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Chapter 7 Psychiatric and Related Drugs © Paradigm Publishing, Inc. 1 Learning Objectives • Differentiate the antidepressant, antipsychotic, and antianxiety agents. • Be prepared to discuss the antidepressant classes, their uses, and their side effects. • Know why and how lithium and other drugs are used in treating bipolar disorders. • Be familiar with antipsychotics and the drugs that prevent their side effects. • Define anxiety, learn its symptoms, and know the drugs used in its treatment. • Recognize the course and treatment of panic disorders, insomnia and alcoholism. © Paradigm Publishing, Inc. 2 Depression and Mood Disorders • Clinical depression is the most severe psychiatric disorder • Women more likely than men to have depression • Depression occurs later in life in men © Paradigm Publishing, Inc. 3 Common Symptoms of Depression • Loss of interest in usual activities • Low self-esteem • Self-pity • Significant weight loss or gain • Insomnia or hypersomnia • Extreme restlessness • Loss of energy • Feelings of worthlessness • Diminished ability to think • Feelings of guilt • Recurrent thoughts of death • Suicide attempts © Paradigm Publishing, Inc. 4 Mood Disorders • Mania – Mood of extreme excitement, excessive elation, hyperactivity, agitation, and increased psychomotor activity • Bipolar disorder – Mood swings that alternate between major depression and mania © Paradigm Publishing, Inc. 5 Mood Disorders • Unipolar depression – Major depression with no previous occurrence of mania • Post-traumatic stress disorder (PTSD) – Disorder characterized by persistent agitation or persistent, recurrent fear after the end of a traumatic event and lasting for over a month or impairing work or relationships © Paradigm Publishing, Inc. 6 Mood Disorders • Seasonal affective disorder (SAD) – Form of depression that recurs in the fall and winter and remits in the spring and summer © Paradigm Publishing, Inc. 7 Discussion What are the differences that may be seen in patients with unipolar and bipolar disorders? Patients with unipolar disorder have depression symptoms. Patients with bipolar disorder have depression and mania symptoms. © Paradigm Publishing, Inc. 8 Neurotransmitters and Depression Therapy • Neurotransmitters – Chemicals produced by nerve cells – Involved in transmitting information in the body – Important in mood disorders and other mental disorders • Antidepressants change levels of two neurotransmitters: serotonin, norepinephrine © Paradigm Publishing, Inc. 9 Four Classes of Antidepressants • Selective serotonin reuptake inhibitor (SSRI) • Serotonin norepinephrine reuptake inhibitor (SNRI) • Tricyclic antidepressants (TCA) • Monoamine oxidase inhibitors (MAOIs) © Paradigm Publishing, Inc. 10 How Antidepressants Work • SSRIs block reuptake (reabsorption) of serotonin, little effect on norepinephrine • SNRIs increase both serotonin and norepinephrine • TCAs prevent reuptake of serotonin and/or norepinephrine • MAOIs inhibit enzymes that break down serotonin and norepinephrine © Paradigm Publishing, Inc. 11 Dispensing Issues of Antidepressants • Delay of onset 10 to 21 days • Never used on an “as needed” basis • Antidepressants are not controlled substances © Paradigm Publishing, Inc. 12 Dispensing Issues of Antidepressants Warning! • Antidepressants as a class must include a Medication Guide – Give to all patients with every dispensing – Pharmacy technicians make sure every antidepressant has Medication Guide attached © Paradigm Publishing, Inc. 13 Side Effects of Antidepressants • SSRIs and SNRIs safer than TCAs • Serotonin syndrome: combining antidepressants that increase serotonin levels with drugs that also stimulate serotonin levels. Can be fatal. – Could occur if patient is prescribed triptans (migraines) with antidepressants – Many people with migraines also depressed © Paradigm Publishing, Inc. 14 Dispensing Issues of Antidepressants Warning! • Technicians—be aware of serotonin syndrome. Will see warnings on