Sample Answer for NURS 6521 Week 5: Neurological System Included After Question
Neurological disorders, such as headaches, seizure disorders, sleep disorders, depression, and dementia can present several complications for patients of all ages. These disorders affect patients physically and emotionally, impacting judgment, school and/or job performance, and relationships with family and friends. Since these disorders may have drastic effects on patients’ lives, it is important for advanced practice nurses to effectively manage patient care. With patient factors and medical history in mind, it is the advanced practice nurse’s responsibility to manage the diagnosis, treatment, and education of patients with neurological disorders.
To prepare:
- Review this week’s media presentation on pharmacology for the nervous system.
- Select one of the following neurological disorders: headaches, seizure disorders, sleep disorders, depression, or dementia. Consider the types of drugs that would be prescribed to patients to treat symptoms associated with this disorder.
- Select one of the following factors: genetics, gender, ethnicity, age, or behavior. Reflect on how this factor might impact the effects of prescribed drugs, as well as any measures you might take to help reduce negative side effects.
With these thoughts in mind:
By Day 3
Post a description of the neurological disorder you selected including types of drugs that would be prescribed to patients to treat associated symptoms. Then, explain how the factor you selected might impact the effects of prescribed drugs, as well as any measures you might take to help reduce negative side effects.
By Day 6
Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days who selected a different neurological disorder than you did. Provide recommendations for alternative drug treatments and patient education strategies for treatment and management.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
According to an article published in the Los Angeles Times, drug misuse is the leading cause of accidental death in the United States. Some of the most common drugs found in association with drug-related deaths are drugs prescribed to treat neurological disorders. These prescription drug-related deaths are often attributed to painkillers such as OxyContin and Vicodin, as well anti-anxiety drugs such as Valium and Xanax (Girion, Glover, & Smith, 2011). This issue emphasizes the importance of the regulation and management of prescription drugs. You must be aware of this when prescribing controlled drugs commonly used to treat neurological disorders such as headaches, sleep disorders, anxiety, and depression. As an advanced practice nurse, you have the responsibility to carefully diagnose and prescribe treatment, as well as to closely monitor the effects of drug therapies on the physical and mental health of your patients.
In the previous weeks of this course, you began to explore disorders and treatments as they relate to specific body systems. This week, you continue this exploration with the nervous system, but with special considerations in mind. Treatments for nervous system disorders present unique issues not just because of the scope and breadth of the disorders, but also because the types of drugs that are often used for treatment. You examine types of drugs prescribed to treat neurological disorders, as well as the impact of patient factors on the effects of the drugs.
Learning Objectives
By the end of this week, students will:
- Analyze types of drugs prescribed to treat neurological disorders
- Evaluate the impact of patient factors on the effects of prescribed drugs for neurological disorders
- Evaluate drug therapy plans for neurological disorders
- Analyze patient education strategies for treatment and management of neurological disorders
- Understand and apply key terms, concepts, and principles related to prescribing drugs to treat neurological disorders
Photo Credit: akindo/DigitalVision Vectors/Getty Images
Learning Resources
This page contains the Learning Resources for this week. Be sure to scroll down the page to see all of this week’s assigned Learning Resources. To access select media resources, please use the media player below.
Required Readings
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.
- Chapter 7, “Principles of Pharmacology in Pain Management” (pp. 93-109)
This chapter begins by examining acute and chronic pain. It also explores the pathophysiology of pain, general principles for managing pain, and drugs used in pain management.
- Chapter 38, “Headaches” (pp. 629-654)
This chapter covers the causes, pathophysiology, and diagnostic criteria for tension and migraine headaches. It then outlines the process of selecting, administering, and managing drug therapy for headaches, including migraines and cluster headaches.
- Chapter 39, “Seizure Disorders” (pp. 655-680)
This chapter explores the causes, pathophysiology, and diagnostic criteria of seizures. It also describes the process of selecting, administering, and managing drug therapy for patients with seizures.
- Chapter 40, “Major Depressive Disorder” (pp. 681-699)
This chapter begins by identifying the causes, pathophysiology, and diagnostic criteria of major depressive disorder (MDD). It then examines types of depressions and drugs prescribed to treat patients suffering from MDD.
- Chapter 41, “Anxiety” (pp. 701-718)
This chapter examines the causes, pathophysiology, and diagnostic criteria for anxiety. It also outlines the process of selecting, administering, and managing drug therapy for patients with anxiety.
- Chapter 42, “Insomnia and Sleep Disorders” (pp. 721-755)
This chapter covers the causes, pathophysiology, and diagnostic criteria of three sleep disorders: insomnia, restless leg syndrome and periodic limb movement disorder, and narcolepsy. It also examines the process of selecting, administering, and managing drug therapy for patients with these sleep disorders.
- Chapter 44, “Alzheimer’s Disease” (pp. 757-780)
This chapter examines the causes and pathophysiology of Alzheimer’s disease (AD). It also describes various drugs used to treat symptoms of AD, including proper dosages and possible adverse reactions.
Required Media
This media presentation outlines drug treatment options for disorders of the nervous system.
Note: The approximate length of this media piece is 7 minutes.
Optional Resources
Refer to the Optional Resources listed in Week 1.
A Sample Answer For the Assignment: NURS 6521 Week 5: Neurological System
Title: NURS 6521 Week 5: Neurological System
Headaches are among the top complaints that patients have when they see their primary care providers (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p.629). There are several types of headaches. When there is no identifiable underline disease process the headache is considered a primary headache, and with secondary headaches, the primary cause is identified (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p.629). Within the two groups are subgroups, primary headaches include tension-type headaches (TTH), migraine, and cluster headache (CH) and secondary headaches have another cause that must be determined first before an acute diagnosis of primary or secondary can be made (Arcangelo, Peterson, Wilbur & Reinhold, 20017, p.629).
The medication prescribed to treat the head would be determined by the type of headache the patient is experiencing. If a headache is a secondary headache, the underlying illness would be treated which would most likely relieve the headache. In tension-type headaches, the provider would initiate be medications that the patient could purchase over the counter (OTC). These medications include acetaminophen, aspirin, non-steroidal Anti-inflammatory drugs (NSAIDs), antiemetic agents, and combinations medications that contain caffeine such as Excedrin (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p.632-633). The aim of treatment for a headache is to decrease the number of attacks and the intensity so that the patient can function as normal as possible.
Treating migraine headaches take a slightly different approach. The drug therapy is tailored to the patient because each patient can have different triggers, different levels of intensity, and a different amount of attacks. While medications are used to manage migraines, the provider may also suggest therapies that are not pharmacological such as stress management, relaxation techniques, and recognizing triggers early (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p.638). Migraines often require more than OTC medications to make the headaches. Medications used in treatment include NSAIDs, caffeine-containing compounds, Triptans, Ergot derivatives, barbiturates, opioids, steroids, antiemetic agents (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p.644-648).
Medications for Migraines:
First Line:
Ibuprofen and aspirin are among the first line of therapy when trying to bring relief from a migraine headache. Ibuprofen is an NSAID used to treat mild to moderate pain. Its mechanism of action is that it reversibly inhibits COX-1 and COX02 enzymes, causing a decrease formation of prostaglandin precursors (Kizior, 2018, p.561). It helps to relieve pain and decrease inflammation. The pharmacokinetics of ibuprofen is that it is absorbed from the GI tract, protein binding 90-99%, broken down by the liver and eliminated in the urine, and cannot be removed by hemodialysis, with a half-life of 2-4 hours (Kizior, 2018, p.561). Ibuprofen must be used with caution in children and the elderly population. Older patients may require a lower dose to avoid toxicity. In children who are less than six months safety has not been determined.
For the acute treatment of a migraine that is of moderate to severe intensity Triptans are used. One of the Triptans used is sumatriptan its therapeutic effect is to relieve migraine headaches. Its mechanism of action is that it binds selectively to serotonin 5-HT1receptors in cranial arteries, to achieve vasoconstrictive effect on cranial blood vessels, the pharmacokinetics of sumatriptan is that it is quickly absorbed after subcutaneous administration; after oral absorption is not complete; a majority is broken down by the liver causing a low bioavailability, protein binding of 10%-21%, it is widely distributed, the amount of medication is decreased before it reaches the systemic circulation with a half-life of 2 hours (Kizior, 2018, p.1095). If the first line of treatment does not work the provider will then move to the second line of treatment. The third line of treatment is much stronger medications in the class containing butalbital and opioids.
Cluster headaches should be evaluated quickly because they could be an indication of a serious issue, so it is best to follow up with a neurologist. The most severe primary headache form is cluster headaches. Treating cluster headaches are done with sumatriptan and may be administered in different routes including subcutaneous and nasal spray (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p.651). There are medications that are used as in chronic and episodic cluster headaches — Verapamil, lithium, melatonin, topiramate, gabapentin, valproic acid, DHE, leuprolide intranasal capsaicin and baclofen (Leone, Giustiniani, Cecchini, 2017, pS46).
