SLIDES FROM SEMINAR
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Antidepressants
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Side effects: Dry mouth and other anticholenergics ( hard candy, sips, oral hygiene)
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Sedation ( bedtime)
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Nausea (take with food)
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Discontinuation syndromes: abrupt stopping may result in dizziness, headache, , worsening of
symptoms,etc. (taper)
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Patho/ Pharm
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Psychopharmocology
Depression
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1.Tricyclic Antidepressants /TCA: up to 4 weeks to see action; selection of medication is based
on symptoms: side effects: sedation, tachycardia, dry mouth, constipation, urinary retention,
low b/p and seizure threshold; caution in use with elders and glaucoma and heart disease
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Blocks reuptakes of neurotransmitters
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Be alert to suicidality as medication begin to work
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Fatal if overdose!
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HYPERTENSIVE CRISIS, hyperpyretic crisis. Severe seizures, tachycardia when used with
MAOI’s.
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Tricyclic PrototypeAmitriptyline(Elavil)50-300mg/D(usually starts with 25 TID or 50 QHS)
Depression; blocks reuptake of norepi, serotonin Adjunct to chronic pain control .Hypertensive
crisis if used with MAOI. Need a 2 week wash out; Check B/P; Cardiac workup prior; SE dizziness,
drowsiness, constipation, urinary retention, EKG changes, hypotension; Suicide precautions;
increased risk of agranulocytosis – Complete blood studies
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2.MAO Inhibitors /MAOI’s
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Blocks reuptake of neurotransmitters when the enzyme, MAO is inhibited at various site in the
nervous system
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HPERTENSIVE CRISIS OCCURS if the patient is using amphetamines, methyldopa, resperpine,
epinephrine, norephinepherine, OR ingests any food with tyramine
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Tyramine: 2 hours- pounding headache, photophobia, choking, neck stiffness, marked
hypertension
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BE ALERT TO TYRAMINE
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What is tyramine?
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Amino acid found in aged cheese, other aged, overripe, fermented foods
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Get a list from the Nutrition department/Pharmacy
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TEXT 160 !!!
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Aged cheese, wine Esp. Chianti, road beans, pickled herring, beef or chicken liver, preserved
lunch meats/sausages, beer and wine, yeast products, chocolate, caffeinated drinks, canned figs,
sour cream, coffee, tea, yogurt, soy sauce, some over the counter cold medications, , diet pills
MAOI Prototype:Tranylcypromine(Parnate)30-60mg/DStart 10 BID; Depression; increase concentration
of endogenous epinephrine, norepi, serotonin, dopamine in CNS by inhibiting MAO ; Hypertensive crisis
if consume food with tyramine or select medications; d/c drug immediately, antihypertensive
medications; serotonin syndrome; SE dizziness, drowsiness, anorexia, orthostatic hypotension; monitor
B/P; Suicide precautions******
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List of MAOI on page 159
3. Heterocyclics “Other”or Misc
Bupropion (Wellbutrin)200-450mg/DStarts with 100 BID;Slow increase of dose; Depression ,Smoking
Cessation; inhibits reuptake of dopamine, norepi, serotonin ;Precaution if seizure or head injury as it
lowers seizure threshold; complete AV block; SE headache, agitation, n, v, rash, impotence; 2-4 weeks to
see effect
4. SSRI Selective Serotonin reuptake inhibitors/ Nonselective reuptake inhibitors
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Prozac, Paxil, Zoloft,Luvox, Celexa, Lexapro
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Fewer anticholenergic side effects, faster acting, good efficiency, headache, insomnia, weight
loss
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SE profile is more manageable
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Action: inhibits the reuptake of serotonin at the brain synapse thus increasing the amount
available at the serotonin sensitive receptor sites
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Serotonin norephenerine reuptake inhibitors
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Act on both serotonin and NE to relieve depression, OCD, pain often accompanying depression
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Serotonin syndrome
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Effexor, Cymbalta
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SSRI Prototype: Fluoxetine (Prozac)20-80mg/D
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Starts 20 qD; Depression’ OCD’ Bulimia nervosa’ PMS Insomnia, headache; serotonin syndrome
when 2 drugs potentiate serotonergic neurotransmission- block serotonin immediately; may be
fatal; do not use with any other medications that increase serotonin or MAOIs. Potentiate many
other drugs, inc St Johns Wort. SE nervousness, insomnia, headache, seizures, tachycardia;
Suicide precautions
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ALERTS FOR SSRI’s
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Serotonin Syndrome: when 2 drugs that potentiate serotonergic transmission are used
concurrently( St johns Wort, MAOIs, pg 159)
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Labile blood pressure, mental status changes, myclonus, hyperreflexia, shivering, tremors
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STOP medications immediately. MD will prescribe medication to block the serotonin receptors.
