Psychopharm Flashcards
1
Q
CYP3a4 inducers
A
Carbamazepine, phenytoin, oxcarbmazepine
2
Q
drugs with increased risk of depression
A
oral contraceptinves, resperine, clonidine, levodopa, alcohol, hydralazine, amantadine, benzos, guanethidine
3
Q
benefits of high potency antipsychotics in pregnancy
A
decreased risk of neonatal hypotension, anticholinergic, antihistaminic.
4
Q
MAOI SE
A
pyridoxine deficiency
sexual SEs, WG
5
Q
mechanism of sexual SEs in antipsychotics
A
ANTIADRENERGIC
alpha 1 receptor effects, cholinergic antagonism,
dopamine blockade decreases sexual arousal.
6
Q
risks of lithium exposure during pregnancy
A
arrythmias, polyhydramnios, floppy infant syndrome, premature delivery
levels can become toxic due to shifting fluid levels.
draw lithium levels weekly beginning at 34 weeks
7
Q
enzyme that metabolizes methylphenidate
A
CES1A1
8
Q
st. johns wart
A
CYP inducer, lowers levels of drugs (warfarin, digoxin), ; also acts as SSRI; avoid with MAOs and SSRIs.
9
Q
donepezil
A
REVERSIBLE ACH esterase inhibitor; SEs of GI upset
10
Q
carbemazepine
A
blocks Na+ channels;
inhibits voltage dependent sodium channels and presynaptic sodium channels
effect on sodium channels result in inhibition of glutamate release.
p450 3A4; absorption is increased by food, can cause beningn neuropenia, rare agranulocytosis,
11
Q
cyp2d6 inhibitors
A
wellbutrin, duloxetine, fluoxetine, paroxetine, zoloft, rotanivir, cemitidine
12
Q
CYP2D6 inducers
A
rifampin, dexamethasone
13
Q
PCOS and depakote
A
PCOS is a SE of depakote, increased risk of SAs.
10% of females develop PCOS every year.
14
Q
lithium and the kidneys
A
causes impaired concentrating capacity by reducing ADH.
LOW SALT diet is likely to increase lithium
can cause nephrogenic diabetes inspidus (increased water output in urine) = hypernatremia; competes with ADH receptors; can use amiloride to reduce
CAN MANAGE polyuria and polydipsia with one single bedttime dose, can use thiazide diuretic or amiloride.
10-20% of people on lithium for over 10 years will have renal changes.
15
Q
lithium and insulin
A
lithium has an insulin like effect: lowers BG, increases appetite and WG
16
Q
associated with clozapine
A
myocarditis, eosinophilic colitis, neutropenia
17
Q
antipsychotics that increase risk of seizures
A
clozapine (4% > 600mg), chlorpromazine is MC in causing seizures
18
Q
6 P450 enzymes that are responsible for 70-80% of all drug metabolism
A
1A2, 2C9, 2C19, 2D6, 3A4, 3A5
19
Q
clozapine mechanism
A
dopamine, serotonin, alpha receptor antagonist
20
Q
abilify mechanism
A
serotonin 5HT1A partial agonist, partial dopamine agonist
antagonist at 5ht2 receptor
NOT D2 blocker!!!
21
Q
atomoxetine
A
selective norepi reuptake inhibitor.
blocks reuptake of norepinephrine
SEs: WL, abdominal pain, decreased appetite, vomiting, nausea, headache, dizziness, fatigue, irritability
SEs worse in slow metabolizers.
22
Q
Lithium induced hypothyroidism
A
MC in women. Need TFTs, EKG, and BMP before starting in pts older than 40. Order renal fucntion test q 3 months and TFT once in 1st 6 months. After 6 mo, order BUB, CR and TFTs q 6-12 months.
usually occurs in 1st 6-18 mo
Hypothyroidism is NOT a CI, treat with levothyroixine
Hypothyroidism associated with rapid cycling and increased depression
23
Q
MAOs
A
sexual SEs and weight gain ie. phenelzine
24
Q
SE of chlorpromazine
A
mild pigmentary changes in retina (large doses)
thioridazine also causes irreversible pigmentary retinopathy in large amounts
25
Mirtazapine drug class
tetracyclic antidepressant. noradrenergic and specific serotenergic antidepressant.
