Dementia Medications Acetylcholinesterase Inhibitors (AChEIs) and Glutamate (NMDA) Receptor Antagonist

Transcription

1 Dementia Medications Acetylcholinesterase Inhibitors (AChEIs) and Glutamate (NMDA) Receptor Antagonist Medication Dosage Indication for Use Aricept (donepezil) Exelon (rivastigmine) 5mg 23mg* ODT 5mg Solution 1mg/mL Capsules: 1.5mg 3mg 4.5mg 6mg Patch: 4.6mg/24 Hour 9.5mg/24 Hour 13.3mg/24 Hour 2mg/mL Alzheimer s Disease Dementia with Lewy Bodies Parkinson s Disease Dementia Vascular Dementia Class Adverse Drug Reactions (ADRs) Nausea Vomiting Diarrhea Weight Loss GI Bleeds Insomnia (9%) Weight Loss (8%) Nightmares (3%) Drug-Specific ADRs & Clinical Pearls Bradycardia/Syncope (2%) QT Prolongation (1%) Starting dose 5mg QD x 4 weeks, then QD, if tolerated titrate to 23mg. Due to risk of syncope dose at bedtime. If abnormal/bothersome dreams or insomnia may switch to daytime dosing. Most likely in drug class to have GI effects. Nausea (30%), Vomiting (15%) GI effects likely with oral formulation. GI effects unlikely with patch formulation. Tremor (17%), Dizziness (7%) Take oral dose with food. Starting dose 1.5mg BID x 4 weeks, titrating to highest tolerated dose. Starting dose for Patch 4.6mg QD x 4 weeks, titrating to highest tolerated dose. 9.5mg Patch = 6mg PO BID. Approved for Dementia associated with Parkinson s Disease.

2 Dementia Medications Acetylcholinesterase Inhibitors (AChEIs) and Glutamate (NMDA) Receptor Antagonist Medication Dosage Indication for Use Razadyne (galantamine) Namenda (memantine) BID 4mg 8mg 12mg 4mg/mL ER Capsules: QD 8mg 16mg 24mg QD or BID 5mg /5mL ER Capsules: QD 7mg 14mg 21mg 28mg **See Previous Page Alzheimer s Disease Vascular Dementia Class Adverse Drug Reactions (ADRs) **See Previous Page Drug-Specific ADRs & Clinical Pearls Anorexia/Weight Loss (9%) Dizziness (9%) Headache (8%) Abdominal Pain (5%) Take with food to minimize GI effects. Starting dose 4mg BID x 4 weeks, titrating to highest tolerated dose. Starting dose for Extended Release formulation 8mg QD x 4 weeks, titrating to highest tolerated dose. Originally named Reminyl Dizziness (7%) Confusion (6%) Headache (6%) Constipation (5%) Give with an AChEI to blunt ADRs and augment clinical benefits. Starting dose 5mg QD x 7 days, then 5mg BID x 7 days, then 5mg QAM & QHS x 7 days, then BID. Starting dose for Extended Release 7mg QD x 7 days, then 14mg QD x 7 days, then 21mg QD x 7 days, then 28mg QD. Renal dosing for CrCL < 30mL/min: 5mg BID, QD, XR 14mg QD. Europe has ALWAYS dosed 20mg QD. Do not mix solution with any other liquid.

3 Medication Dosage Indication for Use Celexa (citalopram) Lexapro (escitalopram) 20mg 40mg /5mL 5mg 20mg 5mg/5mL Anti-Depressants Selective Serotonin Reuptake Inhibitors (SSRIs) Generalized Anxiety Disorder (GAD) Obsessive- Compulsive Disorder (OCD) Panic Disorder Post-Traumatic Stress Disorder (PTSD) Social Anxiety Disorder Class Adverse Drug Reactions (ADRs) Nausea Vomiting Headache Sleep Disturbances Agitation Sexual Dysfunction Tremor Dizziness Constipation Weight Changes Gastrointestinal (GI) Bleeds Drug-Specific ADRs & Clinical Pearls QT Prolongation (dose dependent) Initial dose 20mg QD and maximum dose 40mg QD. Adults > 60 years maximum dose of 20mg QD due to QT prolongation & development of life-threatening arrhythmias. Well tolerated, minimal side-effects, low incidence of drug interactions. Least likely SSRI to be discontinued due to ADRs. Initial dose QD and maximum dose 20mg QD. Geriatric maximum dose is QD. Both 10 and 20mg dose are EQUALLY effective therapy. Isomer of Citalopram Meta-analysis of over 2000 adults found Escitalopram to be significantly more effective than citalopram in overall treatment effect (response & remission rate). Duplicate analysis could not confirm above analysis. Most likely SSRI to have the quickest onset of action. Paxil (paroxetine) 20mg 30mg 40mg CR 12.5mg* 25mg* 37.5mg* /5mL Somnolence (23%), Dry mouth (18%) Headache (18%), Constipation (14%) Sexual Dysfunction (10%) Typically avoided in the elderly d/t anticholinergic activity. Best SSRI for sexual aggression. Immediate Release: Initial dose 20mg QD (Geriatric ) and maximum dose 50mg QD (Geriatric 40mg). Controlled Release: Initial dose 25mg QD (Geriatric 12.5mg) and maximum dose 62.5mg QD (Geriatric 50mg). Anxiety responds best to 20mg QD and higher doses do not appear to provide additional benefit.

