for: neon primary healthcare providers by: michelle … · ssri’s: class side effects nausea...

F O R : N E O N P R I M A R Y H E A L T H C A R E P R O V I D E R S

B Y : M I C H E L L E R O M E R O , D O

M A Y , 2 0 1 3

Psychiatric Medication Guide

Anti-depressants

TCA’s & MAOI’s (Tricyclic Antidepressants & Mono-Amine Oxidase Inhibitors) old, lots of side effects/not well tolerated, rarely used

SSRI’s (Selective Serotonin Reuptake Inhibitors) first line

SNRI’s (Serotonin Norepinephrine Reuptake Inhibitors) second line, after failing 2 SSRI trials

adjunctive

Novel second line, after failing 2 SSRI trials

adjunctive

SSRI’s: class side effects

Nausea & decrease in appetite for 2 weeks after initiating or increasing dose.

Increase in restlessness for 2 weeks after initiating or increasing dose.

Take in AM; may interrupt sleep cycle.

Increased vividness of dreams.

Sexual side effects: prolonged time to ejaculation in males. some also complain of a decrease in libido

SSRI’s: black box warning

Anti-depressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18-24 years of age) with major depressive disorder (MDD) and other psychiatric disorders: consider risk prior to prescribing.

SSRI’s: Fluoxetine (Prozac)

Approval: Major Depressive d/o; Obsessive-Compulsive d/o; Bulimia; Premenstrual Dysphoric d/o; Panic d/o

Also used for: Generalized Anxiety d/o; Post-traumatic Stress d/o

Pregnancy: class C; generally felt safe for use in pregnancy do NOT use in lactation

Forms: Capsule: 10mg, 20mg, 40mg

Tablet: 30mg, 60mg ($$$)

Liquid: 20mg/5ml

SSRI’s: Fluoxetine (Prozac)

Adult dosing: 20mg – 80mg

Start with 20mg

May increase dose every 4-6 weeks by 10-20mg

Higher doses (60-80mg) generally more effective for anxiety than lower doses

On NEON Formulary

Capsules can be found as $4.00 generic at many pharmacies

SSRI’s: Sertraline (Zoloft)

Approval: Major Depressive d/o; Obsessive-Compulsive d/o; Social Anxiety d/o; Panic d/o; Post-traumatic Stress d/o; Premenstrual Dysphoric d/o

Also used for: Generalized Anxiety d/o; Bulimia

Pregnancy: class C; generally felt safe for use in pregnancy

generally thought safe for use in lactation

Forms:

Tablet: 25mg, 50mg, 100mg

Liquid: 20mg/ml

SSRI’s: Sertraline (Zoloft)

Adult dosing: 50mg - 200mg

Start at 50mg



On NEON Formulary

$4.00 medication at Marc’s Pharmacy

SSRI’s: Paroxetine (Paxil)

Approval: Major Depressive d/o; Panic d/o; Social Phobia; Generalized Anxiety d/o; Premenstrual Dysphoric d/o; Obsessive-Compulsive d/o; Post-traumatic Stress d/o

Pregnancy: class D; do not use; may cause congenital malformations do NOT use in lactation

Forms: Tablet: 10mg, 20mg, 30mg, 40mg

CR, tablet: 12.5mg, 25mg, 37.5mg

Oral Suspension: 10mg/5ml

SSRI’s: Paroxetine (Paxil)

High side effect profile: generally not well tolerated

Adult dosing: 20mg – 60mg CR: 25mg – 75mg

May increase every 4-6 weeks by 10mg (CR: 12.5mg)

Higher dosing generally more effective for anxiety than lower dosing

Regular Paroxetine may be on some $4.00 formularies

SSRI’s: Citalopram (Celexa)

Approval: Major Depressive d/o

Also used in: Generalized Anxiety d/o, Obsessive-Compulsive d/o; Panic d/o; Social Anxiety d/o; Post-traumatic Stress d/o; Dementia

