Antipsychotic Drugs Part 2 PDF

U C C ANTIPSYCHOTICS & ANXIOLYTICS PSYCHOSIS – symptomatic in a variety of mental or psychiatric disorders - usually characterized by more than one symptom such as difficulty processing information and coming to a conclusion, delusions, hallucinations, incoherence, catatonia and aggressi...

U C C ANTIPSYCHOTICS & ANXIOLYTICS PSYCHOSIS – symptomatic in a variety of mental or psychiatric disorders - usually characterized by more than one symptom such as difficulty processing information and coming to a conclusion, delusions, hallucinations, incoherence, catatonia and aggressive or violent behavior Shizophrenia – a chronic psychotic disorder in which many of the symptoms are manifested Theory: psychotic symptoms result from an imbalance in the neurotransmitter dopamine in the brain 2 groups a. positive symptoms – agitation, incoherent speech, hallucination, delusion & paranoia b. negative symptom – decrease or loss in function & motivation - more chronic & persistent  ANTIPSYCHOTICS also known as neuroleptics or psychotropics improves the thought processes & behavior of clients specially those with schizophrenia & other psychotic disorders sometimes it is also called as dopamine antagonists Neuroleptics - refers to any drug that modifies psychotic behavior and exerts an antipsychotic effect ▪Indications: Schizophrenia, bipolar disorder ▪Contraindications: Parkinson's disease, CNS depression, QT prolongation, glaucoma, peptic ulcer, urinary or intestinal obstruction, seizure disorder, active alcoholism, immunosuppressed individuals, pregnant and lactating 2 major categories: 1. typical – traditional - phenothiazines & nonphenothiazines 2. atypical – for clients who do not respond to the typical antipsychotic agents - fewer adverse reaction & found to be more useful in positive & negative symptoms of schizophrenia ex. Clozapine ACTION: Antipsychotic block the actions of dopamine and thus may be classified as dopaminergic antagonists promote symptoms of parkinsonism (EPS- extrapyramidal symptoms) resulting to PSEUDOPARKINSONISM  Clozapine(Clozaril) C Atypical antipsychotic, major tranquilizer, decreases both positive and negative symptoms of schizophrenia H Decrease positive symptoms of schizophrenia(delusions, hallucinations, looseness of association, word salad, agitation, ambivalence Decreased negative symptoms(apathy, alogia, avolition, anhedonia) E Best taken after meals C Inform the patient about blood test. WBC and absolute neutrophil count must be performed 10 days before starting treatment then weekly for 18 hours and every 4 weeks after discontinuation. Only patient with normal WBC and ANC should receive the drug Report: fever, sore throat, lethargy, malaise and signs of infection Smoking may decrease effectiveness. Rise slowly to avoid dizziness Ice chips or sugarless gum may help relieve dry mouth K If the WBC counts drops below 3,500/mm, asses the patient for signs of infection. If the WBC count drops to 200/mm, place the patient in protective isolation Note: continuous administration of clozapine despite low level of WBC constitute to malpractice Avoid the use of ST John’s Wort while taking the drug, it may decrease clozapine levels Monitor RR, it may cause respiratory arrest  Haloperidol (Haldol) C Typical antipsychotic, major tranquilizer, decreases positive symptoms of schizophrenia Decrease positive symptoms of schizophrenia (delusions, hallucinations, looseness of association, H word salad, agitation, ambivalence) E Best taken after meals Avoid exposure to sunlight, it may cause photosensitivity. Assess for signs and symptoms of C pseudo parkinsonism that includes tremor, slow movement, shuffling gait, and muscle stiffness. Assess for repetitive, involuntary, purposeless movements including grimacing, tongue protrusion, lip smacking, puckering and pursing and rapid eye movement. These are indicative of tardive dyskinesia. Assess for manifestations of neuroleptic malignant syndrome that include high fever (above 38.5) irregular pulse, tachycardia, tachypnea, muscle rigidity, altered mental status, high or low blood pressure and excessive sweating. Report: Jaundice including sign and symptoms of agranulocytosis like fever, sore throat, lethargy, malaise Monitor BP. It may cause hypotension K The long acting type , haloperidol decanoate, is given once a month per IM. To manage NMS, the 2 most frequent used medications are bromocriptine mesylate(dopamine agonist) and dantrolene sodium(muscle relaxant)  Risperidone (Risperdal) C Atypical antipsychotic, major tranquilizer, decrease both positive and negative symptoms