Factor: Age
Age is a factor when it comes to the medications that are prescribed to patients who suffer from headaches. Medications have to be prescribed cautiously in children and the elderly population for several reasons. Children usually require a much smaller weight-based medication, and the elderly population often metabolize medical different because of natural aging and another underlying disease that affects the kidney and liver. In children and adolescence headaches are common, and they need to see a pediatric neurologist (Jeong, Lee, Lee & Han, 2018, p.1). Sumatriptan can cause heart arrhythmias in patient’s with hypertension, obesity, who are smokers, has diabetes, and a family history of coronary artery disease (Kizior, 2018, p.1096). These are all many diseases that elderly patients suffer from due to normal aging.
Reference:
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017).
Pharmacotherapeutics for advanced practice: A practical approach(4th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Jeong, Y. J., Lee, Y. T., Lee, I. G., & Han, J. Y. (2018). Primary headaches in children and
adolescents – experiences at a single headache center in Korea. BMC Neurology, 18(1), 70. https://doi-org.ezp.waldenulibrary.org/10.1186/s12883-018-1073-9
Kizior, R. (2018). Saunders Nursing Drug Handbook 2019. Elsevier – Health Sciences Division.
Leone, M., Giustiniani, A., & Cecchini, A. (2017). Cluster headache: present and future
therapy. Neurological Sciences, 38, 45–50. https://doi-org.ezp.waldenulibrary.org/10.1007/s10072-017-2924-7
Özge, A., Abu-Arafeh, I., Gelfand, A. A., Goadsby, P. J., Cuvellier, J. C., Valeriani, M., …
Guidetti, V. (2017). Experts’ opinion about the pediatric secondary headaches diagnostic criteria of the ICHD-3 beta. The Journal Of Headache And Pain, 18(1), 113. https://doi-org.ezp.waldenulibrary.org/10.1186/s10194-017-0819-x
A Sample Answer 2 For the Assignment: NURS 6521 Week 5: Neurological System
Title: NURS 6521 Week 5: Neurological System
Depression is a disorder of mood that where cognition, behavior, and physical function is altered that tends to be more prevalent in the fourth decade of life (Arcangelo, Peterson, & Reinhold, 2017). The classic symptoms tend to be a depressed mood, sadness, hopelessness, change in appetite and weight, guilt, difficulty concentrating, loss of interest, sleep disturbances, and suicidal ideation (Arcangelo, Peterson, & Reinhold, 2017). The cause is a interplay of multiple factors including social, genetic, biochemical, physiological, and environmental factors (Arcangelo, Peterson, & Reinhold, 2017). Physiologically, theories have indicated an abnormality and/or decrease in neurotransmitter (Serotonin, norepinephrine, or dopamine) release or postsynaptic sensitivity (Arcangelo, Peterson, & Reinhold, 2017). Types of depression include persistent depressive disorder, postpartum depression, psychotic depression, seasonal affective disorder, and bipolar depressive disorder (U.S. Department of Health and Human Services, 2018).
Persistent depressive disorder occurs when the patient has five or more symptoms that last for two or more years (U.S. Department of Health and Human Services, 2018). Postpartum depression occurs during pregnancy or after delivery, and is characterized by anxiety, extreme sadness, and exhaustion that make it hard for mothers to care for themselves and their babies (U.S. Department of Health and Human Services, 2018). Psychotic depression is severe depression accompanied by psychosis (U.S. Department of Health and Human Services, 2018). Seasonal affect disorder is when depression occurs during the winter months, and bipolar depressive disorder occurs when the patient with bipolar disorder experiences symptoms of depression during their times of low moods (U.S. Department of Health and Human Services, 2018). Non-pharmacological and pharmacological methods of treatment exist, which can be used simultaneously. For the purposes of this discussion, pharmacological treatment with be discussed.
Pharmacological Treatment of Depression
Over the past 25 years, the use of antidepressants has been correlated to the decrease in suicidal mortality associated with depression (Vuorilehto, Melartin, Isometsa, & Riikimaki, 2016). The selection of the pharmacological treatment of the depression is contingent of the side effect profile, symptomology of the patient compared to the desired outcome, and the patient preference (Arcangelo, Peterson, & Reinhold, 2017). The classes of antidepressants that exist are Selective Serotonin Reuptake Inhibitor (SSRI), Serotonin Norepinephrine Reuptake Inhibitor (SNRI), Tricyclic Antidepressant (TCAs), Monoamine Oxidase (MAO) inhibitors, and atypical agents.
SSRIs are a newer class of antidepressants that have replaced the TCAs as the first line pharmacological treatment of depression due to the need for fewer titrations and the reduction in the lethality of the in overdosing on the medication (Arcangelo, Peterson, & Reinhold, 2017). The mechanism of action includes the SSRI hindering the reuptake of the neurotransmitter into the presynaptic neuron by binding with the serotonin transporter (Arcangelo, Peterson, & Reinhold, 2017). The effects of this medication can be seen between 4 to 6 weeks with the full length of the treatment possibly being concluded at the 4 to 6 month period (Arcangelo, Peterson, & Reinhold, 2017). Adverse effects include the possibility of causing insomnia or anxiety, weight gain, and sexual dysfunction (Arcangelo, Peterson, & Reinhold, 2017). Caution should be utilized in patient with seizures and this medication should not be discontinued abruptly (Arcangelo, Peterson, & Reinhold, 2017). SSRIs also hinder various components of the cytochrome P-450 system which can cause elevations of other medications that are metabolized by this system (Arcangelo, Peterson, & Reinhold, 2017). Some drugs included in this class are citalopram, fluoxetine, and paroxetine.
SNRIs are potent protein inhibitors that inhibit the uptake of serotonin and norepinephrine and have a weak hindrance of dopamine reuptake (Arcangelo, Peterson, & Reinhold, 2017). The effect of SNRIs can be seen between 4 to 6 weeks, but can potentially take up to 12 weeks (Arcangelo, Peterson, & Reinhold, 2017). SNRIs are used to treat severe and treatment resistant depression (Arcangelo, Peterson, & Reinhold, 2017). Side effects include dry mouth, constipation, nausea, and insomnia (Arcangelo, Peterson, & Reinhold, 2017). Caution should be utilized when discontinuing this medication due the potential to evoke the discontinuation syndrome (Arcangelo, Peterson, & Reinhold, 2017). Serotonin syndrome ca be induced by the concurrent use with MAO inhibitors (Arcangelo, Peterson, & Reinhold, 2017). Examples of drugs in this class include venlafaxine, desvenlafaxine, and duloxetine.
TCAs were a class considered the first line of treatment before SSRIs were created; however, the challenge with tolerability (secondary to the side effect profile) caused it to be the second or third choice of therapy (Arcangelo, Peterson, & Reinhold, 2017). It works by inhibiting serotonin and norepinephrine; however, the pharmacokinetics are patient based (Arcangelo, Peterson, & Reinhold, 2017). Adverse effects can include sedation (which can be beneficial for patients experiencing insomnia), hypotension (certain drugs in the class), weight gain, and life-threatening cardiac conduction abnormality (Arcangelo, Peterson, & Reinhold, 2017). It should not be used in patients with a history of epilepsy (Arcangelo, Peterson, & Reinhold, 2017). It should not be used with anticholinergic drugs, such as diphenhydramine, and can cause a hypertensive crisis if used concurrently with MAO inhibitors (Arcangelo, Peterson, & Reinhold, 2017).
MAO Inhibitors were the first effective drugs that worked by irreversibly, nonspecifically, inhibiting type A and type B monoamine oxidase which leads to a decreased breakdown of norepinephrine, serotonin, and dopamine in the synapse (Arcangelo, Peterson, & Reinhold, 2017). MAO Inhibitors can cause life-threatening hypertensive crisis, orthostatic hypotension (with certain meds), and is usually the last line of treatment due to the adverse effect profile (Arcangelo, Peterson, & Reinhold, 2017). A strict diet must be followed to eliminate the tyramine-containing foods out of the patients diet, such as aged cheese, beef-liver, chicken liver, and yeast products to prevent hypertensive crisis (Arcangelo, Peterson, & Reinhold, 2017). Concurrent utilization of MAO Inhibitors can cause hypertensive crisis that can result in seizures and death (Arcangelo, Peterson, & Reinhold, 2017). An example of a MAO Inhibitor would be phenelzine.
Atypical antidepressants are ones that do not fit into the traditional classification. An example of an atypical antidepressant is Bupropion and Trazadone (U.S. Department of Health and Human Services, 2018). There mechanisms of actions vary from drug to drug.
