Exam 2 V2: NURS 660 / NURS660 Psychopharmacology and Advanced Mental Health | Complete Questions and Verified Answers (Latest 2026 / 2027)100% Correct - Maryville

Exam 2 V2: NURS 660 / NURS660 Psychopharmacology and Advanced Mental Health | Complete Questions and Verified Answers (Latest 2026 / 2027)100% Correct - Maryville Q: The nurse provides education for clinical staff regarding the processes that move water and electrolytes between body compartments. Which statement made by a participant indicates the need for additional instruction? Answer "osmosis allows the free movement of K across cell membranes" Q: Which process for transporting fluid between the extracellular fluid and the intracellular fluid is impacted when the nurse administers a hypotonic intravenous (IV) solution to the patient who is admitted for the treatment of dehydration? Answer osmosis Q: Which vascular access device (VAD) does the nurse prepare to place for the patient who requires short-term administration of intravenous (IV) antibiotics? Answer peripheral intravenous catheter Q: Which type of intravenous (IV) fluid is isotonic when it first enters a patient's vein but has an effective hypotonic concentration after it flows through the vascular system? Answer dextrose 5% in water (D5W) Q: The health care provider prescribed 2 L of saline over 10 hours for a patient with diarrhea. Calculate the rate of infusion in mL/hr. (Round to the nearest whole number, enter numbers only, no units of measure). Answer 200 Q: The skin of a patient receiving intravenous fluids appears blanched, cool to the touch, and edematous. Upon touch, the patient reports pain. Which complication does the nurse suspect? Answer extravasation Q: A patient who is receiving intravenous therapy develops redness, inflammation, swelling, and purulent drainage at the catheter site. Which nursing intervention(s) is useful in this situation? Select all that apply. Answer -cleaning the skin with alcohol -inserting a new IV line in another extremity Q: Which body fluid is a transcellular fluid? Select all that apply Answer -synovial fluid -peritoneal fluid -cerebrospinal fluid Q: A patient receiving a continuous intravenous (IV) infusion of 0.9% sodium chloride develops shortness of breath and edema in the extremities. Upon auscultation, the nurse hears crackling sounds in the dependent parts of the lungs. Which nursing intervention(s) should the nurse perform? Select all that apply. Answer -stop the IV infusion -elevate the HOB -notify the health care provider Q: For which potential complication(s) should the nurse be vigilant for while assessing the patient who has an intravenous line for fluid therapy? Select all that apply. Answer -bleeding -phlebitis -infection Q: Which intravenous fluid is appropriate for a patient who requires isotonic fluids to correct dehydration? Answer 0.9% sodium chloride Q: Which defining characteristics are consistent with fluid volume deficit? Answer dry mucous membranes, thready pulse, tachycardia Q: Which assessment finding(s) would the nurse expect to observe in a patient who has developed phlebitis? Select all that apply. Answer -red streak along the vein -tenderness and pain -warmth along vein course starting at access site Q: The nurse finds that a patient has sudden weight gain, confusion, edema in the dependent areas, and crackles in the lungs upon auscultation. Which condition does the nurse suspect? Answer ECV (extracellular fluid volume) excess Q: While caring for a patient with gastroenteritis, the nurse finds a supine blood pressure of 90/58 mm Hg and a heart rate of 102 beats per minute. Which condition does the nurse suspect? Answer deficient fluid volume related to vomiting Q: Which condition(s) may lead to an extracellular fluid (ECF) volume deficit? Select all that apply. Answer -burns -hemorrhage -adrenal insufficiency Q: A patient with blood type A is in need of packed red blood cells in an emergency, but none of the donors of this type are available. Which action would the nurse take Answer arrange to provide RBCs of group B Q: Which assessment is most important for the nurse to perform routinely when an older adult patient is receiving intravenous 0.9% NaCl? Answer ausculatate dependent portions of lungs Q: Patients should be taught to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid? Answer fluid that has sodium in it Q: Which solution would the nurse hang with a transfusion of packed red blood cells? Answer 0;9% sodium chloride Q: While receiving a blood transfusion, a patient develops chills, tachycardia, and flushing. Which action would the nurse take first? Answer stop the transfusion Q: why are older adults prone to dehydration? Answer the ability of their kidneys to concentrate urine decreases Q: A patient had 200 mL of ice chips and 900 mL intravenous (IV) fluid during the nurse's shift. Which total intake would the nurse record? Answer 1000mL Q: The nurse administers an intravenous (IV) hypertonic solution to a patient. In which direction will the fluid shift? Answer from intracellular - extracellular Q: A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which solution will the nurse prepare? Answer 0.9% sodium chloride Q: During an assessment of a newly admitted client, the nurse notes tachycardia, orthostatic hypotension, and dry mucus membranes. The client's spouse tells the nurse the patient seems a little confused and unsteady. Based on these assessment findings, the nurse suspects that the client has which condition? Answer dehydration Q: When assessing a patient admitted with nausea and vomiting, which finding supports the nursing diagnosis of fluid volume deficit? Answer urine specific gravity 1.045 Q: Which assessment finding(s) will alert the nurse that a patient's peripheral IV has infiltrated? Select all that apply. Answer Which disease(s) may cause extracellular fluid (ECF) volume excess? Select all that apply Answer -cirrhosis -heart failure -acute oliguric renal disease Which laboratory finding(s) does the nurse expect for a patient with chronic diarrhea? Select all that apply. Answer hypocalcemia -hypernatremia -hypomagnesemia which electrolyte controls the function of neuromuscular junctions? Answer magnesium which ion(s) is a cation? sodium -calcium -potassium for which reason would a patient with chronic diarrhea show chovstek's sign? hypocalcemia Which food item(s) would the nurse include in the patient's diet to help correct hypokalemia? -tomato sauce -milk -potatoes -bananas Which patient(s) would the nurse monitor for most closely for the development of hypokalemia? -patient with diarrhea -patient with vomitting -patient using potassium-wasting diuretics which food item would the nurse include in the diet plan of a patient with a magnesium deficiency spinach which patient is at the highest risk of developing hypokalemia patient with diarrhea which electrolyte disturbance is responsible for tetany and postive Chovstek's and trousseau's sign? hypocalcemia in which patient will the nurse expect to see a positive Chvostek sign? A 24-year-old admitted for chronic alcohol abuse and pancreatitis which patient is at the highest risk of an electrolyte imbalance? a 98 year old with a temp of 102.3 F and diarrhea The nurse receives a report from a transferring facility regarding a patient's Magnesium level of 0.9 mEq/L. When the patient arrives, the provider prescribes intravenous Magnesium Sulfate. Which of the following nursing actions takes priority? assess