Exam 3 Flashcards
Naloxone (Narcan)- class, indication, when to rx, half life
Potent opioid
antagonist
* Treatment of choice for
opiate overdose
* Routinely prescribe for
all patients with opioid
use disorder
* Very short half life
Length of effects 30-90 min
Methadone (Dolophine)- class, administration, federal restrictions, monitoring for adverse effects
Long-acting full opioid
receptor AGONIST at mu
receptor
* 1x/daily
* Restricted federally licensed
substance abuse treatment
programs
* Monitor for QTC prolongation
(cardiac abnormalities)
Buprenorphine (Buprenex, Sublocade)
Buprenorphine/Naloxone(Suboxone)- class, effect, indication, med forms
- Partial Opioid receptor agonist/ opioid
antagonist - Decreases cravings; *** Opioid Use disorder w/ comorbid pain= Suboxone can be used in managing pain
- Can precipitate withdrawal if used too soon after full opioid agonist – it will displace any residual opioids from the mu receptors.
- Sublingual preparation that is safer= Suboxone: Waiver needed to prescribe in outpatient settings
- Suboxone= available Buccal film, sublingual film, sublingual tab
- Buprenorphine= Available sublingual tab; subdermal implant, SQ injection
naltrexone-
class, administration including forms, what patients is this good for? Adverse effect/monitoring
Competitive opioid antagonist
* Precipitate withdrawal if used
within 7 days of heroin use
* Available orally or monthly depot
injection.
Pill works approx. 24 hours; Injection may last up to 30 days.
* **Treatment of choice for highly
motivated patients.
* Risk for LFT elevation
- Available PO (Revia)
- Available IM (Vivitrol)
***NO LIQUID
What could inappropriate use of opioids indicate?
may be an indication that the patient’s pain is uncontrolled
Opioid intoxication sx and management
Drowsiness
N/V
↓GI motility (Constipation; abdominal cramps)
Sedation
Slurred speech
Miosis(constricted pupils)
Seizures
Respiratory depression
Arthralgia/myalgia
Mgt:
Airway support
In overdose, give Naloxone (opioid antagonist)
Ventilator if required
Patients art risk of overdose should be prescribed a naloxone (Narcan) kit to keep at home for emergencies.
Opioid withdrawal- sx, management, buprenorphine or methadone for withdrawal?
Flu-like symptoms (body aches, anorexia, rhinorrhea, fever)
Diarrhea
Anxiety
Insomnia
Mgt: Buprenorphine/naloxone; Clonidine, dicyclomine (Bentyl)
Moderate symptoms= Symptomatic treatment with;
Clonidine for autonomic s/s
NSAIDs for pain, Baclofen for muscular spasms
Benzos for anxiety & agitation
Loperamide for diarrhea
Dicyclomine for abdominal cramps
Promethazine for nausea
Antinausea medications
Hypnotics for insomnia (e.g. trazodone, low dose quetiapine, diphenhydramine)
NOTE: In clinical experience, when administered for detoxification and not maintenance, buprenorphine is more effective at suppressing and controlling withdrawal symptoms as the taper nears completion compared with methadon
cocaine intoxication- sx & tx
Euphoria
Heightened self esteem
Decrease BP
Tachycardia or bradycardia
Nausea
Dilated pupils
Psychomotor agitation or depression
Chills and sweating
Dangerous/Deadly: Seizures, cardiac arrythmias, paranoia, hallucinations
**NOTE: Cocaine has vasoconstrictive effects= can cause MI, stroke
Txt: Lorazepam
cocaine withdrawal- disulfiram (Antabuse) use, meds for sx, contraindicated med
disulfiram/Antabuse use in Cocaine use disorder = increase synaptic dopamine in the brain reward circuit and act as an agonist treatment in the setting of cocaine use disorder
NOTE: Medications for cocaine-induced chest pain and myocardial infarction = Nitroglycerin, Aspirin
**No Metoprolol
(Beta blockers are contraindicated in patients with cocaine induced chest pain – further lowers coronary blood flow thereby worsening ischemia)
ETOH intoxication
- Impaired fine motor control
- Impaired judgement and coordination
- Ataxic gait and poor balance
- Lethargy, difficulty sitting upright, difficulty with
memory, - Nausea/Vomiting
- Coma = Levels 300mg/dL and over
- Respiratory depression and death possible
(***Know ETOH Intoxication vs. Withdrawal)
ETOH withdrawal (mild/mod/severe)
(***Know ETOH Intoxication vs. Withdrawal)
Mild: Insomnia, Irritability, Hand tremor
Moderate: Autonomic hyperactivity (diaphoresis, tachy, HTN), Fever
Severe: Seizures (12-48 hours post consumption); Hallucinations; Delirium Tremens (48-96 hours after last drink)
* Anxiety
* Anorexia
* Nausea/Vomiting
* Psychomotor agitation
NOTE: Use the Clinical Institute Withdrawal Assessment(CIWA) to monitor withdrawal
CIWA protocol (what does it assess? number scale mild/mod/severe?)
Areas assessed – Nausea & vomiting, tremor, paroxysmal sweats, anxiety,
agitation, tactile disturbances, auditory disturbances, visual disturbances,
headaches, orientation
CIWA scoring and what it means.
* < 10= mild;
* 10-15= moderate
* 15+= severe
First line txs ETOH use disorder (class, effect, forms, special consideration for OUD)
naltrexone (Revia; IM-Vivitrol)
- Opioid receptor antagonist
- Can be used for both ETOH and Opioid Use disorders
- Reduces desire/cravings
- First line treatment
- PO or monthly injection (Vivitrol), Implant
- Will precipitate withdrawal in patients with physical opioid dependence
*metabolized by the liver
Acamprosate (Campral)
- Likely modulates glutamate transmission
- First line treatment in maintaining abstinence after detox
- Used for relapse prevention (post detoxification)
- Can be used in liver disease- not metabolized by the liver (not impacted by ETOH use)
- Can be administered to patients with hepatitis, liver disease and those who continue drinking alcohol
- Contraindicated in severe renal disease.
