Drugs Used for Mood Disorders

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Drugs Used for Mood DisordersDrugs Used for Mood Disorders

By:By:

Chris Generans, Karen Sandal &Chris Generans, Karen Sandal &

Aiza EspanolAiza Espanol

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Monoamine Oxidase Monoamine Oxidase InhibitorInhibitor

Mechanism of ActionMechanism of Action: :

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

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RXRX:: Phenelzine (Nardil) Phenelzine (Nardil) 15mg TID max dose 90mg QD15mg TID max dose 90mg QD Tranylcypromine (Parnate)Tranylcypromine (Parnate) 10mg BID max dose 60mg 10mg BID max dose 60mg

QDQD Isocarboxazid (Marplan)Isocarboxazid (Marplan) 10mg BID max dose 60mg 10mg BID max dose 60mg

QD QD Selegiline (Emsam)Selegiline (Emsam) 6mg, 9mg & 12mg TD Q24hr max 6mg, 9mg & 12mg TD Q24hr max

dose of 12mg TD QDdose of 12mg TD QD

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USES:USES:

All four are equally effective and have similar side effects. All four are equally effective and have similar side effects. They are most effective in atypical depression, panic disorder, They are most effective in atypical depression, panic disorder, OCD and some phobic disorders. They are used when tricyclic OCD and some phobic disorders. They are used when tricyclic antidepressants is ineffective or when ECT is inappropriate or antidepressants is ineffective or when ECT is inappropriate or refused. refused.

Therapeutic Outcomes:Therapeutic Outcomes: Elevated mood and reduction of symptoms of depressionElevated mood and reduction of symptoms of depression

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Premedication Assessment:Premedication Assessment:

Obtain blood pressure and pulse rate before and at regular Obtain blood pressure and pulse rate before and at regular interval after initiation of therapy.interval after initiation of therapy.

Monitor blood glucose for patient with DM to establish Monitor blood glucose for patient with DM to establish baseline values. MAOI can cause hypoglycemia; Insulin baseline values. MAOI can cause hypoglycemia; Insulin adjustment and oral hyperglycemic therapy maybe required.adjustment and oral hyperglycemic therapy maybe required.

Patient with renal, liver and cerebrovascular disease or CHF Patient with renal, liver and cerebrovascular disease or CHF will not be given any MAOI therapy. Consult HCP first.will not be given any MAOI therapy. Consult HCP first.

Complete diet history to ensure that the patient has not Complete diet history to ensure that the patient has not ingested food containing high Tyramine content in the past ingested food containing high Tyramine content in the past few days.few days.

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Implementation:Implementation:

Instruct patient on how to limit Tyramine-containing foods Instruct patient on how to limit Tyramine-containing foods that may cause a life-threatening hypertensive crises if that may cause a life-threatening hypertensive crises if ingested with MAOI’s.ingested with MAOI’s.

Dosage should be taken in divided doses, with the last dose Dosage should be taken in divided doses, with the last dose administered no later than 6pm to prevent drug-induced administered no later than 6pm to prevent drug-induced insomnia. Patient should not abruptly discontinue the medicineinsomnia. Patient should not abruptly discontinue the medicine

Missed dose should be taken stat and space the remainder of Missed dose should be taken stat and space the remainder of daily dose throughout the rest of the day.daily dose throughout the rest of the day.

Check to be certain if the patient is not receiving meperidineCheck to be certain if the patient is not receiving meperidine

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EvaluationEvaluation::

Side Effects to Expect:Side Effects to Expect:

Orthostatic Hypotension-Orthostatic Hypotension- more significant with Phenelzine more significant with Phenelzine than Tranylcypromine. Tolerance develops after few days of than Tranylcypromine. Tolerance develops after few days of therapy.therapy.

Drowsiness and sedation-Drowsiness and sedation- mild to moderate sedation with mild to moderate sedation with Phenelzine. Caution while driving or performing other tasks Phenelzine. Caution while driving or performing other tasks that require alertness.that require alertness.

Restlessness, Agitation and Insomnia-Restlessness, Agitation and Insomnia- common with common with Tranylcypromine. Take last dose before 6pmTranylcypromine. Take last dose before 6pm

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Evaluation:Evaluation:


Blurred Vision; Constipation; Urinary retention; Dryness Blurred Vision; Constipation; Urinary retention; Dryness of Mucosa of the Mouth, Throat and Noseof Mucosa of the Mouth, Throat and Nose – Symptoms of – Symptoms of Anticholinergic effects by these agents.Anticholinergic effects by these agents.

