Serotonin Syndrome sx
- shivering
- hyperreflexia/myoclonus
- increased temperature
- vital sign instability
- encephalopathy (altered LOC)
- restlessness
- sweating
Serotonin Syndrome- when does it occur?
- 2+ serotonergic meds
Common Offenders
* SSRI
* SNRI
* TCA
* MAOI
* Trazodone/Mirtazapine
* Triptans
* Anxiolytics
* Antiemetics
* herbals (st john’s wort)
* opioids
* anti-convulsants
* illicit substances
Discontinuation Syndrome- sx
FINISH
* flu like sx
* insomnia
* nausea
* imbalance
* sensory disturbances
* hyperarousal
Discontinuation Syndrome- pt education
- advise pt to never abruptly stop meds
- tape off meds over several wks (reduce dose by 25% each weak) or cross taper onto new med
- Paxil has worst discontinuation syndrome; Prozac has lowest risk discontinuation
TCA OD
- Vitals: hyperthermia, tachycardia, wide QRS
- Neuro: seizure, confusion, diaphoresis
- HEENT: dry mouth, dilated pupils, blurred vision
Metabolic Dysfunction
- complication of psychotic meds
- sx: wt gain, hyperglycemia, hyperlipidemia
- dx: Q6-12 month lipids, wt, BP, A1C
- tx: treat dysfunction as it develops; consider changing med if severe
more common with atypicals/2nd gen
Anti-HAM
- Antihistamine: wt gain, sedation
- Antiadrenergic: orthostatic hypotension, cardiac abnormalities, sexual dysfunction
- Antimuscarinic: dry mouth, tachycardia, urinary retention, blurry vision, constipation, narrow angle glaucoma
more common with typicals/1st gen
Hyperprolactinemia
- sx: low libido, galactorrhea, gynecomastia, impotence, amenorrhea
more common w/ typicals/1st gen
Neuromalignant Syndrome (NMS)
- occurs in 3% of pt on neuroleptics; fatal if missed
- sx: extreme rigidity, AMS, fever, unstable BP, myoglobinemia
- tx: med cessation, dantrolene/bromocriptine, supportive care
EPS
- Akathisia: inner restlessness, cant sit still (tx by reducing doses/changing meds; can give propranolol or clonazepam to manage sx)
- Parkinsonian Sx: tremor, rigidity, shuffling gait, bradykinesia; begins w/in 1 mo of taking med; tx by reducing dose/changing med (or anti-parkinsonian drugs like levodopa)
- Dystonia: acute complication but is curative; involuntary contraction of major msk group (tongue, neck, back, face); tx is anticholinergics (benztropine) and anti-park drugs
- Tardive Dyskinesia: involuntary movements (facial grimacing, tongue protrusion, lateral jaw movements, lip smacking); develops over mo to yrs but can be permanent; tx is to stop ASAP and use VMAT-2 inhibitors (valbenazine/deutrabenazine) anti-cholinergics WORSEN this”
tx for nicotine withdrawal
- Chantix/Varenicline (28d treatment; reduces cravings/withdrawal sx; causes crazy nightmares)
- Bupropion/Wellbutrin (150-300mg XL QD)
- Nicotine Replacement: patch, gum, lozenge, spray, inhaler (to slowly reduce dosage)
Anti-depressants (general overview)
Most antidepressants have similar efficacy in treating depression so your choice of antidepressant should be based on side effect profile and comorbidities
Lots of antidepressants work on multiple neurotransmitters
Start low and go slow
Peds patients typically start at ½ starting dose for 7 days then increase
All antidepressants have a BLACK BOX WARNING for increase suicidal ideation in patients under 25yo
Follow up closely with these patients
Serotonin Side Effects
- Nausea, vomiting, diarrhea
- Headaches, dizziness
- Inducing mania/hypomania
- Increased bleeding risk (serotonin receptors on platelets): Typically presents as easy bruising, but No need to hold medications prior to surgery
- Bone fractures (up to 76% increased risk with SSRIs)
- Seuxal Dysfunction - decreased libido, delayed or inability to climax (F>M)
SSRIs
- Fluoxetine (10-40mg PO QD; Prozac)
- Paroxetine (10-40mg PO QD: Paxil)
- Sertaline (50-300mg PO QD; Zoloft)
- Citalopram (10-40mg PO QD; Celexa)
- Escitalopram (10-20mg PO QD; Lexapro)
- Fluvoxamine (50-300mg PO QD; Luvox)
SSRI- specific med need to knows
- Paroxetine: worst discontinuation syndrome; pregnancy category D
- Escitalopram: “cleanest SSRI” (fewest side effects)
SNRIs
- Venlafaxine (37.5-225mg PO QD; Effexor)
- Desvenlafaxine (50-200mg PO QD; Pristiq)
- Duloxetine (20-120mg PO BID; Cymbalta)
- Levomilnacipran (20-120mg PO QD; Fetzima)
Buproprion
avoid in alcohol use disorder, bulimic pts, and those w/ electrolyte disorders
lack of sexual side effects + appetite suppresion = good choice for those worried about this
Typicals (1st gen)
- MOA: decrease dopamine; works best on positive sx; highest risk EPS + anti-HAM
Meds
* Chlorpromazine (Thorazine)
* Thioridazine (Mellaril)
* Loxapine (Loxitane)
* Thiothixene (Navane)
* Molindone (Moban)
* Perphenazine (Trilafon)
* Haloperidol (Haldol)
* Fluphenazine (Prolixin)
* Trifluoperazine (Stelazine)
* Pimozide (Orap)
Atypicals
- MOA: decrease dopamine; increase serotonin; works on pos + neg sx; has more metabolic side effects
Meds (most end in “apine” or “idone”)
* Quetiapine (Seroquel)
* Ziprasidone (Geodon)
* Olanzapine (Zyprexa)
* Aripiprazole (Abilify)
* Iloperidone (Fanapt)
* Paliperidone (Invega)
* Asenapine (Saphris)
* Risperidone (Risperdal)
* Clozapine (Clozaril)
Antipsychotics- specific med need to knows
- Ziprasidone (Geodon): more QT prolongation than any other atypical
- Olanzapine: expected 10-30 lb wt gain (why we give it to anorexics)
- Risperidone + Paliperidone: causes most EPS + hyperprolactinemia of all atypicals (but typicals still cause more overall)
AUD Tx options
- Naltrexone
- Acamprosate
- Disulfiram
Acamprosate
- for AUD
- glutamate neurotransmission modulation
Naltrexone
- MOA: mu opioid receptor blocker
- LFT monitoring q6mo
- reduces heavy drinking by 25%; suppresses EtOH consumption
Disulfiram
- causes unpleasant physiologic rxn when EtOH is consumed
- MOA: inhibits aldehyde dehydrogenase & prevents the metabolism of EtOH’s primary metabolite, acetaldehyde
