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179 Cards in this Set

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What side effects are common to all SSRIs?
ED/delayed ejaculation
anorgasmia
dec libido (men and women)
anorexia -> weight loss -> weight gain
bruxism
suicidal ideation and behavior
inc risk of UGI bleeding
What must you warn pts about when prescribing an SSRI?
link w/suicide
What is the discontinuation syndrome associated with SSRIs?
N/V/D, agitation, insomnia, anorexia, flu-like illness if you don't titrate down slowly
What inc the risk of UGI bleed in pt taking SSRI?
high dose NSAID use
HTN + fever + hyperreflexia + clonus in the LE + ocular clonus + mental status changes = ?
moderate seratonin syndrome
What is the difference between mild and moderate seratonin syndrome?
mental status changes
What temp is considered severe seratonin syndrome? (in addition to inc severity of other symptoms)
41 C or higher
What are three consequences of poorly controlled hyperthermia from seratonin syndrome?
rhabdo
DIC
ARF
How are seizures and cardiovascular shock related to SSRI use?
seratonin syndrome (severe)
What drugs are most likely to cause serotonin syndrome when taken in combo? Which ones are possible but not as likely?
SSRIs, SNRIs, MAOIs TCAs, St John's Wort, buspirone, mitazipine, trazadone

possibly - INH, linezolid, dextromethorphan, tramadol, Li, meperidine, selegiline
What is the classic MAOI?
phenylzine
What is meperidine? Why is it in the psych drug card list???
opioid analgesic strong agonist in the phenylpiperadine family w/fentanyl -- it may cause seratonin syndrome when given w/SSRI (not likely)
What is selegiline?
MAOB inhibitor (for parkinson's)
How is seratonin syndrome treated?
d/c meds
cool pt down
benzos
cyproheptadine (antihistamine that is a seratonin antagonist)
intubation (maybe)
How does fluoxetine work?
blocks presynaptic serotonin reuptake pump
What are the indications for use of fluoxetine?
MDD
OCD
panic disorder
bulimia nervosa
PMDD
What are the cytochrome interactions of fluoxetine?
2C9 and 2D6 substrate
2D6 inhibitor ***
What skin/allergic events is fluoxetine associated with?
vasculitis, lupus-like syndrome, anaphylactoid rxns
What are the 2D6 substrates?
beta blockers (not atenolol)
TCAs
antiarrythmics (flecainide, mexilitine, propafenone)
Antipsychotics
SSRIs (fluoxetine, paroxetine)
Opiods
donepazil
duloxetine
haloperidol
chlorpromazine
Tramadol
Tamsulosin
Tolteridine
What ar the indications for use of sertraline?
MDD
OCD
panic disorder
PTSD
social anxiety disorder
PMDD
sertraline is FDA approved for which indication that fluoxetine is not?
PTSD and social anxiety disorder
What are the cytochrome interactions of sertraline?
low likelihood!!
2C19 and 2D6 substrate
What are the 2C19 substrates
phenytoin
omeprazole
lansoprazole
sertraline
nelfinavir
What are two 2C19 inhibitors?
gemfibrozil
cimetidine
Which population is more likely to have a mutation impairing metabolism by 2C19?
asian
What is the main reason pts d/c sertraline? this SE is more likely with this than any other SSRI
nausea

*also insomnia, HA,SIADH and anxiety like all SSRIs
What is the side effect unique to paroxetine?
anticholinergic effects (more than the other SSRIs)
What are the cytochrome interactions of paroxetine?
like fluoxetine:

2D6 substrate and inhibitor
Why should you be careful giving paroxetine w/diphenhydramine? What other drugs may cause similar problems?
anticholinergic (xerostomia, constipation, sedation)

TCAs, scopalamine, dimenhydranate, solifenacin, darifenacin, oxybutynin, tolteridine, trospium
what is the only FDA approved clinical indication for citalopram?
depression
What are the cytochrome interactions of citalopram
minimal inhibition like sertraline!

2C19 and 3A4 substrate
What are the 3A4 substrates?
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
What are the 3A4 inhibitors?
cimetidine, macrolides, ritonavir, grapefruit juice, amiodarone
What are the 3A4 inducers?
rifampin, carbamazepine, st john’s wort, phenytoin
What does citalopram claim to cause less of than other SSRIs? (besides less inhibition of hepatic enzymes)
less sexual dysfunction
What is escitalopram?
S-enantiomer of citalopram
What are the cytochrome interactions of escitalopram?
substrate of 2C19 and 3A4 (like citalopram)
What are ADRs of escitalopram?
the usual (HA, somnolence, insomnia, nausea, SIADH)
What is the only thing fluvoxamine is approved for?
OCD
What are the cytochrome interactions of fluvoxamine?
2D6 substrate

