Psychiatry Drugs & Side Effects
Terms in this set (198)
HAM Side Effects
Found in TCAs and low potency anti-psychotics: antiHistamine - sedation, WEIGHT GAIN; antiAdrenergic - hypotension; anti-Muscarinic - dry mouth, blurry vision, urinary retention
Occurs when SSRIs and MAOIs are combined (also others): confusion, flushing, diaphoresis, tremor, myoclonic jerks, hypothermia, hypertonicity, rhabdomyolysis, renal failure
Occurs when MAOIs are combined with tyramine foods (wine, cheese, chicken liver, cured meats)
Extrapyramidal side effects
Occurs with high-potency traditional antipsychotics: Parkinsnism, akathisia (restlessness), dystonia (sustained contraction of muscles in neck, tongue, eyes, diaphragm); reversible
When does hyperprolactinemia occur?
High potency traditional antipsychotics and risperidone
Occurs after YEARS of antipsychotic use, irreversible: choreoathetoid muscle movements, usually mouth and tongue (grimacing and tongue protrusion)
Neuroleptic malignant syndrome
Medical emergency with 20% mortality rate, can be caused by anti-psychotics (more often with traditional) after short or long period of time: fever, tachycardia, HTN, tremor, increased CPK, "lead pipe" rigidity
Treatment for EPS
Which drugs induce CYP450 and what does that do?
Carbamazepine, barbiturates, smoking: leads to decreased drug levels
Which drugs are CYP450 inhibitors and what do they do?
Fluoxetine, Paroxetine, Duloxetine, Sertraline, Fluvoxamine: leads to increased drug levels in system (of note: warfarin dosing and monitoring is key)
Antidepressant withdrawal phenomenon symptoms
dizziness, HAs, nausea, insomnia, and malaise
What can someone taking SSRIs + cough medicine get?
Serotonin Syndrome (can also occur with SSRIs + triptans or MAOIs + SSRIs). With MAOIs, they should be staggered from SSRIs for at least 2 weeks.
Fluoxetine (Prozac): 3 unique benefits
1. Longest half-life of SSRIs (can be weekly dosed)
2. Safe in pregnancy
3. Approved for use in children
Fluoxetine side effects
Common sleep changes and anxiety
Sertraline - unique side effect
SSRI with highest risk for GI disturbances (also has sleep changes); very few drug interactions
Paroxetine (Paxil): 3 downsides
1. More drug interactions
2. Severe anticholinergic effects: sedation, constipation, weight gain
3. Short half-life leads (key) to withdrawal phenomenon
Fluvoxamine (Luvox): unique SSRI
SSRI approved only for use in OCD
Citalopram (Celexa): 2 benefits
1. Fewest drug-drug interactions
2. Fewer sexual side effects
What is Escitalopram (Lexapro)?
Levo-enantiomer of citalopram (both SSRIs) - more expensive but possibly with fewer side effects
Which is hardest to OD: TCAs, MAOIs or SSRIs?
Common Side effects of all SSRIs (6 major ones)
1. Sexual dysfunction (25-30%): decreased interest, anorgasmia, delayed ejaculation (do no resolve quickly)
2. GI disturbance: nausea/diarrhea
3. Insomnia & vivid dreams (often resolve over time)
4. Anorexia / weight loss
5. Restlessness (akathisia that occurs at start and stop of meds)
6. Serotonin Syndrome
Others: seizures, HA, increased suicidal thinking & behavior
What can be used to treat sexual side effects of SSRIs?
What are the 2 major SNRIs to know
Venlafaxine (Effexor) and Duloxetine (Cymbalta) - both anti-depressants
Aside from depression, what else is Venlafaxine (Effexor) used for?
Useful in GAD and ADHD
What SEs does Venlafaxine (Effexor) have?
Similar to SSRIs but in addition, can increase BP. Don't use in patients with HTN or labile BP.
