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AKT - Lizzie Bain > 1. Psychiatry Drugs > Flashcards

1. Psychiatry Drugs Flashcards

1
Q

What are the monitoring requirements for Valproate?

A

Weight/BMI
FBC and LFT
Check on starting, at 6 months, then annually
DO NOT offer to women of childbearing age - would require pregnancy prevention programme

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2
Q

What are the effects of Valproate in pregnancy and what is the Pregnancy Prevention Programme?

Valproate is banned during pregnancy for migraine and bipolar.

A

Birth defects (11%)- spina bifida, cleft palate, limb and organ malformations, developmental disorders incl ASD.
Pregnancy prevention programme -
- patient signed risk acknowledgement form
- highly effective contraception = LARCs: Cu-IUD, LNG-IUS, progestogen only implant, sterilisation.
- see specialist every year

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3
Q

People with severe mental illness are at high risk of which physical illness?

A

Cardiovascular co-morbidity. Due to: genetic factors, poor lifestyle choices and use of antipsychotics

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4
Q

What are the treatments for social anxiety disorder?

A

Self help
Psychological theray - CBT
Medication - SSRI : sertraline or escitalopram

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5
Q

What are the contraindications to SSRIs?

A
  • Manic phase of biopolar
  • Poorly controlled epilepsy
  • Known QT prolongation or congenital Long QT (for citalopram and escitalopram)
  • Use with other drugs which prolong QT ( for citalopram and escitalopram)
  • Severe hepatic impairment (sertraline)
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6
Q

What are the cautions for SSRIs?

A
  • Hx GI bleeding
  • Hx mania
  • Cardiac disease
  • DM
  • Epilepsy (must stop if seizures develop)
  • angle closure glaucoma
  • hepatic impairment (prolongs half life - reduce dose, or increase dosing interval in mild-mod impairment)
  • Renal impairment (for citalopram and escitalopram)
    *Concurrent ECT
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7
Q

What are the adverse effects of SSRIs?

A
  • Cardiac- palps (common), tachycardia, QT prolongation
  • GI - reduced appetite, nausea, diarrhoea, weight changes
  • CNS - headache, dizzy, drowsy, sleep disorders, tremor, paraesthesia, seizure (uncommon), serotonin syndrome (rare).
  • Psychiatric - insomnia (very common), agitation, anxiety (common) Advise that symptoms of anxiety, agitation, hopelessness, or suicidal ideas may increase when starting treatment
  • Skin - rash, hyperhidrosis (common), alopecia, pruritis, urticaria (uncommon)
  • Other: sexual dysfunction (can persist after Rx stopped) Options: switch to mirtazapine, reduce dose of SSRI, reassurance.
    hyponatraemia (rare), thrombocytopenia (rare).
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8
Q

What are the clinical features of serotonin syndrome?

A

Confusion
Delirium
Shivering
Sweating
BP changes
Myoclonus

combo of SSRI nad MAOI most severe

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9
Q

What are the clinical features of hyponatramia?

A

Dizziness
Drowsiness
Confusion
Nausea
Muscle cramps
Seizures

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10
Q

Which drugs interact with SSRIs?

A
  • Anti-epileptics - SSRIs & all antidepressants reduce seizure threshold. Sertraline safest. Carbamazepine reduces sertraline level.
  • Antidiabetics - SSRIs affect BM control. Need to monitor BM when stopping/starting
  • Aspirin /NSAIDs/anticoags/antiplatelets - increased bleeding risk (GI). Monitor INR in warfarin. Cocaine+citalopram. Consider mirtazapine instead.
  • Grapefruit juice - reduced sertraline level.
  • HIV drugs - reduce SSRI efficacy
  • Lithium - serotonin syndrome or NMS. Also increased QT interval.
  • MAOIs = CONTRAINDICATED - fatal SS or NMS. Use mirtazapine instead.
  • SNRIs (venlafaxine/duloxetine) - increased risk SS or NMS - monitor for fever/tremor/diarrhoea/agitation. Increased QT interval with venlafaxine.
  • Tamoxifen with fluoxetine or paroxetine. Both inhibit CYP liver enzme - reduce tamoxifen level
  • sedative drugs
  • St Johns wort, opioids, triptans - increased risk SS or NMS. Try mirtazapine instead with triptans.
  • amiodarone/antiarrhythmics, antipsychotics incl haloperidol, TCAs, sidenafil - all prolong QT. Sertraline preferred.
  • diuretics, NSAIDs, antipsychotics, carbamazepine, CCBs, ACEI, laxatives - all cause hyponatraemia
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11
Q

What advice should be given in general when starting an antidepressant?

