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213 Cards in this Set

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carbamazepine- brand name
tegretol
carbamazepine- seizure types
partial
tonic-clonic
carbamazepine- binding
high binding, low albumin can alter free concentration
carbamazepine- forms
tablet, SR, no IV due to low solubility
carbamazepine- metabolism
-liver converts cbz to cbz by 3A4 epoxide to cbz dihydrodiol
-cbz epoxide is active and toxic
-autoinduction of 3A4
carbamazepine- toxicity
-concentration related
-headache, anticholinergics, SIADH
-leukopenia, hepatitis, rash
carbamazepine- dosing/therapeutic range
-start low and titrate up due to autoinduction
-use tid and qid
-2-12 ug/ml
carbamazepine- drug interactions
-general inducer
Phenytoin- Brand name
Dilantin
Phenytoin- seizure types
partial
tonic-clonic
Phenytoin- binding
extensively bound
Phenytoin- metabolism
-t1/2= 24 hours
-saturable metabolism
-cyp 2c9, 2c19
-pregnants- increased metabolism and changes in binding
-old people- low vmax, low protein
-young people- high vmax
Phenytoin- doses
-tablets and suspensions are free acid
-capsules and inj are 92% phenytoin
-IM- painful, avoid, use fosphenytoin
IV- with NS
-Fosphenytoin is prodrug, give faster, less phlebitis
Phenytoin- toxicity
-CNS effects
-rash
-gingival hyperplasia
-hirsutism, coarse facial features
-osteoporosis due to Vit D metabolsim
Phenytoin- interactions
-cyp and ugt inducer
-ca antacids and sulcrafate
-enteral feedings decrease absoportion
phenytoin- therapuetic levels
10-20 ug/ml total, 1-2 ug/ml free
valproic acid- brand name
dopakote, depakene, depacon
valproic acid- binding
saturable binding
valproic acid- metabolism
-mostly by liver, ugt, b-oxidation
-t1/2- 14 hours in adults, 11 hours in children
-toxic metabolite due to cyp oxidation
valproic acid- toxicity
-weight gain
-tremors
-hyperammonemia
-lowered clotting
-hair loss
valproic acid- dosing
-titrate slowly to avoid slowly
-ER- give once daily but bioavailability is 15% less
valproic acid- forms
-depakene capsules, syrup
-depakote capsules- divalproex sodium
-depacon- no IM
valproic acid- therapeutic range
50-100 ug/ml
valproic acid- interactions
-inhibitor of cyp and udp
-metabolism can be induced
phenobarbital- binding
50%
phenobarbital- metabolism
-about half by cyp, some renal excretion
-really long half life
phenobarbital- adverse effects
-sedation
-decreased cognitive function
-excites kids
-megaloblastic anemia (folate deficiency)
-osteomalacia
-rash
phenobarbital- forms
tablets
syrup
injection
phenobarbital- drug interactions
induces cyp and ugd
phenobarbital- therapeutic range
15-40 ug/ml
gabapentin- brand name
neutontin
gabapentin- absorption
active absorption, saturable at 500 mg
gabapentin- binding
none
gabapentin- elimination
all renal
gabapentin- drug interactions
none
gabapentin- adverse effects
CNS effects
weight gain
edema
tolerate out
pregabalin- brand name
lyrica
pregabalin- absorption
not saturable
pregabalin- binding
none
pregabalin- elimination
renal
pregabalin- interactions
none
pregabalin- adverse effects
dizziness
blurry vision
somnolence
weight gain
euphoria
lamotrigine- brand name
lamictal
lamotrigine- binding
55%
lamotrigine- elimination
mostly hepatic glucuronidation
t1/2- 15 hours with inducer, 60 hours with inhibitor, 24 hours alone
lamotrigine- drug interaction
-metabolism is induced by inducers (cbz, pht, pb, oxc) and bcp
-metabolism is inhibited by vpa
-does not cause interactions
lamotrigine- adverse effects
-modest sedation
-minimal cognitive impairment
-headache
-insomnia
-rash: due to rapid titration, concomitant VPA, kids, rash with other AEDs
lamotrigine- therapeutic monitoring
4-20 ug/ml
Topiramate- brand name
topamax
Topiramate- mechanism
-blocks voltage-gated sodium and calcium channels
-enhance gaba activity
-blockade of excitatory glutamate
Topiramate- elimination
renal
Topiramate- binding
low
Topiramate- interactions
inhibits 2c19
induces 3a4
Topiramate- adverse effects
-with high doses
-CNS
-kidney stones
-weight loss
zonisamide- brand name
zonegran
