Pain and CNS medications

sedative and anxiety medications

• lorazepam

• alprazolam

sleep medications (hypotics)

• zolpidem

opioid pain management and reversal

• morphine

• naloxone

antidepressant and mood disorders

• Fluoxetine

• Amitriptyline

• phenelzine

• lithium

antipsychotics and severe illness

• haloperidol

seizure medications (anticonvulsants)

• phenytoin

• lamotrigine

• diazepam

neurologic movement disorder medications

• levodopa/Carbidopa

• benztropine

muscle relaxants and spasticity

• cyclobenzaprine

• baclofen

anesthesia and paralytics (critical care meds)

• propofol

• succinycholine

migraine medications

• sumatriptan

Lorazepam

• uses: acute anxiety, agitation, seizure control, pre-op sedation

• enhances GABA → CNS depression

• major risks: respiratory depression, oversedation

• older adults: delirium, falls, paradoxical agitation

• risk of dependence and w/d — taper, don’t stop suddenly

• sedative and anxiety med (Benzodiazepine)

• assess RR and depth, LOC, orientation before giving. and use with other sedating meds → respiratory arrest

• older adults can develop delirium, confusion, high fall risk

• abrupt cessation → rebound anxiety, tremors, insomnia, seizures. so taper gradually

alprazolam

• uses: anxiety, panic attacks

• fast onset → higher misuse/abuse risk (so use short term only)

• short-term use only — high dependence potential

• taper slowly to avoid w/d: rebound anxiety, insomnia, tremor, palpitations, seizures

• sedative and anxiety med

• Benzodiazepine

• check LOC, RR, o2 sat and screen for substance abuse disorder (risk of misuse)

• combining w opioids, alcohol, sleep meds, antihistamines → CNS and respiratory depression

zolpidem

• sleep med (hypnotic) non-benzodiazepine

• use: short-term treatment of insomnia

• promotes sleep via GABA receptors (non-benzo hypnotic)

• risks: sleepwalking, sleep-driving, complex sleep behaviors

• older adults: confusion, delirium, falls

• take right before bed, 7-8 hrs of sleep time needed

morphine

• opioid agonist

• moderate to severe pain mgmt, postoperative pain, cancer pain, PE, MI

• respiratory depression risk

• hold if rr <12

• assess LOC and BP before giving (risk of hypotension) and bowel function (constipation → ileus)

• risk of bradycardia, urinary retention, respiratory depression, hypotension, constipation → ileus

• do not drink alcohol

• increase fluid intake, fiber, activity. bowel regimen needed. report severe drowsiness or breathing difficulty

naloxone

• opioid antagonist reversal for opioid OD

• reverses opioid overdose by knocking opioids off receptor sites

• fast onset, short duration

• may require repeat dosing bc short T1/2 (30-90mins)

• monitor respirations continuously, pulse, and responsiveness

• sudden awakening and w/d symptoms may occur: agitation, sweating, nausea/vomiting, tachycardia, pain return

fluoxetine

• SSRI: increases serotonin in the brain.

• uses: 1st line for depression, anxiety, OCD, PTSD, PMDD

• takes 4-6 weeks for full effect

• black box: increases suicidal thoughts in young people

• watch for serotonin syndrome

• antidepressants and mood disorders

• assess: mood, energy, sleep, appetite, ability to perform daily activities

• serotonin syndrome: too much serotonin → agitation, confusion, sweating, fever, tachycardia, tremor, hyperreflexia, diarrhea

• possible side FX: GI upset, headache, insomnia, sexual dysfunction

amitriptyline

• TCA - older antidepressant now used for chronic pain, migraines, insomnia

• strong sedation and anticholinergic effects

• dangerous in overdose → cardiac toxicity (cardiotoxicity and arrhythmias)

• side effects: anticholinergic: dry mouth, constipation, urinary retention, blurred vision

• causes orthostatic hypotension and fall risk (sedation) esp in older adults

• antidepressant and mood disorders

• take at bedtime bc of sedation. taper gradually. change positions slowly

• report: chest pain, palpitations, fainting, or severe constipation/urinary retention

phenelzine

• MAOI: raises NE, serotonin, dopamine

• requires strict tyramine-restricted diet

• risk: HTN crisis bc of Tyramine build up from MAO being inhibited → massive release of NE → severe HTN, headache, stroke risk

  • sudden severe headache, stiff neck, nausea, vomiting, palpitations, HTN, chest pain, sweating, confusion

  • stop med if this happens (emergency)

• many drug interactions (avoid SSRIs, decongestants, SNRIs, TCAs, cold meds)

• used when other antidepressants fail

• antidepressant and mood disorders

lithium

• mood stabilizer for bipolar disorder

• narrow therapeutic range (0.6-1.2 mEq/L)

• hydration and sodium intake must be stable otherwise kidneys retain more lithium -→ toxicity (push fluids)

