Psych disorders- agitation, alz, ADHD, anx, dep, bipolar, eating disorders Flashcards
side effects of bupropion
dry mouth, nausea, insomnia (take in AM), increased suicidal thoughts in those under 25 esp
which drugs are used to treat acute delerium- give examples
antipsyhcotics- haloperiol= most evidence and studied (PO, IV, IM)- small regular doses preferred over prn but still use for short duration
elderly patients with dementia taking antipsychotics long term are at increased risk of
stroke and death (when used for several weeks to months)
why are second generation anti psychotics preferred over first generally
more favorable side effect profile
why is risperidone useful for alzheimers, what dose do you start at? what do you increase to?
has effect on agitation and other behavioural symptoms- start at 0.25mg daily and titrate to usual 1mg, upper limit 2mg
increased risk of falls with trazodone because of this side effect
postural hypotension
which two oral benzos are minimally affected by aging and have no active metabolites?
lorazepam and oxazepam
why shouldn’t olanzapine and benzodiazepines be combined in those with mental illness and agitation?
increased cardiac and resp complications
name second generation (AKA) antispychotics
ie atypical: risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone
non pharm management of anxiety
decrease caffeine, regular sleep, aerobic exercise, stress reduction, mindfullness, meditation, CBT
initial approach to managing anxiety. Then what?
non pharm and use of benzo four days or less per week for acute time (1 week optimal). If continues, CBT or other medication added next. SSRI or SNRI preferred. No relief? increase dose or change within those two classes.No? Augment with 2nd gen antipsych, anticonvulsant or benzo
how long does it take for SSRI or SNRI to have full effect? How can you help?
8 weeks (up to 3 months). Add benzo short term (6-8 weeks)
what can be used to abort a panic attach
benzos; clonaz 0.25-0.5mg BID or loraz or diaz
drug useful for performance anxiety or stage fright and how to take
propranolol 10mg 30 minutes prior to event
medication for specific phobias
not generally used- CBT
why is quetiapine 2nd line for GAD
although effective, SE- metabolic regulation effects and weight gain esp, orthostatic hypotension, antichol SE
1st line GAD
SV-DEPP (Save Johnny Depp)- Sertraline, venlafaxine, duloxetine, escitalopram, paroxetine, pregabalin (advantage of rapid onset relief)
managing anxiety in pregnancy
CBT best, SSRO, SNRI, benzo- use lowest effective dose of any
benzo counselling
sedation/drowsiness (tolerance develops), dizzy, dependence with frequent use, retrograde amnesia, avoid alcohol and other CNS depressants, do not stop suddenly if on long time
gabapentin counselling. Differ from pregabalin?
somnolence, dizzy, ataxia, vision changes. Pregab can cause peripheral edema
reactions with MAOIs. Difference with reversible?
do not use with tyramine containing foods (severe hypertension- hypertensive crisis), and high risk of seratonin syndrome with: SSRI, SNRI, TCAs, meperidine, tryptophan. Reversible- diet not as strict, meperidine/TCA/SSRI worst risk SS.
symptoms of seratonin syndrome. Onset?
HTN, tremor, agitation, hypomania, sweating, racing heart. Onset:
drugs that can contribute to SS
SSRI, amphetamines, DM< dihydroergotamine, linezolid, lithium, meperidine, pentazocine, selegeline, st john’s wort, trazodone, triptans
which SSRI has the longest wash out/half life
fluoxetine- 5 weeks
comment on fluvoxamine vs other ssris
most DI and SE- N,C,Sedation
time between SSRI titration of dose
4 weeks
TCA SE
antichol, N, CV (increased HR, orthostatic hypo, arrhythmias), CNS (drowsy, HA, tremor, seizures)
does tolerance to BNZ anxiolytic effects happen
not usually
best SSRI in preg
fluox because most clinical experience
best drugs for OCD (SSRI)
Stop Pulling Faux Fur
buspirone in anxiety
only for generalized anxiety disorder
duration of trial when starting a stimulant for ADHD, when should see improvement in patient?
