7. Pharmacology in Psychiatry

7/27/2019 7. Pharmacology in Psychiatry

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Pharmacology in

Psychiatry

Antonietta Rosemelinda Edra


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Pharmacology

Goal - To administer themedication and dosage that willmaximize the therapeutic effects andminimize the side effects.


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PharmacologyPsychotropic medicationschemicals that produced profound effects onmind, emotions and body.3 major psychotropic drugs.

antimanic, anti psychotic, anti depressantincludes

anti anxiety/ anxiolytics antipsychotic/ neuroleptics anti depressant

anti manic mood stabilizing agents sedative hypnotic agents

psychotropic drugs during pregnancy


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Pharmacology

Anti anxiety/ anxiolytic drugs

Uses: Treatment of anxiety, alcoholwithdrawal, induction of sleep

Effects : depresses the CNSPreparation: oral and IV preparations

Benzodiazepines ( inhibitoryneurotransmitter in CNS)

opening Cl ion channel inhibition ofneuronal activity firing rate of neurons anxiety.


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PharmacologyTypes

A. Benzodiazepines

Short acting

Alprazolam (Xanax)

Estazolam ( Prosan)

Midazolam ( Versed)Oxazepam ( Serax)

Triazolam ( Halcion)

Medium acting

Lorazepam ( Ativan)

Temazepam ( Restoril)

Long actingChlordiazepoxide ( Librium)

Clonazepam ( Klonopin)

Clorazepate ( Tranxene)

Diazepam ( Valium)

Flurazepam ( Dalmane)

Quazepam ( Doral)


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PharmacologyB. Non barbiturate

Buspirone ( Buspar) Chloral hydrate ( Noctec) Diphenhydramine ( Benadryl) Doxylamine ( Unisom)

Hydromxyzine ( Atarax. Vistaril)

Zolpidem ( Ambien)

C. Antidepressant for anxiety Clomipramine ( Anafranil) Fluoxetine ( Prozac)

Fluvoxamine ( Luvox)

Paroxetine ( Paxil) Sertarline ( Zoloft) Venlafaxine ( Effecxor XR)


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PharmacologyNeuroleptics/ Antipsychotic

Uses- used to treat agitated behavior andpsychotic symptoms.

Actions: Acts by blocking dopamine receptors

in the CNS.They also block muscarinic receptors foracetylcholine, and alpha receptors foracetylcholine.

Preparation: IV, IM, Oral

Effective in treating symptoms of psychosis,May be taken with benzodiazepines to lessenthe dose of neurolepticsEffects seen within 1-2 weeks of treatment


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Pharmacology

These drugs are beneficial for

1. Positive symptoms ( Type I) schizophrenia Hallucinations and

delusionsRespond to newer and traditionalantipsychotic drugs.

2. Negative symptoms ( Type II)

Apathy,flat affect are more responsive to

Newer atypical anti psychotic drugs.


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PharmacologyTypes:Traditional drugs/ Typical drugsPhenothiazinesaliphatics- Chlorpromazine ( Thorazine)Piperidines - Mesoridizine ( serentil), Thioridazine ( Melleril)

Piperazines- a. Fluphenazine ( prolixin, permitil)b. Perphenazine ( triaflon)c. Prochlorperazine- ( Compazine)d. Trifluoperazine ( Stelazine)

B. Butyrophenones : Droperidol ( Inapsine)Haloperidol ( Haldol)

C. Thioxanthines : Chlorprothixene ( Taractan)Thiothixene ( Navane)D. Dibenzoxapine : Loxapine ( loxitane)E. Dihydroindolone Molindone ( Moban)F. Diphenylbutylpiperidine Pimozide ( orap)


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Pharmacology

Atypical drugs

A. Dibenzodiazepine-

Clozapine ( Clozaril)

Quetiapine ( Seroquel)

B. Benzisoxazole- Respiradone (Resperdal) Ziprasidone ( Zeldox,

Geodon)C.Thienobenzodiazepine- Olanzapine (

Zyprexa)


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PharmacologyPrecaution:Drug interactions Potentiate action of alcohol barbiturates, antihypertensives

and anti cholinergics- must be avoided Should be temporary discontinued when spinal and epidural

anesthesia will be used.

Adverse EffectsAgranulocyctosis- sore throat, coldsHepatotoxicity- JaundiceDrowsiness- CNS depressionOrthostatic hypotension- CNS depression

Constipation and urinary retention- anticholinergic effectAnorexia- depressed appetite centersHypersensitivity reactionsCardiac toxicity


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PharmacologyExtrapyramidal Side effects (EPS)

Dystonia- Occurs early in treatment after initial dosage

Manifestation- grimacing , torticollis, intermittentmuscle spasms.

