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PHRM845 > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

When was the DSM-5 published?

A

May 2013

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2
Q

When was the DSM-5, TR published?

A

March 2022

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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

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4
Q

Why was the DSM-5 reorganized from the previous edition?

A

to reflect disorders across continuum based on developmental and lifespan considerations

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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)

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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

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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

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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

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9
Q

How are the neurocognitive disorders organized in the DSM-5?

A

-categorized into major and mild neurocognitive disorders
-specifiers include type

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10
Q

What rating scales are clinically useful for depression?

A

-Patient Health Questionnaire (PHQ-9)
-Beck Depression Inventory (BDI)

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11
Q

What is the purpose of the PHQ-9?

A

screen for depression and suicidal thinking

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12
Q

Who rates the PHQ-9?

A

patient

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13
Q

Who rates the Beck Depression Inventory (BDI)?

A

patient

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14
Q

Who rates the Mood Disorders Questionnaire (MDQ)?

A

patient

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15
Q

What gold standard research rating scales are used for depression?

A

-Hamilton Depression (HAM-D, HDRS)
-Montgomery-Asberg Depression Rating Scale (MADRS)

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16
Q

Who rates the Hamilton Depression?

A

clinician

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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)

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18
Q

How is the Young Mania Rating Scale rated?

A

by the clinician based on patient reports

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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)

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20
Q

Who rates the Positive and Negative Syndrome Scale?

A

clinician

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21
Q

Who rates the Brief Psychiatric Rating Scale?

A

clinician

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22
Q

What rating scales are used for the movement side effects of antipsychotics?

A

-Simpson-Angus (SAS)
-Barnes Akathisia Rating Scale (BARS)

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23
Q

What does the Simpson-Angus (SAS) evaluate?

A

drug-induced Parkinsonian symptoms

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24
Q

Who rates the Simpson-Angus (SAS)?

A

clinician

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25
Q

Who rates the Barnes Akathisia Scale (BARS)?

A

clinician

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26
Q

What rating scales are used for tardive dyskinesia/overall movement side effect assessment?

A

-Abnormal Involuntary Movement Scale (AIMS)
-Extrapyramidal Symptoms Rating Scale (ESRS)

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27
Q

What does the Abnormal Involuntary Movement Scale (AIMS) evaluate?

A

tardive dyskinesia

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28
Q

Who rates the Abnormal Involuntary Movement Scale (AIMS)?

A

clinician

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29
Q

Who rates the Extrapyramidal Symptoms Rating Scale (ESRS)?

A

clincian

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30
Q

What does the Extrapyramidal Symptoms Rating Scale (ESRS) evaluate?

A

Parkinsonian symptoms, akathisia, dystonia, and tardive dyskinesia

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31
Q

What rating scales are used for overall psychiatric functioning assessments?

A

-Clinical Global Impressions (CGI)
-Global Assessment of Functioning (GAF)

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32
Q

What does the CGI-S measure?

A

severity of psychiatric functioning

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33
Q

What does the CGI-I measure?

A

improvement of psychiatric functioning

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34
Q

Who rates the Clinical Global Impressions (CGI)?

A

observer

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35
Q

What is the Clinical Global Impressions (CGI) used for?

A

to assess change of overall psychiatric functioning over time

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36
Q

Who rates the Global Assessment of Functioning (GAF)?

A

clinician

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37
Q

What are the three hypotheses of schizophrenia?

A

-serotonin hypothesis
-glutamate hypothesis
-dopamine hypothesis

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38
Q

serotonin hypothesis of schizophrenia

A

-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

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39
Q

Which two noncompetitive inhibitors of NMDA receptors exacerbate psychosis?

A

phencyclidine and ketamine

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40
Q

dopamine hypothesis of schizophrenia

A

-dopaminergic agents exacerbate symptoms of schizophrenia
-increased D2 receptor density, dopamine release, and receptor occupancy in schizophrenia patients

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41
Q

What receptors are antagonized by antipsychotics?

