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TPX Neuro, Psych, & Sub abuse > Week 2: Schizophrenia, Depressive Disorders > Flashcards

Week 2: Schizophrenia, Depressive Disorders Flashcards

1
Q

Schizophrenia (SPh: my abbreviation)

A

chronic mental disorder that affects the way a person, thinks, acts, expresses emotions, and perceives reality

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2
Q

DSM 5 Criteria for SPh

A

must have 2 or more of the following, each present for a significant portion time during a 1 month period ( or less if successfully treated. at least one must be

1.delusions (fixed false belief)

  1. Hallucinations
  2. Disorganized speech (frequent derailment or incoherence).
  3. Grossly disorganized or catatonic behavior
  4. negative symptoms (i.e diminished emotional expression or avolition

*note: for significant portion of the time since onset of disturbance, level of functioning in one or more areas such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset

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3
Q

Schizoaffective disorder

A

uninterrupted period of illness during which there is a for mood epode (depression or manic)

delusions or hallucinations for 2 or more weeks in the absence of major mood episode during ht lifetime of the illness

SS that meet criteria for major mood episode are present for the majority of the total duration of the illness

disturbance not attributable to the elects of a substance (

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4
Q

Diagnosis of SPh

A
  1. complete patient history
  2. Mental Status Exam
    *Rating Scales: PANSS (Positive and negative Syndrome Scale)
    *Brief Psychiatric Rating Scale
  3. rule out other conditions (Physical, Labs) and co occurring disorders to establish correct diagnosis

Drugs:
*coticosteroids
*stimulants
*marijuana
*DA-Augmenting agents
*Hallucinogens

Diseases:
hiv/aids
EPILEPSY
cva/tbi
infections
Huntingtons disease

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5
Q

Diagnosis of SPh

A
  1. complete patient history
  2. Mental Status Exam
    *Rating Scales: PANSS (Positive and negative Syndrome Scale)
    *Brief Psychiatric Rating Scale
  3. rule out other conditions (Physical, Labs) and co occurring disorders to establish correct diagnosis

Drugs:
*coticosteroids
*stimulants
*marijuana
*DA-Augmenting agents
*Hallucinogens

Diseases:
hiv/aids
EPILEPSY
cva/tbi
infections
Huntingtons disease

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6
Q

Positive symptoms

A

Hallucinations

delusions (fixed false beliefs)

ideas of influence (actions are controlled by external forces

disorganized speech

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7
Q

negative symptoms

A

flat Affect ( (no emotional expression)

alogia (inabilit to carryon a logical conversation)

Anhedonia (inability to experience pleasure int things you used to (depression)

Avolition( lack of motivation )

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8
Q

Cognitive symptomsOF-Schizophrenia

A

impaired attention

impaired working memory

impaired executive function

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9
Q

SPh Treatment

Non Pharm

A

comprehensive psychosocial services are needed in addition to psychotropic medication management to achieve success such as…

psychosocial rehabilitation
pshycoeducation
Therapeutic Alliance
Active community treatment…etc.

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10
Q

What are among the most important factors in choosing an aNTIPSYCHOTIC AGENT for an individual patient

A
  1. SIDE EFECT PROFILES

others include….
*drug interactions
*family history
*adherance
*cost

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11
Q

General Approach to Choosing therapyFOR-SCHIZOPHRENIA

A
  1. SE and other considerations drive choice since differentiating APS based on efficacy is challenging
  2. optimize mono therapy(facilitate balance between efficacy and SE)
  3. Combo drug therapy reserved for treatment resistant pts. (lack of evidence supporting polyp harm, but risks well known, such as non adherence)
  4. Clozapine For treatment resistance or earlier use indicated for suicidal pts.
  5. long acting injectables for those who prefer them
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12
Q

Patho of Dopamine antagonism at different sites

A

Nigrostiratal
*function: extraparymidal system, movement
*effect: movement disorders

Mesolimbic:
function: emotional function, motivational behavior
effect: relief of psychosis

Mesocortical;
function:cognition, executive function
effect: Akathisia (inability to remain still), relief of psychosis

tuberoinfundibulnar
function: prolactin release
effect: increased prolactin

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13
Q

Treatment considerations for stabilization and maintenance-in-MDD

A

full efficacy could take 6-12 weeks or longer, 3-6 months for chronically ill pts.

