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73 Cards in this Set
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Venlafaxine
what class of drug? what kind of patients should not get it? |
Venlafaxine (effexor) is an SNRI
Often used for depression, GAD, and ADHD Low drug interacrtion potential Extended release (XR) allows for once-daily dosing Can increase BP; don't use in patients with untreated or labile BP. what is the other type of SNRI? |
Other than venlafaxine (effexor), DULOXETINE (cymbalta) is the other common type of SNRI.
Duloxetine is great for depression and neuropathic pain. Has more anticholinergic side effects (dry mouth, constipation) compared to SSRI. |
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Duloxetine
what class of drug? in addition to depression, can treat ____. similar side effects to SSRIs, but more of what kind of side effect? |
Duloxetine (cymbalta) = SNRI
Can be used for depression and neuropathic pain. Similar side effects to SSRIs but more dry mouth and constipation (anti-cholinergic) May be more liver side effects |
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What is the mechanism of buproprion?
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Buproprion = wellbutrin
norepinephrine-dopamine reuptake inhbitor (everything but serotonin) Has a relative lack of sexual side effects as opposed to SSRIs. serotonin --> sexual Side effects: increased risk of seizures especially in patients with epilepsy, those also on MAOIs, or with an active eating disorders. |
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what is the one great quality of bupoprion?
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Buproprion (wellbutrin) = norepinephrine/dopamine reuptake inhibitors
relative lack of sexual side effects as opposed to SSRIs. Remember risk of seizures in epileptics, MAOI users and eating disordered. |
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what are side effects of bupoprion?
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increased risk of seizures and psychosis at high doses and anxiety in some.
Contraindicated in patients with seizure or active eating disorders and those on an MAOI. Can also increase anxiety in some. |
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mechanism of trazodone and defazodone?
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serotonin receptor antagonist and agonists
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what is a great use of trazodone?
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Trazodone = serotonin receptor antagonist/agonist
Useful in treating refractory major depression, MDD with anxiety, and INSOMNIA. also, no sexual side effects and do not affect REM sleep side effects: nausea, dizziness, orthostatic hypotension (getting out of bed after your good night's sleep), arrhythmias, SEDATION, and PRIAPISM. |
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mechanism of mirtazapine
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alpha 2 blocker
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drug useful in the treatment of refractory major depression, especially in patients who need to gain weight.
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mirtazapine
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drugs great for depression in elderly- helps with sleep and appetite
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mirtazapine (remeron), an alpha-2 antagonist
side effects = sedation, WEIGHT GAIN, some anticholinergic side effects, rare agranulocytosis no sexual side effects and few drug interactions (even better for old people) |
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What two drugs cause HAM side effects?
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TCAs (amitriptyline, imipramine, clomipramine, doxepin, nortriptyline, desipramine)
low-potency antipsychotics (chlorpromazine, thioridazine) |
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What do HAM side effects stand for?
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HAM = antihistamine (sedation, weight gain), anti-adrenergic (hypotension), antimuscarinic (dry mouth, blurred vision, urinary retention)
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Confusion, flushing, diaphoresis, tremor, myoclonic jerks, hyperthermia, hypertonicity, rhabdomylosis, renal failure, death.
Can be seen in what situation? What drug combinations could cause this? |
Serotonin Syndrome
Confusion, flushing, diaphoresis, tremor, myoclonic jerks, hyperthermia, hypertonicity, rhabdomylosis, renal failure, death. Can occur when SSRI + MAOIs |
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Hypertensive crisis can occur when what two things are combined?
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MAOIs + foods with tyramine (red wine, cheese, chicken liver, cured meats) or plus sympathomimetics
MAOI examples = phenelzine, tranylcypromine, isocarboxazid *selegiline (patch) is MAOI used to treat depression that does not require following the dietary restrictions when used in low dosages. |
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What are the 3 main presentations of extrapyramidal side effects?
what medications do you see EPS side effects? |
EPS can be divided in 3 parts:
1. Parkinsonism: masklike face, cogwheel rigidity, pill-rolling tremor 2. akathisia - restlessness and agitation 3. dystonia - sustained contraction of muscles in neck, tongue, eyes, diaphragm *Occurs with high-potency traditional antipsychotics * Reversible *Occurs within days of starting meds *Can be life threatening (dystonia of diaphragm) |
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What 2 medications can cause hyperprolactinemia? `
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1. high-potency traditional antipsychotics
2. risperidone |
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occurs after years of antipsychotic use (particularly high-potency typicals) and can be irreversible
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tardive dyskinesia: choreoathetoid muscle movements usually of mouth and tongue
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fever, tachycardia, hypertension, elevated CPK, "lead pipe" rigidity.
Can be caused by all antipsychotics after short or long time (more common with typicals) |
neuroleptic malignant syndrome
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Smoking, carbamazepine, barbituates, and st john's wort do what to CYP?
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smoking, carbamazepine, barbituates, and st john's wort INDUCE CYP450, thus decrease the amount of drug in the body.
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Fluvoxamine, fluoxetine, paroxetine, duloxetine, and sertaline do what to CYP?
