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64 Cards in this Set
- Front
- Back
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What is a good way to classify mood stabilizer side effects?
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Side effects at therapeutic levels
Side effects at toxic levels If side effect is dose related Then 1. Life threatening 2. Clinically significant 3. Subclinical Lab problems |
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Lithium
Life threatening side fx? |
Renal Failure
Encephalopathy |
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How does lithium cause acute renal failure? Symptoms? Tx?
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cause is generally due to
severe dehydration and volume depletion due to the combination of natriuresis and water diuresis accompanied by elevated lithium levels, altered mental status, and subsequent poor oral intake lithium nephrotoxicity will occur within a month of onset of use of the drug, manifested predominantly by polyuria and polydipsia Signs of volume depletion - Hypotension, orthostasis, tachycardia, and dry mouth Altered mental status. acute lithium nephrotoxicity picture is dominated by evidence of volume depletion, obtundation, and the potential for cardiovascular collapse high levels of urea in blood Nausea, Vomitting, Diarrhea, Changes in urination frequency and could include blood high phosphates (and low Ca): (low Ca = muscle cramps),bone pain, itching build up potassium: muscle paralsysis, arrthymia fluid build up: swelling, if in lungs SOB Tx: Treat low volume with normal saline Consider dialysis |
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Li Encephalopathy: sx, lab findings, tx?
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Sx: The onset tends to be gradual, with initial confusion, then impaired consciousness leading to coma and occasionally death.
Neurological effects include seizures, choreiform and parkinsonian movements, and cerebellar signs (dysarthria, ataxic gait, incoordination EEG: diffuse slowing throughout the brain with no epileptiform activity Tx: As a general rule aggressive treatment (intravenous fluids, haemodialysis) should be given when serum lithium exceeds 2 mmol/L, but this decision should be governed more by the clinical features than by the spot lithium level |
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Lithium Clinical Side fx: systems?
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Neuromuscular
Endrocrine/Metabolic CardioPULMonary Hematologic Renal Hepatic GI Derm Other |
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Lithium clinical side fx list:
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Neuromusc: lethargy, poor memory (anomia, poor word recall)
Tremor, Twitching (Myoclonus) EndoMetab: Weight gain, HyPOthyroidism No cardio, pulm, heme, hepatic CLINICAL side fx GI: Nausea, Diarrhea Derm: Acne, Psoriasis, Maculo (spots) papular (bumps) rash (redness) at, red area on the skin that is covered with small confluent bumps |
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Lithium Lab changes?
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Endo: Increased TSH
Cadiopulm: EKG T-wave depression Hematologic: Leuokocytosis to 20, 000 Renal: decreased GFR, decreased urine specific gravity |
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Carbamazepine Side Fx?
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LIfe-threatening:
Agranulocytosis (drop in white cells, especially neutrophils) Aplastic Anemia:bone marrow produces too few RBC's Stevens-Johnson Syndrome: epidermis seperates from dermis |
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How manage Agranulocytosis
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1. Monitor CBC/diff q 2weeks X2, then q monthly X2, then q quarterly or if Symptomatic
2. Monitor for Infection, Fever 3. If infection, go to emerg, tx aggressively; notify ID/heme team 4. Consider Li augmentation |
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How manage aplastic anemia?
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CBC
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How manage Stevens-Johnson syndrome?
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1. Stop Rx
2. Supportive therapy; i.e., IV fluids (medical ward) |
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Carbamazepine clinical side effects?
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Neuro/musc: lethargy, blurred vision, ataxia
Hepatic: Jaundice, Nausea Derm: Maculopapular rash; alopecia |
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Carbamazepine Lab problems?
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decreased FTI (decreased FTI is seen in hypothyroidism)
leukopenia increased LFTs |
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Valproic Acid life threatening side fx?
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Hepatic necrosis
Thrombocytopenia (drop in platelets) |
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How hepatic necrosis present? tx?
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mental status change + coagulopathy like INR increased
tx: liver transplant, involve gastroenterology |
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how does thrombocytopenia present?
