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1
Q

What is monoamine?

A

Molecule with a single amine group.

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2
Q

What are the 3 monoamine groups?

A
  • catecholamines: NE, epinephrine, and DA
  • tryptans: 5-HT and melatonin
  • histamines
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3
Q

Antidepressants with anticholinergic effects

A

TCAs, paroxetine, and duloxetine

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4
Q

Antipsychotic with most antichol effect

A
  • clozapine, olanzapine, most FGA
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5
Q

Which antidep we should avoid in moderate hepatic dx?

A

Duloxetine (also kidney dx)

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6
Q

Which antidepressants should have dose reduction with hep disease?

A

Citalopram
Escitalopram
Fluoxetine
Paroxetine

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7
Q

Which mood stabilizers require dose reduction in hep disease?

A

Carbamazepine
Valproate
Lamotrigine

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8
Q

Which SGA we should avoid in severe hep disease?

A

Iloperidone

Asenapine

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9
Q

Which SGA we should reduce dose in hep disease?

A

Lurasidone
Risperidone
Quetiapine
Brexpiprazole

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10
Q

Which FGA we should avoid in severe hep disease?

A

Phenotiazines (fluohenazine, perphenazine, trifluoperazine)

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11
Q

Which hypnotics should be avoided in severe hep disease?

A

Zaleplon

Zolpidem

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12
Q

Which hypnotics should have decrease in dose in hep disease?

A

Eszopione

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13
Q

Which antidepressant should be avoided in severe kidney disease?

A

Duloxetine

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14
Q

Which antidepressants should have dose reduction in kidney disease?

A

Mirtazapine
Paroxetine
Venlafazine

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15
Q

Which mood stabilizers should have dose reduction in kidney disease?

A

Gabapentin
Lamotrigine
Topiramate

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16
Q

Which mood stabilizer should be avoided in severe kidney disease?

A

Lithium

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17
Q

Which BZD should have dose reduction in kidney disease?

A

Chlordiazepoxide

Midazolam

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18
Q

Which hypnotics should have dose reduction in kidney disease?

A

Zaleplon
Zolpidem
Midazolam
Chlordiazepoxide

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19
Q

Which antidepressant should be avoided in pregnancy?

A

Paroxetine- concern for cardiac malformation.

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20
Q

Unsafe medications in pregnancy (category X)

A
  • isotretinoin
  • thalidomide
  • some BZD (triazolam, estazolam, flurazepam, quazepam)
  • leflunomide
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21
Q

Lithium’s risk in pregnancy

A
  • increases risk of Ebstein’s anomaly (malformation of tricuspid valve)
  • increases the risk from 1/20,000 to 1/2000-1/1000 -> 5-fold increase
  • floppy baby syndrome (cianosis, hypotonicity) from exposure during labor
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22
Q

Lithium use in pregnancy- what to do

A
  • get a echocardiogram if exposure during 1st trimester
  • monitor levels and adjust dose due to shifting fluid levels
  • prior to delivery decrease dose to half or stop temporarily
23
Q

Valproate risk in pregnancy

A
  • organ dysgenesis (fetal valproate syndrome): neural tube defects (from 0.03% to 1-5% - 20-50-fold increase) + craniofacial defects + cardiac abnormalities
  • neonatal toxicity: withdrawal sx, liver tox, hypoglycemia
  • neurobehavioral teratogenicity: lower IQ, possible ID/autism

Avoid use in pregnancy! If needed, supplement folate.

24
Q

Carbamazepine risk in pregnancy

A
  • organ dysgenesis (fetal carbamazepine synd): craniofacial defects (11%), fingernail hypoplasia (26%), developmental delay (20%), neural tube defects (0.5 - 1%), doll-like faces, long philtrum, palpebral folds
  • neonatal tox: transient hep tox
  • Avoid if possible. If needed, supplement with vitamin K
25
Q

BZD risk in pregnancy

A

increases risk of oral cleft by 0.01% (not so intense)

26
Q

Safest medication during lactation

A

Acetaminophen

27
Q

Contra-ind in lactation

A

doxepin

28
Q

Meds that interact with Li

A

NSAIDs, ACEi, and angio II antag

29
Q

Meds that interact with TCAs and cause tox

A

fluoxetine and paroxetine (via CYP 2D6)

30
Q

Meds that interact with carbamazepine

A

erythromycin (via CYP 3A4)

31
Q

Med that interact with cariprazine, lurasidone , and quetiapine and cause reduction

A

carbamazepine (via CYP 3A4)

32
Q

Med that interact with lamotrigine and lumateperone and cause tox

A

valproate (via UGT 1A4)

33
Q

Med that interact with valproate, OCP, PPIs and cause reduction

A

carbamazepine

34
Q

FGA and SGA - mostly metabolized by which CYP 450 enzymes? What are the exception?

