Pharm exam 4 - Psych drugs part 1

What is schizophrenia?

• Chronic psychotic disorder

• Affects ability to think clearly, perceive reality, and express emotions

• Characterized by episodes of psychosis with periods of remission or partial remission

• Usually requires lifelong managemen

What causes schizophrenia?

• Exact cause is unknown

• Thought to result from a combination of:

  • Genetic factors

  • Neurobiological changes (brain chemistry/structure)

  • Environmental (nongenetic) factors

What are the three symptom categories of schizophrenia?

• Positive: Added behaviors (hallucinations, delusions, disorganized speech/behavior)

• Negative: Loss of normal function (flat affect, lack of motivation, social withdrawal)

• Cognitive: Problems with attention, memory, and executive functioning

Positive schizophrenia

• Hallucinations

• Delusions

• Agitation

• Disordered speech

• Bizarre behaviors

Negative schizophrenia

• Social withdrawal

• Poor self care

• Lack of motivation

• Poverty of speech

• Blunted affect

Cognitive schizophrenia

• Disordered thinking

• Lack of focus

• Learning disability

• Memory problems

What are the two Main Classes of Antipsychotics

First generation antipsychotics

Second generation antipsychotics

What are the similarities between FGAs and SGAs

- Pharmacology is very similar
- Effectiveness is about the same

What are the differences between FGAs and SGAs

- Adverse effects & tolerance vary greatly

What is the prototype for First generation antipsychotics?

Chlorpromazine

Chlorpromazine MOA:

• block several receptors in the CNS – dopamine, Acetylcholine, histamine, norepinephrine
• Takes 2-4 weeks, several months for full effect
• Inhibits Positive symptoms best

How is Chlorpromazine classified?

By potency

• low, medium, high
• Contributes to severity of adverse effects

Chlorpromazine administration:

• Give with food
• Swallow whole- do not crush
• IM into large muscle- lie flat for 30 minutes
• Antacids/antidiarrheals- 2 hours

What are FGAs adverse effect?

Extrapyramidal Symptoms (EPS)

• more neurological effects

What are the Extrapyramidal Symptoms (EPS)?

• Acute Dystonia

• Parkinsonism

• Akathisia

• Tardive Dyskinesia

What is Acute Dystonia?

Extrapyramidal Symptoms (EPS)

• occurs hours to days, spasm of tongue, face, neck, back

What is Parkinsonism?

Extrapyramidal Symptoms (EPS)

• Occurs within 1 month
• Looks just like Parkinson’s Dz (tremor, rigidity, shuffling, drooling)

What is Akathisia?

Extrapyramidal Symptoms (EPS)

• Occurs within 2 months
• Pacing, restless, agitated, squirming, need for constant motion

What is Tardive Dyskinesia?

Extrapyramidal Symptoms (EPS)

• Occurs months to years
• Involuntary twisting, writhing movements of tongue and face, progresses to difficulty speaking, swallowing, down the body

What are other FGA adverse effects?

• Neuroleptic Malignant Syndrome
• “lead pipe” muscle rigidity, sudden very high fever, labile BP, dysrhythmias
• Anticholinergic effects
• Orthostatic hypotension
• Neuroendocrine effects (gynecomastia & galactorrhea)
• Sedation
• Seizures
• Sexual dysfunction
• Agranulocytosis
• Dysrhythmias
• Photosensitivity

FGA contraindications:

Alcohol withdrawal
Bone marrow suppression
CNS depression
Pregnancy and lactating

FGA precautions:

COPD
Glaucoma
DM
HTN
Prostatic hypertrophy
Thyroid/cardiac/liver disorders

FGA interactions:

• Anticholinergic drugs

• CNS depressants

• Levodopa and direct dopamine receptor agonists

• Overdose of FGAs: Hypotension, CNS depression, EPS

What are SGAs also called?

