RAP EXAM 4 PHARM & TX PROTOCOL Flashcards
Antidepressants, Antipsychotics, ADHD, Substance Abuse, Withdrawal, Overdose, etc. (135 cards)
1
Q
Gold standard treatment for recalcitrant treatment-resistant unipolar depression?
A
ECT
2
Q
Is ECT safe for pregnancy?
A
yes
3
Q
ECT standard procedure and frequency?
A
3x weekly for 6-12 months
under general anesthesia
induced small generalized seizures
4
Q
What do you use to treat serotonin syndrome?
A
Benzos & Cyproheptadine
5
Q
If a patient comes in confused, with high body temperature, sweating, diarrhea, clonus, and hypertonia that come on over the last 24 hours, what are you thinking?
A
Serotonin Syndrome
6
Q
Serotonin Syndrome Triad
A
altered mental status
autonomic hyperactivity
neuromuscular abnormality
7
Q
What drugs can increase the risk of serotonin syndrome?
A
Any that increase 5HT (serotonin)
SSRI, SNRI, MAOIs, Linezolid (skin/pneumonia antibiotic), Tramadol (opiate), Triptan (migraines), Zofran (nausea from chemo)
8
Q
What atypical antidepressant used to treat insomnia?
A
Trazadone
9
Q
TRAZADONE MOA
A
serotonin, alpha 1, and H1 antagonist + weak 5HT reuptake inhibitor
10
Q
TRAZADONE ADSE
A
sedation, postural hypotension, priapism (painful persistent erection)
11
Q
What atypical antidepressant is used to help increase appetite in cancer patients?
A
MIRTAZAPINE
12
Q
MIRTAZAPINE MOA and ADSE
A
alpha 2, 5HT2/3, H1 antagonist
ADSE –> increased appetite and sleep
13
Q
BUPROPRION MOA and ADSE
A
Inhibit NE and DA reuptake
less ADSE than most antidepressants BUT can lower seizure threshold
14
Q
Although Buproprion is an atypical antidepressant that has lower ADSE in sexual dysfunction and weight gain, it is used widely for smoking cessation to improve ADHD symptoms. Who is it CONTRA for?
A
anorexia and bulimia patients –> seizure risk
15
Q
Antidepressant that can be used to treat Parkinson’s?
A
SELEGILINE (MAOI)
16
Q
An antidepressant that can be used to treat nocturnal enuresis (“bed wetting”)?
A
IMIPRAMINE (TCA)
17
Q
Coma, convulsions, and cardiotoxicity are signs of what?
A
TCA overdose/toxicity
18
Q
TCA used to treat OCD?
A
CLOMIPRAMINE
19
Q
An elderly patient, shortly after starting treatment with an old drug for MDD + chronic pain, begins to experience QT prolongation, convulsions, and slips into a coma. What do you use to treat?
A
sodium bicarbonate
(for arrhythmias due to TCA cardiotoxicity from excessive acetylcholine)
20
Q
ADSE of a drug used to treat atypical or treatment-resistant depression and/or anxiety?
A
Hypertension crisis + CNS stimulation via MAOI
21
Q
Ingestion of what is dangerous if the patient is taking an MAOI for Parkinson’s or treatment-resistant depression/anxiety?
A
wine + cheese + fava beans b/c tyramine –> hypertension crisis
22
Q
What should a physician recommend for a patient discontinuing their MAOI medication?
A
2-week wash-out period
23
Q
SNRI is used to treat what generally? Advantages/Disadvantages?
A
2nd LINE depression, GAD, but also effective for diabetic neuropathy and fibromyalgia
similar SSRI side effect profile but extra HTN risk
24
Q
SSRI is used to treat what generally? Advantages/Disadvantages?
A
1st LINE depression, GAD, social anxiety, OCD, premature ejaculation, PDD, bulimia, panic disorder
Advantage: lots of range and generally well tolerated
ADSE: GI (starting), sex dysfunction, SIADH
25
How long for SSRIs and SNRIs to take full effect?
