This presentation consisits about antimanic agents, its mode of action, indication, contraindication, side-effects and nursing management. It also has details of Carbamazepine and Valporate.

2. ANTIMANIC
AGENTS
PREPARED BY:
Prabita Shrestha

3. Introduction:
Antimanic drug, any drug that
stabilizes mood by controlling
symptoms of mania, the abnormal
psychological state of excitement.
Mania is a severe form of emotional
disturbance in which a person is
progressively and inappropriately
euphoric and simultaneously
hyperactive in speech and locomotor
behavior.
This is often accompanied by
significant insomnia (inability to sleep),
excessive talking, extreme confidence,
and increased appetite

4. Contd…
As the episode builds, the person experiences racing
thoughts, extreme agitation, and incoherence, frequently
replaced with delusions, hallucinations, and paranoia,
and ultimately may become hostile and violent and may
finally collapse.
In some persons, periods of depression and mania
alternate, giving rise to bipolar disorder.

5. Anti-manic agent produce many neurochemical changes
in the area of brain.
These changes may affect norepinephrine and serotonin
in the part of CNS involved in emotions.
It may decrease the nerve impulse resulting in
depression or mania.
Mode of action

6. Treatment of acute mania
Prophylaxis of bipolar disorder
Treatment of schizoaffected disorder
Prophylaxis of unipolar mood disorder
Treatment of cyclothymia
Treatment of acute depression
Treatment of chronic alcoholism
Treatment of impulsive aggression
Indication:

7. Side effects:
Drowsiness
Dizziness
Headache
Dry mouth
Thirsty
Nausea/vomiting
Fine hand tremors
Hypotension
Pulse irregularities

8. Contd…
Arrythmias
Polyuria
Dehydration
Weight gain
Thyroid enlargement

9. Hypersensitivity to drugs
Renal impairment
Cardiovascular problems
Pregnancy and lactation
Severe dehydration
Sodium depletion or receiving diuretics
Brain damage
Contraindication:

10. Cautions:
Elderly people
Thyroid disorders
Diabetes mellitus
Urinary retention
History of seizure disorders

11. Nursing Roles
 Give medicine during or after meal to decrease gastric
irritation.
 Make observe of the side effect.
 Instruct patient to drink 10-12 glasses of water everyday.
 Make intake and output chart to note the kidney
functioning.
 Monitor vital signs on regular basis.
 Monitor skin turgor daily.
 Weekly weight record.
11

12. Contd…
 Emphasize importance of maintaining adequate intake of
sodium.
 Advise patient not to increase or decrease medicine
unless advise.

13. Carbamazepine (tegretol)
Lithium carbonate (eskalith, lithane, lithobid)
Lithium citrate (cibalith-s)
Sodium valporate
Valporate chorono
Commonly used drugs for
treatment of Mania

14. Other Antimanic drugs:

15. Carbamazepine (tegretol)
 Mechanism of action
Carbamazepine is a medication that affects nerves and
brain and works by decreasing impulses in nerves that
cause seizures and pain. It appears to decrease
polysynaptic responses and block post tetanic potentiation.
 Indications:
Bipolar disorder
Seizures
Nerve pain (such as trigeminal neuralgia)
Diabetic neuropathy
Neurogenic pain
Psychotic behavior with dementia

16. Contra-indications:
Hypersensitivity to carbamazepine
Kidney disease
Liver disease
Heart disease
Ever had an allergic reaction to a tricyclic antidepressant
such as Elavil (amitriptyline), Anafranil (clomipramine),
Norpramin (desipramine), Ascendin (amoxapine), Tofranil
(imipramine), or Pamelor (nortriptyline)
taken a monoamine oxidase inhibitor (MAOI) such as
Marplan (isocarboxazid), Parnate (tranylcypromine), or
Nardil (phenelzine) within the past 14 days
Have a bone marrow disease or suppressed bone marrow

17.  Serious Side-Effects:
an allergic reaction such as difficulty breathing, closing of
your throat, swelling of your lips, tongue or face, or hives
liver damage, which can include yellowing of the skin or
eyes, nausea, abdominal pain or discomfort, or severe
fatigue
chest pain, high blood pressure, or congestive heart
failure.
numbness or tingling in the hands, feet, arms, or legs
body or muscle jerks
confusion, slurred speech, or fainting
headache, hallucinations, or depression
unusual bleeding or bruising
rash or mouth sores
fever, swollen glands, or a sore throat

18.  Less Serious Side-Effects:
Nausea
vomiting
diarrhea
constipation
decreased appetite
dry mouth
impotence
joint or muscle aches or pains
blurred vision
 Route:
Oral route
 Available forms:
Tablets—200 mg; chewable tablets—100 mg; ER
tablets—100, 200, 400 mg;
ER capsules—200, 300 mg; suspension—100
mg/5 mL

19.  DOSAGES:
 Adults
Epilepsy: Initial dose of 200 mg PO bid on the first day;
increase gradually by up to 200 mg/day in divided doses
q 6–8 hrs. until best response is achieved.
Trigeminal neuralgia: Initial dose of 100 mg PO bid on
the first day; may increase by up to 200 mg/day, using
100-mg increments q 12 hr as needed.
 Pediatric patients
> 12 yr: Use adult dosage.
6–12 yr: Initial dose is 100 mg PO bid on the first day.
Increase gradually by adding 100 mg/day at 6- to 8-hr
intervals until best response is achieved.
 Geriatric patients
Use caution; drug may cause confusion, agitation.

