psychopharmacotherapy
Terms
undefined, object
copy deck
- clozapine
-
Clozaril
Atypical Antipsychotics
Not the first line; refractory cases only! - clozapine (Clozaril) mechanism
- Blocks the dopamine receptors in the limbic system rather than those in the neostratal area of the basal ganglia.
- clozapine (Clozaril)side effects/toxic effects
-
1. Can produce fatal side effect by suppressing bone marrow and induce agranylocytosis rendering patient prone to infection. Regular WBC is mandatory: weekly for the first 6 months and then biweekly.
2. Can induce convulsions and myocarditis. Monitor patient closely.
3. High seizure rate (increases the risk for seizure).
4. Significant weight gain (67%)
5. Excessive salivation
6. Tachycardia -
clozapine (Clozaril)
EPSs, ACh, OH, Sed? - No, High, High, High
- risperidone
-
Risperdal
Atypical Antipsychotics - risperidone (Risperdal)
- treats delusions, and hallucinations without motor abnormalities
- risperidone (Risperdal)complications
-
1. orthostatic hypotension
2. sedation
3. weight gain (18%)
4. sexual dysfunction.
5. insomnia
Compliance issues; Talk to patient. - risperidone (Risperdal)Serious SE
- Increased CVA in elderly with dementia and being treated for agitation.
-
risperidone (Risperdal)
EPSs, ACh, OH, Sed? - Mild, Very Low, Moderate, Low
- quetiapine
-
Seroquel
Atypical Antipsychotics - quetiapine (Seroquel) mechanism
- binds and antagonizes D1, D2, 5-HT1, α1, α2, and H1.
-
quetiapine (Seroquel)
side effects -
1. orthostatic hypotension
2. drowsiness
3. weight gain (23%)
4. headache -
quetiapine (Seroquel)
EPSs, ACh, OH, Sed? - Low, Mide, Moderate, Moderate
- olanzapine
-
Zyprexa
Atypical Antipsychotics -
olanzapine (Zyprexa)
mechanism - antagonizes D2, 5-HT1, α1, α2, H1, and muscarinic receptors.
-
olanzapine (Zyprexa)
side effects -
1. sedation
2. significant weight gain (34%)
3. insomnia
4. agitation and restlessness
5. possibly akathisia or parkinsonism
6. hyperglycemia, and new on-set of type 2 diabetes. -
olanzapine (Zyprexa)
EPSs, Ach, OH, Sed? - Low, Moderate, Moderate, Low
- ziprasidone
-
Geodon
Atypical antipsychotic -
ziprasidone (Geodon)
mechanism - Serotonin-norepinephrine reuptake inhibitor and also binds to 5-HT1, D2, α, and H1.
-
ziprasidone (Geodon)
Main effect/SE: -
1. ECG changes
2. Low propensity for weight gain
3. Targets depressive symptoms
4. hypotension
5. sedation -
ziprasidone (Geodon)
Caution: - can cause prolongation of the QT interval. Not to be used with other drugs known to prolong QT interval. Check Patient history for cardiac arrhythmias, perform ECG and blood chemistry for magnesium and potassium level.
- aripiprazole
-
Abilify
Atypical antipsychotic -
aripiprazole (Abilify)
mechanism - Dopamine system stabilizer, function as a partial agonist at the D2 receptor.