STRONG inhibitor of 1A2, 3A4, and 2C19
What is fluvoxamine more likely to cause in terms of ADRs than other SSRIs (except may sertraline)
N/V
Name two SNRIs
duloxetine
venlafaxine
What might work well for a second option in a pt not responding to SSRIs?
SNRI (duloxetine or venlafaxine)
What are the cytochrome interactions of venlafaxine?
2D6 and 3A4 substrate

minimal inhibition
What are the side effects unique to venlafaxine?
SNRI -
BP elevations possible
abrupt d/c may be more severe than w/SSRIs
OD is similar to TCAs
What is similar between OD on venlafaxine and a TCA?
QT prologation, etc (OD usually will lead to an arrythmia with these two drugs)
What may happen with abrupt discontinuation of SNRI?
dizziness
flu-like symptoms
anxiety
What are the two clinical indications for duloxetine?
MDD
diabetic nephropathy

(venlafaxine was FDA indicated for MDD, GAD, and social anxiety)
What is the most common side effect of duloxetine?
nausea
what are the cytochrome interactions of duloxetine?
1A2 and 2D6 substrate
inhibitor of 2D6
Which is a 3A4 substrate, venlafaxine or duloxetine?
venlafaxine (duloxetine is 2D6)
Which SNRI causes xerostomia?
duloxetine (maybe both, but only this was in powerpoint)
Which antidepressant is a structural analogue of amphetamines?
bupropion
What are the cytochrome interactions of bupropion?
multiple and minimal
What drugs lower the seizure threshold?
antipsychotics
Fluoroquinolones
theophylline
bupropion
This drug is contraindicated in pts w/anorexia or bulimia. Why?
bupropion; seizures
These drugs claim to cause less sexual dysfunction
bupropion*
SNRIs
citalopram
How does trazadone work?
inhibits seratonin reuptake
and
blocks H1 and alpha1-adrenergic receptors
What are the cytochrome interactions of trazadone?
3A4 substrate
2D6 inhibitor (but not strong like fluoxetine and paroxetine)
Is trazadone first line?
NO!
What are the side effects of trazadone?
sedation (of course)
postural hypotension
priapism
nausea (of course)
dysrhythmias
hepatoxicity
What drug similar to trazadone was pulled from the market and why?
nefazadone; hepatoxicity (failure)
Trazadone should be used w/caution in which pts?
cardiac and hepatic disease
How does mirtazapine work?
hits pre and postsynaptic alpha-TWO receptors and seratonin receptors
and
is a H1 antagonist

(inc NE and 5Ht)
What are the cytochrome interactions of mirtazapine?
substrate of 1A2, 2D6, and 3A4
Which drug causes more sedation at low doses? (crazy)
mirtazapine
Which "other" antidepressant causes appetite stimulation and weight gain?
mirtazapine
Mirtazapine causes what side effects?
sedation
weight gain
dry mouth
but less sexual dysfunction
What kills most pts in a TCA OD?
QT prolongation
(but also could be anticholinergic toxicity --> seizures)
Which 3 drugs lead to QT prolongation if OD?
TCAs
theophylline
venlafaxine
What must you do before starting a pt on a TCA?
screen for conduction abnormalities
>40 - get ECG
<40: screen by hx, if neg --> no ECG necessary
What history would prompt you to get an ECG before starting a TCA in a pt <40?
known heart disease
syncope
palpitations
DOE
SOB
CP
strong family hx of heart dz
What happens when you stop the TCA too abruptly?
irritability, agitation, sleep disturbance, flu-like symptoms, cardiac arrythmias (last one is rare)
Which TCAs are tertiary amines?
imipramine
amitriptyline
which TCAs are secondary amines?
desipramine
nortriptyline
Which are better tolerated, secondary or tertiary amines?
secondary
Which TCA has been shown to desensitize adenyl cyclase, down-regulate beta and seratonin receptors?
imipramine
What receptors does imipramien hit besides beta and serotonin?
alpha-1 --> orthostasis
histamine --> sedation/wt gain
muscarinic --> anticholinergic
What are 3 indications for use of imipramine?
depression
nocturnal enuresis
neuropathic pain (off labeL)
what are the cytochrome interactions of imipramine?
2C19 and 2D6 substrate (and 2D6 inhibitor)
Which TCA causes problems with other anticholinergics?
imipramine and amitriptyline especially (but all to some extent)
Name some Qt prolongators?
class Ia and III antiarrhythmics (disopyramide, dofetilide, ibutilide, procainamide, quinidine, sotalol, bepridil, amio)
fluoroquinolones
CCBs?
droperidol
antipsychotics
cisapride (promotility agent)
WHat are the main SEs of imipramine and amitriptyline?
orthostatic hypotension
sedation
anticholinergics
gynecomastia
libido changes
SIADH
gynecomastia is a side effect of which antidepressant?
imipramine, amitriptyline
and some antipsychotics
Whcih receptors does amitriptyline hit more than imipramine?
histaminic and muscarinic
more sedating
Which has worse anticholinergic effects, imipramine or amitriptyline?
amitriptyline
What drug is an active metabolite of imipramine?
desipramine
Which does desipramine block more, norepinephrine or seratonin reuptake?
NE
There is less sedation/dry mouth etc with secondary amine desipramine, but what ADR is still common?
orthostatic hypotension
What are the cytochrome interactions of desipramine?
2D6 substrate and inhibitor
What drug is an active metabolite of amitriptyline?
nortriptyline
Which TCA is twice as potent as other TCAs?
nortriptyline
Which TCA should you probably choose first?
nortriptyline
Which other TCA does the MOA of nortriptyline line up with most?
desipramine
What are the cytochrome interactions of nortriptyline?
same as desipramine
2D6 substrate and inhibitor
Which MAOI is a derivative of ipronaizid?
phenelzine
How does phenelzine probably work?
increases endogenous NE, dopamine, and seratonin by inhibiting MAOa(seratonin and NE) and MAOb(dopamine)
MAOb is responsible for breaking down what NT?
dopamine
What are the contraindications to using phenelzine?
uncontrolled HTN
CHF
pheo
Concurrent use of sympathomimetics, CNS depressants or serotonergic drugs

