Exam 3 Flashcards
Non Pharm Treatment for schizo
Realistic goals and time course
-social rehabilitation
-psych education
-targeted cognitive therapy
-active community treatment
-therapeutic alliance
-comprehensive care ( psych services and psych med)
General Approach for schizo
-Optimized monotherapy, combo for treatment resistant (clozapine)
-lack of evidence supporting APS polypharmacy
-2nd gen A> 1st gen A
-Substantial risk of suicide or attemp- add clozapine
CATIE trial
-equal efficiency between old and newer antipsych
-newer agents have more permanent SEs and more expensive
Dopamine antagonism effects
-Movement disorders
-Relief of psychosis
-akathisia
-increased prolactin (causes abnormal periods and gynecomastia)
-impulsivity
clozapine class, major se, dosing
-only m4 agonist; 2nd gen antipsych
-se inc hyper-salivation (add scopolamine patch), severe constipation, orthostatsis
-if dose interrupted for more than 48hrs, re-titrate fro starting dose
Clozapine DDI
Antiepileptics dec ANCs
-Lithium helps by inc ANC
Clozapine BBW and REMS
Blood dyscrasis
when to start clozapine
must trail 2 other antipsych b/f (treatment resistant)
-if severe risk of suicide can start clozapine earlier
Clozapine DDI
benzos especially lorazepam IM
Treatment considerations for schizo
-lifelong for most; rare possibility of d/c
-relapse is high
-watch out for incomplete switch/titrations
-recommend IM meds for initial rapid relief of sym
-limit time over MDD to 2-4 weeks and re-eval
who is considered treatment resistant in schizo, include time frame
lack of improvement with at least 2 APS from different classes at optimal dose for 8 weeks
What should you do for treatment augmentation in schizophrenia
-add non-APS agent with mood stabilizers
-ECT and/or ziprasidone with clozapine
1st gen antipsych (6)
ChlorprOmaziNe
Fluphenazine
halopeRidOl
perpheNazine
ThioridAzine
ThIOthixeNe
(confrontation)
1st gen antipsych SE (8)
-Extrapyramidal side effects
-OT prolongation
-Prolactin elevation (w/ longer use)
-Dermatologic
-photosensitivity
-blue gray skin
-orthostatic hypotension
-altered thermoregulation
Antipsych BBW
-dementia related psychosis inc mortality
-pt has dementia and schio is okay to use antipsych but if they experience psychosis d/c
2nd gen antipsych LAI approved for BP
Aripiprazole
Risperdone
2nd gen antipsych SE (8)
-Metabolic syndrome (inc trigycleride, glycemia and weight gain)
-QT prolongatio
-Blood dyscrasia/Neutopenias
-Seizure threshold
-Anticholingeric
-Sedation
-prolactin inc
-Ophthalmic effects
Only approved medication for agitation in alzheimers
Brexpiprazole
2nd gen approved for MMD (4)
All brokies owe five quarters
Aripiprazole
Brexpiprazole
Olanzapine w/ Fluoxetine
Quetiapine
- no LAI
Olanzapine
-Class, se, monitoring
2nd gen antipsych
-se for metabolic risk in younger men
-REMS for post inj delirium with LAI
-dress
-3 hr monitoring (rems)
which drug is in niosh and why
Ziprasidone
-2nd gen
-se : DRESS
-short acting inj requiring reconstitution, tablet
LAI pearls
-good for non-adherent patients
-should stabilize on mono therapy before initiating
-oral challenge with the same drug
-oral overlap needed b/c LAI take a while to show effect
which 2 first gen antipsychs are high potency and consequence
fluphenazine & haloperidol
*inc risk of EPS b/c target D2
which 2 first gen antipsychs are low potency and consequence
Chlorpromazine & thioridazine
*high anticholingeric risk
New combination therapy for schizo & BD and its moa
Lybalvi (olanzapine & samidorphan)
- treat acute and maintenance
-mono or adj
-samidorphan is a opioid system modulator acts on mu receptor to reduce metabolic effects of olanzapine
-CI use of opioids
*less weight gain
special populations
-elderly: start low go slow, avoid anticholingerics risk of fall; use SSRI first for depression
-Preg: better to be on therapy; use SSRI
What 1st gen drugs are LAI (2)
Fluphenzaine & Haloperidol
What 2nd gen drugs are LAI (4) and indication
Aripiprazole
Olanzapine
Risperidone
Paliperidone
*water based and better tolerated
- for schizo
Paliperidone LAI
invega hafyera has a dosing interval of 6 months
which 2nd gens cause weight gain (3)
Clozapine
Olanzipine
Quetiapine
2nd gen antipsych that cause EPS
Risperidone & Paliperidone
2nd gen antipsych that cause inc prolactin
Risperidone & Paliperidone
Acute Dystonias symptom, risk and treatment
-Symptom: painful prolong muscle contraction
-Risk: high potency or high dose FGA, younger men
-Treatment: Anticholingersics (benzotropic or diphenhydramine), IM> PO Benzo, dec dose or d/c offending agent
Psuedo-parkinsonism symptom, risk and treatment
-Symptom: Tremor, rigidity, etc.
