Pham 5

ADHD is associated with

dopamine transporter gene and dopamine D4 gene

Causes for ADHD

–Genetic



–Perinatal stress



–Low birth weight



–Traumatic brain injury



–Maternal smoking during pregnancy



–Early deprivation



–Dietary intake of certain chemicals and sugar

four types of symptoms for ADHD

**Behavioral**

* Hyperactivity
* impulsivity
* risk behaviors and reward dependence



**Cognitive**

* Organizational issues,
* poor planning and execution skills,
* deficits in time management



**Social-emotional**

* Emotional impulsivity
* dysphoria, anger, anxiety
* emotional lability
* trouble reading social cues, and issues w/ keeping friends

\
**Deficits in executive function**

* Problems with self-regulation
* sequencing behaviors
* planning and organization,
* working memory and internalized speech



\
\

ADHD symptoms in adults cont.

•Interrupting conversations



•Frequent job changes



•Irritability



•Relationship discord



•Low frustration tolerance

non pharmacologic treatment ADHD

•Behavior modification



•Parent training



•Family therapy



•Social and academic skills training



•Individual psychotherapy



•Cognitive–behavior modification



•Therapeutic recreation

Name two types of stimulants

Dextroamphetamine (adderall)

**Methylphenidate** (Ritalin, Concerta, Methylin, and Metadate)

Dextroamphetamine (adderall)

ex. Dextroamphetamine (adderall) FDA controlled substance class 2

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Side effects

**Report CNS changes**

•Can cause physical dependency

•dry mouth, nausea, vomiting, diarrhea, altered libido

•Diabetes may need to monitor serum glucose can alter requirements

\
Interactions

•Avoid ETOH, caffeine, OTC meds that stimulate

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Contraindications

•Pregnancy cautious use

\
Education

•Taper dose when discontinuing

**Methylphenidate** (Ritalin)

ex. **Methylphenidate** (Ritalin, Concerta, Methylin, and Metadate)

\
Side effects

•cardiovascular events, headache, insomnia, anorexia, nausea, tics, weight loss, vomiting, EPS, NMS

\
Interactions



–Anticonvulsants 

\-Other ADHD medications

–Antidepressants

–Anticoagulants



Contraindications

•Caution with seizure disorders, monitor BP and CBC, growth

Education

•Do not mix with Alcohol, other CNS drugs, take on empty stomach.

two types of Non-Stimulants

**Atomoxetine** (Strattera) 

**Guanfacine** (Tenex)

**Atomoxetine** (Strattera) 

Side effects

•headache, insomnia, xerostomia, abdominal pain, vomiting, anorexia, nausea, cough.



**Box Warning**-may increase risk of suicide ideation in pediatric patients.



Interactions

•Multiple drug interactions



Contraindications

•Pregnancy cautious use



Education

used for adults or children over 6(weight based)

•Dose adjustment with hepatic impairment

**Guanfacine** (Tenex)

**ex. Guanfacine** (Intuniv® extended release tablets)

\
MOA

•Selective alpha-2A adrenergic receptor agonist. Directly engages receptors found in prefrontal cortex (area of brain linked to ADHD



Side effects

\-Somnolence, sedation, abdominal pain, dizziness, constipation, hypotension, drug mouth

\
Interactions

•Multiple drug interactions

\
Contraindications

•Use with caution in patients with hypotension, bradycardia and syncope.



Education

•Treatment of ADHD in children and adolescents ages 6 to 17 years

Dose adjustment with patients with hepatic or renal dysfunction

MOA

Side effects

Interactions

Contraindications

Education

Antidepressants in ADHD

•Tricyclic Antidepressants may also be used.

ex bupropion (wellbutrin)

Clonidine in ADHD

•used for mood, activity level, cooperation and frustration

first line for ADHD

**stimulants**

–Methylphenidate

-amphetamine

Second line for ADHD

**nonstimulants**

–Atomoxetine

–Guanfacine or clonidine

Third line for ADHD

bupropion

neurotransmitters ADHD

monitoring for ADHD

* Connor’s Rating Scale
* take drug exactly as prescribed


* Height and weight in children


* Monitor for change in behavior


* Cardiovascular risk factors- EKG, BP, P; monitor CBC

\

education in ADHD

•If taken in multiple doses, last dose should be before 2:00 PM because of sleep issues.



•Teach parents which adverse effects to monitor for.



