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184 Cards in this Set
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Define the types of GAD.
Primary, secondary, tertiary, quaternary |
primary - occurs by itself and not in response to something else
secondary - due to medical condition or substance tertiary - response to acute stress quaternary - associated with psychiatric disorder |
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Describe the effects of norepinephrine on the following areas:
locus ceruleus, hippocampus, amygdala |
locus ceruleus - tachycardia, sweating
hippocampus - increased unpleasant memory amygdala - magnifies bad memories |
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Overactivity of what leads to a state of constant arousal and hypervigilance?
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norepinephrine
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What are some substances and/or medical conditions that can cause severe anxiety or panic?
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caffeine, alcohol, nicotine, cold meds, cannabis, amphetamines, cocaine, hyperthyroidism, hyperparathyroidism, pheochromocytoma, seizure d/o, cardiac arrhythmias, copd, hypoglycemia, angina, parkinson's, depression, schizophrenia, bipolar d/o, eating d/o, life changes
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What are the four pharmacologic effects obtained from benzodiazepines?
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anxiolytic, anticonvulsant, muscle relaxant, sedative-hypnotic
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What are some off label uses for benzos?
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IBS, PMS, RLS, essential tremor, CP, spasticity assoc. with various neuro. d/o's - CP, paraplegia
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Where are benzos on the drug schedule?
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schedule IV
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What is versed indicated for?
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induction of sedation
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What is klonopin used for?
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anticonvulsant, tx of panic d/o
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What is the half life of klonopin?
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20-50hrs - once daily dosing
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What is the half life and dosing of xanax and ativan?
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10-20 hrs - tid to qid dosing
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what benzos are preferred in patients with liver disease and the elderly?
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lorazepam, temazepam (restoril), oxazepam
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which benzo has the quickest onset of action?
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diazepam
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Which benzo is preferred for IM injection?
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lorazepam
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What are the "high potency" anxiolytic benzos?
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xanax, ativan, klonopin
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What are some off label uses for benzos?
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IBS, PMS, RLS, essential tremor, CP, spasticity assoc. with various neuro. d/o's - CP, paraplegia
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Where are benzos on the drug schedule?
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schedule IV
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What is versed indicated for?
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induction of sedation
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What is klonopin used for?
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anticonvulsant, tx of panic d/o
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What is the half life of klonopin?
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20-50hrs - once daily dosing
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What are the disadvantages of Benzo's?
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potential for abuse and dependence (less with serax and librium), do not treat depression (can cause depression)
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What is librax a combination of?
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anticholinergic and librium
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What are the advantages of using benzos to treat GAD?
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rapid onset, better efficacy for physical anxiety sx, can be used prn, lower cost, better tolerability
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Side effects of benzos?
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sedation, feeling of tiredness, cognitive impairment, anterograde amnesia, paradoxical reaction, psychomotor effects, respiratory depression, discontinuation syndromes
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T or F? Tolerance to benzos develops more quickly in the elderly.
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False. Tolerance to benzos develops more slowly in the elderly
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What are the discontinuation syndromes?
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addiction, physical dependence, relapse, rebound, withrawal
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When does withdrawal start with benzos?
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short half life - 1 to 2 days
long half life - 4 to 7 days |
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What drug can be given to help ease sx of withdrawal from benzos?
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tegretol
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How should you discontinue benzos?
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10 - 25% decrease in dosage every 1-2 weeks
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What are drug interactions with benzos?
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cyp 3a4 inhibitors, alcohol/cns depressants, OCP's
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What are the best choices of benzos for a pregnant woman that has to have them?
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xanax, ativan
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How does buspar work?
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reduces serotonin neurotransmission, enhances dopaminergic neurotransmission
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What are advantages of using buspar to treat GAD?
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no cns depressant effect, no abuse or dependence potential, no sexual dysfunction, may be useful in tx of depression
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How long does it take Buspar to work? What can you give until it begins to take effect?
