Psych Drugs

Question 1

Emotional lability, slurred speech, ataxia, coma, blackouts. Serum γ-glutamyltransferase (GGT)—sensitive indicator of alcohol use. AST value is twice ALT value.

Answer 1

Alcohol INTOxication

Question 2

Symptoms seen in Alchol withdrawl and the recommended Tx

Answer 2

Mild alcohol withdrawal: anxiety, tremor, seizures, insomnia.. Severe alcohol withdrawal can cause autonomic hyperactivity and DTs (5–15% mortality rate).

Treatment for DTs: benzodiazepines.

Question 3

Euphoria, respiratory and CNS depression, gag reflex, pupillary constriction (pinpoint pupils), seizures (overdose).

What’s goint on? How do you Tx the pt?

Answer 3

Opiod Intoxication

Treatment: naloxone, naltrexone.

Question 4

Sweating, dilated pupils, piloerection (“cold turkey”), fever, rhinorrhea, yawning, nausea, stomach cramps, diarrhea (“flu-like” symptoms).

What’s wrong with pt?

What should you Tx with?

Answer 4

Opiod withdrawl

Treatment: long-term support, methadone, buprenorphine.

Question 5

Intox on this drug causes severe resppiratory depression

Withdrawl causes Delirium, life-threatening CV collapse

Answer 5

Barbituates

Question 6

Ataxia, minor respiratory depression when you are Intoxicated on this drug.

What do you tx it with?

Answer 6

Benzos

Treatment: flumazenil (benzodiazepine receptor antagonist, but rarely used as it can precipitate seizures).

Question 7

Euphoria, grandiosity, pupillary dilation, prolonged wakefulness and attention, hypertension, tachycardia, anorexia, paranoia, fever. Severe: cardiac arrest, seizure.

What drug causes this?

What does this pt look like when they are withdrawing from drug?

Answer 7

Amphetamines

Anhedonia,appetite, hypersomnolence, existential crisis.

Question 8

Impaired judgment, pupillary dilation, hallucinations (including tactile), paranoid ideations, angina, sudden cardiac death.

What’s going on with pt and how do we tx them?

Answer 8

Cocaine intoxication;

Treatment: α-blockers, benzodiazepines. β-blockers not recommended.

Question 9

Pts intoxicated with nicoteine

Question 10

Pt is Belligerence, impulsivity, fever, psychomotor agitation, analgesia, vertical and horizontal nystagmus, tachycardia, homicidality, psychosis, delirium, seizures.

What do you treat with?

What do they look like when they are in withdrawal?

Answer 10

PCP

Treatment: benzodiazepines, rapid-acting antipsychotic.

Depression, anxiety, irritability, restlessness, anergia, disturbances of thought and sleep.

Question 11

Perceptual distortion (visual, auditory), depersonalization, anxiety, paranoia, psychosis, possible flashbacks.

Answer 11

LSD intoxication

Question 12

Signs and symptoms of Marjuiana intox and withdrawal

Answer 12

Intox: Euphoria, anxiety, paranoid delusions, perception of slowed time, impaired judgment, social withdrawal,appetite, dry mouth, conjunctival injection, hallucinations

Withdrawal: Irritability, depression, insomnia, nausea, anorexia. Most symptoms peak in 48 hours and last for 5–7 days. Generally detectable in urine for up to 1 month

Question 13

Why do we use Naloxone and buprenorphine together?

Answer 13

Antagonist + partial agonist. Naloxone is not orally bioavailable, so withdrawal symptoms occur only if injected (lower abuse potential).

Question 14

Long-acting oral opiate used for heroin detoxification or long-term maintenance.

Long-acting opioid antagonist used for relapse prevention once detoxified.

Answer 14

Methadone

Naltrexone

Question 15

Prefered Tx for:

ADHD

Alcohol withdrawal

Bipolar

Bulemia

Depression

Answer 15

ADHD: Methylphenidate

Alcohol withdrawal: Benzos

Bipolar:Mood stabalizers “Lithium, Valproic acid, Cabamazepine)

Bulemia: SSRI

Depression: SSRI, SNRI, TCA, buproprion, Mirtazapine

Question 16

Tx for:

OCD

Panic disorder

PTSD

Schizophrenia

Social Phobia

Tourettes

Answer 16

OCD: SSRI or Clomipramine

Panic disorder: SSRI, Venlafaxine, Benzos

PTSD: SSRIs

Schizophrenia: Antipychotics

Social Phobia: SSRI, B-blocker

Tourettes: Haloperidol or Risperpidone

Question 17

Mechanism and Clincal application of Typical antipychotics

Answer 17

All typical antipsychotics block dopamine D2 receptors ([cAMP]).

