ACUTE AGITATION = oral BZD when possible
Antipsychotic first line if:
 Already on antipsychotic
 Psychotic symptoms
 Intense agitation/physical danger
 BZDs haven’t worked
1) VERBAL DE ESCALATE
2) SHOW OF FORCE
3) RESTRAINT
4) SEDATE = manage airway
1st = Oral Diazepam (5-20mg 2-6 hourly) /Lorazepam
2nd = Olanzapine/Respiridone/Haloperidol PO
3rd = IM Midazolam (2.5-10mg IM repeat 20/60) /Olanzapine/Droperidol
ANTI PSYCHOTICS = Mainly block dopamine in mesolimbic pathway
Acute Rx psychosis: diazepam 5-20mg PO / midazolam 2.5-10mg IM  olanzapine 5-10mg PO/IM
BASAL GANGLIA = Nucleus acumbens (Mesolimbic pathway) = controls delusions/hallucinations
 Increased dopamine = delusions/hallucinations
TREAT = Decrease dopamine
 Nigrostriatal pathway = Movement control – PARKINSONISM
 Hypothalamus = Dopamine inhibits Prolactin = INCREASED PROLACTIN
 Nigrocortical pathway = Frontal lobe = NEGATIVE SYMPTOMS
Indications
 Schizophrenia = Olanzapine IM in acute agitation
 Psychotic disorders
 Mood disorders with mania/psychosis = Olanzapine acutely / Quetiapine for biopolar/MDD
 Generalised Anxiety Disorder
 Behavioural disturbance in elderly = Respiridone
 Delirium = Olanzapine
Onset = immediate calming and decrease in agitation - thought disorder respond in 2-4/52
Use = DON’T COMBINE THEORETICALLY BUT DO IN REAL LIF E
 All are equally effective but atypical has better side effect profile
o All moderately treat the positive symptoms
Can add Lithium if resistant
o Only clozapine treats negative symptoms
o Choose a drug the patient has responded to in past
 Route = PO, SA or LA depot for IM injections, sublingal
 Duration = minimum 6/12, usually for life
Long Acting = deep IM injection received on outpatient basis - takes time to reach levels
 Schizophrenia or chronic psychosis who relapse because of non adherence
 Start at low dose then titrate every 2-4 weeks
 AE = EPS, Parkinonism, increased NMS
TYPICALS = Dopamine receptor antagonists
D2
Chlorpromazine, Pericyazine, Thioridazine / Haloperidol, Fluphenazine, Flupenthixol
 Used as 2nd line Rx
 IM works faster
Can give depo
 Effective for Rx of the positive sx’s & for sedation (eg. if agitated)
SE = EPSE, NMS, Increased prolactin
 Marked sedation
 Thioridzine = QTc + Sedation + Anticholinergic
 Chlorpromazine = sediation + postural hypo + anti SLUDGE + long QT + photosensitivity
ATYPICAL = Serotonin-Dopamine Antagonists (SDAs)
 Used as 1st line Rx for schizophrenia & psychosis
 Antagonises different dopamine receptors as well as 5-HT receptors
 Very effective for negative Sx and and effective for +ve Sx
 Minimal or no extrapyramidal Sx (except risperidone) due to looser bonding at D2-receptor sites
Disadvantages:
 Expensive
 Metabolic SE – weight gain, hyperglycaemia, lipid abnormalities
 Clonzapine: SE of agranulocytosis  Blood monitoring system
Mech
Adv
Disadv
Risperidone
(Respiridal)
Blocks 5-HT, D2 &
adrenergic
receptors
Low incidence of
EPS at LD (<8mg)
Insomnia, agitation,
, anxiety, prolactin,
postural hypoTN,
constipation,
dizziness, weight
gain
EPSE!