-
aripiprazole (Abilify)
SE: -
1. sedation
2. hypotension
3. anticholinergic effects
4. Low propensity for weight gain or increase in glucose, HDL, LDL, or triglyceride levels. -
aripiprazole (Abilify)
EPSs, Ach, OH, Sed? - Low, Low-mild, Low-mild, Low
-
ziprasidone (Geodon)
EPSs, Ach, OH, Sed? - Low, Mild, Mild, Low
- Typical (Traditional) Antipsychoyics (7)
-
haloperidol (Haldol)
trifluoperazine (Stelazine)
flupenazine (Prolixin)
Thiothixene (Navan)
loxapine (Loxitane)
molindone (Moban)
chlorpromazine (Thorazine) - haloperidol ()
- Haldol
- trifluoperazine ()
- Stelazine
- flupenazine ()
- Prolixin
- Thiothixene ()
- Navan
- loxapine ()
- Loxitane
- molindone ()
- Moban
- chlorpromazine ()
- Thorazine
- SE/Adverse effects of Typical (Traditional) Antipsychoyics
-
1. EPS
2. Neurobiological effects (sedation, apathy, flat effects)
3. ACh effects
4. Skin rash
5. photosensitivity
6. weight gain
7. withdrawal symptoms of gastritis, nausea, vomitting, headache, tachcardia, insomnia, and dizziness.
8. reduction of seizure thresshold
9. orthostatic hypotension
10. galactorrhea
11. sexual dysfuction -
haloperidol (Haldol)
special considerations -
1. Has low sedative properties; is used in large dose for assultive client to avoid the severe side effect of hypotension
2. Appropriate for the elderly for the same reason as above; lessen the chance of fall from dizziness or hypotension
3. High incidence of EPSs.
2. -
trifluoperazine (Stelazine)
special considerations -
1. Low sedative effects- good for symptoms of withdrawal or paranoia
2. High incidence of EPSs
3. Neuroleptic malignant syndrome may occur. -
flupenazine (Prolixin)
special consideration - among the least sedating
-
Thiothixene (Navan)
special consideration - High incidence of akathisia
-
chlorpromazine (Thorazine)
special considerations -
1. Increases sensitivity to the sun
2. Highest sedative and hypotensive effects; least potent
3. May cause irreversible retinitis pigmentosa at 800 mg/day - Lithium Carbonate (Eskalith, Lithobid)
-
Mood Stabilizers
Mood stabilizing drug in clients with mania (bipolar) and depression affect electrical conductivity in neurons. Level initial and maintenance. -
Lithium Carbonate (Eskalith, Lithobid)
Special considerations -
1. Because lithium represents a potential threat to body functions that are regulated by electrical activity it can induce cardiac dysrhythmias or convulsions, extreme motor dysfunction.
2. Disturbance of calcium and potassium by Lithium, it can altered with the body's ability to regulate fluid balance and the distribution of fluid leading to polyuria, edema, and risk of kidney and thyroid disease.
3. LOWEST THERAPUTIC INDEX: check drug level frequently. -
Lithium Carbonate (Eskalith, Lithobid)
Side Effects -
1. Nervous and Muscular: tremor, ataxia, confusion, convulsion.
2. Digestive: Nausea, vomiting, diarrhea
3. Cardiac: Arrhythmias
4. Fluid and Electrolytes: polyuria, polydipsia, edema
5. Endocrine: Goiter and hypothyroidism - Antiepileptic Drugs (6)
-
Carbamazepine (Tegretol, Valproic Acid, Clonazepam)
Divalproex (Depakote)
Lamotrigine (Lamictal)
Gabapentin (Neuerontin)
Topiramate (Topamax)
Clonazepam (Klonopin) - Carbamazepine ()
-
Tegretol, Valproic Acid, Clonazepam
Antiepileptic - Divalproex ()
-
Depakote
Antiepileptic - Lamotrigine ()
-
Lamictal
Antiepileptic - Gabapentin ()
-
Neuerontin
Antiepileptic - Topiramate ()
-
Topamax
Antiepileptic - Clonazepam ()
-
Klonopin
Antiepileptic -
Carbamazepine (Tegretol, Valproic Acid, Clonazepam)
Indications - - Treatment of bipolar disease, reduce the firing rate of very high frequency neurons in the brain can reduce mood swings, reduce excitement of the manic phase, effective in conditions such as trigeminal neuralgia that involve paroxsysms (bursts) of severe pain, analgesic reduce firing rate and calm.
