Drugs Used for Mood Disorders

1. Drugs Used for Mood Disorders By: Chris Generans, Karen Sandal & Aiza Espanol BATCH 8

2. Monoamine Oxidase Inhibitor • Mechanism of Action: Act by blocking the metabolic destruction of epinephrine, norepinephrine, dopamine and serotonin neurotransmitters in the presynaptic neurons in the brain. It prevent the degradation of these CNS neurotransmitters so that their concentration is increased. The MAO inhibition starts few days after initiating therapy and will have its full effect within 2 to 4 weeks. Approximately 60% of clinical improvements of symptoms of depression occurs in 2 weeks and maximum improvement within 4 weeks. BATCH 8

3. Monoamine Oxidase Inhibitor • RX: • Phenelzine (Nardil) 15mg TID max dose 90mg QD • Tranylcypromine (Parnate)10mg BID max dose 60mg QD • Isocarboxazid (Marplan)10mg BID max dose 60mg QD • Selegiline (Emsam)6mg, 9mg & 12mg TD Q24hr max dose of 12mg TD QD BATCH 8

4. Monoamine Oxidase Inhibitor • USES: All four are equally effective and have similar side effects. They are most effective in atypical depression, panic disorder, OCD and some phobic disorders. They are used when tricyclic antidepressants is ineffective or when ECT is inappropriate or refused. • Therapeutic Outcomes: Elevated mood and reduction of symptoms of depression BATCH 8

5. Monoamine Oxidase Inhibitor • Premedication Assessment: • Obtain blood pressure and pulse rate before and at regular interval after initiation of therapy. • Monitor blood glucose for patient with DM to establish baseline values. MAOI can cause hypoglycemia; Insulin adjustment and oral hyperglycemic therapy maybe required. • Patient with renal, liver and cerebrovascular disease or CHF will not be given any MAOI therapy. Consult HCP first. • Complete diet history to ensure that the patient has not ingested food containing high Tyramine content in the past few days. BATCH 8

6. Monoamine Oxidase Inhibitor • Implementation: • Instruct patient on how to limit Tyramine-containing foods that may cause a life-threatening hypertensive crises if ingested with MAOI’s. • Dosage should be taken in divided doses, with the last dose administered no later than 6pm to prevent drug-induced insomnia. Patient should not abruptly discontinue the medicine • Missed dose should be taken stat and space the remainder of daily dose throughout the rest of the day. • Check to be certain if the patient is not receiving meperidine BATCH 8

7. Monoamine Oxidase Inhibitor • Evaluation: • Side Effects to Expect: • Orthostatic Hypotension- more significant with Phenelzine than Tranylcypromine. Tolerance develops after few days of therapy. • Drowsiness and sedation- mild to moderate sedation with Phenelzine. Caution while driving or performing other tasks that require alertness. • Restlessness, Agitation and Insomnia- common with Tranylcypromine. Take last dose before 6pm BATCH 8

8. Monoamine Oxidase Inhibitor • Evaluation: • Side Effects to Expect: • Blurred Vision; Constipation; Urinary retention; Dryness of Mucosa of the Mouth, Throat and Nose – Symptoms of Anticholinergic effects by these agents. • Encourage adequate fluid intake and foods to provide sufficient bulk. • Give stool softeners as prescribed. • Mucosa dryness may be relieved by sucking hard candy or ice chips or by chewing gum. BATCH 8

9. Monoamine Oxidase Inhibitor • Side Effects to Report: • Hypertension-A major potential complication with MAOI is that of “Hypertensive Crisis”, particularly with Tranylcypromine because MAOI blocks amine metabolism in tissues outside the brain • Foods containing large amount of Tyramine such as aged-cheese, yeast extract, red wines, pickled herring, sauerkraut, overripe bananas, figs, avocados, chicken livers and beers should be avoided. • Severe occipital HA, stiff neck, sweating, N/V and elevated blood pressure– are common prodromal symptoms of Hypertensive crisis. BATCH 8