Comments
Dose
Quick dissolve &
long acting
formulations/ depo
SD – 1-2mg OD/BD
TD – 4 – 8mg/d PO
Olanzapine
Blocks 5-HT, D1-D4,
muscarinic,
adrenergic and
histaminergic
receptors
Well tolerated
Low incidence EPS,
TD
Mild sedation,
insomnia, dizziness,
minimal
anticholinergic
Quetiapine
(Seroquel)
Blocks 5-HT, D1 &
D2, adrenergic &
histaminergic
Associated with less
weight gain cf
clozapine &
olanzapine
Headache,
dizziness,
constipation
Most sedating
Early AST/ALT rise,
Metabolic
syndrome
Weight gain in 7%
ACUTE
Acute use in ED
Lasts 8 hours
SD – 5mg/d PO
TD – 10-30mg/d PO
Clozapine
Blocks 5-HT, D1-D4,
muscarinic, and
histaminergic receptors
Most effective for Rxresistant schizophrenia
DOESN’T worsen TD
~50% pts benefit
Drowsiness/sedation,
hypersalivation,
tachycardia, dizziness,
EPS, NMS
1% agranulocytosis
Dry mouth
Postural hypo
Somnolence
Weight gain
ACUTE
Weekly blood counts for
1 month then 2-wkly
DO NOT use with dugs
that  BM suppression
No EPSE
Use if they have
Parkinsons
SD – 25mg PO BD
TD – 400-800mg/d
PO
SD – 25mg PO BD
TD – 300 – 900mg/d PO
Aripirazole (Albilify) = block DA receptors but also DA agonistic
 Helps negative symptoms
 Less weight gain, No PRL
 Rarely causes EPSE but akathisia + agitation in first 6 weeks, N/V, constipation, headache, insomnia
Paliperidone (Invega) = metabolite of respiridone – very similar
 QTc prolongation
Amisulperide = mainly D2/D3 – no effect on serotnonin
 No EPSE
 Helps negative symptoms at low dose
Ziprasidone = only 2nd gen not associated with weight gain
 AE = QT prolongation – ECG
 Least weight gain
Clozapine = atypical atypical – blocks serotonin 2 receptors in prefrontal cortex which increases dopamine
 Taken twice daily
 Good for negative symtpoms – can mask psychotic smyptoms
Indications:
1) Lack of improvement despite use of 2 antipsychotics for 4-6 weeks
2) Inability to achieve benefit from other antipsychotics because of severe SE
Contraindications:
 Previous hypersensitivity to clozapine
 Hx of granulocytopenia / agranulocytosis (from clozapine or otherwise)
 BM disorders or BM suppressive drugs
 Circulatory collapse and / or CNS depression due to any cause.
 Alcoholic and other toxic states
 Severe renal or cardiac disease (e.g. myocarditis)
 Severe hepatic disease including active liver disease
 Uncontrolled epilepsy
 Paralytic ileus
Pharmacology = taken twice a day – absorbed by GIT tract
 T ½ = 10-16 hours
 Comes in 25 and 100mg tablets
 Dose = start at 12.5 or 25 mg - usually 300 but max 900
 CI = other BM suppression drugs, Lithium
Less AE = no EPSE or PRL
BUT SOME SERIOUS ONES
 Sedation, dizzy, syncope, hypos, tachy, N/V, fever, hypersalivation
 Anticholinergic, fatigue, constipation, weakness
 Metabolic syndrome = Dyslipidaemia
 SEVERE = Seizures, Myocarditis (FIRST FEW DAYS) , Cardiomyopathy (LATE)
 Causes agranulocytosis (1-2%) = blood test weekly – occurs in first 3/12
o Stop Clozapine when WBC < 3/ NC < 1.5
MOINITOR = weekly FBE for first 3/12 then monthy
 CRP/Trops weekly for 4/52, then 3/12 then annually
 Baseline ECG/ECHO – repeat 6/12 then yearly
 BMI, Waist circumference, BSL/Lipids
 Clozapine levels
Interruption = if > 48 hrs start against on 12.5 mg and titrate up + more monitoring
SIDE EFFECTS
Anticholinergic
-adrenergic
blockage
Dopaminergic
blockade
