CNS drugs

[A] CNS drugs

(a) gen anesthetics	商品名
inhalation
Desflurane	Suprane 240ml/bt	維持全麻
Sevoflurane	Ultane 250ml/bt	引導/維持全麻
IV
Etomidate	Etomidate-lipuro 20mg/10ml/amp	引導全麻, 短效安眠藥  Iv 0.2-0.3mg/kg	[副]: myoclonus
Thiamylal sod	Citosol (500mg/20ml/vial, 2.5%)	引導全麻 Sedation: iv 0.5-1.5mg/kg Status epilepticus:  Iv 3-5mg/kg + 2-5mg/kg/h ivd	C/I:  -resp obst  -severe CV instability or shock  -status asthmaticus
Propofol (GABAa agonist)	Fresofol (200mg/20ml/amp) 稀釋 by D5W或直接用	引導/維持全麻 Total IV anesthesia (TIVA), ICU sedation,  Iv 0.25-1mg/kg + 1.5-4.5mg/kg/h status epilepticus:   1-2mg/kg+ 2-4mg/kg/h	[副]: apnea, myoclonus, 低血壓, 高血脂, Rare: 靜脈栓塞 尿液變色<1%	用超過2天 (≥4mg/kg/h) 可導致propofol infusion synd (Major risk factor:  -poor oxygen delivery  -sepsis  -嚴重大腦受傷  -高劑量
Ketamine	Ketalar (50mg/ml, 10ml/vial=500mg)	Induction: iv 0.5-2mg/kg 維持: iv 30-90 ug/kg/min  (60kg=1.8-5.4mg/min= 120mg/h Sedation, analgesia: iv (2-3’) 0.2-0.8mg/kg Ivd 5-10ug/kg/min		Barbiturate & ketamine 勿併用(ppt)
麻醉藥輔助治療
Fentanyl citrate	Fentanyl (0.1mg/2ml/amp) (0.5mg/10ml/amp)	Premedication: iv 25-100ug or 0.5-2ug/kg Adjunct to anesthesia:  Iv 1-3ug/kg ↓Stress response to插管:  Iv 2-6ug/kg	[副]: 口乾, CNS抑制, 呼吸抑制	腎差不需調整劑量
Midazolam	Dormicum (5mg/1ml/amp) Midation (15mg/3ml/amp)	Pre-OP sedation: im 0.07-0.08 mg/kg 全麻:  導引:0.05-0.15 mg/kg維持: 0.05mg/kg prn  0.06mg/kg/h ICU sedation:  0.02-0.1mg/kg + 0.04-0.2mg/kg/h Status epilepticus: IM, intranasal: 0.1-0.2mg/kg  Iv: 0.1-0.2mg/kg + 0.05-0.6/kg/h	[副]: 低血壓, 呼吸抑制, Ffg需減低劑量:  -老者  -虛弱者  -併用CNS抑制劑時	-Tachyphylaxis in status epilepticus (24-48h後,需調高劑量數倍) -給藥48h後,常會蓄積,造成過度sedation

(B) Sedation & hypnotics

(1) BZD (GABAA W1+W2)
Brotizolam	Lendormin (0.25mg/#)	Insomnia: 0.5-1# hs 術前sedation: SL 1-2#  Duration 7h		小心: 嚴重重症肌無力, COPD
Flunitrazepam	Modipanol (1mg/#) (FM2)	Insomnia: 0.5-4# hs		小心: 嚴重重症肌無力, COPD
Estazolam	Eurodine (2mg/#)	Insomnia: 0.5-1# hs	[副]: asthenia, hypokinesia	Ditto
Nitrazepam	Limin (5mg/#)	Insomnia: 1-2# hs		Ditto
(2) Imidazopyridine (GABAA-W1)
Zolpidem	Stilnox (10mg/#) Stilnox CR (6.25mg/#)	Insomnia: 0.5-2# hs  CR 1-2#hs	[副]:夢遊,  依賴/rebound insomnia	Ditto
Zaleplon	Sonimax (10mg/#)	Insomnia: 0.5-2# hs
(3) Barbiturate
Phenobarbital	Phenobarbital 30mg/# Phenobital 100mg/ml/amp	Sedation: PO, 1#tid, 2#bid IM: 0.5-1 amp 抗痙攣: PO, 2# b-tid IM: 0.5-1amp b-tid Status epilepticus:  IM: 20mg/kg (≦60mg/min), 20分後仍SZ, add another 10mg/kg

