Psychopharm Flashcards
What are the HAM side effects? What classes have them (2)?
H- antiHistamine- sedation weight gain
A- antiAdrenergic- hypotension
M-antiMuscarinic- dry mouth, blurred vision, urinary retention
Classes- TCAs (imipramine, amitriptyline, doxepin, etc) and low potency antipsychotics (clozapine, olanzapine, risperidone, quetiapine, etc)
What is serotonin syndrome? What are some drugs that cause it?
Too much serotonin causing neuromuscular (clonus, hyperreflexia), autonomic instability (increased BP, HR, temp), cognitive (AMS), and and GI distress
SSRIs and one of the following- MAOIs, tramadol, triptans, MDMA, cocaine, etc)
What is the treatment for extrapyramidal side effects of neuroleptics?
Benzotropine- anticholinergic
What are the extrapyramidal side effects? What drugs cause them? How long until they can be seen?
Parkinson like symptoms, akthisia (treat with propanolol), dystonia
Occurs with typical antipsychotics (haloperidol, fluphenazine, chlorpromazine, etc)
Can occur within days
What lass of drugs can cause hyperprolactinemia?
Typical antipsychotics AND risperidone
What is Neuroleptic malignant syndrome? Treatment?
Looks like serotonin syndrome without GI distress
Autonomic instability, “lead pipe” rigidity, AMS
Check CPK levels
Treat with cooling blankets and dantrolene
What disorders are only treated by SSRIs? (6)
OCD Pre-menstrual dysphoric disorder PTSD Social Anxiety long term Premature Ejaculation Hot Flashes (specifically Paroxetine)
What typically causes “brain zaps”, anxiety, irritability, dizziness, and headaches?
Serotonin rapid discontinuation
What class of drugs can treat fibromyalgia, chronic back pain due to OA, and neuropathic pain
SNRIs, specifically duloxetine
What % of patients will respond to antidepressants?
30-40%
What is the black box warning for SSRIs?
Increased suicidal thinking and behavior
What makes the following SSRIs special? Fluoxetine Sertraline Paroxetine Fluvoxamine Citalopram Escitalopram
Fluoxetine- longest half life no need to taper
Sertraline- highest risk for GI side effects
Paroxetine- short half life, more anticholinergic side effects (sedation, constipation)
Fluvoxamine- only approved for OCD
Citalopram- no CYP effects
Escitalopram- no CYP effects
Pneumonic for SSRI side effects?
Sex
Stomach
Restlessness
Insomnia
What is special about the following SNRIs? Duloxetine Venlafaxine Desvenlafaxine Savella
Duloxetine- used for fibromyalgia or neuropathic pain, contraindicated in liver disease
Venlafaxine- can increase BP
Desvenlafaxine- metabolite of venlafaxine
Savella- none, used for fibromyalgia
What is buproprion MOA, uses, side effects, special facts?
MOA- NE and dopa reuptake inhibitors
Uses- depression, smoking cessation, ADHD and obesity (causes weight LOSS) are off label
Side effects- lowers seizure threshold, headache, insomnia
Contraindicated in people with eating disorders
NO SEXUAL side effects
What is vilazodone MOA, uses, side effects?
SSRI and partial serotonin 1a agonist
Used for depression
Side effects similar to SSRIs- diarrhea and nausea are common
What is trazodone and nefazodone MOA, uses, side effects?
MOA- serotonin antagonist and reuptake inhibitor
Uses- refractory depression and insomina
Side effects- dizziness, orthostatics, sedation, and priapism
What is the black box warning for nefazodone?
Liver failure
What is mirtazapine MOA, uses, side effects?
MOA- alpha 2 agonist, SNRI, and serotonin antagonist
Uses- refractory depression, good for elderly as helps with sleep or patients who need to gain weight
Side effects- WEIGHT GAIN, sedation, dizziness, constipation
What is the treatment of TCA overdose?
Sodium Bicarbonate
What are the side effects of TCAs (7)? Which of these can be used as advantages (4)?
Anti-histamine
Anti-adrenergic
Anti-muscarinic
Cardiotoxicity- get EKG!
