NURS 660 Psychopharmacology Exam 2
1. Know how to switch patients to and from MAOIs
o Switching from MAOI: Takes 2 (to 3) weeks for new
enzymes to be produced. In meantime, risk of serotonin
syndrome is present. Wait at least 2 weeks before
beginning serotonergic drug.
o Switching to MAOI: Requires a washout of 5
half-lives, typically 5-7 days. FLUOXETINE
(Prozac) takes 5 weeks before starting MAOI -
due to long half-life.
o Management of patient during gap: Careful use of
benzodiazepines, Z-drug sedative hypnotics,
lamotrigine, valproate, trazodone (at <150mg),
gabapentin, etc.
2. Know the major side effects, adverse reactions, drug
interactions, food-drug interactions, applicable lab tests to
order when the medication is prescribed and during
treatment, the neurotransmitters they work on, pregnancy
risk, and the mechanism of action for the following
medications:
o Amitriptyline - Tricyclic
• Major SEs: sedation, anticholinergic,
hypotension, cognitive impairment,
arrhythmias
• ADRs: suicide, narrow angle glaucoma,
QTc, arrhythmias
• Drug interactions: SSRI, SNRI, tryptans
(lyrica, gabapentin), antipsychotics
(Haldol), tramadol, thyroid meds, MAOIs
• Food-drug interactions:
• Lab tests: LFTs, heart
• Affected neurotransmitters: NE, 5HT,
Histamine, acetylcholine
• Pregnancy risk: teratogen (deformation of
tissues)
• MOA: Tricyclic – SERT, NET, H1,
muscarinic/cholinergic, Sigma receptor
(pain, depression, opioid abuse), adenosine
antagonist, VSSC, VSCC
• Notable features: can help with chronic pain,
metabolizes into nortriptyline
• Remember: Overdose risk is high (sxs:
increased reflexes, convulsions, coma).
WIDENED QRS = TCA toxicity (tx is
sodium bicarb)
o Bupropion (Wellbutrin)
1
,• Major SEs: stimulating
• ADRs: SEIZURES at peak plasma
concentrations with immediate and slow
release formulations compared to XR
formulation (>450mg) – particularly in bulimic
patients r/t electrolyte imbalance
2
, • Drug interactions:
• Food-drug interactions:
• Lab tests:
• Affected neurotransmitters: NE, DA
• Pregnancy risk:
• MOA: Theorized NDRI – NET and DAT inhibition
• Notable features: Addresses “dopamine
deficiency syndrome” and reduced positive
affect; Effective for Nicotine addiction r/t DAT
inhibition, no sexual dysfunction, activating
• Remember: Smoking cessation;
prodrug of radafaxine
o Carbamazepine (Tegretol)
• Major SEs: Sedating, dizziness, blurred
vision, coordination, dry mouth,
confusion, rashes
• ADRs: Low WBC (bone marrow suppression),
aplastic anemia, Steven Johnson Syndrome
• Drug interactions: TONS!!! CYP3A4 inducer
(avoid certain atypical antipsychotics)
• Food-drug interactions:
• Lab tests: Hematologic and hepatic hx at
baseline, LFTs, CBC, electrolytes,
BUN/creatinine
• Affected neurotransmitters:
• Pregnancy risk: Teratogenic
• MOA: Blocking VSSC
• Notable features: anticonvulsant for bipolar –
“treats mania from above”; helpful in
neuropathic pain; less weight gain
• Remember: unproven in BP depression
o Citalopram (Celexa) - SSRI
• Major SEs: antihistaminic
• ADRs: QTc prolongation
• Drug interactions: weak inhibitor of CYP2D6,
few
enzyme interactions
• Food-drug interactions:
• Lab tests: EKG @ higher doses (>40mg),
yearly
• Affected neurotransmitters: 5HT, Histamine
• Pregnancy risk:
• MOA: SSRI – both R and S enantiomer – R
containing antihistaminic properties, less
effective on SERT, and may inhibit S
enantiomer from binding to SERT
• Notable features: Excellent first choice, high
tolerability; favorable in elderly - >60yo dose
should be <=20mg, inconsistent efficacy at
3
1. Know how to switch patients to and from MAOIs
o Switching from MAOI: Takes 2 (to 3) weeks for new
enzymes to be produced. In meantime, risk of serotonin
syndrome is present. Wait at least 2 weeks before
beginning serotonergic drug.
