Medications Flashcards
Doxepin
TCA
Clozapine
2nd generation antipsychotic
Reserved for patients who have failed at least 2 schizophrenia antipsychotic trials due to risk of agranulocytosis
Weight gain/metabolic syndrome
For treatment-resistant schizophrenia or schizophrenia with suicidality
Anticholinergic toxicity signs
AMS, tachycardia, hyperthermia, others
Anticholinergic toxicity - what to do
ECG - TCAs can also cause QRS interval prolongation, while others that are antihistamines can cause QTc prolongation, while others can cause cardiac toxicity
Benzos for agitation and seizure
Physostigmine can inhibit cholinesterase, used for severe symptoms
Activated charcoal
Neuroleptic malignant syndrome signs
- Muscular rigidity
- Autonomic instability
- AMS
- Hyperthermia
Bupropion advantage/disadvantage
Norepinephrine-dopamine reuptake inhibitor
No adverse sexual effect or weight gain
Increases risk of insomnia
Lowers seizure threshold - contraindicated in patients with bulimia nervosa or anorexia nervosa (electrolyte abnormalities from vomiting), or epilepsy
Serotonin syndrome difference with NMS
Hyperreflexia, clonus, nausea/vomiting vs muscle rigidity in NMS
Rapid onset (within 24h)
What combination of drugs can cause serotonin syndrome?
Serotonergic agent + MAO inhibitor (e.g. phenelzine)
Donepezil
Cholinesterase inhibitor
Dementia treatment
Memantine
NMDA receptor antagonist
Dementia treatment
Amantadine
Increases dopamine release/inhibits reuptake
Parkinson treatment
Pramipexole
Dopamine agonist
Parkinson treatment
Trazodone
Mild serotonin reuptake inhibitor
Additional activity at 5-HT2A and 5-HT2C receptors
Insomnia in setting of depression
Lamotrigine
Anticonvulsant
Used for bipolar disorder
Imipramine
TCA
Why do 1st-generation antipsychotics cause extrapyramidal symptoms?
Potent dopamine D2 antagonism in nigrostriatal pathway
Which of the 2nd-generation antipsychotics have low metabolic risk profile?
- Aripiprazole
- Lurasidone
- Ziprasidone
Anticholinergics
Diphenhydramine
Benztropine
Used to treat medication-induced dystonia (e.g. dopamine antagonists, antipsychotics)
Phenelzine
MAO inhibitor
Do not use with SSRI due to risk of serotonin syndrome
Rivastigmine
Cholinesterase inhibitor
For cognitive impairment
Meclizine
Antihistamine
Temporary vestibular suppressant to improve symptoms from acute episodes of peripheral vertigo
Nimodipine
Subdural hemorrhage - reduces risk of delayed cerebral ischemia following subdural hemorrhage (possibly by vasodilation of small vessels)
Ropinirole
Dopamine agonist (D2, D3)
Restless leg syndrome
Adverse: impulse control disorders possibly with manic-like signs/symptoms
Trihexyphenidyl
Anticholinergic
Parkinson treatment
Selegiline
MAO type B inhibitor
Parkinson
Restless leg syndrome - signs, treatment
Dysesthesia worse at night - may be due to abnormalities of dopamine signaling (near circadian control center) or iron use in CNS
If severe and nonpharmacologic doesn’t work, treat with alpha-2-delta calcium channel ligands (pregabalin, gabapentin), possibly iron supplementation if ferritin <=75
Lithium toxicity
Ataxia
Lethargy
Slurred speech
GI distress (nausea/vomiting, diarrhea)
Nystagmus
Tremor
Hyperreflexia
Phenytoin toxicity
Cerebellar adverse effects:
Ataxia (wide-based gait), horizontal nystagmus (on lateral gaze), dysmetria
AMS, confusion
CNS depression, coma
Nausea, vomiting
Demedetomidine
A2 agonist
Used in ICU for procedural sedation
Cyproheptadine
Serotonin antagonist
Used for serotonin syndrome
Preferred medication for Parkinson psychosis
2nd-generation antipsychotic without D2R antagonism and act mainly by serotonin 5-HT2A receptor antagonism
Quetiapine (no D2R activity, 1st choice), clozapine (agranulocytosis), pimavanserin (expensive)
What medication withdrawal can cause seizures?
Benzos (particularly short acting like alprazolam and abrupt discontinuation)
Antidepressant discontinuation syndrome
- Acute onset dysphoria
- Fatigue
- Dizziness
- GI distress
- Flu-like symptoms
What medications can cause dose-dependent seizure in those with predisposition?
Bupropion (dopamine/NE reuptake inhibitor)
TCA (e.g. clomipramine)
Tardive dyskinesia
Involuntary movement disorder with dopamine-blocking agents, especially when dose is reduced or discontinued, due to dopamine D2 receptor supersensitivity
Rhythmic movements of face, lips, tongue
Choreoathetoid movements of trunk and extremities
What analgesic has serotonin activity (risk serotonin syndrome)?