4 Medication Dosage Indication for Use Prozac (fluoxetine) Zoloft (sertraline) 20mg 40mg DR 90mg* 20mg/5mL 25mg 50mg 100mg 20mg/mL Anti-Depressants Selective Serotonin Reuptake Inhibitors (SSRIs) **See Previous Page Class Adverse Drug Reactions (ADRs) **See Previous Page Drug-Specific ADRs & Clinical Pearls Headache (21%), Insomnia (19%) Anxiety (10%), Weight Loss (7%) First SSRI to be marketed in the US. Half-life after chronic administration is 4 to 6 days. Long half-life of Fluoxetine allow for once weekly administration in some patients. Initial dose 20mg QD and maximum dose 80mg QD. Delayed Release: Initial dose 90mg QD once weekly, beginning 7 days after the last 20mg daily dose. Anxiety responds well to 20mg QD most studied dose. Bulimia Nervosa dose found to be 60mg QD in clinical studies and smaller doses have not been found effective. May be beneficial treatment for depression or panic disorder in patients suffering from obesity. Headache (25%), Nausea (25%) Insomnia (21%), Diarrhea (20%) Initial dose 50mg QD and maximum dose 200mg QD. Anxiety Disorder Initial dose 25mg QD, after one week, increase to 50mg QD. If necessary maximum dose 200mg QD. Oral solution must be further diluted in an acceptable liquid immediately before administration. Caution recommended for persons with a latex sensitivity because the dropper dispenser contains dry natural rubber.

5 Anti-Depressants Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) Medication Dosage Indication for Use Drug-Specific ADRs & Clinical Pearls Cymbalta (duloxetine) DR Capsules: 20 mg 30 mg 60 mg Diabetic Neuropathy Fibromyalgia Generalized Anxiety Disorder Musculoskeletal Pain Osteoarthritis Off- Urinary Incontinence Nausea (23%), Headache (14%), Dry Mouth (13%), Somnolence/Fatigue (10%) Insomnia (9%), Hyperhidrosis (6%) Initially 20mg BID or 30mg QD titrated to 60mg QD. Maximum dose 120mg QD. Dividing the dose may increase tolerability (30mg BID). Doses greater than 60mg QD have not shown additional benefit but have increased rates of ADRs. CrCL < 30mL/min - therapy NOT recommended. Avoid use in patient with chronic liver disease or cirrhosis. First drug with FDA approval for Diabetic Peripheral Neuropathy. Effexor (venlafaxine) 25 mg 37.5 mg 50 mg 75 mg 100 mg ER Capsules: 37.5 mg 75 mg 150 mg ER 37.5 mg* 75 mg* 150 mg* 225 mg* Generalized Anxiety Disorder (GAD) Panic Disorder Social Anxiety Disorder Off- Diabetic Neuropathy Fibromyalgia Migraine Prophylaxis Obsessive- Compulsive Disorder (OCD) Nausea (30%), Insomnia (18%), Dizziness (16%), Somnolence (15%) Dry Mouth (15%), Hyperhidrosis (11%), Anorexia (10%) Nickname Side-Effexor Administer with food to minimize GI effects. Immediate Release: Initial dose 75mg QD given in 2 to 3 divided doses. Maximum dose for outpatients 225mg QD (2-3 divided doses) and inpatients 375mg QD (3 divided doses). Extended Release: Initial dose 75mg QD (37.5mg can be given to increase tolerability for 3-4 days prior to increasing dose) and maximum dose 225mg QD. First antidepressant to receive FDA approval for the treatment of Generalized Anxiety Disorder (GAD). Anxiety Disorders seem to respond well to 75mg QD and there is little clinical benefit that higher doses yield additional benefit. Doses < 150mg QD = SSRI therapy. Doses > 150mg QD = SNRI therapy. For moderate hepatic impairment reduce dose by 50% For moderate to severe renal function reduce dose by 25 to 50%

