Pharmacology- Psych Flashcards
Site directed, irreversible inhibitor, they block enzymes from breaking down serotonin, dopamine and norepinephrine
MAOi
Side effects of MAOI?
orthostatic hypertension, sedation, dizziness, agitation, weight gain
potentially life threatening emergency situation resulting from excess serotonin?
Serotonin syndrome
what are some of the cognitive effects of serotonin syndrome?
headache, agitation, confusion, coma
what are some of the autonomic effect of serotonin syndrome?
shivering, sweating, hyperthermia, hypertension, nausea, diarrhea
what are some of the somatic effects of serotonin syndrome
muscle twitching,
hyperreflexia (clonus)
tremor
What drugs are TCAs?
amitriptyline, nortriptyline, doxepin
what is the mechanism of action of TCAs
inhibit the re-uptake of serotonin and norepinephrine
*ALSO block alpha adrenergic, histaminergic and M1 cholinergic receptors
TCAs are used for depression but much more likely to be used off-label for?
headaches, pain, IBS
TCA Cautions?
caution for cardiac arrythmias
caution in elderly
can be lethal in small doses
First line choice for depression
SSRIs
what drugs are SSRI
Fluoxetine, paroxetine, sertraline, escitalopram, citalopram, fluvoxemine, Vilazodone
Bind to serotonin re-uptake transporters and inhibits them, which increases the serotonin level within the synaptic cleft
SSRI
Which SSRI/ SNRI are the worst for weight gain
Paroxetine> citalopram> fluoxetine> venlafaxine
which SSRI/SNRI are the worst for sedation
paroxetine> sertraline>citalopram> fluoxetine, venlafaxine, duloxetine
for a patient who does not want the sexual side effects that come with SSRIs, what could you prescribe?
bupropion
patients with depression that have troubles with insomnia might best be put on?
sertraline or citalopram
(paroxetine is rarely used anymore)
what is the mechanism of action for Bupropion?
works by increasing dopamine and norepinephrine
what is a contraindication of bupropion?
avoid in patients with seizure, or eating disorders( cause an electrolyte imbalance making them more susceptible to seizures)
what are some positives to bupropion?
good for smoking cessation, not associated with sexual side effects, can help increase energy
good for patients with fear of serotonin syndrome
what is the mechanism of action for mirtazapine?
the mechanism of action is unknown but it increases serotonin and norepinephrine
What is often used to treat depression with co-morbid insomnia
Mirtazapine
what is odd with mirtazapine?
more weight gain and sedation at lower doses- decreases as you get higher
what are some positives about mirtazapine?
good for geriatric population
useful for appetite loss, GI disturbances
lower incidence of sexual side effects
not a great antidepressant. usually used for its sedating effects (the body doesn’t have a memory for the drug so it doesn’t get used to in)
trazodone
when do you change the dose of an antidepressant?`
initial benefits of antidepressants usually seen in 2-4 weeks. Full benefit appearing in 4-6 weeks.
reassess in 4 weeks and consider dose increase
patient with co-morbid anxiety and depression should consider
mirtazapine
No change in PHQ-9 or feeling better should prompt the provider to
switch medications
first line therapy for patients with ADHD and depression? second line? third line
- bupropion
- SSRI/SNRI + stimulant
- TCA
what is the first line therapy for patients with ADHD and anxiety? Second line? Third line?
- SSRI/SNRI + stimulant (start SSRI/SNRI first)
- atomoxetine
- TCA
what is the first line therapy for bipolar disorder and ADHD?
First line: treat bipolar disorder and once stable, okay to consider stimulant
What is the first line therapy for patients with substance use disorder and ADHD? second line?
- Atomoxetine
- bupropion
which medications fall under the stimulant classification?
methylphenidate
amphetamine
lisdexamfetamine
inhibits the re-uptake of dopamine and norepinephrine (allows increased dopaminergic and noradrenergic activity in the prefrontal cortex
methylphenidate
stimulant mediations should not be used with MAOI or after MAOI use for?
14 days
what forms does methylphenidate come in?
tablets, oral tabs/capsules, oral solution, transdermal patch
Side effects/ class warning for stimulants
seizures
growth inhibition or weight loss
potential to cause psychosis or aggression
worsening or new-onset Tourette’s or tic disorder
cardiovascular safety
mechanism of amphetamine?
inhibits the re-uptake of dopamine and norepinephrine
same as lisdexamfetamine
what is the mechanism of action of atomoxetine?
selective norepinephrine re-uptake inhibitor (weakly increases norepinephrine and dopamine in the prefrontal cortex as compared to stimulants)
atomoxetine is a SNRI, why would you want to caution use with fluoxetine and paroxetine?
the can increase atomoxetine serum levels
What test would you want to get prior to starting atomoxetine?
Baseline LFT (liver function tests)
what is the mechanism of action of clonidine?
postsynaptic alpha 2A receptor in the prefrontal cortex.
