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76 Cards in this Set
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what are the two categories of antipsychotics, and what is the difference between the two?
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typical - block D2 receptors only = stop positive sx; lots of EPS side effects
atypical - block D2 and/or D1, plus 5HT receptors = tx postive and negative sx, less EPS mostly --> CATIE study says all antipsychotics have same efficacy!! |
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pimozide (Orap)
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typical antipsychotic, most potent
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haloperidol (Haldol)
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typical antipsychotic, second most potent, IM or PO, used in tx of acute psychosis
used in pregnancy contraindications: preexisting movement disorder/TD adverse effects: highest risk of EPS/TD, hyperprolactinemia |
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fluphenazine enanthate (Moditen, Modecate for IM)
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typical antipsychotic
contraindications: preexisting movement disorder/TD adverse effects: highest risk of EPS/TD, hyperprolactinemia |
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zuclopenthixol HCl (Clopixol), zuclopenthixol acetate (Acuphase), zuclopenthixol decanoate (Cloxipol Depot)
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typical antipsychotic; second two are IM only
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trifluoperazine (Stelazine)
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typical antipsychotic
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perphenazine (Trilafon)
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typical antipsychotic
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loxapine HCl (Loxitane)
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typical antipsychotic, comes in IM too
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thioridazine (Mellaril)
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typical antipsychotic, least potent
contraindications: preexisting movement disorder/TD adverse effects: risk of EPS/TD, postural hypotension, sedation, anticholinergic (blind/mad/dry/red/hot) |
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Chlorpromazine (Largactil)
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typical antipsychotic, least potent
contraindications: preexisting movement disorder/TD adverse effects: risk of EPS/TD, postural hypotension, sedation, anticholinergic (blind/mad/dry/red/hot) |
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risperidone (Risperdal)
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atypical antipsychotic; highest potency (start 1-2, maint 4-8mg) use 2mg quick-dissolve/liquid for acute psychosis
blocks 5-HT2, D2 and adrenergic receptors; PROS: low incidence of EPS if <8mg CONS: insomnia, agitation, EPS if>8mg (AS BAD AS TYPICALS), h/a anxiety, PROLACTINEMIA, postural hypotension, constipation, dizziness, weight gain |
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olanzapine (Zyprexa)
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atypical antipsychotic; start 5mg, maint 10-30; use 2.5-10 for acute psychosis; blocks 5HT2,3,6, D1-4, muscarinic, adrenergic, histaminergic receptors
PROS: better overall efficacy v haloperidol; well tolerated, low incidence of EPS and TD CONS: mild sedation, insomnia, dizziness, minimal anticholinergic, early AST + ALT elevation, restlessness, WEIGHT GAIN = DM, hyperlipids |
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quetiapine (Seroquel)
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atypical antipsychotic; start 25, maint 400-800mg; blocks 5-HT2A, D1-2, adrenergic and histaminergic receptors
PROS: assocaited with less weight gain vs cloz/olanzapine CONS: h/a, dizziness, constipation, **most SEDATING of 1st line atyp, LONG QT |
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ziprasidone (Zeldox)
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atypical antipsychotic; start 40, incr quickly to 80-160mg
blocks 5-HT2A, moderate D2 receptor antag, moderately potent adrenergic and histaminergic block CONS: sedation, nausea, constipation, dyspepsia **LONG QT, EPS |
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clozapine (Clozaril)
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atypical antipsychotic 2nd line; start 25, main 300-900mg
Ind: failed 2 prev antipsych, preexisting movement disorder sensitivity, suicidality PROS: most effective for tx-resistant schizophrenia, does not worsen/may improve TD, approx 50% pts benefit, esp paranoid and onset >20yrs, LEAST AMT OF EPS! CONS: drowsiness, hypersalivation, tachycardia, dizziness, NMA **1% risk AGRANULOCYTOSIS, SEIZURES, WEIGHT GAIN |
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anticholinergic effects of antipsychotics
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Red as a beet
Hot as a hare (sweating) Dry as a bone (muc mem) Blind as a bat (blurred vision/acute glaucoma) Mad as a hatter (delirium) |
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neuroleptic malignant syndrome cause, s/sx, mortality
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FARM due to massive D block:
Fever Autonomic changes (incr HR/BP, sweating) Rigidity of muscles Mental status change (confusion) labs: incr CPK, WBC; myoglobinuria 5% mortality |
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extrapyramidal side effects
