Somatic tx and psychopharm Flashcards
32 y.o. male admitted to a general hospital after ingesting unknown quantity of Phenylzine. After gastric lavage and administration of charcoal slurry, he is transferred to MICU for monitoring. 24 hours later, he begins to see horses running in the hall and pulls out his IV line. Which of the following treatments would be the most important at this time?
Phenelzine is MAOI –irrev blocker of both MAO-A and MAO-B activity. These medications are extremely dangerous in overdose nd after a brief asymptomatic period of 12-24 hrs may produce hyperpyrexia and autonomic excitability –> rhabdo. Supportive care should be instituted. If delirium develops, as seen here, small doses of IV benzo should be used. Lorazepam is preferred because of its short elimination half life.
12 days after his suicide attempt with phenelzine OD, your pt receives Venlafaxine to treat his depression. One hour after ingestion he becomes tachycardia, diaphoretic and develops myoclonic jerks. Which condition did he develop?
Blocking repute of catecholamines and indolamines in patients already using an MAOI can result in potentially life threatening drug interaction known as serotonin syndrome. This includes SSRIs, TCAs, buspirone, and other antidepressants. Mild: triad of mental status changes, autonomic hyperactivity, and neuromuscular abnormalities. Symptoms include tachycardia, flushing, fever, HTN, ocular oscillations and myoclonic jerks. Severe: serious hyperthermia, coma, autonomic instability, convulsions and death. One must wait at least 14 days after D/C MAOI before starting serotonergic agent.
First line tx for major depressive disorder with atypical features
Atypical features respond best to MAOIs such as phenelzine, although these meds are rarely used due to the hypertensive crisis that can occur when eating certain tyramine containing foods. Atypical features include things like weight gain, hypersomnia, and mood receptivity. SSRIs are now first line tx, although major depression doesn’t always respond as well compared with MAOIs.
Which drugs are used in alcohol withdrawal?
Benzodiazepines are DOC for control of alcohol withdrawal sx and ppx against withdrawal seizures and DTs. Long acting, such as chlordiazepoxide and diazepam are appropriate BUT both are extensively metabolized by liver. Lorazepam, Oxazepam, Temazepam (LOT) only undergo glucuronidation prior to elimination and are therefore NOT dependent on liver functioning. These are preferred in patients with compromised liver states, such as alcoholics.
You are taking care of a patient with a history of alcohol dependence admitted for abdominal pain, nausea, and vomiting. He had been having hallucinations prior to you seeing him and now his temperature is 102.1, pulse is 130 bpm, and BP is 220/120. Which medication should you give and which route of administration?
DTs – > transfer to ICU where IV benzos (Lorazepam, oxazepam, or temazepam) can be administered with greater safety. IV route preferred to ensure adequate and rapid absorption.
Major depressive disorder with psychotic features tx
Best practice recommends a combination of antidepressant and an antipsychotic, such as fluoxetine and risperidone.
A 40 y.o. woman with bipolar disorder presents to ER 2 weeks after starting a new medication. She reports she was doing well until she got a viral gastroenteritis and was unable to eat for several days. While viral symptoms resolved, she now complains of N/V, ataxia, and tremor. What studies should you order first?
Lithium toxicity – check lithium level. Therapeutic is usually 0.8-1.2 At levels around 1.2, pts experience tremor, nausea, diarrhea, and ataxia, followed by seizures at 1.5-2.0, then acute renal failure requiring dialysis at levels >2.0 with coma and death at levels above 2.5 Because lithium has such a narrow therapeutic index, dehydration – > toxicity.
Management of a patient with akithesia as a side effect of their anti-psychotics
Akithesia is more common in first generation than second-generation. Usually begins 5-60 days after initiation. First, the neuroleptic dose should be reduced as much as possible. If sx continue in the absence of other EPS, start a beta-blocker such as propranolol. Second line would be lorazepam.
Treatment of bipolar II depression
First line: lithium, lamotrigine, or quetiapine. Valproic acid may be reasonable second line choice.
Most likely serious complication of neuroleptic malignant syndrome
Rhabdomyolysis
Long term side effect of thioridazine
Retinal pigmentation if used in high doses (>1000 mg/d) that may not remit when thioridazine is discontinued and can eventually lead to blindness.
Potency of benzos from most to least potent
Clonazepam > alprazolam > lorazepam > diazepam > oxazepam > chlordiazepoxide.
Tx of Tourette d/o
D2 receptor untag with haloperidol provides greatest sx relief. Clonidine, alpha-2 agonist, is preferable in tx of MILD touter’s as it does not have same long term side effects as antipsychotics.
