NR210 Psychotropic Medication Study Guide Notes

Antipsychotics

• First-Generation / Conventional Antipsychotics (FGAs) (Haloperidol [Haldol], Chlorpromazine [Thorazine], Fluphenazine [Prolixin]):

  • Indications: Target positive symptoms of schizophrenia and agitation. Haldol may be given IM PRN for agitation.
  • Adverse Effects: Highest risk for extrapyramidal symptoms (EPS). Risks include tardive dyskinesia, orthostatic hypotension, Parkinsonian effects, increased prolactin, and anticholinergic effects.
  • Haldol Risks: Dysrhythmias, leukopenia, hypoglycemia, and dystonia.
  • Neuroleptic Malignant Syndrome (NMS): Characterized by fever, severe muscle rigidity, altered mental status/confusion, tachycardia, rapid breathing, sweating, and fluctuating BP.
  • Labs/Monitoring: LFT and lipid levels at baseline and every $3\,\text{months}$.
  • Patient Teaching: Take daily at the same time; do not stop abruptly or drink alcohol. Use sugarless gum for dry mouth; consume high-fiber foods and $2\text{--}3\,\text{L/day}$ of fluid.

• Second-Generation / Atypical Antipsychotics (SGAs) (Clozapine, Olanzapine, Quetiapine, Risperidone, Ziprasidone, Paliperidone):

  • Indications: First-line treatment for psychotic disorders/schizophrenia (positive and negative symptoms). Zyprexa and Seroquel may be used PRN for agitation. Paliperidone comes PO and as a long-acting injectable.
  • Contraindications/Precautions: Do not use for dementia-related psychosis.
  • Adverse Effects: Highest risk for metabolic side effects (weight gain, elevated lipids/glucose), sedation, agitation, sleep disruption, anticholinergic effects, EPS, NMS, tardive dyskinesia, and increased cardiac disease risk.
  • Labs/Monitoring: LFT, lipids, and A1C at baseline and every $3\,\text{months}$.

• Specific SGA Profile Differences:

  • Clozapine (Clozaril): Second-line for treatment-resistant schizophrenia (TRS). High risk for agranulocytosis (requires Absolute Neutrophil Count [ANC] monitoring) and hypersalivation.
  • Risperidone (Risperdal): Associated with galactorrhea and gynecomastia.
  • Aripiprazole (Abilify): Dopamine stabilizer with the lowest risk for EPS, tardive dyskinesia, weight gain, anticholinergic effects, and metabolic disorders.

Antidepressants

• Selective Serotonin Reuptake Inhibitors (SSRIs) (Fluoxetine [Prozac], Paroxetine [Paxil], Sertraline [Zoloft], Citalopram [Celexa], Escitalopram [Lexapro]):

  • Indications: First-line for MDD, anxiety, OCD, PTSD, social phobia, panic disorder, bulimia, PMDD.
  • Key Risks & Precautions: Avoid St. John's Wort due to Serotonin Syndrome risk. FDA warning for increased suicidality in patients under $24\,\text{years of age}$. Causes sexual dysfunction, initial anxiety/headache/N/V, sweating, and sleep disturbances.
  • Onset: Requires $4\text{--}6\,\text{weeks}$ for full effect ($6\text{--}12\,\text{weeks}$ for OCD, GAD, PTSD).
  • Citalopram (Celexa): QTc prolongation risk leading to torsades de pointes.
  • Fluoxetine (Prozac): Causes akathisia from serotonergic activation.

• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) (Venlafaxine [Effexor], Duloxetine [Cymbalta], Desvenlafaxine [Pristiq]):

  • Indications: Depression, GAD, social anxiety, panic disorder, PTSD, fibromyalgia, menopausal hot flashes.
  • Precautions & Adverse Effects: Caution in HTN; monitor BP and HR. Shares SSRI risks plus increased BP and increased HR.
  • Duloxetine (Cymbalta): Risks include liver toxicity (monitor LFTs), orthostatic hypotension, increased suicidal ideation, and hypoglycemia.

• Bupropion (Wellbutrin):

  • Indications: Depression, SAD, smoking cessation, ADHD, weight loss; adjunct for SSRI-induced sexual dysfunction.
  • Contraindications: Contraindicated in patients with seizure disorders, eating disorders, or those who are pregnant or lactating.
  • Adverse Effects: Tachycardia, insomnia, headache, dry mouth, GI distress, anticholinergic effects.

• Mirtazapine (Remeron):

  • Indications: Depression with insomnia, poor appetite, or weight loss.
  • Key Characteristics: Causes sedation, increased appetite, weight gain, elevated triglycerides/cholesterol, but no sexual dysfunction.

• Trazodone (Desyrel/Oleptro):

  • Indications: Insomnia and anxiety adjunct.
  • Key Risks: High sedation, dizziness, QT prolongation, fall risk, and rare priapism.

• Tricyclic Antidepressants (TCAs) (Amitriptyline [Elavil], Nortriptyline [Pamelor]):

  • Indications: Depression, OCD (clomipramine), neuropathic pain, sleep, migraine, ADHD.
  • Adverse Effects: Anticholinergic effects, orthostatic hypotension, cardiac arrhythmias, sedation, ototoxicity. Advise drinking at least $8\,\text{glasses of water/day}$.

• Monoamine Oxidase Inhibitors (MAOIs) (Phenelzine [Nardil], Isocarboxazid [Marplan], Tranylcypromine [Parnate], Selegiline [Eldepryl/Zeldapar]):

  • Key Risk: Hypertensive crisis when combined with tyramine-containing foods or other antidepressants/SSRIs.
  • Toxicity: Causes cardiac dysrhythmias, confusion, agitation, and seizures. Monitor ABGs during toxicity.

