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Anx-depp-Bipolar Flashcards

1
Q

What are uses of BZD?

A

Anx disorder

Insomnia

Seizure disorder

Status Epilepticus: IV ONLY

Premedication for anesthesia (IV/IM)

Off-lable use:

  - Alcohol withdrawal
  - Chemotherapy-assoc N/V
  - Essential tremor
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2
Q

Which BZD’s are my LONG-ACTING BDZ’s?

A
  • Chlordiazepoxide (LIBRIUM)
    • anx: 5-25mg PO tid-qid
    • alcohol withdrawal
  • Clonazepam (klonopin)
    • panic disorder
    • seizure disorder
  • Diazepam (Valium)
  • Flurazepam (Dalmane)
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3
Q

Which Benzo’s are INTERMEDIATE (10-20 hrs)?

A

Lorazepam (Ativan)

TEMAZEPAM (Restoril)

Estazolam (Prosom)

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4
Q

Short-Acting- BZD’s (<12 HOURS)

A

Alprazolam (Xanax, Xanax-XR)
- 3A4 SUBSTRATE (use with caution w/ INHIBTORS & INDUCERS)

Oxazepam

Triazolam (Halcion)

Midazolam

-SHORT ACTING BENZO’s have the HIGHEST risk of abuse because of RAPID RISE AND FALL of levels!!

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5
Q

Which BZD’s are recommended for OLDER patients?

A

Lorazepam

Oxazepam

Temazepam

LOT!!

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6
Q

For patients taking MULTIPLE MEDS, on METHADONE, or COMPROMISED LIVER FX, which BZD’s do you recommend?

A

LOT

LORAZEPAM

OXAZEPAM

TEMAZEPAM

LOT drugs are mostly cleared by KIDNEYS and thus have DECREASE P450 drug INTERACTIONS. (Most BZD’s except for LOT are metabolized by CYP3A4)

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7
Q

Benzodiazepine SE and PRECAUTIONS

A

Drowsiness/ impair driving

Memory impairment: ANTEROGRADE AMNESIA

Tolerance**

Rebound or Withdrawal s/s FOLLOWING discontinuation

Drug abuse: CAUTION in pts w/ HISTORY of ALCOHOL or DRUG ABUSE

BBW: Can be lethal if combined with OPIODS, ALCOHOL, Or other meds that depress the CNS: result in RESPIRATORY DEPP & DEATH!!

-PREGNANCY CAT D**

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8
Q

BZD Withdrawal SYMPTOMS?

A

-DISTURBED SLEEP
-TREMORS
-MUSCLE ACHES
POOR COORDINATION
MILD PARANOIA
CONFUSION
PSYCHOSIS
SEIZURES**

OVERDOSE: results in RESPIRATORY DEPRESSION, HYPOTENSION, COMA, DEATH

-ANTIDOTE: Flumazenil!!

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9
Q

Buspar

A

BUSPIRONE

MOA: unknown

      - NO EFFECT ON GABA
      - AFFINITY for serotonin 5-HT1A
      - AFFINITY for dopamine D2- receptors

Treats: ANXIETY

Dose: MAX —> 30mg BID

MAJOR CYP3A4 SUBSTRATE

DONT GIVE W/ MAOI

Counseling point: TAKES UP TO 4 weeks to work!!

SE: dizziness, drowsiness, HA, Nervousness

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10
Q

Anxiolytic SUPPLEMENTS

A

Kava-kava - caution: HEPATOTOXIC

Valerian ROOT - Insomnia; not for ANX

PASSION flower - A calming herb

St. John’s Wort - INCREASES 5HT-3

Hops - Relaxing and sedative effect

Chamomile - sedative, ANX, relieves GI distress, MAY INCREASE INR(has warfarin derivatives)

B-Complex: essential for SYNTHESIS of serotonin; Vitamin B deficiency has been associated with ANX & DEPRESSION.

L-Tryptophan and 5-HTP: Precursors used by body for synthesis of serotonin

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11
Q

SSRI

GENERAL INFO

RECEPTOR SPECIFICITY**

A

MOA: inhibit reuptake of serotonin (5-HT) at ALL receptors, acting as a SEROTONIN AGONIST

5-HT1: involves DEPRESSION

5-HT2: involves SEXUAL DISFX

5-HT3: involves GI side EFFECTS

AD’s increase the risk of SUICIDAL THINKING & behavior in short term studies in pts < 24YO w MDD AND A DECREASED RISK IN those > 65 yrs old.

