Exam 4 spring P2 Flashcards
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1st generation antipsychotics
-movement problems: EPS and tardive dyskinesia
- very effective for treating positive symptoms ( worse negative/ cognitive symptoms)
chlorpromazine (thorazine)
-antihistamine effects
- 1st antipsychotic
promethazine (phenergan)
-antihistamine effects
-antiemetic
fluepenazine (oermitil,proxilin)
-eps
thoridazine (mellaril)
-anticholingeric AEs
-sedation
-sexual dysfunction
- cv risk
prochlorperazine (compazine)
-antiemetic
perpehnazine (trilafon)
-CATIE studies-> combo with anticholinergics
thiothixene (navane)
-modest EPS
Haloperidol (haldol)
-EPS
-most commonly used routine and PRN
-most common standing order
haloperidol decanoate
IM injection
-z-track technique
Milindone (Moban)
-moderate EPS
Pimozide (orap)
-used in tourettes to supress tics
2nd gen antipsychotics
- reduced EPS but more metabolic side effects
- D2 (postsynaptic) and 5HT2A (presynaptic) antagonism -> increased synthesis and release of DA
-13
clozapine (clozaril)
-weight gain, sedation, dry mouth, constipation, hypersalvation, GI hypomobility
- 1st atypical antipsychotic (very effective)
-agranulocytosis-> weekly blood monitoring
-third line
- risk of diabetes
- 1A2 substrate
- warning: neutropenia, orthostasis, bradycardia, syncope, seizures, myocarditit, cardiomyipathy
-QTc prolongation
-REMS: weekly, biweekly then every 4 weeks
Olanzapine (zyprexa)
-significant weight gain
-sedation
-risk of diabetes
-1A2 substrate
-high risk metabolic syndrome
-DRESS warning
Olanzapine/ samidorphan (lybalvi)
combo mitigates metabolic syndrome
zyprexa relpravv
-IM injection
-REMS program
-post dose delirium sedation syndrome -> Over dose (CNS depressant)
-can happen 24h later
loxapine (loxitane)
-older agent
-NET Inhibitor
adasuve (loxapine)
nasal spray for inhalation
-not commonly used
Quetiapine (seroquel)
-hypotension (alpha)
-sedation (H1)
-weight gain
-metabolite with antidepressant activity
-decent antipsychotic
-risk of diabetes
-3A4 substrate
-boxed warning -> suicidal ideation
risperidal consta
IM weekly
-must supplement with oral risperidone for first 4 weeks of treatment
perseris (risperidone)
q4w subQ injection
-abdominal
-3A4 inducer - 120mg dose
-may need oral supplementation
rykindo (risperidone)
q2w IM injection
-oral dose overlap is shorter than costa (7 days vs 21-28 days)
Uzedy (risperidone)
-abdominal or upper arm SubQ injection
-monthly or every other month
Risperidone (risperidol)
-low eps
-weight gain
-sedation
-hyperprolactinemia
-orthostasis
- designed to be both 5HT2A and D2 receptor antagonist A24
-2D6 substrate
paliperidone (invega)
-eps
-weight gain
- sedation
- hyperprolactinemia
-orthostasis
-renally eliminated (dose adjustment)
-QTc prolongation
invega sustenna (paliperidone)
-IM injection
-loading dose and booster w/in 7 days then every 4 weeks
-initial loading and booster given in deltoid
-no need for oral overlap
-may require dose adjustment -> renally eliminated
invega trinza (paliperidone)
-q3 months
- deltoid injection
-may be given to patient after 4 months of sustenna
-recommended for deltoid
-renal considerations
invega hafyra (paliperidone)
q6m gluteal IM injection
-may be initiated after sustenna 4 months or 1 dose of trinza
-gluteal only
IIoperidone (fanapt)
-structurally related to risperidone
-very potent at alpha 1 receptors
-high risk for orthostasis and syncope
