PMHNP Study Set for ANCC Guide

PMHNP Study Set for ANCC Guide 1. Review the MOA/DOSAGE for pharmacological therapy for a patient on a stimulant medication(s) for ADHD. (p. 747) **Note: medication therapy not first line **Beware of stimulant use for children with tics **Rx'ing stimulants: ALWAYS assess cardiac risk because can lead to sudden cardiac death a. MOA: inhibit reuptake of dopamine and norepinephrine, thereby increasing concentrations in the presynaptic cleft. Amphetamines directly stimulate the release of dopamine and norepinephrine. b. DOSAGE: Start low, titrate up. In adults, extended release preferred to maximize compliance and minimize risk of abuse. In children, start with short acting to gauge tolerability and response, then switch to a longer-acting. Clozapine Chemical Structure SDA - Serotonin 5HT2A Dopamine D2 antagonist. Clozapine S/E 1. NO EPS, NO TD, NO Hyperprolactinemia 2. Life Threatening S/E agranulocytosis 3. Highest risk for MetX/Cardio Metabolic, greatest degree of weight gain 4. Increased risk seizures 5. Sedating, hyper salivation, risk of myocarditis Clozapine Tx Benefits 1. Reduce risk of suicide in Schizo 2. Efficacy in treating aggression and violence 3. Reduce TD severity "gold standard" on resistant symptoms but never first line of tx Olanzapine Chemical Structure Serotonin 5HT2A and D2 Dopamine antagonist MORE POTENT THAN Clozapine Olanzapine s/e 1. Lacks EPS, sedating d/t Antagonist of M1, H1, a1-adrenergic 2. Highest level of cardio-metabolic s/e - weight gain, insulin resistance, triglyceride levels Olanzapine Indications r/t mood Improves mood not only in schizophrenia but also in Bipolar disorder and in treatment resistant depression. Especially with addition of Fluoxetine Quetiapine Chem Structure Serotonin 5HT2A and D2 Dopamine antagonist Not potent binding at D2 receptor H1 biding - enhance sleep especially with M1 and A1 adrenergic Quetiapine Different Dosing Formulations IR immediate vs. XR extended release 300mg IR- least effective dose for antipsychotic (it will occupy D2 at 60% but quickly decreases due to hitting peak quickly (a few hours) requires multiple doses XR - slowly hit its peak, yet rapid enough for the 60% D2 binding Max Dose - 800mg IR form will only occupy D2 receptors for about 12 hours above the 60% threshold Max Dose - 800mg XR maintains fully effective d2 occupancy x 24 hours, has less peak dose sedation and not an ideal hypnotic due to delayed release Quetiapine different doses different actions: Papa Bear - 800mg XR = antipsychotic Mama Bear - 300mg XR = antidepressant Baby Bear - 50mg IR = sleeping Quetiapine FDA Approved for Bipolar depression and augmentation with SSRI/SNRI in unipolar depression Neurotransmitters Chemicals that transmit signals across a junction "synapse" from one neuron to another 'target' neuron Where are neurotransmitters stored? vesicles Full Agonist mimics the effect of the neurotransmitter Partial Agonist Mimic physiologic actions to a lesser degree -Some affinity but only moderate intrinsic activity -Also referred to as "agonist-antagonist" Antagonist blocks the effect a neurotransmitter inverse agonist chemical substance that produces effects opposite those of a particular neurotransmitter Serotonin Chemical Structure 5-HT - hydroxytriptamine Has 7 5HT receptors serotonergic drugs have a wide range of functions DOMAINS Serotonin effects much "DOMAINS" D for depression -mood regulation O is for Obsession serotonin regulates obsessive thoughts, behavior-requires higher dosage than depression doses M is for Migraines - serotonin receptors in brain abort a migraine A is Anxiety -SSRIs treat I is for Intestines - 90% of serotonin in the gut, it drives motility N is Nausea - block serotonin effective at preventing nausea (zofran) S is sexual side effects Serotonin Syndrome Shits and SHIVERS Shits is for diarrhea S is for shivering - fairly unique symptom H is for Hyperreflexia (overactive) and myoclonus (quick, involuntary muscle jerk) Increased temperature Vital sign instability - HR, BP, RR Encephalopathy (decreased LOC) Restlessness Sweating is an autonomic response a. Latuda FDA approved for b. Off Label For Schizophrenia age 13 and older, Bipolar Depression b. Treatment resistant depression b. mixed manic episode 1. Review the Contra/Adverse for