partial responders would be evaluated for adherence

1st episode treatment:
12 months after remission, continue treatment, chronic lifelong therapy in most pts

treatment resistance: lack of improvement with at least 2 APS from diff classes at optimal dose for at least 8 weeks (some guidelines fewer)

rating scales to track progress

gradual discontinuation unless pt experiencing severe ADR

for switching agents, gradual taper off while other agent is slowly titrated up

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14
Q

treatment resistant-schizophrenia

A

lack of improvement with at least 2 APS from diff classes at optimal dose for at least 8 weeks (some guidelines fewer)

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15
Q

First Generation Antipsychotics
(Typical)

A

Chlorpromazine (Thorazine)
Fluphenazine (Prolixin)
Haloperidol (Haldol)
Perphenazine (Trilafon)
Thiordazine (Mellaril)
Thiothixene (Navane)

END-IN-ZINE-EXCEPT-HALOPERIDOL-AND-THIOTHIXENE

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16
Q

FGA class related side effects-and-BWW

A

extrapyrimdal side effects

Qtc prolongation

prolactin elevation

dermatologic

photosensitivity

blue-gray skin

orthostatic hypotension

altered thermoregulation

BBW: dementia related psychosis (i..e elderly pts with dementia

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17
Q

Black Box warning for FGA

A

Elderly patients with dementia related psychosis treated with FGA increased risk of death

DOES NOT MEAN IT CANNOT BE USED, careful monitoring must be done. benefit should outweigh the risk. can start with smaller dose

this BBW does not include the use of FGA in elderly pts with hx schizophrenia who was on long term treatment

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18
Q

Second Genration Antipsychotcs

A

Aripiprazole (Abilify)

Brexiprazole (Result)

Asenapine (Saphris)

Olanzipine (Zyprexa)

Cariprazine (Vrylar)

Clozapine (Clozaril, Fazaclo)

Iloperidone (Fanapt)

Lumateperone (Caplyta)

Lurasidone (Latuda)

Paliperidone (Invega)

Risperidone (Risperdal)

Ziprasidone (Geodon)

Quetiapine(Seroquel)

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19
Q

SGA (Atypicals) SE profile

A

Metabolic effects
*hypertriglyceriideemia
*hyperglycemia
*weight gain (waist circumference)

qtc prolongation

blood dyscrasia/neutropenia (most common offender clozapine)

decreased seizure threshold

anticholinergic effects (such as constipation(clozapine big offender)

sedation

prolactin elevation

opthalmic effects (quetiapine big offender)

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20
Q

Suggested Schizophrenia pharmacotherapy algorithm

A

Stage 1:
*Treatment naive: any antipsychotic except clozapine
(and olanzipine due to extensive SE profile)
*previously treated w. an APS, and treatment is being restarted : any app except clozapine or previous med that had poor efficacy or intolerance

…
NO IMPROVEMENT IN 2-4 WEEKS
…

Stage 2:
*inadequate response to above
*any psychotic (not used above) except clozapine
NOTE: Clozapine may be considered in severly suicial, EPS, hx violence or substance abuse

…
NO IMPROVEMENT IN 2-4 WEEKS
…

Stage 3:
*inadequate response to above
*considered treatment resistant
*Clozapine mono therapy

Stage 4:
* Inadequate response to above
*can use alternative antipsychotics, augmentation(mood stabilizers, APS polyp harm, etc.)

Note: A;WAYS VERIFY ADHERANCE. Use of Long acting injectables can be considered if poor adherence

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21
Q

treatment considerations for clozapine

A

extensive monitoring.

labs drawn

office visits once a week for first 6 mo.
every other week for next 6 months.

then once ammonite

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22
Q

Long acting Injectables treatment considerations

A
  • good for non adherent patients: HOWEVER, NON ADHERANCE SHOULD NOT BE DUE TO SE PROFILE

*stabilization on oral therapy best approach

oral challenge of the same drug before initiating LAI us best practice

most LAI do not take immediate effect, overlap is often needed, there are exceptions

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23
Q

FGA TREATMENT potencies

A

High
(Haloperidol:Haldol)
FLuphenazine ( Prolixin)

Moderte/ high
Thiothixine (Navane)
Trifluoperazine (Stelline)

Medium moderate
Lozapine
Molindone
Perphenazine

Low potency
Chlorpromazine
Thioridazine

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24
Q

what is the importance of potency

A

potency effects both EPS risk and anticholinergic risk

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25
Q

Trend of anticholinergic and EPS risk with High vs Low potencies

A

Low potency:
increased anticholinergic risk
decreased EPS risk

High potency:
increased EPS risk
decreased anticholinergic risk

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26
Q

Aripiprazole (Abilify)

