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Pharm III > Lecture 8 (psych)- Exam 4 > Flashcards

Lecture 8 (psych)- Exam 4 Flashcards

1
Q

*

A
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2
Q

Generalized Anxiety Disorder
* What is it? How long is the period?
* Patient exhibits what?
* Worry associated with what?

*

A
  • Persistent, excessive anxiety occurs most days in a 6-month period
  • Patients exhibit worry or apprehension that is difficult to control
  • Worry associated with ≥ 3 of the following:
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3
Q

What is the monitoring tool for anxiety? What are the levels?

levels LY

A

GAD 7

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4
Q

What is the first line treatment for GAD?

A
  • Cognitive behavioral therapy OR
  • Pharmacotherapy
  • Cognitive behavioral therapy plus pharmacotherapy (more severe cases)
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5
Q

GAD treatment
* Treatment part of what?
* _ preference
* What are other treatment add ons

A
  • Treatment modality part of shared decision making with patient
  • Patient preference
  • Exercise, meditation, socialization, etc.
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6
Q

GAD - pharmacotherapy
* What is the first line meds? Start how?
* What should you follow?

A
  • SSRIs and SNRIs
  • Start at lowest end of dose range – some suggest starting at 50% below usual starting dose for depression
  • Following same dosing / titration guidelines as when treating depression
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7
Q

GAD - pharmacotherapy
* What are adjunctive treatment? (2)

A
  • Hydroxyzine pamoate (anti-histamine)
  • Benzodiazepines (not first line for maintance-short term)
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8
Q

GAD - pharmacotherapy
* What are the alternative treatments?(3)

A
  • Buspirone
  • Pregabalin
  • Mirtazapine
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9
Q

Hydroxyzine pamoate
* What type of drug?
* What is the MOA?

A

Antihistamine

MOA:
* Competes with histamine for H1-receptor binding sites
* Antagonist of 5HT2A, DAD2 and alpha1 receptors

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10
Q

Hydroxyzine pamoate
* What are the SE? (3)

A
  • Drowsiness (before bedtime)
  • Orthostatic hypotension
  • Dizziness
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11
Q

Buspirone
* What is the MOA?
* How long should you wait before determining effectiveness?

A
  • 5HT1A agonist at postsynaptic membrane; exact mechanism unknown
  • Give minimum of 4 to 6 weeks at maximumly tolerated dose before determining effectiveness

  • Initial dose 10mg/day; titrate dose every 1 to 2 weeks to maximum of 60mg/day
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12
Q

Buspirone
* When is it used?

A

Used as second-line treatment
* Patients who do not tolerate first-line therapies
* Adjunct for patients not responding to maximum doses of first-line therapy

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13
Q

What are the SE of buspirone (4)

A
  • Dizziness
  • Nausea
  • Drowsiness
  • Headache
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14
Q

What is GABA?

A

Gamma-aminobutyric acid
* MC inhibitory neurotransmitter in the human brain

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15
Q

Benzodiazepines
* Gaba agonist cause what? (4)

A
  • Sleep
  • Anxiety relief
  • Muscle relaxation
  • Memory impairment
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16
Q

Benzodiazepines (BDZ)
* What is the MOA?

A
  • Bind to GABAA receptors at a site separate from GABA receptor sites and stimulates the release of GABA
  • GABA activation increases the frequency of GABA receptor opening allowing the influx of more Cl- ions
  • Cl- ion influx causes the cell to be more negatively charged (hyperpolarized)
  • Less likely to fire an action potential or respond to stimuli

Benzo increase freq vs barb open cl channels longer

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17
Q

Benzodiazepines (BDZ)
* Inhibit the effects of what?

A

BZD inhibit the effects of neurons that are responsible for anxiety and arousal

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18
Q

Benzodiazepines (BDZ)
* What are the disorder that CNS depressants are used for? (6)

A
  • Anxiety
  • Panic disorder
  • Seizures
  • Insomnia
  • Anesthesia
  • Treatment alcohol withdrawal
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19
Q

What are the short (4), intermediate (3) and long acting (3) BDZ?

A

Short: ATOM
Intermed: TLC
Long: FDC

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20
Q

BDZ
* Benzodiazepines with shorter elimination half-lives are more likely to produce what?
* Benzodiazepines with longer elimination half-lives usually produce more what?

