Psychopharm Flashcards
Dopamine pathways
Mesolimbic (+ symptoms)
Mesocortical (- symptoms)
Tuberoinfundibular (dopamine suppresses prolactin production)
Nigrostiatal (movement)
HAM side effects
H = weight gain and sedation A = orthostasis M = can't pee, see, poo, think clearly
Akethesia
Subjective sense of restlessness. Treat with beta blocker or benzo.
Acute dystonia
Usually involves oral/buccal/facial. Treat with benztropine, Benadryl, or aromatidine.
Parkinsonism
Cogwheel rigidity, shuffling gait, resting tremor. Can treat by changing meds, may ultimately need to change to clozaril.
TD
Late in onset, insidious, oral/buccal choreathoid movements. Treat by discontinuing medications to prevent this from becoming permanent
Low potency typical antipsychotics
Chlorpromazine, thioridazine.
More likely to have HAM side effects than EPS.
NMS
Autonomic instability (high fever, tachy, sweating, HTN), muscle rigidity, dystonia, agitation. Treat by discontinuing agent and giving dantrolene
Side effects of thioridazine
Retinitis pigmentosa
High potency typical antipsychotics
Haldol, prolexin, pimozide
More likely to have EPS, less likely to have HAM side effects
Possible side effects of all antipsychotics
EPS, HAM, raise QTC, lower seized threshold
Mechanism of atypicals
Block D2 and 5HT2
Will commonly see metabolic syndrome as side effect
Mechanism and side effects of abilify
Partial agonist at dopamine and serotonin 1a receptor and antagonist at post synaptic serotonin 2a receptors
Side effects of clozaril
Agranulocytosis Anticholinergic Weight gain and sedation NMS cardiomyopathy
Actions of various serotonin receptors
5HT1a – decrease depression and anxiety
5HT2a/c – headaches and jitteriness, decreased libido long term
5HT3/4 – gi disturbances
MoA of TCAs
Increase levels of norepi and serotonin in synapse
Highly cholinergic TCAs
Amitryptiline, doxepin, imipramine, clomipramine trimipramine
TCA used to treat OCD
Clomipramine
Less anticholinergic TCAs
Desipramine, nortriptyline, protryptiline, amoxapine
Preventing serotonin syndrome
2 week washout period for SSRIs, but 5 weeks for Prozac because of long half life
SSRI with shortest half life
Paroxetine (Paxil)
Buspirone
Partial 5HT1a agonist
Used to treat GAD
Mirtazapine
Alpha 2 antagonist – leads to increased norepi and serotonin by blocking feedback inhibition.
No interference with sexual function.
Can cause sedation and weight gain
Bupropion
Norepi and dopamine reuptake inhibitor
Lowers seizure threshold
Used for smoking cessation
Nefazadone and trazadone
serotonin antagonist and reputake inhibitor
often used as sleep aid
Trazadone can cause priapism
Lithium dosing range
0.8 - 1.0
Carbamazepine dosing range
8-12
Valproic acid dosing range
80-120
Lithium side effects
neurotoxicity, hypothyroid, diabetes insipidus, leukocytosis
can cause Ebsteins anomaly
Carbamazepine side effects
autoinducer at liver, S/J rash, CBC anomalies
can cause hepatitis
can cause craniofacial and neural tube defects
Valproic acid side effects
hepatitis, CBC abnormalities, sedation, weight gain
can cause neural tube and defects
Lamictal
good for preventing depression
causes serious S/J rash
shortest acting benzo
Alprazolam (xanaz) – quick onset and short half life, so high risk for abuse
mid acting benzo
lorazepam (ativan) – longer to onset and moderate risk of abuse
Longest acting benzo
Clonazepam (klonopin) – long to onset and long half life, so lowest risk of abuse
Patient with cirrhosis needs to go on benzo taper for etoh withdrawal. what do you use?
LOT – Lorezapam, oxazepam, and tomezapm (?) are only glucuronidated, so they spare the liver unlike other benzos
How is benzo overdose reversed?
use Flumazenil. But watch out because it can theoretically lower sz threshold.
