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424 Pharmacology > CNS: Psychopharm and Cannabis > Flashcards

CNS: Psychopharm and Cannabis Flashcards

1
Q

What is a common consideration across antidepressants/anxiolytics?

A

Do not discontinue abruptly

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2
Q

What is the black box warning for all antidepressants?

A

increases risk of SI in children, adolescents and young adults

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3
Q

Common contraindication across TCAs, SSRIs, SNRIs, bupropion, methylphenidate, amphetamines

A

Contraindicated if MAOI use within 2 weeks

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4
Q

What nutrient do MAOIs interact with that make it difficult to prescribe? What can that cause?

A

Tyramine - can cause hypertensive crisis

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5
Q

What is usually prescribed for panic dx?

A

alprazolam, clonazepam, fluoxetine, paroxetine, sertraline, Buspar (not monotherapy)

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6
Q

What is usually prescribed for GAD (generalized anxiety)?

A

alprazolam, duloxetine, escitalopram, paroxetine, venlafaxine

off-label: citalopram, desvenlafaxine, fluoxetine, fluvoxamine, mirtazapine, pregabalin, sertraline

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7
Q

What are the first-line agents for PTSD?

A

VA guidelines: sertraline, paroxetine

Canadian guidelines: paroxetine, venlafaxine, fluoxetine, sertraline

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8
Q

What are some medications to be aware of that affect the CYP450 system and thus interact with several antidepressants/anxiolytics?

A
  • azole antifungals
  • macrolide antibiotics
  • HIV protease inhibitors
  • calcium channel blockers
  • SSRIs
  • nefazodone
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9
Q

What is neuroleptic malignant syndrome?

A

rare but potentially fatal - extreme muscle rigidity, high fevers, coma, death

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10
Q

Tricyclic antidepressants

Amitriptyline, nortriptyline, imipramine, doxepin, trimipramine maleate, amoxapine, desipramine, protriptyline hydrochloride, clomipramine

Indication & MOA

A

Indications: depression, anxiety with sleep disturbance (doxepin, elavil), enuresis in children 6+ (imipramine), OCD (clomipramine), eating disorders

Doxepin: insomnia

MOA: Acts on serotonin, norepinephrine, histamine and acetylcholine

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11
Q

Tricyclic antidepressants

Amitriptyline, nortriptyline, imipramine, doxepin, trimipramine maleate, amoxapine, desipramine, protriptyline hydrochloride, clomipramine

Prescribing considerations

A
  • Long half-life of 6-8 hours
  • Metabolized by the CYP450 system
  • Highly cardiotoxic; can cause life-threatening arrythmias
  • narrow TI OD can be fatal OD dose isn’t that high - avoid in those with SI
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12
Q

Tricyclic antidepressants

Amitriptyline, nortriptyline, imipramine, doxepin, trimipramine maleate, amoxapine, desipramine, protriptyline hydrochloride, clomipramine

Avoid, caution

A
  • Avoid: angle closure glaucoma, suicidal patients, cardiovascular disorders, glaucoma
  • Caution: metabolic syndrome, seizure disorder, elderly (anticholinergic fx, hip fractures)
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13
Q

Tricyclic antidepressants

Amitriptyline, nortriptyline, imipramine, doxepin, trimipramine maleate, amoxapine, desipramine, protriptyline hydrochloride, clomipramine

Adverse fx (5)

A
  • Paradoxical diaphoresis
  • Anticholinergic fx
  • Orthostatic hypotension
  • Sedation
  • drowsiness
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14
Q

SSRIs

Fluoxetine, olanzapine-fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram, escitalopram

Indications & MOA

A

indications: depression, anxiety, panic disorders, OCD, body dysmorphic disorder, bulimia, PDD, PTSD, vasomotor symptoms in menopause

MOA: Selective inhibitory fx on presynaptic serotonin reuptake and weak fx on NE and dopamine reuptake

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15
Q

SSRIs

Fluoxetine, olanzapine-fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram, escitalopram

Considerations (specific to fluoxetine, paroxtine, sertraline, citalopram, escitalopram)

A
  • Long half-life: 26 hours
  • Takes a few weeks to take effect
  • Extensive first-pass metabolism
  • Metabolized by the CYP450 system
  • Fluoxetine: least likely to cause weight gain, increases energy can be activating (may feel like worsening anxiety), long half-life; start low and titrate slow
  • Paroxetine: interacts with a lot of other medications, nasty withdrawal, stimulates appetite, significant weight gain, excessively sedating
  • Sertraline: increases energy
  • Citalopram: BBW for QT prolongation - max dose 40mg daily, 20mg daily if over 60
  • Escitalopram: tends to be weight neutral and neither sedating nor activating
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16
Q

