Transcript Adverse effects

Psych Mental Health Nursing
Must Know Drugs
Haldol (Haldoperidol)
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Class: High Potency Neuroleptic (butyrophenone)
Conventional Antipsychotic Agent
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Mechanism: Block receptors for dopamine, acetylcholine, histamine and norepinephrine.
Therapeutic effect from blocking D2 receptors in mesolimbic region.
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Therapeutic Use: Schizophrenia, Bipolar Disorder, Tourette’s Syndrome.
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Adverse effects: Extrapyramidal Symptoms (EPS)- Acute Dystonia, (oculogyric crisis, laryngeal
dystonia) Parkinsonism, Akathisia, Tardive Dyskinesia (TD), Neuroleptic Malignant Syndrome (NMS),
Anticholinergic effects, orthostatic hypotension, sedation, neuroendocrine effects, lowers seizure
threshold, sexual dysfunction, severe dysrhythmias from prolongation of QT interval.
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Interactions: Alcohol or other CNS depressants. Possible neurotoxicity with lithium. Caution with
drugs that prolong QT interval (ketoconazole, paroxetine). Monitor anticoagulants.
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Nursing Actions: Assess and monitor for EPS (AIMS - Assessment of Involuntary Movement Scale).
Monitor for EKG changes. Administer anticholinergic for treatment of EPS prn. Encourage sugarless
candy for dry mouth. Monitor for orthostatic hypotension.
Thorazine (Chlorpromazine)
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Class: Low
Potency Neuroleptic (phenothiazine)
Conventional Antipsychotic Agent
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Mechanism: Block receptors for dopamine, acetylcholine, histamine and norepinephrine. Therapeutic effect from
blocking D2 receptors in mesolimbic region.
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Therapeutic Use: Schizophrenia, Bipolar Disorder.
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Adverse effects: Extrapyramidal Symptoms (EPS)- Acute Dystonia, (oculogyric crisis, laryngeal dystonia)
Parkinsonism, Akathisia, Tardive Dyskinesia (TD), Neuroleptic Malignant Syndrome (NMS), Anticholinergic effects,
orthostatic hypotension, sedation, neuroendocrine effects, lowers seizure threshold, sexual dysfunction, severe
dysrhythmias from prolongation of QT interval. Photosensitivity.
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Interactions: Alcohol or other CNS depressants. Possible neurotoxicity with lithium. Caution with drugs that
prolong QT interval (ketoconazole, paroxetine). Monitor anticoagulants. Risk for Agranulocytosis – life
threatening.
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Nursing Actions: Assess and monitor for EPS – AIMS (Assessment of Involuntary Movement Scale). Monitor for
EKG changes. Administer anticholinergic for treatment of EPS prn. Encourage sugarless candy for dry mouth.
Monitor for orthostatic hypotension. Educate patient for need for sunscreen and sunglasses due to
photosensitivity. Monitor White Blood Cell Counts, and educate patient about signs of agranulocytosis: ie sore
throat and fever. Neuroloptic must be withdrawn if develops agranulocytosis.
Abilify (Aripiprazole)
Class: Atypical Antipsychotic (Thienobenzodiazepine)
Mechanism: (Dopamine system stabilizer) Blocks H1, 5HT2 and alpha1 receptors, mixed effects on
5HT1 and D2 receptors.
Therapeutic Use: Psychosis, Bipolar Disorder, adjunctive treatment for resistant depression
Adverse effects: Extrapyramidal symptoms (EPS) (less likely, but possible) Neuroleptic Malignant
Syndrome (NMS) – few cases reported. Anticholinergic effects, Orthostatic Hypotension, sedation,
neuroendocrine effects, lower seizure threshold. Most common include headache, anxiety, or agitation.
Interactions: Barbituates, carbamazepine, phenytoin or rifampin can decrease abilify levels.
Ketoconazole, itraconozole, fluconazole, erythromycin, quinidine, fluoxetine or paroxetine can increase
abilify levels.
