Psychopharm Exam 2 Study Guide PDF

Psychopharm Exam 2 Study Guide 1. Understand indications, mechanisms of action, targeted neurotransmitters, targeted symptoms, metabolism and excretion, common side effects, pregnancy effects, monitoring parameters and therapeutic levels (where applicable), symptoms of toxicity, treatment o...

Psychopharm Exam 2 Study Guide 1. Understand indications, mechanisms of action, targeted neurotransmitters, targeted symptoms, metabolism and excretion, common side effects, pregnancy effects, monitoring parameters and therapeutic levels (where applicable), symptoms of toxicity, treatment of toxicity, titrating up and tapering down with rationales, commonly known interactions, and starting doses for the following medications used to stabilize mood (focus especially on first- and second-line treatments): Mood stabilizers Lithium: Completely absorbed in the upper GI tract, Increase absorption with food Half-life: 18 - 36 hours o Indications: to treat or control the manic episodes of bipolar disorder. o Mechanism of action: Normalize reuptake of NE, DA, serotonin in the brain. o Targeted neurotransmitters: Unknown o Targeted symptoms: Mania, bipolar disorder. o Metabolism and excretion: Renal o Common side effects: Nausea, vomiting, diarrhea, tremor, fatigue o Pregnancy effects: increase in fetal cardiac anomalies (Ebstein’s anomaly). No breast feeding - lithium in breast milk at full therapeutic levels. o Monitoring parameters: Lithium levels, thyroid function tests, kidney function tests o Therapeutic trough levels: 0.6 - 1.2 mEq/L GOAL lithium levels: Mania – 0.8 – 1.2 mEq/L Depression - 0.6–1.0 mEq/L Maintenance - 0.4 – 0.6 mEq/L When to draw Lithium Levels: 14 days after every dose change Every 2-3 months once stable on dose  ▪ Every 6 months once stable o Symptoms of toxicity: Nausea, vomiting, diarrhea, muscle weakness, confusion, seizures o Treatment of toxicity: Discontinue medication, supportive care, hemodialysis if severe o Titrating up and tapering down: Start low, go slow, monitor for side effects o Commonly known interactions: Diuretics, NSAIDs, ACE inhibitors Maintenance dose often 1/2 - 2/3 less than acute dose  Pearls DOSE ONCE AT NIGHT o Less polyuria, less risk of renal damage o Longer T ½ in neural tissues o Slower lithium clearance at night lower dose by 25% - reduces peak- related and overall adverse effects o Warning – AM lithium level may be 1.3 x higher than Trough o Responses in acute mania may take 7–14 days even with adequate plasma lithium levels. o only 1/3 of client have adequate relief with monotherapy - most patients need multiple medications Rapid discontinuation: Increases the risk of relapse and possibly suicide Taper over 3 months if to be discontinued after long-term maintenance Divalproex Sodium (Depakote IR, ER, and SR): o Depakote Delayed-Release Tablets and Depakote ER are not interchangeable. o Depakote Extended Release - First Line acute Manic or mixed o Depakote Delayed Release – Manic Episodes o Depakene – valproic acid only o Indications: Bipolar mania, impulse control, aggression o Mechanism of action: Increases GABA levels o Targeted neurotransmitters: GABA o Targeted symptoms: Mania, seizures, mood swings o Metabolism and excretion: Hepatic, first 6 months crucial o Common side effects: Nausea, vomiting, hair loss, tremors, weight gain, PCOS and hyperandrogenism (less in bipolar disorder) o Serious Side Effects: Pancreatitis, leukopenia, thrombocytopenia, hyperammonemia o Toxicity: Confusion, dizziness, disorientation o Does not increase lipids and may prevent the increases in cholesterol induced by some atypical antipsychotics. o Pregnancy effects: Can cause major congenital malformations, particularly neural tube defects (e.g., spina bifida). In addition, valproate can cause decreased IQ scores and neurodevelopmental disorders following in utero exposure. Compatible with breastfeeding. o Monitoring parameters: Liver function tests, plasma levels, blood counts o Therapeutic levels: 50-125 mcg/mL o Divalproex Monitoring (trough level) o 5 days after dose change o Antimanic - >45 µg/mL o Levels up to 100 µg/mL are well tolerated o Levels up to 125 µg/mL in acute mania o Maintenance 50 – 100 mg /L (trough) o Valproate concentration levels ≥110 mcg/mL in females or ≥135 mcg/mL in males increases the risk of thrombocytopenia. o Symptoms of toxicity: Nausea, vomiting, diarrhea, abdominal pain, weakness, lethargy o Treatment of toxicity: Discontinue medication, supportive care o Titrating up and tapering down: o Commonly known interactions: Carbamazepine, phenytoin, rifampin o Starting dose: 250-500 mg/day Dosing: ER - only about 80% as bioavailable as IR Drug levels 10–20% lower When convert from IR increase dose by 8–20% ▪ MANIA  ▪ Start 15 mg/kg in (divided doses or daily for ER) OR 1,000 mg/day; increase dose rapidly ▪ Maximum dose 60 mg/kg per day ▪ Less acute mania, may begin at 250–500 mg the first day, and then titrate upward as tolerated. Depakote with Lamictal, reduce Lamotrigine by 50% Carbamazepine (Tegretol): o Not first line o absorbed slowly and erratically through GI tract o Indications: Acute mania / mixed mania (Equestro) o Mechanism of action: Blocks sodium channels, Potent inducer