병원약사모임강의 _2006_8 بسم الله الرحمن الرحيم. 병원약사모임강의 _2006_8 psycho pharmacotherapy dr.ghasem dastjerdi psychiatrist

병원약사모임강의 _2006_8

الله الرحيم بسم الرحمن


psycho pharmacotherapy

dr.ghasem dastjerdipsychiatrist

درمان کلی مالحظات و اصول

• Diagnosis• Differential diagnosis• Drug choice• Dose• Duration• Drug _Drug interactions• Drug sideeffect

• Diagnosis• Past Treatment Response• Response in Family Members• Concurrent Medical or Psychiatric Disorders


Goals of Pharmacotherapy

• Acute Treatment– Used to alleviate the symptoms of an actively

occurring disorder

• Continuation Treatment– Goal: To prevent a relapse into the same

episode for which treatment began

• Maintenance Treatment– Goal: To prevent recurrences by the ongoing

maintenance use of a medication


Various Reasons for Noncompliance

• Stigma of disorder• Denial of illness• Disruption of cognitive process• Side effects of medication• Slow onset of beneficial effects • Cost


Strategies to Increase Compliance

• Encourage active patient participation• Adequate communication• Empathetic approach/Trusting relationship• Family and community involvement and

support• Emphasis on positive effects of medication• Use the most simplified drug regimen

Classes of Psychotropics

• Antipsychotics• Antidepressants• Mood Stabilizers• Anxiolytics• Anti-Abuse• Stimulant• Cognitive enhancer

که 85ساله،کارمند، 45آقایی • وزن، گرم کیلوای هفته دو

• . تحریک است شده همسرشبدبین به است. دارد بیخوابی و گویی ،خود پذیری

• Substances• Hypothyroidism• Cushing• Brain tumors• ….

• حال شرح• الزم آزمایشات• اسکن تی سی• کانابیس تست• متامفتامین تست• ....

هشت 35خانمی • حدود از ،دیابتیک،که سالهعملکرد،عدم گویی،افت کم دچار قبل سال

و منزل،غمگینی امور انجام در توانایی . توسط است معتقد است گردیده بیخوابی

منزلش در آنها و میگردد کنترل ها همسایه. اند گذاشته کار دوربین

Drug Treatment

• Dopamine Receptor Antagonists– Chlorpromazine (Thorazine)– Haloperidol (Haldol)

• Dopamine and Serotonin Receptor Antagonists– Risperidone, Olanzapine, Aripiprazole … – Clozapine


Dopamine Receptor Antagonist: Side Effects

• Vegetative disorders– decrease in blood pressure– acceleration of pulse rate– modification of myocardial activity– sweating– dry mouth– constipation– impotence– ejaculation disorders– anorgasmia

Dopamine Receptor Antagonist: Side Effects

• Extrapyramidal disorders cont.

– Early dyskinesia • Spasms of tongue, visual spasms, grimacing, gyratory and

rotatory movements of the upper extremities Neuroleptic Parkinsonoid

• akinesia (restriction of motor movement), hypomimia (loss of facial expression), rigor and tremor (in muscles)

– Akathisia• Restlessness, urge to move continuously

– Tardive dyskinesia• Involuntary chewing, smacking of lips, swallowing and rolling

movements of the tongue• Gyratory and flailing movements of the extremities

Typical vs Atypical

• Typical (also called conventional) antipsychotics act primarily at dopamine receptors.

• Atypical antipsychotics are active on other receptors as well as dopamine, and are associated with fewer or no extrapyramidal side-effects, an effect on negative symptoms of schizophrenia.


Antipsychotics (Neuroleptics)

• Typical Neuroleptics– High potency (Haldol)– Medium potency (Stelazine)– Low potency (Thorazine)– Depot/Decanoate (Prolixin-D or

Haldol-D/LA)

• Atypical Neuroleptics– Clozaril (Clozapine)– Risperidol Pisperidone)– Zyprexa (Olanzapine)– Seroquel (Quetiapine)– Geodon (Ziprasidone)


Neuroleptics: Indications

• Schizophrenic disorders• Mania• Acute Psychotic reactions• Mood d/o with psychotic symptoms• Delirium/dementia

،کشاورز، 50آقایی • گرم 85ساله کیلومعده زخم و قلبی بیماری سابقه وزن،با

با دارد را مربوطه داروهای مصرف کهامیدی،بیخوابی،کاهش افسردگی،نا عالیم

جنسی،کاهشتمرکز،کاهشانرژی میل. است کرده مراجعه

Depression: Who Needs Meds?

• Depressed mood with neurovegetative symptoms > 4 weeks

• Previous episodes• Severe, disabling, or

presence of Sx Increase

• Comorbid anxiety d/o• Psychotic symptoms• Family history of

suicide

• TCA (Elavil)• MAOI (Nardil)

– Monoamine oxidase inhibitors

• Selective Reuptake Inhibitors– SSRI (Prozac)– SDRI (Wellbutrin)– SNRI (Effexor)

• Serotonin Modulators– Desyrel– Remeron

• Serotonin & Norepinehrine Reuptake Inhibitor

– Cymbalta (2004)

Antidepressant Classes

dr.dastjerdi

dr.dastjerdi

Pre- and Postsynaptic Active Agents Mirtazapine (Remeron)

15–30

Sedation, weight ↑ No sexual dysfunction.

