Psychiatry Flashcards
1
Q
When was the DSM-5 published?
A
May 2013
2
Q
When was the DSM-5, TR published?
A
March 2022
3
Q
What is the difference between the DSM-5 and DSM-5 TR?
A
DSM-5, TR contains further SDOH and cultural factors in diagnosis
4
Q
Why was the DSM-5 reorganized from the previous edition?
A
to reflect disorders across continuum based on developmental and lifespan considerations
5
Q
What disorders are categorized under neurodevelopmental disorders in the DSM-5?
A
-intellectual disabilities and delays
-communication disorders
-autism spectrum disorders
-attention-deficit/hyperactivity disorder (ADHD)
6
Q
What is the order of bipolar and related disorders, depressive disorders, and schizophrenia spectrum in the DSM-5?
A
schizophrenia spectrum, bipolar and related disorders, depressive disorders
7
Q
What are the separate chapters for anxiety disorders in the DSM-5?
A
anxiety disorders, obsessive-compulsive and related disorders, trauma- and stressor-related disorders
8
Q
What criteria is used for substance-related disorders?
A
criteria is set for all substances, but vary with symptom presentation based on type of substance used
9
Q
How are the neurocognitive disorders organized in the DSM-5?
A
-categorized into major and mild neurocognitive disorders
-specifiers include type
10
Q
What rating scales are clinically useful for depression?
A
-Patient Health Questionnaire (PHQ-9)
-Beck Depression Inventory (BDI)
11
Q
What is the purpose of the PHQ-9?
A
screen for depression and suicidal thinking
12
Q
Who rates the PHQ-9?
A
patient
13
Q
Who rates the Beck Depression Inventory (BDI)?
A
patient
14
Q
Who rates the Mood Disorders Questionnaire (MDQ)?
A
patient
15
Q
What gold standard research rating scales are used for depression?
A
-Hamilton Depression (HAM-D, HDRS)
-Montgomery-Asberg Depression Rating Scale (MADRS)
16
Q
Who rates the Hamilton Depression?
A
clinician
17
Q
What rating scales are used for bipolar disorder and generalized anxiety?
A
-Young Mania Rating Scale (YMRS)
-Hamilton Anxiety Rating Scale (HAM-A)
18
Q
How is the Young Mania Rating Scale rated?
A
by the clinician based on patient reports
19
Q
What gold standard rating scales are used for schizophrenia in clinical trials?
A
-Positive and Negative Syndrome Scale (PANSS)
-Brief Psychiatric Rating Scale (BPRS)
20
Q
Who rates the Positive and Negative Syndrome Scale?
A
clinician
21
Q
Who rates the Brief Psychiatric Rating Scale?
A
clinician
22
Q
What rating scales are used for the movement side effects of antipsychotics?
A
-Simpson-Angus (SAS)
-Barnes Akathisia Rating Scale (BARS)
23
Q
What does the Simpson-Angus (SAS) evaluate?
A
drug-induced Parkinsonian symptoms
24
Q
Who rates the Simpson-Angus (SAS)?
A
clinician
25
Who rates the Barnes Akathisia Scale (BARS)?
clinician
26
What rating scales are used for tardive dyskinesia/overall movement side effect assessment?
-Abnormal Involuntary Movement Scale (AIMS)
-Extrapyramidal Symptoms Rating Scale (ESRS)
27
What does the Abnormal Involuntary Movement Scale (AIMS) evaluate?
tardive dyskinesia
28
Who rates the Abnormal Involuntary Movement Scale (AIMS)?
clinician
29
Who rates the Extrapyramidal Symptoms Rating Scale (ESRS)?
clincian
30
What does the Extrapyramidal Symptoms Rating Scale (ESRS) evaluate?
Parkinsonian symptoms, akathisia, dystonia, and tardive dyskinesia
31
What rating scales are used for overall psychiatric functioning assessments?
-Clinical Global Impressions (CGI)
-Global Assessment of Functioning (GAF)
32
What does the CGI-S measure?
severity of psychiatric functioning
33
What does the CGI-I measure?
improvement of psychiatric functioning
34
Who rates the Clinical Global Impressions (CGI)?
observer
35
What is the Clinical Global Impressions (CGI) used for?
to assess change of overall psychiatric functioning over time
36
Who rates the Global Assessment of Functioning (GAF)?
clinician
37
What are the three hypotheses of schizophrenia?
