Tricyclic’s / action / reaction / Nursing consideration – teachings(in prog) – Flashcards

Tricyclic - Antidepressant - Panic Disorders - Stimulating

Tricyclic - Antidepressant - Panic Disorders - More Sedating

Tricyclic - Antidepressant - Panic Disorders

Tricyclic - Antidepressant - Panic Disorders

Tricyclic - Antidepressant - Panic Disorders

Inhibit the Reuptake of Norepinephrine and serotonin by the Presynaptic neurons in the CNS, increasing the amount of time Norepinephrine and serotonin are available to the postsynaptic receptors

Antagonizes adrenergic, histaminergic, muscarinic and dopaminergic receptors

Tricyclic - Antidepressant - Panic Disorders

Tricyclic - Antidepressant - Panic DisordersStimulating

Tricyclic - Antidepressant - Panic Disorders

Sedation - especially 1st few weeks Dry mouth Blurred Vision Tremors Headache Tachycardia - higher risk in elderly Dysrhythmias - higher risk in elderly Myocardial infarction - higher risk in elderly Heart Block (1st degree AV) - higher risk in elderly Constipation - If severe immediate medical attention Indigestion Urinary retention - immediate medical attention Esophageal reflux Postural Orthostatic Hypotension weight gain

Therapeutic effects similar to SSRI's, BUT Side effects are more prominent. May work better in melancholic depression and in people with comorbid medical conditions. Some therapeutic levels may be monitored.

Lethal in overdose.. Use cautiously in the elderly, with cardiac disorders, elevated intraocular pressure, urinary retention, hyperthyroidism, seizure disorders, and liver or kidney dysfunction.

Sedative effects -(usually subside after 2 weeks) 4 to 8 weeks for full effects

At night due to sedative effect, other side effects happen when sleeping.

Check BP daily Tell PT. to avoid caffeine EKG should be done prior to administration (and periodically) May aggravate glaucoma - (eye exams periodically) May precipitate epilepsy (watch for signs)

Tetracyclic - Antidepressant - Anti Anxiety

sexual dysfunction

Take after intercourse Water - Soluble lubricant is useful for vaginal dryness

Tricyclic - Antidepressant - More Sedating. Use: Depression. Unlabeled Use: Anxiety, insomnia, treatment-resistant depression. Chronic pain syndromes (i.e., fibromyalgia, neuropathic pain/chronic pain, headache, low back pain)

Potentiates the effect of serotonin and norepinephrine in the CNS. Has significant anticholinergic properties. Therapeutic Effects: Antidepressant action.

Patients with pre-existing cardiovascular disease; Prostatic hyperplasia ( INC. risk of urinary retention); History of seizures (threshold may DEC.); OB: Use only if clearly needed and maternal benefits outweigh risk to fetus; Lactation:May cause sedation in infant; Pedi: Children 12 yr (safety not established); Geri: Appears on Beers list. INC. risk of adverse reactions including falls secondary to sedative and anticholinergic effects.

May cause hypotension, tachycardia, and potentially fatal reactions when used with MAO inhibitors (avoid concurrent use— discontinue 2 wk before starting amitriptyline). Concurrent use with SSRI antidepressants may result in INC. toxicity and should be avoided (fluoxetine should be stopped 5 wk before starting amitriptyline). Concurrent use with clonidine may result in hypertensive crisis and should be avoided. Concurrent use with levodopa may result in delayed or DEC. absorption of levodopa or hypertension.

CNS: SUICIDAL THOUGHTS, lethargy, sedation. EENT: blurred vision, dry eyes, dry mouth. CV: ARRHYTHMIAS, TORSADE DE POINTES, hypotension, ECG changes, QT interval prolongation. GI: constipation, hepatitis, paralytic ileus, INC. appetite, weight gain. GU: urinary retention,DEC. libido. Derm: photosensitivity. Endo: changes in blood glucose, gynecomastia. Hemat: blood dyscrasias.

Abrupt discontinuation may cause nausea, vomiting, diarrhea, headache, trouble sleeping with vivid dreams, and irritability. ● May cause drowsiness and blurred vision. Caution patient to avoid driving and other activities requiring alertness until response to drug is known. ● Orthostatic hypotension, sedation, and confusion are common during early therapy, especially in geriatric patients. Protect patient from falls and advise patient to make position changes slowly. Institute fall precautions. Advise patient to make position changes slowly. Refer as appropriate for nutrition/weight management and medical management. ● Advise patient to avoid alcohol or other CNS depressant drugs during and for 3- 7 days after therapy has been discontinued. ● Advise patient, family and caregivers to look for suicidality, especially during early therapy or dose changes. Notify health care professional immediately if thoughts about suicide or dying, attempts to commit suicide, new or worse depression or anxiety, agitation or restlessness, panic attacks, insomnia, new or worse irritability, aggressiveness, acting on dangerous impulses, mania, or other changes in mood or behavior occur. ● Instruct patient to notify health care professional if urinary retention, dry mouth, or constipation persists. Sugarless candy or gum may diminish dry mouth, and an increase in fluid intake or bulk may prevent constipation. If symptoms persist, dose reduction or discontinuation may be necessary. Consult health care professional if dry mouth persists for 2 wk. ● Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions. Alert patient that medication may turn urine blue-green in color. ● Inform patient of need to monitor dietary intake. Increase in appetite may lead to undesired weight gain. ● Advise patient to notify health care professional of medication regimen before treatment or surgery. Medication should be discontinued as long as possible before surgery. ● Advise patient to notify health care professional if pregnancy is planned or suspected or if breast feeding. ● Therapy for depression is usually prolonged and should be continued for at least 3 mo to prevent relapse. Emphasize the importance of follow-up exams to monitor effectiveness, side effects, and improved coping skills. Advise patient and family that treatment is not a cure and symptoms can recur after discontinuation of medication

