Glossary of USMLE Step 2 Psychiatry Antipsychotic Medication Chp. 18
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- Antipsychotic medications
- What do old drugs attach to?
- Newer drugs bind to what?
- What do old drugs S/E?
- block muscarinic receptors: dry mouth, blurry vision, urinary retention, confusion, hallucination
- What other Symp. Do you expect with histamine block?
- sedation and weight gain
- What symp. Do you get with alpha block?
- orthostatic hypotension
- What are the older antipsychotics?
- What antipsychotic gives your retinitis pigmentosa?
- thioridizine eye
- What happens when you block the mesolimbic tract?
- reduce psychotic symptoms
- What happens when you block nigrostriatal block?
- increase tremors, parkinsons EPS symptoms!
- What tract does clozapine block?
- Mesolimbic Tract
- What does a block in the tuberoinfundibilar block?
- no galactorrhea, gynecomastia, amenorrhea
- Pat. w/ psychotic, what tx?
- olanzapine (atypical any)
- If all other drugs fail what is next tx?
- clozapine (agranulocytosis be careful)
- If pat. Is noncompliant?
- 1st choice haloperidol or fluphenazine depot decanoid form
- Pat. Is agitated?
- use IM forms (typicals)
- How do antipsychotic medication work?
- block dopamine receptors
- What do new antipsychotics work as well as D4?
- they work on serotonin as well
- What are some other effects of antipsychotics?
- 1) block central and peripheral cholinergic receptors
2) histaminic block
- What are the symptoms of muscarinic block?
- urinary retention
- If you are going to prescribe to the elderly what do you avoid?
- avoid drugs w/ muscarinic block
- Where do new antipsychotics work on?
- D4 more and also serotonin 5HT3
- What do antipsychotics block?
- muscarinic block, alpha block, histamine block
- What is an important S/E of antipsychotics?
- sedation and weight gain (histamine blockade)
hypotension (alpha block)
dry mouth, urinary retention, constipation, confused, blurry vision (muscarinic block)
- Where do antipsychotics work on?
D2 and D4 receptors
Old work on D2
new on D4
- What are the side-effects of histamine blockade?
- weight gain and sedation
- What do you find with alpha blockade?
so be careful on the elderly
they might fall and break a hip
- Main groups for antipsychotics?
- typicals D2 antagonists only low-potency: Clopromazine
old drugs D2: Haloperidol, Thioridazine, Olanzapine, fluphenazine
new drugs Risperidone
- Of the newer drugs, which one of these cause movement side effects of antipsychotics? EPS symptoms?
- Risperidone is the answer
- WHat are the multiple receptor antagonist work on?
- D2, D4 and Serotonin 5HT
- What are the new antipsychotics multiple receptors?
- What does the D2 blockade cause?
- EPS symptoms
- What decreases EPS symtpoms?
- D4 receptors
- What are the indications of antipsychotics?
patients get agitated
- Which one in the E.R. antipsychotics?
since it comes in I.V.
easier to give them a shot
- DOC for schizophrenia?
- Tx for agitation for schizophrenia, mood disorders, psychoses, delusional disorders, brief psychotic disorders, schizophreniform disorder?
- Why do you avoid giving elderly diazepine?
- makes them more confused
problems with their memory
- What is another name for Dopamine?
- Prolactin Inhibitory Factor
- What happens when you inhibit dopamine with antipsychotics?
- PIF is not there
so prolactin goes up
- What happens when prolactin goes up?
- galactorrhea, gynecomastia, amenorrhea
- What does dopamine block?
- tuberoinfundibular tract
- What happens when you block tuberoinfundibular block?
- prolactin increases
- What are other S/E of the older antipsychotics?
- What antipsychotics produces retinitis pigmentosa?
- What are other problems with thioridazine?
- cardiac conduction problems
- WHat are S/E of clozapine?
- What happens when dopa blocks mesolymbic tract?
- reduce psychotic symptoms
- What happens when you block nigrostriatal tract?
- increase in movement disorders
tremors, parkinsonian disease
- WHat does clozapine block?
no EPS (nigrostriatal)
no amenorrhea, no galatorrhea, no gynecomastia (tuberinfundibular)
- Does clozapine cause amenorrhea, galactorrhea, gynecomastia, EPS symptoms?
only blocks mesolimbic tract
- What are the types of movement disorders?
- acute dystonia
- Which movement disorder is the first one to appear?
- acute dystonia
- When does acute dystonia appear?
- occurs within hours or days of treatment
patients get really scared
- Why do patients get scared with acute dystonias?
