Hand Out - Anat-psychotropic to Antiepileptic

8/12/2019 Hand Out - Anat-psychotropic to Antiepileptic

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DRUGS AFFECTING THE CENTRALNERVOUS SYSTEM

ANATOMY OF THE NEUROLOGICAL SYSTEMBy: Ms. Louradel M. Ulbata, RN, MAN

PHYSIOLOGY OF THE NEUROLOGICSYSTEMOrganization of the Nervous SystemA. Central nervous system (CNS).1. Brain

2. Spinal Cord

B. Peripheral nervous system (PNS).1. Twelve pairs of cranial nerves

2. Thirty-one pairs of spinal nerves

B.1. Autonomic nervous systema. Sympathetic system

b. Parasympathetic system.

B.2. SOMATIC NERVOUS SYSTEMa. Afferent Nerves

b. Efferent Nerves

CELLS OF THE NERVOUS SYSTEM

A. Neuron-the functional cell of the nervoussystem.

1. Common characteristics.a. Responds or reacts to stimuli

b. Conducts impulses

c. Influences other neurons.

2. Structurea. Cell body-contains the cell nucleus whichcontrols cellular activity.

b. Axon-conducts impulses away from the cellbody

c. Dendrites-receive incoming stimuli andtransmit them to the axon of another neuron.

3. Function/classification.a. Afferent neurons (sensory) transmitinformation towards the CNS.

b. Efferent neurons (motor)transmit informationaway from the CNS.

REMEMBER: S MESensory= Afferent; M otor = Efferent

c. Somatic system1). Afferent are sensory neurons that transmit

impulses from the skeletal muscles and skin to

the CNS.

2). Efferent are motor neurons that transmit

impulses that lead to contraction and control of

skeletal muscle.

d. Visceral system.1). Afferent are sensory neurons that transmit

impulses from smooth muscle and cardiac

muscle to the CNS.

2) Efferent are motor neurons that transmit

impulses to the glands, cardiac muscle, and

smooth muscle.

e. Synapse or synaptic terminals are areas of

chemical transmission of an impulse from the

axon of one neuron to the dendrites of another

neuron.

Functional Properties of Neurons

Irritabilityability to respond to stimuli Conductivityability to transmit an

impulse

NERVE FUNCTION is NERVECONDUCTION

ACTION POTENTIALNerve Cell undergoes:

1. Resting Membrane Potential2. Action Potential / Depolarization3. Repolarization / Restabilization

1. RESTING MEMBRANE POTENTIAL Sodium predominates outside the cell,

potassium inside the cell.

Inside of the cell is relatively negativewith the presence of potassium and

large amounts of negative ions.

2. Action Potential / Depolarization When a cell is stimulated, cell

membranes become permeable to

sodium ions.

Sodium moves inside the cell andpotassium moves out.

Inside of the cell becomes positivelycharged.


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Sudden change in the charge of the cellfrom negative to positive is called action

potential.

3. REPOLARIZATION The sodium-potassium pump restores

the original configuration

This action requires ATP Sodium is pumped out of the

cell and potassium back into the

cell.

B.Supporting cells provide support,nourishment, and protection to the neuron.

1. Neurilemmaprotective cells whichsurround the axons in the PNS.

a. Provide for effective regeneration ofPNS nerve fibers.

b. Form the myelin sheath in the PNS.c. No neurilemma present in the CNS.

2. Glial cells protective cells in the CNS;responsible for the formation of the

myelin.

3. Myelin sheath.a. Dense membrane or insulator around

the axon.

b. Facilitates function of the neuron,c. Contributes to the blood-brain barrier to

protect the central nervous system

against harmful molecules.

4. nodes of Ranvier- Intermittent gaps between the

myelin sheath that allow

communication between nerve

fibers.

- Signals jumping from node to

node travel hundreds of

times faster than signals travelingalong the surface of the

axon.

D. Impulse conduction.SALTATORY CONDUCTION An action potential excites one section

of the nerve membrane and electrical

impulse then SKIPS from one node to

the next generating an action potential.

These node-to-node mode ofconduction is termed SALTATORY OR

LEAPING TRANSMISSION

ADVANTAGES OF SALTATORY OfLEAPING TRANSMISSIONMembranes are forming fewer action

potentials so:

1. The speed of conduction is much faster2. The nerve is protected from exhaustion

or using up energy to form multiple

action potentials

Synaptic transmission:TRANSMISSION OF ELECTRICALIMPULSES FROM ONE NEURON TOANOTHER

a. A chemical synapse maintains a one-way communication link between

neurons

synapse -junction between twoneurons.

NERVE SYNAPSE IS MADE UP OF:

1. presynapticnerve -ends BEFOREspecific synapse

2. synaptic cleft -separates synapse bya tiny gap (less than one-

millionth of an inch)

3. Post synaptic Nerve- begins AFTERsynapse

b. Chemical neurotransmitters (neuro-mediators) facilitate the transmission ofthe impulse across the synapse.

1). Acetylcholine.

2). Norepinephrine.

3). Dopamine.

4). Histamine.c. Impulses pass in only one direction.

Impulses are able to cross the synapseto another nerve

Neurotransmitter is releasedfrom a nerves axon terminal

The dendrite of the next neuronhas receptors that are

stimulated by the

neurotransmitter


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An action potential is started inthe dendrite

To return the effector to a resting state sothat it can be stimulated again, the actionsof these neurotransmitter must be stoppedby one or more of these processes:

1. Reuptake by the presynaptic nerve- neurotransmitters are reabsorbed by

the presynaptic nerve to reuse/recycle

2. Inactivation by an enzyme

3. Broken down by enzymes in the area

4. Diffusion out of the synaptic cleft and

removal by the vascular system

d.Nerve regenerationentire neuron is unableto undergo complete regeneration.

1. The axons of the PNS may regenerate via the

connective tissue neurilemma, providing the cell

body of the neuron remains viable.

2. Neuron regeneration in the CNS is very

limited, possibly due to the lack of neurilemma.

3. Scar tissue is a major deterrent to successful

cellular regeneration.

CENTRAL NERVOUS SYSTEM

The brain and the spinal cord within the

vertebral column make up the central nervous

system.

A. The brain and the spinal columnare protected by the rigid bony

structure of the skull and the

vertebral column.

