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Psychiatric Drug Flashcards

1
Q

How long before the antidepressants take effect?

A

Clinical Onset often takes up to 2 weeks

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2
Q

What are the types of antidepressants

A
  1. Tricyclic Antidepressants (TCA)
  2. Selective Serotonin ReUptake Inhibitors (SSRI)
  3. Atypical Agents
  4. Monoamine Oxidase Inhibitors
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3
Q

MOA of TCA

whats the common uses

samples of TCA

A

Mechanism of action

  • Inhibit synaptic reuptake of norepinephrine and serotonin
  • Variable antagonist activity at histamine, anti-muscarinic acetylcholine, α1 adrenergic, NMDA, μ1-opioid receptors, sodium channel blockade

Common medications

  • Amitriptyline
  • imipramine
  • desipramine
  • doxepin
  • nortriptyline

Common uses

  • Depression, chronic pain (neuropathic and fibromyalgia), some forms of acute pain
  • Use decreasing due to side effects
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4
Q

What are the common side effects of TCA

A
  • Postural Hypotension
  • Urinary retention
  • blurred vision
  • dried mouth
  • Hypotension - common
  • QTC prolongation
  • DELIRIUM - CHOLINERGIC DEFICIENCY
  • SEROTONIN SYNDROME
  • NARROW THERAPEUTIC INDEX
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5
Q

drug class that has a narrow therapeutic index

what are the changes that you can see?

A

TCA

Narrow therapeutic index

  • Can cause EKG changes particularly with overdose; non-symptomatic EKG changes will subside with time
  • Flattening/inversion of T waves, widening of QRS complex, prolongation of QT interval, bundle branch block, premature ventricular contractions, conduction abnormities, ventricular arrhythmias

​​Reduction of seizure threshold (dose-dependent) – Caution use with tramadol or meperidine

Serotonin syndrome

  • Avoid use with MAO-I – inhibit breakdown of neurotransmitters (i.e., dopamine, serotonin, norepinephrine)
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6
Q

What effect will chronic TCA use have with pressors

A
  • Decreased response to sympathomimetics with chronic (>6 weeks) TCA use [MORE DRUG TO GET APPROPRIATE RESPONSE]
    • Adrenergic receptors are sensitized, downregulation of β receptors or catecholamine stores depleted
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7
Q

What effect will acute TCA use have with pressors

A

Sympathomimetic agents

  • Exaggerated response of sympathomimetics with new TCA starts – Increased amount of catecholamines present to stimulate post-synaptic receptors due to norepinephrine reuptake blockade
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8
Q

What effect will TCA use have with the induction of anesthesia

A
  • Possible increased incidence of cardiac dysrhythmias (mostly with halothane)
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9
Q

you have a patient on TCA. which drug for N/V when given may cause excessive sedation?

A

Anticholinergic agents (i.e., diphenhydramine,

scopolamine)

  • Additive side effects with anticholinergic drugs –> increased risk for excess sedation, postoperative delirium, confusion
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10
Q

Why would there be an augmented analgesic and ventilatory effects of opioids when used with TCA?

A

Because TCA has CYP450 inhibition

–> may increase opioids and sedatives in the system

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11
Q

SSRI MOA

A

Mechanism of action

– Major mechanism: inhibits the reuptake of serotonin

– Minor mechanisms:

  • Inhibits norepinephrine reuptake
  • Inhibits dopamine uptake
  • Histamine, musarinic receptor antagonist
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12
Q

SSRI that has an active metabolite

A

Fluoxetine

* maybe given to a patient without parenteral access and liver dysfunction because of an active metabolite and long half-life (1-4 days)

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13
Q

Your patient on Fluvoxamine has been NPO for 45 hours (2ish days). what can you expect?

A

You may see withdrawal symptoms

* Fluvoxamine has the shortest half-life among SSRIs (15 h)

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14
Q

SSRI common SE

A

*Should not have much SEDATION

QTC prolongation

*lesser effects when it comes to sedation as compared to TCA

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15
Q

SSRI: FLUOXETINE

ADVERSE SE

A
  • BRADYCARDIA
  • SYNCOPAL OCCASIONAL OCCURENCE IN ELDERLY PATIENTS
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16
Q

What can you expect in an SSRI withdrawal?

when do you see it?

