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First line treatment for major depression. Prevents re-uptake of serotonin Selective Serotonin Reuptake Inhibitors i.e. Zolft, Paxil, Prozac, Celexa
Nursing Considerations for SSRI Taken once in am, avoid ETOH, CI with MAOIs, Assess for serotonin syndrome and discontinuation syndrome.
Side Effects of SSRIs N/V/D, insomnia, fatigue, agitation, dry mouth, hyponatremia, sexual side effects (anorgasmia, low libido)
Serotonin Syndrome Life threatening syndrome caused by too high a dose or interaction with other drugs. AMB Abdominal pain, diarrhea, bloating, fever, tachycardia, elevated BP, delirium, muscle spams, seizures. Can induce high fever, cardiovascular shock, death.
Interventions for Serotonin Syndrome Remove offending agent, initiate treatment: cyproheptadine, methysergide, propranolol, clooing blankets, anticonvulsants, artificial ventilation.
Discontinuation Syndrome AKA Serotonin Withdrawal. AMB dizziness, insomnia, irritability, nervousness, nausea, agitation. TX: wean on schedule.
Celexa (citalopram) SSRI
Lexapro (Escitalopram) SSRI
Prozac (fluoxetine) SSRI
Luvox (Fluvoxamine) SSRI
Paroxetine (paxil) SSRI
Sertraline (Zoloft) SSRI
SNRI - Serotonin Norepinephrine Reuptake Inhibitor Popular next step after SSRIs. Prevents reuptake of serotonin and norepinephrine.
Side Effects of SNRIs Nausea, insomnia, dry mouth, sweating, agitation, headache, sexual dysfunction.
Venlafaxine (Effexor) SNRI. Causes hypertension. Monitor blood pressure. Do not exceed 150 mg/day
Duloxetine (Cymbalta) SNRI. Has advantage of decreasing neuropathic pain.
Nursing considerations with SNRIs. Monitor blood pressure with effexor, discontinuation syndrome.
Norepinephrine Reuptake Inhibitors (NRIs) Blocks reuptake of norepinephrine and enhances its transmission. Useful with severe depression and impaired social functioning.
ADEs of NRIs Insomnia, sweating, dizziness, dry mouth, constipation, urinary hesitancy, tachycardia, decreased libido.
Reboxetine (Vestra) NRI
Serotonin Receptor Antagonists/agonists Selective blockage of serotonin receptors and alpha-adrenergic receptors. Lower risk of long-term weight gain than SSRIs and TCAs. Lower risk of sexual ADEs than SSRI.
Serotonin Receptor Antagonists/agonists ADEs Sedation, hepatotoxicity, dizziness, hypotension, paresthesias.
Nursing Considerations with Serotonin Receptor Antagonists/agonists Life-threatening liver failure possible, priapism of penis and clitoris is rare, CI with MAOIs
Nefaxodone (Serzone) Serotonin Receptor Antagonists/Agonist
Norepinephrine Dopamine Reuptake Inhibitor (NDRI) Blocks reuptake of norepinephrine and dopamine. Stimulant action may reduce appetite, and increase sexual desire. Also used as an aide to quit smoking.
ADES for NDRI Agitation, insomnia, headache, nausea, and vomiting. May have seizures (low risk) CI if high risk for seizure
Bupropion (Wellbutrin) NDRI
Serotonin Norepinephrine Disinhibitors (SNDIs) Blocks alpha 1 adrenergic receptors that normally inhibit norepinephrine and serotonin. Antidepressant effects equal SSRIs and may occur faster.
Side effects of SNDIs Weight gain, sedation, dizziness, headache, sexual dysfunction (rare)
Nursing Considerations for SNDIs Drug-induced somnolence exaggerated by ETOH, Benzos and other CNS depressants. CI with MAOIs.
Mirtazapine (Remeron) SNDI
Tricyclic Antidepressants (TCAs) Inhibits the reuptake of serotonin and norepinephrine.
TCA ADEs ANTICHOLINERGIC EFFECTS: Dry mouth, constipation, urinary retention, blurred vision, orthostatic hypotension, cardiac toxicity sedation.
Length of time before mood elevation occurs with TCAs 7-28 days. Full response may take 3-8 weeks.
Nursing considerations with TCAs Lethal in OD, use cautiously in older adults, cardiac dx, elevated intraocular pressure, hyperthyroidism, seizure disorders, liver/kidney dysfunction. CI with MAOIs
When to administer TCAs At bedtime r/t dizziness, drowsiness
Suddenly stopping TCAs can cause: nausea, altered heartbeat, nightmares, and cold sweats in 2-4 days.
Amitriptyline (Elavil) TCA
Clomipramine (Anafranil) TCA
Desipramine (Norpramin) TCA
Doxepin (Adapin, Sinequan) TCA
Imipramine (Tofranil) TCA
Nortiptyline (Aventyl, Pamelor) TCA
Protriptyline (Vivactil) TCA
Monoamine Oxidase Inhibitors (MAOIs) Inhibits the enzyme monoamine oxidase, which normally breaks down neurotransmitters, including serotonin and norepinephrine.
ADES for MAOIs Insomnia, nausea, agitation, and confusion, weight gain. Potential for hypertensive crises or serotonin syndrome with concurrent use of other antidepressants.
Nursing Considerations for MAOIs Monitor BP routinely for first 6 weeks, avoid TOH, CNS depressants, OTC decongestant drugs, excessive caffeine, foods containing tyramine. CI for 2 wks following surgery
Hypertensive crisis with MAOIs Occurs within a few hours of ingestion of substance, begins with HA, stiff/sore neck, palpitations, increase or decrease in HR, N/V, pyrexia. TX: emergency...CCBs, phentolamine, nifedipine
MAOI dietary restrictions Avocados, bananas, figs, raisins. Pickles, sauerkraut. Beer, soy sauce, yeast, meat tenderizers, licorice, sour cream, yogurt, snails. Avoid chinese restaurants, aged cheeses (camembert, brie, cheddar, gruyere, processed american cheese) Avoid aged meats.