Pregnancy: class C; if pt conceived and is stable while taking medication there is no indication to change may use in lactation

Forms: Tablet: 10mg, 20mg, 40mg

Oral Solution: 10mg/5ml

SSRI’s: Citalopram (Celexa)

Adult dosing: 20-40mg

Start 20mg



Can no longer titrate over 40mg due to increased risk for QTc prolongation without monitoring EKG

Can be found as $4.00 generic at many pharmacies

SSRI’s: Escitalopram (Lexapro)

Approval: Major Depressive d/o; Generalized Anxiety d/o

Also used for: Obsessive-Compulsive d/o; Panic d/o; Social Anxiety d/o; Post-traumatic Stress d/o

Pregnancy: class C

safety unknown in lactation

Forms:

Tablets: 5mg, 10mg, 20mg

Liquid: 5mg/5ml

SSRI’s: Escitalopram (Lexapro)

Generally thought to have low side effect profile and work more quickly than the other SSRI’s


Start 10mg



$$$

SNRI’s: class side effects

Nausea & decreased appetite for 2 weeks after initiating and increasing dose.

Increase in restless for 2 weeks after initiating or increasing dose.

Take in AM; may interrupt sleep cycle.

Increase vividness of dreams.

Sexual side effects: prolonged time to ejaculation in males. Some also complain of a decrease in libido.

SNRI’s: black box warning

Anti-depressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18-24 years of age) with major depressive disorder (MDD) and other psychiatric disorders: consider risk prior to prescribing.

SNRI’s: Venlafaxine (Effexor)

Approval: Major Depressive d/o; Generalized Anxiety d/o; Social Phobia; Panic d/o

Also used for: Obsessive-Compulsive d/o; Post-traumatic Stress d/o

Pregnancy: class C

do NOT use in lactation

Forms:

Tablet: 25mg, 37.5mg, 50mg, 75mg, 100mg

Capsule: 37.5mg, 75mg, 150mg

ER, Capsule: 37.5mg, 75mg, 150mg

SNRI’s: Venlafaxine (Effexor)

Dose dependent HTN & Significant withdrawal symptoms

Adult dosing: Immediate Release (bid or tid dosing): 75mg – 375mg per day

start 37.5mg PO BID; increase by 37.5mg PO BID

Extended Release: 75mg – 225mg

start 37.5mg for 1 week; then 75mg; increase by 37.5-75mg

May increase every 4-6 weeks

Higher dosing generally more effective for anxiety than lower dosing

Immediate release 50 & 75mg tablets at NEON Pharmacy

SNRI’s: Duloxetine (Cymbalta)

Approval: Major Depressive d/o; Generalized Anxiety d/o; Neuropathic Pain associated with Diabetes; Fibromyalgia

Also used for: Obsessive-Compulsive d/o; Social Anxiety d/o; Panic d/o; Post-traumatic Stress d/o; Neuropathic Pain

Pregnancy: class C


Forms:

Capsules: 20mg, 30mg, 60mg

SNRI’s: Duloxetine (Cymbalta)

Avoid if LFT’s elevated


Start 30mg

May increase every 4-6 weeks by 30mg


$$$

SNRI’s: Desvenlafaxine (Pristiq)


Also used for: Generalized Anxiety d/o; Social Anxiety d/o; Panic d/o; Obsessive-Compulsive d/o; Post-traumatic Stress d/0

Pregnancy: class C


Forms:

Tablet: 50mg, 100mg

SNRI’s: Desvenlafaxine (Pristiq)


Start 50mg

May increase to 100mg after 4-6 weeks

Dosing higher than 50mg generally no more effective

$$$

Novel: Buproprion (Wellbutrin)

Side effects: May have a headache for 2 weeks after initiating or increasing dose.

Take in AM; if BID/TID dosing take last dose at dinnertime

Decreased appetite

Increased energy

Do not use if patient already pre-disposed to Seizure d/o

Black box warning: Anti-depressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18-24 years of age) with major depressive disorder (MDD) and other psychiatric disorders: consider risk prior to prescribing.