Atypical Antipsychotics

What is SGA prototype?

risperidone (Risperdal)

What do SGA inhibit?

both positive and negative symptoms

risperidone (Risperdal) MOA:

• block dopamine & serotonin receptors in the CNS
• Takes 2-4 weeks, several months for full effect

risperidone (Risperdal) uses:

Schizophrenia, Bipolar Disorder, irritability associated with Autism

risperidone (Risperdal) administration:

• Oral solutions mix with juice, milk, water, coffee
• Remove from packaging immediately before admin
• Long-acting IM every 2 weeks

SGA Adverse Effects

• Extrapyramidal Symptoms (less likely, but can still occur)
• Neuroleptic Malignant Syndrome
• Metabolic effects: Weight gain, Diabetes, Hyperlipidemia
• Myocarditis (rare)
• Anticholinergic effects
• Orthostatic hypotension
• Neuroendocrine effects (gynecomastia & galactorrhea)
• Sedation
• Seizures
• Sexual dysfunction
• Agranulocytosis
• Dysrhythmias
• Photosensitivity

More metabolic effects

SGA contraindications:

• Breastfeeding (Lactating)
• Severe CNS disorders
• ECG abnormalities
• Psychosis
• Increased risk for CVA or stroke

SGA precautions:

• Frequently exposed to sunlight or tanning beds
• Children younger than 13 (Schizophrenia)
• Caution: Older adults with Parkinson’s, Liver and renal disorders, Hypotension, Seizure disorders, Fluid or electrolyte imbalances, DM, Seizure disorders

SGA interactions:

• Phenytoin (Phenobarbital), Rifampin- decrease risperidone levels
• Antiparkinson’s Drugs- may have an increase in Parkinson's’ symptoms

Nursing Considerations Antipsychotics

Patient/family Education
• EPS and to notify provider if symptoms appear
• Tips to help anticholinergic effects (sip liquids, chew gum, lubricating eye drops, increase fluids & fiber)
• Move slowly when standing (orthostatic hypotension)
• Avoid driving & alcohol and take med at bedtime (sedation)
• Notify provider if sexual effects are bothersome (low libido, ED)
• Report nipple discharge (neuroendocrine effects)
• Report signs of infection immediately (agranulocytosis)
• Report fatigue, dyspnea, tachypnea, chest pain, & palpitations (myocarditis)

Key teaching points Antipsychotic Medications

• Administer safely (oral/IM; don’t crush tablets)

• Teach:
  Report fever, stiffness, or abnormal movements
  Avoid alcohol or CNS depressants
  Maintain balanced diet and exercise

What are the goals of Antipsychotics therapy?

• Suppress acute episodes

• prevent exacerbations

• promote high quality of life and function

Symptom control and minimize side effects

What disorders are FGA and SGA Antipsychotics used for?

schizophrenia or bipolar disorder

What is depression?

Most common psychiatric disorder
• Depressed mood, loss of pleasure or interest in nearly all of one’s usual activities
Treatment can help!
• 30% achieve full remission with medication
• 50% improve symptoms with medications

What does treatment include for depression?

1. Pharmacotherapy (meds)
2. Psychotherapy (counseling)
3. Somatic therapy (ECT or TMS)

Antidepressants: shared properties

Response takes several weeks
• Initial response in 1-3 weeks (watch for SI)
• Maximal therapeutic response in 12 weeks
All classes are equally effective, but have different adverse effects & interactions
Drug choice based on tolerability and safety

What are the different types of antidepressants?

• TCAs amitriptyline

• SSRIs Fluoxetine

• SNRI Venlaxafina

• MAOIs Phenelzine

• Atypical Bupropion

What is Tricyclic Antidepressants (TCAs) prototype?

amitriptyline

amitriptyline MOA:

• prevents reuptake of norepinephrine (NE) and serotonin
• Also blocks histamine, acetylcholine, and NE receptors (causes many side effects)

amitriptyline uses:

Depression, insomnia, pain

amitriptyline administration:

• PO- at bedtime, well-absorbed
• Several weeks to exert therapeutic relief
• Continue using the drug for 6 to 12 months to prevent relapse
• DO NOT STOP ABRUPTLY- Taper over 2 weeks
• Withdrawal sx- headache, anxiety, muscle pain, nausea
• Risk for overdose- dysrhythmias, confusion, seizures
• Treatment- gastric lavage > activated charcoal > sodium bicarb

amitriptyline interactions:

• MAOIs (severe HTN)
• Sympathomimetics
• Anticholinergics
• CNS depressants
• Herbal supplements (St. John’s wart)
• H2 blocker: cimetidine (Tagamet)

amitriptyline adverse effects:

• Orthostatic hypotension
• Sedation
• Anticholinergic effects
• Diaphoresis
• QT prolongation
• Seizures
• Hypomania
• Suicide risk
• Overdose can be deadly

amitriptyline nursing considerations:

• Monitor BP
• Advise night-time
• Advice for anticholinergic effects
• Monitor EKG
• Monitor for seizures
• Monitor for suicidal ideation
• Should not stop abruptly

