carbidopa-levadopa (Sinemet)

class?

Carbidopa-levadopa (Sinemet)

MOA

• promote synthesis of dopamine
• levodopa is able to cross the blood-brain barrier
• the conversion of levodopa into dopamine helps to restore the balance between levodpa and ach

• patients will develop a tolerance
• with long-term use of levodopa the adverse effects may increase as the benefits decline
• this may be reversed with a brief interruption of treatment
• often after it is restarted, lower doses are needed
• MUST take place in the hospital where the pt is immobilized

carbidopa-levodopa (Sinment)

nursing considerations?

• N/V are common side effects
• best on empty stomach but can take with food if needed
• AVOID high protien d/t competition for absorption
• AVOID high B6 food
• May cause orthostatic hypotension
• monitor for effectiveness or toxicity (Extra Perennial Symptoms)
• DO NOT double dose or increase frequency
• take regularly, every day
• Dykinsesias
• Dysrhythmias-tachycardia, SVT
• psychosis
• monitor LFTs (may cause false positive urine ketones)

pramipexole (Mirapex)

class?

pramipexole (Mirapex)

MOA

pramipexole (Mirapex)

indications

pramipexole (Mirapex)

adverse effects

• Nausea
• dizziness
• drowsiness 
• insomina
• postural hypotension
• dyskinsesias
• EPS
• hallucinations
• sleep attacks

pramipexole (Mirapex)

nursing interventions?

• risk for falls-interventions at home
• can no longer drive
• hallucinations
• monitor for N/V, is it effecting their nutrition and weight?
• Renal function- may need to reduce dose
• Monitor for EPS symptoms

entacapone (Comtan)

class?

entacapone (Comtan)

indications

entacapone (Comtan)

MOA

entacapone (Comtan)

adverse effects

• dyskinesia
• Nausea
• diarrhea
• drowsiness
• dizziness
• hallucinations

entacapone (Comtan)

nursing interventions

• montior of EPS
• mental alterness
• caution driving until effects of drug noted
• postural hypotension

carbidopa- prevents it from being broken down in the periphery

COMT- inhibits the metabolism of levodopa

benzotropine (Cogentin)

class?

Cholinesterase inhibitors

drug names?

donepezil (Aricept) oral

rivastigmine (Exelon)- oral and patch

Cholinesterase inhibitors: donepezil (Aricept)

Cholinesterase inhibitors: donepezil (Aricept)

• prevents the breakdown of Ach
• enhances transmisson of central cholinergic neurons that have not yet been destroyed
• helps to slow progression of disease

Cholinesterase inhibitors donepezil (Aricept)

• Cholinergic side effects- drooling ect
• GI (n/v/d, decreased appetite) *biggest problem b/c they already forget to eat*
• dizziness
• headache
• bronchoconstriction

Cholinesterase inhibitors: donepezil (Aricept)

nursing implications

• monitor nutrition
• safety interventions
• may take weeks for effects to be evident
• montior for adverse effects

Cholinesterase inhibitors: donepezil (Aricept)

titration

• high doses create best effects AND the most side effects
• start low and tritate up slowly
• treatment can be indefiniete, side effects or poor effects are usual reasons to stop

memantien (Namenda)

class?

memantien (Namenda)

indications

memantien (Namenda)

why would you use these instead of cholinesterase inhibitors?

memantien (Namenda)

Adverse effects

• dizziness
• headache
• confusion
• constipations
• weight gain

memantien (Namenda)

MOA

phenytoin (Dilantin)

class?

phenytoin (Dilantin)

MOA

phenytoin (Dilantin)

nursing implications

• CAUTION!!!!!!! small increments of change can cause BIG adverse effects due to the liver's inability to metabolize the drug
• used to treat all types of seizures except absence seizures
• narrow therapeutic range (10-20 mcg/mL)
• at level 10-20 mcg/mL sedation and CNS effects are mild

phenytoin (Dilantin)

what are the signs of toxicity when therapeutic level goes above 20 mcg/mL?

• nystagmus
• sedation
• diplopia (double vision)
• ataxia (uncoordinated movement)
• cognitive impairment

phenytoin (Dilantin)

adverse effects

• gingival hyperplasia- swelling, tenderness, bleeding of the gums
• measles-like rash
• fetal hydantin syndrome
• cardiovascular dysrythmias (but can also be used to dysrhythmias
• hirsutism
• interference with vit D metabolism
• male sexual dysfunction
• red/brown urine- EDUCATE PTS

phenytoin (Dilantin)

drug interactions

• stimulates liver enzymes which can decrease effects of other drugs like :
• oral contraceptives
• warfarin
• glucocorticoids
• tegretol, phenobarbitol and ETOH can reduce dilantins plasma levels by accelerating its metabolism in the liver

phenytoin (Dilantin)

