MEDICATION IN-DEPTH Flashcards
Lithium (MOA, Indications, Effects, CI, Drug Interactions, etc.)
→ MOA: may lateral neural sodium transports and influence reuptake of serotonin or norepi
→ Indications: Bipolar DO, Manic Episode, Schizoaffective DO
→ Effects: DECREASES SUICIDE RISK!!!!!
HYPER-parathyroid, -calcemia, -magnesium
HYPO-natremia, -thyroidism
Nephrogenic Diabetes Insipidus
Increased thirst, Tremor, Weight Gain, Leukocytosis, Arrhythmias, V/D
→ NARROW THERAPEUTIC INDEX:
Before prescribing: EKG, CBC, TSH, Preg
Plasma Levels Checked every 4-8 weeks
(0.8-1.2 = Normal), (TOXIC > 1.5)
If CrCl <30 = AVOID
→ CONTRAINDICATIONS:
PREGNANCY: EBSTEIN ANOMALY (heart problem at birth - incorrect tricuspid valve)
→ Drug Interactions:
Lithium levels in the blood can be increased by dehydration, thiazides, TCAs, NSAIDS = can raise to toxic level
Carbamazepine
→ Class: Anticonvulsants
–> MOA: Blocks Na Channels
→ BBW: SJS/TEN, TERATOGENIC (Neural Tube)
Lamotrigine
→ Class: Antiepileptic
→ MOA: Inhibits glutamate/Na Channels
→ INEFFECTIVE FOR ACUTE MANIA**
→ BBW: SJS/TEN/HLA B1502, aplastic anemia, agranulocytosis
Valproate
–> Class: Anticonvulsants
→ MOA: Blocks Na Channels = Increases GABA
→ BBW: NEURAL TUBE DEFECTS (fetal toxicity), HEPATOTOXICITY , Pancreatitis
→ Contraindications: Hepatic Dysfunction
LIST 6 SSRIs
→ FLUOXETINE / Prozac
→ PAROXETINE / Paxil
→ CITALOPRAM / Celexa
→ ESCITALOPRAM / Lexapro
→ SERTRALINE / Zoloft
→ FLUVOXAMINE / Luvox
Which SSRI causes QT prolongation?
Citalopram (avoid with long QT syndrome)
Which SSRI causes anticholinergic SE (dry mouth, dizziness, wt gain)
Paroxetine
Only antidepressant approved for the treatment of Bulimia
Fluoxetine (Longer half life = can switch to MAOI (5 weeks)
When is max dose reached with SSRIs?
4-6 weeks
First line tx for Depression + Neuropathic Pain
Duloxetine (SNRI)
This drug is good for patients who fear sexual dysfunction, weight gain, or want to tey to quit smoking:
Bupropion (Wellbutrin)
Antidepressant (TCA) with the least sexual side effects (but does cause weight gain)
Mirtazapine / Remeron
Name SNRIs (5)
→ Venlafaxine / Effexor
→ Duloxetine / Cymbalta
→ Desvenlafaxine, Levomilnacipran, Milnacipran
SSRIS: MOA, INDICATIONS, SE, BBW
~SSRIs:
→ FLUOXETINE / Prozac
→ PAROXETINE / Paxil
→ CITALOPRAM / Celexa
→ ESCITALOPRAM / Lexapro
→ SERTRALINE / Zoloft
→ FLUVOXAMINE / Luvox
MOA:
Inhibits serotonin reuptakes (keeps the serotonin in the synapse longer) by blocking the serotonin (5HT1A) transporter
Treats:
FIRST LINE IN: Depression, PTSD, OCD, Panic DO, PDD, and Anxiety DO
Side Effects:
GI symptoms, sleep impairments, sexual dysfunction, weight changes
QT Prolongation with CITALOPRAM
Anticholinergic SE with PAROXETINE
Serotonin Syndrome
BBW:
Increases risk of SUICIDE up to the age 25
Fluoxetine = only antidepressant to treat Bulimia (Longer half life = can switch to MAOI (5 weeks)
REACH MAX DOSE ~ 4-6 weeks!!!
