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125 Cards in this Set
- Front
- Back
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clinical features of depression include
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physiologic (GI, Cardiac); psychological (easiest to id); cognitive
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etiology of depression
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biochemical disturbance (deficiency of 5HT-3, NE); genetic background; cognitive state; ability to cope with mood changes
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tx options of depression
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psychotherapy (not good monotherapy); ECT; pharmacologic
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pharmacological tx of depression
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MAOIs; TCAs; others; new generation agents (SSRIs & SNRI)
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MAOIs are not a ____ line drug and are used only when ________ or _________
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first; all others fail; already on them and doing well and don't want to change
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examples of MAOIs are _______, _________, ________
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Phenelzine (Nardil); Tranylcypromine (Parnate); Isocarboxazid (Marplan)
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MAOIs prevent inactivation of ______, such as ____, ____, ____which then leads to a ______ of the NTers in the ______
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monoamines; 5HT-3 and NE & domapine; increase; synaptic cleft
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MAOIs are
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nonspecific
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pts on MAOIs should avoid food with _______ such as
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tyramine; pickled hering, aged cheddar cheese, red wine
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SE of MAOIs
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HTN; HA
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The "washout period" needed before changing or starting new meds is _____ weeks
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two (books says 6)
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examples of TCAs
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Amitriptyline (Elavil); Nortriptyline (Pamelor, Aventyl); Protriptyline (Vivactil); Imipramine (Tofranil); Desipramine (Norpramin); Doxepin (Sinequan)
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MOA
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inhibit reuptake of 5HT3, NE or both
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These inhibit mostly 5HT-3 reuptake
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amitriptyline; protryptiline; imipramine; dexepin
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These inhibit mostly NE
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Nortriptyline; desipramine
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_______ is a metabolite of amitrityline
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nortriptyline
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________ is a metabolite of tofranil
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desipramine
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SE of TCA
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sedation; anticholinergic effects; activation of mania (pretty much all); orthostatic hypotn
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other (atypical) antidepressants
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Maprotiline (Ludiomil); amoxiapine (Asendin); Trazadone (Desyrel)
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Trazadone is a ____ inhibitor of _____ re-uptake. It has a sedating effect probably secondary to its _______ blocking activity
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weak; 5HT-3; H-1
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Trazadone is also use in treating _____ pain
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neuropathic
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Newer agents to treat depression include
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SSRIs and SNRIs and alpha-2 antagonists
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examples of SNRIs are
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Venlafaine (Effexor), effexor XR; Duloxetine (Cymbalta)
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Duloxetine also has ______ properties
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analgesic
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examples of alpha-2 antagonists are
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Mirtazapine (Remeron)
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alpha -2 antag. cause an ___ release of ______ (NT)
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increase; NE
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all antidepressants that cause an ______ of NT in the ______, are good for _____ pain
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increase; synaptic cleft; neuropathic
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examples of SSRIs are
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Fluoxetine (Prozac); Sertratline (Zoloft); Paroxetine(Paxil); Citalopram (Celexa); Escitalopram (Lexapro)
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________ causes more insomnia than the other SSRIs
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zoloft
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only _______ undergoes a significant 1st pass metabolism
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zoloft
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fluoexetine differs from others in the class; as it has a _____ half-life (____ hrs) and it is available in _______, allowing ____ weekly dosing
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longer; 50; sustained release; once
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_________ & _________ are potent inhibitors of cytochrome P450
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fluoxetine and paroxetine
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_________ has less nausea than celexa
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lexapro
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SE of SSRIs
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constipation; diarrhea; dry mouth; fatigue; activation of mania; suicide; suicidal ideation; sexual side effects
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two important considerations in selecting a drug
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past hx of response; differences in adverse effect profile
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other issues to consider
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cost of aquisition; overal cost of therapy; coverage
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Major SE of SSRI
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sedation; anticholinergic effects; orthostatic hyptotn
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meds from most to least with sedation SE
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elavil>trazadone>imipramine>desipramine=SSRIs=venlafaxine