Nursing Actions: Mental status assessment, assess for suicidality, educate and monitor adherence,
assess for orthostatic hypotension, Inform patient about risk for weight gain, monitor weight and
abdominal girth, reduce caloric intake in response to weight gain, educate patient about small potential
for sexual dysfunction. Assess for metabolic syndrome – monitor triglycerides, blood glucose and
cholesterol levels.
Geodon (Ziprasidone HCl)
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Class: Atypical Antipsychotic (Serotonin and Dopamine antagonist)
Mechanism: Blocks D2, 5-HT2, H1 and alpha-adrenergic receptors. Also blocks
reuptake of serotonin and norepinephrine.
Therapeutic Use: Treatment of Schizophrenia or other mood disorders.
Adverse effects: Prolongs Q-T interval, increases risk of torsades de pointes.
Sedation, orthostatic hypotension. Low risk of EPS, TD or NMS. Less risk of weight
gain than other atypicals, but still may contribute to weight gain and metabolic
syndrome. Increased risk of mortality with use in elderly with dementia.
Interactions: Do not combine with any other drugs that prolong QT interval –
(TCAs, Mellaril, several antidysrhythmic drugs, several antibiotics – clarithromycin,
moxiffloxacin, gatifloxacin, sparfloxacin.
Nursing Actions: Mental status assessment, assess for suicidality, educate and
monitor adherence, assess for orthostatic hypotension, Inform patient about risk
for weight gain, monitor weight and abdominal girth, reduce caloric intake in
response to weight gain, educate patient about small potential for sexual
dysfunction. Monitor for EKG changes. Monitor triglyceride, glucose and
cholesterol levels.
Invega (Paliperidone)
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Class: Atypical Antipsychotic (Benzisoxazole)
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Mechanism: Blocks D2, 5HT2, and alpha 2 adrenergic receptors. An extended release preparation
for once daily dosing.
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Therapeutic Use: Schizophrenia
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Adverse effects: Headache, somnolence, anxiety. Cardiac effects – may prolong QT interval. Lower
risk of EPS, TD or NMS. Orthostatic hypotension or syncope. Increased risk of death for use in
elderly with dementia. Monitor for metabolic syndrome.
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Interactions: Avoid alcohol, drugs that prolong QT interval, caution with other CNS drugs or drugs
that cause orthostatic hypotension. May be antagonized by carbamazepine. May antagonize
levodopa or other dopamine agonists.
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Nursing Actions: Mental status assessment, assess for suicidality, educate and monitor adherence,
assess for orthostatic hypotension, Inform patient about risk for weight gain, monitor weight,
reduce caloric intake in response to weight gain, educate patient about small potential for sexual
dysfunction. Monitor for EKG changes.
Fanapt (Piperidinyl-benzisoxasole)
• Class: Atypical Antipsychotic (Piperidinyl-benzisoxazole)
• Mechanism: Unknown. Theoretical - Blocks D2, 5HT2, and alpha 2
adrenergic receptors.
• Therapeutic Use: Schizophrenia in adults
• Adverse effects: May prolong QT interval. Increased mortality in elderly
with dementia. EPS, TD and NMS. Metabolic syndrome. Decreased
seizure threshold. Blood dyscrasias. Hyperprolactinemia. Dysphagia.
Suicide risk. Priaprism.
• Interactions: Do not combine with any other drugs that prolong QT
interval – (TCAs, Mellaril, several antidysrhythmic drugs, several antibiotics
– clarithromycin, moxiffloxacin, gatifloxacin, sparfloxacin. Use with
fluoxetine, paroxetine or ketoconazole can cause increased blood levels of
Fanapt.
• Nursing Actions: Monitor for EKG changes. Monitor CBC. Monitor for
metabolic syndrome, (cholesterol, triglycerides and glucose). Assess for
EPS.
