Buspirone
Tx? (2)
Lag time?
Sedation/cognitive impairment? (Y/N)
Addictive? (Y/N)
Buspirone (BuSpar)
Tx: GAD, social phobia
Lag time: 1 week
No sedation/cognitive impairment
Low potential for abuse/addiction
What class if the 1st line treatment for schizophrenia?
6 examples…
Which 2 are more “weight-neutral”?
–Of these 2, which 1 is associated with QT prolongation?
Which 1 is associated with agranulocytosis, seizures?
Which 1 is associated with increased prolactin?
Which 1 has the lowest extrapyramidal sfx?
What is the last 1?
Atypical Antipsychotics
aripiprazole, ziprasidone - weight neutral
*ziprasidone - QT prolongation
clozapine - agranulocytosis, seizures
risperidone - increased prolactin
(–> amenorrhea, infertility, galactorrhea, sexual dysfunction, weight gain)
quetiapine - lowest EPS
olanzapine
Which atypical antipsychotic is beneficial for tx of schizophrenia, but not first choice due to risk of agranulocytosis?
Atypical antipsychotics carry lower risk of what SFX? carry higher risk of what SFX?
Clozapine - agranulocytosis
Atypical antipsychotics - lower risk of extrapyramidal side effects; higher risk of metabolic syndrome
Name 4 examples of traditional/1st generation antipsychotics. High/low potency?
For tx of schizophrenia, these drugs are more effective at treating what symptoms?
Typical/1st generation antipsychotics
High potency: haloperidol, trifluoperazine
Low potency: chlorpromazine, thioridazine
more effective at treating (+) symptoms
High-potency traditional/1st gen antipsychotics can cause sfx:
EPS (dystonias, parkinsonism, akathisia); tardive dyskinesia; NMS
Tx for SFX?
High potency 1st gen - EPS (eg, dystonias, parkinsonism, akathisia); tardive dyskinesia; NMS
(high potency: haloperidol, trifluoperazine)
Tx:
- antiparkinsonian rx: benztropine, diphenhydramine (anti-parkinsonian)
- benzos/beta blockers (akathisia)
- dantrolene, bromocriptine (NMS)
Lithium = 1st line tx for acute mania; prophylaxis for manic/depressive episodes in bipolar, schizoaffective disorders
Common SFX include AMS, fine/coarse tremors, convulsions, GI distress, weight gain
Name 4 unique SFX related to heart, site of metabolism (kidney), hematology, thyroid.
What is the fetal cardiac defect that can be caused by Lithium?
Lithium
Unique SFX: ECG changes, polyuria/nephrogenic DI, benign leukocytosis, hypothyroidism
Ebstein’s anomaly
What are 6 factors that can increase Li levels, potentially causing Li toxicity?
- -3 conditions
- -3 drug types
Dehydration Hyponatremia/Sweating Impaired renal function NSAIDs ACE Inhibitors Diuretics
SSRIs: fluoexetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram
What side effect is most likely to decrease compliance?
1) highest risk of GI sfx?
2) anticholinergic sfx?
3) safe in pregnancy and children? also longest t1/2
4) approved only for OCD?
5) maybe fewest sfx? (2)
SSRIs
Sexual dysfunction (typically resolve in a few weeks)
1) sertraline - GI sfx
2) paroxetine - anticholinergic sfx
3) fluoxetine - safe in pregnancy, children
4) fluvoxamine - OCD
5) citalopram, escitalopram
SSRIs have an FDA black box warning: increased suicidal thinking/behavior
Serotonin Syndrome: fever, diaphoresis, shivering, tachycardia, HTN, delirium, hyperreflexia
What are 3 types of drugs that can potentially cause SS when taken with an SSRI?
SSRI + (MAOI, cough medicine, triptans) –> Serotonin Syndrome
Tx for anorexia? bulimia?
Anorexia: family therapy
Bulimia: antidepressant (SSRI)
Buproprion
=NE/D reuptake inhibitor
Tx: depression, ADHD, smoking cessation
1) lack of what sfx vs SSRI?
2) two important sfx at high doses?
3) three contraindications?
Buproprion
=NE/D reuptake inhibitor
Tx: depression, ADHD
1) lack of sexual sfx
2) psychosis, seizures
3) seizure, active eating disorder, currently taking MAOI
Tx for panic disorder?
