Psych pharm (in depth)

Drugs that cause EPS, TD

SGAs are significantly less likely to cause TD than FGAs there is evidence that TD risk may be similar to the prevalence of EPS, thus risperidone, paliperidone, aripiprazole, asenapine and lurasidone may carry somewhat higher risk and quetiapine and iloperidone somewhat lower risk (so astart with those) In contrast to other SGAs, clozapine has not been shown to cause TD,

Imipramine (Tofranil®)

Still the "Gold Standard" in response rates; upwards of 80% effective • Usual dose is 150-300mg daily • Used to treat ADHD, Separation Anxiety Disorder and enuresis in children.

Psychostimulant side effects and how you treat them

cardiovascular risks (including sudden unexpected death) Do not use stimulant medications for children with cardiac symptoms or a positive family history of heart disease Side effects of Methylphenedate Or atamoxitine- MAy cause priapism- Go to the ER. Decreased appetite - Administer the medication at or after a meal; encourage the child to eat nutrient dense foods before those with "empty calories;" offer food that the child likes for the noon meal, which is often affected [7,9,90,94]. When making these changes, an important caveat is that meals with high fat content may delay the onset and increase peak concentrations of some formulations (eg, Metadate CD, Methylin chewable tablets or oral solutions, Adderall XR). See methylphenidate drug information and dextroamphetamine drug information. ●Poor growth - Drug holidays may be beneficial for children in whom stimulant therapy is associated with a growth trajectory that crosses two major percentiles (ie, the 5th, 10th, 25th, 50th, 75th, 90th, and 95th) [3]. Drug holidays should only be undertaken if they can be tolerated without marked impairment in functioning. Poor growth that does not respond to drug holidays should be discussed with families to determine preferences for continued treatment. Nutritional consultation to facilitate growth while taking medications may also be warranted. (See 'Drug holidays' below.) ●Dizziness - Monitor blood pressure and pulse; ensure adequate fluid intake; if associated only with peak effect, try a longer-acting preparation (table 3A-B) [94]. ●Insomnia/nightmares - Establish a bedtime routine and good sleep hygiene habits; omit or reduce the last dose of the day, or, if using a long-acting preparation, change to a short-acting preparation (table 3A-B) or administer earlier in the day [25,94,96]. ●Mood lability - If mood lability occurs at the time of peak concentration, try reducing the dose or switching to a longer-acting preparation; irritability, sadness, and increased activity as the medication wears off is particularly common when short-acting medication is used on a morning and noon twice-a-day schedule - try adding an afternoon dose or switching to long-acting form; referral for coexisting mood disorder or anxiety disorder may be warranted [9]. ●Rebound - "Rebound" refers to symptoms or adverse effects that occur as the medication is wearing off; rebound effects may improve by increasing the dose of the long-acting agent administered in the morning or adding a smaller dose of short-acting medication at the end of the day, before rebound symptoms typically occur [3,94,95]. ●Tics - Given the frequency of comorbid tic disorders and ADHD, and the typical waxing and waning pattern of tics, new or worsening tics may be coincidentally rather than causally associated (even if the tics appear to improve when the child is not taking stimulants) [97,98]. If tics begin or are worsened in children taking stimulants, a brief trial off of medication or at a lower dose may be warranted. The trial is most informative if the tics persist when the medication is discontinued; improvement off of medication or at a lower dose may be coincidental. (See "Pharmacology of drugs used to treat attention deficit hyperactivity disorder in children and adolescents", section on 'Tics'.) ●Psychosis - If children taking stimulant medications develop psychotic symptoms (eg, suicidality, hallucinations, or increased aggression), verify that the dose is appropriate and that the medication is being administered as prescribed [94]. If so, discontinue the stimulant; stimulant medications can be discontinued abruptly, without tapering. Referral to a qualified mental health specialist or psychopharmacologist may be warranted to assess for bipolar disorder or a thought disorder [94]. ●Diversion and misuse

The Mono-Amine Oxidase Inhibitors (MAOI's)

Isocarboxazid (Marplan®) Phenelzine (Nardil®) Tranylcypromine (Parnate®) Transdermal Selegilene (Emsam®)

Clomipramine (Anafranil®)

• FDA approved in USA for Obsessive Compulsive Disorder only. • Usual dose 150-250mg daily • Used in Europe as an anti-depressant • May be used for Trichotillomania • Most highly serotonergic TCA • Approved for treatment of OCD in kids 10 years and older • Case reports of orgasms in women during yawns

Haloperidol (Haldol®)

* Most commonly used high potency agent. * Often used in the treatment of delirium. * Has been used to treat Tourette's Syndrome. * Comes in a long acting depot form * Available in an IV form, but it is twice as potent as the oral form as it bypasses first pass metabolism * Toursades has been seen with IV Haldol use

• Clonidine (Catapres®)

* Usually, this is an anti-hypertensive medication * However, it is also used in ADHD and as a first line medication in the treatment of Tourette's Syndrome * This is a Super sedating medication, although it often passes in 3 weeks * Commonly used during ETOH withdrawal protocols but don't do it as it masks the withdrawal checks that are used to determine if prn's are given. Not controlled

Paliperidone (Invega)

-A go to drug for Schizoaffective disorder since it is FDA approved and adherance is often a problem in schizoaffective patients. -The active metabolite of risperidone -Metabilized entirely through the kidney -Minimal peak/trough variation due to OROS technology in delivery method - injection can be given monthly (invega sustenna) or every three months (invega trinsa) -risk of elevated prolactin and decreased libido

Advice on what to expect with psychostimulants

-Explain that it will likely take take 1-3 show in behavior and schoolwork, and after three years of succesful treatment you can have a trial of tapering off. Stimulant effects usually show up 30-40 minutes after the dose is given. High fat meals may delay onset. Start on a weekend so parents can watch for side effects. Write seperate perscription for school so teachers can follow as well

SSRI General info

-These medications inhibit the cytochrome P450 system which can lead to numerous medication side effects -Citalopram and escitalopram have the least cp450 liver enzyme interaction, so give them if drug interaction is a problem. • Sexual problems are common, including decreased libido and delayed ejaculation. (can be combatted with sildafinil • Can also be used to treat Obsessive-Compulsive Disorder (Paroxetine, Fluoxetine, Sertraline and Fluvoxamine are FDA approved) • Can also be used to treat Panic Disorder (Sertraline, Paroxetine and Fluoxetine are FDA approved) • Some are approved to treat PTSD (Sertraline, Paroxetine) and Social Phobia (Paroxetine, Sertraline) • Sertraline, fluoxetine and paroxetine have PMDD indication, paroxetine and escitalopram are indicated for use in GAD. • Overdose with these medications alone are usually non-lethal. • Treat depression by preventing the re-uptake of serotonin from the synaptic cleft. • Only Sertraline (for OCD; age 6 and up), Fluvoxamine (for OCD; age 8 and up) and Fluoxetine (for MDD; age 7 and up)are FDA approved for use in children • In fact, the FDA recently stated that paroxetine and venlafaxine should not be used in anyone under the age of 18 years. -Remember that suicidal ideation/attpemt are a black box warning for kids/teens with depression taking SSRIs/TCA/SNRIs. It's only an increase of .7% vs placebo but you still need to warn the parents, though they are 33x more likely to have a beneficial reaction than a suicidal event. -in general you want to start kids on CBT then move them on to medication.

Vyvanse

-Treats ADHD and Binge eating disorder -like other stimulants assess for abuse potential before perscription. - often causes insomnia, dry mouth, abd pain -may cause mania in bipolar patients. -use with caution in patients with heart problems (like all stimulants)

Akathesia treatment

1st: if feasable decrease antispychotic dose while monitoring closely. If that is not feasable, switch to a similar SGA with lower akathesia risk ( Quetiapine, illoperidone) If that doesn't work, supplament with medication. Propranolol is first line, and Benztropine is second line.

Risperidone (Risperdal®)

10-20 $ with coupon, 60-90 without Has affinity for D2 receptor and is a 5HT2 antagonist. * Lower levels of EPS than typical antipsychotics * May cause an increase in serum prolactin levels * Average dose to treat schizophrenia is roughly 4.7mg/day; Approved for use up to 16mg/day • Available in a rapidly acting oral solution and a rapidly acting dissolvable wafer (M-Tab). • available as a long acting injection (Consta®) • FDA approved for the treatment of irritability asociated with autism

Duloxetine (Cymbalta®)

20 (costco or coupon)- 250 without • Has effects on both serotonin and norepinephrine at starting doses • Is a CYP 2D6 substrate and mild inhibitor • Has utility for pain control like the TCAs • Approved for treatment of MDD • Most common side effects are nausea, dizziness and fatigue -only SNRI that does not cause elevated blood pressure.