- Decreases craving
First line treatment in maintaining abstinence from ETOH after detox (MOA, use, metabolism, contraindication, effect)
Acamprosate (Campral)
Likely modulates glutamate transmission
* First line treatment in maintaining abstinence after detox
* Used for relapse prevention (post detoxification)
* Can be used in liver disease- not metabolized by the liver (not impacted by ETOH use)
* Can be administered to patients with hepatitis, liver disease and those who continue drinking alcohol
* Contraindicated in severe renal disease.
* Decreases craving
Disulfiram(Antabuse)- effect, concurrent ETOH use, what to avoid, contraindications, patient population
2nd line tx ETOH use disorder
Blocks enzyme(Aldehyde dehydrogenase) in the liver
*Causes aversion reaction to ETOH(flushing, headaches, n/v, palpitation, SOB, vertigo, hypotension)
** Do not administer until the person has been alcohol free at least 12 hours
* Educate patients to refrain from using
anything that contains alcohol (vinegar,
aftershave, perfumes, mouthwash, cough medicine) while taking and up to 2 weeks after discontinuation.
* Contraindicated in severe cardiac disease, pregnancy, psychosis
* For highly motivated patients
bupropion/Wellbutrin in ETOH use disorder
Bupropion increases the risk for withdrawal seizures in ETOH patients
Tx for ETOH withdrawal
Benzos(Lorazepam,
Diazepam, Chlordiazepoxide-
Librium)= To keep patient calm and lightly sedated
MOA: Enhance the effects of GABA
Tegretol, Valproic or Gabapentin= use in mild withdrawal
Thiamine, folic acid and
multivitamin= for nutritional deficiencies
Thiamine (to prevent or
treat Wernicke’s encephalopathy= B1 deficiency) and Folate
Fluid and electrolyte balance
leading causes of death in patients with serious mental illness
The leading causes of death in patients with serious mental illness are heart disease, cancer, and cerebrovascular or respiratory disease, which can all be linked to smoking
tobacco use disorder tx options (3)
VARENICLINE(CHANTIX)
* Mimics action of Nicotine
* ***The most effective tobacco cessation
* Reduces rewarding aspects
* Prevents withdrawal symptoms
BUPROPION
(ZYBAN)
* Inhibits reuptake of dopamine and norepinephrine
* Helps reduce craving and withdrawal symptoms
NICOTINE
REPLACEMENT
THERAPY(NRT)
* Available as transdermal patch, gum, lozenge, nasal spray and inhaler
* Nicotine patch- watch for vivid dreams or sleep disruptions
WELL KNOWN METHODS TO PROVIDE BRIEF STOP
SMOKING ADVICE
5A’s:
1. Ask for the smoking status
2. Brief advice to quit
3. Assess the motivation to quit
4. Assist by providing evidence-based
treatment
5. Arrange Follow-up
ABC method/Ask and Act:
1. Ask
2. Brief advice
3. Cessation support
** Every smoker would receive an offer for treatment regardless of their motivation to treat status**
Substances r/t sexual dysfunction
Overall, substances such as alcohol, Cocaine and opioid use disorder can lead to sexual dysfunction.
What med is good for insomnia in substance use disorders?
Gabapentin has been considered as a treatment for insomnia in patients with substance use disorders - also helps with anxiety ( No sedative effects, not metabolized by the liver, does not lower seizure threshold, no blood monitoring)
For geriatric pt, if TCA needed, which is safest?
If TCA is indicated = consider Nortriptyline(fewer anticholinergic side effects)
Tx for elderly with MDD and decreased appetite
Consider mirtazapine (Remeron) = MDD w/ symptoms of insomnia and decreased appetite
Med that can be used as adjunct w/ antidepressants in elderly if severe depression and/or psychomotor retardation
Methylphenidate= can be used in low doses as an adjunct to antidepressants
for patients with severe depression and/ or psychomotor retardation.
Delirium in elderly (what it is, acute/chronic?, subtypes, causes)
- Medical Emergency
- Reversible
- 40% mortality
- Commonly experienced by patients in the ICU and post-op
A person with delirium may experience changes in their awareness of where they are. They may seem “out of it,” lethargic or uninterested in their surroundings. They may be confused, anxious, or see or hear things that are not there. Thinking and remembering are impaired, and anxiety, euphoria or fear may occur
- Develops over hours to days = Acute
- Subtypes: Hyperactive (agitated, restless, hyperalert); Hypoactive(lethargic, slowed,
apathetic); Mixed(cycles between hyperactive and hypoactive - Causes: DELIRIUM(Drugs, Electrolyte imbalance, Low oxygen sat, Infection, Reduced sensory input, Intracranial(strokes), Urinary retention, Myocardial)
Types of Dementia
- Group of disorders characterized by gradual development of cognitive deficits
- Irreversible
Types:
1. *Alzheimer’s disease (AD)= most common
2. *Vascular disease = 2nd most common
3. *Lewy body disease (LBD)
4. *Frontotemporal degeneration (FTD)
5. HIV infection
6. Huntington disease (HD)
Etiology of SUD (neurotransmitter/pathway, etc)
- Positive rewards of reinforcement= mediated by DA pathways
- Reinforcement occurs in the Ventral tegmental area (VTA) and the Nucleus accumbens (Reward center)
- DA release within the reward center is enhanced = by the release of natural morphine-like neurotransmitters(Neuropeptides- enkaphalins, beta endorphins)
- Repeated drug use= DA system becomes increasingly sensitized
Acamprosate (Campral)- MAO, indication, contraindication, effect
Likely modulates glutamate transmission
* First line treatment in maintaining ETOH abstinence after detox
* Used for relapse prevention (post detoxification)
* Can be used in liver disease- not metabolized by the liver (not impacted by ETOH use)
**** Can be administered to patients with hepatitis, liver disease and those who continue drinking alcohol
* Contraindicated in severe renal disease.
***** Decreases craving
When to consider Acamprosate?
after ETOH detox to prevent relapse ?