What receptor do Benzos and Etoh act on?
GABA-a
Uses of lithium
acute mania, prophylaxis for manic and depressive episodes in bipolar and schizoaffective d/o.
Testing needed to initiate lithium treatment
ECG, basic chemistries, thyroid function tests, CBC, pregnancy test.
Need to check lithium blood levels five days after starting therapy
Factors that influence lithium levels
Decrease - NSAIDS
Increase = dehydration, salt deprivation, sweating, impaired renal function, diuretics
Carbamazepine (tegretol) uses
treating mixed episodes and rapid cycling BD.
not as effective in depressed phase
tests needed when starting tegretol
CBC and LFTs
Depakote uses
treating mixed episodes and rapid cycling
what is the interaction between lamictal and depakote?
Valproate will increase lamictal levels, and lamictal will decrease valproate levels.
D is delicious, so it gets eaten first when paired with other drugs.
Dextroamphetamine and amphetamine side effects
weight loss and insomnia
MoA of psychostimulants
increase dopmane and norepi
atomoxetine (strattera) MoA. What is special about it?
presynaptic norepi transport inhibitor
Unlike other stimulants this is less likely to cause tics
has a more gradual onset of action.
Watch out for what with ritalin?
Leukopenia, anemia, increased LFTs
may cause weight loss and insomnia
Donepezil
Acetylcholinesterase inhibitor – dementia
Galantamine
Acetylcholinesterase inhibitor – dementia
Rivastigmine
Acetylcholinesterase inhibitor – dementia
Tacrine
Acetylcholinesterase inhibitor – dementia
Memantine
NMDA receptor antagonist – dementia (augments therapy)
order of atypicals in terms of metabolic syndrome (worst to least)
olanzapine – risperidone – quetiapine – ziprasidone – aripiprazole
What is so typical about risperdal?
It causes the most EPS side effects of the atypicals
Why were we giving out so much seroquel on spruce 6?
Because it’s extremely sedating (and it can also cause orthostatis (anti adrenergic effect)
What is the FALTERED pneumonic for NMS?
F = fever A = autonomic instability L = leukocytosis T = tremor E = elevated CPK R = rigidity E = excessive sweating D = delirium
how is a hypertensive crisis mediated by MAOIs treated?
Give an alpha adrenergic blocker – like phentolamine
What is the initial presentation of serotonin syndrome?
lethargy, restlessness, confusion, flushing, diaphoresis, tremor, mycolonic jerks.
What does the end stage of serotonin syndrome look like?
Hyperthermia, hypertonicity, rhabdo, renal failure, convulsions, coma, and death.
treatment of cateplexy
use sodium oxygate – agonizes GABA b receptor
What are the FDA approved pharm agents for treating acute mania?
Li, VPA, Carb, SGA’s and thorazine.
NOTE: lamictal is not approved to treat mania
What are the FDA approved pharm treatments for bipolar depression?
Olanzapine + fluoxetine, Seroquel, Latuda.
Lithium and lamictal don’t have FDA approval but are still used.
What are the best agents for preventing mania in the maintenance phase?
Antipsychotics > Li»_space;» LMT
What are the best agents for preventing bipolar depression in maintenance phase?
LMT>Li
What are the common side effects of lithium?
Acne, tremor, N/V/D, sedation
Who is most susceptible to SJS with carb?
Asians!
What does VPA do to the blood?
decreases platelet levels
What does carb do to the blood?
Decreases WBC count (watch out for aplastic anemia)
Why do carb levels fall over time, even if the patient is compliant?
Carb is an autoinducer of its own metabolism by the P450 system, so its level will gradually decrease over time before reaching a new steady state.
side effects of nefazadone
hepatitis and liver failure
lithium toxicity syndrome
dysarthria, ataxia, coarse tremor, and ab pain seen early.
later see seizures, neuromuscular irritabilty, impaired consicousness.
