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178 Cards in this Set

  • Front
  • Back
Major antidepressant categories of medications (4)...
TCA
MAOI
SSRI
Atypical
Antidepressant medications: similarities and differences?
All are equally effective in treating MDD, but they differ in their side effect profiles
Antidepressants and abuse potential?
The classic 4 categories have NO abuse potential because they do NOT elevate mood. Sympathomimetics (amphetamine-based) drugs have addiction potential, and they DO elevate mood.
The more popularly prescribed antidepressant categories and why?
SSRI and Atypical due to safety profile
Indications for SSRIs (mnemonic and list)...
POPES DIM PAD

Panic Disorder
Obesseive Compulsive DO
PTSD
Eating Disorders
Social Phobia

Dysthymia
IBS
Migraine

Premenstrual Dysphoric DO
Autism
Depression
General disorders for which TCAs are used (mnemonic and list)
POPE I MIND

Panic DO
OCD
PTSD
Eating DO

IBS

Migraine
Insomnia
Neuropathic Pain
Depression
General disorders for which MAOI are used (mnemonic and list)
SPED

Social phobia
Panic DO
Eating DO
Depression
Generals disorders for which Buproprion is used (mnemonic and list)
DSM

Depression
Smoking cessation
Migraines
TCA General Information
Inhibit reuptake of serotonin and NE; not first line because can be lethal in OD
Examples of TCA medications (8)...
Imipramine
Amitriptyline
Trimipramine
Nortriptyline
Desipramine
Clomipramine
Doxepin
TCA General Suffices
-IPRAMINE
-TRIPTYLINE

(and Doxepin, a random drug)
Clomipramine (special use and mnemonic)
Most serotonin specific, best in treatment of OCD

"Clone me" so I can accomplish all the OCD tasks
Imipramine (special use and mnemonic)
Enuresis

"I MIght Pee"
Nortriptyline (special use and mnemonic)
Least likely to cause orthostatic hypotension

"No Trip"
Desipramine (special use... no mnemonic yet)
Least sedating
Least anticholingergic
TCA overdose treatment?
IV Sodium Bicarb

"Bicarb for Tricyclic OD"
Why do TCA have so many side effects?
Lack of specificity and interaction with other receptors
Tricyclics have 3 sets of side effects (name the 3 sets along with mnemonics)
HAM effects
Antihistamine (sedation)
Antiadrenergic (orthostatic hypotension, arrhythmias, bradycardia)
Antimuscarinic (dry mouth, constipation, urinary retention, blurred vision, tachycardia)

The 3 C's
Coma
Cardiotoxicity
Convulsions

Sexual SE (the penis is DEAD)
Decreased libido
Erectile dysfunction
Anorgasmia
Delayed ejaculation
General action of MAOI
Inhibit destruction of biogenic amines such as NE, serotonin, dopamine, tyramine
What is tyramine?
Intermediate between tyrosine and NE
Specific action of MAOI
Irreversibly inhibit MAO-A and MAO-B enzymes which increases amount of neurotransmitter in the synapse
MAO-A specifically deactives...
Serotonin (5-HIAA)
MAO-B specifically deactivates...
NE and Epi
Both MAO A+B deactivate...
Dopamine and Tyramine
MAOI are very effective for... (2 conditions)
Refractory depression
Refractory panic disorder
Examples of MAOI (3)...
Phenelzine
Tranylcypromine
Isocarboxazid
Hallmark TCA toxicity (cardiac)
Widened QRS (>100msec), used as a treatment treshold (can cause fatal heart block)
Side effect profile of MAOI (3 sets)
Common ones...
Ortho hypotension, drowsiness, wt gain, sexual dysfunction, dry mouth, sleep dysfxn

Serotonin Syndrome

Hypertensive Crisis
Foods to avoid with MAOI (3 general categories)
Aged cheeses
Cured meats
Red wines
Medications to avoid with MAOI (3 categories, and 1 specific)
SSRI
TCA
Sympathomimetics
Meperidine
How does serotonin syndrome occur?
When SSRI or TCA are taken together with MAOI (wait at least two weeks before switching from an SSRI to MAOI)

