Final Exam Overview

SSRIs

Clozapine

risperidone

Clozapine

Destruction of dopamine neurons in the substantia nigra

The indirect pathway. It inhibits movement.

Decr dopamine = decr direct pathway = decr glutamate = decr stimulation of cortex = decr facilitation of movement = incr indirect pathway = decr glutamate = incr inhibition of movement

probable diagnosis if 2 of the 4

• bradykinesia
• resting tremor
• rigidity
• postural imbalance

worsens existing psychosis and dyskinesias

no

• mad as a hatter
• blind as a bat
• hot as a hare
• dry as a bone
• red as a beet

suppresses levodopa induced dyskinesias

• selegiline/rasagiline
• levodopa
• DA agonist

• COMT inhibitors
• MAOB inhibitors
• DA agonists

• Generalized.
• Includes: Grand mal, Absence, etc

• Partial, or focal.
• Can be simple (no loss of consciousness) or complex (impaired consciousness).

Ethosuximide because it is the narrowest-spectrum

Focal epilepsy with partial and secondarily generalized seizures

valproic acid

Phenobarb and phenytoin

• rashes
• bone marrow suppression (decreased WBC count)

CBZ and oxcarbazepine

• methadone
• buprenorphine with naloxone (suboxone)
• naltrexone
• clonidine

• endogenous opiates
• GABA
• dopamine
• glutamine

• ASA, BZD
• IV nitro, nitroprusside or phentolamine (for persistant HTN)
• Avoid B-blockers (b/c alpha would still be stimulated and could lead to worse coronary vasospasm)

• ABCs
• Treat hyperthermia, seizures, agitation (e.g. BZD)
• Manage cardiovascular complications

Acamprosate - CrC must be over 30 to use this

benzoylecgonine

• disulfiram
• naltrexone

• It's an alpha-agonist
• helps with anxiety
• shortens time of WD sx
• normalizes neurochemistry to make pt less addicted

Rivastigmine (Exelon)

dose-dependent weight loss

at least 3 months

• n/v/d
• dizziness
• urinary incontinence
• bradycardia, syncope
• salivation, sweating

• Memantine - may worsen psychiatric sx or cognition
• Olanzapine may exacerbate PD

rivastigmine

• age, vascular disease risk factors, head injury, decreased brain reserve capacity
• diabetes increases risk 3-fold

• NSAIDS
• HMG-CoA reductase inhibitors

• Possible protective effect
• In studies

• risperidone
• aripiprazole

• bradycardia
• sick sinus syndrome
• supraventricular cardiac conduction abnormalities
• peptic ulcer disease
• bladder obstruction

• severe renal or hepatic impairment
• meds or dietary changes that alkalinize the urine - could decrease renal excretion of the medication

• insomnia
• musculoskeletal issues

trazodone

• minimize environmental triggers
• redirect patient attention (minimize noise, background distraction, personal discomfort)

• neuroleptics (haloperidol is DOC, I think ?)
• used when sx compromise safety or interfere with medical care

• CBZ
• VPA
• phenytoin
• phenobarb

• gabapentin
• lamotrigine

• gabapentin
• tiagabine
• levetiracetam
• zonisamide

• Valproate is an inhibitor
• Phenytoin, Phenobarb, Primidone, CBZ are inducers

VPA (but really ethosuximide is best for absence)

• lamotrigine
• OCs enhance its clearance
• (pregnancy also increases its clearance)

VPA

• Benzodiazepines
• lorazepam is DOC

phenytoin

• Sodium: 136-145
• Potassium: 3.5-5
• Chloride: 96-106
• pCO2: 35-45
• HCO3: 22-27
• RR: 18
• Magnesium: 1.7-2.1
• Calcium: 8.5-10.5
• Phosphorus: 2.7-4.5
• Osmolality: 275-290
• BUN: 5-20
• Glucose: 70-110
• Prealbumin: 20-40

