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178 Cards in this Set
- Front
- Back
Major antidepressant categories of medications (4)...
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TCA
MAOI SSRI Atypical |
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Antidepressant medications: similarities and differences?
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All are equally effective in treating MDD, but they differ in their side effect profiles
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Antidepressants and abuse potential?
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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.
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The more popularly prescribed antidepressant categories and why?
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SSRI and Atypical due to safety profile
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Indications for SSRIs (mnemonic and list)...
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POPES DIM PAD
Panic Disorder Obesseive Compulsive DO PTSD Eating Disorders Social Phobia Dysthymia IBS Migraine Premenstrual Dysphoric DO Autism Depression |
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General disorders for which TCAs are used (mnemonic and list)
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POPE I MIND
Panic DO OCD PTSD Eating DO IBS Migraine Insomnia Neuropathic Pain Depression |
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General disorders for which MAOI are used (mnemonic and list)
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SPED
Social phobia Panic DO Eating DO Depression |
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Generals disorders for which Buproprion is used (mnemonic and list)
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DSM
Depression Smoking cessation Migraines |
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TCA General Information
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Inhibit reuptake of serotonin and NE; not first line because can be lethal in OD
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Examples of TCA medications (8)...
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Imipramine
Amitriptyline Trimipramine Nortriptyline Desipramine Clomipramine Doxepin |
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TCA General Suffices
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-IPRAMINE
-TRIPTYLINE (and Doxepin, a random drug) |
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Clomipramine (special use and mnemonic)
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Most serotonin specific, best in treatment of OCD
"Clone me" so I can accomplish all the OCD tasks |
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Imipramine (special use and mnemonic)
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Enuresis
"I MIght Pee" |
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Nortriptyline (special use and mnemonic)
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Least likely to cause orthostatic hypotension
"No Trip" |
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Desipramine (special use... no mnemonic yet)
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Least sedating
Least anticholingergic |
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TCA overdose treatment?
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IV Sodium Bicarb
"Bicarb for Tricyclic OD" |
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Why do TCA have so many side effects?
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Lack of specificity and interaction with other receptors
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Tricyclics have 3 sets of side effects (name the 3 sets along with mnemonics)
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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 |
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General action of MAOI
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Inhibit destruction of biogenic amines such as NE, serotonin, dopamine, tyramine
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What is tyramine?
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Intermediate between tyrosine and NE
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Specific action of MAOI
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Irreversibly inhibit MAO-A and MAO-B enzymes which increases amount of neurotransmitter in the synapse
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MAO-A specifically deactives...
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Serotonin (5-HIAA)
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MAO-B specifically deactivates...
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NE and Epi
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Both MAO A+B deactivate...
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Dopamine and Tyramine
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MAOI are very effective for... (2 conditions)
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Refractory depression
Refractory panic disorder |
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Examples of MAOI (3)...
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Phenelzine
Tranylcypromine Isocarboxazid |
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Hallmark TCA toxicity (cardiac)
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Widened QRS (>100msec), used as a treatment treshold (can cause fatal heart block)
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Side effect profile of MAOI (3 sets)
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Common ones...
Ortho hypotension, drowsiness, wt gain, sexual dysfunction, dry mouth, sleep dysfxn Serotonin Syndrome Hypertensive Crisis |
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Foods to avoid with MAOI (3 general categories)
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Aged cheeses
Cured meats Red wines |
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Medications to avoid with MAOI (3 categories, and 1 specific)
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SSRI
TCA Sympathomimetics Meperidine |
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How does serotonin syndrome occur?
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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 |
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Initial findings of serotonin syndrome?
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Lethargy, restlessness, confusion, flushing, diaphoresis, tremor, myoclonus
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Late findings of serotonin syndrome?
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Hyperthermia, hypertonicity, rhabdomyolysis, renal failure, convulsions, coma, death
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First step when suspecting Serotonin Syndrome?
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Discontinue offending medications/foods
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How does hypertensive crisis occur?
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Taking tyramine rich foods or sympathomimetics together
(sympathomimetics may be found in OTC cold remedies) |
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SSRI how do they work in their mechanism of action?
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Inhibit presynaptic serotonin pumps increasing availability of serotonin in synaptic clefts
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SSRI are preferred choice of meds due to...
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Low S/E profile
Safe in overdose No food restrictions |
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Examples of SSRI (6)...
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Fluoxetine
Sertraline Paroxetine Fluvoxamine Citalopram Escitalopram "FLU to the CITY to SERve my PAROLE EXCITEDLY" |
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Side effects of SSRI...
