Pharm4e Chapter 07

(1)

Chapter 7

(2)

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© Paradigm Publishing, Inc.

Chapter 7 Topics

• Depression and Mood Disorders

• _Psychosis

• Anxiety

• Sleep and Sleep Disorders

(3)

Learning Objectives

• Differentiate the antidepressant,

antipsychotic, and antianxiety agents. • Be prepared to discuss the

antidepressant classes, their uses,

and their side effects.

(4)

© Paradigm Publishing, Inc. 4

Learning Objectives

• 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

(5)

Depression and Mood

Disorders

• Clinical depression is the most severe psychiatric disorder

• Women more likely than men to have depression

(6)

6

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

(7)

Mood Disorders

• Mania

– Mood of extreme excitement, excessive elation, hyperactivity, agitation, and

increased psychomotor activity

• Bipolar disorder

(8)

8

Mood Disorders

• Unipolar depression

– Major depression with no previous occurrence of mania

• Post-traumatic stress disorder (PTSD)

(9)

Mood Disorders

• Seasonal affective disorder (SAD)

(10)

Discussion

What are the differences that may be seen in patients with unipolar and

bipolar disorders?

(11)

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,

(12)

12

Four Classes of

Antidepressants

• Selective serotonin reuptake inhibitor (SSRI)

• Serotonin norepinephrine reuptake inhibitor (SNRI)

• Tricyclic antidepressants (TCA)

(13)

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

(14)

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Dispensing Issues of

Antidepressants

• Delay of onset 10 to 21 days

• Never used on an “as needed” basis • Antidepressants are not controlled

(15)

Dispensing Issues of

Antidepressants

• 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

(16)

16

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

(17)

Dispensing Issues of

Antidepressants

• 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

(18)

Drug List

SSRIs and Related Drugs

– citalopram (Celexa)

– escitalopram (Lexapro)

– fluoxetine (Prozac, Sarafem) – fluvoxamine (none)

(19)

citalopram (Celexa)

• Approved for depression and obsessive-compulsive disorder (OCD)

• OCD: recurrent, persistent urges to

perform repetitive acts, e.g. hand washing • Structurally different from other drugs in

the class

(20)

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fluoxetine (Prozac)

• Indicated for major depression and OCD

(21)

escitalopram (Lexapro)

• Similar to citalopram (Celexa)

(22)

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paroxetine (Paxil)

• Indicated for depression, obsessive-compulsive disorder, and panic

disorder

(23)

sertraline (Zoloft)

• Indicated for depression and obsessive-compulsive disorder • Nausea primary side effect

(24)

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Dispensing Issues of Celexa

• Often confused

– Celexa

– Cerebyx (seizures) – Celebrex (arthritis)

(25)

Dispensing Issues of Prozac

• Look-Alike

– Prozac

– Proscar (prostrate enlargement)

(26)

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Dispensing Issues of Paxil

• Can be confused

– Paxil

– Pepcid (gastric acid reducer)

• Same strengths

• Brand names sound alike

(27)

Dispensing Issues of Zoloft

• Can be confused

– Zoloft

– Zocor (cholesterol reducer)

(28)

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Dispensing Issues of SSRIs

• Do not discontinue abruptly

• Alcohol consumption should be avoided while taking these medications

(29)

SNRIs

• Used when SSRIs are not effective • Affect both serotonin and

norepinephrine reuptake

(30)

Drug List

SNRIs

– duloxetine (Cymbalta) – venlafaxine (Effexor)

(31)

duloxetine (Cymbalta)

• Approved for major depression and pain associated with diabetic neuropathy

• Potent serotonin and norepinephrine inhibitor, weak inhibitor of dopamine

(32)

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venlafaxine (Effexor)

• Blocks reuptake of serotonin and norepinephrine

– At lower dose affects serotonin

– At higher dose also affects norepinephrine

• Prescribed for depression

(33)

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

(34)

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Cyclic Antidepressants

• Two varieties

– 3 fused carbon rings (tricyclic) – 4 fused carbon rings (tetracyclic)

• Tricyclic antidepressants (TCAs)

– Produce response in 50+% of patients

(35)

Drug List

Tricyclic Antidepressants (TCAs)

– amitriptyline (Elavil)

– clomipramine (Anafranil) – desipramine (Norpramin)

– doxepin (Sinequan, Zonalon) – imipramine (Tofranil)