SNRIS: MOA, INDICATIONS, SE, BBW
~SNRIs:
→ Venlafaxine / Effexor
→ Duloxetine / Cymbalta
→ Desvenlafaxine, Levomilnacipran, Milnacipran
MOA:
→ Blocks norepinephrine and serotonin, keeping them both in the synapse longer
** DULOXETINE = 1st line especially with patients with significant FATIGUE or NEUROPATHY PAIN (neuropathic pain, diabetic neuropathic pain, fibromyalgia) **
SE:
→ Norepinephrine effects: sweating, dizziness, dry mouth, constipation
→ anticholinergic effects
** AVOID VENLAFAXINE in patients with HTN bc it causes HTN **
CI:
→ With MAOIs
→ Renal/Hepatic (Kidney/Liver)
→ Seizures
→ Caution with HTN
→ Increased risk of Serotonin Syndrome with use of St. John Wart
BURPROPION/WELLBUTRIN
MOA:
→ NDRI: Norepinephrine-Dopamine Reuptake
Inhibitor - Dopaminergic/Noradrenergic
→ Increase dopamine concentration in the nucleus accumbens
*** NICOTINE ANTAGONIST: Helps stop smoking
Indications:
→ MDD & Seasonal Affective DO
*** LESS GI SYMPTOMS, WT GAIN, and SEXUAL DYSFUNCTION
S/E:
→ LOWER SEIZURES THRESHOLD
→ Worsens suicide ideations
→ CNS s/e: anxiety, insomnia, agitation
→ Can increase psychosis in high doses
C/I:
→ EPILEPSY or INCREASED RISK OF SEIZURE (eating d/o, bulimia, anorexia)
Tricyclic Antidepressants (TCAs):
TERTIARY AMINES:
→ AMITRIPTYLINE (Migraines, Neuropathic/Chronic Pain)
→ CLOMIPRAMINE (approved for OCD)
→ IMIPRAMINE (Nocturnal Enuresis)
→ DOXEPIN (Migraines)
→ AMOXAPINE
SECONDARY AMINES
→ DESIPRAMINE (least sedative/anticholinergic)
→ NORTRIPTYLINE (least likely to cause orthostatic HTN)
MOA:
→ Inhibits reuptake of both Serotonin (5-HT) & Norepinephrine (more in the synapse)
Indications:
→ Depression, Insomnia, Neuropathies, Pain Disorders
*** USED LESS OFTEN = ADVERSE EFFECT/SEVERE TOXICITY WITH OVERDOSE
** CLOMIPRAMINE = approved for OCD (serotonin specific) >= 10
** IMIPRAMINE = nocturnal enuresis
** AMITRIPTYLINE = Neuropathic/Chronic Pain
** AMITRIPTYLINE or DOXEPIN = migraine prophylactic
S/E:
** PROLONGED QT INTERVAL (indication of OD)
** Lower seizure threshold
*** Increased suicide in pt <25
→ Anticholinergic Effects: dry mouth,
constipation, urinary retention, tachycardia, orthostatic hypertension
Amitriptyline and Doxepin = most anticholinergic
→ Antihistamine (H1) Effects = sedation and drowsiness, increased appetite, weight gain, confusion
→ Orthostatic hypotension, dizziness
→ Serotonergic Effects: Sexual Dysfunction
C/I:
→ Use of MAOI, recent MI, Seizure history
Which 2 treatments for Bipolar cause neural tube defects?
Valproate and Carbamazepine
Which antidepressant/SNRI cannot be used in HTN?
