Peds Psychopharm Flashcards
The hypothetical “essence” thought to cause human behavior
mind
What is the recurrent problem with mentalistic explanations of human behavior?
we cannot test hypotheses
What factors does good psychopharmacology depend on?
rapport with the patient and family good team functioning solid formulation and diagnosis treatment of other obvious factors proper use of safe and effective meds
A psychiatric evaluation includes a (blank) evaluation.
medical
Things included in a medical evaluation?
growth charts - height, weight
blood pressure, pulse
labs
Two exams performed by the psychiatrist?
CV exam
neuro exam
Most psychotropic medications are not (blank) for children and adolescents
FDA approved
Children and adolescents generally metabolize (blank) than adults
faster
Sometimes with children, you treat (blank) rather than actual disorders
symptoms
T/F: Polypharmacy is sometimes used, although definitely not the ideal.
True
using a medication that has not received FDA approval for the clinical indication
off label use
A new field of study in which genotyping guides treatment decisions.
Example: allelic variation in CYP 2D6 can affect how quickly some drugs are metabolized.
Faster metabolism – needs higher doses.
genomics
Poor drug metabolizers are at higher risk for (blank). Rapid metabolizers are at risk for (blank)
adverse effects; treatment failure (inaffective treatment)
Which drugs are metabolized by Cyto 2D6?
TCAs Prozac, paxil, trazodone, remeron Effexor, cymbalta Many antipsychotics Strattera, stimulants
Which drugs are metabolized by Cyto 2C19?
Xanax, valium, TCAs Clozaril Methadone Perphenazine Zoloft, Celexa, Lexapro, Prozac, effexor Thioridazine
Except in Asians, the (blank) serotonin transporter gene is associated with more favorable response to SSRIs
long form (esp with two copies)
What are some parental influences that come into play when prescribing drugs for kids?
parents buy into the notion of a quick fix
parents want to believe biology is to blame vs parenting styles
or
parents take too much responsibility for their child’s illness
There is a lack of safety and efficacy studies on psychotropic meds for children. Give two reasons why.
the brain continues to develop into early adulthood
impact of adding psychoactive meds to a developing brain remains unknown
Tetracyclines cause (blank) in kids
dental discoloration
SSRIs cause (blank) in children
suicidality
Aspirin causes (blank) in children
Reye’s syndrome
Cough suppressants can cause (blank) in children
pneumonia
Antiemetics can cause (blank) in children
dystonic and other movement disorders
FDA requires safety and efficacy studies for (blank) population only
target
**ex: only require studies for adults if the drug is intended to be used for adults
T/F: FDA guidelines do not limit which drugs you can prescribe
True
T/F: Research on children is complicated and costly and liability risk potential is higher
True
It is the job of the physician to educate and recommend drugs for children, but the parents are the informed consenters. If a parent refuses treatment, what should you do?
document the refusal
**this is just as important as informed consent
What are these?
Target symptoms Standard of care/ Evidence-based Least risk of serious side effects FDA approval Known previous responses of patient Known previous responses of family members Dosing schedule Clinician preference
Things to consider when selecting a medication
With meds in kids, start with a low dose and continue to raise the dose until…
satisfactory remission of symptoms
upper limit of dose reached
side effects make the dose intolerable
plateau in symptoms or symptoms get worse
When giving stimulants, what are some things you should monitor?
height/weight
pulse
blood pressure
tics
When giving anticonvulsants, what are some things you should monitor?
liver function
blood count
When giving antipsychotics and mood stabilizers, what are some things you should monitor?
fasting blood sugar
lipids
weight
abnormal movements
How often should children on maintenance medications be seen by their prescribing clinician?
at least once every 3 months
**Children in acute settings, displaying unsafe behavior, experiencing significant side-effects, or not responding to a medication trial or in an active phase of a medication trial should be seen more frequently.
Although we have limited information on the long-term effects of drugs on a child’s brain, what is one reason to initiate medical therapy in the kids anyway?
untreated diseases get worse as they progress –> disrupted development can have long term consequences as well
Most widely used anti-depressants in children
SSRIs
Problems with SSRIs in children?
mania EKG changes sleep problems serotonin syndrome sexual side effects weight gain
What are atypical antidepressants?
may work on multiple receptors
Ineffective in treating childhood depression
TCAs
**reports of sudden death
SSRIs may be administered (blank)
once daily
Side effects of SSRIs
GI effects headaches insomnia or sedation serotonin syndrome sexual dysfunction discontinuation syndrome mania
What are these?
Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban (buproprion) Effexor, Effexor XR (venlafaxine) Cymbalta (Duloxetine) Desyrel (trazadone) Remeron (mirtazapine)
atypical antidepressant
Side effects of Wellbutrin?
insomnia** increased risk for seizures (avoid in pts with seizure disorders and those w anorexia/bulimia) CNS stimulation headache constipation dry mouth nausea tremor
Side effects of Trazodone?
sedation **makes patients sleepy weight gain hypotension dry mouth priapism
Side effects of Effexor
hypertension** insomnia anxiety nausea sweating dizziness high incidence of discontinuation syndrome
Side effects of Remeron?
increased appetite
sedation
dry mouth
constipation
What are these?
