🧩 Module 5 · Mental Health Drugs
18 drugs · 14 concepts · tested on Exam 3
💡 The big idea
Psych drugs are neurotransmitter dials: serotonin and norepinephrine for mood, dopamine for psychosis, GABA for anxiety and seizures, dopamine and norepinephrine for ADHD. What actually gets tested is rarely the mechanism — it is the four syndromes that happen when a dial goes too far (serotonin syndrome, NMS, extrapyramidal symptoms, lithium toxicity) and the handful of drugs that need blood levels to stay safe.
🧠 How to think about this module
- Match the neurotransmitter to the problem: too little serotonin/norepinephrine = depression, too much dopamine = psychosis, too little GABA = anxiety and seizures.
- Almost every psych emergency is one of four syndromes, and you tell them apart by the muscles. Serotonin syndrome = hyperreflexia and clonus, onset in hours. NMS = lead-pipe rigidity, onset over days.
- Antipsychotics in one sentence: first generation causes movement problems, second generation causes metabolic problems. That answers most antipsychotic questions.
- Mood stabilizers and anticonvulsants overlap on purpose. Lithium, valproate, carbamazepine, and lamotrigine sit in both lists.
- Anesthesia has three separate jobs done by three separate drugs: sedation (propofol, ketamine, midazolam), analgesia (opioids), and paralysis (neuromuscular blockers). A paralyzed client is not a sedated client.
🏷️ The whole module in 9 classes
Learn these groups and the drug list stops being 18 separate names.
| Class | What it does | Examples | What gets tested |
|---|
| SSRIs and SNRIs | First-line for depression, anxiety, OCD, and PTSD. | fluoxetine, sertraline, escitalopram, paroxetine (SSRI); venlafaxine, duloxetine (SNRI) | Full effect takes 4 to 6 weeks, but energy returns before mood does — suicide risk is HIGHEST in the first few weeks. Never stop abruptly (discontinuation syndrome: flu-like aches, dizziness, brain zaps, irritability). SNRIs also raise blood pressure. |
| TCAs and MAOIs | Older antidepressants, still tested because of what they can do to you. | amitriptyline, nortriptyline, imipramine (TCA); phenelzine, tranylcypromine, selegiline (MAOI) | MAOI plus tyramine (aged cheese, cured or smoked meats, draft beer, soy sauce, fermented foods, overripe fruit) causes hypertensive crisis: BP over 180/120 with a pounding occipital headache. Allow a 2-week washout between an MAOI and any serotonergic drug — 5 weeks after fluoxetine. TCAs are lethal in overdose (cardiac). |
| Benzodiazepines and Z-drugs | Enhance GABA for fast relief of anxiety, sedation, seizures, and alcohol withdrawal. | alprazolam, lorazepam, diazepam, midazolam, clonazepam; zolpidem | Combined with an opioid or alcohol they cause respiratory depression — that combination carries a boxed warning. Antidote is flumazenil. Always taper; abrupt withdrawal can cause seizures. |
| Non-benzodiazepine anxiolytic | Treats generalized anxiety without sedation or dependence. | buspirone | Takes 2 to 4 weeks to work and does NOT work as needed. It is the wrong answer for a panic attack happening now and the right answer for long-term GAD in someone with a substance use history. |
| Mood stabilizer | Controls mania and reduces suicide risk in bipolar disorder. | lithium carbonate | Therapeutic level 0.8 to 1.2 mEq/L; toxicity begins around 1.5. Lithium competes with sodium, so dehydration, low salt intake, vomiting, diarrhea, NSAIDs, ACE inhibitors, and thiazides all push the level up. Early toxicity: coarse tremor, vomiting, diarrhea, ataxia, slurred speech. |
| Anticonvulsants (also used as mood stabilizers) | Stabilize neuronal membranes by acting on sodium channels or GABA. | valproic acid, carbamazepine, lamotrigine, phenytoin, gabapentin, pregabalin, levetiracetam | Valproate: hepatotoxicity, pancreatitis, and neural tube defects — level 50-100 mcg/mL. Carbamazepine: agranulocytosis and hyponatremia — level 4-12 mcg/mL. Lamotrigine: Stevens-Johnson syndrome, so titrate slowly and stop for any rash. Phenytoin: level 10-20 mcg/mL, gingival hyperplasia, ataxia, nystagmus. |
| Antipsychotics | Block dopamine (and, in second generation, serotonin) to control psychosis. | haloperidol, chlorpromazine, fluphenazine (1st gen); risperidone, olanzapine, quetiapine, aripiprazole, clozapine (2nd gen) | First generation causes EPS (acute dystonia, akathisia, pseudoparkinsonism) and tardive dyskinesia. Second generation causes weight gain, hyperglycemia, and dyslipidemia — monitor weight, A1C, and lipids. Clozapine requires scheduled ANC monitoring for agranulocytosis and can also cause myocarditis, seizures, and severe constipation. |
| ADHD stimulants and non-stimulants | Increase dopamine and norepinephrine in the prefrontal cortex. | methylphenidate, dextroamphetamine/amphetamine (stimulants); atomoxetine, guanfacine, clonidine (non-stimulants) | Stimulants suppress appetite and can slow growth and raise heart rate and BP — give in the morning, take a drug holiday if ordered, and plot height and weight. Atomoxetine takes several weeks and carries a suicidality warning in youth. |
| Anesthetics and procedural sedation | Produce unconsciousness, dissociation, or local numbness. | propofol, ketamine, midazolam (sedation/hypnosis); lidocaine, bupivacaine (local) | Propofol provides NO analgesia and drops blood pressure; it is a lipid emulsion, so bottle and tubing are changed every 12 hours. Ketamine causes emergence delirium — recover the client in a quiet, dim room. Lidocaine toxicity starts with circumoral numbness, metallic taste, and tinnitus, then progresses to seizures and cardiac arrest. |
⚖️ Serotonin syndrome vs neuroleptic malignant syndrome
| Serotonin syndrome | Neuroleptic malignant syndrome (NMS) |
|---|
| Cause: too much serotonin — SSRI plus tramadol, triptan, linezolid, MAOI, or St. John's wort | Cause: dopamine blockade — antipsychotics, especially first generation; also abrupt levodopa withdrawal |
| Onset: fast, usually within 24 hours of a dose change | Onset: slow, days to weeks |
| Muscles: hyperreflexia, clonus, twitching, tremor, agitation | Muscles: lead-pipe rigidity, stupor, mutism |
| Pupils dilated, hyperactive bowel sounds, diarrhea | Pupils normal, autonomic instability, very high CK |
| Treat: stop the serotonergic drugs, supportive care, cyproheptadine | Treat: stop the antipsychotic, cooling, dantrolene or bromocriptine |
🚨 Red flags DANGER
- Lithium level at or above 1.5 mEq/L, or coarse tremor, vomiting, diarrhea, and ataxia: hold the dose and call. Any illness with fluid loss is a lithium emergency.
- Any rash on lamotrigine or carbamazepine: stop the drug and call. Stevens-Johnson syndrome starts as 'just a rash.'
- Fever, rigidity, and altered mental status on an antipsychotic: NMS. Stop the drug, cool the client, call rapid response.
- Sore throat, fever, or flu-like symptoms on clozapine: draw an ANC before the next dose — that is agranulocytosis until proven otherwise.
- A benzodiazepine and an opioid ordered for the same client is a boxed-warning combination. Verify the intent before you give it.
🧵 Exam traps ⭐ HIGH YIELD
- Buspirone is not a benzodiazepine and does not work PRN. 'Take it as needed when you feel anxious' is always wrong.
