Exam 1 Mental Health Chapter 14

Chapter 14 Antipsychotic Drugs -Antipsychotic drugs are used to treat schizophrenia, schizoaffective D/O, bipolar D/O psychotic depression >off labeled uses: treatment of insomnia, tics, delirium, stuttering, & hiccoughs -Antipsychotics were accidentally around 1950 -Chlorpromazine is considered the first antipsychotic drug -These drugs are generally called antipsychotic agents, but historically were referred to major tranquilizers, ataractics (drugs that produce calmness), and neuroleptics **Low potency drugs tend to cause more intense 1. Traditional or First-generation antipsychotics (FGAs) anticholinergic (dry mouth, 2. Atypical or Second-generation antipsychotics (SGAs) blurry vision) effects & 3. Atypical or Third-generation antipsychotics (TGAs) antiadgreneric (orthostatic hypotension) effects **High potency drugs cause more extrapyramidial side effects (EPSEs) & prolactin elevation Classification!Systems! **TGAs cause fewer anticholinergic, prolactin, BP, cardiac effects **SGAs are often referred to as atypical because: they reduce the risk of ESPEs; increased effectiveness in treating neg. symptoms; minimal risk of tar dive dyskinesia; reduced risk for elevated prolactin Pharmacologic!Effects -CNS effects include emotional quieting and sedating >allows the patient to take advantage of other forms of therapeutic intervention >sedation decreases insomnia, a frequent complaint of psychotic patients Psychiatric!symptoms!modified!by!antipsychotic!drugs -A tranquilizing effect occurs within an hour or so after ingestion -Antipsychotic drugs are often observed within a few weeks, with improvement contin for 6 to 8 weeks or longer -Most effective in treating positive symptoms of schizophrenia; negative symptoms are responsive >negative symptoms develop over an extended period -As a rule, the more bizzare the behavior of a person experiencing psychotic symptom more likely that an antipsychotic drug with be beneficial -Reduce hallucinations & illusions -Antipsychotic drugs improve reasoning, decrease ambivalence, & decrease delusions -Individuals with schizophrenia are o hyperactive because of their intern turmoil -Antipsychotics slow psychomotor activity -Antipsychotics are effective in decreasing confusion & clouding -Antipsychotics reduce inner turmoil, freeing psychic energy for normal -A flat affect is a cardinal symptoms of negative interpersonal relationships & for th therapeutic nurse-patient relationsh schizophrenia & might respond only to an atypical antipsychotic drug Overview!of!Pharmacokinetics! -Absorption of these drugs is variable >oral meds absorbed in 1-6 minutes >disenegrating tablets absorbed within 2 minutes >lipid soluble accumulate in fatty tissue and are released slowly -Antipsychotics are highly protein bound -Metabolizaed in the liver by the CYP-50 enzyme system >average half life ranges from 10-30 hours >impaired hepatic function extends the half life & effect -Cigarette smoking increases the CYP-50 1A2 enzyme which breaks down several antipsychotics -Oral administration is the preferred route >cheeking: pt holds meds in cheek -A few oral versions dissolve instantly in mouth -Parenteral drugs are usually used to treat acutely disturbed patients or patients who represent significant compliance risks required every 2-6 weeks >beneficial for outpatients tor patients who are nonadherant Antipsychotic!side!Effects! -PNS anticholinergic SE are a result of the blocking of 4 cranial nerves that have parasympathetic components >CN III: oculomotor nerve blockade -> mydriasis & impaired accommodation; b >CN VII: facial nerve blockade -> dry mouth, decreased tearing, dry nasal passag >CN IX: glossopharyngeal nerve blockade -> dry mouth & dry nasal passages >CN X: vagus nerve blockade -> tachycardia, constipation, & urinary hesitation **NURSING ALERT** 1. Can increase intraocular pressure, aggravating narrow angle glaucoma 2. Can intensify prostatic hypertrophy, making urination even more difficult 3. Can trigger arrhythmias & cause death -Hypotension is the major antiadgrenergic effect of antipsychotics -Orthostatic hypotension can cause falls >most often in adults >hypotension also causes a -> general cardiovascular inefficiency >reflex tachycardia: tachycardia that automatically occurs as an adaptive function to compensate for lower extremity vasodilation **Be sure to assess individuals with a history of hypotension, HF, & arrhythmias -Traditional antipsychotics elevate prolactin levels by blocking D2 receptors -Dopamine inhibits prolactin, when dopamine receptors are blocked prolactin levels in -FGAs are much more likely to cause hyperprolactinemia -ESPEs account