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NU664C Study Guide for Midterm Exam
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Know the route of administration for newer agent asenapine (Saphris) and what instructions should be given to the patient regarding administration. Route- Sublingual Not to eat or drink for 10 minutes after medication administration Not to swallow or chew the capsule. Asenapine is an atypical antipsychotic (serotonin-dopamine antagonist, as a mood stabilizer). Asenapine is not absorbed after swallowing (less than 2% bioavailable orally) and thus must be administered sublingually (35% bioavailable), as swallowing would render asenapine inactive. Patients should be instructed to place the tablet under the tongue and allow it to dissolve completely, which will occur in seconds; tablet should not be divided, crushed, chewed, or swallowed. Patients may not eat or drink for 10 minutes following sublingual administration so that the drug in the oral cavity can be absorbed locally and not washed into the stomach (where it would not be absorbed). Due to rapid onset of action, can be used as a rapid acting "prn" or "as needed" dose for agitation or transient worsening of psychosis or mania instead of an injection. Treatment should be suspended if absolute neutrophil count falls below 1,000/mm3. Know and describe the top atypical antipsychotic with greatest incidence of prolonged QTc interval. Ziprasidone (Geodon). Normal QTc =450.
470, Call Cardiologist 500, stop all meds. Ziprasidone (Geodon) has been associated with a dose-related prolongation of the QTc QTc interval prolongation is greatest with ziprasidone and least with olanzapine. Ziprasidone (Geodon) an atypical antipsychotic (serotonin-dopamine antagonist; second-generation antipsychotic; also a mood stabilizer. Ziprasidone is prescribed for Schizophrenia, delaying relapse in schizophrenia, acute agitation in schizophrenia (intramuscular), acute mania/mixed mania, bipolar maintenance, other psychotic d/o,
bipolar depression, behavioral disturbances in dementias, behavioral disturbances in children and adolescents, and disorders associated with problems with impulse control. Ziprasidone blocks dopamine 2 receptors, reducing positive symptoms of psychosis and stabilizing affective symptoms. Blocks serotonin 2A receptors, causing enhancement of dopamine release in certain brain regions and thus reducing motor side effects and possible improving cognitive and affective symptoms. EKGs may be useful for selected patients (e.g., those with personal or family history of QTc prolongation; cardiac arrhythmia; recent myocardial infarction; uncompensated heart failure; or those taking agents that prolong QTc interval (such as pimozide, thioridazine, selected antiarrhythmics, moxifloxacin, sparfloxacin, etc.) Ziprasidone prolongs QTc interval more than some other antipsychotics. Ziprasidone is associated with rare but serious skin condition known as Drug Reaction with Eosinophilia (DRESS). DRESS may begin as a rash but can progress to other parts of the body and can include symptoms such as fever, swollen lymph nodes, swollen face, inflammation of organs, and an increase in white blood cells known as eosinophilia. In some cases, DRESS can lead to death. Clinicians prescribing ziprasidone should inform patients about the risk of DRESS; patients who develop a fever with rash and swollen lymph nodes or swollen face should seek medical care. Pt are not advised to stop their medication without consulting their prescribing clinician. Use with caution in patients with conditions that predispose to hypotension (dehydration, overheating). Priapism has been reported. Dysphagia has been associated with antipsychotic use, and ziprasidone should be used cautiously in patients at risk for aspiration pneumonia. Do Not Use: If pt is taking agents capable of significantly prolonging QTc interval (such as pimozide, thioridazine, selected antiarrhythmics, moxifloxacin, sparfloxacin, etc.) If there is a history of QTc prolongation or cardiac arrhythmia, recent acute myocardial infarction, uncompensated heart failure. Know which antipsychotics have specific instructions for minimum food intake or diet restrictions. Geodon because food affects the absorption of the drug. Lurasidone - Latuda Know an alternative atypical antipsychotic for a patient who has developed diabetes and has a significant weight gain from treatment with olanzapine.