– nortriptyline (Aventyl, Pamelor) – protriptyline (Vivactil)

(36)

Drug List

Tetracyclic Antidepressants

(37)

doxepin (Sinequan, Zonalon)

• Tricyclic antidepressant (TCA) • Used to treat depression

• Cream used for pruritus (itching) in adults, not more than 8 days

(38)

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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

(39)

Dispensing Issues of Cyclic

Antidepressants

• Improvements usually 10 to 21 days • Can be cardiotoxic in high doses

• May cause postural hypotension • Do not discontinue abruptly

(40)

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Side Effects of Cyclic

Antidepressants

• Sedation is common, but

tolerance usually occurs

• Have many

(41)

Discussion

Why would cyclic antidepressants

be prescribed for bed wetting in

children?

(42)

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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

(43)

Drug List

Monoamine Oxidase Inhibitors (MAOIs)

– phenelzine (Nardil)

(44)

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Dispensing Issues of MAOIs

• 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

(45)

Drug List

Other Antidepressant Drugs

– bupropion (Wellbutrin, Zyban) – nefazodone (none)

(46)

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trazodone (Desyrel)

• Prevents reuptake of serotonin and norepinephrine • Better side effect

profile than TCAs • Ginkgo—possible

(47)

bupropion (Wellbutrin,

Zyban)

• Dopamine-uptake inhibitor

• Does not cause sedation, blood

pressure changes, or ECG changes • Maximum daily dose of 450 mg

(48)

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Dispensing Issues of

Wellbutrin

Warning!

• Wellbutrin Three times a day

dosing

• Wellbutrin SR Twice a day dosing

(49)

Dispensing Issues of

Wellbutrin

Warning!

Mistaking the dosing of

(50)

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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

(51)

Bipolar Disorders Depressive

Episodes

• Sadness, excessive crying • Low energy

• Loss of pleasure

• Difficulty concentrating • Irritability

(52)

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Discussion

What is the drug of choice for

treating bipolar disorders?

(53)

Discussion

What is the two-fold objective of

drug therapy for bipolar disorder?

The two objectives are to treat

acute episodes and prevent

(54)

Drug List

Drugs to Treat Bipolar Disorders

– carbamazepine (Epitol, Tegretol) – divalproex (Depakote)

– lithium (Eskalith, Lithobid)

(55)

lithium (Eskalith, Lithobid)

• Drug of choice to treat

– Bipolar disorder and acute mania – Prophylaxis of unipolar and bipolar

disorders

• Patients taking lithium must have

(56)

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Dispensing Issues of Lithium

• Lithobid tablets are effective only for 6 months

• Highlight expiration dates on containers

(57)

carbamazepine (Tegretol) or

divalproex (Depakote)

• For patients who cannot tolerate lithium, either drug can be

substituted:

(58)

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Neurotransmitters in

Schizophrenia

• Dopamine and, to lesser degree, serotonin • Dopamine receptors in 4 pathways,

including limbic system • Limbic system

– Controls emotions

(59)

Terms to Remember

depression

mania

bipolar disorder

unipolar depression

(60)

Terms to Remember

seasonal affective disorder (SAD) neurotransmitter

selective serotonin reuptake inhibitor (SSRI)

serotonin norepinephrine reuptake inhibitor (SNRI)

(61)

Terms to Remember

monoamine oxidase inhibitor (MAOI) serotonin syndrome

obsessive-compulsive disorder (OCD)

(62)

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Psychosis

• Antipsychotics or neuroleptics

• Schizophrenia is primary indication

– Retreat from reality – Delusions

– Hallucinations – Ambivalence – Withdrawal

(63)

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

(64)

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Antipsychotics

• Help with thought disorders, hallucinations, and delusions

• Do not help with emotional and social withdrawal, ambivalence, or poor

(65)

Drug List

Antipsychotic Drugs

– fluphenazine (Prolixin) – haloperidol (Haldol)

– loxapine (Loxitane) – molindone (Moban)

(66)

Drug List

Antipsychotic Drugs

– prochlorperazine (Compazine)

– thioridazine (ceiling dose, not exceed 800 mg/day)

– thiothixene (Navane)

(67)

Side Effects of

Antipsychotics

• Anticholinergic • Cardiovascular • Dermatologic • Endocrine • Hematologic • Ophthalmologic • Withdrawal • Neurologic – Dystonia – Akathisia – Pseudoparkinsonism

