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PSYCH CLERKSHIP > Chapter 18_Psychopharmacology > Flashcards

Chapter 18_Psychopharmacology Flashcards

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1
Q

Typically how long to antidepressants take to see an effect?

A

Most require a trial of at least 3-4 weeks, some as little as 1-2 weeks others needing 6-8 weeks.

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2
Q

What are the most common class of antidepressants used and why?

A

SSRIs.

Low incidence of side effects (most resolve with time), no food restrictions, much safer in overdose

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3
Q

Mechanism of SSRIs

A

inhibit presynaptic serotonin pumps that take up serotonin -> increased availability of serotonin in synaptic clefts.

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4
Q

FDA blackbox warning for all SSRIs?

A

potential to increase “suicidal thinking and behavior” in children and young adults (under 25). Can happen to adults as well

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5
Q

T/F: You can have withdrawal from antidepressants

A

True. “withdrawal phenomena” - dizziness, headaches, nausea, insomnia, malaise…depends on dose and half-life they may need to be tapered

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6
Q

Give some examples of commonly used SSRIs

A

Fluoxetine (prozac), sertraline (zoloft), paroxetine (paxil), citalopram (celexa), escitalopram (lexapro),fluvoxamine (luvox)

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7
Q

Which SSRI is only approved for OCD and has multiple drug interactions due to CYP inhibition?

A

fluvoxamine

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8
Q

Whih SSRI has few drug interactions but higher risk for GI disturbance?

A

sertraline (zoloft)

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9
Q

Which SSRI has the fewest drug drug interactions, but has dose dependent QtC prolongation?

A

citalopram (celexa)

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10
Q

Which is a levo-enantiomer of citalopram but has fewer side effects, does not need to be tapered?

A

escitalopram (lexapro)

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11
Q

Which SSRI has several drug-drug interactions, has anticholinergic effects, and a short-half life leading to withdrawal phenomena if not taken correctly?

A

Paroxetine (paxil)

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12
Q

Why do SSRI’s have fewer side effects than TCAs or MAOIs?

A

serotonin selectivity (they don’t act on histamine, adrenergic or muscarinc receptors

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13
Q

Some side effects of SSRIs

A

GI disturbance (nausea/diarrhea, taking with food helps
insomnia; vivid drems
headache
anorexia, weight loss

USUALLY RESOLVE AFTER A FEW DAYS AS BODY GETS USED TO IT

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14
Q

Other side effects that are more serious/rare/won’t usually resolve?

A

Sexual dysfunction (30-40%) - decreased libido, norgasmia, delayed ejaculation
restlessness
serotonin syndrome (usually seen when combined with MAOIs) = autonomic instability, delirium, hyperreflexia
seizures, hyponatremia

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15
Q

Name two SNRIs

A

venlafaxine (effexor), duloxetine (cymbalta)

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16
Q

Good SNRI for depression and neuropathic pain, and fibromyalgia?

A

duloxetine

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17
Q

What advantage does buproprion (Wellbutrin) have over SSRIs? (norepi/dopamine reuptake inhibitor)

A

Lack of sexual side effects, some efficacy in treatment of ADHD

BUT…can lower seizure threshold, so don’t give to epilepsy or eating disorder patients

ALSO WORKS AS A GOOD SMOKING CESSATION AID

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18
Q

Which antidepressant is useful for treating major depression with insomnia, due to sedative effects?

A

trazodone!! (serotonin receptor antagonist)

just watch out for priapism

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19
Q

Which antidepressant is useful in treating major depression in patients with significant weight loss and/or insomnia?

A

mirtazapine (a2-adrenergic receptor antagonist)

MURTAZA LIKES TO SLEEP AND EAT!

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20
Q

Why are TCAs rarely used as first line agents?

A

LETHALITY IN OVERDOSE, side effect profile, tiration of dosing

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21
Q

Treatment for TCA overdose?

A

sodium bicarbonate

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22
Q

Name some TCAs

A

Amitriptyline, imipramine, clomirpamine, doxepin, nrotriptyline

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23
Q

“Anti” side effects of TCAs

A

Antihistaminic - sedation and weight gain
Anticholinergic - dry mouth, constipation, urinary retention, blurred vision
Antiadrenergic - CARDIOVASCULAR side effects ( orthostati hypotension, dizziness reflex tachcardia, widening QRS QT PR intervals, arrhythmias

3 C’s - cardiotoxicity, convulsions, coma

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24
Q

Mechanism of MAOIs l

A

prevent inactivation of biogenic amines (NE, serotonin, dopamine, tyramine) by irreversibly inhibiting enzyymes MAO-A and -B.

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25
Q

In what situations are MAOIs better than TCAs for depression?

A

Depression with atypical features (hypersomnia, increased appetite, interpersonal rejection sensitivity, leaden paralysis,

26
Q

Name some MAOIs

A

phenelzine, tranylcypromine, isocarboxazid

27
Q

Two big side effects to watch out for with MAOIs

A

serotonin syndrome - usually when SSRIs and MAOIs taken in close proximity due to increased serotonin. Lethargy, restlessness, progress to hyperthermia, hypertonicity, rhabdo.

hypertensive crisis - when MAOIs taken with tyramine-rich foods or sympathomimetics (excessive catecholamines)

28
Q

Treatment when serotonin syndrome is suspected?

