Psychiatric Nsg Exam 03

generic (trade):
➧Citalopram (Celexa)
➧Escitralopram (Lexapro)
➧Fluoxetine (Prozac)
➧Fluovoxamine (Luvox)
➧Sertraline (Zoloft)
➧Paroxetine (Paxil)

action: blocks reuptake of SEROTONIN

notes:
➧1st line Tx of MDD
➧some activate, other sedate, depending on Sx
➧risk of lethal OD minimized
➧least amt S/E & drug interference

S/E: agitation; insomnia; HA; N/V; sexual dysfunction; hyponatremia

warnings:
➧Discontinuation syndrome: occurs w/ abrupt withdrawal; must taper slowly; dizziness, insomnia, nervousness, irritability, N/V, agitation
➧contraindicated w/ MAOIs

genereic (trade): Nefazodone

action: selective blockage of serotonin2 receptors & α1-adrenergic receptors

notes:
➧↓risk of long-term wt gain than SSRIs & TCAs
➧↓risk sexual S/E than SSRIs

S/E: sedation; hepatotoxicity; dizziness; hypotension; parethesias

warnings:
➧life-threatening LF possible
➧priapism of penis/clitoris rare but serious
➧contraindicated w/ MAOIs

generic (trade):
➧Venlafaxine (Effexor)
➧Duloxetine (Cymbalta)

action: binds the reuptake of serotonin & norepinephrine

notes:
➧Effexor is popular next-step after SSRIs
➧Cymbalta has ↓neuropathic pain

S/E: HTN (Effexor); N; insomnia; dry mouth; sweating; agitation; HA; sexual dysfunction

warnings:
➧Effexor: monitor BP esp at higher doses & Hx of HTN
➧discontinuation syndrome

generic (trade): Mirtazapine (Remeron)

action: blocks α1-adrenergic receptors that normally inhibit norepinephrine & serotonin

notes: antidepressant effects equal SSRIs & may occur faster

S/E: Wt gain; sedation; dizziness; HA; sexual dysfunction rare

warnings:
➧drug-induced somnolence exaggerated by CNS depressants
➧contraindicated in MAOIs

generic (trade): Reboxetine (Vestra)

action: blocks reuptake of norepinephrine & enhances its transmission

notes:
➧antidepressant effects similar to SSRIs & TCAs
➧useful w/ severe depression & impaired social functioning

S/E: insomnia; sweating; dizziness; dry mouth; constipation; urinary hesitancy; tachycardia; ↓libido

warnings: contraindicated w/ MAOIs

generic (trade): Bupropion (Wellbutrin)

action: blocks reuptake of norepinephrine & dopamine

notes:
➧stimulant action may ↓appetite: contraindicated w/ eating d/o
➧may ↑sexual desire
➧used as aid to quit smoking

S/E: agitation; insomnia; HA; N/V; seizures

warnings:
➧contraindicated w/ MAOIs
➧↑doses ↑seizure risk

generic (trade):
➧Amitriptyline (Elavil)
➧Clomipramine (Anafranil)
➧Desipramine (Norpramin)
➧Doxepin (Adapin, Sinequan)
➧Imipramine (Tofranil)
➧Nortriptyline (Aventyl, Pamelor)
➧Protriptyline (Vivactil)

action:
➧inhibits reuptake of serotonin & norepinephrine
➧antagonizes adrenergic, histaminergic & muscarinic receptors

notes:
➧therapeutic effect like SSRIs but S/E more prominent
➧may work better in melancholic depression
➧can worsen many cardiac & medical conditions
➧not well-tol; tricky to dose
➧↑ACh affects

S/E: dry mouth; constipation; urinary retention; blurred vision; orthostatic hypo; cardiac toxicity; sedation

warnings:
➧lethal in OD
➧use cautiously in elderly & ppl w/: cardiac d/o, ↑intraocular pressure, urinary retention, hyperthyroidism, seizure d/o, liver or kidney dysfunction
➧contraindicated w/ MAOIs

generic (trade):
➧Phenelzine (Nardil)
➧Selegiline: Transfermal; System Patch (EMSAM)
➧Tranylcypromine (Parnate)

action: inhibits monoamine oxydase, which breaks down neurotransmitters like serotonin & norepinehprine

notes:
➧efficacy similar to other antidepressants but dietary restrictions & potential drug interactions make MAOIs less desirable
➧patch must be rotated; does NOT have dietary issues (bypasses gut)

S/E:
➧insomnia, N, agitation, confusion
➧potential for HTN crisis or serotonin syndrome when used w/ other antidepressants

wanrings:
➧contraindicated w/ other antidepressants
➧Tyramine-rich diet could bring HTN crisis
➧many other drugs interactions

arrhythmias:
➧TCAs
➧avoid in pts w/ cardiac instability or ischemia

HTN:
➧SNRIs, Nupropion/NDRI
➧monitor BP
➧keep lowest possible dose
➧add anti-HTN

HTN crisis:
➧MAOIs
➧seek emergency Tx
➧IV anti-HTN if severe

↑cholesterol:
➧Mitrazapine (SNDI)
➧add statin

Orthostatic hypotension:
➧TCAs; Trazadone, Nefazodone (SRA), MAOIs
➧add fludrocortisol, salt