3-6 weeks
26
BUPROPION MOA
NRDI: NE and DO reuptake inhibitor
27
What class? FLUOXETINE - PAROXETINE - SERTALINE - ESCITALOPRAM
SSRI: selective serotonin reuptake inhibitors
28
What class? DULOXETINE - LEVOMILNACIPRAN - VENLAFAXINE - DESVENLAFAXINE
SNRI: serotonin and NE reuptake inhibitor
29
Discontinuation syndrome of SSRIs and SNRIs?
"FINISH"
flu like - insomnia - nausea - imbalance - sensory disturb - hyperarousal
30
Which drug is implicated the MOST for causing discontinuation syndrome?
VENLAFAXINE (SNRI)
31
Which drug is implicated the LEAST for causing discontinuation syndrome?
FLUOXETINE (SSRI)
32
Who should you especially exercise caution in prescribing SSRIs or SNRIs due to ADSE?
under 25 yo (increased suicidal ideation), people with seizure risks (decreased threshold), hypertensive pts (with SNRIs)
33
Difference between atypical antidepressants: VILAZODONE vs. TRAZADONE/VORTIOXETINE?
VILAZODONE: SSRI and 5HT-R partial agonist
TRAZADONE/VORTIOXETINE: SSRI and 5HT-R antagonist
34
MIRTAZAPINE MOA
a2 antagonist (atypical antidepressant)
less a2 (brainstem to PFC) = more NT release of 5HT and NE at PFC indirectly
35
What class? BUPROPION - MIRTAZAPINE - TRAZADONE - VILAZODONE - VORTIOXETINE
atypical antidepressants
36
What class? PHENELZINE - SELEGILINE - TRANYLCYPROIMINE
MAOIs
37
MAOIs MOA?
monoamine oxidase inhibitor (A) for antidepressive effects via
increased levels of DA, NE, 5HT, and Tyramine, an old school drug that has lots of ADSE and used for recalcitrant depression
38
What class? DESIPRAMINE - IMIPRAMINE - NORTRIPTYLINE - PROTRIPTYLINE
TCAs
39
TCAs MOA?
bind to off-target receptors of NE and 5HT for antidepressant effects, but also receptors having antihistamine, anti-alpha, and antimuscarinic effects
nonselective with limited use
40
What drug class can be used to treat recalcitrant depression and chronic pain?
TCAs - DESIPRAMINE - IMIPRAMINE - NORTRIPTYLINE - PROTRIPTYLINE
41
What drugs can be used for GAD?
SSRI/SNRI, Gabapentin/Preglabin, Benzo, Buspirone
42
BUSPIRONE MOA
DIRECT 5HT-R agonist used to treat GAD
43
How are Gabapentin/Preglabin used to treat GAD?
Inhibition of voltage calcium-gated channels in the amygdala to reduce firing and blunt the fear response
44
How are Benzos used to treat GAD?
increase amounts of post synaptic GABA(a) levels to reduce amygdala neuronal firing = blunt fear response; not used 1st line or long term
45
What drug can reduce lithium clearance due to its effects on the nephron?
Thiazides - CLORTHALIDONE, HYDROCHLOROTHIAZIDE, INDAPAMIDE
46
Bipolar pharm TX options?
COMBO lithium + antipsychotic OR COMBO valproate + antipsychotic
Lithium (prophylactic)
47
What is the hypothesized Lithium MOA to treat bipolar?
disrupts the GPCR pathway and PEP pathway to increase neuronal plasticity and protection
48
Lithium ADSE
tremor, decreased thyroid function, nephrogenic diabetes insipidus
49
Why is Lithium CONTRA to women shortly AFTER they have given birth?
Pregnancy increases GFR, so a normal dose of lithium runs the risk of increased exposure in the post-natal period
50
OCD treatment protocol, FDA approved vs off-label?
