(+)-Hyoscyamine and (–)-Scopolamine
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Table 2. 2012 AGS Beers Criteria for Potentially
Table 2. 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Strength of Organ System/ Recommendat Quality of Recomm Therapeutic Category/Drug(s) Rationale ion Evidence endation References Anticholinergics (excludes TCAs) First-generation antihistamines Highly anticholinergic; Avoid Hydroxyzin Strong Agostini 2001 (as single agent or as part of clearance reduced with e and Boustani 2007 combination products) advanced age, and promethazi Guaiana 2010 Brompheniramine tolerance develops ne: high; Han 2001 Carbinoxamine when used as hypnotic; All others: Rudolph 2008 Chlorpheniramine increased risk of moderate Clemastine confusion, dry mouth, Cyproheptadine constipation, and other Dexbrompheniramine anticholinergic Dexchlorpheniramine effects/toxicity. Diphenhydramine (oral) Doxylamine Use of diphenhydramine in Hydroxyzine special situations such Promethazine as acute treatment of Triprolidine severe allergic reaction may be appropriate. Antiparkinson agents Not recommended for Avoid Moderate Strong Rudolph 2008 Benztropine (oral) prevention of Trihexyphenidyl extrapyramidal symptoms with antipsychotics; more effective agents available for treatment of Parkinson disease. Antispasmodics Highly anticholinergic, Avoid Moderate Strong Lechevallier- Belladonna alkaloids uncertain except in Michel 2005 Clidinium-chlordiazepoxide effectiveness. short-term Rudolph 2008 Dicyclomine palliative Hyoscyamine care to Propantheline decrease Scopolamine oral secretions. Antithrombotics Dipyridamole, oral short-acting* May -
Antiemetics/Antivertigo Agents
Antiemetic Agents Therapeutic Class Review (TCR) May 1, 2019 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, digital scanning, or via any information storage or retrieval system without the express written consent of Magellan Rx Management. All requests for permission should be mailed to: Magellan Rx Management Attention: Legal Department 6950 Columbia Gateway Drive Columbia, Maryland 21046 The materials contained herein represent the opinions of the collective authors and editors and should not be construed to be the official representation of any professional organization or group, any state Pharmacy and Therapeutics committee, any state Medicaid Agency, or any other clinical committee. This material is not intended to be relied upon as medical advice for specific medical cases and nothing contained herein should be relied upon by any patient, medical professional or layperson seeking information about a specific course of treatment for a specific medical condition. All readers of this material are responsible for independently obtaining medical advice and guidance from their own physician and/or other medical professional in regard to the best course of treatment for their specific medical condition. This publication, inclusive of all forms contained herein, is intended to be educational in nature and is intended to be used for informational purposes only. Send comments and suggestions to [email protected]. May 2019 Proprietary Information. Restricted Access – Do not disseminate or copy without approval. © 2004-2019 Magellan Rx Management. All Rights Reserved. 3 FDA-APPROVED INDICATIONS Drug Manufacturer Indication(s) NK1 receptor antagonists aprepitant capsules generic, Merck In combination with other antiemetic agents for: (Emend®)1 . -
Scopolamine As a Potential Treatment Option in Major Depressive Disorder - a Literature Review
Isr J Psychiatry - Vol. 58 - No 1 (2021) Scopolamine as a Potential Treatment Option in Major Depressive Disorder - A Literature Review Dusan Kolar, MD, MSc, PhD, FRCPC Department of Psychiatry, Queen’s University, Mood Disorders Research and Treatment Service, Kingston, Ontario, Canada as selective serotonin reuptake inhibitors (SSRIs) and ABSTRACT serotonin norepinephrine reuptake inhibitors (SNRIs), are currently used as first-line pharmacological treat- Introduction: Slow onset response to antidepressants ments for major depressive disorder (MDD). Despite the and partial response is a common problem in mood availability of a comprehensive list of antidepressants, disorders psychiatry. There is an ongoing need for rapid- approximately 50% of the patients on an antidepressant