-QTc prolongation
-2D6 substrate
aloperidone
sucks
ziprasidone (Geodon/ Zeldox)
- QT prolongation
-5HT2A, D2, alpha 1 affinity
-QTc prolongation
-DRESS warning - take with food
-3A4 substrate
asenapine (saphris)
-antihistamine
-dopaminergic
-alpha antimuscarinic AE
-5HT2A
-D2 antagonist
-Sublingual ONLY
-and patch formulations
-1A2 substrate
-QTc prolongation
asenapine transdermal patch
apply every 24h
-reduce dose if given with strong 1A2 inhibitors-> fluvoxamine
lurasidone (latuda)
-less weight gain and metabolic effects
-fast onset
-low doses effectiveness similar to high dose
-rapid titration
-3A4 substrate
-higher risk for akathisia
-warning for suicide
-take with food
pimavanserin (nuplazid)
-inverse 5HT2A agonist
-used for PD psychosis
-3A4 substrate
D2/D3 receptor partial agonist
-stabilize DA transmission
- associated with more akathisia
-adjunct in depression
-warning for suicide
brexpiprazole (rexulti)
-moderate akathesis
-low moderate weight gain
-2D6 and 3A4 substrate
cariprazine (vraylar)
-akathesia
-low moderate weight gain
-3A4 substrate
lumateperone (caplyta)
-low risk for weight gain
-metabolic side effects
-EPS
-akathesia
-3A4 susbtrate
-once daily
aripiprazole (abilify)
-weight gain
-low risk for D2 effets
-moderate akathesia
-high affinity to 5HT2 and D2
-partial agonist at 5HT1A receptors (depression)
-prodrugs
-2D6 and 3A4 substrate -> interactes with fluoxetine
abilify maintena
-IM deltoid or gluteal q4w
-must overlap with oral aripiprazole for at least 14 days
abilify asimtufii
- gluteal IM q2m
-continue oral aripiprazole for 2 weeks after 1st injection
aristada
-prodrug of aripiprazole
- overlap with oral aripiprazole for 1st 3 weeks
aristada initio
-avoids 21 day overlap of antipsychotic
-avoid in pts who are poor 2D6 metabolizers
-avoid with strong 3A4 or 2D6 inhibitors
VMAT inhibitors
-inhibit VMAT to decrease storage/ increase release DA serotonin and NE
-treat TD
-dose adjustment for 2D6 inhibitors or 3A4 inducers
valbenazine (ingrezza)
-QTc prolongation
-weight gain
- rash
-anxiety
2D6 and 3A4 substrate
Deutetrabenazine (austedo)
-QTc prolongation
-anxiety
-2D6 substrate
Antipsychotics
increased risk of death in elderly pts with dementia with related behaviors
-fall risk assessment
2D6
fluoxetine, paroxetine are inhibitors
1A2
cigarette smoke decreases antipsychotic serum concentrations
-FLUVOZAMINE is a 1A2 inhibitor
3A4
inhibitors- conazole, mycin, grapefruit
inducers- phenobarbital, phenytoin, st. johns wort
CARBAMAZEPINE is inducer
Buspirone (buspar)
- 5HT1A receptor agonist
-partial agonist on brain 5HT1A receptors
-moderate affinity for D2 receptors
-1st line-> GAD
-not good for panic disorder
-AEs: sedation, paradoxical effects, swallowing difficulties, impairment of memory/recall, psychomotor impairment
-target dose of 10-15mg TID
-3-4 weeks for efficacy
alprazolam (xanax)
-BZD
-works on GABA to increase opening frequency
-2nd line if necessart
-short term use after sertonergic trial
-BRIDGE therapy
-approved for panic disorder
-AEs: sedation, paradoxial effects, swallowing difficulties, impairment of memory/recall, psychomotor impairment
-no active metabolites
-D/C requires taper
lorazepam (ativan)
-BZD
-increase GABA opening frequency
-2nd line if necessary
-preferred in elderly
-bridge therapy
-AEs: sedation, paradoxial effects, swallowing difficulties, impairment of memory/recall, psychomotor impairment
clonazepam (klonopin)
-BZD
