Like Tylenol® for Tumors
The role of medications in complex bio-psycho-social
situations
himanshua@nwpltd.org
Family history
Family history
In-utero exposure
Family history
Psychological Abuse
In-utero exposure
Family history
Psychological Abuse
In-utero exposure
Drugs
Family history
Psychological Abuse
In-utero exposure
Drugs
The BioPsychoSocial Model of Treatment
Biological Factors
Genes, Chemicals,
Cells and Molecules
Psychological
Factors
Defenses, ego
strengths,
temperament,
trauma, insight
Social Factors
Family, Friends,
Employment,
Finance,
Housing,
Community
Brain Stuff
DOPAMINE
•Aggression
•Schizophrenia
•Parkinsonism
•Chemical Dependency
•Huntington’s Disease
SEROTONIN
•Rigid Thinking
•Depression & Anxiety
•Sleep Disorders
•Amotivational Syndrome
•Sexual Side Effects
•Gastrointestinal Tract
NOR-ADRENALINE
•ADHD
•Anxiety
•‘Fight or Flight’ response
Under the Microscope – Neurons
No Cure YET !
No Cure YET !
CANCER
DIABETES
ASTHMA
HYPERTENSION
General Principles With All Meds
No ‘Brain Biopsy’ services available….yet
 Double Edged Sword - Risk vs. Benefit
 Start Low, Go Slow - Lowest possible
effective dose

General Principles With All Meds



Keep assessing
– Is it doing what it’s supposed to be doing ?
3 meds,3 times a day - goodbye compliance!
Meds are often used for symptoms, not just
illnesses
Treat the Symptoms !
ADHD
BPAD
Depression
Anxiety d/o
Irritability
+
+
+
+
Increased
activity
+
+
Emotional
Outbursts
+
+
+
+
+
+
+
Poor Sleep
+
Distractibility
+
+
+
Impulsivity
+
+
+
Talkativeness
+
+
Crying spells
+
+
+
Suicidal
thoughts
+
+
+
Special Considerations
Celexa (Citalopram)
Special Considerations
Special Considerations
Celexa (Citalopram)
Special Considerations
Celexa (Citalopram)
Special Considerations
Lexapro (Escitalopram)
“How does this affect my
depression, Willis?”
“Practice-based evidence*”
* Presenter’s subjective opinion- please don’t sue me Forest Pharmaceuticals !
Mood Stabilizers
Medication
Why you might choose it
Lithium
•Classic bipolar I
•Suicide risk
•Very inexpensive
valproate/Depakote
•Rapid cycling, BPAD –II , Cyclothymia
carbamazepine/Tegretol
•Rapid cycling
•Severe sleep problems
•Can't take Depakote ,Can't afford Trileptal,
oxcarbazepine/Trileptal
•Alternative to Depakote as a starting place
•Low long-term risk is appealing
lamotrigine/Lamictal
•Depression is the dominant symptom
•Afraid of weight gain
olanzapine/Zyprexa
•Emergency-level symptoms
•Can use "as-needed" , fast acting
clozapine
•Tried everything else for severe symptoms
•one of the most effective medications we have
Specific principles during crisis
evaluations

Drug intoxication
–
–

Drug withdrawal
–


New meds
Recent increase
Recent reduction
Drug interactions
Drug compliance
–
Do not accept ANY vague answers 
Here we go…
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Wellbutrin
Zoloft
Lexapro
Celexa
Effexor
Cymbalta
Buspar
Paxil
Remeron
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Wellbutrin
Zoloft
Lexapro
Celexa
Effexor
Cymbalta
Buspar
Paxil
Remeron
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Lithium
Anticonvulsants
Haldol
Seroquel
Zyprexa
Abilify
Geodon
Risperidone
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Wellbutrin
Zoloft
Lexapro
Celexa
Effexor
Cymbalta
Buspar
Paxil
Remeron
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Ritalin
Adderall
Dexedrine
Focalin
Concerta
Vyvanse
Strattera
Clonidine
Tenex
Intuniv
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Lithium
Anticonvulsants
Haldol
Seroquel
Zyprexa
Abilify
Geodon
Risperidone
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Wellbutrin
Zoloft
Lexapro
Celexa
Effexor
Cymbalta
Buspar
Paxil
Remeron
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Ritalin
Adderall
Dexedrine
Focalin
Concerta
Vyvanse
Strattera
Clonidine
Tenex
Intuniv
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Lithium
Anticonvulsants
Haldol
Seroquel
Zyprexa
Abilify
Geodon
Risperidone
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Trazodone
Lorazpam
Propranolol
Cogentin
Where should we start ?
Attention Deficit /Hyperactivity Disorder
If treatment is working…