Artificial ventilation may be needed
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May be fatal
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Types of Antidepressants
Table 10-2
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Interactions
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Planning/Implementation
Table 10-4 All Antidepressants
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Dry mouth
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Sedation
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Nausea
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Discontinuation Syndromes
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Offer sugarless candy, gum ice chips, water, oral hygiene
Administer at bedtime; Advise not to use dangerous equipment when experiencing sedation
Take with food to minimize effect
Must taper gradually all antidepressants
Abrupt withdrawal SSRI-dizziness, headache, lethargy, headache;
TCA-hypomania, cardiac arrhythmias, panic attacks; MAOI;s- confusion, hypomania, worsening of
symptoms
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Planning/Implementation
Tricyclics and Wellbutrin
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Reduces seizure threshold
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Weight gain
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Constipation
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Blurred vision
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Urinary retention
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Orthostatic hypotension
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Photosensitivity
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Observe client with seizure disorder closely; Give no more than 150 mg per dose and nor closer
than 8 hours apart
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Encourage increased activity. Nutritional instruction
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High fiber food, increased water
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Should subside after a few weeks; do not drive while blurred
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Monitor any difficulties
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Advise to Rise slowly; avoid hot long showers or baths
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Ensure the use of sunscreen, sunglasses, protective clothing
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Planning/Implementation
SSRI’s
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Insomnia, agitation
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Headache
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Weight loss
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Sexual dysfunction
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Serotonin Syndrome
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Myclonus, restlessness
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Hyperreflexia, tachycardia, shivering, tremors, tremors
Instruct take early in the day, avoid caffeine, teach relaxation prior bedtime
Administer analgesic
Initial loss, instruct maintain caloric intake, daily weights
Men- abnormal ejaculation, impotence; women- delayed or loss of orgasm
Discontinue drug immediately; MD will order a serotonin blocking agent; artificial ventilation may be
required; if med is not discontinued, it may become serious and fatal
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Planning/Implementation
MAOI’s
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Hypertensive Crisis if consumes re occipital headache tyramine
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Severe occipital headache
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Palpitations
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Nausea/vomiting
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Nuchal rigidity
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Fever, sweating
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Increased B/P
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Chest pain
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Coma
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Discontinue drug immediately
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Monitor vital signs, administer antihypertensive agent, use cooling measures
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Mood Stabilizers
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10-5 in text
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Anti manic and anticonvulsant medications; are others
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Action is treatment of bipolar illness is unclear
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Lithium:
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Common side effects include drowsiness, dizziness, dry mouth, GI upset, fine hand tremors,
weight gain.
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Therapeutic Blood levels 1.-1.5 mEq/L for mania;
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For maintenance: 0.6-1.2 mEq/L
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Page 167 in text
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AntimanicLithium(Eskalith)300-600mg TID*Blood levels;Ind to blood levels; May balance
biogenic amines of norepi and serotonin ; alters sodium and potassium transport; decreased
sodium intake and water intake leads to lithium toxicity; increased sodium and water intake
leads to decreased lithium retention SE: Headache, drowsiness, seizure, dry mouth, polyuria,
glycouria, proteinuria, albuminuria, hypotension, leukocytosis; contr liver disease, pregt, OBS,
Many precautions, Excreted by kidney: Many toxic interactions; Teach toxicity symptoms ( V,D,
tremors) BLOOD LevelS weekly then monthly-0.5-1.5 mEq/LMust balance use of sodium and
water intake; initially 2-3 L/D then 1-2 L/D; Embryotoxic
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Lithium Toxicity
Blood levels
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Warning Signs
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Anorexia
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N,V
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Tremor
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Muscle twitching
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Tinnitus
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Vertigo
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Weakness, drowsiness
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Signs
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Fever
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Decreased urine output
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Decreased blood pressure
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Irregular pulse
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EKG changes
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Altered consciousness
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Seizures
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Coma
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Death
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Planning/Implementation:
Side effects and intervention Lithium: 10-6
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Lithium toxicity
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Margin between therapeutic and nontherapeutic are narrow
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Usual ranges:
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Acute mania:1.0-1.5mEq/L
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Maintence0.06-1.2 mEq/L
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Toxicity appears at 1.5 or greater and are dosage determinant
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1.5-2.0 Blurred vision, ataxia, tinnitus, N,V,D
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2.0-3.5 Excess output of urine, tremors, muscular irritability, giddiness, confusion
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3.5 or greater impaired consciousness, nystagmus, seizure, coma oliguria, cardiac
collapse
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Monitor levels weekly until levels are stable then monthly
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Blood draw 12 hours after last dose
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If high or symptoms: Hold dose, notify MD
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Li is similar chemical structure to sodium and competes with sodium in the body; if sodium
intake is reduced or the body is depleted of sodium lithium is reabsorbed by the kidneys
increasing the chance for toxicity
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Patients should consume a diet adequate in sodium and 2,5000-3,000 of fluid each day.