• early toxicity: GI upset, tremor, confusion

• monitor lithium level, kidney, and thyroid function

haloperidol

• treats positive symptoms (hallucinations, delusions)

• high risk for EPS (dystonia, akathisia, tardive dyskinesia)

  • acute dystonia: painful muscle spasms

  • parkinsonism: tremor, rigidity, shuffling gait

  • akathisia: intense inner restlessness, can’t sit still

  • tardive dyskinesia: involuntary repetitive movements

• risk of neuroleptic malignant syndrome (NMS)

  • fever, severe muscle rigidity, confusion, unstable BP, tachycardia (emergency, stop drug asap)

• monitor prolongation of QT interval - potential for arrhythmias

• ongoing adherence critical

• antipsychotic blocks dopamine receptors; effective for symptoms of schizophrenia and acute agitation, aggression

phenytoin

• seizure medications (anticonvulsants)

• treats tonic-clonic seizures by stabilizing neuronal membranes

• narrow tpx range (10-20 mcg/mL phenytoin)

• toxicity: nystagmus (twitching eyes), ataxia (unsteady gait), slurred speech, confusion, double vision

• causes gingival hyperplasia

  • swelling and overgrowth of gums

• major side FX: bone marrow suppression (monitor CBC), rash (steven-johnson syndrome), arrhythmias

• never stop abruptly

• assess baseline mental status, coordination, gait before giving, changes may = toxicity

lamotrigine

• used for seizures and bipolar disorder; blocks sodium channels to reduce neuronal firing for depressive episodes of bipolar

• risk of stevens-johnson syndrome

• must be titrated slowly, otherwise risk of SJS increases

• report any rash immediately bc it can → blistering, peeling, mucosal involvement

diazepam

• benzodiazepine used for acute seizures/status epilepticus, alcohol w/d

• rapid onset by enhancing GABA, suppressing abnormal electrical activity

• high risk for respiratory depression - assess RR, breathing pattern, o2 sat and LOC

• short-term use only bc strong CNS depressant, long T1/2 and high risk of dependence

• emergency seizure medications (anticonvulsants) not used daily

• side effects to monitor: hypotension, RR depression, confusion, unsteady gait (fall)

Levodopa / Carbidopa

• neurologic and movement disorder medications

• increases brain dopamine

• avoid high-protein meals. and take 30 mins before meals

• wearing-off effect

• uses: Parkinson’s to reduce bradykinesia, rigidity, tremors, shuffling gait

• monitor motor symptoms and ADL performance, dyskinesia (involuntary movements) which indicates excess dopamine

• AE: orthostatic hypotension, hallucinations/confusion, dark urine/sweat, dyskinesieas

benztropine

• anticholinergic for tremors/rigidity Parkinsonian and EPS from antipsychotics

• helps with EPS

• avoid overheating

• caution in elderly - confusion, hallucinations, falls

• neurologic and movement disorder medications

• anticholinergic effects: dry mouth, blurred vision, urinary retention, constipation, tachycardia and overheating (blocks sweating) → risk of heat stroke

• teachings: increase fluids and fiber

cyclobenzaprine

• short-term muscle spasm relief

• strong sedation → fall risk

• teaching: avoid alcohol/driving, drink fluids and use gum for dry mouth

• report heart palpitations or severe dizziness

• muscle relaxant and spasticity

• side effects: significant sedation (similar to mild TCA), dry mouth, dizziness, confusion esp in elderly

• safety: avoid CNS depressant and use short-term only

baclofen

• used for spasticity from MS or spinal cord injury - reduces reflex activity in spinal cord

• do not stop abruptly

  • can cause seizures, delirium, high fever, rebound spasticity (life threatening)

• monitor in neurologic PTs

  • assess muscle tone, spasticity, function

  • monitor LOC, sedation, fall risk

• sedation common

• teaching: avoid alc and sedatives, report hallucinations, severe sedation, muscle weakness

Propofol

• anesthesia and paralytics (critical care meds)

• rapid anesthesia/sedation

• risk: hypotension and apnea, bradycardia - airway equipment must be at bedside

• continuous airway, breathing, circulation monitoring

• contra: egg/soy allergy

succinycholine

• rapid paralysis for intubation

• risk: malignant hyperthermia

  • increase in CO2, muscle rigidity, temp inc, tachycardia

  • stop med, administer dantrolene and cool PT with 100% o2

• requires ventilatory support

• short duration

• paralytic for critical care med - muscle depolarization → fasciculations → flaccid paralysis

• must administer sedation/analgesia before paralyzing PT, ensure airway equipment is ready

• monitor potassium levels (hyperkalemia)

Sumatriptan

• migraine med by vasoconstriction of dilated cranial blood vessels

• treats acute migraine (not for prevention)

• vasoconstricts cranial blood vessels

• avoid in CAD/HTN, Stroke/tia, prinzmetal angina

• take at onset of migraine

• major risks:

  • chest pressure or tightness

  • hypertension

  • serotonin syndrome if taken w SSRI/SNRI

• report chest pain