Psychopharmacology Flashcards
HAM side effects: what are they and what drugs cause them?
anti-Histamine: sedation, weight gain
antiAdrenergic: hypotension
anti-Muscarinic: dry mouth, blurred vision, urinary retention, constipation
Caused by low-potency antipsychotics and TCAs
Serotonin syndrome features
Confusion, flushing, hyperreflexia/myoclonus, hyperthermia, rhabdo, renal failure, death
Caused by SSRI + MAOI, or other combo that causes too much serotonin release
Which antidepressants can cause hypertensive crisis and when does this occur?
MAOIs when combined with tyramine-containing food (red wine, cheese, chicken liver, cured meats) or sympathomimetics
Features of drug-induced parkinsonism
Masklike face, cogwheeling, bradykinesia, pill-rolling tremor
Features of drug-induced akathisia
Restlessness, need to move, agitation
Features of drug-induced dystonia
sustained, painful contraction of muscles (neck, tongue, eyes, diaphragm, LARYNX LOOK OUT)
Which psych drugs cause hyperprolactinemia?
High potency typical antipsychotics, also risperidone
Features of drug-induced tardive dyskinesia
Choreoathetoid movements, usually of mouth/tongue
Occurs after years of antipsychotic use
Usually irreversible
Features of neuroleptic malignant syndrome
Mental status change, fever, tachycardia, rigidity (lead pipe) HTN, tremor, high CPK
MEDICAL EMERGENCY
Important CYP450 inducers
Tobacco
Carbamazepine
Barbiturates
St. John’s wort
Important CYP450 inhibitors
Fluvoxamine Fluoxetine Paroxetine Duloxetine Sertraline
Features of fluoxetine
PROZAC
- Longest half-life (no need to taper)
- Safe in pregnancy, okay for kids
- Can elevate levels of antipsychotics
Features of sertraline
ZOLOFT
- Higher risk for GI upset
- Few drug interactions
Features of paroxetine
PAXIL
- Highly protein bound
- Anticholinergic effects
- Short half-life (withdrawal phenomena if not taken consistently)
Features of fluvoxamine
LUVOX
- Approved only for OCD
- Drug interactions 2/2 CYP inhibition
Features of citalopram
CELEXA
Fewest drug-drug interactions
Dose-dependent QTc prolongation
Features of escitalopram
LEXAPRO
- Levo-enantiomer of citalopram, fewer side effects
- Dose-dependent QTc prolongation
Common side effects of SSRIs that usually resolve within days to weeks of starting
GI upset
Insomnia, vivid dreams
Headache
Anorexia and weight loss
Other, more lasting side effects of SSRIs
Sexual dysfunction Restlessness, akathisia-like state Serotonin syndrome (if combined with other serotonergic meds like triptans, MAOIs, etc)
Features of venlafaxine
EFFEXOR, an SNRI
Used for depression, anxiety disorders, neuopathic pain
Similar side effects to SSRIs, + potential to increase BP
Features of duloxetine
CYMBALTA, an SNRI
Used for depression, neuropathic pain, fibromyalgia
Side effects similar to SSRIs + dry mouth, constipation
Potential for hepatotoxicity if using EtOH
Features and mechanism of bupropion
WELLBUTRIN
Dopamine and norepinephrine reuptake inhibitor
Used for depression, smoking cessation
Lack of sexual side effects, can increase anxiety and seizure risk
Contraindications: h/o seizures, eating disorder, concomittant MAOI use
Features of trazodone and nefazodone
Serotonin receptor agonists and antagonists
Used for depression, depression with anxiety, depression with insomnia
Side effects: nausea, dizziness, orthostatic hypotension, arrhythmias, sedation, priapism
Nefazodone: black box warning for liver failure
Features and mechanism of mirtazapine
REMERON
Used for depression, especially in patients with weight loss or insomnia
Side effects: sedation, weight gain, dizziness, tremor, dry mouth, constipation, agranulocytosis
How do TCAs work?
Inhibit reuptake of norepinephrine and serotonin
Why are TCAs not first-line therapy for depression?
