Therapeutics Flashcards
Precautions to using antipsychotics
- Active CD (esp QTC prolongation)
- Parkinson’s disease
- Epilepsy
- Depression
- Myasthenia gravis
- BPH
- Angle closure glaucoma
- Severe respiratory disease
- History of jaundice
- Blood dyscrasia
- Elderly with dementia
Treatment for acute agitation/psychosis
Cooperative:
- PO lorazepam 1-2 mg
- PO antipsychotics (haloperidol 2-5 mg, risperidone 1-2 mg, quetiapine 50-100 mg, olanzapine 5-10 mg)
- Inhaled loxapine 100 mg with standby salbutamol
Uncooperative:
- PO lorazepam 1-2 mg
- IM olanzapine 5-10 mg (not within 1 hour of giving lorazepam)
- IM Aripiprazole 9.75 mg
- IM haloperidol 2.5-10 mg
- IM promethazine 25-50 mg
- IM lorazepam + haloperidol
- IM haloperidol + promethazine
Treatment for acute catatonia in schizophrenia
PO/IM lorazepam
Management of dystonia from antipsychotics
- Associated with high potency antipsychotics, treatment-naive patients, young males
- Treat with IM anticholinergics (benztropine, diphenhydramine)
Management of pseudo-parkinsonism
- Assessed using Simpsons-Angus rating scale
- Associated with elderly females and those with CNS damages
- Reduce dose or switch to SGA
- Use anticholinergics PRN (benzhexol, benztropine)
Management of akathisia
- Due to high potency antipsychotics (risperidone > olanzapine > quetiapine/clozapine)
- Reduce dose or switch to SGA
- Use clonazepam PRN low dose
- Use propanolol 20 mg TDS (max 160 mg/day)
- Anticholinergics are ineffective
Management of tardive dyskinesia
- Associated with FGA > SGA
- Worsened by anticholinergics
- Discontinue any anticholinergics
- Reduce dose or switch to SGA
- Consider using clozapine
- Valbenazine 40-80 mg/day (vesicular monoamine transporter 2 inhibitor)
- Use clonazepam PRN
Management of hyperprolactinemia
- FGA > risperidone > SGA
- Reduce dose
- Use dopamine agonist (amantadine, bromocriptine)
- Switch to aripiprazole
Antipsychotics associated with orthostasis
High: chlorpromazine, clozapine
Low: olanzapine, ziprasidone, aripiprazole, sulpiride
Antipsychotics associated with qtc prolongation
- High doses of antipsychotics
- IV haloperidol
- Concomitant hypokalemia
High: chlorpromazine, clozapine, ziprasidone
Low: risperidone, olanzapine
Antipsychotics associated with VTE
Low potency FGA
Antipsychotics associated with sedation
High: chlorpromazine, clozapine
Low: risperidone, ziprasidone, aripiprazole
Management of seizures due to antipsychotics
High: chlorpromazine, clozapine
Low: risperidone, ziprasidone, aripiprazole
- Use high potency antipsychotics e.g. haloperidol
Management of neuroleptic malignant syndrome
- Associated with high potency antipsychotics
- Use IV dantrolene 50 mg TDS
- Use PO dopamine agonists (amantadine, bromocriptine)
- Switch to SGA
Antipsychotics associated with psychogenic polydipsia & temperature dysregulation
Anticholinergics
Antipsychotics associated with hepatotoxicity
High: chlorpromazine, other FGAs
Intermediate: olanzapine, quetiapine
Low: other SGAs
Antipsychotics associated with ophthalmic changes
Phenothiazines, quetiapine
Antipsychotics associated with derm disorders
Phenothiazines
Antipsychotics associated with agranulocytosis
- Clozapine
- Discontinue if WBC < 3 or ANC < 1.5
Monitoring parameters for antipsychotics
