Psych shelf

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  1. Antidepressants
    • Most have withdrawal phenomenon char by dizziness, headache, nausea, insomnia, and malaise
    • SSRI
    • SNRI
    • TCA
    • MAOI
    • Misc: Buproprion, Trazodone, Nefazodone, Mirtazapine
  2. SSRIs
    • Ex: Fluoxetine, paroxetine, sertraline, citalopram, escitalopram, fluvoxamine
    • MoA: Inhibit presynaptic uptake of 5Ht -> increase availability of 5HT
    • May increase levels of warfarin!!!
    • SE: Sexual dysfunction (decreased interest, anorgasmia, delayed ejaculation), GI upset, insomnia and vivid dreams, increase risk of suicidality (esp teens)¬†
    • Counteract sexual dysfunction by 1) augmenting with bupropion) 2) changing to non-SSRI or 3) add sildenafil
    • Other SE: headache, anorexia/wht loss, akithesia at initiation/discontinuation, seizures
  3. Serotonin Syndrome
    • Char by fever, diaphoresis, shivering, tachycardia, myclonus, hyperreflexia, delirium, flushing, hyperthermia, hypertonicity, rhabdo, renal failure, and death
    • Do NOT give SSRI 2 weeks before or after use of MAOI
    • Also be careful of high-dose antidepressant with OTC cough medicine (has serotonin in it!!)
    • If suspect serotonin syndrome: d/c med, try calcium channel blocker (oral nifedipine), and if carefully monitored, may try chlorpromazine or phentolamine
  4. Fluoxetine (Prozac)
    • SSRI with Longest 1/2 life
    • Safe in pregnancy and can be used in kids
    • SE: sleep changes and anxiety more common
    • May incr neuroleptic levels -> incr SE
  5. Sertraline (Zoloft)
    • SSRI with highest risk of GI upset
    • SE: sleep changes more common
  6. Paroxetine (Paxil)
    • SSRI that is highly protein bound (many drug interactions)
    • SE: Anti-ACh (sedation, constipation, wht gain)
    • Has short 1/2 -> w/d phenomenon
  7. Fluvoxamine (Luvox)
    • SSRI approved only for use with OCD
    • SE: N/V
    • Lots of drug interaction
  8. Citalopram (Celexa)
    • SSRI with fewest drug-drug interaction
    • Has fewer sexual SE
  9. Escitalopram (lexapro)
    SSRI similar to citalopram but with fewer SE and more expensive
  10. SNRIs
    • MoA: Block pre-synaptic reuptake of NE and 5HT
    • Examples: Venlafaxine and duloxetine
    • SE: increases bp
  11. Venlafaxine (Effexor)
    • SNRI
    • Use: depression, GAD, ADHD
    • Has low drug interaction
    • Don't give to pt with untreated or labile bp
    • Desvenlafaxine is new but expensive metabolite on market
  12. Duloxetine (Cymbalta)
    • SNRI
    • Use: Depression and neuropathic pain, or fibrmyalgia
    • SE: Dry mouth, constipation, liver SE (esp if pt has liver disease or heavy EtOH use)
    • Expensive
  13. Buproprion (Wellbutrin)
    • MoA: NE and DA reuptake inhibitor
    • Has lack of sexual SE
    • May help tx ADHD
    • SE: Incr sz risk, psychosis at high doses, and incr anxiety
    • CI: pt with sz (epilepsy), eating disorders, or those on MAOI
  14. Trazodone (Desyrel) and Nefazodone (serzone)
    • MoA:¬†
    • Use: Insomnia, refractory major depression, and major depression with anxiety
    • SE: Priapism (esp trazodone), sedation, N, dizziness, orthostatic hypotension, cardiac arrhythmias
    • Nefazodone has black box warning for liver failure (rare)
  15. Mirtazapine (Remeron)
    • MoA: alpha-2 antagonist
    • Use: Refractory major depression (esp in pt who needs to gain weight)
    • SE: Sedation, wht gain, somnolence, tremor, dry mouth, constipation, and agranulocytosis
    • Esp useful in elderly as helps with sleep and appetite
