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Y3R3 - Psychiatry 🧠 > L16: Pharmacotherapy > Flashcards

L16: Pharmacotherapy Flashcards

1
Q
A
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2
Q

Dopamine Pathways

A
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3
Q

Classification of AntiPsychotic Drugs

A
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3
Q

what are synonyms of AntiPsychotic Drugs?

A
  • Neuroleptic drugs.
  • Anti-schizophrenic drugs.
  • Major tranquilizers.
  • Dopamine receptor antagonists.
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4
Q

what does low potency mean?

A

Needs high dose to reach the therapeutic effect.

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5
Q

Form of most AntiPsychotic Drugs

A

tablets (others may also be injectable e.g. Haloperidol)

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6
Q

Compare Between Typical Antipsychotics and Atypical Antipsychotics in terms of:

  • Mechanism
  • Effect
  • Excretion of drug
  • Discontinuation
  • Metabolic SE
  • Prolactin
  • Extrapyramidal SE
A
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6
Q

MOA of AntiPsychotics

A
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7
Q

Therapeutic Uses (indicatios) of AntiPsychotics

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8
Q

Pharmacological Effects of AntiPsychotics

A
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8
Q

Precaustions of using Antipsychotics

A
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8
Q

Aspects of Adverse effects of Antipsychotics

A
  • CNS
  • ANS
  • GIT
  • Skin & Eye
  • CVS
  • Hematologic
  • Endocrine
  • Extrapyramidal
  • NMS
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8
Q

CI of AntiPsychotics

A

These drugs are contraindicated in:
1. Hypersensitivity
2. CNS depression
3. Blood dyscrasias
4. Parkinson’s disease
5. Liver, renal, or cardiac insufficiency

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9
Q

CNS Adverse effects of Antipsychotics

A
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9
Q

Results of anti-histaminic activity of antipsychotics

A
  • Sedation
  • Weight gain
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10
Q

ANS Adverse effects of Antipsychotics

A
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11
Q

GIT Adverse effects of Antipsychotics

A
  • Nausea
  • Gl upset
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11
Q

Skin & Eye Adverse effects of Antipsychotics

A
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11
Q

CVS Adverse effects of Antipsychotics

A
  • Hypotension due to a adrenergic blocking action
  • Reflex tachycardia & arrythmia
  • ECG: Q-T prolongation and T wave suppression
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12
Q

Hematologic Adverse effects of Antipsychotics

A

Agranulocytosis - associated with: Clozapine (order CBC for follow up)

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13
Q

Endocrine Adverse effects of Antipsychotics

A
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14
Q

Symptoms of Pseudo-parkinsonism

A

tremor, shuffling gait, drooling, rigidity

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15
Q

EPS effects of Antipsychotics

A
  • Pseudo-parkinsonism
  • Akinesia
  • Akathisia
  • Dystonia
  • Oculogyric crisis
  • Tardive dyskinesia
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16
Q

TTT of Pseudo-parkinsonism

A

Anticholinergics

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17
Q

Symptoms of Akinesia

A

muscular weakness

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18
Q

Symptoms of Akathisia

A

continuous restlessness and fidgeting

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19
Q

TTT of Akathisia

A

Propranolol / Benzodiazepine

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20
Q

Symptoms of Dystonia

A

involuntary Painful Sustained muscular movements [spasms] of face, arms, legs, and neck

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21
Q

TTT of Dystonia

A
  • Anticholinergic injection / Benzodiazepines
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22
Q

Def of Oculogyric crisis

A

uncontrolled rolling back of the

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23
Q

TTT of Oculogyric crisis

A

Oral Anticholinergic

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24
Q

Def of Tardive dyskinesia

A

Abnormal Choreoathetoid writhing movements of the tongue, face, and body

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25
Q

Incidence of Tardive dyskinesia

A

More common in women and after at least 6 months of treatment

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26
Q

Prognosis of Tardive dyskinesia

A

Rarely reversible

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27
Q

TTT of Tardive dyskinesia

A

substitute atypical antipsychotic agent, e.g.: CLOZAPINE

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28
Q

Symptoms of Neuroleptic malignant syndrome

A
  • Severe parkinsonian muscle rigidity
  • Hyperpyrexia up to 107° f
  • Tachycardia, Tachypnea, Fluctuations in blood
    pressure, Diaphoresis
  • Rapid deterioration of mental status
  • Stupor and coma
  • Lab shows: elevated liver renal function, myoglobin, WBC, CPK
  • Mortality Rate 20%
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29
Q

