CNS & PNSDrugsGrizel Bello Barja

Rachel Krogstie

CNS Drugs

0 Drugs for ADHD0 Anti-Anxiety

(Benzodiazepines)0 Alzheimer’s Disease Drugs0 Parkinson’s Disease Drugs0 Epilepsy Drugs0 Multiple Sclerosis drugs0 Migraine Suppressants0 Supplements

Drugs for Attention Deficit/Hyperactive Disorder

0 Drugs with proven efficacy include methylphenidate, dexmethylphenidate, dextroamphetamine, and amphetamine mixture. There are no data to support use of one stimulant over another.

0 Accordingly, stimulants cannot give a child good study skills and other appropriate behaviors. Rather, these must be learned once the disruptive behavior is no longer an impediment.

0 Several nonstimulants are used for ADHD, although only three of them––atomoxetine, guanfacine, and clonidine––are FDA approved for this use. The nonstimulants are less effective than the stimulants, and hence are considered second-choice drugs.

0 Atomoxetine is a selective inhibitor of NE reuptake and hence causes NE to accumulate at synapses.

0Drug examples: atomoxetine

Drugs for Attention Deficit/Hyperactive Disorder

0atomoxetine (Strattera)

0Pregnancy Category C0Side Effects/Adverse Drug Events: SUICIDAL

THOUGHTS , ALLERGIC REACTIONS INCLUDING ANGIONEUROTIC EDEMA AND ANAPHYLAXIS.

0Contraindications: Glaucoma0High Risk Populations: Pre- existing psychiatric

illness, cardiovascular disease0Assessments and Lab Tests: CYP2D6

Benzodiazepines(Sedative/Hypnotic)

0 The benzodiazepines have three principal indications: (1) anxiety, (2) insomnia, and (3) seizure disorders.

0 Benzodiazepines are drugs of first choice for anxiety and insomnia.

0 Lower potential for abuse. 0 Less tolerance and physical dependence and are subject to fewer

drug interactions. 0 With increasing dosage, effects progress from sedation to

hypnosis to stupor.

0Drug examples: diazepam, lorazepam

Benzodiazepines(Sedative/Hypnotic)

0diazepam (Valium, Diastat)0 Pregnancy Category D Sch IV0 antianxiety agents, Anticonvulsants,

sedative/hypnotics, skeletal muscle relaxants (centrally acting)

0 Side Effects/Adverse Drug Events: RESPIRATORY DEPRESSION, dizziness, drowsiness, lethargy

0 Contraindications: Comatose patients, Severe pulmonary impairment, Sleep apnea, Severe hepatic/renal dysfunction, Pre-existing CNS depression

0 High Risk Populations: History of Suicide, OB, Pedi, Lact0 Assessments and Lab Tests: CYP2C19, BP, hepatic and

renal function, CBC

Benzodiazepines(Sedative/Hypnotic)

0 LORazepam (Ativan)0 Pregnancy Category D Sch IV0 antianxiety agents, analgesic adjuncts, sedative/hypnotics0 Side Effects/Adverse Drug Events: APNEA, CARDIAC ARREST,

bradycardia, hypotension, dizziness, drowsiness, lethargy0 Contraindications: Comatose patients, Severe pulmonary

impairment, Sleep apnea, Pre-existing CNS depression, OB/LACT

0 High Risk Populations: History of Suicide, Severe hepatic/renal dysfunction, Pedi

0 Assessments and Lab Tests: CYP2C19, BP, hepatic and renal function, CBC

Benzodiazepines(Sedative/Hypnotic)

diazepam (Valium) LORazepam (Ativan)

0 Drug-Drug: Alcohol and other CNS depressants (antidepressants, antihistamines, opioid analgesics, etc.)—concurrent use results in additive CNS depression.

0 Oral contraceptives may ↓ levels.

0 May ↓ the efficacy of levodopa

0 Drug-Natural: Concomitant use of kava-kava, valerian, or chamomile can ↑ CNS depression.

Alzheimer’s Disease0 Progressive memory loss, impaired thinking,

neuropsychiatric symptoms, and inability to perform routine tasks of daily living.

