NEUROBIOLOGY/PSYCHOPHARMACOLOGY FINAL EXAM REVIEW Flashcards
Valerian
Used for sleep and anxiety
GABA
Used for Sleep and Anxiety
St. John’s Wort
Depression
SAM-E
Depression/anxiety(mainly depression)
Black Cohosh
Perimenopause, PMS, Vasomotor symptoms
Antipsychotic uses
Bipolar
Psychosis
Delirium
Anxiety
Depression
Clozapine Monitoring
Monitor ANC weekly x 6 months
Biweekly x 6 months
Then monthly
Looking for Agranulocytosis
When do you stop Clozaril?
ANC <1000
Lithium Normal drug range
0.6-1.2
What class is Lithium?
Mood Stabilizer (oldest mood stabilizer in use). Gold standard for Bipolar 1 treatment.
What do you need to educate patient on regarding Lithium?
-Educate patient about side effects and signs of lithium toxicity
-Let provider know about coarse hand tremor
-Identify medications that could increase toxicity
-Regular lithium levels
-Assess risk factors for lithium toxicity in special populations
-Take at same time daily
-Mild side effects are usually transient
-Report side effects
-Lithium should be taken at night and levels drawn in the morning(8-12 hours after last dose).
Lithium
MOA: Unknown, possibly neuroprotective and neuroproliferative effect to preserve gray matter.
-protective against suicide.
-Monitoring: Baseline serum level after each dose change and then annually.
What condition does Lithium treat?
Bipolar(most effective for mania).
Has anti-suicide action.
When do you stop Lithium? (and contraindications):
Pregnancy (risk for Ebstein’s anomaly)
Renal failure
Untreated hypothyroidism
Significant fluid loss(increases risk of toxicity)
Geriatric patients
Common side effects of lithium:
Nausea: may improve with food or ER formulations
Dry mouth/Thirst: Offer ice chips, sugarless gum, hydration.
Acne: resolves after 1 month
Alopecia: check thyroid functions
Mild fine Tremor: avoid caffeine, treat with propranolol.
Polyuria/Polydipsia(nephrogenic diabetes insipidus)
Weight gain: behavior modification/counseling.
Psoriasis: common over 50 y.o., order topicals, refer to dermatology, consider different agent.
Mild lithium Toxicity
-T-wave depression noted on EKG(generally mild and treatable)
-Toxic level is 1.5-2.0
-Muscle twitching
-Coarse hand twitching, muscle weakness
-Lethargy
-Nausea, vomiting, diarrhea.
Moderate Lithium toxicity
2.0-2.5:
-Severe nausea, vomiting, diarrhea
-Confusion, slurred speech,
-Ataxia, muscle twitching
-EKG changes
-Seizures
-Oliguria
-Circulatory Failure
-Coma
-Death
Severe lithium toxicity
2.5+
-Impaired LOC, coma
-Increased DTR’s
-Syncope
-Seizures
-Death
What is the main side effect of Risperidone?
Hyperprolactinemia. Prolactin levels are increased due to action on tuberoinfundibular pathway(Dopamine neurons from hypothalamus to pituitary).
Which medication most commonly causes QT prolongation?
Ziprasidone, best practice to get an EKG before starting medication.
When should Austedo be started?
Ideally at first sign of EPS.
How should Ziprasidone be taken?
With a 350 calorie meal to allow proper absorption. If not taken with food absorption will be about half.
What are the most common side effects with Seroquel?
Sleepiness and metabolic syndrome.
What is the treatment for parkinsonism?
Benztropine(cogentin)
What causes parkinsonism?
D2 blockade in Nigrostriatal pathway.
What medications are given for Tardive dyskinesias
Think “AI for TD’s”
Austedo
Ingrezza
What are the most common side effects of SSRI’s
GI Symptoms(Diarrhea, nausea, constipation)
Weight Gain
Sexual side effects
How is serotonin synthesized?
Tryptophan is converted to 5HTP(serotonin)
What are the positive symptoms of schizophrenia?
Hallucinations
Delusions
Disorganized thoughts
Agitation
Inappropriate emotions
perception disturbances
What are the negative symptoms of schizophrenia?
5 A’s:
blunted AFFECT
AMBIVALENCE
ALOGIA (Limited speech)
ANHEDONIA
ASOCIALITY
Class Notes: Anhedonia
Blunted emotions
Lack of feeling
What are the cognitive symptoms for schizophrenia( remember they are similar to ADHD)
Difficulty with memory
Difficulty with new learning
Trouble focusing
What are the Mood symptoms of Schizophrenia?(MISS D)
MISS D:
MOTIVATION
INSIGHT
SOCIAL WITHDRAWAL
SUICIDE
DEMORALIZATION
Acute dystonia
-Spasm of muscles of tongue, face, neck, back. May mimic seizures.
