Pharmacology Flashcards
What are the “HAM” side effects?
What drugs are associated with these ADRs?
-anti-“H”istamine (sedation, weight gain)
-anti-“A”drenergic (hypotension)
-anti-“M”uscarinic (dried out)
TCAs, low potency antipsychotics
Symptoms of serotonin syndrome?
Classic cause?
- confusion
- flushing, diaphoresis
- tremor, jerks
- rhabdo –> renal failure –> death
SSRIs + MAOi combination
Classic drug related cause of HTN crisis
-MAOis + tyramine rich foods or sympathomimetics
First line treatment for extrapyramidal symptoms assc with antipsychotics
benztropine (Cogentin)
Hyperprolactinemia is assc with what drug class?
-typical antipsychotics + risperdone
Neuroleptic malignant syndrome: symptoms
- CPK^^
- lead pipe rigidity
- hypertension
- fever
Important psych meds that are cyp INHIBITORS:
Many SSRIs: -fluvoxamine -fluoxetine (Prozac) -paroxetine (paxil) -sertraline Also 1 SNRI: -duloxetine
Three major categories of antidepressants
- SSRIs/SNRIs
- TCAs
- MAOis
Time needed for antidepressant to take effect
3-6 weeks
Which SSRI has weekly dosing option?
Fluoxetine (Prozac); longest half life of antidepressants
OTC drug that may increase serotonin levels
dextromethorphan
Common side effects of SSRIs
- N/V
- sexual side effects
- insomnia/ anxiety
Sertraline (Zoloft): most notable ADR
- highest incidence of GI disturbance
(s) ertraline upsets the (s)tomach
Paroxetine (Paxil): three considerations
- protein bound –> drug interactions
- shortest half life (withdraw)
- anticholinergic effects
Fluvoxamine (Luvox): current FDA approved use
OCD only
Citalopram (Celexa): two considerations
-least drug interactions
-but known for QTc prolongation
(dose capped at 40mg due to cardiac risks, most patients need 80mg! Makes drug nearly useless. Consider Lexapro instead. It is the “s isomer” of citalopram…. Dr. Melvin likes this fact.)
**Note: 4mg selexa= 1 mg Lexapro
What is the generic name for the following SSRIs:
- celexa
- Lexapro
- paxil
- Prozac
- Zoloft
- celexa:citalopram
- Lexapro: excitalopram
- paxil: paroxetine
- Prozac: fluoxetine
- Zoloft: sertraline
Venlafaxine (Effexor):
- MOA
- Most notable side effect
- SNRI
- can raise BP, don’t give to patients with untreated hypertension, can also cause orthostatic hypoTN
How does desvenlafaxine compare to venlafaxine?
Pristiq
- active metabolite
- pricey
- no known benefit over duloxetine (Effexor)
Duloxetine (Cymbalta):
- use
- two considerations
- good for depression + neuropathic/fibromyalgia pain
- hepatotoxic with alcohol use
- pricey
Bupropion (Wellbutrin):
-advantages (3)
- few sexual side effects
- might help with ADHD
- might help with smoking cessation
Major contraindication to Wellbutrin:
**You will be asked this by multiple people in both neuro and psych!! KNOW THIS.
INCREASES SEIZURE RISK. AND ITS REAL/ TRUE. DO NOT GIVE THIS TO EPILEPTIC PATIENT!!!!!!
Trazadone/ nefazadone:
-use
-major depression, but mostly insomnia
What limits trazadones use?
- orthostatic hypotension at higher doses
- possible priapism
- usually have to combine low dose trazadone with SSRI to treat insomnia + depression.
Nefazadone black box warning:
-liver failure, so rarely used.
Remeron/Mirtazapine:
MOA
a2 antagonist –> causes ^^5HT and NE
Why are TCAs rarely first line?
- higher incidence of side effects
- dosing requires titration
- LETHAL IN OD!!!! (THIS IS REAL!!!, WE SAW THIS HAPPEN WITH AMITRIPTYLINE!)
Special use for:
imipramine
clomipramine
amitriptyline
- imipramine: enuresis
- clomipramine: OCD
- amitryptiline: migraines
Doxepine:
MOA
Uses
- TCA
- chronic pain, sleep aid
What neurotransmitters are increased at synapse by TCAs?
NE, 5HT
What are “secondary amines” and why are they useful?
- metabolites of tertiary amines (TCAs)
- less HAM ADRs
List two secondary amines
- desipramine
- nortriptyline
How many TCAs are needed to cause lethality?
-1 week supply!!!! OR LESS IF PATIENT IS TAKING OTHER SEDATING MEDS!!!!
3 major complications of TCAs
- convulsions
- cardiotox
- coma
What antidepressants are preferably in atypical (hypersomnia, hyperphagia, mood reactivity) depression?
MAOis (except not really in real life because its too hard for patients to avoid tyramine)
What is the MOA of MAOis?