10. Monoamine Oxidase Inhibitor • Drug Interactions: • DM, carbamazepine, cyclobenzaprine, methylphenidate, sulfonamides, amphetamines, ephedrine, methyldopa, epi…& norepi…can potentiate the toxicity of MAOI by raising the neurotransmitter levels. • Tricyclic Antidepressants-Imipramine & Desipramine should not be administered concurrently with MAOI. It is recommended 14days lapse between both drug therapy. • SSRI- severe reactions such as convulsion, hyperpyrexia and DEATH may result with concurrent use with MAOI. A 5week interval is recommended when DC Flouxetine and starting MAOI’s. BATCH 8

11. Monoamine Oxidase Inhibitor • Drug Interactions: • General Anesthesia; Diuretics & Antihypertensive Agent- MAOI may potentiate the effects of all three. • Insulin; Oral Hypoglycemic Agents- may cause an additive hypoglycemic effects with MAOI’s. • Meperidine CII- may cause hyperpyrexia, restlessness, hypertension, hypotension, convulsion and COMA when used concurrently with MAOI; it can occur several weeks after DC an MAOI. • Morphine CII can be used as substitute instead of Meperidine. BATCH 8

12. Selective Serotonin Reuptake Inhibitors • Mechanism of Action: Act by inhibiting the reuptake and destruction of serotonin from the synaptic cleft; prolonging the actions of neurotransmitters. It also inhibits norepi …and to a lesser extent, dopamine. SSRI’s are a newer class of antidepressant chemically unrelated to other antidepressants. SSRI’s become the most widely used class of antidepressants It is equally effective as the Tricyclic antidepressants. Advantage of SSRI’s is that they do not have anticholinergic and cardiovascular side effects that often limit the use of the Tricyclic antidepressants. BATCH 8

13. Selective Serotonin Reuptake Inhibitors • RX : • Citalopram (Celexa) 20mg QD; max of 60mg QD; Liquid: 10mg/5ml • Duloxetine (CymbaltaSR ) 20mg, 30mg & 60mg; Initial dose 40mg; max dose of 60mg QD • Escitalopram (Lexapro) 5mg, 10mg & 20mg; Initial dose 10mg QD; Liquid: 5mg/5ml • Fluoxetine (Prozac) Capsule: 10mg, 20mg, 40mg, Initial dose 20mg QAM; max dose of 80mg QD Tabs: 10mg, 20mg; Liquid: 20mg/5ml . BATCH 8

14. Selective Serotonin Reuptake Inhibitors • RX: • Fluvoxamine (Luvox) 20mg, 50mg & 100mg QD; 90mg QHS initial dose; max of 300mg QD • Paroxetine (Paxil) 10mg, 20mg, 30mg & 40mg (PaxilSR):12.5mg, 25mg & 37.5mg Susp: 10mg/5ml; Initial dose 20mg QD; max dose of 50mg QD • Sertraline (Zoloft) 25mg, 50mg &100mg; 1st dose 50mg QD Liquid: Oral conc. 20mg/ml BATCH 8

15. Selective Serotonin Reuptake Inhibitors • USES: • Fluoxetine - is the only SSRI that has been approved by FDA for use in treating depression in children and adolescents. It is also use in treating premenstrual dysphoric disorder (PMDD). • Paxil -has been recommended by FDA not to be administered to patients younger that 18 years of age. • Fluvoxamine; Paroxetine; Sertraline & Fluoxetine -are approved for use in OCD. • Duloxetine -is also approved for treatment of diabetic peripheral neuropathic pain. BATCH 8

16. Selective Serotonin Reuptake Inhibitors • Premedication Assessment: • Obtain baseline blood pressure in supine, sitting and standing positions. • Obtain baseline weight, schedule weekly weights. • Note any GI symptoms before starting therapy. • Monitor CNS symptoms presents such as insomnia or nervousness • Check hepatic studies periodically throughout the course of administration BATCH 8

17. Selective Serotonin Reuptake Inhibitors • Therapeutic Outcome: Elevated mood and reduction of symptoms of depression • Implemention: • Suicide precaution should be maintain during drug therapy. • Symptoms of depression may improve within few days (appetite, sleep & psychomotor activity)—depression still exists; it usually takes several weeks for the therapeutic dose to have its full effect. BATCH 8

