Neurologic and Psychotheraputic Agents

status epilepticus

a continuous seizure state (15 minutes)

partial/focal seizure

• one hemisphere of the brain

• simple

• complex

• secondary generalized seizure

generalized seizure

• both hemispheres involved

• tonic-clonic (grand mal)

• absence (petit mal)

• atonic

• myoclonic

• status epilepticus

• febrile seizure

treatments for epilepsy and seizures

• vagus nerve simulator

• ketogenic diet (low carb, high fat)

• individually tailored

  medication, surgery, focal resection, hemispherectomy, corpus callosotomy surgery

important to check in antiepileptic drugs

plasma levels for therapeutic range

Phenytoin (Dilantin)

MOA: decreases Na into cell

For: partial and tonic-clonic seizures, post neuro sx

• off label antiarrythmic, severe preeclampsia

AE: nystagmus, ataxia, slurred speech, mental confusion, tremor, gingival hyperplasia (20% of pt’s), increased glucose level, teratogenic effects, purple glove syndrome

NC: therapeutic range is 10-20mcg/mL

take with food

is a vesicant, tears up the blood vessels

Carbamezapine (Tegretol)

MOA: blocks the sodium channels (delayed recovery of sodium channels from their inactivated state)

For: 1st drug of choice for focal seizures, generalized onset of tonic-clonic seizures, also for BPD and pain relief

AE: nystagmus and ataxia (muscle problems)

luekopenia, anemia, and thrombocytopenia, rash and photosensitivity

food and drug interactions: warfarin, oral contraceptives, phenytoin (dilantin), phenobarbital, and grapefruit juice

NC: monitor CBC and PLT, monitor serum blood levels of medications, educate food/drug interactions In solutions administered over 30 minutes

Valproate-divalproex (Depakote)

MOA: Increase availability or enhance the action of the GABA receptor site. This is a pre-curser of valproic acid that separates into valproic acid in GI tract

For: all seizure types, migraine HA and bipolar.

NC: take with food to avoid N/V, fatal hepatotoxicity (rare) avoid liver dysfunction patients.

Check LFTs

Highly teratogenic

Comes in Delayed Release, Extended Release and Immediate Release

Life-threatening pancreatitis

Oxcarbazepine (Oxtellar XR, Trileptal)

MOA: decreases Na into cells

Indications: mono and adjunctive therapy for management of focal seizures

Nursing considerations:

Altered renal function

AEs: dizziness, drowsiness, double vision, nystagmus, headache, ataxia, hyponatremia, hypothyroidism, Stevens-Johnson Syndrome, hypersensitivity

Take without regard to food

XR tablets – swallow whole

↓ effectiveness of oral contraceptives

Multiple drug interactions

Topiramate (Topamax)

MOA: blockade of NA+,CA + & glutamate; potentiation of GABA inhibition.

Indications: 2 yrs for adjunct therapy for focal seizures, primary generalized tonic-clonic seizures and associated with Leenox-Gastaut Syndrome.

Off label bipolar, migraine prophylaxis, neuropathic pain, essential tremors, binge-eating disorders.

Nursing Considerations: Dizziness, weight loss, drowsy,& cognitive effects.

Metabolic acidosis

Suicide risk

Kidney stones, glaucoma & paresthesias are rare

Gabapentin (Neurotin)

MOA: Unknown but may enhance GABA release, thereby increasing GABA inhibition of neuron firing.

    Indications: Adjunctive therapy of focal-onset seizures

Off-label use: Neuropathic pain, prophylaxis of migraine, treatment of fibromyalgia, and relief of postmenopausal hot flashes, bi-polar disorder

Adverse Effects: Somnolence, dizziness, ataxia, fatigue, nystagmus, and peripheral edema.

Nursing Considerations: Advise the patient that gabapentin can be taken with or without food.

      Instruct to swallow extended-release tablets without breaking, crushing, dissolving, or chewing.

       Inform to take gabapentin at bedtime to minimize adverse effects.

        Do not suddenly stop gabapentin due to the increased risk of seizures

Levetiracetm (Keppra)

Unique agent that is chemically and pharmacologically different from all other antiseizure drugs

Mechanism of action: Unknown (PO or IV)

Indications:  Adjunctive therapy for myoclonic, focal-onset,  and generalized-onset tonic-clonic seizures

Adverse effects: drowsiness and asthenia

Neuropsychiatric symptoms (agitation,        anxiety, depression, hallucinations)

Drug interaction: Does not interact with other antiseizure      drugs

Nursing Considerations: IV infusion over 15 minutes  Monitor RBC, WBC, and LFT

Paroxetine (Paxil)

MOA: inhibits neuronal reuptake of serotonin in the CNS-SSRI, thus potentiating the activity of serotonin has little effect on norepinephrine or dopamine.