Headaches:
➧SSRIs, SNRIs, Bupropion (NDRI)
➧assess for other etiologies

Myoclonus:
➧TCAs, MAOIs
➧add Clonazepam

Seizures:
➧Bupropion (NDRI), TCAs, Amoxipane
➧assess for other etiologies
➧add anticonvulsant if clinically indicated

Arousal, erectile dysfunction:
➧TCAs, SSRIs, SNRIs
➧add sildenafil, tadalafil, buspirone or bupuproin

Orgasm dysfunction
➧TCAs, SSRIs, Venlafaxine (SNRI), Desvenlafaxine, MAOIs
➧add sildenafil, tadalafil, buspirone or bupuproin

Priapism
➧Trazodone
➧obtain emergency urological eval

Activation:
➧SSRIs, SNRIs, Buprupion
➧admin in AM

Akathisia:
➧SSRIs, SNRIs
➧add beta-blocker or benzodiazepine

Bruxism (teeth gnashing):
➧SSRIs
➧dental eval if clinically indicated

Diaphoresis:
➧TCAs, some SSRIs, SNRIs
➧add α1-adrenergic antagonist (ie Terazosin) or ACh agent (ie Benztropine)

Fall risk:
➧TCAs, SSRIs
➧monitor BP for hypotension or ortho
➧assess sedation, blurred vision or confusion
➧modify enviro
➧be careful w/ elderly

GI bleed:
➧SSRIs
➧ID if concomitant meds may effect clotting

more likely to be reported in pts taking 2+ of: antidepressants, dopamine agonists, analgesics

2wks should elapse after D/C an MAOI & starting SSRI

5-6wks should elapse after D/C SSRI & starting MAOI

S/S:
➧hyperactivity or restlessness
➧tachycardia ⇒ CV shock
➧fever ⇒ hyperpyrexia
➧↑BP
➧altered mental state/delirium
➧irrationality, mood swings, hostility
➧seizures status epilepticus
➧myoclonus, incoordination, tonic rigidity
➧abd pain, D, bloating
➧apnea ⇒ death

Intrvs:
➧remove offending agents
➧serotonin-receptor blockade w/ Cyproheptadine, methysergide, propranolol
➧cooling blankets, chlorpromazine for hypertherm
➧Dantrolene, diazepam for muscle rigidity or rigors
➧anticonvulsants
➧artificial/mechanical ventilation
➧paralysis d/t fall precautions
➧replace fluids

containing Tyramine:
➧avocados; fermented bean curd
➧figs; bananas
➧meats that are fermented, smoked or aged; spoiled meats; liver (unless very fresh)
➧fermented sausages; bologna; pepperoni; salami, etc
➧dried or cured fish; fish that has been fermented, smoked or aged; spoiled fish
➧practically all cheeses
➧yeast extract
➧some imported beers; Chianti wine; red wine; sherry; beer; ale; liqueurs
➧protein supplements; soups w/ protein extract; shrimp paste; soy sauce

contain other vasopressors:
➧chocolate
➧fava beans
➧ginseng
➧caffeinated beverages

OTC meds for colds, allergies or congestion: w/ ephedrine, phenylephrine hydrochloride, or phenylpropanolamine

TCAs: Imipramine; Amitriptyline

narcotics

anti-HTN: Methyldopa, guanethidine, reserpine

amine precursors: levodopa, l-tryptophan

sedatives: ETOH, barbiturates, benzos

general anesthetics

stimulants: amphetamines, cocaine

high suicide risk ⇒ avoid TCAs & MAOIs

concurrent depression & panic attacks or OCD ⇒ Venlafaxine, SSRIs

chronic pain w/ or w/o depression ⇒ Amitriptyline, doxepin, venlafaxine, duloxetine

Weight gain on any other depressants ⇒ Bupropion, SSRIs; avoid mirtazapine

Sensitivity to ACh S/E ⇒ avoid TCAs & paroxetine

Sexual dysfunction ⇒ Bupropion, nefazodone

MDD: all but fluvoxamine (Luvox)

OCD: fluvoxamine (Luvox); sertaline (Zoloft); fluoxetin (Prozac); paroxetine (Paxil)

Bulimia nervosa: fluoxetine (Paxil)

Panic d/o: sertraline (Zoloft); paroxetine (Paxil); fluoxetine (Prozac); citalopram (Celexa)

social anxiety d/o: paroxetine (Paxil)

premenstrual syndrome: fluoxetine (Prozac)

depression:
➧acute depression
➧preventing of relapse
➧other depressive syndromes

panic attacks: imipramine (Tofranil); clomipramine (Anafranil); desipramine (Norpramin)

childhood enuresis: imipramine (Tofranil)

Bulimia nervosa: Imipramine (Tofranil); desipramine (Norpramin)