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Adequate intake and output records
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Planning/Implementation:
Side effects and intervention Lithium: 10-6
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Lithium toxicity
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Margin between therapeutic and nontherapeutic are narrow
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Usual ranges:
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Acute mania:1.0-1.5mEq/L
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Maintence0.06-1.2 mEq/L
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Toxicity appears at 1.5 or greater and are dosage determinant
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1.5-2.0 Blurred vision, ataxia, tinnitus, N,V,D
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2.0-3.5 Excess output of urine, tremors, muscular irritability, giddiness, confusion
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3.5 or greater impaired consciousness, nystagmus, seizure, coma oliguria, cardiac
collapse
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Monitor levels weekly until levels are stable then monthly
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Blood draw 12 hours after last dose
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If high or symptoms: Hold dose, notify MD
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Li is similar chemical structure to sodium and competes with sodium in the body; if sodium
intake is reduced or the body is depleted of sodium lithium is reabsorbed by the kidneys
increasing the chance for toxicity
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Patients should consume a diet adequate in sodium and 2,5000-3,000 of fluid each day.
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Adequate intake and output records
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Planning/Intervention
Lithium
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Drowsiness, dizziness
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Dry mouth
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GI upset, N,V
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Hand tremors
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Hypotension
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Polyuria, dehydration
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Weight gain
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Teach client must not participate in activities that require alertness
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Hard candy, sips, oral hygiene
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Take medication with food
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Report tremors to MD, observe severity
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Monitor vital signs
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Daily weight,intake,output,skin turgor
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Instruct keep adequate intake of sodium; instruct reduced calorie diet if gain weight
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Planning/Interventions
Lithium con’t
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Med noncompliance
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Dietary teaching
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Risk of fetal malformation
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Toxicity
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Instruct to take ,even when feeling well
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Do not skimp on dietary sodium intake, drink 6-8 glasses of water daily
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Avoid caffeine which increases urinary output
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Notify MD if N,V occurs (sodium loss)
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Carry a card regarding Li
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Discuss with MD the desire to become or realization of pregnancy
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As previous, instruct patient on bloodwork, dietary teachings and signs and interventions
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Planning/Intervention
Valproic Acid
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N,V
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Drowsiness, dizziness
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Blood dyscrasias
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Prolonged bleeding time
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Severe rash
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Decreased efficacy of BCP
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Do not discontinue
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Do not mix with alcohol
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Take with food
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Do not operate machinery
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Report bleeding ( gums, bruising)
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Regular bloodwork for therapeutic levels and platelet count
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Instruct to inform of rash
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Make client aware of BCP risks
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Instruct to not abruptly withdrawal , MD will taper
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Carry a card
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Anticonvulsants
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Quicker action
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Can be used with lithium
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Action unknown
( Do you use antidepressants in mania?)
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Anticonvulsant Valproic Acid (Depakote)Psych purposes750 mg QD, max 60mg/kg/dBlood
levelsIncrease GABA in the brain;Manic episodes, adjunctive to schizophrenia, tardive dyskinesia
( Mental health Purposes)Thrombocytopenia, sedation, drowsiness, dizziness, N,V,C,D ,hepatic
failure Valproic acid levels to prevent toxicity 50-100mcg/mlMust wean slowly to prevent
seizuresPhysical dependency may result