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1-2 weeks. give benzo for short term relief of sx
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What is first line tx for anxiety d/o's?
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antidepressants
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What can be seen initially when using antidepressants to treat anxiety?
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initial increase in anxiety
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Which SSRI is indicated for all 5 anxiety disorders?
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Paxil
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side effects of paxil?
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sedation, nausea, dry mouth, constipation, asthenia, HA, sexual dysfunction, wt gain
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What was the first antidepressant approved for GAD?
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effexor
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What can be used to treat physical sx of anxiety (tremor, flushing, tachycardia)?
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beta blockers
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side effects of antihistamines?
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sedation, confusion, cognitive impairment, nausea, constipation
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What is the duration of tx for anxiety?
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6-12 months after response
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List all the med classes available to treat anxiety.
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antidepressants (ssri, tca, snri), benzodiazepines, beta blockers, antihistamines
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T or F. You must lower the dose of Buspar in renal or hepatic impairment.
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true
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What is used to treat panic d/o?
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ssri's, tca's, benzo's
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Which ssri's are FDA approved to treat panic d/o?
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paxil, zoloft, prozac
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Which benzos are FDA approved to treat panic d/o?
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xanax XR, klonopin
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What is a disadvantage to using xanax to treat panic d/o?
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short acting --> breakthrough anxiety
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What is the most effective TCA for tx of panic d/o?
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anafranil
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What is used to treat social anxiety d/o?
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antidepressants (paxil, zoloft, effexor), benzos (klonopin, xanax), buspirone (in addition to ssri's)
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What is the best drug to treat performance anxiety?
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beta blockers
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What are some drugs used to treat PTSD?
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SSRI's (paxil, zoloft), nefazodone, mirtazapine, effexor, buproprion, TCA's (can be dangerous), anticonvulsants, atypical antipsychotics, prazosin (for nightmares), benzos (though generally ineffective)
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Drugs for Tx of OCD?
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SSRI's (luvox, prozac, paxil, zoloft), TCA's (anafranil), effexor, antipsychotics, benzos
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When should you use TCA's for tx of OCD?
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after failure of two ssri's
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In whom should you use TCA's with caution?
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hx of seizures, head injury or other factor that may lower seizure threshhold
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Side effects of TCA's?
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sedation, dry mouth, dizziness, tremor, constipation, nausea, blurred vision, insomnia, HA, wt gain, sexual dysfunction additive effects with etoh
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Monitoring parameters of TCA's?
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EKG - baseline in pts at risk for heart disease and peds pts, LFT's
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Drug interactions with TCA's?
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methylphenidate, haloperidol, SSRI's, modafanil, valproic acid, enalapril - these will all INCREASE Anafranil levels
carbamazepine, dilantin, phenobarbital - these will all DECREASE anafranil levels |
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When using an SSRI with anafranil for tx of OCD, which drug should you lower the dose of ?
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anafranil
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Which antipsychotics are used to treat OCD?
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risperidone, olanzepine, quetiapine
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What might an antipsychotic cause in a schizophrenic pt with OCD?
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worsening of OCD sx
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Although benzos are generally ineffective for tx of OCD, which one is generally the best choice if used?
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klonopin
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What other effects (besides not sleeping) can insomnia have on the body?
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decreased immune system, increased inflammatory processes, decreased brain neurotransmitters, anxiety, depression, hypertension, breathing, GI, pain problems
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What are the stages of sleep?
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I - relaxed wakefulness
II - rapid wave alpha III, IV - slow wave delta REM - has aspects of deep and light sleep |
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T or F. As age increases deep sleep increases.
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False
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What are the neurochemicals that support wakefulness?
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norepi, ach, histamine, substance P, thyrotropin RF, corticotropin RF
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What effect to benzos have on REM?
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suppression via GABA stimulation
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Examples of dyssomnias?
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intrinsic - idiopathic, narcolepsy
extrinsic - hygiene, substance use/abuse circadian - shift work, jet lag |
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Examples of parasomnias?
