Tricyclic Antidespressants: Actions

Transcription

1 Introductory Clinical Pharmacology Chapter 24 Antidepressant Drugs Tricyclic Antidespressants: Actions Increase sensitivity in postsynaptic alpha (α)-adrenergic, serotonin receptors Decrease sensitivity at presynaptic receptor sites Make neurotransmission activity more effective Inhibit reuptake of norepinephrine or serotonin in brain Tricyclic Antidespressants: Uses Used to treat: Depressive episodes Bipolar disorder; obsessive-compulsive disorders; chronic neuropathic pain Depression-anxiety disorders; enuresis; peptic ulcer disease; sleep apnea; panic disorder Bulimia nervosa; premenstrual symptoms; dermatological problems; psychotherapy severe cases 1

2 Tricyclic Antidespressants: Adverse Reactions and Contraindications Adverse reactions: Sedation, dry mouth, visual disturbances, urinary retention, constipation, photosensitivity TCS contraindications: Hypersensitivity to drugs, patients on MAOI antidepressants, myocardial infarction, children, lactating mothers, Sinequan contraindications glaucoma, urinary retention Tricyclic Antidespressants: Precautions Used cautiously in patients with: Cardiac disease, hepatic and/or renal impairment, hyperthyroid disease History of seizure activity, narrow angle glaucoma or increased intraocular pressure Urinary retention Risk of suicide ideation or behavior Tricyclic Antidespressants: Interactions Interactant drug Sedatives, hypnotics, analgesics Dicumarol Cimetidine (Tagamet) Effect of interaction Increased risk of respiratory, nervous system depression Increased risk for bleeding Increased anticholinergic symptoms (dry mouth, urinary retention, blurred vision) 2

3 Tricyclic Antidespressants: Interactions (cont d) Interactant drug MAOIs Adrenergic agents Effect of interaction Increased risk for hypertensive episodes, severe convulsions, and hyperpyretic episodes Increased risk for arrhythmias and hypertension Monoamine Oxidase Inhibitors: Actions and Uses Actions: Increase in endogenous epinephrine, norepinephrine, dopamine, serotonin in nervous system, neurohormones Uses: Depressive episodes, psychotherapy, bulimia, night terrors, migraine headaches, seasonal affective disorder, multiple sclerosis Monoamine Oxidase Inhibitors: Adverse Reactions Neuromuscular reactions: Orthostatic hypotension, dizziness, vertigo, headache, blurred vision Gastrointestinal (GI) and genitourinary (GU) system reactions: Constipation, dry mouth, nausea, diarrhea, impotence Serious adverse reaction: Hypertensive crisis foods containing tyramine 3

4 Monoamine Oxidase Inhibitors: Contraindications and Precautions Contraindications: Elderly patients; hypersensitivity to drugs; pheochromocytoma; liver, kidney, or cerebrovascular disease; hypertension; history of headaches; congestive heart failure Caution: Patients with impaired liver function; history of seizures; parkinsonian symptoms; diabetes; hyperthyroidism; risk of suicidal ideation or behavior Monoamine Oxidase Inhibitors: Interactions Interactant drug Sedatives, hypnotics, and analgesics Thiazide diuretics Meperidine (demerol) Adrenergic agents Effect of interaction Increased risk for adverse reactions during surgery Increased hypotensive effects of the MAOI Increased risk for hypertensive episodes, severe convulsions, hyperpyretic episodes Increased risk for cardiac arrhythmias, hypertension Monoamine Oxidase Inhibitors: Interactions Interactant drug Effect of interaction Tyramine or tryptophan Hypertensive crisis, which may occur up to 2 weeks after the MAOI is discontinued 4

5 Selective Serotonin Reuptake Inhibitors Actions: Stimulant to reverse depression Uses: Depressive episodes, bulimia nervosa, panic, premenstrual, post-traumatic stress disorders, anxiety and social phobias, Raynaud s disease, migraine headaches, diabetic neuropathy, hot flashes Adverse reactions Neuromuscular reactions: Somnolence, dizziness, headache, insomnia, tremor, weakness Selective Serotonin Reuptake Inhibitors (cont d) Gastrointestinal, genitourinary system reactions: Constipation, dry mouth, nausea, pharyngitis, runny nose, abnormal ejaculation Contraindications: Hypersensitivity to drugs; pregnancy category C; patients taking cisapride, pimozide, or carbamazepine should not take fluvoxamine (prozac) Precautions: Diabetes mellitus, cardiac disease, impaired liver or kidney function, risk of suicidal ideation or behavior Selective Serotonin Reuptake Inhibitors: Interactions Interactant drug Other antidepressants Cimetidine (Tagamet) Aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) (e.g., ibuprofen) Lithium (interaction with fluoxetine) Effect of interaction Increased risk of toxic effects Increased anticholinergic symptoms Increased risk for GI bleeding Increased risk of lithium toxicity 5