  16. California Rocket Fuel
    • Combo of venlafaxine and mirtazapine
    • If pt is sad and not eating, use this as it causes appetite stimulation/wht gain and sedation
  17. TCAs
    • Ex: Amitriptyline, nortriptyline, imipramine, comipramine, doxepin, deipramine, amoxepine
    • MoA: Block NE and 5HT reuptake
    • High SE profile and lethal in OD, so rarely used
    • To tx OD use IV sodium bicarb (NaHCO3)
    • SE: Convulsions, cardiac arrhythmias and QTc prolongation, coma, anti-cholinergic, anti-histaminic, antiadrenergic, wht gain, sz, sertonoergic effects (anorgasmia in females and erectile/ejaculatory dysfunction males)
  18. Antihistaminic effects
  19. Antiadrenergic side effects
    Orthostatic hypotension, dizziness, reflex tachy, arrhythmias, QRS/QT/PR widening
  20. Antimuscarinic SE
    Dry mouth, constipation, urinary retention, blurred vision, tachycardia, exacerbation of narrow angle glaucoma
  21. Amitriptyline (Elavil)
    • TCA
    • Use: Chronic pain, migraines, and insomnia
  22. Imipramine (Tofranil)
    • TCA
    • Useful in enuresis (decreases delta wave sleep, the phase when bed wetting is most likely) and panic d/o
  23. Clomipramine (Anafranil)
    • TCA
    • Use for OCD
  24. Doxepine (Sinequan)
    • TCA
    • Good for chronic pain
    • Also useful as sleep aid in low doses
  25. Nortriptyline (Pamelor, aventyl)
    • TCA
    • Is metabolite of tertiary amine and has less anticholinergic effects
    • Ortho hypo less likely
    • Useful in chronic pain
  26. Desipramine (Norpramin)
    • TCA
    • More activating and least sedating/anticholinergic
  27. Amoxapine (Asendin)
    • TCA
    • May cause EPS and has SE like typical antipsychotics
  28. Maprotiline (Ludiomil)
    • TCA
    • High rates sz, arrhythmia, and fatality with OD
  29. MAOI
    • MoA: Block monoamine oxidase enzyme, so monoamines (NE, Epi, 5HT, tyramine) are not degraded and levels increase
    • Ex: Isocarboxide, phenelzine, tranylcypromine, selegiline (MAOI-B, no dietary restrictions)
    • Must avoid decongestants, opiates, and serotonergic drugs with MAOI (including selegiline)
    • Use: Atypical depression, refractory depression, refractory panic/anxiety d/o
    • SE: Risk of hypertensive crisis with tyramine, serotonin syndrome (esp SSRIs), orthostatic hypotension (most common)
  30. OCD
    Tx with SSRIs and clomipramine (TCA)
  31. Panic disorder1
    Tx with SSRIs, imipramine (TCA), and MAOI
  32. Eating disorders
  33. Dysthymia
    Tx with SSRI
  34. Social phobia
    Tx with SSRI, TCA, MAOI
  35. GAD
    Tx with SSRIs, velafaxine (SNRI), TCAs
  36. PTSD
  37. Neuropathic pain
    Amitriptyline and nortriptyline (TCA), duloxetine (SNRI)
  38. Chronic pain
    SSRI and TCA
  39. Fibromyalgia
  40. Migraines
    amitriptyline (TCA), SSRI
  41. Premenstrual dysphoric disorder
  42. Depressive phsae of manic depression
  43. Insomnia
    Mirtazapine, amitriptyline (TCA), trazodone
  44. Antipsychotics
    • Typical (1st gen): Block D2 and treat psychosis; tx + sx via mesolimbic DA pathway
    • Atypical (2nd gen): Block D2 and 5HT2A; also tx +sx via mesolimbic DA pathway
    • Atypicals have increased risk of all cause mortality and stroke in elderly
    • Atypicals also more effective in treating -sx via the mesocortical DA pathway
  45. Typical antipsychotics
    • Vary by potency
    • Low potency: Chlorpromazine (thorazine) and thioridazine (mellaril)
    • Midpotency: Loxapine, thiothixene, trifluoperazine, and perphenazine
