Exam 4: Ott Flashcards
(237 cards)
1
Q
What was added to the DSM-5 and DSM-5, TR? What does the preface say?
A
- DSM-5: express arabic numbers from roman numerals
- DSM-5, TR: added SDOH & cultural factors in diagnosis
- Preface: ome symptom domains, such as depression and anxiety,
involve multiple diagnostic categories and may reflect common underlying
vulnerabilities for a larger group of disorders. In recognition of this reality, the
disorders included in the DSM-5 were reordered into a revised organizational
structure meant to stimulate new clinical perspectives
2
Q
what was the DSM-5 reorganized to reflect?
A
disorders across a continuum based on
developmental and lifespan considerations
3
Q
what does the DSM-5 begin with?
A
neurodevelopment disorders
4
Q
what neurodevelopmental disorders are covered in the DSM-5?
A
ADHD, autism, intellectual disabilities/ delays, communication disorders
5
Q
what is there to know about the mood disorders in the DSM-5?
A
Bipolar and related disorders and Depressive disorders have separate
chapters – with bipolar found between schizophrenia spectrum and
depressive disorders – reflecting the overlapping nature of bipolar
disorder
6
Q
What do the anxiety disorders include in the DSM-5?
A
GAD, SAD, PD
7
Q
what chapters for anxiety are new in the DSM-5?
A
OCD, PTSD
8
Q
what is there to know about the SUD related chapters in the DSM-5?
A
- no more abuse & dependence
- set criteria for all substance that only vary with symptom presentation based on type of substance used
- includes gambling disorder
9
Q
what is the DSM-5 finished up with and how is it categorized?
A
- neurocognitive disorders
- categorized into major/mild
- includes alzheimers
10
Q
what rating scales are there for depression? What are they?
A
PHQ-9 ( depression/ SI, patient rated)
BDI (patient rated)
11
Q
What are the research rating scales for depression and what is info about them?
A
- HAM-D, clinician-rated, gold standard for change over time in clinical trails
- MADRS, validated in clinical trails, gold standard
12
Q
what are the scales for bipolar disorder and generalized anxiety? info about them?
A
- YMRS– clinician rated by patient report
- HAM-A
13
Q
what are the scales for clinical trials of schizophrenia? info about them?
A
- PANSS – gold standard scale, clinician rated
- BPRS, gold standard and clinician rated
14
Q
what are some movement side effects of antipsychotics scales and info about them?
A
- SAS, drug induced PD symptoms and clinician rated
- BARS, clinician rated and observes akathisia
15
Q
what scales are there for tardive dykinesia and overall movement SEs and info about them?
A
- AIMS, assess tardive dyskinesia and clinician rated
- ESRS, clinician rated and assess PD, akathsia, dystonia, and TD
16
Q
what are some overall functioning assessments and info about them?
A
- CGI, (-s = severeity; -i = improvement), observer rated and assess change over time
- GAF, clinician rated and variable results based on clinician eval and experience
17
Q
What are the key features that define psychotic disorders?
A
- delusions
- hallucinations
- disorganized thinking and speech
- disorganized or abnormal motor behavior
- negative symptoms
18
Q
what is the disease course in schizophrenia?
A
- onset late adolescence to early adulthood
- Men – late teens, early 20’s
- women – late 20’s, early 30’s
19
Q
why is there a link to substance use with schizophrenia?
A
- smoking is associated with induction of 1A2, not nicotine, but because of hydrocarbons produced and inhaled, which decreases the serum concentration of 1A2 substrate antipsychotics (apines’)
20
Q
what can marijuana, cocaine, and amphetamines do to schizophrenia?
A
- it can hasten the onset of schizophrenia, exacerbate symptoms, and reduce the time to relapse
21
Q
for antipsychotic drug therapy, what MUST be considered?
A
- doses per day
- side effects
- previous drug therapy
- cost of drug therapy
- concomitant drug therapy
- need for monitoring
22
Q
how are antipsychotic drugs chosen or what is more first line?
A
oral therapy is considered first-line, unless presents with reasons to consider IM depot drug therapy first
23
Q
What are typical antipsychotics? What are some clinical pearls with them?
A
- older agents – primarily D2 antagonists
- efficacy for positive symptoms similar to atypicals
- haloperidol is most common for routine and prn
- more EPS with higher potency typicals
- very effective for positive symptoms but can worsen negative symptoms
24
Q
what are some typical antipsychotics?
A
haloperidol, loxapine, “azines”, chlorpromazine
25
what is there to know about the partial agonists that are atypicals?