-serotonin hypothesis
-glutamate hypothesis
-dopamine hypothesis
38
serotonin hypothesis of schizophrenia
-LSD and mescaline identified as serotonin agonists
-5HT2A receptor is mediator of hallucinations
-5HT2A receptors modulate dopamine release in cortex, limbic region, and striatum; glutamate release; and NMDA receptors
-antagonistic and inverse agonistic activity causes antipsychotic activity
-5HT2C agonists may be beneficial in schizophrenia
39
Which two noncompetitive inhibitors of NMDA receptors exacerbate psychosis?
phencyclidine and ketamine
40
dopamine hypothesis of schizophrenia
-dopaminergic agents exacerbate symptoms of schizophrenia
-increased D2 receptor density, dopamine release, and receptor occupancy in schizophrenia patients
41
What receptors are antagonized by antipsychotics?
-dopamine (major)
-serotonin
-norepinephrine (minor)
-acetylcholine (minor)
-histamine (minor)
42
Are D1 or D2 receptors a more effective drug target?
D2 receptors
43
Where are the primary therapeutic effects of D2 antagonists in the CNS?
mesolimbic system
44
When do extrapyramidal symptoms appear?
early (days to weeks)
45
Are extrapyramidal symptoms reversible?
Yes
46
What are extrapyramidal symptoms?
-dystonia
-pseudoparkisonism
-tremor
-akathisia
47
When does tardive dyskinesia appear?
late (months to a year)
48
Is tardive dyskinesia reversible?
No
49
How can tardive dyskinesia be treated?
-reduce dose of current agent
-change to different drug (preferably newer agent)
-eliminate anticholinergic drugs
-VMAT inhibitors
50
What are the effects of muscarinic cholinoceptor blockade?
-loss of vision
-difficulty urinating
-dry mouth
-constipation
51
What are the effects of alpha adrenoceptor blockade?
-orthostatic hypotension
-impotence
-failure to ejaculate
52
What are the effects of dopamine receptor blockade in the CNS?
-Parkinson's syndrome
-akathisia
-dystonia
-tardive dyskinesia
53
What is the effect of muscarinic blockade?
toxic-confusional state
54
What is the effect of histamine receptor blockade?
sedation
55
What are the effects of dopamine receptor blockade in the endocrine system?
-amenorrhea
-galactorrhea
-infertility
-impotence
56
What is the effect of histamine and serotonin blockade?
weight gain
57
What are the aliphatic phenothiazines?
-chlorpromazine
-promethazine
58
What is the piperidine phenothiazine?
thioridazine
59
What are the piperazine phenothiazines?
-fluphenazine
-prochlorperazine
-perphenazine
60
What is the thioxanthine?
thiothixene
61
What is the butyrophenone?
haloperidol
62
What are the miscellaneous typical first generation antipsychotics?
-molindone
-pimozide
63
chlorpromazine clinical pearls
-first antipsychotic (no longer first-line)
-antihistamine side effects
64
promethazine clinical pearls
-antihistamine
-antiemetic
65
thioridazine side effects
-anticholinergic side effects
-sedation
-sexual dysfunction
-cardiovascular effects
66
fluphenazine side effect
EPS
67
prochlorperazine use
antiemetic
68
perphenazine clinical pearl
cheap yet effective option
69
thiothixene side effect
modest EPS
70
haloperidol side effect
EPS
71
molindone side effect
moderate EPS
72
pimozide use
Tourette's disease
73
typical first generation antipsychotic clinical pearl
movement side effects (EPS and tardive dyskinesia) due to strong D2 block
74
clozapine clinical pearls
-first atypical antipsychotic
-highly effective
-agranulocytosis
-risk of diabetes
75
olanzapine clinical pearls
-weight gain
-risk of diabetes
76
quetiapine clinical pearls
-metabolite with antidepressant activity
-hypotension
-sedation
77
risperidone mechanism of action
5HT2A/D2 receptor antagonist
78
ziprasidone clinical pearls
-5HT2A/D2 receptor antagonist
-alpha-1 affinity
-QTc prolongation
79
lurasidone clinical pearls
-5HT2A/D2 receptor antagonist
-reduced metabolic effects
-rapid titration
80
aripiprazole clinical pearls
-high 5HT2A/D2 affinity
-partial agonist activity
81
atypical second generation antipsychotic clinical pearls
-reduced EPS
-potential efficacy for negative symptoms
-similar/enhanced 5HT2A vs. D2 receptor antagonism
-metabolic problems
-linked to diabetes (greater risk in patients < 50 y/o)
82
What drug is currently in development or under investigation for schizophrenia?
