Exam 3!

Antipsychotics Agents and Schizophrenia Drugs Big Pic

Tx: schizophrenia, delusional disorders, bipolar depressive psychoses, and drug induced psychoses

1st Gen, aka conventional

2nd Gen, aka atypical

1st gen antipsychotics

low potency: chlorpromazine; watch for prolonged QT, agranulocytosis. s/s of fever = stop med!

medium potency: loxapine

high potency: haloperidol; also prolonged QT

1st gen antipsychotics adverse

1. EPS

   1. acute dystonia; onset in days or weeks. Tx with anticholinergics

   2. Parkinson-type symptoms

   3. Akathisia; more difficult to treat. use benzes, anticholinergics, beta blockers.

   4. Tardive dyskinesia; Tx with valbenazine. causes drowsiness, prolonged QT.

2. Neuroleptic Malignant Syndrome

   1. muscle rigidity, sudden high fever, autonomic instability, risk of death.

   2. more likely with high potency first gen drugs.

   3. Tx: give benzes, cooled IVF, give dantrolene and bromcriptine.

3. Orthostatic hypotension

4. Sedation

5. Seizures

6. Sexual dysfunction

7. Do not use in dementia! double mortality rate.

2nd gen antipsychotics

Lower risk of EPS

Increased risk of metabolic effects: weight gain, DM, hyperlipidemia

Ex: Clozapine, Aripiprazole

2nd gen antipsychotics adverse

1. Sedation

2. Metabolic effects

3. Orthostatic hypotension

4. Agranulocytosis (clozapine); so monitor WBC and neutrophils weekly x 6 months, q 2 weeks x 6 months, q 6 months x duration of time on drug.

5. Myocarditis (clozapine); s/s- dyspnea, chest pain, fatigue, palpitations, tachypnea

Depot antipsychotics

deposits drug into localized tissue for gradual absorption

Long acting

injectable

lower relapse rates

Ex: Haloperidol decanoate, risperidone microspheres, olanzapine pamoate

GAD Big Picture

1. Serotonergic Reuptake Inhbitors

   1. SSRI’s

   2. SNRI’s

2. Nonbenzodiazepine-Nonbarbituates

3. Benzodiazepines

Serotonergic Reuptake Inhibitors GAD

SSRI’s: paroxetine, Escitalopram

SNRI’s: Venlafaxine, Duloxetine

Buspirone (GAD)

Does not: work immediately

Does not: intensify CNS depression (positive!)

Does not: have potential for abuse

Cannot use PRN

Decreases seizure threshold

Benzodiazepines for GAD

Alprazolam, Diazepam, Lorazepam

Moa: enhances GABA response

Potential for: abuse, sedation, psychomotor slowing

Physical dependence, w/d leads to: seizures, panic, paranoia, delirium

slowly taper off

To reverse overdose: Flumazenil

Insomnia: Sedative-Hypnotic Drugs Big Pic

Benzodiazepines: Temazepam

Benzo-Like: Zolpidem, scheduled IV

Melatonin Receptor Agonist: Melatonin

Orexin Receptor Antagonist: Suvorexant, scheduled IV

Benzos for Insomnia

1st choice for short term treatment

side effects: anterograde amnesia (can’t remember recent things), sleep driving, daytime sedation

Other insomnia drugs

1. Trazodone

   1. s/e: grogginess, postural hypotension

2. Doxepin (old school TCA)

   1. s/e: nausea, sedation

Bipolar drugs big pic

Mood stabilizers: Lithium, anti epileptic drugs (divalproex sodium, carbamazepine, lamotrigine)

antipsychotics

antidepressants

benzos for sedation in acute manics

Lithium

tx: manic episodes and recurrence of mania and depression

Low therapeutic index- toxicity can occur at levels slightly over

monitoring is mandatory q 2-3 days then q 2-3 months

>1.5 = Toxic!

Draw trough 12 hours post evening dose

Lithium adverse

@ excessive levels: EKG changes, ataxia, giddiness, severe hypotension, coma, seizures, oliguria, death.

@ therapeutic levels: fine hand tremors, polyuria, renal toxicity, goiter, hypothyroidism.

Use caution in renal impairment bc excreted by kidneys.

if Na is low, Li levels can become toxic.

Caution w/ diuretics, ACE inhibitors, and NSAID’s all increase levels.

Caution w/ dehydration. = increase fluids!

