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AGENTS ACTING ON THE CENTRAL NERVOUS SYSTEM Liu Juntian (刘俊田) (Pharmacol Dept, Med School of XJTU) CHAPTER 13 General consideration 1.composition of nervous system (1)central and peripheral nervous systems (2)neuron and synapse* 2.function of CNS: regulating body functions. 3.activity of neuron(conduction of nervous impulse) (1) AP: sodium, calcium, kalium, chloride ion channel: voltage-gated, ligand-gated (2) neurotransmitter: ①NA, ACh, DA, GABA, glutamate, glycine, 5HT, histamine, opioid peptides, tachykinins (excitatory/ inhibitory). ②biosynthesis, storage, release, degradation, reuptake.* (3)receptor * (4)conduction of impulse cross synapse: presynaptic neuron release neurotransmitter synaptic cleft neurotransmitter interacts with receptor neurotransmitter-receptor complex initiates a sequence of events (open ion channel) modulate the electrical activity of the postsynaptic neuron (depolarization/ hyperpolarization). * 4.mechanism of drugs on CNS (1)axon: slow/block axonal electrical conduction e.g. antiepileptics anaesthetics (2)synapse: most drugs ①affect transmitter: synthesis, storage, release, reuptake. e.g. antidepressants ②affect receptor: activation/inhibition(block) e.g. benzodiazepines, antipsychotics ③directly act on ion channels e.g. phenytoin 5.BBB (1) structure barrier between blood and brain cell; 3 parts barrier between blood and cerebrospinal fluid barrier between brain cell and cerebrospinal fluid. endothelial cells (2)function: restrict passage of polar compounds and macromolecules from blood into brain (3)Pharmacological significance: prerequisite e.g. penicillin/SD----meningitis CHAPTER 14 Sedative-Hypnotics 【classification】 1. benzodiazepines. 2. barbiturates. 3.other agents: e.g. chloral hydrate. 【general use】 anxiety, insomnia, convulsion, epilepsy etc. Benzodiazepines 【classification】 1.short-acting triazolam (t1/2 2~4h) 2.intermediate-acting chlordiazepoxide (t1/2 5~10h) oxazepam (t1/2 5~10h) 3.long-acting diazepam (t1/2 30~60h) flurazepam (t1/2 50~100h) 【pharmacokinetics】 • Benzodiazepines are lipophilic and are rapidly and completely absorbed after oral administration and are distributed throughout body. • Most benzodiazepines are metabolized by hepatic microsomal metabolizing system to compounds that are also active. • The benzodiazepines are excreted in urine as glucuronides or oxidized metabolites. 【mechanism of action】 There are benzodiazepine receptors (BZR1, BZR2) in CNS, which are separate from but adjacent to receptor for GABAA. Benzodiazepines activate BZR promote GABA binding to GABAA receptors The binding opens Cl— channel Cl— influx to neurons The influx causes a small hyperpolarization inhibits formation of action potentials inhibitory effect on neuronal conduction.* 【pharmacologic effects and uses】 antianxiety small dose sedation hypnosis anticonvulsion respiratory depression large dose DOSE, ADMINISTRATION 【pharmacologic effects and therapeutic uses】 1. antianxiety (1) effect All sedative-hypnotic drugs are capable of relieving anxiety at sedative doses, but benzodiazepines exert antianxiety action at the lowest effective doses that do not cause sedation. (2) use anxiety states: restlessness worry stress phobia states common drug: chlordiazepoxide, diazepam P.O./small dose 2. sedation(calming effect) use: • general anaesthesis • tracheoscopy examination electric defibrillation (temporary loss of memory, i.v.) common drug: diazepam P.O. / i.v. /small dose 3. hypnosis (1) effect to reduce awaking times, to prolong sleep time to shorten sleep latency. (2) use insomnia, especially insomnia with anxiety common drug: flurazepam, temazepam, triazolam, P.O./middle dose 4. anticonvulsant effect (1) effect to inhibit development and spread of epileptiform activity in CNS. (2)use: convulsion and status epilepticus, injection/large dose. (3) common drug: ①clonazepam for chronic treatment of epilepsy; ②diazepam for terminating grand mal epileptic seizures and status epilepticus; ③chlordiazepoxide, clorazepate, diazepam and oxazepam for alcohol withdrawal. 