Chapter 4 Drugs.pptx

PSYCHOTROPIC DRUGS MEDICATION KNOWLEDGE COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. OUTLINE  Biopsychiatry, sometimes referred to as the biological approach is a theoretical approach to understanding mental health disorders as biological malfuncti...

PSYCHOTROPIC DRUGS MEDICATION KNOWLEDGE COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. OUTLINE  Biopsychiatry, sometimes referred to as the biological approach is a theoretical approach to understanding mental health disorders as biological malfunctions of the nervous system. Implied in this approach is the idea that brain function is related to several factors, including genetics, neurodevelopmental factors, drugs, infection, psychosocial experience, or a combination of more than one of these factors that impact brain functioning. Clinicians using this approach believe that changes in the patient’s behaviour and in mental and emotional experiences are caused by damage to the brain. For example, when the brain is damaged, the way it produces and responds to neurotransmitters—the “chemical messengers” of the nervous system—changes. These changes can result in depressive symptoms, symptoms of anxiety, symptoms of post-traumatic stress disorder, or any other combination of behavioural, emotional, or mental symptoms. Medication is used to augment the effectiveness of the neurotransmitters. The primary goal of drug therapy is to restore “balance” to a malfunctioning brain. During recent years, there has been an explosion of information about the efficacy of psychotropic drugs (medication to treat mental illness) in reversing these alterations; however, a full understanding of how these drugs improve symptoms continues to elude investigators. DISTURBANCES OF MENTAL FUNCTION  Environment  Genes  Altered neurons  Norepinephrine  Serotonin  Dopamine  Glutamate  γ-aminobutyric acid (GABA) 3 COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. MECHANISMS OF ACTION OF PSYCHOTROPIC DRUGS COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. 4 Quality and Safety Education for Nurses Evidence-Informed Practice  Use of Psychotropic Drugs  Drugs Used to Treat Anxiety and Insomnia  Drug Treatment for Depression  Drug Treatment for Bipolar Disorders  Drugs Used to Treat Psychosis  Drug Treatment for Attention-Deficit/Hyperactivity Disorder  Drug Treatment for Alzheimer’s Disease ANTIANXIETY AND HYPNOTIC DRUGS  Benzodiazepines  Diazepam (Valium)  Clonazepam (Rivotril)  Alprazolam (Xanax)  Lorazepam (Ativan)  Used for treatment of anxiety. Ativan also used as emergency treatment for seizures.  Should NOT be mixed with alcohol or any other drug that effects CNS 6 COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. ANTIANXIETY AND HYPNOTIC DRUGS (CONT.)  Flurazepam (Dalmane)  Temazepam (Restoril)  Triazolam (Halcion)  Nitrazepam (Mogadon)  Oxazepam (Serax) 7 COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. ANTIANXIETY AND HYPNOTIC DRUGS (CONT.)  Short-acting sedative–hypnotic sleep agents (“Z-hypnotics”)  Zopiclone (Imovane). Used for sleep  Melatonin receptor agonists  Buspirone hydrochloride (Bustab) 8 COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. ANTIDEPRESSANT DRUGS  Tricyclic antidepressants (TCAs)  Nortriptyline hydrochloride (Aventyl, Norventyl)  Amitriptyline hydrochloride (Elavil, Levate)  Imipramine hydrochloride (Impril) 9 COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. ANTIDEPRESSANT DRUGS (CONT.)  Selective serotonin reuptake inhibitors (SSRIs)  Fluoxetine hydrochloride (Prozac)  Paroxetine hydrochloride (Paxil)  Citalopram hydrobromide (Celexa)  Escitalopram oxalate (Cipralex)  Fluvoxamine maleate (Luvox)  Sertraline hydrochloride (Zoloft)  These drugs work by allowing more serotonin to be available at the synaptic gap. 10 COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. ANTIDEPRESSANT DRUGS (CONT.)  Serotonin–norepinephrine reuptake inhibitors (SNRIs)  Venlafaxine hydrochloride (Effexor XR)  Venlafaxine succinate (Pristiq)  Duloxetine hydrochloride (Cymbalta) 11 COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. ANTIDEPRESSANT DRUGS (CONT.)  Serotonin and norepinephrine disinhibitors (SNDIs)  Mirtazapine (Remeron) 12 COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. ANTIDEPRESSANT DRUGS (CONT.)  Monoamine oxidase inhibitors (MAOIs)  Phenelzine sulfate (Nardil)  Tranylcypromine sulfate (Parnate)  Selegiline hydrochloride (Anipryl)  This classification interferes with most medications. It also prohibits diet significantly. No foods high in tryamine, like aged cheese, beer, cured meats and soy products. COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. 