When you think CNS depressants, which general term can be used to describe side effects?
"Hangover" poor judgement, amnesia, coordination loss and headache
What are two common herbal supplements that interfere with CNS depressants
Kava kava and Valerian
Kava kava
An herbal supplement made of dried rhizomes from Piper methysticum. Can cause discoloration of hair skin and nails with long term use. It has CNS depressing effects and is used to treat anxiety, insomnia and sometimes ADHD.
Valerian
The root of contains acids that are used to treat anxiety, restlessness or sleep disorders. It is used as a CNS depressant. It interacts with most CNS depressants, MAOIs and Phenytoin.
Demographics that suffer from insomnia?
Primarily women, 10-20% suffer from in the US, increases with age.
Non-pharmacologic Sleep Aid
Specific sleep schedule/ritual
Benzodiazepines are indicated for
insomnia, muscle spasms, anxiety, anesthesia, seizures, and status epilepticus
Benzo MOA
Depress CNS- thought to stimulate GABA
Benzo's are contraindicated in?
narrow angle glaucoma, allergy or pregnancy
Benzodiazepines adverse effects
hangover- drowsy, lethargic confused dizzy amnesic and impaired cognitively
Benzodiazepines nomenclature
They end in -pam and -lam
Benzodiazepines Toxicity
More likely when used with other CNS depressants including alcohol, valerian or kava kava
Benzodiazepines overdose/anesthesia
Flumazenil is antidote for overdose/ or do bring patient out of anesthesia. Not often used for general toxicity as it can cause seizures.
Flurazepam
Benzodiazepine
Diazepam
Benzodiazepine
Clonazepam
Benzodiazepine
Alprazolam
Benzodiazepine
Temazepam
Benzodiazepine
Triazolam
Benzodiazepine
Estrazolam
Benzodiazepines
Benzodiazepines Interactions
1.Alcohol and other CNS depressants.
Non-benzodiazepines example
Zolpidem (Ambien)
Zolpidem
Non−benzodiazepine hypnotic, acts via inhibition of the BDZ1 (omega1) neurotransmitter receptor subtype and is reversed by flumazenil; less amnesia and muscle relaxation; lower dependence liability
Non-benzodiazepines indications
Indicated for use in insomniacs
Adverse Effects of non-benzodiazepines
"hangover" (especially amnesic), tolerance, dependence and binge eating.
Barbituates MOA
Facilitate GABA(a) action by inc duration of Cl- channel opening --> dec neuron firing
Barbituates indications
insomniacs, seizure disorders, anesthetic
Barbiturates adverse effects
Most life threatening: respiratory depression, hypotension
Barbiturate toxicity treatment
supportive: Ventilation (mainstay airway assisted ventilation due to respiratory depression), oxygen, fluid replacement and vasopressors (counteract hypotension)
Barbiturates as a sleep aid
No longer used to regularly used to treat insomniacs because of dependency and rapid development of tolerance. Not prescribed more than 2 weeks for sleep.
Assessment for Benzos and non benzos
Drug history, including supplement use (kava/valerian)
Implementation of Benzos and non benzos
-give at night
Assessment barbiturates
-Drug history: Previous use, drugs that may interact
Implementation of barbiturates
Use bed alarm for elderly or first time users
Patient teaching with barbituates/benzos
don't drive, do not use or supplement other drugs with CNS depressing effects, do not stop treatment abruptly and will not take longer than 2 weeks for barbits or 3-4 weeks benzos
Sedatives and the elderly
1 Identify cause of insomnia
CNS Muscle relaxants
relaxes skeletal muscle via CNS stimulus; indicated for muscle spasms; contraindicated in those with severe renal impairment and na glaucoma; has anticholinergic effects, hallucinations, ED, hypotension and fatigue; Interacts with CNS depressants
direct acting muscle relaxants
Emergency drug! act directly on skeletal muscle, Closely resemble GABA; indicated for malignant hyperthermia or neuroleptic malignant syndrome.
