Chapter 15: psych Flashcards
which receptors are blocked by antipsychotics
cholinergic
muscarinic
histamine
dopamine
antipsychotic action
comes from blocking of CNS dopamine receptors in the mesocorttical/mesolimbal systems in the brain
EPS is the result of
dopamine blocking in other parts of the body
EPS
parkinson-like syndrome usually occuring with both classes of antipsychotics as a result of years of exposure
symptoms of EPS
dystonia usually occurs within first 5-30 days
tardive dyskkinesia after 6 months (can be reversible)
rhythmic tongue protrusion, puffing cheeks, puckering of mouth
neuroleptic malignant syndrome (NMS)
life-threatening
starts months after therapy begins but rapidly progresses
treatment of NS
rapid d/cof agent and administration of dantrolene to relax muscles
how should antipsychotic therapy be discontinued
slowly reduce dose over 2-3 weeks
first generation antipsychotics (typical)
phenothiazines
examples of phenothiazines
haloperidol (Haldol)
trifluoperazine (Stelazine)
chlorpromazine (Thorazine)
second generation antipsychotics (atypicals)
aripiprazole (Abilify)
risperidone (Risperdal)
Olanzapine (Zyprexa)
largest group of psychotropic agents
phenothiazines
phenothiazine mechanism of action
unknown
theorized that it is a result of dopamine blockage in certain areas of CNS
effects of long term phenothiazine usage
cardiac arrythmia
hyperlexia (life-threatening)
HTN
rigidity
tardive dyskinesia
clinical uses of phenothiazines
acute, idiopathic psychotic illness marked by agitation
manic phase of bipolar disorder
schizophrenia
phenothiazines interactions
- alcohol (CNS depression)
- anticholinergics (increased anticholinergic effects)
- amphetamines (decrease antipsychotic effect)
- antiparkinson drugs (antagonize antipsychotic effect)
- hypoglycemics (weaken control of diabetes)
- lithium (decreases antisychotic effect)
phenothiazines contraindications
parkinsonism
blood dyscrasia
severe liver impairment, cardiac disease, or CNS depression
Reye’s syndrome
overdose of phenothiazines
fairly common but not fatal
symptoms: worsening CNS depression, hypotension, worsening of EPS
why are atypical antipsychotics considered atypical
hey do not cause EPS, tardive dyskinesia, or elevate prolactin levels
what is the only atypical antipsychotic with clear evidence of efficacy in treatment-resistant schizophrenia
clozapine (Clozaril)
black box warning for all antipsychotics
may increase mortality in elderly with dementia-related psychosis
Clozaril places at increased risk for
agranulocytosis, aeizures, and myocarditis
clinical uses for atypical antipsychotics
psychosis in patients with schizophrenia
depression or mania with psychotic features
bipolar disorder
severe agitation and delusions in dementia patients
when are antipsychotic medications used
psychotic episodes when tranquilizing effect is needed
Tourette’s (pimozide)
examples of atypical antipsychotics
- aripiprazole (Abilify)
- asenapine (Sapris)
- clozapine (Clozaril)
- iloperidone (Fanapt)
- lurasidone (Latuda)
- olanzpine (Zyprexa)
- olanzapine/fluoxetine (Symbyax)
- palpiperidone (Invega)
- quetiapine (Seroquel)
- risperidone (risperdal)
- ziprasidone (Geodon)
atypical antipsychotic interactions
any drug requiring liver metabolism (including alcohol)
atypical antipsychotic contraindications
liver impairment
drug classes used for depression
MAOIs (Monoamine oxidase inhibitors)
TCAs (tricyclic antidepressants)
SSRIs (selective serotonin reuptake inhibitors)
non-TCA Antidepressants
examples of third line MAOIs
tranylcypromine (parnate)
selegiline (Emsam)
phenylamine (Nardil)
RARELY USED ANYMORE
MAOI mechanism of action
irreversible, non-selective inhibitors of MAO in its CNS storage sites
depression relief immediately or within 1 week
HTN crisis with MAOIs can be precipitated by
foods rich in tyramine (alcohol, aged cheese)
sympathomimetic drugs (cough meds containing ephedrin)
tricyclic antidepressants
what herb can cause life-threatening serotonin syndrome when taken with MAOI
St. John’s wort
MAOI contraindication
liver impairment
wash out period when witching from MAOI to SSRI
2 weeks
foods high in tyramine
aged cheese, beer, wine, pickled products, liver, raisins, bananas, figs, avocados, chocolate, yogurt, meat tenderizer
second line tricyclic antidepressants (TCAs)
mechanism of action
blocks neuronal reuptake of norepinephrine and serotonin at presynaptic terminus
has anticholinergic properties
ability to increase mood poorly understood as they do not stimulate the CNS
how long to clinical effect of TCAs
2-8 weeks
clinical uses of TCAs
endogenous depression
reactive depression
depression r/t alcohol/cocaine withdrawal, anxiety, neuropathic pain, enuresis, OCD
examples of TCAs
- amitriptyline (Elavil)
- clomipramine (Anafril)
- doxepine (Silenor)
- imipramine (Tofranil)
- trimipramine (Surmontil)
- amoxapine (Asendin)
- desipramine (Norpramin)
- nortriptyline (Pamelor)
- protriptyline (Vivactil)
TCA interactions
any anticholinergic or barbituate, chlorpropamide, cimetidine, clinodine, epinephrine, ethanol, fluoxetine, neuroleptics, norepinephrine, propoxyphene, quinidine, and SSRIs
TCA contraindications
MAOI use
recovery phase of MI
doxepine is contraindicated with glaucoma or urinary retention