- BMI for weight (monthly x 6 months f/b q3 monthly)
- Waist circumference (every visit x 6 months f/b annual)
- FBG/HbA1c (high risk: 3 months after starting SGA, f/b annual)
- Lipid panel (baseline)
- Prolactin (baseline)
- BP (3 months after initiation of SGA, f/b annual)
- EPS exam (weekly for 2 weeks after initiation, f/b q3 months for FGA, 6 months for SGA)
- WBC & ANC for clozapine (weekly for 18 weeks, f/b monthly)
- ECG for ziprasidone (repeat if s/s of qtc prolongation e.g. syncope)
Etiological factors for MDD
- Biological (increased cortisol, monoamine deficiency)
- Psychological
- Psychosocial
- Genetics
- Medical conditions
- Drug-induced
Medical conditions associated with depression
- Endocrine (hypothyroidism, Cushing’s syndrome, bidirectional with DM)
- Deficiency states (anemia, wernicke’s encephalopathy)
- Infections (CNS, STD/HIV, TB)
- Metabolic (electrolyte imbalance, hepatic encephalopathy)
- CV (CAD, HF, MI)
- Neuro (Alzheimer’s , epilepsy, pain, Parkinson’s, post-stroke)
- Malignancy
Psychiatric conditions associated with MDD
- Alcoholism
- Anxiety
- Eating disorders
- Schizophrenia
Drugs that can induce MDD
- Lipid-soluble beta blockers
- Psychotropics (CNS depressants, ASM, tetrabenazine)
- Withdrawal from alcohol, stimulants
- Systemic glucocorticoids
- Isotretinoin
- Interferon beta-1a
DSM-5 diagnostic criteria for MDD
- Interest
- Sleep
- Appetite
- Depressed mood
- Concentration
- Activity (psychomotor retardation, agitation)
- Guilt
- Energy
- Suicidal
- At least 5 symptoms present for the same 2 week period
- Symptoms must have caused significant functional impairment
- Symptoms not caused by medical conditions or substance
Antidepressants indicated for OCD
- Clomipramine
- Fluoxetine
- Fluvoxamine
- Paroxetine
- Sertraline
Antidepressants indicated for eating disorder
Fluoxetine (bulimia)
Antidepressants indicated for pain
- Amitriptyline (neuropathy, migraine)
- Nortriptyline (neuropathy)
- Duloxetine (diabetic neuropathy, fibromyalgia, MSK pain)
Medical conditions associated with anxiety
- Cardiovascular (arrhythmias, HF, IHD)
- Endocrine (hyperthyroidism. Cushing’s syndrome, hyperkalemia, hyponatremia, hypoglycemia)
- Neurologic (dementia, delirium, parkinson’s, seizures, pain)
- Pulmonary (asthma, COPD)
- Others (anemia, SLE, vestibular dysfunction)
Drugs that can precipitate anxiety
- Sympathomimetics (pseudoephedrine)
- Stimulants
- Methyxanthines (theophylline, caffeine)
- Thyroid hormone (levothyroxine)
- Systemic steroids
- Antidepressants (SSRI, TCA during initiation & dose escalation)
- Dopamine agonists (levodopa)
- beta agonist (salbutamol)
- Antihypertensive (felodipine)
- Anticonvulsants (carbamazepine)
- Antibiotics (quinolones, isoniazid)
- NSAIDs
- Drug withdrawal
- Drug intoxication (anticholinergics, antihistamines, digoxin)
- Akathisia from antipsychotics
Benzodiazepines & Z-hypnotics should not be used in?
- Acute narrow angle glaucoma
- Acute pulmonary insufficiency, respiratory depression
- Neuromuscular weakness e.g. myastheniania gravis
Sedating antihistamines should not be used in?
- Prostatic hypertrophy
- Urinary retention
- Angle closure glaucoma
- Pyloroduodenal obstruction
- Epilepsy
- QC prolongation (hydroxyzine)
- Coronary artery disease (promethazine)
Lemborexant should not be used in?
