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IPT: Neuro > Block 2 > Flashcards

Block 2 Flashcards

1
Q

RF of MS, location

A

> 37th parallel, most common in scandinavian ancestry

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2
Q

Proposed etiology of MS?

A

Attack of self-myelin or self-oligodendrocyte antigens

CD4 cells activated in periphery and recognized myelin basic protein

Activated T cells cross BBB and bind to HLA class II molecules of myelin

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3
Q

Where are the lesions found in MS?

A

Brain, spinal cord, and optic nerves via MRI

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4
Q

What are the T cell subtypes found in MS?

A

Th1 (pro-inflamm)

Th2 (protective)

Th17 (pro-inflamm)

Treg (protective prevention)

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5
Q

Which matter of the brain can be affected by MS?

A

Both white and grey matter

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6
Q

What is relapsing remitting type MS (RRMS)?

A

At onset of new attack that lasts 24hrs, separated by other sx by 30 days followed by remission

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7
Q

First attack of MS is called?

A

Clinically isolated syndrome

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8
Q

What is secondary progressive type MS?

A

20% of RRMS pt enter a progressive phase where attacks/remissions are difficult to identify

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9
Q

What is primary progressive type MS (PPMS)?

A

Occurs in 15% of MS (versus 85 in RRMS)

Slow onset w/o attacks and worsens over time

Increased suicide rate

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10
Q

What is the standard tool for MS diagnosis and progression evaluation?

A

MRI

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11
Q

What are some favorable/unfavorable prognostic indicators for MS?

A

Favorable - <40, female, optic neuritis or sensory sx

Unfavorable - >40, male, motor/cerebellar sx

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12
Q

How do you treat acute RRMS?

A

Acute attack (optic nerve damage)

Tx w/ IV solu-medrol, if they dont respond give plasma exchange

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13
Q

How do you treat RRMS (not acute)?

A

BARPE

Betaseron (1b) - non-glycosylated

Avanex (1a) - glycosylated
Rebif (1a) - glycosylated
Plegridy (1a) - pegylated

Extavia (1b) - non-glycosylated

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14
Q

Betaseron AE?

A

Flu-like sx, SOB, tachycardia, depression

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15
Q

Betaseron, Avanex, Rebif, Plegridy are limited due to what?

A

Neutralizing AB (not dose dependent, but rather time); increases at 6 months, but can develop as early as 3 months

MIGHT be due to number of injections (lower inj = better?)

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16
Q

Glatiramer (Copaxone) aka Copolymer 1 MOA?

A

Suppresses T cell activation and possibly migration

Mimics myelin basic protein of myelin sheath

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17
Q

Glatiramer (Copaxone) aka Copolymer 1 AE?

A

10% experience chest tightness, flushing and dyspnea a few min after inj

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18
Q

What is the first oral agent for MS?

A

Fingolimod (F,Gilenya) + is allowed in PEDIATRICS

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19
Q

Fingolimod MOA?

A

Acts on S1P1R or S1P5R that is responsible for lymphocyte release from lymphoid organs

Depletes CD4 and 8 in the blood AND doesnt inhibit T or B cells (meaning no immunosuppression or increased risk of infection :O)

any drug that ends w/ -mod

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20
Q

Fingolimod AE?

A

Decreased HR, decreased lymph count and increased LFT, QT prolongaition

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21
Q

Teriflunomide MOA?

A

Inhibits dihydroorotate dehydrogenase

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22
Q

Teriflunomide AE?

A

Monitor LFTs 6 months prior and after, alopecia, and flu

BBW of hepatoxicity and teratogenicity

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23
Q

Which MS rx has interactions?

A

Teriflunomide

Inhibits CYP2C8 + induces 1At

Inhibits OAT

Decreases INR w/ warfarin use

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24
Q

Dimethyl Fumarate MOA?

A

Unknown

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25
Q

Dimethyl Fumarate AE?