B. Meningesprotectivemembranes that cover the brain

and are continuous with those ofthe spinal cord. (DAP)

1. Dura mater-a tough membraneimmediately outside the

arachnoid; provides protection

to the brain and spinal cord.

2. Arachnoid-a delicatenonvascular, waterproof

membrane that encases the

entire CNS; the subarachnoid

space contains the cerebral

spinal fluid.

3. Pia mater-a delicate vascularconnective tissue layer that

covers the surfaces of the brain

barrier.

C. Cerebral spinal fluid (CSF).

1. Serves to cushion and protectthe brain and spinal cord; brain

literally floats in CSF.

2. CSF is clear, colorless, wateryfluid; approximately 100 to 200

cc total volume, with a normal

fluid pressure of 70 to 150 mm

of water 9average-125 cm water

pressure).

3. Formation and circulation ofCSF.

a. Fluid is secreted by the choroidsplexus located in the ventricles

of the brain.

b. CSF flows through the lateralventricles into the third ventricle,

flows through the Aqueduct of

Sylvius into the fourth ventricle

where the central of the spinal

column opens.

c. From the fourth ventricle, thereare openings into the cranial

subarachnoid space; CSF flows

around the spinal cord ad brain.

d. Since CSF is formedcontinuously, it is reabsorbed at

a comparable rate by the

arachnoid villi.

D. Brain.I. FOREBRAIN Prosencephalon - Pro Die & Te ll Diencephalon => Thalamus,

Hypothalamus Telencephalon => Cerebrum

1. Cerebrumseat ofconsciousness


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- convolutions or gyri & grooves:

sulci or fissures which

expands or increases the surface

area of the brain

- is divided into left and right

hemispheres connected to

each other by the corpus

callosum

- the cerebral cortex is the

surface layer of each

hemisphere.

A. Major lobes of thecentral cortex.

a. Frontal.1). Coordination of voluntary

skeletal muscle movement.

2). Abstract thinking, morals,

judgment.

3). Speech area, motor speech area

(Brocas area) located in only one

hemisphere.

b. Parietal.1. Interprets sensory nerve impulses

(pain, temperature,

touch).

2. Maintains proprioception.

3. Recognition of size, texture, and

shape of objects.

c. Temporal.1. Auditory area- interprets meaning

of certain sounds.

2. Wernickes area- comprehension

and formulation of

speech.

d.Occipital area-interprets visionand controls ability to understand

written words.

e. The limbic lobeis thought to bea link bet emotional & cognitive(thought) mechanisms.

f. Thecentral lobe (insula)isthought to be involved in both

autonomic & somatic activities.

2.Thalamus.1. relay station for all sensory

information

2. Activities related to

consciousness.

3. . Hypothalamus.1. Regulation of visceral

activities-body temperature,

motility and secretions of the GI

tract, arterial blood pressure.

2. Nerve connections with the

thalamus and the cerebral

cortex make it possible for our

emotions to influence visceral

activity.

3. Regulation of endocrine

glands via influence on the

pituitary gland.

4. Neurosecretion of antidiuretic

hormone (ADH) which is stored in

the pituitary

3. Motor areas of the cerebralcortex.a. Primary function is coordination

and control of skeletal muscle

activity.

b. Corticospinal tracts (pyramidaltracts).

1. Descending tract from the

motor area of the

cerebral cortex to the spinal

cord.

2. Majority of nerves cross in the

medulla to the opposite

side before descending into

the spinal cord.

3. These pathways do not cross

over.

c. Brain cells and the nerve fibers in

the descending tracts of the central

nervous system are called uppermotor neurons.

II. MIDBRAIN (MESENCEPHALON)- Consists of 4 rounded bodies, the corpora

quadrigemina:

Paired upper bodies: serve asvisual reflex centers for head &

eyeball movements


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Paired lower bodies: serve asrelay centers for auditory

information

III. HINDBRAIN (RHOMBENCEPHALON) Brainstem

Pons Medulla oblongata

CerebellumA.. Pons- respiratory apneustic center,

nucleus of cranial nerves-

5,6,7,8

B. Medulla oblongata-a continuation of thespinal cord as it enters into the cranial

vault in the brain.

- respiratory and cardiovascular centers,

nucleus of cranial nerves 9,10,11,12

1. Conduction center and crossing

center for the upper motor neurons.

2. Maintains control of cardiac rate.

3. Vasomotor center for constriction

and dilation of vessels.

4. Respiratory center for changes in

rate and depth of breathing.

5. Vomiting reflex center.

6. Swallowing reflex center.

C. The Cerebellum 2nd largest part of the brain w/c consists

of 2 hemispheres& a connecting

portion, the vermis

responsible for coordination of musclemovements

functions:1. helps make muscular movement

smooth instead of jerky &

trembling

2. helps maintain muscle tone &posture

3. impulses from the vestibularapparatus are continuously

delivered to the cerebellum tohelp maintain equilibrium

RETICULAR FORMATION Nerve fibers arising from the central

core of the medulla and lower pons

Reticular Activating System- arises from reticular formation.

- essential for arousing from

sleep and remaining alert.

- Injury to RAS can cause

anesthesia and coma

Basal ganglia (cerebral nuclei)regulate and program muscle

activity coming from the cerebral

cortex.

Movement is controlled by:

a. Cerebral cortexvoluntaryinitiation of motor activity.

b. Basal ganglia-assist to maintainposture.

c. Cerebellum-coordinates musclemovement.

CEREBRAL CIRCULATIONa. The internal carotid arteriesenter the

cranial vault at the temporal area

b. Vertebral arteriesarise from the

subclavian artery and enter the brain at

the foramen magnum.

c. The Circle of Willisis an arterial

anastomosis at the base of the brain.

The circle ensures continued circulation if

one of the main vessels is

disrupted.

THE SPINAL CORD1. The spinal cord is continuous with the

medulla and extends down the vertebral

columns to the level of the first and

second lumbar vertebra.

2. Each column is divided into functional

groups of nerve fibers.

a. Ascending tractstransmit impulses tothe brain (sensory pathway).

b. Descending tractstransmit impulsesfrom the brain to the various levels of the

spinal cord (motor pathways).3. Structure.

a. Closely approximately vertebrae

provide protection from the spinal cord

and nerve roots.

b. Intervertebral discslie between each

vertebra to provide flexibility to the

spinal column.

c. Nucleus pulposusis a gelatin

substance in the vertebral disc.


