Psychiatry Cheat Sheet Jazzlyn Gallardo, D.O.

Normal TSH: 0.45 – 5.10 mIU/l

Check TSH again 4-6 weeks after each thyroid dose change.

Levothyroxine: starting dose 25 mcg/d

Take thyroid meds on empty stomach as soon as patient gets up in the morning at least one hour

before eating, which helps with absorption; don’t ever take thyroid meds with vitamins

Therapeutic blood levels

Lithium: 0.5-1.0 mEq/l, run towards the lower end to minimize side effects

Depakote: 50-125 mcg/ml

Lamictal: 3-14 mcg/ml

Anafranil (TCAs): 220-500 ng/ml

Bipolar ‘Ceiling’ Drugs

Lithium: start at 300 mg qhs with food in stomach (“little old lady” dose) or 600-900 mg qhs in

younger, healthier patients, & titrate upwards depending on clinical response, side effects, & blood

levels, better for euphoric, rather than irritable, patients

Depakote (valproic acid) – good for rapid cycling (4 or more moodswings per year)/mixed state/irritable

mood in Bipolar with 500 mg qhs starting dose & Depakote titration upwards depending on clinical

response, side effects, & blood levels

oMust start Depakote titration again at low dose if patient stops medication

Tegretol (carbamazepine)/Trileptal(oxcarbazepine) - second-line ceiling drugs

Neuroleptics (preferably second generation)

Bipolar ‘Floor’ Drugs

Lithium

Lamictal (good for concommitant seizures)

Anti-depressants (generally not used as mono-therapy in Bipolar Disorder)

Lithium Management

“Little old lady” dose or for children: starting dose of 300 mg qhs (for healthy patients 600-900 mg

qhs); Emergency: start at 600-900 mg qhs

Titrate upward in 300 mg/d increments

Obtain blood levels 7-10 days after initiating or changing the dosage of lithium (up or down).

oInstruct patient to get blood work done 12 hours after they have taken their last dose (trough).

For lithium-induced hypothyroidism, do not discontinue lithium, instead supplement with

levothyroxine, starting at 25 mcg/d, checking results with repeat TSH in 4-6 weeks

Also get creatinine clearance (CrCl) & TSH every 6-12 months for anyone on lithium plus other

appropriate screening LAB

Lamictal Management

Start at 25 mg qhs (12.5 mg qhs if on concomitant Depakote with corresponding half-strength increased

doses thereafter) for 2 weeks, 50 mg qhs for next 2 weeks, 100 mg qhs for next 2 weeks on Lamictal

Initial target dose at 200 mg qhs (get blood levels after 7-10 days at this dose, 12 hours after dose)

Increase by 100 mg/d thereafter as needed, but not sooner than 2 weeks at each dose (only 50 mg/d

increase if concurrently on Depakote)

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Psychiatry Cheat Sheet Jazzlyn Gallardo, D.O.

