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Pharmacology II > Psych And Elders > Flashcards

Psych And Elders Flashcards

1
Q

What are the 5 uses for antidepressants?

A
  1. Depression
  2. Anxiety disorders
  3. Migraine prophylaxis
  4. ‘Nerve’ pain
  5. Low dose for insomnia
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2
Q

What drug type is sertraline?

A

SSRI; selective serotonin reuptake inhibitors

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3
Q

What drug type is venlafaxine?

A

SNRI; serotonin NorE reuptake inhibitor

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4
Q

What type of drug is trazodone?

A

SSRI + 5HT2A antagonist and H1 antagonist

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5
Q

What type of drug is vortioxetine and vilazodone?

A

SSRI + 5HT1A agonists and 5HT3 antagonist

SSRI + 5HT1A partial agonist

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6
Q

What type of drug is mirtazapine?

A

Serotonin and NE antagonist

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7
Q

What type of drug is bupropion?

A

NorE and dopamine reuptake inhibitor

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8
Q

What type of drug is amitriptyline?

A

Cyclic or tricyclic and tetracyclic antidepressants

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9
Q

What type of drug is phenelzine?

A

Monoamine oxidase inhibitor

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10
Q

Where does TCA’s work on neuron?

A

Pre and post synaptic

  • alpha1AR
  • NET
  • SERT
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11
Q

Where do SNRIs work on neuron?

A

Pre synaptic neuron at NET and SERT

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12
Q

Where do SSRIs work on neuron?

A

Presynaptic neuron at SERT

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13
Q

Where do MAOIs work on neuron?

A

Presynaptic neuron

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14
Q

What can happen with abrupt discontinuation of antidepressants?

A

Discontinuation syndrome

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15
Q

When does discontinuous syndrome begin and how long does it last?

A

Begin within 1-2 days of stopping

Lasts a few days up to 2-3 weeks

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16
Q

How can you treat discontinuation syndrome?

A

Re-initiating antidepressant

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17
Q

What are the symptoms of discontinuation syndrome:

A

Nausea, abdominal pain, diarrhea
Insomnia
Sweating, lethargy, headache, paresthesias
Low mood, irritability, anxiety

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18
Q

TriCyclic antidepressants (TCAs) mechanism?

A

Block reuptake of NE, 5HT, or both

May also affect dopamine

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19
Q

What are some other effects of TCAs?

A

Muscarinic block
Histamine 1 receptor block
Alpha 1 block

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20
Q

If TCAs are given chronically, what can happen?

A

Decrease stores of NE; ECG changes (wide QRS, ventricular arrhythmia, and reduce contractility)

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21
Q

TCA can have additive effects with what drugs?

A

Antimuscarinic drugs

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22
Q

What effects can happen if TCA and antimuscarinic drugs are given?

A

More post op confusion, urinary retention, decreased bowel sounds, tachycardia

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23
Q

What could happen if on TCA and give direct acting vasopressors (phenylephrine, NE)?

A

Exaggerated BP response

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24
Q

What happens if on TCA and given indirect acting vasopressors (ephedrine)?

A

Enhance release of NE from presynaptic terminal and can have exaggerated response

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25
Q

What drugs should you avoid with pts on TCA?

A

Pancuronium
Ketamine
Meperidine
Epi

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26
Q

Why should you avoid TCA and pancuronium?

A

Increase HR, CO, and BP

-inhibit NE uptake transporter

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27
Q

Why should you avoid TCA and meperidine?

A

Weak serotonin reuptake inhibitor

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28
Q

Why should you avoid TCA and Epi?

A

Exaggerated effects

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29
Q

Chronic therapy with TCA may have?

A

Depleted cardiac catecholamines

-potentially cardiac depressant with anesthetic

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30
Q

If hypotension occurs on TCA, what should be given?

A

Use direct acting agent (phenylephrine)

-start lower and titrate

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31
Q

SSRIs mechanism?

A

Inhibit reuptake of 5HT into presynaptic neuron

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32
Q

What are some adverse effects of SSRIs?

A

Lack antimuscarinic effects
Lack hypotensive effects
Lack antihistamine effects

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33
Q

Can SSRIs get discontinuation syndrome?

A

Yes

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34
Q

Fluoxetine (SSRI) is a potent what and can do what?

A

Inhibitor of CYP enzymes and may inhibit clearance of warfarin, phenytoin, benzodiazepines

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35
Q

Frequently results from combining serotonergic agents is what?

A

Serotonin syndrome

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36
Q

Severe effects of serotonin syndrome?

A

Seizures, rhabdomyolysis, renal failure, arrhythmia, coma, death

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37
Q

What are 4 serotinergic agents that can cause serotonin syndrome?

A
  1. Serotonin reuptake inhibitors
  2. Serotonin releasers (amphetamine, ephedrine)
  3. Monoamine oxidase inhibitors
  4. Direct 5HT receptor agonists
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38
Q

Should you avoid these combinations?