Approval: Major Depressive d/o; Seasonal Affective d/o; Adjunct in Smoking Cessation

Also used for: Attention Deficit Hyperactivity d/o; Sexual side-effects of SSRI’s/SNRI’s

Pregnancy: class C


Forms: tablets (cannot be cut/split)

Immediate Release: 75mg, 100mg

Sustained Release: 100mg, 150mg, 200mg

Extended Release: 150mg, 300mg


Safer in Bipolar depression; less likely to induce mania.

Adult dosing: IR (TID dosing): 100mg PO TID; max 450mg total per day

SR (BID dosing): 150mg PO BID; max 400mg total per day

XR (once daily dosing): 150mg – 450mg; start 150mg PO qAM

May increase every 4-6 weeks

150mg XR on NEON Formulary

Novel: Mirtazapine (Remeron)

Side effects:

Take at bedtime

Increase in appetite: will decrease with increase in dose

Sleepiness: will decrease with increase in dose

Black box warning: Anti-depressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18-24 years of age) with major depressive disorder (MDD) and other psychiatric disorders: consider risk prior to prescribing.



Also used for: Generalized Anxiety d/o

Pregnancy: class C do NOT use in lactation

Forms: Tablets: 15mg, 30mg, 45mg

Oral Dissolvable Tablets: 15mg, 30mg, 45mg


Side effects of being sleepy and hungry decrease with higher dosing


Start: 15mg

May increase every 4-6 weeks by 15mg

Higher dosing (45-60mg) generally more effective for anxiety than lower doses

Common Mood Stabilizers

Lithium

Valproic Acid (Depakote)

Lamotrigine (Lamictal)

Lithium

Approval: Bipolar d/o; treatment of Bipolar Mania; Bipolar Maintenance

Also used for: management of Suicidality; adjunctive management for Major Depressive d/o

Pregnancy: class D; Ebstein’s anomaly; safer than Depakote do NOT use in lactation

Forms: Capsules: 150mg, 300mg, 600mg

ER Tablets: 300mg, 450mg

Liquid: 300mg/5ml

Lithium

Common Side Effects: Tremor, Polyuria, Polydipsia, Weight Gain, Alopecia, Fatigue

Black Box Warning: Lithium toxicity is closely related to serum

concentrations and can occur at therapeutic dosing: serum lithium determinations are required to monitor therap. Normal fluid and salt intake must be maintained during therapy.

Lithium Toxicity: Nausea, Vomiting, Diarrhea, Dizziness, Weakness, Hyper-

reflexia, Slurred Speech

Watch out for Dehydration & Avoid NSAID use

Lithium

Monitoring:

Renal Functions

Thyroid Functions

Lithium Level: therapeutic 0.6-1.2

Check initial level 4-5 days after initiation

Re-check every 3 months

Adult Dosing:

Regular Release: 300mg - 2400mg divided BID-TID

Start 600mg (300mg PO BID)

Usual Effective dose: 900-1200mg

May increase by 300mg every week as needed

Lithium

Adult Dosing:

Extended Release: 300mg – 1800mg divided BID-TID

Start 900mg (450mg PO BID)

Usual effective dose: 900-1200mg


Immediate release 300mg capsules available on the NEON Formulary.

Generally a cheap generic option at many pharmacies.


Approval: Mania associated with Bipolar d/o; Migraine Prophylaxis; Seizure d/o

Also used for: Bipolar Maintenance; Impulse Control d/o

Pregnancy: class D; may cause teratogenic effects such as neural tube defects Okay for use in lactation

Forms: Tablets (cannot be cut/split)

Immediate Release: 125mg, 250mg, 500mg

Extended Release: 250mg, 500mg

Sprinkles (capsule): 125mg

Liquid: 250mg/5ml


Common Side Effects:

Diarrhea; Weight Gain; Somnolence; Nausea

Black Box Warning:

Hepatic failure resulting in fatalities has occurred in patients; children under 2 years of age are at considerable risk.