Tx of tardive dyskinesia
Clozapine
One of the more serious risk of SSRI exposure during pregnancy
Persistent pulmonary HTN of newborn –newborns devo rep failure due to postnatal persistence of elevated pulmonary vascular resistance.
Common sx after stopping SSRI
Flu like – dizziness, N/V, fatigue, lethargy. Anxiety, irritability, and crying spells are not unusual.
A 20 y.o. woman is started on lamotrigine for bipolar depression. Two months later, she comes back reporting that her sx are unchanged despite being compliant. You’ double check her med list and discover she was recently started on new meds. Which med is most likely responsible for lack of efficacy?
OCPs. Valproic acid, on the other hand, decreases lamotrigine clearance, increasing its level in the blood.
MOA of trazodone
Antidepressant that affects serotonin system by weak repute inhibition and antagonist activity at 5-HT1a, 5-HT1c, and 5-HT2 receptors. It has a sedative effect, produced by alpha-adrenergic blockade and modest histamine blockade.
ECG changes possible in patients taking lithium
In about 30% of patients it can cause changes, most commonly T-wave depression or inversion.
Name medications that decrease lithium clearance
Diuretics (ethacrynic acid, spironolactone, and triamterene); NSAIDs (except ASA and sulindac) and abx metronidazole and tetracycline
First line tx for OCD
Either SSRI or Clomipramine – equally effective but SSRI side effect profile is more favorable. Other TCAs not as effective as clomipramine because they are not as serotonergic (clomipramine is mixed serotonin and NE reuptake inhibitor)
Refractory OCD treatment
If moderate response to SSRI: keep SSRI, add second gen antipsychotic such as risperidone
IF no response to SSRI : switch SSRI or to clomipramine
Explain MOA of the drug used for refractory schizophrenia
CLOZAPINE. Acts at D1, D2, D4, his-1, muscarinic, alpha-1-adrenergic, and serotonin types 5-HT2, 5-HT2c, and %-HT3 receptors. It is more potent antagonist at D4 receptor compared to D2 especially in limbic system.
Of the TCAs, which is more likely to be associated with side effects? Which is less?
More likely is imipramine, a tertiary amine which blocks multiple receptors and therefore has many side effects (esp. orthostatic hypotension due to alpha 1 blocking). Less likely is nortriptyline, a secondary amine.
First line tx for mania
Valproic acid or lithium with or without concurrent antipsychotic agent.
Contraindication to TCA use
Produce several cardiovascular side effects – most significant being quinidine like effect slowing cardiac conduction. In OD, they can widen QRS complex, cause bundle branch block, and cause tachyarrhythmias. Even at therapeutic doses they can have AE on cardiac conduction.
Drug frequently used to help control agitation that may accompany delirium?
Low dose haloperidol. It does not treat the delirium but it is the most potent of typical antipsychotics, requiring lower doses with fewer anticholinergic or orthostatic side effects. Lorazepam would maybe help sedate but would not help psychosis and could cause disinhibition and worsening of delirium.
Which antipsychotic is often giving to patients in delirium that minimizes risk of falling?
Haloperidol is most ppotent and has least activity at alpha 1 receptors. Therefore, it is the least likely to cause orthostatic hypotension.
2 drugs that can be used to reduce alcohol cravings
Acamprosate (GABA-ergic agonist) and naltrexone, opioid antagonist
Drug class used to treat PTSD
SSRI
Which drug is commonly used to treat the nightmares seen in PTSD?
Prazosin, an alpha 1 adrenergic receptor blocker
Alzheimer’s tx rarely used due to risk of hepatic failure
Tacrine
NDMA receptor antagonist used to treat Alzheimer’s
Memantine
A 25 y.o. man brought into ED lethargic and stuporous. Her responds only to painful stimuli, wakes up briefly and yells, then goes back o sleep. Ambulance personnel report that they found him near a house known for drug trafficking. There is no evidence of physical injury. Which medications should he receive first?
Pts who present with severely altered LOC need to be medically evaluated and quickly treated for reversible causes. These include hypoglycemia, opioid OD, and alcohol intoxication. Airway protection and monitoring of air exchange and CV status are required. Use IV dextrose, usually D50, to treat hypoglycemia; thiamine to guard against devo of Wernicke’s encephalopathy, and naloxone to reverse effects of opioid intox.
Med used for opioid detox
Buprenorphine
Drug used in treatment of both major depression and pain
Duloxetine, an SNRI. Several TCAs also used but they are more lethal in OD than newer meds and generally have more side effects, especially anticholinergic and cardiovascular ones.
