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Psychiatry - First Aid > Psychopharmacology > Flashcards

Psychopharmacology Flashcards

1
Q

What are the HAM side effects of the TCAs and low-potency antipsychotics?

A

antiHistamine (sedation, weight gain)
antiAdrenergic (hypotension)
antiMuscarinic (dry mouth, constipation, blurred vision, urinary retention)

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2
Q

What is the diagnosis: confusion, flushing, diaphoresis, tremor, myoclonic jerks, hyperthermia, hypertonicity, rhabdomyolysis, renal failure….in a patient with lots of psych meds…..

A

serotonin syndrome

classically occurs when an SSRI is taken with an MAOI

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3
Q

What can happen when you take MAOIs plus foods with tyramine (red wine, cheese, etc) or an MAOI with another sympathomimetic?

A

hypertensive crisis (caused by a buildup of stored catecholamines)

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4
Q

What are 3 examples of extrapyramidal side effects seen with the high-potency traditional antipsychotics?

A

parkinsonism, akathisia, or dystonia

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5
Q

What is the typical time of onset for the extrapyramidal side effects?

A

usually within days of starting (or increasing) the med

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6
Q

What is the drug of choice to treat the extrapyramidal symptoms produced by neuroleptics?

A

benzotropine

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7
Q

What other movement disorder can occur with antipsychotic medications, but usually with onset after years of being on the drug?

A

tardive dyskinesia

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8
Q

What’s the diagnosis: fever, tachycardia, hypertension, tremor, elevated creatine phosphokinase, and lead pipe rigidity in a patient on antipsychotics?

A

neuroleptic malignant syndrome - can be caused by all antipsychotics after a short or long period of time

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9
Q

What is the mortality rate for NMS?

A

20%

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10
Q

Are the SSRIs and SNRIs cyp450 inhibitors or inducers? So what does this do to warfarin?

A

inhibitors

increases the levels of warfarin, so requires close monitoring when initiating

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11
Q

True or false: all antidepressants have similar response rates in treating major depression, but differ in safety and side effect profiles

A

true

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12
Q

What percentage of patients with major depression will respond to an antidepressant?

A

about 70%

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13
Q

How long should a trial of an antidepressant last?

A

at least 1 month for effect

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14
Q

Most antidepressants have a withdrawal phenomenon characterized by what symptoms?

A

dizziness, headache, nausea, insomnia and malaise

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15
Q

True or false: if a patient tries an SSRI and it doesn’t work, you shouldn’t try any more SSRIs

A

false - although they are structurally very similar, patients often respond differently to different SSRIs

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16
Q

Why are the SSRIs the most commonly prescribed antidepressants?

A

they work just as well as anything else and have several distinct advantages:

  1. low incidence of side effects, most of which improve with time
  2. no food restrictions
  3. much safer in overdose than the TCAs and MAOIs
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17
Q

What are the 5 main SSRIs?

A 
Fluoxetine (Prozac)
Sertraline (Zoloft)
Paroxetine (Paxil)
Fluvoxamine (Luvox)
Citalopram (Celexa)
Escitalopram (Lexapro)
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18
Q

Which SSRI has the longest half-life and thus doesn’t need a taper to stop?

A

fluoxetine

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19
Q

Which SSRI has the highest risk for GI disturbance?

A

sertraline

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20
Q

Which SRI has the greatest risk for drug-drug interactions because it’s highly protein bound?

A

paroxetine

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21
Q

What else makes paroxetine a less than ideal choice?

A

it has more anticholinergic effects than the others

also with the shortest half-life, so you get a withdrawal phenomena if not taken at the same time every day

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22
Q

Which SSRI is currently only approved for those with OCD (but is used off label quite regularly)?

A

Fluvoxamine (Luvox) - the new one

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23
Q

Which SSRi has the fewest drug-drug interactions and fewer sexual side effects?

A

Citalopram

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24
Q

If someone on an SSRI gets a cold and then comes into the hospital with fever, diaphoresis, shivering, tachycardia, hypertension, delirium and neuromuscular excitability, what happened?

A

Serotonin syndrome from taking OTC cough medications

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25
Q

What are the most common side effects of the SSRIs?