Pseudoparkinsonism- resembles true parkinsonism

Manisfestation- tremor, mask like facies, drooling, restlessness, festinating gait, rigidity.

Akathisia- motor agitation- restlessness , festinating gait,rigidity.Akinesia- fatigue, weakness, ( hypotonia, painful muscles,lack of energy ( anergy)Tarditive Dyskinesia- Late appearing after prolonged useof antipsychotic drugs.- involuntary movement of face ,jawand tongue , lip smacking, grinding of teeth , rolling orprotrusion of tongue.


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PharmacologyConditions disappears with sleep- all anti psychotics shouldbe discontinued to see if symptoms subside.

Neuroleptic malignant syndrome- results from dopamineblockade in the hypothalamus- associated with high dosage of antipsychotic drugs.

Symptoms- Hyperthermia ( cardinal symptom)

Muscular rigidityTremorsImpaired ventilationUnstable blood pressure

Anti Parkinson drugs

Blocks the extrapyramidal symptoms.Anti cholinergics- Benztropin ( Cogentin), Biperiden(Akineton)

Trihexyphenidyl ( Artane)Antihistamine- Diphenhydramine ( Benadryl)


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Pharmacology

Others drugs

Amantadine ( Symmetrel)- neurolepticmalignant syndrome

Benzodiazepine- for akinesia, akathisiaBromocriptine ( Parlodel)- NMS

Clonidine ( Catapres)- EPS

Nifedipine- tarditive dyskinesia

Propranolol- EPS

Verapamil( Calan) Tarditive dyskinesia


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PharmacologyNursing Caremonitor for signs of hepatotoxicity- Jaundicemonitor for signs of infection colds and sore throatmonitor B/P in supine and standing positionassist in ambulation- sit first before standingCBC- for long term theraphy

Avoid alcohol intake with concurrent medication esp. if takingbenzodiazepinesavoid hazardous activitiesAvoid exposure to direct sunlight provide sunscreensEPS noted report to physicianwater and high fiber diet- prevent constipationAvoid mixing neuroleptics with certain juices and beverages ( Coffee, tea,

cola beverages) - effectiveness of the drug.Avoid antacids- or take them 1-2 hours after administration of antipsychotics- decreases absorption of antipsychotics.Avoid smoking- decrease levels of anti psychotics.


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Pharmacology1.TCA nonselective/ Cyclic

1. Amitirptyline ( Elavil, Endep)

2. Clomipramine ( Anafril)

3. Desipramine ( Norpramin)

4. Doxepin ( Sinequan, Triadapin)

5. Imipramine ( Tofranil)

6. Nortrptyline ( Aventyl, Pamelor)

7. Protriptyline ( Vivactil, Triptal)8. Trimipramine ( Surmontil)

2. Monoamine Oxidase Inihibitors

1. Phenelzine sulfate ( Nardil)

2. Selegiline ( Eldepryl)

3. Tranycypromine sulfate ( Parnate)

3. Selective serotonin reuptake inhibitors

1. Citaprolam ( Celexa)2. Fluoxetine ( Prozac, Saralem)

3. Fluvoxamine ( Lexapro, Luvox)

4. Paroxetine ( Paxil)

5. Sertraline ( Zoloft)


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Pharmacology

Atypical New GenerationAmoxapine ( Ascendin)

Bupropion (Wellbutrin) - tx smoking

Maprotiline ( Ludiomil)Mirtazapine ( Remeron)

Nefazodone ( Remeron)

Trazodone ( Desyrel)

Venlafaxine (Effexor)


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PharmacologyDrug Interactions- TCAPotentiates effects of anticholinergics and CNS depressant

Adverse effects

Orthostatic hypotension, skin rash, drowsiness, dry mouth,blurred vision, constipation, urine retention, tachycardia, CNSstimulationolder patients restlessness, incoordination, fine

tremors, night mares , delusions disorientation.

TCA should not be given with narrow angle glaucoma

TCA contraindicated to patients with or during recovery from MI orwith history of cardiac dysrythmias and conduction defects.

Minimum of 14 days between switching TCA to MAOI to avoid

hypertensive crises.Abrupt discontinuation can produce- nausea, head ache, malaise.


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PharmacologyMAO InhibitorsDrug interaction- MAO potentiates the effects of alcohol,barbiturates, anesthetic agents, cocaine , antihistamine,narcotics, corticoids, anticholinergics.Drug Foods interaction- Hypertensive crises- withvascular rupture, occipital head ache, palpitations , stiffnessof neck muscles, emesis, sweating.

Increase neuro-hormonal changes secondary to ingestionof food high in tyramine beer, wine , chicken livers, agedor natural cheese, chocolate caffeine cola, licorice avocado,bananas , bologna.