Aside from depression, what else is Duloxetine (Cymbalta) used for?
Neuropathic pain and fibromyalgia
What are the SEs of Duloxetine (Cymbalta)?
Similar to SSRIs, more dry mouth and constipation. Also, more liver SEs (Careful for patients with liver disease or ETOH use).
What is Buproprion (Wellbutrin) used for?
Depression, smoking cessation and also shown some efficacy in ADHD.
What are the side effects of Buproprion (Wellbutrin)?
Increased risk of seizures and psychosis. Contraindicated in patients with seizures, active eating disorders and using MAOIs.
Whats the major benefit of using Buproprion, compared to SSRIs?
Lacks the sexual SEs of SSRIs.
Why would one use trazodone and nefazodone?
Useful in treatment of refractory major depression, major depression with anxiety, and insomnia (one SE includes somnolence)
Do trazodone/nefazodone have sexual SEs like SSRIs?
No, they don't and they don't affect sleep. However, priapism is seen.
What are the SEs of trazodone and nefazodone?
Both have nausea, orthostatic hypotension, cardiac arrhythmias and sedation. Trazodone is known for causing priapism. Nefazodone can cause rare but serious liver disease.
What type of patient should use Mirtazapine (Remeron)?
Used to treat refractory major depression, particulary in the elderly. Improves sleep and appetite, leading to weight gain.
Does Mirtazapine have sexual SEs?
No, and it does not have many drug interactions
What are the SEs of using Mirtazapine?
Mirtazapine is a NaSSA. SEs include sedation, weight gain, dizziness, can lead to agranulocytosis but rare
How often are TCAs dosed?
Long half-lives, generally once a day
Why are TCAs not considered first-line treatment?
More SEs and is lethal in overdose
Which types of TCAs are more sedating: tertiary amines or secondary amines?
Which TCAs are considered secondary amines?
Nortriptyline (Pamelor, Aventyl) and Desipramine (Norpramin)
Which TCAs are considered tertiary amines?
Amitriptyline (elavil), Imipramine (Tofranil), Clomipramine (Anafranil) and Doxepin (Sinequan)
How does one treat TCA overdose?
IV sodium carbonate
Aside from depression, what else is Amitriptyline used for?
Chronic pain, migraines, diabetic neuropathy and insomnia
Aside from depression, what else is Imipramine used for?
Enuresis and panic disorder
Aside from depression, what else is Clomipramine used for?
Aside from depression, what else is Doxepin used for?
Chronic pain and sleep aid
Which TCA is least likely to cause orthostatic HTN?
Which TCA is least sedating?
What are the major complications of TCAs? (hint: 3 Cs)
1. Cardiotoxicity (messes up QT intervals etc.)
Why do TCAs have lots of SEs?
They are highly protein bound and lipid soluble. So they can interact with many other medications.
Which TCA is linked most to seizures?
Do TCAs also cause sexual SEs, anticholinergic SEs, weight gain and sedation like SSRIs?
What medication can be used not only for depression but also smoking cessation?
What medication is used to treat narcolepsy?
What is first-line treatment for GAD vs. Social anxiety disorder?
SSRIs (ie escitalopram) or SNRIs for GAD vs. Beta blockers for social anxiety disorder
What MRI finding would one see in a schizophrenia patient?
Enlarged cerebral ventricles
What is the best treatment for Impulse Control Disorders (ie. kleptomania)?
What type of depression are MAOIs considered good for?
Atypical depression characterized by hypersomnia, increased appetite and increased sensitivity to interpersonal rejection.
Which MAOI does not need to be used with dietary restrictions? (ie. tyramine foods?)
Selegiline (EMSAM patch). Still need to be aware if used with decongestant opiates like Demerol and serotenergic drugs.
What MAOIs are commonly used?