A

-dopamine (major)
-serotonin
-norepinephrine (minor)
-acetylcholine (minor)
-histamine (minor)

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42
Q

Are D1 or D2 receptors a more effective drug target?

A

D2 receptors

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43
Q

Where are the primary therapeutic effects of D2 antagonists in the CNS?

A

mesolimbic system

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44
Q

When do extrapyramidal symptoms appear?

A

early (days to weeks)

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45
Q

Are extrapyramidal symptoms reversible?

A

Yes

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46
Q

What are extrapyramidal symptoms?

A

-dystonia
-pseudoparkisonism
-tremor
-akathisia

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47
Q

When does tardive dyskinesia appear?

A

late (months to a year)

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48
Q

Is tardive dyskinesia reversible?

A

No

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49
Q

How can tardive dyskinesia be treated?

A

-reduce dose of current agent
-change to different drug (preferably newer agent)
-eliminate anticholinergic drugs
-VMAT inhibitors

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50
Q

What are the effects of muscarinic cholinoceptor blockade?

A

-loss of vision
-difficulty urinating
-dry mouth
-constipation

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51
Q

What are the effects of alpha adrenoceptor blockade?

A

-orthostatic hypotension
-impotence
-failure to ejaculate

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52
Q

What are the effects of dopamine receptor blockade in the CNS?

A

-Parkinson’s syndrome
-akathisia
-dystonia
-tardive dyskinesia

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53
Q

What is the effect of muscarinic blockade?

A

toxic-confusional state

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54
Q

What is the effect of histamine receptor blockade?

A

sedation

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55
Q

What are the effects of dopamine receptor blockade in the endocrine system?

A

-amenorrhea
-galactorrhea
-infertility
-impotence

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56
Q

What is the effect of histamine and serotonin blockade?

A

weight gain

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57
Q

What are the aliphatic phenothiazines?

A

-chlorpromazine
-promethazine

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58
Q

What is the piperidine phenothiazine?

A

thioridazine

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59
Q

What are the piperazine phenothiazines?

A

-fluphenazine
-prochlorperazine
-perphenazine

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60
Q

What is the thioxanthine?

A

thiothixene

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61
Q

What is the butyrophenone?

A

haloperidol

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62
Q

What are the miscellaneous typical first generation antipsychotics?

A

-molindone
-pimozide

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63
Q

chlorpromazine clinical pearls

A

-first antipsychotic (no longer first-line)
-antihistamine side effects

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64
Q

promethazine clinical pearls

A

-antihistamine
-antiemetic

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65
Q

thioridazine side effects

A

-anticholinergic side effects
-sedation
-sexual dysfunction
-cardiovascular effects

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66
Q

fluphenazine side effect

A

EPS

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67
Q

prochlorperazine use

A

antiemetic

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68
Q

perphenazine clinical pearl

A

cheap yet effective option

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69
Q

thiothixene side effect

A

modest EPS

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70
Q

haloperidol side effect

A

EPS

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71
Q

molindone side effect

A

moderate EPS

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72
Q

pimozide use

A

Tourette’s disease

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73
Q

typical first generation antipsychotic clinical pearl

A

movement side effects (EPS and tardive dyskinesia) due to strong D2 block

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74
Q

clozapine clinical pearls

A

-first atypical antipsychotic
-highly effective
-agranulocytosis
-risk of diabetes

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75
Q

olanzapine clinical pearls

A

-weight gain
-risk of diabetes

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76
Q

quetiapine clinical pearls

A

-metabolite with antidepressant activity
-hypotension
-sedation

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77
Q

risperidone mechanism of action

A

5HT2A/D2 receptor antagonist

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78
Q

ziprasidone clinical pearls

A

-5HT2A/D2 receptor antagonist
-alpha-1 affinity
-QTc prolongation

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79
Q

lurasidone clinical pearls

A

-5HT2A/D2 receptor antagonist
-reduced metabolic effects
-rapid titration

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80
Q

aripiprazole clinical pearls

A

-high 5HT2A/D2 affinity
-partial agonist activity

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81
Q

atypical second generation antipsychotic clinical pearls

A

-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)

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82
Q

What drug is currently in development or under investigation for schizophrenia?