of schizophrenia H Decreased positive symptoms of schizophrenia (delusions, hallucinations, looseness of association, word salad, agitation, ambivalence. Decrease negative symptoms of schizophrenia(apathy, alogia, avolition, anhedonia) E Best taken after meals C Side Effects: drowsiness, tardive dyskinesia, dizziness, constipation. Avoid abrupt changing of positions. Report: fever, sore throat, bruising/bleeding, tics/spasms, trembling shuffling gait Assess for manifestations of NMS that include high fever, irregular pulse, tachycardia, tachypnea, muscle rigidity, altered mental status, high or low BP and excessive sweating K Avoid use of alcohol. To manage NMS, the two most frequent used medications are bromocriptine mesylate and dantrolene sodium  Quetiapine Fumarate (Seroquel) C Atypical antipsychotic, major tranquilizer, decreases both positive and negative symptoms of schizophrenia H Decrease positive symptoms of schizophrenia(delusions, hallucinations, looseness of association, word salad, ambivalence). Decrease negative symptoms of schizophrenia(apathy, alogia, avolition, anhedonia) E Best taken after meals C Avoid riving since dizziness may occur. Side effects: hypotension, tachycardia, constipation, seizure, headache. Report sore throat, bleeding and suicidal thoughts. Report signs of neuroleptic malignant syndrome K To manage NMS, the two most frequent used medications are bromocriptine mesylate and dantrolene sodium  Chlorpromazine Hydrochloride (Thorazine) C Typical antipsychotic, major tranquilizer, decreases the positive symptoms of schizophrenia, anti emetic. H Decrease positive symptoms of schizophrenia (delusions, hallucinations, looseness of association, word salad, agitation, ambivalence) E Best taken after meals C Avoid exposure to sunlight. Report signs of neuroleptic malignant syndrome. K Monitor BP, it can cause hypotension, tachycardia, dry mouth, constipation, urinary retention. To manage NMS, the two most frequent used medications are bromocriptine mesylate and dantrolene sodium.  ANXIOLYTICS - also called antianxiety drugs primarily used to treat anxiety & insomnia - Resembles that of the sedative-hypnotics Indications: alcohol withdrawal, seizures, anxiety and anxiety disorders, panic disorder, agitation, insomnia. Contraindications: MG, sleep apnea, bronchitis, COPD  ANXIETY – an emotion characterized by feelings of tension, worried thoughts & physical changes like increased BP - limited degree might be normal, however when its excessive & disabling, anxiolytics could be prescribed 2 types a. Primary – not caused by a medical condition or drug used b. Secondary – related to selected drug use or medical or psychiatric disorders Note: Nonpharmacologic measures should be used for decreasing anxiety before giving anxiolytics  ANTI-ANXIETY AGENTS Lorazepam(Ativan) C Anti-anxiety, minor tranquilizer H Decrease anxiety E Best taken at hours of sleep or on an empty stomach, food delays absorption of drug C The drug may cause dizziness, drowsiness, dry mouth. Avoid driving and caffeine containing foods and alcoholic beverages. K Keep siderails up Flurazepam hydrochloride (dalmane) C Anti- anxiety H Decreased anxiety, adequate sleep E Best taken before meals C Causes mental confusion, hallucinations and ataxia. Avoid alcohol, it increase CNS depression. Avoid caffeine containing foods, it counteracts the effect of the drug k Raise bedside rails. Assess for hepatic renal function  Diazepam (valium) C Anti-anxiety, given as muscle relaxants to patient in traction H Decreased anxiety, adequate sleep E Best taken before meals, food in the stomach delays absorption C Avoid driving, avoid intake of alcohol and caffeine containing foods since it alters the effects of drug K Administer it separately; it is incompatible with any drug. Not given when a patient is taking Valerian or Kava-Kava, herbal sedatives ANTIDEPRESSANTS & MOOD STABILIZERS DEPRESSION – most common psychiatric problem - primarily characterized by mood changes & lost of interest in normal activities Major depression – weight loss or gain, insomnia or hypersomnia, loss of energy, fatigue, feelings of despair, inability to think or concentrate & suicidal thoughts 3 types: a. Reactive or exogenous – sudden onset resulting from a precipitating event (ex. Death of a loved one) b. Major, unipolar or endogenous – loss of interest in work & home, inability to complete tasks & dysphoria (deep depression) c. Bipolar affective disorder – swings between two moods - manic (euphoric) & depressive (dysphoria) Theories: insufficient amount of NE, serotonin & dopamine ECT (ELECTROCONVULSIVE