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1
Q

serotonin - disorders

A
  • decreased in depression, anxiety, insomnia, violent behavior, impulse control, suicide
  • increased in serotonin syndrome and tumors
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2
Q

NE - disorders

A
  • decreased in depression and ADHD

- increased in anxiety

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3
Q

dopamine - disorders

A
  • decreased in depression, parkinsons, ADHD, restless leg syndrome
  • increased in mania, psychosis
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4
Q

why does the clinical effect of SSRIs take so long?

A

takes a long time to regulate B1 and serotonin receptors

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5
Q

SSRI - uses

A

depression (sans fluvoxetine), anxiety disorders, eating disorders, PTSD, premature ejaculation, body dysmorphic disorder, OCD, trichotillomania

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6
Q

SSRI - off label uses

A

cluster B personality disorders, SAD, behavioral problems in dementia or mental retardation

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7
Q

SSRI not to be used in pregancy

A

Paxil (paroxetine)

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8
Q

SSRI most likely to induce mania

A

fluoxetine (Prozac)

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9
Q

Fluoxetine half life

A

long, 2-4 days, wait five weeks before starting MAOI

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10
Q

Fluoxetine SEs

A
  • may increase anxiety and insomnia initially

- CYP2D6 inhibition (inducer)

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11
Q

major SE of citalopram

A
  • long QTc interval, torsade with doses over 40mg/day
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12
Q

differences between citalopram and escitalopram

A

escitalopram is the S isomer, better for GAD, less likely to cause long QT.

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13
Q

fluvoxamine use…

A

OCD only

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14
Q

fluvoxamine SEs

A

GI distress, headaches, sedation, weakness

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15
Q

which SSRI has shortest half life?

A

fluvoxamine

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16
Q

SSRI half lives, short, medium, long

A

short: paroxetine, fluvoxamine, missed doses lead to withdrawal symptoms
medium: sertraline, citalopram, escitalopram
long: fluoxetine, good for people who may miss doses

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17
Q

what does SSRI discontinuation syndrome look like?

A
  • flu like symptoms, agitation, nausea, dysphoria
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18
Q

which SSRI causes the most weight gain?

A

paroxetine

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19
Q

common SSRI SEs

A

sexual, rash, apathy, insomnia, sedation, night sweats, nightmares, tremor, dry mouth, bruising

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20
Q

SSRI electrolyte effect

A

hyponatremia 2/2 to SIADH effect

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21
Q

what does serotonin syndrome look like?

A

common: abd pain, diarrhea, tremor, sweating, restlessness, fever, hyperreflexia, tachycardia, HTN
less common: disorientation, muscle rigidity, myoclonus
least common: death (10%)

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22
Q

SSRI to MAOI switch

A

wait 2 weeks except for fluoxetine which is 5 weeks.

