Which conditions (7) can SSRIs be used to tx?
Anxiety, bulimia, depression, OCD, panic disorder, PTSD, social phobias
What class of drugs should you use for Tourette’s?
Antipsychotics
What three drugs can you use for ADHD?
Methylphenidate, dextroamphetamine, methamphetamine
Which class of drugs should you use to tx alcohol withdrawal?
Benzo’s
How do the CNS stimulants (methylphindate, dextroamphetamine, methamphetamine) work?
Increase catecholamines in the synaptic cleft, especially NE and dopamine
What do you use neuroleptics (antipsychotics) for?
Schizophrenia, psychosis, acute mania, Tourette’s
SPECIFICALLY, neuroleptics are used to tx which shizo sx?
The POSITIVE symptoms
What are the high potency neuroleptics?
Trifluoperazine, Fluphenazine, Haloperidol (Try to Fly High)
What are they low potency neuroleptics?
Chlorpromazine, Thioridazine (Cheating Thieves are Low)
How do the SE’s of high potency vs low potency neuroleptics differ?
High potency: neurologic sx (extrapyramidal)
Low potency: non-neurologic sx (anticholinergic, antihistamine, and alpha 1 blockade)
High potency neuroleptics can cause extrapyramidal sx. Describe specifically what they are and the chronology of their appearance.
Dystonia (muscle spasm, stiffness, oculogyric crisis), akathisia (restlessness), bradykinesia, tardive dyskinesia.
4 hr dystonia
4 day akathisia
4 wk bradykinesia
4 mo tardive dyskinesia
Low potency neuroleptics can cause non-neurological symptoms such as anticholinergic, antihistamine and alpha 1 blockade. What are some examples of these sx?
Dry mouth, constipation, sedation, hypotension
What is neuroleptic malignant syndrome (NMS)?
Adverse rxn to neuroleptics. Think of FEVER
Fever Encephalopathy Vitals unstable Elevated enzymes Rigidity of muscles
Pt can present with myoglobinuria, autonomic instability.
How do you tx NMS?
Dantrolene or D2 agonists like bromocriptine
MOA of antipsychotics
They block dopamine D2 receptors (increase cAMP)
What is a potential endocrine SE of antipsychotics?
Galactorrhea. Lack of dopamine agonism causes increased prolactin (dopamine normally prevents prolactin release from anterior pituitary)
Trifluoperazine can cause 4 mo _____. Describe what this is.
Trifluoperazine is a high potency neuroleptic, meaning it can cause tardive dyskinesia. This causes potentially irreversible oral-facial movements.
Name 6 atypical antipsychotics
Olanzapine, clozapine, quetipine, risperidone, aripiprazole, ziprasidone.
It’s atypical for old closets to quietly risper from A to Z.
How do atypicals differ from typicals in their tx of schizophrenia?
They tx positive AND negative sx, not just the positive ones.
Aside from schizophrenia, what also can atypicals tx (6)?
Bipolar disorder, OCD, anxiety disorder, depression, mania, Tourette’s. Remember that typicals can also be used to tx Tourette’s and mania.
What is an advantage to using atypicals over typicals?
They exhibit fewer extrapyramidal and anticholinergic side effects.
Specific side effect of both olanzapine and clozapine? What about just clozapine? What about Ziprasidone?
Both olanzapine and clozapine can cause weight gain.
Clozapine can cause agranulocytosis and seizures.
Ziprasidone can cause prolonged QT interval.
Name two uses for lithium
Bipolar and SIADH
What’s a useful mnemonic for the SE’s of lithium?
LMNOP:
Lithium side effects- Movement (tremor) Nephrogenic DI HypOthyroidism Pregnancy problems
Why would you want to avoid lithium in a pregnant woman?
It can cause fetal cardiac defects such as Ebstein anomaly (tricuspid valve is pushed further down towards the apex of the RV) and malformation of the great vessels.
