Neuro medication list Quiz

• Psychiatric medications require careful consideration during anesthesia due to their potential side effects and drug interactions.

Selective Serotonin Reuptake Inhibitors (SSRIs)

• SSRIs like fluoxetine, sertraline, citalopram, escitalopram, and paroxetine treat mild to moderate depression, panic disorder, OCD, phobias, and PTSD; fluoxetine also treats anxiety.
• Side effects include insomnia, agitation, headache, nausea, diarrhea, decreased serum sodium (potentially leading to SIADH), increased suicidal thoughts/behaviors in children/adolescents (black box warning), increased antiplatelet activity, and QT prolongation (especially citalopram and escitalopram).
• Discontinuation of SSRIs can lead to major depressive episode, dizziness, and paresthesias.
• Drug interactions include CYP450 inhibition (especially fluoxetine, increasing plasma concentrations of drugs like warfarin), increased risk of serotonin syndrome with serotonergic drugs (e.g., fentanyl, meperidine, methadone, tramadol, ondansetron) and drugs inhibiting CYP450 enzymes.
• Anesthesia considerations include the increased antiplatelet activity, increasing bleeding risk, the risk of serotonin syndrome with serotonergic anesthetic drugs, and QT prolongation with citalopram and escitalopram.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

• SNRIs like venlafaxine, duloxetine, desvenlafaxine, and milnacipran treat depressive disorders, anxiety disorders, and chronic pain syndromes.
• Side effects are similar to SSRIs, plus norepinephrine-related effects (tachycardia, hypertension, potential arrhythmias at high doses), inhibition of CYP2D6, elevated systolic and diastolic BP, and exaggerated HTN and tachycardia with adrenergic agonists.
• Drug interactions include inhibition of CYP 2D6 (affecting antidepressants, antiarrhythmics, opioids, and beta-blockers) and increased risk of serotonin syndrome with other serotonergic drugs.
• Anesthesia considerations include norepinephrine-related effects (tachycardia, hypertension, potential arrhythmias at high doses), exaggerated hypertension and tachycardia with adrenergic agonists, increased risk of serotonin syndrome with serotonergic anesthetic drugs, and altered metabolism and effects of CYP2D6-affected drugs used in the perioperative period.

Tricyclic Antidepressants (TCAs)

• TCAs like amitriptyline, nortriptyline, imipramine, clomipramine, and desipramine treat major depressive disorder, chronic pain syndromes, and obsessive-compulsive disorder.
• Side effects include anticholinergic effects (dry mouth, blurred vision, tachycardia, urinary retention, ileus), sedation, delirium risk (elderly), lowered seizure threshold (pediatrics), extrapyramidal symptoms, tremors, cardiovascular effects (orthostatic HOTN, increased HR, ECG changes, AV node conduction slowing, cardiac depression); fatal in overdose.
• Drug interactions include increased toxicity with MAOIs (hyperthermia, seizure, coma), exaggerated response to anticholinergics (especially atropine) and indirect-acting vasopressors, SNS stimulation (avoid ephedrine), smaller doses of direct-acting vasopressors (like phenylephrine), and exaggerated ventilatory depressant effects of opioids (avoid pancuronium, ketamine, meperidine, epinephrine).
• Anesthesia considerations include increased risk of toxicity with MAOIs, exaggerated response to anticholinergics, avoiding indirect-acting vasopressors and using smaller doses of direct-acting vasopressors, avoiding certain anesthetic agents like pancuronium, ketamine, meperidine, and epinephrine due to exaggerated ventilatory depressant effects of opioids, and cardiovascular effects.

Monoamine Oxidase Inhibitors (MAOIs)

• MAOIs like isocarboxazid, phenelzine, selegiline, and tranylcypromine treat major depressive disorder, panic disorder, Parkinson’s disease, and phobias; selegiline (MAO-B inhibitor) is also used for Parkinson's.
• Side effects include hypotension, anticholinergic-like effects, sedation (phenelzine), paresthesias, weight gain, hepatitis, and hyperadrenergic crisis related to tyramine in the diet (HTN, hyperpyrexia, CVA, dysrhythmias).
• Drug interactions include Type I (excitatory) reaction resembling serotonin syndrome with meperidine and dextromethorphan (avoid); morphine and hydromorphone are safer alternatives.
• A Type II (depressive) reaction with all opioids (enhanced effects) should be reversed with naloxone.
• Contraindicated with indirect-acting sympathomimetics (risk for fatal hypertensive crisis) - avoid ephedrine.
• Risk of exaggerated effects with direct-acting sympathomimetics (use smaller doses of phenylephrine). Avoid ketamine, ephedrine, pancuronium, epinephrine in LA mixtures.
• Phenelzine decreases plasma cholinesterase levels, prolonging action of succinylcholine; reduced metabolism of barbiturates (decrease dose).
• Anesthesia considerations include avoiding meperidine and dextromethorphan, anticipating a Type II (depressive) reaction with all opioids and having naloxone available, avoiding indirect-acting sympathomimetics, using smaller doses of direct-acting sympathomimetics, avoiding certain anesthetic agents like ketamine, ephedrine, pancuronium, and epinephrine in local anesthetic mixtures, considering prolonged action of succinylcholine with phenelzine, and decreasing the dose of barbiturate anesthetics.