- EPS and tardive dyskinesia are not the same thing. EPS is early and reversible — treat with benztropine or diphenhydramine. TD is late and often permanent, and anticholinergics can make it WORSE.
- Lithium is not metabolized by the liver. The kidney handles it and it competes with sodium, so a low-salt diet RAISES the level.
- Phenytoin toxicity shows up as nystagmus and ataxia first. Gingival hyperplasia is a chronic cosmetic effect, not a sign of toxicity.
- Flumazenil reverses benzodiazepines but can trigger seizures in a chronic user or a mixed TCA overdose — it is not the everyday equivalent of naloxone.
- Venlafaxine and duloxetine are SNRIs, not SSRIs, and they raise blood pressure. Check a BP before and during therapy.
🧠 Ways to remember it
- Serotonin syndrome = hyper everything, fast. NMS = rigid and slow.
- Lithium: salt and water keep it level. Dehydration equals toxicity.
- First generation moves you (EPS). Second generation grows you (weight, sugar, lipids).
- Clozapine Closes down the marrow — watch the ANC.
- Phenytoin: the eyes wobble before the client does. Nystagmus first.
🧠 The concepts 14
What are the pharmacological treatment options for anxiety disorders?⭐ HIGH YIELD
SSRIs and SNRIs are FIRST-LINE for long-term treatment of anxiety disorders. BENZODIAZEPINES are for short-term or breakthrough use only. Other options: buspirone, hydroxyzine, propranolol for performance anxiety, and gabapentin or pregabalin as adjuncts. Cognitive behavioral therapy is at least as effective as medication.
- SSRIs and SNRIs take 4 to 6 WEEKS to work and can transiently WORSEN anxiety in the first 1 to 2 weeks. Start low, go slow, and warn the patient so they do not quit on day 3.
- Benzodiazepines (lorazepam, alprazolam, clonazepam, diazepam) work in minutes, which makes them useful for acute panic, but they are Schedule IV, cause tolerance and physical dependence, and should be prescribed for SHORT PERIODS ONLY, typically 2 to 4 weeks per the textbook. Never stop them abruptly: withdrawal can cause seizures.
- Benzodiazepine teaching: no alcohol or other CNS depressants, no driving for 24 to 48 hours after a dose, and do not get out of bed unassisted within 8 hours of a dose because of fall risk. Older adults and children may have PARADOXICAL reactions (agitation, tremor, hallucinations). Antidote is flumazenil.
- BUSPIRONE is the non-sedating, non-addictive alternative: no dependence, no CNS depression, no PRN use. It must be taken scheduled and takes 2 to 4 weeks to work. Avoid grapefruit juice.
- All antidepressants carry a BOXED WARNING for increased suicidality in children, adolescents, and young adults. Monitor closely at initiation and with every dose change, and teach family to report sudden changes in mood or behavior.
- Avoid St John's wort with SSRIs or SNRIs (serotonin syndrome). Avoid caffeine, alcohol, and stimulants, which worsen anxiety.
| Option | Onset | Role |
|---|
| SSRIs: sertraline, escitalopram, paroxetine, fluoxetine | 4 to 6 weeks | FIRST-LINE maintenance for GAD, panic, social anxiety, OCD, PTSD |
| SNRIs: venlafaxine, duloxetine | 4 to 6 weeks | First-line alternative; duloxetine also treats neuropathic pain |
| Benzodiazepines: lorazepam, alprazolam, clonazepam | Minutes | Short-term/bridge only; dependence, falls, no abrupt stop |
| Buspirone | 2 to 4 weeks | Scheduled dosing, no dependence, no sedation; not for PRN or panic |
| Hydroxyzine | Within an hour | PRN, non-addictive; sedating and anticholinergic |
| Propranolol | About an hour | Blocks the physical symptoms (tremor, palpitations) of performance anxiety |
SSRIs for the long game, benzos for the bridge, buspirone if you can't use either. Not PRN.
What are the risk factors for developing serotonin syndrome?🚨 DANGER
The main risk factor is COMBINING SEROTONERGIC DRUGS, or starting or increasing the dose of one. The highest-risk combinations are an SSRI or SNRI with an MAOI, with a triptan, with tramadol, with linezolid, or with St John's wort.
- The textbook names the setup precisely: concurrent use of serotonergic drugs, drugs that impair serotonin metabolism (including MAOIs), or antipsychotics and other dopamine antagonists, with SSRIs and SNRIs.
- MAOI plus any other serotonergic drug is the single most dangerous combination and requires a WASHOUT: 14 days between an MAOI and most SSRIs, and 5 WEEKS after fluoxetine because of its long half-life.
- Other risk factors: overdose or intentional ingestion, dose escalation, adding a CYP450 inhibitor that raises the level of a serotonergic drug, and older age or hepatic impairment.
- The full serotonergic drug list: SSRIs, SNRIs, TCAs, MAOIs, trazodone, buspirone, triptans, TRAMADOL, meperidine, fentanyl, dextromethorphan, ondansetron and metoclopramide, lithium, LINEZOLID (an antibiotic that is a weak MAOI), methylene blue, St John's wort, ginseng, MDMA and cocaine.
- Onset is FAST: usually within 6 to 24 hours of the new drug or dose change. That timing is what distinguishes it from neuroleptic malignant syndrome, which develops over days to weeks.
- Prevention: reconcile every medication including OTC cough syrup and herbal supplements, honor washout periods, and teach the patient to tell every prescriber about their antidepressant.
Two serotonin drugs is the setup. MAOI plus anything is the disaster. Wash out 14 days, 5 weeks for fluoxetine.
What signs and symptoms are associated with serotonin syndrome?🚨 DANGER
Three categories, and they come on FAST (within 6 to 24 hours): MENTAL STATUS CHANGES (agitation, confusion, hallucinations, anxiety), AUTONOMIC INSTABILITY (hyperthermia, tachycardia, labile blood pressure, diaphoresis, dilated pupils, diarrhea), and NEUROMUSCULAR HYPERACTIVITY (hyperreflexia, CLONUS, tremor, rigidity, incoordination).
- CLONUS and HYPERREFLEXIA, worst in the lower extremities, are the findings that clinch the diagnosis. Check ankle clonus.
- GI symptoms are part of it and are easy to miss: nausea, vomiting, and diarrhea.
- Treatment: STOP all serotonergic agents immediately, supportive care, IV fluids, BENZODIAZEPINES for agitation and rigidity, active cooling for hyperthermia, and CYPROHEPTADINE as the serotonin antagonist antidote. Severe cases need intubation and paralysis.
- Do NOT give antipyretics for the fever. The hyperthermia comes from muscle activity, not from a raised hypothalamic set point.
- Most cases resolve within 24 hours once the drug is stopped. Severe cases progress to hyperthermia over 41 C, rhabdomyolysis, DIC, seizures, and death.
- Distinguish from neuroleptic malignant syndrome: serotonin syndrome comes on in HOURS with HYPERreflexia, clonus, dilated pupils, and diarrhea. NMS comes on over DAYS with LEAD-PIPE rigidity, HYPOreflexia, and normal pupils.
| Serotonin syndrome | Neuroleptic malignant syndrome |
|---|
| Onset in HOURS (6 to 24) of a new or increased serotonergic drug | Onset over DAYS to weeks after an antipsychotic |
| HYPERreflexia, CLONUS, tremor | LEAD-PIPE rigidity, bradyreflexia |
| Dilated pupils, hyperactive bowel sounds, diarrhea | Normal pupils, normal or decreased bowel sounds |
| Agitation, hypervigilance | Stupor, mutism, altered consciousness |
| Treat: stop drug, benzodiazepines, CYPROHEPTADINE, cooling | Treat: stop drug, DANTROLENE, BROMOCRIPTINE, cooling |
| Resolves in about 24 hours | Takes days to weeks to resolve |
SHIVERS: Shivering, Hyperreflexia, Increased temp, Vital sign instability, Encephalopathy, Restlessness, Sweating.