Improved attention and ability to concentrate
Reduced hyperactivity
Fewer behavioral problems and outbursts
Improved performance at school
Two major groups
1.
2.
Stimulants
Non- Stimulants
Stimulants
Dosing
 Long acting - take once in morning
 Short acting - may be taken up to three times/day
 Out of your system within the day (Drug holidays?)
Indications
 ADHD
 Narcolepsy
Generic class
Brand names
Duration
Methylphenidate, short-acting
Ritalin®
Methylin®
2-4 hours
Methylphenidate, intermediateacting
Ritalin SR
Metadate® ER
Methylin ER
5 hours
Methylphenidate, long-acting
Concerta®
Daytrana (9 hrs)
Ritalin LA
8 -12 hours
Dextroamphetamine, shortacting
Dexedrine®
Dextrostat®
5 hours
Dextroamphetamine, long- acting Dexedrine spansule
Vyvanse
6-12 hours
Mixed Amphetamine Salt (MAS),
intermediate-acting
Adderall®
5 hours
MAS, long-acting
Adderall-XR
9 hours
Specific Stimulants

Ritalin (Methylphenidate)
–
–
–

Short Acting (2-4 hrs)
Generic
Available in solution form
Adderall
–
–
Stronger efficacy, stronger side effects
(headaches, loss of appetite, stomachaches)
Generic
Concerta - OROS technology
Specific Stimulants

Daytrana
(Methyphenidate
transdermal
patch system)
–
–
Absorbed by the
skin gradually
over 9 hours
Effect lasts for 3
hours after patch
removed
Specific Stimulants

Vyvanse (Lis-dexamfetamine)
–
–
–
–
Dexedrine with an amino acid (Lysine)
attached to it
The amphetamine is inactive until the
amino acid gets detached by liver
Smoother effect
Theoretically, one cannot get ‘high’
Stimulants

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•
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Side effects
Reduced appetite, Weight Loss
Rebound Headache
Jittery feeling, Irritability , “Zombie”, “loss of
personality”
Gastrointestinal upset
Difficulty with sleep
Tics and repetitive movements
May precipitate crisis calls
Stimulants
 Contraindication
 Eating Disorder
• Caution
• Psychosis
• Bipolar disorder
• Anxiety
• FAS
• Autism
Non stimulants




Atomoxetine
Clonidine, Tenex and Intuniv
Wellbutrin
Atypical Antipsychotics
Atomoxetine (Strattera)
a Selective Nor Epinephrine Reuptake Inhibitor.
Indications
–
–
ADHD
? Adjunct in Depression
Dosage
–
–
–
Needs to be taken everyday
Takes weeks to start working
target = 1.2 mg/kg in one/two doses
Side Effects
–
–
–
Nausea - Try Eggs, Peanut Butter, Pepto bismol
Sleepiness
Urinary Retention
Alpha-2 agonists
Clonidine (Catapres)




Up to two divided doses
9 times more potent than Tenex
Sedation
Withdrawal may precipitate crisis
Guanfacine (Tenex)


May give up to three divided doses
Less sleepiness
Alpha-2 agonists
Guanfacine Extended Release
(Intuniv)
•
•
•
Brand new
Once a day dosing
1-4 mg daily dose
Aggression
Aggression




Atypical Antipsychotics
Clonidine and Tenex
Lithium
Anti- Seizure medications
If treatment is working…
–
–
–
–
–
Calmer, less disruption , fewer outbursts
Improved concentration, restlessness
Improvement in irritability, behavioral problems
Better Grades
Fewer Time Outs
Atypical Antipsychotics
Clozapine Clozaril
Risperidone Risperdal
Risperdal M-tab Risperdal Consta
Olanzapine Zyprexa Zyprexa Zydis
Quetiapine Seroquel
Ziprasidone Geodon
Aripiprazole Abilify
Paliperidone Invega
General Side Effects







Dry Mouth
Blurry Vision
Weight Gain
Constipation
Diabetes / Increased Blood Sugars
Increased Cholesterol
Note- smoking reduces blood levels
Acute Dystonic Reactions




Sudden
Dramatic, frightening
Very uncommon with 2nd
generation antipsychotics
Quickly reversible
Pseudo- Parkinsonism
‘Zombie’ ?
 Very uncommon with
SGAs
 Reversible
 Treatable
 Always weigh risk vs
benefits

Akathisia




A subjective feeling
Restlessness, ‘I feel like I want to jump
out of my skin’
May precipitate crisis call
Very uncomfortable but it can be
managed
Tardive Dyskinesia






Slow, writhing Involuntary movements
Usually affect face, neck, hands & feet
Risk increases with duration of treatment
Risk lower with newer meds
Monitor- DISCUS/AIMS (5 min)
Always weigh risks vs benefits
Clozapine (Clozaril)

Potent but toxic

If you need to stop, Gradually taper over 1-2 weeks

Weekly CBC
Sedation, Drooling, Constipation
Smoking reduces Clozaril Levels


Risperidone
(Risperdal – M tab - Consta)