A
  • Benzodiazepines with shorter elimination half-lives are more likely to produce acute withdrawal on abrupt cessation after prolonged use
  • Benzodiazepines with longer elimination half-lives usually produce more delayed and somewhat attenuated withdrawal symptoms
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21
Q

What are the BZD safe for liver dysfunction? Why?

A

Oxazepam, temazepam and lorazepam (LOT)-> because metabolism is conjugation

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22
Q

BDZ
* What are the SE? (6)

A
  • Sedation
  • Dizziness
  • Impaired coordination
  • Decreased reaction time
  • Decreased problem solving
  • Amnesia
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23
Q

BDZ
* What is going on with the beer’s list?

A

not recommended for older adults; increased risk of side effects and falls
* Use smallest dose of short-acting agents without active metabolites

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24
Q

BDZ
* What is the issue with combined substances?(3) What are the substances?(3)

A

ETOH, opioids, CNS depressants
* Combined use increases risk of respiratory depression, coma, and death

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25
Q

BDZ
* Not recommended for what?
* What is the major SE? (3)
* What is the antidote?

A

Not recommended for long-term use
* Risk of tolerance, dependence, withdrawal signs and symptoms, abuse – taper slowly

Zzzzs (sleepy), hypnotic, sedative

Overdose – flumazenil = antidote

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26
Q

BDZ
* Most are Metabolized by what?
* Not recommended for patients with what?
* What are the three agents?

A

Most benzodiazepines metabolized by CYP450 enzymes to active metabolites

Not recommended for use in patients with liver dysfunction

Three agents that can be used:
* Lorazepam
* Oxazepam
* Temazepam

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27
Q

BDZ - Taper
* When do you need to taper?

A

If daily treatment for > 4 weeks
* Taper by 25% per week; slower at end of taper
* Consider changing equivalent dose of long-acting BDZ (diazepam, clonazepam)

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28
Q

BDZ - Taper
* What are the signs of withdrawal? what should you do?

A
  • Agitation, insomnia, irritability, GI symptoms
  • Stop taper; hold dose for 1 to 2 weeks and resume taper
  • Avoid increasing dose if possible
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29
Q

Panic Attack
* Feature of what?
* What is Panic attack?

A
  • Feature of many anxiety disorders but not a disorder in and of itself
  • Panic attack: period of extreme anxiety that peaks w/in 10 minutes and declines in 30-60 minutes
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30
Q

Panic Attack
* Associated with what?

A

Associated with ≥ 4 of the following:

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31
Q

Panic disorder
* What is the criteria for dx?

A
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32
Q

Panic Attacks and Panic Disorder
* What is the nonpharm therapy?

A

CBT (most effective); biofeedback relaxation, desensitization

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33
Q

Panic Attacks and Panic Disorder
* What is the short term and maintenance treatment?

A

Short-term treatment
* Benzodiazepines for acute management short-term management or rescue therapy( ex GAD with triggers/attacks)
* Avoid in patients with a history of substance abuse

Maintenance treatment
* SSRIs
* SNRI-venlafaxine

Continue medication for 8-12 months; risk or relapse 25 to 50%

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34
Q

Phobias
* What are the types?

A

Specific and social

Five Types:
* Animal
* Natural environment
* Blood injection injury
* Situational (social, agoraphobia)
* Other

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35
Q

Phobias
* What is it?
* Patient has insight of what?

A
  • Irrational fear/ anxiety when presented with an object or situation resulting in fear and/or avoidance of trigger
  • Patient has insight that fear is irrational
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36
Q

Phobias - Treatment: Social phobias and agoraphobia
* What are the 3 options? (general)

A
  • No treatment
  • CBT with exposure and desensitization preferred
  • Pharmacotherapy
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37
Q

Phobias - Treatment: Social phobias and agoraphobia
* What are the examples of pharm therapy?(3)

A
  • Beta-blockers (propranolol and atenolol)-> Performance anxiety
  • SSRIs – limited benefit
  • Benzodiazepines – short-term (flight anxiety)
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38
Q

Acute Stress Disorder
* Sx occur when?
* Most prevalent when?