What are the risk factors for developing serotonin withdrawal (serotonin discontinuation⭐ HIGH YIELD
Antidepressant discontinuation syndrome is caused by STOPPING AN SSRI OR SNRI ABRUPTLY. The strongest risk factors are a SHORT HALF-LIFE (paroxetine and venlafaxine are the worst offenders), treatment for 4 to 6 weeks or longer, a higher dose, and previous episodes of discontinuation symptoms.
- The textbook is explicit: taper the dose when discontinuing, do not stop abruptly. That instruction appears in the boxed-warning row for the SSRIs, SNRIs, and TCAs.
- Half-life is the key variable. Paroxetine and venlafaxine have very short half-lives and cause severe symptoms. FLUOXETINE has a long half-life and an active metabolite, so it self-tapers and rarely causes it.
- Other risk factors: missed doses and poor adherence, a rapid taper, an abrupt switch between agents, and running out of a prescription. Hospital admission with medications held is a common real-world trigger.
- Prevention: taper over weeks to months depending on the drug and duration, using the smallest available dose decrements. Teach the patient never to stop on their own even if they feel better.
- It is NOT relapse and it is NOT addiction. Symptoms start 1 to 4 days after stopping and resolve within 24 hours of restarting the drug, which is how it is distinguished from returning depression (which comes back over weeks).
- The same discontinuation risk applies to benzodiazepines, beta blockers, clonidine, corticosteroids, and opioids. None of them should be stopped abruptly.
Short half-life plus a hard stop equals brain zaps. Paroxetine and venlafaxine are the worst; fluoxetine tapers itself.
What signs and symptoms are associated with serotonin withdrawal?⭐ HIGH YIELD
FINISH: Flu-like symptoms, Insomnia, Nausea, Imbalance (dizziness, vertigo), Sensory disturbances (the classic 'BRAIN ZAPS,' electric-shock sensations, paresthesias), and Hyperarousal (anxiety, agitation, irritability). Onset 1 to 4 days after stopping; duration 1 to 2 weeks.
- The textbook lists the abrupt-discontinuation effects as ANXIETY, INSOMNIA, and increased nervousness.
- Brain zaps are the pathognomonic symptom: brief electric-shock sensations in the head, often triggered by eye movement. Patients rarely volunteer this unless asked.
- Also seen: headache, sweating, tremor, vivid dreams and nightmares, crying spells, confusion, and a low mood that mimics relapse.
- It is unpleasant but not dangerous. The exception is stopping an MAOI, which can cause delirium and severe agitation.
- MANAGEMENT: restart the antidepressant (symptoms resolve within 24 hours, which confirms the diagnosis), then taper slowly. Or switch to fluoxetine and taper from there because of its long half-life.
- Distinguishing it from RELAPSE matters clinically: discontinuation symptoms start within days, include physical and sensory symptoms, and reverse immediately with the drug. Relapse takes weeks, is mostly mood symptoms, and takes weeks to reverse.
FINISH: Flu-like, Insomnia, Nausea, Imbalance, Sensory zaps, Hyperarousal. Days after stopping, gone in a day if you restart.
What clinical features are associated with extrapyramidal symptoms?⭐ HIGH YIELD
Four movement syndromes from DOPAMINE (D2) BLOCKADE: ACUTE DYSTONIA (sustained painful muscle spasms, torticollis, oculogyric crisis, laryngospasm), AKATHISIA (motor restlessness, inability to sit still), PSEUDOPARKINSONISM (tremor, rigidity, bradykinesia, shuffling gait, masklike face), and TARDIVE DYSKINESIA (involuntary lip smacking, tongue thrusting, chewing, and wavelike limb movements).
- They appear in a rough time order: dystonia in hours to days, akathisia in days to weeks, pseudoparkinsonism in weeks to a month, tardive dyskinesia after months to years.
- The textbook defines tardive dyskinesia as involuntary contraction of the oral and facial muscles (such as tongue thrusting) with wavelike movements of the extremities, and notes that EPS is often treated with anticholinergics such as BENZTROPINE and TRIHEXYPHENIDYL.
- ACUTE DYSTONIA IS THE EMERGENCY: laryngeal or pharyngeal spasm can obstruct the airway. Treat with IM or IV benztropine or diphenhydramine immediately.
- TARDIVE DYSKINESIA IS OFTEN IRREVERSIBLE and is made WORSE by anticholinergics. Screen with the AIMS (Abnormal Involuntary Movement Scale) at baseline and regularly. Treat by stopping or switching the drug; valbenazine and deutetrabenazine are approved.
- Causes: first-generation antipsychotics above all (haloperidol, fluphenazine, chlorpromazine), second-generation agents to a lesser degree (risperidone at higher doses is the worst of them), and the non-psychiatric dopamine blockers METOCLOPRAMIDE, prochlorperazine, and promethazine.
- Akathisia is frequently mistaken for worsening psychosis or anxiety and then treated with MORE antipsychotic, which makes it worse. Treat with propranolol, a benzodiazepine, or a dose reduction.
| Type | Onset | Signs | Treatment |
|---|
| Acute dystonia | Hours to about 5 days | Sustained spasm: torticollis, jaw and tongue spasm, oculogyric crisis, laryngospasm | IM/IV benztropine or diphenhydramine. AIRWAY EMERGENCY |
| Akathisia | Days to weeks | Inner restlessness, pacing, rocking, cannot sit still | Propranolol, benzodiazepine, or lower the dose |
| Pseudoparkinsonism | Weeks to about 1 month | Resting tremor, cogwheel rigidity, bradykinesia, shuffling gait, masklike face, drooling | Benztropine, trihexyphenidyl, or amantadine; lower the dose |
| Tardive dyskinesia | Months to years | Lip smacking, tongue thrusting, chewing, grimacing, wavelike limb movements | Often IRREVERSIBLE. Stop/switch drug; valbenazine, deutetrabenazine. Anticholinergics make it WORSE |
Dystonia = stuck. Akathisia = can't sit. Parkinsonism = slow. Tardive = tongue. In that order over time.
What signs and symptoms are associated with neuroleptic malignant syndrome?🚨 DANGER
NMS is a life-threatening reaction to dopamine-blocking drugs. FEVER: high FEVER (often over 40 C), Encephalopathy (altered mental status, stupor, mutism), Vital sign instability (labile BP, tachycardia, tachypnea, diaphoresis), Elevated CPK with myoglobinuria, and lead-pipe RIGIDITY.
- The textbook defines it as a potentially life-threatening adverse effect that includes high fever, unstable blood pressure, and myoglobinemia.
- Onset is over DAYS TO WEEKS, usually within the first 2 weeks of starting or increasing an antipsychotic. Contrast with serotonin syndrome, which develops in hours.
- The rigidity is 'LEAD PIPE': uniform resistance through the whole range of motion, unlike the ratcheting cogwheel rigidity of pseudoparkinsonism.
- Labs: CPK is markedly elevated (often thousands) from muscle breakdown, WBC is elevated, and myoglobinuria threatens ACUTE KIDNEY INJURY. Watch for dark cola-colored urine.
