Transcript Pharmacology - Pemberton Counseling

Pharmacology
Overview
Major Types
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Antidepressants
Mood Stabilizers
Anti Anxiety
ADHD
Anti psychotics
Antidepressants
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Major Groups
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Atypicals – unique properties
SSRI – most popular
SNRI – more effective/side effects
NRI - new
Cyclic – react with multiple sites
MAOI – high risk of hypertensive reaction
Antidepressants cont’
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Page 176 – Choice of antidepressant
Special Considerations - 177
Side effects
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Start low
Nausea – take with meal
Insomnia – take in morning
Anxiety – reduce caffeine
Sedation – take at night
Sexual – other medication
Dry mouth – gum, water
Am Psych Assoc
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Mood Stabilizers
The first-line pharmacological treatment for more severe manic or mixed episodes is
the initiation of either lithium plus an antipsychotic or valproate plus an antipsychotic
[I]. For less ill patients, monotherapy with lithium, valproate, or an antipsychotic
such as olanzapine may be sufficient [I]. Short-term adjunctive treatment with a
benzodiazepine may also be helpful [II]. For mixed episodes, valproate may be
preferred over lithium [II]. Atypical antipsychotics are preferred over typical
antipsychotics because of their more benign side effect profile [I], with most of the
evidence supporting the use of olanzapine or risperidone [II]. Alternatives include
carbamazepine or oxcarbazepine in lieu of lithium or valproate [II]. Antidepressants
should be tapered and discontinued if possible [I]. If psychosocial therapy
approaches are used, they should be combined with pharmacotherapy [I].
For patients who, despite receiving maintenance medication treatment, experience a
manic or mixed episode (i.e., a “breakthrough” episode), the first-line intervention
should be to optimize the medication dose [I]. Introduction or resumption of an
antipsychotic is sometimes necessary [II]. Severely ill or agitated patients may also
require short-term adjunctive treatment with a benzodiazepine [I].
When first-line medication treatment at optimal doses fails to control symptoms,
recommended treatment options include addition of another first-line medication
[I]. Alternative treatment options include adding carbamazepine or oxcarbazepine in
lieu of an additional first- line medication [II], adding an antipsychotic if not already
prescribed [I], or changing from one antipsychotic to another [III]. Clozapine may be
particularly effective in the treatment of refractory illness [II]. ECT may also be
considered for patients with severe or treatment-resistant mania or if preferred by
the patient in consultation with the psychiatrist [I]. In addition, ECT is a potential
treatment for patients experiencing mixed episodes or for patients experiencing
severe mania during pregnancy [II].
Manic or mixed episodes with psychotic features usually require treatment with an
antipsychotic medication [II].
Mood Stabilizers cont’
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Choices
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Lithium
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Anticonvulsants – Tegretol/Depakote
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Monitor
Side effects
Different side effects for each
New – Lamictal/Topamax – more research
Atypical Antipsychotics
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Frequently used, more research needed
Antianxiety Medications
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Barbiturates
Benzodiazepines
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Differences in pharmacodynamics
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Atypical Benzo’s
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Half-lives
Where metabolized
Ambien vs Sonata – sleep aids
Buspirone
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Not shown to be addictive
Antianxiety Medications cont’
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Antihistamines
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Not addictive – can build tolerance
Beta blockers
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Used as hypertensives
Interact with many other drugs
Assist in peripheral symptoms of anxiety
Antianxiety Medications cont’
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Other notes
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Withdrawal
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Worse with short half lives
Anxiety can return
Difficult to end treatment
Dependence
Types according to Dr. Amen
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Type 1: Classic ADD
Restlessness, hyperactivity, constant
motion, troubles sitting still, talkative,
impulsive behavior, lack of thinking ahead
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Type 2: Inattentive ADD
Short attention span (especially about
routine matters), distractibility,
disorganization, procrastination, poor
follow-through/task completion.
Types con’t
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Type 3: Overfocused ADD
Worrying, holds grudges, stuck on
thoughts, stuck on behaviors, addictive
behaviors, oppositional/argumentative.
Type 4: Limbic ADD
Sad, moody, irritable, negative thoughts,
low motivation, sleep/appetite problems,
social isolation, finds little pleasure.
Types con’t
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Type 5: Temporal Lobe ADD
Inattentive/spacey/confused, emotional
instability, memory problems, periodic intense
anxiety, periodic outbursts of aggressive
behavior seemingly triggered by small events or
intense angry criticisms directed at himself for
failures and frustrations, overly sensitive to
criticism and slights by others, frequent
headaches and/or stomachaches, learning
difficulties, and serious
misperceptions/distortions of people and
situations.
Types con’t
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Type 6: Ring of Fire ADD
A ring of overactivity in the brain scan
image which surrounds most of the brain
is the source of the name for this type of
ADD.
too many thoughts, very hyper behavior,
very hyper verbal expressiveness, a
hypersensitivity to light, sound, taste, or
touch.
