Part 4 - Second half

Celexa → generic

Lexapro → generic

MOA →

ADE →

DDI →

Unique

• Highest rates of…(ADE)

• Max doses…(if >60 yo…)

Celexa → Citalopram

Lexapro → Escitalopram

MOA → SSRIs increase 5-HT

ADE → sexual dysfunction, bleeding

DDI →

• MAOIs and other serotonergic agents

• Bleeding agents (anticoag, antiplatelets, NSAIDs, ginkgo, garlic, ginger, ginseng, glucosamine, fish oil)

Unique

• Highest rates of QTc prolongation

• Good in pregnancy (just like Sertraline)

• Max doses

  • Citalopram: 40 mg/day (if >60 yo → 20 mg/day)

  • Escitalopram: 20 mg/day (if >60 yo → 10 mg/day)

Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft), Fluvoxamine (Luvox)

Prozac → generic

Paxil → generic

MOA →

ADE → (2)

DDI →

• (2)

Unique →

• CYP…

• Most…, t1/2

Prozac → Fluoxetine

Paxil → Paroxetine

MOA → SSRIs increase 5-HT

ADE → sexual dysfunction, bleeding

DDI →

• MAOIs and other serotonergic agents

• Bleeding agents (anticoag, antiplatelets, NSAIDs, ginkgo, garlic, ginger, ginseng, glucosamine, fish oil)

Unique →

• Both CYP2D6 inhibitor (decrease tamoxifen efficacy)

• Fluoxetine → Most activating, longest t1/2

• Paroxetine → Most sedating, shortest t1/2

Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft), Fluvoxamine (Luvox)

Zoloft

Generic

MOA →

ADE →

DDI →

• (2)

Unique →

• Good for…(population)

Sertraline

MOA → SSRIs increase 5-HT

ADE → sexual dysfunction, bleeding

DDI →

• MAOIs and other serotonergic agents

• Bleeding agents (anticoag, antiplatelets, NSAIDs, ginkgo, garlic, ginger, ginseng, glucosamine, fish oil)

Unique →

• Good in pregnancy (just like Citalopram)

Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft), Fluvoxamine (Luvox)

Luvox

Generic

MOA →

Indication →

Fluvoxamine

MOA → SSRI

Indication → only OCD (not the usual depression)

Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft), Fluvoxamine (Luvox)

Viibryd → generic, Regards to food

Trintellix → generic, CYP

Nefazodone → ADE

Trazodone → ADE, off label indication

MOA →

Less…(ADE)

Viibryd → Vilazodone, Take with food

Trintellix → Vortioxetine, CYP2D6 substrate (avoid with CYP2D6 inhibitors like fluoxetine and paroxetine)

Nefazodone → hepatotoxicity

Trazodone → priapism, off label indication sleep (50-100 mg QHS)

-

MOA → serotonin modulator

Less sexual dysfunction

Effexor XR → generic

Cymbalta → generic

Pristiq → generic

MOA →

ADE →

DDI →

Effexor XR → Venlafaxine

Cymbalta → Duloxetine

Pristiq → Desvenlafaxine

MOA → SNRI (both serotonin and NEP)

ADE → increase HR, dilated pupils, constipation, excessive sweating esp in Venlafaxine

• think NEP = stimulating

DDI → MAOI and other serotonergic agents

Amitriptyline

Doxepin

Pamelor → generic

Which are tertiary vs secondary amines

Indication →

• Amitriptyline →

• Silenor →

MOA →

ADE →

• MOA → ADE (2)

DDI → (1)

Silenor → generic, indication

Tertiary amines

• Amitriptyline

• Doxepin

Secondary amines

• Pamelor → Nortriptyline

Indication → depression (not as much anymore)

• Amitriptyline → migraine ppx

• Silenor → Doexpin used for insomnia

MOA → block serotonin and NE reuptake (just like SNRI)

ADE →

• Anticholinergic → dry mouth, blurred vision, urinary retention, constipation

• Antihistamine → sedation, weight gain

DDI → MAOIs

Generic

• Wellbutrin XL → indication

• Zyban → indication

Auelity → generic, formulation, indication

Contrave → generic, indication

-

MOA →

CI in…(2 conditions)

DDI →

Bupropion

• Wellbutrin XL → depression, seasonal affective disorder

• Zyban → smoking cessation

Auelity → Dextromethorphan + Bupropion, ER tabs, depression

Contrave → Bupropion + Naltrexone, weight management

-

MOA → DNRI (dopamine and NEP reuptake inhibitor, just like mini stimulants)

• No sexual dysfunction (Doesnt touch serotonin)

CI in seizure disorder, anorexia/bulimia (seizure risk)

DDI → MAOIs

Marplan → generic

Nardil → generic

Parnate → generic

Emsam → generic (formulation, frequency)

MOA, ADE

Marplan → Isocarboxazid

Nardil → Phenelzine

Parnate → Tranylcypromine

Emsam → Selegiline (patch QD, MAO-B inhibitor at low doses)

MAOIs that can cause serotonin syndrome

Remeron

Generic

ADE→ (2)

Indication → (2)

Mirtazapine

ADE → sedation and weight gain
Indication → often used for sleep and increase appetite

Antipsychotics approved for MDD

Antipsychotics approved for Bipolar disorder

Antipsychotics approved for MDD

• Aripiprazole (Abilify)

• Brexpiprazole (Rexulti)

• Quetiapine (Seroquel)

• Olanzapine/Fluoxetine (Symbyax)