•Children may require more and higher calorie snacks.



•Screen for self medication with other substances in adolescents and adults.

Alzheimer’s facts

•Characterized by a slow, progressive decline in cognition



•The most common cause of dementia accounting for approximately 60% to 80% of all dementia

\
reduces life span and prevalence increases w/ age

\

risk for Alzheimer’s

**Advanced age**



•Apolipoprotein E (APOE)-e4 gene



•\*Family history (e.g., genetic abnormalities)



•Mild cognitive impairment



•Cardiovascular disease



•Low education



•Traumatic brain injury



•Lack of social and cognitive engagement

Alzheimer’s causes

* Apolipoprotein E (ApoE), a protein involved in cholesterol transport, is linked to the development of AD.



* The E4 allele (homozygote E4/E4) is thought to increase the risk of AD, whereas the E2 allele may be protective.


* age related changes: cortical atrophy in brain, vascular damage, free radicals, inflammation
* destruction of cholinergic neurons
* overstimulation of glutamatergic system in the synapse>>neuronal death
* formation of neurofibrillary tangles and plaque

Alzheimer’s late onset VS early onset

Late: 60s and up; most common; APOE gene

\
Early: 30-60s; rare; genetic from parents

\
•Cognitive symptoms, such as loss of short-term memory, usually present first in mild AD.

Diagnosis for Alzheimer’s

* only confirmed by autopsy
* DSM-5 ( *Diagnostic and Statistical Manual of Mental Disorders)*


* Mini Mental State Examination (MMSE)


* Montreal Cognitive Assessment (MOCA)


* Clock drawing task (CDT)

non pharmacologic for Alzheimer’s

Explore reversible causes:Meds, Metabolic, intracranial infection, toxins,Vitamin B12 def, depression, psychoses

\
Behavior oriented



•Emotion oriented



•Cognition oriented



•Stimulation oriented



•Using calendars, clocks, and written notes or instructions



•Patient and family education

first line for Alzheimer’s

Cholinesterase inhibitors (CIs) once daily

second line Alzheimer’s

•CIs; a trial of second CI may be warranted.



•Vitamin E: may be added to the CI or used as monotherapy in patients who cannot afford CIs.

Cholinesterase Inhibitors

MOA

Prevent the breakdown of acetylcholine; keeps it high

\
\

Memantine

Ex. Memantine (Namenda Namenda XR): __reserved for patients with moderate to severe AD__; may be used in conjunction with a CI.

\
MOA :Regulates the activity of glutamate

Side effects :headache, constipation, confusion and dizziness



Contraindications: hypersensitivity

Education extended release can be opened

\

treatment for Alzheimer’s non-cognitive

Examples of symptoms: agitation, psychosis, anxiety, depression, and sleep disorders. Agents to improve sx include:



* Antipsychotic Agents (all contain a **BBW** -they are associated with an increased risk of death in patients with dementia-related psychosis



* Benzodiazepines (reserve for episodic events)



* Antidepressants (may improve cognition, mood, apathy, function, behavior, appetite, sleep, and overall quality of life)

Alzheimer’s education and monitoring

•Appointments 3-6 months. If clinical improvement does not occur with a cholinesterase inhibitor after 3 to 6 months of treatment, the practitioner may consider switching to another cholinesterase inhibitor.



•They need to understand that __no currently available agents are curative__ and only __modest improvements can be expected__.



•Vitamin E and *Ginkgo biloba*, antioxidants, may be useful in AD treatment.

Parkinson’s fast facts

* Neurodegenerative disorder characterized by a set of hallmark motor and nonmotor symptoms
* drug-induced parkinsonism (DIP) must be considered and ruled out
* common w. 1st gen antipsychotics or neuroleptic drugs

DIP 1st gen

**80 % of patients taking a drug from this class present with more than one kind of extrapyramidal side effects (EPS)**



–Chlorpromazine (psychosis and NV)



–Haloperidol (psychosis, agitation, Tourette syndrome



–Perphenazine (schizophrenia, NV)



–Fluphenazine (psychosis)



–Pimozide (Tourette syndrome)

DIP 2nd gen

–Risperidone (psychosis, tics, bipolar)



–Olanzapine (Zyprexa-schizo, bipolar, agitation, major depression)



–Aripiprazole (Abilify-schizo, bipolar, major depression)



**These 2 alone are known to be lower risk for elderly**



–Clozapine (schizophrenia)



