Ex3 Psychoactive Rx Flashcards by Rachel Unknown

onset for antidepressants

Up to 2 weeks

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Generally - ok to hold medications?

No, unless NPO/high TF residuals

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TCA medications

end in “triptyline”, “ipramine”, “epin”

amitriptyline, imipramine, desipramine, doxepin, nortriptyline

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TCA indications

depression

unique: chronic pain

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TCA MOA

inhibit Serotonin/Norepi reuptake

2. Antagonistic: histamine, anti-muscarinic acetylcholine, alpha1 adrenergic, NMDA, mu opioid

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Metabolism of TCAs

Liver - P450

Active metabolites, erratic bioavailability, long half life (>24h)

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TCA common side effects

Hypotension (increased in elderly)
Anticholinergic/antihistmaine: Urinary retention
fine tremors, Sedation, confusion, delirium
Prolonged QTc (Check EKG prior to case)
Gastric motility, ileus

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TCA dosage effect

narrow therapeutic index: EKG changes

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Risk of TCA

Reduced seizure threshold
Serotonin Syndrome (avoid w/ MAOI)
Withdrawal

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TCA anesthesia considerations

Exaggerated (new) or Diminished (chronic) response to sympathomimetics

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Benadryl/Scopolamine w/ TCA

additive effects - excess sedation/confusion/delirium

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SSRI metabolism

Liver via CYP450

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Longest acting SSRI

Fluoxetine, 1-4 days

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Shortest acting SSRI

Fluvoxamine, 15h

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Which SSRI would it be okay to miss a few doses (days) without issues?

Fluoxetine (d/t long half life + active metabolite)

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Side effects of SSRIs

BBW: suicide under age 24

Hyponatremia (SIADH)

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adverse effects of escitalopram/citalopram

QTc prolongation

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SSRI withdrawal

1-7 days after d/c

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Which SSRI should you be concerned with withdrawal in OR?

Fluvoxamine

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SSRI risk

serotonin syndrome - MAOIs, opioids, linezolid, methylene blue

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AE mirtazipine

decreased seizure threshold

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SNRIs

venlafaxine, duloxetine

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SNRI indications

depression, pain

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AE SNRIs

withdrawal (1/2 life=5 hours), active metabolites

Decreased seizure threshold

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clinical indications - trazodone/nefazodone

depression, insomnia

AEs trazodone/nefazodone

sedation, orthostatic hypotension, QT prolongation, impairment of platelet aggregation

S/S serotonin syndrom

hyperthermia, confusion, agitation, autonomic hyperactivity, myoclonus, hyperreflexia, diaphoresis, tremor, diarrhea, neuromuscular abnormalities, ocular clonus

risk of serotonin syndrome occurs with

serotonin inhibitors + antiemetic (zofran/reglan), fentanyl, linezolid, meperidine, tramadol, valproic acid

Tx serotonin syndrome

1. stop offending agent | 2. serotonin antagonists (cyproheptadine)

prevention of serotonin syndrome

14 day washout

inadequate analgesia may occur in serotonin inhibitors with

codeine

increased risk of _____ in serotonin inhibitors

bleeding

used for smoking cessation

bupropion

MOA norepi/dopa reuptake

bupropion

AE Bupriopion

abrupt w/d=seiz risk | increased HR/BP

MAOIs

phenelzine, selegiline, tranylcypromine

MOA MAOIs

inhibits MAO (monoamine oxidase enzyme) which breaks down Serotonin/norepi/dopa

MAOI Rx Intxns

Opiates, meperidine, any Rx that effects serotonin = serotonin syndrome

AE MAOIs

myoclonic movements

Decreased use of MAOIs

intxn w/ tyramine (cheese/wine)

Effect of tyramine + MAOIs

HTN, tachycardia

Contraindicated with MAOIs

meperidine

DOC - patient with serotonin syndrome has pain

morphine

Cautious during use of _____ with MAOIs

vasopressors - exaggerated response

Etomidate is ____ to use with MAOIs

safe

Goal serum concentration - Lithium

0.6-1 mEq/L

Chronic Side Effects - Lithium

nephrogenic diabetes insipidus, polyuria/polydipsia, hypothyroidism, myxedema coma

Lithium overdose

CNS effects - seizures, coma, tremor, ventricular arrhythmias, t wave inversion, confusion, N/V/D

Increases risk of Lithium Toxicity

Renal insufficiency, hyponatremia

Drug interactions to monitor for w/ Lithium

Thiazide Diuretics, Loop diuretics, NSAIDs, neuroleptic Rx, neuromuscular blockade

AE Lithium + neuromuscular blockade

prolonged duration of NMBA

AE Lithium + diuretic/NSAIDs

Altered Sodium excretion --> renal effect --> increased lithium plasma concentration

AE Lithium + neuroleptic drugs

i.e. reglan | increased EPS, increased risk neuroleptic malignant syndrome

Typical antipsychotics

chlorpromazine, droperidol, fluphenazine, haloperidol, prochlorperazine

Atypical antipsychotics

aripiprazole, olanzipine, quetapine, risperidone, ziprasidone, loxapine, clozapine

MOA antipsychotics

"dirty" - typical vs. atypical

MOA typical antipsychotics

High D2 antagonism, Low 5HT-2A antagonism

MOA atypical antipsychotics

Moderate-high D2 antagonism, High 5-HT2A antagonism

Clozapine AEs

agranulocytosis (1st 3months), myocarditis/cardiomyopathy, seizures

antipsychotic side effects

QTc prolongation**, postural hypotension, sedation, EPS, akathisia, tardive dyskinesia, urinary retention, blurred vision, dystonia

Tardive dyskinesia presentation

repetitive/jerking movements in face, neck, tongue, lips (may affect breathing/swallowing)

Dystonia presentation

sustained muscle contractions (twisting, repetitive movements, abnormal postures), tremor/loss of facial expressions, skeletal muscle rigidity

Tardive dyskinesia tx

no treatment - anticholinergics worsen symptoms

Dystonia tx

IV benadryl 25-50 mg benztropine 2mg dose reduction/avoidance

akathesia

restlessness, urge to move

akathesia tx

propranolol (1st line), benzos, anticholinergic (benztropine), amantadine, clonidine

Parkinsonism

muscle rigidity, tremor, bradykinesia, postural abnormalities, salivation

parkinsonism tx

dose reduction/drug avoidance + anticholinergic (benztropine)

risk of antipsychotics

neuroleptic malignant syndrome

how to differentiate between NMS/serotonin syndrome

history

s/s neuroleptic malignant syndrome

Fever** | renal failure, rhabdo, rigidity, altered LOC, autonomic dysfunction

Tx NMS

dantrolene 0.5-2.5mg/kg q6h

NMS may mimic

malignant hyperthermia

benzos act on

Alpha/Gamma subunit of GABA-A receptor

benzodiazepine metabolism

significant hepatic metabolism | some rx = active metabolites

Benzodiazepines with active metabolites

midazolam, diazepam, chlordiazepoxide (Librium)

Benzodiazepines with inactive metabolites

oxazepam, lorazepam, temazepam

DOC benzo (renal insufficiency, repeated doses)

Lorazepam

Anesthesiology considerations in patients taking Benzos

- additive effects w/ other sedatives | - abrupt stopping of chronic therapy = w/d