Psychiatry - Pharmacology

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jknell
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211322
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Psychiatry - Pharmacology
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2013-04-04 00:06:31
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Psychiatry pharmacology
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  1. Condition → preferred treatment
  2. Alcohol withdrawal
    Benzodiazepines
  3. Anxiety
    • SSRIs
    • SNRIs
    • buspirone
  4. ADHD
    • Methylphenidate
    • amphetamines
  5. Bipolar disorder
    • "Mood stabilizers"
    • -Lithium
    • -valproid acid
    • -carbamazepine

    Atypical antipsychotics
  6. Bulimia
    SSRIs
  7. Depression
    • SSRIs
    • SNRIs
    • TCAs
    • buspirone
    • mirtazapine (especially with insomnia)
  8. Obsessive-compulsive disorder
    • SSRIs
    • clomipramine
  9. Panic disorder
    • SSRIs
    • venlafaxine
    • benzodiazepines
  10. PTSD
    SSRIs
  11. Schizophrenia
    Antipsychotics
  12. Social phobias
    SSRIs
  13. Tourette's syndrome
    Antipsychotics (e.g., haloperidol, risperidone)
  14. CNS stimulants
    mechanism, clinical use
    Methylphenidate, dextroamphetamine, methamphetamine

    • Mechanism:
    • -↑ catecholamines at the synaptic cleft, especially NE and dopamine

    • Clinical use:
    • -ADHD
    • -Narcolepsy
    • -Appetite control
  15. Antipsychotics (neuroleptics)
    Mechanism, clinical use, toxicity
    Haloperidol, trifluoperazine, fluphenazine, thioridazine, chlorpromazine (haloperidol + "-azines")

    • Mechanism:
    • -All typical antipsychotics block dopamine D2 receptors (↑ [cAMP])

    • Clinical use:
    • -Schizophrenia (primarily positive symptoms)
    • -psychosis
    • -acute mania
    • -Tourette's syndrome

    • Toxicity:
    • -lipid soluble, stored in body fat → slowly removed from body
    • -Extrapyramidal system (EPS) side effects: dyskinesias
    • -Endocrine side effects: dopamine receeptor antagonism → hyperprolactinemia → galactorrhea
    • -Blocking muscarinic receptors: dry mouth, constipation
    • -Blocking α1 receptors: hypotension
    • -Blocking histamine: sedation
    • -Neuroleptic malignant syndrome
    • -Tardive dyskinesia
  16. Extrapyramidal system (EPS) side effects
    evolution of EPS side effects
    • 4 hr acute dystonia (muscle spasm, stiffness, oculogyric crisis)
    • 4 day akathisia (restlessness)
    • 4 week bradykinesia (parkinsonism)
    • 4 mo tardive dyskinesia
  17. Neuroleptic malignant syndrome (NMS)
    • Rigidity, myoglobinuria, autonomic instability, hyperpyrexia
    • Tx: dantrolene, D2 agonist (e.g., bromocriptine)

    • *Think FEVER:
    • -Fever
    • -Encephalopathy
    • -Vitals unstable
    • -Elevated enzymes
    • -Rigidity of muscles
  18. Tardive dyskinesia
    • Stereotypic oral-facial movements as a result of long-term antipsychotic use
    • Often irreversible
  19. Antipsychotics
    High vs low potency
    • High potency: Trifluoperazine, Fluphenazine, Haloperidol (Try to Fly High)
    •      - neurologic side effects (extrapyramidal symptoms)
    • Low potency: Chlorpromazine, Thioridazine (Cheating Thieves are low)
    •      - non-neurologic side effects (anticholinergic, antihistamine, and α1-blockade effects)
  20. Atypical antipsychotics (2nd generation)
    Mechanism, clinical use, toxicity
    • Olanzapine, clozapine, quetiapine, resperidone, aripiprazole, ziprasidone
    • *It's atypical for old closets to quietly risper from A to Z

    • Mechanismnot completely understood
    • -Varied effects on 5-HT2, dopamine, and α- and H1-receptors

    • Clinical use:
    • -Schizophrenia (both positive and negative symptoms)
    • -Bipolar disorder
    • -OCD
    • -Anxiety disorder
    • -Depression
    • -Mania
    • -Tourette's syndrome

    • Toxicity:
    • -Fewer extrapyramidal and anticholinergic side effects than traditional antipsychotics
    • -Olanzapine/clozapine: weight gain
    • -Clozapine: agranulocytosis (monitor WBC count weekly), seizures
    • -Ziprasidone: prolong QT interval
  21. MBB
    first generation vs second generation
    • Second generation antipsychotic drugs:
    • -fewer "extrapyramidal" AEs
    • -more effective for negative symptoms
    • -less elevation of prolactin
    • -Metabolic syndrome

    • First generation antipsychotic drugs:
    • -Extrapyramidal side effects (parkinsonism)
    • -dystonia, akathisia, parkinsonian syndrome
  22. Lithium
    mechanism, clinical use, toxicity
    Mechanism: not known

    • Clinical use: mood stabilizer
    • -bipolar disorder (blocks relapse and acute manic events
    • -SIADH