SSRIs

Fluoxetine, olanzapine-fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram, escitalopram

BBW, pregnancy/lactation, peds, contraindications

A
  • BBW for citalopram: QT prolongation
  • Pregnancy/lactation: Eval risk vs. benefit, newborn can have withdrawal symptoms; lactation: sertraline and escitalopram have the lowest relative infant dose
  • Peds: Fluoxetine is first line
  • CI: hypersensitivity to SSRIs, renal or hepatic insufficiency
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17
Q

SSRIs

Fluoxetine, olanzapine-fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram, escitalopram

adverse fx

A
  • CNS: agitation, insomnia, serotonin syndrome, blurred vision, headache, drowsiness, tremor
  • GI: nausea, vomiting, diarrhea, GI bleed, hyponatremia, weight changes, dry mouth, constipation
  • Other: Sexual dysfunction, rash/itching
  • CV: QT prolongation (citalopram)
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18
Q

What is serotonin syndrome?

A
  • ADR that occurs with more than one serotonergic agent taken at the same time
  • Sx = altered mental status or agitation, GI distress, neuromuscular changes (clonus, tremors, hyperreflexia), VS changes, sweating, hyperthermia
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19
Q

SNRIs

Venlafaxine, duloxetine, milnacipran, desvenlafaxine

Indications, MOA

A
  • MDD, GAD, neuropathy, fibromyalgia (Milnacipran), social anxiety, binge eating disorder, OCD, postmenopausal disorder, PTSD, panic disorder
  • MOA: Inhibit reuptake of norepinephrine and serotonin
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20
Q

SNRIs

Venlafaxine, duloxetine, milnacipran, desvenlafaxine

Prescribing considerations

A
  • Long half-life 8-17 hours
  • Metabolized by CYP450
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21
Q

SNRIs

Venlafaxine, duloxetine, milnacipran, desvenlafaxine

Avoid, pregnancy

A
  • Avoid: uncontrolled HTN, renal & hepatic impairment
  • Pregnancy: venlafaxine & desvenlafaxine - consider tapering in 3rd trimester
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22
Q

SNRIs

Venlafaxine, duloxetine, milnacipran, desvenlafaxine

Interactions & Monitoring

A
  • Interactions
    • Antibiotics
    • OTC medications that stimulate or cause insomnia or drowsiness
  • Monitoring
    • Serum transaminase levels
    • SI
    • Activation of hypomanic or manic symptoms
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23
Q

SNRIs

Venlafaxine, duloxetine, milnacipran, desvenlafaxine

Adverse fx

A
  • CNS: Headache, somnolence, dizziness, Insomnia, Fatigue, sedation
  • GI: Dry mouth, Constipation, nausea
  • CV: Orthostatic hypotension
  • GU: Erectile dysfunction, Ejaculation failure
  • Other: sweating
24
Q

Bupropion (Wellbutrin)