6 Anti-Depressants Miscellaneous Medication Dosage Indication for Use Drug-Specific ADRs & Clinical Pearls Desyrel (trazodone) Remeron (mirtazapine) 50 mg 100 mg 150 mg 300 mg ER 150mg* 300mg* 7.5 mg 15 mg 30 mg 45 mg ODT 15 mg 30 mg 45 mg Off- Ethanol Dependence Generalized Anxiety Disorder (GAD) Insomnia Panic Disorder Off- Benign Familial Tremor Pruritus Tremor Drowsiness (41%), Dry Mouth (34%), Dizziness/Lightheadedness (28%) Headache (20%), Blurred Vision (15%), Nausea/Vomiting (13%) : Initial dose 150mg QD in divided doses and maximum dose 400mg QD (outpatients) and 600mg QD (inpatients) Insomnia: Initial dose 100mg (range 25 to 100mg) at bedtime. Possesses some similarities of action to other antidepressant drugs, however, also has some action as an anxiolytic. Sedative effect believed to be produced by modest histamine blockage. May improve sleep patterns associated with depression. Peak concentration is achieved 1 hours after dosing in the fasting state and 2 hours after dosing with food. Response to therapy typically seen by the end of the second week of therapy. Somnolence (54%), Dry Mouth (25%), Increased Appetite (17%), Constipation (13%), Weight Gain (12%) Initial dose 15mg QHS and maximum dose 45mg QHS. Possesses an anxiolytic effect that may be useful in depressed patients who have a coexisting anxiety disorder. Potent antagonist of histamine receptors which may explain it prominent sedative effects. May improve sleep patterns associated with depression. Faster onset of antidepressant efficacy, with maximal effect within 2 to 4 weeks of adequate dosage selection. Avoid abrupt discontinuation withdrawal symptoms have been reported.

7 Anti-Depressants Miscellaneous Medication Dosage Indication for Use Drug-Specific ADRs & Clinical Pearls Wellbutrin (bupropion) TID 75 mg 100 mg SR BID 100 mg* 150 mg* 200 mg* ER QD 150 mg* 300 mg* Nicotine Withdrawal Seasonal Affective Disorder (SAD) Off- Attention-Deficit Hyperactivity Disorder (ADHD) Diabetic Neuropathy Neuropathic Pain Postherpetic Neuralgia Agitation (32%), Dry Mouth (28%), Headache (26%), Constipation (26%), Hyperhidrosis (22%), Nausea/Vomiting (23%), Dizziness (23%), Tremor (21%), Sedation (20%), Insomnia (19%), Blurred Vision (15%), Tachycardia (11%) Immediate Release: 100mg BID titrated to 100mg TID. No single dose should exceed 150mg. Maximum dose 450mg daily. Sustained Release: 150mg QD titrated to 150mg BID. Titration can continue to 200mg BID but at least 8 hours apart. No single dose should exceed 200mg. Maximum dose 400mg daily. Extended Release: 150mg QD and titrate to target dose 300mg daily with maximum dose of 450mg daily. Hepatic & Renal Impairment requires dose reductions. The onset of antidepressant effects takes 1 to 3 weeks, maximal effects may not be noted for 4 weeks. First prescription product approved for patients with a history of Seasonal Affective Disorder. Greater potential for causing seizures compared to other antidepressants. Drug removed from the market from 1985 to 1989 to further evaluate link to Seizures. To avoid or limit the risk of insomnia, do not administer doses at bedtime.

8 Mood Stabilizers Medication Dosage Indication for Use Drug-Specific ADRs & Clinical Pearls Depakote (valproic acid) Capsules: 125mg DR 125mg* 250mg* 500mg* ER 250mg* 500mg* Bipolar Disorder Migraine Prophylaxis Seizures Unlabeled: Agitation Attention-Deficit Hyperactivity Disorder (ADHD) Hiccups Nausea (31%), Somnolence (17%), Dyspepsia (13%), Dizziness (12%), Diarrhea (12%), Vomiting (11%), Abdominal Pain (9%), Tremor (9%) Dose: Start Low, Go Slow, But Go. Actual guidance lacking. Meta-analysis of available data indicate ineffectiveness in treating agitation among patients with dementia and that therapy is associated with an unacceptable rate of adverse effects. Risk of death seen with Valproic Acid was similar to antipsychotics (VA study of 91,000 American Veterans over the age of 65 years of age.) Administer with food to minimize GI irritation. CBC (thrombocytopenia), LFTs, and Ammonia should be monitored. Serum concentration evaluated to rule out potential toxicity not to evaluate efficacy of therapy for behavioral symptoms.