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this is the student post
Hi Professor and class,
A. Select one drug to treat the diagnosis(es) or symptoms. Fluoxetine – this medication seemed to help her when she was taking it for 4 months. She stopped it when she started feeling better. I will ask the patient more details about side effects or if there was another reason she stopped taking the medication.
Fluoxetine should not be used for patients who have bipolar due to possible activation of mania/hypomania in some patients (Your medication information, 2020).
Mood stabilizing agent (MSA) and second‐generation antipsychotic (SGA) – MSAs (lithium, lamotrigine, valproate) and SGAs (quetiapine, lurasidone and cariprazine) are best suited for treating bipolar (Malhi, G. et al., 2020).
For that reason, I will choose Lithium instead of fluoxetine. Pt has high risk for suicide and lithium is known to reduce risk for suicide.
B. List medication class and mechanism of action for the chosen medication. Fluoxetine is a SSRI. It works by boosting serotonin, blocks serotonin reuptake pump, desensitizes serotonin receptors, especially serotonin 1A receptors. Presumably increases serotonergic neurotransmission. Fluoxetine also has antagonist properties at 5HT2C receptors, which could increase norepinephrine and dopamine neurotransmission (Stahl, 2021).
Lithium is a mood stabilizer. How the drug works is unknown and complex. Alters sodium transport across cell membranes in nerve and muscle cells. Alters metabolism of neurotransmitter including catecholamines and serotonin (Stahl, 2021).
C. Write the prescriiption in prescriiption format. (Stahl, 2021).
*Patients name and DOB
Fluoxetine 20mg, by mouth, one a day in the morning
Disp: 14 caps
Pt will have follow-up appt in 2 weeks
Lithium 300mg, by mouth, twice a day
Pt will have follow-up in 1 week
D. Provide an evidence-based rationale for the selected medication using at least one scholarly reference. Textbooks may be used for additional references but are not the primary reference. Done
E. List any side effects or adverse effects associated with the medication. Fluoxetine – sexual dysfunction, gi issues (decreased appetite, nausea, diarrhea, constipation, dry mouth), mostly CNS (insomnia but also sedation, agitation, tremors, headache, dizziness) (Stahl, 2021).
Lithium – ataxia, dysarthria, delirium, tremor, memory problems, polyuria, polydipsia, nephrogenic, diabetes insipidus, diarrhea, nausea and weight gain (Stahl, 2021).
F. Include any required diagnostic testing. State the time frame for this testing (testing is before medication initiation or q 3 months, etc.). Include normal results range for any listed laboratory tests. No test for a healthy individual with fluoxetine (Stahl, 2021)..
Lithium will require kidney function test, thyroid function, ecg if over 50, trough lithium plasma levels, initial monitoring every 1-2 weeks until desired serum concentration is achieved, then every 2-3 months for the first 6 months, stable monitoring every 6-12 months, one-off monitoring after dose changes, bmi d/t frequently associated weight gain, fasting blood glucose, ldl, hdl, triglycerides (Stahl, 2021)..
G. Provide a minimum of three appropriate medication-related teaching points for the client and/or family. Fluoxetine – report any thoughts of suicide, weight gain has been reported but not expected, possible weight loss- short term. Keep taking medication- it could take 2-4 weeks for therapeutic results (Stahl, 2021).
Lithium – Taper drug over 3 months, do not stop suddenly. Do not take NSAIDS- this can increase plasma lithium levels. Diuretics, especially thiazides can increase plasma concentrations. Will require lithium levels the first few months, report weight gain (Stahl, 2021)..
Your Medication Information (2020). Brown University Psychopharmacology Update, 10685308, Jul2020, Vol. 31, Issue 7
https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=143570787&site=ehost-live&scope=site (Links to an external site.)
Malhi, G. et al (2020). The 2020 Royal Australian and New Zealand College of psychiatrists clinical practice guidelines for mood disorders: Bipolar disorder summary. Bipolar Disorders.
Stahl, S.M. (2021). Stahl’s essential psychopharmacology: Prescriber’s guide (7th ed.). Cambridge University Press. ISBN: 9781108926010
this is the instructor question to the student post
This is an excellent point that you will likely see in your practice.
Was the Fluoxetine/ Prozac really helping her, OR was it contributing to some of her Bipolar symptoms??
( there is no right or wrong answer here, you must continue to do detailed assessments with follow-up.)
Remember, Fluoxetine/ Prozac is a great anti-depressant, and you will likely see mood or Bipolar patients on both an anti-depressant ( typical SSRI) AND a mood stabilizer. However, Fluoxetine/ Prozac is one of the medications with a long half-life. Metabolism in the liver, CYP450, 2C19, 2D6 ( primary) substrate, and active metabolite. Also Excreted in the urine 80% and feces 15% with HALF LIFE of 4-6 days ( parent drug) and 9.3 days ( active metabolite).
With that being said, this is a very common medication combination that I see and is used for Bipolar illness, particularly in females.
Take a look and review the below clips for more understanding.