3-4 weeks. Effective? continue. No? try other or reassess diagnosis. See some effect in first week
first line ADHD tx (name)
stimulants- dextroamphetamine, disdecamfetamine, methylphenidate, mixed salts amphetamine)
which ADHD meds can be opened and sprinkles onto food for children who can’t swallow pills?
adderall XR, dexedrine spansules, vyvanse and biphentin
if stopping ADHD stimulant (no longer needed, etc) what is the best way?
over summer (no school), over 2-3 week trial period
drug useful for ADHD and tic symptoms
clonidine
what is atomoxetine
a SNRI used as a non stimulant in ADHD, lasts 24 hours
name short acting ADHD agents
ritalin, dexedrine
name intermediate acting ADHD agents
ritalin SR, dexedrine spansules (up to 8 hours both)
name long acting ADHD agents
concerta, biphentin, adderall, vyvanse - dosed once daily (up to 12 hours)
what should be monitored at baseline for ADHD patients
height, weight, BMI, ECG if family hx of cardiac dsx, etc
what is the significance of adhd meds and decreasing height and weight
about 1 inch and 2.7kg ie still adequate
common stimulant SE for ADHD
decreased appetite (give doses with large meals, supplement with ensure/boost), insomnia (give earlier in day- LA all before 4pm for sure), headache, rebound hyperactivity (switch to longer acting), increased BP/HR
which adhd stimulant can be taken dissolved in water
vyvanse (lisdex)
which stimulant’s shell may be found in stool?
concerta (methylphenidate)- hard shell makes it difficult to divert and abuse!
bipolar 1 vs 2
1 had to have had manic episode, 2 must have had hypo and never full manic. 1 may or may not have had depression, 2 has
first thing to do when treating mania in bipolar
d/c any antidepressants
first line agents for bipolar- mania
lithium, divalproex, second gen/atypical antipsych (if severe, use L or D in combo with 2nd gen x2weeks and reassess ). Carbamaz also okay. START WITH THE Loading Dose (LD= lithium, divalpro)
first line agents for bipolar-depression
lithium, lamotrigine, quetiapine or combo of 2 of these if severe (LL-Qool Jay… very calm). Divalproex in combo or SSRI in combo (short acting incase of switch to mania) also approp. also carbamaz, or olanz with fluox
why the controversy with antidepressant use in bipolar depression?
mod to severe can be considered, but some potential to promote rapid cycling in susceptible ppl
what should patients taking lithium be mindful of
diet- maintain usual salt and caffeine and fluid intake/output - adjust accordingly (esp vomit/D)
maintenance therapy bipolar- first line agents
lithium, lamotrigime, olanzapine, divalproex, quetiapine, several combinations
2nd gen antispych common SE
sedation, dizzy, orthostatic hyoi, headache GI, less tremor vs 1st but still some
asenapine ODT- counsel patients on what
not to eat or drink for 10 minutes after dissolving under tongue
if you choose to d/c bipolar therapy, over what time period should it be done?