Phenelzine (Nardil) MAOI
Selegiline Transdermal System Patch (EMSAM) MAOI
Tranylcypromine (Parnate) MAOI
Lithium Carbonate Tx of bipolar disorder. Limits about 80% of manic and hypomanic episodes within 10-21 days. Reduces elation, grandiosity, flight of ideas, manipulation, anxiety.
Lithium therapeutic levels Takes 7-14 days to reach level During active phase = 0.8-1/4 mEq/L. During maintenance phase = 0.4-1.3 mEq/L
Lithium Toxicity level and intervention Serious toxicity occurs at levels> 2.0 mEq/L. Interventions: gastric lavage and tx with urea, mannitol, aminophylline can increase lithium excretion.
How often should lithium levels be checked? within 5 days of initiating therapy or after dose change. Once therapeutic level is reached, check monthly for 6 months, after 6 months to a year measure every 3 months.
What time of day should lithium be checked? Blood should be drawn in the am, 8-12 hours after last dose of lithium is taken.
Two major long-term risks of lithium therapy are... Hypothyroidism and impairment of the kidney's ability to concentrate urine.
S/Sx of lithium toxicity Tremor, ataxia, confusion, convulsions, N/V/D, arrthymias, polyuria, polydipsia, edema
Anticonvulsant drugs for bipolar disorder valproate (Depakote), carbamazepine (Tegretol), and lamotrigine (Lamictal). Superior for continuously cycling patients.
Valproate (Depakote) Anticonvulsant for bipolar d/o. IND for lithium non responders in acute mania. MONITOR liver fx and platelet count periodically.
Carbamazepine (Tegretol) Monitor liver function and platelet count periodically. Blood levels of carbamazepine should be monitored weekly for first 8 weeks. Can cause bone marrow suppression and liver inflammation.
Tegretol Toxic Level > 12mcg/mL
Lamictal (Lamotrigine) First-line treatment for bipolar depression (can worsen mania). A potentially Life-threatening rash may occur. Seek medical attn.
Clozapine (Clozaril) Atypical Antipsychotic. Causes agranulocytosis, higher risk for seizure. Pt must have weekly WBC for first 6 months, and frequent monitoring thereafter.
Atypical Antipsychotics First-line treatment because they treat both positive and negative symptoms of schizophrenia and produce little EPS or tardive dyskinesia.
Risperidone (Risperdal) Atypical antipsychotic
olanzapine (Zyprexa) Atypical Antipsychotic. High weight gain, high ACh effect.
Quetiapine (Seroquel) Atypical Antipsychotic
ziprasidone (Geodon) Atypical Antipsychotic
Aripiprazole (Abilify) Atypical Antipsychotic
ADEs of Atypical Antipsychotics tendency to cause significant weight gain, metabolic syndrome (weight gain, dyslipidemia, altered glucose metabolism), sedation, low to moderate EPS symptoms
Conventional antipsychotics Blocks dopamine receptor sites in motor areas and causes extrapyramidal side effects (EPS). Treats positive symptoms of schizophrenia. May take 2-6 weeks for full effect.
ADES of Conventional Antipsychotics Anticholinergic effect, sedation, weight gain, sexual ADEs, tardive dyskinesia, orthostatic hypotension, photosensitivity, lowered seizure threshold.
Haloperidol (Haldol) Conventional Antipsychotic. High EPS.
Chlorpromazine (Thorazine) Conventional Antipsychotic. High sedation and ortho HOTN.
Thioridazine (Mellaril) Conventional Antipsychotic. High sedation, ortho HOTN, ACh.
Loxapine (Loxitane), Molindone (Moban), Perphenazine (Trilafon) Medium potency conventional antipsychotics.
Thiothixene (Navane) High potency conventional antipsychotic
Fluphenazine (Prolixin) High potency conventional antipsychotic
Pimozide (Orap) High potency conventional antipsychotic.
Drugs that decrease EPS Centrally acting antiACh drugs i.e. cogentin, benadryl and symmetrel.
Anticholinergic toxicity s/sx and interventions Dry mucous membranes, mydriasis, nonreacctive pupils, hot, dry, red skin, unstable V/S, delirium, seizure. LIFE THREATENING: Hold med/call PCP, emergency cooling measures, benzos, physostigmine.
Pseudoparkinsonism s/sx and interventions Masklike facies, stiff and stooped posture, shuffling gait, drooling, tremor, "pill-rolling" Intervention: admin antiparkinsonian agent (trihexyphenidyl or benztropine), call pcp.
Acute dystonic reactions s/sx and interventions Acute contractions of tongue, face, neck, and back. Administer trihexyphenidyl or benztropine. Or benadryl.
Tardive Dyskinesia s/sx and interventions Protruding and rolling tongue, smacking lips, rapid purposeless movements. Interventions: No known tx, may continue after D/C drug, teach pt ways to conceal movements
Agranulocytosis s/sx and interventions Sore throat, fever, malaise, and mouth sores. Usually occurs during first 12 weeks of therapy. Blood work done Q week for 6 months, then every 2 months. If test positive, D/C drug and reverse isolation.
Neuroleptic Malignant Syndrome (NMS) s/sx and interventions Severe EPS, Hyperprexia (high temp), Autonomic dysfunction (HTN, Tachycardia, diaphoresis, incontinence) Delirium. MEDICAL EMERGENCY: stop drug, Parlodel (relieves muscle rigidity and lowers fever), Dantrium, cool body maintain hydration
Created by: crna2b