Exposure and response therapy + CBT
FDA approved: SSRIs + TCA (CLOMIPRAMINE)
Off-Label: SNRI (VENLAFAXINE)
51
Trichotillomania treatment protocol?
CBT + CLOMIPRAMINE (TCA)
52
What are the general NT implicated in schizophrenia and psychosis?
D2, 5-HT2a/c, Glutamate
53
What dopamine pathway is affected in schizophrenia and how does it translate to its symptoms?
VTA - mesolimbic (+ SYM) inc DA - Nuc Accumbens - mesocortical (- SYM) dec DA- Prefrontal Cortex
54
What dopamine pathways are unaffected by schizophrenia but may be impacted during treatment?
Nigrostriatal pathway (Sub Nigra - Caudate Putamen - 80% DA, EPS SYM)
Tuberoinfundibular Tract (Pituitary - Prolactin)
55
What receptors are generally targeted by meds that want to reduce the (-) SYM of schizophrenia? Where are they concentrated exclusively ? Where relative to synapse? What drug class?
D1 Like DA Receptors (1,5) - hypothalamus exclusive - Gs GPCR - post synaptic - atypical antipsychotics
56
What receptors are generally targeted by meds that want to lower the (+) SYM of schizophrenia? Where are they concentrated exclusively ? Where relative to synapse? What drug class?
D2 Like DA Receptors (2,3,4) - pituitary exclusive - Gi GPCR - pre/post synaptic - 1st Gen Antipsychotics
57
2nd Gen Antipsychotic ADSE profile
EPS, drug induced Parkinson's, dystonia, TDK
58
What kind of DA receptor is more important to the antipsychotic MOA and efficacy?
D2 Antagonists
59
What can a D2 agonist be paired with to reduce the EPS?
cholinergic antagonist - blocks the extra release of Ach from when D2 is blocked - no activation of muscarinic neuron
60
Which first gen antipsychotic causes the worse EPS ADSE?
HALOPERIDOL
61
1st GEN antipsychotics (4)
CHLOPROMAZINE, FLUPHENAZINE, THIOTHIXEME, HALOPERIDOL
62
2ND GEN antipsychotics (4)
CLOZAPINE, RISPERIDONE, OLANZAPINE, QUETIAPINE, ZIPRASIDONE, ARIPIPRAZOLE
63
What should you know about glutamate in schizophrenia?
Phencyclidine that mimics +/-/cognitive schizophrenia sym & NMDA antagonist
hyperactivity of mesolimbic pathway - schizophrenia
NMDA - R hypofunction hypothesis (-) SYM
64
How are 1st gen versus 2nd Gen antipsychotics different in NT Targets
1st GEN: D2 > 5HT2A :2nd GEN
65
robust anticholinergic med with min EPS despite being a 1st Gen antipsychotic?
CHLORPROMAZINE
66
Weak cholinergic med with a high chance among drug class with worse EPS ADSE as a 1st Gen antipsychotic?
HALOPERIDOL
67
Drug with ADSE sedation and orthostatic hypotension used to treat schizophrenia?
HALOPERIDOL
68
What is the first drug of choice to treat schizophrenia?
ARIPRIPRAZOLE "3rd GEN"
69
ARIPRIPRAZOLE MOA
Partial agonist of DA that competes with excess dopamine in mesolimbic pathway (+ SYM) and brings up DA to therapeutic levels in mesocortical pathway (- SYM)
70
What are the TCA "TRI - C" Complications?
cardiotoxicity - convulsions - coma
71
Antidepressant class ADSE postural hypotension, QT prolong, anticholinergic, and sedation?
TCA
72
Antidepressant class with possible ADSE of SIADH leading to nephrogenic diabetes insipidus?
SSRI
73
Drugs research shows reduced suicide rates?
LITHIUM and CLOZAPINE
74
Treatments known to quickly reduce suicidal ideation?
ECT and ESKETAMINE
75
What are some potential risks of HRT (estrogen and testosterone) for gender affirming care?