(C) 抗焦慮藥

(1) BZD
Diazepam	Diazepam (2mg/#) Dupin (5mg/#) Dupin (10mg/2ml/amp)	Anxiety: PO 1# tid, Deep IM 1支 肌肉鬆弛: PO 2-10mg tid  IM, IV 5-10mg Status epilepticus  IV 10mg (0.3mg/kg), may repeat after 10-20’ Acute Alc w/d:  PO 10mg t-qid  IV 5-10mg q5-10’ until calm Insomnia: 1-5mg hs	[副]: 呼吸變慢	Prefer slow iv, if iv not available, ->IM deltoid only
Lorazepam	Lowen (0.5mg/#) Anxicam (2mg/ml/amp)	Hypnotics: 1-8#hs 焦慮: 1-4# tid (max 20#/d) Acute Alc w/d:  PO,SL: 2-4# q4-6h  IM,IV: 1-2支q15-20’ till calm或改ivd Status epilepticus:  Iv,IM 2支(0.1mg/kg), 10-20’後可repeat 止吐: IV, PO/SL: 1-2mgq4-6		小心: 嚴重重症肌無力, COPD
Bromazepam	Lexotan (1.5mg/#)	焦慮: 1-2-4-6# tid 老人: 減半
Alprazolam	Xanax (0.25mg/#)	Anxiety, depression, panic d/o  1-2# tid, max 5-6mg/d		小心: 嚴重重症肌無力, COPD
Oxazolam	Secorin (10mg/#)	Anxiety: 1-2# tid		Ditto

(D) Antidepressants

SSRI/ SNRI w/d syndrome

Criterion A: 使用該藥4-8wk 後, 停藥/interrupted or 減藥

Criterion B: 使用該藥4-8wk 後, 停/減藥 1-10天內, 產生至少2個ffg symp

  Dizziness; N and/or V; HA; lethargy; anxiety and/or agitation; 頭or四肢有tingling(paresthesia),numbness, “’electric”-shock-like 感

