Block 2 Flashcards
(209 cards)
1
Q
RF of MS, location
A
> 37th parallel, most common in scandinavian ancestry
2
Q
Proposed etiology of MS?
A
Attack of self-myelin or self-oligodendrocyte antigens
CD4 cells activated in periphery and recognized myelin basic protein
Activated T cells cross BBB and bind to HLA class II molecules of myelin
3
Q
Where are the lesions found in MS?
A
Brain, spinal cord, and optic nerves via MRI
4
Q
What are the T cell subtypes found in MS?
A
Th1 (pro-inflamm)
Th2 (protective)
Th17 (pro-inflamm)
Treg (protective prevention)
5
Q
Which matter of the brain can be affected by MS?
A
Both white and grey matter
6
Q
What is relapsing remitting type MS (RRMS)?
A
At onset of new attack that lasts 24hrs, separated by other sx by 30 days followed by remission
7
Q
First attack of MS is called?
A
Clinically isolated syndrome
8
Q
What is secondary progressive type MS?
A
20% of RRMS pt enter a progressive phase where attacks/remissions are difficult to identify
9
Q
What is primary progressive type MS (PPMS)?
A
Occurs in 15% of MS (versus 85 in RRMS)
Slow onset w/o attacks and worsens over time
Increased suicide rate
10
Q
What is the standard tool for MS diagnosis and progression evaluation?
A
MRI
11
Q
What are some favorable/unfavorable prognostic indicators for MS?
A
Favorable - <40, female, optic neuritis or sensory sx
Unfavorable - >40, male, motor/cerebellar sx
12
Q
How do you treat acute RRMS?
A
Acute attack (optic nerve damage)
Tx w/ IV solu-medrol, if they dont respond give plasma exchange
13
Q
How do you treat RRMS (not acute)?
A
BARPE
Betaseron (1b) - non-glycosylated
Avanex (1a) - glycosylated
Rebif (1a) - glycosylated
Plegridy (1a) - pegylated
Extavia (1b) - non-glycosylated
14
Q
Betaseron AE?
A
Flu-like sx, SOB, tachycardia, depression
15
Q
Betaseron, Avanex, Rebif, Plegridy are limited due to what?
A
Neutralizing AB (not dose dependent, but rather time); increases at 6 months, but can develop as early as 3 months
MIGHT be due to number of injections (lower inj = better?)
16
Q
Glatiramer (Copaxone) aka Copolymer 1 MOA?
A
Suppresses T cell activation and possibly migration
Mimics myelin basic protein of myelin sheath
17
Q
Glatiramer (Copaxone) aka Copolymer 1 AE?
A
10% experience chest tightness, flushing and dyspnea a few min after inj
18
Q
What is the first oral agent for MS?
A
Fingolimod (F,Gilenya) + is allowed in PEDIATRICS
19
Q
Fingolimod MOA?
A
Acts on S1P1R or S1P5R that is responsible for lymphocyte release from lymphoid organs
Depletes CD4 and 8 in the blood AND doesnt inhibit T or B cells (meaning no immunosuppression or increased risk of infection :O)
any drug that ends w/ -mod
20
Q
Fingolimod AE?
A
Decreased HR, decreased lymph count and increased LFT, QT prolongaition
21
Q
Teriflunomide MOA?
A
Inhibits dihydroorotate dehydrogenase
22
Q
Teriflunomide AE?
A
Monitor LFTs 6 months prior and after, alopecia, and flu
BBW of hepatoxicity and teratogenicity
23
Q
Which MS rx has interactions?
A
Teriflunomide
Inhibits CYP2C8 + induces 1At
Inhibits OAT
Decreases INR w/ warfarin use
24
Q
Dimethyl Fumarate MOA?
A
Unknown
25
Dimethyl Fumarate AE?
CBC every month for 6 months, then annually
LFTs, and FLUSHING
Rash, ab pain
26
What is the last line
| Tx for MS?
Mitoxantrone; cumulative dose is 140mg/mm^2 (max dose = 11)
27
How is Natalizumab given for MS?