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arousal - sleep walking
sleep wake transition - leg cramps REM assoc. - nightmares |
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Non-pharmacologic tx for insomnia?
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dark, phototherapy, no naps, no late exercise/shower, ritual, sleep hygiene
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What drugs should be avoided in pts with sleep apnea?
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sedative-hypnotics
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What drugs are good for sleep onset insomnia?
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sedative-hypnotics
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Examples of sedative-hypnotics.
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sonata, ambien, lunesta
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Which sedative-hypnotic is least likely to cause residual daytime sedation?
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sonata
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What pregnancy category is sonata?
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C
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side effects of sonata?
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dizziness, HA, somnolence
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In whom should you lower the dose of sedative-hypnotics?
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hepatic impairment(sonata), elderly
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What pregnancy category is ambien?
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B
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Can you give ambien to a breastfeeding mother?
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NO
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Side effects of Ambien?
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nausea, dizziness, drowsiness
Rare - delirium, nightmares, hallucinations |
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What is the max dose of lunesta that can be given in pts with hepatic impairment?
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2 mg
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What is a unique "interaction" of Lunesta?
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high fat meal
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What is the pregnancy category of lunesta?
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C
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Adverse effects of lunesta?
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dysgeusia, HA, coldlike sx
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List all the drug classes used to treat insomnia.
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sedative-hypnotics, benzodiazepine hypnotics, antidepressants, melatonin agonists
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What benzos are used to treat insomnia?
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halcion, restoril
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Which benzo is good for sleep onset insomnia?
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halcion
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Which benzo is good for sleep maintenance insomnia?
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restoril
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Contraindications for halcion and restoril?
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narrow angle glaucoma, hx of substance abuse
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drug interactions for halcion?
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phenothiazines, barbiturates, etoh
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adverse effects of halcion?
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dizziness, drowsiness, HA
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adverse effects of restoril?
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drowsiness, HA, nervousness, dizziness
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What antidepressants are used to treat insomnia?
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desyrel, nefazodone, elavil
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What class of drug is Rozerem?
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melatonin agonist
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What type of insomnia is rozerem approved for?
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sleep onset
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when do you give rozerem?
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30 min. before bedtime
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contraindications to rozerem?
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severe hepatic impairment
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drug interactions with rozerem?
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cyp 1a2 (luvox), cyp 3a4 (ketoconazole), cyp 2c9 (fluconazole)
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What pregnancy category is rozerem?
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C
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How do you treat obstructive sleep apnea?
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weight loss, anatomic modification
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How do you treat central sleep apnea?
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C-PAP, prozac, paxil
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In whom is RLS more common?
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elderly
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Tx for RLS?
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decrease caffeine, stop smoking, benzos, dopamine agonists, opioids, some anticonvulsants (tegretol), neurontin, ultram, magnesium
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Some organic causes for RLS?
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parkinson's, hypothyroidism, uremia, chronic bronchitis, iron deficiency, B12 deficiency, decreased Ca?, decreased K?, meds?, akathesia
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T or F? Rozerem does not have the potential for abuse and/or impairment.
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True
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Sx of withdrawal from benzos?
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anxiety, insomnia, irritability, muscle aches/weakness, tremor, loss of appetite
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What is the most important dopamine receptor in the pathophysiology of schizophrenia?
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D2
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Besides dopamine, what neurotransmitters play a role in the pathophysiology of schizophrenia?
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5ht, glutamate, NMDA, GABA
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What are positive sx of schizophrenia?
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hallucinations, delusions, disorganization of thought and behavior
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What are negative sx of schizophrenia?
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flat affect, alogia, anhedonia, avolition
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What role do benzos play in the tx of schizophrenia?
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adjuvants that may allow for lesser dose of primary drug.
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What is the main disadvantage to using benzos in the tx of schizophrenia?
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they disinhibit behavior which is not good for pts who exhibit aggressive behavior
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Can you use lithium or anticonvulsants to treat schizophrenia?