TTT of Neuroleptic malignant syndrome

A
  1. Stop Antipsychotic Medications (first step in management)
  2. Adjust general conditions (adequate fluids & vital signs)
  3. Specific agents: Dantrolene (muscle relaxant), Bromocriptine (Dopaminergic Agonist)
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30
Q

Evolution of Extra Pyramidal Symptoms (EPS) side effects

A
  • 4 hours acute dystonia (muscle spasm, stiffness, oculogyric crisis)
  • 4 days akinesia (parkinsonian symptoms)
  • 4 weeks akathisia (restlessness)
  • 4 months Tardive dyskinesia
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31
Q

SE of Olanzapine /Clozapine

A

May cause significant weight gain.

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32
Q

SE of Chlorpromazine

A

Corneal deposits

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33
Q

SE of Thioridazine

A

Retinal deposits.

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34
Q

SE of Risperidone

A

One of atypical antipsychotics causing hyperprolactinemia and EPS

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35
Q

SE of Aripiprazole

A

Commonly cause akathisia

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36
Q

Characters of Clozapine

A
  • Usually used in: Resistant schizophrenia & Tardive dyskinesia
  • Has antisuicidal effect
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37
Q

SE of Clozapine

A

Side effects:
* Agranulocytosis (requires weakly WBC monitoring)
* Myocarditis
* Risk of seizure (if more than 300mg)
* Hypersalivation
* Metabolic syndrome

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38
Q

Def of Mood Stabilizing Agents

A

Any medication that is able to decrease vulnerability to subsequent episodes of mania or depression; and not exacerbate the current episode or maintenance phase of treatment.

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39
Q

Classification of Mood Stabilizing Agents

A

Antimanic: Lithium carbonate

Anticonvulsants: Carbamazepine, Clonazepam, Valproic acid, Lamotrigine, Gabapentin & Topiramate

Antipsychotics (atypical)

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40
Q

MOA of Lithium Carbonate

A

Exact mechanism is unknown, however it probably works by:

  1. Accelerating presynaptic reuptake and destruction of catecholamine.
  2. Inhibiting the release of catecholamine
  3. Decreasing postsynaptic serotonin receptor sensitivity
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41
Q

indication of Lithium Carbonate

A
  • Acute mania
  • Prophylaxis for bipolar and unipolar mood disorder
  • Schizoaffective disorder
  • Cyclothymia
  • Impulsivity and aggression
  • Others like: bulimia nervosa, trichotillomania, cluster headache, borderline personality disorder.
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42
Q

Dosage of Lithium Carbonate

A

900-2100 mg in 2-3 divided dose.

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43
Q

Blood Lithium levels of Lithium Carbonate

A
  • Therapeutic level 0.8-1.2 mEq/litre
  • Prophylactic level 0.6-1.2 mEq/litre
  • Toxic lithium level >1.5-2 mEq/litre
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44
Q

CI & precautions of Lithium Carbonate

A
  1. Hypersensitivity
  2. Cardiac or renal disease
  3. Dehydration
  4. Sodium depletion
  5. Brain damage
  6. Pregnancy and lactation.
  7. Caution with thyroid disorders, diabetes, urinary retention, history of seizures, and with the elderly
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45
Q

SE of Lithium Carbonate

A
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46
Q

Lithium Toxicity

A
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47
Q

Symptoms at serum levels of lithium 1.5 to 2.0 mEq/L

A
  • Blurred vision
  • Ataxia
  • Tinnitus
  • Persistent nausea and vomiting
  • Severe diarrhea
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48
Q

Symptoms at serum levels of lithium 2.0 to 3.5 mE/L

A
  • Excessive output of dilute urine
  • Increasing tremors
  • Muscular irritability
  • psychomotor retardation
  • Mental confusion
  • Giddiness
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49
Q

Symptoms at serum levels of lithium ≥ 3.5 mEq/L

A
  • Impaired consciousness
  • Nystagmus
  • Seizures
  • Coma
  • Oliguria/ anuria
  • Arrhythmia
  • Myocardial infarction
  • Cardiovascular collapse
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50
Q

Nursing management to avoid side effects of lithium

A
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51
Q

What are anticonvulsants used in mood managment?

