M5 study guide Flashcards
Tricyclic antidepressants
-E.g. Amitriptyline, Clomipramine, Desipramine, Doexpin
-use of these drugs have greatly declined
-2nd line drug
-MOA: block neuronal reuptake of two monoamine transmitters at the CNS intensifying their effects
-Major adverse effects: sedation, orthostatic hypotension, and anticholinergic effects, cardiac toxicity, lower seizure threshold
-Overdose can be life-threatening
-More dangerous and less well tolerated
MAO inhibitors
-E.g. Isocarboxazid, Phenelzine, Selegiline, Tranylcypromine
-More hazardous, typically 3rd choice
-MOA: immediatley inactivates MAO in the synapse cause increased prolongation of NE, 5HT, and dopamine
-Greatest concern: Hypertensive crisis-triggered by eating foods rich in Tyramine
-Many drug interactions- avoid all drugs not approved by provider- HTN crisis with indirect-acting sympathomimetics
-SSRIs and serotonergic drugs can cause serotonin syndrome
-DRUG OF CHOICE FOR ATYPICAL DEPRESSION
-Most administered PO, Ensam (Selegiline) given transdermal (risk of HTN crisis is less w/ transdermal admin)—-AVOID drug-drug interactions by taking other meds not prescribed
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SSRIs
-E.g. Citalopram, Escitalopram, Fluoxetine, Sertraline, Vortioxetine
-Most commonly prescribed, safer, more tolerated
-1st drug choice
-MOA: Selectively block neuronal reuptake of serotonin, more serotonin stays present
-DO NOT block reuptake of dopamine and norepinephrine
-Adverse effects: sexual dysfunction, weight gain, serotonin syndrome
-Like all other antidepressants, monitor for suicidality when treatment is initiated
-MUST TAPER-abrupt discontinuation can cause dizziness
Adverse drug-drug interactions and treatment in patients taking MAO inhibitors
-Avoid all drugs, prescription or OTC, unless approved by DR
-AVOID Combo of TCA-MAOI-can cause severe HTN
-MAOI-SSRIs increase risk for serotonin syndrome–treatment includes discontinue drug, monitor and will resolve spontaneously.
-Antihypertensives- combined use of MAOI can lead to excessive lowering of blood pressure
-DO NOT TAKE W/ TEGRETOL OR TRILEPTAL
Teaching for those taking MAOI
-Patients should be informed about symptoms of HTN crisis (headache, tachycardia, palpitations, N/V, Sweating) -instruct to seek immediate medical attention if experiencing those symptoms-can lead to stroke and death
-Dietary restrictions: tyramine, caffeine, phenylethylamine–all can precipitate HTN in pts taking MAOIs—AVOID
-NO DRUGS OTHER THAN THOSE PRESCRIBED BY PROVIDER
Etiology of depression
-Most common psychiatric diagnosis
-understood to be caused by a deficiency of Monoamine neurotransmitters (serotonin and NE) in the brain
-depressed mood and loss of pleasure in usual activities
-Symptoms: insomnia/hypersomnia, anorexia/weight gain, mental slowing, loss of concentration, feeling of guilt, worthlessness, helplessness, suicidal ideation
Diagnosis: symptoms most of the day, nearly everyday for 2 weeks
Steps in treating someone with Major Depression
-Pharmacotherapy
-depression specific psychotherapy
-somatic therapis-yoga
-electroconvulsive therapy
-rule out non psychiatric causes of depression prior to starting drug therapy-make sure its not a symptom of another illness. E.g. thyroid disorder
Options for those w/ Major Depression who are considered non responders
-increase the dose
-try a different drug in the same class
-try a different class
-add an atypical antidepressant
Nontraditional treatments for major depression
Somatic therapy
Electroconvulsive therapy
Current treatments for GAD. Note any potential for abuse
-SSRI + SNRI= first line treatment for GAD
Can also use buspirone
-GAD can be treated with non drug therapy including supportive therapy, cognitive behavioral therapy, biofeedback, and relaxation training
-2nd line BZD- pts taking BZD carry some abuse potential especially that that abuse w/ ETOH
-Benzos act rapidly, good for a PRN for immediate relief
-potential for abuse by taking benzos since onset of relief is rapid
-avoid pregnancy/lactation-crosses placenta
-caution w/ active metabolites
Treatments/drug classes and important teaching points for medications used in those w/ BD
Commonly treated w/ 3 major groups: mood stabilizers, antipsychotics, and antidepressants
Mood stabilizers
-Relieve symptoms during manic and depressive episodes, prevent recurrence of these episodes, also they DO NOT worsen symptoms of mania or depression
E.g. Lithium and Valproate
Lithium
-antimanic effects can begin in 5-7 days but full effects not until 2-3 wks
-short half life, high toxicity, very low therapeutic index
-check lithium levels frequently
-Pt teaching: no NSAIDS, it is terotogen-birth control, clear all meds w/ prescriber
-Lithium toxicity can occur when Na level are low, monitor in dehydration and if taking diuretics
-DO NOT TAKE NSAIDS OR ANTICHOLINERGICS
Valproate (Depakote)
-first antiseizure drug approved for BPD
-works faster, more desirbale side effect profile compares to lithium, safer
-does not reduce risk for suicide and does NOT decrease risk for recurrence
Antipsychoticsin the setting of bipolar disorder
-given to help control symptoms during severe manic episodes
-usually in combo with mood stabilizer
-2nd generation antipsychotics are preferred
Antidepressants in the setting of bipolar disorder
-given during depressive episode
-always used in combo w/ mood stabilizer to avoid causing mania
-SSRIs can be used
-Avoid TCAs as they increase manic episodes
What med class can be added to BPD treatment to help w/ insomnia, anxiety, and agitation
Benzodiazepines
Treatment for managing acute delirium. Describe contraindications if any.
