chapter 17: psychotherapeutic agents dh206: pharmacology lisa mayo, rdh, bsdh copyright © 2011,...
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Chapter 17: Psychotherapeutic Agents
DH206: PharmacologyLisa Mayo, RDH, BSDH
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Chapter 17 Outline
Psychiatric meds classified:1. Antipsychotic agents: tx of psychosis
(schizophrenia)2. Antidepressant agents: mood elevators
(unipolar, bipolar)3. Anxiolytic agents – CH11 (anxiety disorders)4. Sedative/hypnotic agents – CH11 (for sleep)
Most psychiatric drugs are weak bases (like dental LA) – absorbed from intestines into the blood (best to
take on empty stomach)
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Antipsychotic Agents
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Antipsychotic AgentsO Conditions can cause:
1. Positive symptoms: hallucinations, delusions, paranoia
2. Negative symptoms: emotional withdrawalO Agents very diverse in actionO 2 major groups of drugs (see table 17-1,
p.225) 1. Conventional/Typical antipsychotics2. Atypical antipsychotics
O More patients are now being treated with newer “atypical” antipsychotics
OFewer anticholinergic & sedative effects
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Antipsychotic AgentsO Main action is on the neural pathways
involving the cerebral cortex & limbic systemO These are the areas of the body thought
to have excessive activity of NTs in people with psychosis
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LIMBIC SYSTEMPortion of the brain that deals with emotions,
memories, and arousal
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Antipsychotic AgentsDopamine
O Important role in etiology of psychotic disorderO Controlling dopamine is essential for tx!O Drugs are DOPAMINE ANTAGONISTS
Drugs bind to dopamine (D2) receptors ↓
Prevent dopamine from attaching ↓
↓ dopamine in synapseO Excessive blockage of dopamine receptors is
the main cause of EXTRAPYRIMIDAL SYNDROMEO Conventional drugs block dopamine receptors &
are more likely to cause extrapyramidal effects
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Antipsychotic AgentsO Serotonin (5HT) is another NT that also plays a key role in
psychotic disordersO Atypical drug can block the serotonin receptors as well
as dopamine receptorsO Conventional drugs are only active blockers of
dopamineO Atypical drugs have less extrapyramidal effects than
conventional due to this (important to know!)O Drugs also bind non-specifically to these receptors & will
produce side effects:1. Muscarinic (Anticholinergic effects = dry mouth,
blurred vision, tachycardia, sexual dysfunction, constipation & urinary retention))
2. α1 (SANS effects = hypotension, reflex tachycardia, dizzy, syncope)
3. H1 (Anti-histamine effects = sedation, drowsy, weight gain)
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Dopamine & Serotonin produce the antipsychotic
effects
Side Effects
ConventionalAtypical
Atypical
Don’t need to know which drugs cause which side effects TABLE17-1
Xerostomia
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Extrapyramidal EffectsO All drugs can cause – conventional higher
incidenceO Binding to D2 receptors can causeO 50-75% patients on these drugs will
developO Can be permanent even after stop the drugO Dystonia: muscle spasms (face, tongue,
neck)O Parkinsonism: tremors, rigidityO Akathisia: Most common, swaying from
foot-to-foot, sense that pt must keep moving
O Tardive dyskinesia: involuntary movements involving tongue, lips, face, jaw, extremitiesCan lead to broken teeth, bruxism, tongue
trauma, ulcerations
Antipsychotic Agents
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PHARMACOLOGICAL EFFECTS1. Conventional antipsychotics2. Atypical antipsychotics
Drugs are listed p.204, Table 17-1 & p.206 Table 17-2Only need to know drugs on drug list
Antipsychotic Agents
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1st atypical in USABlack Box *Seizures *Agranulocytosis ATYPICAL
CONVENTIONAL
Phenothiazides *Change in BP common *Limit EPI
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PHARMACOLOGICAL EFFECTS1. Conventional antipsychotics
O Primarily dopamine antagonistsO Active against positive symptoms only (not
negative)O Antiemetic: a result of depression of the
chemoreceptor trigger zone in the medulla of the brain prochlorperazine(Compazine) used most
often
Antipsychotic Agents
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PHARMACOLOGICAL EFFECTS2. Atypical antipsychotic agents