** AVOID VENLAFAXINE in patients with HTN bc it causes HTN **
TRICYCLIC ANTIDEPRESSANTS (TCAs) (7)
TERTIARY AMINES:
→ AMITRIPTYLINE
→ CLOMIPRAMINE
→ IMIPRAMINE
→ DOXEPIN
→ AMOXAPINE
SECONDARY AMINES
→ DESIPRAMINE
→ NORTRIPTYLINE
Which TCA is approved for OCD?
Clomipramine
TCA OVERDOSE:
→ 3 C’S: CARDIOTOXICITY (Wide Complex Tachycardia), CONVULSIONS (Seizures), COMA (respiratory depression)
→ TX:
Sodium Bicarbonate
Clozapine causes?
Agranulocytosis
Last line treatment for treatment resistance psychosis?
Clozapine
Buspirone
Anxiolytics:
~BUSPIRONE:
MOA:
Partially blocks serotonin and dopamine
Indications:
GAD
S/E:
DOES NOT HAVE SEDATING EFFECT
Which benzo has the shortest half-life?
Alprazolam/Xanax
List 5 Benzos
~ ALPRAZOLAM (Xanax), LORAZEPAM (Ativan), DIAZEPAM (Valium), MIDAZOLAM (Versed), Clonazepam (Klonopin)
Benzos
(MOA, S/E, OD Tx)
BENZOS: “pam/lam”
~ ALPRAZOLAM (Xanax), LORAZEPAM (Ativan), DIAZEPAM (Valium), MIDAZOLAM (Versed), Clonazepam (Klonopin)
MOA:
→ Enhance GABA (GABA-induced chloride ion flux = hyperpolarization)
S/E:
→ Sedation + Dependence
OD:
→ Give FLUMAZENIL
~ DISULFIRAM:
~ DISULFIRAM:
Gives you bad symptoms if you do drink alcohol (HYPOTENSION, N/V, flushing, hyperventilation, HA, palpitations
→ MOA: Inhibits Aldehyde Dehydrogenases (can’t metabolize alcohol)
→ CI: heart ds, DM, Hypothyroid, epilepsy, kidney/liver ds
** DO NOT GIVE TO PT WHO IS DRINKING
~ NALTREXONE:
~ NALTREXONE:
Reduces CRAVINGS and alcohol-induced euphoria
→ MOA: Opioid antagonist
***CANNOT BE GIVEN WITH OPIOIDS
Alcohol with Hallucinosis TX:
HALDOL
Alcohol Withdrawal TX:
→ Long-Acting BENZOS
** DIAZEPAM **
Depress the CNS excitation cause by the stop of alcohol
→ Replace:
THIAMINE = Prevents Wernicke’s Encephalopathy and Korsakoff Psychosis
NALOXONE
NALOXONE/NALTREXONE
- Opioid Intoxication
Opioid Antagonist that helps within 2 minutes
Clonidine
Clonidine: Symptomatic Control
-Opioid Withdrawal
Alpha 2 Agonist → Decreases NE and sympathetic output (controls the symp. symptomS)
Methadone
Methadone (Long-Acting/Maintenance)
-Opioid withdrawal
MOA: Long acting opioid receptor agonist
SAFE in Pregnancy
Slowly tapers opioid effects that diminishes effects
S/E: QT Prolongation
Buprenorphine + Naloxone (Suboxone)
Buprenorphine + Naloxone (Suboxone)
-Opioid withdrawal
May start/worsen withdrawal if given too soon
MOA of Buprenorphine: Partial opioid receptor agonist
Naltrexone
Naltrexone:
MOA: Opioid antagonist
DECREASES CRAVINGS for ethanol and alcohol depency
PRECIPITATES WITHDRAWAL WITHIN 7 DAYS of HEROIN USE
Opioid Addiction Meds
Addiction TX:
Methadone
Suboxone
-Long-acting, fever symptoms
Narcan is only active if taken IV so it prevents OD when Suboxone is injected
What vitamin should be given with stimulant intoxication?
Vitamin C
Best treatment for stimulant withdrawal?