Foods with high tyramine content
What are some sympathomimetics?
illicit drugs
pseudoephedrine
PPA (off the market now)
What drug is associated with the cheese rxn?
phenelzine
Why is there a problem with tyramine and MAOIs?
tyramine acts as a sympathomimetic
What drug might be indicated for a situation of atypical depression (e.g. depression + hyperphagia or hypersomnia)?
MAOI
What are the ADRs of MAOIs?
dizziness (not necessarily orthostatic)
xerostomia
Nausea
HA
What can happen when MAOIs are stopped abruptly?
delirium, agitation, myoclonic jerks, insomnia
Which SSRIs should you be careful switching to SNRI or TCA?
fluoxetine and paroxetine (potent 2D6 inhibitors) --> may inc SNRI concentration
Which drugs must you wait 2 wks when switching to or from?
MAOIs - but 6 wks if fluoxetine!
What is buspirone indicated for?
generalized anxiety disorder
What are the cytochrome interactions of buspirone?
3A4 substrate
What are the ADRS of buspirone
dizziness
sedation
Name 4 benzodiazepines used to treat anxiety.
alprazolam (short acting)
lorazepam
diazepam (long acting)
midazolam
How do benzos work?
binds BZD receptors on postsynaptic GABA neuron -> hyperpolarization = stabilization
What drug is an option for pt on SSRI or buspirone who is still having acute situational issues of anxiety?
alprazolam
What are the cytochrome interactions of alprazolam?
3A4 substrate
Which benzo has no cytochrome interactions?
lorazepam
Which 3 benzos are 3A4 substrates?
alprazolam
diazepam
midazolam
Which benzo is a 2C19 substrate?
diazepam (and 3A4 substrate)
Which benzo is listed as teratogenic in the powerpoint? (esp 1st trimester)
alprazolam
What is the IV form of lorazepam used for?
status
preanesthesia
antiemetic
unlabeled use for - ETOH detox, agitation
Which benzo has the highest abusive potential? Why?
diazepam; long acting
Which benzo is clinically indicated for ETOH withdrawal?
diazepam

lorazepam too, but off label
What benzo is used often in ortho as a skeletal muscle relaxant?
diazepam
What two benzos may be used for preop sedation?
midazolam
lorazepam
Which benzo is used for conscious sedation prior to dx/radiographic procedures? (usually + fentanyl for pain)
midazolam
What pscyh drug causes anterograde amnesia? What is it used for?
midazolam; benzo (but does it moreso than others)
What is the usualy age of onset for bipolar disorder?
15-30yrs
What are the 3 phases of bipolar disorder?
1. acute
2. continuation
3. maintenance
What is first line therapy for pts with acute severe manic or mixed episodes?
mood stabilizer plus and antipsychotic

