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179 Cards in this Set
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What side effects are common to all SSRIs?
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ED/delayed ejaculation
anorgasmia dec libido (men and women) anorexia -> weight loss -> weight gain bruxism suicidal ideation and behavior inc risk of UGI bleeding |
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What must you warn pts about when prescribing an SSRI?
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link w/suicide
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What is the discontinuation syndrome associated with SSRIs?
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N/V/D, agitation, insomnia, anorexia, flu-like illness if you don't titrate down slowly
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What inc the risk of UGI bleed in pt taking SSRI?
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high dose NSAID use
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HTN + fever + hyperreflexia + clonus in the LE + ocular clonus + mental status changes = ?
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moderate seratonin syndrome
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What is the difference between mild and moderate seratonin syndrome?
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mental status changes
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What temp is considered severe seratonin syndrome? (in addition to inc severity of other symptoms)
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41 C or higher
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What are three consequences of poorly controlled hyperthermia from seratonin syndrome?
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rhabdo
DIC ARF |
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How are seizures and cardiovascular shock related to SSRI use?
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seratonin syndrome (severe)
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What drugs are most likely to cause serotonin syndrome when taken in combo? Which ones are possible but not as likely?
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SSRIs, SNRIs, MAOIs TCAs, St John's Wort, buspirone, mitazipine, trazadone
possibly - INH, linezolid, dextromethorphan, tramadol, Li, meperidine, selegiline |
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What is the classic MAOI?
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phenylzine
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What is meperidine? Why is it in the psych drug card list???
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opioid analgesic strong agonist in the phenylpiperadine family w/fentanyl -- it may cause seratonin syndrome when given w/SSRI (not likely)
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What is selegiline?
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MAOB inhibitor (for parkinson's)
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How is seratonin syndrome treated?
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d/c meds
cool pt down benzos cyproheptadine (antihistamine that is a seratonin antagonist) intubation (maybe) |
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How does fluoxetine work?
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blocks presynaptic serotonin reuptake pump
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What are the indications for use of fluoxetine?
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MDD
OCD panic disorder bulimia nervosa PMDD |
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What are the cytochrome interactions of fluoxetine?
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2C9 and 2D6 substrate
2D6 inhibitor *** |
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What skin/allergic events is fluoxetine associated with?
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vasculitis, lupus-like syndrome, anaphylactoid rxns
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What are the 2D6 substrates?
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beta blockers (not atenolol)
TCAs antiarrythmics (flecainide, mexilitine, propafenone) Antipsychotics SSRIs (fluoxetine, paroxetine) Opiods donepazil duloxetine haloperidol chlorpromazine Tramadol Tamsulosin Tolteridine |
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What ar the indications for use of sertraline?
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MDD
OCD panic disorder PTSD social anxiety disorder PMDD |
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sertraline is FDA approved for which indication that fluoxetine is not?
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PTSD and social anxiety disorder
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What are the cytochrome interactions of sertraline?
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low likelihood!!
2C19 and 2D6 substrate |
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What are the 2C19 substrates
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phenytoin
omeprazole lansoprazole sertraline nelfinavir |
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What are two 2C19 inhibitors?
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gemfibrozil
cimetidine |
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Which population is more likely to have a mutation impairing metabolism by 2C19?
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asian
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What is the main reason pts d/c sertraline? this SE is more likely with this than any other SSRI
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nausea
*also insomnia, HA,SIADH and anxiety like all SSRIs |
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What is the side effect unique to paroxetine?
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anticholinergic effects (more than the other SSRIs)
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What are the cytochrome interactions of paroxetine?
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like fluoxetine:
2D6 substrate and inhibitor |
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Why should you be careful giving paroxetine w/diphenhydramine? What other drugs may cause similar problems?
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anticholinergic (xerostomia, constipation, sedation)
TCAs, scopalamine, dimenhydranate, solifenacin, darifenacin, oxybutynin, tolteridine, trospium |
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what is the only FDA approved clinical indication for citalopram?
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depression
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What are the cytochrome interactions of citalopram
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minimal inhibition like sertraline!
2C19 and 3A4 substrate |
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What are the 3A4 substrates?