    • High potency: Haloperidol (haldol), fluphenazine (prolixin), and pimozide -> can give these IM for acute agitation or psychosis
    • Lower potency have greater anti-ACh and anti-hist risk; also have greater lethality with OD due to QTc prolongation -> v tach and heart block
    • Higher potency have greater EPS and NMS risk
    • Major SE
    • 1. Antidopiminergic (EPS = parkinsonism, akathisia, dystonia with oculogyric crisis and torticollis) -> occurs via DA pathways in nigrostriatum. Tx with benztropine (anti-ACh), diphenhydramine (anti-hist), or amantadine
    • 2. Hyperprolactinemia due to decr DA in tuberoinfundibular pathway
    • 3. Anti-HAM
    • 4. Tardive dyskinesia: Especially in elderly female; 50% cases permanent. Tx by d/c or changing med (clozapine has decr risk for TD)
    • 5. NMS: Most common in young adult male; see incr CPK, rigidity, diaphoresis, delirium, incr LFT, jaundice. Tx by d/c med, hydrate, cool, dantrolene/bromocriptine/amantadine. NOT an allergic rxn
  46. Onset of neuroleptic sx
    1. Acute dystonia
    2. EPS/akathisia
    • Acute dystonia: hours to days
    • EPS/akathisia: days to months
  47. Chlorpromazine (thorazine)
    • Low potency typical antipsychotic
    • Also used to tx nausea, vomiting, and irretractable hiccups
    • Major SE: Orthostatic hypotension, bluish skin discolration, and photosensitivity
    • Other SE: EPS, hyperprolactinemia, TD, NMS
  48. Thioridazine (mellaril)
    • Low potency typical antipsychotic
    • SE: retinitis pigmentosa
    • Other SE: EPS, hyperprolactinemia, TD, NMS
  49. Loxapine
    • Midpotency typical antipsychotic
    • Produces a metabolite that is an antidepressant
    • Major SE: Incr seizure risk
    • Other SE: EPS, hyperprolactinemia, TD, and NMS
  50. Thiothixene
    • Midpotency typical antipsychotic
    • Major SE: Ocular pigment changes
    • Other SE: EPS, hyperprolactinemia, NMS, and TD
  51. Perphenazine
    • Midpotency typical antipsychotic
    • Other SE: EPS, hyperprolactinemia, TD, NMS
  52. Haloperidol (haldol)
    • High potency typical antipsychotic
    • Available in long acting IM form (decanoate)
    • Doesn't cause agranulocytosis
    • Other SE: EPS, hyperprolactinemia, TD, NMS
  53. Fluphenazine (prolixin)
    • High potency typical¬†antipsychotic
    • Comes in long acting IM form (decanoate)
    • Other SE: EPS, hyperprolactinemia, TD, NMS
  54. Pimozide
    • High potency typical antipsychotic
    • Associated with heart block and v-tach
    • Other SE: EPS, hyperprolactinemia, TD, NMS
  55. Atypical antipsychotics
    • Block both DA and 5HT receptors
    • Have decr risk of EPS, TD, and NMS
    • More effective in tx negative sx of schizophrenia
    • Can also be used for acute mania, bipolar, and as adjunctive in unipolar depression
    • Includes clozapine, risperidone, quetapine, olanzapine, ziprasidone, aripiprazole, paliperidone, asenapine, iloperidone
    • SE:
    • 1. Metabolic syndrome: Ziprasidone and aripiprazole are less associated with weight gain and better choice if this is concern
    • 2. Anti-HAM
    • 3. Wht gain
    • 4. HLD
    • 5. Hyperglycemia and DKA (rare)
    • 6. Liver function-monitor LFT and ammonia yearly
    • 7. QTc prolongation
  56. Clozapine (clozaril)
    • Atypical antipsychotic
    • 30% of tx resistant psychotis responds to this
    • Major SE: Myocarditis, incr seizure risk, agranulocytosis; incr risk of anti-ACh effects; decr risk of TD
    • Must get weekly blood draws for first six months
    • If ANC < 1500 d/c clozapine!!
    • ONLY antipsychotic that decr risk of suicide risk!!