5. muscle relaxation (1) effect inhibitory effects on polysynaptic reflexes and internuncial transmission in CNS, leading to muscle relaxation (2) use relaxing muscle spasm induced by cerebral palsy common drug: diazepam injection/large dose 【adverse effects】 Benzodiazepines have a low toxicity and wide margin of safety (therapeutic index). 1. central inhibitory effect dizziness, asthenia, drowsiness. 2. tolerance, dependence and addiction. 3. acute toxication flumazenil--competitively BZR blocker. Barbiturates 【history】 【classification】 1. ultra-short-acting thiopental (action of duration:0.25h) 2. short-acting secobarbital (action of duration:2~3h) 3.intermediate-acting pentobarbital and amobarbital (action of duration:3~6h) 4. long-acting phenobarbital (action of duration:6~8h) 【pharmacokinetics】 • Duration of action depends on rate of metabolic degradation, degree of lipid solubility, extent of binding to serum proteins. Ultra-short-acting barbiturates are highly lipid-soluble, whereas longacting barbiturates are lowly lipid-soluble. • redistribution: e.g. thiopental. • excretion via kidney. Alkalinization of urine profoundly promotes excretion of barbiturates. 【mechanism of action】 ①to enhance effects of GABA. ②to interfere with sodium and potassium transport across cell membrane that leads to inhibition of mesencephalic reticular activating system. ③to directly activate chloride channel, to prolong opening time of chloride channel, to increase influx of Cl- to enlarge membrane potential in large dose. 【pharmacologic effects】 1. to depress CNS at all levels sedation small dose hypnosis anticonvulsion anesthesia respiratory depression depression of vasomotor center large dose 2.to augment action of other CNS depressants 3.to shorten amount of time in REMS 4.induce hepatic microsomal drugmetabolizing enzymes clinical significance: (1) to increase degradation of the barbiturates, ultimately leading to barbiturate tolerance. (2)to increase inactivation and decreased action of other compounds in drug interaction. 【therapeutic uses】 DOSE, ADMINISTRATION 1.sedation and hypnosis: intermediate and long-acting barbiturates P.O. small dose disadvantages: ① narrow therapeutic-to-toxic dosage range; ② suppressing REMS; ③ tolerance ; ④ high potential for physical dependence and abuse ⑤ drug interaction secondary to microsomal enzyme induction. 2. Anticonvulsion phenobarbital, pentobarbital or amobarbital injection large dose 3. Antiepileptism phenobarbital for epileptism in infant and children injection large dose 4. intravenous anesthetics or intravenous adjunct to surgical anesthetics thiopental intravenous injection large dose 5.cerebral edema, cerebral infarction Barbiturates, especially in anesthetic doses, significantly decrease oxygen utilization by brain, which may be of value in lessening cerebral edema caused by surgery or trauma and in protecting against cerebral infarction duration cerebral ischemia. 6. Hyperbilirubinemia (jaundice) and kernicterus in the neonate. 【adverse effects】 1.CNS depressant effects • Oversedation • nightmare. 2. dependence: physiologic and psychological dependence. Withdrawal of barbiturates may result in grand mal seizures, severe tremors, vivid hallucinations, and psychoses. Abrupt withdrawal should be avoided. 3. acute barbiturate overdosage (1) clinical menifestations coma, diminished reflexes, severe respiratory depression, cardiovascular collapse, renal failure. (2) treatments ① supporting respiration and circulation; ② alkalizing gastric juice, body fluids and urine(sodium bicarbonate), ③ diuresis. Differentiation of barbiturates with benzodiazepines benzodiazepines barbiturates 1. antianxiety: dose lower than same dose as one for sedation. for sedation. 