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5. Upper motor neurons-originate in the

brain, transmit impulses to the

muscles and organs.

6. Lower motor neuronsoriginate in

the spinal cord, transmit impulses

to the muscles and organs.

4. Reflex activity.a. The reflex arch must be intact, the

spinal cord serves as the connection

between the afferent pathway (sensory), and

the efferent pathway (motor).

b. By testing the reflex arc (deep tendon

reflexes), the lower motor neuron and the

sensory/motor fibers from the spinal

column can be evaluated.

Reflex arc

a. Reflexare is the functional unit whichprovides pathways over which nerve

impulses travel.

b. Passage of impulses over a reflex arc

is called a reflex act or a reflex.

c. Reflex arcThe afferent neuroncarries the stimulus to the spine; integrates

it into and through the spine (CNS) to the

efferent neuron; crosses the synapse

with the message from the CNS to the

organ or muscle which responds to the

stimuli. This is the sequence of events

when testing the deep tendon

reflexes.

PERIPHERAL NERVOUS SYSTEM(PNS)

Cranial nerves

1. Twelve pairs of cranial nerves.2. Originate from under the surface

of the brain.

A. Spinal nerves.1. Each pair of nerves is

numbered according to

the level of the spinal

cord from which it

originates.

2. Each spinal nerve is connectedto the cord by two roots.

A. DORSAL (PoSterior)root- receives SENSORYinput from sensory

receptors throughout the

body.

B. Ventral (anterior root)amotor nerve carrying neuron

messages to glands and to

the peripheral area.

REMEMBERDORSAL ROOT/ POSTERIOR=SENSORY

VENTRAL ROOT/ ANTERIOR

= MOTOR

3. The roots fuse at the exit fromthe vertebra to form a mixed

spinal nerve.

4. SPINAL NERVEPLEXUSES

- network of interwoven spinal

nerves

MAJOR PLEXUSES:A. CERVICAL PLEXUSES

a. sends motor impulses to the

NECK muscles

b. Sends out PHRENIC nerve,

activating the diaphragm

c. Receives sensory impulses from

neck snd back of the head

B. BRACHIAL PLEXUSES- Innervates shoulder, arm,

forearm, wrist and hand

c. LUMBOSACRAL PLEXUS- Innervates the lower

extremities.

- Sends out the large SCIATICNERVE

C. Somatic nervous systemassociated withthevoluntarycontrol of body movements via

skeletal muscles,and withsensoryreceptionof

externalstimuli(e.g.,touch,hearing,andsight
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D. autonomic nervous systemregulatesinvoluntary activity (cardiovascular, respiratory,

metabolic, body temperature, etc.)

1. Consists of two divisions that have

antagonistic activity.

2. Parasympathetic divisionmaintains

normal body functions.

- REST & DIGEST

3. Sympathetic division-prepares the

body to meet a challenge or an emergency

(preparation for fight/flight).

SYMPATHETIC VS PARASYMPATHETIC

Parasympathetic:

REST ANDIGEST

Sympathetic:FIGHT

LIGHT

unction: => slows stuffown

=> speed stuffp

ontrol Craniosacral:brain + belowhe belt

Thoracolumbar:bove the belt

Neurotransmittr

ACETYLCHOLIE

EPINEPHRINENE

"DUMBBELS":DiarrheaUrinationMiosis"constrict"BradycardiaBronchoconstrictErection "point"Lacrimation

alivation

Opposite of

Parasympatheti

cs:

Constipation

Urinary retention

Mydriasis "eyes

wide with fright"

Tachycardia

Bronchodilate

Ejaculation

"shoot"

Xerophthalmia

(dry eyes)

Xerostomia (dry

mouth)

CRANIAL NERVES

arenerveswhich start directly from thebrainsteminstead of thespinal cord.

Only the first and the second pairemerge from thecerebrum;the

remaining 10 pairs emerge from the

brainstem.

NUMBER NAME FUNCTION

I.

II.

III.

IV.

V.

VI.

VII.

Olfactory

Optic

Oculomotor

Trochlear

Trigeminal:

Opthalmic

Macillary

Mandibular

Abducens

Facial

Sense of smell

Vision-conducts

information from

the retina

Down and outward

movement of the

eye

Pupillary

constriction and

accommodation

Muscle of the

upper eyelid (ability

to keep the eye

open)

Movement of the

eye

Corneal reflex

Sensory fibers of

the face

Motor nerves for

chewing and

swallowing

Inward movement

of the eye

Facial expression

Sense of taste on

anterior tongue

Muscle of the

eyelid (ability to

close the eye)

VIII.

IX.

X.

Acoustic

Glossopharyngeal

Vagus nerve

Reception of

hearing and

maintenance of

equilibrium

Sense of taste on

posterior tongue

Salivation

Swallowing or

gag reflex

Assists in
http://www.wordiq.com/definition/Nervehttp://www.wordiq.com/definition/Nervehttp://www.wordiq.com/definition/Nervehttp://www.wordiq.com/definition/Brainstemhttp://www.wordiq.com/definition/Brainstemhttp://www.wordiq.com/definition/Spinal_cordhttp://www.wordiq.com/definition/Spinal_cordhttp://www.wordiq.com/definition/Spinal_cordhttp://en.wikipedia.org/wiki/Cerebrumhttp://en.wikipedia.org/wiki/Cerebrumhttp://en.wikipedia.org/wiki/Cerebrumhttp://en.wikipedia.org/wiki/Brainstemhttp://en.wikipedia.org/wiki/Brainstemhttp://en.wikipedia.org/wiki/Brainstemhttp://en.wikipedia.org/wiki/Cerebrumhttp://www.wordiq.com/definition/Spinal_cordhttp://www.wordiq.com/definition/Brainstemhttp://www.wordiq.com/definition/Nerve


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XI.

XII.

Accessory (Spinal)

Hypoglossal

swallowing action

Motor fibers to

larynx for speech

Innervation of

organs in thorax

and abdomen

Important in

respiratory,

cardiac, and

circulatory

reflexes

Ability to rotate

the head and

raise the shoulder

Muscles of the

tongue

PSYCHOTROPIC DRUGS

Drugs that affect mental function Cannot cure psychiatric illness but

they can modify or lessen

symptoms

Classification of Psychotropic Drugs

1. Tranquilizers- decrease anxiety and

hyperactivity causing a marked decrease

in the level of consciousness

1. Antidepressants- Used to treat depression that has

become severe enough to interfere with a

persons ability to function normally.

