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70 Cards in this Set
- Front
- Back
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This scale is used to show efficacy in clinical trials for FDA approval of antidepressants. Response is defined as a reduction of 50% of baseline score.
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Hamilton Rating Scale for Depression. HAM-D
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These medications have adverse effect profiles of depressed mood.
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Interferons, Benzo's, barbiturates, alcohol, lipid soluble beta blockers, stimulant withdrawal, cocaine, amphetamines
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With correct AD chosen, and assuming adequate dose and compliance, how long will it take to see a response.
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Generally 4-6 weeks, but may take up to 8 weeks. Remission up to 12 weeks.
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Class of AD's that is effective for "atypical" depression characterized by hypersomnia, hyperphagia, mood reactivity
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MAO inhibitors
phenlzine, tranylcypromine |
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These are the most sedating SSRI's
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paroxetine (1/2 life 21 hrs)
fluvoxamine (1/2 life 15 hours) |
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These are the most activating SSRI's
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Fluoxetine (1-4 days)
Vilazodone (25 hrs) |
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Management of SSRI induced sexual dysfunction includes
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wait and see
bupropion lowering dose adding sildenafil/cyproheptadine changing to an AD without this SE |
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This SNRI has higher anticholinergic effects in relation to other SNRI's
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Duloxetine
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Monitoring precautions with Duloxetin include
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Concomitant CYP 2D6 inhibitors
hepatic enzymes Blood pressure Do not use if dialysis patients/severe renal isufficiency |
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This antidepressent is sedating (mostly at lower doses), increases appetite, and lacks sexual dysfunction se's and anxiety se. What is it?
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Mirtazapine
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SSRI inhibitors of CYP 2D6
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Fluoxetine/paroxetine - high
Duloxetine - moderate |
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Antidepressants that inhibit CYP 3A4
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Nefazodone - high
Fluvoxamine - moderate |
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Antidepressant that inhibits CYP 1A2
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Fluvoxamine
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These atypical antipsychotics are FDA approved for depression
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Quetiapine XR, aripiprazole
(olanzapine plus fluoxetin is approved for treatment resistant depression as well) |
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When patient is experiencing a partial response to current AD therapy of which they are compliant, what augmentative strategies can you implore?
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1) Lithium (good for tx resistant)
2) T3 therapy, even if euthyroid 3) Buspirone 4) 2nd Gen antipsychotics (xr quetiapine, aripiprazole, olanzapine plus fluoxetine) |
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Lethargy , coarse tremor, confusion, and seizures (progressing to coma) are toxicities of which Bipolar agent?
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Lithium. In patients presenting with any of these sx's initial w/u should include chem-7, and Li level prior to making any changes.
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LIthium is effective for manic and depressive components in Bipolar d/o. How long will it take to see the full effect?
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1 - 2 weeks
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Upon initiation of Li these agents may be added since full effect of Li is delayed.
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antipsychotics, benzo's
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What are the parameters and timing in monitoring Lithium levels?
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Half life is 1 day, steady state in 5 days. Draw level 12 hours after last dose. Concentration - 0.8 - 1.2 meq/L in acute mania, 0.6 to 1.0 during maintenance
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What are the considerations in monitoring divalproex serum levels?
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Target 50 - 125 mcg/ml. Check 3 - 5 days after initiation of dose change. Hypalbuminemia incr. risk of elevated free concen.
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This bipolar mood stabilizer may cause hyponatremia, maybe added to lithium for incomplete responders and has a genetic test, HLB 1502 needed for asian patients.
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carbamazepine
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This med has been FDA approved for Bipolar maintenance, and is effective, particularly in depressed phase. Watch out for rashe!!
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Lamotrigine - rash onset 2-8 weeks. Slow titration, even slower if on valproic acid.
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These are used in Acute phase for agitation, overactivity and may have mood stabilizing properties. Often combined with mood stabilizers.
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Antipsychotics. All FDA approved for acute/mania, mixed episode except clozapine. Quetiapine XR approved for acute mania, mixed episode or maintenance. Olanzapine, aripiprazole approved fro bipolar maintenance as monotherapy.
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These agents are not recommended for long term therapy, may be useful for insomnia, hyperactivity and agitation. They do not prevent relapses.
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Benzo's. Lorazepam/diazepam are used in acute setting.
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First generation antipsychotics that have high incidence of EPS.
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fluphenazine, trifluoperazine, haloperidol, thiothixene,
-- loxapine, perphenazine. |
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Second generation antipsychotics with highest incidence of EPS.
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Risperidone, paliperidone
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Second Generation antipsychotic with no EPS symptoms.
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CLozapine
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Potency of antipsychotics refers to what receptor?
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D2 - dopamine receptor. The higher the potency at this receptor the lower the potency at other receptors (histamine/anticholinergic) , but higher eps
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High potency first generation antipsychotics include?
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Fluphenazine, thiothixene, haloperidol
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Treatment choices for EPS (parkinsonian) related to antipsychotics
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anticholinergics, benzotropine, and trihexyphenidyl. (may also use diphenhydramine)
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Treatment for dystonia related to antipsychotics.
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Anticholinergics (same as for EPS - parkinsonian)
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Treatment choices for akathisia related to antipsychotics.
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Lipophilic beta blockers , anticholinergics
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Intervention of choice for tardive dyskinesia, and other possible interventions that my be helpful include what?
