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SSRIs
MOA: inhibit serotonin reuptake
Therapeutic use: first line treatment for depression, panic disorders, trauma, and stressor related
disorders
Paroxetine (anxiety/trauma/stress disorders/PTSD)
Sertraline (anxiety/trauma/stress disorders)
Fluoxetine (depressive disorders)
Citalopram
Escitalopram
Fluvoxamine
May be taken with food
Take medication AM
Discontinue slowly over 1-2 months
SNRIs
Complications:
- Early AE: nausea, diaphoresis, tremor, fatigue, drowsiness - Later (after 5-6 weeks): sexual dysfunction, weight gain, headache - Weight changes (weight loss short term, gain long term) - GI bleeding - Hyponatremia (more likely in older adults) - Serotonin Syndrome: confusion, agitation, disorientation, seizures, tachycardia, diaphoresis, fever
leading to hyperpyrexia, incoordination, hyperreflexia
- Bruxism: grinding and clenching of teeth, usually during sleep: - Withdrawal: nausea, sensory disturbances, anxiety, tremor, malaise, unease
Contraindications/Precautions
- Paroxetine is a Pregnancy Risk Category D - Fluoxetine is Pregnancy Risk Category C - Contraindicated in clients taking MAOIs or TCAs - Liver and renal dysfunction, seizure disorders, history of GI bleeding - Caution with those who have bipolar disorder (d/t risk of mania)
Interactions:
- Concurrent use of TCAs, MOAIs, or St Johns wort can cause serotonin syndrome - Warfarin (monitor PT and INR levels) - Avoid lithium - Concurrent use of NSAIDS and anticoagulants
MOA: inhibit uptake of serotonin and norepinephrine
Therapeutic use: used for major depression, panic disorders, and generalized anxiety disorders.
Venlafaxine
Duloxetine
Desvenlafaxine
Levomilnacipran
Benzodiazepine Sedative Hypnotic Anxiolytics
Complications:
- Headache, nausea, agitation, anxiety, dry mouth, sleep disturbances - Hyponatremia (especially in older adults) - Anorexia - Hypertension - Sexual dysfunction
Contraindications/Precautions:
- Pregnancy category C - No MAOIs - Duloxetine should not be used in clients with hepatic disease or in
those who consume large amounts of alcohol
Interactions:
- Concurrent use of MAOIS and St. Johns wort can cause serotonin
syndrome
- CNS depression with alcohol, opioids, antihistamines - Concurrent use with NSAIDS and anticoagulants can further suppress
platelet aggregation, thereby, increasing the risk of bleeding
Atypical Anxiolytic
Therapeutic use: generalized anxiety disorder, long term
Buspirone
Not for PRN , scheduled only
Does NOT cause sedation, tolerance, dependence, or
withdrawal manifestations
Take with meals
Full effect: 2-4 weeks
TCAs
Therapeutic use: depressive disorder
Complications:
- CNS effects (dizziness, drowsiness, nausea,
headache, lightheadedness, agitation,
nervousness, sedation, excitement)
- Adverse Effects: xerostomia or dry mouth,
headache, nausea, insomnia
Contraindications/Precautions:
- Pregnancy Risk Category B - No breastfeeding - Liver or kidney dysfunction - Contraindicated for concurrent use with MAOI
antidepressant (or for 14 days after MAOIs are
discontinued. Hypertensive crisis can result)
Interactions:
- Erythromycin, ketoconazole, St. John’s wart, and
grapefruit juice can increase the effects of
buspirone
Other uses: neuropathic pain, fibromyalgia, anxiety, insomnia, bipolar disorder, OCD, ADHD
Amitriptyline
Imipramine
Clomipramine
o Adverse effects:
sedation, orthostatic
hypotension,
anticholinergic effects,
tachycardia, constipation
Doxepin
o Adverse Effects:
constipation,
tachycardia, drowsiness,
weight gain
Nortriptyline
Amoxapine
Trimipramine
Desipramine
o Adverse effect: sedation
NOTE: pseudoephedrine interacts with
TCAs and is contraindicated
MAOIs
Complications:
- Orthostatic hypotension
- Anticholinergic effects
o Urinary retention – report immediately
- Sedation
- Toxicity
- Decreased seizure threshold
- Excessive sweating
- Increased appetite
Contraindications/Precautions:
- Pregnancy Risk Category C
- Contraindicated for seizure disorders
- Caution: CAD, diabetes, liver, kidney, and respiratory
disorders, urinary retention, angle closure glaucoma, benign
prostatic hypertrophy and hyperthyroidism
Interactions:
- Concurrent use with MAOIS can cause severe hypertension
NaSSA
A norepinephrine and serotonin specific
antidepressant
Mirtazapine
Less sexual dysfunction than with SSRIs
Generally well tolerated
Beta Blockers
Decreases elevated vital signs and manifestations of anxiety, panic, hypervigilance, and insomnia
Propranolol
Centrally Acting Alpha Blockers
Can decrease manifestations of hypervigilance and insomnia
Prazosin
Centrally Acting Alpha 2 Agonist
Clonidine
o Expect a child to be drowsy while taking this medication
Other adverse effects: somnolence, fatigue, hypotension
o Can be administered with or without food
o Administer twice daily: morning and evening
o Swallow whole – no crushing, chewing, cutting
o May also treat heroin withdrawal
Adverse Effects:
- Sleepiness that can be exacerbated by other
CNS depressants, increased appetite and
weight gain, elevated cholesterol
to quit
with an
Monitor for hyponatremia
neurol
Mood Stabilizer
Therapeutic use: bipolar disorders,
schizophrenic disorders (Long term
treatment)
Lithium Carbonate
Therapeutic level: 0.6 - 1.
