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IOS 8 Exam 3
Anti epileptic drugs, bipolar, schizophrenia
| Question | Answer |
|---|---|
| Normal Patients given Antipsychotics | Sedation, restlessness, ANS effets (no euphoria) |
| Schizopherinc patients given antipsychotics | Decreased motor activity, akathesia, Dystonia (muscle cramp), Cataleptic immobility,Bradykinesia |
| Signs/Symptoms of Schizophrenia | Auditory hallucinations, Hyperviligant, Paranoid |
| NT involved in Schizophrenia | DA (volume) Ach, GABA (filters), Glutamate (inappropiate memory) |
| Hyperviligance-cause | Loss of sensory gating-theory nicotinic receptor-paired clicks |
| First generation antipsychotics | Chlorpromazine, Perphenazine, Trifluoperazine, Thiothixene, Haloperidal |
| Atypical antipsychotics | Clozapine, Risperidone, Olanzapine, Quetipine, Ziprasidone, Ariprazole |
| Chlorpromazine receptors | alpha1=5HT>D2>D1 |
| Haloperidol receptor | D2>D1=D4>alpha 1>5HT |
| Clozapine receptors | D4=alpha 1>5HT>D2>D1 |
| ADME of antipsychotics | Low ABs, High protein binding, high Vd, various metabolism |
| Area of antipsychotic effect | mesolimbic area |
| First Generation effects on D1 and D2 | DI increase cAMP, D2 decrease cAMP D3 decrease cAMP |
| Neuroleptic compounds work on what receptor | D2 |
| MOA of atypicals | alpha 1, alpha2, M1, H1, 5HTD3, D4 |
| Dopamine Hypothesis | 1. Most drugs block D2 2. Drugs that induce D2- psychosis 3. More receptors (DA) |
| Dopamine Hypothesis shortcomings | 1. NMDA-glutamate receptor can cause more pronounced psychosis 2. Atypicals less DA2 effect |
| Mesolimbic | Substantia niagra to limbic-cortex and antipsychotic effets noted |
| Nigrostriatal | Substantia nigria to putman, caudate, (Basal ganglia) to cause EPS |
| Hypothalamic | tubular vendubar tract-increase prolactin |
| Medullary blockade | Increase eating behavior |
| D1 like (D1 &D5) | Phenothiazine, Thioanthenes, Butrophenones |
| D2 like (D2, D3, D4) | Sulphiride, Phenothiazines, Butrophenones, Clozapine |
| Chlorpromazine receptors | alpha=5HT>D2>D1 |
| haloperidol receptor | D2>D1=D4>alpha1>5HT |
| Clozapine receptor | D4=alpha1>5HT>D2>D1 |
| alpha 1 SE | orthostatic hypoTH |
| D2 SE | EPS |
| D4 SE | agranulocytosis |
| Neurolepetic syndeome | There is suppression of sponantenous behavior but NOT unconditioned avoidance behavior nor spinal reflexes |
| Lithium ADE | Well absorbed, low Vd, Excreted in Urine |
| Lithium Interactions | Slow BBB absorption, Can substitute for Na and cause Action Potentials (cardiotoxic) |
| Lithium MOA | unknown but inhibits second messenger inositol phosphates to (Ca) decrease cell activity |
| Lithium SE | Tremor (propranolol) choreoathetosis, EPS, asthesia, dysarthia, polyuria, polydipsia, edema, vomiting |
| Cerebral Cortex interaction | Decrease seizure threshold (clozapine, chlorpromazine) |
| Mesolimibic system | Area of antipsychotic effects |
| DM risk | Increased with second generation after 5 years |
| Cholesterol levels increase 10% | Olanzapine |
| Cardio problems | Chlorpromazine, Zipraisadone |
| D2 Key SE | Sedation, orthostatic hypotension, EPS, akathesia, seizures, TD, weight gain, increase prolactin |
| Agranulocytosis | Clozapine |
| Deposits in anterior lens | Chlorpromazine |
| Ocular deposits in the retina | Thioridizine |
| Neuroleptic malignant syndrome | Sensitive EPS -life threatening treat with DA agonist-Bromocriptine |
| Antipsycotic DI's | BZD, Barbiturates, anticholinergics |
| Psycharic indications for antipsychotics | Schiz, Bipolar, tourettes, anti-emetics |
| Schizo characterized as | 3 Symptoms-Positive, negative, and cognitive |
| Positive Symptoms | Hallucinations, delusions, Loosing of associations |