Indications & MOA

A
  • indications: good with co-morbid mood dx; ADHD, MDD, smoking cessation
  • MOA: inhibits reuptake of norepinephrine and dopamine
25
Bupropion Contraindication & adverse fx
* CI: bupropion in seizure disorders or when tapering/withdrawing from other CNS depressants; avoid in anxiety * ADR: insomnia
26
Mirtazapine/trazodone Indications, MOA, ADRs
* Indications: Mirtazapine is an antagonist of 5HT2, 5HT3 and histamine receptors * ADR: drowsiness at higher levels
27
Typical Antipsychotics Phenothiazines: Chlorpromazine (Thorazine) Non-phenothiazine: haloperidol (Haldol) MOA, CI, BBW
Block dopamine receptors in the basal ganglia, hypothalamus, limbic system, medulla CI: glaucoma, bone-marrow depression, severe liver or CVD BBW: increased mortality in older adult patients
28
Typical Antipsychotics Phenothiazines: Chlorpromazine (Thorazine) Non-phenothiazine: haloperidol (Haldol) Monitoring & ADRs
* Monitoring: Abnormal involuntary movement scale (AIMS) * ADRs * STANCE * Sedation/sunlight sensitivity/skin effects/sexual side fx * Tardive dyskinesia * Anticholinergic effects and agranulocytosis * Neuroleptic malignant syndrome * Cardiac arrythmias * Extrapyramidal symptoms/akathisia endocrine effects - increased prolactin * Weight gain
29
Atypical antipsychotics Ariprazole (Abilify),clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), ziprasidone (Geodon) Indications & MOA
* psychotic mania, nonpsychotic mania * Block serotonin and dopamine receptors
30
Atypical antipsychotics Ariprazole (Abilify),clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), ziprasidone (Geodon) Considerations, CI, ADRs
* Considerations: -pines are more sedating than the -dones, related to their antihistamine actions * CI: hepatic or renal disease * ADRs * Seizures * Weight gain * Diabetes * Hyperprolactinemia * Dizziness * Orthostatic hypotension * Clozapine: fatal agranulocytosis
31
Benzodiazepines Lorazepam (Ativan), Flurazepam (dalmane), Temazepam (restoril), Triazolam (Halcion) Indications
* anxiety, panic disorders, alcohol withdrawal, seizures, insomnia, muscle spasms, pre-anesthesia sedation, IBS, restless leg syndrome, chemo N/V * Flurazepam, temazepam, triazolam for insomnia * MOA: increase the action of GABA, which decreases the effect of neuronal excitation
32
Benzodiazepines Lorazepam (Ativan), Flurazepam (dalmane), Temazepam (restoril), Triazolam (Halcion) Considerations, caution, CI, peds
* rapidly and widely distributed throughout the body following oral intake; peak 30min-8 hours * Caution: elderly - BEERS * CI: pregnancy, renal & hepatic impairment, hypersensitivity to benzodiazepines, acute narrow-angle glaucoma * Peds: 6+
33
With which medications should you educate your patient to avoid driving while taking? What are the treatment durations of these medications?
* Flurazepam, temazepam, triazolam: Should not be used more than 3x a week for less than 3 months * Zolpidem not to be used longer than 8 weeks; females take half-dose * Zaleplon should not be used longer than 5 weeks
34
Benzodiazepines Lorazepam (Ativan), Flurazepam (dalmane), Temazepam (restoril), Triazolam (Halcion) Interactions, Monitoring, ADRs
* Interactions * digoxin, TCAs: benzo increases level * barbiturates, nefazodone, fluoxetine, fluvoxamine, MAOIs, sertraline, antihistamines: increased CNS depression * Clozapine: increased sedation, salivation, hypotension, delirium, respiratory arrest * Monitoring if long term use: LFTs, CBC, TCA and digoxin levels * ADRs * CNS depression * Sedation * Physical dependence
35
Buspirone (BuSpar) MOA, considerations
* partial agonist for serotonin 5-HT1a receptors in the brain * May take up to 6 weeks to see fx * No physical dependence/withdrawal/abuse potential * Less sedating and limited psychomotor impairment * Lack of interaction with alcohol
36
Buspirone (BuSpar) Interactions, ADRs
* Interactions * MAOIS, SSRIs may cause serotonin syndrome * Atypical antipsychotics * ADRs * Dizziness * Drowsiness * nausea
37
Benzodiazepine receptor agonist Zolpidem (ambien), zaleplon (sonata), eszopiclone (Lunesta) Indication, MOA, CI, Interactions, monitoring, ADRs
* Indication: Insomnia * MOA: agonists on the benzodiazepine site of the GABAa receptor * CI: pregnancy, elderly, children, long-term use * Interactions: Avoid with alcohol, other CNS depressants * Monitoring: LFTs * ADRs: CNS depression, sedation, abnormal behaviors
38
Lithium (Lithobid, eskalith) Indications, considerations
* Indications: Mood stabilizer: manic episodes, maintenance treatment of manic depressive patients with hx of mania; off-label maintenance for bipolar depression and adjunct for MDD, dementia * Considerations * Not metabolized by the liver, excreted by kidneys * Long half-life: 15-36 hours * Maintain adequate salt intake
39
Lithium (Lithobid, eskalith) CI, Monitoring
* CI: pregnancy * Monitoring * Narrow TI - monitor every 10-14 days after initiating then every 2-3 months after * TSH, kidney function, EKG
40
Lithium (Lithobid, eskalith) ADRs
* Toxicity * ECG changes * LMNOP: Lithium can cause movement issues (tremors); nephrotoxicity; hypothyroidism; pregnancy problems
