DOSE: 10mg, 25mg, 50mg, 100mg.
ROUTES: Oral (Tablet, Syrup, and Suspension) Intramuscular, Rectal
USES: Anti-psychotic, Sedative, Agitation, Anorexia Nervosa, and Behavioural Disturbances.
ALIMENTARY TRACT: Dry Mouth, Polydypsia, Anti- Emetic, Appetite Stimulant, Hiccup Control, and Constipation.
SKIN: Photosensitivity, Pigmentation.
EYES: Blurred Vision, Pigmentation, and Oedema.
CARDIO VASCULAR: Hypotension, Tachycardia, and Myocardial Infarction.
GENITO-URINARY: Impotence, Polyuria.
LIVER: Jaundice, Failure, and Hypothermia.
CEREBRAL: Drowsiness, Lethargy, Depression, and Insomnia.
EXTRA PYRAMIDAL REACTIONS: Parkinsonism, Akathesia, Distonia,
Occulogyric Crisis, Tardive Dyskinesia.
OTHER: Antidote to L.S.D.
DRUGS OF THIS TYPE.
Haloperidol, Thioridazine, Promazine, Trifluoperazine.
MORE MAJOR TRANQUILIZERS
BRAND NAME: Haldol
FREQUENCY: 4 times daily plus PRN (if necessary) dose as prescribed
DOSE: 1.5mg-20mg daily initially, to a maximum of 200mg daily up to 4 times daily.
ROUTE: Oral, Liquid, Intramuscular
EFFECTIVITY: 20-30 minutes Intramuscular, 2-3 hours orally
USES: Mental Illness, Anxiety
Sedatives- increases sedation
Anti Cholinergic- increased effect from Haloperidol
Anti Convulsants – Dose may have to be adjusted
Extra Pyramidal Reactions
Heart conditions Parkinson’s Disease
Liver or Kidney conditions Glaucoma
Epilepsy Lung disorders
Thyrotoxic conditions Medications as above
Pregnancy Breast Feeding
Alcohol Work with hazardous machinery
ATYPICAL ANTI PSYCHOTICS
Indications: Psychotic Illnesses, also with accompanying Anxiety and /or Depression
Brand Name: Zyprexa
Missed Dose: Take Dose as soon as possible, do not take 2 doses in one day
Warnings: Pregnancy and Breast Feeding, Driving or using machinery.
Contra-indications: Do not take if Allergic to this drug. Narrow Angle Glaucoma
Precautions: Liver or Kidney Disease. Parkinson’s Disease. Epilepsy. Prostate Problems. Paralytic Ileus. Blood Disorders. Over 65 years need monitoring.
Age Restriction: Not for patients under 18
Food Issues: With or without food, but with water
Dizziness also in Lying or sitting
Extra Pyramidal Reactions
Tremor and Rigidit
Milk Secretion in Women
Missed or Irregular Periods
Treatment-resistant Schizophrenia (patients non-responsive to, or intolerant of conventional neuroleptics).
Initially, 25 – 50mg on the FIRST DAY, increasing by DAILY INCREMENTS OF 25 – 50mg to reach a THERAPEUTIC DOSE within the range of 200 – 450mg daily. Once control is achieved a MAINTENANCE DOSE OF 150-300mg may suffice. MAXIMUM DOSE – 900mg DAILY.
Daily doses should be divided, the larger portion given at night.
25mg and 100mg TABLETS.
CLOZERIL can cause AGRANULOCYTOSIS. (A condition where there is a marked decrease or complete absence of white cells-those formed in the bone marrow-in the blood).
Before prescribing CLOZERIL white blood cell count and deferential count must be performed to ensure only patients with a NORMAL blood count receive CLOZERIL.
For the first 18 weeks white blood count must be monitored WEEKLY, and TWO-WEEKLY thereafter for the ENTIRE TREATMENT.
WITHDRAW IMMEDIATELY if white blood count falls below 3000mm and monitor closely for infection like symptoms.
