Psychology Flashcards

Question

*Treatment-resistant depression:* 1. American Psychiatric Association (APA): guidelines state patient should receive a ____ week trial of medication at a THERAPEUTIC dose before conclude that drug is NOT working. 2. If a patient is NOT improving at this time interval, what should be considered?

Answer 1

1. 4-8 2. Consider: -Changing to new antidepressant -Increase antidepressant dose -Use combination of antidepressants with different MOAs -Augment with buspirone or a low dose of an atypical antidepressants (aripiprazole, olanzapine + fluoxetine = Symbyax, quetiapine XR, brexipiprazole, cariprazine) -Esketamine nasal spray -Augment with lithium, thyorid homrone, or in some cases, electroconvulse therapy (ECT)

Answer 2

Brand: Spravato MOA: NMDA receptor antagonist ROA: nasal spray Administration Considerations: -*Must be administered under supervision of healthcare provider, monitoring for at least 2 hours following administration -Restricted distribution under Spravato REMS program* TX: TX-resistant depression, depression with suicidality BBW: -Sedative and dissociative or perceptual changes, potential for abuse and misuse -Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults

Answer 3

Pathophysiology: altered brain structure and chemistry primarily involving increased dopamine, serotonin, and glutamate DSM-5: -Negative s/sx: loss of interest, *lack of emotion (apathy), social withdrawl, loss of motivation (avolition), lack of speech (alogia)*, inability to plan or carry out activities, poor hygiene -Positive s/sx: *hallucinations (auditory, visual, or somatic), delusions, disorganized thinking/behavior*, incoherent speech, difficulty paying attention Potential Natural Product: fish oil (for inflammation often related to stress)

Answer 4

-Anticholinergics (centrally-acting, high doses) -Dextromethorphan, when used not as indicated -Dopamine or dopamine agonists -Inteferons -Stimulants especially if already at risk -Systemic steroids (typically with lack of sleep -- ICU psychosis) -Illict/recreational substances: cannabis, cocaine, lysergic acid diethylamide (LSD), methamphetamine (ice, crystal), phencyclidine (PCP), synthetic cathinons (bath salts, MDPV)

Answer 5

1. *General TX:* antipsychotics to block dopamine (newer ones can block 5-HT) -First line: second generation antipsychotics (SGAs) due to less extrapyramidal symptoms (EPS) unless a pt is already stabilized on a first generation antipsychotic (FGAs) -Cons: blocking DA can affect pathways involved in focus, attention, and movement 2. Negative symptoms 3. *BBW - NOT indicated for agitation control in elderly with dementia-related psychosis (increased mortality risk mostly due to CV conditions) --> MEDGUIDE REQUIRED -Some also carry warning of stroke in pts with dementia -ALL carry warning for falls*

Answer 6

Dystonias: very painful muscle contractions (common especially in young males) Dyskinesias: abnormal movements Akathisia: restlessness, inability to remain still TD: repetitive, involuntary movements (ex. grimacing and eye blinking) --> can be IRREVERSIBLE and drug should be D/C

Answer 7

*Adherence poor often from pt's inability to recognize the illness; can also have dysphagia* -Long-acting injectables (LAIs): given IM or SQ to eliminate PO QD dosing (ex. Haldol Decanoate, Risperdal Consta, Invega Sustenna, Abilify Maintena) -ODTs: useful in dysphagia and provent cheeking (tablets hidden in cheek and spit out later) --> Abilify Discmelt, Clozapine Fazaclo, Risperidal M-Tab, Zyprexa Zydis, Saphris -Oral solutions/suspensions: useful for children and with feeding tubes -Acute IM injections (haloperidol, fluphenazine, Zyprexa, Geodon): provide "STAT" relief to calm down agitated pt for their safety and others --> can be given as cocktails such as with BZDs and anticholinergics to re

Answer 8

Low potency: chlorpromazine, thioridazine -Increased sedation and lower EPS risk Medium potency: loxapine (Adasuve), perphenazine High potency: decreased sedation and higher EPS risk -*haloperidol (Haldol, Haldol Decanoate)* -fluphenazine -thiothixene -trifluoperazine Structure: -*Many are in phenothiazine class (end in -azine)* -Haloperidol: in butyrophenone class MOA: mainly block dopamine-2 (D2) receptors with minimal 5-HT2A blockade

Answer 9

AVEs: -*Sedation, dizziness, anticholinergic effects*, increased prolactin -*EPS: can give anticholinergic* (ex. benztropine or Benadryl) to limit/avoid painful dystonic reactions -Adasuve (loxapine): dysgeusia (bad, bitter, or metallic taste in mouth) -Injections (haloperidol, fluphenazine): injection site pain/redness *Warnings:* -CV: QT prolongation (especially w/ thioridazine, haloperidol, chlorpromazine, orthostasis/falls, tachycardia) -Anticholinergic: constipation, xerostomia, blurred vision, urinary retention -CNS depression -EPS: including Parkinsonims, dystonic rxns, akathisia, TD (increased EPS with injections) -Hyperprolactinemia: infertility, oligomenorrhea/amenorrhea (fewer or no menstrual periods), galactorrhea (abnormal breast discharge), ED/decreased libido -Neuroleptic maligant syndrome (NMS): monitor for mental status changes, fever, muscle rigidity, autonomic instability -Blood dyscrasisa (leukopenia, neutropenia, agranulocytosis), ocular effects BBW: *elderly pts w/ dementia-related psychosis (increased mortality risk) -Thioridazine: QT prolongation* -Adasuve (loxapine): bronchospasm (REMS program)