OCD: clomipramine (Anafranil) only

acute phase:
➧Severe Mania: Lithium + antipsychomotor OR Divalproex + antipsychotic
➧Less severe Mania: Lithium or Divalproex
➧Severe Mixed: Divalproex
➧Severe Rapid Cycling: Divalproex or Lithium

maintenance phase: Divalproex or Lithium

rapid cycling (long path):
1) Divalproex
2) Lithium or Carbamazepine
3) ECT OR add/substitute 3rd mood stabilizer
4) ECT OR Lamotrigine/Gabapentin OR Nimodipine OR add/substitute w/ Clozadine OR Thyroxine

Expected Signs:
➧level: <0.4-1.0 mEq/L (therapeutic level)
➧S/S: fine hand tremor, polyuria, mild thrist; mild nausea & general discomfort; weight gain
➧Intrvs: Sx may persist thru therapy & often subside; weight gain helped w/ diet, exercise

Early Signs of Toxicity:
➧level: <1.5mEq/L
➧S/S: N/V/D, thirst, polyuria, lethargy, slurred speech, muscle weakness, fine hand tremor
➧Intvrvs: meds withheld; serum LiO3 measured; dose reevaled; address dehydration

Advanced Signs:
➧level: 1.5-2.0mEq/L
➧S/S: coarse hand tremor, persistent GI upset mental confusion, musc hyperirritability; electroencephalographic changes, incoordination, sedation
➧Intrvs: like early or severe depending on severity of circumstance

Severe Signs:
➧level: 2.0-2.5mEq/L
➧S/S: ataxia, confusion, large dilute urine output, serious electroencephalographic changes, blurred vision, clonic movements, seizures, stupor, severe hypotension, coma; death 2ndary to pulm comps
➧Intrvs: hospitalization; drug stopped & excretion hastened; if pt alter, admin emetic

➧level: >2.5mEq/L
➧S/S: convulsions, oliguria, death
➧like severe & hemodialysis

0.5-0.8mEq/L = maintenance
0.8-1.2mEq/L = acute phase

physical exam

EKG

labs:
➧LiO3 level: acute 5days after dose change; maintenance q6mon
➧BUN & Cre: prior to Tx then q2-3mon; maintenance q6mon
➧thyroid: initially; q6mon

women: preggo test

type: anticonvulsant

uses: acute mania

off-label: depression maintenance

recommendation: maintenance Tx for bipolar d/o

S/E:
➧common: fatigue, nausea, dizziness
➧agranulocytosis; aplastic anemia
➧serious: sedation; tolerance; diplopia, incoordination

notes:
➧blood levels & CBC thru 1st 8wks b/c drug induces liver enzymes that speed its own metabolism
➧maintenance level: 6-8mg/L

type: anticonvulsant

uses: acute mania

off-label: depression maintenance

recommendation: 1st line Tx maintenance for bipolar d/o; acute mania

S/E:
➧common: tremors, GI upset, weight gain, alopecia
➧thrombocytopenia
➧serious: fever, chills, RUQ pain, dark urine, malaise, jaundice

notes:
➧baseline liver function tests at regular intervals (6-12mon)
➧contraindicated in preggo

type: anticonvulsant

uses: maintenance (bipolar)

off-label: depression (can worsen mania)

recommendation: 1st line Tx maintenance for bipolar depression; maintenance of bipolar d/o

S/E:
➧common: dizziness, diplopia, HA, ataxia, somnolence
➧serious: rash (Stevens-Johnson syndrome)

notes:
➧caution w/ renal, hepatic or cardiac impairment
➧tolerated well
➧low dose titration to ↓risk rash

antidepressants:
➧used during depressed phases
➧need SHORT half-life or may trigger manic phase

antipsychotics:
➧atypicals recommended d/t superior S/E profile
➧Olanzapine (Zyprexa), ziprasidone (Geodon), queriapine (Seroquel)
➧Clozapine for refractory psychosis

benzodiazepines: short term agitation

preconception:
➧taper over 2wks (shorter tapers correlated to relapse)
➧non-pharm adjuctive intrvs: light, sleep, omega-3 fatty acids, folate 4mg/day
➧prodromal warning Sx use non-teratogenic or least agent in lowest effect dose: 1st gen antipsychs, 2nd gen
➧consider ECT

delivery, postpartum, lactation
➧medicate prophylaxis 2-4wks prior to delivery or immediate postpartum period
➧assess LiO3 levels during & after delivery to prevent toxicity
➧sleep hygiene for BPD dads & moms
➧consider formula feeding
➧if breastfeeding, obsrv infant: lethragy, resp distress, hypotonia, rash

Dry Mouth:
➧freq sips H2O, gum, candy
➧Xero-Lube (saliva sub) if severe

Urinary Retention:
➧check voiding
➧warm towel on abd
➧cath

Constipation: (usually short-term)
➧stool softeners
➧good H2O intake

Blurred vision: (usually 1-2wks)
➧DON'T give thioridazine & check w/ MD

Photosensitivity: wear sunglasses

Dry Eyes: artificial tears

Inhibition of ejaculation or impotence in men: alert MD that pt may want med change