computer • Technicians should notify pharmacist and prescriber if patient is prescribed drugs that could cause such interactions © Paradigm Publishing, Inc. 15 Drug List SSRIs and Related Drugs – citalopram (Celexa) – escitalopram (Lexapro) – fluoxetine (Prozac, Sarafem) – fluvoxamine (none) – paroxetine (Paxil) – sertraline (Zoloft) © Paradigm Publishing, Inc. 16 citalopram (Celexa) • Approved for depression and obsessivecompulsive disorder (OCD) • OCD: recurrent, persistent urges to perform repetitive acts, e.g. hand washing • Structurally different from other drugs in the class • Minimal drug interactions © Paradigm Publishing, Inc. 17 fluoxetine (Prozac) • Indicated for major depression and OCD • Anorexia possible adverse effect • Take in morning to avoid insomnia • Fluoxetine and white light for SAD © Paradigm Publishing, Inc. 18 escitalopram (Lexapro) • Similar to citalopram (Celexa) • More potent with fewer side effects © Paradigm Publishing, Inc. 19 paroxetine (Paxil) • Indicated for depression, obsessivecompulsive disorder, and panic disorder • Side effects: nausea, headache, ejaculatory disturbances, sweating © Paradigm Publishing, Inc. 20 sertraline (Zoloft) • Indicated for depression and obsessive-compulsive disorder • Nausea primary side effect • Also can cause drowsiness © Paradigm Publishing, Inc. 21 Dispensing Issues of Celexa Warning! • Often confused – Celexa – Cerebyx (seizures) – Celebrex (arthritis) © Paradigm Publishing, Inc. 22 Dispensing Issues of Prozac Warning! • Look-Alike – Prozac – Proscar (prostrate enlargement) © Paradigm Publishing, Inc. 23 Dispensing Issues of Paxil Warning! • Can be confused – Paxil – Pepcid (gastric acid reducer) • Same strengths • Brand names sound alike © Paradigm Publishing, Inc. 24 Dispensing Issues of Zoloft Warning! • Can be confused – Zoloft – Zocor (cholesterol reducer) © Paradigm Publishing, Inc. 25 Dispensing Issues of SSRIs Warning! • Do not discontinue abruptly • Alcohol consumption should be avoided while taking these medications © Paradigm Publishing, Inc. 26 SNRIs • Used when SSRIs are not effective • Affect both serotonin and norepinephrine reuptake • More effective for pain than drugs affecting one neurotransmitter © Paradigm Publishing, Inc. 27 Drug List SNRIs – duloxetine (Cymbalta) – venlafaxine (Effexor) – desvenlafaxine (Pristiq) © Paradigm Publishing, Inc. 28 duloxetine (Cymbalta) • Approved for major depression and pain associated with diabetic neuropathy • Potent serotonin and norepinephrine inhibitor, weak inhibitor of dopamine • More interactions than other drugs in class • Do not discontinue abruptly © Paradigm Publishing, Inc. 29 venlafaxine (Effexor) • Blocks reuptake of serotonin and norepinephrine – At lower dose affects serotonin – At higher dose also affects norepinephrine • Prescribed for depression • Adverse effects: sustained increase in blood pressure, may produce manic episodes © Paradigm Publishing, Inc. 30 desvenlafaxine (Pristiq) • Major metabolite of venlafaxine • Approved for depression and hot flashes – Only nonestrogenic drug available • Works same way as venlafaxine, but less side effects • Also used for fibromyalgia and neuropathic pain © Paradigm Publishing, Inc. 31 Cyclic Antidepressants • Two varieties – 3 fused carbon rings (tricyclic) – 4 fused carbon rings (tetracyclic) • Tricyclic antidepressants (TCAs) – Produce response in 50+% of patients – Also used in bed-wetting for children © Paradigm Publishing, Inc. 32 Drug List Tricyclic Antidepressants (TCAs) – amitriptyline (Elavil) – clomipramine (Anafranil) – desipramine (Norpramin) – doxepin (Sinequan, Zonalon) – imipramine (Tofranil) – nortriptyline (Aventyl, Pamelor) – protriptyline (Vivactil) – trimipramine (Surmontil) © Paradigm Publishing, Inc. 33 Drug List Tetracyclic Antidepressants – maprotiline (Ludiomil) – mirtazapine (Remeron) © Paradigm Publishing, Inc. 34 doxepin (Sinequan, Zonalon) • Tricyclic antidepressant (TCA) • Used to treat depression • Cream used for pruritus (itching) in adults, not more than 8 days • Oral liquid used by dentists for “burning mouth syndrome” © Paradigm Publishing, Inc. 35 Mirtazapine (Remeron) • Used to treat mild to severe depression, especially for patients who suffer from nausea • Blocks receptors that inhibit release of serotonin and norepinephrine • Some antianxiety effects © Paradigm Publishing, Inc. 36 Dispensing Issues of Cyclic Antidepressants Warning! • • • • Improvements usually 10 to 21 days Can be cardiotoxic in high doses May cause postural hypotension Do not discontinue abruptly © Paradigm Publishing, Inc. 37 Side Effects of Cyclic Antidepressants • Sedation is common, but tolerance usually occurs • Have many anticholinergic effects © Paradigm Publishing, Inc. 38 Monoamine Oxidase Inhibitors (MAOIs) • Second-line treatment because of many interactions with food and other drugs • Most beneficial in atypical depression • Currently used to treat conditions other than depression © Paradigm Publishing, Inc. 39 Drug List Monoamine Oxidase Inhibitors (MAOIs) – phenelzine (Nardil) – selegiline (Eldepryl, Emsam) – tranylcypromine (Parnate) © Paradigm Publishing, Inc. 40 Dispensing Issues of MAOIs Warning! • 2 weeks washout period before starting new class of antidepressant • Severe hypertensive reactions with food containing high level of tyramine – Aged cheeses, concentrated yeast extracts, pickled fish, sauerkraut, broad bean pods © Paradigm Publishing, Inc. 41 Drug List Other Antidepressant Drugs – bupropion (Wellbutrin, Zyban) – nefazodone (none) – trazodone (Desyrel) © Paradigm Publishing, Inc. 42 trazodone (Desyrel) • Prevents reuptake of serotonin and norepinephrine • Better side effect profile than TCAs • Ginkgo—possible interaction • Priapism © Paradigm Publishing, Inc. 43 bupropion (Wellbutrin, Zyban) • Dopamine-uptake inhibitor • Does not cause sedation, blood pressure changes, or ECG changes • Maximum daily dose of 450 mg • Approved aid to smoking cessation and SAD © Paradigm Publishing, Inc. 44 Dispensing Issues of Wellbutrin Warning! • Wellbutrin • Wellbutrin SR Three times a day dosing Twice a day dosing • Wellbutrin XL Once a day dosing © Paradigm Publishing, Inc. 45 Dispensing Issues of Wellbutrin Warning! Mistaking the dosing of Wellbutrin forms could lead to overdosing or underdosing © Paradigm Publishing, Inc. 46 Bipolar Disorders Mania Episodes • Decreased need for sleep • Distractibility • Elevated or irritable mood • Grandiose ideas • Increase in activity • Racing thoughts • Pressure to keep talking • Excessive involvement in pleasurable activities with large potential for painful consequences © Paradigm Publishing, Inc. 47 Bipolar Disorders Depressive Episodes • • • • • • Sadness, excessive crying Low energy Loss of pleasure Difficulty concentrating Irritability Thoughts of death or suicide © Paradigm Publishing, Inc. 48 Drug List Drugs to Treat Bipolar Disorders – carbamazepine (Epitol, Tegretol) – divalproex (Depakote) – lithium (Eskalith, Lithobid) – olanzapine-fluoxetine (Symbyax) – valproic acid (Depakene) © Paradigm Publishing, Inc. 49 lithium (Eskalith, Lithobid) • Drug of choice to treat – Bipolar disorder and acute mania – Prophylaxis of unipolar and bipolar disorders • Patients taking lithium must have frequent blood tests to assess lithium levels and maintain therapeutic range © Paradigm Publishing, Inc. 50 Dispensing Issues of Lithium Warning! • Lithobid tablets are effective only for 6 months • Highlight expiration dates on containers © Paradigm Publishing, Inc. 51 carbamazepine (Tegretol) or divalproex (Depakote) • For patients who cannot tolerate lithium, either drug can be substituted: • carbamazepine • divalproex © Paradigm Publishing, Inc. 52 Neurotransmitters in Schizophrenia • Dopamine and, to lesser degree, serotonin • Dopamine receptors in 4 pathways, including limbic system • Limbic system – Controls emotions – Psychotic experiences when dopamine levels are excessive © Paradigm Publishing, Inc. 53 Terms to Remember depression mania bipolar disorder unipolar depression post-traumatic stress disorder (PSTD) © Paradigm Publishing, Inc. 54 Terms to Remember seasonal affective disorder (SAD) neurotransmitter selective serotonin reuptake inhibitor (SSRI) serotonin norepinephrine reuptake inhibitor (SNRI) tricyclic antidepressant (TCA) © Paradigm Publishing, Inc. 55 Terms to Remember monoamine oxidase inhibitor (MAOI) serotonin syndrome obsessive-compulsive disorder (OCD) anorexia priapism © Paradigm Publishing, Inc. 56 Psychosis • Antipsychotics or neuroleptics • Schizophrenia is primary indication – – – – – – Retreat from reality Delusions Hallucinations Ambivalence Withdrawal Bizarre or regressive behavior © Paradigm Publishing, Inc. 57 Antipsychotics • Older or typical antipsychotics: many side effects, especially muscle control problems • New or atypical antipsychotics – Improved efficacy and reduced side effects – Limit dopamine-blocking ability to the limbic system pathway – First-line agents © Paradigm Publishing, Inc. 58 Antipsychotics • Help with thought disorders, hallucinations, and delusions • Do not help with emotional and social withdrawal, ambivalence, or poor self-care © Paradigm Publishing, Inc. 59 Drug List Antipsychotic Drugs – fluphenazine (Prolixin) – haloperidol (Haldol) – loxapine (Loxitane) – molindone (Moban) – perphenazine (Trilafon) © Paradigm Publishing, Inc. 60 Drug List Antipsychotic Drugs – prochlorperazine (Compazine) – thioridazine (ceiling dose, not exceed 800 mg/day) – thiothixene (Navane) – trifluoperazine (Stelazine) © Paradigm Publishing, Inc. 61 Side Effects of Antipsychotics • • • • • • Anticholinergic Cardiovascular Dermatologic Endocrine Hematologic Ophthalmologic • Withdrawal • Neurologic – Dystonia – Akathisia – Pseudoparkinsonism • Tardive dyskinesia © Paradigm Publishing, Inc. 62 Drug List Agents to Minimize Side Effects of Antipsychotics – benztropine (Cogentin) – diphenhydramine (Benadryl) – meclizine (Antivert) © Paradigm Publishing, Inc. 63 Atypical Antipsychotics • Improved efficacy and reduced side effects • Better tolerated, but associated with metabolic side effects – – – – Weight gain Hyperglycemia New-onset diabetes Dyslipidemia © Paradigm Publishing, Inc. 64 Drug List Atypical Antipsychotic Drugs – aripiprazole (Abilify) – clozapine (Clozaril) – olanzapine (Zyprexa) – paliperidone (Invega) – quetiapine (Seroquel) – risperidone (Risperdal) – ziprasidone (Geodon) © Paradigm Publishing, Inc. 65 aripiprazole (Abilify) • Improves dopamine activity • Low risk of motor and other side effects • Used mostly for bipolar disorder • Also approved for major depressive disorder © Paradigm Publishing, Inc. 66 clozapine (Clozaril) • Used to manage schizophrenic patients • Reduces white blood cells. Black Box warning. • Leukocyte counts – Should be taken weekly during therapy – Pharmacy documents results © Paradigm Publishing, Inc. 67 Dispensing Issues of clozapine (Clozaril) Warning! • Before dispensing, pharmacy must receive blood work reports • Pharmacy technician must document – White blood count (WBC) > 3500/mm3 – Absolute neutrophil count (ANC) > 2000/mm3 © Paradigm Publishing, Inc. 68 Dispensing Issues of clozapine (Clozaril) Warning! • Look-alike and sound-alike – Clozaril (antipsychotic) – Clinoril (sunlindac), rheumatoid arthritis © Paradigm Publishing, Inc. 69 olanzapine (Zyprexa) • Used for schizophrenia • Blocks dopamine and serotonin receptors • Fewer movement disorders and more effective than clozapine and risperidone • Avoid alcohol © Paradigm Publishing, Inc. 70 Dispensing Issues of olanzapine (Zyprexa) Warning! • Look-alike and sound-alike – Zyprexa (antipsychotic) – Zyrtec (antihistamine) © Paradigm Publishing, Inc. 71 paliperidone (Invega) • Used in treatment of schizophrenia • Few interactions with other drugs • Uses OROS (osmotic-controlled release oral delivery system) – Drug dissolves through pores in shell – When empty, ghost is excreted in stool • Side effect: orthostatic hypotension © Paradigm Publishing, Inc. 72 quetiapine (Seroquel) • Related to Clozaril • Lower incidence of hematologic toxicities © Paradigm