Topiramate(Topamax)- indication, MAO, effect, SEs
2nd line for ETOH use disorder
anticonvulsant
- Potentiates GABA and inhibits Glutamate
- Reduces cravings
- For SE remember DOPE-a-max (impaired cognition, nausea, weight loss, metabolic acidosis.
withdrawal tx for ETOH use disorder (mild vs mod/severe)
- Benzos(Lorazepam, Diazepam, Chlordiazepoxide-Librium)= To keep patient calm and lightly sedated
MOA: Enhance the effects of GABA - Tegretol, Valproic or Gabapentin= use in mild withdrawal
- Thiamine, folic acid and multivitamin= for nutritional deficiencies
- Parenteral Thiamine (to prevent or treat Wernicke’s encephalopathy= B1 deficiency) and Folate
- Fluid and electrolyte balance
Banana Bag ingredients/What are we trying to prevent?
thiamine, multivitamin, folic acid, magnesium sulfate in a saline solution
to prevent or treat Wernicke’s encephalopathy= B1 deficiency
Cocaine withdrawal sx
Post intoxication depression “Crash”
- Fatigue
- Malaise
- Hypersomnolence
- Depression
- Anhedonia
- Hunger
- Constricted pupils
- Vivid dreams
Tx options for cocaine use disorder
NO FDA approved med
Off-label= Naltrexone, modafinil, Topamax
Supportive care (control HTN, arrhythmias)
Mild-moderate agitation= Benzodiazepines
Severe agitation or psychosis – antipsychotics
amphetamines (intoxication/withdrawal/tx)
- Classic amphetamines vs. Substituted (designer , club drugs, MDMA – ecstasy, MDEA- eve)
- Often used in dance clubs and raves
- Have both stimulant and hallucinogenic properties
- Intoxication is similar to cocaine
- Can cause ongoing psychosis
- Withdrawal can cause prolonged depression
Txt: Rehydrate, correct electrolyte and treat hyperthermia
Phencyclidine (PCP) intoxication/tx
Rage
Erythema
Dilated pupils
Delusions
Amnesia
Nystagmus
Excitation
Skin dryness
Txt: Supportive care (rehydration, electrolyte balance etc.)
Benzos for agitation, anxiety, muscle spasms
Haldol for severe agitation and psychosis
Phencyclidine (PCP) withdrawal
No withdrawal
Recurrence of intoxication due to release of the drug from body lipid stores.
Sedative hypnotic intoxication
Benzos, barbiturates, Zolpidem, zaleplon, GHB(date rape drug), etc
Intoxication:
Drowsiness
Confusion
Hypotension
Slurred speech
Incoordination
Ataxia
Mood lability
Impaired judgment
Respiratory depression or death in OD
Biggest risk of sedative hypnotic withdrawal
Abrupt abstinence after chronic use can be life-threatening/seizures
Sedative hypnotic intox. tx
Intoxication Treatment:
Maintain airway, breathing and circulation
Supportive care (improve respiratory status, control hypotension)
Activated charcoal and gastric lavage to prevent further GI absorption= in Overdoses
***Benzos= Flumazenil in OD (Benzo antagonist)
Sedative hypnotic withdrawal tx
Withdrawal Treatment:
Benzodiazepines (stabilize patient and taper gradually)
Carbamazepine or valproic acid (taper not as beneficial)
Marijuana (cannabis, pot, weed, grass) benefits and intoxication
Contains THC(tetrahydrocannabinol) which produces the “high”
Benefits:
N/V; increasing appetite in AIDS patients, chronic pain from cancer and lowering intraocular pressure in glaucoma
Intoxication:
Euphoria, anxiety, impaired motor coordination, mild tachycardia, Conjunctival injection “red eyes”, dry mouth, Munchies= increased appetite
Cannabis induced Psychotic d/o= paranoia, hallucinations and delusions
Marijuana (cannabis, pot, weed, grass) withdrawal/tx
Withdrawal:
Irritability, anxiety, restlessness, aggression, strange dreams, depression, headaches, insomnia, low appetite
Supportive care
Based on symptoms
Nicotine effect and withdrawal
Effects:
Restlessness
Insomnia
Anxiety
Increased GI motility
Withdrawal:
Intense craving
Dysphoria
Anxiety
Poor concentration
Increased appetite
Weight gain
Irritability
Restlessness
Insomnia
Opioids effect on body
Opioid medications/drugs stimulate mu, kappa and delta opiate receptors
Effects on the dopaminergic system which mediates their addictive and rewarding properties
Opioid agonist therapy effect on mortality
Opioid Agonists (Buprenorphine/Methadone)
Decreased mortality d/t overdose
Opioid antagonists and considerations with substance use
Opioid Antagonists (Naltrexone)
Precipitates withdrawal in patients actively using opioids
Need to successfully complete opioid withdrawal prior to treatment (at least 7 days w/o opioids)
buprenorphine vs methadone
Buprenorphine
Preferred as initial treatment
Lower risk of death in overdose – lower potential of causing respiratory depression.
Providers can prescribe this in outpatient settings – no waiver required.
Fewer drug-drug interactions.
Methadone
For individuals with high tolerance
Appropriate for patients with higher level o f physical dependance or prior misuse/diversion of buprenorphine
Requires daily visits to a licensed opioid treatment program (OTP)
What med for OUD w/ comorbid pain
Suboxone can be used in managing pain
What can happen if buprenorphine started too soon after last opioid use
If buprenorphine is used too soon after a patient’s last opioid use, Buprenorphine will displace any residual opioids from the μ receptors and can precipitate withdrawal symptoms
Hallucinogen intoxication sx/tx
Illusions
Hallucinations
Body image distortions
Labile affect
Dilated pupils
Tachycardia
HTN
Hyperthermia
Tremors
Incoordination
Sweating
Palpitations
Txt: May use Benzos and antipsychotic medications for agitation
Hallucinogen withdrawal
Does not cause physical dependence or withdrawal
Inhalant (what are they?) & intoxication sx/tx
Inhalants generally act as CNS depressants
Most common in preadolescents or adolescents
E.g. solvents, glue, paint thinners, fuels, isobutyl nitrates (“huffing” “laughing gas” “rush”)
Intoxication
Perceptual disturbances
Paranoia
Lethargy
Dizziness
Nausea/vomiting
Headache
Nystagmus
Tremor
Muscle weakness
Ataxia
Slurred speech
Euphoria
Clouding of consciousness
Stupor or coma
Txt: Airway monitoring; Chelation depending on solvent
Inhalant withdrawal & tx
Does not usually occur
Irritability
Sleep disturbance
Anxiety
Depression
Nausea/vomiting
Craving
No specific tx (I guess tx sx/emergencies?)