Pseudoparkinsonism: masklike faces, stiff & stooped posture, shuffling gait, drooling, tremor, "pill-rolling"
➧onset: >5-30days
➧alert med staff
➧may give ACh agent: trihexyphenidyl (Artane); benztropine (Cogentin)

Acute Dystonic Rxns: acute contractions of tongue, face, neck, back
a) opisthotonos: titanic heightening of entire body, head & belly up
b) oculogyric: eyes locked upward
➧onset: 1-5days
➧1st choice: Diphenhydramine hydrochloride (Benadryl) 25-50mg IM/IV; relief in minutes
➧2nd choice: Benztropine (Cogentin) 1-2mg IM/IV
➧prevent: ACh agent; calm frightened pt by taking to quiet area & staying w/ until meds

Akathisia: motor inner-driven restlessness
➧onset: 5-60days
➧change antipsych med or give antiparkinsonian
➧may use: Propranolol (Inderal), lorazepam (Ativan), diazepam (Valium)

Tardive Dyskinesia:
a) facial: protruding & rolling tongue, blowing, licking, spastic facial distortion, smacking movement
b) limbs
c) choreic: rapid, purposeless, irregular movements
d) athetoid: slow, complex, serpentine movements
e) trunk: neck, shoulder, dramatic hip jerks & rocking, twisting, pelvic thrusts
➧onset: 6-24mon to yrs
➧NO KNOWN TX; d/c DOESN'T always relieve Sx
➧AIMS Scale: must screen at least q3mon

Hypotension (& orthostatic):
➧check BP before med; SYS80 standing means hold
➧slow movement
➧subsides wjen drug stabilized in 1-2wks
➧elastic bandages to prevent pooling
➧may call MD for vol expanders or pressure agents

Tachycardia:
➧eval cardiac pts before giving antipsych
➧prefer Haloperidol (Haldol) d/t lower ACh effects

Agranulocytosis: sore throat, fever, malaise, mouth sore
➧onset: sudden, evident in 1st 12wks
➧eval ALL flu-like Sx
➧blood work q1wk then q2mon to look for leukopenia or aganulo
➧positive blood work ⇒ d/c med & start reverse isolation

Cholestatic jaundice: fever, malaise, N, abd pain; jaundice 1wk after 1st Sx
➧reversible & benign if caught early enough
➧d/c drug
➧bed rest, ↑protein, ↑carb
➧liver function q6mon

Neuroleptic malignant syndrome:
a) severe EPS: severe muscle rigidity, oculogyric crisis, dysphagia, flexor-extensor posturing, cog wheeling
b) hyperpyrexia: ↑temp (>103F)
c) autonomic dysfunction: HTN, tachycardia, diaphoresis, incontinence
➧onset: can occur 1st wk but often later; rapid progress over 2-3days
➧risk factors: concomitant antipsychos; elderly; female; mood d/o; rapid dose titration
➧d/c med; transfer to ICU
➧Bromocriptine: for muscle rigidity & fever
➧Dantrolene: for muscle spasms
➧cool fever (cooling blankets b/c Tylenol won't work); hydrate; correct lytes; Tx arrhythmias; small doses heparin to prevent PEs

atypical antipsych

therapeutic use: refractory schizo; mood stabilizing for delusional MDD

rxns: agranulocytosis; ↑seizure rate; significant weight gain; ↑lipid abnorms; excessive salivation; tachycardia

contras: w/ bone marrow suppressants; CNS depression; breastfeeding; seizures; CV disease; impaired resp/hepatic/renal function; ETOH withdrawal; urinary retention; glaucoma

notes: WBC/wk; BP monitoring; supervise for SI: weight gain management; NOT 1ST LINE

atypical antipsych

therapeutic use: psych d/o

rxns: hypotension; insomnia; sedation; rarely NMS, TD; sexual dysfunc; weight gain; moderate lipid abnorms

contras: cardiac disease; cerebrovas disease; dehydration; anti-HTNs; lactation; Hx seizures; elderly; preggo

notes: baseline liver/renal tests; monitor BP for initial orthostasis; weight gain management

Papiperdone (Invega) is similar but better tolerated

atypical antipsych

therapeutic use: psych d/o; acute mania

rxns: significant weight gain; ↑lipid abnorms; drowsiness; agitation & restlessness; insomnia; possibly akathisia or parkinsonism

contras: DM; high gluc; kids; hepatic or CV disease; elderly; ACh-avoiding ppl; preggo; seizures; cerebrovas; aspiration PNA risk

notes: hepatic baseline; SI supervision; avoid dehydration; notify MD about preggo; dietary/heart disease teaching

atypical antipsych

therapeutic use: psych d/o

rxns: weight gain; moderate lipid abnorms; HA; drowsiness; ortho

contras: elderly; Alzheimer's; Hx breast CA; CV/cerebrovas disease; dehydration; hyperthyroid; Hx substance abuse

notes: CBC & liver tests/baseline; avoid heat; drowsiness subsides; avoid ETOH

atypical antipsych

therapeutic use: schizo

rxns: prolonged QT interval (arrhythmias, MI); targets depressive Sx; somnolence; EPS; resp d/o