PARTICULAR ATTENTION SHOULD BE PAID TO FLU-LIKE COMPLAINTS, OR OTHER SYMPTOMS, WHICH MIGHT SUGGEST INFECTION, SUCH AS FEVER OR SORE THROAT.
History of drug induced granulocytopenia (reduction in polymorpho-nuclear cells)
Agranulocytosis (reduction/absence of white blood cells),
Comatose conditions and other form of CNS depression,
Severe hepatic or renal disease.
SIDE EFFECTS -
Neutropenia leading to Agranulocytosis.
Possible skin reactions
DO NOT USE IN PREGNANT OR NURSING WOMAN – Use adequate contraceptive measures in woman of child bearing potential
DO NOT GIVE CLOZERIL WITH OTHER DRUGS WITH A POTENTIAL FOR CAUSING AGRANULOCYTOSIS
CLOZERIL may enhance the effects of:
HYPOTENSIVE & ANTICHOLINERGIC AGENTS.
EXTRA PYRAMIDAL REACTIONS.
These are perhaps the most troublesome and frightening side effects of Antipsychotic drug therapy. Chlorpromazine, Haloperidol, Fluphenazine and other depot injection preparations cause them most frequently. They consist of Dystonia, Akathaesia, Parkinsonism-like syndrome and Tardive Dyskinesia.
These reactions are dramatically alarming and disabling. They usually appear in the first five days or in as little time as half an hour after Therapy is started.
This involuntary contraction of muscle groups in the upper part of the body (characterised by grimacing, torticollis, abnormal posturing and occulogyric crisis.) occurs most frequently in men and clients under 25years of age.
They may be misdiagnosed as hysteria or seizures.
“Restless legs” or “inability to sit”.
This is a compelling need to shift positions and to keep pacing without pattern.
This can be inaccurately interpreted as a manifestation of anxiety or agitation.
This is the most frequently observed Extra Pyramidal Reaction is usually marked by slowed, volitional movement or Akinesia, mask like facial expression, pin-rolling motion, rigidity and tremor at rest, a shuffling gait and drooling.
These symptoms occur most frequently in women, and elderly of both sexes and dehydrated clients.
This can be mistaken for depression. Chronic Schizophrenics taking Antipsychotic drugs are especially susceptible to this condition.
These three side effects are thought to result from rebound sensitivity to Dopamine in the Basal Ganglion and can usually be reserved or made more tolerable, by an anticholinergic drug such as Procyclidine. Often the nervous system accommodates to the level of medication and Extra Pyramidal Reactions disappear.
This appears in an undetermined number of clients who have been receiving a Neuroleptic drug for a long time.
This condition is irreversible or nearly irreversible.
Symptoms usually appear with dosage reduction or when the drug is discontinued.
The initial sign is a worm like movement on the surface of the tongue.
Other prominent features include involuntary bizarre movements (chewing movement, smacking and licking of lips, sucking movements, tongue protrusion, blinking grotesque grimaces and spastic facial distortions.) neck and trunk movements.
The onset of this condition during the first three months or after years of therapy warrants either reinstatement of the Dopa-Blocking drug or an increase of dosage.
Symptoms should be watched for and reported as soon as evident to prevent progress toward an irreversible clinical condition.
DOSE: Up to 30mg daily.
ROUTE: Oral, Tablet and syrup, IMI, IVI, Rectal.
USES: Anxiety, Insomnia, Convulsions, Alcohol Withdrawal, Status Epilepticus, Premedication.
CONTRA INDICATIONS: Alcohol/Drug Abuse.
PRECAUTIONS: Glaucoma, Respiratory Disease, Potentiation of Centrally Acting Drugs, (Antidepressants, Tranquillizers, Analgesics, Anaesthetics, ECT).
SIDES EFFECTS: Dependency, Drowsiness, Dizziness, Ataxia Confusion, Dry Mouth, Headache, Sensitivity, Respiratory Depression, IF IVI – Thrombophlebitis
DRUGS IN THIS GROUP: Lorazepam, Chlordiazepoxide.
