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Psycho pharmacology
- 2. Psychopharmacology is the branch of pharmacology that deals with the study of the actions, effects, and development of psychoactive drugs. In its broadest sense it means the study of all pharmacological agents that affect mental and emotional functions. Specifically to the study and synthesis of drugs used in the control of psychiatric illnesses,
- 4. The mentally ill in early communities were generally cared for by family members, however, in severe cases they sometimes ended up in almshouses or jails. Because mental illness was generally thought to be caused by a moral or spiritual failing, punishment and shame were often handed down to the mentally ill and sometimes their families as well. The Treatment of Psychiatry disorders in the past has often constituted of merely institutionalisation (i.e administration in ansylym or mental hospital) with the advent of psychopharmacology in the 6th decade has brought treatment of Psychiatric disorder within the realm of scientific medicine
- 5. Antipsychotics Antidepressants Mood stabilizing drugs Anti anxiety and hypno-sedatives Anti epileptics Alcohol and drug dependence Antiparkinsonians Miscellaneous drugs-(e.g Stimulants , drug used in treatment of eating disorder, alcohol dependence, anaesthetic,dementia,drugs used for child psychiatry, vitamines calcium channel blocker and other drugs)
- 7. OD PD (mg/dl) (mg) Sedatio Hypote n n-sion EPSE Wt.gain Increas e prolact in Chlorpromazi ne 3001000 50-100 +++ +++ + ++ ++ Triflupromazi ne 100-400 30-60 ++ ++ ++ ++ ++ 100-400 ______ ++ + + ++ + +++ ++ + ++ + Drug I.Phenothiaz ines A. Aliphatic B. Piperidines Mesoridazine Thioridazine 300-600 ______
- 9. Drug OD (mg/dl) PD (mg) Sedatio n Hypote n-sion EPSE Wt. gain Increas e prolacti n 25-75 +++ ++ ++ ++ ++ Thioxanthines A.Aliphatics 1.Chlorpromazin 75-600 e B. Piperazines 1.Flupentixol 3-18 _____ + + ++ ++ ++ 2.Thiothixene 6-60 2-6 IM + ++ ++ ++ ++ 3.Zuclopenthixo l 25-150 50-600 IM ++ ++ ++ ++ ++
- 10. OD (mg/dl) PD (mg) Sedatio n Hypoten EPSE -sion Wt. gain Increase prolacti n 1.Haloperidol 5-30 5-10 IM + + +++ + +++ 2.Trifluperidol 0.5-8 2.5-5 IM +/- +/- +++ + ++ 1.Penfluridol 20-60 mg/w ____ + + ++ + ++ 2.Pimozides 4-20 ____ + + ++ + +++ 50-225 ______ ++ 0 + +/- +/- 25-250 _____ ++ ++ ++ + +++ Drug III.Butyropheno ne IV.Diphenylbutylpiperidines V. Indolic Derivatives 1.Molindone VI.Dibenzopine 1.Lorxapine
- 13. Hypoten -sion EPSE Wt.gain Increas ++ +/- 0 ++ 0 _____ 0 0 0 +/- 0 20 _____ 0 0 0 +/- 0 75-300 ______ ++ +/- + ++ ++ OD (mg/dl) PD (mg) Sedation 150-750 ____ 1.Aripiprazole 5-30 2. Bifeprunox Drug e prolacti n E.Dibezodiaze pine Quetiapine F. Partial Agonist G.Dibenzothi epin 1.Zotepine
- 15. The estimates of the common side effect in the table mention are roughly given and is an empirical guideline to the clinical use. The dosage can be change as per the requirement of the patient, clinical symptoms and severity. EPSE=Extra Pyramidal Side Effect ** 0=Absent, +/- = Probable/Very little + = Mild, ++ =Moderate, +++ = Severe
- 16. The exact mechanism of action of antipsychotic is unknown however one of the major mechanism appears to be anti-dopaminergic activity of these drugs Block D2-receptor which are mainly present in mesolimbic-mesocortical system (concern with emotion) nigo-striatal system & tubero-infundibulum system Extra Pyramidal side effect (EPSE) are cause due to blockade in mesolimbic system, & hyperprolactinemia cause by blockade in tubero-infundibular system. Sedation is caused by histaminergic blockade which are usually highest for drugs such as Chlorpromazine and thioridazine.
