Neurological Pharmacology Developed by: Dawn Johnson, RN, MSN, Ed

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Anticonvulsant Medications

Anticonvulsant Medications Hydantoin class Phenytoin (Dilantin) Ethotoin (Peganone) Mephenytoin (Mesantaoin) Fosphenytoin IV (Celebyx) Action: increases Na+ out of neurons depressing abnormal stimulation and discharge

Anticonvulsant Medications Hydantoin class Uses: Seizures of all types without CNS depression Side effects: Drowsiness and dizziness n/v Gingival Hyperplasia-reddened gums that bleed easily Low platelet and WBC count Toxicity: ataxia/slurred speech Diplopia/nystagmus Hypotension Pupils fixed/coma

Anticonvulsant Medications Hydantoin class Contraindications: Bradycardia Heart block Considerations: Dilantin level 10-20ug Must take same brand; no abrupt discontinuation Urine discoloration If down tube feeding: shut off tf for 1 hour prior and 1 hour after due to dilantin binds with protein in tube feedings Give good oral hygiene/dental checks IV: no dextrose; it precipitates Give in large vein < or = 50mg/min Cardiotoxic with low bp

Anticonvulsant Medications Phenytoin-like class Valproic acid (Depakene) (Depakote) Carbamazepine (Tegretol) Topiramate (Topamax) Lamotrigine (Lamictal) Zonisamide (Zonegran) Felbamate (Felbatol)

Anticonvulsant Medications Phenytoin-like class Uses: Absence/simple seizures Trigeminal Neuralgia Side effects: Drowsiness and dizziness Photophobia Blood dyscrasias Hepatoxicity can be life threatening Lamictal rash is life threatening Toxicity: ataxia/slurred speech Diplopia/nystagmus Hypotension Pupils fixed/coma

Anticonvulsant Medications Phenytoin-like class Contraindications: Hepatic disease Blood dyscrasias Considerations: Valproic acid is GI irritant Severe mouth/throat irritation if chewed or carbonated drinks Considerations: Sprinkles for on food for children Notify MD if s&s of neutropenia: Sore throat Fever Oral ulcers S&s or plastic anemia: Fatigue Easy bleeding/bruising

Anticonvulsant Medications Barbiturates class Amobarbital (Amytal) Pentobarbital (Nembutal) Phenobarbital (Luminal) Secobarbital (Seconal) Primadone (Mysoline)

Anticonvulsant Medications Barbiturates class Uses: Grand mal seizures Partial seizures Insomnia Side effects: Drowsiness Decreased BP Respiratory depression Blood dyscrasias Addiction Have a hangover effect

Anticonvulsant Medications Barbiturates class Contraindications: Hepatic disease Addiction Respiratory disease Considerations: Decreases oral contraceptive action Hold with respirations <12 Check for s&s of withdrawal: 8-12 hours minor s&s 16 hours – 5 days: convulsions and delirium

Anticonvulsant Medications Benzodiazepines Clonazepam (Klonopin) Clorazepate (Tranxene) Diazepam (Valium) Lorazepam (Ativan)

Anticonvulsant Medications Benzodiazepines Uses: Absence seizures Partial seizures ETOH withdrawal Status epilepticus Anxiety Muscle spasms

Anticonvulsant Medications Benzodiazepines Side effects: Drowsiness and dizziness Dependence Blood dyscrasias Vit k and d decreased Increases digoxin level Contraindications: ETOH Considerations: Abrupt stop can bring status epilepticus and withdrawal Check respiratory depression Check blood dyscrasias IV diazepam Push only <5mg/min in large vein Do not mix with other drugs

Anticonvulsant Medications Succinimide class Ethosuximide (Zarontin) Methsuximide (Celontin) Phensuximide (Milontin)

Anticonvulsant Medications Succinimide class Uses: Absence seizures Side effects: Drowsiness and dizziness Blood dyscrasias GI: n/v, gingival hyperplasia, tongue swelling Psychosis/mood swings Hematuria common in phensuximide

