Unknown Speaker 00:00 Hi, welcome Speaker 1 00:07 to Rosalind Franklin University, College of Pharmacy top 200 drugs podcast. Speaker 2 00:12 This podcast is produced by the pharmacy faculty members to supplement study material for students learning the top 200 drugs we're hoping that our real life clinical pearls and discussions from practicing pharmacists will help you study for your next drug quiz. Dr. Sean Kane 00:28 And now on to the show. Welcome to Rosalind Franklin University's top 200 drugs podcast, week four, spring edition. I'm your co host, Dr. Kane, and I'm Dr. Holmes, and this week we're talking about atypical antipsychotics, some antidepressants and a few other agents as well. So we'll go ahead and get started. The first agent is Bupropion, and it has two different brand names. One is Wellbutrin, the other is Zyban. Speaker 3 00:55 So the two different brand names are used for two different indications. The brand name Wellbutrin is indicated for depression only, and the brand name Zyban is indicated for smoking cessation only. Dr. Sean Kane 01:08 It's important to note that although this agent is approved for depression, it is not approved for anxiety, like our SSRIs and SNRIs, Speaker 3 01:16 and the reason for that is that it can actually worsen anxiety. Dr. Sean Kane 01:20 So the way that Bupropion or Wellbutrin or Zyban works is that it's a weak dopamine, norepinephrine reuptake inhibitor, so we don't have the serotonergic reuptake inhibition that we saw with SSRIs and SNRIs. Speaker 3 01:33 Some of the adverse drug reactions that we look out for are CNS stimulation. So this might translate to insomnia, restlessness, or as mentioned previously, worsening of anxiety. The medication is actually chemically similar to an amphetamine, which is why it can worsen these CNS effects and cause anxiety, agitation. Some of Dr. Sean Kane 01:55 the other adverse effects, as you would expect, would be weight loss, because it has a stimulating effect. We can see that. And interestingly enough, unlike many of the other antidepressants, we don't see the sexual side effects that we do with something like an SSRI or an SNRI. Speaker 3 02:10 One rare but serious adverse drug reaction with Bupropion would be seizures, which is dose dependent, and we see it more often with immediate release formulation, Dr. Sean Kane 02:20 if I'm not mistaken, Dr. Holmes, it actually has contraindication in patients who have seizure disorders. Speaker 3 02:27 That's right. So any patient with a history of seizure disorder or conditions that might put them at risk for having seizures would be contraindicated to have Bupropion. Conditions that may increase a patient's probability of having a seizure, maybe anorexia or bulimia or benzodiazepine or alcohol withdrawal, any history of a previous seizure or head trauma could be a risk factor for seizure. Yeah. Dr. Sean Kane 02:56 So as far as how Bupropion comes, it comes as three varieties with Wellbutrin. So we have an immediate release that you have to take two times or three times a day. We have a sustained release, or Wellbutrin SR, which you can take daily, up to bid. And then we have an extended release, which is a newer product under Wellbutrin XL, which is a once daily formulation Speaker 3 03:18 with those products. It's important that if we are using the extended release formulation, because this medication can cause insomnia or agitation, that we dose it in the morning, always in the morning. Dr. Sean Kane 03:29 And then finally, our last formulation is for smoking cessation, under the brand name of Zyban, and this is taken either daily or bid. Next we're Speaker 3 03:38 going to move on to the medication, venlafaxine or Effexor. Dr. Sean Kane 03:43 So this agent is approved for depression and anxiety, just like our other SNRI, duloxetine or Cymbalta. So I know that we've covered many of the adverse drug reactions with duloxetine or Cymbalta, and we share many of those adverse effects, like sexual dysfunction. It has a box warning for suicidal ideations, the platelet aggregation inhibition, so risk of bleeding, hyponatremia, a low sodium level. Also, patients who discontinue the drug quickly may experience withdrawal symptoms similar to Cymbalta or duloxetine. We worry about some of the norepinephrine reuptake inhibition effects like hypertension and tachycardia. Speaker 3 04:23 Patients may need to be monitored more closely. If they do have hypertension, they may or may not be on blood pressure medication. They can still be appropriate candidates for this medication, but they certainly need to be monitored for increases in heart rate and blood pressure Dr. Sean Kane 04:38 along the same lines of the norepinephrine reuptake inhibition, we can see