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Psychiatry clerkship > Psychopharmacology > Flashcards

Psychopharmacology Flashcards

1
Q

HAM side effects: what are they and what drugs cause them?

A

anti-Histamine: sedation, weight gain
antiAdrenergic: hypotension
anti-Muscarinic: dry mouth, blurred vision, urinary retention, constipation
Caused by low-potency antipsychotics and TCAs

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2
Q

Serotonin syndrome features

A

Confusion, flushing, hyperreflexia/myoclonus, hyperthermia, rhabdo, renal failure, death

Caused by SSRI + MAOI, or other combo that causes too much serotonin release

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3
Q

Which antidepressants can cause hypertensive crisis and when does this occur?

A

MAOIs when combined with tyramine-containing food (red wine, cheese, chicken liver, cured meats) or sympathomimetics

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4
Q

Features of drug-induced parkinsonism

A

Masklike face, cogwheeling, bradykinesia, pill-rolling tremor

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5
Q

Features of drug-induced akathisia

A

Restlessness, need to move, agitation

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6
Q

Features of drug-induced dystonia

A

sustained, painful contraction of muscles (neck, tongue, eyes, diaphragm, LARYNX LOOK OUT)

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7
Q

Which psych drugs cause hyperprolactinemia?

A

High potency typical antipsychotics, also risperidone

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8
Q

Features of drug-induced tardive dyskinesia

A

Choreoathetoid movements, usually of mouth/tongue
Occurs after years of antipsychotic use
Usually irreversible

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9
Q

Features of neuroleptic malignant syndrome

A

Mental status change, fever, tachycardia, rigidity (lead pipe) HTN, tremor, high CPK
MEDICAL EMERGENCY

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10
Q

Important CYP450 inducers

A

Tobacco
Carbamazepine
Barbiturates
St. John’s wort

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11
Q

Important CYP450 inhibitors

A 
Fluvoxamine
Fluoxetine
Paroxetine
Duloxetine
Sertraline
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12
Q

Features of fluoxetine

A

PROZAC

  • Longest half-life (no need to taper)
  • Safe in pregnancy, okay for kids
  • Can elevate levels of antipsychotics
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13
Q

Features of sertraline

A

ZOLOFT

  • Higher risk for GI upset
  • Few drug interactions
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14
Q

Features of paroxetine

A

PAXIL

  • Highly protein bound
  • Anticholinergic effects
  • Short half-life (withdrawal phenomena if not taken consistently)
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15
Q

Features of fluvoxamine

A

LUVOX

  • Approved only for OCD
  • Drug interactions 2/2 CYP inhibition
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16
Q

Features of citalopram

A

CELEXA
Fewest drug-drug interactions
Dose-dependent QTc prolongation

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17
Q

Features of escitalopram

A

LEXAPRO

  • Levo-enantiomer of citalopram, fewer side effects
  • Dose-dependent QTc prolongation
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18
Q

Common side effects of SSRIs that usually resolve within days to weeks of starting

A

GI upset
Insomnia, vivid dreams
Headache
Anorexia and weight loss

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19
Q

Other, more lasting side effects of SSRIs

A 
Sexual dysfunction
Restlessness, akathisia-like state
Serotonin syndrome (if combined with other serotonergic meds like triptans, MAOIs, etc)
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20
Q

Features of venlafaxine

A

EFFEXOR, an SNRI
Used for depression, anxiety disorders, neuopathic pain
Similar side effects to SSRIs, + potential to increase BP

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21
Q

Features of duloxetine

A

CYMBALTA, an SNRI
Used for depression, neuropathic pain, fibromyalgia
Side effects similar to SSRIs + dry mouth, constipation
Potential for hepatotoxicity if using EtOH

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22
Q

Features and mechanism of bupropion

A

WELLBUTRIN
Dopamine and norepinephrine reuptake inhibitor
Used for depression, smoking cessation
Lack of sexual side effects, can increase anxiety and seizure risk
Contraindications: h/o seizures, eating disorder, concomittant MAOI use

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23
Q

Features of trazodone and nefazodone

A

Serotonin receptor agonists and antagonists
Used for depression, depression with anxiety, depression with insomnia
Side effects: nausea, dizziness, orthostatic hypotension, arrhythmias, sedation, priapism
Nefazodone: black box warning for liver failure

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24
Q

Features and mechanism of mirtazapine

A

REMERON
Used for depression, especially in patients with weight loss or insomnia
Side effects: sedation, weight gain, dizziness, tremor, dry mouth, constipation, agranulocytosis

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25
Q

How do TCAs work?

A

Inhibit reuptake of norepinephrine and serotonin

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26
Q

Why are TCAs not first-line therapy for depression?