A

CBC every month for 6 months, then annually

LFTs, and FLUSHING

Rash, ab pain

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26
Q

What is the last line

Tx for MS?

A

Mitoxantrone; cumulative dose is 140mg/mm^2 (max dose = 11)

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27
Q

How is Natalizumab given for MS?

A

Mono therapy or given with IFNs

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28
Q

Natalizumab AE?

A

PML

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29
Q

Alemtuzumab AE?

A

Monitor CBC, THYROID function every 3 months and then for 48 months after last dose

Causes hypo or hyperthyroidism

Infusion associated reaction (>90%) (all -mabs have this AE)

Increased herpes infection risk (prophylactic acyclovir tx)

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30
Q

What Rx is used for both PP and RRMS?

A

Cladribine + Ocrelizumab

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31
Q

What Rx is used for CIS, RRMS, and SPMS?

A

Siponimod

Only drug that has exclusion criteria for poor metabolizers of CYP2C9

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32
Q

Alemtuzumab has high efficacy for ____ MS

A

relapsing; depletes T + B cells

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33
Q

Ocrelizumab is used for ___ MS

A

relapsing or PPMS

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34
Q

Ocrelizumab MOA?

A

Targets CD20 on surfaces of B cells by inducing B cell self-destruction

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35
Q

What AA are found in Glatiramer?

A

L-Glu

L-Lys

L-Ala

L-Tyr

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36
Q

Mitoxantrone AE?

A

Bone marrow suppression, neutropenia, menstrual disorders

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37
Q

What Rx is an adenosine analog?

A

Cladribine

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38
Q

Cladribine AE?

A

Cytotoxic, malignancies, liver damage, cardiac issues, teratogenic

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39
Q

Dimethyl Fumarate metabolism?

A

Metabolized by esterase in liver and GI tract to active MMF

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40
Q

What is found in the DSM-5?

A

Axis I - Clinical Disorders

Axis II - Personality Disorders/Mental Retardation

Axis III - General Medical Conditions

Axis IV - Psychosocial and environmental problems

Axis V - Global Assessment of Function (GAF)

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41
Q

What is sensitivity and specificity in psychiatric scales?

A

Sensitivity - test ability to detect if an illness is present

Specificity - test ability to determine if an illness is absent when the person does have the illness

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42
Q

How do you interpret reliability scores in psychiatric scales?

A

0-1.0

Anything <0.7 is unreliable

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43
Q

What is PANSS rating scale?

A

Assesses both positive and negative Sx

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44
Q

What is a CGI rating scale?

A

Not specific, but can be used in all psychiatric disorders.FDA requires this

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45
Q

What is the BPRS rating scale?

A

General type of assessment

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46
Q

What is the SANS rating scale?

A

Specific to negative sx, used with BPRS

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47
Q

What are the depression/bipolar rating scales used?

A

MADRS

Beck and Zung (used by pt)

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48
Q

Which psychiatric evaluation does not have a definitive diagnosis?

A

Agitation

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49
Q

Whats found under “Thought Content”?

A

Delusion
Obsession
Idea for reference

Anything else is “Thought Process”

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50
Q

What is a brief psychotic disorder?

A

Presence of one of the following:

  1. Delusions
  2. Hallucinations
  3. Disorganized speech
  4. Grossly disorganized or catatonic behavior

Lasts under a month

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51
Q

What is a delusional disorder?

A

Lasts for 1 month or longer

Criteria A for schizophrenia is NOT met

Not impaired or not odd

EX: takings baths 3 times a day, not delusional just “odd”

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52
Q

What is a schizophreniform disorder?

A

2+ symptoms from below present for 1-6 months

Criteria A:

  1. Delusions
  2. Hallucinations
  3. Disorganized speech
  4. Grossly disorganized or catatonic behavior
  5. Negative sx
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53
Q

What are the negative sx associated w/ schizophrenia?

