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31 Cards in this Set
- Front
- Back
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Symptoms of serotonin syndrome
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Triad of mental status changes, abnormal neuromuscular findings, and autonomic hyperactivity
Hyperthermia: +/- Rigidity: + Reflexes: Increased Mental status: Agitation/coma Skin: Diaphoresis Mucosa: Sialorrhea Bowel Sounds: Hyperactive |
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What causes serotonin syndrome?
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-Results from serotonergic excess – antidepressants that elevate serotonin levels are a concern if taken along with other medications that enhance serotonin levels
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How do you prevent serotonin syndrome?
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-Avoidance of multidrug regimens with significant serotonergic activity is prudent
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What medications may precipitate ss?
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Linezolid, St. John’s Wart, triptans, dextromethorphan, tramadol, meperidine, cocaine, ondansetron
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Causes of neuroleptic malignant syndrome
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a. Caused by: a decrease in central nervous system dopamine function
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What medications can cause neuroleptic malignant syndrome?
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b. Medications: antipsychotics, metoclopramide, prochlorperazine, promethazine
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What are the clinical manifestations of neuroleptic malignant syndrome?
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c. Manifested by high fever, muscle rigidity, autonomic instability, and altered mental status
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Clinical Signs of NMS
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Hyperthermia: ++
Rigidity: ++ Reflexes: Decreased Mental Status: Stupor/coma Skin: Pallor/diaphoresis Mucosa: Sialorrhea Bowel Sounds: Normal or hypoactive |
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What does anticholinergic delirium result from?
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a. Results when high doses or combinations of anticholinergic agents are used
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Clinical presentation of anticholinergic delirium
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agitation, hypervigilance, dry mouth, hot and erythematous skin, constipation, urinary retention, and autonomic instability
Mnemonic: i. "Red as a beet" (cutaneous vasodilation) ii. "Dry as a bone" (anhidrosis) iii. "Hot as a hare" (anhydrotic hyperthermia) iv. "Blind as a bat" (nonreactive mydriasis) v. "Mad as a hatter" (delirium; hallucinations) vi. "Full as a flask" (urinary retention) vii. Other clinical features not included in the above mnemonic include tachycardia, which is the earliest and most reliable sign of anticholinergic toxicity, and decreased or absent bowel sounds |
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Clinical signs of anticholinergic delirium (from chart)
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Hyperthermia: +/-
Rigidity: - Reflexes: Normal Mental Status: Agitation Skin: Hot and dry Mucosa: Dry Bowel Sounds: Hypoactive |
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Adverse effects of SSRIs?
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a. Generally considered first line therapy for depression due to safety in overdose situations and good tolerability
b. Nausea, diarrhea, headache, xerostomia, jitteriness, insomnia, fatigue and sexual dysfunction |
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Adverse effects of Benzodiazepines
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a. Anterograde amnesia, muscle relaxant, sedation, paradoxical reactions, additive effects with other CNS depressants
b. Other side effects include disorientation, confusion, aggression, excitement, and disinhibition c. Seizures with abrupt withdrawal |
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Disadvantages of benzodiazepines
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abuse and dependence, abrupt withdrawal can cause seizures
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Adverse Effects of antipsychotics (general)
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1. Sedation
2. Cardiovascular 3. Anticholinergic 4. Extrapyramidal reactions (EPS) |
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Which antipsychotics cause more sedation?
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generally higher with older agents
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Cardiovascular effects of antipsychotics
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a. Black Box Warning for all agents.
b. Risk of sudden death/stroke in older patients with dementia is approximately 3.5 cases per 100 patient years. |
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Which antipsychotics have more anticholinergic effects?
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generally higher with older agents
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Extrapyramidal reactions (EPS) with antipsychotics
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1. Dystonia
2. Akathisia 3. Parkinsonism 4. Tardive dyskinesia |
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Dystonia with antipsychotic agents
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a. Dystonia: (acute) involves contraction of voluntary muscle that leads to a postural distortion
i. The neck is the most common site of dystonia ii. Appears early in the course of antipsychotic treatment (or with another dopamine blocker) and is more common with higher does and a younger age iii. Treatment consists of stopping the offending agent and administering an anticholinergic agent |
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AAkathisia with antipsychotics
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b. Akathisia: (acute) characterized as the inability to sit still (“feeling of inner restlessness”)
i. Treatment options include beta-blockers ii. Higher-potency typical antipsychotics are associated with more extrapyramidal syndromes than lower potency agents and atypical agents |
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Parkinsonism with antipsychotics
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c. Parkinsonism: (subacute or chronic) characterized by a triad of bradykinesia, rigidity, and tremor
i. Treatment: discontinuing the offending agent or the addition of an anticholinergic agent can be added to ameliorate symptoms |
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Tardive dyskinesias with antipsychotics
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d. Tardive dyskinesia: (subacute or chronic) starting months or years after treatment with an antipsychotic
i. Generally starts with involuntary movements of the muscles of the tongue, lips, mouth, and face ii. No treatment, generally irreversible iii. Risk for all agents: approximately 5 cases per 100 patient years |
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AEs of acetylcholinesterase inhibitors
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Increased acetylcholine activity: Frequent nausea, vomiting, diarrhea; somnolence common but 14% may have insomnia; Bradycardia (esp. with antiarrhythmics); may increase urination, salivation
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AEs of NMDA receptor antagonists
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ADRs - Dizziness/Confusion/HA, GI effects (N/C), Cough/dyspnea, increased blood pressure, others.
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Which drugs have a high incidence of anticholinergic effects?
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amytriptylene (tricyclic)
Thioridazine (antipsychotic) Clozapine (used the charts at the end of the handout. Not sure if that's where I was supposed to get it from) |
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What drugs have an increased risk of dystonic reactions (EPS)?
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-Carbamazepine concentrations above 40 mg/mL (170 micromol/L)
-Almost all typical/older antipsychotics: Fluphenazine Haloperidol Perphenazine Thiothixene (Thioridazine, Chlorpromazine are moderate) |
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How long after starting antipsychotics does acute dystonia usually occur?
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<1 week
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How long after starting antipsychotics does pseudoparkinsonism usually occur?
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1 week
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How long after starting antipsychotics does akathisia usually occur?
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2 weeks
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How long after starting antipsychotics does tardive dyskinesia usually occur?
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years
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