  57. Risperidone
    • Atypical antipsychotic
    • Also approved to tx mania
    • Has long acting injectible that is expensive
    • SE: Incr prolactin, orthostatic hypertension, and reflex tachycardia
  58. Quetapine (Seroquel)
    • Atypical antipsychotic
    • Approved to tx mania
    • Major SE: Sedation and orthostatic hypotension
  59. Olanzapine (zyprexa)
    • Atypical antipsychotic
    • Major SE: Wht gain
  60. Ziprasidone (Geodon)
    • Atypical antipsychotic
    • Less likely to cause wht gain
  61. Aripiprazole (abilify)
    • Atypical antipsychotic
    • Partial D2 agonist
    • Has incr risk of akathisia but decr risk of wht gain
  62. Mood stabilizers
    • Used to treat acute mani and prevent relapses
    • Also used to potentiate antidepressants, antipsychotics, enhance EtOH abstinence, and treat aggression/impulsivity
    • Includes lithium and anti-convulsants
  63. Lithium
    • Mood stabilizer
    • Only mood stabilizer that decr suicidality
    • Metabolized by kidney
    • Obtain EKG, Chem7, TSH, CBC, and pregnancy test before starting
    • Therapeutic state takes 5-7 days, and range is .6-1.2; toxic is >1.5 and lethal is >2.0
    • Monitor Li levels, TSH, and kidney function
    • Toxicity: AMS, tremors, convulsions, death
    • SE: Nephrogenic DI, fine tremor, thyroid enlargement and hypothyroidism, benign leukocytosis, ebstein's anomaly
    • Note that the leukocytosis can be beneficial if used with clonzapine (causes leukopenia)
  64. Factors affecting lithium levels
    Dehydration, salt deprevation, sweating, and impaired renal function all incr

    NSAIDs decr (be careful giving ibuprofen)

    Diuretics and aspirin can also affect levels
  65. Anti-convulsants
    • May be used as mood stabilizers
    • Major SE: GI, wht gain, alopecia, sedation, pancreatitis, hepatotoxicity or benign aminotransferase incr, incr ammonia, thrombocytopenia, neural tube defects
  66. Carbamazapine (Tegretol)
    • Especially good for mixed episode or rapid cycling bipolar disorder, but less effective for depressed phase
    • Blocks sodium channels which blocks action potentials
    • Onset takes 5-7 days
    • Get CBC and LFT before starting
    • SE: GI, CNS (drowsy, ataxic, sedated, confused), SJS, neural tube defects
    • Toxicity: Confusion, stupor, restlessness, nystagmus, tremor, twitching, vomiting
  67. Oxcarbazepine
    Has decreased risk for rash and hepatic toxicity
  68. Valproate (Depakote)
    • Good for mixed episodes and rapid cycling
    • Onset is 3-5 days
    • Range is 50-150
    • Note that valproate will increase lamotrigine levels
  69. Lamotrigine (Lamictal)
    • Good for bipolar depression
    • Affects the NA channels that modulate glutamate and aspartate
    • SE: Dizzy, sedated, headache, ataxia, SJS
    • Note that lamotrigine will decrease valproate levels
  70. Gabapentin (Neurontin)
    Used for anxiety and sleep but little help with bipolar disorder
  71. Pregabalin (Lyrica)
    GAD and fibromyalgia, little help with bipolar
  72. Tiagabine (Gabitril)
  73. Topiramate (Topamax)
    • Helps impulse control disorder and anxiety
    • SE: Causes wht loss (usu good thing!), cognitive slowing (most limiting SE), hypochloremic non-anion gap metabolic acidosis, kidney stones
  74. Anxiolytics and hypnotics
    • Used for anxiety, muscle spasm, seizures, sleep d/o, EtOH W/D, and anesthesia induction
    • Includes benzos, barbs, buspirone
    • Non-benzo hypnotics: zolpidem/zaleplon/eszopiclone
    • Non-benzo anxiolytics: buspirone, hydroxyzine, barbs, propranolol
  75. Benzodiazepines
    • Potentiate GABA and decr anxiety
    • In pt with chronic EtOH use, liver disease, or elderly, use LOT benzoes (lorazepam, oxazepam, and temazepam)
    • Can be long acting (1/2 life >20 hr), intermediate acting (1/2 life 6-20 hr), or short acting (1/2 < 6 hr)
    • Long acting: Diazepam and clonazepam
    • Intermediate: Alprazolam, lorazepam, oxazepam, temazepam
    • Short acting: Triazolam, midazolam
    • SE: Drowsiness, impaired intellectual function, decreased motor coordination (watch for elderly!), anterograde amnesia, W/D -> seizures, respiratory depression (esp if used with EtOH or opiates)
    • OD: Tx with flumazenil (but go slowly as fast W/D can be life threatening)
