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Therapeutics 4 > Exam 4 part 2 > Flashcards

Exam 4 part 2 Flashcards

1
Q

Brand and class: Alprazolam

A

Xanax, benzodiazepine

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2
Q

Brand and class: Amitriptyline

A

Elavil

TCA

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3
Q

Brand and class: Buspirone

A

Buspar, misc. antianxiety agent

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4
Q

Brand and class: Citalopram

A

Celexa

SSRI

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5
Q

Brand and class: Clonazepam

A

Klonopin, benzodiazepine

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6
Q

Brand and class: Desvenlafaxine

A

Pristiq, SNRI

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7
Q

Brand and class: Diazepam

A

Valium, benzodiazepine

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8
Q

Brand and class: Doxepin

A

Sinequan, TCA

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9
Q

Brand and class: Duloxetine

A

Cymbalta, SNRI

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10
Q

Brand and class: Escitalopram

A

Lexapro, SSRI

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11
Q

Brand and class: Fluoxetine

A

Prozac, Sarafem

SSRI

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12
Q

Brand and class: Gabapentin

A

Neurontin, anticonvulsant

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13
Q

Brand and class: Hydroxyzine

A

HCL- Atarax
Pamoate- Vistaril
Antihistamine

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14
Q

Brand and class: Lamotrigine

A

Lamictal

Anticonvulsant

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15
Q

Brand and class: Lorazepam

A

Ativan

Benzo

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16
Q

Brand and class: Paroxetine

A

Paxil, Pexeva

SSRI

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17
Q

Brand and class: Pregabalin

A

Lyrica, anticonvulsant

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18
Q

Brand and class: Propranolol

A

Inderal

Beta blocker

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19
Q

Brand and class: Sertraline

A

Zoloft

SSRI

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20
Q

Brand and class: Topiramate

A

Topamax, Trokendi

Anticonvulsant

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21
Q

Brand and class: Venlafaxine

A

Effexor

SNRI

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22
Q

What is the most common psychiatric disorder in the US?

A

Anxiety disorders

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23
Q

Epidemiology and risk of anxiety disorders

A 
Females > males
Age: median onset 21 years
Genetic component, not as strong as depression
Stress
Low socioeconomic status
Adverse childhood experiences (ACEs)
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24
Q

PANDAS

A

pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections.
Sudden onset of symptomatology (most commonly OCD) that gradually improves following strep infection

