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73 Cards in this Set
- Front
- Back
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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 |
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key adverse effects that differentiate antipsychotics
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EPS
anticholinergic s/e cardiac effects hyperprolactinemia metabolic effects sedation |
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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 |
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What is EPS (Extrapyrimidal sx)?
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EPS is a broad term describing acute and chronic movement disorders
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What EPS occur early in treatment
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early - acute dystonia, parkinsonism, and akathisia
dose dependent and reversible soon after discontinuation 60% on typical antipsychotics clozapine and quetiapine lowest risk |
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EPS later in treatment?
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late - tardive dyskinesia (TD), tardive dystonia and tardive akathisia
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tardive dyskinesia (TD)
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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 |
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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 |
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anticholinergic effects
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common with low potency typicals and atypicals
constipation, urinary retention, dry eyes, mouth, throat |
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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 |
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cardiovascular complications
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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 |
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hyperprolactinemia
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all typicals
resperidone and olanzapine do too leads to galactorrhea, gynecomastia, amenorrhea, anovulation, impaired spermatogenesis, decreased libido and sexual arousal, and anorgasmia |
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weight gain
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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 |
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sedation
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most pronounced w/low potency typicals and clozapine and quetiapine
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why atypicals first choice
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lower risk of EPS and TD
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acute dystonia
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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 |
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anticholinergics to treat antipshcyotic-induced parkinsonism and akathisis
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benztropine (Cogentin)
biperiden (Akineton) diphenhydramine (Benadryl) procyclidine (Kemadrin) trihexyphenidyl (Artane) |
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dopaminergic, gabaminergic and noradrenergic drugs to treat parkinsonism and akathisis
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Dop
amantadine Gaba diazepam clonazepam lorazepam noradrenergic blockers propranolol |
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parkinsonism
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bradykinesia or akinesia
- decreased arm swinging, mask-like face drooling, dec eye blinking, slft, monotonous speech, tremor (rhythmic) |
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parkinsonism treatment
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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 |
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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 |
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Serotonin NE reuptake inhibitors (SNRIs)
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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 |
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Duloxetine Indications
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diabetic peripheral neuropathic pain
fibromyalgia GAD MDD OFF: stress urinary incontinence |
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venlafaxine indications
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MDD
GAD - ER only Social anxiety disorder - ER only Panic disorder - ER only offlabel: autism, binge eating, hot flashes, pain |
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desvenlafaxine indications
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MDD
is a metabolite of venlafaxine |
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SSRIs
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citalopram (Celexa)
escitalopram (Lexapro) paroxetine (Paxil) fluoxetine (Prozac, Sarafem) sertraline (Zoloft) |
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citalopram
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initial - 10
usual - 20-40, max 60mg/d available - 10, 20, 40 tabs, and syrup pearls - used in elderly b/c less ADRs |
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escitalopram
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initial - 10
usual - 10-20mg/d available - 5, 10, 20 tabs pearls - s-isomer of citalopram - 40mg celexa = 10 lexapro |
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fluvoxamine
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initial - 50
usual - 100-300mg/d available - 50, 100 tabs pearls - primarily for OCD drug intxns |
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paroxetine
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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 |
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fluoxetine
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initial - 10-20
usual - 20-80 available - caps, tabs, syrup pearls - tapering unnecessary b/c long t1/2, 90mg tab po qw |
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sertraline
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initial 25-50mg
usual 50-100mg; max 200mg/d available - 25, 50, 100 tabs, liquid pearls - used in elderly; fewer drug intxs |
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Monoamine oxidase inhibitors
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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) |
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MAO indications
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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...) |
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Tricyclic antidepressants
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amitriptyline (Elavil)
nortriptyline (Pamelor, Aventyl) imipramine (Tofranil) doxepin (Sinequan) clomipraine (Anafranil) desipramine (Norpramin) |
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amitriptyline dose and indications
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initial/range 50-75/75-300
indications - depression - chronic and neuropathic pain - migraine prophylaxis - peripheral neuropathy |
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nortriptyline
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initial/range 25-50/40-200
indications - depression - chronic pain |
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imipramine
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initial/range 50-75/75-300
indications - depression - childhood enuresis - chronic and neuropathic pain |
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doxepin
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initial/range 75 divided/75-300
indications - depression - anxiety unlabeled: - chronic and neuropathic pain |
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clomipramine
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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 |
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desipramine
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initial/range 50-75/75-300
indications - depression - chronic pain unlabeled: - peripheral neuropathy |
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tetracyclics
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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 |
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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 |
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other antidepressants
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bupropion (Wellbutrin, SR, XL, Zyban)
trazodone (Deseryl) nefazodone ( ) - available in 50 to 250mg tabs by 50s |
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nefazodone
dose indication |
- available in 50 to 250mg tabs by 50s
- depression |
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trazodone
dose indications |
50, 100, 150, 300mg tabs
indications: depression off label uses: - insomnia - migraine prevention (children/adol) |
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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 |
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Tricyclics
adverse effects |
orthostatic hypotension
tachycardia sedation anticholinergic effects arrhythmias wt gain sexual dysfunction |
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tricyclics
tertiary amines have more intense a/e than secondary amines |
tertiary
- amitriptyline - imipramine - doxepin - clomipramine secondary amines - nortriptyline - desipramine |
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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 |
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tricyclics
MOA |
increase concentration of 5-HT and NE
by blocking reuptake |
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MAOIs
MOA |
increase synaptic concentration of:
NE, DA, 5HT by blocking MAO, the enzyme that breaks these NTs down |
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MAOIs
adverse effects |
orthostatic hypotn
wt gain sex dysfunction anticholinergic effects hypertensive crisis |
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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 |
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SSRIs
Adverse effects |
GI complaints
nervousness insomnia ha fatigue sexual dysfunction |
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Antipsychotics
MOA of typicals |
block
postsynaptic D2 plus anticholinergic antihistaminic alpha blocking |
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antipsychotics
MOA of atypicals |
weak DA blockers
also block following CNS receptors: serotonergic alpha adrenergic histaminic muscarinic |
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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 |
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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 |
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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 |
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Atypical antipsychotics
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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) |
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clozapine
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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 |
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risperidone
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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 |
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olanzapine
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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 |
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quetiapine
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Seroquel 25, 100, 200, 300 mg tabs
300-800mg/d or higher low eps and prolactin elevation risk |
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ziprasidone
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Geodon 20, 40, 60, 80mg caps
20mg/ml injection 40-160 mg/d po 40mg/d MAX IM dose |
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aripiprazole
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Abilify 2, 5, 10, 15, 20, 30
1mg/ml concentrate 10-30mg/d qd dosing benefit |
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paliperidone
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Invega 3, 6, 9 mg ER tabs
6mg/d 12mg/d max SR tab: do not crush etc matrix may be seen in stool |
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Li
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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 |
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divalproex dodium
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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 |
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carbamazepine
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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 |
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lamotrigine
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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 |