alpha 2 adrenergic receptor antagonist,
serotonin 5h2 antagonist
Blocks presynaptic alpha 2 adrenergic receptor, which results in 5-HT-1A activation and increases release of dopamine. 5HT2 antagonist
26
antidepressant not metabolized by p450
desvenlafaxine
27
CYP enzyme present at birth
3A7
28
CYP 3A4 inihibitors
amiodarone, anastrozole, azithromycin, cannabinoids, cimetidine, clarithromycine, clotrimazole, cyclosporine, danazol, delavirdine, diethyldithiocarbamate, diltiazem, dirithromycine, disulfram, entacapone, erythromycin, ethinyl estradiol, fluconazole, fluoxetine, ketoconazole, metronidazole, nefazodone, paroxetine, ranitidine, sertraline, ritonavir, depakote
29
galantamine
competitive inhibitor of aceytylcholinesterase; allosteric modulator of nicotinic acetylcholine receptors
SE GI disturbance
30
SEs of ACHesterase inhibitors
PARASYMPATHETIC/LEAKY
n/v, diarrhea, bradyicardia, hypotension, hypersecretion, bronchoconstriction, GI hypermotility, decreased intraocular pressure
31
MC clozapine SEs
sedation (20-50%)
sialorrhea/drooling (10-40%c)
32
sumatriptan
5-Ht1D and 5-HT1B agonist
33
Topimax and ETOH
antagonizes glutamate and suppresses alcohol induced dopamine release
34
SSRI with greatest WG
Paroxetine
35
SSRI that increases clozaril levels
Fluvoxamine
fluvox also inhibits 3A3/4 which increases xanex, triazolam, trazodone
36
Meds not safe to use with MAOIs
meperidine, epinephrine, loacl anesthetics and decongestants ... can cause hypertensive crisis
37
Anticholinergic Side effects
result from muscarinic cholinergic receptors.
blurred vision, constipation, dry mouth, urinary retention;
tachycardia, ocular crisis in patients with narrow angle glaucoma, confusion, delirium
also ED and impaired vaginal lubcrication (TCA's MAOIs)
tricyclic antidepressants block muscarinic ACH receptors
38
Risks of duloxetine
increases hepatic transanimases and may inc levels in patients with liver dz
39
mood stabilizer that slows cardiac conduction
carbamazepine
avoid in pts with high grade atrioventricular block and sick sinus syndrome
40
primary OD sx in Clozapine
delirium, lethargy, tachycardia, hypotension, respiratory failure
41
increases warfarin levels
SSRIs
42
effect of valproate on lamictal's metabolism
valproate doubles half life. Will have to halve starting dose.
43
modafinil
has histaminergic mechanism in addition to increasing dopamine by binding to transporter.
dopamine reuptake inhibitor
44
Topimax MOA
inhibits NA+ channels, enhances GABA-a receptors, antagonizes subtype of glutamate receptors
antagonizes kainate and AMPA receptors
1% get stones, metabolic acidosis
associated with acute myopia and secondary closure glaucoma , causing ocular pain andd blurred vision.
45
MAO-A vs. MAO-B
MAO-A breaks down tyramine
46
Memantine
glutamatergic NMDA Receptor Antagonist
47
Varenicline MOA
Alpha 4 beta 2 nicotininc acetylcholine receptor partial agonist
48
antipsychotics with highest anticholinergic effects
cloazpine, thioridazine, chlorpromazine
49
where melatonin is produced
pineal gland
50
kava kava
acts on GABA receptors, long term use linked to liver toxicity. Used for sedative and anesthetic qualities
51
Ketamine
NMDA receptor antagonist; acts at opiod recepters and monoamine transporters; hallucinogen and is similar to PCP
dissociative hallucinogen
52
Xyrem
sodium salt of gamma-hydroxybutyric acid (GHB); treats cataplexy associated with narcolepsy.
agonizes GABA-b receptor complex and GHB receptor
53
sertraline and CYP2D6
sertraline at 200mg is an inhibitor of CYP2D6 and increases levels of tramadol
54
disulfram
blocks dopamine beta hydroxylase in brain
55
lithium
Acute: tremor, polyuria, polydipsia, cognitive problems, poor memory and concentration, GI distress, benign leukocytosis, acne and edema.