TRANQUILIZERS

1. Major Tranquilizers- also known as

ANTIPSYCHOTICS

- used to treat psychoses

2. Minor Tranquilizers

- also knows as

ANXIOLYTICS

- used to treat the less

severe neurotic and psychosomatic

MAJOR TRANQUILIZERS/

ANTIPSYCHOTICS

Psychotic Disorders

Definition: Psychotic disorders are

defined as mental disorders in which the

personality is severely altered and a

persons contact with reality is impaired.

Characteristics: delusions, hallucinations,

odd behavior, and incoherent or

disorganized speech

Schizophrenia

literal translation splitmind

separate emotional sidefrom intellectual side

emotional &cognitive processes

don't function

together

Positive schizophrenia

symptoms are caused by an excess

or distortion of normal functions.

The positive symptoms of schizophrenia

include:

Delusions. Delusions are inflexiblemisleading beliefs. They appear as

a result of exaggerations or

distortions of reasoning, as well as

false interpretations of things andevents. For example, one can think

that some book was written

especially for him/her.

Hallucinations. False sensoryperceptions or perceptual

experiences that do not exist in

reality.

Ambivalence.Holding seeminglycontradictory beliefs or feelings

about the same person, event , or

situation

Echopraxia. Imitation of themovements and gestures of

another person whom the client is

observing.

Flight of ideas. Continuous flow ofverbalization in which the person

jumps rapidly from one topic to

another.

Ideas of Reference. Falseimpressions that external eventshave special meaning for the

person.

Perseveration. Persistentadherence to a single idea or topic

; verbal repetition of a sentence,

word or phrase.

Associative Looseness.Fragmented or poorly related

thoughts or ideas


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Negative Symptoms of Schizophrenia

Negative schizophrenia symptoms are

those that reflect a decrease in normal

functions, or a loss of them

Affective flattening ( Flat affect) isusually expressed by the absenceor reduction of emotional

expression, such as mimicry, voice

tone, eye contact and body

language.

Alogiais the tendency to speakvery little or to convey little

substance of meaning ( poverty of

content)

Avolition (Lack of volition) is theabsence of goal-oriented behavior,absence of will, ambition, or drive

to take action or accomplish task.

A person loses interest to the

surrounding world, doesn't do

anything, and sits doing nothing

for long periods of time.

Apathy. Feelings of indifferencetoward people, activities and

events.

Anhedonia. Feeling no joy orpleasure from life or any activitiesor relationships.

Blunted Affect. Restricted range ofemotional feeling, tone or mood.

Catatonia. Psychologically-inducedimmobility occasionally marked by

periods of agitation or excitement;

the client seems motionless, as if in

a trance.

ETIOLOGY OF SCHIZOPHRENIA

NEUROCHEMICAL FACTORSThe dopamine and serotonin

hypothesis:

- schizophrenia is caused by an excess

of dopamine and serotonin activity in the

brain.

Dopamine Pathways

1. Mesolimbic

Projects from brainstem to limbicareas.

Mesolimbic- mesocortical (behavior )

Overactivity produces delusions and

hallucinations

2. Mesocortical

- May be associated with both

positive and negative symptoms

- Blockade may help increase

negative symptoms of schizophrenia

3. Nigrostriatal

- Projects from thesubstania nigra to the basal

ganglia

A part of theextrapyramidal system

Thus side effects arecalled extrapyramidal Extrapyramidal

-> part of the

nervous system that regulates muscle

reflexes.

Types of movement disorderscaused by this pathway include:

Akathisia Dystonia Tardive dyskinesia Tremor, rigidity,

bradykinesia

Drug-inducedParkinsonism

4. Tuberoinfundibular

Tuberoinfundibular- pituitarysystem (endocrine)

Endocrine control - tubero-infundibular system.

- Dopamine and dopamineagonists suppress prolactin release,

dopamine antagonists may stimulate it

leading to increased prolactin

Blockade produces galactorrhea

Antipsychotic drugs

-block DA receptors in both systems and

therefore Parkinsonian symptoms and

EPS are side effects.

CATEGORIES OF ANTIPSYCHOTIC

1. CONVENTIONAL/ TRADITIONAL/TYPICAL ANTIPSYCHOTIC DRUGS

- are dopamine

antagonists

- targets only the

positive signs of schizophrenia

2. ATYPICAL/ NEWER

ANTIPSYCHOTIC DRUGS

- are both dopamine

and serotonin antagonist

- targets both

positive and negative signs of

schizophrenia

Traditional/ Conventional

/Typical Antipsychotics


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Phenothiazines chlorpromazine

(Chlorpromazine Mixture,

Chlorpromazine Mixture

Forte, Largactil)

fluphenazine(Anatensol,Modecate) flupenthixol(Fluanxol) pericyazine(Neulactil) pimozide(Orap) thioridazine(Aldazine) trifluoperazine(Stelazine) zuclopenthixol(Clopixol)

Butyrophenones haloperidol(Haldol,

Serenace)

droperidol(DroleptanInjection) Chlorpromazinewas the

first anti-psychotic drug developed

Mechanism of Action of

Phenothiazines

The drugs found in this class areantagonists.

They work by blocking theDopamine receptors in the

dopamine pathways of the brain;

thus, decreasing the normal effect

of dopamine release.

Blocking the dopamine receptorsin the mesolimbic pathway results

in the antipsychotic effect.

Butyrophenones

Butyrophenones are high-potencyantipsychotics (potency refers not

to effectiveness but rather to the

ability to bind to dopamine

receptors)

Haloperidol (Haldol) is the most

common of the butyrophenones

Mechanism of Action

All the butyrophenones work inthe same manner as the

phenothiazines.

They block the dopaminereceptors in the dopamine

pathways, thus, thwarting any

possible over excitation of the

dopamine receptors.

Typical Antipsychotics

Phenothiazines andButyrophenonesare typical

antipsychotics

These drugs are no longerregarded as the best practice for

treating psychotic disorders, eventhough they are still commonly

utilized in emergency treatments.

The reason for this is that they arenot very selective. They do not

only block the D2 receptors of the

mesolimbic pathway but also

block the D2 receptors in the

nigrostriatal pathway,

mesocortical zone, and

tuberoinfundibularpathway.

