antidepressants
tricyclics, MAIOs, SSRIs, SNRIs, and novel antidepressants
Tertiary Tricyclics
serotonin receptors
meds: Imipramine, amitriptyline, doxepin, clomipramine
Secondary Tricyclics
block norepinephrine
meds: Desipramine, notrtriptyline
same SE as tertiary but less severe
MAOIs
-Bind irreversibly MAO to prevent inactivation of nor epi, dopamine, and serotonin (increases levels)
-Wait 2 wks before switching SSRI to MAOI (exp fluoxetine)
SE: weight gain, sexual dysfunction
HTN crisis: taken with tyramine rich foods (aged foods) or
SSRI
-blocks presynaptic serotonin reuptake
Treats anxiety and depression sx
-SE: GI upset, sexual dysfunction (30%+), anxiety, restlessness, nervousness, insomnia, fatigue, sedation, dizziness
-Little risk for cardiotoxicity
-Discontinuation syndrome (withdra
Paroxetine (Paxil)
-SSRI -> major depression, OCD, panic d/o, PTSD, general anxiety
-Pro: short 1/2 life ? no active metabolite ? no buildup, sedating, relief of anxiety/insomnia, low cardiotoxicity
-Con: sedating, wt gain, discontinuation syndrome (short), cannot be given
Sertraline (Zoloft)
-SSRI -> major depression, OCD, PMDD, PTSD
-Pro: short half life ? lower buildup of metabolites, less sedating
-Con: max absorption with FULL stomach, many GI SE, cannot be given w/in 2 weeks of MAOI
-SE: serotonin syndrome, hallucinations, agitation, com
Fluoxetine (Prozac)
-SSRI, most common -> depression, OCD, bulemia, PMDD
-Pro: long half life ? decrease in discontinuation syndrome ? good for noncompliance, increase energy
-Con: very long half life/ active metabolite ? can cause buildup (not good for hepatic probs and tap
Citalopram (Celexa)
-new gold standard
-Pro: intermediate � life
-Con: dose dependent QT interval prolongation of 10-30mg/ day ? doses > 40 mg/day not rec, GI SE, mildly sedating, cannot be given w/in 2 weeks of MAOI, can increase depression into mania
Escitalopram (Lexapro)
-SSRI, raw product on citalopram -> depression
-Pro: intermediate � life, more effective than citalopram in acute response/remission
-Con: dose dependent QT interval prolongation with doses of 10-30 mg/day, N, HA, ETOH, cautious with ez pt, cannot take th
Fluvoxamine (Luvox)
-SSRI -> OCD, social anxiety
-Pro: shortest � life, tiny, some analgesic properties
-Con: shortest � life (hard to be compliant), GI distress, HA, sedation, weakness, serotonin syndrome, chills, sweaty, fever, suicidal thoughts
SNRI
-Inhibit both serotonin and noradrenergic reuptake (like TCA) but without antihistamine, antiadrenergic, or anticholinergic SE
-Eliminates bad SE (EPS)
-Used for depression, anxiety, and neuropathic pain
Venlafaxine (Effexor)
-SNRI -> anxiety and depression
-Pro: short half life and fast renal clearance, avoids build up
-Con: can cause 10-15 mmHG dose dependent increase in diastolic BP, N with IR (take with food), bad discontinuation syndrome (taper), QT prolongation, sexual S
Desvenlafaxine (Pristiq)
-SNRI (same as effexor)
-Pro: little drug interactions, short � life and fast renal clearance, avoids buildup
-Con: GI distress (take with food), dose related increase in chol/LDL /trigly / BP
Duloxetine (Cymbalta)
-SNRI -> neuropathic pain, fibromyalgia
-Pro: good for physical s/s of depression, less increase in BP (compared to venlafaxine), less SE
-Con: don't break capsule or its ineffective, don't take with hepatic insuff or uncontrolled glaucoma, serotonin synd
Bupropion (Wellbutrin)*
-novel antidepressant
-Pro:good for augmenting, MOA likely reuptake inhibition of dopamine and norepi, no wt gain/ sexual SE/ sedation/ cardiac probs, also used for ADHD
-Con: increase sz risk in high dose (450 mg+) ? avoid in TBI/bulimia/ anorexia pt, do
Mood stabilizers
lithium, anticonvulsants, antipsychotics
lithium -> bipolar, antidepressant, antimanic
-Effective in LT prophylaxis of mania and depressive episodes
-Before therapy: check baseline CR, TSH, and CBC; pregnancy test
-Don't use wellbutrin, not for pregnancy