contras: arrhytmias; prolonged QT; lyte imbals; elderly; preggo; renal probs

notes: ECG baseline; avoid heat (↑risk stroke); avoid ETOH

atypical antipsych

therapeutic use: schizo

rxns: anxiety; constipation; HA; insomnia; N/V; ortho; drowsiness; tremors; rarely akathisia, fever, skin rash, TD, dysphagia, heat stroke, NMS, seizures

contras: Hx heart disease, stroke, dehydra, seizures; Alzheimer's; swallowing; allergies; elderly; preggo

notes: hydrate

Trihexyphenidyl: antiparkinsonian & anticholinergic agent

Benztropine mesylate (Cogentin): antiparkinsonian & anticholinergic

Biperiden (Akineton): antiparkinsonian & anticholinergic

Diphenhydramine hydrochloride (Benadryl): antihistamine (used for ACh properties)

S/E of atypical antipsychs & antidepressants

abd obesity: >40in men, >35in women

triglycerides >150mg/dL

HDL-cholesterol: <40mg/dL men; <50mg/dL women

BP >130mmHg/85mmHg

fasting glucose >110mg/dL

conventional:
➧D2 antagonism: against positive Sx
➧adverse effects: EPS, TD, hyperprolactinemia, photosensitivity
➧low potency: Chlorpromazine (Thorazine); Thioridazine (Mellaril)
➧medium potency: Loxapine (Loxitane); Molindone (Moban); Perphenazine (Trilafon)
➧high potency: Trifluoperazine; Thiothixene (Navane); Fluphenazine (Prolixin); Haloperidol (Haldol); Pimozide (Orap)

Atypical:
➧D2/5-HT2A antagonism: pos & neg Sx
➧adverse effects: metabolic syndrome (weight gain, DM, dyslipidemia); cardiac; sedation; some EPS/hyperprolactinemia
➧Aripiprazole (Abilify);
Clozapine (Clozaril);
Olanzapine (Zyprexa);
Papiperdone (Invega); Quetiapine (Seroquel); Risperidone (Risperdal);
Ziprasidone (Geodon)

Chlorpromazine (Thorazine)
➧↑sun sensitivity
➧highest sedative & hypotensive effects
➧may cause retina pigments at 800mg/day

Thioridazine (Mellaril)
➧not recommended 1st line
➧r/t severe ECG changes: prolonged QTC intervals; may cause sudden death

Loxapine (Loxitane): assoc w/ weight reduction

Molindone (Moban): assoc w/ weight reduction

Perphenazine (Trilafon): can help control severe vomiting

Trifluoperazine (Stelazine)
➧↓sedation; good for withdrawal or paranoia Sx
➧↑EPS incidents
➧NMS may occur

Thiothixene (Navane): ↑akathisia incidents

Fluphenazine (Prolixin): among least sedating

Haloperidol (Haldol)
➧↓sedation; large doses for assaultive pts to avoid severe S/E of hypotension
➧approp for elderly; lessens chance for falls
➧↑EPS incidents

Pimozide (Orap)

drugs: barbituates; benzodiazepines; chloral hydrate; glutethimide; meprobamate; ETOH

intox: slurred speech, incoordination, unsteady gait, drowsiness, ↓BP; disinhibition of sexual drive/aggression, impaired judgement, impaired social/occupational, impaired attn/memory, irritability

OD: CV or resp depress/arrest; coma; shock; convulsions; death

OD Tx:
➧awake: keep awake; induce V; activated charcoal to absorb; VS q15min
➧coma: endotracheal tube; IVF; gastric lavage; check VS frequently for shock/arrest; seizure precautions; maybe hemodialysis; flumazenil (Romazicon) IV

WD:
➧stopping prolonged use: N/V; tachycardia; diaphoresis; anxiety/irritability; tremors in hands, fingers, eyelids; insomnia; grand mal seizures
➧after 5-15yrs: delirium

WD Tx: careful titrated detox w/ similar drug

drugs: coccaine (short high); amphetamines (long high); dextroamphetamine; methamphetamine; ice

intox: tachycardia, dilated pupils, ↓BP, N/V; assultiveness, grandiosity, impaired judgement, impaired social/occupation, euphoria; ↑energy
➧severe: resembling paranoid/schizo; paranoia w/ delusions; psychosis; visual/auditory/tactile hallucinations; severe to panic anxiety; potential for violence
➧paranoia & ideas of reference may persist for months

OD: resp distress; ataxia; hyperpyrexia; convulsions; coma; stroke; MI; death

OD Tx: antipsych; ambient cooling; Diazepam (convulsions)

WD: fatigue; depression; agitation; apathy; anxiety; sleepiness; disorientation; lethargy; craving

WD Tx: antidepressants (desipramine); dopamine agonist; bromocriptine

drugs: opium, heroin, meperdine (Demerol), morphine, codeine, methadone (Dolophine), hydromorphone (Dilaudid), Fentanyl (Sublimaze)

intox: constricted pupils, ↓RR, drowsiness, ↓BP, slurred speech, psychomotor retardation; initial euphoria followed by dysphoria, impairment of attn/judgement/memory