Dopamine Reuptake Inhibitor Bupropion (Wellbutrin)

200–400

Insomnia/agitation, GI distress Twice-a-day dosing with sustained release. No sexual dysfunction or weight gain.

Mixed Action Agents Amoxapine (Asendin)

100–600

Drowsiness, insomnia/agitation, CA, weight ↑, OSH, anticholinergica

Movement disorders may occur. Dose titration is needed.

Clomipramine (Anafranil)

75–300

Drowsiness, weight ↑ Dose titration is needed.

Trazodone (Desyrel)

150–600

Drowsiness, OSH, CA, GI distress, weight ↑

Priapism is possible.

dr.dastjerdi

TCA-Common Side Effects

• Weight gain• Anticholinergic

– Dry mouth, cavities– Blurred vision– constipation– Urinary retention– Tachycardia

• Sedation, fatigue• Tremor, dizziness• Impotence

TCA-Efficacy

• Depression• Anxiety• Panic • OCD (Anafranil Only)• PTSD• Bulimia• Chronic Pain• Headaches

Depression: SSRIs

• Other treatments– Biploar I disorder, dysthymic disorder, eating

disorders, panic disorders, obsessive-compulsive, and borderline personality disorder.

– Prozac has been used for: Anxiety, panic attacks, phobias, obsessive compulsivenss, anorexia and bulimia, seasonal affective disorder, obesity, PMS, chronic pain.


Depression: Commonly Used SSRIs

• Side Effects– mostly involved the central nervous system and the

gastrointestinal system– sexual dysfunction(delayed ejaculation)– some adverse symptoms can disappear or lessen with time.

• Fluoxetine (Prozac, Lilly) (Selective for 5-HT)• Paroxetine (Paxil)• Sertraline (Zoloft)• Escitalopram (Lexapro)• R-Fluoxetine (Mirror of Prozac, 2003)• Duloxetene (Cymbalta, 2004)

SSRI-Efficacy

• Depression• Panic • OCD• PTSD• Social Phobia• Bulimia• PMS, BDD• Chronic Pain

SSRI-Common Side Effects

• Insomnia, headache• Nausea, anorexia

– Diarrhea – Constipation (Paxil)

• Sexual dysfunction– Decreased libido– Anorgasmia

• Nervousness, tremor– Myoclonus– Teeth-clenching


Wellbutrin- Special Factors

• Pro:– No sexual dysfunction– No weight gain– Smoking Cessation– Preference in Bipolar

depression?

• Con:– Poor anxiolytic; not anti-

panic– Seizure issue


Effexor- Special Factors

• Pro:– Energizing– Rapid onset– Severe depression– Anti-panic?– No weight gain

• Con:– Hypertension issue

Remeron-Special Factors

• Pro:– Sleep enhancing at 15

mg.– limited sexual

dysfunction– Anti-nausea – IBS improved?– Chronic pain– Anxiolytic; anti-panic

• Con:– Weight gain

SSRI: Other Indications

• Anxiety/Panic• Bulimia Nervosa• PMDD• OCD-Spectrum• Impulse Control

Clip

Eating Disorders

• Bulimia Nervosa– SSRI– All antidepressants

• Anorexia Nervosa– SSRI

Impulse Control: SSRI-Responsive?

• Kleptomania• Trichotillomania• “Compulsive” D/O

– Paraphilias– Pyromania– Gambling

Chronic Pain States

• TCA– Toxicity/Intolerance

– Alcohol synergism

• Alternatives– Remeron*

– SSRI

• Potential Advantages– Safe & Well-tolerated

• *Preserve sleep architecture


Insomnia

• Trazodone– Males: priapism

– Safe, not abusable, cheap

• Remeron– 15 mg dose

– Safe

• TCA– Low dose

– Toxicity issues

خانمی • خلق 19دختر با سالهمالحظه قابل افسرده،پرخوابی،کندی

به سایکوموتور،ناامیدی،اقدامبا مرتبط افکار و خودکشی،احساسگناه

. است نموده مراجعه مرگ

دچار • بهار در قبل سال ویباال،احساس ،پرحرفی،خلق بیخوابی

افزایش و جنسی انرژی،افزایشمیلکه است بوده گردیده فعالیتسایکوموتور

. است داروییخوبشده درمان با

Mood Stabilizers

• Used for “Bipolar” or “Manic-Depressive” to regulate mood

• Lithium (naturally occurring mineral)

• Carbamazepine (Tegretol)

• Valporic Acid (anticonvulsant)

• Topamax

• Lamotrigine

Mood Stabilizers

• Mood Stabilizers are commonly listed as Anti-Convulsants because of their calming effect and action dealing with seizures.

• They have lately become very effective in treating such things as Bipolar Disorder, Depression, or Anxeity Disorders.