–Quetiapine (Seroquel-schizo, bipolar, anxiety)

other DIP offenders

–Metoclopramide (Reglan, a prokinetic used for NV, GERD)



–Valporic acid (bipolar, migraines, seizures)



–Methyldopa (Aldomet, for mod-severe HTN)



–Prochlorperazine (Compazine for anxiety, NV)



–Amiodorone and Lithium may cause tremors

patho of parkinsons

–degeneration of dopaminergic neurons

–Autophagy dysfunction

–The formation of Lewy bodies in the residual neurons

how to differentiate extrapyramidal symptoms

**Main neurotransmitter of EPS is dopamine**

Definition: Neural network located in the brain that is part of the motor system involved in movement coordination

\
Pyramidal System: pathway for **voluntary movement**

Extrapyramidal: pathway for **movement coordination**

diagnosis and testing for parkinsons

•Functional MRI

•Dopamine transporter imaging

•Movement Disorder Society-sponsored revision of the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS)

•Clinical hx and assessment of risk factors

•Medical and medication history

•Exclusion of DIP

•Neurological exam

Parkinsons symptoms

* Classic Triad

-Resting Tremor

-Rigidity

-Bradykinesia

\
**S** huffling gait

**M** ask like

**A** kinesia (delayed response or freezing mid action)

**R** idgity

**T** remor

\

Dopaminergic Agents

ex Carbidopa-Levadopa (Sinmet)

\
MOA

•Levodopa is precursor to dopamine, it does not cross the BBB.

•Carbidopa-levadopa diffuses levodopa into the CNS, where it is converted in dopamine



\
Side effects

•GI, orthostatic hypotension, Abnormal movements-”bruxism, ballismus”

Bradykinetic episodes- known as “on-off”NMS (non motor symptoms)

Hyperventilation, bizarre breathing patterns, hoarseness, increased nasal secretions.



Interactions

–MAOI, TCA, phenothiazines, pyridoxine



Contraindications

•History of sensitivity

•Undiagnosed pigmented lesions or history of melanoma.

•Closed angle glaucoma

•Caution-cardiac disease, MI, pulmonary, DM, PUD, history of psychiatric disorders



Education

•Oral administration starts to take effect in 1-2 months but may take 6 months for noticeable effects

•Patients should avoid **high protein diet** and avoid foods with **large amounts of pyridoxine**. (ex fish, beef liver and other organ meats)

•Lose effectiveness after 2 to 5 years of therapy

•Dopamine Agonists

\
Pramipexole, bromocriptine, ropinirole (Requip and Mirapex)

MOA

Used as monotherapy to control symptoms and delay use of levodopa ( or when its wearing off.

\
Side effects

•GI, postural hypotension, dyskinesias, somnolence, dizziness unsteadiness, hallucinations and confusion



Interactions

•aminoglutethimide, carbamazepine, phenobarbital, ketoconazole, norfloxacine, ofloxacin, estrogen for ropinirole

\
Contraindications

•Renal impairment use caution

•Hepatic impairment use caution



Education

food does not effect bioavailability

•Avoid St. John’s Wort, Kava, Valerian

•Monoamine Oxidase-B Inhibitors

ex. Selegiline-Eldypryl

MOA: Inhibits the metabolism of dopamine to increase blood concentration

\
Side effects

orthostatic hypotension, hallucinations, agitation, insomnia



Interactions

carbamazepine, SSRI’s, TCA’s, SNRI’s, meperidine.



Contraindications

-Increase BP with tyramine containing foods



\

•Anticholinergics

ex (Bentropine ( Cogentin), Trihexyphenidry (Artane)

MOA

•inhibiting the cholinergic neurons.

\
Not as effective as levodopa

•Amantadine

MOA (antiviral)

•mild PD and drug induced parkinsonism as well as late stage

Mainly for resting tremors and used in combo w/ levodopa

\

What do you NOT give with parkinsons meds

DO NOT give neuroleptics or any dopamine blocking meds\* (prochlorperazine, metoclopramide, promethazine)

complications of parkinsons meds

•Neuroleptic malignant syndrome (NMS)can occur with sudden withdrawal of levodopa or dopamine agonists



•Serotonin syndrome if MAOI’s combined with SSRIs or TCAs



•“On-Off” effect because medications eventually wane

treatment of non-motor parkinsons syptoms

•Psychological symptoms

–Depression, psychosis, and dementia.