1. stabilize dopamine transmission
2. has more akathisia than other antipsychs
3. approved for adjunct tx in depression so all have boxed warning for SI/behavior
26
what is there to know about aripirazole? Brand name?
ABILIFY
1. 2D6/3A4 substrate
2. moderate akathisia
3. low weight gain
27
what is there to know about brexiprazole? Brand name?
REXULTI
- 2D6 and 3A4 substrate
- moderate akathisia
- low-moderate weight gain
28
what is there to know about cariprazine? brand name?
VRAYLAR
- 3A4 substrate
- moderate akathisia
- low-moderate weight gain
29
what is there to know about asenapine? brand name?
SAPHRIS
- sublingual and patch formulations
- 1A2 substrate
- QTc prolongation
30
what is there to know about clozapine? brand name?
CLOZARIL
- 1A2 substrate
- BOXED WARNING: neutropenia, orthostasis, bradycardia, cardiomyopathy
QTc prolongation
31
what are some side effects of clozapine?
1. sedation
2. weight gain
3. constipation
4. dry mouth
5. GI hypomotility
6. hypersalivation
32
What is there to know about olanzapine? Brand name?
ZYPREXA
1. 1A2 substrate
2. significant weight gain and sedation
3. high risk metabolic syndrome
4. DRESS warning
33
what is there to know about quetiapine? brand name?
SEROQUEL
- 3A4 substrate
- QTc prolongation
- weight gain and sedation
- boxed warning for SI
34
What is there to know about the asenapine patch and interactions?
1. apply 1 patch q 24 hours, rotate to minimize application site reactions
2. QTc prolongation warnings
3. UGT & 1A2 substrate: reduce the dose of patch if given with strong 1A2 inhibitors (fluvoxamine)
35
What did you have to do regarding the Clozapine REMS program that was removed last month?
monitor timelines weekly for 6 months, then biweekly for 6 months, then every 4 weeks
36
what drugs are in Lybalvi?
olanzapine/samidorphan
37
what is there to know about Lybalvi?
1. samidorphan added to mitigate weight gain and metabolic syndrome potential of olanzapine
2. samidorphan is an opiod antagonist with preferential activity at the mu opioid receptor.
38
what is there to know about Iloperidone? Brand name?
FANAPT
- high risk of orthostasis an syncope
- QTc prolongation
- 2D6 substrate
39
what is there to know about lurasidone? Brand name?
Latuda
- 3A4 substrate
- higher risk of akathisis
- SI warnings (adjunct for bipolar depression)
- TWF (350 calories) to increase bioavailability
40
what is there to know about ziprasidone? Brand name?
GEODON
- QTc prolongation (CI)
- DRESS warning
- TWF to increase absorption and BA
- 3A4 substrate and aldehyde oxidase (less CYP int.)
41
what is there to know about risperidone? BRAND NAME?
RISPERDAL
- 2D6 substrate (minor 3A4)
- EPS, hyperprolactinemia, weight gain, sedation, orthostasis
42
what is there to know about paliperidone? Brand name?
INVEGA
- renally eliminated; dose adjustments in renal impairment
- similar side effects with risperidone
- QTc prolongation
43
What is there to know about Lumateperone? Brand name?
CAPLYTA
- low risk for weight gain or metabolite side effects
- low risk for EPS or akathisia
- 3A4 substrate
44
what is there to know about pimavanserin? brand name?
1. treatment for hallucinations or delusions in a patient with PD
2. inverse agonists and antagonist at 5HT 2A
3. 3A4 substrate
45
what is there to know about Xanomeline/Trospium? brand name?
COBENFY
- M1/M4 agonist
- 2D6 substrate
- baseline and cont. monitoring LFTs, heart rate
46
what are warnings for all antipsychotics instead of Cobenfy?
1. Boxed warning: increased risk of death in elderly pts. treated with antipsychotics for dementia with related behaviors.
2. metabolic adverse effects
3. EPS
4. risk of somnolence, postural hypotension, and motor and/or sensory instability increases the risk for falls/seizures
5. fall risk assessment should be performed for patients taking other medications or having other disease states that also have a fall/fracture or somnolence/hypotension risk
47
Tell me about haloperidol decanoate?
1. given every 4 weeks
2. load: 20x oral dose
3. maintenance: 10x oral dose
-- if only use maintenance; may need overlap
-- oil-based; z-track
48
what must you do with risperdal consta? (think oral vs. inj.)
MUST supplement with oral risperidone for the first few weeks of treatment (3rd injection (week 4)
49
what is there to know about perseris?
- abdominal SC injection
- 3A4 inducers -- use 120mg dose or may need oral supplementation
50
what is there to know about Rykindo?