Hyper prolactin
Anti-histamine
Hypersensitivity
Endocrine
Cardiac
“Blind as a bat (dilated pupils)
Red as a beet (vasodilation)
Hot as a hare (hyperthermia)
Dry as a bone (dry skin)
Mad as a hatter (hallucinations/agitation)
The bowel and bladder lose their tone (constipation, urinary retention)
And the heart runs alone (tachycardia)”
Orthostatic hypotension, impotence, failure to ejaculate
EPS (dystonia, akathisia, pseudoparkinsonism, dyskinesia), weight gain
Gynaecomastia, galactorrhoea, amenorrhea, anovulation, decreased libido/arousal,
impotence, anorgasm
Sedation (Most at initiation/titrating up = DRIVING RISK)
Liver dysfunction, blood dyscrasia, skin rashes, Neuroleptic malignant syndrome,
altered temp
Metabolic syndrome
QTC prolongation = Torsades
Male = 430 ms
Female = 450 ms
NEUROLEPTIC MALIGNANT SYNDROME = due to massive dopamine blockade,
 incidence with high potency & depot neuroleptics
Risk Factors: sudden increase in medication/new drug, medical illness, dehydration, exhaustion, poor
nutrition, external heat load, male, young adult
 Presentation
o fever, autonomic reactivity (sweating, BP), rigidity, dystonia, akinesia, mental state changes
o Develops over 24-72hours
o Labs: CK, WCC, myoglobinuria
Features
 Treatment – Requires hospital admission and urgent treatment
Fever
o Discontinue drug, hydration, cooling blankets
Encephalopathy
o Dantrolene (used as muscle relaxant) and bromocriptine (DA agonist)
Vitals unstable
 5% mortality
Elevated WBC/CPK
Rigid
EXTRAPYRAMIDAL SYMPTOMS = from dopamine blockage
 Incidence related to increased dose and potency
 Acute (early-onset; reversible) vs tardive (late-onset; often irreversible)

Acute/Tardive
Risk Group
Presentation
Dystonia
Both
Acute: young asian &
black males
Sustained abnormal
posture; torsions,
twisting, contraction
of muscle groups,
muscle spasms (i.e.
laryngospasm,
torticollis)
Beware Larynx
Acute: within 5 days
Tardive: > 90days
Akathisia
Both
Pseudoparkinsonism
Acute
Elderly females
Dyskinesia
Tardive
Elderly females
Motor restlessness; Tremor
Purposeless,
crawling sensation
Rigidity (cogwheel)
constant
in legs relieved by
Akinesia
movements
walking; very
Postural instability
involving facial
distressing,
and mouth
(/absent arm-swing,
increased risk of
musculature or
stooped posture,
suicide and poor
less commonly,
shuffling gait, difficulty
adherence
limbs
pivoting)
Onset
Acute: within 10
Acute: within 30 days
>90 days
days
Tardive: > 90days
Treatment
Acute: benztropine
Lorazepam,
Acute: benztropine
No good
DECREASE
or diphenhydramine
propanolol or
treatment,
DOSE
diphenhydramine
Prevention only
**benztropine, amantadine, diphenhydramine = anticholinergic agents (antiparkinsonian)
ANTIDEPRESSANTS =
Block reuptake = Serotonin/Noradrenaline
Block enzymes = MAO/COMT
Onset = neurovegetative 1-3/52, emotional/cognitive 2-6/52
 May use mild stimulant (methylphenidate) for severe neurovegetative sx briefly
 Patients at risk of suicide over first 2/52 = neuroveg resolve while emotional/cognitive don’t
 Once improved = 6-12 month course to prevent relapse
o 2nd episode = 5 years
o 3rd episode = Lifelong
AVOID ALCOHOL
 Must take drug daily
AE Common = N/V, Diarrhea
Weight gain
Postural hypo, tachycardia
Sexual dysfunction
Sedation/Agitation
Insomnia
Withdrawal = Depends on t ½ and patient sensitivity