The fact that they are not veryselective causes the extrapyramidal symptoms such as

tardive diskinesia

Atypical Anti-psychotics

Were developed in an attempt tominimize the side effects of typical

anti-psychotics

They have proven to cause fewerextra

pyramidal symptoms (EPS) when

compared

to typical anti-psychotics.

They produce fewer EPS becausethey are

more selective.

Atypical agents aripiprazole(Abilify) clozapine(CloSyn, Clopine,

Clozaril)

risperidone(Risperdal) quetiapine(Seroquel) amisulpride(Solian) olanzapine(Zyprexa) ziprazidone(Zeldoxx)

Mode of Action

Dopamine and serotoninAntagonists

Atypical antipsychotic drugs havea similar blocking effect on

dopamine receptors but appear to

be more selective in targeting the

intended pathway to a larger

degree than typical antipsychotics.

They also interact with otherneurotransmission systems,

particularly with the serotonergic

and noradrenergic pathways.


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SIDE EFFECTS OFANTIPSYCHOTIC DRUGS

A. NEUROLOGIC SIDE EFFECTS

1. EXTRAPYRAMIDAL SIDE EFFECTS(EPS)

2. TARDIVE DYSKENISIA3. SEIZURES4. NEUROLEPTIC MALIGNANT

SYNDROME

EXTRAPYRAMIDAL SIDE

EFFECTS (EPS)

- Are reversible movementdisorders induced by neurolepticmedication.

- Include:a. Dystonic reactions

b.

Pseudoparkinsonism

c. Akathisia

1. DYSTONIA- characterized by spasms in

discrete muscle groups such as theneck muscles (torticollis) or eye

muscles ( oculogyric crisis)

- these may also be accompanied

by protrusion of the tongue,

dysphagia, and laryngeal spasms

- extremely frightening and painful

to the pt

- Treatment:

Diphenhydramine (Benadryl)

Benztropine (Cogentin)

2. Pseudoparkinsonism

- Neuroleptic-induced

parkinsonism

- characterized by:

a. shuffling gait

b. masklike facies

c. muscle stiffness

d. rigidity

e. drooling

f. akinesia ( slowness and

difficulty

initiating movement)

g. tremors

Treatment:

-Benztropine Sulfate

(Cogentin)

- Biperiden ( Akineton)

3. AKATHISIA

- characterized by restlessness,

movement, pacing, inability to

remain still.

Treatment:

Propranolol (Inderal)

Benzodiazepines

TARDIVE DYSKINESIA

- a late appearing

side effect of antipsychotic

medications

- characterized by

abnormal, involuntary movements

such as lip smacking, tongue

protrusion, chewing, blinking,

grimacing.

- Irreversible once ithas appeared

CLOZAPINE atypical

antipsychotic has not not been

found to have this effect

SEIZURE

- Clozapine is a

notable exception

- associated with

high dosage of med

NEUROLEPTIC MALIGNANT

SYNDROME ( NMS)

- serious and fatal side

effect

- characterized by:

FFever AAutonomic instability LLeukocytosis TTremor EElevated enzymes (elevated

CPK)

RRigidity of muscles- treated by stopping the medication- Prescribe bromocriptine and

dantrolene (dopaminergic

agonists)

NON-NEUROLOGIC SIDE

EFFECTS

Blurred visionConstipationUrinary retentionMemory dysfunctionDry mouthSinus tachycardiaSedation, drowsinessWeight gainHypotension


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aminobutyric acid (GABA) more

effective causing interference with

neuron firing.

OTHER ANXIOLYTIC ANDHYPNOTIC DRUGS

1. Paraldehyde ( Paral)

- A very old drug used orally andrectally to sedate patients with

delirium tremens or psychiatric

conditions characterized by

extreme excitement

- Has distinctive odor- Cannot be stored in plasticcontainers or dispensed with a

plastic spoon or syringe

- Dilute first before using, use foodto improve taste, keep away from

heat and flame, discard any

unused portion

2. Buspirone ( Buspar) A newer antianxiety agent Has no sedative, anticonvulsant or

muscle relaxant properties

It reduces the signs and symptomsof anxiety w/o many of the CNS

effects and severe adverse effects

associated with other anxiolytic

drugs.

Rapidly absorbed by the GI Metabolized in the LIVER Excreted in the URINE Caution in pts with hepatic or

renal impairment and elderly

patients

May cause dry mouth andheadache

3. Ramelteon ( Rozerem)

Introduced in 2005 First of a new class of

sedatives/hypnotics, MELATONIN

RECEPTOR AGONISTS

Stimulates the melatonin receptorwhich are thought to be involved

in the maintenance of circadian

rhythm and the sleep-wake cycle

Used for treatment of insomniacharacterized by difficulty with

sleep onset

Metabolized in the LIVER Excreted in FECES and URINE Should be administered 30minutes before bed; allow 8 hours

of sleep

Patients should be monitored fordepression and suicidal ideation

NURSING IMPLICATION FOR

PSYCHOTROPIC DRUGS

1. Careful initial assessment of ptsbehavior

2. Pts with psychiatric disturbancesshould watched as they take their

meds

- stay w/ them as

they take the meds and check the

mouth if it has been swallowed

3. MAJOR TRANQUILIZERS: Close

observation and reporting of the

earliest signs of EPS.

Earliest sign of TD : AbN

movt of tongue muscles

4. Caution pt not to drive or

perform potentially dangerous

activities

5. POSTURAL HYPOTENSION :

Warn not to change body position

quickly.