A
  1. Carbamazpine
  2. Valproic Acid
  3. Lamotrigine
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52
Q

Indications of Carbamazepine

A

Especially useful in:
1. treating mania with mixed features
2. rapid-cycling bipolar disorder
* Less effective for the depressed phase.

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53
Q

Monitoring in Carbamazepine

A

CBC and LFTs must be obtained before initiating treatment and regularly monitored during treatment

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54
Q

MOA of Carbamazepine

A
  • Acts by blocking sodium channels and inhibiting action potentials. (exact mechanism is unknown)
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55
Q

osnet of Carbamazepine

A

Onset of action Is 5-7 days (quicker than lithium)

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56
Q

SE of Carbamazepine

A
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57
Q

MOA of Valproic acid

A

Multiple mechanisms of action:
1. Blocks sodium channels
2. Increases GABA concentrations in the brain.

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58
Q

Indications of Valproic acid

A

Useful in treating acute mania, mania with mixed features, and rapid cycling.

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59
Q

Monitoring of Valproic acid

A

CBC and LFTs must be obtained before initiating treatment and regularly monitored during treatment

60
Q

Therapeutic level of Valproic acid

A
  • Therapeutic range is 50-150 pg/mL.
  • Drug levels should be checked after 4-5 days.
61
Q

SE of Valproic acid

A

Care should be given in women of childbearing age as it is:
1. Contraindicated in pregnancy (cause neural tube defects).

  1. Causes:
    Polycystic ovary (PCO)
    Weight gain
    Alopecia
62
Q

MOA of Lamotrigine

A

Believed to work on sodium channels that modulate glutamate and aspartate.

63
Q

Indication of Lamotrigine

A

Efficacy for bipolar depression, though little efficacy for acute mania or prevention of mania.

64
Q

SE of Lamotrigine

A
  • Most common side effects are dizziness, sedation, headaches, and ataxia.
  • Most serious side effect is Stevens-Johnson syndrome (life-threatening)
  • Rash involving skin and mucous membranes in 0.1 %, This is most likely in the first 2-8 weeks, but is minimized by starting with low doses and increasing slowly.
65
Q

Effects of valproate & lamotrigine on each other

A
  • Valproate will increase lamotrigine levels
  • Lamotrigine will decrease valproate levels
66
Q

what are anti-suicidal drugs?

A

lithium - clozapine

67
Q

Introduction to Antidepressants

A
  • Used in many psychiatric disorders other than Depression.
  • Full clinical response in 6-8 weeks in major depression, up to 6/12 weeks in obsessive compulsive disorder (OCD).
68
Q

Indications of Antidepressants

A
69
Q

Phases of TTT of Antidepressants

A
70
Q

Categories of Typical Antidepressants

A
  • MAOI
  • TCA
  • SSRI
  • SNRI
71
Q

Examples of Monoamine oxidase (MAO) inhibitors

A

Phenelzine
Tranylcypromine
Selegiline (selective MAO-B inhibitor)

72
Q

MOA of Monoamine oxidase (MAO) inhibitors

A
  • Nonselective MAO inhibition, Increase levels of amine neurotransmitters
73
Q

Indications of Monoamine oxidase (MAO) inhibitors

A
  1. Atypical depression
  2. Anxiety
  3. Hypochondriasis
74
Q

MOA of TCA

A

Block reuptake of NE and serotonin

75
Q

SE of Monoamine oxidase (MAO) inhibitors

A
  • Hypertensive crisis with tyramine ingestion (in many foods, such as wine and cheese) and CNS stimulants (ß agonists, pseudoephedrine)
  • Contraindicated with SSRIs or Meperidine [To prevent serotonin syndrome].
76
Q

Types of TCA

A
77
Q

Uses of TCA

A
  1. Major depression
  2. Bed wetting (imipramine)
  3. OCD (clomipramine)
  4. Fibromyalgia
78
Q

SE of TCA

A
  • Sedation, alpha blocking effects.
  • Atropine-like (anticholinergic) side effects: tachycardia, urinary retention.
  • Tertiary TCAs (amitriptyline) have more anticholinergic effects than the secondary TCAs (nortriptyline).
  • Desipramine is the least sedating and has lower Seizure threshold
79
Q

Toxicity of TCA

A
  • 3Cs: Convulsions, Coma, Cardiotoxicity (arrhythmias).
  • Respiratory depression, hyperpyrexia.
  • Confusion and hallucination in elderly due to anticholinergic side effects [use nortriptyline].