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Changing to clozapine is toc. Vitamin E may help. Lowering dose of offending agent may help but symptoms may return.
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This side effect of antipsychotics is manifested by agitation, confusion, sweating, changing levels of consciousness and is more common with high potency agents.
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Neuroleptic malignant syndrome
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Therapy for NMS include these.
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supportive - fluids, cooling. Dantrolene and bromocriptine have been used.
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The secretion of this hormone is blocked by dopamine. Administration of antipsychotics may result in the increased release of this.
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Prolactin - leading to galactorrhea and menstrual change effects
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First generation Antipsychotics that have the highest risk for weight gain.
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Low potency (due to higher effect at histamine/serotonin receptors)
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AE of antipsychotics from a retrospective study found an increased risk of this in both first and second generation users. Second generation had a higher incidencts
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Venous thromboembolism
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These two agents cause pigmentary changes in retina and corneal opacity
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Thioridazine, chlorpromazine
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T/F. Many typical antipsychotics can cause QT prolongation and arrhythmias.
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True
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T/F. IV haloperidol is route of choice in acutely agitated patient.
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False, iv route = toxicity (torsades). IM route is route of choice
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Characteristics of Second generation antipsychotics
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1. Risk of eps lower than 1st gen antipsychotics
2. Tardive risk is lower 3. 5ht2 receptor blocking property is present |
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Main se of clozaril that requires blood draws.
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Agranulocytosis and reduced ANC count
weekly blood x 6 mos, then every two weeks, then monthly after 1 yr of wbc > 3500. |
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SGA used for "treatment resistant" patients.
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clozaril. tends to selectively affect cognitive and affective parts of the brain - mesolimbic A10 tract and not the A9 tract that involves movement)
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Second generation antipsychotic that has dose related EPS phenomenon
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Risperidol (doses > 6mg per day)
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Second generation antipsychotic that had a long acting parenteral with a black box warning regarding post injection delirium/sedation syndrome and increased mortality in elderly with demetia psychosis.
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olanzapine. can only administer in registered facilities.
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Second generation antipsychotic of choice in Parkinsonian related psychosis
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Quetiapine
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QT prolongation appears to be highest with these antipsychotics
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thioridazine, clozapine, ziprasidone, iloperidone
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This antipsychotic is referred to a dopamine-serotonin stabilizing agent. It has a low risk of TD or eps.
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Aripiprazole. (Dopamine D2/5-HT1 partial agonist, and
5-HT2 antagonist) |
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This antipsychotic has a low risk of metabolic effects and eps, but a high risk for orthostasis. It is also available in a sublingual form.
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Asenapine (saphris)
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This antipsychotic has low risk for metabolic/cardiac/EPS effects but has potent antagonistic effects at 5-HT7 and high affinity for 5-HT1a recpetors (beneficial cognitive and anxiolytic effects)
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Lurasidone
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Order from Highest to lowest risk of metabolic side effects from 2nd generation antipsychotics (weight gain, hyperglycemia, lipid abnormalities)
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clozapine-olanzapine>risperidone-quetiapine>paliperidone,iloperidone>ziprasidone,aripiprazole, asenapine, lurasidone.
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Adjunctive medication that may augment effect of antipsychotic
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Lithium
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Effect of half life on benzodiazepine potency
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Shortest half - life, highest potency
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T/F. Tolerance to anxiolytic properties of benzo's is a problem and dose escalation is often necessary
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FALSE
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Treatments for Generalized Anxiety Disorder
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1. Antidepressants
2. Benzo's use as bridge until other agents take effect. D/c in 3 mos or so 3. Buspirone - takes 2-4 weeks to work 4. CBT |
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Treatmemts of choice for panic disorder
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1. antidepressants
2. benzo's high potency - rapid onset. 3. CBT (buspirone is ineffective) |
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Treatments of Obsessive Compulsive Disorder
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1. Serotonergic agents - clomipramine, fluvoxamine and other ssris
2. CBT - secondary to meds |
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Treatments for PTSD
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1. Sertraline and Paroxetine are first line
2. Valproic acid for aggression and anger |
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Short acting non benzo hypnotic
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zaleplon - 1 hr
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long acting non benzo hypnotic
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eszopiclone (lunesta) 6 hours
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This hypnotic has no effect on GABA receptors and there is no evidence of dependence or tolerance to its effect
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Ramelteon (rozerem)
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THis sleep aid may worsen dementia in elderly and definitely shouldn't be used if on Alzheimer drugs
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DIphenhydramine
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This drug is good for SSRI induced insomnia, and has low propensity for dependence.
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Trazodone
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How soon after alcohol abstinence can Deleiurm tremens occur
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3 - 5 days
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How soon after alcohol abstinence can sizures occur
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12 - 48 hours. Benzo's are tx of choice
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This is administered prior to Glucose in alcohol withdrawal b/c it is a cofactor in glucose metabolism
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Thiamine
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This agent is reserved for highly motivated patients for alcohol abstinence therapy due to compliance issues
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Disulfiram - alcohol dehydrongenase inh.
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This drug should be used with CBT and may cause liver toxicity. It is also available in IM formulation but you need to be able to abstain from etoh in an outpatient setting prior to tx
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Naltrexone
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THis drug is not metabolized, is a structural analog of GABA and reduces alcohol cravings. It has to be administered three times a day
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Acamprosate
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