Psychiatric Medications & Disorders

• The text describes Psychiatric Medications, including medications for Psychiatric Disorders, Psychosis, Mood Stabilizers, Antipsychotics, Antidepressants, Anxiolytics & Sedative-Hypnotics, Treatments for Epilepsy/Spasticity, Chemotherapy, Drugs for Inflammation, Rheumatoid Arthritis, and Gout.

Psychiatric Disorders

• Types of Depression:
• Primary: Generalized, part of family history or genetics.
• Secondary: Specific neurological event, such as stroke or brain injury.
• Situational: Short term, situation-based
• Post-partum: Occurs after having a child and is hormone-based.
• Types of Anxiety:
• Generalized: Genetically based.
• Situational: Based on the situation.
• Other Disorders include: Schizophrenia: Chronic psychosis, disordered thinking, and positive (exaggerated normal function) or negative (diminished normal function) symptoms.
• Bipolar: Manic/depressive episodes.

Psychosis

• Definition: Disconnection from reality leading to false beliefs or experiences.
• Manifestations: Hallucinations and delusions.
• Management includes:
• Identifying causes involving an underlying disease.
• Medication.
• Therapy.

Mood Stabilizers

• Primary Use: Bipolar disorder, severe chronic depression.
• Key Medication: Lithium.
• Mechanism of Action: Affects neurotransmitter synthesis, release, and reuptake, aiming to regulate the entire body system.
• Side Effects:
• L: Monitor lithium levels.
• I: Increased urination.
• T: Thirst, tremors, toxicity.
• H: Hair thinning, hypothyroidism.
• I: Interactions.
• U: Upset stomach.
• M: Muscle weakness.
• S: Skin effects.
• There is a need to know therapeutic range: 0.6-0.8 (very tight); hypertherapeutic: 0.8-1.5 (not helpful); toxic: 1.5 or greater (nausea, vomiting, diarrhea, changes in walking, dizziness, horse tremors).

Antipsychotics

• Uses: Primarily for schizophrenia, bipolar disorder, and Tourette's syndrome; off-label use for anti-nausea.
• Classification by Potency:
• Low Potency: Chlorpromazine (1st gen, inhibits dopaminergic neurotransmission).
  • Uses: Mood disorders/schizophrenia.
• Moderate Potency: Clozapine, Quetiapine, Risperidone (2nd gen, inhibits dopaminergic neurotransmitters and blocks serotonin).
  • Uses: Mood stabilization, severe anxiety, bipolar disorder.
• High Potency: Haloperidol (1st gen, inhibits dopaminergic neurotransmission).
  • Uses: Acute agitation, acute psychosis (*risk for resp depression and addiction).
• Atypical: Olanzapine, Aripiprazole (mostly used as add-on drugs)
  • Considered moderate to high potency
  • Uses: Schizophrenia, bipolar, add-on for major depressive disorder.
• Side Effects:
• Orthostatic hypotension.
• Sedation.
• Gynecomastia and menstrual irregularities.
• Anticholinergic effects.
• Sexual dysfunction.
• Seizures.
• Agranulocytosis.
• Prolonged QT interval.
• Extrapyramidal: Neurological symptoms resembling pseudoparkinson's disease and tardive dyskinesia.
• Neuroleptic malignant syndrome: Rare, autonomic instability, rigidity, sweating, fever, fatal QT.
• Third generation: cariprazine (vraylar), brexpiprazole (Rexulti)- partially selective, only works on properly functioning receptors, to get dopamine levels down

Antidepressants

• Selective Serotonin Reuptake Inhibitors (SSRIs) are the most used.
• Examples: Fluoxetine, Citalopram, Escitalopram, Fluvoxamine, Paroxetine, Sertraline.
• Mechanism of Action: Selectively inhibits serotonin reuptake and can take up to 6 weeks to start.
• Indications: Major depressive disorder, panic disorders, OCD, depressive stage of bipolar disorder (can only use with mood stabilizers).
• Side Effects: Sexual dysfunction, gastrointestinal issues, CNS effects, weight gain.
• Adverse Effects: Serotonin syndrome, neonatal withdrawal, pulmonary hypertension.
• Drug Interactions: MAOI (needs a washout- SSRI needs to be stopped for 5 weeks), warfarin, tricyclic antidepressants, lithium (increases risk of toxicity).
• Drugs that contribute to Serotonin Syndrome:
• Antidepressants. CNS- meth.