- 17. Atypical or 2nd generation Antipsychotic has action only on mesolimbic system but has no eefect on nigro-striatal or tubero-infundibular system. The SGAs and clude Risperidone,Quetiapine,Olanzapine, Amisulpride,Papiperidone,Zointepine,Ziprasidone and Aripiprazole. so it reduce s/e such as Extapyrimidal s/e (EPSE)and hyperprolatinemia s/e It mainly act on D4 & 5-HT2 receptor and has weak D2 antagonism less incidence of tardive dyskinesia & Neuroleptic Malignant syndrome.
- 18. Organic Psychotic disorder Non organic Psychotic disorder Delirium Schizophrenia Schizo-Effective disorder Drug induce psychosis Acute psychoses Other: Organic hallucination 1.Mania 2.Bipolar Organic delusion disorder Major Depression Secondary mania Delusional disorder Medical Disorder Severe, intractable & disabling anxiety Dementia Neurotic & other psychiatric Disorder Hungtington Chorea Rx refractory OCD Intractable hiccup Anorexia Nervousa Nausea & Vomiting Tic disorder e.g Gilles de la tourette syndrom
- 19. Autonomic Side effects Dry Mouth, Constipation, Cycloplegia,Mydriasis, Urinary Retention Central Anti Cholinergic Syndrome (Delirium) Impotence, Impaired Ejaculation. Extra Pyrimidal Side Effects Parkinsonian Syndrome (esp tremor), Akanthisia (Motor restlessness), Acute Dystonia, Rabbit Syndrome (Peri oral tremor), Tardive Dyskinesia (late onset oro-facial dyskinesia), Neuroleptic Malignant Syndrome(Fever,EPS,High CPK catotonic symptom and autonomic dysfunction)
- 20. Other Central Nervous System Side Effects Seizure, Sedation Depression or Pseudo depression Metabolic And Endocrine side effects Weight Agin,Diabetes, Galactorrhea with/without Amenorrhea Allergic Side effect: Cholestatic Jaundice, Agranulocytosis
- 21. Cardiac Side effect EKG Changes (e.g QTc Prolongation) Ocular Side Effect Granular side effect not know in cornea and lens,Pigmentatary retinopathy resembling retinitis pigmentosa. Dermatological side effect: Contact dermatitis, Photosensitivities reaction, Bleu-ray metallic Discoloration
- 22. ANTIDEPRESSANT DRUG Drug use to treat depressive disorder Also know as Mood elevator and thymoleptic
- 23. Sedation Orthostatic hypotension Anticholiner gic 1.Amitriptylline 75-300 +++ +++ +++ 2.Clomipramin e 75-250 ++ ++ ++ 3.Dosulepin 75-300 +++ +++ ++ 4. Doxepine 75-300 +++ +++ + 5.Imipramine 75-300 ++ ++ ++ 6.lofepramine 70-210 + + + 7.TriImipramine 75-300 +++ ++ ++ Drugs Oral dose Tricyclic Tertiary amines
- 24. Oral dose Sedation Orthostatic hypotension Anticholiner gic 1.Desipramine 75-300 +/- + ++ 2.Nortriptyline 75-200 + ++ + 3.Protriptyline 15-60 0 ++ ++ 1.Amoxapine 150-400 + + ++ 2.Maprotiline 75-225 ++ ++ ++ 3..Mianserin 30-120 +++ +/- +/- 100-300 +/- +/- +/- Drugs B Ticyclic 2nd Amine C. Tricyclic Antidepressant D.Bicyclic Antidepressant 1.Viloxazine
- 25. Oral dose Sedation Orthostatic hypotension Anticholinergi c 1.Citalopram 20-40 +/- +/- 0 2.Estitalolopra m 10-20 +/- +/- 0 3.Fluoxamine 20-60 +/- 0 0 4.Fluvoxamine 50-300 +/- +/- +/- 5.Paroxetine 20-40 +/- 0 +/- 6.Setraline 50-200 +/- 0 Drugs II. SSRI IV SNRIs 1.Duloxetine 60 +/- +/- +/- 2.Venlafaxine 50-200 +/- +/- +/-
- 27. Drugs Oral dose Sedation Orthostatic hypotension AntiCh +/- +/- +/- VIII.NARI 1.Reboxetine IX.MAOIs A.Reversible Selective MAO-B Inhibitor 1.Selegiline 5-10 Use in Parkinsonis m 300-600 Activating 0 0 20-50 + 0 0 B.Reversible Selective MAOA inhibitor(RIMAs) 1.Meclobemide X.Melatonin Receptor agonist & 5-HT2c antagonist 1.Alomelatin
- 28. It increase catecholamine levels in brain TCA: 1. Blocking the reuptake of norepinephrine,serotonine and/or Dopamine at the nerve terminal thus increase NE,5-HT and/or DA level at the reactor site 2. Down regulation of Beta adenergic receptor
- 29. Depression: Depressive Episode (also called Major depression,endogenous depression) Depressive episode with melancholia (with or without ECTs) Depressive Episode with Psychotic feature (with antipsychotic or ECTs) Dysthymia (with Psychotherapy)
