Lorazepam (Ativan) Pharmacology Podcast

On this podcast episode, I discuss lorazepam (Ativan) pharmacology, adverse effects, and common drug interactions.

Lorazepam has numerous dosage forms and the IV formulation does contain propylene glycol which can accumulate if it is used for longer periods of time.

There is a boxed warning for lorazepam when it is used with opioids. The risk for opioid overdose, coma, and death increases significantly.

Lorazepam is an intermediate acting benzodiazpine. It’s half-life for most adult patients is in the 12-18 hour range.

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Clonazepam Pharmacology Podcast

On this podcast episode, I discuss clonazepam pharmacology, adverse effects, pharmacokinetics, and drug interactions.

Clonazepam is a benzodiazepine that enhances the activity of GABA which is an inhibitory neurotransmitter in the central nervous system.

It is important to try to avoid using benzodiazepines like clonazepam with opioids as it can increase the risk of respiratory depression and death.

Clonazepam is an intermediate-acting benzodiazepine that is only commercially available as an oral dosage form.

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Lurasidone Pharmacology

On this podcast episode, I discuss lurasidone pharmacology, adverse effects, and drug interactions.

CYP3A4 is an important enzyme in the breakdown of lurasidone. I discuss this further on this episode.

Lurasidone is best taken with food as this enhances absorption and helps improve drug concentrations.

Lurasidone tends to have a lower risk for metabolic syndrome compared to other antipsychotics which is a nice advantage.

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Desvenlafaxine Pharmacology

On this episode, I discuss desvenlafaxine pharmacology, adverse effects, pharmacokinetics, and drug interactions.

Desvenlafaxine is a serotonin and norepinephrine reuptake inhibitor that can be used for depression.

Renal elimination is an important method of deactivation of desvenlafaxine. Dose adjustments may be recommended as renal function drops below 50 mls/min.

Withdrawal syndrome due is a risk with desvenlafaxine as it has a significantly short half-life.

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Venlafaxine Pharmacology

In this episode, I discuss venlafaxine pharmacology, adverse effect, dose conversion of IR to ER, and drug interactions.

Venlafaxine is notorious for producing withdrawal symptoms when discontinued abruptly. I discuss these in detail on the podcast.

How significant is the interaction of venlafaxine with antiplatelet agents? I discuss that in this episode.

The onset of action is a critical education point that patients must be aware of as it takes some time for venlafaxine to work.

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Trihexyphenidyl (Artane) Pharmacology

On this episode, I breakdown trihexyphenidyl (Artane) pharmacology, adverse effects, and drug interactions.

Trihexyphenidyl is highly anticholinergic and can cause constipation, dry eyes, dry mouth, and urinary retention.

Dementia medications like donepezil can have their effects blunted by the use of trihexyphenidyl.

Trihexyphenidyl is an older anticholinergic that is rarely used for the management of EPS caused by antipsychotics.

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Duloxetine Pharmacology

On this episode, I discuss duloxetine pharmacology, adverse effects, and common drug interactions.

Duloxetine is an SNRI that is used for depression, anxiety, and various pain syndromes like neuropathy and fibromyalgia.

Duloxetine can inhibit CYP2D6 which can lead to higher concentrations of clozapine and propranolol and lower activity of tamoxifen.

CYP1A2 inhibitors like ciprofloxacin can raise concentrations of duloxetine leading to an increased potential for adverse effects.

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Amitriptyline Pharmacology

On this episode, I discuss amitriptyline pharmacology, adverse effects, and drug interactions.

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Quetiapine Pharmacology

On this episode, I discuss quetiapine pharmacology, adverse effects, pharmacokinetics, and drug interactions.

Quetiapine (Seroquel) is a medication seen a fair amount particularly in the geriatric population where there is psychosis associated with dementia. It is classified as an antipsychotic. Mechanistically it’s going to block dopamine receptors, specifically D2. It also has some serotonin receptor blockade antagonism. It does have other activity as well from a mechanism of action standpoint. There is alpha-blocking activity potentially as well as an antihistamine/anticholinergic type of activity. Uses of this medication are schizophrenia, bipolar disorder with associated mania, miscellaneous psychotic disorders, and Parkinson’s type disease with psychosis. Off-label you may see it used for OCD, or augmentation for PTSD and depression.

There is a boxed warning of increased risk of mortality in elderly/dementia patients. As a class, antipsychotics have extrapyramidal symptoms, metabolic syndrome, anticholinergic activity, QTC prolongation, sexual dysfunction, hyperprolactinemia, neuroleptic malignant syndrome, sedation, fall risk, and potentially a drop in blood pressure as well. With quetiapine it is important to recognize that antipsychotics can have varying degrees of how much these adverse effects happen and a lot of them are dose-dependent.

There are three important points in comparison to other antipsychotics. Quetiapine is not that great as far as metabolic syndrome risk goes. It’s in the middle of the other antipsychotics. Its extrapyramidal symptoms are better than most, which is why it’s used so often in Parkinson’s. Quetiapine tends to be more sedating than other antipsychotics. This can be helpful when patients are having psychosis worse in the evening or at night.

Metabolic syndrome is something to worry about more in younger patients. The long-term risk of diabetes and hyperlipidemia is going to be a lot higher for them than an 80-year-old using a low dose for dementia-related aggression.

3A4 is a pathway of breakdown for quetiapine drug interactions. With larger food intakes absorption can increase about 15% to 25% and that’s in the area under the curve. This is not something to be very concerned about unless patients change the way they take it. 

Quetiapine’s drug interactions are mostly additive effects. Watch out for other sedative drugs such as alcohol, opioids, and benzodiazepines. The same goes for drugs causing QT prolongation. Quetiapine has alpha-blocking activity and an added effect on patients with borderline low blood pressure or at risk for falls. It also mechanistically has a potential antihistamine burden that can play a role in adding on to anticholinergic effects. Then lastly it is metabolized partly by CYP3A4 so there is some potential there for drug interactions. Classic enzyme inducers are St. John’s Wort and carbamazepine that would lower the concentration of quetiapine.

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Fluvoxamine Pharmacology

On this episode, I discuss fluvoxamine pharmacology, adverse effects, and most importantly, drug interactions.

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Drug Interactions In Primary Care (Amazing Resource for Practicing Clinicians)

Perils of Polypharmacy (Great Resource for Those Who Work in Geriatrics)