Publishing, Inc. 73 risperidone (Risperdal) • Indicated for management of psychotic disorders and dementia in elderly • First drug approved for autism • Serotonin-dopamine antagonist © Paradigm Publishing, Inc. 74 ziprasidone (Geodon) • Used for schizophrenia • Causes less weight gain than other antipsychotic agents – Some patients quit taking antipsychotic agents if gain weight • May lead to arrhythmia and death © Paradigm Publishing, Inc. 75 Terms to Remember antipsychotic narcoleptic schizophrenia tardive dyskinesia osmotic-controlled release delivery system (OROS) ghost autism © Paradigm Publishing, Inc. 76 Anxiety • State of uneasiness characterized by apprehension and worry about possible events • Two types of anxiety – Exogenous: response to external stresses – Endogenous: not related to external stresses, result of abnormality in cellular function in CNS © Paradigm Publishing, Inc. 77 Antianxiety Agents • Also called sedatives • Include both noncontrolled and controlled substances • Benzodiazepines, buspirone, and to a lesser extent, beta blockers are most used for panic attacks © Paradigm Publishing, Inc. 78 Drug List Antianxiety Agents – amoxapine (none), TCA – buspirone (azapirone) (BuSpar) – hydroxyzine (Vistaril), antihistamine – meprobamate (Miltown) – paroxetine (Paxil), SSRI © Paradigm Publishing, Inc. 79 Drug List Antianxiety Agents – propranolol (Inderal), beta blocker – trifluoperazine (Stelazine), antipsychotic – venlafaxine (Effexor), SNRI © Paradigm Publishing, Inc. 80 Drug List Antianxiety Agents Benzodiazepines – alprazolam (Xanax) – chlordiazepoxide (Librium) – clorazepate (Tranxene) – diazepam (Valium) – lorazepam (Ativan) – oxazepam (Serax) © Paradigm Publishing, Inc. 81 Benzodiazepines • May cause physical or psychological dependence or both, C-IV • Should not be stopped abruptly • Side effects – Muscle relaxation – Paradoxical excitement – Sedation © Paradigm Publishing, Inc. 82 propranolol (Inderal) • Beta blocker used to treat physical symptoms of anxiety • Not officially indicated for this use • Reduces heart rate which decreases nervousness due to stage fright or test anxiety © Paradigm Publishing, Inc. 83 buspirone (Buspar) • Selectively antagonizes serotonin receptors • Take with food • Report changes in senses: hearing, smell, or taste • Also used for depression © Paradigm Publishing, Inc. 84 Dispensing Issues of buspirone (Buspar) Warning! • Look-alike and sound-alike: buspirone and bupropion – Buspirone, antidepressant/antianxiety – Bupropion, antidepressant © Paradigm Publishing, Inc. 85 Panic Disorders • Panic: form of intense, overwhelming, and uncontrollable anxiety • Neither a controllable voluntary emotion nor a condition that can be avoided by ignoring it or wishing it away © Paradigm Publishing, Inc. 86 Panic Disorders • Can occur anywhere at anytime • Criteria for diagnosis – Three attacks in a three-week period – At least four qualifying symptoms © Paradigm Publishing, Inc. 87 Pathophysiology of Panic Disorders • Result from neurochemical defect in part of the brain • Stimuli can be excessively amplified and cause an overreaction © Paradigm Publishing, Inc. 88 Treatment of Panic Disorders • Combination of antipanic medication and behavioral therapy • Psychotherapy preferred treatment when symptoms cause significant discomfort or impairment • Antianxiety medications indicated for short-term treatment © Paradigm Publishing, Inc. 89 Terms to Remember anxiety a state of uneasiness characterized by apprehension and worry about possible events exogenous anxiety anxiety caused by factors outside the organism © Paradigm Publishing, Inc. 90 Terms to Remember endogenous anxiety anxiety caused by factors within the organism panic intense, overwhelming, and uncontrollable anxiety © Paradigm Publishing, Inc. 91 Sleep and Sleep Disorders • Sleep is fundamental to human health • Four stages of sleep © Paradigm Publishing, Inc. 92 Four Stages of Sleep • Stage I. Somewhat aware of surroundings, relaxed, NREM • Stage II. Unaware of surroundings. Easily