- 30. Reactive depression (with Psychotherapy) Depressive equivalent and masked depression Atypical Depression Secondary Depression (e.g in Hypothyroidism, cushing Syndrome) Abnormal Grief Reaction
- 31. Enuresis Attention Deficit disorder with Hyperactivity School Phobia Separation anxiety disorder Somnambulism Night tremor
- 32. Panic Attack Borderline Personality Agoraphobia Disorder Trichotillomania Depersonalisation syndrome Post traumatic stress syndrome Generalise Anxiety Disorder Narcotic dependence Alcohol Dependence Obsessive compulsive disorder with or without depression Cataplexy (associated with narcolepsy) Aggression in Elderly Eating Disorder
- 33. Chronic Pain Migraine
- 35. These drug are usually effective in treatment of mania Therefore the words Antimania is often use to describe them. Effective in preventing Mood swing in Bipolar Disorder These Drug include Lithium , Valproate , Carabamazepine and Lamotrigine
- 37. INDICATION: Rx of Acute Mania Prophylais of Bipolar mood Disorder Rx of Schizo -effective disorder Prophylaxis of Unipolar mood disorder Rx of cyclothymia Rx Of Acute Depression Rx Acute Alcoholism Rx of Impulsive Aggression
- 38. It effect the Na+ K+ ATPase and accumulates intracellularly as substitute of Na+ It inhibit the adenyle Cyclase and thus decrease cAMP (II Messenger) intracellularly It accelarate the presynaptic reuptake and destruction of catecholamine,like norepinephrine It inhibit the release of the catecholamine in synapse It decrease the post synaptic serotonin 5-HT2 receptor sensitivity It stabilizes the membrane, along with Ca++ and Mg++ It decreases the Ca++ mobilisation from the intracellular pools by ITP(inositol-triphophate)- dependent Ca++ channels (II Messenger system)
- 39. Lithium Carbonate (300mg tablets;400mg sustained release tablet) Lithium citrate (300MG/5ML liqiud) Before starting treatment,it is essential to ensure normal functioning of kidney, thyroid, heart and CNS
- 40. Routine and general systemic physical examination Routine blood count(Hb,TC,DC) Urine:R/E and Microscopic ECG RFT (blood urea,serum creatinine)24hours urine volume, urine specific gravity). TFT (T3,T4,TSH)
- 41. Doses: Initial starting dose for lithium is 900-1200mg/dl given in 1-3 doses. During Rx it is essential to estimate blood level of lithium Therapeutic levels=0.6-1.2 mEq/L (for Rx of Acute Mania) Prophylactic levels=0.6-1.0 mEq/L (for relapse prevention in Bipolar) Toxic lithium levels >2.0mEq/L When stopping lithium Rx it is essential to taper the dose over several days / weeks in order to minimise the risk of relapse on discontinuation
- 42. Side effects:Lithium I. Neurologic: Tremor, Muscular weakness,Cogwheel rigidity,Seizure,Neurotoxicity(Delirium,cerebellar sign,abnormal involuntary movement seizure & later coma) II.Renal: Polyuria, polydipsia, Tubular changes,Nephrogenic diabetes insipidus, Nephrotic syndrome III. Cardiovascular: similar to those of Hypokalemia (T-wave depression) IV. Endocrine Goitre,Hypothyroidism,Wt.Gain,Abnormal TFT V.Gastrointestinal: Nausea,Vomiting,Diarrhoea,metallic taste, and abdominal pain VI.Dermatological: Acneiform eruption, Papular eruption and exacerbation of Psoriasis VII. S/E during pregnancy: Teratogenic,Ebstein anomaly,secretion in milk 30-100 % of maternal Lithium level therefore cause toxicity in Infant
- 44. Valproate Dosage- 1000-3000mg/day oral dose in divided dose Therapautic blood level is 50-125mg/ml
- 45. Bipolar Disorder Neurological Disorder- Migraine and pain Syndrome,Trigeminal Neuralgia, and Neuropathic pain,Seizure(Absence seizure,complex partial seizure,myoclonic seizures and generalise tonic clonic seizure) Other: Behavoural agitation in dementia,severe symptom in mental retardation,ADHD and conduction disorder,Schizoaffective disorder (bipolar type),alcohol withdrawal,tadive dyskinesia,impulse control disorder,panic disorder and borderline personality disorder.
