Ppt chapter022

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Introduction to Clinical Pharmacology

Chapter 22-Antidepressant Drugs


Tricyclic Antidespressants: ActionsTricyclic Antidespressants: Actions• Increase sensitivity in postsynaptic alpha (a)-

adrenergic, serotonin receptors

• Decreases sensitivity-presynaptic receptor sites

• Makes neurotransmission activity more effective

• Inhibits reuptake of norepinephrine or serotonin in brain


Tricyclic Antidespressants: Uses 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


Tricyclic Antidespressants: Adverse Reaction and ContraindicationsTricyclic Antidespressants: Adverse Reaction 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: PrecautionsTricyclic Antidespressants: Precautions• Used cautiously in patients:

– Cardiac disease, hepatic and/or renal impairment, hyperthyroid disease

– History of seizure activity, narrow angle glaucoma or increased intraocular pressure

– Urinary retention, and risk of suicide ideation or behavior


Tricyclic Antidespressants: InteractionsTricyclic Antidespressants: Interactions

Interactant drug Effect of interaction

Sedatives, hypnotics, analgesics

Increased risk ofrespiratory, nervoussystem depression

Dicumarol Increased risk for bleeding

Cimetidine (tagamet) Increased anticholinergicsymptoms (dry mouth, urinary retention, blurred vision)


Tricyclic Antidespressants: Interactions (cont’d)Tricyclic Antidespressants: Interactions (cont’d)


MAOIs Increased risk for hypertensive episodes, severe convulsions, and

hyperpyretic episodes

Adrenergic agents Increased risk for arrhythmias and hypertension


Monoamine Oxidase Inhibitors: Actions and Uses Monoamine Oxidase Inhibitors: Actions and Uses • Actions: Increase in endogenous epinephrine,

norepinephrine, dopamine, serotonin in nervous system, increase in neurohormones

• Uses: Depressive episodes, psychotherapy, bulimia, night terrors, migraine headaches, seasonal affective disorder, multiple sclerosis


Monoamine Oxidase Inhibitors: Adverse Reaction Monoamine Oxidase Inhibitors: Adverse Reaction

– 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


Monoamine Oxidase Inhibitors: Contraindications and Precautions 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: InteractionsMonoamine Oxidase Inhibitors: InteractionsInteractant drug Effect of interaction

sedatives, hypnotics, and analgesics

Increased risk for adverse reactions during surgery

Thiazide diuretics Increased hypotensive effects of the MAOI

Meperidine (demerol) Increased risk for hypertensive episodes, severe convulsions, hyperpyretic episodes

Adrenergic agents Increased risk for cardiac arrhythmias, hypertension


Monoamine Oxidase Inhibitors: InteractionsMonoamine Oxidase Inhibitors: Interactions


Tyramine or tryptophan Hypertensive crisis, which may occur up to 2 weeks after the MAOI is discontinued


Selective Serotonin Reuptake InhibitorsSelective 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)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: InteractionsSelective Serotonin Reuptake Inhibitors: Interactions


Other antidepressants Increased risk of toxic effects

Cimetidine (Tagamet) Increased anticholinergic symptoms

Aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), e.g., ibuprofen

Increased risk for GIbleeding

Lithium (interaction with fluoxetine)

Increased risk of lithium toxicity


Miscellaneous Antidepressants: Actions and Uses 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 ReactionsMiscellaneous 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: Contraindication and PrecautionsMiscellaneous Antidepressants: Contraindication 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


Miscellaneous Antidepressants: InteractionsMiscellaneous Antidepressants: Interactions Interactant drug Effect of interaction

Sedatives, hypnotics and analgesics

Increased risk for respiratory & nervous system depression

Warfarin (Coumadin) and cimetidine (Tagamet)

Increased risk for bleeding, increased anticholinergic symptoms

Antihypertensive agents Increased risk for hypotension

MAOIs Increased risk for hypertensive episodes, severe convulsions, & hyperpyretic episodes


Nursing Process: AssessmentNursing 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, straight-forward questions


Nursing Process: AssessmentNursing Process: Assessment

• Ongoing assessment:

– Monitor vital signs, report change to primary healthcare provider

– Observe response to therapy

– Document general summary- outward behavior, complaints, problems, compare previous notations, observations


Nursing Process: Nursing Diagnosis and PlanningNursing Process: Nursing Diagnosis and Planning• Self-Care Deficit Syndrome

• Disturbed sleep pattern

• Nutrition, imbalanced less than bodily requirements

• Risk for suicide

• Pain


Nursing Process: Nursing Diagnosis and PlanningNursing Process: Nursing Diagnosis and Planning• The expected outcome includes an optimal

response to therapy:

– Reason for administration of antidepressant

– Optimal response to drug therapy

– Support patient for adverse drug reactions

– Understanding, compliance: Prescribed therapeutic regimen


Nursing Process: ImplementationNursing 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, decreased

– Patients with depression: Develop nursing care plan, antidepressants, keep patient lying down for 30 minutes


Nursing Process: ImplementationNursing Process: Implementation

• Monitoring and managing patient’s need:

– Self-care deficit syndrome

• Assist when depression- no physical, or emotional energy to perform self-care activities

• Minimize injury risk: Safe environment, assist in changing positions, Assist-activities of daily living, encourage self care, give positive feedback, write behavioral records-periodic intervals, frequency depends– hospital, unit guidelines


Nursing Process: ImplementationNursing Process: Implementation• Monitoring and managing patient’s need

(cont’d):

– Disturbed sleep pattern: Promote sleep, wakefulness during day, shut drape at night, opened in day, help patient reorient to day, night time

– Imbalanced nutrition, less than bodily requirements:

•Monitor fluid dietary intake, monitor weight loss, gain, good oral hygiene, frequent sips of fluids, sugarless gum



(cont’d):

•Strict dietary control- foods containing tyramine not be eaten for patients on MAOIs, no food from outside

– Risk for suicide: Well-supervised environment, wait for therauptic effect; report for: expressions of guilt, hopelessness, helplessness, insomnia, weight loss, direct/indirect threats of suicide, care while swallowing



(cont’d):

– Pain, Acute:

•Drugs: Trazodone, priapism-impotence, prolonged, inappropriate penile erection, injection of alpha-adrenergic stimulants, surgical intervention


Nursing Process: ImplementationNursing Process: Implementation

• Educating the patient and family

– Managing reactions; patients- 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-water, sucking hard candy, chewing gum


Nursing Process: ImplementationNursing 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: Experience prolonged, inappropriate, painful erections-stop drug, notify primary care provider

• Evaluation

– Therapeutic effect: Achieved

– No evidence of injury apparent


Nursing Process: ImplementationNursing Process: Implementation• Evaluation (cont’d):

– Patient: Perform self-care

– Adverse reactions: Identified, reported primary health care provider, managed successfully- appropriate nursing interventions

– Patient verbalizes: Treatment modalities, importance continued follow-up care

– Patient and family demonstrate: Drug regimen


End of Presentation

Health & Medicine

Ppt chapter022