Pharm Psych exam Flashcards
Olanzapine and fluoxetine
Symbax
Acute depressive episodes in bipolar 1.
Treatment resistant depression (TRD)
Box warning:
Increased mortality in elderly with dementia related psychosis, Suicidal thoughts and behaviors.
mirtazepine
(Remeron)
Antidepressant
Sedation and weight gain are two prominent side effects of this agent.
Dextroamphetamine, methamphetamine MOA
Methylphenidate and Dexmethylphenidate MOA =
Unknown but it does block reuptake and increase release of norepinephrine and dopamine extraneuronal space
Autistic disorder
lifelong disorder with few of these individuals living independently
Behavioral management techniques are used to reduce the rigid behaviors and improve social functioning
Neuroleptics are used to help decrease aggressive behaviors
Antipsychotics EPS
Extrapyramidal Symptoms=
Akathisia-subjective feeling of restlessness can be treated with a BZD like lorazepam (Ativan).
Parkinsonism such as shuffling gait, cogwheel rigidity=benztropine (Cogentin).
Acute dystonias=involuntary contractions of major muscle groups such as TD = Cogentin or Artane (trihexyphenidyl)
Trazodone
(Oleptro)
Predisposition to priapism;
Adverse Reactions:
Somnolence/sedation, dizziness, constipation, blurred vision, dry mouth, syncope, arrhythmias, hypotension,
MOA of SSRI’s
(SSRI’s block reabsorption of serotonin)
(SSRIs inhibit the serotonin reuptake pump and increase postsynaptic serotonin receptor occupancy. )
- Major route of removal of serotonin is to reuptake of
serotonin - inhibit reuptake of 5HT only
- Cause increase in availability of 5HT Locally
- Relieves depression
Enuresis Treatment
Desmopressin- synthetic antidiuretic hormone
Imipramine- (Tricyclic antidepressant)
Neurotransmitter:
Dopamine
Controls Complex movements, motivation, cognition, regulates emotional responses
Lithium labs
Lithium levels should be measured
Prior to beginning medication,
UA, BUN, Creatinine, Thyroid, Calcium, HCG and ECG for those over 40
BUN/Creatinine should be checked every 2-3 months for first 6 months and 6-12 months from then on.
Thyroid should be checked once or twice in first 6 months and every 6-12 months from then on.
buspirone
Buspar
The mechanism of action of buspirone is unknown.
Buspirone has a high affinity for serotonin 5-HT1Aand 5-HT2receptors, without affecting benzodiazepine-GABA receptors
Bulimia Nervosa
Normal body weight (or above normal body weight) is maintained
Treatment:
SSRIs (fluoxetine) (only FDA approved med)
TCAs
MAOIs
Individual psychotherapy, family therapy and group therapy
Russell’s sign (callous knuckles)
Cocaine Toxicity
Know Benzodiazepine (Valium) is best for agitation, Hypertension and Myocardial Ischemia
DO NOT GIVE BETA BLOCKERS such as Labetalol!!
REASON: There are theoretical concerns of coronary artery vasoconstriction and systemic hypertension, which can result from unopposed alpha-adrenergic stimulation
Personality disorders
Cluster B
Antisocial
Borderline
Histrionic
Narcissistic
Stimulants Cocaine
Cocaine—
The reinforcing properties of cocaine are mediated by its ability to block the dopamine transporter and increase dopaminergic activity in critical brain regions
SNRI’s
Drugs
desvenlafaxine (Pristiq)
duloxetine (Cymbalta)
venlafaxine (Effexor)
sodium oxybate
Xyrem
(Anti-narcoleptic) (CNS depressant) (MOA is unknown)
Cataplexy or excessive daytime sleepiness in patients ≥7yrs of age with narcolepsy.
Contraindications:
Concomitant sedative hypnotics or alcohol
Boxed Warning:
CNS depression. Abuse and misuse
Risk of CNS depression.
REMS Yes
MOA of SSRI’s
(SSRI’s block reabsorption of serotonin)
- Major route of removal of serotonin is to reuptake of
serotonin - inhibit reuptake of 5HT only
- Cause increase in availability of 5HT Locally
- Relieves depression
Suicide mnemonic
IS PATH WARM
I = ideas/threats about suicide communicated directly S = Substance abuse/excessive or increased P = purposelessness, giving up, no reason to live A = Anxiety/agitation/insomnia T = Trapped, no way out of tough situation H = Hopeless/nothin will ever change or get better W = withdrawing from friends/family/society A = Anger (uncontrolled, rage, seeking revenge R = Recklessness/risky/don't care behaviors M = Mood Changes (guilt/grief/ wish I was never born)
PMS managment
A number of approaches, including lifestyle measures (exercise and relaxation techniques), cognitive behavioral therapy, and medications (selective serotonin reuptake inhibitors [SSRIs]
Why are SSRI’s used as first line?
Selective serotonin reuptake inhibitors (SSRIs) are frequently used as first-line antidepressants because of their efficacy, tolerability, and general safety in overdose.
