Psychopharm Flashcards
Haloperidol and ____ used in combo in some patients can cause an encephalopathic syndrome resembling NMS as well as prolong QT interval
Lithium
Fluoxetine and paroxetine inhibit __________
CPY2D6
_____ has evidence in tx of trichotillomania
N-acetylcysteine
Ramelteon MOA is ______, with significant binding to _____. FDA approved for insomnia
melatonin receptor agonist; MT1 and MT2
____, a salt of gamma hydroxybutyrate, is thought to improve daytime alertness in narcolepsy
Sodium oxybate
___, used for tx of hepatitis C, can induce depressive disorder in 10% to 40% of pts; can also induce mania/hypomania
Interferon
Lorazepam, oxazepam and temazepam are primarily metabolized by ___, a capacity maintained even with severe hepatic compromise
glucuronidation (phase 2 metabolism)
Alprazolam, clonazepam, diazepam, and triazolam require microsomal oxidation via ___, and are thus subject to metabolism in competition with other substrates and to reduced elimination in the presence of liver disease
the cytochrome P450 enzyme system
Concurrent use of ___ can result in lithium toxicity is inhibition of prostaglandin synthesis resulting in vasoconstriction and decreased lithium excretion
NSAID’s (ibuprofen)
Valproic acid ___ levels of lamotrigene by ___
Increases; inhibition of glucuronidation pathway (3a4)
Cochrane Systematic Review found evidence supporting the use of ___ and ___ for prolonging abstinence from cocaine among cocaine dependent users
bupropion and dextroamphetamine
only FDA-approved medication for treatment of psychosis in Parkinson’s disease
Pimavanserin
Atomoxetine carries an FDA black box warning in the package insert for increasing risk of which one of the following conditions
Suicidal ideation
The manufacturers’ package inserts for clozapine, paliperidone, risperidone, and lurasidone have recommended dosage adjustments based on ___
Renal function
Low dose ____ has been shown helpful to improve cancer-related fatigue
Methylphenidate
Itraconazole antifungals inhibit hepatic oxidative metabolism via ____
CYP 3A4
Fluvoxamine is both a potent inhibitor of the ___ isoform and a substrate for it
CYP 1A2
Anti-epileptic medication most often associated with hyponatremia
Oxcarbazepine
__ and __ are first-line treatments for Restless Leg Syndrome
Dopamine agonists (e.g., pramipexole,) and calcium channel alpha-2-delta antagonists (e.g., gabapentin)
Which combo of meds has the best evidence for maintenance treatment to prevent relapse of MDD following a course of ECT?
Nortriptyline and lithium
___ associated photopigmentation/photosensitivity occurs due to an unknown mechanism. It is known to bind to melanin-containing tissues and toxic accumulation over time may lead to photosensitivity
Lamotrigene
The risk of developing ___ (of which hirsutism is a common symptom) is increased during treatment with valproic acid
polycystic ovary syndrome
Fluoxetine and Paroxetine are strong ___ in comparison to other SSRIs and can inhibit the metabolism of commonly used cardiovascular medications (e.g., S-metoprolol)
2D6 inhibitors
___ is the only mediction listed that is FDA approved for sleep initiation and maintenance, having a half life of about 6 hours
Eszopiclone (Lunesta)
___ are the only neuroleptic agents in this list that are FDA approved for treatment of Tourette syndrome
Pimozide and haloperidol
Mechanism of action of memantine is ___
N-methyl-D-aspartate (NMDA) receptor antagonism
Mechanism of action of atomoxetine (Strattera) is ___
Selective norepinephrine reuptake inhibitor
Patients with a history of asthma or COPD potentially can experience increased airway reactivity following use of what medications?
Cholinesterase inhibitors (donepezil, galantamine, Rivastygmine)
Minimum duration of methadone maintenance treatment should be what length of time?