Tape TCAs slowly
Bipolar Depression = DON’T USE MONOTHERPAY as can trigger mania
 Mood stabiliser + SSRI/bupropion
 Already on a mood stabiliser = add/switch to lithium/lamotrigine
How to choose antidepressant = 50% respond to initial – assess at 2-4/52
 Well = continue dose
 No response = increase dose -> assess at 2-4/52
o Partial response = increase dose
o No response = change
START LOW THEN INCREASE
Which drug? = All SSRIs have similar effectiveness, but consider side effects and half lives
 Bupropion causes less sexual dysfunction, weight gain and sedation but is CI for patients with PHx of seizure,
stroke, brain tumour, brain surgery, closed head injury
 Mirtazapine – useful if insomnia or agitation are prominent, or to Rx depression with cachexia
 Sertraline, citalopram, escitalopram – least interactions with other drugs & sleep-wake neutral
 Fluoxetine and paroxetine – most activating drugs, taken in the morning
 Fluvoxamine – always sedating, taken in the evening
 Moclobemide = no sexual dysfunction
COMBO = Californian Rocket Fuel = Mirtazapine + Venlafaxine (fewer AE + better tolerated for resistant)
SELECTIVE SEROTONIN RE UPTAKE INHIBITOR - trial 2 SSRI for 4-6/52 then move to another class
Citalopram (Cipramil) = not for oldies with heart stuff (20mg max 40mg)
Prolonged QT
Fluoxetine (Prozac) = best for teenagers (20mg mane – long t ½ so less likely to get discontinuation syndrome)
Fluvoxamine (Movox) = (100mg nocte)
Paroxetine (Aropax) = (20mg, mane)
HTN, Weight gain , Sexual dysfunction
Sertraline (Zoloft) = OCD SD 50mg, TD 50-200mg
Diarrhea
Escitalopram (Lexapro) = depression w/anxiety – lowest issue with libido (SD 10mg, TD 10-20mg) Less AE
Use
MoA
depression (typical & atypical), anxiety, OCD, eating disorders
Selectively inhibits CNS serotonin reuptake
SE
Few (even at high doses (i.e. safe in overdose)  better compliance
CNS: tremor, insomnia, headache, drowsy, initial anxiety may occur (suicide risk)  Rx w BZDs
GI: N/V, diarrhoea, abdo cramps, weight loss
GIT bleed
Sexual dysfunction, impotence, anorgasmia (most common)
CVS: HR, conduction delay
Serotonin syndrome, EPS
SIADH ( hyponatriaemia in elderly)
CHECK UEC
OD
Safe
Interactions – inhibits P450
SEROTONIN NORADRENALINE REUPTAKE INHIBITOR (SNRI)
Desvenlafaxine(Pristiq)
Venlafaxine (Efexor) = 75-375mg
Use
MoA
Depression & anxiety, PTSD, OCD
Blocks noradrenaline and serotonin (5HT)
Fibromyalgia, Hot flushes, Incontinence
Like a ‘suped-up’ SSRI; efficacy with matching toxicity
SE
LD insomnia
HD – tremors, tachycardia, sweating, hypertension (diastolic) Sexual dysfunction
OD
Seizures, Tachycardia and N&V
Taper slow
Interactions: MAOI, SSRI
REVERSIBLE INHIBITOR OF MONOAMIDE OXIDASE (RIMA)
Moclobemide (Arima)
Use
Refractory depression to other therapies
MoA
Reversible inhibitor of monamine oxidase A (MAO-A) to CNS monoamines (NA and 5HT)
SE
OD
Only antidepressant that does not cause sexual dysfunction; SE’s similar to SSRI’s otherwise
Fatal overdose if combined with citalopram or clomipramine
NO CHEESE REACTION
NORADRENERGIC AND SPECIFIC SEROTONERGIC AD (NaSSA) Mirtazapine (Avanza)
Use
patients with insomnia, agitation or depression with cachexia
MoA
Blocks 2-receptors  5HT & NA, & also block 5HT2, 3 receptors, enhancing 5HT1 serotonergic
transmission.