1st line Treatment for ADD / ADHD
Pharmacotherapy (1st line treatment)
Stimulants
Methylphenidate (ritalin)
Dextroamphetamine (Vyvanse)
Dextroamphetamine /amphetamine salts (Adderall)
greatest efficacy
contraindicated in known cardiac risk/ abnormalities
Drug holidays
Autistic disorder
Meds
Irritability- 2 second generation antipsychotics
risperidone (Risperdal)
aripiprazole (Abilify)
Hyperactivity/Impulsivity
Methylphenidate (Ritalin)
Repetitive Behaviors
Selective Serotonin Reuptake Inhibitors (SSRI)
risperidone (Risperdal)
valproate (Depakote)
valbenazine
Ingrezza
(Vesicular monoamine transporter 2 (VMAT2) inhibitor)
used for Tardive dyskinesia.
Warnings:
Somnolence. Avoid in congenital long QT syndrome or arrhythmias associated with a prolonged QT interval
Adverse Reactions:
Somnolence, anticholinergic effects, balance disorders/fall,
Vesicular monoamine transporter 2 (VMAT2) inhibitors,
Deplete dopamine at presynaptic striatal nerve terminals, are a class of drugs that have long been used to treat hyperkinetic movement disorders
Nitrous oxide
Nitrous oxideis abused most commonly as “whippets
What is the SSRI of choice when drug - drug interactions are a concern?
Citalopramandescitalopraminhibit liver enzymes less than other SSRIs and are thus the SSRIs of choice for situations in which drug-drug interactions are a concern.
MAOI Diet
MAO is distributed in tissues throughout the body. The blockade of MAOIa in the gastrointestinal tract is responsible for the “cheese reaction” associated with MAOIs. This refers to a severe hypertensive crisis that can occur after patients on MAOIs ingest foods containing the sympathomimetic tyramine.
Neurotransmitter:
Serotonin
Regulation of emotions, controls food intake, sleep/wakefulness, pain control, sexual behaviors
Personality disorders
Cluster A
Paranoid
Schizoid
Schizotypal
PTSD & Acute Stress Disorder
Treatments
Support
Encouragement to discuss event
Education about a variety of coping mechanisms
Psychotherapy
MEDS:
Selective Serotonin Reuptake Inhibitors
Tricyclics
Anticonvulsants
Hallucinogens
DXM = Dextromethorphan
PCP = Phencyclidine or phenylcyclohexyl piperidine
Ketamine
LSD = Lysergic acid diethylamide
Mescaline = 3,4,5-trimethoxyphenethylamine
desmopressin
Vasopressin (synthetic).
Primary nocturnal enuresis.
Contraindications:
Moderate to severe renal impairment
(CrCl <50mL/min). History of Hyponatremia
MOA of bupropion
Reuptake inhibition of : Norepinephrine transporter (NET) Dopamine transporter (DAT)
MOA may involve the presynaptic release of Norepi or dopamine
Treatment for ADD / ADHD (non stimulant)
Atomoxetine (straterra)
SSRI’s
A- agonists
Clonodine (catapres, kapvay)
Antihypertensive agents
Mechanism in ADHD unknown
ADHD meds
Adderall: dextroamphetamine/amphetamine
Adderall XR: dextroamphetamine/amphetamine
Catapres: clonidine
Concerta: methylphenidate
Dexedrine: dextroamphetamine
Effexor: venlafaxine
More meds: Intuniv: guanfacine Kapvay: clonidine Ritalin: methylphenidate Ritalin LA: methylphenidate Strattera: atomoxetine Tenex: guanfacine Vyvanse: lisdexamfetamine Wellbutrin: bupropion hydrochloride
First-generation antipsychotic medications (FGAs), also known as neuroleptics or conventional antipsychotics, cause
High rates of extrapyramidal side effects (EPS), including rigidity, bradykinesia, tremor, and akathisia (restlessness).
They also frequently lead to tardive dyskinesia—hyperkinetic, involuntary movements most readily observed in the face and extremities.
MOA of SNRI’s
The serotonin-norepinephrine reuptake inhibitors (SNRIs) appear to treat depression by initially blocking presynaptic serotonin and norepinephrine transporter proteins.
This inhibits reuptake of these neurotransmitters and leads to increased stimulation of post-synaptic receptors.
Side effects include nausea, dizziness, dry mouth, constipation, insomnia, and diaphoresis.
Watch out for patients with HTN!!
lamotrigine
Lamictal
Slight risk of Stevens-Johnson syndrome -(TEN)
Treatment of ADHD may involve
Behavioral/psychologic interventions,
medication,
and/or educational interventions,
alone or in combination.
Decisions regarding the choice of therapy should involve the patient and his or her parents.
2nd generation of atypical antipsychotics
MOA
Primarily Block D2 and 5HT2A receptors
1st gen blocks only D2
Posttraumatic Stress Disorder Treatment
SSRIs (paroxetine, sertraline)
clonidine
Kapvay (Central alpha-2 agonist)
used in ADHD, as monotherapy or as an adjunct to stimulant medications.
