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73 Cards in this Set

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Antipsychotics

typicals - low potentcy
chlorpromazine (Thorazine)
50-2000mg/d
tabs, caps, syrup, supp, injection

thioridazine (Mellaril)
50-800mg/d
tabs, suspention
key adverse effects that differentiate antipsychotics
EPS
anticholinergic s/e
cardiac effects
hyperprolactinemia
metabolic effects
sedation
antipsychotics

typicals - high potency
fluphenazine (Prolixin)
1-65mg/d PO
12.5-75mg IM q2w (decanoate inj.)
tabs, elixir, injection

haloperidol (Haldol)
1-100mg/d PO
50-300 mg IM q4w (decanoate)

trifluoperazine (generic only) tabs
thiothixene (Navane) Caps
loxapine (Loxitane) caps
molindone (Moban) tabs
What is EPS (Extrapyrimidal sx)?
EPS is a broad term describing acute and chronic movement disorders
What EPS occur early in treatment
early - acute dystonia, parkinsonism, and akathisia

dose dependent and reversible soon after discontinuation

60% on typical antipsychotics

clozapine and quetiapine lowest risk
EPS later in treatment?
late - tardive dyskinesia (TD), tardive dystonia and tardive akathisia
tardive dyskinesia (TD)
involuntary movements of the:

face - tics, blinking, grimacing
tongue - chewing, protrusion, tremor
lips - smacking, pursing, puckering
neck and trunk - torsion and torticollis
limbs - toe tapping, pill rolling, writhing

that may be:
choreiform (rapid, jerky)
athetoid (slow, sinuous, continual)
rhythmic
TD

progression?

Treatment
not progressive and usually mild

ideally, d/c the drug
switch to atypical
if on atypical use lowest effective dose
if still TD - can try (limited evidence)
- GABA augmenters (benzos, VPA)
- adrenergics (propranolol, clonidine)
- vitamin E
anticholinergic effects
common with low potency typicals and atypicals

constipation, urinary retention, dry eyes, mouth, throat
cardiovascular complications

orthostasis from alph1-adrenergic blockade
most common

low-potency typicals and atypicals pose greatest risk

common during initiation of treatment and dose changes

tolerance seen usually in 4-6 weeks
cardiovascular complications
orthostasis

tachycardia - CLOZAPINE
- treat with BB (aten, prop)

QTc prolongation
- leads to ventricular arrhytimias like
torsades de pointes and vent fib
- death

all have potential to prolong QTc
- black box for thioridazine
hyperprolactinemia
all typicals

resperidone and olanzapine do too

leads to galactorrhea, gynecomastia, amenorrhea, anovulation, impaired spermatogenesis, decreased libido and sexual arousal, and anorgasmia
weight gain
most significant concern with antipsychotics - particularly atypicals

most common w/ clozapine, olanzapine

lowest w/ ziprasidone, aripiprazole

intermediate w/ risperidone and quetiapine

impaired glucose tolerance, type II DM, hyperlipidemia, increased mortality
sedation
most pronounced w/low potency typicals and clozapine and quetiapine
why atypicals first choice
lower risk of EPS and TD
acute dystonia
earliest onset of all EPS-few hours or days after initiation or dose increase

sustained muscle contractions
- tongue protrusion
- eyes rolling back
- jaw spasm
- arching back

treatment
benztropine 1-2mg or
diphenhydramine 25-50mg IM
lorazepam if CIs for anticholinergics
anticholinergics to treat antipshcyotic-induced parkinsonism and akathisis
benztropine (Cogentin)
biperiden (Akineton)
diphenhydramine (Benadryl)
procyclidine (Kemadrin)
trihexyphenidyl (Artane)
dopaminergic, gabaminergic and noradrenergic drugs to treat parkinsonism and akathisis
Dop
amantadine

Gaba
diazepam
clonazepam
lorazepam

noradrenergic blockers
propranolol
parkinsonism
bradykinesia or akinesia
- decreased arm swinging, mask-like face drooling, dec eye blinking, slft, monotonous speech, tremor (rhythmic)
parkinsonism treatment
intervention not required if sx not bothersome

trihexyphenidyl is least sedating
diphenhydramine is most sedating
benztropine has longest doa-bid dosing

longterm risks of treatment are anticholinergic s/e
- constipation, dry mouths, blurred vision, impaired memory, esp in elderly
akathisisa

what is it

how is it treated
subjective feeling of restlessness or urge to move

semipurposeful movement - rocking, pacing, inability to sit or stand still

days to weeks after initiating therapy

treat w/propranolol first then anticholinergic
Serotonin NE reuptake inhibitors (SNRIs)
duloxetine (Cymbalta)
20, 30, 60mg caps

venlafaxine (Effexor)
IR - 23, 37.5, 50, 75, 100 tabs
XR - 37.5, 75, 150 caps

desvenlafaxine (Pristiq)
ER - 50, 100mg
Duloxetine Indications
diabetic peripheral neuropathic pain