- TREATMENT: STOP the antipsychotic immediately, aggressive cooling, IV fluids to protect the kidneys, and DANTROLENE (a muscle relaxant that stops calcium release) plus BROMOCRIPTINE or amantadine (dopamine agonists) to restore dopamine tone. ICU-level supportive care.
- Causes: first-generation antipsychotics most of all (haloperidol, fluphenazine), but also second-generation agents, metoclopramide, promethazine, prochlorperazine, and ABRUPT WITHDRAWAL of levodopa or another dopamine agonist. The textbook also warns that lithium plus an antipsychotic raises neurotoxicity risk. Mortality is roughly 10 to 20% if unrecognized. Any patient on an antipsychotic with a new fever and rigidity gets NMS ruled out.
FEVER: Fever, Encephalopathy, Vitals unstable, Elevated CPK, Rigidity (lead pipe). Stop the drug, cool them, dantrolene.
How to the expected adverse effects differ between first generation and second-generation⭐ HIGH YIELD
FIRST-GENERATION (typical) antipsychotics cause MOVEMENT problems: extrapyramidal symptoms, tardive dyskinesia, and NMS, plus anticholinergic and orthostatic effects. SECOND-GENERATION (atypical) antipsychotics cause METABOLIC problems: weight gain, hyperglycemia, and hyperlipidemia, with much less EPS.
- The textbook's framing: first-generation drugs block dopamine broadly, producing tranquilizing effect plus adverse effects from blocking alpha-adrenergic, dopamine, endocrine, histamine, and muscarinic receptors. Second-generation drugs block specific D2 AND serotonin-2 receptors, causing fewer adverse effects.
- BOTH generations carry the SAME BOXED WARNING: increased risk of death in ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS, from cardiovascular events and infection. Monitor those patients closely for cardiac events and pneumonia.
- BOTH generations can cause AGRANULOCYTOSIS (the textbook states this for both), NMS, and hypersensitivity reactions, and both cause falls from sedation, motor instability, and postural hypotension.
- Metabolic monitoring for second-generation drugs: weight and BMI, waist circumference, fasting glucose and A1C, and a lipid panel at baseline and periodically. Olanzapine and clozapine are the worst; ziprasidone, aripiprazole, and lurasidone are the most weight-neutral.
- First-generation drugs also cause hyperprolactinemia (galactorrhea, gynecomastia, amenorrhea, sexual dysfunction); among the atypicals, RISPERIDONE does this the most.
- Both classes: avoid alcohol and other CNS depressants, do not drive until the effect is known, space doses evenly, allow SEVERAL WEEKS for full effect, and do not stop abruptly (dizziness, nausea and vomiting, and uncontrolled movements of the mouth, tongue, or jaw). Haloperidol is contraindicated in Parkinson's disease and Lewy body dementia.
| 1st generation (typical) | 2nd generation (atypical) |
|---|
| haloperidol, fluphenazine, chlorpromazine, thiothixene | risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, clozapine |
| HIGH extrapyramidal symptoms and tardive dyskinesia | LOW EPS (risperidone at higher doses is the exception) |
| Higher NMS risk | NMS possible but less common |
| Anticholinergic, sedation, orthostatic hypotension, hyperprolactinemia, photosensitivity | METABOLIC: weight gain, hyperglycemia/new diabetes, hyperlipidemia |
| Better for POSITIVE symptoms (hallucinations, delusions) | Treats positive AND negative symptoms (flat affect, withdrawal, avolition) |
| Cheaper, available as long-acting injections | First-line today; clozapine is reserved for treatment-resistant disease |
| Boxed warning: increased death in elderly with dementia-related psychosis | SAME boxed warning |
Typicals wreck the MOVEMENTS. Atypicals wreck the METABOLISM. Both kill elderly patients with dementia.
What are the pharmacological treatment options for schizophrenia?⭐ HIGH YIELD
SECOND-GENERATION (atypical) antipsychotics are first-line: risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone. First-generation agents (haloperidol, fluphenazine) are alternatives. CLOZAPINE is reserved for TREATMENT-RESISTANT schizophrenia. Long-acting injectables are used when adherence is the problem.
- 'Treatment-resistant' means failure of at least two adequate trials of other antipsychotics. Clozapine is the only drug proven effective there, and it also reduces suicidality, but it requires ANC monitoring for agranulocytosis.
- LONG-ACTING INJECTABLES (LAIs) are given every 2 weeks to every 6 months: risperidone, paliperidone, aripiprazole, haloperidol decanoate, fluphenazine decanoate. They are the answer for repeated relapse from nonadherence.
- It takes SEVERAL WEEKS to see full benefit, and doses should be evenly spaced through the day. Positive symptoms improve first; negative and cognitive symptoms improve slowly if at all.
- For ACUTE agitation, IM haloperidol with lorazepam (with or without diphenhydramine) is common. Long-term, an atypical is preferred.
- Adjuncts: antidepressants for comorbid depression, mood stabilizers for aggression, and benztropine or diphenhydramine to treat EPS. Nonpharmacologic care (case management, family education, supported employment, CBT for psychosis) is part of the plan, not optional.
- Monitor at baseline and on schedule: weight and BMI, fasting glucose and A1C, lipids, blood pressure, AIMS for tardive dyskinesia, and ANC for clozapine. Never stop an antipsychotic abruptly. The textbook adds that patients on lithium AND an antipsychotic must be watched for neurotoxicity (weakness, lethargy, fever, tremulousness, confusion, EPS) and that this should be reported immediately.
Atypical first, clozapine last, long-acting injection when they keep stopping it.
Which medications are indicated for the treatment of both bipolar disorder and seizure⭐ HIGH YIELD
The ANTICONVULSANT MOOD STABILIZERS: VALPROIC ACID/DIVALPROEX, CARBAMAZEPINE, and LAMOTRIGINE. All three treat seizures AND bipolar disorder. (Lithium is a mood stabilizer but is NOT an anticonvulsant.)
- VALPROATE/DIVALPROEX: first-line for acute MANIA and for mixed episodes; also used for generalized, absence, and partial seizures. HEPATOTOXICITY, PANCREATITIS, and TERATOGENICITY (neural tube defects) are boxed warnings. Absolutely avoid in pregnancy. Monitor LFTs, CBC, ammonia, and drug levels (therapeutic 50 to 125 mcg/mL).
- CARBAMAZEPINE: used for bipolar disorder, partial seizures, and trigeminal neuralgia. Boxed warnings for APLASTIC ANEMIA/AGRANULOCYTOSIS and for SJS/TEN, with HLA-B*1502 testing required in patients of Asian ancestry. It AUTO-INDUCES its own metabolism and induces CYP3A4, so it wrecks oral contraceptives, warfarin, and many other drugs. Also causes hyponatremia/SIADH.
- LAMOTRIGINE: best for the DEPRESSED pole of bipolar disorder and for maintenance; also used for partial and generalized seizures. The critical point is the SLOW TITRATION required to avoid STEVENS-JOHNSON SYNDROME. Teach the patient to report ANY rash immediately and never to restart it on their own after a break.
- LITHIUM is the classic mood stabilizer but does NOT treat seizures. Narrow therapeutic index of 0.6 to 1.2 mEq/L; toxicity over 1.5. Maintain consistent sodium and fluid intake; dehydration, low sodium, NSAIDs, ACE inhibitors, and thiazides all raise lithium levels.
- Second-generation antipsychotics (quetiapine, olanzapine, aripiprazole, lurasidone) are also used in bipolar disorder but are not anticonvulsants.