acting antidepressants, particularly after introducing regimen experience non-response to treatment (3, 4). ketamine in the treatment of depression. Scopolamine Furthermore, the mood elevating effects of antidepres- may have promise as an antidepressant. sant medication is often delayed (5). It is recommended Methods: The author conducted a literature review to that the patient be treated for at least six weeks with identify available treatment trials of scopolamine in the adequate dosage of the given antidepressant before unipolar and bipolar depression in PubMed, the Cochrane considering making changes to the treatment (5). Partial database, Ovid Medline and Google Scholar. to no response to treatment with antidepressants and delayed onset of action indicate that there is a need for Results: There have been eight treatment trials of the development of novel and improved medications scopolamine in MDD and bipolar depression. Seven for the treatment of depression. Many studies in recent studies confirmed significant antidepressant effects years have recognised two different classes of drugs with of scopolamine used as monotherapy and as an rapid and robust antidepressant effects. -
The Promise of Ketamine
Neuropsychopharmacology (2015) 40, 257–258 & 2015 American College of Neuropsychopharmacology. All rights reserved 0893-133X/15 www.neuropsychopharmacology.org Editorial Circumspectives: The Promise of Ketamine William A Carlezon*,1 and Tony P George2 1 2 Department of Psychiatry, Harvard Medical School, McLean Hospital, Belmont, MA, USA; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada Neuropsychopharmacology (2015) 40, 257–258; doi:10.1038/npp.2014.270 In this issue we reprise a Feature called Circumspectives. offering hope that fast-acting but safe antidepressants are The general format of a Circumspectives article is similar to possible. a debate, with separate sections in which two thought Despite growing enthusiasm for ketamine and its leaders articulate their individual positions on a topic of promise, Dr Schatzberg describes some sobering details great importance to our community of researchers. The and gaps in knowledge. Ketamine is a drug of abuse and, distinguishing element, however, is that the piece ends with despite some exceptionally elegant studies on the mechan- a ‘reconciliation’ that is co-authored by both and includes ism (eg, Li et al, 2010; Autry et al, 2011), there is no ideas or experiments that will move the field forward. consensus on how it produces therapeutic effects. As one The current Circumspectives (Sanacora and Schatzberg, example, Dr Schatzberg points out similarities in some of 2015) is entitled ‘Ketamine: Promising Path or False the molecular actions of ketamine and scopolamine, Prophecy in the Development of Novel Therapeutics for another familiar and long-standing member of our phama- Mood Disorders?’. It is co-authored by Gerard Sanacora and copea shown to produce rapid antidepressant effects (Furey Alan F Schatzberg, who are leaders in this field. -
Drugs to Avoid in Patients with Dementia
Detail-Document #240510 -This Detail-Document accompanies the related article published in- PHARMACIST’S LETTER / PRESCRIBER’S LETTER May 2008 ~ Volume 24 ~ Number 240510 Drugs To Avoid in Patients with Dementia Elderly people with dementia often tolerate drugs less favorably than healthy older adults. Reasons include increased sensitivity to certain side effects, difficulty with adhering to drug regimens, and decreased ability to recognize and report adverse events. Elderly adults with dementia are also more prone than healthy older persons to develop drug-induced cognitive impairment.1 Medications with strong anticholinergic (AC) side effects, such as sedating antihistamines, are well- known for causing acute cognitive impairment in people with dementia.1-3 Anticholinergic-like effects, such as urinary retention and dry mouth, have also been identified in drugs not typically associated with major AC side effects (e.g., narcotics, benzodiazepines).3 These drugs are also important causes of acute confusional states. Factors that may determine whether a patient will develop cognitive impairment when exposed to ACs include: 1) total AC load (determined by number of AC drugs and dose of agents utilized), 2) baseline cognitive function, and 