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Integrative Psychopharmacology > Psychopharmacology for the Naturopath > Flashcards

Psychopharmacology for the Naturopath Flashcards

1
Q

SSRI - Uses

A

FDA-approved

  • Major Depressive Disorder
  • Generalized Anxiety Disorder
  • Obsessive Compulsive Disorder
  • Panic Disorder
  • Social Anxiety
  • PMDD
  • PTSD

Non-FDA-approved
- Sexual compulsions/aggression

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2
Q

SSRIs

A
  • Fluoxetine (Prozac)
  • Paroxetine (Paxil)
  • Sertraline (Zoloft)
  • Citalopram (Celexa)
  • Escitalopram (Lexapro)
  • Fluvoxamine (Luvox)
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3
Q

SSRIs - MOA

A
  • Increase 5HT by inhibiting the function of SERT
  • Increased 5HT causes 5HT1a receptors to downregulate
  • Serotonergic neurons become uninhibited
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4
Q

SSRIs - side effects

A
  • Sexual dysfunction
  • Akathisia
  • CYP450 interactions
  • Hyperhydrosis
  • Insomnia or sedation
  • B12 depletion
  • Serotonin syndrome
  • Platelet dysfunction (if also taking NSAIDs)
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5
Q

SSRIs - CYP450 interactions

A

Least to Most

  • Escitalopram
  • Citalopram
  • Sertraline
  • Fluoxetine
  • Fluvoxamine
  • Paroxetine
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6
Q

SSRIs - efficacy for MDD

A

Best to Worst

  • Escitalopram
  • Citalopram
  • Sertraline/fluoxetine/paroxetine
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7
Q

SSRIs - withdrawal syndrome

A

Least to Most

  • Fluoxetine
  • Escitalopram
  • Citalopram
  • Sertraline
  • Paroxetine
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8
Q

SSRIs - activation

A

Least to Most

  • Sertraline
  • Escitalopram
  • Citalopram
  • Paroxetine
  • Fluoxetine
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9
Q

SSRIs - sedation

A

Least to Most

  • Fluoxetine/sertraline/escitalopram
  • Citalopram
  • Paroxetine
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10
Q

Fluoxetine - trade name

A
  • Prozac
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11
Q

Fluoxetine

A
  • 1st introduced SSRI
  • Longest half life
    > Fewest discontinuation problems, but also slowest onset of action
  • Activating
  • Can use it to taper other drugs down
  • Takes about 21 days to feel a difference
  • Only SSRI FDA-approved for kids/adolescents
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12
Q

Paroxetine - trade name

A
  • Paxil
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13
Q

Paroxetine

A
  • Significant teratogen (only SSRI that is)
  • Significant CYP interactions
  • Likely to cause activation or over-sedation
  • Do not use! Suggest patients switch if they’re on it
  • Main good use is to decrease sexual thoughts/aggressions
  • Causes a lot of side effects
  • Patients might feel so fatigued that they think there’s a medical problem as well
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14
Q

Sertraline - trade name

A
  • Zoloft
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15
Q

Sertraline

A
  • Largest dosing window (50mg - 200mg
    > Best for anxiety (use larger doses of SSRIs when treating anxiety)
  • Commonly causes insomnia and stomach issues (usually resolve within two weeks)
  • Go-to for anxiety!
  • Less activating than others
  • Might cause bruxism
  • Go-to for PTSD with both anxiety and MDD
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16
Q

Citalopram - trade name

A
  • Celexa
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17
Q

Citalopram

A
  • Often causes drowsiness
  • Significant QTc prolongation
    > If taking >30 mg, do regular EKGs
    > More significant with co-morbidities (Hep C, diabetes, etc.)
  • Causes fewer other side effects
  • Less sexual dysfunction than other SSRIs
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18
Q

Escitalopram - trade name and notes

A
  • Lexapro
  • Cleaner isomer of citalopram
  • Use 1/2 the dose of escitalopram (eg. 20mg of citalopram = 10mg of escitalopram)
  • Fewer side effects
  • Great efficacy
  • May cause bruxism
  • Go-to for depression!
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19
Q