Antipsychotics approved for Bipolar disorder

• Aripiprazole

• Quetiapine

• Olanzapine

• Asenapine

• Risperidone

• Ziprasidone

• Lurasidone

Symbyax

Generic

Indication →

Taken at…(time of day)

Olanzapine/Fluoxetine

MOA → adjunctive therapy for treatment resistant depression

Taken at night (fluoxetine activating but olanzapine sedating)

Spravato

Generic

MOA →

Formulation →

Schedule…controlled substance, only given by…

Must check…

Esketamine

MOA → NMDA receptor antagonist

Formulation → nasal spray

Schedule 3 controlled substance, only given by healthcare provider

Must check BP

Depression Diagnosis

OTC meds for depression

OTC meds for depression:

• St John’s Worts

• SAMe also for osteoarthritis

DSM-5 Diagnostic Criteria for Schiz

Negative vs Pos s/s

EPS Side Effects

More common in…

Test →

Akathisia (presentation) → DOC

Dystonia (presentation) → DOC

Pseudoparkinsonism → DOC

More common in first gen antipsychotics

Test → AIMS (abnormal involuntary movement scale)

Akathisia (inner restlessness) → propranolol (alt → BZD)

Dystonia (involuntary muscle contractions) → Bentropine

Pseudoparkinsonism → anticholinergics (Trihexyphenidyl, Diphenhydramine, Benztropine, Amantadine)

TD (lip smacking, involuntary tongue movementsm, side jaw movements) →

Antipsychotics (both typical and atypical)

MOA:

• First gen (typical) antipsychotic →

• Second gen (atypical) antipsychotic →

ADE

• (6)

MOA:

• First gen (typical) antipsychotic → block D2 receptors (affect pos symptoms)

• Second gen (atypical) antipsychotic → block D2 AND 5-HT2 receptors (affect pos AND neg symptoms)

ADE

• Sedation

• EPS

• TD (use lowest dose or switch to clozapine)

• Hyperprolactinemia → release milk (only fluid high secretion bc anticholinergic)

• Anticholinergic ADE (mainly clozapine)

• Neuro malignant syndrome (central autonomic instability → muscle rigidity, hyperthermia, CK >1000) tx →

  • Stop antipsychotic. Control patient temp.

  • Relax muscles → Dantrolene and sometimes Bromocriptine (increase DA)

  • Try new antipsychotic once better

Chlorpromazine → …potency → ADE

Generic → …potency → ADE

• Haldol → formulation

• Haloperidol Decanoate → formulation, frequency

Fluphenazine decanoate → …potency, formulation, frequency

Chlorpromazine → low potency → high sedation, low EPS

Haloperidol → high potency → low sedation, high EPS

• Haldol → PO, IV/IM

• Decanoate → IM only, monthly

Fluphenazine decanoate → high potency, IM, Q 2 weeks

Antipsychotics formulations

Oral solution → acronym

• Names

ODT → acronym

• Names

Rapid acting IM → acronym

• Names

Use if patient has QTc prolongation → acronym

• Names

Oral solution → H-CAR

• Haloperidol

• Clozapine

• Aripiprazole

• Risperidone

ODT → O-CAR

• Olanzapine

• Clozapine

• Aripiprazole

• Risperidone

Rapid acting IM → HZZ

• Haloperidol

• Ziprasidone

• Zyprexa

Use if patient has QTc prolongation → C LAB

• Cariprazine

• Lurasidone

• Aripiprazole

• Brexpiprazole

Antipsychotics formulations

Long acting injectables → acronym

• Names

Long acting injectables → OPAR-HF

• Olanzapine

  • Zyprexa Relprevv → Q2-4 weeks

• Paliperidone

  • Invega Sustenna → Q monthly, no overlap

  • Invega Trinza, Invega Hafyera → Q3 months, Q6 months respectively, both overlap with Sustenna for at least 4 weeks

• Aripiprazole

  • Abilify Maintena or Abilify Asimtufii → Q monthly, Q2 months respectively, both 2 weeks overlap

  • Aristada → Q1-2 months, 3 weeks overlap

• Risperidone (SQ)

  • Risperidone Consta, Rykindo → Q2 weeks, Consta overlap for 3 weeks

  • Perseris → Q monthly

  • Uzedy → Q1-2 months

• Haloperidol

  • Haldol decanoate → Q monthly

• Fluphenazine

  • Fluphenazine decanoate → Q 2 weeks

Generic, class

• Abilify Maintena, Abilify Asimtufil → LAI frequency

• Aristada → LAI frequency

Rexulti → generic

ADE → (1)

-

Formulation

QTc

Aripiprazole, 2nd gen antipsychotic (D2 partial agonist, not the usual antagonism)

• Abilify Maintena or Abilify Asimtufii → Q monthly, Q2 months respectively, both 2 weeks overlap

• Aristada → Q 1-2 months

Rexulti → Brexpiprazole

ADE → Akathsia (-piprazole)

-

Oral solution → H-CAR

• Haloperidol

• Clozapine

• Aripiprazole

• Risperidone

ODT → O-CAR

• Olanzapine

• Clozapine

• Aripiprazole

• Risperidone

Use if patient has QTc prolongation → C LAB

• Cariprazine

• Lurasidone

• Aripiprazole

• Brexpiprazole

-

Paliperidone

• Invega Trinza, Invega Hafyera → Q3 months, Q6 months respectively, both overlap with Sustenna for at least 4 weeks

Aripiprazole

• Abilify Maintena or Abilify Asimtufii → Q monthly, Q2 months respectively, both 2 weeks overlap