Cyclobenzaprine
CNS acting Muscle Relaxant
Dantrolene
direct acting muscle relaxant
Amphetamines
drugs that stimulate norepinephrine and dopamine release, causing speeded-up body functions and associated energy and mood changes
Amphetamines are indicated for
ADHD and Narcolepsy
COntraindications amphetamines
glaucome, hyperthyroidism, structural cardiac abnormalities, parkinson's and anxiety
Most important amphetamine adverse effects
Tachycardia, palpitations and hypertension
This should especially be monitored in children who take amphetamines or amphetamine like drugs
failure to gain weight with age/weight loss that can be symptomatic of growth deficiency
Interactions Amphetamines
MAOIs- hypertensive crisis that can lead to stroke or MI
Methylphenidate is also known as
Ritalin
Methylphenidate
Amphetamine-like drug used to treat adhd
Patient Teaching with amphetamines
1. Report tachycardia or palpitations
Sumatriptan MOA and use
Migraine tx; constricts cranial arteries, but can have systemic effects; therefore should not be used in patients with cardiovascular disease or uncontrolled hypertension, previous MI or stroke.
Signs of a stroke
numbness, tingling and warm sensation
Sumatriptan adverse effects
tingling, numbness, warm sensation N/V/D, muscle cramps dysrhythmia, thromboembolism MI and Stroke
What is a seizure?
Paroxysmal, uncontrolled electrical discharge of neurons in the brain that interrupts normal function.
Post-ictal phase
The final phase of a generalized seizure, during which the patient becomes extremely fatigued and is recovering.
seizure versus epilepsy
Seizure is a one time occurrence or one time collection of seizures due to trauma.
partial seizure
a seizure that affects only one part or one side of the brain
complex partial seizure
a partial seizure, starting from a focus and remaining localized, that produces loss of consciousness
Partial simple seizure
the patient maintains consciousness, is aware and remembers
Generalized seizures
seizures that involve the entire brain
Auras
peculiar sensations that precede a seizure, may take the form of a taste, smell, sight, or sound; dizziness; or funny feeling
Pregnancy and Seizures
Increased risk of having a seizure while pregnant, hypoxia occurs during these episodes putting mom and fetus at risk, many drugs are teratogens and can inhibit optimum pregnancy folate and potassium levels
Hydantoins
Most commonly prescribed antiepileptic and are indicated for use in tonic-clonic and complex/partial seizures
Phenytoin
Hydantoin Anticonvulsant
Important adverse effects of phenytoin
can cause gingival hyperplasia and is a teratogen
Phenytoin interacts with
Anti coagulants- warfarin
Phenytoin administration
Very small therapeutic range 10-20mcg/mL
Phenobarbital
a barbiturate used as a sedative and as an anticonvulsant
Phenobarbital MOA
brain stem depressant
Phenobarbital administration
Narrow therapeutic range 15-40 mcg/mL
Phenobaribital adverse effects
sedation and tolerance
Limostilbenes
anticonvulsant class of drugs including carbamazepine
Carbamazepine
Anticonvulsant
Carbamazepine adverse effects
bone marrow suppression
Carbamazepine administration
Narrow therapeutic range (4-12 mcg/mL)
Valproic Acid
Anticonvulsant
valproic acid contraindications
pregnancy, caution in young pts and elderly, pts with hepatic impairment
Valproic acid adverse effects
Liver failure/ jaundice
Valproic acid administration
Narrow therapeutic range (50-125 mcg/mL)
febrile seizures
Seizures that result from sudden high fevers; most often seen in children and lead to increased risk of developing epilepsy.
Assessment for anticonvulsants
Assess location, duration, and characteristics or seizure activity
Implementation of anticonvulsants
IV phenytoin can only be mixed with normal saline
Patient teaching anticonvulsants
Maintain proper oral hygeine and biannual dentist visits
Opioid Substance abuse
Peak:1-3 days
Stimulant withdrawal
Peak:1-3 days
Depressant withdrawal
Short acting
Alcohol withdrawal
Mild alcohol withdrawal: symptoms similar to other depressants.
Nicotine withdrawal
Nicotinic receptors all over body, reduced stimulation=w/drawl S/S
Parasympathetic nervous system
the division of the autonomic nervous system that calms the body, conserving its energy. Rest and Digest
sympathetic nervous system
the division of the autonomic nervous system that arouses the body, mobilizing its energy in stressful situations.
Non pharma treatment of anxiety
relaxation techniques, group therapy, solo therapy.
