pharm 4 drug list (missing growth hormone & womens health)

Antipsychotic effect

blockade of dopamine Rs in the limbic system, controls the hallucinations, agitation, hyperactivity, delusions and paranoia NOT for dementia; also antiemetic effect

Chlorpromazine (largactil)

low potency

Haloperidol (haldol)

high potency

Chlorpromazine, haloperidol

first generation antipsychotic

Chlorpromazine, haloperidol (FGA) considerations

oral/IM, given in divided doses to start then at night as one dose, care with liver and kidney disease (elderly), excretion is very slow, slow onset of action (4 to 6 weeks), withdrawal slowly

Chlorpromazine, haloperidol (FGA ) ADR

(movement disorders), extrapyramidal side effects EPSE (acute dystonia, parkinsonism, akathisia, tardive dyskinesia), neuroleptic malignant syndrome, anticholinergic, orthostatic hypotension, sedation, dermatology, agranulocytosis (WBC)

Managing EPSE

anticholinergic (benztropine) \= acute dystonia, parkinsonmis, akathisia; NO CURE \= tardive dyskinesia

Clozapine, aripiprazole

second generation antipsychotics

Clozapine, aripiprazole (SGA) use

treat psychotic disorders, aripiprazole as adjunct therapy in depression

Clozapine, aripiprazole (SGA) action

dopamine and serotonin receptor blockers

Clozapine, aripiprazole (SGA) considerations

equally as effective as FGA, less likely to cause EPSE (including TD), BUT metabolic ADRs

Clozapine, aripiprazole (SGA) ADR

metabolic effects (wt gain, hyperglycemia, diabetes and dyslipidemia), anticholinergic, orthostatic hypotension, sedation, agranulocytosis

Depression

deficiency in brain amine neurotransmitters

Antidepressant drugs

increase levels of brain amines, help correct the imbalance in the neurotransmitters that affect mood and behavior

fluoxetine

SSRI (selective serotonin reuptake inhibitory) serotonin only

Fluoxetine (SSRI)

Selectively blocks the neuronal reuptake of serotonin (greater concentration of serotonin in the synaptic cleft \= compensate for serotonin deficiency in depressed patients)

Fluoxetine (SSRI) use

depression, anxiety disorders

Fluoxetine (SSRI) considerations

taken oral once a day in the morning, liver and kidney disease (elderly), effects usually seen after 1 to 4 weeks

Fluoxetine (SSRI) ADR

very few, very mild!! GI (NVD, dry mouth) CNS (nervousness, insomnia, HA), sexual dysfunction, sweating, wt gain, serotonergic syndrome (first few days, altered mental status, sweating, sudden fever

amitriptyline

Tricyclic antidepressants (TCA), NE and serotonin

amitriptyline (TCA)

block neuronal reuptake of monoamines compensate for MA deficiency in depression

amitriptyline (TCA) use

depression, some anxiety, pain syndromes

amitriptyline (TCA) ADR

less specific so more ADR than SSRI; sedation, ortho hypotension, anticholinergic effects, cardiac toxicity

amitriptyline (TCA) considerations

oral, effects after 3 weeks, liver and kidney disease (elderly), narrow TI, take at night

phenelzine

MAOIs monoamine oxidase inhibitor

Phenelizine (MAOI)

inhibit the enzyme MAO (prevents degradation of NE and serotonin (concentration increased)

Phenelzine (MAOI) use

depression unresponsive to other treatments, atypical depression, anxiety disorder

Phenelzine (MAOI) considerations

oral, liver and kidney disease (elderly), 2 to 3 week onset, effects persist 2 weeks after stopping treatment, care with narrow TI

Phenelzine (MAOI) ADR

orthostatic hypertension, cardiac toxicity, anticholinergic effect, narrow TI, food and drug interactions

Phenelzine (MAOI) food interaction

NO tyramine (leads to hypertensive crisis), avoid (aged cheese, avocados, chianti wine, pickled and smoked meats, soy sauce, tap beer) can cause \= cerebral hemorrhage, stroke, coma, death

MAOI + SSRI

serotonin syndrome

MAOI + TCA

hypertensive crisis

Mania

excess of brain amine (racing thoughts, reduced sleep)

Treatment of mania

decrease levels of brain amines (serotonin)

Lithium use

mood stabilizer, DOC for mania (long term), also used in bipolar

Disturbed sleep patterns

impending manic episode

Lithium considerations

monitor sleep patterns, oral, can cause kidney damage, narrow TI, constant blood monitoring, take with food, NO thiazide diuretics

Lithium if too high

drink fluids to dilute out

Lithium ADR

toxic drug, at therapeutic levels \= GI (NVD), polydipsia and polyuria, fine tremors in hands, lethargy and slurred speech

*Lithium range

0.6 to 1.2 mEq/L

*Lithium toxicity

causes generalized convulsions and death; weekly blood tests, higher \= more serious, (drink fluids to dilute out no antidote), toxicity aggravated by low sodium levels (can't get too low) (NO thiazide diuretics)

Carbamazepine (antiepileptic)

blocks sodium channels to decrease excitation, especially bipolar “fast cyclers”

diazepam /lorazepam

benzodiazepines “pam” (CNS depressants)