-
Carbamazepine (Tegretol, Valproic Acid, Clonazepam)
SE -
1. nausea
2. sedation
3. ataxia
4. rash may occur. -
Carbamazepine (Tegretol, Valproic Acid, Clonazepam)
Special considerations - - Recommended baseline laboratory: Liver function tests (AST, ALT), CBC, ECG, and electrolytes levels. Also monitor the therapeutic blood level regularly.
-
Divalproex (Depakote)
Indications - First-line treatment for bipolar disorder
-
Divalproex (Depakote)
SE/ special considerations -
SE:
hair loss, tremor, weight gain, and sedation.
Serious SE: thrombocytopenia, pancreatitis, hepatic failure, and birth defects.
Baseline level: liver function, CBC, and therapeutic blood level. - Neuroleptic malignant syndrome is characterized by:
-
1) decreased level of consciousness
2) greatly increased muscle tone
3) autonomic dysfunction including:
Hyperpyrexia (over 103)
Labile hypertension
Tachycardia
Tachypnea
Diaphoresis
Drooling. - Treatment of Neuroleptic malignant syndrome consists of:
-
1) early detection
2) discontinuation of the antipsychotic agent
3) management of fluid balance
4) reduction of temperature
5) monitoring for complications. - Medications for the treatment of Neuroleptic malignant syndrome are:
-
Mild cases of neuroleptic malignant syndrome are treated with bromocriptine (Parlodel)
more severe cases are treated with intravenous dantrolene (Dantrium) and even with electroconvulsive therapy in some cases. - Pseudoparkinsonism:
-
masklike fades, stiff and
stooped posture, shuffling
gait, drooling, tremor, "pill-rolling" phenomenon -
Pseudoparkinsonism:
Onset - 5 hours-30 days
-
Pseudoparkinsonism:
Nursing Measures -
Alert medical staff.
An anticholinergic agent (e.g., trihexyphentdyl [Artane] or benztropine [Cogentin]) may be used - Acute dystonic reactions:
-
acute contractions of
tongue, face, neck, and
back (tongue and jaw first)
Opisthotonos: tetanic
heightening of entire body,
head and belly up
Oculogyric crisis: eyes
locked upward -
Acute dystonic reactions:
Onset - 1 -5 days
-
Acute dystonic reactions:
Nursing Measures -
First choice: diphenhydramine hydrochloride (Benadryi) 25-50 mg IM/IV. Relief occurs in minutes.
Second choice: benztropine, 1-2 mg IM/IV. Prevent further dystonias with any anticholinergic agent.
Experience is very frightening. Take client to quiet area and stay with him or her until medicated. - Akathisia:
-
motor inner-driven restlessness (e.g.,
tapping foot incessantly,
rocking forward and backward in chair, shifting weight from side to side. -
Akathisia:
Onset - 2 hours-60 days
-
Akathisia:
Nursing Measures -
Physician may change antipsychotic agent or give antiparkinsonian agent.
Tolerance does not develop to akathisia, but akathisia disappears when neuroleptic is discontinued.
Propranolol (Inderal), lorazepam (Ativan), or diazepam (Vaiium) may be used. -
Tardive dyskinesia:
Onset - Months to years
-
Tardive dyskinesia:
Nursing Measures -
No known treatment Discontinuing the drug does not always relieve symptoms.
Possibly 20% of clients taking these drugs for >2 years may develop tardive dyskinesia.
Nurses and doctors should encourage clients to be screened for tardive dyskinesia at least every 3 months. - Agranulocytosis:
-
symptoms include sore throat, fever, malaise, and mouth sores.
It is a rare occurrence, but a possibility the nurse should be aware of; any flulike symptoms should be carefully evaluated. -
Agranulocytosis:
Onset - Usually occurs suddenly and becomes evident in the first 12 weeks
-
Agranulocytosis:
Nusing Measures -
Blood work usually done every week for 6 months, then every 2 months.