Fluvoxamine - trade name

A
  • Luvox
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20
Q

Fluvoxamine

A
  • Rarely seen in US
    > Prescribed commonly in Europe
  • Only FDA approval is for OCD
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21
Q

Poop out syndrome

A
  • Patient has good response to SSRI for a while (can be years), but gradually it stops working
  • Can switch to a different SSRI and it will likely work
  • Can discontinue the original SSRI for 6 months and then it will work again after the break
    > Each subsequent use of the original SSRI will last for a shorter time before it poops out again
  • Happens pretty commonly
    > Especially when another life stressor occurs
  • Tachyphylaxis is technical name for when a drug causes a great response at first, but then stops working quickly
    > Poop out syndrome is only kinda-sorta the same since it’s a longer process
  • When true tachyphylaxis occurs with an SSRI, it’s a red flag for bipolar disorder (because they likely just need a mood stabilizer)
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22
Q

PTSD

A
  • Evidence for SSRIs in PTSD is pretty poor, though SSRIs can be helpful for PTSD patients
  • Significant evidence shows that SSRIs increase hippocampal volume in patients with PTSD by increasing BDNF
  • Rare to see a patient with PTSD without another mood disorder, especially depression
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23
Q

Contraindications to SSRIs

A
  • Past sensitivity to drug class
  • Concurrent significant NSAID use (platelet dysfunction)
  • History of long QTc syndrome
  • Concurrent use of other QTc prolonging diagnoses or agents
  • Concurrent tramadol use (for seizures)
  • Bipolar disorder
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24
Q

