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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
Q

Medical causes of anxiety

A

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

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26
Q

Drug induced anxiety

A 
Anticonvulsants
Antidepressants
Antihypertensives- clonidine, felodipine
Antimicrobials- Isoniazid, FQs
Theophylline
Corticosteroids
Sympathomimetics- albuterol, epinephrine
Thyroid hormone
Stimulants- cocaine, meth
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27
Q

Pathophysiology of anxiety

A

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

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28
Q

GAD diagnosis

A

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

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29
Q

Social anxiety disorder diagnosis

A

Marked fear or anxiety about social situations involving possible scrutiny by others. Duration > 6 months.

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30
Q

Panic attack diagnosis

A

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
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31
Q

Panic disorder

A

> 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

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32
Q

Anxiety rating scales

A

GAD-7
Panic disorder severity scale
Social phobia inventory

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33
Q

Management of anxiety

A 
Psychological therapy
-Cognitive behavioral therapy, exposure therapy
Stress management 
Exercise
Drugs
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34
Q

Kava Kava

A

Effectve in anxiety, but takes 8 weeks for onset

Significant concern for hepatotoxicity

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35
Q

Valerian

A

Limited data in anxiety, dont use

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36
Q

Peppermint

A

Limited data in anxiety

Dont use

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37
Q

Lavender

A

Silexan 80mg QD effective for anxiety

Low risk of AE

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38
Q

Pharmacologic options for anxiety

A

Benzodiazepines, SSRIs, SNRIs, TCAs, buspirone, hydroxyzine, propranolol, pregabalin, atypical antipsychotics, antidepressants

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39
Q

Anxiety therapy targets

A

F/U every 1-2 weeks until stable
Efficacy: 4-6 week trial
Maintenance- typically 12+ months at full dose

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40
Q

GAD/panic algorithm

A

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

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41
Q

1st line options for GAD

A

SSRIs: Escitalopram, paroxetine, sertraline
SNRIs: duloxetine, venlafaxine XR
Pregabalin

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42
Q

1st line for PD

A

SSRIs

SNRI- venlafaxine XR

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43
Q

1st line for SAD

A

CBT
SSRI: escitalopram, fluvoxamine, paroxetine, sertraline, fluoxetine
Venlafaxine CR
Pregabalin

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44
Q

BZD MOA

A

Binds to GABAa receptor at y subunit and acts to increase affinity for GABA. Inhibits excitatory activity and increases rate of Cl channel opening.

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45
Q

BZD place in therapy for anxiety

A

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

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46
Q

PK of BZDs

A

Lorazepam
Oxazepam
Temazepam
Liver

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47
Q

AE of BZDs

A

CNS depression, psychomotor impairment, confusion, aggression, disinhibition, amnesia

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48
Q

BZD interactions

A

CNS depressants
BBW: use with opioids
Alprazolam, chlordiazepoxide, clonazepam, diazepam- 3A4 susbtrates, fluvoxamone, grapefruit juice, CNS depression

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49
Q

BZD withdrawal-

A

Common- anxiety, insomnia, irritability, muscle aches, tremor, anorexia, HTN, tachycardia
Less common - confusion, nausea, depression, hyperreflexia, blurred vision
Rare- seizures, delirium, psychosis, catatonia

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50
Q

BZD tapering

A 
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
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51
Q

BZD OD

A

CNS depression, respiratory depression
Not likely to be fatal if only substance involved
Reversal agent: flumazenil

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52
Q

Anxiety vs depression dosing

A

Anxiety needs 1/2 doses of depression

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53
Q

Which SSRIs are approved for anxiety?

A

GAD0 escitalopram, paroxetine
Panic-fluoxetine, paroxetine, sertraline
OCD- fluvoxamine, fluoxetine, paroxetine, sertraline
PTSD- paroxetine, sertraline

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54
Q

Which SNRI has the most data for anxiety?

A

Venlafaxine

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55
Q

Buspirone (Buspar)

A

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

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56
Q

AE of buspirone

A

Dizziness, nausea, HA, akathisia (restlessness)

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57
Q

Hydroxyzine

A

MOA: blocks histaminic receptors and serotonin receptors, CNS depression
2nd line for GAD
Rapid onset

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58
Q

When is hydroxyzine useful?

A

In GAD pts with abuse history, insomnia, pediatric anxiety

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59
Q

Hydroxyzine AE

A

CNS depression, anticholinergic effects, QTc prolongation

60
Q

Prazosin

A

MOA: blocks alpha-1 adrenergic receptors in the CNS

Use in PTSD related disturbances, not FDA approved

61
Q

Prazosin AE

A

Low blood pressure (monitor), orthostasis, drowsiness, dizziness

62
Q

Pregabalin

A

1st line for GAD in some guidelines, works within 1 week

Not FDA approved

63
Q

Propranolol

A

Blocks cardiac beta receptor activation- decreases rate and force of contraction and BP
Beneficial in event related anxiety

64
Q

DSM-5 criteria for OCD

A

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
Q

Obsessions

A

Recurrent and persistent thoughts, urges, or images that are experienced and are intrusive/unwanted.
The individual attempts to ignore or suppress such thoughts.

