Psychopharmacology: Alprazolam and Quetiapine

Alprazolam (Xanax)

• Antianxiety Agent
• Available in tablet, disintegrating tablet, ER tablet, and solution forms
• FDA approved for anxiety and panic disorder
• Enhances the postsynaptic effect of GABA
• Causes drowsiness
• Avoid activities requiring mental alertness
• Avoid alcohol
• Do not crush tablets
• Can be mixed in liquid or semi-solid food
• Discard half a tablet if only taking half
• Not for use in children
• Reduce dose in patients with hepatic impairment
• Avoid use in the elderly
• Has addictive potential
• Avoid abrupt discontinuation after chronic use
• May cause seizures
• Common adverse side effects: Ataxia, lethargy, retrograde amnesia, somnolence, weight gain, change in appetite, constipation, fatigue, cognitive dysfunction, decreased libido

Quetiapine Fumarate (Seroquel)

• Antipsychotic
• Available in tablet and ER tablet forms
• FDA approved for bipolar disorder and schizophrenia
• Antagonizes 5-HT1a, 5-HT2, dopamine D1 and D2, histamine H1, and adrenergic α1 and α2 receptors
• Take with food
• Avoid alcohol
• Avoid activities requiring mental alertness
• Rise slowly from a sitting position
• Report signs and symptoms of hyperglycemia, bradycardia, arrhythmia, tardive dyskinesia, or neuroleptic malignant syndrome
• Avoid concomitant use with opioids
• Elderly patients with dementia-related psychosis taking quetiapine have an increased risk of death compared to placebo
• Common adverse side effects: Agitation, headache, HTN, somnolence, weight gain, xerostomia

Metoprolol Tartrate (Lopressor)

• Antihypertensive
• Available in tablet, ER tablet, ER capsule, and 24h Sprinkle forms
• FDA approved for angina, HF with reduced ejection fraction, HTN, and AMI
• Cardioselective β-adrenergic blocker
• Take on an empty stomach
• Avoid alcohol
• Avoid abrupt discontinuation
• Report signs and symptoms of hypotension, heart failure, or exacerbation of angina
• In diabetics, this drug may mask symptoms of hypoglycemia.
• Limit use of calcium channel blockers
• Injectable metoprolol is also used in atrial fibrillation patients
• Conversion from IV to PO: 2.5 mg po to 1 mg IV
• Common adverse side effects: Dizziness, fatigue, hypotension

Tamsulosin Hydrochloride (Flomax)

• BPH agent
• Available in oral capsule form
• FDA approved for benign prostatic hyperplasia
• Selectively blocks postsynaptic α1-adrenergic receptors
• Administer 30 minutes after the same meal daily
• Avoid activities that require coordination
• May cause vertigo and dizziness
• Rise slowly from a sitting position
• Syncope or loss of consciousness is possible after the first dose
• Not first-line treatment
• Has a longer half-life
• May result in hypotension less often than other agents
• Common adverse side effects: Dizziness, headache, abnormal ejaculation, rhinitis

Oxycodone Hydrochloride (OxyContin, Roxicodone)

• Opioid Analgesic
• Available in capsule, tablet IR, tablet ER 12h abuse-deterrent, solution, and concentrate forms
• FDA approved for chronic, moderate, and severe pain
• Mu agonist
• Use laxative to prevent constipation
• May cause drowsiness
• Avoid tasks requiring motor coordination
• Avoid alcohol or other CNS depressants
• Tolerance and dependence may occur
• Avoid abrupt discontinuation
• Do not crush tablets
• ER: Do not use in children
• Do not use with benzodiazepines
• Use in combination with acetaminophen for beneficial pain management
• FDA is requiring updates to opioid labeling
• Common adverse side effects: Constipation, GI distress, sedation, sweating, pruritus

Fluticasone Propionate (nasal) (Flonase)

• Antiallergy agent
• Available in nasal spray and nasal exhaler suspension forms
• FDA approved for allergic rhinitis, non-allergic rhinitis, and nasal polyps
• Corticosteroids: anti-inflammatory, antipruritic, vasoconstrictive
• Show patients how to properly administer
• Monitor for signs and symptoms of toxicity
• May have a scent
• Relief or adverse effects may occur for several days after the first use
• Available OTC
• Topical and inhalation forms are also available for the treatment of asthma and other allergic disorders
• Common adverse side effects: Headache, nasal irritation, burning

Donepezil (Aricept)

