Phenytoin (Dilantin)

Phenytoin (Dilantin)

• It is a hydantoin
• Other medications include Fosphenytoin and ethotoin
• It blocks Na+ channels and increases GABA-mediated inhibition which decreases Ca2+ influx
• It stabilizes the neuronal membrane by altering Na+ influx during nerve impulse generation
• It exerts anti-seizure activity without general CNS depression
• It treats all types of focal and tonic-clonic seizures excluding absence seizures and is used for trigeminal neuralgia
• Side effects includes nystagmus, diplopia & ataxia, ataxia, gingival hyperplasia, hirsutism, sedation, coarsening of facial features (long-term), abnormalities in Vit D metabolism with OM, and fetal hydantoin syndrome
• Nystagmus occurs early
• Diplopia & ataxia are the most common dose-related side effects
• Toxicity can manifest as excitatory signs
• Lethal levels of toxicity can result in decerebrate rigidity
• At plasma concentrations less than 10 mg/L leads to Rare side effects
• Plasma concentrations of 10-20 mg/L may lead to occasional mild horizontal nystagmus on lateral gaze
• Plasma concentrations of 20-30 mg/L can cause Nystagmus
• Plasma concentrations of 30-40 mg/L triggers ataxia, slurred speech, tremor, N/V
• Plasma concentrations of 40-50 mg/L leads to lethargy, confusion, hyperactivity
• Plasma concentrations greater than 50 mg/L may cause coma & seizures
• Monitor bone density and any changes in dentition
• Monitor Cr (baseline), CBC, folate, LFTs, and serum drug levels periodically
• Monitor blood pressure, ECG, and respiratory function continuously during and 20 minutes after IV load
• Get dental exams every 3 months
• Monitor for depression, behavior changes, and SI ideation
• Contraindications includes sinus bradycardia, 2nd or 3rd AV block, and sinoatrial block
• It is important to replace folic acid when taking, as Dilantin blocks absorption
• Increases metabolism of contraceptives, increasing risk of unplanned pregnancy

Donepezil (Aricept)

• It is a reversible cholinesterase inhibitor
• It is an anticholinesterase and a noncovalent reversible inhibitor
• Reversibly binds the active site of acetylcholinesterase.
• Increases intra-synaptic levels of acetylcholine, alleviating cholinergic symptoms of Alzheimer’s disease
• It readily crosses the blood-brain barrier, with a 7-fold higher CNS concentration compared to plasma
• It treats mild to moderate Alzheimer’s disease
• It produces a small improvement in cognition and daily activities
• Lack of response in some patients may result from the loss of presynaptic release of acetylcholine, caused by disease progression
• Common side effects are GI issues (N/V/D, abd pain, anorexia) and CV issues like bradycardia
• Cholinergic side effects occur in ~20% of patients at typical doses
• Aricept patient response to cholinesterase inhibitors is variable
• 30-50% of patients show no observable benefit, while ~20% show a greater than average response
• Tacrine, approved in 1993, was limited by hepatotoxicity
• Donepezil, the primary treatment for mild-to-moderate Alzheimer’s, starts at 5 mg daily, increasing to 10 mg if tolerated
• A 23-mg sustained-release form benefits moderate-to-severe cases
• Side effects include nasopharyngitis, diarrhea, nausea, vomiting, and rare rhabdomyolysis
• Co-treatment with memantine shows no added benefit over high-dose donepezil
• Rivastigmine is available orally and as a patch, and has similar side effects but a higher fatality rate, possibly linked to transdermal misuse
• Galantamine, is another AChE inhibitor which has a similar profile to donepezil
• Cholinesterase inhibitors and memantine cross the blood-brain barrier, slowing cognitive decline temporarily without modifying disease pathology
• Current research focuses on inflammation, neurodegeneration, cholinergic modulation, and amyloid-tau interactions

Topiramate (Topamax)

