opioid antagonist that decreases cravings for alcohol and blocks reinforcing (pleasurable) effects

therapeutic use: AUD (maintenance) and OUD (after detoxification)

adverse effects: GI effects (abd pain, N, D), HA, sedation, anxiety, injection site rxns with IM form, liver toxicity (contra in pt w acute hepatitis or liver failure)

nursing implications: form daily PO (ReVia) or 1x/month IM (Vivitrol). DDI w opioids, concurrent pain management difficult

Acamprosate

MOA: decreases unpleasant feelings associated with abstinence

therapeutic use: AUD (maintenance)

adverse effects: diarrhea (17%), suicide-related events (rare)

nursing implications: avoid in pregnancy, caution ESRD or CrCl < 30mL/min. evaluate renal fxn. start 5 days after alc stopped. PO, admin 3x/day w food

Benzodiazepines (for insomnia) - Triazolam

therapeutic use: short-term insomnia treatment (short-acting/low dose for insomnia)

adverse effects: tolerance and rebound insomnia (dt short half life), anterograde amnesia, daytime sedation, complex sleep-related behaviors, dependence, withdrawal syndrome, paradoxical rxns

nursing implications: cause respiratory depression w other CNS depressants. OD mgmt w Flumazenil (Benzo antagonist). do not abruptly DC long-term/high-dose therapy → can lead to withdrawal, anxiety, insomnia, increased CNS excitability that can cause seizure activity. schedule IV controlled substance

BZDRAs - Zolpidem

therapeutic use: insomnia only

adverse effects: respiratory depression, drowsiness, dizziness, sleep-related behaviors (sleepwalking, eating, confusional arousals)

nursing implications: cause respiratory depression when used with other CNS depressants (pt ed to avoid). has rapid onset and short duration

MRA (melatonin receptor agonist) - Ramelteon

therapeutic use: for insomnia (long-term tx is permitted)

adverse effects: very well-tolerated, but can have somnolence, dizziness, fatigue, increased prolactin levels, possible sleep-driving

nursing implications: has a wide therapeutic index, is not habit-forming. DDI w CNS depressants, although effect is additive - does not increase respiratory depression risk

Sedating antidepressants - Trazodone

therapeutic use: insomnia, esp in conjunction with antidepressants that cause CNS stimulation

adverse effects: daytime sedation, anticholinergic AEs, weight gain, orthostatic hypotension, dizziness

Antihistamine OTC sleep aids - Diphenhydramine

therapeutic use: FDA approved to treat insomnia → Benadryl, Tylenol PM

adverse effects: daytime sedation, anticholinergic AEs

CMA OTC sleep aid - Melatonin

therapeutic use: reset circadian rhythms in cases like jet lag, shift work, blind pts. minimal evidence for effectiveness on insomnia

adverse effects: HA, dizziness, nausea, daytime sedation

nursing implications: take 1-2 hr before bed. DDI w anticoagulants, anti-HTN meds, hypoglycemics, CNS depressants. alert provider of use dt DDIs

Benzodiazepines (for anxiety) - Diazepam, Lorazepam, Midazolam

therapeutic use: short-term, for acute anxiety (fast acting), IV used for sedation, alcohol withdrawal syndrome, status epilecticus

adverse effects: oral - produces anxiolysis (minimal sedation) - must monitor response with first dose. IV - moderate sedation (esp w other CNS depressants) and requires monitoring of vital signs, respirations

nursing implications: longer half-life compared to triazolam. schedule IV controlled substance

Nonbenzo-nonbarb - Buspirone

therapeutic use: anxiolytic only

adverse effects: dizziness, nausea, HA, drowsiness

nursing implications: takes weeks to see effects, not to be used PRN. DDI w ketoconaozle, erythromycin, grapefruit juice. no concern for use with other CNS depressants, no tolerance issues, not a controlled substance

SSRIs/SNRIs for anxiety - Fluoxetine, Venlafaxine

therapeutic use: DOC for all chronic anxiety disorders

nursing implications: slow response time, not appropriate for PRN use. abrupt dc can produce withdrawal s/s. effectiveness is improved w psychotherapy or CBT. long-term tx

Stimulants - Amphetamine/Dextroamphetamine (Adderall), Methylphenidate (Ritalin)

therapeutic use: ADHD, narcolepsy

adverse effects: CNS stimulation/effects, CV effects, weight loss, HA, abd pain, lethargy. OD symptoms: dizziness, confusion, hallucination, paranoid delusions, palpitations, dysrhythmias, HTN. hypersensitivity concern w patch formation

nursing implications: DDI w MAOIs, caffeine. schedule II drug dt dependence and tolerance concerns. contraindicated in pt w symptomatic CV disease, hyperthyroidism, h/o SUD. dose is IR, SR, ER (amph-dextro does not have SR). pt ed to take dose after breakfast and last dose before 4pm