Seroquel (Quitiapine)
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Class: Atypical Antipsychotic (Dibenzothiazepine)
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Mechanism: Blockade of 5-HT2 (Seratonin) receptors, and weak blockade of D2 (Dopamine)
receptors. Also blocks H1 (Histamine) receptors and alpha-adrenergic receptors.
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Therapeutic Use: Schizophrenia and Bipolar Disorder.
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Adverse effects: Sedation, orthostatic hypotension, weight gain. Metabolic syndrome. Low risk of
EPS. TD has not been reported, but theoretically is possible. Increase risk of Diabetes and
increased mortality in elderly with dementia has been reported. Lens changes and increased risk of
cataracts.
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Interactions: Metabolism of drug is increased by phenytoin, barbituates, carbamazepine or
rifampin. Inhibitors of CYP3A4 (Ketoconazole, itraconazole, fluconazole, erythromycin may increase
levels of quitiapine and pose risk of toxicity.
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Nursing Actions: Mental status assessment, assess for suicidality, educate and monitor adherence,
assess for orthostatic hypotension, Inform patient about risk for weight gain, monitor weight,
reduce caloric intake in response to weight gain, monitor blood glucose level. Educate patient
about small potential for sexual dysfunction.
Zyprexa (Olanzapine)
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Class: Atypical Antipsychotic (Thienobenzodiazepine)
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Mechanism: Blocks receptors for serotonin, dopamine, histamine, acetylcholine and
norepinephrine. Therapeutic effects from blocking 5HT2 and D2 receptors.
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Therapeutic Use: Schizophrenia and Bipolar Disorder. Adjunctive treatment of depression.
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Adverse effects: Weight gain and metabolic syndrome (increased cholesterol, triglycerides and risk
for diabetes). Lower risk of EPS, TD or NMS. Increase mortality in elderly with dementia.
Sedation, constipation and orthostatic hypotension are also possible.
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Interactions: Metabolism of drug is increased by phenytoin, barbituates, carbamazepine or
rifampin. Inhibitors of CYP3A4 (Ketoconazole, itraconazole, fluconazole, erythromycin may increase
levels of quitiapine and pose risk of toxicity. Alcohol or other centrally acting drugs may potentiate
effects.
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Nursing Actions: Mental status assessment, assess for suicidality, educate and monitor adherence,
assess for orthostatic hypotension, Inform patient about risk for weight gain, monitor weight,
reduce caloric intake in response to weight gain, monitor blood glucose level. Educate patient
about small potential for sexual dysfunction
Prozac (Fluoxetine)
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Class: SSRI Antidepressant (Selective Serotonin Reuptake Inhibitor)
Mechanism: Selective inhibition of serotonin reuptake, and intensifies
transmission at serotonergic synapses.
Therapeutic Use: Depression, Anxiety Disorders – OCD, Bulimia nervosa and
premenstrual dysphoric disorder.
Adverse effects: Sexual dysfunction, nausea, headache and nervousness or
insomnia. Weight gain. Serotonin syndrome – usually on initiation – altered
mental status, myoclonus, hyperreflexia, sweating, tremor and fever. Can cause
EPS – ie akathisia or restlessness. Bruxism – clenching or grinding teeth – can
cause dental problems. May impede platelet aggregation and increase risk of
bleeding. Can cause hyponatremia – especially in elderly. Diarrhea or excess
sweating may also occur.
Interactions: Stop MAOI 14 days before giving Prozac, and do not give MAOI for at
least 5 weeks following Prozac administration. Monitor response to Warfarin
closely. May increase plasma levels of TCAs or Lithium – use together with caution
Nursing Actions: Educate patient to taper dose before discontinuation. Educatie
patient to reduce dose / take drug holiday intermittently to treat sexual
dysfunction.
Cymbalta (Duloxetine)
• Class: S/NRI Antidepressant (Serotonin and Norepinephrine Reuptake
Inhibitor)
• Mechanism: Block neuronal reuptake of serotonin and norepinephrine
• Therapeutic Use: Major Depression, Anxiety Disorders, Pain management
• Adverse effects: Nausea, dry mouth, insomnia, somnolence, reduced
appetite, fatigue, increased sweating and blurred vision. May caused
small increase in BP in some. May impact liver – rare hepatotoxicity caution use with liver disease. Not recommended with renal insufficiency.