| Negative Symptoms | Anhedonia, Avolution, Povery of speech, Flat affect |
| Cognition symptoms | Loss of short term memory, |
| Schizo heterogenous presentation | prodromial (negative, cognitive), then later positive |
| Hallmarks of acute psychosis | Response in 2 weeks and decreases severity and frequency of symptoms |
| Chlorpromazine SE | Pronlong QT interval, block D2, alpha 1, M1, H1, 5HT |
| Haloperidol use | ER and surgery |
| haloperidol SE | Dystonia (1 day), Akathesia (1 wk), Pseudoparkinson (6 wk) TD( 6 months), tubular vendubular tract innervation (prolactin) |
| Cloazapine SE | agranulocytosis, seizures, mycordial inflammation, weight gain, hypersalivation |
| Clozapine EPS and TD | Does not cause EPS or TD |
| Clozapine monitoring | WBC, Weight, lipids(5 y), DM |
| Chlorpromazine Stop will see | TD symptoms initially (were masked) |
| Atypical antipsychotics treat | Positive, and negative symptoms |
| Risperidone 2 problems | EPS and Most potent prolactin release (Orthostasis, wt gain, sedation) |
| Olanzapine (Zyprexia) SE | GLucose met, weight gain, Akathesia |
| Quetipine (Seroquel) Se | Orthostastis, weight gain, sedation (good for parkinson pt & elderly) |
| Ziprasidone (Geoden) SE | QT elongation, arrhythmias >>80mg |
| Ariprazole (abilify) SE | Akathesia, insomnia, nausea |
| FDA Mania (antipsychotics | Ariprazole, Olanzapine |
| Ariprazole Receptor | Partial DA2 |
| Ziprassidone Not good for | Bipolar |
| Quetipine receptor | DA2 /5HT antagonist |
| Ziprasidone Extra effects | NE and 5HT receptor uptake do not used in Bipolar-causes Mania |
| Dystonia | Uncoordinated involuntary contraction-non-compliance or dose esculation-anticholinergic |
| Akathesia | Restlessness-after 1week, decrease dose or BZD or propranolol, |
| Pseudoparkinson | Onset 1-2 week, decrease dose last choice add anticholinergic |
| Tardive Dyskinesia | After 6 months choreorthetoid motions |
| AIMS or DISCUS | Monitor all antipsychotics every 6 months and 3 months if symptoms |
| Low EPS or TD | clozapine, Quetipine |
| No weight gain | Ziprasidone, or Aripiprazole |
| Increase Lipids and glucose | clozapine, olanzapine |
| EKG symptoms avoid | Ziprasidone |
| Seizures avoid | Clozapine |
| EPS/sedation then avoid | Risperidone |
| Antipsychotic effects on day 1-7 | Decrease hostility, agitation and increase sleep |
| antipsychotic effects in 2 -12 days | Decrease hallucinations, paranoia, delusions, better judgement, increased participation |
| Antipsychotic effects in months to years | Increase insight, decrease delusions, decrease Negative symptoms |
| Antipsychotic monitoring | Weight, DM (base, 12, annual) Lipid( base, 12 week) |
| Bipolar I DSM IV | 1 MDE and mania |
| Bipolar II DSMIV | I MDE and hypomania |
| Cyclithalmic disorder | Less severe depression and mania |
| Manic Episode | elevated or irritable mood lasting 1 week, and > 3 symptoms (4 if irritable): decreased sleep, more talkative, Flight of ideas, Distract, increased directed activity |
| Bipolar I prevelance | Men=WOmen 10-15% of MDE develop bipolar Onst 20 y, LARGE FHX |
| Bipolar II prevelance | Women> men and 5-15% become Bipolar I |
| Bipolar general | 25-50% attempt sucide, substance abuse high, with increase in age, increase in frequency of episodes |
| Recurrrence | Precipitated by sleep/wake cycle, and antidepressants |
| Hypomanic | Decreased depression and mania, No psychotic symptoms |
| Rapid cycling | >4 episidoes in 12 months women > men |
| Mixed Bipolar | Combined state of depression and mania |
| Lithium Dose | 300mg TID |
| Lithium serum level acute | 0.8-1.4mEq/L |
| Lithium serum level maintenance | 0.6-1.2mEq/L |