Venlafaxine (Effexor-XR®)

20$ Inhibits the uptake of both NE (150mg/day) and 5HT (immediately) • Long acting form (XR) can be given once daily. • No clinically significant cytochrome P-450 inhibition • At higher doses, 7% of patients may develop increased diastolic blood pressure of 10-12 points. • May be helpful in patients who have not responded to other therapies • Low amount of protein binding (27%) compared to other antidepressants. • Approved for use in those patients with social anxiety disorder, GAD, MDD and panic disorder • FDA recommends it not be used in patients under 18 years old • Has been associated with increasing intraocular pressure; do not use if the patient has narrow angle glaucoma -Basically the same as Desvenlafaxine, however it is cheaper but with more side effects.

• Milnacipran (Savella®)

2009 350$ • FDA Approved for fibromyalgia only; should work as an antidepressant as it is an SNRI • Target dose is 50mg bid; max dose is 100mg bid • Has been associated with an increase in both diastolic and systolic BPs of about 8%of patients • Has a significant withdrawal syndrome with symptoms such as mood changes, irritability, agitation, numbness in hands and feet, headache and confusion. • May close narrow angle glaucoma, may increase bleeding risk • Has been associated with serotonin syndrome (MS changes, labile BP, diaphoresis, hyperthermia, tremor, hyperthermia, seizures, myoclonus, etc.) if mixed with other serotonergic medications • Has been associated with testicular pain in men

• Iloperidone (Fanapt®)

2009 480$ with coupon • Approved in 2009 for the treatment of schizophrenia • Doses range between 12 and 24mg daily (in two doses) • Side effects include orthostatic hypotension, dizziness and somnolence • Known to cause QTc prolongation • It is a 2D6 and 3A4 substrate

Asenapine (Saphris®)

2009 604$ with coupon • Sublingual tablets for treatment of schizophrenia and bipolar disorder • 15% of patients will have a 7% or greater increase in weight • Known to cause QTc prolongation and prolactin elevation • Side effects include akathisa, somnolence, dizziness and EPS • Weight gain has been noted • 10-20 mg daily in two divided doses

Lurasidone (Latuda®)

2010 1,250$ with coupon • Approved to treat schizophrenia and bipolar depression • Should not use with a strong 3A4 inhibitor (ketoconazole) or inducer (rifampin, carbamazepine) • Effect mediated by D2 and 5HT2A antagonism • Side effects include akathisia, somnolence, agitation; minimal weight gain his noted • Take with food for good absorption • Has been associated with increased prolactin levels o Your go to pregnancy antipsychotic and bipolar disorder drug o Can be used as an adjunct for valproate or lithium o Weight neutral drug o Take with food for less vivid dreams

Vilazodone (Viibryd®)

2011 255$ with coupon • FDA approved for major depression • Serotinin agonism by blocking serotonin re-uptake and partial agonist of 5HT1A presynaptic receptor • Similar in structure to bupspirone, there may be anxiolytic activity • Side effects are usually GI in nature; headache common as well • No weight gain and no sexual side effects

Vortioxetine (Trintellix®)

2013 350$ with coupon • FDA approved for major depression • It is an SSRI with multimodal activities including 5HT1A agonism and 5HT3 antagonism • Downstream it increases NE, DA, and Ach; felt to help cognitive effects associated with depression • Helpful for depressed patients with cognitive deficits, especially elderly patients • Sexual dysfunction and weight gain were the same as placebo. o "fight the fog"- used after 1-2 other failed therapies due to fogginess, weight gain, or sexual side effects (same as the placebo) o The side effects were the same as the placebo o The big side effect is nausea, but If there is nausea it is dose dependent. You can back the dose down. And it usually is gone after two weeks. o People reported sleeping better, but it is not actually sedating

Levomilnacipran (Fetzima®)

2013 370$ • FDA approved for major depression • This is an SNRI, but with the most activity through NE pathways. • Due to NE activity, should theoretically improve cognitive function (including concentration and motivation) and social function • Weight neutral • Has been asociated with increased pulse and heart rate; also with erectile dysfunction • May be a good choice to treat patients with impaired social function and chronic pain • Metabolized through the kidney, may need to decrease dose in patients with miderate renal disease.

Cariprazine (Vraylar®)

2015 1,200 with coupon • FDA approved to treat schizphrenia and mixed/manic episodes of bipolar disorder -Switch to this if they are complaining about drowsyness and cognitive function. • Starting dose is 1.5mg and maximum dose is 6mg daily for schizophrenia and bipolar disorder • Acts as a D2 and D3 partial agonist • Major side effects include akathisia, and insomnia • May possibly cause cataracts • May enhance cognitive function through dopamine modulation - less weight gain than many others

Brexpiprazole (Rexulti®)

2015 1,200$ with coupon • FDA approved to treat schizphrenia and as an adjunctive agent to treat major depression (acts pretty quickly to augment depression meds) o Not indicated for schizoaffective • Acts as a partial agonist of the 5HT1A and D2 receptors, also an antagonist of 5HT2A • Starting dose 1mg/day; maximum dose for MDD is 3mg daily, 4mg daily for schizophrenia • Metabolized by CYP 3A4 and 2D6, so need to monitor side effects whe used in conjunction with inhibitors or inducers • Side effects include weight gain, akathisia, agitation, increased prolactin, and sweating • Neonatal EPS if used durind 3rd trimester o 62% decrease in depression when added to an antidepressant o Can have increase in triglicerides o Goal dose is 2 mg o Not on formulary for South Seminole o Weight gain is usually about three Lbs

Pimavanserin (Nuplazid®)

2016 2,767 with coupon • Only medication specifically approved for the treatment of hallucinations and delusions associated with Parkinson Disease • Exerts it's effect through a combination of inverse agonist and antagonist activity at serotonin 5-HT2A receptors and to a lesser extent at serotonin 5-HT2C receptors; no dopaminergic activity • Side effects include the development of a confusional state, nausea, and peripheral edema

Fluvoxamine (Luvox®)

25$ FDA approved for OCD in adults and kids 8 and above * Has the most problematic drug interaction profile of all the SSRIs * Short half-life requires BID Dosing * There have been deaths in single drug overdoses from cardiac conduction difficulties

Remeron (Mirtazapine®)

30$ (12 with coupon) * Treats MDD via Alpha-2 Adrenergic Blockade; also blocks 5HT2A 5HT2C * Severe neutropenia has been reported (0.1%) * Gives patients a ravenous appetite, there is significant weight gain * Extremely anti-histaminergic, sedating, especially at low doses * Available in Sol-Tab dissolvable wafer

Ziprasidone (Geodon®)

30-50$ without coupon- 150 without * Serotonin-dopamine antagonist * Found to be a *weight neutral* antipsychotic * Available as a pill and in a rapidly acting IM shot (10-20mg) * *Cost is best* of the atypical agents * Has the most *QTc interval prolongation* of the atypical agents * FDA approved up to 200mg/day

Paroxetine (Paxil®, Paxil-CR®)

4$ FDA approved for GAD, OCD, MDD, PTSD, PMDD, social anxiety and panic disorder. * Given (once daily) at night because of sedative effects. * No active metabolites * Half-life is about 24 hours. * Often causes significant weight gain during treatment * Noted to be somewhat anticholinergic * FDA recommends it not be used in children Causes problems with ejaculation, so great if it is a male with premature ejaculation, but avoid in sexually active males

Trazodone (Desyrel®)

4$ * Used to be one of the most commonly used medications in America. * Can cause necrotizing priapism. * Very sedating, some doctors use it as a sleeping aid. * Inhibits serotonin uptake and may be a serotonin agonist as well. * May cause serotonin syndrome if used in combination with the SSRIs o Seratonin Antagonist Reuptake inhibitor o Works as a sleep aid because it is an antihistamine at lower dosages.

Citalopram (Celexa®)

4$ Only FDA approved for the treatment of major depression * Has been known to cause cardiac conduction delay (QT prolongation), especially in overdose. Therefore, likely not as safe as other SSRIs • There have been deaths in single drug overdoses • 4 dollar pill

Fluoxetine (Prozac®)

4$ • FDA approved to treat MDD, OCD, panic disorder, PMDD, bulimia [the only one], MDD in kids • The first SSRI available (around 1988) • Has been unjustly accused of being dangerous by the scientology cult (Tom Cruise, John Travolta, Kirstie Alley, etc.) • Given in the AM because of energizing effect • Norfluoxetine (active metabolite) has a half life of ten days. • You must wait 5 weeks to start an MAOI after discontinuation of Fluoxetine because Norfluoxetine is still active and can react with the MAOI to cause a serotonin syndrome (hypertensive crisis, etc). You must wait between 2 and 3 weeks to start fluoxetine after the discontinuation of an MAOI. • A different preparation (Sarafem) is available for the treatment of PMDD.

