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P. pharm > Exam 1 study guide > Flashcards

Exam 1 study guide Flashcards

1
Q

First approved treatments SPECIFICALLY for TD

A

Valbenazine (Ingrezza)
Deutetrabenazine (Austedo)

Think about “benazine” being similar to treatment with benztropine

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2
Q

How to treat TD

A

Lower med dose, d/c, switch to clozapine lowest TD risk

*Benztropine(cogentin)
Clonazepam
Amantidine
Tetrabenazine

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3
Q

Tx akathisia (restlessness)

A

Beta blocker (propranolol)
Low dose mirtazapine based on its antagonist activity at the serotonin 5-HT(2A)/5-HT(2C) receptors

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4
Q

Tx pseudo parkinsonism

A

Benztropine/cogentin

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5
Q

Baseline exams FGA

A

EKG (QTc prolongation)
Lipids
LFTs
AIMS

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6
Q

EPS

A

dystonia, akathisia, pseudo-parkinsonism

d/t alpha 1 blockade & D2 blockade in nigrostriatal pathway

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7
Q

NMS symptoms

A

FALTERED

F- fever
A- autonomic dysfunction
L- leukocytosis
T- tremor
E- elevated CK
R- rigidity
E- excessive sweating
D- delirium

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8
Q

NMS tx

A

d/c med
fluids
IV benzos
cooling blankets
sodium dantrolene, bromocriptine, amantadine
ECT

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9
Q

why not prescribe drugs with FGA to prevent EPS

A

high anticholinergic SE risk

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10
Q

SGA use

A

acute mania, bipolar, adjunct in unipolar depression

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11
Q

metabolic syndrome

A

HTN ( >135/85), elevated triglycerides, truncal obesity, low HDL

SE of SGA

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12
Q

Baseline exams SGA

A

lipids
Glucose
A1C
Bp, weight, waist circumference, BMI

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13
Q

how often to do labs if established on SGA already

A

yearly (lipids, A1c, glucose)

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14
Q

Most common SGA meds to cause weight gain

A

clozapine, quetiapine, olanzapine

“pine”

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15
Q

SGA meds least associated with weight gain

A

aripiprazole, ziprazidone, lurasidone (& FGA haliperidol)

“done” and “ole”

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16
Q

SGA with strongest H1 antagonism

A

quetiapine
leads to sedation and weight gain

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17
Q

what SGA for acute agitation IM

A

olanzapine (Zyprexa)
works in 15 min

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18
Q

post injection syndrome

A

concern with olanzapine LA injection called relprevv

monitor x3 hours s/p injection d/t risk delirium & sedation syndrome

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19
Q

what SGA has the greatest elevated prolactin risk

A

risperidone (Risperdal)

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20
Q

Weight neutral SGAs

A

ziprasidone (Geodon)
aripiprazole (Abilify)

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21
Q

SGA approved for bipolar depression

A

lurasidone (Latuda)

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22
Q

med for refractory schizophrenia (Tx resistant)

A

clozapine

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23
Q

SGA that lowers SI

A

clozapine

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24
Q

SGA to most likely cause weight gain & hypersalivation/sialorrhea

A

clozapine

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25
Q

what special program is needed for clozapine and why

A

REMS d/t risk agranulocystosis highest in first 3 months of tx

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26
Q

how often to do labs for clozapine/why

A

monitor WBC/ANC weekly x6 months d/t risk of agranulocytosis
d/c if < 1.5 (1500)

*highest risk in first 3 months of tx

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27
Q

med for parkinson-related psychosis

A

pimavanserin (Nuplazid)

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28
Q

is smoking a CYP450 inhibitor or inducer & what does that mean

A

inducer
activates CYP1A2 enzymes & therefore lowers levels of some antipsychotics

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29
Q

Special consideration with haldol and prolixin decanote injections

A

use sesame oil- watch for allergic rxn

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30
Q

What’s a black box warning for all antipsychotics

A

increased risk of death in elderly & dementia

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31
Q

when can you use antipsychotic for dementia patient

A

no antipsychotic is approved
can use if sx severe & dangerous, significant distress

