Pharm Flashcards
1
Q
Lorazepam
Clonazepam - *most common treatment of REM behavior disorder
Oxazepam
Diazepam
A
Acute Anxiety Benzos
• GABAergic in that they potentiate the actions of the inhibitory neurotransmitter GABA
• Bind to GABAA receptors in CNS neuronal synapses, thereby facilitating GABA-mediated Cl- ion channel opening and enhancing membrane hyperpolarization.
• Anxiolytic doses result in CNS depression that is manifested by a calming effect with concomitant reduction of anxiety.
• 1st-line agents for rapid relief of acute anxiety states in generalized anxiety disorder (GAD) or panic disorder.
• Should be used for short periods, no longer than 2-4 weeks.
2
Q
Midazolam
A
acute anxiolytic benzo
• Midazolam is labeled for sedation prior to medical or surgical procedures.
Benzo: refer to other slides
3
Q
Adverse effects of Benzos
A
- Risk of dependence (schedule IV controlled substances).
• Taper slowly (over weeks) to avoid precipitation of withdrawal symptoms.
• Additive effects with ethanol, anticholinergics, and antihistamines. - abrupt cessation can lead to withdrawal states
ManifestationsofCNS depressant effects:
Drowsiness
Impaired judgement
Diminished motor skills
Anterograde amnesia
Lethargy
Confusional states in the elderly (slower metabolism)
4
Q
Clorazepate
A
Benzo acute anxiolytic
- GABAergic in that they potentiate the actions of the inhibitory neurotransmitter GABA
• Bind to GABAA receptors in CNS neuronal synapses, thereby facilitating GABA-mediated Cl- ion channel opening and enhancing membrane hyperpolarization. - Anxiolytic doses result in CNS depression that is manifested by a calming effect with concomitant reduction of anxiety.
• 1st-line agents for rapid relief of acute anxiety states in generalized anxiety disorder (GAD) or panic disorder.
• Should be used for short periods, no longer than 2-4 weeks.
5
Q
Alprazolam
A
aka Xanax - acute anxiety benzo
- GABAergic in that they potentiate the actions of the inhibitory neurotransmitter GABA
• Bind to GABAA receptors in CNS neuronal synapses, thereby facilitating GABA-mediated Cl- ion channel opening and enhancing membrane hyperpolarization. - Anxiolytic doses result in CNS depression that is manifested by a calming effect with concomitant reduction of anxiety.
• 1st-line agents for rapid relief of acute anxiety states in generalized anxiety disorder (GAD) or panic disorder.
• Should be used for short periods, no longer than 2-4 weeks.
6
Q
Escitalopram
A
Lexapro
SSRI
Clinical uses: major depression, anxiety disorder, OCD, PTSD, PMDD, bulimia
Mechanism of action for anti-anxiety is unclear.
• Implicated in the modulation of receptor activation of neuronal signal transduction pathways connected to serotonin, dopamine, and norepinephrine.
• Theorized to activate stress-adapting pathways.
- Reduce somatic anxiety symptoms and the general distress associated with those symptoms.
- 1st-line agents for the chronic management of GAD, particularly with comorbid depression.
• Anti-anxiety response requires 2 to 4 weeks or longer.
• Assessment of initial response should be after 4 to 6 weeks of therapy at adequate doses.
7
Q
Adverse effects of SSRIs and SNRIs
A
First Aid:
SNRI: increase BP, stimulant effects, sedation, nausea
SSRI: fewer than TCA’s. GI distress, SIADH, sexual dysfunction (anorgasmia, decreased libido)
Most common adverse effects include:
Diarrhea
Nausea and vomiting
Sexual dysfunction
Insomnia
Weight gain
Headache
Diaphoresis
seizures with gross overdose
The
diaphoresis are often transient, whereas weight gain and sexual dysfunction may continue in long-term treatment.
• Discontinuation rates secondary to side effects tend to be higher with the SNRIs than the SSRIs.
8
Q
Paroxetine
A
SSRI
Clinical uses: major depression, anxiety disorder, OCD, PTSD, PMDD, bulimia
*potent inhibitor of CYP2D6
Mechanism of action for anti-anxiety is unclear.
• Implicated in the modulation of receptor activation of neuronal signal transduction pathways connected to serotonin, dopamine, and norepinephrine.
• Theorized to activate stress-adapting pathways.
- Reduce somatic anxiety symptoms and the general distress associated with those symptoms.
- 1st-line agents for the chronic management of GAD, particularly with comorbid depression.
• Anti-anxiety response requires 2 to 4 weeks or longer.
• Assessment of initial response should be after 4 to 6 weeks of therapy at adequate doses.
9
Q
Sertraline
A
aka Zoloft
SSRI
Clinical uses: major depression, anxiety disorder, OCD, PTSD, PMDD, bulimia
Mechanism of action for anti-anxiety is unclear.
• Implicated in the modulation of receptor activation of neuronal signal transduction pathways connected to serotonin, dopamine, and norepinephrine.
• Theorized to activate stress-adapting pathways.
- Reduce somatic anxiety symptoms and the general distress associated with those symptoms.
- 1st-line agents for the chronic management of GAD, particularly with comorbid depression.
• Anti-anxiety response requires 2 to 4 weeks or longer.
• Assessment of initial response should be after 4 to 6 weeks of therapy at adequate doses.
10
Q
Duloxetine
A
aka Cymbalta
SNRI Uses: major depression chronic pain fibromyalgia menopausal symptoms
Mechanism of action for anti-anxiety is unclear.
• Implicated in the modulation of receptor activation of neuronal signal transduction pathways connected to serotonin, dopamine, and norepinephrine.
• Theorized to activate stress-adapting pathways.
- Reduce somatic anxiety symptoms and the general distress associated with those symptoms.
- 1st-line agents for the chronic management of GAD, particularly with comorbid depression.
• Anti-anxiety response requires 2 to 4 weeks or longer.
• Assessment of initial response should be after 4 to 6 weeks of therapy at adequate doses.
