Treatments Flashcards
Treatment for ADHD, side effects?
CNS stimulants (eg, methylphenidate, dextroamphetamine, amphetamine salts [dextroamphetamine and amphetamine combo]). ■ Adverse effects: Weight loss (↓ appetite), insomnia, anxiety, irritability, headache, tic exacerbation, and ↓ growth velocity (normalizes when medication is stopped). ■ Alternatives: Nonstimulants. ■ Atomoxetine (norepinephrine reuptake inhibitor): Can be tried first because of the negative side-effect profile of CNS stimulants.
Treatment for Autism spectrum disorders
Intensive special education, behavioral management, and symptomtargeted medications
Treatment for intellectual development disorders
Family counseling and support; speech and language therapy; occupational/physical therapy; behavioral intervention; educational assistance; and social skills training.
Treatment for Tourette syndrome
Antidopaminergic agents: ■ Dopamine-depleting agents (eg, tetrabenazine [VMAT-2 inhibitor; results in ↓ uptake of monoamines]): Preferred over dopamineblocking agents; does not cause tardive dyskinesia (TD). ■ Dopamine-blocking agents: Antipsychotics (eg, fluphenazine, risperidone, haloperidol, pimozide). ■ Severe, refractory tics: Treat with haloperidol or pimozide (typical antipsychotics). ■ α2-agonists (eg, clonidine, guanfacine): Less effective at tic reduction; more favorable side-effect profile.
What is EPS? Evolution of EPS?
Side effects of Dopamine blocking agents, like haloperidol.
4 hours: Acute dystonia 4 days: Akinesia 4 weeks: Akathisia 4 months: Tardive dyskinesia (often permanent)
Treatment for schizophrenia
■ Antipsychotics (see Table 2.14-2); long-term follow-up. ■ Supportive psychotherapy, training in social skills, vocational rehabilitation, and illness education may help. ■ Negative symptoms may be more difficult to treat than positive symptoms; atypical antipsychotics are the drug of choice.
Fluphenazine
High potency typical antipsychotics
D2 antagonist
Psychotic disorders, acute agitation, acute mania, Tourette syndrome Thought to be more effective for positive symptoms of schizophrenia If compliance is a major issue, consider antipsychotics available in long-acting depot form
Extrapyramidal symptoms (EPS) > anticholinergic symptoms (dry mouth, urinary retention, constipation)
QTc prolongation and torsades, especially IV haloperidol Neuroleptic malignant syndrome
Chlorpromazine
Low potency typical antipsychotics
D2 antagonist
Psychotic disorders, acute agitation, acute mania, Tourette syndrome
Thought to be more effective for positive symptoms of schizophrenia
If compliance is a major issue, consider antipsychotics available in long-acting depot forma
Anticholinergic > EPS
More sedating Greater risk for orthostatic hypotension
Thioridazine causes dose-dependent QTc prolongation and irreversible retinal pigmentation
Thioridazine
Low potency typical antipsychotics
D2 antagonist
Psychotic disorders, acute agitation, acute mania, Tourette syndrome
Thought to be more effective for positive symptoms of schizophrenia
If compliance is a major issue, consider antipsychotics available in long-acting depot forma
Anticholinergic > EPS More sedating Greater risk for orthostatic hypotension Thioridazine causes dose-dependent QTc prolongation and irreversible retinal pigmentation
Haloperidol
High potency typical antipsychotics
D2 antagonist
Psychotic disorders, acute agitation, acute mania, Tourette syndrome Thought to be more effective for positive symptoms of schizophrenia If compliance is a major issue, consider antipsychotics available in long-acting depot form
Extrapyramidal symptoms (EPS) > anticholinergic symptoms (dry mouth, urinary retention, constipation)
QTc prolongation and torsades, especially IV haloperidol Neuroleptic malignant syndrome
Risperidonea, quetiapine, olanzapinea, paliperidonea, ziprasidone, clozapine
Atypical antipsychotic
D2 antagonist/ 5HT 2a antagonist
First-line treatment for schizophrenia given fewer EPS and anticholinergic effects
Clozapine is reserved for severe treatment resistance and severe tardive dyskinesia
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↓ EPS (d/t 5-HT2A antagonism) Weight gain, dyslipidemia, type 2 diabetes mellitus, somnolence, sedation, and QTc prolongation (ziprasidone), hyperprolactinemia (risperidone) Clozapine can cause agranulocytosis; requires weekly CBC monitoring during first 6 months
acute dystonia? Tx?