Avoid alcohol, OTC sleep meds, and herbal supplements

amitriptyline actions:

Monitor: BP, EKG (QT prolongation), seizure activity, mental status
Assess: for suicidal ideation (especially early in therapy)
Encourage: adherence and follow-up appointments
Document: side effects and teaching provided

amitriptyline contraindications:

children younger than 12, recent MI, cardiac dysrhythmias, MAOI

amitriptyline caution:

angle closure glaucoma, prostatic hypertrophy, urinary retention, liver/renal disorders, respiratory disorders, DM, alcoholism

What is Selective Serotonin Reuptake Inhibitor (SSRIs) prototype?

fluoxetine (Prozac)

fluoxetine (Prozac) MOA:

Prevents 5-HT (receptors) reuptake of serotonin

• increases serotonin only

• improves mood, anxiety, sleep

fluoxetine (Prozac) uses:

depression, panic disorder, OCD, premenstrual dysphoric disorder, and bulimia nervosa; (first choice)

fluoxetine (Prozac) administration/ absorption:

• PO, well-absorbed
• 94% protein-bound

fluoxetine (Prozac) metabolism:

• Initially converted to norfluoxetine, an active metabolite
• total T1/2 ~ 9 days

fluoxetine (Prozac) interactions:

• Any drug that increases serotonin activation (MAOIs, herbal supplement)
• TCAs & lithium (fluoxetine raises the levels of these drugs)
• Antiplatelets & anticoagulants (fluoxetine displaces warfarin for protein binding)
• NSAIDS increase the risk of GI bleeding

fluoxetine (Prozac) adverse effects:

• Nausea & HA
• Insomnia
• Sexual dysfunction
• Weight gain
• Hyponatremia
• Withdrawal syndrome
• Serotonin syndrome
• Suicidal Ideation

What is serotonin syndrome?

• A group of symptoms caused by excessive accumulation of serotonergic transmission in the CNS
• Develops within hours or days
• Risk higher with concurrent use of other drugs that increase serotonin

What is serotonin syndrome symptoms:

• Altered mental status – agitation, confusion, disorientation, hallucinations, poor concentration
• Increased SNS activity – incoordination, hyperreflexia, excessive sweating, tremor, fever
• Can be fatal if not treated

What is serotonin syndrome symptoms treatment:

stop the SSRI

What is the Serotonin/Norepinephrine Reuptake Inhibitor (SNRIs) prototype?

venlafaxine (Effexor XR)

Teaching for SSRI:

Takes weeks to feel better → don’t stop early
Never stop abruptly (withdrawal)
Take with food if nauseated
Report agitation, tremor, confusion, or fever
Avoid NSAIDs, St. John’s Wort, and MAOIs

Teaching for SNRI:

Takes weeks to feel better → don’t stop early
Never stop abruptly (withdrawal)
Take with food if nauseated
Report agitation, tremor, confusion, or fever
Check BP regularly
Avoid NSAIDs, St. John’s Wort, and MAOIs

venlafaxine (Effexor XR) MOA:

Block the neuronal uptake of both serotonin and norepinephrine
• Similar to SSRIs

• increases serotonin and norepinephrine

• improves mood + energy/focus

venlafaxine (Effexor XR) uses:

major depression, social anxiety, generalized anxiety

venlafaxine (Effexor XR) adverse effects:

• Similar to SSRI
• Most common- Nausea
• Also, anorexia, serotonin syndrome, and HTN

venlafaxine (Effexor XR) administration:

• Start low and titrate
• DO NOT STOP ABRUPTLY- taper
• Withdrawal sx- anxiety, tremors, headache, tachycardia, nausea, tinnitus, vertigo

venlafaxine (Effexor XR) contraindications:

• MAOI or within 14 days of last dose
• Same as other SSRIs

venlafaxine (Effexor XR) interactions:

• Trazadone and St. John’s Wort- increase Serotonin Syndrome
• Cimetidine (Tagamet)- increase blood levels of SNRI

Nursing Considerations SSRI/SNRI

• Serotonin syndrome
• Suicide risk
• Educate that effects will build slowly
• Don’t stop the drug abruptly (SNRI > SSRI)
• Report sexual dysfunction
• Monitor for headaches and weight throughout therapy
• Monitor blood pressure
• Monitor serum sodium level
• Less than 7 should not take
• Caution for older adults and clients who have liver disease, peptic ulcer disease, or diabetes

What is MonoAmine Oxidase Inhibitors (MAOIs) prototype:

phenelzine (Nardil)

phenelzine (Nardil) MOA:

• irreversibly inhibits MAO (enzyme that degrades 5-HT, NE, & dopamine)
• Allows more uptake of NE & serotonin

MAOIs increase serotonin, norepinephrine, and dopamine
Effective but carry serious risks

phenelzine (Nardil) uses:

depression, OCD

phenelzine (Nardil) pharmacokinetics:

• PO, well-absorbed
• There is a patch- Emsam

phenelzine (Nardil) interactions:

• Get ALL new meds approved (OTC & Rx)
• TCAs & SSRIs
• Meds for HTN
• Dietary tyramine

phenelzine (Nardil) adverse effects:

• CNS stimulation
• Orthostatic hypotension
• GI symptoms- N/V, constipation
• Hypertensive crisis (from dietary tyramine)

Foods Containing Tyramine

a dietary substance that promotes the release of NE from sympathetic neurons

• Cheese, meats, pizza, wine, soy sauce, avacado, beer

phenelzine (Nardil) nursing considerations:

• Monitor for CNS stimulation
• Monitor BP, education to stand slowly
• Monitor for suicidal ideation, mental status
• Educate on foods to avoid and alcohol

• Do not take new meds or supplements without approval

• Educate on s/s of hypertensive crisis

  • severe headache, chest pain, or palpitations

phenelzine (Nardil) contraindications:

for clients older than 60 or younger than 6; taking an SSRI, or have a history of glaucoma or alcohol or drug addiction
• Use with caution in patients who have epilepsy, DM, schizophrenia, or mania

What is the Atypical Antidepressants prototype?

bupropion

bupropion MOA:

Prevents reuptake of NE & dopamine

Increases norepinephrine and dopamine levels
NE = focus & energy
Dopamine = motivation & pleasure
Does not affect serotonin → fewer sexual side effects

bupropion uses:

Depression, smoking cessation aid

bupropion administration/absorption:

• PO, well absorbed
• Do not crush/chew XR
• Metabolized by CYP P450 enzyme

bupropion benefits:

• Weight loss
• Increased libido

bupropion interactions:

• Some SSRIs (d/t CYP enzymes, use lowest bupropion dosage)
• MAOIs (can cause bupropion toxicity)

bupropion adverse effects:

• Seizures
• CNS stimulation (agitation, tremors, tachycardia, insomnia)
• N/V
• Increased risk for psychosis, hallucinations, delusions, as well as suicidal ideation (young)

bupropion nursing considerations:

• Monitor for seizures
• Thorough health history
• Educate to take in AM
• Give with food to decrease GI symptoms
• Monitor weight (anorexia)
• Monitor for CNS effects
• Discuss to take exactly as prescribed to avoid accidental overdose

Do NOT crush chew or double dose

What are the anxiety disorders?

Generalized Anxiety Disorder (GAD)
Panic Disorder
Obsessive-Compulsive Disorder (OCD)
Social Anxiety Disorder
Post-Traumatic Stress Disorder (PTSD)

General Anxiety Disorder treatment:

• Serotonin Reuptake Inhibitors (SRIs)

  • Selective Serotonin Reuptake Inhibitors (SSRIs)

  • Serotonin/Norepinephrine Reuptake Inhibitors (SNRIs)

• Benzodiazepines (not first line)

• Anxiolytic drug: buspirone

What is the anxiolytic drug?

buspirone

buspirone MOA:

Unclear, but thought to bind to serotonin receptors (and some dopamine receptors)
• Not a CNS depressant, but just as effective
• No abuse potential
• No cross-dependence with benzos
• Therapeutic effect takes 1 week - take weeks to work — don’t stop early

buspirone uses:

First-line, non-sedating anxiety control

buspirone administration/absorption:

• PO daily- not PRN
• Begin drug therapy 2 to 4 weeks before tapering Benzodiazepines
• Food delays absorption

buspirone adverse effects:

• Nausea
• HA
• Dizziness/ Lightheadedness
• Sedation in some, excitement in others

buspirone interactions:

• Grapefruit juice, erythromycin, ketoconazole (can increase buspirone levels)
• Concurrent use with MAOIs can cause severe HTN

avoid grapefruit juice and MAOIs

buspirone nursing considerations:

• Make sure clients report any occurrences of paradoxical, GI, or CNS effects
• Suggest taking with food
• Suggest OTC analgesic for relief of HA
• Advise slow positional changes
• Caution use in clients who have liver or kidney insufficiency