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620 Advanced Pharmacology > Psychopharmacologics > Flashcards

Psychopharmacologics Flashcards

1
Q

What is the response in the elderly population and antidepressants?

A

Elderly are at risk for drug toxicity

  • may not be able to tolerate antidepressants
  • have neuronal changes that can decrease their response to these medications
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2
Q

How are antidepressants classified?

A

Classified based on their chemical structures and neuropharmacologic effects

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3
Q

True or False the MOA of antidepressants is known

A

False. UNKNOWN
- thought process: they act by altering non-adrenergic neurotransmission and/or serotoninergic neurotransmission

  • Lead to believe that antidepressants work by increasing the amount of norepinephrine & serotonin in synapses.
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4
Q

What are the most broadly prescribed antidepressants ?

A

SSRIs

  • drug of choice for mild to moderate depression
  • 1st line treatment for panic disorder and obsessive compulsive d/o.
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5
Q

What is the MOA of SSRIs?

A
  • Block the reuptake of serotonin - which then increases the amount of serotonin
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6
Q

What is the MOA of SNRIs

A

act on serotonin & norepinephrine pathways in the brain by a variety of mechanisms
- Enhance serotengic activity

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7
Q

What do SSRIs lack?

A

They lack anticholinergic properties

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8
Q

Can a person overdose on an SSRI?

A

No not really

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9
Q

What are common side effects of SSRIs?

A
  1. Insomnia
  2. Agitation
  3. Headache
  4. Nausea
  5. Diarrhea
  6. SEXUAL DYSFUNCTION (main reason for non-compliance) - decreased libido, anorgasmia, delayed ejaculation
  7. Abrupt d/c = dizziness & parenthesis, visual disturbance
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10
Q

Which SSRIs have a short half-life and require tapering?

A

Paroxetine & Venlafaxine

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11
Q

What is the Black Box Warning for SSRIs?

A

In children and adolescents = increased risk to have suicidal tendencies

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12
Q

Prozac- Fluoxetine side effects

A
  • Nausea
  • Anorexia
  • Insomnia
  • Sexual dysfunction
  • Agitation
  • Neuromuscular restlessness
  • Effective analgesic for chronic pain that is associated with RA
  • Does not cause hypotension
  • Bradycardia & syncope in elderly
  • If discontinuing & trying to switch to an MAOi - need to wait 5 weeks for the washout
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13
Q

What is the most potent inhibitor of certain hepatic cytochrome P-450 enzymes?

A

Prozac- Fluoxetine***

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14
Q

If you combine Prozac with an MAOi what will happen?

A

Serotonin Syndrome***

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15
Q

What is Serotonin Syndrome?

A
  • Agitation/restlessness, insomnia, Confusion, RAPID HR & HTN
    Dilated pupils, loss of muscle coordination or twitching of muscles, heavy sweating, diarrhea, headache, shivering, erector pili

Mild symptoms can go away within a day or two when you stop taking that medication or take drugs that block serotonin*

  • Syndrome can start w/in hrs of taking a new drug or increasing the dose of a drug you’re already taking
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16
Q

When does Serotonin Syndrome become life threatening?

A
  • High fever
  • Tremor
  • Seizures
  • Irregular heartbeat
  • Unconsciousness
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17
Q

What is the treatment for Serotonin Syndrome?

A

Most cases mild = stop medication

  • benzos may help
  • cyprohepatadine (a serotonin 2A antagonist), 12 mg orally- followed by 2 mg every 2 hrs
  • H1 receptor antagonists receptors (an antihistamine) which is also used to treat Cushing’s syndrome too
  • Methylene Blue is not supposed to be administered to patient using psychopharmacology SSRIs
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18
Q

How does sertraline (Zoloft) SSRI compare to Prozac?

A

Similar but less potent inhibitor of hepatic microsomes enzymes than Prozac

  • can cause more gastric symptoms (nausea diarrhea)
  • less insomnia & agitation
  • Has an active metabolite w/ half life of 60-70 hrs
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19
Q

What is the recommended washout period of Sertraline (Zoloft) before starting an MAOI

A

14 days

Very different than Prozac- 5 weeks

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20
Q

What is the half-life of Paroxetine (Paxil) SSRI?

A

24 hrs

21
Q

What SSRI should you caution because it enters into the breast more than others?

A

Paroxetine (Paxil)

22
Q

True or False: Paroxetine (Paxil) decreases the effects of Warfarin

A

False: enhances the anticoagulant

23
Q

What fatal rhythm can be caused from Citalopram (Celexa)/ Escitalopram (Lexapro)

A

Citalopram causes prolonged dose-dependent QT interval prolongation which places pts at risk for TORSADE’S de Points*

  • Escitalopram does too, but to a lesser degree
24
Q

What SSRI is effective for smoking cessation?

A

Bupropion

25
Q

When will you see therapeutic effects of Bupropion?

A

2-4 weeks

26
Q

MOA of Bupropion

A

Inhibition of dopamine & norepinephrine reuptake

27
Q

Can Bupropion cause serotonin syndrome

A

Yes. Bupropion is an SSRI and cause serotonin syndrome

28
Q

Venlafaxine (Effexor XR)

A

SNRI - inhibits reuptake of norepinephrine and serotonin

    • Potentiate the action of dopamine in the CNS**
  • efficacy like TCAs
    • Metabolized by CYP450 enzymes & is a weak inhibitor of these enzymes
  • Elimination T1/2 is 5 hrs & it does have an active metabolite for 11 hrs
  • Do not use with an MAO inhibitor, washout period is 24 days
29
Q

At high doses Venlafaxine (Effexor XR) can what affect on BP?