A

Higher incidence of side effects
Titration of dosing required
Lethal in overdose

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27
Q

Amitriptyline

A

ELAVIL

Useful in chronic pain, migraines, and insomnia

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28
Q

Imipramine

A

TOFRANIL
Useful in enuresis (bed wetting) and panic disorder
Has an IM form

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29
Q

Clomipramine

A

Most serotonin-specific TCA

Used in treatment of OCD

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30
Q

Doxepin

A

Useful in treating chronic pain

Used as sleep aid at low doses

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31
Q

Nortryptyline

A

Least likely TCA to cause orthostatic hypotension

Useful in chronic pain

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32
Q

Desipramine

A

More activating/less sedating

Least anticholinergic TCA

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33
Q

Treatment for TCA overdose

A

IV NaHCO3

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34
Q

Side effects of TCAs

A

Antihistamine: sedation + weight gain
Antiadrenergic: CV side effects including OH, tachycardia, arrhythmias, ECG changes
Antimuscarinic: Dry mouth, constipation, urinary retention, blurred vision, tachycardia, exacerbation of glaucoma

35
Q

Indications for MAOIs

What are the MAOIs?

A

Refractory depression, depression with atypical features, and refractory anxiety disorders
Phenelzine, tranylcypromine, and isocarboxazid

36
Q

Side effects of MAOIs

A 
Serotonin syndrome with taken with SSRIs or other serotonergic drugs
Hypertensive crisis if taken with tyramine-rich foods
OH
Drowsiness
Weight gain
Sexual dysfunction
Dry mouth
Sleep changes
Liver toxiciy, seizures, edema (rare)
37
Q

Indications for mood stabilizers

A

Acute mania and prevention of relapse manic episodes in BPAD
Augmentation of antidepressants in MDD
Potentiation of antipsychotics in patients with schizophrenia and schizoaffective disorder
Treatment of aggression and impulsivity
Enhancement of abstinence in treatment of alcoholism

38
Q

What are the mood stabilizers?

A

Lithium and anti-convulsants (valproate, lamotrigine, and carbamazepine)

39
Q

Indications for lithium

A

DOC for acute mania and maintenance in bipolar

Cyclothymic disorder and unipolar depression

40
Q

Metabolism of lithium (and clinical relevance of this)

A

Metabolized renally, so may need to adjust doses in patients with renal dysfunction

41
Q

Tests you need to get before starting lithium

A

ECG, BMP, thyroid function tests, CBC, and pregnancy test

42
Q

Onset of action of lithium

A

5-7 days

Check blood levels after 5 days after starting and then every 2-3 days until therapeutic

43
Q

Therapeutic, toxic, and lethal ranges of lithium

A

Therapeutic: 0.6-1.2 (can still have side effects)
Toxic: >1.5
Potentially lethal: 2.0

44
Q

Presentation of lithium toxicity

A

AMS, coarse tremors, convulsions, delirium, coma, death

45
Q

Regular labs to monitor for patients on lithium

A

Lithium levels
TSH
Kidney function

46
Q

Other side effects of lithium

A 
Fine tremor
Nephrogenic DI
GI upset
Weight gain
Sedation
Goiter and hypothyroidism
ECG changes
Benign leukocytosis
Ebstein anomaly in babies
47
Q

Psychiatric indications for carbamazepine

A

Mania with mixed features

Rapid-cycling bipolar disorder

48
Q

Labs to get before starting carbamazepine

A

CBC and LFTs

49
Q

Side effects of carbamazepine

A

Most common are GI upset and CNS (drowsiness, ataxia, sedation, confusion)
Possible skin rash –> Stevens-Johnson syndrome
Leukopenia, hyponatremia, aplastic anemia, thrombocytopenia, and agranulocytosis
Transaminitis/hepatitis
TERATOGENIC (neural tube defects)
CYP450 interactions

50
Q

Features of carbamazepine toxicity

A

Confusion, stupor, restlessness, ataxia, tremor, nystagmus, twitching, vomiting

51
Q

Factors that increase lithium levels

A 
NSAIDs
Aspirin
Thiazide diuretics
Dehydration
Salt deprivation
Sweating
Decreased renal function
52
Q

Indications for valproic acid

A

Acute mania, mania with mixed features, rapid cycling

53
Q

Considerations for using valproic acid

A

Need to monitor CBCs and LFTs
Should check drug level 4-5 days after starting, therapeutic range is 50-150ug/mL
Contraindicated in pregnancy (neural tube defects)

54
Q

Indications for lamotrigine

A

Bipolar depression, not as effective in acute mania or prevention of mania

55
Q

Considerations for using lamotrigine

A

Common side effects: dizziness, sedation, HA, ataxia

Risk of Stevens-Johnson syndrome in 0.1% of pts

56
Q

Interaction between valproate and lamotrigine

A

Valproate will increase lamotrigine levels

Lamotrigine will decrease valproate levels

57
Q

Difference in mechanism between typical and atypical antipsychotics

A 
Typical = block dopamine D2 receptors
Atypical = block dopamine D2 and serotonin 2A receptors
58
Q

How are the typical antipsychotics divided?