Risperidone

• Risperidone Consta, Rykindo → Q2 weeks, Consta ONLY overlap for 3 weeks

Clozaril

Indication →

ADE →

Unique

• Does NOT cause…

• ADE (discontinued REMS)

  • Before starting, ANC…

  • Stop when ANC…

-

Formulation

Clozaril

Clozapine, 2nd gen antipsychotic

Indication → treatment resistant schiz

ADE → metabolic syndrome, weight gain (-apine)

Unique

• Does NOT cause EPS or TD (good to switch if have TD from other meds)

• Agranulocytosis (discontinued REMS)

  • Before starting, ANC >1,500/mm3

  • Stop when ANC <1000/mm3

-

Oral solution → H-CAR

• Haloperidol

• Clozapine

• Aripiprazole

• Risperidone

ODT → O-CAR

• Olanzapine

• Clozapine

• Aripiprazole

• Risperidone

Lutada → generic, regards to food

Geodon → generic, regards to food, ADE

Seroquel → generic, regards to food

2nd gen antipyschotic

Lutada → Lurasidone, with food

Geodon → Ziprasidone, with food, QTc prolongation

Seroquel → Quetiapine, empty stomach

-

ADE →

• -done → EPS

• -apine → weight gain, metabolic syndrome

-

Use if patient has QTc prolongation → C LAB

• Cariprazine

• Lurasidone

• Aripiprazole

• Brexpiprazole

Generic

• Zyprexa

• Zydis → formulation

• Zyprexa Relprevv → formulation, frequency,…program

ADE →

Formulation

Symbyx → generic

Lybalvi → generic

Olanzapine

• Zyprexa

• Zydis → ODT

• Zyprexa Relprevv → LAI IM, Q 2-4 weeks, REMS program (monitored for 3 hrs post injection)

ADE → metabolic syndrome, weight gain (-apine)

Symbyx → Olanzapine + Fluoxetine

Lybalvi → Olanzapine + Samidorphan (decrease Olanzapine-induced weight gain

-

ODT → O-CAR

• Olanzapine

• Clozapine

• Aripiprazole

• Risperidone

Generic

• Invega Sustenna →

• Invega Trinza, Invega Hafyera →

ADE →

Paliperidone

• Invega Sustenna → IM Q monthly, no overlap

• Invega Trinza, Invega Hafyera → IM Q3 months, Q6 months respectively, both overlap with Sustenna for at least 4 weeks)

ADE → EPS (-done)

-

Paliperidone

• Invega Trinza, Invega Hafyera → Q3 months, Q6 months respectively, both overlap with Sustenna for at least 4 weeks

Aripiprazole

• Abilify Maintena or Abilify Asimtufii → Q monthly, Q2 months respectively, both 2 weeks overlap

Risperidone

• Risperidone Consta, Rykindo → Q2 weeks, Consta ONLY overlap for 3 weeks

Generic, class

• Risperidone Consta, Rykindo → formulation, frequency

• Perseris → formulation, frequency

• Uzedy → formulation, frequency

ADE →

Risperidone, 2nd gen antipsychotics

• Risperidone Consta, Rykindo → IM, Q2 weeks (Consta overlap for 3 weeks)

• Perseris → SQ, Q monthly

• Uzedy → SQ, Q1-2 months

All other 2nd gens are IM

ADE → EPS (-done)

-

Oral solution → H-CAR

• Haloperidol

• Clozapine

• Aripiprazole

• Risperidone

ODT → O-CAR

• Olanzapine

• Clozapine

• Aripiprazole

• Risperidone

-

Paliperidone

• Invega Trinza, Invega Hafyera → Q3 months, Q6 months respectively, both overlap with Sustenna for at least 4 weeks

Aripiprazole

• Abilify Maintena or Abilify Asimtufii → Q monthly, Q2 months respectively, both 2 weeks overlap

Risperidone

• Risperidone Consta, Rykindo → Q2 weeks, Consta ONLY overlap for 3 weeks

Generic

• Saphris → formulation

• Secuado → formulation

ADE →

Asenapine, 2nd gen antipsychotic for bipolar

• Saphris → SL, dont eat/drink for 10 min

• Secuado → patch

ADE→ tongue numbness (for SL)

Mania Diagnosis

Bipolar 1 vs 2

Bipolar 1 (mania + depression) vs Bipolar 2 (HYPOmania + depression)

Lithobid

Generic

Levels →

Clearance rule →

DDI

• Increase Lithium levels

• Decrease Lithium

• Increase risk of…

Manageable ADE

• (5)

Toxicity signs

Lithium carbonate vs citrate (formulation, %)

Equivalence

Avoid in…(population)

Lithium

Levels → 0.6-1.2 mEq/L (trough)

Clearance rule → Low sodium = high lithium (and vice versa)

DDI

• Increase Lithium levels

  • NSAIDs (except Aspirin, Sulindac), ACEi/ARBs → high K → low Na

  • thaizide/loops → low Na

  • Renal insufficiency, dehydration, Na restrictions

• Decrease Lithium

  • Caffeine, Theophylline

  • High salt intake, sodium bicarb

  • Acetazolamide

  • Pregnancy

• Increase risk of serotonin syndrome with SSRI/triptans

Manageable ADE

• Hand tremor (treat with propranolol)

• Hyper/Hypothyroidism

• Hypercalcemia / Hyperparathyroidism

• Weight gain and GI upset (take with food)

• Polyuria, polydipsia

Toxicity signs

• Mild-Moderate: Coarse hand tremor, persistent diarrhea, vomiting, hyperreflexia, slurred speech.

• Severe (> 2.0 mEq/L): CNS depression, arrhythmias, seizures, coma, death.

