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95 Cards in this Set
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General tx OCD
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SSRIs (higher dose than depression), TCAs, clomiprimine
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General tx panic disorder
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SSRIs, TCAs, MAOIs
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General tx eating d/o
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SSRIs, TCAs and MAOIs
NOT bupropion |
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General tx neuropathic pain
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TCAs, SNRI
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smoking cessation tx
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Bupropion
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Autism tx
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SSRI
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General tx insomnia
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mirtazapine, TCAs, trazodone
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General info: TCAs!!
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inhibit reuptake of NE and serotonin, increasing availability in the synapse
rarely used as 1st line agents because have higher incidence of side effects, require greater monitoring of dosing and can be LETHAL IN OVERDOSE!!! pts usually started on low doses to allow acclimation to common early anticholinergics |
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ex of TCAs
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imipramine (tofranil)
amitriptyline (elavil) trimipramine (surmontil) nortriptyline (Pamelor) desipramine (norpramin) Clomipramine (anafranil) Doxepin (sinequan) |
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amitriptyline
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TCA
elavil...sedating, not tolerated well |
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TCA least likely to cause orthostatic hypotension
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Nortriptyline (Pamelor)
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TCA that is least sedating, least anticholinergic side effects and well tolerated
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Desipramine (Norpramin)
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TCA that is most serotonin specific, useful in treatment of OCD (if fail SSRI)
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clomipramine
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Mainstay of tx for TCA overdose
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IV sodium bicarbonate
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hallmark of TCA toxicity
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widened QRS ( > 100 msec) - used as threshold to treatment
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Anti-HAM
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Histamine, adrenergic and muscarinic...
TCA side effects!!! |
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major complications of TCA side effects
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convulsions, coma, cardiotoxicity (increased QTc)
avoid in patients with preexisting conduction abnormalities |
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Anti-histamine TCA side effect
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sedation
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Antiadrenergic TCA side effects
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cardiovascular: orthostatic hypotension (alpha blockade)...most life threatening!!!
tachycardia, arrhythmias, cardiotoxic |
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Antimuscarinic TCA side effects
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dry mouth, constipation, urinary retention, blurred vision, tachycardia
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TCAs can cause weight gain.
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thats all i have to say.
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TCA lethality 2/2 OD
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one week supply of these drugs is enough to be lethal in OD
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Mechanism of MAO-I
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prevent inactivation of biogenic amines like NE, serotonin, dopamine and tyramine
irreversibly inhibits MAO-A and MAO-B...increase amounts of neurotransmitters in synapses |
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MAO A
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preferentially works on serotonin
does dopamine and tyramine |
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MAO B
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preferentially works on NE/epinephrine
also works on dopamine and tyramine |
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MAO-I are NOT 1st line, but are effective in...
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REFRACTORY DEPRESSION and in refractory panic disorder
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phenelzine (nardil), tranylcypromine (parnate) and isocarboxazid (marplan)
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examples of MAO-I
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Common side effects of MAO-I
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orthostatic hypotension, drowsiness, weight gain, sexual dysfunction, dry mouth, sleep dysfunction
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Serotonin syndrome
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occurs when SSRIs and MAOIs are taken TOGETHER!!!
initially characterized by lethargy, restlessness, confusion, flushing, diaphoresis, tremor and myoclonic jerks may progress to hyperthermia, hypertonicity, rhabdomyolysis, renal failure, convulsions, coma and death WAIT AT LEAST 2 WEEKS BEFORE SWITCHING FROM SSRI TO MAOI |
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Hypertensive crisis with MAOIs
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when MAOIs are taken with tyramine-rich foods or sympathomimetics
foods with tyramine (red Chianti wine, cheese, chicken liver, fava beans, cured meats) cause a buildup of stored catecholamines |
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Why SSRIs are first line for depression
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low incidence of side effects, no food restrictions and much safer in OD
inhibit presynaptic serotonin pumps, leading to increased availability of serotonin in synaptic clefts also used in tx of some anxiety disorders, OCD and premenstrual dysphoric disorder |
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Fluoxetine
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Prozac
SSRI longest half life with active metabolites...do NOT need to taper...half life is about 1-3 days |
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Sertraline
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Zoloft
SSRI highest risk for GI disturbances |
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Paroxetine
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Paxil
SSRI most serotonin specific, most activating (stimulant) effective, but can cause weight gain |
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Fluvoxamine
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Luvox
SSRI currently approved only for use in OCD |
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Citalopram
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Celexa
SSRI |
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Ecitalopram
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Lexapro
SSRI levo enantiomer of citalopram; similar efficacy, fewer side effects, much more expensive |
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side effects of SSRIs
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less side effects than TCAs and MAOIs because of serotonin selectivity
sexual dysfunction (25-30%) GI disturbance (big at first) Insomnia Headaches Anorexia, weight loss serotonin syndrome when used with MAOIs weight gain - Paxil is the worst |
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Atypical antidepressants
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SNRIs (serotonin/NE reuptake inhibitors)
NDRIs (NE/dopamine reuptake inhibitors) SARIs (serotonin antagonist and reuptake inhibitors) NASAs (NE and serotonin antagonists) |
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Venlafaxine
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EFFEXOR!!