12 months
Treatment for hepatic encephalopathy
Lactulose
The exact MOA of valbenazine in the treatment of tardive dyskinesia is not known, but is may be mediated through ___
Reversible inhibition of vesicular monoamine transporter 2 (VMAT2)
___, an oxazolidinone antibiotic, has antidepressant effects through mild reversible nonselective inhibition of monoamine oxidase inhibitors. In combo w/ SSRI, there is a documented risk for serotonin syndrome
Linezolid
___ is FDA approved for the treatment of narcolepsy with excessive daytime sleepiness and cataplexy. MOA is ___
sodium oxybate, a salt of GHB; agonist at GABA-B
NSAIDs act by inhibiting ___, an essential enzyme in the formation of prostaglandins. For individuals with congestive heart failure, ascites, hypovolemia, or chronic renal diseaseconditions which often occur in the elderlyNSAIDs can adversely affect renal blood flow and glomerular filtration rate:
cyclooxygenase (COX)
Clozapine metabolism is typically ___ by tobacco smoke causing levels after cessation to be relatively ___
induced; increased
The two TCAs with the lowest anticholinergic activity are ___
nortriptyline and desipramine
A pregnant female is requesting detoxification from heroin. Assuming good adherence, which treatment for opioid use disorder would be most likely to result in the best maternal outcome and the lowest risk of neonatal abstinence syndrome for the newborn?
buprenorphine
Most common adverse effects of naltrexone?
nausea (10%), headache (7%)
The dose of acamprosate should be reduced in patients with ___
moderate renal impairment
Methadone withdrawal begins ___ after the last dose, and ends in 10 to 14 days. Buprenorphine withdrawal has been observed to peak at about ___ after the last dose and is generally mild, although symptoms may persist for weeks.
1-3 days ; 5 days
___, a non-specific 5HT1A and 5HT2A serotonin antagonist, is an FDA-recognized antidote for serotonin syndrome
Cyproheptadine
___ is the commonest drug causing hypernatraemia; serum sodium levels as high as 196 mmol/L have been reported
Lithium (Li)
Isoenzyme ___ is induced by smoking
CYP1A2
___ is an FDA-approved drug for the treatment of delusions and hallucinations associated with Parkinson’s disease psychosis (PDP). It has antagonistic actions at serotonin 5HT2A receptors with a weaker antagonist/inverse agonist actions at 5HT2C receptors
Pimvanserin
___ is the first drug approved in the US for the treatment of adults with tardive dyskinesia (TD), and its MOA is ___
Valbenazine; reversible vesicular monoamine transporter 2 (VMAT2) inhibitor
Which antipsychotics do not appear to cause consistent, congenital harm to the fetus in pregnant women?
Olanzapine
A 23 y/o F is brought to the ED for overdosing on tricyclic antidepressants and is minimally responsive to painful stimuli with seizures and is hypotension. What is the best way to manage this patient?
IV sodium bicarbonate, lipid emulsion, and plasmapheresis
cytochrome P450 ___ metabolizes about 95% of the caffeine ingested. This enzyme is ___ by fluvoxamine
1A2; inhibited
___ is the most widely studied drug indicated for cannabis abstinence in adolescents. The drug has shown to reduce cravings and promote abstinence
N-acetylcysteine
A 79 y.o. female nursing home resident is found unresponsive. Her nephew, who visited that day, is called and admits to giving the patient some ‘generic Benadryl’ for her allergies. Which medication is most likely to reverse the patient’s delirium
Physostigmine
The mainstay of treatment of lithium-induced nephrogenic diabetes insipidus (polyuria, polydipsia in the setting of low osmolarity urine despite increased plasma osmolality, and a low urine specific gravity) is ___
amiloride, a potassium-sparing diuretic
What anti-emetic is used to treat post-operative delirium and what is its MOA?
Ondansetron - selective serotonin type-receptor 5HT3 antagonist (acts via inhibition of vagal nerves)
Which acetylcholinesterase inhibitor is FDA-approved for treatment of anticholinergic delirium?