11
Q
Venlafaxine XR
A
SNRI
*metabolized extensively via CYP2D6 - so inhibitors or inducers need to be considered
major depression
chronic pain
fibromyalgia
menopausal symptoms
Mechanism of action for anti-anxiety is unclear.
• Implicated in the modulation of receptor activation of neuronal signal transduction pathways connected to serotonin, dopamine, and norepinephrine.
• Theorized to activate stress-adapting pathways.
- Reduce somatic anxiety symptoms and the general distress associated with those symptoms.
- 1st-line agents for the chronic management of GAD, particularly with comorbid depression.
• Anti-anxiety response requires 2 to 4 weeks or longer.
• Assessment of initial response should be after 4 to 6 weeks of therapy at adequate doses.
12
Q
Buspirone
A
First AID: GAD, does not cause sedation, addiction or tolerance. Does not interact with alcohol as opposed to barbituates and benzodiazepines.
It does not interact with GABAergic systems.
• Mechanism uncertain.
Partial agonist at 5- HT1A receptors
Also has affinity for dopamine D2
receptors.
Selective anxiolytic without causing marked sedative, hypnotic, or euphoric effects.
2nd-line agent for the chronic management of GAD.
• Classified as 2nd-line due to inconsistent reports of long-term efficacy and lack of suitability for comorbid disorders (e.g., panic disorder or depression).
• Anxiolytic effects take 2 weeks or longer to become established.
13
Q
Adverse effects Buspirone
A
Most common adverse effects are typically transient, and include:
Nausea
Abdominal pain
Drowsiness
Dizziness
• Interacts with inducers and inhibitors of CYP3A4 as well as monoamine oxidase (MAO) inhibitors.
14
Q
Pregabalin
A
aka Lyrica
GABAergic agent that does not interact with the GABAA receptor.
• Thought to potentiate GABA activity in two ways:
1. Increasing presynaptic GABA release by binding to the alpha2delta subunit of voltage- gated calcium channels and altering calcium influx.
2. Increasing GABA biosynthesis by modulating the actions glutamate decarboxylase and branched chain aminotransferase.
Produces anxiolytic effects similar to the benzodiazepines and antidepressants.
2nd-line agent for the chronic management of GAD.
• Not currently approved as a 1st-line agent for GAD in the US, due to a lack of sufficient clinical experience.
15
Q
Adverse effects Pregabalin
A
Most common adverse effects include:
Dizziness
Somnolence
Incoordination
Dry mouth
Blurred vision
Weight gain
• More idiosyncratic adverse effects include:
Peripheral edema Thrombocytopenia
• Lower risk of dependence than the benzodiazepines (schedule V controlled substance) but you can still get withdrawal symptoms with abrupt discontinuation
16
Q
Imipramine
A
TCA (acts like an SNRI) Uses: major depression, chronic pain, OCD
inhibit NE and 5 HT reuptake, more selective for 5HT!
Produces anxiolytic effects similar to the newer antidepressants.
2nd-line agent for the chronic management of GAD.
• Classified as 2nd-line due to higher toxicity and adverse effect rates than the newer antidepressants.
17
Q
Adverse effects imipramine
A
Adverse effects are related to blockade of histamine, muscarinic/cholinergic, and alpha -adrenergic receptors.
• Antihistamine effects include:
Sedation
Somnolence
• Anticholinergic (muscarinic block) effects
include:
Dry mouth
Constipation
Blurred/double vision
Tachycardia
• Antiadrenergic effects include:
Orthostatic hypotension
• Risk of serious toxicity (including seizures, tachycardia, and cardiac arrest) with high doses.
First AID: TriC’s: Convulsions, Coma, Cardiotoxicity (arrhytmia)
18
Q
Hydroxyzine
A
potent H1 antihistamine that also acts as a strong antagonist at 5-HT2a receptors.
• Antiserotonergic activity is thought to underlie its anxiolytic properties.
Produces anxiolytic effects similar to buspirone and the benzodiazepines.
Alternative agent for the treatment of GAD.
• Although commonly used in the primary care setting, it is considered an alternative agent due to adverse effects and lack of efficacy for comorbid disorders.
• Used as a sedative prior to dental procedures.
19
Q
Adverse effects Hydroxyzine
A
Adverse effects are related to blockade of histamine, muscarinic/cholinergic, and dopamine receptors.
• Antihistamine effects include:
Sedation
Somnolence
- Anticholinergic effects
include:
Dry mouth
Constipation
Blurred/double vision - Antidopaminergic effects include:
Extrapyramidal symptoms (dyskinesias and tremors) - Overdose can result in hallucinations and cardiac effects (QT prolongation and Torsades des Pointes).
20
Q
Quetiapine XR
A
Atypical antipsychotic
Antagonist activity at 5-HT2a receptors is thought to underlie its anxiolytic properties.
• Produces anxiolytic effects similar to the newer antidepressants, but with an earlier onset of action.
• Alternative agent for the treatment of GAD.
• It is considered an alternative agent due to adverse effects and insufficient clinical experience with regard to long-term risks and benefits.
21
Q
Quetiapine XR adverse effects
A
Adverse effects are related to blockade of alpha-adrenergic, muscarinic/cholinergic, and dopamine receptors.
• Antiadrenergic effects include:
Orthostatic hypotension
• Anticholinergic effects
include:
Dry mouth
Constipation
Tachycardia
• Antidopaminergic effects include:
Extrapyramidal symptoms (tardive dyskinesia and akathisia)
22
Q
Adverse effects of Quetiapine XR
A
Adverse effects are related to blockade of -adrenergic, muscarinic/cholinergic, and dopamine receptors.
• Antiadrenergic effects include:
Orthostatic hypotension
• Anticholinergic effects
include:
Dry mouth
Constipation
Tachycardia
• Antidopaminergic effects include:
Extrapyramidal symptoms (tardive dyskinesia and akathisia)
23
Q
Estazolam
A
Decrease sleep latency (time to fall asleep) and the number of awakenings.
• Increase total sleep time.
Sleep disorders characterized by difficulty in falling asleep.
• Hypnotic doses are higher than those used for anxiolytic applications.
• Should be used at the lowest possible dose for the shortest possible time period.