May reduce regression and decrease
impulsivity
Valproic acid can be administered safely with lithium
Hold the dose if patient reports nausea with frequent episodes of emesis
Complications:
- Headache, dry mouth, GI distress, increased HR, nausea,
restlessness, insomnia, dizziness
- Appetite suppression – weight loss
- Seizures at high doses
- Priapism can be a serious adverse effect of trazadone
Contraindications/Precautions:
- Bupropion is Pregnancy Risk Category B medication
- Contraindicated in seizure disorder
- Those taking MAOIs
- Bupropion is contraindicated for anorexia and bulimia
- Trazadone: caution in clients who have cardiac disease
Interactions:
- MAOIs
- Increased risk of seizures with concurrent use of SSRIs
Complications:
- GI distress: nausea, diarrhea, abdominal pain
o Administer with meals or milk
o Administer beta-blocker (propranolol)
o Use potassium sparing diuretic (spironolactone)
- Weight gain
- Renal toxicity
o Monitor BUN and creatinine
- Goiter and hypothyroidism, with long term treatment
o Obtain baseline T3 T4 and TSH levels
o Administer levothyroxine
- Bradydysrhythmias, hypotension, and electrolyte
imbalances
Contraindications/Precautions:
- Pregnancy Risk Category D
- Teratogenic especially in the first trimester of pregnancy
- Discourage breastfeeding
- Renal or cardiac disease, hypovolemia, schizophrenia
Interactions:
NSAIDS
2.0-2.5 (advanced
indication)
Extreme polyuria and dilute urine,
tinnitus, giddiness, jerking
movements, blurred vision, ataxia,
seizures, severe hypotension and
stupor leading to coma, possible
death from respiratory
complications
Administer an emetic to alter clients, or
administer gastric lavage
Urea, mannitol, or aminophylline may be
prescribed to increase the rate of
excretion
Greater than 2.
(severe toxicity)
Rapid progression of
manifestations leading to coma
and death
Hemodialysis can be warranted
Mood Stabilizing Antiepileptic Meds
Therapeutic use: prevent relapse of manic and depressive episodes,
particularly useful for clients who have mixed mania and rapid-cycling
bipolar disorders
Carbamazepine
Valproate
Lamotrigine
Valproic Acid
o Monitor liver function regularly
Topiramate
Oxcarbazepine
Contraindications:
- Pregnancy Risk Category D, they can result in birth defects
Carbamazepine:
- Minimal effect on cognitive function
- CNS effects: nystagmus, double vision, vertigo, staggering gait,
Antipsychotics (Overview)
Lurasidone
Olanzapine
Quetiapine
Aripiprazole
Risperidone
Asenapine
Cariprazine
Ziprasidone
Ziprasidone
Olanzapine
Aripiprazole
Lamotrigine:
- Double or blurred vision, dizziness,
headache, n/v
- Serious skin rashes (stevens-Johnson
syndrome)
- Slowly titrate
- Interactions: carbamazepine, phenytoin,
phenobarbital, oral contraceptives
Valproate:
ingestion
- Hepatotoxicity
- Pancreatitis
- Thrombocytopenia
- Tetra genesis
- Weight gain
- Monitor plasma levels
o therapeutic
Range: 50-
anticonvulsants
Are useful during acute mania with or
without valproate or lithium
Can be used long-term as prophylaxis
against mood episodes.