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CCBs (diltiazem and verapamil inhibit it), benzos (alparazolam, diazepam, midazolam), Statins (atorvastatin and lovastatin), Macrolides (not azithro), PIs, OCPs, losartan, sildenafil, amiodarone, theophylline, carbamazepine
citalopram, mirtazapine |
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What are the 3A4 inhibitors?
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cimetidine, macrolides, ritonavir, grapefruit juice, amiodarone
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What are the 3A4 inducers?
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rifampin, carbamazepine, st john’s wort, phenytoin
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What does citalopram claim to cause less of than other SSRIs? (besides less inhibition of hepatic enzymes)
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less sexual dysfunction
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What is escitalopram?
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S-enantiomer of citalopram
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What are the cytochrome interactions of escitalopram?
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substrate of 2C19 and 3A4 (like citalopram)
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What are ADRs of escitalopram?
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the usual (HA, somnolence, insomnia, nausea, SIADH)
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What is the only thing fluvoxamine is approved for?
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OCD
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What are the cytochrome interactions of fluvoxamine?
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2D6 substrate
STRONG inhibitor of 1A2, 3A4, and 2C19 |
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What is fluvoxamine more likely to cause in terms of ADRs than other SSRIs (except may sertraline)
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N/V
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Name two SNRIs
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duloxetine
venlafaxine |
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What might work well for a second option in a pt not responding to SSRIs?
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SNRI (duloxetine or venlafaxine)
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What are the cytochrome interactions of venlafaxine?
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2D6 and 3A4 substrate
minimal inhibition |
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What are the side effects unique to venlafaxine?
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SNRI -
BP elevations possible abrupt d/c may be more severe than w/SSRIs OD is similar to TCAs |
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What is similar between OD on venlafaxine and a TCA?
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QT prologation, etc (OD usually will lead to an arrythmia with these two drugs)
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What may happen with abrupt discontinuation of SNRI?
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dizziness
flu-like symptoms anxiety |
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What are the two clinical indications for duloxetine?
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MDD
diabetic nephropathy (venlafaxine was FDA indicated for MDD, GAD, and social anxiety) |
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What is the most common side effect of duloxetine?
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nausea
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what are the cytochrome interactions of duloxetine?
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1A2 and 2D6 substrate
inhibitor of 2D6 |
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Which is a 3A4 substrate, venlafaxine or duloxetine?
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venlafaxine (duloxetine is 2D6)
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Which SNRI causes xerostomia?
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duloxetine (maybe both, but only this was in powerpoint)
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Which antidepressant is a structural analogue of amphetamines?
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bupropion
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What are the cytochrome interactions of bupropion?
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multiple and minimal
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What drugs lower the seizure threshold?
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antipsychotics
Fluoroquinolones theophylline bupropion |
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This drug is contraindicated in pts w/anorexia or bulimia. Why?
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bupropion; seizures
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These drugs claim to cause less sexual dysfunction
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bupropion*
SNRIs citalopram |
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How does trazadone work?
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inhibits seratonin reuptake
and blocks H1 and alpha1-adrenergic receptors |
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What are the cytochrome interactions of trazadone?
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3A4 substrate
2D6 inhibitor (but not strong like fluoxetine and paroxetine) |
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Is trazadone first line?
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NO!
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What are the side effects of trazadone?
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sedation (of course)
postural hypotension priapism nausea (of course) dysrhythmias hepatoxicity |
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What drug similar to trazadone was pulled from the market and why?
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nefazadone; hepatoxicity (failure)
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Trazadone should be used w/caution in which pts?
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cardiac and hepatic disease
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How does mirtazapine work?
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hits pre and postsynaptic alpha-TWO receptors and seratonin receptors
and is a H1 antagonist (inc NE and 5Ht) |
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What are the cytochrome interactions of mirtazapine?
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substrate of 1A2, 2D6, and 3A4
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Which drug causes more sedation at low doses? (crazy)
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mirtazapine
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Which "other" antidepressant causes appetite stimulation and weight gain?
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mirtazapine
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Mirtazapine causes what side effects?
