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Therapeutics Flashcards

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1
Q

Precautions to using antipsychotics

A
  • Active CD (esp QTC prolongation)
  • Parkinson’s disease
  • Epilepsy
  • Depression
  • Myasthenia gravis
  • BPH
  • Angle closure glaucoma
  • Severe respiratory disease
  • History of jaundice
  • Blood dyscrasia
  • Elderly with dementia
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2
Q

Treatment for acute agitation/psychosis

A

Cooperative:
- PO lorazepam 1-2 mg
- PO antipsychotics (haloperidol 2-5 mg, risperidone 1-2 mg, quetiapine 50-100 mg, olanzapine 5-10 mg)
- Inhaled loxapine 100 mg with standby salbutamol

Uncooperative:
- PO lorazepam 1-2 mg
- IM olanzapine 5-10 mg (not within 1 hour of giving lorazepam)
- IM Aripiprazole 9.75 mg
- IM haloperidol 2.5-10 mg
- IM promethazine 25-50 mg
- IM lorazepam + haloperidol
- IM haloperidol + promethazine

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3
Q

Treatment for acute catatonia in schizophrenia

A

PO/IM lorazepam

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4
Q

Management of dystonia from antipsychotics

A
  • Associated with high potency antipsychotics, treatment-naive patients, young males
  • Treat with IM anticholinergics (benztropine, diphenhydramine)
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5
Q

Management of pseudo-parkinsonism

A
  • Assessed using Simpsons-Angus rating scale
  • Associated with elderly females and those with CNS damages
  • Reduce dose or switch to SGA
  • Use anticholinergics PRN (benzhexol, benztropine)
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6
Q

Management of akathisia

A
  • Due to high potency antipsychotics (risperidone > olanzapine > quetiapine/clozapine)
  • Reduce dose or switch to SGA
  • Use clonazepam PRN low dose
  • Use propanolol 20 mg TDS (max 160 mg/day)
  • Anticholinergics are ineffective
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7
Q

Management of tardive dyskinesia

A
  • Associated with FGA > SGA
  • Worsened by anticholinergics
  • Discontinue any anticholinergics
  • Reduce dose or switch to SGA
  • Consider using clozapine
  • Valbenazine 40-80 mg/day (vesicular monoamine transporter 2 inhibitor)
  • Use clonazepam PRN
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8
Q

Management of hyperprolactinemia

A
  • FGA > risperidone > SGA
  • Reduce dose
  • Use dopamine agonist (amantadine, bromocriptine)
  • Switch to aripiprazole
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9
Q

Antipsychotics associated with orthostasis

A

High: chlorpromazine, clozapine
Low: olanzapine, ziprasidone, aripiprazole, sulpiride

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10
Q

Antipsychotics associated with qtc prolongation

A
  • High doses of antipsychotics
  • IV haloperidol
  • Concomitant hypokalemia

High: chlorpromazine, clozapine, ziprasidone
Low: risperidone, olanzapine

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11
Q

Antipsychotics associated with VTE

A

Low potency FGA

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12
Q

Antipsychotics associated with sedation

A

High: chlorpromazine, clozapine
Low: risperidone, ziprasidone, aripiprazole

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13
Q

Management of seizures due to antipsychotics

A

High: chlorpromazine, clozapine
Low: risperidone, ziprasidone, aripiprazole

  • Use high potency antipsychotics e.g. haloperidol
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14
Q

Management of neuroleptic malignant syndrome

A
  • Associated with high potency antipsychotics
  • Use IV dantrolene 50 mg TDS
  • Use PO dopamine agonists (amantadine, bromocriptine)
  • Switch to SGA
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15
Q

Antipsychotics associated with psychogenic polydipsia & temperature dysregulation

A

Anticholinergics

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16
Q

Antipsychotics associated with hepatotoxicity

A

High: chlorpromazine, other FGAs
Intermediate: olanzapine, quetiapine
Low: other SGAs

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17
Q

Antipsychotics associated with ophthalmic changes

A

Phenothiazines, quetiapine

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18
Q

Antipsychotics associated with derm disorders

A

Phenothiazines

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19
Q

Antipsychotics associated with agranulocytosis

A
  • Clozapine
  • Discontinue if WBC < 3 or ANC < 1.5
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20
Q