A 
sexual dysfunction in 25-30% (typically do not resolve)
Nausea/diarrhea (so take with food)
Insomnia and vivid dreams
headache
anorexia and weight loss
restlessness
seizures at 0.2%
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26
Q

What are the three main options for dealing with the sexual side effects of the SSRIs

A
  1. augment with buproprion
  2. switch to a non-SSRI
  3. add sildenafil for men
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27
Q

Why do the SSRIs have a black box warning from the FDA?

A

increased suicidal thinking and behavior in children and adolescents, but may be accurate for adults as well

(theory is that it decreases the indecisiveness and lack of energy before it improves mood, so they’re more likely to carry out suicide plans that were already present)

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28
Q

What are the two SNRIs?

A

venlafaxine (Effexor)
desvenlafaxine (pristiq) - just the active metabolite
duloxetine (Cymbalta)

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29
Q

Besides depression, what is venlafaxine typically used for?

A

anxiety disorders (especially GAD) and may have some use in ADHD

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30
Q

Venlafaxine shouldn’t be used in patients with which chronic medical condition?

A

hypertension - it can increased blood pressures

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31
Q

Besides depression, what is duloxetine often used for?

A

neuropathic pain and fibromyalgia

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32
Q

The side effects of duloxetine are similar to the SSRIs with what minor differences?

A

constipation instead of diarrhea and more dry mouth

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33
Q

Why shouldn’t you use duloxetine in patients with heavy alcohol use?

A

it can have liver side effects

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34
Q

What is the norepinephrine-dopamine reuptake inhibitor?

A

buproprion

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35
Q

Bupropion is usually very well tolerated, but what are the worrisome side effect potentials?

A

increased seizure risk
psychosis at high doses
increased anxiety in some

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36
Q

In what patients is bupropion contraindicated

A

patients with a hx of seizures, patients with active eating disorders and in those currently on an MAOI

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37
Q

What are the two serotonin receptor mixed antagonists/.agonists

A

trazodone and nefazodone

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38
Q

Trazodone isn’t a great antidepressant, so what do we use it for?

A

primarily insomnia

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39
Q

What are the side effects of trazodone and nefazodone?

A

nausea, dizziness, orthostatic hypotension, cardiac arrhythmias, sedation and priapism (trazobone)

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40
Q

Why does nefazodone carry a black box warning?

A

rare, but serious liver failure

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41
Q

What’s the antidepressant that works as an alpha-2 adrenergic receptor antagonist?

A

mirtazapine

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42
Q

Who are the best patients to use mirtazapine for?

A

little old ladies with depression who need to gain some weight

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43
Q

Mirtazapine has the typical antidepressant side effects with the addition of what rare effect?

A

agranulocytosis

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44
Q

How do TCAs work?

A

they inhibit the reuptake of NE and 5HT

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45
Q

What are the 6 main TCAs?

A 
amitriptyline
imipramine
clomipramine
doxepin
nortriptyline
desipramine
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46
Q

Which TCAs are used in chronic pain and migraines?

A

amitryptiline and nortryptiline

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47
Q

Which TCA is helpful in enuresis?

A

imipramine

48
Q

Which TCA is used mainly in OCD?

A

clomipramine

49
Q

The danger with TCAs is their risk for lethal overdose. What is the mainstay treatment for TCA OD?

A

IV sodium bicarbonate

50
Q

What are the major complications of the TCAs? Hint: triCs….

A

cardiotoxicity (orthostatic hypotension, dizziness, reflex tachy, arrhythmias, widening QRS, prolonged QT and PR)

convulsions

coma (in OD)

51
Q

How do MAOIs work?

A

they block the inactivation of biogenic amines like NE, 5HT, DA, etc., so these NTs increase in the synapse

52
Q

MAOIs are not classically first line, but in what type of depression are they particularly useful?

A

atypical depression characterized by hypersomnia, increased appetite, increased sensitivity to interpersonal rejection and a leaden sensation in the legs

53
Q

What are the three main MAOIs?

A

phenelzine
selegiline
tranylcypromine
isocaboxazid

54
Q

How long do you need to wait to switch from an SSIR to an MAOI to avoid serotonin syndrome?

A

at least 2 weeks (but actually 5-6 with fluoxetine because of the long half life)

55
Q

What is the management for serotonin syndrome?

A

stop the drug

you can also try calcium channel blockers like nifedipine

if carefully monitored, try chlorpromazine or phentolamine

56
Q

People on MAOIs can have hypertensive crisis if they eat tyramine rich foods. Besides the elevated BP, what side effects do they often have?