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sedation
weight gain dry mouth but less sexual dysfunction |
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What kills most pts in a TCA OD?
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QT prolongation
(but also could be anticholinergic toxicity --> seizures) |
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Which 3 drugs lead to QT prolongation if OD?
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TCAs
theophylline venlafaxine |
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What must you do before starting a pt on a TCA?
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screen for conduction abnormalities
>40 - get ECG <40: screen by hx, if neg --> no ECG necessary |
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What history would prompt you to get an ECG before starting a TCA in a pt <40?
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known heart disease
syncope palpitations DOE SOB CP strong family hx of heart dz |
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What happens when you stop the TCA too abruptly?
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irritability, agitation, sleep disturbance, flu-like symptoms, cardiac arrythmias (last one is rare)
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Which TCAs are tertiary amines?
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imipramine
amitriptyline |
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which TCAs are secondary amines?
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desipramine
nortriptyline |
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Which are better tolerated, secondary or tertiary amines?
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secondary
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Which TCA has been shown to desensitize adenyl cyclase, down-regulate beta and seratonin receptors?
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imipramine
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What receptors does imipramien hit besides beta and serotonin?
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alpha-1 --> orthostasis
histamine --> sedation/wt gain muscarinic --> anticholinergic |
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What are 3 indications for use of imipramine?
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depression
nocturnal enuresis neuropathic pain (off labeL) |
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what are the cytochrome interactions of imipramine?
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2C19 and 2D6 substrate (and 2D6 inhibitor)
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Which TCA causes problems with other anticholinergics?
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imipramine and amitriptyline especially (but all to some extent)
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Name some Qt prolongators?
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class Ia and III antiarrhythmics (disopyramide, dofetilide, ibutilide, procainamide, quinidine, sotalol, bepridil, amio)
fluoroquinolones CCBs? droperidol antipsychotics cisapride (promotility agent) |
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WHat are the main SEs of imipramine and amitriptyline?
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orthostatic hypotension
sedation anticholinergics gynecomastia libido changes SIADH |
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gynecomastia is a side effect of which antidepressant?
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imipramine, amitriptyline
and some antipsychotics |
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Whcih receptors does amitriptyline hit more than imipramine?
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histaminic and muscarinic
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more sedating
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Which has worse anticholinergic effects, imipramine or amitriptyline?
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amitriptyline
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What drug is an active metabolite of imipramine?
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desipramine
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Which does desipramine block more, norepinephrine or seratonin reuptake?
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NE
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There is less sedation/dry mouth etc with secondary amine desipramine, but what ADR is still common?
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orthostatic hypotension
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What are the cytochrome interactions of desipramine?
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2D6 substrate and inhibitor
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What drug is an active metabolite of amitriptyline?
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nortriptyline
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Which TCA is twice as potent as other TCAs?
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nortriptyline
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Which TCA should you probably choose first?
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nortriptyline
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Which other TCA does the MOA of nortriptyline line up with most?
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desipramine
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What are the cytochrome interactions of nortriptyline?
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same as desipramine
2D6 substrate and inhibitor |
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Which MAOI is a derivative of ipronaizid?
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phenelzine
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How does phenelzine probably work?
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increases endogenous NE, dopamine, and seratonin by inhibiting MAOa(seratonin and NE) and MAOb(dopamine)
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MAOb is responsible for breaking down what NT?
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dopamine
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What are the contraindications to using phenelzine?
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uncontrolled HTN
CHF pheo Concurrent use of sympathomimetics, CNS depressants or serotonergic drugs Foods with high tyramine content |
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What are some sympathomimetics?
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illicit drugs
pseudoephedrine PPA (off the market now) |
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What drug is associated with the cheese rxn?
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phenelzine
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Why is there a problem with tyramine and MAOIs?
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tyramine acts as a sympathomimetic
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What drug might be indicated for a situation of atypical depression (e.g. depression + hyperphagia or hypersomnia)?
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MAOI
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What are the ADRs of MAOIs?
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dizziness (not necessarily orthostatic)
xerostomia Nausea HA |
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What can happen when MAOIs are stopped abruptly?
