Exam 1 study guide Flashcards
First approved treatments SPECIFICALLY for TD
Valbenazine (Ingrezza)
Deutetrabenazine (Austedo)
Think about “benazine” being similar to treatment with benztropine
How to treat TD
Lower med dose, d/c, switch to clozapine lowest TD risk
*Benztropine(cogentin)
Clonazepam
Amantidine
Tetrabenazine
Tx akathisia (restlessness)
Beta blocker (propranolol)
Low dose mirtazapine based on its antagonist activity at the serotonin 5-HT(2A)/5-HT(2C) receptors
Tx pseudo parkinsonism
Benztropine/cogentin
Baseline exams FGA
EKG (QTc prolongation)
Lipids
LFTs
AIMS
EPS
dystonia, akathisia, pseudo-parkinsonism
d/t alpha 1 blockade & D2 blockade in nigrostriatal pathway
NMS symptoms
FALTERED
F- fever
A- autonomic dysfunction
L- leukocytosis
T- tremor
E- elevated CK
R- rigidity
E- excessive sweating
D- delirium
NMS tx
d/c med
fluids
IV benzos
cooling blankets
sodium dantrolene, bromocriptine, amantadine
ECT
why not prescribe drugs with FGA to prevent EPS
high anticholinergic SE risk
SGA use
acute mania, bipolar, adjunct in unipolar depression
metabolic syndrome
HTN ( >135/85), elevated triglycerides, truncal obesity, low HDL
SE of SGA
Baseline exams SGA
lipids
Glucose
A1C
Bp, weight, waist circumference, BMI
how often to do labs if established on SGA already
yearly (lipids, A1c, glucose)
Most common SGA meds to cause weight gain
clozapine, quetiapine, olanzapine
“pine”
SGA meds least associated with weight gain
aripiprazole, ziprazidone, lurasidone (& FGA haliperidol)
“done” and “ole”
SGA with strongest H1 antagonism
quetiapine
leads to sedation and weight gain
what SGA for acute agitation IM
olanzapine (Zyprexa)
works in 15 min
post injection syndrome
concern with olanzapine LA injection called relprevv
monitor x3 hours s/p injection d/t risk delirium & sedation syndrome
what SGA has the greatest elevated prolactin risk
risperidone (Risperdal)
Weight neutral SGAs
ziprasidone (Geodon)
aripiprazole (Abilify)
SGA approved for bipolar depression
lurasidone (Latuda)
med for refractory schizophrenia (Tx resistant)
clozapine
SGA that lowers SI
clozapine
SGA to most likely cause weight gain & hypersalivation/sialorrhea
clozapine
what special program is needed for clozapine and why
REMS d/t risk agranulocystosis highest in first 3 months of tx
how often to do labs for clozapine/why
monitor WBC/ANC weekly x6 months d/t risk of agranulocytosis
d/c if < 1.5 (1500)
*highest risk in first 3 months of tx
med for parkinson-related psychosis
pimavanserin (Nuplazid)
is smoking a CYP450 inhibitor or inducer & what does that mean
inducer
activates CYP1A2 enzymes & therefore lowers levels of some antipsychotics
Special consideration with haldol and prolixin decanote injections
use sesame oil- watch for allergic rxn
What’s a black box warning for all antipsychotics
increased risk of death in elderly & dementia
when can you use antipsychotic for dementia patient
no antipsychotic is approved
can use if sx severe & dangerous, significant distress
classes of antidepressants
SSRI *(first line), SNRI, SPARI, NDRI, TCA, MAOI
top distressing SE antidepressants
sexual, sleep, weight gain
antidepressants with highest risk sexual dysfunction
venlafaxine & SSRIs
antidepressants with lowest sexual SE incidence
bupropion, trazodone, nefazodone, mirtazapine
Serotonin syndrome
SHIVERS
S- shivering
H- hyperreflexia
I- increased temp
V- vital instability
E- encephalopathy (confusion)
R- restlessness
S- sweating
first line tx sexual SE from antidepressants
switch to bupropion
tx of serotonin syndrome
stop med
cyproheptadine (5HT antagonist)
ECT
SSRI SE & black box warning
initially worsen anxiety
transient GI 1-2 weeks
sexual
weight
sleep
**Black box= suicidality in children/adolescents
fluoxetine (class, indication, unique feature, warning)
SSRI
approved in pediatrics
bulimia
longest half life
can elevate antipsychotic levels
*activating; good for fatigue
citalopram
most lethal SSRI in OD
sertraline
preferred in pregnancy/breast feeding
activating; good for energy but can= agitation/anxiety