- 46. Side effect: Valproate Adverse effect is more common with valproate concentration above 100mg/dl Common side effect are nausea , sedation , tremor, flushing, weight gain thrombocytopenia , menstrual disturbance, n hair loss Other most serious, though relatively uncommon include Hepatic toxicity , Acute hemorrhagic pancreatitis and Steven-Johnson Syndrome.
- 49. SEIZURES Complex partial seizure (CPS) Generalised tonic clonic seizures Alcohol withdrawal seizures (rum fits) PSYCHIATRIC DISORDERS: Bipolar mood disorder Impulse control disorder and aggression Psychosis with epilepsy Borderline personality disorder Cocaine withdrawal syndrome PAROXYSMAL PAIN SYNDROME Trigeminal neuralgia Phantom limb pain
- 50. Diplopia,drowsiness,dizziness,nausea,vomiting ataxia, Skin rash, Steven-johnson syndrome(erythema multiforme major),photophobia, cholestatic jaudice ,acute oliguria with hypertension,leucopenia and thrombocytopenia purpura. The most dangerous side effect include bone marrow depression (causing aplastic anemia) agranulocytosis and cardiovascular collapse.
- 52. WHAT IS ANXIETY?? It is an emotional state, unpleasant in nature, associated with uneasiness, discomfort and concern or fear about some re -defined or undefined future threat. Anxiety is being in a state of stress, which is brought upon by many stressors.
- 53. It is the normal human response. Anxiety is regarded as a disorder only when it occurs in the absence of appreciable degree, or kind, of threat or danger.
- 54. CLINICAL PRESENTATIONS Palpitations. Chest pain. Breathlessness. Sweating, chills, nausea. Trembling, fear of dying or losing control. Numbness, feeling of detachment.
- 56. BENZODIAZEPINES Mode of action Modulates the gamma-amino butyric acid(GABA),the main inhibitory neuro- transmitter of CNS,by influencing the GABAa receptor complex.
- 57. The GABAa receptor complex includes binding sites for BZD,barbiturates and steroids. the chlorine ion channel is controlled by the GABA binding site.When the neuro transmitter GABA binds with the receptor it triggers a conformational change in the pore, allowing more chlorine to enter the cell. Resulting in hyperpolarisation of cell membrane, increasing the firing threshold and producing an inhibition of action potential firing. Upon binding,BZDs lock the GABAa receptor into a conformation that increases the binding of GABA. Increased GABA binding increases the frequency of opening the chlorine channel and amplifying the inhibitory effect.
- 58. Class of drug Eliminatio n T1/2 (hr) Oral Dosage Mg/day Very short acting 1.Triazolam 2-5 0.125-0.25 2.Midazolam Parenter al dose (mg) Active Comment metabol s ites α-hydroxy triazolam. 2-5 Short acting 1.Oxazepam 5-15 15-120 2.Lorazepam 10-20 2-6 3.Temazepa m 4.Alprazolam 5.Estazolam 10-20 15-30 6-20 0.5-6 8-24 1-2 Rapid oral absorption, marked as hypnotic, used as anesthesia 1-2 iv or im Oxazepa m α-hyroxy alprazola m Slow oral absorption, high dependenc e potential
- 59. Class of drug Eliminatio n T1/2 (hr) Oral Dosage Mg/day Parenteral dose (mg) Active Comment metabolite s s 50-100 iv slowly 2-20 iv or im Desmethyldemoxypam Long acting 1.Chlordiaze poxide 2.Diazepam 25-48 15 -100 14-90 2 – 60 3.Flurazepa m 4.Chlorazep ate 5.Nitrazepa m 6.Prazepam 30-100 15-60 Desmethyhydroxy-ethylflurazepam 30-100 7.5-60 Nordiazeapam Nordiazepam 20-60 5-20 30-60 20-60 7.Halazepa m 8.Clonazepa m 9.Quazepa m 30-60 Nordiazepam, diazepam Nordiazepam 40-160 2-5 im 20-40 0.5-20 40-160 7.5-15 Nordiazepam Erratically absorbed after IM injection, Marked as hypotic, Hydrolyzed to active form in stomach Marked as hypnotic Slow oral absorption Also used in mania .probably selective for BZD receptor l and may cause less cognitive and motor disturbances
- 60. INDICATIONS OF ANTI-ANXIETY DRUGS Triazolam and midazolam:- For Generalized anxiety, panic attacks. Oxazepam,Lorazepam,Temazepam,Alprazolam, Estazolam—For Insomnia,nightmares,muscle relaxation, drug withdrawal, acute mania attacks Chlordiazepoxide,Diazepam,Flurazepam,Chlorazep ate,Nitrazepam,Prazepam,Halazepam,Clonazepam ,Quazepam—For Minor surgery, acute psychosis,narcoanalysis,anti convulsant,somnambulism,agitation depression attacks.