deep tendon reflexes and initiate seizure precautions a nurse is planning care for a patient with hypokalemia. which interventions should be included in the plan of care? -implement safety measure to prevent falls -instruct the client about foods that contain potassium -encourage the client to obtain assistance to ambulate The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? sodium: 119 mEq/ L A patient reports light-headedness and tingling of the fingers. Arterial blood gas laboratory findings show the pH to be above 7.45. Which of the following conditions would the nurse suspect? respiratory alkalosis which symptoms may indicate resp. alkalosis in a patient? increased rate of respirations a patient with COPD is at risk of which condtion? resp. acidosis A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are: pH: 7.20 PaCO2: 21 mm Hg PaO2: 92 mm Hg HCO3-: 8 mEq/L. Which condition do these laboratory values indicate? metabolic acidosis which complication would a patient with DKA likely experience? hyperkalemia A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe? metabolic alkalosis Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis? pH 7.53, PaCO2 30 mmHg, HCO3- 24 mEq/L A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient? renal You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH: 7.33 PaO2: 47 mm Hg PaCO2: 60 mm Hg HCO3-: 32 mEq/L SpO2: 92%. What is the correct interpretation of these results? partially compensated respiratory acidosis which patient is most likely to have metabolic acidosis? acute kidney injury; pH 7.23; abdominal pain; compensatory hyperventilation Fluoxetine (Prozac) Major Side Effects SSRI -Sexual dysfunction (men: delayed ejaculation, erectile dysfunction; men and women: decreased sexual desire, anorgasmia) Note: patients with diagnosed or undiagnosed bipolar or psychotic disorders may be more vulnerable to CNS-activating actions of SSRIs -Autonomic (sweating) -Bruising and rare bleeding SIADH (syndrome of inappropriate antidiuretic hormone secretion) -Fluoxetine's unique 5HT2C antagonist properties could contribute to agitation, anxiety, and undesirable activation, especially early in dosing Fluoxetine major adverse effects Rare seizures Rare induction of mania Rare activation of suicidal ideation and behavior (suicidality) (short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo beyond age 24) Fluoxetine major drug interactions -Tramadol increases the risk of seizures in patients taking an antidepressant -Can increase TCA levels; use with caution with TCAs or when switching from a TCA to fluoxetine -Can cause a fatal "serotonin syndrome" when combined with MAOIs, so do not use with MAOIs or for at least 14 days after MAOIs are stopped,Do not start an MAOI for at least 5 weeks after discontinuing fluoxetine -May displace highly protein bound drugs (e.g., warfarin) -Can rarely cause weakness, hyperreflexia, and incoordination when combined with sumatriptan, or possibly with other triptans, requiring careful monitoring of patient -Possible increased risk of bleeding, especially when combined with anticoagulants (e.g.,warfarin, NSAIDs) NSAIDs may impair effectiveness of SSRIs and increase the plasma levels of some beta blockers and of atomoxetine -Via CYP450 2D6 inhibition, fluoxetine could theoretically increase concentrations of thioridazine and cause dangerous cardiac arrhythmias -May reduce the clearance of diazepam or trazodone, thus increasing their levels -Via CYP450 3A4 inhibition, may increase the levels of alprazolam, buspirone, and triazolam -Via CYP450 3A4 inhibition, fluoxetine could theoretically increase concentrations of certain cholesterol lowering HMG CoA reductase inhibitors, especially simvastatin, atorvastatin, and lovastatin, but not pravastatin or fluvastatin, which would increase the risk of rhabdomyolysis; thus, coadministration of fluoxetine with certain ----HMG CoA reductase inhibitors should proceed with caution Via CYP450 3A4 inhibition, fluoxetine could theoretically increase the concentrations of pimozide, and cause QTc prolongation and dangerous cardiac arrhythmias Fluoxetine lab tests *Don't have to taper! none in healthy individuals Fluoxetine neurotransmitters -serotonin -norepinephrine (bc of antagonistic properties5HT2C receptors) -dopamine (bc of antagonistic properties at 5HT2C receptors) Fluoxetine pregnancy risk not recommended, especially in first trimester -may need to continue @ 3rd trimester if depressive disorder increased postpartum depression -Neonates exposed to SSRIs or SNRIs late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding; reported symptoms are consistent with either a direct toxic effect of SSRIs and SNRIs or, possibly, a drug discontinuation syndrome, and include respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying Fluoxetine mechanism of action -Boosts neurotransmitter serotonin -Blocks serotonin reuptake pump (serotonin transporter) -Desensitizes serotonin receptors, especially serotonin 1A receptors -Presumably increases serotonergic neurotransmission -Fluoxetine also has antagonist properties at 5HT2C receptors, which could increase norepinephrine and dopamine neurotransmission Escitalopram (Lexapro) Major Side Effects SSRI *May be best tolerated anti-depressants *may be assoc w/ less sexual dysfunction *least interaction w/ CYP 2D6 and 3A4 -Sexual dysfunction -GI (dry mouth, constipation, nausea, diarrhea, decreased appetite) -Mostly central nervous system (insomnia but also sedation, agitation, tremors, headache, dizziness) Note: patients with diagnosed or undiagnosed bipolar or psychotic disorders may be more vulnerable to CNS-activating actions of SSRIs -Autonomic (sweating) -Bruising and rare bleeding -Rare hyponatremia (mostly in elderly patients and generally reversible on discontinuation of escitalopram -SIADH (syndrome of inappropriate antidiuretic hormone secretion) Escitalopram major adverse effects -Rare seizures -Rare induction of mania -Rare activation of suicidal ideation and behavior (suicidality) (short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo beyond age 24) Escitalopram major drug interactions -Tramadol increases the risk of seizures in patients taking an antidepressant -Can cause a fatal "serotonin syndrome" when combined with MAOIs, so do not use with MAOIs or for at least 14 days after MAOIs are stopped -Do not start an MAOI for at least 5 half-lives (5 to 7 days for most drugs) after discontinuing escitalopram -Could theoretically cause weakness, hyperreflexia, and incoordination when combined with sumatriptan or possibly other triptans, requiring careful monitoring of patient -Possible increased risk of bleeding, especially when combined with anticoagulants (e.g., warfarin, NSAIDs) NSAIDs may impair effectiveness of SSRIs -Few known adverse drug interactions Escitalopram lab tests none in healthy individuals Escitalopram neurotransmitters and mechanism of action -Boosts neurotransmitter serotonin -Blocks serotonin reuptake pump (serotonin transporter) -Desensitizes serotonin receptors, especially serotonin 1A autoreceptors -Presumably increases serotonergic neurotransmission Escitalopram pregnancy risks -Not generally recommended for use during pregnancy, especially during first trimester -Nonetheless, continuous treatment during pregnancy may be necessary and has not been proven to be harmful to the fetus -Neonates exposed to SSRIs or SNRIs late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding; reported