Cardiovascular events: stroke, heart problems, and blood clots
Bone density changes (increased or decreased) - monitor w/h Vit D levels
76
Drug used with CBT and Nutritional therapy to treat Anorexia?
OLANZAPINE
77
What drug is used to reduce episodes of binge eating?
LISDEXAMFETAMINE
78
What drug can be used alongside diaphragmatic breathing to treat rumination?
BACLOFEN (GABA-B Agonist)
79
CLONIDINE MOA
nonselective a2 agonist (postsynaptic brainstem)
80
GUANFACINE
selective a2A agonist
81
What class of drugs can be used to treat ADHD and Narcolepsy?
METHYLPHENIDATE (stimulant)
82
METHYLPHENIDATE MOA
NRDI - presynaptic NE and DA reuptake inhibitor
Low Dose - PFC selective
High Dose - impaired cognition
83
AMPHETAMINE MOA
pseudo substrate that acts as a competitive inhibitor to DA - stimulant
84
RITALIN and FOCALIN
short act methylphenidates (stimulant)
85
RITALIN (LA/SR), CONCERTA, FOCALIN (XR)
long acting methylphenidates (stimulant)
86
AMPHETAMINE: short acting vs. long acting?
Adderall (short) + Vyvanse (long)
87
Why are ATOMOXETINE and CLONIDINE good options for patients with a history of substances abuse that would like pharm treatment for their ADHD?
ATOMOXETINE - SNRI - selective NE reuptake inhibitor
CLONIDINE - nonselective a2 agonist
Both do not increase NE or DA at the Nucleus Accumbens decreasing the abuse potential
88
Treatment for AIDs related toxoplasmosis encephalopathy?
pyrimethamine + sulfadiazine + leucovorin OR TMP-SMX
89
Treatment for AIDs related cryptococcal CNS infection?
amphotericin B + Fluctosin -- fluconazole -- low dose fluconazole
90
Treatment for late stage trypanosomiasis (CNS symptoms)
Eflornithine +/- Nifurtimox OR melarsoprol
91
Treatment for early hemolymphatic stage of trypanosomiasis (gambiense vs. rhodesiense)
gambiense - PENTAMIDINE
rhodesiense - SURAMIN
92
post exposure prophylaxis protocol for rabies
rabies immune globulin (RIG), clean wound, rabies vaccine series
93
Drug used to reduce nightmares and flashbacks useful for PTSD TX?
PRASOZIN
94
PRASOZIN ADSE
orthostatic hypotension
95
PTSD treatment protocol?
THERAPY + PHARM
psychotherapy (EMDR, CBT, exposure based) + SSRI (low dose) Prazosin
96
What drug to generally avoid when treating PTSD?
Benzos
97
Drug used to restore balance to the overactive glutaminergic system implicated in Alzheimer's Dx and Parkinson's via NMDA receptor antagonism?
MEMANTINE
98
First line drug class (and drugs) in Alzheimer's TX?
cholinesterase inhibitors: DONEPAZIL, RIVASTIGMINE, GALANTAMINE
99
CONTRA for cholinesterase inhibitors (DONEPAZIL, RIVASTIGMINE, GALANTAMINE)?
Asthma and Bradycardia
100
Gold standard for acute mood stabilizer?
LITHIUM
101
FDA approved TX bipolar mania
LITHIUM, VALPROATE, CARBAMAZEPINE, All 2nd Gen Antipsychotics (except lurasidone)
102
FDA approved bipolar maintenance TX
ARIPIPRAZOLE, RISPERIDONE, DANZAPINE, LITHIUM, LAMOTRIGINE
103
FDA approved bipolar depression TX
OLANZAPINE + FLUOXETINE; QUETIAPINE; LURASIDONE
104
VALPROATE BBW?
hepatoxic, pancreatitis, neural tube defect
105
CARBAMEZAPINE BBW?
SJS, agranulocytosis
106
LITHIUM CONTRA?
ACE, ARBs, Diuretics, 1st trimester pregnant
107
Difference between Amphetamines and Methylphenidates?
