Psych pharm Flashcards
Most psychotropic medications - how are they soluble?
lipid-soluble and metabolized by cytochrome P450 liver enzymes
if you’re a slow metabolizer, more likely to get
seratonin syndrome or Parkinsonism. or if too fast, meds won’t be as effective - need higher doses.
Most antipsychotics block which receptors?
postsynaptic dopamine (D2) receptors. (Atypicals also antagonize 5HT2 - this is serotonin) which reduces the amount of dopamine.
dont need to memorize - Effects on the ***mesolimbic area (limbic hallucinations)
decrease psychotic symptoms, especially hallucinations and delusions
dont need to memorize Effects on basal ganglia- too much (gang up on the ESPs)
produce EPS due to the many different transmitters and synapses utilized in this area
dont need to memorize - Effects on the hypothalamus - think milk
lead to increased pituitary production of prolactin with endocrine side effects (e.g. gynecomastia and galactorrhea (breast milk in ppl who should not be lactating)
Blockade of acetylcholine at muscarinic receptors results in
anticholinergic side effects - careful w/ elderly pts.
Antagonism of norepinephrine at alpha-1 receptors results in (nora is slow w/ ejaculation)
orthostatic hypotension and ejaculatory dysfunction
Blockade of H1 receptors for histamine results in (sneezing weight)
sedation and weight gain
Abrupt withdrawal of antipsychotics may cause (a syndrome)
discontinuation syndrome - Therefore, antipsychotics should be tapered slowly, esp. after long-term use. - main reason is ppl can relapse
Cross-tolerance can occur with
antipsychotics
Typicals - less effective for what?
Effective at treating positive symptoms (e.g. hallucinations and delusions), but less effective at treating negative symptoms (e.g. avolition, alogia, apathy, social withdrawal)
typicals - High potency neuroleptics (and examples) - (high potency, high EPS) (hi pro hal)
High potency neuroleptics (e.g. Haldol and Prolixin) have higher risk of EPS, but less anti-cholinergic side effects.
typicals - Low potency neuroleptics (antipsychotics) (low potency, low BP)
have less risk of EPS, but higher risk for orthostatic hypotension, sedation and anticholinergic side effects (urinary retention)
typicals - Depot injections: ex. and how long do they last? (hal is a pro at injections)
Haldol and Prolixin can both be given as IM Decanoates (deep muscle time released) that last q3-4 to weeks.
deconoates - problem
No antidote for decanoates if someone has a bad reaction - ie. NMS or dystonia. it’s usually give PO to see if pt can tolerate it before a shot. Extremely useful for very disorganized and noncompliant clients. Don’t confuse Depot injections with short-acting IM solutions!
atypicals - good or bad at selecting dopamine receptors?
Greater selectivity for dopamine receptor subtypes and/or block 5HT receptor sites.
atypicals - better at treating what
Believed to be more effective than typicals at treating negative symptoms, with less risk of EPS (but CATIE study has cast doubt on this belief!)
atypical - Clozaril (clozapine)
Clozaril (clozapine): very effective, but a “last-resort” drug b/c of the 1-3% chance of agranulocytosis (destruction of WBC). Pts must comply with life-long, frequent blood draws (WBC/ANC).
atypical - Olanzapine - side effect
(Ola is severely heavy)
Zyprexa (olanzapine): also works well, but associated with severe weight gain (average = 28 pounds in first-year), DM, lipid abnormalities.
atypical - Risperdal (risperidone) - side effect
(risper is unsteady and heavy)
Risperdal (risperidone): (most like typical antipsychotics) fewer anticholinergic side effects (considered safer in the elderly), but some orthostatic hypotension and weight gain.
atypical - Seroquel - what abnormal lab?
Seroquel (quetiapine): most common side effects include orthostatic hypotension and sedation (often given off label for anxiety, agitation and insomnia). Can also cause some weight gain and lipid abnormalities.
Ziprasidone - typical or atypical)
atypical
atypical - Abilify - MOA (pip is able to stabilize dopamine)
Abilify (aripiprazole): technically a “Third generation antipsychotic (TGA); dopamine stabilizer; efficacy less clear
Newer SGAs (second generation psychotics): (larisa in 2nd)
Larisadone and Asenapine
Newer TGAs (third generation antipsychotics): (Brex’s car is 3rd generation, but new)
brexpiprazole and Cariprazine
Atypical Decanoates: (a typical deacon taking Zs with Susan Vega)
Zyprexa Relprevv, Invega Sustenna
how to select which med
Conditions that contraindicate a certain med
Past response to a med in patient or relative
Predicted adherence
Present clinical status: PO or IM needed?
Genetic testing (CYP450 (liver) SNPs)
pregnancy
how to select which med
Vital signs, especially BP
MSE (one sign is fever)
Labs, especially CBC, LFTs, baseline glucose
EKG in elderly or PRN (esp with geodon) range of motion - some can cause dystonic symptoms - to assess - hold out arm and bend elbow, if it’s not smooth- it’s cogwheel rigidity - can be a sign of parkinsonism.