A
  • Symptoms occur w/in one month of traumatic event and last from 2 days to 4 weeks
  • Most prevalent in younger ages
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39
Q

Acute Stress Disorder
* What is the txt? What is not helpful?

A
  • Trauma-focused CBT-> Reduces symptoms and progression to PTSD
  • Anxiolytics (benzodiazepines) – short term
  • Antidepressants generally not helpful
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40
Q

Posttraumatic Stress Disorder (PTSD)
* What is the criteria for it?

A

The trauma is persistently re-experienced (>1 month) has ≥ 1 of the following:
* Intense memories
* Disturbing dreams
* Repeatedly reliving the event
* Physiologic distress when exposed to reminders of the trauma
* Avoidance of stimuli that remind patient of the event

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41
Q

Posttraumatic Stress Disorder
* What is the first line txt?

A
  • Trauma-focused psychotherapy
  • Exposure
  • Exposure + CBT
  • Eye Movement Desensitization and Reprocessing (EMDR)
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42
Q

Posttraumatic Stress Disorder
* When do you use pharmacotherapy? What are the medications?

A

Alternative based on patient preference / access to psychotherapy
* SSRIs first-line pharmacotherapy
* Paroxetine and sertraline most studied

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43
Q

PTSD
* No difference in what?

A

No difference in outcomes if psychotherapy combined with pharmacotherapy

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44
Q

Posttraumatic Stress Disorder
* What is the first line for sleep disturbance/nightmares?

A

Sleep disturbance / nightmares
* First-line: prazosin (+therapy)
* Take 30 to 60 minutes before bedtime
* Reduction of nightmares / sleep disturbances in 50% of patients

Pra(y)zosin before bed

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45
Q

What is the MOA of prazosin?

A
  • blocking central alpha-1 receptors in the brain, which might lead to better, deeper sleep
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46
Q

Obsessive compulsive disorder
* What are obsessions and compulsions?

A
  • Obsessions: recurrent intrusive thoughts that lead to anxiety
  • Compulsions: actions to decrease anxiety from the obsessions
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47
Q

OCD Treatment:
* What is first line? (general)

A

Systematic desensitization and pharm

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48
Q

OCD Treatment: Behavioral
* What is the systematic desensitization?

A
  • Exposure ritual/response prevention (ERP) has been demonstrated to be the most effective treatment for OCD.
  • Cognitive behavior therapy
  • Thought stopping
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49
Q

OCD Treatment: Behavioral
* What is the pharm?

A

Selective Serotonin Reuptake Inhibitors (SSRIs) – first-line (high-dose usually required)
Clomipramine (TCA) may be an adjunct to an SSRI in some patients(first line)
* 40 to 60% of patients will respond to pharmacotherapy
* Response = decrease in symptoms by 20 to 40%

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50
Q
A
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51
Q

What is the description of AN? What is the treatment?

*

A

Description:
* Patients have distorted body image and intense fear of becoming fat or weight gain
* Low BMI
* Females / homosexual males

Treatment: Nutritional rehabilitation
* Psychotherapy
* Limited role for pharmacotherapy
* Olanzapine used for weight restoration

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52
Q

Eating disorders
* What is the bulimia nervosa decription?
* What is the treatment?

*

A

Description:
* Binge eating followed by purging, use of laxatives/diuretics, or excessive exercise to avoid gaining weight
* Normal to high BMI

Treatment:
Nutritional rehabilitation
* Psychotherapy + pharmacotherapy best

Pharmacotherapy
* First line – fluoxetine (Prozac)
* Goal: 60 mg/day (high dose)
* Second-line – sertraline, escitalopram

Blumia pts get the flu

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53
Q

What is binge eating disorder? What is the treatment?

*

A

Description:
* Binge eating episodes ≥ 2days/wk for 6 months
* Patients generally obese

Treatment:
* Psychotherapy
* Pharmacotherapy: Lisdexamfetamine (Vyvanse) and other stimulants

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54
Q

PMS management
* What is the management for mild PMS?

A

Does not cause personal, professional, or social dysfunction
* Stress reduction strategies
* Exercise
* Meditation

Mild: does not affect daily life

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55
Q

PMS management
* What is the management of moderate/severe PMS or PMDD?

