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97 Cards in this Set

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***Depression***
What medications are first line for depression?

SSRIs
Desipramine
Nortriptyline
Bupropion
Venlafaxine
MAOIs are reserved in patients do not respond, due to side effects and drug interactions
How long is an adequate therapy trial considered?
6-8 weeks
***In 2005, the FDA required that all product labeling for antidepressants include a boxed warning for potential increased risk of clinical worsening and suicidality in children, adolescents, and young adults
Name the 6 SSRIs
Citalopram (Celexa)
Escitalopram (Lexapro)
Sertraline (Zoloft)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Fluvoxamine (Luvox)
Primary side effects of SSRIs
Sexual dysfunction
Somnolence
Fatigue
Tremor
Hallucinations
Xerostomia
Pertinent drug interactions
Other serotonergic medications:
- MAOIs
- SSRIs
- Triptans
- Tramadol
- St Johns wart
- Linezolid (weak MAOI)
How long would you want to wait before d/c of and SSRI and induction of an MAOI?
5 weeks for washout - long half-life
Difference between citalopram and escitalopram
Escitalopram (Lexapro) is only S isomer (citalopram is racemic mixture)
Name the 9 tri-cyclic antidepressants
Amitriptyline (Elavil)
Amoxipine
Clomipramine
Desipramine
Doxepin
Imipramie
Nortriptyline (Pamelor)
Protriptyline
Trimipramine
Primary side effects of TCAs
Anti-cholinergic effects
TCAs
Dangerous in overdose situations - avoid in patients with high suicidality
Also used in sleep disorders
Name 4 SNRIs
Duloxetine (Cymbalta)
Venlafaxine (Effexor)
Nefazadone (Serzone)
Desvenlafaxine (Pristiq)
Name the MAOIs
Isocarboxazid
Phenelzine
Tranylcypromine
Selegiline
MAOIs are used very infrequently due to side effect profile
Selegiline is used primarily for parkinsons disease
Common contraindications of MOAIs
Cardiovascular disorder
HTN
Cerebrovascular disorder
General anesthesia
History of HA
Pheochromocytoma
Severe renal impairment
While taking an MAOI, avoid caffeine, chocolate as well as these foods that contain tyramine
Red wine
Aged cheeses
Avocado
Egg plant
Figs
Soy based foods
What is the MOA of bupropion (Wellbutrin, Zyban)
Dopamine, Norepinephrine reuptake inhibitor
What is an advantage of bupropion?
No sexual side effects
Also used in smoking cessation
Bupropion is contraindicated in these situations
MAOI
Bulimia or anorexia
Seizure disorders
Major side effect of Bupropion
Increased seizure activity
Name the two tetracyclic anti-depressants
Mirtazapine (Remeron)
Maprotiline
Name 4 SNRIs
Duloxetine (Cymbalta)
Venlafaxine (Effexor)
Nefazadone (Serzone)
Desvenlafaxine (Pristiq)
Name the MAOIs
Isocarboxazid
Phenelzine
Tranylcypromine
Selegiline
MAOIs are used very infrequently due to side effect profile
Selegiline is used primarily for parkinsons disease
Common contraindications of MOAIs
Cardiovascular disorder
HTN
Cerebrovascular disorder
General anesthesia
History of HA
Pheochromocytoma
Severe renal impairment
While taking an MAOI, avoid caffeine, chocolate as well as these foods that contain tyramine
Red wine
Aged cheeses
Avocado
Egg plant
Figs
Soy based foods
What is the MOA of bupropion (Wellbutrin, Zyban)
Dopamine, Norepinephrine reuptake inhibitor
What is an advantage of bupropion?
No sexual side effects
Also used in smoking cessation
Bupropion is contraindicated in these situations
MAOI
Bulimia or anorexia
Seizure disorders
Major side effect of Bupropion
Increased seizure activity
Name the two tetracyclic anti-depressants
Mirtazapine (Remeron)
Maprotiline
Side effects of mirtazapine
Increased appetite
Hyperlipidemia
Weight gain
Constipation
Elevated LFTs
***Anxiety***
Name the benzodiazepines
Alprazolam (Xanax)
Clonazepam (Klonopin)
Clorazepate (Tranxene)
Diazepam (Valium)
Lorazepam (Ativan)
Oxazepam
MOA of benzodiazepines
Binds to GABA receptors
Side effects of benzodiazepines
Somnolence
Deceased libido
Confusion
Constipation
Blurred vision
What pregnancy category are benzodiazepines?