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yes, if the pt has a poor or partial response to antipsychotics
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T or F? High potency antipsychotics are more likely to cause drowsiness.
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F. They are less likely to cause drowsiness but more likely to cause extrapyramidal side effects.
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Regarding extrapyramidal side effects, what does PADA stand for?
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P - parkinson's
A - akathesia D - dystonia A - akinesia |
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By what mechanism do antipsychotics work?
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D2 and 5ht receptor antagonism
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T or F? Tardive dyskinesia is probably reversible.
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False. It is difficult if not impossible to reverse
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In general, what are some adverse drug reactions associated with antipsychotics?
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orthostasis, tachycardia, long qt, torsade's, wt gain, NMS, hepatic abnormalities (benign unless cholestatic jaundice is present), seizures (low potency typicals)
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What neurotransmitters are involved in depression?
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5ht, NE, Dopamine
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If a pt exhibits anhedonia, decreased energy, and/or decreased memory, what neurotransmitter is more likely to be involved?
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nor-epinephrine
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What sx does 5ht affect?
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appetite, sleep, libido, motor function, anxiety, aggression
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Regarding depression, which pts do you reserve benzos for?
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treatment resistant, severe vegetative state, psychotic depression, and depression in pregnancy
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T or F? All medications for depression have delayed onset of therapeutic effects.
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true
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What are some concurrent medical/psychiatric conditions to consider when choosing an antidepressant?
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obesity - no TCA or mirtazapine
seizure d/o - no buproprion HTN - no effexor anxious or insomnia - no mirtazapine or nefazodone |
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What is the minimum duration of tx for depression?
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7 months after full therapeutic response
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What drug class is 1st line for tx of depression?
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SSRI's
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Side effects of ssri's?
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nausea, diarrhea, constipation, insomnia, somnolence, EPS with paxil, sexual dysfunction HA, wt gain
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What is the onset and duration of discontinuation syndrome seen with ssri's?
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onset 48-72 hrs after last dose
duration 3-7 days |
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Pregnancy category of ssri's?
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C
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Pregnancy category of buproprion?
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B
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What ssri's are contraindicated in breastfeeding?
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doxepin and prozac
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drug interactions of ssri's?
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TCA, CCB, estrogen, theophylline, dilantin, warfarin, triazolobenzodiazepines, and cisapride
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what ssri's have the lowest potential for drug interactions?
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zoloft, citalopram, escitalopram
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ssx of serotonin sydrome?
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anxiety, shivering, diaphoresis, tremor, hyperreflexia, autonomic instability,
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Side effects of TCA's?
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dry mouth, sedation, constipation, blurred vision, urinary retention, orthostatic hypotension, arrhythmias,
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Contraindications/precautions with TCA's?
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BPH, cardiac arrhythmias, narrow angle glaucoma, dementia
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Side effects of phenylpiperazines (serzone and desyrel)?
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sedation, orthostatic hypotension, liver failure (serzone), priapism (desyrel)
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Advantages to phenylpiperazines?
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no wt gain or sexual side effects
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drug interactions with phenylpiperazines?
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triazolam, xanax, midazolam, - all cause increase in half life
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What neurotransmitters do effexor and cymbalta effect?
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serotonin and norepi
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side effects of snri's?
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GI, sleep disturbances, sexual dysfunction, HTN(high doses)
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Side effects of wellbutrin?
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nausea, insomnia, jitteriness, wt loss,
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Contraindications for wellbutrin?
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hx of epilepsy, bulimia
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drug interactions with wellbutrin?
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effexor - increased levels
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define bipolar I.
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one or more mixed or manic episodes without depression
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define bipolar II.
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hypomania and depression without mania or mixed
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what are some drugs that can induce mania?
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antidepressants, CNS stim., corticosteroids, anabolic steroids, caffeine, levodopa, otc stim., energy drinks?
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Can you use antidepressant monotherapy for bipolar depressive episodes?
