N402 EXAM 2: Psychopharmacology

Antipsychotics

block dopamine (too much dopamine makes you hear/see things)

- first and second gen

first generation (typical) antipsychotic

used for...

- psychosis

- schizophrenia

- agression/irritability

- biploar

(postive psychosis symptoms)

Extrapyramidal Side Effects (EPSE)

positive symptoms of psychosis

Delusions, hallucinations, disorganized speech, and disorganized/catatonic behavior

negative symptoms of psychosis

Reduced/absent emotional expression, reduced quantity/fluency of speech, reduced initiative or will to do things (avolition)

- harder to detect things, patient can hide them

EPSE

- dystonia

- drug induced parkinsonism

- akathisia

- tardive dyskinesia

dytonia

bizarre/severe muscle contractions (severe spasm)

- reversible

- can occur abruptly or w other s/e

EPSE

drug induced parkinson's (parkinsonism syndrome)

Masked like faces, resting tremor, cogwheel rigidity, shuffling gait, and bradykinesia.

- commonly occurs after week or two of the medication

- results of dopamine blockade

EPSE

what meds can we give patients experiencing parkinsonism syndrome?

diphenhydramine (benadryl)

benzatropine (cogentin)

trihexyphenidyl (artane)

DiphBenzTri for parkinsonism

Akathisia

lots of energy, cannot sit --> restlessness/vague feeling of apprehension/irritability

- desire to move

- occurs after 3 or more wks of Tx

Ex: restless, tapping leg

EPSE

Tardive Dyskinesia

involuntary movements of the facial muscles, tongue, and limbs; a possible neurotoxic side effect of long-term use of antipsychotics

- lip smacking, etc.

SEVERE d/t IRREVERSIBLE

- late onset, could be on med for years

EPSE

first gen antipsychotic meds

Haloperidol (Haldol)

Chlorpromazine (Thorazine)

"azine's"

second generation (atypical) antipsychotics

used for...

- psychotic dx

- schizphrenia

- bipolar

- depression

- aggression

more metabolic s/sx

- increased weight

- increased BS

- hyperprolactinemia

- irregular cycle

second gen antipsychotic meds

Clozapine (Clozaril)

Risperidone (Risperdol)

Olanzapine (Zyprexa)

Quetiapine (Seroquel)

Ziprasidone (Geodone)

Apriprazole (Abilify)

Lurasidone (Latuda)

Paliperidone (Invega)

"idone" and "apine"

second gen - heart s/s

keep an eye, these can irritate the heart

Ziprasidone (Geodone)

Apriprazole (Abilify)

take w food --> bioavailability - binds w food

Risperidone (Risperdol)

black box warning for older adults (progress cognitive dx --> dementia)

Clozapine (Clozaril)

Agranulocytosis

can affect WBC --> s/s of infection/increased WBC is s/e

anticholinergic s/e

in general for all antipsychotics

- dry mouth

- blurry vission

- constipation

- urinary retention

- tachy

NMS

neuroleptic malignant syndrome

F - fever

E - encephalopathy --> change in LOC/confusion

V - vitals change --> high BP/HR

E - enzymes --> Cr-Phos, if high damages muscles (REGIDITY)

R - rigidity

comes from antipsychotic meds

antidepressants risks

- serotonin syndrome

- discontinuation syndrome

- sexual s/e

serotonin syndrome

With any drug that increases serotonin --> hyperthermia, confusion, myoclonus, cardiovascular instability, flushing, diarrhea, seizures.

- confusion

- h/a

- irritability

discontinuation syndrome

patient stops taking med (withdrawal, irritability, anxious, etc.)

ETOH w antidepressatns

is an antidepressant --> decreases effect

antidepressant - SSRI's

depression/anxiety, premenstrual dysphoric disorder, PTSD, OCD

SSRI meds

Fluoxetine (Prozac)

Sertraline (Zoloft)

Fluvoxamine (Luvox)

"xetine" and "opram"

- n/v

- constipation, diarrhea

- dry mouth

- h/a

- dizziness

- sleep disturbance

- tremor

- sexual s/e (erectile dysfunction)

SSRI common s/e

serotonin syndrome and serotonin discontinuation syndrome s/e's too !