Indications: GAD, OCD, and  Major Depression Disorder

Adverse Effects: Neuroleptic malignant syndrome (fever, shakes, effects BP), suicidal thoughts, stevens johnson syndrome, serotonin syndrome, dizziness, drowsiness, anxiety, headache, insomnia, weakness, constipation, dry mouth, sweating

Nursing Inmplications:  Assess for suicidal tendencies and Serotonin Syndrome

Monitor for development of neuroleptic malignant syndrome (fever,   respiratory distress, tachycardia, seizures, diaphoresis, HTN or     hypotension, pallor, tiredness)

Inform patient that frequent mouth rinses, good oral hygiene and sugarless gum or candy may minimize dry mouth

Advise patient to notify HCP if headache, weakness, anorexia, anxiety or insomnia persists

Buspirone (Buspar)

MOA: mechanism to relieve anxiety is unknown but it binds with high affinity to receptors for serotonin and lower affinity to receptors for dopamine.

Indications: Treatment of anxiety for patients who are known to abuse alcohol or other drugs.

Adverse Effects: Dizziness, nausea, headache, nervousness, lightheadedness, excitement, paresthesia, sleep disturbances, chest pain, tinnitus, nasal congestion, sore throat

Nursing Implications: Do not administer concurrently with MAOI or grapefruit juice            

May lead to dizziness, drowsiness, fatigue, and weakness        Patient may experience chest pain, palpitations, tachycardia      Instruct patient to take as directed                                        Instruct patient to avoid alcohol and other CNS depressants

                                                 

Diazepam (Valium)

MOA: enhances the action of GABA (PO/IM/IV)

Indications: anxiety, sedation, muscle relaxation, decreased seizure activity with a few general type seizures-not all, and treatment of status epilepticus (Used with a long acting anti-convulsant)

AE: dizziness, drowsiness, depression, slurred speech, HA, N/V, constipation, rash, dry mouth, sexual dysfunction

Nursing Implications:

gradual withdrawal is recommended

     avoid driving if drowsiness occurs        

     notify MD if pregnant

     increase fluids consumed

      rise slowly from a seated position

      avoid caffeine

      avoid other CNS depressant

Fluoxetine (Prozac) SSRI

MOA:  blocks reuptake of serotonin increases serotonin in in the brain

Produces CNS excitation

Indications: major depression, bipolar disorder, panic disorder, OCD

~4 weeks to reach a steady state

Nursing implications:

Common AEs: weight gain, nausea, suicidal thoughts, sexual dysfunction, insomnia

Serotonin syndrome: begins w/in 2-72 hours

Concurrent use of MAOIs increases risk (shivers acronym)

Confusion, agitation, disorientation, anxiety, AMS

Spontaneous resolution when medication stopped

Venlafaxine (Effexor XR) SNRI

MOA: blocks reuptake of serotonin and norepinephrine, gives more serotonin and norepinephrine in the body

SSRIs may be better tolerated

Indications: GAD, major depression, social anxiety disorder, panic disorders

Nursing implications:     

Common AEs: N/V, headache, HTN, nervousness, anorexia,insomnia 

Taper over 2 weeks to avoid withdrawal  

Serotonin syndrome       

Imipramine (Tofranil) tricyclic antidepressant

MOA: block reuptake of serotonin and norepinephrine – multiple pathways

Prolonged half-life = once daily dosing

Indications: depression, bipolar disorder, fibromyalgia syndrome

Nursing implications:

Common AEs: sedation, orthostatic hypotension, anticholinergic effects: dry mouth, blurred vision, urinary retention, constipation, tachycardia, photophobia

Serious AEs: cardiac toxicity, sudden death

Overdose: lethal dose = 8x average therapeutic dose

Treatment = gastric lavage, activated charcoal

Give suicidal patients 1-week supply = minimize overdose

Phenelzine (Nardil) MAOI’s

MOA: block monoamine oxidase, ↑ NE, dopamine, serotonin, and tyramine

Indications: depression, bulimia nervosa, panic disorder, PTSD, OCD

Nursing implications: does not work well with other drugs, and is last resort for depression med

Common AEs: orthostatic hypotension, many drug interactions

Hypertensive crisis when tyramine-rich foods are consumed

MAO Inhibitors AE

• sweating

• dizziness

• increased pounding HR

• NO cheese, wine, pickled foods

Bupropion (Wellbutrin)

atypical antidepressants

MOA: blocks dopamine and/or NE reuptake

Effects seen 1-3 weeks

Indications: major depression, prevention of SAD, unlabeled ADHD

Zyban or Buproban (bupropion): smoking cessation

Nursing implications:

Common AEs: agitation, headache, dry mouth, constipation, weight loss, GI upset, dizziness, tremor, insomnia, blurred vision, tachycardia, seizures

