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Drugs > Psych and neuro > Flashcards

Psych and neuro Flashcards

1
Q

Fluoxetine

A

Prozac

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2
Q

SSRI Indications

A

MDD, GAD

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3
Q

BZD Time to Effect/Length of Therapy

A
  • Time to Effect:
    • Alprazolam:oral 1-1.5 hours
    • Lorazepam: oral 20-30 minutes, IV 15-20minutes
    • Diazepam: oral 30 minutes, IV 15 –30 minutes
  • Length of Therapy:
    • Variable; patient specific
    • Should only be used short-term for anxiety
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4
Q

Status Epilepticus

A
  • Results from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms, which lead to abnormally, prolonged seizures
  • Several forms including generalized convulsive status epilepticus (GCSE) and nonconvulsivestatus epilepticus (NCSE)
  • Aggressive treatment of seizures lasting 5 minutes or more is strongly recommendedInitial treatment: BZDs (IV lorazepam, IV diazepam, or rectal diazepam)
  • If unresponsive to BZD: Other ASM such as phenytoin, valproic acid, or levetiracetam
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5
Q

Glutamate

A

High levels - neurotoxicity, sleep disturbances

Low levels - fatigue, poor memory, low brain function

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6
Q

Antiseizure medications

A

Phenytoin (1st gen)

Valproic acid (1st gen)

Levetiracetam (2nd gen)

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7
Q

Bupropion (SR, XR)

A

Wellbutrin (SR, XR)

NDRI - norepinephrine and dopamine reuptake inhibitor

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8
Q

Epilepsy Treatment Guidelines

A
  • ASMs - mainstay of epilepsy treatment; only symptomatic treatment
  • Surgery - only possibly curative therapy; a select number of patients qualify for surgery
  • ASM selection based on seizure classification, comorbid conditions, and side effects
  • First-generation ASMs are very efficacious in epilepsy; use is becoming more and more limited due to side effects
    • Second generation ASMs have similar efficacy, greater tolerability, fewer drug–drug interactions, and generic availability
    • First-generation ASMs should generally be considered after second-generation ASMs have failed
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9
Q

ASM Administration

A

Do not chew or crush extended release formulations

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10
Q

GAD Treatment Guidelines

A
  • Treatment plans usually consist of psychotherapy + drug therapy
  • Psychotherapy is the least invasive and safest treatment option
    • Cognitive behavioral therapy (CBT - self-monitoring of worry, cognitive restructuring, relaxation training, and rehearsal of coping skills)
  • Drug therapy indicated if patient experiencing severe symptoms that impair function
    • BZDs are the most effective and commonly prescribed drugs for the rapid relief of acute anxiety symptoms
    • Antidepressants are the treatment of choice for the management of chronic anxiety
      • First-line drugs: SSRIs (escitalopram, citalopram, and paroxetine) + SNRIs (duloxetine and venlafaxine XR)
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11
Q

Escitalopram

A

Lexapro

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12
Q

Bupropion Contraindications

A
  • Concurrent use with a MAOI or use within 14 days of discontinuing an MAOI
  • Anorexia/Bulimia (patients are prone to electrolyte abnormalities and are therefore at higher risk for seizure activity)
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13
Q

Seizures

A

Neurologic condition in which a person is prone to recurrent epileptic seizures

Many types of epilepsies characterized by different seizure types, ranging in severity and etiologies

Pathophysiology:

  • Disturbed regulation of electrical activity in the brain resulting in synchronized and excessive neuronal discharge
  • Focal seizures start in a network of cells on only one side of the brain (localized)•Generalized seizures start in a network of cells encompassing both side of the brain
  • Types of generalized seizures – absence, myoclonic, tonic-clonic, aclonic
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14
Q

Phenytoin

A

Dilantin

(oral or IV)

