Antiepileptics, anxiety drugs & sedative-hypnotic drugs

Phenytoin (Dilantin) MOA

decreases Na+ into cell

Phenytoin (Dilantin) indications

partial and tonic-clonic seizures, post-neuro sx

• Off-label antiarrhythmic, severe preeclampsia

Phenytoin (Dilantin) nursing considerations

Therapeutic range: 10-20mcg/mL

• Toxicity >20mcg/mL

Dose adjustments: levels Q 5-7 days, taper off discontinuation

Take with food

AEs: Nystagmus, ataxia, dysarthria, slurred speech, mental confusion, tremor, headache, insomnia, hirsutism, gingival hyperplasia (20% of patients), increased glucose level, teratogenic effects, and purple glove syndrome

Vesicant

Carbamezapine (Tegretol) MOA

Delayed recovery of sodium channels from their inactivated state.

Carbamezapine (Tegretol) indications

first drug of choice for focal seizures, generalized onset of tonic-clonic seizures, role of management in BPD and pain relief.

Carbamezapine (Tegretol) AE

Nystagmus and ataxia, Leukopenia, anemia, and thrombocytopenia, Rash and photosensitivity reaction

Food and drug interactions: warfarin, oral contraceptives, phenytoin, phenobarbital, and grapefruit juice.

Carbamezapine (Tegretol) nursing considerations

Monitor CBC and PLT,

Monitor serum blood levels of medications

Educate on food and drug Interactions

IV 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.

Valproate-divalproex (Depakote) indications

all types of seizures, migraine HA, and bipolar disorder.

Valproate-divalproex (Depakote) nursing considerations

Take with food to avoid n/v, fatal hepatoxicity (rare), avoid liver dysfunction pts.

Check LFTs

Highly teratogenic

Comes in Delayed Release, Extended Release and Immediate Release

Life-threatening pancreatitis

Oxcarbazepine (Oxtellar XR, Trileptal) MOA

↓ Na+ into cell

Oxcarbazepine (Oxtellar XR, Trileptal) indications

mono and adjunctive therapy for management of focal seizures

Oxcarbazepine (Oxtellar XR, Trileptal) nursing considerations

Altered renal function

Oxcarbazepine (Oxtellar XR, Trileptal) AE

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.

Topiramate (Topamax) 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.

Topiramate (Topamax) nursing considerations

Dizziness, weight loss, drowsy,& cognitive effects.

Metabolic acidosis

Suicide risk

Kidney stones, glaucoma & paresthesias are rare

Gabapentin (Neurontin) MOA

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

Gabapentin (Neurontin) 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

Gabapentin (Neurontin) AE

Somnolence, dizziness, ataxia, fatigue, nystagmus, and peripheral edema.

Gabapentin (Neurontin) 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

Levetiracetam (Keppra)

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

Levetiracetam (Keppra) MOA

Unknown (PO or IV)

Levetiracetam (Keppra) indications

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

Levetiracetam (Keppra) AE

drowsiness and asthenia

Neuropsychiatric symptoms (agitation, anxiety, depression, hallucinations)

Drug interaction: Does not interact with other antiseizure drugs

Levetiracetam (Keppra) 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.

Paroxetine (Paxil) indications

GAD, OCD, and Major Depression Disorder

Paroxetine (Paxil) AE

Neuroleptic malignant syndrome, suicidal thoughts, stevens johnson syndrome, serotonin syndrome, dizziness, drowsiness, anxiety, headache, insomnia, weakness, constipation, dry mouth, sweating

Paroxetine (Paxil) nursing implications

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.

Buspirone(Buspar) indications

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

Buspirone(Buspar) AE

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

Buspirone(Buspar) 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)

Diazepam (Valium) 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)

Diazepam (Valium) AE

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

Diazepam (Valium) 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 depressants

Alprazolam (Xanax)

PO benzodiazepine

Alprazolam (Xanax) MOA

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

Alprazolam (Xanax) indications

Anxiety disorders and procedural anxiety

Off-label for acute treatment of vertigo

Alprazolam (Xanax) AE

Central nervous and respiratory system depression

Anterograde amnesia

Paradoxical effects, including excitation and euphoria

Abuse and misuse

Alprazolam (Xanax) nursing considerations

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

Administer IV flumazenil (Romazicon) as a reversal agent due to its benzodiazepine receptor antagonist effects

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

Zolpidem (Ambien)

PO sedative-hypnotic

Zolpidem (Ambien) MOA

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

Zolpidem (Ambien) AE

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

Zolpidem (Ambien) 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