Treatment: NaHCO3 for CV toxicity.

80
Q

Examples of SSRIs

A

Fluoxetine
Paroxetine
Sertraline
Citalopram
Escitalopram

81
Q

MOA of SSRIs

A
  • Serotonin-specific reuptake inhibitors.
  • Normally takes 2 weeks for antidepressants lo have an effect.
82
Q

Indications of SSRIs

A
  1. Depression
  2. OCD
  3. Eating disorders
  4. Social phobias
83
Q

SE of SSRIs

A
  • Fewer than TCAs
  • Gl distress, diarrhea
  • Sexual dysfunction (anorgasmia)
  • Serotonin syndrome
84
Q

Serotonin syndrome

A
  • “Serotonin syndrome” with any drug that that increase serotonin (e.g.MAO inhibitors), symptoms are:
    1. Hyperthermia, muscle rigidity
    2. Cardiovascular collapse
    3. Flushing
    4. Seizures

Treatment of Serotonin Syndrome: cyproheptadine (5-HT, receptor antagonist)

85
Q

MOA of SNRIs

A

Venlafaxine
Duloxetine

86
Q

Examples of SNRIs

A

Inhibit serotonin and NE reuptake.

87
Q

Indications of SNRIs

A
  1. Depression.
  2. Venlafaxine is also used in generalized anxiety disorder
  3. Duloxetine is also indicated for diabetic peripheral neuropathies
  4. Duloxetine has greater effect on NE
88
Q

SE of SNRIs

A
  • Increase BP most common
  • stimulant effects
  • Sedation
  • Nausea
89
Q

what are atypical antidepressants?

A
  • Trazodone
  • Bupropion
  • Mirtazapine (NaSSA)
90
Q

MOA of Trazodone

A

Primarily inhibits serotonin reuptake.

91
Q

Indications of Trazodone

A

insomnia, As high doses are needed for antidepressant effects.

92
Q

Toxicity of

Toxicity of Trazodone

A

sedation, nausea, priapism, postural hypotension. vip

93
Q

MOA of Bupropion

A

Inhibits DA and NA uptake has excitant effect

94
Q

Uses of Bupropion

A
  • reduce smoking
  • Approved for resistant and Bipolar depression
95
Q

SE of Bupropion

A

No sexual Side effect

96
Q

Toxicity of Bupropion

A

stimulant effects (tachycardia, insomnia), headache, seizure in bulimic patients.

97
Q

MOA of Mirtazapine (NaSSA)

A
  • Noradrenergic and specific serotonergic antidepressant
  • Block a2 adrenergic antagonist (increase release of NE and serotonin) potent 5-HT2 and 5-HT receptor antagonist.
98
Q

Toxicity of Mirtazapine (NaSSA)

A

No Sexual or Git side effects

99
Q

SE of Mirtazapine (NaSSA)

A

sedation, increase appetite, weight gain, dry mouth

100
Q

Indications of Anti-Anxiety Drugs

A
  1. Generalized Anxiety (GAD)
  2. Post-Traumatic Stress Disorder (PTSD)
  3. Phobias
  4. Obsessive Compulsive Disorder (OCD)
  5. Panic Disorder
  6. Insomnia related to Anxiety
101
Q

Classification of Anti-Anxiety Drugs

A
  • Barbiturates
  • Benzodiazepines
  • Non barbiturates and non benzodiazepines
102
Q

Uses of Benzodiazepines

A
  • Benzodiazepines are considered CNS depressants.
  • They are used to produce sedation, induce sleep, relieve anxiety and muscle spasms, and to prevent seizures
103
Q

MOA of Benzodiazepines

A
  • Enhance the actions of the neurotransmitter, GABA, which slows down brain activity.
  • This produces a drowsy or calming affect
104
Q

