Pyschiatry Flashcards
1
Q
Examples of SSRIs
A
- Fluoxetine / Prozac
- Sertraline / Zoloft
- Citalopram / Celexa
2
Q
SSRI Indications
A
- First-line defense for anxiety disorder and depression
3
Q
Who is sertraline good for?
A
postpartum moms who are breastfeeding
4
Q
Who is escitalopram good for?
A
If celexa was helpful but there are many side effects b/c it is a metabolite of celexa
5
Q
What is Fluoxetine commonly written for?
A
OCD symptoms along with mood disorder
6
Q
Which SSRI has the longest half life?
A
fluoxetine - greater than 100 hours
7
Q
paroxetine/paxil has a little impact similar to what other class of drugs?
A
SNRIs
8
Q
SSRI MOA
A
bind to reuptake transporters on the presynapse for serotonin and prevent removal of serotonin from the synaptic cleft –> increased serotonin available to bind postsynaptic receptors
9
Q
How long does it take for SSRIs to work?
A
up to 6-8 weeks to see full impact of drug
10
Q
typical SSRI half life and what does this mean?
A
24 hours or more –> once a day administration
11
Q
Patient education for starting SSRI
A
may start to feel side effects of drug before they start to feel the pharmacologic effects
start at lose dose and titrate up, will reevaluate at 8-12 weeks
12
Q
Which SSRI is good for noncompliant pateints?
A
Fluoxetine because it has such a long half life
13
Q
SSRI Indications
A
- Major depressive disorder
- Obsessive Compulsive Disorder
- Generalized Anxiety Disorder
- Panic Disorder
- Bulimia nervosa
- off-label for IBS-D, post traumatic head injury
14
Q
SSRI absolute CIs and why
A
- MAOIs used w/in 2-3 weeks
- Can cause serotonin syndrome which can be fatal
- washout period is 2-3 weeks
15
Q
SSRI General S/E
A
- sexual dysfunction (MC)
- GI distress (N/V, constipation) - nausea initially but transient, usually lasts 1-2 weeks
- agitation (fluoxetine)
- tremor
- insomnia
- serotonin syndrome
- bleeding
- suicide
16
Q
What do you do if patient has sexual dysfunction on SSRI?
A
- try different SSRIs
2. if still not helpful, then add a little bit of Wellbutrin
17
Q
Specific side effects of fluoxetine / prozac
A
- tremor
2. insomnia
18
Q
Specific side effects of paroxetine / paxil
A
- excessive sedation
- weight gain
dose at bedtime
19
Q
Specific side effects of sertraline / zoloft and citalopram / celexa
A
- often well tolerated
2. both less stimulating than Prozac
20
Q
Specific side effects of citalopram / celexa
A
- prolonged QT interval!!
- -> don’t exceed 40 mg/day
21
Q
What is serotonin syndrome?
A
- hyperthermia
- muscle rigidity
- myoclonus
- rapid fluctuations in vital signs
- rapid fluctuations in mental status
22
Q
Do you need to stop SSRIs prior to surgery?
A
no
23
Q
who is at increased risk for suicide with SSRIs
A
patients under 24 years (more motivation than feel good initially)
24
Q
Lifestyle modifications to suggest when giving SSRI
A
CBT, relaxation, meditation, therapy
25
What does SNRI stand for
serotonin noradrenaline reuptake inhibitors
26
SNRI examples
1. venlafaxine / effexor
| 2. duloxetine / cymbalta
27
SNRI MOA
inhibit reuptake and increase concentration of both serotonin and noradrenaline in synaptic cleft
28
When do you try SNRIs
if failed multiple SSRIs
29
lower doses (<150 mg) of effexor also affect which neurotransmitter
serotonin reuptake
30
what is duloxetine uniquely indicated for?
neuropathy
31
is cymbalta/duloxetine or effexor/venlafaxine stronger? What does this mean?
duloxetine/cymbalta more potently blocks serotonin and NE --> higher risk of increased HR, BP
32
half life of SNRIs compared to SSRIs
shorter
| should take at same time every day so do not have withdrawal
33
Who should you not give SNRIs to?
noncompliant patients (can get withdrawal)
34
symptoms of SNRI withdrawal
1. aches
2. flu-like symptoms
3. nausea
4. brain zaps
35
who is effexor good for?
perimenopausal women because good for headaches, symptoms of menopause
36
SNRIs Indications
1. depression
2. generalized anxiety disorder
3. social anxiety disorder
4. panic disorder
37
SNRIs Absolute CIs and why
MAOIs --> can cause serotonin syndrome and hypertensive crisis
allow for 2 week wash period
38
SNRIs S/E
1. Nausea, constipation
2. dizziness (unique from SSRI)
3. somnolence (initially)
4. insomnia
5. sexual dysfunction
6. sweating
7. increased intraocular pressure
8. tremor
9. dry mouth
10. sustained HTN
11. suicidal thoughts/behavior
39
What do you need to be cautious of with SNRIs
Need to gradually taper off b/c withdrawal response - nausea, flu-like symptoms, brain zaps, aggression, agitation, convulsions
40
What does NDRI stand for?