- For any of these, do not stop abruptly: abrupt withdrawal can precipitate seizures or a mood episode.
| Drug | Bipolar role | Seizure role | Biggest danger |
|---|
| Valproic acid / divalproex | Acute mania, mixed episodes | Generalized, absence, partial | Hepatotoxicity, pancreatitis, neural tube defects |
| Carbamazepine | Mania, maintenance | Partial seizures, trigeminal neuralgia | Aplastic anemia/agranulocytosis, SJS/TEN, huge CYP450 induction |
| Lamotrigine | Bipolar DEPRESSION, maintenance | Partial and generalized | STEVENS-JOHNSON SYNDROME - titrate slowly, report any rash |
| Lithium (not an anticonvulsant) | Mania and maintenance; reduces suicide | None | Narrow therapeutic index; toxicity with dehydration, low sodium, NSAIDs |
Valproate, Carbamazepine, Lamotrigine: they calm the seizure AND the mood. Lithium only does the mood.
During general anesthesia, which medications provide sedation and which medications provide🚨 DANGER
SEDATION/hypnosis (unconsciousness and amnesia) comes from PROPOFOL, etomidate, ketamine, midazolam, and the inhaled volatile agents (sevoflurane, desflurane, isoflurane, nitrous oxide). ANALGESIA comes from OPIOIDS: fentanyl, remifentanil, sufentanil, morphine. PARALYSIS comes from NEUROMUSCULAR BLOCKERS: succinylcholine, rocuronium, vecuronium, cisatracurium.
- THE SAFETY POINT: neuromuscular blockers provide NO sedation, NO amnesia, and NO analgesia. A paralyzed patient can be fully awake, in pain, and unable to signal it. Always pair a paralytic with a sedative and an analgesic.
- Propofol is the textbook's example of an IV general anesthetic; it induces anesthesia within about 40 seconds. It causes hypotension and apnea and has NO analgesic properties, so opioids are still required.
- The textbook's three categories of anesthesia: LOCAL (lidocaine injected at the site; EMLA cream is lidocaine plus prilocaine used before IV starts, especially in children), CONSCIOUS SEDATION (midazolam for relaxation plus fentanyl for pain, patient awake and breathing, used for colonoscopy), and GENERAL ANESTHESIA (medication-induced reversible unconsciousness with loss of protective reflexes, requiring airway control).
- Nursing role across all of it: monitor respiratory rate, depth, quality, and SpO2, level of consciousness, and pain, before, during, and after.
- Reversal agents: naloxone for opioids, flumazenil for benzodiazepines, neostigmine with glycopyrrolate or sugammadex for non-depolarizing paralytics. Succinylcholine has NO reversal agent.
- Ketamine is the outlier: it provides sedation AND analgesia AND amnesia while largely preserving airway reflexes and respiratory drive. Malignant hyperthermia is triggered by the volatile inhaled agents and by succinylcholine. Propofol, ketamine, opioids, benzodiazepines, nitrous oxide, and rocuronium are safe alternatives.
| Purpose | Drugs | Note |
|---|
| Sedation / hypnosis / amnesia | propofol, etomidate, midazolam, ketamine, sevoflurane, isoflurane, desflurane, nitrous oxide | Propofol and etomidate give NO pain relief |
| Analgesia | fentanyl, remifentanil, sufentanil, morphine, hydromorphone; ketamine; local anesthetics | Opioids give no amnesia |
| Paralysis | succinylcholine (depolarizing); rocuronium, vecuronium, cisatracurium (non-depolarizing) | NO sedation, NO amnesia, NO analgesia - never give alone |
Sleep, pain, and paralysis are three separate jobs and three separate drugs. Never paralyze someone who is awake.
Clozapine – monitoring🚨 DANGER
Clozapine requires ABSOLUTE NEUTROPHIL COUNT (ANC) monitoring because of the risk of AGRANULOCYTOSIS. Baseline ANC must be 1500/mm3 or higher (1000 or higher for benign ethnic neutropenia), then WEEKLY for 6 months, EVERY 2 WEEKS for the next 6 months, and MONTHLY thereafter for as long as the drug is taken.
- Any fever, sore throat, flu-like symptoms, or mouth ulcers on clozapine means CHECK THE ANC NOW. Teach the patient to report these immediately and never to 'wait and see.'
- Clozapine has FIVE boxed warnings: severe NEUTROPENIA, ORTHOSTATIC HYPOTENSION with bradycardia and syncope, SEIZURES (dose-related), MYOCARDITIS and cardiomyopathy, and increased mortality in elderly patients with dementia-related psychosis.
- SEVERE CONSTIPATION and paralytic ileus can be FATAL and are underappreciated. Assess bowel function at every visit and start a bowel regimen.
- Other monitoring: weight, BMI, fasting glucose and A1C, lipids (it causes the worst metabolic effects of any antipsychotic), blood pressure and pulse with dose titration, and troponin/CRP/echo if myocarditis is suspected (usually in the first 4 to 8 weeks).
- Hypersalivation (sialorrhea) is common and paradoxical for an anticholinergic drug; it is worst at night. Also sedation, tachycardia, and dose-related seizures.
- If the drug is interrupted for 48 hours or more, it must be RETITRATED from a low dose, because tolerance to the hypotension is lost quickly. Note: the FDA eliminated the Clozapine REMS program in February 2025, so the centralized registry no longer exists. The ANC monitoring schedule remains in the drug labeling and is still the standard of care and the exam answer.
| Time on clozapine | ANC monitoring frequency |
|---|
| Before the first dose | Baseline ANC must be 1500/mm3 or higher (1000 or higher if benign ethnic neutropenia) |
| First 6 months | WEEKLY |
| Months 6 to 12 | Every 2 WEEKS |
| After 12 months | MONTHLY, indefinitely |
No blood count, no clozapine. Weekly, biweekly, monthly. Fever or sore throat = check the ANC today.
Ketamine⭐ HIGH YIELD
Ketamine is a DISSOCIATIVE anesthetic that blocks NMDA receptors. Unlike other anesthetics it provides sedation, ANALGESIA, and amnesia while largely PRESERVING airway reflexes, spontaneous respiration, and blood pressure. Used for procedural sedation, induction in hypotensive or asthmatic patients, refractory pain, and (as esketamine) treatment-resistant depression.
- EMERGENCE REACTIONS are the signature adverse effect: vivid unpleasant dreams, hallucinations, delirium, and agitation as the patient wakes up. Reduce them by recovering the patient in a QUIET, DIMLY LIT room with minimal stimulation and tactile contact, and by pretreating or treating with a benzodiazepine (midazolam).
- It INCREASES heart rate, blood pressure, and cardiac output (sympathomimetic), which makes it valuable in shock and hypotension but a poor choice in uncontrolled hypertension, aortic dissection, or severe coronary disease.
- It is a BRONCHODILATOR, so it is the induction agent of choice in status asthmaticus.
- Causes hypersalivation (an antisialagogue such as glycopyrrolate may be given), nystagmus, and increased intraocular pressure. It is one of the SAFE agents in malignant hyperthermia risk.
- Esketamine (Spravato) is an intranasal formulation for treatment-resistant depression and depression with acute suicidality. It carries a REMS: it must be given in a certified health care setting with 2 HOURS of observation, and the patient cannot drive for the rest of the day.
- Ketamine is a Schedule III controlled substance with abuse potential ('Special K'). Chronic misuse causes cystitis and cognitive impairment. Count and waste it per policy.
