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Pharm Fall 2019 > Ex3 Psychoactive Rx > Flashcards

Ex3 Psychoactive Rx Flashcards

1
Q

onset for antidepressants

A

Up to 2 weeks

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2
Q

Generally - ok to hold medications?

A

No, unless NPO/high TF residuals

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3
Q

TCA medications

A

end in “triptyline”, “ipramine”, “epin”

amitriptyline, imipramine, desipramine, doxepin, nortriptyline

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4
Q

TCA indications

A

depression

unique: chronic pain

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5
Q

TCA MOA

A
  1. inhibit Serotonin/Norepi reuptake

2. Antagonistic: histamine, anti-muscarinic acetylcholine, alpha1 adrenergic, NMDA, mu opioid

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6
Q

Metabolism of TCAs

A

Liver - P450

Active metabolites, erratic bioavailability, long half life (>24h)

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7
Q

TCA common side effects

A
  1. Hypotension (increased in elderly)
  2. Anticholinergic/antihistmaine: Urinary retention
  3. fine tremors, Sedation, confusion, delirium
  4. Prolonged QTc (Check EKG prior to case)
  5. Gastric motility, ileus
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8
Q

TCA dosage effect

A

narrow therapeutic index: EKG changes

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9
Q

Risk of TCA

A

Reduced seizure threshold
Serotonin Syndrome (avoid w/ MAOI)
Withdrawal

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10
Q

TCA anesthesia considerations

A

Exaggerated (new) or Diminished (chronic) response to sympathomimetics

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11
Q

Benadryl/Scopolamine w/ TCA

A

additive effects - excess sedation/confusion/delirium

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12
Q

SSRI metabolism

A

Liver via CYP450

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13
Q

Longest acting SSRI

A

Fluoxetine, 1-4 days

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14
Q

Shortest acting SSRI

A

Fluvoxamine, 15h

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15
Q

Which SSRI would it be okay to miss a few doses (days) without issues?

A

Fluoxetine (d/t long half life + active metabolite)

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16
Q

Side effects of SSRIs

A

BBW: suicide under age 24

Hyponatremia (SIADH)

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17
Q

adverse effects of escitalopram/citalopram

A

QTc prolongation

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18
Q

SSRI withdrawal

A

1-7 days after d/c

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19
Q

Which SSRI should you be concerned with withdrawal in OR?

A

Fluvoxamine

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20
Q

SSRI risk

A

serotonin syndrome - MAOIs, opioids, linezolid, methylene blue

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21
Q

AE mirtazipine

A

decreased seizure threshold

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22
Q

SNRIs

A

venlafaxine, duloxetine

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23
Q

SNRI indications

A

depression, pain

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24
Q

AE SNRIs

A

withdrawal (1/2 life=5 hours), active metabolites

Decreased seizure threshold

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25
Q

clinical indications - trazodone/nefazodone

A

depression, insomnia

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26
Q

AEs trazodone/nefazodone

A

sedation, orthostatic hypotension, QT prolongation, impairment of platelet aggregation

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27
Q

S/S serotonin syndrom

A

hyperthermia, confusion, agitation, autonomic hyperactivity, myoclonus, hyperreflexia, diaphoresis, tremor, diarrhea, neuromuscular abnormalities, ocular clonus

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28
Q

risk of serotonin syndrome occurs with

A

serotonin inhibitors + antiemetic (zofran/reglan), fentanyl, linezolid, meperidine, tramadol, valproic acid

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29
Q

Tx serotonin syndrome

A
  1. stop offending agent

2. serotonin antagonists (cyproheptadine)

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30
Q

prevention of serotonin syndrome

A

14 day washout

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31
Q

inadequate analgesia may occur in serotonin inhibitors with

A

codeine

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32
Q

increased risk of _____ in serotonin inhibitors

A

bleeding

33
Q

used for smoking cessation

A

bupropion

34
Q

MOA norepi/dopa reuptake

A

bupropion

35
Q

AE Bupriopion

A

abrupt w/d=seiz risk

increased HR/BP

36
Q

MAOIs

A

phenelzine, selegiline, tranylcypromine

37
Q

MOA MAOIs

A

inhibits MAO (monoamine oxidase enzyme) which breaks down Serotonin/norepi/dopa

38
Q

MAOI Rx Intxns

A

Opiates, meperidine, any Rx that effects serotonin = serotonin syndrome

39
Q

AE MAOIs

A

myoclonic movements

40
Q

Decreased use of MAOIs

A

intxn w/ tyramine (cheese/wine)