SSRI + tramadol, CYP inhibitors, sumatriptan, meperidine, fentanyl, dextromethorphan, linezolid, phenelzine

A

YES

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39
Q

Monoamine Oxidase inhibitors (MAOIs) mechanisms:

A

Enzyme responsible for NT degradation

  • impact NE, dopamine, 5HT
  • amount of NE and 5HT increase at receptor site
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40
Q

What are contraindicated drugs with pts on MAOIs?

A

Indirect acting as they may cause fatal HTN crisis

-ephedrine, amphetamine

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41
Q

How do direct acting vasopressins affect pts with MAOIs?

A

May have enhanced effect due to additive effects so start very low dose and titrate
-Phenylephrine, NE

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42
Q

What drugs should be avoided with pts on MAOIs?

A

Pancuronium
Ketamine
Local anesthetics containing Epi

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43
Q

What drugs inhibit 5HT uptake with pts on MAOIs?

A

Opioid analgesics: meperidine, dextromethorphan, propoxyphene, methadone, fentanyl

44
Q

Which opiate drugs are considered safe with pts on MAOIs?

A

Codeine, morphine, oxycodone

45
Q

Which serotonin transport affinity drugs have the most potent interaction when combined with MAOI?

A

SSRI

46
Q

Which serotonin transport affinity drugs have fairly potent interaction when combined with MAOI?

A

SNRI and TCA

47
Q

Management of serotonin syndrome:

A

5HT2A and 5HT1A receptor antagonists (chlorpromazine, cyproheptadine)

48
Q

Which agents of 5HT2A and 5HT1A are ineffective/worsens serotonin syndrome with pts on MAOI?

A

Bromocriptine and propranolol

49
Q

Anesthesia in pts on MAOIs may reduce hepatic metabolism of what drugs?

A

Barbiturates (thiopental, methohexital)

Opioids; reduce clearance and enhance effects (respiratory depression)

50
Q

What is considered safe in anesthesia in pts on MAOI:

A 
Propofol 
Etomidate 
Dexmedetomidine
Benzodiazepines
Inhaled anesthetics 
Antimuscarinics
NSAIDs
51
Q

5 therapeutic uses for antipsychotics:

A
  1. Schizophrenia
  2. Bipolar disorder
  3. Severe/refractory depression
  4. Tourette’s
  5. Huntington’s syndrome
52
Q

What system deals with dopamine hypothesis of schizphrenia; hypothesis of positive psychotic symptoms (hallucination, paranoia, delusions)

A

Meso-limbic system

53
Q

Meso-limbic system has what kind of hormones?

A

Excess of dopamine

54
Q

Which system deals with mediates negative and cognitive symptoms of schizophrenia?

A

Meso-cortical system

55
Q

What does Meso-cortical system hormones look like?

A

Deficiency of dopamine and excess 5HT

56
Q

What are the 4 key pathways involved in pathophys of schizophrenia?

A
  1. Mesolimbic
  2. Mesocortical
  3. Nigrostriatal
  4. Tuberoinfundibular
57
Q

Therapeutic for mesolimbic pathway?

A

Decrease dopamine with D2 receptor antagonism

58
Q

Therapeutic for mesocortical pathway?

A

Increase dopamine with 5HT receptors)

59
Q

Which antipsychotic pathway deals with control of motor movements?

A

Nigrostriatal

60
Q

Which antipsychotic pathway deals with temp regulation, prolactin secretion?

A

Tuberoinfundiular pathway

61
Q

What is D2 good to combine with for antipsychotic?

A

5HT2A

62
Q

What is first generation of antipsychotic agents?

A

Typical antipsychotics; D2 receptor antagonists

63
Q

What is second generation of antipsychotic agents?

A

Atypical antipsychotics; D2 + 5HT2A receptor antagonists

64
Q

What does antipsychotic agents - first generation D2 receptor block cause?

A

Extrapyramidal side effects of Parkinson’s like adverse effects, dystopia, akathisia

65
Q

How does antipsychotic agents -first generation have other receptors and effects?

A 
Muscarinic receptor antagonists
Alpha1 receptor antagonists (hypotension)
Histamine1 receptor block (sedation)
Lower seizure threshold 
QT prolongation
66
Q

How does antipsychotic agents -second generation affect the pathways?

A

Mesolimbic: weaker but adequate D2 receptor block

Mesocortical, NS, TIF: weake D2 and block of 5HT2A that enhances dopamine release

67
Q

What are some side effects to antipsychotic agents - second generation?

A

Wt gain, hyperlididemia, glucose intolerance/DMT2

68
Q

What drug should you avoid for a pt on antipsychotic agents and why?

A

Ketamine due to decrease in seizure threshold

69
Q

Common side effects of pts on antipsychotic agents? (7)

A

Tachycardia, hypotension, increase body wt, DM, impaired temp regulation, decreased stress response, neuroleptic malignant syndrome

70
Q

Rare, potentially life-threatening neurological disorder associated with first generation agents - related to D2 receptor potency

A

Neuroleptic malignant syndrome

71
Q

What does neuroleptic malignant syndrome look like:

A

Hyperthermia, muscle rigidity, altered mental status, autonomic dysfunction, elevated CK

72
Q

What is a supportive therapy for neuroleptic malignant syndrome?