A
  • Dizziness,GI complaints,flu-like symptoms,anxiety, insomnia, paresthesias, myalgia, visual disturbances
  • Requires atleast ~1month therapy to be at risk
  • More severe with shorter acting agents paroxetine,Fluvoxamine)
  • Seen within 1-7days after discontinuation
  • Taper before discontinuation
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17
Q

Serotonin Syndrome

A

– Avoid use with MAO-I or have an adequate washout

– Cautious use with drugs with MAO-I properties(i.e, opioids, linezolid, methylene blue)

– Have adequate washout of the drug from the system if possible

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18
Q

MIRTAZAPINE

POTENT ANTAGONIST OF

A
  • Potent antagonist of 5-HT2 and 5-HT3 serotonin receptors and H1 histamine receptors
  • Moderate peripheral α1 adrenergic and muscarinic antagonist
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19
Q

NE:SE reuptake inhibitors

SE

A

decrease seizure threshold

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20
Q

TRIAZOLOPYRADINES

sample agents

used for insomnia

where is it metabolized?

SE?

A

Agents

  • trazodone
  • nefazodone

Mechanism of action

  • Serotoninreuptakeinhibition
  • α1 antagonist, histamine antagonist

Hepatic metabolism through CYP450

  • +activemetabolites
  • Inhibits CYP450

Common adverse effects

  • Qtc Prolongation
  • Sedation
21
Q

Anesthesia considerations in patients receiving SSRI

SIGNS OF Serotonin Syndrome

when does it occur?

what is the tx

what is the ideal washout period before starting MAOI inhibitor?

A

Signs of serotonin syndrome (occurs within 24h)

  • Hyperthermia[fever!!], confusion, agitation, autonomic hyperactivity, myoclonus, hyperreflexia, diaphoresis, tremor, diarrhea, neuromuscular abnormalities, ocular clonus
  • Treatment: stop offending agent + begin supportive care + serotonin antagonists
  • Serotonin antagonists: cyproheptadine –

Prevention

• Ideal washout period before starting MAOI inhibitor is 14 days

22
Q

If your patient got codeine, what can happen to it when given with SSRI?

