Psychopharmacology For Doctors (Part 2)

Front 1

Bupropion formulations

Back 1

Wellbutrin; Wellbutrin SR (bid); Wellbutrin XL (qd); Aplenzin ER (qd); Zyban (Sr bid)

Front 2

Bupropion dosing

Back 2

Depression IR 75 bid, 100mg bid; 100mg tid (450mg max); SR 100mg bid 3days 150mg bid 4weeks then ^ (max 400mg); XL 150mg qam 4days 300mg qam max 450mg qam; bromide 174qam max 522md qam

Front 3

Zyban for smoking

Back 3

SR 150md qd 3 days 150mg bid 1-2weeks before smoking stop date. Continue treatment for 6 mon. Can be given w patch or gum

Front 4

Bupropion HBr (Aplezin)

Back 4

174=150; 348=300; 522=450; MDD start 174mg qam 4 days 348mg; Seasonal affective 348mg qam for 4-6mon; Decrease risk of seizures

Front 5

Advantages of bupropion

Back 5

1. Less likely to ppt mania 2. Less sedation 3. Less weight gain 4. Does not disrupt sleep architecture 5. Helps w sexual dysfunction

Front 6

Bupropion SE

Back 6

1. Dry mouth, constipation, nausea, weight loss 2. Insomnia, dizziness, tremor, headache, abdominal pain 3. Sweating, rash 4. Hypertension 5. Rare seizures , mania, suicidality

Front 7

Bupropion risk of seizures

Back 7

1. Never give more then 100mg IR, 150 SR and 450XL as a single dose 2. Greater risk after 400mg per day 3. Never give to eating d/o pt 4. Evaluate for history of seizures, risk factors for seizures

Front 8

Bupropion seizure risk eval

Back 8

1. Past seizures 2. Head trauma 3. Organic brain dz 4. Recent alcohol or benzo withdrawal 5. Eating disorder

Front 9

Bupropion caution

Back 9

1. Drugs that decrease seizure threshold - TCA, LI, phenothiazine 2. Levodopa and amantadine dopamine effect 3. Sever insomnia 4. Bipolar

Front 10

Bupropion Do Not Use

Back 10

1. History of seizures 2. Eating do 3. ETOH or benzo withdrawal 4. Head injury or tumor 5. MAOI 6. Thioridazine

Front 11

Venlafaxine (Effexor XR) dosing

Back 11

Depression 37.5mg qd increase 1week 75mg 4days by 75mg to 225mg qd (375mg max); GAD 150-225mg. Try doses of 75mg increments for a few weeks before increasing. Dual NE action kicks in at 225-375mg range

Front 12

Venlafaxine FDA approval

Back 12

MDD, GAD, sSocial anxiety, Panic do

Front 13

Venlafaxine augmentation

Back 13

1. Mirtazapine "California rocket fuel" double serotonin and NE 2. Desipramine, nortriptaline,atomoxetine, bupropion enhance NE caution w activation SI and bipolar 3. Trazadone or sleep aids insomnia 4. Modafinil concentration and fatigue 5. Mood stabilizers and atypicals for bipolar or tx resistant depression 6. Benzo anxiety 7. Buspirone or thyroid

Front 14

Venlafaxine augmentation

Back 14

1. Mirtazapine "California rocket fuel" double serotonin and NE 2. Desipramine, nortriptaline,atomoxetine, bupropion enhance NE caution w activation SI and bipolar 3. Trazadone or sleep aids insomnia 4. Modafinil concentration and fatigue 5. Mood stabilizers and atypicals for bipolar or tx resistant depression 6. Benzo anxiety 7. Buspirone or thyroid

Front 15

Venlafaxine SE

Back 15

Most dose related 1. Headache, nervousness, insomnia, sedation 2. Nausea diarrhea lower appetite 3. Sexual dysfunction 4. Aesthenia, seating 5. SIADH hyponatremia 6. Dose dependant ^BP 7. Rare seizures, hypomania, SI 8. Withdrawal symptoms

Front 16

Venlafaxine augmentation

Back 16

1. Mirtazapine "California rocket fuel" double serotonin and NE 2. Desipramine, nortriptaline,atomoxetine, bupropion enhance NE caution w activation SI and bipolar 3. Trazadone or sleep aids insomnia 4. Modafinil concentration and fatigue 5. Mood stabilizers and atypicals for bipolar or tx resistant depression 6. Benzo anxiety 7. Buspirone or thyroid

