Final exam review Flashcards
What does chronic activation of the monoamine receptors do?
-increases BDNF signaling
-downregulates the HPA axis
What medication is MAO-B selective?
Selegiline
What medication is MAO-A selective?
Moclobemide
What are the non-selective MAO inhibitors?
Phenelezine, Tranylcypromine
What must be present for a diagnosis of depression?
Depressed mood OR loss of interest or pleasure in doing things
What is SIGE CAPS?
S- Sleep (insomnia/hypersomnia)
I- Interest Decreased
G- Guilt/worthlessness
E- Energy loss/fatigue
C- Concentration difficulties
A- Appetite change (increase/decrease)
P- Psychomotor agitation/retardation
S- Suicidal Ideation
What are the SSRI medications?
fluoxetine, escitalopram, citalopram, paroxetine, fluvoxamine, sertraline
What SSRI has the most weight gain, sedation, and anticholinergic effects?
Paroxetine (Paxil)
What SSRI has more GI upset than other antidepressants?
Sertraline (Zoloft)
What SSRI has QTc prolongation (high doses)?
citalopram
What SSRI has weight loss and a long T 1/2 (96-144 hours)?
fluoxentine
What class effect adverse effects are there for the SSRIs?
sexual dysfunction, increased risk of bleeding (platelet inhibition), Hyponatremia (more likely in elderly)
What SNRI has an FDA warning for hepatotoxicity and needs slow titration due to nausea side effect?
Duloxetine
-obtain LFTs every 6 months or if symptomatic
What SSRIs/SNRIs are 2D6 inhibitors?
Fluoxetine, Paroxetine, Sertraline, Duloxetine, Venlafaxine (higher doses)
What SNRI has a fibromyalgia indication?
Milnacipran
What SNRI must be adjusted for renal impairment or strong 3A4 inhibitors?
Levomilnacipran
What SNRI has a dose-limiting side effect of nausea but no major CYP reactions?
Desvenlafaxine
What are the SNRI class effects?
blood pressure elevation, nausea
-can be useful in fibromyalgia, musculoskeletal pain, neuropathic pain
What are the TCA class effects?
CNS: sedation, confusion, lower seizure threshold
Cardiovascular: tachycardia, orthostatic hypotension
Anticholinergic: blurred vision, urinary retention, constipation
Other: weight gain, sexual dysfunction, narrow therapeutic index
Caution: serotonin syndrome, hypertensive crisis
What MAO inhibitor does not require the tyramine diet?
Selegiline 6mg/24 hour patch
What class of antidepressants requires a 2 week washout period before switching to another class (5 weeks for fluoxetine)?
MAO inhibitors
What are the bupropion clinical pearls?
-2D6 inhibitor, CI in seizure and eating disorders
What medications can be combined with SSRIs/SNRIs?
Bupropion, Mirtazapine
What are the mirtazapine clinical pearls?
warnings: agranulocytosis, increased cholesterol
-sedation, increased appetite (doses < 15 mg/day)
What are the SSRI + 5HT1A partial agonists?
Vilazodone, Vortioxetine
-do not use these with SSRIs/SNRIs
-nausea
What are the FDA approved augmentation agents for depression?
Aripiprazole, Brexpiprazole, Cariprazine, Quetiapine
What is the criteria needed for Bipolar I disorder?
at least 1 or more manic episodes
What is the criteria needed for Bipolar II disorder?
hypomanic episodes that generally last 4 or more days
What are the adverse effects/toxicities associated with Lithium?
polyuria, polydipsia (diabetes inspidus), hypothyroidism, acne, GI toxicity, ataxia, seizure, lethargy, confusion, agitation, dry mouth, weight gain, ECG changes, coarse/fine hand tremor, teratogenic (cardiac structural abnormality in 1st trimester)
What drugs can decrease renal clearance of Lithium (increase lithium levels)?
ACEis, ARBS, NSAIDS, thiazide diuretics, dehyrdration
What drugs can increase renal clearance of Lithium (decrease lithium levels)?
osmotic diuretics, +/- loop diuretics, caffeine
What drugs can increase excretion of Lithium (decrease lithium levels)?
sodium bicarbonate, high Na intake
What adverse effects/toxicities are associated with valproate/valproic acid/divalproex?
Thrombocytopenia, hyperammonemia, N/V/D, teratogenicity (neural tube defects and lower IQ in offspring), PCOS, increased appetite-weight gain, anoxeria, dyspepsia, ulceration, platelet dysfunction
What drug interactions are important to consider for valproate?
Lamotrigine -increased risk for SJS
What are important clinical pearls for carbamazepine (tegretol) in bipolar disorder treatment?
thrombocytopenia/hematologic effects
What are important clinical pearls for oxcarbazepine (trileptal) in bipolar disorder treatment?