- 61. AZAPIRONES Class of drug Elimination T½ Dose Mode of action Adverse effects Buspirone 2-3.5 hrs 15-30mg/day 5-HT1a partial agonist and a selective DA autoreceptor antagonist Dizziness.hea dache,lighthe adedness and diarrhoea. Gepirone Ispapirone
- 62. SEDATIVE ANTIHISTAMINES Mode of action Selective anxiolytic action with sedation. Seldom used nowadays. Diphenhydramine, Hydroxyzine and Promithazine.
- 63. ΒETA-BLOCKERS Example is propranolol effective in peripheral manifestations of anxiety. C/I in asthmatics and cardiac conditions. Dose is 40-240mg/day.
- 64. NEWER DRUGS Buspirone-non BZD anti-anxiety drug. its is a 5-HT1a partial agonist and a selective DA auto-receptor antagonist. also inhibits the auto-firing of neurons. It does not seem to act on BZD receptor. It is anxio-selective with no sedative action, and no anti-anticonvulsant or muscle relaxant properties. Dose is 15-30mg/day, in a thrice daily schedule due to short half-life.not useful in t/t of panic disorders.
- 65. Zopiclone—belongs to a new class of group, the cyclopyrrolone.They act on GABA receptors but at a site different from that of BZDs.Has a short duration of action as well as shorter onset.Elemination t½ is 4-6hrs. Usual dose is 3.75-7.5 mg at bed time. Side effects include bitter taste, dry mouth,drowsiness,nausea and headache Clinically superior to BZDs in subjective awakening quality, well being and attention span in morning.
- 66. Zolpidem—it is an imidazopyridine derivative which is marketed as a hypnotic. It is administered in a dose of 5-10 mg for hypnotic use. It has a half life of 2-3 hrs; therefore it is useful in treatment of difficulty in initiation of sleep(initial insomnia). Side effects include drowsiness,dizziness,headache,depression,nausea ,dry mouth and myalgia. It should not be used for more than two weeks at one time. Safety in children, in pregnancy and lactation is not proven.
- 67. Zolpelon-it is a pyrazolo-pyrimidine derivative, marked as a hypnotic. It acts on omega-1 benzodiazepine receptor located on the alpha sub-unit of the GABA-A receptor complex, with a very little effect on omega-2 and omega-3 receptors. Given in a dose of 5-10 mg for hypnotic use.T½ being of 1 hr with a rapid onset of effect. Side effects include headache,drowsiness,dizziness,nausea and myalgia.It should not be used for more than 2 weeks at one time.
- 68. Other drugs—these include suriclone(a cyclopyrrolone derivative; a hypnotic), bretazenil and imidazenil(partial benzodiazepine agonists; anxiolytic without sedation; rapid onset of action),abecarnil(β-carboline partial agonist at benzodiazepine receptor; anxiolytic and anticonvulsant),tiagabine,riluzole,and alpidem(anxiolytic). Pregabalin is licensed for treatment of anxiety in some countries. Cognitive behavior therapy with or without medication is helpful in treatment of several anxiety disorders.
- 69. ANTI-EPILEPTICS
- 70. WHAT IS EPILEPSY It is a brief recurrent disorder of cerebral function that is usually associated with disturbance of consciousness and accompanied by a sudden, excessive electrical discharge of cerebral neurons.