2. shortening REMS : weak obvious 3. central muscular have no 4. anaesthesis: no have 5. hepatic microno have some induction: 6. margin of safety: wide narrow 7. depression of weak strong respiration: Chloral hydrate 1. a relatively safe hypnotic drug, inducing sleep in a half hour and lasting about 6 hours. 2. relatvely small reduction in REM sleep. 3. use: children and the elderly with insomania, most effective for 1-3 nights. 4. bad-tasting and irritating to the gastrointestinal tract, administered by enema in children. 5. addiction can occur. Paraldehyde 1. CNS depressant activity of paraldehyde resembles that of alcohol, chloral hydrate and barbiturates. 2. use exclusively for patients undergoing withdrawal from alcohol and for patients with hepatic or renal failure. Summary for this chapter 1. main effects 2. main uses 3.main adverse reactions central inhibition dependence toxic effects 4.common drugs 5.dose and administration CHAPTER 15 Agents used in the treatment of seizures 1.etiology (1) primary epilepsy: inherited abnormality. (2) secondary epilepsy: such as brain tumors, head injury, hypoglycemia, meningeal infection, rapid withdrawal of alcohol from an alcoholic. 2.pathogenesis sudden, excessive and abnormal discharge of cerebral neurons which diffuses to local or whole brain in short time over-excitement. 3. clinic manifestation regional or whole brain dysfunction: • motor • vegetative and mental episodes • loss of consciousness etc. 4. classification (1)generalized ①grand mal epilepsy (tonic-clonic) epilepticism (status epilepticus) ②absence epilepsy(petit mal) ③ myoclonic epilepsy ④febrile seizures (2)Partial ①Simple partial ②Complex partial * 5.treatment (1) primary epilepsy antiepileptic drugs (2) secondary epilepsy antiepileptic drugs + against primary cause Mechanisms of action of drugs: • Inhibiting sodium influx • Potentiating GABA-neuronal function Phenytoin 【pharmacokinetics】 • high concentrations in brain, • high plasma albumin binding, • half-life: 24 hours. 【mechanism of action】 to decrease Na+ conductance in neurons to stabilize nervous cellular membranes to reduce the influx of calcium ions during depolarization suppresses highfrequency repetitive firing halts seizure activity. 【pharmacologic effects】 1.antiepileptic effect effective for tonic-clonic seizures 2. Anti-peripheral neuralgia 3. antiarrhythmia and partial 【therapeutic uses】 1. epilepsy. • highly effective for all partial seizures, tonic-clonic seizures and status epilepticus. • not effective for absence seizure. 2. peripheroneural pain. trigeminal neuralgia, glossopharyngeal neuralgia and sciatic neuralgia etc.. 3. arrhythmia (see antiarrhythmic drugs) 【adverse effects】 1. gastrointestinal irritation administration with or after meal. 2. depression of CNS 3. blood dyscrasias 4.cardiovascular collapse (arrhythmia, calcium antagonism) 5. gingival hyperplasia 6. hepatitis in the long administration 7. allergic reaction 8. fetal malformation 9. to induce the P-450 system Barbiturates 1.characteristics (1)mechanism of action is unknown but involves potentiation of inhibitory effects of GABA neurons. (2)dose required for antiepileptic action is lower than dose that causes pronounced CNS depression for the patient. More selectivity in anticonvulsant action than in sedative effect. 2.use (1) 50% effective rate for simple partial seizure. (2) not effective for complex partial seizure. (3) first-choice drug for epilepticism in infant and children. (4) effective for recurrent tonic-clonic seizures, especially in patients who do not respond to diazepam plus phenytoin. Benzodiazepines Intravenous diazepam is used for epilepticism in adults. Clonazepam is used for absence and myoclonic seizure in children. Carbamazepine 1.The actions and mechanism are similar to those of phenytoin. • highly effective for all partial seizure as first-choice drug, • highly effective for tonic-clonic seizures, • effective for trigeminal neuralgia etc.. 2.More adverse effects, especially serious liver toxicity. Ethosuximide 1.effective for absence seizure, no effective for other seizures. 