0 Affects about 5.3 million older Americans and kills about 100,000 each year, fourth leading cause of death in adults

0 ACh is critical to forming memories, and its decline has been linked to memory loss.

0 Five drugs have been approved for the treatment of Alzheimer’s dementia, and none of them is very effective,

0Drug examples: donepezil, memantine, (neostigmine)

NMDA Receptor Antagonists0memantine (Namenda) 0Pregnancy Category B0 Side Effects/Adverse Drug Events: dizziness, fatigue,

headache, sedation, hypertension, rash, diarrhea, weight gain, urinary frequency, anemia.

0High Risk Populations: Severe renal impairment, Concurrent use of other NMDA antagonists, Concurrent use of drugs or diets that cause alkaline urine, Conditions that ↑ urine pH, OB/Lactation/Pedi:  Safety not established.

0Assessments and Lab Tests: May cause anemia, Assess cognitive function

0Caution patient and caregiver that memantine may cause dizziness.

Cholinesterase Inhibitors0donepezil(Aricept)

0 Pregnancy Category C0 Side Effects/Adverse Drug Events: headache,

diarrhea, nausea0 High Risk Populations: Underlying cardiac disease, History of

ulcer disease or currently taking NSAIDs, History of seizures, History of asthma or obstructive pulmonary disease, OB/Lactation/Pedi:  Discontinue drug or bottle-feed.

0 Assessments and Lab Tests: cognitive function. Monitor heart rate.

0 Do not confuse Aricept with Aciphex or Azilect. 0 Drug-Natural: Jimson weed and scopolia may antagonize

cholinergic effects.

Myasthenia gravis (MG)0Myasthenia gravis (MG) is a neuromuscular disorder

characterized by fluctuating muscle weakness and a predisposition to rapid fatigue.

0Common symptoms include ptosis (drooping eyelids), difficulty swallowing, and weakness of skeletal muscles.

0Patients with severe MG may have difficulty breathing owing to weakness of the muscles of respiration.

Myasthenia gravis (MG)0neostigmine (Bloxiverz, Prostigmin)

0 Pregnancy Category C0 Side Effects/Adverse Drug Events: SEIZURES,

bronchospasm, excess secretions, bradycardia, abdominal cramps, diarrhea, excess salivation, nausea, vomiting, sweating

0 Contraindications: Mechanical obstruction of the GI or GU tract, Lactation

0 High Risk Populations: History of asthma, Ulcer disease, Cardiovascular disease, Seizure disorder, Hyperthyroidism, OB: May cause uterine irritability after IV administration near term, newborns may display muscle weakness.

0 Assessments and Lab Tests: Assess pulse, respiratory rate, and BP prior to administration

Parkinson’s Disease Drugs0Two types of drugs are used: 0(1) dopamine agonists (i.e., drugs that directly

or indirectly cause activation of dopamine receptors) 0levodopa-carbidopa

0(2) anticholinergic agents (i.e., drugs that block receptors for ACh).0selegiline

Parkinson’s Disease Drugs0 levodopa-carbidopa (Sinemet)

0 Pregnancy Category C0 Side Effects/Adverse Drug Events: involuntary movements, urges

(gambling, sexual), nausea, vomiting, darkening of urine or sweat. 0 Contraindications: glaucoma, MAOI, Malignant melanoma,

Undiagnosed skin lesions, tartrazine, phenylalanine, or aspartame and should be avoided in patients with known hypersensitivity

0 High Risk Populations: History of cardiac, psychiatric, or ulcer disease, OB/Pedi/Lactation: May ↓ serum prolactin.

0 Assessments and Lab Tests: blood glucose, hepatic and renal function, CBC

0 Do not confuse Sinemet with Janumet

Parkinson’s Disease Drugs0 selegiline (Zelapar, Eldepryl)

0 Pregnancy Category C0 Side Effects/Adverse Drug Events: urges (gambling, sexual),

vivid dreams, nausea, dry mouth0 Contraindications: Concurrent meperidine, opioid analgesic ,

SSRIs or tricyclic antidepressants.0 High Risk Populations: tyramine-containing foods and some

medications, History of peptic ulcer disease0 May initially ↑ risk of side effects

of levodopa/carbidopa (dose of levodopa/carbidopa may need to be ↓ by 10–30%).

