Psychiatric Medication Review. July 2015

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1 Psychiatric Medication Review July 2015

2 Purpose The purpose of this training module is to offer basic information on medications and their recommendations of use for specific psychiatric disorders. This module in no way is intended to be used as treatment recommendations. It is recognized that a licensed practitioner is responsible for the ordering of medications, however a nurses responsibility is to understand classification of psychiatric medications, recommended dosing, side effects, and other information to provide a high quality of nursing care.

3 Medication Categories will include Antipsychotics Antidepressants Mood Stabilizers Anxiolytics CNS Stimulants Cholinesterase Inhibitors

4 Antipsychotics also referred to as neuroleptics and major tranquilizers used to treat schizophrenia, other psychotic disorders ( bipolar mania), and severe anxiety

5 2 groupings of antipsychotics Typical Antipsychotics is the older antipsychotic medications, now referred to as typical antipsychotics. These are primarily effective in reducing the positive symptoms of schizophrenia (refer to DU module on schizophrenia). medications have an exhaustive side effect profile that complicates treatment and contributes to noncompliance. Atypical Antipsychotics is the newer generation. The atypical antipsychotic medications have an impact on the neurotransmitter serotonin as well as on dopamine. Therefore, they help produce a reduction in positive symptoms as well as an impact on the negative, or less obvious, psychotic symptoms. less severe side effect profile than the typicals.

6 Examples Typical Antipsychotics Chlorpromazine (Thorazine) Thioridazine (Mellaril) Haloperidol (Haldol) Fluphenazine (Prolixin) Thiothixene (Navane) Trifluoperazine (Stelazine) Perphenazine (Trilafon) Atypical Antipsychotics Aripiprazole (Abilify Ziprasidone (Geodon) Quetiapine (Seroquel) Clozapine (Clozaril) Olanzapine (Zyprexa) Paliperidone Risperidone (Risperdal) Lurasidone (Latuda)

7 Allergies Allergies to antipsychotics are rare. Since the side effects can often be frightening and difficult to tolerate patients may report allergies to these medications rather than side effects. Reviewing the details of the patient s allergic response may play a role in deciding the treatment regime.

8 Side Effects The side effect profile is extensive and some may be dangerous and potentially life-threatening. Some side effects are irreversible and some are treatable. Educating the patient of all the risks and benefits is an essential component of best practice. The following slides high-lights some side effects and possible actions necessary

9 Antipsychotic Side Effects Possible Action CNS drowsiness, sedation Many patients adjust to over 5-10 days Agranulocytosis ( especially with Clozaril) Periodic WBC GI Nausea Offer with meals Cardiac orthostatic hypotension Monitor vital signs, instruct to rise slowly Skin - Photosensitivity, rash Use sunscreen and avoid direct sunlight Anticholinergic dry mouth, constipation, urinary retention, blurred vision, dilated pupils Monitor and treat symptoms Reduced seizure threshold ( especially with Clozaril) Monitor as needed

10 Antipsychotic Side Effects Possible Actions Endocrine false positive pregnancy test, lactation, gynecomastia, weight gain, amenorrhea, decreased libido Cardiac prolonged QT intervals and irregularities Explain & reassure EKG & vital sign monitoring Tardive Dyskinesia often irreversible, bizarre facial and tongue movements, involuntary gross motor movements, incoordination, muscle rigidity. Withdraw medication and report immediately. Evaluate using AIMS prior to initiation and during course of treatment. Neuroleptic Malignant Syndrome (NMS) - rare and potentially fatal complication. Rigidity, elevated temp, increased pulse and respiratory rate, diaphoresis, elevated CPK, and deterioration in mental status Discontinue medication immediately. Provide support systems as indicated.

11 Antipsychotic Side Effects Possible Actions Extrapyramidal Symptoms (EPS): Akathesia - restlessness and inability to sit still, which might be confused with agitation Pseudoparkinsonism Dystonia and muscle rigidity Oculogyric crisis Treat EPS with monitoring, education, and antiparkinsonism drugs, as ordered. These include benztropine (Cogentin), and diphenhydramine (Benadryl), which can be administered PO, IM, or IV. Careful monitoring and early intervention for these side effects is essential in establishing patient confidence in the ability to take the medications long-term. Akinesia - muscle weakness Hyperglycemia and diabetes, particularly with the atypical antipsychotics. Monitor weight. Monitor blood glucose as needed. Educate patient regarding signs and symptoms of diabetes

12 Long-acting Antipsychotics These may be prescribed and administered weekly, or every two, three or four weeks. This tactic can be helpful when patients have difficulty remembering to take their medications or when they have a tendency to be noncompliant. The medications are administered IM and will slowly release over a relatively long period of time. These medications include: Haldol Decanoate Prolixin Decanoate Consta (Risperdal) Note: This medication requires refrigeration.