A

Diminished emotional expression

Avolition

Alogia

Anhedonia

Asociality

Everything else are positive symptoms or cognitive symptoms

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54
Q

What is avolition?

A

Decreased in motivated in activaties

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55
Q

What is alogia?

A

Diminished speech output

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56
Q

What is anhedonia?

A

Decreased ability to experience pleasure from positive stimuli

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57
Q

What is asociality?

A

Lack of interest in social interactions

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58
Q

What are some anatomic abnormalities with schizophrenia?

A

Larger brain ventricles

Hippocampus changes

Less gray and white matter volume

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59
Q

Parts of brain + schizophrenia?

A

Hippocampus - learning/memory

Limbic system - emotion

Frontal lobe - critical thinking

Basal ganglia - movement and emotions

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60
Q

Neurotransmitter system, dopaminergic activity + schizophrenia?

A

Positive sx come from hyperdopaminergic activity in MESOLIMBIC

Negative from HYPOdopaminergic activity in MESOCORTICAL

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61
Q

Which brain pathway involves in hyperprolactemia?

A

Tuberoinfundibular pathway

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62
Q

Which brain pathway involves EPS and tardive dyskinesia?

A

Nigrostriatal pathway

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63
Q

D2 antagonists + brain pathways, what is happening?

A

Relieves psychosis via mesolimbic and mesocortical but…

Induces EPS sx via nigrostriatal pathway and increase prolactin via tuberoinfundibular pathway

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64
Q

Antipsychotics and binding affinity?

A

All antipsych rx have both DA and 5-HT receptor affinity except pimavanserin for PD

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65
Q

Which anti-psych meds are first gen?

A

Typical

Chlorpromazine (Phenothiazine-like)

Haloperidol (Butyrophenone-like)

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66
Q

Which anti-psych meds are second gen?

A

Atypical

  • apine (clozapine aka Benzazepine-like)
  • idone (risperidone aka Benzisoxazole-like)
  • azole (aripiprazole in Benzisoxazole-like, but also an aryl piperazine)
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67
Q

Which benzazepine-like anti psych med is the only first gen rx?

A

Loxapine

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68
Q

Which butyrophenone-like anti psych med is the only second gen rx?

A

Lumateperone

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69
Q

Which anti psyche structural class traces its roots to antihistamines?

Phenothiazine-like
Butyrophenone-like
Benzazepine-like
Benzisoxazole-like

A

Phenothiazine-like

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70
Q

Typical vs Atypical anti psychs, what receptors do they target?

A

Typical - more D2 vs 5HT2A receptors

Atypical - more 5HT2A vs D2 receptors

Therefore D2 antagonism is associated w/ EPS and hyperprolactinemia release

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71
Q

Phenothiazine-like anti psyche AE?

A

Sedation, orthostatic hypotension, and anticholinergic effects are more severe in this class (chlorpromazine, thioridazine, etc)

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72
Q

What is a common metabolic pathway for many CNS drugs like anti psychs?

A

Oxidative N-dealkylation

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73
Q

Are phenothiazines-like anti psychs metabolized via P450?

A

Yes

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74
Q

Butyrophenone-like anti psych meds efficacy is due to what functional groups?

A

Tertiary amine attached to 4th carbon of skeleton

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75
Q

How do you increase the duration of action on butyrophenone-like anti psychs?

A

Replace ketone group w/ a second 4-fluorophenyl group

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76
Q

AE of butyrophenone-like anti psychs vs phenothiazine-like?

A

Sedation, wt gain, orthostatic hypotension, and anticholinergic effects are less severe in this class (haloperidol, etc) vs in phenothiazine-like

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77
Q

Haloperidol metabolism?

A

Leads to neurotoxic metabolite HPP+ that can cause severe and irreversible dyskinesias

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78
Q

Lumateperone vs other drugs in butyrophenone-like class?

A

2nd gen drug (more 5-HT2A antagonism)

Less EPS and hyperprolactinemia relative to haloperidol

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79
Q

Valbenazine metabolism and DI?