A

Patients who desire contraception
* Estrogen/progesterone contraception

Patients not interested in hormonal contraception: SSRIs
* Continuous
* Luteal phase
* Symptom onset

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56
Q

Postpartum Depression
* Consider if ?
* Sxs start when?

A
  • Consider if symptoms persist longer than 2 weeks
  • Symptoms start in the first 4 weeks post delivery
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57
Q

Postpartum Depression
* What is the criteria?

A

Same diagnostic criteria as Major Depressive Disorder (DSM-5)
* Five or more symptoms present during 2-week period with at least one symptoms being
* Depressed mood
* Loss of interest or pleasure

Remember: SIG E CAPS

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58
Q

Postpartum Depression
* What is the treatment?

A
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59
Q

Schizophrenia and other Psychotic Disorders
* What is brief psychotic disorder? Schizophreniform? Schizophrenia? Schizoaffective disorder?

*

A

Brief psychotic disorder
* Duration at least 1 day but less than 1 month

Schizophreniform disorder
* 1-6 months duration

Schizophrenia
* 6 months duration

Schizoaffective disorder
* Schizophrenia and major depression/Bipolar

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60
Q

Diagnosis of Schizophrenia
* What is the criteria

A
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61
Q

Diagnosis of Schizophrenia
* How long is the duration? What if 1-6 months?

A

Duration of illness for at least 6 months (including prodromal or residual periods in which above criteria may not be met)
* If between 1-6 month – it is schizophreniform d/o

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62
Q

Diagnosis of Schizophrenia
* Sx not due to what?

A

Symptoms not due to medical, neurological, or substance-induced disorder (dementia, UTI, Drug use, Delirium).

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63
Q

Bottom-line schizophrenia
* What is needed for acute psychosis?(3)

A
  • Hospitalization – psychiatric
  • Psychiatric consultation
  • Psychosocial therapy
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64
Q

Bottom line schizophrenia
* What can happen acutely if not cooperative/agitated?
* What agents are preferred?

A

Antipsychotic medication
* Initial dose may require IM administration if patient not cooperative / agitated
* Second generation preferred – exact agent depends on patient-specific factors and provider preference

65
Q

Bottom-line schizophrenia
* How do you start medications? (dose)
* What are the two more favorable drugs?
* What is resevere for 3rd/4th line? Why?

A

Start low and titrate dose every two to 4 weeks to lowest effective dose
* Aripiprazole and risperidone have favorable side effect profiles
* Clozapine very effective but reserved for third-line or fourth-line therapy due to risk of agranulocytosis / seizure risks

66
Q

Bottom-line schizophrenia
* When do you have initial response?
* What are the inital adverse effects?(3)

A
  • Initial response: within first two weeks; four to six weeks to full effect
  • Initial adverse effects: sedation, orthostatic hypotension, restlessness
67
Q

Bottom-line schizophrenia
* What are the maintenace treatment goals?

A
  • Minimize symptoms and functional impairment
  • Minimize antipsychotic side effects
  • Avoid relapses
  • Full integration into society
  • Multidisciplinary care
  • Patient education to promote treatment adherence
68
Q

Bottom-line schizophrenia
* What do you do if patient has full response to pharmacotherapy?
* What do you do if patient has partial response to pharmacotherapy?

A

Full response to pharmacotherapy
* Continue same medication

Partial response to pharmacotherapy
* Check for compliance – long acting, IM dosage forms available to help with compliance
* Switch to alternative to non-clozapine second-generation antipsychotic-> Clozapine reserved for 3rd or 4th line treatment

69
Q

Bottom-line schizophrenia
* What do you need to do depending on underlying psychosis?
* What happens life long in many cases?
* Monitor what?

A
  • Discontinuation – depends on underlying psychosis
  • True schizophrenia life-long in many cases
  • Monitor closely for adverse effects
70
Q

*

A
71
Q

*

A
72
Q
A
73
Q

What is teh DSM-5 Dx criteria of ADHD?

A
74
Q

ADHD rating scales
* What are the different sclaes?
* Who and how do they fill them out?
* Establish what?

