Week 2: Schizophrenia, Depressive Disorders Flashcards
Schizophrenia (SPh: my abbreviation)
chronic mental disorder that affects the way a person, thinks, acts, expresses emotions, and perceives reality
DSM 5 Criteria for SPh
must have 2 or more of the following, each present for a significant portion time during a 1 month period ( or less if successfully treated. at least one must be
1.delusions (fixed false belief)
- Hallucinations
- Disorganized speech (frequent derailment or incoherence).
- Grossly disorganized or catatonic behavior
- negative symptoms (i.e diminished emotional expression or avolition
*note: for significant portion of the time since onset of disturbance, level of functioning in one or more areas such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset
Schizoaffective disorder
uninterrupted period of illness during which there is a for mood epode (depression or manic)
delusions or hallucinations for 2 or more weeks in the absence of major mood episode during ht lifetime of the illness
SS that meet criteria for major mood episode are present for the majority of the total duration of the illness
disturbance not attributable to the elects of a substance (
Diagnosis of SPh
- complete patient history
- Mental Status Exam
*Rating Scales: PANSS (Positive and negative Syndrome Scale)
*Brief Psychiatric Rating Scale - rule out other conditions (Physical, Labs) and co occurring disorders to establish correct diagnosis
Drugs:
*coticosteroids
*stimulants
*marijuana
*DA-Augmenting agents
*Hallucinogens
Diseases:
hiv/aids
EPILEPSY
cva/tbi
infections
Huntingtons disease
Diagnosis of SPh
- complete patient history
- Mental Status Exam
*Rating Scales: PANSS (Positive and negative Syndrome Scale)
*Brief Psychiatric Rating Scale - rule out other conditions (Physical, Labs) and co occurring disorders to establish correct diagnosis
Drugs:
*coticosteroids
*stimulants
*marijuana
*DA-Augmenting agents
*Hallucinogens
Diseases:
hiv/aids
EPILEPSY
cva/tbi
infections
Huntingtons disease
Positive symptoms
Hallucinations
delusions (fixed false beliefs)
ideas of influence (actions are controlled by external forces
disorganized speech
negative symptoms
flat Affect ( (no emotional expression)
alogia (inabilit to carryon a logical conversation)
Anhedonia (inability to experience pleasure int things you used to (depression)
Avolition( lack of motivation )
Cognitive symptomsOF-Schizophrenia
impaired attention
impaired working memory
impaired executive function
SPh Treatment
Non Pharm
comprehensive psychosocial services are needed in addition to psychotropic medication management to achieve success such as…
psychosocial rehabilitation
pshycoeducation
Therapeutic Alliance
Active community treatment…etc.
What are among the most important factors in choosing an aNTIPSYCHOTIC AGENT for an individual patient
- SIDE EFECT PROFILES
others include….
*drug interactions
*family history
*adherance
*cost
General Approach to Choosing therapyFOR-SCHIZOPHRENIA
- SE and other considerations drive choice since differentiating APS based on efficacy is challenging
- optimize mono therapy(facilitate balance between efficacy and SE)
- Combo drug therapy reserved for treatment resistant pts. (lack of evidence supporting polyp harm, but risks well known, such as non adherence)
- Clozapine For treatment resistance or earlier use indicated for suicidal pts.
- long acting injectables for those who prefer them
Patho of Dopamine antagonism at different sites
Nigrostiratal
*function: extraparymidal system, movement
*effect: movement disorders
Mesolimbic:
function: emotional function, motivational behavior
effect: relief of psychosis
Mesocortical;
function:cognition, executive function
effect: Akathisia (inability to remain still), relief of psychosis
tuberoinfundibulnar
function: prolactin release
effect: increased prolactin
Treatment considerations for stabilization and maintenance-in-MDD
full efficacy could take 6-12 weeks or longer, 3-6 months for chronically ill pts.