zonisamide- binding
40%
zonisamide- t1/2
long
zonisamide- drug interactions
-does not inhibit or induce
zonisamide- metabolism
by cyp 3a4
zonisamide- adverse effects
-CNS
-depression
-kidney stones
-rash
-increse in serum creatinine
levatiracetem- brand name
keppra
levatiracetem- binding
low
levatiracetem- metabolism
mostly renal and metabolized outside of liver
levatiracetem- therapeutic monitoring
10-50 ug/ml
levatiracetem- adverse effects
-sedation
-behavioral effects
-weight neutral
-titrate slowly
oxcarbazepine- brand name
trileptal
oxcarbazepine- interactions
-induces 3a4 and ugt
-inhibits 2c19
-increases pht levels
-pb, cbz, pht decreases levels
oxcarbazepine- adverse effects
-CNS effects
-abdominal pain
-tremors
-hyponatremia
mental status exam
joimat
judgement, orientation, intellectual function, memory/mood, apprearance/affect, thought
types of schizophrenia
-paranoid
-disorganized
-catatonic
-undifferentiated
-residual
-schizophreniform
-schizoaffective disorder
-psychotic disorder due to general medical condition or sunstance induced
criteria for schizophrenia
-2 or more of the following: dilusions, hallucinations, disorganized speech, disorganized or catonic behavior, negative symptoms
-social or occupational dysfunction
-continuous signs of the disorder for more than 6 months
-exclude mood disorders
-not due to medical disorder or substance
-PPD must have delusions or hallucinations for a month
epidemiology of schizophrenia- age
15-25
epidemiology of schizophrenia- males to female
equal
clinical couse of schizophrenia- onset
abrupt or insidious, most have prodromal phase with negative symptoms
clinical couse of schizophrenia- intitial diagnosis
with positive symptoms
clinical couse of schizophrenia- disease course
fluctuates but ends up deteriorating
clinical couse of schizophrenia- remission
unlikely
schizophrenia- positive symptoms
hallucinations
delusions
disorganzed speech
bizarre behavior
psychomotor aggitation
schizophrenia- negative symptoms
alogia
flattened affect
avolition
anhedonia
poverty of speech
psychomotor retardation
schizophrenia- other symptoms
cognitive symptoms
mood symptoms
social and occupational symptoms
etiology of schizophrenia-
general 1%
sibling 10%
offspring 13%
dizygotic twin 10-15%
monozygotic twin 50%
pathophysiology of schizophrenia
-diseases or drugs that cause DA enhancement cause positive symptoms
--amphetamine and cocaine
-DA high in limbic
-DA low in prefrontal
-low glutamate
-NMDA receptor dysfunction
goals of schizophrenia
-acute stabalization: reduce threat, improve function, interventions
-stabalization: minimize relapse, compliance, optimize dose
-maintenance: improve QOL, maintain function, monitor for relapse, minimize ADR, maintain compliance and dose
conventional antipsychotics
-mesolimbic
-mesocortical
-nigrotriatal
-tuberoinfundibular
-stops positive symptoms
-increases negative symptoms
-causes EPS
-prolactin rises
high potency convential antipsychotics
haloperidol, fluphenazine
mid potency convential antipsychotics
loxapine, molindone, thiothixene, perphenazine
low potency convential antipsychotics
thioidazine, mesoridazine chloropromazine
EPS- acute dystonia
-acute muscle spasms
-within 5 days of initiation
-due to high potency, IM/IV, large dose
-treat with diphenhydramine, benztropine, anticholinergics, switch meds
EPS- pseudoparkinsonism
-20-40%
-starts within several months
-DA block cuases relative imbalance of DA and ACh
-decrease movement, muscle rigidity, resting hand tremor, drooling, mask-like face, shuffling gait
-treat by lowering dose, changing AP, give amantidine (antiparkinson agent)but will make worse
EPS- akathisia
-20% to all conventionals, 50% in high potency
-days to weeks, often months
-more presynaptic DA blockade vs postsynaptic DA blockade
-DA blockade in mesocortical tract increases locomotor activity
-can't distinguish from anxiety or psychosis
-inner restlessness, can't sit still
-treat- either up or lower dose, change AP or add b-blocker or add nezodiazepine
Tardive dyskinesia
-pathology: postsyn DA block leads to hypersensitivity