A

Conners’ Rating Scale / Vanderbilt scales
* Parent version and teacher version
* Complete separately
* Establish diagnosis including inattentive, hyperactive or both

75
Q

ADHD rating scales
* What do some other scale also evaluate?
* Complete what is ideal?

A
  • Some scales also evaluate for ODD, conduct disorder
  • Complete neurodevelopment workup ideal if available (2 day process)
76
Q

ADHD
* What is the cause?
* What are the NT levels?

A

Cause: environmental and genetic (not completely understood)

Patients with ADHD are thought to have decrease levels of NE and DA
* DA= reward, risk, impulsiveness
* NE= attention and arousal

77
Q

ADHD
* What are common coexisting conditions?(5)

*

A

ODD, conduct disorder, anxiety, tic disorder, sleep disorders

78
Q

ADHD
* What is the treatment?

A

Behavioral psychotherapy – time management and organization skills
* Parents – behavioral parent training
* Teachers – behavioral classroom management
* First-line recommendation for most patients < 6 years

Medications
* First-line: stimulants -> methylphenidate, dextroamphetamine, amphetamine salts
Alternatives: non-stimulants -> atomoxetine, clonidine, guanfacine

79
Q

Stimulants: First-line therapy
* Blocks what?
* Improves what?

A
  • Block the reuptake of DA and NE at the presynaptic neuron
  • Improves focus and impulsivity
80
Q

What are the SE of stimulants?

*

A
  • Decreased appetite
  • Weight loss or lack of gain
  • Growth suppression
  • Stomach pain
  • Sleep disturbances
  • Headache
  • Irritability
  • Tachycardia / increased blood pressure
81
Q

Stimulants: First-line therapy
* What are the events that can happen? What is recommended?

A

Cardiovascular events
* EKG recommended for patients at risk
* Some physicians will obtain annual EKG

82
Q

Stimulants: First-line therapy
* Caustion with who?
* CI in who?

A
  • Caution: not recommended for patients with concomitant tic disorders – may exacerbate
  • CI: during or within 14 days of MAOIs (stimulants inhibit MAO – coadministration may cause hypertensive crisis)
83
Q

What are the frequent SE of stimulants reported by young adults?

A
84
Q

Stimulants
* What class?
* Not recommended for who?

A
  • Class II controlled substances
  • Not recommended for patients with underlying addiction disorder
85
Q

Stimulants
* Watch closely for what? MC in who?
* MC reason is what?

A

Watch closely for diversion – self or friends
* Diversion MC in college students (5 to 35%)
* MC in Caucasians, fraternity and sorority members, students with low GPAs, students reporting ADHD symptoms
* MC reasons for stimulant diversion included staying awake, studying, improved alertness, experimenting, and “getting high”

86
Q

What are the methylphenidate examples?

FYI

A
87
Q
FYI
A
88
Q
FYI
A
89
Q
FYI
A
90
Q
A
91
Q
A
92
Q
A
93
Q

Non-Stimulants: Atomoxetine
* What line of therapy?
* When do you give them? (4)

A

Second-line therapy
* Parent/patient request to avoid stimulant
* Cannot tolerate side effects of stimulant
* Tic disorder
* Stimulant non-responders (10 to 30%)

94
Q

Non-stimulant: atomoxetine
* What is the MOA?

A

Selective NE reuptake inhibitor

Increases concentrations of NE and DA in prefrontal cortex
* Not a controlled substance
* Slower onset of action
* Not as effective

95
Q

Non-Stimulants: Atomoxetine
* What are the SE?

*

A
  • Somnolence
  • Dry mouth
  • Nausea/constipation/abdominal pain
  • Dizziness
  • Decreased appetite / weight loss
  • Insomnia
  • Irritability
  • Increase in heart rate and blood pressure
  • No impact on growth
  • Hepatotoxicity
96
Q

Non-Stimulants: Atomoxetine
* What is the BBW?
* What is CI?

*

A
  • BBW: risk of suicidal ideation
  • CI: during or within 14 days of MAOI
97
Q

Non-stimulants: Alpha 2-agonist
* What is the MOA
* Resevered for who?