when to consider SNRI
significant fatigue or comorbid chronic pain
SE SNRI
sustained elevated BP, nausea, diarrhea, dizziness, anticholinergic
list of SNRI
venlafaxine, duloxetine, levomilnacipran, milnacipran
venlafaxine (Effexor) indication
good for anxiety/panic attacks in depressed patients
NDRI
inhibits reuptake of DA & NE
bupropion
bupropion
weight neutral, least likely to have sexual SE
good for ADHD & smoking cessation d/t effect on DA
*contraindicated in seizures & ED, lowers seizure threshold
list of atypical antidepressants/serotonin antagonists & agonists
mirtazpine, trazodone, nefazodone
trazodone (class, mechanism of action, indication, SE)
Serotonin antagonist and reuptake inhibitors (SARI)
acts on alpha-adrenergic receptors
MDD, anxiety, *insomnia
SE: nausea, dizziness, orthostasis, sedation, **priapism
antidepressant associated w/ priaprism
trazodone
nefazodone black box
*Off the market
BLACK box= liver failure
mirtazapine (class/mechanism of action, effect, indication, dose/sedation relationship)
alpha 2 adrenergic and 5HT2 antagonist (increases 5HT & NE)
sedating, increases appetite
*good if sx depression= weight loss & insomnia
inverse relationship between dose/sedation
second line treatment for depression
TCA
TCA SE
3 C’s= cardiotoxic, convulsions, coma
antiadrenergic (EKG changes, arrhythmias, orthostasis, reflex tachycardia) *Avoid in conduction issues/recent MI
anticholinergic (dry mouth, constipation, blurred vision, memory issues, urinary retention, narrow angle glaucoma)
antihistaminic (sedation, weight gain)
most lethal antidepressant class and med within that class
TCAs
only prescribe 1 week at a time
*desipramine most lethal TCA
tx TCA OD
gastric aspiration
cardiac monitoring
TCAs with highest SEs & lethality
imipramine
clomipramine (Anafranil)
amitriptyline
doxepine
antidepressant for enuresis
TCA
imipramine (Tofranil)
antidepressant for OCD
TCA
clomipramine (Anafranil)
secondary amines/TCAs with less SE
nortriptyline *therapeutic level, safe in geriatrics
desipramine
amoxapine
nortriptyline
TCA
*therapeutic level, safe in geriatrics
MAOIs (mechanism of action, MOA-A vs MOA-B, indication)
deactivates enzymes for 5HT, DA, tyramine
selective MOA-A for MAJOR depression
MOA-B for Parkinson’s & Alzheimer’s
*last resort d/t food & drug interactions
SE MAOIs and potential emergencies/how?
insomnia, weight gain, anticholinergic, sexual, orthostasis, photophobia, drowsiness, sleep dysfunction
liver toxicity, seizures, edema
*Hypertensive crisis if eats tyramine!
Serotonin syndrome if take with SSRIs
Sx hypertensive crisis, cause, treatment
Cause= tyramine rich foods * MAOI
can’t metabolize dietary amines, increases NE
sx: sudden explosive HA, high BP, facial flushing, palpitations, diaphoresis, fever, n/v, photophobia, autonomic instability, chest pain, arrhythmia, death
tx: d/c med
supportive care
phentolamine (NE antaognist)
tyramine rich foods
fava beans, red wine, aged cheese, cured meat, chicken liver
MAOI med interactions
SSRIs, TCAs, atypical antipsychotics, St. Johns Wort, asthma meds, decongestants, opiates
wash out period of MAOIs
2 weeks before switching from SSRI to MAOI, 5-6 weeks with fluoxetine
phenelzine
MAOI
animal phobia, MDD w/ atypical
features, MDD w/ psychotic features and social phobia.
selegiline (Ensam)
MAOI that doesn’t require tyramine diet restriction
vortioxetine (Trintellix or Brintellex)
Effect & indication
activates glutamate (excitatory) in frontal cortex
effective in patients with COGNITIVE DEFICITS in MDD
antidepressant withdrawal
(sx, least likely meds to cause, onset, how to avoid)
FINSIH
F- flu like sx
I- insomnia
N- nausea
I- imbalance
S- sensory disturbance (tremor, sensation electrical shock)
H- hyperarousal
*least likely with fluoxetine and vortioxetine
sx within 5 days d/c
avoid with 4 week taper (longer with Paxil & Effexor)
how to avoid antidepressant withdrawal
4 week taper (longer with Paxil & Effexor)
what qualifies as treatment resistant depression & why important to prevent relapse?