Mono therapy or given with IFNs
28
Natalizumab AE?
PML
29
Alemtuzumab AE?
Monitor CBC, THYROID function every 3 months and then for 48 months after last dose
Causes hypo or hyperthyroidism
Infusion associated reaction (>90%) (all -mabs have this AE)
Increased herpes infection risk (prophylactic acyclovir tx)
30
What Rx is used for both PP and RRMS?
Cladribine + Ocrelizumab
31
What Rx is used for CIS, RRMS, and SPMS?
Siponimod
Only drug that has exclusion criteria for poor metabolizers of CYP2C9
32
Alemtuzumab has high efficacy for ____ MS
relapsing; depletes T + B cells
33
Ocrelizumab is used for ___ MS
relapsing or PPMS
34
Ocrelizumab MOA?
Targets CD20 on surfaces of B cells by inducing B cell self-destruction
35
What AA are found in Glatiramer?
L-Glu
L-Lys
L-Ala
L-Tyr
36
Mitoxantrone AE?
Bone marrow suppression, neutropenia, menstrual disorders
37
What Rx is an adenosine analog?
Cladribine
38
Cladribine AE?
Cytotoxic, malignancies, liver damage, cardiac issues, teratogenic
39
Dimethyl Fumarate metabolism?
Metabolized by esterase in liver and GI tract to active MMF
40
What is found in the DSM-5?
Axis I - Clinical Disorders
Axis II - Personality Disorders/Mental Retardation
Axis III - General Medical Conditions
Axis IV - Psychosocial and environmental problems
Axis V - Global Assessment of Function (GAF)
41
What is sensitivity and specificity in psychiatric scales?
Sensitivity - test ability to detect if an illness is present
Specificity - test ability to determine if an illness is absent when the person does have the illness
42
How do you interpret reliability scores in psychiatric scales?
0-1.0
Anything <0.7 is unreliable
43
What is PANSS rating scale?
Assesses both positive and negative Sx
44
What is a CGI rating scale?
Not specific, but can be used in all psychiatric disorders.FDA requires this
45
What is the BPRS rating scale?
General type of assessment
46
What is the SANS rating scale?
Specific to negative sx, used with BPRS
47
What are the depression/bipolar rating scales used?
MADRS
Beck and Zung (used by pt)
48
Which psychiatric evaluation does not have a definitive diagnosis?
Agitation
49
Whats found under "Thought Content"?
Delusion
Obsession
Idea for reference
Anything else is "Thought Process"
50
What is a brief psychotic disorder?
Presence of one of the following:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
Lasts under a month
51
What is a delusional disorder?
Lasts for 1 month or longer
Criteria A for schizophrenia is NOT met
Not impaired or not odd
EX: takings baths 3 times a day, not delusional just "odd"
52
What is a schizophreniform disorder?
2+ symptoms from below present for 1-6 months
Criteria A:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative sx
53
What are the negative sx associated w/ schizophrenia?
Diminished emotional expression
Avolition
Alogia
Anhedonia
Asociality
Everything else are positive symptoms or cognitive symptoms
54
What is avolition?
Decreased in motivated in activaties
55
What is alogia?
Diminished speech output
56
What is anhedonia?
Decreased ability to experience pleasure from positive stimuli
57
What is asociality?
Lack of interest in social interactions
58
What are some anatomic abnormalities with schizophrenia?
Larger brain ventricles
Hippocampus changes
Less gray and white matter volume
59
Parts of brain + schizophrenia?
Hippocampus - learning/memory
Limbic system - emotion
Frontal lobe - critical thinking
Basal ganglia - movement and emotions
60
Neurotransmitter system, dopaminergic activity + schizophrenia?
Positive sx come from hyperdopaminergic activity in MESOLIMBIC
Negative from HYPOdopaminergic activity in MESOCORTICAL
61
Which brain pathway involves in hyperprolactemia?
Tuberoinfundibular pathway
62
Which brain pathway involves EPS and tardive dyskinesia?
Nigrostriatal pathway
63
D2 antagonists + brain pathways, what is happening?
Relieves psychosis via mesolimbic and mesocortical but...