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Fluvoxamine, fluoxetine, paroxetine, duloxetine, and sertarile INHIBIT CYP, thus increase the amount of drug in the body.
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What is the average amount of time for antidepressants to kick in?
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3-4 weeks
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Which SSRI has the longest half-life, thus does not need to be tapered?
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Fluoxetine (prozac) has the longest half-life, thus does not need to be tapered.
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Which SSRI has the highest risk for GI disturbances?
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Sertraline (zoloft) has the highest risk for GI disturbances.
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Which SSRI has several drug interactions (because it is heavily protein bound), has more anticholinergic symptoms, and a short half life leading to withdrawls.
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Paroxetine (paxil) has several drug interactions (because it is heavily protein bound), has more anticholinergic symptoms, and a short half life leading to withdrawls.
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______ is an SSRI that is currently approved for use in OCD.
Nausea and vomiting are common, lots of drug interactions. |
fluvoxamine (luvox) is an SSRI that is currently approved for use in OCD.
Nausea and vomiting are common, lots of drug interactions. |
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which SSRI has the FEWEST drug-drug interactions?
Also, possibly less sexual side effects |
Citalopram (celexa)
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How do you treat the sexual side effects of SSRIs?
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Augmenting the regimen with buproprion (norepinephrine/dopamine reuptake inhibitors), changing to a non-SSRI, or by adding medications like sildenafil for men.
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What are the 7 side effects of SSRIs?
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1. sexual dysfunction
2. GI disturbance 3. insomnia (also vivid dreams) 4. headache 5. anorexia, weight loss 6. restlessness 7. seizures (0.2% risk) |
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What is the mechanism of TCAs?
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inhibit reuptake NE and serotonin
*becayse of the long 1/2 lives, most are dosed once daily *TCAs are rarely used as the first line agents because they have a higher incidence of side effects and require greater monitoring of dosing |
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which antidepressant can be lethal in overdose?
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TCAs
*even a 1 week supply of TCAs can be lethal in OD Present with agitation, tremors, ataxia, delirium, hypoventilation, depression, hyperreflexia, seizures, coma |
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What type of TCA is highly anticholinergic, more sedating, and greather lethality in overdose?
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Tertiary amines are highly anticholinergic, more sedating, and greather lethality in overdose.
ex: amitriptyline, imipramine, clomipramine, doxepin |
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Which type of TCA is less cholinergic, less sedating?
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secondary amines are less cholinergic, less sedating.
ex: nortriptyline, desipramine |
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how do you treat a TCA overdose?
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IV sodium bicarbonate
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What are two examples of tetracyclic antidepressants?
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amoxapine ((may cause EPS) and maprotiline (higher risk of seizure, arrhythmias, fatality on OD)
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what antidepressant can cause orthostatic hypotension, reflex tachycardia, and ECG changes (wide QRS, QT, PR intervals)
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TCAs cause anti-HAM smptoms (think T.C.A --> H.A.M)
antihisamine = sedation, weight gain anti-adrenergic = hypotension, ECG changes anti-muscarinic = dry mouth, blurred vision, urinary retention, constipation *also can cause seizures 0.3% *lastly, erectile/ejaculatory dysfunction, anorgasmia |
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wha is the most common side effect of MAOIs?
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orthostatic hypotension
other side effects include: drowsiness, weight gain, sexual dysfunction, dry mouth, sleep dysfunction don't forget HTN crisis, and serotonin syndrome |
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What is the treatment for OCD?
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What is the treatment for OCD?
SSRI (in high doses), TCAs (clomipramine) |
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What is the treatment for panic disorder?
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What is the treatment for panic disorder?
SSRIs, TCAs (imipramine), MAOIs |
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What is the treatment for eating disorders?
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What is the treatment for eating disorders?
SSRIs (in high dosease), TCAs, MAOIs |
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What is the treatment for dysthymia?
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What is the treatment for dysthymia?
SSRIs |
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What is the treatment for social phobia?
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What is the treatment for social phobia?
SSRIs, TCAs, MAOIs |
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What is the treatment for GAD?
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What is the treatment for GAD?
SSRIs, SNRIs (venlafaxine), TCAs |
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What is the treatment for PTSD?
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What is the treatment for PTSD?
SSRIs |
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What is the treatment for IBS?
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SSRIs, TCAs
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What is the treatment for eneuresis?
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What is the treatment for eneuresis?
TCAs (imipramine)* Remember, TCA = HAM, anti-muscarinic = urinary retention |
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What is the treatment for neuropathic pain?
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What is the treatment for neuropathic pain?
TCAs (amitriptyline, nortriptyline) duloxetine |
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What is the treatment for chronic pain?
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What is the treatment for neuropathic pain?
SSRIs, TCAs |
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What is the treatment for fibromyalgia?
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What is the treatment for fibromyalgia?
SSRIs |
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What is the treatment for migraine headaches?
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What is the treatment for migraine headaches?
TCAs (amitriptyline), SSRIs |
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What is the treatment for smoking cessation?