dual M1/M4 muscarinic agonist combined with peripheral muscarinic antagonist
83
What are examples of positive symptoms in schizophrenia?
-delusions
-hallucinations
-disorganized thinking and speech
-disorganized or abnormal motor behavior
84
When is schizophrenia typically diagnosed?
late adolescence to early adulthood
85
Is schizophrenia diagnosed earlier in men or women?
men
86
What is associated with the induction of 1A2?
smoking
87
What effect does smoking have on 1A2 antipsychotic drug concentrations?
decreases serum concentration
88
What are the effects of marijuana, cocaine, and amphetamine on schizophrenia?
-hasten onset
-exacerbate symptoms
-reduce time to relapse
89
What route of administration for antipsychotics is considered first-line?
oral
90
What typical antipsychotic is most commonly used?
haloperidol
91
What are the partial agonist antipsychotics?
-aripiprazole
-brexpiprazole
-cariprazine
92
What side effect are partial agonist antipsychotics associated with more than others?
akathisia
93
What is the boxed warning for partial agonist antipsychotics?
suicidal thoughts/behavior
94
What substrate is aripiprazole?
2D6 and 3A4
95
What substrate is brexpiprazole?
2D6 and 3A4
96
What substrate is cariprazine?
3A4
97
What are the side effects of partial agonist antipsychotics?
-moderate akathisia
-low-moderate weight gain (only low for aripiprazole)
98
asenapine clinical pearls
-sublingual and patch formulations
-1A2 and UGT substrate
-QTc prolongation
99
clozapine clinical pearls
-1A2 substrate
-boxed warnings for neutropenia, orthostasis, bradycardia, syncope, seizures, myocarditis, cardiomyopathy
-side effects: sedation, weight gain, constipation, hypersalivation, dry mouth, GI hypomotility with obstruction risk, QTc prolongation
100
olanzapine clinical pearls
-1A2 substrate
-significant weight gain and sedation
-high risk metabolic syndrome
-DRESS warning
101
quetiapine clinical pearls
-3A4 substrate
-QTc prolongation
-weight gain and sedation
-boxed warning for suicidal ideation
102
What is the brand name for the asenapine transdermal patch?
Secuado
103
What is the dosing frequency of Secuado?
Q24H
104
What are the monitoring timelines for clozapine?
-weekly for 6 months
-biweekly for 6 months
-every 4 weeks
105
What is samidorphan?
opioid antagonist with preferential activity at mu opioid receptor
106
iloperidone clinical pearls
-high risk for orthostasis and syncope
-QTc prolongation
-2D6 substrate
107
lurasidone clinical pearls
-5HT2A/D2 receptor antagonist
-reduced metabolic effects
-rapid titration
-3A4 substrate
-higher risk for akathisia
-warning for suicidal thoughts
-take with food to increase bioavailability
108
ziprasidone clinical pearls
-5HT2A/D2 receptor antagonist
-alpha-1 affinity
-QTc prolongation (contraindication)
-DRESS warning
-take with food to increase absorption and bioavailability
-3A4 and aldehyde oxidase substrate
109
risperidone clinical pearls
-2D6 substrate
-side effects: EPS, hyperprolactinemia, weight gain, sedation, orthostasis
110
paliperidone clinical pearls
-renally eliminated
-similar side effects with risperidone
-QTc prolongation
111
lumateperone clinical pearls
-low risk for weight gain or metabolic side effects
-low risk for EPS or akathisia
-3A4 substrate
112
pimavanserin clinical pearls
-FDA-approved for treatment of hallucinations or delusions in patient with Parkinson's Disease
-5HT2A inverse agonist and antagonist
-3A4 substrate
113
haloperidol injection clinical pearls
-Q4W
-loading dose: 20x PO dose
-maintenance: 10x PO dose (may need PO overlap)
-Z-track injection technique
114
What is the generic for Risperdal Consta?