SE of Benzodiazepines

A
  • Drowsiness, dizziness, loss of coordination, fatigue, mental slowing, confusion.
  • Withdrawal reactions are possible, 5/S: anxiety, shakiness, headache, dizziness, seizures.
105
Q

CI of Benzodiazepines

A

Acute narrow angle glaucoma

106
Q

Precautions while using Benzodiazepines

A
  • With elderly
  • Lung disease
  • Liver disease
  • Kidney disease
  • Sleep apnea
107
Q

Safety Concerns while using Benzodiazepines

A
  • Risk of addiction: should be only used short term.
  • Patient should not drive or operate heavy machinery.
  • Not to be mixed with ETOH, opiates, OTC cough/allergy medications, dental anesthetics - can be life threatening (resp, depression)
  • MUST NOT be discontinued abruptly (Taper schedule is prescribed).
108
Q

Classification of Benzodiazepines

A
  • Long Acting (Half-life: >20 Hours)
  • Intermediate Acting (Half-Life: 6- 20 Hours)
  • Short Acting (Half-life:<6 Hours)
  • Very short half-life
109
Q

Half-Life of Long Acting Benzos

A
  • more than 20 hours
110
Q

Examples & Uses of Long Acting Benzos

A

Diazepam (Valium): Rapid onset, Effective for muscle spasm, Less commonly prescribed to treat anxiety because of euphoria

Clonazepam (Klonopin): Avoid with renal dysfunction.

111
Q

Half-Life of Intermediate Acting Benzos

A

Between 6 & 20 Hours

112
Q

Half-Life of Short Acting Benzos

A

Less than 6 Hours

113
Q

Examples & Uses of Intermediate Acting Benzos

A

Alprazolam (Xanax): Treatment of anxiety, including panic attacks

Lorazepam (Ativan): Treatment of panic attacks, alcohol and sedative-hypnotic-anxiolytic detoxification, agitation. Not metabolized by liver

114
Q

Uses of Very Short Acting Benzos

A

Primarily used in medical and surgical settings

115
Q

Examples & Uses of Short Acting Benzos

A

Triazolam (Halcion): Treatment of insomnia.

  • Risk of anterograde amnesia and sleep-related activities (e.g., eating, driving)
116
Q

Examples of Non-Benzo Anxiolytics

A
  • Buspirone (BuSpar)
  • Z-agents
  • Antihypertensives acting on autonomic nervous system
117
Q

Characters of Buspirone (BuSpar)

A
  • In contrast to BZs, buspirone is nonsedating and is
    not associated with dependence, addiction, or withdrawal
  • It is used primarily to treat conditions causing chronic anxiety, in which BZ dependence can become a problem (e.g., generalized anxiety disorder)
  • Buspirone takes up to 2 weeks to work
118
Q

what are Z-Agents?

A
  • Zolpidem (Ambien)
  • zaleplon (Sonata)
  • eszopicione (Lunesta)
  • ramelteon (Rozerem)
119
Q

Characters of Z-Agents

A
  • are short-acting agents
  • used primarily to treat insomnia.
  • Z-agents act on the GABA Receptor
  • In contrast, ramelteon is a selective melatonin
    ramelteon (Rozerem) agonist.
120
Q

Characters of ramelteon

A

ramelteon is a selective melatonin agonist.

121
Q

Examples of Antihypertensives acting on autonomic nervous system

A
  • beta blockers (block both a-1 and ß-2 adrenergic receptors) propranolol (Inderal)
  • a-2 adrenergic receptor antagonists such as clonidine (Catapres)
122
Q

Actions of Antihypertensives acting on autonomic nervous system

A

decrease autonomic hyperarousal and are used to treat symptoms of anxiety (e.g., tachycardia), particularly in patients with social anxiety.

123
Q

Uses of Psychostimulants

A

Used in ADHD, Narcolepsy and in treatment of refractory depression.

124
Q

Examples of Psychostimulants

A
  • Dextroamphetamine and amphetamines (Dexedrine, Adderall)
  • Methylphenidate (Ritalin, Concerta)
  • Atomoxetine (Strattera)
  • Modafinil (Provigil)
125
Q

Characters of Dextroamphetamine and amphetamines (Dexedrine, Adderall)

A

..