-Goal: therapeutic blood level between 0.6-1.2
-SE: common (GI distress ? Reduced appet
Valproic acid (Depakote)
-Anticonvulsant
-effective as lithium in mania but not good for depression
-Before: baseline LFT, pregnancy test, CBC, folic acid supplement (women) and preg test, give with food
-Goal: target level is 50-125
-SE: transaminitis (abnormal LFT), thrombocyto
Carbamazepine (Tegretol)
-anticonvulsants
-1st line for mania /mania prophylaxis
-Before: baseline LFT, CBC, and EKG, take with food
-Goal: target levels 4-12 mcg/mL -> steady state in 5 days and CBC 12 hrs after last dose
-SE: Rash (most common), transaminitis, ataxia, confusion
Lamotrigine (Lamictal)
-Anticonvulsant, neuropathic pain, bipolar maintenance
-compliance hard
-Indications: similar to anticonvulsants, or neuropathic pain
-Before: baseline LFT, pregnancy test
-Initiation/titration: 25 mg/day X 2 weeks ? increase to 50 mg X 2 weeks ? then inc
Antipsychotics
-typical or atypical
-Mesocortical: where negative s/s and cognitive disorders (lack executive function) arise. Too little dopamine (take away)
-Mesolimbic: where positive s/s come from (hallucinations, delusions, and thought disorders). Too much dopamine
Typical Antipsychotics
-D2 dopamine receptor antagonists ? high potency ? bind ? high affinity ? higher risk for EPS SE
(Fluphenazine, Haloperidol, Pimozide)
-Low potency ? less affinity to D2 ? interact with non dopaminergic receptors ? cardiotoxic and anticholinergic AE (seda
atypical antipsychotics
called this bc the way they affect dopamine/serotonin neurotransmission in the four key dopamine pathways in the brain
Risperidone (Risperdal): tab, IM, rapidly dissolving tablet, depo?
-atypical -> bipolar, autism, psychotic disorder
-Like typical when given > 6 mg, increased EPS (dose dependent), most likely to induce hyperprolactinemia, weight gain and sedation (gain lots, v sedating)
Olanzapine (Zyprexa): tabs, IR IM, rapid dissolving tab, depo form (1 month)
-atypical
-long half life, not good for acute isse
-Weight gain (can be 30-50 lbs), hypertriglyceridemia, hypercholesterolemia, hyperglycemia , hyperprolactinemia (<), transaminitis (<)
Quetiapine (Seroquel): tab
-antipsychotic -> schizophrenia
-Can cause transaminitis (<), weight gain, hypertriglyceridemia, hypercholesterolemia, hyperglycemia, mostly likely to cause orthostatic hypotension, take with food
Ziprasidone (Geodon): tab, IM IR
-2nd gen antipsychotic -> schizo, bipolar
-QT prolongation, hyperprolactinemia (<), NOT associated with weight gain, absorption increased with food, no thorazine
Aripiprazole (Abilify): tab, IR IM, and depo
-atypical -> schizo, bipolar, autistic
-Low EPS, no QT prolongation, low sedation, increase sz, not associated with weight gain, no preg
Clozapine (Clozaril): tab
-atypical -> severe schizo
-last ditch
-Agranulocytosis (<) ? blood draws (look for fever, RR, sweaty, immune dys), increased sz risk, associated with sedation (highest), weight gain, and transaminitis, increased risk of hypertriglyceridemia/ hypercholest
Iloperidone (Fanapt): tab (BID)
-atypical
-Titrate over 4 days to 12 mg/day to decrease orthostatic hypotension
-Low EPS, akathisia, wt gain, and metabolic disturbances, QT prolongation, no bad hepatic impairment
Asenapine (Saphris): SL ? no food/liq for 10 min, BID
-2nd gen antipsychotic
-Low wt gain and metabolic disturbances (no food before med?), sedation, somnolence, akathisia, no bad hepatic impairment
Lurasidone (Latuda): once a day
-atypical
-No QT prolongation (little risk of cardiotoxicity), less weight gain/metabolic disturbances, administer with food, akathisia, sedation
Buspirone (Buspar)
-Anxiolytic
-Pro: good augmentation strategy, independent release of serotonin, no sedation
Con: takes 2 weeks to notice results, will not reduce anxiety in pt using BZD ? no sedation
diazepam
-benzo -> insomnia, antianxiety, d/c ETOH withdrawal
-SE: somnolence, amnesia, dependence