• It is a 2nd generation anti-epileptic
• Blocks voltage-gated Na channels to control sustained depolarizations during seizures
• Reduces membrane depolarization by AMPA/Kainate receptors
• Enhances GABA-A receptor activity to enhance inhibitory effects
• It weakly inhibits carbonic anhydrase where acidosis in the brain partially protects against seizures by downregulating NMDA receptor activity and antagonizes glutamate receptors
• It manages and treats epilepsy and migraine.
• Has approval for chronic weight management for individuals with a BMI above 30
• Common side effects are somnolence, fatigue, weight loss, and nervousness
• It may precipitate renal calculi due to inhibition of carbonic anhydrase
• Cognitive impairment means patients may complain about change in taste of carbonated drinks
• Monitor creatinine and bicarbonate
• Off label uses include neuropathic pain, psychotropic drug-induced weight gain, ETOH use disorders, cluster HA prevention, binge eating disorder, bulimia nervosa, and obesity with HTN
• Treats neuralgiform attacks
• Can be used as adjunctive therapy in BID, unipolar depression, borderline personality disorder, OCD, PTSD, tourette syndrome, and essential tremor
• It is a sulfamate-substituted monosaccharide that is FDA-approved
• For Focal-onset or primary generalized tonic-clonic seizures it is used as:initial monotherapy for patients at least 10 years old or adjunctive therapy ( > 2 YO)
• Can be used for Lennox Gastaut syndrome which has onset > 2 years old
• Can be used as Migraine HA prophylaxis in adults

Common SNRIs (Duloxetine, Venlafaxine)

• It is a Serotonin-Norepinephrine Uptake Inhibitor (SNRI)
• Inhibits serotonin transporter (SERT) & norepinephrine (NET)
• Prevents 5HT & NE reuptake, leading to enhanced serotonergic & noradrenergic neurotransmission
• Affects neurotransmitter ↑ Serotonin (5HT) and ↑ Norepinephrine (NE)
• Used for Depression, anxiety disorders, and PTSD
• Common side effects are similar to SSRIs like nausea, constipation, insomnia, HA, and sexual dysfunction
• For chronic treatment give for sustained effects of depression etc.
• Duloxetine treats depression and anxiety
• Treats fibromyalgia, diabetic neuropathy, and stress urinary incontinence off-label
• Venlafaxine is used as a first-line treatment for generalized anxiety disorder and treats depression
• Venlafaxine off-label treats hot flashes, pain syndromes, autisms, PMDD, and binge-eating disorder and PTSD
• Venlafaxine SE includes may cause diastolic HTN (Venlafaxine IR)
• It is contraindicated in Pregnancy
• Both medications may require dose adjustments for renal/hepatic impairment
• It is similar to SSRIs where initial inhibition of SERT induces activation of 5HT1A and 5HT1D autoreceptors
• These ↓ serotonergic neurotransmission by a negative-feedback mechanism until these serotonergic autoreceptors are desensitized
• The enhanced 5HT concentration in the synapse can interact with postsynaptic 5HT receptors

SSRIs (Fluoxetine)

• It is a Selective Serotonin Reuptake Inhibitor
• Blocks serotonin transporter (SERT) to prevent 5HT reuptake, leading to enhanced serotonergic neurotransmission
• Long-term effects include downregulating 5HT receptors, decreased SERT expression, and increased neurogenesis
• It is a first-line treatment for anxiety
• Treats depression, OCD, and PTSD
• SERT selective, with little effect on NET
• Treats PMDD
• Can treat Perimenopausal and Vasovagal symptoms
• Common side effects includes sexual dysfunction, GI upset, Serotonin Syndrome (when combined with other serotonergic drugs) and Weight gain
• It causes a Risk of bleeding, mania/hypomania, seizures, and may increase SI or behavior
• Causes serotonin syndrome with MAOIs
• Has numerous drug-drug interactions mediated by CYPs, sexual dysfunction, weight gain (less with vilazodone), and GI disturbances
• Has Antimuscarinic side effects like dry mouth, urinary retention, and confusion
• Causes insomnia, increased anxiety, and irritability
• Decreases libido
• Causes erectile dysfunction, anorgasmia, and ejaculatory delay (more with paroxetine)
• Causes nausea, diarrhea, vomiting, dulling of intellectual abilities, decreased concentration, and can lead to gradual withdrawal of medication
• It is contraindicated in Pregnancy
• It is used in combination with atypical antipsychotics for treatment resistant MDD
• Medications used in combination include: ARIPIPRAZOLE (ABILIFY) + SSRI/SNRI, QUETIAPINE (SEROQUEL) + SSRI/SNRI, and OLANZAPINE (ZYPREXA) + FLUOXETINE (PROZAC)
• Is a first-line treatment for depression due to fewer side effects than TCAs and MAOIs
• Primary mechanism is serotonin reuptake. It is used to terminate 5HT neurotransmission
• Long-term use cause leads to receptor desensitization and increases serotonergic tone, explaining delayed antidepressant effects (typically 4-6 weeks)