Noradrenaline and Dopamine Reuptake Inhibitor
41
NDRI example
Bupropion / Wellbutrin
42
Bupropion MOA
inhibits presynaptic reuptake of both dopamine and noradrenaline --> increased levels of both of these in synaptic cleft
43
Who is wellbutrin good for?
patient only depressed, no anxiety, no panic
44
buproprion as smoking cessation drug MOA
nicotinic receptor antagonist --> prevents exogenously administered nicotine from binding to this receptor --> decreases reward that smokers gets from nicotine
45
NDRI Indications
1. depression
| 2. smoking cessation
46
NDRI Contraindications
1. seizures - lowers seizure threshold
2. MAOIs - HTN crisis
3. thioridazine - increased risk of ventricular arrhythmia
47
NDRI S/E
1. dry mouth
2. nausea
3. insomnia
4. seizures (rare)
48
benefit of buproprion
no sexual side effects
49
Tricyclic Antidepressant Examples
1. amitriptyline / Elavil
| 2. nortriptyline / Pamelor
50
benefit of amitriptyline
helps with neuropathic pain
51
off label uses for TCAs
1. post traumatic head injuries
2. IBS-D
3. sleep
52
TCA MOA
1. serotonin, NE reuptake inhibitors
| 2. block H1-histamine and alpha-adrenergic receptors
53
who should not used TCAs
the elderly --> orthostatic hypotension, cardiac problems
| young athletes with low BP
54
TCA S/E
1. sedation
2. dry mouth
3. constipation
55
TCA overdose
1. cardiac arrhythmias
2. hypotension
3. CNS involvement
56
TCA indications
1. depression
2. OCD
3. panic disorder
4. neuropathic pain (amitriptyline)
57
TCA Contraindications
1. MAOIs
2. recovery phase of MI
3. doxepin in glaucoma or urinary retention
58
TCA S/E
1. dry mouth (MC)
2. confusion
3. urinary retention
4. constipation (MC)
5. blurred vision
6. increase intraocular pressure
7. photosensitivity
8. neurologic - confusion, delusions, hallucinations, aggressiveness, mania, sedation
9. arrhythmias if high dose
10. orthostatic hypotension
59
what do you have to consider when prescribing TCA
wide range of potential drug interactions
| think about liver metabolism issues w/ other drugs
60
MAOI indications
depression
61
MAOI MOA
irreversible, nonselective inhibitors of monoamine oxidase in CNS --> increased levels of epi, NE, serotonin, and dopamine
62
how quickly do MAOIs work
relief of symptoms in days up to 2 weeks
63
MAOI contraindications
1. drug interactions
2. sympathomimetics (ie. ritalin, methyldopa)
3. SSRIs
4. TCAs
5. foods with tyramine (pickles, pepperoni, vinegar, wine, cheese)
6. alcohol
64
MAOI S/E
1. sleep disorders - insomnia, reduction in REM sleep
2. weight gain
3. postural hypotension
4. sexual disturbances
5. serotonin syndrome!
6. hypertensive crisis!
65
Atypical antidepressant examples
1. trazadone / desyrel
| 2. mirtazapine / remeron
66
what is trazadone good vs. not good for
terrible for depression, doesn't work at all
| good for sleep !