Contraindications for the ND

A
  • Hypericum
  • 5HTP
  • Yohimbe
  • L-tryptophan
  • Melatonin (may neutralize the intended enzymatic activity of the SSRI)
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25
Depletions for the ND
- Melatonin? > Some suggest supplementing with 1-3mg before bed > Luvox appears to actually increase melatonin
26
How to stop SSRIs
- Very, very slowly - Can replace others with very low dose Prozac to help with titration (because of its long half life) - Can use other serotonergic support (5HTP, etc.) - Make sure to differentiate between relapse and withdrawal symptoms > Look for dizziness, sensitivity, suicidality
27
Buproprion - trade name
- Wellbutrin
28
Buproprion - FDA approvals
- MDD - ADHD - Smoking cessation - Commonly prescribed along with SSRIs
29
Buproprion - formulation types
- Regular (dose TID 5 hours apart) - Sustained Release (SR) (dose BID 3-4 hours apart morning and noonish) - Extended Release (XL) (dose QD) - SR often for smoking cessation and ADHD
30
Buproprion - MOA
- Inhibition of NE and dopamine reuptake
31
Buproprion - side effects
- Anxiety - Sleep disturbance - Jaw tightening - Hypertension - Lowers the seizure threshold (esp Regular and SR - must take it as prescribed) - Can be very stimulating in the first few days, but then evens out > Decreased sleep and appetite
32
Buproprion - interactions
- MAOIs - Tramadol > Also lowers the seizure threshold
33
Buproprion - contraindications
- History of seizure disorder - History of eating disorders > Brings back ED behaviors, even if they've been gone for years
34
SNRIs
Selective Serotonin and Norepinephrine Reuptake Inhibitors - Venlafaxine (Effexor) - Duloxetine (Cymbalta) - Desvenlafaxine (Pristiq)
35
SNRIs - FDA approved for
- MDD - Chronic Anxiety Disorder - Panic Disorder - Social Anxiety Disorder - Chronic musculoskeletal pain** - Fibromyalgia** **Cymbalta only
36
SNRIs - MOA
- Serotonin and NE reuptake inhibition
37
SNRIs - side effects
Same as SSRIs - Sexual dysfunction - Akathisia - CYP450 interactions (fewer than SSRIs) - Hyperhydrosis - Insomnia or sedation - B12 depletion - Serotonin syndrome - Platelet dysfunction (if also taking NSAIDs) - Hypertension - Elevated hepatic enzymes
38
SNRIs - interactions
Same as SSRIs - Hypericum - 5HTP - Yohimbe - L-tryptophan - Melatonin (may neutralize the intended enzymatic activity of the SSRI) - Past sensitivity to drug class - Concurrent significant NSAID use (platelet dysfunction) - History of long QTc syndrome - Concurrent use of other QTc prolonging diagnoses or agents - Concurrent tramadol use (for seizures) - Bipolar disorder - Caution with L-tyrosine
39
SNRIs - contraindications
- Glaucoma
40
Venlafaxine - trade name
- Effexor
41
Duloxetine - trade name
- Cymbalta
42
Desvenlafaxine - trade name
- Pristiq
43
Venlafaxine
- Very bad withdrawal symptoms > Use Prozac to taper off - Similar to Paxil in that it doesn't get used as often anymore
44
Duloxetine
- Better for pain than for mood
45
Desvenlafaxine
- Nicer version of Effexor - Useful for patients who haven't had good responses to SSRIs, or patients who are drowsy/needing more energy - Becoming cheaper and more commonly prescribed - Commonly used for patients with a history of opiate addiction
46
Tricyclic antidepressants
- Amitriptyline (Elavil) - Nortriptyline (Pamelor) - Clomipramine (Anafranil) - Imipramine (Tofranil) - Doxepin (Sinequan)
47
TCAs - MOA
- Block serotonin transporter (SERT) and NE transporter (NET) > Block reuptake for 5HT and NE - Increase concentrations in synaptic space
48
TCAs - side effects
- Prolonged QTc - Antimuscarinic effects > Dry mouth > Urinary retention > Dry eyes > Constipation - Sexual dysfunction - Akasthisia (rarely)
49
TCAs - interactions
Same as SSRIs - Hypericum - 5HTP - Yohimbe - L-tryptophan - Melatonin (may neutralize the intended enzymatic activity of the SSRI) - Past sensitivity to drug class - Concurrent significant NSAID use (platelet dysfunction) - History of long QTc syndrome - Concurrent use of other QTc prolonging diagnoses or agents - Concurrent tramadol use (for seizures) - Bipolar disorder - SAMe (accelerates the onset of action of TCAs) - More CYP interactions than SSRIs
50
TCAs - contraindications
- Suicidality (TCAs are lethal at low doses)
51
Clomipramine
- Considered first line for OCD (then NAC, then Luvox) > Doesn't treat depression/anxiety as well as Luvox > Has more side effects and CYP interactions than Luvox