awakened, NREM • Stages III and IV. Increased autonomic activity, REM with dreams, 4 to 5 times a night © Paradigm Publishing, Inc. 93 Insomnia • Difficulty falling or staying asleep, or not feeling refreshed on awakening • Treated with hypnotics (drugs that induces sleep) • Chronic, occasional, or short-term insomnia • Transient insomnia not sleep disorder © Paradigm Publishing, Inc. 94 Causes of Some Sleep Disorders • Situational: job stress, hospitalization, travel • Medical: pain, respiratory or GI problems • Psychiatric: schizophrenia, depression, mania • Drug induced: alcohol, caffeine, sympathomimetic agents © Paradigm Publishing, Inc. 95 Treatment for Sleep Disorders • Diagnosis and effective treatment can often eliminate need for hypnotic drugs • For clearly defined insomnia, hypnotics used as an adjunct © Paradigm Publishing, Inc. 96 Narcolepsy • Recurring, inappropriate episodes of sleep during the daytime hours • No known cause • Occurs four times more in men than women © Paradigm Publishing, Inc. 97 Four Characteristics of Narcolepsy 1. Patient feels sleepy during daytime and immediately enters REM sleep 2. Patient experiences cataplexy with sudden emotions 3. Sleep paralysis 4. Very vivid hallucinations at the onset of sleep © Paradigm Publishing, Inc. 98 Treatment of Narcolepsy • Nondrug Therapy – Lifestyle changes • Drug Therapy – Stimulants – Tricyclic antidepressants – SSRIs © Paradigm Publishing, Inc. 99 Treatment of Sleep Disorders • Pharmacological: hypnotics • Nonpharmacological – – – – – – Normalizing sleep schedule Increase physical exercise Discontinue alcohol as a sedative Sleep only 7 to 8 hours in 24-hour period Reduce caffeine and nicotine intake Eliminate any drug that could lead to insomnia © Paradigm Publishing, Inc. 100 Sleep Agents • Should be used in conjunction with other medical therapeutics • Take 1 hour before bedtime • Take only a limited number of times each week • Duration of use: 4 to 6 week period © Paradigm Publishing, Inc. 101 Drug List Sleep Agents – alprazolam (Xanax) – chlordiazepoxide (Librium) – clorazepate (Tranxene) – diazepam (Valium) – estazolam (ProSom) – flurazepam (Dalmane) © Paradigm Publishing, Inc. 102 Drug List Sleep Agents – lorazepam (Ativan) – oxazepam (Serax) – quazepam (Doral) – temazepam (Restoril) – triazolam (Halcion) © Paradigm Publishing, Inc. 103 Drug List Sleep Agents Barbiturates – amobarbital (Amytal), C-II – butabarbital (Butisol), C-III – secobarbital (Seconal), C-II Antihistamines – diphenhydramine (Benadryl) – hydroxyzine (Vistaril) © Paradigm Publishing, Inc. 104 Antihistamines • Do not reduce REM sleep • Safest drugs to use in treating insomnia © Paradigm Publishing, Inc. 105 Drug List Sleep Agents Hypnotics – chloral hydrate (none) – ramelteon (Rozerem) © Paradigm Publishing, Inc. 106 chloral hydrate • Does not reduce REM sleep © Paradigm Publishing, Inc. 107 ramelteon (Rozerem) • Approved for sleep onset insomnia • Not a controlled substance because works in a different way than other hypnotics • Rapid onset, no next-day hangover © Paradigm Publishing, Inc. 108 Dispensing Issues of Rozerem Warning! • Look-alike – Rozerem – Razadyne (galantamine), Alzheimer disease © Paradigm Publishing, Inc. 109 Z Hypnotics • Preferred treatment of sleep disorders • No seizures if drug abruptly discontinued • Relatively short half-life • Do not significantly impact REM sleep © Paradigm Publishing, Inc. 110 Drug List Sleep Agents Z Hypnotics – eszopiclone (Lunesta) – zaleplon (Sonata) – zolpidem (Ambien) © Paradigm Publishing, Inc. 111 Side Effects of Z Hypnotics • Sleepwalking, eating, or driving (sleepdriving) with no recall of events • FDA looking at side effects and encouraging manufacturers to include in labelingA © Paradigm Publishing, Inc. 112 eszopiclone (Lunesta) • Approved for chronic insomnia • Causes an unpleasant taste, usually disappears after a couple of weeks • Take immediately before bedtime © Paradigm Publishing, Inc. 113 zaleplon (Sonata) • Shortest-acting hypnotic • Duration of action 