Psych Pharm Flashcards
What are the HAM side effects?
Anti-
Histamine (causing sedation and weight gain)
Adrenergic (causing hypotension)
Muscarinic (causing dry mouth, blurred vision, urine and fecal retention)
Commonly seen with TCAs and low potency 1st gen antipsycotics
What are the signs/symptoms of serotonin syndrome?
Confusion, flushing, diaphoresis, tremor, myoclonis, hyperthermia, and hypertonicity that can lead to rhabdo, renal failure, and death
Which drugs have serotonin syndrome as a possible side effect?
Classically (as in on tests) when SSRIs and MAOIs are combined
What foods should be avoided with MAOIs? why?
ingestion of tyramine rich foods (red wine, cheese, liver, cured meats) can lead to a buildup of catecholamines causing a hypertensive crisis.
What are the signs/symptoms of extrapyramidal side effects (EPS)?
- Parkinsonism: mask-like face, cogwheel rigidity, bradykinesia, pill-rolling tremor
- akathesia
- dystonia
Note this is reversible and starts soon (hours to days) after starting a new drug/dose
Which drugs have EPS as a possible side effect?
High potency 1st gen anti-psychotics
Which drugs have hyperprolactinemia as a possible side effect?
High potency 1st gen anti-psychotics and risperidone
What are the signs/symptoms of tardive dyskinesia?
Choreo like movements of the mouth and tongue –> grimacing and protrusion of the tongue
Note this is usually irreversible and occurs after years of drug use
Which drugs have tardive dyskinesia as a possible side effect?
High potency 1st gen anti-psychotics
Which drugs are considered high potency 1st gen (typical) anti-psychotics?
Holy Fuck That’s Psycho!
Haloperidol
Fluphenazine
Trifluoperazine
Pimozide
What are the signs/symptoms of Neuroleptic malignant syndrome?
- Altered Mental Status*
also: fever, tachycardia, hypertension, elevated CPK, “lead pipe” rigidity (resistance to even passive movement)
Which drugs have Neuroleptic malignant syndrome as a possible side effect?
ALL antipsychotics, but increased risk with high potency 1st gen anti-psychotics
Which drug class is known to exacerbate dementias?
anticholinergics
What are the 6 SSRIs that NBME wants us to know?
Effective For Panic, Sadness, & Fucked-up Compulsions
(also serves as a reminder of the indications: Anxiety, PTSD, depression, OCD)
Escitalopram Fluoxetine Paroxetine Sertraline Fluvoxamine Citalopram
What are the 3 SNRIs that NBME wants us to know?
Vexed and Depressed, Dude
(also serves as a reminder of the indications: Anxiety and Depression)
Venlafaxine
Duloxetine
Desvenlafaxine
What is the treatment for EPS?
stop the anti-psychotic and give the patient beztropine
What are the 3 TCAs that NBME wants us to know?
ACID North Dakota
(ACID are the tertiary amines that work on both NE and 5HT2. These have a higher risk of OD. ND work predominately on NE.)
Amitriptyline
Clomipramine
Imipramine
Doxepin
Nortriptyline
Desipramine
How does buproprion work?
NE-DA reuptake inhibitor
What is the most common side effect of SSRIs?
decreased libido
What are the 3 MAOIs that NBME wants us to know?
TIP
Tranylcypromine
Isocarboxazid
Phenelzine
What is the treatment for acute TCA OD?
IV sodium bicarb
How do 1st Gen antipsychotics work?
They are D2 agonists. They treat primarily positive psychotic symptoms
How do 2nd Gen antipsychotics work?
They are 5HT2 and D4>D2 agonists. they treat both positive and negative psychotic symptoms.
What is the major side effect of 2nd Gen (atypical) antipsychotics?
Metabolic syndrome
What are the 2nd Gen antipsychotics?
Honestly there are a bunch. Just remember it’s anything ending in -azine that is not one of the 1st Gen antipsychotics.
Remeber them?
Holy Fuck That’s Psycho!
Haloperidol
Fluphenazine
Trifluoperazine
Pimozide
A patient on an antipsychotic comes in with jaundice and a purple-grey metallic rash over her sun exposed areas. What medication is she taking?
chlorpormazine
A patient on an antipsychotic comes in with prolonged QTc and pigmentary retinopathy. What medication is she taking?