o Switching to MAOI: Requires a washout of 5
half-lives, typically 5-7 days. FLUOXETINE
(Prozac) takes 5 weeks before starting MAOI -
due to long half-life.
o Management of patient during gap: Careful use of
benzodiazepines, Z-drug sedative hypnotics,
lamotrigine, valproate, trazodone (at <150mg),
gabapentin, etc.
2. Know the major side effects, adverse reactions, drug
interactions, food-drug interactions, applicable lab tests to
order when the medication is prescribed and during
treatment, the neurotransmitters they work on, pregnancy
risk, and the mechanism of action for the following
medications:
o Amitriptyline - Tricyclic
• Major SEs: sedation, anticholinergic,
hypotension, cognitive impairment,
arrhythmias
• ADRs: suicide, narrow angle glaucoma,
QTc, arrhythmias
• Drug interactions: SSRI, SNRI, tryptans
(lyrica, gabapentin), antipsychotics
(Haldol), tramadol, thyroid meds, MAOIs
• Food-drug interactions:
• Lab tests: LFTs, heart
• Affected neurotransmitters: NE, 5HT,
Histamine, acetylcholine
• Pregnancy risk: teratogen (deformation of
tissues)
• MOA: Tricyclic – SERT, NET, H1,
muscarinic/cholinergic, Sigma receptor
(pain, depression, opioid abuse), adenosine
antagonist, VSSC, VSCC
• Notable features: can help with chronic pain,
metabolizes into nortriptyline
• Remember: Overdose risk is high (sxs:
increased reflexes, convulsions, coma).
WIDENED QRS = TCA toxicity (tx is
sodium bicarb)
o Bupropion (Wellbutrin)
1
,• Major SEs: stimulating
• ADRs: SEIZURES at peak plasma
concentrations with immediate and slow
release formulations compared to XR
formulation (>450mg) – particularly in bulimic
patients r/t electrolyte imbalance
2
, • Drug interactions:
• Food-drug interactions:
• Lab tests:
• Affected neurotransmitters: NE, DA
• Pregnancy risk:
• MOA: Theorized NDRI – NET and DAT inhibition
• Notable features: Addresses “dopamine
deficiency syndrome” and reduced positive
affect; Effective for Nicotine addiction r/t DAT
inhibition, no sexual dysfunction, activating
• Remember: Smoking cessation;
prodrug of radafaxine
o Carbamazepine (Tegretol)
• Major SEs: Sedating, dizziness, blurred
vision, coordination, dry mouth,
confusion, rashes
• ADRs: Low WBC (bone marrow suppression),
aplastic anemia, Steven Johnson Syndrome
• Drug interactions: TONS!!! CYP3A4 inducer
(avoid certain atypical antipsychotics)
• Food-drug interactions:
• Lab tests: Hematologic and hepatic hx at
baseline, LFTs, CBC, electrolytes,
BUN/creatinine
• Affected neurotransmitters:
• Pregnancy risk: Teratogenic
• MOA: Blocking VSSC
• Notable features: anticonvulsant for bipolar –
“treats mania from above”; helpful in
neuropathic pain; less weight gain
• Remember: unproven in BP depression
o Citalopram (Celexa) - SSRI
• Major SEs: antihistaminic
• ADRs: QTc prolongation
• Drug interactions: weak inhibitor of CYP2D6,
few
enzyme interactions
• Food-drug interactions:
• Lab tests: EKG @ higher doses (>40mg),
yearly
• Affected neurotransmitters: 5HT, Histamine
• Pregnancy risk:
• MOA: SSRI – both R and S enantiomer – R
containing antihistaminic properties, less
effective on SERT, and may inhibit S
enantiomer from binding to SERT
• Notable features: Excellent first choice, high
tolerability; favorable in elderly - >60yo dose
should be <=20mg, inconsistent efficacy at
3