A
  • symptoms of anxiety, agitation, hopelessness, or suicidal ideas may increase when starting treatment
  • Usually starts to work within 4 weeks
  • Medication usually needed for >6 months after remission of symptoms - to reduce relapse risk
  • Not addictive but withdrawal symptoms can happen if stopped suddenly
  • May affect alertness/concentration and ability to drive - especially on starting or increasing dose.
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12
Q

When should a person be reviewed after starting (or increasing) antidepressant medication?

A
  • After 1 week if aged 18-25 years, or high risk of suicide. Then again within 4 weeks.
  • Within 2 weeks for most other people. Then further reviews as needed.

Ensure they have social support and sources of help if symptoms worsen

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13
Q

they are both SSRIs

Which two drugs should not be cross tapered with a TCA?

A

paroxetine
fluvoxamine

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14
Q

Which two classes of drugs should not be cross-tapered with Clomipramine (TCA)?

A

SSRIs
SNRIs

clomiramine should be withdrawn first (and vice versa)

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15
Q

How long should fluoxetine be stopped for before starting an SSRI, SNRI or TCA?

A

4-7 days

Due to its long half-life

Interactions can still occur 5 weeks after stopping fluoxetine

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16
Q

Which three antidepressant drugs can fluoxetine be cross-tapered with cautiously?

A

Mirtazapine
Reboxetine (SNRI)
Trazodone

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17
Q

What are the withdrawal (discontinuation symptoms) of stopping antidepressants?

A
  • appear within a few days, resolve <2 weeks (longer for some)
  • sweating
  • sleep disturbance
  • restlessness
  • Mood changes
  • Physical symptoms
  • can be confused with relapse of depression - so people think they can’t stop
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18
Q

How should an antidepressant be withdrawn/stopped?

A
  • gradual taper to reduce risk of withdrawal
    *reduce the dose by half every week, using liquid for the lower doses, until stopping completely after around 4 weeks.

Can advise patient that recent RCT showed 4 in 10 people are able to stop antidepressants without relapse. (patients in the RCT had 2 previous relapses)

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19
Q

What are the side effects of SSRI/SNRI in pregnancy?

A
  • data conflicting- teratogenicity unproven
  • after 20 weeks - increased risk of persistent pulmonary hypertension of the newborn and neonatal withdrawal
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20
Q

What are the cautions for pregabalin?

A
  • Hx substance abuse/addiction - euphoria
  • DM - weight gain
  • Renal impairment
  • People at risk of Resp depression - resp disease/neuro condition/other CNS depressants/over 65 yrs
  • Severe congestive HF
  • Elderly - increased risk falls - dizziness, drowsiness, confusion, blurred vision, parkinsonism
  • suicidal ideation - increases
  • risks of constipation - on opioids.
  • if on clozapine -can increase levels of clozapine.
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21
Q

When should Lithium Levels be checked?

A

12 hours post-dose

narrow therapeutic window
aim concentration of 0.4-1 mmol/l

22
Q

Which are the first generation (typical) antipsychotics? How do they act?

A
  • Chlorpromazine
  • Flupentixol
  • Haloperidol
  • Levomepromazine
  • Prochlorperazine
  • Sulpiride
  • Zuclopentixol

They act by blocking dopamine-2 receptors in the brain.

more likely to cause EPS and hyperprolactinaemia

23
Q

Which are the second generation (atypical) antipsychotics? How do they act?

A
  • Amisulpride
  • Aripiprazole
  • Clozapine
  • Olanzapine
  • Paliperidone
  • Quetiapine
  • Risperidone

They act on a range of receptors in the brain

lower risk of EPS and tardive dyskinesia
but can cause weight gain and glucose intolerance

24
Q

What are extra-pyramidal symptoms? (EPS)

A
  • Adverse effects of anti-psychotics - more common with 1st generation (typical) antipsychotics.
  • Dose related
  • Individual susceptibility
  • Include:
  • Parkinsonian symptoms - bradykinesia, tremor (more common in elderly females, or stroke, may appear gradually)
  • Dystonia - uncontrolled muscle spasm of the face/body (more common in young males, can occur within hrs of starting drug)
  • akathisia - restlessness (occurs within hours-weeks of starting drug - can be mistaken for agitation)
  • tardive dyskinesia - abnormal involuntary movements of lips, tongue, face, jaw. Develops on long term, high dose Rx - or after discontinuation, can be irreversible. Stop drug ASAP. (more common in elderly females)
25
Q

What are the other side effects of antipsychotics (other than EPS)?