Gabapentin (Neurontin)

• It is an Antiepileptic
• It interacts with voltage-gated N-type Ca channels in the CNS
• Shows high affinity for binding sites throughout the brain correspondent to the presence of voltage-gated Ca channels, especially alpha-2-delta-1
• Seems to inhibit the release of excitatory neurotransmitters in the presynaptic area which participate in epileptogenesis
• Treats seizures, focal seizures, movement disorders, depression/anxiety, ETOH withdrawal, and postherpetic neuralgia
• Can treat migraines as a preventative
• Is a first-line treatment for neuropathic pain and peripheral neuropathy
• Side effects includes GI irritation, weight gain, sedation & dizziness, unsteadiness, and nystagmus
• Serious Reaction includes suicidality, depression, SJS, anaphylaxis, angioedema, erythema multiforme, rhabdomyolysis, and withdrawal seizure or withdrawal symptoms if discontinued abruptly
• Monitor creatinine Clearance
• If creatinine Clearance is less than 60 mL/min then use 1,200 mg/24 hr formulation
• Medication is cleared renally and excreted unchanged in the urine
• It doesn't have a high risk of an OD but can increase the euphoria caused by opioids and reduce drug withdrawals
• Can bypass the blocking effects of addiction treatment medications and does not show up in UDS

Amantadine (Symmetrel)

• It is an NDMA receptor agonist and a Glutamate antagonist
• Used as adjunct to levodopa with dose-related fluctuations and dyskinesias
• Alters dopamine (DA) release in the striatum, has anticholinergic properties, and blocks NMDA glutamate receptors
• Used in the management of tremor, rigidity, and bradykinesia
• Used as initial therapy of mild Parkinson’s Disease
• Causes Dizziness, lethargy, anticholinergic effects, and sleep disturbance and can cause N/V
• Considerations for elderly is they are prone to confusion.
• May cause livedo reticularis (diffuse mottling of extremities with LLE)

Diazepam (Valium)

• It is a Benzodiazepine
• Enhances GABA-mediated synaptic inhibition and binds to receptors located between alpha and gamma subunits of GABA-A receptor/channel complexes
• Minimizes seizures and associated neuronal toxicity
• Used in Status epilepticus (SE) but is NOT 1st line
• Used as a muscle relaxant
• Treats anxiety disorders, ETOH withdrawal, skeletal muscle relaxation, can be given as a preanesthetic medication
• Can treat Meniere disease off-label
• Side effects includes, hypotonia, dysarthria, and dizziness
• In children: aggression, hyperactivity, irritability
• Has a long half-life of 20-80hrs

Adderall, Ritalin and Atomoxetine HCL

• Amphetamines (Adderall) is an Indirectly acting sympathomimetic
• Increases the release of norepinephrine, dopamine, and serotonin from nerve terminals
• Treats Attention-deficit disorders (ADD) and narcolepsy
• Causes nervousness, insomnia, palpitations, HTN, hyperpyrexia, HA, dizziness, anorexia, weight loss, and dryness of mouth
• Methylphenidate (Ritalin, Concerta) enhances effects of norepinephrine and dopamine in brain regions that can improve attention, concentration, executive function, and wakefulness
• Enhancement of dopamine actions in the basal ganglia may improve hyperactivity
• Enhancement of dopamine & norepinephrine in the medical prefrontal cortex & hypothalamus may improve depression, fatigue & sleepiness
• treats Attention deficit hyperactivity disorder (ADHD) in children & adults
• Treats narcolepsy(metadate ER, Methlin ER, Ritalin, Ritalin SR)
• Is a mild CNS stimulant with more prominent effects on mental than on motor activities
• May affect BP and should be used with caution in patients in HTN, hyperthyroidism, or history of drug abuse
• Should avoid in cases of children that are not growing or gaining weight and treatment should STOP (at least temporarily)
• May inhibit the metabolism of SSRIs so avoid concomitant/overlapping use with MAOIs
• Stimulants have a high potential of abuse

Atomoxetine (Strattera)