41
Valproic acid Indications, MOA, consideration, CI, monitoring
* Indications - Mood stabilizer: acute mania and mixed episodes; off-label: maintenance tx of bipolar disorder, bipolar depression, psychosis, schizophrenia * MOA: Block GABA * Considerations: Metabolized by the CYP450 system * CI: pregnancy * Monitoring * Plasma levels every 3 months * Platelets, LFTs, coagulation studes
42
Lamotrigine, gabapentin, topiramate Indications, monitoring, ADRs
* Indications: Mood stabilizer: maintenance of bipolar I; off-label: bipolar depression, bipolar mania, neuropathic/chronic pain, MDD * Monitoring: ophthalmological checks required, baseline kidney/liver function tests * ADRs * Somnolence * Dizziness * Weight changes * Topiramate has 1% chance of renal calculi
43
Carbamazepine (Tegretol) Indications, considerations, monitoring
* Indications: off-label - bipolar depression, bipolar maintenance, psychoses, schizophrenia adjunct * Considerations: Ancestry across broad areas of asia should consider screening for HLA-B1502 allele - can increase risk of Stevens-Johnson syndrome * Monitoring: CBCs, LFTs, kidney function, TSH
44
Stimulants Methylphenidate, dexamphetamine, amphetamine Indications, MOA
* First line ADHD, narcolepsy * increase neurotransmission of dopamine and norepinephrine
45
Stimulants Methylphenidate, dexamphetamine, amphetamine Considerations
* Methylphenidate: food slows absorption and onset of action * Amphetamines - Vyvanse is the least likely to cause addiction
46
Stimulants Methylphenidate, dexamphetamine, amphetamine General CI & caution, then specific to methylphenidate vs. other amphetamines
* CI: CVD, HTN, pregnancy * Caution: glaucoma, other mental health conditions, personal/family hx of Tourette's or tics, seizure dx, Anxious/agitated/tense patient * Methylphenidate: circulation issues in fingers or toes * Amphetamines: hyperthyroidism, history of drug misuse, hx of issues with stimulants, liver or kidney issues, thyroid issues
47
Stimulants Methylphenidate, dexamphetamine, amphetamine ADRs
* Insomnia * Weight loss * Palpitations * HA * HTN
48
Non-stimulants Atomoxetine, guanfacine, clonidine Indications, MOA, considerations
* Indications: 2nd line ADHD * Guanfacine, clonidine: best if hyperactivity and impulsivity poorly controlled * MOA: inhibits presynaptic norepinephrine transport * Consideration: Potential for patients with hx of substance abuse, tics or severe adverse fx to stimulants
49
Cannabis Indications, MOA
* Indications * THC: analgesia, anti-inflammatory fx, antiemetic * CBD: analgesic, anti-inflammatory and anti-seizure * CB1: cannabinoid receptors in the CNS modulate cognition, memory, motor function and analgesia * CB2: cannabinoid receptors found in tissues related to immune fxn such as WBC, bone marrow, tonsils, thymus and spleen
50
Cannabis Types
* Sativa: uplifting, energetic, anti-depressive fx, preferred for daytime use * Indica: relaxing, calming, sedating, preferred for nighttime use * CBD/THC: can be used day or night - CBD mitigates the psychoactive component of THC
51
Cannabis ADRs
* Xerostomia, nausea, vomiting with excessive use, drowsiness, somnolence, vertigo/dizziness * Cannabinoid hyperemesis syndrome may occur with people who smoke excess of marijuana daily and long term - once stopped this should go away but can return if use resumes
52
Clonidine MOA & Indications
* MOA: centrally acting alpha-2 agonist * Indications: approved for HTN and ADHD; off-label for PTSD, social anxiety, Tourette's, substance withdrawal, menopausal flushing, severe pain not relieved by opiates alone
53
Propranolol (Inderal) Indications & MOA
* Indication: off-label: PTSD, GAD, violence/aggressive behavior * MOA: * Helps to prevent the development of PTSD: blocks beta-1 adrenergic receptors and may prevent fear conditioning and reconsolidation of fear * Violence/aggression: presumed to be related to central actions at beta adrenergic and serotonin receptors
54
Pediatric considerations for the following: Lithium, olanzapine, risperidone, ariprazole, ziprasidone, asenapine
* Lithium: approved for acute mania/mixed mania and bipolar maintenance 7+ * Olanzapine: approved 13+ for schizophrenia and acute mania; 10+ in combo with fluoxetine for bipolar depression * Risperidone: approved 13+ for schizophrenia; 10+ acute mania/mixed mania; 5-16 for autism-related irritability * Ariprazole: approved 13+ schizophrenia; 10+ acute mania/mixed mania; 6-17 autism related irritability; 6-18 Tourette's * Ziprasidone: clinical trials have demonstrated efficacy for behavioral disturbances in children and adolescents * Asenapine: approved 10-17
55
Pregnancy considerations for the following: Lithium, valproates, carbamazepine, lamotrigine
* Lithium: associated with increased neonatal readmissions, first-trimester exposure has major risk for malformation in infant * Valproate: avoid as it can cause fetal abnormalities * Carbamazepine: avoid as it can cause fetal carbamazepine syndrome * Lamotrigine: potential option for maintenance therapy

424 Pharmacology (12 decks)

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