Three potential cardiac SE’s of lithium
Heart block (mom, or I guess anyone else for that matter) Ebstein anomaly and malformation of the great vessels (baby)
Why do you need to closely monitor serum levels of lithium?
It has a narrow therapeutic window
How is lithium excreted? Reabsorbed?
By the kidneys. It’s reabsorbed with Na+ at the PCT
MOA of Buspirone
Stimulates 5-HT1A receptors
Use of buspirone
Generalized anxiety disorder.
What are some advantages and disadvantages to buspirone?
It doesn’t cause sedation, addiction, or tolerance. It also doesn’t interact with alcohol.
Takes 1-2 weeks to take effect, so it should probably be used in prophylactic and chronic situations.
What are 5 classes of drugs that can be used for depression?
SSRIs, SNRIs, TCAs, MAO-I, atypical antidepressants
What are venlafaxine and duloxetine?
SNRIs
What’s the main difference in the MOA of SSRIs vs SNRIs?
SNRIs inhibit both serotonin and NE reuptake, whereas SSRIs only inhibit serotonin reuptake. SNRIs are newer and more expensive and usually saved for pts refractory to SSRIs.
Aside from serotonin syndrome, what’s the feared SE of SSRIs?
Sexual dysfunction (anorgasmia and decreased libido)
What are fluoxetine, paroxetine, sertraline, and citalopram?
SSRIs
Aside from depression, what can venlafaxine (SNRI) be used for?
Generalized anxiety and panic disorders
Aside from depression, what can duloxetine (SNRI) be used for?
Diabetic peripheral neuropahy
What’s the most common SE of SNRIs? Aside from that what other 3 SE’s can occur?
Increased BP. Can also cause sedation, nausea, and stimulant effects
All TCAs end in -iptyline or -ipramine except for ____ and ____.
Doxepin and amoxapine
How do TCAs work? What else works this way?
They inhibit reuptake of NE and serotonin. So do SNRIs. So what’s the difference? First Aid doesn’t say. I looked it up on wiki and apparently TCAs also act as agonists/antagonists to loads of other receptors that aren’t worth learning.
What are the 3 C’s of TCAs (Tri-C’s)?
Convulsions, coma, cardiotoxicity (arrhythmias)
How would you tx arrhythmias caused by imipramine?
As with all other TCAs you tx cardiotoxicity with NaHCO3
Aside from the 3 C’s, what the 3 general categories TCA SE’s can fit into?
Sedation, alpha 1 blocking effects, and atropine like side effects. Think postural hypotension and tachycardia, urinary retention, dry mouth.
Which two drug classes can cause alpha 1 blocking effects?
TCAs and low potency antipsychotics
What respiratory SE do we worry about when giving amitriptyline
With TCAs we worry about respiratory depression
What would be the advantage of giving old folks nortriptyline over amitriptyline?
Nortriptyline is a second generation TCA, whereas amitriptyline is a third generation. Third generations have more anticholinergic effects than second generations. In the elderly, we specifically worry about confusion and hallucinations, so give them nortriptyline.
What are tranylcypromine, phenelzine, isocarboxacid, and selegeline?
Monoamine oxidase inhibitors
Which neurotransmitter levels are increased because of MAO-Is?
Amine NT: NE, serotonin, dopamine
What are the three clinical uses for a MAO-I?
Atypical depression, anxiety, hypochondria
Beverly is a pt of yours with depression. You consider giving her an amitriptyline but then, upon careful H and P, you realize she is a sommelier. Why then, should you not give her amitriptyline?
Wine and cheeses contain tyramine, which can cause hypertensive crisis in pts on MAO-Is
With which drugs are MAO-Is contraindicated?