Higher incidence of side effects
Titration of dosing required
Lethal in overdose
Amitriptyline
ELAVIL
Useful in chronic pain, migraines, and insomnia
Imipramine
TOFRANIL
Useful in enuresis (bed wetting) and panic disorder
Has an IM form
Clomipramine
Most serotonin-specific TCA
Used in treatment of OCD
Doxepin
Useful in treating chronic pain
Used as sleep aid at low doses
Nortryptyline
Least likely TCA to cause orthostatic hypotension
Useful in chronic pain
Desipramine
More activating/less sedating
Least anticholinergic TCA
Treatment for TCA overdose
IV NaHCO3
Side effects of TCAs
Antihistamine: sedation + weight gain
Antiadrenergic: CV side effects including OH, tachycardia, arrhythmias, ECG changes
Antimuscarinic: Dry mouth, constipation, urinary retention, blurred vision, tachycardia, exacerbation of glaucoma
Indications for MAOIs
What are the MAOIs?
Refractory depression, depression with atypical features, and refractory anxiety disorders
Phenelzine, tranylcypromine, and isocarboxazid
Side effects of MAOIs
Serotonin syndrome with taken with SSRIs or other serotonergic drugs Hypertensive crisis if taken with tyramine-rich foods OH Drowsiness Weight gain Sexual dysfunction Dry mouth Sleep changes Liver toxiciy, seizures, edema (rare)
Indications for mood stabilizers
Acute mania and prevention of relapse manic episodes in BPAD
Augmentation of antidepressants in MDD
Potentiation of antipsychotics in patients with schizophrenia and schizoaffective disorder
Treatment of aggression and impulsivity
Enhancement of abstinence in treatment of alcoholism
What are the mood stabilizers?
Lithium and anti-convulsants (valproate, lamotrigine, and carbamazepine)
Indications for lithium
DOC for acute mania and maintenance in bipolar
Cyclothymic disorder and unipolar depression
Metabolism of lithium (and clinical relevance of this)
Metabolized renally, so may need to adjust doses in patients with renal dysfunction
Tests you need to get before starting lithium
ECG, BMP, thyroid function tests, CBC, and pregnancy test
Onset of action of lithium
5-7 days
Check blood levels after 5 days after starting and then every 2-3 days until therapeutic
Therapeutic, toxic, and lethal ranges of lithium
Therapeutic: 0.6-1.2 (can still have side effects)
Toxic: >1.5
Potentially lethal: 2.0
Presentation of lithium toxicity
AMS, coarse tremors, convulsions, delirium, coma, death
Regular labs to monitor for patients on lithium
Lithium levels
TSH
Kidney function
Other side effects of lithium
Fine tremor Nephrogenic DI GI upset Weight gain Sedation Goiter and hypothyroidism ECG changes Benign leukocytosis Ebstein anomaly in babies
Psychiatric indications for carbamazepine
Mania with mixed features
Rapid-cycling bipolar disorder
Labs to get before starting carbamazepine
CBC and LFTs
Side effects of carbamazepine
Most common are GI upset and CNS (drowsiness, ataxia, sedation, confusion)
Possible skin rash –> Stevens-Johnson syndrome
Leukopenia, hyponatremia, aplastic anemia, thrombocytopenia, and agranulocytosis
Transaminitis/hepatitis
TERATOGENIC (neural tube defects)
CYP450 interactions
Features of carbamazepine toxicity
Confusion, stupor, restlessness, ataxia, tremor, nystagmus, twitching, vomiting
Factors that increase lithium levels
NSAIDs Aspirin Thiazide diuretics Dehydration Salt deprivation Sweating Decreased renal function
Indications for valproic acid
Acute mania, mania with mixed features, rapid cycling
Considerations for using valproic acid
Need to monitor CBCs and LFTs
Should check drug level 4-5 days after starting, therapeutic range is 50-150ug/mL
Contraindicated in pregnancy (neural tube defects)
Indications for lamotrigine
Bipolar depression, not as effective in acute mania or prevention of mania
Considerations for using lamotrigine
Common side effects: dizziness, sedation, HA, ataxia
Risk of Stevens-Johnson syndrome in 0.1% of pts
Interaction between valproate and lamotrigine
Valproate will increase lamotrigine levels
Lamotrigine will decrease valproate levels
Difference in mechanism between typical and atypical antipsychotics
Typical = block dopamine D2 receptors Atypical = block dopamine D2 and serotonin 2A receptors
How are the typical antipsychotics divided?