  76. Diazepam (Valium)
    • Long acting benzo (1/2 llife > 20 hr)
    • Has rapid onset and is used for EtOH/anxiolytic W/D or for seizure
  77. Clonazepam (Klonopin)
    • Long acting benzo (1/2 life > 20 hr)
    • Used to tx anxiety and panic attakcs
    • Don't use in renal dysfunction
    • Can do 1x daily dosing
  78. Alprazolam (xanax)
    • Intermediate acting benzo (1/2 life 6-20 hr)
    • Used for anxiety and panic attacks
    • Has short, rapid onset --> high abuse potential
  79. Lorazepam (ativan)
    • Intermediate benzo (1/2 life 6-20 hr)
    • Used for W/D and panic attacks
    • Safer to use in elderly
    • Not metabolized in liver
  80. Oxazepam (serax)
    • Intermed benzo (1/2 life 6-20 hr)
    • Used for W/D
    • Not metabolized in liver
  81. Temazepam (restoril)
    • Intermed benzo (1/2 lfie 6-20 hr)
    • Used for insomnia but has high dependence
    • Not metabolized in liver
  82. Traizolam (Halcion)
    • Short acting benzo (1/2 life < 6hr)
    • Used to tx insomnia
  83. Midazolam (versed)
    Short acting benzo (1/2 life < 6 hr)
  84. zolpidem (ambien)
    • Non-benzo hypnotic
    • Used to tx insomnia in short term
    • SE: anterograde amnesia, hallucinations, sleepwalking, GI upset
  85. Zaleplon (Sonata)
    • non-benzo hypnotic
    • used to tx insomnia in short term
    • SE: anterograde amnesia, hallucinations, sleep walking, GI upset
  86. Eszopiclone (Lunesta)
    • Nonbenzo hypnotic
    • Used to tx insomnia in short term
    • SE: anterograde amnesia, hallucinations, sleepwalking, GI upset
  87. 1/2 of non-benzo hypnotics
    Eszopiclone > zolpidem > zaleplon

    Zaleplon has shortest half life
  88. Diphenhydramine (Benadryl)
    • Non-benzo hypnotic that is antihistamine
    • SE: Sedation, dry mouth, constipation, urinary retention, blurry vision
  89. Chloral hydrate (Noctec, somnote)
    • Non benzo hypnotic
    • Not commonly used because of tolerance and dependence
    • Causes hepatic and liver failure
    • Lethal in OD
  90. Remelteon (Rozerem)
    • Non-benzo hypnotic
    • Melatonin MT1 and MT2 agonist
    • No tolerance or dependence
  91. Buspirone
    • Nonbenzo anxiolytic
    • 5HT1A agonist
    • Takes 1-2 weeks for effect
    • Not very effective solo and used with SSRI or other drug as combo
    • Does NOT potential CNS depression of EtOH and so can be safely used in alcoholics
    • Has low abuse/addiction potential
  92. Hydroxyzine (Atarax)
    • Nonbenzo anxiolytic
    • Antihistamine
    • Good as a quick acting, short term alternative in a patient who cannot tolerate a benzo
  93. Barbiturates
    • Nonbenzo anxiolytic
    • Includes butalbitol, phenobarbitol, amobarbitol, pentobarbitol
    • Rarely used as OD can be lethal
  94. Propranolol
    • Nonbenzo anxiolytic
    • Beta blocker used to tx autonomic sx of panic attacks and performance anxiety (palp, sweating, tachycardia) and to tx akathisia
  95. Dextroamphetamine and amphetamine (dexedrine, adderall)
    • Psychostimulant used in ADHD and refractory depression
    • Adderall is Schedule II drug with high abuse potential
    • Monitor BP, watch for wht loss and insomnia
  96. Methylphenidate (ritalin, concerta)
    • Psychostimulant used for ADHD and refractory depression
    • Schedule II CNS Stimulant
    • Watch for leukopenia, anemia, incr LFTs, BP, wht loss, and insomnia
  97. Atomxetine (Strattera)
    • Psychostimulant used for ADHD and refractory depression
    • Inhibits presynaptic NE transporter
    • Has less appetite suppression and insomnia vs other meds
    • Causes liver toxicity (rare) and possible incr SI in kids/teens
  98. Modafinil
    Psychostimulant used in narcolepsy
  99. Procainamide and quinidine can cause what sx?
    Confusion and delirium
  100. Albuterol can cause what sx?
    Anxiety and confusion
  101. Isoniazid can cause what sx?
  102. Tetracycline can cause what sx?
  103. Nifedipine and verapamil can cause what sx?
  104. Cimetidine can cause what sx?
    Depression and psychosis
  105. Steroids can cause what sx?
    Agressiveness/agitation, hypomania, anxiety, and psychosis
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Psych shelf
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