- q2wk IM inj
- oral dose overlap is shorter than risperdal consta (7d vs. 21d)
51
What is there to know about Uzedy?
- abdominal or upper arm SC inj.
- given once monthly or q2months
52
What is there to know about invega sustenna (paliperidone)?
1. loading dose, then booster, then every 4 weeks ( starting 5 weeks after loading injection)
2. initial loading dose and booster doses must be given in deltoid to improve absorption consistency.
3. if loading strategy followed, no need for oral overlap antipsych tx
4. may require dose adjustment in mod-sev. renal impairment
53
What is there to know about invega trinza?
1. May be initiated for a patient who has been on a stable monthly (every 4 week) IM injection of Invega Sustenna (only way that it should be used), at least FOUR stable Invega Sustenna doses
2. given deltoid, gluteal = lower cmax
3. not recommended if CrCl <50
4. q 3 month injection
54
what is there to know about invega Hafyera?
1. may be initiated after stable Invega Sustenna for 4 months or stable Invega Trinza after one 2-month dose
2. gluteal injection only
55
what is there to know about Zyprexa Relprevv?
REMS association
- PDSS- post/dose delirium sedation syndrome
56
what is there to know about abilify maintena?
- MUST overlap with oral abilify (or another) for at least 14 days after first injection
- deltoid or gluteal inj.
57
when are there dosing adjustments are there for abilify maintena?
If taking 2D6 or 3A4 inhibitors or 3A4 inducers
for more than 14 days as concomitant therapy --> reduce dose
58
what is there to know about abilify asimtufii?
1. every 2 month dosing
2. gluteal injection only
3. cont. oral abilify for 2 weeks after first injection
59
what is there to know about aristada that is important?
overlap with oral abilify for 3 weeks after first injection unless aristada initio given first
60
What is there to know about aristada initio?
1. developed to avoid need for 21 day oral overlap of antipsychotic
2. avoid in patients who are 2D6 poor metabolizers or with strong 3A4 or 2D6 inhibitors
61
what meds are used commonly for psych emergencies?
haloperidol, chlorpromazine, fluphenazine are used (haloperidol is most common)
62
what medication is given for psych emergencies as an inhalation?
loxapine (adasuve)
63
what meds CANNOT be given at the same time in an injection due to boxed warning of respiratory depression?
olanzapine and benzo via IM inj.
64
what do you do to treat acute dystonia?
IM anticholinergic NOW dose (benz 2mg or diph 50mg)
65
how do you treat drug induced PD?
oral anticholinergic (trihexphenidyl, benadryl, benztropine)
66
how to treat akathisia?
BB (propranolol is preferred)
Benzo (norm lorazepam)
67
how do you treat tardive dyskinesia?
VMAT inhibitors
68
What VMAT inhibitors are we using?
Xenazine, Ingrezza, Austedo
69
what is there to know about Valbenazine? brand name?
INGREZZA
- 2D6/3A4 substrate
- QTc prolongation
70
what is there to know about deutetrabenazine? brand name?
AUSTEDO
- 2D6 substrate
- QTc prolongation
71
what is neuroleptic malignant syndrome? Symptoms?
It is life-threatening and a medical emergency
- Hyperpyrexia, tachycardia, labile blood pressure
- muscle rigidity (elevated) CK, myoglobinuria
72
is treatment supportive for NMS and can one use antipsychs again?
1. treatment is supportive
2. future psych use is not CI and they could be switched to another agent
73
what are some metabolic adverse effects of NMS?
hyperglycemia, hyperlipidemia, hypertension
74
what anti-psychs cause the most and lowest risk of NMS?
MOST: clozapine = olanzapine
LEAST: ziprasidone, lurasidone, aripiprazole
75
what metabolic monitoring needs done with NMS?
personal/family hx, weight, waist cir., BP, A1C/FBG, lipid panel
76
what is the risk of recurrence for depression based on episodes?
1 episode: 50-60%
2 episodes: 70%
3 episodes: 90%
77
What are some pathologies and diseases related to depression?
- chronic pain syndrome
- stroke
- fibromyalgia
- low back pain/ chronic pelvic pain
- bone/ disease related pain
- MS
- Hypo/ hyperthyroidism
- TBI
78
What does recurrence look like for depression and what can symptoms look like with episodes and remission?
1. risk becomes lower over time as duration of remission increases
2. persistent mild symptoms during remission is a predictor of recurrence
3. function deteriorates during the episode and goes back to baseline upon remission
79
for the DSM-5 diagnostic criteria, what MUST one of the symptoms be?
depressed mood or loss of interest or pleasure in doing things
80
what is the mnemonic for diagnostic criteria for the DSM-5 for depression?