(mnemonic) |
Sexual dysfxn
Sleeping dysfxn Reduced appetite Intestinal (gastro) problems Serotonin syndrome when used with MAOI |
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Drugs that can be used to relieve the negative effects of SSRI on sexual function...
(mnemonic) |
Cyproheptadine
Bethanecol Amantidine Bupriprion Yohimbine "Create BABY" |
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What is SSRI discontinuation syndrome?
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With abrupt D/C, can get dizzy, N/V, lethargy, flu-like sx, sleep disturbance... Happens 1-3 days after last dose
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Fluoxetine (unique)
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Longest half life due to active metabolites, does not need to be tapered
"Long Flights" |
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Sertraline (unique)
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Highest GI disturbances
"Sit in the toilet all day long" |
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Escitalopram (unique)
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Enantiomer of citalopram with similar efficacy, fewer S/E, much more expensive
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Citalopram (unique)
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Very few drug interactions, good in pts with lots of comorbidities
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4 general categories of atypical antidepressants
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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) |
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SNRI (representative drugs)
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Venlaxafine
Duloxetine |
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Venlaxafine (characteristics)
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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 |
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Duloxetine (use?)
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Neurogenic Pain
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NDRI (representative drug)
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Buproprion
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Bupropion uses
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Smoking cessation
Seasonal affective disorder Adult ADHD Depression Migraines Narcolepsy |
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Bupropion benefits
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Increases energy and increases concentration
Lack of sexual side effects |
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Bupropion side effects
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Dopaminergic effects at high doses can cause psychosis
Can lower seizure threshold causing seizures |
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Do NOT use Bupropion with...
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Pts with significant anxiety
Pts with seizure disorders Pts with active eating disorders Pts using MAOI |
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SARI (sample drug)
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Nefazodone
Trazodone |
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SARI major uses
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Refractory MDD
Insomnia |
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SARI major side effects
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Sedation, Priapism (esepcially with trazodone)
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How to treat priapism associated with trazodone?
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1) Intracorporeal injection of epinephrine
2) Drainage of blood from penis |
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NASA (sample drug)
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Mirtazapine
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Mirtazapine uses
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Refractory MDD especially when weight gain is needed
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Mirtazapine S/E
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Seadtion, weight gain, agranulocytosis
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Mirtazapine dosing concentration dual role
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Low dose (below 15mg) is sedating
High dose (above 15mg) is excitatory |
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Typical vs. Atypical antipsychotics and their receptor indications
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Typicals block dopamine, and also HAM
Atypicals block dopamine and serotonin, but not HAM |
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Low potency typical antipsychotics (2)
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Chlorpromazine
Thioridazine |
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Chlorpromazine problem?
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Pigment deposition into cornea and lens
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Thioridazine problem?
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Pigmentary retinopathy
|
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Low potency typical antipsychotics (benefits and problems in general)
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Block HAM receptors causing more problems with those
Lower incidence of EPSE and NMS |
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High potency typical antipsychotics (5)
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Haloperidol
Fluphenazine Trifluoperazine Perphenazine Pimozide |
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Long acting forms of high potency typical AP available for...
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Haloperidol
Fluphenazine |
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High potency typical antipsychotics (benefits and problems in general)
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Higher incidence of EPSE and NMS
Lower incidence of anti-HAM side effects (better for older population because of this) |
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Typical and Atypical AP in terms of symptom treatment
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Both types are equally effective for positive symptoms (delusions, hallucinations)
Atypical much better for negative symptoms (flattened affect, social withdrawal) |
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Traditional Antipsychotic Side Effects
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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 |
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Tardive Dyskinesia, hypothesis of the pathogenesis?
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Increased number of dopamine receptors causing lower levels of acetylcholine
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EPSE of typical antipsychotics
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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) |
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Treatment for EPSE of typical antipsychotics
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Parkinsonism - Amantdaine or Levodopa
Akasthisia - Propranolol, Benzos Dystonia - Anticholinergics such as Benztropine, Benadryl |
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Hyperprolactinemia of typical antipsychotics
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Decreased libido
Galacthorrhea (primary effect in women) Gynecomastia Impotence (primary effect in men) Amenorrhea Osteoporosis |
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Ophthalmologic problems of typical antipsychotics
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Retinal pigmentation with thioridazine
Corneal and lens pigmentation with chlorpromazine |
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Dermagologic problems of typical antipsychotics
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Rashes and photosensitivity
Blue gray skin discoloration with chlorpromazine |
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Seizure problems of typical antipsychotics
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Lower seizure thresholds, low potency more likely to do so than high potency
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Tardive Dyskinesia
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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) |
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Rabbit Syndrome
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Uncommon side effect of typical antipsychotics, often confused with TD; but with rabbit syndrome there are chewing movements (rapid) but no tongue involvement
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Tardive Dyskinsia Treatment
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Discontinue current antipsychotic
Sometimes anxiolytics or cholinomimetics may help |
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NMS of typical antipsychotics (most common group affected and presentation)
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Occurs most often in males early in tx with neuroleptics.