NO sexual dysfunction all is wellbutrin

weight loss AE considerations

Look at patients BMI prior to administering, do not give if anorexic or if have risk of seizures

weight loss AE medications

• Bupropion (Wellbutrin)

• Venlafaxine (Effexor XR) SNRI

• Topiramate (Topamax)

• Amphetamine-dextroamphetamine (Adderall)

Alprazolam (Xanax)

•PO benzodiazepine

•MOA: Potentiates GABA’s effects by increased neuronal membrane permeability of chloride ions

•Indications:

  Anxiety disorders and procedural anxiety; drug of choice for anxiety

  Off-label for acute treatment of vertigo

•Adverse Effects:

  Central nervous and respiratory system depression

  Anterograde amnesia

  Paradoxical effects, including excitation and euphoria

  Abuse and misuse

•Nursing Considerations:

  Adverse effects may often be worsened due to concurrent CNS depressant use

  Antidote: IV flumazenil (Romazicon)

  Monitor for anxiety signs and symptoms and progression while on   pharmacotherapy along with non-pharmacological treatment measures

Zolpidem (Ambien)

•PO sedative-hypnotic

•MOA: Potentiates GABA’s effects via selective agonism at the benzodiazepine-1 receptor to increase chloride conductance to help with insomnia

•Adverse Effects:

  Central nervous system depression, including next-day     drowsiness and decreased mental alertness

  Complex sleep behaviors

  Other psychiatric and behavioral effects, including hallucinations, delirium, and worsening of depression

  Withdrawal with chronic administration of supratherapeutic doses

Women need half the dose that men do

•Nursing Considerations:

  Rapid onset (30 minutes) can help with people having difficulty falling asleep and duration (6 - 8 hours) can help with people staying asleep

  Should only be used if insomnia cannot be managed by other means, including non-drug measures, and by addressing any underlying pathology

Acute Dystonia

Spasm of muscles of the tongue, face, neck, and back

Parkinson’s

Bradykinesia, masklike facies, tremor, rigidity, shuffling gait, drooling, stooped posture

Akathisia

Compulsive, restless movement, symptoms of anxiety, agitation

Tardive Dyskinesia

Oral-facial dyskinesiasthat develop after prolonged use of antipsychotic medications, characterized by involuntary movements of the face, tongue, and limbs.

Haloperidol

1st generation antipsychotic

•MOA: Blocking dopamine receptors in the brain.

•High potency —> give less

•Peaks 2-6 hrs

•Indications: Schizophrenia, acute psychosis, & Tourette's syndrome

•Nursing implications:

•Common AEs: acute dystonia, parkinsonism, akathisia.

•Uncommon AE: sedation, hypotension, and anticholinergic effects.

•Caution with dysrhythmias causes long QT syndrome.

•Neuroleptic malignant syndrome-high fever, BP fluctuation, dysrhythmias, muscle rigidity, diaphoresis, tachycardia, & change in LOC.

•Stop antipsychotic medication! 

Neuroleptic Malignant Syndrome Acronym

FEVER

Fever

Encephalopathy

Vs unstable

Elevated CPK Rigidity

Clozapine (Clozaril)

2nd generation antipsychotic

MOA: Blockade of receptors for dopamine and serotonin.

•High potency

•Peaks 2-6 hrs

•Indications: Schizophrenia only

•Nursing implications:

•Common AEs: sedation, weight gain, ortho stat hypotension, constipation, urinary retention & sexual dysfunction.

•Linked to metabolic effects-DM, dyslipidemia, & obesity.

•Do not use with dementia related psychosis

•Uncommon AE: Agranulocytosis occurs in 1-2% of pts, myocarditis and extrapyramidal symptoms. 

Ziprasidone (Geodon)

•MOA:  PO/IM antagonism of dopamine type 2 (D2) and serotonin type 2 (5-HT2). Also antagonizes α2-adrenergic receptors

•Indication: Schizophrenia; IM form is reserved for control of acutely agitated patients. Bipolar mania (manic and manic/mixed episodes)

•Adverse Effects: CNS: NEUROLEPTIC MALIGNANT SYNDROME, seizures, dizziness, drowsiness, restlessness, extrapyramidal reactions, syncope, tardive dyskinesia. CV: PROLONGED QT INTERVAL, orthostatic hypotension. GI: constipation, diarrhea, nausea, dysphagia. Derm: rash, urticaria.

•Nursing Considerations: Assess heart rate, ECG, and heart sounds

•* Be alert for new seizures or increased seizure activity

•* Assess motor function and be alert for extrapyramidal symptoms.