Encourage adequate fluid intake and foods to provide Encourage adequate fluid intake and foods to provide sufficient bulk.sufficient bulk.

Give stool softeners as prescribed.Give stool softeners as prescribed. Mucosa dryness may be relieved by sucking hard candy or ice Mucosa dryness may be relieved by sucking hard candy or ice

chips or by chewing gum.chips or by chewing gum.

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Side Effects to Report:Side Effects to Report: Hypertension-Hypertension- A major potential complication with MAOI A major potential complication with MAOI

is that of “is that of “Hypertensive CrisisHypertensive Crisis”, particularly with ”, particularly with Tranylcypromine because MAOI blocks amine metabolism in Tranylcypromine because MAOI blocks amine metabolism in tissues outside the braintissues outside the brain

Foods containing large amount of Tyramine such as aged-Foods containing large amount of Tyramine such as aged-cheese, yeast extract, red wines, pickled herring, sauerkraut, cheese, yeast extract, red wines, pickled herring, sauerkraut, overripe bananas, figs, avocados, chicken livers and beers overripe bananas, figs, avocados, chicken livers and beers should be avoided.should be avoided.

Severe occipital HA, stiff neck, sweating, N/V and elevated Severe occipital HA, stiff neck, sweating, N/V and elevated blood pressure– are common prodromal symptoms of blood pressure– are common prodromal symptoms of Hypertensive crisisHypertensive crisis..

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Drug Interactions:Drug Interactions:

DM, carbamazepine, cyclobenzaprine, methylphenidate, DM, carbamazepine, cyclobenzaprine, methylphenidate, sulfonamides, amphetamines, ephedrine, methyldopa, sulfonamides, amphetamines, ephedrine, methyldopa, epi…& norepiepi…& norepi…can potentiate the toxicity of MAOI by …can potentiate the toxicity of MAOI by raising the neurotransmitter levels.raising the neurotransmitter levels.

Tricyclic Antidepressants-Tricyclic Antidepressants- Imipramine & DesipramineImipramine & Desipramine should not be administered concurrently with MAOI. It is should not be administered concurrently with MAOI. It is recommended 14days lapse between both drug therapy.recommended 14days lapse between both drug therapy.

SSRI-SSRI- severe reactions such as convulsion, hyperpyrexia and severe reactions such as convulsion, hyperpyrexia and DEATH may result with concurrent use with MAOI. A 5week DEATH may result with concurrent use with MAOI. A 5week interval is recommended when DC interval is recommended when DC FlouxetineFlouxetine and starting and starting MAOI’s.MAOI’s.

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General Anesthesia; Diuretics & Antihypertensive Agent-General Anesthesia; Diuretics & Antihypertensive Agent- MAOI may potentiate the effects of all three.MAOI may potentiate the effects of all three.

Insulin; Oral Hypoglycemic Agents-Insulin; Oral Hypoglycemic Agents- may cause an additive may cause an additive hypoglycemic effects with MAOI’s.hypoglycemic effects with MAOI’s.

Meperidine CII- Meperidine CII- may cause hyperpyrexia, restlessness, may cause hyperpyrexia, restlessness, hypertension, hypotension, convulsion and COMA when used hypertension, hypotension, convulsion and COMA when used concurrently with MAOI; it can occur several weeks after DC concurrently with MAOI; it can occur several weeks after DC an MAOI. an MAOI.

Morphine CII Morphine CII can be used as substitute instead of can be used as substitute instead of Meperidine.Meperidine.

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Selective Serotonin Reuptake Selective Serotonin Reuptake InhibitorsInhibitors

Mechanism of Action:Mechanism of Action:

Act by inhibiting the reuptake and destruction of serotonin from Act by inhibiting the reuptake and destruction of serotonin from the synaptic cleft; prolonging the actions of neurotransmitters. It the synaptic cleft; prolonging the actions of neurotransmitters. It also inhibits norepi …and to a lesser extent, dopamine.also inhibits norepi …and to a lesser extent, dopamine.

SSRI’sSSRI’s are a newer class of antidepressant chemically unrelated are a newer class of antidepressant chemically unrelated to other antidepressants. to other antidepressants. SSRI’s SSRI’s become the most widely used become the most widely used class of antidepressants It is equally effective as the Tricyclic class of antidepressants It is equally effective as the Tricyclic antidepressants. Advantage of SSRI’s is that they do not have antidepressants. Advantage of SSRI’s is that they do not have anticholinergic and cardiovascular side effects that often limit the anticholinergic and cardiovascular side effects that often limit the use of the Tricyclic antidepressants.use of the Tricyclic antidepressants.

