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YSM Semester 3 > Geri + Psych Pharm > Flashcards

Geri + Psych Pharm Flashcards

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1
Q

Describe the WHO analgesic ladder

A

Step 1: NSAID +/- adjacent

Step 2: Low potent opioid (codeine)
+/- Step 1

Step 3: use of high potent opioid (piritramine)
+/- step 1

Step 4: interventional treatments
+/- Step 1-3

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2
Q

What is the MOA and AEs for NSAIDs

A

MOA: COX inhibitor - prevents COX from forming prostaglandins
- decreases inflammation + pain

AEs
- inhibits platelet aggregation: bleeds
- renal/hepatic impairment
- GI AEs: ulcers, bleeds

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3
Q

What are some co-analgesics and adjuvants?

A

antidepressants
anticonvulsants
corticosteroids

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4
Q

Define polypharmacy. What are issues associated with it?

A

use of at least 5 medications
- can increase AEs
- can decrease proper adherence

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5
Q

Describe the prevalence, risk factors, and clinical implications of polypharmacy in the elderly

A

~40% of 65+ have polypharmacy

unintended consequences: can mimic geriatric syndrome

pill-burden: increases non-adherence and cost

common meds with drug-drug interactions

increased number of meds associated with
- falls + dizziness
- AEs
- hospitalizations

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6
Q

Describe the indications, MOA, and AEs of MAO inhibitors

A

agents: Phenelzine, tranylcypromine, isocarboxazid

MOA: inhibits monoamine oxidase
- enzyme that metabolizes 5TH, HE, DA

AEs
- hypertensive crisis: requires low tyramine diet (no cheese, smoked meats, wine, beans, liver)
- orthostatic hypotension
- Serotonin syndrome
- sexual dysfunction
- weight gain

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7
Q

Describe the difference between secondary and tertiary amine tricyclic antidepressants. What are their indications?

A

secondary: blocks reuptake of NE only
- desipramine, nortryptyline

tertiary: blocks reuptake of 5HT and NE
- imipramine, amitriptyline, clomipramine

also blocks ACh, histamine, and alpha adrenergic receptors

indications
- second line for anxiety + depression
- depression + chronic pain
- neuropathic pain
- migraine PPX
- clomipramine: OCD
- Imipramine: nocturnal enuresis

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8
Q

What are the AEs, drug interactions, and contraindications of tricyclic antidepressants

A

AEs
- orthostatic hypotension
- anticholinergic block: dry mouth, blurry vision, confusion, urinary retention, constipation
- alpha-1 blockade: long QT, arrhythmias
- H1: sedation, weight gain
- CNS: confusion, hallucinations
- fatal overdose: cardiac arrhythmia, seizures

drug interactions:
- Serotonin syndrome
- anticholinergic toxicity - hyperthermia, tachycardia, delirium, mydriasis, ileus, urinary retention

Contraindications
- tertiary amines: avoided in elderly due to side effect profile
- secondary amines less likely to cause anticholinergic effects

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9
Q

What is the MOA and indications for SSRIs?

A

agents: fluoxetine, paroxetine, sertraline, citalopram, escitalopram, fluvoxamine

MOA: inhibition of 5HT reuptake in synaptic cleft = increased 5HT

Indications
first-line: MDD, generalized anxiety , PTSD, panic disorder

premature ejaculation
premenstrual dysphoric disorder
binge-eating disorder
bulimia nervosa
somatic symptom disorder
gambling disorder
IBD
social anxiety disorder

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10
Q

How long does it take for SSRIs to take effect? What are the early and late AEs?

A

takes about 4-6 weeks to see significant change in 5HT in blood levels

early AEs: onset/resolution within 1 week
- headache,
- diarrhea, NV
- activating effects: agitation, anxiety, insomnia

Late AEs
- sexual dysfunction: anorgasmia, decreased libido, ED/ejaculatory dysfunction
- SIADH + hyponatremia
- Serotonin syndrome - typically mild symptoms: nausea, mild tremor

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11
Q

What are the drug interactions and contraindications of SSRIs?