MAOI + Meperidine can also cause serotonin syndrome
Initial findings of serotonin syndrome?
Lethargy, restlessness, confusion, flushing, diaphoresis, tremor, myoclonus
Late findings of serotonin syndrome?
Hyperthermia, hypertonicity, rhabdomyolysis, renal failure, convulsions, coma, death
First step when suspecting Serotonin Syndrome?
Discontinue offending medications/foods
How does hypertensive crisis occur?
Taking tyramine rich foods or sympathomimetics together

(sympathomimetics may be found in OTC cold remedies)
SSRI how do they work in their mechanism of action?
Inhibit presynaptic serotonin pumps increasing availability of serotonin in synaptic clefts
SSRI are preferred choice of meds due to...
Low S/E profile
Safe in overdose
No food restrictions
Examples of SSRI (6)...
Fluoxetine
Sertraline
Paroxetine
Fluvoxamine
Citalopram
Escitalopram

"FLU to the CITY to SERve my PAROLE EXCITEDLY"
Side effects of SSRI...
(mnemonic)
Sexual dysfxn
Sleeping dysfxn
Reduced appetite
Intestinal (gastro) problems

Serotonin syndrome when used with MAOI
Drugs that can be used to relieve the negative effects of SSRI on sexual function...
(mnemonic)
Cyproheptadine
Bethanecol
Amantidine
Bupriprion
Yohimbine

"Create BABY"
What is SSRI discontinuation syndrome?
With abrupt D/C, can get dizzy, N/V, lethargy, flu-like sx, sleep disturbance... Happens 1-3 days after last dose
Fluoxetine (unique)
Longest half life due to active metabolites, does not need to be tapered

"Long Flights"
Sertraline (unique)
Highest GI disturbances

"Sit in the toilet all day long"
Escitalopram (unique)
Enantiomer of citalopram with similar efficacy, fewer S/E, much more expensive
Citalopram (unique)
Very few drug interactions, good in pts with lots of comorbidities
4 general categories of atypical antidepressants
1) SNRI (serotonin NE reuptake inhibitor)
2) NDRI (NE Dopramine reuptake inhibitor)
3) SARI (Serotonin antagonist reuptake inhibitor)
4) NASA (NE antagonist and Serotonin antagonist)
SNRI (representative drugs)
Venlaxafine
Duloxetine
Venlaxafine (characteristics)
Refractory depression, Panic DO

Very low drug interaction potential

Side effect profile similar to SSRI

Can increase BP so do not use in patients with BP probs

Withdrawal symptoms are flu-like or may have electrical zaps or shocks
Duloxetine (use?)
Neurogenic Pain
NDRI (representative drug)
Buproprion
Bupropion uses
Smoking cessation
Seasonal affective disorder
Adult ADHD
Depression
Migraines
Narcolepsy
Bupropion benefits
Increases energy and increases concentration

Lack of sexual side effects
Bupropion side effects
Dopaminergic effects at high doses can cause psychosis

Can lower seizure threshold causing seizures
Do NOT use Bupropion with...
Pts with significant anxiety
Pts with seizure disorders
Pts with active eating disorders
Pts using MAOI
SARI (sample drug)
Nefazodone
Trazodone
SARI major uses
Refractory MDD
Insomnia
SARI major side effects
Sedation, Priapism (esepcially with trazodone)
How to treat priapism associated with trazodone?
1) Intracorporeal injection of epinephrine

2) Drainage of blood from penis
NASA (sample drug)
Mirtazapine
Mirtazapine uses
Refractory MDD especially when weight gain is needed
Mirtazapine S/E
Seadtion, weight gain, agranulocytosis
Mirtazapine dosing concentration dual role
Low dose (below 15mg) is sedating

High dose (above 15mg) is excitatory
Typical vs. Atypical antipsychotics and their receptor indications
Typicals block dopamine, and also HAM

Atypicals block dopamine and serotonin, but not HAM
Low potency typical antipsychotics (2)
Chlorpromazine
Thioridazine
Chlorpromazine problem?
Pigment deposition into cornea and lens
Thioridazine problem?
Pigmentary retinopathy
Low potency typical antipsychotics (benefits and problems in general)
Block HAM receptors causing more problems with those