• Alzheimer's Dementia Agent
• Available in tablet and disintegrating tablet forms
• FDA approved for Alzheimer's disease and dementia
• Central cholinesterase inhibitor
• Take at bedtime with or without food
• Adverse effects may be more frequent at dose escalation and will resolve when continued
• Safety and effectiveness not established in children
• No evidence shows that it alters the course of Alzheimer's
• Common adverse side effects: Asthenia

Clopidogrel Bisulfate (Plavix)

• Hematological Agent
• Available in tablet form
• FDA approved for acute ST segment elevation MI managed, and thrombosis prevention in ASCVD
• Platelet aggregation inhibitor
• Report signs and symptoms of bleeding
• Do not stop therapy abruptly
• Discontinue 5 days prior to elective surgery if antiplatelet effect is desired
• Actively metabolized by CYP2C19
• Common adverse side effects: Headache

Methylphenidate (Ritalin, Methylin, Metadate, Concentra)

• CNS agent for ADHD
• Available in tablet, chewable tablet, chewable tablet ER, tablet ER, disintegrating tablet ER, tablet ER 24 hours, capsule ER, capsule ER 24 h, solution, suspension, patch, and transdermal patch forms
• FDA approved for ADHD and narcolepsy
• CNS stimulant (C-II)
• Avoid taking at night as it may cause insomnia
• Avoid abrupt discontinuation
• Patch: Apply at the same time each day and alternate hips. Remove after 9 hours
• High potential for abuse
• Consider drug holidays
• Avoid confusion over multiple different brand names and formulations
• Common adverse side effects: Weight loss, loss of appetite, headache, insomnia, irritability

Allopurinol (Zyloprim)

• Gout agent
• Available in tablet form
• FDA approved for gout, hyperuricemia, and nephrolithiasis
• Xanthine oxidase inhibitor: Decreases the production of uric acid
• Take after meals
• Maintain adequate hydration
• Avoid alcohol and caffeine
• Seek medical attention if experiencing myelosuppression, agranulocytosis, or Steven Johnson syndrome
• Full effect in chronic gout may take 2-6 weeks, slow dose titration
• Common adverse side effects: None known

Risperidone (Risperdal)

• Antipsychotic
• Available in tablet, dispersible tablet, and solution form
• FDA approved for autistic disorder, acute manic or mixed episodes of bipolar I, and schizophrenia
• Serotonin 5-HT2 antagonist with weaker dopamine antagonism
• Take with food
• Avoid alcohol and other CNS depressants
• Avoid activities requiring mental alertness or coordination
• Rise slowly from a sitting or supine position
• Report signs and symptoms of hyperglycemia
• Can be mixed in coffee, orange juice, and low-fat milk, but not cola or tea
• Common adverse side effects: Edema, headache

Cyclobenzaprine Hydrochloride (Flexeril, Amrix, Fexmid)

• Muscle Relaxant
• Available in tablet and capsule ER forms
• FDA approved for skeletal muscle spasm
• Centrally acting skeletal muscle relaxant
• Avoid activities requiring mental alertness
• Should be used only for short periods (2-3 weeks)
• Avoid use with opioids
• Avoid use in the elderly
• Common adverse side effects: Xerostomia, headache, dizziness, drowsiness

Lisdexamfetamine Dimesylate (Vyvanse)

• CNS agent for ADHD
• Available in capsule and chewable tablet forms
• FDA approved for ADHD and binge eating disorder
• Prodrug: Amphetamine CNS stimulant (C-II)
• Take dose in the morning with or without food
• Can be dissolved in water, yogurt, or orange juice
• Report any chest pain, palpitations, or dyspnea
• High potential for abuse
• A complete family and patient history of serious CV adverse events is required before administration.
• Common adverse side effects: Insomnia, irritability, loss of appetite, upper abdominal pain, xerostomia

Oxybutynin Chloride (Ditropan, Ditropan XL)

• Urinary bladder modifier
• Available in tablet, tablet ER, syrup, and transdermal gel forms
• FDA approved for overactive or neurogenic bladder
• Competitive muscarinic receptor antagonist
• No important patient counseling
• Be cautious in the decision to engage in potentially dangerous activities until drug effects have been determined.
• Common adverse side effects: Constipation, xerostomia, blurred vision

Mirtazapine (Remeron)

• Antidepressant
• Available in tablet and disintegrating tablet forms
• FDA approved for depression
• α2 antagonist
• Take in the evening prior to sleep.