1st generation

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15
Q

PHQ-9 Mild depression

A

5-9

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16
Q

PHQ-9 Moderate depression

A

10-14

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17
Q

GAD-7 Moderate Anxiety

A

10-14

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18
Q

Bupropion Monitoring

A
  • Effectiveness
    • PHQ-9 (ifusing for MDD)
    • Patient reported symptom improvement
  • Safety
    • Signs and symptoms of suicidal ideation
    • Signs and symptoms of insomnia
    • Body weight
    • Blood pressure
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19
Q

ASM MOA

A
  • Four broad ASM MOA categories:
    • Modification of ionic conductance
    • Enhancement of GABAergic (inhibitory) neurotransmission
    • Suppression of excitatory (usually glutamergic) excitatory
    • Other unique or unknown mechanisms
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20
Q

SSRI MOA

A

Inhibit the reuptake of 5-HT, increasing the amount of 5-HT in the synaptic cleft, and resulting in mood improvement

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21
Q

Alprazolam

A

Xanax (oral)

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22
Q

SNRI Contraindications

A

Concurrent use with a MAOI or use within 14 days of discontinuing a MAOI

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23
Q

Lorazepam

A

Ativan (oral, IV)

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24
Q

Serotonin (5-HT) effects

A

High levels - HA, sweating, N/V

Low levels - depression/low mood, anxiety, sleeping difficulties

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25
Q

SSRI Serious Side Effects and Precautions/Warnings

A
  • Serotonin Syndrome (“SHIVERS”)-
    • Shivering
    • Hyperreflexia
    • Increased temperature-
    • Vital sign instability
    • Encephalopathy (brain swelling)
    • Restlessness-Sweating
  • Seek immediate medical attention, do not double-up on missed doses, limit additional serotonergic agents, counsel patient on symptoms
  • Discontinuation Syndrome (“FINISH”)-
    • Flu-like sx.
    • Insomnia
    • Nausea
    • Imbalance
    • Sensory disturbance
    • Hyperarousal
  • Promote adherence, educate patient to taper off under medical supervision, counsel patient on symptoms
  • QT prolongation
    • Associatedwith citalopram
    • Use with caution/ avoid other QT prolonging agents (additive effect). Monitor ECG/EKG in high risk patients
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26
Q

PHQ-9 Moderately severe

A

15-19

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27
Q

Citalopram

A

Celexa

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28
Q

Diazepam

A

Valium (oral, rectal, IV)

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29
Q

SR - Sustained Release

A

Twice daily dosing

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30
Q

BZD Monitoring

A
  • Effectiveness
    • GAD-7 (if using for anxiety)
    • Electroencephalogram (EEG) (if using for seizures)
    • Patient reported symptom improvement
  • Safety
    • Mental status
    • Respiratory rate
    • Early refills or dose escalations
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31
Q

BZD MOA

A
  • Mechanism of Action:
    • Bind to the GABA receptorand promote influxof chloride ions andhyperpolarizes the cell
    • Decreases neuronal firing and improves/ reduces anxiety
    • More effective on the physical symptoms of GAD
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32
Q

BZD Common Side Effects

A
  • Drowsiness/fatigue:
    • Tolerance to sedation develops after repeated dosing
    • Use other agents that causedrowsiness/ fatigue with caution (additive effect)
    • Use with caution in older adults (increased risk of falls)
  • Memory Impairment
    • Typically is limited to events occurring after drug ingestion (anterograde amnesia)
    • Morelikely with BZDs with high affinity for binding to the benzodiazepine receptor (i.e., alprazolam)
    • Avoid alcohol intake to reduce risk
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33
Q

Valproic Acid

A

Depakote

(oral or IV)

1st generation

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34
Q

SNRI Administration

A

Venlafaxine should be taken with food due to increased likelihood of causing nausea