-increase GABA opening frequency
-2nd line
-bridge therapy
-approved for panic
-AEs: sedation, paradoxial effects, swalloing difficulties, impairment of memory/recall, psychomotor impairment
diazepam (valium)
-BZD
-increase GABA opening frequency
-AEs: sedation, paradoxial effects, swallowing difficulties, impairment of memory/recall, psychomotor impairment
-2nd line
-bridge therapy
-LONG ACTING metabolite-> accumulation
oxazepam (serax)
-BZD
-increase GABA opening frequency
-AEs: sedation, paradoxial effects, swallowing difficulties, impairment of memory/recall, psychomotor impairment
-2nd line
-bridge therapy
-preferred in elderly
-no active metabolite
temazepam (restoril)
-BZD
-increase GABA opening frequency
-AEs: sedation, paradoxial effects, swallowing difficulties, impairment of memory/recall, psychomotor impairment
-2nd line
-bridge therapy
-short term hypnotic
-preferred in elderly
-no active metabolite
midazolam (rversed)
-BZD
-increase GABA opening frequency
-AEs: sedation, paradoxial effects, swallowing difficulties, impairment of memory/recall, psychomotor impairment
-rapid anesthesia
hydroxyzine
-5HT2A antagonist
-histamine (H1) receptor antagonist
-GAD
-prn anxiety or insomnia
-avoid in elderly
-AEs: sedation, anticholinergic, QTc prolongation, fall risk
Propranolol (inderal)
-beta blocker
-low dose for anxiety
-acute physiological symptoms of anxiety
-preformance and situational anxiety
-AEs: hallucination, vivid dreams, lethargy, impotence, CV effects
-evaluate CV conditions
-may require test dose
Gabapentin/ pregabalin
-occasionally prescribed for GAD
-good for those with bipolar disorder with anxiety symptoms or neuropathic pain
quetiapine
-not endorsed
-theorized to have anxiolytic properties at low doses
-used for anxiety and sleep
paroxetine/escitalopram
-SSRI
-1st line for all anxiety disorders
-jitteriness syndrome-> start at low doses
-AEs: insomnia, n/v, drowsiness
-25-50% reduction in OCD symptoms
-onset of action is 2-4 weeks
duloxetine/ venlafaxine
-SNRI
-useful 1st line in GAD if pt also has pain syndrome
-venlafaxine applicable for social and panic
-jitteriness syndrome-> start low
-onset of action ~2-4 weeks
aripiprazole/ risperidone
-atypical antipsychotics (serotonergic and dopaminergic blockade)
-NOT FDA approved for anxiety
-clinical evidence suggest efficac for tx resistant OCD (in addition to SSRI)
-AEs: weight gain, low EPS risk, akathasia, jitteriness, constipation
-do not drink on this medication -> enhance CNS depression
clomipramine
-TCA
- 2nd line for OCD
azosin
- used for sleep nightmares associated with PTSD
clonidine (catapres)
-alpha 2 agonist
-panic attacks, anxiety associated with withdrawl
fluoxetine (prozac)
-SSRI
-jitteriness syndrome -> start low
-AEs: insomnia, appetite supression, ED, n/v, drowsiness
setraline (zoloft)
-SSRI
-PTSD
-AEs: dizziness, trouble sleeping
Romazicon
-tx BZD overdose (and z-hypnotics)
-AEs: agitation, confusion, nausea, vomiting, HA
BZDs
NOT USED IN PTSD
Zalepon (sonata)
-z-hypnotic
-interacts with alpha 1 subunit of GABA-A receptor
-sleep onset
-SHORT TERM
-AEs: somnolence, dizziness, ataxia, HA, parasomnia, n/v
-rapid action and elimination
-little tolerance or dependence
-3A4 metabolite
-flumazenil for OD
Eszopiclone (lunesta)
-z-hypnotic
-interacts with alpha 1 subunit of GABA-A receptor
-sleep onset and maintenance
-LONG TERM
-AEs: hangover, metallic taste, somnolence, dizziness, ataxia, HA, parasomnia, n/v