OD: possible pupil dilation d/t anoxia; resp dist; coma; shock; convulsions; death

OD Tx: Narcotic agonist (naloxone [Narcan]) to quickly reverse CNS depress

WD: yawning, insomnia, irritability, runny nose, panic, diaphoresis, cramps, N/V/D, muscle aches/bone pain, chills, fever, lacrimation

WD Tx: methadone tapering; Clonidine-naltrexone detoxl Buprenorphine substitution

intox phys: pupil dilation, tachycardia, diaphoresis, palpitations, tremors, incoordination, ↑temp/pulse/RR

intox psych: fear of going crazy, paranoid ideas, marked anxiety/depression, synthesia, depersonalization, hallucinations, grandiosity

OD effects: psychosis; brain damage; death

OD Tx:
➧room w/ low stimuli, minimal light
➧1 person stays, talk down pt
➧diazepam or chloral hydrate for extreme anxiety or tension

intox phys: vertical/horizontal nystagmus, ↑BP/HR/temp, ataxia, muscle rigidity, seizures, blank stare, chronic jerking, belligerence, assultiveness, impulsiveness; impair judgement/social/occupational

intox psych: hallucincations, paranoia, bizarre/regressive behavior; violent bizarre behaviors; very liable behaviors

OD effects: psychosis; possible HTN crisis or CV accident; resp arrest; hypertherm; seizures

OD Tx:
➧gastric lavage can cause laryngeal spasms
➧acidify urine w/ Ammonium chloride
➧room w/ minimal stimuli
➧don't talk down!
➧Diazepam
➧Haloperidol for severe behavioral disturbance
➧med intrvs: hyperthermia, ↑BP, resp dist, HTN

Organic solvents: gasoline, lighter fluid, paint thinner, nail polish remover, acetone, chloroform
➧Intox: ETOH-like effects of euphoria, impaired judgement, slurred speech, CNS depression; visual hallucinations & disorientation
➧OD: chronic use is toxic to heart, liver, kidneys; sudden death from anoxia, vagal stimulation, resp depres, dysrhythmias
➧Tx: none

Volatile nitrates: room deodorizers, products sold for recreational use
➧Intox: enhanced sexual pleasure
➧OD: venodilation causes profound ↓SYSBP (dizziness, lightheadedness, palpitations, pulsate HA); methemoglobinemia
➧Tx: methylene blue, O2

Anesthetics: gas (nitrous oxide from dental work & whipped cream), liquid, local
➧Intox: giggling, laughter; euphoria
➧OD: numbness, weakness, sensory loss, balance loss, phys dependence; possible polyneuropathy & myelopathy in chronic use
➧Tx: B12 vitamin

Naltrexone (Trexan, Revia):
➧opiate antagonist
➧weakens the reinforcing affects of ETOH & ↓cravings
➧3-7days post WD; 3-6mon up to 1yr
➧contra: liver impairment

Acamprosate (Campral)
➧amino acid derivative
➧effects GABA & glutamate neurotransmission
➧for pts who quit & want to be sober
➧7days post-WD; 1yr duration
➧contra: renal impairment

Topiramate (Topamax): inhibits release of mesocorticolimbic dopamine ⇒ ↓cravings

Disulfiram (Antabuse)
➧for motivated pts whose drinking is triggered by events that ↑cravings
➧ETOH-disulfiram causes unpleasant effects that last 30-120min, ended after sleep: facial flush, sweating, throbbing HA, neck pain, tachycardia, N/V, resp dist, very ↓BP

Nalmefene (Revex)
➧opiate antagonist
➧similar & fewer S/E than Naltrexone

Benzodiazepines
➧Chlordiazapoxide; Diazepam (not rec d/t short half-life); Lorazepam
➧↓WD Sx; stabilize VS; prevent seizures & delirium tremens

Beta-adrenergic blockers:
➧Atenolol; Propranolol
➧stabilize VS; ↓craving; ↓autonomic WD Sx

Alpha-adrenergic blockers
➧Clonidine
➧↓autonomic WD Sx

Antiepileptics
➧Carbamazepine
➧↓WD Sx; prevent seizures

Methadone (Dolophine)
➧synthetic opiate
➧blocks craving for heroin; WD drug
➧dose must prevent WD Sx, block craving & block effects of illicit use of short-acting narcotics

Levo-alpha-acetylmethadol (LAAM)
➧longer-acting than Methadone
➧similar therapeutic & S/E as morphine

Naltrexone (Trexan, Revia)
➧antagonist that blocks euphoric effects of opiates
➧long lasting (72hrs); long term use helps ↓drug-seeking behaviors
➧doesn't produce dependence

Clonidine (Catapres)
➧nonopioid suppressor of opioid Sx
➧nonaddicting
➧combo w/ Naltrexone

Buprenorphine (Subutex)
➧opioid agonist
➧low doses can block WD S/S (inpt & outpt)