- 73. Class of drug Eliminat Dose ion T½ Phenobarb 80- 120 itone hrs 60- 180 mg /day Primidone 250-500mg BD 6-14 hrs Phenytoin 12-24 hrs 200-400 mg/day as single dose. Indications Mode of action Adverse effects Primary generalized tonic clonic,partia l seizures. GABAa receptor mediated synaptic inhibition Hangover Idiosyncrasy Hypersensitivit y Dependence. Generalized T-C,simple and complex partial, status epilepticus,t rigeminal neuralgia Prolongatio n of sodium channel inactivation . Gum hypertrophy Hirsutism Hypersensitivit y Megaloblastic anemia Osteomalacia Hyperglycemia
- 74. Class of drug Eliminati on T½ Dose Indications Mode of action Adverse effects Carbamaze pine 20-40hrs 6001800mg/day in 2-3 divided doses Primary generalized tonic clonic,partia l seizures. Prolongati on of sodium channel inactivatio n. Sedation,dizz iness,vertigo, diplopia,ataxi a. Ethosuximi de 48 hrs 7501250mg/day as single dose Absence seizures Inhibition of T type calcium current G-I intolerance, Mood changes,hea dache,drowsi ness.
- 75. Class of drug Eliminati Dose on T½ Indications Mode of action Adverse effects Valproic acid 10-15 hrs 4003000mg /day in 2-3 divided doses Absence seizures,GTCS ,SPS and CPS Prolongation of Na channel inactivation. Attenuation of Ca mediated T current. Rise in serum transaminas e,alopecia,c urling of hair,inc. blood ammonia,ful minant hepatitis Clonazepa 24 hrs m 1-12 mg/day 1060mg/d ay 0.20.5mg/k g Myoclonic szrs Facilitation of GABA mediated Cl channel opening. Sedation,dul lness Thrombophl ebitis,respira tory depression, fall in BP. Clobazam 35 hrs Diazepam 30-60 hrs GTCS,SPS,CP S Insomnia,anxiet y,night b4 surgery
- 76. Class of drug Elimin ation T½ Dose Indication s Mode of action Adverse effects Lamotrigine 24hrs 50mgday- Add on 300mg/da therapy in y refractory partial and GTCS Modifies maximal electroshock and decreases electrically evoked afterdischarge duration. Sleeplessn ess,dizzine ss,diplopia, ataxia and vomiting Gabapentin 6-8 hrs 300mg/da Absence y seizures,G TCS,SPS and CPS Enhances GABA release and inhibits PTZ induced clonic seizures. Mild sedation,tir deness,dizz iness and unsteadine ss
- 78. WHAT IS DEPENDENCE?? According to ICD-10 the dependence syndrome is a cluster of physiological , behavioral and cognitive phenomena in which the use of a substance or a class takes much higher priority for a given individual than other behaviors that once had great value.
- 79. PSYCHOACTIVE SUBSTANCE ABUSE Drug Route of administration Physical Psychic dependen dependenc ce e Tolerance Alcohol Oral ++ ++ + Opioids Oral,IV,smoking +++ +++ +++ +,-- ++ + Cocaine Inhalation,oral,sm +,-oking parental ++ Ampheta mines Oral,parentral ++ Cannabis Smoking,oral (Marihuan a) ++ +++
- 80. Drug Route of Physical administrat dependenc ion e Psychic dependenc e Tolerance Lysergic acid diethyl amide(LSD) Oral + + Barbiturates Oral,parentr al ++ ++ +++ Benzodiazepines Oral,parentr al + + + Volatile solvents Inhalation +,- ++ + Phencyclidine (PCP) Smoking,inh +,alation,pare ntral,oral + + Caffeine Oral + ++ + Nicotine Oral,smokin g + ++ +
- 81. TREATMENT Addiction is a complex but treatable disease that affects brain function and behavior. No single treatment is appropriate for everyone. Treatment needs to be readily available. Remaining in treatment for an adequate period of time is critical.
- 83. DETOXIFICATION Symptoms produced by the removal of the toxin(alcohol). The aim of detoxification is symptomatic management of emergent withdrawal symptoms. Drug of choice are usually benzodiazepines. Chlordiazepoxide(80-200mg/day) Diazepam (40-80mg/day)
- 84. TREATMENT Behavior therapy-aversion therapy, using either a sub-threshold electric shock or an emetic such as apomorphine. Other methods like(covert sensatisation,relaxation techniques, assertiveness training, self control training and positive reinforcement) has been used along with aversion therapy. Considered unethical in treatment of alcohol dependence.