| Lithium Onset | 7-14 days |
| Lithium monitoring | CBC- leukocytosis and UA- specific gravity, neprogenic diabetes insipidous, Pregnancy D |
| Lithium SE | Tremor, Diarrhea( take w/food) , weight gain,Competes with Na, acute renal failure( renal excretion), electrolyte abnormalities, leucocytocytosis, hyperthyroidism, |
| Sign of Lithium toxcity < 1.8 mEq/L | Lethergy, sedation, nausea, anorexia, increased tremor |
| Lithium toxcity <2.3 | Slurred speech, blurred vision |
| Lithium toxicity< 2.3 | Coma |
| Lithium DI | NSAIDS, Diiuretics, Acei, Chinese food, caffeine, excerise |
| Valproic Acid Monitoring | LFT, CBC-leukocytosis, B-HCG Pregnancy |
| Valprotic Acid- Black box warning | Hepatotoxcity (children), hemorrhagic pancreatitis, Thrombocytopenia, Rash (SJS), ALopecia |
| Valproic Acid Dose | 250TID, increase by 250mg Q 2 days until at serum level |
| Valproic acid serum level | 50-125 mcg/mL |
| Valproic acid first line | Mixed mania |
| Valprotic acid SE | GI-(take w/food), Sedation, Tremor, WEight Gain, Hyperammonemia (not significant) |
| Valprotic Acid DI | Lamotrigine (SJS rash), Warfarin |
| Carbamazepine use | DI limits use-inducer and autoinducer |
| Carbamazepine Monitoring | Aplastic anemia, hyponatremia, hepatotoxcity, Pregnancy C-low birth |
| Carbamaxepine SE | Sedation, Dizziness, SJS rash |
| Carbamazepine DI | inducer and autoinducer (2 weeks) warfarin, Birth control, Theophylline |
| Oxacarbamazepine SE-Bipolar | less hyponatremia, but does not have efficacy data |
| Lamotrigine Bipolar indication | First line if in bipolar depression |
| Lamatrigine Biopolar dose | Start low 25mg then increase weekly by 25mg (SJS rash avoid fast titration) |
| Lamatrigine SE | HA, N/V, Rash (SJS) |
| Benzodiazipines acute mania | Lorazepam 1-2mg BID (watch addiction) |
| Non-pharm Bipolar | Stay away from illicit drugs, and alcohol, sleep cycles, stress, ECT, family/friend support |
| Acute mania drug choices | mood stabilizer +/- BZD and or antipsychotic |
| Maintainenance Bipolar | Mood stabalizer may consider antipsychotic |
| Mixed Mania first line | Valprotic Acid consider Carbamezapine or oxcarbamazepine |
| Depressive Bipolar | Mood stabalizer and antidepressant |
| Seizure length | Usually seconds to minutes |
| Biochemical changes of seizures | Can last days and patient do not remember occurances |
| Pseudoseizures | Conversion disorder related to stress |
| 3 Categories of seizures | 1. Primary generalized (bilateral) 2. Focal partial onset seizure( mono), Epilepsy syndrome |
| Primary generalized seizures-types | Tonic-clonic, tonic, clonic, atonic, absence, myoclonic |
| Tonic-clonic | Called Gran Mal-Increased tone and rhythum |
| Atonic | Without tone, the helemet people |
| Absence | Children who stare and have 50-100 per day |
| Simple partial seizue | Have the aura (feeling, smell, ) awareness is NOT impaired -can jump corpus collisum and cause Complex partial seizure |
| Complex partial Seizure | Awareness impaired- blank look, speech arrest, communication is garbled, walk around |
| Juvienile Myoclonic Epilepsy | onset near puberty- seizure associated with sleep Give Valprotic Acid) |
| Lennox Gastaut Syndrome | Difficult to treat- Have gamut of seizures, generalized tonic clonic, atonic, partial=developmentaly disabled people |
| Receptors used to treat epilepsy | GABA receptor, Ion channels (NA, CA) amino acid receptors (NMDA, AMPA) |
| GABAergic drugs | Pregabalin, gabapentin, Tiagabine, Barbs, BZDs, Topimate, Felbamate, Valproate |
| Na Channel blockers | Phenytoin, Carb, Valproate, Lamatrogine, Primadone, Topiramate, Oxcarbazepine, Zonisamide |
| Drugs that block Ca channels "Absence Seizures" | Ethosuximide, valproate, topiramatem pregabalin, gabapentin |