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delirium, agitation, myoclonic jerks, insomnia
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Which SSRIs should you be careful switching to SNRI or TCA?
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fluoxetine and paroxetine (potent 2D6 inhibitors) --> may inc SNRI concentration
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Which drugs must you wait 2 wks when switching to or from?
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MAOIs - but 6 wks if fluoxetine!
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What is buspirone indicated for?
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generalized anxiety disorder
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What are the cytochrome interactions of buspirone?
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3A4 substrate
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What are the ADRS of buspirone
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dizziness
sedation |
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Name 4 benzodiazepines used to treat anxiety.
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alprazolam (short acting)
lorazepam diazepam (long acting) midazolam |
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How do benzos work?
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binds BZD receptors on postsynaptic GABA neuron -> hyperpolarization = stabilization
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What drug is an option for pt on SSRI or buspirone who is still having acute situational issues of anxiety?
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alprazolam
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What are the cytochrome interactions of alprazolam?
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3A4 substrate
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Which benzo has no cytochrome interactions?
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lorazepam
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Which 3 benzos are 3A4 substrates?
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alprazolam
diazepam midazolam |
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Which benzo is a 2C19 substrate?
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diazepam (and 3A4 substrate)
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Which benzo is listed as teratogenic in the powerpoint? (esp 1st trimester)
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alprazolam
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What is the IV form of lorazepam used for?
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status
preanesthesia antiemetic unlabeled use for - ETOH detox, agitation |
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Which benzo has the highest abusive potential? Why?
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diazepam; long acting
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Which benzo is clinically indicated for ETOH withdrawal?
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diazepam
lorazepam too, but off label |
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What benzo is used often in ortho as a skeletal muscle relaxant?
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diazepam
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What two benzos may be used for preop sedation?
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midazolam
lorazepam |
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Which benzo is used for conscious sedation prior to dx/radiographic procedures? (usually + fentanyl for pain)
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midazolam
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What pscyh drug causes anterograde amnesia? What is it used for?
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midazolam; benzo (but does it moreso than others)
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What is the usualy age of onset for bipolar disorder?
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15-30yrs
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What are the 3 phases of bipolar disorder?
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1. acute
2. continuation 3. maintenance |
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What is first line therapy for pts with acute severe manic or mixed episodes?
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mood stabilizer plus and antipsychotic
(e.g. lithium or valproate + olanzapine or risperidone) |
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What drugs are 1st line for acute depression in bipolar disorder?
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lithium or lamotrigine
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How does lithium work?
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Alters cation transport across cell membrane in nerve and muscle cells & influences reuptake of serotonin +/or NE
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What tests are recommended before begininning lithium tx?
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BUN/Creat
pg thyroid fcn ECG (>40yrs) |
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Which tests should be repeated after the 1st year of tx with lithium?
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renal fcn
thyroid fcn |
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how often do you increase lithium dose in the beginning of tx?
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q4-5days
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When should lithium levels be checked?
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8-12 h after each dose increase and before the next
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When do you get lithium toxicity? (what level)
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1.5mEq/L
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Name 4 classes of drugs that interact w/lithium
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ACEs
ARBs diuretics MAOIs |
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MAOI + ________ = malignant hyperpyrexia?
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Lithium
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What do diuretics and ACE/ARBs do to lithium?
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inc conc by decreasing excretion
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What are the ADRs of lithium?
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polyuria
loose stool weight gain hypo/hyperthyroid tremor DI renal impairment |
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How long should a pt be treated (maintenence) after an acute manic episode?
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>1-yr (long term)
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Which bipolar pts should be treated with lifetime maintenance therapy?
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those who have had >3 manic episodes
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What is the mainstay of maintenance therapy for bipolar disorder?
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mood stabilizers
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What is the most likely reason for agitation? (hint: it is not psychosis!)
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infection or med OD (commonly quinolone OD)
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Which symptoms respond to antipsychotic meds and which respond more to psychosocial interventions? (in schizophrenia)
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meds for positive symptoms
psychosocial interventions for negative symptoms |
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Name the conventional antipsychotics. (1st generation)
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thioridazine
mesoridazine haloperidol chlorpromazine |
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Name the high potency conventional antipsychotics.