Physostigmine
Giving ___ is contraindicated when a person is on an MAOI
meperidine
MAO of memantine is ___
antagonist at NMDA receptors
Sumatriptan MOA is ___; Contraindicated in patients with ___
serotonin 5-HT1A and 5HT-1B agonist; uncontrolled HTN or coronary ischemic heart disease
Benzo’s that are safe for patients with compromised liver functioon (no active metabolites, no need for oxidation by liver)
“Lorazepam, Oxazepam, Temazepam (““LOT””)”
What two psychotropic medication classes increase TCA levels through interaction with the cytochrome P450 system?
Antipsychotics + methylphenidate
Psychotropic drug that decreases TCA levels
Lithium
Adverse effects for this medication include hirsutism in women, facial dysmorphism, and gingival hypertrophy
Phenytoin
Psychotropic medications contraindicated with levodopa/carbidopa repletion there as they are postsynaptic enzymatic metabolizers of dopamine
MAO-A type inhibitors
Valproate is a classic inhibitor of ___, which causes inhibition of enzymatic clearance of lamotrigene
cytochrome P450 3A4
MOA of Ropinirole, used to treat restless legs syndrome
Dopamine agonist
What antipsychotic inhibits serotonin (5-HT 1A) and norepinephrine reuptake
Ziprasidone
Treatment of choice for Wilson’s disease
Penicillamine
Reserpine interferes with Mg and ATP-dependent uptake of biogenic amines, which results in ___. In this way, it can relieve sx of dystonia and also causes depression, sedation, and a Parkinson’s like syndrome
depletion of DA, NE, serotonin neurotransmitters
Medications that should be stopped prior to ECT
Lithium (–> postictal delirium), Clozapine, Bupropion
Carbamazepine is an inducer of what CYP450 enzymes?
2C19 and 3A4 (auto inducer)
MOA for Buspirone
full agonist on the serotonin 1A (5HT1A) autoreceptor and as a partial agonist on the postsynaptic 5-HT1A receptor.
Tricyclic antidepressants that are secondary amines:
Desipramine, Nortriptyline, Protriptyline
Tricyclic antidepressants that are tertiary amines:
Doxepin, Imipramine, Amitriptyine, Clomipramine, Trimipramine
Tricyclic antidepressants are metabolized by ___?
CYP 2D6
Tricyclic antidepressant used to treat childhood enuresis
Imipramine - not v effective
___ block peripheral degradation of peripheral levodopa and central degradation of I-DOPA and dopamine, thereby increasing I-DOPA and dopamine levels centrally. Given concomitant with each dose of carbidopa-levodopa throughout the day to improve parkinsonian symptoms
Entacapone (Comtan) and Tolcapone (Tasmar) = catechol-O-methyltransferance (COMT) inhibitors
___ can be used to treat lithium-induced neprogenic diabetes insipidus
Amiloride
Drugs that can increase lithium levels
ibuprofen, naproxen, ACE inhibitors, thiazide diuretics
MOA for Atomoxatine is ___. Useful when trying to treat both tics and ADHD, as it does not worsen the tic condition
norepinephrine reuptake inhibition
Clonidine’s MOA is ___, reducing the amount of norepinpehrine that is released from the synaptic bouton. THis effect decreases sympathetic tone and bodily arousal and activation
presynaptic a2-receptor agonist
MOA for sildenafil, vardenafil, and tadalafil
phosphodiesterase 5 (PDE5) inhibiton
Tricyclic antidepressant that has a metabolite with dopamine-blocking actiity (can possibly cause parkinsonian symptoms)
Amoxapine
Lithium toxicity occurs at levels above ___. IF the level is above ___, or the patient shows serious signs of toxicity (nephrotoxicity, convulsions, coma), patient must have hemodialysis
2.5 mEq/L; 4 mEq/L
Meperidine (Demerol) can never be given with ___
an MAOI
MOA of Bromocriptine, used to treat Parkinson’s
mixed dopamine agonist-antagonist