● Obtain weight and BMI initially and periodically during treatment. ● Assess fasting glucose and cholesterol levels in overweight/obese individuals. ● Monitor BP and pulse before and during initial therapy. Notify health care professional of decreases in BP (10- 20 mm Hg) or sudden increase in pulse rate. Patients taking high doses or with a history of cardiovascular disease should have ECG monitored before and periodically during therapy. ● Depression: Monitor mental status (orientation, mood behavior) frequently. Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. ● Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. Risk may be increased in children, adolescents, and adults 24 yrs. After starting therapy, children, adolescents, and young adults should be seen by health care professional at least weekly for 4 wk, every 3 wk for next 4 wk, and on advice of health care professional thereafter. ● Pain: Assess intensity, quality, and location of pain periodically during therapy. May require several weeks for effects to be seen. Use pain scale to monitor effectiveness of medication. Assess for sexual dysfunction (decreased libido; erectile dysfunction). Geri: Geriatric patients started on amitriptyline may be at an increased risk for falls; start with low dose and monitor closely. Assess for anticholinergic effects (weakness and sedation). ● Lab Test Considerations: Assess leukocyte and differential blood counts, liver function, and serum glucose before and periodically during therapy. May cause an INC. serum bilirubin and alkaline phosphatase. May cause bone marrow depression. Serum glucose may be INC. or DEC. ● Dose increases should be made at bedtime because of sedation. Dose titration is a slow process; may take weeks to months. May give entire dose at bedtime. Sedative effect may be apparent before antidepressant effect is noted. May require tapering to avoid withdrawal effects. ● PO: Administer medication with or immediately after a meal to minimize gastric upset. Tablet may be crushed and given with food or fluids.

Ineffective coping (Indications) Chronic pain (Indications) Risk for injury (Side Effects)

Tricyclic - Antidepressant -Obsessive-Compulsive Disorder (OCD).Unlabeled Use: Depression, neuropathic pain/chronic pain.

Potentiates the effect of serotonin (antiobsessional effect) and norepinephrine in the CNS. Has moderate anticholinergic effects. Therapeutic Effects: Diminished obsessive-compulsive behavior.

Hypersensitivity; Angle-closure glaucoma; Recent myocardial infarction; History of QTc interval prolongation; Cardiac arrythmias; Heart failure; Concurrent use of MAO inhibitors or or MAO-like drugs (linezolid or methylene blue); OB: Potential for fetal harm or neonatal withdrawal syndrome; Lactation: Discontinue drug or bottle feed. Use Cautiously in: History of seizures (threshold may be lowered); Patients with pre-existing cardiovascular disease; Older men with prostatic hyperplasia (may be more susceptible to urinary retention); Hyperthyroidism (INC. risk of arrhythmias); May INC. risk of suicide attempt/ideation especially during dose early treatment or dose adjustment; risk may be greater in children or adolescents; Pedi: Children 10 yr (safety not established); Geri: INC. risk of arrhythmias.

Concurrent use with MAO inhibitors may result in serious potentially fatal reactions (MAO inhibitors should be stopped at least 14 days before clomipramine therapy. Clomipramine should be stopped at least 14 days before MAO inhibitor therapy). Concurrent use with MAO-inhibitor like drugs, such as linezolid or methylene blue may INC. risk of serotonin syndrome; concurrent use contraindicated; do not start therapy in patients receiving linezolid or methylene blue; if linezolid or methylene blue need to be started in a patient receiving clomipramine, immediately discontinue clomipramine and monitor for signs/symptoms of serotonin syndrome for 2 wk or until 24 hr after last dose of linezolid or methylene blue, whichever comes first (may resume clomipramine therapy 24 hr after last dose of linezolid or methylene blue). May prevent the therapeutic response to antihypertensives. Hypertensive crisis may occur with clonidine. INC. CNS depression with other CNS depressants including alcohol, antihistamines, opioids, and sedative/hypnotics. Adrenergic and anticholinergic side effects may be INC. with other agents having adrenergic/anticholinergic properties. Effects and toxicity may be INC. by concurrent use with SSRI antidepressants (wait several weeks after stopping SSRIs to start clomipiramine; up to 5 weeks for fluoxetine), phenothiazines, cimetidine, or oral contraceptives. Drugs that affect serotonergic neurotransmitter systems, including SSRIs, SNRIs, fentanyl, buspirone, tramadoland triptans INC. risk of serotonin syndrome. Nicotine may INC. metabolism and DRC. effectiveness. Transient delirium may occur with disulfiram. Drug-Natural Products: Use with St. John's wort INC. of serotonin syndrome. Kava,valerian, or chamomile can INC. CNS depression. Drug-Food: Grapefruit juice INC. serum levels and effect