-Occurs after 1-5 days on medication
-Antiparkinsonian agents are diagnostic and curative
Parkinsonism
-Bradykinesia, rigidity, variable tremor, mask-like facies, shuffling gait.
-occurs at 5-30 days of treatment
-Treatment is antiparkinsonian agents.
Neuroleptic malignant syndrome
Mneumonic: FEVER
Fever
Encephalopathy
Vital Sign Instability
Elevated WBC, CPK
Rigidity.
-Catatonia, stupor, fever, unstable blood pressure, myoglobinemia, can be fatal.
-occurs after weeks of treatment. can persist for days after treatment.
-Treatment is hospitalization, stopping the drug, Dantrolene or bromocriptine may help. Antiparkinsonian agents are NOT effective.
Tardive dyskinesia
-Oral-facial dyskinesia, widespread choreoathetosis or dystonia
-occurs after months or years on treatment(worse on withdrawal)
-prevention crucial, FDA approved drugs (i.e. valbenazine).
Perioral tremor (Rabbit syndrome)
-May be a late variant of parkinsonism, generally occurs after months or years of treatment. Antiparkinsonian agents often help
What is Akathisia?
-Motor restlessness, not anxiety or agitation
-occurs after 5-60 days of treatment
What is the Treatment for akathisia?
Treatment is to reduce or change drug. Antiparkinsonian agents, benzos, propranolol may help.
How are the positive symptoms of psychosis treated?
Treat with antipsychotics which work by blocking dopamine in the mesolimbic pathway.
Which class of drugs are TD’s most common with?
First-generation antipsychotics
What causes Tardive dyskinesia?
D2 receptor blockade on nigrostriatal pathway
What are SSRI’s used for?
-Premenstrual dysphoric disorder
-Major depressive disorder
-Generalized anxiety disorder
-Obsessive-compulsive disorder
-Post-traumatic Stress disorder
What SSRI’s are approved to treat OCD in teens and pediatrics?
Sertraline and fluoxetine
What SSRI’s are approved to treat Anxiety in teens and peds?
Lexapro
(Teens are so L.A.: Lexapro for anxiety)
What SSRI’s are approved to treat major depressive disorder in teens and peds?
Lexapro
Sertraline
Fluoxetine
What is the elderly warning for elavil(amitriptyline) and other TCA’s?
Anti-cholinergic effects.
Specifically confusion, dry mouth, difficulty urinating.
What criteria do we need to consider with elderly patients?
BEERS criteria.
Beers Criteria
Recommendations for medications which are inappropriate and should be avoided in older adults.
Recommendations can be categorized as Strong, Weak, or Insufficient.
Dementia
Loss of intellectual abilities that interfere with function in at least one of the following categories:
-abstract thinking
-Impaired judgment
-personality change
-cortical dysfunction
Mild cognitive impairment (Clinical Presentation)
One of the following domains impaired(but remains able to perform ADL’s):
-May lose valuables
-Difficulty with executive functioning
-Loss of recent and remote memory
What 2 classes of medications are used to treat ADHD in children?
Stimulants
Non-stimulants
What are the non-stimulant medications used in pediatrics?
Clonidine
Guanfacine
In addition to stimulants, what other medications are used for ADHD in adults?
non-stimulants
Strattera
Welbutrin
What are the signs of Metabolic syndrome?
-Increased waist circumference
-Elevated blood sugar
-elevated lipids
-Hypertension
What side effect do all second generation antipsychotics have in common?
Increase risk of metabolic syndrome
Which second generation antipsychotic has the lowest risk for metabolic syndrome?
Latuda.
Justice
Doing what is fair. Fairness in all aspects of care
Beneficience:
Promoting well-being and doing good. Doing what is best for the patient.
Non-maleficience
Doing no harm
Fidelity:
Being truthful, keeping your promises, being virtuous.
Autonomy
The patient’s ability/right to make decision’s for him/her self.
Veracity
Conveying the truth without bias, deceit or omission.
Respect
Treating everyone with equal respect
Confidentiality
Do not disclose information without the patient’s consent.
Alzheimer’s:
-Ventricles will tend to enlarge and the cortex will tend to shrink
-Medications: Namenda, Aricept, Rivastigmine
Delirium
-Acute onset/sudden
-Causes may be: intoxication, electrolyte imbalances, infections, metabolic disturbances
-most common causes are UTI and dehydration.