-^^ ALL monoamines, least selective, blocks MAO-A and B
NE, 5HT, DOPA, tyramine
List three MAOis
phenelzine
tranylcypromine
isocarboxazid
Three drugs indicated for insomnia
trazadone
TCAs
mirtazapine
How do antipsychotics effect the elderly?
treat behavioral symptoms but ^ risk all cause mortality
MOA for typical vs atypical antipsychotics
- typical: block D2C receptors
- atypical: block D2 and 2A receptors
What side effects are present in LOW POTENCY TYPICAL antipsychotics? What are two low potency antipsychotics?
HAM ADRs
More lethality in OD due to QT prolongation
- chlorpromazine
- thioridazine
Chlorpromazine:
weird ADR
weird use
blue grey skin discoloration
N/V, hiccups
Thiroidazine: weird ADR
retinitis pigmentosa
Loxapine:
two considerations
- increases seizure risk
- metabolite = antidepressant (luvox, fluvoxetine)
Thiothixene weird ADR
ocular pigment changes
List four high potency antipsychotics
- Haldol
- fluphenazine
- pimozide
- trifluphenazine
Thugs pressed homicidal fairies
Which of the high potency antipsychotics is assc with QTc prolongation + v tach?
pimozide
List six atypical antipsychotics
- aripiprazole
- risperdone
- clozapine
- olanzapine
- quetiapine
- ziprasidone
Aardvarks Really Can Offer Quilts (to) Zebras!
Lurasidone/Latuda:
What is it?
Use?
- used for bipolar depression
- new antipsychotics, expensive
How are acute manic episodes treated?
How is bipolar maintained?
- acute mania: atypical + mood stabilizer
- maintenance: monotherapy with atypicals
Black box warning clozapine
agranulocytosis
Special use for clozapine?
-psychosis in Lewey Body demenentia because LESS DOPA BLOCKADE
What are the mood stablizers?
- lithium
- AEDs (valproate, lamotrigine, carbamazepine)
For what conditions is lithium DOC?
- acute mania
- px for episodes in bipolar/ schizoaffective d/o
- cyclothymic disorder
When prescribing lithium, what levels must be monitored?
- creatinine **(renal fxn may decrease, beware also giving NSAIDs)
- thyroid function
- lithium levels
What is the major drawback of lithium?
narrow therapeutic index
also NDI/ nephro/thyro toxic
What psych drugs require getting “levels’
- lithium
- valproate
- carbamazepine
- clozapine
How does lithium effect CBC?
leukocytosis, may be helpful if fiven with clozapine which= agranulocytosis
Carbamazepine:
MOA
labs needed to start treatment
- blocks sodium channels
- CBC, LFTs
Notable side effects of carbamazepine:
-hyponatremia**
(which is in itself a seizure risk. If patient is refractory to carbamazepine check Na before stopping.)
-agranulocytosis
For what is carbamazepine used in psychiatry?
-mania + mixed features or rapid cycling BP
Carbamazepine metabolic consideration
autoinduction of metabolism= requires increasing dosages
Valproate MOA
blocks Na channels and increases GABA
Labs that must be done when using valproate
CBC
LFTs
Drug levels
Lamotrigine: use in psychiatry
Most serious side effect
bipolar depression
stevens johnsons syndrome
What drug increases the level of lamotrigine?
- increased by valproate
- decreases valproate
Oxcarbazepine (trileptal):
- What should be monitored?
- What preferable over carbamazepine if possible?
- sodium
- less rash, less hepatox
(more effective for mood disorders, less for seizures)
Most limiting side effect of topiramate?
Use in psych?
- cognitive slowing (also kidney stones, acidosis, weight loss)
- impulse control disorders
Antidote for BDZ withdraw
Flumazenil
List 1 short 1 med 2 long acting benzos
short: lorazepam
med: diazepam
long: clonazepam, chlordiapoxide something another
What is the most effective treatment for major depressive disorder +/- psychotic symptoms?
ECT
Atypicals clearly have a better side effect profile than typical psychotics. So why do we give typicals?
-typicals can be given IM (depot) once a month and are needed in poorly compliant patients
(also some patients were started on typicals decades ago before atypicals existed)
Rules for dosing SSRIs
- try for 6 weeks
- treat for 6 months
- 3 weeks wash out
- max the dose
Who shouldn’t get bupropion?
- bulimics
- epileptics
Valproate ADRs
- NTDs
- pancreatitis
- low platelets
- agranulocytosis
Order of drug choices for mood stabilizers
1) lithium
2) valproate
3) carbamazepine/lamotrigine
Order of choices for antipsychotics
1) atypicals
2) typicals
3) clozapine
Contrast specificity and potency of atypical and typical antipsychotics
- atypicals: poor potency, good specificity
- typicals: good potency, poor specificity
ADRs assc with carbamazepine
- AV block
- cleft palate
Weird ADR assc with lamotrigine
blurred vision
What’s in “B52”?
Haldol
lorazepam
diphenhydramine