67
what class is mirtazepine
tetracyclic antidepressant
68
Mirtazepine MOA
1. antagonist at presynaptic alpha receptors --> increases synaptic NE and serotonin
2. potent antihistamine blocking response
3. inhibits serotonin 5HT2 and 5HT3
69
who is mirtazepine good for
elderly people - b/c increases appetite
cancer patients
people for whom tricyclic is effective but not tolerated
70
mirtazepine indication
depression
71
dosing considerations for mirtazepine
1. dose reduction in patients with liver or kidney disease
72
trintellix indication
major depressive disorder
73
trintellix CI
1. MAOIs
74
trintellix MOA
enhances serotinergic activity in CNS through inhibition of reuptake of serotonin
75
trintellix S/E
1. N/V, constipation
2. suicide risk
3. serotonin syndrome
4. abnormal bleeding
5. activation of mania/hypomania
6. hyponatremia
76
Lithium indications`
1. bipolar disorder - prophylaxis and treatment of manic phase
2. refractory depression
77
lithium CIs
1. use w/ extreme caution in patients w/ significant renal or cardiovascular disease
2. use w/ extreme caution in patients w/ severe dehydration or sodium depletion
78
What do you need to check with giving lithium
follow BMP, BUN and creatinine especially
Lithium levels b/c narrow therapeutic index
TSH, T4 (risk of hypothyroidism w/ long term use - yearly)
79
lithium MOA
inhibits dopamine neurotransmission
80
Lithium serious S/E
acute lithium toxicity
1. N/V/D
2. renal failure
3. ataxia, tremor, confusion, delirium, seizures
81
Lithium S/E
1. arrhythmias
2. hypotension
3. goiter
4. hypothyroidism
5. nephrotoxicity
6. weight gain
7. Nausea, GI irritation
8. memory disturbances, cognitive dulling
82
Lithium drug interactions
1. NSAIDs
2. Diuretics
3. ACE inhibitors
4. Fluoxetine decreases efficacy of lithium
many more
83
First Generation Antipsychoitc examples
1. chlorpromazine / thorazine
2. Prochlorperazine / compazine
3. haloperidol / Haldol
84
compazine uses
1. excellent antiemetic
85
uses of haldol and thorazine
1. agitation acutely in ER
| 2. intractable hiccups
86
First Gen Antipyschotic indications
1. psychosis
2. acute agitation, delirium, mania (haloperidol)
3. N/V (chlorpromazine)
4. Tourette's syndrome (haldol)
5. intractable hiccups (haldol, chlorpromazine)
87
FGAs MOA
antagonist at dopamine D2 receptors
| also antagonists at adrenergic, cholinergic, histamine H1 receptors
88
FGA half-life
12-24 hours
89
FGA CI
severe CNS depression
| avoid if decreased consciousness
90
FGA S/E
1. anticholinergic - dry mouth, constipation, difficulty urinating
2. alpha antagonism - orthostatic hypotension, ejaculatory failure
3. sedation
4. extrapyramidal syndrome!!
5. tardive dyskinesia
6. akathisia - inability to sit still
7. dystonia - muscles spasms of face, tongue, back, neck
91
what is extrapyramidal syndrome
blockage of dopamine receptors in basal ganglia --> Parkinson-like symptoms (slow movements, stiffness, tremor)
92
what is tardive dyskinesia
repetitive involuntary movements of face, arms, trunk
| rhythmic tongue protrusion, puffing out cheeks, puckering of mouth
93
FGA rare but serious side effects
1. neuroleptic malignant syndrome (NMS) - hyperthermia accompanied by extrapyramidal and autonomic disturbances that may be fatal
2. agranulocytosis - severe reduction in # of leukocytes --> neutropenia
3. cardiac conduction abnormalities, long QT
94
Second Generation (Atypical) Antipsychotics examples
1. olanzapine / zyprex
2. risperidone / risperdal
3. quetiapine / seroquel
95
what else is olanzapine used for
sleep
96
2nd gen antipsychotic indications
1. disorders of thought
2. depression or mania w/ psychotic features
3. bipolar disorder
4. severe agitation and delusions in pts w/ dementia
97
2nd gen antipsychotic CIs
hx of neuroleptic malignant syndrome
98
2nd gen antipsychotic MOA
1. antagonize dopamine and serotonin receptors primarily
2. D2 receptor antagonists
3. potent antagonists of 5 HT2 receptors
4. also antagonize adrenergic, cholinergic, histamine H1 receptors
99
2nd gen antipsychotic metabolism
liver
100
2nd gen antipsychotic serious S/E
1. increased mortality in elderly patients
2. endocrine - exacerbation of diabetes, hyperglycemia, dyslipidemia, hyperprolactinemia
3. Neuroleptic malignant syndrome
4. extrapyramidal symptoms
101
what should you screen for when giving 2nd gen antipsychotic
CMP, lipid panel, A1c, weight gain
102
2nd gen antipsychotic common S/E
1. orthostatic hypotension
2. sedation
3. anticholinergic
4. N/V
103
switching from 2nd gen antipsychotic
cross-titrate rather than wash out
104
Natural antidepressants
1. exercise
2. exposure to light
3. supplements