Adverse Reactions/Side Effects CNS: SEIZURES, SUICIDAL THOUGHTS, lethargy, sedation, weakness, aggressive behavior. EENT: blurred vision, dry eyes, dry mouth, vestibular disorder. CV: ARRHYTHMIAS, ECG changes, orthostatic hypotension. GI: constipation, nausea, vomiting, weight gain, eructation. GU: male sexual dysfunction, urinary retention. Derm: dry skin, photosensitivity. Endo: gynecomastia. Hemat: anemia. MS: muscle weakness. Neuro:extrapyramidal reactions.Misc: hyperthermia.

May cause drowsiness and blurred vision. Caution patient to avoid driving and other activities requiring alertness until response to drug is known. ● Orthostatic hypotension, sedation, and confusion are common during early therapy, especially in geriatric patients. Protect patient from falls and advise patient to change positions slowly. ● Advise patient to avoid alcohol or other CNS depressant drugs during course of therapy and for 3- 7 days after cessation of therapy. ● Advise patient, family, and caregivers to look for suicidality, especially during early therapy or dose changes. Notify health care professional immediately if thoughts about suicide or dying, attempts to commit suicide, new or worse depression or anxiety, agitation or restlessness, panic attacks, insomnia, new or worse irritability, aggressiveness, acting on dangerous impulses, mania, or other changes in mood or behavior or if symptoms of serotonin syndrome occur. ● Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking any other Rx, OTC, or herbal products. ● Instruct patient to notify health care professional if dry mouth or constipation persists or if urinary retention, uncontrolled movements, or rigidity occurs. Sugarless candy or gum may diminish dry mouth, and an increase in fluid intake or bulk may prevent constipation. If these symptoms persist, dosage reduction or discontinuation may be necessary. Consult health care professional if dry mouth persists for more than 2 wk. ● Advise patient to inform health care professional if sexual dysfunction occurs. Inform male patients that sexual dysfunction is common with this medication. ● Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions. ● Inform patient of need to monitor dietary intake because possible increase in appetitemay lead to undesired weight gain. ● Advise patient to notify health care professional of medication regimen beforetreatment or surgery. ● Instruct female patients to inform health care professional if pregnancy is plannedor suspected, or if they plan to breast feed. ● Emphasize the importance of follow-up exams to monitor effectiveness and side effects and to improve coping skills. ● Inform patients taking high doses (250- 300 mg/day) that risk of seizures is increased.

● Monitor mental status (orientation, mood, behavior) frequently. Assess patientvfor frequency of OCD. Note degree to which these thoughts and behaviors interfere with daily functioning. ● Monitor BP and pulse before and during initial therapy. Notify physician or other health care professional of decreases in BP (10- 20 mmHg) or sudden increase in pulse rate. Patients taking high doses or with a history of cardiovascular disease should have ECG monitored before and periodically during therapy. ● Assess weight and BMI initially and throughout treatment. Assess FBS and cholesterol levels in obese individuals. Refer as appropriate for nutritional/weight management and medical management. ● Observe for onset of extrapyramidal parkinsonian side effects (difficulty speaking or swallowing, loss of balance control, pill rolling with hands, mask-like face, shuffling gait, rigidity, tremors). Notify physician or other health care professional if these symptoms occur; reduction in dose or discontinuation of medication may be necessary. Trihexyphenidyl or diphenhydramine may be used to control these symptoms. ● Assess for suicidal tendencies, especially during early therapy and dose changes. Restrict amount of drug available to patient. Risk may be increased in children, adolescents, and adults 24 yr. After starting therapy, children, adolescents, and young adults should be seen by health care professional at least weekly for 4 wk, every 3 wk for the next 4 wk, and on advice of health care professional thereafter. ● Assess for serotonin syndrome (mental changes [agitation, hallucinations, coma], autonomic instability [tachycardia, labile BP, hyperthermia], neuromuscular aberrations [hyperreflexia, incoordination], and/ or GI symptoms [nausea, vomiting, diarrhea]), especially in patients taking other serotonergic drugs (SSRIs, SNRIs, triptans). ● Lab Test Considerations:Serum glucose may be INC. or DEC. ● Monitor CBC and differential during chronic therapy. May rarely cause bone marrow suppression. ● In chronic therapy, periodically monitor hepatic and renal function. ● Do not confuse clomipramine with clomiphene or desipramine. ● PO: Administer medication with or immediately after a meal to minimize gastric irritation. After titration of dose, total daily dose may be given at bedtime.

Ineffective coping (obsessive-compulsive behaviors), related to repressed anxiety (Indications) Risk for injury (Side Effects) Chronic pain (Indications)