Benzodiazepines for anxiety
Lorazepam (Ativan) and diazepam (Valium)
Busiprone
Psych
Busiprone interactions
grapefuit juice
affective disorders
Emotional disorders that are characterized by changes in mood.
manic phase
a person experiences elation, extreme confusion, distractibility, feelings of grandeur and racing thoughts
depressed phase of bipolar
lack of energy, concentration, low self esteem, loss of interest, and helplessness
Carbomazepine
Indicated for SEIZURES and BIPOLAR disorder
Lithium
Last resort bipolar treatment as it has lts of adverse effect, narrow therapeutic range and lots of interactions
Li MOA
Alters Na transport in neurons
Li toxicity
At toxic levels, Li can cause ataxia, dysarthria, coarse tremors, and delirium, potentially culminating in seizures, coma, and death.
Li interactions
-Diuretics (BP management)
When treating with Li
- monitor effectiveness (1-2 weeks)
MAOIs (monoamine oxidase inhibitors)
-antidepressants that inhibit the action of an enzyme (monoamine oxidase) that is responsible for breakdown of NE and 5-HT
selective serotonin reuptake inhibitors that take about 3 weeks to work.
Fluoxetine
Prozac (SSRI)
eseitalopram
SSRI
Citalopram
Celexa
Sertraline
Zoloft
Paroxetine
SSRI (Paxil)
Fluxetine
SSRI
SSRI side effects
Side effects of SSRIs may include, among others:
SSRI interactions
MAOIs or St. John's Wort = serotonin syndrome
Serotonin Syndrome
With any drug that increases 5-HT (e.g., MAO inhibitors, SNRIs, TCAs) hyperthermia, confusion, myoclonus, cardiovascular instability, flushing, diarrhea, seizures.
SNRIs
serotonin and norepinephrine reuptake inhibitors used to treat depression, anxiety and social anxiety, or adjunct treatment for chronic pain.
SNRI side effects
*BAD SNRI*
SNRI interactions
MAOIs, SSRI, Alcohol, kava, valerian, and st. johns wort
TCA
tricyclic antidepressant indicated for major depression and agitated depression
Venlafaxine
SNRI
Duloxetine
SNRI
Desvenlafaxine
SNRI
Amitriptyline
TCA
Nortryptyline
TCA
TCA contraindications
Careful use in clients who have a seizure disorder or recent MI, clients at risk for suicide should receive one weeks supply at a time.
TCA interactions
anticholinergics (atropine, scopalamine)
EPS
extrapyramidal symptoms
Four types of EPS
Dystonia
Dystonia
a condition of abnormal muscle tone that causes the impairment of voluntary muscle movement
Pseudoparkinsonism
A medication-induced temporary constellation of symptoms associated with Parkinson's disease, including tremors at rest, reduced accessory movements, impaired gait, drooling and stiffening of muscles.
Akathisia
Most common EPS-restlessness, inability to sit still, pacing, shifting from side to side.
Tardive dyskinesia (TD)
a late-onset, irreversible neurologic side effect of antipsychotic medications; characterized by abnormal, involuntary movements such as lip smacking, tongue protrusion, chewing, blinking, grimacing, and choreiform movements of the limbs and feet
NMS
-NMS is like S&M;
Two kinds of antipsychotics
typical and atypical
atypical antipsychotics
Antipsychotics that do not have significant side effects common to older antipsychotics.
Typical Antipsychotics
Block D2 (Gs) therefore high chance of EPS
Chlorpromazine
typical antipsychotic- moderate EPS risk, weight gain and severe orthostatic HoTN possible
Fluphenazine
typical antipsychotic often used for antiemetic effects- SEVERE EPS, low sedation
Thiorazidine
typical antipsychotic- low EPS, possible NMS, weight gain and anticholinergic effects
Haloperidol
typical antipsychotic can cause EPS, NMS, sedation, anticholinergic effect, and seizures
Typical Antipsychotics interactions
anticholinergics
Clozaprine
atypical antipsy that is used in patients who are intolerant of other drugs and can cause agranulocytosis-monitor WBC
ariprazole
atypical antipsychotic- BLOCKS SEROTONIN and especially known for weight gain
Olanazapine
atypical antipsychotic- does not cause agranulocytosis and less likely to cause EPS
risperidone
atypical antipsychotic- very low incidence of EPS- insomnia and akathisia
ziprasidone
atypical antipsychotic-caution in cardiac patients, prolongs QT in contraction therefore monitor ECG
Implementation of antipsychotics
1. Check for cheeking
Patient teaching and antipsychotics
1. takes approx three weeks for effect
Sulfanamides
also known as sulfa drugs
Bactrium
Sulfonamides abx
Trimethoprim
Sulfonamides abx
Sulfamethoxazole
Sulfonamides abx
Penicillin
abx from fungus, beta lactam ring interferes with cell wall synthesis inhibiting division and homeostatic water control
Tyes of penicillin
natural- narrow gram+
Penicillin contraindication
ALLERGY (monitor 1st and 2nd dose, especially in penicillin naive)
Penicillin adverse effects
Allergy/anaphylaxsis
Penicillin interactions
NSAIDs, oral contraceptives, warfarin
How do you know from the name that it is a penicillin?