of many CYP enzymes o CYP 450 autoinduction (3A4) Drug encourages its own metabolism so it becomes less effective after a few weeks. o uT ½ = 12 hours with long-term administration o udosage adjustments in first weeks of therapy o uUsually stable after 3 – 4 weeks: blood level check 3-4 weeks o T ½ = 36 hours after single dose, T ½ = 12 hours with long-term administration  o Targeted neurotransmitters: Unknown o Targeted symptoms: Mania, seizures, pain o Metabolism and excretion: Hepatic o Common side effects: Dizziness and diplopia, ataxia, somnolence, nausea headache, dry mouth, hyponatremia o Rare SE: aplastic anemia, agranulocytosis, purpura, SJS o Pregnancy effects: Spina Bifida, Must use adequate birth control methods o Non-hormonal o Higher doses of estrogen (CBZ lowers estrogen levels) o Monitoring parameters: Carbamazepine level, CBC, LFTs, pregnancy, agranulocytosis, Asian population screen for HLA-B 1502 allele (increased risk of Stevens Johnson Syndrome) o Therapeutic levels: 4-12 mg/L Response NOT correlated with blood levels o Symptoms of toxicity: Drowsiness, confusion, seizures o Treatment of toxicity: Discontinue medication, supportive care o Titrating up and tapering down: Titrate slowly to response or side effects o Commonly known interactions: Oxcarbazepine, phenytoin, valproic acid o Dosing: Start at 200mg BID then increase by 200 mg every 4 days to target 400/600 BID. Depression - 200 mg H.S. Mania - 600–800 mg Lamotrigine (Lamictal) *LamITCHtal*: o Indications: Prevent recurrence of mania and depression in bipolar disorder o Mechanism of action: Blocks glutamate and sodium channels o Targeted neurotransmitters: Glutamate, GABA o Targeted symptoms: Mania, seizures o Metabolism and excretion: Hepatic o Common side effects: Rash, dizziness, nausea, fatigue o Pregnancy effects: Interacts with birth control may need to increase the dose of both medications. o Monitoring parameters: Liver function tests o Therapeutic levels: Not established o Symptoms of toxicity: Rash, fever, swollen lymph nodes, Stevens - Johnson – risk with quick titration, high doses and with use of valproic acid. ▪ Prodrome ▪ Systemic symptoms – “flu-like” with fever ▪ Lesions 1 – 3 days later ▪ Painful NOT itchy ▪ On throat or trunk ▪ Individual lesions with vesicles and painful central sores ▪ Facial swelling ▪ Swollen lips ▪ May affect other mucous membranes – eyes, throat ▪ Up to 95% of patients will have mucous membrane lesions ▪ ~85% will have conjunctival lesions ▪ Genital – ask about dysuria o Treatment of toxicity: Discontinue at first sign of rash or bruising, supportive care, If stopped/missed dose -restart initial titration o Titrating up and tapering down: Start low, go slow, monitor for side effects o Commonly known interactions: Carbamazepine, phenytoin, valproic acid ▪ BENIGN RASHES (occur in 10% of clients) ▪ Onset 1 – 5 day or after 8 – 12 weeks ▪ Spotty, non-confluent, non-tender, no systemic features ▪ Reduce or stop increase of lamotrigine – WAIT ▪ Antihistamine and/or topical corticosteroid  ▪ Monitor closely ▪ uSERIOUS RASH (< 1%) ▪ Stop lamotrigine (and valproate if prescribed) ▪ Monitor organ involvement (hepatic, renal, hematologic) ▪ May require hospitalization ▪ Monitor very closely o Starting dose: Start 25mg QD for 2 weeks, then 50mg QD for 2 weeks then 100mg qd – 2 weeks, then 200mg day o Reduce lamotrigine dose by 50% if used with valproate (Depakote). o If a patient has discontinued lamotrigine for a period of more than 5 half-lives, it is recommended that initial dosing recommendations and guidelines be followed. Oxcarbazepine (Trileptal): o Indications: Bipolar disorder, epilepsy o Mechanism of action: Blocks sodium channels o Targeted neurotransmitters: Unknown o Targeted symptoms: Mania, seizures o Metabolism and excretion: Hepatic o Common side effects: Dizziness, nausea, drowsiness, headache o Pregnancy effects: Category C o Monitoring parameters: Liver function tests o Therapeutic levels: Not established o Symptoms of toxicity: Drowsiness, confusion, seizures o Treatment of toxicity: Discontinue medication, supportive care o Titrating up and tapering down: Start low, go slow, monitor for side effects o Commonly known interactions: Carbamazepine, phenytoin, valproic acid  Topiramate: o Indications: Bipolar disorder, epilepsy, migraine o Mechanism of action: Blocks glutamate and GABA receptors o Targeted neurotransmitters: Glutamate, GABA o Targeted symptoms: Mania, seizures, weight loss o Metabolism and excretion: Renal o Common side effects: Drowsiness, paresthesia, cognitive impairment o Pregnancy effects: Category C o Monitoring parameters: Kidney function tests o Therapeutic levels: Not established o Symptoms of toxicity: Drowsiness, confusion, seizures o Treatment of toxicity: Discontinue medication, supportive care o Titrating up and tapering down: Start low, go slow, monitor for side effects o Commonly known interactions: Diuretics, NSAIDs, ACE inhibitors Atypical antipsychotics Aripiprazole (Abilify): o Indications: Bipolar Mania / maintenance 10+, schizophrenia 13+, depression Adjuvant, Tourette’s 6-18 yr o Mechanism of action: Partial dopamine agonist, serotonin antagonist o Targeted neurotransmitters: Dopamine, serotonin o Targeted symptoms: Positive and negative symptoms of psychosis, mood stabilization o Metabolism and excretion: Hepatic o Common side effects: Akathisia, insomnia, nausea, weight gain o Pregnancy effects: Category C o Monitoring parameters: Lipid profile, glucose levels  o Therapeutic levels: Not established o Symptoms of toxicity: Tardive dyskinesia, hyperprolactinemia o Treatment of toxicity: Discontinue medication, supportive care o Titrating up and tapering down: Start low, go slow, monitor for side effects o Commonly known interactions: Fluoxetine, paroxetine Risperidone: o Indications: Bipolar mania/ mixed/ maint. 