Monitoring parameters for antipsychotics

A
  • BMI for weight (monthly x 6 months f/b q3 monthly)
  • Waist circumference (every visit x 6 months f/b annual)
  • FBG/HbA1c (high risk: 3 months after starting SGA, f/b annual)
  • Lipid panel (baseline)
  • Prolactin (baseline)
  • BP (3 months after initiation of SGA, f/b annual)
  • EPS exam (weekly for 2 weeks after initiation, f/b q3 months for FGA, 6 months for SGA)
  • WBC & ANC for clozapine (weekly for 18 weeks, f/b monthly)
  • ECG for ziprasidone (repeat if s/s of qtc prolongation e.g. syncope)
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21
Q

Etiological factors for MDD

A
  • Biological (increased cortisol, monoamine deficiency)
  • Psychological
  • Psychosocial
  • Genetics
  • Medical conditions
  • Drug-induced
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22
Q

Medical conditions associated with depression

A
  • Endocrine (hypothyroidism, Cushing’s syndrome, bidirectional with DM)
  • Deficiency states (anemia, wernicke’s encephalopathy)
  • Infections (CNS, STD/HIV, TB)
  • Metabolic (electrolyte imbalance, hepatic encephalopathy)
  • CV (CAD, HF, MI)
  • Neuro (Alzheimer’s , epilepsy, pain, Parkinson’s, post-stroke)
  • Malignancy
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23
Q

Psychiatric conditions associated with MDD

A
  • Alcoholism
  • Anxiety
  • Eating disorders
  • Schizophrenia
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24
Q