Physician may order blood work to determine pres ence of leukopenia or agranulocytosis. If test results are positive, the drug is discontinued, and reverse isolation may be initiated. Mortality is high if the drug is not ceased and if treatment is not initiated. - Cholestatic jaundice:
-
rare, reversible, and usually benign if caught in time; prodromal symptoms are fever, malaise, nausea, and abdominal pain; jaundice
appears 1 week later. -
Cholestatic jaundice:
Nusing Measures - Discontinue drug; give bed rest and high-protein, high-carbohydrate diet. Liver function tests should be performed every 6 months.
- Neuroleptic malignant syndrome (NMS):
-
somewhat potentially fatal. Severe extrapyramidal: severe muscle rigidity, oculogyric crisis, dysphasia, flexor-extensor posturing, cogwheeling
Hyperpyrexia: elevated temperature (over 103° F or 39° C)
Autonomic dysfunction: hypertension, tachycardia, diaphoresis, incontinence. -
Neuroleptic malignant syndrome (NMS):
Onset -
Can occur in the first week of drug therapy but often occurs later.
Rapidly progresses over 2 to 3 days after initial manifestation. -
Neuroleptic malignant syndrome (NMS):
Risk factors -
Concomitant use of psychotropics
Older age
Female gender (3:2]
Presence of a mood disorder (40%)
Rapid dose titration -
Neuroleptic malignant syndrome (NMS):
Nusing Measures -
Stop neuroleptic.
Transfer STAT to medical unit.
Bromocriptine (Parlodel) can relieve muscle rigidity and
reduce fever.
Dantrolene (Dantrium) may reduce muscle spasms,
Cool body to reduce fever
Maintain hydration with oral and IV fluids.
Correct electrolyte imbalance.
Arrhythmias should be treated.
Small doses of heparin may decrease possibility of
pulmonary embolism
» Early detection increases client's chance of survival. - Bupropion
-
(Wellbutrin)
(Zyban)
Atypical antidepressants -
Bupropion (Wellbutrin)(Zyban)
Advantages: -
Sexual dysfunction rare
No weight gain
Stimulant properties
Antianxiety properties -
Bupropion (Wellbutrin)(Zyban)
Adverse Effects -
Medication-induced seizures if over 300 mg.
High seizure risk in "at risk" individuals.
Some nausea - Trazodone
-
(Desyrel)
Atypical antidepressants -
Trazodone (Desyrel)
Advantages: -
No anticholinergic side effects
low potential for cardiac effects
In conjunction with other antidepressants, can aid sleep -
Trazodone (Desyrel)
Adverse Effects -
Possible priapism
Postural hypotension
Weight gain
Memory dysfunction - Venlafaxine
-
(Effexor)
Atypical antidepressants
Dual-Action Reuptake Inhibitors—SNRIs (Serotonin and Norepinephrine) -
Venlafaxine (Effexor)
Advantages: -
Useful for treatment-resistant chronic depression
Low potential for drug interaction -
Venlafaxine (Effexor)
Adverse Effects -
Possible increase in blood pressure (10-15 mm Hg)
Possible somnolence, dry mouth, and dizziness - Mirtazapine
-
(Remeron)
Atypical antidepressants
Dual-Action Reuptake Inhibitors—SNRIs (Serotonin and Norepinephrine) -
Mirtazapine (Remeron)
Advantages: -
Antidote to SSRI sexual dysfunction
Noninterference with sleep
Low interference with metabolism of other drugs
Anxiolytic properties -
Mirtazapine (Remeron)
Adverse Effects -
Strong sedating effect
Possible increased appetite, weight gain, and cholesterol elevation - Duloxetine
-
(Cymbalta)
Atypical antidepressants
Dual-Action Reuptake Inhibitors—SNRIs (Serotonin and Norepinephrine) -
Duloxetine (Cymbalta)
Advantages: -
Response to medication within 1-4 weeks
Mild side effects -
Duloxetine (Cymbalta)
Adverse Effects -
Nausea
Somnolence
Dry mouth
Constipation
Decreased appetite
Increased sweating
Fatigue
Twice-a-day dosing - Contraindications for bupropion (Wellbutrin)
-
seizure disorders
seizure-prone client (head injury)
Nonadherence to twice-daily dosing, agitaion or insomnia. - Contraindications for venlafaxine (Effexor)
-
Mental condition with poor impluse control.