-Haloperidol-member of the butyrophenone family, high potency agent. Early extrapyramidal reactions occur, also can cause prolonged QT interval causing serious dysrhythmias, especially when given IV or at high doses
-Chlorpromazine-low potency agent
-Clozapine-can cause agranulocytosis, orthostatic hypotension, dry mouth, blurry vision, urinary retention, constipation, tachycardia. Clozapine can cause weight gain, diabetes, dyslipidemia
-Treat hyperactive delerium- no FDA drug approved
-Choose a med like haldol-QTC monitoring
-Supportive care
EPS pathophysiology
-All first generation antipsychotic medications (FGAs) produce a strong blockade of dopamine in the CNS
-Resulting in serious movement disorders, known as EPS
-Movement disorders resulting from effects of FGAs which act on the extrapyramidal motor system
-Although the exact cause is unknown, it is thought to be related to D2 receptors
Which population should BZD be avoided
-Avoid in patients with respiratory disorders
-COPD-benzos may worsen hypoventilation
-OSA- may exacerbate apneic episodes
-Snoring patient-benzos may convert partial airway obstruction into OSA
-Old people bitch
Indications for treatment with: SSRI and BZD
-SSRIs- most commonly prescribed antidepressant
-BZD- treatment of anxiety, insomnia, and seizure disorder
Side effects/ clusters of side effect symptoms that may be seen in those being treated with psychotherapeutic drugs
-Side effects: most troubling side effects are EPS-especially tardive dyskinesia
-acute dystonia
-parkinsonism
-akathisia
-NMS-worse possible side effect
-anticholinergic effects
-orthostatic hypotension
-sedation
-seizures
-sexual dysfunction
-neuroendocrine effects
-agranulocytosis
-severe dysrhythmias
Non pharm treatment for insomnia
-melatonin-a hormone that helps regulate the circadian clock
-sleep hygeine, CBT, relaxation therapy, multicomponent therapy
Neuroleptic Malignant Syndrome (NMS)
-Very rare, 4% die
-most of the drugs that cause NMS are antipsychotic drugs. First generation (typical) and 2nd generation (atypical)
-Symptoms: rigidity, very high temps may exceed 41 degrees C, sweating, autonomic instability manifested as dysrhythmias and fluctuations in BP
-LOC may rise and fall-can appear confused or mute, seizures and coma may develop
-Hyperthermia should be controlled w/ cooling blankets + antipyretics
-Treatment consists of supportive measures, drug therapy, and immediate withdrawal of antipsychotic meds
-Hydration w/ fluids
-Benzos can help relieve anxiety and reduce BP
-2 meds may be helpful: bromocriptine(dopamine receptor antagonist) and dantrolene (direct acting muscle relaxant)
-wait 2 weeks before resuming treatment, use lowest effective dose
Serotonin Syndrome
-Occurs 2-72 hours after treatment onset
-Symptoms: AMS, confusion, disorientation, anxiety, hallucinations, poor concentration, incoordination, myoclonus, hyperflexia, excessive sweating, tremor, fever
-symptoms resolve spontaneously after discontinuing drug
-IVF, cooling blanket for treating
-Figure out if patient is taking MAOI + SSRI
-MAOI + other drugs–increase risk
-“mad as a hatter, red as a heat, dry as a bone”
Techniques to assist w/ patient adherence to the prescribed regimen of atypical antidepressants
-atypical antidepressants (2nd generation)
-Clozapine-first SGA, most effective drug for scizizophrenia
-Monitor CBC regularly to assess for life-threatening agranulocytosis
-Evaluate for improvement of psychotic symptoms