Zaleplon (Sonata) has MOA of ___ and half life of ___
benzodiazepine receptor agonist; half life 1 hr
Of sleeping agents, ___ as half life of about 6 hours, making it most likely to cause next-day drowsiness
Eszopiclone (Lunesta)
The least anticholinergic of the tricyclic antidepressants
Desipramine
___ has been shown to be helpful in some cases of Exhibitionistic D/O and can be useful in any sexual disorder in which the patients are extremely hypersexual to the point of being out of control or dangerous
Medroxyprogesterone acetate
MOA for Gabapentin ___
GABA-modulating agent
___ is a selective GABA reuptake inhibitor, FDA-approved as an adjunctive treatment for partial complex seizures
Tiagabine (Gabitril)
MOA for Memantine is ___, used to treat ___
NMDA antagonist; moderate to severe Alzheimer’s dementia
Benzodiazapines bind to ___ receptors, which is a chloride ion channel
GABA-A
MOA of Naltrexone
opioid antagonist
MOA of Methadone
opioid agonist
MOA of buprenorphine
mixed opioid agonist/antagonist mixed opioid agonist/antagonist
___ can be used to treat urinary hesitancy or retention in patients having anticholinergic side effects from psychotropics
Bethanechol
What antibiotic, when given with carbamazepine, causes carbamazepine levels to increase?
Erythromycin
MOA of triptans (abortive agents for migraines)
Agonists at 5-HT 1B and 5-HT 1D receptors
FDA approved for treatment of chorea in Huntington’s Disease
Tetrabenazine
FDA approved for postherpetic neuralgia
Gabapentin
Liothyronin (Cytomel) can be used as augmenting agent for depressive d/o. It should not be taken by patients with ___
cardiac disease, angina, or HTN
MOA for Ramelteon (Rozerem)
melatonin agonist
Differences in metabolism of Risperidone vs Paliperidone
Risperdal is hepatically cleared; Paliperidone is 80% metabolized through kidney
MOA of Varenicline (Chantix)
partial nicotine agonist 4alpha2
Treatment for organophosphate insectivide exposure and poisoning
IV pralidoxime (accelerates reactivation of inhibited acetylcholinesterase) with atropine (counteracts muscarinic effects)
Thiazide diuretic increases ___
lithium level
MOA of Botulinism toxin
blocks release of acetylcholine at neuromuscular junction
What benzodiazepines are metabolized via hepativ glucoronidation rather hepatic oxidation?
“Lorazepam, Oxazepam, Temazepam (““LOT””)”
Carbamazepine has autoinduction of its own metabolism via hepatic ___ enzymes
CYP 3A4
Most common side effects of donepezil
nausea, abdominal cramping
___, can be used to treat hypertensive emergencies, most notably due to pheochromocytoma as well as hypertensive crisis 2/2 MAOI. Mechanism of action is ___
Phenoxybenzamine, Alpha-blocker
For pt on clozapine who develops ANC between ___, the correct action is to stop the clozapine
500-999
For a pt whose ANC on clozapine is between 1000-1499, you can ___
switch to 3x weekly monitoring until it is back above 1500
Phenelzine has less _______ than tranylcypromine because tranylcyprome has significant inhibitory effects on the uptake of norepinephrine, dopamine, and serotonin. Phenelzine is more sedating due to the following reasons: It does not stimulate release of norepinephrine and dopamine, it increases levels of GABA, and it has greater H1 antihistaminergic properties.
activation
_____ of patients treated with lamotrigine develop a benign rash that is non-confluent, non-tender, and spotty, and usually resolves in 10 to 14 days.
8-10%
Cimetidine has what effect on CYP enzymes?
Inhibits CYP 2D6 (leads to higher levels of substrate)
Also inhibits 1A4, 2C19
MOA of ondansetron
potent 5-HT3 antagonist
MOA of metaclopromide
D2 antagonist