Tramadol
Glucorticoid psych symptoms
Psychosis, mania, depression
Alcoholic cerebellar degeneration - signs
Wide-based gait
Truncal ataxia
Nystagmus
Impaired postural coordination (tandem walk, heel-knee-shin) but intact limb coordination (finger-nose)
Later: Postural tremor of fingers and thighs, dysarthria, visual problems
Tourette syndrome - pharmacological treatment
VMAT2 inhibitors
a2 agonists for comorbid ADHD or behavior symptoms
Tourette syndrome - pharmacological treatment
VMAT2 inhibitors
a2 agonists for comorbid ADHD or behavior symptoms
What can be used first-line for neuropathic pain?
SNRI (duloxetine, venlafaxine)
Amitriptylines
Gabapentinoids
Phenytoin pharmacodynamics
Cytochrome p450 (inhibited by Bactrim, fluconazole)
Protein bound (displaced by valproic acid)
Renal or hepatic dysfunction
Why should pralidoxime only be given after atropine first for organophosphate toxicity?
May cause initial AChesterase inhibition prior to reactivation, worsening toxicity
Narcolepsy first-line
Modafinil
Narcolepsy meds
First: Modafinil
Second: Stimulants
Significant cataplexy (emotion-induced loss of muscle tone): antidepressants, sodium oxybate
What meds cause polyneuropathy?
Metronidazole, fluoroquinolones, dapsone
Digoxin, amiodarone
Acute causes burning pain as well
Trigeminal neuralgia med
Carbamazepine
Cluster headache treatment and prophylaxis
100% oxygen; prophylaxis with verapamil
What meds to avoid in catatonia
Antipsychotics
Antiparkinsonian medications for antipsychotic side effects
Benztropine (anticholinergic)
Amantadine (dopamine agonist without psychosis)
Neuroleptic malignant syndrome - treatment
Benzos –> bromocriptine or amantadine –> dantrolene
As opposed to just extrapyramidal symptoms from antipsychotics: benztropine –> amantadine
Bupropion is contraindicated in whom?
Hx of seizures, eating disorders (eating too little)
Quetiapine mechanism
Serotonin 2A and dopamine D2 receptor antagonist
What SSRI has a long 5-week washout period?
Fluoxetine
What bipolar med can cause hyperPTH and hypercalcemia?
Lithium
What seizure meds can cause Stevens-Johnson syndrome?
Lamotrigine
Carbamazepine
Alcohol use disorder medications
First-line: naltrexone, acamprosate (glutamate modulator, more for maintenance of abstinence)
Naltrexone contraindicated in current opioid use and acute hepatitis/liver failure
Acamprosate contraindicated in siginificant renal impairment
How should SNRIs be monitored?
Blood pressure - dose-dependent increase in systolic and diastolic pressures
Primidone
Centrally acting anticonvulsant, barbiturate - used for essential tremor in those with contraindications to nonselective beta blockers
What specific should be watched with ziprasidone?
QTc prolongation
Diazepam
Lorazepam
Midazolam
Diazepam - Valium
Lorazepam - Ativan
Midazolam - Versed
Entacapone
COMT inhibitor
Parkinson treatment
When can ropinirole or pramipexole be used first in Parkinson?
Under 60 and tremor-predominant symptoms
Essential tremor - treatments
Propranolol
If resistant: deep brain stimulation to the ventral intermediate nucleus (VIM) of the thalamus
Alzheimer treatment categories
- Cholinesterase inhibitors (donepezil, rivastigmine)
- NMDA antagonist (memantine)
- Anti-Abeta antibody (lecanemab)
Migraine prophylaxis: tiers
Tier 1: propranolol/metoprolol/timolol, candesartan, topiramate
Tier 2: Amitriptyline, valproate
Tier 3: Anti-calcitonin gene related peptide (CGRP) antibody (e.g. galcanezumab)
Triptans are contraindicated in…
Atherosclerosis - due to vasoconstrictive effects
Migraine abortive treatment - tiers
Tier 1: NSAIDs +/- acetaminophen/caffeine
Tier 2: NSAIDs + triptans
Tier 3: -gepants or -ditans
Only prophylaxis for tension headaches
Amitriptyline
Trigeminal neuralgia - treatment
Carbamazepine
TCA overdose - what to do
ECG - monitor QRS
QRS >100 ms associated with increased risk of arrhythmia and seizures, so give sodium bicarbonate
Can use activated charcoal within 2h of ingestion unless ileus
TCA overdose - cardiac effects
Due to inhibition of fast Na channels in His-Purkinje and myocardium:
Tachycardia with hypotension (from a1 antagonism)
Prolonged PR/QRS/QT
Arrhythmia
Use sodium bicarbonate
When to dialyze for lithium toxicity
When >2.5 with symptoms or >4 and Cr >2 regardless of symptoms
Which SSRIs are most known to cause QT prolongation?
Citalopram and escitalopram
What seizure meds can cause SJS?
Phenytoin, carbamazepine
