MC3 Psychopharmacology
Reference Cards
Developed by Paresh Patel, MD, PhD
in collaboration with
Sheila Marcus, MD
Richard Dopp, MD
Maria Muzik, MD, MS
Nasuh Malas, MD, MPH
www.depressioncenter.org/mc3
These reference cards have been made available through a generous gift
from the Ravitz Foundation
Medication
Preg. Class
FDA appr. in
Youth
Antidepressants*
Antidepressants*
Start (mg)
(Target)
Fluoxetine
≥7y OCD
(Prozac)
C ≥8y MDD
5-10
(20-40)§
Sertraline
(Zoloft)
12.5-25
(50-200)§
Titration
Interval
1° Advantages
1° Disadvantages
Long titration or
washout duration
t ½ (h)
7-14 days
Behaviorally activating
Long t ½ (~1 week)
26
27-32
96-384
4 days
~“Decaf Prozac” (less
activating)
Escitalopram
≥12y MDD
(Lexapro) C
5-10
(10-20)
4-5 days
± Fewer side effects
Few drug interactions
Fluvoxamine
≥8y OCD
(Luvox)
C
25
(50-200)§
3-4 days
Citalopram
-(Celexa)
C
5-10
(20-40)
4-5 days
Few drug interactions
Bupropion
-(Wellbutrin) C
37.5-75
(150-300)
4-5 days
Behaviorally activating ↑Anxiety
Augment SSRI; Tx ADHD ↓Seizure threshold
21-37
Trazodone C --
25 (100)
2 days
1° for insomnia
Priapism (rare)
10
Mirtazapine
-(Remeron) C
7.5-15
(15-30)
4-5 days
1° for insomnia
Weight gain
20-40
Paroxetine
-(Paxil)
D
5-10
(10-40)
4 days
Mildly sedating and
anxiolytic
↑SI risk of SSRIs
↑Drug interactions
21
Venlafaxine
-(Effexor)
C
25-37.5
(150-300)
3-4 days
Hypertension
↓Lit. support
5-11
Duloxetine
-(Cymbalta) C
20
(40-60)
3-4 days
↓Lit. support
12
Paresh Patel, MD,
2015 MC3
C
≥6y OCD
n/v, HAs
16
↑QTc risk at >40mg
35
* Also used for anxiety and chronic pain management. §Higher doses needed for OCD.
Greyed out medications are less typically used (i.e., only after failed 1st and 2nd trials)
Antipsychotics
Antipsychotics (1)
(1)
Generic
Risperidone
Aripiprazole
FDA Approval
≥13y schizophrenia (oral)
≥10y bipolar mania/mixed
≥5y to 16y autistic irritability
≥6y autistic agitation
≥10y bipolar mania
≥13y schizophrenia
Ziprasidone
Quetiapine
Olanzapine
Haloperidol
Paliperidone
Pimozide
Chlorpromazine
Thioridazine
Clozapine
Paresh Patel, MD,
2015 MC3
≥13y schizophrenia (IR)
≥10y bipolar
≥13y schizophrenia
≥13y bipolar mixed/manic
≥3y psychosis, Tourette's,
severe behavior d/o
≥12y Tourette's
≥6y severe behavior d/o
≥2y
1º Advantages
↓Cost
Long t ½
± Antidepressant
↓Metabolic risk
↓Metabolic, NMS risk
Sedation
↓TD, NMS risk
Clozapine-like
↓Cost
Minimal weight gain
OROS form
Sedation
Sedation
↓TD risk
Sedation
1 º Disadvantages
↑Prolactin
↑Cost
Akathisia
↑QT
↑Metabolic risk
↑TD risk
↑Prolactin
↑TD risk
Arrhythmias
Retinopathy, Arrhythmias
Agranulocytosis, Seizures
↑Metabolic risk
OROS = osmotic release oral system TD = tardive dyskinesia NMS = neuroleptic malignant syndrome
Antipsychotics (2)
Generic
(Trade)
Formulations (mg)
†CPZ
100=
Starting
Dose (mg)
Target
Dose (mg)
Titration Plasma
Interval Peak (h)
t 1/2
(hr)
Risperidone *
(Risperdal)