Ketamine: keeps the airway, keeps the pressure, keeps the pain away. Wake them up in a dark quiet room.
Risperidone & olanzapine⭐ HIGH YIELD
Both are SECOND-GENERATION (atypical) antipsychotics that block D2 and serotonin-2 receptors. RISPERIDONE causes the most EPS and the most HYPERPROLACTINEMIA of the atypicals. OLANZAPINE causes the most WEIGHT GAIN and metabolic syndrome. Both carry the boxed warning for increased mortality in elderly patients with dementia-related psychosis.
- RISPERIDONE is the textbook's prototype atypical: indicated for schizophrenia, acute manic episodes, and irritability associated with autism. At doses above about 6 mg/day it starts behaving like a first-generation drug, with real EPS.
- Risperidone's hyperprolactinemia causes GALACTORRHEA, GYNECOMASTIA, AMENORRHEA, sexual dysfunction, and long-term bone loss. Ask about these directly; patients will not bring them up.
- OLANZAPINE is the metabolic worst case: substantial weight gain, new-onset diabetes, and hyperlipidemia. Monitor weight and BMI, waist circumference, fasting glucose and A1C, and lipids at baseline and on schedule. It is also strongly sedating and anticholinergic.
- IM olanzapine plus IM benzodiazepine should be separated by at least 1 hour because of excessive sedation and cardiorespiratory depression. Olanzapine pamoate (the long-acting injection) requires 3 hours of observation for post-injection delirium/sedation syndrome.
- Both: agranulocytosis is possible, NMS is possible, both cause orthostatic hypotension and falls, both need several weeks for full effect, and neither should be stopped abruptly.
- Both are available as LONG-ACTING INJECTIONS for patients who relapse from nonadherence. Teach both: no alcohol, no driving until the effect is known, evenly spaced doses, rise slowly, and report fever with rigidity (NMS) or any abnormal involuntary movements (tardive dyskinesia).
| Risperidone | Olanzapine |
|---|
| Most EPS of the atypicals, especially above 6 mg/day | Very low EPS |
| Highest PROLACTIN elevation: galactorrhea, gynecomastia, amenorrhea | Little prolactin effect |
| Moderate weight gain | GREATEST weight gain and metabolic syndrome of any atypical |
| Schizophrenia, acute mania, irritability in autism | Schizophrenia, bipolar mania, agitation; also used as an antiemetic |
| Less sedating | Strongly sedating and anticholinergic |
RisperiDONE moves you (EPS and prolactin). OlanZAPine ZAPs your metabolism (weight and sugar).
💉 The drugs 18
💉 AlprazolamHIGH ALERTBLACK BOX
Antianxiety, Benzodiazepine (short/intermediate acting)
What it is for
Anxiety, panic disorders with or without agoraphobia, anxiety with depressive symptoms
How it works
Depresses subcortical levels of CNS, including limbic system, reticular formation, may be mediated by GABA
Watch for
- CNS Dizziness, drowsiness, confusion, headache, stimulation, poor coordination, suicide
- EENT Blurred vision
- GI Constipation, dry mouth, nausea, vomiting, anorexia, diarrhea, weight gain/loss
- GU Decreased libido
- INTEG Rash, dermatitis
Teaching
- Not to double doses; to take exactly as prescribed; if dose is missed, take within 1 hr as scheduled; that product may be taken with food
- Not to use for everyday stress or for more than 4 mo unless directed by prescriber; not to take more than prescribed amount; that product may be habit forming; that memor …
- To avoid OTC preparations unless approved by prescriber, not to use with grapefruit juice
- Not to discontinue medication abruptly after long-term use
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 AtomoxetineBLACK BOX
Psychotherapeutic—miscellaneous (ADHD), Selective norepinephrine reuptake inhibitor
What it is for
Attention-deficit/hyperactivity disorder
How it works
Selective norepinephrine reuptake inhibitor; may inhibit the presynaptic norepinephrine transporter
Watch for
- CNS Insomnia, dizziness, irritability, crying, mood swings, fatigue, lethargy, paresthesia, suicidal ideation
- CV Palpitations, hot flushes, tachycardia, increased B/P, palpitations, orthostatic hypotension, QT prolongation
- GI Dyspepsia, nausea, anorexia, dry mouth, weight loss, vomiting …
Teaching
- To avoid OTC preparations, other medications, herbs, supplements unless approved by prescriber; no tapering needed when discontinuing product
- To avoid alcohol ingestion
- To avoid hazardous activities until stabilized on medication
- To get needed rest; patients will feel more tired at end of day; not to take dose late in day, insomnia may occur
🔗 Full card in the drug guide
💉 BuspironeHIGH ALERT
Antianxiety, sedative, Azaspirodecanedione
What it is for
Generalized anxiety disorders
How it works
Acts by inhibiting the action of serotonin (5-HT); has shown little potential for abuse; a good choice with substance abuse
Watch for
- CNS Dizziness, headache, stimulation, insomnia, nervousness, numbness, paresthesia, incoordination
- CV Tachycardia, palpitations, hypo/hypertension, chest pain
- EENT Sore throat, tinnitus, blurred vision, nasal congestion …
Teaching
- That product may be taken consistently with/without food
- To avoid OTC products, alcohol ingestion, other psychotropic medications unless approved by prescriber; to avoid large amounts of grapefruit juice
- To avoid activities that require alertness because drowsiness may occur
- Not to discontinue medication abruptly after long-term use; if dose is missed, do not double
🔗 Full card in the drug guide
💉 CarbamazepineBLACK BOX
Anticonvulsant, Iminostilbene derivative
What it is for
Tonic-clonic, complex-partial, mixed seizures; trigeminal neuralgia; bipolar disorder
How it works
Exact mechanism unknown; appears to decrease polysynaptic responses and block posttetanic potentiation
Watch for
- CNS Drowsiness, dizziness, fatigue, headache, suicidal thoughts/behaviors
- CV Hypertension, AV block, hypotension
- EENT Dry mouth, blurred vision, diplopia, nystagmus
- ENDO SIADH (geriatric patients)
- GI Nausea, anorexia, increased hepatic enzymes, pancreatitis, hepatotoxicity
- GU Retention …
Teaching
- To carry emergency ID stating patient’s name, products taken, condition, prescriber’s name, and phone number
- To avoid driving, other activities that require alertness usually for the first 3 days of treatment; dizziness, drowsiness may occur
- Not to discontinue medication quickly after long-term use; seizures may occur
- To immediately report chills, rash, light-colored stools, dark urine, yellowing of skin and eyes, abdominal pain, sore throat, mouth ulcers, bruising, blurred vision, diz …
🔗 Full card in the drug guide
💉 DiazepamHIGH ALERTBLACK BOX
Antianxiety, anticonvulsant, skeletal muscle relaxant, central acting, Benzodiazepine, lon
What it is for
Anxiety, acute alcohol withdrawal, adjunct for seizure disorders; preoperatively as a relaxant for skeletal muscle relaxation; rectally for acute repetitive seizures
How it works
Potentiates the actions of GABA, especially in the limbic system, reticular formation; enhances presympathetic inhibition, inhibits spinal polysynaptic afferent paths
Watch for
- CNS Dizziness, drowsiness, headache, hangover, slurred speech, paradoxical excitation
- CV Hypotension, tachycardia
- EENT Blurred vision
- GI Constipation, nausea, vomiting, diarrhea, weight gain
- INTEG Rash, dermatitis, itching, phlebitis (IV) …
Teaching
- That product may be taken with food
- That product not to be used for everyday stress or for >4 mo unless directed by prescriber; to take no more than prescribed amount; that product may be habit forming, rev …