Age and Treatment of Depression
Age plays a significant factor in the selection of pharmacological treatment of depression. In patients 25 years old and younger, SSRIs can increase the suicidal attempts and completion (Arcangelo, Peterson, & Reinhold, 2017). SSRIs have no impact on the rate of suicidal attempts and completion in 25-65 years old patients (Arcangelo, Peterson, & Reinhold, 2017) and they have a decreased rate of suicidal attempts and completion in patients greater than 65 years old (Arcangelo, Peterson, & Reinhold, 2017). SNRIs can cause sexual dysfunction, which is particularly important to the sexually active individual. TCAs are contraindicated in the elderly due to the increased incidence of cardiovascular adverse effects. Caution should be utilized with all individuals with certain disabilities, which the presence of comorbidities are usually increased in the elderly population.
Measures to Decrease Side Effects
Medication review and reconciliation would be the first step to decreasing the potential for side effects. Ensuring there are not any drugs that can interact with the prescribed medication is crucial. Monitoring the effects and potential side effects of the antidepressants is another method, especially MAO inhibitors, would be another method through frequent follow-ups (especially in the beginning of prescribing the medication) to ensure the patient is taking the medications and gauge the side effects versus he benefits. Patient education about all of the potential side effects, the length of time it takes for the medication to take effect, and the impact abruptly stopping the medication can have on the body would be crucial. Lastly, when prescribing MAO Inhibitors, prescription of support stockings, stimulants or mineralocorticoids can help decrease the hypotensive effect (Arcangelo, Peterson, & Reinhold, 2017).
Summary
In summary, depression is a mood disorder that can be treated pharmacologically or non-pharmacologically. Drug classes used to treat depression are Selective Serotonin Reuptake Inhibitor (SSRI), Serotonin Norepinephrine Reuptake Inhibitor (SNRI), Tricyclic Antidepressant (TCAs), Monoamine Oxidase (MAO) inhibitors, and atypical agents. Selection of the agent is based on the side effect profile, the desire of the patient, and the symptomology of the patient in comparison to the desired outcome. Age has a significant impact on the effects of the medication. Medication review, patient education, and appropriate treatments would be prescribed to minimize the effects of the medications prescribed.
Reference
Arcangelo, V. P., Peterson, A. M., & Reinhold, J. A. (2017). Pharmacotherapeutics for Advanced Practice: A Practical Approach. Ambler, PA: Lippincott Williams & Wilkins.
U.S. Department of Health and Human Services. (2018). Deppression. Retrieved from National Institue of Mental Health: https://www.nimh.nih.gov/health/topics/depression/index.shtml
Vuorilehto, M. S., Melartin, T., Isometsa, E. T., & Riikimaki, K. (2016). Pharmacological and psychosocial treatmet of depression in primary care: Low intensity ad poor adherence and continuity. Journal of Affective Disorders, 145-152.
A Sample Answer 3 For the Assignment: NURS 6521 Week 5: Neurological System
Title: NURS 6521 Week 5: Neurological System
The theories behind what causes depression vary, but primarily suggest that imbalances of the monoamine catecholamines norepinephrine, serotonin, and dopamine play a leading role (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Drugs that may be prescribed for major depressive disorder (MDD) include medications from selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and atypical antidepressants. Because the drugs from all classes have similar efficacy, prescribing from these drug classes is primarily based on patient preference, focused treatment of symptoms, and avoidance of side effects (Arcangelo et al., 2017). While a decrease of 50 percent of pretreatment symptoms is considered a meaningful response, the treatment goal is complete relief (Saltiel & Silverstein, 2015).
SSRIs selectively inhibit serotonin reuptake by the presynaptic neuron leaving more serotonin (5HT) in the synaptic cleft (Whalen, Finkel, & Panavelil, 2015). This change occurs rapidly, but clinical results take four to six weeks to show; this gap in the change of available serotonin to positive result challenge the theories that an imbalance of monoamine catecholamines are the primary cause of MDD and this applies to traditional classes of antidepressants (Arcangelo et al., 2017). SSRIs are associated with causing sexual dysfunction and weight gain; this is a common cause for noncompliance (Arcangelo et al., 2017).
SSRIs are well absorbed orally and operating at their peak level in two to eight hours, and dosage should be adjusted for patients with liver disease (Whalen et al., 2015). SSRIs inhibit pieces to the cytochrome P-450 (CYP450) system; other medications that rely on this metabolism pathway may need to have their dosage decreased, and SSRIs should not be given with a MAOI (Arcangelo et al., 2017). Escitalopram is an example of an SSRI; over fifty percent is protein bound, metabolized mainly in the liver, and has a half-life of 27-32 hours (DrugBank, n.d.)
Plasma half-lives are between 16-36 hours for most SSRIs except fluoxetine which has a half-life of 50 hours; this information is essential for the clinician discontinuing patient treatment with these medications.
SNRIs work by inhibiting both serotonin and norepinephrine reuptake and may be useful in patients with MDD who also have chronic pain because pain is also modulation by these pathways (Whalen et al., 2015); there is some discussion that SNRIs may be more effective than SSRIs for those with severe MDD because of their broader action (Arcangelo et al., 2017).
SRNIs are metabolized by the CYP450 system as well and drug-drug interactions must be considered; dry mouth, constipation, insomnia, and nausea are side effects secondary to noradrenergic activity (Arcangelo et al., 2017). They also weakly inhibit reuptake of dopamine (Arcangelo et al., 2017).
An example of an SRNI is venlafaxine. Venlafaxine primarily inhibits serotonin reuptake with higher doses also inhibiting norepinephrine intake (Whalen et al., 2015). Its absorption is not affected by food intake, has a bioavailability of about 45 percent, is metabolized by the liver, excreted by the kidneys, and has a half-life of five hours (DrugBank, n.d.).
TCAs are like SNRIs in that they block the reuptake of both serotonin and norepinephrine but differ in that they block the action of serotonergic, alpha-adrenergic, histaminic, and muscarinic receptors (Whalen et al., 2015). The side effects associated with their broader spectrum of action is also responsible for increased adverse side effects, and as a result, TCAs are no longer considered first-line treatment for MDD (Arcangelo et al., 2017). This class of drugs is associated with sedation as well as anticholinergic effects because of muscarinic blocking action of the drugs (Whalen et al., 2015). TCAS can also be lethal in amounts equaling five to six times the standard dose; drugs should be prescribed in small quantities (Whalen et al., 2015).
Nortriptyline is a TCA and is an active metabolite of amitriptyline but has fewer anticholinergic effects than amitriptyline and is an active inhibitor or norepinephrine reuptake (DrugBank, n.d.). Over ninety percent of the drug is protein bound, metabolized by the liver, and excreted by the kidneys; it has a half-life of twenty-six hours (DrugBank, n.d.). Nortriptyline is less likely to cause orthostatic hypotension which may make it a good choice for elderly patients (Arcangelo et al., 2017).
MAOIs inhibit monoamine oxidase (MAO) which is a mitochondrial enzyme that inactivates neurotransmitters including norepinephrine, serotonin, and dopamine (Arcangelo et al., 2017). Inactivation of the enzyme is caused the formation of stable complexes of the MAO and MAOI; this may be irreversible, and because MAOs are also utilized in the liver and gut, high drug-drug and drug-food interactions are associated with MAOI use. For example, patients taking MAOIs should be counseled to avoid foods high in tyramine (cured meats are one example) to avoid a hypertensive crisis (Arcangelo et al., 2017). MAOIs are well absorbed by oral intake and enzyme regeneration can take up to two weeks after the drug is stopped to occur (Whalen et al., 2015). TCAs and MAOIs should not be prescribed together, and extreme caution used when using MAOIs in combination with SSRIs or SSNIs (Arcangelo et al., 2017). This class of drug is second or third choice and may be useful in those patients with refractory depression when drugs from other classes have failed to effect a therapeutic response (Arcangelo et al., 2017).
Phenelzine is one example of an MAOI and also increases catecholamines and gamma-aminobutyric acid (GABA) in the brain (DrugBank, n.d.). It is readily absorbed after oral administration and has a half-life of less than twelve hours (DrugBank, n.d.).
Atypical antidepressants have diverse areas of action, and do not fit into the SSRI, SNRI, TCA, or MAOI classes (Whalen et al., 2015). Bupropion is a commonly prescribed drug from this class and is metabolized by the CYP2D6 pathway (Whalen et al., 2015). It is believed to block dopamine reuptake, is highly protein bound, and excreted by the kidneys (DrugBank, n.d.).