Non-Alzheimer’s dementia
Chronic and progressive, decline in cognitive function(for example after a stroke)
How do you adjust the dose of olanzapine after a patient stops smoking?
Decrease the dose.
Zolpidem
Zolpidem (Ambien)
Formulation: tab 5mg, 10mg
CR-ER tab 6.25mg, 12.5mg
Schedule IV drug (controlled substance)
Alpha 1 isoform agonist (subtype of benzodiazepine receptor)
Enhances inhibitory effects of GABA
FDA approved: Short term treatment of insomnia; CR indication not restricted to short-term use
Half life is 2½ hours
Side effects: abnormal dreams, confusion, retrograde amnesia, decreased in CR product
Black box warning: May cause sleepwalking, sleep driving or other complex sleep behaviors, even death.
Beers List: Avoid in elderly patients with delirium
Lunesta
Eszopiclone (Lunesta)
Formulation: tab 1mg, 2mg, 3mg
Schedule IV drug (controlled substance)
Alpha 1 isoform agonist (benzodiazepine receptor)
Enhances inhibitory effects of GABA
FDA: Insomnia
Initial insomnia: 1mg at bedtime, Terminal insomnia: 2 mg at bedtime
Maximum dose is 3mg at bedtime
Half-life of 6 hours; peaks in one hour
Unpleasant taste is a reported side effect
Black box warning: May cause sleepwalking, sleep driving or other complex sleep behaviors, even death.
Beers List: Avoid in elderly patients with delirium
Sonata
zaleplon (Sonata)
Benzodiazepine receptor agonist hypnotic
Formulation: cap 5mg, 10mg
Schedule IV drug (controlled substance)
Alpha 1 isoform agonist (benzodiazepine receptor)
Enhances inhibitory effects of GABA
FDA approved: Short term treatment of insomnia, not intended for long term use
Half-life is ONE HOUR
Can be used for middle of the night awakening;
Sonata 10mg QHS; maximum dose 20mg
Black box warning: May cause sleepwalking, sleep driving or other complex sleep behaviors, even death.
Beers List: Avoid in elderly patients with delirium
Ramelteon
Agonist of Melatonin 1 and 2 receptors
SSRI names
Fluoxetine (Prozac)
Citalopram (celexa)
Sertraline (Zoloft)
Escitalopram(Lexapro)
Paroxetine (Paxil)
Vilazodone(vibryd)
Fluvoxamine (luvox)
Vortioxetine(trintellix)
SNRI names
Venlafaxine( effexor)
Desvenlafaxine(Pristiq)
Duloxetine(cymbalta)
Tricyclic antidepressant names
CANDI Acronym:
Clomipramine(anafranil)
Amitripytline (elavil)
Notriptyline(pamelor)
Doxepin(sinequan)
Imipramine(tofranil)
NDRI (norepinephrine Dopamine reuptake inhibitors)
Bupropion
Serotonin Modulator
Mirtazapine(remeron)
Trazodone (desyrel)
Nefazodone (Serzone)
Vilazadone(Viibryd)
Vortioxetine(trintellix)
MAOI’s
PISTacronym:
Phenelzine(nardil)
Isocarboxazid (marplan)
Selegiline transdermal(EMSAM)
Tranylcypromine(parnate)
Extrapyramidal symptom types:
ADAPT
Acute Dystonia
Akathisia
Parkinsonism
Tardive Dyskinesia
Phenomenology of Schizophrenia: (w/mneumonic)
HD BS Network:
HALLUCINATIONS
DELUSIONS
disorganized BEHAVIOR
disorganized SPEECH
NEGATIVE SYMPTOMS
2-4-6-OPHRENIA
You need 2 symptoms 4 at least 6 months.
What value would indicate a prolonged QT interval on an EKG?
> 450 milliseconds.
L-methylfolate
Which anticonvulsant for Bipolar 2 does NOT require blood monitoring?
Lamictal
Lithium has an inverse serum relationship with which element?
Sodium
Z Drug Black box warning
Names of the Z drugs
Names of the Antipsychotics
First Generation:
-Chlorpromazine-thorazine
-Haloperidol-Haldol
Second Generation:
-Clozapine-Clozaril
-Lurasidone-Latuda
-Olanzapine-Zyprexa
-Quetiapine-Seroquel
-Risperidone-Risperdal
-ziprazidone-Geodon
-Aripiprazole-Abilify
-Asenapine-Saphris
