Medications, By Class, in TBI

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Medications, By Class, in TBI Generic/Brand Name Drawback Advantage Mood Stabilizers (anti-seizure medications) Carbamazepine (Carbatrol ) (Equetro ) (Tegretol ) Gabapentin (Neurontin ) Lamotrigine (Lamictal ) Levetiracetam (Keppra) Some anticholinergic effects. Blood tests with relatively narrow therapeutic window. Affects the blood levels of many medications and vice versa. Rare risk of serious rash Sedating early Multiple daily dosing Very slow titration 5% risk of rash Rare but real risk of serious rash May induce hostility or aggression, especially at low dose Some antidepressant effects. Minor negative neurological effects. Renal excretion (very few medications are) so useful in hepatic illness Anti-anxiety without the negative neurological consequences of benzodiazepines Neuropathic pain decrease Has antidepressant properties (stabilizes from below) Has neuroprotective properties (anti-glutaminergic) Very few side effects No blood tests needed, but can be done to guide high dosing (target 6) Does not have much impact on other medications because of renal excretion Overall mood elevating/activating Oxcarbazepine (Trileptal ) More frequent effects on sodium (hyponatremia) Rare but real risk of serious rash Does not have much impact on other medications compared with carbamazepine September 24, 2009 1

Pregabalin (Lyrica) Somewhat sedating Neuropathic pain decrease Tiagabine (Gabitril) Somewhat sedating Can have reverse effects Can cause seizures Antianxiety without the negative neurological effects of benzodiazepine. Topiramate (Topamax) Valproate (Depakote ) (Depakene ) Negative cognitive effects require dose limitation and slow titration Weight gain (lack of satiety) Hair loss It can raise ammonia levels and have neurotoxic effects. Neuropathic and migraine pain relief Cognitive enhancement Appetite suppressant Rapid titration Good for aggression Blood levels meaningful Zonisamide (Zonegran ) Relatively slow titration Neuropathic pain control Stimulants/ADD Treatment Catacholaminergic Medications (norepinephrine and dopamine) Methylphenidate (Ritalin ) (Metadate ) (Concerta ) Potential for abuse Short acting form requires multiple dosing Long experience Diffuse activation of the brain Short acting means no adverse impact on sleep Dextroamphetamine (Dexedrine ) Greater abuse potential More potent Mixed Catacholaminergic Salts (Adderall ) Greater abuse potential Usually smoother effect in ABI Modafinil (Provigil ) Kinder gentler stimulant September 24, 2009 2

Bupropion (Wellbutrin ) (Zyban ) Atomoxetine (Strattera ) Amantadine (Symmetrel ) Pramipexole (Mirapex ) Ropinirole (Requip ) Some seizure risk (although when used properly not really more than other meds) Provides general activation with long half-life so sleep can be impaired Slow titration Hepatic dysfunction Can trigger paranoia Can trigger paranoia Associated with weight gain Can trigger paranoia No abuse potential Antidepressant effects Anti-addiction effects Avoids abuse potential of stimulants. Avoids the tic potential of stimulants Decreases motor restlessness Decreases centrally induced motor stiffness Prevents influenza! Decreases motor restlessness Decreases centrally induced motor stiffness Mood elevator Decreases motor restlessness Decreases centrally induced motor stiffness Mood elevator SSRI's (selective serotonin reuptake inhibitors) All SSRI s Paroxetine (Paxil ) Sexual inhibition, especially delay in orgasm Neurasthenia (fatigue without structure in afternoon) Discontinuation syndrome (flu like symptoms as blood level drops) GI effects; especially early Most sedating Some anticholinergic effects Discontinuation syndrome No independent suicide potential Decrease anger (negative side is an increase in apathy) Sedation can improve agitation early More useful for nightmares September 24, 2009 3