35
Q

SSRI Common Side Effects

A
  • Gastrointestinal upset (NVD), anxiety, headache
    • Dose dependent side effect; Mild and limited to first 1-2 weeks after initiation or dose increases
    • Take medication with food if experience upset stomach
  • Somnolence
    • Paroxetine associated with most sedation
    • Take in the evening/at bedtime
  • Insomnia
    • Fluoxetine associated with most activation
    • Take in the morning
  • Sexual dysfunction
    • Significant reason for nonadherence
    • Consider switching to a different agent with less sexual side effects such as bupropion
  • Weight gain
    • Paroxetine associated with most weight gain
    • Consider switching to a different agent with less weight gain such as bupropion
  • Hyponatremia
    • Monitor at baseline and periodically thereafter
    • More frequent monitoring required in high-risk groups (i.e., older adults)
36
Q

ASM Indications

A

Focal or generalized seizures

37
Q

Norepinephrine effects

A

High levels - increased BP

Low levels - lack of focus/energy/motivation

38
Q

Paroxetine

A

Paxil

39
Q

ASM TIme to Effect/Length of Therapy

A
  • Time to Effect:
    • Oral formulations - 1 to 17 hours depending on the formulation
    • IV formulations - ~ 30 min to 1 hour
  • Length of Therapy:
    • Chronic; Life-long in most cases
40
Q

BZD Indications

A

Anxiety

Seizures (status epilepticus)

41
Q

Bupropion Administration

A

May be taken without regard to meals

One of the most activating antidepressants; administer in the morning to prevent insomnia

42
Q

Major depressive disorder

A

Pathophysiology: Predominant theory - caused by decreased brain levels of 5-HT, DA, and NE

Diagnostic Criteria: Depressed mood or loss of interest + >4 other symptoms present nearly every day over at least 2 weeks and represents a change from baseline functioning. Important to also assess for medical-or drug-induced cause(s)

43
Q

Dopamine effects

A

High levels - psychosis, schizophrenia

Low levels - lack of motivation, poor motor control

44
Q

BZD Contraindications

A
  • Acute narrow-angle glaucoma
  • Alprazolam: concurrent use with other potent CYP3A4 inhibitors
  • Lorazepam: severe respiratory insufficiency (except during mechanical ventilation)
45
Q

Generalized Anxiety Disorder (GAD)

A

Pathophysiology: Several different theories involving multiple regions of the brain and abnormal function in several neurotransmitters including 5-HT, NE, GABA, and DA

Diagnostic Criteria: Persistent and excessive anxiety and worry + 3 psychological or physiological symptoms for most days for at least 6 months

46
Q

SSRI Contraindications

A

Concurrent use with a monoamine oxidase inhibitors (MAOI) or use within 14 days of discontinuing a MAOI

47
Q

SSRI Time to Effect/Length of Therapy

A
  • Time to effect:
    • Anxiety: Improvements often not observed until after 4 weeks
    • Depression: Physical improvement in 1-2 weeks and psychological improvement in 2-4 weeks
  • Length of therapy:
    • Variable; patient specific
    • Treatment should be continued for at least 6 months to 1 year to reduce the risk of recurrence
48
Q

Bupropion Serious Side Effects and Precautions/Warnings

A
  • Suicidal ideation
    • Monitor mental status for depression, suicidal ideation (especially at the beginning of therapy or when doses are increased or decreased)
  • Seizures
    • Risk of seizure strongly dose-related
    • Avoid use in patients with predisposing factors (i.e., history of prior seizure activity, severe alcohol withdrawal, head trauma, or CNS tumor)
49
Q

SNRI Indications

A

MDD

GAD

Neuropathy

50
Q

BZD Administration

A

Oral - no special instructions

Can also be IV (lorazepam, dizepam)

Can also be rectal (diazepam)

51
Q

PHQ-9 Severe depression

A

20-27

52
Q

Phenytoin Side Effects

A
  • Gingival hyperplasia(overgrowth of gum tissue)
  • Hirsutism (hair growth in abnormal places)
  • Inducerof many CYP isoenzymesresulting in significant drug-drug interactions
53
Q

Venlafaxine (XR)

A

Effexor (XR)