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What is the treatment for smoking cessation?
buproprion |
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What is the treatment for PMDD?
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What is the treatment for PMDD?
SSRIs |
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What is the treatment for insomnia?
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What is the treatment for insomnia?
mirtazapine, TCAs (amiriptyline) |
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How long should you wait when stopping an SSRI and starting an MAOI
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at least 2 weeks and for fluoxetine, at least 5-6 weeks
*remember, fluoxetine is the long lasting, thus there is no need to taper it. |
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what drugs can you use when you suspect serotonin synrome?
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first D/C medication (SSRI/MAOI), then can try CCB (oral nifedipine)/ If carefully monitored, you can try chlorpromazine or phentolamine
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when prescribing lithium what 3 things should you monitor?
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1. Lithium levels (check after 5 days, then every 2-3 days until therapeutic. Therapeutic = 0.6 - 1.2, toxic > 1.5, lethal > 2.0
2. Creatine (it is metabolized by the kidney) 3. Thyroid levels (it can cause hypothyroidism) prior to initiating, check ECG, basic chemistries, TFTs, CBC, and pregnany test. *Onset = 5-7 days |
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What is the mechanism of typical (1st gen) antipsychotics?
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Blocking dopamine (D2) receptors
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What is the mechanism of atypical (2nd gen) antipsychotics?
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Block both dopamine (D2) and serotonin (2A) receptors
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Which antipsychotics are more effective in treating negative symptoms (flattened affect, social withdrawal)?
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atypical (2nd gen) antipsychotics
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What are the two low potency typical antipsychotics?
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Low potency typical antipsychotics have a lower affinity for dopamine receptors, therefore a higher dose is required.
1. chlorpromazine (thorazine) 2. thiroridazine (mellaril) |
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which typical antipsychotics have the highest incidence of anticholinergic and antihistamine side effects?
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Low-potency typical antipsychotics (chlorpromazine, thioridazine) have the highest incidence of anticholinergic and antihistamine side effects
*however, they have a lower risk of EPS and neuroleptic malignant syndrome |
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which typical antipsychotics have the highest risk for lethality in overdose?
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low-potency (chlorpromazine, thioridazine) typical antipsychotics have the highest risk for lethality in overdose because they can cause prolonged QT, heart block, and v tach
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which TYPICAL antipsychotic can cause bluish skin discoloration, and photosensitivity?
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chlorpromazine (thorazine) is a low-potency typical which can cause orthostatic hypotension. bluish skin discoloration, photosensitivity.
*remember since it's low-potency, you need higher doses, and i causes more anticholinergic/histaminic, and lethality - but lower EPS/NMS |
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which low potency typical antipsychotic is associated with retinitis pigmentosa?
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thioridazine is a low potency typical antipsychotic which is associated with retinitis pigmentosa
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loxapine, thiotixene, trifluoperazine, pephenazine are all examples of ___?
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loxapine, thiotixene, trifluoperazine, pephenazine are all examples of midpotency typical antipsychotics
loxapine - higher risk of seizure thiothixine - ocular pigment changes (like thioridazine) trifluoperazine - can reduce anxiety |
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which two antipsychotics have long-lasting IM forms (decanoate) that are useful if patients don't like taking medications
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1. haloperidol (haldol)
2. fluphenazine (prolixin) *remember, high potency typicals have less sedation, orthostatics, and anticholinergics, but higher risk for EPS and tardive dyskinesia |
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what part of the brain is responsible for the positive symptoms of schizophrenia?
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the positive symptoms of schizophrenis is treated by the medications in the MESOLIMBIC dopamine pathway (which includes the nucleus accumbens, fornix, amygdala, and hippocampus)
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What part of the brain is responsible for the negative symptoms of schizophrenia?
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the MESOCORTICAL pathway is responsible for the negative symptoms of schizophrenia
(N C) |
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what are the major types of side effects with typical antipsychotics
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antidopaminergic (parkinsonism, akathisia, dystonia)
hyperprolactinemia anti-HAM tardive dyskinesia Neuroleptic malignant syndrome |
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what types of people get tardive dyskinesia?
what about neuroleptic malignant syndrome? |
tardive dyskinesia --> older women
neuroleptic malignant syndrome --> younger men |
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What does "FALTERED" for neuroleptic malgnant syndrome stand for?
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Fever
Autonomic instability (tachycardia, labile hypertension, diaphoresis) Leukocytosis Tremor Elevated CPK Rigidity (lead pipe rigidity) Excessive sweating Delirium Treatment = d/c current meds and hydrate, cool, etc |
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What is the treatment for EPS?
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1. reduce dose of antipsychotic
2. administer anticholinergic like benztropine (congentin), an antihistaminergic like diphenhydramine (benadryl), or an antiparkinsonian like amantadine |
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what 2 drugs can cause eye deposits in TYPICAL antipsychotics?
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1. thioridazine - irreversible retinal pigmentation
2. chlorpromazine - deposits in lens and cornea |
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what TYPICAL antipsychotic causes skin problems?
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chlorpromazine causes blue gray skin discoloration and photosensitivity
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