• Typically maintain hypnotic efficacy for 1 month, but tolerance can develop with time.
24
Q
Quazepam
A
Sleep Benzo
Decrease sleep latency (time to fall asleep) and the number of awakenings.
• Increase total sleep time.
Sleep disorders characterized by difficulty in falling asleep.
• Hypnotic doses are higher than those used for anxiolytic applications.
• Should be used at the lowest possible dose for the shortest possible time period.
• Typically maintain hypnotic efficacy for 1 month, but tolerance can develop with time.
25
```
Adverse effects of 'Estazolam
Flurazepam
Quazepam
Temazepam
Triazolam
```
ManifestationsofCNS depressant effects:
Daytime sedation
Psychomotor
incoordination
Cognitive deficits
Anterograde amnesia
• Risk of dependence(schedule IV controlled substances).
• After prolonged use, abrupt cessation can result in withdrawal symptoms, with associated rebound insomnia.
• Additive effects with ethanol and other CNS depressants.
26
Zolpidem (Ambien) Zaleplon (Sonata) Eszopiclone (Lunesta
Similar GABAergic mechanism to the benzodiazepines.
• More selective than the benzodiazepines with regard to the specific GABAA receptor isoform they bind.
All decrease time to persistent sleep.
• Zolpidem and eszopiclone increase total sleep time, while zaleplon does not.
• Reduced potential for amnesic effects and day-after psychomotor depression relative to the benzodiazepine hypnotics.
Sleep disorders characterized by difficulty in falling asleep.
• Should be used at the lowest possible dose for the shortest possible time period.
27
Adverse effects of Z drugs
Adverse effects are dose related and can include:
Somnolence
Dizziness
Headache
GI upset
Muscle pain
• Risk of dependence(schedule
IV controlled substances).
• After prolonged use, abrupt cessation can result in withdrawal symptoms and rebound insomnia, though typically of less intensity than those associated with the benzodiazepine hypnotics.
28
Ramelteon (Rozerem) Tasimelteon (Hetlioz)
Agonists at MT1 and MT2 receptors in the brain.
• No GABAergic activity.
Decrease sleep latency and increase sleep periods, with no rebound insomnia or risk of dependence.
Ramelteon is approved for sleep disorders characterized by difficulty in falling asleep.
• Tasimelteon is approved for non-24 hour sleep- wake disorder.
29
Side effects of Melatonin Receptor agonists
Ramelteon, Tasimelteon
Most common adverse effects of ramelteon include:
Somnolence
Dizziness
Fatigue
Endocrine changes
(↓testosterone and ↑prolactin)
• Most common adverse effects of tasimelteon include:
Drowsiness
Headache
Abnormal dreams or
nightmares
Urinary tract infection
30
Suvorexant
Antagonist at OX1 and OX2 receptors in the brain.
• No GABAergic activity.
Decreases sleep latency and increases sleep periods.
Sleep disorders characterized by difficulty in falling asleep.
31
Adverse effects of Suvorexant
Most common adverse effects include:
Day-after somnolence Dizziness
Headache
• Can cause “sleep-driving” behavior and amnesic effects.
• Risk of dependence (schedule IV controlled substance).
32
Flumazenil
GABAa receptor antagonist
Acts as a competitive antagonist at the benzodiazepine binding site on the GABAA receptor.
• Antagonizes the CNS depressant effects of benzodiazepines and the non- benzodiazepine GABAergic hypnotics (zolpidem, zaleplon, and eszopiclone).
It is approved for use in reversing the CNS depressant effects of benzodiazepine overdose.
• Hastens recovery after benzodiazepine use in medical procedures.
• Typically requires repeated administration, due to its shorter half- life (0.7 to 1.3 hours) relative to the benzodiazepines.
33
Adverse effects of Flumazenil
Agitation and confusion.
• Potential for precipitating withdrawal symptoms in cases of drug dependence.w
which is why it is controversial
34
Reserpine
a compound that was found to induce depression and its MOA was used to model depression
Reserpine inhibits VMAT on vesicles which prevents NT from concentrating in the presynaptic neuron. Little or no NT is released
35
Fluoxetine
aka Prozac
SSRI
Clinical uses: major depression, anxiety disorder, OCD, PTSD, PMDD, bulimia
Inhibit 5-HT reuptake
selectively as compared to NE
reuptake
* *metabolite of fluoxetine - norfluoxetine has a half life of 7 to 9 days, be wary when transition to MAOI
* potent inhibitor of 2D6.
```
• Relatively selective for
5-HT transporter, thus
side effects limited to
effects on 5-HT-
mediated responses
__________________________
-also used as treatment for ADHD
```
-also used in treatment of BULIMIA- regardless if patient has depression, it is the only FDA approved medication
36
fluvoxamine
SSRI
Clinical uses: major depression, anxiety disorder, OCD, PTSD, PMDD, bulimia
**Potent inhibitor of CYP3A4
Inhibit 5-HT reuptake
selectively as compared to NE
reuptake
```
• Relatively selective for
5-HT transporter, thus
side effects limited to
effects on 5-HT-
mediated responses
```
37
Citalopram
SSRI
Clinical uses: major depression, anxiety disorder, OCD, PTSD, PMDD, bulimia
Inhibit 5-HT reuptake
selectively as compared to NE
reuptake
```
• Relatively selective for
5-HT transporter, thus
side effects limited to
effects on 5-HT-
mediated responses
```
38
Adverse effects of SNRIs
- nausea
- headache
- anxiety
- agitation
- insomnia
- sexual dysfunction
- extrapyramidal effects (early in treatment)
- seizures with gross overdose
- serotonin syndrome with MAOI
* anticholinergic
* sedation
* hypertension (venlafaxine)
39
Amitriptyline
TCA (acts like an SNRI) Uses: major depression, chronic pain, OCD
Inhibit reuptake
transporters for both
NE and 5-HT (like SNRIs)
• Tend to interact with
variety of other receptors, therefore
broad range of side effects
40
Clomipramine
TCA (acts like an SNRI) Uses: major depression, chronic pain, OCD
Inhibit reuptake
transporters for both
NE and 5-HT (like SNRIs)
• Tend to interact with
variety of other receptors, therefore
broad range of side effects
41
Desipramine
TCA (acts like an SNRI) Uses: major depression, chronic pain, OCD
Inhibit reuptake
transporters for both
NE and 5-HT (like SNRIs)
• Tend to interact with
variety of other receptors, therefore
broad range of side effects
*metabolite of imipramine, however favors NE > 5HT
42
Nortriptyline
TCA (acts like an SNRI) Uses: major depression, chronic pain, OCD
43
Phenelzine
MAOI
treats major depression unresponsive to other drugs
Inhibit monoamine oxidase (MAO) - degradation of catecholamines
• phenelzine combines irreversibly
with MAO to provide long-lasting
inhibition
44
Tranylcypromine
MAOI
treats major depression unresponsive to other drugs
Inhibit monoamine oxidase (MAO) - degradation of catecholamines
• tranylcypromine does NOT bind irreversibly but still has prolonged effect
45
Adverse effects of Monoamine inhibitos
hypertensive reactions in response to indirectly acting sympathomimetics
- hyperthermia
- CNS stimulation (agitation, convulsions)
- hypertensive crisis with tyramine
- containing foods serotonin syndrome with SSRI
- orthostatic hypotension
46
Nefazodine (include adverse effects)
5-HT2 antagonist
- used only to treat major depression
* block box warning due to hepatotoxicity
Adverse effects:
sedation, alpha block (orthostatic hypotension)
47
trazodone (include adverse effects)
prodrug converted to 5HT2A antagonist
used not only for major depression but also as a hypnotic.