ROM
Polypharmacy - which meds metabolized by P450?
Polypharmacy - the possible complications are infinite. 80% of drug-drug interactions are not tested. All psychotropics except lithium are metabolized by cytochrome P450 (a class of 30+ hepatic isoenzymes) and many drugs can inhibit this.
Geriatric patients are more likely to develop which side effects?
confusion, agitation, restlessness, delirium, lethargy and orthostatic hypotension.
Plasma levels - indicated in the following circumstances (think the main drugs…and allergic)
most common are depakote and lithium
Possible nonadherence
Partial or poor response or adverse reaction
Monitoring side effects, especially in elderly
Determining drug-drug interactions
monotherapy is best - meaning 1 antipsychotic or just one drug.
Extrapyramidal symptoms (EPS) - what about dopamine?
Extrapyramidal symptoms (EPS) - caused by blockade of D2 receptors in the extrapyramidal motor system. Be careful to assess properly before giving any meds to treat EPS. Improper administration can cause or exacerbate anticholinergic crisis (which can look like delirium or worsening psychosis).
Parkinsonism - characteristics (a form of EPS) (Fox is slow and heavy) and pain?
Fatigue
Lack of interest
Slowness
Heaviness
Lack of ambition
Vague body discomforts
Dystonias
muscle spasms of the face, head, neck and back
dystonia - Oculogyric crisis
eyes rolled upward (treatment usually given IM)
dystonia - Torticollis –(stoned tortoise)
Torticollis – twistindg of cervical muscles w/ unnatural head position
dystonia - Retrocollis (retro stoned)
Retrocollis – head drawn directly backwards
dystonia - Glossospasm (glossy-eyed stoner) –
Glossospasm – stiff or thick tongue (most common) ppl will talk funny with this one
dystonia Usually occurs during what time frame?
first three months of treatment, but can happen anytime
risk factors for dystonia (young man is stoned)
Risk factors include: high-potency FGAs (first generation antipsychotics), high doses, IM injections, young males
treatment for dystonia/glossospasm? (Art has a stoned BAC)
Treatment is IM***(because this is emergent) Benadryl, Cogentin or Artane
Akathisia (Akilia can’t stop moving)
Akathisia - motor restlessness accompanied by the subjective sense of restlessness, nervousness and in patients.
Tardive dyskinesia (TD) - (what body parts) (tardy tongue)
Tardive dyskinesia (TD) - involuntary tonic muscular spasms typically involving the tongue, fingers, toes, neck, trunk or pelvis
TD - when does it occur?
Usually occurs after long-term treatment (months to years)
Often irreversible (50%)
Risk is up to 5-10% with typicals, 1% with atypicals.
TD - how to treat?
Historically, treatment is to switch antipsychotics while slowly tapering original antipsychotic.
Neuroleptic malignant syndrome (NMS) - caused by what neurotransmitters? (and one more)
caused by dopamine deficiency in nigrostriatum (controls movement) and hypothalamus (regulates BP and temp).
NMS - Seen in patients on which meds? (Fox takes a holiday from names)
antipsychotics and in Parkinson’s patients on a “drug holiday.”
NMS - risk factors (name the young males who get IM)
Risk factors include: use of FGAs, esp. high potency e.g. (Haldol, Prolixin), rapid titration, IM meds, young males
NMS - emergency? and what diseases does it cause? (name the rhab)
NMS is a medical emergency. Mortality rate =10% (complications include renal failure, rhabdomyolysis and DVTs)
NMS - s/sx (Akila is MAD as F at NMS)
**must know this - muscular rigidity, akinesia, dysphagia, fever
NMS - treatment
Hold all antipsychotics
Antipyretics, cooling blankets
Antidepressants - how long to start working?
Antidepressants – all have delayed onset (can take four to six weeks for full effects)
Tricyclics (TCAs) - works best for which patients?
Oldest group of antidepressants (first discovered in the 1950s), therefore well studied and inexpensive
May work best for clients with severe major depression
Monoamine oxidase inhibitors (MAOIs) EX -
(phen is trans w/ mono)
e.g. Tranylcypromine, Phenelzine
Many drug interactions (many drugs are metabolized by MAO. For example, patients must be off MAOIs at least two weeks before beginning other antidepressants)
Requires intensive teaching on the tyramine-reduced diet (e.g. avoid Chianti wine, smoked meats, aged cheeses, Fava beans, MSG, etc.)
Selective serotonin reuptake inhibitors (SSRIs) - ex (just the 3 main ones)
e.g. fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil)
SSRIs
Newest and most widely used antidepressants (first-line agent)
Less side effects than TCAs and MAOIs
Side effects include HA, nausea, insomnia, initial anxiety/agitation and sexual side effects
Monitor closely for serotonin syndrome (slow metabolizers are at risk) and withdrawal syndrome
Many off-label uses (e.g. premature ejaculation)
Buproprion (Wellbutrin) - worst side effect if you take too much
acts on norepinephrine and dopamine (NDRI), rather than serotonin. Useful for clients who experience sexual side effects with SSRIs. Also used for smoking cessation (Zyban). Side effects include insomnia, seizures (only if you exceed the max dose), sweating. really not that helpful.