pharmacological therapy for a patient on a stimulant medication(s) for ADHD. (p. 747) c. CONTRAINDICATIONS: Do not rx methylphenidate in patients with marked anxiety, tension or agitation, glaucoma or hx of tics/Tourettes. Pre-existing cardiovascular disease, moderate/severe HTN, hyperthyroidism, or hx of substance abuse. d. ADVERSE REACTIONS: a. Cardiovascular palpitations, tachycardia, HTN, arrhythmias b. GI Change in appetite, N/V c. Neurological HA, insomnia, seizure activity d. Growth retardation e. Stimulant Medications - One doesn't show efficacy over another. a. Methylphenidate (Ritalin/Concerta) b. Dextroamphetamine (Dexedrine) c. Amphetamine/dextroamphetamine (Adderall) Which dementia type has a relatively quick onset? Delirium Which following type of dementia is characterized by early changes in behaviors vs. impairments in memory? Fronto-temporal dementia Which dementia is characterized by early persistent visual hallucinations, early fluctuations in cognition and attention and EPS? LBD Which is the following dementias are characterized by Parkinson-like movements? LBD Lewey Body Dementia Neurodegenerative disorder of cognition, related to Parkinsons, path by abnormal aggregation of the Alpha-Synculien Disease process of LBD Neurdegenerative disorder of cognition related to Parkinsons Path by abnormal aggregation of alpha synuclien 1. Progressive loss of memory, language, reasoning or higher mental functions like calculating numbers, intense visual hallucinations - common to see people, animals, errors in perception, seeing faces within inanimate objects 2. Path: abnormal protein deposits forming inside the brains nerve cells. these deposits called "lewy" bodies that interrupt messages in the sections of the brain that control thinking and movement Treatment regarding LBD? Cholinesterase inhibitors /parkinsonian meds, avoid HALDOL and any meds with anticholinergic properties which can worsen cognition or dopamine agonists Acetylcholine is broken down by AChE and BChE which drug works on both? Rivastigmine Greater indicator of Suicide not SI? Ambivalence AD is characterized by plaques and tangles. Plaques are formed as a result of a buildup of proteins and inflammation around deposits of which of the following? Plaques - extracellular, result from accumulation of proteins and an inflammatory reaction around deposits of Beta Amyloid A major difference between plaques and tangles in based on where each accumulates. Plaques are typically found _____ while tangles are located ______ 1. Plaques are extracellular result from accumulation of proteins and an inflammatory reaction around deposits of Beta Amyloid 2. Neurofibrillary tanges - INTRACELLULAR aggregates of hyper phosphorylated micro tubular protein tau The cholinergic Hypothesis postulates that memory loss in AD is related to loss of cholinergic neurons in the basal forebrain. The changes typically begin in which of the following structures? Nucleus basal is of Meynert loss of cholinergic neurotransmission in cerebral cortex Neuronal degradation also occurs by excessive activation of NMDA receptors by glutamate. Which of the following drugs addresses that as an NMDA receptor antagonist? Namenda/Mamenta Evidence from which of the following led the FDA to require a black box warning on the use of antipsychotics in the treatment of psychosis in dementia? FGAs slightly more than SBAs vs. non use. Risperdone who had a positive response when taken off Risperdal showed higher rates of or relapse of agitation Campral/Acamprosate Commonly prescribed for? Chem Class? Alcohol Abstinence (FDA Approved) Glutamate multi-modal/Alcohol dep Tx. Campral/Acamprosate MOA 1. reduce excitatory glutamate neurotransmission 2. increase inhibitory GABA transmission, binds/blocks to certain glutamate receptors 3. acts as "artificial alcohol" like in post alcohol consumption there is excessive glutamate activity and deficientGABA Cameral mitigates theres Acamprosate s/e 1. diarrhea, nausea, (GI effects d/t large amount of amino acid derivative, increasing osmotic absorption, leading to diarrhea) 2. anxiety and depression 3. life threatening - SI 4. weight gain and sedation unusual Acamprosate dosage 666mg po TID (60kg) 666mg BID (60kg) Comes in 333mg tablets Acamprosate Pharmacokinetics 1/2 life, Excreted, drug Interactions