Induces EPS sx via nigrostriatal pathway and increase prolactin via tuberoinfundibular pathway
64
Antipsychotics and binding affinity?
All antipsych rx have both DA and 5-HT receptor affinity except pimavanserin for PD
65
Which anti-psych meds are first gen?
Typical
Chlorpromazine (Phenothiazine-like)
Haloperidol (Butyrophenone-like)
66
Which anti-psych meds are second gen?
Atypical
- apine (clozapine aka Benzazepine-like)
- idone (risperidone aka Benzisoxazole-like)
- azole (aripiprazole in Benzisoxazole-like, but also an aryl piperazine)
67
Which benzazepine-like anti psych med is the only first gen rx?
Loxapine
68
Which butyrophenone-like anti psych med is the only second gen rx?
Lumateperone
69
Which anti psyche structural class traces its roots to antihistamines?
Phenothiazine-like
Butyrophenone-like
Benzazepine-like
Benzisoxazole-like
Phenothiazine-like
70
Typical vs Atypical anti psychs, what receptors do they target?
Typical - more D2 vs 5HT2A receptors
Atypical - more 5HT2A vs D2 receptors
Therefore D2 antagonism is associated w/ EPS and hyperprolactinemia release
71
Phenothiazine-like anti psyche AE?
Sedation, orthostatic hypotension, and anticholinergic effects are more severe in this class (chlorpromazine, thioridazine, etc)
72
What is a common metabolic pathway for many CNS drugs like anti psychs?
Oxidative N-dealkylation
73
Are phenothiazines-like anti psychs metabolized via P450?
Yes
74
Butyrophenone-like anti psych meds efficacy is due to what functional groups?
Tertiary amine attached to 4th carbon of skeleton
75
How do you increase the duration of action on butyrophenone-like anti psychs?
Replace ketone group w/ a second 4-fluorophenyl group
76
AE of butyrophenone-like anti psychs vs phenothiazine-like?
Sedation, wt gain, orthostatic hypotension, and anticholinergic effects are less severe in this class (haloperidol, etc) vs in phenothiazine-like
77
Haloperidol metabolism?
Leads to neurotoxic metabolite HPP+ that can cause severe and irreversible dyskinesias
78
Lumateperone vs other drugs in butyrophenone-like class?
2nd gen drug (more 5-HT2A antagonism)
Less EPS and hyperprolactinemia relative to haloperidol
79
Valbenazine metabolism and DI?
Used to tx tardive dyskinesias
Prodrug that forms active metabolite DHTBZ via hydrolysis of L-valine ester
Metabolized by 3A4, reduce dose with inhibitors and dont recommend w/ inducers
80
Deutetrabenazine metabolism?
Derivative of valbenazine metabolite
Six deuterium atoms (H2) functions as bioisosteres of hydrogen, which slows rate of metabolism
First example of deuterated drug to receive FDA approval
81
H1 antagonism
M1 antagonism
alpha1 antagonism
5-HT2c antagonism
Which one leads to weight gain?
H1 + 5-HT2c
82
H1 antagonism
M1 antagonism
alpha1 antagonism
5-HT2c antagonism
Which one leads to orthostatic hypotension?
Alpha 1
83
H1 antagonism
M1 antagonism
alpha1 antagonism
5-HT2c antagonism
Which one leads to sedation?
H1
84
H1 antagonism
M1 antagonism
alpha1 antagonism
5-HT2c antagonism
Which one leads to tachycardia?
M1
85
H1 antagonism
M1 antagonism
alpha1 antagonism
5-HT2c antagonism
Which one leads to anticholinergic effects?
M1 (anticholinergic = dry mouth, blurry vision, impaired memory, tachycardia
86
Weight gain + anti psych meds, which ones are most likely causing it (first gen)?
Clozapine and olanzapine
87
Which anti psych meds cause the highest risk of diabetes?
Clozapine and olanzapine
88
Which benzazepine-like anti psych med causes the most AE?
Clozapine; sedation, orthostatic hypotension, anticholinergic effects
Dose-dependent seizures, agranulocytosis
89
Benzazepine-like metabolism?