Not recommended during pregnancy or lactation.
• Interactions: Alcohol. Tryptophan, SSRIs, SNRIs, Thioridazine.
Potentiated by cimetidine, fluvoxamine or quinolones, also paroxetine,
fluoxetine, TCAs or phenothiazines. Caution with triptans, lithium,
traomadol, or St. John’s Wort. Increased bleeding risk with ASA,
anticoagulants or NSAIDs.
• Nursing Actions: Monitor BP prior to therapy, and periodically thereafter.
Monitor and assess for suicidal ideation.
Effexor (Venlafaxine)
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Class: S/NRI Antidepressant (Serotonin and Norepinephrine Reuptake Inhibitor)
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Mechanism: Block neuronal reuptake of serotonin and norepinephrine
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Therapeutic Use: Depression and Anxiety Disorders
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Adverse effects: Nausea, headache, anorexia, nervousness and insomnia. Abrupt
discontinuation can cause intense withdrawal syndrome. May cause dose
dependent diastolic hypertension. Sexual dysfunction. Caution use with heart
disease, renal or hepatic dysfunction.
Interactions: MAOI – must discontinue 14 days before starting. Avoid alcohol use.
Monitor for serotonin syndrome if used in combination with SSRIs. Caution use
with cimetidine, haldol, or diuretics.
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Nursing Actions: Warn patients not to stop abruptly. Montior BP before and
during therapy. Assess and monitor for suicidal ideation.
Amitriptyline (Elavil)
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Class: TCA – Tricyclic Antidepressant
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Mechanism: Block neuronal reuptake of norepinephrine and seratonin.
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Therapeutic Use: Depression. Off label use for pain management.
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Adverse effects: Sedation, orthostatic hypotension and anticholinergic effects.
May cause cardiac toxicity.
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Interactions: During or within 5 weeks of PROZAC. Hyperpyretic crisis, seizure and
death with MAOIs. Potentiates alcohol, barbituates and other CNS depressants.
Delerium with disulfiram. Paralytic ileus with anticholinergics.
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Nursing Actions: Assess and monitor for orthostatic hypotension. Monitor for EKG
changes. Educate patient about sedation – patient should not drive, etc.
Nardil (Phenelzine sulfate)
• Class: Monoamine oxidase inhibitor antidepressant (MAOI)
• Mechanism: Inhibits monoamine oxidase, which normally inhibits the
activity of epinephrine, norepinephrine, serotonin and dopamine, and
may help depression by increasing amount of norepinephrine and
serotonin thus available.
• Therapeutic Use: Depression. Due to potential for serious interactions
with food and other drugs, these drugs are usually reserved for patients
who have not responded to SSRIs or TCAs.
• Adverse effects: CNS stimulation may cause anxiety, dizziness, headache
or agitation. Orthostatic hypotension. Risk for Hypertensive Crisis from
Dietary Tyramine: headache, tachycardia, HTN, nausea and vomiting.
• Interactions: Foods containing tyramine, caffeine. Sympathomimetic
agents (ephedrine, amphetamine) and other antidepressants: TCAs and
SSRIs. Use with SSRIs also poses risk of serotonin syndrome as well as
hypertensive crisis. Alcohol or other CNS depressants – ie Demerol.
• Nursing Actions: Assess for suicidal ideation. Assess mental status. Teach
client about food and drug interactions, and educate to avoid foods
containing tyramines. Assess and educate for orthostatic hypotension.
Wellbutrin (Bupoprion HCL)
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Class: Atypical Antidepressant (Aminoketone)
Mechanism: Unknown. Theoretical blockade of dopamine uptake.
Therapeutic Use: Depression, smoking cessation.