-Risk: high potency or high dose FGA, older age, female
-Treatment: Anticholingerics, dec dose or d/c offending agent
Akathisia symptom, risk and treatment
-Symptom: restlessness, distress, etc
-Risk: high potency FGA, aripiprazole, risperidone
-Treatment: Beta blockers dec dose or d/c offending agent
Tardive dyskinesia symptom, risk and treatment
-Symptom: tongue thrusting, lip smacking, etc
-Risk: high potency or high dose FGA, female, older age, AA
-Treatment: DC offending agent, dont use anticholingeric, VMAT2i (Valbenazine & Deutetrabenazine)
NMS symptom, at risk, treatment
-Symptom: rapidly over 24-72 hrs, inc muscle rigidity, inc wbc/lfts/bp, normal pupils, dec or norm bowel sounds
-Rare potentially lethal, seen with high potency drugs and ALL antipsychs
-at risk: dehydrated, organic mental disorder
-Treatment: d/c antipsychs & da agonist like bromo
-re-challenge in 2 weeks
Serotonin syndrome
- Onset: less than 12 hours
- inc muscle tone
- Hypereflexia
- Dilated pupils
- Inc bowel sounds
Which drugs have CYP1A2 activity
Clozapine and Olanzapine
Medication class that can cause depression (7)
-CV: Beta blockers, Calcium Channel Blockers
-Hormonal: oral contraceptives and steroids
-Antiepileptics: Levetiracetam & Topiramate
-Opioids
-Stimulants
SSRI approved in MDD (5)
Citalopram
Escitalopram
Fluoxetine
Paroxetine
Sertraline
SNRI approved in MAD
Desvenlafaxine
Duloxetine
Levomilnacipran
Venlafaxine
SSRI approved in GAD (2)
Escitalopram
Paroxetine
SNRI approved in GAD (2)
Duloxetine
Venlafaxine
SSRI approved for OCD (4)
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
SSRI approved for PAD (3)
Fluoxetine
Paroxetine
Sertraline
SNRI approved for PAD
Venlafaxine
SSRI approved for PTSD
Paroxetine
Sertaline
SSRI approved for SAD
Paroxetine
Sertraline
SNRI approved for SAD
Venlafaxine
best 2ng gen antipsych
Lurasidone, Aripiprazole, Ziprasidone
-less metabolic effects
Which antipsychs cause DRESS
Olanzapine & Ziprasidone
Asenapine class and clinical pearls
2nd gen
comes in sublingual tab and transdermal patch
hallmark NMS symptoms
-autonomic instability
-altered mental
-muscle ridigity
-fever
what drug is approved for agitation in schizo and bipolar depression
Dexmedetomidine
Bupropion se and caution
-caution in eating disorders and both hepatic and renal function
-se hypertension, insomnia, activation and anxiety
Mirtazapine se
very sedating, inc cholestrol and extreme weight gain, inc LFTs
Esketamine se, CI, clinical pearls
-Nasal spray
-Control sub; reserved for resistant patients
-SE: impaired ability to drive, inc BP, cog impairment
-CI: aneurysm and intracranial hemorrhage
Eskatamine BBW and CI
- Sedation, disassociation, abuse and misuse, suicidal thoughts and behaviors
- REMS given under supervision of healthcare provider w/ 2 hr observation
- CI anerysm intracerebral hemorrhage
Brexanolone use, dosing, ae, who to avoid
-postpartum depression
-IV inf over 2.5 days
-ae: hypoxia and excessive sedation
not recommended in preg
-Avoid in end stage renal disease
What med to avoid in pts with seizures and eating disorders
Bupropion
what med to avoid in patients w/ substance abuse
benzo
what med to avoid in patients with cardiac complications
TCA : amitriptyline, amoxapine, clomipramine, doxepin
what med to avoid in pts w/ GI bleeding and anticoag
SSRI
What should you use to as augmentation in Depression
- mood stabilizer: lithium, valproate
- 2nd gen antipsych
- triiodothyronidine
Nefazodone class and clinical pearl
-5HT3 modulator
-BBW: Hepatic failure (child pough)
MAOI clinical pearls
-washout periods vary b/w 2-5 wks
-usually takes 4-5 half lives
-DDI w/ Tyramine foods; hypertensive crisis
Treatment for PTSD nightmares
Antiadrenergrics: Prazosin, Clonidine, (add trazodone for sleep)
Treatment for PSTD anger
Anticonvulsants: Lamotrigene
Treatment for PTSD psychosis/flashbacks/dissocation
Antipsych: Quetiapine, Rispersidone, Olanzapine
FDA approved anticonvulsants and when are they used
Valproate - acute mania & mixed episodes; mood stabilizer
Lamotrigene - maintenance (slowly titrate to avoid SJS)
Carbamazepine - acute mania & mixed episodes
What two agents can be used in all 3 stages of bipolar depression (acute mania, maintenance, acute depression)
Olanzapine and quetiapine
2nd gen antipsychotics that can not be used in BP
Can’t use In BiPolar
Clozapine, iloperidone, Brexpiprazole, Paliperidone, pimavanserin.