SIGE CAPS
1. sleep
2. interest decreased
3. guilt/ worthlessness
4. energy loss/fatigue
5. concentration difficulties
6. appetite change
7. psychomotor agitation/retardation
8. suicidal ideation
81
what are the self administered rating scales for depression and some helpful tips?
1. PHQ-9 --> developed for the primary care setting
2. MDQ --> (can be used to rule out bipolar disorder)
82
what is the risk of suicidality with depression meds?
Boxed warning for suicidality in ALL antidepressant meds (for patients aged < or equal to 24 of age)
83
what are the SSRI meds?
citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
84
what are some clinical pearls with citalopram?
1. dose-dependent QTc prolongation
2. substrate of 2C19 and 3A4
85
what are some clinical pearls with fluoxetine?
1. long half life (96-144hrs)
2. activating potential
3. 2D6, 3A4 inhibitor (norfluoxetine)
86
what are some clinical pearls with fluvoxamine?
indicated for 1A2, 2C19
87
what is there to know about paroxetine?
1. MUST taper due to anticholinergic effects
2. weight gain, sedation
3. septal wall defect risk to fetus
4. inhibitor 2D6, 2B6
88
what is there to know about sertraline?
more GI upset than other antidepressants
89
what are the adverse effects for SSRIs?
sexual dysfunction, increased bleeding risk, hyponatremia (elderly)
90
what side effect does paroxetine cause?
weight gain
91
what side effects does fluoxetine cause?
weight loss
92
what are the SNRI drugs?
desvenlafaxine, duloxetine, venlafaxine, levomilnacipran
93
what is there to know about desvenlafaxine?
1. active metabolite of venlafaxine
2. dose-limiting side effect: nausea
3. no major cyps interactions
94
what is there to know about duloxetine?
1. slow titration to help with nausea
2. hepatotoxicity FDA warning
3. inhibitor 2D6
95
what is there to know about levomilnacipran?
1. MUST adjust in renal impairment or strong 3A4
2. substrate 3A4
96
what is there to know about venlafaxine?
1. must be > 150 mg/day to have NE effects
2. 2D6 inhibitor at higher doses
97
what are the major side effects with SNRIs?
1. blood pressure elevation
2. nausea
3. useful in pain and fibromyalgia
98
what must we monitor for duloxetine?
LFTs at baseline and when symptomatic or every 6 months
99
what is amitriptyline?
a tertiary amine (TCA)
100
what are some adverse effects with TCAs?
1. CNS: sedation, reduced seizure threshold
2. anticholinergic: blurred vision, urinary retention, constipation
3. cardiovascular: orthostatic hypotension, tachycardia
4. other: weight gain, sexual dysfunction
101
why is there a narrow therapeutic index for TCAs and why?
1. fatal overdose as low as 1000mg (4-10 tabs) due to cardiac arrhythmias or seizures
102
what kind of diet is required for MAOis?
tyramine diet
103
what is included in the tyramine diet?
smoked, aged, pickled meats or fish; aged cheeses; yeast; flava beans; wine/beer
104
what is there to know about the mechanism of action of bupropion?
dopamine and NE reuptake inhibitor
- stimulating
105
what side effects can wellbutrin cause?
insomnia and appetite suppresion
106
what dosing form is used in bupropion and what are some clinical pearls with it?
1. XL
2. 2D6 inhibitor
3. CI in seizure or easting disorders
4. can be used in combo
107
what is an important dosing point about mirtazapine?
sedation and increased appetite occur with doses < or equal to 15 mg/day
108
what are the clinical pearls associated with mirtazapine?
Warnings: agranulocytosis, increased cholesterol
- can be used in combo with other drugs
109
what is the dosing for trazodone with sleep vs. depression?
higher doses are needed for depression
110
what are the side effects for trazodone?
orthostatic hypotension; risk of priapism (medical emergency)
111
what is the mechanism for Vilazodone (Viibryd)?
primarily SSRI, may have some 5HT1a agonism which may provide anxiolytic effects
112
what are some important pearls about vilazodone?
- dont use in combo with SSRI/SNRI
- take with food to increase bioavialability and reduce nausea
- substrate 3A4
113
what is the mechanism of vortioxetine (trintellix)
SSRI + 5HT1A agonist + 5HT3 antagonist
114
what are some clinical pearls to know about vortioxetine?
- dont combine with SSRI/SNRIs
- possibly less sexual dysfunction
- substrate 2D6
- nausea
115
what is there to know about serotonin syndrome?
it is a medical emergency
116
what is there to know about antidepressant withdrawal syndrome?