Chronic: hair loss, weight gain, possible kidney damage, thyroid disfunction,
EKG: changes in repolarization phase, worsening existing arrhythmias and (less commonly) inducing new ones.
reduces effect of ADH on kidney
associated with hyperplasia and adenomas of parathyroid glands
56
Topimax 200mg or more
interferes with OCPs
57
treat lithium induced polyuria
HCTZ or amiloride(K+ sparing)
58
depakote in mania
increases GABA
superior to lithium in mixed sx
superior to lithium in patients with prominent depressive sx during mania or with multiple prior mood episodes
less effective than olanzapine for acute mania
response rates: 48-53%
depakote increased GABA in the brain
59
selegiline
irreversible MAO-B inhibitor
Contraindicated in pheochromocytoma and surgery- excess norepinephrine can lead to hypertensive crisis
used to target PD sx by increasing levels of dopamine
60
SSRIs in bleeding
cause dec platelet activation due to reduction of serotnin in platelets. No serotonin in platelets impairs ability of platelets to aggregate.
risk of bleeding is similar to NSAIDs
61
CI for lithium use
Sick sinus syndrome.
lithium affects the SA node and atrial node transmissio.
62
TCA CI in breastfeeding
doxepin.
causes sedation, hypotonia, respiratory depression,
has long half life.
63
transdermal MPH to oral extended release ratio
10mg transdermal to 15mg oral ER
64
things to monitor with tegretol
bone marrow suppression sx: bruising, bleeding, aplastic anemia, thrombocytopenia, agranulocytosis
65
common clozaril SEs
tremor (6%), hypokinesia (4%), muscle rigidity (3%)
low risk of tarditive dyskinesia
66
hypnotic with 1-2 hr half life and won't cause grogginess in the AM
Zalelpon
67
varenicline (Chantix)
partial agonist at alpha4beta2 nicotinic acetylcholine receptors and full agonist at alpha7 nicotinic acetylcholine receptors
68
Fluoxetine increase the drug levels of...
TCAs (cardiac risk)
Thioridazine (cardiac risk)
Benzos (sedation)
Tegretol (toxicity)
Phenytoin (toxicity)
Warfarin (toxicity)
Bupropion (seizure)
69
age that abosorption and transportation of drugs are comparable between children and adults
4 months
GFR- 1 year
Adult P450 values: 1 year
70
possible SEs of olanzapine
DKA and Hyperosmolar Non Ketotic Coma
71
Antidepressants associated with hyponatremia
SSRIs
dizziness, light headedness
72
Topimax tetratogenicity
cleft lip, palate, hypospadias
73
Drinks that inhibit p450
red grapes
grapefruit juice
kava kava
red wine
*antioxidants inhibit p450 enzymes
74
Food that induce CYP1A2 enzyme
and therefore increase cyp450 substrates
cauliflower, brussels sprouts, charcoal broiled foods
75
antipsychotic with antidepressant effects
geodon
take with food to double bioavailability
works as norepi reuptake inhibitor
76
name for St. Johns Wart
Hypericum perforatum
77
p450 inhibitors
valproate, fluoxetine, sertraline, fluvox
red grapes, grapefruit, kava kava, red wine
78
p450 inducers
phenytoin, carbamazepine, phenobarbital, rifampin
79
strattera MOA
inhibit reuptake of norepinehrine
80
xyrem (sodium oxybate)
FDA approved for excessive daytime sleepiness and cataplexy associated with narcolepsy.