CNS stimulation, so insomnia or anxiety, and also maybe even a modest decrease in total body weight. We can see modest increases in lipids, specifically triglycerides and total cholesterol. So this also needs to be monitored as far as how it comes we have two different flavors of venlafaxine or Effexor. We have regular Effexor, which is an immediate release formulation. Then we have Effexor XR, which is a daily extended release formulation. Speaker 3 05:09 And again, we would tend to dose Effexor XR, or extended release venlafaxine in the morning, due to its risk of activating type side effects, such as insomnia, anxiety and nervousness, so Dr. Sean Kane 05:22 kind of switching gears. The next four top 200 drugs that we're going to be discussing are atypical antipsychotics. Dr. Holmes, could you explain to the listeners when we would use atypical antipsychotics in a clinical setting? Speaker 3 05:34 Sure, traditionally, antipsychotics of both generations were used just for schizophrenia or psychosis. But within the last 10 years, we've seen an increase in indications labeled indications for a variety of uses, including adjunct treatment for depression, bipolar disorder, autism, Tourette's and the list goes on and on. Mainly, we're using these medications for psychotic disorders and schizophrenia or add on treatment for depression and bipolar disorder. In terms of indications, it's important to remember that every product has different indications, which is outside the scope of this podcast. So typical antipsychotics, traditionally referred to as neuroleptics, are older generation of antipsychotic medications, they tend to have different side effects than our newer generation or atypical antipsychotics. The most important way to differentiate the two generations is by side effects, so older generation antipsychotics or typical antipsychotics, tend to have more adverse drug reaction related to movement disorders, muscle disturbances, extra pyramidal symptoms such as tardive dyskinesia and akathisia, whereas atypical antipsychotics, we see less movement disorders and more metabolic changes, so changes in weight, changes in cholesterol, changes in waist circumference with the new generation antipsychotics. Dr. Sean Kane 07:07 So Dr. Holmes for the listeners, could you give an example of the most typical, typical antipsychotic? Speaker 3 07:14 So the one that comes to mind is traditionally, haloperidol, or Haldol, a class wide box warning to remember with all antipsychotics, typical antipsychotics and atypical antipsychotics. So both generations do have a box warning regarding an increased risk of mortality when used for dementia related psychosis. So when used for this purpose, patients do have an increased risk of all cause death. Dr. Sean Kane 07:41 The first atypical antipsychotic is aripiprazole or Abilify. The brand and generic names are fairly easy to remember because they both start with the letter A. Speaker 3 07:51 This is an atypical or newer generation antipsychotic, also called a second generation antipsychotic, and it works by reducing dopamine through partial dopamine agonism. Dr. Sean Kane 08:04 So I'm sure that our astute pharmacy students would understand the difference between a full and a partial agonist, right? I should hope so. So, because it's a partial agonist, it means that it does activate the dopamine receptor, but it's not as good as traditional dopamine, which would be a full agonist. So what happens is, it sits on the receptor, it will activate it, but it will also block too much dopamine. So we call it partial in that if the patient doesn't have enough dopamine, it increases the amount of receptor activity, but if the patient has too much dopamine, it actually decreases the total amount of receptor activation. Clinically. What kinds of adverse effects do you see in your patients who take Abilify or aripiprazole? Speaker 3 08:46 So aripiprazole is generally pretty well tolerated. We did mention that all second generation or atypical antipsychotics do have a risk of metabolic changes, but we see more CNS activation with this agent when compared to the others. So this might translate to some agitation, perhaps insomnia. And what we see in a lot of patients is this term, akathisia. So akathisia is a feeling of inner restlessness. The patient can't sit still. They have the need to walk around and move their legs and feel jittery all the time. Dr. Sean Kane 09:23 So as far as the dosage forms of Abilify or aripiprazole, we have the traditional tablet. We have an orally disintegrating tablet they call a Discmelt. We have an oral solution and then a monthly intramuscular injection called Abilify Maintena. So our next atypical antipsychotic is Quetiapine or