Mental Health Chapter 4 PDF

Chapter 4 Psychopharmacology Copyright ©2023 F.A. Davis Company Historical Perspectives § Before 1950, sedatives and amphetamines were the only significant psychotropic drugs available. § Since the 1950s, psychopharmacology has expanded to include antipsychotic, antidepressant, and antianxiety drugs...

Chapter 4 Psychopharmacology Copyright ©2023 F.A. Davis Company Historical Perspectives § Before 1950, sedatives and amphetamines were the only significant psychotropic drugs available. § Since the 1950s, psychopharmacology has expanded to include antipsychotic, antidepressant, and antianxiety drugs. § Psychotropic drugs are intended to be used as an adjunct to individual or group psychotherapy. Copyright ©2023 F.A. Davis Company Role of the Nurse § Ethical and legal implications Nurses must understand the ethical and legal implications associated with the administration of psychotropic medications. Most states adhere to the client’s right to refuse treatment, except in emergency situations. Copyright ©2023 F.A. Davis Company Role of the Nurse (continued_1) § Assessment A thorough baseline assessment must be conducted before a client is placed on a regimen of psychopharmacological therapy. Copyright ©2023 F.A. Davis Company Role of the Nurse (continued_2) § Medication administration and evaluation The nurse is the key health-care professional in contact with the individual receiving medication. The nurse monitors for side effects and adverse reactions and evaluates the therapeutic effectiveness of the medication. Copyright ©2023 F.A. Davis Company Role of the Nurse (continued_3) § Patient education The nurse translates the complex information related to the medication into terms that can be easily understood by the client. Nurses should use the latest informatics resources to provide current and relevant education on medication-related topics. Copyright ©2023 F.A. Davis Company How Do Psychotropics Work? § Psychotropic medication affects neurotransmission. Reuptake is the process of neurotransmitter inactivation. § Antidepressants § Antipsychotics § Benzodiazepines § Psychostimulants Copyright ©2023 F.A. Davis Company Describe how psychotropics affect neurotransmission § Most psychotropic medications have their effects at the neuronal synapse, producing changes in neurotransmitter release and the receptors to which they bind. § Researchers hypothesize that most antidepressants work by blocking the reuptake of neurotransmitters, specifically, serotonin and norepinephrine. Reuptake is the process of neurotransmitter inactivation by which the neurotransmitter is reabsorbed into the presynaptic neuron from which it had been released. Blocking the reuptake process allows more of the neurotransmitter to be available for neuronal transmission. This mechanism of action may also result in undesirable side effects. § Antipsychotic medications block dopamine receptors, and some affect muscarinic cholinergic, histaminergic, and α-adrenergic receptors. The “atypical” (or novel) antipsychotics focus primarily on blocking specific serotonin receptors. Benzodiazepines facilitate the transmission of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). The psychostimulants work by increasing norepinephrine, serotonin, and dopamine release. Copyright ©2023 F.A. Davis Company Antianxiety Agents: Background Assessment Data § Indications Anxiety disorders, anxiety symptoms, acute alcohol withdrawal, skeletal muscle spasms, convulsive disorders, status epilepticus, and preoperative sedation § Action Depression of the central nervous system (CNS; exception: buspirone) Copyright ©2023 F.A. Davis Company indications, actions, contraindications, and precautions for antianxiety agents § Antianxiety drugs are also called anxiolytics and historically were referred to as minor tranquilizers. They are used in the treatment of anxiety disorders, anxiety symptoms, acute alcohol withdrawal, skeletal muscle spasms, convulsive disorders, status epilepticus, and preoperative sedation. They are most appropriate for the treatment of acute anxiety states rather than long-term treatment. § Antianxiety drugs depress subcortical levels of the CNS, particularly the limbic system and reticular formation. They may potentiate the effects of the powerful inhibitory neurotransmitter gamma-aminobutyric