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RX :RX :

Citalopram (Celexa) Citalopram (Celexa) 20mg QD; max of 60mg QD; 20mg QD; max of 60mg QD; Liquid: 10mg/5mlLiquid: 10mg/5ml Duloxetine (CymbaltaDuloxetine (Cymbalta SRSR ) ) 20mg, 30mg & 60mg; Initial dose 20mg, 30mg & 60mg; Initial dose

40mg; max dose of 60mg QD 40mg; max dose of 60mg QD

Escitalopram (Lexapro)Escitalopram (Lexapro) 5mg, 10mg & 20mg; Initial dose 10mg 5mg, 10mg & 20mg; Initial dose 10mg QD; Liquid: 5mg/5mlQD; Liquid: 5mg/5ml

Fluoxetine (Prozac)Fluoxetine (Prozac) Capsule: 10mg, 20mg, 40mg, Initial dose Capsule: 10mg, 20mg, 40mg, Initial dose 20mg QAM; max dose of 80mg QD 20mg QAM; max dose of 80mg QD

Tabs: 10mg, 20mg; Liquid: 20mg/5mlTabs: 10mg, 20mg; Liquid: 20mg/5ml

. .

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RX:RX:

Fluvoxamine (Luvox) Fluvoxamine (Luvox) 20mg, 50mg & 100mg QD; 90mg 20mg, 50mg & 100mg QD; 90mg QHS initial dose; max of 300mg QD QHS initial dose; max of 300mg QD

Paroxetine (Paxil)Paroxetine (Paxil) 10mg, 20mg, 30mg & 40mg 10mg, 20mg, 30mg & 40mg (Paxil(Paxil SRSR):):12.5mg, 25mg & 37.5mg12.5mg, 25mg & 37.5mg Susp: 10mg/5ml; Initial dose 20mg QD; max dose Susp: 10mg/5ml; Initial dose 20mg QD; max dose of 50mg QDof 50mg QD Sertraline (Zoloft)Sertraline (Zoloft) 25mg, 50mg &100mg; 1st dose 50mg QD 25mg, 50mg &100mg; 1st dose 50mg QD

Liquid: Oral conc. 20mg/mlLiquid: Oral conc. 20mg/ml

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USES:USES:

Fluoxetine Fluoxetine - - is the only SSRI that has been approved by FDA for 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 depression in children and adolescents. It is also use in treating premenstrual dysphoric disorder (PMDD).use in treating premenstrual dysphoric disorder (PMDD).

Paxil -Paxil - has been recommended by FDA not to be administered to has been recommended by FDA not to be administered to patients younger that 18 years of age.patients younger that 18 years of age.

Fluvoxamine; Paroxetine; Sertraline & Fluoxetine -Fluvoxamine; Paroxetine; Sertraline & Fluoxetine - are are approved for use in OCD.approved for use in OCD.

Duloxetine -Duloxetine - is also approved for treatment of diabetic peripheral is also approved for treatment of diabetic peripheral neuropathic pain.neuropathic pain.

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Obtain baseline blood pressure in supine, sitting and standing Obtain baseline blood pressure in supine, sitting and standing positions.positions.

Obtain baseline weight, schedule weekly weights.Obtain baseline weight, schedule weekly weights. Note any Note any GI symptomsGI symptoms before starting therapy. before starting therapy. Monitor Monitor CNS symptomsCNS symptoms presents such as insomnia or presents such as insomnia or

nervousnessnervousness Check Check hepatic studieshepatic studies periodically throughout the course of periodically throughout the course of

administrationadministration

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Therapeutic Outcome: Therapeutic Outcome: Elevated mood and reduction of symptoms of depressionElevated mood and reduction of symptoms of depression

Implemention: Implemention: Suicide precautionSuicide precaution should be maintain during drug therapy. should be maintain during drug therapy. Symptoms of depression may improve within few days Symptoms of depression may improve within few days

(appetite, sleep & psychomotor activity)—depression still (appetite, sleep & psychomotor activity)—depression still exists; it usually takes several weeks for the therapeutic dose exists; it usually takes several weeks for the therapeutic dose to have its full effect.to have its full effect.

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Evaluation:Evaluation: Side Effects to Report:Side Effects to Report: Restlessness, Agitation, Anxiety & Insomnia-Restlessness, Agitation, Anxiety & Insomnia- Occurs early Occurs early

in the therapy and may require short term treatment. Avoid in the therapy and may require short term treatment. Avoid bedtime doses to prevent insomnia.bedtime doses to prevent insomnia.