Depakote Toxicity:

Nausea, Vomiting, Decreased level of Concsiousness, Confusion


Monitoring: Liver Functions

CBC

Valproic Acid Level: therapeutic 85-125

Check initial level 3-4 days after starting medication

Recheck all lab levels every 6 months

Adult Dosing: 250mg – 2500mg daily Usual effective dose: 1500-2000mg

Start 1000mg

May increase by 250-500mg every week as needed

If switching from regular release to extended release increase total dose by 20%


Regular release 500mg tablets and Extended release 250mg & 500mg tablets available on the NEON Formulary.

Regular release generally a cheap generic at many pharmacies.


Approval: maintenance treatment of Bipolar I in adults

Also used for: maintenance of Bipolar II; Bipolar depression

Pregnancy: class C; watch serum concentrations and increase folic acid intake (5mg daily)


Forms:

Tablets: 25mg, 100mg, 150mg, 200mg

Easy to cut/split


Generally well tolerated

Black Box Warning:

Severe and potentially life-threatening skin rashes requiring hospitalization have been reported; risk may be increased by co-administration with valproic acide, higher than recommended started doses, and rapid dose titration.


Adult Dosing: 200mg (100mg if co-administered with Valproic Acid)

Titration: 25mg daily for 2 weeks; 50mg daily for 2 weeks; 100mg daily for 1 week, 150mg daily for 1 week, then 200mg

Titration with Valproic Acid: 25mg every other day for 2 weeks, 25mg daily for 2 weeks, 50mg daily for 2 weeks, 75mg daily for 2 weeks, then 100mg

If patient misses dose for 2-3 days, generally okay to resume regular dosing, if misses dose for longer need to restart titration, but may titrate weekly (unless in combination with valproic acid).


Some doses available on NEON Formulary.

Generic ranges from $30-60/month as most pharmacies.

Anti-psychotics

Typical/First Generation

Monitor AIMS (Abnormal Involuntary Movement Scale) for Extrapyramidal Symptoms (EPS), Tardive Dyskinesia (TD), and Dystonic Reactions.

Atypical/Second Generation

Monitor fasting lipids, fasting glucose/HbA1c, BMI/waist circumference, and weight at initiation and then at 3 months, 6 months, 12 months, annually.

If > 5% weight gain, consider changing to a different medication.

Anti-psychotics

Black Box Warning: Elderly patients with dementia-related psychosis treated with anti-psychotics are at an increased risk of death compared with placebo.

Typical/First Generation: Haldol (Haloperidol)

Approval: Schizophrenia; Tourette’s syndrome; Severe Behavioral Problems in Children

Also used for: Bipolar d/o

Pregnancy: class C; generally thought safe for use during pregnancy at lowest effective dose


Forms:

Tablets: 0.5mg, 1mg, 2mg, 5mg, 10mg, 20mg

Decanoate (IM): 100-200mg IM q4wks

Typical/First Generation: Haloperidol (Haldol)

Common Side Effects:

Mild Sedation

EPS/TD: manage with Benztropine (Cogentin) or Benadryl

Acute Dystonic Reaction: mange with Benadryl

Neuroleptic Malignant Syndrome

Adult Dosing: 1mg – 100mg BID-TID

Average dosing: 10-60mg BID-TID

Starting dose dependent on severity of symptoms

May increase by up to 5-10mg every 5 days as needed

Typical/First Generation: Haloperidol (Haldol)

1mg tablets available on the NEON Formulary.

Can also be found on $4.00 formularies at several pharmacies.

Old, cheap generic medication.