CYP1A2 for clozapine and olanzapine
90
Loxapine metabolism?
Remember it's a first gen anti psych
Forms amoxapine and 7-hydroxyloxapine
7-hydroxyloxapine has higher D2 affinity
Amoxapine forms antidepressant effects via N-demethylation
91
Quetiapine metabolism?
CYP3A4; active metabolite is norquetiapine
92
Benzisoxazole-like anti psychs vs other anti psychs, what kind of activity do they lack?
Anticholinergic activity
93
Weight gain in benzisoxazole-like anti psychs is NOT present in which ones?
Ziprasidone and lurasidone (minimal for both technically)
94
Risk of orthostatic hypotension is greatest in which benzisoxazole-like anti psych?
Risperidone and iloperidone
95
Risperidone metabolism?
2D6 or 3A4 to paliperidone, excreted unchanged via renal elimination
96
Which anti psychs have long-acting properties? Why is that?
Paliperidol, haloperidol, olanzapine, and fluphenazine
Esterified w/ saturated FA. Because they are IM inj, they are in tissues and slowly cleaved by esterases to release parent rx over time
97
What's special about olanzapine IM?
PK parameters are absorption-rate rather than elimination rate processes
98
What is the dopamine hypothesis?
For schizophrenia, anti psychs block D2 receptors only
Drugs used for PD, exacerbate schizophrenia
Glutamate receptors might be suggested due to phencyclidine, ketamine, and NMDA antagonist as they produce schizophrenia sx
Serotonin receptors might be suggested due to higher serotonin levels higher in schizophrenic pt vs "normal" pt
99
1st vs 2nd gen anti psychs, which one is likely to cause EPS and hyperporlactinemia?
First gen
EPS = dystonia, akathisia, tardive dyskinesia, pseudo-parkinsonism
100
What other uses do anti psychs have?
Some second gen = Bipolar, depression, and both 1st/2nd gen = antiemetic effects
Exception to antiemetic = aripiprazole, brexipiprazole, cariprazine, lurasidone
101
Which anti-psych AE involves neuroleptic malignant syndrome?
Haloperidol, possibly due to drop in dopamine activity
102
Which anti psych is a partial agonist at D2 and 5HT1A, but a 5HT2A antagonist?
Aripiprazole
Brexipiprazole
Cariprazine
103
Which 2nd gen anti psych AE has EPS?
Ziprasidone, risperidone, paliperidone
104
Common AE of Quetiapine and Ziprasidone?
Somnolence
105
Which second gen anti psychs cause weight gain?
Paliperidone and risperidone
106
Which anti psych can cause constipation of GI hypomotility?
Clozapine
107
Which Rx are used to treat tardive dyskinesia?
Valbenazine + deutetrabenazine (both inhibit VMAT2)
108
Which anti psych is preferred with uncontrolled diabetes??
First gen
109
Which anti psych is preferred with lower metabolic risk if pt is obese or diabetic?
Second gen (only aripiprazole, lurasidone, or ziprasidone)
110
Which anti psych is preferred with new onset of schizophrenia?
Second gen
111
Max dose of thioridazine?
800mg; causes QTc prolongation and retinopathy
112
What is the only anti psych med that is sublingual?
Asenapine
113
Lumateperone info?
5HT2A and D2 antagonist
Dose = 42mg only
Primarily metabolized by 3A4 and UGT; one of the only drugs to avoid certain drugs (UGT or 3A4 inhibitors)
114
Cariprazine info?
D2 + 3 receptor agonist + has active metabolites
115
Treating acute schizophrenia, stabilization, and maintenance therapy
Acute: goal for first 7 days is to decrease agitation, then slowly up the dose PRN. Switch drug if no improvement in 2-4 wks
Stabilization: Improvement occurs slowly over 6-12 weeks or longer; partial response can occur
Maintenance: Purpose is to prevent relapse. First episode should be treated for 1 yr, chronic illness for at least 5 yrs
116
Which long-acting injectable anti psychs do not require PO overlap?