partial responders would be evaluated for adherence
1st episode treatment:
12 months after remission, continue treatment, chronic lifelong therapy in most pts
treatment resistance: lack of improvement with at least 2 APS from diff classes at optimal dose for at least 8 weeks (some guidelines fewer)
rating scales to track progress
gradual discontinuation unless pt experiencing severe ADR
for switching agents, gradual taper off while other agent is slowly titrated up
treatment resistant-schizophrenia
lack of improvement with at least 2 APS from diff classes at optimal dose for at least 8 weeks (some guidelines fewer)
First Generation Antipsychotics
(Typical)
Chlorpromazine (Thorazine)
Fluphenazine (Prolixin)
Haloperidol (Haldol)
Perphenazine (Trilafon)
Thiordazine (Mellaril)
Thiothixene (Navane)
END-IN-ZINE-EXCEPT-HALOPERIDOL-AND-THIOTHIXENE
FGA class related side effects-and-BWW
extrapyrimdal side effects
Qtc prolongation
prolactin elevation
dermatologic
photosensitivity
blue-gray skin
orthostatic hypotension
altered thermoregulation
BBW: dementia related psychosis (i..e elderly pts with dementia
Black Box warning for FGA
Elderly patients with dementia related psychosis treated with FGA increased risk of death
DOES NOT MEAN IT CANNOT BE USED, careful monitoring must be done. benefit should outweigh the risk. can start with smaller dose
this BBW does not include the use of FGA in elderly pts with hx schizophrenia who was on long term treatment
Second Genration Antipsychotcs
Aripiprazole (Abilify)
Brexiprazole (Result)
Asenapine (Saphris)
Olanzipine (Zyprexa)
Cariprazine (Vrylar)
Clozapine (Clozaril, Fazaclo)
Iloperidone (Fanapt)
Lumateperone (Caplyta)
Lurasidone (Latuda)
Paliperidone (Invega)
Risperidone (Risperdal)
Ziprasidone (Geodon)
Quetiapine(Seroquel)
SGA (Atypicals) SE profile
Metabolic effects
*hypertriglyceriideemia
*hyperglycemia
*weight gain (waist circumference)
qtc prolongation
blood dyscrasia/neutropenia (most common offender clozapine)
decreased seizure threshold
anticholinergic effects (such as constipation(clozapine big offender)
sedation
prolactin elevation
opthalmic effects (quetiapine big offender)
Suggested Schizophrenia pharmacotherapy algorithm
Stage 1:
*Treatment naive: any antipsychotic except clozapine
(and olanzipine due to extensive SE profile)
*previously treated w. an APS, and treatment is being restarted : any app except clozapine or previous med that had poor efficacy or intolerance
…
NO IMPROVEMENT IN 2-4 WEEKS
…
Stage 2:
*inadequate response to above
*any psychotic (not used above) except clozapine
NOTE: Clozapine may be considered in severly suicial, EPS, hx violence or substance abuse
…
NO IMPROVEMENT IN 2-4 WEEKS
…
Stage 3:
*inadequate response to above
*considered treatment resistant
*Clozapine mono therapy
Stage 4:
* Inadequate response to above
*can use alternative antipsychotics, augmentation(mood stabilizers, APS polyp harm, etc.)
Note: A;WAYS VERIFY ADHERANCE. Use of Long acting injectables can be considered if poor adherence
treatment considerations for clozapine
extensive monitoring.
labs drawn
office visits once a week for first 6 mo.
every other week for next 6 months.