Answer 10

Brand: Abilify MOA: second generation antipsychotic (SGA) that blocks D2 and 5-HT2A receptors -*Unique MOA: D2 and 5-HT1a partial AGONIST* ROA: *PO or IM* -Abilify MyCite: tablets embedded w/ ingestible sensor to track drug compliance -IM: Ability Maintena, Aristada, Abilify Asimtufii -Aristada Initio: one-time IM LD along with PO abilify when starting or restarting Aristada AVEs: *akathisia*, activation or sedating, HA, anxiety, constipation -*Lower risk of weight gain, some QT prolongation, ESP more in children*

Answer 11

Brand: *Clozaril* MOA: second generation antipsychotic (SGA) that blocks D2 and 5-HT2A receptors ROA: PO TX: NO sooner than 3rd-line for schizophrenia (very effective and decreased risk of EPS/TD, BUT serious other side effects related to metabolic and neutropenia)

Answer 12

AVEs: *agranulocytosis, seizures, constipation*, somnolence, metabolic syndrome (increased weight, BG< lipids), sialorrhea (hypersalivation), hypotension BBW: -*Significant risk of life-threatening neutropenia/agranulocytosis (REMS program)* -Bradycardia, orthostatic hypotension, syncope and cardiac arrest (risk highest in initial titration period, especially w/ rapid dose increases --> titrate slowly) -*Myocarditis and cardiomyopathy* --> D/C if suspected -*Seizures (dose-related):* start at no higher than 12.5mg QD or BID, titrate slowly using divided doses (use in caution w/ hx of seizure, head trauma, alcoholism, or takine medications that lower seizure threshold) *Monitoring:* -REMS: prescribers and pharmacies must be certified and pts must enroll -To start TX: baseline ANC must be >/=1500/mm3; check ANC weekly x6 months then Q2 weeks x6 months then Qmonth --> stop therapy if ANC <1000/mm3

Answer 13

Brand: *Latuda* MOA: second generation antipsychotic (SGA) that blocks D2 and 5-HT2A receptors ROA: PO Administration Considerations: take CF (at least 350 kcal) AVEs: *somolence, EPS (dystonias), nausea -Decreased risk of metabolic syndrome compared to other SGAs* CI: use w/ CYP450 3A4 inducers and inhibitors

Answer 14

Brand: *Zyprexa* MOA: second generation antipsychotic (SGA) that blocks D2 and 5-HT2A receptors ROA: PO, IM Administration: take QHs (due to sedation) AVEs: *somnolence, metabolic syndrome (increased weight, BG, lipids)*, orthostasis BBW (Zyprexa Relprevv): *sedation (including coma) and delirium (agitation, anxiety, confusion, disorientation) following injection; must administer in registered healthcare facility and pts to be monitored 3 hours post-injection (Zyprexa RElprevv REMS program requirements)*

Answer 15

Drugs Combos: -Fluoxetine + Olanzapine = Symbyax: TX-resistant depression -Samidorphan + Olanzapine = Lybalvi: schizophrenia, bipolar disorder --> samidorphan is an opioid recepotr antagonist that can help mitigate weight gain from olanzapine (CI in pts taking opioids or undergoing acute opioid withdrawl) *Sedation and breathing difficulty risk: combined w/ BZDs*

Answer 16

Brand: *Invega* MOA: second generation antipsychotic (SGA) that blocks D2 and 5-HT2A receptors -Very similar to risperidone, just lasts longer ROA: PO or IM -*Invega Trinza: IM Q3 months -Invega Hafyera: IM Q6 months* TX considerations: adequate TX w/ IM must be established before starting Invega Trinza or Invega Hafyera -Osmotic release oral system (OROS) enables once daily dosing -do NOT break or crush AVEs: -*Increased prolactin: sexual dysfunction, galactorrhea, irregular/missed periods -EPS, especially at higher doses* -Tachycardia, QT prolongation -*Metabolic syndrome (increased weight, BG, lipids)* -Somnolence -Invega can have ghost tablet (empty shell) in stool

Answer 17

Brand: Seroquel MOA: second generation antipsychotic (SGA) that blocks D2 and 5-HT2A receptors ROA: PO *Administration considerations: take XR at night WITHOUT food or with light meal -IR can take w/ or w/o food* *AVEs: somnolence, metabolic syndrome (increased weight, BG, lipids), orthostasis, possible occular effects (cataracts) -LOW EPS risk (often used for psychosis in PD)*