126
Q

Characters of Methylphenidate (Ritalin, Concerta)

A

..

127
Q

Characters of Atomoxetine
(Strattera)

A

..

128
Q

Characters of Modafinil (Provigil)

A

Used in narcolepsy, not ADHD

129
Q

Drugs for Alcohol withdrawal

A

Benzodiazepines

130
Q

Drugs for Anorexia/bulimia

A

SSRIs

131
Q

Drugs for Anxiety

A
  • Benzodiazepines
  • Buspirone
  • SSRIs
132
Q

Drugs for ADHD

A
  • Methylphenidate (Ritalin)
  • Amphetamines (Dexedrine)
133
Q

Drugs for Atypical Depression

A
  • MAO inhibitors
  • SSRIs
134
Q

Drugs for Bipolar

A

“Mood stabilizers”:
* Lithium
* Valproic acid
* Carbamazepine
* Atypical antipsychotics

135
Q

Drugs for Depression

A
  • SSRIs
  • SNRIs
  • TCAS
136
Q

Drugs for Depression with insomnia

A

Mirtazapine

137
Q

Drugs for OCD

A
  • SSRIs
  • Clomipramine
138
Q

Drugs for PTSD

A

SSRIs

139
Q

Drugs for Panic Disorder

A
  • SSRIs
  • TCAs
  • Benzodiazepine
140
Q

Drugs for Schizophrenia

A

Antipsychotics

141
Q

Drugs for Tourette Symdrome

A

Antipsychotics (haloperidol)

142
Q

Drugs for Social Phobias

A

SSRIs

143
Q

Steps of ECT

A
  1. Patients are often premedicated with atropine, and then given general anesthesia (typically with methohexital) and muscle relaxants (e.g., succinylcholine).
  2. A generalized tonic-clonic seizure is then induced using unilateral or bilateral electrodes.

While the mechanism of action of ECT is not fully known, there are likely anticonvulsant effects, as well as brain perfusion and connectivity changes involved.

144
Q

Indications of ECT

A
  1. ECT is the most effective treatment for major depressive disorder, especially with psychotic features, as well as for acute mania and catatonia.
  2. It is often used in patients who cannot tolerate medications or who have failed other treatments.
145
Q

Duration of ECT

A
  • ECT is discontinued after symptomatic improvement, typically a course of 8-12 sessions given three times weekly.
146
Q

Monthly maintenance ECT is often used to prevent ….

A

relapse of symptoms.

147
Q

SE of ECT

A

The most common side effects are:

  • muscle soreness, headaches, amnesia ,and confusion. Bilateral electrode placement is more efficacious, but I memory impairment and confusion.
148
Q

What is DBS?

A
  • DBS is a surgical treatment involving the implantation of a medical device that sends electrical impulses to specific parts of the brain.
149
Q

Uses of DBS

A

DBS in select brain regions has provided benefits for Parkinson’s disease and disabling dystonia, as well as for chronic pain and tremors.

150
Q

Mechanism of DBS

A

Its underlying principles and mechanisms are still not clear.

151
Q

Indications of DBS in Psychiatry

A

DBS has been used to treat various affective disorders, including major depression.

152
Q

Effect of DBS

A

DBS directly changes brain activity in a controlled manner and its effects are reversible (unlike those of lesioning techniques).

153
Q

what is Repetitive transcranial magnetic stimulation (rTMS)?

A

rTMS is a noninvasive method to excite neurons in the brain.

154
Q

,.

A
155
Q

SE of Repetitive transcranial magnetic stimulation (rTMS)

A

include seizures (rare), as well as headache and scalp pain.

156
Q

Characters of Repetitive transcranial magnetic stimulation (rTMS)

A
  • Weak electric currents are induced in the tissue by rapidly changing magnetic fields, a process called electromagnetic induction.
  • In this way, brain activity can be triggered with minimal discomfort.
  • rTMS can produce longer-lasting changes than nonrepetitive stimulation.
  • Numerous small-scale studies have demonstrated efficacy in the treatment of major depression; however, studies show less efficacy than for ECT, and the price of treatment is high
157
Q

..

A

Y3R3 - Psychiatry 🧠 (19 decks)

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