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12
Q

SSRI SIDE EFFECTS:

A
  • SSRI’s reduce platelet aggregation (INCREASE BLEEDING)
  • Link to Increase GI BLEEDING

CAUTION W/: NSAIDS, aspirin, WARFARIN

Luvox & Celexa: Known to have LESS Bleeding

  • Activating or Sedating
    (Fluoxetine: Activating)
    (Fluvoxamine: Sedating)
  • GI effects: Nausea/ Diarrhea
  • Weight Gain!!
  • Sexual dysfx!!
  • HeadAche
  • Hyponatremia
  • Orthostatic Hypotension
  • Bone Fractures
  • Ocular effects
  • Suicidal thinking

PREGNANCY CAT C (pulmonary HTN)
-Paxil: Heart Defects

-Anticholinergic: Dry mouth

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13
Q

SSRI DRUG INTERACTIONS

A

Fluvoxamine- STRONG CYP1A2 INH

Fluoxetine/Paroxetine- STRONG CYP2D6 INHIBITORS

- Avoid combining w/ TAMOXIFEN!!
- Avoid w/ Codeine (CYP2D6 substrate)

Vortioxetine: substrate of CYP2D6 & CYP3A4

Vilazodone: substrate of CYP3A4

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14
Q

Celexa

A

Citalopram

Treats: MAJOR DEPP DISORDER

form: tabs; solution (10mg/5mL)

Max: 40mg/d; 20mg/d > 60YO DUE TO QT prolongation**

CAUTION: Cardiac disease, low k/mg, liver impairment

Drug Interactions: 2C19 SUBSTRATE

  • avoid going over 20mg w/ CYP2C19 inhibitors: OMEPRAZOLE & Cimetidine
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15
Q

Lexapro

A

EsCitalopram

Treats: MDD; GAD

DOSE: 10qd AM/PM

MAX: 20mg/d after one week QD

FORMS: tabs; soln

DI: Major substrate of CYP2C19/ CYP3A4

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16
Q

Prozac/ Sarafem

A

Treats: MDD, OCD, Bulimia nervosa, PreMENSTRUal dysphoric disorder, PANIC disorder

  • approved in CHILDREN W/ MDD > 8 yo
  • approved in children w/ OCD >7 YO

Forms: caps; solution
MAX: 80mg/d

CAUTION: **MAOI’s should be D/C at least 14 days before initiating fluoxetine. If on fluoxetine, d/c fluoxetine at least 5 weeks before going on MAOI due to its LONG half life

DI: PROZAC is a STRONG inhibitor of CYP2D6

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17
Q

LuVOX

A

Fluvoxamine

Treats: OCD

FORMS: tabs; ER caps

Administer: BEDTIME(VERY SEDATING)

CYP2c19 substrate

CYP450 Inhibitor: PRIMARILY 1A2

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18
Q

PAXIL, PAXIL CR, PEXEVA, Brisdelle

A

ParoxeTiNE

Indication: MDD, GAD, OCD, panic disorder, PMDD, SAD, PTSD, Vasomotor symptoms of menapause (BRISDELLE) ONLY

CYP450 STRONG Inhibitor of : 2D6

  • DO NOT D/C abruptly

Pregnancy CATEGORY D due to CARDIAC TOX!!

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19
Q

Zoloft

A

Sertraline

Treats: MDD, OCD, Panic disorder, PMDD

DOSE: MAX:200mg/d

-Moderate/Weak inhibitor of CYP450
:CYP2D6 ( like paxil/prozac)

FOOD ^ BIOAVAILABILITY

But can take W/WO food.

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20
Q

Trintellix

A

Vortioxetine

Treats: MDD

MOA: SRI/ 5HT1a agonist/ 5HT1b partial agonist/ 5HT3a; 5HT7 ANTAGONIST

DOSE: MAX: 20mg/d

CONTRAINDICATION: Dont use MAOI’s within 21 days of STOPPING TrinTELLIX

SE: NAUSEA, no effect on WEIGHT GAIN

DI: SUBSTRATE of CYP2D6 & CYP3A4. Decrease dose by 1/2 w INHIBITORS

BUPROPION ^ TRINTELLIX BY 2X’s

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21
Q

SNRI

GENERAL INFO

A

Serotonin-Norepi-Reuptake- INHIBITOR

Venlafaxine(EFFEXOR)

DesVenlafaxine(Pristiq)

DesVenlafaxine(Khedezla)

DULOXETINE (CYMBALTA)

Milnacipran (SAVELL)

LevoMilnacipran(Fetzima)

ALL SNRI need DOSE ADJUSTMENT IN RENAL/HEPATIC

SE: NAUSEA(most common), CONSTIPATION, DRY MOUTH, DIZZINESS, SWEATING, ^^BP^^, sexual dysfx.