acid (GABA) in the brain, thereby producing a calmative effect. All levels of CNS depression can be affected, from mild sedation to hypnosis to coma. The most commonly prescribed antianxiety agents are benzodiazepines, including clonazepam (Klonopin), diazepam (Valium), and alprazolam (Xanax). Copyright ©2023 F.A. Davis Company Antianxiety Agents: Background Assessment Data (continued_1) § Interactions Increased effects when taken with alcohol, barbiturates, narcotics, antipsychotics, antidepressants, antihistamines, neuromuscular blocking agents, cimetidine, disulfiram, or herbal depressants Decreased effects with cigarette smoking and caffeine consumption Serious side effects and possible death when combined with opioid pain or cough medications Copyright ©2023 F.A. Davis Company Antianxiety Agents: Background Assessment Data (continued_2) § Diagnosis Risk for injury Anxiety Risk for activity intolerance Disturbed sleep pattern § Outcome criteria and evaluation Copyright ©2023 F.A. Davis Company Practice Question 1. Which of the following medications would be an appropriate prn medication for an individual with anxiety symptoms? A. Buspirone B. Alprazolam C. Fluoxetine D. Sertraline Copyright ©2023 F.A. Davis Company Practice Answer Correct Answer: B Alprazolam is a benzodiazepine that works as a central nervous system depressant to produce quick-acting effects of relaxation in an individual with anxiety symptoms. Copyright ©2023 F.A. Davis Company Antidepressants: Background Assessment Data § Indications Dysthymia, major depressive disorder, depression associated with organic disease, alcoholism, schizophrenia, intellectual disability, depressive phase of bipolar disorder, and depression accompanied by anxiety Benefits of antidepressant medications on patients experiencing severe depression can be substantial Copyright ©2023 F.A. Davis Company indications and actions for antidepressants. § Antidepressants work to increase the concentration of norepinephrine, serotonin, and/or dopamine in the body. This is accomplished in the brain by blocking the reuptake of these neurotransmitters by the neurons (tricyclics [TCAs], heterocyclics, SSRIs, and serotonin norepinephrine reuptake inhibitors [SNRIs]). § There are several groups of antidepressants, including Monoamine oxidase inhibitors Tricyclic antidepressants SSRIs Serotonin and norepinephrine reuptake inhibitors (SNRIs) Heterocyclics Copyright ©2023 F.A. Davis Company Antidepressants: Background Assessment Data (continued_1) § Action Increase concentration of norepinephrine, serotonin, and/or dopamine in the body either by blocking their reuptake by the neurons (tricyclics, tetracyclics, selective serotonin reuptake inhibitors [SSRIs], serotonin and norepinephrine reuptake inhibitors [SNRIs]) or by inhibiting the release of monoamine oxidase inhibitors (MAOIs). Copyright ©2023 F.A. Davis Company Antidepressants: Drug Interactions With SSRIs Interacting Drugs Adverse Effects Buspirone (BuSpar), tricyclic antidepressants (TCAs; especially clomipramine), selegiline (Eldepryl), Saint John’s Wort Monoamine oxidase inhibitors (MAOIs) Warfarin, NSAIDs Serotonin syndrome Alcohol, benzodiazepines Increased sedation Antiepileptics Lowered seizure threshold Copyright ©2023 F.A. Davis Company Hypertensive crisis Increased risk of bleeding Antidepressants: Drug Interactions With TCAs Interacting Drugs Adverse Effects Monoamine oxidase inhibitors (MAOI’s) Saint John’s Wort, tramadol (Ultram) High fever, convulsions, death Clonidine (Catapres), epinephrine Severe hypertension Acetylcholine blockers Paralytic ileus Seizures, serotonin syndrome Alcohol and carbamezipine (Tegretol) Blocks antidepressant action, increases sedation Cimetidine (Tagamet), bupropion Increased tricyclic antidepressant blood (BuSpar) levels, increased side effects Copyright ©2023 F.A. Davis Company Antidepressants: Drug Interactions With MAOIs Interacting Drugs Adverse Effects Selective serotonin reuptake inhibitors, tricyclic antidepressants, atomoxetine (Strattera), duloxetine (Cymbalta), dextromethorphan (an ingredient in many cough syrups), venlafaxine (Effexor), Saint John’s wort, ginkgo Morphine and other narcotic pain relievers, Antihypertensives All other antidepressants, pseudoephedrine, amphetamines, cocaine cyclobenzaprine (Flexeril), dopamine, methyldopa, levodopa, epinephrine, buspirone (BuSpar) Serotonin syndrome Buspirone (BuSpar) Psychosis, agitation, seizures Antidiabetics Hypoglycemia Tegretol Fever, hypertension, seizures Copyright ©2023 F.A. Davis Company Hypotension Hypertensive crisis (these side effects can occur even if taken within 2 weeks of stopping monoamine oxidase inhibitors) Antidepressants: Background Assessment Data (continued_2) § Diagnosis Risk for suicide Risk for injury Social isolation Risk for constipation Insomnia § Safety issues § Outcome and criteria evaluation Copyright ©2023 F.A. Davis Company Evidence-based Practice § Because there is so much new information and new drug development, practicing nurses should assure that they are accessing evidence-based informatics to keep up to date on side effects and significant drug or food interactions. Copyright ©2023 F.A. Davis Company Mood-Stabilizing Agents: Background Assessment Data § Indications: Bipolar disorder characterized by roller-coaster cycle of “ups and downs” in mood, generating cycles of depression and manic episodes Understanding that lithium is a salt is relevant in explaining some of these interactions. Because lithium is an imperfect substitute for sodium, anything that depletes sodium will make more receptor sites available to lithium and increase the risk for lithium toxicity. This is also the rationale for advising patients to maintain their usual dietary sodium and fluid intake, because major fluctuations impact lithium levels. For example, significant increases in dietary sodium intake may reduce the effectiveness of lithium because sodium will bind at more receptor sites, and lithium will be excreted. Other drugs that increase serum sodium levels will also have an impact on lithium levels. Copyright ©2023 F.A. Davis Company Mood-Stabilizing Agents: Background Assessment Data (continued_1) § Action: Mechanism unclear. Impact on cellular sodium transport, gamma-aminobutyric acid modulation, and raising seizure threshold have all been advanced as possible explanations. Copyright ©2023 F.A. Davis Company Mood-Stabilizing Agents: Background Assessment Data (continued_2) § Lithium, anticonvulsant medications, and second-generation atypical antipsychotics § Interactions Because lithium is an imperfect substitute for sodium, anything that depletes sodium will make more receptor sites available to lithium and increase the risk for lithium toxicity Copyright ©2023 F.A. Davis Company Mood-Stabilizing Agents: Background Assessment Data (continued_3) § Diagnosis Risk for injury Risk for self-directed or other-directed violence Risk for injury related to lithium toxicity Risk for injury related to adverse effects of mood-stabilizing drugs Risk for activity intolerance Copyright ©2023 F.A. Davis Company Mood-Stabilizing Agents: Lithium Maintenance § Therapeutic range 1.0 to 1.5 milliequivalents per liter (acute mania) 0.6 to 1.2 milliequivalents per liter (maintenance) § Ensure that client consumes adequate sodium and fluid in diet. § Monitor serum levels one to two times per week until stable, then monthly. § Blood samples should be drawn 12 hours after last dose. Copyright ©2023 F.A. Davis Company Mood-Stabilizing Agents: Planning/Implementation § Educate client and family about the medication § Outcome criteria/evaluation Copyright ©2023 F.A. Davis Company Antipsychotics: Background Assessment Data § Indications Used for the treatment of schizophrenia and other psychotic disorders; selected agents are also used in the treatment of bipolar mania, as antiemetics, in the treatment of intractable hiccoughs, and for control of tics and vocal utterances in Tourette’s disorder. Copyright ©2023 F.A. Davis Company Antipsychotics: Background Assessment Data (continued) First-generation or “typical” antipsychotics have higher risk for extrapyramidal side effects that interfere with normal movements, including acute dystonias (muscle spasms) and Parkinsonian-like symptoms Second-generation or “typical” antipsychotics were developed and have lower potential for extrapyramidal symptoms Copyright ©2023 F.A. Davis Company Antipsychotics: Action § Typical antipsychotics Block postsynaptic dopamine receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla. Demonstrate varying affinity for cholinergic, alpha1adrenergic, and histaminic receptors. Inhibit