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Psychiatry > Psych Pharms > Flashcards

Psych Pharms Flashcards

1
Q

2 Major antipsychotic classes

A

Dopamine receptor antagonists (typical antipsychotics)

Serotonin-dopamine antagonists (atypical antipsychotics)

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2
Q

Indications for antipsychotic use

A
  • psychotic disorders
  • dementia (esp. with behavioral Sx)
  • augmentation in MDD and OCD (major depressive disorder, obsessive compulsive disorder)
  • tic disorders
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3
Q

Typical antipsychotic actions

A

D2 antagonists
Also antagonists of M1, H1 and alpha-1 receptors
-M1: muscarinic cholinergic block

DA receptor block is immediate, but antipsychotic effect takes weeks

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4
Q

D2 block effects

A
  • antipsychotic effect (mesolimbic pathway)
  • worsens negative Sx (mesocortical pathway)
  • movement disorders and EPS (nigrostriatal pathway)
  • hyperprolactinemia (tuberoinfundibular pathway)
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5
Q

Muscarinic cholinergic block effects

A
  • Ach and Da have reciprocal relationship in nigrostriatal pathway
  • cholinergic block mitigates effects of D2 block in nigrostriatal pathway
  • therefore less EPS
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6
Q

4 Dopamine pathways

A

Mesolimbic
Mesocortical
Nigrostriatal
Tuberoinfundibular

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7
Q

Mesolimbic pathway

A
  • Hyperactivity of DA -> hallucinations, delusions, thought disorders
  • Role in aggressive Sx
  • drugs that increase DA -> psychotic Sx
  • antipsychotics decreases Da (blocks receptors)
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8
Q

Mesocortical Pathway

A
  • Projects to different brain areas

- DA deficit -> role in neg. and cogn. Sx

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9
Q

Causes of low DA

A
  • excito-toxicity of glutamate system
  • 2ndary inhibition by excess serotonin
  • D2 block by antipsychotics
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10
Q

Nigrostriatal Pathway

A
  • part of extrapyramidal nervous system
  • controls motor movements
  • decreased DA -> movement disorders and EPS
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11
Q

Tuberoinfundibular Pathway

A

-controls prolactin secretion

DA inhibits prolactin secretion

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12
Q

Acute Management of Psychosis

A 
Chemical restraints for aggression:
- Lorazepam 2-4mg IMI
                 \+
- Antipsychotic with acute onset IMI
     - Haloperidol
     - Olanzapine (not with BZ)
     - Ziprasidone
     - Zuclopenthixol acetate

-Decide if admission is necessary

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13
Q

Haloperidol dose

A

5-10mg 2-4hrly (max 40mg/d)

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14
Q

Olanzapine dosage

A

10mg 2-4hrly (max 30mg/d)

-don’t use with a benzodiazepine!! (Eg lorazepam)

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15
Q

Ziprasidone dosage

A

10-20mg 4hrly (max 40mg/d)

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16
Q

Zuclopenthixol acetate dosage

A

50-100mg per 72h (max 400mg over 2w)

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17
Q

Typical Antipsychotics

A 
Haloperidol
Chlorpromazine
Trifluoperazine
Fluphenazine
Pimozide
Sulpride
Flupenthixol
Zuclopenthixol

Peak [ ]

  • oral 1-4h
  • IV 30-60m

High potency ass. w.

  • increased EPS
  • decreased anticholinergic activity
  • decreased epileptogenic effect
18
Q

Atypical Antipsychotics

A 
Clozapine
Risperidone
Olanzapine
Quietapine
Aripiprazole
Ziprasidone
Paliperidone
Amisulpride
Sulpiride

5-HT2A and D2 antagonism
5-HT1A agonism - increases DA release in prefrontal cortex and decreased glutamate release (Clozapine, Quietapine, Ziprazidone)

19
Q

Typical AP SE

A

Neuroleptic induced movement disorders

-EPSE & tardive dyskinesia

20
Q

Atypical AP SE

A 
Metabolic disturbances (dyslipidemia, hyperglycemia, obesity)
Cardiac conduction abnormalities
21
Q

Indications for Atypicals

A
  1. Severe EPS
  2. Tardive dyskinesia
  3. Young person with 1st episode
  4. Better for neg. Sx
  5. Rx resistant: clozapine
  6. Rechallenge after NMS
  7. Unacceptable prolactin levels
  8. Mood Sx and suicide risk
  9. Elderly with behavioural Sx
22
Q