- its a muscle spasms
- What happens to Ach when Dopamine is high?
- Ach decreases
- What are first choice drugs of psychosis?
- Olanzapine, Quetiapine, Ziprasidone
- What are the S/E of Olanzapine, quetiapine, ziprasidone?
- Weight gain and sedation
- What is the S/E of clozapine?
- What are the S/E of ziprasidone?
- prolongation of QT interval
- What patients have a contraindication of ziprasidone?
- What are the S/E of Olanzapine and Clozapine?
- Cause Diabetes
- What patients have a contraindication of Olanzapine/Clozapine?
- What antipsychotics are used to tx non-compliant patients?
- haloperidol and fluphenazil
- Why do haloperidol and fluphenazil are prolonged in their action?
- they have the decanoid form
- Is Tardive Diskinesia reversible or irreversible for Step 2 USMLE?
- Antidepressants are used to Tx what?
- Mood disorders, adjustment disorders, psychotic disorders
- What are other uses for antidepressants?
- anxiety disorders
- Why is anxiety treated with antidepressants?
- use same neurotransmitter
- What percentage of pat. w/ depression have anxiety?
- 90% of the patients have anxiety w/ depression
- Why are antidepressants used to tx bulemia?
- act on same neurotransmitter
- Why do antidepressants work on impulse control disorders?
- What are amytriptiline of TCA (triciclics) commonly used for?
- If the patient has depression he will surely have?
- What is used for chronic pain?
- Why is amytriptiline used for chronic pain?
- amytriptiline increases endorphins
increase endogenous opiates
patients complain less of pain
- Which ones are dangerous in OD?
- specially TCA
- Pat. comes after OD of TCA, what do they need to be attached to?
- cardiac monitor
causes conduction problems
- What is the effect/toxicity of TCAs Overdose?
- heart conduction problems
- How do TCAs work?
- block the reuptake of neurotransmitter (serotonin and NE, and dopamine)
work by down regulation of beta adrenagic receptors
- How do the MAO inhibitors work?
- work on the enzyme that metabolizes Sertonin, NE, Dopa
doesn't break down the neurotransmitters
so more NE, Ser, DOPA
- Where do the SSRIs work?
- they only block the reuptake of serotonin
- Why do you choose an SSRI instead of TCA or MAO?
- because of less S/E
- What is the first line of antidepressants?
cleaner, pat. like it, less S/E
- What other receptors are blocked w/ TCAs?
- muscarinic receptors are blocked
- What do you expect w/ the TCA muscarinic block?
- What are other two receptors that TCA block?
- Histamine and alpha receptors
- What happens when you give TCAs and block alpha receptors?
- What happens when you give TCAs and block histamine?
- sedation and weight gain
- Which TCA is the worst cause it gives you the most S/E?
takes you on a bad trip!
- What patient would be a relative contraindication for giving him amytriptiline?
- 90 yo, demented, w/ glaucoma, and prostathic hyperthrophy...
why? hypotension, urinary retention, blurry vision (might fall)
- TCA stands for?
- T for upTake blocker
T is for hisTamine blocker
C is for musCarinic blocker
A is for alpha blocker
- Which drugs are the fasest of the TCAs?
- nortryptiline and disipramine
- What are antidepressants used for?
- Tx: depression,
- depression in Bipolar Dis.
- ALL anxiety dis.
- What is the efficacy of antidepressants?
- Which drugs are used first?
- Newer ones
- Which antidepressants are more dangerous?
- usually older ones
- How long do we keep patients before we know the antidepressants are working?
- they start working until 4-6 weeks
- What is the MCC of drug failure?
- the time doctors try the drugs less than 4-6 weeks.
Need to maximize doze and maximize dose switching
- When do you stop antidepressants?
- if S/E are not tolerated by patient
- If you have a patient not responding you need to give another medication in order to boost 1st antidepressants?
- Lithium or Thyroxine
or even Amphetamine like drugs
- HOw long do we keep patients on antidepressants?
- Tx should continue for 6 months to 1 year
since they relapse
- What antidepressant drugs cause the most sedation?
- Doxapine, amytriptiline, trazodone
- What is the use of doxapine and trazodone?
- give it to patients at night so they can sleep
- Which antidepressants cause less sedation?
- Cleaner ones, newer less S/E
Desipramine, protrityline and SSRIs
- Which antidepressant causes most Hypotension?
- Which TCA causes the most hypotension?
- Which is Best TCA for antidepressants?
- Nortriptyline and Desipramine
- Which antidepressant drug has the worst anticholingergic?