Sertraline (Zoloft ) Citalopram (Celexa ) Escitalopram (Lexapro ) Fluoxetine Most stimulating Can have pseudo akathisia Neutral between sedating and activating Rather specific for serotonin Even more specific. The dextro isomer, escitalopram, is the active ingredient in citalopram Long half-life means no discontinuation syndrome SSRI + Stimulant (serotonergic and catacholaminergic) Duloxetine (Cymbalta ) Venlafaxine (Effexor ) Desmethyl venlafaxine (Pristiq ) SSRI side effects with more GI side effects GI side effects (much less with sustained release form Requires high dose (>225 mg/day) to get noradrenergic effect Provides effects similar to both bupropion and SSRI even at low dose More analgesic effect than the SSRI s Provides effects similar to both Bupropion and SSRI More analgesic effect than the SSRI s Sedative/Antianxiety (gabaminergic) Zolpidem (Ambien ) Zaleplon (Sonata ) Eszopiclone (Lunesta ) Expensive (except generic zolpiden) Partial γ-amino butyric acid agonism. (older benzodiazepines are full agonists) leading to minimal if any negative neurological effects Short half-life means no hangover Buspirone (Buspar ) Actually 5-HT1a agonism and D2 antagonism Very gradual effects Decrease bruxism Excellent top-off for agitation September 24, 2009 4

SGA s (Second Generation Antipsychotics) Also called: Broad Spectrum Psychotropics Risperidone (Risperdal ) Paliperidone (Invega ) Has mild D 2 blocking effects Orthostatic hypotension Most like older antipsychotics Most impact on prolactin Rapid onset Olanzapine (Zyprexa ) CHO craving can lead to weight gain and metabolic syndrome Mild anticholinergic effects - especially peripheral Mood elevating Calming Quetiapine (Seroquel ) (Seroquel XR ) Sedating Short half-life, but new XR formulation is ideal for HS dosing Very calming No D 2 blocking effect Neuroprotective (cortisol suppressed) Ziprasidone (Geodon ) Has to be taken with food Can affect cardiac conduction (fear more than reality) Can be activating Sedative effect can be used too No D 2 blocking effect Neuroprotective (cortisol suppressed) Aripiprazole (Abilify ) A new class of partial agonist, but used like the SGA s Early nausea and vomiting Early EPS (akathisia and dystonia) Early activation Weight neutral Minimal prolactinemia Long half-life Others Trazodone (Desyrel ) Hypotension Non-benzodiazepine, nonaddicting, no negative neurological effects Mirtazapine (Remeron ) Sedating Weight Gain Can double as sleeper Benefit for cephalgia Not sexually inhibiting Nefazodone (Serzone ) Weak antidepressant Occasional hepatic failure Helps anxiety Good for PTSD type nightmares Not sexually inhibiting September 24, 2009 5

Lithium Carbonate (Lithobid ) and others Blood levels with narrow therapeutic window Some negative neurological impact Weight gain from H 2 O retention Effective for classical bipolar type symptoms Effective for aggression Donepezil (Aricept ) Galantamine (Reminyl ) (Razadyne ) (Nivalin ) Can worsen asthma Multiple drug interactions Effect usually quite small (cortical dementia) Blocks acetylcholinesterase which decreases acetylcholine Rivastigmine (Exelon ) Memantine (Namenda ) Activation (can be a benefit) NMDA antagonist (neuroprotective), especially with stress. Helps with cognition more than memory (subcortical). Neutriceuticals Omega-3 Fatty Acids (Omacor ) (CorOmega ) and others. Target 1800 mg of EPA Can increase bleeding (blood thinner) Fish burps Oily Stools Stabilizes mood Delays dementia Increase cognitive flexibility (IQ) Decreases anger (especially sudden) Decreases stroke/heart attack Curcumin, Turmeric, Saffron Decreases neurodegenerative disorders by blunting oxidation (free radicals) Huperzine A (Chinese cold moss) Natural Cholanesterase Inhibitor September 24, 2009 6

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