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no - it might induce mania
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What is first line tx for mania?
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lithium, divalproex, atypical antipsychotics, or a combination
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Which has a more rapid onset of action - lithium or valproate?
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valproate
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monitoring parameters for valproate?
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baseline - cbc, platelets, LFT, hcg monthly x 3 months, then every 3-6 months
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drug interactions for valproate?
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asa, dilantin, phenobarbital, lamictal, rifampin, warfarin, tegretol
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enzyme inducing drugs like dilantin and tegretol will cause increased clearance of valproate. Likewise, valproate causes increases in free serum dilantin
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side effects of valproate?
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gi, sedation, ataxia, tremor, benign hepatic enzyme elevations, thrombocytopenia, alopecia, wt gain, pcos, hyperammonemia, fulminant liver failure, agranulocytosis, pancreatitis
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At what level hepatic transaminase elevation do you dc valproate?
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>2-3 x ULN
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monitoring parameters for lithium?
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baseline - ecg (if cardiac risk), electrolytes, bun/cr, urine sp. gravity, tsh, t4, wbc, hcg
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side effects of lithium?
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intention tremor, diarrhea, polyuria, renal dz, hypothyroidism
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ssx of mild lithium toxicity?
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apathy, lethargy, muscle weakness, nausea, irritability
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ssx of moderate lithium toxicity?
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coarse tremor, slurred speech, unsteady gait, drowsiness, confusion, muscle twitches, blurred vision
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ssx of severe lithium toxicity?
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seizures, coma, stupor, cardiovascular collapse
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What should you tell your pts can lead to increased lithium levels?
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dehydration, fever, vomiting, too much Na
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What are some drugs that can increase lithium levels?
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nsaids, diuretics, ACEi
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What are some drugs that can lower lithium levels?
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caffeine, theophylline, acetazolamide, sodium
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What are some drugs that can increase lithium toxicity?
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methyldopa, tegretol, CCB's, antipsychotics, ssri's
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When should you draw the sample for a lithium level?
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12 hrs after last dose
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What pregnancy category is lithium?
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D
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T or F? atypical antipsychotics are effective in mania only when psychotic sx are present.
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false.
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side effects of zyprexa?
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hyperglycemia, development of DM, wt gain, somnolence, dry mouth, slurred speech, postural hypotension
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side effects of risperdal?
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EPS
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drug interactions with risperdal?
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tegretol may decrease levels by 50%
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T or F? seroquel is not as useful as other antipsychotics for acute agitation/psychosis
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true
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monitoring parameters for seroquel?
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semiannual eye exams to monitor for lens changes
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In which bipolar pts do you use clozaril?
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only those who fail to respond to other tx
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side effects of clozaril?
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agranulocytosis, seizures, wt gain, sedation, anticholinergic se's, cognitive impairment
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drug interactions with clozaril?
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benzos
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major side effect of geodon?
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qt prolongation
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what effect does tegretol have on the following; oral contraceptives, warfarin, theophylline, haloperidol, TCA's?
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reduced effect
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what drugs can increase tegretol levels?
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e-mycin, tagamet, prozac, CCB's
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they are all cyp 3a4 inhibitors
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side effects of tegretol?
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ataxia, blurred vision, diplopia, fatigue, leukopenia, agranulocytosis, thrombocytopenia, aplastic anemia, hyponatremia, rash (sjs), wt gain, gi, elevated liver enzymes, can cause neural tube defects
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monitoring parameters of tegretol?
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baseline - cbc, LFT every 2 weeks x 2 months then every 3 months
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side effects of lamictal?
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dizzines, HA, ataxia, blurred vision, gi, rash (SJS)
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When are benzos used for bipolar d/o?
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as an adjunct for acute agitation
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when is haldol used for bipolar d/o?
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short term mgmt of agitated mania
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side effects of haldol?
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tachycardia, lightheadedness
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T or F? Haldol has no use for bipolar d/o beyond the acute stage.
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true
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