Answer 18

Brand: *Risperdal* MOA: second generation antipsychotic (SGA) that blocks D2 and 5-HT2A receptors ROA: *PO, IM, SQ* AVEs: -*Increased prolactin: sexual dysfunction, galactorrhea, irregular/missed periods -ESP, especially at higher doses* -Tachycardia, QT prolongation -*Metabolic syndrome (increased weight, BG, and lipids)* -Somnolence

Answer 19

Brand: *Geodon* MOA: second generation antipsychotic (SGA) that blocks D2 and 5-HT2A receptors ROA: PO, IM *Administration considerations: PO --> CF* AVEs: somnolence, EPS, dizziness, nausea CI: *QT prolongation (do NOT use w/ QT risk)*

Answer 20

Brand: Saphris, Secuado MOA: second generation antipsychotic (SGA) that blocks D2 and 5-HT2A receptors ROA: PO, patch Administration considerations: *no food/drink for 10 minutes after dose* AVEs: somnolence, *tongue numbness (SL),* EPS, QT prolongation CI: severe hepatic impairment

Answer 21

ALL: second generation antipsychotic (SGA) that blocks D2 and 5-HT2A receptors Unique MOAs: -D2 and 5-HT1a partial agonists: brexipiprazole, cariprazine -5-HT2a antagonist: brexipiprazole

Answer 22

1. 6 weeks at least including adequate dose and adherence 2. AVOID if: -Cardiac risk/QT prolongation (especially w/ low K and Mg; D/C if QT >500msec): ziprasidone > haloperidol > thioridazine; chlorpromazine -Hx of movement disorder: FGAs, risperidone, paliperidone (at higher doses) --> quetiapine preferred -Overweight/metabolic risk: olanzapine, quetiapine --> lower risk: aripiprazole, ziprasidone, lurasidone, asenapine 3. clozapine (tablets: Clozaril, suspension: Versacloz)

Answer 23

1. -Highest: clozapine, olanzapine, quetiapine -Moderate: risperidone, paliperidone -Lower risk: aripiprazole, ziprasidone, lurasidone, osenapine 2. Risperidone, paliperidone

Answer 24

Pimavanseron (Nuplazid) -MOA: inverse agonist and antagonist at 5-HT2A receptors and lesser extent at 5-HT2C receptors (NO impact on DA receptors, thus does NOT worsen PD) -AVEs: peripheral edema, confusion -Warnings: NOT appropriate for dementia-related psychosis; QT prolongation (avoid in pts w/ risk factors or drugs that increase QT interval)

Answer 25

ALL: -Can prolong QT interval (high risk FGA: thioridazine, chlorpromazine; high risk SGAs: ziprasidone, haloperidol, droperidol): caution w/ other QT-prolonging drugs -BZDs: monitor respiratory depression and hypotension (do NOT use w/ olanzapine) -DA blocking drugs (ex. metoclopramide): EPS and TD risk further increased Smoking: can reduce plasma levels of olanzapine and clozapine (may need higher doses) Clozapine: avoid concurrent drugs that lower seizure threshold Risperidone, paliperdone: caution w/ CYP2D6 inhibitors (including fluoxetine and paroxetine) --> can increase prolactin and cause EPS

Answer 26

Drugs: valbenazine (Ingrezza), deutetrabenazine (Austedo, Austedo XR) MOA: *reversibly inhibit vesicular monoamine transporter 2 (VMAT2) that regulates momamine uptake from cytoplasm to synpatic vesicle for storage and release* Warnings: *somnolence*, QT prolongation CI *(deutretrabenazine): hepatic impairment*, use with tetrabenazine or valbenazine, use with MAOI within 14 days DDIs: -Avoid use w/ MAOIs -Substrates of CYP3A4 and 2D6: dose reduction required w/ CYP3A4 inhibitors or 2D6 (paroxetine, fluoxetine) -Valbenazine: P-gp inhibitor that can increase digoxin concentrations

Answer 27

NMS: rare, but *highly lethal condition* where usually starting within 2 weeks or immediately following high dose increase of dopamine antagonist causing intese muscle contractions that can lead to renal injury due to rhabdomylosis, suffocation, and death S/Sx: -*Hyperthermia (high fever, profuse sweating), extreme muscle rigidity (called "lead pipe" rigidity)* that can lead to respiratory failure, mental status changes, tachycardia, tachypnea, blood pressure changes -Increased creatinine phosphokinase -Increased WBCs TX: -*STOP ANTIPSYCHOTIC* -Supportive care: cardiorespiratory and hemodynamic support, manage electrolytes -Control pt's temperature: cooling bed, antipyretics, cooled IV fluids -Relax muscles: BZDs, *dantrolene* (Ryanodex, Dantrium, Revonto) or potentially a dopamine agonist (bromocriptine) -After resolution, consider different antipsychotic