2nd
Generation Antipsychotics
Control positive and negative symptoms
First line treatment for schizophrenia
ALL second gen meds can cause diabetes, weight gain, and dyslipidemia
Risperidone
o Potential adverse effect: elevated blood glucose, dyslipidemia
Asenapine
o Sublingual tablets (DO NOT SWALLOW). Do not eat and drink for 10 minutes after
dosing.
o Adverse effects: drowsiness, prolonged QT interval, EPS for higher doses, temporary
numbing of mouth
Iloperidone
o Significant risk for weight gain, prolonged QT interval, and orthostatic hypotension
o Common adverse effects: dry mouth, sedation, fatigue, nasal congestion
Lurasidone
o approved for bipolar depression
o Low risk for weight gain, diabetes, and dyslipidemia
o No anticholinergic effects
o Administer with food (at least 350 calories)
o Common adverse effects: sedation, akathisia, parkinsonism, agitation and anxiety,
nausea
Paliperidone
Quetiapine
o Periodic glucose tests should be performed
Clozapine
o Adverse effects: agranulocytosis, constipation, high risk for weight gain, diabetes, and
dyslipidemia, sedation, orthostatic hypotension, hypersalivation, anticholinergic effects
o You should have your WBC checked once per week for six months (notify provider if
evidence of infection)
Olanzapine
o Adverse effect: Leukopenia and neutropenia, sedation, orthostatic hypotension,
anticholinergic effects
o low risk for EPS
o high risk of diabetes, weight gain, dyslipidemia
Ziprasidone
o Adverse effect: Leukopenia and neutropenia
2nd Generation Antipsychotics – Continued
Advantages:
- Decrease in affective findings (depression, anxiety) and suicidal behaviors
- Improvement of neurocognitive defects, such as poor memory
- Few or no EPS
- Fewer anticholinergic effects (with the exception of clozapine)
- Less relapse
o Dosing schedule for 2-3 times daily
o Sustained-release is taken 1-2 daily
Alcohol Withdrawal
Benzodiazepines (used first)
o Chlordiazepoxide
o Diazepam
minimize manifestations of withdrawal
Feelings of sedation should resolve in about 1 week (7-10 days)
o Lorazepam
For acute withdrawal
o Oxazepam
Adjunct Medications
o Carbamazepine (decrease in seizures)
o Clonidine
o Propranolol (decrease in craving)
o Atenolol (decrease in craving)
Alcohol Maintenance (following withdrawal)
Disulfiram
o Type of aversion (behavioral) therapy
o If used with alcohol/ any alcohol containing products–
acetaldehyde syndrome will occur
n/v, weakness, sweating, palpitations, hypotension.
Can progress to respiratory depression, seizures, and
death
this can occur two weeks even after stopping medication
ensure no alcohol intake for at least 12 hours prior to administration
o wear a medical alert bracelet
o administered as a deterrent to prevent future alcohol use
o NO pure vanilla extract
Naltrexone
o Suppresses the craving and pleasurable effects of alcohol
(also used for opioid withdrawal)
o Take with meals
o Can be given monthly via IM injections
Acamprosate
o Orally three times a day
o Diarrhea can result
o Avoid if pregnant
Opioids
Methadone
o Used for withdrawal and long-term maintenance for opioid
use disorder
o Prescribed as a substitute for opioids prior to detoxification
Clonidine
o Does not reduce the craving for opioids
o Avoid activities that require mental alertness until
drowsiness subsides
o Chew gum, etc. to prevent dry mouth
o Obtain baseline vitals
Buprenorphine
o Used for both withdrawal and maintenance
o Decreases feelings of craving
o Administer sublingually
Naltrexone
o Opioid antagonist that is used for the long-term
maintenance of opioid use disorder
o The usual medication of choice following detoxification
from opioids
Think: All Dads Need..
alcohol
(Acamprosate,
Disulfiram, Naltrexone)
o One spray in each nostril = amt in one cigarette
o NOT for client’s who have upper respiratory system disorders
o Contains menthol
Lozenges
o Avoid oral intake 15 minutes prior and during usage
o Allow to dissolve in the mouth (20-30 minutes)
o Limit use to 5 in a 6 hour period, MAX of 20/day
o Available in 2mg and 4mg strengths
Inhaler
Random
- Donepezil can improve cognitive function in the early stages of Alzheimer’s disease
o Administer the medication at bedtime to reduce the risk of injury due to bradycardia
and syncope
o Taking with NSAID increases the risk of GI bleeding
- Thioridazine hydrochloride
o Administer benztropine to reverse extrapyramidal effects of thioridazine
o Treats moderate to severe Alzheimer’s disease