A

headache, sweating, nausea, vomiting, photophobia, autonomic instability, chest pain, arrhythmias

57
Q

What type of receptors are blocked by the first generation, or typical, antipsychotics?

A

D2 receptors

58
Q

What receptors are blocked by the second gen, or atypical, antipsychotics?

A

D2 and Serotonin (2A) receptors

59
Q

Although atypical antipsychotics are used to treat the symptoms of dementia and delirium, why is their use in the elderly controversial?

A

they are associated with an increased risk for all-cause mortality and stroke

60
Q

What are the two low-potency typical antipsychotics?

A

chlorpormazine and thoridazine

61
Q

The low-potency typicals have lower incidence of PS and NMS than the high-potency typicals, but what do they have an increased risk for?

A

anticholinergic and antihistaminic side effects

also more lethality in overdose due to QTc prolongation and potential for heart block and vtach

62
Q

Chlorpromazine is associated with what unique side effects?

A

orthostatic hypotension
bluish skin discoloration
photosensitivity

63
Q

What is chlorpromazine also used for besides psychosis?

A

nausea, vomiting and intractable hiccups

64
Q

What side effect is associated with thioridazine?

A

retinitis pigmentosa

65
Q

What are the four midpotency typical antipsychotics?

A

loxapine
thiothixene
trifluoperazine
perphenazine

66
Q

What are the three high-potency typical antipsychotics?

A

haloperidol
fluphenazine
pimozide

67
Q

The antipsychotics treat the symptoms of schizophrenia through action in the medolimbic dopamine pathway. What are the brain structures included in this pathway?

A

nucleus accumbens
fornix
amygdala
hippocampus

68
Q

The negative symptoms are thought to occur to dopamine action in what pathway?

A

mesocortical

69
Q

The extrapryamidal side effects are from the medication effects on what pathway?

A

nigrostriatum

70
Q

What are some of the hyperprolactinemia effects from the blockage of dopamine in the tuberoinfundibular pathway?

A

decreased libido, galactorrhea, gynecomastia, impotence, amenorrhea and osteoporosis

71
Q

How many cases of tardive dyskinesia will spontaneously remit?

A

50%, but many cases are permanent

72
Q

Which atypical antipsychotic is the least likely to cause TD?

A

clozapine

73
Q

What is the treatment for NMS?

A

stop the drug
supportive therapy: hydration, cooling
sodium dantrolene, bromocriptine, amantadine

74
Q

True or false: if the patient develops NMS on a drug, they shouldn’t take that drug ever again

A

false - they can actually go back on it without an increased risk of recurrence

75
Q

Although atypical antipsychotics have lower risk for EPS, TD and NMS, what do they have an increased risk for?

A

metabolic syndrome

76
Q

If a patient on an atypical antipsychotic develops metabolic syndrome, what are the options?

A

switch to a more weight-neutral atypical antipsychotic like aripiprazole or ziprasidone

or switch to a typical antipsychotic

77
Q

Clozapine has been shown to be the most efficacious antipsychotic (30% of treatment-resistant psychosis will respond and it’s the only one to decrease suicide risk), but why don’t we use it as first line?

A

risk of agranulocytosis and need for weekly monitoring

note - it also has increased anticholinergic side effects, mayocarditis and higher seizure risk

78
Q

At what absolute neutrophil count do you need to stop clozapine?

A

less than 1500/microL

79
Q

What is the particular side effect of risperidone?

A

increases prolactin more than the others, so more risk for galactorrhea, etc.

also orthostatic hypotension and reflex tachy

80
Q

Which atypical antipsycotic has the highest risk for weight gain?

A

olanzapine

81
Q

How is aripiprazole’s mechanism of action special among the atypicals?

A

it has partial D2 AGONISM

means if can be more activating and less sedating
also less potential for weight gain

82
Q

What are the four mood stabilizers?

A

lithium
valproid acid (depakote)
lamotrigine
carbamazepine

83
Q

Which is the only mood stabilizer shown to decreased suicidality?

A

lithium

84
Q

Besides mania, what can lithium be used for?

A

cyclothymia and as an adjunct in unipolar depression

85
Q

How is lithium metabolized?