Adverse effects:
sedation, alpha block (orthostatic hypotension)
48
Bupropion
Heterocyclic used for major depression and *smoking cessation
Unknown mechansim of action, just know it enhances NE and DA transmission. (DA and NE reuptake inhibitors)
Lowers seizure threshold
________________
+also used as treatment for ADHD
49
Mirtazapine +adverse effect
Heterocyclic used for major depression and **sedation
It blocks alpha2 adrenergic receptor (5HT2A/2C) & (5HT3) which inhibits NE and 5HT release, so this drug disinhibits
Adverse effect
-also sedation
50
What are the pharmacokinetics of antidepressant agents
In general most
- have rapid oral absorption
- reach peak plasma concentration in 2-3 days
- have half life on order of .5 to a day
- metabolized by liver
- eliminated by kidney
51
Symptoms of serotonergic syndrome
Can occur with any drug that increase 5-HT (eg, MAOIs, SSRIs, SNRIs, TCAs, tramadol, ondansetron,
triptans, linezolid, MDMA, dextromethorphan).
Characterized by 3 A’s: neuromuscular hyperActivity
- clonus,
- hyperrelexia,
- hypertonia,
- tremor,
- seizure)
Autonomic stimulation
- hyperthermia
- diaphoresis
- diarrhea),
and Agitation.
Treatment: cyproheptadine (5-HT2 receptor antagonist).
52
Overdoses of
```
TCA's
MAOis
SSRis
Bupropion
Mirtazapine
```
TCAs - extremely dangerous, prescribed on "no refill" basis
MAOis - intoxication rare, requires supportive treatment
SSRIs - OD fatalities rare, intoxication requires supportive treatment
Bupropion - seizures
Mirtazapine - disorientation, tachycardia
53
Lithium
LiTHIUM
Low Thyroid
Heart
Insipidus
Unwanted Movements
Mechanism:
Not established; possibly related to inhibition of
phosphoinositol cascade.
Mood stabilizer for bipolar disorder; blocks relapse and acute manic events.
```
Adverse effects:_________________
-Tremor,
-hypothyroidism,
-polyuria (causes
nephrogenic diabetes insipidus), -teratogenesis.
```
Causes Ebstein anomaly in newborn if taken by pregnant mother. Narrow therapeutic window requires close monitoring of serum levels. Almost exclusively excreted by kidneys; most is reabsorbed at PCT with Na+.
Thiazides (and other nephrotoxic agents) are implicated in lithium toxicity.
Diuretics decrease renal clearance by 25%
-some NSAIDs decrease clearance by increasing Lithium reabsorption in proximal tubules
54
What are advantages to benzodiazepines
1. rapid onset of action
2. Relatively high TI and there is available treatment for overdose
3. Low risk of drug interactions based on liver enzymes (no drug drug interaction)
4. Minimal effects on cardiovascular and autonomics
55
Describe serotonin synthesis and catabolism
Serotonergic neuron takes in Tryptophan
Tryptophan (tryptophan hydroxylase) > 5-HTP > (5 -hydroxytryptophan decarboxylase) > serotonin aka 5-HT > (monoamine oxidase) > 5-HIAA
56
Describe norepinephrine synthesis and catabolism
Tyrosine is taken in by noradrenergic neuron
Tyrosine > (tyrosine hydroxylase) >
DOPA > (aromatic L-amino acid decarboxylase)
> DOPAMINE > (dopamine beta hydroxylase)
> NOREPINEPHRINE > (Phenylethanolamine N-methyltransferase)
> EPINEPHRINE
57
Ketamine (antidepressant)
used for treatment resistant depression - NMDA receptors but increases AMPA (GluR1) receptor levels has strong antidepressant effects
Single low dose:
• 63 % of SSRI treatment resistant patients respond to ketamine treatment
• works within 2 hours of IV infusion
• therapeutic response persists for two weeks
58
Histone deacetylase inhibitors
Stress increases histone and DNA methylation causing reduced transcription of genes involved in antidepressant effects (i.e. increases likelihood of depression).
Histone acetylation promotes transcription so histone deacetylase (HDAC) inhibitors act as antidepressants.
59
PCP
"hallucinogen"
- dissociative anesthetic
- long half life: 24 hours
- taken orally, IV, smoking, snorted
- PCP intoxication: psychosis resembling schizophrenia (paranoid, agitated, hallucinating)
- marked neurological signs: vertical nystagmus, ataxia
- profound autonomic effects (rapidly changing blood pressure, pulse)
- NMDA receptor/glutamate (which people found was linked to schizophrenia so it helped understand it.