A

Dantrolene

73
Q

What are 4 pharmacotherapy of Parkinson’s disease?

A
  1. Antimuscarinic agents (benztropine, trihexphenidyl)
  2. Dopamine replacement (levodopa)
  3. Inhibitors of dopamine metabolism (dopa decarboxylase inhibitor, COMT inhibitor, MAO inhibitor)
  4. Dopamine receptor agonists (pramipexoole, ropinrole)
74
Q

Is levodopa transported across BBB?

A

Yes

75
Q

What drug is a Peripheral decarboxylase inhibitor that increases amount of levodopa to reach brain and decrease peripheral dopamine related adverse effects

A

Carbidopa

76
Q

What is a dopamine agonists for PD with DQ administration?

A

Apomorphine

77
Q

What is a severe side effect of apomorphine?

A

Nausea

78
Q

What are selective D3 agents for PD?

A

Pramipexole and ropinrole

79
Q

What are COMT inhibitors for PD and side effect?

A

Tolcapone, entacopone

Nausea and diarrhea

80
Q

MAOI for PD and side effect?

A

Selegiline, rasagiline

Nausea and vomiting

81
Q

Do PD pts continue usual meds?

A

Yes

82
Q

When do you administer levodopa for PD pts?

A

20 min before induction, repeat intra, and postop

83
Q

What is the exception for PD pts to take their med prior to surgery?

A

Deep brain stimulator implantation (treatment for PD)

84
Q

What should be avoided in PD pts for normal surgery?

A

Dopamine antagonist antiemtics (chlorpromazine, promethazine)

85
Q

What should be avoided in PD pts undergoing brain stimulator transplantation?

A

Agents that affect GABA (benzodiazepines, propofol)

86
Q

Which meds are safe for PD pts undergoing brain stimulator transplantation?

A

Dexmedetomidine

87
Q

Alzheimer’s disease pharmacotherapy?

A 
Cholinesterase inhibitors (donepezil, rivastigmine, galantamine)
NMDA receptor antagonist (memantine)
88
Q

What drug interaction with neuromuscular blockers in Alzheimer’s disease pts?

A

Prolongation of Sux and resistance to non-depolarizing agents so need larger dose

89
Q

Do you use shorting acting sedatives, hypnotics, anesthetics, opioids for Alzheimer’s disease pts?

A

Yes

90
Q

How do you handle acetylchoinesterase inhibitors prior to elective surgery for Alzheimer’s pts?

A

Hold

91
Q

If not able to hold acetylcholinesterase inhibitors prior to surgery, what kind of interactions can there be? (4)

A
  1. Avoid NMB
  2. If using nondepolarizing NMB then need larger dose
  3. Sux has prolonged block (phase II block)
  4. Monitoring peripheral nerve stimulator a must
92
Q

What drugs to avoid for post op delerium in Alzheimer’s disease pts?

A

Benzodiazepines

Drugs with antimuscarinic profile

93
Q

4 CNS changes with elders:

A
  1. Reduction in NTs and receptors
  2. Increased sensitivity to IV agents that act in CNS (propofol, opioids, benzodiazepines but decrease MAC)
  3. Exaggerated respiratory desires ant affects (impaired response to hypercapnia and hypoxemia)
  4. Pain perception (higher thresholds, delay)
94
Q

3 cardiovascular changes in elders:

A
  1. Vascular stiffening
  2. Dysautonomia (impaired beta receptor response to increase CO )
  3. More BP liability, hypotension
95
Q

4 respiratory changes in elders:

A
  1. Reduced pulmonary reserve
  2. Increased stiffening of chest wall and decreased elasticity of lung, increased work of breathing (risk of atelectasis and hypoxemia)
  3. Impaired pharyngeal function, aspiration
  4. Exaggerated respiratory depressant (opioids, benzodiazepines, volatiles anesthetics)
96
Q

3 hepatic and renal changes in elders:

A
  1. Reduced liver function
  2. Decline GFR, creatinine clearance
  3. Volume of distribution (decreased TBW, increased adipose tissue)
97
Q

What are the anesthetic drugs to avoid for elders:

A

Benzodiazepines
NSAIDs (ketorolac)
Opioids
Antimuscarinic

98
Q

3 general approaches for anesthesia in elders:

A
  1. Reduce initial dose
  2. Increase interval between repeated doses
  3. Use shorter acting agents
99
Q

What 2 benzodiazepines not recommended?

A

Lorazepam and diazepam

100
Q

What do you reduce propofol to?

A

40-50% for induction (1.-1.75mg/kg IV over 30 sec)

30-40% for infusion

101
Q

Ketamine with elders:

A

Rarely used but could be used if pt has hypovolemia and need bronchodilation
-use for potent analgesic to avoid opioids

102
Q

How much do you reduce opioids for elders?

A

25-50%

103
Q

What is recommended longer or shorter acting agents for elders?

A

Shorter

104
Q

Reduction in hepatic metabolism prolong duration of what drugs?

A

Pan, vec, and rocuronium

105
Q

How is sugammadex affected in elders?

A

Recovery is slower

Pharmacology II (8 decks)

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