SSRI's and antiepileptics

lowered seizure threshold

SSRI's and alcohol, benzodiazepines

increased sedation

SSRI's and warfarin, NSAIDs

increased risk of bleeding

SSRI's and MAOIs

hypertensive crisis

SSRI's and Buspirone (BuSpar), TCAs (especially clomipramine), selegiline (Eldepryl), St. John's Wort

serotonin syndrome

bruxism and SSRI's

zoloft, efexor cause

give busbar - helps w managing anxiety (can decrease bruxism)

bruxism

grinding teeth

Tricyclic antidepressants

Imipramine (Trofranil)

Amitriptyline (Elavil)

Nortriptyline (Pamelor)

"Triptyline" and "Pramine"

TCA's indication

depression/anxiety and pain

blocks serotonin and norepinephrine

- many CONTRA's

-N/V

-H/A

-Constipation

-Tachycardia

-Dizziness

-Ortho hypotension

-Dysrhythmias

-Blurred vision

-Sexual side effects

TCA's s/e

TCA's and MAOI's

High fever, convulsions, death

TACs and St. John's Wort, tramadol (Ultram)

Seizures, serotonin syndrome

TCAs and Clonidine (Catapres), epinephrine

severe HTN

TCAs and Acetylcholine blockers

paralytic HTN

TCAs and Alcohol and carbamezipine (Tegretol)

Blocks antidepressant action, increases sedation

TCAs and Cimetidine (Tagamet), bupropion (BuSpar)

Increased TCA blood levels, increased side effects

Monnamine Oxidase Inhibitors

MAOIs

Nar, Par, Mar

Nardil (phenelzine)

Parnate (tranyclypramine)

Marplan (isocarboxazid)

selegiline (emsam) trasndermal patch

MAOIs

depression/anxiety

Tyramine induced HTN crisis

- food, sluids, or meds w tyramine --> cheese syndrome

MAOIs and SSRIs, TCAs, atomoxetine (Strattera), duloxetine (Cymbalta), dextromethorphan (an ingredient in many cough syrups), venlafaxine (Effexor), St. John's Wort, ginkgo

serotonin syndrome

MAOIs and Morphine and other narcotic pain relievers,

antihypertensives

hypotension

MAOIs and All other antidepressants, pseudoephedrine, amphetamines, cocaine cyclobenzaprine (Flexeril), dopamine, methyldopa, levodopa, epinephrine, buspirone (BuSpar)

Hypertensive crisis (these side effects can occur even if taken within 2 weeks of stopping MAOIs)

MAOIs and Buspirone (BuSpar)

psychosis, agitation, seizures

MAOIs and antidiabetcis

hypoglycemia

MAOIs and Tegretol

fever, HTN, seizures

SNRIs

Venlafaxine (Effexor)

Duloxetine (Cymbalta)

antidepressant

NDRI

Bupropion (Wellbutrin)

depression/smoking and ADHD

SARI

Desyrel (Trazodone)

Venlafaxine (Effexor)

s/e HTN

Desyrel (Trazodone)

"trazobone"

often used at bedtime --> sedating effect, dreams

lithium and salt

lithium is a salt --> anything depleting sodium makes more receptors available = increased risk for lithium toxicity

need adequate fluid and salt intake

mood stabilizers

Lithium (eskalith, lithobid)

Lamotrigine (Lamictal)

Gabapentin (Neurontin)

Carbamazepine (Tegretol)

Lamotrigine (Lamictal)

risk for steven-johnson syndrome

- any concerns over skin, itch, etc. --> STOP

Gabapentin (Neurontin)

antianxiety and pain

Carbamazepine (Tegretol)

risk for agranulocytosis --> monitor WBC

Valporic Acid (Depakote)

mood stabilizor

most common for acute mania

monitor platelets and liver

lithium safe level

0.6-1.2

- diarrhea

- n/v

- ataxia

- tremors

- muscle

- weakness or unsteady gait

lithium toxicity s/s

lithium: watch...

kidney/thyroid as lithium can affect other organs

Anxiolytics

antidepressants (SSRI and others)

Benzodiazepines

Clonazepam (Klonopin)

Alprazolam (Xanax)

Lorazepam (Ativan)

DIazepam (Valium)

"Pam" and "Lam"

addicting - not long term

Anxiolytics: short acting

Alprazolam (Xanax)

Lorazepam (Ativan)