Know the role of buspirone in the treatment of anxiety and the recommended dose and time for onset of action. Management of anxiety; Binds to serotonin and dopamine receptors in the brain. Increases norepinephrine metabolism in the brain. Recommended dose 5 mg 3 times daily; Usual dose 20-30 mg/day. Know what medication may be an option for patients noncompliant on antipsychotics resulting in multiple hospital stays Fluphenazine and haloperidol have been formulated as long-acting injectables (LAI)s. Long-acting forms of risperidone, paliperidone, aripiprazole, and olanzapine are also available. Know baseline labs and vital measurements tests for the patient who will be prescribed an antipsychotic such as quetiepine (Seroquel). A1C, Lipids, CBC, CMP, LFT Weight, HR, B/P = monitoring for metabolic syndrome Describe common side effects/disadvantages of antihistamines. ·Antihistamines are commonly associated with sedation, dizziness, and hypotension, all of which can experience the anticholinergic effects of those drugs. Other common adverse effects include epigastric distress, nausea, vomiting, diarrhea, and constipation. Because of mild anticholinergic activity, some people experience dry mouth, urinary retention, blurred vision, and constipation. For this reason, antihistamines should be used only as very low doses. Identify 3-4 disorders/situations when benzodiazepines may be indicated. · Acute Alcohol withdrawal · Acute Benzo withdrawal · Acute Agitation associated with substance use · Acute Panic Attack
Describe 2-3 common side effects of atypical antipsychotics. · Weight gain · Sedation · Metabolic Syndrome · EPS (unlikely to cause? QTc Prolongation) Know and describe the name of long-acting olanzapine and a key adverse side effect. Zyprexa Relprevv · Post-injection Delirium Sedation Syndrome (PDSS) Excessive Sedation Patients need to be monitored after getting the injection. Know and describe screening tools for depression, anxiety, schizophrenia, and mania symptoms.
Depression - Becks Depression Inventory: minimal range = 0-9, mild depression = 10-16, moderate depression = 17-29, and severe depression = 30-63. PHQ9: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe Anxiety - GAD7: 0-5 mild 6-10 moderate 11-15 moderately severe anxiety. 15-21 severe anxiety. Hamilton Anxiety Rating Scale: <17 indicates mild severity, 18-24 mild to moderate severity and 25- 30 moderate to severe. Schizophrenia - Positive & Negative Symptoms Scale (PANSS); Scale for the Assessment of Positive Symptoms (SAPS); Scale for the Assessment of Negative Symptoms (SANS); NSA-16; CGI-SCH). Mood Disorder/Mania - Young Mania Rating Scale (YMRS), Bech Rafaelsen Mania Rating Scale (MRS).
· Occurs/Onset within 24 hours · Typically caused by use of 2 or more serotonergic drugs, SSRI, MAOI, TCA, Amphetamines · Labs: None · Resolution of Serotonin Syndrome <24 hours · Treatment: Supportive Care, increase Oxygen to >94% sat, I.V. crystalloid to treat volume depletion; Use benzos to sedate; Need ICU care. What population across the lifespan are most at risk for suicide? How does your health, gender, and genetics play a role in being at a higher risk for suicide? · Most risk 15-24 and >65 (age) · Most risk Young, elderly, Caucasian males · Depression · *Serious physical illness · Schizophrenia 5% of suicides; other mental disorders increase risk 5-10%. What are some factors that may increase the risk for suicide? Protective factors? · Gender differences. - Men commit suicide more than four times as often as women. · Age. - Most suicides now are among those aged 35 to 64. Among men suicides peak after age 45; with women suicides occurs after age 55. · Race. - Suicide rates among white men and women are approximately two to three times as high as Black men and women across the life cycle. · Religion. - Protestants and Jews in the U. S. have had higher suicide rates than Catholics. · Marital Status. - Divorce increase suicide risk, with divorced men three times more likely to kill themselves as divorced women. Widows and widowers also have high rates. Homosexual men and women appear to have higher rates of suicides than heterosexuals. · Occupation. - The higher the person's social status, the greater the risk of suicide, but a drop in social status also increase the risk. Occupational rankings, professionals, particularly physicians, have traditionally been considered to be at greatest risk. WORK, IN GENERAL PROTECTS AGAINST SUICIDE. · Climate. - No significant seasonal correlation with suicide has been found.