Answer 28

BP: fluctuations in mood from depression (extremely sad or hopeless states) to abnormally elevated, overexcited, or irritable moods (mania or hypomania - milder form of mania) for at least a week in duration (or any duration if hospitalization needed); some states can be mixed S/Sx: -Inflated self-esteem; high-risk, pleasurable activities (ex. shopping sprees, sexual indiscretions, gambling) -More talkative than normal -Jumping from topic to topic, easily distracted -Increased in goal-directed activity -Needs less sleep DSM-5: exhibits 3 or more symptoms (if mood is only irritable, exhibits 4 or more)

Answer 29

Classifications: -Bipolar I: at least one episode of *mania* and usually bouts of intense depression (depressive episodes NOT required) --> *mania associated with significant impairment in social/work functioning, psychosis/delusions, or requires hospitalization* -Bipolar II: at least one episode of *hypomania* (lasting 4 or more consecutive days) and at least one depressive episode (leasting 2 weeks or more) --> *hypomania does NOT affect social/work functioning, does NOT cause psychosis, and does NOT require hospitalization* Cyclothymia: related disorder consisting of periods of hypomanic and depressive symptoms w/o meeting defined criteria for major depressive, manic, or hypomanic episode

Answer 30

Goal is to stabilize moods without inducing a depressive or manic state -Mood stabilizers: lithium, antiepileptic drugs (valproate, lamotrigine, carbamazepine) -Antipsychotics: NOT traditional mood stabilizers, but can stabilize mood when mania occurs w/ psychosis; SGAs preferred due to less EPS (options: aripiprazole, olanzapine, quetipaine, risperidone, ziprasidone, lurasidone, olanzapine/fluoxetine) -Antidepressants: can incude or exacerbate manic episode as MONOTHERAPY --> use in combination with mood stabilizer

Answer 31

Manic episode: first line = antipsychotic (olanzarpine, risperidone), lithium, or valproate (severe: antipsychotic + lithium or valproate) Depressive episode: first line = antipsychotic (quetiapine, lurasidone); alternatives or add ons: lithium, valproate, or lamotrigine (lamotrigine: longer titration, not helpful in acute mania)

Answer 32

Preferred safer options: lamotrigine most favorable sfaety profile; SGAs safer than valproate, carbamazepine, or lithium -Valproate: increases risk of fetal anomalies including long-term adverse cognitive effects (decreased IQ), neural tube defects, and fetal valproate syndrome (avoid especially in first trimester, worst of all BP drugs) -Carbamazepine: can cause fetal carbamazepine syndrome resulting in facial abnormalities and incomplete organ development, including cardiac effects (especially avoid in first trimester) -Lithium: can increase congenital cardiac malformations

Answer 33

Brand: Lithobid MOA: proprosed mechanism is influencing of reputake of 5-HT and/or NE or by moderating gluatamate levels in brain -Glutatamte is primary excitatory neutransmitter that could cause mania ROA: PO TX: Bipolar disorder -Off-label: refractory depression as augment Therapeutic range: 0.6-1.2 mEq/L (trough level); acute mania may require 1.5mEq/L initially -NTI drug

Answer 34

AVEs within therapeutic range: *GI upset (N/D), cognitive effects, cogwheel rigidity, fine hand tremor, thirst, polyuria/polydipsia, weight gain, hypothyroidism*, hypercalcemia, cardiac abnormalities, edema, anorexia, worsening psoriasis, blue-gray skin pigmentation, impotence *AVES within toxic ranges:* ->1.5mEq/L: ataxia (lack of muscle coordination/balance), coarse hand tremor, vomiting, persistent diarrhea, confusion, sedation ->2.5mEq/L: CNS depression, arrhythmias, seizure, coma Warnings: *renal impairment*, hyponatremia, dehydration (increased lithium toxicity), *serotonin syndrome* BBW: *serum lithium levels should be monitored to avoid toxicity* CI: *avoid in pregnancy* (cardiac malformations in first trimester), avoid in breastfeeding Monitoring: *serum levels, renal function, thyroid function (TSH, T4)*, electrolytes (Ca, Phos, Na). ECG (pt >40yo) -Lithium is 100% renally cleared

Answer 35

Lithium levels increase with: -*Reduced salt intake, sodium loss (ex. ACEIs, ARBs, thaizide diuretics) -NSAIDs: ASA and sulindac are safer options* Lithium levels decrease with: *increased salt intake*, caffeine, theophylline Risk of 5-HT syndrome: * SSRIs, SNRIs, triptans, linezolid, etc.* Increased risk of neurotoxicity (ataxia, tremors, nausea): verapamil, diltiazem, phenytoin, carbamazepine ***Lithium changes with Na intake because the kidneys cannot tell the difference between Na and Li. Therefore, increasing Na, the kidney will try to clear Na and also Li

Answer 36

1. Take with food or at end of meal to reduce nausea 2. Maintain consistent salt intake 3. Maintain adequate hydration with NON-caffeinate beverages 4. Notify healthcare provider immediately for worsening nausea or diarrhea, slurred speech, shakiness, or confusion 5. Can cause impaired alterness: caution when driving or during tasks that require alertness

