Psych and neuro Flashcards
1
Q
Fluoxetine
A
Prozac
2
Q
SSRI Indications
A
MDD, GAD
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
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
5
Q
Glutamate
A
High levels - neurotoxicity, sleep disturbances
Low levels - fatigue, poor memory, low brain function
6
Q
Antiseizure medications
A
Phenytoin (1st gen)
Valproic acid (1st gen)
Levetiracetam (2nd gen)
7
Q
Bupropion (SR, XR)
A
Wellbutrin (SR, XR)
NDRI - norepinephrine and dopamine reuptake inhibitor
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
9
Q
ASM Administration
A
Do not chew or crush extended release formulations
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)
11
Q
Escitalopram
A
Lexapro
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)
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
14
Q
Phenytoin
A
Dilantin
(oral or IV)
1st generation
15
Q
PHQ-9 Mild depression
A
5-9
16
Q
PHQ-9 Moderate depression
A
10-14
17
Q
GAD-7 Moderate Anxiety
A
10-14
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
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
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
21
Q
Alprazolam
A
Xanax (oral)
22
Q
SNRI Contraindications
A
Concurrent use with a MAOI or use within 14 days of discontinuing a MAOI
23
Q
Lorazepam
A
Ativan (oral, IV)
24
Q
Serotonin (5-HT) effects
A
High levels - HA, sweating, N/V
Low levels - depression/low mood, anxiety, sleeping difficulties
25
SSRI Serious Side Effects and Precautions/Warnings
* 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
26
PHQ-9 Moderately severe
15-19
27
Citalopram
Celexa
28
Diazepam
Valium (oral, rectal, IV)
29
SR - Sustained Release
Twice daily dosing
30
BZD Monitoring
* 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
31
BZD MOA
* 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
32
BZD Common Side Effects
* 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
33
Valproic Acid
Depakote
(oral or IV)
1st generation
34
SNRI Administration
Venlafaxine should be taken with food due to increased likelihood of causing nausea
35
SSRI Common Side Effects
* 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
ASM Indications
Focal or generalized seizures
37
Norepinephrine effects
High levels - increased BP
Low levels - lack of focus/energy/motivation
38
Paroxetine
Paxil
39
ASM TIme to Effect/Length of Therapy
* 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
BZD Indications
Anxiety
Seizures (status epilepticus)
41
Bupropion Administration
May be taken without regard to meals
One of the most activating antidepressants; administer in the morning to prevent insomnia
42
Major depressive disorder
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
Dopamine effects
High levels - psychosis, schizophrenia
Low levels - lack of motivation, poor motor control
44
BZD Contraindications
* Acute narrow-angle glaucoma
* Alprazolam: concurrent use with other potent CYP3A4 inhibitors
* Lorazepam: severe respiratory insufficiency (except during mechanical ventilation)
45
Generalized Anxiety Disorder (GAD)
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
SSRI Contraindications
Concurrent use with a monoamine oxidase inhibitors (MAOI) or use within 14 days of discontinuing a MAOI
47
SSRI Time to Effect/Length of Therapy
* 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
Bupropion Serious Side Effects and Precautions/Warnings
* 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
SNRI Indications
MDD
GAD
Neuropathy
50
BZD Administration
Oral - no special instructions
Can also be IV (lorazepam, dizepam)
Can also be rectal (diazepam)
51
PHQ-9 Severe depression
20-27
52
Phenytoin Side Effects
* Gingival hyperplasia(overgrowth of gum tissue)
* Hirsutism (hair growth in abnormal places)
* Inducerof many CYP isoenzymesresulting in significant drug-drug interactions
53
Venlafaxine (XR)
Effexor (XR)
54
Buprpion Common Side Effects
* 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
Valproic Acid Side Effects
* Weight gain
* Dose-dependent thrombrocytopenia
* Teratogenic
56
Benzodiazepines
Alprazolam
Lorazepam
Diazepam
57
SNRI Monitoring
* 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
GAD-7 Mild Anxiety
5-9
59
Bupropion Indications
MDD
Seasonal Affective Disorder (SAD)
Smoking cessation
60
ASM Serious Side Effects and Precautions/ Warnings
* 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
Bupropion Time to Effect/Length of Therapy
* 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
ASM Common Side Effects
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
SNRI
Duloxetine
Venlafaxine
64
ASM Monitoring
* 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
BZD Serious Side Effects and Precautions/Warnings
* 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
GAD-7 Severe Anxiety
\>15
67
SSRI
Paroxetine
Fluoxetine
Citalopram
Escitalopram
68
Duloxetine
Cymbalta
69
MDD Treatment Guidelines
Non-pharmacologic
* 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
Bupropion MOA
Increases the concentration of NE ANDDA in the synapse by blocking reuptake resulting in improved mood and energy
71
SSRI Monitoring
* 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
SNRI Serious Side Effects and Precautions/ Warnings
* 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
XR - extended release
once daily dosing
74
GAD-7 Minimal Anxiety
0-4
75
Levetiracetam Side Effects
* Behavior efforts(i.e., aggression, agitation, anger,anxiety, apathy, depression, hostility, irritability)
* Psychosis and hallucinations
76
ASM Contraindications
Valproic acid: hepatic disease or significant impairment
77
SNRI Time to Effect/Length of Therapy
* 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
MDD Treatment Guidelines
Pharmacologic
* 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
SSRI Administration
* 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
SNRI Common Side Effects
* 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
SNRI MOA
* 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
GABA effects
High levels - SOB
Low levels - anxiety, sleep disturbances
83
Levetiracetam
Keppra
(oral or IV)
2nd generation - wider therapeutic window, fewer serious side-effects, less complicated PK