A

dual M1/M4 muscarinic agonist combined with peripheral muscarinic antagonist

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83
Q

What are examples of positive symptoms in schizophrenia?

A

-delusions
-hallucinations
-disorganized thinking and speech
-disorganized or abnormal motor behavior

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84
Q

When is schizophrenia typically diagnosed?

A

late adolescence to early adulthood

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85
Q

Is schizophrenia diagnosed earlier in men or women?

A

men

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86
Q

What is associated with the induction of 1A2?

A

smoking

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87
Q

What effect does smoking have on 1A2 antipsychotic drug concentrations?

A

decreases serum concentration

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88
Q

What are the effects of marijuana, cocaine, and amphetamine on schizophrenia?

A

-hasten onset
-exacerbate symptoms
-reduce time to relapse

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89
Q

What route of administration for antipsychotics is considered first-line?

A

oral

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90
Q

What typical antipsychotic is most commonly used?

A

haloperidol

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91
Q

What are the partial agonist antipsychotics?

A

-aripiprazole
-brexpiprazole
-cariprazine

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92
Q

What side effect are partial agonist antipsychotics associated with more than others?

A

akathisia

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93
Q

What is the boxed warning for partial agonist antipsychotics?

A

suicidal thoughts/behavior

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94
Q

What substrate is aripiprazole?

A

2D6 and 3A4

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95
Q

What substrate is brexpiprazole?

A

2D6 and 3A4

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96
Q

What substrate is cariprazine?

A

3A4

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97
Q

What are the side effects of partial agonist antipsychotics?

A

-moderate akathisia
-low-moderate weight gain (only low for aripiprazole)

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98
Q

asenapine clinical pearls

A

-sublingual and patch formulations
-1A2 and UGT substrate
-QTc prolongation

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99
Q

clozapine clinical pearls

A

-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

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100
Q

olanzapine clinical pearls

A

-1A2 substrate
-significant weight gain and sedation
-high risk metabolic syndrome
-DRESS warning

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101
Q

quetiapine clinical pearls

A

-3A4 substrate
-QTc prolongation
-weight gain and sedation
-boxed warning for suicidal ideation

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102
Q

What is the brand name for the asenapine transdermal patch?

A

Secuado

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103
Q

What is the dosing frequency of Secuado?

A

Q24H

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104
Q

What are the monitoring timelines for clozapine?

A

-weekly for 6 months
-biweekly for 6 months
-every 4 weeks

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105
Q

What is samidorphan?

A

opioid antagonist with preferential activity at mu opioid receptor

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106
Q

iloperidone clinical pearls

A

-high risk for orthostasis and syncope
-QTc prolongation
-2D6 substrate

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107
Q

lurasidone clinical pearls

A

-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

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108
Q

ziprasidone clinical pearls

A

-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

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109
Q

risperidone clinical pearls

A

-2D6 substrate
-side effects: EPS, hyperprolactinemia, weight gain, sedation, orthostasis

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110
Q

paliperidone clinical pearls

A

-renally eliminated
-similar side effects with risperidone
-QTc prolongation

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111
Q

lumateperone clinical pearls

A

-low risk for weight gain or metabolic side effects
-low risk for EPS or akathisia
-3A4 substrate

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112
Q

pimavanserin clinical pearls

A

-FDA-approved for treatment of hallucinations or delusions in patient with Parkinson’s Disease
-5HT2A inverse agonist and antagonist
-3A4 substrate

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113
Q

haloperidol injection clinical pearls

A

-Q4W
-loading dose: 20x PO dose
-maintenance: 10x PO dose (may need PO overlap)
-Z-track injection technique

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114
Q

What is the generic for Risperdal Consta?