-Incidence: 20% on conventionals
-Risks: conventional AP, elderly, women
-Presentation: involuntary movements, lip smacking, blinking, face, neck, trunk, extremities
-Treatment: none
-management: minimize exposure, minimize dose, Vit E, change to clozapine
neuroleptic mailignant syndrome
-inidence is .2%
-mortatlity is 5-20%
-mean age- 40
-higher risk: mood disorders, lithium, catatonia
- all classes of typical AP
-1/3 will represent if rechallenged
nms diagnosis criteria
-on AP for 7 days
-hyperthermia >38
-muscle rigidity
-5 of the following: change in mental status, tachycardia, labile bp, tachypnea or hypoxia, diaphoresis or sialorrhea, tremor, incontinence, CPK elevation or myoglobinuria, leukocytosis, metabolic acidosis
-no other drug or medical reason
NMS treatment
-reduce risk factors
-early recognition and dc of AP
-supportive care
--fluids
--temperature
--cardiac, respiratory, kidneys
-DA agonists- bromocriptine, amantadine
Depot Ap
-haloperidol- 10-15 times daily dose, once a month
-fluphenazine- 1.25 times daily amount, every 2 weeks
-z track method
-stabalize on oral first
olanzapine- brand name
zyprexa
olanzapine- EPS
none
olanzapine- TD
low
olanzapine- adverse effects
-sedation
-weight gain
-orthostatic hypotension
-anticholinergics
olanzapine- forms
-rapid dissolve- zyprexa zydis
-Im is short acting
olanzapine- dose
5-20 mg/day
Riperidone- brand name
Risperdal
Riperidone- EPS
dose related > 6 mg
Riperidone- Td
low
Riperidone- adverse effects
-prolactin elevation
-othrostasis
-sexual dysfunction
Riperidone- forms
M tab
LA inj: risperdal consta (2 wk)
Riperidone- dose
4-16 mg
quetiapine- brand name
seroquel
quetiapine- EPS
none
quetiapine- TD
low
quetiapine- adverse effects
sedation
hypotension
HA
weight gain
lenticular formation
quetiapine- dose
250-750 mg
ziprasidone- brand name
geoedon
ziprasidone- eps
none
ziprasidone- td
low
ziprasidone- adverse effects
mild sedation
minimal weight gain
QTc prolongation
ziprasidone- forms
IM available
ziprasidone- dose
40-160 mg/day
clozapine- brand name
clozaril
clozapine- eps
minimal
clozapine- td
low
clozapine- adverse effects
agranulocytosis
seizures
sedation
hypotension
salivatoin
weight gain
clozapine- who
refractory patients
clozapine-monitoring
-weekly 6 months, bi weekly 6-12 months, monthly post 12 months
-WBC and ANC
-don't do if WBC<3500 and ANC<2000
clozapine- dose
200-900 mg
aripiprazole- brand name
abilify
aripiprazole- moa
partial agonist of D2 receports
antagonist of 5HT2A
partial agonist of 5HT1A
aripiprazole- EPS
none
aripiprazole- TD
none
aripiprazole- adverse effects
anxiety
HA
Nausea
constipatin
aripiprazole- dose
5-30 mg/day
metabolic syndrome
-need 3 of the following: abdominal obesity, hypertension, impaired fasting glucose, decreased HDl, elevated triglycerides
-atypical AP have been associated with weight gain, diabetes, lipid abnormalaties
Good reponse to treatment
-have precipitating factors
-abrupt onset
-positive symptoms
-less frequent family history
-good premorbid adjustment
bad response to treatment
-no precipitating factors
-insidious onset
-negative symptoms
-frequent in family history
-poor premorbid adjustment
Criteria for depressions
->5 of the following: DSIGECAPS
-social/occupational dysfunction
-not due to medical condition or drug use
-not due to bereavement
-not due to another mental health illness
types of depressions
-major (atypical, typical, psychotic)
-dysthimia
-organic caused
-substance induced
-medication induced
epidemiology of depression
-17%
-late 20s
-episode lasts 16 weeks
risks of depressions
family history
female
previous episode
chronic illness
substance abuse
pathophysiology of depression
-chemical imbalance
-decreased levels of neurotransmitter (5HT, DA, NE)
-dysregulation of receptors
Lab assessment for depression
-cbc for anemia
-thyroid- hypothyroid
-urine drug screen for substance abuse
amitriptyline-brand name
elavil
amitriptyline- antidepressant class
TCA
nortiptyline- brand name
pamelor
nortriptyline- antidepressant class
TCA
impiramine- brand name
tofranil