- To avoid OTC preparations unless approved by prescriber
- To avoid driving, activities that require alertness; drowsiness may occur
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 FluoxetineBLACK BOX
Antidepressant, SSRI (selective serotonin reuptake inhibitor)
What it is for
Major depressive disorder, obsessive-compulsive disorder (OCD), bulimia nervosa, premenstrual dysphoric disorder (PMDD), panic disorder Unlabeled: Binge eating disorder, body dysmorphic disorder, fibromyalgia, generalized anxiety disorder …
How it works
Inhibits CNS neuron uptake of serotonin but not of norepinephrine
Watch for
- CNS Headache, nervousness, insomnia, drowsiness, anxiety, tremor, dizziness, fatigue, sedation, poor concentration, abnormal dreams, agitation, seizures, apathy, euphoria, hallucinations, delusions, psychosis, suicidal ideation, neuroleptic malignant syndrome–like reactions
- CV Hot flashes …
Teaching
- That therapeutic effect may take 1-4 wk, not to discontinue abruptly, that follow-up will be required
- To use caution when driving, performing other activities requiring alertness because of drowsiness, dizziness, blurred vision
- To avoid alcohol, other CNS depressants
- To notify prescriber if pregnant, planning to become pregnant, or breastfeeding
🔗 Full card in the drug guide
💉 Gabapentin
Anticonvulsant, GABA analogue
What it is for
Adjunct treatment of partial seizures, with/without generalization in patients >12 yr; adjunct for partial seizures in children 3-12 yr, postherpetic neuralgia, primary restless leg syndrome in adults, ALS, neuropathic pain
How it works
Mechanism unknown; may increase seizure threshold; structurally similar to GABA but does not bind to GABAa or GABAb; gabapentin binding sites in neocortex, hippocampus
Watch for
- CNS Dizziness, fatigue, somnolence, ataxia, amnesia, abnormal thinking, depression; children 3-12 yr old, emotional lability, aggression, thought disorder, hyperkinesia, hostility
- CV Vasodilation, peripheral edema
- EENT Dry mouth, blurred vision, diplopia, nystagmus …
Teaching
- To carry emergency ID stating patient’s name, products taken, condition, prescriber’s name and phone number
- To avoid driving, other activities that require alertness until response is known because dizziness, drowsiness may occur
- Not to discontinue medication quickly after long-term use; to taper over ≥1 wk because withdrawal-precipitated seizures may occur; not to double doses if dose is missed; …
- To report changes in vision, diplopia, eye irritation to provider
🔗 Full card in the drug guide
💉 LamotrigineBLACK BOX
Anticonvulsant—miscellaneous, Phenyltriazine
What it is for
Adjunct for the treatment of partial, tonic-clonic seizures; children with Lennox-Gastaut syndrome, bipolar disorder
How it works
Inhibits voltage-sensitive sodium channels, thus decreasing seizures
Watch for
- CNS Dizziness, ataxia, headache, fever, insomnia, tremor, depression, anxiety, suicidal ideation, seizures, poor concentration
- EENT Nystagmus, diplopia, blurred vision
- GI Nausea, vomiting, anorexia, abdominal pain, hepatotoxicity
- GU Dysmenorrhea
- HEMA Anemia, DIC, leukopenia …
Teaching
- To take PO doses divided, with or after meals to decrease adverse effects; not to discontinue product abruptly because seizures may occur
- To avoid hazardous activities until stabilized on product
- To carry emergency ID; to notify prescriber of skin rash, increased seizure activity; to use sunscreen, protective clothing if photosensitivity occurs
🔗 Full card in the drug guide
💉 Lidocaine (What are the signs/symptoms of toxicity?)HIGH ALERT
Antidysrhythmic (Class Ib), Aminoacyl amide
What it is for
Ventricular tachycardia, ventricular dysrhythmias during cardiac surgery, digoxin toxicity, cardiac catheterization Unlabeled: Attenuation of intracranial pressure increased during intubation/endotracheal tube suctioning
How it works
Increases electrical stimulation threshold of ventricle, His-Purkinje system, which stabilizes cardiac membrane, decreases automaticity
Watch for
- CNS Headache, dizziness, involuntary movement, confusion, tremor, drowsiness, euphoria, seizures, shivering
- CV Hypotension, bradycardia, heart block, CV collapse, arrest
- EENT Tinnitus, blurred vision
- GI Nausea, vomiting, anorexia
- HEMA Methemoglobinemia
- INTEG Rash, urticaria, edema, swelling …
Teaching
- About the use of automatic lidocaine injection device if ordered for personal use
- To report signs of toxicity immediately
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Lithium (What are the signs/symptoms of toxicity? What are the monitoring requirements?)BLACK BOX
Mood stabilizer, Alkali metal ion salt
What it is for
Bipolar disorders (manic phase), prevention of bipolar manicdepressive psychosis
How it works
May alter sodium, potassium ion transport across cell membrane in nerve, muscle cells; may balance biogenic amines of norepinephrine, serotonin in CNS areas involved in emotional responses
Watch for
- CNS Headache, drowsiness, dizziness, tremors, twitching, ataxia, seizure, slurred speech, restlessness, confusion, stupor, memory loss, clonic movements, fatigue
- CV Hypotension, ECG changes, dysrhythmias, circulatory collapse, edema, Brugada syndrome, QT prolongation
- EENT Tinnitus …
Teaching
- About the symptoms of minor toxicity: vomiting, diarrhea, poor coordination, fine motor tremors, weakness, lassitude; major toxicity: coarse tremors, severe thirst, tinni …
- To monitor urine specific gravity, emphasize need for follow-up care to determine lithium levels; to monitor lithium levels to ensure effective levels and treatment
- Not to operate machinery until lithium levels are stable
- To use emergency ID with diagnosis, product used
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 MethylphenidateBLACK BOX
Cerebral stimulant, Piperidine derivative
What it is for
Attention deficit disorder (ADD), attention-deficit/hyperactivity disorder (ADHD); narcolepsy (except Concerta, Metadate CD, Ritalin LA)
How it works
Increases release of norepinephrine, DOPamine in cerebral cortex to reticular activating system; exact action not known
Watch for
CNS: Hyperactivity, insomnia, restlessness, talkativeness, dizziness, drowsiness, toxic psychosis, headache, akathisia, dyskinesia, masking or worsening of Tourette’s syndrome, seizures, hallucinations, malignant neuroleptic syndrome, aggression …
Teaching
- To decrease caffeine consumption (coffee, tea, cola, chocolate); may increase irritability, stimulation; not to use guarana, yerba maté, cola nut
- To avoid OTC preparations unless approved by prescriber
- To always use dosing dispenser provided for oral suspension dose
- To taper off product over several weeks because depression, increased sleeping, lethargy will occur
🔗 Full card in the drug guide
💉 Phenelzine (What dietary restrictions should the client follow?)BLACK BOX
Antidepressant, Monoamine oxidase inhibitor (MAOI)
What it is for
Depression that has not responded to other antidepressants; described on the label as atypical, nonendogenous or neurotic depression. It is a later-line drug, not a first choice.
How it works
Blocks monoamine oxidase — the enzyme that breaks down serotonin, norepinephrine and dopamine — IRREVERSIBLY and non-selectively. It destroys the enzyme rather than just occupying it, so the body has to build new enzyme before normal breakdown resumes.
Watch for
- CNS Dizziness, drowsiness, insomnia, tremor, hyperreflexia, toxic delirium.