0 Do not confuse selegiline with Salagen (pilocarpine). Do not confuse Zelapar (selegiline) with Zyprexa (olanzapine).

Drugs for Epilepsy0Nearly all AEDs act through four basic mechanisms:

0 suppression of sodium influx, 0 suppression of calcium influx, 0 blockade of receptors for glutamate, 0 potentiation of gamma-aminobutyric acid (GABA).

0Monitor closely for emergence or worsening of suicidal thoughts or behavior or depression.

0Drug Examples: topiramate, phenytoin, gabapentin, carbamazepine, pregabalin, phenobarbital, valproic acid

Anti-Epileptics

0 " ABCDEFGH  "0Ataxia0Blood dyscrasia0Cleft lip0Dupuytrens /

Vit. D deficiency0Exfoliation of skin

& Stevens Johnson's0GI upset/Gum

hypertrophy0Hepatitis/ Hairy

Drugs for Epilepsy

0 topiramate (Topamax, Trokendi XR)0 Pregnancy Category D0 Side Effects/Adverse Drug Events: ↑SEIZURES, SUICIDAL

THOUGHTS 0 Contraindications: Lactation 0 High Risk Populations: All patients (may ↑ risk of suicidal

thoughts/behaviors); Renal /Hepatic impairment; Patients predisposed to metabolic acidosis; Patients allergic to sulfa; OB, Pedi, Geri

0 Assessments and Lab Tests: CBC w/diff, LFT, metabolic acidosis

Drugs for Epilepsy0 phenytoin (Dilantin, Phenytek)

0 Pregnancy Category D 0 Side Effects/Adverse Drug Events: SUICIDAL THOUGHTS,

AGRANULOCYTOSIS, APLASTIC ANEMIA, ALLERGIC REACTIONS INCLUDING STEVENS-JOHNSON SYNDROME

0 Contraindications: Alcohol intolerance, Sinus bradycardia, sinoatrial block, 2nd- or 3rd-degree heart block, or Stokes-Adams syndrome.

0 High Risk Populations: All patients (may ↑ risk of suicidal thoughts/behaviors); Hepatic /renal disease, severe cardiac or respiratory disease  OB, Pedi

0 Assessments and Lab Tests: HLA-B*1502

" PHENYTOIN "

0  P: Fetal hydantoin syndrome  

0H: Hirsutism, Hypersensitivity

0ENY: Anemia0T: Thick gums00: Osteomalacia0 I: Inhibits insulin0N: Neutropenia

Drugs for Epilepsy0gabapentin (Gralise, Horizant, Neurontin)

0 Pregnancy Category C 0 Partial seizures, Restless legs syndrome (Horizant only) 0 Side Effects/Adverse Drug Events: SUICIDAL

THOUGHTS, MULTI-ORGAN HYPERSENSITIVITY REACTIONS

0 High Risk Populations: all patients (may ↑ risk of suicidal thoughts/behaviors); Renal insufficiency, OB/Ped/Lac

0 Do not confuse Neurontin with Noroxin (norfloxacin).

Drugs for Epilepsy0 carBAMazepine (Carbatrol, TEGretol, Teril)

0 Pregnancy Category D 0 Side Effects/Adverse Drug Events: SUICIDAL THOUGHTS,

STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, AGRANULOCYTOSIS, APLASTIC ANEMIA, THROMBOCYTOPENIA

0 Contraindications: Bone marrow suppression; use within 14 days of MAO inhibitors; use of nefazodone; OB, Lact

0 High Risk Populations: Cardiac or hepatic disease; Renal failure; glaucoma; Geri:  prostatic hyperplasia

0 Assessments and Lab Tests: HLA-B*1502, CBC 0 Drug-Food: Grapefruit juice0 Do not confuse carbamazepine with oxcarbazepine. Do not

confuse Tegretol with Trental or Tegretol XR.

Drugs for Epilepsy0 Pregabalin (Lyrica)

0 Pregnancy Category C Sch V 0 Side Effects/Adverse Drug Events: SUICIDAL

THOUGHTS, dizziness, drowsiness, edema, dry mouth, 0 Contraindications: Myopathy; Lactation. 0 High Risk Populations: All patients; Renal impairment; HF;

History of drug dependence/drug-seeking behavior; OB, Ped, Geri

0 Assessments and Lab Tests: May cause ↑ creatine kinase levels. May cause↓ platelet count

0 Interactions: Antacids, Kava-kava, valerian, or chamomile 0 Do not confuse Lyrica (pregabalin) with Lopressor

(metoprolol).

