PHRX 4040 Psychiatry - Exam 5 Drug Charts

naltrexone: indication

1st line for AUD

naltrexone: MOA

mu opioid antagonist

naltrexone: oral brand name

Revia

naltrexone: oral dosing

50 mg daily

naltrexone: IM LAI brand name

vivitrol

naltrexone: IM LAI dosing

380 mg Q4W

naltrexone: oral onset/duration

onset = 15-60 min

duration = 24 hrs

naltrexone: IM LAI onset/duration

onset = 2-3 days

duration = 4 weeks

naltrexone: efficacy monitoring

- number of drinking days

- cravings

- total alcohol consumption

naltrexone: safety monitoring

LFTs

naltrexone: warnings and precautions

BBW = risk of dose related hepatocellular injury

naltrexone: contraindications

- use of opioid within 7 days (14 if buprenorphine or methadone)

- acute hepatitis

- severe hepatic impairment; if LFTs are 5x the upper limit of normal

naltrexone: ADEs

- common = n/v, headache, low energy, insomnia, anxiety, nervousness, rash or injection site rxns

- rare = liver toxicity

acamprosate: brand name

campral

acamprosate: indication

1st line for AUD

acamprosate: MOA

NMDA antagonist

acamprosate: dosing

- 666 mg TID

- 50% dose reduction if CrCl 30-50 ml/min

acamprosate: onset/duration

onset within 3-8 hrs but may take several days for full effects

acamprosate: efficacy monitoring

- number of drinking days

- cravings

- total alcohol consumption

acamprosate: safety monitoring

mental status = depressive or suicidal

acamprosate: warnings and precautions

suicidal ideation

acamprosate: contraindications

CrCl under 30 ml/min

acamprosate: ADEs

- common = diarrhea and insomnia

- rare = attempted or completed suicide

disulfiram: indication

2nd line for AUD

disulfiram: MOA

blocks aldehyde dehydrogenase

disulfiram: onset and duration

- onset = rapid but may take up to 12 hrs for full effect

- duration = 1-2 weeks after last dose

disulfiram: efficacy monitoring

abstinence from alcohol

disulfiram: safety monitoring

- LFTs

- serum electrolytes

- CBC

- function

disulfiram: warnings and precautions

- must be alcohol free for 12 hrs or have 0% BAC prior to starting and for at least 14 days after

- severe renal and hepatic impairment

- cerebrovascular disease

- psychosis

- avoid oral or topical alcohol containing products

disulfiram: contraindications

- psychosis

- OTC topical alcohol products

- metronidazole

- severe myocardial disease

disulfiram: ADEs

- common = abnormal taste, fatigue, drowsiness

- rare = liver toxicity, disulfiram run due to accumulation of acetaldehyde, increase HR or papilations, decrease BP, n/v, SOB, sweating, anxiety, dizziness, blurred vision, confusion

benzodiazepines: indication

1st line for alcohol withdrawal

which benzos are preferred for alcohol withdrawal?

longer acting benzos

- chlordiazepoxide

- diazepam

which benzos are prefered for pts elderly and susceptible to over sedation or poor liver function?

LOT agents

- lorazepam

- oxazepam

- temazepam

chlordiazepoxide: CIWA-Ar dosing

25-100 mg

diazepam: CIWA-Ar dosing

2.5-10 mg

lorazepam: CIWA-Ar dosing

0.5-2 mg

oxazepam: CIWA-Ar dosing

15-30 mg

what is the current standard of care for using benzos for alcohol withdrawal?