Inhalant and other Psychoactive Substance Use disorders
Loss of ability to control the use of inhalants
Compulsivity to use inhalants
Negative emotional state when not sniffing/breathing inhalants
Common among teenagers
E.g., volatile solvents, aerosols, gases, nitrites
Methods: Sniffing, spraying into nostrils or mouth, bagging, huffing- breathing in from rag soaked with the chemical; inhalation from balloons
Clinical presentation inhalant/psychoactive use disorder
Ataxia
Smell of chemicals on body or clothing
Sores and scabs around nose and mouth (Glue Sniffer’s rash)
Slurred speech
Drowsiness
Headaches
Emergency effects inhalant/psychoactive use disorder
Agitation
Fever
Seizures
Hallucinations
Confusion
Loss of consciousness
Coma
Fatal accidental injury
treatment/management inhalant/psychoactive use disorder
Treat presenting symptoms
Benzodiazepines for managing withdrawal and emergency symptoms (e.g., Valium, Lorazepam.
Caffeine use disorder/ intoxication & tx
Caffeine is Most used psychoactive substance in the United States
Coffee, tea or energy drinks
Intoxication
Anxiety
Insomnia
Muscle twitching
Rambling speech
Flushed face
GI disturbance
Restlessness
Excitement
Tachycardia
More than 1g= tinnitus, severe agitation, cardiac arrhythmias
More than 10g = Death can occur secondary to seizures and respiratory failure
Txt: Supportive and symptomatic
Caffeine withdrawal
Occurs if cessation is abrupt
Headache
Fatigue
Irritability
Nausea
Vomiting
Drowsiness
Muscle pain
Depression
Geriatric considerations w/ SUD
When assessing and treating older adults, clinicians not only need to take the above factors into account but also need to consider the potential interaction between alcohol and both prescribed and over-the-counter medications, especially psychoactive medications such as benzodiazepines, barbiturates, and antidepressants.
The Alcohol Use Disorders Identification Test (AUDIT) and the CAGE often a`re used to screen for at-risk substance use or misuse among older adults
Alcohol problems are common among older adults.
The use of pharmaceutical drugs is prevalent in older adulthood, and the risk of misusing prescription and over-the-counter medications, which include substances such as sedatives/hypnotics, narcotic and nonnarcotic analgesics, diet aids, and decongestants, also increases with age.
Incidentally, benzodiazepines also tend to be one of the most inappropriately prescribed psychotherapeutic medications among older adults
Screening tool for alcohol use disorder in geriatric population
The Alcohol Use Disorders Identification Test (AUDIT) and the CAGE often are used to screen for at-risk substance use or misuse among older adults
Tx considerations in geriatric population
Clinicians should be cautious when prescribing or recommending a treatment, take both risks and benefits into account when determining a treatment plan, and clearly communicate guidelines for appropriate use to patients.
Clinicians also should carefully consider discontinuing medications that do not prove effective
Illicit drug use among older adults is rare.
Thus, rates of illicit substance use and abuse among older adults will likely continue to rise in the next several decades because of the aging of the baby boom cohort.
When assessing and treating older adults, clinicians not only need to take the above factors into account but also need to consider the **potential interaction between alcohol and both prescribed and over-the-counter medications, especially psychoactive medications such as benzodiazepines, barbiturates, and antidepressants.**
Alcohol, Cocaine and opioid use disorder can lead to sexual dysfunction T/F
true
Withdrawal seizures are commonly associated with which substances?
Bzo’s, etoh
If a TCA is indicated in geriatric patient, what TCA & why?
consider Nortriptyline(fewer anticholinergic side effects)
Med for geriatric pt with MDD + sx insomnia and/or decreased appetite
mirtazapine/Remeron
methylphenidate use in geriatric population
can be used in low doses as an adjunct to antidepressants
for patients with severe depression and/ or psychomotor retardation
Delirium in elderly tx
Txt: Symptom treatment
1:1 sitter
Agitation and Psychotic symptoms
* Haldol (PO, IM, IV); Atypical antipsychotics
Timeframe of development of delirium in elderly
Develops over hours to days = Acute
Subtypes of delirium in elderly
Hyperactive (agitated, restless,
hyperalert); Hypoactive(lethargic, slowed,
apathetic); Mixed(cycles between hyperactive
and hypoactive
Causes of delirium in elderly (pneumonic)
DELIRIUM:
Drugs
Electrolyte imbalance
Low oxygen sat
Infection
Reduced sensory input
Intracranial(strokes)
Urinary retention
Myocardial)
Dementia vs delirium
dementia = irreversible,chronic, gradual onset
delirium = reversible, fast onset, acute
Alzheimer’s disease characteristics (3 A’s)
- Gradual progressive decline
- Most common type
- Affects memory, learning and language
- Aphasia (difficulty with speech)
- Apraxia (inability to perform previously learned
tasks - Agnosia (inability to recognize an object)
Alzheimer’s disease etiology & tx
Etiology: Accumulation of beta-amyloid plaques and intraneuronal tau protein tangles
Txt: Cholinesterase inhibitors
NMDA receptor antagonists
Vascular disease dementia (cause & risk factors)
2nd most common
* Cognitive decline secondary to large vessel strokes
* Risk factors: HTN, DM, Smoking, obesity, HLD, A-fib, Age
Lewy Body Disease (LBD) characteristics
Characterized by waxing and waning cognition
* Visual hallucinations (well formed images of animals and small people)
* Develop EPS (Parkinsonism) @ least 1 year after cognitive decline
Lewy Body Disease etiology & tx
Etiology: Lewy bodies and Lewy neurites in brain (primarily basal ganglia)
Txt: Cholinesterase inhibitors
- Seroquel and Clozaril (low doses/short termfor agitation)
- Levodopa/Carbidopa (parkinsonism sx)
- Melatonin and/or Clonazepam (REM sleep disorder)
Kluver-Bucy Syndrome
hypersexual, hyperorality
seen in Frontotemporal Degeneration (FTD)
What med to tx agitation in Lewy body disease & what risk should you consider
tx can be Seroquel and Clozaril (low doses/short term)
There is potential for severe sensitivity reactions, including exacerbation of parkinsonism, confusion, or autonomic
dysfunction, which limits the usefulness of antipsychotic medications in these patients = Sensitive to antipsychotics
Frontotemporal Degeneration (FTD)- presentation & tx
40% familial
Individuals with frontotemporal dementia usually present before age 65, and have behavior symptoms early on, with relative sparing of memory. Symptoms include personality changes, impaired judgement, apathy, and disinhibition
- Atrophy of the frontal and temporal lobes
Personality/Behavioral:
* Disinhibition (verbal, physical sexual)
Language:
* Difficulty with speech and comprehension
Kluver-Bucy Syndrome: hypersexual, hyperorality
Txt:
* Symptom focus
* SSRI to help with disinhibition
*atypical antipsychotics can be used for psychosis.