Answer 37

Pathophysiology: NOT well understood --> imbalance of catecholamine metabolism with subsequent decreased DA DSM-5: -Primary symptoms: inattention, hyperactivity, and impulsivity -Inattention or hyperactivity/impulsivity: >/=6 symptoms of intattention for children up to age 16 (>/= 5 symptoms for 17 yo and older) that are present for at *least 6 months and inappropriate for developmental level* -Several inattentive or hyperactive-impulsive symptoms present *before age 12* -Symptoms must have been *present in 2 or more settings* (ex. home, work, school, friends) -Symptoms intefere w/ functioning and NOT caused by another disorder

Answer 38

*General TX:* -Age 4-5yo: first line is parent training in behavior management and/or behavior classroom intervention -6 yo and older: behavioral interventions + medications (first line = stimulants) -Non-stimulants in ADHD: atomoxetine, viloxazine --> after trial of 2-3 stimulants (or first line in concern of abuse or diversion) -Add-on medications: guanfacine ER (Intuniv), clonidine ER (Kapvay) -To help sleep at night: clonidine IR, diphenhydramine, melatonin Supplements: data for efficacy LIMITED and not routinely recommended (fish oil was studied with limited evidence, some limited data on combined omega-3 and omega-6 supplementation) -*Melatonin may be helpful for sleep onset insomnia in pts taking stimulants*

Answer 39

When putting capsule contents in food, use a small amount of food (do NOT warm the food). Eat the food right away, without chewing. -If beads are chewed, drug can become IR Capsules that can be opened: -Many long-acting capsules (ex. Adderall XR, Ritalin LA, Aptension XR, Folacin XR): can sprinkle on applesauce -Vyvanse capsules: can be mixed in water, orange juice, or yogurt (unique because most stimulant levels decreased with acid - aka orange juice) --> take right away, do NOT let sit Other options: -Chewable tablets: Vyvanse, QuilliChew ER (only ER that can be crushed) -ODTs -Patches: Daytrana -Suspensions

Answer 40

1. CII; medguide 2. High potential for abuse and dependence -Can contribute to development of substance use disorder -Misuse can lead to overdose and death -Symptoms of misuse: dilated pupils, increased HR/BP, sweating, tremor, anxiety 3. Use with MAOI within 14 days --> hypertensive crisis 4. Administration: Qam, titrated up Q7 days PRN -Do NOT need to be tapered off when used as directed (aka NOT abused)

Answer 41

-Stimulant abuse and misuse can lead to drug diversion -Increased DA and NE can increase HR and BP, causing serious CV events w/ or w/o pre-existing disease -Other vascular problems: priapism, Raynaud's disease: may require dose reduction or D/C -New-onset psychosis or mania or exacerabtion of pre-existing psychosis -Loss of appetite very common: can decrease child's growth trajectory -Risk of serotonin syndrome w/ other serotonergic drugs -Some can lower seizure threshold -Visual disturbances: difficulty w/ accomodation and blurry vision

Answer 42

Ritalin (IR tablet): start at 5mg BID, taking 30 minutes before breakfast and lunch Ritalin LA (ER capsule): take Qam Concerta (ER tablet w/ OROS delivery): start at 18-36mg Qam -OROS delivery: outer coat dissolves fast for immediate action, but rest released slowly and harder to crush which decreases drug abuse potential -Can see ghost tablet in stool

Answer 43

Jornay PM (ER capsule): take Qpm -Outer coating delays intial drug release 10 hours to allow for evening dosing -Inner coating controls slow release of drug during the day Daytrana (transdermal patch): apply to hip (alternating) Qam -Apply 2 hours before desired effect (or as soon as child awakens to deliver prior to school) -Remove after 9 hours -Discard used patches by flushing down the toilet QuilliChew ER (chewable tablet): Qam -Contain phenylalanine (avoid with PKU)

Answer 44

Brands: Riltain, Ritalin LA, Jornay PM, QuilliChew ER, Concerta, Daytrana, Relexxii MOA: stimulant that blocks reuptake of NE and DA AVEs: *insomnia, decreased appetite/weight loss, HA, irritability*, N/V, blurry vision, dry mouth Warnings: -Daytrana (transdermal patch): loss of skin pigmentation at appllication site and areas distant from site (can resemble vitiligo); allergic contact dermatitis wth local rxns (edema, papules) -Concerta, Relexxii (both OROS delivery): do NOT use w/ GI narrowing conditions (ex. motility issues, small bowel disease) Monitoring: -*Consider ECG prior -Monitor BP and HR*, cardiac symptoms, CNS effects, and abuse potential -*Children: monitor height and weight*

Answer 45

1. *Dexmethylphenidate (Folacin, Folacin XR)* 2. Serdexmethylphenidate; Azstarys 3. *Lisdexamphetamine (Vyvanse)* 4. Desoxyn

Answer 46

Brands: -*Combination = Adderall, Adderall XR*, Mydavis -Amphetamine = Adzenys XR-ODT, Dyanavel XR, Evekeo, Evekeo ODT -Dextroamphetamine = Dexedrine, ProCentra, Zenzedi, Xelstrym MOA: stimulant that blocks reuptake of NE and DA IR products: children 3 yo or older EXCEPT Evekeo ODT -Dextroamphetamine: NOT recommended in children 5 yo or younger Administration considerations: -ER formulations: CANNOT be substituted for other products on a mg-per-mg basis --> follow dosing schedule per manufacturer -Dyanavel XR: shake suspension prior to use -do NOT take w/ acidic foods such as juice or vitamin C (decrease absorption)