Teratogenic- don’t use in first trimester.

better than anti epileptics d/t reduced suicide risk and relapse prevention. worse d/t side effects and toxicity.

Divalproex Sodium aka valproate

Antiepileptic for bipolar disorder

1. tx: acute mania, not great for depression

2. faster onset, better TI and tolerated than Lithium

3. Can cause toxicity- pancreatitis, liver failure, thrombocytopenia, teratogenic

4. also GI distress and wt. gain but still keep taking med

Carbamazepine

Antiepileptic for bipolar disorder

1. tx: prevent and treat manic episodes, not great for depression

2. s/e- visual disturbances, ataxia, vertigo, HA

3. usually resolve w/ time

4. not safe to drive

5. Uncommon side effects: hematologic, do CBC and platelets at baseline and periodically

Lamotrigine

Antiepileptic for bipolar disorder

1. tx: prevent relapse into mania and depression

2. used alone or with other mood stabilizers

3. s/e: HA, dizziness, diplopia. no driving. call provider! don’t just stop taking.

4. Rare s/e: SJS and TEN so start w/ low doses and gradually increase.

Antidepressants big pic

1. SSRI’s

2. SNRI’s

3. Tricyclics

4. Monoamine oxidase inhibitors

5. atypical antidepressants

Selective Serotonin Reuptake Inhibitors (SSRI’s)

ex: Fluoxetine

s/e: nausea, agitation, sexual dysfunction

Adverse: suicide risk. serotonin syndrome: agitation, confusion, hallucinations, fever, profuse sweating, hyperreflexia = stop taking med!. withdrawal syndrome: HA, anxiety, tremors, dizziness.

Neonatal abstinence syndrome and persistent pulmonary hypertension of newborns

Serotonin-Norepinephrine Reuptake Inhibitors (SNRI’s)

ex: Venlafaxine

s/e: nausea, HA anorexia

adverse: diastolic HTN

combining w MAOI’s- increased risk of serotonin syndrome

Abrupt d/c: very intense withdrawal symptoms

Tricyclic Antidepressants

ex: Amitriptyline

Adverse: orthostatic hypotension, anticholinergic effects, sweating, sedation, lowers seizure threshold, cardiac toxicity.

combined with MAOI’s: severe HTN!

Acutely depressed pts: give 1 week of meds at a time to decrease risk of overdose

Monamine Oxidase Inhibitors (MAOI’s)

2nd or 3rd choies unless atypical depression

ex: Isocarboxazid, Selegiline (transdermal patch)

Adverse: CNS stimulation, orthostatic hypotension, HTN crisis from dietary tyramine (charcuterie)

Drug interactions: amphetamines, cocaine, TCA’s, serotonergics, BP meds, meperidine

Bupropion

Norepinephrine-Dopamine reuptake inhibitors

Atypical antidepressant

mech: not well understood

pro: treats anxiety and increases sexual pleasure

Adverse: agitation, HA, wt loss, seizures (avoid high doses in pts w/ previous seizures and avoid other drugs that lower seizure threshold)

Mirtazapine

NDRI

Atypical antidepressant

adverse: drowsiness, weight gain

Esketamine

NDRI

Atypical antidepressant

nasal spray

for drug resistant depression

adverse: sedation, HTN, dissociate

CNA stimulants and ADHD big pic

1. CNS Stimulants

   1. Amphetamines

   2. Methylxanthines

   3. Miscellaneous- Modafanil

2. Nonstimulants

   1. Atomexetine

   2. Guanfacine

   3. Clonidine

Amphetamines

stimulate release of norepinephrine and dopamine

examples: Dexmethylphenidate, Dextroamphetamine, Amphetamine mixture (adderall), Lisdexamfetamine, Methylphenidate

therapeutic uses: narcolepsy and ADHD

positives- increase wakefulness, alertness, and elevates mood

negatives- physical dependence, potential for abuse, wt loss, increase bp, increase angina, psychosis

Methylanthines

caffeine!

HA treatment

CNS stimulant

Modafinil

off label ADHD treatment

FDA approved for shift-work sleep disorder narcolepsy

mechanism unknown

positives- less potential for abuse

Adverse: uncommon, SJS, TEN, erythema multiforme

stop meds with any changes in skin!

Nonstimulants for ADHD

less effective

2nd choice

Atomoxetine

Guanfacine

Clonidine

s/e: hypotension, sedation