WEEK 3: MEDICATIONS Flashcards
(35 cards)
1
Q
ANTIPSYCHOTIC MEDICATIONS
A
- Treat psychotic symptoms (not its underlying causes) - predominately the positive symptoms (delusions, hallucinations, thought disorder)
- Based on the dopamine hypothesis, the antipsychotic activity appears to be related to the dopamine blocking activity in the brain
- Typical antipsychotics have an affinity to D1 and D2 receptors
- Atypical antipsychotics high affinity with D2 & 5-HT receptors
- The side effects are results of the dopamine antagonism
2
Q
TYPICAL OR FIRST GENERATION ANTIPSYCHOTICS (OLDER)
A
- Each group of typical antipsychotics equally effective for reducing/eliminating positive symptoms
- Poor side effect profile- became a cause for concern because of effect on quality of life and their link with non-adherence, high risk for EPSE
- May be prescribed for treatment of agitation in addition to regular antipsychotics. E.g. Chlorpromazine
- Still commonly used in long acting injection (depot) form E.g. Zuclopenthixol, Fluphenazine & Haloperidol decanoate
3
Q
TYPICAL ANTIPSYCHOTICS
A
- Long acting IMIs (commonly used in community settings)
- Zuclopenthixol, Flupenthixol, Haloperidol, Fluphenazine
- Medium acting IMI (Used in acute situations e.g. acute inpatient setting)
- Zuclopenthixol Acetate ‘Clopixol Acuphase’
- Side effects: Restlessness, tremor, muscle stiffness, constipation, weight gain, EPSEs, neuroleptic malignant syndrome
4
Q
ATYPICALS OR 2ND GENERATION ANTIPSYCHOTICS (NEWER)
A
- Efficacy similar to typical antipsychotics in reducing positive symptoms
- Better side effect profile, less neurological side effects- however other S/Es metabolic issues
- Usually the treatment of choice for psychotic symptoms
- Efficacy similar to older antipsychotics- but more effective in reducing negative symptoms of psychosis
5
Q
CLOZAPINE
A
- Atypical antipsychotic- far more effective than any other antipsychotic BUT has potentially very severe side effects that limit its use to people with ‘treatment resistant schizophrenia’
- Most common SEs- increased appetite, sedation, hyper salivation, low BP, dizziness
- Serious SEs- agranulocytosis, myocarditis, seizures, hepatotoxicity, diabetes, severe constipation and potential bowel obstruction
- Clinical protocols established, regular blood tests (FBC) cardiac monitoring (ECG and echo), metabolic monitoring, be aware of potential toxicity with smoking cessation (dose may need to be reduced)
6
Q
SIDE EFFECTS: EXTRAPYRAMIDAL (EPSEs)
A
- Caused by dopamine antagonists- causing motor disturbances
- The extrapyramidal system is part of the motor system involved in coordination of movement
- Much more common with older antipsychotic medications, however still potential risk with risperidone and amisulpride
7
Q
SIDE EFFECT: NEUROLEPTIC MALIGNANT SYNDROME
A
- Rare and potentially life threatening condition characterised by fever, rigidity, tremor, sympathetic nervous system dysregulation and creatine kinase (CK) elevation
- Managed by discontinuing medication and monitoring and immediate medical intervention (usually in a general hospital) if suspected
- Both typical and atypical antipsychotics can cause NMS
8
Q
SIDE EFFECTS: METABOLIC SYNDROME
A
- Weight gain and the development of metabolic syndrome associated with atypical antipsychotics; serious issue
- Weight gain usually occurs in the first 4-12 weeks of treatment and associated with abdominal obesity and enhanced adiposity (linked with increased morbidity and mortality)
- Metabolic syndrome made up of a cluster of abnormalities
- Abdominal obesity, Hypertension, Hyperlipidaemia, Hyperglycaemia
- When experienced together, lead to an increased risk of diabetes and cardiovascular disease
9
Q
FIRST EPISODE PSYCHOSIS
A
- For FEP, “start low, go slow”
- Start with one of these atypical antipsychotics: Amisulpride, Aripiprazole, Quetiapine, Risperidone, Ziprasidone
- Importance of non-pharmacological approaches (like with anyone with a psychotic illness)
- Tops 5 goals of young people with FEP: employment, education, housing, relationships and health
- Working with the family of the person with FEP
10
Q
SMOKING AND ANTIPSYCHOTIC MEDICATION
A
- Smoking may increase the metabolism of some antipsychotic medications (e.g. clozapine, olanzapine, haloperidol)
- Plasma levels of both clozapine & olanzapine may be reduced by up to 50% in people who smoke tobacco
- Need to be aware of the potential increase in the levels if the person stops smoking abruptly
- Higher doses of the these medications are required to achieve the same therapeutic effect in smokers, compared to non smokers
11