–Pramipexole and venlafaxine have been shown to be efficacious, while tricyclic antidepressants and dopaminergic drugs have been labeled as likely efficacious.

•Sleep problems: insomnia

•Autonomic or other problems: orthostatic hypotension

monitoring during parkinsons

symptom journals

•Monitor for drugs that can exacerbate parkinsonism.



•MDS-UPDRS can be used to assess disability and impairment.

how do they work?

excitatory neurons>> decrease excitation of neurons

\
inhibitor neurotransmitter >> slow down neural impulses

Phenytoins

ex  Dilantin

One of the oldest and most effective aED's (Antiepileptic Drugs)

Use:

* Commonly used for generalized tonic-clonic (grand mal), but can be used for any type seizure


*  prevents seizure post head trauma, neurosurgery, hemorrhagic stroke

MOA



◦Decreases the influx of sodium ions across cell membranes

◦Regulates neuronal excitability by inhibiting calcium conduction



Side effects

\*gingival hyperplasia, hirsutism, anemia, Stevens-Johnson

 (works too well)->>hypotension, bradycardia, arrhythmias, CV collapse, thrombophlebitis (Causes inhibition = slowing)



Interactions

Multiple Interaction

Contraindications: allergy

\
Education

 Monitor serum drug levels

Fosphenytoin (Cerebyx)

 Prodrug of phenytoin



 Short-term use when phenytoin unavailable, inappropriate, or less advantageous



 WARNING:  Do not confuse Cerebyx with Celebrex

Carbamazepine (Tegretol)

MOA: Believed to limit influx of Na ions; several po forms;

Side effects: hematologic abnormalities, drowsiness, fatigue, SIADH, rash, GI upset, confusion; May exacerbate myoclonic szs; Increased risk SJS in asians with HLA-B 1502 allele

Interactions: Multiple

Contraindications: allergy to drug or TCA, bone marrow suppression, or recent MAOI

Education: Start low and increase weekly; Drug monitoring necessary

Oxcarbazepine (Trileptal)

MOA: unknown, but thought to block Na channels to stabilize hyper neural membranes; used in Monotherapy or adjunctive partial szs in adults/children

Side effects: dizziness, somnolence, diplopia, n/v, ataxia, abd pain

Interactions: Multiple

Contraindications: Allergy

Education: Also used for Bipolar disorder, Trigeminal neuralgia

Valproic Acid (Divalproex, Depakote)

MOA: unknown, but though to work on GABA; 1st line therapy for generalized tonic clonic, simple partial, complex partial, and absence

Side effects: fatigue, tremor, GI upset, behavioral changes, weight gain; Severe AE: thrombocytopenia, pancreatitis, encephalopathy, hepatotoxicity

Interactions: Multiple

Contraindications: hepatic disease, urea cycle disorders

Education: Also used for bipolar disorder-manic, migraine prophylaxis

Ethosuximide (Zarontin)

Drug of choice for absence szs;

MOA: not known

Side effects: GI upset, fatigue

Interactions: CYP3A4

Contraindications: allergy

Education: Always used in combo with another drug

Barbiturates (Phenobarbital)

Alternative monotherapy in generalized tonic clonic; Sedating;

MOA: binds to GABA

Side effects: drowsiness, fatigue, ataxia, n/v, blurred vision, constipation, cognitive impairment, arryhthmias, dizziness

Interactions: Multiple, Increased toxicity of benzo’s, CNS depressants, methylphenidate

Contraindications: severe liver disease, respiratory disease, history of sedative or hypnotic addiction

Education: Cheap; loading dose followed by maintenance dose; frequent drug monitoring needed

Gabapentin (neurontin)

adjunct therapy complex partial szs and generalized tonic-clonic

MOA: structurally related to GABA and is thought to reduce presynaptic GABA release

Side effects: fatigue, dizziness, blurred vision. May resolve over time; possible weight gain

Interactions: not many; Antacids may block absorption

Contraindications: hypersensitivity

Education: Mainly used in neuropathic pain control

Pregabalin (Lyrica)

Adjunctive therapy for partial onset szs

MOA: Binds to ca channels to inhibit excitator neurotrans release

Side effects: peripheral edema, weight gain

Interactions: enhance sedative effect of CNS depressants

Contraindications: hypersensitivity

Education: one of the newest; other uses are Fibromyalgia, post-herpetic neuralgia, neuropathic pain