Anxiolytics: long acting

Clonazepam (Klonopin)

DIazepam (Valium)

Chlordiazepoxide ( Librium)

benzo

acute ETOH withdrawal

Clorazepate (Tranxene)

benzo

anxiety, sleeping, ETOH withdrawal

Oxazepam (Serax)

Benzo

Tx anxiety/depression and ETOH withdrawal

benzos

ETOH withdrawal mostly

Buspirone (Baspar)

works gradually (low dependence rate) --> helps w general anxiety

Propranol (Inderol)

helps w anxiety (brings BP down) helps w tremors

Clonidine (Catapres)

relaxes blood vessels (helps w withdrawal)

- Tx anxiety

Hydroxyzine (atarax/vistaril)

has antihistamine and sedative effect

- Tx anxiety

A 32-year-old female client arrives to the unit from the emergency department and reports an increase in anxiety. She reports that she is experiencing nausea. She reports that she has recently discontinued alprazolam (Xanax) and that she takes this medication on a regular basis. You note that the patient is sweating, becoming agitated, and having tremors. The nurse reviews the client’s assessment data to prepare the plan of care.

1.Administering buspirone (BuSpar) to decrease the patient’s anxiety

2.Contacting the doctor immediately to notify of signs/symptoms and notify that the patient recently discontinued alprazolam (Xanax)

3.Assessing the patient for signs of developing tolerance

4.Instructing the patient not to stop taking the drug abruptly in the future

4

Abrupt withdrawal of a benzodiazepine can be life-threating. The appropriate action is to contact the doctor immediately to notify of signs/symptoms and notify that the patient recently discontinued alprazolam (Xanax).

Which of the following medications would be an appropriate prn medication for an individual with anxiety symptoms?

a)Buspirone

b)Alprazolam

c)Fluoxetine

d)Sertraline

B

•Alprazolam is a benzodiazepine that works as a CNS depressant to produce quick-acting effects of relaxation in an individual with anxiety symptoms.

•Buspirone has a delayed effect and should not be used on a prn basis.

•Fluoxetine and sertraline may be used on a long-term basis with individuals who have anxiety disorders but are not effective on a prn basis for anxiety symptoms.

sedative-hypnotics

anxiety and insomnia

- Barbiturates ("barbitols")

- Benzodiazepines ("lam" and "pam")

- Eszopiclone ( Lunesta)

- Zaleplon (Sonata)

- Zolpidem ( Ambien)

** start them off ensuring they have sleep routine

methylphenidate (Ritalin)

ADHD agents: Tx narcoepsy + obesity

Clonidine (Catapres) and guanfacine (Tenex)...

Tx HTN, ADHD, opioid withdrawal

psychostimulants

- used for ADHD, narcolepsy, depression

Nausea, Weight loss, decreased appetite, headache, insomnia, tachycardia, nervousness

psychostimulants s/e

psychostimulants things to think about

- growth stage? apetite affected

- heart stuff? stimulant not good

Psychostimulants

Dextroamphetamine and Amphetamine (Adderall)

Dextroamphetamine (Dexedrine)

Lisdexamfetamine (Vyvanse)

Methylphendiate (Ritalin, Concerta)

A child is taking guanfacine for ADHD. Which of the following would be part of the client education associated with administration of this medication?

a)Do not take with foods that contain tyramine.

b)Always use sunblock when spending time outdoors.

c)Report for blood tests once a month.

d)Do not discontinue the medication abruptly.

D

•Clients taking an alpha agonist should not discontinue therapy abruptly.

•To do so may result in symptoms of nervousness, agitation, headache, and tremor, and a rapid rise in blood pressure.

•Dosage should be tapered gradually under the supervision of the physician.

Donepezil (Aricept)

Memantine (Namenda)

"mine"

cognitive enhancers

won't fix, but slow down progression

s/e - N,V, Diarrhea Constipation, weight loss, fatigue

Disulfram (antabuse)

Naltrexone (Revia)

Buprenorphine/Naloxone (Suboxone)

Acamprostate (Campral)

substance abuse

Disulfram (antabuse)

help w ETOH withdrawal

Naltrexone (Revia)

helps w ETOH/opioid

Acamprostate (Campral)

helps w balancing and reducing cravings

Serotonin Syndrome table

NMS table