risperidone
115
Risperdal Consta clinical pearl
must supplement with PO risperidone or other antipsychotic for first few weeks of treatment
116
What is the generic for Perseris?
risperidone
117
Perseris clinical pearls
-abdominal subcutaneous injection
-use 120 mg dose or may need PO supplementation for patients taking 3A4 inducers
118
What is the generic for Rykindo?
risperidone
119
Rykindo clinical pearls
-Q2W IM injection
-1 week PO dose overlap
120
What is the generic for Uzedy?
risperidone
121
Uzedy clinical pearls
-abdominal or upper arm subcutaneous injection
-Q1M or Q2M
122
What is the generic for Invega Sustenna?
paliperidone
123
Invega Sustenna clinical pearls
-loading dose --> booster --> Q4W
-loading and booster dose must be given in deltoid to improve absorption consistency
-PO overlap not needed
-may require dose adjustment in moderate to severe renal impairment
124
What is the generic for Invega Trinza?
paliperidone
125
Invega Trinza clinical pearls
-may be initiated for patient on stable monthly IM injection of Invega Sustenna for at least 4 doses
-Q3M
-recommended to inject in deltoid
-not recommended if CrCl <50 mL/min
126
What is the generic for Invega Hafyera?
paliperidone
127
Invega Hafyera clinical pearls
-may be initiated after stable Invega Sustenna for 4 months OR Invega Trinza for 1 dose
-gluteal injection only
128
What is the generic for Zyprexa Relprevv?
olanzapine
129
What is required for the dispensing of Zyprexa Relprevv?
REMS
130
What is a side effect of Zyprexa Relprevv?
post-dose delirium sedation syndrome (PDSS)
131
What is the generic for Abilify Maintena?
aripiprazole
132
Abilify Maintena clinical pearls
-must overlap with PO aripiprazole or other antipsychotic for at least 14 days after first injection
-deltoid or gluteal injection
-must adjust dose if taking 2D6/3A4 inhibitors OR 3A4 inducers >14 days as concomitant therapy
133
What is the generic for Abilify Asimtufii?
aripiprazole
134
Abilify Asimtufii clinical pearls
-Q2M
-gluteal injection only
-continue PO aripiprazole for 14 days after first injection
135
What is the generic for Aristada?
aripiprazole lauroxil
136
Aristada clinical pearl
overlap with PO aripiprazole for 21 days after first injection
137
Aristada Initio clinical pearls
-21 day PO overlap not needed
-avoid in patients who are poor 2D6 metabolizers or taking strong 2D6/3A4 inhibitors
138
What IR antipsychotic injections are used in psychiatric emergencies?
-haloperidol
-chlorpromazine
-fluphenazine
139
What cannot be given at the same time as a benzodiazepine IR injection?
olanzapine IR IM injection
140
What IR antipsychotic is an inhalation used for psychiatric emergencies?
loxapine
141
What is used to treat acute dystonia?
IM anticholinergic (benztropine 2 mg OR diphenhydramine 50 mg)
142
What is used to treat drug-induced Parkinson's?
oral anticholinergic (benztropine, trihexyphenidyl, diphenhydramine)
143
What is used to treat akathisia?
-beta-blocker (propranolol)
-benzodiazepine (lorazepam)
144
What is used to treat tardive dyskinesia?
VMAT inhibitors
145
What are VMAT inhibitors?
-valbenazine
-deutetrabenazine
146
valbenazine clinical pearls
-2D6/3A4 substrate
-QTc prolongation
147
deutetrabenazine clinical pearls
-2D6 substrate
-QTc prolongation
148
What are symptoms of neuroleptic malignant syndrome?
-hyperpyrexia
-tachycardia
-labile blood pressure
-muscle rigidity
149
Is future antipsychotic use contraindicated in patients with a history of neuroleptic malignant syndrome?
