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Psychiatry Cheat Sheet: Check TSH again 4-6 weeks after each thyroid dose change.
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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)
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)
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