1. common with ALL antidepressants EXCEPT fluoxetine
- antidepressants with anticholinergics, should be tapered no matter what
- NOT life threatening
117
what meds are approved for augmentation?
Apiprazole, brexpiprazole, cariprazine, quetiapine (atypicals)
118
what specific purposes are antidepressants used for?
1. post-partum depression
2. treatment-resistant depression
119
What drugs can cause anxiety?
albuterol, caffeine, decongestants, levothyroxine, steroids, stimulants
120
What is Buspirone? What is its approved use? Target dosing for anxiety and how long to work?
1. 5HT-1a receptor agonist
2. GAD
3. 10-15 mg tid
4. 3-4 weeks for initial efficacy
121
what is the overall efficacy of using benzos even though they are not a main priority in anxiety due to potential abuse?
much higher than other treatments such as SSRIs
122
what are some side effects/warnings with benzos? how long should they be used?
1. not used for long term
2. acute withdrawal can cause seizures
3. warnings with other CNS depressants and overdose death risk --> particularly with opioids
123
what benzos do not have an active metabolite and are less likely to have a fall risk?
alprazolam, lorazpeam, clonazepam, oxazepam
124
what benzos have a long acting metabolite?
diazepam, clorazepate, chlordiazepoxide
125
what are the side effects if benzos?
sedation, paradoxical excitement, swallowing difficulties, impairment of memory and recall, and psychomotor impairment
126
what do you have to do for discontinuation of benzos?
slow taper over weeks to months
127
if used in elderly, what medications do we prefer if we use it?
LOT (lorazepam, oxazepam, temazepam
128
what is hydroxyzine used for and how is it most commonly used?
1. FDA approved for GAD
2. as needed for anxiety/ insomnia instead of benzo
129
what are some common side effects with hydroxyzine and who should avoid these medications?
- sedation and anticholinergic effects
- QTc prolongation
- avoid in elderly
130
what is propranolol useful for and its action? What must be evaluated before using?
1. dec. psychological symptoms of acute anxiety
2. performance or situational anxiety
3. low doses
4. eval for hx/current asthma and cardiovascular conditions
131
What can kava cause?
hepatotoxicity
132
what is there to watch out for with St. John's Wort? (side effect wise)
1. it is a strong 3A4 inducer
- mild MAO inhibitor
- do not take with other antidepressants or serotonergic drugs --> serotonin syndrome risk
133
what is important to know about valerian?
avoid use in pregnancy
134
What is there to know about the use of passionflower?
avoid in pregnancy due to a risk of uterine stimulation
135
when should chamomile be avoided?
avoid with blood thinners and ragweed allergy
136
when are gabapentinoids considered in a patient in anxiety?
when they have bipolar and have comorbid neuropathic pain
137
what is the first line medication for all anxiety disorders?
SSRIs and SNRIs
138
what is another medication that is used for GAD?
buspirone
139
when are benzos considered in anxiety disorder treatment?
only if necessary
140
what is the clinical evidence relating abilify and risperidone (atypicals) according to FDA?
not approved in anxiety but show benefit on treatment-resistant OCD
141
what is GAD presented as or how does it present? name symptoms and how many yu need
1. excessive worry/anxiety
2. need 3 of following symptoms:
- restless
- fatigue
- difficulty concentrating
- irritable
- muscle tention
- sleep issues
3. need to be present for at least 6 months
142
What is the treatment for GAD? Any important info for treatment?
1. SSRIs (2-4 wks for onset relief)
2. useful as 1st line if pain syndrome (SNRI)
3. benzo
--> must taper if LT dose and bridge therapy needed to cover time of SSRI/SNRI
4. buspirone
5. hydroxyzine prn
--> QTc prolongation risk
143
what is considered for social anxiety disorder?
1. persistent fear about social and/ or performance situations in which the patient fears embarrassment or humiliation that is unreasonable
2. specific situations may be avoided in a manner that interferes with the patient's normal routine
3. duration of symptoms for at least 6 months
144
what is the treatment like for SAD?
1. SSRIs
2. BBs for non-generalized performance related SAD
145
what is considered as panic disorder?
1. recurrent, unexpected panic attacks
2. an abrupt surge of intense fear or discomfort by at least 4 physical and psychological symptoms, including sweating,
palpitations, nausea, dizziness, fear of losing control, “going crazy”, or dying
3. at least one attack has been followed by one month or more of at least one of the following (behavior changes)
146
what is the treatment for panic disorder?
