USMLE: Psychiatry Pharmacology II
Terms in this set (75)
CNS stimulants: NAME 3
Methylphenidate, dextroamphetamine, methamphetamine.
CNS stimulants: Methylphenidate, dextroamphetamine, methamphetamine MECHANISM
catecholamines in the synaptic cleft, especially norepinephrine and dopamine.
CNS stimulants: Methylphenidate, dextroamphetamine, methamphetamine CLINICAL USE (3)
ADHD, narcolepsy, appetite control.
Haloperidol, trifluoperazine, fluphenazine, thioridazine, chlorpromazine (haloperidol + "-azines"). ARE EXAMPLES OF
Typical Antipsychotics (neuroleptics)
typical Antipsychotics (neuroleptics): mechanism
All typical antipsychotics block dopamine D2 receptors (increase [cAMP]).
typical Antipsychotics (neuroleptics): clinical use (4)
Schizophrenia (primarily positive symptoms), psychosis, acute mania, Tourette syndrome.
typical Antipsychotics (neuroleptics): toxicity (5)
Highly lipid soluble and stored in body fat; thus, very slow to be removed from body.
Extrapyramidal system side effects (e.g., dyskinesias:involuntary muscle movement).
Endocrine side effects (e.g., dopamine receptor antagonism--> hyperprolactinemia--> galactorrhea).
Side effects arising from blocking muscarinic (dry mouth, constipation), α1 (hypotension), and histamine (sedation) receptors.
Can cause QT prolongation
Antipsychotics (neuroleptics): name high potency typical antipsychotics (3)
High potency: Trifluoperazine, Fluphenazine, Haloperidol (Try to Fly High)—neurologic side effects (e.g., Huntington disease, delirium, EPS symptoms)
Antipsychotics (neuroleptics): name low potency typical antipsychotics (2)
Chlorpromazine, Thioridazine (Cheating Thieves are low)—non-neurologic side effects (anticholinergic, antihistamine, and α1-blockade effects).
typical Antipsychotics (neuroleptics): Corneal deposits
Antipsychotics (neuroleptics): retinal deposits
Antipsychotics (neuroleptics): Neuroleptic malignant syndrome (NMS), tardive dyskinesia (1)
Antipsychotics (neuroleptics): Extrapyramidal system side effects (e.g., dyskinesias) Treatment (2)
benztropine or diphenhydramine.
typical Antipsychotics (neuroleptics): other toxicities; give symptoms of neuroleptic malignant syndrome (5)
Neuroleptic malignant syndrome (NMS)— hyperpyrexia, autonomic instability, myoglobinuria, ,rigidity.
For NMS, think FEVER: Fever, Encephalopathy, Vitals unstable, increase Enzymes, Rigidity of muscles
Antipsychotics (neuroleptics): other toxicities; give treatment of neuroleptic malignant syndrome (2)
dantrolene, D2 agonists (e.g., bromocriptine)
Antipsychotics (neuroleptics): other toxicities; give symptoms of Tardive dyskinesia
stereotypic oral facial movements as a result of long-term antipsychotic use
Evolution of EPS side effects:
4 hr acute dystonia (muscle spasm, stiffness, oculogyric crisis ( fixation of the eyeballs in one position))
4 day akathisia (restlessness)
4 wk bradykinesia (parkinsonism)
4 mo tardive dyskinesia
atypical antipsychotics (6)
aripiprazole, Olanzapine, clozapine, quetiapine, risperidone, ziprasidone
atypical antipsychotics: mechanism
Not completely understood. Varied effects on 5-HT2, dopamine, and α- and H1-receptors.
atypical antipsychotics: clinical use (7)
Schizophrenia—both positive AND NEGATIVE symptoms, bipolar disorder, OCD, anxiety disorder, depression, mania, Tourette syndrome
atypical antipsychotics: common toxicity and advantage over typicals
Fewer extrapyramidal and anticholinergic side effects than traditional antipsychotics. All may prolong QT interval.
atypical antipsychotics: toxicity: cause significant weight gain. (2)
Olanzapine and clozapine
atypical antipsychotics: toxicity: agranulocytosis + seizures
Clozapine (requires weekly WBC monitoring)
atypical antipsychotics: toxicity: increase prolactin (causing lactation and gynecomastia)--> decrease GnRH, LH, and FSH (causing irregular menstruation and fertility issues)
Fluoxetine, paroxetine, sertraline, citalopram
SSRIs : mechanism
5-HT-specific reuptake inhibitors.
SSRIs : clinical use (7)
Depression, generalized anxiety disorder, panic disorder, OCD, bulimia, social phobias, PTSD.
SSRIs : toxicity (4)
GI distress, SIADH, sexual dysfunction (anorgasmia, decrease libido).
Serotonin syndrome with any drug that increase 5-HT (e.g., MAO inhibitors, SNRIs, TCAs)
Fewer than TCAs.