· Physical Health. - About one third of all persons who commit suicide have had medical attention within 6 months of death, and a physical illness is estimated to be an important contributing factor in about half of all suicides. Certain drugs can produce depression, which may lead to suicide in some cases. Among these drugs are reserpine (Serpasil), corticosteroids, antihypertensives, and some anticancer agents. Etoh-related illnesses, such as cirrhosis, are associated with higher suicide rates. · Mental Illness. - Almost 95% of all persons who commit, or attempt suicide have a diagnosed mental disorder. Depressive d/o accounts for 80%, schizophrenia accounts for 10%, and dementia or delirium for 5%. · Protective Factors. - Not all suicides are preventable; some may be inevitable. About 1/3 of all completed suicides occur in persons who are receiving treatment for a psychiatric d/o, most commonly depression, bipolar d/o, or schizophrenia. To consider suicide inevitable the patient must have received the highest standard of treatment and the treatment must have failed. Inevitability assumes, among many other factors, that everything that could have been done was done - and done correctly - yet the patient died. What group/population has the shortest life span? Black males Know which organ systems need to be evaluated prior to and at scheduled intervals when prescribing lithium or Depakote (valproate acid).
Lithium · Before initiating Lithium treatment, kidney function tests (including creatinine and urine specific gravity) and thyroid function tests; ecg for patients over 50 · Repeat kidney function tests 1 - 2 times per year. · Frequent test to monitor trough lithium plasma levels (about 12 hours after last dose; should generally be between 1.0 and 1.5 mEq/L for acute treatment, 0.6 and 1.2 mEq/L for chronic treatment). · Initial monitoring: every 1-2 weeks until desired serum concentration is achieved, then every 2- 3 months for the first 6 months. · Stable monitoring: every 6-12 months. · One-off monitoring after dose change, other medication change, illness change (not before 1 week). · Since lithium is frequently associated with weight gain, before starting treatment, weigh all pts and determine if the pt. is already overweight (BMI 25.0-29.9) or obese (BMI >30).
- Quetiapine, Seroquel
- Lurasidone, Latuda
- Olanzepine(Zyprexa) + Fluoxetine(Prozac a SSRI) (Symbyax)
Insomnia Sleep hygiene Benzos (see GAD, CIV risk factors) TCAs
- Doxepin>sleep maintenance OTC Antihistamine
- Benadryl (not in elderly= increases s/s Alzheimer's) Non-Benzo/sedative/Z-hypnotics (CIV risk factors)
- Ambien, Zolpidem>onset, CR only help with maintenance
- Sonata, Zaleplon
- Lunesta, Eszopiclone> onset, maintenance and chronic
- Belsomra, Suroxevant>onset and maintenance Melatonin receptor Agonist
- Rozerem, Ramelteon>onset, chronic therapy OTC Supplement
- Melatonin
ADHD Stimulants (first-line, CII, if one doesn't work switch to another stimulant)
- Amphetamines, Adderall>BBW sudden death, CV events
- Methylphenidate, Ritalin Alpha 2 Adrenergic Agonists (2nd line)-use if tic present, with optional other agents (Wellbutrin), taper off
- Clonidine, Kaprax
- Guanfacine, Intuniv Antidepressants (2nd line therapy)
- Atomoxetine (Strattera SNRI))-use if substance abuse-BBW suicidality
Generalized Anxiety Disorder CBT Antidepressants (1st line- treat the root of the problem) Benzodiazepines (for acute management, has hypnotic, muscle relaxant, amnesia, anticonvulsant features. Taper off: can take 1 year)
- Short Acting- Tranxene, Triazolam, Prazepam
- Intermediate Acting-Xanax, Restoril(elderly), Ativan (best in Elderly), Oxazepam, Librium
- Long Acting- Diazepam (not elderly), Clonazepam Non-Benzo/GABA Agonist
- Buspar, Buspirone Alternative to Benzos
- Lyrica, pregabalin
- Neurontin, gabapentin
Social Anxiety Disorder (SAD) CBT-1st line therapy Antidepressants (SSRI and SNRI(Cymbalta)) are 1st line Lyrica/Neurontin-1st or second line Benzos- adjunct 2nd line
