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Pathopharm Exam 3 > PDF > Flashcards

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1
Q

Psychotropic drugs
off-label uses

A
  • Tourette’s syndrome
  • eating disorders
  • insomnia
  • chronic pain
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2
Q

Which psych med should be stopped before surgery? for how long?

A

lithium
stop 72H before surgery

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3
Q

Antidepressant medications are generally continued in the perioperative period to…

A

prevent relapse of symptoms and withdrawal

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4
Q

tricyclic antidepressants + meperidine

A

seizures

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5
Q

indirect-acting vasopressors (ephedrine) + ____ = hypertensive crisis

A

MAOI

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6
Q

TCAs and MAOIs, a regional anesthetic may be used but…

A

avoid LAs with epi as it can cause hypertensive crisis

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7
Q

Cognitive impairment due to psychotropic drugs can mask serious medical conditions such as…

A

stroke, drug overdose, and diabetic ketoacidosis

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8
Q

T/F
TCAs prolong the QT interval

A

False
SSR/SNRI
antipsychotics

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9
Q

Which drug classes & interactions are a/w Serotonin Sydnrome?

A

SSR/SNRI
Second gen antidepressants
MAOI: NO meperidine

TCAs:
* phenylpiperidine opioids (meperidine, methadone, and fentanyl)
* tramadol
* ondansetron & metoclopramide
* metronidazole
* second generation antipsychotics
* St. John’s wort

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10
Q

Which drug classes & interactions are a/w Hypertensive crisis?

A

MAOI + …
* Indirect-acting vasopressors (ephedrine)
* ketamine
* LAs w/ epinephrine
* amphetamine
* phenylephrine
* reserpine
* Meperidine

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11
Q

Prolongs neuromuscular blockade with succinylcholine

A

MAOI

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12
Q

TCAs
Primary moA

A

inhibits serotonin & norepinephrine reuptake

some affect primarily serotonin while others act primarily on norepinephrine

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13
Q

TCAs
Anticholinergic effects

A
  • sedation
  • urinary retention
  • constipation
  • prolonged gastric emptying
  • dry mouth
  • blurry vision
  • confusion
  • delirium
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14
Q

TCAs with highest Anticholinergic effects

A

amitriptyline

  • sedation
  • urinary retention
  • constipation
  • prolonged gastric emptying
  • dry mouth
  • blurry vision
  • confusion
  • delirium
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15
Q

Due to the anticholinergic and cardiac depressant properties, drug overdose with ___ is among the most dangerous

A

TCAs

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16
Q

Abrupt cessation of TCAs in the perioperative period

A

cholinergic rebound withdrawal:
* malaise
* rhinorrhea
* abdominal pain

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17
Q

T/F
TCAs are first-line antidepressants.

A

False
significant side effect profile and lower tolerability

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18
Q

The triad of serotonin syndrome

A
  • mental status (agitation, confusion)
  • autonomic instability (hyperthermia, HD unstable)
  • neuromuscular abnormalities (hyperreflexia, rigidity)
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19
Q

How do some TCAs affect pressors?

A

inhibition of norepi reuptake
⬇️
exaggerated response to indirect-acting vasopressors & sympathetic stimulation

AVOID: ketamine, pancuronium, meperidine, LAs with epi

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20
Q

T/F
Hypotension can occur with TCAs.

A

True
chronic catecholamine depletion = unopposed anesthetic cardiac depression

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21
Q

If your pt on TCAs becomes hypotensive, what should you give?

A

small dose of a direct-acting vasopressor, such as phenylephrine

not indirect-acting (ephedrine)

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22
Q

T/F
TCAs may have increased MAC or total anesthetic requirements.

A

True
enhanced brain catecholamines

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23
Q

TCAs used with other anticholinergics, such as atropine & scopolamine

A

increased risk of postoperative sedation and delirium

24
Q

well-tolerated and frequently considered first-line treatment for depression

A

SSRI/SNRI

25
Q

SSRI & SNRI
drugs

A

SSRIs: fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram

SNRI: desvenlafaxine, duloxetine, milnacipran, levomilnacipran

26
Q

Are SSR & SNRIs safer than MAOIs & TCAs?