0.25, 0.5, 1, 2, 3, 4, 1mg/ml
SL: 0.5, 1, 2, 3, 4
Dp: 12.5, 25, 37.5, 50 mg
2
0.25 to 1
Child: 0.5-2
Adol: 1 - 4
q5-7d
1 to 2
20 to 30
Aripiprazole *
(Abilify)
2, 5, 10, 15, 20, 30, 1mg/ml
SL: 10, 15
IM: 7.5mg/ml
7.5
2 to 5
Child: 2.5-15
Adol: 5 - 30
q7-14d
3 to 5
50 to 72
Ziprasidone
(Geodon)
20, 40, 60, 80
IM: 20mg/ml
60
20 to 40
20 to 160
qd
5
5 to 7
Quetiapine *
(Seroquel)
25, 50, 100, 200, 300, 400
XR: 50, 150, 200, 300, 400
75
IR: 12.5-25
50 - 750
XR: 50
qd
2
6 to 7
Olanzapine *
(Zyprexa)
2.5, 5, 7.5, 10, 15, 20
SL: 5, 10, 15, 20
IM: 10mg vial
Dp: 210, 300, 405 mg
5
2.5 to 5
2.5-20
q5-7d
6
21 to 54
Paliperidone
(Invega)
1.5, 3, 6, 9
Dp: 39, 78, 156, 234 mg
3
3
3 to 12
q5-7d
24
21 to 30
Haloperidol *
(Haldol)
0.5, 1, 2, 5, 10, 20, 2mg/ml
IM: 5mg/ml
Dp: 50, 100mg/ml
2
0.25 to 1
1 to 6
q5-7d
2 to 6
3 to 6
Clozapine
(Clozaril)
25, 50, 100, 200, 50mg/ml
SL: 12.5, 25, 100, 150, 200
50
6.25 to 25
Child: 150-300
q1-2d
Adol: 200-600
1 to 4
12
Paresh Patel, MD,
2015 MC3
SL = sublingual, IM = intramuscular, Dp = depot; XR = extended release; * = FDA
approved in children †= approx. dose equivalents to 100 mg of chloropromazine
Paresh Patel, MD,
2015 MC3
·
·
·
·
·
∆∆∆
·
·
·
·
*
·
·
·
∆∆∆
·
·

·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·

·
·
·
*
·

?
·
·
·
·
·
·
·
*
·
·
·
·
*
·
·
∆∆∆ ∆∆∆
·
*
Topiramate
·
·
·
·
∆∆∆
·
*
·
·
·
·
Valproate
·
·

·
·
·
(Ox)Carbam
azepine
∆∆∆
∆∆∆
·
·
Quetiapine
·
*
·
·
·
Lamotrigine
·
·



-
Lithium
∆∆∆
∆∆∆
Haloperidol
·
·
Paliperidone
Olanzepine
Clozapine
·
·
·
·
·
∆∆∆ ∆∆∆
∆∆∆ ∆∆∆
Ziprasidone
·

Risperidone
Acute Parkinsonism
Akathisia
Diabetes
↑ Lipids
Liver Toxicity
Neutropenia
Orthostasis
↑ PRL/galactorrhea
↑ QTc interval
↓ Renal fxn
Sedation
Seizures
SJS, TEN, Rash
Tardive Dyskinesia
↓ Thyroid fxn
Withdrawal Dyskinesia
Weight Gain
Aripiprazole
Antipsychotic &
Mood Stabilizer
Side Effects
·
·
·
∆∆∆ = major,  = moderate, * = mild, · = minor, empty cell = none or minimal
PRL = prolactin, SJS = Stevens-Johnsons Synd, TEN = toxic epidermal necrolysis
·
Antipsychotics - Starting and Monitoring in Children
UM Guidelines, based on Correll, Int Rev Psychiatry 2008;20(2):195-201
Generic
Pre-Screen
Mood Stabilizer Safety
Monitor
Serious Risks
↓Renal fxn
↓[Na]
↓Thyroid
↑Parathyroid
Unmask Brugada syndrome
Lithium
Preg, CBC, BUN, Cr, UA,
TFTs, Calcium
NSAIDs, diuretics
q1-2wk until stable: EKG, [Li]
q1-2mo: [Li]
Stable: q6mo CBC, BUN, Cr, UA, TFTs,
[Li], [Ca]
Valproic Acid
(VPA)
Preg, CBC, LFTs
Urea cycle d/o
1, 2mo: CBC, LFTs, [VPA]
Stable: q4-6mo CBC, LFTs, [VPA]
Suicidal Ideation
Hepatic Necrosis (<2yo)
↑[NH4]
↓Platelets
Carbamazepine (Carb)
Preg, BUN, CBC, LFTs
Recent MAOIs?
h/o porphyrias?
h/o cytopenia?
q1wk until stable: CBC, LFTs
Stable: q3-6mo CBC, LFTs, [Carb]
± Eye exams, UA, BUN
Suicidal Ideation
Agranulocytosis
↑IOP
SJS/TEN
Liver failure
Lamotrigine
Preg, Allergies/Rashes
SLE?