LY

A
  • Exact mechanism unknown; thought to mimic NE effects at the alpha-2 adrenoreceptors in the prefrontal cortex
  • Reserved for patients who respond poorly to a trial for stimulants or selective NE reuptake inhibitors or who have unacceptable adverse effects
98
Q

Non-stimulants: Alpha 2-agonist
* Works best to control what?
* Can be used as what?
* What are the two examples?

A

Works best to control hyperactivity and impulsivity

Can be used as adjunct therapy to stimulants for ADHD with and without concomitant personality disorders (ODD, conduct disorder)
* Clonidine (Kapvay)
* Guanfacine (Intuniv)

kNOW NAMES

99
Q
A
100
Q
A
101
Q

Monitoring and Patient education
* Follow what?
* Evaluate what? (2)
* Monitor what?
* Ask about what?

A
  • Follow weight and growth curves
  • Evaluate symptom improvements – objective measures ideal
  • Evaluate duration of effects
  • Monitor BP and HR
  • Ask about sleep and irritability
102
Q

Monitoring and Patient education
* What do you need to educate on (3)

*

A

* Eat before morning dose
* Timing of dose and sleep
* Drug holidays – weekends vs summer

103
Q

Narcolepsy
* Repeated what?
* they also experience what?

A
  • Repeated sleep attacks in which patients are unable to resist falling asleep suddenly
  • They also experience cataplexy and/or recurrent period of transition between sleep and wakefulness
104
Q

Narcolepsy
* What are the sxs?
* Irresistible attacks of what?timing?

A
  • Symptoms include paralysis, hypnopompic and/or hypnagogic hallucinations
  • Irresistible attacks of sleep that occur daily over at least 3 months and not related to substance
105
Q

Narcolepsy
* What is the first line therapy? What is the MOA?

*

A

Modafinil
* Increases extracellular concentration of dopamine by inhibiting its reuptake
* May inhibit NE reuptake
* Increases daytime wakefulness

106
Q

Narcolepsy
* What are the SE of modafinil?(3)

A
  • Headache
  • Nervousness
  • Nausea
107
Q

Insomnia
* What all three criteria need to be met?
* What is key?

A

All three criteria much be met
* Trouble falling or staying asleep
* Adequate opportunity for sleep
* Daytime dysfunction

Good history key

108
Q

Insomnia treatment - nonpharmacologic
* What can you for therapy?

A

CBT-Insomnia (CBT-I)
* Efficacy = pharmacotherapy
* Better long-term benefit
* Delivered in four to seven sessions

109
Q

Insomnia treatment - nonpharmacologic
* What is the sleep hygiene?

A
  • Dark, quiet, cool room
  • Avoid sleep disturbing substances – caffeine, alcohol, nicotine
  • Avoid vigorous exercise before bed
  • Wind down routine
  • Program out conditioned arousal
  • Use bed for sleep and sex only – only go to bed when sleepy, leave bedroom if not sleepy
110
Q

Insomnia treatment - nonpharmacologic
* What is the sleep restriction?

A
  • 5-hour restriction with slow build
  • Can exacerbate underlying seizure disorder or precipitate psychiatric disorders
111
Q

Insomnia treatment - nonpharmacologic
* Attention to what?

A

Attention to sleep-related worries
* Address stressors
* Tools to reduce nighttime worries

112
Q

Insomnia Pharmacologic treatments
* What are the melatonin receptor agonist?

A
  • Melatonin (OTC)
  • Ramelteon (Rx)
113
Q

Insomnia Pharmacologic treatments: melatonin receptor agonist
* Hormone released by what?
* What is not completely known?
* No clear what?
* Best for what?

A
  • Hormone released by pineal gland during the dark period of the day
  • Mechanism of sleep induction not completely known
  • No clear dose-response relationship
  • Best for delayed sleep-onset insomnia (> 30 minutes to fall asleep)
114
Q

Insomnia Pharmacologic treatments: melatonin receptor agonist
* What are the SE?(5)

A
  • Headache
  • Sedation
  • Nausea
  • Slowed reaction time
  • No abuse potential
115
Q

Insomnia pharmacologic treatments
* What is the selective H1 antagonists?(2) What is it good for?

