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What medications are MAOIs?
Phenelzine (Nardil)
Tranylcypromine (Parnate)
Selegiline transdermal (Emsam)
True or False? MAOIs are effected by tyramilne containing foods
True
What is a notable side effect that can be seen with MAOIs?
Hypertensive crisis
What class of medications are derived from phenothiazines (antipsychotics) tha can also be used for insomnia & pain conditions?
TCAs
What medication class increases 5-HT & NE concentrations?
TCAs
What medications are TCAs?
Amoxapine (Asendin)
Amitriptyline (Elavil)
Clomipramine (Anafranil)
Desipramine (Norpramin)
Doxepin (Sinequan)
Imipramine (Tofranil)
Nortriptyline (Pamelor)
What medication class affects many receptors causing them to have a multitude of side effects?
TCAs
What antidepressant medication class prevent reuptake of 5-HT, increasing synaptic concentrations?
SSRIs
What is the first-line medication class for MDD?
SSRIs
What medications are SSRIs?
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac, Sarafem)
Fluvoxamine (Luvox)
Paroxetine (Paxil)
Sertraline (Zoloft)
What antidepressant medication class has a discontinuation/withdrawal phenomenon and requires a tapered discontinuation?
SSRIs
Which SSRIs have QT interval prolongation?
Citalopram (Celexa)
Escitalopram (Lexapro)
What is a BBW that is shared amongst almost all antidepressants?
Suicidality
What antidepressant medication class target SERT and NET transporters and have fewer side-effects than TCAs?
SNRIs
What medications are SNRIs?
Venlafaxine (Effexor)
Desvenlafaxine (Pristiq)
Duloxetine (Cymbalta)
Milnacipran (Savella)
Levomilnacipran (Fetzima)
What antidepressant medications are mixed serotonergic agents?
Trazodone (Desyrel)
Nefazodone (Serzone)
Vilazodone (Viibryd)
What antidepressant medcations are 5-HT2 antagonists and 5-HT reuptake inhibitors?
Trazodone (Desyrel)
Nefazodone (Serzone)
What are two notable side effects associated with Trazodone (Desyrel)?
Hypotension
Priapism
Why has Nefazodone (Serzone) had less clinical use?
Due to cases of liver failure
What antidepressant medications are often prescribed for sleep when trying to avoid using narcotics?
Trazodone (Desyrel)
Nefazodone (Serzone)
Vilazodone (Viibryd)
What antidepressant medication inhibits the reuptake of NE and DA and may enhance the release of both NE and DA?
Bupropion (Wellbutrin)
What antidepressant medication has less sexual dysfunction side effects than SSRIs?
Bupropion (Wellbutrin)
What antidepressant medication antagonizes 5-HT2 and 5-HT3 receptors while also antagonizing histamine receptors?
Mirtazapine (Remeron)
What medication is a newer antidepressant agent that acts as an SSRI and acts as a 5HT agonist, partial agonist, and antagonist at various receptor subtypes?
Vortioxetine (Trintellix)
A patient who is a poor metabolizer of CYP2D6 may accumulate what antidepressant drug?
Vortioxetine (Trintellix)
What medication class regulate glutamate activity by blocking NMDA receptor and can be used to treat depression?
Ketamine (Ketalar)
Esketamine (Spravato)
True or false? Esketamine (Spravato) does not have a REMS program
False
What are some risks seen with Ketamine & Esketamine?
Misuse/abuse (CIII)
Sedation
Disassociation
What is the management/treatment for Serotonin Syndrome?
Hydration w/ IV fluids
Evaporative cooling
Cyproheptadine (Antihistamine with serotonin blocking effects)
Which SSRI has a longer half-life and/or active metabolite?
Fluoxetine (Prozac, Sarafem)
What is a herbal supplement with efficacy in mild depression? Why?
St. John's Wort → it has a compound (hypericin) that has MAOI action
True or false? St. John's Wort should be used alongside other antidepressants
False, it can cause serotonin syndrome if combined with other antidepressants
What herbal supplement is a CYP3A4 & P-glycoprotein inducer?
St. John's Wort
What bipolar medication is not metabolized but excreted unchanged in the urine, resembles sodium in the body, and is not protein bound?
Lithium (Lithobid)
What medication is first-line therapy for mood stabilization?
Lithium (Lithobid)
True or false? Abrupt discontinuation of Lithium (Lithobid) may lead to relapse
True
What are some chronic side effects of Lithium (Lithobid)?
