quick clinical review of commonly prescribed psychiatric drugs
DESCRIPTION
Quick Clinical Review of Commonly Prescribed Psychiaric Drugs ANTIDEPRESSANTS MOOD STABILIZER LITHIUMTRANSCRIPT
COMMONLY PRESCRIBED PSYCHIATRIC DRUGS- CLINICAL PERPSECTIVE
COMMONLY PRESCRIBED PSYCHIATRIC DRUGS- CLINICAL PERPSECTIVE
Dosages-BenzodiazepinesDosages-Benzodiazepines
Generic Brand name Dosage range (mg/day)
Alprazolam Xanax 0.75-10
Cholrdiazepoxide Librium 15-100
Clonazepam Klonopin 0.50-4.0
Diazepam Valium 4-40
Lorazepam Ativan 1-10
Oxazepam Serax 30-120
Dosages-Nonbenzodiazepine hypnoticsDosages-Nonbenzodiazepine hypnotics
Generic Brand name Dose
Chloral hydrate Noctec 500-2000
Zaleplon Sonata 5-20
Zolpidem Ambien 5-10
DOSAGES OF SEROTONIN ANTAGONISTSDOSAGES OF SEROTONIN ANTAGONISTS
GENERIC BRAND NAME DOSAGES
BUPROPION WELLBUTRINWELLBUTRIN SR
200-450150-400
CITALOPRAM CELEXA 20-60
FLUOXETINE PROZAC 20-80
PAROXETINE PAXIL 20-60
DULOXETINE CYMBALTA 30-60
SERTALINE ZOLOFT 50-200
VENLAFAXINE EFFEXOR/XR 75-375/75-225
DOSAGES OF MOOD STABILIZERSDOSAGES OF MOOD STABILIZERS
GENERIC BRAND NAME DOSAGE
CARBAMAZEPIN TEGRETOL 400-1600
GABAPENTIN NEURONTIN 300-3600
LAMOTRIGENE LAMICTAL 25-400
LITHIUM LITHOBID 600-1800
VALPROIC AC/ DIVALEPROX
DEPAKOTE 750-4200
DOSAGE OF TYPICAL ANTIPSYCHOTICSDOSAGE OF TYPICAL ANTIPSYCHOTICS
GENERIC BRAND NAME DOSAGESChlorpromazine Thorazine 30-800Thioridazine Mellaril 20-800Fluphenazine Prolixin 1-40Trifluoperazine Stelazine 2-40Thiothixene Navane 6-60Haloperidol Haldol 1-100Loxapine Loxitane 20-250
DOSAGES Of ATYPICAL ANTIPSYCOTICSDOSAGES Of ATYPICAL ANTIPSYCOTICS
GENERIC BRAND NAME DOSAGES
CLOZAPINE CLOZARIL 12.5-900
OLANZAPINE ZYPREXA 5-20
QUETIAPINE SEROQUEL 50-750
RISPERIDONE RISPERIDAL 1-6
ZIPRASIDONE GEODON 40-160
ARIPIPRAZOLE ABILIFY 10-30
DOSAGES OF TRICYCLICSDOSAGES OF TRICYCLICSGENERIC BRAND NAME DOSAGE
AMITRYPTILINE ELAVIL 50-300
AMOXAPINE ASENDIN 50-600
DESIPRAMINE NORPRAMINE 25-300
DOXEPIN SINEQUAN 25-300
IMIPRAMINE TOFRANIL 30-300
NORTRIPTYLINE PAMELOR 30-150
PROTRIPTYLINE VIVACTIL 15-60
TRIMIPRAMINE SURMONTIL 50-300
MAO INHIBITOR DOSAGESMAO INHIBITOR DOSAGES
GENERIC TRADE NAME DOSAGE
ISOCARBOXAZID MARPLAN 20-60
PHENELZINE NARDIL 30-90
TRANYLCYPROMINE
PARNATE 30-60
ALZHEIMER’S THERAPYALZHEIMER’S THERAPYGENERIC BRAND CLASS DOSAGE
DONEZEPIL ARICEPT CHOLINESTERASE INH.
