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 ...
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.
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