Benzodiazepines

widely used for anxiety and insomnia

Diazepam (benzo) use

short term anxiety

Lorazepam (benzo) use

sedation

Benzodiazepines other uses

diazepam and other benzos (anticonvulsants, anesthetics: short surgical procedures, muscle relaxant) potentiate GABA

diazepam /lorazepam (benzo) ADR

decreased mental alertness, drowsiness, morning sedation, HA, orthostatic hypotension, respiratory depression , NVD, allergic reaction, blurred vision, paradoxical reaction, short term memory issues

diazepam /lorazepam (benzo) considerations

do not drive, drink, care with other CNS depressants, REM sleep suppression, CARE with tolerance and dependence

diazepam /lorazepam (benzo) guidelines

limit number of prescriptions and doses, do not increase dose, only give for shortest effective period, dosage must be individualized, minimize withdrawal (do not stop abruptly (taper off gradually), warn about withdrawal effects

diazepam /lorazepam (benzo) patient teaching

can relieve symptoms temporarily but not solve underlying problems, non drug measures should also be used, avoid factors that cause nervousness or insomnia, drugs not for long term use, goal \= relieve anxiety and sleeplessness without permitting alertness to fall below safe levels, NO other CNS depressants

diazepam /lorazepam (benzo) CI

respiratory depression, hypersensitivity, pregnancy, lactation

diazepam /lorazepam (benzo) antidote

flumazenil (reverse sedation)

Flumazenil ADR

dizziness, agitation, confusion, NV, seizures

“Z drugs”

short term management of insomnia (not anxiety)

Zolpidem, zaleplon

insomnia short term management, benzodiazepine like action (act on GABA receptor but different site)

Barbiturates

once widley used, narrow TI and other ADRs, now only for anticonvulsants and anesthesia

methylphenidate (ritalin), amphetamine mixture (adderall)

CNS stimulant, ADHD

methylphenidate, amphetamine (CNS stim)

increase NE (improve attention) for ADHD

methylphenidate, amphetamine (CNS stim) ADRs

excessive CNS stimulation, wt loss, CV adverse effect, risk of dependence and abuse

methylphenidate, amphetamine (CNS stim) considerations

take after breakfast, then in early afternoon, give a drug holiday

Phenytoin

hydantoin, blocks sodium channels (decreased excitatory)

Phenytoin use

DOC for tonic clonic and partial seizures in adults

Phenytoin considerations

complex, narrow TI, low dose short ½ life, high dose long ½ dose (more risk of toxicity), *take at the same time each day, care with other CNS depressants

Phenytoin ADR

CNS (dizziness, drowsiness, HA), gingival hyperplasia, nausea, vomiting, hypotension, tachycardia, bone marrow suppression, nystagmus, urine discoloration, hirsutism, allergic rash

Phenytoin pregnancy

fetal hydantoin syndrome

Phenytoin toxic effects

sedation and cognitive impairment, visual disturbances (nystagmus, diplopia), ataxia, unsteadiness

Phenytoin drug interactions

induction of hepatic enzyme (more metabolism of other drugs; decreased efficacy of other drugs, warfarin, COCP) CNS depressant

Phenytoin drug levels

10 to 20 toxic \= over 30

Carbamazepine

iminostilbene class, block sodium channels (decrease excitatory)

Carbamazepine use

tonic clonic, partial seizures, also used to treat mania/bipolar

Phenytoin

Carbamazepine has less ADR than

Carbamazepine ADR

CNS (minimal effects on cognitive function), visual disturbances (ataxia, tolerance), BMS, birth defects, allergic rash, SJS, hepatotoxicity and pancreatitis

Ethosuximide

succinimide, block calcium channels (decrease excitatory)

Ethosuximide use

DOC for absence seizures

Ethosuximide ADR

drowsiness and lethargy (initially)

Barbiturates

potentiate GABA (increase inhibitory)

Barbiturates ADR

sedation, drowsiness, tolerance, dependence (less), NO pregnancy, narrow TI so danger of OD

Benzodiazepines

“pam, lam” potentiate GABA (increase inhibitory)

Benzodiazepines ADR

decreased mental alertness, drowsiness, morning sedation, HA, orthostatic hypotension, respiratory depression , NVD, allergic reaction, blurred vision, paradoxical reaction, short term memory issues

Levetiracetam

newer AED

Levetiracetam advantages

better tolerated, smaller risk to fetus, less drug interactions

Diabetes mellitus

high blood sugar level over prolonged period of time (polydipsia, polyuria, polyphagia)

Insulin preparations

short duration (\=6hrs) intermediate (12 hr) long (24hr)

Rapid onset insulin

lispro

Lispro (Rapid onset)

rapid onset \= 15 min; peak \= 1 to 3 hrs; duration \= about 6 hrs

Lispro (rapid onset) considerations

take in association with meals, clear solution (do not use if not clear), sub Q (IV in emergency)

Slower onset

regular insulin

Regular insulin (Slower onset)

onset \= 30 to 60 min; Peak \= 1 to 5 hrs; duration \= 8 hrs

Regular insulin (Slower onset) considerations

take hour before eating, clear solution (U100, U500), sub Q

Intermediate duration

NPH (neutral protamine hagedorn)

NPH (Intermediate duration)

onest \= 1hr; peak \= 8 to 10 hr; duration \= 12 to 20 hrs

NPH (Intermediate duration) considerations

cloudy suspension (rotate gently), sub Q, suspension (isophane insulin), allergic reaction possible, twice daily (basal control), often in conjunction with SA insulin (mix in same syringe 30/70)

NPH (Intermediate duration) mixture order

clear first then cloudy

Long duration

glargine

Glargine (Long duration)

onset \= 4hr; duration \= 24 hr

Glargine (Long duration) considerations

once daily, sub Q, clear solution

twice a day dosing

meal cover 2 and background cover; lack flexibility (bad if you skip a meal, have a large meal, or exercise a lot)

Basal bolus dosing

much better; give long acting and give rapid dosing when eating, very tight glucose control, huge flexibility, more complex, increased risk for hypoglycemia

Sub Q

best results in abdomen, change injection sites everyday, check for cloudiness or clumps, keep refrigerated (pens can be room temp for a month)