Pharmacology

News of Note

New Generic Versions of Naloxone

Topics: Addiction | Addiction Treatment | Clinical practice | Medication | Naloxone | News of Note | Opioid epidemic | Opioid Use Disorder | Opioids | Overdose | Pharmacology

Naloxone, a rescue medication effective for reversing opioid overdoses, will soon be available in two generic forms for layperson use. Naloxone nasal spray is the generic version of branded Narcan Nasal, which currently sells for $150 for two doses. The generic version will be much cheaper. Naloxone auto-injector is the generic version of Evzio au

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Research Update

Gabapentin Enacarbil XR Efficacy Less Than Expected for AUD

Topics: Addiction | Addiction Treatment | Alcohol | Alcohol use disorder | Alcoholism | Clinical practice | extended-release | Medication | Novel Medications | Pharmacology | Psychopharmacology | Research Update

Review of: Falk DE et al, Alcohol Clin Exp Res 2019;43(1):158–169 Gabapentin enacarbil extended-release (GE-XR) (Horizant) is an extended-release version of gabapentin. GE-XR is a prodrug, meaning that once ingested it is metabolized into gabapentin. It is currently approved for treatment of postherpetic neuralgia and restless legs syndrome. It di

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Research Update

Can Buprenorphine Improve PTSD Symptoms?

Topics: Addiction | Addiction Treatment | Antidepressants | Buprenorphine | Co-occurring disorders | Comorbidity | Dual diagnosis | Medication | Opioid Use Disorder | Pharmacology | PTSD | Research Update | SSRIs

Review of: Lake EP et al, Am J Addict 2019;28(2):86–91 For many years, the mainstay of treatment for PTSD has been the SSRI class of medications, but many of our patients still suffer crippling symptoms despite optimal antidepressant medication dosing. PTSD is often accompanied by opioid misuse, sometimes in an effort to self-treat the hyperarousal

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Article

Mirtazapine Augmentation: Running Low on Rocket Fuel

Topics: Antidepressant Augmentation | Antidepressants | Depression | Depressive Disorder | Mirtazapine | Pharmacology | Pharmacology Tips | Psychopharm Myths | Psychopharmacology | Psychopharmacology Tips | SSRIs | Treatment-Resistant Depression | Venlafaxine

Adding mirtazapine (Remeron) to a serotonergic antidepressant is a popular augmentation strategy. When added to venlafaxine, the combo was thought to possess a particularly potent synergy that Stephen Stahl called “California Rocket Fuel.” However, the strategy has failed in a handful of new studies, some of them much larger than the original data.

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Ask The Editor

Is Paxil the Best SSRI for Anxiety?

Topics: Antidepressants | Anxiety | Anxiety Disorder | Generalized Anxiety Disorder | Panic Disorder | Pharmaceutical Industry | Pharmacology | Pharmacology Tips | Practice Tools and Tips | Psychopharm Myths | Psychopharmacology | Psychopharmacology Tips | PTSD | Social Anxiety Disorder | SSRIs

Dear Dr. Aiken: Your review of Paxil’s risks in the May issue failed to mention a benefit that’s unique to this drug. Isn’t it the best SSRI for anxiety? Dr. Aiken: Paroxetine’s (Paxil’s) reputation as the anti-anxiety SSRI got off to a running start. It was first launched for panic disorder in 1996, two years before its approval for depres

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Article

l-Methylfolate for Depression: Costly Mistake or Good Thinking?

Topics: Antidepressants | CAM Treatments | Deplin | Depression | Depressive Disorder | Folate | Folic Acid | l-methylfolate | methylfolate | Natural Medications | Nutrition | Pharmacology | Pharmacology Tips | Psychopharmacology | Psychopharmacology Tips | Treatment-Resistant Depression

Folate (Vitamin B9) has a long track record as a low-cost, low-risk augmentation strategy in depression. It’s also available in a more expensive form, l-methylfolate (Deplin), that promises better results but at a premium price. So, is the cost worth it? Folate pathwaysFolate (the natural form of folic acid) is a B vitamin that’s important in psych

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News of Note

A New Treatment for Bipolar Depression

Topics: Antipsychotics | Atypical Antipsychotics | Bipolar Depression | Bipolar Disorder | Depression | News of Note | Pharmacology | Psychopharmacology

On May 28, 2019, cariprazine (Vraylar) became the fourth atypical antipsychotic to receive FDA approval for bipolar depression. The approval was based on two randomized controlled trials involving 1,051 patients and lasting 6–8 weeks. These studies grouped patients into fixed doses from 0.75–3 mg/day. The sweet spot seems to be 1.5 mg/day, which was

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Article

Esketamine Gets FDA Approval

Topics: Depression | Depressive Disorder | Esketamine | Pharmacology | Treatment-Resistant Depression

On March 5, 2019, the FDA approved esketamine (Spravato) nasal spray as add-on therapy to traditional antidepressant medications for treatment-resistant depression (TRD). In this article, I will describe the events that led to esketamine’s development, review the data submitted to the FDA, and discuss what the future might hold for esketamine. Backgr

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Article Links

Risk Evaluation and Mitigation Strategy (REMS) Programs

Topics: Depression | Depressive Disorder | Esketamine | Pharmacology | Treatment-Resistant Depression