Potentiated by alcohol, other CNS depressants
(eg, benzodiazepines, antipsychotics, barbiturates)
Potentiates AV block, bradycardia with drugs that affect sinus node function or AV node conduction
(eg, digitalis, calcium channel blockers, β-blockers)
Additive effects with anti-hypertensives
Hypotensive effects may be antagonized by tricyclic antidepressants
Adverse Reactions:
Somnolence, fatigue, irritability, insomnia, nightmares, constipation, dry mouth, decreased appetite, dizziness; bradycardia
Postpartum Depression
Five or more symptoms present during 2-week period with at least one symptoms being
Depressed mood
or
Loss of interest or pleasure
Treatment:
Serotonin Reuptake Inhibitors (SSRI)
desmopressin MOA
reduction in overnight urine production
via stimulation of ADH
which causes less urine production
SSRI Side Effects
Sexual dysfunction – 17 percent
Drowsiness – 17 percent
Weight gain – 12 percent
Lithium General info
First med specifically for Bipolar disorder (1940’s)
Unknown why it works for mania
Levels should be measured
(watch for lithium toxicity)
Lithiumlevels are closely related to renal function, salt balance, and water balance.
Dehydration causes higher lithium levels,
increasing sodium intake causes lower lithium levels, and
decreased sodium intake causes an increase in serum lithium levels.
Lithiumis contraindicated in patients with significant renal impairment, sodium depletion, dehydration, significant cardiovascular disease.
Excessivelithiumlevels can lead to toxicity with severe side effects and multisystem dysfunction which can be fatal if not recognized.
Side effects included Nausea, tremor, polyuria and thirst, weight gain, loose stools, and cognitive impairment
Venlafaxine
Effexor (SNRI)
Initially 75mg/day in 2–3 divided doses; may increase at 4-day intervals in 75mg/day increments to 150mg/day;
Contraindications:
During or within 14 days of MAOIs (see Interactions).
Boxed Warning:
Suicidal thoughts and behaviors.
Warnings:
Monitor for serotonin syndrome; discontinue immediately if occurs.
Pre-existing hypertension, cardio- or cerebrovascular disease. Monitor BP before and during treatment; consider dose reduction or discontinuation if elevated BP persists. Heart disease (eg, recent MI, heart failure).
Extrapyramidal symptoms Time frames
Minutes - hours = Acute dystonic reaction
Torticollis, laygospasms, oculogyric crisis
Tx: Benztropine / anticholinergics
Days = Pseudoparkinsonism
Bradykinesia, rigidity, cogwheel rigidity, perioral tremor
Tx: Benztropine
Days-weeks = Akithisia
Tx: Benzodiazepines, Beta blockers
Long term = Tardive dyskinesia
Tx: Atypical or clozapine
(often irreversible)
bupropion
Zyban
Aid in smoking cessation.
Contraindications:
Seizure disorders.
Boxed Warning:
Suicidal thoughts and behaviors.
(Persistent Depressive Disorder-DSM-V)
Tx:
Treatment:
SSRIs, bupropion, TCAs and MAOIs
Psychotherapy (esp. effective when combined with pharmacotherapy)
flumazenil
Benzodiazepine antagonist.
Reversal of benzodiazepine sedative effects in overdose, general anesthesia or conscious sedation
Contraindications:
Patients treated with benzodiazepines for life threatening conditions
Boxed Warning:
Occurrence of seizures.
Adverse Reactions:
Seizures, local reactions, dizziness
Warnings/Precautions:
Monitor for resedation (at least 2hrs), respiratory depression, other residual benzodiazepine effects, seizures
Disulfiram MOA
inhibits acetaldehyde dehydrogenase
Results in increased acetalaldehyde in blood
causes unpleasant reaction when alcohol is consumed
Solriamfetol
Sunosi
To improve wakefulness in adults with excessive sleepiness associated with narcolepsy, obstructive sleep apnea (OSA)
Contraindications:
During or within 14 days of MAOIs.
Interactions:
May increase risk of hypertensive reaction with concomitant MAOIs.
Schedule III meds
Narcotics (Tylenol 3, Buprenorphine)
Ketamine
Premenstrual Dysphoric disorder
Citalopram 10mg Escitalopram 5-10mg Fluoxetine 10mg Paroxetine 10mg Sertraline 25mg
SSRI’s 2nd gen antipsychs
phentermine
Lomaira
(Sympathomimetic-MOA unknown but stimulate CNS activity)
A short-term (a few weeks) adjunct in a regimen of weight reduction based on exercise, behavioral modification and caloric restriction in the management of exogenous obesity for patients with an initial body mass index ≥30kg/m2, or ≥27kg/m2in the presence of other risk factors (eg, hypertension, diabetes, hyperlipidemia).
Contraindications:
Cardiovascular disease (eg, coronary artery disease, stroke, arrhythmias, CHF, uncontrolled hypertension). During or within 14 days of MAOIs.
Hyperthyroidism. Glaucoma. Agitated states.
History of drug abuse.
Pregnancy (Cat.X). Nursing mothers.
In Summary on Depression!
Pharmacology – initiate SSRI anti-depressant
Non-pharmacology – exercise, regular meals, socialization (Things to treat anhedonia)
Patient Education – signs/symptoms of worsening, call the office or 911-ER
Get a contract for safety and find community resources.
Follow-up – appointment made for counseling with therapist
Return to your office in one to three weeks for follow-up. Sooner with any concerns or thought of self-harm.
Make sure patient are seeing PCP!
Adjustment Disorder
Treatment
Psychotherapy remains the treatment of choice for adjustment disorder
Crisis intervention may be necessary
Pharmacological agents are not indicated except for co-existing conditions – depression, anxiety
What meds have anticholinergic properties
Antipsychotics
Serotonin Syndrome
Although classically described as the triad of
mental status changes, autonomic hyperactivity, and neuromuscular abnormalities,
serotonin syndrome is actually a spectrum of clinical findings ranging from benign to lethal.