A

risperidone

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115
Q

Risperdal Consta clinical pearl

A

must supplement with PO risperidone or other antipsychotic for first few weeks of treatment

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5
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116
Q

What is the generic for Perseris?

A

risperidone

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117
Q

Perseris clinical pearls

A

-abdominal subcutaneous injection
-use 120 mg dose or may need PO supplementation for patients taking 3A4 inducers

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118
Q

What is the generic for Rykindo?

A

risperidone

119
Q

Rykindo clinical pearls

A

-Q2W IM injection
-1 week PO dose overlap

120
Q

What is the generic for Uzedy?

A

risperidone

121
Q

Uzedy clinical pearls

A

-abdominal or upper arm subcutaneous injection
-Q1M or Q2M

122
Q

What is the generic for Invega Sustenna?

A

paliperidone

123
Q

Invega Sustenna clinical pearls

A

-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
Q

What is the generic for Invega Trinza?

A

paliperidone

125
Q

Invega Trinza clinical pearls

A

-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
Q

What is the generic for Invega Hafyera?

A

paliperidone

127
Q

Invega Hafyera clinical pearls

A

-may be initiated after stable Invega Sustenna for 4 months OR Invega Trinza for 1 dose
-gluteal injection only

128
Q

What is the generic for Zyprexa Relprevv?

A

olanzapine

129
Q

What is required for the dispensing of Zyprexa Relprevv?

A

REMS

130
Q

What is a side effect of Zyprexa Relprevv?

A

post-dose delirium sedation syndrome (PDSS)

131
Q

What is the generic for Abilify Maintena?

A

aripiprazole

132
Q

Abilify Maintena clinical pearls

A

-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
Q

What is the generic for Abilify Asimtufii?

A

aripiprazole

134
Q

Abilify Asimtufii clinical pearls

A

-Q2M
-gluteal injection only
-continue PO aripiprazole for 14 days after first injection

135
Q

What is the generic for Aristada?

A

aripiprazole lauroxil

136
Q

Aristada clinical pearl

A

overlap with PO aripiprazole for 21 days after first injection

137
Q

Aristada Initio clinical pearls

A

-21 day PO overlap not needed
-avoid in patients who are poor 2D6 metabolizers or taking strong 2D6/3A4 inhibitors

138
Q

What IR antipsychotic injections are used in psychiatric emergencies?

A

-haloperidol
-chlorpromazine
-fluphenazine

139
Q

What cannot be given at the same time as a benzodiazepine IR injection?

A

olanzapine IR IM injection

140
Q

What IR antipsychotic is an inhalation used for psychiatric emergencies?

A

loxapine

141
Q

What is used to treat acute dystonia?

A

IM anticholinergic (benztropine 2 mg OR diphenhydramine 50 mg)

142
Q

What is used to treat drug-induced Parkinson’s?

A

oral anticholinergic (benztropine, trihexyphenidyl, diphenhydramine)

143
Q

What is used to treat akathisia?

A

-beta-blocker (propranolol)
-benzodiazepine (lorazepam)

144
Q

What is used to treat tardive dyskinesia?

A

VMAT inhibitors

145
Q

What are VMAT inhibitors?

A

-valbenazine
-deutetrabenazine

146
Q

valbenazine clinical pearls

A

-2D6/3A4 substrate
-QTc prolongation

147
Q

deutetrabenazine clinical pearls

A

-2D6 substrate
-QTc prolongation

148
Q

What are symptoms of neuroleptic malignant syndrome?

A

-hyperpyrexia
-tachycardia
-labile blood pressure
-muscle rigidity

149
Q

Is future antipsychotic use contraindicated in patients with a history of neuroleptic malignant syndrome?

A

No

150
Q

What are metabolic adverse effects from antipsychotics?

A

-hyperglycemia
-hyperlipidemia
-hypertension

151
Q

What is the main target for sleep medications?

A

GABA

152
Q

What are the effects of benzodiazepines?

A

-facilitate GABA action
-increase frequency of chloride channel opening

153
Q

Which benzodiazepine has a long half-life?