How do you know from the name that it is a cephalosporin?
Begins with cef- or ceph-
Important Cephalosporin interaction
Interacts with calcium salts. Calcium salt found in total nutrition and lactaid ringers.
Cephalo abx implemntation
Causes pain with fast infusion therefore infuse over 30 minutes
Should take into consideration for all anitbiotics
-renal fx (BUN, urine output and creatinine)
Contraindication Cephalo abx
Active gallbladder dz, existing C.dif infection, allergy to penicillin or cephalo
Ceftaroline
5th generation cephalosporin that can fight MRSA
Macrolides
Translation inhibiting abx, broad spectrum and can be bacteriostatic or bactericidal depending on dosage
How do you know from the name that it is a macrolide?
all end in -thromycin or -thromicin
Erythromycin
Macrolide abx that interferes with penicillin effectiveness
Clarithromycin
macrolide abx
Azithromycin
Macrolide abx
Unique macrolide contraindication
hypokalemia or hypomagnesemia
macrolide indication
patients who are allergic to penicillin
Macrolide Administration
IM injection is painful and not given
Macrolide Adverse
Tinnitus/Ototoxicity and hearing loss
macrolide interactions
-inhibit metabolism of drugs like warfarin/digoxin
Tetracyclines
inhibit translation, broad spectrum and dose dependent bactericidal/static
doxacycline
tetracycline
Aminoglycosides
TOXIC AND DANGEROUS- last resort abx
Aminoglycosides adverse effects
nephrotoxicity and ototoxicity
aminoglycosides interactions
Other ototoxic drugs (loop diruetics, vancomycinand cephalosporins)
Streptomycin
Aminoglycosideabx
Gentamicin
Aminoglycoside abx
Kanamycin
Aminoglycoside abx
Tobramycin
Aminoglycoside abx
How do you know from the name that it is a aminoglycoside?
end in micin/mycin NOT thromycin
Two "QT's" say NO to OBs.
quinolones and tetracyclines should not be given to pregnant women due to teratogenic effects
Quinolones and fluoroquinolones
act against prokaryotic DNA gyrase
How do you know from the name that it is a Quinolones and fluoroquinolones?
they end in -floxacin
Levofloxacin
Fluoroquinolone Antibiotic
Moxifloxacin
Quinolones or fluoroquinolones abx
Ciprofloxacin
Fluoroquinolone abx
Quinolones and fluoroquinolones should not be given to
pregnant, myasthenia gravis, or renal dz
Quinolones and fluoroquinolones should be given with caution to
those with seizures, renal disorders, elderly, kids under 14 and those with cardiac dysrhythmias
Vancomycin
Glycopeptide abx used for treatment of MRSA and C. dif infections
Adverse effect of Vancomycin
Measure troughs regularly
red man's syndrome
Vancomycin mediated rash from giving it too quickly
Administration of Vancomycin
Monitor serum levels of abx to prevent ototoxicity and renal toxicity
Nitromidazoles
Disrupt central Dogma
which antibiotic has a reaction with alcohol (drink or sanitizer)?
nitromidazoles- metranidazole
Metranidazole
nitromidazole
SJS
Stevens-Johnson Syndrome
Acyclovir
Antiviral: inhibits DNA synthesis in herpes simplex and varicella zoster. Requires activation by viral thymidine kinase (TK− strains are resistant). Tox: behavioral effects and nephrotoxicity (crystalluria), but not myelosuppression
Oseltamivir
Tamiflu
HAART
highly active antiretroviral therapy- use of combinations of drugs that are effective against AIDS to reduce symptoms increse survival rate and prevent oppurtunistic infections.
HAART Goals
Decrease VL to undetectable levels
Latent TB infection
type of tuberculosis in which the person carries the disease but does not show symptoms and cannot infect others.