Lamotrigine (Lamictal)

Generalized tonic-clonic, absence, complex partial

MOA: stabilizes neuronal membranes by acting on amino acid release and sodium channels

Side effects: n/v, fatigue, dizziness

Interactions: other aed’s

Contraindications: hypersensitivity

Education: also used for bipolar maintenance

Levetiracetam (Keppra)

Adjunctive partial onset or primary generalized tonic-clonic

MOA: thought to facilitate GABA transmission, reduce K currents

Side effects: somnolence, HA, infection, usually within first 4 weeks; Behavioral changes

Interactions: No clinically relevant ones

Contraindications: hypersensitivity

Topiramate (Topamax)

Monotherapy or adjunctive partial onset szs and generalized tonic-clonic szs

MOA: Block Na channels by enhancing GABA activity

Side effects: fatigue, dizziness, somnolence, psychomotor slowing (stupidimate), memory difficulty, nausea, weight loss, change in taste

Interactions: CYP2C19

Contraindications: hepatic or renal impairment, pregnancy, breast-feeding

Education: Also used for migraine prophylaxis; weight control

Amphetamines for weight loss

MOA: increase release norepi

Side effects: cardiovascular issues, High risk for abuse

Interactions:

Contraindications:

Education: Use at lowest effective dose; Schedule II; Not widely used

Appetite Suppressants

Schedule III; Non-amphetamine derivatives; diethylpropion (Tenuate), phendimetrazine (Bontril), phentermine (Adipex)

MOA: decrease appetite by stimulating hypothalamus to release catecholamines norepi and dopamine

Side effects: CNS stimulation, dry mouth nausea, increase BP, tachycardia. Caution in DM’s

Interactions: None

Contraindications: MAOI

Education: Tolerance may develop after a few weeks; potential for abuse

Lipase Inhibitor

Example: Orlistat (Xenical, Alli)

MOA: Works locally in GI; blocks absorption of fats

Side effects: diarrhea, fatty stools, flatulence, leakage, nausea, abd pain, decrease absorption of fat soluble vitamins; Take MVI

Interactions: Caution on patients taking Coumadin b/c changes in Vitamin K

Contraindications: malabsorption syndrome, cholestasis

Education: Take during or 1 hr after fat containing meal. Meal should contain less than 30% fat

Qsymia

(phentermine and topiramate)

MOA: combination of appetite suppressant & anti-seizure medication

Side effects: Tachycardia, suicidal behavior/ ideation, glaucoma, mood & sleep d/o, cognitive impairment, metabolic acidosis

Contraindications: Pregnancy Cat X

Education: Potential sz with abrupt withdrawal of medication

Contrave

(Naltrexone Sustained Release/Bupropion

MOA: Naltroxene - narcotic antagonist; Bupoprion - dopamine/norepinephrine reuptake inhibitor; cause appetite suppression by working on 2 areas of brain involved with food regulation; hypothalamus & limbic systems

Side effects: Nausea, constipation, HA, vomiting, dizziness, potential suicidal ideations/ serious neuropsychiatric events

Interactions: opioid dependency/ opioids

Contraindications: uncontrolled HTN, seizure disorder, bulimia, anorexia nervosa, drug/ETOH withdrawal; MAOI use; pregnancy & lactation

Education: monitor for psychiatric changes; dose is titrated up when started & down when discontinuing

insomnia drug classes

Hypnotics:



* Benzodiazepines



-Short /Intermediate/Long acting (LA)



•Benzodiazepine receptor agonists



\-Orexin receptor antagonist



\-Melatonin receptor agonists



\-First generation antihistamines



\-Sedating antidepressants

fast facts for insomnia drugs

\*\*Hypnotics should be used at the lowest dose for the shortest period of time-can be habit forming

\


\*Provider should prescribe for as short a time as possible (Short term=2-3 weeks)



\*Wean pt’s slowly off hypnotics to prevent rebound effects

insomnia drugs benzos

Alprazolam (Xanax) SA

Estazolam (ProSom ) IA

Flurazepam (Dalmane)LA

Lorazepam (Ativan) IA

Temazepam (Restoril) IA

Triazolam (Halcion) SA

\
short= to initiate sleep

intermidiate= to maintain

insomnia drugs bzra

\*\***Benzodiazepine receptor agonist**\*\*





Eszopiclone (Lunesta)

Zolpidem (Ambien, Ambien CR)

Zolpidem tartrate (Intermezzo

Zaleplon (Sonata)

drugs used for insomnia cont.