Unique MOA:
Generation:
Dosage form Availability and notes

A

Unique MOA: partial D2 and 5HT1A agonist

Generation:second generation

Dosage form Availability:
PO tab
LAI: Maintena: 14 day overlap
Aristada: 21 day overlap
Mycite

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27
Q

Apripiprazole (abilify clinical pearls

A

IMPULSIVITY: MUST COUNSEL

little weight gain

may cause insomnia, akathisia, restlessness,

pts and caregivers should be alert for uncontrollable and excessive urges

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28
Q

Asenapine (Saphris)
Unique MOA:
Generation:
Dosage form Availability and notes

A

Unique MOA: high affinity antagonism D2 sand 5HT2a

Generation: SECOND GENERATION

Dosage form Availability and notes;
Topical Patch: wear for 24hours upper arm back, abdomen, or hip. can shower but cannot win, don’t apply heat

Sublingual tablet: must counsel cannot eat or drink for 10 min

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29
Q

Asenapine (Saphris)

Clinical Pearls

A

NEW TOPICAL PATCH AVAILABLE

among least anticholinergic and less sedating

do not eat or drink after SL dose for 10 min

high risk of QTC prolongation.

CI: severe hepatic disease

topical patch may cause skin irritation

anaphylaxis may occur after single dose

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30
Q

Brexipprazole (Rexulti)
Unique MOA:
Generation:
Dosage form Availability and notes

A

Unique MOA: partial 5HT1A and D2 receptor agonist and 5HT2A receptor antagonist

Generation: second generation

Dosage form Availability and notes: oral tab only

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31
Q

Brexipiprazole Clinical pearls

A

IMPULSIVITY

dose related Akathisia,

long half life (91 hours)

Fewer metabolic changes than others

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32
Q

Clozapine (Clozaril)
Unique MOA:
Generation:
Dosage form Availability and notes

A

Unique MOA: antagonist of D1 ad D4(D2 less, 5-HT2 and others, M4 for agonist

Generation: second

Dosage form Availability and notes:
PO tablet
ODT (oral disintegrating tablet)
Oral solution:
ODT and oral EXPENSIVE. NOT usually covered by insurance

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33
Q

Clozapine clinical pearls

A

gold standard for treatment resistant schizophrenia or earlier if pt has high suicidal risk

BLOOD DYSCRASIA

HIGH METABOLIC RISK

CONSTIPATION-can lead to bowel obstruction. can lead to hospitalization or death.

DDI: Clozapine/ olanzapine use with benzos(especially lorazepam IM)

monitor ANC(absolute neutrophil count) levels as per REMS monitoring

REMS monitoring program
first 6 mo. q week

every other week for next 6 mo.

every month thereafter

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34
Q

Illoperidone

Unique MOA:
Generation:
Dosage form Availability and notes

A

Unique MOA: high affinity D2, D3, and 5ht2a

Generation: SECOND

Dosage form Availability and notes

PO

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35
Q

Illoperidone (Fanapt)

clinical pearls

A

ORTHOSTATIC HYPOTENTION. slow titration needed

no notable prolactin elevation reported

qtc prolongation

LLOWWWWW-BP

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36
Q

Lorasidone (Latuda)

Unique MOA:
Generation:
metabolism
Dosage form Availability and notes

A

Unique MOA: antan: D2 and 5HT2a

Generation:second

metabolism: cyp3a4

Dosage form Availability and notes: PO

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37
Q

Lorasidone (Latuda)

clinical Pearls

A

DO NOT USE WITH STRONG CYP3A4 inhibitors/inducer

alsoindicated for use in adolescents

indicated for depression associated w. bipolar disorder or in adolescents with major depressive episodes

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38
Q

Lumateperone (Caplyta)

Unique MOA:
Generation:
Dosage form Availability and notes

A

Unique MOA:
Generation: second

Dosage form Availability and notes:
oral capsule

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39
Q

Lumateperone Clinical Pearls

A

DO NOT USE WHEN BREASTFEEDING

may impair fertility especial if taken in 3rd trimester

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40
Q

Olanzipine (Zyprexa)

Unique MOA:
Generation:
Dosage form Availability and notes

A

Unique MOA:

Generation: SECOND

Dosage form Availability and notes
PO,
ODT
short acting IM
LAI (Relprevv): requires 3 hr observation period due to post injection delirium and sedation

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41
Q

Olanzipine (zyprexa)Treatment-considerations

A

can cause DRESS

METABOLIC ISSUES

post injection delirium-PDSS REMS PROGRAM FOR LAI

Qtc-risks

sedation

anticholinergic

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42
Q

Paliperidone (Invega)
Unique MOA:
Generation:
Dosage form Availability and notes

A

Unique MOA:
Generation:
Dosage form Availability and notes:
PO: OROS TABLET,LAI

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43
Q

Paliperidone clinical pearls

A

EPS
Prolactin
No PO overlap required for LAI

med shell may be seen in stool

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44
Q

Pimavanersin (Nuplazid)

Unique MOA:
Generation:
Dosage form Availability and notes

A

Unique MOA: TARGETS SERETONIN

Generation:
Dosage form Availability and notes

45
Q

Pimavanserin (Nuplazid)-Considerations

A

NO DOPAMINE

indicated for hallucination and delusions associated with Parkinson’s disease psychosis

46
Q

Quetiapineclinical pearls

A

sedation (often used as a sleep aide)

may be misused by pts.

anticholinergic effects

cataracts

47
Q

Risperidone
Unique MOA:
Generation:
Dosage form Availability and notes

A

Unique MOA:
Generation:
Dosage form Availability and notes:
tab
odt
LAI (IM ORSQ)
SQ uncomfortable, administer carefully, if use SQ, don’t touch or rub

48
Q

Risperidone clinical pearls

A

EPS

PROLCTIN

49
Q

Ziprasidone
Unique MOA:
Generation:
Dosage form Availability and notes

A

Unique MOA:
Generation:-second
Dosage form Availability and notes-oral-tab
SAI-requires,reconstitution

50
Q

Ziprasidone Clinical Perals

A

CI in those w. increased risk for QTc prolongation

DRESS

51
Q

Special populations consideration-for-schizophrenia-treatment

A

elderly: start low, use cation for renal or hepatic impairment

Pregnancy/ lactation: lowest effective dose, higher doses for clozapine and olanzapine

Peds: may be more sensitive to EPS and metabolic effects

52
Q

PED aprovals for Schizophrenia

also-BBW

A

Aripiprazole
Lurasidone
Olanzapine
Paliperidone
Quetiapine
Risperidone

all of these also indicated for depression

BBW: increased suicidal thoughts in children, adolescents and young adults

53
Q

Long acting Injectables

A

first gen: fluphenazine
haloperidol

second gen:
aripiprazole
olanzapine
Risperiodne
Paliperidone

54
Q

Acute dystonias

Signs
high risk APs
Treatments

A

painful prolonged muscle contractions

highriskAP:high,potency,or,FGA,

treatment:
A)anticholinergics(benzotropin,diphenhydramine,trihexylphenydil,biperidin)
b)IM-BZDS
c)decrease-or-DC-offending-agent

55
Q

pseudoparkinsonism
Signs
high risk APs
Treatments

A

bradikinesia, tremor, pill rolling, cogwheel rigidity

high-risk-APS:high-potency-or-FGA

Treatments:-
a)anticholinergics-
b)d/c-offending-agent

56
Q

akathisia

Signs
high risk APs
Treatments

A

restlessness,pacing,shuffling,compulsion-to-stay-in-motion.Subjective-feelings-of-distress

high-risk-APS:high-potency,FGA-aripiprazole,risperidone

treatment:-Beta-blockers,D/C-offending-agent

57
Q

tardive dyskenisia

Signs
high risk APs
Treatments

A

tongue thrusting

chewing

lip smacking

grimacing

highriskAPS:high-potency-or-high-dose-FGA

treatment:
a)prevention
b)d/c-offending-agent
c)anticholinergics-MASKKK-SYMPTOMS

58
Q

Major Depressive Disorder Etiology

A

unknown and complicated

but common consensus that there are altered neurotransmitters

59
Q

MDD Oresentation

A

initial symptoms develop over days to weeks

SS of anxiety often appeared

if left untreated, can last 4 months or more

symptoms vary person to person

repeat episodes are common

medical disorders must be ruled out

60
Q

MDD Emotional symptoms

A

diminished capacity to experience pleasure in activities that once brought them pleasure

anxiety symptoms

psychotic features , but may require hospitalization and stabilization with APS

61
Q

MDD physical presentation

A

psychomotor retardation (sow movement and speech)

