Sedative anxiolytics: Benzodiazepines

1. Sedative anxiolytics: Benzodiazepines • Alpralozam • Diazepam • Lorazepam • Ch;ordiazepoxide • Chlorazepate • Oxazepam • Clonazepam • Expected pharmacological action: enhances the inhibitory effects of GABA (the “feel good” neurotransmitter) in the CNS

2. Therapeutic uses • Trauma and stress-related disorders such as PTSD • Seizure disorders • Insomnia • Muscle spasms • Alcohol withdrawal (chlordiazepoxide) • Induction of anesthesia • Amnesic prior to surgery or other procrdures www.PresentationPro.com

3. Complications • CNS depression: lightheadedness, ataxia, decreased cognitive function • Anterograde amnesia: dificult to recall events that occur after taking • Acute toxicity: drowsiness, lethargy, confusion • Paradoxical response: insomnia, excitation, euphoria, anxiety, rage • Potential for abuse: withdrawal symptoms are anxiety, insomnia, diaphoresis, hypertension, tremors, lightheadedness, delirium, muscle twitching, seizures • Antidote: romazicon www.PresentationPro.com

4. Contraindications/precautions • Pregnancy/breastfeeding • Sleep apnea, respiratory depression, or glaucoma • Use cautiously in older clients • Generally, therapy is short-term due to riak for dependence • Interactions: • CNS depressants (alcohol, barbiturates, opioids) can cause respiratory depression • Grapefruit can reduce metabolism • High-fat meals can reduce absorption

5. Nursing administration • Advise patient to take as prescribed- do not stop suddenly • When discontinuing, taper dose gradually • Administer with food if GI distress occurs • Administer at bedtime if possible due to sedation • Advise patient to keep med in a secure place

6. Cholinesterase inhibitors • Neostigmine • Physostigmine • Edrophonium • Donepezil • Expected pharmacological action: increase the amount of acetylcholine available at receptor sites, thereby improving muscular function Used to treat myasthenia gravis, glaucoma, and Alzheimer’s www.PresentationPro.com

7. Complications • Excessive stimulation: excessive GI motility, diaphoresis, increased salivation, bradycardia, urinary urgency • Cholinergic crisis: respiratory depression from neuromuscular blockade • Contraindications/precautions: • Pregnancy, obstruction of GI or renal systems • Use cautiously in seizure disorders, hyperthyroidism, peptic ulcer disease, asthma, bradycardia, or hypotension www.PresentationPro.com

8. Interactions and nursing administration • Atropine counteracts the effects of the meds • Neostigmine dosing is PO, IM, IV, or sub-q • Inform patient that dosing is very individual; starts at very low doses until therapeutic level is found • Advise patient to wear a medical alert bracelet www.PresentationPro.com

9. Anti-Parkinson’s medications • Dopaminergic meds promote dopamine synthesis • Dopamine synthesis med (levodopa) is given with a dopamine agonist (carbidopa) • Other meds (dopamine agonists) • Selegiline • Rasagiline • Amantadine • These meds can increase the effectiveness of carbidopa/levodopa • Expected pharmacological action: do not halt the progression of the disease; but they do offer relief from dyskinesias and tremors and increase the ability to perform ADLs www.PresentationPro.com

10. Adverse effects • Nausea, vomiting • Drowsiness • Dyskinesias (head bobbing, tremors, tics) • Orthostatic hypotension • Tachycardia, palpitations • Psychosis • Discoloration of sweat and urine • Sudden inability to stay awake • Daytime sleepiness • Impulse control disorder www.PresentationPro.com

11. Patient education • Family members should assist the patient with medications at home • Notify provider if loss of beneficial effects occurs • Effects might not be noticed for several weeks or months • Avoid high-protein meals and snacks • Avoid pregnancy • Do not stop taking medication abruptly www.PresentationPro.com

12. Antiepileptics (AEDs) • Traditional: • Phenobarbital • Primidone • Phenytoin • Carbamezepine • Valproic acid • Other: • Benzodiazepines- diazepam, lorazepam www.PresentationPro.com

13. Newer antiepileptic meds • Lamotrigine • Leviteracetam • Topiramate • Oxcarbazepine • Gabapentin • Pregabalin • Lacosamide • Vigabatrin www.PresentationPro.com

14. Expected pharmacological action • Control seizure activity by several mechanisms • Slows the rate of neuron firing • Suppressing neuronal firing • Enhancing the effects of gamma butyric acid (GABA) • Suppresses generalized seizure activity in the affected neurons • Complications • Drowsiness, dizziness, depression • Confusion, anxiety • Irritability, hyperactivity • Toxicity: nystagmus, ataxia, coma, pinpoint pupils, hypotension, death • Phenytoin: gingival hyperplasia www.PresentationPro.com