Paliperidone and olanzapine
117
Olanzapine clinical pearl
Post injection delirium sedation syndrome
118
What is the only anti psych rx used for treatment resistance?
Clozapine
119
Deficiency of monoamines + depression link?
Almost every compound that increases monoamine levels (serotonin, NE, dopamine, etc) have antidepressant effects
WEAKNESS: more primary abnormalities may be responsible for deficiency
120
Genetic vulnerability + depression link?
Use of family history to estimate genetic risk, genetic factors is around 30-40%
WEAKNESS: no solid evidence for specific genes or gene-environment
interactions, however evidence is growing
121
Altered HPA axis activity + depression link?
Hypothalamus releases CRH in stress
Pituitary secretes corticotropin
Adrenal gland releases cortisol
Might be linked to early life stress and increased risk of MDD in adults
WEAKNESS: Most subjects have no evidence of HPA axis dysfunction, drugs that target HPA axis have inconsistent antidepressant effects
122
Dysfunction of specific brain regions + depression link?
Untreated depression may lead to hippocampal volume loss which can increase stress sensitivity
WEAKNESS: limited evidence from neuroimaging studies
123
Neurotoxic/neurotropic processes + depresion link?
Brain volume loss during depressive illness
WEAKNESS: no evidence in humans for specific neurobiological mechanisms
124
Reduced GABA activity + depression link?
Reduced total GABA, GABA inhibits nerve transmission
WEAKNESS: drugs that target GABA system have inconsistent
antidepressant effects
125
Glutamate dysregulation + depression link?
Glutamate is a major excitatory neurotransmitter which plays a role in
mood or anxiety disorders
WEAKNESS: questionable specificity since glutamate is involved in
numerous systems
126
Impaired circadian rhythm + depression link?
Impaired sleep-wake regulation in depressed pt
WEAKNESS: no molecular understanding of this relationship with MDD
127
Which drugs cause drug-induced depressive symptoms?
CHASMIC
Cardiovascular (BB, methyldopa, clonidine)
Hormonal therapy
Acne tx (Isotretinoin)
Smoking cessation
antiMigraine (triptans)
Immunologic (IFN)
antiConvulsants
128
What is the USPSTF screening recommendations?
Children 12-18yo should be screened for MDD
All adults (especially pregnant and PP women) should be screened in primary care setting
129
What is the DSM-5 diagnostic criteria
≥5 "symptoms" of depression during a 2 week period. One of the symptoms have to be depressed mood or loss of interest
130
What do you do if someone screens positive from the PHQ-2 questionnaire?
Go to PHQ-9
131
How are TCA antidepressants (ADs) broken up?
Tertiary amines (imipramine, amitriptyline, doxepin)
Secondary amines (desipramine, nortriptyline)
Both ^^ are further categorized into tetracycline ADs = mirtazapine (serotonin and alpha blockage)
**All of these are categorized as first gen SNRIs
132
What are the second gen SNRIs?
Venlafaxine
Desvenlafaxine
Duloxetine
Levomilnacipran
133
What are the NDRIs?
Bupropion
134
What are the MAOIs?
Phenelzine
Tranylcypromine
Selegiline
135
What are the aryl piperazines used as antipsychotics that have AD effects?
Trazodone and Vilazodone
136
What are the steroid AD?
Brexanolone
137
What are the NMDA antagonists?
Esketamine
138
What are the SSRIs?
```
fluoxetine
sertraline
paroxetine
citalopram
escitalopram
vortioxetine
```
139
In TCA ADs, what is needed for the AD activity?
3 carbon tether + terminal basic amine
140
Which transporters do TCA AD affect? Secondary vs Tertiary amine?
Targets NET, SERT highly vs DAT (same with SNRIs)
Secondary has lowered number for NET (but it means more potent vs tertiary)
141
TCA AD AE are contributed thanks to what?
They are also active on muscarinic, histamine, and alpha 1 receptors
142
TCA OD can cause what?
Cardiac arrhythmias
143
TCA AD metabolism is slow in 7% of the population due to what polymorphism?