A

diazepam

154
Q

Which benzodiazepine has a slow elimination rate?

A

diazepam

155
Q

Which benzodiazepine has an intermediate elimination rate?

A

clonazepam

156
Q

Which benzodiazepine has a rapid elimination rate?

A

midazolam

157
Q

Do barbiturates or benzodiazepines have a clinically safer profile?

A

benzodiazepines

158
Q

How do benzodiazepines affect sleep physiology?

A

-decrease REM
-decrease stage 3 and 4

159
Q

What is flumazenil used for?

A

to treat benzodiazepine overdose

160
Q

Which non-benzodiazepines are approved for short-term treatment of insomnia?

A

-zolpidem
-zaleplon

161
Q

Which non-benzodiazepine is approved for long-term treatment of insomnia?

A

eszopiclone

162
Q

Which barbiturate is long-acting?

A

phenobarbital

163
Q

Which barbiturate is short- to intermediate-acting?

A

pentobarbital

164
Q

What is a side effect of barbiturates?

A

respiratory depression

165
Q

What are the effects of barbiturates?

A

-increase duration of channel opening
-direct effects on GABAa channel

166
Q

What are the effects of non-benzodiazepines?

A

-bind to GABAa BZ1 receptors of alpha-1
-increase frequency of GABAa channel opening

167
Q

What is a concern with gamma-hydroxybutyric acid (GHB)?

A

no antagonist treatment

168
Q

What is the mechanism of action of ramelteon?

A

melatonin agonist

169
Q

What is a benefit of ramelteon?

A

no abuse, withdrawal, or dependency risk

170
Q

What is the mechanism of action of tasimelteon?

A

melatonin agonist

171
Q

What is the drug registration of tasimelteon?

A

orphan product

172
Q

What is the mechanism of action of suvorexant?

A

orexin receptor antagonist

173
Q

Where are orexin receptors located?

A

hypothalamus

174
Q

What is the effect of suvorexant?

A

reduce rewarding stimuli via receptors that modulate mesolimbic projections between VTA and nucleus accumbens

175
Q

What is the mechanism of action of buspirone?

A

5HT1A receptor partial agonist

176
Q

Is the onset of action of buspirone shorter or longer than benzodiazepines?

A

longer (adaptive response)

177
Q

What is a benefit of buspirone?

A

low abuse potential

178
Q

What drugs can cause anxiety?

A

-albuterol
-caffeine (high doses)
-decongestants
-levothyroxine
-steroids
-stimulants

179
Q

What is buspirone approved for?

A

generalized anxiety disorder

180
Q

What is the target dose of buspirone?

A

10-15 mg PO TID

181
Q

How long does buspirone take for initial efficacy?

A

3-4 weeks

182
Q

Is long-term use of benzodiazepines recommended?

A

No

183
Q

What can acute withdrawal of benzodiazepines lead to?

A

life-threatening seizures

184
Q

What are the warnings for benzodiazepines?

A

-concomitant use with other CNS depressants
-overdose death risk

185
Q

Which benzodiazepines have a lower fall risk?

A

-alprazolam
-lorazepam
-clonazepam
-oxazepam

186
Q

Which benzodiazepines have long-acting active metabolites?

A

-diazepam
-clorazepate
-chlordiazepoxide

187
Q

What are side effects of benzodiazepines?

A

-sedation
-paradoxical excitement
-swallowing difficulties
-impairment of memory and recall
-psychomotor impairment

188
Q

Which benzodiazepines are preferred in the elderly?

A

-lorazepam
-oxazepam
-temazepam

189
Q

What is hydroxyzine approved for?

A

generalized anxiety disorder

190
Q

Is hydroxyzine used as maintenance or “as needed” therapy?

A

as needed

191
Q

What are side effects of hydroxyzine?

A

-sedation
-anticholinergic side effects
-QTc prolongation

192
Q

What population should hydroxyzine be avoided in?

A

elderly

193
Q

What is the effect of propranolol?