A

Low potency and high potency typical antipsychotics

59
Q

Features of low-potency typical antipsychotics

A

Lower affinity for dopamine receptors –> need higher doses

Higher incidence of HAM side effects, lower incidence of EPS

60
Q

What are the low-potency typical antipsychotics?

A

Chlorpromazine (can cause OH, skin discoloration, photosensitivity)
Thioridazine (associated with retinal deposits)

61
Q

What are the high-potency typical antipsychotics?

A

Haloperidol
Fluphenazine
Trifluoperazine
Pimozide

62
Q

Features of high-potency typical antipsychotics?

A

Higher affinity for dopamine receptors

Less sedating, less OH, less anticholinergic effects compared to low-potency

63
Q

Typical antipsychotics block dopamine D2 receptors. Depending on which neural pathway dopamine is blocked in, explain the effects of these drugs

A

DA blockade in mesolimbic pathway –> improvement in positive symptoms of schizophrenia
DA blockade in nigrostriatal pathway –> EPS
DA blockade in tuberoinfundibular pathway –> hyperprolactinemia

64
Q

What are the different types of extrapyramidal signs?

A

Akathisia
Parkinsonism
Dystonia
Tardive dyskinesia

65
Q

Treatments for the different types of extrapyramidal signs

A

Akathisia: dose reduction, Beta-blockers, benzos
Parkinsonism and dystonia: dose reduction, benztropine or diphenydramine, maybe amantadine
Tardive dyskinesia: Usually irreversable; discontinue current antipsychotic and try a different one

66
Q

Risk of tardive dyskinesia

A

5% chance each year treated with typical antipsychotic

Clozapine less likely to cause TD

67
Q

Uses for atypical antipsychotics

A

Schizophrenia
Acute mania, bipolar disorder, unipolar depression
Borderline PD, PTSD, tic disorders

68
Q

Features/side-effects of clozapine

A

Less likely to cause TD
More effective in treatment-resistant schizophrenia
More anticholinergic effects than other antipsychotics
Risk of agranulocytosis, seizures, myocarditis
Increased salivation and tachycardia

69
Q

Features/side-effects of risperidone

A

Can cause hyperprolactinemia
Orthostatic hypotension and reflex tachycardia
Comes in long acting injectable (LAI) form

70
Q

Features/side-effects of quetiapine

A

Low risk of EPS

Sedation and OH

71
Q

Common side-effects of olanzapine

A

Weight gain

Sedation

72
Q

Features/side-effects of ziprasidone

A

Less likely to cause weight gain
QT prolongation
Must be taken with food

73
Q

Features/side-effects of aripiprazole

A

Partial agonist of D2 receptors
More activating, less sedating
Less potential for weight gain

74
Q

Features of lurasidone

A

Must be taken with food

Used in bipolar depression

75
Q

General side effects of atypical antipsychotics

A

Metabolic syndrome (weight gain, HLD, insulin resistance)
–monitor with baseline weight, waist circ, BP, fasting glucose, fasting lipids
HAM side effects
Elevated LFTs (should monitor yearly)
QTc prolongation

76
Q

Indications for benzos

A

Anxiety, akathisia, agitation, insomnia, panic disorder, EtOH or sedative-hypnotic withdrawal…

77
Q

What are the long-acting benzos (half-life >20hrs)?

A

Diazepam (valium)

Clonazepam (klonopin)

78
Q

What are the intermediate-acting (half-life 6-20hrs) benzos?

A

Alprazolam (Xanax)
Lorazepam (Ativan)
Oxazepam (Serax)
Temazepam (Restoril)

79
Q

What are the short-acting benzos?

A

Triazolam (Halcion)

Midazolam (Versed)

80
Q

Features of diazepam

A

Rapid onset, long half-life
Used for EtOH detox, seizures
Effective for muscle spasm

81
Q

Features of clonazepam

A

Treatment of anxiety, including panic attacks

Avoid with renal dysfunction

82
Q

Features of alprazolam

A

Treatment of anxiety, including panic attacks

Higher abuse potential

83
Q

Features of lorazepam

A

Treatment of panic attacks, EtOH detox, agitation

Psychiatry clerkship (11 decks)

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