List of Cholinesterase Inhibitors
Treat dementia
Donepezil (Aricept), Rivastigmine (Exelon), Galantimine (Razadyne)
Donepezil (Aricept)- class, indication, SE, benefit, SE that warrants d/c
Cholinesterase Inhibitor Slows clinical deterioration by 6-12
months
- Once daily dosing
* ** For mild-moderate NCD (is approved for ALL stages including severe) **
- Not effective in severe, end-stage
disease
** Should STOP if side effects of
nausea/vomiting develop *****
S/E: diarrhea, weight loss, abnormal
dreams, insomnia, dizziness
Galantimine (Razadyne)
Cholinesterase Inhibitor
* Twice daily dosing
* GI side effects
* For mild –moderate NCD
Rivastigmine (Exelon)
Cholinesterase Inhibitor
- Twice daily dosing
* For mild-moderate AD & Parkinson’s
disease dementia
** Transdermal patch available – daily
form with fewer side effects**
* For Mild to moderate NCD
Highest GI side effects*
Tx mood sx in dementia
SSRIs
Tx Aggression/Agitation/Psychosis in dementia
Consider atypical antipsychotics
(Zyprexa, Seroquel, Risperdal,
Haldol)
Note: Reserve Benzos for short term and acute episodes
Memantine(Namenda)
NMDA receptor antagonist
* Moderate – severe dementia
* Fewer side effects as compared to
the Cholinesterase inhibitors
** Promotes synaptic plasticity
* May be used in conjunction with
cholinesterase inhibitors
e.g. Namzric (Mamantine/Donepezil)
**May cause hallucinations
Anticholinergic SE in elderly
blurred vision, dry eyes
dry mouth
constipation
skin flushing, unable to sweat, overheating
drowsiness, dizziness, confusion, hallucinations
rapid HR
urinary retention
Intellectual Disability Disorder (IDD)- what is it/effect, causes, management, caution
Impaired cognitive and adaptive/social functioning.
* Deficits in intellectual functioning (i.e. reasoning, problem solving,
planning, abstract thinking, judgement and learning)
* Deficits in adaptive functioning i.e. communication, social participation
and independent living.
* Severity is mild, moderate, severe and profound
Causes: Genetic (Down syndrome); Prenatal (rubella, herpes simplex etc.)
Perinatal (Anoxia, prematurity, birth trauma) and Postnatal (malnutrition,
toxin exposure, trauma)
Management: Behavioral Therapy
**Caution with patients with IDD as they may not be able to self-report drug-related problems.
ADHD first line tx/MOA
- The first-line pharmacological tx are stimulants which help to increase DA in PFC
- These also, notably, can increase DA in the nucleus accumbens and reward circuitry
- Treatment: Multimodal(i.e., Medications + educational and behavioral interventions)
- 1st line med: Stimulants (methylphenidate compounds, dextroamphetamine, mixed
amphetamine salts)= Ritalin, Concerta, Adderall (Scchedule II)
***MOA: Increase DA in the prefrontal cortex, nucleus accumbens and reward circuitry
Monitoring/concern w/ stimulants especially in children
- *Monitor Height, weight, BP, CBC w/ diff; Pulse quarterly (Height and weight d/t risk of growth restriction)
- In healthy individuals, it is not necessary to obtain an EKG prior to initiating a stimulant
- Prescription Monitoring Program should be checked
- Note: With stimulants, evidence of growth suppression is not clear, seems transient
and resolves in mid-adolescence - Note: If a child is taking their medication twice daily (i.e. at home and school) and parents request to solely administer the medication= consider switching to an extended release form (e.g. Methylphenidate CD= extended release)
2nd line ADHD in children
2nd line: Alpha-2 agonists (Clonidine, guanfacine)
When to consider non stimulant in ADHD
Atomoxetine (Strattera); Bupropion
(Wellbutrin) ; Alpha 2 adrenergic
agonist (Clonidine, Guanfacine)
- Stimulants are not working well to control ADHD symptoms
- Stimulants cause too many side effects (often intolerable) – e.g. anxiety
- The child or teen has problems with
substance abuse - The child or teen has a medical condition for which stimulants cannot be used - e.g. tic disorder
- Adjunctive therapy for stimulants.
Autism
- Characterized by impairments in social communication/interaction and restrictive, repetitive behaviors/interests
- 4:1 ration (male/female)
- Recognized ages 12-24 months
Tx approach to autism
- Early intervention, behavioral therapy, psychoeducation
- Alpha-2 agonists (clonidine, guanfacine) and low dose atypical antipsychotics (Risperidone, Abilify)=
to help reduce disruptive behaviors, aggression and irritability - Melatonin for sleep,
- Remeron for sleep, anxiety
Risperidone for autism (indication/age)
Indication:
Autism associated irritability,
aggression, temper tantrums, self-injurious behaviors, mood lability
Age range:
Children 5+ and Adolescents
less than 18 (weight based)
aripiprazole for autism (indication/age)
Indication:
Autism associated irritability,
aggression, temper tantrums, self-injurious behaviors, mood lability
Age range:
Children and Adolescents 6-
17 years old
What antidepressants cause sexual SE and what are they
Most of the antidepressants EXCEPT Bupropion (Wellbutrin) &
Mirtazapine (Remeron) cause sexual problems
- Desire (libido)
- Frequency of sexual activity
- Arousal (lubrication in females and erectile function in males)
- Orgasm (delayed orgasm and anorgasmia)
How to manage sexual SE from antidepressants
Watchful waiting; if sexual impairment persists:
* Decrease the dose of the SSRI within the therapeutic range.