A

decrease physiological symptoms of acute anxiety

194
Q

What is propranolol used for?

A

performance and situational anxiety

195
Q

Is propranolol used in low or high doses for anxiety?

A

low doses

196
Q

What are considerations for the use of propranolol?

A

history of/current asthma and cardiovascular conditions

197
Q

kava clinical pearls

A

-may cause hepatotoxicity and platelet aggregation
-may aggravate symptoms of Parkinson’s disease

198
Q

St. John’s Wort clinical pearls

A

-strong 3A4 inducer
-avoid drug-drug interactions

199
Q

valerian clinical pearls

A

-avoid in pregnant women
-potential hepatotoxicity

200
Q

passionflower clinical pearls

A

-may cause dizziness, ataxia, and confusion
-avoid in pregnancy

201
Q

chamomile clinical pearl

A

avoid with blood thinners and ragweed/daisy allergy

202
Q

In what patient populations can gabapentinoids be considered in?

A

-bipolar disorder with anxiety symptoms
-comorbid neuropathic pain

203
Q

Is quetiapine endorsed to use in insomnia?

A

No

204
Q

What is first-line therapy for anxiety disorders?

A

SSRIs, SNRIs, or buspirone

205
Q

For what anxiety disorder can atypical antipsychotics be used for?

A

treatment-resistant OCD (aripiprazole and risperidone)

206
Q

What are the DSM-5, TR diagnostic criteria for generalized anxiety disorder?

A

-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
Q

When are SNRIs considered before SSRIs for generalized anxiety disorder?

A

if patient has pain syndrome

208
Q

When are benzodiazepines used for generalized anxiety disorder?

A

bridge therapy until onset of SSRI/SNRI only if necessary

209
Q

What are the DSM-5, TR diagnostic criteria for social anxiety disorder?

A

-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
Q

What are the DSM-5, TR diagnostic criteria for panic disorder?

A

-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
Q

What SNRI is approved for the treatment of panic disorder?

A

venlafaxine

212
Q

How much reduction in symptoms can be expected in the treatment of OCD?

A

25% - 50%

213
Q

What is second-line treatment for OCD?

A

clomipramine

214
Q

What are the DSM-5, TR diagnostic criteria for PTSD?

A

-exposure to real or threatened death, serious injury, or sexual violence
-flashbacks
-re-experiencing
-avoidance
-hypervigilance
-negative alterations in mood or cognition

215
Q

What drug may be helpful for sleep or nightmares in patients with PTSD?

A

prazosin

216
Q

What drug is NOT recommended in PTSD?

A

benzodiazepines

217
Q

What nonpharmacological treatments may be helpful in PTSD?

A

-cognitive behavior therapy (CBT)
-eye movement desensitization and reprocessing (EMDR)

218
Q

What can result from the use of SSRIs and SNRIs when treating anxiety disorder?

A

“jitteriness” syndrome

219
Q

What is the onset of action for SSRIs and SNRIs?

A

2-4 weeks

220
Q

What disease states, medications, and substances are associated with insomnia?

A

-anxiety
-mood disorders
-amphetamines
-beta agonists
-beta blockers
-bupropion
-caffeine
-decongestants
-methylphenidate
-modafinil
-nicotine
-thyroid medications

221
Q

What are the DSM-5, TR diagnostic criteria for insomnia disorders?

A

-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
Q

What is first-line treatment of insomnia disorders?

A

nonpharmacological

223
Q

What are the most commonly used sleep medications for the treatment of insomnia disorders?

A

z-hypnotics

224
Q

What is the initial dose of zolpidem in women and the elderly?

A

5 mg

225
Q

What drug has a metallic taste?

A

eszopiclone

226
Q

What substrates are z-hypnotics?

A

3A4

227
Q

What are side effects of z-hypnotics?

A

-somnolence
-dizziness
-ataxia
-headaches

228
Q

What benzodiazepine is used for insomnia?

A

temazepam

229
Q

What warning do all FDA-approved insomnia medications have?