52
Amitriptyline
- Readily used in primary care for sleep, headaches, and neuropathic pain
53
Nortriptyline
- Essentially the same as amitriptyline, but cleaner and more powerful > 50mg of amitriptyline = 25mg of nortriptyline > Fewer side effects than amitriptyline - Good for sleep
54
Doxepine
- Good for insomnia
55
Anxiolytics
- SSRIs - Benzos - Gabapentin - Buspar - Propranolol - Clonidine - Prazosin
56
SSRIs
- Start lower (1/2 usual dose) - Go slower (wait at least 2 weeks between increasing dose) - Go higher (will likely need the max dose to treat anxiety) - Go-to is Zoloft - "Max dose" is a recommendation, and some providers go higher (they just haven't been studied at higher than "max dose")
57
Benzodiazepines
- Alprazolam (Xanax) - Lorazepam (Ativan) - Clonazepam (Klonopin) - Diazepam (Valium) - Temazepam (Restoril)
58
Benzodiazepines - FDA approved for
- Panic disorders - Anxiety disorders - Insomnia - Preoperative anxiety - Seizures - Muscle spasms (often used in sports medicine) - Alcohol withdrawal - Anything that needs the CNS suppressed...
59
Benzodiazepines - detox
- Prioritize detoxing patients - Comfortable schedule for detox > Significant patient education (decreases REM, increases anxiety, increases depression) > Convert to Lorazepam, Valium, or Klonopin to taper (reference Ashton manual) > Consider adding Gabapentin (300mg TID) > 10-20% dose decrease every 2-4 weeks > Support with GABAnergic supplements ^ Passiflora ^ Skullcap ^ GABA ^ Valerian ^ Kava ^ Phenibut
60
Benzodiazepines - differences
- Onset of action - Half life - Receptor sites > All bind to GABA A receptors with differences within subtypes
61
Benzodiazepines - side effects
- Sedation - Anxiety - Depression - Dizziness - Ataxia - Forgetfulness, feeling "fuzzy" - "Being snowed" - Reduced REM sleep (sleep more, but not getting rest)
62
Benzodiazepines - depletions
- Calcium | - Vitamin D
63
Benzodizepines - contraindications
- DHEA (esp Klonopin) - CNS suppressing herbs (like Kava) - Hypericum (CYP interactions)
64
Alprazolam - trade name
- Xanax
65
Lorazepam - trade name
- Ativan
66
Clonazepam - trade name
- Klonopin
67
Diazepam - trade name
- Valium
68
Temazepam - trade name
- Restoril
69
Benzodiazepines - general notes
- Just don't use them if possible... - Research says there's no long-term reason to use them for longer than 4 weeks - Good for patients who have bad akathisia from antipsychotics - If discontinue abruptly, can be deadly - Can develop tissue depletion and addictive behaviors - Increase risk of dementia and Alzheimer's by 60-75% - Make EMDR less effective - Make it more likely for patients with an acute stress response to develop PTSD (if they're already showing PTSD symptoms) - "Legacy" patients are ones who have been on a drug so long that it might actually be more beneficial to keep them on a low dose than to discontinue it totally
70
Gabapentin - trade name
- Neurontin
71
Gabapentin - MOA
- Neuronal calcium channel blocker - Decreases release of glutamate - Makes the experience of there being more GABA
72
Gabapentin - general notes
- Great patients who have liked CNS suppressants (benzos, opioids - Great for easing benzo/alcohol withdrawal symptoms - TID dosing - Has the possibility of being abused, but much safer than benzos and opiates
73
Gabapentin - interactions
- Naproxen
74
Gabapentin - contraindications
- Few to none | - Monitor patients with poor kidney function
75
Gabapentin - Depletions
- B6 (when lumped in with other anticonvulsant medications...)
76
Buspirone - trade name
- Buspar
77
Buspirone - MOA
- 5-HT1A receptor partial agonist | - Minimal D4 receptor agonist
78
Buspirone - FDA approval
- Anxiety disorders
79
Buspirone - dosing
- TID
80
Buspirone - interactions
- Serotonergic agents and supplements - MAOIs - Significant CYP interactions
81
Buspirone - contraindications
- Bipolar disorder
82
Antihypertensives
- Propranolol (Inderal) - Clonidine (Catapress) - Prazosin (Minipress)
83
Antihypertensives - side effects
- Hypotension
84
Propranolol - trade name
- Inderal
85
Propranolol - MOA
- Beta blocker
86
Propranolol - uses
- Social anxiety/public speaking - PTSD prevention (give in first 3 days) - Especially indicated for patients with somatic anxiety
87
Propranolol - contraindications
- Diabetes mellitus (masks the s/s of hypoglycemia) - Hypotension - COPD
88
Propranolol - interactions
- Beta agonists - Hypotensive agents - Hawthorne
89
Propranolol - depletions
- CoQ10