fibromyalgia

GAD

MDD

OFF: stress urinary incontinence
venlafaxine indications
MDD

GAD - ER only

Social anxiety disorder - ER only

Panic disorder - ER only

offlabel: autism, binge eating, hot flashes, pain
desvenlafaxine indications
MDD

is a metabolite of venlafaxine
SSRIs
citalopram (Celexa)

escitalopram (Lexapro)

paroxetine (Paxil)

fluoxetine (Prozac, Sarafem)

sertraline (Zoloft)
citalopram
initial - 10

usual - 20-40, max 60mg/d

available - 10, 20, 40 tabs, and syrup

pearls - used in elderly b/c less ADRs
escitalopram
initial - 10

usual - 10-20mg/d

available - 5, 10, 20 tabs

pearls - s-isomer of citalopram
- 40mg celexa = 10 lexapro
fluvoxamine
initial - 50

usual - 100-300mg/d

available - 50, 100 tabs

pearls - primarily for OCD drug intxns
paroxetine
initial - 10-20 (CR - 12.5 - 25)

usual - 10-40 (CR - 25-37.5)

available - 10,20,30,40 and suspension
- CR - 12.5, 25, 37.5 tabs

pearls - least-activating SSRI
- SR associated w/less s/e
fluoxetine
initial - 10-20

usual - 20-80

available - caps, tabs, syrup

pearls - tapering unnecessary b/c long
t1/2, 90mg tab po qw
sertraline
initial 25-50mg

usual 50-100mg; max 200mg/d

available - 25, 50, 100 tabs, liquid

pearls - used in elderly; fewer drug intxs
Monoamine oxidase inhibitors
phenelzine (Nardil) 15mg tabs
- start 15mg tid
- up by 15mg/wk to 60-90mg/d

tranylcypromine (Parnate) 10mg tabs
- start 30mg/d divided
- up by 10mg/d q1-3w to 30-60mg/d

isocarboxazid (Marplan)
MAO indications
Depression: in general atypical and in those unresponsive to other tx

rarely first drug of choice due to drug-food interaction w/tyramine-containing foods (cheese, red wine...)
Tricyclic antidepressants
amitriptyline (Elavil)

nortriptyline (Pamelor, Aventyl)

imipramine (Tofranil)

doxepin (Sinequan)

clomipraine (Anafranil)

desipramine (Norpramin)
amitriptyline dose and indications
initial/range 50-75/75-300

indications
- depression
- chronic and neuropathic pain
- migraine prophylaxis
- peripheral neuropathy
nortriptyline
initial/range 25-50/40-200

indications
- depression
- chronic pain
imipramine
initial/range 50-75/75-300

indications
- depression
- childhood enuresis
- chronic and neuropathic pain
doxepin
initial/range 75 divided/75-300

indications
- depression
- anxiety
unlabeled:
- chronic and neuropathic pain
clomipramine
initial 25-100qd titrate up for 2w
range 200-250
max 250 due to dose-related seizure risk

indications
- ocd
- depression
- panic attacks
- chronic pain
desipramine
initial/range 50-75/75-300

indications
- depression
- chronic pain
unlabeled:
- peripheral neuropathy
tetracyclics
maprotiline (generic)
- 25, 50, 75
- anxiety and depression

mirtazapine (Remeron)
- tabs - 7.5, 15, 30, 45
- oral disintegrating - all but 7.5
- indications: MDD
- off label
- chronic urticaria, hot flashes,
hyperhidrosis, migraine prophylax
pruritis
mirtazapine

adverse effects?
clinical pearls?
sedation, increased appetite, wt gain, constipation, inc LFTs, inc Trigs,

may be useful in elderly since increases appetite and no sig drug interactions
other antidepressants
bupropion (Wellbutrin, SR, XL, Zyban)

trazodone (Deseryl)

nefazodone ( )
- available in 50 to 250mg tabs by 50s
nefazodone

dose

indication
- available in 50 to 250mg tabs by 50s

- depression
trazodone

dose

indications
50, 100, 150, 300mg tabs

indications: depression

off label uses:
- insomnia
- migraine prevention (children/adol)
bupropion

indications, doses
IR-75, 100
ER-100, 150, 200, 300
Zyban er 150

indications:
- MDD (IR and ER)
- seasonal aff d/o (XL only)
- smoking cessation

off-label uses:
- aphthous ulcers
- adhd kids and adults
- wt loss
`
`
Tricyclics

adverse effects
orthostatic hypotension
tachycardia
sedation
anticholinergic effects
arrhythmias
wt gain
sexual dysfunction
tricyclics

tertiary amines have more intense a/e than secondary amines
tertiary
- amitriptyline
- imipramine
- doxepin
- clomipramine

secondary amines
- nortriptyline
- desipramine
tricyclics

CIs

Precautions
CIs
uses of MAOI w/in last 14 days
- 5HT syndrom
pregnancy
lactation
narrow angle glaucoma

precautions
avoid abrupt w/d in pts on for long time
cardiac conduction disturbances
seizures
hyperthyroidism
renal or hepatic impairment
tricyclics