Treatment of children follows the basic rule of all pharmacological treatment choices for MDD; because most anti-depressants have similar efficacy, choosing one with the least side effects for the patient is a central piece to drug choice (Arcangelo et al., 2017). For example, fluoxetine is the only SSRI approved for treatment of MDD in children eight years and older because of increased risks of mania and suicide associated with SSRI use in children and teens (Arcangelo et al., 2017). Older adults have more comorbidities and longer drug list increasing the risk for adverse effects and alterations in absorption, distribution, metabolism, and excretion of antidepressants and initial doses should be one-third to one-half of typical adult doses (Arcangelo et al., 2017).
References
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice a practical
approach (4th ed.). Philadelphia, PA: Wolters Kluwer.
DrugBank. (n.d.). Bupropion. Retrieved December 26, 2018, from https://www.drugbank.ca/drugs/DB01156
DrugBank. (n.d.). Escitalopram. Retrieved December 26, 2018, from https://www.drugbank.ca/drugs/DB01175
DrugBank. (n.d.). Nortriptyline. Retrieved December 27, 2018, from https://www.drugbank.ca/drugs/DB00540
DrugBank. (n.d.). Phenelzine. Retrieved December 25, 2018, from https://www.drugbank.ca/drugs/DB00780
DrugBank. (n.d.). Venlafaxine. Retrieved December 26, 2018, from https://www.drugbank.ca/drugs/DB00285
Saltiel, P. F., & Silverstein, D. I. (2015). Major depressive disorder: mechanism-based prescribing for personalized medicine.
Neuropsychiatric Disease and Treatment, 2015(11), 875-888. https://doi.org/10.2147/ND.573261
Whalen, K., Finkel, R., & Panavelil, T. A. (2015). Lippincott illustrated reviews: Pharmacology (6th ed.). Philadelphia, PA: Wolters Kluwer.
A Sample Answer 4 For the Assignment: NURS 6521 Week 5: Neurological System
Title: NURS 6521 Week 5: Neurological System
Seizure disorders
Seizures or epilepsies is a brain disorder is where brain activity is being disturbed that causes unresponsive, life-threatening and disabilities (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). A seizure is also caused by extremely high fevers, alcohol withdrawal, and traumatic head injury. There are two major groups, partial and generalized seizures. Status epilepticus is a life threating condition which causes seizures lasting longer than five minutes without recovery (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
First line therapy carbamazepine, phenytoin, fosphenytoin, valproic acid, lamotrigine, lacosamide, topiramate, oxcarbazepine (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Carbamazepine is not entirely understood but believed to alter synaptic transmission (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). The absorption is complete, and the elimination half-life is about 35 hour, ranging 18 to 65 hours(Bertilsson, 1978). During multiple dosing, the half-life is decreased to 10-20 hours, probably due to autoinduction of the oxidative metabolism of the drug (Bertilsson, 1978). Phenytoin and fosphenytoin blocks posttetanic by stabilizing neuronal membranes(). The rate of absorption varies considerably among dosage Phenytoin is poorly soluble in water and is commonly given as phenytoin sodium salt, which dissolves more readily(Browne, Kugler, & Eldon, 1996). The small intestine is the primary site of phenytoin absorption. Phenytoin may be given IV for rapid onset of drug effect. Phenytoindisbutes into the body tissues, including the brain, within 30 to 60 minutes after reaching the systemic circulation(Browne, Kugler, & Eldon, 1996). Fosphenytoin is metabolized, the half-life of 8 to 15 min, to phenytoin by endogenous phosphatases(Browne, Kugler, & Eldon, 1996).
Genetics
Many families contain multiple individuals that are affected with epilepsy, indicating that there is a substantial genetic contribution to many types of epilepsy. However little is known about the specific genes or genetic alterations that cause epilepsy.
Gender
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Epilepsy is a condition that can affect each person differently. Gender can be a factor in how epilepsy will affect the particular person. Care also needs to consider gender-related differences in epilepsy, with health considerations, hormonal changes, and social function(Epilepsy foundation, 2014). Epilepsy is different for a woman than a man. The differences arise because of the biological differences between women and men, and also because of the different social roles of each gender(Epilepsy foundation, 2014).
Age
More than 570,000 adults aged 65 years old and older have seizures(Lazare, 2016). The older adults are the fastest growing population to be affected by seizures(Lazare, 2016). There are two peak periods during, childhood and after the age of 65 years old. The older adults onset of seizures can contribute to brain conditions like stroke, cardiac disease, dementia, or brain injured or tumors (Lazare, 2016).
Behavior
Behavioral symptoms are based on the primary mood disorder of impulse control (Thaler & Reeve, 2015). During a seizure, a person may strike out, aggressive behavior. Aggression occurs during the post-ictal phase. The individual may damage property and anything in their path of movement during the seizure. This behavior is characterized by poor awareness, no memory and lack of complex motor behavior (Thaler & Reeve, 2015).
Reduce the negative side effects
To reduce never side effects of seizure to ensure the individual is compliant with medications. Seizure medication should be taken daily, without missing a dose. Check with primary care provider for drug interactions with daily home medications. For example, acetaminophen decreases the level in carbamazepine by speeding up the drug metabolism, causing potential liver problems.
Reference
Lazare, J. (2016). Seizures in Older Adults. Retrieved from http://www.todaysgeriatricmedicine.com/archive/spring2011_p30.shtm
Thaler, G., Reeve, A. (2015) Behavior Manifestations of Seizures. Retrieved from https://coc.unm.edu/common/resources/Behavior_Seizures.pdf
Laureate Education, Inc, (Executive Producer). (2012). Pharmacology for the nervous system. Baltimore, MD: Author.
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017).Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Bertilsson, L. (1978). Clinical pharmacokinetics of carbamazepine. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/346287/
Epilepsy Foundation (2014). Gender issues. Retrieved from https://www.epilepsy.com/learn/gender-issues
Browne, T., Kugler, A., Eldon, M. (1996). Pharmacology and Pharmacokinetics of fosphenytoin. Retrieved from http://n.neurology.org/content/46/6_Suppl_1/3S
A Sample Answer 5 For the Assignment: NURS 6521 Week 5: Neurological System
Title: NURS 6521 Week 5: Neurological System
Major Depressive Disorder (MDD) affects 155 million people in the world and cost the United States about $83 billion in a year from sick days to other indirect costs. If a person experiences MDD once they are very likely to experience it again in their lifetime (Arcangelo, Peterson, Wilber, & Reinhold, 2017).
Medications that treat depression which are selective serotonin reuptake inhibitors (SSRIs), Serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), monoamine oxidase (MAO) inhibitors, and atypical agents (Arcangelo, Peterson, Wilber, & Reinhold, 2017). SSRIs increase serotonin in the brain by blocking the reabsorption of serotonin which makes more serotonin available and metabolized in the liver (Mayo Clinic, 2018). Side effects include dry mouth, nausea, increased sweating, excessive tiredness, and insomnia. Contraindications for SSRIs is MAO inhibitor therapy. An SSRI should be taken in the morning to avoid insomnia as well as about 6% of men experience erectile dysfunction and about 3% experience impotence (Arcangelo, Peterson, Wilber, & Reinhold, 2017). SNRIs block the reabsorption of serotonin and norepinephrine in the brain. Side effects can include erectile dysfunction, increases in blood pressure, as well as dry mouth, nausea, constipation, tiredness, and insomnia (Mayo Clinic, 2016). Contraindications include not using within 14 days of a MAO inhibitor and caution in narrow angle glaucoma.
Special considerations include monitor blood pressure closely, monitor cholesterol levels and triglycerides, and with duloxetine some patients with bipolar disorder can become mania or hypomanic (Arcangelo, Peterson, Wilber, & Reinhold, 2017). TCAs also block the reabsorption of serotonin and norepinephrine in the brain but also effect other chemical make ups which produce more side effects (Mayo Clinic, 2016). Most of the drugs in this class have the side effects of sedation, orthostatic hypotension, and dry mouth but others have cardia conduction disturbances, anticholinergic effects, and possible seizures. Contraindications include history of cardiovascular disease, history of epilepsy, and risk for falling (Arcangelo, Peterson, Wilber, & Reinhold, 2017). Special considerations include a need to follow therapeutic plasma concentration (Arcangelo, Peterson, Wilber, & Reinhold, 2017). MAO inhibitors work by nonspecifically and irreversibly inhibiting type A and B MAOs (Arcangelo, Peterson, Wilber, & Reinhold, 2017). The most common side effect of a MAO inhibitor is orthostatic hypotension. Special precautions need to be made when receiving a corticoid or a TCAs, they need to be monitored for a hypertensive crisis. As well as patients on this class of drug need to be on a strict diet avoiding tyramine containing foods (Arcangelo, Peterson, Wilber, & Reinhold, 2017).