Lithium carbonate caps/ tabs (40%)

Lithium citrate syrup (20%)

300 mg of Lithium Carbonate = 8 mEq = 5 mL of Lithium Citrate syrup

Avoid in pregnancy

Meds also indicated for bipolar disorder

Antiseizure meds (3)

2nd gen antipsychotics (6)

Antiseizure meds

• Lamotrigine

• Valproate (and deriv)

• Carbamazepine

2nd gen antipsychotics → LOZ-QAR

• Lurasidone

• Olanzapine

• Ziprasidone

• Quetiapine

• Aripiprazole

• Risperidone

Anti-anxiety meds

• First line →

• Beta blocker →

• Alt →

• First line → SSRI, SNRI

• Beta blocker → Propranolol (stage fright)

• Alt → BZD

Buspar

Generic

MOA → ADE

Indication →

Takes…(time) to work

Buspirone

MOA → unknown, effect on serotonin receptors → serotonin syndrome (avoid MAOIs, 14 days)

Indication → anxiety without tolerance/dependence issues (vs BZD)

Takes 4 weeks to work

Class

• Xanax → generic

• Klonopin → generic

• Valium → generic

• Ativan → generic

MOA →

Indication

• (3)

Schedule…controlled substance (abuse, dependence, tolerance w chronic use)

ADE

Avoid in…(2 populations, 1 condition)

If used in elderly and hepatic impairment →

t1/2

• Short → (1)

• Intermediate → (1)

• Long → (2)

BZD

• Xanax → Alprazolam

• Klonopin → Clonazepam

• Valium → Diazepam

• Ativan → Lorazepam

MOA → enhance GABA (just like Phenobarbital, Primidone, Propofol, Ethanol) → think CNS/resp depression

Indication

• Anxiety after SSRI/SNRIs

• Sleep after non-BZD hypnotics (ie Zolpidem)

• Seizures

  • IV/IM → Lorazepam, Diazepam (Valium), Midazolam

  • Rectal → Diazepam (Diastat)

Schedule 5 controlled substance (abuse, dependence, tolerance w chronic use)

ADE: Confusion, amnesia, abuse

Avoid in pregnancy and age >65 yo, liver disease

If used in elderly and hepatic impairment → LOT drugs (metabolized via conjugation and cleared by kidneys)

• Lorazepam

• Oxazepam

• Temazepam

t1/2

• Short → Lorazepam

• Intermediate → Alprazolam

• Long → Diazepam, Clonazepam

2nd gen antipsychotics

Highest rates of weight gain → 2

Highest rates of EPS → 2

Lowest rates of EPS → 2

Highest rates of weight gain → Clozapine, Olanzapine

Highest rates of EPS → Risperidone, Paliperidone

Lowest rates of EPS → Clozapine, Quetiapine

Gout: Acute treatment

NSAIDs

• (1 med)

Steroids

• PO → 2 meds

• Intra-articular (directly into joint) → 3 meds

Colchicine

• Dose (max dose)

• DDI → CYP

NSAIDs

• Indomethacin (Indocin)

• Naproxen (Aleve)

Steroids

• Prednisone/Prednisolone → PO

• Methylpred → Intar-articular (directly into joint) and PO

Colchicine

• 0.6 mg (max 1.8 mg/day or 3 doses)

  • max 1.2 mg/day in chronic tx

• DDI → avoid CYP3A4 inhibitors

Aloprim

Zyloprim

MOA →

…testing, avoid if positive

Renal

• CrCl 10-20 → max dose

• CrCl <10 → max dose

DDI

• Decreases…(2 meds) levels

• Increases…(1 meds) effects

Uloric → generic, not used that often due to….

Allopurinol

MOA → xanthine oxidase inhibitors

HLA-B*5801 testing, avoid if positive

Renal

• CrCl 10-20 → max 200 mg/day

• CrCl <10 → max 100 mg/day

DDI

• Decreases azathioprine and 6-MP levels

• Increases warfarin effects

Uloric → Febuxostat, not used that often due to increased risk of death

Carbamazepine → HLA-B*1502

Abacavir → HLA-B*5701

Benemid

MOA →

• Avoid in CrCl

• ADE →

Indication →

Decrease renal clearance of…

Probenecid

MOA → excrete excess uric acid through urine

• Avoid in CrCl <50

• ADE → kidney stones (Drink lots of water)

Indication → gout, chronic tx

Decrease renal clearance of PCN

Krystexxa

Generic

MOA →

Indication →

Formulation →

Pegloticase

MOA → convert uric acid to allantoin (easily excreted substance)

Indication → chronic gout tx, reserved when gout is severe

Formulation → IV

Parkinson’s vs Schizophrenia (neurotransmitters)

Parkinson’s symptoms

Meds that cause pseudoparkinsons (looks like parkinsons) → (3)

Parkinson’s → Too little dopamine, higher acetylcholine

Schizophrenia → Too high dopamine, lower acetylcholine

Meds that cause pseudoparkinsons (looks like parkinsons) →

• Haloperidol (Haldol)

• Metoclopramide (Reglan)

• Prochlorperazine

Medication starts to wear off → will need to increase dose, add COMT-inhibitors to levodopa etc

Trihexyphenidyl

Cogentin → generic

Indication →

MOA →

Trihexyphenidyl

Cogentin → Benztropine

Indication → Parkinsons (low dopamine, high ACh)

MOA → anticholinergics, low ACh to even out imbalance

Generic

Sinemet

Duopa → formulation

Rytary → formulation

-

MOA →

Carbidopa

• Role →

• Need at least…mg to block enzyme

Carbidopa/Levodopa

Sinemet

Duopa → oral susp

Rytary → ER caps

-

MOA → dopamine precursor (avoid within 14 days of MAOIs)