60
Cocaine intoxication
hyperalertness, restlessness/pacing, talkative/pressured speech, aggression or elation, impulsivity, chest pain, other ischemia because cocaine is a potent vasoconstrictor
61
Cocaine
Pharmacokinetics:
Distribution & Metabolism
Rapidly crosses BBB
Rapid enzymatic breakdown; plasma (half life - 1 hr)
freely crosses placenta
Mixing uppers and downers: cocaine + alcohol = cocaethylene (neurotoxic); cocaine + heroin = speedballing (intense euphoria)
speed of onset is very fast (10 secs)
Duration of effects is short 2-4 hrs...
IV has the highest Cmax (highest concentration in plasma)
No cocaine specific treatment, no detoxification needed, withdrawal is not life threatening
Used on rare occasions during sinus surgery used as a local anesthetic.
Powerful CNS stimulant
Topical anesthetic (like lidocaine, novocaine, etc.)
Inhibits reuptake of DA, NE and serotonin (5-HT)
Produces euphoria, ↑ sympathetic drive ↑ energy and alertness,
tachycardia, vasoconstriction, ↑ bp, and restlessness, mydriasis,
hyperthermia
After effects: depression, fatigue, drowsiness
Can cause cardiac dysrhythmias, MI, seizures, stroke and death
High-dose, chronic use can cause toxic paranoid psychosis, aggressive homicidal behavior
Not physically addictive but causes psychological dependence
ڏCrack cocaine "free base" highly addictive after first dose
62
Cocaine withdrawal
agitation and restless behavior, depressed mood, fatigue, generalized malaise, increased appetite, vivid and unpleasant dreams, slowing of activity, craving
63
D-methamphetamine
Approved uses of amphetamines: ADHD, narcolepsy, weight reduction
Methamphetamine is called the poor man’s cocaine
↑ DA, NE and 5-HT neurotransmitters
Fast CNS penetration
Produces immediate stimulation, euphoria
So, higher potential for addiction and abuse
Effects are dose related; tolerance develops
Low doses cause mental alertness, wakefulness and increased energy
High doses can cause psychoses and oral damage aka "meth mouth"
Like cocaine, meth crosses the placenta (found in breast milk)
_____________________________________
"meth", "speed", "chalk".
the hydrochloride formulation can be smoked (ice, crystal, glass, tina)
Schedule II stimulant which is used for treating narcolepsy, ADHD.
Can be taken orally, snorted, injection or smoking
Mainly a problem in West coast
It is one of the highest release of dopamine, they will change brain structure (destruction), severe structural and functional changes in areas of the brain associated with emotion and memory. Reduced motor speed and impaired verbal learning. Damages dopaminergic and serotonin neurons.
8-24 hours, you get super stimulated, increased wakefulness, physical activity, respiration, heart rate, blood pressure, ireggular heartbeat and hyperthermia, decrease appetite
Long term use leads to paranoia, aggressivness, extreme anorexia, memory loss, visual and auditory hallcuinations, delusions and severe dental problems
64
Adverse effects of meth
sympathomimetic
-irritability, anxiety, insomnia, confusion, tremors, convulsions, cardiovascular collapse/death
Long term: paranoia, aggressiveness, extreme anorexia, memory loss, visual and auditory hallucinations, delusions and severe DENTAL problems
65
Methylphenidate (ritalin) and Amphetamine (adderall)
used for ADHD, Narcolepsy
Methylphenidate: aka Ritalin - CNS stimulant, first line for ADHD treatment.
Blocking the reuptake of NE and Dopamine
Amphetamine will ADDITIONALLy, to blocking reuptake, also block entry of dopamine and NE into storage vesicles (VMAT) vesicular monoamine transporter so you have an abundance of norepinephrine and dopamine that doesn't get stored and just released. (also possibly reverses the direction of the transporter
BOTH are mild inhibitors of MAO thereby increasing levels of dopamine and norepineprhine _
66
Atomoxetine
Atomoxetine (NE reuptake inhibitor) is better suited to adults, due to 2+
week lag time before effects appear, children are not as patient
Non-stimulant so little to no abuse potential and rarely used on their own. Usually as adjuncts to CNS stimulants or when stimulants are not tolerable
67
Bupropion and Tricyclic Antidepressants
ADHD
DA and NE reuptake inhibitors)
Non-stimulant so little to no abuse potential and rarely used on their own. Usually as adjuncts to CNS stimulants or when stimulants are not tolerable
68
Guanfacine and clonidine
Non stimulant
( a2 adrenergic agonists): Stimulation of a2
adrenergic receptors in the prefrontal cortex enhances executive
functioning, attentiveness, and working memory
Non-stimulant so little to no abuse potential and rarely used on their own. Usually as adjuncts to CNS stimulants or when stimulants are not tolerable
69
Common adverse effects of CNS stimulants (methyphenidate, amphetamine)
AGI HRI
ADHD girls invest in radical hats
Reduced appetite, weight loss:
Give high-calorie meal when stimulant effects are low (at breakfast or at bedtime)
Stomach ache: Administer stimulant on a full stomach; lower dose if possible
Insomnia: Give dose earlier in the day; lower the last last dose; prescribe a sedative at bedtime (e.g., guanfacine, clonidine, melatonin)
Headache: Divide dose, give with food, or give an analgesic (e.g., acetaminophen or ibuprofen)
Rebound symptoms: Consider longer-acting stimulant
Irritability/jitteriness: Assess for comorbid condition (e.g., bipolar disorder); reduce dosage; consider mood stabilizer or atypical
70
Mechanism of action: Cocaine and aphetamine
Both stimulate the sympathetic nervous system.
• Amphetamine is a substrate for DAT, thereby inhibits DA reuptake.
• Amphetamine also blocks vesicular monoamine transporter (VMAT) storage, thereby increasing release of DA into synapse.
* Cocaine blocks DA, NE, and 5-HT reuptake transporters (DAT, NET, SERT), thereby ↑ neurotransmitter levels and activity in synapse
* Peripherally, their adrenergic (NE) effects activate the sympathetic fight or flight syndrome ;
71
Treatment of cocaine addiction and overdose
No antidote for overdose, and no approved treatment for addiction.