A

d/c meds, provide supportive care with benzos and serotonin antagonist cyproheptadine

29
Q

MAO-A preferentially deactivates…

A

serotonin and norepinephrine (blocking this with MAOI helps with depression)

30
Q

MAO-B preferentially deactivates…

A

phenethylamine (acts on tyramine and dopamine along with MAO-A)

31
Q

Difference between typical and atypicals

A

typical (aka neuroleptics) - block dopamine (D2 receptors) -> EPS!
atypicals - block dopamine (D2, D4,) and serotonin (2A) receptors (less EPS, more metabolic syndrome); better at treating negative symptoms?

32
Q

Low potency typicals vs high potency typicals

A

Compared to high potency typicals, low potency typicals have…

  • lower affininty for dopamine receptors, meaning you need a higher dose for effect (not the same as lower efficacy)
  • higher incidence of antiadrenergic, -cholinergic, and -histamine side effecs
  • lower incidence of EPS and possibly neuroleptic malig syndrome (NMS)
33
Q

Name one low potency typical

A

chlorpromazine (thorazine)

34
Q

Side effects of chlorpromazine

A
  • orthostatic hypotension
  • blu-gray skin discoloration
  • photosensitivity
35
Q

Name some high potency typicals

A

haloperidol (decanoate long acting), fluphenazine, trifluoperazine, pimozide

36
Q

Compared to low potency typicals, high potency typicals…

A
  • have greater affinity for dopamine -> lower doses needed
  • greater risk for EPS, NMS, and tardive dyskinesia
  • less sdation, orthostatic hypotension, anticholinergic effects
37
Q

What are anti-HAM effects and what medication classes typically cause them?

A

Antihistamine - sedation, weight gain
Antiadrenergic - orthostatic hypotension, cardiac abnormalities, sexual dysfunction
antimuscarinic - dry mouth, constipation, tachycardia, urinary retention, blurry vision, precipitation of narrow-angle glaucoma

typically caused by TCAs (amitriptyline, nortriptyline, doxepin) and low potency antipsychotics

38
Q

What are the antidopaminergic effects seen in antipsychotics?

A
  • EPS!!! (parkinsonism, akathisia, dystonia)

- hyperprolactinemia - decreased libido, galactorrhea, gynecomastia, impotence, amenorrhea

39
Q

How does EPS occur?

A

antipsychotics block dopamine pathways in the NIGROSTRIATUM

40
Q

Positive symptoms of schizphrenia are treated by the actions of medications in the….pathway

A

mesolimbic dopamine pathway

41
Q

Negative symptoms of schizophrenia are thought to occur due to decreased dopaminergic action in the …. pathway

A

mesocortical

42
Q

Atypical least likely to cause EPS

A

clozapine

43
Q

Most weight friendly atypicals

A

aripriprazole and ziprasodone

44
Q

Atypical most likely to cause EPS

A

risperdone

45
Q

Besides schizophrenia, what else can atypicals treat?

A

bipolar, acute mania, adjunct to dpression, PTSD and borderline, tics also

46
Q

LAST resort antipsychotic for refractory schizophrenia

A

clozapine

47
Q

Only antipsychotic known to reduce suicide risk

A

clozapine

48
Q

which atypical has risk for agranulocytosis and myocarditis

A

clozapine

49
Q

What makes aripiprazole unique compared to other atypicals?

A

unique mechanism of partial D2 agonism -> can be more activating (akathisia) and less sedating, but less potential for weight gain

50
Q

Which atypical is associated with qtc prolongation

A

ziprasidone; must be taken with food

51
Q

Which atypical can cause increased prolactin

A

risperdone

52
Q

Therapeutic and toxic range of lithium

A

therapeutic - 0.6 - 1.2

toxic - >1.5

53
Q

What labs to regularly monitor for patient on lithium

A

lithium level, thyroid , CBC, renal function

54
Q

Side effects lithium

A

teratogen (Ebstein’s anomaly), nephrogenic DI, thyroid enlargement (hypo), GI disturbance, weight gain/sedation, benign leukocytosis, ECG changes, fine tremor (altered mental status, seizures, delirium, coma, death)

55
Q

How long before checking first lithium level?

A

5 days, then every 2 days after that

56
Q

Good anticonvulsant treatment for mania with mixed features and rapid cycling bipolar?

A

carbemazepine!

57
Q

Most serious side effect of lamotrigine?

A

steven johnson syndrome

58
Q

mechanism of benzos?

A

potentiate GABA in order to reduce anxiety; can treat akathisia

59
Q

how to treat benzo OD?

A

flumazenil; but don’t induce withdrawal too quickly

60
Q

treatment for restless leg syndrome?

A

dopamine agonists and benzos

61
Q

what lab to check of restless leg syndrome?

A

ferritin, iron replacement if low

PSYCH CLERKSHIP (10 decks)

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