What are 4 categories of anxiolytic drugs?
Benzodiazepines, Beta-Blockers, SSRIs, Others
How do benzodiazepines work?
these bind to the GABA receptor-chloride channel molecule, and intensify the inhibitory effects of GABA
What is the antidote for benzodiazepine overdose?
flumazenil (Romazicon)
Info about flumazenil (Romazicon)
antidote for benzodiazepine O/D; administered rapid IV injection; competes w/ benzodiazepines for the GABA receptor and reverses sedation; short duration, may need to repeat
What are our 3 anxiolytic prototype drugs?
lorazepam (Ativan); diazepam (Valium); zolpidem (Ambien)
Prototype drug 1: benzodiazepines
lorazepam (Ativan)
lorazepam (Ativan) primary use
anxiety disorders and insomnia
lorazepam (Ativan) MOA
intensifies inhibitory effects of GABA
lorazepam (Ativan) adverse effects
tolerance; respiratory depression; psychological and physical dependence; sedation; dizziness
lorazepam (Ativan) alerts
Pregnancy Cat D; narcotic; additive effects w/ opioids; antidots is flumazenil
lorazepam (Ativan) interactions
any CNS depressants, digoxin, antiparkinson drugs (intensifies them)
Prototype drug 2: benzodiazepines
diazepam (Valium)
diazepam (Valium) primary use
sedative and hypnotic
diazepam (Valium) MOA
intensifies inhibitory GABA effects; inhibits brain impulses from passing through limbic and reticular activating systems
diazepam (Valium) alerts
Pregnancy Cat D; narcotic additive (potentiates narcotics); antidote is flumazenil; IV/IM/PO routes
diazepam (Valium) adverse effects
tolerance, respiratory depression; psychological and physical dependence; sedation; dizziness
diazepam (Valium) interactions
any CNS depressants, digoxin, antiparkinson drugs (intensifies them)
Prototype drug: Nonbenzodiazpine, nonbarbiturate
zolpidem (Ambien)
zolpidem (Ambien) primary use
short-term use (less than 2 weeks) for treatment of insomnia (rebound sleep disorder if used >2wks)
zolpidem (Ambien) MOA
binds to GABA receptors intensifying inhibitory GABA effects
zolpidem (Ambien) alerts
Pregnancy Cat B; short-term use only; flumazenil may have weak reversal effects
zolpidem (Ambien) adverse effects
mild nausea; diarrhea; dizziness; daytime drowsiness; amnesia, sleepwalking, ingesting carbs while sleepwalking
zolpidem (Ambien) interactions
any CNS depressants; food delays absorption
Nurse's role in the treatment of anxiety and sleep disorders
VS, medical/drug history; Assess intensity, duration of symptoms; teach good "sleep hygiene"; administer anxiolytics w/ caution in elderly, suicide potential, impaired renal or liver function, use of alcohol or other CNS depressants
What are the 4 classes of anti-depressants?
Selective serotonin reuptake inhibitors (SSRIs); tricyclic antidepressants (TCAs); atypical antidepressants; monoamine oxidase inhibitors (MAOIs)
Prototype drug: Selective Serotonin Reuptake Inhibitors (SSRIs)
fluoxetine (Prozac)
fluoxetine (Prozac) primary use
depression, anxiety, PTSD, OCD
fluoxetine (Prozac) MOA
selectively block re-uptake of 5-HT, w/ slight effect on DA and NE; slows reuptake of serotonin; increases post-synaptic receptor activity
fluoxetine (Prozac) adverse effects
Pregnancy Cat C; sexual dysfunction; nausea, headache, weight gain, insomnia; may cause dizziness or drowsiness
fluoxetine (Prozac) interactions
avoid MAOI, St. John's Wort; no suicide potential, can't OD on this drug
fluoxetine (Prozac) & other SSRI nursing considerations
monitor for suicidal ideation, esp. pediatric and adolescent, during 1st few weeks; encourage pt to keep taking drug (effects take 2-6 wks to be felt); do not abruptly stop this drug
bupropion (Wellbutrin) info
effective at blocking DA reuptake; no effect on 5-HT or NE; may be similar action to cocaine; lowers seizure threshold; no weight gain; limited to no sexual side effects
Prototype drug: atypical antidepressants
bupropion (Wellbutrin)
bupropion (Wellbutrin) primary use
depression, anxiety, smoking cessation
bupropion (Wellbutrin) MOA
inhibit reuptake of NE and DA and nicotinic antagonist
bupropion (Wellbutrin) alerts
increases seizure potential
bupropion (Wellbutrin) adverse effects
headache, insomnia, HTN, dry mouth, nausea; numerous drug interactions
What is the major problem w/ tricyclic antidepressants?
side effects: cardiotoxicity, sedative action, high incidence of sexual dysfunction, weight gain; block ACh (blurred vision, dry mouth, urinary retention, constipation, mental confusion)
Prototype drug: tricyclic antidepressants
amitriptyline (Elavil)
amitriptyline (Elavil) primary use
depression, neuropathic pain, migraine prevention, sleep induction
amitriptyline (Elavil) MOA
inhibit reuptake of NE and serotonin
amitriptyline (Elavil) adverse effects
dry mouth; drowsiness; constipation; urinary retention; insomnia; ortho hypo; sedation; rarely cardiac dysrhythmias
amitriptyline (Elavil) alerts
Pregnancy Cat D; limit use in elderly; interacts w/ CNS depressants, grapefruit juice, photosensitivity
TCAs - nursing considerations
Assess for contraindications (heart disease, use of thyroid meds); monitor for suicidal ideation; encourage compliance; drug has high suicide potential, O/Ds are highly lethal
Which class of AD is used as a last resort?