2.more adverse effects. • Stevens- Johnson syndrome in sensitive individuals • Urticarria • leukopenia, aplastic anemia and thrombocytopenia Sodium valproate • most effective for myoclonic seizure to reduce incidence and severity of tonicclonic seizures, • effective for absence seizure but second choice because of its hepatotoxicity. Other new agents: gabapenitin in 1993 lamotrigine in 1994 tiagabine in 1998* Summary for this chapter 1. choice of drugs for different patterns of epilepsies 2. effects and uses of phenytoin CHAPTER 16 Anticonvulsant drugs 1. pathogenesis 2. anticonvulsant drugs • Barbiturates/ injection, large dose • Benzodiazepines / injection, large dose • chloral hydrate/ enema • magnesium sulfate injection etc. Magnesium sulfate 【pharmacologic effects】 ADMINISTRATION, DOSE 1.oral administration laxative effect and promoting bile excretion 2. injection administration (1)anticonvulsant • inhibiting CNS by Mg2+ (central mechanism) • relaxing skeletal muscle (peripheral mechanism) Ca2+ antagonism inhibiting ACh release (2)hypotensive: direct vasodilation 【therapeutic uses】 1. constipation, promoting excretion of toxic substances and parasites in the intestinal tract. P.O/ large dose 2. convulsion and hypertensive emergencies (crisis, encephalopathy): injection 【adverse effects】 • breathe inhibition and hypotention, even death. • calcium chloride or calcium gluconate should be administered. Summary for this chapter 1. drugs used for convulsion 2. effects, mechanism of action, and uses of magnesium sulfate CHAPTER 17 Agents Used in the Treatment of Parkinsonian Disorders 1.classification of Parkinsonian disorders Parkinsonian disease Parkinsonian syndrome 2.Pathogenesis nigra caudatum ○ ○ (D2R) DA Ach(MR) striatum (-) (+) motor neurons in anterior horn of spinal cord skeletal muscle contraction 3.Clinical menifestations tremor, muscular rigidity, bradykinesia etc. 4.therapy reestablish dopamine/ acetylcholine balance. (1) To increase function of dopaminergic neurons in nigrostriatum. (2) To decrease function of cholinergic neurons. Clinical effect: reliefing symptoms, not stoping progress 5. classification of drugs (1) dopaminomimetic • metabolite precursor: levodopa • decarboxylase inhibitor: carbidopa • DA receptor agonist: bromocriptine • MAO inhibitor: selegiline • COMT inhibitor: tocapone • drug releasing dopamine: amantadine (2) anticholinergic drug: trihexyphenidyl Levodopa (L-dopa) 【mechanism of action】 L-dopa is transformed to dopamine via dopa decarboxylase in brain and corrects dopamine deficiency in nigrostriatum.??? 【pharmacokinetics】 1. Dopamine does not cross BBB, thus L-dopa (precursor of dopamine) is given instead and is readily transported into CNS. 2.L-dopa is well absorbed from small intestine; however, 99% is rapidly decarboxylated in periphery, resulting in peripheral side effects. So, large dose of L-dopa is required.* 【pharmacologic effects】 1.Improvement of bradykinesia and rigidity is more rapid and complete than of tremor. 2. L-dopa is more effective for young and mild patients or early disease than old and severe patients. 3. L-dopa is ineffective for Parkinsonian syndrome induced by antipsychotic drug phenothiazides. 4. Tolerance to both beneficial and adverse effects from L-dopa occurs with time. Ldopa is more effective in the first 2-5 years of therapy. 【therapeutic uses】 • effective for Parkinsonian disease • effective for Parkinsonian syndrome caused by other causes except phenothiazides (1st choice) • combination of L-dopa with carbidopa 【adverse effects】 1.cardiovascular effects tachycardia, arrhythmias etc. 2.central nervous side effects vivid dream, delusion etc. mental disturbances. 3.gastrointestinal reaction: nausea, vomiting. 