A

Drug interactions: increased risk of 5HT syndrome if used concomitantly with other serotonergic drugs

contraindications: paroxetine in pregnant patients
- first trimester: fetal cardiovascular malformation
- third trimester: fetal pulmonary HTN

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12
Q

What is the MOA and indications for SNRIs?

A

agents: venlafaxine, duloxetine, desvenlafaxine, levomilnacipran

MOA: inhibits 5HT and NE reuptake in synaptic cleft = increased 5HT and NE

indications
second line: MDD, general anxiety disorder
neuropathic pain/diabetic neuropathy

duloxetine: stress incontinence

duloxetine + milnacipran: fibromyalgia

venlaxafine:
social anxiety disorder
OCD
panic disorder
PTSD

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13
Q

What are the AEs of SNRIs?

A

takes about 4-6 weeks to see significant change in 5HT in blood levels

similar to SSRI
- stimulant effects
- increased BP: should be well-controlled before + after initiating SNRI
- insomnia, strange dreams, nightmares
- can increased cholesterol + triglycerides
- nausea
- 5HT syndrome

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14
Q

What is the MOA of trazodone + nefazodone?

A

MOA: blocks postsynaptic type 2 5HT receptors (5HT2)
- weak inhibition of 5HT reuptake = increased 5HT
- antagonist of H1 + alpha 1 adrenergic receptors

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15
Q

What are the indications and AEs of trazodone + nefazodone?

A

MOA: blocks 5HT2 receptors

indications
- mainly used as adjunct to other antidepressants for insomnia with depression
- insomnia
- MDD - requires high dose

AEs
- priapism
- H1 antagonist: sedation
- alpha-1-adrenergic antagonist: orthostatic hypotension
- nausea
- 5HT syndrome

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16
Q

Describe the MOA and indications of mirtazapine

A

MOA: selective alpha-2 adrenergic antagonists = increases 5TH and NE release
- 5HT2/3 receptor antagonist = increased effect of 5HT on free 5HT1R

indications: MDD - especially patients who are underweight and/or have insomniaW

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17
Q

What are the AEs of mirtazapine?

A

MOA: selective alpha 2-adrenergic antagonist = increases 5HT + NE release

AEs
- increased appetite + weight gain
- H1 antagonism: sedation
- increased serum cholesterol + triglycerides
- dry mouth

minimal sexual side effects

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18
Q

What are the indications and AEs of bupropion?

A

unknown MOA

indications
- smoking cessation
- MDD

AEs
- stimulant effect
- tachycardia, palpitations
- weight loss
- neuropsychiatric: insomnia, agitation, headache
- dry mouth
- no sexual side effects/weight gain

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19
Q

What are the contraindications, pros and cons of bupropion?

A

contraindications
- relative: reduces seizure threshold
- eating disorders

pros:
- less sexual side effects, weight loss
- good augmentation to SSRI

Cons
- contraindiations in seizures + eating disorders
- does not help anxiety

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20
Q

Describe the MOA and indications for trazodone

A

MOA: block postsynaptic type 2 serotonin receptors (5HT2)
- H1 and alpha 1-adrenergic receptors

indications
- mainly an adjunct to other antidepressants for insomnia associated with depression
- insomnia
- MDD - requires high dose

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21
Q

What are AEs of trazodone?

A

priapism
sedation - due to H1 antagonism
orthostatic hypotension
nausea
can cause 5HT syndrome

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22
Q

Describe the MOA and indication for buspirone

A

MOA: partial 5HT1A receptor agonist
- D2 receptor antagonist

indication: second line for anxiety disorder
requires consistent daily intake of at LEAST 2 weeks = delayed onset of action
- NOT used for acute treatment

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23
Q

What are the AEs of buspirone?