symptoms are consistent with either a direct toxic effect of SSRIs and SNRIs or, possibly, a drug discontinuation syndrome, and include respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying Sertraline (Zoloft) Major side effects SSRI *Sertraline also has some ability to block dopamine reuptake pump (dopamine transporter), which could increase dopamine neurotransmission and contribute to its therapeutic actions -Sexual dysfunction (dose-dependent; men: delayed ejaculation, erectile dysfunction; men and women: decreased sexual desire, anorgasmia) -Gastrointestinal (decreased appetite, nausea, diarrhea, constipation, dry mouth) -Mostly CNS (insomnia but also sedation, agitation, tremors, headache, dizziness) Note: patients with diagnosed or undiagnosed bipolar or psychotic disorders may be more vulnerable to CNS-activating actions of SSRIs -Autonomic (sweating) -Bruising and rare bleeding Rare hyponatremia (mostly in elderly patients and generally reversible on discontinuation of sertraline) Rare hypotension SIADH (syndrome of inappropriate antidiuretic hormone secretion) Sertraline Major Adverse Reactions an increase in the risk of suicidality with antidepressants compared to placebo beyond age 24) Sertraline lab tests none for healthy individuals Sertraline Major drug interactions -Tramadol increases the risk of seizures in patients taking an antidepressant -Can increase TCA levels; use with caution with TCAs or when switching from a TCA to sertraline -Can cause a fatal "serotonin syndrome" when combined with MAOIs, so do not use with MAOIs or for at least 14 days after MAOIs are stopped,Do not start an MAOI for at least 5 half-lives (5 to 7 days for most drugs) after discontinuing sertraline -May displace highly protein bound drugs (e.g., warfarin) -Can rarely cause weakness, hyperreflexia, and incoordination when combined with sumatriptan or possibly with other triptans, requiring careful monitoring of patient -Possible increased risk of bleeding, especially when combined with anticoagulants (e.g., warfarin, NSAIDs) -NSAIDs may impair effectiveness of SSRIs - Via CYP450 2D6 inhibition, sertraline could theoretically interfere with the analgesic actions of codeine, and increase the plasma levels of some beta blockers and of atomoxetine -Via CYP450 2D6 inhibition sertraline could theoretically increase concentrations of thioridazine and cause dangerous cardiac arrhythmias -Via CYP450 3A4 inhibition, sertraline may increase the levels of alprazolam, buspirone, and triazolam -Via CYP450 3A4 inhibition, sertraline could theoretically increase concentrations of certain cholesterol lowering HMG CoA reductase inhibitors, especially simvastatin, atorvastatin, and lovastatin, but not pravastatin or fluvastatin, which would increase the risk of rhabdomyolysis; thus, coadministration of sertraline with certain ----HMG CoA reductase inhibitors should proceed with caution -Via CYP450 3A4 inhibition, sertraline could theoretically increase the concentrations of pimozide, and cause QTc prolongation and dangerous cardiac arrhythmias -Via CYP450 3A4 inhibition, sertraline could theoretically increase the concentrations of pimozide, and cause QTc prolongation and dangerous cardiac arrhythmias -False-positive urine immunoassay screening tests for benzodiazepine have been reported in patients taking sertraline due to a lack of specificity of the screening tests. False-positive results may be expected for several days following discontinuation of sertraline Sertraline neurotransmitters and moa -Boosts neurotransmitter serotonin -Blocks serotonin reuptake pump (serotonin transporter) -Desensitizes serotonin receptors, especially serotonin 1A receptors -Presumably increases serotonergic neurotransmission -Sertraline also has some ability to block dopamine reuptake pump (dopamine transporter), which could increase dopamine neurotransmission and contribute to its therapeutic actions Sertraline pregnancy risks Not generally recommended for use during pregnancy, especially during first trimester Nonetheless, continuous treatment during pregnancy may be necessary and has not been proven to be harmful to the fetus At delivery there may be more bleeding in the mother and transient irritability or sedation in the newborn Must weigh the risk of treatment (first trimester fetal development, third trimester newborn delivery) to the child against the risk of no treatment (recurrence of depression, maternal health, infant bonding) to the mother and child For many patients this may mean continuing treatment during pregnancy Exposure to SSRIs early in pregnancy may be associated with increased risk of septal heart defects (absolute risk is small) SSRI use beyond the 20th week of pregnancy may be associated with increased risk of pulmonary hypertension in newborns, although this is not proven Exposure to SSRIs late in pregnancy may be associated with increased risk of gestational hypertension and preeclampsia Neonates exposed to SSRIs or SNRIs late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding; reported symptoms are consistent with either a direct toxic effect of SSRIs and SNRIs or, possibly, a drug discontinuation syndrome, and include respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying Duloxetine (Cymbalta) Major Side Effects SNRI commonly prescribed for: Major depressive disorder •Generalized anxiety disorder •Fibromyalgia •Diabetic peripheral neuropathic pain (PDN) Orthostatic hypotension and syncope usually within the first week of use, constipation, dry mouth, sweating, diarrhea, fatigue, loss of appetite, nausea, weight loss, hypertension, headache, asthenia (abnormal physical weakness or lack of energy), dizziness, insomnia, somnolence *Try magnesium for constipation Duloxetine (Cymbalta) Major Adverse Reactions Serotonin syndrome •Hepatotoxicity •Rare activation of mania, depression, or suicidal ideation •Rare worsening of coexisting seizure disorders Duloxetine Major Drug Interactions CYP2D6 inhibitors (duloxetine, paroxetine, fluoxetine, bupropion) cimetidine, and valproic acid can increase drug concentration •Concomitant use of potent CYP1A2 inhibitors (fluvoxamine, cimetidine, quinolone antimicrobials [eg, ciprofloxacin, enoxacin]) should be avoided •Serotonin release by platelets is important for maintaining hemostasis. Combined use of SSRIs or SNRIs (such as duloxetine) and NSAIDs, and/or drugs that affect anticoagulation has been associated with an increased risk of bleeding •CYP2D6 and 1A2 enzyme inducers, such as rifamycin, nicotine, phenobarbital, can lower levels •May cause serotonin syndrome when used within 14 days of MAO inhibitors •May increase risk of cardiotoxicity and arrhythmia when used with tricyclic antidepressants vccccccccccccc Duloxetine lab tests check blood pressure at baseline and when increasing dose *Not recommended for patients with severe renal function impairment (creatinine clearance less than 30mL/min) or end-stage renal disease *Not recommended for patients with hepatic function impairment Duloxetine neurotransmitters and moa -Blocks serotonin and noradrenergic reuptake pumps, increasing their levels within hours, but antidepressant effects take weeks. ------Effect is more likely related to adaptive changes in serotonin and norepinephrine receptors systems •Weakly blocks dopamine reuptake pump (dopamine transporter) Duloxetine pregnancy risk -Category C. =Generally not recommended for the treatment of headache or neuropathic pain during