- Which antidepressant has less anticholinergic effects?
- nortriptyline and desipramine
also SSRIs since they only work on serotonin
- What do you have to remember about the TCAs and the heart?
- prolong the QRS interval
need to do a EKG
- What is the effects of antidepressant and seizures?
- lower the seizure threshold
- Which TCA causes the most seizures?
- Does bupoprion cause seizures?
- Do women with bulemia have a high incidence of seizures?
- Do antidepressants cause sexual dysfunction?
- yes all of them cause
- What are the sexual dysfunction S/Es caused by antidepressants?
- What antidepressant causes anorgasmia and decrease libido? also delayed ejaculation
- What antidepressant causes priapisms?
- Which one of the SSRIs causes less sexual dysfunction?
- What is priapism?
- prolonged and painful erections
- What are the SSRIs?
- SSRI with least sexual S/E?
- Why are SSRIs used to Tx OCD?
- serotonin involved
panic as well as bulemia
- What are the S/E of SSRIs?
- patient agitation
- What do you tell a patient that gets agitated when takin SSRI?
- tell them to take it at night
- What if a pat. feels sedation of SSRIs?
- take the SSRI at night to take advantage of the S/E
- What are all the S/E of SSRI?
- What is trazodone called?
- heterocyclic antidepressant
off shoot of TCA family
used for its sedation effect
used in insomnia
- Where does fenazodome works?
- NE and serotonin
more like an SSRIs
- What is bupoprion used for tx what age patients?
- older patients less S/E
- What neurotransmitter is involved when using Bupoprion?
- What is bupoprion similar to?
used as Wellbutrin
dose is different
- Why is dopamine associated with smoking sessation?
- Dopamine is linked to reward centers
decrease the pleasure
- What is bupoprion use to Tx?
- smoking sessation
- What drug blocks the pleasure of alcohol?
- What is venlafaxine similar to?
- What is mirtazapine similar to and S/E?
lots of Sedation
- What are TCAs divided into?
- tertiary and secondary
- What are the teriary TCAs?
- What are the secondary TCAs?
- What happens when imipramine is broken down from its tertiary form?
- it converts into its active form desipramine secondary form
- When amitriptyline breaks down, what does it form?
the secondary active form
- Which ones are cleaner talking about S/E between tertiary and secondary?
- secondary don't have that many S/E since they are the active form of the drug
- What is a problem for all TCAs?
- they have a therapeutic window
the drug has to fall within range to be effective
- What is the efficacy of TCA drugs?
- mood disorders
- Which drug can be used to tx panic?
- What is clomipramine used for?
works most on serotonin
- What is amytriptyline used for?
- Chronic Pain
- Why are MAOIs are not used in a regular basis?
- Can't eat foods rich in Tyramine
will cause a reaction of increase blood pressure
- What foods should you avoid if taking MAOIs?
- - red wine
- aged cheeses
- pickled products
white wine ok, processed cheeses ok
- What is the best tx for depression?
- Is ECT the MC tx for depression?
- Why is ECT not used as first line for depression?
- nobody wants ECT
- When is ECT prescribed?
- severely depressed/suicidal tendencies
1)patient still tries to kill himself
2) patient has not responded on TCA,MAIO, Lithium, Amphetamine like drugs
- Is ECT used only for depression?
- no, also:
- In synthesis when do you use ECT?
- typically when all other conventional therapies have failed
- Are there any absolute contraindications of ECT use?
- What is the only situation you have to be careful with the use of ECT?
- only in a case of increase intracraneal pressure
since ECT increase pressure
- What is another case in a pat. w/ depression which you might be inclined to use ECT?
- when the pat. has received ECT previously w/ success
- What is the only problem w/ ECT?
- some memory loss
- What is the characteristic of the memory loss w/ ECT?
- What does transient memory loss mean?
- when the Tx is over, your memory comes back
- What are some of the complications of ECT?
- Do you need a seizure in order for ECT to work?
- What is the typical course of ECT?
- 10-15 treatments
- What tests are done before ECT administration?
rule out tumors that increase intracraneal pressure
x-rays of bodies (fractures that haven't healed)
- WHat are the mood stabilizer medications?
- lithium (bipolar)
- What are some of the symptoms treated w/ mood stabilizers?
impulse control disorder
- What are the indications of lithium?
- bipolar disorder
also mood disorders
(augment response to medication)
- What is lithium not perfect?
- Has a narrow margin or safety
- What does narrow margin of safety mean?
- constantly have to monitor lithium in blood
check blood levels since it could become toxic/lethal
- What is the most common S/E of lithium?