Carbidopa

• Role → prevent degradation of Levodopa before it reaches the BBB

• Need at least 75 mg to block enzyme

Generic

Eldepryl

Zelapar → formulation

Emsam → formulation

MOA →

Indication →

DDI →

Take when…

Selegiline

Eldepryl

Zelapar → ODT

Emsam → patch

MOA → MAO-B inhibitor prevent breakdown of dopamine

Indication → Parkinsons, monotherapy or adjunct to “wearing off” effect of Levodopa

DDI → serotonin syndrome DDI (MAOI, tyramine foods, SSRI, tramadol, cyclosporine etc)

Produces amphetamine-like metabolites → take in the morning (insomnia)

Remember Rasagiline (Azilect) do not produce amphetamine like metabolites

Azilect

Generic

MOA →

DDI →

Rasagiline

MOA → MAO-B inhibitor prevent breakdown of dopamine

Indication → Parkinsons, monotherapy or adjunct to “wearing off” effect of Levodopa

DDI → serotonin syndrome DDI (MAOI, tyramine foods, SSRI, tramadol, cyclosporine etc)

Selegiline (Eldepryl, Zelapar ODT, Emsam patch)

Generic, MOA

Parlodel → indication

Cycloset → indication

Bromocriptine, dopamine agonist

Parlodel → Parkinson’s

Cycloset → DM

Bromocriptine (Parlodel), Rotigotine (Neupro), Pramipexol (Mirapex), Ropinirole (Requip), Apomorphine (Apokyn)

MOA for what indication

Neupro → generic formulation changed…

Mirapex → generic, goes through the…

Requip → generic, goes through the…

Dopamine agonist for Parkinson’s (esp as initial monotherapy in younger patients to delay levodopa-induced dyskinesias)

Neupro → Rotigotine patch changed daily

Mirapex → Pramipexole, goes through the kidneys

Requip → Ropinirole, goes through the liver

Bromocriptine (Parlodel), Apomorphine (Apokyn)

Apokyn

Generic

Indication →

Formulation for what indication

Vomiting PPX →

ADE → → Avoid…(med)

Apomorphine

Indication → dopamine agonist

SQ for “wearing-off” episodes in advanced Parkinson’s

Vomiting PPX → Trimethobenzamide (Tigan) 3 days before

ADE → hypotension → Avoid 5-HT3 antagonist

Bromocriptine (Parlodel), Rotigotine (Neupro), Pramipexol (Mirapex), Ropinirole (Requip), Apomorphine (Apokyn)

Gocovri

Osmolex

Generic

MOA for Indication

Amantadine ER

Dopamine reuptake inhibitor for Parkinson’s

Nuplazid

MOA →

Indication →

Caution in CrCl…

Pimavanserin

MOA → Serotonin 5-HT2A receptor antagonist

Indication → Parkinson’s associated psychosis

Caution in CrCl <30

Nourianz

Generic

MOA →

Indication →

Istradefylline

MOA → adenosine A2a receptor blocker

Indication → Parkinsons during levodopa “off” period

Think

• Dopamine is the gas pedal that promotes movement

• Adenosine is the brake pedal that inhibits movement

Comtan → generic

Tasmar → generic

Ongentys → generic

-

MOA →

Indication →

Comtan → Entacapone usually used

Tasmar → Tolcapone not used often due to hepatoxicity

Ongentys → Opicapone

-

MOA → COMT inhibitors increase duration of levodopa

Indication → Parkinsons’s, add on therapy only used WITH Carbidopa/Levodopa (Sinemet, Duopa oral susp, Rytary ER caps)

Stalevo → Levodopa/Carbidopa + Entacopone

Stalevo

Generic

Indication

Levodopa/Carbidopa + Entacopone

Dopamine precursor + COMT-i

Indication → Parkinson’s

Entacapone (Comtan), Opicaone (Ongentys), Tolcapone (Tasmar)

Migraine PPX given when…(2)

In the absence of CI, for initial tx → (3)

If they have HTN think…(2)

• Comorbities → use what

For patients with

• Raynaud’s →

• Depression →

• Epilepsy →

• Insomnia →

• Obesity →

Women of childbearing age / wanting to get pregnant → Don’t give…

Summary meds

• HTN med (2)

• Antidepressants (2)

• Antiseizures (2)

• IM…

• Dietary supplement (2)

Migraine PPX given when >3 a month or lasting >12 hr

Summary

• HTN med → BB (proproanol, timolol), Verapamil

• Antidepressants → Amitriptyline, Venlafaxine ER (Effexor XR)

• Antiseizures → Divalproex sodium (Depakote max dose 1000 mg/day), Topiramate (Topamax)

• IM botox

• Dietary supplement → feverfew, butterbur

Migraine Treatment limited to …a week

Mild to moderate NOT associated with nausea →

• Excedrin, Cambia, Motrin, Toradol, Naprosyn, Indocin

Moderate to severe →

• Symbravo

• Treximet

Last line →

For nausea → (all formulations)

Migraine Treatment limited to twice a week

Mild to moderate NOT associated with nausea →

• Excedrin (Acetaminophen + Ibuprofen + Caffeine)

• NSAIDS

  • FDA approved → Diclofenac (Cambia), Ibuprofen (Motrin)

  • Also Ketorolac (Toradol), Naproxen (Naprosyn), Indomethacin (Indocin)

Moderate to severe → triptans

• Rizatriptan + Meloxicam (Symbravo)

