MEDS

1.     Stimulants (ADHD): Increase norepinephrine and dopamine in the synapse.

  1. Common drugs: Methylphenidate, Amphetamines.

2.     Acetylcholinesterase Inhibitors (AD): Increase acetylcholine levels in the brain.

  1. Common drugs: Donepezil, Rivastigmine.

3.     NMDA Receptor Antagonists (AD): Slow neuronal degeneration by blocking glutamate receptors.

  1. Common drugs: Memantine.

4.     Dopamine Replacement/Enhancement (PD): Replace or enhance dopamine in the brain.

  1. Common drugs: Levodopa/Carbidopa, Dopamine Agonists (Pramipexole, Ropinirole).

5.     COMT Inhibitors and MAO-B Inhibitors (PD): Prolong dopamine activity.

  1. Common drugs: Entacapone, Selegiline.

6.     Anticholinergics (PD): Balance dopamine and acetylcholine in the basal ganglia.

  1. Common drugs: Benztropine, Trihexyphenidyl.

  2. Levodopa/Carbidopa (PD): Precursor to dopamine, helps increase dopamine levels in the brain. Common drugs: Sinemet, Parcopa.

  3. ADHD Stimulants: Anxiety, insomnia, appetite suppression, cardiovascular effects.

  4. Alzheimer's Drugs: Nausea, vomiting, bradycardia, GI bleeding.

  5. Parkinson's Drugs: Nausea, dyskinesia, confusion, hallucinations, dry mouth.

  6. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

    • Block reuptake of both serotonin and norepinephrine.

    • Best effect on lifting and smoothing mood plus increase focus

    • Use when SSRI is not working

    • Common SNRIs: Venlafaxine (Effexor), Desvenlafaxine(Pristiq), Duloxetine (cymbolta) use for mood and neuropathic pain, levomilnacipra

    • Adverse Effects: Activation or sedation, weight changes, sexual dysfunction.

  7. Other Antidepressants

    • Mirtazapine: Enhances norepinephrine and serotonin release, can cause weight gain. Second generation

    • Bupropion: Stimulates dopamine and norepinephrine, minimal sexual side effects, CNS activation. Dopamine component is useful in patients with anhedonia (reduced ability to experience pleasure or interest) lower seizure threshold, head injury? Can be helpful for craving  

    • Trazodone: 5HT2 receptor blocker, highly sedating, often used for insomnia.

Mirtazapine(Remerom) and Bupropion are especially useful for patients with depression and appetite loss or sexual side effects from other antidepressants.

  • Benzodiazepines:

    • Mechanism: Facilitate GABA neurotransmission, resulting in CNS depression and anxiolysis. GABA agonist

    • Common Benzodiazepines: Diazepam, Lorazepam, Alprazolam.

    • Adverse Effects: Sedation, dependence, withdrawal symptoms, CNS depression, alcohol interaction.

    • Metabolism: CYP3A4, with metabolites like desmethyldiazepam having long duration.

    • Abuse Potential: Counseling is essential to avoid chronic use. They should be tapered, not stopped abruptly.

  • Alternative Drugs for Anxiety:

    • Buspirone: An anxiolytic that doesn't cause sedation. Partial serotonin agonist, alternative to benzo

    • Pregabalin: Used for generalized anxiety and pain.

Hydroxyzine: A non-habit forming anxiolytic

Drugs for Insomnia

  • GABA-BZ Drugs:

    • Zolpidem, Zaleplon, Zopiclone: These act on the GABA-A receptor for sleep induction.

    • Fewer drug interactions compared to benzodiazepines but still potent sedatives.

    • Adverse Effects: Risk of drowsiness, dizziness, and CNS depression.

  • Melatonin Receptor Agonists:

    • Ramelteon: A drug that mimics melatonin’s effects and promotes sleep.

    • Long term acting

Benzodiazepine receptor agonist

-       Zolpidem, zaleplon, eszopiclone

-       Short term

Benzodiazepine

-       Alprazolam, lorazepam, temazepam

-       Addictive, can cause seizures if discontinued abruptly

-       Rebound anxiety, relapse and withdrawal

-       Short

Bipolar Disorder:

  1. Lithium:

    • Lithium is the cornerstone of bipolar disorder treatment. It's effective in suppressing mania but has a low therapeutic index, so blood levels must be monitored carefully.

    • Adverse effects include tremor, mental confusion, thyroid issues, and nephrogenic diabetes insipidus.

    • Lithium has numerous drug interactions (e.g., diuretics, NSAIDs like naproxen), which can increase its toxicity.

Selective Serotonin Reuptake Inhibitors (SSRIs)

    • Block serotonin reuptake, increasing serotonin in the synapse.

    • Common SSRIs: Fluoxetine (Prozac), Sertraline(Zoloft), Citalopram (no more than 40mg/day and do not exceed 20mg per day for pt older than 60 yr, hepatic impairment,), Paroxetine (anticholinergic side effect) , Fluvoxamine. Escitalopram (Lexapro)

    • Adverse Effects: Sexual dysfunction, weight gain, GI upset. Withdrawal syndrome, serotonin syndrome, avoid st.wart , suicidal idealization

Smoking Cessation:

  1. Nicotine Addiction:

    • Nicotine is the primary addictive substance in cigarettes, and smoking is a major cause of preventable death.

    • Smoking cessation often involves behavioral interventions and pharmacological support.

  2. Medications:

    • Nicotine replacement therapy (patches, gum) helps reduce withdrawal symptoms.

    • Bupropion, an antidepressant, and varenicline (Chantix) are both effective for smoking cessation. However, Chantix has a black-box warning due to the risk of increasing suicidal thoughts, especially in individuals with subclinical depression.

Zoloft Sertraline SSRI (Selective Serotonin

Reuptake Inhibitor)

Lexapro Escitalopram SSRI (Selective Serotonin

Reuptake Inhibitor)

Cymbalta Duloxetine SNRI (Serotonin-Norepinephrine

Reuptake Inhibitor)

Wellbutrin Bupropion NDRI (Norepinephrine-Dopamine

Reuptake Inhibitor)

Xanax Alprazolam Benzodiazepine

Buspar Buspirone Anxiolytic

Ambien Zolpidem Non-Benzodiazepine Hypnotic