-
All Antipsychotics
- block D2 receptor (typicals only D2, atypicals 5HT2A also)
- lower seizure threshold (only clozapine known to induce seizures)
- potentially prolong QTc
- atypicals augment partial responders to SSRI's
-
Side Effect Receptors (HAM)
Anti- Histamine
...symptoms?
weight gain, sedation
-
Side Effect Receptors (HAM)
Anti- Alpha 1
...symptoms?
orthostasis, cardiac arrhythmias
-
Side Effect Receptors (HAM)
Anti- Muscarinic (Anti-ACh)
...symptoms?
delirium, blurred vision, xerostomia (dry mouth), constipation, urinary retention
(remember: mad as a hatter, blind as a bat, dry as a bone, red as a beet, hot as a hare)
-
Extrapyramidal Symptoms (EPS)
nigrostriatal pathway, too little DA
- acute dystonia
- akathisias (subjective sense of restlessness)
- parkinsonism
- tardive dyskinesia
- neuroleptic malignant syndrome (NMS- altered MS, rigidity, hyperthermia, autonomic dysfunction)
-
5HT1A
increased 5HT -->
relief of depression and anxiety
-
5HT2A/C
increased 5HT -->
decrease libido (long-term), insomnia (long-term), headache and jitteriness (temporary)
-
5HT3/4
increased 5HT -->
GI upset (N/V/D) - temporary
-
Acute Dystonia
Definition?
Treatment?
sustained muscle contractions causing twisting and repetitive movements or abnormal postures (1 week)
- Benztropine (Cogentin) -anti-cholinergic
- Diphenhydramine (Benadryl)- anticholinergic
-
Akathisia
Definition?
Treatment?
Subjective sense of restlessness, need to move
- beta blockers (propranolol)
- Benzos (calming effect)
- anti-cholinergic
-
Parkinsonism
Definition?
Treatment?
bradykinesia, rigidity, tremor, postural instability (couple weeks)
change offending medication
-
Tardive Dyskinesia
definition?
treatment?
involuntary movements usually the mouth (3-6 months)
none (might be permanent), switch meds
-
Neuroleptic Malignant Syndrome
Definition?
Treatment?
altered MS, rigidity, hperthermia, autonomic dysfunction, increased CK
IV fluids (supportive), dantrolene (muscle relaxant), bromocriptine (DA agonist)
-
Haloperidol
- Haldol
- Typical, first generation
- High potency, low HAM action
- high incidence of EPS
- available in decanoate shots
-
Fluphenazine
- Prolixin
- Typical, 1st gen
- High potency, low HAM
- high incidence of EPS
- available in decanoate shots
-
Perphenazine
- Trilafon
- Typical, 1st gen
- Mid potency, mix of SE's
- (not really important to know details)
-
Chlorpromazine
- Thorazine
- Typical, 1st gen
- Low potency, high HAM (orthostasis, sedating)
- avoid in elderly (falls)
-
Olanzapine
- Zyprexa
- Atypical, 2nd gen
- worst for metobolic SE, sedating
-
Risperidone
- Risperdal
- Atypical, 2nd gen
- binds tightly (most "typical" of atypicals)- EPS
- 2nd worst for metabolic syndrome (of our list)
- available in decanoate (Risperdal Consta)
-
Quetiapine
- Seroquel
- Atypical, 2nd gen
- extremely sedating, causes orthostasis
- middle of the pack as far as metabolic SE's
- used for sleep also
-
Ziprasidone
- Geodon
- Atypical, 2nd gen
- specifically worry about QT prolongation
- least metabolic SE's
-
Aripiprazole
- Abilify
- Atypical, 2nd gen
- partial D2 agonist (novel MOA)
- least metabolic SE's
-
Clozapine
- Clozaril
- Atypical, 2nd gen
- most effective and most dangerous
- risks: aplastic anemia, seizures, cardiomyopathy, hypotension (also drooling)
- good for TD
- (this and lithium are the only two drugs known to decrease suicide)
-
Phenelzine
Tranylcypromine
- MAOI A&B
- very powerful
- drug-drug interactions
- too much NE--> malignant HTN (drug-food interactions, avoid tyramine)
- too much 5HT--> serotonin syndrome (2 wk wash out from other anti-depressants)
- (don't use with demerol)
-
Selegiline
- MAOI B
- very powerful
- drug-drug interactions
- available as a patch
- too much NE--> malignant HTN (drug-food interactions, avoid tyramine)
- too much 5HT--> serotonin syndrome (2 wk wash out from other anti-depressants)
- (don't use with demerol)
-
Serotonin Syndrome
- Clinical presentation (Usually present with 6 hours of administration or change of drug):
- Mental status changes: anxiety, delirium, restlessness, and disorientation.
- Autonomic changes: diaphoresis, tachycardia, hyperthermia, hypertension, vomiting,
- diarrhea.
- Neuromuscular hyperactivity: tremor, muscle rigidity, myoclonus, hyperreflexia,
- bilateral babinski.