66
Q

Compulsions

A

Repetitive behaviors or mental acts that one person feels driven to perform in response to an obsession

67
Q

Insight in OCD

A

Good insight- the person recognizes that the beliefs are definitely or probably not true

68
Q

OCD cycle

A

Obsessive thoughts, tension and anxiety, compulsive urge, short-term relief, negative thoughts (anger, guilt)

69
Q

Prevalence/impact of OCD

A

Fewer than 40% of patients receive OCD related medications
Most patients have continuous symptoms
Difficult to treat and identify

70
Q

Diagnostic tests for OCD

A

Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)
OCI-SV
Florida OC Inventory

71
Q

Pathophysiology of OCD

A

Hyperactive CSTC loop circuitry

72
Q

OCD treatment

A

Mild: CBT
Moderate: SSRI or clomipramine
Continue 1-2 years

73
Q

What medications are add ons for OCD?

A

Aripirpazole, risperidone, quetiapine, olanzapine
Memantine
N-AC

74
Q

SSRI dosing in OCD

A

High doses of SSRIs- higher than depression

75
Q

How long do you trial an SSRI for OCD?

A

12 weeks, continue for 1-2 years

76
Q

Clomipramine for OCD monitoring

A

Anticholinergic AE
Risk of arrhythmia and seizures at doses >200mg
Therapeutic drug monitoring 230-450ng/mL

77
Q

Trauma and stressor related disorders

A

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
Q

Can you have PTSD after 1 month?

A

No, <1 month is acute stress disorder

79
Q

PTSD DSM-5 criteria

A

> 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
Q

Fear conditioning

A

Amygdala- remembers the stimuli associated with a fearful event
Thalamus- provides sensory input to amygdala
Hippocampus- remembers the context of fear conditioning

81
Q

Fear response-

A

Amygdala
Hypothalamus- endocrine responses
Prefrontal cortex-emotions
Brainstem/LC- motor reactions, ANS

82
Q

Fear extinction

A

Progressive reduction of the response to a fear stimulus. New learning allows inhibition of fear response. l
GABA suppresses glutamate driven dear response

83
Q

Fear dysregulation in PTSD

A

Deficits in fear extinction
Increased generalization of fear
Negative bias of threat from neutral stimuli
Feeling of danger in safe environment

84
Q

Treatment of PTSD

A 
CBT
Paroxetine
Fluoxetine
Sertraline
Venlafaxine
85
Q

Venlafaxine AE

A

Can elevate BP

86
Q

Other meds for PTSD

A 
Prazosin for nighttime PTSD
Antipsychotics for psychosis that occurs with PTSD
Benzo
MDMA
Cannabinoids
87
Q

Cannabis receptor locations

A

CB1 receptor primarily in CNS

CB2 more peripherally

88
Q

Actions of cannabinoids

A

Inhibit pro-inflammatory mediators in the CNS
Modulate neurotransmitters
Antioxidant
Regulate pain transmission
Effects on appetite, emotion, nausea, cancer-cell death

89
Q

Endogenous cannabinoid

A

Anandamide; 2-arachidonylglycerol

90
Q

Dronabinol

A

Synthetic THC used for cancer, anorexia

91
Q

Cannabidiol

A

Plant-derived CBD

Used for dravet syndrome, LGS

92
Q

Nabiximols

A

Plant derived THC/CBD

Not approved in US

93
Q

THC DDI

A

Metabolized by 3A4 and 2C9

94
Q

CBD DDI

A

Substrate of 3A4 and 2C19

95
Q

Smoked marijuana interactions

A

1A2 induction (cigarettes)

96
Q

Sympathomimetic agents and weed ddi

A

increase tachycardia and HTN

97
Q

CNS depressants and weed DDI

A

Increase drowsiness and ataxia

Increases with alcohol, barbiturates, benzos

98
Q

Anticholinergic agents and weed DDI

A

increase tachycardia and drowsiness

99
Q

Psychiatric effects of cannabis

A

Potentially causes earlier or more severe onset of depression, anxiety, bipolar disorder, SUD, and psychosis

100
Q

Is marijuana addictive?

A

Yes, 8.9%

101
Q

Marijuana withdrawal

A

Craving, sleep problems, nightmares, anger, irritabiltiy, dysphoria, nausea

102
Q

Ohio Medical Marijuana Control Program (MMCP)

A

Ohio Department of Commerse
State medical Board of Ohio
Ohio BOP

103
Q

Do prescribers prescribe marijuana?