A

1A2, 2D6, 3A4

  • lumateperone (phase 2)
  • olanzapine (phase 2)
  • ziprasidone (aldehyde oxidase)
35
Q

OCPs- mostly metabolized by which CYP 450 enzymes?

A

3A4

36
Q

TCAs - inhibit which of the CYP 450 enzymes?

A

2C19

37
Q

fluoxetine - inhibits which of the CYP 450 enzymes?

A

2C19, 2D6 , (some 2C9)

38
Q

fluvoxamine - inhibits which of the CYP 450 enzymes?

A

1A2, 2C9, 2C19, (some 3A4)

39
Q

paroxetine and other SSRIs/SNRIs- inhibits which of the CYP 450 enzymes?

A

2D6

40
Q

Drugs that could interact and cause hypertensive crisis

A
  • MAOI
  • bupropion
  • L-dopa
  • methylphenidate
  • pseudoephedrine
  • tyramine-rich foods
41
Q

Drugs that could interact and cause serotonin synd

A
  • MAOI, TCA, SSRI, mirtazapine
  • opiates: methadone, meperidine, fentanyl, tramadol
  • linezolin (Zyvox) - ATB with MAOI activity
  • methylene blue
42
Q

Serotonin synd

A

Confusion, agitation, dilated pupils, headache, autonomic instab, N/V, diarrhea, tachycardia, tremor, sweating

43
Q

Only conclusive rec re: genotyping (International society of psychiatric genotyping 2019)

A
  • HLA-A and HLA-B prior to use of carbamazepine and oxcarbazepine
  • genetic info for CYP 2C19 and CYP 2D6 would likely be most beneficial for pt with inadequate response or adverse reaction to a previous antidepressant or antipsychotic trial
44
Q

Caffeine - metabolized by which CYP 450?

What increases caffeine’s level? What meds’s levels are increased by caffeine?

A

1A2 (and inhibits it) = same as fluvoxamine and opposite of smoking

  • levels increased by: fluvox, fluoxetine, parox, cimetidine, omeprazole
  • caffeine increases: asenapine, clozapine, pimozide, duloxetine, ropinirole
45
Q

Grapefruit - metabolized by which CYP 450? What other meds are met by the same enzyme?

What meds’s levels are increased by grapefruit?

Grapefruit interferes with gut absorption of which meds?

A

3A4 (and inhibits it) = same as lumateperone, pimozide, erythromycin, ketoconazole, cannabidiol

  • increases level of many BZD, amphetamine, sertraline, morphine, buprenorphine, buspirone, some antipsychotics
  • decreases gut absorption of digoxin and statins
46
Q

cannabidiol

  • pharmacokinetic caution with which meds?
  • metabolized by which CYP 450?
  • inhibits which CYP 450 enzyme?
  • other pharmacodynamic cautions
A
  • valproate, clobazam, acetaminophem = all increase ALT/AST
  • 3A4, 2C9, 2C19
  • 3A4 -> can increase level of BZD, opioids
  • CNS depressants (alcohol, opioids, BZD, etc)
47
Q

Cigarette and cannabis smoking induces what CYP 450 enzyme?
Which substance is responsible for it?
It means decrease in which meds?

A
  • 1A2
  • polycyclic aromatic hydrocarbons
  • some TCAs, dulo, fluvo, mirta, trazodone, FGA, clozapine, olanzapine, asenapine, alprazolam, diazepam, ropinirole, heparin, caffeine

Hospitalization / quitting may result in increase level of those meds!

48
Q

St. John’s Wort

  • met and inducer of what P 450?
  • decreases level of what?
  • another important pharmacodynamic concern
A
  • 3A4
  • OCP, sertraline, valproate, phenytoin, haloperidol, MDZ
  • inhibits reuptake of 5-HT, NE, and DA - can contribute to serotonin synd
49
Q

Omeprazol and other PPIs

  • inhibits what enzyme?
  • met by which enzyme?
A
  • 2C19 - increases level of citalopram (max dose 20 mg daily), escitalopram, DZP
  • 3A4
50
Q

Cimetidine inhibits which enzyme?

Increases level of which meds?

A
  • 3A4

- chlordiazepoxide, diazepam, some TCAs, citalopram

51
Q

Elevated gastric pH increases absorption of which med?

A

amphetamines

52
Q

Meds assoc with orthostatic hypotension

A
  • phenelzine
  • tranylcypromine
  • clozapine
  • quetiapine
53
Q

Antidep more likely to cause manic-flip

A

TCAs

Psychopharm (3 decks)

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