Bottom Line for Schizophrenia disorders
Patients treated with an antipsychotic for schizophrenia should be assessed prior to treatment if possible and at regular intervals for:
Signs of a movement disorder including extrapyramidal symptoms and tardive dyskinesia.
Symptoms of metabolic syndrome including measurements of body mass index, waist circumference, hemoglobin A1c, serum lipids, and blood pressure
ECG for patients with a history of cardiac disease or when starting an antipsychotic that prolongs the QT interval.
We recommend antipsychotic medication as first-line medication treatment for acute and maintenance phase treatment for schizophrenia.
For patients with schizophrenia who have recovered from an acute psychotic episode, we suggest that antipsychotic medication should be continued indefinitely at the lowest effective dose that achieves therapeutic goals. This approach is suggested even for patients who have achieved remission from a first psychotic episode.
Typical or First Generation Antipsychotics
First-generation antipsychotics (FGAs) are characterized by strong antagonism of dopamine D2 receptors in both cortical and striatal areas.
haloperidol (Haldol)
fluphenazine (Prolixin)
chlorpromazine (Thorazine)
Why should olanzapine (zyprexa) not be used as a first-line agent for first-episode patients
olanzapineis associated with significant weight gain and metabolic adverse effects
May be considered for those that fail first line tx
guanfacine
Intuniv (Central alpha-2A agonist)
used in ADHD, as monotherapy or as an adjunct to stimulant medications.
Warnings:
Concomitant antihypertensive, other risks for hypotension, syncope, bradycardia, heart block, cardiovascular or cerebrovascular disease. Monitor heart rate and BP prior to initiation, after dose increases, and periodically during therapy. Avoid abrupt discontinuation to minimize risk of rebound hypertension
Avoid with alcohol.
varenicline
Chantix (Nicotinic receptor partial agonist)
Dosage:
Initially 0.5mg once daily on Days 1–3, then 0.5mg twice daily on Days 4–7, then 1mg twice daily thereafter.
Warnings
Monitor for neuropsychiatric adverse events (eg, behavioral changes, agitation, depression, suicidal ideation);
Pre-existing psychiatric disorders. History of seizures or other factors that can lower seizure threshold. Cardiovascular disease; monitor for new or worsening signs/symptoms
Interactions:
May affect alcohol tolerance; reduce alcohol consumption until effects are known
Adverse Reactions:
Nausea, other GI effects (eg, constipation, flatulence, vomiting), sleep disturbance (eg, abnormal dreams, insomnia); nicotine withdrawal symptoms (due to smoking cessation), neuropsychiatric symptoms (may be serious), cardiovascular events; seizures
Orlistat
Xenical-Rx or Alli-OTC
(Lipase inhibitor)
Adjunct to reduced-calorie diet in obesity management, including weight loss and weight maintenance.
Contra:
Pregnancy (Cat.X).
Chronic malabsorption syndrome.
Cholestasis.
Adverse:
GI effects (oily spotting, flatus with discharge, fecal urgency, fatty/oily stools, oily evacuation, increased defecation, fecal incontinence);
cholelithiasis;
rare: severe liver injury.
OCD vs OCPD
OCD:
The person feels compelled to continue despite an awareness that the thoughts or behaviors may be excessive or inappropriate, and feels distress if they stop them such as washing hands excessively due to germs.
Tx: SSRIs (fluoxetine)-1st line, SNRIs (venlafaxine), and clomipramine (Anafranil)-TCA. Therapy.
Narcolepsy:
Excessive daytime sleepiness
People with narcolepsy feel moderately or severely tired during the day
They have difficulty paying attention, concentrating, and staying awake, even if they’ve slept a lot the night before
People with narcolepsy can start out feeling rested, but have trouble staying awake for long periods of time and fall asleep during routine daytime activities
with or without cataplexy
Whatis the only drug approved by the US Food and Drug Administration (FDA) for the short-term (up to 12 weeks) treatment of obesity
Phentermineis only approved by the US Food and Drug Administration (FDA) for the short-term (up to 12 weeks) treatment of obesity because of potential side effects, potential for abuse, and regulatory surveillance.
Neurotransmitter:
Nor/Epi
Causes changes in attention, learning, memory and mood
Schizoaffective disorder
Schizophrenia and major depression/Bipolar
What adverse effect to look out for with atypical antipsychotics?
Hyperglycemia
2nd generation Antipsychotics
Less likely to cause EPS and tardive dyskinesia than 1st gen (but may still occur)
More likely to have metabolic abnormalities (elevated glucose, lipids, weight gain) than 1st Gen
Major Depressive Episode:
Dx:
≥ 5 of the following symptoms present in the same two week period, at least one of which is depressed mood or loss of interest
Sleep issues Interest-diminished (anhedonia) Guilt Energy reduction Concentration issues Appetite or weight issues Psychomotor retardation issues Suicide thoughts or plan
Panic Disorder etiology
Dysregulation of norepinephrine, serotonin, and GABA
Neuroleptic malignant syndrome (NMS)
A life-threatening neurologic emergency associated with the use of antipsychotic agents and characterized by a distinctive clinical syndrome.