CYP2D6
144
SSRIs vs TCA AD, which one doesnt have CV side effects?
SSRIs
Same goes w/ SNRIs
145
Escitalopram metabolism
Unlike TCAs, escitalopram is metabolized by many CYPs, therefore there is less chance of rx interactions or genetic polymorphisms
T1/2 = 10 days
146
Which SSRI DOES have major interactions?
Paroxetine + CYP2D6
Fluoxetine + CYP2D6 (Pimozide and thioridazine; leads to QTc prolongation)
147
Which SSRI has similar metabolism like escitalopram where it involves many CYPs?
Sertraline + Vortioxetine
148
Venlafaxine vs Desvenlafaxine, CYP3A4 inhibitors affect which one greatly?
Venlafaxine
Desvenlafaxine has UGT metabolism as well
149
Which AD doesnt use CYP enzymes?
Levomilnacipran
150
Duloxetine and Levomilnacipran AE?
Postmarketing cases of liver injury via metabolite of oxidation of thiophene ring
Duloxetine; dont give in chronic liver disease or heavy alcohol use
151
What special about mirtazapine's receptor target?
Its a tetracycline ADs
Blocks alpha 2 and 5-HT2/3 + H1
Associated with wt gain and sedation
152
Bupropion metabolism?
Only inhibits DAT and NET only (NDRI)
The tert-butyl group prevents N-dealkylation to metabolites with stimulant effects
153
Aryl Piperazine AD, what do they target?
Trazodone = 5-HT2a and SERT, H1, alpha 1 (so it has their AE)
Vilazodone = 5-HT1a partially and SERT
154
Which AD form metabolites that cause idiosyncratic hepatotoxicity?
Trazodone, the metabolites are iminoquinone and epoxide for glutathione conjugation
155
Which AD class can take up to 2 weeks after d/c for activity to recover?
Long acting MAO-A/B (phenelzine and tranylcypromine)
156
Which AD carry diet restrictions?
MAOi (to avoid hypertensive crisis)
157
What kind of interactions do MAOi have?
With SSRIs, you need a washout period
Food interactions too!
158
Which AD functions as a positive allosteric modulator of GABA_a receptors?
Brexanolone, used for PPD
159
Brexanolone BBW?
Sedation and sudden loss of consciousness, needs REMS program called Zulresso REMS
160
Which AD is used for treatment-resistant depression?
Esketamine
161
Esketamine MOA?
S-enantiomer of ketamine,, non-competitive antagonist of NMDA receptors
162
Esketamine BBW?
Sedation, dissociation, abuse, suicidal thoughts, available through SPRAVATO REMS
163
What is the monoamine hypothesis and what are the current theories that we favor?
Monoamine = depletion of MA by reserpine (anti-HTN rx) that causes depression-like sx; AD rx increase brain monoamine
Current theory = dysregulation of 5-HT, NE, DA
164
For MAOi to be effective, they must inhibit type (A/B)
A
165
Which AD is used for bedwetting in peeps aged >6yo?
Imipramine (TCA)
166
Which AD is used for insomnia in low doses?
Amitriptyline and Doxepin (TCA)
167
Which TCA AD has withdrawal Sx?
Amitriptyline
168
Which AD class has a high therapeutic index?
SNRIs
169
What is the first line therapy for depression?
SSRIs
Equal in efficacy to TCAs
170
Which class of AD causes many serotonin-related AE?
SSRIs
Brain 5-HT2 (insomnia, anxiety, low libido)
Spinal 5-HT2 (erectile dysfunction, anorgasmia)
Brain/peripheral 5-HT3 (nausea)
Sudden withdrawal syndrome
Wt gain, falls
171
What is serotonin syndrome?
Triad of Sx
Mental status change
Autonomic instability
Neuromuscular abnormalities/Somatic
172
Citalopram vs other SSRIs, what AE is specific to citalopram?
QTc prolongation
173
Which AD drugs have a long half life?
Escitalopram + Fluoxetine
174
Fluoxetine vs other SSRIs, what AE is specific to fluoxetine?
Anorexia
175
Paroxetine vs other SSRIs, what AE is specific to Paroxetine?
