Psychotropics

Question 1

Neurotransmitters impacted by antidepressants

Answer 1

Question 2

Symptoms of neurotransmitter deficiency

Answer 2

Question 3

Which drug classes effect which neurotransmitters?

Answer 3

Question 4

Nonselective norepinephrine-serotonin reuptake inhibitors(aka Tricyclic Antidepressants) mechanism of action

Answer 4

Block the reuptake of serotonin and norepinephrine at the presynaptic neuron

šBlock histamine and acetylcholine receptors (causes side effects)

šBlock alpha adrenergic and Na+ channels

Question 5

TCA examples and indications

Answer 5

Amitriptyline, Imipramine, Desipramine, Nortriptyline

Indications: depression, OCD, chronic pain, Enuresis (imipramine)

Question 6

TCA off label uses

Answer 6

Panic disorder, bulemia, phantom leg pain, PMS, migraine prophylaxis

Question 7

TCA side effects

Answer 7

Anticholinergic effects (Beers criteria, use caution in older adults)

Sexual dysfunction

Weight gain

Drowsiness (take before bed)

Contraindicated with CV disease d/t arrhythmias (consider baseline EKG)

***Risk for fatal overdose with supply greater than 2 weeks***

Question 8

Selective serotonin reuptake inhibitor mechanism of action

Examples

Answer 8

Inhibits serotonin reuptake in the presynaptic cell

No impact on histaminic, or cholinergic receptors or Na+ pumps (less side effects)

Fluoxetine (Prozac), Citalopram (Celexa), Escitaopram (Lexapro), Sertraline (Zoloft)

Question 9

SSRI side effects

Answer 9

Transiet (typically resolve within several weeks): nausea, light headedness, headache, sedation, sleep distrubance, increased sweating, agitation

Sexual side effect: decreased libido, difficulty acheiving organism. These are typically dose dependent

Weight changes (Paxil has more)

Question 10

Considerations for prescribing SSRIs

Answer 10

Serotonin syndrome: MAOIs, caution with triptans, St. John’s Wort

Recommended to take for at least 6-9 months if effective

Increased risk for suicide in first 3 weeks

Withdrawl syndrome: nausea, dizziness, paresthesias, sleep disturbance, headache

Question 11

Symptoms of serotonin syndrome

Answer 11

šNausea, diarrhea, chills, sweating, HTN, tremor, agitation, disorientation, seizures

Can be fatal

Question 12

Serotonin–norepinephrine reuptake inhibitor mechanism of action

Examples

Answer 12

Block the reuptake of serotonin and norepinephrine at the presynaptic cell

Venlafaxine (Effexor), duloxetine (Cymbalta), desvenlafaxine (Pristiq)

Question 13

SNRI inidcations and monitoring

Answer 13

šVenlafaxine works well for persons with depression and anxiety, phobias, PTSD

šDuloxetine is also FDA approved for neuropathic pain and overactive bladder

Monitor BP: can cause HTN

LFTs with duloxetine

Question 15

SNRI side effects

Answer 15

Headache, nausea, dizziness, insomnia, dry mouth, constipation, sexual dysfunction

Need to be weaned slowly as they can cause significant withdrawl symptoms. Typically tapered over several months

Question 16

Norepinephrine and dopamine reuptake inhibitors mechanism of action

Example

Answer 16

Blocks reuptake of dopamine and norepinephrine at the presynaptic cell

Bupropion

Question 17

NDRI side effects

Answer 17

Insomnia, jitteriness, weight loss, irritability, headache, dry mouth

May cause exacerbation of anxiety

Lowers seizure threshold ***contraindicated with any hx of seizure***

Question 18

NDRI positve side effects

Answer 18

Can increase energy levels (good for patients with hypersomnia)

Appetite suppressant

Fewer sexual side effects

Question 19

Trazadone

Answer 19

Subclass of SSRI

Doses used for depression are very sedating

Most commonly used for sleep

Side effects: headache, dizziness, hypotension

Question 20

MAOIs

Answer 20

Rarely used due to extensive drug interactions

Avoid foods with tyramine (aged meats and cheeses)