Sedative EffectsSedative Effects: Take precaution while driving of : Take precaution while driving of performing other tasks that require alertness.performing other tasks that require alertness.

GI EffectsGI Effects: Effects may be minimized by temporary reduction : Effects may be minimized by temporary reduction of dosage and administration with food.of dosage and administration with food.

Suicidal Actions:Suicidal Actions: Monitor patients for changes in thoughts, Monitor patients for changes in thoughts, feelings and behavior during initial stages of therapy.feelings and behavior during initial stages of therapy.

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Tricyclic Antidepressants- Tricyclic Antidepressants- Interaction of SSRI and Tricyclic Interaction of SSRI and Tricyclic antidepressants is very complex that may result from increased antidepressants is very complex that may result from increased in toxicity, such as dysrhythmias, seizure activity and CNS in toxicity, such as dysrhythmias, seizure activity and CNS stimulation.stimulation.

Lithium Toxicity- Lithium Toxicity- manifested by nausea, anorexia, fine manifested by nausea, anorexia, fine tremors, persistent vomiting, profuse diarrhea, lethargy and tremors, persistent vomiting, profuse diarrhea, lethargy and weakness.weakness.

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MAOI’s- MAOI’s- severe reactions, including excitement, diaphoresis, severe reactions, including excitement, diaphoresis, rigidity, convulsion, hyperpyrexia, and DEATH. Must be rigidity, convulsion, hyperpyrexia, and DEATH. Must be 14days lapse when DC MAOI. A 5weeks stop interval when 14days lapse when DC MAOI. A 5weeks stop interval when DC Fluoxetine and starting MAOI’s.DC Fluoxetine and starting MAOI’s.

Haloperidol-Haloperidol- increased level and frequency of extrapyramidal increased level and frequency of extrapyramidal symptoms when used concurrently with Fluoxetine and symptoms when used concurrently with Fluoxetine and Fluvoxamine.Fluvoxamine.

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Phenytoin & Phenobarbital- Phenytoin & Phenobarbital- complex reactions. Paroxetine complex reactions. Paroxetine enhance the metabolism these drugs and vice versa-resulting enhance the metabolism these drugs and vice versa-resulting in potential toxicity.in potential toxicity.

Carbamazepine- Carbamazepine- enhance the excretion of Citalopram, enhance the excretion of Citalopram, leading to decreased therapeutic effect.leading to decreased therapeutic effect.

Propanolol & Metoprolol- Propanolol & Metoprolol- Monitor closely for bradycardia Monitor closely for bradycardia and hypotension. Reduce the dose of beta-blocker PRNand hypotension. Reduce the dose of beta-blocker PRN..

Cimetidine - Cimetidine - inhibits the metabolism of Paroxetine and inhibits the metabolism of Paroxetine and Sertraline.Sertraline.

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Warfarin - Warfarin - may enhance the anticoagulation effect. Monitor may enhance the anticoagulation effect. Monitor for bleeding gums, nosebleeds and dark tarry stools. Monitor for bleeding gums, nosebleeds and dark tarry stools. Monitor PT & INR.PT & INR.

Smoking- Smoking- enhances the effect of Fluvoxamine.enhances the effect of Fluvoxamine.

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Tricyclic AntidepressantsTricyclic Antidepressants


The exact mechanism as antidepressant is unknown.The exact mechanism as antidepressant is unknown.

It prolongs the action of norepi… dopamine, and It prolongs the action of norepi… dopamine, and serotonin to varying degrees by blocking the reuptake serotonin to varying degrees by blocking the reuptake of these neurotransmitters in the synaptic cleft of these neurotransmitters in the synaptic cleft between neurons.between neurons.

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RX :RX :

Amitriptyline; AmoxepineAmitriptyline; Amoxepine Clomipramine (Anafranil)Clomipramine (Anafranil) Desipramine (Sinequan)Desipramine (Sinequan) Imipramine (Tofranil)Imipramine (Tofranil) Nortriptyline (Pamelor)Nortriptyline (Pamelor) Protriptyline (Vivactil )Protriptyline (Vivactil ) Trimipramine (SurmontilTrimipramine (Surmontil))

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USES:USES:

After 2 to 4 weeks of therapy, they elevate mood, improve After 2 to 4 weeks of therapy, they elevate mood, improve appetite and increased alertness. appetite and increased alertness.