for many readmissions -High potency traditional antipsychotics are most likely & atypical antipsychotics are l to cause ESPE’s -Subjective feeling of restlessness exhibited by restless legs, jittery feelings, & nervou -Most common ESPE & responds poorly to treatment -Akinesia is the absence of movement >late manifestation of Parkinson’s disease >responds to anticholinergics -Bradykinesia is slowed movement >early manifestation of Parkinson’s disease >more likely -Symptoms include weakness, fatigue, painful muscles, & anergia -Abnormal postures caused by involuntary musc spasms; elicit a sustained, twisted, & contrac position of limbs, trunk, neck, & mouth -Appear early in treatment -Several types: >torticollis: contracted position of neck >oculogyric crisis: contracted position of eye >laryngeal: pharyngeal constriction (potentia life threatening) -Respond to anticholinergic drugs -TD is an ESPE that tends to develop after ~ 6 months or more of antipsychotic therap -Anticholinergics typically worsen symptoms of TD -Typical symptoms: (stop with sleep) >tongue writhing >tongue protrusion >teeth grinding >lip smacking -Often irreversible, but can be if patient is monitored closely & meds are stopped when symptoms first appear -Older individuals more susceptible -Leaning to one side -Higher doses of antiparkinsonian drugs may be helpful -NMS is potentially lethal -Occurs when most often when high potency antipsychotics are prescribed -Not related to toxic drug levels; onset is within a week or so after initiation of antipsy -Cardinal symptoms: high fever (101-103 F, but can reach 108 F) & rigidity -Related & other symptoms: tremors, impaired ventilations, muteness, altered consciou & automatic hyperactivity -Antipsychotics should not be reinstituted for at least 2 weeks after complete resolution -Insulin resistance syndrome -Manifests as reduced metabolism of glucose & resistance to insulin -Type 2 DM can result with the associated problems of hyperglycemia, obesity, elevat levels, coagulations abnormalities, & HTN -SGAs are more likely to cause metabolic syndrome -The following constitute metabolic syndrome: 1. Truncal obesity 2. High cholesterol levels 3. Elevated BP or treatment for same 4. High fasting glucose -Sexual activity can be divided into 3 phases: 1. Desire 2. Arousal 3. Orgasm -Desire deficits are most likely caused by a dopamine blockade -Weight gain can be significant -Insulin resistance is an outcome & a cause of excessive weight gain -Carbohydrtae craving is a common feature -Jaundice -Rare but serious blood dyscrasias -Susceptibility to hyperthermia -Sun sensitive skin -Nasal congestion -Wheezing -Memory loss -Agranulocytosis, rare but potentially fatal Nursing!Implications! -Overdose is seldom fatal -Causes severe CNS depression, hypotension, & ESPEs -Other indicatiors: restlessness or agitation, convulsions, hyperthermia, increase antic symptoms, & arrhythmias -Pose few risks during pregnancy but human data is limited -They should be avoided during the 1st trimester -They readily pass the placental barrier, reach significant levels in the fetus, & may ca ESPEs in some newborns -All of these drugs potentially worsen of cause glucose intolerance -Reducing dosage is imperative due to decreased hepatic metabolism capability -ESPEs & anticholinergic effects can be heightened -Higher risk for TD -Should not be given to patients with dementia related psychosis due to increased risk dying form sudden death or pneumonia -Antipsychotics interact with many other drugs -CNS depressants such as alcohol, antihistamines, anti anxiety drugs, antidepressants, barbiturates, meperidine & morphine can cause profound CNS depression Decreased antipsychotic effect All cause resp depression & increase sedation; all decrease serum levels, hypo Increase sedation; resp depression is possible Decreases serum level of some drugs Control of DM is weakened Decreased antiparkinsonian effect of levodopa; might exacerbate psyc Increased sedation; resp depression augmented -The nurse should use discretion in selecting the content of education sessions because patients have a tendency to become anxious & paranoid about potential side effects -The nurse should focus on symptoms that can be seen or felt -Patient & family should be taught: >avoid immersion in hot water because hypotension might occur >use sunscreen to prevent sunburn >dress appropriately in hot whether & drink plenty of water to prevent heat stroke >avoid abrupt withdrawal >take the drug as prescribed >immediately report signs of a sore throat, malaise, fever, or bleeding (blood dyscra ANTIPSYCHOTIC!DRUGS! -Low potency -First antipsychotic -Results in anticholinergic & antiadgreneric effects -Sedating & causes weight gain -ESPEs are moderately produced -May cause neuroleptic malignant syndrome, sedation, TD, hypotension, agranulocytosis -Adult maintenance range is 200-1000 mg/day -Moderate potency -Less expensive -Adult maintenance range is 12-64 mg/day -High potency -Commonly prescribed & considered to be effective -Long acting form is beneficial for noncompliant patients; injection ever 2 to 5 weeks -High potency FGA -Most frequently prescribed -Tneds to cause more ESPEs & less anticholinergic effects that low potency FGAs -Side effects can be severe -Injectin can be given every 2 to 4 weeks -Adult maintenance range is 1-15 mg/day -SGAs are atypical because they work differently than traditional drugs, and have a greater effect on ne symptoms -Introduced in the US in 1990 -Referred to as the “gold standard” in the management of treatment-resistant schizophrenia -Major side effects: neutropenia (WBC count <3000), agranulocytosis (Absolute neutrophil count <50 dyscrasia >indicated ONLY after patietns with severe schizophrenia fail to respond to other drugs -Causes significant side effects: sedation, weight gain, tachycardia, constipation, dizziness, sexual dysf orthostatic -Primarily metabolized by CYP-450 1A2; cigarette smoking induces CYP-450 1A2 -> decreased level -Side effects: dose related seizures & excessive salivation -Myocarditis: patients need to report dyspnea, fever, CP, palpitations, tachycardia, & other symptoms o -Fatal overdose -Adult maintenance range **Protocol for clozapine therapy** 75-900 mg/day 1. Obtain baseline weight, CMP, fasting glucose, fasting lipids, CBC 2. Absolute neutrophil count (ANC) of > 2000 & WBC > 3500 3. Weekly ANC for 6 months >then, ANC every 2 weeks for 6 months >then, ANC every 4 weeks after 12 months 4. Discontinue drug if WBC <3000 & ANC <1500 >monitor counts daily >If no infection is present, resume drug when counts return to normal >permantely discontinue if WBC <2000 or ANC <1000 -Risperidone has a favorable receptor profile for both positive & negative schizophrenia -Well tolerated drug with minimal anticholinergic side effects -SE: orthostatic hypotension, sedation, appetite stimulation, agitation, h/a, anxiety, rhinitis, insomnia -At higher doses, patients have experienced ESPEs & hyperprolactinemia -Use cautiously with DM & cardiac history -Long acting IM available -Select prototype medication -Adult maintenance range 0.5-6 mg/day -Taking results in anticholinergic effects: sedation, weight gain, orthostasis -Few incidents of ESPEs -Proven effective in treating schizophrenia, acute mania, & BP disorder -Long acting injectable form available -Adult maintenance range 5-20 mg/day -Similar to clozapine -Few anticholinergic side effects -Side effects: orthostatic hypotension, sedation, & appetite stimulation -Effective for positive & negative schizophrenia symptoms -Provokes few ESPEs & does not significantly increase serum prolactin levels -Appears to improve cognitive function -Taken orally, intranasally, IV -Provides anxiolytic & sedative effect -Newer second generation drug -Adult maintenance range 200-800 mg/day -Availble only as sublingual tablet -Approved treatment for schizophrenia BP D/O -Effective for positive & negative symptoms of schizophrenia -Low tendency to cause ESPEs; may -Causes few ESPEs, anticholinergic effects, & mild antihistaminic have some cases of akathisia -Effective in treatment of cognitive & effects negative symptoms -Appears to cause less weight gain than other atypical agents -Adult maintenance range 10-20 mg/da -Linked to potential cardiac problems -Absorption is increased when given with food -SE: nausea, dyspepsia, abd pain, constipation, somnolence, insomnia, coryzal symptoms (head cold) -Newer second generation -SE: weight gain, sedation, & orthostasis -Possibly decreases depression & anxiety -Related to risperidone; can precipitate ES -IM injection available -Adult maintenance range 40-160 mg/day prolactin elevation, & hyperprolactinem -Adult maintenance range 12-24 mg/day -Newer second generation -Has antianxiety properties -Absorption is improved with food (similar to ziprasidone) -Good SE profile: dizziness, orthostatic hypotension, sedation, weight gain reported -Adult maintenance range 40-90 mg/day -Referred to as dopamine system stabilizer -#1 best selling drug in the US -Reduces positive symptoms -Patietns feel better with more energy -Negative symptoms subside -Adult maintenance range 10-30 mg/day -Appears to have favorable side effect -Reduced incidents of akathisia, restlessness, & insomnia compared to other TGAs -Speculated that this mediation might “mediate behavi abnormalities”