Front 17

Venlafaxine SE

Back 17

Most dose related 1. Headache, nervousness, insomnia, sedation 2. Nausea diarrhea lower appetite 3. Sexual dysfunction 4. Aesthenia, seating 5. SIADH hyponatremia 6. Dose dependant ^BP 7. Rare seizures, hypomania, SI 8. Withdrawal symptoms

Front 18

Venlafaxine drug interactions

Back 18

1. Few known d/d 2. Tramadol seizures 3. MAOI 4. Risk bleeding w NSAIDS and warfarin 5. Cimetidine increases level

Front 19

Venlafaxine augmentation

Back 19

1. Mirtazapine "California rocket fuel" double serotonin and NE 2. Desipramine, nortriptaline,atomoxetine, bupropion enhance NE caution w activation SI and bipolar 3. Trazadone or sleep aids insomnia 4. Modafinil concentration and fatigue 5. Mood stabilizers and atypicals for bipolar or tx resistant depression 6. Benzo anxiety 7. Buspirone or thyroid

Front 20

Venlafaxine SE

Back 20

Most dose related 1. Headache, nervousness, insomnia, sedation 2. Nausea diarrhea lower appetite 3. Sexual dysfunction 4. Aesthenia, seating 5. SIADH hyponatremia 6. Dose dependant ^BP 7. Rare seizures, hypomania, SI 8. Withdrawal symptoms

Front 21

Venlafaxine drug interactions

Back 21

1. Few known d/d 2. Tramadol seizures 3. MAOI 4. Risk bleeding w NSAIDS and warfarin 5. Cimetidine increases level

Front 22

Venlafaxine caution

Back 22

1. Seizures 2. Heart Disease (^BP) 3. Bipolar if not on stabilizer 4 DO NOT give w narrow angle glaucoma

Front 23

Advantages of Venlafaxine

Back 23

1. Pt who fail SSRI 2. Pt w pain 3. Hot flashes

Front 24

Desvenlafaxine (Prisitq ER) dosing

Back 24

MDE 50mg to 100mg max; vasomotor 100mg qd; may be used for fibromyalgia (not FDA)

Front 25

Desvenlafaxine SE

Back 25

Dose related 1. ^ BP caution in narrow angle glaucoma and heart dz 2. SIADH hyponatremia 3. Sedation, dizziness 4. Insomnia 5. Sweating 6. Sexual 7. Rare seizures, hypomania, SI

Front 26

Desvenlafaxine D/D

Back 26

1. MAOI 2. Weak 3A4 triptans weakness 3.few known interactions

Front 27

Duloxetine (Cymbalta) dosing

Back 27

MDD start 20mg bid (40-60mg qd/bid)
GAD,chronic pain start 60mg qd max 120mg qd
Fibromyalgia 30md qd to 60mg qd after 1week
At 60mg both 5HT and NE

Front 28

Mirtazapine D/D

Back 28

No significant Tramadol and MAOI

Front 29

Mirtazapine Caution

Back 29

1. May lower WBC 2. May increase cholesterol 3. Alcohol may increase sedation

Front 30

Advantages of mirtazapine

Back 30

Low sexual SE, no major d/d, good augmenting agent, may reverse GI SE from Venlafaxine or SSRI

Front 31

Duloxetine D/D

Back 31

1A2, 2D6
Do not give in pt w narrow angle glaucoma, thioridazine, alcohol use, MAOI

Front 32

Duloxetine SE

Back 32

1. BP 2. Urinary retention 3. Wt gain 4. Sedation 5. Sweating 6. GI 7. Sexual

Front 33

Levomilnacipram (Fetzima) dosing

Back 33

MDD start 20mg ER 2 days 40mg Po qd (max 120mg)

Front 34

Milnacipram (Savella) dosing

Back 34

Approved only for fybromayalgia start 12.5mg qd 2 days 12.5mg bid 4days 25mg bid 4 days 50mg bid (50-100mg bid)

Front 35

Milnacipram SE

Back 35

NE ache 1. Dry mouth, constipation, urinary retention (treat w a1 blocker tamsulosin) 2. BP dose dependent
3. Sexual
4. SIADH
5. Sweating

Front 36

Milnacipran D/D

Back 36

1. Few known
2. Usual Tramadol, MAOI, bleeding, careful w other NE enhancers

Front 37

Mirtazapine (Remeron Soltab) how does it work?