4.no Vit B6 during therapy. • • • • • Carbidopa inhibitor of dopa decarboxylase not penetrating BBB to reduce peripheral conversion of L-dopa to dopamine Use: in combination with L-dopa augmenting beneficial effects of L-dopa reducing dose and adverse effects of Ldopa. no use alone. Amantadine 1.history 2. action mechanisms • stimulating synthesis and release of dopamine from surviving dopaminergic nerve terminals • delaying its reuptake in nigrostriatum 3. effects • More effective than anticholinergic agents against rigidity and bradykinesia • Less effective than L-dopa in treatment of Parkinsonian disorders • No effective for tremor 4. uses • Alone for early Parkinsonian disease • Various Parkinsonian diseases in combination with L-dopa 5.adverse effects restlessness, agitation, confusion and hallucination. Trihexyphenidyl (Artane) 1.action mechanism blocking M receptors in CNS reducing function of cholinergic nerves in nigrostriatum restoring balance between dopaminergic and cholinergic neurons. 2.effect: • Less efficious than levodopa. • More effective on tremor, less effective on bradykinesia and rigidity. 3.use • alone for: mild patients patients of discontinuation of L-dopa due to adverse effects, Parkinsonian syndrome induced by phenothiazides • all Parkinsonian disorders in combination with Ldopa 4.side effects similar to those of atropine. scopolamine Summary for this chapter 1. mechanisms of action of all drugs. 2. characteristics of drugs. 3. uses of drugs. 4. main adverse reactions of L-dopa. 5. combination of drugs. CHAPTER 18 Agents used in the Treatment of Psychiatric Disorders 【classification】 1.antipsychotic agents phenothiazines 2.antimanic and antidepressive agents lithium carbonate,imipramine 3.antianxiety agents benzodiazepines I Antipsychotic Agents (antischizophrenic drugs, major tranquilizers, neuroleptic drugs) 1.use schizophrenia, manic states of other psychiatric disorders. 2.schizophrenia manifestation delusions, hallucinations, thinking or speech disturbances. 【classification of drug】 Based on the structure of the drug: 1.phenothiazines chlorpromazine, fluphenazine, promethazine, thioridazine etc. 2. benzisoxazoles: risperidone 3.dibenzodiazepines: clozapine 4.butyrophenones: haloperidol 5.thioxanthenes: thiothixene* 【pathogenesis of schizophrenia】 Relevance of pathogenesis of schizophrenia to dopaminergic nerve in CNS: Evidences 1.DA increases in the brain of the patient. 2.DR increases in the brain of the patient. 3.functions of dopaminergic neurons increase. 4.promotion of DA release induces episode of schizophrenia. 5.blocking DR inhibit episode of schizophrenia. Dopaminergic nervous pathway 1.limbic system- mesencephalic pathway emotion 2.cortico- mesencephalic pathway thinking and motion 3.nigrostriatum pathway motion 4.hypothalamo-hypophysis pathway endocrine 【mechanism of action】 antagonism of dopaminergic receptors (D2) in CNS. 1.to block dopamine receptors in limbic system -mesencephalic pathway to improve emotion 2.to block dopamine receptor in corticomesencephalic pathway to restore thinking and motion 3.to block dopamine receptor in nigrostriatum pathway to cause extrapyramidal symptoms 4.to bock dopamine receptor in hypothalamohypophysis pathway to cause endocrine dysfunction Phenothiazines 【classification】 Drug Major use Frequency of Adverse Effects orthostatic extrapyramidal hypotension symptoms chlorpromazine antipsychotic moderate moderate (wintermin) antiemetic clozapine antipsychotic low low anticholinergic antihistaminic thioridazine antipsychotic moderate low triflupromazine antipsychotic moderate high fluphenazine antipsychotic low high prochlorperazine antiemetic low low~moderate promethazine antihistaminic moderate low 【pharmacologic effects】 1.effects on CNS (1) antipsychotic effect (2) sedation and synergism with other CNS depressives (3) antiemetic effects (4) effects on temperature-regulating mechanisms 2.altering endocrine 3.peripheral effects 1.effects on CNS 1) antipsychotic effects (1) tranquilization: • to make animals docile and friendly, rapidly to control manic states of psychotic patients and make them quiet (calming effect) and peaceful; • to make patients feel indifferent, then induce sleep in few days. (2) intellect restoration, emotional quieting, reducing psychomotor excitement of the patient in few weeks. (3) to eliminate hallucination and illusion of the patient in few months. action mechanism blocking dopamine D2 receptor in limbic system- mesencephalic and corticomesencephalic pathways. 