Adverse effects: Agitation, headache, dry mouth, constipation,
weight loss, GI upset, dizziness, tremor, insomnia, blurred vision
and tachycardia. Does have risk for seizures, and is contraindicated
for use in individuals with history of head injury, seizure disorder,
bulima or anorexia nervosa.
• Interactions: MAOIs – must be discontinued at least 2 weeks prior
to initiation with bupropion. Caution use with other drugs that
lower seizure threshold. Use with alcohol, opiates or cocaine may
enhance these risks.
• Nursing Actions: Assess and monitor for suicidal ideation. Educate
patient about careful attention to dosing, increased amounts can
contribute to increased risk for seizures – patient should not double
dose.
Remeron (Mirtazapine)
• Class: (Other) (Tetracyclic) Antidepressant
• Mechanism: Blocks two serotonin receptors (5-HT2 and 5-HT3) as
well as histamine receptors.
• Therapeutic Use: Depression
• Adverse effects: Sedation and weight gain are most common.
Increased appetite, dizziness, nausea, dry mouth, edema, increase
cholesterol levels, rare agranulocytosis and neutropenia may occur.
Rare occurrences of NMS or serotonin syndrome. May lower
seizure threshold.
• Interactions: Sedation exacerbated by alcohol, benzodiazepine or
other CNS depressants. MAOIs.
• Nursing Actions: Educate patient about sedation, need for pm
dosing, avoid driving etc. Counsel patient regarding risk for
increased appetite and weight gain. Monitor cholesterol and CBCs.
Monitor for suicidal ideation.
Lithium Carbonate
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Class: Lithium salt; Mood Stabilizer
Mechanism: Specific mechanism unknown. Theoretical balancing of calcium or
sodium channels, and decreases sensitivity to neurotransmitters.
Therapeutic Use: Bipolar Disorder
Adverse effects: GI upset, nausea, diarrhea, anorexia, fatigue, muscle weakness,
polyuria, tremor, hypothyroidism, acne, thinning hair and teratogenesis. Toxicitynausea, vomiting, diarrhea, thirst, polyuria, lethargy, slurred speech, muscle
weakness, tremor, ataxia, confusion, ECG changes, could progress rapidly and lead
to death. Contraindicated with cardiac or renal disease.
Interactions: Diuretic use increases risk of lithium toxicity. NSAIDs can increase
lithium levels, and also contribute to toxicity. (Note: exception aspirin does not
increase Li levels) Anticholinergic drugs (antihistamines, phenothiazine
antipsychotics or TCAs) could cause urinary hesitancy.
Nursing Actions : Monitor blood levels - therapeutic levels – 0.8 – 1.2mEq/L. (.4
to 1.0 for maintenance, and 1-1.5 for acute mania) Assess and monitor for signs
of Lithium toxicity. TID dosing is required due to short half life, so ensure
adherence to dosing schedule. (BID dosing with extended release formulations –
ie Lithobid) Assess for suicidal ideation. Obtain baseline ECG and monitor
periodically for changes. Monitor thyroid and renal function via labs (TSH, T3, T4,
BUN, BMP and CBC). Overdose may be fatal, requires gastric lavage.
Depakote (Valproic Acid)
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Class: AED (Antiepileptic Drug) Mood Stabilizer
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Mechanism: Suppression of high-frequency neuronal firing through blockade of sodium channels.
Suppress Calcium influx through T-type calcium channels. Augment the inhibitory influence of
GABA
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Therapeutic Use: Seizure Disorders, Bipolar Disorder, Migraine.
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Adverse effects: Minimal sedation or cognitive impairment. Nausea, vomiting or indigestion
common, but transient. Rare hepatotoxicity or pancreatitis. Teratogenicity effects – Pregnancy risk
category D. Rash, weight gain, tremor and blood dyscrasias (thrombocytopenia or clotting
abnormalities).
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Interactions: Phenobarbital or Phenytoin levels may be increased and could lead to toxicity.
Monitor levels of Valproate with enzyme inducers – potentiated by ASA, levels reduced by
rifampin, phenytoin, phenobarbital, carbamazepine.