Lithium

4$ at walmart * This is a non-sedating medication. * Still the "gold standard" for the treatment of Bipolar Disorder (about 70% effective) * Can cause a cardiac malformation (Ebstein's Anomaly) in babies. * You need to carefully monitor therapeutic levels (0.8 to 1.5) of lithium. (Only mood stabilizers and the TCA's require blood level monitoring). * Lithium concentrates in the kidney, thyroid and bone, causing: • Kidney: diabetes insipidus (polyuria/polydipsia), or just plain kidney damage (always monitor BUN & Cr) • Thyroid: hypothyroidism (some cases of hyperthyroidism have been reported), and exophthalmos (always check TFT's) • Bone: No adverse reactions known yet. * Lithium causes a benign leukocytosis (13-14,000) without a left shift * During pregnancy, lithium clearance increases, necessitating an increased dose of lithium to maintain control. However, as soon as the little monster is born, lithium clearance decreases to the pre-pregnant levels and the dose must be decreased as to avoid lithium toxicity. * Severe acne, especially in adolescents. Can cause tremors

Escitalopram (Lexapro®)

40$ FDA approved for the treatment of major depression and GAD * Four times more potent than citalopram (10mg=40mg) * S-enantiomer of citalopram * Side effects less than citalopram o Like citalopram this also has QT prolongation o Due to the QT prolongation it is a good idea to only give younger patients who don't have heart problems and no other medications o Much more expensive than celexa 40 dollars without coupon or insurance

Desvenlafaxine (Pristiq®)

40$ with coupon-350 with (70 at costco) • This is the active metabolite of venlafaxine • It may cause an increase in blood pressure, just like the parent compound • Low amount of prorein binding (30%) • Associated with heavy sweating, dizziness, tremor • Withdrawal is severe and includes "brain zaps," flu-like symptoms, headaches, dizziness, mood swings

Quetiapine (Seroquel®)

6$ with coupon- 90$ without * Mixed affinity for serotonin, dopamine, histaminergic receptors * Optimal control of Schizophrenic symptoms is at 600mg/day * Minimal EPS and akathesia, but they can still occur; makes it a great choice for treating *Parkinson's Disease* patients who have psychosis * Associated with orthostatic hypotension and somnolence * Dogs on quetiapine have developed cataracts. FDA recommends pre-treatment ophthalmologic examinations • Some physicians will use this antipsychotic as a sleep agent; but that should be avoided • Has been approved to treat bipolar depression • Can also give for Schizoaffective

Quetiapine (Seroquel®)

6$ with coupon- 90$ without * Mixed affinity for serotonin, dopamine, histaminergic receptors * Optimal control of Schizophrenic symptoms is at 600mg/day * Minimal EPS and akathesia, but they can still occur; makes it a great choice for treating *Parkinson's Disease* patients who have psychosis if thyey cannot afford nuplazid * Associated with orthostatic hypotension and somnolence * Dogs on quetiapine have developed cataracts. FDA recommends pre-treatment ophthalmologic examinations • Some physicians will use this antipsychotic as a sleep agent; but that should be avoided • Has been approved to treat bipolar depression • Can also give for Schizoaffective

Decreased libido in atypical antipsychotics

60 to 70 percent of patients taking paliperidone and risperidone experienced sexual side effects 50 to 60 percent of those on olanzapine, quetiapine, and ziprasidone Less than 50 percent on clozapine 16 to 27 percent on aripiprazole

Nefazodone (Serzone®)

70$ • Chemically similar to trazodone • Has been associated with priapism and hepatotoxicity * BID dosing, but very variable dosing range (between 100-600mg per day) * Has SSRI action but also with 5HT-2 blockade * No sexual side effects, may actually help * Less sedating than trazodone, also associated with dizziness and headache * Highly protein bound (99+%) and significant P-450 3A4 inhibitor

Sertraline (Zoloft®)

9$ FDA approved for the treatment of MDD, panic disorder, social anxiety disorder, OCD, PMDD, PTSD and OCD in kids. * Given in the AM secondary to an energizing effect. * FDA approved for OCD in children and adults. * Nausea, headache and diarrhea are common side effects. * Active metabolite half-life is about 2.5 days.

Amoxapine (Ascendin®)

A breakdown product of the anti-psychotic loxitane. Therefore, it can cause the anti-psychotic side effects such as NMS, TD, and EPS. • While it would initially seem to make sense to use this medication for psychotic depressions, it makes more sense to use two medications (an anti-depressant and an anti-psychotic) so the anti-psychotic could be discontinued as soon as the psychosis was controlled (thereby avoiding nasty side effects).

Things to check prior to starting stimulants in children

A comprehensive, cardiovascular-focused patient history, family history, and physical examination should be completed. ●The child's baseline height, weight, blood pressure, and heart rate should be measured. ●A pretreatment baseline should be established for common side effects associated with pharmacotherapy for ADHD (eg, appetite, sleep pattern, headaches, abdominal pain). ●Adolescent patients should be assessed and treated for substance use or abuse [7].

• Rivastigmine (Exelon®)

Acetylcholinesterase and butyrylcholinesterase inhibitor that slows the progression of AD • May work better in later stages of AD, when butyrylcholinesterase is more prevalent • Requires BID dosing • Problems with nausea, vomiting and diarrhea • Not as well tolerated as other acetylcholinesterase inhibitors

Donepezil (Aricept®)

Acetylcholinesterase inhibitor • Well tolerated and easy to dose • Most commonly seen side effects are nausea and diarrhea • Has become a "drug of choice" for AD

Suvorexant (Belsomra®)

Acts as an orexin receptor antagonist; therefore decreasing the activity of orexin (which promotes wakefulness), which acts as make one sleepy • May be addictive; big problems with next day sleepiness (espercially at 20 mg dose) • Side effects include headache, somnolence, abnormal dreams, diarrhea • Studies found that it made people sleep 6 minutes earlier and stay asleep 16 minutes longer • Can cause walking, eating, and having sex while asleep Not my first choice

Benzodiazapines: Generalized Anxiety

All the above anxiolytics except for temazepam, triazolam, eszopiclone, ramelteon, zaleplon and zolpidem (they are sleep medications)

Clozapine (Clozaril®) 85$ with coupon

Almost free of EPS and TD * Approved for the treatment of refractory schizophrenia and to reduce the risk of suicidal behaviors in schizophrenic and schizoaffective patients * Clozapine can cause fatal agranulocytosis in about 1% of patients and there must be weekly checks of the patient's WBC level for the first 6 months of treatment; after that the WBC can be checked bi-weekly. 95% of cases occur in the first six months. Period of biggest risk is between weeks 4 and 18 * Causes severe sialorrhea (drooling) and weight gain (40-45 lbs in 6 mos). * Low affinity for D2 receptors, high for D4 receptors and is also a 5HT-2 antagonist. * Seizures are a significant risk (4% when at 600mg daily and above) and postural hypotension are common. • Has FIVE black box warnings: Seizures, agranulocytosis, myocarditis, Cardiovascular/cardiorespiratory collapse and increased mortality when treating elderly demented patients • Do not use with other medications that suppress bone marrow (like carbamazepine, phenytoin, etc.) • Usually no effect under 200 mg, and you don't want to give above 500mg • Because of the risk of agranulocytosis they must fail two other antipsychotics

• Oxcarbazepine (Trileptal®)

An analog of carbamazepine; may be helpful as an antimanic agent, but minimal data to support this • No blood levels necessary • No blood dyscrasias • 3-5% develop hyponatremia; need to monitor, especially in elderly • May inactivate oral contraceptives

Contrave (buproprion/naltrexone)

Anorexiant; Antidepressant, Dopamine/Norepinephrine-Reuptake Inhibitor; Opioid Antagonist Used in (BMI) of ≥30 kg/m2 or ≥27 kg/m2 in the presence of at least one weight-related comorbid condition titrate up by one tablet every week until its 2x in the morning and 2x at night If they haven't lost 5% at 3 months, give up. Not gonna work. Side effects- nausea/GI/HA Increased suicidality in teens and young adults, just like normal welbutrin. Just like Buproprion- decreases seizure threshhold. Just liek naltrexone- Blocks opiod receptors, so patients will not get high on opiods, but they can sill overdose if they keep trying to get high. Also, they are at risk of overdose due to re-sensitization if they start and then stop

Bipolar treatment strategy

Attempt to prescribe only two medications, although three may be necessary The combined drugs should not have the same or opposing mechanisms of action 1st line should always be what controlled their initial manic episode. 1st line for mania is usually a second generation antispychotic. If they start to break through that medication, or fail it second line is lithium or one of the mood stabilizers. 2nd line Lithium (fewest suicides) (reduces relapse by 30%) Valproate (divalproex) (30%) Quetiapine (16%) Lamotrigine (better tolerated than lithium, similar efficacy) 3rd line (just as good, but less consistant in studies) (olanzapine not tolerated well due to weight gain) Aripiprazole (oral or long acting injectable formulations) Olanzapine Risperidone Lithium or Valproic acid + one of the antipsychotics (best is quetiapine) are superior to single drugs. never use an SSRI as monotherapy, short half life antidepressants and wellbutrin can be used in severely depressed patients, but azre generally avoided alltogether in patients who have a Hx of medication induced/withdrawl induced mania.