Acute Dystonia

A

Risk of acute dystonia increased:

  • high potency meds
  • young males

Def: painful, prolonged contraction of muscles resulting in abnormal movements/posture

  • torticollis of neck
  • trismus of jaw
  • protrusion of tongue
  • dysphagia
  • laryngo-pharyngeal spasm
  • oculogyric crisis (eyes turn upwards)
23
Q

Acute Dystonia Rx

A

Biperidine 5mg IVI/IMI

24
Q

Parkinsonism Rx

A

Tremors, rigidity, bradykinesia

  1. Anticholinergics
    -orphenadrine 50mg PO 1-3x/d
    OR
    -biperidine 2mg 1-3x/d
  2. Lower the dose of AP meds
  3. If severe, replace with atypical
25
Q

Akathisia Sx

A
  • restless & agitated

- unable to sit still

26
Q

Akathisia Rx

A
  1. B-blocker: propranolol 10-30mg tds
  2. Benzodiazepine: eg lorazepam
  3. Lower the AP dose (if possible) or change to atypical
27
Q

Tardive Dyskinesia

A

Abnormal involuntary movements

  • oral movements, tongue protrusion, grimaces
  • choreoathetosis (involuntary twitching or writhing) of extremities and abnormal postures

Appears very late (>4y); irreversible

Risk fx: female, elderly, high dose

28
Q

Tardive dyskinesia Rx

A

-irreversible

Reduce dose
Stop anticholinergics
Try atypical esp. clozapine

29
Q

Neuroleptic Malignant Syndrome Sx

A
  • emergency - potentially lethal
  • occurs in 1st week of Rx

Muscle rigidity and fever with:

  • diaphoresis
  • autonomic instability (labile BP/tachycardia)
  • tremor
  • dysphagia
  • mutism
  • incontinence
  • leukocytosis
  • change in lvl of consciousness (delirium)
  • lab evidence of injured muscle (increased CK)
30
Q

Neuroleptic Malignant Syndrome Management

A
  1. Stop antipsychotics
  2. Admit to high care
  3. Exclude other serious conditions
  4. Supportive measures:
    - cool off pt
    - hydrate
    - monitor vitals
    - nasogastric tube
  5. Diazepam/Lorazepam for muscle rigidity
  6. DVT prophylaxis / avoid anticholinergics
  7. Beware renal failure (increased CK/myoglobin)
  8. If all else fails: dantrolene/bromocriptine
  9. If no response: ECT
    10: rechallenge - with low dose, atypical, or ECT
31
Q

Clozapine indications

A

Rx resistant schizophrenia
Intolerable EPS
Tardive dyskinesia

Commonly causes sedation and hypersalivation

32
Q

Clozapine risks

A 
Granulocytosis (monitor WBC)
Myocarditis
Toxic megacolon
Seizures at high doses
Metabolic syndrome
33
Q

Depot AP preparations

A

Use in those who are non-compliant to treatment regimen

Use after oral medication efficacy has been demonstrated

34
Q

MDD Rx

A

Psychoeducation
Meds
CBT, ECT, DBS

SSRI - selective serotonin reuptake inhibitors
SNRI - serotonin and norepinephrine reuptake inhibitors
TCA - tricyclic antidepressants
MAOI - Monoamine oxidase inhibitors
NDRI - Norepinephrine dopamine reuptake inhibitors
SARI - Serotonin antagonist and reuptake inhibitors
NASSA - Noradrenergic and specific serotonin antidepressants
NRI - Norepinephrine reuptake inhibitors

35
Q

SSRI - selective serotonin reuptake inhibitors

A

Fluoxetine
Citalopram
Paroxetine
Sertraline

36
Q

SNRI - serotonin and norepinephrine reuptake inhibitors

A

Venlafaxine

Duloxetine

37
Q

TCA - tricyclic antidepressants

A

Amitryptiline
Imipramine
Desipramine

38
Q

MAOI - Monoamine oxidase inhibitors

A

Tranylcypromine

Moclobemide

39
Q

NDRI - Norepinephrine dopamine reuptake inhibitors

A

Buproprion

40
Q

SARI - Serotonin antagonist and reuptake inhibitors

A

Trazodone

41
Q

NASSA - Noradrenergic and specific serotonin antidepressants

A

Mirtazapine

42
Q

NRI - Norepinephrine reuptake inhibitors

A

Reboxetine

Atomoxetine

Psychiatry (8 decks)

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