A

nonbenzodiazepine anxiolytic (partial 5HT1A receptor stimulation agonist

AEs
- headache
- dizziness, nausea
- risk of 5HT syndrome
- seizures resulting from chronic use

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24
Q

Describe the MOA, indications, and AEs of varenicline

Study These Flashcards
A

MOA: partial nicotinic ACh receptor agonist
- stimulates DA activity
- decreases nicotine cravings + withdrawal

Indication: smoking cessation

AEs
sleep disturbances
seizure

25
What are the risk factors for serotonin syndrome?
risk factors: - use of serotonergic drugs - switching from one serotonergic drug to another without tapering - OD anything that increased 5HT in the synapse. some random meds include - anticonvulsants: valproate - opioids: tramadol, meperidine - NMDA receptor antaginist: dextromethorphan - antibiotics: linezolid - herbal supplements: St. John's wort, ginseng, tryptophan - recreational stimulants: NMDA, cocaine
26
What are the clinical features of serotonin syndrome?
acute onset (with 24 H) and resolution (within 24 H of treatment) Classic triad - autonomic dysfunction: diaphoresis, tachycardia, HTN, mydriasis (dilated pupils) - neuromuscular excitability: hyperreflexia, myoclonus, hypertonicity, rigidity; can lead to hyperthermia - AMS: delirium, psychomotor agitation, coma other features - NVD - Anxiety - Hypotension - Seizure
27
What is the treatment for serotonin syndrome?
discontinue all serotonergic drugs immediately treat the symptoms moderate/refractory: consider cyproheptadine - 5HT2A antagonist
28
What is discontinuation syndrome? What are its clinical features?
caused by abrupt withdrawal or dose reduction of antidepressants taken ≥ 4 weeks - occurs within 3 days after drug cessation clinical features - flu-like symptoms - insomnia: vivid dreams, nightmare - nausea - imbalance: gait instability, dizziness/vertigo, lightheaded - sensory disturbances: paresthesia - hyperarousal - dysphoria, irritability - psychosis - esp with MAOI
29
Describe the MOA and indications for methadone
MOA: long-acting, FULL opioid agonist - binds to receptors = reduced euphoric effect of subsequent opioid use indications: withdrawal detoxification + longer-term treatment - must be licensed opioid treatment program to prescribe
30
What are the AEs, drug interactions, and contraindications for methadone?
AEs - lightheaded/dizzy - sedation - NV - sweating - QT prolongation + Torsades de Pointes drug interactions - metabolized by CYP3A4 - can cause 5HT syndrome contraindications - respiratory depression - severe bronchial asthma - paralytic ileus
31
What are the MOA and indications for buprenorphine?
MOA: PARTIAL opioid agonist - high affinity to mu receptors + slow-dissociation kinetics - milder and less uncomfortable withdrawal symptoms - ceiling effect on respiratory depression indications: opioid detoxification + maintenance
32
What are the AEs, drug interactions, and contraindications for buprenorphine?
AEs - sedation - NV - Dizziness - constipation BLACK BOX: - respiratory depression: accidental exposure can be fatal - neonatal opiate withdrawal Drug interactions: - concomitant use with benzodiazepines/CNS depressants - metabolized by CYP3A4 - risk of 5HT syndrome contraindications - GI obstruction (paralytic ileus) - substantial respiratory depression - acute/severe bronchial asthma
33
What is the MOA and indications for naltrexone?
MOA: opioid ANTAGONIST - blocks effects of opioids if used - blocks mu receptors + euphoric effects = alters reinforcement Indications - maintenance treatment to prevent OUD: most effective in highly motivated/closely supervised pts - alcohol dependence - smoking cessation - weight management with bupropion
34
What are the AEs, drug interactions, and contraindications for naltrexone?
AEs - somnolence - headache - NV - fatigue, insomnia - Anxiety - decreased appetite - depression BLACK BOX WARNING: dose related hepatotoxicity - Requires monitoring of LFTs drug interactions: - pts will not receive therapeutic beneficiaries from any opioid agonists - disulfiram - both potentially hepatotoxic - opioid use within 14 days contraindications - acute opioid withdrawal - non detoxified pts - acute hepatitis/hepatic failure
35
What is the MOA, indications, and AEs of naloxone?