Cr, CBC, LFTs
Stable: q3-6mo Cr, CBC, LFTs
± Eye exams (prolonged tx)
Suicidal Ideation, SJS/TEN, Liver failure,
Dyscrasias. Adjust dose ↓ with VPA or
↑ with other AEDs
Topiramate
Preg, IEMs
Cr, [HCO3-], LFTs
Stable: q3-6mo Cr, [HCO3-], [NH4],
LFTs
Suicidal Ideation
Metabolic acidosis
↑[NH4]
Glaucoma
Sedation (“Dopamax”)
Oxcarbamazepine
Preg, Cr, Na, CBC, LFTs
Recent MAOIs?
h/o porphyrias?
h/o cytopenia?
Stable: q3-6mo [Na], LFTs
Suicidal Ideation
SJS/TEN
Liver failure
SIADH
Dyscrasias
Paresh Patel, MD,
2015 MC3
IOP = Intraocular pressure; SJS/TEN = Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis
Mood Stabilizer (MS) Dosing
Generic
(Trade)
LS Preg Starting Daily
Class Total (mg)
<25kg: 300
A
Lithium
25-40kg: 600
D
(Lithobid, Eskalith)
>40kg: 900
<25kg: 250
Valproic Acid
B
25-40kg: 375
D
(Depakene, Depakote)
>40kg: 500
<25kg: 100
B
Carbamazepine
25-40kg: 200
D
(Tegretol)
>40kg: 400
<40kg: 12.5
C
Lamotrigine
C >40kg: 25
(Lamictal)
<40kg: 15
C
Topiramate
D >40kg: 25
(Topamax)
Oxcarbamazepine D
(Trileptal)
Paresh Patel, MD,
2015 MC3
C
8-10/kg/d
Titration
Typical Daily mg
Schedule (mg) (Target Blood Level)
600-1500
300 mg
25-30mg/kg/d
q3-5d
(0.6-1.2 mEq/L)
500-2000
10 mg/kg/d
30mg/kg/d
q3-4d
(50-120 mg/L)
12-27 ∝ age
100 mg
q5d
400-1200
(8-12 mg/L)
18-55 initial
12-17 stable
12.5 - 25 mg
q7d
25 mg
q3-7d
5 mg/kg/d
q3d
75 - 400
(4.5-7.5mg/kg/d)
50 - 400
SZ: 5-9mg/kg/d
600-2100
t 1/2 (hr)
4-14 child
9-18 adult
13
21
parent: 2
10-OH: 9
LS = literature support: A = effective in placebo-controlled randomized trials (PC-RT) in children, B =
effective in PC-RT in adults, C = positive results in child/adol open trial(s), D = positive in child/adol
case report(s). SZ = dosing in seizures.
Stimulants (1)
Ritalin
Methylin c
Methylin Soln.
Ritalin SR *
Methylin ER *
Metadate ER *
Ritalin LA s
Metadate CD s
Concerta *
Daytrana (patch)
Quillivent XR
Focalin
Formulations
(mg)
5, 10, 20
2.5, 5, 10
1mg/ml, 2mg/ml
20
10, 20
20
10, 20, 30, 40
10, 20, 30, 40, 50, 60
18, 27, 36, 54
10, 15, 20, 30 /9 hrs
5mg/ml
2.5, 5, 10
Focalin XR *
Adderall
5, 10, 15, 20, 25, 30, 35, 40
5, 7.5, 10, 12.5, 15, 20, 30
+
+++
+
30
mg/d
Adderall XR s
5, 10, 15, 20, 25, 30
+++
Dexedrine
5, 10, 15
40
mg/d
DexAMPH
AMPH
DexMPH
MPH
Type
Trade
t½
FDA
Appr
FDA
Max
Starting
Dose
60
mg/d
0.25 to 1
mg/kg/d
+
++
≥6y
+++
0.1 to 0.5
mg/kg/d
≥3y
+
5, 10, 15
Dexedrine CR s
++
20, 30, 40, 50, 60, 70
Vyvanse
+++
≥6y
70 mg
20-30 mg
For All: discuss risk for anorexia, insomnia, tics, ↑BP, arrhythmia, ↓growth (±)
Paresh Patel, MD,
2015 MC3
MPH = Methylphenidate; AMPH = Amphetamine, * = do not crush or
cut, c = chewable available, s = may be sprinkled on food
Stimulants (2)
Pre-Screen
• Pt and family cardiovascular hx (not recommeded if pt has a structural heart defect
or family hx of sudden cardiac death)
• May unmask Tourette’s disorder
• Obtain Baseline: PE, HR, BP, height & weight
Dose Titration
•
•
•
•
Adequate Trial
• 1 week at max dose
Monitor
• Weekly for 2-4 wks (titration period)
• monthly until “stable” then at discretion
• Review HR, BP, height, weight at each visit
Prognosis
• Rule of thirds (1/3 remain syndromal, 1/3 subsyndromal, 1/3 remit).