Depot injections were introduced soon after Phenothiazines in the fifties as a form of maintenance treatment of psychotic disorders. This being as all but one of the common preparations are Phenothiazines, the exception being Haloperidol Decanoate they tend to be more convenient than oral preparations in being less time consuming and ensuring patient compliance, this being as they have to be nurse administered and given on a regular periodic basis.
Deep intra-muscular injection, using Z-tracking technique, given over a period of 1 to 4 weeks. Before a course of treatment may be commenced a test dose of limited quantity must be injected to ensure there will be no serious side effects. Care must also be taken in ensuring that no more 2mls be injected in any one site, this is because if damage to body tissue as explained later.
As with all drugs there are certain circumstances which mean that Depots should not be used. These are as follows; if a patient is a young child in organic Confusional states in coma caused by Central Nervous System depressants, Parkinsonism, Intolerance to Psychotropic medication, Pregnancy, Cardiac dysfunction.
Mainly the same side effects as in the oral Phenothiazine range of drugs see Phenothiazines. However there are some effects encountered more specifically in use of Depot injections and are as follows; increased Extra-Pyramidal Reactions, Behavioural Disturbances including Aggression, Over-Excitement and Agitation. Erythema and associated skin problems. Injection site problems (usually due to bad techniques) including; pain at site, Nodules and Swelling, Abscesses, Intra-Venous/Articular Injection.
DRUGS IN THIS GROUP:
FLUPHENAZINE DECANOATE – “MODECATE”
FLUPHENAZINE ENANTHATE – “MODITEN”
FLUPHENTHIXOL DECANOATE – “DEPIXOL”
CLOPENTHIXOL DECANOATE -“CLOPIXOL”
HALOPERIDOL DECANOATE -“HALDOL”
SELECTION OR INDICATION
Certain depot injections are more suitable for specific disorders and these are briefly as follows: –
CLOPIXOL- Agitation and aggression in schizophrenia and related psychoses.
DEPIXOL- Maintenance in Schizophrenic and related psychoses
MODECATE- see Moditen
MODITEN- Maintenance and used in agitation or excitation.
HALDOL- Maintenance and Mania in Schizophrenia. etc
LIST OF APPROXIMATE EQUIVALENTS: – CLOPIXOL-200mg
EXAMPLE – AMITRIPTYLINE
DOSE – 10mg, 25mg, 50mg, to a maximum of 300mg daily.
ROUTE – ORAL, TABLET, SYRUP.
USES – Depression. Nocturnal Enuresis in children.
NOT TO BE USED WITH MAOIs
Recovery phrase of a Heart Attack, Heart Block, Arrhythmia’s, Mania, Severe Liver Disease.
PRECAUTIONS – 14 days lapse between MAOI and tricyclic Administration, Narrow Angle Glaucoma, Lower effects of anti-hypertensive agents. May precipitate psychosis or mania.
- Hypertension including Postural Hypertension
- Miocardial Infarction
CENTRAL NERVOUS SYSTEM
- Confusion Paraesthesia
- Incoordination Ataxia Tremors Convulsions
- Extra Pyramidal Reactions Tinitus
- Peripheral Neuropathy Alteration of EEG
- Disorientation Delusions
- Hallucinations Excitement
- Anxiety Restlessness
- Insomnia Nightmares
- Dry mouth Blurred Vision
- Disturbance of Accommodation Paralytic IIeus
- Urinary Retention Urinary Tract Dilatation
- Skin Rash Urticaria
- Photosensitivity Oedema of Head & Face
- Bone Marrow Depression
- Nausea / Vomiting / Diarrhoea
- Weight loss
- Testicular Swelling
- Increased or Decreased Libido
- Urinary Retention or Frequency
DRUGS IN GROUP
MONO AMINE OXIDISE INHIBITOR
DOSE: 15mg [last dose no later than midday usually]
USES: Depressive illness [often used when other antidepressants have failed]
DIET: see DIETARY RESTRICTIONS
TRICYCLIC Antidepressants should have been withdrawn for 2 weeks prior to treatment. Avoid cold & Decongestants.