The factor I selected is the postpartum population. It is normal to have what people call “baby blues” but postpartum depression starts to happen about a month after the baby is born and can last for over a year after the baby’s birth (Office on Women’s Health, 2018). SSRIs are the most studied antidepressant for breast feeding mothers and seem to be safest and least drug that passes through to breast milk (MGH Center for Women’s Mental Health, n.d.).
References
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins
Mayo Clinic. (2016, June 21). Serotonin and norepinephrine reuptake inhibitors (SNRIs). Retrieved from https://www.mayoclinic.org/diseases-conditions/depression/in-depth/antidepressants/art-20044970
Mayo Clinic. (2016, June 28). Tricyclic antidepressants (TCAs). Retrieved from https://www.mayoclinic.org/diseases-conditions/depression/in-depth/antidepressants/art-20046983
Mayo Clinic. (2018, May 17). Selective serotonin reuptake inhibitors (SSRIs). Retrieved from https://www.mayoclinic.org/diseases-conditions/depression/in-depth/ssris/art-20044825
MGH Center for Women’s Mental Health. (n.d.). Breastfeeding & psychiatric medications. Retrieved from https://womensmentalhealth.org/specialty-clinics/breastfeeding-and-psychiatric-medication/
Office on Women’s Health. (2018, August 28). Postpartum depression. Retrieved from https://www.womenshealth.gov/mental-health/mental-health-conditions/postpartum-depression
A Sample Answer 6 For the Assignment: NURS 6521 Week 5: Neurological System
Title: NURS 6521 Week 5: Neurological System
Headaches of many varieties will be a common occurrence in our practice and many factors need to be considered prior to initiation of treatment. Tension headaches are typically mild to moderate, dull in character and the pain radiates bilaterally from the forehead to the occiput in a band-like fashion (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). The pain can radiate down the neck and even into the trapezius muscle (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Migraines are defined as “an abnormal neurovascular reaction that occurs in a genetically vulnerable organism” (Soares, Louçana, Nasi, Sousa, Sá and Silva-Néto, 2018). Migraines are typically throbbing head pains ranging from moderate to severe that can include nausea, appetite changes, photophobia, and phonophobia (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Both types of headaches can have many causes. It is important to determine what medications/ treatments patients have tried as well as what they are still currently do to avoid interactions with the newly prescribed medications.
Education to identify and avoid triggers as well as encouraging a healthy diet, getting plenty of sleep, decreasing tobacco and alcohol use and using good posture will help with treating headaches (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Clinical treatment of tension headaches and migraines includes use of Acetaminophen, acetylsalicylic acid, NSAID’s, antiemetics, combination agents, antidepressants, triptans, ergot derivatives, barbiturates, and steroids. Tension headache treatment should begin with aspirin/ acetaminophen, NSAID’s the using a barbitaol combination compound as third-line (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Migraine first-line therapy includes NSAID’s/ aspirin then should include over the counter caffeine containing compounds and triptans as third-line choices (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
Acetaminophen
Acetaminophen, in the maximum single dose of 650mg (recommended) or 1,000mg is often effective for relief of mild and moderate tension headaches (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Acetaminophen primarily works in the central nervous system by inhibiting both isoforms of cyclooxygenase, COX-1, COX-2, and COX-3 enzymes involved in prostaglandin (PG) synthesis which results in an increased pain threshold (DrugBank, 2018a). Acetaminophen is rapidly and almost complete absorbed, 25% protein bound, metabolized by the liver and gut, and 80% in excreted in the urine (DrugBank, 2018a). Acetaminophen has a half-life of one to four hours (DrugBank, 2018a).
Acetylsalicylic acid (aspirin)
Acetylsalicylic acid may be used for relief of mild to moderate tension headaches as well and is considered the first-line treatment of tension headaches and migraines and can be given in initial doses of up to 900mg (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Acetylsalicylic acid works by inhibiting prostaglandin synthesis which reduces the inflammatory response and platelet aggregation (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Acetylsalicylic acid is rapidly and completely absorbed following oral administration, is 99.5% bound to albumin, metabolized rapidly in the liver, and is excreted in the urine (DrugBank, 2018c). The half-life of acetylsalicylic acid can vary depending on the dose (DrugBank, 2018c). Acetylsalicylic acid and other NSAID’s are not recommended for use together (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
NSAID’s
Non-steroidal anti-inflammatory drugs (NSAID’s) are commonly used for moderate tension headaches and migraines. NSAID’s work by inhibiting COX-2 which is responsible for prostaglandin synthesis which reduces inflammation (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Common NSAID’s used for tension headaches include ibuprofen, naproxen, ketoprofen, diclofenac, and indomethacin (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Several different NSAID’s may need to be tried before finding one that works (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
Ibuprofen is the most commonly used NSAID (DrugBank, 2018g). Ibuprofen inhibits COX-2 as well the activity of COX-1 (DrugBank, 2018). Ibuprofen is very well absorbed in the upper gastrointestinal tract once administered orally, is more than 99% bound to plasma proteins, metabolized and biotransformed in the liver, eliminated in the urine as metabolites and has a half-life of 1.2-2 hours (DrugBank, 2018g).
Antiemetics
Antiemetic agents may help augment the effects of analgesics by decreasing gastric emptying which improves analgesic absorption (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Prochlorperazine is commonly used for tension headaches as well as migraines (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Prochlorperazine works by blocking the D2 somatodendretic autoreceptor which further blocks the postsynaptic dopamine receptors in the mesolimbic system and results in a dopamine turnover (DrugBank, 2018h). Following oral administration prochlorperazine is rapidly absorbed, 91-99% protein bound, metabolized by the gastric mucosa and first pass through the liver and has a half-life of 6-8 hours (DrugBank, 2018h).
Combination Agents/ Barbituates
Fioricet and Fiorinal, which include combinations of butalbital, acetaminophen, caffeine and aspirin, are commonly used for the third-line treatment of tension headaches (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). These combinations should be used very carefully and sparingly and be tapered when discontinued (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Combinations including acetaminophen and narcotics are no longer recommended (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Fioricet and Fiorinal work by increasing the duration of time for which the Cl-isopore is open by binding to a distinct binging site at the GABAa receptor which further prolongs the post-synaptic inhibitory effect of GABA in the thalamus (DrugBank, 2018d). Both are well absorbed from the gastrointestinal tract, distributed to most tissues in the body, 45% protein bound, metabolized by the kidneys, 59-88% eliminated by the kidneys, and has a half-life of 35 hours (DrugBank, 2018d).
Antidepressents
Amitriptyline, venlafaxine and mirtazapine are commonly used for prevention of tension headaches (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Amitriptyline is the first-line, gold standard drug for prevention of tension headaches (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Recommended dosages are 10-75mg, which is much lower than a dose used to treat depression (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
Amitriptyline works by inhibiting the membrane pump mechanism that is responsible for the uptake of norepinephrine and serotonin with may potentiate or prolong neuronal activity (DrugBank, 2018b). Amitriptyline is rapidly absorbed following oral administration, undergoes first pass metabolism, is 95% protein bound in tissue and plasma, undergoes metabolism in the liver, is eliminated in the urine as metabolites and has a half-life of about 25 hours (DrugBank, 2018b).
Triptans
Triptans work on the 5-HT1 serotonin receptor agonists which results in vasocontraction (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Triptans are indicated for the treatment of moderate to severe migraines and mild migraines that did not respond to treatment with NSAID’s, aspirin or combination drugs (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Mutiple different triptans may be needed for adequate relief and limited use is recommended (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
Sumatriptan is the fastest acting of this class and comes in tablets, nasal spray, nasal powder, subcutaneous injections and transdermal patches (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Sumatriptan in a dose of 6mg, given subcutaneously, reaches peak plasma concentration in 12 minutes, has an onset of 10 minutes and relieves migraines in 82% of patients within two hours (Landy, Munjal, Brand-Schieber, & Rapoport, 2018). Sumatriptan also comes as a combination with Naproxen. Zolmitriptan in also available in several forms and should be started at an initial dose of 2.5mg (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Naratriptan should be given as an initial dose of 1-1.25mg, reaches serum concentration in two to three hours, has an onset of one to two hours and has a half-life of six hours (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
Rizatriptan can have an onset as early as 30 minutes and can last from 14 to 16 hours and can be given as five or 10 mgs. Almotriptan has a half-life of three to four hours and is metabolized by three different pathways (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Eletriptan should be given initially in a dose of 40mg which can be repeated once in two hours is relief is not felt (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Half-life of this drug is four hours (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Frovatriptan has a half-life of 26 hours and is metabolized by the kidneys and hepatic CYP1A2 (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
Ergot Derivatives
Ergot derivatives were the first drugs marketed to be migraine specific (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Ergotamine, DHE, cafergot are common ergot derivatives (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Ergotamine is a vasoconstrictor and alpha adrenoreceptor antagonist which causes constriction of peripheral and cranial blood vessels and produces depression of central vasomotor centers (DrugBank, 2018f). Once taken sublingually ergotamine is metabolized by the liver, excreted in the bile as metabolites and has a half-life of two hours (DrugBank, 2018f).