  Tremors; sweating; insomnia; irritability; vertigo; diarrhea

(1) SSRI
Fluoxetin	Fluronin (20mg/cap)	Depression, OCD, panic d/o: 1# qd (max 80mg/d)	[副]: 緊張,HA,GI, insomnia, anorgasm, bruising, mydriasis, delayed ejaculation
Sertraline	Zoloft (50mg/#)	Depression, OCD, Panic   1-2#/d (max 4#)	Ditto
Paroxetine	Seroxat (20mg/#)	Depression, OCD, panic   1-2#/d (max 3#)	Ditto
Escitalopram	Lexapro (10mg/#)	Depression, OCD, panic   1-2# qd	Ditto
(2) SNRI (serotonin/NE reuptake inhibitors)
Venlafaxine	Efexor XR (3.75mg/cap) Efexor XR (75mg/cap)	Depression, OCD, panic   初:1-2 cap qd (max 75mg x3-4 cap/d)	Ditto BW↓or↑(edema)	<150mg: 只serotonergic effect 150mg: dual effect (+NE)
Duloxetine	Cymbalta (30mg/cap)	Depression, anxiety, neuropathic pain, stress incontinence, fibromyalgia   1-2 cap qd (max 4#/d)	Ditto
(3) NE/dopamine reuptake inhibitor (NDRI)
Bupropion	Wellbutrin XL (150mg/#)	Depression  1-2# qd (max 3)	[副]: agitation, tremor, insomnia, Nausea, nightmare, SZ (0.1%)	小心: epilepsy
(4) 5HT2 /α2/ 5HT3 antagonist
Mirtazapine	Smilon (30mg/#)	Depression, pruritus, migraine: 0.5-2#/d hs-bid	頭嗜睡, 口乾, 便秘 REM behavior d/o	特性: block major receptor s/w pruritus (H1, 5HT2, 5HT3)
(5) 5HT2 antagonist
Trazodone	Mesyrel (50mg/#)	Depression: 1# b-tid (max 8-12#) Insomnia: 0.5-3# hs, Erectile dysfxn: 1-2# hs	[副]: 嗜睡, GI, 姿態低血壓, priapism, HA
(6) melatonergic agonist/ 5-HT2C antagonist
Agomelatine	Valdoxan (25mg/#)	Depression: 1-2# hs	S/E: GI, drowsy
(7) Tricyclic drugs
Imipramine	Fronil (25mg/#)	Depression, enuresis, neuralgia: 1-4#/d or hs Insominia: 1-4# hs	S/E: 心悸,口乾,便秘,尿滯留,視力模糊
Doxepine	Sinequan (2mg/cap)	Depression< anxiety, insomnia, urticaria:  1-6# hs or divided (max 12#)	Ditto
Deanxit 複方	Flupentixol 0.5mg (neuroleptics極低劑量) Melitracen 10mg (TCA)	Depression, anxiey, apathy:  初:1-2# om, 1# noon  維: 1# om
(8) Reversible MAO-A inhibitor
Moclobemide	Moclod (150mg/#)	Atypical depression, depression in dementia, resistant depression:  1-2# b-tid (max 4-6#/d)	S/E: sleep disturbance, dizziness, nausea, HA	含tyramine高食物勿食用過量

(e) anti-manic drug

Lithium carbonate	Ligilin (300mg/cap)	Acute mania or 預防 預防migraine or cluster HA: 1-4 cap HS or 2 cap bid	S/E: 多尿/口渴,無力, tremor, 水腫, vertigo, acne	下列情形很易造成鋰中毒: 嚴重腎病,脫水,低血鈉,利尿劑

(f) Anti-psychotic drug

   -突然停用此類藥, 可能在數日到數周內導致psychotic symp rebound akathisia / Parkinsonism or w/d dyskinesia惡化/復發,