3) individual patient pharmacodynamic and pharmacokinetic features (e.g., renal/hepatic function).1 Evidence suggests that impairment of cholinergic transmission plays a key role in the development of Alzheimer’s dementia. Thus, the development of the cholinesterase inhibitors (CIs). When used appropriately, the CIs (donepezil [Aricept], rivastigmine [Exelon], and galantamine [Razadyne, Reminyl in Canada]) may slow the decline of cognitive and functional impairment in people with dementia. In order to achieve maximum therapeutic effect, they ideally should not be used in combination with ACs, agents known to have an opposing mechanism of action.1,2 Roe et al studied AC use in 836 elderly patients.1 Use of ACs was found to be greater in patients with probable dementia than healthy older adults (33% vs. -
Nomination Background: Ketamine Hydrochloride (CASRN: 1867-66-9)
KETAMINE Nomination TABLE OF CONTENTS Page 1.0 BASIS OF NOMINATION 1 2.0 BACKGROUND INFORMATION 1 3.0 CHEMICAL PROPERTIES 2 3.1 Chemical Identification 2 3.2 Physico-Chemical Properties 3 3.3 Purity and Commercial Availability 4 4.0 PRODUCTION PROCESSES AND ANALYSIS 6 5.0 PRODUCTION AND IMPORT VOLUMES 7 6.0 USES 7 7.0 ENVIRONMENTAL OCCURRENCE 7 8.0 HUMAN EXPOSURE 7 9.0 REGULATORY STATUS 7 10.0 CLINICAL PHARMACOLOGY 7 11.0 TOXICOLOGICAL DATA 13 11.1 General Toxicology 13 11.2 Neurotoxicology 14 12.0 CONCLUSIONS 15 APPENDIX A 17 APPENDIX B 23 APPENDIX C 27 1 KETAMINE 1.0 BASIS OF NOMINATION Ketamine, a noncompetitive NMDA receptor blocker, has been used extensively off - label as a pediatric anesthetic for surgical procedures in infants and toddlers. Recently, Olney and coworkers have demonstrated severe widespread apoptotic degeneration throughout the rapidly developing brain of the 7-day-old rat after ketamine administration. Recent research at FDA has confirmed and extended Olney’s observations. These findings are cause for concern with respect to ketamine use in children. The issue of whether the neurotoxicity found in this animal model (rat) has scientific and regulatory relevance for the pediatric use of ketamine relies heavily upon confirmation of these findings that may be obtained from the conduct of an appropriate study in non-human primates. 2.0 BACKGROUND INFORMATION The issue of potential ketamine neurotoxicity in children surfaced as a result of FDA’s reluctance to approve an NIH pediatric clinical trial using this compound because of its documented neurotoxic effects in young rats (published in several papers over the last ten years by Olney and co-workers). -
The Anticholinergic Toxidrome
Poison HOTLINE Partnership between Iowa Health System and University of Iowa Hospitals and Clinics July 2011 The Anticholinergic Toxidrome A toxidrome is a group of symptoms associated with poisoning by a particular class of agents. One example is the opiate toxidrome, the triad of CNS depression, respiratory depression, and pinpoint pupils, and which usually responds to naloxone. The anticholinergic toxidrome is most frequently associated with overdoses of diphenhydramine, a very common OTC medication. However, many drugs and plants can produce the anticholinergic toxidrome. A partial list includes: tricyclic antidepressants (amitriptyline), older antihistamines (chlorpheniramine), Did you know …… phenothiazines (promethazine) and plants containing the anticholinergic alkaloids atropine, hyoscyamine and scopolamine (Jimson Weed). Each summer, the ISPCC receives approximately 10-20 The mnemonic used to help remember the symptoms and signs of this snake bite calls, some being toxidrome are derived from the Alice in Wonderland story: from poisonous snakes (both Blind as a Bat (mydriasis and inability to focus on near objects) local and exotic). Red as a Beet (flushed skin color) Four poisonous snakes can be Hot as Hades (elevated temperature) found in Iowa: the prairie These patients can sometimes die of agitation-induced hyperthermia. rattlesnake, the massasauga, Dry as a Bone (dry mouth and dry skin) the copperhead, and the Mad as a Hatter (hallucinations and delirium) timber rattlesnake. Each Bowel and bladder lose their tone (urinary retention and constipation) snake has specific territories Heart races on alone (tachycardia) within the state. ISPCC A patient who has ingested only an anticholinergic substance and is not specialists have access to tachycardic argues against a serious anticholinergic overdose. -