Lower incidence of EPSE and NMS
High potency typical antipsychotics (5)
Haloperidol
Fluphenazine
Trifluoperazine
Perphenazine
Pimozide
Long acting forms of high potency typical AP available for...
Haloperidol
Fluphenazine
High potency typical antipsychotics (benefits and problems in general)
Higher incidence of EPSE and NMS

Lower incidence of anti-HAM side effects (better for older population because of this)
Typical and Atypical AP in terms of symptom treatment
Both types are equally effective for positive symptoms (delusions, hallucinations)

Atypical much better for negative symptoms (flattened affect, social withdrawal)
Traditional Antipsychotic Side Effects
1) EPSE
2) Hyperprolactinemia
3) Anti-HAM
4) Weight gain
5) Increased LFTs
6) Ophthalmologic problems
7) Seizures
8) Tardive Dyskinesia
9) NMS
10) Dermatologic Problems
Tardive Dyskinesia, hypothesis of the pathogenesis?
Increased number of dopamine receptors causing lower levels of acetylcholine
EPSE of typical antipsychotics
Parkinsonism - Masklike facies, cogwheel rigidity, pill rolling tremor

Akasthisia - Subjective anxiety and restlessness, objective fidgetiness

Dystonia - Sustained contraction of muscles of neck, tongue, eyes (painful)
Treatment for EPSE of typical antipsychotics
Parkinsonism - Amantdaine or Levodopa

Akasthisia - Propranolol, Benzos

Dystonia - Anticholinergics such as Benztropine, Benadryl
Hyperprolactinemia of typical antipsychotics
Decreased libido

Galacthorrhea (primary effect in women)

Gynecomastia

Impotence (primary effect in men)

Amenorrhea

Osteoporosis
Ophthalmologic problems of typical antipsychotics
Retinal pigmentation with thioridazine

Corneal and lens pigmentation with chlorpromazine
Dermagologic problems of typical antipsychotics
Rashes and photosensitivity

Blue gray skin discoloration with chlorpromazine
Seizure problems of typical antipsychotics
Lower seizure thresholds, low potency more likely to do so than high potency
Tardive Dyskinesia
Choreoathetoid (writhing) movements of mouth and tongue occur in patients who have used neuroleptics for more than 6 months

Most often occurs in older women

50% of cases spontaneously remit, though untreated cases may be permanent

May emerge or temporarily worsen as medication is decreased (withdrawal dyskinesia)
Rabbit Syndrome
Uncommon side effect of typical antipsychotics, often confused with TD; but with rabbit syndrome there are chewing movements (rapid) but no tongue involvement
Tardive Dyskinsia Treatment
Discontinue current antipsychotic

Sometimes anxiolytics or cholinomimetics may help
NMS of typical antipsychotics (most common group affected and presentation)
Occurs most often in males early in tx with neuroleptics.

Medical emergency with 20% mortality if untreated
NMS often preceded by...
Catatonic state
NMS Symptoms
FALTER

Fever (most common)
ANS Instability (tachy, HTN)
Leukocytosis
Tremors
Elevated CPK
Rigidity (lead pipe rigidity)
NMS Tx
D/C current medications!

Supportive care (hydrate, cool)

Dantrolene, Bromocriptine, Amantadine (these are used infrequently because of their own side effects)
Is NMS an allergic reaction?
No
Can you restart the same neuroleptic that caused NMS in the first place?
Yes
Examples of atypical antipsychotics (5)
Clozapine
Risperidone
Quetiapine
Olanzapine
Ziprasidone
Clozapine specific side effects
Agranulocytosis
Seizures
Olanzapine Side Effects
Hyperlipidemia, Glucose intolerance, Weight gain, Liver toxicity
Quetiapine side effects
Causes cataracts in dogs