MAOIs - these break down many chemicals, including tyramine (found in cheeses, red wine, alcohol, smoked fish)
Prototype drug: Monoamine Oxidase Inhibitors (MAOIs)
phenelzine (Nardil)
phenelzine (Nardil) primary use
severe and unrelenting depression
phenelzine (Nardil) MOA
irreversibly inhibits monoamine oxidase, which causes intensification of NE
phenelzine (Nardil) alerts
Pregnancy Cat C; lasts 2-3 weeks beyond last dose
phenelzine (Nardil) adverse effects
ortho hypo; headache; insomnia; diarrhea; abrupt d/c will cause severe HTN
phenelzine (Nardil) interactions
extensive interactions w/ other meds (opioids, insulin, dextromethorphan), foods w/ tyramine, and herbals
MAOIs - nursing considerations
can have severe SE (hypertensive crisis w/ foods w/ tyramine), dysrhythmias; teach about foods to avoid; monitor or restrict caffeine; assess for w/drawal s/s
Which foods have tyramine (avoid w/ MAOIs)?
cheese, red wine, smoked fish
What kind of drug is prescribed for bipolar?
mood stabilizers
Prototype drug: mood stabilizers
lithium carbonate (Eskalith)
lithium carbonate (Eskalith) primary use
bipolar disorder
lithium carbonate (Eskalith) MOA
exact mechanism not understood; influences DA, NE, 5-HT
lithium carbonate (Eskalith) alerts
has no effect outside of bipolar disorder; narrow therapeutic index; Pregnancy Cat D; risk of toxicity is high
lithium carbonate (Eskalith) adverse effects
nausea, loss of appetite; slight tremors; fatigue; excessive loss of sodium; can cause hypothyroidism
Which drug causes excessive loss of sodium?
lithium carbonate (Eskalith) causes loss of this
Lithium - nursing considerations
diuretics, NSAIDs increase lithium levels; monitor for s/s of toxicity (headache, lethargy, recent memory loss, fine hand tremors, kidney impairment, bad heart rhythms, thyroid problems, WBC problems)
Which class of drug can you never take w/ lithium?
diuretics because of excessive loss of sodium from lithium and from diuretic
What class of drug treats schizophrenia?
Antipsychotics
What other conditions do antipsychotics treat?
bipolar disorder; psychotic symptoms of other disorders
What are the categories of antipsychotic drugs?
Typical - control positive s/s of schiz; older drugs
Atypical - control positive and negative s/s of schiz; newer
What are extrapyramidal symptoms? (EPS)
tardive dyskinesia; acute dystonias; akathisia; parkinsonism syndrome; Muscular rigidity, tremor, bradykinesia, and difficulty walking induced by neuroleptic medications; drug-induced parkinsonism.
neuroleptic malignant syndrome (NMS)
A potentially fatal syndrome marked by hyperthermia, catatonic rigidity, altered mental status, profuse sweating, and occasionally rhabdomyolysis, renal failure, seizures, and death. It typically occurs after exposure to drugs that alter levels of DA in t
Prototype drug: typical antipsychotic/ phenothiazines
chlorpromazine (Thorazine)
chlorpromazine (Thorazine) primary use
treats positive symptoms of schiz; severe mood disorders; severe unrelenting N/V; uncontrolled hiccups; porphyria
chlorpromazine (Thorazine) MOA
block DA and 5-HT receptors
chlorpromazine (Thorazine) alerts
Pregnancy Cat C; lowers the seizure threshold - may need a higher dose of anticonvulsant if at risk for seizures
chlorpromazine (Thorazine) adverse effects
EPS, NMS and numerous others
Prototype drug: typical antipsychotic/ nonphenothiazines
haloperidol (Haldol)
haloperidol (Haldol) primary use
treats positive symptoms of schiz; sedative
haloperidol (Haldol) MOA
blocking of the DA type 2 receptor
haloperidol (Haldol) adverse effects
same as the phenothiazines: EPS, NMS, many others
haloperidol (Haldol) routes, interactions
PO, IM, IV; there is a long-lasting (1x/mo IM route); interacts w/ CNS depressants
Which antipsychotic class treats pos and neg symptoms?
atypical antipsychotics control both types of symptoms; new ones have slightly fewer SE than older ones
Prototype drug: (2nd gen) atypical antipsychotics
risperidone (Risperdal)
risperidone (Risperdal) primary use
schiz; bipolar; autism; elderly dementia (although not recommended); depression
risperidone (Risperdal) MOA
block DA, 5-HT and alpha-adrenergic receptors
risperidone (Risperdal) alerts
Pregnancy Cat C; can be used in children; avoid in elderly or dementia
risperidone (Risperdal) adverse effects
fewer than those of typical antipsychotics, less EPS; obesity; diabetes; stroke
Prototype drug: atypical antipsychotics (DA system stabilizer)
aripiprazole (Abilify)
aripiprazole (Abilify) primary use
treat both positive and negative symptoms of schiz
aripiprazole (Abilify) MOA
dopamine system stabilizer
aripiprazole (Abilify) advantages
little to no weight gain, small risk of EPS; does not lower seizure threshold; comes in po, SL dissolving, IM routes
aripiprazole (Abilify) adverse effects
NMS can occur; grapefruit juice can lead to toxic levels
What are anticholinergic side effects of meds?
dry mouth, nose, throat; constipation; drowsiness; flushing & overheating; confusion & memory loss; blurred vision