Trazodone

• It treats MDD and insomnia.
• Side effects include orthostatic hypotension and dry mouth.
• The mechanism includes SRI activity, 5-HT2A antagonism, and Alpha-1 antagonism.
• Anesthesia considerations include accounting for orthostatic hypotension during intraoperative and postoperative blood pressure management.

Bupropion

• It treats MDD, smoking cessation, ADHD, and may have some benefit in neuropathic pain management.
• Side effects include seizures and stimulant-like effects.
• The mechanism includes inhibition of DA and NE reuptake, elevating norepinephrine and dopamine like buspirone.
• Anesthesia considerations include the potential for seizures, especially with anesthetic agents that may lower the seizure threshold, and the effects of stimulant-like effects and elevated norepinephrine and dopamine on hemodynamic responses during anesthesia.

Lithium

• Treats bipolar disorder, treatment-resistant major depression, and suicide risk.
• Side effects include polyuria, nephrogenic diabetes insipidus, chronic kidney disease, endocrine (hypothyroidism), cardiac (T wave changes, SA nodal block, bradycardia), and decreased ability to concentrate urine.
• Toxicity (>1.5 mEq/L) can cause dysrhythmias, ECG changes, hypotension, weakness, ataxia, seizures, and confusion.
• Drug interactions include increased lithium levels with thiazide & loop diuretics, NSAIDs, and ACEIs.
• Increased neurotoxicity is possible with neuroleptic drugs (antipsychotics) and anticonvulsants and beta-blockers decrease lithium-induced tremor.
• Depolarizing and nondepolarizing MRs can cause prolonged muscle blockade and inhaled and IV anesthetics may lead to a decrease in anesthetic requirements and barbiturates can delay recovery.
• Anesthesia considerations include prolonged effects of muscle relaxants, decreased requirements for inhaled and intravenous anesthetics, delayed recovery with barbiturates, cardiac effects, and the importance of avoiding sodium depletion.

Haloperidol (Haldol)

• A butyrophenone antipsychotic that helps with psychosis-related anxiety and can be used off-label for emergence and ICU delirium, acute agitation and aggression, and also has antiemetic effects.
• Side effects include sedation, extrapyramidal side effects, and delayed emergence at higher doses.
• The mechanism includes D1 and D2 antagonism and depressing the reticular activating system (RAS).
• Anesthesia considerations include the sedating effect and potential to delay emergence, the risk of extrapyramidal side effects, and antiemetic effects.

Droperidol

• A butyrophenone antipsychotic related to haloperidol that is an effective antiemetic and sedative and used off-label for delirium and as a GA adjunct with opioids.
• Has a black Box Warning due to risk of prolonged QT and arrhythmias.
• Requires baseline and follow-up ECGs.
• Anesthesia considerations include the black box warning for prolonged QT and arrhythmias, the requirement for baseline and follow-up ECGs, and cardiac risks.

Aripiprazole

• A second-generation antipsychotic (SGA) with mixed agonist/antagonist activity at D2 used to treat bipolar disorder and MDD.
• Side effects include akathisia and engagement in risky behaviors.
• There are no specific anesthesia considerations mentioned in the source.

Ziprasidone, Lurasidone

• Second-generation antipsychotics (SGAs) that are moderately effective.
• Side effects include QTc prolongation and akathisia and minimal metabolic effects.
• Anesthesia considerations include QTc prolongation.

Quetiapine

• A second-generation antipsychotic (SGA) with primary 5-HT antagonism and little D2 antagonism.
• Side effects include sedation and orthostatic hypotension.
• Anesthesia considerations include sedation and orthostatic hypotension.

Methylphenidate (Ritalin)

• Treats ADHD, ADD, and narcolepsy by increasing arousal and respiratory drive.
• Acts as an indirect sympathomimetic, blocks reuptake of NE and DA, and increases dopamine release.
• Side effects include hypertension, tachycardia, arrhythmias, weight loss, and insomnia.
• Can actively induce emergence in isoflurane and propofol anesthesia and may result in higher anesthetic requirements.
• Anesthesia considerations include the potential for inducing emergence from anesthesia and sympathomimetic effects.