Prolonged, painful tonic muscle contraction or spasm (eg, torticollis, oculogyric crisis)
Anticholinergics (benztropine or diphenhydramine) for acute therapy; patients who are prone to dystonic reactions
Akathisia? Tx?
Subjective/objective restlessness
β-blockers (propranolol)
Dyskinesia? Tx?
Pseudoparkinsonism (eg, shuffling gait, cogwheel rigidity)
Anticholinergics (benztropine) or dopamine agonist (amantadine)
Tardive dyskinesia? Tx?
Stereotypic, involuntary, painless oral-facial movements Probably from dopamine receptor sensitization from chronic dopamine blockade Often irreversible (50%)
consider changing neuroleptic (eg, to clozapine or risperidone) Giving anticholinergics or ↓ neuroleptic dose may initially worsen tardive dyskinesia
Neuroleptic malignant syndrome? tx?
Fever, muscle rigidity, autonomic instability, elevated creatine kinase and white blood cells, delirium
dantrolene or bromocriptine
Treatment for GAD?
Selective serotonin reuptake inhibitors (SSRIs; eg, fluoxetine, sertraline, escitalopram).
SSRI eg? Uses? Side effects?
fluoxetine, sertraline, paroxetine, citalopram, escitalopram)
GAD, OCD, panic disorder
Nausea, GI upset, somnolence, sexual dysfunction,
Buspirone
5HT partial agonist
Not first-line treatment for GAD, social phobia
No tolerance, dependence, or withdrawal
Propranolol use? Side effects?
Performance only social anxiety disorder
Bradycardia, hypotension
clonazepam, alprazolam class? Uses? Side effects?
Anxiety (short-term), insomnia, alcohol withdrawal, muscle spasm, night terrors, sleepwalking
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risk for abuse, tolerance, and dependence; Abruptly stopping a short-acting benzodiazepine (eg, alprazolam) can result in seizures
Alternative to for GAD??
Serotonin norepinephrine reuptake inhibitors (SNRIs; eg, venlafaxine, duloxetine), buspirone, tricyclic antidepressants (TCAs), benzodiazepines (short-term treatment).
To for panic disorder?
Best initial treatment: Benzodiazepines (eg, clonazepam).
Long-term treatment: SSRIs (eg, sertraline). ■ Psychotherapy: Cognitive behavioral therapy (CBT);
Phobias tx?
CBT, involving desensitization through incremental exposure ■ Best initial treatment: SSRIs. Alternatives include benzodiazepines with exposure techniques. ■ Social anxiety disorder, performance only: First-line treatment with β– blockers (eg, propranolol). Alternatives include CBT, benzodiazepines, and/or SSRIs. ■ Specific phobias: First-line treatment is CBT. Alternatives include SSRIs, benzodiazepines.
OCD tx?
Best initial treatment: SSRIs (high-dose). ■ Alternative: Clomipramine (TCA). ■ CBT using exposure and desensitization relaxation techniques.
PTSD tx?
Best initial treatment: Trauma-focused CBT, with or without pharmacotherapy. ■ Pharmacotherapy: SSRIs, SNRIs. ■ Prazosin (α1-blocker) is used to treat PTSD-related nightmares.
Tx for Alzheimer’s
Best initial treatment: Cholinesterase inhibitors (donepezil, rivastigmine, galantamine). ■ Moderate/severe Alzheimer dementia (AD): Add memantine (N-methylD-aspartate [NMDA] antagonist). ■ Aggression/psychosis: Low-dose antipsychotics (use with caution in elderly; black box warning for increased mortality).
Tx for delirium
Treat underlying causes (delirium is often reversible). ■ Normalize fluids and electrolytes. ■ Optimize the sensory environment, and provide necessary visual and hearing aids. ■ Use low-dose antipsychotics (eg, haloperidol) for agitation and psychotic symptoms.
TCA toxicity?
Convulsions Coma Cardiac arrhythmias
Tx for MDD
Pharmacotherapy: Best initial treatment is with an SSRI (eg, fluoxetine, sertraline, paroxetine, citalopram, escitalopram). ■ Allow 2–6 weeks to take effect; adjust dose as needed. ■ Continue for at least 6 months (at the same effective dose) beyond the time of achieving full remission.
+psychotherapy
SSRI examples? Indications? Side effects?