A

Selective H1 antagonists
* Doxepin
* Tricyclic antidepressant with strong H1 antagonist activity
* Therapeutic effects largest early morning hours; best for individuals who wake towards the end of the night/ early morning – sleep maintenance

116
Q

Insomnia pharmacologic treatments: Selective H1 antagonist
* What are the SE?
* Avoid use with what?
* Ideal for who?

A

Adverse effects:
* Daytime sedation
* No abuse potential
* Avoid use within two weeks of MAOI
* Ideal for older patient with early morning awakening

117
Q

Insomnia pharmacologic treatments
* What are the other H1 Antagonist not recommended?
* Watch other for what?

A

Other H1 antagonists not recommended
* Diphenhydramine (Benadryl)
* Doxylamine (Unisom)

Watch for anticholinergic adverse effects

118
Q

Insomnia pharmacologic treatments: nonbenzo BDZ receptor agonist
* Selectively bind to what?
* High concentrations in what?
* Trigger what?
* Increase what?

A
  • Selectively bind to the alpha-1 subunit of the GABAA receptor
  • High concentrations in wake-promoting areas in the brain
  • Trigger chloride channel opening and cell hyperpolarization
  • Increase sedation
119
Q

Insomnia pharmacologic treatments: nonbenzo BDZ receptor agonist
* Most for what?
* What are the examples?

A

Most for both sleep onset and sleep maintenance insomnia
* Eszopiclone (Lunesta)
* Zaleplon (Sonata) – sleep onset
* Zolpidem (Ambien)

Ezzz (make you sleepy)

120
Q

Insomnia pharmacologic treatments: nonbenzo BDZ receptor agonist
* What are the SE?(3)
* What schedule drug?

A

Adverse effects:
* Sedation
* Memory loss
* Impaired cognitive function

Schedule IV controlled substance

121
Q

Insomnia Pharmacologic treatments: Dual orexin receptor antagonists
* Orexins arise from what?

A

Orexins arise from the neurons of the hypothalamus and promote wakefulness / arousal

122
Q

Insomnia Pharmacologic treatments: Dual orexin receptor antagonists
* Blocks what?
* What are the examples and what are for?
* All metabolized by what?

A

Block orexin A and orexin B receptors
* Lemborexant (DayVigo) – get to sleep
* Suvorexant (Belsomra) – stay asleep
* Daridorexant (recently FDA approved)

All metabolized by CYP3A4 – avoid strong inhibitors or inducers

123
Q

Insomnia Pharmacologic treatments: Dual orexin receptor antagonists
* Appropriate for what?
* Suvorexant robust effects on what?
* What type of schedule?

A
  • Appropriate for sleep onset and sleep maintenance insomnia
  • Suvorexant robust effects on sleep onset and at last third of night without significant morning sedation
  • Schedule IV controlled substance
124
Q

Insomnia pharmacologic treatments
* What are the different examples of benzos? Do not seem to develop what?

A

Benzodiazepines
* Triazolam
* Flurazepam
* Temazepam – sleep onset only

Do not seem to develop dependence or tolerance per short-term studies

125
Q

What are the SE of benzos? What type of schedule?

A

Adverse effects:
* Sedation
* Psychomotor impairment
* Abuse potential

Schedule IV controlled substance

126
Q

Insomnia pharmacologic treatments
* What are the antidepressants, antipsychotics, anticonvulants?

A

Antidepressants
* Trazodone
* Mirtazapine

Antipsychotics
* Quetiapine
* Olanzapine

Anticonvulsants
* Gabapentin
* Pregabalin (more sedation)

127
Q

*

A
128
Q

*

A
129
Q

What is the alcohol withdrawal timeline?

A
130
Q

,

Alcohol withdrawal treatment
* What is the acute treatment?(3)

A

Fluid replacement
* Thiamine (B1)
* Folic acid
* Magnesium
* Multivitamins
* Saline

Antiemetics

Benzodiazepines – serves as alcohol substitute at the GABA receptors; decreases severity of withdrawal symptoms

131
Q

CIWA-Ar
* Each category scored on what?

A
  • Nausea and vomiting
  • Paroxysmal sweats
  • Headache
  • Auditory disturbances
  • Visual disturbances
  • Anxiety
  • Tremor
  • Tactile disturbances
  • Orientation and clouding of sensorium
  • Agitation
132
Q

CIWA-Ar
* What is the score range?
* What needs and does not need intervention?