Answer 47

Drugs: *atomoxetine (Strattera)*, viloxazine (Qelbree) ROA: PO Administration Considerations: -*Atomoxetine: do NOT open capsules (ocular irritant)* -Viloxazine: capsule can be opened and contents sprinkled on 1 tsp of pudding or applesauce (swallow without chewing) TX: ADHD (non-stimulants)

Answer 48

AVEs: *decreased appetite, insomnia, somnolence, dry mouth, increased BP/HR*, HA, nausea, abdominal pain Warnings: -CV events, psychosis, mania: assess at baseline and PRN -Atomoxetine: aggressive behavior, hepatotoxicity, priapism, urinary hesistancy/retention, growth delays CI: *MAOI use within past 14 days* -Atomoxetine: glaucoma, pheochromocytoma, severe CVDs -Viloxazine: concurrent use of CYP1A2 substrates (or substrates w/ NTI) BBW: *risk of suicidial ideation* Monitoring: BP, HR, ECG, mood, weight DDIs: -Volxazine: strong CYPA1A2 inhibitor and weak CYP2D6/3A4 inhibitor -Atomoxetine: CYP2D6 substrate

Answer 49

Drugs: *clonidine ER (Kapvay), guanfacine ER (Intuniv)* ROA: PO -*Take QHS -Must be tapered off* due to increased risk of rebound HTN (decreased dose Q3-7 days; clonidine:

Answer 50

Pscyhiatric Medications: antipsychotics (ex. aripiprazole, haloperidol), bupropion, stimulants Others: 1. Albuterol: if used too frequently or incorrectly 2. Caffeine, in high doses 3. Decongestants (ex. pseudophedrine) 4. Illict drugs 5. Levothyroxine, if therapeutic overdose occurs 6. Steroids 7. Theophylline - converted to caffeine

Answer 51

1. -Common: generalized anxiety disorder (GAD), panic disoder (PD), social anxiety disorder (SAD) -Disorders w/ anxiety: obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD) 2. Non-pharmacological TX: -*Cognitive behavioral therapy (CBT): trained clinicians help explore patterns of thinking that lead to problem-solving, relaxation techniques, and worry exposure* -Treat comorbid conditions (ex. hyperthyroidism) -Lifestyle changes: increased physical activity, community involvement, meditation

Answer 52

Natural Products: generally limited by safety issues -Kava: relaxant, but severe liver damage (NOT recommended) -Valerian: for anxiety/sleep, but may be contaminated w/ liver toxins -Passionflower: appears to be safe and listed as possibly effective via NatMed -5-HTP, L-typtophan: eosinophilia mylagia syndrome -St John's Wort: strong CYP3A4 inducer, photosensitivity, serotonin snydrome

Answer 53

First line: SSRIs and SNRIs -FDA approved: escitalopram, fluoxetine, paroxetine, stetraline, duloxetine, venlafaxine -Start low and titrate slowly to avoid jitteriness or exacerbation of anxiety -Takes at least 4 weeks to see benefit Second line: -Buspirone: takes 2-3 weeks to see benefit, can use in combo w/ antidepressants (more favorable in elderly than BZDs) -TCAs: anticholinergic AVEs, NOT FDA approved -Hydroxyzine: sedating antihistamine, used only as short term, does NOT treat underlying condition -Pregabalin, Gabapentin: for anxiety (NOT FDA approved) and neuropathic pain Stage Fright: Propranolol -NOT FDA approved, but can reduce symptoms of stage fright or performance anxiety (ex. tremors, tachycardia) -Can cause CNS AVEs (dizziness, confusion) -Dose 10-40mg one hour prior to event Short term only: benzodiazepines (BZDs)

Answer 54

Brand: BuSpar MOA: not fully known, but may have affinity for 5-HT1A and 5-HT2 receptors ROA: PO Administration: tablets scored to easily break into half or two thirds TX: anxiety *-NO potential for abuse, tolerance, or psychological dependence -Takes 2-4 weeks for optimal effect -When switching from BZD to buspirone, BZD should be tapered slowly*

Answer 55

AVEs: dizziness, drowsiness, HA, lightheadedness, nausea, excitement Warnings: *risk of serotonin syndrome* CI: -*MAOI use within 14 days or with linezolid or IV methylene blue* -Avoid in severe kidney or liver impairment DDIs: *CYP3A4 substrate* -Avoid grapefruit, grapefruit juice (may increase levels of buspirone) -Decrease dose w/ strong inhibitors or increase w/ strong inducers -Avoid alcohol: CNS depression -Avoid opioids: profound sedation, respiratory depression, coma, and death