**Good for elderly w insomnia/low appetite
Have long elimination ½ lives, allowing once daily dosing
SE:
Weight gain, Sedation, postural hypotension, dry mouth
Interactions: MAOI, SSRI, SNRI, RIMA
OD: Less lethal
2nd Line Pharm. Rx (MDD)
TRICYCLIC ANTIDEPRESSANTS (TCA’s)
Amitriptyline, Nortriptyline, Imipramine, Clomipramine
Use
Melancholic depression, OCD (clomipramine)
MoA
Non-selective reuptake inhibitors of 5HT & NA
Extensively metabolised in the liver, Long ½ life  once-daily admin, usually in the evening
SE
Prolonged QRS and arrythmias
Anticholinergic SE = dry mouth, blurred vision, constipation, urinary retention
Noradrenergic SE – tremors, tachycardia, sweating, insomnia, erectile dysfunction
-1 adrenergic: orthostatic hypotension, weight gain, sedation
Antihistamine – sedation, weight gain
CNS – seizures
DELIRUM IN ELDERLY
OD
Toxic – 3x therapeutic dose is lethal = anticholinergic, CNS stimulation, then depression & seizures
ECG: prolonged QT
Rx – activated charcoal, cathartics, supportive Rx, IV diazepam for seizure
C/I
CVS disease, glaucoma, bladder neck obstruction.
MONOAMIDE OXIDASE INHIBITOR (MAOIs)
Phenelzine (irreversible – no selective)
Use
depression that doesn’t respond to SSRI or is atypical
MoA
irreversibly inhibit MAO-A & MAO-B  NA & 5HT in brain and other tissues.
Duration of action = 2-3 weeks while new enzymes form.
SE’s
Hypertensive crisis w tyramine foods (wine, cheese) – headache, flushes, palpitations, N&V,
photophobia – ONLY WITH NON SELECTIVE
Dizziness, tachycardia, postural hypotension, sedation, insomnia, weight gain
Social dysfunction, energy
Minimal anticholingeric & antihstamine**
Interacts: alcohol, noradrenergic medications (TCA, decongestants, amphetamines), SS with SSRIs
NORADRENALINE DOPAMINE REUPTAKE INHIBITOR (NDRI)
Bupropion
Use
Depression, seasonal depression; also eating disorders, smoking cessation
NOT for anxiety
MoA
SE
OD
C/I
Blocks noradrenaline & dopamine
Less than others
tremors and seizures
drugs and states (conditions) that reduce seizure threshold
SEROTONIN SYNDROME = rare, more common with SSRI/ MAO I together
Within 24 hours
 Rare but potentially life-threatening, Due to over-stimulation of the serotonergic system
 SSRI’s SHOULD NOT be co-administered with a MAOI, lithium or L-trytophan as 5HT levels
 Can  myoclonus, seizures, hyperthermia, rigor, H tonia  delirium, coma & CVS collapse, death
 SSRI + MAOI / Serotenergic TCA (Clomipramine, Amitriptyline)
Tramadol/Pethidine
COGNITIVE = headache, agitation, hypomania, confusion, hallucination, coma
AUTONOMIC = shiver, sweat, hyerpthermia, HTN, tachycardia, nausea, diarrhoea, dilated pupils, flushed
NEUROMUSCULAR HYPERREACTIVITY = myocolonus, Hreflexia, tremor, ocular clonus, muscle rigidity,
Babinski signs
Mx = Discontinue medication, administer emergency care = O2 > 94, IV fluids, cardiac monitor
 Severe = Cyproheptadine (5 HT antagonist) bolus 12 mg PO then 2mg every hour