A

SSRI can inhibit the metabolism of Codeine to morphine

  • may get inadequate analgesia
23
Q

DRUGS THAT INCREASE THE RISK OF SEROTONIN SYNDROME WHEN GIVEN WITH SSRI

A
  • Antiemetic (metoclopramide, ondansetron)
  • Fentanyl
  • Linezolid
  • Meperidine
  • Methadone
  • Tramadol
  • Valproic acid
25
## Footnote **SE OF BUPROPRION**
## Footnote **SEIZURE RISK**
26
## Footnote **MAOI SE**
SEDATION THE FACT THAT THERE ARE DRUG INTERACTION!
27
How long is the duration of **MAOI inhibition?**
## Footnote **10 - 14 days**
28
**MAO- I** - what does it do to tyramine
29
How will MAOIs affect vasopressor effects?
**May increase risk of vasopressor effect and _hypertensive crisis_** ## Footnote * Inhibits systemic clearance of catecholamines via inhibition of MAO- dependent degradation * **May need to use 1/3 of the normal dose of vasoactive medication**
30
What drugs should you absolutely **AVOID with MAOI?** burn this in your brain
**_MEPERIDINE AND TRAMADOL_**
31
**LITHIUM** MOA What is the goal?
Goal cerum concentrration (maintenance) **0.6 - 1 meq/L**
32
**LITHIUM** CHRONIC SIDE EFFECTS
**CHRONIC SIDE EFFECT** * **N**ephrogenic diabetes insipidus * **P**olyuria/ polydipsia * **H**ypothyroidism * **M**yxedema coma
33
LITHIUM ## Footnote **ACUTE OVERDOSE**
* Nausea, vomiting, diarrhea * Confusion * Tremor * Myoclonus * Seizures * Coma * _T-wave inversion_ Ventricular arrhythmias
34
Conditions that are contraindicated with **Lithium** may increase **lithium toxicity**
**_Renal Insufficiency_ - highly renally cleared** **Hyponatremia** 90% of Li+ is reabsorbed in proximal convoluted tubule and competes with Na+ reabsorption
35
**DRUG INTERACTIONS** pertinent to anesthesiology
**mostly risk for AKI** so be careful with diuretics
36
What did Mona say about Typical Antipsychotics?
that they are not much used anymore-- probably just **Haldol** only because it's very convenient its IV and can also be given IM
37
what do Antipsychotics block? MOA?
everything. **Mechanism of action** * Blocks histamine, α1 , cholinergic, dopamine, serotonin receptors to varying degrees * Typical antipsychotics * **High D2 antagonism and low 5-HT2A antagonism** * Atypical antipsychotics * Moderate to high D2 antagonism and high 5-HT2A antagonism
38
How ARE **Antipsychotics** **Metabolized?**
## Footnote **_LIVER_ JUST LIKE EVERYTHING ELSE** **extensive CYP** **hALF LIFE 18-40 HOURS**
39
**Antipsychotic side effects** **what do you worry about?** **WHAT ARE THE TREATMENTS?** **TD** **DY** **AKA** **PARK**
movement type of disorders **Tardive dyskinesia** occurs in up to 20% of patients taking antipsychotics for \>1 year * ***_No treatment (anticholinergics worsen symptoms)_*** **Dystonia** occurs in ~2% of patients within f**irst 72 hours** * ***_TREATMENT:***_ Response quickly to _***IV diphenhydramine 25-50 mg, Benztropine 2 mg, dose reduction/drug avoidance_*** Antipsychotics: Extrapyramidal side effects **Akathisia** * ***_Treatment: propranolol 20-120mg/day(generallyfirstline),_*** **_benzodiazepines, anticholinergic (benztropine), amantadine or clonidine_** **Parkinsonism** * ***_Treatment : dose reduction/drug avoidance and anticholinergic (benztropine)_***
40
TREATMENT FOR **TARDIVE dyskinesia**
**No treatment (anticholinergics worsen symptoms)**
41
TREATMENT FOR **DYSTONIA**
**Dystonia** occurs in ~2% of patients within first 72 hours TREATMENT: Response quickly to **IV diphenhydramine 25-50 mg, Benztropine 2 mg, dose reduction/drug avoidance**
42
## Footnote **TREATMENT FOR AKATHISIA**
**Akathisia** Treatment: **propranolol 20-120mg/day (generally first line)**, **benzodiazepines, anticholinergic (benztropine), amantadine or clonidine**
43
**TREATMENT FOR PARKINSONISM**
Parkinsonism Treatment : **dose reduction/drug avoidance and anticholinergic (benztropine)**
44
a rare but **fatal condition resulting from abrupt dopamine blockade**
**NEUROLEPTIC MALIGNANT SYNDROME** ## Footnote May occur even after discontinuation of antipsychotics especially if long acting depot agents are used - high fever and profound muscle contraction - rigidity rhabdo
45
SEVERE **NEUROLEPTIC MALIGNANT SYNDROME** CAN BE **TREATED** WITH?
**DANTROLENE IV** \*pt might be unable to take PO medications
46
DRUGS THAT WILL INCREASE THE RISK fOR MALIGNANT HYPERTHERMIA
* Malignant hyperthermia associated with anesthesia and with **central anticholinergic syndrome may mimic neuroleptic malignant syndrome** * Additive effect with sedating medications * **QTc prolongation (common drugs used perioperatively)**
47
**Where are benzos metabolized?** If you have a pt that was on benzos before their liver resection, what should you consider before restarting the medication?
LIVER \* THINK BEfore you start the same dose that they are at home **\* LIVER DYSFUNCTION** --\> RESP. DISTRESS, EXTRA SEDATION
48
Anesthesiology considerations in patients receiving benzodiazepines
* Additive effects with other sedating agents * **Increase sensitivity in elderly patients** * Careful with dosing in patients after hepatectomies or with new onset liver dysfunction * **Delirium associated with benzodiazepines** * Abrupt stopping of chronic therapy can precipitate withdrawal * **May cause prolonged sedation** * **Perform careful medication reconciliation**

Anesthesia Pharm (25 decks)

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