SSRI/SNRI
147
what should not be considered first line unless inadequate response to serotonergic meds?
benzos
148
in OCD what is the obsession side of things?
recurrent thoughts or images that are intrusive and cause anxiety; patient attempts to ignore, suppress or neutralize with other thoughts or actions
149
in OCD what is the compulsions side of things?
repetitive behaviors or mental acts performed in response to obsession; aimed at reducing or preventing distress; not always connected in a realistic way to the fear
150
In the treatment of OCD; what is used for treatment, what helps and is also used for OCD if needed?
1. SSRIs first line
2. TCAs second
3. 25-50% reduction can be expected in symptoms
4. antipsychs can be considered as augmentation with SSRI/SNRI (risperidone/abilify)
151
what is considered PTSD?
1. exposure to real or threatened death, serious injury, or sexual violence (either victims, witness, discovery, exposure to details of traumatic event)
2. flashbacks, re-experiencing, avoidance, hypervigilance
3. negative alterations in mood or cognition
152
what is used for treatment of PTSD? what is not used? what should be implemented along with medication for PTSD?
1. SSRI/SNRI is first line (only approved class)
2. benzos NOT recommended
3. CBT and EMDR may be helpful
153
what is common with PTSD in addition to PTSD? (think treatment/other issues)
polytherapy and substance use
154
when Jitteriness occurs from SSRIs/SNRIs, how is that handled?
lower doses to minimize
155
what should you do regarding benzos with anxiety before bridge therapy or d/cing meds?
1. eval severity on functionality impact
2. abrupt stop can be life threatening
156
What meds, disease state, substances are associated with insomnia?
anxiety, hyperthyroidism, caffeine, modafinil, amphetamines, beta-agonists, bbs, nicotine, thyroid meds, bupropion, decongestants, methylphenidate
157
what is considered an insomnia disorder from DSM-5?
1. difficulties with sleep initiation (latency), sleep maintenance, and/or early-morning awakening
2. takes place at least 3 nights per week
3. present at least 3 months
158
what is used for treatment of insomnia disorders?
1. first line is non-pharm
--> sleep hygeine
2. z-hypnotics are most common sleep meds
159
what are some of the z-hypnotics, what are some side effects, and issues with them?
1. zolpidem, eszopiclone, Zaleplon
2. CYP 3A4 substrates
3. somnolence, dizzy, ataxia, headaches, parasomnias
4. potential for misuse since controls
5. addictive
160
what is a common side effect patients think of when taking lunesta (eszopiclone)?
metallic taste
161
what main warning do all sleep meds have?
unusual actions while a person is sleeping (warning for all meds used for sleep)
162
what is there to know about the MAR (melatonin receptor agonists)? drugs?
1.ramelteon and tasimelteon
2. CI with fluvoxamine
3. GI upset, next day somnolence, hyperprolactinemia, prolactinoma
4. 1A2 substrates
163
what is tasimelteon fda-approved for?
FDA approved for non-24 sleep-wake disorder in adults
164
what are the 3 orexin receptor antagonsits?
suvorexant (belsomra), lemborexant (dayvigo), daridorexant (quviviq)
165
what is there to know regarding all Orexin receptor antagonist medications?
1. need at least 7 hours of sleep
2. CI in narcolepsy -- causes narcolepsy like side effects
3. 3A4 substrate
166
what info is there to know about doxepin regarding insomnia? brand name?
SILENOR
TCA -- low doses exert effect through H1 receptor antagonism
1. anticholinergic side effects
167
what is there to know about trazodone regarding insomnia?
1. not FDA approved for insomnia
2. long half life --> may see daytime hangover
168
What is there to know about mirtazapine for insomnia?
clinically used as sleep agent, especially in patients with depression who have difficulty sleeping
169
what is there to know about quetiapine for insomnia?
low dose quetiapine is not recommended for us in insomnia unless there is a co-morbid psychiatric disorder
170
when is melatonin considered for sleep? interactions?
can be considered in jet lag and people with low melatonin levels
- cyp 1A2
171
what is the first line treatment for anxiety?
CBT and behavior therapy
172
what is considered Obstructive sleep apnea?What are the symptoms?
1. patient must have evidence of at least 5 obstructive apneas per hour of sleep confirmed by polysomnography
2. symtpoms include excessive daytime sleepiness, snoring, pauses in breathing during sleep, headache, irritable, sore throat, ed, impaired memory, gerd, mood disturbance
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if a patient has insomnia and sleep apnea (which is more common), how are they treated?
both conditions
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According to the diagnostic testing for sleep aapnea when can you not use a polysomnography?
significant cardiorespiratory disease, potential muscle weakness from neuro-musclar conditions, sleep-related hypoventilation, chronic opioid use, Hx of stroke, severe insomnia
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How is sleep apnea treated?