pregnancy. Neonates exposed to duloxetine or other SNRIs or SSRIs late in the third trimester have developed complications necessitating extended hospitalizations, respiratory support, and tube feeding. Respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying consistent with a toxic effect of the drug or drug discontinuation syndrome have been reported Paroxetine (Paxil) Major Side effects SSRI Commonly Prescribed for Major depressive disorder (paroxetine and paroxetine CR) Obsessive-compulsive disorder (OCD) Panic disorder (paroxetine and paroxetine CR) Social anxiety disorder (social phobia) (paroxetine and paroxetine CR) Posttraumatic stress disorder (PTSD) Generalized anxiety disorder (GAD) Premenstrual dysphoric disorder (PMDD) (paroxetine CR) Vasomotor symptoms (Brisdelle) *Some patients may experience relief of insomnia or anxiety early after initiation of treatment *Withdrawal effects can be more common or more severe with paroxetine than with some other SSRIs -Sexual dysfunction (dose-dependent; men: delayed ejaculation, erectile dysfunction; men and women: decreased sexual desire, anorgasmia) -Gastrointestinal (decreased appetite, nausea, diarrhea, constipation, dry mouth) -Mostly CNS (insomnia but also sedation, agitation, dose-dependent tremors, headache, dizziness) -Weight gain -Activation (short-term; patients with diagnosed or undiagnosed bipolar or psychotic disorders may be more vulnerable to CNS-activating actions of SSRIs -Autonomic (dose-dependent sweating) -Bruising and rare bleeding -SIADH (syndrome of inappropriate antidiuretic hormone secretion) Paroxetine Major Adverse reactions *Inhibits CYP450 2D6 Tramadol increases the risk of seizures in patients taking an antidepressant Can increase TCA levels; use with caution with TCAs or when switching from a TCA to paroxetine Can cause a fatal "serotonin syndrome" when combined with MAOIs, so do not use with MAOIs or for at least 14 days after MAOIs are stopped Do not start an MAOI for at least 5 half-lives (5 to 7 days for most drugs) after discontinuing paroxetine May displace highly protein bound drugs (e.g., warfarin) There are reports of elevated theophylline levels associated with paroxetine treatment, so it is recommended that theophylline levels be monitored when these drugs are administered together May increase anticholinergic effects of procyclidine and other drugs with anticholinergic properties Can rarely cause weakness, hyperreflexia, and incoordination when combined with sumatriptan or possibly with other triptans, requiring careful monitoring of patient Possible increased risk of bleeding, especially when combined with anticoagulants (e.g., warfarin, NSAIDs) NSAIDs may impair effectiveness of SSRIs Via CYP450 2D6 inhibition, paroxetine could theoretically interfere with the analgesic actions of codeine, and increase the plasma levels of some beta blockers and of atomoxetine Via CYP450 2D6 inhibition, paroxetine could theoretically increase concentrations of thioridazine and cause dangerous cardiac arrhythmias Paroxetine increases pimozide (antipsychotic) levels, and pimozide prolongs QT interval, so concomitant use of pimozide and paroxetine is contraindicated Paroxetine lab tests None for healthy individuals Renal Impairment: Lower dose [initial 10 mg/day (12.5 mg CR), maximum 40 mg/day (50 mg/day CR)] Hepatic Impairment: Lower dose [initial 10 mg/day (12.5 mg CR), maximum 40 mg/day (50 mg/day CR)] Cardiac Impairment Preliminary research suggests that paroxetine is safe in cardiovascular patients Treating depression with SSRIs in patients with acute angina or following myocardial infarction may reduce cardiac events and improve survival as well as mood Paroxetine pregnancy risks Not generally recommended for use during pregnancy, especially during first trimester Epidemiological data have shown an increased risk of cardiovascular malformations (primarily ventricular and atrial septal defects) in infants born to women who took paroxetine during the first trimester (absolute risk is small) Unless the benefits of paroxetine to the mother justify continuing treatment, consider discontinuing paroxetine or switching to another antidepressant Paroxetine use late in pregnancy may be associated with higher risk of neonatal complications, including respiratory distress At delivery there may be more bleeding in the mother and transient irritability or sedation in the newborn Must weigh the risk of treatment (first trimester fetal development, third trimester newborn delivery) to the child against the risk of no treatment (recurrence of depression, maternal health, infant bonding) to the mother and child For many patients this may mean continuing treatment during pregnancy SSRI use beyond the 20th week of pregnancy may be associated with increased risk of pulmonary hypertension in newborns, although this is not proven Exposure to SSRIs late in pregnancy may be associated with increased risk of gestational hypertension and preeclampsia Neonates exposed to SSRIs or SNRIs late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding; reported symptoms are consistent with either a direct toxic effect of SSRIs and SNRIs or, possibly, a drug discontinuation syndrome, and include respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying Paroxetine neurotransmitters and moa -Boosts neurotransmitter serotonin -Blocks serotonin reuptake pump (serotonin transporter) -Desensitizes serotonin receptors, especially serotonin 1A autoreceptors -Presumably increases serotonergic neurotransmission -Paroxetine also has mild anticholinergic actions -Paroxetine may have mild norepinephrine reuptake blocking actions Fluvoxamine (Luvox) SSRI Major Side Effects Commonly Prescribed for Obsessive-compulsive disorder (OCD) (fluvoxamine and fluvoxamine CR) Social anxiety disorder (fluvoxamine CR) *Fluvoxamine's sigma 1 agonist properties may contribute to sedation and fatigue in some patients Notable Side Effects Sexual dysfunction (men: delayed ejaculation, erectile dysfunction; men and women: decreased sexual desire, anorgasmia) Gastrointestinal (decreased appetite, nausea, diarrhea, constipation, dry mouth) Mostly CNS (insomnia but also sedation, agitation, tremors, headache, dizziness) Note: patients with diagnosed or undiagnosed bipolar or psychotic disorders may be more vulnerable to CNS-activating actions of SSRIs Autonomic (sweating) Bruising and rare bleeding Rare hyponatremia Fluvoxamine Major Adverse Reactions Rare seizures Rare induction of mania Rare activation of suicidal ideation and behavior (suicidality) (short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo beyond age 24) Fluvoxamine Major Drug Interactions -Tramadol increases the risk of seizures in patients taking an antidepressant -Can increase tricyclic antidepressant levels; use with caution with TCAs -Can cause a fatal "serotonin syndrome" when combined with MAO inhibitors (MAOIs), so do not use with MAOIs or for at least 14 days after MAOIs are stopped -Do not start an MAOI for at least 5 half-lives (5 to 7 days for most drugs) after discontinuing fluvoxamine -May displace highly protein-bound drugs (e.g., warfarin) -Can rarely cause weakness, hyperreflexia, and incoordination when combined with sumatriptan or possibly with other triptans, requiring careful monitoring of patient -Possible increased risk of bleeding, especially when combined with anticoagulants (e.g., warfarin, NSAIDs) NSAIDs may impair effectiveness of SSRIs Via CYP450 1A2 