Serotonin/Norepinephrine Reuptake Inhibitors (SNRIs)

• Examples: Venlafaxine, Duloxetine.
• Mechanism of Action: Blocks reuptake of serotonin and norepinephrine.
• Indications: Major depressive disorder, generalized anxiety, eating disorders, panic disorders.
• Side Effects: Nausea, headache, sexual dysfunction, serotonin syndrome, withdrawal.
• Drug Interactions: Similar to SSRIs.

Monoamine Oxidase Inhibitors (MAOIs)

• Examples: Phenelzine, Selegiline.
• Mechanism of Action: Blocks MAO-a, increasing the availability of norepinephrine, serotonin, dopamine, and tyramine.
• Uses: Depression with atypical presentation (oversleeping, overeating, lack of care), bulimia, OCD, panic disorders.
• Side Effects: CNS overstimulation, orthostatic hypotension.
• Interactions: SSRI;s dietary tyramine.
• Dietary Consideration: Avoid tyramine-rich foods to prevent hypertensive crisis.
• MAOI's prevent the breakdown of tyramine, while tyramine promotes the release of foods with high tyramine content: avocado, bean curd, soybean paste, smoked meat &sausages, aged cheeses, wine, beer.
• Hypertensive crisis can occur (defined by diastolic number ^120) with symptoms: headache (HA), tachycardia, palpitations, N/V, confusion, profuse sweating.
• Treatment: Rapid BP reduction, IV phentolamine, IV labetalol, sublingual nifedipine.

Tricyclic Antidepressants

• Examples: Amitriptyline, Doxepin.
• Mechanism of Action: Blocks reuptake of norepinephrine and serotonin.
• Indications: Depression, neuropathic pain.
• Side Effects: Anticholinergic effects, sedation, and confusion.
• Adverse Effects: Orthostatic hypotension, seizures, cardiac toxicity.
• Interactions: SSRI's, wean off slowly.

Atypical Antidepressants

• Examples:
• Bupropion: May block reuptake, off-label for ADHD, neuropathy, smoking cessation.
• Used for depression and the depressive side of bipolar.
• Mirtazapine: Increased release, off-label for sleep.
• Trazodone: Selectively blocks, off-label for sleep.

Serotonin Cycle

• Serotonin helps with blood clotting, nausea, sexual function, and participates in osteoporosis.

Anxiolytics & Sedative-Hypnotics

• Anxiolytics: Purpose: Reduce anxiety and suppress CNS.
• Mechanism: Enhance GABA actions.
• Sedative-Hypnotics:
• Purpose: Induce, extend/treat sleep.
• Mechanism: Directly mimic GABA.
• The difference lies in the DOSE- higher dose, more sleep effects anxiolytics - may cause respect depression, high risk for dependence/ abuse.

Benzodiazepines

• Examples: Diazepam, Lorazepam, Midazolam, Alprazolam, Temazepam.
• Mechanism of Action: Enhances GABA effects.
• Uses: Anxiety, sleep, insomnia, delirium, alcohol withdrawal.
• Side Effects: Drowsiness, dizziness, confusion, retrograde amnesia, dry mouth, N/V.
• Adverse Effects: Respiratory depression, overdose, ataxia.
• Administered: IV, Oral, IV can cause profound hypotension, resp & cardiac arrest.
• BLACK BOX: fetal abnormalities

Benzo-like Drugs

• Examples: Zolpidem, Eszopiclone.
• Mechanism of Action: GABA receptor agonists.
• Uses: Sleep (not anxiety).

Barbiturates

• Examples: Phenobarbital, Secobarbital, Thiopental.
• Mechanism of Action: Directly mimics GABA.
• Uses: Seizures, anesthesia.
• Adverse Effects: Respiratory depression, high overdose risk.

Nursing Considerations

• Safety Concerns: Monitor for side effects and interactions.
• Patient Education: Importance of adherence to medication and awareness of side effects.

Treatment of Epilepsy & Spasticity

Seizures vs Epilepsy Seizures:

• Brief episodes of abnormal electrical activity in nerve cells of the brain.
• Sudden onset.
• May have an aura- a feeling it coming.
• May be caused by underlying disease process changes in electrolytes or ions, high fever, trauma, hypoglycemia, or history of brain damage.
• Epilepsy: One or more seizures not caused by a reversible medical condition (idiopathic).