1. weight loss, smoking cessation, avoid alcohol and CNS depressant, sleep on side
2. CPAP machine
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what can you do if treating excessive daytime sleepiness from sleep apnea?
modafinil or armodafinil
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what is considered as narcolepsy?
recurring episodes of irresistible need to sleep, fall asleep, or nap; three times per week over the past 3 months (excessive daytime sleepiness)
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what is the narcolepsy tetrad? how often does it occur?
1. EDA (more severe in type 1) 100%
2. cataplexy (sudden loss of muscle tone triggered by emotion) 75%
3. hallucinations (30-60%)
4. sleep paralysis (25-50%)
5. all 4 symptoms(10-33%)
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If a patient has cataplexy, what is used? sodium content ? who can use it?
1. sodium oxybate(xyrem) -- ghb -- high sodium
2. Xywav -- adults and children aged 7 or older, also approved for idiopathic hypersomnia in adults -- lower sodium content
3. lumryz -- for adults only -- ER dosage form, once nightly dosing, high sodium
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What else can we give for excessive daytime sleepiness since modafinil/armodafinil is associated with life-threatening rash?
1. sodium oxybate
2. Pitolisant and solriamfetol (recently approved)
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What is there to know about Pitolisant (Wakix)? Specifically MOA and Interations.
1. H3 Receptor antagonist/ Inverse agonist
2. CI in severe hepatic impairment (not recommended if impairment at all)
3. 2D6/3A4 substrate
4. weak 3A4 inducer -- may reduce effectiveness of oral contraceptives
5. avoid use with centrally-acting H1 receptor antagonists (OTC)
6. Prolongs QT interval
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what is there to know about Solriamfetol?
- DNRI
- indicated for improvement in wakefulness in adults with EDS
- mod renal impairment (start slow and increase)
- WARNING: B/P and HR increases (avoid if unstable CV and arrythmias)
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what can you give for shift work sleep disorder? when do you take it?
modafinil and armodafinil are drugs of choise, taken 1 hour before work period starts during "wake time".
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what is the drug therapy for restless legs syndrome?
1. gabapentin encarbil - prodrug of gabapentin, FDA approved, may be 1st line
2. dopamine agonists (IR form) -- pramipexole or ropinirole
3. iron supplements may be considered
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according to the DSM-5, what is considered anorexia nervosa?
1. restriction of energy intake leading to significantly low body weight
2. intense fear of gaining weight or becoming fat
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what is a common co morbidity with anoerexia?
depression
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what are the two types of anorexia?
restricting and binge-eating/purging
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what is the specifiers of anorexia?
BMI
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what does the CDC consider to be for the BMI on the low end of normal?
18.5
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what are some health consequences that one can have with anorexia?
1. abnormally slow heart rate, low bp
2. decreased bone density
3. weakness
4. electrolyte abnormalities, hypoglycemia
5. dry skin; hair loss
6. severe dehydration
7. downy layer of hair all over body
8. cold intolerance
9. delayed gastric emptying
10. constipation
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what is the treatment focus for inpatient hospitalizations?
treatment of acute risks
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what is the treatment focus for outpatient hospitalization?
treatment of chronic symptoms and relapse prevention
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what is re-feeding syndrome? how does it happen?
1. results in shift from fat metabolism to glucose metabolism
2. hypokalemia, water retention, and severe edema
3. multiple organ failure
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what is the treatment regarding re-feeding snydrome?
increase calories slowly
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what other treatment is needed for anorexia ? what meds are CI?
1. cognitive behavioral therapy
2. bupropion
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what is considered as binge eating disorder?
1. recurrent episodes of binge eating
2. at least once a week for 3 weeks
3. NOT associated with the recurrent use of inappropriate compensatory behavior
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what is the specifier for bing-eating disorder? what do they look for?
episodes
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what are some health consequences of binge-eating disorder?
similar to obesity (HTN, high chol.)
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what medication is used for treatment of binge eating disorder?
vyvnase along with CBT
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what is considered as bulimia?
1. recurrent episodes of binge eating
2. recurrent inappropriate compensatory behaviors
3. at least once a week for 3 months
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what is the specifier for bulimia?
episodes
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what are some health consequences of bulimia?
1. recurrent bingeing and purging can affect the entire digestive tract
2. inflammation, gastric rupture, and esophageal rupture from frequent vomiting
3. diabetic ketoacidosis from withholding insulin in type 1 DM.