6. PHOTOSENSITIVIY: Warn not to

stay outside in bright sunlight as

this can lead to eye damage and

skin pigmentation.7. Warn pt & family bwt changes in

body appearance and sexual

function (eg; weight gain,

gynecomastia, changes in mens,

galactorrhea, decreased libido)

8. inform client of side effects and

encourage to report problems

instead of discontinuing

medication

teach client methods of managing

or avoiding unpleasant side effects

and maintaining medication

regimen:

dry mouth sugar-freefluids and sugar-free hard

candy

* client should avoid calorie-ladenbeverages and candy

constipation exercise,increase water and bulk-

forming foods; stool


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softener permissible but

avoid laxatives

photosensitivity sunscreen

10. Report signs of infection (fever,

sorethroat

ANTIDEPRESSANTS

DEPRESSION

- Is an affective disordercharacterized by overwhelming

sadness, despair and hopelessness

that is inappropriate with respect

to the event or events that

precipitated the depression.-

BIOGENIC AMINE THEORY OF

DEPRESSION

States that depression is caused bydeficiency of biogenic amines

norepinephrine (NE), serotonin (

5HT) and dopamine in certain

areas of the brain

Causes of Deficiency of Biogenic

Amine

1. Monoamine Oxidase ( MAO) maybreak them down to be recycled or

restored in the neuron

2. Rapid fire of the neurons may leadto their depletion

3. Numbers or sensitivity ofpostsynaptic receptors may

increase depletingneurotransmitter levels

DRUG THERAPY FOR

DEPRESSION

ANTIDEPRESSANT DRUGS

- most effective

means of treating depression

- counteracts the

effects of neurotransmitter

deficiencies

- Increases the level

of biogenic amines in the brain

in three ways:

a) may inhibit the

effects of MAO

b) block reuptake by

the releasing nerve

c) may regulate

receptor sites and breakdown

of neurotransmitters

THREE (3) GROUPS: 1. TRICYLIC ANTIDEPRESSANTS

(TCAs)

2. MONOAMINE OXIDASEINHIBITORS (MAOIs)

3. SELECTIVE SEROTONINREUPTAKE INHIBITORS (SSRIs)

MONOAMINE OXIDASE INHIBITORS

(PANAMA)

1. Tranylcypromine (Parnate)2. Phenelzine ( Nardil)3. Isocarboxacid ( Marplan)

THERAPEUTIC ACTIONS

- Inhibit MAO, an enzyme found innerves and other tissues that

breaks down the biogenic amine

NE, dopamine and 5GT.

It takes 2-3 weeks before initial

therapeutic effects become

noticeable

DRUG FOOD INTERACTIONS

Patients taking MAOIs shouldavoid TYRAMINE-CONTAINING

FOODS

Tyramine and other amines thatare found in food which are

normally metabolized by MAO

enzymes in the GI may be

absorbed in high concentrations in

the presence of MAOIs, resulting in

increased blood pressure (

HYPERTENSIVE CRISIS)

Tyramine causes the release ofstored NE in the nerve terminals

which further contributes to high

BP

HYPERTENSIVE CRISIS

- characterized by:a. Occipital

Headache

b. Palpitations

c. Neck stiffness

d. N& V

e. sweating

f. dilated pupils

g. photophobia

h. tachycardia

i. chestpain

j. may progress to

intracranial bleeding and stroke

TYRAMINE CONTAINING FOODS


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A VOCADO B ANANA C HEDDAR and AGED CHEESE S OY SAUCE & PRESERVED

FOODS

DRUG-DRUG INTERACTIONS

MAOIs w/ TCAs:- hypertensive crisis

- coma

- severe convulsions MAOIs with SSRI :

- Serotonin

Syndrome

- rapid

changes in vital signs (fever,

oscillations in blood pressure),

sweating, nausea, vomiting,

rigid muscles, myoclonus,

agitation, delirium, seizures,

and coma.

- A period of 6 weeks should elapseafter stopping an SSRI before

beginning therapy with a MAOI

TRICYCLIC ANTIDEPRESSANTS

(TCAs)

- All reduces the reuptake of 5HTand NE into the nerves

- It takes 2-3 weeks before initialtherapeutic effects become

noticeable.

THERAPEUTIC ACTIONS

Inhibit presynaptic reuptake of the

neurotransmitters NE and 5HT

which leads to the accumulation of

these neurotransmitters in the

synaptic cleft and increased

stimulation of the postsynaptic

receptors.

TRICYCLIC ANTIDEPRESSANTS

Imipramine (Tofranil) Amitriptylline Amoxapine (Asendril) Clomipramine (Anafranil) Desipramine (Nopramin) Doxepin (Sinequan)

TCA:

CHECK:

1. BP it causes HYPOTENSION2. HEART RATE it causes CARDIAC

ARRYTHMIAS

SELECTIVE SEROTONINREUPTAKE INHIBITORS

Newest group of antidepressantdrugs

Specifically blocks the reuptake of5HT, with little to no known effect

on NE

Do not have the many adverseeffects associated with TCAs and

MAOIs so they are a better choice

for many patients

THERAPEUTIC ACTIONS

Specifically blocks the reuptake of5HT, with little to no known effect

on NE, increasing the levels of 5HT

in the synaptic cleft.

SELECTIVE SEROTONIN

REUPTAKE INHIBITORS

FLUOXETINE (prozac)- first SSRI

- Indicated to treat

depression, obsessive-

compulsive d/o, bulimia, panic

disorders and premestrual

dysphoric disorder

Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) Citalopram (Celexa)

SIDE EFFECTS OF

ANTIDEPRESSANTS

Dry mouth -it is helpful to drinksips of water; chew sugarless gum;

brush teeth daily.

Constipation -bran cereals, prunes,fruit, and vegetables should be in

the diet.

Bladder problems -emptying thebladder completely may be

difficult, and the urine stream may

not be as strong as usual. Older

men with enlarged prostate

conditions may be at particular

risk for this problem. The doctor

should be notified if there is any

pain.

Sexual problems -sexualfunctioning may be impaired; if


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this is worrisome, it should be

discussed with the doctor.

Blurred vision -this is usuallytemporary and will not necessitate

new glasses. Glaucoma patients

should report any change in visionto the doctor.

Dizziness -rising from the bed orchair slowly is helpful.

Drowsiness as a daytime problem -this usually passes soon. A person

who feels drowsy or sedated

should not drive or operate heavy

equipment. The more sedating

antidepressants are generally

taken at bedtime to help sleep andto minimize daytime drowsiness.

Increased heart rate -pulse rate isoften elevated. Older patients

should have an electrocardiogram

(EKG) before beginning tricyclic

treatment.

NURSING IMPLICATION

Arrange for lower dosage inelderly patients and in those withrenal or hepatic impairment bcoz

of the potential for severe adverse

effects

Monitor for patients for up to 4weeks to ascertain onset of full

therapeutic effect before adjusting

dosage

Establish suicide precautions forseverely depressed patients and

limit the quantity of the drug

dispensed to decrease the risk ofoverdose

Administer the drug once a day in

the morning to achieve optimal

therapeutic effects. If the dosage is

increased or if the patient is having

severe GI effects, the dosage can be

divided

MAOI:

Monitor BP and signs of HPN Crisis Have phentolamine or another

adrenergic blocker on standby as

treatment in case of hypertensive

crisis

Provide a list of potential drug-food interactions that can cause

severe toxicity to decrease the risk

of a serious drug-food interaction.