• It is a Norepinephrine Reuptake Inhibitor and CNS Stimulant
• Treats ADHD for Children and adults
• Selective norepinephrine reuptake inhibitor that produces therapeutic effects in patients with ADHD
• Mechanism of how selective inhibition of presynaptic norepinephrine exerts effects in ADHD has not been determined.
• One should avoid activities requiring mental alertness or coordination until drug effects are realized
• Growth rate and weight may need to be monitored more frequently in children
• Report any new or worsened psychiatric problems, chest pain, palpitation, dyspnea, or s/s of cardiac dysrhythmias, MI, or CVA.
• Safety and effectiveness not established in children under 6 years of age
• There is an increased risk of suicidal ideation in short-term studies in children or teens with ADHD
• Monitor patients closely for suicidality (suicidal thinking and behavior)
• Hepatic dosing is as follows: Class B initial and target doses should be reduced to 50% of normal dose, Class C initial and target doses should be reduced to 25% of normal dose
• Renal dosing is not required
• It cannot be dialyzed
• Category C in pregnancy so way the risks and benefits
• Normal metabolizers may have 63% absorption and poor metabolizers may have 94% absorption
• Food doses do not affect absorption
• VD is 0.85 L/kg, 98% protein bound
• Metabolism is extensive and hepatic via CYP2D6 to 1 active metabolite
• Eliminated renally at 80% and at 17% in feces, with a half-life of 5.2-21.6 hr
• CYP2D6 poor metabolizers, dose as with drug interaction with CYP2D6 inhibitor
• Contraindications includes hypersensitivity to atomoxetine, concomitant use of MAOIs, narrow angle glaucoma, adn pheochromocytoma
• A black Box warning includes pediatric suicidality

Flumazenil (Romazicon)

• It is a Benzodiazepine receptor antagonist
• It is a DEA schedule IV drug
• Antagonizes the actions of benzodiazepines; binds competitively to benzodiazepine binding sites on GABA-A receptors
• Competitively inhibits the activity at the benzodiazepine receptor site on the GABA/benzodiazepine receptor complex
• Treats benzo overdose and can be used for reversal of sedative effects during anesthesia
• Side effects includes dizziness, increased sweating, HA, and abnormal or blurred vision
• Administration is IV preferred and is given in small injections over 1-3 minutes
• Contraindications includes patients who have been given a benzo for control of a potentially life-threatening condition (e.g., seizures) and patients showing signs of serious cyclic antidepressant overdose
• Flumazenil does not antagonize the CNS effect of the drugs affecting GABA-ergic neurons by means other than the benzodiazepine receptor like ethanol, barbiturates, and general anesthesia
• It can not reverse the effects of opioids
• Is not effective for other drug overdoses like opioids and barbiturates

Carbidopa/Levodopa (Sinemet)

• It is a Mainstay treatment for Parkinson’s Disease
• Composed of a combo of carbidopa, and levodopa
• Carbidopa is an MSD (aromatic amino acid decarboxylase inhibitor)
• Levodopa is an MSD (metabolic precursor of dopamine)
• Treats Parkinson’s Disease
• Causes Induction of hallucinations and confusion, it happens more in elderly or those with preexisting cognitive dysfunction
• Drug Interactions: Administration of levodopa with nonspecific inhibitors of MAO accentuates the actions of levodopa and may precipitate life-threatening hypertensive crisis and hyperpyrexia, therefore nonspecific MAO inhibitors should always be discontinued at least 14 days before levodopa is administered
• Conventional antipsychotics agents, agents are effective against levodopa-induced psychosis but may cause marked worsening of parkinsonism due to actions at the D2 DA receptor and should nt be used in PD. So phenothiazines should be avoided
• Education is to avoid abrupt withdrawal of levodopa or other dopaminergic medications may precipitate the neuroleptic malignant syndrome of confusion, rigidity, and hyperthermia, a potentially lethal adverse effect
• If levodopa is used alone, the drug is largely decarboxylated by enzymes in the intestinal mucosa and other peripheral sites so that less than 1% penetrates the CNS
• Peripheral decarboxylase limits the peripheral decarboxylation to dopamine and increases the bioavailability of levodopa in substantia niagra
• Initial nausea can be managed by starting carbidopa DAILY
• The combination reduces the dose of levodopa