Possible Causes of Seizures

• Idiopathic (often associated with epilepsy).
• Fever.
• Hypoglycemia.
• Electrolyte imbalances.
• Drug overdoses.
• Withdrawal from alcohol or sedative-hypnotics.
• Developmental defects.
• Birth injury.
• Eclampsia.
• Alzheimer's.
• Head injury.
• Stroke.
• Brain tumor.

General Mechanism of Action

• There is a need GABA(chill) and Glutamate(cray cray) balance to function properly. Nerve impulse suppression:
• More negative ions post-synapse.
• Antagonism of glutamate.
• Suppression of sodium influx. Nerve impulse excitement:
• More positive ions post-synapse.
• Potentiation of glutamate.
• Suppression of calcium.

GABA & Glutamate Balance

Types of Seizures Generalized Seizures

• Widely conducted seizure activity throughout both hemispheres.

Partial Seizures

• Begins focally/localized in the cortex of the brain with limited spread to adjacent cortical areas. Partial Seizures
• Simple partial:
• No loss of consciousness.
• Can affect:
• Motor- ticks, muscle tightening, sensory changes, tingling.
• Sensory- numbness, tingling, skin crawling.
• Autonomic- blank stare, eyes move from side to side, pain of discomfort, nausea, sweating, flushed face, dilated pupils, rapid HR, changes in vision. Psych- affecting feeling or thoughts- causes difficulty managing emotions.
• Complex partial:
• Change in level of consciousness.
• Most common type of epilepsy in adults.
• Usually more common in boys than girls.
• Events typically last between 30 seconds and 2 minutes.
• Blank stare with physical manifestations.
  • Wether to treat them or not depends on how long, and how much its effecting daily life.

Generalized Seizures Tonic-Clonic (Grand mal)

- Intense, convulsive, and dangerous, can last 30 minutes.
- Abrupt onset, may experience a pre-seizure aura (abnormal sensations, such as smell, vertigo, nausea, or anxiety).

Absence Seizures

- Brief loss of consciousness, sudden lapse in conciousness.
- Person looks like they are staring into space, no memory of it afterwards, sudden lip smakc, eye flutter without falling

Tics:

• Brief. Atonic (Drop Seizure):
• Brief loss of muscle tone, awake but may drop partial or complete loss, causes collapse, falling, or dropping of the head. Myoclonic:
• Brief increased muscle tone; can be a combination to atonic; awake as if theyve been jolted with electricity, dose not cause loss of awareness.

Traditional Anti-Epileptic Drugs (AEDs)

• Phenytoin (Dilantin).
• Phenobarbital (Luminal).
• Carbamazepine (Tegretol).
• Valproic Acid (Depakote).
• Benzodiazepines.
• Diazepam (Valium).
• Clonazepam (Klonopin).
• Lorazepam (Ativan). Goal: Reduce seizure frequency and preserve quality of life.

Phenytoin (Dilantin)

• MOA: Increases Na channel inactive period to decrease excitability, not allowing it to reset, ^ inactivity period
• Treats: Grand mal seizures, complex partial seizures Side/Adverse Effects:
• Common: confusion, decreased muscle coordination, gum hyperplasia, difficulty swallowing, hypotension.
• Potentially Fatal: acute idiosyncratic drug-induced liver disease, difficulty breathing, arrhythmias. Nursing Considerations: Labs, serum levels, LFT. Administer IV doses slowly. Monitor for neuro- or hepatotoxicity. Education.

Carbamazepine (Tegretol)

• MOA: Not 100% understood, but interacts with Na channels, reduces ion exchange ate
• Side/Adverse Effects: Common: photophobia; vertigo.
  • Serious: blood dyscrasias(changes in blood); hyponatremia; SIADH; pancreatitis; hepatitis.
• Nursing Considerations:
  • Labs.
  • Education.
  • Birth defects.