Sedation is more notable with Amitriptyline and doxapinSedation is more notable with Amitriptyline and doxapin ProtriptylineProtriptyline has no sedative properties and produce mild has no sedative properties and produce mild

stimulation to some patients.stimulation to some patients. All All TricyclicTricyclic compoundscompounds displays anticholinergic activity; displays anticholinergic activity;

considered patients with cardiac disease, BPH or glaucoma.considered patients with cardiac disease, BPH or glaucoma.

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Tricyclic AntidepressantsTricyclic Antidepressants USES:USES:

Imipramine-Imipramine- is approved for treating enuresis in children ages is approved for treating enuresis in children ages 6 and older.6 and older.

ClomipramineClomipramine is used not to treat depression but is approved is used not to treat depression but is approved to treat OCD.to treat OCD.

SelectedSelected TricyclicTricyclic antidepressants are used to treat phantom antidepressants are used to treat phantom limb pain, chronic pain, cancer pain, neuralgia, eating disorder limb pain, chronic pain, cancer pain, neuralgia, eating disorder and PMS. and PMS.

Therapeutic Outcomes:Therapeutic Outcomes: Elevated mood and reduction of symptoms of depressionElevated mood and reduction of symptoms of depression

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Note the consistency of bowel movement; constipation is Note the consistency of bowel movement; constipation is common.common.

Obtain baseline BP in supine and standing positions.Obtain baseline BP in supine and standing positions. Check for HX for symptoms of dysrhythmias, tachycardia, CHF Check for HX for symptoms of dysrhythmias, tachycardia, CHF

and seizures.and seizures.

Implementation: Implementation: Suicide precaution should be maintained during therapy.Suicide precaution should be maintained during therapy.

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Blurred vision, constipation, Urinary retention, Dryness of Blurred vision, constipation, Urinary retention, Dryness of mucosa of the mouth, throat and nose-mucosa of the mouth, throat and nose- these are the effect these are the effect of the anticholinergic agents.of the anticholinergic agents.

Orthostatic Hypotension-Orthostatic Hypotension- dizziness and weakness may occur dizziness and weakness may occur Sedative effects-Sedative effects- single dose at HS may diminish the sedative single dose at HS may diminish the sedative

effect.effect.

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Evaluation:Evaluation: Side Effects to Report:Side Effects to Report:

Tremor, Numbness, TinglingTremor, Numbness, Tingling Parkinsonian SymptomsParkinsonian Symptoms Dysrhythmias, tachycardia, Heart FailureDysrhythmias, tachycardia, Heart Failure Suicidal ActionsSuicidal Actions Report for further evaluation.Report for further evaluation.

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Enhanced Enhanced AnticholinergicAnticholinergic Activity Activity Enhanced Enhanced SedativeSedative Activity Activity BarbituratesBarbiturates- stimulate the metabolism of Tricyclic - stimulate the metabolism of Tricyclic

antidepressantsantidepressants BupropionBupropion - Increase serum levels of Tricyclic - Increase serum levels of Tricyclic

antidepressantsantidepressants

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CarbamazepineCarbamazepine- vertigo, tremor, HA, N/V as a result in - vertigo, tremor, HA, N/V as a result in toxicity.toxicity.

MAOI & SSRI-MAOI & SSRI- severe reaction that can result in toxicity and severe reaction that can result in toxicity and fatal.fatal.

SmokingSmoking- enhance the metabolism of Tricyclic - enhance the metabolism of Tricyclic antidepressantsantidepressants

Thyroid hormones-Thyroid hormones- increased serum levels of Tricyclic meds increased serum levels of Tricyclic meds

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Miscellaneous AgentsMiscellaneous Agents

RX:RX:

Bupropion HCl (Wellbutrin) Bupropion HCl (Wellbutrin) Maprotiline HCl ( Maproetileen)Maprotiline HCl ( Maproetileen) Mirtazepine (Remeron)Mirtazepine (Remeron) Nefazodone (Serzone)Nefazodone (Serzone) Trazodone (Desyrel)Trazodone (Desyrel) Venlafaxine (Effexor)Venlafaxine (Effexor)

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Its mechanism of action is unknown; weak inhibitor Its mechanism of action is unknown; weak inhibitor of the reuptake and inactivation of the of the reuptake and inactivation of the neurotransmitters. Pharmacologic response is similar neurotransmitters. Pharmacologic response is similar to that of Tricyclic antidepressants.to that of Tricyclic antidepressants.