Category D
What pregnancy category are SSRIs?
Category C
Except paroxetine is category D
Category C =
Category D =
Have not been studied in humans, but appear to cause harm in animal studies
Have been shown to cause harm in humans
How long do SSRIs, SNRIs or MOAIs generally take to work?
2-4 weeks
Avoid alcohol
Do not abruptly discontinue
Which SSRIs are indicated for GAD?
Escitalopram
Paroxetine
Venlafaxine
Which SSRIs are indicated for OCD?
Fluoxetine
Paroxetine
Sertraline
Fluvoxamine
Which SSRIs are indicated for panic disorder?
Fluoxetine
Paroxetine
Sertraline
Venlafaxine
Which SSRIs are indicated for SAD?
Paroxetine
Sertraline
Venlafaxine
Which SSRI is indicated for PTSD?
Sertraline
Besides SSRIs, benzodiazepines, propranolol, what options do you have in treating anxiety?
Buspirone (Buspar)
Venlafaxine (Effexor)
Nefazodone (Serzone)
Hydroxyzine (Vistaril)
Meprobamate
Advantages/Disadvantages of Buspirone
Advantage = Pregnancy category B
Disadvantage = Do not use in renal or hepatic impairment
Nefazodone has unlabeled use in GAD, Panic disorder, PTSD, SAD
However, it has a black box warning for this
Suicidal ideation
Mechanism of hydroxyzine
Competes with histamine for H-1 receptor sites on effector cells in GI, blood vessels, and respiratory tract
It is an antihistamine (little affinity for cholinergic receptors - no cholinergic side effects) and an anxiolytic (stemming from its 5-HT2 antagonist properties)
Avoid hydroxyzine in
elderly and renal impairment
***Bipolar Disorder***
Differentiate type I vs type II
Type I - Major depressive and manic episodes
Type II - Major depressive and hypomanic episodes (no history of full manic episode)
What are the first line options for acute manic episodes?
Lithium
Valproate
Aripiprazole
Quetiapine
Risperidone
Ziprasadone
Olanzapine
Carbamezepine
What are the first line options for acute depressive episodes?
Lamotrigine
OR
Lamotrigine + antimania therapy
What is the maintenance therapy for bipolar disorder?
Lithium + Valproate
Lithium MOA
Alters Na channels leading to a shift toward intraneuronal metabolism of catecholamines
Serum drug monitoring concentration
0.6-1.5
Primary side effects of Lithium
Diarrhea
Vomiting
Drowsiness
Muscle weakness
Coordination
Ataxia
Blurred vision
Tinnitus
Significant drug interactions exist with lithium and these two classes of drug
ACEI's
Diuretics
Decreased lithium clearance and increased toxicity
Brand names and MOAs for Valproic acid, Oxcarbazepine, Lamotrigine
Depakote - Increased GABA
Trileptal - Blocks voltage-gated Na channels resulting in stabilization of hyperexitable neuronal membranes
Lamotrigine - Effects Na channels stabilizing neuronal membranes
What serious side effects exist with Valproic acid?
Hepatic impairment
Thrombocytopenia
Pancreatitis
What serious side effects exist with Oxcarbazepine?
Hyponatremia
Rash (possibly Stevens-Johnson syndrome)
What serious side effects exist with Lamotrigine?
Diplopia
Stevens-Johnson syndrome
***Schizophrenia***
Tardive Dyskinesia is caused by long-term dopamine antagonism
It can reversed at first, but after a long period of time is not reversible
Options for treating tardive dyskinesia
Prevention is best treatment
Use lowest effective dose
Possibly irreversible - d/c if possible
Switch to atypical or clozapine
Use anti-cholinergics only when indicated and for the shortest possible time
Lithium MOA
Alters Na channels leading to a shift toward intraneuronal metabolism of catecholamines
Serum drug monitoring concentration
0.6-1.5
Primary side effects of Lithium
Diarrhea
Vomiting
Drowsiness
Muscle weakness
Coordination
Ataxia
Blurred vision
Tinnitus
Significant drug interactions exist with lithium and these two classes of drug
ACEI's
Diuretics
Decreased lithium clearance and increased toxicity
Brand names and MOAs for Valproic acid, Oxcarbazepine, Lamotrigine
Depakote - Increased GABA
Trileptal - Blocks voltage-gated Na channels resulting in stabilization of hyperexitable neuronal membranes
Lamotrigine - Effects Na channels stabilizing neuronal membranes
What serious side effects exist with Valproic acid?