then once ammonite
Long acting Injectables treatment considerations
- good for non adherent patients: HOWEVER, NON ADHERANCE SHOULD NOT BE DUE TO SE PROFILE
*stabilization on oral therapy best approach
oral challenge of the same drug before initiating LAI us best practice
most LAI do not take immediate effect, overlap is often needed, there are exceptions
FGA TREATMENT potencies
High
(Haloperidol:Haldol)
FLuphenazine ( Prolixin)
Moderte/ high
Thiothixine (Navane)
Trifluoperazine (Stelline)
Medium moderate
Lozapine
Molindone
Perphenazine
Low potency
Chlorpromazine
Thioridazine
what is the importance of potency
potency effects both EPS risk and anticholinergic risk
Trend of anticholinergic and EPS risk with High vs Low potencies
Low potency:
increased anticholinergic risk
decreased EPS risk
High potency:
increased EPS risk
decreased anticholinergic risk
Aripiprazole (Abilify)
Unique MOA:
Generation:
Dosage form Availability and notes
Unique MOA: partial D2 and 5HT1A agonist
Generation:second generation
Dosage form Availability:
PO tab
LAI: Maintena: 14 day overlap
Aristada: 21 day overlap
Mycite
Apripiprazole (abilify clinical pearls
IMPULSIVITY: MUST COUNSEL
little weight gain
may cause insomnia, akathisia, restlessness,
pts and caregivers should be alert for uncontrollable and excessive urges
Asenapine (Saphris)
Unique MOA:
Generation:
Dosage form Availability and notes
Unique MOA: high affinity antagonism D2 sand 5HT2a
Generation: SECOND GENERATION
Dosage form Availability and notes;
Topical Patch: wear for 24hours upper arm back, abdomen, or hip. can shower but cannot win, don’t apply heat
Sublingual tablet: must counsel cannot eat or drink for 10 min
Asenapine (Saphris)
Clinical Pearls
NEW TOPICAL PATCH AVAILABLE
among least anticholinergic and less sedating
do not eat or drink after SL dose for 10 min
high risk of QTC prolongation.
CI: severe hepatic disease
topical patch may cause skin irritation
anaphylaxis may occur after single dose
Brexipprazole (Rexulti)
Unique MOA:
Generation:
Dosage form Availability and notes
Unique MOA: partial 5HT1A and D2 receptor agonist and 5HT2A receptor antagonist
Generation: second generation
Dosage form Availability and notes: oral tab only
Brexipiprazole Clinical pearls
IMPULSIVITY
dose related Akathisia,
long half life (91 hours)
Fewer metabolic changes than others
Clozapine (Clozaril)
Unique MOA:
Generation:
Dosage form Availability and notes
Unique MOA: antagonist of D1 ad D4(D2 less, 5-HT2 and others, M4 for agonist
Generation: second
Dosage form Availability and notes:
PO tablet
ODT (oral disintegrating tablet)
Oral solution:
ODT and oral EXPENSIVE. NOT usually covered by insurance
Clozapine clinical pearls
gold standard for treatment resistant schizophrenia or earlier if pt has high suicidal risk
BLOOD DYSCRASIA
HIGH METABOLIC RISK
CONSTIPATION-can lead to bowel obstruction. can lead to hospitalization or death.
DDI: Clozapine/ olanzapine use with benzos(especially lorazepam IM)
monitor ANC(absolute neutrophil count) levels as per REMS monitoring
REMS monitoring program
first 6 mo. q week
every other week for next 6 mo.
every month thereafter
Illoperidone
Unique MOA:
Generation:
Dosage form Availability and notes
Unique MOA: high affinity D2, D3, and 5ht2a
Generation: SECOND
Dosage form Availability and notes
PO
Illoperidone (Fanapt)
clinical pearls
ORTHOSTATIC HYPOTENTION. slow titration needed
no notable prolactin elevation reported
qtc prolongation
LLOWWWWW-BP
Lorasidone (Latuda)
Unique MOA:
Generation:
metabolism
Dosage form Availability and notes
Unique MOA: antan: D2 and 5HT2a
Generation:second
metabolism: cyp3a4
Dosage form Availability and notes: PO
Lorasidone (Latuda)
clinical Pearls
DO NOT USE WITH STRONG CYP3A4 inhibitors/inducer
alsoindicated for use in adolescents
indicated for depression associated w. bipolar disorder or in adolescents with major depressive episodes
Lumateperone (Caplyta)
Unique MOA:
Generation:
Dosage form Availability and notes
Unique MOA:
Generation: second
Dosage form Availability and notes:
oral capsule
Lumateperone Clinical Pearls
DO NOT USE WHEN BREASTFEEDING
may impair fertility especial if taken in 3rd trimester
Olanzipine (Zyprexa)
Unique MOA:
Generation:
Dosage form Availability and notes
Unique MOA:
Generation: SECOND
Dosage form Availability and notes
PO,
ODT
short acting IM
LAI (Relprevv): requires 3 hr observation period due to post injection delirium and sedation
Olanzipine (zyprexa)Treatment-considerations
can cause DRESS
METABOLIC ISSUES
post injection delirium-PDSS REMS PROGRAM FOR LAI
Qtc-risks
sedation
anticholinergic
Paliperidone (Invega)
Unique MOA:
Generation:
Dosage form Availability and notes
Unique MOA:
Generation:
Dosage form Availability and notes:
PO: OROS TABLET,LAI
Paliperidone clinical pearls
EPS
Prolactin
No PO overlap required for LAI
med shell may be seen in stool
Pimavanersin (Nuplazid)
Unique MOA:
Generation:
Dosage form Availability and notes
Unique MOA: TARGETS SERETONIN
Generation:
Dosage form Availability and notes
Pimavanserin (Nuplazid)-Considerations
NO DOPAMINE
indicated for hallucination and delusions associated with Parkinson’s disease psychosis
Quetiapineclinical pearls
sedation (often used as a sleep aide)
may be misused by pts.