SNRI - serotonin/NE reuptake inhibitor useful in refractory depression and CAP low drug interaction potential side effects similar to SSRIs can INCREASE BP!!! potential withdrawal symptoms can be seen with 1-3 missed doses...not life threatening, but very uncomfortable (including flulike symptoms and electric shock like symptoms/zaps) |
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Buproprion (Wellbutrin)
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NDRI: NE/dopamine reuptake inhibitor
commonly used to aid in smoking cessation - also useful in seasonal affective d/o and adult ADHD LACK OF SEXUAL SIDE EFFECTS!!! as compared to SSRIs bupropion's dopaminergic effect in higher doses can exacerbate psychosis |
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Side effects of Wellbutrin
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wellbutrin = bupropion
similar to SSRIs - increased sweating and increased risk of seizures and psychosis at high doses can lower seizure threshold...use with caution in epileptics not optimal for patients with significant anxiety and are CI in patients with seizure or active eating disorders and those currently on MAO-I |
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Nefazodone (serzone) and Trazodone (Deyrel)
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SARI - atypical antidepressant
serotonin antagonist and reuptake inhibitor especially useful in tx of refractory major depression, major depression with anxiety and INSOMNIA (secondary to sedative effects) |
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Side effects of trazodone and nefazodone
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nausea, dizziness, orthostatic hypotension, cardiac arrhythmias, SEDATION and PRIAPSIM!!!!
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priapism
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with trazodone...use epinephrine to reverse this.
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Mirtazapine (remeron)
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NE and serotonin antagonists
used for refractory depression, especially in patients who need to gain weight side effects: WEIGHT GAIN, dizziness, somnolence, tremor and agranulocytosis maximal sedative effect at doses of 15mg and les at higher doses, increases NE uptake and is therefore less sedating |
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Traditional antipsychotics vs. atypical antipsychotics
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traditional block dopamine receptors
atypical (newer) antipsychotics block both dopamine and serotonin receptors...effect on dopamine is weaker - associated with fewer side effects |
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Chlorpromazine (thorazine)
Thioridazine (Mellaril) |
traditional antipsychotics
LOW potency - have a lower affinity for dopamine receptors and therefore a higher dose is required...POTENCY refers to action on dopamine receptors - not the level of efficacy |
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side effects of low potency antipsychotics
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higher incidence of anticholinergic and anti-histaminic side effects than high potency traditional antipsychotics
lower incidence of EPSEs and neuroleptic malignant syndrome Chlorpromazine (thorazine) - a/w sedation, orthostatic, dec BP Thioridazine (mellaril) - a/w retinitis pigmentosa - loss of night vision half life of 24 hours |
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high potency antipsychotics
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greater affinity for dopamine receptors and therefore a relatively low dose is needed for effect
Haloperidol (haldol) - EPS common Fluphenazine (prolixin), trifluoperazine (stelazine) Perphenazine (trilafon) Pimozide (orap) |
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side effects of high potency traditional antipsychotics
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higher incidence of EPSEs and neuroleptic malignant syndrome
lower incidence of anticholinergic and antihistaminic side effects |
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traditional vs. atypical antipsychotics
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both have similar effects in treating presence of positive symptoms - such as hallucinations and delusions
Atypicals have been shown to be more effective in treating NEGATIVE symptoms (such as flattened affect and social withdrawal) |
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Decanoate
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long-acting haloperidol and fluphenazine
fluphenazine: administer q2-3 weeks IM Halperidol: administer q4-5 weeks IM |
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anti-dopaminergic effects of traditional antipsychotics
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extrapyramidal side effects -
1. parkinsonism - masklike face, cogwheel rigidity, pill-rolling tremor...tx with levodopa or amantidine 2. akathisia - subjective anxiety and restlessness, objective fidgetiness...tx with propranalol 3. dystonia - sustained contraction of muscles of neck, tongue, eyes (painful)...can use benztropine (congentin) to prevent this HYPERPROLACTINEMIA: leading to decreased libido, galactorrhea, gynecomastia, impotence, amenorrhea and osteoporosis (realize that dopamine normally inhibits prolactin and acetylcholine secretion) |
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anti-HAM effects with traditional antipsychotics