(e.g. lithium or valproate + olanzapine or risperidone)
What drugs are 1st line for acute depression in bipolar disorder?
lithium or lamotrigine
How does lithium work?
Alters cation transport across cell membrane in nerve and muscle cells & influences reuptake of serotonin +/or NE
What tests are recommended before begininning lithium tx?
BUN/Creat
pg
thyroid fcn
ECG (>40yrs)
Which tests should be repeated after the 1st year of tx with lithium?
renal fcn
thyroid fcn
how often do you increase lithium dose in the beginning of tx?
q4-5days
When should lithium levels be checked?
8-12 h after each dose increase and before the next
When do you get lithium toxicity? (what level)
1.5mEq/L
Name 4 classes of drugs that interact w/lithium
ACEs
ARBs
diuretics
MAOIs
MAOI + ________ = malignant hyperpyrexia?
Lithium
What do diuretics and ACE/ARBs do to lithium?
inc conc by decreasing excretion
What are the ADRs of lithium?
polyuria
loose stool
weight gain
hypo/hyperthyroid
tremor
DI
renal impairment
How long should a pt be treated (maintenence) after an acute manic episode?
>1-yr (long term)
Which bipolar pts should be treated with lifetime maintenance therapy?
those who have had >3 manic episodes
What is the mainstay of maintenance therapy for bipolar disorder?
mood stabilizers
What is the most likely reason for agitation? (hint: it is not psychosis!)
infection or med OD (commonly quinolone OD)
Which symptoms respond to antipsychotic meds and which respond more to psychosocial interventions? (in schizophrenia)
meds for positive symptoms

psychosocial interventions for negative symptoms
Name the conventional antipsychotics. (1st generation)
thioridazine
mesoridazine
haloperidol
chlorpromazine
Name the high potency conventional antipsychotics.
haloperidol
chlorpromazine
Which are less sedating and less anticholinergic, high or low potency 1st gen. antipsychotics?
high potency
High potency conventional antipsychotics have higher incidence of which side effect compared to low potency drugs like thioridazine or mesoridazine?
EPS
Name the atypical antipsychotics
risperidone
olanzapine
quetiapine
ziprasidone
aripiprazole
clozapine
Which conventional antipsychotics can cause problems with QT prolongation?
low potency agents (thioridazine, mesoridazine) and haloperidol (in same family as droperidol)
WHat problems do the 2nd generation antipsychotics generally cause that 1st generation do not?
issues with weight gain and DM
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?
chlorpromazine
What are the indications for chlorpromazine?
mania
schizophrenia
intractable hiccups
What antipsychotic is indicated for intractable hiccups? what class is it?
chlorpromazine; high potency conventional
What are the cytochrome interactions of chlorpromazine?
2D6 substrate and inhibitor
Chlorpromazine may cause hypotension when given with which meds?
antihypertensives

(because chlorpromazine has alpha blocking effect)
What are the ADRs of chlorpromazine?
postural hypotension
drowsiness
EPS
NMS
lactation/gynecomastia/amenorrhea (from inc prolactin)
Which antipsychotic is a butyrophenone that blocks D1 and D2 receptors in the brain and depresses release of hormones?
haloperidol
What are the indications for use of haloperidol?
schizo
tics/utterances (Tourette's)
off label for psychosis or emergency sedation
What are the cytochrome interactions of haloperidol?
2D6 and 3A4 substrate and inhibitor
Which antipsychotic is indicated for tics?
haloperidol
Haloperidol and chlorpromazine are substrates and inhibitors of which hepatic enzyme?
2D6

haloperidol also 3A4
What are the ADRs of haloperidol?
same as chlorpromazine

postural hypotension
drowsiness
EPS
NMS
lactation/gynecomastia/amenorrhea (from inc prolactin)
What drug is the best atypical antipsychotic?
clozapine - for treatment refractory schizo
What are the cytochrome interactions of clozapine?
1A2 subtrate
2D6 inhibitor
Which antipsychotic has overlapping toxicity with anticholinergic meds?
clozapine (atypical)
What are the ADRs of clozapine?
ortho hypo
tachy
drowsiness, etc (duh)
constipation (antichol)
weight gain/DM
agranulocytosis
With which antipsychotic must you monitor the CBC qwk X 6mo b/c risk of agranulocytosis?
clozapine
Which atypical antipsychotics is indicated for schizo or acute manic episodes?
olanzapine, quetiapine, risperidone, ziprasidone, aripiprazole

*all except clozapine
What are the ADRs of olanzapine?
dose-dependent sedation/EPS
weight gain
DM
drug fever
Which atypical antipsychotics have a risk of drug fever?
olanzapine, quetiapine,
What are the cytochrome interactions of olanzapine?
1A2 substrate only
WHich atypical antipsychotic is a 3A4 substrate?
quetiapine,
Which atypical antipsychotic is a 2D6 substrate?
risperidone, and aripiprazole
Which atypical antipsychotics are 1A2 substrates? Which is also a 2D6 inhibitor?
clozapine and olanzapine; clozapine
If you push the dose of atypical antipsychotics high enough which SE will you get that is common with the conventional antipsychotics?
EPS
What atypical antipsychotic interacts with QT prolongators? (has dose dependent QT prolongation)
ziprasidone
What labs should be monitored in pts taking atypical antipsychotics?
BMI
lipids (baseline, 3mo, annual)
Glucose (baseline, 3 mo, annual)
What ABX causes hypoglycemia?(random i know)
gatifloxacin