(but less propensity to gain weight)
Test to get for Clozapine?
QWeekly CBC to check agranulocytosis
Test to get for Olanzapine?
LFTs to check for liver toxicity
Test to get for Quetiapine?
Bi-yearly slit lamp examinations to check for cataracts
Which atypical antipsychotics are approved for tx of MANIA? (2)
Ziprasidone
Quetiapine
Most effective atypical antipsychotics for negative symptoms? (2)
Olanzapine
Clozapine
Common side effects to all atypical antipsychotics
metabolic syndrome things such as HTN, dyslipidemia, glucose intolerance, weight gain
Which two atypical antipsychotics cause the most weight gain, HTN, dyslipidemia?
Olanzapine
Clozapine
Mood stabilizers and pregnancy, problem?
Many are teratogenic, need to check for pregnancy before starting them...
Another name for mood stabilizers?
Anti-Manics
Mood stabilizers treat mania, but what other indications? (4)
Potentiate antidepressants in MDD

Potentiate antipsychotics in schizophrenia

Enhance abstinence in alcoholism

Treat aggression/impulsivity (dementia, intoxication, MR, personality DO, general medical condition)
Mood stabilizing drugs (3)
Lithium
Carbamazepine
Valproic Acid
Lithium uses
Drug of choie for acute mania

PPX for both manic and depressive episodes
Mechanism of lithium fxn?
Alter neuronal sodium transport (as it is also monovalent)
Lithium excreted by...
Kidneys
Lithium onset of action...
5-7 days
Drawback of lithium...
High incidence of SE

Narrow therapeutic range
Therapeutic range of lithium...
0.7 - 1.2
Toxic and lethal ranges of lithium
Toxic >1.5
Lethal >2.0
Things that affect lithium levels
NSAID

Not enough water (increase)
Sodium deprivation (increase)
Aspirin/NSAIDs (increase)
Impaired renal fxn (increase)
Diuretics (decrease)
Side FX of lithium
Fine tremor, sedation, ataxia, thirst, metallic taste, polyuria, edema, wt gain, GI problems, benign leukocytosis, thyroid enlargement, hypothyroidism, NDI
Toxic levels of lithium side FX
COARSE tremors
Altered MS
Convulsions
Death
Things to regularly monitor in lithium using patients
Thyroid function (hypothyroid)
Kidney function (GFR)
Blood levels of lithium
Lithium toxicity tx
Dialysis
How do NSAIDs cause lithium toxicity?
Reduced formulation of prostaglandins in the renal tubules will decreased renal blood flow, causing buildup of lithium levels
Describe lithium tremor
Fine tremor is benign, high frequency, worse with activities requiring fine motor control

(NOTE: Coarse tremors are a sign of a toxic level)
Therapy for benign lithium tremors
Decreased dose
Eliminate caffeine
Slow release lithium preparation
Beta blockers
Carbamazepine, trade name?
Tegretol
Carbamazepine and its uses in mood disorders
Mixed episodes

Rapid cycling bipolar DO
Carbamazepine and its use in things other than mood DO
Trigeminal neuralgia (tic doulereaux)
Mechanism of action of Carbamazepine
BLocks sodium channels inhibiting action potentials
Onset of action of Carbamazepine
5-7 days, much like lithium
Carbamazepine S/E
Nonspecific: Rash, ataxia, drowsy, slurred speech

Specific: Leukopenia, Hyponatremia, Aplastic anemia, Agranulocytosis, elevated LFTs

Teratogenic: Neural tube defects
Carbamazepine must be monitored with what labs?
CBC (agranulocytosis, leukopenia, aplastic anemia)

BMP (hyponatremia)

Liver toxicity (LFTs)
Valproic Acid, tradename?
Depakene
Valproic Acid, best for what types of mania?
Mixed episodes and rapid cycling disorders, just like carbamazepine
Mechanism of action of valproic acid?
Increase CNS levels of GABA
Valproic Acid S/E
Nonspecific: sedation, weight gain, alopecia

Specific: Hemorrhagic pancreatitis, hepatotoxicity, thrombocytopenia

Teratogenic: NTD
What labs to monitor with valproic acid?
CBC (thrombocytopenia)