dopamine-mediated transmission of neural impulses at the synapses. Copyright ©2023 F.A. Davis Company Antipsychotics: Action (continued) § Atypical antipsychotics Weaker dopamine receptor antagonists than the typical antipsychotics Potent antagonists of the serotonin type 2A (5-HT2A) receptors Exhibit antagonism for cholinergic, histaminic, and adrenergic receptors Copyright ©2023 F.A. Davis Company Antipsychotics: Contraindications § Contraindicated in hypersensitive, comatose, or severely depressed patients; elderly patients with dementia-related psychosis; certain medications are contraindicated in patients with a history of QT prolongation or other heart issues. Copyright ©2023 F.A. Davis Company Typical and atypical antipsychotics § § § § Typical antipsychotics are contraindicated in clients with known hypersensitivity (cross sensitivity may exist among phenothiazines). They should not be used in comatose states or when central nervous system depression is evident; when blood dyscrasias exist; in clients with Parkinson’s disease or narrow-angle glaucoma; those with liver, renal, or cardiac insufficiency; in individuals with poorly controlled seizure disorders; or in elderly clients with dementia-related psychosis. Caution should be taken in administering these drugs to clients who are elderly, severely ill, or debilitated, and to diabetic clients or clients with respiratory insufficiency, prostatic hypertrophy, or intestinal obstruction. The risk for metabolic disturbances such as weight can be particularly dangerous in the elderly. Atypical antipsychotics are contraindicated in hypersensitivity, comatose or severely depressed patients, elderly patients with dementia-related psychosis, and lactation. Ziprasidone, resperidone, paliperidone, asenapine, and iloperidone are contraindicated in patients with a history of QT prolongation or cardiac arrhythmias, recent myocardial infarction, uncompensated heart failure, and concurrent use with other drugs that prolong the QT interval. Clozapine is contraindicated in patients with myeloproliferative disorders, with a history of clozapine-induced agranulocytosis or severe granulocytopenia, and in uncontrolled epilepsy. Lurasidone is contraindicated in concomitant use with strong inhibitors of cytochrome P450 isozyme 3A4 (CYP3A4) (e.g., ketoconazole, an antifungal) and strong CYP3A4 inducers (e.g., rifampin, an antitubercular). Caution should be taken in administering these drugs to elderly or debilitated patients; patients with cardiac, hepatic, or renal insufficiency; to those with a history of seizures; to patients with diabetes or risk factors for diabetes; to clients exposed to temperature extremes; under conditions that cause hypotension (dehydration, hypovolemia, treatment with antihypertensive medication); and to pregnant clients or children (safety not established). Copyright ©2023 F.A. Davis Company Antipsychotics: Precautions § Caution with elderly or debilitated patients; patients with cardiac, hepatic, or renal insufficiency; those with a history of seizures; patients with diabetes or risk factors for diabetes; clients exposed to temperature extremes under conditions that cause hypotension; and pregnant clients or children Copyright ©2023 F.A. Davis Company Antipsychotics: Interactions Interacting Drugs Adverse Effects Antihypertensives, central nervous Additive and potentially severe system depressants hypotension Epinephrine or dopamine in combination with haloperidol or phenothiazines Oral anticoagulants with phenothiazines Less effective anticoagulant effects Drugs that prolong QT intervals Additive effects Drugs that trigger orthostatic hypotension Additive hypotension Drugs with anticholinergic effects, prescription and over-the-counter drugs Additive anticholinergic effects including anticholinergic toxicity, which includes flushing, dry mouth, mydriasis, altered mental status, tachycardia, urinary retention, tremulousness, hypertension (Ramnarine & Ahmed, 2015) Copyright ©2023 F.A. Davis Company Antipsychotics: Diagnosis § Risk for other-directed violence § Risk for injury § Risk for activity intolerance § Noncompliance Copyright ©2023 F.A. Davis Company Antipsychotics: Additional Issues § Safety issues in planning and implementing care § Additional issues for patient education Copyright ©2023 F.A. Davis Company