The diagnosis should be suspected when any two of the four cardinal clinical features
(mental status change, rigidity, fever, or autonomic instability)
appear in the setting of antipsychotic use or dopamine withdrawal.
When there is any suspicion of NMS, antipsychotic agents should be withheld
Consider dantrolene,bromocriptine, and/oramantadine
(mental status change, rigidity, fever, or autonomic instability)
Neuroleptic malignant syndrome (NMS) Meds
dantrolene (Dantrium)-Muscle relaxant by decreasing intracellular calcium in skeletal muscle; good for chronic spasticity
bromocriptine (Parlodel)- Good for dystonias (dopamine agonist-inhibits anterior pituitary prolactin secretion
amantadine (Symmetrel)-Good for EPS symptoms and parkinsonism MOA is unknown; Also used for Influenza A
What is the SSRI of choice when drug - drug interactions are a concern?
Citalopramandescitalopraminhibit liver enzymes less than other SSRIs and are thus the SSRIs of choice for situations in which drug-drug interactions are a concern.
These inhibit liver enzymes less
Benzo OD
Flumazenil is a nonspecific competitive antagonist of the BZD receptor.
It can be used to reverse BZD-induced sedation following general anesthesia, procedural sedation, or overdose.
Neurotransmitter:
GABA
Modulates other neurotransmitters
Citalopram
(Celexa)
Initially 20mg once daily
Increased risk of suicidality.
Increased risk of suicidal thinking and behavior in children, adolescents and young adults;
monitor for clinical worsening and unusual changes.
Congenital long QT syndrome,
Celexa, suicide, history of long QT
MAOI’s
Drugs
tranylcypromine (Parnate)
phenelzine (Nardil)
selegiline-Few Brand names
all 3 are -ine’s
Schedule II meds
Narcotics (morphine, codeine, Fentanyl, oxy, hydro, methadone)
Stimulants
Cocaine
Phenobarbital
SSRI’s
citalopram (Celexa) escitalopram (Lexapro) fluoxetine (Prozac)(Sarafem) fluvoxamine (Luvox) paroxetine (Paxil)(Pexeva) sertraline (Zoloft)
benztropine
Cogentin (Anticholinergic) (injection)
Used as an adjunct in Parkinsonism, drug-induced extrapyramidal disorders
Warnings:
Tardive dyskinesia: not recommended. Narrow-angle glaucoma. Tachycardia
Adverse Reactions:
Anticholinergic and antihistaminic effects, weakness, confusion
MOA of most antipsychotics
decrease the action of dopamine by blocking the Dopamine D2 receptors of nerves in the brain.
1st generation Antipsychotics side effects
More likely to cause EPS (dystonia, akathisia, pseudoparkinsonism, and tardive dyskinesia)
than 2nd gen
Less likely to have metabolic abnormalities than 2nd gen
Feeding and eating disorders Treatments
phenelzine (Nardil) MAOI 15 mg PO TID for bulimia
lisdexamfetamine (Vyvanse) 50-70 mg PO (start at 30 mg) in the morning for moderate to severe binge-eating disorder; NDRIs
fluoxetine (Prozac) SSRI 60 mg PO in the morning for bulimia
topiramate
Topamax
2nd-line or off-label
Has weight loss properties!
Major Depressive Episode:
Tx:
Antidepressants should be continued 3-6 weeks (if well tolerated) to determine efficacy
CBT should be included while on medications.
SSRIs (fluoxetine, paroxitine, sertraline), SNRIs, and bupropion or venlafaxine are first line
Selection based on side effect profile
Tricyclic Antidepressants (TCAs) Drugs
amitriptyline (Elavil) desipramine (Norpramin) nortriptyline (Pamelor) protriptyline (Vivactil) clomipramine (Anafranil)-Used for OCD Imipramine (Tofranil)
Atypical Antipsychotics meds to know
quetiapine (Seroquel)
lurasidone (Latuda)
Other insomnia meds
Ramelteon
Trazadone
Doxepin
Hallucinogen Therapy
We suggest that acute agitation and dysphoria from acute hallucinogen intoxication be managed with benzodiazepines.
Treatment options includemidazolam, lorazepam, ordiazepam
If psychotic features persist aggressive benzos and suggest haloperidol if persistent
Gastrointestinal (GI) decontamination via Charcoal isnotnecessary in the vast majority of cases.
Bipolar (maintenance)
The goals for maintenance therapy are to reduce subsyndromal symptoms, delay or prevent recurrence of new mood episodes, reduce the risk of suicide, and promote psychosocial functioning.
For most patients who respond to acute pharmacotherapy, we suggest maintenance treatment with the same regimen, rather than switching medications.
For patients who do not respond to or toleratelithium, we suggestvalproate,quetiapine, orlamotriginerather than other medications.
For patients who do not respond to or cannot tolerate these drugs,aripiprazole,olanzapine, orrisperidoneare reasonable alternatives.
Children and adolescents with ADHD have an increased risk of
increased risk of substance use,
oppositional defiant disorder or conduct disorder,
intentional and unintentional injuries
increased risk of motor vehicle accidents
Benzodiazepines
Benzodiazepines exert their principal pharmacodynamic effect via CNS GABA receptors, potentiating the effects of endogenous GABA, the main inhibitory neurotransmitter.