Symptoms: agitation, ↑BP, tachycardia, psychosis / hallucinations,
hyperthermia, MI, seizures, coma, death.
-hyperalertness, restlessness, talkative, aggression or elation, impulsivity, chest pain (vasoconstrictor)
Effects of withdrawal: apathy, anxiety/irritability, disorientation,
depression.
No detox needed and psychiatric counseling.
Psychosis: Treat with antipsychotics (haloperidol, chlopromazine).
Cardiac dysrhythmias: Treat with antidysrhythmics.
Anxiety/depression: Treat with anxiolytics/antidepressants.
Seizures, nausea, irritability: Treat with benzodiazepines: diazepam,
lorazepam (also relax muscles, induce sleep)
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Treatment of meth addiction/withdrawal
Treatment of Addiction:
Like cocaine, no antidote for overdose and no approved treatment for
addiction.
Best treatment of cocaine or meth addiction is prevention.
Next best treatment: Cognitive-behavioral therapy.
Vaccines and antibodies for cocaine and meth are under development.
_______________________________________
Treatment of Withdrawal:
Withdrawal effects similar to cocaine, but longer duration.
a1-adrenergic antagonists (prazosin) to relieve withdrawal symptoms.
Antipsychotics (chlorpromazine, haloperidol).
Anxiolytics (lorazepam, diazepam, etc.) for anxiety, seizures.
Antidepressants (fluoxetine, desipramine) for depression.
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Compare meth and cocaine
Cocaine and meth produce many similar acute and chronic effects:
mydriasis (pupil dilation), euphoria, grandiosity (consuming feeling of immortality and importance, excuding with confidence, talking loudly in public), paranoia, psychosis,
tachycardia, hyperthermia, hypertension, loss of appetite, insomnia.
Cocaine half-life: 1-2 hours
Meth half-life: 8-12 hours - meth effect is longer lasting
Cocaine paranoia: 4-8 hours following drug cessation
Meth paranoia: 7-14 days
Meth psychosis may require medication / hospitalization
and may be irreversible.
Overdosing can cause severe convulsions followed by cardiovascular
and respiratory collapse, coma and death.
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GHB (gamma hydroxybutyric acid)
MDMA
Bath salts
GHB - date rape drug, when mixed with alcohol they get reduction of resistance and unable to move, empathogenic, more willingness to become close to someone. People with social anxiety can take this and feel more secure
MDMA (ectasy) derivative of methaphetamine, used at raves, it is mixed with alcohol, empathogenic also at low doses, at higher doses can cause hallucinations and is dangerous
Bath salts - amphetamine like stimulant designer drug called cathiones that have appearance of salts -
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Methamphetamine
Approved uses of amphetamines: ADHD, narcolepsy, weight reduction
Methamphetamine is called the poor man’s cocaine
↑ DA, NE and 5-HT neurotransmitters
Fast CNS penetration
Produces immediate stimulation, euphoria
So, higher potential for addiction and abuse
Effects are dose related; tolerance develops
Low doses cause mental alertness, wakefulness and increased energy
High doses can cause psychoses and "meth mouth!" oral damage
Like cocaine, meth crosses the placenta (found in breast milk)
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There is no real evidence based pharm to treat autism however, what kinds of drugs can you give
- Atypical antipsychotic
- [Stimulants (comorbid ADHD)
- SSRIs: may help with anxiety
- Anticonvulsants
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Alcohol Intoxication
One (or more) of the following
Slurred speech • Incoordination • Unsteady gait • Memory or attention
impairment • Stupor or coma • Nystagmus
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Which drugs are in a standard urine drug screen
```
Cocaine
PCP
Cannabis
Opiate
Barbiturate
Amphetamine
```
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Alcohol withdrawal
```
Stage 1 (12-48 hrs)
Stage 2 (48 - 72 hrs)
Stage 3 (72-105 hrs)
Stage 4 (>7 days)
```
Chronic use of alcohol leads to decreased receptor sensitivity of GABA receptors, aka tolerance.
So during withdrawal, you have less GABA, and less sensitivity to GABA so...EXCITATION
2 or more after alcohol cessation
- insomnia
- flushing
- tremor
- nausea or vomiting
- physical agitation, anxiety
- sweating or rapid pulse
- hyperreflexia
- transient visual, tactile or auditory hallucinations or illusions
- grand mal seizures (first 48 hrs)
```
Stage 1 (12-48 hrs): peak severity, 90% of AW seizures, most cases are self limited.
Stage 2 (48 - 72 hrs): increase stage 1 symptoms
Stage 3 (72-105 hrs): delirium tremens (really severe)
Stage 4 (>7 days)
```
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Delerium Tremens
medical emergency! Found in stage 3 of alcohol withdrawal (72-105 hrs)
20% mortality if untreated
Autonomic instability, perceptual disturbances, hyperactivity to lethargy
5% of hospitalized population with AUD, preceded by seizure, 3-7 days
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Treatment of alcohol withdrawal
Benzodiazepine taper (4-6 days), all of them are effective, you will increase GABA receptor function, and decrease seizures, also anxiolytic so prefered
Anticonvulsants - Carbemazapine and Phenobarbital are also used.
Thiamine: (deficiency can be reversed)
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Oxycontin (other opiods include oxycodone and morphine)
-long acting oxycodone- it has delayed absorption which make it "abuse resistant" apparently. But patient crush, sniff and inject getting a powerful high greater than 8 hours.
They now have a more abuse deterrent forms making it harder to crush, break or dissolve and mix with nalaxone. Subsequently heroin use began to rise that year.
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Opiate intoxication/withdrawal
EVERYTHING GOES DOWN
- miosis
- constipation
- CNS depression (drowsy or comma)
- respiratory depression
- bradycardia
- slurred speech
- hypothermia
- hypotension
Opiate withdrawal is not life threatening, just irritating- EVERYTHING OPENS UP AGAIN .