• loss of acid (vomiting, diuretics)
• Gain of bicarb

hyperventilation

• hypoventilation
• (depression of resp center, decreased diffusion, loss of bellows action of chest)

• gain of a strong acid
• loss of bicarb

12 +/- 4

• it helps us determine the cause of metabolic acidosis
• - if it is because of gain of HCl or loss of bicarb, the anion gap is normal
• - if it is d/t gain of exogenous acid, the anion gap is increased = anion gap acidosis

• Methanol
• Uremia
• Lactate
• Ethylene glycol
• Paraldehyde
• Aspirin
• Ketoacidosis

• TPN
• Renal tubular acidosis
• diarrhea (loss of bicarb)

First order

2[Na] + Gluc/18 + BUN/2.8

aldosterone; perfusion pressure in the kidney

ADH; when osmolality is high

loss of bicarb or gain of HCl (TPN, renal tubular acidosis, diarrhea)

Gain of exogenous acid

pt is probably dehydrated and could be having kidney problems d/t poor perfusion

• #1. Salt rules volume. (if you have too much volume, this means you have too much salt) - talking about TOTAL BODY sodium here
• #2. Water rules tonicity. - talking about SERUM sodium and FREE water

• If replace with free water - hyponatremia
• If replace with NS - hypernatremia

you have lost free water and must replace it

• give D5W
• secrete ADH
• drink it
• pull it in with glucose

• add sodium
• secrete aldosterone

• Total body sodium is down
• Free water is low overall (relatively high, though)

• restore circulating volume (use NS)
• minimize sodium loss
• stop diuretics

• Serum sodium is low
• Total body sodium is normal
• Free water is high

Treat with NS + loop diuretic + ADH inhibitor (because of SIADH)

• syndrome of inappropriate antidiuretic hormone
• too much ADH
• ADH should be "off" because the osmolality is low, but it isn't

• Antipsychotics
• SSRIs
• TCAs
• CBZ and oxcarbazepine
• antineoplastics
• antidiuretic hormones

long term tx: demeclocycline

• Total body sodium is high
• Total body H2O is high
• Serum sodium is low

Causes: (things that turn on aldosterone leading to hypervolemia) Heart failure, cirrhosis, nephrotic syndrome, renal failure

Treatment: restrict sodium and water intake (< 1 - 1.5 L/d), give diuretics (lasix)

• increase by NMT 12 mEq/L/day
• decrease by 0.5 - 1 mEq/L/day

low magnesium

potassium

• < 3
• KCl is the only appropriate treatment
• can give 20 mEq/h if using central line - must monitor ECG
• can give only 10 mEq/h if using peripheral line
• NEVER give IV push

hyperkalemia - goes away when acidosis is corrected, so be careful

• 1. stabilize the heart - use Calcium Chloride
• 2. Drive K+ intracellularly - use insulin + glucose
• 3. Remove from the body - use Kayexelate or Lasix
• 4. Decrease intake

Magnesium Oxide

relaxant/sedative type actions: dilates veins and arteries, decreases BP, relaxes muscles

renally

• PTH increases it
• Vitamin D increases it
• Calcitonin decreases it

[(4 - albumen) x 0.8] + serum Ca

prolonged QT interval

Have to treat low Mg before IV Calcium can increase serum calcium levels

• K-phos original does not have sodium
• both K-phos products contain potassium - the original has more than the neutral formulation
• Fleet phospho-soda and sodium phosphate both do not contain potassium

• Calcium
• Sevelamer

• Risperidone
• Quetiapine
• Olanzapine

• Clozapine and olanzapine are the worst
• Ziprasidone and aripiprazole are the best - they are weight neutral

clozapine

• Agranulocytosis - stop drug
• Seizures - if continued tx is indicated, add VPA and keep doses of clozapine to < 900 mg/d