- Clonazepam B-Blocker-2nd line- for performance anxiety MAOI-2nd line
Panic Disorder (PD) SSRI/SNRI- 1st line (start low)
- SSRI- Escitalopram, Fluoxetine (Prozac), Paroxetine (Paxil),
- Sertraline (Zoloft). NOT Fluvoxamine (Luvox)
- SNRI- NOT Effexor (Cymbalta) Mirtazapine, TCAs, Trazadone and MAOIs-2nd line
- TCAs (preventative measure for PD, 25% have hyper stimulatory (worsening) symptoms>start low)
- Amitriptyline, Doxepin
· In opioid-dependent pts, too much naloxone may produce signs of withdrawal as well as reversal of administration may be repeated after intervals of a few minutes. · It was thought that if no response was observed after 4 to 5 mg, the CNS depression was probably not caused solely by opioids. Know the most common medications used to treat Alzheimer's Disease and the method of administration. · Donepezil is well tolerated and widely used. · Memantine (Namenda) protects neurons from excessive amounts of glutamate, which mat be neurotoxic. The drug is sometimes combined with Donepezil. It has been known to improve dementia. · In general, drugs with high anticholinergic activity should be avoided. · Donepezil (Aricept), rivastigmine (Exelon), galantamine (Remiryl), and tacrine (Cognex) are cholinesterase inhibitors used to treat mild to moderate cognitive impairment in Alzheimer's disease. Know and describe cognitive therapy strategies and how these are used to treat anxiety. · Three major schools of psychological theory - psychoanalytic, behavioral, and existential - have contributed theories about the causes of anxiety. · Psychoanalytic - To understand fully a particular patient's anxiety from a psychodynamic view, it is often useful to relate the anxiety to developmental issues. Some anxiety is obviously related to multiple conflicts at various developmental levels. · Behavioral - The behavioral or learning theories of anxiety postulate that anxiety is a conditioned response to a specific environmental stimulus. In the social learning model, a child may develop an anxiety response by imitating the anxiety in the environment, such as in anxious parents. · Existential - Existential theories of anxiety provide models for generalized anxiety, in which no specifically identifiable stimulus exists for a chronically anxious feeling. Anxiety is their response to the perceived void in existence and meaning. Describe 2-3 common side effects of typical (first-generation) Antipsychotics. · Antipsychotics can be categorized into two main groups: the older conventional antipsychotics, which have also been call first-generation antipsychotics or dopamine receptor antagonists, and the newer
drugs, which have been called second-generation antipsychotics or serotonin dopamine antagonists (SDAs). · Clinicians have a number of alternatives for treating extra-pyramidal side effects. These include reducing the dose of the antipsychotic (which is most commonly a DRA), adding an anti-Parkinson medication, and changing the patient to an SDA that is less likely to cause extrapyramidal side effects. · First-generation antipsychotics have a high rate of extrapyramidal side effects, including rigidity, bradykinesia, dystonias, tremor, and akathisia. Tardive dyskinesia (TD)—that is, involuntary movements in the face and extremities—is another adverse effect that can occur with first-generation antipsychotics. · The risk in elderly pts. Is much higher. Although seriously disabling dyskinesia is uncommon, it can affect walking, breathing, eating, and talking when it occurs. Individuals who are more sensitive to acute extrapyramidal side effects appear to be more vulnerable to developing tardive dyskinesia. · Sedation and postural hypotension can be important side effects for patients who are being treated with low-potency DRAs, such as perphenazine. · All DRAs, as well as SDAs, elevate prolactin levels, which can result in galactorrhea and irregular menses.