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25
Medical causes of anxiety
CV disease- MI, CHF, HTN, arrhythmias Endocrine/metabolic disorders- DM, hyperthyroidism, cushings disease, electrolye abnormalities, anemia Neurologic disorders- migraines, seizures, uncontrolled pain, stroke, neoplams Resp disease- COPD, asthma, pulmonary embolism, pneumonia
26
Drug induced anxiety
``` Anticonvulsants Antidepressants Antihypertensives- clonidine, felodipine Antimicrobials- Isoniazid, FQs Theophylline Corticosteroids Sympathomimetics- albuterol, epinephrine Thyroid hormone Stimulants- cocaine, meth ```
27
Pathophysiology of anxiety
Noradrenergic- LC stimulates NE (stress hormone), anxiolytics inhibit LC firing. GABA- GABA inhibits 5-HT, NE, DA. Enhancing GABA causes anxiety. Serotonin- 5-HT is inhibitory in raphe nuclie. Anxiety may be from abnormal function of release and/or uptake
28
GAD diagnosis
Excessive anxiety and worry present most days for >6 months about a number of activities. Associated with >3: Restlessness, fatigue, irritability, difficulty concentrating, muscle tension, sleep disturbance
29
Social anxiety disorder diagnosis
Marked fear or anxiety about social situations involving possible scrutiny by others. Duration > 6 months.
30
Panic attack diagnosis
Abrupt surge of intense discomfort or fear that occurs in minutes with >4: ``` Palpitations/increase HR Sweating Trembling Smothering Choking sensation N/abdominal distress Chest pain/discomfort Dizziness Chills or hot flashes Parasethsias Derealization/depersonalizations Fear of losing control Fear of dying ```
31
Panic disorder
>1 panic attack followed by > 1 month of: Consistent worry/concern about additional panic attacks or their consequences Significant maladaptive change in behavior related to the attacks
32
Anxiety rating scales
GAD-7 Panic disorder severity scale Social phobia inventory
33
Management of anxiety
``` Psychological therapy -Cognitive behavioral therapy, exposure therapy Stress management Exercise Drugs ```
34
Kava Kava
Effectve in anxiety, but takes 8 weeks for onset | Significant concern for hepatotoxicity
35
Valerian
Limited data in anxiety, dont use
36
Peppermint
Limited data in anxiety | Dont use
37
Lavender
Silexan 80mg QD effective for anxiety | Low risk of AE
38
Pharmacologic options for anxiety
Benzodiazepines, SSRIs, SNRIs, TCAs, buspirone, hydroxyzine, propranolol, pregabalin, atypical antipsychotics, antidepressants
39
Anxiety therapy targets
F/U every 1-2 weeks until stable Efficacy: 4-6 week trial Maintenance- typically 12+ months at full dose
40
GAD/panic algorithm
SSRI OR SNRI +/- BZD (BZD therapy up to 6 weeks, then taper down) Inadequate response- add other 1st or 2nd line agents or BZD When effective, continue for 12-24 months
41
1st line options for GAD
SSRIs: Escitalopram, paroxetine, sertraline SNRIs: duloxetine, venlafaxine XR Pregabalin
42
1st line for PD
SSRIs | SNRI- venlafaxine XR
43
1st line for SAD
CBT SSRI: escitalopram, fluvoxamine, paroxetine, sertraline, fluoxetine Venlafaxine CR Pregabalin
44
BZD MOA
Binds to GABAa receptor at y subunit and acts to increase affinity for GABA. Inhibits excitatory activity and increases rate of Cl channel opening.
45
BZD place in therapy for anxiety
Not everyone needs BZD, reserve for high/crisis level anxiety Acute use- PTSD MAX 6 week course then taper dose, long term use only for severe refractory cases
46
PK of BZDs
Lorazepam Oxazepam Temazepam Liver
47
AE of BZDs
CNS depression, psychomotor impairment, confusion, aggression, disinhibition, amnesia
48
BZD interactions
CNS depressants BBW: use with opioids Alprazolam, chlordiazepoxide, clonazepam, diazepam- 3A4 susbtrates, fluvoxamone, grapefruit juice, CNS depression
49
BZD withdrawal-
Common- anxiety, insomnia, irritability, muscle aches, tremor, anorexia, HTN, tachycardia Less common - confusion, nausea, depression, hyperreflexia, blurred vision Rare- seizures, delirium, psychosis, catatonia
50
BZD tapering