Back 37

A2 antagonist raphe and cortex ^NE and 5HT
Mirtazapine plus SNRI "California rocket fuel" double swrotonin plus NE plus DA

Front 38

Mirtazapine dosing

Back 38

depression 15mg qhs (7.5 more sedation) 1-2weeks to 45mg qhs

Front 39

Mirtazapine SE

Back 39

Most go away w time
1. Histamine sedation and weight gain
2. Dry mouth, constipation, increase appetite
3. Flu like leukocytosis
4. Hypotension

Front 40

Trazadone (Oleptro ER) how does it work?

Back 40

Serotonin 5HT2A and 2C antagonist and SERT

Front 41

Trazadone dosing

Back 41

Depression 150-375mg ER
Insomnia 25-50mg qhs

Front 42

Trazadone SE

Back 42

1. Alpha adrenergic Hypotension and syncope, sedation
2. Sinus bradycardia long term
3. Rare rash
4. GI
5. Blurred vision dry mouth
6****** Priapism

Front 43

Vilazodone (Viibryd) how does it work?

Back 43

SPARI serotonin partial agonist and reputake inhibitor and ^5HT

Front 44

Vortioxetine D/D

Back 44

1. Avoid sertraline increase risk of serotonin syndrome, SIADH and hyponatremia
2. 2D6 precautions
3. Caution w NSAIDS (SIADH) and aspirin bleeding

Front 45

Advantages Vortioxerine

Back 45

Less sedation and insomnia
Less wt gain
Less sexual
Increase cognitive function

Front 46

Vildazodone (Viirbyd) dosing

Back 46

Depression start 10mg qd 1 week 20mg to 40mg (max) w FOOD

Front 47

Vilazodone SE

Back 47

Increase in seratonin
1.GI (diarrhea)
2. Insomnia (increase 5ht in sleep center)/ akathysia
3. Sexual

Front 48

Vilazadone D/D

Back 48

1.MAOI
2. Strong -3A4 increase the dose grapefruit juice, fluoxetine decrease to 20mg
3. Strong +3A4 decrease level
4. Weakness w triptans

Front 49

Advantages Vilazodone

Back 49

1. Less sexual SE then SSRI/SNRI
2. Less wt gain
3. Depression and anxiety
4. May have faster onset

Front 50

Vortioxetine (Brintellix) how does it work?

Back 50

New class
SERT
Partial agonist 5HT1A and B
Antagonist 5HT3A which increases serotonin, NE, DA, acetylcholine and histamine in a cortex (olanzapine)

Front 51

What drugs have 5HT1A partial agonism?

Back 51

5HT1A agonism increases NE and DA
Buspirone
Aripiprazole
Quetiapine
Lurasidone
Iloperidone

Front 52

What makes atypical antipsychotics?

Back 52

D2 antagonist + 5HT2A antagonism (allows release of dopamine in striatum less eps and no serotonin stimulation of prolactin)

Front 53

Vortioxetine (Brintellix) dosing

Back 53

Start 10mg Po qd to 20mg qd
Poor 2D6 metabolizers give 10 max

Front 54

Vortioxetine (Brintellix) SE

Back 54

GI
Headache
Dry mouth
Sweating (hyperhidrosis)

Front 55

Colomipramine (Anafranil) dosing

Back 55

Start 25mg qhs over 2 weeks to 100mg qd max 250mg
OCD 200-250mg
Risk of seizure above 250 and really up 300mg

Front 56

Colomipramine SE

Back 56

1. Anticholinergic sedation, dry mouth, constipation, blurred vison
2. Antihistaminic sedation and we gain (BMI and metabolic work up)
3. A1 blocker hypotension, dizziness
4. Unusual taste
5. Sexual SE
6. Sweating

Front 57

Colomipramine Caution

Back 57

1.orthostatic hypotension, arrhythmia, death.
2. QTc prolongation (check EKG)
3. Lower seizure treshold
4. Paralytic ileus w other anti-cholinergic
5. Hepatic failure
6. EPS
7. Mania suicidality