Borderline or labile hypertension.
Insomnia
Agitation
Manic phase of bipolar disorder. - amitriptyline
-
Elavil
Endep
TCAs - amoxapine
-
Asendin
TCAs - desipramine
-
(Norpramin)
TCAs - doxepin
-
Adapin
Sinequan
TCAs - imipramine
-
Tofranil
TCAs - nortriptyline
-
Aventyl
Pamelor
TCAs - protripryline
-
(Vivactil)
TCAs - Trimipramine
-
(Surmontil)
TCAs - maprotiline
-
Ludiomil
TCAs - Common Adverse Reactions of TCAs
-
anticholinergic actions: dry mouth
blurred vision
tachycardia
constipation
urinary retention
esophageal reflux
*Urinary retention and severe constipation warrant immediate medical attention.
postural-orthostatic hypotension
tachycardia
*Postural hypotension can lead to dizziness and increase the risk of falls. - Potential Toxic Effects of TCAs are
-
cardiovascular:
(1) dysrhythmias
(2) tachycardia
(3) myocardial infarction
(4) heart block have been reported
*Because the cardiac side effects are so serious, TCA use is considered a risk in clients with cardiac disease and in the elderly. Clients should have a thorough cardiac workup before beginning TCA therapy. - Contraindications for TCAs
-
myocardial infarction (or other cardiovascular problems)
narrow-angle glaucoma
history of seizures
pregnant women -
TCAs:
Client Teaching -
mood elevation may take from 7 to 28 days. Up to 6 to 8 weeks may be required for the full effect
drowsiness, dizziness, and hypotension usually subside after the first few weeks.
be careful working around machines, driving cars, and crossing streets
No Alcohol
take the full dose at bedtime
If the client forgets the bedtime dose for the once-a-day dose), the client should take the dose within 3 hours; otherwise the client should wait until the usual medication time the next day. The client should not double the dose.
Suddenly stopping TCAs can cause nausea, altered heartbeat, nightmares, and cold sweats in 2 to 4 days. call the physician or take one dose of TCA until the physician can be contacted. - phenelzine
-
(Nardil)
Monoamine Oxidase Inhibitors - tranylcypromine sulfate
-
(Parnate)
Monoamine Oxidase Inhibitors - Common Adverse Reactions of MAOIs
- orthostatic hypotension, weight gain, edema, change in cardiac rate and rhythm, constipation, urinary hesitancy, sexual dysfunction, vertigo, overactivity, muscle twitching, hypomanic and manic behavior, insomnia, weakness, and fatigue.
- Potential Toxic Effects of MAOIs
- Hypertensive crisis: increase in blood pressure, with the possible development of intracranial hemorrhage, hyperpyrexia, convulsions, coma, and death
-
Hypertensive crisis:
Signs and symptoms -
headaches
stiff or sore neck
palpitations
increase or decrease in heart rate, often associated with chest pain
nausea
vomiting
increase in temperature (pyrexia). -
Hypertensive crisis:
Treatments -
Antihypertensive medications, such as phentolamine (Regitine), are slowly administered intravenously.
Pyrexia is treated with hypothermic blankets or ice packs. - Use of MAOIs may be contraindicated when one of the following is present:
-
Cerebrovascular disease
Hypertension and congestive heart failure
Liver disease
Consumption of foods containing tyramine, tryptophan, and dopamine
Use of certain medications
Recurrent or severe headaches
Surgery in the previous 10 to 14 days
Age younger than 16 years