18. Selective Serotonin Reuptake Inhibitors • Evaluation: • Side Effects to Report: • Restlessness, Agitation, Anxiety & Insomnia- Occurs early in the therapy and may require short term treatment. Avoid bedtime doses to prevent insomnia. • Sedative Effects: Take precaution while driving of performing other tasks that require alertness. • GI Effects: Effects may be minimized by temporary reduction of dosage and administration with food. • Suicidal Actions: Monitor patients for changes in thoughts, feelings and behavior during initial stages of therapy. BATCH 8

19. Selective Serotonin Reuptake Inhibitors • Drug Interactions: • Tricyclic Antidepressants- Interaction of SSRI and Tricyclic antidepressants is very complex that may result from increased in toxicity, such as dysrhythmias, seizure activity and CNS stimulation. • Lithium Toxicity- manifested by nausea, anorexia, fine tremors, persistent vomiting, profuse diarrhea, lethargy and weakness. BATCH 8

20. Selective Serotonin Reuptake Inhibitors • Drug Interactions: • MAOI’s- severe reactions, including excitement, diaphoresis, rigidity, convulsion, hyperpyrexia, and DEATH. Must be 14days lapse when DC MAOI. A 5weeks stop interval when DC Fluoxetine and starting MAOI’s. • Haloperidol- increased level and frequency of extrapyramidal symptoms when used concurrently with Fluoxetine and Fluvoxamine. BATCH 8

21. Selective Serotonin Reuptake Inhibitors • Drug Interactions: • Phenytoin & Phenobarbital- complex reactions. Paroxetine enhance the metabolism these drugs and vice versa-resulting in potential toxicity. • Carbamazepine- enhance the excretion of Citalopram, leading to decreased therapeutic effect. • Propanolol & Metoprolol- Monitor closely for bradycardia and hypotension. Reduce the dose of beta-blocker PRN. • Cimetidine - inhibits the metabolism of Paroxetine and Sertraline. BATCH 8

22. Selective Serotonin Reuptake Inhibitors • Drug Interactions: • Warfarin - may enhance the anticoagulation effect. Monitor for bleeding gums, nosebleeds and dark tarry stools. Monitor PT & INR. • Smoking- enhances the effect of Fluvoxamine. BATCH 8

23. Tricyclic Antidepressants • Mechanism of Action: • The exact mechanism as antidepressant is unknown. • It prolongs the action of norepi… dopamine, and serotonin to varying degrees by blocking the reuptake of these neurotransmitters in the synaptic cleft between neurons. BATCH 8

24. Tricyclic Antidepressants • RX : • Amitriptyline; Amoxepine • Clomipramine (Anafranil) • Desipramine (Sinequan) • Imipramine (Tofranil) • Nortriptyline (Pamelor) • Protriptyline (Vivactil ) • Trimipramine (Surmontil) BATCH 8

25. Tricyclic Antidepressants • USES: • After 2 to 4 weeks of therapy, they elevate mood, improve appetite and increased alertness. • Sedation is more notable with Amitriptyline and doxapin • Protriptyline has no sedative properties and produce mild stimulation to some patients. • All Tricycliccompounds displays anticholinergic activity; considered patients with cardiac disease, BPH or glaucoma. BATCH 8

26. Tricyclic Antidepressants • USES: • Imipramine- is approved for treating enuresis in children ages 6 and older. • Clomipramine is used not to treat depression but is approved to treat OCD. • SelectedTricyclic antidepressants are used to treat phantom limb pain, chronic pain, cancer pain, neuralgia, eating disorder and PMS. • Therapeutic Outcomes: • Elevated mood and reduction of symptoms of depression BATCH 8

27. Tricyclic Antidepressants • Premedication Assessment: • Note the consistency of bowel movement; constipation is common. • Obtain baseline BP in supine and standing positions. • Check for HX for symptoms of dysrhythmias, tachycardia, CHF and seizures. • Implementation: • Suicide precaution should be maintained during therapy. BATCH 8

28. Tricyclic Antidepressants • Side Effects to Expect: • Blurred vision, constipation, Urinary retention, Dryness of mucosa of the mouth, throat and nose- these are the effect of the anticholinergic agents. • Orthostatic Hypotension- dizziness and weakness may occur • Sedative effects- single dose at HS may diminish the sedative effect. BATCH 8