A

Used to tx tardive dyskinesias

Prodrug that forms active metabolite DHTBZ via hydrolysis of L-valine ester

Metabolized by 3A4, reduce dose with inhibitors and dont recommend w/ inducers

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80
Q

Deutetrabenazine metabolism?

A

Derivative of valbenazine metabolite

Six deuterium atoms (H2) functions as bioisosteres of hydrogen, which slows rate of metabolism

First example of deuterated drug to receive FDA approval

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81
Q

H1 antagonism
M1 antagonism
alpha1 antagonism
5-HT2c antagonism

Which one leads to weight gain?

A

H1 + 5-HT2c

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82
Q

H1 antagonism
M1 antagonism
alpha1 antagonism
5-HT2c antagonism

Which one leads to orthostatic hypotension?

A

Alpha 1

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83
Q

H1 antagonism
M1 antagonism
alpha1 antagonism
5-HT2c antagonism

Which one leads to sedation?

A

H1

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84
Q

H1 antagonism
M1 antagonism
alpha1 antagonism
5-HT2c antagonism

Which one leads to tachycardia?

A

M1

85
Q

H1 antagonism
M1 antagonism
alpha1 antagonism
5-HT2c antagonism

Which one leads to anticholinergic effects?

A

M1 (anticholinergic = dry mouth, blurry vision, impaired memory, tachycardia

86
Q

Weight gain + anti psych meds, which ones are most likely causing it (first gen)?

A

Clozapine and olanzapine

87
Q

Which anti psych meds cause the highest risk of diabetes?

A

Clozapine and olanzapine

88
Q

Which benzazepine-like anti psych med causes the most AE?

A

Clozapine; sedation, orthostatic hypotension, anticholinergic effects

Dose-dependent seizures, agranulocytosis

89
Q

Benzazepine-like metabolism?

A

CYP1A2 for clozapine and olanzapine

90
Q

Loxapine metabolism?

A

Remember it’s a first gen anti psych

Forms amoxapine and 7-hydroxyloxapine

7-hydroxyloxapine has higher D2 affinity

Amoxapine forms antidepressant effects via N-demethylation

91
Q

Quetiapine metabolism?

A

CYP3A4; active metabolite is norquetiapine

92
Q

Benzisoxazole-like anti psychs vs other anti psychs, what kind of activity do they lack?

A

Anticholinergic activity

93
Q

Weight gain in benzisoxazole-like anti psychs is NOT present in which ones?

A

Ziprasidone and lurasidone (minimal for both technically)

94
Q

Risk of orthostatic hypotension is greatest in which benzisoxazole-like anti psych?

A

Risperidone and iloperidone

95
Q

Risperidone metabolism?

A

2D6 or 3A4 to paliperidone, excreted unchanged via renal elimination

96
Q

Which anti psychs have long-acting properties? Why is that?

A

Paliperidol, haloperidol, olanzapine, and fluphenazine

Esterified w/ saturated FA. Because they are IM inj, they are in tissues and slowly cleaved by esterases to release parent rx over time

97
Q

What’s special about olanzapine IM?

A

PK parameters are absorption-rate rather than elimination rate processes

98
Q

What is the dopamine hypothesis?

A

For schizophrenia, anti psychs block D2 receptors only

Drugs used for PD, exacerbate schizophrenia

Glutamate receptors might be suggested due to phencyclidine, ketamine, and NMDA antagonist as they produce schizophrenia sx

Serotonin receptors might be suggested due to higher serotonin levels higher in schizophrenic pt vs “normal” pt

99
Q

1st vs 2nd gen anti psychs, which one is likely to cause EPS and hyperporlactinemia?

A

First gen

EPS = dystonia, akathisia, tardive dyskinesia, pseudo-parkinsonism

100
Q

What other uses do anti psychs have?