BOTH increase NE and DA by blocking its reuptake = increasing DA at mesolimbic pathway as STIMULANT = both available in racemic and dextro- formulations BUT
BUT methylphenidate more NE > DA selective
108
Although a stimulant, why does LISDEXAMFERTAMINE have less abuse potential than other drugs in this class?
prodrug formulation allows for more selective, steady slow rise in concentrations, that are constant over a long period of time offering a drug delivery pharmokinetic profile that is slow = not pulsatile = less abuse potential
109
ATOMOXETINE ADSE
somnolence, suicidal ideation, fatigue
110
What is the go to adjunct therapy for ADHD and ODD?
a2 receptor agonist + stimulant
111
Where does ATOMOXETINE increase DA levels?
SNRI - increased NE and DA at PFC NOT Nuc Acc
112
Illicit drugs that do not have withdrawal?
PCP, Inhalant, Hallucinogens
113
Drug that is used to discourage drinking alcohol when recovering from alcohol abuse but can be extremely dangerous if any alcohol is ingested/exposed due to its MOA inhibiting aldehyde dehydrogenase?
DISULFRAM (seizures - death)
114
DISULFRAM ADSE
hepatotoxic, neurologic polypharm, derm rash/itch, seizures death
115
Drug that is used to reduce alcohol craving and intoxication euphoria?
NALTREXONE (opioid antagonist mu receptor)
116
Alcohol withdrawal treatment protocol?
Benzo + Valproic Acid + Thiamine --> dextrose
117
Benzo/Barbituate taper protocol?
if outpatient = decrease every 1-2 weeks 5mg DIAZEPAM equivalent
if rapid taper = +/- CARBAMAZEPINE or VALPROIC ACID
118
TX for BENZO/BARB overdose?
FLUMAZENIL (benzo-R antag = seizure risk)
119
Benzos that are metabolized by glucoronidation so okay to use in patients even if they have liver insufficiency
LORAZEPAM, OXAZEPAM, TEMAZEPAM
120
TX for opioid overdose?
NALOXONE (aka NARCAN - short act opiod antag)
121
Drugs to treat opioid withdrawal?
METHADONE, NALTREXONE, BUPRENORPHINE
122
BUPRENORPHINE MOA
partial mu agonist with ceiling
recommended for highly motivated patients with opioid sub abuse
123
METHADONE MOA
long acting mu receptor agonist
124
Best TX plan for tobacco substance use dx?
CBT + BUPROPION + Nicotine Replace Therapy (VARENICLINE)
125
TX plan for PCP dissociative episode?
antipsychotic or benzo, low stimulation environment, acidify urine
126
schizophrenia patient develops orthostatic hypotension, blue-grey skin, photosensitive, and corneal deposits what drug?
CHLORPROMAZINE
127
schizophrenia patient develops retinal deposits (retinitis pigmentosa) what drug?
THIORIDALINE
128
TX if schizophrenia patient develops EPS: dystonia
acute - anticholinergics (BENZTROPINE)
chronic - switch meds to SGA
129
TX if schizophrenia patient develops EPS: akathisia
Acute - Beta Blockers
130
TX if schizophrenia patient develops tardive dyskinesia
Acute - VMAT inhibitors ("-BENAZINE")
Taper meds and switch to SGA
131
TX protocol if you suspect neuroleptic malignant syndrome (slow onset of rigidity, abnormal vitals, fever, encephalopathy, and elevated CPK)?
STOP antipsychotic med, IV fluids, cool, DANTROLENE or BROMOCRIPTINE
132
Gold standard for treatment resistant schizophrenia?
CLOZAPINE
133
What do you need to monitor in patients taking CLOZAPINE?
Weekly for 1 year then monthly CBC for agranulocytosis risk
134
Antipsychotic with the greatest risk for prolactinemias?
RISPERIDONE
135
Antipsychotic with the greatest risk of weight gain?
OLANZAPINE