- tremor, shaking
- What test is essential to perform before administering lithium?
- TSH before starting lithium
- What are other major S/E of Lithium?
- What is the most important S/E for Lithium?
- What are the teratogenic effects of lithium on the fetus?
- cardiac malformations
(tricuspid valve affected)
- What test do you give a woman that is young and needs to start lithium Tx?
- Test pack
- What advice do you give the female patient if they are on lithium?
- make sure not to get pregnant while on lithium
- if she does get pregnant she should stop lithium immediately
- What is the therapeutic index of lithium?
- 0.6-1.3 or 1.5
you should keep it at 1
the higher the dose, the higher the S/Es
- What is a recommendation to ALL patients on Lithium?
- drinks lots of fluids
- if pat. becomes dehydrated, then toxic levels may accumulate in plasma
hyponatremia increases toxicity
lithium follows sodium
- What is the Tx of Choice for Lithium at toxic levels above 2.0?
- What are some S/E of lithium at hight doses?
- What is one of the first indications that lithium levels are high?
- gait disturbances (Ataxia)
- What is valproex used for?
rapid cyclers (within days)
- When do you use valproex?
- - when lithium is not working
- when lithium is contraindicated (ie. thyroid disease)
- How many days does valproex take to reach desired effect?
- 10-14 days
- What are the S/E of divalproex?
tremors (like lithium)
- What is the difference in toxicity of valproex?
- What test do you request before administering divalproex?
- liver function tests
hepatic function panel
- What is the teratogenicity of valproex?
- Spina Bifida
shape of the letter V
- What is second line of bipolar?
also valproate (divalproex)
- Tx of Choice for bipolar disorder?
(if lithium not there divalproex)
last resort carbamazepine
- What toxicity does carbamazepine produce?
- hepatic toxicity
- What are S/E of carbamazepine?
- What are two drugs that cause agranulocytosis?
- carbamazepine and clozapine
escarba colcha y cloza
- What are the other mood stabilizers?
not as effective
- What is different about topiramate?
- helps patients reduce weight
- Pat. comes in w/ mania... tx?
- mood stabilizer
if not divalproic acid
- If a pat. has acute mania (emergency) can't wait two weeks to calm him down?
- What are the anxiolytics?
- MOA of axiolytics/benzodiazepines?
- work on GABA receptors
open Cl- channels increaseing the frecuency
- What are other uses of benzodiazepines other than anxiety?
- insomnia specially in the elderly
- Where does buspirone work?
- buspirone maybe works on serotonin
- What is buspirone used for?
- Generalized Anxiety Disorder (GAD)
- What is the Tx. for adjustment disorder? anxious
- benzos w/ psychotherapy
- What is the Tx. for Panic Disorder? anxiety
- Benzos, SSRIs
- What is the Tx. of OCD?
- What is MC used for social phobias?
- What do you adjust with the elderly on Tx. w/ benzos?
- lower the dosage
sedation, memory problems, confusion
- What DDI (drug drug interaction) is lethal w/ benzos?
respiratory arrest (diaphragm paralisis)
- What is the problem with taking benzos?
- Very Addictive
- What are the S/Es of benzos?
- sedation, memory problems, confusion
impairment of cognitive and motor performance
- Is buspirone addictive?
- What is buspirone the DOC for?
- GAD (generalized anxiety disorder)
- Pat. alcoholic that needs to be placed on anti-anxiety medication?
- then better to place him on buspirone since not addictive/no withdrawal symptoms
pat. is going to drink and might have DDI w/ benzo+alcohol
- What is the only S/E of buspirone?
complain some patients headache
- Tx for Depression? A) fluoxetine or b) nortriptiline?
- Tx for Depression?
Nortryptiline or Amytriptiline?
- Pat. w/ bipolar disorder who has kidney problems?
- not lithium
but valproic acid (metabolized in liver)
- What 3 test do you ask for if patient needs to start lithium?
- Pregnancy Test
regular blood work
- Tx for panic disorder? general and specific...
- any benzos but specifically alprazolam
- What drug is used for the prevention of alcohol withdrawal?
chlordiazepoxide (taper dose)
- What other drug besides chlordiazepoxide is used on alcohol withdrawal?
- safe detox with oxazepam
(out the liver)
- Which benzo doesn't go through CP450?
- OTL out the liver
- Pat. comes in w/ alcohol abuse, while in E.R. he becomes agitated? What benzo do you use?
- Oxazepam, temazepam, or lorazepam
lorazepam is I.V. or I.M.
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