Phenobarbital (Luminal)

• MOA: Interacts with GABA to decrease excitability.
• Used: All types accept absence
  • Side/Adverse Effects:
    • Common: drowsiness, dizziness, nausea, ataxia, paradoxical hyperactivity in children.
    • Serious: decreased breathing effort.
• Nursing Considerations:
  • Contraindication: COPD patients, breastfeeding and pregnancy, AIP
  • Labs monitor LFT and signs of liver toxicity
  • Barbiturates can be habit-forming.
  • Given Iv,oral, IM, needs more doses overtime

Valproic Acid (Depakene/Depakote)

• MOA: Blocks ion channels inhibiting nerve transmission, can be used for migraines, and bipolar disorders
• Used for: myoclonic, absence, generalized convulsions, partial seizures Side/Adverse Effects:
• Common: Gl symptoms, Stevens-Johnson syndrome, maybe some, hyperammonemia hallucinations, PCOS- makes it worse .
• Serious: mild hepatotoxicity, electrolyte imbalances, myelosuppression, toxic epidermal necrolysis.
• Nursing Considerations:
• Be VERY aware of the form and dose ordered- extended, short term, delayed release.
• Labs-monitors CBC and ammonia levels
• Give with food. Be aware of the slightest change in skin

Benzodiazepines

• MOA: Binds to GABA, decreasing excitability, used in acute situations- prolonged seizures/status epilepticus( first line of tx for SE due to rapid onset and tolerability Side/Adverse Effects: Common: drowsiness, impaired motor function.
• Serious: confusion, respiratory suppression, arrhythmias. Nursing Considerations- lots of education about safety, not the time to make major decisions, HIGHH risk for addiction, divided dose, monitor respiratory function

Newer AEDS

LAMOTRIGINE (LAMICTAL). LEVETIRACETAM (KEPPRA). TOPIRAMATE (ТОРАМАХ) Characteristics: Effective, generally less toxic, better tolerated.

Lamotrigine (Lamictal)

• MOA: Suppress the release of glutamate & aspartate, reducing the nerve impulse/ excitability Used in lennox- gastaut syndrome( rare childhood epilepsy, focal seizures, tonic-clonic, used for bipolar Side/Adverse Effects:
  • Common: rash, fever, fatigue, photophobia, Stevens-Johnson syndrome (SJS).
  • Serious: aseptic meningitis, DRESS syndrome, and toxic epidermal necrolysis (TEN). Nursing Considerations:
• BLACK BOX WARNING- DRESS- drug interactions causing change in eosinophil causing systemic symptoms.
• Wear sunscreen, skin checks, watch for infection, effected by hormonal birth control

Levetiracetam (Keppra)

• MOA: Different from other anti seizure medications; binds to a unique synaptic vesicle protein 2A (SV2A- reduces release of glutamate).
• Used in partial seizures, in babies, clonic tonic seizures in people 6 or older Side/Adverse Effects:
  • Common: extreme fatigue, increased infections, depression, nausea.
  • Serious: mood & behavior changes; hallucinations, myelosuppressive Nursing Considerations:
  • Monitor behavior.
  • Monitor for mood changes.
  • Education- take with food

Topiramate (Topamax)

MOA: Blocks sodium channels reducing ion exchange ; decreases impulse release Used: migraines, alcohol dependance, generalized and focal seizures

• Side/Adverse Effects:
  • Common: feeling tingly, tired, loss of appetite, abdominal pain, weight loss, decreased cognitive function, reduced effectiveness of birth control
  • Serious: increased serum ammonia levels.
• Nursing Considerations:
  • Contraindicated in pregnancy and breastfeeding. Decreased effectiveness of oral contraceptives.

Antispasmodics

CARISOPRODOL (SOMA). BACLOFEN (GABLOFEN). CYCLOBENZAPRINE HYDROCHLORIDE (FLEXERIL). TIZANIDINE HYDROCHLORIDE (ZANAFLEX)

• Purpose: Muscle spasm relief in neuro & neuromuscular disorders; can be short or long-term.
• **
• Carisoprodol (Soma)
  • MOA: block interneuronal I activity, suppresses movement of electricity in the periphery, block pain sensation
  • Manages: MS, parkinsons, ALS side/adverse effects:
• Common: Neuro, dizziness, drowsiness, balance issues, difficulty with muscle coordination
• Serious: acute intermittent porphyria- Nursing Considerations: Education of handling heavy machinery, fall risk, can be habit forming

Baclofen (Gablofen)

• MOA: Work in the spinal cord to inhibit neurotransmission from the spinal cord outwords Route: oral, divided dose, resioiurar- given intrathecal, directly into the spinal colum Side/Adverse Effects: Common: drowsiness, fatigue, muscle weakness, headache.
• Serious: hypotension, euphoria, insomnia, confusion. Nursing Considerations: Safety concerns potential for hypotensions, can become euphoric and aggressive when dose decreases, dont sleep well get kinda high, increase dose a little at a time, avoid alc

Cyclobenzaprine Hydrochloride (Flexeril)

• Characteristics: Short term; oral only., used after car accident, whip lash

Tizanidine Hydrochloride (Zanaflex)

MOA: disruptus norepi relases, disrupting nerve transmissions Side/Adverse Effects: Drowsiness, dizziness, dry mouth.