O Active against positive & negative symptoms of the psychosis Conventional antipsychotics: only positive
symptomsO Receptor action: effective at more receptors
Dopamine, Norepi, Serotonin Conventional: only dopamine
Antipsychotic Agents
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O Preferred agents now are the atypicals because they have less extrapyrimidal effects All but Clonazepine do not cause significant
anticholinergic, α-blocking or antihistaminic actions compared to conventional
Antipsychotic Agents
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DRUG INTERCATIONS Metabolized by P450 enzymes (many drug
interactions) Epinephrine
O Many drugs are α–receptor blockersO Epi could cause hypotension & reflex tachycardiaO Administer cautiously & prevent intravascular
injectionsO Avoid levonordephrinO Cardiac dose of epiO Book correction: epi CANNOT be used safely in the
dental office (p.206) EITHER AVOID OR CARDIAC DOSE
Antipsychotic Agents
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Antidepressant Agents
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Antidepressant AgentsO Research has shown that the levels of
SEROTONIN & NOREPI in the brain influence mental behaviors
O Action drugs is to ↑ serotonin and/or norepi but blocking the re-uptakeO TricyclicO SSRI
O MAOI action different: inhibit monoamine oxidase enzyme which breaks down epi & norepi
Antidepressant Drug Classes
Tricyclic antidepressants (TCAs)
Selective serotonin reuptake inhibitors (SSRIs)
Monoamine oxidase inhibitors (MAOI)
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Atypical Antidepressants
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Antidepressant Agents
TRICYCLIC ANTIDEPRESSANTSAmitripyyline(Elavil)Desipramine(Norpramin)Doxepin(Adapin, Sinequan)Imipramine(Tofranil)
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Antidepressant AgentsTricyclic Antidepressants
O 1st antidepressants on marketO Many severe adverse side effects – not used as
much with the development of newer drugsO Full effect of the drug can take weeks to occurO Uses
DepressionNocturnal bruxismChronic orofacial pain
P.208
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Antidepressant AgentsTricyclic Antidepressants
ADVERSE EFFECTSO Non-selective blocking of other receptors (like
antipsychotics)1. Muscarinic (Anticholinergic effects)2. α1 (SANS effects = hypotension, reflex
tachycardia, dizzy, syncope)3. H1 (Anti-histamine effects = sedation, drowsy,
weight gain) O Do not use in cardiac patientsDENTAL CONSIDERATIONSLA with cardiac doseNo levonordefrin
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All of the following drugs are tricyclic antidepressants EXCEPT which one?a. Amitriptyline(Elavil)b. Clomipramine(Anafranil)c. Imipramine(Tofranil)d. Sertraline(Zoloft)
NBQ
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All of the following drugs are tricyclic antidepressants EXCEPT which one?a. Amitriptyline(Elavil)b. Clomipramine(Anafranil)c. Imipramine(Tofranil)d. Sertraline(Zoloft)
NBQ
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Antidepressant Agents
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Antidepressant Agents
SSRICitalopram(Celexa)Escitalopram(Lexapro)Fluoxetine(Prozac) PROTYPEFluvoxamine(Luvox)Paroxetine(Paxil)Sertraline(Zoloft)
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Antidepressant Agents
SSRIO More selective drug than TCAs: LESS SIDE
EFFECTSO Protype: fluoxentine(Prozac)O NO contraindication for EPI in LA (only one
in this ppt!)O Increase serotonin levels
Inhibit reuptake of serotoninDo NOT interact with Norepi
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Antidepressant Agents
SSRI USESDepressionAnxiety disordersEating disordersOCDPMSFibromalagia
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Antidepressant AgentsSSRI ADVERSE EFFECTS
O ↑ Bleeding (esp if take aspirin, ibuprofen)O Reduced apatite: weight loss (gain with
TCAs)O Sexual dysfunctionO Oral side effects
Can induce bruxismBook correction: remove otheroral side
effects p.207
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Antidepressant AgentsSSRI DRUG INTERCATIONS
O EPI can be used with no precautionsO Jan 2006 warning
venlafaxine(Effexor) can cause hypertension = monitor BP
O “Serotonin Syndrome”Elevated serotonin levels = fatalResults when combo SSRI + MAOI
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Antidepressant Agents
Selective Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Duloxetine(Cymbalta)
Venlafaxine(Effexor)