Non-stimulants - Atomoxetine

therapeutic use: 2nd line for ADHD; depression

adverse effects: GI rxns, allergic rxn, (angioneurotic edema), suicidal thinking, weight loss, growth delay, severe liver injury

nursing implications: DDI w MAOIs. pt ed: may take a few weeks to see full effects, report AEs/change in behavior of pediatric pt. not a controlled substance

Dopamine Replacement - Carbidopa/Levodopa

therapeutic use: gold standard tx for Parkinson’s. most effective med for motor fluctuations, used for “wearing off” effect and “on/off” phenomenon

adverse effects: dyskinesias (w/ late-stage PD), GI upset (N/V), orthostatic hypotension, peripheral neuropathy, psychiatric disturbances (agitation, confusion, hallucinations, psychosis)

nursing implications: DDI w FGAs, MAOIs, hypotensive agents, alcohol (category X, causes dumping for ER formulation). do NOT stop abruptly → NMS (Neuroleptic Malignant Syndrome, life-threatening high fever, severe motor rigidity, altered mental status, autonomic instability). oral tablet dosed multiple times per day, do not administer w high protein meals

Dopamine Agonist - Pramipexole

therapeutic use: can be used first-line for mild to moderate PD in younger PTs, restless leg syndrome

adverse effects: issues w impulse control (gambling, compulsive sexual behavior, compulsive shopping), sleep attacks, GI upset (N/V), orthostatic hypotension

nursing implications: DDIs w antipsychotic agents, CNS depressants, sedating meds. contraindicated in pregnancy, reduce dose w renal impairment. oral tablet dosed multiple times per day

COMT inhibitor - Entacapone

therapeutic use: always prescribed with carbidopa/levodopa (increases serum levels of levodopa available to enter brain → helps address “wearing off” symptoms

adverse effects: nausea, diarrhea, dyskinesia, behavioral changes (hallucinations)

nursing implications: DDI w methyldopa, dobutamine, isoproterenol

Anticholinergic - Benztropine

therapeutic use: helps preserve response to levodopa early in PD, beneficial for pt w tremors

adverse effects: anticholinergic AEs (dry mouth, urinary retention, confusion, blurred vision, constipation)

nursing implications: on BEERS list (caution older adults), DDI w other anticholingergic meds and CNS depressants, do not abruptly DC → slowly titrate down. available as oral sln and tablet

Lithium

therapeutic use: BPD, first-line for all pt w euphoric mania. other use: alcoholism, bulimia, schizophrenia

adverse effects: polyuria, thirst (dt antagonism of ADH), hypothyroidism (5-35%), fine hand tremor, renal dysfxn with long-term use. lithium toxicity ➡ levels > 1.5mEq/L are toxic, must keep well below this dt individual variation among pts (there is no antidote, tx is supportive, hemodialysis may be needed)

nursing implications: short half-life, dose at least BID. eliminated via renal excretion, use extreme caution w renal dysnfxn. do not use in pregnancy. DDI w ACEIs/ARBs, NSAIDs, Diuretics (they all increase Lithium levels). DFI: pt should never be salt-restricted since changes in Na or fluid intake change levels (hyponatremia or hypovolemia increase levels). monitor blood levels, SrCr/BUN, electrolytes, thyroid fxn

FGAs - Haloperiodol

therapeutic use: schizophrenia, psychosis, DOC for Tourette’s Syndrome

adverse effects: EPS (acute dystonia, akathesia, Parkinsonism, tardive dyskinesia) ➡ occur early in tx, more common w high-potency FGAs. Neuroleptic Malignant Syndrome (NMS), anticholinergic effects, orthostatic hypotension, sedation, severe dysrhythmias, neuroendocrine effects, seizures, sexual dysfxn, agranulocytosis, dementia (w older adult pts, contraindicated in pt who already have dementia), EPS/withdrawal in neonates

nursing implications: assess for effectiveness (ability to perform ADLs, social interactions, sleep/eat, resolution of symptoms). pt on QT drugs are high risk. promote adherence, pt ed on s/s of early and late EPS (use AIMS - Abnormal Involuntary Movement Scale) and s/s of agranulocytosis (fever, sore throat)