• both cause agranulocytosis
• thrombocytopenia
• worsening of psychosis

increased clozapine concentrations and increased risk of its SEs

risperidone

• CYP 2D6 (it is a substrate)
• it has DIs with 2D6 inhibitors and inducers, especially SSRIs

paliperidone - may have even more prolactin elevation than risperidone

• olanzapine
• (the EPSEs are dose dependent)

virtually none

olanzapine

quetiapine

3A4

somnolence

• little to no weight gain
• minimal metabolic effects
• (note: must give with food to increase bioavailability)

• ziprasidone
• Antiarrhythics, Antihistamines, Erythromycin, possibly TCAs

Asenapine - only comes in SL tablets

• D2 partial agonist
• 5-HT1A partial agonist
• 5-HT2A partial antagonist
• (acts like antagonist in mesolimbic and agonist in mesocortical)

aripiprazole

aripiprazole

aripiprazole (and risperidone too)

aripiprazole

• agranulocytosis
• seizure

• dose-dependent EPSEs
• prolactin increase

• weight gain
• diabetes
• dose-dependent EPSEs

lack of effect on negative symptoms of schizophrenia

• lack of effect on negative symptoms of schiz
• dose-dependent EPSEs
• QTc prolongation
• (note: little weight gain)

• nausea
• akathisia

• confusion
• delerium
• memory dysfxn
• dry eyes
• exacerbation of angle closure glaucoma
• blurred vision
• tachycardia
• constipation
• urinary retention

• agranulocytosis or granulocytopenia (or hx of it)
• uncontrolled epilepsy
• severe renal disease

• recent MI
• HF
• Hx of arrhythmias
• QT prolongation
• drugs that can prolong QT interval

asenapine

aripiprazole

• dextrose content NMT 10%
• osmolarity must be less than 900 mOsm/L

[grams of dextrose/L x 5] + [grams of amino acid/L x 10] + [mEq cations/L]

150 mEq/L

Calcium and Phosphorus - can form precipitates

calcium gluconate

insulin and H2 blockers (ex. ranitidine)

• good for 24 hours
• change tubes q24h if fluids have lipids; q72h if only a dextrose and AA sol'n

5 mg/kg/min

reduce calories and dextrose in TPN

It is a lipid based emulsion that provides 1.1 kcal/ml of the infusion. Need to reduce lipid in the TPN.

• Reduce the amino acid goal
• Concern in renal patients

• If acidotic: reduce chloride and increase acetate
• If alkalotic: reduce acetate and increase chloride

intestinal atrophy

Vitamin C

• characterized by simultaneous hypophosphatemia, hypokalemia, hypomagnesemia and sometimes deficiency in thiamine and sodium
• Occurs from fat metabolism becoming the main source of energy in starvation, then feeding being begun again and a shift to carbohydrate metabolism occurs. Pt needs ATP and there is a sudden cellular uptake of phosphate leading to severe hypophosphatemia which can lead to neurologic, cardiac, respiratory, and hematologic abnormalities, even death.

This means the protein synthesis is low and we must increase carbs and AAs

• It is made in the liver
• Half life of 20 days
• Mild depletion = 2.8 - 3.5 g/dl
• Moderate depl = 2.1-2.7 g/dl
• Severe depl = < 2.1 g/dl

A blood plasma protein for iron delivery

• K+ is 40-100
• Na+ is 80-150

BEE x Stress Factor

1500 ml for the first 20 kg of weight and 20 ml/kg for each add'l kg

• Ranges from 0.6-2.0g/kg/d
• Common is 1.2-2
• Renal failure is 0.6-0.8

• it is approx 1/3 of the non-protein calorie goal
• usually around 0.7 - 1.1 g/kg

it's the difference betw the calorie goal and the AA + lipids (or about 2/3 of the non-protein calorie goal)