Nursing implications

• give PO doses with food to reduce GI upset
• BUT stagger dosing 2 hrs with enteral feeding
• DO NOT interchange chewable and capsules- NOT BIOEQUIVALANT
• may be given IV GO SLOW!!!!!!!! (50 mg/min)
• mix only with NS and flush well!!!! will crystallize with dextrose
• assess oral hygiene
• monitor drug level

carbamazepine (Tegretol)

uses

• epilepsy
• bipolar disorder
• trigeminal and glossopharyngeal neuralgias

carbamazepine (Tegretol)

adverse effects

• neurologic effects: nystagmus, ataxia
• hematologic effects: leukopenia, anemia, thrombocytopenia
• birth defects
• hypo-osmolarity- promotes ADH secretion (fluid overload)
• dermatologic effects

carbamazepine (Tegretol)

drug-drug effects 

• oral contraceptives and warfarin will increase metabolism of tegretol (see seziures start back up)
• phenytoin and phenobarbital increases metabolism of tegretol
• grapefruit juice- increases peak and trough levels by 40%

carbamazepine (Tegretol)

nursing implications

• monitor seizure activity and history
• monitor CBC, plt count, iron levels, LFTs BUN
• monitor therapeutic drug levels
• may take with food to decrease GI upset or at bedtime to decrease sedations effects
• may crush tablets unless XR formula
• do not mix liquid with other liquids
• teach regular dosing
• instruct pt to report fever, sore throat, mouth ulcers
• XR formula coating is not dissolved and may be seen in feces

valproic acid (Depakote)

uses

• seizure DO
• bipolar DO
• migranes

valproic acid (Depakote)

adverse effects

• GI effects
• hepatotoxicity- liver failure
• pancreatitis
• teratogenic effects

valproic acid (Depakote)

drug interactions

• phenobarbitol- decreases its metabolism so depakote will be high levels
• phenytoin- displaces from binding so depakote will be high levels

phenobarbitol

MOA

phenobarbitol

adverse effects

• lethargy
• depression
• drowsiness
• CNS effects
• learning impairment

phenobarbitol

major adverse effect?

typical antipsychotic agents

MOA

• conventional antipsychotic drugs block a variety of receptors within and outside the CNS
• Dopamine
• acetylcholine
• histamine
• nroepinephrine
• Block dopamine2

typical antipsychotic agents

uses

• schizophrenia
• Bipolar DO
• tourette's syndrome
• prevention of emesis
• other

typical antipsychotic agents

• extrapyramidal symptoms
• neuroleptic malignant syndrome
• anticholinergic effects
• orthostatic hypotension
• sedation
• neuroendocrine effects
• seizures
• sexual dysfunction
• dermatologic effects- photosensitivity
• severe dysrhythmias

• acute dystonia
• parkinsonism
• akathisia
• tardiva dyskinesia-irreversible

typical antipsychotic agents

• anticholinergic drugs: intensifies action
• avoid antihistimines and OTC sleep aids
• CNS depressants: intensifies CNS depression
• avoid alcohol, antihistimines, benzos, barbituates
• levodopa and direct-dopamine- receptor agonists: counteraction

typical antipsychotic agents

• very safe but do produce EPS s/s and CNS depression
• death by overdose is extremely rare
• treatment by IV fluids to suuport BP
• gastric lavage
• unable to treat with emetics d/t drug having antiemetic properties

chlorpromazine (thorazine)

uses

low-potency agent

• schizophrenia
• bipolar
• antiemetic
• hiccups

• PO, IM, IV, PR
• IM or IV plasma levels 10 x higher 
• excreted by kidneys as metabolites

• sedation
• ortho hypo
• anticholinergic
• gynecomastia
• menstral irregularities
• photosensitivity
• lowers seizure threshold

• assess mental status and psych s/s-document
• monitor BP laying/sitting/standing
• assess I&O and bowel function
• assess EPS/TD/neuroleptic malignant syndrome
• assess CBC, LFTs
• with food to decrease GI upset
• do NOT give SQ
• offer mouth care
• may cause false + or - pregancy tests

loxapine (Loxitane)

molindone (Moban)

perphenazine (Trilafon)

haloperidol (Haldol)

MOA

• blocks receptors - dopamine, ach, histamine, norepinephrine

• PO or IM, depot use
• hepatic metabolism
• renal excretion

• EARLY EPS potential
• slightly less anticholinergic effects and hypotension
• TD incidence same
• gynecomastia and menstral irregularities
• prolong QT interval

• long-acting, injectable formulations used for long-term maintenance therapy of schizophrenia
• 2-4 weeks

olanzapne (Zyprexa)

class?

olanzapne (Zyprexa)

MOA

olanzapne (Zyprexa)

uses

• schizophrenia
• acute bipolar DO

olanzapne (Zyprexa)

pharmacokinetics

olanzapne (Zyprexa)

adverse effects

• CNS-drowsiness, agitation, sedation
• EPS- TD, neuroleptic syndrome
• Weight gain
• development of diabetes/hyperglycemia

olanzapne (Zyprexa)

promoting adherence

• ensure med is taken
• encourage family to oversee med for outpts
• provide instructions
• must be taken on reg schedule
• inform about side effects
• they do not cause addiction
• establish a good therapeutic relationship
• IM depot prep for long-term therapy

tricyclic antidepressants: amitriptyline (Elavil)

drugs names?