anticholinergic effects
cataracts
Risperidone
Unique MOA:
Generation:
Dosage form Availability and notes
Unique MOA:
Generation:
Dosage form Availability and notes:
tab
odt
LAI (IM ORSQ)
SQ uncomfortable, administer carefully, if use SQ, don’t touch or rub
Risperidone clinical pearls
EPS
PROLCTIN
Ziprasidone
Unique MOA:
Generation:
Dosage form Availability and notes
Unique MOA:
Generation:-second
Dosage form Availability and notes-oral-tab
SAI-requires,reconstitution
Ziprasidone Clinical Perals
CI in those w. increased risk for QTc prolongation
DRESS
Special populations consideration-for-schizophrenia-treatment
elderly: start low, use cation for renal or hepatic impairment
Pregnancy/ lactation: lowest effective dose, higher doses for clozapine and olanzapine
Peds: may be more sensitive to EPS and metabolic effects
PED aprovals for Schizophrenia
also-BBW
Aripiprazole
Lurasidone
Olanzapine
Paliperidone
Quetiapine
Risperidone
all of these also indicated for depression
BBW: increased suicidal thoughts in children, adolescents and young adults
Long acting Injectables
first gen: fluphenazine
haloperidol
second gen:
aripiprazole
olanzapine
Risperiodne
Paliperidone
Acute dystonias
Signs
high risk APs
Treatments
painful prolonged muscle contractions
highriskAP:high,potency,or,FGA,
treatment:
A)anticholinergics(benzotropin,diphenhydramine,trihexylphenydil,biperidin)
b)IM-BZDS
c)decrease-or-DC-offending-agent
pseudoparkinsonism
Signs
high risk APs
Treatments
bradikinesia, tremor, pill rolling, cogwheel rigidity
high-risk-APS:high-potency-or-FGA
Treatments:-
a)anticholinergics-
b)d/c-offending-agent
akathisia
Signs
high risk APs
Treatments
restlessness,pacing,shuffling,compulsion-to-stay-in-motion.Subjective-feelings-of-distress
high-risk-APS:high-potency,FGA-aripiprazole,risperidone
treatment:-Beta-blockers,D/C-offending-agent
tardive dyskenisia
Signs
high risk APs
Treatments
tongue thrusting
chewing
lip smacking
grimacing
highriskAPS:high-potency-or-high-dose-FGA
treatment:
a)prevention
b)d/c-offending-agent
c)anticholinergics-MASKKK-SYMPTOMS
Major Depressive Disorder Etiology
unknown and complicated
but common consensus that there are altered neurotransmitters
MDD Oresentation
initial symptoms develop over days to weeks
SS of anxiety often appeared
if left untreated, can last 4 months or more
symptoms vary person to person
repeat episodes are common
medical disorders must be ruled out
MDD Emotional symptoms
diminished capacity to experience pleasure in activities that once brought them pleasure
anxiety symptoms
psychotic features , but may require hospitalization and stabilization with APS
MDD physical presentation
psychomotor retardation (sow movement and speech)
chronic fatigue, pain
sleep disorders like insomnia,
changes in appetitie
MDD physical presentation
psychomotor retardation (sow movement and speech)
chronic fatigue, pain
sleep disorders like insomnia,
changes in appetitie
watch for residual symptoms
Major Depressive Disorder
DSM5-criteria
depressed mood most of the day , everyday
diminished interest or pleasure
significant weightloss
insomnia or hypersomnia
phychomotor agitation
fatugue or loss of energy
gelling of worthlessness or excessive inappropriate guilt
diminished ability to think or concentrate
recurrent thoughts of death
(suicidal ideation, w. or w.o a plan)
FACTORSTHAT-INCRease-risks of suicide
male
single/ living alone
scribing feelings of hopelessness/ spice plans
substance abuse
unusual behavior-missed work, giving things away
during initial stages of medication therapy
BBW for antidepressants
what to do
increased risk of sucide in children, adolescents and young adults.