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meds from most to least with anticholinergic effects
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elavil>doxepin >nortriptyline>trazadone=SSRIs=venlafaxine/duloxetine (effexor/cymbalta)
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meds from most to least with orthostatic hypotn
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elavil>Trazadone>nortriptyline =SSRIs=venlaxafine(effexor)(?doxazosin)
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pharmacoeconomic considerations
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acquisition costs; cost of hospitalization; cost of missed days at work; cost on managing side effects; cost of managing lack of efficacy
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complications of bipolar illness
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increased cardiovascular mortality; increased suicide rate; excessive risk-taking behavior; substance abuse
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goal of tx of BPD
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stabilize mood
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pharmacologic options for tx of BPD
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lithium; carbamazepine; valproic acid
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Lithium has a _____ onset of action, a ___ therapeutic range, and ____-______ interactiosn
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long; narrow; food-drug
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lithium is a ___ molecular ion, in competes with __ at absorption excretion sites. It affects the ____ and if in excess can lead to ____ ____
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low; Na; kidneys; diabetes insipidous
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monitoring parameters are
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Cr, BUN, Urine sg, electrolytes, EKG, CBC, thyroid fxn, glucose, lithium level, beta HCG (repeat q 3 mo)
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lithium SE
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cognitive effects, fine tremor, GI upset, diarrhea, hypothyroidism, polyuria, polydypsia (signs of diabetes insipidus), wt gain, rashes
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_______ increase the level of lithium
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NSAIDS, Diuretics, ACE inhibitors
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________ decrease lithium levels
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theophyline, caffine, acetazolamide, sodium
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all diuretics will lead to lithium ________ as they inhibt ______ reabsorption, but not lithium reabsorption
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toxicity; NA
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if a pt is on lithium, eats a lot of salt chips then takes an antacid, they will have a _______ overload which will ______ lithium off reabsorption site, leading to ______
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Na, kick, mania
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drugs that lead to lithium toxicity
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methyldopa; carbamazepine; Ca channel blockers; antipsychotics; SSRIs
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Carbamazepine (tegretol) acts on ______ channels, dosing starts at ____ mg _____, is available as ______ and ______and target drug level is ____ mcg/ml
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sodium; 200; BId; tablets; suspension; 8-12
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tegretol is usually a _____ line med
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firt line
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SE of tegretol are
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leukopenia; thrombocytopenia; hyponatremia; sedation; tremor; diplogia;
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drug interactions
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importance of expoxide
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valproate SE
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nausea (divalproex better tolerated); elevation in transaminases; teratogenicity
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LFTs should be tested
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at start of tx, then monthly for first 3 mo, the q 6 months
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what drug should you choose for a child bearing age female
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tegretol and give folate supplementation
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valproate drug interactions. It ______ other drugs from ____ binding sites, it ___ hepatic metabolism, hepatic ____ ____ lower its efficacy
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displaces; protein; inhibits; enzyme inducers
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other BPD agents
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verapamil, gabapentin; levothyroxine (best for type 2)
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if increased mania use _____
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antipsychotics
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The need for antipsychotic therapy starts with evaluation of
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agitation; aggressiveness and evaluation of other causes (hypoxia)
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antipsychotic drugs block _______ receptors in _____ (5) and affect ___ and ______ receptors
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dopamine; basal gangila; hypothalmus; limbic system; brain stem; medulla; D-1; D-2
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examples of phenothyzines are
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chlorpromazine (Thorazine); Thioridazine (Mellaril); Mesoridazine (Serentil); Thiothixine (Navane); Fluphenzine (Prolixin)
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All phenothyzines lower __ ___ and accentuate _____ pain
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sz threshold; neuropathic
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if pt has hx dm with neuropatic pain should you use Thorazine?
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no
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______ has SE of QT segment prolongation
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Thiordazine (mellaril)
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_______ is the injectible form of Thiordazine
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Mesoridazine (Serentil)
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________ is also injectable
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Thiothixene (Navane)
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________ is used a lot in pts secondary to its fast acting and available in lq
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Fluphenazine (Prolxin)
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SE of phenothiazines
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sedation; extrapyramidal sx (erratic movements to muscle spasm to sz), sz (can get with antiemetics)
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Drug interactions
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etoh (accentuates CNS depression); valproic acid; tegretol (inducing enzyme?)
