Exam 4 psych Flashcards
What are the questionnaires used for depression?
Patient Health care questionnaire (PHQ-9) & Beck depression inventory (BDI)
-both patient rated
Hamilton Depression (HAM-D, HDRS) & Montgomery-Asberg Depression Rating Scale (MADRS)
-both clinician rated (used in clinical trials)
What evidence exists for the Glutamate hypothesis in Schizophrenia?
Phenycyclidine and ketamine (inhibitors of NMDA) exacerbate psychosis and cognition deficits
What evidence exists for the Serotonin hypothesis in Schizophrenia?
5HT2a receptors are bad for schizophrenia; they modulate dopamine release, gluamate release and NMDA receptors
5HT2c recetors may be good for schizophrenia
What evidence exists for the dopamine hypothesis in Schizophrenia?
-strong correlation between binding affinity and clinical effectiveness of D2 receptor antagonists
-Dopaminergic agents (L-DOPA, amphetamine, bromocriptine) exacerbate schizophrenia symptoms
What drug induced movement disorders are associated with D2 antagonism?
Extrapyramidal Symptoms (EPS)
Tardive Dyskinesia
Neuroleptic Malignant Syndrome (NMS)
When do the movement disorders associated with D2 antagonism occur?
EPS- early, days/weeks, reversible
Tardive Dyskinesia- later, months/year, irreversible
Neuroleptic Malignant Syndrome- rapid, serious 10% fatality
What are the treatments for EPS associated with D2 antagonism?
Drug induced Parkinson’s- Benztropine, trihexphenidyl, diphenhydramine (Benedryl), Amantadine
Akathisia- propranolol
Acute Dystonia- IM benzotripine 2 mg, IM diphenhydramine 50 mg
What are the treatments for tardive dyskinesia associated with D2 antagonism?
Prevention
-low dose, less risky agents, newer agents
-VMAT inhibitors
*Tetrabenazine, Valbenazine, Deutetrabenazine
What are the treatments neuroleptic malignant syndrome associated with D2 antagonism?
-DA agonists, diazepam, dantrolene
-Discontinue drug asap
What is important to know about clozapine& monitoring?
agranulocytosis, risk of diabetes, QTc prolongation
monitoring timeline: weekly x6 months, biweekly x6 months, then every 4 weeks
What is important to know about Olanzapine?
weight gain, risk of diabetes, DRESS warning, sedation
What is the interaction between cigarette smoking and CYP1A2?
smoke induces 1A2 which decreases serum concentration of 1A2 substrate antipsychotics (olanzapine, asenapine, clozapine, loxapine)
What are the typical antipsychotics?
Haloperidol, Fluphenazine, Loxapine, Chlorpromazine, Perphenazine, Thioridazine
What are the atypical antipsychotics?
Aripiprazole, Asenapine, Brexpiprazole, Cariprazine, Clozapine, Iloperidone, Lumateperone, Lurasidone, Olanzapine, Paliperidone, Quetiapine, Risperidone, Ziprasidone
What are the partial agonist antipsychotics
-increased akathisia
-aripiprazole, Brexpiprazole, cariprazine
What is important to know about Quetiapine?
boxed warning for suicidal ideation, sedation, weight gain
What is important to know about Asenapine?
-SL and patch formulations
What antipsychotics have QTc prolongation?
Asenapine, Clozapine, Quetiapine, iloperidone, Ziprasidone (Contraindication), Paliperidone
What are the risperidone long-acting injections?
Risperdal Consta -3/4 weeks oral overlap
Perseris- abdonimal SC injection
Rykindo -1 week overlap (every 2 week IM injection)
Uzedy- can give every 1 or 2 months
What are the paliperidone long-acting injections?
Invega sustenna
Invega trinza
Invega Hafyera
What are the aripiprazole long-acting injections?
Abilify Maintena- overlap for 2 weeks; adjust dose if on 2D6 or 3A4 inhibitor/inducers
Abilify Asimtufii- overlap for 2 weeks; every 2 month dosing
Aristada- prodrug; overlap for 3 weeks
Aristada Initio- no overlap; avoid in poor 2D6 metabolizers & strong 3A4/2D6 inhibitors
What medications are used for psychiatric emergenices?
most common: Haloperidol
chlorpromazine, fluphenazine, Olanzapine IM (CI with benzo’s)
loxapine (inhalation formulation)
What is important to know about Lumateperone?
-newest agent
-lower risk for EPS, akathisisa, metabolic AE’s, 3A4 substrate
What is the indication for Pimaranserin?
hallucinations/delusions in a patient with parkison’s disease, 3A4 substrate
What medications have an increased risk for DRESS syndrome?
Ziprasidone, Olanzapine
What medications need to be taken with food to increase absorbtion?
Lurasidone, Ziprasidone
-both 3A4 substrates
What is the benzodiazepine and Z-hypnotics antagonist?
Flumazenil
AE’s: induces convulsions; panic attacks for those who developed dependence
Where do Barbiturates bind?
bind to all GABAa 1-5 and increase the duration of channel opening; and direct effects on GABAa channel; higher risk
Where do Benzodiazepines bind?
bind to all GABAa 1-5 and increase frequency of GABAa channel opening; medium risk
Where do Z-Hypnotics bind?
bind to GABAa BZ1 receptors increase FREQUENCY of GABAa channel opening; lower risk
What is the Orexin Receptor Antagonist drug?