13 Long-acting Antipsychotics do not wear off in several hours. The medication is released into the system over a period of weeks. Prior to the administration of the long-acting the short acting medication needs to be given to the patient to monitor their response and/or effectiveness.

14 Antidepressants Primarily used in treatment of Depression & Generalized Anxiety Disorders.

15 Categories of antidepressants Monoamine Oxidase Inhibitors (MAOI s) Tricyclic Antidepressants (TCA s) Selective Serotonin Reuptake Inhibitors (SSRI s) Serotonin Norepinephrine reuptake inhibitors (SNRI s) Other

16 Monoamine Oxidase Inhibitors Inhibits monoamine oxidase (which metabolizes an the enzyme that breaks down serotonin & norepinephrine which is related to depressive symptoms Takes 4-6 weeks to reach therapeutic levels Must avoid some medications and high-tyramine food (details in next slide)

17 Examples of MAOI s Phenelzine (Nardil) Tranylcypromine (Parnate) Isocarboxazid (Marplan)

18 MOAI s and Tyramine Certain medications and foods high in tyramine may react to MAOI s potentially causing a hypertensive crisis, which could be very severe. Foods high in tyramine to avoid include: bananas plums soy products aged meats and cheeses prunes avocados chianti wines oranges liver eggplant grapes chocolate figs raisins pineapples nuts Patient education related to the tyramine free diet and possible side effects needs to be completed

19 Tricyclic Antidepressants (TCA s) Inhibits the reuptake of Serotonin & Norepinephrine, causing an increase in availability Takes 4-6 weeks to reach therapeutic levels Caution in elderly due to being cardiotoxic and dangerous in overdose

20 Examples TCA s Amitriptyline (Elavil) Clomipramine (Anafranil) Desipramine (Norpramin) Imipramine (Tofranil)

21 Side Effects of TCA s Anticholinergic effects which can include dry mouth, constipation, blurred vision, & urinary retention Drowsiness Orthostatic hypotension (drop of 20/1omm of Hg may be considered significant)

22 Selective Serotonin Reuptake Inhibitors (SSRI s) Inhibits reuptake of Serotonin Reaches therapeutic levels in 1-3 weeks Side effects include: Decrease in sexual libido Headache Insomnia Nervousness Nausea

23 Examples of SSRI s Citalopram (Celexa) Fluoxetine (Prozac) Fluvoxamine (Luvox) Escitalopram ( Lexapro) Paroxetine (Paxil) Sertraline (Zoloft)

24 Serotonin Norepinephrine reuptake inhibitors (SNRI s) SNRIs block the absorption (reuptake) of the neurotransmitters serotonin and norepinephrine in the brain Reaches therapeutic levels in 1-3 weeks The most common side effects of SNRIs include: (mild and go away after a few weeks) Nausea Sexual libido Constipation Headache Insomnia Nervousness

25 Examples of SNRI s Duloxetine (Cymbalta) Venlafaxine (Effexor XR) Desvenlafaxine (Pristiq)

26 Other Antidepressants Buproprion ( Wellbutrin, Zyban) also associated with smoking cessation Trazadone ( Desyrel) may be used as sedative Venlafaxine (Effexor) Duloxetine (Cymbalta)

27 General antidepressants Difficulty tolerating adverse effects is the most common reason for discontinuation Any medication involving serotonin regulation has potential to cause serotonin toxicity also known as serotonin syndrome

28 Serotonin Syndrome Occurs with an excess of serotonin that may induce: Mania Restlessness Agitation Emotional lability Insomnia Confusion

29 Discontinuation Syndrome Occurs if on antidepressant for at least 4 weeks Abruptly stopped taking medication or fast tapered off medication Last for one to four weeks and usually resolve on own

30 Flu-like symptoms Sleep changes Discontinuation Syndrome Symptoms insomnia, nightmares, sleepiness Sensory disturbances imbalance, tremors, vertigo Mood disturbances dysphoria, anxiety, agitation Cognitive disturbances confusion & hyperarousal

31 Mood Stabilizers Used to treat Bipolar Disorder, manic Phase, & Schizoaffective Disorder Takes 5-10 days to reach therapeutic levels until reach therapeutic level may see antipsychotic medication for control of agitation and anxiety

32 Examples of Mood Stabilizers Lithium Anticonvulsants Clonazepam (Klonopin) Carbamazepine (Tegretol) Lamotrigine (Lamictal) Valproic acid (Depakote) Gabapentin (Neurontin) Topiramate (Topamax)

33 Anticonvulsants May be used in conjunction to Lithium Take 5-10 days to reach therapeutic level Some anticonvulsants monitored by blood levels

34 Lithium During the initial days of therapy, it is very important to ensure that patients are provided with adequate amounts of fluid and Na+. Narrow therapeutic window requiring frequent blood levels daily when first start followed by monthly monitoring Therapeutic levels range