- -Pharm - which SSRIs?
- -Therapy?
- -Immediate relief?
Antidepressants: SSRIs: paroxetine, sertraline
TCAs, MAO-Is may also be effective
CBT
Benzodiazepine
TCAs
Tertiary amines: amitriptyline, imipramine, clomipramine, doxepin
Secondary amines: nortriptyline, desipramine
- Inhibit reuptake of what two hormones?
- SFX?
- Contraindication?
- Tx for TCA overdose?
TCAs
- inhibit reuptake of NE, serotonin
- anticholinergic sfx: dry mouth, blurred vision, dizziness, pupillary dilation
- Previous suicide attempt
- not first line because lethal in overdose; tx: NaBicarb
Tx for PTSD?
–also tx for flashbacks/nightmares?
SSRIs
Anticonvulsants for re-experiences (and Prazosin!)
3 benzos not metabolized by liver? (LOT))
Tx for benzodiazepine overdose?
Lorazepam, Oxazepam, Temazepam (for chronic alcoholics or liver disease)
Flumazenil
(don’t induce withdrawal too quickly)
Two long-acting benzos? (DC)
Four intermediate benzos? (ALOT)
Two short-acting benzos? (TM)
Long Acting
–Diazepam, Clonazepam
Intermediate Acting
–Alprazolam, Lorazepam, Oxazepam, Temazepam
Short Acting
–Triazolam, Midazolam
To treat CNS anticholinergic effects, use ?
To treat peripheral anticholinergic effects, use ?
Bethanecol: tx central anticholinergic effects
Physostigmine: tx peripheral anticholinergic effects
Which atypical antipsychotics…
…are less sedating and have less potential for weight gain? (2)
…can cause an increased prolactin?
…has more anticholinergic sfx?
Ziprasidone, Aripiprazole – less sedating; less potential for weight gain
Risperidone – increased prolactin
(–> amenorrhea, infertility, galactorrhea, sexual dysfunction, weight gain)
Clozapine – more anticholinergic sfx (also agranulocytosis!)
Tx for narcolepsy?
Modafinil (a non-amphetamine stimulant)
Lamotrigine
- tx: bipolar depression
- common sfx: dizziness, sedation, headaches, ataxia
Most serious side effect?
Lamotrigine
- tx: bipolar depression
- common sfx: dizziness, sedation, headaches, ataxia
Stevens-Johnson syndrome
Valproic Acid
- tx: mixed episodes of bipolar; rapid cycling
- tx of choice when Li is contraindicated
- Need to monitor what two levels?
- What other caution?
Valproic Acid
-tx: mixed episodes of bipolar; rapid cycling
- Need to monitor CBC, LFTs (hepatotoxicity)
- Teratogenic (NTDs)
Only FDA approved tx for bipolar disorder in youth ages 12+?
What is an option for younger children?
Lithium
- -1st line tx for non-psychotic mania in youth
- -consider atypical antipsychotic in presence of psychotic symptoms
Divalproex
- -used to tx seizures in younger children
- -may be better choice to tx bipolar in youth
Which two drugs are useful in treating mixed episodes or rapid-cycling bipolar disorder?
Carbamazepine, Valproic Acid (Depakote, Depakene)
Carbamazapine can tx mixed episodes; rapid-cycling bipolar disorder. Common sfx include: GI; CNS (drowsiness, ataxia, sedation)
Serious sfx re:
- Skin
- Blood (4)
- Liver
- Pregnancy
How is it metabolized?
Carbamazapine can tx mixed episodes & rapid-cycling bipolar disorder. Common sfx include: GI & CNS (drowsiness, ataxia, sedation)
Serious sfx re:
- Skin: Stevens-Johnson Syndrome
- Blood: leukopenia, aplastic anemia, thrombocytopenia, agranulocytosis
- Liver: hepatitis
- Pregnancy: teratogenic NTDs
Metabolized via P450. Potential autoinduction, requiring higher dosages.
Tx for Benzo overdose?
Tx for barbiturate overdose?
Tx for opiate OD?