Anxiety Medications

• Propranolol:

  • Indications: Beta blocker used for panic attacks and physical symptoms of anxiety.
  • Nursing Care: Monitor HR and BP for $2\,\text{hours}$ post-initiation/dose changes. Hold if HR < $60\,\text{bpm}$.

• Benzodiazepines (Lorazepam, Alprazolam, Clonazepam, Diazepam, Temazepam):

  • Indications: First-line for acute rising anxiety levels, status epilepticus, alcohol withdrawal (CIWA), and CINV.
  • Adverse Effects: Sedation, respiratory depression, habit-forming/addictive potential.
  • Antidote: Flumazenil.

• Buspirone (Buspar):

  • Indications: Non-benzodiazepine, non-barbiturate anxiolytic for chronic GAD.
  • Key Characteristics: Non-sedating, non-addictive, no dependence issues. Takes $2\text{--}4\,\text{weeks}$ for full efficacy. Avoid alcohol and grapefruit juice.

Mood Stabilizers / Anticonvulsants

• Lithium (Eskalith):

  • Indications: Bipolar I mood disorder.
  • Therapeutic Range & Toxicity: Therapeutic range is $0.8\text{--}1.2\,\text{mEq/L}$. Toxicity occurs at $1.5\,\text{mEq/L}$.
  • Monitoring & Interactions: Monitor sodium, hydration, thyroid, and renal function (long-term use risks thyroid/kidney disease). NSAIDs, thiazide diuretics, ARBs, and ACE inhibitors increase lithium levels; caffeine and theophylline decrease levels.
  • Teaching: Do not double missed doses; do not take missed doses within $6\,\text{hours}$ of the next scheduled dose. Maintain consistent sodium and high fluid intake.

• Valproic Acid (Depakote):

  • Indications: Mood disorders/bipolar, impulsive aggression, seizures, migraines.
  • Key Risks: Teratogenicity, hepatotoxicity, pancreatitis, low platelets, increased ammonia levels, PCOS, weight changes, ataxia, and tremor.
  • Monitoring: Baseline LFTs, blood counts, and serum levels drawn $12\,\text{hours}$ post HS dose.

• Carbamazepine (Tegretol):

  • Indications: Bipolar acute mania, seizures, agitation, post-brain-injury impulsivity.
  • Adverse Effects: Stevens-Johnson syndrome (SJS), aplastic anemia, hyponatremia, elevated liver enzymes, and ataxia.
  • Interactions: Induces metabolism of oral contraceptives, Depakote, and Lamictal (lowering their levels).

• Lamotrigine (Lamictal):

  • Indications: Bipolar maintenance and seizure control.
  • Precautions: Requires slow dose titration. Discontinue immediately and call provider if a skin rash develops due to life-threatening Stevens-Johnson syndrome (SJS). Does not cause weight gain.

Alcohol Use Disorder Medications

• Disulfiram (Antabuse):

  • Mechanism: Acetaldehyde dehydrogenase inhibitor for aversion therapy.
  • Adverse Reaction: Causes severe illness (SOB, headache, violent N/V, cardiovascular collapse) if alcohol is consumed.
  • Teaching: Avoid all alcohol (including mouthwash, foods, medications). Patient must be off medication for $2\,\text{weeks}$ before consuming alcohol.

• Naltrexone (Revia/Vivitrol):

  • Indications: Alcohol use disorder and opioid use disorder; reduces cravings and blocks euphoric effects.
  • Requirement: Patient must be completely opioid-free for $7\text{--}10\,\text{days}$ before initiation to prevent precipitated withdrawal. Risk for hepatotoxicity.

• Acamprosate (Campral):

  • Indications: Restores GABA-glutamate balance to maintain alcohol abstinence and reduce withdrawal cravings.
  • Requirement & Renal Profile: Patient must be abstinent for $3\text{--}7\,\text{days}$ before initiation. Excreted renally (safe for use in liver disease).

Opioid Use Disorder / Overdose Medications

• Naloxone (Narcan):

  • Indications: Opioid overdose antidote.
  • Administration: Administer every $2\text{--}3\,\text{minutes}$ in alternating nostrils until respiration returns or emergency services arrive.

• Suboxone (Buprenorphine + Naloxone):

  • Indications: Mild-to-moderate OUD. Has a ceiling effect that reduces overdose risk.
  • Requirements & Risks: Require abstinence from opioids for > $12\,\text{hours}$ before first dose. Sublingual route risks dental decay/oral breakdown. Wait $30\,\text{minutes}$ to eat or drink post-administration.

• Methadone:

  • Indications: Full mu-opioid receptor agonist for OUD maintenance/detox and severe chronic pain.
  • Precautions: Long half-life. Onset takes $4\text{--}6\,\text{weeks}$ for full therapeutic effect. Requires baseline, $30\,\text{day}$, and annual EKGs due to QT prolongation risk.

EPS Medications and Terminology

• Benztropine (Cogentin): Anticholinergic used to treat drug-induced EPS (akathisia, dystonia, Parkinsonism).
• Valbenazine (Ingrezza): Used to treat tardive dyskinesia (TD).
• EPS Definitions:
  • Akathisia: Subjective inner anxiety/restlessness and physical inability to sit still.
  • Akinesia: Loss of voluntary muscle movement, Parkinsonian rigidity, and shuffling gait.
  • Ataxia: Loss of voluntary muscle coordination, clumsy movements, and impaired balance.
  • Dystonia: Involuntary muscle spasms, abnormal repetitive movements, cramps, and abnormal postures.