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Psych > Benzos, anxiolytics, and mood stabilizers > Flashcards

Benzos, anxiolytics, and mood stabilizers Flashcards

1
Q

What two properties do benzodiazepines have?

A

anxiolytic and hypnotic

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2
Q

What do anxiolytics do?

A

reduces anxiety with little effect on motor function and moderates excitement

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3
Q

What do hypnotics do?

A

produces drowsiness and promotes the onset and maintenance of sleep

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4
Q

What are the two major subtypes of GABA?

A

GABAa and GABAb

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5
Q

How many subunits form a chloride channel and GABAa receptor?

A

5

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6
Q

What receptors can benzodiazepines bind to?

A

alpha 1, 2, 3, 4, and 5

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7
Q

Which alpha receptor controls sleep

A

1

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8
Q

Which alpha receptors are responsible for anxiolytic, muscle relaxation?

A

2 and 3

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9
Q

Which alpha receptor affects cognition?

A

5

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10
Q

What is the MOA of benzodiazepines?

A

increase the frequency of Cl channel opening through allosteric modulation, allowing influx of chloride ions

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11
Q

What are the adverse effects of benzodiazepines?

A
  1. dose-dependent CNS depression
  2. drowsiness, impaired judgment
  3. anterograde amnesia
  4. lethargy
  5. respiratory depression
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12
Q

What are the most common side effects of typical use of benzos?

A
  1. sedation
  2. drowsiness
  3. memory difficulties
  4. fatigue
  5. muscle weakness
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13
Q

What are the most common symptoms of benzo overdose?

A
  1. over-sedation
  2. confusion
  3. dysarthria
  4. diplopia
  5. ataxia
  6. lethargy
  7. dizziness
  8. difficulty breathing
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14
Q

What are the contraindications for benzodiazepines?

A
  1. hypersensitivity
  2. acute narrow angle glaucoma
  3. sleep apnea
  4. respiratory insufficiency
  5. concomitant CNS depressants
  6. Hx of drug dependence
  7. abrupt withdrawal
  8. falls and mental alertness
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15
Q

What are the withdrawal symptoms for benzos?

A
  1. anxiety
  2. agitation
  3. insomnia
  4. restlessness
  5. muscle tension
  6. irritability
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16
Q

What is considered short term use of a benzo?

A

4-8 weeks

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17
Q

How long should a patient taper off of short term benzo use?

A

1-2 months

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18
Q

How long should a patient taper off of long term benzo use?

A

2-6 months

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19
Q

How long should a patient taper off of extended benzo use?

A

2-3 months (10-25% q4wks)

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20
Q

What is considered long term benzo use?

A

greater than 1 year

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21
Q

Which benzo has a rapid onset and distribution half life?

A

diazepam

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22
Q

Which benzo is highly lipophilic and crosses the BBB readily?

A

diazepam

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23
Q

What benzo is the only pregnancy category X?

A

temazepam

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24
Q

What is the MOA of buspirone?

A

5HT1A partial agonist and 5HT2 agonist, moderate dopamine antagonist

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25
Q

What is the onset of buspirone?

A

greater than 2 weeks (not a good prn drug)

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26
Q

What are the uses for buspirone?

A

GAD and off-label MDD (adjunct therapy)

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27
Q

What is the MOA of hydroxyzine?

A

histamine receptor antagonist

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28
Q

What are the approved uses of hydroxyzine?

A

pruritus and anxiety withdrawal symptoms in alcoholics

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29
Q

What are the off-label uses of hydroxyzine?

A

insomnia and anxiety

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30
Q

What is the onset of hydroxyzine?

A

15-20 minutes

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31
Q

What is one of the favorable factors of hydroxyzine?

A

no abuse liability

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32
Q

What are the adverse effects of hydroxyzine?

A

anticholinergic effects: sedation, dry mouth, and tremor

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33
Q

What is the black box warning on the mood stabilizers?

A

increased suicidality

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34
Q

Which mood stabilizer does not have the black box warning?

A

lithium

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35
Q

What is the MOA of lithium?

A

1) It’s thought to alter cation transport across nerve and muscle cell membranes
2) influences reuptake of serotonin and/or norepinephrine
3) effect on second messenger systems

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36
Q

What is the CrCl cutoff of lithium?

A

< 50 mL/min

37
Q

Since lithium is a NTI drug, when are drug levels taken?

A

8-12 hours post dose (trough)

38
Q

What is the goal lithium level for acute depression?

A

0.6-1.0

39
Q

What is the goal lithium level for maintenance/prophylaxis?

A

0.7-1.0

40
Q

What is the goal lithium level for acute mania?

A

1.0-1.5

41
Q

What is the drug level cut off for lithium toxicity?

A

> 1.5 with symptoms

42
Q

What is more important in the management of lithium toxicity?

A

treating symptoms rather than drug levels

43
Q

What should you do if a patient does not have symptoms of toxicity?

A

redraw level to make sure it was a trough

44
Q

What are the mild symptoms of lithium toxicity (1.5-2.0)?

A
  1. N/V
  2. loose stools
  3. lethargy
  4. drowsiness
  5. coarse hand tremor
  6. muscular weakness
45
Q

What are the moderate symptoms of lithium toxicity (2.1-2.5)?

A
  1. severe N/V
  2. diarrhea
  3. confusion
  4. dysarthria
  5. nystagmus
  6. ataxia
  7. myoclonic twitches
46
Q

What are the severe symptoms of lithium toxicity (> 2.5)?

A
  1. severe N/V
  2. diarrhea
  3. impaired consciousness
  4. increased deep tendon reflex
  5. seizures
  6. syncope
  7. coma
47
Q

What are the baseline labs needed before initiation of lithium?

