Psychotropics Flashcards
Neurotransmitters impacted by antidepressants
Symptoms of neurotransmitter deficiency
Which drug classes effect which neurotransmitters?
Nonselective norepinephrine-serotonin reuptake inhibitors(aka Tricyclic Antidepressants) mechanism of action
Block the reuptake of serotonin and norepinephrine at the presynaptic neuron
Block histamine and acetylcholine receptors (causes side effects)
Block alpha adrenergic and Na+ channels
TCA examples and indications
Amitriptyline, Imipramine, Desipramine, Nortriptyline
Indications: depression, OCD, chronic pain, Enuresis (imipramine)
TCA off label uses
Panic disorder, bulemia, phantom leg pain, PMS, migraine prophylaxis
TCA side effects
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***
Selective serotonin reuptake inhibitor mechanism of action
Examples
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)
SSRI side effects
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)
Considerations for prescribing SSRIs
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
Symptoms of serotonin syndrome
Nausea, diarrhea, chills, sweating, HTN, tremor, agitation, disorientation, seizures
Can be fatal
Serotonin–norepinephrine reuptake inhibitor mechanism of action
Examples
Block the reuptake of serotonin and norepinephrine at the presynaptic cell
Venlafaxine (Effexor), duloxetine (Cymbalta), desvenlafaxine (Pristiq)
SNRI inidcations and monitoring
Venlafaxine works well for persons with depression and anxiety, phobias, PTSD
Duloxetine is also FDA approved for neuropathic pain and overactive bladder
Monitor BP: can cause HTN
LFTs with duloxetine
SNRI side effects
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
Norepinephrine and dopamine reuptake inhibitors mechanism of action
Example
Blocks reuptake of dopamine and norepinephrine at the presynaptic cell
Bupropion
NDRI side effects
Insomnia, jitteriness, weight loss, irritability, headache, dry mouth
May cause exacerbation of anxiety
Lowers seizure threshold ***contraindicated with any hx of seizure***
NDRI positve side effects
Can increase energy levels (good for patients with hypersomnia)
Appetite suppressant
Fewer sexual side effects
Trazadone
Subclass of SSRI
Doses used for depression are very sedating
Most commonly used for sleep
Side effects: headache, dizziness, hypotension
MAOIs
Rarely used due to extensive drug interactions
Avoid foods with tyramine (aged meats and cheeses)
Phenelzine (Nardil), tranylcypromine (Parnate), selegiline (Emsam), isocarboxazid (Marplan)
FDA warnings for antidepressants
Drugs that cause depression
Beta blockers
Corticosteroids (mania and euphoria common with short term use)
Fluoroquinolones
Interferon
Anticonvulsants (CNS depression)
Opioids
Hormonal BC
PPI (inhibits absorption of B-12)
Anti-depressants (increased suicidal ideation)
Antidepressants used for anxiety
Benzodiazepine mechanism of action and indications
Acts as a CNS depressant
Enhances GABA which is an inhibitor of neuronal activity
Indications include: Insomnia, Induce relaxation and loss of memory of medical procedures or surgery, Reduce anxiety (anxiolytic), Panic disorders, Treat or prevent seizures, Alcohol withdrawal treatment, Muscle relaxant
Half life considerations of benzodiazepines
Shorter half life drugs have more addictive properties
Consider using longer acting formulations to reduce risk for misuse
Benzodiazepine adverse effects
Depression, emotional anaesthesia, aggression, increased suicide risk in elderly
Use caution in elderly: confusion, 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)
Increased accident risk
Tolerance & rebound insomnia
Alcohol & CNS depressants potentiate adverse effects
**Black box warning with opioids**
Benzodiazepine withdrawl
Acute withdrawal: insomnia, irritability, GI distress, tremors, agitation, muscle spasms, seizures
Taper if daily use for > 30 days
Consider switching to loger acting formulation for tapering to reduce withdrawal symptoms
Typical antipyschotics mechanism of action and examples
Block dopamine (D2) receptors causing reduction in positive symptoms (mesolimbic pathway)
Not as effective at treating negative symptoms
Chlorpromazine, Acetaphenazine, Fluphenazine, Haloperidol, Trifluoperazine, Triflupromazine
Typical antipsychotics adverse effects
Too much D2 blockade leads to EPS (nigrostriatal pathway)
motor abnormalities (parkinsonism), tardive dyskinesia or hyperkinetic movement disorder, sedation, anticholinergic effects
Hyperprolactinemia
Atypical antipsychotics mechanism of action and examples
Effect on multiple dopamine pathways as well as serotonin pathways reducing negative and positive symptoms
Aripiprazole (Abilify), Clozapine (Clozaril), Risperidone (Risperdal), Olanzapine (Zyprexa), Quetiapine (Seroquel), Ziprasidone (Geodon)
Atypical antisychotic adverse effects
SIGNIFICANT incidence of metabolic syndrome, weight gain, diabetes
Less EPS than typical antipsychotics
Antipsychotics black box warning (typicals and atypicals)
1) Increased Mortality in Elderly Patients With Dementia-Related Psychosis
2) Suicidal behavior when combined with antidepressants
Stimulant examples and indications
Methylphenidate (Ritalin, Concerta)
Dexmethylphenidate (Focalin)
Amphetamines [Dextroamphetamine (Dexedrine), Dextroamphetamine-amphetamine (Adderall), Lisdexamfetamine (Vyvanse)]
Indications: ADD/ADHD, Narcolepsy, Fatigue, depression (palliative care setting)
Schedule II controlled substance, need to check PDMP
Stimulant adverse effects
Anorexia, weight loss
Sleep disturbance
Jitteriness
Emotional lability
Increased pulse and BP