A

At high doses: 5-7% have diastolic blood pressure increases

30
Q

Duloxetine (Cymbalta)

A

SNRI - Serotonin & Noradrenaline (NE) reuptake inhibitor similar to Venlafaxine
- For major depression, fibromyalgia, diabetic neuropathy
- S/E: nausea dry mouth, insomnia, sexual dysfunction
- no significant changes in BP
AVOID if renal dysfunction &/or chronic liver disease

31
Q

Trazodone

A

Inhibits serotonin reuptake & norepinephrine & may also act as a serotonin agonist due to the active metabolite

32
Q

What drug is good for management of depression but is better for insomnia ?

A

Trazodone - SNRI

  • insomnia is induced by SSRIs or Bupropion
  • S/E: sedation, orthostatic hypotension, nausea, vomiting, priapism in males,
  • take at night
33
Q

What is the anesthetic implication for SSRIs?

A
  • SSRIs should be continued throughout the perioperative period
  • Can cause HYPONATREMIA in the elderly
    • Increase the risk of bleeding by inhibiting serotonin reuptake by platelets
  • takes two to three weeks for a full washout
34
Q

What medications do you have to be careful giving with an SSRI?

A

Any drug that relies on hepatic metabolism:
- Specifically Beta Blockers, Benzos, Antiarrhythmics, and any other serotonergic medication that can cause serotonin syndrome.

35
Q

What are the Anesthesia implications for SNRIs?

A
  • Cause a dose dependent increase in BP**
  • S/E: increased sweating, tachycardia, & urinary retention
  • Severe symptoms recur when abruptly stopped esp. venlafaxine & desvenlafaxine b/c they have short T1/2 lives
36
Q

When would you use a TCA (Tricyclic Antidepressant)?

A

Moderate to severe treatment resistant depression
- most commonly used as adjunct analgesic in the management of both neuropathic & somatic chronic pain

Amitriptyline is a prototype

37
Q

What are the main side effects of TCAs?

A

Anticholinergic effects:

- orthostatic hypotension
- urinary retention
- constipation
- dry mouth
- blurred vision
- confusion

Other s/e:

- weight gain
- sexual dysfunction
- cardiac conduction delay
38
Q

Why are TCAs hardly used anymore?

A

Narrow Therapeutic Index!
- potentially lethal in an overdose = resulting in part d/t inhibition of sodium channels, reflecting a slowing of conduction of cardiac impulses & appearance of life-threatening cardiac dysrhythmias

39
Q

What drugs do TCAs interact with in anesthesia?

A

Sympathomimetics
- increased peripheral catecholamines from TCA may produce exaggerated responses to indirect acting vasopressors such as EPHEDRINE

Halogenated agents
- an increase in CNS catecholamines may increase the MAC of an inhalation agent

Anticholinergics
Antihypertensives
Opioids
TCAs bind to plasma albumin
Phenytoin, aspirin, & scopolamine
40
Q

Contraindicated to use Amitriptyline in patients who have: (5)

A
  1. History of heart disease
  2. Conduction disorders
  3. Arrhythmias
  4. Heart failure
  5. Closed angle glaucoma
41
Q

How are MAOIs dosed in the elderly?

A

Same dose for young people as for elderly people.

- Elderly often have higher MAO levels & the metabolism does not seem to be affected by age.

42
Q

MAO-A is found where and what is it known to do?

A

MAO-A is found in the brain and the enzyme is known to breakdown (deaminate)

  • Serotonin
  • Epi
  • Norepi
43
Q

What drugs should be avoided in patients taking an MAOI?

A
  • Cyclic antidepressants
  • Prozac
  • Cold/allergy medications
  • Nasal decongestants
  • Sympathomimetics drugs
  • Opioids
44
Q

What is the blood pressure response associated with MAOIs?

A

Hypertensive crisis

45
Q

Which are physiologic effects associated with serotonin syndrome?

A. Hyperthermia
B. Hypocalcemia
C. Bradycardia
D. Autonomic instability

A

A. Hyperthermia

D. Autonomic instability

46
Q

Which medication should be used to treat hypotension in a patient taking an MAOI?

A

Phenylephrine due to the direct alpha and not using endogenous catecholamines like ephedrine.
- Ephedrine causes an exaggerated hypertensive response

47
Q

Your patient is taking Lithium, you know this will affect your anesthetics how?

A

Decrease IV anesthetics & inhalation agents with patients on Lithium

48
Q

A patient ingested ecstasy & presents with hyperthermia, muscle rigidity, & mydriasis. What is the MOST appropriate treatment?

A. Cyproheptadine
B. Methylene Blue
C. N-Acetylcysteine
D. Dantrolene

A

A. Ecstasy can cause serotonin syndrome

  • signs include:
    • akathisia, agitation, coma, tremor, clonus, muscle rigidity, & midrasis
  • Cyproheptadine (5-HT32a antagonist) is the treatment for serotonin syndrome
49
Q

What drugs are associated with Serotonin Synd. (Nagelhout chart)

A
  • MAOIs
  • SSRIs
  • SNRIs
  • TCAs
  • Linezolid (ABX)
  • Opiate analgesics (Meperidine, Fentanyl, Tramadol)
  • Dextromethorphan (OTC cough med)
  • Almotriptan & sumatriptan (antimigraine)
  • Amphetamine, Cocaine, MDMA/ECSTASY, LSD
  • Antiemetics - Metoclopramide & Ondansetron
  • Anticonvulsants - Carbamazepine & Valproic acid
  • Herbals - Ginseng, nutmeg, & St. John’s wort
  • Others - Lithium, Methylene Blue, Buspirone, Tryptophan

620 Advanced Pharmacology (9 decks)

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