Lithium Depakote (Valproic Acid) Lamotrigine Tegretol Trileptal
Mood stabilizers
Awkward side effect of many psychiatric meds
priapism
**can occur in females
Does Dr. Zelan prescribe Trazodone in men? Why?
he doesn’t, because the risks are uncertain and potentially harmful, patients/doctors are under-educated and embarrassed to discuss em, benefits are so-so; if you do, careful history taking is required!!!
What is one major clinical con for use of mood stabilizers?
following levels and evaluating for toxicity
useful for treatment of bipolar depression, major problem is length of titration and risk of SJ syndrome.
Lamictal
rather less effective mood stabilizer but doesn’t cause weight gain (actually loss of appetite in some) and don’t need levels.
Topamax
How is lithium excreted?
renally
What must be done if you administer lithium?
baseline labs, including a pregnancy test (can’t be used in prego women)
follow lithium levels
How long might lithium take to work?
~4-6 weeks
Side effects of lithium?
GI distress weight gain fuzzy thinking polyuria with polydipsia (always have to pee, always thirsty) hypothyroidism cardiovascular acne, rash, itching hematology
Two potentially life threatening side effects of lithium?
seratonin syndrome
neuroleptic malignant syndrome
Hyperkinetic neuromuscular findings of tremor or clonus and hyperreflexia should lead the clinician to consider the diagnosis of (blank)
serotonin syndrome
Meds that can cause serotonin syndrome in kids
anti-migraine meds pain meds illicit drugs herbal supps (St. John's wort) OCC cold meds anti-nausea meds linezolid ritonavir
How is neuroleptic malignant syndrome (NMS) different from serotonin syndrome?
serotonin syndrome: sudden onset (w/i 24 hours), agitation and diarrhea, dilated pupils, myoclonus, hyperreflexia
NMS seen more with antipsychotics and chronic schizophrenia: slower onset (w/i 7 days), dysphagia, hypersalivation, incontinence, hyperthermia, akinesia, extrapyramidal rigidity
How can lithium toxicity occur? What are the symptoms?
decreased fluids, increased fluid loss, decreased salt, drugs that act on renal system, too much lithium; GI (nausea, vom, diarrhea), coarse tremor, ataxia, slurred speech, confusion, arrythmias
Severe lithium toxicity occurs when levels exceed (blank)
2.5mEq/L
What are Depakote and Depakene (Valproic acid)?
mood stabilizers
Depakote and Depakene should be avoided in patients with (blank) because it is cleared by the (blank)
liver disease; liver
Do levels of Depakote and Depakene need to be monitored? When will therapeutic effect occur?
yes; check serum levels 7 days after first dose and then continue to monitor; terapeutic effect in 2-4 weeks
Side effects of Depakote and Depakene?
sedation
dizziness
nausea
vom
*hepatitis
pancreatitis
etc
Safer mood stabilizer for pregnancy, can cause rash
Lamictal (lamotrigine)
This mood stabilizer affects blood count
Tegretol (carbamazepine)
This mood stabilizer is better tolerated than Tegretol, but may not be as effective
Trileptal (oxcarbazepine)
This mood stabilizer is not used for bipolar disorder
Topamax (topirimate)
Alternatives to traditional mood stabilizers?
second generation antipsychotics
Can progress to toxic epidermal necrolysis – medical emergency, sometimes ICU level (resemble severe burns).
Fever and rash, especially involving mucous membranes.
Rash may be preceeded by flu like symptoms (fever, sore throat, fatigue, cough).
Rash can be painful and involving blisters.
Stevens-Johnson syndrome
Meds that can cause SJS?
anticonvulsants PCN ibuprofen, tylenol, naproxen allopurinol radiation therapy
In what disorders are antipsychotics OK for children?
childhood schizo childhood bipolar disorder ASD Tourette's disorder substance induced psychosis
What are some side effects of the second generation anti-psychotics?
GI effects headache sedation weight gain dry mouth
Second gen anti-psychotic that causes WEIGHT GAIN
Zyprexa, Zydis
We know that antipsych drugs can cause cardiovascular risk factors. What are some compounding risk factors that might precipitate cardiovascular disease?
females
Low K+, low Mg++
CV disease
prolonged QT syndrome
What are two psychostimulants?
ritalin
adderall
Alternative meds given for ADHD?
Strattera (atomaxatine)
Wellbutrin (buproprion)
**used to give Tenex and clonidine
What is one problem with anxiolytics?
fast acting anxiolytics may have a quick reinforcing effect, but then they wear off, which causes an emotional “roller coaster”
Most effective treatment for anxiety?
behavioral therapy
**can use benzos but they cause tolerance and increasing demand
What should be considered first in sleep disorders?
meds with low side effects like Benadryl or Atarax, can try remeron (a melotonin receptor agonist) or melatonin
Rank the following in terms of safety/efficacy:
antipsychotics
SSRIs
mood stabilizers
stimulants
stimulants > SSRIs > mood stabilizers > antipsychotics
T/F: MONOpharmacy is better than POLYpharmacy
True
T/F: Although FDA approval is not necessary for final word, it is important to pay attention to different categories
Duh
Always make sure to do this regardless of what you are prescribing
document!!!