SSRIs, TCAs, St. John’s Wort, meperdine and dextromethorphan (both opioid analgesics)
Name 4 atypical antidepressants
Buproprion, mirtazapine, maprotiline, trazodone
Bupropion toxicity
stimulant effects (tachycardia, insomnia), headache, seizure in bulimic pts
Advantage of bupropion over an SSRI
Bupropion doens’t cause any sexual dysfunction
Aside from depression, what’s another use for bupropion?
Smoking cessation
MOA of mirtazapine
Alpha 2 antagonist and potent 5-HT2 and 5-HT3 receptor antagonist.
What are the 4 main SE’s of mirtazapine?
Sedation, increased appetite, weight gain, dry mouth
MOA of maprotiline
Blocks NE reuptake
SE’s of maprotiline
Sedation orthostatic hypotension
What are the two uses of trazodone?
Insomnia and depression. It’s mostly used for insomnia since really high doses are needed to tx depression
MOA of trazodone
Inhibits serotonin reuptake
Trazodone toxicity (4)
Sedation, nausea, priapism (trazoBONE), postural hypotension
Give me 4 things that can cause orthostatic hypotension (three are antidepressants, an example of the fourth is chlorpromazine)
TCAs, maprotiline, trazodone, and low potency neuroleptics
What kind of drug would you give someone with bulimia? What would you NOT want to give them? Why?
Give them an SSRI. Do not give them bupropion, it causes seizures in bulimic pts
Which TCA can be used to tx bedwetting?
Imipramine
What can you use to tx OCD (one is a drug class, the other is something specific)? You can also use ____ (general drug class, not first line)
SSRIs or clomipramine (a TCA). Atypical antipsychotics
What could you give a diabetic with depression and peripheral neuropathy?
Duloxetine, which is an SNRI
You’re treating someone for depression and they develop myoclonus, confusion, and hyperthermia. What did you give them and what do you call their condition?
You gave them a serotonergic drug (SSRI, SNRI, MAO-I, TCA) and they have serotonin syndrome
How do you tx serotonin syndrome?
Cyproheptadine
What kind of drug is doxepin?
TCA
Which antidepressants can you use to tx fibromyalgia?
TCAs
A man you’re treating for depression comes to your office complaining of a crappy sex life. What are you likely treating him with?
SSRI, since that causes sexual dysfunction and is first line for depression. It’s possible he could also be on trazodone, which can cause priapism
What kind of drugs can you use to tx social phobias?
SSRIs
Name 4 MAO-Is
Tranylcypromine, Phenelzine, Isocarboxazid, Selegiline (MAO Takes Pride In Shanghai)
Name 4 SSRIs
Fluoxetine, paroxetine, sertraline, citalopram
Which MAO-I can be used in the tx of Parkinsons?
Selegeline. It’s an adjunct to L-dopa therapy because it increases the availability of dopamine
What do you use to tx panic disorders?
SSRI, venlafaxine, benzos
What would be a great way to tx someone with depression AND insomnia?
Mirtazapine since it causes sedation
You are treating a pt with oliguria with demeclocycline. She is refractory to tx and eventually you tx her with a “last resort” drug for her condition. Later she presents complaining of weight gain, dry skin, brittle hair and constipation. What did you give her?
Lithium. She has SIADH and has developed hypothyroidism
How long does it usually take for antidepressants to take effect?
4-8 weeks
What’s the most common side effect of venlafaxine?
Increased BP. Same is true for duloxetine
What could you give an anorexic pt with depression?
Mirtazapine, it causes weight gain
What do you give for post traumatic stress?
SSRIs
What two things do you tx with dantrolene?
Neuroleptic malignant syndrome and malignant hyperthermia (a SE of inhaled anesthetics and succylcholine)
Which atypical antipsychotic do you need to monitor closely and why?
Clozapine (watch clozapine clozely!), because it can can agranulocytosis. Monitor WBCs weekly.
Harold is constantly showing up to your office because he’s worried that he might be sick. He’s terrified of germs and is always going online and self diagnosing himself with diseases. What is something you can tx him with?
A MAO-I