2) sedation and synergism with other CNS depressives (analgesics, sedative-hypnotics, anesthetics). 3) antiemetic effects: to block D2 receptors in medullary CTZ. In high doses, the agents may directly depress medullary vomiting center. 4)effect on temperature-regulating mechanism to inhibit temperature-regulating center in hypothalamus to induce poikilothermia (hypothermia, hyperthermia). 2.altering endocrine to depress hypothalamus by blocking dopamine receptors to induce endocrine alteration • lactation and gynecomastia, • abnormal pigmentation, • decrease of corticotropin release • decrease of secretion of pituitary growth hormone (for gigantism) • weight gain • increased appetite. 3. peripheral effects • orthostatic hypotension and miosis by αreceptor blocking; • blurred vision, constipation, dry mouth, decreased sweating, mydriasis and rarely urinary retention by blockade of M receptors. 【therapeutic uses】 1.psychotic disorders • mania, • paranoid states, • Schizophrenia • psychoses associated with chronic alcoholism (alcoholic hallucinosis). 2.most phenothiazines except thioridazine • effective for nausea and vomiting, • ineffective for vomiting induced by stimulating vestibules of ears (motion sickness). 3.artificial hibernation* 4.antipruritics: promethazine (H1 blocking). 5. intractable hiccup: chlorpromazine. Lyticcocktail and physical reduction of body temperature ↓ body temperature↓+ central depression(sleep) ↓ irritability to pathologic reaction↓; basal metabolism↓→ O2 consumption↓; vasodilation→to improve microcirculation ↓ to protect the important organs from damage to gain enough time for effective etiological treatment by other drugs. Artificial hibernation therapy can be used in serious patients with toxic infection, toxication and trauma etc. 【adverse effects】 1.general adverse effects central depression, M-receptor blockage 2.extrapyramidal effects manifestation: • Parkinsonian syndrome, • acute dystonic reaction (facial grimacing and torticollis) • tardive dyskinesia (sucking and macking of the lips and other involuntary facial movements). pathogenesis: blocking DR in the nigrostriatum. treatment: artane. 3. cardiovascular effects: orthostatic hypotension (NA), syncope and reflex tachycardia. 4. allergic reactions. Summary 1. blocking 3 types of receptors • DR • MR • αR 2. effect on 3 systems • CNS • endocrine system • Autonomic nervous system 3. 3 main clinical uses • psychotic disorders • nausea and vomiting, • artificial hibernation 4. 3 main adverse reactions • central depression • extrapyramidal effects • cardiovascular effects II Mood-Altering Drugs (Antimanic and Antidepressive Agents) Use: affective disorder(mania, depression) • Pathogenesis of depression is thought to be related to deficiency of monoamines such as 5HT and noradrenaline in certain key sites of brain. • Mania would be induced by an overproduction of these neurotransmitters. • All clinically useful antidepressant drugs directly or indirectly potentiate noradrenaline, dopamine, and/ or serotonin in brain. classification of depression: • major (endogenous) • reactive • bipolar(manic-depressive) Antimanic agents—lithium carbonate 【mechanism of action】 Mechanism of action is unknown. It is currently proposed that lithium acts by altering the cellular concentration of inositol triphosphate (IP3). 【therapeutic uses】 1.mania, manic episodes of bipolar disorder 2.useful in reducing the intensity of depression? 