• Nursing Considerations: Drug interactions, very addictive, very drowsy, combined with certain antibiotic and antivirals can cause hepatotoxicity but fine on its own, change positions slowly, DON'T DRIVE, kicks in quick, NO ALC

Tizanidine Hydrochloride (Zanaflex)

MOA: Reduced norepi disrupts nerve impulse conduction, long term, absorbs slower, Side/Adverse Effects: Common: (anticholinergic) drowsiness, dizziness, constipation,dry mouth

• Serious: hypotension, hallucination, liver toxicity.
• Nursing Considerations: Drug interactions, liver toxicity; education on signs of liver toxicity, watch LFT

Chemotherapy

Role of Chemotherapy

Cure/Curative Intent. Control- shrink growth. Palliation- symptom management

Factors Influencing Plan & Response

Tumor Characteristics- what kind, how big, how mutated is it? Some cancers are just hard to kill. Patient Characteristics- lots of comorbidities?, generally healthy? Support system? Administration Plan- do they have to take off work? How long? Can they tolerate SE? Chemotherapy Regimens Single or Combination Agent Low or High Dose Regional Chemotherapy- hard to do, just where the tumor is Adjuvant therapy- added onto something else Neo-adjuvant therapy- new/experimental Concurrent Therapy- adjuvant and combination Why Combination Chemo? Neurotoxicity- very toxic, neuro, renal, liver Neutropenia- Anticancer Effect Example Regimen- combined to reduce neutropenia and not as many side effects Cyclophosphamide (Alkylating agent) Vincristine (Mitotic Inhibitor) Combination: Cyclophosphamide + Vincristine Handling Antineoplastics (chemotherapy) Vertical Laminar Air Flow Hood Must be chemotherapy certified Low Permeability Gown Chemotherapy Gloves Face Shield or Goggles Chemotherapy Waste Disposal Container No Food or Drink in Area

Classifications of Cancer Drugs

Grouped by: Mechanism of Action Chemical structure Relationship to other drugs

Work on different cell cycle phases. Specific and Non-specific. Individual or combination

• Similar general side effects- hair loss, N/V Anti-metabolites Structure similar to cancer cell DNA, plug themselves into the DNA of cancer therefore stopping the replication Inhibits replication by: Mimicking nucleotides, acts as decoy Blocking enzymes Disrupting DNA synthesis Nursing Considerations- Cause immunosuppression, raise uric acid levels (gout), risk of dehydration, NVD, GI SE pyrimidine Interferes with anticoagulation , all have photosensitivity, methotrexate caused reinfection of cytomegalovirus *Do not give withing 2 weeks of a live vaccine

Medications

Purine antagonists: 6-MP (6-Mercaptopurine) **IV- must be given central line Pyrimidine antagonists: 5-FU (5-fluorouracil) **IV- must be given central line Folic acid antagonists (antifolates): Methotrexate (used for RA) Epothilones *(Ixabepilone) MOA: Interrupts cell division- inhibits spindle formation causing no cells Route & Dosing: IV Nursing Considerations: Premedicate- causes an immune response, give histamine blockers, benedryl Monitor for interactions - alcohol based, be mindful for recovery alcholoic or low tolerance Dose-limiting factors: VERYYY myleosupressive, causes thrombocytopenia, neutropenia and hepatotoxicity likely used in combination * No grapefruit or st. john's wort- increases metabolism causing too much in the system May get LFT, CBC focused on neutrophils Vinca