35 Lithium Side effects - drowsiness dizziness headache thirsty N/V fine tremor bowel changes weight gain arrhythmias

36 Lithium Toxicity Occurs when serum Lithium level is above the therapeutic window. Signs of toxicity blurred vision tinnitus sever diarrhea severe N/V confusion seizures muscular irritability extreme lethargy Could lead to cardiovascular collapse

37 Lithium toxicity treatment Hold the medication Treat the symptoms IV hydration if necessary Monitor for electrolyte imbalances

38 Anxiolytics Anti-anxiety Used to treat mild to moderate anxiety May be used in alcohol detoxification Acute anxiety may commonly see benzodiazepines used for a short period of time Physiologically addictive in large amounts over long periods of time may occur

39 Other Anxiolytics most SSRIs have anxiolytic properties. Barbituates exert an anxiolytic effect linked to the sedation they cause Azapirones approved for use are Buspironeb(Buspar) and tandospirone (Sediel). Most common group of anxiolytics are the benzodiazepines

40 Examples of Benzodiazepines (Benzos) Alprazolam (Xanax) Chlordiazepoxide (Librium) Clonazepam (Klonopin) Clorazepate (Tranxene) Diazepam (Valium) Lorazepam (Ativan) Oxazepam (Serax)

41 Side Effects of Benzos Sedation Ataxia Dependence Orthostatic hypotension Paradoxical excitement Nausea & vomiting Anticholinergic effects such as dry mouth

42 Benzos categorized by action time: The action time (or time it takes for the body to eliminate half the dose) will help decide on which category of benzos to be prescribed Long-acting benzodiazepines such as diazepam & chlordiazepoxide are often prescribed for benzodiazepine or alcohol withdrawal as well as for anxiety if constant dose levels are required throughout the day. Shorter-acting benzodiazepines are often preferred for insomnia due to their lesser hangover effect.

43 Benzodiazepine Onset of Action * Peak Onset (hrs) Half-life parent (hrs) Chlordiazepoxide (Librium ) Int. (po) 2-4(po) 5-30 Diazepam 1 (Valium ) Rapid (po, IV) 1(po) Flurazepam (Dalmane ) Rapid inactive Alprazolam 1 (Xanax ) Clonazepam 1 (Rivotril ) Lorazepam 1 (Ativan ) Oxazepam 1 (Serax ) Int Int Int. (po), Rapid (sl, IV) (po) Slow Rapid onset = within 15 minutes, Intermediate = minutes, Slow = minutes Temazepam 1 (Restoril ) Slow Midazolam 1 (Versed ) Most Rapid IV (IV ) 1-4 Triazolam (Halcion ) Int

44 special notes about benzos Generally viewed as safe for short-term duration Paradoxical reaction may worsen agitation or panic Elderly are at increased risk of adverse effects Long term use may cause physical dependence and/or decrease in effectiveness

45 CNS Stimulants Used in the treatment of Attention-Deficit Hyperactivity Disorder (ADHD) by reducing hyperactivity and Impulsivity and improve focus.

46 CNS Stimulants Methylphenidate (Concerta, Ritalin) Dextroamphetamine (Dexedrene) Dexmethylphenidate (Focalin) Adderall The FDA has issued a warning about the risk of drug abuse with amphetamine stimulants. FDA safety advisors are also concerned about the possibility that all amphetamine and methylphenidate stimulants used for ADHD may increase the risk of heart and psychiatric problems.

47 Non Stimulant used to treat ADHD Intuniva Atomoxetine (Strattera) Both of the above are long-acting extended release lasting 24 hours

48 Cholinesterase Inhibitors Enhances cholinergic transmission in the brain by stopping acetylcholine from breaking down Used to treat dementia in patients with Alzheimer's they don't stop or reverse the destruction of brain cells and loss of acetylcholine that occur in Alzheimer s Disease. They don't prevent the disease from getting worse, but they may slow it down

49 Examples and common side effects Generic Brand Side Effects Donepezil Aricept Nausea, vomiting, loss of appetite and increased frequency of bowel movements. Galantamine Razadyne Nausea, vomiting, loss of appetite and increased frequency of bowel movements. Rivastigimine Exelon Nausea, vomiting, loss of appetite and increased frequency of bowel movements. Tacrine Cognex Possible liver damage, nausea, and vomiting.

50 References Boyd, M.A. Atypical antipsychotics: Impact on overall health and quality of life, Journal of the American Psychiatric Nurses Association, August delange, E. Pharmacometrics in psychiatric diseases, chapter 10.Applied Pharmacometrics, V14, Schmidt & Derendorf. Jarboe, K.S. Considering the impact on overall patient health when choosing antipsychotic therapy. The American Psychiatric Nurses Association, 13(5). Littrell, K.H. & Litrell, S.H. Emerging applications of newer antipsychotic agents in specific patient populations. Journal of the American Psychiatric Nurses Association, 4(4). National Institute of Mental Health. Mental health medications overview. Available

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