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Nursing Actions: Teach patients to watch for rare but serious symptoms of pancreatitis- (abdominal
pain, nausea, vomiting or anorexia). Monitor for suicidal ideation. Educate patient to avoid abrupt
cessation. Monitor platelets, bleeding time, CBC, Liver function tests. Educate females of
childbearing potential of risks to fetus. Monitor for therapeutic level: 50-100 mcg/ml.
Lamictal (Lamotrigine)
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Class: Antiepileptic Drug (AED). Mood Stabilizer
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Mechanism: Unknown. Theoretical - inhibits sodium channels, stabilizing
neuronal membranes and modulating GABA.
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Therapeutic Use: Seizure Disorder, Bipolar Disorder
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Adverse effects: Headache, dizziness or double vision. Rare –serious, life
threatening rash due to Stevens-Johnson syndrome).
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Interactions: Valproate (potentiates Lamictal). Lamictal levels decreased by
phenytoin, carbamazepine, phenobarbital or rifampin. Lamictal levels may be
decreased by oral contraceptives, and may interfere with contraceptive efficacy.
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Nursing Actions: Educate about risk for rash, and serious reaction which needs
immediate attention and discontinuation of medication. Medication must be
started at low dose and titrated slowly.
Busparone (Buspar)
• Class: Anti-Anxiety (Azaspirone)
• Mechanism: Binds with high affinity to receptors for serotonin and
with lower affinity to receptors for dopamine.
• Therapeutic Use: Anxiety Disorders
• Adverse effects: Dizziness, GI upset, headache, nausea.
• Interactions: Hypertensive crisis with MAOIs. Avoid alcohol or
large amounts of grapefruit juice. May potentiate haldol, valium,
nefazodone. Potentiated by CUP3A3 inhibitors, erythromycin or
ketoconazole. Antagonized by CYP3A4 inducers such as rifampin,
phenytoin, phenobarbital or cabamazepine.
• Nursing Actions: Educate patient regarding need for 1 – 2 weeks
for therapeutic effects. No evidence of tolerance, physical
dependence or withdrawal, so may be better choice than long term
use of benzodiazepines, or for individuals with chemical
dependency.
Vistaril (Hydroxyzine pamoate)
• Class: Antihistamine (anti-anxiety)
• Mechanism: H1 antagonist – block histamine receptors
• Therapeutic Use: Anxiety (also sedation)
• Adverse effects: anticholinergic side effects – blurred vision, dry
eyes, dry mouth, urinary hesitancy.
• Interactions: Alcohol and other CNS depressants potentiate effects.
• Nursing Actions: Educate patient about potential for sedation, ie to
avoid driving etc. , utilize pm dosing etc. Recommend sugarless
candy and frequent sips of fluid for dry mouth.
Zoloft (Sertraline)
• Class: SSRI (Selective Serotonin Reuptake Inhibitor)
• Mechanism: inhibits neurons from reuptaking serotonin, making more
available in synapse
• Therapeutic uses: Depression, Anxiety/OCD, PTSD, PMDD
• Adverse effects: H/A, sexual dys, weight gain, tremor, insomnia, agitation,
N/D, Serotonin syndrome (<72hrs), discontinuation syndrome.
• Interactions: MAOI
• Nsg Actions: Assess adverse effects, educate 2 weeks before begins
working; do not d/c suddenly
Ativan (Lorazepam)
• Class: benzodiazepine, anxiolytic (minor tranquilizers)
• Mechanism: makes GABA receptors more active, slowing neural
activity
• Therapeutic uses: anxiety, insomnia, seizures, ETOH withdrawal
• Adverse effects: CNS depression (sedation), anterograde amnesia
(blackout), Resp depression, abuse, paradoxical effects
• Interactions: other CNS depressants, esp opioids and ETOH
• Nsg Actions: assess, fall precautions, educate about interactions;
monitor resp if on other CNS depressants