SGAs - Risperidone, Clozapine

therapeutic use: schizophrenia, BPD, levodopa-induced psychosis, impulse control disorders

adverse effects: metabolic AEs ➡ weight gain, diabetes (new-onset), dyslipidemia (monitor all at baseline and throughout tx). other AEs such as seizures, EPS, agranulocytosis (esp w Clozapine ➡ REMS program), myocarditis, orthostatic hypotension, dementia (older adults)

nursing implications: assess for effectiveness (ability to perform ADLs, social interactions, sleep/eat, resolution of symptoms). pt w/ diabetes are high risk. promote adherence (med is swallowed not “cheeked”, get family involved, explain importance of taking regularly, use IM depot which has lower rate of relapse than oral therapy and decreased TD risk, usually dosed q2-4 wks), pt ed on s/s of early and late EPS (use AIMS - Abnormal Involuntary Movement Scale - although this is much less common than with FGAs), s/s of agranulocytosis (fever, sore throat), and s/s of metabolic effects (weight gain, diabetes)

traditional anti-seizure drug - Phenytoin

therapeutic use: widely used for epilepsy. also dysrhythmias

adverse effects: CNS side effects (all of which could indicate toxicity) ➡ cognitive impairment, sedation, nystagmus, ataxia, diplopia; cosmetic side effects (gingival hyperplasia, hirsutism); rash (Morbilliform rash 2-5%, risk is increased if pt has HLA-B*1502 genotype, so test). with IV admin, concern for CV effects (hypotension, dysrhythmias) and purple glove syndrome. is teratogenic ➡ fetal hydantoin syndrome

nursing implications: high-alert drug w narrow TU, normally 90% protein bound but this decreases with hypoalbuminemia (can be caused by both renal and hepatic dysfxn, and DDI w valproic acid). DDIs - potent CYP450 inducer, other drugs can increase or decrease levels, CNS depressants can cause additive CNS effects. IV used less frequently with phenytoin bc it’s less safe, but would admin slowly to prevent hypotension (<50mg/min) and flush w saline after infusing to prevent local vein irritation. w oral admin, give w meal to decrease gastric upset and hold tube feeds for 2 hr before and after giving. do not abruptly dc

traditional anti-seizure drug - Fosphenytoin

therapeutic use: epilepsy (is a prodrug that gets converted to phenytoin in the body)

adverse effects: hypotension, dysrhythmias. paresthesia and itching are temporary side effects of IV administration.

nursing implications: infuse slowly (do not exceed 150mg PE - phenytoin equivalent/min) to reduce risk of hypotension (should resolve ~10 min after stopping infusion) and dysrhythmias. slow infusion if CV effects occur

traditional anti-seizure drug - Carbamazepine

therapeutic use: epilepsy, BPD, neuralgias (is auto-inducer, induces its own metabolism)

adverse effects: neuro (diplopia, ataxia, HA), hematologic (leukopenia, anemia, thrombocytopenia), dermatologic (rash, photosensitivity, SJS, TEN ➡ risk is increased with HLA-B*1502 genotype, conduct pharmacogenetic test before starting), birth defects (teratogenic), hyponatremia secondary to SIADH

nursing implications: DDIs - potent CYP450 inducer, grapefruit juice (avoid). administration - oral only, give w food. SHAKE oral suspension, caution regular vs XR pill forms. pts can develop tolerance to neuro side effects, admin largest portion of dose at bedtime to help mitigate risk

traditional anti-seizure drug - Valproic acid

therapeutic use: epilepsy, BPD, migraines

adverse effects: cause N/V (take w food), alopecia, weight gain, hepatotoxicity (avoid in pt w pre-existing liver dysfxn), pancreatitis, highly teratogenic (contraindicated in children <2 yrs and pregnant pt)

nursing implications: caution dosage form confusion. salt forms - Valproic Acid (Depakene, Depacon), Valproate (Depakene), Divalproex sodium (Depakote, DR, ER, Sprinkles ➡ can open but do not chew). DDI: may lead to toxicity if used in combo w phenytoin, carbamazepine, phenobarbital, topiramate ➡ cause hyperammonemia (s/s altered LOC, vomiting, lethargy). carbapenem antibiotics greatly decrease levels, monitor for seizures if these two are given together

NSAIDs - Aspirin

therapeutic use: analgesic for mild to moderate pain, inflammatory disorders (e.g. dysmenorrhea, arthritis), anti-pyretic, anti-inflammatory, anti-platelet

adverse effects: GI distress, heartburn, nausea, occult bleeding, Reye’s syndrome, renal impairment (acute/reversible), hypersensitivity (contraindicated), teratogenic effects. aspirin poisoning/salyclism (compensated respiratory alkalosis w respiratory depression, acidosis, hyperthermia, sweating, dehydration, electrolyte imbalance, coma, death - tx is supportive (pump stomach, charcoal, cooling fluids, bicarb IV)

nursing implications: DDI w Heparin, Warfarin (contraindicated for pt w bleeding disorders), glucocorticoids