A
  • weight gain
  • dyslipidaemia
  • hyperprolactinaemia
  • sedation
  • anticholinergic effects
  • hypertension
  • postural hypotension
  • reduced seizure threshold
  • hyperglycaemia
  • QT prolongation
  • Stroke risk
  • VTE
  • Neuroleptic Malignant Syndrome
  • pneumonia
  • neutropenia (stop if <1.5)
  • abnormal LFTs- hepatitis
  • restless legs syndrome
26
Q

What are the signs and symptoms of NMS?

A
  • fever
  • sweating
  • rigidity
  • confusion
  • fluctuating consciousness
  • fluctuating BP
  • tachycardia
  • raised CK
  • raised WCC
  • raised LFTs
27
Q

Which antipsychotics cause the most weight gain?

A
  • second generation (atypicals)
  • clozapine and olanzapine worst
28
Q

What are the symptoms of hyperprolactinaemia?

Which antipsychotics do not raise prolactin in normal doses?

A
  • galactorrhoea
  • amenorrhoea
  • gynaecomastia
  • hypogonadism
  • sexual dysfunction
  • increased risk osteoporosis

clozapine, olanzapine, quetiapine and aripiprazole don’t raise prolactin above normal range at their normal doses.

29
Q

Which antipsychotics cause most sedation?

Which cause the least?

A
  • Most: clozapine, chlorpromazine (1st gen)
  • Least: aripiprazole, amisulpride,sulpiride.

tolerance usually develops

30
Q

Which antipsychotics cause the most anticholinergic effects?

And what are the symptoms?

A

dry mouth, blurred vision, urinary retention, constipation, flushing.

Clozapine and chlorpromazine (1st Gen)

31
Q

Which antipsychotic commonly causes HTN?

A

clozapine

also reports with 2nd Gen (aripiprazole, olanzapine, quetiapine, risperidone)

32
Q

Which antipsychotic has the greatest risk of lowering seizure threshold?

A

clozapine

all antipsychotics have a risk - the higher the dose the greater the risk

33
Q

Which antipsychotics increase risk of stroke in elderly dementia patients?

A

olanzapine
risperidone

34
Q

which antipsychotic can uncommonly cause diplopia?

A

aripiprazole

34
Q

Which interactions are common to all antipsychotics?

A
  • sedatives (alcohol, analgesics, TCAs, sedating antihistamines)
  • anti-hypertensives (increased postural hypotension)
  • Drugs that prolong QT interval (anti-arrhythmics, macrolides, TCA)
  • Diuretics - can cause hypokalaemia - increased risk of arrhythmia - needs monitoring.

macrolides: erythromycin, clarithromycin, azithromycin, fidaxomicin

35
Q

Which antipsychotics interact with azole antifungals?

fluconazole, itraconazole, ketoconazole

A

Aripiprazole (half the dose of aripiprazole if taking itraconazole)
Haloperidol - levels increased by itraconazole

36
Q

SSRIs can increase the levels of which antipsychotics?

A

Haloperidol (fluoxetine)
Risperidone (fluoxetine, paroxetine)
Clozapine and olanzapine (fluoxetine, paroxetine, sertraline)

monitor and alter dose of antipsychotic accordingly

37
Q

Smoking induces the metabolism of which antipsychotics?

A

clozapine
olanzapine

if stops smoking - levels could increase - check for adverse effects and adjust dose if needed

38
Q

What baseline tests should be done before starting an antipsychotic?

A
  • weight
  • fasting glucose
  • HbA1c
  • lipids
  • prolactin (then 6 months, then yearly)
  • FBC, U&E, LFTs
  • ECG
  • BP
39
Q

Which tests are needed every 12 months for antipsychotic monitoring?

