Psych Pharm

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ashboeri
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96346
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Psych Pharm
Updated:
2011-08-20 15:59:32
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psych medical pharm
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psych pharm
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  1. SSRI half lives
    • Most are 24 hours.
    • Fluoxetine is 2-4 days (it's metabolite norfluoxetine is 7-10 days. this means it takes over a month to reach steady-state plasma concentrations, the others take 5 days)
  2. SSRIs are bound to...
    Plasma proteins (except fluoxetine). Have much less effect on muscarinic, histaminic, and adrenergic receptors, compared to TCAs so they are better tolerated.
  3. How long does it take for SSRIs to start treating depression?
    2-4 weeks. Should be continued 6-8 weeks before pt is considered refractory
  4. Adverse drug reactions of SSRIs
    GI, decreased appetite, insomnia (most common with fluoxetine), headaches, sexual dysfunction, serotonine syndrome (if used with MAOIs)

    In general the lesser effects go away after consistent use
  5. CYP450 Inducers
    Smoking, Carbamazepine, Barbiturates, St. Johns wort
  6. CYP450 Inhibitors
    Fuoxetine, Paroxetime, Duloxetime, Sertraline
  7. Features of Fluoxetine
    • longest half life, so no need to taper
    • safe in pregnancy
    • can elevate levels of neuroleptics
  8. Features of Sertraline
    • high risk for GI disturbances
    • very few drug interactions
  9. Features of Paroxetine
    • highly protein bound, so several drug interactions
    • anticholinergic effects: sedation, constipation, weight gain
    • short half life causes withdrawal if not take consistantly
  10. Features of Fluvoxamine
    • treats OCD
    • lots of drug interactions
    • CYP inhibitor
  11. Features of Citalopram
    fewest drug-drug interactions
  12. If taken with cough medicine, SSRIs cause
    serotonin syndrome
  13. Features of serotonin syndrome
    • fever
    • tachycardia
    • hypertension
    • delerium
    • hyperreflexia
    • "electric jolt" limb movements
  14. Features of Venlafaxine
    • used for depression and GAD
    • low drug interaction potential
    • elevates BP (don't use for pts with htn)
  15. Features of Duloxetine
    • used for pts with depression and neuropathic pain
    • side effects include dry mouth and constipation
    • liver effects, don't give to alcoholics
  16. Features of Trazodone
    • useful for refractory MDD, insomnia
    • no sexual side effects, doesn't effect REM sleep
    • side effects: nausea, dizziness, orthostatic hypotension, arrhythmias, sedation, and priapism
  17. Features of Mirtazapine
    • used for refractory MDD, especially in pts who need to gain weight
    • good for elderly, helps with sleep and appetite
  18. Features of Amitriptyline
    • TCA (sedating)
    • Useful in chronic pain, migraines, and insomnia
  19. Features of Imipramine
    • TCA
    • used in enuresis and panic disorder
  20. Features of Clomipramine
    • TCA
    • most serotonin specific
    • used for OCD
  21. Features of Doxepin
    • TCA
    • used for chronic pain
  22. Features of Nortriptyline
    • TCA
    • least likely to cause orthostatic hypotension
    • used for chronic pain
  23. Desipramine
    • TCA
    • least anticholinergic
  24. Treatment for TCA overdose
    IV sodium bicarbonate
  25. MAOIs prevent the breakdown of...
    norepi, serotinin, dopamine, and tyramine
  26. MAO-A preferentially deactivates...
    serotonin