41
Q

Effect of tyramine + MAOIs

A

HTN, tachycardia

42
Q

Contraindicated with MAOIs

A

meperidine

43
Q

DOC - patient with serotonin syndrome has pain

A

morphine

44
Q

Cautious during use of _____ with MAOIs

A

vasopressors - exaggerated response

45
Q

Etomidate is ____ to use with MAOIs

A

safe

46
Q

Goal serum concentration - Lithium

A

0.6-1 mEq/L

47
Q

Chronic Side Effects - Lithium

A

nephrogenic diabetes insipidus, polyuria/polydipsia, hypothyroidism, myxedema coma

48
Q

Lithium overdose

A

CNS effects - seizures, coma, tremor, ventricular arrhythmias, t wave inversion, confusion, N/V/D

49
Q

Increases risk of Lithium Toxicity

A

Renal insufficiency, hyponatremia

50
Q

Drug interactions to monitor for w/ Lithium

A

Thiazide Diuretics, Loop diuretics, NSAIDs, neuroleptic Rx, neuromuscular blockade

51
Q

AE Lithium + neuromuscular blockade

A

prolonged duration of NMBA

52
Q

AE Lithium + diuretic/NSAIDs

A

Altered Sodium excretion –> renal effect –> increased lithium plasma concentration

53
Q

AE Lithium + neuroleptic drugs

A

i.e. reglan

increased EPS, increased risk neuroleptic malignant syndrome

54
Q

Typical antipsychotics

A

chlorpromazine, droperidol, fluphenazine, haloperidol, prochlorperazine

55
Q

Atypical antipsychotics

A

aripiprazole, olanzipine, quetapine, risperidone, ziprasidone, loxapine, clozapine

56
Q

MOA antipsychotics

A

“dirty” - typical vs. atypical

57
Q

MOA typical antipsychotics

A

High D2 antagonism, Low 5HT-2A antagonism

58
Q

MOA atypical antipsychotics

A

Moderate-high D2 antagonism, High 5-HT2A antagonism

59
Q

Clozapine AEs

A

agranulocytosis (1st 3months), myocarditis/cardiomyopathy, seizures

60
Q

antipsychotic side effects

A

QTc prolongation**, postural hypotension, sedation, EPS, akathisia, tardive dyskinesia, urinary retention, blurred vision, dystonia

61
Q

Tardive dyskinesia presentation

A

repetitive/jerking movements in face, neck, tongue, lips (may affect breathing/swallowing)

62
Q

Dystonia presentation

A

sustained muscle contractions (twisting, repetitive movements, abnormal postures), tremor/loss of facial expressions, skeletal muscle rigidity

63
Q

Tardive dyskinesia tx

A

no treatment - anticholinergics worsen symptoms

64
Q

Dystonia tx

A

IV benadryl 25-50 mg
benztropine 2mg
dose reduction/avoidance

65
Q

akathesia

A

restlessness, urge to move

66
Q

akathesia tx

A

propranolol (1st line), benzos, anticholinergic (benztropine), amantadine, clonidine

67
Q

Parkinsonism

A

muscle rigidity, tremor, bradykinesia, postural abnormalities, salivation

68
Q

parkinsonism tx

A

dose reduction/drug avoidance + anticholinergic (benztropine)

69
Q

risk of antipsychotics

A

neuroleptic malignant syndrome

70
Q

how to differentiate between NMS/serotonin syndrome

A

history

71
Q

s/s neuroleptic malignant syndrome

A

Fever**

renal failure, rhabdo, rigidity, altered LOC, autonomic dysfunction

72
Q

Tx NMS

A

dantrolene 0.5-2.5mg/kg q6h

73
Q

NMS may mimic

A

malignant hyperthermia

74
Q

benzos act on

A

Alpha/Gamma subunit of GABA-A receptor

75
Q

benzodiazepine metabolism

A

significant hepatic metabolism

some rx = active metabolites

76
Q

Benzodiazepines with active metabolites

A

midazolam, diazepam, chlordiazepoxide (Librium)

77
Q

Benzodiazepines with inactive metabolites

A

oxazepam, lorazepam, temazepam

78
Q

DOC benzo (renal insufficiency, repeated doses)

A

Lorazepam

79
Q

Anesthesiology considerations in patients taking Benzos

A
  • additive effects w/ other sedatives

- abrupt stopping of chronic therapy = w/d

Pharm Fall 2019 (33 decks)

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