Anxiolytics CSA schedule

Benzodiazepines- Schedule 4 Buspirone- Not a controlled substance Pregabalin (lyrica)- Schedule 5

Anticholinergics and general info

Benztropine (Cogentin®) Trihexiphenidyl (Artane®) Diphenhydramine (Benadryl®) Amantadine (Symmetrel®) I. General Anticholinergics block acetylcholine, which acts as a neurotransmitter, but also acts throughout the body as the chemical transmitter for the parasympathetic nervious system. So when it is blocked, you become dry as a bone, blind as a bat, etc. • These medications are used to treat the extra-pyramidal side effects (EPS) of antipsychotics. • Note that these are all anti-parkinsonian medications (sort of makes sense if you take the dopamine hypothesis into mind) • Can use IV benztropine or diphenhydramine to treat acute dystonic reactions or oculogyric crises • Watch out for anti-cholinergic delirium in debilitated patients on more than one medication with anti-cholinergic properties (reverse with physostigmine) These (particularly cogentin or diphenhydramine) are given with IM injections of haldol, especially if they are antipsychotic naive to prevent acute dystonic reaction. in general, you do not give these prophylactically for SGA unless the patient has a history of susceptability to EPS symptoms.

Atypical Anti-Depressants

Bupropion (Wellbutrin®, Wellbutrin-SR®, Wellbutrin-XL®) Trazodone (Desyrel®) Nefazodone (Serzone®) Mirtazapine (Remeron®) Vilazodone (Viibryd®) Vortioxetine (Trintellix®)

Thioridazine (Mellaril®)

Can cause retinitis pigmentosa at doses greater than 800mg/day * Recently "Black boxed" by the FDA secondary to QTc interval prolongation

The Low Potency Conventional Antipsychotics and general info

Chlorpromazine (Thorazine®) Thioridazine (Mellaril®) I. General • Low potency agents have less EPS, but more orthostatic hypotension, sedation and anticholinergic effects than high potency agents • These meds (more so than the high potency agents) lower the seizure threshold.

Atypical Antipsychotics (AAs)

Clozapine (Clozaril®) Risperidone (Risperdal®) Olanzapine (Zyprexa®) Quetiapine (Seroquel®) Ziprasidone (Geodon®) Aripiprazole (Abilify®) Paliperidone (Invega®) Iloperidone (Fanapt®) Asenapine (Saphris®) Lurasidone (Latuda®) Brexpiprazole (Rexulti®) Cariprazine (Vraylar®) Pimavanserin (Nuplazid®) These medications can treat the negative symptoms of schizophrenia • many Do not have the sedative effects commonly seen in the low potency conventional antipsychotics *always warn about skin conditions (sjs/TENS) some are worse than others -Dosing at bedtime is generally preferred because of the sedation associated with many of these drugs, but medications work equally well irrespective of the time of the dose.

Additional Prescription Requirements

Clozapine- Clozapine REMS program Buprenorphine- Additional licencing.

Nonbenzodiazapine anxiolytic general info

Currently the major non-BDZ anxiolytic is Buspirone (Buspar), • If the benzodiazepines are a fine wine, buspirone is Mad Dog 20/20 • Buspirone works best in people who have never been on a benzodiazepine before. These persons have never experienced BDZ's and are more willing to let buspirone work. Once you've had "the good stuff" (BDZ) you never want to go back to the inferior stuff (non-BDZ). • Buspirone is an excellent medication for patients with a history of substance abuse (you worry about the addiction potential) • Buspirone is not a good medicine for acute anxiety, as it takes about 3 weeks to work.

Nonbenzodiazapine anxiolytic general info

Currently the major non-BDZ anxiolytic is Buspirone (Buspar), • If the benzodiazepines are a fine wine, buspirone is Mad Dog 20/20 • Buspirone works best in people who have never been on a benzodiazepine before. These persons have never experienced BDZ's and are more willing to let buspirone work. Once you've had "the good stuff" (BDZ) you never want to go back to the inferior stuff (non-BDZ). • Buspirone is an excellent medication for patients with a history of substance abuse (you worry about the addiction potential) • Buspirone is not a good medicine for acute anxiety, as it takes about 3 weeks to work. Pregabalin- Off label use. Is on of the go to drugs for fibromyalgia.

The Others That Don't Fit Anywhere Else:

Disulfiram (Antabuse®) Clonidine (Catapres®) Atemoxetine (Strattera®) Sodium Oxybate (Xyrem®) Buprenorphine/naloxone (Suboxone)

Pimozide (Orap®)

FDA approved in the USA only for Tourette's Syndrome. * Has cardiac effects at higher doses * It is a cytochrome P-450 2D6 substrate, so be wary using it with a 2D6 inhibitor like fluoxetine or paroxetine

Tardive dyskonesia treatment

First line in treatment is to remove the medication, and start them on a SGA instead. Prevention and removing the medication are the two most important things. if they fail that move to clonazepam next step is to start on Benzodiazepine (low dose clonazepam) (gaba is depleted), botulism injections, and tetrabenzine are all ways to decrease symptoms. especially helpful if they also have anxiety. FOr more severe cases you can give botulin toxin injections, and/or tetrabenzine. Last line for unresponsive patients is deep brain stimulation.

The Serotonin Selective Re-uptake Inhibitors (SSRI's)

Fluoxetine (Prozac®) Sertraline (Zoloft®) Paroxetine (Paxil® and Paxil-CR®) Fluvoxamine (Luvox®) Citalopram (Celexa®) Escitalopram (Lexapro®)

Anxiolytics

For anxiety you use an SSRI, and give a benzo for acute exacerbations. Once the SSRI begins to take effect you taper the benzos off slowly to avoid dependence and withdrawl. Also start CBT. Don't give if they have a Hx of substance abuse. A- alcohol withdrawal, K- Renal metabolism, Z- General Anxiety P-Panic Disorder,I- Insomnia (Equivalent dose in mg) ( T1/2 , Metabolite T1/2) Specific Actions .25 Triazolam 2 (Halcion®) Z .25 Clonazepam 18-50 (Klonipin®) Z, P .5 Alprazolam 6-12 (Xanax®) Z, P 1 Lorazepam 6-12 (Ativan®) A, K, Z, P 5 Diazepam 20-100 36-200(Valium®) A, Z, P 10 Temazepam 8-72 (Restoril®) K, I 15 Oxazepam 4-15 (Serax®) A, K, Z, P 25 Chlordiazepoxide 5-30 36-200(Librium®) A, Z, P, I Non-Benzdiazepines Buspirone (Buspar®) Z Pregabalin (Lyrica®) Z

CBD oil (Cannabidiol)

Given for a specific type of seziure.... nothing in the psych world. Several studies have shown that it may have an effect on depression, anxiety, pain, ETC, ETC. More research is needed to assess its efficacy and safety. In general, research is needed to assess its efficacy and safety and at this time I wouldn't suggest it. I can't prescribe it any marijuana anything, they would have to go to a Marijuana Dr. Plus just because something is legal doesn't mean it is good for you. Also, don't believe

atypical antipsychotics available as rapidly dissolving

Good for patients that "cheek" their medication aripiprazole,olanzapine, and risperidone. asenapine, clozapine

The Psychostimulants:

Half-life Methylphenidate (Ritalin®) 4 hours Dextroamphetamine (Dexedrine®) 4 hours Modafinil (Provigil®) 15 hours -If stimulants don't work, or If you're worried about Rx abuse in pt or family use atomoxetine (strattera) (an SNRI) instead of one of the stimulants.