Available in many forms
Risperdal Consta – 12.5 -25 mg / 2 weeks; takes 3-6
weeks to start acting
Sleepiness, Milky discharge, Problems with Menses
More likely to cause Dystonia & Parkinson’s-like
side effects
Quetiapine
( Seroquel - Seroquel XR)




Wide range of dosage (25 mg to 1400mg)
Helpful for anxiety
Sleepiness
Reduced Blood Pressure
Ziprasidone (Geodon)



Sleepiness OR restlessness/activation
Get an EKG before starting
Take with Food
Olanzapine
(Zyprexa - Zyprexa Zydis)



Tablet, Orally disintegrating tab, Intramuscular shot
Sleepiness, Weight gain
Diabetes
Aripiprazole
(Abilify – Discmelt)

May be Activating in certain pts.
Paliperidone (Invega)



OROS
Related to Risperdione
New baby on the block
BIPOLAR DISORDER
If treatment is working…



Fewer, less severe periods of mania (or
hypomania) and depression
Fewer day to day emotional lability, mood
swings
Less disruption, better functioning
Lithium
(Eskalith – Eskalith CR - Lithobid - Lithium
Carbonate - Lithium Citrate Solution )




Main Indication – Bipolar Disorder
Dose :Target Li level 0.8 – 1.4 mEq/L
:Start 300 mg, usually up to 1800
mg in two divided doses
Precautions –Avoid dehydration, NSAIDS (Tylenol,
Sulindac OK), Many BP meds
Regular blood tests
Common Side Effects





Increased frequency of urination
Fine Tremor
Cognitive Slowing
Diarrhea
Nausea, Vomiting
Valproic acid
syrup - Depakote delayed release tab Depakote sprinkle caps Depakote EC tab





Main Indication – Bipolar Disorder
Dose :Target Depakote level 40 -100 mcg /ml
Extended release form available –once a night
Regular Blood Tests
Beware –Failure of BCP
Common Side effects






tiredness
dizziness
Nausea, vomiting
tremor
hair loss, acne
weight gain
Lamotrigine
(Lamictal)




Very Gradual increase (over weeks) to avoid Rash
Taper over 2 weeks
Caution – Depakote, Tegretol & BCPs may increase
levels of Lamictal
Any rash with Lamictal should be taken seriously
Topiramate
(Topamax)
Neutralizes / Negates weight gain – used
in combos
 ‘Dope-a-max’

Other Mood Stabilizers…

Carbamazepine (Tegretol)

Oxcarbamazepine (Trileptal)

Gabapentin (Neurontin)
ANXIETY DISORDERS
Anti Anxiety Meds


First Line – SSRIs, SNRIs
Others
- Benzodiazepines
- Antihistamines
Benadryl, Vistaril
- Propranolol, Atenolol
If treatment is working…




Improvement in mood and sense of well being
Less fixated / rigid / preoccupied
Improved sleep and appetite
Better functioning at school and home
SNRIs




Act on Nor Epinephrine in addition to Serotonin
- ? Better for anxiety
Main Indications – Anxiety, Depression,
Diabetic Neuropathy, ? ADHD
May cause increase in blood pressure
Withdrawal may precipitate crisis call
SNRIs
Venlafaxine Effexor Effexor XR



Capsules
Usual Dose 37.5 mg -225 mg in up to two doses
Taper slowly to avoid Withdrawal
Pristiq (Desvenlafaxine)
 Metabolite of Venlafaxine
 Single daily dosage of 50 mg

Taper slowly to avoid Withdrawal
Duloxetine Cymbalta


Capsules
Usual Dose -40 to 60 mg in two divided doses
Benzodiazepines



Main Indications
- Panic Disorder
- Social Phobia
- Generalized Anxiety Disorder
- Used as Sleep Aid
Use for short periods to avoid tolerance
Taper slowly - Sudden withdrawal is dangerous
(Seizures, arrhythmias)- may precipitate crisis call
Benzos
SHORT ACTING
Half Life
Usual Dose
Triazolam Halcion
2 Hours
0.125 -0.5 mg at
bedtime
Temazepam Restoril
8
7.5 – 30 mg at bedtime
Alprazolam Xanax
6
0.25 -0.5 mg TID (Max
4mg)
Lorazepam Ativan
10
1 – 6 mg in 2 or 3 div
doses
Clonazepam Klonopin
18
0.5 – 2 mg up to 2 div
doses
Alprazolam Xanax XR
12
3 – 6 mg once a day
Diazepam Valium
30
2 -10 mg
MEDIUM ACTING
LONG ACTING
Beta Blockers
Block Physical symptoms of anxiety
 Use with Caution in Diabetics, asthmatics
 Side Effects – lower blood pressure & heart rate,
sleepiness, ? Depression
 Taper slowly to avoid rebound increase in BP
Propranolol Inderal
 Usually 20 mg BID, or as needed
Atenolol Tenormin
 50 -100 mg in up to two divided doses