chronic fatigue, pain

sleep disorders like insomnia,

changes in appetitie

62
Q

MDD physical presentation

A

psychomotor retardation (sow movement and speech)

chronic fatigue, pain

sleep disorders like insomnia,

changes in appetitie

watch for residual symptoms

63
Q

Major Depressive Disorder

DSM5-criteria

A

depressed mood most of the day , everyday

diminished interest or pleasure

significant weightloss

insomnia or hypersomnia

phychomotor agitation

fatugue or loss of energy

gelling of worthlessness or excessive inappropriate guilt

diminished ability to think or concentrate

recurrent thoughts of death
(suicidal ideation, w. or w.o a plan)

64
Q

FACTORSTHAT-INCRease-risks of suicide

A

male
single/ living alone
scribing feelings of hopelessness/ spice plans

substance abuse

unusual behavior-missed work, giving things away

during initial stages of medication therapy

65
Q

BBW for antidepressants

what to do

A

increased risk of sucide in children, adolescents and young adults.

what to do? counsel patients
possible ADRs could include agitation

deal with subject of suicide directly

get help immediately

66
Q

Frist Line therapy for Depression

A

Selective Seretonin Reuptake Inhibitors (SSRI’s)

Selective Serotonin and Norepinephrine Reuptake Inhibitors (SNRI)

buproprion

mirtazipine

Vortioxetine

67
Q

antidepressive agent classes

A

SSRI

SNRI

Seretonin modulators

Triciclyc antidepressants nd other norepinephrine inhibitors

Monoamine Oxidase Inhibits (MAO-I)

Miscellaneous

68
Q

Treatment considerations for MDD

A
  • all antidepressants equally efficacious, so must consider other factor such as se PROFILEs for treatment options

*black box warning for ages up to 24

  • carefully assess for possible BIPOLAR disorder. monotherapy antidepressive treatment in bipolar disorder could induce manic/mixed episode
69
Q

General MDD Treatment Approach

A
  • thorough initial evaluation and med review

first line agents: SSRI’s, SNRI’s bupropion, mirtazipine, vortioxetine

if response to treatment ( 50% reduction of symptoms) after 4 weeks, AD @optimal doseshould be continued and evaluated at 6, 8, and 12 weeks

if symptoms persist after an adequate trial (4-8 weeks), guidelines suggest switching to alternative AD or AUGMENTING with an AD with dif MOA, SGA or psychotherapy

70
Q

pharmacotherapy for MDD approach

A

antidepressant pharmacotherapy initiated

…
AFTER 1-4 WEEKS
…

Partial or no response:
*assess adherance
*increase dose if clinically indicated
*assess issued with toldrability
*for sever symptom, consider etc

Full response:
maintain treatment if no issues with tolerability

…
AFTER 4-8 WEEKS
…
partial or no response:
*increase dose OR
*change or augment AD OR
consider ECT
Full response:
*move to continuation phase

71
Q

pharmacotherapy for MDD approach

A

antidepressant pharmacotherapy initiated

…
AFTER 1-4 WEEKS
…

Partial or no response:
*assess adherance
*increase dose if clinically indicated
*assess issued with toldrability
*for sever symptom, consider etc

Full response:
maintain treatment if no issues with tolerability

…
AFTER 4-8 WEEKS
…
partial or no response:
*increase dose OR
*change or augment AD OR
consider ECT
Full response:
*move to continuation phase

72
Q

Phases of therapy for MDD

Acute phase

Length:
Goal:

A

Phases of therapy for MDD

Acute phase

Length: 2-3 months
Goal: remission (absence of symptoms)

73
Q

Phases of therapy for MDD

Remission phase

Length:
Goal:

A

Phases of therapy for MDD

Length: 4-9 months
Goal: prevent relapse or residual symptoms

74
Q

Phases of therapy for MDD

if indefinite or lifelong

Length:
Goal:

A

Phases of therapy for MDD

Length:indefinite/ lifelong
Goal: prevent recurrence

75
Q

Phases of therapy for MDD

if indefinite or lifelong

Length:
Goal:

A

Phases of therapy for MDD

Length:indefinite/ lifelong
Goal: prevent recurrence

76
Q

Tratment expectationsfor-MDD

Week 1
Week 1-3

Weeks 2-4

A

Week 1: decreased anxiety

improved sleep

improved appetite

Week 2: increased activity, sex drive, self care, and memory

thinking and movements become more normal

sleeping and eating become more normal

weeks 2-4
relief of depressed mood
thoughts of suicide begin to subside

77
Q

Tratment expectations

Week 1
Week 1-3

Weeks 2-4

A

Week 1: decreased anxiety

improved sleep

improved appetite

Week 2: increased activity, sex drive, self care, and memory

thinking and movements become more normal

sleeping and eating become more normal

weeks 2-4
relief of depressed mood
thoughts of suicide begin to subside

78
Q

Pt education for SSRIs

A

timeline symptoms

Discontinuation Syndrome: FINISH: flu like symptoms, insomnia, nausea, imbalance , sensory disturbances, hyper arrousal. also electric shock sensations

must taper if possible, except for prozac due t o long t1/2

may be initial anxiety so start low and go slow with dosing. insomnia, headache are common initial adverse effects

hyponatremia and SIADH (rare). monitor for increased lethargy mentallerl status

insomnia or sedation: take in morning or switch to another with less insomnia .

increased-bleeding-for-pts-on-nsaids,ANTI-PLATELETS,and-anticoagulants

sexual dysfunction: may need to switch to another agent such as bupropion

Seretonin syndrome counsel on symptoms:
mental status changes
autonomic disability
neuromuscular abnormality
GI symptoms

79
Q

Seretonin syndrome ****

A

SS: BASICALLY-HYPERACTIVITY

agitation
restlessness
confusion
diarrhea
sweating
tachycardia
HTN
dilated pupild
loss of muscle coordination
muscle rigidity

can occur if taking multiple agents with serotonin

such as…
triptan migraine agents
pain medication such as fentanyl and tramadol
nausea products such as zofran(ondansetron) and reglan(metoclopramide)
Busprione
Linezolid
Ritonavir

avoid drugs that impair the metabolism of serotonin

80
Q

SSRI DDI

A

Qtc prolongation with concaminant meds
increased risk of bleeding with Nsaids, anti platelets or anticoagulants

81
Q

SSRI considerations

A

discontinuation syndrome

abnormal bleeding due to 5HT reuptake on patelets

hyponatremia

seretonin syndrome

potential cognitive and motor impairment.

degrees of Qtc prolongation

require caution/ dose modifications with hepatic impairment

82
Q

SSRI
Special considerations drugs specific

Citalopram(Celexa)

A

QTc prolongation

MDD 20 mg for
*elderly pts.
CYP2C19
hepatic repairmen

83
Q

SSRI
Special considerations drugs specific

Escitalopram (Lexapro)

A

MDD 10 mg for hepatic empairment

also-used-for-GAD

84
Q

SSRI
Special considerations drugs specific

FLuvoxamine

A

one of most sedating

NOT-USED-FOR-MDD.JUST-APPROVED-FOR-OCD

85
Q

SSRI
Special considerations drugs specific
Fluoxetine

A

Once weekly dosing

86
Q

SSRI
Special considerations drugs specific

Paroxetine

A

avoid in pregnancy
short half life

87
Q

SSRI
Special considerations drugs specific

Sertraline

A

concentrate can be mixed WITH only WATER, GINGERALE, LEMON/LIME SODA, LEMonade, or orange juice

88
Q

SNRI considerations

A

abnormal bleeding due to 5HT reuptake on platelets

potential for increased activation of mania

elevated BP
hyponatremia and seretonin syndrome

discontinuation syndrome

tend to be more energy boosting than any other AD

89
Q

SNRI
Special considerations drugs specific

Desvenlafaxine

A

3a4 interactions, don’t crush or chew
hyperlipidemia reported
eosinophilic pneumonia

90
Q

SNRI
Special considerations drugs specific

Venlafaxine

A

Give with food
2d6 Interactions
BP changes seen at higher doses and Eosinophillic pneumonia reported
Dose reductions up to 50% for mild to moderate hepatic or renal impairment

91
Q

SNRI
Special considerations drugs specific

Duloxetine(cymbalta)

A

avoid use in pts w. liver dysfunction or ESRD

avoid ETOH

1a@ and 2D6 interactions: . do not crush or chew

potential hepatotoxicity

urinary retention

HYPOTENSION reported

less insomnia report than other SNRIs

92
Q

SNRI
Special considerations drugs specific

Levomilnacipran

A

Urninary retention

increased heart rate

93
Q

Tricyclic Antidepressants special considerations

A

anticholinergic and cardiovascular events

CV ventricular tachycardia and heart block (Qt prolongation

AE: Weight gain
sexual dysfunction
drug interaction

baseline EKG

TCA withdrawal syndrome (insomnia, sweating, abdominal pain, diarrhea)