Normal TSH: 0.45 – 5.10 mIU/l Check TSH again 4-6 weeks after each thyroid dose change. Levothyroxine : starting dose 25 mcg/d  Take thyroid meds on empty stomach as soon as patient gets up in the morning at least one hour before eating, which helps with absorption; don’t ever take thyroid meds with vitamins Therapeutic blood levels  Lithium : 0.5-1.0 mEq/l, run towards the lower end to minimize side effects  Depakote : 50-125 mcg/ml  Lamictal : 3-14 mcg/ml  Anafranil (TCAs): 220-500 ng/ml Bipolar ‘Ceiling’ Drugs  Lithium: start at 300 mg qhs with food in stomach (“little old lady” dose) or 600-900 mg qhs in younger, healthier patients, & titrate upwards depending on clinical response, side effects, & blood levels, better for euphoric, rather than irritable, patients  Depakote (valproic acid) – good for rapid cycling (4 or more moodswings per year) / mixed state/irritable mood in Bipolar with 500 mg qhs starting dose & Depakote titration upwards depending on clinical response, side effects, & blood levels o Must start Depakote titration again at low dose if patient stops medication  Tegretol (carbamazepine)/Trileptal(oxcarbazepine) - second-line ceiling drugs  Neuroleptics (preferably second generation) Bipolar ‘Floor’ Drugs  Lithium  Lamictal (good for concommitant seizures)  Anti-depressants (generally not used as mono-therapy in Bipolar Disorder) Lithium Management  “Little old lady” dose or for children: starting dose of 300 mg qhs (for healthy patients 600-900 mg qhs); Emergency: start at 600 - 900 mg qhs  Titrate upward in 300 mg/d increments  Obtain blood levels 7 - 10 days after initiating or changing the dosage of lithium (up or down). o Instruct patient to get blood work done 12 hours after they have taken their last dose (trough).  For lithium-induced hypothyroidism, do not discontinue lithium, instead supplement with levothyroxine, starting at 25 mcg/d, checking results with repeat TSH in 4-6 weeks  Also get creatinine clearance (CrCl) & TSH every 6-12 months for anyone on lithium plus other appropriate screening LAB Lamictal Management  Start at 25 mg qhs (12.5 mg qhs if on concomitant Depakote with corresponding half-strength increased doses thereafter) for 2 weeks, 50 mg qhs for next 2 weeks, 100 mg qhs for next 2 weeks on Lamictal  Initial target dose at 200 mg qhs (get blood levels after 7- 10 days at this dose, 12 hours after dose)  Increase by 100 mg/d thereafter as needed, but not sooner than 2 weeks at each dose (only 50 mg/d increase if concurrently on Depakote)

o To allow the body to get used to the drug and to avoid Stevens-Johnson Syndrome (life- threatening rash) o Must restart original titration protocol at 25 mg qhs if they miss Lamictal more than 3 days in a row  Side effects: tremor, dizziness, word-finding problems, rash Medications that need Tapering (basically everything except LiCO3)

Medication Groups

Atypical Antipsychotics/Second-generation neuroleptics  Abilify (aripiprazole)  Geodon (ziprasidone)  Seroquel (quetiapine) – start 25 mg po qhs then increase by 25 - 100 mg/day  Zyprexa (olanzapine) – start 5 mg po qhs, may adjust by 5 mg/day prn o if still cannot sleep within 3 hours of first dose, add another 5 mg o *Seroquel and Zyprexa have the most anti-histaminic properties, and are therefore weight gainers OTHERS:  Risperdal (risperidone)  Latuda (lurasidone)  Clozaril (clozapine)   Serotonin-Norepinephrine Re-Uptake Inhibitors (SNRIs) for depression, OCD, panic disorder, anxiety, chronic pain  Effexor (venlafaxine) - cheaper than Pristiq; start at 25 mg bid (take after breakfast & after lunch, may cause upset stomach)  Cymbalta (duloxetine) - still more expensive than Effexor; starting dose 30-60 mg; may cause upset stomach  Pristiq (desvenlafaxine) - first active metabolite of venlafaxine, just more expensive  Fetzima (levomilnacipran) – as expensive as Pristiq  _ Selective Serotonin Re-Uptake Inhibitor (SSRIs) : for depression, OCD, panic disorder, anxiety  Prozac (fluoxetine) – preferred; long half-life (if patient misses dose, won’t go into discontinuation syndrome); relatively weight neutral; associated with decreased libido (or other sexual dysfunction, like delayed orgasm) o start at 10 - 20 mg po qam, take with food in stomach; can go up in 10-20 mg/d increments not more than every 2 weeks  Zoloft (sertraline)  Luvox (fluvoxamine)  Lexapro (escitalopram) – not used as much due to potential QTc prolongation  Celexa (citalopram) – not used as much due to potential QTc prolongation  Paxil (paroxetine) – may cause severe discontinuation syndrome, weight gain   ____________________________________________________________________________________  Remeron (Mirtazapine) – helpful for anxious depression with insomnia, starting dose: 30 mg qhs  α 2 Antagonist (increases release of NE and serotonin) and potent 5-HT 2 and 5-HT 3 receptor antagonist  sedation, weight gain