15. Contraindications/precautions and interactions • Pregnancy • Interactions • Barbiturates decrease the effects of oral contraceptives, warfarin and glucocorticoids • Alcohol, benzodiazepines and cimetidine increase phenytoin levels • Chronic alcohol use decreases phenytoin levels • Grapefruit juice inhibits metabolism • Concurrent alcohol consumption depresses the CNS • Benzodiazepines, alcohol, and opioids intensify CNS effects www.PresentationPro.com

16. Client education • Monitor therapeutic plasma levels • These meds manage symptoms, but do not cure the disorder • Keep a seizure diary • Take meds as prescribed, do not stop abruptly • Avoid activities that require alertness until effects of the med are known • Avoid pregnancy www.PresentationPro.com

17. Medications for multiple sclerosis • Dimethyl fumarate (Tecfidera)- has side effects of GI upset, nausea and dizziness, drowsiness • Fingolimod (Gilenya)- has much the same side effects • These medications have to come from a specialty pharmacy • Fingolimod: first dose must be monitored in a medical facility • Interferon 1a (Avonex): an immune modifier; acts on specific receptor cells to alter immune response • Given IM or sub-q • Complications: seizures, depression, fatigue, GI distress • Monitor CBC, H&H and LFTs www.PresentationPro.com

18. Methylprednisolone • A corticosteroid and immunosuppressant; used systemically in the management of inflammation, allergic, hematologic, and autoimmune disorders • Suppresses inflammation and the normal immune response • Contraindications: active untreated infection, epidural use, chronic treatment • Complications: personality changes, psychosis, hypertension, N/V, acne, decreased wound healing, weight gain • Route: PO, IM, IV • Monitor I&O and for edema, weight gain, and dyspnea www.PresentationPro.com

19. Mannitol (osmotic diuretic) • Indicated for increased intracranial or intraocular pressure • Acts by increasing the osmotic pressure of the blood, thereby inhibiting the reabsorption of water and electrolytes • Contraindications: anuria, dehydration, active intracranial bleeding • Given IV in critical-care environment • Complications: confusion, headache, blurred vision, chest pain, electrolyte imbalances • Monitor vital signs, I&O, assess for dehydration • Effectiveness measured by urine output (will increase) www.PresentationPro.com

20. Eye and ear disorders • Beta blockers: timolol, carteolol, levobunolol • Expected pharmacological action: decrease IOP by decreasing the amount of aqueous humor the ciliary body produces • Used to treat open- and closed-angle glaucoma • Complications: temporary stinging sensation, blurry vision, dry eyes; an overdose can have systemic effects • Contraindications: chronic respiratory disiease, sinus bradycardia and AV block, use caution in patients with heart failure www.PresentationPro.com

21. Interactions and nursing administration • Oral beta blockers and CCBs can increase cardiovascular and respiratory effects • Beta blockers can interfere with some effects of insulin • Instill one drop in each affected eye once or twice daily • Review procedure for eye drops with patient • Use sterile technique when handling the applicator • Hold pressure on the nasolacrimal duct after instillation • Monitor heart rate and rythm www.PresentationPro.com

22. Alpha-2 agonists • Brimonidine, apraclonidine • Decreases the production of and increases the outflow of aqueous humor to lower IOP • Complications: • Stinging, pruritus • Dilated pupils, blurry vision • Headache • Dry mouth • Reddened sclera • Hypotension • Drowsiness www.PresentationPro.com

23. Contraindications/precautions/interactions • Advise contact lens wearers to administer the drops after lenses have been removed; do not reinsert for 15 minutes • Antihypertensive meds can increase hypotension from brimonidine • MAO inhibitors can decrease the effects of brimonidine and cause hypertensive crisis • Review with patient the procedure for instilling eye drops • Monitor BP for hypo/hypertension www.PresentationPro.com

24. Prostaglandin analogs-latanoprost, travoprost, bimatoprost • Reduce IOP by increasing aqueous humor outflow through relaxation of ciliary muscles • Firstline med for patients with open-angle glaucoma and ocular hypertension • Complications: • Bulging of ocular blood vessels • Increase of pigmentation of iris • Stinging, burning or reddened conjunctiva • Blurry vision • Migraine- rare adverse effect www.PresentationPro.com

25. Carbonic anhydrase inhibitors-acetazolamide, methazolamide • Reduce the production of aqueous humor by causing diuresis through the kidneys • Quickly lowers IOP in patients in who other meds have been ineffective • Complications: • Severe allergic reaction (possible anaphylaxis) • Bone marrow depression • GI distress • Electrolyte depletion, dehydration • Generalized flu-like symptoms • Fatigue, sleepiness, seizures (rare) • Glucose disturbances in diabetic patients www.PresentationPro.com

26. Contraindications/precautions and interactions • Pregnancy, lactation • Serious effects such as metabolic acidosis can occur with high-dose aspirin • Can increase the toxic effects of quinidine • Can decrease lithium levels • Sodium bicarb: increases risk of kidney stones • Nursing administration: available orally as a tablet or capsule www.PresentationPro.com