• Sumatriptan + Naproxen (Treximet)

Last line → ergots

For nausea → Metoclopramide (Reglan), Prochlorperazine, Chlorpromazine (all IV/IM)

Migraine Tx

ODT → 2

Nasal → 2

SQ → 1

IM/SQ → 1

ODT → Rizatriptan (Maxalt), Zolmitriptan (Zomig)

Nasal → Zolmitriptan, Sumatriptan

SQ → Sumatriptan (Imitrex, Zembrace) → fastest formulation

IM/SQ → DHE 45

Remember For nausea → Metoclopramide (Reglan), Prochlorperazine, Chlorpromazine (all IV/IM)

Triptans

MOA →

Indication →

ADE →

• (2)

Avoid in…(2 conditions, 1 population)
Pregnancy

CI with…(3 meds)

Wait…hrs btwn doses except for…

• (2)

Think increase serotonin and vasoCONSTRICTion

MOA → serotonin receptor agonist

Indication → migraine Tx (not PPX)

ADE →

• Headache recurrence (esp if used too often)

• Paresthesia (tingling/numb sensation on skin), Chest tightness → bc vasoconstriction

Avoid in CAD, uncontrolled HTN, pregnancy

Pregnancy Category C

CI with MAOI, SSRI (serotonin syndrome) and ergots

Wait 2 hrs btwn doses except for

• Naratriptan (Amerge) → 4 hrs

• Sumatriptan → SQ and Tosymra nasal spray

Amerge

Generic

Fast/slow onset?

Wait…hrs btwn doses

Naratriptan

Slow onset (just like Frovatriptan (Frova))

Wait 4 hrs btwn doses (vs the usual 2 hrs in triptans)

Maxalt

Generic

Formulation → (2)

Rizatriptan

Formulation → oral and ODT

Remember Zolmitriptan (Zomig) comes oral tab, ODT, nasal spray

Remember Symbravo (Rizatriptan + Meloxicam)

Generic

Formulations → (3)

Imitrex

Zembrace → dosing, formulation (max dose…)

Onzetra → formulation

Tosymra → formulation, dosing (max dose…)

Oral tabs max dose…

Wait 2 hrs btwn doses for…

Wait 1 hr btwn doses for…(2)

Sumatriptan

Formulation → oral, SQ, nasal

-

Imitrex

Zembrace → 3 mg SQ (max dose 12 mg/day aka 4 doses)

Onzetra → intranasal powder

Tosymra → nasal spray, 10 mg as single spray in one nostril (max dose 30 mg/day aka 3 doses)

-

Oral tabs max dose 200 mg/day

Wait 2 hrs btwn doses for tabs, nasal spray and intranasal powder

Wait 1 hr btwn doses for SQ and Tosymra nasal spray

Remember

• Zolmitriptan (Zomig) comes oral tab, ODT, nasal spray

• Treximet (Sumatriptan + Naproxen)

• Naratriptan (Amerge) wait 4 hrs btwn doses

Axert → generic

Frova → generic (…onset)

Relpax → generic (avoid CYP…)

Axert → Almotriptan

Frova → Frovatriptan (slow onset like Naratriptan (Amerge))

Relpax → Eltriptan (avoid CYP3A4 inhibitors)

Ergots

MOA →

Indication →

ADE →

DDI → (2)

Avoid in…(5)

Pregnancy

MOA → vasoCONSTRICTion + increases 5-HT, DA and NE (triptans the same but without DA/NE)

Indication → migraines tx

ADE → numbness, muscle pain, peripheral ischemia (bc vasoconstriction)

DDI

• BB (both cause numbness in fingers)

• Inhibitors

Avoid in CAD, uncontrolled HTN, pregnancy (just like triptans) and also renal/hepatic impairment (bc vasoconstriction)

Pregnancy Category X

Generic

Migranal → formulation

DHE 45 → formulation

Dihydroergotamine

Migranal → nasal spray

DHE 45 → IV/IM/SQ

Ergomar → generic

Ergotamine

Generic

Cafergot → formulation

Migergot → formulation

Caffeine + Ergotamine

Cafergot → tabs

Migergot → suppositories

Indication →

Fioricet, Esgic → generic

Fiorinal (C-…) → generic

Max dose…tabs/day

Indication → mild-moderate migraine attacks NOT associated with n/v

Fioricet, Esgic → Butalbital + Caffeine + Acetaminophen

Fiorinal (C-3) → Butalbital + Caffeine + Aspirin

Max dose 6 tabs/day

Remember Execredin (Ibuprofen + Caffeine + Acetaminophen)

Excedrin

Generic

Max tabs per day

• Minor pains →

• Migraine →

Avoid in…allergy and…(population)

Ibuprofen + Caffeine + Acetaminophen

Max tabs per day

• Minor pains → 8 tabs

• Migraine → 2 tabs

Avoid in aspirin allergy and pregnancy

Nurtec

Generic → indication

MOA →

Dosing, formulation, repeat dose when

Rimegepant → migraine TREATMENT

MOA → CGRP antagonist

75 mg ODT, single dose every 24 hrs, may repeat after 24 hrs

Remember Ubrogepant (Ubrelvy) -> may repeat every 2 hrs

Ubrelvy

Generic → indication

MOA →

May repeat dose…

Ubrogepant → migraine TREATMENT

MOA → CGRP antagonist

May repeat dose after 2 hrs

Remember Rimegepant (Nurtec) -> 75 mg ODT, single dose may be repeated every 24 hrs