Issues in Antipsychotic Maintenance Therapy § § § § Clozapine (Clozaril) and agranulocytosis risk Extrapyramidal side effects Hormonal side effects Due to the risk of agranulocytosis, the U.S. Food and Drug Administration requires that clozapine be part of a risk evaluation and mitigation strategy (REMS) program to ensure that risk for agranulocytosis is monitored, managed, and reported. Agranulocytosis is a potentially fatal blood disorder in which the patient’s absolute neutrophil count (ANC) drops to extremely low levels (less than or equal to 500 µL). This condition is called neutropenia. § § Extrapyramidal Side Effects Several distinct types of extrapyramidal side effects may occur with antipsychotics, and the nurse must be familiar with them to conduct a thorough assessment: Pseudoparkinsonism (tremor, shuffling gait, drooling, rigidity): Symptoms may appear 1 to 5 days following initiation of antipsychotic medication; occurs most often in women, the elderly, and dehydrated patients. Akinesia (muscular weakness): Same as for pseudoparkinsonism. Akathisia (continuous restlessness and fidgeting): This side effect occurs most frequently in women; symptoms may occur 50 to 60 days after therapy begins. Dystonia: This side effect is characterized by involuntary muscle spasms in the face, arms, legs, and neck and occurs most often in men and in people younger than 25 years of age. If untreated, it can progress to laryngospasms and can be fatal. Dystonia should be treated as an emergency situation, and the physician should be contacted immediately. Dystonia is typically treated with intramuscular or IV benztropine (Cogentin). Stay with the patient and offer reassurance and support; these adverse effects can be very frightening. Oculogyric crisis (uncontrolled rolling back of the eyes): This side effect may appear as part of the syndrome described as dystonia and may be mistaken for seizure activity. As with other symptoms of acute dystonia, this side effect should be treated as a medical emergency. Tardive dyskinesia: This later-onset adverse effect is characterized by bizarre facial and tongue movements, a stiff neck, and difficulty swallowing. It may occur with all classifications but is more common with first-generation antipsychotics. § § § § § § § § § § Following are sexual side effects that may accompany these medications: Decreased libido, retrograde ejaculation (the discharge of seminal fluid into the bladder rather than through the urethra); gynecomastia (men) Amenorrhea (women) These side effects can be very troubling for anyone, and for a patient struggling with thought disturbances, they can become the foundation for delusions. Copyright ©2023 F.A. Davis Company Antipsychotics: Planning/Implementation § Current developments in psychopharmacological treatment of schizophrenia § Educate client and family about drug § Outcome criteria/evaluation Copyright ©2023 F.A. Davis Company Sedative-Hypnotics: Background Assessment Data § Indications Short-term management of various anxiety states and treatment of insomnia; selected agents are used as anticonvulsants, preoperative sedatives, and to reduce anxiety associated with alcohol withdrawal. § Action: Depression of central nervous system Exception: Ramelteon’s sleep-promoting properties are the result of agonist activity on selective melatonin receptors. Copyright ©2023 F.A. Davis Company Sedative-Hypnotics: Background Assessment Data (continued_1) § Contraindications Contraindicated in known hypersensitivity, pregnancy, and lactation, and in severe hepatic, cardiac, respiratory, or renal disease. § Precautions Caution is advised with clients with hepatic, cardiac, renal, or respiratory insufficiency. Caution is also advised with those who are suicidal and those who have been addicted to drugs. Copyright ©2023 F.A. Davis Company Sedative-Hypnotics: Background Assessment Data (continued_2) § § Interactions Barbiturates: The effects of barbiturates are increased with concomitant use of alcohol, other central nervous systemt (CNS) depressants, monoamine oxidase inhibitors (MAOIs), or valproic acid. The effects of barbiturates may be decreased with rifampin. Possible decreased effects of the following drugs may occur when used concomitantly with barbiturates: anticoagulants, beta blockers, carbamazepine, clonazepam, oral