Medical emergency with 20% mortality if untreated |
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NMS often preceded by...
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Catatonic state
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NMS Symptoms
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FALTER
Fever (most common) ANS Instability (tachy, HTN) Leukocytosis Tremors Elevated CPK Rigidity (lead pipe rigidity) |
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NMS Tx
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D/C current medications!
Supportive care (hydrate, cool) Dantrolene, Bromocriptine, Amantadine (these are used infrequently because of their own side effects) |
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Is NMS an allergic reaction?
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No
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Can you restart the same neuroleptic that caused NMS in the first place?
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Yes
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Examples of atypical antipsychotics (5)
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Clozapine
Risperidone Quetiapine Olanzapine Ziprasidone |
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Clozapine specific side effects
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Agranulocytosis
Seizures |
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Olanzapine Side Effects
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Hyperlipidemia, Glucose intolerance, Weight gain, Liver toxicity
|
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Quetiapine side effects
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Causes cataracts in dogs
(but less propensity to gain weight) |
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Test to get for Clozapine?
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QWeekly CBC to check agranulocytosis
|
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Test to get for Olanzapine?
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LFTs to check for liver toxicity
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Test to get for Quetiapine?
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Bi-yearly slit lamp examinations to check for cataracts
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Which atypical antipsychotics are approved for tx of MANIA? (2)
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Ziprasidone
Quetiapine |
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Most effective atypical antipsychotics for negative symptoms? (2)
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Olanzapine
Clozapine |
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Common side effects to all atypical antipsychotics
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metabolic syndrome things such as HTN, dyslipidemia, glucose intolerance, weight gain
|
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Which two atypical antipsychotics cause the most weight gain, HTN, dyslipidemia?
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Olanzapine
Clozapine |
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Mood stabilizers and pregnancy, problem?
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Many are teratogenic, need to check for pregnancy before starting them...
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Another name for mood stabilizers?
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Anti-Manics
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Mood stabilizers treat mania, but what other indications? (4)
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Potentiate antidepressants in MDD
Potentiate antipsychotics in schizophrenia Enhance abstinence in alcoholism Treat aggression/impulsivity (dementia, intoxication, MR, personality DO, general medical condition) |
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Mood stabilizing drugs (3)
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Lithium
Carbamazepine Valproic Acid |
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Lithium uses
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Drug of choie for acute mania
PPX for both manic and depressive episodes |
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Mechanism of lithium fxn?
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Alter neuronal sodium transport (as it is also monovalent)
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Lithium excreted by...
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Kidneys
|
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Lithium onset of action...
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5-7 days
|
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Drawback of lithium...
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High incidence of SE
Narrow therapeutic range |
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Therapeutic range of lithium...
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0.7 - 1.2
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Toxic and lethal ranges of lithium
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Toxic >1.5
Lethal >2.0 |
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Things that affect lithium levels
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NSAID
Not enough water (increase) Sodium deprivation (increase) Aspirin/NSAIDs (increase) Impaired renal fxn (increase) Diuretics (decrease) |
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Side FX of lithium
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Fine tremor, sedation, ataxia, thirst, metallic taste, polyuria, edema, wt gain, GI problems, benign leukocytosis, thyroid enlargement, hypothyroidism, NDI
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Toxic levels of lithium side FX
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COARSE tremors
Altered MS Convulsions Death |
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Things to regularly monitor in lithium using patients
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Thyroid function (hypothyroid)
Kidney function (GFR) Blood levels of lithium |
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Lithium toxicity tx
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Dialysis
|
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How do NSAIDs cause lithium toxicity?
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Reduced formulation of prostaglandins in the renal tubules will decreased renal blood flow, causing buildup of lithium levels
|
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Describe lithium tremor
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Fine tremor is benign, high frequency, worse with activities requiring fine motor control
(NOTE: Coarse tremors are a sign of a toxic level) |
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Therapy for benign lithium tremors
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Decreased dose
Eliminate caffeine Slow release lithium preparation Beta blockers |
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Carbamazepine, trade name?