Side effects of benzodiazepines include:
impairment of psychomotor performance, amnesia, dependence and withdrawal symptoms after long-term treatment, and rebound anxiety after short-term treatment.
Withdrawal and cognitive or learning impairment are more likely for persons taking higher doses.
Quetiapine
Seroquel
Monotherapy for bipolar I
or
Adjunct to lithium or valproate (valproic acid) for acute mania and maintenance
or
Depressive episodes associated with bipolar disorder
Box warning:
Increased mortality in elderly with dementia related psychosis, Suicidal thoughts and behaviors.
Interactions:
Avoid drugs that prolong QT including
Class 1A (quinidine, procainamide)
Class 3 antiarrhythmics
Parasomnias
Complex movements and behaviors during sleep
Encompass common or bizarre behaviors as well as seemingly purposeful movements, perceptions, dreaming, and autonomic output during sleep or sleep transitions.
OCPD
OCPD:
List-making, hoarding, stinginess, and scheduling.
Treatment: Therapy!
Chlordiazepoxide
Librium
For anxiety
Personality disorders (3 clusters)
Cluster A: Social detachment w/ unusual behavior
Cluster B Drama
Cluster C Anxious and fearful
Benzo MOA
Benzos potentiate GABA
at
GABA A receptors (benzodiazepine receptors)
Benzos bind at the GABA receptor separate from the GABA binding site and create an allosteric effect increasing action at the GABA receptor
This increases the length of time the that GABA activates the receptor
This allows Chloride to enter the neuron
This hyperpolarizes the neuron and makes it less likely the neuron will fire
(i.e. inhibits the firing of neurons through GABA)
Stimulants Methamphetamine
Methamphetamine—
The reinforcing effects of methamphetamine are mediated both by blockade of the dopamine transporter and by stimulating the presynaptic release of dopamine.
Duration:
Brief psychotic disorder
-Duration at least 1 day but less than 1 month
Other meds for depression
Buproprion (Wellbutrin)
SSRI’s
Drugs
citalopram (Celexa) escitalopram (Lexapro) fluoxetine (Prozac)(Sarafem) fluvoxamine (Luvox) paroxetine (Paxil)(Pexeva) sertraline (Zoloft)
Serotonin Modulators
Trazadone (Desyrel or Oleptro)
Cocaine withdrawal Tx
Modafinil
a mild stimulant used to treat narcolepsy and shift-work sleep disorder, has shown mixed results in several clinical trials of patients with DSM-IV cocaine dependence
Disulfiram
a medication with some evidence of efficacy in alcohol use disorder, has shown promise for cocaine use disorder
Modafinil & Disulfiram
Duration:
Schizophreniform disorder
-1-6 months duration
Clonidine and guanfacine
MOA= Alpha 2 agonist
modest reduction in ADHD symptoms
must taper slowly or risk rebound hypertension
Valproic acid/Vaproate/divalproex sodium
Depakote
Was first used as a Anti-Convulsant and still is!
Also used for prophylaxis of migraines
Hepatic failure resulting in fatalities has occurred in patients receiving valproate.
These incidents usually have occurred during the first 6 months of treatment.
Fetal risk=Birth defects and life-threatening pancreatitis!
Common side effects ofvalproateinclude weight gain, nausea, vomiting, hair loss, easy bruising, and tremor
Contra:
Hepatic disease or significant hepatic dysfunction
Boxed Warning:
Life-threatening adverse reactions (eg, hepatotoxicity, fetal risk, pancreatitis).
Bipolar (Acute Phase)
Second line treatment
Second line treatment options for these patients include:
•Olanzapineplusfluoxetine
- Valproatemonotherapy
- Combination therapy withquetiapineorlurasidonepluslithiumorvalproate
•Combination therapy withlithiumplusvalproateorlamotrigine
Symbax,
Depakote,
seroquel/latuda + lithium/depakote
lithium + depakote or lamictal
Short-term insomnia
Short-term insomnia (less than one month) usually results from psychologic or physiologic stress.
Lurasidone
Latuda (Atypical antipsychotic)
Major depressive episodes associated with bipolar 1 as monotherapy in patients over 10
or
Adjunct to lithium or valproate (valproic acid) in adults
Box warning:
Increased mortality in elderly with dementia related psychosis, Suicidal thoughts and behaviors.
Phobias - Treatment
Social phobias and agoraphobia
Beta-blockers (propranolol and atenolol) Performance anxiety SSRIs (paroxetine) Benzos Venlafaxine Buspirone TCAs (imipramine)
atomoxetine
Strattera (SNRI)
Used for ADHD
Contra:
During or within 14 days of MAOIs. Narrow angle glaucoma. history of Pheochromocytoma. Severe cardiovascular disorders that might deteriorate with clinically important increases in HR and BP
Boxed Warning:
Suicidal ideation in children and adolescents.
Monitor closely
Schizophrenia treatment
Typical neuroleptic and antipsychotic medications best for decreasing positive sxs
OTC sleep meds
Diphenhydramine (Benadryl): 1st generation histamine
(H1) blockers (side effects?)
Doxylamine (Unisom): 1st generation histamine (H1) blockers
Anticholinergic side effects above!
OCD
OCD:
The person feels compelled to continue despite an awareness that the thoughts or behaviors may be excessive or inappropriate, and feels distress if they stop them such as washing hands excessively due to germs.