A

Some second gen = Bipolar, depression, and both 1st/2nd gen = antiemetic effects

Exception to antiemetic = aripiprazole, brexipiprazole, cariprazine, lurasidone

101
Q

Which anti-psych AE involves neuroleptic malignant syndrome?

A

Haloperidol, possibly due to drop in dopamine activity

102
Q

Which anti psych is a partial agonist at D2 and 5HT1A, but a 5HT2A antagonist?

A

Aripiprazole

Brexipiprazole

Cariprazine

103
Q

Which 2nd gen anti psych AE has EPS?

A

Ziprasidone, risperidone, paliperidone

104
Q

Common AE of Quetiapine and Ziprasidone?

A

Somnolence

105
Q

Which second gen anti psychs cause weight gain?

A

Paliperidone and risperidone

106
Q

Which anti psych can cause constipation of GI hypomotility?

A

Clozapine

107
Q

Which Rx are used to treat tardive dyskinesia?

A

Valbenazine + deutetrabenazine (both inhibit VMAT2)

108
Q

Which anti psych is preferred with uncontrolled diabetes??

A

First gen

109
Q

Which anti psych is preferred with lower metabolic risk if pt is obese or diabetic?

A

Second gen (only aripiprazole, lurasidone, or ziprasidone)

110
Q

Which anti psych is preferred with new onset of schizophrenia?

A

Second gen

111
Q

Max dose of thioridazine?

A

800mg; causes QTc prolongation and retinopathy

112
Q

What is the only anti psych med that is sublingual?

A

Asenapine

113
Q

Lumateperone info?

A

5HT2A and D2 antagonist

Dose = 42mg only

Primarily metabolized by 3A4 and UGT; one of the only drugs to avoid certain drugs (UGT or 3A4 inhibitors)

114
Q

Cariprazine info?

A

D2 + 3 receptor agonist + has active metabolites

115
Q

Treating acute schizophrenia, stabilization, and maintenance therapy

A

Acute: goal for first 7 days is to decrease agitation, then slowly up the dose PRN. Switch drug if no improvement in 2-4 wks

Stabilization: Improvement occurs slowly over 6-12 weeks or longer; partial response can occur

Maintenance: Purpose is to prevent relapse. First episode should be treated for 1 yr, chronic illness for at least 5 yrs

116
Q

Which long-acting injectable anti psychs do not require PO overlap?

A

Paliperidone and olanzapine

117
Q

Olanzapine clinical pearl

A

Post injection delirium sedation syndrome

118
Q

What is the only anti psych rx used for treatment resistance?

A

Clozapine

119
Q

Deficiency of monoamines + depression link?

A

Almost every compound that increases monoamine levels (serotonin, NE, dopamine, etc) have antidepressant effects

WEAKNESS: more primary abnormalities may be responsible for deficiency

120
Q

Genetic vulnerability + depression link?

A

Use of family history to estimate genetic risk, genetic factors is around 30-40%

WEAKNESS: no solid evidence for specific genes or gene-environment
interactions, however evidence is growing

121
Q

Altered HPA axis activity + depression link?

A

Hypothalamus releases CRH in stress

Pituitary secretes corticotropin

Adrenal gland releases cortisol

Might be linked to early life stress and increased risk of MDD in adults

WEAKNESS: Most subjects have no evidence of HPA axis dysfunction, drugs that target HPA axis have inconsistent antidepressant effects

122
Q

Dysfunction of specific brain regions + depression link?

A

Untreated depression may lead to hippocampal volume loss which can increase stress sensitivity

WEAKNESS: limited evidence from neuroimaging studies

123
Q

Neurotoxic/neurotropic processes + depresion link?

A

Brain volume loss during depressive illness

WEAKNESS: no evidence in humans for specific neurobiological mechanisms

124
Q

Reduced GABA activity + depression link?

A

Reduced total GABA, GABA inhibits nerve transmission

WEAKNESS: drugs that target GABA system have inconsistent
antidepressant effects

125
Q

Glutamate dysregulation + depression link?