``` Consider: dose, duration of exposure Symptoms of withdrawal often subside in 1-2 weeks Onset varies depending on T1/2 of drug Outpatient- decrease 10-25% q 1-2 weeks Inpatient- taper dose over 1-2 weeks ```
51
BZD OD
CNS depression, respiratory depression Not likely to be fatal if only substance involved Reversal agent: flumazenil
52
Anxiety vs depression dosing
Anxiety needs 1/2 doses of depression
53
Which SSRIs are approved for anxiety?
GAD0 escitalopram, paroxetine Panic-fluoxetine, paroxetine, sertraline OCD- fluvoxamine, fluoxetine, paroxetine, sertraline PTSD- paroxetine, sertraline
54
Which SNRI has the most data for anxiety?
Venlafaxine
55
Buspirone (Buspar)
MOA: Partial agonist at 5-HT 1A receptor 2nd line for GAD, augmenting or monotherapy Takes about 2 weeks to work Avoid in severe/ renal impairment
56
AE of buspirone
Dizziness, nausea, HA, akathisia (restlessness)
57
Hydroxyzine
MOA: blocks histaminic receptors and serotonin receptors, CNS depression 2nd line for GAD Rapid onset
58
When is hydroxyzine useful?
In GAD pts with abuse history, insomnia, pediatric anxiety
59
Hydroxyzine AE
CNS depression, anticholinergic effects, QTc prolongation
60
Prazosin
MOA: blocks alpha-1 adrenergic receptors in the CNS | Use in PTSD related disturbances, not FDA approved
61
Prazosin AE
Low blood pressure (monitor), orthostasis, drowsiness, dizziness
62
Pregabalin
1st line for GAD in some guidelines, works within 1 week | Not FDA approved
63
Propranolol
Blocks cardiac beta receptor activation- decreases rate and force of contraction and BP Beneficial in event related anxiety
64
DSM-5 criteria for OCD
Presence of obsessions, compulsions, or both The obsessions/ compulsions are time consuming (>1 hour/day) The obsessions/compulsions are not attributable to the physiological effects of a substance or another medical condition The disturbance is not better explained by another disorder
65
Obsessions
Recurrent and persistent thoughts, urges, or images that are experienced and are intrusive/unwanted. The individual attempts to ignore or suppress such thoughts.
66
Compulsions
Repetitive behaviors or mental acts that one person feels driven to perform in response to an obsession
67
Insight in OCD
Good insight- the person recognizes that the beliefs are definitely or probably not true
68
OCD cycle
Obsessive thoughts, tension and anxiety, compulsive urge, short-term relief, negative thoughts (anger, guilt)
69
Prevalence/impact of OCD
Fewer than 40% of patients receive OCD related medications Most patients have continuous symptoms Difficult to treat and identify
70
Diagnostic tests for OCD
Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) OCI-SV Florida OC Inventory
71
Pathophysiology of OCD
Hyperactive CSTC loop circuitry
72
OCD treatment
Mild: CBT Moderate: SSRI or clomipramine Continue 1-2 years
73
What medications are add ons for OCD?
Aripirpazole, risperidone, quetiapine, olanzapine Memantine N-AC
74
SSRI dosing in OCD
High doses of SSRIs- higher than depression
75
How long do you trial an SSRI for OCD?
12 weeks, continue for 1-2 years
76
Clomipramine for OCD monitoring
Anticholinergic AE Risk of arrhythmia and seizures at doses >200mg Therapeutic drug monitoring 230-450ng/mL
77
Trauma and stressor related disorders
Disorders in which exposure to a traumatic or stressful event is explicitly part of diagnostic criteria Psychological distress following exposure to a traumatic event is variable, many pts have responses other than fear. Separate category from anxiety and OCD
78
Can you have PTSD after 1 month?
No, <1 month is acute stress disorder
79
PTSD DSM-5 criteria
>6 years old - Exposure to actual or threatened death, serious injury, or sexual violence -Presence of one )or more symptoms associated with traumatic event -Persistent avoidance of stimuli associated with event -Negative alterations in cognition and mood associated with the traumatic events -Marked alterations in arousal and reactivity >1 month
80
Fear conditioning