Convulsions
Coma
LETHAL IN OVERDOSE- assess suicide risk
Urinary retention- use imipramine to treat enuresis
Sedation- doxepin used to treat insomnia
Anti-histamine- doxepin used to treat itching
IBS, neuropathic pain, migraines- use amytriptyline to treat
What makes these TCAs special? MOA of TCAs? Amitriptyline Imipramine Clomipramine Doxepin Nortriptyline Desipramine Amoxapine Trimipramine Protryptiline
MOA- inhibits reuptake of 5HT and NE Amitriptyline- used for IBS, migraines Imipramine- used in enuresis, IM form Clomipramine- used in OCD Doxepin- used for insomnia and itching Nortriptyline- less orthostatics Desipramine- least anticholinergic, less sedation Amoxapine- similar side effects of antipsychotics Trimipramine- none Protryptiline- none
What are the dosing and treatment strategies for antidepressants?
Start low and titrate as tolerated
At least 6 weeks at maximum dose if no side effects seen
Then switch to other classes
Then augmentation
Phenelzine, Tranylcypromne, Isocarboxazid, selegiline- MOA, uses, side effects, anything special?
MAOIs- prevent the break down of NE, 5HT, dopa, and tyramine
Used for atypical or refractory depression
Major side effect profile- serotonin syndrome with SSRIs, hypertensive crisis and many more
Selegiline has a patch that can avoid hypertensive crisis via certain foods- does not affect MAO in the gut
What are three things to monitor when prescribing lithium?
Creatinine, lithium and thyroid levels
What does potency mean when discussing antipsychotics?
Action on dopamine receptors
Which typical antipsychotics are considered low potency and how are they special (3)?
Chlorpromazine, mesoridazine, and Thioridazine
Have lower affinity for dopamine, more anticholinergic and antihistaminic side effects, less EPS side effects
Chlorpromazine- photosensitivity, can treat hiccups
Thioridazine- associated with retinitis pgimentosa
Mesoridazine
What are the midpotency typical antipsychotics and how are they special (4)?
Loxapine, Thiothixene, trifluoperazine, perphenazine
Have midrange properties for affinity and side effects
Loxapine- high risk of seizure
Thiothixene- can cause ocular pigment changes
Trifluoperazine- can reduce anxiety
Perphenazine- can treat nausea and vomiting in pregnant women
Other typical antipsychotics to know and why (1)?
Molindone- described as both typical and atypical, causes weight loss
What are the high potency typical antipsychotics and how are they special (3)?
Haloperidol, Fluphenazine, Pimozide
Highest affinity for dopamine receptors, more EPS side effects, greatest risk for tardive dyskinesia, less anticholinergic and antihistaminic effects
What two drugs have been shown to decrease risk of suicide?
Lithium and clozapine
What class of drugs cause metabolic syndrome?
Atypical antipsychotics
Which atypical antipsychotics are FDA approved for Depression?
Quetiapine
Which atypical antipsychotics are FDA approved for maintenance of bipolar disorder?
Quetiapine, olanzapine, aripiprazole, ziprasidone
Which atypical antipsychotics are FDA approved depression as augmentation with at least one other drug?
Aripiprazole
Which brain pathway is responsible for positive schizophrenia symptoms?
Mesolimbic
Which brain pathway is responsible for negative schizophrenia symptoms?
Mesocortical
What makes the following atypical antipsychotics special? MOA of atypicals? Clozapine Risperidone Quetiapine Olanzapine Ziprasidone Aripiprazole Paliperidone Asenapine Iloperidone Lurasidone
MOA- 5HT2A and D2 receptors blockade
Clozapine- more efficacious than any other antipsychotic, can cause agranulocytosis or myocarditis, orthostatics
Risperidone- hyperprolactinemia, has long acting indictable form
Quetiapine- less EPS side effects, more sedation, lots of FDA approvals
Olanzapine- lowest discontinuation, weight gain is common
Ziprasidone- less weight gain
Aripiprazole- less sedating, can be used as adjunct treatment for depression
Paliperidone- metabolite of risperidone, long acting forms
Asenapine- none
Iloperidone- none
Lurasidone- none
What stimulants are used in narcolepsy, OSA?
Modafanil, Armodafinil
What are the stimulants used in ADHD and refractory depression (5)? MOA? Biggest side effect?
Dextroamphetamine, Amphetamine salts, Lis-Dextroamphetamine, Methamphetamine, Methylphenidate
Inhibit reuptake of dopamine and NE
Major potential for abuse
Weight loss, insomnia, and hypertension are other side effects
What is the MOA of amphetamines?