Most common side effect of olanzapine
Weight gain –useful in both psychotic disorders and bipolar disorders.
MOA of Risperidone
2nd gen antipsychotic with potent 5-HT2a antagonist properties as well as blocking at D2 and alpha-1 receptors. Because of alpha 1 blocking, it may cause orthostatic hypotension.
If patient with bulimia fails several SSRI treatments, what should you try next?
Topiramate.
Antipsychotic most liekly to cause hyperglycemia – > diabetes
Clozapine. Also has the most significant effect on cholesterol
Which drug used to treat bipolar disorder increases risk for pancreatitis
valproic acid
High potency typical antipsychotics
Trifluoperazine
Fluphenazine
Haloperidol
Neurologic side effects (EPS) due to the strong blockade of dopaminergic neurons – > excess cholinergic influence, causing EPS.
Low potency antipsychotics (typical)
Chlorpromazine
Thioridazine
Non-neurologic side effects (anticholinergic, antihistamine, and alpha 1 blockade)
Evolution of EPS side effects and tx
4 hours acute dystonia (tx with diphenhydramine, benztropine)
4 day akathisia (tx with propranolol)
4 wk bradykinesia
4 mo tardive dyskinesia (tx with clozapine)
4 AE of clozapine
Agranulocytosis
Sz
Myocarditis
Metabolic syndrome
Which antipsychotic can treat psychosis due to Parkinson treatment?
Quetiapine
Which antipsychotic can prolong the QT interval?
Ziprasidone
Which 2 antipsychotics are associated with significant weight gain
Olanzapine/clozapine
DOC for chorea seen in huntington’s
Tetrabenazine. 2nd generation atypical antipsychotics also work.
3 types of medications that can cause focal dystonia
Typical antipsychotics
Metoclopramide
Prochlorperazine
First line tx for specific phobia
Cognitive behavioral therapy
MOA of buspirone and benefit vs. barbiturates and benzos
Stimulates 5-HT1A receptors and does not interact with alcohol.
Which anti-depressant is also indicated for diabetic peripheral neuropathy?
Duloxetine, which has greater effect n NE. It is an SNRI.
Which TCA has a higher seizure threshold?
Desipramine
Which anti-depressant is also used in smoking cessation?
Buproprion. Increases NE and dopamine via unknown mechanism.
What is the MOA of Mirtazapine?
Alpha-2 antagonist (increases release of NE and serotonin ) and potent 5-HT2 and 5-HT3 receptor antagonist.
What is MOA of Maprotiline?
Blocks NE reuptake.
What is MOA of trazodone and primary indication?
Inhibits serotonin reuptake. Used primarily for insomnia as high doses are needed for antidepressant effects.
Risk for bipolar disorder in first degree family member (son, daughter, etc.) and risk in identical twins
First degree family member: 10%
Identical twin: 80-90%
What’s a major medical cause to look for in a 75 y.o. patient that presents for the first time with mania?
Right frontal hemisphere stroke (right MCA)
Pain medications to be used in patients on lithium
Aspirin
Sulindac (Clinoril)
EKG findings and tx for lithium toxicity
Looks like hypokalemia. You’ll see t-wave flattening or inversion as well as U waves. Treatment with fluid resuscitation. Do emergent dialysis if lithium>4 or if patient has kidney disease.
Lithium: MOA, side effects, therapeutic levels
MOA: suppresses inosital triphosphate
SE: weight gain and acne, GI irritation, cramps
Therapeutic levels: 0.6-1.2
What kind of medical monitoring should you do for patients on lithium?
Li level every 4-8 weeks.
TFTs every 6 mos (lithium can cause hypothyroidism)
Cr, UA, CBC, EKG
Contraindications to lithium use
Severe renal disease (processed by kidneys therefore decreased clearance increases chances for toxicity) MI Diuretics or digoxin Myasthenia gravis Pregnancy/breastfeeding
Preferred tx for bipolar disorder in pregnant pts
Clonazepam, especially in 1st trimester.
If a patient is bipolar and has elevated LFTs and hepatitis – > what med are they probably taking?
Valproic acid. Also causes N/V/D, skin rash.
If a patient is bipolar and has Steven’s Johnson syndrome, what med are they probably taking?
Lamotrigine. Less likely – > carbamazepine
If a patient is bipolar and has agranulocytosis, what med are they taking?
If ANC<1000 –tx?
Carbamazepine. Should check CBC regularly!
If ANC <1000, d/c carbamazepine.
If a patient is bipolar and has increased AFP at 20 weeks gestation, what med could have caused this?