No
150
What are metabolic adverse effects from antipsychotics?
-hyperglycemia
-hyperlipidemia
-hypertension
151
What is the main target for sleep medications?
GABA
152
What are the effects of benzodiazepines?
-facilitate GABA action
-increase frequency of chloride channel opening
153
Which benzodiazepine has a long half-life?
diazepam
154
Which benzodiazepine has a slow elimination rate?
diazepam
155
Which benzodiazepine has an intermediate elimination rate?
clonazepam
156
Which benzodiazepine has a rapid elimination rate?
midazolam
157
Do barbiturates or benzodiazepines have a clinically safer profile?
benzodiazepines
158
How do benzodiazepines affect sleep physiology?
-decrease REM
-decrease stage 3 and 4
159
What is flumazenil used for?
to treat benzodiazepine overdose
160
Which non-benzodiazepines are approved for short-term treatment of insomnia?
-zolpidem
-zaleplon
161
Which non-benzodiazepine is approved for long-term treatment of insomnia?
eszopiclone
162
Which barbiturate is long-acting?
phenobarbital
163
Which barbiturate is short- to intermediate-acting?
pentobarbital
164
What is a side effect of barbiturates?
respiratory depression
165
What are the effects of barbiturates?
-increase duration of channel opening
-direct effects on GABAa channel
166
What are the effects of non-benzodiazepines?
-bind to GABAa BZ1 receptors of alpha-1
-increase frequency of GABAa channel opening
167
What is a concern with gamma-hydroxybutyric acid (GHB)?
no antagonist treatment
168
What is the mechanism of action of ramelteon?
melatonin agonist
169
What is a benefit of ramelteon?
no abuse, withdrawal, or dependency risk
170
What is the mechanism of action of tasimelteon?
melatonin agonist
171
What is the drug registration of tasimelteon?
orphan product
172
What is the mechanism of action of suvorexant?
orexin receptor antagonist
173
Where are orexin receptors located?
hypothalamus
174
What is the effect of suvorexant?
reduce rewarding stimuli via receptors that modulate mesolimbic projections between VTA and nucleus accumbens
175
What is the mechanism of action of buspirone?
5HT1A receptor partial agonist
176
Is the onset of action of buspirone shorter or longer than benzodiazepines?
longer (adaptive response)
177
What is a benefit of buspirone?
low abuse potential
178
What drugs can cause anxiety?
-albuterol
-caffeine (high doses)
-decongestants
-levothyroxine
-steroids
-stimulants
179
What is buspirone approved for?
generalized anxiety disorder
180
What is the target dose of buspirone?
10-15 mg PO TID
181
How long does buspirone take for initial efficacy?
3-4 weeks
182
Is long-term use of benzodiazepines recommended?
No
183
What can acute withdrawal of benzodiazepines lead to?
life-threatening seizures
184
What are the warnings for benzodiazepines?
-concomitant use with other CNS depressants
-overdose death risk
185
Which benzodiazepines have a lower fall risk?
-alprazolam
-lorazepam
-clonazepam
-oxazepam
186
Which benzodiazepines have long-acting active metabolites?
-diazepam
-clorazepate
-chlordiazepoxide
187
What are side effects of benzodiazepines?
-sedation
-paradoxical excitement
-swallowing difficulties
-impairment of memory and recall
-psychomotor impairment
188
Which benzodiazepines are preferred in the elderly?
-lorazepam
-oxazepam
-temazepam
189
What is hydroxyzine approved for?
generalized anxiety disorder
190
Is hydroxyzine used as maintenance or "as needed" therapy?
as needed
191
What are side effects of hydroxyzine?
-sedation
-anticholinergic side effects
-QTc prolongation
192
What population should hydroxyzine be avoided in?
elderly
193
What is the effect of propranolol?
decrease physiological symptoms of acute anxiety
194
What is propranolol used for?
performance and situational anxiety
195
Is propranolol used in low or high doses for anxiety?
low doses
196
What are considerations for the use of propranolol?
history of/current asthma and cardiovascular conditions
197
kava clinical pearls
-may cause hepatotoxicity and platelet aggregation
-may aggravate symptoms of Parkinson's disease
198
St. John's Wort clinical pearls
-strong 3A4 inducer
-avoid drug-drug interactions
199
valerian clinical pearls
-avoid in pregnant women
-potential hepatotoxicity
200
passionflower clinical pearls
-may cause dizziness, ataxia, and confusion
-avoid in pregnancy
201
chamomile clinical pearl
avoid with blood thinners and ragweed/daisy allergy
202
In what patient populations can gabapentinoids be considered in?