Anorexia nervosa:
➧NOTHING PROVEN but some stuff for comorbid conditions
➧Fluoxetine (Prozac): SSRI for ↓obsessive-compulsive behavior after reaching maintenance wt
➧Conventional antipsychs: Chlorpromazine (Thorazine) may delusional or overactive pts
➧Atypical antipsychs: Olanzapine (Zyprexa) improving mood, ↓obsessional behaviors & resistance to wt gain

Bulimia nervosa:
➧SSRIs ↓binge eating/V over short terms
➧Fluoxetine (Prozac): SSRI, prevent relapse

Buproprion (Wellbutrin) CONTRAINDICATED d/t seizure risk & wt loss

TCAs AVOIDED in under-wt & +SI

Cholinesterase Inhibitors

N-methyl-D-aspartate (NMDA) Antagonist

SSRIs

Antianxiety Agents

Atypical Antipsychs

Anticonvulsants

generic (trade): Tacrine* (Cognex); Donepezil* (Aricept); Rivastigmine* (Exelon); Galantamine* (Razadyne)

action: prevent breakdown of acetylcholamine & ↑ its availability at cholinergic synapses

indications: modestly improves cognition, behavior, function; slows disease progress

S/E: N/V/D, insomnia, fatigue, muscle cramps, incontinence, bradycardia, syncope

notes:
➧1st line for Alzheimer's
➧Tacrine hepatotoxic; Donepezil better tol
➧Rivastigmine patch available

generic (trade): Memantine* (Namenda)

action: normalizes levels of glutamate (contributes to neurodegeneration when ↑)

indications: Tx of moderate to severe

S/E: dizziness, agitation, HA, constipation, confusion

notes:
➧2nd line for Alzheimer's
➧clearance reduced w/ renal impairment

generic (trade): Citalopram (Celexa); Escitalopram (Lexapro); Fluoxetine (Prozac); Paroxetine (Paxil); Sertraline (Zoloft)

action: blocks reuptake of serotonin, making more available & improving mood

indications: useful w/ depression, irritability, sleep disturbances, anxiety

S/E: agitation, insomnia, HA, N/V, sexual dysfun, hyponaturemia

notes: taper slowly d/t effects of d/c syndrome (dizziness, insomnia, nervousness, irritability, N, agitation) w/ abrupt WD

generic (trade): Lorazepam (Ativan); Oxazepam (Serax)

action: facilitates action of inhibitory neurotransmitter GABA

indications: anxiety, restlessness, verbally disruptive behavior, resistance

S/E: drowsiness, dizziness, HA; restlessness, insomnia, ↑anxiety possible

notes: use cautiously d/t risk for further memory impairment, sedation, falls

generic (trade): Aripiprazole (Abilify); Olanzapine (Zyprexa); Quetiapine (Seroquel); Risperidone (Risperdal); Ziprasidone (Geodon)

action: blockage of serotonin & dopamine receptors

indications: EXTREME CAUTION w/ paranoid thinking, hallucinations & agitation

S/E: many like EPS, TD, etc; wt gain, ↑gluc, hyperlipidemia

notes:

generic (trade): Carbamazepine (Tegretol); Divalproex (Depakote)

action: reduces excitability of neurotransmission

indications: agitated & aggressive behavior, emotional lability

S/E: ataxia, sedation, confusion, (rarely) bone marrow suppression

notes: monitor complete CBC & liver enzymes

Antianxiety agents
➧Benzodiazepines: Alprazolam (Xanax); Chlordiazepoxide (Librium); Clonazepam (Klonopin); Diazepam (Valium); Lorazepam (Ativan); Oxazepam (Serax)
➧Nonbenzodiazepines: Buspirone (BuSpar)

Antidepressants
➧SSRIs: Citalopram (Celexa); Escitalopram (Lexapro); Fluoxetine (Prozac); Fluoxamine (Luvox); Paroxetine (Paxil); Sertraline (Zoloft)
➧SNRIs: Duloxetine (Cymbalta); Venalafaxine (Effexor)
➧TCAs: Amtriptyline (Elavil); Clomipramine (Anafranil); Desipramine (Norpramin); Doxepin (Adapin, Sinequan); Imipramine (Tofranil); Nortriptyline (Aventyl, Pamelor)
➧MAOIs: Phenelzine (Nardil); Tranylcypromine (Parnate)

Other classes
➧Antihistamines: Hydroxyzine hydrochloride (Atarax); Hydroxyine pamoate (Vistaril)
➧Beta-blockers: Atenolol (Tenormin); Propranolol (Inderal)
➧Anticonvulsants: Carbamazepine (Tegretol); Gabapentin (Neurotin); Valporic acid (Depakote)

goal: decrease affective Sx of panic d/o & moderate to severe anxiety w/ psychopharmacology

SSRIs w/ lose starting dose: Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil)

TCAs RARE, but low starting dose: Clomipramine (Anafranil), Imipramine (Tofranil)

BuSpar w/ max dose in 4-6wks

if ADL severely impaired, benzos 1st line but must be d/c d/t tolerance

goal: decrease rate of obsessions & compulsions w/ psychopharm

SSRIs to max dose for min of 10-12wks: Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil)