3 Drugs That May Cause Delirium Or Problem Behaviors CARD 03 19 12 JUSTIFIED.Pub
Drugs that May Cause Delirium or Problem Behaviors Drugs that May Cause Delirium or Problem Behaviors This reference card lists common and especially problemac drugs that may Ancholinergics—all drugs on this side of the card. May impair cognion cause delirium or contribute to problem behaviors in people with demena. and cause psychosis. Drugs available over‐the‐counter marked with * This does not always mean the drugs should not be used, and not all such drugs are listed. If a paent develops delirium or has new problem Tricyclic Andepressants Bladder Anspasmodics behaviors, a careful review of all medicaons is recommended. Amitriptyline – Elavil Darifenacin – Enablex Be especially mindful of new medicaons. Clomipramine – Anafranil Flavoxate – Urispas Desipramine – Norpramin Anconvulsants Psychiatric Oxybutynin – Ditropan Doxepin – Sinequan Solifenacin – VESIcare All can cause delirium, e.g. All psychiatric medicaons should be Imipramine – Tofranil Tolterodine – Detrol Carbamazepine – Tegretol reviewed as possible causes, as Nortriptyline – Aventyl, Pamelor Gabapenn – Neuronn effects are unpredictable. Trospium – Sanctura Anhistamines / Allergy / Leveracetam – Keppra Notable offenders include: Insomnia / Sleep Valproic acid – Depakote Benzodiazepines e.g. Cough & Cold Medicines *Diphenhydramine – Sominex, ‐Alprazolam – Xanax *Azelasne – Astepro Pain Tylenol‐PM, others ‐Clonazepam – Klonopin *Brompheniramine – Bromax, All opiates can cause delirium if dose *Doxylamine – Unisom, Medi‐Sleep ‐Lorazepam – Avan Bromfed, Lodrane is too high or -
Medicare Part D Excluded Drug List
MEDICARE PART D EXCLUDED DRUGS LIST 2016_updated July 2016 Reason: LIST = multiple reasons it's excluded; "not covered under Part D law" Reason: Not properly listed with FDA = CMS considers it best practice for Part D sponsors to consider the proper listing of a drug product with the FDA as a prerequisite for making a Part D drug coverage determination. The FDA is unable to provide regulatory status determinations through their regular processes if a drug product is not properly listed. Therefore, Part D sponsors should begin the drug coverage determination process by confirming that a prescription drug product national drug code (NDC) is properly listed with the FDA. Reason: DESI = Less Than Effective (LTE) drug for ALL indications Label Name Reason 1ST BASE CRE Bulk Ingredient 2-FUCCOSYLLA PAK LACTO-N Medical Food ABANEU-SL SUB Vitamin/Mineral ABLAVAR INJ 244MG/ML Diagnostic Agent ACACIA EXTRA SOL 1:20 Non-standardized allergenic ACCUCAINE INJ 1% LIST ACD FORMULA SOL A Blood Component ACD-A SOL Blood Component ACLARO PD EMU 4% Cosmetic ACREMONIUM SOL 20000PNU Non-standardized allergenic ACTCT FLEX 3 PAD 4"X4" Not properly listed with FDA ACTHREL INJ 100MCG Diagnostic Agent ACTI ANTIMIC PAD 2"X2" Not properly listed with FDA ACTI ANTIMIC PAD 4"X4" Not properly listed with FDA ACTICOAT 7 PAD 2"X2" Not properly listed with FDA ACTICOAT 7 PAD 4"X5" Not properly listed with FDA ACTICOAT ABS PAD 4"X5" Not properly listed with FDA ACTICOAT MOI PAD 2"X2" Surgical Supply/Medical ACTICOAT MOI PAD 4"X4" Surgical Supply/Medical ACTICOAT MOI PAD -
Ce4less.Com Ce4less.Com Ce4less.Com Ce4less.Com Ce4less.Com Ce4less.Com Ce4less.Com
Hallucinogens And Dissociative Drug Use And Addiction Introduction Hallucinogens are a diverse group of drugs that cause alterations in perception, thought, or mood. This heterogeneous group has compounds with different chemical structures, different mechanisms of action, and different adverse effects. Despite their description, most hallucinogens do not consistently cause hallucinations. The drugs are more likely to cause changes in mood or in thought than actual hallucinations. Hallucinogenic substances that form naturally have been used worldwide for millennia to induce altered states for religious or spiritual purposes. While these practices still exist, the more common use of hallucinogens today involves the recreational use of synthetic hallucinogens. Hallucinogen And Dissociative Drug Toxicity Hallucinogens comprise a collection of compounds that are used to induce hallucinations or alterations of consciousness. Hallucinogens are drugs that cause alteration of visual, auditory, or tactile perceptions; they are also referred to as a class of drugs that cause alteration of thought and emotion. Hallucinogens disrupt a person’s ability to think and communicate effectively. Hallucinations are defined as false sensations that have no basis in reality: The sensory experience is not actually there. The term “hallucinogen” is slightly misleading because hallucinogens do not consistently cause hallucinations. 