10+, schizophrenia 13+, depression o Mechanism of action: Dopamine and serotonin antagonist o Targeted neurotransmitters: Dopamine, serotonin o Targeted symptoms: Positive and negative symptoms of psychosis, mood stabilization o Metabolism and excretion: Hepatic o Common side effects: Drowsiness, sedation, weight gain, prolactin elevation, gynecomastia, Akathisia o Pregnancy effects: Category C o Monitoring parameters: Lipid profile, glucose levels, prolactin levels o Therapeutic levels: Not established o Symptoms of toxicity: Tardive dyskinesia, hyperprolactinemia o Treatment of toxicity: Discontinue medication, supportive care o Titrating up and tapering down: Start low, go slow, monitor for side effects o Commonly known interactions: Fluoxetine, paroxetine o Dosing: ▪ Adults: initial – 2mg; target 4mg -16mg Daily (bipolar mania 1mg-6mg Daily) ▪ Peds: initial – 0.5mg; target 1mg – 6mg Daily ▪ 60% D2 blockade at 4mg  Clozapine: o Indications: Treatment-resistant schizophrenia o Mechanism of action: Dopamine and serotonin antagonist o Targeted neurotransmitters: Dopamine, serotonin o Targeted symptoms: Positive and negative symptoms of psychosis o Metabolism and excretion: Hepatic o Common side effects: Drowsiness, sedation, weight gain, agranulocytosis o Pregnancy effects: Category C o Monitoring parameters: Complete blood count (CBC), white blood cell count (WBC) o Therapeutic levels: Not established o Symptoms of toxicity: Agranulocytosis, seizures, myocarditis o Treatment of toxicity: Discontinue medication, supportive care o Titrating up and tapering down: Start low, go slow, monitor for side effects o Commonly known interactions: Fluoxetine, paroxetine Olanzapine (Zyprexa): o Indications: Bipolar disorder mania/mixed >13, schizophrenia >13, depression (with fluoxetine) o Mechanism of action: Dopamine and serotonin antagonist o Targeted neurotransmitters: Dopamine, serotonin o Targeted symptoms: Positive and negative symptoms of psychosis, mood stabilization o Metabolism and excretion: Hepatic o Common side effects: Drowsiness, severe sedation, weight gain, increased cholesterol and triglycerides, Extrapyramidal Symptoms, Tardive Dyskinesia  o Pregnancy effects: Category C o Monitoring parameters: Lipid profile, glucose levels o Therapeutic levels: Not established o Symptoms of toxicity: Tardive dyskinesia, hyperprolactinemia o Treatment of toxicity: Discontinue medication, supportive care o Titrating up and tapering down: Start low, go slow, monitor for side effects o Commonly known interactions: Fluoxetine, paroxetine o Dosing: ▪ Adults: 5mg – 20mg Daily ▪ Peds: 2.5mg – 20mg Daily ▪ Used IM for acute psychosis/aggression (NEVER with benzo) Quetiapine (Seroquel): o Indications: Bipolar Mania/mixed, maintenance 10+, schizophrenia 13+, depression adjunctive o Mechanism of action: NET Inhibition o Targeted neurotransmitters: Dopamine, serotonin o Targeted symptoms: Positive and negative symptoms of psychosis, mood stabilization o Metabolism and excretion: Hepatic o Common side effects: Drowsiness, Severe sedation, severe weight gain, increased cholesterol and triglycerides o Pregnancy effects: Category C o Monitoring parameters: Lipid profile, glucose levels o Therapeutic levels: Not established o Symptoms of toxicity: Tardive dyskinesia, hyperprolactinemia o Treatment of toxicity: Discontinue medication, supportive care o Titrating up and tapering down: Start low, go slow, monitor for side effects  o Commonly known interactions: Fluoxetine, paroxetine, St John’s Wort makes ineffective. o Dosing: ▪ IR: Daily, receptor occupancy remains after blood levels decrease ▪ XR: once Daily, 3-4 hours before bedtime WITHOUT FOOD ▪ Schizophrenia: 300mg/day (400mg-800mg daily), peds 13-17 50mg/day ▪ Bipolar: 300mg/day (400mg – 800mg), peds 50mg/day ▪ MDD & Bipolar depression: 50mg/day (up to 300mg/day) Lurasidone (Latuda): Indications: Bipolar depression 10+, schizophrenia 13+ Mechanism of action: Dopamine and serotonin antagonist Targeted neurotransmitters: Dopamine, serotonin, glutamate Targeted symptoms: Positive and negative symptoms of psychosis, mood stabilization Metabolism and excretion: Hepatic Common side effects: Drowsiness, sedation, weight gain, increased cholesterol and triglycerides Pregnancy effects: Category B, May consider Monitoring parameters: Lipid profile, glucose levels Therapeutic levels: Not established Symptoms of toxicity: Tardive dyskinesia, hyperprolactinemia Treatment of toxicity: Discontinue medication, supportive care Titrating up and tapering down: Start low, go slow, monitor for side effects Commonly known interactions: Fluoxetine, paroxetine Dosing: MUST TAKE WITH FOOD Schizophrenia:  ▪ Adult – 40mg – 160mg daily ▪ Peds – 40mg – 80mg daily Bipolar Depression ▪ Adult – 20-120mg Daily ▪ Peds – 20-80mg Daily Ziprasidone (Geodon): Indications: Bipolar disorder, schizophrenia Mechanism of action: Dopamine and serotonin antagonist Targeted neurotransmitters: Dopamine, serotonin Targeted symptoms: Positive and negative symptoms of psychosis, mood stabilization Metabolism and excretion: Hepatic Common side effects: Dizziness, Drowsiness, QT Prolongation, sedation, LOWEST risk of weight gain Pregnancy effects: Category C Monitoring parameters: EKG, Lipid profile, glucose levels Therapeutic levels: Not established Symptoms of toxicity: Tardive dyskinesia, hyperprolactinemia Treatment of toxicity: Discontinue medication, supportive care Titrating up and tapering down: Start low, go slow, monitor for side effects Commonly known interactions: Fluoxetine, paroxetine Asenapine: Indications: Bipolar disorder, schizophrenia Mechanism of action: Dopamine and serotonin antagonist Targeted neurotransmitters: Dopamine, serotonin  Targeted symptoms: Positive and negative symptoms of psychosis, mood stabilization Metabolism and excretion: Hepatic Common side effects: Drowsiness, sedation, weight gain, increased cholesterol and triglycerides Pregnancy effects: Category C Monitoring parameters: Lipid profile, glucose levels Therapeutic levels: Not established Symptoms of toxicity: Tardive dyskinesia, hyperprolactinemia Treatment of toxicity: Discontinue medication, supportive care Titrating up and tapering down: Start low, go slow, monitor for side effects Commonly known interactions: Fluoxetine, paroxetine 1. Know the severe and life-threatening side effects of mood stabilizers to monitor for including SJS Severe and Life-Threatening Side Effects of Mood Stabilizers (Including SJS) Lamotrigine: Stevens-Johnson Syndrome (SJS) is a rare but serious skin reaction. Early signs include fever, rash, and blisters. Valproic Acid: Hepatotoxicity (liver damage), pancreatitis (inflammation of the pancreas). Lithium: Lithium toxicity can cause tremors, confusion, seizures, coma, and even death. Carbamazepine: Agranulocytosis (low white blood cell count), aplastic anemia (bone marrow failure), SJS. 2. Know and be able to identify the difference between dementia and delirium  Feature Dementia Delirium Gradual, over months Sudden, within hours or Onset or years days Fluctuating, often worse at Course Progressive decline night Usually intact in Attention Impaired early stages Consciousness Usually clear Can be altered Often reversible if Reversibility Generally irreversible underlying cause treated 3. Be able to state common causes of delirium · Medications: Especially anticholinergics, benzodiazepines, and opioids. · Infections: Urinary tract infections, pneumonia, sepsis. · Metabolic disturbances: Dehydration, electrolyte imbalances, low blood sugar. · Withdrawal: From alcohol, benzodiazepines, or other substances. · Post-operative state 4. Know and understand the general classes of medications used to treat dementia and risk factors / side effects Medications for Dementia: Cholinesterase inhibitors (e.g., donepezil, rivastigmine, galantamine): Increase acetylcholine in the brain. Side effects: Nausea, vomiting, diarrhea, dizziness. NMDA receptor antagonists (e.g., memantine): Regulate glutamate activity. Side effects: Headache, dizziness, constipation. 5. Be familiar with BEERS criteria and what common medications NOT to use in the elderly and why  The BEERS Criteria are guidelines for healthcare professionals to help improve the safety of prescribing medications for older adults. They identify medications that are potentially inappropriate for older adults due to increased risks of adverse events. Some commonly cited medications to avoid or use with caution in the elderly include: o Anticholinergics: Can cause confusion, urinary retention, constipation. o Benzodiazepines: Increased risk of falls, cognitive impairment, and dependence. o Non-steroidal anti-inflammatory drugs (NSAIDs): Increased risk of gastrointestinal bleeding and kidney problems. 6. Understand neural pathways and neurotransmitters involved in addictions · Mesolimbic dopamine pathway: The primary reward pathway in the brain. Drugs of abuse increase dopamine in this pathway, leading to feelings of pleasure and reinforcement. · Neurotransmitters involved: Dopamine, glutamate, GABA, serotonin, endorphins. 7. Know treatments for smoking cessation including forms of nicotine replacement, bupropion and varencicline. Know indications, targeted neurotransmitters and symptoms, side effects and major precautions. Know pros and cons of treatments. Smoking Cessation Treatments Nicotine replacement therapy (NRT): Patches, gum, lozenges, inhalers, nasal spray. Provides nicotine without the harmful chemicals in cigarettes. Bupropion: Antidepressant that also reduces cravings and withdrawal symptoms. Varenicline: Partial nicotine receptor agonist. Reduces cravings and blocks the rewarding effects of nicotine. Pros and Cons of Smoking Cessation Treatments Treatment Pros Cons  Readily available, Nicotine various forms to Can be less effective than Replacement choose from, can other treatments, potential Therapy reduce cravings and for dependence. withdrawal symptoms. Not suitable for people Can be effective, also with seizure disorders, can Bupropion helps with depression. cause insomnia and dry mouth. Most effective Can cause nausea and treatment, can reduce vivid dreams, potential for Varenicline cravings and block the serious neuropsychiatric rewarding effects of side effects. nicotine. 