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Tegretol
|
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Carbamazepine and its uses in mood disorders
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Mixed episodes
Rapid cycling bipolar DO |
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Carbamazepine and its use in things other than mood DO
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Trigeminal neuralgia (tic doulereaux)
|
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Mechanism of action of Carbamazepine
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BLocks sodium channels inhibiting action potentials
|
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Onset of action of Carbamazepine
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5-7 days, much like lithium
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Carbamazepine S/E
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Nonspecific: Rash, ataxia, drowsy, slurred speech
Specific: Leukopenia, Hyponatremia, Aplastic anemia, Agranulocytosis, elevated LFTs Teratogenic: Neural tube defects |
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Carbamazepine must be monitored with what labs?
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CBC (agranulocytosis, leukopenia, aplastic anemia)
BMP (hyponatremia) Liver toxicity (LFTs) |
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Valproic Acid, tradename?
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Depakene
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Valproic Acid, best for what types of mania?
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Mixed episodes and rapid cycling disorders, just like carbamazepine
|
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Mechanism of action of valproic acid?
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Increase CNS levels of GABA
|
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Valproic Acid S/E
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Nonspecific: sedation, weight gain, alopecia
Specific: Hemorrhagic pancreatitis, hepatotoxicity, thrombocytopenia Teratogenic: NTD |
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What labs to monitor with valproic acid?
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CBC (thrombocytopenia)
LFT (hepatoxicity) |
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Anxiolytics (sedative/hypnotics), what are the general categories? (3)
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Benzos
Barbiturates Buspirone |
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Anxiolytics, general mechanism of action?
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Diffusely depress CNS, causing sedation
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Common indications for sedative/hypnotics (6)
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Anxiety DO
Muscle spasm Seizures Sleep DO Alcohol WD Anesthesia induction |
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Teratogenicity of Lithium?
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Ebstein's anomaly
|
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Teratogenicity of valproic acid and carbamazepine?
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Neural tube defects
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BDZ main problem...
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Potential for tolerance and dependence after prolonged use
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BDZ + Alcohol =
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Possibly death
|
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BDZ mechanism of action...
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Increase frequency of chloride channel opening in GABA
|
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Long acting Benzos (1-3 days)
|
Chlordiazepoxide
Diazepam Flurazepam |
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Intermediate Benzos (1/2 to 1 day)
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Clonazepam
Lorazepam Temazepam Alprazolam |
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Short Benzos (4-8 hours)
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Oxazepam
Triazolam |
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Chlordiazepoxide uses (Librium)
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Alcohol detox
|
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Diazepam uses
|
Anxiety, Seizures
(rapid onset) |
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Flurazepam uses
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Insomnia
(rapid onset) |
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Lorazepam uses (Ativan)
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Alcohol WD
|
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Temazepam uses
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Insomnia
|
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Triazolam uses
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Insomnia
|
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What Benzos for insomnia?
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Triazolam, Temazepam, Flurazepam
|
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What benzos for anxiety attacks?
|
CALm down
Clonazapam Alprazolam Lorazepam |
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What benzos for seizures?
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Lorazepam
Diazepam |
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What benzo for alcohol WD?
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Lorazepam
|
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What benzo for alcohol detox?
|
Chlordiazepoxide
|
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Varenicline (Chantix)... mechanism and indication and main SE?
|
Partial nicotinic agonist
Smoking cessation Bad nausea in 1/3 patients |
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Acute benzo intoxication?
|
Flumazenil
|
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Benzo intoxication in a chronic user?
|
Flumazenil may precipitate seizures, so better to protect airway and have benzos wean themselves off
|
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S/E of BDZ
|
Drowsiness, impaired intellect, reduced motor coordintaion
|
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Lethality of BDZ
|
Respiratory depression, especially when combined with alcohol
|
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Zolpidem (Ambien)
Zoleplon (Sonata) What are they? |
Chemically similar to BDZ but not a BDZ, but has same effect
|
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Mechanism of action of Zolpidem and Zoleplon
|
Selectively bind to BDZ site on GABA receptor
|
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Indication for Zolpidem and Zoleplon
|
Short term treatment for insomnia
|
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Compared to BDZ, Zolpidem and Zoleplon do NOT have
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Anticonvulsant or muscle relaxant properties
|
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Good things about Zolpidem and Zoleplon (3)
|
No WD effects
Minimal rebound insomnia Little/No dependence/tolerance |
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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
|
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Buspirone + Alcohol =
|
No problem as it does not potentiate alcohol effects, useful in alcoholics
|
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Buspirone, abuseable?
|
Low potential for addiction
|
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5HT =
|
Serotonin
|
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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) |
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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
|