MOA: centrally acting, competitive opioid receptor antagonist - higher affinity: removes opioid from receptors - RAPID acting: HL 30-90 minutes indication: acute opioid intoxication/overdose - EMERGENCY - reverses respiratory depression AEs acute opioid withdrawal - anxiety - aggression - NVD - abdominal pain - rhinorrhea can also precipitate pulmonary edema NO absolute contraindications in an emergency setting
36
Describe the MOA, indications, AEs, contraindications, and monitoring for acamprosate
MOA: GABA-like drug that acts on same NMDA receptor system affected by chronic alcohol use indications: alcohol use disorder AES: - diarrhea - asthenia: abnormal loss of strength - depression Contraindications Severe renal impairment: ClCr < 30 mL/min Monitoring: - baseline Cr - Depression and suicidality
37
What is the MOA, indications, and reaction for disulfiram?
MOA: blocks aldehyde dehydrogenase enzyme - hepatic enzyme that breaks down alcohol - blocking enzyme = prevents acetylaldehyde from becoming acetate Disulfiram reaction: alcohol intake increases serum acetylaldehyde, causes: - diaphoresis - palpitations - facial flushing - nausea - vertigo - hypotension + tachycardia indications: alcohol dependence - pt must be highly motivated + understand rxn - must be abstinent from alcohol > 12 hours
38
What are the AEs, drug interactions, and contraindications of disulfiram? What labs do you need to monitor?
AEs - drowsiness - hepatotoxicity - neuropathy, optic neuritis - psychosis, confusion - metallic/garlic-like aftertaste drug interactions - increase serum barbiturates + anticoagulants - isoniazid: AMS - contraindicated drugs: alcohol, metronidazole Contraindications - alcohol - metronidazole: acute psychosis/confusion - severe myocardial disease - coronary occlusion - psychosis
39
What is the MOA and indications for flumazenil?
MOA: benzodiazepine receptor antagonist - competitively inhibits benzodiazepine from binding to GABA receptor - rapidly reverses CNS depression - does NOT reliably reverse respiratory depression Indication: benzodiazepine overdose emergencies - not routinely recommended for reversal of sedative overdose in ED
40
What are the AEs, drug interactions, and contraindications for flumazenil?
AEs: - seizures - tachyarrhythmias - acute benzodiazepine withdrawal - aggressive behavior/agitation - NV - abdominal cramping drug interactions: - cyclic antidepressants: increased risk of seizures Contraindications: - chronic benzodiazepine use - history of seizure - contraindicated use of cyclic antidepressants - suspected co-injection of proconvulsive or proarrhythmic substances
41
give examples of short, intermediate, and long acting benzodiazepines. What are their half-lives?
Short: 1-12 hr HL: midazolam, triazolam Intermediate: 12-40 Hr HL: lorazepam, alprazolam Long acting: > 40 hour HL: diazepam, chloridiazepoxide
42
What is the MOA and indications for benzodiazepines?
MOA: indirect GABA A receptor agonist - increases opening frequency of Cl channels causes hyper polarization - decreases neuronal excitability Indications: - seizures + status epilepticus: first line - alcohol withdrawal: first line - insomnia - anxiety (second line to SSRI/SNRI) - short term panic disorder - preop/procedural sedation
43
What are the AEs and contraindications for benzodiazepines?
AEs - anterograde amnesia - confusion - blunted effect, residual sedation - reduced coordination - risk of OD when used with ofter CNS depressants - tolerance + withdrawal - risk of SUD - CYP450 induction contraindications - narrow-angle glaucoma - respiratory depression: COPD, respiratory failure - myasthenia gravis - history of SUD - pregnancy EXCEPT for unresponsive eclampsia
44
What are the first, second, and third line treatments for ADHD?
first: stimulants second: atomoxetine, guanfacine, clonidine third: bupropion, modafinil
45
What is the MOA and indications for methylphenidate?
ritalin - stimulant MOA: increased release and blocked reuptake of NE and DA - increase mental performance + fine motor skills indications: ADHD in children ≥ 6 + adults
46
What are the AEs, drug interactions, and contraindications of methylphenidate?
ritalin AEs - decreased appetite + weight loss - headache - insomnia - dizziness - abdominal pain - nervousness - emotional lability - dry mouth - LOWERS SEIZURE THRESHOLD - increased risk risk associated with excessive use - cardiovasulcar failure - irregular heartbeat - HTN - paranoia contraindications: MAOI within last 14 days - can cause HYPERTENSIVE CRISIS