8. Know signs and symptoms of Alcohol Use Disorder and withdrawal. Know major stages of withdrawal. Alcohol Use Disorder (AUD) and Withdrawal Signs and symptoms of AUD: Craving, loss of control, physical dependence, tolerance, withdrawal symptoms. Withdrawal symptoms: Anxiety, tremors, sweating, nausea, vomiting, seizures, delirium tremens (DTs). Stages of withdrawal: o 4 - 8 hours - tremors o 8 – 10 hours – psychosis o 12 – 24 hours – seizures o 24 – 36 hours – Delirium Tremens (DTs) – 20% risk of death if not treated. 9. Know and understand the rationale for AUD treatments including benzodiazepines (Ativan), Librium, Vitamin B1, folic acid, cyanocobalamin and multivitamins.  Benzodiazepines (e.g., Ativan, Librium) Rationale: Alcohol withdrawal can be dangerous, even life-threatening. Benzodiazepines like lorazepam (Ativan) and chlordiazepoxide (Librium) are central nervous system depressants that act on GABA receptors. This helps to: o Reduce anxiety: A major symptom of alcohol withdrawal. o Prevent seizures: Alcohol withdrawal can cause seizures, which benzodiazepines help to control. o Ease withdrawal symptoms: They can lessen the severity of tremors, agitation, and insomnia. o Manage delirium tremens (DTs): DTs is a severe form of alcohol withdrawal with confusion, hallucinations, and autonomic instability. Benzodiazepines are critical in managing DTs. Important Note: Benzodiazepines should be used cautiously in AUD due to their own potential for dependence and abuse. They are typically tapered off gradually once the acute withdrawal phase has passed. Vitamin B1 (Thiamine) Rationale: People with AUD are often deficient in thiamine (vitamin B1) due to poor nutrition and alcohol's interference with thiamine absorption. Thiamine is essential for brain function. o Prevents Wernicke-Korsakoff syndrome: This is a serious neurological disorder caused by thiamine deficiency. It can lead to confusion, memory loss, ataxia (difficulty with coordination), and vision problems. o Supports brain health: Helps to protect the brain from damage caused by alcohol. Administration: Thiamine is often given intramuscularly or intravenously in the initial stages of treatment, followed by oral supplementation. Folic Acid Rationale: Folic acid is a B vitamin crucial for cell growth and function. Alcohol interferes with folate absorption and metabolism. o Corrects deficiency: Replenishes depleted folate stores. o Supports red blood cell production: Alcohol can lead to anemia, and folic acid helps in red blood cell formation. o May improve cognitive function: Some studies suggest that folic acid supplementation may help improve cognitive function in people with AUD. Cyanocobalamin (Vitamin B12) Rationale: Vitamin B12 is important for nerve function and red blood cell production. Alcohol can impair B12 absorption. o Corrects deficiency: Replenishes B12 levels. o Supports neurological health: Helps to prevent and treat peripheral neuropathy (nerve damage) that can occur with AUD.  o Improves red blood cell production: Contributes to resolving anemia. Multivitamins Rationale: People with AUD often have multiple nutritional deficiencies due to poor diet and malabsorption. o Provides overall nutritional support: Helps to correct deficiencies in essential vitamins and minerals. o Supports recovery: Ensures the body has the nutrients it needs for healing and overall well-being. 10. Know medications for AUD maintenance including indications, major precautions, and prescribing guidelines. 1. Naltrexone (ReVia, Vivitrol) Indications: o Reduces cravings for alcohol. o Blocks the pleasurable effects of alcohol, making it less rewarding. o Helps prevent relapse to heavy drinking. Major Precautions: o Opioid use: Naltrexone is an opioid antagonist. It can precipitate severe withdrawal in people who are physically dependent on opioids. Patients must be opioid-free for 7-10 days before starting naltrexone. o Liver disease: Use with caution in patients with acute hepatitis or liver failure. o Pregnancy: Category C; potential risks to the fetus. Prescribing Guidelines: o Available in oral (ReVia) and injectable (Vivitrol) forms. o Oral: 50 mg once daily. o Injectable: 380 mg intramuscularly once a month. o Should be used in conjunction with counseling and psychosocial support. 2. Acamprosate (Campral) Indications: o Reduces cravings for alcohol.  o Helps maintain abstinence. o May reduce anxiety and insomnia associated with early recovery. Major Precautions: o Renal impairment: Acamprosate is excreted by the kidneys, so dosage adjustments are needed for patients with kidney disease. o Pregnancy: Category C; potential risks to the fetus. Prescribing Guidelines: o 333 mg tablets, usually taken three times a day. o Initiate as soon as possible after alcohol withdrawal, ideally within 5 days of abstinence. o Most effective when combined with counseling and support groups. 