-active enantiomer of zopiclone
-only Z-hypnotic approved for long term use
-3A4 metabolite
-flumazenil for OD
zolpidem (ambien)
-z-hypnotic
-interacts with alpha 1 subunit of GABA-A receptor
-sleep onset and maintenance
-SHORT TERM
-AEs: somnolence, dizziness, ataxia, HA, parasomnia, n/v
-intital dose in women and elderly is lower (5mg)
-ambien CR for sleep maintenance
-3A4 metabolite
-flumazenil for OD
temazepam
-BZD
-sleep onset and maintenance
-Benzo drug of choice for sleep
-AEs: drowsiness, dizziness, cognitive impairment, increased fall risk
Triazolam
-BZD
-sleep onset
barbiturate moa
bind GABA-A
-increase DURATION of channel opening
phenobarbital (luminal)
-barbituate
-anticonvulsant
- dependence, tolerance, abuse, withdrawl, after effect, respiratory and CNS depression at high doses
- Higher risk of CNS/ respiratory depression
pentobarbital (nembutal)
-barbituate
-sedative/hypnotic
-not commonly used
-dependence, tolerance, abuse, withdrawl, after effect, respiratory depression and CNS depression at high doses
-HIGHER risk of CNS/respiratory depression
melatonin agonist
-high affinity for MT1 and 2 receptors
-sleep onset
-ramelteon
-tasimelteon
Ramelton (rozerem)
-melatonin agonist
-sleep onset
-AEs: GI upset, next day somnolence, hyperprolactinemia, prolactinoma
-1A2 substrate
-contraindiacets w/ fluvoxamine
-NO abuse, withdrawl/dependency
Tasimelton (hetlioz)
-melatonin agonist
-sleep onset
-FDA approved for non-24 sleep wake disorder in adults
-orphan product
orexant receptor antagonist
-high affinity for OX1 and 2 receptors in the hypothalamus
-decrease arousal and attention
-reduce rewarding stimuli (DA release) that modulate mesolimbic projection between VTA and nucleus accumbens
-Sleep maintenance
-narcolepsy like side effects, morning impairment likely
-3A4 substrates
-contraindicated in narcolepsy
-7 hours of sleep
-potential for worsening depression and suicidal ideation
-Suvorexant (belsomra)
-lemborexant
-daridorexant
Dozepin (silenor)
-TCA
-low doses exert effect through H1 receptor antagonism
-sleep maintenance
-AEs: suicidality warning, sleep behaviors, anticholinergic side effects
trazadone
-antidepressant
-NOT FDA approved for insomnia
-daytime hangover
mirtazapine
-sleep agent for depressed pts
-sedation and weight gain
quetiapine
-atypical antipsychotic
- low dosed
-not recommended without comoribid psychiatric disorder
modafinil
-wakefulness drug for excessive daytime sleepiness
-sleep apnea and narcolepsy
- shift work disorder
-AE: rash
-tx obstructive sleep apnea before recommending sedative/hypnotic drug
armodafinil
-wakefulness drug
-sleep apnea and narcolepsy
- low dose
-only if other psychiatric comorbidity present
-shift work disorder
-AE: rash
-tx sleep apnea FIRST
sorlamfetol
-tx excessive daytime sleepiness
-treast sleep apnea first
sodium oxbyabte (GHB) -Xyrem
-binds to GABA-B, GABA-A, and GHB receptors
-narcolepsy
-AEs: loss of consciousness/reflexes, amnesia, n/v, HA, seizures, death
-HIGH sodium content
-2x night dosing
-presribing program
- can cause increased wakefulness in combo with stimulant -> CNS depression (dizziness, drowsiness, COMA
Sodium oxybate (GHB) - Xywav
- narcolepsy
-lower sodium content
-2x night dosing
sodium oxybate (GHB) - lumryz
-narcolepsy
-ER dose
-adult only
-HIGH sodium content
pitolisant (wakix)
-H3 receptor antagonist/ reverse agaonist
-excessive daytime sleepiness (narcolepsy)