Schizophrenia (primarily positive symptoms), psychosis, acute mania, Tourette syndrome.

Question 18

What drugs are high potentency Typical antipsychotics and what side effect do we see from them?

Answer 18

High potency: Trifluoperazine, Fluphenazine, Haloperidol

(Try to Fly High)

neurologic side effects (e.g., Huntington disease, delirium, EPS symptoms).

Question 19

What are low potency typical antipyschotics and what side effects do we see with them?

Answer 19

Low potency: Chlorpromazine, Thioridazine

(Cheating Thieves are low)

—non-neurologic side effects (anticholinergic, antihistamine, and α1-blockade effects).

Chlorpromazine = corneal deposits

Thioridozine = retinal deposits

Question 20

General on Side effect profile of Typical antipsychotics:

Haloperidol, trifluoperazine, fluphenazine, thioridazine, chlorpromazine

Answer 20

Highly lipid soluble and stored in body fat; thus, very slow to be removed from body.

Extrapyramidal system side effects (e.g., dyskinesias). Treatment: benztropine or diphenhydramine.

Endocrine side effects (e.g., dopamine receptor antagonismhyperprolactinemia galactorrhea).

Side effects arising from blocking muscarinic (dry mouth, constipation), α1 (hypotension), and histamine (sedation) receptors.

Can cause QT prolongation.

Question 21

Pt comes in with Fever, encephalopathy, unstable vitals, elevated enZ on labs and rigdig muscles. Have a history of Schizophrenia managed with medications.

What’s going on and how do we tx?

Answer 21

Neuroleptic malignant syndrome (NMS)— rigidity, myoglobinuria, autonomic instability, hyperpyrexia.

Treatment: dantrolene, D2 agonists (e.g., bromocriptine).

Question 22

What is the rule of 4 involving the evolution of EPS side effects

Answer 22

Evolution of EPS side effects:

ƒ 4 hr acute dystonia (muscle spasm, stiffness,

oculogyric crisis)

ƒ 4 day akathisia (restlessness)

ƒ 4 wk bradykinesia (parkinsonism)

ƒ 4 mo tardive dyskinesia

Question 23

What are the Atypical antipsychotics?

What is their mechanism?

What is their clinical use?

Answer 23

Olanzapine, clozapine, quetiapine, risperidone, aripiprazole, ziprasidone.

Not completely understood. Varied effects on 5-HT2, dopamine, and α- and H1-receptors.

Schizophrenia—both positive and negative symptoms. Also used for bipolar disorder, OCD, anxiety disorder, depression, mania, Tourette syndrome.

Question 24

Side effects we worry about with Clozapine

With Risperidone

With Olanzapine

Answer 24

Clozapine: agranulocysosis

Olanzapine: wt gain

Risperidone: may increase prolactin (causing lactation and gynecomastia)–> Decreased GnRH, LH, and FSH (causing irregular menstruation and fertility issues).

****All may prolong QT interval

Question 25

Why are atypicals preferred over typical antipsychotics?

What are some side effects we still worry about?

Answer 25

Fewer extrapyramidal and anticholinergic side effects than traditional antipsychotics.

All prolong QT

Treat + and - symptoms

Question 26

Uses of Lithium and it’s toxicity profile

Answer 26

Mood stabilizer for bipolar disorder; blocks relapse and acute manic events. Also SIADH.

MNOP—Lithium side effects:

Movement (tremor)

Nephrogenic diabetes insipidus

HypOthyroidism

Pregnancy problems

Question 27

Causes Tremor, hypothyroidism, polyuria (causes nephrogenic diabetes insipidus), teratogenesis. Causes Ebstein anomaly in newborn if taken by pregnant mother. Narrow therapeutic window requires close monitoring of serum levels. Almost exclusively excreted by kidneys; most is reabsorbed at PCT with Na+.