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caused by actions on histamine, adrenergic and muscarinic receptors
antihistamine - results in sedation anti-alpha-adrenergic - results in orthostatic hypotension, cardiac abnormalities and sexual dysfunction antimuscarinic - anticholinergic effects: dry mouth, tachycardia, urinary retention, blurry vision and constipation |
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Other side effects of traditional antipsychotics
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WEIGHT GAIN
elevated LFTs, jaundice ophthalmologic problems - rashes and photosensitivity (blue-gray skin discoloration with chlorpromazine) seizures - lower seizure thresholds; low potency antipsychotics are more likely to cause seizures than high potency ones |
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Tardive dyskinesia
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side effect of traditional antipsychotics...
thought to be caused by increase in number of dopamine receptors, causing lower levels of acetylcholine choreoathetoid (writhing) movements of mouth and tongue that may occur in patients who have used neuroleptics for more than 6 months most often in older women 50% cases will spontaneously remit - untreated cases may be PERMANENT! |
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Neuroleptic malignant syndrome
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side effect of traditional antipsychotics
rare - most often in males in tx with neuroleptics...MEDICAL EMERGENCY...20% mortality rate if left untreated...often preceded by a catatonic state characterized by: Fever (most common presenting symptom) Leukocytosis Tremor Elevated CPK Rigidity (lead pipe rigidity) |
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Treatment of NMS
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discontinue current meds
supportive medical care (hydration, cooling, etc) sodium dantrolene, bromocriptine and amantadine...useful but are infrequently used because of their own side effects NOT an allergic reaction...patient not prevented from restarting same neuroleptic at a later time |
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Why atypical antipsychotics are better than traditional antipsychotics
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block both dopamine and serotonin receptors - associated with FEWER SIDE EFFECTS...
more effective in treating negative symptoms first line tx of schizophrenia |
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Clozapine (clozaril)
Risperidone (risperdal) Quetiapine (seroquel) Olanzapine (zyprexa) Ziprasidone (geodon) Abilify (aripiprazole) |
atypical antipsychotics
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atypical antipsychotics FDA approved for tx of mania
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Quetiapine (seroquel) and ziprasidone (geodon)
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Clozapine side effects
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1% incidence of agranulocytosis and 2-5% incidence of seizures
must have weekly blood draws to check WBC counts because it can cause agranulocytosis |
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Olanzapine side effects (zyprexa)
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can cause hyperlipidemia, glucose intolerance, weight gain, and liver toxicity
monitor LFTs |
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Quetiapine (seroquel) side effects
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less propensity for weight gain but has been shown to cause cataracts in beagle dogs - periodic (q6 months) slit lamp examination recommended
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Other uses for mood stabilizers
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potentiation of antidepressants in patients with major depression refractory to monotherapy
potentiation of antipsychotics in patients with schizophrenia enhancement of abstinence of alcoholism tx of aggression and impulsivity (dementia, intoxication, mental retardation, personality d/o, general medical conditions) |
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antipsychotics can be used as adjuncts to mood stabilizers for behavioral control early in the course of a manic episode if psychotic symptoms persist
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: )
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drug of choice for acute mania and prophylaxis for both manic and depressive episodes in bipolar disorder
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LITHIUM
mech unknown - alters neuronal sodium transport secreted by kidney, onset of action 5-7 days |
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narrow therapeutic index of lithium
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therapeutic range: 0.7 - 1.2
toxic > 1.5 lethal > 2.0 |
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factors that affect lithium levels
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NSAIDs (decrease levels)
aspirin dehydration (increase levels) salt deprivation (increase levels) impaired renal function (increase levels) diuretics |
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side effects of lithium
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fine tremor, sedation, ataxia, thirst, metallic tast, polyuria, edema, weight gain, GI problems, benign leukocytosis, thyroid enlargement, HYPOTHYROIDISM and NEPHROGENIC DIABETES INSIPIDUS...can also have delusions
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toxic levels of lithium can cause...