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Miscellaneous AgentsMiscellaneous Agents Therapeutic Outcomes:Therapeutic Outcomes: Elevated mood and reduction of symptoms of depression.Elevated mood and reduction of symptoms of depression.

USES:USES: Use for depressive phase of Bipolar disorder.Use for depressive phase of Bipolar disorder. For patients who cannot tolerate or unresponsive to Tricyclic For patients who cannot tolerate or unresponsive to Tricyclic

antidepressants.antidepressants. Treatment for depression associated with schizophrenia, Treatment for depression associated with schizophrenia,

tremor, anxiety associated with alcohol dependence.tremor, anxiety associated with alcohol dependence. Treatment for Insomnia for patients with substance abuseTreatment for Insomnia for patients with substance abuse

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Obtain BP, HR. Obtain BP, HR. Obtain baseline weight-weeklyObtain baseline weight-weekly Check hepatic studies.Check hepatic studies. Report significant lowering BPReport significant lowering BP Note and monitor GI and CNS symptomsNote and monitor GI and CNS symptoms Report HX for renal & hepatic disease and subs. abuse.Report HX for renal & hepatic disease and subs. abuse.

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Dizziness, DrowsinessDizziness, Drowsiness Nausea, AnorexiaNausea, Anorexia Restlessness, AgitationRestlessness, Agitation Sedation, Orthostatic Hypotension, Sedation, Orthostatic Hypotension, Anxiety, InsomniaAnxiety, Insomnia

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Side Effects to Report: Side Effects to Report:

Suicidal ActionsSuicidal Actions SeizuresSeizures HepatotoxicityHepatotoxicity BradycardiaBradycardia ConfusionConfusion

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LevodopaLevodopa RetonavirRetonavir DigoxinDigoxin St John’s WortSt John’s Wort MAOIMAOI CimetidineCimetidine CisaprideCisapride

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Antimanic AgentAntimanic Agent

RX:RX: Lithium Carbonate (Eskalith)Lithium Carbonate (Eskalith)

MOA:MOA:Lithium is a monovalent cation that competes with other Lithium is a monovalent cation that competes with other

monovalent and divalent cation (KCl, Na, Ca, Mg) .It monovalent and divalent cation (KCl, Na, Ca, Mg) .It replaces the intracellular and intraneuronal sodium replaces the intracellular and intraneuronal sodium stabilizing the neuronal membrane. It reduces the stabilizing the neuronal membrane. It reduces the release of norepi…release of norepi…

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Uses:Uses: Treatment for acute mania and prophylaxis of recurrent manic Treatment for acute mania and prophylaxis of recurrent manic

and depressive episodes of Bipolar disorder.and depressive episodes of Bipolar disorder.

Therapeutic Outcome:Therapeutic Outcome:

Maintaining the patient at the optimal level of functioning with Maintaining the patient at the optimal level of functioning with minimal exacerbations of mood swingsminimal exacerbations of mood swings

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Implementation:Implementation:

Administer medicine 300 to 600mg TQID. Give with food Administer medicine 300 to 600mg TQID. Give with food and remain adequate diet to remain normal sodium levels and and remain adequate diet to remain normal sodium levels and prevent toxicity. Full therapeutic effect requires 10 to 21days.prevent toxicity. Full therapeutic effect requires 10 to 21days.

Side Effects to Expect:Side Effects to Expect: N/V, Anorexia, Abdominal CrampsN/V, Anorexia, Abdominal Cramps Excessive thirst and UrinationExcessive thirst and Urination Fine Hand TremorFine Hand Tremor

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Antimanic AgentAntimanic Agent Side Effects to Report:Side Effects to Report:

VomitingVomiting Profuse DiarrheaProfuse Diarrhea LethargyLethargy WeaknessWeakness Progressive FatigueProgressive Fatigue Weight GainWeight Gain PruritusPruritus Ankle EdemaAnkle Edema Nephrotoxicity Nephrotoxicity

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Reduced Reduced Serum Sodium levels-Serum Sodium levels- it can enhance the toxicity of it can enhance the toxicity of Lithium; low Sodium levels result in low Lithium levelsLithium; low Sodium levels result in low Lithium levels

Methyldopa-Methyldopa- can cause N/V, diarrhea, speech difficulty as a can cause N/V, diarrhea, speech difficulty as a result of Lithium toxicity.result of Lithium toxicity.

Indomethacin, Piroxicam -Indomethacin, Piroxicam - reduced renal excretion of reduced renal excretion of LithiumLithium

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Drugs Used for Mood Disorders