Provide a diet low in tyramine.

Inform pt that these foods mustnot be eaten while the medication

is being taken or 2-3 weeks after it

has been discontinued.

Anti- manic agent

LITHIUM CARBONATE

Decreases pts HYPERACTIVITY Best taken after meals Takes 10-14 days before

therapeutic effect becomes

evident.

- Antipsychotic is

administered during the first two

(2) weeks to manage the acutesymptoms of mania until lithium

takes effect.

Instruct pt to increase fluid intake(3L/ day) and sodium intake

(3gm/day)

Monitor serum levelNormal : .5 -

1.5 meq/ L

LITHIUM TOXICITY

- Nausea, Anorexia,

Vomiting, Diarrhea, AbdominalCramps

Mannitol administered if toxicity

occurs

ANTI-EPILEPTIC DRUGS

I. Epilepsy

- Is characterized by seizures thatresult from sudden discharge ofexcessive electrical energy from

nerve cells in the brain

Pathological Basis: Abnormal electrical discharge in the

brain. Imbalances occur between

glutamate-mediated excitatory

neurotransmission and gamma-

aminobutyric acid (GABA) mediatedinhibitory neurotransmission.

Changes in ion channels

TYPES OF SEIZURES

2 BROAD CATEGORIES:

1.generalized

- are produced by electrical impulsesfrom throughout the entire brain,

2. partial (also called local or focal).


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- are produced (at least initially) by

electrical impulses in a relatively small part

of the brain.- The part of the brain generating the

seizures is sometimes called the FOCUS

Generalized seizures

1. Grand-mal seizure- also known as tonic-clonic

seizure

- involve dramatic tonic-clonic

muscle contractions, loss of consciousnessand a recovery period characterized

by confusion and exhaustion.

2. Absence seizures( Petit mal)- involve abrupt, brief (3-5 seconds)

periods of loss of consciousness.

- The patient typically interrupts an activity

and stares blankly.

- Patients are usually not aware that they arehaving a seizure, except that they

may be aware of "losing time."

- occurs more frequently in children anddisappears at puberty

3. Myoclonic seizures- consist of sporadic periods of

muscle contractions, usually on both sides of

the body.

- Patients sometimes describe the jerks asbrief electrical shocks. When violent, these

seizures may result in dropping or

involuntarily throwing objects.

4. FEBRILE SEIZURES

- are related to very high fevers and usually

involve convulsions.- most frequently occur in children

- usually self-limited and do not reappear

5. STATUS EPILEPTICUS- the most dangerous of all seizure

conditions- a state in which seizures rapidly recur

again and again

Partial Seizures

Partial seizures are divided into:

1. simple

2. complex

1. SIMPLE- awareness is retained- occur in a single part of the brain and may

involve a single muscle movement or

sensory alteration

2. Complex partial seizures- by definition, include impairment of

awareness.- involve complex sensory changes such as

hallucinations, mental distortion, changes in

personality, loss of consciousness and lossof social inhibition

ANTIEPILEPTIC DRUGS

A drug which decreases the frequencyand/or severity of seizures in people withepilepsy

Treats the symptom of seizures, not theunderlying epileptic condition

Goal

maximize quality of life byminimizing seizures and adverse drug

effects

Basis of Pharmacological Rx

Most anti-epileptic agents act either by

blockade of depolarization channels (Na+and Ca++)

OR

Enhancing the activity of GABA

(neurotransmission inhibition)

DRUGS FOR TREATING TONIC-

CLONIC SEIZURES

1. HYDANTOINS

2. BARBITURATES ANDBARBITURATE-LIKE DRUGS

3. BENZODIAZEPINES

THERAPEUTIC ACTION

- all stabilize nerve membranesthroughout the CNS to decrease excitability

and hyperexcitability to stimulation.

- BENZODIAZEPINES- Decrease excitability and

conduction

HYDANTOINS & BARBITURATES- Stabilize the nerve membraneby influencing ionic channels in

the cell membranes

HYDANTOINS* promote the exit of sodium ions from the

cell, returning the cell to a stable restingmembrane potential

* less sedating than many other

antiepileptics


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- Phenytoin ( Dilantin)

- Ethotoin ( Peganone)

- Fosphenytoin (Cerebyx)

PHENYTOIN (DILANTIN)

Although an effective and well triedantiepileptic, it is not the first line intreatment of partial or generalized

epilepsy due to its toxicity

Limited water solubility not giveni.m.

Slow, incomplete and variableabsorption..

Metabolized by liver Therapeuticplasma concentration:

10-20 g/ml

CONTRAINDICATION

Those who are allergic to Dilantin,phenytoin, or any inactivecomponents used to make the

medication.

DRUG INTERACTIONS

Alcohol- Alcohol can interfere with the way

the body handles Dilantin.

- Chronic alcohol intake candecrease the level of Dilantin in the

blood, while short-term intake of a large

amount of alcohol can increase the level

of Dilantin in the blood.

SIDE EFFECTS:

Confusion. Dizziness Insomnia Twitching Headaches Nausea,vomiting, or constipation Larger or fuller lips Excessive body or facial hair. High blood sugar (hyperglycemia) Signs of liver damage, such as

yellow skin or eyes (jaundice)

Unexplained bruising or bleeding Swollen or tender lymph nodes Bending of the penis (which makes

intercourse difficult)

Suicidal thoughts or behavior Signs of an allergic reaction,

including unexplained rash, hives,

itching, and unexplained swelling.

Gingival Hyperplasia Sexual-Endocrine Effects:

Osteomalacia- softening of the bones due

to defective bone mineralization.

Hirsutism- excessive hairiness on

humans in those parts of the body whereterminal hair does not normally occur or is

minimal

Hyperglycemia

Teratogenic effects

Fetal hydantoin syndrome Cleft lip Cleft palate Congenital heart disease Mental retardation

NURSING RESPONSIBILITIES:

Dilantin comes in extended-releasecapsules, chewable tablets, and an

oral suspension. These products are

not interchangeable. It can be taken with or without food.

If it upsets the stomach, it may be

taken with food. It is important thatpt takes it consistently the same way

(either with food or without food).