- CV Orthostatic hypotension in ordinary use — and a dangerous pressure SPIKE in hypertensive crisis. Edema.
- GI Nausea, constipation, weight gain.
- GU Sexual dysfunction, urinary retention.
Teaching
- TYRAMINE IS THE ONE TO KNOW. Aged cheese, cured or smoked meat, pickled herring, liver, yogurt, meat or yeast extracts, sauerkraut, soy sauce, draft and craft beer, red wine, and any protein food that has been left out or stored badly. Tyramine plus an MAOI causes a hypertensive crisis.
- Non-alcoholic beer and wine are NOT a safe substitute — the label restricts those too.
- The food and drug rules continue for TWO FULL WEEKS after the last dose. The enzyme was destroyed, not merely blocked, and the body has to rebuild it.
- Hypertensive crisis: a sudden OCCIPITAL headache that may spread forward, stiff or sore neck, palpitations, sweating, nausea and vomiting, dilated pupils, light sensitivity, chest pain. The pulse may be FAST OR SLOW — do not rule it out because the heart rate is low. Emergency.
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Phenytoin (What are the signs/symptoms of toxicity?)BLACK BOX
Anticonvulsant; antidysrhythmic (IB), Hydantoin
What it is for
Generalized tonic-clonic seizures; status epilepticus; nonepileptic seizures associated with Reye’s syndrome or after head trauma; complex partial seizures Unlabeled: Digoxin toxicity; seizures, prophylaxis in head trauma, subarachnoid hemorrhage
How it works
Inhibits spread of seizure activity in motor cortex by altering ion transport; increases AV conduction
Watch for
- CNS Dizziness, insomnia, paresthesias, depression, suicidal tendencies, aggression, headache, confusion, slurred speech, peripheral neuropathy
- CV Hypotension, ventricular fibrillation, bradycardia, cardiac arrest
- EENT Nystagmus, diplopia, blurred vision
- ENDO Diabetes insipidus
- GI Nausea …
Teaching
- That, if diabetic, blood glucose should be monitored
- That urine may turn pink
- Not to discontinue product abruptly because seizures may occur
- Oral hygiene: about the proper brushing of teeth using a soft toothbrush, flossing to prevent gingival hyperplasia; about the need to see dentist frequently
🔗 Full card in the drug guide
💉 Pregabalin
Anticonvulsant, γ-Aminobutyric acid (GABA) analog
What it is for
Neuropathic pain associated with spinal cord injury/diabetic peripheral neuropathy, partial-onset seizures, postherpetic neuralgia, fibromyalgia
How it works
Binds to high-voltage–gated calcium channels in CNS tissues; this may lead to anticonvulsant action similar to the inhibitory neurotransmitter GABA; anxiolytic, analgesic, and antiepileptic properties
Watch for
- CNS Dizziness, drowsiness abnormal thinking, suicidal ideation
- EENT Dry mouth, blurred vision, sinusitis
- GI Constipation, abdominal pain, weight gain, nausea, vomiting, increased appetite
- GU Gynecomastia
- HEMA Thrombocytopenia
- MS Back pain, rhabdomyolysis, myopathy
- OTHER Pruritus …
Teaching
- To carry emergency ID stating patient’s name, products taken, condition, prescriber’s name and phone number
- To avoid driving, other activities that require alertness because dizziness, drowsiness may occur, to obtain clearance from provider if driving is acceptable
- Not to discontinue medication quickly after long-term use; to taper over ≥1 wk; that withdrawal-precipitated seizures may occur; not to double doses if dose is missed, to …
- To notify prescriber if pregnancy is planned or suspected; to avoid breastfeeding
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 PropofolHIGH ALERT
General anesthesia, Phenol derivative
What it is for
Induction or maintenance of anesthesia as part of balanced anesthetic technique; sedation in mechanically ventilated patients
How it works
Produces dose-dependent CNS depression by activation of GABA receptor, hypnotic
Watch for
- CNS Involuntary movement, headache, fever, dizziness, shivering, abnormal dreams, euphoria, fatigue
- CV Bradycardia, hypotension, hypertension
- GI Nausea, vomiting, abdominal cramping, dry mouth
- GU Urine retention, green urine, phlebitis, hives, burning/stinging at inj site, rash
- RESP Apnea …
Teaching
- That product will cause dizziness, drowsiness, sedation; to avoid hazardous activities until drug effect wears off
- That drug may cause burning sensation during administration
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Valproic acid (What are the monitoring requirements?)BLACK BOX
Anticonvulsant, vascular headache suppressant, Carboxylic acid derivative
What it is for
Simple (petit mal), complex (petit mal), absence, mixed seizures; manic episodes associated with bipolar disorder, prophylaxis of migraine, adjunct for schizophrenia, tardive dyskinesia, aggression in children with ADHD, organic brain syndrome, mania …
How it works
Increases levels of γ-aminobutyric acid (GABA) in the brain, which decreases seizure activity
Watch for
- CNS Sedation, drowsiness, dizziness, headache, depression, behavioral changes, tremors, aggression, weakness, coma, suicidal ideation, hypothermia
- CV Peripheral edema
- EENT Visual disturbances, taste perversion
- GI Nausea, vomiting, constipation, diarrhea, dyspepsia, anorexia, pancreatitis …
Teaching
- To avoid driving, other activities that require alertness
- To drink plenty of fluids
- To discuss with health care professional all OTC, Rx, herbals, supplements taken
- Not to discontinue medication quickly after long-term use, seizures may result; to take as directed; not to skip, double doses; not to chew capsules; to take with milk to …
🔗 Full card in the drug guide
💉 VenlafaxineBLACK BOX
Antidepressant—SNRI, SNRI
What it is for
Prevention/treatment of major depression; depression at the end of life; long-term treatment of general anxiety disorder, panic disorder, social anxiety disorder (Effexor XR only) Unlabeled: Vasomotor symptoms in menopause, andropause, fibromyalgia
How it works
Potent inhibitor of neuronal serotonin and norepinephrine uptake, weak inhibitor of dopamine; no muscarinic, histaminergic, or α-adrenergic receptors in vitro
Watch for
- CNS Emotional lability, dizziness, weakness, headache, hallucinations, insomnia, anxiety, suicidal ideation in children/adolescents, seizures, neuroleptic malignant syndrome–like reaction, anxiety, abnormal dreams, paresthesia
- CV Hypertension, chest pain, tachycardia, change in QTc interval …
Teaching
- To notify prescriber of rash, hives, allergic reactions, bleeding
- To use with caution when driving, performing other activities requiring alertness because of drowsiness, dizziness, blurred vision
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 ZolpidemHIGH ALERTBLACK BOX
Hypnotic, Imidazopyridine
What it is for
Insomnia, short-term treatment
How it works
Produces CNS depression at limbic, thalamic, hypothalamic levels of CNS; may be mediated by neurotransmitter γ-aminobutyric acid (GABA), not a benzodiazepine …
Watch for
CNS: Headache, lethargy, drowsiness, daytime sedation, dizziness, confusion, lightheadedness, anxiety, irritability, amnesia, poor coordination, complex sleep-related reactions (sleep driving, sleep eating), depression, somnolence, suicidal ideation …
Teaching
- That dependence is possible after long-term use
Antidote / reversal: 1
🔗 Full card in the drug guide
Nothing matched that. Try a shorter word.
Where this came from. The drug cards come from your own drug guide, fact-checked against FDA labeling. The explanations were written from your course textbook,
Pharmacology (WTCS, 2e). If anything here contradicts your instructor, believe your instructor — they write the exam.