 Sedating antidepressants: Remeron  Tertiary tricyclics (potentially dangerous/toxic)   Weight gain: Seroquel, Depakote, mirtazapine, Paxil  Weight neutral: Prozac, Lamictal, Tegretol    Cogentin (benztropine) – anticholinergic remedy for extrapyramidal side effects from neuroleptics; H antagonist  start at 1 mg bid, titrating upwards to 2 mg bid   Terminology  Mixed state : feeling depressed yet manic “high” symptoms at the same time Reduced by Depakote/ Atypical Antipsychotics (Second-generation neuroleptics) o  Pharmacokinetic drug-drug interaction : one drug affects the blood level of the second drug o Example: Depakote and Lamictal  Pharmacodynamic drug-drug interaction : two drugs accomplish the same action or side effect o Cross-tolerance : one can be used to withdraw another  Recurrence : new episode of symptoms after having been taken off the medicine for more than 6 months  Relapse : old/original episode coming back less than 6 months after being taken off the medication  Response : 50% improvement in symptoms  Remission : PHQ-9 score of 4 or less (minimal to no depression or anxiety)  Serotonin syndrome : occurs with any drug that increases serotonin (e.g., MAO inhibitors, SSRI’s, SNRI’s)

hyperthermia, myoclonus, cardiovascular collapse, flushing, diarrhea (serotonin receptors activated in GI tract), seizures.   Pearls  Anxiety and panic disorders generally respond to serotonergic drugs not norepinephrine ones.  Anti-convulsants/SNRI’s have anti-pain properties (especially chronic pain).  Generic drugs may be "porcelain clangers" (go through patient unabsorbed)  “The dose that got them well, keeps them well.” You typically don’t reduce the dose if they’re doing well.   Zyprexa and Seroquel: more sedation  Abilify, Geodon: less weight gain, more likely to cause EPS, less sedation   Clozaril/clozapine must get CBCs each week; terrible weight gain; seizures; gold standard for refractory psychosis with potentially less Tardive Dyskinesia (TD).   Anticholinergic effects in tertiary TCAs  Blind as a bat ( blurred vision )  Dry as a bone ( dry mouth ) o Remedy: tart substances; sugarless candy/gum or water with unsweetened lemon juice  Red as a beet ( flushing )  Mad as a hatter ( confusion )  Hot as a hare ( hyperthermia )

 Can’t see ( vision changes )  Can’t pee ( urinary retention )  Can’t sh*t ( constipation )   Toxicities  Typical Antipsychotics/Neuroleptics o Highly lipid soluble and stored in body fat; thus, very slow to be removed from body o Extrapyramidal system (EPS) side effects  4 hours : acute dystonia – muscle spasm, stiffness, oculogyric crisis  4 days : akinesia – parkinsonian symptoms  4 weeks : akathisia (restlessness)  4 months : tardive dyskinesia – stereotypic oral-facial movements and twisting/tapping of the lower extremities due to long-term antipsychotic use; often irreversible o Endocrine side effects (e.g., dopamine receptor antagonism  hyperprolactinemia  galactorrhea) o Side effects arising from blocking receptors  Muscarinic – dry mouth, constipation  Alpha adrenergic – hypotension  Histamine – sedation  Atypical antipsychotics o Fewer extrapyramidal/TD side effects than traditional antipsychotics o olanzapine/clozapine/quetiapine - significant weight gain (insulin resistance and hyperlipidemia) o Clozaril/clozapine – agranulocytosis (requires weekly WBC monitoring) o Geodon/ziprasidone – QTc prolongation o Seroquel/quetiapine – cataracts o Risperidal/risperidone – highest risk of all atypicals for developing EPS and hyperprolactinemia

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Psychiatry Cheat Sheet Jazzlyn Gallardo, D.O.

Medication Groups