SSRIs : onset: It normally takes ........for antidepressants to have an effect
SSRIs : toxicity: treatment of serotonin syndrome
cyproheptadine (5-HT2 receptor antagonist).
SSRIs : toxicity: Serotonin syndrome symptoms (7)
diarrhea, flushing, hyperthermia, confusion, myoclonus, seizures, cardiovascular instability,
5-HT and NE reuptake inhibitors.
SNRIs: clinical use (common+unique)
Venlafaxine: generalized anxiety disorder, panic disorder, PTSD.
Duloxetine: diabetic peripheral neuropathy
SNRIs: toxicity (4)
increase BP (most common); stimulant effects, sedation, nausea
Tricyclic antidepressants (7)
Amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, doxepin, amoxapine.
Tricyclic antidepressants: clinical use (5)
Major depression, OCD (clomipramine), peripheral neuropathy, chronic pain, migraine prophylaxis.
Tricyclic antidepressants: toxicity (6)
1) Tri-C's: Convulsions, Coma, Cardiotoxicity (arrhythmias; can prolong QT interval.)
2) α1-blocking effects: postural hypotension
3) atropine-like (anticholinergic) side effects: tachycardia, urinary retention, dry mouth. Confusion and hallucinations in elderly due to anticholinergic side effects (use nortriptyline).
4)Hyperpyrexia (high fever)
6) Respiratory depression
Tricyclic antidepressants: toxicity: 3° TCAs (amitriptyline) have more................... than 2° TCAs (nortriptyline).
Tri-C's of TCAs
Convulsions, Coma, Cardiotoxicity
Tricyclic antidepressants: toxicity: Confusion and hallucinations in elderly due to anticholinergic side effects: use
Tricyclic antidepressants: toxicity: Treatment
NaHCO3 to prevent arrhythmia
Monoamine oxidase (MAO) inhibitors (4)
Tranylcypromine, Phenelzine, Isocarboxazid, Selegiline (selective MAO-B inhibitor).
Monoamine oxidase (MAO) inhibitors : mechanism
Nonselective MAO inhibition increase levels of amine neurotransmitters (norepinephrine, 5-HT, dopamine)
Monoamine oxidase (MAO) inhibitors : clinical use (2)
Atypical depression, anxiety.
Monoamine oxidase (MAO) inhibitors: toxicity (2)
Hypertensive crisis (most notably with ingestion of tyramine, which is found in many foods such as wine and cheese); CNS stimulation.
Monoamine oxidase (MAO) inhibitors: toxicity: contraindications (5)
Contraindicated with SSRIs, TCAs, St. John's wort, meperidine, dextromethorphan (to prevent serotonin syndrome)
Treatment: stimulants (e.g., methylphenidate) +/- cognitive behavioral therapy (CBT); atomoxetine may be an alternative to stimulants in selected patients.
Tourette syndrome: treatment
Treatment: psychoeducation, behavioral therapy. For intractable tics, low-dose high-potency antipsychotics (e.g., fluphenazine, pimozide), tetrabenazine, and clonidine may be used.
bipolar disorder: treatment
mood stabilizers (e.g., lithium, valproic acid, carbamazepine), atypical antipsychotics.
atypical depression: treatment
Treatment: CBT and SSRIs are first line. MAO inhibitors are effective but not first line because of their risk profile.
postpartum depression: treatment
postpartum psychosis: treatment
Treatment: hospitalization and initiation of atypical antipsychotic; if insufficient, ECT may be used.
anxiety disorder: treatment
Treatment: CBT, SSRIs, SNRIs.
social anxiety disorder: treatment
Treatment: CBT, SSRIs
Treatment: CBT, SSRIs, MAO inhibitors.
generalized anxiety: treatment
Treatment: CBT, SSRIs, SNRIs are first line. Buspirone, TCAs, benzodiazepines are second line.
adjustment disorder: treatment
CBT, SSRIs, and clomipramine are first line.
body dismorphic disorder: treatment
acute stress disorder: treatment
CBT; pharmacotherapy is usually not indicated.
CBT, SSRIs, and venlafaxine are first line.
borderline personality disorder: treatment
Treatment: dialectical behavior therapy
psychotherapy and nutritional rehabilitation are first line. Refeeding syndrome (hypophosphatemia) can occur in significantly malnourished patients.
night terror treatment
daytime stimulants (e.g., amphetamines, modafinil(1st line)) and nighttime sodium oxybate (GHB).
Treatment: atypical antipsychotics (e.g., risperidone) are first line.
sodium oxybate: mechanism
Treats loss of muscle control (cataplexy) and excessive daytime sleepiness caused by narcolepsy.
first line treatment of benign essential tremor
primidone (note: propanolol is a alternative first line agent )
metabolities of primidone
central nervous system depression
elevated phenobarbital levels
primidone: clinical use
benign essential tremor
partial seizures with or without secondary generalization
TCA inhibit ..............channels resulting in arrhythmias (most common cause of death due to overdose) + hypotension from alpha antagonism
baclofen is a secnd line treatment for
3 MAO inhibitors