Atypical/Second Generation

Olanzapine (Zyprexa) Risperidone (Risperdal) Quetiapine (Seroquel/Seroquel XR) Ziprasidone (Geodon) Aripiprazole (Abilify) Paliperidone (Invega)

Olanzapine (Zyprexa)

Approval: Schizophrenia; Acute Mixed Episodes; Maintenance of Bipolar d/o; Acute Agitation

Pregnancy: class C; occasionally used


Forms:

Tablets: 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg

Oral Dissolvable Tablets: 5mg, 10mg, 15mg, 20mg

Olanzapine (Zyprexa)

Adult Dosing: 2.5mg – 20mg

Start 2.5-5mg qHS

May increase by 2.5-5mg every 5 days as needed

Generally sedating.

Generally contributes to a lot of weight gain/increase in appetite.

Risperidone (Risperdal)

Approval: Schizophrenia; Acute Mania or Mixed episodes associated with Bipolar I; Irritability or Aggression associated with Autistic d/o Consta: maintenance of Bipolar I

Pregnancy: class C do NOT use in lactation

Forms: Tablets: 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg

Oral Dissolvable Tablets: 0.5mg, 1mg, 2mg, 3mg, 4mg

Liquid Solution: 1mg/1ml

Consta IM Injection : 12.5mg – 50mg q2wks

Risperidone (Risperdal)

Adult Dosing: 1-8mg

Usual effective dosing: 2-6mg

Start 0.5-1mg daily

Increase by 0.5-1mg weekly as needed

Monitor Prolactin: most likely to cause galactorrhea (lactation) in females and males.

Some tablet dosages available on the NEON Formulary.

Quetiapine (Seroquel)

Approval: Schizophrenia; Acute Manic Episodes; Maintenance of Bipolar I d/o in combination; Depression associated with Bipolar d/o; Adjunctive management of Unipolar Depression

Additional Black Box Warnings: Anti-depressants increase the risk of suicidal thinking and

behavior in children, adolescents, and young adults (18-24 years of age) with major depressive disorder (MDD) and other psychiatric disorders; consider risk before prescribing.

Quetiapine is no FDA approved for use in children.

Quetiapine is approved for the treatment of bipolar depression.


Pregnancy: class C


Forms:

Tablets: 25mg, 50mg, 100mg, 200mg, 300mg, 400mg

XR, Tablets: 50mg, 150mg, 200mg, 300mg, 400mg

Adult Dosing: 50mg – 800mg daily

Regular Release: usual effective dose 200-400mg daily

Divided, BID, dosing

May increase by 25-50mg every week as needed


Adult Dosing:

Extended release: usual effective dose 300-600mg

Once daily dosing: should be in the evening, about 12 hours before wanting to wake up the next morning.

Start 150-300mg

Increase by 150-300mg every week as needed

Generally sedating.

Generally contributes to weight gain.

Ziprasidone (Geodon)

Approval: Schizophrenia; Acute Manic or Mixed episodes with or without psychosis; Maintenance of Bipolar d/o as adjunct; Acute Agitation in Schizophrenia

Also used for: adjunctive management of Major Depressive d/o

Pregnancy: class C


Forms:

Capsules: 20mg, 40mg, 60mg, 80mg

Ziprasidone (Geodon)

Adult Dosing: 40mg – 160mg (BID dosing)

Start 20mg PO BID

Increase by 20-40mg every week as needed

Take with food

Does not generally lead to weight gain and may actually contribute to weight loss.

Monitor QTc (if >450-500 don’t start; monitor for overall change in QTc); monitor BP, pulse, serum potassium, and serum magnesium.

Aripiprazole (Abilify)

Approval: Acute and Maintenance treatment of Schizophrenia; Stabilization, Maintenance, and Adjunct in Bipolar d/o; Adjunct in Major Depressive d/o; Irritability associated with Autistic d/o

Additional Black Box Warnings: Anti-depressants increase the risk of suicidal thinking

and behavior in children, adolescents, and young adults (18-24 years of age) with major depressive disorder (MDD) and other psychiatric disorders; consider risk before prescribing.

Aripiprazole is not FDA approved for adjunctive treatment of depression in children.


