DOC, MC, CI for Test 4 Flashcards
(Lecture 1)
An anticonvulsant used in Bipolar Disorder, this is the current DOC in most manic indications
Valproic Acid/ Divalproex sodium
Effective as lithium in acute and prophylactic management
PREFERRED FOR RAPID CYCLERS (>4 MANIC EPISODES /YR)
PREGNANCY CAT D
(Lecture 1) This class of drugs is used first line in treating: -Depression -OCD -Panic Disorder -Social Phobia -PTSD -Premenstrual Dysphoric Disorder (PDD) -Generalized Anxiety Disorder
Selective Serotonin Reuptake Inhibitors (SSRIs)
(EX: Fluoxetine; Fluvoxamine; Paroxetine; Sertraline; Citalopram; Escitalopram; Vilazodone; Vortioxetine
- not as lethal in cases of OD as are TCAs
- ONSET OF ACTION TAKES 3-8 WEEKS (OR LONGER IN SOME CASES)
(Lecture 1)
This drug is used as a first line treatment of PTSD along with SSRIs
Venlafaxine (an SNRI)
-WORKS AS AN SSRI AT DOSES ~75mg/day; SNRI AT > 225mg/day
ADE: GI… INCREASE IN BP… ABRUPT DISCONTINUATION can yield withdrawal syndrome similar to SSRI w/d (taper dose)
CI: MAOIs and -triptans (serotonin syndrome)
(Lecture 1)
This drug is a 2nd line agent for MDD
Desvenlafaxine (as SNRI)
is an active metabolite of venlafaxine… no advantage over venlafaxine
(Lecture 1)
This drug is considered a 2nd or 3rd line agent used for anxious depression or in SSRI use that is too activating/ causing sexual dysfunction
Nefazodone (a Serotonin Receptor Antagonist… inhibits 5HT2 family of receptors)
-BLACK BOX WARNING for risk of liver failure
(Lecture 1)
This MAOI, used for atypical depression in patients refractory to other anti-depressants is considered LAST LINE agent
Tranylcypromine
(Lecture 1)
This NDRI is contraindicated for PATIENTS AT RISK FOR SEIZURES, those with a hx of eating disorders, and those withdrawing from alcohol or benzos
Bupropion
(Lecture 1)
This anti-depressant is “not likely” to cause sexual dysfunction
Bupropion
(Lecture 1)
These 2 anti-depressants are “less likely” to cause weight gain
Bupropion
and
Fluoxetine
(Lecture 1)
These 3 are good choices for antidepressants which avoid/reduce somnolence
Mirtazapine
Paroxetine
and
Trazodone
(Lecture 1)
These anti-depressants can increase energy
- Bupropion or an SNRI
- Fluoxetine and Sertraline are more activating than other SSRIs
(Lecture 1)
These anti-depressant classes are recommended if the PT is currently experiencing anxiety; this drug can increase anxiety
- SSRI or SNRIs are recommended in anxiety
- Bupropion can increase anxiety
(Lecture 1)
These two anti-depressants can be used in depression plus fibromyalgia or neuropathic pain
Duloxetine
or
Venlafaxine
(Lecture 1)
These two anti-depressants have indication for diabetic neuropathy
Amitriptyline
and
Imipramine
(Lecture 2) This class of drugs is DOC for parkinsonism induced by drugs (anti-psychotics and Metoclopromide (Antiemetic))
Anticholinergics
EX: Benztropine (useful for control of EPS other than tardive dyskinesia)
and
Trihexyphenidyl
(Lecture 2)
This drug may be the best choice for patients with mild-moderate Parkinson’s
Controlled release Carbidopa/Levodopa
-no measurable effect on “freezing”
(immediate release version for ERRATIC disease)
(Lecture 2) drug class considered first line mono-therapy in most symptomatic Parkinson's Pts because of less dyskinesias and not oxidizing into free radicals
Dopamine Agonists
- may delay need for Levodopa for several years
- can cause daytime sleepiness
- USE WITH CAUTION IN PTS W/ PSYCHOSIS OR DEMENTIA (may worsen sx)
(Lecture 2)
IMPROVEMENT OF MOTOR DISABILITY in Parkinson’s is better with which drug?
Levodopa
- greatest effect on bradykinesia and rigidity
- initial therapy for elderly (>70), dementia, and patients with significant cognitive impairment
- wearing-off and on-off phenomena
(Lecture 2) LESSENING OF MOTOR COMPLICATIONS in Parkinson's is better with which class of drugs?