Amen’s interventions
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Type 1: Classic ADD
Stimulant medication (Ritalin, Adderall,
etc.), a diet with more protein and less
carbohydrates, intense aerobic
exercise.
Type 2: Inattentive ADD
Stimulant medication, perhaps
stimulating antidepressants (Welbutrin,
for example), a diet with more protein
Amen’s interventions
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Type 3: Overfocused ADD
An antidepressant that has a dual focus on
two brain transmitters (seratonin and
dopamine) (Effexor, for example), and/or
an antidepressant that enhances seratonin
(Prozac, Zoloft, Paxil, or others, for
example). A stimulant medication may
need to be added. A diet with less protein
and increased complex carbohydrates will
help, along with intense aerobic exercise.
Amen’s interventions
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Type 4: Limbic ADD
An antidepressant that is also
stimulating (Effexor or Welbutrin, for
example), with a stimulant medication
could be added; a balanced diet, and
intense exercise.
Amen’s interventions
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Type 5: Temporal Lobe ADD
Anticonvulsant medication (Neurontin,
Depakote for example), a stimulant could be
added; a diet with more protein and less
simple carbohydrates.
Type 6: Ring of Fire ADD
Anticonvulsant medication (Neurontin,
Depakote for example, a stimulant
medication could be added; sometimes
some of the newer, different anti-psychotic
medications may help (Risperdal, or
Zyprexa); a diet with more protein and less
Types of Medications
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Methylphenidate
Dextroamphetamine
Atomoxetene
Dexmethylphenidate
Antidepressants
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SSRI’s
Tricyclics
Basic Elements of
Methylphenidate
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Known as: Ritalin, Ritalin SR, Ritalin LA,
Concerta, Metadate ER, Metadate CD,
Focalin
Pharmacology: It is a CNS stimulant, which
is chemically related to amphetamine
Preparations – 5, 10, 20 mg tabs; sustained
release 20 mg tabs; LA 20, 30, and 40 mg
capsules. The SR tablet should be
swallowed and not crushed or chewed.
Concerta comes in 18 and 36 mg extended
release tablets. Metadate CD 20 mg
capsules; Metadate ER 10 – and 20 – mg
Methylphenidate, cont’d
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Half-Life – 3-4 hours; 6-8 hours for
sustained release
It’s a schedule II controlled substance,
requiring a triplicate prescription
Pre-Drug Work-Up
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Blood pressure and general cardiac
status
baseline and periodic blood counts and
liver function tests
Weight and growth should be monitored
Methylphenidate, cont’d
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Adverse Drug Reactions
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Nervousness and insomnia; can be reduced by
decreasing dose.
Cardiovascular – Hypertension, tachycardia, and
arrhythmias.
CNS – Dizziness, euphoria, tremor, headache,
precipitation of tics and Tourette’s syndrome,
and rarely psychosis.
GI – Decreased appetite, weight loss.
Case reports of elevated liver enzymes and liver
failure.
Hematological –Leukopenia and anemia have
been reported
Dextroamphetamine
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Known as: Adderall, Adderall XR
Pharmacology:causes the release of
norepinepherine from neurons. At
higher doses, it will also cause
dopamine and serotonin release
Preparations – Adderall 5-, 7.5-, 10-,
12.5-, 15-, 20-, 30-mg tablets; Adderall
XR 5-, 10-, 15-, 20-, 25-, 30-mg
capsules.
Dextroamphetamine, cont’d
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Half-Life – 10-25 hours
It’s a schedule II controlled substance,
requiring a triplicate prescription
Pre-Drug Work-Up
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Blood pressure and general cardiac status
should be evaluated prior to initiating
dextroamphetamine.
Can precipitate tics
Contraindicated in in patients with hypertension,
hyperthyroidism, cardiac disease or glaucoma. It
is not recommended for psychotic patients ot
patients with a history of substance abuse.
Dextroamphetamine, cont’d
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Adverse Drug Reactions
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Side effects – most common side effects are
psychomotor agitation, insomnia, loss of
appetite, and dry mouth. Tolerance to loss of
appetite tends to develop. Effect on sleep can be
reduced by making sure no drug is given after
12 pm.
Cardiovascular – Palpitations, tachycardia,
increased blood pressure.
CNS – Dizziness, euphoria, tremor, precipitation
of tics, Tourette’s syndrome, and rarely,
psychosis.
Basic Elements of
Atomoxetene
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Known as: Strattera
Pharmacology:works via presynaptic
norepinepherine transporter inhibition
Preparations – 10, 18, 25, 40, and 60
mg capsules .