Steroids
Brief courses of steroids, typically dexamethasone 6 mg for five days, can be used when all other choices fail (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Dexamethasone works by binding with high affinity to specific cytoplasmic glucocorticoid receptors which results in modification of transcription and protein synthesis to achieve inhibition of leukocyte infiltration at the site of inflammation, interference of mediators of inflammatory response, suppression of humoral immune responses, and reduction in edema or scar tissue. Dexamethasone is 80-90% absorbed, 70% protein bound, metabolized by the liver and has a half-life of 36-54 hours (DrugBank, 2018e).
Anticonvulsants, beta-blockers, triptans, angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, antidepressants and antihistamines can also be used as prophylactic management of migraines (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Opioids have also been used as “rescue” medications but are not recommended for regular use (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Individuals with cluster headaches should be promptly referred to a neurologist for treatment (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Vatzaki, Straus, Dogne, Garcia Burgos, Girard, & Martelletti (2018), also recommend the use of Valproate in prophylaxis of migraines in woman of childbearing age. Valproate, mainly used as an anticonvulsant, is rapidly absorbed by the gastrointestinal tract and metabolized fully by the liver (DrugBank, 2018i).
Factor: Age
A patient’s age can greatly affect the medications that are used to alleviate their suffering from tension headaches and migraines. The use of aspirin in children younger than 16 years who also have a viral infection should be avoided (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). NSAIDs should be used cautiously in elderly individual’s due to the heightened risk of adverse effects (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Barbiturates should not be prescribed to elderly individuals either and amitriptyline and venlafaxine should be used with caution in this age group as well (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Zolmitriptan, almotriptan and frovatriptan when given to post-menopausal women and males over the age of 40 increases their risk of heart disease and should be avoided (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Naratriptan should be avoided in older persons and rizatriptan should be used with caution in this population (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Dihydroergotamine, dexamethasone and butorphanol nasal spray should also be used with caution in the elderly (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Starting low and increasing the dose slowing, while monitoring the side effects frequently, is the best way to avoid any adverse effects in the elderly, or any age group. Their entire medication regimen, as well as the use of natural products and over the counter drugs must be carefully assessed as well to avoid any interactions.
References
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017).
Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.
DrugBank. (2018, December-a). Acetaminophen. Retrieved
from https://www.drugbank.ca/drugs/DB00316
DrugBank. (2018, December-b). Amitriptyline. Retrieved from
https://www.drugbank.ca/drugs/DB00321
DrugBank. (2018, December-c). Aspirin. Retrieved from
https://www.drugbank.ca/drugs/DB00945
DrugBank. (2018, December-d). Butalbital. Retrieved from
https://www.drugbank.ca/drugs/DB00241
DrugBank. (2018, December-e). Dexamethasone. Retrieved from
https://www.drugbank.ca/drugs/DB01234
DrugBank. (2018, December-f). Ergotamine. Retrieved from
https://www.drugbank.ca/drugs/DB00696
DrugBank. (2018, December-g). Ibuprofen. Retrieved from
https://www.drugbank.ca/drugs/DB01050
DrugBank. (2018, December-h). Prochlorperazine. Retrieved from
https://www.drugbank.ca/drugs/DB00433
DrugBank. (2018, December-i). Valproic Acid. Retrieved from
https://www.drugbank.ca/drugs/DB00313
Landy, S., Munjal, S., Brand-Schieber, E., & Rapoport, A. M. (2018). Efficacy and safety of
DFN-11 (sumatriptan injection, 3 mg) in adults with episodic migraine: a multicenter, randomized, double-blind, placebo-controlled study. The Journal Of Headache And Pain, 19(1), 69. https://doi-org.ezp.waldenulibrary.org/10.1186/s10194-018-0881-z
Soares, A. de A., Louçana, P. M. C., Nasi, E. P., Sousa, K. M. de H., Sá, O. M. de S., & Silva-
Néto, R. P. (2018). A double- blind, randomized, and placebo-controlled clinical trial with omega-3 polyunsaturated fatty acids (OPFA ɷ-3) for the prevention of migraine in chronic migraine patients using amitriptyline. Nutritional Neuroscience, 21(3), 219–223. https://doi-org.ezp.waldenulibrary.org/10.1080/1028415X.2016.1266133
Vatzaki, E., Straus, S., Dogne, J.-M., Garcia Burgos, J., Girard, T., & Martelletti, P. (2018).
Latest clinical recommendations on valproate use for migraine prophylaxis in women of childbearing age: overview from European Medicines Agency and European Headache Federation. The Journal Of Headache And Pain, 19(1), 68. https://doi-org.ezp.waldenulibrary.org/10.1186/s10194-018-0898-3
A Sample Answer 7 For the Assignment: NURS 6521 Week 5: Neurological System
Title: NURS 6521 Week 5: Neurological System
For this week posting I decided to go with depression. Depression, also known as Major Depressive Disorder (MDD) or Clinical Depression is a serious condition where individuals manifest a series of symptoms who make them unable to perform physically, mentally and emotionally consistently (National Institute of Mental Health, 2018). The NIMH also pointed out that, in order to be diagnosed with depression, symptoms must be present for at least two weeks.
It is believed that a multifactorial relationship between physiologic, social, genetic environmental and biochemical factors are implicated in the cause for depression (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Some of the symptoms that can be present most of the day, nearly every day during the two weeks period, and from which patients have to had at least five of them present in order to positively made a diagnosis of MDD are described by American Psychiatric Association (2013):
- Depressed mood it can be indicated by patient as feeling sad, empty, hopeless, or by a witness like appears tearful. In children and adolescents, it can be expressed as irritable mood.
- Distinctly diminished interest or pleasure in all or almost all activities.
- Substantial weight loss without trying or weight gain (more than 5% of body weight in a month). In children the consideration also will be failure to make expected weight gain.
- Insomnia or hypersomnia.
- Psychomotor retardation or agitation, this must be observed by others, not just subjective feeling of restlessness or feeling down.
- Fatigue or loss of energy
- Feeling worthless, or excessive or inappropriate quilt (which can be delusional). Just self-reproach or quilt about being sick does not qualifies as a diagnostic symptom.
- Diminished ability to think or concentrate, or indecisiveness.
- Recurrent thoughts of death, suicidal ideations or attempts or specific plans to commit suicide.
Also, these symptoms must clinically significant distress or impairment in social, occupational or other areas of functioning and the episode cannot be attributable to the physiological effects of a substance or to another medical condition (American Psychiatric Association, 2013). The DMS-5 also noted that, if all the criteria previously mentioned are met, then the patient can be diagnosed with MDD.
There are different types of depressions:
Major Depression: This is the classic depression, its characterized for a lack of desire to perform any type of activities. “Symptoms of this type of depression include trouble sleeping, appetite changes or weight, loss of energy, and feeling worthless. Thoughts of death or suicide may occur. It is usually treated with psychotherapy and medication” (Harvard Medical School, 2018). The DSM-5 also indicated that a person may experience a single or recurrent depressive episodes which can be classified as mild, moderate or severe. Specifiers such as “in remission,” “in partial remission,” “with psychotic features” etc. are also possible when looking at this disorder (American Psychiatric Association, 2013).
Persistent Depressive Disorder: This disorder was previously called Dysthymia. It refers to low mood that has lasted for at least two years but may not reach the intensity of major depression. “Many people with this type of depression type are able to function day to day, but feel low or joyless much of the time. Other depressive symptoms may include appetite and sleep changes, low energy, low self-esteem, or hopelessness” (Harvard Medical School, 2018).
Bipolar Disorder: This disorder was previously known as Manic-Depressive disease. Individuals suffering from it have periods of depressive mood, but also have periods of unusually high levels or activity (manic period). “Manic symptoms look like the opposite of depression symptoms: grandiose ideas, unrealistically high self-esteem, decreased need for sleep, thoughts and activity at higher speed, and ramped-up pursuit of pleasure including sex sprees, overspending, and risk taking. Being manic can feel great, but it doesn’t last long, can lead to self-destructive behavior, and is usually followed by a period of depression” (Harvard Medical School, 2018).
Seasonal Affective Disorder: This disorder usually happens as day get shorter and colder during winter periods, individuals tend to feels more depressed. It is characterized for an increase in eating with weight gain as consequence. Also, an increase in sleepiness and chronic fatigue are other symptoms present with this disorder (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
Postpartum Depression: This disorder happens after child birth, usually within first 6 weeks and may last from 3 to 14 month (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
Other types of depression have been studied and identified, but for the purpose of this paper we will continue describing MDD.