- prolongs QTc interval
- contraindicated in hepatice impairment
-2D6/3A4 substrate
-weak 3A4 inducer -> decreases effect of oral contraceptives
-avoid use with OTC antihistamines
solriamfetol (sunosi)
-dopamine noreponephrine reuptake inhibitor (DNRI)
-wakefulness drug for excessive daytime sleepiness (sleep apnea and narcolepsey)
-AEs: increases BP and HR
-renal dosing 37.5mg
-avoid use in unsatble CV disease and arrythmias
-caution in pts with a history of psychosis or bipolar
restless leg syndrome
-gabapentin enacarbil
-pramipexole
-ropinerol
Anorexia
-refeeding inpatient: 2-3lbs/ week
-outpatient is 0.5-1lb/ week
-increase calories slowly: inpatient- 500 cals/day, outpatient- 1200-1500 cal/day
-no approved drug therapy
olanzapine (zyprexa)
-atypical antipsychotic
-anorexia
-WEIGHT GAIN
SSRIs
-anorexia
-little benefit for core symptoms
lisdexamfetamine (vyvanse)
-stimulant
-FDA approved for binge eating disorder
drugs studied for binge eating
-atomoxetine
-TCAs
-armodafinil
fluoxetine (prozac)
-SSRI
-FDA approved for bulimia nervousa
well studied for bulimia
-citalopram
-sertaline
stimulant AEs
-loss of appetite
-abdominal pain
-sleep disurbances
-decreased growth-hallucinations or other psychosis symptoms
-increased BP and HR
-sudden cardiac death (rara)
-priapism
-peripheral Raynauds
Methylphenidate
-1st line for preschool or elementary/middle school kids or adults
-HTN, tachycardia, bipolar, anorexia, tourettes, seizure disorder
-monitor CV health, height, and weight
-IR for pts <16kg
amphetamine
-1st line for elementary/middle school aged children
-HTN, tachycardia, bipolar, anorexia, tourettes, seizure disorder
mixed amphetamine salts
mydayis
methylphenidate LA
-daytrana
-patch stimulant
lisdexamfetamine (vyvanse)
-1st line for adults
-prodrug converted to dextroamphetamine
-conversion requirement = missue detterent
methylphenidate HCL
-journay PM
-take dose in the evening to cover next morning
alpha 2 agonist
-2nd line choice for elementary/middle school aged kids, adjunct tx with stimulants
-AEs: decreased HR/BP, orthostasis, somnolence, dizziness, rebound hypertension
-must be tapered to avoid rebound HTN
guanfacine ER (intuniv)
-3A4 substrate
clonidine ER
kapvay
atomoxetine (strattera)
-2nd line for elementary/middle school kids
-Norepinephrine reuptake inhibitor
-AEs: increase HR and BP, increase in suicidal thinking
-2D6 substrate
-weight based dosing around 70kg
-monitor liver fxn
Vilozazine (quelbree)
-NET inhibitor
-2D6 substrate/ UGT substrate
-strong 1A2 inhibitor
-swallow whole
bupropion (welbutrin)
-not FDA approved for ADHD
-2D6 inhibitor
-CI in siezure and eating disorder
-3rd line
modafinil (provigil)
-FDA approved for narcolepsy, obstructive sleep apnea, shift work sleep disorder
-AEs: HA, decrease appetite, GI intolerance
-Warning for SJS/TENS
desipreamine
-TCA
-AE: cardiac conditions -> sudden cardiac death
Carbamazepine and Valproate
-atypical antipsychotics
-useful in comorbid bipolar, conduct disorder, intermittent explosive disorder
-NOT MONOTHERAPY
clonidine (kapvay)
-1st line for tics-> 30% decrease
-atypical antipsychotic
guanfacine (intuniv)
-tic disorder
aripiprazole
-2nd line for tics ->30-60% decrease
-atypical antipsychotic
risperidone
-tic disorder
Haloperidol
-3rd line for tics -> 80% reduction
-typical antipsychotic
pimozide
-tic disorder
Oppositional Defiant Disorder/ Conduct Disorder
- 1st line combo of stimulants and clonidine/guanfacine