contraceptives, corticosteroids, digitoxin, doxorubicin, doxycycline, felodipine, fenoprofen, griseofulvin, metronidazole, phenylbutazone, quinidine, theophylline, and verapamil. Concomitant use with methoxyflurane may enhance renal toxicity. Benzodiazepines: The effects of the benzodiazepine hypnotics are increased with concomitant use of alcohol or other CNS depressants, cimetidine, oral contraceptives, disulfiram, isoniazid, or probenecid. The effects of the benzodiazepine hypnotics are decreased with concomitant use of rifampin, theophylline, carbamazepine, or Saint John’s wort and with cigarette smoking. The effects of digoxin or phenytoin are increased when used concomitantly with benzodiazepines. There is increased bioavailability of triazolam with concurrent use of macrolides. Eszopiclone: Additive effects of eszopiclone occur with alcohol or other CNS depressants. Decreased effects of eszopiclone occur with CYP3A4 inducers (e.g., rifampin, phenytoin, carbamazepine, phenobarbital), with lorazepam, or following a high-fat or heavy meal. Increased effects of eszopiclone occur with CYP3A4 inhibitors (e.g., ketoconazole, clarithromycin, nefazodone, ritonavir). There are decreased effects of lorazepam with concomitant use. Zaleplon: Additive effects of zaleplon occur with alcohol or other CNS depressants. Decreased effects of zaleplon occur with CYP3A4 inducers (e.g., rifampin, phenytoin, carbamazepine, phenobarbital) or following a high-fat or heavy meal. There are increased effects of zaleplon with cimetidine. Zolpidem: Increased effects of zolpidem occur with alcohol or other CNS depressants, azole antifungals, ritonavir, or selective serotonin reuptake inhibitors. Decreased effects of zolpidem occur with flumazenil and rifampin, and with food. There is a risk of life-threatening cardiac arrhythmias with concomitant use of amiodarone. Ramelteon: Increased effects of ramelteon occur with alcohol, ketoconazole (and other CYP3A4 inhibitors), or fluvoxamine (and other CYP1A2 inhibitors). Decreased effects of ramelteon occur with rifampin (and other CYP3A4 inducers) and following a heavy or high-fat meal. Copyright ©2023 F.A. Davis Company Sedative-Hypnotics: Diagnosis § Risk for injury § Disturbed sleep pattern/insomnia § Risk for activity intolerance § Risk for acute confusion Copyright ©2023 F.A. Davis Company Sedative-Hypnotics: Planning/Implementation § Monitor client for the following side effects: Abnormal thinking and behavioral changes § Outcome criteria/evaluation Copyright ©2023 F.A. Davis Company ADHD Agents: Background Assessment Data § Indications Attention deficit-hyperactivity disorder (ADHD) in children and adults § Action The central nervous system (CNS) stimulants increase levels of norepinephrine, dopamine, and serotonin in the CNS. Their effectiveness in the treatment of ADHD is thought to be based on the activation of dopamine D4 receptors in the basal ganglia and thalamus, which depress, rather than enhance, motor activity. Copyright ©2023 F.A. Davis Company ADHD Agents: Background Assessment Data (continued) § Action Atomoxetine inhibits reuptake of norepinephrine, and bupropion blocks neuronal uptake of serotonin, norepinephrine, and dopamine. Clonidine and guanfacine stimulate central alphaadrenergic receptors in the brain, resulting in reduced sympathetic outflow from the central nervous system (CNS). The exact mechanism by which these nonstimulant drugs produce the therapeutic effect in attention deficit-hyperactivity disorder (ADHD) is unclear. Copyright ©2023 F.A. Davis Company ADHD Agents: Contraindications § Central nervous system (CNS) stimulants Contraindicated in clients with hypersensitivity to sympathomimetic amines; clients with advanced arteriosclerosis, cardiovascular disease, hypertension, hyperthyroidism, glaucoma, agitated or hyperexcitability states; clients with a history of drug abuse, seizure disorder, bulimia or anorexia nervosa; clients during or within 14 days of receiving therapy with monoamine oxidase inhibitors (MAOIs); in children younger than 3 years of age; and in pregnancy and lactation Copyright ©2023 F.A. Davis Company ADHD Agents: Contraindications (continued) § Atomoxetine and bupropion Contraindicated in clients with hypersensitivity to the drugs, in lactation, and in concomitant use with or within 2 weeks of using