What is this drug and what drug should NEVER be given with it?

Answer 27

Lithium

Thiazide use is implicated in lithium toxicity in bipolar patients.

Question 28

What drugs are the SSRIs and what is their clincal use?

Answer 28

Fluoxetine, paroxetine, sertraline, citalopram.

5-HT–specific reuptake inhibitors.

Depression, generalized anxiety disorder, panic disorder, OCD, bulimia, social phobias, PTSD.

Question 29

Your friends patient suffers from depression and has been on SSRIs for three months and hasn’t gotten better. He added Selegiline to the mix, hoping to get better coverage. Soon after the patient is rushed to the ER with terribler hyperthermia, confusion, flusing diarrhea and seizures. What the heck is going on and what is the antidote?

Answer 29

Serotonin syndrome with any drug that 5-HT (e.g., MAO inhibitors, SNRIs, TCAs)—hyperthermia, confusion, myoclonus, cardiovascular instability, flushing, diarrhea, seizures.

Treatment: cyproheptadine (5-HT2 receptor antagonist).

Question 30

What drugs are the SNRIs adn what are their uses?

What side effect do we see?

Answer 30

Venlafaxine, Duloxetine

Depression.

Venlafaxine is also used in generalized anxiety disorder, panic disorder, PTSD.

Duloxetine is also indicated for diabetic peripheral neuropathy.

Sides: BP most common; also stimulant effects, sedation, nausea.

Question 31

Amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, doxepin, amoxapine.

These are what type of drugs?

MOA?

Uses?

Answer 31

TCAs

Block reuptake of norepinephrine and 5-HT.

Major depression, OCD (clomipramine), peripheral neuropathy, chronic pain, migraine prophylaxis.

Question 32

Toxicity from TCAs

Answer 32

Sedation, α1-blocking effects including postural hypotension, and atropine-like (anticholinergic) side effects (tachycardia, urinary retention, dry mouth). 3° TCAs (amitriptyline) have more anticholinergic effects than 2° TCAs (nortriptyline). Can prolong QT interval.

Question 33

The three C’s of TCAs

Answer 33

Tri-C’s: Convulsions, Coma, Cardiotoxicity (arrhythmias); also respiratory depression, hyperpyrexia. Confusion and hallucinations in elderly due to anticholinergic side effects (use nortriptyline).

Treatment: NaHCO3 to prevent arrhythmia.

Question 34

What are the 5 MAOI’s and how do they work?

What are their uses?

Answer 34

Tranylcypromine, Phenelzine, Isocarboxazid, Selegiline (selective MAO-B inhibitor). (MAO Takes Pride In Shanghai).

Nonselective MAO inhibitionlevels of amine neurotransmitters (norepinephrine, 5-HT, dopamine).

Use: Atypical depression, anxiety.

Question 35

What are the negative side effects seen with MAOIs?

Answer 35

Hypertensive crisis (most notably with ingestion of tyramine, which is found in many foods such as wine and cheese); CNS stimulation.

Contraindicated with SSRIs, TCAs, St. John’s wort, meperidine, dextromethorphan (to prevent serotonin syndrome).

Question 36

α2-antagonist (release of norepinephrine and 5-HT) and potent 5-HT2 and 5-HT3 receptor antagonist.

Toxicity: sedation (which may be desirable in depressed patients with insomnia), appetite, weight gain (which may be desirable in elderly or anorexic patients), dry mouth.

Answer 36

Mirtazapine

Question 37

Primarily blocks 5-HT2 and α1-adrenergic receptors. Used primarily for insomnia, as high doses are needed for antidepressant effects.

Toxicity: sedation, nausea, priapism, postural hypotension. Called trazobone due to male-specific side effects.

Answer 37

Trazodone

Question 38

What is the first line agent for absence seizures and what is it’s MOA?

Answer 38

Ethosuximide

Blocks T-type Ca++ channels that trigger and sustain rhythmical burst discharge in thalamic neurons; thus have hyperpolarization

Question 39

What seizure medications work by inhibiting high-frequency firing via reduction of ability of Na+ channels to recover from inactivation?

Answer 39

Phenytoin, Carbamazepine, Valproic acid