Exam 5 Flashcards
Bupropion adverse reactions ?
tachycardia photosensitivity hyper/hypoglycemia anorexia weight loss nausea dry mouth
Bupropion contrindications ?
Current or history of seizures
Anorexia
bulimia
Bupropion interactions ?
First pass effect – avoid drugs with hepatic metabolism with similar competitive effects
Bupropion information ?
Advise patient and family that may take 2 to 4 weeks of treatment for optimal results
Some improvement 7-10 days
Mirtazapine adverse reactions ?
Flu-like symptoms
Higher risk of inducing seizure (no history)
Sedation Weight gain Constipation Dry mouth Vomiting
Mirtazapine interactions ?
MAOI’s
CNS depressants
drugs affecting CYP-450 system
Amitriptyline adverse reactions ?
Anticholinergic effects-blurred vision, confusion, dry mouth, hot dry skin, urinary retention
Orthostatic hypotension, tachycardia, arrhythmias (torsade de pointes)
Prolonged QT interval
GI distress, jaundice, metallic taste
Confusion, hallucinations, SI
Amitriptyline interactions ?
Many Watch other anticholinergics Alcohol SSRI’s Cimetidine
TCA’s in the elderly cause _________________ , especially ___ in elderly male!!
arrhythmias, CHF, MI
BPH
Class of meds tend to cause more sedation and orthostatic hypotension ?
Tricyclic Antidepressants
Amitriptyline (Elavil) + 8 others
Named because of their three ringed structure
1957 – used to elevate mood
Considered second-line due to side effects
Amitriptyline considerations ?
Second-line therapy
Effective with severe depression, anxiety and OCD
Overdose - fatal arrhythmias
Taper dose discontinuance
Monitor blood counts and SI
Monoamine Oxidase Inhibitor (MAOI) pharmacokinetics ?
Major first pass effects
Phenelzine adverse reactions ?
Dilated pupils
HTN crisis
Serotonin syndrome
Sexual dysfunction
Weight gain
Phenelzine drug-drug interactions ?
Foods high in tyramine / caffeine = HTN crisis
Ct John’s wort + MAOI’s = Serotonin Syndrome / Fatalities
Amphetamines
Antidiabetic drugs
SSRI’s, TCA’s
Alcohol
MAOI’s must be stopped for ________ before starting other anti-depressants
10-14 days
Monoamine Oxidase Inhibitor (MAOI) may cause ?
serotonin syndrome
Hypertensive crisis can be caused by ingesting foods rich in ________ , white taking MAOI’s.
tyramine
cheese, beer and wine and also caffeine
Trazodone pharmacokinetics ?
Peak plasma level in 1 hour on empty stomach
Absorbed well, 2/3 patients get relief in several weeks, usually by end of second week
Metabolized live
Excreted urine
Half-life 5-9 hours
Trazodone adverse reactions ?
Orthostatic hypotension 4-6 hours after dose
Nausea / vomiting
Priapism
drowsiness
What what when taking Trazodone ?
Watch with digoxin and Coumadin (protein bound drugs)
Trazodone interactions ?
Strong sedating effect
Used at bedtime for depression and insomnia
Haloperidol / Chlorpromazine pharmacokinetics ?
Absorbed well orally
Onset ½ to 1 hour
Highly metabolized by lever and GI mucosa
Excreted by kidneys
Half life 30 hours
Haloperidol / Chlorpromazine adverse reactions ?
Dizziness Hypotension Photosensitivity Hyperglycemia Impaired thermoregulation
Haloperidol / Chlorpromazine adverse reactions cont.. ?
Decreased libido
Urinary retention
Extrapyramidal symptoms
Impaired memory
Haloperidol / Chlorpromazine contrindication ?
Parkinsonism
Blood dyscrasias
Liver impairment
Cardiac disease
Rey’s syndrome
________ only atypical with clear evidence in tx of resistant-schizophrenia
Clozapine
Introduced in the 1990’s with breakthrough in treating
Schizophrenia
Ability to NOT cause extrapyramidal side effects
Some may cause elevated prolactin levels
Antipsychotics (Second Generation)
Antipsychotics (Second Generation) examples ?