Bupropion
Bromocriptine
SSRI
~Varenicline (Chantix):
~Varenicline (Chantix):
MOA: Blocks Nicotine Receptors - Partial agonist at alpha 4 beta 2 subunit of nicotinic ACH receptors
Binds and produces stimulation (blocks) of the subunit of nicotinic receptor to
REDUCE WITHDRAWAL SYMPTOMS
Reduced the REWARD ASPECT OF SMOKING
Basically blocks the tobacco from binding to the receptor
Start medication and Stop Smoking 1 week after = up to 12 weeks
Therapy beginning 1 week before quitting and 4 months after
S/E: NAUSEA, increased suicidality
~Bupropion (Wellbutrin, Zyban):
~Bupropion (Wellbutrin, Zyban):
MOA: Enhances CNS noradrenergic and dopaminergic release (Dopamine and NE reuptake inhibitor)
Reduced nicotine cravings and withdrawal
SAFE in CVD or COPD
APPROVED IN PREGNANCY and kids
Start one week prior to quit date
~ Nicotine Replacement Therapy (NRT)
~ Nicotine Replacement Therapy (NRT)
** Long acting + Short acting = 1st Line
PATCHES: (long-acting)
Start of QUIT DAY:
>10 weeks = highest dose
New Patch each day and remove at bedtime
GUM: (short-acting)
4mg
Avoid Acidic Drinks: coffee, carbonation = lowers pH
Lozenges:
Looks like a “tic-tac” - dissolves
4mg who smoke within 30 mins of waking
5 every 6 hrs = MAX
2nd Gen Atypical Long-acting injectable form –> MC agents used for Schizophrenia –> GREATEST INCIDENT of MOVEMENT DO (also causes increased prolactin = galacterrea)
Risperidone
2nd gen that has the LOWEST incidence of movement do’s
Quetiapine (Seroquel)
Last line 2nd Gen due to agranulocytosis and myocarditis (even though it treats Schizophrenia the best)
Clozapine
2nd gen with highest SE of Wt Gain & DM
Olanzapine
2nd gen that is more weight neutral (less potential for weight gain) but has a high risk of prolonged QT - 500 cals
Ziprasidone (Geodon)
2nd Gen that is a partial dopamine agonist that has a less potential for weight gain. Common SE is akathesia
Aripiprazole
2nd gen - safe with pregnancy - must be taken with food and can be used for BPD (350cals)
Lurasidone (Latuda)
3 First Gen AntiPsychotics + MC SE
Haloperidol
Fluphenazine
Chlorpromazine
Increased risk of Cardiac Symptoms + EPS/TD + Increased Prolactin
3 2nd Gens that cause weight gain, hyperlipidemia and increased glucose
Quetiapine (Seroquel)
Clozapine (Clozaril)
Olanzapine (Ziprexa)
4 2nd gens that cause cardiac s/e, including the 2 atypical second gens that causes movement dos
Lurasidone (needs 350cals)
Ziprasidone (needs 500 cals - weight neutral)
ATYPICALS:
Risperidone
Paliperidone
3 2nd gens that are partial dopamine agonists that increase dopamine and cause akathesia
Aripiprazole (Abilify)
Brexpiprazole
Cariprazine (Vraylar)
Treatment for TD
Valbenazine (Ingrezza) or DEUTETRABENAZINE
ANTI-PSYCHOTICS:
1st Generation:
-MOA: Selectively antagonizes dopamine D2 receptors (butyrophenone)
-S/E: Increased risk of TD, EPS, HYPERprolactin (GALACTORRHEA), Increased risk of Cardiac S/E (qt prolongation) & NMS (neuropathic malignant syndrome)
** DEMENTIA RELATED PSYCHOSIS **
-Indications: Positive Symptoms (Psychosis) + Less Sedating & Decreased HYPOtns risk
→ Haloperidol:
→ Fluphenazine:
→ Chlorpromazine: Less EPS, More Anticholinergic
3 FGAP
→ Haloperidol:
→ Fluphenazine:
→ Chlorpromazine:
2nd Generation Antipsych
-MOA: Dopamine Antagonist (Higher affinity for D3/D4 than D2 (which causes the EPS symptoms) & also effects SEROTONIN (5-HT2A & 5-HT1A))
-S/E: Each Subsection has their own
-Indications: 1st Line for Psychosis !!!