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22
Q

SNRI SIDE EFFECTS:

A

HEADACHE/HYPONATREMIA

OCULAR

BONE FRACTURES

SUICIDAL THINKING

GI: Nausea; GI Bleeding, ^ risk of BLEED

^^^ BLOOD PRESSURE^^^

NE “psuedoanticholinergic” EFFECT ( Constipation, dry mouth, Urinary RETENTION)

  • NAUSEA, dizziness, Dry Mouth, Sweating, BP
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23
Q

Effexor

A

Venlafaxine

Treats: MDD, GAD, panic disorder (XR- ONLY)

Dose: Administer w/ FOOD

Forms: tabs(BID/TID), XR CAPS, ER TABS

CRCL<30 reduce dose by 1/2

SE: Activating/ Sedating, agitation, GI, HTN, HA

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24
Q

PRISTIQ

A

DESVENLAFAXINE SUCCINATE

SNRI**

Treats: DEPRESSION

CRCL< 30 50mg QOD

^^ BP^^

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25
Khedezla
Desvenlafaxine BASE SNRI TREATS: MDD MAX:400mg/d
26
Cymbalta/ Irenka
Moa: SNRI INDICATION: Depression, GAD, fibromyalgia, chronic musculoskeletal pain, chronic osteoarthritis pain, and chronic low back PAIN. Max: 120mg DI: Substrate CYP1A2, CYP2D6/ Inhibits CYP2D6 - AVOID in CrCL < 30mL/min & Hepatic impairment Monitor: BP
27
Savella
Milnacipran SNRI Treats: Fibromyalgia (3 drugs approved for fibromyalgia are: Lyrica, Cymbalta, Savella) Max:200mg ESRD: NOT RECOMMENDED
28
Fetzima
LEVOmilnacipran SNRI TREATS: MDD(NOT fibromyalgia) **CYP3A4 SUBSTRATE** - ESRD: NOT RECOMMENDED Dose: ONCE DAILY **DO NOT TAKE W/ ALCOHOL**
29
NE & DOPAMINE (NDRI) REUPTAKE INHIBITORS
BUPROPION - Wellbutrin SR - Wellbutrin XL - Aplenzin (ER) - Zyban
30
Wellbutrin; Aplenzin; Zyban
BuPROPION MOA: D2/NE agonist - preferred if worried about sexual dysfx Indication: MDD/Smoking cessation/ SAD- seasonal affective DISORDER - MAX dose/d: - IR: 450mg/d - SR: 400mg/d - XL: 450mg Aplenzin: 522mg SE: **SEIZURES**
31
Bupropion SE & DRUG INTERACTIONS
SE: 1) ACTIVATION 2) SEIZURES CAUTION: bulimia**, Alcoholics, Seizures, psychosis WEIGHT-LOSS GI Effects DI: Moderate CYP2D6 Inhibitor Avoid ethanol, Valerian root, St. Johns WORT, SAMe, kava kava( may increase CNS depression)
32
Serotonin MODULATORS
Trazodone Nefazodone Vilazodone
33
Trazodone
MOA: blocks serotonin reuptake (LESS POTENT than SSRI’s) & alpha-Adrenergic Blocker!!) - Serotonin Modulators Treats: MDD, Sleep disorder SE: GI, sexual dysfx, Orthostasis, **PRIAPISM!!**
34
Nefazodone
MOA: serotonin reuptake blocker & alpha1 blocker Treats: MDD BBW: **HEPATOTOXICITY** monitor LFT’s
35
viiBRYD
Vilazodone CLASS: Serotonin MODULATOR MOA: blocks 5HT reuptake & partial 5HT1a receptor AGONIST treats: MDD DOSE: Start 10mg WD w FOOD x 7 days Maint/ max: 40mg QD w FOOD -: **NO WEIGHT GAIN** DI: **SUBSTRATE OF CYP3A4** Contraindications: **14 days D/C with MAOI’s** Se: Same as SSRI’s
36
Remeron
Mirtazapine Treats: MDD MOA: alpha2 antagonist —> ^ NOR; 5HT3 - Antagonist @ 5HT2a, 5HT2C, 5HT3 Form: tabs; ODT** SE: 1) Sedation 2) appetite(^ weight gain) 3) ^ lipids 4) anticholinergic (dry mouth, constipation) 5) QT Prolongation
37
TCA MOA
MOA: Blocks NOR & 5HT3 reuptake Tertiary - Higher 5HT3 Affinity Secondary - Higher NOR affinity Also stimulate: - alpha adrenergic: Orthostasis - Histaminergix : Weight gain; Sedation - anticholinergic: dry mouth, urinary ret, constip