Dopamine agonists
EX: Bromocriptine; Pramipexole; Ropinirole; Apomorphine
(Lecture 2)
Treatment strategy for Parkinson’s PT with side effect of Dyskinesia?
- Reduce L-Dopa dose
- Add amantadine (NMDA receptor Inhibitor) or an anticholinergic
(Lecture 2)
Treatment strategy for Parkinson’s PT with side effect of severe motor fluctuations despite optimal oral therapy?
consider SQ apomorphine (a short acting D2 selective Dopamine angonist)
- FOR ACUTE, INTERMITTENT TX OF “OFF” EPISODES
- IF NO DOSING >1 WEEK, RESTART AT 0.2 ml INCREASE
or
Duodopa
(Lecture 2) This class of drug is most useful in Parkinson's PTs with tremors, but side effects and CIs are a concern
Anticholinergics
(Lecture 2)
Stimulation of this family of dopamine receptors improves rigidity and bradykinesia
D2
(Lecture 2)
These 2 non-ergot D2 and D3 selective dopamine Agonists are used in mild Parkinsons and both have indication for Restless Leg Syndrome
Pramipexole
-POSSIBLE NEURO-PROTECTIVE EFFECT
and
Ropinirole
(Lecture 2)
This drug is used for prophylaxis of SEVERE N/V with Parkinson’s PTS on APOMORPHINE; used 3 days prior to start - first month of tx
TRIMETHOBENZAMIDE
(Lecture 2) Use of this short-acting D2 selective dopamine agonist in Parkinson is CI'd for -IV use -PTs with Sulfite sensitivity -PTs on 5-HT3 Antagonists
Apomorphine
(Lecture 2)
This Dopamine analog DOES NOT CROSS THE BBB
Carbidopa
(Lecture 2)
This Dopamine analog HAS THE ABILITY TO CROSS THE BBB and is CONVERTED INTO DOPAMINE IN THE PERIPHERY
Levodopa
“HONEYMOON” PTs usually respond well for 3-5 years of tx, then effects start to decline
(Lecture 2)
Treatment of “WEARING OFF” phenomenon (sx return before the next dose)
-INCREASE THE FREQUENCY (SHORTEN THE DOSING INTERVAL) of levodopa or -add a dopamine agonist or -add an MAO-B or COMT inhibitor
(Lecture 2)
Treatment of “ON-OFF” phenomenon (unpredictable return of sx w/o regard to dosing interval with severity ranging from akinesia (off) to periods of mobility with dyskinesias (on))
-redistributing dietary protein (high protein diet reduces absorption... keep steady intake) or -add a dopamine agonist or -add an MAO-B or COMT inhibitor
These drugs carry a risk of SEROTONIN SYNDROME
-MAO-B (Selegiline and Rasagiline)
-
SEROTONIN SYNDROME, a potentially life-threatening rxn) looks like this…
(clinical triad)
- COGNITIVE EFFECTS
- NEUROMUSCULAR DYSFUNCTION
- AUTONOMIC DYSFUNCTION
This is how you tx SEROTONIN SYNDROME
- W/d offending agents
- Supportive care
- Benzos for anxiety/seizures
- ice/cooling blankets for hyperthermia
- cyproheptadine (1st gen antihistamine and 5HT1A and 5HT2 antagonist
Compared to Selegiline, Rasagiline is…
- 5X MORE POTENT
- NOT METABOLIZED TO AMPHETIMINE derivative
- ADDITIONAL TESTING NEEDED to determine HTN CRISIS POTENTIAL
- WARNING to avoid tyramine foods
(Lecture 2)
This NMDA receptor inhibitor was originally designed as an ANTIVIRAL TO TX TYPE A INFLUENZA. It notably carries an ADE of LIVEDO RETICULARIS rashes.
Amantadine
(Lecture 2)
This COMT Inhibitor used to manage motor fluctuations in Parkinson’s (“wearing-off” effect) and is an adjunct to (must be used with) levodopa/carbidopa is known to CAUSE ORANGE DISCOLORED URINE and does not cross the BBB.
Entacapone
(STALEVO is a brand combo agent containing Carbidopa,
Levodopa, and Entacapone)
(Lecture 2)
When tx hallucinations in Parkinsons… what 2 strategies should be used?
- stop meds that may contribute to psychosis beginning with anticholinergics
- Avoid typical antipsychotics, risperidone, and olanzapine
(Lecture 2)
If cognitive D/Os occur with Parkinson’s, discontinue/reduce Parkinson’s drugs as tolerated. If antipsychotics are needed, treat with these newer neuroleptics:
- Quetiapine
- Clozapine (best option, but bad side effects of agranulocytosis)