A
  • BMI (weekly for first 6 weeks, then 3 months, then every 12)
  • U&E
  • FBC
  • Lipids (3 months then 12)
  • HbA1c (3 months then 12) (EXTRA test at 1 month for clozapine and olanzapine)
  • LFTs
  • Prolactin (NOT needed for aripiprazole, clozapine, quetiapine, olanzapine at <20mg daily)
  • ECG
  • BP (not mandatory for aripiprazole)

Also monitor for movement disorders!

40
Q

How long should patients be monitored for after withdrawal of antipsychotic?

A
  • high risk of relapse if stopped after 1-2 years
  • monitor for 2 years after stopping.
41
Q

Which antidepressant can precipitate acute angle closure glaucoma?

A

mirtazapine

patients at risk - hypermetropia (long sightedness), DM

42
Q

What is an organic brain disorder?

A

An ‘organic’ brain disorder implies an underlying physiological cause of altered brain function.

e.g dementia, delirium, alcohol, metabolic

visual hallucinations are most likely to represent an organic brain disorder (rather than auditory hallucinations, persecutory delusions, flight of ideas)

43
Q

Which SSRI causes higher risk of withdrawal reactions?

A

Paroxetine - due to short half life.

44
Q

What are the signs and symptoms of lithium toxicity?

A

Dry mouth
Altered taste
Increased thirst
Polyuria
Nausea, vomiting
Increasing Diarrhoea
Muscle weakness
Ataxia
Coarse tremor of extremities and lower jaw
Tinnitus
Slurred speech
Blurred vision
Lethargy
Confusion
Hyper-reflexia
Seizures

Rx: supportive, dialysis

45
Q

What are the monitoring requirements for Lithium?

A
  • Lithium levels: one week after starting, one week after every dose change, weekly until levels stable. Once stable: every 3 months. Take 12 hours post-dose.
  • BMI/weight, U&E, calcium, TFTs every 6 months. (more frequent if renal fn declines)
  • ECG prior to treatment.
46
Q

What are the initial adverse effects of Lithium after starting treatment?

A
  • nausea
  • diarrhoea
  • muscle weakness
  • vertigo
  • ‘dazed’ feeling
    These Often resolve.
  • fine hand tremors
  • Polyuria, polydipsia
  • May persist
47
Q

What are the longer-term side effects of lithium?

A
  • hypothyroidism +/-goitre (give levothyroxine - usually normalises once lithium stopped)
  • Hyperthyroidism = rare
  • Hyperparathyroidism - causing hypercalcaemia (stop lithium)
  • Nephrotoxicity (reduction in egfr of 20%). Rarely - interstitial nephritis. Nephrogenic diabetes insipidus (reduction in urinary concentrating capacity) - reversible short term, irreversible long term.
  • renal tumours >10 year Rx
  • Rhabdomyolysis- muscle weakness

Review dose if pt develops diarrhoea, intercurrent infection, vomiting, after surgery - likely dehydrated- levels will increase

48
Q

What are the key drug interactions with lithium?

A
  • diuretics- THIAZIDES- severe- raise lithium levels.
  • NSAIDs- increase lithium levels
  • Haloperidol, Quetiapine- neurotoxicity
  • Carbamazepine,AEDs - neurotoxicity
  • Dapagliflozin. - increases renal lithium clearance - lowers lithium level
  • ACEI - decrease renal excretion of lithium, can cause renal failure
  • serotonergic antidepressants - SSRI, SNRI, TCAs. CNS toxicity.
  • Drugs that prolong QT interval
  • Drugs that cause hypokalaemia
  • Tetracyclines (doxy), metronidazole- lithium toxicity
49
Q

What are the contraindications with lithium?

A
  • cardiac disease with arrhythmia
  • significant renal impairment
  • untreated hypothyroidism
  • Brugada syndrome
  • Hyponatraemia
  • Addisons disease
  • Hx diabetes insipidus
  • refuse regular bloods
  • High risk of overdose (intentional or not)
  • Breastfeeding.
50
Q

What are the CD prescribing including methadone Rules?

A
  • full name, address and, where appropriate, age.
  • form and strength of the preparation.
  • dose to be taken.
  • A dose of ‘as directed’ or ‘when required’ is not acceptable, but ‘one to be taken as directed/when required’ is acceptable.
  • The total quantity of the preparation or the number of dose units in both words and figures.
  • The signature of the prescriber who has written the prescription.
  • The date of signing by the prescriber who has written the prescription.

AKT - Lizzie Bain (55 decks)

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