Aripiprazole (Abilify)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Clozapine (Clozaril)
Antipsychotics (Second Generation) pharmacokinetics ?
Metabolized liver
Excreted 50% urine, 50% feces
Half-Life 4-66 hours
Antipsychotics (Second Generation) BBW ?
May increase mortality in elderly with dementia-related psychosis
Increased risk of agranulocytosis, seizures and myocarditis / Cardiomyopathy
Severe neutropenia
Orthostatic hypotension, bradycardia, syncope
Methylphenidate interactions and adverse effects ?
Not with MAOI’s
Ay cause “Tourette like” syndrome
Hypoglycemia
Arrhythmias
Methylphenidate pharmacokinetics ?
Metabolized CYP-450
Excreted urine, small amt feces
Half-life 3.5 hrs
Methylphenidate facts ?
Get echo after 5 years use
Watch weights loss, insomnia, agitation, HTN
May cause dependency
Methylphenidate (Concerta)
/ Atomoxetine facts ?
Newer generation of medications
Reduced dosage BID
Higher incidence of “Tourette” like syndrome
Addictive properties
Abuse / Black market
Benzodiazepines pharmacokinetics ?
Most lipid soluble and thus taken orally
Popular PO anxiolytic
Traditional drug for treatment of seizures however replaced by lorazepam
Active metabolites
Absorption
-Well absorbed orally
diazepam onset 30-60 min
-Peak effects usually occur in 1 to 2 hours (valium slow)
-Duration last 2 to 3 hours
-Given IM midazolam and lorazepam onset 1 to 5 min
Active metabolites increase the effective half-life
what benzos are all injectable ?
Midazolam (Versed)
Diazepam (Valium)
Lorazepam (Ativan)
__________ only available in injectable (only water soluble) can be given intranasal
Midazolam
_______ poorly absorbed via IM injection
Diazepam
Benzodiazepines what is better than injectable ?
Oral
Benzodiazepines adverse effects ?
Respiratory depression
Retrograde amnesia (why midazolam used preoperatively)
Orthostatic hypotension
Constipation, nausea, vomiting, diarrhea
CNS effects of ataxia, drowsiness, dizziness, slurred speech, confusion, somnolence
Benzodiazepines prescribing considerations ?
DEA schedule IV controlled substance
Beers Criteria in elderly
Addictive property
Not a primary therapy
Not effective comorbid depression
Lethal when used with alcohol or other CNS depressants
Impaired driving / cognitive skills 1mg alprazolam = BAC 0.15
Benzo OD tx. ?
Flumazeril (Romazicon)
Benzodiazepines BBW ?
watch for seizures with chronic use and withdrawal, prepare seizure management
Flumazeril (Romazicon)
dosing ?
0.2 mg IV q min x 1 to 5 doses
Selective serotonin reuptake inhibitors (SSRIs) examples ?
fluoxetine (Prozac
paroxetine (Paxil)
sertraline (Zoloft)
citalopram (Celexa)
Escitalopram (Lexapro)
Selective serotonin reuptake inhibitors (SSRIs) BBW ?
Increased suicide risk in children, adolescents, and young adults w/ major depressive or other psychiatric disorders
**suicide risk in kids **
Selective serotonin reuptake inhibitors (SSRIs) pharmacokinetics ?
Significant first pass metabolism by liver
Excreted by Kidneys
Half-life 24 hours average
Prozac half-life 4-6 days, effects up to 14 days
MUCH LONGER HF
Selective serotonin reuptake inhibitors (SSRIs) adverse reactions ?
Aggitation, insomnia, headache, nervousness, sedation, tremor
Serotonin syndrome
- Nausea / Vomiting
- Anorgasmia in both men and women
- Ejaculatory disturbances in men
Serotonin Syndrome ?
Myoclonus (intermittent jerking or twitching)
Hyperreflexia (greater in upper limbs)
Increased heart rate
Shivering
Sweating
Dilated pupils
Serotonin Syndrome , other information ?
abnormalities such as hyperactive bowel sounds, high blood pressure and hyperthermia
temperature as high as 40°C (104°F)
Mental changes include hypervigilance or insomnia and agitation
include metabolic acidosis, rhabdomyolysis, seizures and renal failure
Seen in OD and MDMA’s (Ecstasy)
**almost like encephalopathy with a fever
check a CK-MM ( if this is high then check CR) **
Venlafaxine pharmacokinetics ?