* Switch to Bupropion (Wellbutrin)
* phosphodiesterase-5 inhibitor (ie sildenafil and tadalafil) cause the blood vessels to relax.
If a woman with a distressing sexual problem greatly desires a
pharmacologic intervention, after non pharmacologic treatments have
been tried, what med is first line
bupropion
premature ejaculation- what is it? Tx?
- Recurrent pattern of ejaculation during sex within 1 minute and before individual wishes it
Treatment:
* Prolong time from SSRI and TCAs
stimulation to orgasm
* *****(e.g. Clomipramine- 15mg – 30 mg – take 2 hours before intercourse is effective and a safe treatment ,
Fluoxetine, Paroxetine)
Phosphodieterase-5 inhibitors (PDE-5)- ex, what to avoid, caution w/ what med class?
Sildenafil (Viagra)- take 30 min to 4hours before sexual activity
Tadalafil (Cialis)- take 30-60 min before sexual activity
Note: Avoid concomitant use w/ nitrates (e.g. nitroglycerine, isosorbide dinitrate, amyl nitrate “poppers”) - can cause an unsafe drop in blood pressure
Caution with patients taking alpha-adrenergic blockers
Cluster A personality disorders
❖ Familial association with
psychotic disorders
❖ Patient seem eccentric,
peculiar or withdrawn
* Schizoid
* Schizotypal
* Paranoid
Cluster B personality disorders
❖ Familial association with
mood disorders
❖ Patients seem emotional,
dramatic or inconsistent
* Antisocial
* Borderline
* Histrionic
* Narcissistic
Cluster C personality disorders
❖ Familial association with
anxiety disorders.
❖ Patients seem anxious or
fearful
* Avoidant
* Dependent
* Obsessive-compulsive
General tx personality disorders
Personality disorders are generally very difficult to treat especially since few patients will acknowledge they need help
These disorders tend to be chronic and lifelong
Pharmacologic treatments have limited usefulness except
when treating co-morbid mental conditions (e.g. MDD)
Borderline personality disorder (BPD)
- Fear of abandonment
- Aggression
- Impulsive
- Repeated SI attempts/gestures/self-mutilation
- “Splitting”
- Txt:
*****Gold standard=Dialectical behavior therapy(DBT) - Pharmacotherapy as adjunct to psychotherapy.
- . Mood stabilizers and low dose antipsychotic meds have been found to be effective for mood swings
and lability - Avoid the use of Benzodiazepines
Antisocial personality disorder
- Failure to conform to social norms
- Deceitful, manipulative for personal gain
- Reckless, irritable
- Lack remorse
- ***NOTE: Begins as conduct disorder in childhood
- Txt:
- Psychotherapy is ineffective
- Treat symptoms of anxiety, depression or
aggression but with caution d/t high
comorbidity with substance use disorders.
General tx guidelines personality disorders
- First-line treatment for personality disorders is psychotherapy.
- Symptom-focused, medication treatment of personality disorders is
generally considered to be an adjunct to psychotherapy. - Avoid prescribing medications that can be fatal in overdose, such as
tricyclic antidepressants. - Avoid prescribing medications that can induce physiological dependence and tolerance, including benzodiazepines.
- Avoid changing medication each time there is a crisis or change in
mood symptoms, which may occur frequently and suddenly, and also
remit suddenly in some people with personality disorders. - Symptom expression in patients with personality disorders often
waxes and wanes in relationship to life circumstances.
Targeted sx domains in personality disorders & what meds for what sx/how dosed
- Cognitive and perceptual disturbances
- Impulsivity or behavioral dyscontrol
- Affective dysregulation
Antidepressants and mood stabilizers are dosed as they would be for
major depressive disorder and bipolar disorder (e.g. Lithium, Lamictal)
Antipsychotics are in general used at a lower dosing range compared
with doses used in the treatment of schizophrenia (e.g. Abilify,
Risperdal, Seroquel)
Role of basal ganglia & what type of dementia primarily occurs here
The “basal ganglia” refers to a group of subcortical nuclei responsible primarily for motor control, as well as other roles such as motor learning, executive functions and behaviors, and emotions.
Lewy body dementia
Oppositional defiant disorder description/general tx
Enduring pattern of anger or irritable mood, argumentative, defiant or vindictive behavior
Common in males
TX
Target symptoms= mood and aggression
Treat comorbid conditions (such as ADHD)
Behavior modification
Conduct disorder description/general tx
Violates the rights of other humans and animals
Inflicts cruelty and harm through physical and sexual violence
May lack remorse
TX
Behavioral modification, family and community
Meds used to target comorbid symptoms and aggression (SSRIs, guanfacine, propranolol, mood stabilizers, antipsychotics)
Autism spectrum disorder description & tx
Characterized by impairments in social communication/interaction and restrictive, repetitive behaviors/interests
4:1 ration (male/female)
Recognized ages 12-24 months
Early intervention, behavioral therapy, psychoeducation
Alpha-2 agonists (clonidine, guanfacine) and low dose atypical antipsychotics (Risperidone, Abilify)= to help reduce disruptive behaviors, aggression and irritability
Melatonin for sleep,
Remeron for sleep, anxiety
Tic disorder (Tourette’s) description/tx
Sudden, rapid, repetitive, stereotyped movements or vocalizations
Anxiety, excitement and fatigue are aggravating factor for tics
Tourette’s disorder: most severe characterized by multiple motor tics (face, head, eye blinking, throat clearing) an at least one vocal tic lasting for at least 1 year
- Vocal tics( Copralalia/Echolalia)
Behavioral interventions
Consider meds if tics become severely impairing.
