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36 Cards in this Set
- Front
- Back
Name the 5 neuroleptic-induced syndromes
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acute dystonic reaction, akathisia, parkinsonism (including rabbit syndrome), Tardive dyskinesia, Neuroleptic malignant syndrome (NMS)
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What is the timeline for each neuroleptic induced syndrome?
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ADS (hrs-days), akathisia (days-wks), parkinsonism (wks-mos), TD (mos-yrs)
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Name 2 SSRI-related syndrome
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serotonin syndrome, SSRI-discontinuation syndrome
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Described acute dystonic reaction. Treatment?
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hrs-days: early EPS characterized by acute msucle spasm, more often d/t typical antipsychotics in a high dose or to an antipsychotic-naive patient. Can be torticollis or oculogyric crisis (painful upward deviations of eyes), and generally involves the neck/face/throat. Occurs w/in hurs but can be delayed up to a day after neuroleptic andminstration. Treat w/ benztropine (central acting anti-cholinergic/histamine) or IM diphenyldramine
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Which Rx, used as antiemitics, can also cause acute dystonic reactions?
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promethazine (phenegran), prochlorperazine (compazine), metoclopramide (Reglan).
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Which is the most dangerous dystonic reaction?
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laryngospasm (protect the airway)
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Describe akathisia. Treatment?
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inner feeling of restlessness + motoric restlessness that makes the person unable to sit still; takes days to weeks to occur. Can be d/t SSRI and by the antiemetics metoclopramide and prochlorperazine. Tx w/ BB, benzo (loraepam) or anticholinergic (benztropine/benadryl).
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Define parkinsonism (including rabbit syndrome)
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resembles PD but not idiopathic. Takes weeks to months.
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Define Tardive Dyskinesia. Management?
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takes months, usually years to develop. Associated w/ long-term or high dose use of dopamine antagonists. antipsychotics (typicals > atypicals) are usual culprits. Sx include involutnary purposeless reptitive tics and spasms, generally oro-buccal, which are NOT distressing. 50% cases reversible, failure to disclose this SE is a reaction for legal action!! stop offending agent, if 2/2 to antipsychotic, consider a switch to clozapine (least EPS)
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Define NMS. Rx?
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usually occurs days after starting antipsychotic or increasing its dose (usually typicals). Often missed or misdiagnosed. 10% fatal. Look for muscle cramps w/ lead pipe rigidity, high fever, autonomic instability, and mental status changes consistent with delirium. Leukocytosis and CPK increases (~20K). treatment involves stopping the offender, bringing down fever and hydrating to prevent renal failure from rhabdo. Rx: dantrolene and bromocriptine (dopamine agonist)
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What syndrome is very similar to serotonin syndrome?
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NMS! questions on this typically involve the addition of a new pro-serotonin Rx to a patient who is already on a medication that has pro-serotonin properties (i.e. linezolid, tramadol, SSRI, SNRI, TCA, MAOI) or an insufficient wash-out period b/t Rx (SSRI/SNRI/TCA + MAOI). Sx same as NME but may also have myoclonus (jerks) where NMS is more lead pipe rigidity. Tx by removing offending agents & supporting care. Tx by removing offending agents & supporting care.
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Define SSRI discontinuations syndrome.
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abrupt d/c of SSRI leads to the syndrome FLU-like sx. Rx at highest risk if d/c'd abruptly is paroxetine (shortest-half life). similar syndrome occurs w/ SNRIs (esp venlafaxine immediate release aka side effexor). SNRI d/c syndrome more likely to cause paresthesias and "electrical sensations" in extremities (the "zaps").
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Define Hypertensive crisis. Treatment?
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Pt on MAOI ingestes tyramine (wine, cheese, fava beans, cured meats, etc.). Can also be with MAOI +meperidine aka demerol). Tx: lower BP w/ phentolamine or Na nitroprusside infusions for true emergencies (diastolic > 120).
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Why is tyramine c/i in patients taking MAOI?
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tyramine is an indirect sympathomimetic which is converted to NE pre-synaptically.
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What serum level does lithium toxicity occur?
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serum levels > 1.5 (therapeutic levels 0.6-1.2).
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list symptoms at lithium levels b/w 1.5-2.0.
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n/v/ataxia, slurred speech, weakness, nystagmus
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list symptoms at lithium levels b/w 2.0-2.5
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axnorexia, blurred vision, fasiculations, delirium, stupor, increased DTRs
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list symptoms at lithium levels > 2.5
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generalized convulsions, oliguric renal failure.
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list symptoms at lithium levels > 3.5
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severe! cardiovascular collapse, potentially lethal.
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Treatment for mild v severe lithium toxicity?
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mild/moderate: IVF; severe: hemodialysis (look for seizures, delirium, stupor, coma, etc.)
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Lithium side effects (therapeutic levels)?
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hypothyroidism (F>M), nephrogenic DI, acne, weight gain, sedation, benign leukocytosis, psoriasis
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teratogenic side effects of lithium?
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ebsteins abnormality (highest risk in 1st trimester; tricuspid valve is displaced down)
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therapeutic trough levels of valproic acid
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50-100 (can titrate to side effects)
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Mild sx of valproic acid toxicity
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GI upset w/ n/v and confusion
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Sx of severe valproic acid toxicity
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hypotension, cerebral edema --> lethargy, coma, cardiac arrest. treat based on symptoms.
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Side effects of valproic acid (at therapeutic levels)
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sedation, weight gain and tremor (use propranolol).Alopecia, thrombocytopenia are rare. hepatotoxicity (encephalopathy, edema, jaundice) and pancreatitis (black box warning).
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T/F: any physician can prescribe clozapine
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False. need a special license to prescribe it
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What are the 5 black box warnings of clozapine?
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1. agranulocytosis 2. seziures 3 myocarditis (may see peripheral eosinophilia) 4. cardiopulmonary collapse 5. increased mortality in treating psychosis related to dementia
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Define agranulocytosis.
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absolute neutrophil count (ANC) < 1000.
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What CBC finds should make you suspicious of possible agranulocytosis in patients using clozapine?
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If WBC drops 3-4k, stop clozpaine. w/o neutrophils the body can't fight infections ))> malaise, fever, sepsis and death
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Other side effects of clozapine (not black box)
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significant drooling (d/t esophageal dysmotolity), orthostatic hypotension and can SIGNIFICANT (40+ lbs) we gain/metabolic syndrome
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Side effects of Lamotrigine
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Stevens-Johnson syndrome/toxic episdermal necrolysis; 8% w/ benign rash but up to 1:1000 develop SJS/TEN
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Major side effects of Carbamazepine
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aplastic anemia and agranulocytosis
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Acute dystonic reaction is a typical side effect in what psychiatric drug?
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typical antipsychotics (short-term use)
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Tardive dyskinesia is a long term side effect of what drug?
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typical antipsychotic
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Major side effect of tarzodone? Nefazodone?
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priapism and hepatotoxicity
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