NSAIDs - Ibuprofen

therapeutic use: inflammatory conditions causing pain, fever

adverse effects: GI effects (distress, heartburn, nausea, occult bleeding), renal impairment, cross-hypersensitivity with aspirin, AEs in pregnancy, CV risk, SJS

nursing implications: max amount is 1200mg/day OTC and 3200 mg/day prescription

NSAIDs - Celecoxib

therapeutic use: osteoarthritis, acute pain

adverse effects: GI effects (distress, heartburn, nausea, occult bleeding), CV risk, renal impairment, AEs in pregnancy

nursing implications: cross hypersensitivity with aspirin and/or sulfa allergy

non-opioid analgesic/antipyretic - Acetaminophen

therapeutic use: analgesic, antipyretic (NOT anti-inflammatory)

adverse effects: well-tolerated at normal doses. anaphylaxis (rare), skin rxns (stop drug immediately), acute hepatotoxicity w dose >4000mg/day, OD (stage 1 24 hr is GI effects, progress to stage 2-3 24-96 hr is liver toxicity, stage 4 within 2 weeks - recovery or death. acetylcystine is antidote, administer immediately after OD recognized, up to 24 hrs)

nursing implications: dose is 325mg-1000mg q4-6hr (adult), max dose 4,000mg/day. outpatient rec max dose 3,000mg/day. do not drink alc, or if drinking no more than 2,000mg/day. avoid in pt w liver disease, pt ed on dangers of “combination” products (e.g. NyQuil, Vicodin, Percocet - liver damage)

opioid analgesics - Morphine

therapeutic use: moderate to severe pain, cough suppression, suppressing bowel motility, sedation

adverse effects: respiratory depression (risk increases with other CNS depressants such as benzos, ETOH, analgesics, antihistamines (DDI)), constipation (DDI w anticholinergics bc also causes urinary retention), orthostatic hypotension (DDI w hypotensive drugs), N/V, dizziness, cough suppression, sedation, miosis, tolerance/dependence/abuse. toxicity ➡ coma, respiratory depression, pinpoint pupils

nursing implications: concern for first pass metabolism with oral dose, also available IM, IV, SQ, epidural, intrathecal. excreted renally.

opioid analgesics - Hydromorphone

therapeutic use: moderate to severe pain, cough suppression, suppressing bowel motility

adverse effects: respiratory depression (risk increases with other CNS depressants such as benzos, ETOH, analgesics, antihistamines (DDI)), constipation (DDI w anticholinergics bc also causes urinary retention), orthostatic hypotension (DDI w hypotensive drugs), N/V, dizziness, cough suppression, sedation, miosis, tolerance/dependence/abuse. toxicity ➡ coma, respiratory depression, pinpoint pupils

nursing implications: formulations are IV (JHH - IV push over 1mg/min), IM, ER (do not crush or chew). safety ➡ 1 mg hydromorphone = 7 mg morphine

opioid analgesics - Fentanyl

therapeutic use: acute pain (IV), chronic pain (transdermal)

adverse effects: respiratory depression - be extra aware of risk since effects extend beyond patch removal (risk increases with other CNS depressants such as benzos, ETOH, analgesics, antihistamines (DDI)), constipation (DDI w anticholinergics bc also causes urinary retention), orthostatic hypotension (DDI w hypotensive drugs), N/V, dizziness, cough suppression, sedation, miosis, tolerance/dependence/abuse. toxicity ➡ coma, respiratory depression, pinpoint pupils

nursing implications: synthetic opioid, 80x more potent than morphine. DDI - levels increase w other CYP3A4 inhibitors (e.g. Ritonavir, Ketonazole). patch has slow onset and peaks at 24hr and effects continue ~17hr after patch removal. remove patch q3 days. if pt has fever, absorption is increased by 15%. patch should not be used in pt under 2 years or under 110 lbs

drugs for gout pain - Colchicine

therapeutic use: acute gouty arthritis, prophylaxis of gout attacks - decreases inflammation only for gout

adverse effects: GI distress, BM suppression, rhabdomyolysis

nursing implications: pt ed to take w food, avoid foods high in purine and maintain adequate water intake. caution w elderly pts, renal dysfxn. DDI: strong CYP3A4 inhibitors (increase levels)

drugs for gout pain - Allopurinol

therapeutic use: hyperuricemia dt gout of cancer, DOC for chronic tophaceous gout

adverse effects: hypersensitivity rxn, acute kidney toxicity, hepatitis, GI distress

nursing implications: pt ed to take w food, avoid foods high in purine and maintain adequate water intake. caution w elderly pts, renal dysfxn.

drugs for migraine - Sumatripan

therapeutic use: DOC to abort migraines

adverse effects: well-tolerated but can have chest pressure, angina, dizziness, teratogenic effects

nursing implications: do not give to patients w uncontrolled HTN or at risk for CAD. DDIs w MAOIs, SSRIs, Ergots (not within 24hr). pt ed to take at symptom onset and avoid triggers