“A-Pine” = “A - Pound” 2nd Gens
-S/E: WEIGHT GAIN + Increased LIPIDS + Increased Glucose (Hyperlipidemia + DM)
→ Quetiapine/Seroquel: Sedative!!!
→ Clozapine: ** LAST LINE for Tx Resistant Psychosis → Most Potent BUT RISK of AGRANULOCYTOSIS + increased Seizure risk
Need to order a CBC weekly!!
→ Olanzapine/Zyprexa: Sedative!!! + MOST WEIGHT GAIN “blow up like an O”
→ Clozapine:
** LAST LINE for Tx Resistant Psychosis → Most Potent BUT RISK of AGRANULOCYTOSIS + increased Seizure risk
Need to order a CBC weekly!!
“Dones” = “Don’t go breaking my heart” 2nd Gen
-S/E: Cardiac S/E = QTc Prolongation
- Atypicals: ** S/E mimic 1st Gen ** (EPS, Prolactin)
→ Risperidone: Prolactin + Galactorrhea + TD
→ Paliperidone: Prolactin + Galactorrhea + TD - TAKE WITH FOOD:
→ Lurasidone/Latuda: 350 cals
→ Ziprasidone/Geodon: MOST WT NEUTRAL + Take with Food + QTC prolongation
“2 Pips & a Rip” 2nd Gen
PARTIAL DOPAMINE AGONIST
S/E = Akathisia: “ants in pants”
→ Aripiprazole/Abilify:
→ Brexpiprazole/Rexulti:
→ Cariprazine/Vraylar:
Tx of NMS
→ TX:
1st: STOP ANTIPSYCHOTIC
IV Fluids + Cooling Blanket
BENZOS (Lorazepam, Diazepam)
Add DANTROLENE (Muscle relaxer)
Add Dopamine Agonist (Bromocriptine, Amantadine)
TX OF SEROTONIN SYNDROME
-1st=STOP AGENT
-Fluids, Benzos
-May add Cyproheptadine (serotonin agonist)
TX OF SEROTONIN SYNDROME
Tx:
-1st=STOP AGENT
-Fluids, Benzos
-May add Cyproheptadine (serotonin agonist)
Stimulants for children >6 for ADHD
Methylphenidate (Ritalin, Concerta)
Dexmethylphenidate (Focalin)
Amphetamine/Dextroamphetamine (Adderall)
Non-stimulant used for ADHD/hx of abuse pt
Atomoxetine (Strattera)
Good for hx of abuse
ADHD Medication/Stimulants:
** >6 Years Old **
MOA:
Upregulate DOPAMINE by blocking reuptake of dopamine at the synapse
S/E:
Decreased appetite, growth stunt, tics, etc.
→ Methylphenidate (Ritalin, Concerta)
→ Dexmethylphenidate (Focalin)
→ Amphetamine/Dextroamphetamine (Adderall)
Non-Stimulants ADHD:
Non-Stimulants:
** Good for Hx of Abuse **
MOA:
Selective Norepi reuptake inhibitors
SE:
Dry mouth, decreased appetite, insomnia
→ Atomoxetine
→ Viloxazine
OTHER OPTIONS FOR ADHD
Alpha-2-Adrenergic Agonist:
Resistant ADHD
S/E:
Hypotension and Dizziness, Wt Gain
→ Guanfacine
→ Clonidine: Worse SE
** Can also use Wellbutrin or Venlafaxine **