Anticonvulsant Medications Succinimide class Contraindications: Psychiatric history Considerations: Abrupt stop can bring on seizure Check blood dyscrasias Check tongue swelling/psych status Teach oral care/dental checks

Anticonvulsant Medications GABA agent class Gabapentin (Neurontin) Tiagabine (Gabitril) Uses: Partial seizures Neuralgia Nerve pain

Anticonvulsant Medications GABA agent class Side effects: Drowsiness and dizziness Blood dyscrasias Contraindications: MAO inhibitors Considerations: Check for blood dyscrasias

Anticonvulsant Medications Misc Oxacarbazepine (Trileptal) Levetiracetam (Keppra) Trimethadone (Tridione) Uses: Second line and adjunctive treatment for seizures

Anticonvulsant Medications Misc Side effects: Drowsiness and dizziness Blood dyscrasias Contraindications: MAO inhibitors Considerations: Check for blood dyscrasias

Sedatives

Sedatives Barbiturates class Short acting: Phenobarbital (Nembutal) Secobarbital (Seconal) Intermediate acting: Amobarbital (Amytal) Aprobarbital (Alurate) Butabarbital (Butisol) Long acting: Mephobarbital (Mebaral) Phenobarbital (Luminal)

Sedatives Barbiturates class Uses: Low dose: anxiety Moderate dose: sleep, seizures High dose: anesthesia Side effects: Drowsiness and dizziness Decrease BP Tolerance develops Respiratory depression Blood dyscrasias Addiction Low margin of safety: Excessive dose will cause respiratory depression and coma

Sedatives Barbiturates class Considerations: Hold with respirations <12 Decrease oral contraceptive Limit medication for hoarding Tapered for withdrawal Check for s&s withdrawal: 8-12 hours minor s&s 16 hours – 5 days: convulsions and delirium Contraindications: Hepatic disease Drug abuse history Suicidal history Respiratory disease Considerations: reduces REM sleep Effectiveness on insomnia without daytime sedation

Sedatives Benzodiazepine Estazolam (Prosom) Flurazepam (Dalamane) Quazepam (Doral) Temazepam (Restoril) Triazolam (Halcion)

Sedatives Benzodiazepine Uses: Insomnia Side effects: Drowsiness and dizziness Respiratory depression Dependence Blood dyscrasias Greater margin of safety but with other CNS depressants can be fatal Herbs: Kava and valerian with increase the effects

Sedatives Benzodiazepine Contraindications: Suicidal history Drug abuse history CNS depression Elderly NA Glaucoma Uncontrolled pain Considerations: Limit to 7-10 days treatment Withhold if systolic pressure drops 20mm while standing or respirations <12/min Check neutropenia/aplastic anemia Antacids and smoking decrease effects No hazardous activity

Sedatives dopamine and serotonin agonist Buspirone (Buspar) Uses: Insomnia Anxiety Side effects: Well tolerated Dystonias; akisthesia Contraindications: Renal disease Liver disease MAO inhibitors Considerations: Does not cause sedation, tolerance, CNS depression, no abuse potential Takes several weeks to take full effect

Sedatives GABA Binder Zolipidem (Ambien) Uses: Side effects: Insomnia Induces sleep Side effects: Daytime drowsiness Confusion Amnesia Dependence in 10 days Contraindications: Liver disease Lung disease Apnea Psych history Elderly Considerations: Rapid effect Take when pt in bed due to fall risk

Sedatives Antihistamines Diphenhydramine (Benadryl) (Sominex) Hydroxyzine (Vistaril) Promethazine (Anergan 50) (Phenergan) Uses: Insomnia Allergic reaction Side effects: Drowsiness Anticholinergic side effects

Sedatives Antihistamines Contraindications: Glaucoma Peptic ulcer MAOIs BPH COPD Children can have CNS over stimulation and decrease response at the same time leading to heat stroke, seizures and can easily overdose