- Lab features: Elevated WBCs, elevated CPK, decreased serum bicarb. Rarely may
- progress to DIC, rhabdomyolysis, metabolic acidosis, renal failure, ARDS.
Treatment:Discontinue all serotonergic agents, stabilize vitals, Sedate with benzos, Give serotonin antagonist (cyproheptadine)
-
Amitriptyline
- Elavil
- TCA
- 5HT and NE
- most lethal in overdose (TdP, cardiotoxicity)
- high SE profile (*anti-cholinergic*, anti-histamine)
- pain syndromes
-
Clomipramine
- TCA
- mostly 5HT
- lethal in overdose (TdP, cardiotoxicity)
- high SE profile (*anti-cholinergic*, anti-histamine)
- OCD
-
imipramine
- TCA
- Mostly 5HT
- lethal in overdose (TdP, cardiotoxicity)
- high SE profile (*anti-cholinergic*, anti-histamine)
- enuresis
-
nortriptyline
- TCA
- mostly NE
- lethal in overdose (TdP, cardiotoxicity)
- high SE profile (*anti-cholinergic*, anti-histamine)
- elderly depression
-
Venlafaxine
- Effexor
- SNRI
- Pro-5HT at doses up to 150mg; Pro-NE btwn 150-300mg
- SE's of 5HT (GI, etc) and NE (HTN)
- lowest protein binding
- good for comorbid pain syndromes
-
Duloxetine
- Cybalta
- SNRI
- (equal increase in 5HT and NE with increasing dose, unlike venlafaxine)
- SE's of 5HT (GI, etc) and NE (HTN)
- good for comorbid pain syndromes
-
Citalopram
- Celexa
- SSRI
- 5HT SE's (2A/C (Sexual dysfunction, insomnia), 3/4(GI))
-
Escitalopram
- Lexapro
- SSRI
- 5HT SE's (2A/C (Sexual dysfunction, insomnia), 3/4(GI))
-
Fluoxetine
- Prozac
- SSRI
- 5HT SE's (2A/C (Sexual dysfunction, insomnia), 3/4(GI))
- Longest 1/2 life (least risk of discontinuation syndrome)
-
Fluvoxamine
- Luvox
- SSRI
- 5HT SE's (2A/C (Sexual dysfunction, insomnia), 3/4(GI))
- Hepatic Failure
-
Paroxetine
- Paxil
- SSRI
- 5HT SE's (2A/C (Sexual dysfunction, insomnia), 3/4(GI))
- shortest 1/2 life (high risk of discontinuation)
-
Sertraline
- Zoloft
- SSRI
- 5HT SE's (2A/C (Sexual dysfunction, insomnia), 3/4(GI))
-
Buspirone
- BuSpar
- partial 5HT1A agonist
- primarily for GAD, also as adjunctive to primary antidepressant
-
Buproprion
- Wellbutrin, Zyban
- NDRI
- lowers seizure threshold
- potentially makes anxious/jittery
- good for craving, bad for psychosis, no sexual SE's
-
Mirtazapine
- Remeron
- alpha2 antagonist
- acts by modulating 5HT and NE via autoreceptors
- only med that increases secretion of monoamines
- very H1 at low doses (good for sleep)
- no sexual SE's, significant weight gain (good for low appetite)
-
Nefazodone
- Serzone
- SARI (5HT antagonist and reuptake inhibitor)
- 5HT2 antagonist , partial 5HT1A agonist
- fatal hepatitis
-
Trazodone
- SARI (5HT antagonist and reuptake inhibitor)
- 5HT2 antagonist , partial 5HT1A agonist
- dose too high for antidepressant effects so used as a sleeping agent
- priapism
-
Lithium
- Mood Stabilizer
- therapeutic range= .8-1.2
- SEs: neurotoxicity, hypothyroid, DI, leukocytosis, GI, tremor
- Teratogenicity: Ebsteins Anomaly
- Metabolism: Renal
-
Carbamazepine
- Mood Stabilizer
- therapeutic range= 8-12
- SEs: Autoinducer at liver (increase cyp3A4), S/J rash, CBC abnl, acute hepatitis
- Teratogenicity: Craniofacial Defects
- Metabolism: Hepatic
-
Valproic Acid
- Mood Stabilizer
- therapeutic range= 80-120
- SEs: hepatitis, CBC abnl (decr platelets), sedation, wt gain, acute pancreatitis, acne, alopecia
- Teratogenicity: Ebsteins Anomaly
- Metabolism: Neural Tube Defects
-
Lamotrigine
- Lamictal
- good for prevention of depression in Bipolar
- no level needed
- S/J rash
-
Alprozolam
- Xanax
- Benzo (short t1/2 6-12hrs)
- another short acting- midazolam (versed)
-
Lorazepam
- Ativan
- Benzo, intermediate t1/2
- liver safe
-
Oxazepam
- Serax
- Benzo, short t1/2
- liver safe
-
Temazepam
- Restoril
- Benzo, short t1/2
- liver safe
-
-
Diazepam
- Valium
- Benzo, long t1/2
- active metabolites
-
Flumazenil
- Benzo receptor antagonist
- good for benzo OD
|
|