A

Glutamate is a major excitatory neurotransmitter which plays a role in
mood or anxiety disorders

WEAKNESS: questionable specificity since glutamate is involved in
numerous systems

126
Q

Impaired circadian rhythm + depression link?

A

Impaired sleep-wake regulation in depressed pt

WEAKNESS: no molecular understanding of this relationship with MDD

127
Q

Which drugs cause drug-induced depressive symptoms?

A

CHASMIC

Cardiovascular (BB, methyldopa, clonidine)

Hormonal therapy

Acne tx (Isotretinoin)

Smoking cessation

antiMigraine (triptans)

Immunologic (IFN)

antiConvulsants

128
Q

What is the USPSTF screening recommendations?

A

Children 12-18yo should be screened for MDD

All adults (especially pregnant and PP women) should be screened in primary care setting

129
Q

What is the DSM-5 diagnostic criteria

A

≥5 “symptoms” of depression during a 2 week period. One of the symptoms have to be depressed mood or loss of interest

130
Q

What do you do if someone screens positive from the PHQ-2 questionnaire?

A

Go to PHQ-9

131
Q

How are TCA antidepressants (ADs) broken up?

A

Tertiary amines (imipramine, amitriptyline, doxepin)

Secondary amines (desipramine, nortriptyline)

Both ^^ are further categorized into tetracycline ADs = mirtazapine (serotonin and alpha blockage)

**All of these are categorized as first gen SNRIs

132
Q

What are the second gen SNRIs?

A

Venlafaxine
Desvenlafaxine
Duloxetine
Levomilnacipran

133
Q

What are the NDRIs?

A

Bupropion

134
Q

What are the MAOIs?

A

Phenelzine
Tranylcypromine
Selegiline

135
Q

What are the aryl piperazines used as antipsychotics that have AD effects?

A

Trazodone and Vilazodone

136
Q

What are the steroid AD?

A

Brexanolone

137
Q

What are the NMDA antagonists?

A

Esketamine

138
Q

What are the SSRIs?

A 
fluoxetine
sertraline 
paroxetine 
citalopram
escitalopram 
vortioxetine
139
Q

In TCA ADs, what is needed for the AD activity?

A

3 carbon tether + terminal basic amine

140
Q

Which transporters do TCA AD affect? Secondary vs Tertiary amine?

A

Targets NET, SERT highly vs DAT (same with SNRIs)

Secondary has lowered number for NET (but it means more potent vs tertiary)

141
Q

TCA AD AE are contributed thanks to what?

A

They are also active on muscarinic, histamine, and alpha 1 receptors

142
Q

TCA OD can cause what?

A

Cardiac arrhythmias

143
Q

TCA AD metabolism is slow in 7% of the population due to what polymorphism?

A

CYP2D6

144
Q

SSRIs vs TCA AD, which one doesnt have CV side effects?

A

SSRIs

Same goes w/ SNRIs

145
Q

Escitalopram metabolism

A

Unlike TCAs, escitalopram is metabolized by many CYPs, therefore there is less chance of rx interactions or genetic polymorphisms

T1/2 = 10 days

146
Q

Which SSRI DOES have major interactions?

A

Paroxetine + CYP2D6

Fluoxetine + CYP2D6 (Pimozide and thioridazine; leads to QTc prolongation)

147
Q

Which SSRI has similar metabolism like escitalopram where it involves many CYPs?

A

Sertraline + Vortioxetine

148
Q

Venlafaxine vs Desvenlafaxine, CYP3A4 inhibitors affect which one greatly?

A

Venlafaxine

Desvenlafaxine has UGT metabolism as well

149
Q

Which AD doesnt use CYP enzymes?

A

Levomilnacipran

150
Q

Duloxetine and Levomilnacipran AE?

A

Postmarketing cases of liver injury via metabolite of oxidation of thiophene ring

Duloxetine; dont give in chronic liver disease or heavy alcohol use

151
Q

What special about mirtazapine’s receptor target?