impiramine- antidepressant class
TCA
desipramine- brand name
norpramin
desipramine- antidepressant calss
TCA
clomipramine- brand name
anafranil
clmipramine- antidepressant class
TCA
TCA mechanism of action
-5HT and NE reuptake inhibitor
-amount of 5HT and HE effects depends on structure:
--three amines: 5HT
--two amines: NE
TCA side effects
-cardiovascular
-anticholinergic
-sedation
-weight gain
-sexual dysfunction
Phenelizine- brand name
nardil
phenelizine- antidepressant class
MAOI
tranylcypromine- brand name
parnate
tranylcypromine- antidepressant class
MAOI
MAOI mechanism of action
irreversible inhibition of MAOA and MAOB which increases 5HT, DA, NE
MAOI side effects
-hypotension
-dizziness
-weight gain
-insomnia
-cardiac effect
-constipation
-sexual dysfunction
MAOI risks
-hypertensive crisis
-food-drug interaction with tyramine
MAOI drug interactions
-stimulants
-CNS antihypertensives
-antidepressents
-start SSRI after 14 days
-5 half-life wash out of previous antidepressant
Tyramine contraindications
-absolute: aged cheese, aged and cured meats, banana peel, sauerkraut, soy sauce, tap beer, marmite
-moderate: red/white wine, bottled/canned beer
MAOI and merperidine/demerol
agitation, seizures, coma
MAOI and SSRI
hypertensive crisis
MAOI and TCA
hypertensive crisis
MAOI and stimulants
hypertensive crisis
MAOI and levadopa
hypertensive crisis
selegiline patch- brand name
emsam
selegiline patch- indication
major depression
selegiline patch- Mechanism of action
-MAOA inhibitor, MAO B at dose dependent
-food restrictions at 9 mg
-start low
citalopram- brand name, andtidepressant class
celexa
SSRI
escitalopram- brand name, antidepressant class
lexapro
SSRI
Fluoxetine- brand name, antidepressant class
prozac, prozac weekly, sarafem
SSRI
Fluvoxamine- brand name, antidepressant class
luvox
SSRI
Paroxetine- brand name, antidepressant class
paxil, paxil CR
SSRI
sertraline- brand name, antidepressant class
zoloft
SSRI
fluoxetine- half life
long (72 hours)
fluoxetine- metabolism
2d6, 3a4, 2c inhibition
sertraline- metabolite
active
fluoxetine- metabolite
active
fluvoxamine- metabolism
1a2, 3a4, 2c inhibition
paroxetine- side effects
anticholinergic
paroxetine- half life
shortest
paroxetine- metabolite
not active
paroxetine- inhibition
2d6
citalopram- activity
only 5HT activity
escitalopram- what is it
s-enantiomer of citalopram
SSRI side effects
-2 weeks: nausea, diarrhea, sedation, insomnia, anxiety
-chronic: headache, sexual dysfunction, night sweats, nightmares
SSRI toxicity
serotonin syndrome: hyperthermia, excitement, rigidity, hypotensinon, diaphoresis, tachycardia
Venlafaxine- brand name
effexor, effexor ER
Venlafaxine- MOA
SNRI but only at higher doses
Venlafaxine- metabolite
active
Venlafaxine- side effects
-N/D
-headache
-hypertension
-sexual dysfunction
-nervousness
-anxiety
-XR reduces side effects
Duloxetine- brand name
cymbalta
Duloxetine- MOA
SNRI
Duloxetine- side effects
nausea
insomnia
headache
Duloxetine- substrate fo
2d6, 1a2
Buproprion- brand name
wellbutrin, wellbutrin SR, wellbutin XL
Buproprion- MOA
NDRI
Buproprion- contraindications
seizure disorder
eating disorder
zyban
Buproprion- side effects
GI upset
headache
restlessness
seizures
insomnia
no sexual dysfuntion
Nefazodone- brand name
serzone
Nefazodone- MOA
SRI and S2 antagonist
Nefazodone- drug interactions
3a4 inhibitor
Nefazodone- forms available
only generic due to liver damage
Nefazodone- side effects
dry mouth
nausea
dizziness
constipation
sedation
liver failure: monitor LFT
no sexual dysfunction
Mirtazapine- brand name
remeron, remeron sol tabs
Mirtazapine- MOA
-alpha 2 antagonist, 5HT3, 2A, 2C antagonist
-increased NE, 5HT
Mirtazapine- side effects
Sedation
weight gain
dry mouth
constipation
no sexual dysfunction
Trazodone- class
heterocyclic antidepressant
Trazadone- MOA
increase 5HT, block H1
Trazadone- uses
insomnia now, not depressino
SJW-interaction
bcp
refractory depression
-adequate trial of initial agent
-assess for unrecognized drug and medical causes
-combo antidepressants
-augmentation: lithium, antipsychotics, stimulants, thyroid
-ECT