Sedatives Antihistamines Considerations: No hazardous activity Do not mix with ETOH/CNS depressants Sugarless candy for dry mouth Monitor BP and pulse Check urinary function Z track vistaril Use with other antihistamine products including topicals increase effect

Sedatives Misc Side effects: Meprobamate (Equanil) (Milltown) Drowsiness Respiratory depression Contraindications: Elderly Uncontrolled pain Considerations: Give chloral hydrate after meal due to GI irritant Mix with fluids due to poor taste Meprobamate (Equanil) (Milltown) Chloral hydrate (Noctec) Uses: Insomnia Preoperative sedation Anxiety

Anxiolytics

Anxiolytics Benzodiazepines Alprozolam (Xanax) Chlordiazepoxide (Librium) Clonazepam (Klonopin) Clorazepate (Tranxene) Diazepam (Valium) Halezepam (Paxipam) Lorazepam (Ativan) Oxazepam (Serax)

Anxiolytics Benzodiazepines Uses: Insomnia Anxiety Side effects: Drowsiness and dizziness Respiratory depression Dependence Blood dyscrasias Vit K and D decreased Increases digoxin level

Anxiolytics Benzodiazepines Contraindications: NA Glaucoma Suicide history Considerations: Check respiratory depression No hazardous activity Do not mix with ETOH/CNS depressants Check blood dyscrasias Caution with herbs: kava, valerian, chamomile, hops due to CNS depression IV diazepam/lorazepam: IV push <5mg/min in large vein Can not mix with other drugs Rapid acting

Benzodiazepine Antagonist Flumazenil (Romazicon) Uses: benzodiazepine toxicity/overdose Side effects: seizures Contraindications: Status epilepticus ICP Considerations: IV: 0.2mg, 0.3mg 0.5mg over 30 secs q minute prn Effects last one hour: watch 2 hours after last dose Seizure precautions Does not reverse respiratory depression

CNS Stimulants

CNS Stimulants Anorexiants class Bensphetamine (Didrex) Diethylpropion (Proprioan) Sibutramine (Meridia)

CNS Stimulants Anorexiants class Uses: Narcolepsy ADHD ADD Obesity Side effects: Restlessness, insomnia Palpitations Dysmennorhea Tachycardia Reverse HTN treatment Decrease seizure threshold Dependence and abuse

CNS Stimulants Anorexiants class Contraindications: NA glaucoma Hyperthyroid CV disease Drug abuse history <12yrs old Agitation Anxiety Tourettes syndrome Considerations: Give on empty stomach Take 6hrs before bed No OTCs can have fatal reaction

CNS Stimulants Amphetamines Ampehtamine SO4 (Adderall) Dexroamphetamine (Dexadrine) Dexmethylphenidate (Focalin) Pemoline (Cylert) (PemADD) Methylphenidate (Ritalin) (Concerta) (Metadate) (Methylin)

CNS Stimulants Amphetamines Uses: ADHD Obesity Narcolepsy Side effects: Restlessness, insomnia, hyperactivity, talkative Palpitations Tachycardia Side effects: Arrythmias Low BP, CV collapse Dry mouth n/v Impotence Libido change Growth suppression Dependence and abuse

CNS Stimulants Amphetamines Considerations: Empty stomach 1st dose wakening Last dose 6hrs before bed ADD/ADHD benefits in 3-4 wks Avoid caffeine, colas, chocolate, tea No OTC fatal reaction No abrupt discontinuation Withdrawal: HA, N/V, myalgia, depression, fatigue, hunger Contraindications: Glaucoma Hyperthyroid CV disease Drug abuse history Agitation Anxiety Tourettes sydrome

CNS Stimulants Amphetamine Doxapram (Dopram) Uses: stimulate respirations post anesthesia Side effects: Arrythmias Low BP, CV collapse Dry mouth n/v Impotence Libido change Growth suppression Dependence and abuse Considerations: Check respiratory status while administering: rate, depth, lung sounds, ABGs

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