4 categories |
dystonia (acute and tardive)
akathisia (acute and tardive) pseudoparkinsonism (acute) dyskinesia (tardive) |
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dystonia
onset, epi, s/sx, tx |
acute (w/in 5d, young Asian and Black males) and tardive (>90 d) onset
sustained abnormal posture -torsions, twisting, contraction of muscle groups, muscle spasms (oculogyric crisis, laryngospasm, torticollis) tx: lorazepam or benztropine |
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akathisia
onset, epi, s/sx, tx |
acute (w/in 10d) or tardive (>90d)
motor restlessness - crawling sensation in legs relieved by walking; very distressing, increases suicide risk and poor adherence tx: lorazepam, propanolol, diphenhydramine |
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pseudoparkinsonism
onset, epi, s/sx, tx |
acute (w/in 30d) in elderly F
Tremor Rigidity (cogwheel) Akinesia Postural instability (no armswing, stooped, shuffling) tx: benzodiazepine or benzotropine |
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diskinesia
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tardive (>90d) in elderly F
purposeless, constant movements involving facial and mouth muscles or less commonly the limbs tx: try clozapine instead |
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benztropine (Cogentin)
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anticholinergic agent/antiparkinsonian agent
tx/prevent acute EPS 2 mg PO, IM, IV |
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procyclidine (Kemadrine)
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anticholinergic agent/antiparkinsonian agent
tx/prevent acute EPS 15mg PO |
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biperiden (Akineton)
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anticholinergic agent/antiparkinsonian agent
tx/prevent acute EPS 2mg PO, IM, IV BID |
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amantadine (Symmetrel)
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anticholinergic agent/antiparkinsonian agent
tx/prevent acute EPS 100mg PO BID |
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tridezyphenidyl (Artane)
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anticholinergic agent/antiparkinsonian agent
tx/prevent acute EPS 1-15 mg PO |
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diphenhydramine (Benadryl)
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anticholinergic agent/antiparkinsonian agent
tx/prevent acute EPS 25-50 mg PO/IM QID |
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SSRIs
use, method of action, side effects, risk in overdose, drug interactions |
use: anxiety, ED, OCD, SAD, typical and atypical depression
MOA: block 5HT reuptake SE: less than TCA, GI upset, restlessness, tremor, insomnia, h/a, drowsy, sexual dysfxn, EPS, SIADH, serotonin syndrome very safe in overdose interact: inhibit P450 enzyme |
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TCAs
use, method of action, side effects, risk in overdose, drug interactions |
use: OCD (clomipramine), melancholic depression
MOA: block norepi and 5HT reuptake SE: anticholinergic effect, noradrenergic effect (tremor, tachycardia, sweat, insomnia, erectile/ejactulation prob); a1 adrenergic (orthostatic hypotension), antihistamine (sedation, weight gain) incr HR, conduction delay, sedation, stimulation, decr seizure threshold OD: lethal at 3x therapeutic dose -- present as anticholinergic ->CNs stimulation -> depression and seizures; prolonged QT; don't give ipecac as tx! interact: w/ MAOI, SSRI, EtOH |
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MAOIs
use, method of action, side effects, risk in overdose, drug interactions |
use: moderate/severe depression refract to SSRI, atypical depression
MOA: irreversible inhibition of monoamine oxidase A and B = increased NE and 5HT SE: HTN crises with tyramine rick foods like wine and cheese = h/a, flushes, palp, n/v, photophobia dizziness, reflex tachycardia, post hypotension, sedate, insomnia, weight gain, social dysfxn, energizing OD: toxic but wider safety margin than TCAs interact: EtOH, noradrenergic meds (TCA, decongestants, amphetamines = HTN crises), serotonin syndrome with SSRIS, tryptophan, dextromethorphan |
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SNRIs
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use: depression, anxiety
MOA: block NE and 5HT uptake SE: low dose = insomnia (5HTic), high dose (NEic) = tremor, tachycardia, sweat, insomnia, incr diastolic BP interact: MAOI, SSRI |
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timeline for onset of antidepressant effects
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neurovegetative sx 1-3 weeks
**higher risk of suicide untill emotional/cognitive sx 2-6 weeks |
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fluoxetine (Prozac)
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SSRI, start 10-20, t20-80mg
*independent study shows efficacy in teens |
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fluvoxamine (Luvox)
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SSRI, s50-100, t150-300mg
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paroxetine (Paxil)
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SSRI, s10, t20-60mg
worst for weight gain |
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sertraline (Zoloft)
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SSRI, s25-50, t50-200mg
good starting adult med *independent study shows efficacy in teens least interact with other drugs |