what to do? counsel patients
possible ADRs could include agitation
deal with subject of suicide directly
get help immediately
Frist Line therapy for Depression
Selective Seretonin Reuptake Inhibitors (SSRI’s)
Selective Serotonin and Norepinephrine Reuptake Inhibitors (SNRI)
buproprion
mirtazipine
Vortioxetine
antidepressive agent classes
SSRI
SNRI
Seretonin modulators
Triciclyc antidepressants nd other norepinephrine inhibitors
Monoamine Oxidase Inhibits (MAO-I)
Miscellaneous
Treatment considerations for MDD
- all antidepressants equally efficacious, so must consider other factor such as se PROFILEs for treatment options
*black box warning for ages up to 24
- carefully assess for possible BIPOLAR disorder. monotherapy antidepressive treatment in bipolar disorder could induce manic/mixed episode
General MDD Treatment Approach
- thorough initial evaluation and med review
first line agents: SSRI’s, SNRI’s bupropion, mirtazipine, vortioxetine
if response to treatment ( 50% reduction of symptoms) after 4 weeks, AD @optimal doseshould be continued and evaluated at 6, 8, and 12 weeks
if symptoms persist after an adequate trial (4-8 weeks), guidelines suggest switching to alternative AD or AUGMENTING with an AD with dif MOA, SGA or psychotherapy
pharmacotherapy for MDD approach
antidepressant pharmacotherapy initiated
…
AFTER 1-4 WEEKS
…
Partial or no response:
*assess adherance
*increase dose if clinically indicated
*assess issued with toldrability
*for sever symptom, consider etc
Full response:
maintain treatment if no issues with tolerability
…
AFTER 4-8 WEEKS
…
partial or no response:
*increase dose OR
*change or augment AD OR
consider ECT
Full response:
*move to continuation phase
pharmacotherapy for MDD approach
antidepressant pharmacotherapy initiated
…
AFTER 1-4 WEEKS
…
Partial or no response:
*assess adherance
*increase dose if clinically indicated
*assess issued with toldrability
*for sever symptom, consider etc
Full response:
maintain treatment if no issues with tolerability
…
AFTER 4-8 WEEKS
…
partial or no response:
*increase dose OR
*change or augment AD OR
consider ECT
Full response:
*move to continuation phase
Phases of therapy for MDD
Acute phase
Length:
Goal:
Phases of therapy for MDD
Acute phase
Length: 2-3 months
Goal: remission (absence of symptoms)
Phases of therapy for MDD
Remission phase
Length:
Goal:
Phases of therapy for MDD
Length: 4-9 months
Goal: prevent relapse or residual symptoms
Phases of therapy for MDD
if indefinite or lifelong
Length:
Goal:
Phases of therapy for MDD
Length:indefinite/ lifelong
Goal: prevent recurrence
Phases of therapy for MDD
if indefinite or lifelong
Length:
Goal:
Phases of therapy for MDD
Length:indefinite/ lifelong
Goal: prevent recurrence
Tratment expectationsfor-MDD
Week 1
Week 1-3
Weeks 2-4
Week 1: decreased anxiety
improved sleep
improved appetite
Week 2: increased activity, sex drive, self care, and memory
thinking and movements become more normal
sleeping and eating become more normal
weeks 2-4
relief of depressed mood
thoughts of suicide begin to subside
Tratment expectations
Week 1
Week 1-3
Weeks 2-4
Week 1: decreased anxiety
improved sleep
improved appetite
Week 2: increased activity, sex drive, self care, and memory
thinking and movements become more normal
sleeping and eating become more normal
weeks 2-4
relief of depressed mood
thoughts of suicide begin to subside
Pt education for SSRIs
timeline symptoms
Discontinuation Syndrome: FINISH: flu like symptoms, insomnia, nausea, imbalance , sensory disturbances, hyper arrousal. also electric shock sensations
must taper if possible, except for prozac due t o long t1/2
may be initial anxiety so start low and go slow with dosing. insomnia, headache are common initial adverse effects
hyponatremia and SIADH (rare). monitor for increased lethargy mentallerl status
insomnia or sedation: take in morning or switch to another with less insomnia .