3. Disulfiram (Antabuse) Indications: o Works as an aversion therapy. o Inhibits the breakdown of alcohol, leading to unpleasant reactions (flushing, nausea, vomiting, headache, rapid heartbeat) if alcohol is consumed. o Helps to deter drinking. Major Precautions: o Alcohol ingestion: Even small amounts of alcohol can cause a severe reaction. Patients must be fully abstinent before starting disulfiram. o Cardiac disease: Use with caution in patients with heart conditions. o Liver disease: Can worsen liver function. Prescribing Guidelines: o 250-500 mg once daily. o Requires careful patient selection and education. o Must be used with patient's full understanding and consent. o Not recommended for routine use due to limited effectiveness and potential for serious side effects. 11. Know signs and symptoms of opioid use disorder. Behavioral Signs and Symptoms: Cravings: Intense desire or urge to use opioids. Loss of control: Difficulty controlling opioid use, taking larger amounts or using for longer periods than intended. Time spent: Significant time spent obtaining, using, or recovering from the effects of opioids. Neglecting responsibilities: Failing to fulfill major role obligations at work, school, or home due to opioid use. Social problems: Continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by opioid use. Risky use: Recurrent opioid use in physically hazardous situations (e.g., driving). Continued use despite problems: Continued use despite knowledge of having a persistent or recurrent physical or psychological problem likely caused or exacerbated by opioids. Tolerance: Need for increased amounts of opioids to achieve the desired effect or diminished effect with continued use of the same amount. Withdrawal: Experiencing withdrawal symptoms when opioid use is stopped or reduced, or using opioids (or a related substance) to relieve or avoid withdrawal symptoms. Physical Signs and Symptoms: Constricted pupils (pinpoint pupils) Drowsiness or sedation Slurred speech Impaired coordination Slowed breathing Constipation Nausea and vomiting Track marks (from injections)  Scars or abscesses (from injections) Withdrawal Symptoms: Intense cravings Muscle aches and spasms Restlessness or anxiety Runny nose and watery eyes Insomnia Yawning Nausea, vomiting, and diarrhea Abdominal cramps Dilated pupils Goosebumps ("cold turkey") Sweating Rapid heart rate High blood pressure 12. Know names, dosage, precautions and indications of opioid reversal medications: Naloxone and Nalfexene. Naloxone (Narcan, Evzio) Indications: o Opioid overdose: Rapidly reverses the effects of opioid overdose, including life- threatening respiratory depression (slowed or stopped breathing). o Suspected opioid overdose: Used when an opioid overdose is suspected, even if not confirmed. Dosage: o Intranasal: Most common form for first responders and laypersons. One spray into one nostril, may repeat in 2-3 minutes if needed. o Intramuscular (IM) or Subcutaneous (SC) injection: 0.4 mg to 2 mg, may repeat every 2-3 minutes until response is achieved. o Intravenous (IV) injection: 0.4 mg to 2 mg, may repeat every 2-3 minutes if needed. IV route provides the fastest onset of action. Precautions:  o Opioid withdrawal: Can precipitate withdrawal symptoms in individuals physically dependent on opioids. o Short duration of action: Naloxone has a shorter half-life than many opioids, so repeated doses or continuous infusion may be necessary. o Limited effect on non-opioid drugs: Naloxone only reverses the effects of opioids. It will not reverse overdoses from other substances like benzodiazepines or stimulants. Naltrexone (ReVia, Vivitrol) Indications: o Opioid use disorder (OUD): Blocks the effects of opioids, reducing cravings and preventing relapse. o Alcohol use disorder (AUD): Reduces cravings for alcohol and helps maintain abstinence. Dosage: o Oral (ReVia): 50 mg once daily for OUD and AUD. o Injectable (Vivitrol): 380 mg intramuscularly once a month for OUD and AUD. Precautions: o Opioid withdrawal: Can precipitate severe withdrawal in people who are physically dependent on opioids. Patients must be opioid-free for 7-10 days before starting naltrexone. o Liver disease: Use with caution in patients with acute hepatitis or liver failure. o Pregnancy: Category C; potential risks to the fetus. Key Differences between Naloxone and Naltrexone: Primary use: Naloxone is primarily used for emergency opioid overdose reversal. Naltrexone is used for long-term treatment of OUD and AUD. Onset of action: Naloxone has a very rapid onset of action (within minutes). Naltrexone has a slower onset (30-60 minutes for oral, days for injectable). Duration of action: Naloxone has a relatively short duration of action (30-90 minutes). Naltrexone has a longer duration of action (24 hours for oral, one month for injectable). 