Buspirone
(Buspar)


Indication –Generalized Anxiety Disorder
Common Side Effects –light headedness, Insomnia,
Headache
SSRIs
SSRIs - Indications

Mood disorders


Anxiety disorders


Depression
PTSD, GAD, OCD, Elective mutism,
Social phobia, Separation anxiety
Developmental disorders

Autism, FAS

All developmental disorders with repetitive behaviors
If treatment is working…


Autism, FAS
 Improvement in perseveration /rigidity/ compulsive
behavior
 Better with transitions, calmer
Depression
 Improvement in mood and sense of well being
 less irritable
 fewer headaches and stomachaches
 Improved sleep and appetite
 Resolution/improvement of suicidality
 Better grades, invested in relationships
Trade
name
Generic
Available As
Dose
Range
(mg)
Comments
Celexa
Citalopram
Tab, Solution
2.5 -40
generic
Prozac
Fluoxetine
Tab, Solution
5 - 40
Longest half
life;
Paxil
Paroxetine
Tab, liquid
5 - 40
Withdrawal,
sleepy,
weight gain
Zoloft
Sertraline
Tab,
Concentrate
25 - 200
Sexual side
effects
Lexapro
Escitalopram
Tab, Solution
2.5 - 20
Newest
SSRI
Luvox
Fluvoxamine
Tab
25 – 300 Headache,
insomnia
Other Antidepressants
Bupropion
(Budeprion - Wellbutrin SR – Wellbutrin XLZyban)



Main Indications –Depression, ADHD, Smoking
Cessation Aid
Common Side Effects – agitation, Insomnia.
Good Sexual Side Effect Profile – used as adjunct to
SSRIs
Tricyclic Antidepressants

Commonly Used Ones




Clomipramine (OCD) (Anafranil)
Amitriptyline (Elavil )
Nortriptyline (Pamelor- Aventil)
Desipramine

Main Indications – Adjuncts to depression, as Sleep
aids, Bed Wetting, Chronic Pain

“Dirty Drugs” –
dangerous in overdose
Selegiline Transdermal system
(Emsam)



MAO inhibitors make a come back !
Safe in lower dose (6 mg), dietary restrictions with
higher dose
May be better for ‘atypical depression’ (weight gain,
oversleeping)
Mirtazapine
(Remeron)




Tab, Orally disintegrating tab
Main Indication – Depression, Sleep Aid
Usual Dose 7.5 mg – 45 mg at night
Side Effects - Sleepiness and weight gain,
especially with lower doses!
Antidepressants and crisis calls


Suicidality (FDA black box warning)
Manic switching
–
–
–
–
–

Decreased Need for sleep
Rages/ severe irritability
Grandiosity, disinhibition, hypersexuality
Change in distractibility, talkativeness
Family history of BPAD
FAS, Autism, MR
Alzheimer’s Dementia


Beware of drug-drug interactions
Donepezil (Aricept)
–
–
–

For all stages of dementia
5-10 mg daily
Nausea
Memantine (Namenda)
–
–
–
For moderate to severe dementia
Titrate up to 10 mg BID
Dizziness
Meds to counteract side effects
from other meds!
Insomnia
Techniques to ensure good sleep
hygiene
Benadryl / Melatonin
(if difficulty falling asleep)
Trazodone /Melatonin SR/ Ambien –
CR
(if difficulty staying asleep)
Clonidine/Seroquel / Remeron / Paxil
(Two birds, one stone)
Trazodone




Weak Antidepressant in higher doses
Used for side effect of sleepiness
Watch out for early morning grogginess
Rare - priapism in males - take to ER!
SGA –induced Extra Pyramidal
Side Effects

Cogentin (Benztropine)
–

Benadryl
–

Dry mouth, constipation, urinary retention,
confusion
Dry mouth, sedation
Lorazepam
–
Sedation, agitation
Lithium-induced tremor

Lorazepam/ Clonazepam
–

Sedation, agitation
Propranolol
SGA induced weight gain

Metformin
–
–
Diarrhea, nausea
Lactic acidosis
“Is there a Generic for that?”
Depression/
Anxiety
Celexa
Wellbutrin SR and XL
Prozac
Zoloft
Paxil
Effexor XR
Inderal
Remeron
Antipsychotics
Risperdal
Mood
Stabilizers
ADHD
Depakote ER
Adderall
Dexedrine
spansule
Eskalith
Ritalin
Lamictal
Topamax
Ritalin SR
Tenex
Tegretol
Trileptal
Metadate ER
Clonidine
Thank You
himanshua@nwpltd.org