Assessing & Management of side effects: Part 1 and managing side effects.pdf · Potential side...
-
Upload
nguyendang -
Category
Documents
-
view
232 -
download
0
Transcript of Assessing & Management of side effects: Part 1 and managing side effects.pdf · Potential side...
Potential side effects Central nervous system Movement disorders [EPSEs] Thermoregulatory effects [NMS] Central anticholinergic toxicity Sedation Cardiovascular Hypotension Tachycardia EGC changes
Haematological Neutropenia Leukopenia Agranularcytosis Gastrointestinal effects Sialorrhoea Constipation Opthalmological Neuroendocrine Hyperprolactineamia Sexual dysfunction Weight gain Glucose and lipid metabolism Genitourinary [incontinence] Dermatological [rashes]
Mechanism of Action Dopamine hypothesis of schizophrenia
Schizophrenia is associated with impaired dopaminergic neurotransmission in the brain
Hyperactivity: Positive symptoms
Hypoactivity: Negative symptoms
Mesocortical pathway - Learning and memory
Mesolimbic pathway - Emotions
Nigrostriatal pathway - Movement regulation
Tuberoinfundibular pathway - Prolactin regulation
Stahl SM. Essential Psychopharmacology of antipsychotics and mood stabilizers. 1st ed. Cambridge: Cambridge University Press; 2002
Clozapine Olanzapine Haloperidol Risperidone
Hist. H1
α1-adren. α2-adren.
Musc 5-HT2C 5-HT2A D4 D2
Sertindole Quetiapine Ziprasidone Zotepine
D1 Broad receptor binding profile
Chlorpromazine
Data from Bymaster et al., 1996, unpublished observations; Schotte et al., 1996,
Increase in negative
symptoms
Mesocortical pathway
Stahl, Essential Psychopharmacology;Cambridge University Press 2000
Prolactin levels rise
Tuberoinfundibular pathway
Stahl, Essential Psychopharmacology;Cambridge University Press 2000
drowsiness
decreased blood pressure
dizziness
1 INSERTED
Stahl, Essential Psychopharmacology;Cambridge University Press 2000
constipation
LAXATIVE
blurred vision
dry mouth drowsiness
M1 INSERTED
Stahl, Essential Psychopharmacology;Cambridge University Press 2000
H1 INSERTED
drowsiness
weight gain
Stahl, Essential Psychopharmacology;Cambridge University Press 2000
5HT7
5HT6
H1 1
2 5HT2A
D2 quetiapine
Stahl, Essential Psychopharmacology;Cambridge University Press 2000
5HT6
5HT3
5HT2C
M1 H1 1
D1
D3 D4
5HT2A
D2 olanzapine
Stahl, Essential Psychopharmacology;Cambridge University Press 2000
5HT1D SRI
NRI
5HT7
5HT2C
5HT1A
1
D3
5HT2A
D2 ziprasidone
Stahl, Essential Psychopharmacology;Cambridge University Press 2000
Current practice Survey of 250 CPNs/Thorn graduates CPNs report that medication management is
part of their role Routinely monitor psychopathology; side effects
Very high priority for training Measures infrequently used (KGV 5%;
LUNSERS 25%) 25% ask about sexual dysfunction Thorn training improves reported practice
Gray R. et al (2001) JP&MHN, 7, 4, 12-18
LUNSERS Based on the UKU Self-report Symptom experienced in
the last month 51-items rated on a five
point scale Red herrings Sub-scales Some validity/reliability
data available
Advantages Easy to use Comprehensive Allows side effects to be
prioritised
Disadvantages Side effects will be missed Time consuming to score Dubious red herrings Some patients are unable
to complete
LUNSERS sub-scales Extrapyramidal symptoms Anticholinergic effects Other autonomic
Dizziness; feeling sick; palpitations; etc
Allergic reactions Psychic side effects
Sedation; tension; depression; etc
Hormonal side effects Miscellaneous Red herrings
Example items from the LUNSERS Each item is rated on a five point scale
Not at all; very little; a little; quite a lot; very much Rash Difficulty staying awake Runny nose Increased dreaming Headaches Dry mouth Swollen or tender chest
Dystonia Signs & symptoms Muscle spasm in any part of the body. Trismus (contraction of
the masculatory muscles);Blepharospasm (sustained forceful eye closure); Facial grimacing; Oculogyric spasm (eyes rolling back) Tortocolis (head and neck twisted to the side); Retrocolis (head and neck forced back): laryngeal spasm Patient may be unable to speak or swallow
How common is it? Approx 10%. Associated with typicals. More common in young men, drug naïve, high potency meds
How long does it take to develop?
Minutes after administering IM, hours after oral (acute) months- years (tardive)
Assessment observation
Treatment Administration of anticholinergic meds Oral (patient may not be able to swallow) IM (response 20 minutes) IV ( response 5 minutes)
Pseudo-parkinsonism Signs & symptoms Motor symptoms: Rigidity (limbs resistive to passive
movements); tremor; postural abnormalities; Bradykinesia or akinesia (characterised by a reduction in spontaneous facial movements); decreased facial expression, flat monotone voice, decreased arm swing, inability to initiate movement Mental effects: Bradyphrenia (slow thinking), mental clouding salivation
How common is it? Approx 20% more common in elderly females, pre existing head injury, stroke
How long does it take to develop?