A

sleep behavior

230
Q

What is ramelteon contraindicated with?

A

fluvoxamine

231
Q

What are side effects of ramelteon?

A

-GI upset
-next day somnolence
-hyperprolactinemia
-prolactinoma

232
Q

What is tasimelteon FDA-approved for?

A

non-24 sleep-wake disorder in adults

233
Q

What substrates are melatonin agonists?

A

1A2

234
Q

How much sleep does a patient need to get if taking an orexin receptor antagonist?

A

7 hours

235
Q

What are orexin receptor antagonists contraindicated in?

A

narcolepsy

236
Q

What substrates are orexin receptor antagonists?

A

3A4

237
Q

What side effects does doxepin have?

A

anticholinergic

238
Q

Is trazodone FDA-approved for insomnia?

A

No

239
Q

Does trazodone have a long or short half-life?

A

long half-life

240
Q

What is mirtazapine used for?

A

sleep agent, especially in patients with depression who have difficulty sleeping

241
Q

What are the DSM-5, TR diagnostic criteria for obstructive sleep apnea?

A

-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
Q

When should a polysomnography be used over home sleep apnea testing?

A

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
Q

What are nonpharmacological treatments for sleep apnea?

A

-weight loss (adjunctive)
-smoking cessation
-avoid alcohol and CNS depressants
-sleep on side rather than back
-continuous positive airway pressure (CPAP)

244
Q

What medications can be used to treat excessive daytime sleepiness in sleep apnea?

A

-modafinil
-armodafinil

245
Q

What is the narcolepsy tetrad?

A

-excessive daytime sleepiness (EDS)
-cataplexy
-hallucinations
-sleep paralysis

246
Q

What drugs are used to treat cataplexy?

A

-Xyrem
-Xywav
-Lumryz

247
Q

Which drug used for cataplexy has the lowest sodium content?

A

Xywav

248
Q

Which drug used for cataplexy is approved in children?

A

Xywav

249
Q

What drugs are used to treat excessive daytime sleepiness?

A

-modafinil
-armodafinil
-sodium oxybate
-pitolisant
-solriamfetol

250
Q

pitolisant clinical pearls

A

-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
Q

solriamfetol clinical pearls

A

-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
Q

What drugs are used to treat shift work sleep disorder?

A

-modafinil
-armodafinil

253
Q

When should modafinil/armodafinil be taken for shift work sleep disorder?

A

1 hour before work period starts

254
Q

What drugs are used to treat restless leg syndrome?

A

-gabapentin enacarbil
-dopamine agonists (pramipexole and ropinirole)
-iron supplementation

255
Q

What are the DSM-5, TR diagnostic criteria for anorexia nervosa?

A

-restriction of energy intake leading to significantly low body weight
-intense fear of gaining weight or becoming fat

256
Q

What are the specifier types for anorexia nervosa?

A

-restricting type
-binge-eating/purging type

257
Q

What are health consequences of anorexia nervosa?

A

-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

258
Q

What is refeeding syndrome?

A

shift from fat metabolism to glucose metabolism

259
Q

What are physiological effects of refeeding syndrome?

A

-hypokalemia
-water retention
-severe edema
-multiple organ failure

260
Q

What are the recommended treatments for anorexia nervosa?

A

-increase calories slowly
-cognitive behavioral therapy

261
Q

What medication is contraindicated in anorexia nervosa?

A

bupropion

262
Q

What are the DSM-5, TR diagnostic criteria for binge eating disorder?

A

-recurrent episodes of binge eating
-occurs at least once a week for 3 months
-NOT associated with recurrent use of inappropriate compensatory behavior

263
Q

What are the severity specifiers for binge eating disorder and bulimia nervosa?

A

-mild: 1-3 episodes/week
-moderate: 4-7 episodes/week
-severe: 8-13 episodes/week
-extreme: ≥14 episodes/week

264
Q

What are the health consequences of binge eating disorder?

A

-hypertension
-elevated cholesterol
-CV disease
-T2DM
-gallbladder disease

265
Q

What are the recommended treatments for binge eating disorder?