LFT (hepatoxicity)
Anxiolytics (sedative/hypnotics), what are the general categories? (3)
Benzos
Barbiturates
Buspirone
Anxiolytics, general mechanism of action?
Diffusely depress CNS, causing sedation
Common indications for sedative/hypnotics (6)
Anxiety DO
Muscle spasm
Seizures
Sleep DO
Alcohol WD
Anesthesia induction
Teratogenicity of Lithium?
Ebstein's anomaly
Teratogenicity of valproic acid and carbamazepine?
Neural tube defects
BDZ main problem...
Potential for tolerance and dependence after prolonged use
BDZ + Alcohol =
Possibly death
BDZ mechanism of action...
Increase frequency of chloride channel opening in GABA
Long acting Benzos (1-3 days)
Chlordiazepoxide
Diazepam
Flurazepam
Intermediate Benzos (1/2 to 1 day)
Clonazepam
Lorazepam
Temazepam
Alprazolam
Short Benzos (4-8 hours)
Oxazepam
Triazolam
Chlordiazepoxide uses (Librium)
Alcohol detox
Diazepam uses
Anxiety, Seizures
(rapid onset)
Flurazepam uses
Insomnia

(rapid onset)
Lorazepam uses (Ativan)
Alcohol WD
Temazepam uses
Insomnia
Triazolam uses
Insomnia
What Benzos for insomnia?
Triazolam, Temazepam, Flurazepam
What benzos for anxiety attacks?
CALm down

Clonazapam
Alprazolam
Lorazepam
What benzos for seizures?
Lorazepam
Diazepam
What benzo for alcohol WD?
Lorazepam
What benzo for alcohol detox?
Chlordiazepoxide
Varenicline (Chantix)... mechanism and indication and main SE?
Partial nicotinic agonist

Smoking cessation

Bad nausea in 1/3 patients
Acute benzo intoxication?
Flumazenil
Benzo intoxication in a chronic user?
Flumazenil may precipitate seizures, so better to protect airway and have benzos wean themselves off
S/E of BDZ
Drowsiness, impaired intellect, reduced motor coordintaion
Lethality of BDZ
Respiratory depression, especially when combined with alcohol
Zolpidem (Ambien)
Zoleplon (Sonata)

What are they?
Chemically similar to BDZ but not a BDZ, but has same effect
Mechanism of action of Zolpidem and Zoleplon
Selectively bind to BDZ site on GABA receptor
Indication for Zolpidem and Zoleplon
Short term treatment for insomnia
Compared to BDZ, Zolpidem and Zoleplon do NOT have
Anticonvulsant or muscle relaxant properties
Good things about Zolpidem and Zoleplon (3)
No WD effects
Minimal rebound insomnia
Little/No dependence/tolerance
Buspirone, mechanism of action?
Partial agonist at 5HT-1A receptor
Buspirone, general indication?
Anxiolytic

Alternative to BDZ or Venlafaxine for GAD
Buspirone time of onset?
1-2 weeks, takes longer than BDZ
Buspirone + Alcohol =
No problem as it does not potentiate alcohol effects, useful in alcoholics
Buspirone, abuseable?
Low potential for addiction
5HT =
Serotonin
Propranolol indications (3)
Panic attacks
Performance anxiety

For the above two, treats the autonomic FX such as tachycardia, sweating, palpitations

Akasthisia - EPSE of typical antipsychotics
HAM side effects?
H - Drowsy, Sedation
A - Hypotension
M - Dry mouth, blurred vision, urinary retention, constipation
HAM S/E found mostly in...
TCA

Typical antipsychotics (low potency)
Serotonin syndrome can happen when you combine MAOI with...
SSRI
TCA
Meperidine
Tx for Parkinson like features?
Amantidine, Levodopa
Tx for Akasthisia?
Propranolol
Tx for Dystonia?
Benztropine or Benadryl
Dystonia, some features?
Occurs more with high potency typical antipsychotics

Reversible with anticholinergics

Occurs within days of drug use

Can be life threatening if respiratory path blocked from muscular contraction
Anticholinergics and the brain...
Difficulty concentrating, impaired short term memory, disoriented, delirium
Tardive Dyskinsia, monitor...
Abnormal Involuntary Movement Scale (AIMS) Q6 Months