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1. bruising, bleeding gums
Tx: stop rx, if necessary platelet infusion |
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Valproid Acid non-life threatening side fx:
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Neuromusc: lethargy, depression, tremor, ataxia
Endo/metab: weight gain Hematologic: Bleding (Thrombocytopenia platelets less than 20K) Hepatic: jaundice, nausea, (Increased LFTS) Derm: maculopapular rash Other: back pain |
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Lamotrigine life threatening side fx?
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Stevens-Johnson syndrome
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Lamotrigine Non-life threatening side fx?
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Lethargy
NeuroMusc: Ataxia blurred vision Headache GI: Nausea Derm: Maculopapular Rash |
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Life Threatening Problems for Li, Carbamazepine, Lamotrigine, Valproic Acid?
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Li: renal failure, encephalopathy
Carbamazepine: Agranulocytosis, aplastic anemia, SJS Lamotrigine: Steven Johnson Syndrome Valproic Acid: Hepatic Necrosis, Thrombocytopenia |
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BTP: lab parameters to watch in carbamazepine
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Preg
CBC, Lytes Kidney (BUN, Cr) Liver Fxn (LFTs) TSH Urine analysis Drug Level |
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carbamazepine testing frequency?
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q 2 weeks
q monthly X 3 then q 3 months then if symptoms arise |
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Carbamazipine warning to patients (Rare, Serious, Common)
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Rare: This medicine may cause a form of anemia. Watch for unusual bleeding or bruising, fever, sore throat, rash (petechiae), mouth ulcers.
Serious: Blurred vision, uncontrollable eye or muscle twitches, slurred speech, increased seizures, severe tremor, sudden decrease in urination, severe dizziness, dark urine, yellowish skin or eyes. Common: Sedation, dizziness, tremors, clumsiness (ataxia), nausea, menstrual disturbances. |
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Carbamazepine drug interactions?
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Diltiazem (Cardizem and others), propoxyphene (Darvocet and others), verapamil (Calan and others), cimetidine (Tagamet and others),
erythromycin (Erythrocin and others), and fluoxetine (Prozac and others) increase drug level. • Phenobarbital (Luminal and others) and phenytoin (Dilantin and others) decrease drug level. • Carbamazepine can decrease the level of TCAs, warfarin (Coumadin and others), bupropion (Wellbutrin and others), oral contraceptives, valproic acid (Depakote and others), and atypical antipsychotics and its own levels. |
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BTP Lithium Lab parameters?
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Pregnancy
CBC, Lytes, Bun ,Cr ECG Urine Analysis TSH Drug Concentration BMI/Waist size |
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Frequency of lithium testing?
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drug levels q weekly X 4 weeks, then q monthly X 4months, then q quartely
Blood work q annually or symptomatic |
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Lithium warning: Caution, Serious, Other:
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Patients should use caution in hot weather, avoid activities that cause heavy sweating, and avoid drinking large amounts of caffeine (in cola drinks, coffee, and tea), which can cause dehydration by increasing urination. They should not make major changes in eating habits or go on a diet without consulting a doctor. Water and salt loss while taking this medicine can lead to serious side effects.
• Serious: Diarrhea, severe weakness, severe tremor, vomiting, slurred speech, blurred vision, infection with fever. • Other: Fatigue, weight gain, increased thirst, increased urination, mild tremor of hands, decreased libido, mild nausea/vomiting. |
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Lithium Drug Interactions?
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Nonsteroidal anti-inflammatory drugs (NSAIDs) and COX2 inhibitors, thiazides, spironolactone (Aldactone), triamterene (Dyrenium and others), and
angiotensin-converting enzyme (ACE) inhibitors increase lithium drug level. • Caffeine and osmotic diuretics decrease lithium drug level. |
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Valproic Acid Lab parameters to monitor
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Pregnancy
CBC, Lytes Kidney, Liver PROTHROMBIN time BMI Amylase Androgens Drug concentration |
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Frequency of Valproic Acid Lab tests?
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q 2weeks
then monthly X 6months (especially LFTs) then quartely |
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Valproic Acid warnings?
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Rare: This medicine may cause liver damage. Patients should contact their health care provider immediately, if they develop severe abdominal pain, weakness, tiredness, loss of appetite, vomiting, or yellowing of skin or eyes.