• *Administer IM in dorsal gluteal/ventral gluteal for acutely agitated  patients and ask for assistance in holding patient

Lithium (Lithobid) - mood stabilizer

•MOA: unknown – may block serotonin receptor binding, alter glutamate uptake/release, inhibiting glycogen synthase kinase

•Neuroprotective/neurotrophic = ↓ atrophy, ↑ neuron growth

•Indications: Acute manic episodes, prophylaxis mania/depression

•Nursing implications: keep levels < 1.5mEq/L

•Therapeutic range: 0.4 – 1mEq/L

•Common AEs: GI upset, muscle weakness, fine hand tremors, polyuria, lethargy, slurred speech

•Monitor kidney, thyroid, and Na+ levels

DO NOT DRINK ALCOHOL!

•Improvement 5-7 days, full benefits 2-3 weeks

•ADEQUATE HYDRATION

•Drug Interactions: Diuretics, NSAIDS, ACE inhibitors, and anti-cholinergic

Divalproex sodium (Valproate)

Antiepileptic Drug

•Mixture of valproic Acid and sodium salts.

•Antiseizure medication approved for BPD.

•Prevent acute mania relapse.

•Lithium reduces suicide better than valproic acid.

•Start 250 mg TID, maintenance 1000-2500 mg/day.

•Adverse effects: thrombocytopenia, pancreatitis and liver failure.

Antiepileptic drugs used for Bipolar

•Carbamazepine (Tegretol)

•Reduces symptoms of manic episodes

•Target trough plasma level: 4 to 12 mcg/mL

•AE: neurological side effects, hematologic side effects

•Please refer to previous slide

•Lamotrigine (Lamictal)

•MOA: Block sodium channels and decrease release of glutamate

•Indicated for long-term maintenance

•Used to prevent affective relapses into mania or depression

•Can be used alone or in combination with other drugs

•AE: headaches, dizziness, double vision, and SJS.

Adderall

•MOA:  PO CNS stimulant causes the release of NE and dopamine and partly inhibits the reuptake of both transmitters.

•Indications: ADD and narcolepsy

•AE: physical dependence, abuse. Insomnia, restlessness, extreme weight loss, tachycardia, HTN, psychosis.

•Nursing implications: Inform patients about drug holidays

        Inform patients to take medication in the morning.
       Educate patients on abstinence syndrome from abrupt

       withdrawal.

      Avoid use with MAOIs and other CNS Stimulants

Modafanil (Provigil)

•Nonamphetamine stimulant

•MOA: unclear but does inhibit activity of sleep-promoting neurons

•Indications:  Narcolepsy, OSAHS, and shift work sleep disorder. Those who work night shift, take one hour before shift starts.

•AE: generally well tolerated, HA, N/V, diarrhea, tachycardia, and HTN

•Nursing Implications: Monitor alertness Monitor Vital Signs Educate patients on taking in AM or 1-hour before “shift”. Monitor any breathing problems, and report difficult/labored breathing reduced pulse     oximetry values, or other signs of lung dysfunction.

Methylphenidate (RItalin)

MOA: promotion of NE and DA release, inhibition of NE and DA reuptake

works different than the others, leaves more in the body

For: ADHD and narcolepsy

AE: insomnia, reduced appetite, emotional liability, and abuse liability

NC: same as amphetamines

The nurse identifies the mechanism of action of the amphetamines as what? (Select all that apply.)

A. causing the release of norepinephrine

C. causing the release of dopamine

D. inhibiting the reuptake of norepinephrine

E. inhibiting the reuptake of dopamine release

Which medication should the nurse question prescribed to a patient taking lithium?

Furosemide (Lasix)

Renal function should be evaluated before the administration of Lithium, patients with reduced renal function are at risk for lithium toxicity

What are the s/s of lithium toxicity?

polydipsia, slurred speech, and fine hand tremors

Think of a person getting pulled over and they seem drunk - however it is just lithium toxicity

T/F: older patients require smaller doses of antipsychotics?

True; typically 30-50% of older patients require a smaller dosage

A patient is diagnosed with type 2 diabetes mellitus and schizophrenia. The nurse will closely monitor the blood sugar if the patient receives which medication for the treatment of schizophrenia?

Clozapine (Clozaril)

2nd generation antipsychotics carry a higher risk of serious metabolic effects (such as diabetes and dyslipidemia) than 1st generations (loxapine, thioxene, haloperidol). Clozapine should be used with caution in patients with diabetes.

What are manifestations are associated with tardive dyskinesia?

Twisting, worm-like movements of the tongue and face

2nd & 3rd generation antipsychotics

MOA: 2nd blocks serotonin & < dopamine receptors

3rd stabilize dopamine system both agonist and antagonist.

1st generation antipsychotics

MOA: blocks dopamine, acetylcholine, histamine and norepinephrine receptors in the brain and periphery