Amygdala- remembers the stimuli associated with a fearful event Thalamus- provides sensory input to amygdala Hippocampus- remembers the context of fear conditioning
81
Fear response-
Amygdala Hypothalamus- endocrine responses Prefrontal cortex-emotions Brainstem/LC- motor reactions, ANS
82
Fear extinction
Progressive reduction of the response to a fear stimulus. New learning allows inhibition of fear response. l GABA suppresses glutamate driven dear response
83
Fear dysregulation in PTSD
Deficits in fear extinction Increased generalization of fear Negative bias of threat from neutral stimuli Feeling of danger in safe environment
84
Treatment of PTSD
``` CBT Paroxetine Fluoxetine Sertraline Venlafaxine ```
85
Venlafaxine AE
Can elevate BP
86
Other meds for PTSD
``` Prazosin for nighttime PTSD Antipsychotics for psychosis that occurs with PTSD Benzo MDMA Cannabinoids ```
87
Cannabis receptor locations
CB1 receptor primarily in CNS | CB2 more peripherally
88
Actions of cannabinoids
Inhibit pro-inflammatory mediators in the CNS Modulate neurotransmitters Antioxidant Regulate pain transmission Effects on appetite, emotion, nausea, cancer-cell death
89
Endogenous cannabinoid
Anandamide; 2-arachidonylglycerol
90
Dronabinol
Synthetic THC used for cancer, anorexia
91
Cannabidiol
Plant-derived CBD | Used for dravet syndrome, LGS
92
Nabiximols
Plant derived THC/CBD | Not approved in US
93
THC DDI
Metabolized by 3A4 and 2C9
94
CBD DDI
Substrate of 3A4 and 2C19
95
Smoked marijuana interactions
1A2 induction (cigarettes)
96
Sympathomimetic agents and weed ddi
increase tachycardia and HTN
97
CNS depressants and weed DDI
Increase drowsiness and ataxia | Increases with alcohol, barbiturates, benzos
98
Anticholinergic agents and weed DDI
increase tachycardia and drowsiness
99
Psychiatric effects of cannabis
Potentially causes earlier or more severe onset of depression, anxiety, bipolar disorder, SUD, and psychosis
100
Is marijuana addictive?
Yes, 8.9%
101
Marijuana withdrawal
Craving, sleep problems, nightmares, anger, irritabiltiy, dysphoria, nausea
102
Ohio Medical Marijuana Control Program (MMCP)
Ohio Department of Commerse State medical Board of Ohio Ohio BOP
103
Do prescribers prescribe marijuana?
No they recommend
104
Ohio Certificate to Recommend (CTR)
Must have Ohio ML, OARRS, DEA registration No conflict of interest 2 hours of CE Application
105
Minimial standard of care when recommending
Physician-patient relationship Medical records maintained for 3 years Annual report to medical board regarding effectiveness
106
Minimal standard of care after diagnosis
Must determine if the patient already has active registration or recommendation for tx by reviewing OARRS
107
Medical marijuana approved dosage form
Oral Vapor Transdermal Topical
108
Medical marijuana package requirements
Packaging may not be attractive to children CHild proof Light resistant Lab analysis and cannabinoid profile
109
Amphetamine/Dextroamphetamine brand and class
Adderall | Stimulant
110
Atomoxetine brand and class
Strattera | NE reuptake inhibitor
111
Clonidine brand and class
Catapres, Nexiclon, Kapvay | Central alpha 2 agonist
112
Guanfacine brand and class
Intuniv | Selective alpha 2a agonist
113
Lisdexamfetamine brand and class
Vyvanse, stimulant
114
Methylphenidate brand and class
Brand- ritalin, methylin, metadate, concerta | Class- stimulant
115
What is ADHD?
Most prevalent neurodevelopmental disorder diagnosed among children 50-60% of children continue being symptomatic until adulthood
116
ADHD male vs female
Male- more common, hyperactive, comorbid behavior issues common Female- comorbid anxiety or depression more common
117
Risk factors for ADHD
Low socioeconomic status First degree relative with ADHD Exposure to environmental toxins (lead) Maternal use of drugs, alcohol, or smoking during pregnancy Premature birth Children who are the youngest in their class
118
DSM-5 Criteria for ADHD