-bipolar disorder with anxiety symptoms
-comorbid neuropathic pain
203
Is quetiapine endorsed to use in insomnia?
No
204
What is first-line therapy for anxiety disorders?
SSRIs, SNRIs, or buspirone
205
For what anxiety disorder can atypical antipsychotics be used for?
treatment-resistant OCD (aripiprazole and risperidone)
206
What are the DSM-5, TR diagnostic criteria for generalized anxiety disorder?
-excessive anxiety/worry for at least 6 months
-symptoms include at least 3 of the following: restlessness/feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind "going blank," irritability, muscle tension, sleep disturbances
207
When are SNRIs considered before SSRIs for generalized anxiety disorder?
if patient has pain syndrome
208
When are benzodiazepines used for generalized anxiety disorder?
bridge therapy until onset of SSRI/SNRI only if necessary
209
What are the DSM-5, TR diagnostic criteria for social anxiety disorder?
-persistent fear about social and/or performance situations in which patient fears embarrassment or humiliation that is unreasonable
-specific situations may be avoided in manner that interferes with patient's normal routine
-duration of symptoms for at least 6 months
210
What are the DSM-5, TR diagnostic criteria for panic disorder?
-recurrent, unexpected panic attacks
-at least one attack has been followed by ≥1 month of ≥1 of the following: persistent concern about additional attacks or their consequences or significant maladaptive change in behavior related to attacks
211
What SNRI is approved for the treatment of panic disorder?
venlafaxine
212
How much reduction in symptoms can be expected in the treatment of OCD?
25% - 50%
213
What is second-line treatment for OCD?
clomipramine
214
What are the DSM-5, TR diagnostic criteria for PTSD?
-exposure to real or threatened death, serious injury, or sexual violence
-flashbacks
-re-experiencing
-avoidance
-hypervigilance
-negative alterations in mood or cognition
215
What drug may be helpful for sleep or nightmares in patients with PTSD?
prazosin
216
What drug is NOT recommended in PTSD?
benzodiazepines
217
What nonpharmacological treatments may be helpful in PTSD?
-cognitive behavior therapy (CBT)
-eye movement desensitization and reprocessing (EMDR)
218
What can result from the use of SSRIs and SNRIs when treating anxiety disorder?
"jitteriness" syndrome
219
What is the onset of action for SSRIs and SNRIs?
2-4 weeks
220
What disease states, medications, and substances are associated with insomnia?
-anxiety
-mood disorders
-amphetamines
-beta agonists
-beta blockers
-bupropion
-caffeine
-decongestants
-methylphenidate
-modafinil
-nicotine
-thyroid medications
221
What are the DSM-5, TR diagnostic criteria for insomnia disorders?
-difficulties with sleep initiation, sleep maintenance, and/or early-morning awakening
-takes place at least 3 nights per week
-present for at least 3 months
222
What is first-line treatment of insomnia disorders?
nonpharmacological
223
What are the most commonly used sleep medications for the treatment of insomnia disorders?
z-hypnotics
224
What is the initial dose of zolpidem in women and the elderly?
5 mg
225
What drug has a metallic taste?
eszopiclone
226
What substrates are z-hypnotics?
3A4
227
What are side effects of z-hypnotics?
-somnolence
-dizziness
-ataxia
-headaches
228
What benzodiazepine is used for insomnia?
temazepam
229
What warning do all FDA-approved insomnia medications have?
sleep behavior
230
What is ramelteon contraindicated with?
fluvoxamine
231
What are side effects of ramelteon?
-GI upset
-next day somnolence
-hyperprolactinemia
-prolactinoma
232
What is tasimelteon FDA-approved for?
non-24 sleep-wake disorder in adults
233
What substrates are melatonin agonists?