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23
Q

order of 2D6 inhibition in SSRIs

A

fluvoxamine > paroxetine > fluoxetine > sertraline > citalopram > escitalopram

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24
Q

similarities and differences between SNRIs and TCAs

A
  • both work on serotonin and NE

- SNRIs cause fewer antihistamine, anti adrenergic, and anticholinergic SEs

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25
what are the two SNRIs?
venlafaxine and duloxetine
26
what neurotransmitters does bupropion work on?
NE and dopamine (NDRI)
27
where does mirtazapine work?
antagonist at a2, serotonin, and H1.
28
other use for SNRIs besides depression
chronic neuropathic pain, diabetic neuropathy (venlafaxine)
29
other use for bupropion besides depression
tobacco addiction
30
other use for mirtazapine and trazodone besides depression
insomnia
31
venlafaxine ups and downs
- good for geriatrics because fast renal clearance - fewer SEs than TCAs - short half life so can cause withdrawal symptoms - can cause significant nausea - 10-15mmHG increase in BP
32
duloxetine vs venlafaxine?
- duloxetine doesn't cause increase in BP, better for those with HTN
33
mirtazapine and dosage
- 30mg is the cut off between the H1, serotonin effects and the a2 effects - sedating under 30, activating NE effects over 30
34
trazadone - possible SE
priapism - painful erection that needs to be treated in ER
35
secondary vs tertiary TCAs
tertiary - imipramine, amitriptyline, doxepin, chlomipramine - more SEs than secondary, get metabolized to secondary secondary - nortriptyline, desipramine
36
what are three categories of SEs of TCAs? examples
anticholinergic - dry mouth - constipation - blurred vision - urinary retention - arrhythmias antiadrenergic - anti a1, orthostatic hypotension antihistaminergic - sedation - weight gain
37
serious TCA warnings
- 3 C's, convulsions, coma, cardiotoxic in overdose (don't give to suicidal patients) - can push undiagnosed BPAD into mania - can cause long QT even at therapeutic serum levels, so have to obtain EKGs
38
SE unique to MAOIs
acute hypertensive crisis, worsened by sympathomimetic stimulants such as cold remedies, tyramine containing foods
39
how does selegiline differ from other MAOIs?
- it is selective for MAO-B at low doses (parkinson) so diet is not an issue - at higher doses it acts as a typical MAOI - Emsam - patch for depression
40
where is lithium limited in affective disorders?
- less effective in rapidly cycling bipolar or in mixed states
41
labs for lithium
creatinine, TSH, CBC, pregnancy test (ebsteins anomaly)
42
lithium blood level goal
.8-1.2
43
lithium major SEs
- mild: polyuria/polydipsia 2/2 to nephrogenic DI - severe: coarse tremor, gait instability, vomiting, diarrhea, confusion, cognitive slowing, renal failure, seizures - hypothyroid - ebstein anomaly - risk factors: salt restriction, sweating, NSAIDs other than aspirin, diuretics, ACE/ARBs
44
valproic acid vs lithium uses
valproic acid better in rapid cycling states
45
valproic acid, other uses
migraines, seizures
46
valproic acid labs
LFT, pregnancy, CBC
47
valproic acid monitoring
steady state after 4-5 days, recheck labs | goal is 80-120
48
valproic acid SEs
- nausea, weight gain, sedation, unsteadiness, hair loss, tremor - liver dysfunction - thrombocytopenia - hyperammonemia - neural tube defects - acute pancreatitis (rare) - PCOS (rare)
49
carbamazepine labs
LFT, CBC, EKG
50
carbmazepine monitoring
- same as valproic acid, steady state in 4-5 days, recheck labs - 8-12
51
carbamazepine SEs
GI: nausea, constipation, decreased appetite, diarrhea CNS: sedation, dizziness, unsteadiness, confusion Derm: SJS birth: cleft palate, IUGR cardio: AV conduction delays heme: agranulocytosis/aplastic anemia SIADH
52
drugs that increase carbamazepine levels/toxicity
acetazolamide, cimetidine, clozapine, VPA, diltiazem, INH, fluvoxamine
53
drugs that decrease carbamazepine efficacy
neuroleptics, barbs, phenytoin, TCAs
54
lamotrigine best for.....
bipolar depression, bipolar maintenance therapy
55
lamotrigine SEs
- SJS/TEN titrate slowly | - aseptic meningitis
56
what increases/decreases lamotrigine levels?
- valproic acid increases | - carbamazepine decreases
57
four brain pathways:
mesocortical - ventral tegmentum to cortex, too little dopamine, negative symptoms mesolimbic - ventral tegmentum to limbic system, too much dopamine, positive symptoms nigrostriatal - substantia nigra to basal ganglia, smooth movement regulation, parkinsons tuberoinfundibular - hypothalamus to anterior pituitary, blocking dopamine causes hyperprolactinemia
58
mechanism of typical vs atypical antipsychotics
typical are dopamine antagonists, atypical are dopamine and serotonin antagonists
59
high potency vs low potency typical antipsychotics
high potency - bind D2 more tightly, cause more EPS low potency - bind D2 less tightly but also bind muscarinic receptors leading to cardio toxicity and anti-cholinergic effects
60
typical antipsychotics by potency
low: thioridazine, chlorpromazine (low EPS, high AC) medium: perphenazine, loxapine, molindone, thiothixene, trifluoperazine (high EPS, medium AC) high: haloperidol, fluphenazine, pimozide (high EPS, low AC)
61
EPS includes
- dystonia - parkinsonism (akinesia) - akathisia - tardive dyskinesia
62
EPS - acute dystonia, description and treatment
- sustained contraction of throat, tongue, neck, eyes - can be live threatening - starts within few minutes to an hour - treat with benztropine or benadryl
63
EPS - parkinsonism, description and treatment
- pill rolling, shuffling, masked facies, cog wheeling, muscle stiffness, drooling - beyond 1 week after starting med - treat with benxtropine or benadryl
64
EPS - akathisia, description and treatment
- restlessness, repeated movement, unable to sleep - generally in first weeks of treatment - treat with beta-blocker or benzo
65
EPS - TD, description and treatment
- usually irreversible spastic movements of face | - more than 6 months of use
66
NMS - cause, description, treatment
- usually high potency FGAs, but SGAs are possible - pipe-like rigidity, fever, tremor, altered consciousness - hypotension, tachycardia - rhabdomyolysis - mortality 10-20%
67
labs in NMS
high WBC and CK
68
AC side effects
- dry mouth - blurred vision - constipation - urinary retention - sedation - tachycardia - confusion - delirium - mydriasis - cycloplegia
69
hyperprolactinemia SEs
- amenorrhea, galactorrhea, gynecomastia, sexual dysfunction
70
general SEs of typical antipsychotics
- neutropenia - seizures - cardiac arrhythmias - hyperthermia - cataracts - priapism - metabolic syndrome (mostly SGA)
71
4 important inducers, what is their effect?
- smoking - carbamazepine - barbs - st. john's wort decrease blood concentration of other drugs
72
5 important inhibitors, what is their effect?
- fluvoxamine - fluoxetine - paroxetine - duloxetine - sertraline increase blood concentration of other drugs
73
which SSRI has a weekly dosing option?
fluoxetine
74
which SSRI causes the most GI SEs?
sertraline
75
which SSRI has the most drug interactions?
paroxetine
76
which SSRI is most likely to cause withdrawal symptoms?
paroxetine
77
which SSRI has the most anti-cholinergic effects?
paroxetine
78
symptoms of serotonin syndrome
- flushing - fever - diaphoresis - shivering - hypertension - hyperreflexia - delirium - tachycardia - "electric jolt" limb movements
79
how does trazodone work?
serotonin receptor antagonist
80
what are two tetracyclic antidepressants?
- amoxapine | - maprotiline
81
name 4 MAOIs
- selegiline - phenelzine - tranylcypromine - isocarboxazid
82
3 new expensive atypical antipsychotics
- paliperidone (invega) - metabolite of risperidone - asenapine - iloperidone
83
thioridazine can cause...
retinal pigmentation
84
toxic and lethal blood levels of lithium
toxic 1.5 | lethal 2.0
85
benzodiazepines by length of acting
long acting (>20 hours): diazepam, clonazepam medium acting (6-20 hours): alprazolam, lorazepam, oxazepam, temazopam short acting (
86
benzos not metabolized by the liver
- lorazepam - oxazepam - temazepam
87
how does buspirone work? when used?
- 5HT-1A partial partial agonist - in addition to SSRI for anxiety symptoms - good for alcoholics in place of benzo

psych rotation (2 decks)

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