increased-bleeding-for-pts-on-nsaids,ANTI-PLATELETS,and-anticoagulants
sexual dysfunction: may need to switch to another agent such as bupropion
Seretonin syndrome counsel on symptoms:
mental status changes
autonomic disability
neuromuscular abnormality
GI symptoms
Seretonin syndrome ****
SS: BASICALLY-HYPERACTIVITY
agitation
restlessness
confusion
diarrhea
sweating
tachycardia
HTN
dilated pupild
loss of muscle coordination
muscle rigidity
can occur if taking multiple agents with serotonin
such as…
triptan migraine agents
pain medication such as fentanyl and tramadol
nausea products such as zofran(ondansetron) and reglan(metoclopramide)
Busprione
Linezolid
Ritonavir
avoid drugs that impair the metabolism of serotonin
SSRI DDI
Qtc prolongation with concaminant meds
increased risk of bleeding with Nsaids, anti platelets or anticoagulants
SSRI considerations
discontinuation syndrome
abnormal bleeding due to 5HT reuptake on patelets
hyponatremia
seretonin syndrome
potential cognitive and motor impairment.
degrees of Qtc prolongation
require caution/ dose modifications with hepatic impairment
SSRI
Special considerations drugs specific
Citalopram(Celexa)
QTc prolongation
MDD 20 mg for
*elderly pts.
CYP2C19
hepatic repairmen
SSRI
Special considerations drugs specific
Escitalopram (Lexapro)
MDD 10 mg for hepatic empairment
also-used-for-GAD
SSRI
Special considerations drugs specific
FLuvoxamine
one of most sedating
NOT-USED-FOR-MDD.JUST-APPROVED-FOR-OCD
SSRI
Special considerations drugs specific
Fluoxetine
Once weekly dosing
SSRI
Special considerations drugs specific
Paroxetine
avoid in pregnancy
short half life
SSRI
Special considerations drugs specific
Sertraline
concentrate can be mixed WITH only WATER, GINGERALE, LEMON/LIME SODA, LEMonade, or orange juice
SNRI considerations
abnormal bleeding due to 5HT reuptake on platelets
potential for increased activation of mania
elevated BP
hyponatremia and seretonin syndrome
discontinuation syndrome
tend to be more energy boosting than any other AD
SNRI
Special considerations drugs specific
Desvenlafaxine
3a4 interactions, don’t crush or chew
hyperlipidemia reported
eosinophilic pneumonia
SNRI
Special considerations drugs specific
Venlafaxine
Give with food
2d6 Interactions
BP changes seen at higher doses and Eosinophillic pneumonia reported
Dose reductions up to 50% for mild to moderate hepatic or renal impairment
SNRI
Special considerations drugs specific
Duloxetine(cymbalta)
avoid use in pts w. liver dysfunction or ESRD
avoid ETOH
1a@ and 2D6 interactions: . do not crush or chew
potential hepatotoxicity
urinary retention
HYPOTENSION reported
less insomnia report than other SNRIs
SNRI
Special considerations drugs specific
Levomilnacipran
Urninary retention
increased heart rate
Tricyclic Antidepressants special considerations
anticholinergic and cardiovascular events
CV ventricular tachycardia and heart block (Qt prolongation
AE: Weight gain
sexual dysfunction
drug interaction
baseline EKG
TCA withdrawal syndrome (insomnia, sweating, abdominal pain, diarrhea)
examples of TCAs
amitriptyline
amoxapine
clamipramine
desipramine
Doxepin
Imipramine
Notriptyline
Maprotiline
Monoamine oxidase Inhibitors MAO-I considerations
- after stopping an interacting medication, must wait 4-5 t1/2 before starting MAO-I
fluoxetine(>5 weeks) and vortioxetine(3 weeks) have longest t-1/2 of the SSRi’s so need to wait >2 weeks before starting MAO-I
dietary restrictions of tyramine containing foods:
aged products, smoked and pickled products, yeast extracts- can cause hypertensive crisis. MONITOR BP
other SE: postural hypotension, diarrhea, anticholinergic drying effects, sexual dysfunction
typical REserved for last resort
MAO-I DDI
hypertensive crisis
amphetamines
decongestants
methylphenidate
seretonin syndrome with dextromethorphan, etc.