A

in the kidneys, so you have to adjust the dose and monitor levels closely in patients with renal dysfunction

86
Q

Prior to initiating lithium, what lab tests should a patient receive?

A

ECG, basic chemistries, thyroid function test, CBC and a pregnancy test

87
Q

How long is onset of action for lithium?

A

5-7 days

88
Q

Blood levels actually correlate with clinical efficacy for lithium, so how often should you check them when starting?

A

at 5 days and then every 2-3 days until therapeutic

89
Q

What is the major drawback to lithium?

A

low therapeutic range (0.6-1.2; toxic over 1.5 and lethal over 2)

90
Q

What are some side effects of lithium?

A

altered mental status, coarse tremors, convulsions and death

thyroid dysfunction
kidney damage
nephrogenic diabetes insipidus
GI distrubance
weight gain
sedation
ECG changes
benign leukocytosis
91
Q

What is the birth defect caused by lithium?

A

epstein’s anomaly

92
Q

What are some factors that will affect Lithium levels?

A 
NSAIDs will decrease
aspirin
dehydration will increase
salt deprivation will increase
sweating (salt loss) will increase
impaired renal function will increase
diuretics and thiazides
93
Q

Carbamazepine is particularly useful in treating mixed episodes and rapid-cycling bipolar disorder. What are the sommon side effects?

A

GI effects, drowsiness, ataxia, sedation, confusion

skin rash - stevens-johnson syndrome
leuopenia, hyponatremia, aplastic anemia, thrombocytopenia, agranulocystosis

neural tube defects if used in pregnancy

94
Q

What are some of the side effects of valproic acid?

A 
GI
weight gain
sedation
alopecia
pancreatitis
hepatotoxicity!!
thrombocytopenia
teratogenic - neural tube defects
95
Q

What are the anxiolytics used for besides anxiety?

A 
muscle spasms
seizures
sleep disorders
alcohol withdrawal
anesthesia induction
96
Q

In chronic alcoholics or liver disease, you need to use benzos that are not metabolized by the liver. What are some examples? (mnemonic: there are a LOT of them)

A

Lorazepam
oxazepam
temazepam

97
Q

Why aren’t benzos a great idea for anxiety?

A

many patients become dependent on them and require increasing doses for the same clinical effect

98
Q

Which two benzos are long acting?

A

diazepam

clonazepam

99
Q

Diazepam isn’t really used to treat anxiety much anymore, so what do we use it for?

A

detox from alcohol or sedative-hypnotic anxiolytics

and for seizures

100
Q

What are the 4 intermediate acting benzos? (mnemonic: A LOT)

A

alprazolam
lorazepam
oxazepam
temazepam

101
Q

Which drug do we use in benzo OD?

A

flumazenil

102
Q

Which two benzos are short acting?

A

triazolam

midazolam (versed)

103
Q

What are the side effects of benzos?

A

drowsiness
impaired intellectual function
reduced motor coordination (so careful in elderly)
anterograde amnesia

104
Q

Why is withdrawal from benzos life threatening?

A

seizures

105
Q

How do the z-hypnotics work?

A

they bind to the benzo receptor 1, which is responsible for the sedation, but not the euphoria.

106
Q

Rank the three z-hypnotics by half life, shortest to longest.

A

zaleplon > zolpidem > eszopiclone

107
Q

How does ramelteon work for sleep?

A

selective melatonin MT1 and MT2 agonist

108
Q

How does buspirone work?

A

partial agonist at the 5HT-1A receptor

109
Q

How long does it take for buspirone to take effect?

A

1-2 weeks

110
Q

Buspirone is not as effective as other options, so what do we usually combine it with?

A

an ssri

111
Q

So if buspirone doesn’t work as well as the benzos, why do we use it?

A

because it doesn’t potentiate the CNS depression of alcohol and has a low potential for abuse/addiction

112
Q

If someone wants a quick-acting short-term medication (unlike buspirone) that isn’ta benzo, what is the best option?

A

hydroxyzine (atarax)

113
Q

Why don’t we use barbs hardly ever anymore?

A

risk of lethal OD and bad side effect profile

114
Q

Which hypertension med is useful in treating the autonomic effects of panic attacks or performance anxiety?

A

propranolol

115
Q

Propranolol is also used to treat what side effect of the typical antipsychotics?

A

akathisia

Psychiatry - First Aid (18 decks)

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