Valproate OR carbamazepine – both lead to NTD. Remember a reproductive age female should be taking 4 g of folic acid daily.
Therapeutic levels of valproate
6-12
Therapeutic levels of carbamazepine
60-120
Medications that might cause depression
IFN, beta blockers, a-methyldopa, L-dopa, OCPs, ETOH, cocaine/amph withdrawal, opiates
Medical disease that might cause depression
HIV, Lyme, Hypothyroidism, Porphyria, Uremia, Cushings dz, Liver dz, Huntingtons, MS, Lupus, L-MCA stroe
Best treatment for atypical depression
MAOIs
Which SSRI has most drug-drug interactions? Least?
Most: paroxetine (prozac)
Least: citalopram (celexa)
Which SSRI does not have to be tapered when stopped?
Fluoxetine – shortest half life.
SSRI-discontinuation syndrome and 2 drugs most commonly associated
HA, N/V/D, dizziness, and fatigue. Most common with sertraline and fluvoxamine
Buproprion MOA and contraindications
DA and NE reuptake inhibiror. contraindications in bulemics, alcoholics, and epilepics since it lowers seizure threshold.
Treatment for hypertensive crisis 2/2 MAOIs and cheese eating
5 mg IV phentolamine, alpha blocker.
EKG findings on TCA overdose? Tx?
EKG: widened QRS complexes and prolonged QT interval.
Tx: activated charcoal if ingestion within 1-2 hours. Give IV sodium bicarb (helps metabolic acidosis and cardioprotective)
Which atypical antipsychotic has highest risk for EPS and increased prolactin?
Risperidone
Which atypical antipsychotic is weight neutral but prolongs QTc?
Ziprasidone
Which atypical antipsychotic is weight neutral but increases akathisia?
Aripiprazole
Which atypical antipsychotic causes orthostasis and cataracts?
Quetiapine 2/2 alpha blocking properties.
Drug regimen of choice for patients with panic disorder
Alprazolam or clonazepam low dose PRN short term with SSRIs being preferred drug. Don’t give benzos to drug addicts, copiers, or restrictive lung disease!*
Sx of benzo withdrawal and treatment.
Fever, convulsions, confusion, and HTN. Similar to DTs! Tx with diazepam or chlordiazepoxide plus haloperidol if psychotic
Best tx for patients with specific phobia
CBT with flooding or exposure/extinction. Can give benzos for situational use.
Best tx for patients with avoidant personality disorder
CBT
Best tx for GAD
Buspirone (5HT 1a partial agonist) but give benzos to bridge because it takes >3 weeks to work.
Gold standard and first line for OCD
Gold standard: clomipramine
First line: SSRIs
Tx for MDD with psychotic features
Atypical antipsychotic + SSRI or ECT (esp if pregnant)
MOA of haloperidol
D2 receptor antagonist at mesolimbic tract –> helps positive symptoms but causes hyperprolactinemia and EPS.
Which antipsychotic causes purple-grey metallic rash over sun exposed areas and jaundice?
Chlorpromazine
Which antipsychotic causes prolonged QTc and pigmentary retinopathy?
Thioridazine
Tx for patient with schizophreniaa and coarse resting tremor, masked facies, unsteady gait, bradykinesia.
Benztropine/diphenhydramine.
Second line: amantidine, bromocriptine.
NEVER GIVE L-DOPA.
Medications that can cause NMS
Metoclopramide, compazine, droperidol
Fluctuation in consciousness, visual hallucinations, and shuffling gait. Path shows intra-cytoplasmic alpha synuclein inclusions in neocortex. Tx?
Lewi body dementia – give ACH-Ease inhibitors.
Frontotemporal dementia/Picks disease or if path shows lobar atrophy, intra-neuronal silver staining inclusions. Tx?
Olanzapine for severe disinhibiton.
Tx for opiate withdrawal
Tx the symptoms.
Clonidine for aututonomic sx
Ibuprofen for muslce cramps
Loperimide for diarrhea.
MOA and SE of Methylphenidate (Concerta, Ritalin)
Blocks DA reuptake.
SE: Nausea, decreased appetite, increased HR and BP, stunted growth
MOA and SE of Amphetamine (Adderall)
Blocks DA/NE reuptake and stimulates release
SE: nausea, decreased appetite, increased HR and BP, stunted growth
MOA and SE of ATomoxetine (Strattera)
NE reuptake inhibitor. Non-stimulant.
AE: Dry mouth, insomnia, decreased appetite
MOA and SE of clonidine, guanfacine
Alpha 2 agonists
AE: decreased BP. causes sedation.