Suvorexant (Belsomra), Lemborexant, Daridorexant
-3A4 substrates
-CI in narcolepsy
What are the melatonin agonist medications?
Ramelteon (Rozerem), Tasimelteon (Hetlioz)
-Tasimelteon approved for non-24 sleep-wake disorder in adults (blind people)
-Ramelton CI with fluvoxamine
both are 1A2 substrates -watch for inhibitors/inducers
What neurotransmitters are involved in anxiety?
Norepinephrine -dysregulated in GAD,
GABA- signaling is reduced
Serotonin- reflects tone at multiple receptors
What is the mechanism of action of Buspirone?
partial agonist on 5HT1a receptors; leads to an adaptive response
What drugs do you take as an elderly for benzodiazepines?
lorazepam, oxazepam, temazepam
What is the first line treatment for Generalized Anxiety Disorder?
SSRI antidepressants
-takes 2-4 weeks to find initial symptom relief
-paroxetine and escitalopram
-2nd line SNRIs/Benzos
What is the first line treatment for Social Anxiety Disorder?
SSRI antidepressants
2nd line- SNRIs (Venlafaxine)
What is the first line treatment for Panic Disorder
SSRIs
2nd line- SNRIs (Venlafaxine)
-benzos are not really recommended
What is the first line treatment for OCD?
SSRIs
-25-50% reduction in symptoms can be expected
2nd line: Clomipramine
adjunct therapy possible with risperidone
What is the first line treatment for Posttraumatic Stress Disorder?
SSRIs/SNRIs
-Prazosin may be helpful for nightmares
-Benzos not recommended
What side effects can arise from using SSRIs and SNRIs for anxiety therapy?
-Jitteriness
-initial doses should be lower than doses used for depression to minimize jitteriness
What are some drugs that are associated with insomnia?
Modafinil, Buproprion, Thyroid meds, Mood disorders
What is first line treatment for Insomnia disorders?
1st line: non-pharm –sleep hygeine
2nd line: Zolpidem, eszopiclone, zaleplon)
eszopiclone- complaints of metallic taste
-all can cause parasomnias (weird sleep behaviors)
-additive effects with other CNS depressants
-3A4 substrates -metabolism is impacted by 3A4 Inhibition and induction
What potential benzodiazepines can be used for sleep?
Temazepam
What other drugs can be used for insomnia?
Doxepin -TCA; low doses; high anticholinergic adverse effects
Trazodone- not FDA approved, low doses, may have a daytime hangover
Mirtazepine- useful if patient also has depression
Quetiapine- low dose only recommended if there is a co-morbid psychiatric disorder
What is the narcolepsy tetrad?
Cataplexy (sudden loss of muscle tone triggered by emotion), Hallucinations, Sleep paralysis, EDS (extreme daytime sleepiness)
What medications treat cataplexy?
Sodium oxybate (Xyrem), GHB (high sodium content, most effective)
Xywav -lower sodium, approved for 7 & up
Lumryz -adults only, ER dosage, high sodium content
What medications treat excessive daytime sleepiness?
modafinil/armodafinil, sodium oxybate, Pitolisant, Solriamfetol
What are some important counseling points for Pitolisant?
avoid with OTC antihistamines; may reduce efficacy of oral contraceptives; CI in severe hepatic impairment; QTc prolongation
-MOA is a H3 receptor antagonist
What are some important counseling points for solriamfetol?
-caution in patients with CV issues (increases BP and HR); caution in patients with psychosis/bipolar disorders
What are common counseling points for Aripiprazole, Brexpiprazole?
2D6 and 3A4 substrate
low weight gain vs low-moderate for brexpiprazole
moderate akathisia
What alpha 2 agonists are indicated in ADHD?
guanfacine ER -3A4 substrate
clonidine ER -must be tapered to avoid rebound hypertension if discontinued
What are the Norepinephrine Reuptake Inhibitors?
Atomoxetine -weight based dosing
Viloxazine
*boxed warning for increase in suicidal thinking
What are the ADHD guidelines for adults?
1st line: Methylphenidate or lisdexamfetamine
2nd line: Dextroamphetamine
3rd line: Atomoxetine
What is the treatment for Tourette’s disorder?
rule of thirds!
1st line: clonidine; Guanfacine (ER)
2nd line: Aripiprazole - weight based dosing,
3rd line: Haloperidol, Pimozide
What are the indications for Risperidone in peds?
Bipolar disorder; Irritability with autism; Schizophrenia
What are the indications for Aripiprazole in peds?
Bipolar disorder; Tourette’s Disorder; Schizophrenia; Irritability with Autism
What antipsychotics have a boxed warning for suicidal ideation?
Lurasidone, Quetiapine, Aripiprazole, brexpiprazole, Cariprazine
What is the treatment for Bulimia Nervosa?
Fluoxetine is FDA-approved
What is the treatment for Binge Eating Disorder?
Lisdexamfetamine (Vyvanse) is FDA-approved
-CBT + medication = best outcome
What drug is CI in anorexia nervosa?
Bupropion is contraindicated