The Psychostimulants:

Half-life Methylphenidate (Ritalin®) 4 hours Amphetamine (Adderall) 10 hours Dextroamphetamine (Dexedrine®) 4 hours Modafinil (Provigil®) 15 hours -If stimulants don't work, or If you're worried about Rx abuse in pt or family use atomoxetine (strattera) (an SNRI) instead of one of the stimulants.

The High Potency Conventional Antipsychotics and general info

Haloperidol (Haldol®) Fluphenazine (Prolixin®) Perphenazine (Trilafon®) Trifluoperazine (Stelazine®) Thiothixene (Navane®) Pimozide (Orap®) I. General • High potency agents have higher incidences of EPS than low potency agents • Dystonic reactions are common (Jaw is the #1 area affected) • There are two long acting IM (Decanoate) forms: Haloperidol and Fluphenazine • All treat the positive symptoms of schizophrenia equally well. • Negative symptoms much harder to treat. • Low anticholinergic effects, Low orthostatic hypotension • Low sedative effects compared to the low potency agents. • Often given with ativan • Given with cogentin or benadryl to prevent EPS

Treatment of acute mania

Hypomanic- monotherapy with risperadol, zyprexa, or any other Rx listed below) Manic- 1st line is lithium Plus an antipsychotic (abilify, olanzapine, risperidone, (can use haldol if severe) all show 20% more efficacy and shorter response than lithium alone, though akasthesia is higher) Valproate (depakote) can also be used instead of lithium if lithium cannot be tolerated. If one doesn't work, switch to another. Avoid Geodon, wont help don't add an antipsychotic to carbamazepine, it increases metabolism. Treatment of acute mania: • All the classic mood stabilizers take between 3-5 days to begin working. Initially, you may have to also treat your manic patient with a sedating agent to calm them down until the mood stabilizer kicks in -goal is remission (reduce to 1-2 mild symptoms and no psychosis) - if the pt is not responding, check their blood levels of the medication. (not for 2nd gen antipsychotics, they don't have set theraputic levels) -D/C antidepressants abruptly, any drugs, alcohol, cafeine, or nicotene. depending on symptoms and SI, inpatient, partial hospital, or outpatient treatment may be necessary. -If the pt does not show improvement by the first week, it is unlikely that they will remit by week 3. Improvement in week one is a good indicator of remission by week 3.

Wellbutrin IR VS SR Vs XL

IR-Immediate release, used 3-4 times daily (not used as much because its more pills, and more side effects), better if they have insomnia Usually SR- (sustained release)12-hour- one in the morning and one at night. XL- 24-hour extended-release formulations (hydrochloride salt): once a day, however formula is different (hydrobromide vs hydrochloride) XL is the one we usually go with.

Abilify in OCD

If a pt is taking an SSRI (Zoloft or Prozac in kids) and it just isn't cutting it, you can add a low dose of Abilify for 60-90 days. It will push the Zoloft over the treatment edge, but isn't long enought to usually start up their EPS. (For OCD as a last resort get an EKG and switch to a tricyclic)

Tricyclic Antidepressants

Imipramine (Tofranil®) Desipramine (Norpramin®) Amitriptyline (Elavil®) Nortriptyline (Pamelor®) Doxepin (Sinequan®) Clomipramine (Anafranil®) Amoxapine (Ascendin®)

Eszopiclone (Lunesta®)

Improves sleep quality, onset and maintenance • Studies show that effects last over one year • Unsure of mechanism of action • Has longer half-life, so very good for sleep maintenance • Usual dose: 2-3mg daily (adult); 1-2mg daily (elderly)

EPS

Includes akathisia, parkinsonism, and dystonias. All of the antipsychotic medications have the potential for causing EPS, though SGA are much less common than FGA Patients starting an antipsychotic medication should be evaluated for EPS weekly until the medication dose has been stable for at least two weeks. Two weekly assessments should also follow any significant dose increase [3]. Once the patient's dose has been stabilized, the frequency of EPS assessment should depend on the patient's sensitivity to EPS and the EPS liability of their antipsychotic. (

Treatment of Bipolar disorder in children/adolescents

Initial pharmacotherapy for pediatric mania is a second-generation antipsychotic, such as aripiprazole, asenapine, olanzapine, quetiapine, risperidone, or ziprasidone. If there is partial response, add lithium. If there is no response, taper the antipsychotic down and add lithium.

Olanzapine IM (Relprevv®)

Injections can be given q2 weeks or q4 weeks • Weight gain common • Post Injection Delirium Syndrome (PIDS) occurs in one percent of patients; after any injection at any time patient can become sedated, sleepy or comatose • Patients must be watched for a minimum of three hours after each injection; patients should not be alone after injections

Aripiprazole (Abilify®)

Kind of the go to drug for atypicals. generic and maintaina 25$ with coupon, 750 without. Aristada 2500 with coupon (wow) * Mixed dopamine agonist/antagonist; must cross taper slowly when switching from another agent * Available as a rapidly acting injection and as a dissolving wafer (that is not rapidly acting) • Available as two long acting injectables: • Maintena - q4 weeks; need to dissolve powder in water • Aristada - q4-6 weeks; pre-filled syringe o Forgiving with Missed dose allows several weeks of coverage once it has been built up o Allows multiple dosing options * Significantly improves positive and negative symptoms at 15mg/day, but positive only at 30mg/day • Weight neutral • Most common side effects are headache, somnolence and agitation • FDA approved for the treatment of irritability asociated with autism • Now associated with compulsive behaviors like gambling, eating, shopping and having sex • For maintaina you need pills for two weeks, and for abilify you need three weeks of pills before you switch to the shots • Invega is easier than these two injections because you can give it right away (but it causes sexual side effects and prolactin and abilify doesnt). • *Good for patients who are overweight, DM, etc.* • Use these for schizophrenia, but not schizoaffective. - Approved for bipolar, but don't give if they have a history of gambling, shopping, poor deciscions with sex ETC with their manic episodes. • Twitching with OD

Gabapentin (Neurontin®)

Large, double blind studies have failed to differentiate gabapentin from placebo in the treatment of bipolar disorder • Indirectly increases brain GABA levels • Has sedative and anxiolytic properties • Completely renally metabolized • No blood levels necessary

The Mood Stabilizers: and general info

Lithium Carbamazepine (Tegretol®) Valproic Acid (Depakote®) Lamotrigine (Lamictal®) Gabapentin (Neurontin®) Topiramate (Topamax®) Oxcarbazepine (Trileptal®) I. General • These are used for treatment of Type I, Type II or rapid cycling bipolar disorder. • Some (along with beta blockers) can be used to treat aggression and violence. • All the classic mood stabilizers take between 3-5 days to begin working. Initially, you may have to also treat your manic patient with a sedating antipsychotic agent( abilify, haldol, or zyprexa IM) to calm them down until the mood stabilizer kicks in

Benzodiazapine :Alcohol Withdrawal

Medications: Lorazepam, Diazepam, Chlordiazepoxide, Oxazepam General: These are the best medications to withdraw someone off alcohol. Chlordiazepoxide works well because of it's long half life. Lorazepam and Oxazepam are preferred in liver failure patients

Tricyclic General Info

Major use is the treatment of Major Depression and associated affective states. • Usually given at night because of sedating effects. Amitriptyline and Doxepin are probably the most sedating. • Very easy to overdose on TCA's: LD 50 is about 1000mg (about 7 days worth). • A Therapeutic Window exists for Nortriptyline. This means that if you exceed the range, or have a blood level lower than the range, the medication will not work (this has nothing to do with side effects). The other TCA's still work above the therapeutic window, and dose is only limited by side effects and the patient's ability to tolerate them. • Imipramine is metabolized into (Imipramine + Desipramine), while Amitriptyline is metabolized into (Amitriptyline + Nortriptyline). • These were the drugs of choice until 1988 when the SSRI's came on the scene. • Imipramine, Desipramine and Nortriptyline are occasionally used to treat ADHD. • The TCA's can also be used to treat enuresis in children • All the TCA's have some efficacy in the treatment of Panic Disorder. • Treat depression by modulating norepinephrine. • Side Effects include: *Anticholinergic Symptoms:* orthostatic hypotension, blurry vision, constipation, urinary retention, dry mouth. * Cardiac Effects:* This is the cause of death in overdose. Cardiac conduction is blocked and the heart stops. End of story. * Decreased Libido *

Carbamazepine (Tegretol®)

May be the drug of choice (along with valproic acid) for rapid cycling bipolar disorder. • Most serious side effects include hepatitis, blood dyscrasias and skin reactions * has significant teratogenic effects (neural tube defects, fingertip hypoplasia, low set ears) * Initially, there is a small decrease in the WBC in a minority of patients. However, as there have been reports of aplastic anemia and agranulocytosis, so the WBC must be checked regularly. * In times of toxicity, diplopia is commonly seen as a side effect. • Remember, it induces it's own metabolism • May develop rashes which may progress to SJS or EM • May inactivate oral contraceptives - Inactivates 2nd gen antispychotics due to increased metabolism

Renal Metabolism Benzodiazapines

Medications: Lorazepam, Oxazepam, Temazepam [L-O-T] General: These meds are both renally and hepatically metabolized. Therefore, it makes sense to use these in patients with cirrhosis. Example: If a person with cirrhosis needs something for ETOH withdrawal, you might choose a medication also metabolized in the kidney such as oxazepam and lorazepam.