Dantrolene

• acts intracellularly in skeletal muscle to lessen the excitation-contraction coupling interaction between actin and myosin within the individual sarcomere
• inhibits Ca2+ release from the sarcoplasmic reticulum of skeletal muscle by limiting the capacity of Ca2+ and calmodulin to activate the ryanodine receptor (RYR1)
• Used in management & prevention of malignant hyperthermia
• Treats chronic muscle spasticity associated with upper motor neuron disorders (SCI, CVA, CP, or MS)
• Off-label treats neuroleptic malignant syndrome by blocking the excitation-contraction coupling in the sarcoplasmic reticulum)
• Can cause skeletal muscle weakness, dyspnea, respiratory muscle weakness, and decreased inspiratory capacity - due to MOA all are expected
• BB: oral Dantrolene - potential for hepatotoxicity. Therefore Hepatic function should be evaluated before administration and require monitoring throughout the course of treatment. STOP IMMEDIATELY if liver function becomes impaired
• Peripheral action generalized weakness. Should be reserved for non ambulatory patients with severe spasticity

Memantine (Namenda)

• It is a NMDA receptor channel antagonist
• Blocks extra-synaptic NMDA receptors in the CNS
• Block of NMDA receptor channels may be neuroprotective by reducing excessive (pathologic) glutamate-induced excitotoxicity
• Treats MOD-SEVERE Alzheimer's disease (AD)
• Produces a modest effect to reduce the rate of clinical deterioration, no clinical benefit for milder forms of AD
• Mild side effects includes ha and dizziness
• Check kidney function
• Can be used with or without food

Calcitonin Gene-Related

• The medications is Galcanezumab (Emgality), Erenumab (Aimovig), Fremanuzumab (Ajovy), and Atogepant (Qulipta)
• Is a Class Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist

Peptide (CGRP) Antagonists

• This class includes Gepants which are monoclonal antibodies and non-peptide small molecules.
• The monoclonal antibodies are erenumab, eptinezumab, galcanezumab, and fremanezumab
• This group includes monoclonal antibodies against the CGRP receptor and CGRP receptor antagonists (remegepant and ubogepan);
• Atogepant and zavegepant are other receptor antagonists that are FDA approved but have no information in PP
• It prevents and treats acute migraines in adults
• Common side effects include hypersensitivity (sometimes severe) and injection site reactions
• Long-term effects: chronic vascular hemodynamic impairment
• Atogepant (Qulipta) - hightest % of side effects, including serious adverse effects
• No dosage adjustment for mild-moderate renal impairment; 10 mg daily for patients with severe to end-stage renal disease
• It is vital to monitor with careful pharmacovigilance and safety monitoring

Ropinirole (Requip)

• It is a Dopaminergic agonist
• Can be used in conjunction with lower doses of L-DOPA in a combined therapy approach as monotherapy
• Targets D2-like receptors and interferes with degradation of dopamine and results in prolonged dopaminergic activity
• Used to treat Parkinson’s Disease and restless legs syndrome
• Management of dose-related fluctuation in motor state and may be helpful in preventing motor complications
• Causes Hallucinosis or confusion, nausea, and orthostatic hypotension, fatigue and somnolence
• Warn about potential sleepiness, especially while driving

Bupropion (Wellbutrin)

• is a Norepinephrine-Dopamine Reuptake Inhibitor (NDRI)
• Inhibits norepinephrine (NE) and dopamine (DA) reuptake by blocking the norepinephrine transporter (NET) and dopamine transporter (DAT)
• May also increase presynaptic release of NE & DA
• Effects on the vesicular monoamine transporter (VMAT) may contribute to enhanced neurotransmission
• It treats Major depressive disorder (MDD) as a monotherapy OR adjunct with SSRIs
• Also treats seasonal affective disorder (SAD) prevention
• Has smoking cessation, neuropathy pain, ADHD, and weight loss
• Results in less sexual dysfunction and less weight gain than SSRIs
• Common common side effects includes anxiety, tachycardia, HTN, irritability, tremor, HA, nausea, dry mouth, constipation, appetite suppression, insomnia, aggression, impulsivity, agitation
• Seizures = dose dependent (high risk if greater than 450 mg/day)
• Renal and hepatic dosing adjustments required
• Often combined with SSRIs to enhance antidepressant response and counteract SSRI-induced sexual dysfunction and weight gain
• Contraindicated in patients to avoid if they have seizure disorders lowers SZ threshold
• Do not give in cases of eating disorders
• Can not give if there is uncontrolled HTN
• Drug Interactions: CYP2B6 metabolism; increased risk of seizures with other meds that lower the seizure threshold
• Activating antidepressant has beneficial for enhancing energy and attention
• Should not give in cases of seizures or eating disorders
• Good options to patients concerned about sexual dysfunction or weight gain