- Narcolepsy
- Moderate-strong 3A inhibitors/inducers
- Severe hepatic impairment
Precautions for benzodiazepines
- Renal/hepatic impairment
- Pregnancy / breastfeeding
- History of substance abuse or psychiatric disorders e.g. psychosis
- Prolonged useage
- Undergoing ECT
- Patients taking opioids
Drugs that can contribute to BPSD in dementia
- Anticholinergics
- Anticonvulsants
- Systemic steroids
- Sedatives
- Anti-Parkinsonian drugs
Mood stabilisers for pregnant patients
- SGA (quetiapine, olanzapine, risperidone) but monitor for gestational diabetes
- FGA (generally not teratogenic)
- ECT for severe mania
Mood stabiliser for patients with cardiac disease
Valproate (monitor BP, HR, peripheral edema)
Mood stabiliser for liver impairment
Lithium
Mood stabiliser for renal impairment
Valproate
Mood stabiliser for children & adolescents
Lithium, valproate
Mood stabilisers for elderly
- Avoid renally excreted drugs
- Avoid carbamazepine (hyponatremia)
- Consider lamotrigine
Mood stabiliser for aggression or violence
- Optimise existing lithium or valproate
- Consider adding antipsychotics
Antidepressants in obese patients
Consider bupropion, SSRI (except paroxetine), SNRI
Avoid mirtazapine, TCA, MAOI
Antidepressants in CVD patients
Consider sertraline
Avoid TCA, escitalopram
Antidepressants in cerebrovascular events
Consider SSRI (fluoxetine)
Antidepressants in DM
Avoid TCAs
Antidepressants in renal insufficiency
Avoid duloxetine
Use paroxetine, vortioxetine with caution
Antidepressants in hepatic insufficiency
Avoid agomelatine, duloxetine
Use paroxetine, escitalopram with caution
Antidepressants in hypertension
Avoid TCA, SNRI
Antidepressants in pregnancy
Avoid paroxetine, bupropion
Consider nortriptyline in late stage pregnancy
Antidepressants in breastfeeding
Consider sertraline, mirtazapine
Antidepressants in postpartum depression
Consider brexanolone
Antidepressants safer for hyponatremia
Agomelatine, mirtazapine, bupropion
Antidepressant safest for bleeding risk
Agomelatine
Antidepressants associated with discontinuation syndrome
Worst: paroxetine, venlafaxine
Safest: fluoxetine, bupropion
Antipsychotics for pregnancy
Olanzapine, clozapine
Antipsychotics for breastfeeding
Olanzapine, quetiapine
Clozapine to not breastfeed
Antipsychotics for renal impairment
PO aripiprazole
Avoid sulpiride, amisulpride
Antipsychotics for hepatic impairment
Sulpiride, amisulpride
Hoehn and Yahr staging
1: Unilateral symptoms
2: Bilateral symptoms
3: Postural instability
4: Severe disability
5: Bedridden
Non-motor symptoms of PD
Cognitive: dementia
Psychiatric: depression, psychosis
Sleep: REM sleep behavioural disorder
Autonomic: N/C, orthostasis, sialorrhea
Fatigue
Medications causing parkinsonism
High:
D2 antagonist (antipsychotics)
Dopamine depleters (tetrabenazine, reserpine)
Dopamine synthesis inhibitors (a-methyldopa)
P-calcium channel antagonists (flunarizine, cinnarizine)
Moderate:
Ziprasidone
Antiemetic agents
L-calcium channel antagonists
Antiepileptics (phenytoin, valproate, levetiracetam)
Lithium
Low:
Antiarrhythmics (amiodarone, procaine)
Immunosuppressants (cyclosporin, tacrolimus)
Antidepressants (MAOi, TCA, SSRI)
Antibacterials (bactrim)
Antivirals (anti-HIV, acyclovir)
Statins
Amphotericin B
Levothyroxine, methdroxyprogesterone, epinephrine
Drugs to treat drug-induced parkinsonism
Anticholinergics
Amantadine
Medications indicated for GAD
Escitalopram
Paroxetine
Venfalaxine XR
Duloxetine
Alprazolam
Diazepam
Lorazepam
Hydroxyzine
Pregabalin
Medications indicated for PD
Fluoxetine
Paroxetine
Sertraline
Venlafaxine XR
Alprazolam
Clonazepam
Medications indicated for SAD
Fluvoxamine
Paroxetine
Sertraline
Venlafaxine XR
Medications indicated for OCD
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
Clomipramine
Medications for PTSD
1st line: CBT
Paroxetine
Sertraline