Phenelzine, Isocarboxazid, Tranylcypromine
What are the major side effects to worry about with MAOIs? (2 major ones and a bunch of minor SEs)
1. Serotonin Syndrome (when taken with SSRIs) - lethargy, restlessness, confusion, flushing, diaphoresis, myoclonic jerks, can lead to coma and death.
2. Hypertensive crisis (with tyramine foods)
3. Orthostatic hypotension (most common minor one)
All SSRI SEs are also common.
Which SSRI in particular should be stopped with caution when considering MAOIs?
Fluoxetine - need 5-6 weeks before starting MAOIs. Other SSRIs should be stopped for 2 weeks before starting MAOIs.
What major side effect should one look out for with clozapine? And how should one monitor?
Agranulocytosis. WBC count should be monitored weekly for first 6 months then tapered.
What 3 levels should one check when prescribing lithium to a patient?
1. Lithium levels
2. Creatinine levels
3. Thyroid levels
What warning should one heed when using atypical antipsychotics in the elderly?
Increased risk of mortality and stroke
Which type of anti-psychotics (typical vs atypical) are better at treating negative symptoms of psychosis?
atypical; both are effective at treating positive symptoms
What are typical antipsychotics also referred as?
Neuroleptics; hence, neuroleptic malignant syndrome
What are the major low-potency, typical antipsychotics? (2)
Chlorpromazine (Thorazine) and Thioridazine (Mellaril)
What are the pros and cons of low potency, typical antipsychotics? (in terms of SEs)
1. Higher incidence of anticholinergic reaction compared to high potency
2. Lower incidence of EPS and NMS
3. More lethality in overdose due to QTc prolongation
4. Rare risk of agranulocytosis and seizure
5. Higher dose is required
What specific SEs are associated with chlorpromazine?
1. Orthostatic HTN
2. Cause bluish skin discoloration
Aside psychosis, what else can chlorpromazine treat? (2)
It is a typical antipsychotic.
1. Nausea / vomiting
2. Intractable hiccups
What specific SEs are associated with Thioridazine?
What are the midpotency, typical antipsychotics? (4)
1. Loxapine (Loxitane)
2. Thiothixene (Navane)
3. Trifluoperazine (Stelazine)
4. Perphenazine (Trilafon)
Which typical antipsychotic is at highest risk for seizure?
Which typical antipsychotic is associated with ocular pigment changes?
Thiothixene (also Thioridazine?)
What are the high-potency, typical antipsychotics? (3)
1. Haloperidol (Haldol)
2. Fluphenazine (Prolixin)
3. Pimozide (Orap)
What are the pros and cons of high potency, typical antipsychotics?
1. Low dose needed
2. Causes less sedation, orthostatic HTN, and anticholinergic effects
3. Greater risk for EPS and tardive dyskinesia
What organ system is affected by use of Pimozide?
Heart: heart block, ventricular tachycardia can occur
What forms do Haloperidol and Fluphenazine come in?
oral and IM (which is long-acting). Useful if patient does not want to take PO form.
Does clozapine cause tardive dyskinesia?
No, its the first atypical antipsychotic discovered.
What % chance does one have in getting tardive dyskinesia annually with typical antipsychotic use?
1% chance per year
What are the 5 major side effects that are experienced by all typical antipsychotics?
1. Extrapyramidal Symptoms
3. Anti-HAM effects (more common in low potency)
4. Tardive dyskinesia
5. Neuroleptic Malignant Syndrome
What the 3 major symptoms of EPS?
What are the symptoms of hyperprolactinemia?
Decreased libido, galactorrhea, gynecomastia, impotence, amenorrhea
What 3 medications can be used to treat EPS?
1. Benztropine (anticholinergic)
2. Diphenhydramine (antihistaminic)
3. Amantadine (antiparkinsonism)
What is the most common sign of tardive dyskinesia?
Writhing movements of the mouth and tongue
Is tardive dyskinesia reversible?
50% of cases will spontaneously remit, many are permanent
Which population does tardive dyskinesia occur most in?