Fine hand tremor
Nephrogenic diabetes insipidus
Nephrotoxicity
Hypothyroidism
Reversible cardiac effects
Acne, pruritic dermatitis, psoriasis exacerbation
Weight gain
Slurred speech, ataxia
How do you treat nephrogenic diabetes insipidus induced by Lithium (Lithobid)?
Loop or thiazide diuretics
True or False? Lithium (Lithobid) has many CYP interactions
False, it does not have any CYP interactions
What are the anticonvulsant agents used for Bipolar Disorder?
Valproic Acid (Depakote, Depacon)
Carbamazepine (Tegretol)
Oxcarbazepine (Trileptal)
Lamotrigine (Lamictal)
What is the most prescribed mood stabilizer in the US?
Valproic Acid (Depakote, Depacon)
What is the difference between 1st & 2nd generation antipsychotics?
1st generation: block DA2 receptors
2nd generation: block DA2 and 5HT-2a receptors
What are the alternative agents for bipolar disorder?
Benzodiazepines
Calcium channel antagonists
What medication class is good for acute mania, agitation, panic and insomnia or for patients who can't take mood stabilizers?
Benzodiazepines
What are some side effects of antipsychotics?
Gynecomastia
Menstrual irregularities
EPS
Akathisia
Tardive dyskinesia
NMS
What antipsychotic side effect is seen most often with high potency D2 blockers (Haloperidol, fluphenazine)?
Neuroleptic Malignant Syndrome (NMS)
What are the 1st generation antipsychotics we should know?
Chlorpromazine (Thorazine)
Thioridazine (Melleril)
Prochlorperazine (Compazine)
Fluphenazine (Prolixin)
Haloperidol (Haldol)
Which 1st generation antipsychotics are high potency D2 blockers but have less antimuscarinic, alpha 1, & antihistamine side effects?
Fluphenazine (Prolixin)
Haloperidol (Haldol)
Which 1st generation antipsychotics are low potency D2 blockers but have more antimuscarinic, alpha 1, & antihistamine side effects?
Chlorpromazine (Thorazine)
Thioridazine (Melleril)
Prochlorperazine (Compazine)
1st gen or 2nd gen antipsychotic?
Very effective for positive symptoms
1st generation
How is EPS from antipsychotics treated?
Treated with anticholinergics (usually antihistamines)
- Diphenhydramine (Benadryl)
- Trihexyphenidyl (Artane)
- Benztropine (Cogentin)
True or false? You can also use Benzodiazepines to treat EPS if anticholinergics fail
True
How do we treat tardive dyskinesia from antipsychotics?
Avoid anticholinergics
Discontinue treatment
Drug holidays
Switch to second generation agent
How do we treat NMS from antipsychotics?
Discontinue offending agent
Cool patient
Hydrate patient
Dantrolene (Dantrium)
Bromocriptine
What medication is a peripheral skeletal muscle relaxant that is used to treat NMS but is also used to treat malignant hyperthermia?
Dantrolene (Dantrium)
1st gen or 2nd gen antipsychotic?
Fewer extrapyramidal and prolactin effects
2nd generation
1st gen or 2nd gen antipsychotic?
More efficacy for negative and cognitive symptoms
2nd generation
1st gen or 2nd gen antipsychotic?
Less tardive dyskinesia with prolonged use
2nd generation
1st gen or 2nd gen antipsychotic?
Should be first line unless contraindicated
2nd generation
What is the MOA for 2nd gen antipsychotics?
Less affinity for D2 receptors in striatal tract
5HT-2 receptor antagonism
What 2nd gen antipsychotic should you avoid prescribing? Why?
Clozapine → causes agranulocytosis
True or false? Clozapine has a REMS program
True
True or false? 2nd generation antipsychotics are very good for elderly patients
False, elderly patients are at an increased risk for death (BBW)
Which 2nd gen antipyschotics have greater sedation effects?
Clozapine (Clozaril), Olanzapine (Zyprexa), and Quetiapine (Seroquel) → administer QHS
Which 2nd gen antipyschotics have greater anticholinergic effects?
Clozapine (Clozaril)
Olanzapine (Zyprexa)
Which 2nd gen antipyschotics have greater seizure risk?
Clozapine (Clozaril)
Olanzapine (Zyprexa)
If a patient is taking a 2nd generation antipsychotic, what other medications would you not want to have them take because it can cause an increased risk of EPS?