A

Score range: 0 to 67
* Score < 8 usually requires no pharmacologic intervention
* Specific follow-up and treatment depends on CIWA score

133
Q

CIWA-AR
* What is the gold standard txt for alcohol intox? What are some considerations?

A

Benzodiazepines gold-standard treatment for alcohol intoxication
* Specific BDZ dependent on patient organ function – especially liver
* BDZ dose and frequency dependent on CIWA score

134
Q

CIWA-AR

A
135
Q
A

All drug therapy should be combined with evidence-based structured psychotherapy

136
Q

Fill in covered

A

All drug therapy should be combined with evidence-based structured psychotherapy

137
Q

Fill in covered part

A

All drug therapy should be combined with evidence-based structured psychotherapy

138
Q

What is the Opioid withdrawal timeline?

*

A
139
Q

What are the Opioid acute withdrawal sxs?

FYI

A
  • Pulse
  • GI upset
  • Sweating
  • Tremor
  • Restless
  • Yawning
  • Pupil size
  • Anxiety/irritability
  • Gooseflesh skin
  • Bone or joint aches
  • Running nose or tearing
140
Q

Opioid acute withdrawal
* What is the scoring system and what is the score interpretation?

FYI

A

Cows

Score interpretation
* 5 to 12 mild
* 13 to 24 moderate
* 25-36 moderately severe
* 37 to 48 severe

141
Q

Opioid Withdrawal
* What is required?
* Specific prescribing privileges are needed tp what?

A

Medical supervision generally required

Specific prescribing privileges are needed to prescribe controlled substances for purposes of addition medicine
* Medications for Addictions Training (MAT training)

142
Q

Opioid Withdrawal
* What are the primary agents used to decrease withdrawl sxs?(3)

A
  • Buprenorphine
  • Methadone
  • Clonidine: Usually used as adjunct with opioid agonists to decrease autonomic symptoms including sweating, nausea, diarrhea, anxiety, irritability
143
Q
A
144
Q

Fill in covered part?

A
145
Q
A
146
Q
A
147
Q

Opioid withdrawal / OUD
* What are two alternative treatments?

A

Buprenorphine + naloxone (Suboxone) and Naltrexone

148
Q

Buprenorphine + naloxone (Suboxone)
* What is special about this?

A
  • Naloxone has no effect when Suboxone given at correct doses
  • Poorly absorbed orally; if given parenterally will trigger withdrawal symptoms
149
Q

Naltrexone
* What is special about this?

A
  • Long-acting opioid antagonist
  • Used to prevent relapse in patients after opioid withdrawal complete
  • Oral tablets or long-acting injection(LAI)
  • Improves abstinence rates short term; long-term benefits
150
Q

What is the benzo withdrawal timeline?

A
151
Q

Benzodiazepine withdrawal
* Change patient to what?
* Monitor for what?
* Continue BZD therapy with what?

A
  • Change patient to long-acting benzodiazepine at dose that eliminates withdrawal symptoms
  • Monitor for respiratory depression
  • Continue BZD therapy with long taper over several months
152
Q

Benzodiazepine withdrawal
* What can you give for OD?
* What is hte BBW?

A
  • Antidote: flumazenil
  • Rarely needed
  • BBW: can precipitate seizures
153
Q

Withdrawal from other drugs

Most substances without specific antidotes – supportive care
* Give what to decrease agitation/anxiety?
* what are the stimulants?
* What are the hallucinogens?
* What other drug?

A
  • Benzodiazepines often indicated to decrease agitation / anxiety
  • Stimulants – cocaine, methamphetamine, amphetamines
  • Hallucinogens – LSD, PCP
  • Cannabinoids
154
Q

Most substances without specific antidotes – supportive care
* With cocaine. avoid what?

A

avoid beta-blockers as antihypertensives; concerns of coronary artery vasoconstriction and systemic hypertension, which can result from unopposed alpha-adrenergic stimulation

155
Q

Smoking cessation
* What is the general approach?
* What is the first line pharm?

A
156
Q
A
157
Q
A
158
Q
A

Pharm III (14 decks)

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