MAO-I inhibitor examples
Phenelzine
Selegiline
Tranlycypromine
Seretonin Modulators
ex: Trazadone, Nefazadone
mixed 5HT
Nefazedone
hepatic BBW: life threatening hepatic failure have been reported.
TRazadone:
sedating
risk of priapism
Vortioxetine (tritellix) cosiderations
RAPID ONSET OF ACTION
IMPROVED TOLERABILITY-COGNITIVE EFFECTS
Buproprion considerations
lowers seizures threshold
caution in pts with eating disorders or alcohol use disorders
CI: anorexia
Mirtazipine considerations
sedating
weight gain
cholesterol elevation
Spravato (Esketamine) treatment connsiderations
treatment resistant depression
failure of atleast2 other drugs
NMDA receptor antagonist
designed to be used in combo with po antidepressant
CI in pts with hx of aneurysmal vascular disease or intracranial hemmorhae
increase BP, cognitive impairment, impaired ability to drive or operate machinery
AE: dissociation, dizziness, N/V, sedation, vertigo, hypoeshesia, anxiety, lethargy, increased bp, feeling drunk
BBW: sedation, dissociation, abuse and misuse, suicidal thoughts and behaviors
must be administered by health care professional and must be monitored for 2 hours after admin.
Brexanolone
post partum depression
apart of REMS . monitor pulse ox
recommending an optimal therapeutic regimen-for-MDD
consider pt preferences
multiple use of single agents
agents to avoids for certain conditions
seizure disorders: bupropion
substance abuse: benzos
cardiac complications (TCA’s
gi bleeding and anticoagulation: SSRIs
Treatment Resistance depression
non responsive to 2 separate trip of ad WITH ADEQUATE DOSE AND DURATION (4weeks to start seeing effects, 6-8 weeks for full effects
what to do; switch to an alternative . can cross titrate od d/c and start
Augmentation agents for MDD
lithium
triiodothyronine
SGA(aripiprazole,brexipiprazole,eutiapine,combo-olanzapine/fluoxetine
buspirone
stimulant
Neuroleptic malignant syndrome (NMS)
cause
ss
trtmt
dopamine antagonists
onset variable 1-2 days
htn
hyperthermia
diaphoresis
pallor
LEAD PPIPE RIGIDITY
HYPOREFLEXIA
NORMAL PUPILS
NORMAL OR DECREASED BOWELS
confusion
oincreased muscle tone/ rigidity
increased WBC, CPK, LFTs
cause: high potency APS, including clozapine
treatment:
*d/c offending agent
*can rechallenge. acceptable in most w. observation for atleast 2 weeks
or choose diff SGA or low potency FGA, slow dose titration
Seretonin syndrome
seretonin agents
onset variable
htn
hyperthermia
hypersalivation
diaphoresis
increased tone in lower extremities
HYPERREFLEXIA
DILATED PUPILS
HYPERACTIVE BOWEL SOUNDS