(68)

Drug List

Agents to Minimize Side Effects of Antipsychotics

– benztropine (Cogentin)

(69)

Atypical Antipsychotics

• Improved efficacy and reduced side effects • Better tolerated, but associated with

metabolic side effects

– Weight gain – Hyperglycemia

(70)

Drug List

Atypical Antipsychotic Drugs

(71)

aripiprazole (Abilify)

• Improves dopamine activity

• Low risk of motor and other side effects

• Used mostly for bipolar disorder

(72)

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clozapine (Clozaril)

• Used to manage schizophrenic patients

• Reduces white blood cells. Black Box warning.

• Leukocyte counts

(73)

Dispensing Issues of

clozapine (Clozaril)

• Before dispensing, pharmacy must receive blood work reports

• Pharmacy technician must document

– White blood count (WBC) > 3500/mm3

– Absolute neutrophil count (ANC) > 2000/mm

(74)

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Dispensing Issues of

clozapine (Clozaril)

• Look-alike and sound-alike

– Clozaril (antipsychotic)

– Clinoril (sunlindac), rheumatoid arthritis

(75)

olanzapine (Zyprexa)

• Used for schizophrenia

• Blocks dopamine and serotonin receptors • Fewer movement disorders and more

(76)

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Dispensing Issues of

olanzapine (Zyprexa)

• Look-alike and sound-alike

– Zyprexa (antipsychotic) – Zyrtec (antihistamine)

(77)

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

(78)

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quetiapine (Seroquel)

• Related to Clozaril

(79)

risperidone (Risperdal)

• Indicated for management of

psychotic disorders and dementia in elderly

(80)

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ziprasidone (Geodon)

• Used for schizophrenia

• Causes less weight gain than other antipsychotic agents

– Some patients quit taking antipsychotic agents if gain weight

(81)

Terms to Remember

antipsychotic narcoleptic

schizophrenia

tardive dyskinesia

osmotic-controlled release delivery system (OROS)

(82)

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Anxiety

• State of uneasiness characterized by apprehension and worry about possible events

• Two types of anxiety

– Exogenous: response to external stresses

(83)

Discussion

What is the most common self-prescribed treatment for anxiety?

(84)

84

Antianxiety Agents

• Also called sedatives

• Include both noncontrolled and controlled substances

• Benzodiazepines, buspirone, and to a lesser extent, beta blockers are

(85)

Drug List

Antianxiety Agents

– amoxapine (none), TCA

– buspirone (azapirone) (BuSpar)

– hydroxyzine (Vistaril), antihistamine – meprobamate (Miltown)

(86)

Drug List

Antianxiety Agents

– propranolol (Inderal), beta blocker – trifluoperazine (Stelazine),

antipsychotic

(87)

Drug List

Antianxiety Agents

Benzodiazepines

– alprazolam (Xanax)

– chlordiazepoxide (Librium) – clorazepate (Tranxene)

(88)

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Benzodiazepines

• May cause physical or psychological dependence or both, C-IV

• Should not be stopped abruptly • Side effects

– Muscle relaxation

(89)

propranolol (Inderal)

• Beta blocker used to treat physical symptoms of anxiety

• Not officially indicated for this use

(90)

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buspirone (Buspar)

• Selectively antagonizes serotonin receptors

• Take with food

• Report changes in senses: hearing, smell, or taste

(91)

Dispensing Issues of

buspirone (Buspar)

• Look-alike and sound-alike: buspirone and bupropion

– Buspirone, antidepressant/antianxiety – Bupropion, antidepressant

(92)

92

Panic Disorders

• Panic: form of intense, overwhelming, and uncontrollable anxiety

• Neither a controllable voluntary

(93)

Panic Disorders

• Can occur anywhere at anytime • Criteria for diagnosis

(94)

94

Pathophysiology of Panic

Disorders

• Result from neurochemical defect in part of the brain

(95)

Treatment of Panic Disorders

• Combination of antipanic medication and behavioral therapy

• Psychotherapy preferred treatment when symptoms cause significant discomfort or impairment

(96)

Terms to Remember

anxiety

a state of uneasiness characterized by apprehension and worry about

possible events

exogenous anxiety

(97)

Terms to Remember

endogenous anxiety

anxiety caused by factors within the organism

panic

(98)