Days to weeks
Assessment Simpson & Angus EPSE rating scale. Observation. Patient report
Treatment Reduce dose Change to atypical Prescribe anticholinergic
Simpson-Angus Scale (SAS) Reference: Simpson GN and Angus JWS (1970) Acta Psych Scand,
212 (sup 44), 11-19 10 item measure for drug induced parkinsonism Facilitates standardised clinical assessment of
Rigidity, tremor and salivation Has validity Ten items rated on a five point scale (0=complete absence of the
condition, 4=presence of the condition in extreme form) 7/10 items measure rigidity
Shoulder shaking, arm dropping, and elbow and wrist rigidity Items from tremor and pooling of saliva in the mouth The global score in the summation of all the items divided by the
number of items Scores of up to 0.3 are considered within the normal range
Model for assessing side effects
LUNSERS+observation every six months
Management: consult Maudsley prescribing guidelines
Observe or pt reports stiffness: Simpson/Angus scale
Discussion with multi-disciplinary team
Feedback to the patient
Feedback to the patient
Review and re assess
akathesia Signs & symptoms “Can’t sit still”; Subjective inner restless; foot stamping when
sitting down; rocking from foot to foot; pacing; mental unease, unrest or dysphoria
How common is it? Approx 25%
How long does it take to develop?
Hours to weeks
Assessment Barnes Akathisia Scale. Observation, patient report
Treatment Reduce dose Switch to atypical (clozapine, quetiapine) Antimuscarinic (benzatropine) Propranalol/diazepam/clonazepam
* Anticholinergics not useful for akathesia
Barnes akathesia rating scale (BAS or BARS) Reference
Barnes TRE (1989) Br J Psych 154, 672-676 Measures Objective features of motor restlessness Subjective complaints of restlessness
And associated distress Rated on a scale of 0-3
Operational definitions for each scale point Also a global severity rating on a six-point scale (0=absent, 5=severe) Diagnostic for mild moderate and severe akathisia Scale should be completed after observation of the patient for five
minutes
Model for assessing side effects
LUNSERS+observation every six months
Management: consult Maudsley prescribing guidelines
Observe or pt reports restlessness: Barnes akathisia scale
Discussion with multi-disciplinary team
Feedback to the patient
Feedback to the patient
Review and re assess
Tardive Dyskinesia Signs & symptoms Involuntary repetitive movements. Perioral movements (lip
smacking, sucking, darting, twisting tongue, chewing, lip puckering, puffing cheeks) facial and eye (grimacing, tics, blinking, brow arching) extremities and trunk (choriform movements) noisy breathing
How common is it? 5% after first year of exposure. More common in females, people with negative symptoms, co morbidity – dementia, mood disorder, diabetes). The longer the exposure the greater the risk
How long does it take to develop?
Months to years
Assessment Abnormal Involuntary movement Scale (AIMS) Observation, patient report
Treatment Stop anticholinergic medication. Switch to an atypical (clozapine, olanzapine, quetiapine). Tetrabenazine, clonazepam, vitamin E
Treatment outcome Parkinsonism and dystonia not associated
with a worse outcome Akathisia associated with a worse outcome
Suicide/violence
The course of EPS Fig 1. The time course of acute extrapyramidal
symptoms (Casey 1996)
0
5
10
15
20
25
30
7 14 30
Time (days)
EPS
(% o
f pat
ient
s)
AkathisiaDystoniaParkinsonism
Overview of the AIMS Introduced by US National Institute of Mental Health (NIMH)
- Guy (1976) Global instrument Divided into seven body regions Each item rated on a five point scale Additionally global ratings of
Overall severity Incapacitation Patient awareness
Dental status can be recorded Tremor is excluded Total score of 0-40 Detailed examination protocol
AIMS rating scale 0= None/normal 1= Minimal 2= Mild 3= Moderate 4= Severe
Model for assessing side effects
LUNSERS+observation every six months
Management: consult Maudsley prescribing guidelines
Discussion with multi-disciplinary team
Feedback to the patient
Feedback to the patient
Review and re assess
Observe unusual movements (not rhythmic): AIMS
Problem solving Formulation
Brief summary of assessments agreed by interviewer and patient
Problem identification (SM) Target (SMART)
Evidence based intervention Agree plan review
Single case study design
010203040506070
Baselin
e
Evaluati
on
Durabilit
y
LUNSERS Baseline assessment Formulation/problems
and targets Specific problems Design intervention Implement intervention Evaluation Durability
Rating scales General - LUNSERS Parkinsonism – Simpson-Angus
Akathisia – Barnes Akathisia Scale
Tardive Dyskinesia – Abnormal
Involuntary Movement Scale (AIMS)
Role play exercise In pairs: Practice: Introducing the LUNSERS to the patient Work through the assessment (guided completion
notion..) For any side effect identified rate the associated
distress… if you have time consider the grouping of SE’s experienced (how may their prescription be contributing to this?)
FEEDBACK TO GROUP