Q
THEORIES OF DRUG ACTION
A
- Important neurotransmitters that act on neurons, the brain’s information processing units
- 100 billion neurons and 1 trillion glia in the brain
- GABA→ Gamma-aminobutyric acid- main inhibitory neurotransmitter
- Glutamate→ Main excitatory neurotransmitter
- Monoamines→ Dopamine: Noradrenaline (aka norepinephrine); Serotonin
- Others→ Acetylcholine; Histamine; Endogenous cannabinoids; Endogenous opioids
12
Q
THEORIES OF DRUG ACTION
A
Agonist→ enhances or mimics transmitter action
- Binds to receptor
- Inhibits reuptake
- Inhibits enzymatic breakdown
Antagonist→ Prevents transmitter action
- Block receptor
Direct effects on ion channels
- Most anticonvulsant drugs work this way
13
Q
FACTORS THAT DETERMINE THE RESPONSE TO A DRUG
A
- Genetic predisposition and epigenetic modulation
- Pharmacokinetics- How drugs are absorbed and metabolised - Liver is important
- Pharmacodynamics- How drugs interact with their brain and body targets (brain receptors important)
- Environmental influences→ e.g. diet- St John’s wort
- Pharmacogenomics→ Personalised response- epigenetics- whether genes are turned on or off- Cytochrome CYP2D6 gene affects drug metabolism
14
Q
DRUGS USED IN MOOD DISORDERS AND ANXIETY
A
- Antidepressants→ SSRIs/ SNRIs, MAOIs/TCA’s, NASSA’s
- Mood stabilisers→ Lithium, Valproate, Carbamazepine, Lamotrigine
- Anxiolytics and Sedatives→ Benzodiazepines, Z drugs, Antihistamines
15
Q
ANTIDEPRESSANT MEDICATION- Types
A
- SSRIs→ selective serotonin reuptake inhibitors
- SNRIs → Serotonin and noradrenaline reuptake inhibitors
- Noradrenaline reuptake inhibitors
Tricyclics - MAOI- Monoamine oxidase inhibitors
- Melatonergic antidepressants
- RIMA’s → Reversible inhibitors of MAO
- Tetracyclics
- Tricyclic analogue of mianserin NaSA
16
Q
BIOLOGICAL TREATMENTS
A
- Antidepressants
- Antipsychotics
- Mood stabilisers
- Electroconvulsive therapy
- Transcranial magnetic stimulation
17
Q
PSYCHOLOGICAL TREATMENTS
A
- Brief cognitive behavioural therapy
- Formal cognitive behavioural therapy
- Interpersonal therapy
- Mindfulness
- Acceptance and commitment therapy
- Schema therapy
18
Q
SOCIAL TREATMENTS
A
- Family psychoeducation family/friends - Formal support groups - Community groups - Caregivers - Employment - Housing
19
Q
LIFESTYLE TREATMENTS
A
- Exercise
- Diet
- Smoking cessation
- Alcohol cessation
- Ceasing drugs
- Managing substance misuse
- Sleep
20
Q
CHOICE OF ANTIDEPRESSANT: 1st Line
A
- SSRIs- Citalopram, Escitalopram, Fluvoxamine, Fluoxetine, Paroxetine, Sertraline
- NARI- Reboxetine
- NaSSA- Mirtazapine, Mianserin
- Melatonergic agonist→ Agomelatine
- NDRI- Bupropion
21
Q
CHOICE OF ANTIDEPRESSANT: 2nd Line
A
- SNRI’s - Desvenlafaxine, Venlafaxine, Duloxetine, Milnacipran
- Tricyclics- TCA- Amitriptyline, Clomipramine, Dothiepin, Imipramine, Nortriptyline, Trimipramine, Doxepin
- Serotonin Modulator- Vortioxetine
22
Q
CHOICE OF ANTIDEPRESSANT: 3rd Line
A
- Monoamine oxidase inhibitors (MAOIs) - Phenelzine, Tranylcypromine
- Reversible MAOI- Moclobemide
- Adjunctive SARI- Trazodone
23
Q
COMMON SIDE EFFECTS OF SSRI’s AND SNRI’s
A
- Nausea, headache, dry mouth agitation, insomnia, sweating, bruxism, sexual dysfunction and weight gain
- Some consumers may experience distressing agitation with serotonergic drugs and cannot tolerate them
- Sexual dysfunction- diminished interest and desire, performance and satisfaction- which may indicate change to another class of antidepressant
- MAOIs - essential dietary restrictions to avoid foods containing tyrosine: cheeses, beer, red wine, some spirits, liquor, soybeans, fava beans, bean curd, sauerkraut, shrimp paste, yeast extract, aged or processed meats such as sausage or salami, and smoked, fermented, aged or pickled fish
- There may be restrictions too many decongestants, cold and flu remedies, allergy medications
- High BP causing headache, nausea, vomiting, stroke or death
24
Q
RISKS OF TRICYCLICS
A
- Can be lethal in overdose due to effects on cardiovascular system
- Increased risk of seizures in overdose- can reduce seizure threshold in people with epilepsy
- Interactions of common complementary medicines with many antidepressants (and mood stabilisers and anxiolytics) : including St John’s wort, SAMe
Herbal teas such as valerian, chamomile can reduce the effectiveness of medications
25
SEROTONIN TOXICITY
- Cognitive: Confusion, agitation, restlessness
- Autonomic: hyperthermia, sweating, mydriasis, tachycardia, hypertension, flushing, shivering
- Neuromuscular: clonus, hyperreflexia, hypertonia, ataxia, tremor
- Medication attention is required urgently as severe cases can be fatal