29. Tricyclic Antidepressants • Evaluation: • Side Effects to Report: • Tremor, Numbness, Tingling • Parkinsonian Symptoms • Dysrhythmias, tachycardia, Heart Failure • Suicidal Actions • Report for further evaluation. BATCH 8

30. Tricyclic Antidepressants • Drug Interactions: • Enhanced Anticholinergic Activity • Enhanced Sedative Activity • Barbiturates- stimulate the metabolism of Tricyclic antidepressants • Bupropion - Increase serum levels of Tricyclic antidepressants BATCH 8

31. Tricyclic Antidepressants • Drug Interactions: • Carbamazepine- vertigo, tremor, HA, N/V as a result in toxicity. • MAOI & SSRI- severe reaction that can result in toxicity and fatal. • Smoking- enhance the metabolism of Tricyclic antidepressants • Thyroid hormones- increased serum levels of Tricyclic meds BATCH 8

32. Miscellaneous Agents • RX: • Bupropion HCl (Wellbutrin) • Maprotiline HCl ( Maproetileen) • Mirtazepine (Remeron) • Nefazodone (Serzone) • Trazodone (Desyrel) • Venlafaxine (Effexor) BATCH 8

33. Miscellaneous Agents • Mechanism of Action: Its mechanism of action is unknown; weak inhibitor of the reuptake and inactivation of the neurotransmitters. Pharmacologic response is similar to that of Tricyclic antidepressants. BATCH 8

34. Miscellaneous Agents • Therapeutic Outcomes: • Elevated mood and reduction of symptoms of depression. • USES: • Use for depressive phase of Bipolar disorder. • For patients who cannot tolerate or unresponsive to Tricyclic antidepressants. • Treatment for depression associated with schizophrenia, tremor, anxiety associated with alcohol dependence. • Treatment for Insomnia for patients with substance abuse BATCH 8

35. Miscellaneous Agents • Premedication Assessment: • Obtain BP, HR. • Obtain baseline weight-weekly • Check hepatic studies. • Report significant lowering BP • Note and monitor GI and CNS symptoms • Report HX for renal & hepatic disease and subs. abuse. BATCH 8

36. Miscellaneous Agents • Side Effects to Expect: • Dizziness, Drowsiness • Nausea, Anorexia • Restlessness, Agitation • Sedation, Orthostatic Hypotension, • Anxiety, Insomnia BATCH 8

37. Miscellaneous Agents • Side Effects to Report: • Suicidal Actions • Seizures • Hepatotoxicity • Bradycardia • Confusion BATCH 8

38. Miscellaneous Agents • Drug Interactions: • Levodopa • Retonavir • Digoxin • St John’s Wort • MAOI • Cimetidine • Cisapride BATCH 8

39. Antimanic Agent • RX: • Lithium Carbonate (Eskalith) MOA: Lithium is a monovalent cation that competes with other monovalent and divalent cation (KCl, Na, Ca, Mg) .It replaces the intracellular and intraneuronal sodium stabilizing the neuronal membrane. It reduces the release of norepi… BATCH 8

40. Antimanic Agent • Uses: Treatment for acute mania and prophylaxis of recurrent manic and depressive episodes of Bipolar disorder. • Therapeutic Outcome: Maintaining the patient at the optimal level of functioning with minimal exacerbations of mood swings BATCH 8

41. Antimanic Agent • Implementation: Administer medicine 300 to 600mg TQID. Give with food and remain adequate diet to remain normal sodium levels and prevent toxicity. Full therapeutic effect requires 10 to 21days. • Side Effects to Expect: • N/V, Anorexia, Abdominal Cramps • Excessive thirst and Urination • Fine Hand Tremor BATCH 8

42. Antimanic Agent • Side Effects to Report: • Vomiting • Profuse Diarrhea • Lethargy • Weakness • Progressive Fatigue • Weight Gain • Pruritus • Ankle Edema • Nephrotoxicity BATCH 8

43. Antimanic Agent • Drug Interactions: • Reduced Serum Sodium levels- it can enhance the toxicity of Lithium; low Sodium levels result in low Lithium levels • Methyldopa- can cause N/V, diarrhea, speech difficulty as a result of Lithium toxicity. • Indomethacin, Piroxicam - reduced renal excretion of Lithium BATCH 8