5-10
GALANTAMINE
REMINYL --DO-- 8-24
RIVASTIGMINE
EXELON --DO-- 3-12
TACRINE COGNEX --DO-- 40-80
MEMANTINE NAMENDA NMDA-ANTA 5-20
ADHD/NARCOLEPSY AGENTSADHD/NARCOLEPSY AGENTS
GENERIC BRAND CLASS DOSAGE
ATOMOXETINE
STRATERA NE REUPTAKEINHIBITOR
40-100
ADHD/NARCOLEPSY AGENTSADHD/NARCOLEPSY AGENTS
GENERIC BRAND CLASS DOSAGE
PEMOLINE CYLERT OXAZOLIDINE 37.5-112.5
ADHD/NARCOLEPSY AGENTSADHD/NARCOLEPSY AGENTS
GENERIC BRAND CLASS DOSAGE
AMPHETA +DEXTROAM
ADDERALL SYMPATHOMIMETICS
5-60
DEXMETHYLPHENIDAT
FOCALIN --DO-- 5-20
DEXTROAMPHETAMINE
DEXEDRINDEXTROST
--DO-- 2.5-60
METAMPHETAMINE
DESOXYN --DO-- 5-25
ADDITIONAL INDICATIONS FOR ANTIDEPRESSANTS ADDITIONAL INDICATIONS FOR ANTIDEPRESSANTS ADDITIONAL INDICATIONS
DRUGS
PSYCHOTIC DEPRESSION AMOXAPINE, DOXEPIN
OCD CLOMIPRAMINE, FLUOXETINE, FLUVOXAMINE, PAROXETINE, SERTRALINE
BULIMIA NERVOSA FLUOXETINE
PTSD SERTRALINE
CHILDHOOD ENURESIS IMIPRAMINE
GAD PAROXETINE, VENFLAFAXINE ER, DOXEPIN
ATYPICAL DEPRESION PHENELZINE
SMOKING CESSATION BUPROPION
HALF LIVES OF ANTIDEPRESSANTSHALF LIVES OF ANTIDEPRESSANTS
DRUGS HALF-LIFE DRUGS HALF-LIFE
Sertraline 26 Citalopram 35
Fluoxetine 48-72 Venlafaxine 3-7
Paroxetine 21 Clomipramin 19-37
Fluvoxamine 15.6 Amitriptyline 9-46
Nefazodone 2-4 Mirtazapine 20-40
CNS NEUROTRANSMITTERS:TCA
CNS NEUROTRANSMITTERS:TCA
AGENT SEROTONIN NE DOPAMINE
Amitryptiline ++++ ++++ 0
Amoxapine +++ +++ 0
Desipramine + ++++ 0/+
Imipramine +++ ++ 0/+
Maprotiline 0 ++++ 0
Trimipramine ++ ++ 0
NEUROTRANSMITTERS: SSRI/SNRINEUROTRANSMITTERS: SSRI/SNRI
AGENTS SEROTONIN NE DOPAMINE
Bupropion 0/+ + ++
Citalopram ++++ 0 0
Fluoxetine ++++ 0 0/+
Fluvoxamine +++ 0/+ 0/+
Paroxetine ++++ 0/+ 0/+
Sertraline ++++ 0 0/+
Venflafaxine ++++ +++ 0/+
Trazodone ++ 0 0
Drug Interactions: TCADrug Interactions: TCA
DRUG INTERACTION MECHANISMAlcohol >sedation,ataxia Synergistic depressionCarbamazep <TCA level Live enzyme inductionHaloperidol >level of Halo CYP 2D6 inibitionMethadone <TCA level Inhibit TCA metabolismSSRI >TCA level Inhibit many CYP systeStimulants >TCA levels Inhibit TCA metabolism
DRUG INTERACTIONS: SSRI/SNRIDRUG INTERACTIONS: SSRI/SNRIDRUG INTERACTI
ONSMECHANISM
Cyproheptadine Reverse SSRI effect
Serotonin antagonism
Dextromethrophan Serotonin sy Serotonin synergism
Hallucinogens >LSD flashbs 5-HT2 antagonism
MAOIs Serotonin sy Serotonin synergism
TCAs TCA toxicity Inhibit CYP systems
Theophylline Theo Toxicity Inhibit theo metabolisn(Fluvo)
Warfarin >warfarin levels Inhibit CYP 2C
DRUG INTERACTIONS-MAOIDRUG INTERACTIONS-MAOIDRUGS INTERACTIONS MECHANISM
Barbiturates >Sedation Inhibit barbiturate metabo
Hypoglycemics >effects hypoglyc Lowers blood glucose
Meperidine Serotonin syndre Serotonin synergism
SSRIs ---do--- ----do--
TCAs ----do--- ----do---
Sucinylcholine Prolonged apnea in surgery
< cholinesterase levels
Sympathm/Tyra Hypertensive crisi Indirect pressor effect
