- Secondary undesired effect from a medication - Known/ expected to occur - Usually mild in nature

- Undesired and unexpected - Often due to an unrecognized drug-drug interaction

- A side effect usually viewed as beneficial - Often previously undescribed or unexpected

- Usually self limiting - Increase dietary fiber

Side Effect Mitigation- Dr. Campbell Flashcards by Madison Denny

Side effect

Secondary undesired effect from a medication
Known/ expected to occur
Usually mild in nature

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Adverse effect

Undesired and unexpected

- Often due to an unrecognized drug-drug interaction

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Pleotropic effect

A side effect usually viewed as beneficial

- Often previously undescribed or unexpected

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Nausea & Vomiting Mechanism

Altered GI transition time
Often due to increased serotonergic tone
Decreased dopaminergic/ cholinergic tone

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Nausea & Vomiting worst offenders

SSRIs
SNRIs
MAOIs
Cariprazone
Aripiprazole

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Nausea & Vomiting solution

Split into smaller doses
Take with food
Change agent if unrelenting

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Diarrhea mechanism of action

-Increased GI serotonin

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Diarrhea worst offenders

Sertraline
SSRIs
SNRIs
Lithium

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Diarrhea solution

Usually self limiting

- Increase dietary fiber

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Constipation mechanism

-Anticholinergic effect

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Constipation worst offenders

TCAs
Dozapine
Paroxetine
Stimulants

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Constipation Solution

Increase fluid intake
Increase physical activity
Stimulant + Osmotic laxative
ex. Osmotic= PEG
ex. Stimulants= senna, bisacodyl

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Anticholinergic side effects

Can’t

See
Pee
Spit
Shit

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Two mechanisms of Anticholinergic side effects

1) Inhibition of the PNS (more common)
ex. TCAs, Paroxetine
2) Activation of SNS (less common)
ex. SNRIs, stimulants

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Sedation: Histamine antagonism

Associated with rapid tolerance
Usually does not require any specific treatment
Wait it out

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Sedation: Anticholinergic

Highly variable

- Try bed time dosing

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Sedation: 5HT2A antagonism

Effect seems to be related to peak concentration

- Try bed time dosing

Sedation: Enhancement of GABA

Sedation is the desired effect
Treatment is unnecessary
Try using a shorter acting agent to avoid “Hang over” effect
Temazepam > Zolpidem

4 mechanisms that can lead to sedation

H1 antagonism
5HT2A
Anticholinergics
GABA upregulation

What is the mechanism behind orthostatic hypotension

Alpha 1 antagonism
20mmHg drop in systolic
10mmHg drop in diastolic

Biggest offenders for orthostatic hypotension

Clozapine
Quetiapine
Prazosin
TCAs

QT interval prolongation

MONITOR ECG
taper off offending agent
If TdP developes immediately defibrillate

Loss of libido or Anorgasmia

Change to agent with lower potential
Mirtazapine
Nefazodone
Bupropion

Erectile dysfunction

PDE5is are prefered agent

- Use same dose as used for ED

Withdrawal effects: Serotonergic agents

- Flu like symptoms - Agitation - Anxiety - Insomnia - Paresthesia - ETC - Diarrhea

Withdrawal effects: Benzos & Barbiturates

- Anxiety - Imparied concentration - Hallucinations - Psychosis - Seizures

Withdrawal effects: Stimulants

- Depressed mood - Anxiety - Hypersomnolence - Hyperphagia

Serotonin Syndrome

- Rare outside of overdose situation - Due to overactivation of serotonin synaptic transmission - Altered mental status - Neuromuscular hyperactivity - Autonomic hyperactivity

Treatment of serotonin syndrome

- Stop causative agent - Supportive therapy - Benzos - Avoid physical restraints - Cyproheptadine - Atypical antipsychotics??

Neuroleptic Malignant Syndrome (NMS)

- Similar presentation as serotonin syndrome - Hyporeflexia (lead pipe) Rigidity - Most commonly due to high potency FGAs

Neuroleptic Malignant Syndrome (NMS) treatment

- Bromocriptine: dopamine agonist - Dantrolene: muscle relaxer - Sodium bicarbonate and IV hydration - Benzos: to minimize agitation

Antidepressants and suicidality

- slight increase in suicidal thoughts - Do NOT increase rates of suicide - Benefits of therapy out weigh the risks

Death related to antipsychotic use

- Increase in death in elderly with dementia - Due to increased MI and stroke risk - More common with FGAs than SGAs - Campbell likes VALPROIC ACID best - Aripiprazole, quetiapine, and olanzapine are lower risk too

Priapism

- Trazodone is the biggest offender | - Requires emergency phenylephrine

Ways to treat tremor

-Primidone may be an option

Side effects found with Lithium

- Polyurea/polydyspia - Tremor - Diarrhea - Thyroid abnormalities - Nephrotoxicity

Side effects found with Valproic acid

- Fatigue - Dizziness - Tremor - N/V - Thrombocytopenia - Weight gain - Pancreatitis - Hepatitis

Side effects found with Antipsychotics

- Pseurdoparkinsonism - Akathisia - Hyperprolactinemia - Cardiometabolic - Sedation - Constipation

Tardive Dyskinesia

- Can occur after weeks or even years of antipsychotic therapy - Jerky, rigid, uncontrollable movements - Due to chronic D2 and D3 antagonism - Slowly withdrawal the offending antipsychotic agent = best treatment

VMAT 2 inhibitors

- FDA approved for Tardive Dyskinesia - Sequesters dopamine in the presynaptic nerve ending - Leads to depletion of dopamine - Overall little benefit to TD and high risk of inducing depressive symptoms

Examples of VMAT 2 inhibitors

- Dutertrabenazine (Austedo) | - Valbenazine (Ingrezza)