-it is a nonselective alpha 2 receptor so also binds to alpha 2B, alpha 2C
All antipsychotics act to block which receptor? why?
dopamine D2 receptor
* if dopamine is blocked then hopefully they can decrease the positive symptoms*
prolonged blockage of D2 receptors can lead to extrapyramidal symptoms. What are some examples of that?
pseudo parkinsonism
Akathsia
dystonia
Tardive dyskinesia (TD)
Neuromalignant syndrome (NMS)
What medication would you consider putting a patient on if they were showing symptoms of EPS due to antipsychotic medication?
anticholinergic medication like benzotropine, trihexyphenidate
what medication would you consider putting a patient on if they were displaying symptoms of akathisia due to antipsychotic medication?
- beta blocker like propranolol, inderal (Long acting) or benzodiazepines
Medication management of acute dystonia consists of?
IM or IV diphenhydramine (benadryl) or benzotropine
Tardive dyskinesia typically occurs
later in treatment >6 months of being on treatment
what medications are typical antipsychotics
haloperidol
chlorpromazine
what is the mechanism of action of typical antipsychotics
Dopamine D2 receptor antagonist
Haloperidol, a typical antipsychotic is known for causing these adverse side effects
High EPS
Akathisia
despite the side effects of clozapine, when is it the most effective? when should you consider clozapine?
- for patients who don’t respond to other antipsychotic medications.
- after two failed trials
what is the mechanism of Atypical antipsychotics
Dopamine D2 and serotonin 5HTA receptor antagonist
atypical antipsychotics usually have anticholinergic side effects such as
dry mouth, constipation, diminished sweating, blurred vision
What is a big side effect of the atypical antipsychotic Quetiapine?
Sedation
risperidone is often prescribed for what? what type of patient is this given to?
often prescribed for patients with behavior issues.
what common adverse side effect is risperidone known for?
Hyperprolactinemia (high levels of prolaction) EPS and weight gain (#3 after clozapine and olanzapine) Galactorrhea ( breast secretions)
what do ziprasidone and lurasidone have in common
both should be taken with food for maximum absorption. At least 500 calories for ziprasidone and 350 calories for lurasidone
common adverse side effect of ziprasidone that happens more than any other atypicals? what should be done before starting
QTc prolongation
EKG should be done before starting
Mechanism of Action of aripiprazole
Dopamine D2 and serotonin 5HT1A receptor partial agonist (unlike other atypical) and serotonin 5HT2A antagonist
common adverse effects of Aripiprazole
Akathisia
When is use of Lurasidone most preferred
adolescents with schizophrenia
what is the mechanism of action of lurasidone
Dopamine D2 and serotonin 5HT2A and 5-HT7 receptor full antagonist. Minimal histamine interaction (thus low weight gain)
most likely antipsychotic to bring on weight gain?
clozapine, olanzapine, quetiapine
most likely antipsychotic to cause sedation
clozapine, olanzapine, quetiapine
most likely antipsychotic to cause cardiac issues
ziprasidone
most likely antipsychotic to cause EPS symptoms
Haloperidol (typical antipsychotic)
risperidone (atypical antipsychotic)
most likely antipsychotic to cause akathisia?
Aripiprazole
what is the mechanism of action of anticonvulsant
blocks voltage gated sodium channels, may impact GABA
What are some side effects of the anticonvulsant valproic acid
Nausea, diarrhea, weight gain, liver damage
Hair loss, PCOS, sedation, lethargy, tremor
downside to carbamazepine
many interactions, effects gait, cognitive blunting
Which medication is:
better tolerated than other anticonvulsants
better at preventing depression not mania
liked to stevens johnson syndrome
lamotrigine
fever, whole body rash, mucous membrane involvement and liver abnormalities
stenven johnson syndrome
what is first line treatment for bipolar depression
lurasidone
What is the mechanism of Action for antihistamines
blockage of H1 histamine receptors result in sedation. Thought to increase the input resistance of neurons by affection potassium leakage
*primary mechanism unknown
which drugs are antihistamines?
diphenhydramine
doxylamine (don’t use in kids under 12)
doxepin
which medication is used to treat circadian rhythm disorders or jet-lag
melatonin
ramelton binds to which two receptors? What is the mechanism? which hormone does it mimic
- binds to MT1 & MT2 receptors
- it is a melatonin receptor agonist
- mimics melatonin
which medications are non-benzodiazepine GABA agonists
Zolpidem
zaleplon
eszopiclone
what is the MOA of non-benzodiazepine GABA agonists
bind GABA receptor “near” the benzodiazepine site
what is the MOA of benzodiazepines
Bind to the GABA receptor (alpha) increases chloride channel permeability
how do benzodiazepines work
they decrease REM and increase stage 2 sleep `
which medications are benzodiazepines?
Alprazolam (high abuse potential)
lorazepam
clonazepam
diazepam
temazepam
what are drawbacks of benzodiazepines
cognitive impairment
respiratory depression
interactions with alcohol
physiologic dependence/ discontinuation
abuse potential
in the elderly specifically avoid these benzos.
clonazepam, diazepam
for those with impaired liver function which benzo should be administered
use lorazepam
mirtazipines primary antidepressant action is through? sedation?
alpha 2 noradrenergic antagonism
blocks H1 histamine receptors
blocks primary specific serotonin receptors
orexin receptor antagonists
suvorexant
daridorexant
lemborexant
sedating antipsychotics
quetiapine and olanzapine best for treatment of comorbid psychiatric illness