monoamine oxidase inhibitors (MAOIs) § Alpha agonists § Contraindicated in clients with known hypersensitivity to the drugs, should not be used in advanced arteriosclerosis, cardiovascular disease, hypertension, hyperthyroidism, glaucoma, agitated or hyperexcitability states, in clients with a history of drug abuse, during or within 14 days of receiving therapy with MAOIs, in children younger than 3 years of age, and in pregnancy and lactation. § Atomoxetine is contraindicated in clients with narrow-angle glaucoma. Bupropion is contraindicated in individuals with known or suspected seizure disorder, in the acute phase of myocardial infarction, and in clients with bulimia or anorexia nervosa. Alpha agonists are contraindicated in clients with known hypersensitivity to the drugs. Copyright ©2023 F.A. Davis Company ADHD Agents: Precautions § Central nervous system (CNS) stimulants Use caution in children with psychoses; clients with Tourette’s disorder, anorexia, or insomnia; elderly, debilitated, or asthenic clients; and clients with a history of suicidal or homicidal tendencies; prolonged use may result in tolerance and physical or psychological dependence. § Dexmethylphenidate and methylphenidate Effects of concomitant use Hypertensive crisis may occur with coadministration of monoamine oxidase inhibitors (MAOIs) Copyright ©2023 F.A. Davis Company ADHD Agents: Precautions (continued) § Atomoxetine and bupropion Use caution in clients with urinary retention; hepatic, renal, or cardiovascular disease; suicidal clients; pregnancy; and elderly and debilitated clients. § Alpha agonists Use caution in clients with coronary insufficiency, recent myocardial infarction, or cerebrovascular disease; in chronic renal or hepatic failure; the elderly; and in pregnant clients and those lactating. Copyright ©2023 F.A. Davis Company ADHD Agents: Interactions § Central nervous system (CNS) stimulants (amphetamines): Cautionary coadministration with alkalinizers, acidifiers, monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs). § Dexmethylphenidate and methylphenidate: Cautionary coadministration with antihypertensives, anticoagulants, anticonvulsants, tricyclic antidepressants (TCAs), SSRIs, MAOIs. § Atomoxetine: Cautionary coadministration with albuterol, vasopressors, MAOIs and CYP2D6 inhibitors Copyright ©2023 F.A. Davis Company ADHD Agents: Interactions (continued) § Bupropion: Cautionary coadministration with amantadine, levodopa, ritonavir, carbamazepine, monoamine oxidase inhibitors (MAOIs), nicotine replacement agents, alcohol, warfarin § Alpha agonists: Cautionary coadministration with calcium channel blockers, beta blockers, central nervous system (CNS) depressants, clonidine, tricyclic antidepressants, prazosin, levodopa, barbiturates, phenytoin Copyright ©2023 F.A. Davis Company ADHD Agents: Diagnosis § Risk for injury § Risk for suicide § Imbalanced nutrition § Insomnia § Nausea related to side effects of atomoxetine or bupropion § Pain related to side effects of abdominal pain with atomoxetine or bupropion or headache § Risk for activity intolerance Copyright ©2023 F.A. Davis Company ADHD Agents: Planning/Implementation § Monitor client for the following side effects: Overstimulation, restlessness, insomnia, palpitations, tachycardia, anorexia, weight loss, tolerance, physical and psychological dependence, nausea and vomiting, constipation, dry mouth, sedation or rebound syndrome, potential for seizures, liver damage, and new or worsened psychiatric symptoms § Educate client and family about the drug § Outcome criteria/evaluation Copyright ©2023 F.A. Davis Company Practice Question 2. A child is taking guanfacine for ADHD. Which of the following would be part of the client education associated with administration of this medication? A. Do not take with foods that contain tyramine. B. Always use sunblock when spending time outdoors. C. Report for blood tests once a month. D. Do not discontinue the medication abruptly. Copyright ©2023 F.A. Davis Company Practice Answer Correct Answer: D Clients taking an alpha agonist should not discontinue therapy abruptly. To do so may result in symptoms of nervousness, agitation, headache, and tremor, and a rapid rise in blood pressure. Dosage should be tapered gradually under the supervision of the physician Copyright ©2023 F.A. Davis Company