Suvorexant (Belsomra)

Ramelteon (Rozerem)

antihistamines



**Sedating antidepressants:**



***Use for pt’s with comorbid conditions***

•Mirtazapine (Remeron)

•Trazodone

•Doxepin (Silenor)



\

first line for insomnia

•benzodiazepine (e.g., alprazolam, lorazepam, temazepam)

• benzodiazepine receptor agonists (BZRAs) (zolpidem, zaleplon, escitalopram) or ramelteon

• first-generation antihistamine—doxylamine succinate

second line for insomnia

•alternating short-acting BZRAs (zaleplon, eszopiclone) with ramelteon;

•sedating antidepressants (trazodone, amitriptyline, doxepin, mirtazapine)

third line for insomnia

•sedating antiepilepsy agents (gabapentin)

•atypical antipsychotics (quetiapine, olanzapine);

•orexin receptor antagonist (suvorexant)

restless leg treatment

•Ropinirole (Requip)



•Pramipexole (Mirapex)



•Rotigotine transdermal (Neupro)

\
anticonvulsants and benzos

narcolepsy treatment

•Psychostimulants (wake-promoting)

Armodafinil (Nuvigil)



•Amphetamines (wake-promoting)\\

•Modafinil (Provigil):



•Sodium oxybate (only distributed through manufacturer)

Sodium oxybate (Xyrem)



•Antidepressants-Venlafaxine (Effexor), Duloxetine (Cymbalta)

hypotheses of depression

•**Serotonin hypothesis:** a __functional or an absolute deficiency__ in the neurotransmitter **serotonin**



•**Catecholamine hypothesis:** a functional or an absolute deficiency in the neurotransmitter's **norepinephrine, serotonin, or dopamine**



•**Permissive hypothesis:** __diminished serotonin__ gives “permission” for a superimposed norepinephrine deficiency to manifest as depression



•**Beta-adrenergic receptor hypothesis:** depression results from __increased beta-adrenergic__ receptor sensitivity

MDD diagnostic criteria

***A patient must exhibit at least** __**5 of these signs or symptoms in the same 2-week period along**__ **with symptoms of depressed mood or anhedonia, the inability to gain pleasure from normally pleasurable experiences.**

depression monitoring

•**Acute treatment phase**: 6 to 8 weeks up to 12 weeks



•The goal is to treat the patient until __full remission and a return to the premorbid level of function.__



•**Continuation phase:** the time after a treatment response is seen in the acute phase and usually lasts 9 months to 1 year



•The practitioner should continue antidepressant therapy for 4 to 6 months __after symptom resolution.__



•**Maintenance phase:** long-term or indefinite therapy

SSRI

Ex. Escitalopram (Lexapro);Fluoxetine (Prozac);Fluvoxamine (Luvox);Paroxetine (Paxil);Sertraline (Zoloft)

\
\
Side effects

•Weight gain

•Sexual dysfunction

•Discontinuation syndrome-flu-like symptoms, anxiety

•**BBW: increased risk for suicide**

\
Education

•Administer in the AM due to potential to induce insomnia and anxiety

•Inhibits CYP450 system, causing elevation of other medications that are metabolized by this system

•Must be tapered off

SNRI

ex. Venlafaxine (Effexor);Desvenlafaxine (Pristiq);Duloxetine (Cymbalta);Levomilnacipran (Fetzima)

\
Side effects

**r/t increased adrenergic effects**

•Dry mouth, constipation, nausea, HTN

•Sexual dysfunction

•Discontinuation syndrome-flu-like symptoms, anxiety

•**BBW: increased risk for suicide**

\
Education

•Do not administer with MAOI as can cause serotonin syndrome

•Inhibits CYP450 system, causing elevation of other medications that are metabolized by this system

•Must be tapered off

\

TCAs

\
Ex. Amitriptyline (Elavil);Doxepin (Sinequan);Imipramine (Tofranil);Nortriptyline (Pamelor);Protriptyline (Vivactil);Trimipramine (Surmontil)

\
Side effects

•Weight gain, other adrenergic symptoms, gynecomastia, sexual, galactorrhea, epileptogenic