Anxiety, yawning, diaphoresis, tearing, rhinorrhea, pupil dilation, piloerection/muscle twitching, nausea vomiting, diarrhea
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Opiate withdrawal treatment
methadone - only certain licensed facilities or Emergencies
Buprenorphine (early withdrawal) - partial agonist
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Buprenorphine
Suboxone
Subutex
partial mu agonsit with a ceiling, decreased risk
Long duration of action and self tapered
**Suboxone - buprenorphine with naloxone, further deter injection
Subutex - buprenorphine tablet without nalaxone .
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Fentanyl
Schedule 2 synthetic opioid
80-100 times stronger than morphine. It can be easily produced and sold for less. Even incorporated into low quality heroin. Fentanyl fatalities appear to be heroin ODs .
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Hallucinogens general overview (PCP, angel dust, LSD
changes in thoughts, perceptions and mood
- minimal sedation, no change in memory or intellectual function, hallucinations or illusions in clear consciousness
- there appears to be serotonergic action
**there is no abstinence syndrome and no withdrawal side effects so no detoxification needed, lethal overdose is rare, they can get a psychological dependence but there is no physiological dependence
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PCP
dissociative anesthetic, long half life of 24 hrs
-resutlt in psychosis resembling schizophrenia.
Marked neurological signs, vertical nystagmus and ataxia.
Profound autonomic effects, NMDA receptor/glutamate
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Chlorpromazine
..Typical - substantial risk of EPS, reduce positive but NOT negative symptoms
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Phenothiazine
..Typical - substantial risk of EPS, reduce positive but NOT negative symptoms v
* *EPS particularly, decrease the dose and administration of antimuscarinic agent.
- acute dystonic reactions are really painful so administer with diphenhydramine or muscarinic blocking agents
* **sedation
- strong autonomic effects (**) - alpha block and really high muscarinic block
- postural hypotension
- failure to ejaculate
- muscarinic blockade (not really)
- atropine like effects
- CNS: toxic, confusional state
- urinary retention
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Halopridol
..Typical - substantial risk of EPS, reduce positive but NOT negative symptoms
- the most potent/strongest D2 block
- weakest autonomic effects
* *MOST frequently EPS particularly, decrease the dose and administration of antimuscarinic agent.
- acute dystonic reactions are really painful so administer with diphenhydramine or muscarinic blocking agents
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Thioridazine
.Typical - substantial risk of EPS, reduce positive but NOT negative symptoms
- strongest autonomic effects - alpha block and really high muscarinic block
- postural hypotension
- failure to ejaculate
- muscarinic blockade (***)
- atropine like effects
- CNS: toxic, confusional state
- urinary retention
** the only antipsychotic with a metabolite (mesoridazine) which is more active than parent compound.
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Clozapine
.. atypical - reduced risk of EPS, treats the positive AND negative symptoms
- severe weight gain, hyperglycemia,
* **agranulocytosis - so only reserved for treatment resistant schizophrenia
Atypicals have higher 5-HT2 relative to D2 blockade activity as compared to typical agents
**NO EFFECT on D2, only blocks sertonin 5-HT2, and D4!
- most atypicals have intermediate autonomic effects
- metabolized by CYP3A4, CYP2D6
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Olanzapine
.. atypical - reduced risk of EPS, treats the positive AND negative symptoms
Atypicals have higher 5-HT2 relative to D2 blockade activity as compared to typical agents
-severe weight gain, hyperglycemia,
- most atypicals have intermediate autonomic effects
- metabolized by CYP2D6
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Quetiapine
.. atypical - reduced risk of EPS, treats the positive AND negative symptoms
QT interval prolongation
Atypicals have higher 5-HT2 relative to D2 blockade activity as compared to typical agents
-most atypicals have intermediate autonomic effects
- really short half life relatively, most others last for a day, this is 6 hrs
- metabolized by CYP3A4
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Risperidone
.. atypical - reduced risk of EPS, treats the positive AND negative symptoms . atypical - reduced risk of EPS, treats the positive AND negative symptoms
Atypicals have higher 5-HT2 relative to D2 blockade activity as compared to typical agents
-most atypicals have intermediate autonomic effects
metabolized by CYP3A4, CYP2D6
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Ziprasidone
.. atypical - reduced risk of EPS, treats the positive AND negative symptoms
- severe weight gain, hyperglycemia,
- QT interval prolongation
Atypicals have higher 5-HT2 relative to D2 blockade activity as compared to typical agents
- most atypicals have intermediate autonomic effects
- 7.5 hours half life, SHORT, metabolized by CYP3A4
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Aripiprazole
. atypical - reduced risk of EPS, treats the positive AND negative symptoms
-severe weight gain, hyperglycemia,
Atypicals have higher 5-HT2 relative to D2 blockade activity as compared to typical agents
***unique: partial agonist at D2
- most atypicals have intermediate autonomic effects
- metabolized by CYP3A4, CYP2D6
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Tardive dyskinesia
Side effect of antipsychotics - choreoathetoid movements of the muscle of the lips and buccal cavity and may be irreversible!
Develop after several years, have appeared as early as 6 months after drug intiation
To Treat: discontinue or reduce dose of current antipsychotic, eliminate all drugs with central anticholinergic action, add diazepam to enhance GABAergic activity
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Neuroleptic malignant syndrome.
- muscle rigidity
- excessive sweating
- exceptionally high fever
- autonomic instability which may be life threatening
* this is the most severe adverse effect of typical agents and is fatal in 10% of cases. Thought to arise in part from actions of DA on hypothalamus.
Treatment is dantrolene- the muscle relaxant that acts at the Ryr to restorye calcium levels in muscle cells and dopamine agonists (bromocriptine)
FA: mirror malignant hyperthermia: Mutations in voltage-sensitive ryanodine receptor
cause increase Ca2+ release from sarcoplasmic reticulum. Reuptake of the calcium leads to increased AMP expenditure leading to hyperthermia. Treatment: dantrolene (a ryanodine receptor antagonist).
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What are endocrine and metabolic side effects of antipsychotics
D2 blockade in pituitary
- hyperprolactinemia
- gynecomastia -development of breasts in males
- amenorrhea-galactorrhea syndrome
- infertility - too high prolactin
Metabolic
-severe weight gain, hyperglycemia,
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Doxepin
the only well studied H1 blocker, fda improved for insomnia
ITs the STRONGST most antihistaminic drug in existence .
