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845 > SE of Psychotropics > Flashcards

SE of Psychotropics Flashcards

1
Q

Side Effect

A
  • Secondary, undesired effect of a medication or medical treatment
  • Known or expected effect described in clinical or post-marketing trials
  • Generally mild in nature, often reversible with withdrawal
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2
Q

Adverse Effect

A
  • Undesired and unexpected effect considered detrimental or harmful
  • Doesn’t mean unknown or unobserved previously
  • Often unappreciated DDI
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3
Q

Pleotropic Effect

A
  • SE viewed as beneficial for most patients or a select group of patients
  • Previously undescribed/unexpected effect discovered in post-marketing
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4
Q

Anticholinergic SE

A

-Dried out
-MoA: inhibition of parasympathetic NS by TCAs or Paroxetine (SSRI)
-Alt MoA: activation of sympathetic NS (less common) by SNRIs or stimulants
Treatment: reduce dose, switch agents, start therapy to address specific symptoms

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5
Q

Constipation Treatment Options

A
  • Increase water intake
  • Increase physical activity
  • Osmotic laxatives: polyethylene glycol
  • Stimulant laxatives: senna, bisacodyl, magnesium hydroxide
  • Caution with bulking agents: could worsen constipation if taken w/o adequate water
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6
Q

Dry Mouth Treatment Options

A
  • Artificial saliva (Biotene)
  • Sugar free chewing gum or hard candy
  • Pilocarpine ophthalmic drops given sublingually
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7
Q

Urinary Retention/Confusion/Dizziness/Sedation Treatment Option

A
  • Change in therapy

- Dose reduction

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8
Q

Sedation + Histamine Antagonism

A
  • Associated with rapid tolerance
  • Doesn’t usually need specific treatment
  • Wait it out
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9
Q

Sedation + Anticholinergic

A
  • Highly variable between patients and agents
  • Trial evening/bedtime dosing
  • Alternative agent in medication class
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10
Q

Sedation + 5HT2A Antagonism

A
  • Development of tolerance highly variable between patients
  • Effect appears to be related to [peak]
  • Often best addressed with bedtime/evening dosing
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11
Q

Sedation + GABA Enhancement

A
  • Sedation usually desired effect
  • Treatment unnecessary
  • Use shorter acting agents to mitigate hangover effect (temazepam, zolpidem)
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12
Q

Weight Gain + Metabolic Syndrome

A
  • No single MoA
  • 5HT2C antagonism and H1 antagonism can alter lipid metabolism
  • Enhancement of 5HT, antagonism of DA can effect GI motility and appetite
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13
Q

Weight Gain/Metabolic Syndrome Treatment

A
  • Metformin as a prophylactic for antipsychotic induced weight gain
  • No evidence is metabolic syndrome was already present
  • Dose: 500-1000 mg per day
  • Can also increase activity and reduce caloric intake
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14
Q

Orthostatic Hypotension

A
  • > 20 mmHg drop in systolic or 10 mmHg drop in diastolic BP within 3 minutes of changing from sitting/lying down to standing
  • Mechanism: alpha-1 antagonism
  • Offenders: clozapine, quetiapine, prazosin, TCAs
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15
Q

Orthostatic Hypotension Treatment

A
  • Patient education about making changes slowly
  • Start low and titrate dose of medication based on response
  • Some degree of tolerance will develop
  • Fluticasone or midodrine can be used for refractory cases when lowering dose isn’t possible
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16
Q

QT Interval Prolongation

A
  • > 450 msec for males, >460 msec for females
  • Risk of developed Torsades which can be fatal when untreatment
  • Additional Risk facotrs: > 65 y.o., female, hypokalemia, hypomagnesemia, heart failure, bradycardia
  • Most implicated meds: citalopram, chlorpromazine, thiordazine, ziprasidone, quetiapine
17
Q

QT Prolongation Prevention

A
  • Monitor ECG!!!
  • Limit offender use once QTc is at previously 450 for males and 460 for females (CI at >500 msec)
  • Use agents which are neutral or shortening
  • Correct modifiable risk factors
  • Document verification or direct review or monitoring
18
Q

QT Prolongation Treatment

A
  • Don’t tell to abruptly stop in most cases
  • Work with patient and provider to taper offending agent
  • TdP requires immediate electrical defibrillation
19
Q