Symptoms of inattention or hyperactivity-impulsivity for at least 6 months to an extend that is disruptive and inappropriate for his/her development Scales completed by parent, teacher, and patient (if able). 2 teachers if >12 yo. Must have been present in >2 settings
119
Inattention
``` Forgets daily activities Distracted by external stimuli Difficulty listening Loses needed items Trouble organizing Unable to follow/finish tasks Avoids activities requiring continuous attention Makes careless mistakes ```
120
Hyperactivity/impulsivity
``` Talks excessively Difficulty waiting turn Impulsively blurts answers Runs/climbs inappropriately Cannot remain seated when needed Fidgets/squirms in seat Unable to engage in quiet leisure Always "on the go" ```
121
ADHD presentations
Subtypes may not persist over a lifetime and DSM-5 defines as presentations rather than specific types Primarily inattentive Primarily hyperactive/impulsive Combined
122
Pathophysiology of ADHD
DA and NE dysregulation
123
ADHD symptom trend by age
Inattention becomes more predominant over time
124
Non-pharm therapy for ADHD
Parent Training in Behavior Management (PTBM)
125
1st line treatment for ADHD
``` 4-5= PTBM and classroom interventions 5-12= Methylphenidate or Amphetamine 12-18= FDA approved medication with adolescents consent ```
126
Treatment algorithm of ADHD
1st line- stimulants fail therapy- 2nd stimulant 3rd line- 3rd stimulant or atomoxetine, augment with guanfacine or clonidine
127
Adults ADHD tx
No SUD- stimulant or atomoxetine SUD- atomoxetine, lisdexamfetamine, methylphenidate 3rd line- bupropion Alpha 2 agonists not effective in adults
128
Methylphenidate MOA
Selectively inhibits presynaptic reuptake of DA and NE | DA>NE
129
Amphetamine MOA
Decreases pre-synaptic reuptake of DA and NE and increases amount of DA released from vesicles, enhances NE release
130
Therapeutic result of stimulants
Increased intrasynaptic levels of DA and NE in the prefrontal cortex
131
Stimulants admin
Peak delayed with high fat meal DOA dependent on formulation Typically initiated at recommended starting dose and titrated weekly until response
132
BBW of stimulants
Stimulants are associated with a high potential for abuse and dependence. Misuse of amphetamines may cause sudden cardiac death and CV events
133
Contraindications/precautions with stimulants
``` Hypothyroidism, SUD HTN, Tachycardia May exacerbate tics, psychosis, seizures May cause peripheral vasculopathy Increased risk of suicidal thoughts or behaviors ```
134
AE of sstimulants
``` Decreased appetite, weight loss Stomach upset Insomnia HA Rebound symptoms Psychosis or mania Aggression/violent behavior Severe anxiety or panic attacks Height and weight deficiency ```
135
Stimulant ADR management
Monitor weight, instruct to eat a high-calorie breakfast and dinner Stimulant "holidays" over the summer to catch up on growth inhibition
136
Stimulants DDI
CNS stimulants, antihypertensives, TCAs, opioids, acid suppression, MAOIs, CYP2D6
137
Safety and monitoring of stimulants
At baseline obtain CV function, BP, HR, weight, SUD | At f/u- BP and HR, weigt and height, priapism (older), anxiety, insomnia, agitation, dysphoria "feeling weird"
138
Methyphenidate formulations
IR, Intermediate, LA, Transdermal
139
Amphetamine formulations
IR, Intermediate, intermediate LA
140
Atomoxetine
Blocks NE reuptake pump on the presynaptic membrane BBS: suicidal ideation Warnings: aggressive behavior, treament emergent psychotic or manic symptoms, orthostasis and syncope, allergic rxns, priapism
141
Viloxazine
Blocks NE reuptake pump on presynaptic membrane BBW: suicidal ideation Warnings: BP/HR increase, treatment emergent psychotic or manic symptoms, sombolence and fatigue
142
Guanfacine vs clonidine
Less sedation and dizziness with guanfacine
143
Pregnancy and stimulants
Premature birth and low birth weight
144
Lactation and sitmulants
Use with caution | AMP may decrease milk production
145
Elderly and stimulants
Little data available | Typically used for depression/apathy in older adults

Therapeutics 4 (8 decks)

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