Tx: SSRIs (fluoxetine)-1st line, SNRIs (venlafaxine), and clomipramine (Anafranil)-TCA. Therapy.
OCPD:
List-making, hoarding, stinginess, and scheduling.
Treatment: Therapy!
When can you use injectable antipsychotics
injectable (LAI) antipsychotic medication may be useful for patients with schizophrenia when non-adherence to oral antipsychotics leads to frequent relapse.
LAI antipsychotics are administered at two to four week intervals.
Bupropion
MOA= inhibits Norepi and dopamine
Equivalent to methylphenidate
Side effects = tics, lowers seizure threshold
Management of acute inhalant intoxication
Primarily consists of support of airway, breathing, and circulation
Acutely, patients with findings of inhalation abuse should undergo screening for substance use disorder, depression and suicidality
Benzodiazepines
Estazolam Flurazepam Lorazepam Temazepam Triazolam
Drugs with a box warning of:
Increased mortality in elderly with dementia related psychosis, Suicidal thoughts and behaviors.
Latuda (Lurasidone)
Seroquel (Quetiapine)
Symbax (Olanzapine and fluoxetine)
Trazadone (Oleptro) MOA
Trazadone (Oleptro):
Antidepressant,
MOA unknown but inhibits serotonin reuptake (serotonin modulator).
Watch out for priapism
Antipsychotics MOA
most antipsychotic meds decrease the action of dopamine by blocking the Dopamine D2 receptors of nerves in the brain.
Schedule V meds
cough syrups with codeine
antitussive, antiemetics with narcotics
Postpartum Psychosis characterized by
Rapid onset
Treatment
Pharmacotherapy
Lithium, Valproic acid (Depakote), carbamazepine
Tricyclic Antidepressants (TCAs) MOA
Inhibits reuptake of both serotonin and norepinephrine, which increases the amount of neurotransmitter in the synaptic cleft.
Medications that can cause or worsen Tardive dyskinesia
Meds that can cause TD: Antipsychotics Antiemetics Antidepressants Anticonvulsants Mood stabilizers Antihistamines Antimalarial Stimulants
Meds that can worsen TD:
Anticholinergics
Antiparkinsonians
Stimulants
MOA of bupropion
Reuptake inhibition of : Norepinephrine transporter (NET) Dopamine transporter (DAT)
MOA may involve the presynaptic release of Norepi or dopamine
pregablin
Lyrica
Tolerance, withdrawal, and dependence are possible, but pregabalin is generally better tolerated than benzodiazepines
Serotonin syndrome
vs
Neuroleptic malignant syndrome (NMS)
Serotonin syndrome onset = within 24 hours
NMS onset = days to weeks
Serotonin syndrome = hyperactivity (tremor, clonus)
NMS = Bradyreflexia, muscular rigidity
Serotonin syndrome causes = Serotonin agonist
NMS causes = Dopamine agonist
Serotonin syndrome Tx = Benzos, cyproheptadine
NMS Tx = Bromocriptine
Serotonin syndrome Resolves = within 24 hours
NMS resolves = days to weeks
Non benzo benzos
Eszopiclone (lunesta)
Zaleplon (sonata)
Zolpidem (ambien)
Naltrexone
Revia (opioid agonist)
Alcohol dependence
Adverse: Hepatic toxicity
gabapentin
Neurontin
2nd-line or off-label
Side effects-mainly sedation
bupropion
(Wellbutrin-and other names)
Bupropionis used to treat major depression, seasonal affective disorder, attention deficit hyperactivity disorder (ADHD), tobacco dependence (Zyban), hypoactive sexual disorder, and obesity.
Contra: seizure disorders
In addition,bupropion should be used cautiously in patients receiving other drugs that can lower seizure threshold
Some authorities classify the drug as a dopamine norepinephrine reuptake inhibitor,
Stimulants Amphetamines
Amphetamines—
Amphetamines and other diverted pharmaceutical stimulants have a mechanism of action similar to methamphetamine with both blockade of the dopamine transporter as well as stimulate release of dopamine.
Methylphenidatehas a mechanism of action more similar to that of cocaine with simple blockade of the dopamine transporter.
Schizophrenia and other Psychotic Disorders
Schizophrenia
- 6 months duration
Schizophreniform disorder
-1-6 months duration
Schizoaffective disorder
-Schizophrenia and major depression/Bipolar
Brief psychotic disorder
-Duration at least 1 day but less than 1 month
Anorexia nervosa
Self-imposed starvation
usually resulting in less than 85% of expected
or
ideal weight for height (<17.5 BMI)
Major Depressive Episode:
Time frame
Depressive signs and sxs present for most days during a 2 week period
Depressed mood or anhedonia must be present
Benzodiazepines half lives and withdrawals
Benzodiazepines with shorter elimination half-lives (eg,alprazolam,lorazepam, andoxazepam) are more likely to produce acute withdrawal on abrupt cessation after prolonged use
Benzodiazepines with longer elimination half-lives (eg,clorazepate,diazepam,flurazepam, prazepam, andclonazepam) usually produce more delayed and somewhat attenuated withdrawal symptom
Clonidine and guanfacine MOA
Clonidine and guanfacine =
alpha-2 agonists
but MOA is unknown
Melatonin
plays a role in your natural sleep-wake cycle. Natural levels of melatonin in the blood are highest at night.