4 hours • Can be taken in middle of night © Paradigm Publishing, Inc. 114 zolpidem (Ambien) • Schedule IV drug • Many of the same properties as benzodiazepines, but structurally different • Approved for long-term use • Prevents early awakening © Paradigm Publishing, Inc. 115 Dispensing Issues of zolpidem (Ambien) Warning! • Watch prescriptions—should not be used more than 10 days • Alert pharmacist, but may be exceptions © Paradigm Publishing, Inc. 116 Terms to Remember insomnia difficulty falling asleep or staying asleep or not feeling refreshed on awakening hypnotic a drug that induces sleep narcolepsy a sleep disorder involving recurring inappropriate attacks of sleep during the daytime hours © Paradigm Publishing, Inc. 117 Alcoholism • Disease can be arrested, not cured • Lifetime disease, potentially fatal • Can be controlled through behavioral changes • Complex genetic disease © Paradigm Publishing, Inc. 118 Effects of Alcoholism on Metabolism • Alcohol is an anesthetic and can cause loss of consciousness • Emetic action prevents death by preventing absorption of lethal concentrations • Alcoholics metabolize alcohol rapidly, which increases tolerance © Paradigm Publishing, Inc. 119 Side Effects of Alcoholism • • • • • Obesity with vitamin deficiency Gastritis and loss of appetite Organic brain damage Alcoholic psychosis and dementia Cirrhosis of the liver (irreversible damage) © Paradigm Publishing, Inc. 120 Symptoms of Dependence on Alcohol • Blackouts or lapses of memory • Concerns of family, friends, and employers about the drinking • Doing things that cause regret afterwards • Financial or legal problems from drinking • Loss of pleasure without alcohol © Paradigm Publishing, Inc. 121 Symptoms of Dependence on Alcohol • Neglecting responsibilities • Trying to cut down or quit drinking, but failing • Using alone; hiding evidence • Drinking to forget about problems • Willingness to do almost anything to get alcohol © Paradigm Publishing, Inc. 122 Four Steps Towards Recovery from Alcoholism 1. Acknowledge the problem 2. Limit time spent with substance abusers 3. Seek professional help 4. Seek support from recovering alcoholics © Paradigm Publishing, Inc. 123 Alcohol Withdrawal Symptoms • Agitation • Circulatory disturbances • Convulsions • Delirium treatments (DTs) • Digestive disorders • Disorientation • Extreme fear • Hallucinations • • • • Mental disturbances Nausea and vomiting Restlessness Sweating • Temporary REM sleep suppression • Tremor and weakness © Paradigm Publishing, Inc. 124 Drug List Alcohol Antagonists – acamprosate (Campral) – disulfiram (Antabuse) – naltrexone (ReVia, Vivitrol) – topiramate (Topamax) © Paradigm Publishing, Inc. 125 acamprosate (Campral) • Moderately successful in clinical trials • Combination of acamprosate and disulfiram (Antabuse) may work better than either drug alone • Take with food © Paradigm Publishing, Inc. 126 disulfiram (Antabuse) • Stops metabolism of alcohol • When alcohol ingested, these side effects – – – – – – Blurred vision Chest pain Confusion Difficulty breathing Face hot & scarlet Nausea – – – – – Severe headache Severe vomiting Throbbing in head Thirst Uneasiness © Paradigm Publishing, Inc. 127 disulfiram (Antabuse) • Patients must read labels to avoid alcohol in everyday products – Cough medicines – Mouthwashes – Flavorings – Salad dressings – Wine vinegars © Paradigm Publishing, Inc. 128 topiramate (Topamax) • Anticonvulsant that reduces cravings for alcohol • 6 weeks to be effective • Topamax with behavioral therapy promising in treating alcoholism • Must be taken daily, poor compliance © Paradigm Publishing, Inc. 129 Terms to Remember delirium tremens (DTs) a condition caused by cessation of alcohol consumption in which coarse, irregular tremors are accompanied by vivid hallucinations © Paradigm Publishing, Inc. 130 Assignments • Complete Chapter Review activities • Answer questions in Study Notes document • Study Partner – Quiz in review mode – Matching activities – Drug tables © Paradigm Publishing, Inc. 131