1 ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com How hallucinogens cause alterations in a person’s sensory experience is not entirely understood. Hallucinogens work, at least in part, by disrupting communication between neurotransmitter systems throughout the body including those that regulate sleep, hunger, sexual behavior and muscle control. Patients under the influence of hallucinogens may show a wide range of unusual and often sudden, volatile behaviors with the potential to rapidly fluctuate from a relaxed, euphoric state to one of extreme agitation and aggression. -
Hyoscyamine, Atropine, Scopolamine, and Phenobarbital
PATIENT & CAREGIVER EDUCATION Hyoscyamine, Atropine, Scopolamine, and Phenobarbital This information from Lexicomp® explains what you need to know about this medication, including what it’s used for, how to take it, its side effects, and when to call your healthcare provider. Brand Names: US Donnatal; Phenohytro What is this drug used for? It is used to treat irritable bowel syndrome. It is used to treat ulcer disease. It may be given to your child for other reasons. Talk with the doctor. What do I need to tell the doctor BEFORE my child takes this drug? If your child is allergic to this drug; any part of this drug; or any other drugs, foods, or substances. Tell the doctor about the allergy and what signs your child had. If your child has any of these health problems: Heart problems due to bleeding, bowel block, enlarged colon, glaucoma, a hernia Hyoscyamine, Atropine, Scopolamine, and Phenobarbital 1/9 that involves your stomach (hiatal hernia), myasthenia gravis, slow-moving GI (gastrointestinal) tract, trouble passing urine, or ulcerative colitis. If your child has ever had porphyria. If your child has been restless or overexcited in the past after taking phenobarbital. If your child is addicted to drugs or alcohol, or has been in the past. This is not a list of all drugs or health problems that interact with this drug. Tell the doctor and pharmacist about all of your child’s drugs (prescription or OTC, natural products, vitamins) and health problems. You must check to make sure that it is safe to give this drug with all of your child’s other drugs and health problems. -
Hb 185 an Act Listing Synthetic
62nd Legislature HB0185 AN ACT LISTING SYNTHETIC MARIJUANA AND SALVIA AS DANGEROUS DRUGS; REQUIRING RULEMAKING BY THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES; PROVIDING PENALTIES; AMENDING SECTIONS 44-12-102, 45-9-101, 45-9-102, 45-9-110, 50-31-306, 50-31-310, AND 50-32-222, MCA; AND PROVIDING AN IMMEDIATE EFFECTIVE DATE. BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MONTANA: Section 1. Section 44-12-102, MCA, is amended to read: "44-12-102. Things subject to forfeiture. (1) The following are subject to forfeiture: (a) all controlled substances that have been manufactured, distributed, prepared, cultivated, compounded, processed, or possessed in violation of Title 45, chapter 9; (b) all money, raw materials, products, and equipment of any kind that are used or intended for use in manufacturing, preparing, cultivating, compounding, processing, delivering, importing, or exporting any controlled substance in violation of Title 45, chapter 9, except items used or intended for use in connection with quantities of marijuana in amounts less than 60 grams; (c) except as provided in subsection (2)(d), all property that is used or intended for use as a container for anything enumerated in subsection (1)(a) or (1)(b); (d) except as provided in subsection (2), all conveyances, including aircraft, vehicles, and vessels, that are used or intended for use in any manner to facilitate the commission of a violation of Title 45, chapter 9; (e) all books, records, and research products and materials, including formulas, microfilm, tapes, and data,