54
Q

Buprpion Common Side Effects

A
  • Activation - Side effect is helpful for decreased motivation, low energy, and fatigue (common symptoms of MDD)
    • Take medicationin the morning to prevent insomnia
  • GI upset(nausea/ vomiting)
    • Take with food if experience GI upset
  • Tremor
    • Monitor
  • Dry mouth
    • Monitor
    • Consider alternative antidepressant or symptom management as clinically appropriate (i.e., sipping fluids, gums, and/ or over-the-counter artificial saliva products)
  • Weight loss
    • Monitor bodyweight
  • Newonset or worsening hypertension
    • Monitor blood pressure
55
Q

Valproic Acid Side Effects

A
  • Weight gain
  • Dose-dependent thrombrocytopenia
  • Teratogenic
56
Q

Benzodiazepines

A

Alprazolam

Lorazepam

Diazepam

57
Q

SNRI Monitoring

A
  • Effectiveness
    • PHQ-9 (ifusing for MDD)
    • GAD-7 (if using for GAD)
    • Patient reported symptom improvement
  • Safety
    • Signs and symptoms of serotonin syndrome especially if patient is on multiple serotonergic medications
    • Signs and symptoms of suicidal ideation
    • Blood pressure
    • Liverfunction (duloxetine)
58
Q

GAD-7 Mild Anxiety

A

5-9

59
Q

Bupropion Indications

A

MDD

Seasonal Affective Disorder (SAD)

Smoking cessation

60
Q

ASM Serious Side Effects and Precautions/ Warnings

A
  • Drug rashes
    • Range from mild to Stevens-Johnson Syndrome (SJS) or Toxic Epidermal Necrolysis (TEN)
    • Can occur with any ASM; more likely with phenytointhan valproicacid or levetiracetam
    • If rash, discontinue medication immediately and seek emergency/ urgent care
    • May require admission to burn intensive care unit (ICU) in severe cases
  • Suicidal behaviorand ideation
    • Assess risk of suicidal behavior andideation, especially in patients with concurrent depression and anxiety
    • Counsel that increase the risk of suicidal thoughts/Advise to be on the alert for any unusual changes in mood or behavior
  • Hepatitis
    • Monitor liver function
  • Blood dyscrasias
    • Monitor completeblood count (CBC)
  • Osteomalaciaand osteoporosis
    • Consider supplemental vitamin D and calcium
    • Bone mineral density testing if other risk factors for osteoporosis are present
61
Q

Bupropion Time to Effect/Length of Therapy

A
  • Time to Effect:
    • Depression: Physical improvement in 1-2 weeks and psychological improvement in 2-4 weeks
  • Length of Therapy:
    • Variable; patient specific
    • Depression: Treatment should be continued for at least 6 months to 1 year to reduce the risk of recurrence
62
Q

ASM Common Side Effects

A

Sedation, Dizziness, Blurred or double vision, Difficulty with concentration, Ataxia (impaired balance or coordination), Impaired cognition

Management options include decreasing dose (since dose-related adverse effects) and/or trying alternative ASM

63
Q

SNRI

A

Duloxetine

Venlafaxine

64
Q

ASM Monitoring

A
  • Effectiveness
    • Seizures
    • Drug levels: phenytoin & valproicacid
  • Safety
    • Mental status
    • Drug levels: phenytoin & valproicacid
    • Liver function tests (LFTs)
    • CBC
    • Bone MineralDensity Testing (if other osteoporosis risk factors present)
65
Q

BZD Serious Side Effects and Precautions/Warnings

A
  • Respiratory depression
    • Avoid administering with other CNS depressants (i.e., opioids, alcohol)
    • Conside ruse of flumazenil (BZD reversal agent) for life-threatening depression
  • Dependence
    • Use with caution in individualswith history of misuse of multiple agents (i.e., alcohol or sedatives)
    • Monitor for early refills or escalation of dosage
    • Abrupt discontinuation may result in withdrawal (anxiety, insomnia, restlessness, muscle tension, and irritability)and/or rebound anxiety; Taper dose upon discontinuation
66
Q