90
Clonidine - trade name
- Catapress
91
Clonidine - MOA
- Central alpha agonist
92
Clonidine - uses
- Generalized anxiety with rapid thoughts
93
Clonidine - contraindications
- Hypotension | - Diabetes mellitus
94
Clonidine - interactions
- Hypotensive agents - CNS depressants - Hawthorne
95
Clonidine - depletions
- CoQ10 - B6 - B1 - Zinc
96
Prazosin - trade name
- Minipress
97
Prazosin - MOA
- Peripheral alpha blocker
98
Prazosin - uses
- PTSD (gold standard)
99
Prazosin - contraindications
- Hypotension
100
Prazosin - interactions
- Hypotensives | - Alpha agonists
101
Prazosin - depletions
- CoQ10 | - Zinc
102
Prazosin - general note
- Slow upward titration
103
Second Generation Antipsychotics (SGAs)
- Clozapine (Clozaril) - Olanzapine (Zyprexa) - Aripiprazole (Abilify) - Quetiapine (Seroquel) - Risperidone (Risperdal) - Paliperidone (Invega) - Ziprasidone (Geodon) - Lurasidone (Latuda) - Asenapine (Saphris)
104
SGA - FDA approval
- Schizophrenia - Schizoaffective disorder - Acute mania - Bipolar disorder - Bipolar depression (Latuda, Seroquel, Abilify)
105
SGA - MOA
- Blocks D2 receptors in some regions of the brain - Blocks 5HT 2A receptors > Causes enhancement of dopamine release in certain brain regions
106
SGA - side effects
``` - Metabolic syndrome > Hyperglycemia > Hyperlipidemia > Weight gain (central) - Akathisia - Other extra-pyramidal symptoms - QTC prolongation - Sedation ```
107
SGA - metabolic concerns
Least to Most - Lurasidone and ziprasidone - Aripiprazole - Asenapine - Risperidone - Quetiapine - Olanzapine
108
SGA - side effects scale
Least to Most - Lurasidone and ziprasidone - Aripiprazole - Risperidone - Asenapine - Quetiapine - Olanzapine
109
Aripiprazole - trade name
- Abilify
110
Aripiprazole - notes
- "Third generation" antipsychotic - Partial agonist of D2 receptors - More serotonergic activity than other SGAs - More anti-depressant effects - Fewer metabolic and EPS SEs - Causes problematic akathisia - Causes gambling - One of the most commonly used - Often 1st line for bipolar - Often used for adjunctive depression therapy
111
Olanzapine - trade name
- Zyprexa
112
Olanzapine - notes
- Mania sledgehammer > Best for acute psychosis - Very sedating - Increases CRP with just one dose - Very popular - Can cause 10lbs of weight gain in one week - Can use it acutely and then transfer to a different SGA
113
Quetiapine - trade name
- Seroquel
114
Quetiapine - notes
- Very sedating - Used for sleep issues - Some anti-depressant effects - Significant SEs with prolonged use - Causes QTC prolongation > Second to Geodon - Causes the least amount of EPS SEs
115
Risperidone - trade name
- Risperdal
116
Risperidone - notes
- Cheapest, first covered by insurance - Medium sedation - Minimal anti-depressant effect - Causes prolactinemia - Causes breast enlargement - Becomes a 1st generation antipsychotic at 4mg - Go-to middle-of-the-road SGA when no significant needs stand out - In the middle for SEs and efficacy
117
Clozapine - trade name
- Clozaril
118
Clozapine - notes
- 1st SGA developed - Not used as often anymore - Most effective - Causes such bad SEs that patients must be on a national registry if they're taking it
119
Paliperidone - trade name
- Invega
120
Paliperidone - notes
- There's an injectable version that is well-tolerated
121
Ziprasidone - trade name
- Geodon
122
Ziprasidone - notes
- IM used for psychosis | - Worst for causing QTC prolongation
123
Lurasidone - trade name
- Latuda
124
Lurasidone - notes
- Also FDA-approved for bipolar | - Currently very expensive
125
SGA - contraindications
- DMII (okay with monitoring) | - QTC prolongation
126
SGA - interactions
- Dopaminergic medications > Ex. - Levadopa - Some CYP interactions
127
Mood stabilizers - general notes
- Prevent mania - Alleviate depression (SSRIs CI in bipolar) - Alter progression of the "disease" - Many are anti-seizure drugs - Some stabilize from above (tamp down mania) and some stabilize from below (lift up depression)
128
Mood stabilizers
- Lamictal (Lamotrigine) - Lithium - Depakote (Valproic acid (VPA) or Depakene) - Tegretol - Topomax
129
Lamictal - trade name
- Lamotrigine
130
Lamictal - MOA
- Anti-convulsant | - Blocks voltage-sensitive sodium channels
131
Lamictal - notes
- Best anti-depressant mood stabilizer - Slow titration schedule to reduce allergic response/chances of developing Stevens Johnsons Syndrome - Stabilizes from below > Probably helps with some mania/hypomania, but more depression-oriented - Can take up to 400-800mg/day - After 200mg, don't get much more mood effects, but can really help with anxiety and irritability