Fluoxetine, sertraline, paroxetine, citalopram, escitalopram, fluvoxamine
Depression and anxiety
Sexual side effects, GI distress, agitation, insomnia, tremor, diarrhea Serotonin syndrome (fever, myoclonus, hyperreflexia, altered mental status, cardiovascular collapse) can occur if SSRIs are used with MAOIs, illicit drugs, or herbal medications Paroxetine should be avoided during pregnancy; can cause cardiac defects (first trimester) and pulmonary hypertension (third trimester) in the fetus
Atypical antidepressant e.g.? Side effect?
Bupropion, mirtazapine, trazodone
Bupropion: ↓ Seizure threshold; minimal sexual side effects Contraindicated in patients with eating disorders and seizure disorders Mirtazapine: Weight gain, sedation, minimal sexual side effects Trazodone: Highly sedating; priapism
SNRI eg? Indications? Side effect?
Venlafaxine, duloxetine
Depression, anxiety, neuropathic pain
Noradrenergic side effects at higher doses Venlafaxine: Diastolic hypertension
TCA e.g.? Indication? side effect?
Nortriptyline, desipramine, amitriptyline, imipramine, clomipramine
Depression, anxiety, neuropathic pain, migraine headaches, enuresis (imipramine), OCD (clomipramine)
Antihistaminic effects: Sedation, weight gain Anticholinergic effects: Dry mouth, tachycardia, urinary retention Antiadrenergic effects: Orthostatic hypotension TCA overdose can be lethal and cause convulsions (seizures), coma, cardiotoxicity (prolonged conduction through AV node, prolonged QRS), hyperpyrexia, and respiratory depression Treatment: sodium bicarbonate if prolonged QRS (> 100 msec), hypotensive, or ventricular arrhythmia Alleviates depressant effect of TCA on cardiac fast sodium channels
MAOI e.g. and indications?
Phenelzine, tranylcypromine, selegiline
Depression, especially atypical
ECT? Indications?
produce a generalized seizure under anesthesia. Safe and highly effective treatment option for severe depression. Usually requires 2–3 treatments per week for a total of 6–12 treatments. ■ Indications are as follows: ■ Refractory or treatment-resistant depression. ■ Major depression with psychotic features. ■ Need for rapid improvement: Actively suicidal, refusal to eat/drink, catatonia, pregnancy. ■ Bipolar depression or mania.
Tx for PDD
Psychotherapy is the most effective treatment. ■ Often resistant to treatment. Consider antidepressants (eg, SSRIs) and ECT.
Tx for adjustment disorder
Psychotherapy
Tx for bipolar I and II
Maintenance therapy: Mood stabilizers (see Table 2.14-13). Most patients require lifelong mood stabilizer treatment. ■ Best initial treatment: Lithium. ■ Acute mania: Considered a psychiatric emergency because of impaired judgment and risk for harm to self or others. ■ Mild to moderate mania: Atypical antipsychotics (olanzapine, quetiapine).
Lithium class? Use? Side effects?
First-line mood stabilizer Used for acute mania (in combination with antipsychotics), for prophylaxis in bipolar disorder, and for augmentation in depression treatment Also ↓ suicide risk
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Thirst, polyuria, diabetes insipidus, tremor, weight gain, hypothyroidism, nausea, diarrhea, seizures, teratogenicity (if used in the first trimester, 0.1% risk for Ebstein anomaly), acne, vomiting
Lithium toxicity (blood level > 1.5 mEq/L): Presents with ataxia, dysarthria, delirium, and acute renal failure Contraindicated in patients with ↓ renal function,
Lamotrigine use? Side effect?
Second-line mood stabilizer; anticonvulsant
Stevens-Johnson syndrome. ↑ Dose slowly to monitor for rashes
Carbamazepine
Alternative mood stabilizer; anticonvulsant; trigeminal neuralgia
skin rash, leukopenia, AV block. Teratogenicity (0.5–1% neural tube defect) Rarely, aplastic anemia (monitor CBC biweekly). Stevens-Johnson syndrome
Valproic acid
Bipolar disorder, anticonvulsant
GI side effects (nausea, vomiting), tremor, sedation, alopecia, weight gain, teratogenicity (3–5% risk for neural tube defect) Rarely, pancreatitis, thrombocytopenia, fatal hepatotoxicity, and agranulocytosis Contraindicated in patients with hepatic disease
Tx for severe mania
Mood stabilizer (lithium/valproate) + antipsychotic. ■ Refractory mania: ECT.