- Drugs implicated in serotonin syndrome:
L-tryptophan; tricyclics, MAOIs, Pethidine, Tramadol, LSD, Buspirone, St John’s wort, Amphetamines, Lithium, atypical antidepressants
26
ANTIDEPRESSANT DISCONTINUATION SYNDROME (ADS)
Symptoms include:
- Disequilibrium: dizziness, vertigo, ataxia
- Gastrointestinal: Nausea, vomiting
- Flu-like: Fatigue, lethargy, myalgia, chills
- Sensory: Paresthesias, electric shock
- Sleep disturbances: Insomnia, vivid dreams
- Also- Core psychological symptoms of anxiety/agitation, crying spells and irritability
- Treatment emergent affective switch (TEAS) → When antidepressants used in the absence of mood stabilisers produce mania
27
SPECIFIC RISKS FOR ADOLESCENTS AND ANTIDEPRESSANTS
- Increased risk of serotonergic syndrome
- Increased risk of agitation and akathisia
- Increased risk of suicidal thoughts
- Monitoring for these risks must occur
- Risks for elderly people: start low, go slow
28
MOOD STABILISERS
- Lithium Carbonate- LiCo3
- Importance of regular blood tests to monitor serum lithium concentration for therapeutic levels
- Narrow window of therapeutic effectiveness: 0.5-0.8 mmol/L on commencing Lithium and for maintenance
0.8-1.2 mmol/L during acute mania
>2.0= toxicity→ potentially lethal
- The usual serum concentration may not be tolerable for elderly people
- Lithium carbonate→ In maintenance and prophylaxis as a mood stabiliser (even when symptom free)
- Side effects: Increased thirst, polyuria, nausea, vomiting and diarrhoea, metallic taste, fatigue, headache, fine muscle tremor, weakness, dry skin
- Long term use may affect kidney and thyroid function, weight gain
- Signs of Lithium toxicity→ Fatigue, sleeplessness, confusion, muscle weakness, limb heaviness, slurred speech, hand and jaw tremors, muscle twitches, unsteady gait, upset stomach, ringing in the ears, ataxia
29
ANTICONVULSANT MEDICATION IN MOOD DISORDERS
Sodium valproate- Epilim:
- Side effects: Nausea, indigestion, weight gain, sedation, tremor, hair loss
- Adverse effects: Fever, rash, systemic organ involvement
Carbamazepine- Tegretol
- Caution in impaired liver and cardiac function
- Side effects: Ataxia, drowsiness, blurred vision
- Adverse effects: Anaemia, agranulocytosis
Lamotrigine- Lamictal
- Adverse effects: Serious skin rash, fever, fatigue, Steven- Johnsons syndrome, toxic epidermal necrolysis
30
ANTIPSYCHOTIC MEDICATION USE IN BIPOLAR DISORDER
- Adjunctive use of antipsychotic medication is indicated when psychosis emerges
- Amisulpride, Asenapine, Chlorpromazine, Olanzapine, Paliperidone, Quetiapine, Risperidone, Ziprasidone
- Benzodiazepines use in bipolar disorder: Clonazepam, diazepam, lorazepam, midazolam
31
ADDITIONAL INTERVENTIONS- ECT AND rTMS
- ECT Electroconvulsive therapy is usually indicated when other interventions have not been effective, or when the depression is so severe that the person refuses to eat or drink, is catatonic, is highly distressed or has previously had a good response to ECT
- Side effects: Memory impairment
Repetitive transcranial magnetic stimulation uses pulsed magnetic field stimulation to the DLPFC.
- Side effects: Discomfort at stimulation site and headache
32
ANXIOLYTICS- BENZODIAZEPINES
- Anxiety disorders
- Anxiety and agitation associated with many mental health presentations
- Insomnia
- Alcohol withdrawal
- Seizures
- Risks of dependence
- Potential for paradoxical effects
- Dose related problems of drowsiness and respiratory depression
33
ANXIETY DISORDERS: Interventions
- Psychological interventions should be the first line treatment, and attention to sleep, hygiene, relaxation and mindfulness, social supports, e-therapies and bibliotherapy (reading books and other literature on how to understand and manage anxiety)
- Medication may be necessary in the short term, including anxiolytics (being aware of risks of dependence) on antidepressants (usually SSRIs)
34
SLEEP DISTURBANCE: interventions
- Requires a thorough assessment of sleep problems and a discussion of sleep hygiene techniques
- Short term benzodiazepines, Z-class drugs such as zolpidem (risks of sleep walking) or short term antihistamines
- Antipsychotic medication use to promote sleep is sometimes used but side effect risk should suggest this as a last resort
35
FINAL CONSIDERATIONS IN MENTAL HEALTH TREATMENTS
- People do have remission without medication
- Pharmaceutical industry pushing off label use of medications
- Nurses moral and ethical positions in medication administration
- Need to focus on therapeutic use of self of the nurse as much as use of medication, and observe principles of trauma informed care