• Ramelteon (Rozerem®)

Melatonin receptor (MT1 & MT2) agonist for insomnia • Half-life is 1-2.6 hours • Not recommended for those with COPD or sleep apnea • Usual dose is 8mg nightly • May increase prolactin and decrease testosterone Not my first choice due to side effects Only non scheduled sleep medication. ...just give them melatonin

Bupropion (Wellbutrin®, Wellbutrin-SR®, Wellbutrin XL®, Zyban®) 42 (19 with coupon)

NE/Dopamine reuptake inhibitor * Minimal sexual side effects, may even be helpful. * Decreases seizure threshold. The maximum dose is 450mg/day (IR and XL) or 400mg/day (SR). Maximum single dose is 150mg (IR) or 200mg (SR). This medication cannot be used in persons with a history of seizure disorder or an eating disorder. * Comes in immediate release (TID) and long acting forms (BID and QD) * Useful for depression, smoking cessation and possibly ADHD * New research states that bupropion may cause less manic overshoot (in bipolar patients) than other anti-depressants. * It structurally resembles amphetamine, and can therefore cause agitation, weight loss and insomnia in some patients. • Generally a well tolerated medication • Inhibits CYP P450 2D6 isoenzyme -pregnancy class B (most other antidepressants are class C)

Can PAs prescribe controlled psychiatric drugs to juveniles.

No, which is a major pain when it comes to treating kids with ADHD.

Guanficine (intuniv, Tenex)

Non stimulant ADHD Medication ages 6-17 Alpha2-Adrenergic Agonist; Antihypertensive Biggest side effect is that it is sedating. Recommended to be used as part of a comprehensive treatment program for attention-deficit disorders; safety and efficacy of long-term use for the treatment of ADH (used along with other ADHD drugs)

anti alzheimers CSA schedule

Not Controlled

Contrave (buproprion/naltrexone)

Not Controlled Anorexiant; Antidepressant, Dopamine/Norepinephrine-Reuptake Inhibitor; Opioid Antagonist Used in (BMI) of ≥30 kg/m2 or ≥27 kg/m2 in the presence of at least one weight-related comorbid condition titrate up by one tablet every week until its 2x in the morning and 2x at night If they haven't lost 5% at 3 months, give up. Not gonna work. Side effects- nausea/GI/HA Increased suicidality in teens and young adults, just like normal welbutrin. Just like Buproprion- decreases seizure threshhold. Just liek naltrexone- Blocks opiod receptors, so patients will not get high on opiods, but they can sill overdose if they keep trying to get high. Also, they are at risk of overdose due to re-sensitization if they start and then stop

Atypical antidepressant CSA Class

Not a controlled Substance

Mood Stabilizers CSA class

Not a controlled substance

SSRI CSA Class

Not a controlled substance

atypical antipsychotics CSA Class

Not a controlled substance

SNRI CSA Class

Not a scheduled drug

Disulfiram (Antabuse®)

Not controlled * Used as aversive therapy to alcohol consumption * Can cause ataxia, and leave a metallic taste in the mouth * It blocks aldehyde dehydrogenase * Can be very hepatotoxic, watch patient's LFT's during treatment. * The biggest problem is that a patient will think that he can drink while on disulfiram which could lead to vomiting, then increased ICP and a possible CVA.

Tetrabenzine (Xenazine)

Not controlled Central Monoamine (seratonin, NE) -Depleting Agent; Vesicular Monoamine Transporter 2 (VMAT2) Inhibitor 1st line for Tourettes Contraindicated in actively suicidal patients. Used for Chorea in Huntingtons, but be careful as they are often suicidal. Monitor for akasthesia, depression, NMS, elevated prolactin, orthostatic hypotension.

Acamprosate (campral)

Not controlled Helps curb craving for alcohol, only started after the pt is through DTs once they have achieved abstinence and should be maintained if patient relapses. Should be used as part of a comprehensive program. decrease dose and do not use first line if the Pt has renal impairment. Acts on and restores balance to GABA and glutamate (a neurotransmitter) activities which appear to be disrupted in alcohol use disorder.

Fibanserin (Addyi)

Not controlled Mixed seratonin agonist and antagonist Treats hypoactive sexual disorder in women Not indicated for the treatment of HSDD in postmenopausal women or in men, or to enhance sexual performance. Contraindicated with alcohol (hypotension and syncope), and hepatic impairment, Side effects: dizzyness, drowsiness, nausea

Naltrexone (Vivitrol)

Not controlled Not to be confused with Naloxone (Narcan) Opiod antagonist used in Alcohol use disorder and opiod dependence, off label for gambling disorders. Patient must be opiod free for 7-10 days to prevent a sudden and severe withdrawal. Must get a drug test prior to starting. Blocks opiod receptors, so patients will not get high on opiods, but they can sill overdose if they keep trying to get high. Also, they are at risk of overdose due to re-sensitization if they start and then stop Can be given in pill or long acting injection Can be hepatotoxic, don't give to liver failure patients and monitor for hepatitis. Rare but serious side effects:Monitor for eosinophilic PNA, increased thoughts of suicide, and injection site reactions/necrosis.

Atemoxetine (Strattera®)

Not controlled (only med PAs can give for ADHD) * A non-stimulant treatment of ADHD * It is a norepinephrine re-uptake inhibitor (NRI), sort of like the TCA's * Theoretically, should work for treating depression, no recent studies * Most common side effects include insomnia and decreased appetite. • May cause increased heart rate or hypertension • Metabolized via the CYP 2D6 isoenzyme • Discontinue medication if jaundice occurs; a few cases of severe liver damage _priaprism may occur in rare cases.

Tricyclic CSA Schedule

Not controlled drugs

Med to give when Determining ADHD Vs Bipolar or ADHD VS depression

Often fixing the mood disorder ends up fixing the ADHD Bipolar- Abilify works for both. Depression- Wellbutrin.

The Mono-Amine Oxidase Inhibitors (MAOI's) General Info

On the Boards, this is the Drug of Choice for an Atypical Depression (hypersomnia, hyperphagia,weight gain, reverse diurnal variation) • May be used to treat Panic Disorder • During a six month regimen, a patient should not be surprised to have a 40 - 50 pound weight gain. • Hypotension is the most common side effect. • A hypertensive crisis can develop if the patient eats foods with tyramine in them (cheese, pickles, pizza, pepperoni, salami, beer, fava beans, etc.). A person can have a raise in BP so extreme that a CVA could develop. • These may decrease a patient's libido • Tranylcypromine is a methylphenidate analog and has stimulant properties. Don't give after 3PM so the patient can sleep. • Cannot be used with SSRI's, venlafaxine, dextromethoraphan or meperidine because of a possible serotonin syndrome. • By inhibiting MAO, this decreases the degredation of serotonin and norepinephrine, thereby increasing NE and 5HT levels.