Alkaloids & Taxanes (Taxoids)* widely used, high potency

Spindle Inhibitors: Interrupts cell division (pulling apart of cell). Route dosing : Well tolerated, given in lower amounts. Nursing Considerations: Usually used in combination. High potency Dose limiting factors: severe hypoglycemia, high incidence of long term peripheral neuropathy Teach them about signs of hypoglycemia. We give through port* Vincristine, Vinblastine Cell-Cycle Non-specific Alkylating agents: Interfere with DNA replication, work anywhere in the cell cycle, mutates it Cross the blood-brain barrier- good for brain cancer, kills bone, pancreatic cancers more effectivly- BIG GUNS Route: IV Nursing Considerations: Highly nero, renal, and hepatoxic, VERRY mylosupressive, can be used for lupus Nitrogen Mustards: Cyclophosphamide. Nitrosoureas: Streptozocin General Side Effects of Chemo General SE- weight changes, fatigue, dry skin, infection, nausea, vomiting, constipation/ diarrhea, increased risk of bleeding, hair loss, brain fog, mood changes, anemia, muscle pain Anemia: Hgb < $10 mcl/L Symptoms: Fatigue, weakness, pale. Treated with: Erythropoietin (Epogen or Procrit) Thrombocytopenia: Decreased Platelets Symptoms: Bruising, bleeding gums, blood in stool and urine. Treated with: Platelet transfusion or neumega Leuko-/Neutropenia: WBC < 4.5 mcl/L, Neutrophil < 1.5 (<1-1.2 may need neutropenic precautions).

• Symptoms: Increased infection risk Treated with: Neupogen Integumentary Side Effects Dry Skin & Mucosa. Gum hyperplasia. Rashes & Blister. Fragile Hair & Nails. Extravasation- highly toxic drug leaks out and affects tissue Nausea/Vomiting. Mucositis and Stomatitis Gastrointestinal & Genitourinary Side Effects N/V- small frequent meals, encourage fluids, no spicy foods Muscosits & stomatisis- Mouth sores. Bowel Hepatic Toxicity. Hemorrhagic Cystitis: Inflammation and bleeding- encouage fluids, bladder irigation. Renal Insufficiency: Acute and chronic (long term use) since kidenys work so hard to excrete fluids Cardiovascular & Pulmonary Side Effects(usually temporary unless they have fibrosis) Cardiotoxicity: Phlebitis, Venous fibrosis. Pulmonary: Edema, Pneumonitis.

Neurological Side Effects

Central Neurotoxicity. Metabolic encephalopathy- acid base out of wack. Peripheral Neuropathy. Ototoxicity- usually during infusion Reproductive Side Effects Infertility Changes in Libido. Erectile Dysfunction. Amenorrhea Tumor Lysis Syndrome- chemotherapy is breaking down cancer cells faster than they can be cleared out from the system Medical emergency. Caused complete shutdown of renal system Electrolyte & Glucose Imbalances Symptoms: N/V/D, decreased urine output, hematuria, weakness, seizures, fainting, irregular heartbeat, hypotension Starts 72 hour after chemo Treatment: Diuresis, remove excess electrolytes, dialysis Corticosteroids Examples: Hydrocortisone (Cortef), prednisone (Deltasone), prednisolone, methylprednisolone (Medrol), dexamethasone (Decadron).

Drugs for Inflammatory Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Types of NSAIDs: Salicylates. 1st generation NSAIDs 2nd generation NSAIDs. Nonsalicylates COX-1-effects across all 4- may impact bleeding and Gl issues vs COX-2 just inflamatory COX = cyclo-oxygenase- enzyme thats timulates prostiglanins Porstaglandins 1=stomach and mucosa 2= platelets aggregation 3=pain 4=inflamation Salicylates Aspirin (ASA) Mechanism of Action: Inhibits COX 2 enzymes. Uses: Sometimes: anti-inflammatory, analgesia, antipyretic. Usually: used for platelets Side Effects: Increased bleeding. Gl upset Adverse Effects: Salicylism Reyes's syndrome- common in kids, high fever, Hypersensitivity- may see increased bleeding Toxicity. May cause liver damage and cirrhosis Drug Interactions: on something else for increased bleeding or NUR CARE: absorbed slowly, given often orally Newer First Generation NSAIDs Examples:

Ibuprofen and Naproxen

Ibuprofen (Motrin, Advil) Naproxen (Aleve) Ketorolac (Toradol) Mechanism of Action: COX-1 and COX-2 inhibition. Uses: pain, inflammation, fever Has a little effect on platelets, Gl irritation plus platelets changes increases risk for gl bleeds Dosing: given oral, adults and children ALEVE IS ADULTS ONLY Side & Adverse Effects: Gl upset. Renal failure Stevens-Johnson Syndrome-big fat rash Nursing Considerations: suggest having with food, Ketorolac (Toradol) Use: Pain management, not for chronic pain Dosing: PO, IM, IV, ophthalmic. Side & Adverse Effects: significantly toxic, Gl upset, less platelets, high potential for renal toxicity Nursing Considerations: watch BUN & Creatinie, short term use