 If hyperthermia = Rapid Sequency intubation
Hyperthermia
Autonomic instability
Rigidity
Myoclonus
Encephalopathy
Diaphoresis
DISCONTINUATION SYNDROME
 Caused by abrupt cessation of antidepressant, most frequently paroxetine, fluvoxamine, venlafaxine
 Sx begin within 1 – 3 days: anxiety, insomnia, irritability, mood lability, N/V, dizziness, headache, Dystonia,
tremor, chills, fatigure, lethargy, myalgia
 Rx: restart antidepressant at same dose patient was taking, & initiating a slow taper over several weeks
Flu like
Insomnia
Nausea
Imbalance (Dizzy)
Sensory disturbance
Hyperarousal (anxiety/agitation)
MOOD STABILISERS
Before initiating = FBE, UEC, CMP, FBG, TFT, ECG, Urinalysis + ACR (BHCG)
 Can use Olanzapine (good for pregnancy)
LITIHUM = harder to take but more effective
Use
Acute mania, maintenance of bipolar disorder, augmentation antidepressants, schizoaffective,
chronic aggression & antisocial behaviour, recurrent depression
MoA
Unknown; therapeutic response within 1-2weeks ( ?acute coverage w BZD pr antipsychotic)
Dose
Start at 300mg, titrate up to 900-1800mg/day
ACUTE = 750-1500mg
Adult: 600-1500mg/d
Geriatric 150-600mg/d (once daily dosing)
Taper slowly if ceasing. If taken erratically, efficacy diminishes and may not work again
Monitoring
BASELINE = FBE, ECG, Urinalysis, UEC, TSH, Blood urea nitrogen
Monitor serum levels until therapeutic - always wait 12h after dose
Lithium Levels = biweekly/monthly until steady state is reached, then every 2 months
Aim = 0.6-0.8 mmol/L
ACUTE = 0.8-1.2mmol / L
Every 6 months: thyroid and renal (Cr) function; every year urinalysis, CMP, PTH
Side effects
Withdrawal over 2/12 as can have withdrawal
GI, CNS (fine tremor, headache), haem (reversible leucocytosis)
Renal = polyuria, renal failure, microalbimunira
Thyroid = hypothyroidism and hyper PTH
Cardiac = Sinus blocke
Serotonin syndrome
Acne and psoriasis
Weight gain
hypo TH
Teratogenic (Ebstein’s anomaly)
ECG
Muscles weakness
Combinations
Interactions
with sodium valproate or carbamazepine in non-responders
NSAID, ACEi/ARB, Antidepressants (SSRI), Anti epileptics, Anti psychotics, Diuretics
AVOID CALICUM CHANNEL BLOCKERS = rare fatal neurotoxicity
Lithium toxicity = diagnose clinically = overdose, Na/Fluid loss/medical illness
TOXIC > 1.5mmol/L
 Sx:
GI – N&V and diarrhoea;
Cerebellar – ataxia, slurred speech, loss of coordination,
Cerebra – drowsy, myoclonus, chorea/parkinsonism, UMN signs, seizures, delirium, coma
Management = Discontinue lithium for several doses  restart at lower dose when was non-toxic
 Serum lithium levels, UEC, renal function tests
 Saline infusion + Hemodialysis if lithium >2mmol/L, coma, shock, severe dehydration, failure to respond
in 24h, deterioration
Sodium Valproate
SD – 200-400mg BD; TD 1500-3000mg
Therapeutic level = 660+mol/L
 Alternative; also 1st line Rx acute mania & bipolar maintenance; Antidepressant action in 1/3 of pt’s.