Valproic Acid (Depakote®)

Possibly hepatotoxic, more worrisome in the very young on dual anti-seizure medications. (Which is why if they have a Kidney problem you give DepaKote, but if they have a Liver problem you give Lithium) * Also teratogenic (neural tube defects) * Drug of choice for rapid cycling bipolar disorders. * May cause polycystic ovary disease in some young women * May cause significant weight gain • Has been associated with the development of thrombocytopenia (ITP) • Available in a once daily, extended release formulation (Depakote ER)

• Topiramate (Topamax®)

Potentiates the action of GABA (primarily an anti epileptic drug) • A large number of placebo controlled studies failed to find any eveidence of antimanic activity (so use would be off label) • Some patients lose substantial amounts of weight (used off label to counteract antipsychotic weight gain) • Patients are at increased risk for developing renal stones • Has been reported to cause "cognitive dulling"

Nudexta (dextromethorphan and quinidine)

Pseudobulbar affect- innapropriate laughing or crying, often seen in disease/injury to the brain Stroke Amyotrophic lateral sclerosis (ALS) Multiple sclerosis (MS) Traumatic brain injury Alzheimer's disease Parkinson's disease Anticholinergic, DIzziness, hepatotoxic, hypersensitivity reactions, thrombocytopenia,

FL PA schedule II drug laws

Prescribing privileges are limited to a seven day Supply. After that, the prescription needs to be filled out by the attending. (PAs can't abuse it by having them refill on a weekly basis either) require a written prescription which must be manually signed by the practitioner or an electronic prescription that meets all DEA requirements for electronic prescriptions for controlled substances No calling in perscriptions, no refills. Basically the PA never signs for these, they get the doc to sign for a 30 day prescription, and to sign for childrens prescription. You can, but technichally Just don't write for 7 day supply. Stimulants- you date for today, and say "do not fill until XXX" You can write for up to three months at a time, three separate 30 day prescriptions and have the doc sign off on it.

Prolactin in atypical antipsychotics

Prolactin secretion is inhibited by dopamine, so antispychotics causes elevated prolactin by decreasing dopamine. Sx:gynecomastia, galactorrhea, menstrual disturbances, sexual dysfunction, and infertility. A serum prolactin level is needed if they develop these symptoms. risperidone and paliperidone are the antipsychotics most assosciated with elevated prolactin, and pt's on these Rx should be asked about the above symptoms every six months. Second is asenapine , olanzapine, Pretty much all other atypicals are assosciated with little to no change in prolactin.

Modafinil (Provigil®)

Promotes wakefulness through unknown mechanism • FDA approved for excessive sleepiness due to narcolepsy, OSA, and shift work sleep disorder • A favorite of the rave crowd as there is no rebound sleepiness • Has been tried as a treatment for ADHD • Use with caution in those with pre-existing psychosis; may activate

Lamotrigine (Lamictal®)

Recently approved for bipolar disorder (mania and depression; not good for acute control) * Inhibits glutamate release which decreases CNS excitability * Pregnancy category "C" * No blood levels necessary * Major side effect is severe rash (which may become SJS) that occurs in 0.3% of adults who take it. * Recommend starting at a low dose and move up VERY slowly • Concurrent use of valproic acid requires lower lamotrigine dose, as valproic acid inhibits lamotigine's metabolism, leading to higher levels • Concurrent use of carbamazeoine requires a higher lamotrigine dose, as carbamazepine induces lamotigine's metabolism, leading to lower levels

buprenorphine/naloxone (Bunavail; Suboxone; Zubsolv)

Schedule 3 Opiod agonist used in treating opiod dependence. the narcan is added so that they cannot shoot it up. Normally given sublingually or buccally, which will not activate the narcan. (Sublingual preferred as the chance of activating the Narcan is lower) Started when they start to have withdrawl symptoms, but it must have been greater than 6 hours since their last opiod use. Must start under supervision. On Day 1, an induction dosage of up to 8 mg/2 (over the course of the day) start with an initial dose of 2 mg/0.5 mg or 4 mg/1 mg buprenorphine/naloxone and titrate at 2-hour intervals On Day 2, a single daily dose of up to 16 mg/4 after day 2, titrage up by 4/1mg daily until pt's withdrawl symptoms are diminished and the pt can continue with their treatment/ life. The recommended target dosage of buprenorphine and naloxone sublingual film during maintenance is 16 mg/4 mg buprenorphine/naloxone/day as a single daily dose. Max dosage 24 mg/6 can be treated indefinitely if needed. Monitor for decreased respiration, abuse, etc

Sodium Oxybate (Xyrem®)

Schedule 3 • Used to treat narcolepsy (hallucinations, cataplexy, sleepiness) • Also known as GHB (date rape drug) • High abuse potential • Must take when already sitting in bed; exceptionally sedating

Schedule III-IV

Schedules III and IV controlled substances may be refilled if authorized on the prescription. However, the prescription may only be refilled up to five times within six months after the date of issue. After five refills or after six months, whichever occurs first, a new prescription is required. May be called in

Parkinsonisms and treatment

Secondary parkinsonism consists of mask-like facies, resting tremor, cogwheel rigidity, shuffling gait, and psychomotor retardation (bradykinesia). First, if feasable, cautiosly reduce the dosage while monitoring for psychosis. 2nd Benztropine (cogentin)- if able to tolerate an anticholenergic medication 2nd amantadine- if unable to tolerate an anticholinergic, or already on an anticholinergic.

Parkinsonisms and treatment

Secondary parkinsonism consists of mask-like facies, resting tremor, cogwheel rigidity, shuffling gait, and psychomotor retardation (bradykinesia). First, if feasable, cautiosly reduce the dosage while monitoring for psychosis. 2nd Benztropine (cogentin)- if able to tolerate an anticholenergic medication (increases dopamine) 2nd amantadine- if unable to tolerate an anticholinergic, or already on an anticholinergic.

Anti-Alzheimer's Medications

Tacrine (Cognex®) Donepezil (Aricept®) Rivastigmine (Exelon®) Galantamine (Razadyne®) Memantine (Namenda®)

When do you need to check Eforce

The PDMP (perscriptian Drug Monitoring program) must be checked each time a prescription for a controlled substance is written. (new law in July 1 of 2018

Dispensing rule for controlled substances

The dispensing of a controlled substance must be reported to the database no later than the close of the next day. Need to register as a dispensing PA.

Chlorpromazine (Thorazine®)

The first major tranquilizer (many side effects, many metabolites, "a dirty drug") * Causes serious skin problems. Severe sunburns are common, there can also be pigment changes on the skin (blue is a common color) • Don't plan to use because of the skin problems and metabolites.

Antidepressants in pregnancy

The risks of untreated moderate to severe maternal major depression, to both the mother and fetus, often outweigh the risks associated with antidepressants. some data suggest that SSRIs (particularly paroxetine) may be associated with a small absolute increase in congenital heart defects, several studies have found no such association. 2 more babies with heart defects out of 1000 babies. Overall SSRI's and SNRI's and Wellbutrin are class C. PAXIL IS CLASS D Prozac and Zoloft are the lesser of the evils when it comes to SSRIs and pregnancy. So if they have to have one then give them that. SSRIs have a 1% higher chance (3% instead of 4%) of postpartum hemerage

Psychostimulants General Info

These are a first line treatment for ADHD. Bupropion, atemoxetine (strattera) and the TCA's can also be used • Can be used to treat depression in the medically ill (especially cancer patients) • May be used to treat narcolepsy. • The most important side effect is tics (like in Tourette's). They usually go away when the stimulant leaves the body. This is why some physicians shy away from pemoline. • Can cause weight loss; can cause insomnia if the stimulant is given after 3PM. • There were a number of cases of hepatotoxicity (with associated liver transplant) associated with pemoline use.

Psychostimulant CSA Classification

They are all schedule 2 Strattera (not a stimulant) is not a scheduled drug but can be perscribed by PAs for juveniles.

Patients who are trying to get more of a controlled substance

This is not a negotiation- the laws have changed, I cannot write for that much Also, don't assume drug seekers. always clarify "why do you ask for X"

Antidepressants and breastfeeding

Use paxil or zoloft (and therapy!) for postpartum depression Patients with postpartum mental disorders who require pharmacotherapy should generally not be discouraged from breastfeeding All psychotropic medications are transferred to breast milk in varying amounts and thus are passed onto the nursing infant.Exposure can generally be decreased by choosing medications with shorter half-lives and greater protein binding which is why Paxil and Zoloft levels are usually undetectable, and why they are most often used. The drug should be started at the lowest effective dose and titrated slowly. Pediatricians should assess the baby before and during mom's SSRI treatment, If there are any adverse effects, stop.

The Serotonin/Norepinephrine Reuptake Inhibitors (SNRIs)

Venlafaxine (Effexor-XR®) Desvenlafaxine (Pristiq®) Duloxetine (Cymbalta®) Levomilnacipran (Fetzima®) Milnacipran (Savella®) all have a low risk of increasing BP except for Duloxetine, which has none. All can be used to treat chronic pain

labwork prior to antipsychotic treatment

When feasible, laboratory evaluations should be initiated before starting an antipsychotic. With the exception of patients treated with clozapine, the antipsychotic can usually be started before the results of laboratory tests are available. ●CBC, electrolytes, fasting glucose, lipid profile, liver, renal and thyroid function tests ●White blood cell (WBC) count with differential for patients treated with clozapine ●ECG for patients with a cardiac history or those being treated with antipsychotics that may prolong the QT interval such as clozapine, thioridazine, iloperidone, ziprasidone.