Second Generation NSAIDs

Examples: Celecoxib (Celebrex). Valdecoxib (Bextra) Mechanism of Action: Inhibition of COX-2, reducing pain and inflammation without inhibiting COX-1 (less GI ulceration). Uses: Osteoarthritis, Rheumatoid arthritis, acute pain used more for inflammation then pain Adverse Effects: Gl distress, renal impairment. Drug Interactions: Enhances the effects of Warfarin (Coumadin). Contains SULFA!, history of penicillin allergy Acetaminophen (Tylenol) MOA: Analgesic and antipyretic properties

Rheumatoid Arthritis (RA) Characteristics

Autoimmune disorder. Autoimmune disorder Affects ~1% of the population Usually occurs in the 3rd or 4th decade of life In younger populations, females are 3x more affected than males. Drug Therapy for RA: NSAIDs- celebrex Disease Modifying Antirheumatic Drugs (DMARDs) TNF Blockers - slows down disease process Corticosteroids Disease Modifying Antirheumatic Drugs (DMARDs) Purpose: Reduce inflammation & joint destruction and slow disease progression Characteristics: Delayed onset and perceived benefits. More toxic than NSAIDs.

Methotrexate (Rheumatrex)

Action: Suppresses B & T lymphocytes which cause inflammation Characteristics: Most rapid-acting DMARD Therapeutic effects in 3-6 weeks Extensive use in RA treatment Relatively safe, efficacious, and low cost Major Toxicities: Hepatic fibrosis, bone marrow suppression, Gl ulceration, pneumonitis

Hydroxychloroquine (Plaquenil)

Properties: Antimalarial. Action: Does not slow progression .

TNF Blockers

Examples: Etanercept (Enbrel). Infliximab (Remicade). Adalimumab (Humira) Action: Suppresses inflammation by neutralizing tumor necrosis factor (TNF). Indications: moderate to severe RA, psoriatic arthritis, Crohn's disease Adverse Effects: serious infection Very expensive Glucocorticoids Characteristics: Powerful anti-inflammatory agents It can relieve symptoms and may slow disease progression Can be given orally for diffuse disease or intra-articularly for specific joints Should be used short term Gout Characteristics: Recurrent inflammatory disorder High levels of uric acid and episodic severe joint pain Treatment Objectives: Reduce uric acid collection or decrease reaction to uric acid Colchicine Action: Decreases the inflammatory reaction to uric acid crystals Use: Treats acute gout and prevents recurrence. Side Effects: Mostly GI, NVD Adverse Effects: Hepatotoxicity, bone marrow suppression Interactions: grape fruit EOTH Allopurinol Action: Enzyme inhibition Treatment Objective: get plasma uric level below 7 in males, 6 in females, decrease risk for tohpi, decrease risk for neuropathy Use: Acute and chronic tophaceous gout Side Effects: N/V/D, vertigo, arganulocytes Adverse Effects:

Antispasmostics -spasms

Carrisoprodol (Soma) MOA: blocks intraneuronal activity, depresses the movement of electricity in the periphery, blocks pain sensation Manages: MS, SE: neurological, changes in swallowing, muscular weakness, dizziness, sometimes drowsey NC: falls risk, don't operate heavy machinery, no focus on intensive tasks Baclofen (Gablofen) MOA: work in the spinal cord inhibits nerve transmission from the spinal cord to spread impulses out to the periphery Route: oral, divided dose, or intrathecal SE: Drowsiness, fatigue, weakness, HA, hypotension, euphoria, insomnia, confusion NC: Safety concerns, be aware of changes in behavior based on dose Flexeril- muscle relaxant for acute issues only, not meant for long term, VERY addictive, oral only, hypertonicity SE: drowsiness, dizziness, dry mouth. NC: Change positions slowly, DO NOT drive, no alcohol Zanaflex- long term, reduces norepi release, and nerve impulse SE: Anticolingeric effects, *liver toxicity NO ANTIVIERALS AND CHEMO DRUGS NC: drug interactions, liver toxixcity, education