Psychopharmacology For Doctors Part 3

Front 1

Buspirone (Buspar) dosing

Back 1

Start 15mg bid 2-3days by 5mg max 60mg

Front 2

Buspirone How does it work?

Back 2

Partial agonist at 5HT1A

Front 3

Buspirone SE

Back 3

Dizziness
Sedation
Headache
Nausea
Restless
Caution in renal and hepatic impairment

Front 4

Buspirone D/D

Back 4

3A4

Front 5

Advantages Buspirone

Back 5

Lacks sexual SE
May reduce sexual SE from SSRI
Generally reserved as augmenting agent because sedation above 20mg

Front 6

Gabapentin (Neurontin) dosing

Back 6

Off label neuropathic pain and anxiety (efficacy bid)
No efficacy in bipolar
900-1,800mg per day
300mg day 1
300mg bid day 2
300mg tid day 3

Give 2hrs before antacids

May see results in 2 weeks give 6-8week trial

Front 7

Gabapentin (Neurontin) dosing

Back 7

Off label neuropathic pain and anxiety (efficacy bid)
No efficacy in bipolar
900-1,800mg per day
300mg day 1
300mg bid day 2
300mg tid day 3

Give 2hrs before antacids

May see results in 2 weeks give 6-8week trial

Front 8

Gabapentin SE

Back 8

Sedation
Dizziness
Ataxia
Nystagmus
Wt gain
Tremor
Blurred vision
GI
Excreted unchanged renal

Front 9

Pregabalin (Lyrica) dosing

Back 9

50mg tid 3-7days 100mg tid 7days 200mg tid (max)
BID might work

Front 10

Pregabalin (Lyrica) dosing

Back 10

50mg tid 3-7days 100mg tid 7days 200mg tid (max)
BID might work

Front 11

Pregabalin FDA approval

Back 11

Diabetic peripheral neuropathy
Post heretic neuralgia
Fibromyalgia
Partial seizures
Off-label second line for GAD, social, panic, PTSD

Front 12

Advantages of pregabalin

Back 12

Works better then gabapentin clinically
Enhances slow wave delta sleep in pt w pain

Front 13

Advantages of pregabalin

Back 13

Works better then gabapentin clinically
Enhances slow wave delta sleep in pt w pain

Front 14

Pregabalin SE

Back 14

Same as gabapentin
Caution when adding to another sedating agent
Renal excretion intact
Cat C in pregnancy

Front 15

GAD treatment 1st line

Back 15

Pregabalin
SSRI SNRI
BZ
Buspirone

Front 16

GAD adjunct

Back 16

Hypnotic
CBT
Atypical quetiapine or aripiprazole

Front 17

Social anxiety 1st line

Back 17

SSRI
SNRI
Pregabalin

Front 18

Social anxiety adjunct

Back 18

CBT ****sometimes better then drugs
Hypnotic
Atypical
Naltrexone/acamprosate for substance abuse comorbid

Front 19

Panic d/o fist line

Back 19

SSRI
SNRI
Pregabalin
BZ

Front 20

Panic do adjunct

Back 20

Hypnotic
Atypical
CBT - modify cognitive distortion; diminish phobic avoidance by behavioral exposure

Front 21

PTSD first linr

Back 21

SSRI
SNRI

Front 22

PTSD adjunct

Back 22

High co morbid depression, insomnia, substance abuse and pain
CBT - address core symptoms not tx by meds; exposure therapy to deal w avoidance
A1 antagonist prazosin for nightmares
Mirtazapine
Hypnotic w caution
Naltrexone for substance abuse

Front 23

Anxiety symptoms deferential

Back 23

1.Akathysia
2.Depression
3.Secondary to psychotic sx
4.Cardiovascular angina, mi
5. Dietary caffeine, vit deficiency, msg
6. Anemia
7.metabolic- cortisol (cushings) electrolytes, hypoglycemia, thyroid,menopause
8. CNS tumor, encephalitis NMS
9. Respiratory asthma
10. Drugs stimulants, cocaine, sudafed, hallucinogens