GAD-7 Severe Anxiety

A

>15

67
Q

SSRI

A

Paroxetine

Fluoxetine

Citalopram

Escitalopram

68
Q

Duloxetine

A

Cymbalta

69
Q

MDD Treatment Guidelines

Non-pharmacologic

A
  • Cognitive behavioral therapy (CBT)
    • Should not be used as only treatment strategy for patients with psychotic features; Use as primary treatment is limited in practice by cost and logistics
    • Effects of psychotherapy and drug therapy are additive so often combined
70
Q

Bupropion MOA

A

Increases the concentration of NE ANDDA in the synapse by blocking reuptake resulting in improved mood and energy

71
Q

SSRI Monitoring

A
  • Effectiveness
    • PHQ-9 (ifusing for MDD)
    • GAD-7 (if using for GAD)
    • Patient reported symptom improvement
  • Safety
    • Signs and symptoms of serotonin syndrome especially if patient is on multiple serotonergic medications
    • ECG/EKG if patient is on citalopram +/-other QT prolonging medications
    • Signs and symptoms of suicidal ideation
    • Sodium
72
Q

SNRI Serious Side Effects and Precautions/ Warnings

A
  • Similar to SSRIs
  • Discontinuation or withdrawal syndrome more severe with SNRIs than SSRIs
  • Idiosyncratic hepatotoxicity
    • Associated with duloxetine
    • Monitor liver function at baseline and periodically as clinically indicated (i.e., if patient experiences s/sxof liver dysfunction)
73
Q

XR - extended release

A

once daily dosing

74
Q

GAD-7 Minimal Anxiety

A

0-4

75
Q

Levetiracetam Side Effects

A
  • Behavior efforts(i.e., aggression, agitation, anger,anxiety, apathy, depression, hostility, irritability)
  • Psychosis and hallucinations
76
Q

ASM Contraindications

A

Valproic acid: hepatic disease or significant impairment

77
Q

SNRI Time to Effect/Length of Therapy

A
  • Time to effect:
    • Anxiety: Improvements often not observed until after 4 weeks
    • Depression: Physical improvement in 1-2 weeks and psychological improvement in 2-4 weeks
  • Length of therapy:
    • Variable; patient specific
    • Treatment should be continued for at least 6 months to 1 year to reduce the risk of recurrence
78
Q

MDD Treatment Guidelines

Pharmacologic

A
  • Antidepressants are first-line for moderate to severe MDD (SSRI, SNRI, bupropion)
  • Initial treatment choice is made empirically
    • Antidepressants are equally effective
    • Cannot predict which will be most effective in an individual patient
    • Need to consider antidepressant properties, concurrent medical conditions, potential adverse effects and contraindications, and patient preferences
  • Failure to respond to one antidepressant class or one antidepressant agent within a class does not predict a failed response to another class or another agent within the same class
79
Q

SSRI Administration

A
  • Administer in morning or evening based on side effect profile
    • Paroxetine is the most likely to be sedating, if a patient reports sedation advise them to take the medication in the evening
    • Fluoxetine is likely to be activating, if a patient reports insomnia advise them to take the medication in the morning
80
Q

SNRI Common Side Effects

A
  • Hyperhidrosis
    • Monitor
    • Consider alternative antidepressants if side effect bothersome
  • Elevated blood pressure
    • More associated with venlafaxine than duloxetine
    • Monitor blood pressure at baseline and regularly during therapy
    • Consider alternative antidepressants for patients with uncontrolled hypertension
81
Q

SNRI MOA

A
  • Mechanism of Action:
    • Increases the concentration of 5-HT AND NE in the synapse by blocking reuptakeresulting in improved mood and energy
    • Venlafaxine inhibits 5-HT reuptake at lower doses and NE reuptake at higher doses
    • Duloxetine inhibits 5-HT and NE reuptake across all doses
82
Q

GABA effects

A

High levels - SOB

Low levels - anxiety, sleep disturbances

83
Q

Levetiracetam

A

Keppra

(oral or IV)

2nd generation - wider therapeutic window, fewer serious side-effects, less complicated PK

Drugs (5 decks)

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