ReyVow

Generic

MOA →

Schedule…controlled substance

Should not

Benefit over triptan →

Lasmiditan

MOA → selective serotonin 5-HT1F agonist

Schedule V controlled substance (bc euphoric effects)

Should not operate/drive machinery for at least 8 hrs

Benefit over triptan → does not cause vasconstriction, can be used in patients with cardiovascular risk factors

Aimovig

Generic

Erenumab, CGRP antaognist (monoclonal ab, SQ) for migriane PPX

Remembe Fremanezumab (Ajovy), Galcanezumab (Emgality), Eptinezumab (Vyepti)

Ajovy

Generic

Fremanezumab, CGRP antagonist (monoclonal ab, SQ) for migriane PPX

Remember Erenumab (Aimovig), Galcanezumab (Emgality), Eptinezumab (Vyepti)

Emgality

Generic

Galcaneuzumab, CGRP antagonist (monoclonal ab, SQ) for migriane PPX

Remember Erenumab (Aimovig), Fremanezumab (Ajovy), Eptinezumab (Vyepti)

Vyepti

Generic

Eptinezumab, CGRP antagonist (monoclonal ab, SQ) for migriane PPX

Remember Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality)

Ovulation test detect…

Pregnancy test detect…

Ovulation test detect rise in LH (will also notice increase in temp)

Pregnancy test detect rise of beta-HCG

MOA of COC

• Estrogen →

• Progestin →

• Both →

Indications of COC

• (3)

NOT for…

MOA of COC

• Estrogen → Inhibition of LH surge and FSH secretion (ovulation)

• Progestin → Alteration in cervical mucus (sperm can’t get to egg)

• Both → Cycle control

Indications of COC

• Menstrual cycle irregularity

• Acne, hirsutism

• Prevention of menstrual migraine

NOT for STI prevention

DDI for COC

• (3)

Day 1 start vs Sunday start (how to, benefits)

DDI

• CYP3A4 substrate → avoid CYP3A4 inducers and inhibitors

  • Griseofulvin (CYP3A4 inducer) reduces estrogen efficacy

• COC decrease conc of lamotrigine by 45-60%

Day 1 start vs Sunday start

• Begin on the first day of your period → eliminated need for contraception

• Begin first Sunday after period begins → prevent period on weekends

Contraindications of combined oral contraceptives

…cancer

Hx of…

Severe…disease

…with…

Uncontrolled…

Age…who…

Breast and endometrial cancer

Hx of stroke and VTE

Severe hepatic disease

Migraine with aura

Uncontrolled HTN (>160/100)

**Age over 35 yo who smoke heavily (15 cig)**

Emergency Contraception for unprotected sex

OTC → (1) → use within…

Rx → (2) → use within…

Weight → If BMI…or weight… → use …

-

Ella

OTC → Levonorgestrel 1.5 mg tab (Plan B, My Way) → use within 3 days (no age restriction)

Rx →

• Ulipristal 30 mg tab (Ella) → selective progesterone receptor modulator

• Copper IUD → avoid in Wilson’s disease and pelvic inflammatory disease

• Both use within 5 days

Weight → BMI >25 or weight >75 kg → use Copper IUD (levonorgestrel and Ulipristal less effective)

Norethindrone

Class

Give when…

• (2)

Initate on…, what kind of pills

Considered missed dose if…

Missed dose instructions →

Class → “Mini-pill” (progestin only pills)

Give in patients who don’t want to use estrogen…

• Worried about clots (estrogen)

• Patient is early postpartum and breastfeeding → estrogen reduction in milk production

-

Initiate on the 1st day of menses. No placebo (just like all progestin only)

Considered missed dose if >3 hrs late

Missed dose instructions → take 1 pill now, continue 1 pill at usual time tmr, backup for 48 hrs, emergency contraception with recent unprotected sex (within 5 days)

Lybrel (levonorgestrel + EE) also no placebo

Generic

Depo-Provera → dosing, formulation

Depo-Provera 104 → dosing, formulation

Both frequency

ADE →

Medroxyprogesterone (progestin only)

Depo-Provera → 150 mg IM

Depo-Provera 104 → 104 mg SubQ

Both given by PCP every 3 months

ADE → weight gain

Remember

• Mini pills

  • Depo-Provera (IM), Depo-Provera (SQ) -> Medroxyprogesterone

  • Norethindrone -> progestin only, no placebo

  • Slynd -> Drospirenone, only mini pill WITH placebo

• Prempro (Medroxyprogesterone + Estrogen)

Missed doses COC

1 dose →

2 doses →

2 doses in week 3 or 3 doses anytime →

1 dose → take 2 doses ASAP. No backup needed

2 doses → Take 2 doses ASAP. Backup for 7 days

2 doses in week 3 or 3 doses anytime → Finish active tab then start new pack. Backup for 7 days.

Chewable COC (2)

Minastrin Fe, Femcon Fe

Fe = has iron → drink w water to avoid constipation

NuvaRing

Generic

Used for…

Stored in…, can be out for…

Discard →

Etonorgestrel + EE

Used for 3 weeks

Stored in the fridge, can be out of the fridge for 4 months

Discard → throw in trash, dont flush (limit environmental release)

Yaz / Yasmin (→ generic)

Yaz →

Drospirenone + EE

Has Drospirenone → good for acne

Yaz → shorter periods with fewer placebo days

Slynd

Generic

Only …pill that...

• (2)

Good for…

ADE →

Equivalent to…

Drospirenone

Only progestin only pill that...