Metabolized Liver
Excreted Urine
Venlafaxine PO dosing ?
Start: 37.5-75 mg PO qd, incr. by 75 mg/day q4-7 days
Max: 225 mg/day
Info: give w/ food; may open cap, but do not cut/crush/chew/dissolve contents
Venlafaxine taper dose by no more than ?
75 mg/wk to D/C
**dont abrutply stop it cause they will get the worse flu like sxs. they ever had **
Venlafaxine BBW ?
Increased suicidality risk in children, adolescents, and young adults w/ major depressive or other psychiatric disorders
Trazodone (DESYRYL) pharmacokinetics ?
Metabolized liver
Excreted in urine
Trazodone (DESYRYL) 50 mg ?
light orange circle
Trazodone (DESYRYL) 100 mg ?
white circle
Trazodone (DESYRYL) 150 mg ?
light orange bar
Trazodone (DESYRYL) PO dosing ?
Start: 25-50 mg PO bid-tid, may incr. by 50 mg/day q3-4 days
Max: 400 mg/day if outpatient
600 mg/day if inpatient
Info: taper dose gradually to D/C
**start low and go slow **
Trazodone (DESYRYL) BBW ?
Increased suicidality risk in children, adolescents, and young adults w/ major depressive or other psychiatric disorders
Bupropion (Wellbutrin SR, Zyban) PO dosing ?
Start: 150 mg PO qam,
Increase after 3 days
Max: 400 mg/day
Info: do not cut/crush/chew tab
Bupropion (Wellbutrin SR, Zyban) BBW ?
Monitor for serious neuropsychiatric events including behavior change, hostility, agitation, depression, and suicidality
Worsening of preexisting psychiatric con’d
-pts taking bupropion for smoking cessation and after discontinuation
Bupropion (Wellbutrin SR, Zyban) BBW pt. 1 ?
Some cases possibly complicated by nicotine withdrawal symptoms
Reported in patients who continue to smoke while taking bupropion
Weigh bupropion risks vs. benefits of smoking cessation
Bupropion (Wellbutrin SR, Zyban) PO dosing smoking cessation ?
Start: 150 mg PO qd x3 days
Max: 300 mg/day
Info: separate doses by at least 8h
last dose no later than 6pm
stop smoking after 5-7 days of tx
do not cut/crush/chew tab
Mirtazapine (Remeron) PO dosing ?
Start: 15 mg PO qhs; Info: taper dose gradually to D/C
Mirtazapine (Remeron) BBW ?
Increased suicidality risk in children, adolescents, and young adults w/ major depressive or other psychiatric disorders
Duloxetine (Cymbalta) pharmacokinetics ?
Metabolized by Liver
Excreted in Urine
Duloxetine (Cymbalta) PO dosing ?
Start: 15 mg PO qhs
Info: taper dose gradually to D/C
Duloxetine (Cymbalta) BBW ?
Increased suicidality risk in children, adolescents, and young adults w/ major depressive or other psychiatric disorders
Lithium side effects related to serum level ?
Nausea / Vomiting
Tremor
Muscle weakness
Hyper-reflexia
Drowsiness
Increased thirst and urinary
frequency
Hypokalemia
Lithium levels > 4 = ?
Impaired renal function
Decreased consciousness, seizures, or life-threatening dysrhythmias, regardless of lithium levels
**difference is how fast it is metabolized off **
Levels are _____ mEq/L, significant confusion is noted, or the expected time to reduce levels to ____ mEq/L is more than 36 hours
> 5.0
< 1.0
**difference is how fast it is metabolized off **
Lithium Toxicity treatment ?
Supportive therapy is the mainstay treatment
Protect airway
Seizure control with benzo’s
Gastric lavage if < 1 hour
IV Fluid therapy (Watch CHF patients)
Monitor electrolytes
Dialysis if needed
Lithium OD are bad as soon as you lavage then get them to the ICU