    also dopamine and tyramine
  27. MAO-B preferentially deactivates
    norepi/epi

    also dopamine and tyramine
  28. Commen MAOIs
    • Phenelzine
    • Tranylcypromine
    • Isocarboxazid
    • Selegeline
  29. To aid in treating serotonin syndrome
    calciam channel blockers (nifedipine). Monitor carefully if use chlorpromazine or phentolamine
  30. Antidepressants that treat... OCD
    • SSRIs (high doses)
    • TCAs (clomipramine)
  31. Antidepressants that treat... Panic disorders
    • SSRIs
    • TCAs (imipramine)
    • MAOIs
  32. Antidepressants that treat... Eating disorders
    • SSRIs (high dose)
    • TCAs
    • MAOIs
  33. Antidepressants that treat... social phobia
    • SSRIs
    • TCAs
    • MAOIs
  34. Antidepressants that treat... GAD
    • SSRIs
    • SNRIs (venlafaxine)
    • TCAs
  35. Antidepressants that treat... IBS
    • SSRIs
    • TCAs
  36. Antidepressants that treat... PTSD
    SSRIs
  37. Antidepressants that treat... Enuresis
    TCAs (imipramine)
  38. Antidepressants that treat... Neuropathic pain
    • TCAs (amitriptyline and nortriptyline)
    • Duloxetine
  39. Antidepressants that treat... chronic pain
    • SSRIs
    • TCAs
  40. Antidepressants that treat... Fibromyalgia
    SSRIs
  41. Antidepressants that treat... Migrane headaches
    • TCAs (amitriptyline)
    • SSRIs
  42. Antidepressants that treat... PMDD
    SSRIs
  43. Antidepressants that treat... depressive phase of bipolar
    SSRIs
  44. Antidepressants that treat... insomnia
    • Mirtazapine
    • TCAs (amitriptyline)
  45. Atypical vs Typical antidepressant MOIs
    • typical block dopamine receptors (D2)
    • atypical block D2 and serotonin (2A) receptors
  46. When presribing Lithium, check
    lithium levels, creatinine, and thyroid levels
  47. Low potency typical antipsychotics
    • higher incidence of anticholinergic and antimuscarinic side effects
    • QTc prolongation
    • Chlorpromazine - orthostaic hypotension, blue skin discoloration, pohosensitivity, can treat nausea, vomitting, and irretractable hiccups
    • Thioridazine - retinitis pigmentosa
  48. High potency typical antipsychotics
    • less sedation, orthostatic hypotension, and anticholinergic effects, greater risk for EPS and tardive dyskinesia
    • Haloperidol
    • Fluphenazine
    • Pimozide - cardiac side effects
  49. Positive symptoms of schizophrenia treated via
    mesolimbic pathway: nucleus accumbens, fornix, amygdala, hippocampus
  50. Negative symptoms of schizophrenia via...
    mesocortical pathway
  51. Symptoms of Neuroleptic Malignant Syndrome
    • FALTERED:
    • Fever
    • Autonomic instability
    • Leukicytosis
    • Tremor
    • Elevated CPK
    • Rigidity (lead pipe)
    • Excessive sweating
    • Delerium
  52. Onset of neuroleptic side effects
    • hours to days - acute dystonia
    • days to months - EPS/akathisia
    • months to years - tardive dyskinesia
  53. Clozapine
    • great in refractory schizo, only antipsychotic shown to decrease risk of suicide
    • tachycardia, hypersalivation
    • more anticholinergic side effects than atypicals or high potency typical
    • can develop myocarditis
    • agranulocytosis - must stop if absolute neutrophil count drops below 1500
  54. Risperidone
    • can increase prolactin
    • orthostatic hypotension and reflex tachycardia
  55. Quetiapine
    sedation and orthostatic hypotension
  56. Olanzapine
    weight gain
  57. Aripiprazole
    • Unique mechanism of partial D2 agonism
    • less potential for weight gain
    • more activating and less sedating
  58. Common side effects of atypical antipsychotics
    • metabolic syndrome
    • weight gain
    • hyperlipidemia
    • hyperglycemia
    • liver function
    • QTc prolongation
  59. Lithium
    • metabolized by kidney
    • Prior to initiating, do ECG, basic chemistry, thyroid function tests, CBC, pregnancy test
    • onset of action 5-7 days
  60. Factors that affect lithium levels
    • NSAIDS (decrease)
    • Aspirin
    • Dehydration (increase)
    • Salt deprivation (increase)
    • Sweating - salt loss (increase)
    • Impaired renal function (increase)
    • Diuretics, esp thiazides
  61. Carbamazepine
    • anticonvulsant
    • tx mixed episodes and rapid-cycline bipolar disorder (less for depressed phase)
    • tx trigeminal neuralgia
    • acts by blocking Na channels and inhibiting action potentials
    • Onset of action 5-7 days
    • Must do CBC and LFTs before treatment, monitor regularly - leukocytosis esp dangerous if given with other meds that lower WBC (clozapine)
    • Side effects - GI, sedation, ataxia, Steven-Johnson syndrome, leukopenia, hyponatremia, aplastic anemia, agranulocytosis, elevation of liver enzymes causing hepatitis, TERATOGENIC (neural tube defects)
    • Autoinduction of CYP450
  62. Valproic Acid
    • tx mixed and rapid-cycling bipolar
    • Must montor LFTs and CBC
    • Levels checked after 3-5 days (normal 50-150)
    • Side effects: GI, weight gain, sedation, alopecia, pancreatitis, hepatotoxicity, increased ammonia, thrombocytopenia, teratogenic (neural tube)
  63. Lamotrigine (Lamictol)
    • tx bipolar depression (not mania)
    • works on Na channels that modulate glutamate and aspartate
    • May cause Stevens-Johnson syndrome by 4-6 weeks