Which 2nd gen drugs can cause akathisia
Aripiprazole and risperidone
Valproate se & formulations
- se: weight gain & alopecia
- er formulation less bioavailability
Valproate BBW
Hepatic toxicity (childs pough), teratogenic , pancreatitis
What are beta blockers indicated in and how to take it
- used in SAD
- helps with autonomic symptoms but not curative
- take 1 hr prior to event.
Which benzo is not metabolized heptically (no cyp metabolism)
Over the liver
- oxazepam, temazepam, lorazepam
Which SSRI can be used in patients with bulimia
Fluoxetine
High risk of nms
High potency antipsychotics ( haloperidol & fluohenazine)
But all antipsychotics can lead to it
TCA Side effects
- anticholingeric, delirium, lethal overdose, suicide attempts
lithium toxicity and DDI that might worsen it (affects renal)
greater or equal to 1.5 is toxic, monitor ANC, can cause Blood dyscrasis *renal metabolism
- ACEs, ARBs, Loops, CCB (Dilitiazem, Amlodipine, Nifedipine), ECT (neuro complications)
Lithium ADE
Hypothyroidism
What is SIADH and what drugs can cause this
SIADH (syndrome of inappropriate secretion of antidiuretic hormone) can lead to water retention that leads to HYPONATREMIA na <135
- Carbamazepine (and metabolite), SSRI, SNRI
LAI FDA approved for Bipolar
Aripiprazole
Risperidone
What meds are teratogenic
- Valproate
- Paroxetine
- Carbamazepine
- Lithium
- Lamotrigine
- Divalproex
Buspirone indication
- GAD on a scheduled basis
Venlafaxine class and indication
SNRI
- MDD, GAD, PAD, SAD
Fluvoxamine class and indication
SSRI
OCD
Fluoxetine class and indication
- SNRI
- MDD, OCD, PAD, PMDD, Bulimia
Which antipsychotics are sedating
Low potency FGA
Clozapine
Quetiapine
When to dose adjust for SSRI
Hepatic dysfunction (childs pough)
Citalopram dosing adj in MDD
hepatic dysfunction, 60yrs and older, poor cyp2c19 metabolizer
escitalopram dosing adj in MDD
Hepatic dysfunction; 10 mg
floxetine dosing
once weekly doing due to long half life, comes in liquid
What drug class should be avoided in Bipolar Depression and why
SNRI and TCA cause manic episodes
What meds can be used in Acute Depression as monotherapy
(Our queen loves little cakes)
Olanzapine, Quetiapine, Lumateperone, Lurasidone, Cariprazine
When to use Benzos
GAD and PAD after they fail SSRI
Dec lipophilic Benzos and its effect
Lorazepam (best tolerated), Oxazepam
-slower absorption, longer duration
Inc Lipophilic Benzos and its effect
Dizepam, Clorazepam
-faster absorption, shorter duration, more misuse, cross BBB
HAMD
inc score= inc severity depression
MADRS
tells treatment response depression
Duloxetine indications
MDD, GAD, pain
Doxepin indications
TCA
- Depression and Insomnia
High potency benzos and indication
- Alprazalam, clonzapem, lorazepam
- Rapid relief in panic disorder
Which two 2nd gen antipsychs are most sedating
Quetiapine & Clozapem
Which two 1st gen antipsych are most sedating
Low potency; Chlorpromazine & Thioridazine
Which antipsych is most activating
Aripiprazole
In which anxiety disorder is CBT most often used and what is always CI w/ that treatment
- PTSD
- Benzos can interfere w/ CBT
Which 1st gen antipsychotic can be used for a cute psychosis
Chlorpromazine