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citalopram (Celexa)
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SSRI, s20, t20-60mg
*independent study shows efficacy in teens least interact with other drugs |
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escitalopram (Cipralex)
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SSRI, s10, t10-20mg
good starting adult med least interact with other drugs |
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venlafaxine (Effexor)
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SNRI, s37.5-75, t75-225mg
follow BP |
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duloxetine (Cymbalta)
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SNRI, s40, t40-60mg
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bupropion (Wellbutrin)
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NDRI (norepinephrine and dopamine reuptake inhibitor)
s100, t300-450mg tx depression, ED, not anxiety, good if hx cog deficits/ADHD PRO:LESS SEXUAL DYSFXN, weight gain, sedation CON:reduces seizure threshold |
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amitriptyline (Elavil)
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TCA (3o amine); s75-100, t150-300mg
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imipramine (Tofranil)
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TCA (3o amine); s75-100, t150-300mg
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nortiptyline (Aventyl)
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TCA (2o amine); s75-100, t75-150mg
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desipramine (Norpramin)
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TCA (2o amine); s75-100, t150-300mg
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phenelzine (Nardil)
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MAOI; s45, t60-90mg
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tranylcypromine (Parnate)
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MAOI; s30, t10-60mg
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moclobemide (Manerix)
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RIMA (reversible inhibition of MAO-A)
s300, t300-600 leaves MAO-B active so can still break down tyramine |
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mirtazapine (Remeron)
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NASSA (noradrenergic and specific serotonin antagonists)
s15, t15-45mh very sedating with weight gain helpful if insomnia or agitation are prominent, or to tx depression with cachexia |
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serotonin syndrome
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rare, life-threatening adverse reaction to SSRIs, esp when switch SSRI ->MAOI
sx: nausea, diarrhea, palpitation, chills, restlessness, confusion, lethargy --> myoclonus, hyperthermia, rigor, hypertonicity |
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discontinuation syndrome
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FINISH:
Flu-like sx Insomnia Nausea Imbalane Sensory disturbances Hyperarousal (agitated/anx) caused by arupt stop antidepressant, esp paroxetine, fluvoxamine, venlafaxine --sx may last 1-3 weeks, relieve by restarting antidepressant & do slow taper |
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lithium
indications for use side effects |
treats acute mania (+/- antipsychotic) and maintenance of bipolar
reponse w/in 7-14d SE: N/V/D, GI pain, polyuria, polydipsia, GN, RF, nephrogenic DI, fine tremor, lethargy, fatigue, H/A, leukocytosis, teratogenic, weight gain, edema, sporiasis, hypothyroidism, hair thinning muscle weakness, ECG changes |
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Lithium Toxicity
presentation and management |
GI: severe N/V/D
Cerebellar: ataxia, slurred speech, lack of coordination Cerebral: drowsiness, myoclonus, cheoreiform/Parkinsonian, UMN signs, seizures, delirium, coma TX: d/c lithium, measure Li levels, BUN, lytes; NS IVF; dialysis if Li>2mmol/L |
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lamotrigine (Lamictal)
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adjuvant mood stabilizer in bipolar
good for rapid cycling, mixed phase SE: N/V/D, ataxia, dizzy, diploplia, H/A, somnolescence, RASH (risk of Stevens Johnson syndrome) |
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divalproex (Epival)
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mood stabilizer for both acute mania and maintenance for bipolar
SE: LIVER dysfunction, N//V/D, ataxia, drowsy, tremor, sedation, congitive blurring, hair loss, weight gain, transient thrombocytopenia, teratogenic (NTD) |
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carbamazepine (Tegretol)
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mood stabilizer for bipolar -- second line and for rapid cyclers
SE: N/V/D, HEPATIC TOXICITY, AGRANULOCYTOSIS, BLOOD DYSCRASIAS, RASH (Stevens-Johnson syndrome); transient leukopenia, aplastic anemia, ataxia, dizzy, slurred speech, drowsy, confusion, nystagmus, diploplia |
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clonazepam (Rivitrol)
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long acting benzodiazepine
use: akathisia, GAD, seizure prevention, panic disorder SE: drowsiness, cognitive impairment, reduced motor coordination, memory impairment Physical dependence, tolerance |
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diazepam (Valium)
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NOT IN CANADA!