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altered mental status, coarse tremors, convulsions and death
need to regularly monitor blood levels of lithium, thyroid function (TSH) and kidney function (GFR) |
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Carbamazepine
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Tegretol
anticonvulsant mood stabilizer especially useful in treating MIXED episodes and RAPID-CYCLING bipolar disorder used in management of trigeminal neuralgia acts by blocking sodium channels and inhibiting action potentials onset of action 5-7 days |
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side effects of carbamazepine
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skin rash, drowsiness, ataxia, slurred speech, LEUKOPENIA, HYPONATREMIA, APLASTIC ANEMIA and AGRANULOCYTOSIS
elevates LFTs and has teratogenic effects when used during pregnancy (neural tube defects) pretx: CBC and LFTs...monitored regularly |
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valproic acid
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depakene/depakote
anticonvulsant mood stabilizer especially useful in treating mixed manic episodes and rapid cycling bipolar disorder mech unknown increase CNS levels of GABA |
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side effects of valproic acid
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sedation, weight gain, alopecia, hemorrhagic pancreatitis, HEPATOTOXICITY and THROMBOCYTOPENIA
teratogenic effects during pregnancy (neural tube defects) monitor LFTs and CBCs |
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long acting benzos
1-3 days |
chlordiazepoxide (librium)
diazepam (valium) flurazepam (dalmane) |
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Chlordiazepoxide
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LIBRIUM
long acting benzo (1-3 days) used in alcohol detoxification, presurgery anxiety |
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Diazepam
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valium...long acting benzo (1-3 days)
RAPID onset, used in treatment of anxiety and seizure control less potent |
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Flurazepam
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Dalmane
long acting benzo (1-3 days) rapid onset, tx of insomnia |
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FLUMAZENIL
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tx of benzo OD
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Alprazolam
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XANAX.
int acting benzo (10-20 hrs) tx of panic attacks...dont use anymore |
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Clonazepam
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Klonopin
int acting benzo (10-20hrs) tx of panic attacks, anxiety slow onset, strong, potent |
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Lorazepam
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Ativan
int activing benzo (10-20 hrs) tx of panic attacks, alcohol withdrawal |
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Temaepam
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Restoril
int acting benzo (10-20 hrs) tx of insomnia |
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Oxazepam
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Serax
short acting benzo...3-8 hrs |
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Triazolam
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Halcion
short acting benzo...3-8hrs rapid onset, tx of insomnia |
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Zolpidem (Ambien)
Zaleplon (Sonata) |
short term tx of insomnia
selectively binds to benzo binding site on GABA receptor no anticonvulsant/muscle relaxant properties no withdrawal effects minimal rebound insomnia little or no tolerance/dependence occurs with prolonged use Sonata - newer, shorter half life than ambien chemically not a benzo, though has the same effect |
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Buspirone
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Buspar
alternative to benzos or venlafaxine to tx generalized anxiety disorder slower onset of action than benzos - takes 1-2 weeks for effect anxiolytic action is at 5HT-1A receptor (partial agonist) does not potentiate the CNS depression of alcohol (useful in alcoholics) low potential for abuse/addiction |
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can use propranolol to treat akathisia (side effect of typical antipsychotics)
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kill this sh*t.
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meds that have HAM side effects
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TCAs and low potency antipsychotics
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Serotonin syndrome (2)
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confusion, flushing, diaphoresis, tremor, myoclonic jerks, hyperthermia, hypertonicity, rhabdomyolysis, renal failure and death
when SSRIs and MAOIs are combined tx: STOP f'ing drugs |
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EPSE...
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happens more with high potency traditional antipsychotics
...also hyperprolactinemia occurs with high--potency traditional antipsychotics... high potency antipsychotics - tardive dyskinesia monitor pts with various screening exams...AIMS and DISCUS q6months |
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drug induced psychosis
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may be caused by sympathomimetics, analgesics, antibiotics (like isoniazid), anticholinergics, anticonvulsants, antihistamines, corticosteroids and antiparkinsonian agents
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drug induced depression
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may be caused by antihypertensives, antiparkinsonian agents, corticosteroids, calcium channel blockers, NSAIDs, antibiotics and peptic ulcer drugs
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