The American Psychiatric Association practice guidelines is the most current guideline for the treatment of MDD (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Many indicators have to be taken into consideration when prescribing medications, amid those factors are: severity of the symptoms, type of depression, duration of therapy, patient’s age, sex, comorbidities and other medications the patient is currently taking (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
According to Arcangelo, Peterson, Wilbur, & Reinhold (2017), the drug therapy consists in three phases, acute, continuation and maintenance. Also, a multidisciplinary team consistent of psychologists, social workers and others must be part of the treatment in all phases. There are many different types of drugs classes available for the treatment of the depress patient: “Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonin Norepinephrine Reuptake Inhibitors (SNRIs), Tricyclic Antidepressants (TCAs), Monoamine Oxidase (MAO) inhibitors and Atypical agents” (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). All antidepressant drugs wield a pharmacologic effect by impacting one or more of the primary neurotransmitters believed to contribute to depression. There are various groups of medication classes used to treat depression, but for the purpose of the post we will be discussing SSRIs.
SSRIs:
Inhibits the reuptake of select isoforms of serotonin the synaptic cleft. Some of the medications we can find in this class are citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline and escitalopram. This class of drugs is the drug class of choice for the treatment of depression because it needs little titration, and has a reduced lethality in overdose (the leading cause of death in depressed population). SSRIs works by binding to the serotonin transporter and inhibiting the reuptake of this neurotransmitter into the presynaptic neurons (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). The authors listed anxiety and insomnia as adverse effects. In order to treat that we can prescribed benzodiazepine like alprazolam, clonazepam, chlordiazepoxide, diazepam, lorazepam temazepam and triazolam or we can prescribe a non-benzodiazepine GABA-A receptor agonist like zolpidem.
Another undesirable side effect for patients taking SSRIs is the sexual dysfunction. This is also one of the reasons listed by the patients for stopping the treatment. Paroxetine is one of the medications with the highest rate of sexual side effects. It’s very important to notify patients of this possible side effect prior to start the treatment as well as the measures we can take to minimize the occurrence and the possible treatments, reinforcing the importance of continuation of the treatment. Adding bupropion is one of the possible strategies when mitigating the sexual dysfunction, also adding sildenafil (Viagra), tadalafil (Cialis) or Vardenafil (Levitra) to the treatment of antidepressants can help some male patients suffering from erectile dysfunction (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
It’s very important for us, as providers, to know the interactions of these medications with other medications specially MAO inhibitors because this interaction may lead to an increase in systemic serotonin which can be life threatening “serotonin Syndrome”. Some of the symptoms are heat stroke, vascular collapse, fever and tachycardia (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
SSRIs require about 4 to 6 weeks and in some cases up to 12 weeks to show a full pharmacologic effect. Although this may seem like a lot of time, some depression symptoms can start to subside since the first week of treatment.
For the first line of treatment for depression, the use of SSRIs or SNRIs are considered safe and are used in patients without contraindications. Some of the medications should be avoided if the cause of the depression is directly related to the possible side effects, for example, if insomnia is problematic, paroxetine can be a good choice of treatment; SSRIs and SNRIs should be avoided if sexual dysfunctions is part of the patient’s group of depression symptoms. If weight gai is a problem then a medication like bupropion can be ordered and paroxetine should be avoided, since is the medication with the highest tendency for weight gain (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
If the first line of treatment fails, a second line of treatment can be started, this line of treatment consists on dose optimization, augmentation, and switching (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). The authors also mentioned that second drug added is to address residual symptoms like insomnia and anxiety that did not improved with initial treatment.
Ethnicity and genetics
According to Arcangelo, Peterson, Wilbur, & Reinhold (2017) the enzyme CYP2D6 responsible for the metabolism of many psychotherapeutic agents is influenced by age, gender, and ethnicity. Up to 10 % of Whites, and about 19% of African Americans, are considered poor metabolizers of this enzyme. Also, 33% of African Americans and 37% of Asians are considered poor metabolizers when it comes to the enzyme CYP2C19. Because of this poor metabolism, patients may respond quicker to the drugs and obtain a greater than expected action of the agent or more pronounced side effects.
Conclusions
Depression is a disorder that does not discriminate with regards of age, socioeconomical status or educational level. Although multiple factors like genetics, ethnicity and sex and affects the presence of this disease, and the way we may respond may affect its course. It’s imperative that a multi-step treatment with an approach that involves a multi-disciplinary team is established in order to obtain best results. Medication may not work when treating depression, a psychological evaluation and the input and help managing the disease by a counselor may be included.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5). Washington: American Psychiatric Publishing.
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017). Pharmacotherapeutics for Advanced Practice A Practical Approach. Philadelphia: Wolters Kluwer.
Harvard Medical School. (2018, June 9). Six common depression types. Retrieved from Harvard Health Publishing: https://www.health.harvard.edu/mind-and-mood/six-common-depression-types
National Institute of Mental Health. (2018, February). Depression. Retrieved from National Institute of Mental Health: https://www.nimh.nih.gov/health/topics/depression/index.shtml
A Sample Answer 8 For the Assignment: NURS 6521 Week 5: Neurological System
Title: NURS 6521 Week 5: Neurological System
Migraine headaches affect approximately in 18.9% of females and nine percent of males with a national prevalence of over 13% and have been documented as the seventh highest cause of disability in the world by the Global Burden of Disease Study of 2010 (Archangelo, Peterson, Wilbur & Reinhold, 2017). Migraines can be mild or severe with throbbing pain with nausea, appetite changes, photophobia, and sensitivity to sound and so many patients have auras that predict an oncoming headache (Archangelo, Peterson, Wilbur & Reinhold, 2017). Triggers for migraine headaches can be food, a colored dye that is put into foods, sleep pattern, hormonal and lifestyle factors with many of the triggers being avoidable and modifiable with a small percentage of nonmodifiable such as hormonal factors, age, and gender (Archangelo, Peterson, Wilbur & Reinhold, 2017). My sister and I have suffered from migraine headaches since we were children and I consider them to be moderate throbbing pain with nausea which resulted in vomiting which helped relieve the symptoms. Our migraines did not require medication, but I have met many migraine sufferers that were entirely disabled by the pain and required pharmacological interventions. The purpose of this post is to discuss pharmacological options to help patients manage the symptoms related to the neurological syndrome and explain how the pharmacological treatment plan would change for pediatric patients including how to deal with adverse effects of some of the medications.
Medications for Migraine Headaches
Treatment options for are based on the severity of pain, how long the migraine attacks last, triggers (especially modifiable), current medications, co-morbidities and associated symptoms such as nausea and vomiting (Archangelo, Peterson, Wilbur, & Reinhold, 2017). The pharmacological goal of therapy for migraine headaches is the prevention of the attack or to relieve the attack without significant side effects that would add different issues for the patient (Archangelo, Peterson, Wilbur & Reinhold, 2017). Short-term treatment goals would be focused on reducing the severity of the attack, the frequency and number of days that the patient has migraine symptoms and finally to prevent nausea and vomiting and long-term goals would include improvement in the quality of life, reduction in disability of the attack and improve the patient’s function, education and having patients be able to manage the disease without exacerbations(Archangelo, Peterson, Wilbur & Reinhold, 2017).
First line treatment plan for mild to moderate attacks would include Acetaminophen and Aspirin with initial doses recommend at 900 mg for Aspirin and 1000 mg for Acetaminophen (Archangelo, Peterson, Wilbur & Reinhold, 2017). According to Vallerand, Sanoski, & Quiring (2019), aspirin can be used for inflammatory disorders, mild to moderate pain, fever, and ischemic attack prophylaxis by inhibiting production of prostaglandins and decreasing platelet aggregation. Aspirin is absorbed in the upper part of the small intestine with a rapid distribution that can cross the placenta and is found in breast milk; it is metabolized by the liver with the kidney excreting inactive metabolites with an onset between 5 to 30 minutes and a peak effect between 1-3 hours (Vallerand, Sanoski, & Quiring, 2019). Bleeding is the primary adverse reaction with this medication and should be used cautiously with patients that have a history of gastrointestinal bleeding or disorders such as ulcers, and severe hepatic disease (Vallerand, Sanoski & Quiring, 2019). The use of medications such as Excedrin Migraine with caffeine is an option, but because this medication can increase the probability of medication overuse headaches, it should be limited to 3 days per month or no more than 48 hours at a time, but this medication also includes acetaminophen and aspirin which would limit how much additional medicines that a patient could take with Excedrin (Archangelo, Peterson, Wilbur & Reinhold, 2017).