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haloperidol (Haldol) has ____ effect on sz threshold; is administered via ____ and _____, ____ and ______ acting
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no; po and injectible; sustained release and short acting injectible
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SE of haldol
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extrapyramidal sx; tardive dyskinesia (with phenothiazines)p therapy stops, no way to prevent; pseudoparkinsonism (gait disturbance, will go away p 1 mo stopped
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When Haldol is given IM it forms a ________ that has slow release x ___ weeks
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precipiate, 2, ___ acute setting
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tx extrapyramidal sx with _______, or _______
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benztropine (cogentin); benadryl
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the key is _______ and monitoring
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prevention (start above when starting Haldol)
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examples of newer antipsychotic agents
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clozapine (clozaril); Risperidone (rispradal); olanzapine (zyprexa); quetiapine fumarate (seroquel); ziprasidone (geodon) aripiprazole (abilify); paliperidone (invega)
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SE specific to clozapine (clozaril) and how to manage that se
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agranulocytosis, CBC Q 2 weeks with only two weeks of meds distributed at a time
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routes of admin for riperidone
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orally dis. tab and injectable (risperdol consta) given q 2 weeks
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problem with olanzapine (zyprexa)and routes of admin
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qt segment prolongation; po orally dis. tab (zytres) and injection
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olanzapine has _____ se than clozaril
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less
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quetiapine fumarate (seroquel) is metabolized by the ______. It has a better effect with _____ dose. It is admin via _____ only. and has a se of _____
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liver; increased; po; qt seg prolongation that can lead to fatal arrhythmia
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aripiprazole (abilify) has ___ se than others, but its drawback is:____ despite it being available to be admin via what route
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less; doesn't work fast enough; injectible
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paliperidone (invega)is a metabolite of ________
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risperdal
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ziprasidone (geodon)is availble by ________
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po and injection
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SE of newer antipsychotics
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hematologic; pro-arrhythmic effects (tor sades); metabolic disturbance (inc lipid, inc wt, inc DM II, leads to heart dz); dyskinesias (less than orginals); postural hyptotn; risk of stroke (independent of cardiovascular status)
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one should avoid the combo of ______ and antipsychotic meds as the combo could lead to ________
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valproic acid; fatal arrhythmia
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failure to dx and tx ______ can lead to increase in morbidity and _______
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anxiety; mortality
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associated medical disorders
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cardiovascular dz; respiratory; endocrinology; GI; neurologic
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drugs that cause anxiety
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cns stimulants (legal and illicit); cns depressant (etoh in excess)
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a deficiency of ______ and _______ NT can lead to anxiety
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GABA; 5HT (with depression)
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excess of ______ and _______ can lead to anxity
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NE; 5HT
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neurochemical theories are
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noradrenergic model; benzodiazepine model; serotonin model
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noradrenergic model deals with
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shortage of NE
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benzodiazepine model deals with
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GABA inhibition
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serotonin models deal with
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decrease in 5HT in synaptic cleft
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when tx GAD there is no _____-______ relief with ____ only. ______ is needed also
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long-term; meds; therapy/counceling
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benzodizaepines used to tx GAD
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Alprazolam (xanax); lorazepam (ativan); oxazepam (serax); diazepam (valium); chlordiazepoxide (librium)
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______ is the most commonly used axietolytic drug. It is _______ acting
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xanax; very short
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_______ has the highest incidence of sz with abrupt discontinuation
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xanax
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these benzos are can be administered via injection as well
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ativan; valium; librium
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these benzos are pro drugs
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valium; librium
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adverse effects of benzos
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sedation (when taken with other cns depressants, esp etoh, effect is addative and synergistic; dependence (sz upon withdrawl)
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meds to tx anxiety
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benzos; buspirone; beta blockers; antidepressants
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buspar is a partial _____ agonist, has a _____ onset
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serotonin; long
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adverse effects of buspar
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light sedation and drug interactions (cytochrome P450 metabolism)
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beta blockers used to tx anxiety
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propranolol (max 20mg TID)
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buspirone can make anxiety ______ on a rare occassion
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worse
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BB don't ______ BP considerably and are good for ______ anxiety. a SE is _______ loss
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lower; situational; short-term memory
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particularly _______ are good antidepressants to tx anxiety
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SSRIs
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#1 drug used to tx panic do is _______ and it works by enhancing _______
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benzos; GABA
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______ and _______ are used in the prevention of panic attacks
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TCA (elavil max 50mg qd); SSRIs
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another thing to look at in tx of panic attacks
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lifestyle; dont watch news or read scare book before bed; avoid etoh as it exacerbates panic do
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specific phobias are ______ to pharmacotherapy. One must stear away from _____ situations
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unresponsive; fearfull
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Tx for social phobias are
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MAOIs (low dose); benozos; SSRIs
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a concern with use of benzos is
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they need to be used chronically and then dependence is an issue
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Buproprion (wellbutrin) works as an _______ and ______
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antidepressant and antianxiety
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buproprion (wellbutrin) is a ______ inhibitor of neuronal uptake of _____, ______, and _______
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dopamine; NE; serotonin
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zyban is used for _______, and helps to decrease ______ for _______ and _______
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smoking cessation; cravings; tobacco; etoh
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caution must be used with chronic etoh use as withdrawl can lead to
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sz
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precautions in using wellbutrin
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sz; incrased risk of suicidal behavior
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SE of wellbutrin is
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hypertension; mania; depression
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