What are the symptoms of Neuroleptic Malignant Syndrome? (hint: think acronym)
Fever (most common symptom)
Autonomic instability (tachycardia, labile HTN)
Rigidity (lead pipe)
What is the treatment for Neuroleptic Malignant Syndrome?
- Discontinue current medication
- Administrate supportive care (ie. hydration, cooling, etc.)
Which typical antipsychotics will cause ophthalmologic problems?
1. Thioridazine can cause irreversible retinal pigmentation
2. Chlorpromazine can lead to deposits in lens and cornea
Which typical antipsychotic will cause dermatologic problems?
Chlorpromazine can cause blue-gray skin discoloration
Which type of typical antipsychotic will more likely cause seizures?
Low-potency is more likely to cause vs. high potency
Which symptom of EPS is most likely to occur first?
Dystonia can occur in hours to days
Which atypical antipsychotic is the "big gun"?
Clozapine can cause 30% of refractory psychosis to respond
What are atypical antipsychotics used to treat, aside from psychosis?
Acute mania, bipolar disorder and sometimes used for personality disorders
What 2 clinical benefits are unique to clozapine?
1. Only antipsychotic to be more efficacious
2. Only antipsychotic to show decreased risk of suicide
When must clozapine be stopped?
Absolute neutrophil count is below 1500/ul
What 6 major SEs are associated with clozapine?
3. 1-2% risk of agranulocytosis
4. 2-5% risk of seizure
6. More anticholinergic SEs than other atypicals and high potency typicals
Why might haloperidol be considered a more appropriate medication than clozapine?
What are the 3 main SEs of using Risperidone (Risperdal)?
1. Increase in prolactin
2. Orthostatic HTN
3. Reflex tachycardia
What are the 2 SEs associated with Quetiapine (Seroquel)?
2. Orthostatic HTN
What is main SE associated with Olanzapine (Zyprexa)
What is the main SE of Ziprasidone (Geodon)
Long QT (less weight gain)
What is the main SE associated with Aripiprazole (Abilify)?
More akathisia (activating)
Why would one use Aripiprazole over other atypical antipsychotics?
Less weight gain (ie. olanzapine) and less sedating (ie. quetiapine)
What are the main 6 atypical antipsychotics?
Which type of antipsychotics will lead to diabetic ketoacidosis?
Atypicals; they can cause hyperglycemia and also DKA
Which mood stabilizer has been shown to decrease suicidality?
Which psychiatric medications should be tested with blood levels? (4)
2. Valproic Acid
What organ metabolizes Lithium?
How long does it take for Lithium to take effect?
What medication conditions is lithium used to treat? (2)
1. Acute mania
2. Prevent relapses in bipolar and schizoaffective disorder
Does lithium have a broad or narrow therapeutic index?
Narrow (big drawback). That's why levels need to be tested. Range is 0.6-1.2. If level is > 1.5, toxic.
What drug should Lithium not be used with and what happens if used together?
NSAIDS, use of NSAIDS will lower Li levels in the body
What happens in babies of mothers taking Lithium?
Ebstein's anomaly, a cardiac defect found in babies
Which medication can cause diabetes insipidus?
What happens to the thyroid on Li usage?
Enlarged thyroid and hypothyroidism
Toxic levels of lithium can lead to what 3 serious side effects?
1. Altered mental status
2. coarse tremors
What happens to WBCs with Li usage?
Increases, leads to leukocytosis (can be useful since this counteracts other meds like clozapine - agranulocytosis)
When is carbamazepine used? (3)
1. Mixed episodes of bipolar disorder
2. rapid-cycling bipolar disorder
3. Trigeminal neuralgia
What tests does one need to get (2) before starting carbamazepine?
What are the major SEs of carbamazepine (6)?