Front 24

Benzodiazepines half life

Back 24

1. Long >20 hours
Clonazepam
Diazepam (Valium)

2. Intermediate 6-20 hours
Lorazepam
Alprazolam (Xanax)
Chlordiazepoxide (Librium)


3. Short <6 hours
Triazolam (Halcion) 2-3hrs

Front 25

Benzodiazepines half life

Back 25

1. Long >20 hours
Clonazepam
Diazepam (Valium)

2. Intermediate 6-20 hours
Lorazepam
Alprazolam (Xanax)
Chlordiazepoxide (Librium)


3. Short <6 hours
Triazolam (Halcion) 2-3hrs

Front 26

Benzodiazepine pharmacology

Back 26

1. Absorbed unchanged GI
2. Long half life less sever withdrawal, but day time sedation and psychomotor impairment
3. Short half life more sever withdrawal, rebound insomnia, anterograde amnesia

Front 27

Benzodiazepines half life

Back 27

1. Long >20 hours
Clonazepam
Diazepam (Valium)

2. Intermediate 6-20 hours
Lorazepam
Alprazolam (Xanax)
Chlordiazepoxide (Librium)


3. Short <6 hours
Triazolam (Halcion) 2-3hrs

Front 28

Benzodiazepine pharmacology

Back 28

1. Absorbed unchanged GI
2. Long half life less sever withdrawal, but day time sedation and psychomotor impairment
3. Short half life more sever withdrawal, rebound insomnia, anterograde amnesia

Front 29

Benzodiazepine Caution

Back 29

1. H/o substance abuse
2. D in pregnancy
3. CNS depression
4. Precaution operating machinery
5. Always adjust w elderly, hepatic and respiratory problems
6. AVOID clozapine and benzos delirium

Front 30

Clonazepam (Klonapin)

Back 30

FDA for Panic disorder
Start 0.25mg bid 3 days 1mg qhs or split bid (4max)
3A4 drugs may affect clearance but not clinically significant

Front 31

Diazepam (Valium)

Back 31

1.FDA anxiety do, alcohol delirium , muscle spasm, anxiety during procedures, status epilepticus (IV)
2. Available rectal and injection
3. Po 2-10mg bid-qid
4. Etoh detox 10mg tid-qid 1 day; 5mg tid-qid reaccess
5. Cimetidine increase clearance
6. Caution w etoh users, pulmonary impairment, depressed pt worsening si, disinhibition

Front 32

Lorazepam (Ativan)

Back 32

1. FDA anxiety do
2. Start 2-3mg per day bid-tid max 10mg
Catatonia 1-2mg repeat in 3hrs and another q3hrs
3. Valproate can increase level
Oral contraceptives decrease level
4 Flumazenil in overdose can ppt seizures
5. Useful for treatment of delirium im w haldol

Front 33

Lorazepam (Ativan)

Back 33

1. FDA anxiety do
2. Start 2-3mg per day bid-tid max 10mg
Catatonia 1-2mg repeat in 3hrs and another q3hrs
3. Valproate can increase level
Oral contraceptives decrease level
4 Flumazenil in overdose can ppt seizures
5. Useful for treatment of delirium im w haldol

Front 34

Alprazolam (Xanax, Xanax XR, Niravam)

Back 34

1. FDA GAD and Panic do (IR, XR)
2. Anxiety IR 0.75-1.5mg tid 3-4 days adjust until relief (4mg max)
Panic IR 1.5mg tid 3-4d 1mg (4mg)
XR 0.5-1mg qam 3-4d 1mg (10mg max)
3. 3A4 is a problem grapefruit juice, fluoxetine, abtifungal
+3A4 carbamazepine
4. Alprazolam XR longer acting then clonazepam

Front 35

Chlordiazepoxide (Librium)

Back 35

1. FDA anxiety, preoperative anxiety, alcohol withdrawal
2. Po mild to mod 15-40mg tid-qid; sever 60-100mg tid-qid
IM 50-100mg then 25-50mg tid-qid
3. No d/d interactions

Front 36

Chlordiazepoxide (Librium)

Back 36

1. FDA anxiety, preoperative anxiety, alcohol withdrawal
2. Po mild to mod 15-40mg tid-qid; sever 60-100mg tid-qid
IM 50-100mg then 25-50mg tid-qid
3. No d/d interactions

Front 37

Chlordiazepoxide (Librium tapper)

Back 37

50mg Po q6hrs x 4 doses
25ng Po q6hrs x4 doses
10mg Po q6hrs x 4 doses

25-50mg Po q6hrs prn; if hepatic impairment use lorazepam

Front 38

Benzodiazepines SE

Back 38

1. Sedation, fatigue, depression
2. Dizziness ataxia slurred speech
3. Forgetfulness confusion
4. Hyper excitability nervousness disinhibition
5. Rare hallucinations mania
6. Hypotension, respiratory depression