20.  Pharmacokinetics:
T1/2= 18-65 hours
Metabolized in liver and excreted in urine; feces
 Nursing management:
 ASSESSMENT
• History: Hypersensitivity to carbamazepine; history of bone
marrow depression; history of adverse hematologic reaction
to any drug; glaucoma or increased intraocular pressure;
history of cardiac, hepatic, or renal damage; psychiatric
history; lactation; pregnancy
• Physical: Weight; skin color, lesions; orientation, affect,
reflexes; ophthalmologic exam; T, P, BP, R, auscultation;
bowel sounds, oral mucous membranes; normal urinary
output, voiding pattern; CBC; hepatic function tests,
urinalysis, BUN, thyroid function tests, EEG

21.  INTERVENTIONS
• Use only for classifications listed. Do not use as a
general analgesic. Use only for epileptic seizures that
are refractory to other safer agents.
• Give drug with food to prevent GI upset.
• Arrange for frequent liver function tests; discontinue drug
immediately if hepatic dysfunction occurs.
• Arrange for patient to have CBC, including platelet,
reticulocyte counts, and serum iron determination, before
initiating therapy; repeat weekly for the first 3 mo of
therapy and monthly thereafter for at least 2–3 yr.
• Arrange for frequent eye exams, urinalysis, and BUN
determinations.

22. • Arrange for frequent monitoring of serum levels of
carbamazepine and other antiepileptic drugs given
concomitantly, especially during the first few weeks of
therapy. Adjust dosage on basis of data and clinical
response.
• Counsel women who wish to become pregnant; advise the
use of barrier contraceptives.
 TEACHING POINTS
• Take drug with food as prescribed. Swallow extended-
release tablets whole, do not cut, crush, or chew.
• Do not discontinue this drug abruptly or change dosage,
except on the advice of your physician.

23. • Avoid alcohol, sleep-inducing, or OTC drugs; these could
cause dangerous effects.
• Arrange for frequent checkups, including blood tests, to
monitor your response to this drug. Keep all
appointments for checkups.
• These side effects may occur: drowsiness, dizziness,
blurred vision (avoid driving or performing other tasks
requiring alertness or visual acuity); GI upset (take the
drug with food or milk, eat frequent small meals).
• Report bruising, unusual bleeding, abdominal pain,
yellowing of the skin or eyes, pale feces, darkened urine,
impotence, CNS disturbances, edema, fever, chills, sore
throat, mouth ulcers, rash, pregnancy.

24. • Valproic acid(depakene),sodium valproate(depacon)and
divalpreoex sodium have been used as antiepileptic
agents,and these drugs were approved for treatment of
mania and are considered first line agents
Valproate

25.  Mechanism of action
 Valproate increases levels of ‫-ץ‬amino butyric acid
(gaba)in the brain ,which decreases seizure activity.
 Uses
Manic episodes associated with bipolar disorder
Prophylaxis of migraine
Adjunct for schizophrenia
Tardive dyskinesia
Organic brain syndrome,mania

26.  Doses
• 15mg/kg day
 Contraindications:
o Hypersensitivity to drug
o Liver disease
o Pregnancy
o Renal disease

27.  Side effects
 CNS: sedation, drowsiness, dizziness, depression, coma
 GI: nausea, vomiting, dyspepsia, anorexia,cramps
 Rash, alopecia, dry skin
 Leucopenia, bruising
 Pharmacokinetics
 Metabolized by liver
 Excreted by kidney
 Plasma life life:6-16hour

28.  Nursing consideration
• Assess seizure disorder: location, duration
• Migraine: frequency, intensity, alleviating factors
• Blood studies: RBC, serum folate, serum ammonia, PT
• Blood levels: therapeutic level 50-100mcg/ml
• Respiratory dysfunction: respiratory depression,
character, rate, rhythm

29. REFERENCES:
• Subedi D. Mental Health And Psychiatric Nursing; 2010
Edition; Page No. :295-299
• Neupane N. Shrestha; R. Behavioural Science; 2011
Edition; Page No. : 277-279
• Mosby Drug Book; Page No: 233-235,1199,730-132
• Kapoor B. Psychiatric Nursing; Volume II; Page No. : 72-
73
• Basvantha BT. Essentials Of Mental Health Nursing;
Page No. 170-172

30. Contd….
• http://www.britannica.com/EBchecked/topic/28175/antim
anic-drug
• http://en.wikipedia.org/wiki/Mood_stabilizer
• http://web.squ.edu.om/med-
Lib/MED_CD/E_CDs/Psychiatric%20Nursing%20Care%
20Plans/monographs/carbamazepine.htm