A

Its a tetracycline ADs

Blocks alpha 2 and 5-HT2/3 + H1

Associated with wt gain and sedation

152
Q

Bupropion metabolism?

A

Only inhibits DAT and NET only (NDRI)

The tert-butyl group prevents N-dealkylation to metabolites with stimulant effects

153
Q

Aryl Piperazine AD, what do they target?

A

Trazodone = 5-HT2a and SERT, H1, alpha 1 (so it has their AE)

Vilazodone = 5-HT1a partially and SERT

154
Q

Which AD form metabolites that cause idiosyncratic hepatotoxicity?

A

Trazodone, the metabolites are iminoquinone and epoxide for glutathione conjugation

155
Q

Which AD class can take up to 2 weeks after d/c for activity to recover?

A

Long acting MAO-A/B (phenelzine and tranylcypromine)

156
Q

Which AD carry diet restrictions?

A

MAOi (to avoid hypertensive crisis)

157
Q

What kind of interactions do MAOi have?

A

With SSRIs, you need a washout period

Food interactions too!

158
Q

Which AD functions as a positive allosteric modulator of GABA_a receptors?

A

Brexanolone, used for PPD

159
Q

Brexanolone BBW?

A

Sedation and sudden loss of consciousness, needs REMS program called Zulresso REMS

160
Q

Which AD is used for treatment-resistant depression?

A

Esketamine

161
Q

Esketamine MOA?

A

S-enantiomer of ketamine,, non-competitive antagonist of NMDA receptors

162
Q

Esketamine BBW?

A

Sedation, dissociation, abuse, suicidal thoughts, available through SPRAVATO REMS

163
Q

What is the monoamine hypothesis and what are the current theories that we favor?

A

Monoamine = depletion of MA by reserpine (anti-HTN rx) that causes depression-like sx; AD rx increase brain monoamine

Current theory = dysregulation of 5-HT, NE, DA

164
Q

For MAOi to be effective, they must inhibit type (A/B)

A

A

165
Q

Which AD is used for bedwetting in peeps aged >6yo?

A

Imipramine (TCA)

166
Q

Which AD is used for insomnia in low doses?

A

Amitriptyline and Doxepin (TCA)

167
Q

Which TCA AD has withdrawal Sx?

A

Amitriptyline

168
Q

Which AD class has a high therapeutic index?

A

SNRIs

169
Q

What is the first line therapy for depression?

A

SSRIs

Equal in efficacy to TCAs

170
Q

Which class of AD causes many serotonin-related AE?

A

SSRIs

Brain 5-HT2 (insomnia, anxiety, low libido)

Spinal 5-HT2 (erectile dysfunction, anorgasmia)

Brain/peripheral 5-HT3 (nausea)

Sudden withdrawal syndrome

Wt gain, falls

171
Q

What is serotonin syndrome?

A

Triad of Sx

Mental status change

Autonomic instability

Neuromuscular abnormalities/Somatic

172
Q

Citalopram vs other SSRIs, what AE is specific to citalopram?

A

QTc prolongation

173
Q

Which AD drugs have a long half life?

A

Escitalopram + Fluoxetine

174
Q

Fluoxetine vs other SSRIs, what AE is specific to fluoxetine?

A

Anorexia

175
Q

Paroxetine vs other SSRIs, what AE is specific to Paroxetine?

A

More anticholinergic effects

176
Q

Nefazodone MOA and AE?

A

MOA = 5-HT2antagonist + SSRI

AE = Liver issues

177
Q

Special info on bupropion?

A

450mg/day increases seizure risk

Doesnt cause wt gain or sexual dysfunction

Will cause Insomnia!!

178
Q

Lithium info

A

Treats manic-depressive illness

Only mood stabilizer w/ data on suicide reduction in bipolar pt

MOA = unknown

179
Q

Psychotherapy, when should you recommend it for depression?