Certain psychiatric treatments require both the healthcare provider and patient to enroll in a Risk Evaluation and Mitigation Strategy (REMS) program before they are administered. Below are links to enroll: Brexanolone (Zulresso) http://www.zulressorems.com/ Buprenorphine-based therapies (Suboxone, Subutex) https://www.samhsa.gov/medication-assi

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Expert Q&A

Medication Side Effects: Nausea, Sweating, and Dry Mouth

Topics: Pharmacology | Pharmacology Tips | Side Effects

TCPR: What’s the best way to manage side effects: lower the dose of the current medication or use an antidote? Dr. Mago: If the patient can stay well on a lower dose, that’s usually my first approach. Most side effects are dose related. TCPR: For the rest of this interview, we’ll assume that lowering the dose or changing the medication was not

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News of Note

A New Dopamine and Norepinephrine Reuptake Inhibitor for Excessive Sleepiness

Topics: Novel Medications | Pharmacology | Sleep Apnea | Sleep Disorders

Solriamfetol (Sunosi), a new dopamine and norepinephrine reuptake inhibitor (DNRI), has been approved by the FDA “to improve wakefulness in adult patients with excessive daytime sleepiness associated with narcolepsy or obstructive sleep apnea.” The medication has never been studied in psychiatry, but is likely to have important psychiatric ­effects

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News of Note

Brexanolone (Zulresso) for Postpartum Depression

Topics: Depression | Depressive Disorder | Pharmacology | Postpartum Depression | Pregnancy

On March 19, 2019, the FDA approved brexanolone (Zulresso), the first medication for postpartum depression (PPD). Delivered by intravenous injection, brexanolone is an analogue of the hormone allopregnanolone. Allopregnanolone levels fall abruptly after childbirth, which is thought to contribute to PPD by destabilizing GABAA receptors. We covered brexa

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Research Update

A New Proposal for SSRI Withdrawal

Topics: Pharmacology | Pharmacology Tips | SSRIs | Withdrawal

Review of: Horowitz MA and Taylor D, Lancet Psychiatry, March 2019, published online Type of Study: Literature review and clinical guideline Withdrawal problems rank among patients’ top concerns with antidepressants. They include insomnia, flu-like symptoms, irritability, distractibility, and unusual sensory experiences such as “brain zaps.” To

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Article Link

SSRI withdrawal symptoms

Topics: Pharmacology | Pharmacology Tips | SSRIs | Withdrawal

Withdrawal problems rank among patients’ top concerns with antidepressants. They include insomnia, flu-like symptoms, irritability, distractibility, and unusual sensory experiences such as “brain zaps.” Use this PDF tool to check if the patient is having any SSRI withdrawal symptoms at baseline.

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Research Update

Mood Stabilizers and Stroke Risk in Bipolar Disorder

Topics: Bipolar Disorder | Lithium | Medical Comorbidities | Mood Stabilizers | Pharmacology

Review of: Chen PH et al, Br J Psychiatry 2018;1–6. doi:10.1192/bjp.2018.203 Study Type: Case-crossover study People living with bipolar disorder already have a decreased life expectancy of 10+ years compared to the general population (Crump C et al, JAMA Psychiatry 2013;70:931–939). Most of these years of lost life have been attributed to cardiov

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Research Update

New Augmentation Strategies in OCD

Topics: Amphetamines | Novel Medications | OCD | Pharmacology

Review of: Naderi S, Psychiatry Clin Neurosci 2019;73(4):169–174 and Zheng H et al, Eur Neuropsychopharmacol 2019;29(3):397–404 Study types: Positive RCTs Serotonergic agents—both SSRIs and clomipramine—have historically been the cornerstone of pharmacotherapy for OCD. However, response rates are notoriously low, and few patients achieve full

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Article

A Second Look at Genetic Testing

Topics: GeneSight | Genetic Testing | Pharmacology

Genetic tests are marketed with a bold claim: that a handful of genes can predict medication response. AssureRx’s GeneSight is the most popular of these tests, and in 2015 we reviewed the evidence behind its panel. In short, it was lacking, but the company has just released new data that may move it a little closer to the mainstream. What’s

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Article

Ask the Editor: Should You Prescribe Lithium to Suicidal Patients?

Topics: Lithium | Pharmacology | Suicidality

Dear Dr. Aiken: You recommended lithium for suicidal patients in the TCPR 2018 summer issue, but isn’t there a risk of overdose with this strategy? Dr. Aiken: From firearms to bridges, the suicide rate goes down when we erect barriers to the means. Barriers work because suicidal impulses are brief, lasting only 1–2 hours on average. It

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Article

Benzodiazepines in Children and Adolescents

Topics: Benzodiazepines | Child Psychiatry | Pharmacology

Michael, who’s 9, is brought in by his parents for his first psychiatric assessment. His parents report that lately, Michael has been worrying all the time. He asks to sleep in his parents’ bed. This past month, he also began having problems separating from his parents in the morning for school. Michael’s therapist suggested a medication assessmen

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Tales From History

The History of Depakote

Topics: Pharmacology

Valproate originally saw the light of day in the German laboratory of Beverly Burton, in 1882. She was engaged in research on fatty acids, and synthesized a new one, called 2-propylvaleric acid. But she was not able to make this acid into a salt, which is necessary in order to turn it into a solid form, and so she stopped working on it. The compound res

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