Atomoxetene, cont’d
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Half-Life – approximately 4 hours
Not a schedule II controlled substance
Clinical Guidelines –
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Dividing the dose may reduce some side effects
Dose reductions are necessary in presence of
moderate hepatic insufficiency
Atomoxetine should not be used within 2 weeks of
discontinuation of a MAO inhibitor.
Atomoxetine should be avoided inpatients with
narrow angle glaucoma and, it should be used with
caution in patients with tachycardia, hypertension, or
cardiovascular disease.
It can be discontinued without taper.
Pregnancy C category.
Atomoxetene, cont’d
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Adverse Drug Reactions
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Cardiovascular – increased blood
pressure and heart rate (similar to those
seen with conventional psychostimulant).
BI – Anorexia, weight loss, nausea,
abdominal pain.
Miscellaneous – Fatigue, dry mouth,
constipation, urinary hesitancy and
erectile dysfunction.
Dexmethylphenidate
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Known as: Focalin, Focalin XR
Pharmacology:causes the release of
dopamine from neurons. Is an isomer
of Ritalin.
Preparations – Focalin 2.5, 5 ,10-mg
tablets; Focalin XR 5-, 10-, 20-mg
capsules.
Dexmethylphenidate, cont’d
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Half-Life – 2.2 hours
It’s a schedule II controlled substance,
requiring a triplicate prescription
Pre-Drug Work-Up
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Blood pressure and general cardiac status
should be evaluated prior to initiating
Dexmethylphenidate.
Can precipitate tics
Contraindicated in in patients with hypertension,
hyperthyroidism, cardiac disease or glaucoma. It
is not recommended for psychotic patients or
patients with a history of substance abuse.
Dexmethylphenidate, cont’d
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Adverse Drug Reactions
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Side effects – most common side effects are
psychomotor agitation, insomnia, loss of
appetite, and dry mouth. Tolerance to loss of
appetite tends to develop. Effect on sleep can be
reduced by making sure no drug is given after
12 pm.
Cardiovascular – Palpitations, tachycardia,
increased blood pressure.
CNS – Dizziness, euphoria, tremor, precipitation
of tics, Tourette’s syndrome, and rarely,
psychosis.
Release Characteristics
Concerta
Metadate
CD
Ritalin LA
Immediate 22%
Release
30%
50%
Delayed
Release
70%
50%
Eurand
SODAS
78%
Technolog Oros
y
Other Medications
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Dexadrine
Cylert
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Since marketing in 1975, 13 cases of acute
hepatic failure have been reported to the FDA.
11 resulted in death or transplant.
Attenade
Paxil
Wellbutrin
Zoloft
Trileptal
Celexa/Lexapro
Effexor
When to use, when to change
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Side effects
Past history
Substance abuse
Efficacy
Onset time
Stimulant first line, Strattera second
Follow MD
Closing Thoughts
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Stimulants still first line defense
Look at choice of drug based upon
time of release
Be aware of study sponsor
Addictive nature
Subscribe to Medscape
Tools/Resources
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ADD/ADHD Behavior-Change
Resource Kit
Teenagers with ADD: A Parents’ Guide
www.myadhd.com
www.adhdhelp.com
www.amenclinic.com
ADDitude Magazine
References
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American Academy of Pediatrics. Diagnosis and evaluation of the child with attentiondeficit/hyperactivity disorder. Pediatrics. 2000;105:1158-1170.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. DSM-IV-TR.
In: Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence: Diagnostic Criteria for
Attention-Deficit/Hyperactivity Disorder. Washington, DC: American Psychiatric Association; 1994:9293.
National Institute of Mental Health. National Institutes of Health. Attention deficit hyperactivity disorder.
Available at: http://www.nimh.nih.gov/publicat/helpchild.cfm. Accessed April 19, 2002.
U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General.
Available at: http://www.surgeongeneral.gov/library/mentalhealth/chapter3/sec4.html. Accessed April
19, 2002.
Dulcan M. Practice parameters for the assessment and treatment of children, adolescents, and adults
with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 1997;369(suppl):8551215.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. DSM-IV-TR.
In: Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence: Diagnostic Criteria for
Attention-Deficit/Hyperactivity Disorder. Washington, DC: American Psychiatric Association; 1994:9293.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. DSM-IV-TR.
In: Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence: Diagnostic Criteria for
Attention-Deficit/Hyperactivity Disorder. Washington, DC: American Psychiatric Association; 1994:9293.
National Institute of Mental Health. National Institutes of Health. Attention deficit hyperactivity
disorder—questions and answers. Available at: http://www.nimh.nih.gov/publicat/adhdqa.cfm.
Accessed April 19, 2002.
National Institute of Mental Health. National Institutes of Health. Attention deficit hyperactivity
disorder—questions and answers. Available at: http://www.nimh.nih.gov/publicat/adhdqa.cfm.
Accessed April 19, 2002.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.
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