atomoxetine is also off label for narcolepsy
81
1st line for melancholic depression in geriatrics
nortriptyline
82
etoh detox agent used
lorazepam
83
quickest nicotine level
tobacco cigarette---> spray-->inhaler--->lozenge-->gum-->patch
84
most serious SE of mirtazapine
agranulocytosis (1/1000)
mirtazapine has fewer sexual SEs
85
lithium toxicity and SEs
>1.5 tremors, GI, blurred vision, vertigo, confusion, increased DTRs
>2.5 seizures, comas, arrythmias, permanent neurological damage
treatment: supportive, gastric lavave, emesis
>6 hemodyalisis
86
buspar acts on this receptor
5HT1A
87
eosinophilic colitis is associated with these meds
clozapine, valproate
88
false positives on UDS
PCP- venlafaxine
LSD- amitriptyline
Barbituates- Naproxen
Benzos- Sertraline
Amphetamines- Trazodone
89
time to wait after discontinuing prozac to start MAOI
1 month, 5 weeks
90
DR to ER depakote dosing
increase ER by 15%
91
MOA of Carbamazepine
blocks sodium gated channels (voltage dependent and presynaptic sodium)
food inc absorption
serum level equilibrates after 3-5 weeks
metabolized by p450 3A4
Neutropenia occurs early but is benign
substrate AND inducer of p450 3A4
92
protriptyline
inhibits reuptake of serotonin and norepinephrine
energizing. used off label for narcolepsy
93
ginko biloba
perceived effects on blood flow and cognitive enhancement
avoid w/ anticoagulants
94
buspar MOA
FULL PRE
PARTIAL POST
5ht1a receptor partial agonist at post synaptic receptors in hippocampus and cortex
5HT1A receptor full agonist at presynaptic receptors
mild-moderate presynaptic dopamine antagonist at d2, d3, and d4 receptors
partial alpha 1 receptor agonist
95
tamoxifen
lowered by meds that are metabolized by CYP 2D6
like paroxetine, fluoxetine, buproprion
desvenlafaxine is NOT metabolized by p450
96
completes autoinduction in 4-5 weeks
carbamazepine
autoinduction due to transcriptional upregulation of genes invovled in metabolism
CYP3a4 and CYP2B6
97
most rapidly absorbed benzo when taken orally
diazepam : 100% oral availability, 90% rectal
next is clorazepate 100% bioavailability
98
interacts with MAOIs
meperidine, epinephrine, local anesthetics, decongestants can induce hypertensive crises.
99
associated with irreversible pigmentary retinopathy
Thioridazine
100
imipramine
TCA used to treat nocturnal enuresis in children
serotonin, norepi
downregulates beta adrenergic receptors and serotonin receptors
desensitizes adenyl cyclase
101
keppra
excreted by glomerular filtration with subsequent partial tubular reabsorption
clearance reduced in pts with impaired renal function
102
most common SE, EPS, associated with clozapine
Tremors
103
enzyme metabolizes alprazolam
CYP450 CYP3A4
104
what to do with common lithium SEs
nausea (10-20% of patients)- switch to sustained release formulation
diarrhea: switch to immediate release
hypothyroidism- treat with thyroid, continue lithium
edema- administer spironolactone and follow lithium levels
tremor- administer propranolol (10-30mg TID) or primidone (25mg-100mg/day)
polydipsia/polyria- amiloride (5-20mg/day) or HCTZ (50mg/day, use half the lithium dose and follow lithium levels closely)
105
associated with hyponatremia, particularly in elderly females
SSRIs like sertraline
106
associated with rise in lithium levels include...
diuretics
ACEIs
NSAIDs
COX-2 inhibitors
salt restricting diets
dehydration
high heat
poor oral intake
107
chinese people have lower level of
CYP2d6
108
associated with hyperplasia and adenomas of parathyroid gland
aka hyperparathyroidism
Lithium
109
causes hypernatremia
lithium via inducing nephrogenic diabetes insipidus
competes with ADH hormones, increases water output in urine. causing Nephro diabetic insipidus.
Amelioride blaokcs lithium entry, also partially blocks potassium wasting induced by thiazine
110
meds that REDUCE suicidality
lithium in MOOD disorders
Clozapine in schizphrenia/schizoaffective
111
MOA of lamictal
inhibits Na+ and Ca2+ channels in addition to weak inhibitor of 5HT3
inhibits glutamate.
112
depakote loading dose in acute mania
20mg/kg
113
hypercalcemia
lithium long term use
looks like nausea, dry mouth, vomitting, constipation, polyuria, polydips, arrhythmia, short qt interval
114
carbamazapine and depakote
inc carbamazepine decreases depakote
carbamazepine induces p450 system.