TCAs to max dose: Clomipramine (Anafranil), Imipramine (Tofranil)

controlling emotional dysregulations:
➧atypical antipsychs
➧SSRIs
➧mood stabilizers

reducing impulsitivity: mood stabilizers

transiet psychosis episodes: antipsychotics

reducing self-injurious behavior
➧Naltrexone for dissociative Sx
➧atypical antipsychs

decreasing anxiety: Buspirone; careful use of benzos

goal: improve attention-span

antipsychotics:
➧for agitation, self-injurious behavior
➧Riserpidone (Risperdal): reduces hyperactivity, fidgetiness & labile affect
➧Olanzapine (Zyprexa): reduces hyperactivity, social WD, use of language & depression

Methylphenidate: inattn, impulsivity, overactivity

Opioid Antagonist:
➧Naltrexone: activity level, attn

Clonidine: fever, self-stimulation, irritability

SSRIs: compulsive behavior, WD, irritability

LiO3: mood liability

Beta-blockers: reduces anxiety

Buspirone & Trazodone: reduce anxiety & agitation

Antipsychotics:
➧Haloperidol (Haldol): reduces irritability & labile affect

Beta-blocker:
➧Propranolol (Inderal): reduces rage outbursts, aggression & severe anxiety

SSRIs:
➧Clomipramine (Anafranil): Tx anger & compulsive behavior

goal: reduce hyperactivity

<3yo: Destroamphetamine (Dexedrine)
>6yo: Methylphenidare (Ritalin); Pemoline (Cylert)

Stimulants: (improve ADHD Sx)
➧Methylphenidare (Ritalin); salts + L-amphetamine (Adderall); Destroamphetamine (Focalin); Pemoline (Cylert)

Antidepressants: (improve hyperactivity, attn & global funct)
➧Nortriptyline (Aventyl); Bupropion (Wellbutrin); Fluoxetine (Prozac);

α-adrenergic agonists:
➧Clonidine (Catapres): for aggressiveness, impulsivity & hyperactivity

Antipsychotics:
➧Risperidone: ↓aggression

Stimulants:
➧Methylphenidate: ↓antisocial behavior

Antidepressants:
➧Carbamazepine (Tegretol): & LiO3 ↓aggression

α-adrenergic agonists:
➧Clonidine (Catapres): for aggressiveness & disordered behaviors

Panic & Social Phobia:
➧SSRIs: Citalopram (Celexa), fluoxetine (Prozac), parozetine (Paxil)
➧TCAs: Imipramine (Tofranil)

OCD:
➧SSRIs: Fluoxetine (Prozac) & paroxetine (Paxil)
➧TCAs: Clomipramine (Anafranil)
➧Atypical antipsychs: Buspirone (BuSpar) as adjust to Tx of refractory OCD

Separation Anxiety D/O:
➧TCAs: Imipramine
➧SSRIs: Fluoxetine

Social Phobia:
➧TCAs: Imipramine
➧Anxiolytics: Buspirone

PTSD: atypical antipsychs like Risperidone to control flashbacks & aggression

MDD & Dysthymia:
➧SSRIs: Fluoxetine ↓depressive Sex
➧Atypical antidepressants: Nefazodone (Serzone)

Psychotic Sx:
➧antipsych: Quetiapine (Seroquel); Risperidone

Benzodiazepine

Beta-blockers: ↓cortisol in amygdala to ↓hyperarousal right after combat for veterns

Antidepressants (SSRIs)

Atypical antipychs

Benzodiazepines: more immediate Tx; for intrusive thoughts/nightmares

SSRIs

Mood stabilizers

Antipsychs: for intrusive thoughts/nightmares

Antianxiety agents (Benzodiazepines):
➧Lorazepam (Ativan): 1st line; caution w/ hepatic dysfun
➧Alprazolam (Xanax): paradoxical response w/ personality d/o & elderly
➧Diazepam (Valium): rapid onset of calming/sedating; long half-life; caution w/ elderly

Conventional Antipsychs
➧Haloperidol (Haldol): favorable S/E profile; d/t NMS risk, keep pt hydrated, check VS & test muscle rigidity
➧Chlorpromazine (Thorazine): very sedating; watch hypotension

Atypical Antipsychs
➧Risperidone (Risperdal): calms while Tx underlying conditions; watch for hypotension; ↑stroke risk in elderly
➧Olanzapine (Zyprexa): good for pts unresp to Haldol; clams while Tx underlying conditions; avoid w/ lorazepam; ↑stroke risk w/ elderly
➧Ziprasidone (Geodon): careful for QT prolongnation; less sedating

Combos
➧Haloperidol (Haldol), lorazepam (Ativan) & diphenhydramine (Benadryl) or benztropine (Cogentin): acute setting; young, athletic men at risk for dystonia; consider akathisia if agitation ↑
➧Perphenazine (Trilafon), lorazepam (Ativan) & diphenhydramine (Benadryl) or benztropine (Cogentin): consider this if pt already has difficulty taking Haldol