A

yes
* milder SE profile (little/no anticholinergic or cardiac activity)
* decreased risk of fatal overdose

27
Q

Primary side effects of SSRIs vs SNRIs

A

SSRI: headache, nausea, tinnitus, agitation, insomnia, sexual side effects: erectile dysfunction; dysorgasmia

SNRIs: HTN d/t ↓norepi reuptake, tachycardia, sexual dysfunction, mydriasis, urinary constriction, dry mouth, dizziness, sedation

28
Q

SSRIs and SNRIs can result in ….. secondary to alterations of platelet serotonin levels

A

abnormal bleeding

29
Q

MAOIs are now reserved for resistant depression due to

A

toxicity profile and dietary restrictions

30
Q

MAOIs act by

A

inhibits oxidative deamination of amines
increasing concentrations of MAO substrates:
* norepinephrine
* serotonin
* dopamine

31
Q

nonselective irreversible MAOIs

A
  • phenelzine
  • isocarboxazid
  • tranylcypromine

for refractory depression

32
Q

Which class can cause orthostatic hypotension & elevated liver enzymes?

A

MAOIs

33
Q

MAOIs & tyramine

A

MAOIs reduce the monoamine degradation of tyramine
⬇️
excess tyramine displaces stored monoamines (dopamine, norepi, epi) from the presynaptic vesicles
⬇️
hypertensive crisis

34
Q

T/F
MAOIs can cause serotonin syndrome.

A

True
phenylpropanolamine, phenylephrine, dextromethorphan, pseudoephedrine, as well as drugs that have the potential to increase serotonin leading to serotonin syndrome

35
Q

Do we continue MAOIs periop? Why?

A

Yes
long tapering period, possible increased suicidal ideation, and withdrawal symptoms of agitation, cognitive dysfunction, and headache

36
Q

MAOI + Meperidine

A

contraindicated
serotonin syndrome

37
Q
A
37
Q

T/F
MAOIs decrease MAC.

A

False
increased secondary to increased circulating norepi

depth of anesthesia recommended given the risk of sympathetic stimulation

38
Q

Atypical antidepressants
classes

A
  • second gen SNRIs
  • norepinephrine & dopamine reuptake inhibitors (NDRIs)
  • serotonin antagonist & reuptake inhibitors (SARIs)
  • combined reuptake inhibitors and receptor blockers (CRIBs)
39
Q

Atypical antidepressants
drugs

A
  • bupropion
  • trazodone
  • nefazodone
  • venlafaxine
  • vilazodone
  • vortioxetine
40
Q

Should supplements for depression be continued periop?

A

discontinued at least 2 weeks before surgery

41
Q

Induces the CYP 3A4 enzyme system can lead to delayed emergence

A

St. John’s wort

42
Q

Due to the inhibition of neurotransmitter reuptake and slight MAOI, patients taking St. John’s wort are at risk of

A

serotonin syndrome

43
Q

Meds to avoid in ppl taking St. John’s wort

A

drugs that increase serotonin, MAOIs, and meperidine

(serotonin syndrome)

44
Q

T/F
Second generation or atypical APDs have a higher incidence of extrapyramidal side effects.

A

False
lower

45
Q

Typical vs Atypical
APD
moA

A

typical APDs: block postsynaptic brain dopamine D2 receptors

atypical APDs: higher affinity for serotonin 5HT2r

46
Q

associated with an increased incidence of sudden cardiac death

A

Both typical and atypical APDs

block repolarizing potassium currents & prolong QT → ventricular arrythmias and cardiac arrest; Torsades

47
Q

have high levels of histamine H1 receptor antagonism and can be highly sedating

A

Chlorpromazine and thioridazone

48
Q

APDs & seizures

A
  • Typical & atypical reduce the seizure threshold
  • not a/w new onset seizures
  • highest risk with clozapine
49
Q

Neuroleptic malignant syndrome (NMS)

A
  • life-threatening emergency
  • a/w antipsychotics
  • esp haloperidol and fluphenazine
  • mental status changes, rigidity, fever, and dysautonomia
50
Q

The most important risk factor for NMS

A

prior history of NMS

51
Q

NMS Treatment

A
  • stop the APD
  • supportive therapy
  • severe cases: dantrolene, bromocriptine, amantadine, benzos
52
Q

Differential diagnosis of NMS, serotonin syndrome, MH, cholinergic crisis

A

NMS: chorea, akinesia, opisthotonos, trismus, blepharospasm, and oculogyric crisis

SS: myoclonus, mydriasis, hyperreflexia, hyperactive bowel sounds, agitation, and hypervigilance, delirium

MH: ↑CO2, tachypnea

CC: diarrhea, GI cramps, emesis, miosis, weakness, ataxia, slurred speech

Chorea: involuntary, unpredictable movements

53
Q

Lithium TW

A

0.6–1.2 mmol/L
> 1.5 = toxicity

confusion, sedation, muscle weakness, tremors, and slurred speech

54
Q

Drugs that can prolong Lithium

A
  • NSAIDs can increase levels 10–25%
  • thiazide diuretics reduce renal clearance

Pathopharm Exam 3 (18 decks)

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