Hepatic impairment
Thrombocytopenia
Pancreatitis
What serious side effects exist with Oxcarbazepine?
Hyponatremia
Rash (possibly Stevens-Johnson syndrome)
What serious side effects exist with Lamotrigine?
Diplopia
Stevens-Johnson syndrome
***Schizophrenia***
Tardive Dyskinesia is caused by long-term dopamine antagonism
It can reversed at first, but after a long period of time is not reversible
Options for treating tardive dyskinesia
Prevention is best treatment
Use lowest effective dose
Possibly irreversible - d/c if possible
Switch to atypical or clozapine
Use anti-cholinergics only when indicated and for the shortest possible time
PORT Guidelines
"Second Generation medications, including clozapine and several adjunctive agents have been evaluated for the treatment of TD. However, there is insufficient evidence to support a recommendation for the use of any specific agent to treat TD"
Name the typical anti-psychotics
Chlorpromazine (Thorazine)
Fluphenazine (Prolixin)
Perphenazine (Trilafon)
Trifluoperazine
***All block dopamine in brain
Prochlorperazine (Compazine)
Thioridazine (Mellaril)
Continued
Haloperidol (Haldol)
Pimozide
Loxapine (Loxitane)
Molindone (Moban)
Thiothixene (Navane)
Name the atypical anti-psychotics
Aripiprazole (Abilify)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)
Clozapine (Clozaril)
***Mixed dopamine/serotonin antagonist activity
Name the primary side effects of typical anti-psychotics
Orthostatic hypotension
Sedation
Xerostomia
Constipation
Urinary retention
Blurred vision
Photosensitivity
EPS
Name the primary side effects of atypical anti-psychotics
Weight gain
Hyperglycemia
Hyperlipidemia
Sedation
Prolonged QT-interval
Rare = Hyperprolactinemia, EPS, Tardive dyskinesia
Which agent has the lowest risk of metabolic syndrome?
Aripiprazole
What dangerous side effect is associated with clozapine?
Agranulocytosis
Hyperprolactinemia caused by dopamine antagonism can cause
galactorrhea
amenorrhea
loss of libido (men and women)
decreased bone mineral density (men and women)
gynecomastia
hypospermatogenesis
Which anti-psychotic is most likely to cause hyperprolactinemia
Risperidone
PORT Guidelines
Clozapine should be offered to people with SZ who continue to experience persistent and clinically significant positive symptoms after 2 adequate trials of other anti-psychotic agents
Which anti-psychotic is associated with the greatest degree seizure threshold lowering?
Clozapine
Don't give with Bupropion!
What is the interaction between clozapine and cigarette smoking?
Clozapine = CYP 1A2 substrate
Cigarette smoking is a CYP 1A2 inducer
The levels of clozapine would be lower than if you didn't smoke. If you stopped smoking while on clozapine, the levels would increase.
Which agent has the most anticholinergic effects?
Clozapine
Clozapine can also cause hypotension. What situation is most relevant to this?
If you stop taking clozapine for more than 48 hours, you must start at a lower dose to avoid marked hypotension
PORT Guidelines for first episode of positive symptoms
Anti-psychotic medications, other than clozapine and olanzapine
Why is Olanzapine not considered first line agent?
Lacks extremely sedating properties of clozapine, but has significant weight gain
Clozapine
Most efficacious, but most dangerous - therefore not a first line option
Most likely to cause anti-cholinergic effects, lower seizure thresshold, orthostatic hypotension, sedation, weight gain, diabetes, obesity, and dyslipidemia
Also agranulocytosis and multiple drug interactions
Anticholinergic effects
Clozapine > Olanzapine > Quetiapine > Risperidone = Ziprasidone = Aripiprazole
Weight gain
Clozapine = Olanzapine > Quetiapine = Risperidone > Ziprasidone > Aripiprazole
Orthostatic hypotension
Clozapine > Risperidone = Quetiapine > Olanzapine = Ziprasidone = Aripiprazole
Prolactin
Risperidone > Olanzapine = Ziprasidone = Quetiapine = Clozapine > Arirpiprazole
One advantage of using conventional anti-psychotics over atypical anti-psychotics?
Cost
Atypicals and Typicals are equally effective for positive symptoms
Typicals can actually worsen negative symptoms
What makes an atypical anti-psychotic atypical?
Little to no EPS
Minimal increase in prolactin
Decrease in both positive and negative symptoms
5HT2 antagonism
Fast receptor dissociation from D2 receptors