A

No they recommend

104
Q

Ohio Certificate to Recommend (CTR)

A

Must have Ohio ML, OARRS, DEA registration
No conflict of interest
2 hours of CE
Application

105
Q

Minimial standard of care when recommending

A

Physician-patient relationship
Medical records maintained for 3 years
Annual report to medical board regarding effectiveness

106
Q

Minimal standard of care after diagnosis

A

Must determine if the patient already has active registration or recommendation for tx by reviewing OARRS

107
Q

Medical marijuana approved dosage form

A

Oral
Vapor
Transdermal
Topical

108
Q

Medical marijuana package requirements

A

Packaging may not be attractive to children
CHild proof
Light resistant
Lab analysis and cannabinoid profile

109
Q

Amphetamine/Dextroamphetamine brand and class

A

Adderall

Stimulant

110
Q

Atomoxetine brand and class

A

Strattera

NE reuptake inhibitor

111
Q

Clonidine brand and class

A

Catapres, Nexiclon, Kapvay

Central alpha 2 agonist

112
Q

Guanfacine brand and class

A

Intuniv

Selective alpha 2a agonist

113
Q

Lisdexamfetamine brand and class

A

Vyvanse, stimulant

114
Q

Methylphenidate brand and class

A

Brand- ritalin, methylin, metadate, concerta

Class- stimulant

115
Q

What is ADHD?

A

Most prevalent neurodevelopmental disorder diagnosed among children
50-60% of children continue being symptomatic until adulthood

116
Q

ADHD male vs female

A

Male- more common, hyperactive, comorbid behavior issues common
Female- comorbid anxiety or depression more common

117
Q

Risk factors for ADHD

A

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
Q

DSM-5 Criteria for ADHD

A

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
Q

Inattention

A 
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
Q

Hyperactivity/impulsivity

A 
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
Q

ADHD presentations

A

Subtypes may not persist over a lifetime and DSM-5 defines as presentations rather than specific types
Primarily inattentive
Primarily hyperactive/impulsive
Combined

122
Q

Pathophysiology of ADHD

A

DA and NE dysregulation

123
Q

ADHD symptom trend by age

A

Inattention becomes more predominant over time

124
Q

Non-pharm therapy for ADHD

A

Parent Training in Behavior Management (PTBM)

125
Q

1st line treatment for ADHD

A 
4-5= PTBM and classroom interventions
5-12= Methylphenidate or Amphetamine
12-18= FDA approved medication with adolescents consent
126
Q

Treatment algorithm of ADHD

A

1st line- stimulants
fail therapy- 2nd stimulant
3rd line- 3rd stimulant or atomoxetine, augment with guanfacine or clonidine

127
Q

Adults ADHD tx

A

No SUD- stimulant or atomoxetine
SUD- atomoxetine, lisdexamfetamine, methylphenidate
3rd line- bupropion

Alpha 2 agonists not effective in adults

128
Q

Methylphenidate MOA

A

Selectively inhibits presynaptic reuptake of DA and NE

DA>NE

129
Q

Amphetamine MOA

A

Decreases pre-synaptic reuptake of DA and NE and increases amount of DA released from vesicles, enhances NE release

130
Q

Therapeutic result of stimulants

A

Increased intrasynaptic levels of DA and NE in the prefrontal cortex

131
Q

Stimulants admin

A

Peak delayed with high fat meal
DOA dependent on formulation
Typically initiated at recommended starting dose and titrated weekly until response

132
Q

BBW of stimulants

A

Stimulants are associated with a high potential for abuse and dependence.
Misuse of amphetamines may cause sudden cardiac death and CV events

133
Q

Contraindications/precautions with stimulants

A 
Hypothyroidism, SUD
HTN, Tachycardia
May exacerbate tics, psychosis, seizures
May cause peripheral vasculopathy
Increased risk of suicidal thoughts or behaviors
134
Q

AE of sstimulants

A 
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
Q

Stimulant ADR management

A

Monitor weight, instruct to eat a high-calorie breakfast and dinner
Stimulant “holidays” over the summer to catch up on growth inhibition

136
Q

Stimulants DDI

A

CNS stimulants, antihypertensives, TCAs, opioids, acid suppression, MAOIs, CYP2D6

137
Q

Safety and monitoring of stimulants

A

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
Q

Methyphenidate formulations

A

IR, Intermediate, LA, Transdermal

139
Q

Amphetamine formulations

A

IR, Intermediate, intermediate LA

140
Q

Atomoxetine

A

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
Q

Viloxazine

A

Blocks NE reuptake pump on presynaptic membrane
BBW: suicidal ideation
Warnings: BP/HR increase, treatment emergent psychotic or manic symptoms, sombolence and fatigue

142
Q

Guanfacine vs clonidine

A

Less sedation and dizziness with guanfacine

143
Q

Pregnancy and stimulants

A

Premature birth and low birth weight

144
Q

Lactation and sitmulants

A

Use with caution

AMP may decrease milk production

145
Q

Elderly and stimulants

A

Little data available

Typically used for depression/apathy in older adults

Therapeutics 4 (8 decks)

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