Thioridazine
A patient on an antipsychotic comes in complaining of his eyes “stuck” looking up (or his head is “stuck” turned to the side)
What is this called?
What class of medication is he taking?
What is the treatment?
Is it permanent?
This is dystonia. He is likely taking a high potency anti-psychotic.
Treatment is benztropine or diphenhydramine
It is not permanent.
A patient on an antipsychotic comes in and reports feeling like they “always have to move.”
What is this called?
What class of medication is he taking?
What is the treatment?
Is it permanent?
This is akathesia. He is likely taking a high potency anti-psychotic.
1st line treatment is propranolol (you have to monitor BP as it can make them hypotensive)
It is not permanent.
A patient on an antipsychotic comes with coarse resting tremor, masked facies, unsteady gait, and bradykinesia..
What is this called?
What class of medication is he taking?
What is the treatment?
Is it permanent?
Parkinsonism He is likely taking a high potency anti-psychotic.
You treat with benztropine/diphenhydramine, amantidine or bromocriptine. DO NOT treat medication related parkinsonism with L-dopa!!
It is not permanent.
A new psychotic patient of yours who has been on fluphenazine for 8 years presents with new onset involuntary tongue movements and grimacing.
What is this called?
What is the treatment?
Is it permanent?
Tardive Dyskinesia.
You treat by stopping the antipsychotic and switching to an atypical or clozapine.
Unfortunately this is likely permanent.
2 hours after giving a psychotic patient haloperidol (or metoclopramide, compazine or droperidol) IV for safety concerns he beings to develop ↑CPK, Tmax 103F, rigidity, autonomic instability, and delirium.
What is this called?
What is the treatment?
Neuroleptic Malignant Syndrome.
You treat by 1st d/c the offending med.
Then you cover with cooling blankets and give dantroline Na
What are SSRIs prescribed for?
MDD, OCD, bulemia, anxiety, PTSD, Premenstraul dysphoria, and premature ejaculation
Which SSRI has the most drug-drug interactions? why?
Paroxetine. It utilizes Cyp450 the most.
Which SSRI has the shortest half-life? What does this mean for us?
Fluoxetine
You don’t have to taper it when stopping.
Which SSRI has the fewest drug-drug interactions?
Citalopram
What is serotonin discontinuation syndrome? With which SSRIs is it most common?
If a patient suddenly stops an SSRI (most commonly sertraline and fluvoxamine) they may develop HA, n/v/d, dizziness and fatigue.
What is serotonin syndrome? Which combination of drugs classically causes it?
Clonus, diaphoresis, agitation, tachycardia, high
BP, hyperreflexia, n/v/d.
Classically SSRIs and MAOIs
“Oh no! I’ve started taking my SSRI but now I cant get it up! What can you do, Doc?”
Switch to buproprion
“Oh no! I started taking this drug you gave me and now I’ve had an erection for >4 hours! What did you give me?”
most likely trazadone
more like trazaBONE! amarite?! anyone? I’ll show myself out…
Your patient is a 90yo 90lb lady who says that she has been too sad to eat or sleep since “My Gerald passed a couple years back.”
What is the drug of choice for her? why?
Mirtazepine. in addition to being an anti-depressant it also increases appetite and sleep.
Your patient comes in for a 1 month follow up after starting them on an SNRI, you notice that their BP is markedly elevated from before. What herbal supplement are they likely taking?
St. Johns Wort.
I don’t know why but Emma Ramahi says it was on her shelf and who the hell am I to disagree
Little Billy, being the nosy little shit that he is, got into mommy’s purse and ate some pills. Mommy has MDD and fibromyalgia. Billy comes to the ED with a widened QRS and prolonged QT. He also has dry mouth, tachycardia, vomiting, urinary retention, and seizures.
What was the drug class?
How could this kill him?
What is the treatment?
Tricyclic Antidepressant
Arrhythmia –>torsades–> v-fib–> death
Treat with activated charcoal if ingestion w/in 1-2hrs.
Give IV sodium bicarbonate as it reduces metabolic acidosis and is cardioprotective
What are the 2 weight neutral antipsychotics?
Ziprazodone (may prolong the QTc)
Aripiprazole (may increase akathesia)
Which antipsychotic is MOST associated with weight gain?
Olazepine