• OK to consider drug holidays.
Other Notes
•
•
•
•
•
•
Paresh Patel, MD,
2015 MC3
q3-4 days to weekly
Short-acting forms given BID or TID; Long-acting are daily
May supplement with a short-acting form after school
Last dose (short-acting) no later than 4pm
Abuse potential less w/ longer acting forms (esp. Vyvanse)
Watch for irritability as medication wears off later in the day
Watch for mood deterioration (bipolar risk?)
Higher doses may increase risk for psychosis
Some forms should not be crushed, cut or chewed
Long term benefit remains an open question
Stimulant “Alternatives”
Bupropion
Atomoxetine
Dosing
≤70 kg: 0.5 mg/kg/d;
Titrate incrementally q3d (minimum)
to 1.2 mg/kg/d
Max: 1.4 mg/kg/d or 100 mg/d
>70 kg: 40 mg/day
↑after 3d (minimum) to 60-80 mg/d
Max: 100 mg/d
t ½ = 5 hrs
8-12yo: 75mg/d
↑q1-2wk by 50-75mg
Adol: 100 mg/d
↑q1-2wk by 50-100mg
Max: Least of 6 mg/kg/d or 300 mg
IR: BID to TID, SR: BID, XL: daily
t ½ = 21 (parent) to 37 (metab) hrs
Paresh Patel, MD,
2015 MC3
Notes
• When transitioning from stimulants, cross-taper
• Adj. dose if on CYP2D6 inhibitors
• Adj. dose if hepatic insufficiency
• 1.6 to 1.8 mg/kg/d may be OK
• BID dosing better tolerated
• Black box warning (suicidality)
• FDA approved for ≥6yo
SEs: N/V, decreased appetite, dizziness, fatigue,
mood swings, headache, insomnia, and hot flushing
• Indications (adult): Intolerance to stimulants,
smoking, ADHD with depression, seasonal mood d/o
• Lowers seizure threshold - Limit to < 150mg/8hr
• Avoid in bulimia, anorexia, or bipolar disorder
• Black box warning (suicidality)
• Not FDA approved in children
SEs: insomnia, tremor, agitation, weight loss, N/V,
dizziness
α2-agonists
Dosing
Start: 0.05mg
0.05 mgatqHS
Start:
time of day needed
Clonidine
á
by 0.05mg
per week,
↑0.05
mg every
3 toconsider
7d BID dosing
Typical range: 0.05 to 0.4 mg/d
Frequency: 3 to 4 doses/d for ADHD ; or
qHS only for PTSD, insomnia.
Must be taken daily; caution parents not
to give other prn if using for insomnia.
Kapvay is an extended release alternative to
clonidine and can be initiated at 0.1 mg qHS.
Preg
class C ; t ½ = 12-16 hr
Kapvay should not be crushed/chewed.
Preg class C ; t ½ =12-16 hr
Guanfacine
Start:
time of day needed
Start: 0.05mg
0.5 mg at
qHS
↑0.5 mg/wk
Typical range: 0.5 to 4 mg/d
1 to 2 doses/d (1x/d
(1x/dfor
forIntuniv)
Intuniv)
Intuniv is a once daily formulation started at 1mg.
Preg class B ; t ½ = 17 hr
Intuniv should not be crushed/chewed.
Preg class C ; t ½ =17 hr
Paresh Patel, MD,
2015 MC3
Notes
• Baseline EKG advisable
• Monitor BP @ baseline, dose ∆, f/u
• SEs: sedation (50%), dizziness, anorexia,
orthostatic HTN, ↓BP, ↓HR, ↓vascular
resistance, depression, nightmares,
enuresis.
• Rebound HTN, insomnia if stopped
abruptly - taper over 1-2 weeks
• Available as a patch (same dosing)
• Baseline EKG advisable
• Monitor BP @ baseline, dose ∆, f/u
• SEs: sedation (less than Clonidine),
otherwise same.
• Less risk for rebound HTN
© 2015 Regents of the University of Michigan: Michael J. Behm, Mark J. Bernstein,
Laurence, B. Deitch, Shauna Ryder Diggs, Denise Ilitch, Andrea Fischer Newman,
Andrew C. Richner, Katherine E. White, Mark S. Schlissel, ex officio.
An equal opportunity/affirmative action employer.
5/2015 v.5