Seroquel. Speaker 3 09:43 So the mechanism of action is similar to the other atypical antipsychotics. It's an antagonist of dopamine and serotonin. Dr. Sean Kane 09:52 So the main adverse effect profile that we see with Quetiapine or Seroquel is somnolence or sedation. Sometimes the medication is actually given for this Speaker 3 10:00 purpose, we also see other anticholinergic type side effects such as orthostasis, dry mouth, dry eye, possible, and we tend to see quite a bit of weight gain with this agent. Dr. Sean Kane 10:12 One way to remember the adverse effect of somnolence is that the word quiet is almost in the generic name of Quetiapine. Speaker 3 10:20 So dosage forms of Quetiapine are immediate release, which is, tends to be twice a day dosing, and then an extended release product, which is usually daily dosing. Dr. Sean Kane 10:31 And I'm guessing that most patients would probably want to take the medication before bed. Speaker 3 10:35 That's right. Dr. Kane, and oftentimes this medication is used off label, therefore it is not indicated for this use, but is used off label as a hypnotic medication due to its sedating qualities. Dr. Sean Kane 10:49 So the next top 200 atypical antipsychotic drug is Risperidone or Risperdal. And this works similarly to all of our other atypical antipsychotics, which are serotonin and dopamine antagonists, Speaker 3 11:03 so they were pretty creative with the brand generic names of this medication. Risperdal is the brand name. Risperidone is the generic name. Pretty easy, pretty easy. Dr. Sean Kane 11:14 As far as its adverse effect profile, we do see the somnolence that we saw with agents like Quetiapine or Seroquel. But unlike many of our atypicals, we do see some movement disorders with this that we don't usually see with our other atypicals. Speaker 3 11:27 Yeah, that's right. Dr. Kane, so we tend to remember that it's the older generation or the typical antipsychotics that do have a higher incidence of movement disorders, but we can see it in this generation as well, and we do see movement disorders associated with Risperidone. Dr. Sean Kane 11:43 So the other two interesting adverse effects with Risperidone or Risperdal is weight gain, which we do see with many of the atypical antipsychotics. But the more interesting one is lactation. Even in men, Speaker 3 11:56 prolactin is mediated through the dopamine pathway, and as it's antagonized with this medication, prolactin levels can increase in both men and women, resulting in lactation or gynecomastia, which would be breast enlargement, again, both men and women. Dr. Sean Kane 12:12 So the dosage forms that we have for Risperidone or Risperdal are the traditional tablet, an orally disintegrating tablet, which is called the M-TAB, a solution, and then every 2 week injection called Risperdal Consta. Speaker 3 12:28 Next, we're moving on to olanzapine or Zyprexa, another atypical antipsychotic. Dr. Sean Kane 12:33 Now, when I think of Zyprexa or olanzapine, I think of an agent that hits all sorts of different receptors in the Speaker 3 12:39 body, which usually translates to all sorts of different side effects. Dr. Sean Kane 12:44 In addition to the dopamine and serotonin antagonism that we saw with the other atypical antipsychotics, we also have alpha one antagonism, which causes problems like orthostatic hypotension and anticholinergic antihistamine side effects that causes things like sedation, other Speaker 3 13:00 adverse drug reactions with this medication, olanzapine, brand name Zyprexa, would be similar to what we see in the other atypical antipsychotics, such as metabolic changes, or what is termed a metabolic syndrome, and it tends to be pretty significant with this medication. So with metabolic syndrome, we're looking at weight gain, diabetes, increased fasting blood glucose and increase in waist circumference. Olanzapine or Zyprexa comes in several different dosage forms, an oral tablet, an orally disintegrating tablet or Zydis. Zyprexa Zydis is the orally disintegrating tablet, an immediate release IM injection used for more acute situations and a sustained release IM injection or Relprevv. It's important to remember that Relprevv injections require the patient to be monitored for a minimum of three hours post injection due to a risk of a very severe sedation syndrome. So three hours for Relprevv, post injection, they need monitoring. Dr. Sean Kane 14:04 All right, kind of switching gears. We're going to talk about Sinemet, or carbidopa-levodopa, which is not an agent for psychosis. Speaker 3 14:11 So this medication is actually used for Parkinson's disease. Kind of the opposite of our psychotic disorders where we have an imbalance of dopamine where there is not enough dopamine in the