   -如果需停藥, taper it over 4-8 wks

(1) Typical anti-psychotic
Flupentixol	Fluanxol depot (20mg/amp)	Psychotic d/o:  1-2 amp deep IM q2-4wk
Prochlorperazine	Novamin (5mg/#) Novamin (5mg/1ml/amp)	Nausea/ vomiting, acute or chronic psychosis:  1-2# t-qid; IM 1-2 amp q3-4h (max 8支/d) Post-OP N/V: 術後1-2支IM	S/E: EPS, dyspnea, HA, drowsy, 姿態低血壓
Haloperidol	Binin-U (5mg/#) Haldol (5mg/1ml/amp) Haldol decanoas (50mg/1ml/amp)	Psychotic d/o:  1-5mg hs-tid (max 6#/d)  IM 1-2支, q1-4h prn  Decanoas: IM 1-3支q4wk Tourette’s d/o, hiccup  PO: 0.5-5mg hs (max 2-3#/d)	S/E: EPS, drowsy, 姿態低血壓, QT延長	在甲狀腺亢進病人May cause嚴重neurotoxic 反應
Sulpiride	Dogmatyl (50mg/#) Sulpin (200mg/#)	Depression: 50-100-200 tid Psychosis/schizophrenia:  100-200mg tid or 200-400mg bid (max 1.2-2.4g/d	[副]: agitation, dizzy, sedation, 乳漏, 無月經, ESP (rare)
(2) Novel anti-psychotic
Multi-receptor antagonist
Clozapine	Clozaril (25mg/#) Clozaril (100mg/#)	Schizophrenia:  初: 0.5-1#/d(12.5-25mg/d), then ↑ 1-2#/d (25-50mg/d) q2-3 wk  Dose range 200mg hs or 100-150mg b-tid (max: 600-900mg/d)	副: 姿態低血壓, 體重↑, granulocytopenia, drowsy, SZ, 便秘,尿失禁, 流口水, 高血糖 (in wks to yrs)	C/I: WBC ≦3000
Olanzapine	Zyprexa zydis (5mg/#) 口溶錠	Schizophrenia, bipolar d/o, 1-4# qd Depression:輔助藥 1-2.5#qd	副: HA, 嗜睡, dizzy, 乳漏 (↑PRL) 體重↑/水腫, 口渴,便秘,尿失禁, 高血糖 (in wks to yrs) 高TG.
Zotepine	Lodopin (50mg/#)	Schizophrenia: 0.5-1# tid (max 6-9#/d)	S/E: 嗜睡/失眠, dizzy 心悸, 口渴, 便秘,體重↑(less), 乳漏(↑PRL),
Quetiapine	Seroquel XR (50mg/#) Seroquel XR (300mg/#)	Schizophrenia/ bipolar d/o:  300-600mg qd (晚上) (max 800-1200mg/d) MDD (major depressive d/o):  輔助藥:初:50mg, then 150-300mg qd 失眠: 25-100mg Anxiety: 50-150mg/d	副: 姿態低血壓, 嗜睡/失眠, HA, dizzy, 水腫, 口乾, 體重↑(less),
5HT2/D2 antagonist
Risperidone	Risperdal (2mg/#) Risperdal oral solution (1mg/ml, 30ml/bt) Risperdal Consta 25mg/vial Risperdal Consta 37.5mg/vial	Schizophrenia, bipolar d/o:  PO: 0.5-4# qd or divided  IM: 1-2支Q2WK    Onset: 3wk duration:3-4wk	[副]: Sedation, HA, 口乾/便秘,尿滯留 乳漏(↑PRL), 水腫 EPS (≥6mg/d)
Paliperidone	Invega ER (6mg/#) Invega ER (9mg/#)	Schizophrenia, bipolar d/o:   6-12mg (1-2#) qd		-為risperidone之主要活性代謝物
Zaprasidone	Geodon (60mg/cap)	Schizophrenia, bipolar d/o:   1 cap qd-bid (max 4 cap/d)	S/E: sedation, HA, N/V, rash, 便秘, EPS(rare), QT延長(rare)
D2/D3 antagonist
Amisulpride	Solian (200mg/#)	Schizophrenia  Negative synd: 0.25-1.5# qd  Positive synd: 2# hs-bid (max 3# bid)	S/E: 嗜睡,乳漏, 姿態低血壓(rare)
Dopamine/5-HT partial agonist
Aripiprazole	Abilify (10mg/#)	Schizophrenia, bipolar d/o:   1-3# qd 憂鬱症: 輔助藥 0.25-1.5# qd	S/E: HA, 失眠, 嗜睡, 體重↑(less) PRL(No or輕微↑)

(g) Anti-convulsants

(1) Hydantoin
Phenytoin (DPH)	Dilantin (100mg/cap) Aleviatin (250mg/5ml/amp) -give undiluted or in N/S	Grand mal, complex partial SZ, neuralgia Seizure d/o: PO  Load: 3 cap tid or 5 cap bid (15-20mg/kg/d)  維:3 cap hs Status epilepticus: IV  15-20mg/kg (60kg=900-1200mg=4支) (25-50mg/min)	S/E: N/V, 嗜睡, nystagmus, 牙齦hyperplasia, acne, 多毛	Give additional 5-10mg/kg if SZ 持續
L.A 複方	Phenytoin 50mg Phenobarbital 20mg	1-2# tid
(2) Barbiturate
Phenobarbital	Phenobarbital 30mg/# Phenobital (100mg/amp)
(3) BZD
Diazepam	Diazepam (2mg/#) Dupin (5mg/#) Diazepam (10mg/2ml/amp)
Nitrazepam	Limin (5mg/#)