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Ryan Shared "0.1 Psychopharm 2" - 29 Picmonics

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0.1 Psychopharm 2

1st Generation/Typical LAIs
BBW: Death in elderly with dementia-related psychosis
Increase TCA concentration
Inhibit CYP2D6
Considerations
CI in Parkinson's Disease
CI in Lewy Body Dementia
Stored in lipophilic sesame oil
Teratogen - limb malformation, EPS, withdrawal
Avoid Breastfeeding
Side effects
Anticholinergic Effects
Cataracts
Agranulocytosis - DC if ANC <1000
Lower seizure threshold
QTc Prolongation
Liver impairment
Hyperprolactinemia
Extrapyramidal Symptoms
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Dystonia Treatment
Acute Treatment
Benztropine (Cogentin)
Diphenhydramine (Benadryl)
Diazepam (Valium)
Slow IV Push
Maintenance
Cogentin and Benadryl preferred for maintenance
Trihexyphenidyl (Artane)
Benztropine for prophylaxis
Considerations
Switch antipsychotic and evaluate for 2 weeks
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Akathisia Treatment
Propranolol (Inderal) 1st line tx
Clonidine (Catapres) alpha 2 agonist
Mirtazapine (Remeron)
Clonazepam (Klonopin)
Benztropine (Cogentin)
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Antipsychotic-Induced Parkinsonism Treatment
Switch AP to Seroquel or Clozaril
Benztropine (Cogentin)
Amantadine (Symmetrel)
Hypotension and Agitation with amantadine
Levodopa
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Malignant Catatonia
Fever
Hypertension
Tachycardia
Delerium
Low serum iron and high creatinine kinase
Lorazepam and ECT
Leukocytosis
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Clozapine (Clozaril)
Mechanism
Atypical Antipsychotic
Indications
Schizophrenia
Levodopa-Induced Psychosis
Side Effects
Weight Gain
Hypersalivation (Sialorrhea)
Myocarditis
Agranulocytosis
Sedation
Orthostatic Hypotension
Constipation (Risk of Bowel Ileus)
Considerations
Weekly Lab Tests
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2 mins
Zyprexa (olanzapine)
Sedation - less then Clozaril
Muscarinic (M1) blocker, H1 blocker, alpha-1 blocker
Cardiometabolic Side Effects
CYP450 1A2 Metabolism
Smoking decreases Zyprexa - 1A2 Inducer
5HT2A blocker - more potent than D2
Improves Mood in Bipolar and TRD
Fluoxetine - Best adjunct for mood
Caution Luvox (1A2 inhibitor)
Sexual Dysfunction - 50% of patients
Monitor DRESS and Post Delirium Sedation Syndrome for Relprevv
Uncommon EPS
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Seroquel (quetiapine)
CYP450 3A Metabolism
Hypnotic at 50 mg
H1 Blocker
Antidepressant at 300 mg
Increase DA and NE from 5HT2C blocking and NET
Antipsychotic at 800 mg
5HT2A blocker - more potent than D2
NET inhibition from Norquetiapine metabolite
Cataracts??