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Identify clozapine’s unique
pharmacodynamic property and unique
toxicity
limitd D2 block, it has higher affinity for 5-HT2A and especially unique is D4!
Unique toxicity is risk of agranulocytosis
-it is effective but only reserved for treatment resistant schizophrenia
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Describe the pharmacodynamic properties of aripiprazole as a partial agonist
It is a partial AGONIST at D2 and 5HT1A with antagonist activity at 5HT2A
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What are Torsades?
specific form of polymorphic ventricular tachycardia in patients with a long QT interval. It is characterized by rapid, irregular QRS complexes, which appear to be twisting around the ECG baseline. This arrhythmia may cease spontaneously or degenerate into ventricular fibrillation.
-a toxic effect of antipsychotics
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When on antipsychotics what would indicate the need to switch to an agent with less antimuscarinic effects?
Urinary retention
- the agent with the strongest animuscarinic activity is thioridazine
- most atypicals only have intermediate autonomic effects
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Notable pharmacokinetics of antipsychotics
- readily absorbed when given orally, high first pass transformation
- lipid soluble, readily enters CNS
Metabolism is by P450s, glucuronidation, sulfation,
All of them are around a day half life bexpect for quetiapine and ziprasidone (coincidentally the two known for QT interval elongation)
All the atypicals are metabolized by CYPs 3A4 and 2D6 s
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What are cognitive enhancers for treating dementia
flowing Galantly DOwn the River
Galantamine, Donepazil, Rivastigmine, there are all acetylcholinesterase inhibitors
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How do you treat opiate withdrawal?
Methadone + Buprenorphine (partial agonist)
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After extended use of benzos, you can get withdrawal symptoms which are?
After extended use, abrupt cessation can precipitate withdrawal symptoms (characterized by states of increased anxiety, insomnia, and CNS excitability that may progress to convulsions).
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What is the MAO of Buspirone
Partial agonist at 5HT1A receptors
- some affinity for dopamine receptors
- no influence on GABA
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What is MAO of pregabalin?
Binds to voltage gated calcium channels and alters calcium influx thus increasing presynaptic release of GABA
- increases GABA biosynthesis
- mechanism is different from benzos which bind to GABA receptor.
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What unique set of symptoms do you look for with marijuana intoxication?
- increased appetite
- dry mouth
- paranoid delusions
- agitation, restless, anxious
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What is Hydroxyzine?
It is a potent H1 antihistamine + strong antagonist at 5HT2a (different from buspirone)
so possibly 5HT1a > 5HT2a
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What are adverse effects of hydroxyzine?
antihistamine, anticholinergic, and
antidopaminergic properties, and include somnolence, dry mouth, GI
disturbances, blurred/double vision, and dyskinesias (dopamine blockade).
besides the alphaadrenergic of TCA with addition of dopamine blockade.
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What functionally differentiates the non-benzodiazepine hypnotics (z drugs) from benzos?
They ALL lack anticonvulsant and muscle relaxing properties.
117
Describe the synthesis and catabolism of monoamines
Tryptophan > 5HTP (5-hydroxytryptophan) > Serotonin > (monoamine oxidase) > 5-HIAA
Tyrosine > DOPA > Dopamine > Norepinephrine > Epinephrine > MAOs
118
List all the SSRIs?
citalopram, escitalopram, paroxetine, setraline, fluoxetine, fluvoxamine
used to treat depression and anxiety disorders + *bulemia
119
What are the clinical uses of SNRIs (venlafaxine duloxetine)
anxiety,
major depression chronic pain
fibromyalgia
menopausal symptoms
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Imipramine vs desipramine
Imipramine selectively binds serotonin reuptake vs NE reuptake.
Desipramine favors NE reuptake.
121
How to treat OCD?
CBT, SSRis
and CLOMIPRAMINE! a TCA
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at are the MAOis and when are they used?
Tranny Phemales
Tranylcypromine
Phenelzine
they are used for treatment resistant depression
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Adverse effects of MAOis?
- they sensitize to indirectly acting sympathomimetics which will cause hypertension
- hyperthermia
- CNS stimulation (agitation, convulsions)
- hypertensive crisis with tyramine-containing foods
- serotonin syndrome with SSRI
- orthostatic hypotension
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Mirtazapine?
Its a heterocyclic
- blocks presynaptic alpha 2 autoreceptor in NE and SE neurons which will facilitate release
- antagonist at 5HT2A
besides major depression is used for sedation
125
Which antidepressant has a long half life, 7 to 9 days?
Fluoxetine
126
What is the antidepressant drug to know is metabolized by CYP2D6?
Venlafaxine
127
Which antidepressant inhibit CYP2D6
Paroxetine, Fluoxetine
128
What are the symptoms of serotonin syndrome?
Almost the same as alcohol cessation!
- tachycardia, agitation, tremor, hyperreflexia, vomiting/nausea, sweating
- ataxia, shivering, hypertension, fever
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What are the adverse effects of lithium and contraindications?
Tremor - propanolol or atenolol used to treat
- reversibly decreases thyroid function
- reversibly causes polydipsia and polyuria
- inhibits potassium entry into myocytes leading to abnormal repolarization, extracellular hyperkalemia, intracellular hypokalemia
- therefore it is contraindicated in patients with severe dehydration or sodium depletion.
- patients with cardiovascular disease
- patients with renal impairment (excreted entirely in urine, which is why its affected by diuretics. Also NSAIDs increase lithium reabsorption in the proximal tubules)
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Atomoxetine
non-stimulant used to treat ADHD, its a norepinephrine reuptake inhibitor
131
Guanfacine, Clonidine
Both are nonstimulants used to treat ADHD
they are alpha 2 adrenergic agonists - when stimulated enhances functioning, attentiveness and working memory.
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HIR SIR
common side effects of CNS stimulants
- headache
- insomnia
- Rebound symptoms
- stomach ache
- irritability
- reduced appetite