Sexual Dysfunction

A
  • Multiple types, clarify and distinguish exact symptoms
  • Treatment varies per symptom
  • SSRIs, SNRIs, TCAs, and MAOIs all common offenders
20
Q

Loss of Libido + Treatment

A
  • Little or no desire to engage in sex
  • Trial addition of bupropion or change to bupropion
  • Change to lower potential agents like mirtazapine, nefazodone, or buproprion
21
Q

Anorgasmia + Treatment

A
  • Inability to reach orgasm

- Treat similarly to loss of libido

22
Q

Erectile Dysfunction + Treatment

A
  • PDE5i are preferred

- Dosing the same as organic ED

23
Q

Withdrawal Effects

A
  • Symptoms associated with abrupt or accelerated discontinuation of drug
  • Doesn’t infer addiction (only dependence)
  • Range and severeity varies by medication class, agent, and duration of prior exposure
24
Q

5HT Syndrome

A
  • Exceedingly rare outside of overdoses
  • Risk increases with number of serotonergic agents take
  • MoA: over-activation of 5HT synaptic transmission, usually 5HT1A and 5HT2A
  • Presentation: altered mental status, neuromuscular hyperactivity, autonomic hyperactivity
25
Q

5HT Syndrome Prevention

A
  • No routine monitoring due to low incidence
  • Counsel about signs and symptoms when risk appears higher
  • Check for DDI that could increase [serotonergic agent]
26
Q

5HT Syndrome Treatment

A
  • Stop implicated agents
  • Supportive, symptom-based care
  • Benzo shown to improve survival when used for agitation and anxiety
  • Avoid physical restraints due to lactic acidosis risk
  • May need neuromuscular blockade for hyperthermia
  • Cyproheptadine, 5HT antagonist, can be used to block serotonergic activity
  • Atypical antipsychotic can be used in severe, refactory cases
27
Q

Neuroleptic Malignant Syndrome

A
  • Exceedingly rare
  • Presentation: similar to 5HT syndrome except with neuromuscular “lead pipe” rigidity with hyporeflexia
  • Mechcanism: excessive DA antagonism from antipsychotics, more common with FGAs
28
Q

Neuroleptic Malignant Syndrome Prevention

A
  • Conservative dosing of antipsychotics
  • Avoid rapid escalations
  • Reserve use of high-potency FGAs in refractory cases
29
Q

NMS Treatment

A
  • Supportive, symptom based care
  • Bromocriptine – dopamine agonist to reverse antagonist effect of antipsychotic
  • Dantrolene – direct-acting muscle relaxer can be used for muscular rigidity
  • Sodium bicarbonate and IV hydration to prevent/treat AKI from rhabdomyolysis
  • Ice baths/packs and cooled saline for hyperthermia
  • Benzodiazepines to minimize agitation
30
Q

Suicidality + Antidepressants

A
  • Small increase in suicidal thoughts and behavior in early therapy
  • Does NOT increase suicide rates
  • Risk of untreated depression outweighs risk of antidepressant therapy
31
Q

Death + Antipsychotics

A
  • All antipsychotics have this black box warning
  • Unknown mechanism, associated with elderly patients with dementia
  • FGAs have higher risk
  • Risk diminishes over time
32
Q

Death Treatment

A
  • Prevention is best and only treatment
  • Use non-pharm interventions first for behavioral disturbances
  • Antidepressants have best initial pharmacotherapy evidence if nonpharm fails
  • Valproic acid/divalproex has minimal evidence but is commonly used
  • Use antipsychotics if necessary at minimal doses and durations
  • Aripiprazole, quetiapine, or olanzapine are the best options
33
Q

Tremor

A
  • Mechanism is unknown
  • Centrally active beta blockers (metoprolol, propranolol, and carvedilol) are effective
  • Primidone may be option for refractory cases
34
Q

Hyperhydrosis/Diaphoresis

A
  • Atypical effect of SSRI/SNRIs/stimulants
  • Likely from sympathetic NS activation
  • Alpha blockers can be effective if topicals are insufficient
35
Q

Hyponatremia

A
  • Common occurrence in elderly with all serotonergic antidepressants
  • Lowest risk with mirtazapine
36
Q

Lithium SE

A
  • Most SE can be minimized by altering dosing, formulation or timing
  • Changing therapy often necessary to completely eliminate SE
  • SE: polyuria/polydypsia, tremor, diarrhea, thyroid abnormalities, nephrotoxicity

845 (24 decks)

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