94
Q

examples of TCAs

A

amitriptyline

amoxapine

clamipramine

desipramine

Doxepin

Imipramine

Notriptyline

Maprotiline

95
Q

Monoamine oxidase Inhibitors MAO-I considerations

A
  • after stopping an interacting medication, must wait 4-5 t1/2 before starting MAO-I

fluoxetine(>5 weeks) and vortioxetine(3 weeks) have longest t-1/2 of the SSRi’s so need to wait >2 weeks before starting MAO-I

dietary restrictions of tyramine containing foods:

aged products, smoked and pickled products, yeast extracts- can cause hypertensive crisis. MONITOR BP

other SE: postural hypotension, diarrhea, anticholinergic drying effects, sexual dysfunction

typical REserved for last resort

96
Q

MAO-I DDI

A

hypertensive crisis
amphetamines
decongestants
methylphenidate

seretonin syndrome with dextromethorphan, etc.

97
Q

MAO-I inhibitor examples

A

Phenelzine

Selegiline

Tranlycypromine

98
Q

Seretonin Modulators

A

ex: Trazadone, Nefazadone

mixed 5HT

Nefazedone
hepatic BBW: life threatening hepatic failure have been reported.

TRazadone:
sedating
risk of priapism

99
Q

Vortioxetine (tritellix) cosiderations

A

RAPID ONSET OF ACTION
IMPROVED TOLERABILITY-COGNITIVE EFFECTS

100
Q

Buproprion considerations

A

lowers seizures threshold
caution in pts with eating disorders or alcohol use disorders

CI: anorexia

101
Q

Mirtazipine considerations

A

sedating
weight gain
cholesterol elevation

102
Q

Spravato (Esketamine) treatment connsiderations

A

treatment resistant depression

failure of atleast2 other drugs
NMDA receptor antagonist

designed to be used in combo with po antidepressant

CI in pts with hx of aneurysmal vascular disease or intracranial hemmorhae

increase BP, cognitive impairment, impaired ability to drive or operate machinery

AE: dissociation, dizziness, N/V, sedation, vertigo, hypoeshesia, anxiety, lethargy, increased bp, feeling drunk

BBW: sedation, dissociation, abuse and misuse, suicidal thoughts and behaviors

must be administered by health care professional and must be monitored for 2 hours after admin.

103
Q

Brexanolone

A

post partum depression

apart of REMS . monitor pulse ox

104
Q

recommending an optimal therapeutic regimen-for-MDD

A

consider pt preferences

multiple use of single agents

105
Q

agents to avoids for certain conditions

A

seizure disorders: bupropion

substance abuse: benzos

cardiac complications (TCA’s

gi bleeding and anticoagulation: SSRIs

106
Q

Treatment Resistance depression

A

non responsive to 2 separate trip of ad WITH ADEQUATE DOSE AND DURATION (4weeks to start seeing effects, 6-8 weeks for full effects

what to do; switch to an alternative . can cross titrate od d/c and start

107
Q

Augmentation agents for MDD

A

lithium
triiodothyronine
SGA(aripiprazole,brexipiprazole,eutiapine,combo-olanzapine/fluoxetine
buspirone
stimulant

108
Q

Neuroleptic malignant syndrome (NMS)

cause
ss
trtmt

A

dopamine antagonists
onset variable 1-2 days
htn
hyperthermia
diaphoresis
pallor
LEAD PPIPE RIGIDITY
HYPOREFLEXIA
NORMAL PUPILS
NORMAL OR DECREASED BOWELS
confusion
oincreased muscle tone/ rigidity
increased WBC, CPK, LFTs

cause: high potency APS, including clozapine

treatment:
*d/c offending agent
*can rechallenge. acceptable in most w. observation for atleast 2 weeks
or choose diff SGA or low potency FGA, slow dose titration

109
Q

Seretonin syndrome

A

seretonin agents
onset variable
htn
hyperthermia
hypersalivation
diaphoresis
increased tone in lower extremities
HYPERREFLEXIA
DILATED PUPILS
HYPERACTIVE BOWEL SOUNDS

TPX Neuro, Psych, & Sub abuse (7 decks)

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