so decreases depakote
also depakote is inhibitor of p450 system CYP 2c9
115
SSRIs approved for panic attacks
zoloft
prozac
paxil
116
med with highest risk of suicide in female patients
depakote
117
meds associated with depression
clonidine
OCPs
reserpine
xanex
ETOH
hydralazine
amantadine
guanethidine
118
how to stop clonidine
dec dose slowly over 1 week
119
risk of liver failure
nefazodone
iproniazid
phenelzine
imipramine
amitriptyline
duloxetine
buproprion
trazodone
tianeptine
agomelatine
120
treatment for drug induced psychosis in patients with Parkinson's disease
clozapine
121
foods to avoid on MAO-i
cheese (can eat cream cheese and cottage)
caviar
liver
smoked/picked/cured fis and meats
ripe avocados
canned figs
yeast extract
chianti red wine
fava beans
raisins
prunes
beer w/ yeast
122
phenytoin
folate antagonist
cleft lip in babies
fetal phenytoin sundrome 10-30% of mothers who took phenytoin while pregnant
orofacial clefts, cardiac malformations, genitourinary defects
123
SSRI greatest weight gain risk
paxil
124
production of serotonin
raphe nuclei
125
late life depression
SSRIS
celexa, max dose is 20mg
126
WEllbutrin
dopamine norepi reuptake inhibitor
dose dependent seizure risk
taper off is rec
127
atypical depression
emotional reactivity, hypersensitivity to loss or rejection, hypersomnia, hyperphagia
tx. MAOIs like
phenelzine and traylcypromine
128
ebstein's anomoly
malformation of tricupsid valve. downward displacement of septal leaflet and atrialized right ventricle
maternal exposure to benzos and/or lithium.
129
tanner stage for hormone replacement
2- secondary sex characteristics begin to present
130
CYP1A2 substrates
(drugs metabolized by this enzyme)
caffeine
cloazapine
duloxetine
imipramine
olanzapine
imipramine
ramelteon
anitriptyline
131
cyp1a2 inhibitors
fluvoxamine
cimetidine
ciprofloacin
grapefruit juice
ketoconazole
132
CYP1A2 Inducers
charcoal-broiled beef
tobacco
marijuana
omeprazole
cruciferous vegetables
133
L dopa
precursor to neurotrasmitters dopamine, norepinephrine, epinephrine
(catecholamines)
134
amitriptyline
TCA that has anticholinergic effects
inc risk of urinary retention
135
glutamate antagonists
ethanol
some epileptic drugs
ketamine
glutamate is main excitatory CNS neurotransmitter
136
keppra
excreted renally
least effect on hepatic p450 system
137
p450 enzyme present at birth
3A7
138
SE of MAOIs
orthostatic hypotension
sedation
fatigue
insomnia
urinary hesitancy
constipation
muscle cramps
arrhythimias
weight gain
phenelzine particularly associated with weight gain of MAOs
HYPERTENSIVe crisis is most serious reaction to MAOI
139
worst combo with serotonin syndrome
SSRI + MAOI like phenelzine
MAOIs require 2 week washout following discontinuation of MAOI before starting any serotonergic meds
140
discontinuation syndrome
dizziness, nausea, cramps, sweating, dysethesias, irritability
*meds with shorter half lives*
141
combat hypotension caused by MAOI
increase salt
fludrocortisone 0.6-.8mg daily
support stocking
adequate hydration
142
TCA preference
desimpramine and nortriptyline are preferred over amitriptyline, imipramine and doxepin due to LESS cholinergic blockage and less orthostatic hypotension
143
zolpidem
non benzo hypnotic that is selective agonist of GABA-a/benzo receptors.
half life 2.6 and 2.5 hrs for 5 and 10mb tabs
onset of action 45 min and peak action around 1.6 hours
renal excretion
144
yohimbine
adrenergic antagonist that helps SSRI induced sexual dysfunction.
anxiogenic
switching to or adding wellbutrin may be effective
145
associated with irreversible pigmentary retinopathy, blindness can occur
thioridazine
>800mg
146
TCA overdose
severe sedation
hypotension
anticholinergic delirium
*withdrawal syndrome is result of cholinergic rebound
147
SSRI with less sexual SE
fluoxetine!!
148
avoid in AIDS patients taking protease inhibitors, can inc toxicity of protease inhibitors
Nefazodone
149
disulfram reaction
disulfram inhibits conversion of acetaldehyde to acetyl-coenzyme A by inhibiting aldehyde dehydrogenase
causes 5-10x inc of acetaldehyde upon conusmption of ETO
nausea, vom, HA, flushing, sweating, tachycardia, chest pain, vertigo, blurred vision.
half life is 60-120 hours
reaction stops after pt has stopped taking disulfram for over 2 weeks.
150
amoxapine
TCA
a metobolite of LOXAPINE, an antipsychotic and can have dopamine blockign effects.
DONT TAKE in parkinsons.
151
antidepressants in epilepsy
celexa
zoloft
remeron