Drug interactions: LithiumDrug interactions: Lithium
DRUGS INTERACTIONS
Fluoxetine-ACE inhibitorsDiuetics-NSAIDs
Increases lithium levels
Acetazolemide-Osmotic diuretics-Theophylline
Decreases lithium levels
Antipsychotics Increases lithium neurotoxicity
DRUG INTERACTIONS-BENZODIAZEPINESDRUG INTERACTIONS-BENZODIAZEPINES
DRUG INTERACTION MECHANISM
ANTACIDS < level and absorb >gastric pHCarbamazepine < benzo level CYP inductionDigoxin >digoxin level CYP inhibitionEthanol Sedation/resp dep CNS additiveOpioids >sedation/resp dep CNS additiveSSRIs >diazepam &
alprazolam level2D6 and 3A4 inhibition
Valproic acid > Benzo level <metabolism
Mood stabilizer- CarbamazepineMood stabilizer- Carbamazepine
Plasma levels
4-12 ug/ml Daily dose 400-1600 mg
Onset of action
3-15 days Elimination Renal (72%);Fecal (28%)
Interaction Induces metabolism of CYP3A4-dependent drugs. Reduces phenobarb, phenytoin, haloperidol, valproate, Cal channel block
Adverse effects
Dizziness, drowsiness, ataxia, and weight gain
Mood stabilizer- Valproic acidMood stabilizer- Valproic acidPlasma levels
50-100 ug/ml Daily dose 750-4200 mg
Onset of action
5-15 days Elimination Renal by glucurodina
Interaction Interacts with the drugs that are hepatically metabolised. Can increase phenobarbital by impairment of nonrenal clearance (severe CNS depression )
Adverse effects
GI distress, diplopia, sedation, tremor, edema, weight gain, alopecia and thrombocytopenia
MOOD STABILIZER- LITHIUMMOOD STABILIZER- LITHIUM
Plasma levels
0.6-1.2 mEq/L Daily dose 600-1800 mg
Onset of action
5-14 days Elimination Renal
Interaction 1. Li conc is increased fluoxetine, ACE inhibitors, diuretics and NSAIDs.
2. Antipsychotic increases toxicity and level
3. Li conc. Is decreased by acetazolamide, osmotic diuretics
Adverse effects
Nausea, vomiting, diarrhea, polyuria, polydypsia, tremor and hypothyroidis
Baseline and Routine Monitoring for Mood Stabilizers- Lithium
Baseline and Routine Monitoring for Mood Stabilizers- Lithium
Plasma concent
Weekly x 4 wks; monthly x 3 months, then q 3 mo
Urinalysis Baseline, then as clinically indicated
CBC Baseline, monthly x 3 mo, then as clinically ind
PT/PTT ---
Blood chemistries
Baseline, then q 12 mo
Thyroid function
Baseline, then q 12 mo
ECG Baseline, then q 12 mo
Baseline and Routine Monitoring for Mood Stabilizers- Carbamazepines
Baseline and Routine Monitoring for Mood Stabilizers- Carbamazepines
Plasma concent
2 weeks after initiation, then q3 months
CBC Baseline, then monthly X 3 months, then as clinically indicated
Urinalysis Baseline, then as indicated
PT/PTT -------
Blood chemistries
Baseline, then as indic
Thyroid function
Baseline, then q 12 hrs
ECG Baseline, then q 12 months
Baseline and Routine Monitoring for Mood Stabilizers- Valproic acid
Baseline and Routine Monitoring for Mood Stabilizers- Valproic acid