CYP3A4 inducer (no auto-induction), hyponatremia
What are important clinical pearls for lamotrigine in bipolar disorder treatment?
-1st line treatment for depressive symptoms of bipolar; not useful for acute treatment or manic/hypomanic symptoms
What are important clinical pearls for topiramate in bipolar disorder treatment?
weight loss, heat intolerance/hypohydrosis, metabolic acidosis, kidney stones, possible teratogen (cardiac structural effects), DRESS warning
What are the FDA-approved antipsychotics for bipolar disorder treatment?
quetiapine, lurasidone, olanzapine/fluoxetine
What antipsychotics are commonly used off-label for bipolar disorder treatment?
aripiprazole, brexpiprazole
What clinical pearls are important to consider for use of atypical antipsychotics in bipolar disorder treatment?
all monitoring parameters for metabolic syndrome and movement side effects apply when used for bipolar disorder!
What are the known/possible teratogenic medications for bipolar disorder treatment?
Lithium, Valproic acid, carbamazepine, topiramate
What is periphery pain circuit system?
peripheral nociceptors —–> peripheral neurons ——> dorsal root ganglion ——> dorsal horn (spinal cord) ——> spinothalamic tract (ascending input) ——-> brain + nocicpetion-inhibiting neurons —–> descending modulation —–> dorsal horn (spinal cord)
What channels and receptors are involved in temperature sensitive pain signaling?
Transient receptor potential cation channel (TRP)
heat sensitive: TRPV (Vanniloid)
cold sensitive: TRPM (Melastatin)
What channels and receptors are involved in acid sensitive pain signaling?
Acid sensing ion channel (ASIC)
-activated by H+
-conduct Na
What channels and receptors are involved in chemical irritant sensitive pain signaling?
-Histamine, Bradykinin
What ion channels are responsible in conduction of pain signals from the periphery to the spinal cord?
Nav1.8 (action potential signaling along axon), Glutamate receptors, AMPA receptos, NMDA receptors
What are the three fibers involved in transducing pain signals?
AB fibers- fastest, non-noxious, responds to touch, pressure
ADelta fibers- first pain sensation, cold, myelinated, fast
C-Fibers - second pain sensation, dull, aching, unmyelinated, slow
What role does substance P play in peripheral sensitization?
- vasodilation
- degranulation of mast cells
- release of histamines
- inflammation and prostaglandins
leads to increase in pain receptors and sensitization of area
What are the two pathways thought to lead to neuropathic pain sensitization (spinal cord)?
spinal sensitization - increased AMPA and NMDA expression/sensitivity, glutamate
Spontaneous afferent activity- enhanced expression of Na channels, increased cellular excitability and action potential
What type of receptors play a role in pain in the brain circuitry?
Mu opioid receptors
-abundant & play a role in modulation of pain signals
What are the types of opioid receptors?
GPCRs
Mu -what morphine brings to
Kappa -is dysphoric, can offset euphoria of Mu receptors
Delta -no FDA approved due to seizures, can help pain, alcoholism, hyperalgesia, hibernation receptor
Nociceptan/orphanin FQ receptor
What does CYP3A4 do in opioid metabolism?
CYP3A4 (four) makes opioids start with nor (less active metabolites)
What is the endogenous opioid for Mu opioid receptors?
Endorphins
What is the endogenous opioid for Kappa Opioid receptors?
Dynorphins
What is the endogenous opioid for Delta Opioid receptors?
Enkephalins
What is the endogenous opioid for Orphanin-Receptor-Like Subtype 1 (ORL1), Nociceptin?
Nociceptin/Orphanin FQ
What role does VTA and NAc play in addiction?
Ventral tegemental area- source of dopamine
Nucleus accumbens -pleasure, valuation
What are the analgesic adjuvants?
gabapentinoids, serotonin norepinephrine re-uptake inhibitors, tricyclic antidepressants, skeletal muscle relaxants, anti-epileptics, topical agents
What are the non-opioid options for pain treatment?
acetaminophen, NSAIDs
What is the pediatric dosing for tylenol?
10-15 mg/kg PO Q4H PRN
MAX: 75mg/kg/day or 3-4 g/day
What is the pediatric dosing for Ibuprofen?
5-10mg/kg/day PO q4-6h PRN
MAX: 40mg/kg/day or 2400 mg whichever is less;;l
What are the clinical pearls for ketorolac (Teradol)?
-max duration is 5 days (parenteral + oral formulations) due to high risk for GI bleed
What is the recommended dosing for the Gabapentinoids?
Gabapentin (Neurontin)- 100-300 mg po tid MAX 3600mg/day)
Pregabalin (Lyrica) - 75 mg po bid MAX 600 mg/day (schedule V)