long acting benzodiazepine use: GAD, seizure prevention, muscle relaxant, EtOH withdrawal SE: drowsiness, cognitive impairment, reduced motor coordination, memory impairment Physical dependence, tolerance |
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chlordiazepoxide (Librium)
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long acting benzo
use: sleep, anxiety, EtOH w/d SE: drowsiness, cognitive impairment, reduced motor coordination, memory impairment Physical dependence, tolerance |
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flurazepam (Dalmane)
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long acting benzo
use: sleep only SE: drowsiness, cognitive impairment, reduced motor coordination, memory impairment Physical dependence, tolerance |
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Benzodiazepines
Side Effects |
CNS: drowsiness, cognitive impairment, reduced motor coordination, memory impairment
Physical dependence, tolerance Unpleasant w/d, possible OD |
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Benzodiazepine Withdrawal
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sx: anxiety, insomnia, dysperceptions, autonomic hyperactivity
onset: 1-2 d for short acting, 2-4 d long lasts weeks/months if dep to higher doses: seizures, delirium, arrhythmias, psychosis |
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flumazenil (Anexate)
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benzodiazepine antagonist
used for suspected benzo OD's |
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alprazolam (Xanax)
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short acting benzo
use: panic disorder SE: drowsiness, cognitive impairment, reduced motor coordination, memory impairment HIGH DEPENDENCY RATE |
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lorazepam (Ativan)
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short acting benzo
use: sleep, GAD, akathisia, EtOH w/d SE: drowsiness, cognitive impairment, reduced motor coordination, memory impairment Physical dependence, tolerance |
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oxazepam (Serax)
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short acting benzo
use: sleep, GAD, EtOH w/d SE: drowsiness, cognitive impairment, reduced motor coordination, memory impairment Physical dependence, tolerance |
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temazepam (Restoril)
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short acting benzo
use: sleep only SE: drowsiness, cognitive impairment, reduced motor coordination, memory impairment Physical dependence, tolerance |
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trazolam (Halcion)
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shortest acting benzo (shortest t1/2)
use: rapid sleep but rebound insomnia SE: drowsiness, cognitive impairment, reduced motor coordination, memory impairment |
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buspirone (Buspar)
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azapirone (partial 5HT agonist)
use: generalized anxiety disorder non sedating! SE: dizziness, drowsiness, nausea, h/a, nervousness, EPS |
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zopiclone (Imovane)
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azapirone (partial 5HT agonist)
use: sleep only SE: dizziness, drowsiness, nausea, h/a, nervousness, EPS |
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clonidine
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alpha adrenergic agonist
use: ADHD to reduce arousal |
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dextroamphetamine
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stimulant
use: ADHD |
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methylphenidate (Ritalin, Concerta)
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stimulant
use: ADHD |
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pemoline
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sympathomimetic agent
tx: ADHD SE: HEPATIC FAILURE |
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trazodone
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serotonin antagonist and uptake inhibitor
use: insomnia!! (depression, fibromyalgia) SE: PRIAPISM |