Answer 56

Drugs: *alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium), lorezapam (Ativan)*, chlordiazepoxide, clorazepate (Tranxene), oxazepam MOA: *enhance gamma-aminobutyric acid (GABA), an inhibitory neutrotransmitter* that causes CNS depression resulting in anxiolytic, anticonvulsant, sedative, and/or muscle relaxant properties ROA: PO, injection, intranasal *Considerations in Anxiety TX:* -Provide fast relief of symptoms, but do NOT treat underlying cause -Useful in short-term of acute anxiety preventing restful sleep and disrupting life -Taken long-term: risk of developing tolerance (recommended to use for only 1-2 weeks then D/C and if used longer, taper off slowly to prevent withdrawl symptoms) -Consider BZD w/ longer T1/2 to reduce risk of abuse (clonazepam, lorazepam, diazepam) Others Uses: -Sleep: lorazepam, temazepam -Seizures: diazepam rectal gel (Diastat AcuDial)

Answer 57

AVEs: *somnolence, dizziness, ataxia*, weakness, lightheadedness Warnings: -*CNS depression -Anterograde amnesia -Potential for abuse* -*Safety risks in 65 yo and older: imapired cognition, delirium, falls/fractures* -Extravasation w/ IV use -Paradoxical rxns -Severe renal or liver impairment -*Pregnancy: crossess placenta and can cause birth defects or neonatal withdrawl syndrome* CI: -Acute narrow-angle galucoma -Sleep apnea, severe respiratory insufficiency -*Severe liver disease (clonazepam, diazepam)* -Myasthenia gravis (diazepam) -NOT for infants <6 months (diazepam) or premature infants (lorazepam) *BBW:* -Use w/ opioids: sedation, respiratory depression, coma, death -Risk for abuse, misuse, and addition leading to overdose and death (less in clonezpam since longer T1/2) -Continued use leads to physical dependence and abrupt D/C can cause withdrawl symptoms (taper off slowly when using >10 days) DDIs: -*Additive CNS depression (most pain meds, alcohol, skeletal muscle relaxants, etc)* -Diazepam, clonazepam, chlordiazepoxide, and clorazepate: caution w/ CYP3A4 inhibitors -*Alprazolam: CI with strong CYP3A4 inhibitors* -Valproate increases levels of lorazepam

Answer 58

1. LOT drugs: Lorazepam, Oxazepam, Temazepam 2. Lorazepam, diazepam, chlordiazepoxide 3. Diazepam

Answer 59

1. Alprazolam 2. Midazolam (Versed) 3. Flumazenil

Answer 60

Insomnia: symptoms at least three times per week for at least 3 months despite adequate opportunity to sleep: -Difficulty falling asleep (sleep initiation or sleep latency) -Reduced sleep duration -Poor sleep quality (ex. awakenings after sleep onset) Non-pharmacological TX: -Cognitive behavioral threapy (CBT-I): PREFERRED -Address underlying medical conditions (ex. pain, SOB from HF, anxiety, BP, depression, alcohol use disorder) -D/C medications that cause insomnia Natural Products: -Melatonin 1-5mg Qpm: substrate of CYP1A2 and prolonged effects can occur w/ 1A2 inhibitors (ex. ciprofloxacin, fluvoxamine); can help w/ jet lag (adjusting to different sleep time) -Valerian, Kava: NOT recommended due to hepatotoxicity -Chamomile tea: can help pt to feel calmer

Answer 61

Psychiatric/Neurologic Medications: acetylcholinesterase inhibitors, aripiprazole, atomoxetine, buproprion, stimulants, fluoxetine (if taken late in day) Others: 1. Alcohol - can help induce sleep, BUT reduces QUALITY of sleep 2. Caffeine 3. Decongestants (ex. pseudophedrine) 4. Diuretics (from nocturia) 5. Nicotine (including NRT) 6. INSTIs 7. Steroids 8. Varenicline

Answer 62

First line: NON-PHARM -Keep bedroom dark, comfortable, and quiet -Keep regular sleep schedule -Avoid daytime naps, even after poor night of sleep or limit to 30 minutes -Reserve bedroom for sleep and other appropriate activities (NO TV or other stimulants) -Turn face of clock aside to minimize anxiety -If unable to sleep, get up and do something to take mind off sleeping -Extablishe pre-bedtime ritual to condition body (ex. soft music, mild stretching, yoga, pleasurable reading) -Avoid exercising right before bed -Do NOT eat heavy meals before bedtime -Do NOT consume caffeine in afternoon Second Line: -Trouble falling asleep: Z drugs (eszopiclone, zolpidem, zaleplon), Ramelteon -Trouble staying asleep: eszopiclone, zolpidem, doxepin, suvorexant -BOTH: eszopiclone, zolpidem Short-term: benzodiazepines, OTC first-generation antihistamines

Answer 63

Drugs: *eszopiclone (Lunesta), zolpidem (Ambien, Edluar)*, zaleplon (Sonata) MOA: non-BZD hypnotics that act *selectively at the BZD receptor to increase GABA*, an inhibitor neurotransmitter to induce CNS depression ROA: PO -Edluar: SL tablet