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Pharmacology

Adverse Effects-

CNS- orthostatic hypotension,

Hypersensitivity resction- skin rash

CNS depression- drowsiness

Anticholinergic effects- dry mouth, blurredvision,tachycardia

Autonomic effect- sexual disfunctionCNS stimulation- nightmares, delusion,disorientation, insomnia


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Pharmacology

Selective Serotonin ReuptakeInhibitor(SSRI`s)Drug interaction- may interact withtryptophan..

Diazepam, Warfarin, Digoxin should bediscontinued 4-6 weeks before startingSSRI.Adverse Effect- insomnia, head ache, dry

mouth sexual dysfunction, anxiety,diarrhea.SSRI`s are given at noon time to avoidinsomnia, or sleep disturbances.


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Pharmacology

Atypical New Generations drugs

Adverse effects- increase appetite,weight gain and sleep disturbances.

Bupropion- affect dopamine can resultto agitation.

used in treatment of smoking cessation.


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Pharmacology

Nursing Care for patients receiving Antidepressants

monitor self destructive behavior esp. duringthe 2nd week of treatment when suicidal ideationremains and energy increases.

Monitor serum glucose levels.Expect therapeutic effect to be delayed .

< 3wks with MAOI , 3-4 wks with the otherantidepressants.

Avoid concurrent administration with adrenergics., limit or eliminate caffeine use- to preventexacerbation of depression.


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Pharmacology

Anti Manic and Mood stabilizing Agents

Action: Use to control manic episodes andmood disorders, it decrease psychomotor

response/ activity to environmentalstimuli.

LITHIUM affects neurotransmitters ofmultiple systems including dopamine,

serotonin, norepinephrine, GABAandacetylcholine.

Preparation: oral tablets and capsules


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Pharmacology

Types Anti manic agents and mood stabilizersLithium Carbonate (Eskalith, Lithotabs, Lithane ,Lithonate)Lithium Carbonate sustained released ( EskalithC-R, Lithobid)Alternative anti manic and mood stabilizingagentsCarbamazepine ( Tegretol)Gabapentin ( Neurontin)

Lamotrigine ( Lamictal, Lamivtal cd)Topiramate ( Topimax)Valproate ( Depakene, Dapakote, Depacon,Epival)


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Pharmacology

Precautions:

Drug /Food interaction: Diuretics increase thereabsorption of lithium.- Toxicity

When given with haloperidol and thioridazine-

encephalopathic syndromeNa bicarbonate, Na Cl Increases the excretionof Lithium.

Daily intake of 250 mg of caffeine with lithium

decreases effect of antimanic drugs.Thetapeutic level of Lithium- 0.5-1.5 mEq/L

Clinical response is 1-2 wks after taking the firstdose


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Pharmacology

Nursing care

Administer with meals- prevent gastric irritation

Ensure that drug is not crushed nor chewed

Medication should not be discontinued abruptly

Maintain Na intake-Hyponatremia anddehydration- Lithium toxicity

Monitor therapeutic levels of lithium

Check for signs of toxicity- vomiting , diarrhea,

tremors , weakness, severe thirst, tinnitus. visualdisturbances and skin rashes.


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Pharmacology

Sedative and Hypnotic drugs

Uses: insominia, hypersomnias, narcolepsy,parasomnias, periodic leg movements (nocturnalmyoclonus), sleep apnea.

Preparations : Available in Oral, IMHypnotic cause sleep and have a more potenteffect on the CNS than sedatives.

Sedative hypnotics are classified chemically into

3 groupsBarbiturates, Benzodiazepins, nonbenzodiazepines


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Pharmacology

Precautions/ nursing consideration

Intended only for short term use- physiologicaddiction, overdose

Barbiturates- increase the metabolism of anti

coagulants because they induce liver enzymesynthesis.

Chloral hydrate and paraldehyde- not use inalcohol withdrawal- toxic

Paraldehyde- status epilepticus when all drugshave failed

Once tolerance have developed abruptdiscontinuation could lead to withdrawal


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Pharmacology

Withdrawal- insomnia, weakness, muscle tremors,anxiety, irritability, sweating, anorexia, fever,nausea and vomiting, head ache , incoordination.To avoid withdrawal- taper dosing of sedativehypnotic medications.

Any of the sedative hypnotic when taken inexcess could lead to unconsciousness, coma anddeath.Assess for signs of alcohol and suicide attempts.Assess for undesired effects such as respiratory

depression.Evaluate clients response to medications andunderstanding of teaching.


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Pharmacology

End of lecture

Reference

Mosby`s comprehensivereview of Nursing for NCLEX RN 8thedition

Rosemelle C. Edra

7. Pharmacology in Psychiatry

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