•Cardiac-QT prolongation, tachycardia, stroke, AV block, hypotension

•**BBW: increased risk for suicide**

\
Education

•Inhibits CYP450 system, causing elevation of other medications that are metabolized by this system

•Must be tapered off

•Blood levels for therapeutic range

MAOIs

•Phenelzine (Nardil)



•Tranylcypromine(Parnate)

Atypicals

**Trazodone (Desyrel)**

•**adverse effects** include orthostatic hypotension, nausea, blurred vision, and priapism



**Bupropion (Wellbutrin**)

•Frequently used in patients __who cannot tolerate the sexual adverse effects__ of SSRIs and SNRIs

•**Adverse effects-** can lower the seizure threshold, especially when combined with alcohol.



**Mirtazapine (Remeron)**

better for low weight older or ill

•rare cases of reversible agranulocytosis









\

Novel agents

**Vilazodone (Viibryd)**

**Adverse effects**-GI-nausea and diarrhea

\


**Vortioxetine (Trintellix)**

•**Adverse effects-** dizziness, diarrhea, vomiting, and xerostomia. Sexual dysfunction in men and women occurs at a rate of 34% to 50%’

\
**Esketamine (Spravato) (r/t Ketamine)**

\-add on therapy

•**Adverse effects**-increases in blood pressure, cognitive impairment and impaired ability to drive and operate machinery due to the risks of sedation and dissociation, and embryo-fetal toxicity

•**BBW**-sedation and dissociation (Schedule 3 drug)

\

warning signs of SI

•Pacing, agitated behavior, frequent mood changes, and chronic episodes of sleeplessness



•Actions or threats of assault, physical harm, or violence



•Delusions or hallucinations



•Threats or talk of death



•Putting affairs in order, such as giving possessions away or writing a new will



•Unusually risky behavior (e.g., unsafe driving, abuse of alcohol, or other drugs)

Special considerations for depression treatment

children older than 8 =Fluoxetine (Prozac)

children older than 12 =Escitalopram (Lexapro)

Black box warning for suicidal ideation in children taking SSRIs

* geriatrics
* start low and slow due to decreased renal and hepatic function
* woman
* young women more likely than older women

\

first line for depression

•**First line: SSRIs and SNRI**

second line for depression

•**Second line: TCA (desipramine or nortriptyline) or atypical antidepressant**

third line for depression

•Depending on past response to other agents and side effect profile

patho of anxiety disorders

•**Norepinephrine, serotonin, and gamma-aminobutyric acid (GABA)** are the major neurotransmitters

\
they have __malfunctioning noradrenergic systems__ with a low threshold for arousal (hypersensitive)

non pharmacologic for anxiety

•Psychoeducation



•Supportive counseling



•Behavioral therapy



•Cognitive therapy



•Stress management techniques



•Meditation



•Exercise

antidepressants for anxiety

SNRI and SSRI

ex. Paroxetine (Paxil);Sertraline (Zoloft);Citalopram (Celexa);Escitalopram (Lexapro);Fluoxetine (Prozac)

SNRI Venlafaxine (Effexor XR);Duloxetine (Cymbalta) 



\*\*Adverse Effects: weight gain, GI, insomnia, sexual dysfunction

\*\* 2-4 weeks until typical response seen

\
**(MAO-I)**

•Phenelzine (Nardil)

•Adverse Effects: anticholinergic (dryness of mouth, blurred vision, constipation, urinary hesitancy)

benzos for anxiety

ex. Alprazolam (Xanax);Chlordiazepoxide (Librium);Clonazepam (Klonopin);Clorazepate (Tranxene);Diazepam (Valium);Lorazepam (Ativan);Oxazepam (Serax)



**MOA:** binds ot GABA-A receptors in the brain-opens channels and causes increased endogenous GABA



Adverse Effects: drowsiness, psychomotor impairment, increased depression, confusion, habit forming

azapirones

Buspirone (buspar)

misc anxiety meds

Hydroxyzine HCl (Atarax)

Hydroxyzine Pamoate (Vistaril)

first line for anxiety GAD

•**First-Line**: SSRI’s and SNRI’s, and BZD’s-taper off until above working

second line for anxiety GAD

•**Second-Line:** Buspirone (BuSpar) or Imipramine (Tofranil)

first line for panic disorder

•**First-Line:** __Nonpharmacologic,__ SSRI’s or Venlafaxine (Effexor), BZD’s