1A2
234
How much sleep does a patient need to get if taking an orexin receptor antagonist?
7 hours
235
What are orexin receptor antagonists contraindicated in?
narcolepsy
236
What substrates are orexin receptor antagonists?
3A4
237
What side effects does doxepin have?
anticholinergic
238
Is trazodone FDA-approved for insomnia?
No
239
Does trazodone have a long or short half-life?
long half-life
240
What is mirtazapine used for?
sleep agent, especially in patients with depression who have difficulty sleeping
241
What are the DSM-5, TR diagnostic criteria for obstructive sleep apnea?
-evidence of at least 5 obstructive apneas per hour of sleep confirmed by polysomnography
-symptoms: excessive daytime sleepiness, snoring, pauses in breathing during sleep, headache, irritability, sore throat, erectile dysfunction, impaired memory, GERD, mood disturbance
242
When should a polysomnography be used over home sleep apnea testing?
significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, sleep-related hypoventilation, chronic opioid medication use, history of stroke, or severe insomnia
243
What are nonpharmacological treatments for sleep apnea?
-weight loss (adjunctive)
-smoking cessation
-avoid alcohol and CNS depressants
-sleep on side rather than back
-continuous positive airway pressure (CPAP)
244
What medications can be used to treat excessive daytime sleepiness in sleep apnea?
-modafinil
-armodafinil
245
What is the narcolepsy tetrad?
-excessive daytime sleepiness (EDS)
-cataplexy
-hallucinations
-sleep paralysis
246
What drugs are used to treat cataplexy?
-Xyrem
-Xywav
-Lumryz
247
Which drug used for cataplexy has the lowest sodium content?
Xywav
248
Which drug used for cataplexy is approved in children?
Xywav
249
What drugs are used to treat excessive daytime sleepiness?
-modafinil
-armodafinil
-sodium oxybate
-pitolisant
-solriamfetol
250
pitolisant clinical pearls
-H3 receptor antagonist/inverse agonist
-contraindicated in severe hepatic impairment
-QTc prolongation
-2D6/3A4 substrate
-may reduce effectiveness of oral contraceptives
-avoid with centrally acting H1 receptor antagonists (OTC antihistamines)
251
solriamfetol clinical pearls
-dopamine norepinephrine reuptake inhibitor
-indicated for improvement in wakefulness in adults with excessive daytime sleepiness due to narcolepsy or obstructive sleep apnea
-warnings: BP and HR increase; use with caution in patients with history of psychosis or bipolar disorder; use with caution with dopaminergic drugs
252
What drugs are used to treat shift work sleep disorder?
-modafinil
-armodafinil
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When should modafinil/armodafinil be taken for shift work sleep disorder?
1 hour before work period starts
254
What drugs are used to treat restless leg syndrome?
-gabapentin enacarbil
-dopamine agonists (pramipexole and ropinirole)
-iron supplementation
255
What are the DSM-5, TR diagnostic criteria for anorexia nervosa?
-restriction of energy intake leading to significantly low body weight
-intense fear of gaining weight or becoming fat
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What are the specifier types for anorexia nervosa?
-restricting type
-binge-eating/purging type
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What are health consequences of anorexia nervosa?
-abnormally slow HR and low BP
-decreased bone density
-muscle weakness
-electrolyte abnormalities
-hypoglycemia
-dry skin
-hair loss
-severe dehydration
-downy layer of hair on body
-cold intolerance
-delayed gastric emptying
-constipation
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What is refeeding syndrome?
shift from fat metabolism to glucose metabolism
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What are physiological effects of refeeding syndrome?
-hypokalemia
-water retention
-severe edema
-multiple organ failure
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What are the recommended treatments for anorexia nervosa?
-increase calories slowly
-cognitive behavioral therapy
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What medication is contraindicated in anorexia nervosa?
bupropion
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What are the DSM-5, TR diagnostic criteria for binge eating disorder?
-recurrent episodes of binge eating
-occurs at least once a week for 3 months
-NOT associated with recurrent use of inappropriate compensatory behavior
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What are the severity specifiers for binge eating disorder and bulimia nervosa?
