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
2
Q
Adverse Effect
A
- Undesired and unexpected effect considered detrimental or harmful
- Doesn’t mean unknown or unobserved previously
- Often unappreciated DDI
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
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
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
6
Q
Dry Mouth Treatment Options
A
- Artificial saliva (Biotene)
- Sugar free chewing gum or hard candy
- Pilocarpine ophthalmic drops given sublingually
7
Q
Urinary Retention/Confusion/Dizziness/Sedation Treatment Option
A
- Change in therapy
- Dose reduction
8
Q
Sedation + Histamine Antagonism
A
- Associated with rapid tolerance
- Doesn’t usually need specific treatment
- Wait it out
9
Q
Sedation + Anticholinergic
A
- Highly variable between patients and agents
- Trial evening/bedtime dosing
- Alternative agent in medication class
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
11
Q
Sedation + GABA Enhancement
A
- Sedation usually desired effect
- Treatment unnecessary
- Use shorter acting agents to mitigate hangover effect (temazepam, zolpidem)
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
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
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
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
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