132
Lamictal - side effects
- Benign rash - Deadly rash (SJS) - Sedation (rare) - Blurred vision (rare) - Stop taking immediately at first sign of a rash
133
Lamictal - interactions
``` - Depakote > Increases lamictal concentrations and risk of rash - Some oral contraceptives > Decrease lamictal concentrations - Many CYP reactions ```
134
Lamictal - contraindications and depletions
- None known
135
Lithium - MOA
- "unknown and complex" | - Alters sodium transport across cell membranes
136
Lithium - notes
- Gold standard for bipolar 1 - 3 forms: orotate, carbonate, and various "slow release" forms - Must monitor thyroid function, kidney function, and calcium at baseline and then at least yearly > Not true for orotate form - Stabilizes from above - Stops suicidal ideation within a day of a minimum dose - If dehydrated, lithium blood levels will increase (because it's a salt)
137
Lithium - dosing
- 0.8-1.1 mmol/L is therapeutic range - 0.6-0.7 mmol/L is suboptimal, but okay for maintenance - Above 1.2 is toxic - 0.9 is best for mania prevention - 1.0+ has more SEs - Can stay lower for MDD and suicidal ideation - Must reach 0.5-0.6 for mania
138
Lithium - side effects
- Weight gain - Stomach upset (switch to the long-acting form) - Thyroid dysfunction - Kidney dysfunction - When reach toxicity: ataxia, delirium, tremor, nausea, vomiting (looks like serotonin syndrome)
139
Lithium - interactions
``` - Cox-2 inhibitors (like NSAIDs) > Increase lithium levels - Diuretics > Increase lithium levels - ACE inhibitors > Increase lithium levels ```
140
Lithium - contraindications
- Kidney disease - Cardiovascular disease - Sodium depletion
141
Lithium - possible positive additive effects
- Folic acid - 5-HTP - Inositol (watch for re-emergence of mania)
142
Lithium - depletions
- Chromium
143
Depakote - MOA
- Blocks voltage-sensitive sodium channels by an unknown mechanism - Increases GABA by an unknown mechanism - Anti-convulsent
144
Depakote - dosing
- 0.6 - 1.0 ug/mL | - Requires regular plasma
145
Depakote - notes
- Generally stabilizes from above - Good for patients with a lot of anger > Otherwise choose other meds
146
Depakote - interactions
- Lamictal (VPA increases lamictal plasma levels) - Carbamazapime (VPA levels will be lowered) - Aspirin (will increase VPA levels) - Clonazepam (potential for rare seizures) - CYP interactions
147
Depakote - contraindications
``` - Poor liver health > Monitor enzymes closely - Pancreatitis - Very teratogenic > Monitor anyone who has the potential of becoming pregnant ```
148
Depakote - depletions
- Folic acid - Zinc - Selenium - Carnitine - Biotin - B12 - B1 - Copper
149
Sleepers
- Trazodone - Seroquel - Ambien - Temazepam
150
Trazodone - MOA and class
- SARI (5HT agonist/reuptake inhibitor)
151
Trazodone - side effects
- Hangover - Others more uncommon > N/V > Anticholinergic SEs > Syncope > EKG changes - Hangover usually doesn't last too long, but is pretty common
152
Trazodone - interactions
- Many, but fairly mild | - Possibly serotonergic agents, but can be used with SSRIs
153
Trazodone - notes
- Go-to for falling asleep and staying asleep - Doesn't interrupt REM - Aids in PTSD nightmare reduction - No tolerance, dependence, or withdrawal - Some people get activated if they don't fall asleep within 30 minutes of taking it - Possibly suppresses melatonin
154
Quetiapine - trade name
- Seroquel
155
Quetiapine - notes
- Highly sedating atypical antipsychotic - Great for nightmares if prazosin or trazodone fail - Must do same monitoring as all SGAs - Causes SGA SEs - 25-100mg for sleep > Very histaminergic - 150-300mg for antidepressant/mood/anxiolytic - >400mg for antipsychosis
156
Zolpidem - trade name
- Ambien
157
Zolpidem - notes
- Almost, but not quite a benzo > Good to just consider it one when considering prescribing it - Dependence and withdrawal - Does not allow REM > Harmful in PTSD - Different doses depending on biological sex - Decreases life expectancy - Patients report doing unsafe things while on it, or even the morning after
158
Temazepam - trade name
- Restoril
159
Temazepam - notes
- It's a benzo - Causes fewer euphoric effects, but more sedative effects - Less anxiolytic than other benzos

Integrative Psychopharmacology (2 decks)

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