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32
Q

classes of antidepressants

A

SSRI *(first line), SNRI, SPARI, NDRI, TCA, MAOI

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33
Q

top distressing SE antidepressants

A

sexual, sleep, weight gain

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34
Q

antidepressants with highest risk sexual dysfunction

A

venlafaxine & SSRIs

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35
Q

antidepressants with lowest sexual SE incidence

A

bupropion, trazodone, nefazodone, mirtazapine

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36
Q

Serotonin syndrome

A

SHIVERS

S- shivering
H- hyperreflexia
I- increased temp
V- vital instability
E- encephalopathy (confusion)
R- restlessness
S- sweating

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37
Q

first line tx sexual SE from antidepressants

A

switch to bupropion

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38
Q

tx of serotonin syndrome

A

stop med
cyproheptadine (5HT antagonist)
ECT

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39
Q

SSRI SE & black box warning

A

initially worsen anxiety
transient GI 1-2 weeks
sexual
weight
sleep

**Black box= suicidality in children/adolescents

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40
Q

fluoxetine (class, indication, unique feature, warning)

A

SSRI

approved in pediatrics
bulimia
longest half life
can elevate antipsychotic levels
*activating; good for fatigue

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41
Q

citalopram

A

most lethal SSRI in OD

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42
Q

sertraline

A

preferred in pregnancy/breast feeding
activating; good for energy but can= agitation/anxiety

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43
Q

when to consider SNRI

A

significant fatigue or comorbid chronic pain

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44
Q

SE SNRI

A

sustained elevated BP, nausea, diarrhea, dizziness, anticholinergic

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45
Q

list of SNRI

A

venlafaxine, duloxetine, levomilnacipran, milnacipran

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46
Q

venlafaxine (Effexor) indication

A

good for anxiety/panic attacks in depressed patients

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47
Q

NDRI

A

inhibits reuptake of DA & NE
bupropion

48
Q

bupropion

A

weight neutral, least likely to have sexual SE
good for ADHD & smoking cessation d/t effect on DA

*contraindicated in seizures & ED, lowers seizure threshold

49
Q

list of atypical antidepressants/serotonin antagonists & agonists

A

mirtazpine, trazodone, nefazodone

50
Q

trazodone (class, mechanism of action, indication, SE)

A

Serotonin antagonist and reuptake inhibitors (SARI)
acts on alpha-adrenergic receptors
MDD, anxiety, *insomnia
SE: nausea, dizziness, orthostasis, sedation, **priapism

51
Q

antidepressant associated w/ priaprism

A

trazodone

52
Q

nefazodone black box

A

*Off the market
BLACK box= liver failure

53
Q

mirtazapine (class/mechanism of action, effect, indication, dose/sedation relationship)

A

alpha 2 adrenergic and 5HT2 antagonist (increases 5HT & NE)
sedating, increases appetite

*good if sx depression= weight loss & insomnia

inverse relationship between dose/sedation

54
Q

second line treatment for depression

A

TCA

55
Q

TCA SE

A

3 C’s= cardiotoxic, convulsions, coma

antiadrenergic (EKG changes, arrhythmias, orthostasis, reflex tachycardia) *Avoid in conduction issues/recent MI

anticholinergic (dry mouth, constipation, blurred vision, memory issues, urinary retention, narrow angle glaucoma)

antihistaminic (sedation, weight gain)

56
Q

most lethal antidepressant class and med within that class

A

TCAs
only prescribe 1 week at a time

*desipramine most lethal TCA

57
Q

tx TCA OD

A

gastric aspiration
cardiac monitoring

58
Q

TCAs with highest SEs & lethality

A

imipramine
clomipramine (Anafranil)
amitriptyline
doxepine

59
Q

antidepressant for enuresis

A

TCA
imipramine (Tofranil)

60
Q

antidepressant for OCD

A

TCA
clomipramine (Anafranil)

61
Q

secondary amines/TCAs with less SE

A

nortriptyline *therapeutic level, safe in geriatrics
desipramine
amoxapine

62
Q

nortriptyline

A

TCA
*therapeutic level, safe in geriatrics

63
Q

MAOIs (mechanism of action, MOA-A vs MOA-B, indication)

A

deactivates enzymes for 5HT, DA, tyramine

selective MOA-A for MAJOR depression
MOA-B for Parkinson’s & Alzheimer’s

*last resort d/t food & drug interactions

64
Q

SE MAOIs and potential emergencies/how?