47
What is the MOA and indications for atomoxine?
non-stimulant MOA: selective NE reuptake inhibitor - less effective, slower onset than stimulants indications: - non stimulant treatment of ADHD - pt does not respond/tolerate stimulants - pt/family history of SUD
48
What are the AEs and contraindications of atomoxine?
non stimulant ADHD treatment AEs - NV, abdominal pain - weight loss + decreased appetite - tachycardia - headache - insomnia BLACK BOX: increased risk of SI in children/adolescents Contraindications: - recent MAOI use = hypertensive crisis - angle-closure glaucoma
49
What is the MOA, indications and duration of guanfacine and clonidine?
non-stimulant ADHD meds MOA: alpha-2 receptor agonist - inhibits presynaptic NE release + increases blood flow to the prefrontal cortex - not as affective as stimulants for mono therapy duration: - Guanfacine: 18 H - clonidine: 12 H indications: children with ADHD aged 6-17 with - contraindication or preference against stimulants - adjunctive therapy to stimulants
50
What are the AEs of guanfacine and clonidine?
non-stuimulant ADHD treatment for children AEs - orthostatic hypotension - abrupt cessation can cause rebound HTN - sedation + dizziness (clonidine > guanfacine) - respiratory depression - miosis - pupil constriction - dry mouth - rash - bradycardia
51
What are the first generation antipsychotics? What are the high and low potency meds?
High potency: haloperidol, fluphenazine, trifluphenazine Low potency: thioridazine, chlorpromazine
52
What is the MOA and indications for the first generation antipsychotics?
FGAs: haloperidol + "-azine" MOA: Dopamine D2 specific antagonists - reduces positive symptoms indications: - schizophrenia - bipolar - Tourette - acute psychosis - acute agitated states - OCD - Huntington
53
What are the common AEs for FGAs? List the common and specify AEs for high vs low potency
Common - Hyperprolactinemia - QT interval elongation/Torsades de Pointes - Neurologic malignant syndrome: high fever, AMS, muscle rigidity, autonomic instability
54
What are the AEs specific to high potency FGA?
extrapyramidal symptoms: dystonia - painful muscle contracture - within minutes akathisia: motor restlessness - most common extra pyramidal symptom - within days tardive dyskinesia: persistent, involuntary choreoathetoid movements of head, neck, trunk - 3-6 months of treatment
55
What AEs are specific to low potency FGAs?
antimuscarinic + anticholinergic effects - Dry mouth - urinary retention/constipation - blurred vision secondary to pupil dilation H1 histamine receptor antagonist - sedation Alpha-1 adrenergic blockade - orthostatic hypotension - tachycardia Ophthalmologic side effects - thioridazine: retinal deposits - chlorpromazine: corneal deposits
56
What are the second generation/atypical antipsychotics? What is their MOA and indications?
agents: clozapine, risperidone, paliperidone, ilioperlidone, arippirazole, brexpiprazole, ziprasidone MOA: - blocks D2 receptors in CNS - blocks 5HT2A receptors - blocks H1 receptors - blocks muscarinic receptors (less than FGAs) Indications: - schizophrenia: negative and positive symptoms - Tourette - treatment-resistant depression - OCD: adjunctive with SSRI
57
What are the AEs of SGA/atypical antispsychotics?
AEs - metabolic effects (mostly clozapine + olanzapine, lowest risk is ziprasidone) - weight gain - dyslipidemia - hyperglycemia/DM Similar to low potency FGA - H1 block = sedation - alpha-1 block = orthostatic hypotension - antimuscarinic block (esp clozapine): dry mouth, constipation, blurred vision, urinary retention similar for FGA, but less severe - Extrapyramidal: acute dystonia, akathisia, Parkinsonism (risperidone has greatest risk) - elevated prolactin - neuroleptic malignant syndrome: AMS, rigidity, autonomic instability, fever, rhabdo - QT elongation/Torsades de Pointes
58
Describe clozapine and its specific AEs
Second generation antipsychotic BIG AEs AGRANULOCYTOSIS: granulocyte count < 500 - monitoring: biweekly 6 months, monthly 6 months, once monthly after a year MYOCARDITIS/CARDIOMYOPATHY PE/DVT LOWERS SEIZURE THRESHOLD other AEs - orthostatic hypotension - sedation - constipation - weight gain - dyslipidemia - hyperglycemia - hepatitis
59

YSM Semester 3 (3 decks)

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