Drugs that can induce MDD

A
  • Lipid-soluble beta blockers
  • Psychotropics (CNS depressants, ASM, tetrabenazine)
  • Withdrawal from alcohol, stimulants
  • Systemic glucocorticoids
  • Isotretinoin
  • Interferon beta-1a
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25
DSM-5 diagnostic criteria for MDD
- Interest - Sleep - Appetite - Depressed mood - Concentration - Activity (psychomotor retardation, agitation) - Guilt - Energy - Suicidal - At least 5 symptoms present for the same 2 week period - Symptoms must have caused significant functional impairment - Symptoms not caused by medical conditions or substance
26
Antidepressants indicated for OCD
- Clomipramine - Fluoxetine - Fluvoxamine - Paroxetine - Sertraline
27
Antidepressants indicated for eating disorder
Fluoxetine (bulimia)
28
Antidepressants indicated for pain
- Amitriptyline (neuropathy, migraine) - Nortriptyline (neuropathy) - Duloxetine (diabetic neuropathy, fibromyalgia, MSK pain)
29
Medical conditions associated with anxiety
1. Cardiovascular (arrhythmias, HF, IHD) 2. Endocrine (hyperthyroidism. Cushing's syndrome, hyperkalemia, hyponatremia, hypoglycemia) 3. Neurologic (dementia, delirium, parkinson's, seizures, pain) 4. Pulmonary (asthma, COPD) 5. Others (anemia, SLE, vestibular dysfunction)
30
Drugs that can precipitate anxiety
1. Sympathomimetics (pseudoephedrine) 2. Stimulants 3. Methyxanthines (theophylline, caffeine) 4. Thyroid hormone (levothyroxine) 5. Systemic steroids 6. Antidepressants (SSRI, TCA during initiation & dose escalation) 7. Dopamine agonists (levodopa) 8. beta agonist (salbutamol) 9. Antihypertensive (felodipine) 10. Anticonvulsants (carbamazepine) 11. Antibiotics (quinolones, isoniazid) 12. NSAIDs - Drug withdrawal - Drug intoxication (anticholinergics, antihistamines, digoxin) - Akathisia from antipsychotics
31
Benzodiazepines & Z-hypnotics should not be used in?
- Acute narrow angle glaucoma - Acute pulmonary insufficiency, respiratory depression - Neuromuscular weakness e.g. myastheniania gravis
32
Sedating antihistamines should not be used in?
- Prostatic hypertrophy - Urinary retention - Angle closure glaucoma - Pyloroduodenal obstruction - Epilepsy - QC prolongation (hydroxyzine) - Coronary artery disease (promethazine)
33
Lemborexant should not be used in?
- Narcolepsy - Moderate-strong 3A inhibitors/inducers - Severe hepatic impairment
34
Precautions for benzodiazepines
- Renal/hepatic impairment - Pregnancy / breastfeeding - History of substance abuse or psychiatric disorders e.g. psychosis - Prolonged useage - Undergoing ECT - Patients taking opioids
35
Drugs that can contribute to BPSD in dementia
- Anticholinergics - Anticonvulsants - Systemic steroids - Sedatives - Anti-Parkinsonian drugs
36
Mood stabilisers for pregnant patients
- SGA (quetiapine, olanzapine, risperidone) but monitor for gestational diabetes - FGA (generally not teratogenic) - ECT for severe mania
37
Mood stabiliser for patients with cardiac disease
Valproate (monitor BP, HR, peripheral edema)
38
Mood stabiliser for liver impairment
Lithium
39
Mood stabiliser for renal impairment
Valproate
40
Mood stabiliser for children & adolescents
Lithium, valproate
41
Mood stabilisers for elderly
- Avoid renally excreted drugs - Avoid carbamazepine (hyponatremia) - Consider lamotrigine
42
Mood stabiliser for aggression or violence
- Optimise existing lithium or valproate - Consider adding antipsychotics
43
Antidepressants in obese patients
Consider bupropion, SSRI (except paroxetine), SNRI Avoid mirtazapine, TCA, MAOI
44
Antidepressants in CVD patients
Consider sertraline Avoid TCA, escitalopram
45
Antidepressants in cerebrovascular events
Consider SSRI (fluoxetine)
46
Antidepressants in DM
Avoid TCAs
47
Antidepressants in renal insufficiency
Avoid duloxetine Use paroxetine, vortioxetine with caution
48
Antidepressants in hepatic insufficiency
Avoid agomelatine, duloxetine Use paroxetine, escitalopram with caution
49
Antidepressants in hypertension
Avoid TCA, SNRI
50
Antidepressants in pregnancy
Avoid paroxetine, bupropion Consider nortriptyline in late stage pregnancy
51
Antidepressants in breastfeeding
Consider sertraline, mirtazapine
52
Antidepressants in postpartum depression
Consider brexanolone
53
Antidepressants safer for hyponatremia
Agomelatine, mirtazapine, bupropion
54
Antidepressant safest for bleeding risk
Agomelatine
55
Antidepressants associated with discontinuation syndrome
Worst: paroxetine, venlafaxine Safest: fluoxetine, bupropion
56
Antipsychotics for pregnancy
Olanzapine, clozapine
57
Antipsychotics for breastfeeding
Olanzapine, quetiapine Clozapine to not breastfeed
58
Antipsychotics for renal impairment
PO aripiprazole Avoid sulpiride, amisulpride
59
Antipsychotics for hepatic impairment
Sulpiride, amisulpride
60
Hoehn and Yahr staging
1: Unilateral symptoms 2: Bilateral symptoms 3: Postural instability 4: Severe disability 5: Bedridden
61
Non-motor symptoms of PD
Cognitive: dementia Psychiatric: depression, psychosis Sleep: REM sleep behavioural disorder Autonomic: N/C, orthostasis, sialorrhea Fatigue
62
Medications causing parkinsonism
High: D2 antagonist (antipsychotics) Dopamine depleters (tetrabenazine, reserpine) Dopamine synthesis inhibitors (a-methyldopa) P-calcium channel antagonists (flunarizine, cinnarizine) Moderate: Ziprasidone Antiemetic agents L-calcium channel antagonists Antiepileptics (phenytoin, valproate, levetiracetam) Lithium Low: Antiarrhythmics (amiodarone, procaine) Immunosuppressants (cyclosporin, tacrolimus) Antidepressants (MAOi, TCA, SSRI) Antibacterials (bactrim) Antivirals (anti-HIV, acyclovir) Statins Amphotericin B Levothyroxine, methdroxyprogesterone, epinephrine
63
Drugs to treat drug-induced parkinsonism
Anticholinergics Amantadine
64
Medications indicated for GAD
Escitalopram Paroxetine Venfalaxine XR Duloxetine Alprazolam Diazepam Lorazepam Hydroxyzine Pregabalin
65
Medications indicated for PD
Fluoxetine Paroxetine Sertraline Venlafaxine XR Alprazolam Clonazepam
66
Medications indicated for SAD
Fluvoxamine Paroxetine Sertraline Venlafaxine XR
67
Medications indicated for OCD
Fluoxetine Fluvoxamine Paroxetine Sertraline Clomipramine
68
Medications for PTSD
1st line: CBT Paroxetine Sertraline

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