- 85. Psycho-therapy—both group and individual. patient is educated about the risks of continuing alcohol use. Motivational enhancement therapy with or without cognitive behaviour therapy and life style modification.
- 86. The deterrent agents—disulfiram(tetraethyl thiuram disulfide) When alcoholics ingested by a person who is on disulfiram,alcohol-derived acetaldehyde cannot be oxidised to acetate and this leads to accumulation of acetaldehyde in blood. This causes the disulfiram ethanol reaction(DER) characterized by
- 87. flushing,tachycardia,hypotension,tachypnoe a,palpitation,headache,sweating,nausea,vo miting,giddiness and a sense of impending doom. Onset of reaction occurs within 30minutes becomes full blown within 1 hr and subsides within 2 hrs of ingestion of alcohol. The usual dose is 250-500mg/day.
- 88. Parkinsonism
- 89. WHAT IS PARKINSONISM?? Extrapyramidal motor disorder characterized by rigidity, tremor and hypokynesia with secondary manifestations like defective posture and gait, mask like face sialorrhoea,dementia may accompany.
- 91. ANTI-PARKINSONISM'S Drugs affecting brain dopaminergic system Dopamine precursorLevodopa(L-dopa). Peripheral decarboxylase inhibitor-carbidopa,benserazide. Dopaminergic agonistbromocriptine,pergolide,piribedil,r opinirole,pramipexole
- 92. MAO-B inhibitors-Selegiline COMT inhibitorsentacapone,tolcapone Dopamine facilitatorAmantadine.
- 93. DRUGS AFFECTING BRAIN CHOLINERGIC SYSTEM Central anticholinergicstrihexyphenidyl(benhexol),proc yclidine,biperidine. Anti-histaminicsorphanadrine,promithazine.
- 94. LEVODOPA (L-DOPA) Mode Orally of action- administered L-dopa after absorption crosses blood brain barrier and gets metabolized to dopamine. Dopamine cannot cross BBB so,a peripheral decarboxylase inhibitor is given such as carbidopa or benserazide.
- 96. DOSAGE AND T1/2 Started with a low dose of 50mg/dose. Full therapeutic effect may take 4-8 weeks. Maximum dose is 8001000mg/day. Plasma t1/2 of levodopa is 1-2 hrs.
- 97. ADVERSE EFFECTS At initiation of therapynausea,vomiting,postural hypotension, cardiac arrhythmias, exacerbation of angina, alteration of taste sensation. After prolonged therapy-abnormal movements, fluctuation in motor performance.
- 98. PERIPHERAL DECARBOXYLASE INHIBITORS Carbidopa and benserazide are given along with levodopa to increase the t1/2 in periphery and make more of it available to cross BBB and to reach its site of action. Maintenance dose is 0.4-0.8g of levodopa with 75-100mg carbidopa or 100-200mg of benserazide given in 3-4 divided doses.
- 99. DEMENTIA
- 100. WHAT IS DEMENTIA?? Refers to acquired global impairment of intellect, memory and personality(cognitive function) in the absence of gross clouding of consciousness or motor involvement.
- 102. COGNITION ENHANCERS Nootropic (cognition enhancer)-piracetam Metabolic enhancerdihydroergotoxine(codergocrine),nicergoline ,piribedil Cholinergic activatorstacrine,rivastigmine,donepezil,galantamine Vasoactive cerebral protector-pyritinol(pyrithyoxine) ,ginkgo biloba
- 103. INDICATIONS Senile dementia and confusional states of old age. Mental retardation and learning problems in children. Cerebrovasular accidents-to hasten recovery of neuronal function. To reduce impairment of consciousness following brain surgery, memory impairment after ECT,and central vertigo.
- 104. Class of drug Dose Mode of action Adverse effects Piracetam 0.8-1 g TDS Enhances learning and memory. Facilitates inter hemisphere information transfer. Increased tonic cortical control on subcortical areas. Gastric discomfort,excite ment,insomnia,di zziness and skin rash. Dihydroergotoxin 1-1.5mg TDS e(Codergocrine) Nicergoline 30mg OD Piribedil 50mg OD
- 105. What we have learned so far…
- 106. The drug groups can be chosen according to the pattern and severity of the disorders. Accordingly the dosage of the drugs can be managed. Pyscho-pharmacology is one of the important measures in the management of the mental disorders.
- 107. Thank