• Serious: Unusual bruising or bleeding, severe tiredness, confusion, increased seizures. • Other: Weight gain, diarrhea, drowsiness, mild stomach upset, dizziness, vision changes, tremor, joint pain, nausea, menstrual disturbances. |
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Valproic Acid Drug Interactions?
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Carbamazepine, phenytoin, and phenobarbital decrease valproic acid drug level.
• Valproic acid can increase drug levels of amitriptyline (Elavil and others), lamotrigine (Lamictal), diazepam (Valium and others), phenytoin, and phenobarbital. • No effect on oral contraceptives. |
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Lamotrigine monitoring warning?
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Serious: Rash, seizures. Patients should contact their health care provider immediately if they develop a rash, or if seizures are not controlled or get worse.
• Other: Headache, drowsiness, double vision, nausea, dizziness, sun sensitivity. |
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Lamotrigine monitoring?
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pregnancy test
liver, kidney fxn |
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Drug Interactions
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• Lamotrigine does not change levels of lithium, valproic acid, carbamazepine, phenytoin, or oral contraceptives.
• Valproic acid increases lamotrigine drug levels. • Phenytoin, carbamazepine, and phenobarbital decrease lamotrigine drug levels |
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antipsychotic warnings (atypicals)
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If patients develop involuntary movements (uncontrollable facial or body twitching, restlessness, excessive rigidity), they should contact their
health care provider immediately. • Some of these medications (ie, olanzapine, quetiapine, risperidone) may cause weight gain and diabetes. • For elderly patients, recent studies have shown that these agents may increase the risk of cerebrovascular and cardiovascular events (ie, strokes, heart failure, sudden death). 23-26 • Serious: Lightheadedness from low blood pressure, abnormal heartbeats, high fever, and muscle stiffness (NMS). • Other: Increased appetite and weight gain, increased sensitivity to heat and sunlight, somnolence (or insomnia), agitation, tremors, headache, dizziness, nausea. |
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Atypical interactions?
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Drug Interactions:
• Carbamazepine decreases all antipsychotic drug levels. • Smoking decreases drug levels of olanzapine. • Ciprofloxacin (Cipro and others), fluvoxamine (Luvox), and caffeine increase drug levels of olanzapine. • Fluoxetine, paroxetine (Paxil and others), and quinidine increase drug levels of risperidone and aripiprazole. • Ziprasidone is contraindicated with dofetilide, sotalol, quinidine, other Class IA and III anti-arrhythmics, mesoridazine, thioridazine, chlorpromazine, droperidol, pimozide (Orap), sparfloxacin, gatifloxacin (Tequin and others), moxifloxacin (Avalox and others), halofantrine, mefloquine (Larium), pentamidine, arsenic trioxide (Trisenox), levomethadyl acetate, dolasetron mesylate (Anzemet), probucol, and tacrolimus (Prograf and others). |
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Atypicals labs?
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Metabolic Parameters: BMI/weight (monthly) waist circum, Blood Pressure, Fasting Glucose, Insulin, Lipd Profile,
Prolactin Pregnancy Test Baseline ECG |
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Ziprasidone unique monitoring?
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In patients taking ziprasidone, which may cause QT prolongation (may also consider checking potassium and magnesium, as hypokalemia and
hypomagnesemia can increase risk of QT prolongation) |
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Clozapine Monitoring parameters
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Pregnancy Test
Metabolic: Weight/BMI, Waist Circumference, Fasting Glucose, Insulin, Lipid Profile Prolaction Clozapne level Agranulocytosis stuff: WBC, Neutrophils EKG, Troponin if suspect myocarditis |
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Clozapine Warnings?
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If patients develop involuntary movements (uncontrollable facial or body twitching, restlessness, excessive rigidity), they should contact their
health care provider immediately. • For the first 3 months of treatment, high fever may occur. If this happens often or is severe, patients should contact their health care provider. • This medication can cause weight gain and diabetes. Frequent blood testing is needed to monitor the white blood cell count. • Serious: Extreme tiredness, sore throat, seizures, tremors, fast heartbeat. • Other: Excessive salivation, somnolence, headache, drowsiness, confusion, dry mouth, nightmares. |
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Clozapine Interactions?