13. Know treatments, rationale, major precautions, mechanisms of action for the following medications used to treat Alcohol Use Disorder and Opioid Use Disorder including: methadone naltrexone buprenorphine buprenorphine/naloxone  disulfuram lofexidine Methadone Treatment: Opioid Use Disorder (OUD) Rationale: o Long-acting opioid agonist: Methadone activates opioid receptors in the brain, but it does so more slowly and for a longer duration than short-acting opioids like heroin. This helps to: ▪ Suppress withdrawal symptoms: Reduces the intensity and duration of withdrawal. ▪ Reduce cravings: Helps control cravings for opioids. ▪ Block the effects of other opioids: If a person uses other opioids while on methadone, they are less likely to experience the euphoric effects. Mechanism of Action: µ-opioid receptor agonist. Major Precautions: o Respiratory depression: Can cause slowed or stopped breathing, especially at higher doses or combined with other sedatives. o QT prolongation: Can prolong the QT interval on an EKG, increasing the risk of a dangerous heart rhythm. o Overdose risk: Methadone overdose can be fatal. o Drug interactions: Many drug interactions, especially with medications that affect the CYP450 enzyme system. Naltrexone Treatment: Opioid Use Disorder (OUD) and Alcohol Use Disorder (AUD) Rationale: o Opioid antagonist: Naltrexone blocks opioid receptors, preventing opioids from binding and producing their effects. This helps to: ▪ Prevent relapse: Reduces cravings and blocks the euphoric effects of opioids, making them less rewarding.  ▪ Support abstinence: Helps individuals maintain abstinence from opioids. o For AUD: While the exact mechanism is not fully understood, naltrexone may reduce cravings for alcohol and block some of its pleasurable effects. Mechanism of Action: µ-opioid receptor antagonist. Major Precautions: o Opioid withdrawal: Can precipitate severe withdrawal in individuals physically dependent on opioids. Patients must be opioid-free for 7-10 days before starting naltrexone. o Liver disease: Use with caution in patients with acute hepatitis or liver failure. o Pregnancy: Category C; potential risks to the fetus. Buprenorphine Treatment: Opioid Use Disorder (OUD) Rationale: o Partial opioid agonist: Buprenorphine activates opioid receptors but to a lesser extent than full agonists like heroin or methadone. This helps to: ▪ Suppress withdrawal symptoms: Reduces the intensity and duration of withdrawal. ▪ Reduce cravings: Helps control cravings for opioids. ▪ Lower overdose risk: Has a ceiling effect, meaning that increasing the dose beyond a certain point does not produce greater effects, reducing the risk of overdose. Mechanism of Action: Partial agonist at the µ-opioid receptor. Major Precautions: o Respiratory depression: Can cause slowed or stopped breathing, especially when combined with other sedatives. o Precipitated withdrawal: Can cause withdrawal symptoms if given to someone physically dependent on opioids and who has not been abstinent for a sufficient period. o Drug interactions: Can interact with other medications, especially those affecting the CYP450 enzyme system.  Buprenorphine/Naloxone Treatment: Opioid Use Disorder (OUD) Rationale: o Combines buprenorphine's benefits with naloxone's safety: Buprenorphine provides the partial agonist effects to reduce withdrawal and cravings. Naloxone is an antagonist that is poorly absorbed when taken sublingually (under the tongue) but blocks the effects of opioids if the medication is injected, deterring misuse. Mechanism of Action: Buprenorphine is a partial µ-opioid receptor agonist; naloxone is a µ-opioid receptor antagonist. Major Precautions: o Similar to buprenorphine: Respiratory depression, precipitated withdrawal, drug interactions. Disulfiram Treatment: Alcohol Use Disorder (AUD) Rationale: o Aversion therapy: Disulfiram inhibits the breakdown of alcohol, leading to unpleasant reactions (flushing, nausea, vomiting, headache, rapid heartbeat) if alcohol is consumed. This helps deter drinking. Mechanism of Action: Inhibits aldehyde dehydrogenase, an enzyme involved in alcohol metabolism. Major Precautions: o Alcohol ingestion: Even small amounts of alcohol can cause a severe reaction. Patients must be fully abstinent before starting disulfiram. o Cardiac disease: Use with caution in patients with heart conditions. o Liver disease: Can worsen liver function. Lofexidine Treatment: Alcohol withdrawal Rationale:  o Reduces withdrawal symptoms: Lofexidine is a centrally-acting alpha-2 adrenergic agonist that helps reduce the autonomic hyperactivity (e.g., sweating, tremors, agitation) associated with alcohol withdrawal. Mechanism of Action: α2-adrenergic receptor agonist. Major Precautions: o Hypotension: Can lower blood pressure, so monitor blood pressure closely. o Bradycardia: Can slow heart rate. o Sedation: Can cause drowsiness. 1. Know the signs and symptoms of withdrawal from benzodiazepines and potential treatments Withdrawal symptoms can range from mild to severe and may include: Anxiety Insomnia Tremors Sweating Nausea and vomiting Seizures Delirium Potential Treatments Gradual Tapering: The most common and effective treatment for benzodiazepine withdrawal is a gradual tapering of the dose. This allows the brain to slowly adjust to the decreasing levels of the drug, minimizing withdrawal symptoms. Medication-Assisted Treatment: In some cases, other medications may be used to help manage specific withdrawal symptoms. For example, anticonvulsants may be used to prevent seizures, and beta-blockers may be used to control tremors and heart rate. Supportive Care: Providing a supportive and comfortable environment can also be helpful during withdrawal. This may include ensuring adequate hydration, nutrition, and rest.  