Answer 64

AVEs: *somnolence, dizziness, ataxia, HA*, lightheadedness, "pins and needles" feeling on skin -Eszopiclone: dysgeusia (altereted sense of taste) Warnings: -*CNS depression and next-day impairment with <7-8 hours of sleep* (especially at high doses or coadministration w/ other CNS depressants including alcohol) -Abnormal thinking, behavioral changes, worsening depression, respiratory depression -*Potential for abuse and dependence* (can cause withdrawl if used longer than 2 weeks) CI: *hx of complex sleep disorder* BBW: *complex sleep behavior (ex. sleep-walking, sleep-driving, engaging in other activities while NOT fully awake)* DDIs: -Caution w/ potent CYP3A4 inhibiotrs -Additive CNS depression -do NOT take w/ fatty foods, a heavy metal, or alcohol

Answer 65

Drugs: daridorexant (Quviviq), lemborexant (DayVigo), suvorexant (Belsomra) MOA: *orexin receptor antagonist that inhibits orexin neuropeptide signaling system that promotes wakefulness* ROA: PO Administration: -do NOT take if <7 hours of sleep remaining -Onset of action delayed if taken with meal AVEs: *somnolence*, HA, dizziness, abnormal dreams Warnings: worsening depression/SI, sleep paralysis, hallucinations, cataplexy-like symptoms (sudden loss of muscle tone), complex sleep behavior, daytime impairment (risk when use w/ other CNS depressants) -NOT recommended in severe hepatic impairment CI: *narcolepsy* DDIs: caution with CYP3A4 inhibitors

Answer 66

Drugs: ramelteon (Rozerem), tasimelteon (Hetlioz) MOA: *agonists at MT1 and MT2 melatonin receptors that promote sleepiness and regulate circadian rhythm to coordinate sleep-wake cycle* ROA: PO Administration: do NOT take with fatty food -*NOT a controlled substance among the other sleep drugs* TX *(tasimelteon): specifically for NON-24 hour sleep-wake disorder (do NOT have normal cycle - ex. blind pt)* AVEs: *somnolence*, dizziness Warnings: -Ramelteon: complex sleep behavior DDIs: do NOT take w/ fluvoxamine (strong CYP1A2 inhibitor that increases concentrations of this drug class)

Answer 67

Brand: Silenor MOA: tricyclic antidepressant that inhibits NE and 5-HT reuptake along with inhibition of ACh and histamine ROA: PO Considerations for sleep: -For insomnia, use ER version to stay asleep -Warning of complex sleep disorder -AVEs: seizures, somnolence, anticholinergic effects -Increase in SI in young pts

Answer 68

Drugs: *diphenhydramine (Benadryl), doxylamine (Unisom, SleepTabs)* MOA: *inhibits H1 receptor* AVEs: -*Sedation: tolerance to sedative effects that can develop after 10 days of usage* -Confusion, seizures (high dose, older adults) -Paradoxical excitation in young children (do NOT use in children <12 yo) -*Peripheral anticholinergic AVes: dry mouth, urinary retnetion, dry eyes/blurry vision, constipation* Considerations: -*Avoid use in BPH (can worsen symptoms) and glaucoma (can elevate IOP)* -Avoid in older adults (Beers Criteria): confusion, dizziness, risk of falls, hypotension -Risk of mix-up: some OTX Unisom branded-products contain diphenhydramine

Answer 69

Narcolepsy: excessive daytime sleepiness with cataplexy (sudden loss of muscle tone) and sleep paralysis which can last from a few seconds to several minutes General TX: -Stimulants: armodafinil, modafinil -Sodium oxybate (Xyrem) -Others: pitolisant (histamine-3 receptor antagonist/inverse agonist), solriamfetol (DA and NE reuptake inhibitor) Stimulants (armodafinil, modafinil): -AVEs: HA, insomnia, anxiety, nause -Warnings: caution in pre-existing cardiac, hepatic, renal, or psychiatric conditions; severe rash that can be life-threatening (ex. SJS) -C-IV Sodium oxybate (Xyrem): -MOA: active moiety of oxybate salts in sedative GHB (derived from GABA) -AVEs: dizziness, confusion, nausea -Warnings: depression, suicide, psychosis, anxiety, sleepwalking -*CI: use w/ sedative-hypnotics, alcohol -BBW: STRONG CNS DEPRESSANTS --> respiratory depression, coma, and death risk; drug can be used illicitly and sometime to facilitate sexual assault ("date rape" drug --> REMS PROGRAM) -C-III*

Answer 70

RLS: urge to move lower legs sometimes described as a "creeping sensation" that is worse at night and relieved w/ movement Pathophysiology: thought to be from dysfunction of dopamine *General TX:* -Primarily dopamine agonists (pramipexole, ropinirole --> though taken for PD, taken IR 1-3 hours before bed for RLS; ritigotine: patch applied daily) -Gabapentin enacarbil (Horizant): for RLS or postherepetic neuralgia --> taken at 5pm daily (XR version of gabapentin); take w/ food and swallow whole