Common weight gain, cardiometabolic effects
Uncommon EPS
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Saphris (asenapine)
MOA
5HT2A and D2 antagonism
CYP 1A2/2D6 metabolism
Adverse effects
Common sedation and weight gain
Uncommon EPS
Considerations
Sublingual
Tongue numbness
Increases concentration of antihypertensives
Looks like Remeron
Indication
BpD1 Mixed and Manic
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Risperdal (risperidone)
Indications
BPD Mixed and Manic
Autism-Associated Irritability
Bipolar 1 Maintenance (Adults)(Consta)
Considerations
Increase concentration of antihypertensives
Carbamazepine decreases levels
Paxil and Prozac increases levels
"Conventional" at higher doses
Rare seizures
Common EPS, weight gain, sedation
Gynecomastia
Sexual dysfunction - 60-70% of patients
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Invega (paliperidone) vs Risperdal
Indication
Central D2 and 5HT2A antagonist
MOA
Invega FDA approved for Schizoaffective d/o
Considerations
QTc Prolongation (additive)
Increase effect of antihypertensives
NOT metabolized by liver, so better tolerated than Risperdal
Renally excreted
Less sedation, orthostasis, weight gain and fewer EPS than Risperdal
Caution with 3A4 inducers
CYP 3A4 substrate
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Geodon (ziprasidone)
Indications
Schizophrenia acute agitation/delay relapse
BPD Mixed/manic/maintenance
Considerations
DRESS syndrome
MUST be taken with food, doubles absorption, BID
Half-life 10 hours
Increase effect of antihypertensives
Increase QT prolongation (NOT dose dependent)
Uncommon weight gain, sedation, tardive
No weight gain, no dyslipidemia, no insulin resistance
EPS common
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Fanapt (iloperidone)
Schizophrenia and maintenance only
Indication
Considerations
Increase effects of antihypertensives
CYP2D6 Metabolism
Paxil, Prozac, Cymbalta, Quinidine increases levels by inhibiting 2D6
May increase QT prolongation
Common weight gain and sedation
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Latuda (lurasidone)
Indication
Schizophrenia if older than 13
Bipolar Depression
Considerations
CYP3A4 Metabolism
Levels increase with Prozac, Luvox, nefazodone (3A4 inhibitors)
Contrindicated with 3A4 inducers (rifampin)
No H1 blocking activity
Reduced metabolic risk and sedation
5HT7 blocking activity
Leads to improved mood and cognition
Common EPS
Give with food
Half-life 10 hours
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Abilify (aripiprazole)
Indication
BPD Mixed and Manic
Autism-Associated Irritability
Unipolar MDD (Augmenter)
Bipolar 1 Maintenance (LAI Maintena)
MOA
Partial D2 Agonist
5HT1A Partial Agonism (Maintena)
5HT2A Blocker
Less sexual side effects from 5HT2A antagonism
Metabolism
CYP2D6 and CYP3A4 Metabolism
Increased with 2D6 inhibitors (Prozac, Cymbalta, TB meds)
Decreased with 3A4 inducer carbamazepine
Adverse effects
Common Activation and Akathisia
Risk of Obsessive Compulsive Behaviors (Like gambling)
Uncommon weight gain and sedation
No QTc prolongation
Considerations
Augment with Abilify for elevated PRL in patients on Risperdal
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Vraylar (cariprazine)
CYP450 metabolism into 2 metabolites
Long Half-life (start 1.5 mg every other day)
Better for positive symptoms than 'pips'
Late onset of adverse effects (2-3 days)
Common akathisia, GI upset, sedation
Uncommon NMS, weight gain
Carbamazepine decreases levels, and Prozac and Cymbalta increases levels
D3 action at low doses
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Rexulti (brexpiprazole)
Indication
Schizophrenia, Treatment resistant MDD adjunct
Adverse effects
Common weight gain, akathisia, sedation
Uncommon TD, activation
Considerations
Avoid with 3A4 Inducers, adjust for 3A4/2D6 inhibitors
Risk for compulsive behaviors
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Caplyta (lumateperone) Receptors
Indication
Schizophrenia
Receptors
Robust 5HT2A blocker (more than 2 pips and rip). 60 times D2.
D2 blocker with some D1 blocking activity
SERT blocker
alpha 1 blocker
5HT2C blocker
ADVERSE EFFECTS
Common sedation
Uncommon weight gain and metabolic neutral
Avoid with renal and hepatic impairment (Has 1 dose only)
Considerations
1 evening dose 42 mg with food
Avoid with 3A4 inducers and 2D6 inhibitors
Terminal Half-life 18 hours
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Nuplazid (pimavanserin)
Indication
Parkinsonian Psychosis
MOA
Selective 5HT inverse agonist on 5HT2A (blockade)
CYP3A4 Metabolism
Adverse effects
Common weight gain and akathisia
Uncommon sedation and TD
Considerations
34 mg PO daily dosing without titration
Adjust dose for severe renal impairment
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Vyvanse (lisdexamfetamine)
Most common long-acting amphetamine
12 hour duration
Low risk of abuse, activated in GI
Can mix with food
Levels are steady (calm, slow release) all day
Start 30 mg, max 70 mg daily
Increase 10-20 mg q week
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