Pregnancy: class C


Forms:

Tablets: 2mg, 5mg, 10mg, 15mg, 20mg, 30mg

Oral Dissolvable Tablets: 10mg, 15mg

Liquid: 1mg/1ml

Adult Dosing: 2mg – 30mg

Lower dosing (2-10mg) for depression

Mid-range dosing (10-20mg) for bipolar

Upper range dosing (15-30mg) for schizophrenia


Adult Dosing:

Starting dose depends on disorder and severity of presentation.

May increase by 2-5mg every week as needed.

Generally does not lead to weight gain or sedation.

Watch for Akasthesia (inner restlessness).

Treat with Propranolol

Paliperidone (Invega)

Approval: Acute and Maintenance Treatment of Schizophrenia and Schizoaffective d/o

Also used for: Bipolar d/o

Pregnancy: class C


Forms:

Capsules: 1.5mg, 3mg, 6mg, 9mg

Sustenna (IM): 234mg IM x 1; then 156mg IM x 1 in 7 days; then 117mg IM q4wks

Paliperidone (Invega)

Adult Dosing: 3mg – 12mg

Start 6mg


Monitor Prolactin

Enantiomer of Risperidone

May contribute to galactorrhea (lactation)

Anti-anxiety

Buspirone (Buspar)

SSRI’s

SNRI’s

Mirtazapine (Remeron)

Benzodiazepines

Buspirone (Buspar)

Approval: Generalized Anxiety d/o

Also used for: Social Anxiety d/o

Pregnancy: class B


Forms:

Tablets (easy to cut/split): 5mg, 7.5mg, 10mg, 15mg, 30mg

Buspirone (Buspar)

Adult Dosing: 10mg – 60mg per day

Divided dosing: BID – TID

Start 10mg PO BID

Increase by 5-10mg per week as needed

May be slightly sedating, but generally well tolerated.

No risk of dependency/abuse.

Benzodiazepines: Clonazepam (Klonopin)

Approval: Panic d/o

Generally BID dosing Not necessary to dose more frequently than TID

Start 0.5mg PO BID technically no upper limit

Taper slowly

Pregnancy: class D do NOT use in lactation

Monitor for dependency/abuse frequently monitor OARRS

Benzodiazepines: Lorazepam (Ativan)

Approval: Anxiety disorders and Anxiety associated with Depression

Generally TID dosing

Can be up to every 4 hours; generally lasts 6-8 hours

Start 0.5mg PO TID

Technically no upper limit

Taper slowly

Pregnancy: class D, but sometimes used in limited dosing and not close to delivery


Benzodiazepines: Lorazepam (Ativan)

Do not use in hepatic failure.

Monitor for dependency/abuse.

frequently monitor OARRS

Benzodiazepines: Alprazolam (Xanax)

Approval: Generalized Anxiety d/o; Panic d/o; Anxiety associated with Depression

May need to be dosed 4 times a day

Generally lasting only 22-4 hours with pretty immediate onset of action.

Quick onset and short duration of action increases the likelihood of dependence/abuse.

Start 0.5mg PO TID

Doses over 4mg daily not recommended

Technically no upper limit

Benzodiazepines: Alprazolam (Xanax)

Taper slowly

Pregnancy: class D


Monitor for dependency/abuse

frequently monitor OARRS

Others

Trazodone: frequently used for sleep Dose 50mg – 200mg PO qHS

Hydroxyzine: frequently used for anxiety and/or sleep Dose: 12.5mg – 50mg PO TID & qHS

Propranolol: frequently used for anxiety, especially performance based anxiety Dose: 10mg – 20mg PO TID

Prazosin: frequently used for nightmares in Post-traumatic Stress d/o Dose: 1mg – 2mg PO qHS

Gabapentin: frequently used as add-on management for anxiety or mood-stabilization Dose: 100mg – 300mg PO TID with higher bedtime dosing for sleep

for: neon primary healthcare providers by: michelle … · ssri’s: class side effects nausea...

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