Psychostimulant Dosing

While titrating dose, start at the lowest dose and go up. Titration phase lasts 1-3 months, and requires close monitoring by the physician (some of which is done over the phone. The optimal dose is the dose at which target outcomes are achieved with minimal side effects. - in younger kids (preschool) you want to start with CBT, then add methylphenydate (rittalin), its more effective in their age group. Use short acting forms in preschool kids. (more sensative to dose dependant adverse effects. -In grade school kids start CBT, Home behavioral interventions, and start on a stimulant methylphenedate and amphetamines (adderol) are pretty similar. You give older kids (6 and up) the longer acting forms of the medications, starting with the lowest dose and titrating up. -if older kids do well in school, but poorly when they get home, you can give them a long acting in the morning, and a short acting as soon as they get home. -The exact treatment that you use is going to vary based on weather or not the child can actually take pills. (see word document)

Tardive Dyskenesia

Why you don't give the antipsychotis if you don't have to. And why you don't give them alongside the antiemetic metoclopramide. Always inform patients of the risk of TD before starting antipsychotics. Always monitor during sessions. risk increases with age and exposure. remission in 50 to 90 percent of patients. Remission of TD usually occurs within several months after withdrawal of the offending agent, but may occur as late as in one to three years [6].

Insomnia Medications, and what to r/o

Zolpidem (Ambien®) Zaleplon (Sonata®) Ramelteon (Rozerem®) Eszopiclone (Lunesta®) Suvorexant (Belsomra®) Temazepam (Ristoril) Before you use medication make sure it isnt due to a medical disorder (pain, sleep apnea, SOB, restless leg syndrome) or other medication (stimulants, some antidepressants, glucocorticoids, prolonged opiod use) and talk about sleep hygene. Only use a sleep study if you suspect sleep apnea, restless leg, or if they are refractory to multiple medications. Medications: Temazepam, zaleplon, triazolam, zolpidem, eszopiclone and ramelteon are most commonly used. Zolpidem, eszopiclone, ramelteon and zaleplon are non-BDZand should not induce withdrawal. Eszopiclone has a longer half-life (6 hours) and works well in those patients having problems with sleep maintenance ( sonata and ambien put you to sleep, lunesta keeps you asleep. Acute: (due to stress) Eszopiclone or zolpidem for 2-4 weeks. Chronic: CBT+ Eszopiclone or zolpidem with plan to taper off of the medication at 6-8 weeks.

Insomnia medication CSA Schedule

Zolpidem (Ambien®)-4 Zaleplon (Sonata®)-4 Ramelteon (Rozerem®)- Not controlled Eszopiclone (Lunesta®)-4 Suvorexant (Belsomra®)-4 Temazepam (Ristoril)-4

Vesicular Monoamine Transporter 2 (VMAT 2)

a transporter that moves neurotransmitters from the cytosol inside the neuron into the synaptic vessicles, also needed for GABA to unctions

Long-Acting Injectable atypical Antipsychotics

aripiprazole, olanzapine, risperidone, and paliperidone

Tests to get prior to starting lithium, and during treatment

blood urea nitrogen, creatinine, electrolytes, thyrotropin (thyroid stimulating hormone), and an electrocardiogram. These are repeated once a stable blood lithium level has been achieved. serum lithium concentration is retested every Subsequently, lithium serum concentrations, blood urea nitrogen, creatinine, and thyrotropin are measured every three to six months.

switching antipsychotics

changing from one antipsychotic to another is beneficial when the problem is side effect based, but less likely to be beneficial if the problem is efficacy... unless you are switching to clozapine (requires two failures). start clozapine, dont start on two antipsychotics. A standard cross-titration for a stable patient: Simultaneous taper of the current medication with titration of the replacement drug in three to four steps over several days to several weeks. look up discontinuation practices if stopping. Certain drugs like clozapine cause cholinergic rebound if stopped too quickly.

Immediate-release injectable atypical antispychotics

emergency situations, such as an agitated, acutely psychotic patient. aripiprazole, olanzapine, and ziprasidone

Dystonia and treatment

involuntary contractions of major muscle groups, and are characterized by symptoms such as torticollis, retrocollis, oculogyric crisis, and opisthotonos (backward arching of the head and neck). Rare-laryngiospasm can be life threatening. Dystonias that are very disturbing can be treated with 1 to 2 mg of benztropine or 50 mg of diphenhydramine IV or IM Once the acute phase is treated, switch to an antipsychotic with a lower risk of EPS (Quetiapine, iloperidone, then clozapine as a last line) Prophylactic IV or IM Benztropine or diphenhydramine is given prophylactically for IM haldol, but not for SGA.

Anticholinergic CSA Class

not controlled

Akathesia

the most common form of EPS. motor restlessness with a compelling urge to move and an inability to sit still. Individuals with milder akathisia may describe a subjective feeling of restlessness but not show restless motor behavior.

What is the scope of drugs a Physician assistant can write for

the only medications you should write for are those medications authorized by your supervising physician within the scope of his/her practice since you are also limited to practice within the scope of your supervising physician's practice. In a hospital setting the law is different. You may write orders for any medications, including controlled substances.

Tacrine (Cognex®)

• Acetylcholinesterase inhibitor • High incidence of hepatotoxicity; a second line agent • If transaminases reach 3X normal, then discontinue

Galantamine (Razadyne®)

• Acetylcholinesterase inhibitor that slows the progression of AD • Requires BID dosing • Clearance impaired by renal disease (66%) • Nausea and vomiting are common side efffects • It may modulate nicotinic receptors

Desipramine (Norpramin®)

• Breakdown Product of Imipramine • Usual dose of 150-300mg daily • Approved by FDA for the treatment of adolescent depression • Used to be very commonly used for ADHD, but there have been multiple episodes of cardiac sudden death.

Memantine (Namenda®)

• NMDA antagonist • Often used in conjunction with an acetylcholinesterase inhibitor • Protects cells from glutamate a neurotransmitter created in excess in Alzheimers that can be cytotoxic. • Relatively well tolerated; dizziness and headache are most common

Nortriptyline (Pamelor®)

• The TCA of choice for use in the elderly (secondary amine); has the least orthostatic hypotension • Usual dose of 75-150mg daily • Has been used with ADHD • Mildly sedating • Therapeutic window

Amitriptyline (Elavil®)

• The TCA with the most orthostatic hypotension. The elderly should avoid this, as they may fall and break their hips. • Usual dose 150-300mg daily • Also is very anti-cholinergic. • Commonly used for Chronic Pain. • Used by many as a treatment for insomnia, but too many side effects.

Transdermal Selegiline (Emsam®)

• Usual dose 6mg, 9mg or 12mg daily • Patch must be changed on a daily basis • No dietary restriction at lowest dose; 9 and 12mg doses require tyramine free diet • Low doses inhibit MAOB, not gut MAOA • At higher doses, becomes a non-selective MAO inhibitor • Need a two week "wash out" before starting a new antidepressant or lifting dietary restrictions

Doxepin (Sinequan®)

• Very sedating; often used to induce sleep • Usual dose 100-300mg daily • Very orthostatic • Approved for treatment of depression in adolescents • Very antihistaminergic; dermatologists use doxepin cream for the antihistaminergic effects

Contraindications/ risk factors to benzodiazepine or nonbenzodiazepine hypnotics

●Pregnancy - Sedative-hypnotics may increase the risk of fetal malformations if used during the first trimester. ●Alcohol consumption - Sedative-hypnotics should not be combined with alcohol because there is a risk of excessive sedation and respiratory suppression whenever central nervous system suppressants are combined. ●Renal or hepatic disease - Most sedative-hypnotic medications undergo hepatic and renal clearance. Metabolic clearance may be delayed in patients who have renal or hepatic disease, leading to accumulation and excessive sedation. ●Pulmonary disease or sleep apnea - Many sedative-hypnotics are respiratory suppressants that can worsen obstructive sleep apnea or hypoventilation. ●Nighttime decision makers - Sedative-hypnotics should not be taken by individuals who may be called upon to make important decisions during the night (eg, clinicians on-call or single parents responsible for the care of young children) because they can cause excess sedation and impair decision-making. ●Older adults - The risk of adverse effects is increased in older adults, especially those who are older than 75 years. This is a consequence of multiple comorbidities and central nervous system changes associated with aging. (See 'Older adults' below.)