Metoclopramide (Reglan) and promethazine (Phenergan) → these are dopamine blockers as well
Which 2nd generation antipsychotic have worse side effects?
Clozapine (Clozaril)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Which 2nd generation antipsychotics have milder side effects?
Aripiprazole(Abilify)
Iloperidone (Fanapt)
Ziprasidone (Geodon)
Paliperidone (Invega)
Risperadone (Risperdal)
Asenapine (Saphris)
Lurasidone (Latuda)
What are the other 2nd gen antipsychotics that are newer?
Brexipiprazole (Rexulti)
Iloperidone (Fanapt)
Cariprazine (Vraylar)
Pimavanserin (Nuplaszid)
If patients have failed most antipsychotics, what is the last option you should try?
Clozapine (Clozaril)
If you are switching antipsychotics, what should you do?
Taper 1st agent over 2 weeks after 2nd antipsychotic has been started low and titrated up
What is used to treat acute anxiety?
Benzodiazepines
What is used to manage chronic anxiety?
Antidepressants
What are some alternative anxiolytic medications?
Buspirone (BuSpar)
Rarely second gen. antipsychotics
True or false? Antidepressants are not effective for acute/long term GAD
False, they are effective
What is second line for acute/long term GAD?
Imipramine (Tofranil)
What medications are Benzodiazepines?
Alprazolam (Xanax)
Chlordiazepoxide (Librium)
Clobazam (Onfi)
Clonazepam (Klonopin)
Clorazepate (Tranxene)
Diazepam (Valium)
Lorazepam (Ativan)
Midazolam (Versed)
Oxazepam (Serax)
Temazepam (Restoril)
Triazolam (Halcion)
Which Benzodiazepines are preferred in elderly patients?
Lorazepam (Ativan)
Oxazepam (Serax)
Temazepam (Restoril)
Triazolam (Halcion)
LOTT are good for the elderly
Most Benzodiazepines have CYP3A4 metabolism except which agents?
Lorazepam (Ativan), Clonazepam (Klonopin), Oxazepam (Serax)
Which Benzodiazepines have high lipid solubility?
Clorazepate (Tranxene)
Diazepam (Valium)
True or false? Benzodiazepines are synergistic with other depressants (EtOH)
True
True or false? We don't have to worry about withdrawal effects with Benzodiazepines
False, can cause rebound anxiety; must be titrated off slowly
What is a non-benzodiazepine anxiolytic that is second line for GAD?
Buspirone (BuSpar)
Why is Buspirone (BuSpar) a second line option for GAD?
Lack of consistent efficacy
True or false? Buspirone (BuSpar) takes 2+ weeks for it to be efficacious
True
True or false? Benzodiazepines are not controlled substances
False, all of them are controlled substances
True or false? Buspirone (BuSpar) is metabolized by CYP3A4
True
What is the MOA for BB when treating anxiety?
Blunt physiologic effects of anxiety
Reduce effects of endogenous catecholamines
If a patient gets anxious when performing in front of others, what could you give to treat their anxiety?
Beta blockers
What BBs are used for performance-based anxiety?
Propranolol (Inderal) or Atenolol (Tenormin)
True or false? When treating performance-based anxiety, you should take a BB 3 hours before the performance
False, should take it 1 hour before
True or false? You should have a patient take a test dose of BBs at home to determine tolerance and adverse effects before they use it in a performance-based situation
True
If there are urgent symptoms of anxiety, what should you start with?
Begin with short-term benzodiazepine (2-4 weeks)
Begin SSRI or SNRI therapy
If there are non-urgent symptoms of anxiety, what should you start with?
SSRI or SNRI
If there is no adquate response to Benzodiazepines, SSRIs or SNRIs for anxiety, what should you consider prescribing?
Imipramine (Tofranil) or other TCA
What is the first-line therapy for ADHD?
Stimulants
What is the MOA for stimulants when treating ADHD?
Block MAO
Inhibit reuptake of dopamine and norepinephrine
Amphetamines increase catecholamine release
What medications are stimulants used for ADHD treatment?
Methylphenidate (Ritalin, Metadate, Concerta, Quillivant)
Dexmethylphenidate (Focalin)
Mixed amphetamine salts (Adderall)
Lisdexamphetamine (Vyvanse)
True or false? All stimulants used to treat ADHD are C-II substances
True