Plasma concent
2 weeks after start, then q 3 mo
Urinalysis Baseline, then q 6 mo or as indicated
CBC Baseline, then monthly q 6 mo or as indicated
PT/PTT Baseline, then q 6 months or as clinically indicated
Blood chemistries
Baseline, then q monthly X 6 months, then q 6 mo
ECG Baseline, then as clinically indicated
Thyroid funct Not needed
Typical Antipsychotic- DosagesTypical Antipsychotic- Dosages
Drug Class Dosage Range (mg/day) PO
Chlorpromazine(Thorazine)
Aliphatic phenothiazine
30-800
Fluphenazine(Prolxin)
Piperazinephenothiazine
1-40
Thiothixene(Navane)
Thioxanthene 6-60
Haloperidol Butyrophenone 1-100
Typical Antipsychotics-Adverse EffectsTypical Antipsychotics-Adverse Effects
Drug Extrapyramidal
Sedation Anticholinergic
Orthostatic hypotensio
Chlorpromazine
++ +++ +++ +++
Fluphenazine
++++ ++ ++ ++
Thiothixen +++ ++ ++ ++
Haloperido ++++ + + +
ADVERSE EFFECTS OF ANTIPSYCHOTICSADVERSE EFFECTS OF ANTIPSYCHOTICS
Drugs Extrapyramidal
Sedatio Wt gain Anticholinergic
Orthstatihypo
CLOZA 0 +++ ++++ ++++ ++++
RISP 0/+++ ++ + + ++
OLANA 0/+ ++ +++ ++ +
QUETI 0/+ ++/+++ ++ ++ ++
ZIPRA ++ ++ +/0 + ++
DEPOT PREPARATIONSDEPOT PREPARATIONS
DRUG t max t ½ Time to steady state
Haloperidoldeconate
4-11 days 21 days 12 weeks
FluphenazineDeconate
2-3 days 14 days 4-8 weeks
ANTIPSYCHOTIC DRUG INTERACTIONSANTIPSYCHOTIC DRUG INTERACTIONS
DRUG CLINICAL EFFECT
DRUG CLINICALEFFECT
ANTICHOLINERGICS
< antipsychEffects
Barbiturat < antipsychconcntration
Beta blockers
Severe hypotension
Carbamazepine
UP to 50% reduction antip
Ethanol Impaired psychomoto skills
Lithium Rarely neurotoxicity
ANTIPSYCHOTIC DRUG INTERACTIONSANTIPSYCHOTIC DRUG INTERACTIONS
DRUG CLINICAL EFFECTS
DRUG CLINICAL EFFECTS
VALPROIC ACID
INCREASED VPA LEVEL
SSRI Sudden onset of extrapyramidal
Phenytoin Decreased phenytoin level
Benzodiazipine
Resp. depression, stupor, hypotension
Antidepressants
Increased antidepressant level
ACE inhibitor
Additive hypotensive effects
ACUTE NEUROLOGICAL SIDE EFFECTS OF ANTIPSYCHOTICS
ACUTE NEUROLOGICAL SIDE EFFECTS OF ANTIPSYCHOTICS
Reaction Clinical features onset Treatment
Acutedystonia
Spasm-tongue, throat, jaws, neck muscles
<1 wk Injectable benztropine, or diphenhydramine followed by oral anticholinegi/benzo
Akathisia Motor restlessness; inability to sit still
1-2 wks
If possible, reduce dose of antipsychotics; add beta blockers, benzo- or anticholinergics
Psuedoparkinsonism
Bradykinesia, rigidity. Resting tremors, flat affect
1 wk Add anticholinergic or amantadine; diphenhydramine and lorazepam may also be effective
PSYCHOSTIMULANTSPSYCHOSTIMULANTSAGENT DOSAGE
Mg/dayINDICATIONS
Dextroamphetamine(Dexedrine)
5-405-60
ADHDNarcolepsy
Dextroamphetamine + Amphetamine-Adderall
5-40 ADHDNarcolepsy
Methylphenidate(Ritalin)
10-4010-60
ADHDNarcolepsy
Methyphenidate HCL(Concerta)
18-54 ADHD