A

-lisdexamfetamine (FDA-approved)
-CBT and medication (best outcomes)

266
Q

What are the DSM-5, TR diagnostic criteria for bulimia nervosa?

A

-recurrent episodes of binge eating
-recurrent inappropriate compensatory behavior
-occurs at least once a week for 3 months

267
Q

What are the health consequences of bulimia nervosa?

A

-digestive tract complications
-amenorrhea
-orthostatic hypotension
-bradycardia
-arrhythmias
-osteopenia
-osteoporosis

268
Q

What are the methods of purging?

A

-vomiting
-laxatives
-diuretics
-excessive exercise
-“diabulimia”

269
Q

What are the recommended treatments for bulimia nervosa?

A

-fluoxetine (FDA-approved)
-CBT and medication (best outcomes)

270
Q

What are the diagnostic criteria for ADHD?

A

-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

271
Q

stimulant dosing considerations

A

-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

272
Q

What drug needs to be dosed differently for children with ADHD?

A

mydayis

273
Q

What dosage formulation is Daytrana?

A

transdermal patch

274
Q

What is the active metabolite of lisdexamfetamine?

A

dextroamphetamine

275
Q

What are the adverse effects of stimulants?

A

-appetite loss
-abdominal pain
-headaches
-sleep disturbances
-decreased growth
-hallucinations or other psychotic symptoms
-increased BP and HR
-sudden cardiac death
-priapism
-peripheral vasculopathy

276
Q

What is the monitoring for stimulants?

A

-appetite
-behavior
-blood pressure
-growth rate
-heart rate
-sleep
-ECG (if cardiac risk)

277
Q

What are the alpha-2 agonists used to treat ADHD?

A

-guanfacine ER
-clonidine ER

278
Q

What substrate is guanfacine?

A

3A4

279
Q

Why should alpha-2 agonists be tapered if discontinued?

A

to avoid rebound hypertension

280
Q

What norepinephrine reuptake inhibitors are used to treat ADHD?

A

-atomoxetine
-viloxazine

281
Q

What substrate is atomoxetine?

A

2D6

282
Q

How is atomoxetine dosed?

A

weight-based dosing (cutoff is 70 kg)

283
Q

What substrate is viloxazine?

A

2D6/UGT; strong 1A2 inhibitor

284
Q

What are adverse effects of alpha-2 agonists?

A

-decreased HR and BP
-orthostasis
-somnolence
-dizziness

285
Q

What are side effects of norepinephrine reuptake inhibitors?

A

-increased HR and BP
-increased in suicidal thinking (boxed warning)

286
Q

What are monitoring parameters for non-stimulants?

A

-appetite
-behavior
-BP
-growth rate (atomoxetine)
-HR
-LFTs (atomoxetine)
-sleep

287
Q

bupropion clinical pearls

A

-not FDA-approved for ADHD
-2D6 inhibitor
-contraindicated in seizure and eating disorders

288
Q

tricyclic antidepressant clinical pearls

A

-less effective than methylphenidate
-cardiac concerns

289
Q

mood stabilizer and atypical antipsychotic clinical pearls

A

-may be useful if comorbid bipolar disorder, conduct disorder, and/or intermittent explosive disorder
-should not use atypical antipsychotics as monotherapy

290
Q

What medication is first-line for preschool age patients with ADHD?

A

methylphenidate

291
Q

What medication is first-line for elementary/middle school/adolescent patients with ADHD?

A

stimulants

292
Q

What medication is second-line for elementary/middle school/adolescent patients with ADHD?

A

-atomoxetine
-guanfacine ER
-clonidine ER

293
Q

What medications are used as adjunctive therapy in ADHD?

A

-guanfacine ER
-clonidine ER

294
Q

What is the stepwise treatment guideline for adults with ADHD?

A

-methylphenidate OR lisdexamfetamine
-dextroamphetamine
-atomoxetine

PHRM845 (2 decks)

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