Mirtazapine (Remeron) - MOA- (Mirt makes me happy) and used for what?
is a norepinephrine and serotonin specific antidepressant (NaSSA).
Venlafaxine - what type of drug? (venla is a snail)
an SNRI.
Dysvenlafaxine (Pristiq), Levomolnacipran (Fetzima) and Duloxetine (Cymbalta) are (and esp good for what?)
the newest SNRIs. Cymbalta may also be effective for chronic pain. esp good for severe depression.
Desyrel - MOA (desrell makes me happy) and what else can it cause? and what is it used for? (desrell no issues there)
predominantly serotonergic. Used more for insomnia 2/2 side effect of pronounced sedation. Can cause priapism.
Esketamine (Spravato) - esp good for what?
is an NMDA receptor antagonist and a dissociative agent. Used especially for TRD (treatment resistant depression) and SI. Ketamine is also given off label for other conditions.
Brexanolone (Zulresso) (brex just had a baby)
is a neuroactive steroid given IV for postpartum depression.
panic disorder - how long?
Panic disorder - recurrent panic attacks followed by a month or more of persistent concern about having another panic attack — needs to be treated urgently
Generalized anxiety disorder - how long?
excessive, for 6 months, but no panic attacks.
what important assessment for anxiety?
Important to assess if anxiety is chronic (a.k.a. trait anxiety) vs situational or reactive anxiety (e.g., following a severe loss or stressor).
treatment for anxiety - benzos
Benzodiazepines are best for short-term, situational anxiety and initially for panic disorder. Provide immediate relief, but high potential for addiction/withdrawal requires careful screening. Less abuse potential with longer acting BZDs (e.g. Klonopin). Always assess respirations and level of sedation!
treatment for anxiety - SSRIs
SSRIs, especially Prozac, Lexapro and Zoloft and Paxil, are first-line agents for long-term maintenance and for chronic anxiety. SNRIs like Effexor and Cymbalta are also used frequently.
social anxiety - use propranolol
treatment for anxiety - Buspirone (Buspar) - how long to work? and who don’t they work for? (bupe doesn’t work for us)
Buspirone (Buspar) is a non-benzodiazepine and not addictive. However, it takes a few weeks to work and is often ineffective, particularly in patients who have a history of PSA. only about 30% effective.
general considerations w/ anxiety
Always teach non pharmacological relaxation techniques as well (e.g., deep breathing, progressive relaxation, guided imagery)
Monitor for side effects carefully, especially in the elderly (e.g. paradoxical agitation)
Screen for history of SUD prior to giving BZDs. Monitor for s/sx of abuse and/or withdrawal.
during a panic attack - use someone’s name, short statements “breathe with me”
drug detox
Etoh: BZDs (Ativan - used for elderly, safer for liver - 2nd choice), Librium (long half life, best choice), Serax, Valium)
Opiates: Clonidine (inpatient), Methadone, Buprenorphine
Disulfiram (Antabuse) –
Disulfiram (Antabuse) – produces extreme reaction (e.g. flushing, severe HA, sweating, increased BP, pulse) if patient drinks
Naltrexone (Revia)
Naltrexone (Revia) blocks the euphoric effects of opioids
Aside from BAD, mania can be induced by (3 things)
drugs, neurologic conditions and metabolic disorders.
Benzodiazepines or atypical antipsychotics (e.g. Zyprexa, Risperdal) can be used as an
adjunct until mood stabilizers take effect.
Antidepressants & mania?
precipitate (trigger) mania
lithium - do we understand the MOA?
Very efficacious, especially for mania/BAD Type I, but mechanism of action is still poorly understood (alters electrical conductivity)
lithium is made of what?
salt, so dehydration can cause lithium toxicity
how long for lithium to work?
Therapeutic effect takes two to four weeks.
Lithium levels can be affected by:
Medical illnesses, especially ones with GI effects
Surgery
Crash dieting
Very hot climate (diaphoresis/dehydration)
Advanced age
lithium is metabolized more in kidneys than the liver
Strenuous exercise
who doesn’t respond to lithium? (lithium doesn’t mix)
20 to 40% of patients do not respond to Li, especially BAD clients with more pronounced depressive symptoms or mixed episodes
lithium - how often for blood draws?
Initial blood draws are done one to two times a week, then monthly. Dosage and administration and lab draws should be standardized (i.e., done at the same time of day each time).
lithium - Mild to moderate toxicity number
Mild to moderate toxicity – 1.5 to 2.0 mEq/L
lithium -Severe toxicity - (number)
Severe toxicity - > 2.0 mEq/L
lithium is hard on what organs?
THYROID AND KIDNEYS**