Drugs for Epilepsy0 PHENobarbital (Luminal)

0 Pregnancy Category D Sch IV barbiturates0 Side Effects/Adverse Drug Events: LARYNGOSPASM,

HYPERSENSITIVITY REACTIONS INCLUDING ANGIOEDEMA AND SERUM SICKNESS

0 Contraindications: Comatose patients, pre-existing CNS depression; Severe respiratory disease; Uncontrolled severe pain; Known alcohol intolerance, Lactation

0 High Risk: Hepatic/Renal impairment; History of suicide attempt or drug abuse; Chronic use may lead to dependence; OB: drug dependency in the infant

0 Assessments and Lab Tests: Monitor respiratory status, pulse, BP and angioedema. Equipment for resuscitation and artificial ventilation should be readily available. Geri: marked excitement, depression, and confusion. LFT and CBC 

0 Do not confuse phenobarbital with pentobarbital.

Drugs for Epilepsy0 Valproic Acid (Depakene, Stavzor, Depakote)

0 Pregnancy Category D, X (migraines)0 Side Effects/Adverse Drug Events: SUICIDAL THOUGHTS,

HEPATOTOXICITY, PANCREATITIS, HYPERAMMONEMIA, HYPOTHERMIA

0 Contraindications: Hepatic impairment, urea cycle disorders 0 High Risk Populations: All patients (may ↑ risk of suicidal

thoughts/behaviors); Bleeding disorders; History of liver disease; Organic brain disease; Bone marrow depression; Renal impairment; OB, Lactation, Pedi:  Children, especially <2 yr

0 Assessments and Lab Tests: Monitor hepatic function (LDH, AST, ALT, and bilirubin) and serum ammonia concentrations, CBC, platelet count, and bleeding time

"VALPROATE"

0 Vomiting 0 Alopecia 0 Liver toxicity 0 Pancreatitis/Pancytopenia0 Retention of fat / Reduced

sleep0 Oedema  0 Allergic reactions / Abd

cramps/ Appetite ↑ 0 Tremor / Thrombocytopeni

a0 Enzyme inducer (liver)

Drugs for Multiple Sclerosis

0Mechanism appears to be autoimmune.0MS has four subtypes—relapsing-remitting, secondary

progressive, primary progressive, and progressive-relapsing—which are defined by the clinical course the disease follows.

0Drug examples: azathioprine (Approved in Germany, not in US)

0Multiple Sclerosis Association of America

Drugs for Multiple Sclerosis0azaTHIOprine (Azasan, Imuran)

0 Pregnancy Category D 0 Side Effects/Adverse Drug Events: MALIGNANCY (INCLUDING

POST-TRANSPLANT LYMPHOMA, HSTCL, AND SKIN CANCER), SERUM SICKNESS

0 Contraindications: Concurrent use of mycophenolate; OB: Has been shown to cause fetal harm; Lactation

0 High Risk Populations: Infection; Malignancies; ↓ bone marrow reserve; radiation therapy; Severe renal impairment; TPMT enzyme OB, Ped

0 Assessments and Lab Tests: Assess for infection, vital signs, WBC, and Renal, hepatic, hematologic functions.

0 Do not confuse azaTHIOprine with azaCITIDine0 Drug-Natural Products: echinacea and melatonin

Migraine Suppressants0Migraine is a neurovascular disorder involving

dilation and inflammation of intracranial arteries.0For mild to moderate symptoms, an aspirin-like drug

may be sufficient. 0For moderate to severe symptoms, patients should

take a migraine-specific drug—either an ergot alkaloid or a serotonin1B/1D agonist.

