Quick Clinical Review of Commonly Prescribed Psychiaric Drugs ANTIDEPRESSANTS MOOD STABILIZER LITHIUM

1. COMMONLY PRESCRIBED PSYCHIATRIC DRUGS- CLINICAL PERPSECTIVE

2. Dosages-Benzodiazepines 30-120 Serax Oxazepam 1-10 Ativan Lorazepam 4-40 Valium Diazepam 0.50-4.0 Klonopin Clonazepam 15-100 Librium Cholrdiazepoxide 0.75-10 Xanax Alprazolam Dosage range (mg/day) Brand name Generic

3. Dosages-Nonbenzodiazepine hypnotics 5-10 Ambien Zolpidem 5-20 Sonata Zaleplon 500-2000 Noctec Chloral hydrate Dose Brand name Generic

4. DOSAGES OF SEROTONIN ANTAGONISTS 30-60 CYMBALTA DULOXETINE 75-375/75-225 EFFEXOR/XR VENLAFAXINE 50-200 ZOLOFT SERTALINE 20-60 PAXIL PAROXETINE 20-80 PROZAC FLUOXETINE 20-60 CELEXA CITALOPRAM 200-450 150-400 WELLBUTRIN WELLBUTRIN SR BUPROPION DOSAGES BRAND NAME GENERIC

5. DOSAGES OF MOOD STABILIZERS 750-4200 DEPAKOTE VALPROIC AC/ DIVALEPROX 600-1800 LITHOBID LITHIUM 25-400 LAMICTAL LAMOTRIGENE 300-3600 NEURONTIN GABAPENTIN 400-1600 TEGRETOL CARBAMAZEPIN DOSAGE BRAND NAME GENERIC

6. DOSAGE OF TYPICAL ANTIPSYCHOTICS 20-250 Loxitane Loxapine 1-100 Haldol Haloperidol 6-60 Navane Thiothixene 2-40 Stelazine Trifluoperazine 1-40 Prolixin Fluphenazine 20-800 Mellaril Thioridazine 30-800 Thorazine Chlorpromazine DOSAGES BRAND NAME GENERIC

7. DOSAGES Of ATYPICAL ANTIPSYCOTICS 10-30 ABILIFY ARIPIPRAZOLE 40-160 GEODON ZIPRASIDONE 1-6 RISPERIDAL RISPERIDONE 50-750 SEROQUEL QUETIAPINE 5-20 ZYPREXA OLANZAPINE 12.5-900 CLOZARIL CLOZAPINE DOSAGES BRAND NAME GENERIC

8. DOSAGES OF TRICYCLICS 50-300 SURMONTIL TRIMIPRAMINE 15-60 VIVACTIL PROTRIPTYLINE 30-150 PAMELOR NORTRIPTYLINE 30-300 TOFRANIL IMIPRAMINE 25-300 SINEQUAN DOXEPIN 25-300 NORPRAMINE DESIPRAMINE 50-600 ASENDIN AMOXAPINE 50-300 ELAVIL AMITRYPTILINE DOSAGE BRAND NAME GENERIC

9. MAO INHIBITOR DOSAGES 30-60 PARNATE TRANYLCYPROMINE 30-90 NARDIL PHENELZINE 20-60 MARPLAN ISOCARBOXAZID DOSAGE TRADE NAME GENERIC

10. ALZHEIMER’S THERAPY 5-20 NMDA-ANTA NAMENDA MEMANTINE 40-80 --DO-- COGNEX TACRINE 3-12 --DO-- EXELON RIVASTIGMINE 8-24 --DO-- REMINYL GALANTAMINE 5-10 CHOLINESTERASE INH. ARICEPT DONEZEPIL DOSAGE CLASS BRAND GENERIC

11. ADHD/NARCOLEPSY AGENTS 40-100 NE REUPTAKE INHIBITOR STRATERA ATOMOXETINE DOSAGE CLASS BRAND GENERIC

12. ADHD/NARCOLEPSY AGENTS 37.5-112.5 OXAZOLIDINE CYLERT PEMOLINE DOSAGE CLASS BRAND GENERIC

13. ADHD/NARCOLEPSY AGENTS 5-25 --DO-- DESOXYN METAMPHETAMINE 2.5-60 --DO-- DEXEDRIN DEXTROST DEXTROAMPHETAMINE 5-20 --DO-- FOCALIN DEXMETHYLPHENIDAT 5-60 SYMPATHOMIMETICS ADDERALL AMPHETA + DEXTROAM DOSAGE CLASS BRAND GENERIC