A

insomnia, weight gain, anticholinergic, sexual, orthostasis, photophobia, drowsiness, sleep dysfunction

liver toxicity, seizures, edema

*Hypertensive crisis if eats tyramine!
Serotonin syndrome if take with SSRIs

65
Q

Sx hypertensive crisis, cause, treatment

A

Cause= tyramine rich foods * MAOI
can’t metabolize dietary amines, increases NE

sx: sudden explosive HA, high BP, facial flushing, palpitations, diaphoresis, fever, n/v, photophobia, autonomic instability, chest pain, arrhythmia, death

tx: d/c med
supportive care
phentolamine (NE antaognist)

66
Q

tyramine rich foods

A

fava beans, red wine, aged cheese, cured meat, chicken liver

67
Q

MAOI med interactions

A

SSRIs, TCAs, atypical antipsychotics, St. Johns Wort, asthma meds, decongestants, opiates

68
Q

wash out period of MAOIs

A

2 weeks before switching from SSRI to MAOI, 5-6 weeks with fluoxetine

69
Q

phenelzine

A

MAOI
animal phobia, MDD w/ atypical
features, MDD w/ psychotic features and social phobia.

70
Q

selegiline (Ensam)

A

MAOI that doesn’t require tyramine diet restriction

71
Q

vortioxetine (Trintellix or Brintellex)

Effect & indication

A

activates glutamate (excitatory) in frontal cortex
effective in patients with COGNITIVE DEFICITS in MDD

72
Q

antidepressant withdrawal

(sx, least likely meds to cause, onset, how to avoid)

A

FINSIH

F- flu like sx
I- insomnia
N- nausea
I- imbalance
S- sensory disturbance (tremor, sensation electrical shock)
H- hyperarousal

*least likely with fluoxetine and vortioxetine
sx within 5 days d/c
avoid with 4 week taper (longer with Paxil & Effexor)

73
Q

how to avoid antidepressant withdrawal

A

4 week taper (longer with Paxil & Effexor)

74
Q

what qualifies as treatment resistant depression & why important to prevent relapse?

A

inadequate response to 2+ antidepressants

each relapse increases sx severity, decreases tx response, heightens risk of tx resistance

75
Q

first line tx severe melancholic depression

A

ECT

76
Q

tx acute mania

A

lithium, VPA, atypical antipsychotics

77
Q

tx acute mania w/ severe sx (agitation)

A

atypical antipsychotics (olanzapine, ziprasidone, haloperidol)

78
Q

tx bipolar depression

A

lithium, quetiapine, lurasidone

79
Q

lithium
(Indication, unique quality, onset, therapeutic index, SE)

A

*gold standard tx bipolar (acute mania)
only mood stabilizer decreases suicidality

onset= 5-7 days
narrow therapeutic index 0.6-1.2 (> 1.5 toxic, >=2 potentially lethal)

SE: weight gain, cognitive slowing/dulling, impaired thyroid, GI, sedation, fine tremor, ECG change (T wave inversion), leukocytosis, hypothyroidism, epstein anomaly (cardiac defect in babies)

80
Q

Lithium- considerations and baseline/continued monitoring, interactions

A

baseline= TSH, Cr/BUN, Hcg, EKG (>50/risk), CBC, CMP

continued monitor= Li level 3-7 days after dose change, TSH, renal

6-8 glasses water/day
birth control
avoids NSAIDs, aspirin, thiazides, dehydration, sweating, salt deprivation, ACEi, antiHTN

81
Q

S/s lithium toxicity

A

n/v/d, coarse tremor, ataxia

late= seizures, coma, death

82
Q

gold standard tx bipolar (acute mania)

A

lithium

83
Q

gold standard tx rapid-cycling mania

A

carbamazepine (Tegretol)

84
Q

carbamazepine (Tegretol)
(Black box, therapeutic level and how often check, SE, unique feature)

A

mood stabilizer
***blackbox= agranulocytosis & aplastic anemia

therapeutic level= 8-12
check level initially, then week 3, 6, 9 wait 3-7 days after dose change

SE: elevation LFTs > hepatitis, neural tube defects

*autoinduction of own metabolism 3-5 days after initiating= decreased plasma levels