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Carbamazepine, captopril (Capoten and others), and sulfonamides increase the risk of agranulocytosis.
• Smoking, carbamazepine, phenytoin, and phenobarbital decrease drug levels. • Ciprofloxacin, SSRIs, erythromycin, and caffeine increase clozapine drug levels. |
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How frequently monitor parameters in clozapine?
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First half of year: weekly
Second six months: q 2weeks Once a month after that |
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Tricyclic Antidepressants monitoring parameters?
Frequency? |
Preg
Metabolic: Weight, Glucose ECG (if >40, preexisting cardiac disease) Cbc, Lytes, LFT DRUG level Freq: baseline, yearly, Sx |
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Tricyclic Warnings
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• This medicine may cause dry mouth. Taking sips of water or chewing sugarless gum may help.
• This medicine may cause drowsiness or blurred vision. Patients should not drive or operate machinery unless they are fully alert and can see clearly. • This medication can cause weight gain, affect diabetes, and decrease your ability to urinate. • Serious: Serious muscle problems, rapid heartbeat, fever with increased sweating or rash, severe twitching. • Other: Headache, dizziness, drowsiness, dry mouth, nausea, bad taste, increased appetite, weight gain, sexual dysfunction. |
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Tricyclic Antidepressants Drug Interactions:
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• Contraindicated with monoamine oxidase inhibitors (MAOIs).
• Carbamazepine, phenytoin, and phenobarbital decrease TCA drug levels. • Selective serotonin reuptake inhibitors (SSRIs), antipsychotics, and cimetidine increase TCA drug levels. |
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Monoamine Oxidase Inhibitors (MAOIs) - Phenelzine (Nardil), Tranylcypromine (Parnate), and others
Monitoring parameters? Frequency? |
BP
LFTs Freq: baseline, symptoms |
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Monoamine Oxidase Inhibitors (MAOIs) - Phenelzine (Nardil), Tranylcypromine (Parnate),
WARNINGS |
• Dietary interactions: Foods high in tyramine content (eg, beer, aged cheese, wine, liver) may cause a hypertensive crisis. Patients should not take any
other medicines without the approval of their health care provider (many drug interactions). • Serious: Dark urine, yellowish eyes or skin, rash, diarrhea, heavy sweating, severe chest pain, faster or slower heartbeat, large pupils, stiff neck, throbbing headache (hypertensive crisis). • Other: Dry mouth, trouble urinating, decreased blood pressure, tremor, mild headache, blurred vision, weakness, drowsiness. |
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MAOI Drug Interactions:
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Antidepressants, amphetamines, atomoxetine (Strattera), herbals, levodopa (Larodopa and others), lithium, methyldopa (Aldomet and others),
meperidine (Demerol and others), morphine (MS Contin and others), pseudoephedrine (Sudafed and others), tramadol (Ultracet and others), and triptans may cause serotonin syndrome or hypertensive crisis. |
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45 Selective Serotonin Reuptake Inhibitors (SSRIs) - Citalopram (Celexa and others), Fluvoxamine (Luvox), Paroxetine (Paxil), Sertraline (Zoloft and others), Escitalopram (Lexapro), Fluoxetine (Prozac and others) monitoring parameters |
Baseline Na and yearly
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SSRI Warnings
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• Some controversial studies have shown an increase in suicidal thoughts and behaviors during treatment with SSRIs, especially in children and
adolescents. • Common: Sexual dysfunction. • Serious: Severe nausea, vomiting, headache or diarrhea; severe agitation and confusion (serotonin syndrome). • Other: Nausea, headache, apathy, drowsiness, stomach pain, trouble sleeping, dizziness, dry mouth, sweating. |
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SSRI Drug Interactions:
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• Contraindicated with MAOIs
• SSRIs can increase drug levels of TCAs, phenytoin, and antipsychotics such as haloperidol (Haldol), fluphenazine (Prolixin), clozapine (Clozaril and others), and risperidone (Risperdal). • SSRIs can potentiate the effects of beta-blockers and warfarin. • Fluvoxamine can increase drug levels of caffeine, theophylline (Theolair and others), olanzapine, and benzodiazepines. • Risk of serotonin syndrome with other serotonin agents such as triptans, tramadol, and linezolid (Zyvox). |
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Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) - Venlafaxine (Effexor), Duloxetine (Cymbalta)
monitoring labs? |
BP baseline and quaterly
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SNRI's warnings (Venlafaxine, and Duloxetine)
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• Serious: Seizures (convulsions), thoughts of suicide.