0 If these agents fail to relieve pain, an opioid analgesic may be needed

0Drug examples: Sumatriptan, Ergotamine, Valproic Acid

Migraine Suppressants0 SUMAtriptan (Imitrex, Sumavel DosePro)

0 Pregnancy Category C0 Side Effects: dizziness, vertigo, tingling, warm sensation,

injection site reaction0 Contraindications: Ischemic heart disease, Prinzmetal's angina,

uncontrolled hypertension; Stroke or transient ischemic attack; Peripheral vascular disease; MAOI; Hemiplegic or basilar migraine; ergotamine-containing or ergot-type drugs or other 5HT1 agonists; Severe hepatic impairment

0 High Risk Populations: OB, Lactation, Ped, Cardiovascular risk factors (hypertension, hypercholesterolemia, smoking, obesity, diabetes, family history, women or men >40 yr)

0 Assessments and Lab Tests: Monitor for serotonin syndrome in patients taking SSRIs or SNRIs concurrently with sumatriptan.

Migraine Suppressants0Ergotamine (Ergomar)

0 Pregnancy Category X0 Side Effects/Adverse Drug Events: MYOCARDIAL

INFARCTION0 Contraindications: Peripheral vascular disease; Ischemic

heart disease; Uncontrolled hypertension; Severe renal or liver disease ; Malnutrition; Pregnancy; Lactation.

0 High Risk Populations: Illnesses associated with peripheral vascular pathology such as diabetes mellitus; Concurrent administration of other vasoconstricting agents; Pedi:  Children <6 yr

0 Assessments and Lab Tests: Monitor BP and peripheral pulses. Report any increases in BP. Assess for signs of ergotism. Assess for nausea and vomiting.

Magnesium Sulfate0 Pregnancy Category B 0 Uses: Treatment/prevention of hypomagnesemia. Treatment of

hypertension. Anticonvulsant associated with severe eclampsia, pre-eclampsia, or acute nephritis.

0 Side Effects/Adverse Drug Events: drowsiness, ↓ respiratory rate, arrhythmias, bradycardia, hypotension, diarrhea, muscle weakness,

0 Contraindications: Hypermagnesaemia; Hypocalcemia; Anuria; Heart block; OB

0 High Risk Populations: Renal insufficiency0 Assessments and Lab Tests: Monitor pulse, BP, respirations, and ECG,

Respirations should be at least 16/min before each dose. Patellar reflex, Monitor intake and output ratios.

0 High Alert: Have second practitioner independently double-check original order, dose calculations, and infusion pump settings

Coenzyme Q10coQ10, ubiquinol, ubiquinone

0 Common Uses: Heart failure. Coenzyme Q–10 deficiency. Mitochondrial disorders. Muscular dystrophy. Immune stimulant in HIV infection. Parkinson's disease, Migraine

0 Side Effects: Dizziness, hypotension, rash, nausea, vomiting, diarrhea, heartburn, decreased appetite.

0 Contraindications: Pregnancy and lactation0 High Risk Populations: Hypotension; Surgery 0 Assessments and Lab Tests: Monitor BP, coagulation

studies, lipid levels, serum lactate0 Instruct patient to take with a meal containing fat, as

directed.0 May cause dizziness. Caution patient to avoid driving or

other activities requiring alertness until response to medication is known

PNS Drugs0Muscarinic Antagonists0Neuromuscular Blockers 0 Indirect Acting Anti-

Adrenergic

Autonomic Nervous System

Cholinergic (Parasympathomimetics) (Anti-

Adrenergic)

Indirect Anti-Adrenergic

Anticholinergic (Sympathomimetic)

Anti-muscarinic (muscarinic antagonists)

Neuromuscular Blocker

Muscarinic Antagonists0Muscarinic antagonists competitively block the

actions of acetylcholine at muscarinic receptors.0Other names for these agents are antimuscarinic

drugs, muscarinic blockers, and anticholinergic drugs.

0When a drug is characterized as anticholinergic, this means that it produces selective muscarinic blockade—not blockade of all cholinergic receptors.

0Drug examples: Atropine, Dicyclomine

Muscarinic Antagonists0 Atropine (Atro- Pen)

0 Pregnancy Category C0 Side Effects/Adverse Drug Events: drowsiness, blurred

vision, tachycardia, dry mouth, urinary hesitancy, impotency, tachypnea, pulmonary edema, flushing

0 Contraindications: glaucoma, Acute hemorrhage, Tachycardia secondary to cardiac insufficiency or thyrotoxicosis, Obstructive disease of the GI tract

0 High Risk Populations: Chronic renal, hepatic, pulmonary, or cardiac disease, Infants with Down syndrome, children with spastic paralysis or brain damage

0 Assessments and Lab Tests: Vital signs, ECG tracings, intake/output ratios in elderly & surgical patients, abdominal distention, bowel sounds

Nicotinic Cholinergic Blockers0Neuromuscular blocking agents prevent acetylcholine

from activating nicotinic receptors on skeletal muscles.

