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Stimulants (e.g., methylphenidate)
Long-acting benzodiazepines (e.g.,chlordiazepoxide, lorazepam, diazepam)
Lithium, valproic acid, atypical antipsychotics
Bulimia and Depression
Generalized anxiety disorder
SSRIs, venlafaxine, benzodiazepines
Antipsychotics (e.g., fluphenazine, pimozide),tetrabenazine, clonidine
Haloperidol, trifluoperazine, fluphenazine, thioridazine, chlorpromazine (haloperidol + “-azines”).
Antipsychotics( neuroleptics) moa
All typical antipsychotics block dopamine D2 receptors ( inc [cAMP]).
High potency Antipsychotics
Trifluoperazine, Fluphenazine,Haloperidol (Try to Fly High)—neurologic side effects (e.g., Huntington disease, delirium,EPS symptoms).
Chlorpromazine, Thioridazine(Cheating Thieves are low)—non-neurologicside effects (anticholinergic, antihistamine, and α1-blockade effects).
Evolution of EPS side effects
- 4 hr acute dystonia (muscle spasm, stiffness,oculogyric crisis)
- 4 day akathisia (restlessness)
- 4 wk bradykinesia (parkinsonism)
- 4 mo tardive dyskinesia
Neuroleptic malignant syndrome (NMS
- rigidity, myoglobinuria, autonomic instability,hyperpyrexia. Treatment: dantrolene, D2agonists (e.g., bromocriptine)
- For NMS, think FEVER: Fever Encephalopathy Vitals unstable Enzymes Rigidity of muscles
stereotypic oral facial movements as a result of long-term antipsychotic use.
Olanzapine, clozapine, quetiapine, risperidone,aripiprazole, ziprasidone.
Atypical antipsychotics toxicity
Fewer extra pyramidal and anticholinergic side effects than traditional antipsychotics. Olanzapine/clozapine may cause significant weight gain. Clozapine may cause agranulocytosis (requires weekly WBC monitoring) and seizure. Risperidone may increase prolactin (causing lactation and gynecomastia) dec GnRH, LH, and FSH(causing irregular menstruation and fertility issues). All may prolong QT interval.
Lithium side effects:
- LMNOP—Lithium side effects:
- Movement (tremor)
- Nephrogenic diabetes insipidus
- Pregnancy problems (Ebstein anomaly)
Stimulates 5-HT1A receptors
Fluoxetine, paroxetine, sertraline, citalopram.
Flashbacks paralyze senior citizens.
5-HT–specific reuptake inhibitors
Serotonin syndrome tx
cyproheptadine (5-HT2 receptor antagonist).
Inhibit 5-HT and norepinephrine reuptake
Duloxetine is also indicated for
diabetic peripheral neuropathy
Amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, doxepin, amoxapine
Tricyclic antidepressants moa
Block reuptake of norepinephrine and 5-HT.
Tricyclic antidepressants toxicity & tx
Sedation, α1-blocking effects including postural hypotension, and atropine-like (anticholinergic)side effects (tachycardia, urinary retention, dry mouth). 3° TCAs (amitriptyline) have more anticholinergic effects than 2° TCAs (nortriptyline). Can prolong QT interval.
Tri-C’s: Convulsions, Coma, Cardiotoxicity (arrhythmias); also respiratory depression,hyperpyrexia. Confusion and hallucinations in elderly due to anticholinergic side effects (usenortriptyline). Treatment: NaHCO3 to prevent arrhythmia.
Monoamine oxidase(MAO) inhibitors are
- Tranylcypromine, Phenelzine, Isocarboxazid, Selegiline (selective MAO-B inhibitor).
- (MAO Takes Pride In Shanghai).
Monoamine oxidase(MAO) inhibitors moa
Nonselective MAO inhibition inc levels of amine neurotransmitters (norepinephrine, 5-HT, dopamine).
Hypertensive crisis (most notably with ingestion of tyramine, which is found in many foods such as wine and cheese); CNS stimulation. Contraindicated with SSRIs, TCAs, St. John’s wort,meperidine, dextromethorphan (to prevent serotonin syndrome)
Atypical antidepressants are
Bupropion moa and toxicity
- Also used for smoking cessation. inc norepinephrine and dopamine via unknown mechanism.
- Toxicity: stimulant effects (tachycardia, insomnia), headache, seizures in anorexic/bulimic patients. No sexual side effects.
Mirtazapine moa and toxicity
α2-antagonist ( inc release of norepinephrine and 5-HT) and potent 5-HT2 and 5-HT3 receptor antagonist.
Toxicity: sedation (which may be desirable in depressed patients with insomnia), inc appetite, weight gain (which may be desirable in elderly or anorexic patients), dry mouth.
Trazodone moa and toxicity
- Primarily blocks 5-HT2 and α1-adrenergic receptors. Used primarily for insomnia, as high doses are needed for antidepressant effects.
- Toxicity: sedation, nausea, priapism, postural hypotension. Called trazobone due to male-specific side effects.