Taken up by VMAT causing release of dopamine, NE, and 5HT
What are some side effects of Methylphenidate?
Leukopenia, anemia, increased LFTs, weight loss, insomnia
Stimulant used for AHDHD
What is atomoxetine MOA, uses, side effects?
Presynaptic NE transporter inhibitor
Used for ADHD
Side effects- LESS appetite suppression and insomnia
What is Guanfacine and C ionidine MOA, uses, side effects?
MOA- alpha 2 agonist, located in prefrontal cortex leading to increased attention
Uses- ADHD, HTN, anxiety, Tics, withdrawal of alcohol, opioids
Side effects- abdominal pain, constipation, dry mouth, headaches
What is the difference between methadone and buprenorphine?
Methadone is just an agonist while buprenorphine is an agonist and antagonist
Buprenorphine is more efficacious- has longer duration of action
What is acamprosate MOA, uses, side effects?
MOA- reduces excitatory glutamate and increases GABA
Used for alcohol dependance
GI side effects common
Can be used in liver failure as not hepatically metabolized
What is Naltrexone MOA, uses, and side effects?
MOA- blocks mu opioid receptor preventing alcohol from binding
Uses- alcohol dependance
Side effects- n/v, eosinophilic PNA, hepatocellular injury
What is disulfiram MOA, uses?
MOA- inhibits aldehyde dehydrogenase that causes nausea, vomiting, diaphoresis, flushing, and dyspnea when alcohol is consumed
Used for alcohol dependance
What alpha 2 agonist can be used for ADHD?
Clonidine
What mood stabilizer typically causes SJS? (2)
Lamotrigine is most common
Also Carbamazepine
What are the side effects of carbamazepine (6)?
SJS, GI distress, CNS effects, HYPONATREMIA, Hepatitis, Teratogenic
What should be monitored when giving a patient Valproic Acid/ Depakote?
LFTs!!
What mood stabilizer causes fine tremor?
LITHIUM
Lithium uses, side effects (7)? Special considerations (2)
Used for acute mania and maintenance of bipolar disorder, also schizoaffective disorder
Side effects- Tremor, AMS, diabetes insipidus, ECG changes, weight gain, hypothyroid, Ebstein’s anomaly (teratogen)
MONITOR BLOOD LEVELS and kidney function, avoid NSAIDs
Carbamazepine MOA, uses
Blocks Na channels inhibiting action potentials
Used for mixed episodes and rapid cycling bipolar disorder
What are two advantages of oxcarbazepine vs carbamazepine?
Better tolerated
Less risk of rash and hepatic toxicity
Two uses for gabapentin other than anticonvulsant?
Anxiety, insomnia
Two uses for pregabalin other than anticonvulsant?
GAD, fibromyalgia
Topiramate uses, side effects (4)
Used for anxiety and impulse control
Side effects- Weight loss is advantage, metabolic acidosis, kidney stones, COGNITIVE SLOWING
Long acting BZDs? (4)
Diazepam, Clonazepam, Flurazepam, Clorazepate,
Intermediate acting BZDs? (5)
Alprazolam, Lorazepam, Oxazepam, Temazepam, Chlordiazepoxide
Short acting BZDs?
Triazolam, Midazolam
Side effects of BZDs (5)
Drowsiness, Amnesia, Decreased coordination, Withdrawal, Respiratory depression
Buspirone MOA, uses, side effects?
MOA- 5HT-1A receptor partial agonist
Used for GAD
Few side effects, low potential for abuse
Hydroxyzine MOA, uses, side effects
MOA- antihistamine
Uses- Anxiety- quick acting
Side effects- sedation, dry mouth, constipation, urinary retension
Propanolol uses (2)
Performance anxiety, Akathisia
Clonidine MOA, uses (2), side effects (3)?
MOA- alpha 2 agonist
Uses- ADHD, anxiety,
Side effects- dizziness, orthostatic hypotension, somnolence
Zolpidem, Zalelpon, Eszopiclone MOA, uses, side effects (4)
MOA- BZD receptor 1 agonist
Uses- insomnia
Side effects- GI distress, amnesia, hallucinations, sleepwalking
Ramelteon MOA
Melatonin receptor agonist