nigrostriatal tract, so patients need more dopamine to normalize their movements. Dr. Sean Kane 14:29 You probably notice that there's two different medications in Sinemet. The first is levodopa, which is kind of a precursor to dopamine that in the body will get converted to dopamine. The other is carbidopa. This essentially blocks the peripheral breakdown of levodopa so more levodopa can make it into the brain before it gets converted to dopamine and broken down. Speaker 3 14:50 Probably the biggest adverse drug reaction associated with this medication, and most common would be GI upset. So we do give it with meals, and this is also due to absorption. Dr. Sean Kane 15:00 And so some of the less common adverse effects are things like orthostatic hypotension and then also somnolence, and sometimes the sedative effect can be very quick in onset. Even when patients are doing normal daily activities, they can fall asleep very quickly. Speaker 3 15:15 One other risk associated with long term use of carbidopa levodopa is a risk of dyskinesias. Some important patient counseling points to remember are to space doses evenly over the waking hours due to a very short half life of the medication being about 1.5 hours, and sometimes patients will need to take smaller doses more frequently for better control. Dr. Sean Kane 15:37 So as far as dosage forms of carbidopa, levodopa or Sinemet. We have a tablet, a CR tablet, and then an orally disintegrating tablet. So moving on to our over the counter products. The first is pramoxine. It has a number of different brand names, and the brand name depends on the dosage form. But this is essentially a topical anesthetic that blocks the sodium channel so it prevents pain or irritation on the skin. Speaker 3 16:01 So we'd use this, typically, to relieve pain from hemorrhoids or other skin irritations. Dr. Sean Kane 16:07 And as far as the dosage forms that we have, it's really everything under the sun, from a rectal foam called Proctofoam. We have a topical gel, lotion, ointment, cream, even a suppository and a spray. And a number of different brand names include Itch-X, Tucks and Anusol. The next over the counter agent is Neosporin, or triple antibiotic, and the ingredients are Polymyxin B, Neomycin and Bacitracin. Speaker 3 16:34 This medication is used topically to prevent infections and cuts or scrapes. Dr. Sean Kane 16:39 The only patient counseling point I would have about Neosporin is, obviously, if the infection or the cut starts to look worse, that they should see a healthcare provider, and Neosporin can sometimes cause a topical dermatitis, which is allergen mediated. So our last over the counter agent is povidone iodine. The brand name is Betadine. Speaker 3 16:59 This is a topical anti fungal agent that kills more than just bacteria, working on fungi, viruses and other microorganisms. It's commonly used to prep skin for surgical procedures, but unfortunately, can cause skin irritation and will definitely stain clothing Dr. Sean Kane 17:17 All right. So to wrap up, week four, the first agent we discussed was Bupropion, and it had two different brand names, Wellbutrin and Zyban. Speaker 3 17:25 The second medication we discussed was venlafaxine, which is also known as Effexor and Effexor XR. Dr. Sean Kane 17:32 We then discussed four different atypical antipsychotics. The first was aripiprazole or Abilify, then Quetiapine or Seroquel. Then we moved to Risperidone or Risperdal Speaker 3 17:44 olanzapine or Zyprexa was last. Dr. Sean Kane 17:47 And then we switched gears and talked about carbidopa-levodopa, or Sinemet for Parkinson's disease. Then we talked Speaker 3 17:53 about some over the counter products for wound care and burns, starting with pramoxine, which would be Itch-X, Anusol, Tucks pads. Dr. Sean Kane 18:02 And then we talked about Neosporin or Polymyxin B, Neomycin and Bacitracin all combined into one. Speaker 3 18:09 And then povidone iodine, which is also known as Betadine. Dr. Sean Kane 18:13 That concludes week four of Rosalind Franklin University's top 200 drugs podcast. I'm your co host, Dr. Kane, Unknown Speaker 18:19 and I'm Dr. Holmes. Study hard. Speaker 1 18:23 This has been an educational production by the Rosalind Franklin University College of Pharmacy. Dr. Sean Kane 18:27 This podcast is copyright Rosalind Franklin University of Medicine and Science. Speaker 1 18:32 No participants have any conflicts of interest to disclose. This podcast is for educational purposes only and is not intended to treat a particular patient. This information this information should not be used in lieu of the judgment of a healthcare provider. Theme music for this podcast is an excerpt of Metro Mix by sea salt released under Creative comedy.