• Has placebo

• Does not need backup if missed 1 pill

Good for acne

ADE → hyperkalemia (anti-mineralocorticoid activity)

3 mg Drospirenone = 25 mg spironolactone

Remember

• Mini pills

  • Depo-Provera (IM), Depo-Provera (SQ) -> Medroxyprogesterone

  • Norethindrone -> progestin only, no placebo

  • Slynd -> Drospirenone, only mini pill WITH placebo

• Yaz / Yasmin -> Drospirenone + EE

Lybrel

Generic

Placebo

ADE

Levonorgestrel + EE

No placebo days

ADE→ Early breakthrough bleeding that decreases with time

Remember Triphasil 28, Lybrel, Seasonique, Quartette → Levonorgestrel + EE

Seasonique, Quartette -> 7 days low EE (not placebo)

Natazia

Generic

…phase

Need…

Dienogest + estradiol valerate (not the usual ethinyl estradiol)

4-phase OC

Need backup for 9 days when starting (not the usual 7)

Remember Ortho Tri-Cyclen → norgestimate + EE

Seasonique, Quartette

Generic

…cycle

Unique tabs

Levonorgestrel + ethinyl estradiol

Extended cycle preparation (91 days)

Unique tabs → 84 active, 7 days low EE (not placebo)

Remember Triphasil 28, Lybrel, Seasonique, Quartette → Levonorgestrel + EE

Lybrel → no placebo

Xulane

Formulation changed…for…with.,..

Associated with… → increased risk of…

If patch fails off for…

• (2)

Transdermal patch changed once weekly for 3 weeks with 1 patch free week

Associated with increased estrogen exposure than COC → may increase risk of VTE

If patch fails off for…

• <24 hrs → just put back on

• >24 hrs → new patch + backup 7 days

Contraceptive diaphragm

What is it, how does it work

Always use with…

Avoid with…

Reusable female contraceptive device blocks sperm entry to cervix

Always use with spermicide (nonoxynol 9)

Avoid with oil based lubricants (deterioration)

Duavee

Generic

Indication

ADE

Bazedoxifene (SERM) + Estrogen

Hormone replacement therapy for intact uterus but with SERM instead of progestin

• SERM still protects against estrogen-induce endometrial effects (alt to progestin)

• Estrogen still helps with…

  • Vasomotor symptoms in menopause

  • Prevention of postmenopausal osteoporosis

ADE -> clots (SERM)

Osphena

Generic, class

Indication

ADE → (2)

Ospemifene (SERM)

Non-estrogen option for dysparenuia (pain during intercourse) caused by menopausal atrophic vaginitis (vag dryness)

ADE→ hot flashes, clots (like all SERMs)

Remember Vagifem = estrogen vag tab for same indication

Remember Clomiphene (Clomid) = SERM for infertility

Vagifem

Formulation for what indication

Do NOT take…NOT

Estradiol vaginal tab indicated for dysparenuia (pain during intercourse) caused by menopausal atrophic vaginitis (vag dryness)

Do NOT take during pregnancy. NOT birth control

Does not have systemic absorption → wont cause clots

Remember Osphemifene (Osphena) = SERM for same indication

Prometrium

Class

Avoid in…

Progesterone

Avoid in peanut allergy

Yeast infection → Presentation → check for…(condition)

Bacterial Vaginosis → Presentation → use…(tx)

Yeast infection → itching, no smell → check for DM

Bacterial Vaginosis → fishy odor → use metronidazole or secnidazole

Gyne-Lotrimin → generic

Monistat → generic

Vagistat → generic

Indication

Insert…

Gyne-Lotrimin → Clotrimazole

Monistat → Miconazole

Vagistat → Tioconazole

All OTC for yeast infection

Insert at night

Clomid

Generic, class

Indicated for…by…

Clomiphene (SERM)

Indicated for infertility by inducing ovulation (may cause clots)

Remember Osphemifene (Osphena) = SERM for menopausal atrophic vaginitis

Annovera Vaginal Ring

Generic

vs Nuvaring

Segestrol (progestin) + EE

Similar to Nuvaring (Etonorgestrel + EE) but use the same ring for the whole year

Prempro → generic

Premarin → generic

Indication, when to use what

Hormone replacement therapy

Prempro (Medroxyprogesterone + Estrogen)

Premarin (Estrogen only)

After hysterectomy → switch to Premarin and eliminate progestin’s protection of the uterus to prevent estrogen-induced endometrial cancer → keep estrogen just for postmenopausal vasomotor symptoms treatment and osteoporosis prevention

Remember Depo-Provera → Medroxyprogesterone

Remember: Duavee, Prempro, Cliamapro, Combipatch → progestin + estrogen products for same indication

ClimaraPro → contains…

Menostar, Climara, Fempatch → contains…

Formulation, frequency

Hormone replacement therapy

ClimaraPro → contains progestin + estrogen

Menostar, Climara, Fempatch → estrogen only (used w/ hx of hysterectomy)

Transdermal patch applied ONCE WEEKLY (vs Combipatch, Vivelle, Minivelle TWICE WEEKLY)

Remember: Duavee, Prempro, Cliamapro, Combipatch → progestin + estrogen products for same indication

Combipatch → contains…

Vivelle, Vivelle Dot, Minivelle → contains…

Formulation, frequency

Hormone replacement therapy

Combipatch → contains progestin + estrogen

Vivelle, Vivelle Dot, Minivelle → estrogen only (used w/ hx of hysterectomy)

Transdermal patch applied TWICE WEEKLY (vs ClimaraPro, Climara, Menostar, Fempatch ONCE WEEKLY)

Remember: Duavee, Prempro, Cliamapro, Combipatch → progestin + estrogen products for same indication