M.A.O.I.s Potentiate Anti-Hypertensives, Hypoglycaemic Agents. Local Anaesthetics, Central Nervous System. Depressants, including BARBITURATES. Sympathomimetic Anti-Parkinson Drugs.
E.C.T. or Elective surgery should be avoided for 2 weeks
Weakness Dry mouth
Pedal Oedema Rash
Blurred Vision Dysurea Tremor
Increased Appetite Weight Gain
Delayed Ejaculation Peripheral Neuritis
Leading to CVA,
DRUGS OF THIS GROUP
MAOI DIET RESTRICTIONS
The following foods and drinks should be avoided for the duration of treatment with an MAOI, and for ten days after stopping the tablets.
CHEESE: avoid mature cheese and cheese spreads in any for Non matured cheese, such as cottage cheese or cream cheese appear to be safe
YEAST OR MEAT EXTRACTS: Such as Maritime, Bovril and Oxo must be avoided. Bisto appears to be safe.
LIVER: Avoid chicken liver, liver pate and any liver, which is not fresh.
ALCOHOL: Drink in moderation only. Avoid Chianti, Red Wines, Home Made Beers and Wines.
GAME: or other red meat, which has been hung, should be avoided.
PICKLED HERRINGS: Should be avoided.
IN GENERAL: EAT ONLY FRESH FOODS THAT HAVE BEEN FROZEN OR CANNED
AVOID ANY FOODS OR DRINKS WHICH MAKE YOU FEEL UNWELL.
SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS (SSRIs)
BRAND NAME: PROZAC
FREQUENCY: Once daily in the morning
DOSE: 20-80mg daily
ROUTE: Oral Capsules
EFFECTIVITY: Becomes effective between 14 and 28 days. Non addictive.
USES: Depression, Bulimia Nervosa: Obsessive Compulsive Neurosis.
MISSED DOSE: Take within 6 hours of dose, otherwise take single dose and miss next dose
MAOIs: 14 days should lapse between taking MAOIs and Fluoxetine, and visa versa
Sedatives, including alcohol, increases sedative properties of Fluoxtetine
Triptophan: Used jointly may cause agitation, restlessness and gastric symptoms
Tricyclic Anti Depressants: Causes sedation, dry mouth and constipation
Lithium: Increases Serum Lithium Levels causing dizziness and stiffness
Anxiety Sexual Dysfunction
Rash Appetite Decrease
Epilepsy Liver Problems
Heart Trouble Diabetes
Kidney Problems Allergy History
Pregnancy Breast Feeding
Utilised as a drug since 1945.
Type: Mood Stabiliser.
Doses: 250mg, 300mg, 400mg, 450mg.
Uses: Mood stabilisation and regulation in Manic-Depressive Illness.
SIDE EFFECTS – 3 LEVELS OF CONCERN.
LEVEL 1: Safe but uncomfortable side effects.
LEVEL 2: Signs of Intoxication- WITHDRAW LITHIUM.
Blurred vision Anorexia
Nausea and Vomiting Drowsiness
Ataxia Course Tremor
Lack of Co-ordination Dysarthria.
LEVEL 3: Severe Overdose- URGENT TREATMENT NEEDED.
Hyper-extension of limbs.
Blood levels for Lithium must be taken weekly, initially until stabilisation, then every 3 – 6 months. Tests also for Urea, Electrolytes and Thyroid Function need to be undertaken.
Goitre, Hypothyroidism, A.D.H, Hypokalaemia, E.C.G Changes, Kidney Changes, Exacerbation of Psoriasis.
Not to be used in Pregnancy, or when attempting to conceive.
There are two types of drugs used in the treatment of insomnia or sleepless nights. These are Hypnotics or Sedatives (usually minor tranquillisers).
Before night medication is prescribed the cause of the insomnia should be established, and any factors which may be contributing or worsening the problem should first are treated.
May occur in those with ‘normal’ sleep pattern and is due to factors such as shift work, jet lag and noise. A short-term drug of fast elimination is indicated.