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what are the esophageal ruptures called from purging in bulimia?
mallory weiss tears
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what are some methods of purging?
vomiting, laxatives, diuretics, excessive exercise, diabulimia
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what medication is fda approved for bulimia treatment?
fluoxetine
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what is the overall rate of ADHD if a first-degree relative has it? Also what is the etiology?
higher rate and multifactorial
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what is the clinical course of adhd? (is there co-morbid conditions and what is the diagnosis into adulthood?)
1. one-third of children with ADHD will have the diagnosis in adulthood
2. increased risk f substance use and antisocial personality disorder if ADHD is left untreated
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what is the ADHD diagnostic criteria?
1. each symptom domain, must have at 6 symptoms present and present in two or more settings
2. for older adolescents/ adults (17 and older), at least 5 symptoms are required for either of the two specifiers
--> several inattentive or hyperactive symptoms must be present prior to age 12 years and present in two or more settings
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What is there to know about stimulant dosing?
dose response effects seen in a short period of time
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what is there to know about the different formulations of stimulant dosings and counseling with it?
1. late afternoon symptoms may require longer - acting formulation
2. avoid giving dose too late in the day, may give an after-school dose
3. don't use two different stimulants; can use two different dosage forms of the same stimulant
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what formulation is preferred for patients < 16 kg? What is this due to?
IR
- limited low-dose availability of long-acting stimulants
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What is there to know about Mydayis? What formulation?
1. mixed amphetamine salts
2. age 13-17
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what is there to know about Daytrana? What formulation?
1. methylphenidate
2. patch
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what is there to know about vyvanse? what formulation?
1. prodrug converted to dextroamphetamine
2. lisdexamfetamine
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What is there to know Jornay PM? What formulation?
1. take dose in the evening between 6:30-9:30 pm
2. methylphenidate hydrochloride
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what are adverse effects of stimulants?
1. appetite loss
2. sleep disturbances
3. decreased growth
4. increased BP
5. increased HR
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If you have a side effect of reduced appetite, weight loss, what do you do?
high- calorie meal when stimulant effects are low (breakfast, dinner)
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If you have a side effect of insomnia, what do you do?
dose earlier in day, lower last dose of day or give earlier, consider sedating med at bedtime
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If you have a side effect of rebound symptoms, what do you do?
longer-acting stimulant trial, atomoxetine, antidepressant
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what would you do for the uncommon symptom of inc. BP or HR with stimulants?
reduce dose, change stimulant
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what would you do for the uncommon symptom of hallucinations with stimulants?
d/c stimulant, reassess diagnosis
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what would you do for the uncommon symptom of sudden cardiac death risk in stimulants?
risk no greater in clinical trials than general population -- assess risk; if concern, cardiac ECHO
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what is the monitoring for stimulants?
appetite, behavior, blood pressure, growth rate (height/weight), heart rate, sleep, ECG (considered on cardiac risk)
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what are the alpha 2 agonists with adhd? Important info?
guanfacine ER -- 3A4 substrate
clonidine ER
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what are the NE reuptake inhibitors?
atomexetine and viloxazine
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what is there to know about atomoxetine?
2D6 substrate & weight based dosing
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what is there to know about viloxazine?
capsules- swallow whole or put in applesauce
- 2D6/UGT substrate: strong 1A2 inhibitor
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what are the side effects of a2 agonists?
decreased HR and BP, orthostasis, somnolence, dizziness, rebound HTN if abrupt d/c
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what are the NE reuptake inhibitors side effects?
increased HR and BP, increased in suicidal thinking (boxed warning)
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what are the monitoring for non-stimulants?
appetite, blood pressure, HR, LFTs (atomoxetine)
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What is there to know about bupropion?
1. Not FDA-approved for ADHD
2. 2D6 inhibitor
3. CI in seizure disorders and eating disorders
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What is there to know about TCAs for ADHD?
1. less effective than methylphenidate
2. cardiac concerns -- sudden cardiac death in children, lethal in overdose
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What is there to know about mood stabilizers for ADHD?
1. may be useful if there is comorbid bipolar disorder, conduct disorder, intermittent explosive disorder
2. should not use atypical antipsychotics as monotherapy
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what is the first line treatment for preschool age children?
methylphenidate
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what is the first line for elementary/ middle school/ adolescents?
1. stimulants
2. atomexetine, guafacine ER, clonidine ER
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what is the guideline for adjunctive tx for ADHD?
1. only guanfacine ER and clonidine ER have evidence as adjuncts to stimulants
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what is the NICE guidelines in terms of line treatment?
1. methylphenidate or lisdexamfetamine
2. dextroamphetamine
3. atomoxetine