13 OTHER ANTIDEPRESSANT DRUGS Bupropion hydrochloride (Wellbutrin, Zyban) COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. Trazodone hydrochloride (Oleptro, Trazodone, Trazorel) 14 MOOD STABILIZERS  Lithium carbonate (Carbolith, Lithane, Lithmax)  Anticonvulsant drugs  Valproate (available as sodium divalproex and valproic acid [Depakene])  Carbamazepine (Tegretol)  Lamotrigine (Lamictal)  Gabapentin (Neurontin)  Topiramate (Topamax)  Oxcarbazepine (Trileptal)  Drugs used to treat bipolar and other mental health disorders. COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. 15 First-generation, conventional, typical of standard antipsychotic drugs ANTIPSYCHOTIC DRUGS Strong antagonists (blocking agents) Reduce Bind to D2 receptors 16 Block attachmen t of dopamine dopaminer gic transmissio n COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. FIRST-GENERATION (CONVENTIONAL) ANTIPSYCHOTIC DRUGS (CONT.)  Antagonists (a substance that interferes with or inhibits the action of another)of receptors for  Acetylcholine  Norepinephrine  Histamine  Significant adverse effects  Weight gain  Sedation  dizziness 17 COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. SECONDGENERATION (ATYPICAL) ANTIPSYCHOTIC DRUGS (CONT.) Produce fewer extrapyramidal side effects -EPS (drug induced movement disorders that include acute and tardive symptoms) Target both the negative and positive symptoms Often chosen as first-line treatment 18 COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. SECOND-GENERATION (ATYPICAL) ANTIPSYCHOTIC DRUGS (CONT.)  Dopamine and serotonin blockers 19 COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. SECOND-GENERATION (ATYPICAL) ANTIPSYCHOTIC DRUGS (CONT.)  Clozapine (Clozaril)  Risperidone (Risperdal)  Quetiapine fumarate (Seroquel)  Olanzapine (Zyprexa) – can get hyperactivity under control quickly. Used for mania as well as psychosis.  *Clozapine can cause potentially fatal blood dyscrasia (neutropenia). Report flu like symptoms immediately. Sore throat, fever. 20 COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. SECONDGENERATION (ATYPICAL) ANTIPSYCHOTIC DRUGS (CONT.) 21 Ziprasidone hydrochloride monohydrate (Zeldox) Paliperidone (Invega) Paliperidone palmitate (Invega Sustenna) COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. ANTI-PSYCHOTICS  Anti-psychotics can cause a condition called Neuroleptic Malignant Syndrome/ NMS.  This is an adverse reaction to dopamine receptor antagonist or a rapid withdrawal of other dopaminergic medications.  Symptoms include; drooling, muscle stiffness, difficulty swallowing, increased temperature, increased respiratory rate.  If rapid treatment is sought the patient may recover within 2 weeks. If treatment is not sought immediately, it can cause permanent damage to organs or may cause death. THIRD-GENERATION ANTIPSYCHOTIC DRUG  Aripiprazole (Abilify)  Dopamine stabilizer 23 COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. OTHER DRUGS  For attention deficit hyperactivity disorder (ADHD)  Methylphenidate hydrochloride (Biphentin, Concerta, Ritalin)  Dextroamphetamines, such as amphetamine aspartate monohydrate (Adderall XR) 24 COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED.  For Alzheimer's disease  Donepezil hydrochloride (Aricept) OTHER DRUGS (CONT.)  Galantamine hydrobromide (Reminyl)  Rivastigmine hydrogen tartrate (Exelon)  Memantine hydrochloride (Ebixa), a noncompetitive N-methyl-Daspartate (NMDA) receptor antagonist COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. 25 EXAMPLES OF SSRIS FOR ANXIETY INCLUDE:  citalopram (Celexa)  escitalopram (Lexapro)  fluoxetine (Prozac)  fluvoxamine (Luvox)  paroxetine (Paxil, Pexeva)  sertraline (Zoloft) EXAMPLES OF SNRIS FOR ANXIETY ARE:  duloxetine (Cymbalta)  venlafaxine (Effexor XR) EXAMPLES OF TCAS FOR ANXIETY INCLUDE: AMITRIPTYLIN E (ELAVIL)  amitriptyline (Elavil)  imipramine (Tofranil)  nortriptyline (Pamelor) MOA’S  Nardil  Parnate BENZODIAZEPINES INCLUDE:  alprazolam (Xanax)  chlordiazepoxide (Librium)  diazepam (Valium)  lorazepam (Ativan) DRUGS TO TREAT MAJOR DEPRESSION (SSRI) Generic Name Brand Name Celexa citalopram Lexapro escitalopram Paxil, Paxil CR, Pexeva paroxetine Prozac, Prozac Weekly fluoxetine Trintellix vortioxetine Viibryd vilazodone Zoloft sertraline  Common Side Effects  Nausea  Tremor (shaking)  Nervousness  Problems sleeping  Sexual problems SIDE EFFECTS  Sweating  Agitation  Feeling tired  Less Common, but Serious, Side Effects  Seizures  Abnormal bleeding or bruising  Withdrawal symptoms *Ask your healthcare provider about serotonin syndrome. SNRI Brand Name Generic Name Cymbalta duloxetine Effexor, Effexor XR venlafaxine Fetzima levomilnacipran Pristiq, Khedezla desvenlafaxine SIDE EFFECTS  Common Side Effects  Nausea  Vomiting  Dry mouth  Constipation  Fatigue  Feeling drowsy  Dizziness  