TCAs are most effective in which population
severe depression, especially with greater disturbances and melancholia
advantages of SSRI
act quicker and more reliabily than other antidepressants and have fewer side effects
SSRI mechanism of action
selectively inhibits 5-HT neuronal reuptake at selected nerve terminals in the CNS and inhibit CYP450
SSRI effect on norepinephrine and dopamine reuptake
little to no effect
clinical uses of SSRIs
major depression
depression in patients with comorbidities
panic disorder
examples of SSRIs
citalopram (Celexa)
fluoxetine (Prozac)
fluvoxamine (Luvox)
paroxetine (Paxil)
sertraline (Zoloft)
escitaloprma (Lexapro
how long does it take SSRIs to relieve depression
up to 6 weeks
Luvox (SSRI) is used only for
OCD
(produces no anticholinergic effects)
which SSRIs should be taken in the morning and why
Prozac, Paxil, Zoloft because they can induce insomnia
SSRIs and NSAIDs
concurrent use can increase GI bleeding risk
SSRI interactions
buspirone
diazepam
lithium
MAOIs
neuroleptics
tricyclics
SSRI contraindications
MAOI use within 14 days
pregnancy and lactation
Prozac dosage with liver problems
must be reduced because Prozac is a strong inhibitor of the CYP450 system
Prozac elevates the levels of which drugs
antiarrhythmics, other antidepressants, phenothiazine, risperidone, theophylline
antidepressant for a patient that presents with a flat affect and fatigue
Prozac because it one of the more stimulating SSRIs
most sedating SSRI
Paxil
depressed patient that presents with anxiety, agitation and severe insomnia
Paxil
which SSRI has a higher incidence of weight gain and side effects, requiring frequent monitoring
Paxil
symptom of abrupt d/c of Paxil
flu-like syndrome
middle of the road SSRI
Zoloft
newer SSRI that is highly bound to plasma protein
Celexa
SSRi with the most favorable drug-drug interaction profile
Celexa because it has the least effect on the CYP450 system
when did non-TCA antidepressants enter the market
1990’s
classes of non-TCAs
SNRI (serotonin and norepinephrine reuptake inhibitors)
NDRIs (norepinephrine and dopamine reuptake inhibitors)
SRIs (serotonin reuptake inhibitors)
TeCa (tetracycline antidepressant)
examples of SNRIs
Ymbalta
Pristiq
Effexor
aside from depression, SNRIs are approved to treat
anxiety
panic disorder
OCD
bulimia
common off label uses for SNRIs
insomnia
chronic pain (diabetic neuropathy)
SNRI contraindications
MAOI use within 14 days
example of NDRIs
bupropion (Wellbutrin)
wellbutrin adverse reactions
- CV: tachycardia
- DERM: photosensitivity
- ENDO: hyperglycemia, hypoglycemia
- GI: anorexia, weight loss, nausea, constipation, dry mouth
- META: weight loss
- NEURO: tremors/seizures if not taken correctly (dose dependent)
wellbutrin interactions
common are phenobarbital and tegretal because they all undergo first pass metabolism
wellbutrin contraindications
history of seizure, anorexia, bulimia
MAOI use within 14 days
example of SRI
trazadone (Desyrel)
clinical uses of trazadone
depression with insomnia, anxiety, and chronic pain
off label uses of trazadone
sedative, panic attacks, agoraphobia, cocaine withdrawal, aggressive behavior
trazadone interactions
digoxin and coumadin
(take in divided doses)
trazadone contraindications
hypersensitivity
example of tetracyclic antidepressant (TeCA)
mirtazipine (Remeron)
clinical uses of remeron
depression
PTSD
remeron interactions
- MAOIs (HTN, seizures, death from serotonin syndrome)
- CNS depressants (increased CNS depression)
- any drug affecting CYP450
remeron contraindications
hypersensitivity
agents used to treat bipolar mania
lithium
valproates
carbamazepine
itium mechanism of action
unknown
clinical uses of lithium
bipolar disorder
with other antidepressants for major depression
with antipsychotics for schizophrenia
what are lithium side effects related to
serum level
signs of lithium toxicity and serum levels at which they occur
2.0-2.5 mEq/L or greater
- CV: severe hypotension, ARRYTHMIAS, ECG changes, circulatory failure
- NEURO: ataxia, blurred vision, giddiness, tinnitus, SEIZURES
- GU: oliguria, nephrogenic diabetes insipidus
lithium contraindications
significant renal impairment
significant cardiovascular disease
significant thyroid disease
diabetes
severe dehydration
sodium depletion
pregnancy
how often should lithium levels be drawn
biweekly until stable and then every 2-3 months
what can happen with abrupt withdrawal of depakote
status epilepticus
valproaes mechanism of action and uses
mechanism of action is unknown
acts as an anticonvulsant, anti-manic, and antimigraine
Benzo pharmacokinetics
page 288
benzo interactions
alcohol, CNS depressants, opiod analgesics, anesthetics, TCAs can cause enhanced CNS depression
benzo contraindications
comotose
uncontrolled severe pain
severe hypotension
angle-closure glaucoma
sleep apnea
specific contraindications for Halcion and Xanax
taking ketoconazole and itraconazole
schedule of benzodiazepines
IV
Meprobamate (Equanil, Miltown)
schedule IV drug that is a carbamate derivative
use today is almost non-existant
meprobamate
mechanism of action
affects thalamus and limbic systems as well as inhibits multi-neuronal spinal reflexes
clinical use of meprobamate
relieve pain of muscle spasms and rigidity
implications for special populations
pages 289-290