inhibition, fluvoxamine may reduce clearance of theophylline and clozapine, thus raising their levels and requiring their dosing to be lowered Fluvoxamine administered with either caffeine or theophylline can thus cause jitteriness, excessive stimulation, or rarely seizures, so concomitant use should proceed cautiously Metabolism of fluvoxamine may be enhanced in smokers and thus its levels lowered, requiring higher dosing Via CYP450 3A4 inhibition, fluvoxamine may reduce clearance of carbamazepine and benzodiazepines such as alprazolam and triazolam, and thus require dosage reduction Via CYP450 3A4 inhibition, fluvoxamine could theoretically increase concentrations of certain cholesterol lowering HMG CoA reductase inhibitors, especially simvastatin, atorvastatin, and lovastatin, but not pravastatin or fluvastatin, which would increase the risk of rhabdomyolysis; thus, coadministration of fluvoxamine with certain HMG CoA reductase inhibitors should proceed with caution Via CYP450 3A4 inhibition, fluvoxamine could theoretically increase the concentrations of pimozide, and cause QTc prolongation and dangerous cardiac arrhythmias Fluvoxamine lab tests None for healthy individuals Renal Impairment Consider lower initial dose Hepatic Impairment Lower dose or give less frequently, perhaps by half; use slower titration Cardiac Impairment Preliminary research suggests that fluvoxamine is safe in these patients Treating depression with SSRIs in patients with acute angina or following myocardial infarction may reduce cardiac events and improve survival as well as mood Fluvoxamine neurotransmitters and moa Boosts neurotransmitter serotonin Blocks serotonin reuptake pump (serotonin transporter) Desensitizes serotonin receptors, especially serotonin 1A receptors Presumably increases serotonergic neurotransmission Fluvoxamine also binds at sigma 1 receptors Fluvoxamine pregnancy risks Controlled studies have not been conducted in pregnant women Not generally recommended for use during pregnancy, especially during first trimester Nonetheless, continuous treatment during pregnancy may be necessary and has not been proven to be harmful to the fetus At delivery there may be more bleeding in the mother and transient irritability or sedation in the newborn Must weigh the risk of treatment (first trimester fetal development, third trimester newborn delivery) to the child against the risk of no treatment (recurrence of depression, maternal health, infant bonding) to the mother and child For many patients this may mean continuing treatment during pregnancy Exposure to SSRIs early in pregnancy may be associated with increased risk of septal heart defects (absolute risk is small) SSRI use beyond the 20th week of pregnancy may be associated with increased risk of pulmonary hypertension in newborns, although this is not proven Exposure to SSRIs late in pregnancy may be associated with increased risk of gestational hypertension and preeclampsia Neonates exposed to SSRIs or SNRIs late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding; reported symptoms are consistent with either a direct toxic effect of SSRIs and SNRIs or, possibly, a drug discontinuation syndrome, and include respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying Venlafaxine (Effexor) Major Side Effects SNRI Commonly Prescribed for (FDA approved in bold) •Depression •Generalized anxiety disorder •Panic disorder •Social phobia Constipation, dry mouth, sweating, blurry vision, loss of appetite, nausea, weight loss or gain, hypertension, headache, asthenia, dizziness, tremor, dream disorder, insomnia, somnolence, abnormal ejaculation, impotence, orgasm disorder, sweating, itching, sedation, nervousness, restlessness Venlaxafine Major Adverse Reactions •Serotonin syndrome •Rare hepatitis •Rare activation of mania or suicidal ideation •Rare worsening of coexisting seizure disorders Venlafaxine Major Drug Interactions CYP2D6 inhibitors (paroxetine, fluoxetine, bupropion), cimetidine, and valproic acid and CYP3A4 inhibitors (clarithromycin, ketoconazole, itraconazole) may increase drug concentration •The release of serotonin by platelets is important for maintaining hemostasis. Combined use of SSRIs or SNRI's (such as venlafaxine) and NSAIDs, and/or drugs that effect anticoagulation have been associated with an increased risk of bleeding •CYP2D6 and 1A2 enzyme inducers, including rifampin, nicotine, phenobarbital, can lower levels •May decrease effects of antihypertensive medications, such as metoprolol •May decrease clearance and increase effect of antipsychotics (haloperidol, clozapine.) •May increase the risk of seizure with tramadol •May cause serotonin syndrome when used within 14 days of MAO inhibitors •May increase risk of cardiotoxicity and arrhythmia when used with tricyclic antidepressants Venlafaxine Lab tests Check blood pressure at baseline and when increasing dose Renal Impairment •Use with caution. Decrease usual dose by 25-50% Hepatic Impairment •Use with caution. Decrease usual dose by 50% Cardiac Impairment •Use with caution. Dose-dependent effect on blood pressure Venlafaxine pregnancy risk Category C. Generally not recommended for the treatment of headaches or neuropathic pain during pregnancy. Neonates exposed to venlafaxine or other SNRIs or SSRIs late in the third trimester have developed complications necessitating extended hospitalizations, respiratory support, and tube feeding. Respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying consistent with a toxic effect of the drug or drug discontinuation syndrome have been reported Venlafaxine neurotransmitters and moa -Blocks serotonin and norepinephrine reuptake pumps, increasing their levels within hours, but antidepressant effects take weeks. Effect is more likely related to adaptive changes in serotonin and norepinephrine receptor systems over time •Weakly blocks dopamine reuptake pump (dopamine transporter) Agomelatine (Valdoxan) NRI Major Side Effects -Nausea and dizziness are most common -Other adverse reactions are somnolence, fatigue, insomnia, headache, anxiety, diarrhea, constipation, upper abdominal pain, vomiting, hyperhidrosis -Increase of transaminase levels *Stop if transaminase levels reach 3 times the upper limit of normal Agomelatine Major Adverse Reactions -Rare hepatitis, hepatic failure -Theoretically rare induction of mania (class warning) -Rare activa-tion of suicidal ideation and behavior (suicidality) (short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo beyond age 24) (class warning) Agomelatine drug interactions Use of agomelatine with potent CYP450 1A2 inhibitors (e.g., fluvoxamine) is contraindicated Tramadol increases the risk of seizures in patients taking an antidepressant (class warning) Agomelatine dosing range Usual Dosage Range 25-50 mg/day at bedtime Agomelatine lab tests Liver function tests before initiation of treatment and then at 3 weeks, 6 weeks, 12 weeks, 24 weeks, and thereafter when clinically indicated When increasing the dose, liver function tests should be performed at the same frequency as when initiating treatment Liver function tests should be repeated within 48 hours in any patient who develops raised transaminases Renal Impairment Drug should be used with caution Hepatic Impairment Contraindicated Cardiac Impairment Dose adjustment not necessary Agomelatine pregnancy risk Not generally recommended for use during pregnancy, especially during first trimester Must weigh the risk of treatment (first