Desvenlafaxine(Pristiq)
Similar action to TCAs
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Antidepressant Agents
MAOI
Isocarboxazid(Marplan)
Phenelzine(Nardil)
Tranylcypromine(Parnate)
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Antidepressant AgentsMAOI
O Monoamine oxidase enzyme (MAO)O Function: break down norepi & serotoninO MAO-Inhibitors prevent MAO from
removing norepi & serotonin thus increases levels of both in the brain
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Antidepressant AgentsMAOI
O Last line drugs due to adverse rxns & food restrictionsO Dietary Restrictions
O One of main disadvantages of these drugsO Many foods contain tyramine (causes release norepi
inside nerve endings) ↓
When MAO is inhibited by these drugs, tyramine can cause a dramatic increase in norepi
↓
Cause stroke or hypertensive crisisO Foods that contain tyramine: cheese, bananas,
raisins, avocados, soy sauce, yogurt, sour cream, bologna, salami, hot dogs, sauerkraut, wine, beer, herring(fish)
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Antidepressant AgentsMAOI
O Dental Epi with cardiac dose No levonordefrin
O Drug Interactions Sympathetic drugs used to tx cold symptoms
(decongestants & bronchodilators) O Adverse Rxns: MANY! P.209
Xerostomia, urinary retention, constipation, blurred vision, hypotension, weight gain, sexual dysfunction
Fatal liver damage
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NBQ
All of the following are MAOI EXCEPT which one?a. Paroxetine(Paxil)b. Isocarboxazid(Marplan)c. Tranylcypromine(Parnate)d. Phenelzine(Nardil)
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NBQ
All of the following are MAOI EXCEPT which one?a. Paroxetine(Paxil)b. Isocarboxazid(Marplan)c. Tranylcypromine(Parnate)d. Phenelzine(Nardil)
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Antidepressant Agents
Atypical Antidepressantsnefazodone(Serozone)
Black-box: liver failure
bupropion(Wellbutrin)
Smoking cessation
trazadone(Desyrel)Similar action to TCAs
Book has this category listed as “Other Antidepressants,” but they are atypical antidepressants
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NBQ
All of the following are used to treat psychosis EXCEPT which one?a. Chlorpromazine(Thorazine)b. Risperidone(Risperdal)c. Nitrous oxided. Quetiapine(Seraquel)e. Haloperidol(Haldol)
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NBQ
All of the following are used to treat psychosis EXCEPT which one?a. Chlorpromazine(Thorazine)b. Risperidone(Risperdal)c. Nitrous oxided. Quetiapine(Seraquel)e. Haloperidol(Haldol)
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Drug Used To Tx HIGH Levels of NTs
O All other drugs up to this point addressed LOW levels of NTs in psychosis, these are the drugs for HIGH levels (usually assoc with bipolar disorder)
1. Lithium 2. Anticonvulsants3. Atypical Antipsychotics
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Drug Used To Tx Bipolar
Drug Name Classification Dental Considerations
Lithium carbonate(Eskalith)
Unknown: alters Na channels & catecholamines
Orthostatic hypotensionXerostomiaTongue movementsMetallic taste
Carbamazepine(Equetro, Tegretol)
Anticonvulsant Monitor WBC counts & vitals
Lamotrigine(Lamictal) Anticonvulsant Orthostatic hypotension
Valproic acid(Depakene) Anticonvulsant Monitor clotting
Gabapentin(Neurotin) Anticonvulsant Xerostomia
Olanzapine(Zyrexia) Atypical antipsychotic (1st approved atypical for bipolar)
Orthostatic hypotension
Quetiapine(Seroquel) Atypical antipsychotic Orthostatic hypotension
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Drug Used To Tx HIGH Levels of NTs
1. lithium(Eskalith, Lithobid)O Used to be the only drug on the market for
tx bipolarO Treat manic & depressive statesO Black box: narrow therapeutic indexO MANY systemic side effectsO Drug Interactions
No metronidazole, NSAIDsP450 enzymes NOT involved
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Drug Used To Tx HIGH Levels of NTs
2. AnticonvulsantsO Used for mixed episode states (mania &
depression)
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NBQ
Which 2 groups of antidepressant drugs has the highest incidence of dry mouth?a. Tricyclic antidepressantsb. SSRIc. Serotonin and norepinephrine reuptake
inhibitorsd. MAOI
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NBQWhich 2 groups of antidepressant drugs has the highest incidence of dry mouth?a. Tricyclic antidepressantsb. SSRIc. Serotonin and norepinephrine reuptake
inhibitorsd. MAOI
Remember: SNRI similar to TCAs