38
TCA SIDE EFFECTS
1) sedation 2) anticholinergic 3) weight gain 4) tachycardia/arrhythmias - risk of QTc prolongation - Lower seizure threshold **DO NOT D/C abruptly**
39
Elavil
Amitriptyline (Tertiary) TCA TREATS: 1) Depression - OFF-LABLE: 1) chronic pain 2) Diabetic Neuropathy 3) migraine ppx 4) PTSD
40
Anafranil
Clomipramine (Tertiary) Class: TCA TREATS: OCD
41
Silenor
Doxepin (Tertiary) Class: TCA Treats: Depression/anxiety/INSOMNIA OFF-LABLE: 1) CHRONIC UTICARIA (Hives)
42
Tofranil
Imipramine (Tertiary) Class: TCA - Indicated: Depression * * ENURESIS** BED WETTING!!! OFF-LABLE: **Bulimia**, Neuropathic PAIN
43
Surmontil
TRIMIPRAMINE (Tertiary) Class: TCA
44
Amoxapine
TCA(secondary) MOA: Blocks NE & DOPAMINE (ONLY ONE)
45
Norpramin
Desipramine TCA : 2nd Treats: Depression OFF-LABLE: Neuropathic pain
46
Maprotiline
TCA: SecondAry
47
PaMEloR
Nortriptyline CLASS: TCA: 2nd Treats: DEPRESSION OFF-LABLE: 1) Chronic pain 2) IBS 3) Post-Herpetic Neuralgia 4) Smoking cessation
48
Protriptyline
Class: TCA; 2nd
49
What meds can also be used for BED-WETTING?
1) Imipramine 2) anticholinergics - fesoterodine - oxybutynin - Tolterodine 3) DDAVP (Desmopressin)
50
MONOAMINE OXIDASE INHIBITORS
Inhibit MAOa & MAOb - 1) Isocarboxazid (Marplan) - 2)phenelzine (Nardil) - 3) Tranylcypromine (Parnate) ``` Selegilime (EmSAM) QD PATCH (SELECTIVE FOR MAOb at low doses and NONSELECTIVE AT HIGHER) ```
51
MAOI SE; MOA; Indications
MOA: MAOI’s inhibit the BREAKDOWN OF DOPAMINE; 5HT3, and NOR-EPi Indications: MDD - Can be effective in treatment resistant depression E: Insomnia, anticholinergic, Orthostasis, Weight Gain, Edema, Sexual dysfx.
52
MAOI DRUG INTERACTIONS: **VERY IMPORTANT**
1) Dextromethorphan - Hyperpyrexia 2) Meperidine; Fentanyl; Methadone; Tramadol (^ Effect of MAOI) 3) Morphine/Hydromorphone/Hydrocodone - (^^ CNS Depression & hypotension) 4) TCA; SSRI: 5) Oral INHALATION; Anticholinergics; Umeclidinium: Tiotropium - May enhance Anticholinergic effects 6) Sympathomimetics( amphetamines, Ephedrine, psuedophedrine, Beta-Agonist) - Hypertensive CRISIS
53
Emsam
Selegiline Indication: MDD FORM: PATCHES (DAILY)
54
What are other MAOI’s that arent in the depression chapter?
1) Linezolid (ABX) 2) Tidezolid (ABX) 3) Rasagiline 4) Procarbazine (Chemo)
55
Which AP’s are approved for MDD?
1) Abilify 2) Symbyax (Olanzapine/Fluoxetine) 3) Quetiapine (XR) 4) Brexipiprazole (Rexulti)
56
OTC meds for DEPRESSiON
1) SAM-e 2) ST. John’s WORT - Photosensitivity - P450 Inducer - Watch for Serotonin Syndrome
57
Celexa
Citalopram Treats: MAJOR DEPP DISORDER form: tabs; solution (10mg/5mL) **Max: 40mg/d; 20mg/d > 60YO** DUE TO QT prolongation** **CAUTION: Cardiac disease, low k/mg, liver impairment** Drug Interactions: 2C19 SUBSTRATE - avoid going over 20mg w/ CYP2C19 inhibitors: OMEPRAZOLE & Cimetidine
58
Lexapro
EsCitalopram Treats: MDD; GAD DOSE: 10qd AM/PM MAX: 20mg/d after one week QD FORMS: tabs; soln DI: Major substrate of CYP2C19/ CYP3A4
59
Prozac/ Sarafem