PMS, hot flashes

Prevention of recurrent UTIs

boosts the immune system

migraine prophylaxis

HTN, hyperlipidemia, mental health, anticoagulant, CHD, stroke

constipation, diarrhea, diabetes, menopause, HTN, CAD, hyperlipidemia

hyperlipoproteinemia, arteriosclerosis

venous conditions, eczema, leg pains, hemorrhoids, phlebitis, menstruation

• cerebral circulatory disturbances
• peripheral arterial circulatory disturbances

• "adaptogen" for increasing resistance to environmental stress
• energy
• concentration

liver protectant

BPH

anxiety, depression

• restlessness
• nervous disturbance of sleep

osteoarthritis, inhibition of breakdown of cartilage

CHF, HTN, stable angina, ventricular arrhythmias, cancer, heart surgery, periodontal disease

• circadian rhythm sleep disorders in the blind
• jet lag
• insomnia
• depression
• cancer

• immune-modulating formulation:
• omega-3s
• antioxidants
• arginine
• glutamine
• nucleic acids

• one that has anti-inflammatory lipids and antioxidants
• "pulmonary" formulas not recommended

immediately

standard polymeric formulations

ProMod

Polycose

Lipomul

they help stimulate growth of beneficial GI bacteria

• Clonidine- drug addiction
• Methyldopa- pregnancy/breastfeeding

labetalol - it has the most data in pregnancy

ACEIs and ARBs

Beta blockers (especially non-selective such as verapamil)

beta-blockers

beta-blockers and non-DHP CCBs

• beta-blockers
• alpha-2 agonists

• beta-blockers
• non-DHP CCBs

ACEs and ARBs

thiazides

• use: ACEs, ARBs, loops
• avoid: K+ sparing, thiazides

• normal <120/<80
• prehypertension 120-139/80-89
• stage 1 HTN 140-159/90-99
• stage 2 HTN >160/>100

• rosuvastatin
• atorvastatin
• simvastatin
• pitavastatin
• lovastatin
• pravastatin
• fluvastatin

statins

Niacin

niacin

fibric acid

heparin

When a pt is on treatment doses of unfractionated heparin

5000 units SQ q8-12h

• loading dose is 80 units/kg IV
• maintenance is 18 units/kg IV

d/c when INR has been therapeutic for 24 hours for a minimum of 5 days

30 mg SQ bid (or 40 mg SQ qd)

1 mg/kg SQ bid

protamine sulfate

• Direct thrombin inhibitors (lepirudin, argatroban)
• fondaparinux

inhibits vitamin K-epoxide reductase which decreases levels of vitamin K in the body

3 months

2-3

lifetime

• lifetime
• 2.5-3.5

as soon as APTT is therapeutic from heparin

at least 5 days

• 5-10 mg PO QD for treatment
• 2.5 - 5 mg PO QD for prophylaxis

• INR of 3-5 and pt not bleeding, hold 1-2 doses and resume tx at lower dose
• INR of 6-9 and pt not bleeding, stop therapy, give 2.5 mg PO Vitamin K, recheck in 24 h
• INR of 10-20 and pt not bleeding, stop therapy, give Vitamin K 5 mg PO, recheck INR in 24 h
• INR >20 or seriously bleeding, stop therapy, give Vitamin K 10 mg IV infusion, recheck INR q 6-12 h, may repeat Vitamin K IV q 12 h, may supplement with fresh frozen plasma or prothrombin complex concentrates, resume heparin therapy until patient responsive to warfarin

• Warfarin not with pregnancy - Category X - ok to use heparin
• Warfarin ok in breastfeeding - heparin no

• antibiotics
• azole antifungals
• antidepressants
• antiplatelets
• anti-inflammatory agents
• amiodarone
• acetaminophen
• alternative remedies
• antileptics
• alcohol

Because if they come into the clinic and their INR is high, we can still adjust that day's dose

beta-blockers

GP Ib

• Protein C
• Factor VIII
• Factor V
• Fibrinogen

At factor X

GP IIb/IIIa