-mild: 1-3 episodes/week
-moderate: 4-7 episodes/week
-severe: 8-13 episodes/week
-extreme: ≥14 episodes/week
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What are the health consequences of binge eating disorder?
-hypertension
-elevated cholesterol
-CV disease
-T2DM
-gallbladder disease
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What are the recommended treatments for binge eating disorder?
-lisdexamfetamine (FDA-approved)
-CBT and medication (best outcomes)
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What are the DSM-5, TR diagnostic criteria for bulimia nervosa?
-recurrent episodes of binge eating
-recurrent inappropriate compensatory behavior
-occurs at least once a week for 3 months
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What are the health consequences of bulimia nervosa?
-digestive tract complications
-amenorrhea
-orthostatic hypotension
-bradycardia
-arrhythmias
-osteopenia
-osteoporosis
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What are the methods of purging?
-vomiting
-laxatives
-diuretics
-excessive exercise
-"diabulimia"
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What are the recommended treatments for bulimia nervosa?
-fluoxetine (FDA-approved)
-CBT and medication (best outcomes)
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What are the diagnostic criteria for ADHD?
-at least 6 symptoms present for each symptom domain
-at least 5 symptoms required for either of two specifiers for older adolescents and adults
-several inattentive or hyperactive symptoms present before 12 y/o
-symptoms present in ≥2 settings
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stimulant dosing considerations
-quick onset of action
-do not calculate dose for pediatric patients based on mg/kg
-IR preferred for patients <16 kg
-avoid giving dose late in day
-late afternoon symptoms may require longer-acting formulation
-do not use two different stimulants; only different dosage forms of SAME stimulant
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What drug needs to be dosed differently for children with ADHD?
mydayis
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What dosage formulation is Daytrana?
transdermal patch
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What is the active metabolite of lisdexamfetamine?
dextroamphetamine
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What are the adverse effects of stimulants?
-appetite loss
-abdominal pain
-headaches
-sleep disturbances
-decreased growth
-hallucinations or other psychotic symptoms
-increased BP and HR
-sudden cardiac death
-priapism
-peripheral vasculopathy
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What is the monitoring for stimulants?
-appetite
-behavior
-blood pressure
-growth rate
-heart rate
-sleep
-ECG (if cardiac risk)
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What are the alpha-2 agonists used to treat ADHD?
-guanfacine ER
-clonidine ER
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What substrate is guanfacine?
3A4
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Why should alpha-2 agonists be tapered if discontinued?
to avoid rebound hypertension
280
What norepinephrine reuptake inhibitors are used to treat ADHD?
-atomoxetine
-viloxazine
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What substrate is atomoxetine?
2D6
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How is atomoxetine dosed?
weight-based dosing (cutoff is 70 kg)
283
What substrate is viloxazine?
2D6/UGT; strong 1A2 inhibitor
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What are adverse effects of alpha-2 agonists?
-decreased HR and BP
-orthostasis
-somnolence
-dizziness
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What are side effects of norepinephrine reuptake inhibitors?
-increased HR and BP
-increased in suicidal thinking (boxed warning)
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What are monitoring parameters for non-stimulants?
-appetite
-behavior
-BP
-growth rate (atomoxetine)
-HR
-LFTs (atomoxetine)
-sleep
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bupropion clinical pearls
-not FDA-approved for ADHD
-2D6 inhibitor
-contraindicated in seizure and eating disorders
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tricyclic antidepressant clinical pearls
-less effective than methylphenidate
-cardiac concerns
289
mood stabilizer and atypical antipsychotic clinical pearls
-may be useful if comorbid bipolar disorder, conduct disorder, and/or intermittent explosive disorder
-should not use atypical antipsychotics as monotherapy
290
What medication is first-line for preschool age patients with ADHD?
methylphenidate
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What medication is first-line for elementary/middle school/adolescent patients with ADHD?
stimulants
292
What medication is second-line for elementary/middle school/adolescent patients with ADHD?
-atomoxetine
-guanfacine ER
-clonidine ER
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What medications are used as adjunctive therapy in ADHD?
-guanfacine ER
-clonidine ER
294
What is the stepwise treatment guideline for adults with ADHD?
-methylphenidate OR lisdexamfetamine
-dextroamphetamine
-atomoxetine