Important Considerations: Medical Supervision: Benzodiazepine withdrawal should be managed under medical supervision, especially in cases of severe dependence or a history of seizures. Individualized Treatment: The treatment plan should be individualized based on the severity of withdrawal symptoms and the person's overall health and needs. Long-Term Support: Recovery from benzodiazepine dependence often requires ongoing support, such as therapy or support groups, to address the underlying causes of addiction and prevent relapse. 2. Know the signs and symptoms of amphetamine and PCP withdrawal and treatments Amphetamine Withdrawal Amphetamines are powerful stimulants that increase the activity of dopamine, norepinephrine, and serotonin in the brain. Chronic amphetamine use can lead to dependence and withdrawal symptoms upon cessation. Signs and Symptoms: Psychological: o Fatigue o Depression o Irritability o Anxiety o Difficulty concentrating o Vivid dreams or nightmares o Increased appetite o Cravings for amphetamines Physical: o Sleep disturbances (insomnia or hypersomnia) o Headaches o Muscle aches o Tremors o Slowed movements Treatments: Supportive Care: The primary treatment for amphetamine withdrawal is supportive care. This includes: o Ensuring a safe and comfortable environment  o Promoting rest and sleep o Addressing nutritional needs o Providing emotional support and counseling Medications: There are no FDA-approved medications specifically for amphetamine withdrawal. However, certain medications may be used to manage specific symptoms, such as: o Antidepressants (for depression) o Benzodiazepines (for anxiety and agitation) o Sleep aids (for insomnia) PCP Withdrawal PCP (phencyclidine) is a dissociative anesthetic that alters perception, mood, and cognition. It primarily affects the NMDA receptor in the brain. Chronic PCP use can lead to dependence and withdrawal symptoms. Signs and Symptoms: Psychological: o Cravings for PCP o Anxiety o Depression o Irritability o Difficulty concentrating o Memory problems o Paranoia o Hallucinations o Delusions Physical: o Sweating o Tremors o Muscle aches o Nausea and vomiting o Seizures Treatments: Supportive Care: Similar to amphetamine withdrawal, supportive care is the mainstay of treatment for PCP withdrawal. This includes: o Ensuring a safe and comfortable environment o Monitoring for and managing seizures o Providing emotional support and counseling Medications: There are no FDA-approved medications specifically for PCP withdrawal. However, certain medications may be used to manage specific symptoms, such as: o Benzodiazepines (for anxiety, agitation, and seizures) o Antipsychotics (for psychosis)  3. Review P450 system language and how genetic pre-disposition for metabolism could impact the dosing of medication Metabolism: The process by which the body breaks down and eliminates drugs. Enzymes: Proteins that catalyze (speed up) chemical reactions in the body, including drug metabolism. Genetic variations: Differences in genes that can lead to variations in enzyme activity. Dosage: The amount of medication a person needs to take to achieve the desired therapeutic effect. How Genetic Variations Impact Dosing Ultra-rapid metabolizers: These individuals have genetic variations that lead to increased enzyme activity. They metabolize drugs more quickly, potentially requiring higher doses or more frequent administration to achieve the desired effect. Extensive metabolizers: These individuals have normal enzyme activity and metabolize drugs at a typical rate. Intermediate metabolizers: These individuals have reduced enzyme activity compared to extensive metabolizers. They may require lower doses or less frequent administration to avoid side effects. Poor metabolizers: These individuals have very low or absent enzyme activity. They are at increased risk for side effects and drug accumulation, often requiring significantly lower doses or alternative medications. Implications for Treatment Individualized dosing: Genetic variations in the P450 system highlight the importance of individualized dosing based on a person's genetic makeup and metabolic profile. Therapeutic drug monitoring: In some cases, therapeutic drug monitoring (measuring drug levels in the blood) may be helpful to guide dosage adjustments, especially for medications with a narrow therapeutic index (where the difference between an effective dose and a toxic dose is small).  Pharmacogenomic testing: Pharmacogenomic testing can identify genetic variations in the P450 system, providing valuable information for personalizing medication selection and dosing. Examples CYP2D6: This enzyme metabolizes many antidepressants, antipsychotics, and opioids. Genetic variations in CYP2D6 can significantly affect the response to these medications. CYP2C19: This enzyme metabolizes certain antidepressants, antiplatelet drugs, and proton pump inhibitors. Genetic variations in CYP2C19 can influence the effectiveness and safety of these medications.