Front 58

Colomipramine DO Not Use

Back 58

1. Recent MI
2. Taking meds prolong QTc some antiarrhythmics, pimozide, thioridazine
3. Uncompensated heart failure or arrhythmia
4. Strong 2D6 inhibitors or poor metabolizers
5. W ECT risk of cardiac effects
6. MAOI

Front 59

Advantages Colomipramine

Back 59

Highest serotonin impact from TCAs approved for OCD
Treatment resistant depression

Front 60

Selegiline transdermal (Emsam) dosing

Back 60

Depression start 6mg/24hr patch 2 weeks 9mg/24hr patch 2 weeks 12mg/24 hr patch max

Front 61

Selegiline patch how it works?

Back 61

MAOI A and B in the brain irreversible but not MAOI A in the gut no dietary restriction at lower dose

Front 62

Selegiline patch how it works?

Back 62

MAOI A and B in the brain irreversible but not MAOI A in the gut no dietary restriction at lower dose

Front 63

Selegiline transdermal SE

Back 63

1. Site reaction change daily
2. Headache
3.insomnia (give benzo)
4. Diarrhea
5. Dry mouth
6. Caution tyramine ingestion above 6mg
7. Wt gain do BMI and metabolic assessment
8. Monitor BP

Front 64

Selegiline patch how it works?

Back 64

MAOI A and B in the brain irreversible but not MAOI A in the gut no dietary restriction at lower dose

Front 65

Selegiline transdermal SE

Back 65

1. Site reaction change daily
2. Headache
3.insomnia (give benzo)
4. Diarrhea
5. Dry mouth
6. Caution tyramine ingestion above 6mg
7. Wt gain do BMI and metabolic assessment
8. Monitor BP

Front 66

MAOI hypertensive crisis tx

Back 66

Sinful oral or sublingual dose of calcium channel blocker nifedipine
Acidify urine

Front 67

MAOI D/D

Back 67

Patch minimal interactions
1. Sypathomimetics, stimulants, decongestant ^BP
2. Fatal w meperidine ( Demorol)
3. Hypertensive crisis w SSRI, SNRI or any agent increases serotonin including St John wart
4. Do not give if pheochromocytoma, methodone, diuretics, bupropion
5. Wash out 14 days after MAOI d/c
6. 5-7 days after SSRI d/c 5 weeks w fluoxetine

Front 68

Augment antidepressants

Back 68

1. Li
2. 2nd antidepressant (bupropion)
3. Thyroid
4. Stimulant (modafinil)
5. Aripiprazole, quetiapine, olanzapine
6. Folate or L-methylfate (needed for enzyme to form NE, DA, 5HT)
7. SAME methyl donor for silencing COMT genes
8. rTranscranial magnetic stimulation

Front 69

Thyroid augmentation

Back 69

Liothyronine (Cytomel) 25-50mg 7-14 days if woks cont for 2 mon then tapper
SE headache wt loss insomnia and BP
Need to increase insulin in diabetic
Increase digitalis
Do Not Use if cardiac dz, angina, HTN

Front 70

Thyroid test

Back 70

TSH 0.3-3
If increased TSH and decrease T4 hypothyroidism

If decrease TSH and T4 pituitary problem

Front 71

Thyroid test

Back 71

TSH 0.3-3
If increased TSH and decrease T4 hypothyroidism

If decrease TSH and T4 pituitary problem

Front 72

L-Methylfolate (Deplin) how it works?

Back 72

Derived from Folate and form that enters the brain
Get folate level
Get homocysteine level if high more sensitive to detect folate deficiency

Front 73

Thyroid test

Back 73

TSH 0.3-3
If increased TSH and decrease T4 hypothyroidism

If decrease TSH and T4 pituitary problem

Front 74

L-Methylfolate (Deplin) how it works?

Back 74

Derived from Folate and form that enters the brain
Get folate level
Get homocysteine level if high more sensitive to detect folate deficiency

Front 75

L-Methylfolate dosing

Back 75

7.5 to 15mg per day
No notable SE
May reduce level of anticonvulsants
Pt taking anticonvulsants may need higher levels
Can mask symptoms of B12 deficiency