• Other: Nausea, headache, drowsiness, dizziness, blurred vision, trouble sleeping, agitation, loss of appetite, sweating, dry mouth, sexual dysfunction, increased blood pressure. |
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SNRI's interactions (Venlafaxine, and Duloxetine)
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Drug Interactions:
• Contraindicated with MAOIs. • Duloxetine can increase drug levels of TCAs. • Increased drug levels of duloxetine with concurrent use of fluvoxamine, quinolone antibiotics, and paroxetine. |
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Noradrenergic/Specific Serotonergic Antidepressants - Mirtazapine (Remeron and others)
Monitoring labs |
Metabolic
CBC baseline and if symptoms arise |
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Noradrenergic/Specific Serotonergic Antidepressants - Mirtazapine (Remeron and others)
Warnings |
Warn patients about:
• Common: Increased appetite and weight gain. • Serious: Severe drowsiness, unusual excitement, severe nausea or vomiting. • Other: Sedation, dry mouth, abnormal dreams, lightheadedness |
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Noradrenergic/Specific Serotonergic Antidepressants - Mirtazapine (Remeron and others)
Interactions |
• Contraindicated with MAOIs.
• Clonidine (Catapres and others) decreases antihypertensive effect due to α-2 antagonism |
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Serotonin-2 Antagonist/Reuptake Inhibitors - Nefazodone (previously Serzone), Trazodone (Desyrel)
lab parameters |
LFTS baseline and quaterly
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Serotonin-2 Antagonist/Reuptake Inhibitors - Nefazodone (previously Serzone), Trazodone (Desyrel)
warnings |
Warn patients about:
• Black box warning: Risk of liver failure in nefazodone- 1/250,000. Patients should contact their health care provider immediatley if they develop nausea, vomiting, fever, fatigue, dark urine, light colored bowel movements, yellowing of eyes or skin. • Serious: Severe nausea or vomiting, severe drowsiness. • Other: Drowsiness, dry mouth, headache, weight gain, abnormal dreams, dizziness/lightheadedness. |
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Serotonin-2 Antagonist/Reuptake Inhibitors - Nefazodone (previously Serzone), Trazodone (Desyrel)
Interactions |
• Contraindicated with MAOIs.
• Nefazodone can cause increased drug levels of simvastatin (Zocor and others), cyclosporine (Sandimmune and others), tacrolimus, and triazolobenzodiazepines (triazolam and alprazolam [Xanax and others]). • Nefazodone drug levels are decreased by carbamazepine. • Trazodone can cause increased levels of carbamazepine and digoxin (Lanoxin and others). • Nefazodone, ketoconazole (Nizoral and others), and fluoxetine can cause increased drug levels of trazodone. |
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Norepinephrine and Dopamine Reuptake Inhibitors - Bupropion (Wellbutrin)
lab monitoring |
nil
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Norepinephrine and Dopamine Reuptake Inhibitors - Bupropion (Wellbutrin)
Warnings |
Warn patients about:
• Serious: Seizures (especially in patients with eating disorders), unusual excitement, chest pain. • Other: Hallucinations/vivid dreams, insomnia, increased tics, headache, nausea, rash, loss of appetite, agitation/anxiety. |
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Norepinephrine and Dopamine Reuptake Inhibitors - Bupropion (Wellbutrin)
Drug Interactions: |
• Bupropion may increase drug levels of paroxetine, fluoxetine, duloxetine, TCAs, risperidone, aripiprazole (Abilify), haloperidol (Haldol and
others), and beta blockers. • Contraindicated with MAOIs. |