1. GI symptoms
2. CNS symptoms (drowsiness, ataxia, sedation)
3. Skin rash - STEVEN JOHNSONS Syndrome
5. Hepatitis and elevated liver enzymes (also metabolized by cytochrome P450)
6. Teratogenic effects (neural tube defects)
When is valproic acid used?
similar to carbamazepine: mixed and rapid cycling episodes of bipolar
What are the side effects of valproic acid?
Similar to carbamazepine
What is Lamotrigine (Lamictal) used for?
Good for bipolar depression, little efficacy on acute mania or prevention of mania
What are the 2 main things to worry about with Lamotrigine (Lamictal)?
1. STEVENS JOHNSONS Syndrome happens in 10% (occurs often in first 4-6 wks)
2. CNS symptoms like sedation, HAs, dizziness, ataxia
What happens if valproic acid and lamotrigine are used together?
Lamotrigine levels will go up and valproic acid levels will go down
Oxcarbazepine - what is it?
Its a better version of carbamazepine. Similar efficacy but less rash or hepatotoxicity.
What is gabapentin used for? (3)
Little efficacy in bipolar disorder
What is pregabalin used for? (2)
Little efficacy in bipolar disorder
What is Tiagabine (Gabitril) used for?
Helpful with anxiety
What is Topiramate (Topamax) used for? (2)
1. Helpful with impulse control disorders
What beneficial SE is associated with Topiramate?
What are the main SEs of Topiramate? (4)
Used to treat seizures and prevent migraines.
1. Weight loss (beneficial)
2. Non-anion gap metabolic acidosis
3. Kidney stones
4. Cognitive slowing
6 SEs to know about with valproic acid
1. Hepatotoxicity (AST elevations)
2. Teratogenic effects (neural tube defects)
3. Increased ammonia levels
What kind of benzos should be used in patients with ETOH or liver disease?
Benzos that are not metabolized by the liver. These include: lorazepam, oxazepam and temazepam.
What are the 2 longest acting benzos?
1. Diazepam (Valium)
2. Clonazepam (Klonopin)
Half life is > 20 hours
What happens if benzos are mixed with ETOH?
Respiratory depression that can lead to death
What is clonazepam used for?
Often used for panic attacks
What does one need to worry about when using clonazepam?
Renal dysfunction - avoid
Also can be teratogenic
What drug is used in a benzos overdose?
Which benzo is known for high abuse potential?
Which 2 benzos are known for treatment of alcohol detox?
lorazepam (Ativan) and oxazepam (Serax)
Which 2 benzos are considered short-acting and what are they used for?
1. Triazolam (Halcion) used for insomnia
2. Midazolam (Versed) used in med/surg settings
What are 3 commonly used non-benzos medications provided to treat insomnia?
zolpidem (Ambien), zaleplon (Sonata) and eszopiclone (Lunesta). Lunesta has the longest half-life, Sonata the shortest.
When is Buspirone (BuSpar) used?
IT is used often in combo with SSRI to treat anxiety. Main benefit: low potential for abuse/addiction and also can be used in alcoholics. Buproprion is used for smoking cessation.
What is Hydroxyzine (Atarax) used for?
Used for sedation; it is an antihistamine that can be used when benzos cannot
What medication is used to treat akathisia?
What medication is used to treat performance anxiety?
What two types of medications are used for ADHD?
1. Dextroamphetamine (Dexedrine, Adderall)
2. Methylphenidate (Ritalin, Concerta)
What are the 4 main SEs of dextroamphetamine?
3. Weight loss
4. Labile BP
What are the 7 main SEs of methylphenidate?
3. Increase in LFTs
1. weight loss
4. Labile BP
What is Atomoxetine (Strattera)?
Used in ADHD with less insomnia or appetite suppression. May cause increased SI in children.
Which 2 medications are commonly used to treat dementia?
1. Donepezil (Aricept)
2. Memantine (Namenda)
What psychiatric symptoms can procainamide and quinidine (antiarrhythmics) cause?
confusion and delirium
What psychiatric symptoms can albuterol cause?
anxiety and confusion
What psychiatric symptoms can isoniazid cause?