6 Miscellaneous Antidepressants: Actions and Uses Affects neurotransmission of serotonin, norepinephrine, dopamine Uses: Depressive episodes, anxiety disorders, neuropathic pain, enhancing weight loss, treating aggressive behaviors, menstrual disorders, cocaine withdrawal, alcohol cravings, fibromyalgia, stress incontinence Miscellaneous Antidepressants: Adverse Reactions Neuromuscular reactions: Somnolence, migraine headache, hypotension, dizziness, lightheadedness, vertigo, blurred vision, photosensitivity, insomnia, nervousness or agitation, tremor Gastrointestinal reactions: Nausea, dry mouth, anorexia, thirst, diarrhea, constipation, bitter taste Generalized body system reactions Miscellaneous Antidepressants: Contraindications and Precautions Contraindications: Hypersensitivity drugs; maprotiline seizure disorder; patients on cisapride, pimozide, carbamazepine Precautions: Cardiac disease; renal and/or hepatic impairment; hyperthyroid disease; risk of suicidal ideation or behavior 6

7 Miscellaneous Antidepressants: Interactions Interactant drug Sedatives, hypnotics, and analgesics Effect of interaction Increased risk for respiratory and nervous system depression Warfarin (Coumadin) and cimetidine (Tagamet) Antihypertensive agents MAOIs Increased risk for bleeding, increased anticholinergic symptoms Increased risk for hypotension Increased risk for hypertensive episodes, severe convulsions, hyperpyretic episodes Nursing Process: Assessment Preadministration assessment Obtain medical history Assess mental status, subjective feelings, slowness to answer questions, monotone speech pattern, sadness or crying Physical assessment, including blood pressure, pulse, respiratory rate, weight, suicidal thoughts Ask about intent using simple, straightforward questions Nursing Process: Assessment Ongoing assessment Monitor vital signs, report change to primary health care provider Observe response to therapy Document general summary outward behavior, complaints, problems, compare previous notations, observations 7

8 Nursing Process: Nursing Diagnosis and Planning Self-care deficit syndrome Disturbed sleep pattern Imbalanced nutrition less than bodily requirements Risk for suicide Pain Nursing Process: Nursing Diagnosis and Planning The expected outcome includes an optimal response to therapy Reason for administration of antidepressant Support patient for adverse drug reactions Understanding, compliance: Prescribed therapeutic regimen Nursing Process: Implementation Promoting an optimal response therapy Observe patient for adverse reactions: Notify primary health care provider Observe behavioral changes during initial therapy when dosage increased or decreased Patients with depression: Develop nursing care plan, give antidepressants, keep patient lying down for 30 minutes 8

9 Nursing Process: Implementation Monitoring and managing patient needs Self-care deficit syndrome Assist when depressed no physical or emotional energy to perform self-care activities Minimize injury risk: Safe environment, assist in changing positions; assist with activities of daily living; encourage selfcare; give positive feedback; write behavioral records at periodic intervals frequency depends on hospital or unit guidelines Nursing Process: Implementation Monitoring and managing patient needs (cont d) Disturbed sleep pattern: Promote sleep by keeping awake during day; shut drape at night, opened during day; help patient reorient to day and night Imbalanced nutrition, less than bodily requirements Monitor fluid dietary intake, monitor weight loss or gain, good oral hygiene, frequent sips of fluids, sugarless gum Nursing Process: Implementation Monitoring and managing patient needs (cont d) Strict dietary control foods containing tyramine should not be eaten by patients on MAOIs; no food from outside Risk for suicide: Well-supervised environment, wait for therauptic effect; report expressions of guilt, hopelessness, helplessness, insomnia, weight loss, direct/indirect threats of suicide, care while swallowing 9

10 Nursing Process: Implementation Monitoring and managing patient needs (cont d) Pain, acute Drugs: Trazodone, priapism impotence; prolonged, inappropriate penile erection; injection of alphaadrenergic stimulants or surgical intervention Nursing Process: Implementation Educating the patient and family Managing reactions: Patients should continue proper drug regimen, evaluate ability to take responsibility of drugs, explain adverse reactions Teaching plan: Inform primary health care provider, dentist; dizziness: rise slowly of bed, chair; help changing positions; relieve dry mouth: frequent sips of water, sucking hard candy, chewing gum Nursing Process: Implementation Educating the patient and family (cont d) Teaching plan: Report unusual changes, physical effects; avoid prolonged exposure to sunlight or sunlamps; male patients: If they experience prolonged, inappropriate, painful erections, stop drug and notify primary care provider Evaluation Therapeutic effect: Achieved No evidence of injury apparent 10

11 Nursing Process: Implementation Evaluation (cont d) Patient: Perform self-care Adverse reactions: Identified, reported to primary health care provider, managed successfully appropriate nursing interventions Patient verbalizes: Treatment modalities, importance of continued follow-up care Patient and family demonstrate knowledge of drug regimen End of Presentation 11