trimester fetal development, third trimester newborn delivery) to the child against the risk of no treatment (recurrence of depression, maternal health, infant bonding) to the mother and child For many patients this may mean continuing treatment during pregnancy Agomelatine neurotransmitters and moa Actions at both melatonergic and 5HT2C receptors may be synergistic and increase norepinephrine and dopamine neurotransmission in the prefrontal cortex; may resynchronize circadian rhythms that are disturbed in depression No influence on extracellular levels of serotonin Bupropion (Wellbutrin) dopamine reuptake inhibitor and releaser (D-RIRe) Major Side Effects Commonly Prescribed for *Major depressive disorder (bupropion, bupropion SR, and bupropion XL) *Seasonal affective disorder (bupropion XL) *Nicotine addiction (bupropion SR) Bipolar depression Attention deficit /hyperactivity disorder (ADHD) Sexual dysfunction Dry mouth, constipation, nausea, weight loss, anorexia, myalgia Insomnia, dizziness, headache, agitation, anxiety, tremor, abdominal pain, tinnitus Sweating, rash Hypertension Bupropion Major Adverse Reactions Seizures!!!!!! -Rare seizures (higher incidence for immediate-release than for sustained-release; risk increases with doses above the recommended maximums; risk increases for patients with predisposing factors) -Anaphylactoid/anaphylactic reactions and Stevens-Johnson syndrome have been reported -Hypomania (more likely in bipolar patients but perhaps less common than with some other antidepressants) -Rare induction of mania -Rare activation of suicidal ideation and behavior (suicidality) (short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo beyond age 24) -Weight Gain Bupropion Drug Interactions -Can be added to SSRIs to reverse SSRI-induced sexual dysfunction, SSRI-induced apathy (use combinations of antidepressants with caution as this may activate bipolar disorder and suicidal ideation) -Can be added to SSRIs to treat partial responders -Often used as an augmenting agent to mood stabilizers and/or atypical antipsychotics in bipolar depression -Tramadol increases the risk of seizures in patients taking an antidepressant -Can increase TCA levels; use with caution with TCAs or when switching from a TCA to bupropion -Use with caution with MAOIs, including 14 days after MAOIs are stopped (for the expert) -There is increased risk of hypertensive reaction if bupropion is used in conjunction with MAOIs or other drugs that increase norepinephrine -There may be an increased risk of hypertension if bupropion is combined with nicotine replacement therapy -Via CYP450 2D6 inhibition, bupropion could theoretically interfere with the analgesic actions of codeine, and increase the plasma levels of some beta blockers and of atomoxetine thioridazine and cause dangerous cardiac arrhythmias Bupropion lab tests *Don't have to taper when d/c! Recommended to assess blood pressure at baseline and periodically during treatment Renal Impairment Lower initial dose, perhaps give less frequently Drug concentration may be increased Patient should be monitored closely Hepatic Impairment Lower initial dose, perhaps give less frequently Patient should be monitored closely In severe hepatic cirrhosis, bupropion XL should be administered at no more than 150 mg every other day Cardiac Impairment Limited available data Evidence of rise in supine blood pressure Use with caution Bupropion neurotransmitters and moa -Boosts neurotransmitters norepinephrine/noradrenaline and dopamine -Blocks norepinephrine reuptake pump (norepinephrine transporter), presumably increasing norepinephrine neurotransmission dopamine transporters, bupropion can increase dopamine neurotransmission in this part of the brain -Blocks dopamine reuptake pump (dopamine transporter), presumably increasing dopaminergic neurotransmission Bupropion pregnancy risk Controlled studies have not been conducted in pregnant women Epidemiological studies do not indicate increased risk of congenital malformations overall or of cardiovascular malformations In animal studies, no clear evidence of teratogenicity has been observed; however, slightly increased incidences of fetal malformations and skeletal variations were observed in rabbit studies at doses approximately equal to and greater than the maximum recommended human doses, and greater and decreased fetal weights were observed in rat studies at doses greater than the maximum recommended human doses Pregnant women wishing to stop smoking may consider behavioral therapy before pharmacotherapy Not generally recommended for use during pregnancy, especially during first trimester Must weigh the risk of treatment (first trimester fetal development, third trimester newborn delivery) to the child against the risk of no treatment (recurrence of depression, maternal health, infant bonding) to the mother and child For many patients this may mean continuing treatment during pregnancy Clomipramine (Anafranil) major side effects TCA Commonly Prescribed for *Obsessive-compulsive disorder Depression Severe and treatment-resistant depression Cataplexy syndrome Anxiety Insomnia Neuropathic pain/chronic pain Blurred vision, constipation, urinary retention, increased appetite, dry mouth, nausea, diarrhea, heartburn, unusual taste in mouth, weight gain Fatigue, weakness, dizziness, sedation, headache, anxiety, nervousness, restlessness Sexual dysfunction, sweating Clomipramine major adverse reactions -paralytic ileus, hyperthermia (TCAs + anticholinergic agents) -Lowered seizure threshold and rare seizures -Orthostatic hypotension, sudden death, arrhythmias, tachycardia -QTc prolongation -Hepatic failure, extrapyramidal symptoms -Increased intraocular pressure -Rare induction of mania -Rare activation of suicidal ideation and behavior (suicidality) (short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo beyond age 24) Clomipramine major drug interactions -Tramadol increases the risk of seizures in patients taking TCAs -Can cause a fatal "serotonin syndrome" when combined with MAOIs, so do not use with MAOIs or at least for 14 days after MAOIs are stopped -Do not start an MAOI for at least 5 half-lives (5 to 7 days for most drugs) after discontinuing clomipramine -Use of TCAs with anticholinergic drugs may result in paralytic ileus or hyperthermia -Fluoxetine, paroxetine, bupropion, duloxetine, and other CYP450 2D6 inhibitors may increase TCA concentrations -Fluvoxamine, a CYP450 1A2 inhibitor, can decrease the conversion of clomipramine to desmethyl-clomipramine, and increase clomipramine plasma concentrations represent the induction of a bipolar state, especially a mixed dysphoric bipolar II condition sometimes associated with suicidal ideation, and require the addition of lithium, a mood stabilizer or an atypical antipsychotic, and/or discontinuation of clomipramine Clomipramine lab tests -Baseline ECG is recommended for patients over age 50 -Monitoring of plasma drug levels is potentially available at specialty laboratories for the expert -Since tricyclic and tetracyclic antidepressants are frequently associated with weight gain, before starting treatment, weigh all patients and determine if the patient is already overweight (BMI 25.0-29.9) or obese (BMI ≥30) -Before giving a drug that can cause weight gain to an overweight or obese patient, consider determining whether the patient already has pre-diabetes (fasting plasma glucose 100-125 mg/dL), diabetes (fasting plasma glucose 126 mg/dL), or dyslipidemia (increased total cholesterol, LDL cholesterol and triglycerides; decreased HDL cholesterol), and treat or refer such patients for treatment, including nutrition and weight management, physical activity counseling, smoking cessation, and medical management -Weight and BMI during treatment While giving a drug to a patient who has gained 5% of initial weight, consider evaluating for the presence of pre-diabetes, diabetes, or dyslipidemia, or consider switching to a different antidepressant -EKGs may be useful for selected patients (e.g., those with personal or family history of QTc prolongation; cardiac arrhythmia; recent myocardial infarction; uncompensated heart failure; or taking agents that prolong QTc interval such as pimozide, thioridazine, selected antiarrhythmics, moxifloxacin, sparfloxacin, etc.) -Patients at risk for electrolyte disturbances (e.g., patients on diuretic therapy) should have baseline and periodic serum potassium and magnesium measurements Clomipramine neurotransmitters and moa -Boosts neurotransmitters serotonin and norepinephrine/noradrenaline -Blocks serotonin reuptake pump (serotonin transporter), presumably increasing serotonergic neurotransmission -Blocks norepinephrine reuptake pump (norepinephrine transporter), presumably increasing noradrenergic neurotransmission -Presumably desensitizes both serotonin 1A receptors and beta adrenergic receptors -Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, which largely lacks dopamine transporters, clomipramine can increase dopamine neurotransmission in this part of the brain Clomipramine pregnancy risk Controlled studies have not been conducted in pregnant women Clomipramine crosses the placenta Adverse effects have been reported in infants whose mothers took a TCA (lethargy, withdrawal symptoms, fetal malformations) Must weigh the risk of treatment (first trimester fetal development, third trimester newborn delivery) to the child against the risk of no treatment (recurrence of depression, worsening of OCD, maternal health, infant bonding) to the mother and child For many patients this may mean continuing treatment during pregnancy Amitriptyline (Elavil) major side effects TCA Commonly Prescribed for *Depression *Endogenous depression Neuropathic pain/chronic pain Fibromyalgia Headache Low back pain/neck pain Anxiety Insomnia Treatment-resistant depression Blurred vision, constipation, urinary retention, increased appetite, dry mouth, nausea, diarrhea, heartburn, unusual taste in mouth, weight gain Fatigue, weakness, dizziness, sedation, headache, anxiety, nervousness, restlessness Sexual dysfunction (impotence, change in libido) Sweating, rash, itching Amitriptyline major adverse reactions Paralytic ileus, hyperthermia (TCAs + anticholinergic agents) Lowered seizure threshold and rare seizures Orthostatic hypotension, sudden death, arrhythmias, tachycardia QTc prolongation Hepatic failure, extrapyramidal symptoms Increased intraocular pressure Rare induction of mania Rare activation of suicidal ideation and behavior (suicidality) (short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo beyond age 24) Amitriptyline drug interactions -Tramadol increases the risk of seizures in patients taking TCAs -Use of TCAs with anticholinergic drugs may result in paralytic ileus or hyperthermia -Fluoxetine, paroxetine, bupropion, duloxetine, and other CYP450 2D6 inhibitors may increase TCA concentrations nortriptyline and increase amitriptyline plasma concentrations -Cimetidine may increase plasma concentrations of TCAs and cause anticholinergic symptoms -Phenothiazines or haloperidol may raise TCA blood concentrations -May alter effects of antihypertensive drugs; may inhibit hypotensive effects of clonidine -Use of TCAs with sympathomimetic agents may increase sympathetic activity -Methylphenidate may inhibit metabolism of TCAs -Activation and agitation, especially following switching or adding antidepressants, may represent the induction of a bipolar state, especially a mixed dysphoric bipolar II condition sometimes associated with suicidal ideation, and require the addition of lithium, a mood stabilizer or an atypical antipsychotic, and/or discontinuation of amitriptyline Amitriptyline lab tests -Monitor weight and BMI during treatment While giving a drug to a patient who has gained 5% of initial weight, consider evaluating for the presence of pre-diabetes, diabetes, or dyslipidemia, or consider switching to a different antidepressant -Renal Impairment Use with caution; may need to lower dose -Hepatic Impairment Use with caution; may need to lower dose -Cardiac Impairment *Baseline ECG is recommended TCAs have been reported to cause arrhythmias, prolongation of conduction time, orthostatic hypotension, sinus tachycardia, and heart failure, especially in the diseased heart Myocardial infarction and stroke have been reported with TCAs TCAs produce QTc prolongation, which may be enhanced by the existence of bradycardia, hypokalemia, congenital or acquired long QTc interval, which should be evaluated prior to administering amitriptyline -Use with caution if treating concomitantly with a medication likely to produce prolonged bradycardia, hypokalemia, slowing of intracardiac conduction, or prolongation of the QTc interval infarction, and uncompensated heart failure -TCAs may cause a sustained increase in heart rate in patients with ischemic heart disease and may worsen (decrease) heart rate variability, an independent risk of mortality in cardiac populations Since SSRIs may improve (increase) heart rate variability in patients following a myocardial infarct and may improve survival as well as mood in patients with acute angina or following a myocardial infarction, these are more appropriate agents for cardiac population than tricyclic/tetracyclic antidepressants Risk/benefit ratio may not justify use of TCAs in cardiac impairment Amitriptyline neurotransmitters and moa -Boosts neurotransmitters serotonin and norepinephrine/noradrenaline -Blocks serotonin reuptake pump (serotonin transporter), presumably increasing serotonergic neurotransmission -Blocks norepinephrine reuptake pump (norepinephrine transporter), presumably increasing noradrenergic neurotransmission -Presumably desensitizes both serotonin 1A receptors and beta adrenergic receptors -Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, which largely lacks dopamine transporters, amitriptyline can increase dopamine neurotransmission in this part of the brain Amitriptyline pregnancy risk Controlled studies have not been conducted in pregnant women Crosses the placenta -Adverse effects have been reported in infants whose mothers took a TCA (lethargy, withdrawal symptoms, fetal malformations) -Must weigh the risk of treatment (first trimester fetal development, third trimester newborn delivery) to the child against the risk of no treatment (recurrence of depression, maternal health, infant bonding) to the mother and child -For many patients this may mean continuing treatment during pregnancy Lithium (eskalith) major side effects (Mood stabilizer) Commonly Prescribed for *Manic episodes of manic-depressive illness *Maintenance treatment for manic-depressive patients with a history of mania Bipolar depression Major depressive disorder (adjunctive) Vascular headache Neutropenia -Ataxia, dysarthria, delirium, tremor, memory problems -Polyuria, polydipsia (nephrogenic diabetes insipidus) -Diarrhea, nausea -Weight gain -Euthyroid goiter or hypothyroid