98

Sleep and Sleep Disorders

• Sleep is fundamental to human health

(99)

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

(100)

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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

(101)

Causes of Some Sleep

Disorders

• Situational: job stress, hospitalization, travel

• Medical: pain, respiratory or GI problems • Psychiatric: schizophrenia, depression,

mania

(102)

102

Treatment for Sleep

Disorders

• Diagnosis and effective treatment

can often eliminate need for hypnotic drugs

(103)

Narcolepsy

• Recurring, inappropriate episodes of sleep during the daytime hours

• No known cause

(104)

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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

(105)

Treatment of Narcolepsy

• Nondrug Therapy

– Lifestyle changes

• Drug Therapy

– Stimulants

(106)

106

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

(107)

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

(108)

Drug List

Sleep Agents

– alprazolam (Xanax)

– chlordiazepoxide (Librium) – clorazepate (Tranxene)

(109)

Drug List

Sleep Agents

– lorazepam (Ativan) – oxazepam (Serax) – quazepam (Doral)

(110)

Drug List

Sleep Agents

Barbiturates

– amobarbital (Amytal), C-II – butabarbital (Butisol), C-III – secobarbital (Seconal), C-II

Antihistamines

(111)

Antihistamines

• Do not reduce REM sleep

(112)

Drug List

Sleep Agents

Hypnotics

(113)

chloral hydrate

(114)

114

ramelteon (Rozerem)

• Approved for sleep onset insomnia • Not a controlled substance because

works in a different way than other hypnotics

(115)

Dispensing Issues of

Rozerem

• Look-alike

– Rozerem

– Razadyne (galantamine), Alzheimer disease

(116)

116

Z Hypnotics

• Preferred treatment of sleep disorders

• No seizures if drug abruptly discontinued

• Relatively short half-life

(117)

Drug List

Sleep Agents

Z Hypnotics

– eszopiclone (Lunesta) – zaleplon (Sonata)

(118)

118

Side Effects of Z Hypnotics

• Sleepwalking, eating, or driving

(sleepdriving) with no recall of events • FDA looking at side effects and

(119)

eszopiclone (Lunesta)

• Approved for chronic insomnia

(120)

120

zaleplon (Sonata)

• Shortest-acting hypnotic • Duration of action 4 hours

(121)

zolpidem (Ambien)

• Schedule IV drug

• Many of the same properties as benzodiazepines, but structurally different

(122)

122

Dispensing Issues of

zolpidem (Ambien)

• Watch prescriptions—should not be used more than 10 days

• Alert pharmacist, but may be exceptions

(123)

Terms to Remember

insomnia

difficulty falling asleep or staying asleep or not feeling refreshed on awakening

hypnotic

a drug that induces sleep

narcolepsy

(124)

124

Alcoholism

• Disease can be arrested, not cured • Lifetime disease, potentially fatal

• Can be controlled through behavioral changes

(125)

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

(126)

126

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

(127)

Symptoms of Dependence on

Alcohol

• Blackouts or lapses of memory

• Concerns of family, friends, and employers about the drinking

(128)

128

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

(129)

Four Steps Towards

Recovery from Alcoholism

1. Acknowledge the problem

2. Limit time spent with substance abusers

3. Seek professional help

(130)

130

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

(131)

Drug List

Alcohol Antagonists

– acamprosate (Campral) – disulfiram (Antabuse)

(132)

132

acamprosate (Campral)

• Moderately successful in clinical trials • Combination of acamprosate and

disulfiram (Antabuse) may work better than either drug alone

(133)

disulfiram (Antabuse)

– Blurred vision – Chest pain

– Confusion

– Difficulty breathing – Face hot & scarlet – Nausea

– Severe headache – Severe vomiting – Throbbing in head – Thirst

– Uneasiness

• Stops metabolism of alcohol

(134)

134

disulfiram (Antabuse)

• Patients must read labels to avoid alcohol in everyday products

– Cough medicines – Mouthwashes

– Flavorings

(135)

topiramate (Topamax)

• Anticonvulsant that reduces cravings for alcohol

• 6 weeks to be effective

• Topamax with behavioral therapy promising in treating alcoholism

(136)

Terms to Remember

delirium tremens (DTs)

(137)

Assignments

• Complete Chapter Review activities • Answer questions in Study Notes

document

• Study Partner