Usually related to emotional problems or medical illness, may last for a few weeks, and may reoccur from time to time. A hypnotic should be given for no more than three weeks, and should be rapidly eliminated.
Barely remedied by hypnotic and may be due to careless prescribing resulting in mild dependence. Common causes, predominantly depression and other psychiatric conditions. Therefore the initial problem should be treated primarily.
The drugs used to treat insomnia are:-
These include as follows:-
Nitrazepam – Mogadon
Flurazepam – Dalmane
Temazepam – Normison
Diazepam – Valium
Hangover with drowsiness
Ataxia (particularly in elderly)
Prolonged use may lead to rebound insomnia, tolerance, dependency and toxicity.
May affect ability to drive
Avoid abrupt withdrawal
These include as follows:-
Chloral Hydrate – Mist Chloral
Chlormethiazole – Heminevrin
Dichloralphenazone – Welldorm
Conjunctival irritation G I irritation
Cardio/respiratory Depression (high doses)
Sneezing Skin rashes
Usually given in syrup form and diluted with water to minimises the chance of gastro-intestinal upsets.
Avoid contact with skin and mucous membranes; also avoid taking with alcohol.
The drugs in this group include
Promethazine – Phenergan
Trimeprazine – Vallergan
See under Major Tranquillisers
CAUTIONS:- As above
ANTI – CONVULSANTS.
The object in treating epilepsy with these drugs is to suppress seizures by maintaining an effective concentration of the drug in the blood. This is achieved by adjusting doses and gradually increasing them until fits are controlled or side effects are met.
Oral administration for purpose of maintenance or long term treatment. Intra-muscular or Intra venous injection in treatment of Status Epilepticus.
CAUTIONS: – Do not withdraw drug rapidly as this may precipitate convulsions. Patient may drive only if fit free for two years. Regular blood samples must be taken to check serum levels of drug to ensure adequate effect.
CONTRA – INDICATIONS.
Previous sensitivity, Current MAOI therapy, Kidney, Liver, Heart.
Breast feeding, Severe respiratory depression.
Dizziness, Weight loss/gain, Renal/Gastro-intestinal disturbances, Blood dyscrasias such as anaemia, leucopenia and others. Skin rashes, Ataxia, Headache / Depression, Paradoxical excitement, Confusion in elderly, Tremor, Coarse faeces (Phenytoin), visual disturbances.
DRUGS IN THIS GROUP
PHENYTOIN SODIUM – EPANUTIN
SODIUM VALPORATE – EPILIM
CARBAMAZEPINE – TEGRETOL
PHENOBARBITONE – N/A
PRIMIDONE – MYSOLINE
N.B. Diazepam (Valium) may be used in injection form as treatment for status epilepticus, as may Chlormethiazole (Hemineverin) and Paraldehyde. This is notable as these are used in treating other conditions.
DRUGS USED IN E.C.T.
DEPOLARISING MUSCLE RELAXANTS
Suxamethonium-It has five minute duration of action. It acts by mimicking the action of acetylcholine at the neuromuscular junction but causes blockade. Depolarisation is prolonged since disengagement from the receptor site and subsequent breakdown is slower than for acetylcholine.
It produces rapid, complete, and predictable paralysis and recovery is spontaneous. It is contra-indicated in severe liver disease and in burned patients. Premedication with Atropine is desirable. Suxamethonium Chloride – by intra venous injection.
Scoline- by intra venous injection.
Methohexitone Sodium. -Intra venous anaesthetics may be used alone to produce anaesthesia for short surgical procedures.
It can cause apnoea and hypotension and so adequate resuscitative facilities MUST be available. It is contra indicated in all patients in whom the anaesthetist is not confident to maintain the airway, and in cases of Porphyria.
It is usually used in 1% solution induction sometimes has an incident of hiccup, tremor, involuntary movements and pain on injection. Britoil sodium-powder for reconstruction.
Atropine is the most commonly used. Intravenous administration immediately before anaesthesia. Intra muscular injection should be given 30-60 minutes before the operation. Atropine sulphate used for drying secretions, reversal of excessive bradycardia; with neostigmine for reversal of competitive neuromuscular block.