Mood stabilizer-Side effect

• Depend on specific drug• Li: Thyroid, kidney S/E• Carbamazepine: blood cell• Valproic acid: weight • Topamax/lamotrigine: skin eruption

ماهی 40آقایی • چند معدن، ساله،کارگراضطراب،طپش از حمالتی از که است

احساساز نفسو قلب،احساستنگی . وی است خویششاکی کنترل دادن دستوسواسشستشوهم ساله چندین سابقه

دارد.

Anxiety

• That first date, an important job interview, the big speech, a critical test . . . times when most people feel a little anxious. Sweaty palms and "butterflies" in the stomach during challenging situations are normal.

• Anxiety disorders, however, are medical illnesses that differ dramatically from normal feelings of nervousness. The symptoms of these disorders often occur without warning and make the simplest of life’s routines sources of nearly unbearable discomfort.

Anxiety Disorders: Differentiation

Disorder Core Fear Common Triggers

OCD Obsession Obsession or “Tension”

Panic Disorder Dying Crowds, bridges, etc.

Agoraphobia Being Trapped Open spaces, crowds

GAD Everything Anything stressful

Social Phobia Public Public speaking, Embarrassment Performance anxiety

PTSD Recurrence of Trauma-related places Traumatic Event or experiences

Anxiolytics

• Antidepressants• Benzodiazepines• Buspirone• Antihistamines

– over-rated– tolerance develops

fast

• Neuroleptics


Anxiety Pharmacotherapy

Disorder Acute/Situational Chronic

GAD Buspirone or BZD AD

Panic D/O BZD + AD AD

Social Phobia BZD or b-blocker AD

OCD SSRI same

PTSD BZD AD

BZD=benzodiazepine AD=antidepressant

GAD=generalized anxiety disorder

OCD=obsessive-compulsive disorder

PTSD=post-traumatic stress disorder


Benzodiazepines

• Short-term use or situational anxiety

• Tolerability• Cognitive effects• Enhanced effects

– gender– age– alcohol


Common Benzos: Dosing

Generic Brand Name Starting Dose Usual Dose

Alprazolam Xanax .25-.5 TID 0.75-4.0

Clonazepam Klonopin 0.5-1.0 BID 0.5-4.0

Lorazepam Ativan 0.5-1.0 TID 2.0-6.0

Oxazepam Serax 15-30 TID 30-120

Chlordiazepoxide Librium 5-25 TID 15-100

Zolpidem Ambien 2-5 TID 5-10

Gabapentin Neurontin 2-5 TID 5-10


Benzodiazepine Side Effects

• Behavioral Disinhibition– hostility, aggressiveness, rage reactions

– paroxysmal excitement, irritability

• Psychomotor Impairment– synergistic effects with ETOH

• Cognitive Impairment– impaired visuospatial ability & sustained attention tasks

• Withdrawal Phenomena– flu-like symptoms (mild), psychotic s(x)s or seizures (severe


Miscellaneous• Sexual dysfunction

– Yohimbine• Commonly used but major side effects: Elevated blood pressure and

heart rate, nausea, vomiting, sweating, urinary frequency – Recent 2003 Studies show no effect on sexual performance.

– Sildenafil Citrate (Viagra) (2001)• Originally developed to tx cardiovascular disease. • Side Effects: Combination with nitroglycerin might cause death (severe

hypotension). Blurred vision, blue vision, temp color blindness, breast enlargement, priaprism. 1 study showed 40% of men with heart disease using Viagra with ED had a serious reaction.

– Vardenafil (Levitra) (2003)Newly released by Bayer/SmithGlaxoKline for the tx of ED (similar side effect), similar effectiveness (80%)—more potent.


ADHD

• 3 to 6% of school population

• Treatment– Ritalin (methylphenidate)

– Adderall (Dexedrine & Amphetamine)

• from the amphetamine family

– Atomoxetine

– No clinical proof one is better than the other (Dulcan, 1986)


Methylphenidate (MPH)

• Stimulates many mental functions by blocking dopamine transporter

(i.e.re-uptake blockade at synapse)



• Stimulates many mental functions by blocking dopamine transporter (i.e.re-uptake blockade at synapse)

• Not addictive in ADHD treatment

• Sustained release preparations popular



• Appetite decrease

• Onset insomnia

• Growth problems infrequent with immediate release (Ritalin, Equasym), unknown frequency with sustained release preparations (Concerta XL, Equasym XL)


Atomoxetine

• non-stimulant (?) ADHD treatment• blocks norepinephrine transporter,

especially in frontal lobes• no insomnia though some reduced weight

gain with growth in first 12 months of use• likely to be non-controlled


Risperidone

• reduces aggressive behaviour and rage• reduces tics• looks useful in PDDs • weight gain a problem

علت 24خانمی • ساله،مطلقه،به . حال شرح در است شده ارجاع پرخاشگری

نوسانات و داشته تریاک و مصرفسیگاراقدام بار تحصیلی،چند توفیق خلقی،عدم

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병원약사모임강의 _2006_8 بسم الله الرحمن الرحيم. 병원약사모임강의 _2006_8 psycho pharmacotherapy dr.ghasem dastjerdi psychiatrist