**1st choice: Guanfacine (alpha-2 agonist)*
Clonidine (more sedating)
Severe cases, consider atypical (e.g. risperidone)
What is one of the biggest things to monitor w/ antipsychotic tx for ASD
sedation r/t risperidone or aripiprazole
*also metabolic SE
Youngest age for risperidone & aripiprazole rx in children for ASD
risperidone= Children 5+ and Adolescents less than 18 (weight based)
aripiprazole= Children and Adolescents 6-17 years old
Enuresis tx
*Recurrent urination into clothes or bed wetting
Treatment: Psychoeducation, behavioral program
**1st line: Desmopressin (DDAVP) an antidiuretic **
**2nd line: Imipramine (TCA) at low doses **
Encopresis tx
*Recurrent defecation into inappropriate places (e.g. clothes, floor)
*Treatment: Psychoeducation, bowel retraining
Intellectual disability disorder (IDD) - sx, cause, tx
Impaired cognitive and adaptive/social functioning.
Deficits in intellectual functioning (i.e. reasoning, problem solving, planning, abstract thinking, judgement and learning)
Deficits in adaptive functioning i.e. communication, social participation and independent living.
Severity is mild, moderate, severe and profound
Causes: Genetic (Down syndrome); Prenatal (rubella, herpes simplex etc.) Perinatal (Anoxia, prematurity, birth trauma) and Postnatal (malnutrition, toxin exposure, trauma)
Management: Behavioral Therapy
Important caution/consideration in IDD r/t meds
they may not be able to self-report drug-related problems.
ADHD presentation & etiology
Characterized by inattention, hyperactivity and impulsivity inconsistent with the patient’s developmental stage.
Males > females
Etiology:
Abnormalities of fronto-subcortical pathways (i.e. frontal cortex and basal ganglia)
Dopamine dysfunction
NE dysfunction
Does response to stimulant prove dx ADHD
No
First line tx ADHD & MAO
Meds & educational/behavioral interventions
The first-line pharmacological tx are stimulants (methylphenidate & amphetamine) which help to increase DA in prefrontal cortex
MOA: Increase DA, NE, 5HT in the prefrontal cortex, nucleus accumbens and reward circuitry
SE stimulants
Side effects: GI upset, anorexia, weight loss, BP changes, ↑ HR, Growth suppression(rare),sleep disturbance, jitteriness, headaches, dizziness, mood lability -irritability, psychosis (rare), social withdrawal
2nd line and other tx of ADHD
2nd line: Alpha-2 agonists (Clonidine, guanfacine)
Can be used instead or as an adjunctive therapy to stimulants
Used in children who respond poorly to other meds, experience side effects or have coexisting conditions such as tics.
Atomoxetine (Strattera)- NE reuptake inhibitor (consider when a hx or family hx of illicit substance use is present)
Bupropion= Wellbutrin (NDRI)
What’s important to monitor with stimulant tx
Monitor Height, weight, BP, CBC w/ diff (risk leukopenia or anemia); Pulse quarterly (Height and weight d/t risk of growth restriction)
In healthy individuals, it is NOT necessary to obtain an
EKG prior to initiating a stimulant
Prescription Monitoring Program should be checked
Contraindication to stimulants
DO NOT USE WITH PREEXISTING CARDIAC CONDITIONS & SYMPTOMS
Symptomatic cardiovascular disease
Moderate to severe hypertension
Hyperthyroidism
Known hypersensitivity or idiosyncrasy to sympathomimetic amines
Motor tics or Tourette syndrome
Glaucoma
Agitated states
Anxiety
History of drug abuse
Concurrent use or use within 14 days of the administration of monoamine oxidase inhibitors
Methylphenidate (Ritalin, Concerta)- what schedule, SE, how to help SE
- Schedule II
- Watch for Leukopenia or anemia
- Common side effects(loss of appetite, headache, stomachaches, nausea, weight loss, insomnia) -
Taking AM dose after eating breakfast can also help manage s/e of nausea or decreased appetite
Long-acting forms help with convenience and reduce the rebound side effects. Long acting avoids dosing in school
Dextromethylphenidate (Dexedrine, Adderall)- schedule, indication, age, SE
Schedule II d/t high potential for abuse/diversion
May help reduce adverse effects in those who had good response to methylphenidate, but dosing limited because of adverse effects.
Short Acting (Dexedrine, Adderall; Focalin)= 4-6 hours duration
Long Acting (Adderall XR, Vyvanse)= 8-12 hours
FDA approved for children 3+
Side effect: Loss of appetite, headaches, ↑BP; stomachaches, nausea, weight loss, insomnia, anticholinergic, tics/repetitive movements, psychosis
How to choose stimulant for ADHD
Choice often driven by insurance formularies: general rule of thumb is to pick either a methylphenidate or an amphetamine formulation and then switch if not responding after titration to reasonable dose
When to consider non stimulant meds for ADHD
Stimulants are not working well to control ADHD symptoms
Stimulants cause too many side effects
The child or teen has problems with substance abuse
The child or teen has a medical condition for which stimulants cannot be used - e.g. tic disorder
Growth suppression & stimulants
With stimulants, evidence of growth suppression is not clear, seems transient and resolves in mid-adolescence
atomoxetine (Strattera)- black box, class, age, indication
**Black box warning for SI thinking in children/adolescents
A Selective Norepinephrine Reuptake Inhibitor
FDA approved in children 6+
Not classified as a controlled substance (less abuse potential)
Alternative to stimulants for children and adolescents who have a substance abuse problem, household member with substance abuse problem, tics or severe side effects from stimulants.
Less effective
Rare liver toxicity
Alpha 2 adrenergic agonists for ADHD (when each indicated; how long until effective; how to d/c them/why)
can be used alone or as adjunctive txt.