Mixed Amphetamine Salts (Adderall)

• Contains levoamphetamine and dextroamphetamine.
• Blocks reuptake of NE and DA and increases presynaptic dopamine release.
• Side effects include tolerance, dependency risk, anxiety, insomnia, exacerbation of tics, increased HR, and BP.
• Anesthesia considerations include increased heart rate and blood pressure.

Clonidine

• FDA approved for ADHD and also used for regional anesthesia adjunct, anxiety, opioid withdrawal, and impulsivity/aggression.
• Acts as an Alpha-2 agonist.
• Side effects include hypotension and bradycardia.
• Anesthesia considerations include hypotension and bradycardia.

Diphenhydramine (Benadryl)

• A Histamine-1 antagonist with anticholinergic effects.
• Can be used for symptom management or acute crisis in Parkinson's and given perioperatively
• Used to treat dystonia related to droperidol or other antipsychotic use.
• Anesthesia considerations include anticholinergic effects and its use in treating dystonia.

Levodopa

• Treatment for Parkinson's Disease to restore dopaminergic function.
• A dopamine precursor that can cross the blood-brain barrier and is converted to dopamine.
• Adverse effects include nausea, vomiting, endocrine (inhibits prolactin, increases aldosterone), cardiovascular (cardiac stimulation, orthostatic hypotension, tachycardia, arrhythmias, skin flushing), neuromuscular (abnormal involuntary movements), psychiatric (confusion, hallucinations, paranoia), and Parkinsonism Hyperpyrexia Syndrome with abrupt withdrawal.
• Drug interactions include dopamine antagonists (antipsychotics, some antiemetics), MAOIs, anticholinergic drugs, and Vitamin B6.
• Anesthesia considerations include cardiovascular effects and the risk of Parkinsonism Hyperpyrexia Syndrome with abrupt withdrawal and interactions with dopamine antagonists and MAOIs.

Carbidopa

• Inhibits peripheral dopa decarboxylase, preventing breakdown of levodopa before it reaches the CNS; used in combination with levodopa (Sinemet) for Parkinson's Disease.
• As carbidopa is always used in conjunction with levodopa, the anesthesia considerations are the same as for levodopa.

Dopamine Agonists

• Examples include bromocriptine, pramipexole, ropinirole, and rotigotine.
• Directly bind to dopamine receptors, mimicking dopamine's effects in Parkinson's Disease.
• Adverse effects include hallucinations, hypotension, dyskinesia, fibrosis, vertigo, and nausea.
• Anesthesia considerations include hypotension and nausea.

Amantadine

• Improves Parkinson's symptoms, usually as adjunct therapy and is also an influenza A antiviral.
• May increase dopamine release and delay reuptake, possibly anticholinergic and glutamate antagonist effects.
• Adverse effects include anticholinergic effects, edema, confusion, and psychosis.
• Anesthesia considerations include anticholinergic effects and the potential for confusion and psychosis.

MAO-B Inhibitors

• Examples include selegiline and rasagiline.
• Inhibit the breakdown of dopamine, increasing circulating dopamine in Parkinson's Disease.
• Adverse effects include insomnia, confusion, and hallucinations.
• Anesthesia considerations include potential interactions with opioids and sympathomimetics and insomnia, confusion, and hallucinations.

COMT Inhibitors

• Examples include tolcapone and entacapone.
• Inhibit catechol-O-methyltransferase, increasing levodopa's availability to the CNS in Parkinson's Disease.
• Adverse effects include worsened dyskinesias, nausea, rare hepatotoxicity, and rhabdomyolysis.
• Anesthesia considerations include nausea.

Anticholinergics

• Examples include benztropine and trihexyphenidyl.
• Block excitatory effects of acetylcholine, helping balance dopamine and acetylcholine in Parkinson's Disease, primarily for tremor and excess salivation.
• Adverse effects include general anticholinergic side effects.
• Anesthesia considerations include that the general anticholinergic side effects can be additive with other anticholinergic medications used perioperatively.

Diazepam

• Short-term treatment of acute seizures, status epilepticus, alcohol withdrawal, and preferred for local anesthetic systemic toxicity (LAST).
• Positive allosteric modulator of GABA receptors.
• Adverse effects include sedation, paradoxical excitation, ataxia, skeletal muscle incoordination, tolerance, and withdrawal seizures with abrupt discontinuation.
• Anesthesia considerations include use for LAST and sedative effects.

Midazolam

• Short-term treatment of acute seizures, status epilepticus, and alcohol withdrawal and the nasal form is effective for status epilepticus.
• Positive allosteric modulator of GABA receptors.
• Adverse effects include sedation, paradoxical excitation, ataxia, skeletal muscle incoordination, tolerance, and withdrawal seizures with abrupt discontinuation.
• Anesthesia considerations include sedative effects.

Clonazepam

• Often added to other drugs for myoclonic seizures and may be first-line for this type.
• Mechanism: Positive allosteric modulator of GABA receptors