85
Q

carbamazepine baseline & continued labs

A

baseline= pregnancy, CBC, LFTs
regular= CBC, LFT

86
Q

carbamazepine toxicity

A

range= 8-12
acute intoxication= ataxia
confusion, stupor, motor restlessness, ataxis, tremor, nystagmus, twitching, vomiting

87
Q

valproic acid/Depakote/Depakene mechanism of action, blackbox, therapeutic level, SE, labs, interaction

A

blocks Na channels, increases GABA concentrations in brain
*blackbox= hepatotoxicity, pancreatitis

therapeutic range= 80-120
check level after 4-5 days
rare rxn= depakote induced thrombocyctopenia

Labs= CBC, LFTs

neural tube defects

*VALPROATE INCREASES LAMICTAL LEVELS

88
Q

lamotrigine/Lamictal considerations/SE, important interaction

A

start low go slow
RARE SE: Steven Johnson syndrome

*lamictal dose must be cut in half when taken with depakote because VPA an increase levels

Lamictal May increase levels of carbamazepine

89
Q

lamotrigine interaction with carbamazepine

A

Lamotrigine potentially increases the concentration of Carbamazepine and Carbamazepine decreases the concentration of Lamotrigine

90
Q

oxcarbazepine (Trileptal) monitoring

A

hyponatremia
monitor Na levels

91
Q

topiramate (Topamax) most limiting SE

A

cognitive slowing

92
Q

what SE are all mood stabilizers and especially antiepileptics associated with and what are the safest

A

hepatic SE
gabapentin and pregabalin are safest

93
Q

teratogenic SE psychotropic meds

A

BZO= floppy baby syndrome, cleft palate
carbamazepine/Tegretol= neural tube defects
lithium= epstein anomoly
depakote= neural tube defects

94
Q

CYP-450 induction

A

increases metabolism and an reduce drug levels/effects

95
Q

CYP-450 inhibition

A

decreases metabolism and an increase drug levels/effects > adverse effects

96
Q

common CYP-450 inhibitors (can increase other drug levels)

A

bupropion, clomipramine/Anafranil. cimetidine, SSRIs, clarithromycin, fluoroquinolones, grapefruit, ketoconazole, nefazodone

97
Q

common CYP-450 inducers (can reduce other drug levels)

A

carbamazepine, St. John’s Wort, phenytoin, phenobarbital, tobacco

98
Q

how many D2 receptors need to be occupied by antipsychotic to = EPS

A

more than 80%

99
Q

mesolimbic

A

increased DA= positive sx psychosis

100
Q

mesocortical

A

reduced DA= neg sx schizophrenia

101
Q

tuberoifundibular

A

decreased DA= increased prolactin

102
Q

nigrostriatal

A

decreased DA= motor SE

103
Q

where is NE made

A

locus cerelus

104
Q

where is 5HT made

A

ralphe nuclei

105
Q

What increases risk of TD

A

high doses, substance abuse (heavy smoking) DM, older age, women, h/o EPS, long-term antipsychotics, African American

106
Q

low potency meaning

A

low EPS risk but high other SE
More lethal in overdose d/t QTC prolongation

107
Q

high potency meaning

A

high EPS risk but low other SE

108
Q

TD s/s

A

mostly irreversible

torticollis (contraction of neck muscles)

Involuntary Choreoathetoid movements of face, mouth, lips (lip smacking) tongue (fly catcher tongue) and other body
parts (facial grimacing, eye blinking, trunk, limbs etc. )

109
Q

Duration maintenance therapy in depression

A

6-13 months

110
Q

Factors affecting drug choice

A

cost, sx, previous tx of pt/family, SE, comorbidities, risk of suicide

111
Q

Meds to avoid in pts with SI

A

BZO, TCA…

112
Q

Progression of serotonin syndrome

A

rhabdomyolysis, renal failure, convulsions, coma = DEATH

113
Q

Acute intoxication of carbamazepine causes…

A

ataxia

can even cause at therapeutic levels

114
Q

Good prognostic indicator for Lithium=

A

episode pattern of mania,
depression and euthymia

115
Q

when to check VPA level

A

after 4-5 days

P. pharm (8 decks)

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