The treatment for acute or severe migraines with or without aura would be 5-Ht1 serotonin receptor Agonists or Triptans because they cause cerebral vasoconstriction and aids in pain reduction and treats nausea associated with a migraine (Archangelo, Peterson, Wilbur, & Reinhold, 2017). Triptans are vascular headache suppressants that are used for acute migraine management and also helps with cluster headache episodes by acting as a selective serotonin agonist that acts specific intracranial receptor sites resulting in vasoconstriction in the arteries located in the brain (Vallerand, Sanoski, & Quiring, 2019). Subcutaneous administration is well absorbed, but oral administration absorption undergoes substantial hepatic metabolism resulting in very low bioavailability; the medication is mostly metabolized by the liver with onset orally within 30 minutes and a peak between 2-4 hours and usually lasts over 24 hours whereas subcutaneous administration has onset within 30 minutes with a peak up to 2 hours and also lasts about 24 hours (Vallerand, Sanoski, & Quiring, 2019). This medication should not be taken more than nine days per month and should not be used in conjunction with other vasoconstricting medicines and should be used with caution in patients with coronary artery disease, cerebrovascular disease or severe peripheral vascular disease (Archangelo, Peterson, Wilbur & Reinhold, 2017).
Pediatric Migraine Medication Options
Migraine headaches affect children, as well as adults but these headaches, present differently in pediatric patients with the prevalence being higher in boys than girls prior to puberty and the pain is similar with throbbing and aching but is located bilaterally either bifrontal or bitemporal usually lasting between one to three hours (Archangelo, Peterson, Wilbur & Reinhold, 2017). Treatment options for mild or moderate migraines are the same as adults including nonsteroidal anti-inflammatory or acetaminophen, but most triptans are FDA approved for adults only except for almotriptan that is recommended for pediatric patients that are 12 years or older and rizatriptan that has been recommended for children six years and older (Harding & Clark, 2014). The most important treatment option for children would be eliminating exposure to triggers, promoting sleep hygiene, avoiding caffeine and dietary modifications but pediatric patients might also need preventative medications such as antihistamines, gabapentin, beta blockers and topiramate (Harding & Clark, 2014). Topiramate is the only medication that is FDA-approved for treatment of migraines for pediatric patients but the other drugs can be used but must be approved by a physician and monitored by the patient’s parents (Harding & Clark, 2014). Sedation and dizziness are common side effects and taking the medication at night might help the patient maintain an appropriate sleeping pattern and also allows for metabolism of the medication. Koch & Oakley (2018) recommend a 4 tier system for the management of pediatric migraines that includes lifestyle modifications in the first tier, integrative therapies such as biofeedback and herbal supplements for the second tier, pharmacological treatment for the third tier including acute and preventative treatments and other treatments for the fourth tier that includes nerve blocks and implanted devices to help manage the migraine symptoms.
References
Archangelo, V.P., Peterson, A.M., Wilbur, V & Reinhold, J.A. (Eds.).
(2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins
Harding, A., & Clark, L. (2014). Pediatric migraine: common, yet treatable. The
Nurse Practitioner, 39(11), 22–31. https://doi-org.ezp.waldenulibrary.org/10.1097/01.NPR.0000454980.88918.f0
Koch, T., & Oakley, C. B. (2018). Pediatric migraine: Diagnostic criteria
and treatment. Contemporary Pediatrics, 35(6), 22–30. Retrieved from https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=130143173&site=eds-live&scope=site
Vallerand, A. H., Sanoski, C. A., & Quiring, C. (2019). Daviss drug guide for
nurses
A Sample Answer For the Assignment: NURS 6521 Week 5: Neurological System
Title: NURS 6521 Week 5: Neurological System
Sleep Disorders
Individuals seeking help from clinicians for sleep disorders is very common. However, it is vital for clinicians to get a thorough history from the patient so they can figure out if it is a primary or secondary sleep disorder to assist them in finding the appropriate treatment plan. Primary sleep disorders are caused by an internal origin of the sleep-wake generating or timing mechanisms while secondary sleep disorders are caused by an underlying medical condition such as anxiety or depression (Lubit, 2015). Persistent trouble falling asleep or staying asleep may be described as insomnia. More importantly, it is critical for providers to rule out physiologic causes before attributing insomnia as psychological (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Furthermore, primary sleep disorders can be divided into two classes: parasomnias or dyssomnias. Parasomnias are unusual behaviors or experiences that happen during sleep such as sleep terror disorders, sleepwalking, and nightmare disorders. Dyssomnias are characterized by abnormalities in the amount, quality, or timing of sleep which include breathing-related sleep disorders, primary insomnia and hypersomnia, narcolepsy, and circadian rhythm sleep disorders (Lubit, 2015).
Pharmacological Treatments for Sleep Disorders
To help select an appropriate pharmacological drug, some factors must first be considered such as the individual’s symptom pattern, treatment goals, past treatment responses, patient preference, cost, medication interactions, and side effects (Arcangelo et al., 2017). A short-term drug therapy is preferred in restoring a normal sleep pattern in insomnia. In general, hypnotic including benzodiazepines are approved for 2 weeks or less of continuous use. However, in chronic insomnia, longer uses of hypnotic drugs may be indicated but will require long-term supervision to ensure continuous appropriate use of the medication (Lubit, 2015). Other medications used to treat insomnia are benzodiazepine receptor agonist (BRZA), first-generation antihistamines, and anti-depressants (Arcangelo et al., 2017).
Benzodiazepines
A benzodiazepine (BZP) such as alprazolam may be indicated. While alprazolam depresses subcortical levels of the central nervous system, its exact mechanism is unknown. It is used in anxiety and panic disorders; however, it may be used short-term for insomnia. It is administered orally and widely distributed with an onset of 30 minutes. Alprazolam is metabolized by the liver and excreted by the kidneys. Common adverse effects include dizziness, drowsiness, orthostatic hypotension, with life-threatening adverse effects of suicidal thoughts, angioedema, tachycardia and electrocardiogram (ECG) changes (Skidmore-Roth, 2018).
Benzodiazepine receptor agonist (BRZA)
Zolpidem tartrate is a BRZA and is also used for short-term treatment of insomnia. Zolpidem shares some of the pharmacological properties of BZPs, however, it is a hypnotic agent with a chemical structure unrelated to BZPs, barbiturates, or other drugs with known hypnotic properties. Specifically, zolpidem favorably binds to BZ1 receptors. It is administered by mouth in tablet form and quickly absorbed from the gastrointestinal tract. Zolpidem tartrate is metabolized by the liver and excreted as an inactive metabolite by the kidneys. It has a half-life of approximately 2.5 hours. Most common side effects are drowsiness, dizziness, diarrhea, grogginess or feeling as if you have been drugged (Drugs.com, 2017).
First-generation antihistamines
An example of a commonly used first-generation antihistamine is diphenhydramine. Diphenhydramine competes with histamine for H1-receptor sites and may be used for allergies, rhinitis, motion sickness and nighttime sedation. It is taken orally in forms of capsules, liquid, or tablets and should not be given to those under two years old. Diphenhydramine is metabolized in the liver, excreted in urine with a half-life of 2-4 hours. General side effects are dizziness, drowsiness, urinary retention with life-threatening side effects of thrombocytopenia, seizures, and anaphylaxis (Skidmore-Roth, 2018).
Antidepressants
Mirtazapine is an antidepressant that may be used to treat insomnia only in patients with coexisting depression. Mirtazapine is a potent antagonist of histamine receptors, which may explain its well-known sedative effects. Mirtazapine comes in tablets are rapidly and completely absorbed after oral administration with peak plasma concentrations reached in about 2 hours. It is metabolized by the liver and excreted via urine and feces. The most common adverse side effects are sleepiness, constipation, increased appetite, dizziness, weight gain, dry mouth, and abnormal dreams. When mirtazapine is taken with other antidepressants, serious side effects include worsening depression and suicidal thoughts (RxList, n.d.).
Patient Factor That May Impact the Effects of Medications for Sleep Disorders
A patient factor that must be taken into consideration when prescribing medications for sleep disorders is female gender as pharmacokinetic differences have been demonstrated in select BRZA in women (Arcangelo et al., 2017). For example, women clear zolpidem tartrate from the body at a lower rate than men, therefore, the recommended initial dose of zolpidem tartrate tablets for adult women is 5 mg, and the recommended dose for adult men is 5 or 10 mg (Drugs.com, 2017). In females of all ages, mirtazapine has been noted to exhibit significantly longer elimination half-lives than in males (RxList, n.d.).
References
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Drugs.com. (2017). Zolpidem. Retrieved from https://www.drugs.com/pro/zolpidem.html
Lubit, R. H. (2015). Sleep disorders. Retrieved December 26, 2018, from Medscape.
RxList. (n.d.). Remeron. Retrieved from https://www.rxlist.com/remeron-drug.htm#description
Skidmore-Roth, L. (2018). Mosby’s 2018 nursing drug reference (31st ed.). St. Louis, MO: Elsevier.