0Neuromuscular blockers fall into two major groups: competitive (nondepolarizing) agents and depolarizing agents.

0Drug examples: Succinylcholine, Pancuronium

Nicotinic Cholinergic Blockers

0 Succinylcholine (Anectine, Quelicin)0 Pregnancy Category C0 Side Effects/Adverse Drug Events: APNEA, HYPERKALEMIA,

RHABDOMYOLYSIS, ANAPHYLAXIS,MALIGNANT HYPERTHERMIA

0 Contraindications: Plasma pseudocholinesterase deficiency, Children and neonates, Personal history of malignant hyperthermia.

0 High Risk Populations: anaphylaxis to other neuromuscular blockers, History of pulmonary disease, renal or liver impairment, Glaucoma, digoxin, Myasthenia gravis

0 Assessments and Lab Tests: respiratory status, ECG, heart rate, and BP

Nicotinic Cholinergic Blockers

0 Pancuronium (Pavulon)0 Skeletal muscle paralysis and facilitation of intubation 0 Pregnancy Category C0 Side Effects/Adverse Drug Events: bronchospasm,

hypertension, tachycardia, excessive salivation, ANAPHYLAXIS

0 Contraindications: Hypersensitivity0 High Risk Populations: Low plasma pseudocholinesterase

levels, Obese patients, Shock, Dehydration, Renal/Hepatic Impairment, MYASTHENIA GRAVIS

0 Assessments and Lab Tests: respiratory status, ECG, heart rate, and BP

Indirect Acting Anti-Adrenergic

0The indirect-acting antiadrenergic agents prevent the activation of peripheral adrenergic receptors by mechanisms that do not involve direct interaction with peripheral receptors.

0 Centrally acting alpha2 agonists, or drugs that act within the central nervous system (CNS) to reduce the outflow of impulses along sympathetic neurons.

0Drug examples: clonidine

Indirect Acting Anti-Adrenergic

0Clonidine (Catapres, Doraclon)0 Pregnancy Category C0 Antihypertensive (ADHD)0 Side Effects/Adverse Drug Events: Dry mouth,

drowsiness, depression, nightmares, erectile dysfunction

0 Contraindications: anticoagulant therapy0 High Risk Populations: Cardiac/cardiovascular disease, 0 Assessments and Lab Tests: Monitor input/output ratio,

Assess pain location

CAUTION!!0High Alert

0 Magnesium Sulfate0 Pancuronium0 Succinylcholine

0BEERS List0 Diazepam

0REMS0 topiramate

ReferencesFDA and ISMP Lists of Look-Alike Drug Names with Recommended Tall Man

Letters. (n.d.). Retrieved from http://www.ismp.org/tools/tallmanletters.pdf

Institutional High-Alert Medications. (n.d.). Retrieved September 13, 2014, from http://www.ismp.org/tools/institutionalhighAlert.asp

ISMP List of High-Alert Medications in Community/Ambulatory Healthcare. (n.d.). Retrieved September 13, 2014, from http://www.ismp.org/communityRx/tools/ambulatoryhighalert.asp

ISMP’s List of Confused Drug Names. (n.d.). Retrieved from http://www.ismp.org/tools/confuseddrugnames.pdf

Lehne, R. A., & Rosenthal, L. (2014). Pharmacology for Nursing Care (8th Edition.). Elsevier Health Sciences.

Part, M. (2014). Gregory J. Hughes and Judith L. Beizer OUTLINE Objectives Test Questions Pharmacokinetic Changes in the Elderly. Ham’s Primary Care Geriatrics: A Case-Based Approach, 67.

Vallerand, A. H., & Sanoski, C. A. (2012). Davis’s Drug Guide for Nurses (13 edition.). F.A. Davis Company. Retrieved from www.drugguide.com