Clonidine = helps with over aroused, easily frustrated, highly active, aggressive impulsivity and hyperactivity ; Monitor BP
Guanfacine (Tenex/Intuniv- Long acting): Rarely but can cause low BP and cardiac arrhythmias. FDA approved for children 6-17years
Can take up to 2 weeks to see clinical response
Often used if stimulant not effective enough or not tolerated
Tends to best target sx of children/adolescents including hyperarousal, hyperactivity, aggression, low frustration tolerance
No tics reported
Must be tapered to avoid rebound hypertension
Qelbree (viloxazine)
Relatively new (approval 2021) for ADHD
Approved for children ages 10+
Non-stimulant
Norepinephrine reuptake inhibitor
Common s/e: nausea, decreased appetite, insomnia, GI upset, diarrhea/constipation, tremor, dizziness, orthostatic hypotension
Rare but serious suicidal thoughts/behaviors, seizure
First line tx for personality disorders
psychotherapy
What does antisocial personality disorder start as in childhood**
conduct disorder
Gold standard tx BPD
**dialectical behavior therapy
Pharmacotherapy as adjunct to psychotherapy.
Mood stabilizers and low dose antipsychotic meds have been found to be effective for mood swings and lability.
Should BZO be used in personality disorders
NO
Avoid meds that can lead to dependence/tolerance or fatal in OD like TCAs
Dopamine & serotonin impact on sexual function
Dopamine enhances libido
Serotonin inhibits sexual function
Sildenafil (Viagra) tx, SE
erectile disorder/dysfunction/impotence= Difficulty obtaining or maintaining an erection
Most common sexual dysfunction in men
*Phosphodieterase-5 inhibitor (PDE-5)
*Enhances blood flow to the penis
S/E: headaches, flushing, dizziness, hypotension
May cause prolonged erection and priapism
TX premature ejaculation
Prolong time from SSRI and TCAs stimulation to orgasm
(e.g. Clomipramine, Fluoxetine, Paroxetine)
- When to use benzos in pt w/ dementia
Reserve Benzos for short term and acute episodes
Black box warning antipsychotics in pts w/ dementia
Black box warning for antipsychotic use in dementia patients= ↑ risk of death = low doses for short periods if necessary ( consider Zyprexa, Seroquel, Risperdal)
ESPECIALLY in Lewy Body dementia
Leqembi
new treatment for mild cognitive impairment (MCI)
Anti-Amyloid Monoclonal Antibody; Immune Globulin; Monoclonal Antibody; targets harmful amyloid proteins; reducing existing amyloid brain plaque.
SE: Amyloid Related Imaging Abnormalities or “ARIA”, HA, confusion, dizziness, vision change, nausea, difficulty walking, seizures
Normal aging in geriatric patients impacting med choices
- Decreased brain weight/enlarged ventricles
- Decreased muscle mass/increased fat
- Impaired vision and hearing
- Decreased renal function
- Decreased ability of liver to metabolize drugs
**Decreased protein levels = more free meds in the body= risk for toxicity **
Safer option for sedative hypnotic in elderly
trazodone
What “criteria” used for inappropriate prescribing in elderly
BEERS criteria
Side effect of benztropine/Cogentin use in the elderly
Anticholinergic (dry mouth, confusion, blurred vision, urinary retention, constipation etc.)
Sx & age of onset frontotemporal dementia
Individuals with frontotemporal dementia usually present before age 65, and have behavior symptoms early on, with relative sparing of memory. Symptoms include personality changes, impaired judgement, apathy, and disinhibition
Difference between Lewy body dementia & parkinsons demetia
both irreversible, the main difference between the two is the sequence of events
In Parkinson’s disease, the symptoms of parkinsonism usually come first followed by dementia. On the other hand, in Lewy body dementia, dementia comes first, followed by parkinsonism and individuals are “dopamine-sensitive”, meaning it can cause them to hallucinate, become agitated, and be confused.
How to mitigate GI SE of rivastigmine (cholinesterase inhibitor)
** Transdermal patch available – daily
form with fewer side effects**
Only cholinesterase inhibitor approved for all stages of dementia (mild-severe)
Donepezil
Disulfiram MOA
It acts by inhibiting aldehyde dehydrogenase (ALDH), leading to high blood levels of acetaldehyde.
(causing aversion rxn)
To administer Disulfiram, a patient must be alcohol free for at least….. hours
AT LEAST 12 hrs but preferably 24h & can cause aversion reaction for 2 weeks
S/S of aversion reaction associated with Disulfiram
flushing, headaches, n/v, palpitation, SOB, vertigo, hypotension
Marketed as Zyban and helps reduce tobacco related craving and
withdrawal symptoms
bupropion SR
Various medications available for Opioid withdrawal s/s
* Muscle spasms =__________
* Anxiety and agitation =____________________
* Diarrhea =_____________
* Abdominal cramps =________________
* Nausea =___________
* Insomnia =________
* autonomic ssx
- Muscle spasms = baclofen
- Anxiety and agitation = benzo
- Diarrhea = Loperamide
- Abdominal cramps =dicyclomine
- Nausea = promethazine
- Insomnia = sedative hypnotics (trazodone, quetiapine, Benadryl)
- autonomic ssx= clonidine
Most used psychoactive substance in the United States
Caffeine
Target symptoms when medications are used in conduct disorder
Meds used to target comorbid symptoms and aggression (SSRIs, guanfacine, propranolol, mood stabilizers, antipsychotics)
ADHD symptoms result from a dysfunction of ____________ and ___________
DA & NE
This medication commonly prescribed to ADHD has a Blackbox warning for SI in children and adolescents =
atomoxetine
Psychopharmacologic management of delirium
antipsychotics
haldol has least anticholinergic SE
Cholinesterase inhibitors work by reversible inhibition of
acetylcholinesterase, the enzyme that breaks down acetylcholine, thereby increasing the duration of action of acetylcholine
Common side effects of Cholinesterase inhibitors
*GI
symptoms of overstimulation of the parasympathetic nervous system, such as increased hypermotility, hypersecretion, bradycardia, miosis, diarrhea, and hypotension
This criteria has a list of medications considered potentially inappropriate
for use in older patients mostly due to high risk for adverse events
Beers
Neurotransmitters most commonly associated w/ dementia
decreased NE and acetylcholine