【adverse effects】 high toxic and low therapeutic index, to maintain serum concentration between 0.8 and 1.5mmol/L. toxic effects: ataxia,tremors,convulsion,anorexia, vomiting, diarrhea, excessive thirst and polyuria, somnolene, confusion and psychomotor disturbances, cardiovascular anomalies in the newborn, hypotension and cardiac arrhythmias. Chronic lithium use results in thyroid enlargement. Lithium toxication can usually be reversed by osmotic diuresis or, in more severe cases, by dialysis. Antidepressants agents 【classification】* 1. NA and 5-HT reuptake inhibitors (tricyclic or polycyclic antidepressants) imipramine, amitriptyline, desipramine, nortriptyline, doxepin, trimipramine. 2. MAO inhibitors (1) hydrazides: isocarboxazid, phenelzine (2) nonhydrazides: tranylcypromine 3.selective 5-HT reuptake inhibitors fluoxetine, sertraline, paroxetine, bupropion, venlafaxine etc. Tricyclic/ polycyclic antidepressants 【mechanism of action】 • to block NA and 5-HT reuptakes into the presynaptic neurons to increase NA and 5HT level in the synaptic cleft in CNS. • Monoamine receptor densities in the brain may change over 2 to 4 week with drug use and may be important in the onset of activity. 【pharmacokinetics】 • well absorbed upon oral administration, • widely distributed, • readily to penetrate into the CNS, • long half-life, • low and inconsistent bioavailability because of variable first pass metabolism in the liver. Therefore the patient response is used to adjust dose.The initial treatment period is typically 4 to 8 weeks.The dose can be gradually reduced unless relapse occurs. 【pharmacologic effects】 All tricyclic antidepressants have similar therapeutic efficacy. 1. effects on CNS 2.cardiovascular effects 3. effects on autonomic nervous system 1. effects on CNS (1)A nondepressed person experiences sleepiness after administration. In addition, anxiety and toxic anticholinergic effects may be experienced. (2)In depressed patient, tricyclic antidepressants elevate mood, improve mental alertness, increase physical activity and reduce morbid preoccupation. Onset of mood elevation is slow and requires 2 to 3 weeks after administration. Latency period can be as long as 4 weeks. (3)Tricyclic antidepressants can cause extrapyramidal symptoms and ataxia. High doses of tricyclic antidepressants are capable of producing seizures and coma. 2.cardiovascular effects orthostatic hypotension, arrhythmias, tachycardia, slow atrioventricular conduction. 3. effects on autonomic nervous system anticholinergic effect. 【therapeutic uses】 1. severe endogenous depression. 2. enuresis(bed-wetting): imipramine. 3. obsessive-compulsive neurosis accompanied by depression, and phobic anxiety syndromes, chronic pain, and neuralgia may respond to tricyclic agents. 【adverse effects】 Adverse effects of tricyclic anti-depressants resemble to phenothiazines. 1.peripheral effects anticholinergic actions 2.central effects ataxia, dizziness and muscle tremor; manic excitement and delirium can occur in the patients with bipolar illness. 3. cardiovascular effects cardiac arrhythmias and hypotension Differentiation of tricyclic antidepressants drug t1/2(h) inhibition of reuptake sedation anticholinergic of monoamines 5-HT NA imipramine 9~24 ++ ++ ++ ++ desipramine14~76 0 +++ + + amitriptyline17~40 +++ + +++ +++ doxepin 8~24 weak weak +++ +++ MAO inhibitors MAO inhibitors inhibit MAO activity to increase store of noradrenaline, serotonin and dopamine within the neuron. MAO inhibitors are indicated for depression patients who are unresponsive or allergic to tricyclic antidepressants or who experience strong anxiety. Selective 5-HT reuptake inhibitors* The selective 5-HT reuptake inhibitors specially inhibit serotonin reuptake. Compared with tricyclic antidepressants, these drugs cause fewer anticholinergic effects and lower cardiotoxicity. III Agents Used in the Treatment of Anxiety (anxiolytic drugs or minor tranquilizers) 1.anxiety: symptom, anxiety sydrome 2.use: anxiety or neurosis 3.characteristics • sedative • hypnotic properties • central skeletal muscle relaxant activity • habituation and physical dependence • lower incidence of adverse effects than the antipsychotic agents.*