| Glutamate block | Felamate, Topitamate, Lamotrigine, Pregabalin |
| Broad Spectrum | Valproate, Zonisimise, pregabalin, Levetiracetam, Topiramate, Felbamate, Lamotrigine |
| Blocks Synaptic vesicle 2 receptor | Levetiracetam |
| Inducers | Phenytoin, Phenobarbital, primidone, Carbamazepine (autoinducer) |
| Enzyme inhibitor | Valprotic acid |
| Phase II metabolism | Lamotrigine, Tigabine |
| Pregnancy-metabolism | Clearance increase in last trimeter- do not forget to decrease dose after birth |
| Protein Binding-clinical significance | Valprotic acid and phenytoin |
| Conditions that alter protein binding | Pregnancy, malnutrition, alcholism (bad liver), age extremes, Hypo-albumin |
| Hypersensitivity syndrome- | Can happen 1 year after starting, Rash, and systemic because aromatics arene oxides lack epoxide hydroxylase to metabolize- Never give other AED with aromatic ring (NO antibiotics with aromatic ring) |
| Drunk Feeling when toxic | Carbamazepine, lamotrigine |
| Vaprotic acid-lab changes | CBC-thrombocytopenia, WBC, down, PTL down, AED- trough |
| Phenobarbital SE | Aggression, hepatotoxic, osterperosis, sexual dysfunction |
| DI birth control pills | All inducers |
| No effect on Birth Control | Valproate, Lamotrigine, gabapentin, zonisamide |
| Inducers and inhibitors | Oxacarbamazeptine, Felbamate, Topiramate |
| Injectable drugs | Phospenytoin, Phenobarbital, phenytoin, depason, levetriacetan (coming) |
| Phenytoin MOA | Na channel blocker |
| Phenytoin administration | proplyene glycol (solubility) causes crystalizations Rate<50mg/min monitor cardiac arrythmias |
| Phenytoin SE | osteropeosis, gingival hyperplasia, hirtism, sexual dysfunction |
| Phosphenytoin-prodrug | IV phenytoin must give >150mg/mL |
| Phosphenytoin SE | groin itch(lower rate) |
| Ethosuximide | treats absence seizures |
| Carbamazepine MOA | Sodium channel blocker |
| Carbamazepine does not treat what type of seizure | absence |
| Carbamazepine Dose | 400-600mg QD (TID) |
| Carbamazepine Contra | Sucidial patients |
| Carbatrol | 3 beads of various release carbamazepine |
| Valproate MOA | Increase GABA, Block Na channel |
| Valproate Dose-AED | 500TID |
| Valproate serum concentration AED | 50-150mcg/mL |
| Valproate SE | High hepatotoxicity, tremor, hair changes, weight gain, osteroperosis, polysystic ovarian syndrome |
| Osteroporosis need Ca | Inducers-Phenytoin, Carbamazepine, Phenobarbital, Primadone, Felbamate (osetoblast inhibited-valproate) |
| Felbamate SE | aplasic anemia, hepatic failure (6-12 months!) |
| Felbamate monitor | CBC (aplastic anemia), & LFT 2-4 times first 6-12 months |
| Lamotrigine DI | Birth control decrease concentration of drug |
| Gabapentin MOA | L-Type Ca channel in the gut has absorption limit 1200mg TID |
| Topiramate-carbonic anhydrase SE | kidney stones, fast dose escalation (confusion), weight loss, glaucoma |
| Avoid if sulfa allergy | Topiramate, Zonismide |
| Tiagabine SE | if withdraw fast cause status epilepitus |
| Levetriacetam Dose | 500BID immediately at theraputic level |
| Oxacarbamazepine-prodrug | Monitor Monohydroxy derrivative and sodium levels |
| Zonisamide benefit | Therapeutic in week! |
| Zonisamide SE | parathesia, kidney stones |
| Pregabalin excretion | renal |
| Staus Epilepticus-first line | Lorazepam 0.1mg/kg (cool CNS) repeat in 15 min if does not work |
| Status Epilepticus-second line | Phenytoin load 18-20mg, the NTE-50mg/min repeat half load if not effective |
| Status epilepticus 3rd line | paraldehyde, propofol, lidocaine,depacon, depakote rectal |
Created by:
liza001
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