A
  1. BUN
  2. SCr
  3. TFT
  4. ECG if > 40 yo
  5. CBC
  6. HCG (females)
48
Q

What are the common side effects of lithium?

A

thirst, increased urination, tremor, weight gain

49
Q

What are the dose related, transient, GI side effects of lithium?

A

N/V, anorexia, diarrhea, and abdominal pain

50
Q

What are the common neuro/cognitive side effects of lithium?

A

lethargy, fatigue, weakness, and cognitive slowing

51
Q

What are the other side effects of lithium?

A

hypothyroidism, arrhythmias, acne, psoriasis, increased WBCs, and weight gain

52
Q

What drugs can increase lithium levels?

A

NSAID, ACE/ARB, CCBs, and thiazides

53
Q

What drugs can decrease lithium levels?

A

loop diuretics and caffeine

54
Q

What are the symptoms of lithium toxicity?

A

coarse tremor, ataxia, confusion, and visual changes

55
Q

What are the severe symptoms of lithium toxicity?

A

seizures, delirium, coma, and death

56
Q

What is the MOA of valproate?

A

It is a voltage-sensitive sodium channel antagonist

57
Q

No matter the formulation of valproic acid, what does it circulate in the body as?

A

valproate sodium

58
Q

When do you draw a valproate trough level?

A

1 hour prior to the next dose

59
Q

What drug specifically makes it difficult to achieve therapeutic VPA levels?

A

carbamazepine

60
Q

What are the monitoring parameters for VPA?

A

CBC w/ diff, LFTs, BUN/SCr, TDM, weight, electrolytes, ammonia, prothrombin time, bone marrow suppression, and HCG if suspicion of pregnancy

61
Q

What are the common side effects of VPA?

A

N/V, anorexia, heartburn, thrombocytopenia, LFT increases, liver impairment, sedation, dizziness, headache, tremor, ataxia, weakness, hair loss, and weight gain

62
Q

What is the MOA of carbamazepine and oxcarbazepine?

A

inhibits voltage-sensitive sodium channels

63
Q

Why do carbamazepine and oxcarbazepine have so many drug interactions?

A

both agents are inducers of CYP3A4

64
Q

What other enzymes does carbamazepine induce?

A

1A2, 2C9, 2C19, 2C8, and PGP

65
Q

What unique metabolism characteristic does carbamazepine have that isn’t seen with oxcarbazepine?

A

It auto-induces its own metabolism

66
Q

What are the NTI drugs?

A

carbamazepine, oxcarbazepine, and lithium

67
Q

What are the renal adjustments for carbamazepine?

A

avoid if CrCl is less than 60 mL/min

68
Q

What are the renal adjustments for oxcarbazepine?

A

start with 300mg QD instead of BID if CrCl is less than 30 mL/min

69
Q

What monitoring is crucial in the 1st 3 months with carbamazepine and oxcarbazepine?

A

Chem 7

70
Q

What monitoring is needed for carbamazepine and oxcarbazepine?

A

CBC w/ diff (not for oxcarbazepine), ECG, LFT, TFT, BUN/SCr, TDM, weight, electrolytes, rash development, and HCG if suspicion of pregnancy

71
Q

What allele requires testing due to serious skin reactions?

A

HLA-B*1502

72
Q

What are the side effects of carbamazepine and oxcarbazepine?

A

GI upsets, aplastic anemia, LFT elevations, hyponatremia, and reduced efficacy of contraceptives

73
Q

What are the main differences between oxcarbazepine and carbamazepine?

A

less sedating, less bone marrow toxicity, fewer CYP3A4 interactions, and no auto-induction

74
Q

What is the MOA of lamotrigine?

A

inhibits voltage-sensitive sodium channels

75
Q

What is the interaction between lamotrigine and oral contraceptives?

A

estrogen contraceptives can reduce lamotrigine levels

76
Q

What is the dosing regimen of lamotrigine for bipolar disorder?

A

titrated slowly to avoid skin rash (SJS). 25 mg daily x 2 weeks, then 50 mg daily x 2 weeks, the 100 mg daily x 1 week, then 200 mg/day

77
Q

What should you do to the dose of lamotrigine in the presence of valproic acid or any other substance that induces glucuronidation?

A

double the dosing schedule

78
Q

What is the most severe side effect of lamotrigine that is seen in about 10% of patients?

A

Stevens Johnson syndrome

79
Q

What is the MOA of topiramate?

A

It interferes with both calcium and sodium channels, enhances GABA, and reduces glutamate function

80
Q

What is topiramate used for?

A

adjunct in bipolar (not studied enough for monotherapy as a mood stabilizer)

81
Q

What are the side effects of topiramate?

A

Dizziness, ataxia, somnolence, psychomotor slowing, memory difficulties, fatigue, decreased concentration, and confusion

82
Q

What is the MOA of pregabalin and gabapentin?

A

alpha-2-delta ligands that binds to the alpha-2-delta subunit of voltage sensitive calcium channels

83
Q

What can pregabalin be used for in psych?

A

anxiety

84
Q

What are the side effects of pregabalin?

A

dizziness and cognitive impairment

85
Q

What is gabapentin used for in psych?

A

off-label for anxiety

86
Q

What are the side effects of gabapentin?

A

dizziness, drowsiness, ataxia, fatigue, and edema

87
Q

What is the biggest therapeutic consideration for gabapentin?

A

renal dose adjustments

88
Q

What is the MOA of levetiracetam?

A

inhibition of N-type calcium channels, potassium channel blockade, GABAergic actions

89
Q

What are the major side effects of levetiracetam?

A

behavioral symptoms, somnolence, headache, and hostility

Psych (3 decks)

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