 Better tolerated in ELERLY – can combine with lithium for nonresponders/rapid cyclers
 SE: alopecia, weight gain, hepatitis (initial) tremor and sedation. Iatrogenic (neural tube defects),
pancreatitis (ongoing), GIT, Angranulocytosis
Baseline= FBE, UEC, LFT and repeat 3/12
SECOND LINE
Carbamazepine (Tegretol) 400-1600mg/d (BD, TDS),
Therapeutic level = 350-700mol/L
 2nd line Rx for acute mania & bipolar prophylaxis = non-responders, rapid cycling
 Potent enzyme inducer so many drug interactions (eg. warfarin, OCP)
 Weekly blood counts for first months – risk of agrunylocytosis
 AE = hepatitis, agranulocytosis, drug interactions, rash, sedition, CNS toxicity (ataxia, diplopia, dizzy)
Lamotrigine (Lamictal) =2nd line Rx bipolar, also mania & depression
 inhibits 5-HT3 & potentiates Da activity
 SE: CNS – dizziness, headache, ataxia, nausea, fever, anxiety, skin: rash, Steven-Johnson syndrome (0.1%)
ANIXIOLYTICS/HYPONOTICS = mask or alleviate symptoms, DO NOT CURE
Indications








Acute anxiety = BZA
Chronic anxiety
o Anti depressant = SSRI – Venladaxine
o Mirtazapine = sedative, increase appetite and weight gain
o Buspirone
MAO I/TCA
Panic disorder = Clonazepam + Paroxetine
OCD = SSRI
Insomnia
o BZD = Flurazepam, Temazepam
o Trazodone
o Non BZD = Zolpidem (Still nox) , Zaleplon
o Quetiapine = may cause daytime sedation
o Ramelteon = Melatonin receptor agonist
Agitation in dementia
EPSE
Seizure disorders, MSK disorders
Relative Contraindications = MDD, History of drug/alcohol abuse, Pregnancy/Breastfeeding
BENZODIAZEPINES = potent binding of GABA to receptors =  neuronal activity
 Should be used for limited periods (week – months) to avoid dependence
 All benzodiazepines are sedating; all have similar efficacy
High potency = Alprazolam (Xanax), Clonazepam
Good for panic attacks
Rapid onset = Diazepam (2-40mg/d), Triazolam
Slow onset = Oxazepam
Builds up
Worse withdrawal
Impairs concentration/memory
Very short = Midazolam
t 1/2 < 6 hours
Short = Oxazepam/Temazepam
t½
6-12 hours
Medium = Lorazepam
12=24 hours
Better for elderly
Long = Diazepam >24 hours
Temazepam = sleep
Side effects
 Cognitive Impairment= memory impairment, drowsy
 Behaviour disinhibition = hostility, aggressive, rage reaction, irritability
 Psychomotor impairment = synergistic effects with alcohol  Physical dependence, tolerance
Withdrawal = Taper slowly over weeks to months (otherwise risk of withdrawal reactions)
 LD withdrawal: Flu like, HR, HTN, panic, insomnia, anxiety,  memory & concentration, perceptual
 HD withdrawal: hyperpyrexia, seizures, psychosis, death
Onset: 1 – 2 days (short-acting), 2 – 4 days (long acting)
Duration: weeks to months
Cx: >50mg diazepam: seizures, delirium, arrhythmias, psychosis = similar to bad etOH withdrawal; can be fatal
Rx: taper with long-acting benzodiazepine
Overdose = commonly used, rarely fatal, more dangerous & can lead to death if combined w depressants
 Rx: Flumazenil (benzodiazepine antagonist)
Buspirone =Partial agonist of 5-HT receptors
Generalised Anxiety Disorder
 Preferred to BZD bc: non-sedating, no interaction with alcohol, no affect on seizures, not prone to abuse
 Onset of action at 2 weeks
 Side effects: dizziness, drowsiness, nausea, headache, nervousness
STIMULANTS = decrease hyperactivity, increase attention, reduce impulsivity


Critical for success in school
Short duration of action = 2-3 daily dose – school nurse
Methylphenidate (Ritalin)
Dextroamphetidine
AE = poor appetite (dose after breakfast), growth impairment (catch up), poor sleep, tics
CHOLINESTERASE INHIBITORS = increase synaptic Ach
 Mild – moderate Alzheimer’s
 Delays decrease in function and memory loss
Donepizil (Aricept)
Rivastigmine (Exelon) = more AE
Memantine (Namenda)