Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Pharmacology Overview Major Types Antidepressants Mood Stabilizers Anti Anxiety ADHD Anti psychotics Antidepressants Major Groups 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’ Page 176 – Choice of antidepressant Special Considerations - 177 Side effects 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 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’ Choices Lithium Anticonvulsants – Tegretol/Depakote Monitor Side effects Different side effects for each New – Lamictal/Topamax – more research Atypical Antipsychotics Frequently used, more research needed Antianxiety Medications Barbiturates Benzodiazepines Differences in pharmacodynamics Atypical Benzo’s Half-lives Where metabolized Ambien vs Sonata – sleep aids Buspirone Not shown to be addictive Antianxiety Medications cont’ Antihistamines Not addictive – can build tolerance Beta blockers Used as hypertensives Interact with many other drugs Assist in peripheral symptoms of anxiety Antianxiety Medications cont’ Other notes Withdrawal Worse with short half lives Anxiety can return Difficult to end treatment Dependence Types according to Dr. Amen Type 1: Classic ADD Restlessness, hyperactivity, constant motion, troubles sitting still, talkative, impulsive behavior, lack of thinking ahead . Type 2: Inattentive ADD Short attention span (especially about routine matters), distractibility, disorganization, procrastination, poor follow-through/task completion. Types con’t 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 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 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 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 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 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 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 Methylphenidate Dextroamphetamine Atomoxetene Dexmethylphenidate Antidepressants SSRI’s Tricyclics Basic Elements of Methylphenidate 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 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 Blood pressure and general cardiac status baseline and periodic blood counts and liver function tests Weight and growth should be monitored Methylphenidate, cont’d Adverse Drug Reactions 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 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 Half-Life – 10-25 hours It’s a schedule II controlled substance, requiring a triplicate prescription Pre-Drug Work-Up 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 Adverse Drug Reactions 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 Known as: Strattera Pharmacology:works via presynaptic norepinepherine transporter inhibition Preparations – 10, 18, 25, 40, and 60 mg capsules . Atomoxetene, cont’d Half-Life – approximately 4 hours Not a schedule II controlled substance Clinical Guidelines – 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 Adverse Drug Reactions 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 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 Half-Life – 2.2 hours It’s a schedule II controlled substance, requiring a triplicate prescription Pre-Drug Work-Up 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 Adverse Drug Reactions 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 Dexadrine Cylert 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 Side effects Past history Substance abuse Efficacy Onset time Stimulant first line, Strattera second Follow MD Closing Thoughts 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 ADD/ADHD Behavior-Change Resource Kit Teenagers with ADD: A Parents’ Guide www.myadhd.com www.adhdhelp.com www.amenclinic.com ADDitude Magazine References 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. www.pembertoncounseling.com