Treats: MDD, OCD, Bulimia nervosa, PreMENSTRUal dysphoric disorder, PANIC disorder - approved in CHILDREN W/ MDD > 8 yo - approved in children w/ OCD >7 YO Forms: caps; solution MAX: 80mg/d CAUTION: **MAOI’s should be D/C at least 14 days before initiating fluoxetine. If on fluoxetine, d/c fluoxetine at least 5 weeks before going on MAOI due to its LONG half life DI: PROZAC is a STRONG inhibitor of CYP2D6
60
Which meds can be used for BiPolar DISORDER?
1) Lithium 2) Anticonvulsants - Divalproex sodium (Depakote) - Lamotrigine (Lamictal) - Carbamazapine (Equetro) 3) Antipsychotic - Quetiapine XR - Olanzapine (Zyprexa); Symbyax - Ziprasidone - Aripiprazole - Lurasidone - Asenapine (Saphris) In General: Lithium or Depakote combined w/ an antipsychotic is more EFFECTIVE than monotherapy
61
DOC for Bipolar
Lithium, IF TOLERABLE
62
Which drugs have been shown to be effective in treating BiPolaR DePressIoN?
1) Lithium 2) quetiapine 3) Lurasidone 4) symbyax (Olanzapine + Fluoxetine)
63
Which Anticonvulsant is effective for prevention of RECURRENT depressive episodes?
Lamictil (Lamotrigine)
64
Which two Anticonvulsant can be for maint Tx but are usually less effective than Lithium?
Valproate (Depakote) Carbamazepine
65
Lithobid
Lithium Indication: 1) Bipolar Depression 2) Off-label; Depression MOA: Unknown; Believe to influence reuptake of 5HT and/or NOR - (+) charge element similar to Na/K - EFFECT ON electrolytes (Na, K, Ca, Magnesium) **OPPOSITE effect on SODIUM**
66
Lithium DOSAGE Forms
Lithium Carbonate ``` - (IR) forms: 150,300, 600 CAPS 300mg tabs (Eskalith) ``` - (CR): 300mg Lithobid - XR: 300mg & 450mg Lithium citrate SYRUP - 8mEq/5mL soln (5mL = 8meq= 300mg)
67
Lithium DOSAGE!!
Starting dose: 300-600mg BID-TID Effective range: **900-1800mg/**day(15-20 mg/kg) - Elderly and Renal: Decrease dose - 300mg/ day w/ LEVELS of 0.4-0.6 mEq are Usually effective in elderly patients - Pregnancy cat D * *100% RENALLY CLEARED** Therapeutic Monitoring: Draw serum levels JUST BEFORE next dose, after 5(FiVE) days of TREATMENT - Acute Levels: 0.8-1.2 mEq/L - Maintenance: 0.6-1.0 mEq/L **Lithium effect usually begin in 1 WEEK and full effect w/I 2-3 WEEKS**
68
Lithium SIDE EFFECTS
1) GI(N/VD) take w/ FOOD**!!! 2) Fine intentional HAND TREMOR 3) Nephrogenic diabetic insipid-us: - Chronic lithium ingestion can cause ADH not to work causing POLYURIA/POLYDIPSIA which may cause Lithium TOXICITY!! - If possible D/C lithium - For patients whom lithium therapy is necessary Add POTASSIUM (K)- sparring Diuretic, AMiLoRiDe 4) Leukocytosis (^WBC) 5) Thyroid** 6) Parathyroid - Hypercalcemia: Hyperparathyroidsm 7) Weight gain ** 8) Bradycardia 9) Acne: Alopecia 10) CNS adverse RXN: Ataxia, Blackout spells, Cogwheel rigidity
69
Lithium toxicity
1) > 1.5: **TREMOR**, Vomiting, CONFUsion, Ataxia, slurred speech **HOLD DOSE** 2) > 2: arrhythmias, SEIZURES, COMA - NS IV infusion, Hemodialysis 3) > 3.5: Lethal Toxicity!!
70
LITHIUM DRUG INTERACTIONS
- Thiazides; ACEI’s, NSAIDS - Sodium RESTRICTION, dehydration, RENAL IMPAIRMENT - ** ^^ Na will DECREASE LITHIUM!! - SODIUM BICARB MAY ALSO DECREASE LITHIUM!! Lithium w/ SSRI’s: Serotonin Syndrome S/s: confusion, agitation, Diarrhea, Tremor, diaphoresis
71
Which NSAID can be recommended w/ Lithium?
Sulindac Aspirin

Top 100 Drugs (Brand-Generic) (19 decks)

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