Tx for Mania/hypomanic in pregnancy
Mania/hypomania in pregnancy: Antipsychotics; typical antipsychotics (eg, haloperidol) are generally first line and have fewer risks to the developing fetus than mood stabilizers. ■ ECT can be used for severe or refractory mania in pregnancy.
Tx for bipolar depression
Mood stabilizers with or without antidepressants. Start mood stabilizer first to avoid inducing mania.
Tx for personality disorder?
Psychotherapy.
Tx for opioid intoxication
Naloxone and naltrexone are opioid receptor antagonists and reverse the effects of opioids; may require redosing because of short half-life
TX for amphetamine intoxication
Haloperidol can be given for severe agitation and symptom-targeted medications (eg, antiemetics, NSAIDs)
Tx for Cocaine intoxication
Treat with haloperidol for severe agitation along with symptomspecific medications (eg, to control hypertension)
TX for PCP intoxication
Give benzodiazepines or haloperidol for severe symptoms; otherwise reassure Gastric lavage can help eliminate the drug
TX for LSD
Supportive counseling; traditional antipsychotics for psychotic symptoms; benzodiazepines for anxiety
Tx for AUD?
Abstinence: ■ Best initial treatment: Naltrexone (μ-opioid receptor blocker). ■ ↓ Cravings. Can start while patient is still drinking. ■ Long-term rehabilitation (eg, Alcoholics Anonymous). ■ Aversion: ■ Disulfiram (acetaldehyde dehydrogenase inhibitor): Produces an unpleasant response (eg, flushing, nausea, vertigo, palpitations) when EtOH is consumed. ■ Withdrawal: ■ Stabilize vital signs; correct electrolyte abnormalities. ■ Thiamine (administer before glucose to prevent Wernicke encephalopathy), glucose, and folic acid. ■ Start medium-length benzodiazepine taper (eg, lorazepam, diazepam, chlordiazepoxide). ■ Add haloperidol for hallucinations and psychotic symptoms.
Tx for anorexia nervosa
Monitor calorie intake and weight gain; hospitalize if necessary Watch for refeeding syndrome (electrolyte abnormalities [↓ phosphate], arrhythmias, respiratory failure, and seizures after sudden ↑ in caloric intake) Psychotherapy: Address maladaptive family dynamics Antidepressants (SSRIs) are not effective
Tx for bulimia nervosa
Psychotherapy ± antidepressants (SSRIs) Treat comorbidities. Avoid bupropion because of risk for seizure
Tx for sexual disorder
insight-oriented psychotherapy and behavioral therapy. Antiandrogens (eg, medroxyprogesterone injection) have been used for hypersexual paraphilic activity.
Tx for gender dysphoria
Educate the patient about culturally acceptable behavior patterns. Address comorbidities, psychotherapy, sex-reassignment surgery, or hormonal treatment (eg, estrogen for men, testosterone for women).
Tx for sexual dysfunction
PDE5 inhibitors (eg, sildenafil, tadalafil). If dysfunction is caused by antidepressants (SSRI), switch to bupropion.
Tx for 1o insomnia
Best initial treatment: Initiate good sleep hygiene measures. ■ Next best treatment: Pharmacotherapy; should be initiated with care for short periods of time (< 2 weeks). Pharmacologic agents include diphenhydramine, zolpidem, zaleplon, and trazodone.
Tx for 1o hypersomnia
Best initial treatment: CNS stimulants (eg, amphetamines).
Tx for narcolepsy
Treat with a regimen of scheduled daily naps plus stimulant drugs such as amphetamines or modafinil; give SSRIs for cataplexy.
Tx for sleep apnea
OSA: Nasal continuous positive airway pressure (CPAP). Weight loss if obese. In children, most cases are caused by tonsillar/adenoidal hypertrophy, which is corrected surgically. ■ CSA: Mechanical ventilation (eg, BiPAP) with a backup rate for severe cases.
Tx for circadian rhythm sleep disorder
Jet-lag type usually resolves within 2–7 days without specific treatment. ■ Shift-work type and delayed sleep-phase type may respond to light therapy. Modafinil is approved for shift-work type sleep disorder. ■ Oral melatonin
Tx for somatic symptom disorders
Psychotherapy
Tx for conversion disorder
Psychotherapy
Tx for factitious disorder
Psychotherapy
legal authorities (factitious disorder imposed on another).
Tx for suicidality
requires emergent inpatient hospitalization even against his or her will. ■ Suicide risk may ↑ after antidepressant therapy is initiated because a patient’s energy to act on suicidal thoughts can return before the depressed mood lifts.