What psychiatric symptoms can tetracycline cause?
What psychiatric symptoms can nifedipine and verapamil cause?
What psychiatric symptoms can cimetidine (antihistamine) cause?
What syndrome looks like Neuroleptic Malignant Syndrome?
Malignant Catatonia: associated with schizophrenia, severe depression, bipolar, ptsd etc.
Symptoms: waxing etc.
Treated with benzos (ECT sometimes used)
What is the treatment for malignant catatonia?
Benzos are first line and then ECT
Which SSRI is most effective for GAD?
Which drug is used to treat social phobia?
What is the difference in symptom between amphetamine OD vs. cocaine OD?
Psychosis can occur with amphetamine OD
What must be monitored in cocaine OD and how is it treated?
Myocardial infarction, treat with benzos
What is a tip-off for opiate withdrawal?
Diarrhea and other GI symptoms
With substance abuse, what does one always need to look out for?
Diagnosis: Teenager with ataxia and nystagmus presents to ED
What are the symptoms of PCP overdose?
Patient will be super strong, agitated, combative, sometimes violent
What are the symptoms of Wernicke's encephalopathy?
Ataxia, nystagmus, confusion (non-memory related)
Where does Wernicke's encephalopathy affect in the brain and how is it treated?
Mammary bodies, treat with high dose thiamine (usually symptoms are irreversible)
Which is the longest acting and shortest acting SSRIs?
Longest is fluoxetine, shortest is paroxetine
With citalopram, what is the one SE to monitor for?
Which is the most common side effect with SSRIs?
GI symptoms, not sexual SEs
How long is needed to diagnose persistent depressive disorder?
2 years of depressed mood
What 2 timeframes are important for adjustment disorder diagnosis?
Stressor must have occurred within 3 months of mood change, symptoms must resolve within 6 months after stressor ends
What time frame is acute stress disorder relevant?
Last 3 days to a month; very similar to PTSD. Must have serious stressor event at outset.
What factor separates anorexia nervosa and bulimia nervosa?
BMI < 16 kg/m2 for anorexia; potentially also amenorrhea
When is IM Haloperidol used?
Not first-line, used for compliance reasons (long-acting)
What is the difference between somatic symptom disorder and illness anxiety disorder?
Somatic symptom disorder involves excessive anxiety and preoccupation with a single unexplained symptom (ie. getting scoped multiple times without findings bc dad died of colon cancer)
Illness anxiety disorder involves excessive anxiety with NO symptoms
What is the difference between somatic disorder and factitious disorder?
Factitious disorder involves intentionally faking symptoms to achieve sick role
Psychosis between 1 day and 1 month
Brief psychotic disorder
Psychosis between 1 month and 6 months
Psychosis longer than 6 months
Delusions longer than 1 month without psychosis
What is the maintenance therapy for bipolar disorder?
1. Mood stabilizer (Li/lamotrigine/valproate)
2. Atypical + mood stabilizer
For mild to moderate patients, atypical antipsychotic monotherapy can be used.
Generic name for Geodon
Generic name for Latuda
What does Akathisia look like?
Unable to sit still, repeatedly crossing and re-crossing one's legs
Can happen with any anti-psychotic. Treat with beta blockers.
How does one treat akathisia?
Unable to sit still, repeatedly crossing and re-crossing one's legs
Can happen with any anti-psychotic. Treatment with beta blockers.
Which atypical anti-psychotic is most likely to cause EPS?
How long after response should someone with MDD be treated?
6 more months
What symptoms does someone with histrionic personality disorder have?
Excessively labile emotions, attention-seeking behavior
What do anti-social disorder patient's most likely have as kids?
How long should a patient with 2+ manic episodes be treated?
years of treatment, ie. with Li
Time frame for PTSD diagnosis
Symptoms over one month
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