CAUTION: Cardiovascular Disease.
SIDE EFFECTS: Tachycardia.
Dose: Premedication by I.V.I.300-600 micrograms, immediately before anaesthesia.
One of the groups of side effects caused by phenothiazines is known as Extra-Pyramidal Symptoms or EPS for short. Please refer to the file on Major Tranquillisers [MAJOR T] for detailed information on symptoms.
The effect Phenothiazines have is block dopamine receptors in the brain and leads to E P S in some patients. In order to counter-act these undesirable symptoms which resemble Parkinson’s Disease and which are referred to as Parkinsonian Effects a certain group of Anti-Parkinson drug called Anticholinergics are used too treat the symptoms as they arise.
There are only four main drugs used in this field and they all come in tablet or injection preparation they include;
- Benzhexol Hydrochloride – Artane
- Orphenadrine Hydrochloride.- Disipal
- Procyclidine Hydrochloride- – Kemadrin
- Benztropine Mesylate – Cogentin
The side effects experienced are generally the same for all four of the drugs but some are more pronounced in certain drugs and they are in brackets after the effect.
- Gastro-Intestinal Disturbances
- Dry Mouth
- Psychiatric Disturbances; Nervousness
- Confusion [High Dose]
- Euphoria [Disipal]
- Insomnia [Disipal]
- Sedation [Cogentin]
- Drowsiness [Kemadrin]
- Hepatic/Renal Impairment
As with all drugs the above are contra-indicated in some circumstances, these include;
- Hepatic/Renal Impairment
CAUTIONS INCLUDE; -
DO NOT DRIVE OR OPERATE ANY MACHINERY WHILST ON COGENTIN. AVOID ABRUPT DISCONTINUATION.
DRUGS IN THE EMERGENCY BOX.
Atrial fibrillation: Supra ventricular tachycardia.
Side effects: Nausea, Vomiting, Diarrhoea, Bradycardia, Heart Block, and Heart Block treatable by Atropine.
Congestive Cardiac Failure, Pulmonary Oedema, Renal Failure.
Peak effect takes place 30 minutes I.V.I.
Side effects: Hyponatraemia, Hypokalaemia.
Status Asthmaticus, Anaphylactic Shock, Slow intravenous infusion.
Side effects as with all steroids.
Ventricular Arrhythmia’s, Ventricular Fibrillation, Status Epilepticus.
Slow intravenous infusion or I.V.I.
Side effects: Confusion, Convulsions.
Supra-Ventricular Tachycardia, Ventricular Arrhythmia’s.
Side effects: Bradycardia, Hypotension, Heart Failure, Bronchospasm
SODIUM BICARBONATE 8.4%
Metabolic Acidosis, following Myocardial Infarction, or Respiratory Arrest.
NO MORE than 200mls or patient could go Alkalotic.
ADRENALIN 1 in 1000
Hypotension, Allergic Reaction, Anaphylactic Shock, Bronchospasm.
Caution with Tricyclic Antidepressants, Hypothyroidism.
ADRENALIN 1 in 10000
Bradycardia after MI slows Bigeminy in Digitalis overdose.
CAUTION: Glaucoma, Paralytic Ileus.
SIDE EFFECTS: Tachycardia Confusion, Dry mouth.
Bronchospasm, Left Ventricular Failure.
Caution: Liver Disease, Epilepsy, and Lactation.
Side effects: Tachycardia, Palpitations, Arrhythmia’s, and Convulsions.
By slow I.V.I. ONLY.
CALCIUM CHLORIDE 13.4%
Cardiac muscle contraction, Tetany.
Allergic reaction, Anaphylactic Shock.
PROCHLORPERAZINE ( Stematil)
Nausea, Vomiting, Anxiety, Agitation.
Differential diagnosis in diabetes.
Status Epilepticus, Ventricular Arrhythmia’s caused by Digitalis poisoning.
Side effects: Bradycardia, Hypotension, and confusion.
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