More anticholinergic effects
176
Nefazodone MOA and AE?
MOA = 5-HT2antagonist + SSRI
AE = Liver issues
177
Special info on bupropion?
450mg/day increases seizure risk
Doesnt cause wt gain or sexual dysfunction
Will cause Insomnia!!
178
Lithium info
Treats manic-depressive illness
Only mood stabilizer w/ data on suicide reduction in bipolar pt
MOA = unknown
179
Psychotherapy, when should you recommend it for depression?
Only if pt is willing to participate
Might be used alone in mild/moderate MDD
NEVER alone in Severe or psychotic MDD or maintenance
180
FDA label warning for antidepressants?
Bleed risk (esp. w/ NSAIDs, anticoagulants, and antiplatelets)
Suicide risk (greatest % in <24yo)
181
Which SSRI inhibits 2C9?
Fluoxetine
182
Which SSRI inhibits 1A2?
Fluvoxamine
183
```
What class of AD carries a risk of persistent pulmonary HTN of the
newborn (PPHN)?
```
SSRIs
184
When is the best time to take SSRI?
Prior to bedtime or w/ food
If there is sleeping issues, start rx at low dose, take w/ BB or benzodiazepines
185
Which SSRI causes the highest % of sexual AE?
Citalopram > paroxetine > sertraline > fluoxetine
186
What is d/c syndrome + SSRIs?
Occurs when SSRIs are abruptly d/c
Change to fluoxetine when tapering to prevent this issue
187
Which SNRI has the most sexual dysfunction?
Venlafaxine ER
188
Specific AE to Venlafaxine?
When taking >150mg/day, BP can go up
189
Which AD must be renally adjusted or lowered for the elderly?
Mirtazapine
Regular max = 45mg
Elderly = 15mg
190
Which AD causes increased cholesterol?
Mirtazapine
191
Which AD must be adjusted due to CYP3A4 inhibition/induction?
Vilazodone
Inhibitor = dont exceed 20mg
Inducer = increase dose to 80mg
192
Which AD is useful in concomitant anxiety?
Vilazodone, maybe buspirone
193
Which AD must be adjusted due to CYP2D6 inhibition/induction?
Vortioxetine
Inhibitor = reduce dose by half
Inducer = increase dose, max 3x dose
194
Which TCA AD is least likely to cause orthostatic hypotension?
Nortriptyline
195
Washout Period + AD?
Everything takes 2 weeks, except going from fluoxetine to MAOI, that takes 5-6wks
196
What can cause HTN crisis w/ MAOIs?
Diet (tyramine)
SSRIs, SNRIs, TCAs and OTC decongestants
197
Which AD is FDA approved for pt <18yo?
Fluoxetine
198
How do you assess response of AD?
Remission - baseline returned
Partial remission- >50% decrease
Partial response - 26-49% decrease in sx
Nonresponse <25% decrease
199
Phase of AD Tx?
Acute - 6-12 wks Goal = remission
Consolidation - 4-9months after remission
Goal = eliminate sx and prevent relapse
Maintenance - >12 months
Goal = prevent recurrence
200
Which AD should you not use w/ BPH?
Duloxetine + Levomilnacipran, TCAs
201
Which AD should you not use w/ glaucoma?
TCAs
202
Is prophylaxis for acute dystonia recommended per WHO?
No unless they are high risk
203
What is akathisia?
Motor restlessness, "always moving" usually treated w/ propranolol
204
Which psychotic AE doesnt occur during sleep?
Tardive dyskinesia
205
Which antipsych causes the highest incidence of seizures?
Clozapine + Chlorpromazine
206
What antipsych causes retinitis pigmentosa?
Thioridazine
207
Which antipsychotics cause neutropenia?
Clozapine (most), chlorpromazine, and olanzapine
If WBC<3k or ANC<1k, STOP IT!
208
Pregnancy + Antipsychs, what are your options?
Haldol or risperidone
Avoid long-acting inj
209
A change in ___mmHg or more is significant when checking a pt for orthostatic hypotension
20