inadequate response to 2+ antidepressants
each relapse increases sx severity, decreases tx response, heightens risk of tx resistance
first line tx severe melancholic depression
ECT
tx acute mania
lithium, VPA, atypical antipsychotics
tx acute mania w/ severe sx (agitation)
atypical antipsychotics (olanzapine, ziprasidone, haloperidol)
tx bipolar depression
lithium, quetiapine, lurasidone
lithium
(Indication, unique quality, onset, therapeutic index, SE)
*gold standard tx bipolar (acute mania)
only mood stabilizer decreases suicidality
onset= 5-7 days
narrow therapeutic index 0.6-1.2 (> 1.5 toxic, >=2 potentially lethal)
SE: weight gain, cognitive slowing/dulling, impaired thyroid, GI, sedation, fine tremor, ECG change (T wave inversion), leukocytosis, hypothyroidism, epstein anomaly (cardiac defect in babies)
Lithium- considerations and baseline/continued monitoring, interactions
baseline= TSH, Cr/BUN, Hcg, EKG (>50/risk), CBC, CMP
continued monitor= Li level 3-7 days after dose change, TSH, renal
6-8 glasses water/day
birth control
avoids NSAIDs, aspirin, thiazides, dehydration, sweating, salt deprivation, ACEi, antiHTN
S/s lithium toxicity
n/v/d, coarse tremor, ataxia
late= seizures, coma, death
gold standard tx bipolar (acute mania)
lithium
gold standard tx rapid-cycling mania
carbamazepine (Tegretol)
carbamazepine (Tegretol)
(Black box, therapeutic level and how often check, SE, unique feature)
mood stabilizer
***blackbox= agranulocytosis & aplastic anemia
therapeutic level= 8-12
check level initially, then week 3, 6, 9 wait 3-7 days after dose change
SE: elevation LFTs > hepatitis, neural tube defects
*autoinduction of own metabolism 3-5 days after initiating= decreased plasma levels
carbamazepine baseline & continued labs
baseline= pregnancy, CBC, LFTs
regular= CBC, LFT
carbamazepine toxicity
range= 8-12
acute intoxication= ataxia
confusion, stupor, motor restlessness, ataxis, tremor, nystagmus, twitching, vomiting
valproic acid/Depakote/Depakene mechanism of action, blackbox, therapeutic level, SE, labs, interaction
blocks Na channels, increases GABA concentrations in brain
*blackbox= hepatotoxicity, pancreatitis
therapeutic range= 80-120
check level after 4-5 days
rare rxn= depakote induced thrombocyctopenia
Labs= CBC, LFTs
neural tube defects
*VALPROATE INCREASES LAMICTAL LEVELS
lamotrigine/Lamictal considerations/SE, important interaction
start low go slow
RARE SE: Steven Johnson syndrome
*lamictal dose must be cut in half when taken with depakote because VPA an increase levels
Lamictal May increase levels of carbamazepine
lamotrigine interaction with carbamazepine
Lamotrigine potentially increases the concentration of Carbamazepine and Carbamazepine decreases the concentration of Lamotrigine
oxcarbazepine (Trileptal) monitoring
hyponatremia
monitor Na levels
topiramate (Topamax) most limiting SE
cognitive slowing
what SE are all mood stabilizers and especially antiepileptics associated with and what are the safest
hepatic SE
gabapentin and pregabalin are safest
teratogenic SE psychotropic meds
BZO= floppy baby syndrome, cleft palate
carbamazepine/Tegretol= neural tube defects
lithium= epstein anomoly
depakote= neural tube defects
CYP-450 induction
increases metabolism and an reduce drug levels/effects
CYP-450 inhibition
decreases metabolism and an increase drug levels/effects > adverse effects
common CYP-450 inhibitors (can increase other drug levels)
bupropion, clomipramine/Anafranil. cimetidine, SSRIs, clarithromycin, fluoroquinolones, grapefruit, ketoconazole, nefazodone
common CYP-450 inducers (can reduce other drug levels)
carbamazepine, St. John’s Wort, phenytoin, phenobarbital, tobacco
how many D2 receptors need to be occupied by antipsychotic to = EPS
more than 80%
mesolimbic
increased DA= positive sx psychosis
mesocortical
reduced DA= neg sx schizophrenia
tuberoifundibular
decreased DA= increased prolactin
nigrostriatal
decreased DA= motor SE
where is NE made
locus cerelus
where is 5HT made
ralphe nuclei
What increases risk of TD
high doses, substance abuse (heavy smoking) DM, older age, women, h/o EPS, long-term antipsychotics, African American
low potency meaning
low EPS risk but high other SE
More lethal in overdose d/t QTC prolongation
high potency meaning
high EPS risk but low other SE
TD s/s
mostly irreversible
torticollis (contraction of neck muscles)
Involuntary Choreoathetoid movements of face, mouth, lips (lip smacking) tongue (fly catcher tongue) and other body
parts (facial grimacing, eye blinking, trunk, limbs etc. )
Duration maintenance therapy in depression
6-13 months
Factors affecting drug choice
cost, sx, previous tx of pt/family, SE, comorbidities, risk of suicide
Meds to avoid in pts with SI
BZO, TCA…
Progression of serotonin syndrome
rhabdomyolysis, renal failure, convulsions, coma = DEATH
Acute intoxication of carbamazepine causes…
ataxia
can even cause at therapeutic levels
Good prognostic indicator for Lithium=
episode pattern of mania,
depression and euthymia
when to check VPA level
after 4-5 days