more than 4 weeks
with bipolar meds, least favorable choices for: diabetes/metabolic syndrome, kidney failure or dsx,
DB- antipsychs, kidney-lithium
common SE with lithium
acts like salt! polyuria/dypsia, sig weight gain, tremor } most common. Counsel to maintain consistent salt diet
interactions with lithium
acts like a salt! ACE/ARB, diuretic, NSAIDs,
signs of lithium toxicity
drowsy, tremor and slurred speech are first, followed by arrhythmia seizure coma death. Therapeutic level is 0.6-1 to be taken q6-12 months when stable
how to start lithium, and maintenance dose
300mg HS, then 300mg BID- 1200mg HS is usual, 1800mg is max
what is the mainstay of therapy in alzheimers and why
cholinesterase inhibitors- good for cognitive, functional, behavioural and psych symptpoms
examples of cholinesterase inhibitors and general principles
galantamine, denepezil, rivastigmine - all equal efficacy, change to another if one doesn’t work or SE, higher doses improve outcomes, effectiveness is improvement or no change in target sx
what is memantine
NMDA receptor antagonist- used for alzheimers, blocks glutamate induced neuronal excitotox (process in final pathway of neuronal death)
which TCAs have a lower incidence of causing anticholinergic effects
desipramine, nortrip
cholinesterase inhibitor SE
H/A, N, D } main, V, fatigue, sleep disturbance, syncope, urinary frequency, decreased HR possible (caution with bradycardia/HR lowering agents)
major interaction cholinesterase inhibitors
anticholinergic agents
how long does it take to see a noticeable effect from antidepressants? full effect? how long until bothersome SE go away?
2-4 weeks to see improvement. Full up to 8. 2 weeks to tolerate sx
important counselling in depression
remember to keep taking even if you are feeling better, and if want to stop or taper see dr to make schedule
2 of the most effective and well tolerated agents for depression
sertraline and escitalopram
who should ssris be avoided in
those at increased risk of bleeding or with hx of it
which se of ssris is it least likely to develop tolerance to- which agents may be better
sexual dysfunction- buprop, mirt, moclobemide
how does buproprion work
NE and DA reuptake inhibition
benefits of mirtazapine for depression, and downsides. How does it work?
ben- lower GI and sexual dysf, but more sedation and weight gain. NA and Seratonin mechanisms
at what dose does venlafaxine also inhibit NE
greater than 150
what makes TCAs 2nd line for depression?
tolerability, safety concerns esp cardiotox following overdose
name the irreversible and reversible MAOI inhibitors
irr- tranylcypromine, phenelzine. rev- moclobemide
what can be done when a patient shows partial response to an antidepressant, and what can you use
augment- lithium has great evidence. also 2nd gen antispych for insomnia and anxiety that persist, as long as not long term use.
what are patients at risk of after 6 or more weeks especially of any antidepressant therapy if they suddenly stop
discontinuation syndrome- within 1-7 days of stopping, (untreated, subside in 3 weeks- severe sx within 3 days usually
worst ssri in pregnancy
paroxetine- very short t1/2, CV malformations possible. If prescribed, use lowest effective dose (as with all other antidepr in preg)
which antidepressants have low concentrations in breast milk
sertraline, paroxetine, nortriptylline
how long should you taper antidepressants over
4-6 weeks- esp imp for venlafax and parox
prokinetic agents used in anorexia-which is preferred? Which was pulled from market and why?
domperidone and metoclopramide- reduce feeling of fulness. Domperidone preferred becuase of lower EPS unless you need the antinauseant effect of meto. ALso prucalopride (seratonin agonist that normalizes colonic fx). cicapride had too much dysarrythmia and death so was pulled from market
used in anorexia to increase weight gain rate
zinc gluconate- take with food to avoid N
used for weight gain in anorexia
olanzapine- only up to BMI of 17 as after weight gain and increase in appetite are too much and patient’s don’t want. Typical duration 3 months
how to manage anxiety of anorexia
clonazepam 0.25-0.5mg bID or quetiapine. SSRI, esp fluox
what do you need to give at the beginning of refeeding in anorexia and why
thiamine 100mg daily f5d to prevent encephalopathy (wernicke-korsakoff syndrome)
how to deal with laxative abuse in anorexia
taper over months to years
treatment for bullemia
antidepressants can reduce binging episodes by greater than 50% in 2/3 patients. Fluox has most evidence, also other SSRI, venlafax and trazodone can be used. Continue 6-12 months and taper
what is trazodone, and what are common side effects and dose?
100-500mg daily in single or divided, seratonin agonist, SE= sedation**, antichol SE