šPhenelzine (Nardil), tranylcypromine (Parnate), selegiline (Emsam), isocarboxazid (Marplan)

Question 21

FDA warnings for antidepressants

Answer 21

Question 22

Drugs that cause depression

Answer 22

šBeta blockers

šCorticosteroids (mania and euphoria common with short term use)

šFluoroquinolones

šInterferon

šAnticonvulsants (CNS depression)

šOpioids

šHormonal BC

šPPI (inhibits absorption of B-12)

šAnti-depressants (increased suicidal ideation)

Question 23

Antidepressants used for anxiety

Answer 23

Question 24

Benzodiazepine mechanism of action and indications

Answer 24

Acts as a CNS depressant

Enhances GABA which is an inhibitor of neuronal activity

šIndications include: Insomnia, šInduce relaxation and loss of memory of medical procedures or surgery, šReduce anxiety (anxiolytic), šPanic disorders, šTreat or prevent seizures, šAlcohol withdrawal treatment, šMuscle relaxant

Question 25

Half life considerations of benzodiazepines

Answer 25

Shorter half life drugs have more addictive properties Consider using longer acting formulations to reduce risk for misuse

Question 26

Benzodiazepine adverse effects

Answer 26

ššDepression, emotional anaesthesia, aggression, increased suicide risk in elderly Use caution in elderly: šconfusion, memory impairment, over sedation (most common S/E) & falls (40% increase risk for hip fracture) Physical dependence common (risk for dependence increases with hx of substance use disorder) šIncreased accident risk šTolerance & rebound insomnia šAlcohol & CNS depressants potentiate adverse effects \*\*Black box warning with opioids\*\*

Question 27

Benzodiazepine withdrawl

Answer 27

šAcute withdrawal: insomnia, irritability, GI distress, tremors, agitation, muscle spasms, seizures šTaper if daily use for \> 30 days šConsider switching to loger acting formulation for tapering to reduce withdrawal symptoms

Question 28

Typical antipyschotics mechanism of action and examples

Answer 28

Block dopamine (D2) receptors causing reduction in špositive symptoms (mesolimbic pathway) Not as effective at treating negative symptoms šChlorpromazine, šAcetaphenazine, šFluphenazine, šHaloperidol, šTrifluoperazine, šTriflupromazine

Question 29

Typical antipsychotics adverse effects

Answer 29

šToo much D2 blockade leads to EPS (nigrostriatal pathway) šmotor abnormalities (parkinsonism), tardive dyskinesia or hyperkinetic movement disorder, sedation, anticholinergic effects Hyperprolactinemia

Question 30

Atypical antipsychotics mechanism of action and examples

Answer 30

šEffect on multiple dopamine pathways as well as serotonin pathways reducing negative and positive symptoms šAripiprazole (Abilify), šClozapine (Clozaril), šRisperidone (Risperdal), šOlanzapine (Zyprexa), šQuetiapine (Seroquel), šZiprasidone (Geodon)

Question 31

Atypical antisychotic adverse effects

Answer 31

šSIGNIFICANT incidence of metabolic syndrome, weight gain, diabetes Less EPS than typical antipsychotics

Question 32

Antipsychotics black box warning (typicals and atypicals)

Answer 32

1) Increased Mortality in Elderly Patients With Dementia-Related Psychosis 2) Suicidal behavior when combined with antidepressants

Question 33

Stimulant examples and indications

Answer 33

šMethylphenidate (Ritalin, Concerta) š Dexmethylphenidate (Focalin) Amphetamines [šDextroamphetamine (Dexedrine), šDextroamphetamine-amphetamine (Adderall), šLisdexamfetamine (Vyvanse)] Indications: ADD/ADHD, šNarcolepsy, Fatigue, depression (palliative care setting) Schedule II controlled substance, need to check PDMP

Question 34

Stimulant adverse effects

Answer 34

šAnorexia, weight loss šSleep disturbance šJitteriness šEmotional lability šIncreased pulse and BP