Sweating  Sexual problems  Less Common, but Serious, Side Effects  Increase in blood pressure  Abnormal bleeding or bruising  Seizures  *Do not take with MAOI’s TRICYCLIC ANTI-DEPRESSANTS Brand Name Generic Name Asendin amoxapine Elavil Amitriptyline* Ludiomil maprotiline Norpramin desipramine Pamelor Nortriptyline* Sinequan doxepin Surmontil trimipramine Tofranil imipramine Vivactil protriptyline  Common Side Effects  Dry mouth  Constipation  Blurred vision  Drowsiness SIDE EFFECTS  Low blood pressure  Less Common, but Serious, Side Effects  Problems urinating  Confusion  Fainting  Seizures  Life-threatening irregular heartbeat  *Do Not take with MAOI’s NDRI’S  Wellbrutrin Side effects:  Agitation  Insomnia  n/v SNRDI’S  Remeron  Side effects:  Weight gain  Sedation  Dizziness  Sexual dysfunction MAOI  Nardil  Pronate  Side Effects:  Insomnia  N/V  Agitation  Confusion  Hypertensive crisis  * Interacts with most medications* Some meds that are used for epilepsy treat bipolar Lithium Carbonate – used in acute mania/mood stabilizer Valproic Acid – Mania DRUGS USED TO TREAT BIPOLAR Epival – Mania Lamictal – Maintenance Atypical Meds Abilify Risperidol Zyprexa Zeldox Seroquel LITHIUM TOXICITY  Lithium can cause upset stomach when taken without food. Always encourage patients to take with meals.  Lithium also has a very narrow therapeutic window. (0.6-1.2 is therapeutic, 1.5 is toxic)  Symptoms of toxicity are;  Loss of appetite/vomiting  Blurred vision  Excessive thirst DRUGS USED FOR SCHIZOPHRENIA AND PSYCHOSIS Atypical (pos & neg symptoms) Conventional Antipsychotics (pos symptoms) Abilify - aripiprazole Chlorpromazine (low) Fluanxol Depot Clozaril - clozipine Loxapac (med) Zyprexia-olanzapine Perphenazine (med) Invega - paliperidone Haldol (high) Seroquel - quetiapine Navane (high) Risperdiol respiridone Modecate (high) Zeldox - ziprasidone Orap (high) Conventional with limited data Clopixol SIDE EFFECTS  Dry mouth  Urinary retention  Constipation  Blurred vision  Photosensitivity  Dry eyes NATURAL PRODUCTS  Many patients take natural products and supplements  Major concerns  Potential long-term effects  Nerve damage  Kidney damage  Liver damage  Possibility of adverse chemical reactions  With other substances  With conventional medications  *St. John’s wart interferes with many medications 44 COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. ALL RIGHTS RESERVED. CASE STUDY Ursula has an organic brain disorder that causes aggression, anxiety, and sleeplessness. She explains to her doctor, “I feel like my engines are always revving. I don’t get super-hyper; I am super-hyper, like all the time.” In addition to anxiety, panic attacks, and insomnia, episodes of paranoia cause Ursula’s bouts of aggression. Initially, Ursula is put on an antipsychotic, but unfortunately, Ursula develops extrapyramidal side effects, including “a lot of uncontrolled movements,” which frighten and embarrass her. Her psychiatrist identifies these as extrapyramidal side effects, and he tries lowering her dosage, to little avail. Ursula has changed physicians and is now being treated with a different antipsychotic and is relieved to find that not only do all her symptoms fall under more control, but also the movement problems, which embarrassed her so much, have disappeared. “Now,” she says, “my main problem is, I’m getting fat. I think it’s the new drugs. Every time I go off them, I get skinny again, but also more hyper.” 1. Looking at Ursula’s history of side effects and compliance issues, (a) predict what two types of drugs she’s taken. (b) What may be causing her weight gain? ANSWER  ANS: (a) Ursula’s symptoms suggest that she’s taking an antipsychotic. Her side effects suggest that she started out on a first-generation agent, which is associated with motor abnormalities. Her second drug, which eliminated the motor side effects, sounds like a second-generation product. These reduce the movement side effects but have others, such as appetite stimulation, which leads to weight gain.  (a) The first-generation antipsychotics are strong antagonists (blocking the action) of the D2 receptors for dopamine. Because dopamine (D2) in the basal ganglia plays a major role in the regulation of movement, it is not surprising that dopamine blockage can lead to motor abnormalities. Based on both improvement and a reduction in these side effects, it’s reasonable to assume that her switch was probably to a second-generation antipsychotic. (b) These drugs produce fewer extrapyramidal side effects, but can increase the risk of metabolic syndrome with increased weight, blood glucose, and triglycerides. The simultaneous blockade of receptors 5-HT2C and H1 is associated with weight gain from increased appetite stimulation.