14. ADDITIONAL INDICATIONS FOR ANTIDEPRESSANTS PAROXETINE, VENFLAFAXINE ER, DOXEPIN GAD PHENELZINE ATYPICAL DEPRESION BUPROPION SMOKING CESSATION IMIPRAMINE CHILDHOOD ENURESIS SERTRALINE PTSD FLUOXETINE BULIMIA NERVOSA CLOMIPRAMINE, FLUOXETINE, FLUVOXAMINE, PAROXETINE, SERTRALINE OCD AMOXAPINE, DOXEPIN PSYCHOTIC DEPRESSION DRUGS ADDITIONAL INDICATIONS

15. HALF LIVES OF ANTIDEPRESSANTS 20-40 Mirtazapine 2-4 Nefazodone 9-46 Amitriptyline 15.6 Fluvoxamine 19-37 Clomipramin 21 Paroxetine 3-7 Venlafaxine 48-72 Fluoxetine 35 Citalopram 26 Sertraline HALF-LIFE DRUGS HALF-LIFE DRUGS

16. CNS NEUROTRANSMITTERS:TCA 0 ++ ++ Trimipramine 0 ++++ 0 Maprotiline 0/+ ++ +++ Imipramine 0/+ ++++ + Desipramine 0 +++ +++ Amoxapine 0 ++++ ++++ Amitryptiline DOPAMINE NE SEROTONIN AGENT

17. NEUROTRANSMITTERS: SSRI/SNRI 0/+ +++ ++++ Venflafaxine 0 0 ++ Trazodone 0/+ 0 ++++ Sertraline 0/+ 0/+ ++++ Paroxetine 0/+ 0/+ +++ Fluvoxamine 0/+ 0 ++++ Fluoxetine 0 0 ++++ Citalopram ++ + 0/+ Bupropion DOPAMINE NE SEROTONIN AGENTS

18. Drug Interactions: TCA Inhibit TCA metabolism >TCA levels Stimulants Inhibit many CYP syste >TCA level SSRI Inhibit TCA metabolism <TCA level Methadone CYP 2D6 inibition >level of Halo Haloperidol Live enzyme induction <TCA level Carbamazep Synergistic depression >sedation,ataxia Alcohol MECHANISM INTERACTION DRUG

19. DRUG INTERACTIONS: SSRI/SNRI Inhibit CYP 2C >warfarin levels Warfarin Inhibit theo metabolisn(Fluvo) Theo Toxicity Theophylline Inhibit CYP systems TCA toxicity TCAs Serotonin synergism Serotonin sy MAOIs 5-HT2 antagonism >LSD flashbs Hallucinogens Serotonin synergism Serotonin sy Dextromethrophan Serotonin antagonism Reverse SSRI effect Cyproheptadine MECHANISM INTERACTIONS DRUG

20. DRUG INTERACTIONS-MAOI Indirect pressor effect Hypertensive crisi Sympathm/Tyra < cholinesterase levels Prolonged apnea in surgery Sucinylcholine ----do--- ----do--- TCAs ----do-- ---do--- SSRIs Serotonin synergism Serotonin syndre Meperidine Lowers blood glucose >effects hypoglyc Hypoglycemics Inhibit barbiturate metabo >Sedation Barbiturates MECHANISM INTERACTIONS DRUGS

21. Drug interactions: Lithium Increases lithium neurotoxicity Antipsychotics Decreases lithium levels Acetazolemide-Osmotic diuretics-Theophylline Increases lithium levels Fluoxetine-ACE inhibitors Diuetics-NSAIDs INTERACTIONS DRUGS

23. Mood stabilizer- Carbamazepine Dizziness, drowsiness, ataxia, and weight gain Adverse effects Induces metabolism of CYP3A4-dependent drugs. Reduces phenobarb, phenytoin, haloperidol, valproate, Cal channel block Interaction Renal (72%); Fecal (28%) Elimination 3-15 days Onset of action 400-1600 mg Daily dose 4-12 ug/ml Plasma levels

24. Mood stabilizer- Valproic acid GI distress, diplopia, sedation, tremor, edema, weight gain, alopecia and thrombocytopenia Adverse effects Interacts with the drugs that are hepatically metabolised. Can increase phenobarbital by impairment of nonrenal clearance (severe CNS depression ) Interaction Renal by glucurodina Elimination 5-15 days Onset of action 750-4200 mg Daily dose 50-100 ug/ml Plasma levels