Mirabegron (Myrbetriq)

• It is a B3-Adrenergic Agonist
• Causes relaxation of the detrusor muscles during the storage phase of micturition cycle, reducing irritative voiding symptoms or number of incontinence episodes
• 2nd line for overactive bladder/incontinence
• Requires 4-8 weeks for affects to take hold
• Side effect includes: HTN, nasopharyngitis, UTI, HA
• Contraindicated if creatinine clearance is less than 15 mL/min, ESRD, hepatic impairment, and UNCONTROLLED HTN, therefore Monitor: urinary retention and increased BP

Neostigmine (Prostigmin)

• It is Class Carbamate Anticholinesterase and Cholinomimetic
• Enhances cholinergic action by facilitating the transmission of impulses across neuromuscular junctions
• Increases response of myasthenic muscle to repetitive nerve impulses, primarily by the preservation of released endogenous ACh
• Contains quaternary ammonium group which does not cross the BBB
• Symptomatic treatment of myasthenia gravis
• Used off-label, for Non-obstructive ileus which is paralysis of the bowel
• Side effects include salivation and fasciculation which are visible, involuntary twitching

Ambien (Zolpidem)

• Novel Benzodiazepine Receptor Agonists/Z compound
• Alternative treatment for insomnia, sleep disorders and are a safer alternative to barbiturates due to lower abuse potential & better safety profile (agonist to GABA-A) producing sedative effects but are chemically distinct from traditional benozos
• Little effect on the stages of sleep, does improve sleep latency and prolongs total sleep time
• May be beneficial for one week following discontinuation with mild rebound insomnia on the first night after d/c
• More morning sedation (especially if administered late) than Zaleplon
• daytime drowsiness, cognitive impairment, sleepwalking, and sleep driving in some cases
• Side effect includes daytime drowsiness, cognitive impairment, sleepwalking, and sleep-driving in some cases
• Has less potential for dependence compared to benzos but does lead to tolerance and physical dependence with prolonged use
• Limitations:is less effective than benzodiazepines for conditions like seizures and muscle spasms
• For short term use
• Taper gradually to avoid rebound insomnia and other withdrawal symptoms when attempting to withdrawl

Quetiapine (Seroquel)

• It is an Atypical Antipsychotics
• has no mechanism of action
• Has treatment-resistant MDD (combined with antidepressants - SSRIs + SNRIs); OCD - may be less tolerable
• A side effectis metabolic effects as seen by weight gain, increase lipids
• Dosings include Acute Antipsychotic for 1st episode and for Chronic treatment.
• maintenence dose for 1st episode and for chronic treatment.

Buspirone (Buspar)

• Clas: Non-Benzodiazepine Anxiolytic
• MOA: partial serotonin and dopamine receptor agonist
• Treats Generalized Anxiety Disorder (GAD) ONLY (not effective for other anxiety disorders)
• Does require chronic use and lacks sedative or immediate effects
• It requires chronic treatment for sustained effects

Lithium

• Modulates levels of monoamines
• Alteration of Sodium and Calcium Ion Flow: May alter ion transport by affecting sodium & calcium across membranes so that May alter ion transport by affecting sodium & calcium across membranes. This can change the excitability of neurons so that may alter transport to modulate the flow of dopamine, serotonin, and norepinephrine
• Inhibition of inositol monophosphatase and modulation of PI pathway therefore Decreased activity of protein kinases, including PKC and GSK-3β for acute prophylaxis,reducing sucidality, neuroprotection and adjunct therapy Effective in reducing suicide
• Tremors, Cognitive
• Kidney Effect
• Narrow TI
• Slow through Blain Barrier
• Eliminated after 24 hours
• Can lead to Toxicity/Overdose
• Clinical Presentation: Vomiting, diarrhea, tremors, and CNS effects
• Ebstein anomaly risk
• Neonatal Effects toxicity
• Monitor dosing and side effect, suicide risks

Pitolisant (Wakix)

• It is a H3 Receptor Blockers
• MOA: Increase histamine activity and are used for narcolepsy treatment and Is an inverse agonist at H3 receptors
• Signals through 4 GPCR subtypes, influencing adenylyl cyclase or PLC activity
• Treats Narcolepsy