The most common melatonin side effects include:
Headache, Dizziness, Nausea, Drowsiness
Melatonin can interact with Anticoagulants and anti-platelet drugs Anticonvulsants Contraceptive drugs Diabetes medications Medications that suppress the immune system (immunosuppressants)
Bipolar I major depression in patients who are not receiving antimanic drugs
Patients with bipolar I disorder often present with major depression in the absence of antimanic drug therapy. For these patients, we suggest initial treatment withquetiapineorlurasidonerather than other medications
Seroquel or Latuda
modafinil
Provigil
The exact mechanism of action is unclear. Modafinil has been shown to significantly increase dopamine in the brain by blocking dopamine transporters; however, has a lower affinity for dopamine receptors compared to amphetamines.
To improve wakefulness in adults with excessive sleepiness associated with narcolepsy, obstructive sleep apnea (OSA), or shift work disorder (SWD)
Warnings:
History of LV hypertrophy or symptomatic mitral valve prolapse (eg, ischemic ECG changes, chest pain, arrhythmias associated with CNS stimulants): not recommended.
Adverse Reactions:
Headache, nausea, nervousness
Panic Attacks and Panic Disorder Treatment
Benzos for acute management
SSRIs (paroxetine, fluoxetine and sertraline)
SNRI-venlafaxine XR
TCAs (nortriptyline, desipramine, and imipramine)
MAOIs (phenelzine, tranylcypromine)
Cognitive-behavioral Psychotherapy (alone for mild cases); relaxation, desensitization
Exposure Therapy can be used in agoraphobia
GABA
Gamma amino butyric acid
most common inhibitory neuro transmitter in brain
GABA agonists cause sleep, anxiety relief, muscle relaxation and memory impairment
Modulates other neurotransmitters
Atypical or 2nd Generation Antipsychotics
Like First-generation, Second-generation antipsychotics (SGAs) are characterized by strong antagonism of dopamine D2 receptors in both cortical and striatal areas.
risperidone (Risperdal)
olanzapine (Zyprexa)
quetiapine (Seroquel)
ziprasidone (Geodon)
aripiprazole (Abilify) (Aristada)
clozapine (Clozaril)=Watch out for Agranulocytosis (Low WBC)
Duration:
Schizophrenia
- 6 months duration
Schizophrenia symptoms
Positive psychotic symptoms:
Hallucinations, delusions
Positive disorganization symptoms:
Disorganized speech, thought language
thought blocking, tangentiality, loose associations
disorganized behavior
Negative symptoms Flat affect alogia (poverty of speech) Poor attention Avolition (loss of motivation) anhedonia loss of social interest attention deficits
Personality disorders
Cluster C
Avoidant
Dependent
Obsessive compulsive
Cocaine withdrawal
The dopamine agonists, long-acting amphetamine and methamphetamine, bind to the same receptor as cocaine, but are less abusable than cocaine because of their relatively slower uptake and longer duration of action
ADHD Ages and treatment
For preschool children (age 4 through 5 years
behavior therapy rather than meds
For most school-aged children (≥6 years) and adolescents
medication rather than behavior therapy alone or no intervention
We suggest that behavioral interventions be added to medication therapy
Depression symptoms
SIG E CAPS
Sleep issues Interest-diminished (anhedonia) Guilt Energy reduction Concentration issues Appetite or weight issues Psychomotor retardation issues Suicide thoughts or plan
acamprosate
Campral
Maintenance of abstinence from alcohol in alcohol-dependent patients who are abstinent at treatment initiation, in conjunction with psychosocial support.
Contraindications:
Severe renal impairment (CrCl≤30mL/min). Sulfite allergy.
Adverse Reactions:
GI upset, myalgia/arthralgia, headache, rash, syncope, impotence,
What treatment is available for disorders such as REM sleep behavior disorder
Effective pharmacologic therapy is available for certain disorders, such as REM sleep behavior disorder (RBD). Melatonin or (short-term benzos)
Tricyclic Antidepressants (TCAs) Side effects:
cardiac effects, anticholinergic effects, antihistaminic effects, decreased seizure threshold, sexual dysfunction, diaphoresis, and tremor. These drugs are dangerous in overdose by suicidal patients.
Anticholinergic side effects
Hot, red, dry, blind, mad
Generalized Anxiety Disorder Treatment
SSRIs: (1st-line) paroxetine and escitalopram (FDA approved)
SNRIs: (1st line) venlafaxine XR (FDA approved)
Buspirone (Mechanism is unknown) May have affinity with Serotonin and Dopamine receptors
TCAs: imipramine
Benzodiazepines (Alprazolam, Clonazepam) (short-term)
Behavioral and insight oriented therapy
Side effect of bupropion
Dry mouth – 21 percent of patients who receivedbupropion
treatment of generalized anxiety disorder (GAD).
SRI’S
SSRI’s
SNRI’s
Cannabis Treatment
No FDA therapy at this time.
CBT and/or support groups is the key!
Schedule IV meds
Tramadol
Benzos
Schedule I meds
Heroin ,marijuana, LSD
Antipsychotic meds should be used with in caution with?
Anyone with seizures or orthostasis
QTC intervals or weight gain
Meds like risperidone have Alpha adrenergic blocking effects