- symptom trigger approach

- administer benzo if CIWA score 8+

thiamine: dosing

100 mg po/IM/IV daily for 1-4 weeks

naloxone: brand name

narcan

naloxone: indication

1st line for opioid overdose

naloxone: MOA

opioid receptor antagonist

naloxone: IM/IV/SQ dosing

- 0.4-2 mg every 2-3 mins until pt is breathing

- max = 10 mg

naloxone: IN dosing

- 4 mg every 2-3 min until pt is breathing in alternate nostrils

- max = 10 mg

naloxone: high dose IN brand name and dosing

- kloxxado

- 8 mg

naloxone: onset and duration

- onset = under 5 mins

- duration of IM longer than IN

naloxone: PK

half life = 30-80 mins

naloxone: ADEs

abrupt reveraal may result in:

- tachycardia

- HTN

- pulmonary edema

- injection site rxns

methadone: indication

1st line for withdrawal and OUD maintenance

methadone: MOA

full opioid agonist

methadone: maintenance dosing

- initiate with 30-40 mg daily

- titrate to 80-120 mg daily

methadone: onset and duration

- onset = 2 hrs

- duration = 24-36 hrs

methadone: PK

metabolism:

- 3A4

- 3B6

- 2C19

- 2C9

- 2D6

methadone: efficacy monitoring

- reduction in withdrawal

- opioid cravings

- opioid use

- Utox

- urine methadone

methadone: safety monitoring

- RR

- HR

- BP

- cognition

- QTC

- DDIs

methadone: boxed warning

- QTC prolongation (consider discontinuation or decrease dose if qtc greater than 500 ms)

- fatal respiratory depression

- risk of misuse or dependence

methadone: DDIs

- qtc prolonging meds

- meds contributing to low K, Mg, Ca

- 3A4 inhibitors

- MAOIs

- naltrexone

methadone: contraindications

- respiratory depression

- acute brachial asthama

- paralytic ileus

- concurrent MAOI use

methadone: ADEs

- common = HOTN, diaphoresis, constipation, n/v, dizziness and sedation

- rare = QTC prolongation, respiratory depression, serotonin syndrome

buprenorphine +/- naloxone: indication

1st line for withdrawal and OUD maintenance

buprenorphine +/- naloxone: MOA

- buprenorphine = partial mu opioid agonist

- naloxone = opioid antagonist

buprenorphine +/- naloxone: maintenance dosing standard initiation

- pt MUST be in withdrawal

- start buprenorphine 2 mg/naloxone 0.5 mg or buprenorphine 4 mg/naloxone 1 mg and administer every 2 hrs until symptoms are controlled

- goal = 8 mg buprenorphine/2 mg naloxone

buprenorphine +/- naloxone: maintenance dosing low dose initiation

- pt not in withdrawal

- start with buccal buprenorphine and pt continues full opioid agonist for several days until buprenorphine dose is titrated up to therapeutic levels

buprenorphine +/- naloxone: maintenance dosing goals

- goal = buprenorphine 16 mg/naloxone 4 mg daily

- doses of buprenorphine greater than 24 mg buprenorphine/naloxone 6 mg do not have clinical advantage

buprenorphine +/- naloxone: PO/buccal/SL onset and duration

- onset = 20-40 min

- duration = 24-42 hrs

buprenorphine +/- naloxone: long acting implant onset and duration

- onset = 12 hrs

- duration = 20 weeks

buprenorphine +/- naloxone: PK

metabolism:

- 3A4 substrate

- inhibits 2D6 and 2A4

buprenorphine +/- naloxone: monitoring

LFTs and Utox (including urine buprenorphine)

buprenorphine +/- naloxone: warnings and precautions

- CV and respiratory disease

- hepatic impairment

- misuse potential

buprenorphine +/- naloxone: warnings and precautions for buprenorphine ER LAI

- pts taking other CNS depressants

- sublocade and brixaldi have REMS program

buprenorphine +/- naloxone: DDIs

- 3A4 modulators

- naltrexone

- CNS depressants

buprenorphine +/- naloxone: ADEs

- common = injection site reactions, constipation, n/v/d, headache, somnolence/fatigue, insomnia

- rare = HOTN, bowel obstruction, hepatic injury or liver failure, drug withdrawal

clonidine: indication

1st line for opioid withdrawal

clonidine: MOA

- alpha 2 adrenergic agonist

- decreases noradrenergic hyperactivity but not helpful for cravings or muscle aches

clonidine: FDA approved indications

- ADHD

- pain (cancer and hypertension)