    Note: Valproate will increase lamotrigine levels, and lamotrigine with decrease valproate levels
  64. Oxcarbazepine
    mood stabalizer like carbamasepine, but less risk of rash and hepatotoxicity
  65. Gabapentin
    often used adjunctively to help with anxiety and sleep
  66. Topiramate
    • tx impulse control disorder and anxiety
    • weight loss, hypochloremic non-anion gap metabolic acidosis, kidney stones, cognitive slowing
  67. Benzos not metabolized by liver
    • LOT:
    • Lorazepam
    • Oxazepam
    • Temazepam
  68. Diazepam
    • Valium
    • Rapid onset, long acting
    • used for detox
  69. Clonazepam
    • tx anxiety, panic attacks
    • long acting
    • avoid with renal dysfunction
  70. Alprazolam
    • Xanax
    • tx anxiety, panic attacks
    • shot onset of action causes euphoria, high abuse potential
  71. Lorazepam
    • Ativan
    • tx panic attacks, detox, agitation
  72. Temazepam
    • Restoril
    • tx insomnia
  73. Triazolam
    • short acting
    • tx insomnia, medical and surgical settings
  74. Tx benzo overdose with...
    flumazenil (must be done slowly so withdrawal isn't too quick)
  75. Midazolam
    • Versed
    • used in medical and surgical settings
  76. Zolpidem/zaleplon.eszopiclone
    • non-benzo hypnotics
    • selective receptor binding to bendo receptor 1, which is responsible for sedation
  77. Ramelteon
    • non-benzzo hypnotic
    • selective melatonin MT1 and MT2 agonist
  78. Buspirone
    • partial agonist of 5HT-1A receptor
    • takes 1-2 weeks for effect
    • tx anxiety when combined with SSRI, useful in alcoholics bc doesn't potentiate CNS depression of alcohol
  79. Propanolol
    tx autonomic effects of panic attacks or performanch anxiety, or to tx akathisia from typical antipsychotics
  80. Meds that may cause psychosis
    • sympathomimetics
    • analgesics
    • antibiotics (isoniazid)
    • anticholinergis
    • anticonvulsants
    • antihistamines
    • corticosteroids
    • anti-parkinsonian meds
    • esp: isoniazid, cimetidine, steroids
  81. Meds that may cause agitation/confusion/delerium
    • antipsychotics
    • antidepressants
    • antiarrhythmics
    • antineoplastics
    • corticosteroids
    • cardiac glycosides
    • esp: procainamide, quinidine, albuterol
    • NSAIDs
    • antiasthmatics
    • antibiotics
    • antihypertensives
    • antiparkinsonian mends
    • thyroid hormones
    • esp: albuterol, quinidine, procainamide, steroids
  82. Meds that may cause depression
    • antihypertensives
    • antiparkinsonian agents
    • corticosteroids
    • Ca channel blockers
    • NSAIDs
    • antibiotics
    • peptic ulcer drugs
    • esp: tetracycline, nifedipine, verapamil, cimetidine
  83. Meds that may cause anxiety
    • sympathomimetics
    • antiasthmatics
    • antiparkosonian meds
    • hypoglycemic
    • NSAIDs
    • thyroid hormones
    • esp: albuterol, steroids
  84. EPS
    • Parkonsonian - masklike face, cog-wheel rigidity, pill-rolling tremor
    • akathisia - restlessness and agitation
    • dystonia - sustained contraction of muscles of neck, tongue, eyes, diaphragm
    • Occur with high potency typical antipsychotics
    • tx: benztropine
  85. Major complications of TCAs
    • Cardiotoxicity
    • Convulsions
    • Coma

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