The medication should be taken atthe same time each day to maintain

even levels of the drug in the blood.

It should not be stopped without firstdiscussing with thehealthcare

provider.

Seizure medications, includingDilantin, may increase the risk ofsuicidal thoughts or behavior. If pt

feels depressed or has any suicidal

thoughts, let the healthcare provider

know right away Dilantin may increase blood sugar.

This is especially important for

people with diabetes. Dilantin may cause bone weakness,

because it affects the way the body

deals with vitamin D (which isimportant for strong bones).

* As with all seizure medications, Dilantin

should not be stopped suddenly.* Because Dilantin can cause gum problems,

good dental care is very important while pt

is taking Dilantin

BARBITURATES & BARBITURATE-

LIKE DRUGS

Phenobarbital (Luminal)- Primidone (Mysoline)

- Mephobarbital (Mebaral)

PHENOBARBITAL(SOLFOTON, LUMINAL)


19/20

- available in oral and parenteral

forms

- used for emergency control ofstatus epilepticus and acute

seizures

- TSL: 15-40 mcg/ml

BENZODIAZEPINES

DIAZEPAM (VALIUM) CLONAZEPAM ( KLONOPIN) Potentiate the effects of GABA, an

inhibitory neurotransmitter

DIAZEPAM (VALIUM)

- not used for long term management

of epilepsy- well absorbed from the GI tract

- metabolized in the liver

- excreted in the urine

DRUGS FOR TREATING ABSENCE

SEIZURES

1. SUCCINAMIDES

Modulate the inhibitoryneurotransmitter GABA

a. Ethosuximide (Zarontin)

B. Methsuximide (Celontin)

ETHOSUXIMIDE (ZARONTIN)

DOC for treating absence seizures Has fewer adverse effects compared

with many other antiepileptic drugs

Available for oral use TSL: 40-100 mcg/ml

METHOSUXIMIDE (CELONTIN)

Oral drug used to treat absenceseizures that are resistant to other

drugs

Associated with bone marrowsuppression

THERAPEUTIC ACTION:

Suppress the abnormal electricalactivity in the brain that is assoc with

absence seizure

Ethosuximide should be tried first;methosuximide should be reserved

for the tx of seizures that are

resistant to other agents because it isassociated with more severe adverse

effects

OTHER DRUGS FOR TREATING

ABSENCE SEIZURES

1. VALPROIC ACID (DEPAKENE)

- reduces abnormal electrical activity

in the brain and may also increase GABA

activity at inhibitory receptors- DOC for the treatment of

myoclonic seizures

- 2nd DOC for the treatment ofabsence seizures because it is associatedwith hepatic toxicity and has more SE.

2. Acetazolamide (Diamox)

- sulfonamide drug

- tx of absence seizures- also used to tx open-angle and

secondary glaucoma, acute mountain

sickness, decrease edema assoc with CHF

3. ZONISAMIDE (Zonegram)- newer agents that inhibit voltage-

sensitive sodium and calcium channels, thus

stabilizing nerve cell membranes- should be tapered over 2 weeks

when discontinuing as this could increase

the risk of seizure.- pt should increase fluid intake

because of the risk of renal calculi

DRUGS FOR TREATING PARTIAL

(FOCAL)SEIZURES

1. CARBAMAZEPINE (TEGRETOL)

MECHANISM OF ACTION It works by blocking sodium

channels in the brain. By blocking

sodium channels, the medicationmay decrease the activity of nerve

cells, preventing them from firing

abnormally.

SIDE EFFECTS

dizziness upset stomach headache unsteadiness double vision N& v

ADVERSE EFFECTS:

Anemia or other blood disorders- Aplastic anemia

- Agranulocytosis

Unusual bruising or bleeding Worsening of seizures Hallucinations Depression Suicidal thoughts or behaviors Increased infections or infections

that do not go away


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Water retention, swelling, ordifficulty breathing, which can be

signs of (CHF)

HBP (HPN) or LBP (hypotension) An irregular heart rhythm

(arrhythmia) Yellowing of the whites of the eyes

or skin (jaundice), which may be a

sign of liver damage, including liver

failure or hepatitis Difficulty passing urine or a sudden,

unexplained decrease in urine

production (which can be a sign ofkidney damage)

Low sodium levels in the blood(hyponatremia),which may cause

symptoms such as:

Loss of appetite Nausea or vomiting Irritability Excessive tiredness Confusion Hallucinations Muscle weakness Muscle spasms or cramps

Signs of an allergic reaction,including:

An unexplained rash Hives Itching Unexplained swelling

Stevens-Johnson syndrome (SJS) ortoxic epidermal necrolysis (TEN).

- very dangerous skin

reactions

- These problems start outas skin rashes but can progress

to permanent disfigurement or

even loss of life.

CONTRAINDICATIONS:

Those who: Are allergic to carbamazepine or any

of the inactive components used to

make carbamazepine.

Have had bone marrow depression inthe past. Bone marrow depression is

a blood disorder in which the bone

marrow does not function properly toproduce blood cells.

Are allergic to TCAs Have taken a monoamine oxidase

inhibitor (MAOI) within the past twoweeks.

2. Oxacarbazepine

derivative of carbamazepine Similar mechanism of action and

toxicity to carbamazepine

No report of hepatic failure or bonemarrow suppression

less drug interactions Partial seizure

3. LAMOTRIGINE (LAMICTAL)

Indications Partial seizures +/- secondary

generalization Lennox-Gastaut Syndrome Also used in primary

generalized epilepsy(absence, myoclonic)

Lennox-Gestaut syndrome Childhood epileptic encephalopathy(Lennox-Gastaut syndrome [LGS])

is a devastating pediatric epilepsysyndrome

Child-onset epilepsy (4-6 years) 5 % of epileptic attacks in children Severe and difficult to treat Multiple attacks daily

ADVERSE EFFECTS Signs of a dangerous allergic

reaction, including:

Hives or any rash Fever Swollen lymph nodes

(swollen "glands")

Painful sores in or around themouth or eyes

Swelling of the lips or tongue Suicidal thinking or behavior Lamictal can cause very serious skin

rashes and allergic reactions.

- These rashes can cause

large sections of the skin to dieand can cause disfigurement or

even loss of life

- SJS and TEN- Gradual administration

decreases the risk

Documents

Hand Out - Anat-psychotropic to Antiepileptic