A

Only if pt is willing to participate

Might be used alone in mild/moderate MDD

NEVER alone in Severe or psychotic MDD or maintenance

180
Q

FDA label warning for antidepressants?

A

Bleed risk (esp. w/ NSAIDs, anticoagulants, and antiplatelets)

Suicide risk (greatest % in <24yo)

181
Q

Which SSRI inhibits 2C9?

A

Fluoxetine

182
Q

Which SSRI inhibits 1A2?

A

Fluvoxamine

183
Q 
What class of AD carries a risk of persistent pulmonary HTN of the
newborn (PPHN)?
A

SSRIs

184
Q

When is the best time to take SSRI?

A

Prior to bedtime or w/ food

If there is sleeping issues, start rx at low dose, take w/ BB or benzodiazepines

185
Q

Which SSRI causes the highest % of sexual AE?

A

Citalopram > paroxetine > sertraline > fluoxetine

186
Q

What is d/c syndrome + SSRIs?

A

Occurs when SSRIs are abruptly d/c

Change to fluoxetine when tapering to prevent this issue

187
Q

Which SNRI has the most sexual dysfunction?

A

Venlafaxine ER

188
Q

Specific AE to Venlafaxine?

A

When taking >150mg/day, BP can go up

189
Q

Which AD must be renally adjusted or lowered for the elderly?

A

Mirtazapine

Regular max = 45mg

Elderly = 15mg

190
Q

Which AD causes increased cholesterol?

A

Mirtazapine

191
Q

Which AD must be adjusted due to CYP3A4 inhibition/induction?

A

Vilazodone

Inhibitor = dont exceed 20mg

Inducer = increase dose to 80mg

192
Q

Which AD is useful in concomitant anxiety?

A

Vilazodone, maybe buspirone

193
Q

Which AD must be adjusted due to CYP2D6 inhibition/induction?

A

Vortioxetine

Inhibitor = reduce dose by half

Inducer = increase dose, max 3x dose

194
Q

Which TCA AD is least likely to cause orthostatic hypotension?

A

Nortriptyline

195
Q

Washout Period + AD?

A

Everything takes 2 weeks, except going from fluoxetine to MAOI, that takes 5-6wks

196
Q

What can cause HTN crisis w/ MAOIs?

A

Diet (tyramine)

SSRIs, SNRIs, TCAs and OTC decongestants

197
Q

Which AD is FDA approved for pt <18yo?

A

Fluoxetine

198
Q

How do you assess response of AD?

A

Remission - baseline returned

Partial remission- >50% decrease

Partial response - 26-49% decrease in sx

Nonresponse <25% decrease

199
Q

Phase of AD Tx?

A

Acute - 6-12 wks Goal = remission

Consolidation - 4-9months after remission
Goal = eliminate sx and prevent relapse

Maintenance - >12 months
Goal = prevent recurrence

200
Q

Which AD should you not use w/ BPH?

A

Duloxetine + Levomilnacipran, TCAs

201
Q

Which AD should you not use w/ glaucoma?

A

TCAs

202
Q

Is prophylaxis for acute dystonia recommended per WHO?

A

No unless they are high risk

203
Q

What is akathisia?

A

Motor restlessness, “always moving” usually treated w/ propranolol

204
Q

Which psychotic AE doesnt occur during sleep?

A

Tardive dyskinesia

205
Q

Which antipsych causes the highest incidence of seizures?

A

Clozapine + Chlorpromazine

206
Q

What antipsych causes retinitis pigmentosa?

A

Thioridazine

207
Q

Which antipsychotics cause neutropenia?

A

Clozapine (most), chlorpromazine, and olanzapine

If WBC<3k or ANC<1k, STOP IT!

208
Q

Pregnancy + Antipsychs, what are your options?

A

Haldol or risperidone

Avoid long-acting inj

209
Q

A change in ___mmHg or more is significant when checking a pt for orthostatic hypotension

A

20

IPT: Neuro (4 decks)

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