goiter, possibly with increased TSH and reduced thyroxine levels -Acne, rash, alopecia -Leukocytosis -Side effects are typically dose-related Lithium major adverse reactions -Lithium toxicity -Renal impairment (interstitial nephritis) -Nephrogenic diabetes insipidus -Arrhythmia, cardiovascular changes, sick sinus syndrome, bradycardia, hypotension -T wave flattening and inversion -Rare pseudotumor cerebri Lithium drug interactions -Non-steroidal anti-inflammatory agents, including ibuprofen and selective COX-2 inhibitors (cyclooxygenase 2), can increase plasma lithium concentrations; add with caution to patients stabilized on lithium -Diuretics, especially thiazides, can increase plasma lithium concentrations; add with caution to patients stabilized on lithium -Angiotensin-converting enzyme inhibitors can increase plasma lithium concentrations; add with caution to patients stabilized on lithium -Metronidazole can lead to lithium toxicity through decreased renal clearance -Acetazolamide, alkalizing agents, xanthine preparations, and urea may lower lithium plasma concentrations -Methyldopa, carbamazepine, and phenytoin may interact with lithium to increase its toxicity -Use lithium cautiously with calcium channel blockers, which may also increase lithium toxicity -Use of lithium with an SSRI may raise risk of dizziness, confusion, diarrhea, agitation, tremor -Some patients taking haloperidol and lithium have developed an encephalopathic syndrome similar to neuroleptic malignant syndrome -Lithium may prolong effects of neuromuscular blocking agents -No likely pharmacokinetic interactions of lithium with mood-stabilizing anticonvulsants or atypical antipsychotics Lithium neurotransmitters and moa *Unknown and complex -Alters sodium transport across cell membranes in nerve and muscle cells -Alters metabolism of neurotransmitters including catecholamines and serotonin -May alter intracellular signaling through actions on second messenger systems -Specifically, inhibits inositol monophosphatase, possibly affecting neurotransmission via phosphatidyl inositol second messenger system neurotransmission -Increases cytoprotective proteins, activates signaling cascade utilized by endogenous growth factors, and increases gray matter content, possibly by activating neurogenesis and enhancing trophic actions that maintain synapses Lithium therapeutic levels 0.6-1.2 mEq/L Lithium toxicity can happen when this level reaches 1.5 mEq/L or higher Lithium toxicity s/s Toxicity Gastric Irritation (Initial Sign) Slurred Speech Course tremors Hallucination Tinnitus Strabismus / Nystagmus Seizure Oligura / Anuria Death Lithium pregnancy risk -Evidence of increased risk of major birth defects (perhaps 2-3 times the general population), but probably lower than with some other mood stabilizers (e.g., valproate) -Evidence of increase in cardiac anomalies (especially Ebstein's anomaly) in infants whose mothers took lithium during pregnancy observed -If lithium is continued, monitor serum lithium levels every 4 weeks, then every week beginning at 36 weeks -Dehydration due to morning sickness may cause rapid increases in lithium levels -Lithium administration during delivery may be associated with hypotonia in the infant; most recommend withholding lithium for 24-48 hours before delivery -Monitoring during delivery should include fluid balance -After delivery, monitor for 48 hours for "floppy baby syndrome" -Use in women of childbearing potential requires weighing potential benefits to the mother against the risks to the fetus -Recurrent bipolar illness during pregnancy can be quite disruptive -Taper drug if discontinuing -Given the risk of bipolar relapse in the postpartum period, lithium should generally be restarted immediately after delivery -This may mean no breast feeding, since lithium can be found in breast milk, possibly at full therapeutic levels -Atypical antipsychotics may be preferable to lithium or anticonvulsants if treatment of bipolar disorder is required during pregnancy -Bipolar symptoms may recur or worsen during pregnancy and some form of treatment may be necessary Carbamazepine (Tegretol) Major Side Effects *Anticonvulsant Commonly Prescribed for *Partial seizures with complex symptomatology *Generalized tonic-clonic seizures (grand mal) *Mixed seizure patterns *Pain associated with true trigeminal neuralgia *Acute mania/mixed mania (Equetro) Glossopharyngeal neuralgia Bipolar depression Bipolar maintenance Psychosis, schizophrenia (adjunctive) -Sedation, dizziness, confusion, unsteadiness, headache -Nausea, vomiting, diarrhea -Blurred vision -Benign leukopenia (transient; in up to 10%) -Rash Carbamazepine major adverse reactions *voltage-sensitive sodium channel antagonist -Rare aplastic anemia, agranulocytosis (unusual bleeding or bruising, mouth sores, infections, fever, sore throat) -Rare severe dermatologic reactions (purpura, Stevens-Johnson syndrome) -Rare cardiac problems -Rare induction of psychosis or mania -SIADH (syndrome of inappropriate antidiuretic hormone secretion) with hyponatremia -Increased frequency of generalized convulsions (in patients with atypical absence seizures) -Rare activation of suicidal ideation and behavior (suicidality) Carbamazepine drug interactions Carbamazepine lab tests -Before starting: blood count, liver, kidney, and thyroid function tests -During treatment: blood count every 2-4 weeks for 2 months, then every 3-6 months throughout treatment -During treatment: liver, kidney, and thyroid function tests every 6-12 months for the presence of the HLA-B 1502 allele; those with HLA-B1502 should not be treated with carbamazepine Carbamazepine neurotransmitters and moa -Acts as a use-dependent blocker of voltage-sensitive sodium channels -Interacts with the open channel conformation of voltage-sensitive sodium channels -Interacts at a specific site of the alpha pore-forming subunit of voltage-sensitive sodium channels -Inhibits release of glutamate Carbamazepine therapeutic levels For acute treatment, levels should be between 1.0 and 1.5 mE1/L; for maintenance treatment, levels should be between 0.6 and 1.2 mEq/L Carbamazepine toxicity s/s Toxicity causes several adverse effects, including: Renal toxicity Impaired urine concentration ability Drug induced nephrogenic diabetes insipidus Sodium-losing nephritis Cardiovascular effects T wave flattening Sinus node dysfunction QT prolongation intraventricular conduction defects U waves GI effects Endocrine effects inhibition of thyroid hormone synthesis and subsequent release, leading to hypothyroidism Carbamazepine pregnancy risk -Use during first trimester may raise risk of neural tube defects (e.g., spina bifida) or other congenital anomalies -Use in women of childbearing potential requires weighing potential benefits to the mother against the risks to the fetus -If drug is continued, perform tests to detect birth defects -If drug is continued, start on folate 1 mg/day early in pregnancy to reduce risk of neural tube defects -Antiepileptic Drug Pregnancy Registry: (888) 233-2334 -Use of anticonvulsants in combination may cause a higher prevalence of teratogenic effects than anticonvulsant monotherapy -Taper drug if discontinuing -Seizures, even mild seizures, may cause harm to the embryo/fetus -For bipolar patients, carbamazepine should generally be discontinued before anticipated pregnancies -Recurrent bipolar illness during pregnancy can be quite disruptive -For bipolar patients, given the risk of relapse in th