Low potency and high potency typical antipsychotics
Features of low-potency typical antipsychotics
Lower affinity for dopamine receptors –> need higher doses
Higher incidence of HAM side effects, lower incidence of EPS
What are the low-potency typical antipsychotics?
Chlorpromazine (can cause OH, skin discoloration, photosensitivity)
Thioridazine (associated with retinal deposits)
What are the high-potency typical antipsychotics?
Haloperidol
Fluphenazine
Trifluoperazine
Pimozide
Features of high-potency typical antipsychotics?
Higher affinity for dopamine receptors
Less sedating, less OH, less anticholinergic effects compared to low-potency
Typical antipsychotics block dopamine D2 receptors. Depending on which neural pathway dopamine is blocked in, explain the effects of these drugs
DA blockade in mesolimbic pathway –> improvement in positive symptoms of schizophrenia
DA blockade in nigrostriatal pathway –> EPS
DA blockade in tuberoinfundibular pathway –> hyperprolactinemia
What are the different types of extrapyramidal signs?
Akathisia
Parkinsonism
Dystonia
Tardive dyskinesia
Treatments for the different types of extrapyramidal signs
Akathisia: dose reduction, Beta-blockers, benzos
Parkinsonism and dystonia: dose reduction, benztropine or diphenydramine, maybe amantadine
Tardive dyskinesia: Usually irreversable; discontinue current antipsychotic and try a different one
Risk of tardive dyskinesia
5% chance each year treated with typical antipsychotic
Clozapine less likely to cause TD
Uses for atypical antipsychotics
Schizophrenia
Acute mania, bipolar disorder, unipolar depression
Borderline PD, PTSD, tic disorders
Features/side-effects of clozapine
Less likely to cause TD
More effective in treatment-resistant schizophrenia
More anticholinergic effects than other antipsychotics
Risk of agranulocytosis, seizures, myocarditis
Increased salivation and tachycardia
Features/side-effects of risperidone
Can cause hyperprolactinemia
Orthostatic hypotension and reflex tachycardia
Comes in long acting injectable (LAI) form
Features/side-effects of quetiapine
Low risk of EPS
Sedation and OH
Common side-effects of olanzapine
Weight gain
Sedation
Features/side-effects of ziprasidone
Less likely to cause weight gain
QT prolongation
Must be taken with food
Features/side-effects of aripiprazole
Partial agonist of D2 receptors
More activating, less sedating
Less potential for weight gain
Features of lurasidone
Must be taken with food
Used in bipolar depression
General side effects of atypical antipsychotics
Metabolic syndrome (weight gain, HLD, insulin resistance)
–monitor with baseline weight, waist circ, BP, fasting glucose, fasting lipids
HAM side effects
Elevated LFTs (should monitor yearly)
QTc prolongation
Indications for benzos
Anxiety, akathisia, agitation, insomnia, panic disorder, EtOH or sedative-hypnotic withdrawal…
What are the long-acting benzos (half-life >20hrs)?
Diazepam (valium)
Clonazepam (klonopin)
What are the intermediate-acting (half-life 6-20hrs) benzos?
Alprazolam (Xanax)
Lorazepam (Ativan)
Oxazepam (Serax)
Temazepam (Restoril)
What are the short-acting benzos?
Triazolam (Halcion)
Midazolam (Versed)
Features of diazepam
Rapid onset, long half-life
Used for EtOH detox, seizures
Effective for muscle spasm
Features of clonazepam
Treatment of anxiety, including panic attacks
Avoid with renal dysfunction
Features of alprazolam
Treatment of anxiety, including panic attacks
Higher abuse potential
Features of lorazepam
Treatment of panic attacks, EtOH detox, agitation