    • Toxicity:
    • LMNOP
    • -Lithium side effects:
    • -Movement (tremor)
    • -Nephrogenic diabetes insipidus
    • -HypOthyroidism
    • -Pregnancy problems
    • -sedation
    • -edema
    • -heart block
    • -polyuria (ADH antagonist → nephrogenic DI)
    • -Fetal cardiac defects: Ebstein anomaly, malformation of great vessels

    • *Narrow therapeutic window; monitor serum levels closely
    • Excretion: kidney (most is reabsorbed at proximal convoluted tubules following Na+ reabsorption)
  23. Buspirone
    Mechanism, clinical use
    Mechanism: Stimulates 5-HT1A receptors

    • Clinical use:
    • -Generalized anxiety disorder
    • -Does not cause sedation, addiction, or tolerance
    • -Takes 1-2 weeks to take effect
    • -No interaction with alcohol (vs. barbiturates, benzodiazepines)

    *I'm always anxious if the bus will be on time, so I take buspirone
    • Antidepressants mechanism of action
    • NE reuptake: SNRIs, Desipramine, maprotiline
    • 5-HT reuptake: Fluoxetine, trazodone
    • α2-receptor: Mirtazapine
    • MAO inhibitors
  24. SSRIs
    Mechanism, clinical use, toxicity
    • Fluoxetine, paroxetine, sertraline, citalopram
    • *Flashbacks paralyze senior citizens

    Mechanism: Serotonin-specific reuptake inhibitor

    • Clinical usenormally takes 4-8 weeks for antidepressants to have an effect
    • -Depression
    • -Generalized anxiety disorder
    • -Panic disorder
    • -OCD
    • -Bulimia
    • -Social phobias
    • -PTSD

    • Toxicity:
    • -Fewer than TCAs
    • -GI distress, sexual dysfunction (anorgasmia, ↓ libido)
    • -Serotonin syndrome: any drug that ↑ serotonin (MAO inhibitors, SNRIs, TCAs)
    •      - hyperthermia, confusion, myoclonus, cardiovascular collapse, flushing, diarrhea, seizures
    •      - Tx: cyproheptadine (5-HT2 receptor antagonist)
  25. SNRIs
    Mechanism, clinical use, toxicity
    Venlafaxine, duloxetine

    Mechanism: Inhibit serotonin and NE reuptake

    • Clinical use:
    • -Depression
    • -Venlafaxine: also used in generalized anxiety and panic disorders
    • -Duloxetine: diabetic peripheral neuropathy
    • -Duloxetine has greater effect on NE

    • Toxicity:
    • - ↑ BP most common
    • - stimulant effects
    • - sedation
    • - nausea
  26. Tricyclinc antidepressants (TCAs)
    Mechanism, clinical use, toxicity
    Amitriptyline, nortriptyline, imapramine, desipramine, clomipramine, doxepin, amoxapine ("-iptyline" or "-ipramine")

    • Mechanism:
    • -Block reuptake of NE and serotonin

    • Clinical use:
    • -Major depression
    • -bedwetting (imipramine)
    • -OCP (clomipramine)
    • -Fibromyalgia

    • Toxicity:
    • -anti-histamine side effects: sedation
    • 1-blocking effects: postural hypotension
    • -anticholinergic side effects (tachycardia, urinary retention, dry mouth) (amitriptyline > nortriptyline)
    • -Tri-C'sConvulsions, Coma, Cardiotoxicyity (arrhythmias)
    • -respiratory depression
    • -hyperpyrexia
    • -Confusion and hallucinations in elderly (use nortriptyline)

    Tx: NaHCO3 for cardiovascular toxicity
  27. Monoamine oxidase (MAO) inhibitors
    mechanism, clinical use, toxicity
    • Tranylcypromine, Phenelzine, Isocarboxazid, Selegiline (selective MAO-B inhibitors)
    • **MAO Takes Pride IShanghai

    • Mechanism:
    • -Nonselective MAO inhibition ↑ levels of amine neurotransmitters (NE, serotonin, dopamine)

    • Clinical use
    • -Atypical depression
    • -Anxiety
    • -Hypochondriasis

    • Toxicity:
    • -Hypertensive crisis ( with ingestion of tyramine - wine and cheese)
    • -CNS stimulation
    • -Contraindicated with SSRIs, TCAs, St. John's Wort, meperidine, dextromethorphan (prevent serotonin syndrome)
  28. Atypical antidepressants
    • Bupropion
    • Mirtazapine
    • Maprotiline
    • Trazodone
  29. Bupropion
    • Mechanism: unknown → ↑ NE and dopamine
    • Toxicity: stimulant effect (tachycardia, insomnia), headache, seizures in bulimic patients
    • *No sexual side effects
    • Other uses: smoking cessation
  30. Mirtazapine
    • Mechanism
    • 2-antagonist (↑ release of NE and serotonin)
    • -potent 5-HT2 and 5-HT3 receptor antagonist

    Toxicity: sedation (desirable in depressed pts with insomnia), ↑ appetite, weight gain, dry mouth
  31. Maprotiline
    • Mechanism: Blocks NE reuptake
    • Toxicity: sedation, orthostatic hypotension
  32. Trazodone
    • Mechanism: Primarily inhibits serotonin reuptake
    • Clinical use: insomnia
    • -High doses needed for antidepressant effects
    • Toxicity: sedation, nausea, priapism, postural hypotension
    • *Trazobone due to male-specific side effects

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