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haloperidol
chlorpromazine |
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Which are less sedating and less anticholinergic, high or low potency 1st gen. antipsychotics?
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high potency
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High potency conventional antipsychotics have higher incidence of which side effect compared to low potency drugs like thioridazine or mesoridazine?
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EPS
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Name the atypical antipsychotics
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risperidone
olanzapine quetiapine ziprasidone aripiprazole clozapine |
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Which conventional antipsychotics can cause problems with QT prolongation?
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low potency agents (thioridazine, mesoridazine) and haloperidol (in same family as droperidol)
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WHat problems do the 2nd generation antipsychotics generally cause that 1st generation do not?
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issues with weight gain and DM
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WHat drug is a phenothiazine antipsychotic that blocks postsynaptic mesolimbic dopaminergic receptors in the brain and has stong alpha blocking eefect to depress release of hypothalamic/hypophyseal hormones?
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chlorpromazine
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What are the indications for chlorpromazine?
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mania
schizophrenia intractable hiccups |
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What antipsychotic is indicated for intractable hiccups? what class is it?
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chlorpromazine; high potency conventional
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What are the cytochrome interactions of chlorpromazine?
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2D6 substrate and inhibitor
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Chlorpromazine may cause hypotension when given with which meds?
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antihypertensives
(because chlorpromazine has alpha blocking effect) |
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What are the ADRs of chlorpromazine?
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postural hypotension
drowsiness EPS NMS lactation/gynecomastia/amenorrhea (from inc prolactin) |
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Which antipsychotic is a butyrophenone that blocks D1 and D2 receptors in the brain and depresses release of hormones?
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haloperidol
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What are the indications for use of haloperidol?
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schizo
tics/utterances (Tourette's) off label for psychosis or emergency sedation |
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What are the cytochrome interactions of haloperidol?
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2D6 and 3A4 substrate and inhibitor
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Which antipsychotic is indicated for tics?
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haloperidol
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Haloperidol and chlorpromazine are substrates and inhibitors of which hepatic enzyme?
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2D6
haloperidol also 3A4 |
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What are the ADRs of haloperidol?
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same as chlorpromazine
postural hypotension drowsiness EPS NMS lactation/gynecomastia/amenorrhea (from inc prolactin) |
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What drug is the best atypical antipsychotic?
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clozapine - for treatment refractory schizo
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What are the cytochrome interactions of clozapine?
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1A2 subtrate
2D6 inhibitor |
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Which antipsychotic has overlapping toxicity with anticholinergic meds?
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clozapine (atypical)
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What are the ADRs of clozapine?
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ortho hypo
tachy drowsiness, etc (duh) constipation (antichol) weight gain/DM agranulocytosis |
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With which antipsychotic must you monitor the CBC qwk X 6mo b/c risk of agranulocytosis?
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clozapine
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Which atypical antipsychotics is indicated for schizo or acute manic episodes?
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olanzapine, quetiapine, risperidone, ziprasidone, aripiprazole
*all except clozapine |
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What are the ADRs of olanzapine?
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dose-dependent sedation/EPS
weight gain DM drug fever |
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Which atypical antipsychotics have a risk of drug fever?
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olanzapine, quetiapine,
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What are the cytochrome interactions of olanzapine?
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1A2 substrate only
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WHich atypical antipsychotic is a 3A4 substrate?
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quetiapine,
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Which atypical antipsychotic is a 2D6 substrate?
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risperidone, and aripiprazole
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Which atypical antipsychotics are 1A2 substrates? Which is also a 2D6 inhibitor?
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clozapine and olanzapine; clozapine
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If you push the dose of atypical antipsychotics high enough which SE will you get that is common with the conventional antipsychotics?
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EPS
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What atypical antipsychotic interacts with QT prolongators? (has dose dependent QT prolongation)
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ziprasidone
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What labs should be monitored in pts taking atypical antipsychotics?
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BMI
lipids (baseline, 3mo, annual) Glucose (baseline, 3 mo, annual) |
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What ABX causes hypoglycemia?(random i know)
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gatifloxacin
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