Benzo OD: Tx = Flumazenil
Barbiturate OD: Tx = NaHCO3
Opiate OD: Tx = Naloxone
Tx for ADHD
1) CNS stimulants (3)
2) 2nd line: alpha-2 agonists (2)
Tx for ADHD
CNS stimulants
- -methylphenidate
- -dextroamphetamine
- -amphetamine salts (Adderall)
Alpha-2 Agonists
- -clonidine
- -guanfacine
What side effect is much less likely with use of atypical antipsychotics versus typical?
What side effect is more common with use of atypicals?
Less common: Tardive dyskinesia
(no treatment)
More common: Metabolic syndrome
1st line treatment for specific phobia?
Exposure Therapy (eg, systemic desensitization)
Can use benzo or beta blocker during desensitization to help control autonomic symptoms.
What SSRI is approved for the treatment of social anxiety disorder?
What drugs are commonly used to control autonomic symptoms of performance anxiety?
Paroxetine
Beta Blockers (eg, propranolol)
Name the two drugs:
- -members of Serotonin receptor antagonists and agonists
- -Tx: insomnia, refractory MDD, and MDD with anxiety
- -both cause sedation as a prominent sfx
Which causes priapism?
Which carries a black box warning for liver failure?
- -members of Serotonin receptor antagonists and agonists
- -Tx: insomnia, refractory MDD, and MDD with anxiety
- -both cause sedation as a prominent sfx
Which causes priapism?
–Trazodone
Which carries a black box warning for liver failure?
–Nefazodone
Which SSRI has highest risk for GI disturbances?
Sertraline
Which SSRI has the most anticholinergic sfx? (eg, sedation, constipation, weight gain)
Paroxetine
Which SSRI is approved for treating OCD?
Which SSRI is approved for treating bulimia?
Fluvoxamine: OCD
Fluoxetine: Bulimia
What are the most appropriate treatment options for a patient with MDD with psychotic features (elderly or not)?
(2 options)
MDD with psychotic features
- antidepressant/antipsychotic combo
- ECT
MAO-Is
-phenelzine, tranylcypromine, isocarboxazid, selegiline
1) More effective in what type of depression?
2) SSRI + MAO-I = ?
3) MAO-I + tyramine food or sympathomimetic = ?
MAO-Is
-phenelzine, tranylcypromine, isocarboxazid, selegiline
1) Atypical depression (hypersomnia, increased appetite, increased sensitivity to interpersonal rejection)
2) SSRI + MAO-I = Serotonin Syndrome
3) MAO-I + tyramine food or sympathomimetic = Hypertensive Crisis
Trazadone
Major treatment use?
–also used for refractory MDD, MDD with anxiety
Main sfx? (2)
Trazadone
-serotonin receptor antagonist/agonist
Tx: insomnia
Main sfx: priapism, sedation
TCAs
- -highly anticholinergic
- -potentially lethal in OD
Tertiary amines include amitriptyline, doxepin, and two others
- -one is used to treat OCD?
- -one is used to tx enuresis, panic disorder?
Name the two secondary amines
TCAs
- -highly anticholinergic
- -potentially lethal in OD
Tertiary amines: amitriptyline, doxepin, and
- -Clomipramine: tx OCD
- -Imipramine: tx enuresis, panic disorder
Secondary amines: nortriptyline, desipramine
After d/c MAO-I, how long should you wait to washout before starting an SSRI?
14 days
BP drug that commonly causes depression?
Propranolol
Which category of drugs should be used with caution in elderly patients due to their potential for causing confusion, disinhibition, anterograde amnesia, and reduced motor function?
Benzodiazepenes
Which antidepressant can also be used for smoking cessation? Mechanism of action?
Buproprion
NE/D reuptake inhibitor
Primary form of treatment for adjustment disorder?
Psychodynamic psychotherapy
Can use pharmacotherapy for associated symptoms (eg, insomnia, depression, anxiety)
A non-benzodiazepene hypnotic used for short-term treatment of insomnia
SFX include GI sfx, anterograde amnesia, hallucinations, sleepwalking
Zolpidem
Tx for ADHD in individuals with substance abuse problems, individuals with tics, or patients with comorbid anxiety?
Atomoxetine
- -inhibits NE reuptake
- -gradual onset, may take 2-3 weeks
NB: Dx of ADHD requires SIX+ symptoms of inattention or hyperactivity/impulsivity. Must be present for at least 6 months.