THERAPY) – used to treat psychosis & depression before the introduction of antipsychotics & antidepressants - no longer frequently used  ANTIDEPRESSANTS used for depressive episodes accompanied by findings of hopelessness and helplessness mood stabilizers are effective for bipolar disorder mood elevators 4 groups: 1. Tricyclic Antidepressants (TCAs) or tricyclics Indications: Depression, OCD Contraindications: allergy to TCA’s, myocardial infarction, myelography within previous 24 hours or in next 48 hours. Concurrent use of MAOI’s, pregnant and lactating. Preexisting cardiovascular disorders  TRICYCLIC ANTIDEPRESSANTS Amitriptyline Hydrochloride (Elavil) C Tricyclic antidepressant; prevents reuptake of norepinephrine H Increased appetite, adequate sleep E Best taken before meals C Initial therapeutic effect may become evident only after 2-3 weeks of intake; full therapeutic effects occur after 3- weeks k Check the BP, it causes, hypotension. Check the heart rate, it causes cardiac arrhythmias Imipramine(Tofranil) C Tricyclic antidepressant H Increased appetite, adequate sleep E Best taken after meals C Change position slowly. Acidic drinks may decrease the absorption of drug k Monitor heart rate, it may cause palpitations, or cardiac arrhythmias 2. Monoamine Oxidase Inhibitor Indication: depression Contraindication: Allergy to MAOI’s, pheochromocytoma (tumor of the adrenal medulla), CV diseases, myelography within previous 24 hours or in next 48 hours, pregnant and lactating Monoamine oxidase inhibitor C Antidepressant H Increased appetite; adequate sleep E Best taken after meals C Report headache, it indicates hypertensive crisis. Avoid tyramine containing foods like: Avocado, Banana, Cheddar(aged, Swiss cheese), Soy sauce and preserved foods K Monitor BP, it may cause hypertensive crisis  Phenelzine (Nardil) C Antidepressant (MAOI) H Increased appetite, adequate sleep E Best taken after meals C Report headache, it indicates hypertensive crisis. Avoid tyramine containing foods like: Avocado, Banana, Cheddar(aged, Swiss cheese), Soy sauce and preserved foods K Monitor the BP. There should be at least two-week interval when shifting from one antidepressant to another. Not taken in combination with herbal antidepressant like St Johns Worth 3. Selective Serotonin Reuptake inhibitor (SSRI) Indications: depression, OCD’s, panic attacks, bulimia, social phobias, social anxiety disorder Contraindications: Allergy to SSRI, hepatorenal disease, severely depressed and suicidal patients, pregnant and lactating Fluoxetine HCL (Prozac) C Antidepressant, SSRI H Normal mood E Best taken after meals C Side effects: palpitations, nausea, diarrhea/constipation, urinary retention, pruritus Adverse effects: impotence, decreased libido K Take consistently at the same time each day. Full therapeutic effects may require 4 weeks of drug intake. Avoid use with alcohol 4. Serotonin-norepinephrine Reuptake Inhibitors Indications: major depressive disorder, OCD, social phobia, ADHD Contraindications: use of MAOI within the last 2 weeks, anorexia nervosa or bulimia, narrow angle glaucoma. Duloxetine HCL(Cymbalta) C Antidepressant, SNRI H Recovery from depression manifested by adequate sleep and increased appetite E Maybe taken with or without food C Do not crush, chew, sprinkle capsule content on food Side effects: diarrhea, decreased libido, erectile dysfunction, fatigue, weight gain, Therapeutic effects occur in 1-4 weeks Use sunscreen when outdoors K Do not withdraw abruptly Avoid: Kava-kava, valerian, chamomile  ANTIMANIC AGENTS Indication: Mania (in patients with bipolar disorder) Contraindications: Significant renal and cardiac diseases, history of leukemia, dehydration, pregnant women and lactating mothers LITHIUM CARBONATE C Anti Manic H Decreased hyperactivity E Best taken after meals C Increase fluid intake (3L/day) and sodium intake (3g/day). Avoid activities that increase perspiration as these may affect the body’s sodium levels K It take 10-14 days before therapeutic effects becomes evident. An antipsychotic is administered during the first two weeks to manage the acute symptoms of mania until lithium takes effect. Monitor serum level, the normal levels are ▪ 0.5-1.5mEq/L- adult acute dose ▪ 0.6-1.2 mEq/L- adult maintenance dose ▪ 0.4-1.0 mEq/L-elderly above 65 yrs old Nausea, anorexia, vomiting, diarrhea, abdominal cramps, blurred vision and confusion indicate lithium toxicity. Fine hand tremors may be associated with lithium side effects. If the fine hand tremors progress to coarse hand tremors, suspect neurotoxicity Mannitol or Diamox is administered if toxicity occurs