tricyclic antidepressants: amitriptyline (Elavil)

MOA

tricyclic antidepressants: amitriptyline (Elavil)

uses

• depression
• bipolar disorder
• chronic pain (neuropathic pain)

tricyclic antidepressants: amitriptyline (Elavil)

pharmacokinetics

long half lives- 1-50 hours

highly protein bound 95%

tricyclic antidepressants: amitriptyline (Elavil)

adverse effects

• orthostatic hypotension
• sedation
• significant anticholinergic effects
• toxicity of Elavil- OD is lethal at 8x usual dose
• cardiotoxicity
• dysrhythmias
• confusions/hallucinations
• seizures: lower threshold
• coma

tricyclic antidepressants: amitriptyline (Elavil)

cautions

• extreme caution in elderly
• glaucoma
• constipation
• BPH- already have trouble emptying bladder and this causes significant anticholinergic effects
• DO NOT give with MAOI (severe hypertension!!!)
• do not stop abruptly to avoid withdrawal s/s

SSIR's

MOA

• selective inhibition of serotonin reuptake
• increases transmission at synapses
• NO effect on dopamine or NE
• no blocking of cholinergic, histamine or alpha1-adrenergic receptors
• CNS excitiation not sedation

• highly protein bound 94%
• excreted in the urine
• half life 2 days for drug (7 days for active metabolite)
• takes close to a month to plateau!!!

• Depression
• OCD
• PMDD

• sexual dysfunction 70%
• weight gain
• serotonin syndrome
• withdrawal syndrome- do not stop abruptly
• watch for hyponatremia in elderly 

• agitation or restlessness
• confusion
• increase HP/BP
• dialated pupils
• loss of muscle coordination of twitiching muscles
• heavy sweating
• diarrhea
• headache
• shivering
• goose bumps
• if severe: fever, seizures, irregular HR, coma

• MOAI
• warfarin
• TCA's
• lithium

MAOI

when would you use this?

MAOI

what types of food should be avoided?

MAOI

MOA

• mao-enzyme found in liver, intestinal wall and neuronal terminals
• converts monoamine neurotransmitters into inactive products
• increases norepinephrine and serotonin

bupropion (Wellbutrin)

class?

bupropion (Wellbutrin)

MOA

bupropion (Wellbutrin)

adverse effects

• seizures at higher doses
• agitation, headache, GI upset, dry mouth, constipation, insomnia, blurred vision, tachycardia

bupropion (Wellbutrin)

drug interactions

Lithium

class

lithium levels- MUST be below 1.5 mEg/L!!!!!!!!

monitor sodium levels as low NA increases lithium toxicity

• GI upset, increase tremor, confusion
• Ataxia, ECG changes, seizures, severe hypotension, coma, death

• N/V/D, thirst, polyuria, lethargy, slurred speech, muscle weakness, fine hand tremor
• renal toxicity
• thyroid changes goiter/hypothyroid
• not recommended in first trimester, enters breast milk readily

• diuretics
• NSAIDs
• anticholinergics
• dosing must be multiple doses a day (3-4 times) spaced evenly (pt must be able to maintain this schedule)

Benzodiazepines

drug names?

Benzodiazepines

action

Benzodiazepines

uses

• anxiety
• sleep aid
• muscle relaxation
• seizures
• adjuncts in anesthesia
• panic disorder

Benzodiazepines

pharmacokinetics

Benzodiazepines

adverse effects

• CNS depression
• anterograde amnesia
• paradoxical effects
• respiratory

Benzodiazepines

abuse potential

• is lower than barbiturates
• dose have tolerance and physical dependence effects
• will have withdrawal symptoms if been on it for a long time

Benzodiazepines

use in pregnancy/lactation

• cross placenta, teratogenic/congenital defects
• enters breast milk, increase risk of toxicity in infant

Benzodiazepines

drug interactions

Benzodiazepines

how to give IV

• valium- do not dilute! push 5mg/min
• ativan- dilute with equal amounts D5W or NS, push 2mg/min

Benzodiazepines

acute toxicity

• oral dose- rarely serious, causes excessive drowsiness, confusion, CV and resp effects uncommon
• IV toxicity: may cuase profound hypotension, CV and resp arrest 2% of cases

Benzodiazepines

overdose/toxicity treatment

• flumazenil (Romazicon)- competitive benzo receptor antagonist, reverses benzo effects
• Given IV slowly for 30 sec, may need repeat doses

• zolpidem (Ambien)
• zaleplon (Sonata)
• eszopiclone (Lunesta)

Barbiturates

uses

• powerful resp depressant!!!!!!!!
• fatal in overdose
• NEVER use as antanxiety in suicidal pts

Symptoms:

• resp depression
• coma
• pinpoint pupils

Treatment:

• removal of barbiturates from the body
• maintenance of an adequate oxygen supply to the brain

buspirone (BuSpar)

class?

buspirone (BuSpar)

used

• not a CNS depressant
• no sedation
• no abuse potential
• does not intensify CNS depressant effects