26. Baseline and Routine Monitoring for Mood Stabilizers- Lithium Baseline, then q 12 mo ECG Baseline, then q 12 mo Thyroid function Baseline, then q 12 mo Blood chemistries --- PT/PTT Baseline, monthly x 3 mo, then as clinically ind CBC Baseline, then as clinically indicated Urinalysis Weekly x 4 wks; monthly x 3 months, then q 3 mo Plasma concent

27. Baseline and Routine Monitoring for Mood Stabilizers- Carbamazepines Baseline, then q 12 months ECG Baseline, then q 12 hrs Thyroid function Baseline, then as indic Blood chemistries ------- PT/PTT Baseline, then as indicated Urinalysis Baseline, then monthly X 3 months, then as clinically indicated CBC 2 weeks after initiation, then q3 months Plasma concent

28. Baseline and Routine Monitoring for Mood Stabilizers- Valproic acid Not needed Thyroid funct Baseline, then as clinically indicated ECG Baseline, then q monthly X 6 months, then q 6 mo Blood chemistries Baseline, then q 6 months or as clinically indicated PT/PTT Baseline, then monthly q 6 mo or as indicated CBC Baseline, then q 6 mo or as indicated Urinalysis 2 weeks after start, then q 3 mo Plasma concent

29. Typical Antipsychotic- Dosages 1-100 Butyrophenone Haloperidol 6-60 Thioxanthene Thiothixene (Navane) 1-40 Piperazine phenothiazine Fluphenazine (Prolxin) 30-800 Aliphatic phenothiazine Chlorpromazine (Thorazine) Dosage Range (mg/day) PO Class Drug

30. Typical Antipsychotics-Adverse Effects + + + ++++ Haloperido ++ ++ ++ +++ Thiothixen ++ ++ ++ ++++ Fluphenazine +++ +++ +++ ++ Chlorpromazine Orthostatic hypotensio Anticholinergic Sedation Extrapyramidal Drug

31. ADVERSE EFFECTS OF ANTIPSYCHOTICS ++ + +/0 ++ ++ ZIPRA ++ ++ ++ ++/+++ 0/+ QUETI + ++ +++ ++ 0/+ OLANA ++ + + ++ 0/+++ RISP ++++ ++++ ++++ +++ 0 CLOZA Orthstatihypo Anticholinergic Wt gain Sedatio Extrapyramidal Drugs

32. DEPOT PREPARATIONS 4-8 weeks 14 days 2-3 days Fluphenazine Deconate 12 weeks 21 days 4-11 days Haloperidol deconate Time to steady state t ½ t max DRUG

33. ANTIPSYCHOTIC DRUG INTERACTIONS Rarely neurotoxicity Lithium Impaired psychomoto skills Ethanol UP to 50% reduction antip Carbamazepine Severe hypotension Beta blockers < antipsych concntration Barbiturat < antipsych Effects ANTICHOLINERGICS CLINICAL EFFECT DRUG CLINICAL EFFECT DRUG

34. ANTIPSYCHOTIC DRUG INTERACTIONS Additive hypotensive effects ACE inhibitor Increased antidepressant level Antidepressants Resp. depression, stupor, hypotension Benzodiazipine Decreased phenytoin level Phenytoin Sudden onset of extrapyramidal SSRI INCREASED VPA LEVEL VALPROIC ACID CLINICAL EFFECTS DRUG CLINICAL EFFECTS DRUG

35. ACUTE NEUROLOGICAL SIDE EFFECTS OF ANTIPSYCHOTICS Add anticholinergic or amantadine; diphenhydramine and lorazepam may also be effective 1 wk Bradykinesia, rigidity. Resting tremors, flat affect Psuedoparkinsonism If possible, reduce dose of antipsychotics; add beta blockers, benzo- or anticholinergics 1-2 wks Motor restlessness; inability to sit still Akathisia Injectable benztropine, or diphenhydramine followed by oral anticholinegi/benzo <1 wk Spasm-tongue, throat, jaws, neck muscles Acute dystonia Treatment onset Clinical features Reaction

36. PSYCHOSTIMULANTS ADHD 18-54 Methyphenidate HCL (Concerta) ADHD Narcolepsy 10-40 10-60 Methylphenidate (Ritalin) ADHD Narcolepsy 5-40 Dextroamphetamine + Amphetamine-Adderall ADHD Narcolepsy 5-40 5-60 Dextroamphetamine (Dexedrine) INDICATIONS DOSAGE Mg/day AGENT