MOA
increase concentration of 5-HT and NE

by blocking reuptake
MAOIs

MOA
increase synaptic concentration of:
NE, DA, 5HT
by blocking MAO, the enzyme that breaks these NTs down
MAOIs

adverse effects
orthostatic hypotn
wt gain
sex dysfunction
anticholinergic effects
hypertensive crisis
MAOIs

CI

precautions
CIs
renal or hepatic dysfN
CVD
concomitant sympathomimetic tx
- pseudoephderine, epedra
CANNOT BE USED W/IN 5 WEEKS of fluoxetine or within 2 weeks of other SSRIs
SSRIs

Adverse effects
GI complaints
nervousness
insomnia
ha
fatigue
sexual dysfunction
Antipsychotics

MOA of typicals
block
postsynaptic D2 plus
anticholinergic
antihistaminic
alpha blocking
antipsychotics

MOA of atypicals
weak DA blockers
also block following CNS receptors:
serotonergic
alpha adrenergic
histaminic
muscarinic
Lithium

indications
bipolar mania only labeled indication
-acute episodes
-prophylaxis

serum levels 0.6 to 1.2 mEq/L
900 to 1,200 mg daily in divided doses
Lithium

CIs and Precautions
CIs
renal dz
severe cvd
hx of leukemia
first trimester of pregnancy

precautions
thyroid dz
pts on diuretics
dehydrated patients
na depletion
Lithium

drug toxicity levels: mild, mod, severe
mild 1.5-2mEq/L
GI n/v/d
muscle weakness, fatigue
find hand tremor
hard to concentrate and remember

mod 2-2.5 mEq/L
ataxie, lethargy, nystagmus, severe GI

severe >3mE/L
severe impaired consciousness
coma
seizures
respiratory complicaitons
death
Atypical antipsychotics
clozapine (Clozaril)
- FazaClo - disintegrating tabs
risperidone (Risperdal)
- Risperdal-M - disintegrating tabs
- Risperdal Consta - long-acting inj
olanzapine (Zyprexa)
- Zyprexa Zydis (disintegrating tabs)
quetiapine (Seroquel)
ziprasidone (Geodon)
aripiprazole (Abilify)
paliperidone (Invega)
clozapine
Clozaril 25, 100 mg tabs
FazaClo same

12.5mg titrated to 300-900mg/d

weekly CBC w/diff required
WBC < 3500 or ANC < 1500 MUCT d/c

may go to CBC q2w if stable for 6m
may go to CBC q4w if stable for 6 more months
risperidone
Risperdal 0.25, 0.5, 1,2,3,4mg tabs
Risperdal-M 0.5, 1, 2
Risperdal Consta 25, 37.5, 50mg

max 16mg/d

must overlap risperidone and Consta for at least 3 weeks
olanzapine
Zyprexa 2.5, 5, 7.5, 10, 15, 20 mg tabs
Zydis 5, 10, 15, 20
10mg/ml injection

10-20mg/d
max IM dose is 30mg/d
quetiapine
Seroquel 25, 100, 200, 300 mg tabs

300-800mg/d or higher

low eps and prolactin elevation risk
ziprasidone
Geodon 20, 40, 60, 80mg caps
20mg/ml injection

40-160 mg/d po
40mg/d MAX IM dose
aripiprazole
Abilify 2, 5, 10, 15, 20, 30
1mg/ml concentrate

10-30mg/d

qd dosing benefit
paliperidone
Invega 3, 6, 9 mg ER tabs

6mg/d
12mg/d max

SR tab: do not crush etc
matrix may be seen in stool
Li
Lithobid 150, 300, 600mg caps
Eskalith CR 300, 450 tabs
Cibalith-S (syrup 300mg/5ml)

starting 900-1200 divided doses
titrate to desired response/level

adverse effects: tremor, polydipsia, polyuria, N, D, wt gain, mental dulling

monitor blood levels
acute: 0.6-1.2mEQ/L
maintenance: 0.8-1.0mEq/L
divalproex dodium
Depakote 125, 250, 500 tabs
ER 250, 500 tabs

adverse effects: GI upset, sedation, tremor, wt gain, alopecia, LFT inc (transient)

Black box warnings:
hepatotoxicity, hemorrhagic pancreatitis, teratogenicity

monitor blood levels: 50-125mcg/ml
carbamazepine
Tegretol 200mg tabs
chewable 100 mg
ER 100, 200,400 tabs
100mg/5ml susp

usual range 400-1600mg/d

s/e: ataxia, diziness, sedation, slurred speech, aplastic anemia

blood levels: 4-12 mcg/ml
lamotrigine
Lamictal 25, 100, 150, 200 tabs
chewable tabs 2, 5, 25mg

start 25mg/d weeks 1 and 2; titrate up to 200mg/d by week 6

dizziness, ha, ataxia, nausea, diplopia, rash

black box warning: severe rashes like Stevens-Johnson Syndrome
titrate to avoid rash