8 - Psychiatric Drugs (Antipsychotics, Anxiolytics, Hypnotics) Flashcards

1
Q

What is the mechanism of action of first generation (typical) antipsychotics and name 5 examples?

A

D2 antagonists

Takes 4-6 weeks to work

  • Chlorpromazine
  • Haloperidol
  • Prochlorperazine
  • Flupentixol
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2
Q

How are antipsychotics stopped?

A
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3
Q

How does prescribing antipsychotics differ in the elderly?

A

Elderly prone to postural hypotension and if have dementia small risk of stroke when using antipsychotics

  • Antipsychotic drugs should not be used in dementia, unless they are at risk of harming themselves or others, or experiencing agitation, hallucinations or delusions that are causing them severe distress.
  • Lowest effective dose for shortest period of time
  • Treatment should be reviewed at least every 6 weeks
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4
Q

What are some patient groups you have to be careful with when prescribing antipsychotics?

A
  • Blood dyscrasias
  • Parkinson’s disease (may be exacerbated)
  • QT prolongation
  • Breast cancer
  • Cardiovascular disease
  • Depressiom
  • Epilepsy
  • Diabetes
  • History of jaundice
  • Prostatic hypertrophy
  • Severe respiratory disease
  • Susceptibility to angle-closure glaucoma
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5
Q

What are the general side effects of all antipsychotics?

A
  • Extrapyramidal symptoms (FGA)
  • Weight gain
  • Sedation
  • QT prolongation
  • Acute dystonia
  • Hyperprolactinaemia (FGA and Risperidone) (Amenorrhoea, Galactorrhea)
  • Sexual dysfunction
  • Neuroleptic Malignant Syndrome
  • Tachycardia, arrhythmias, hypotension
  • Postural hypotension (usually SGA)
  • Hyperglycaemia and Diabetes
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6
Q

What is some general life advice to give patients on antipsychotics?

A
  • Sedation so be careful driving
  • Effects of alcohol enhanced
  • Photosensitivity so be careful in sun
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7
Q

What are some examples of extrapyramidal symptoms?

A
  • Parkinsonian symptoms (including bradykinesia, tremor)
  • Dystonia (uncontrolled muscle spasm in any part of the body), more common in young males
  • Akathisia (restlessness), within hours to weeks of starting antipsychotic treatmen
  • Tardive dyskinesia (abnormal involuntary movements of lips, tongue, face, and jaw), in some patients it can be irreversible.
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8
Q

Hyperprolatinaemia is common with antipsychotics as dopamine inhibits prolactin release. What are some symptoms of raised prolactin?

A
  • Sexual dysfunction
  • Reduced bone mineral density
  • Menstrual disturbances
  • Breast enlargement
  • Galactorrhoea
  • Increased risk of breast cancer
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9
Q

When are depot injections for antipsychotics used?

A
  • Non-adherance
  • Patient preference

Higher risk of EPSE when using first-generation antipsychotics. Zuclopenthixol may be most effect FGA in depot form

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10
Q

What are the pros and cons of depot injections for antipsychotics?

A

Pros

  • Better adherance
  • Less hospitalisations as less relapses

Cons

  • Side effects last longer
  • Pain at injection site
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11
Q

What are the side effects of FGA and SGA separately?

A

FGA

  • Extrapyramidal side effects
  • Weight gain
  • Sedation
  • Hyperprolactinaemia

SGA

  • Weight gain
  • Dyslipidaemia
  • QT prolongation
  • Hyperglycaemia
  • Sexual dysfunction
  • Anticholinergic effects
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12
Q

What are some examples of atypical (second-generation) antipsychotics and how do they work?

A

D2 antagonist and 5HT2A antagonist

Less likely to have EPSE but more likely to have metabolic SE

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13
Q

What is some general monitoring that needs to be done with antipsychotics?

(Focus on image)

A

Weight: at the start, then weekly for the 6 weeks, then at 12 weeks, at 1 year, and then yearly.

All patients should have yearly physical review!!!!

Fasting blood glucose, HbA1c, and blood lipid concentrations: baseline, 12 weeks, 1 year, and then yearly

Prolactin: baseline

ECG: before starting

Blood pressure: before starting, at 12 weeks, at 1 year and then yearly during treatment

FBC, U+Es, LFTs: at the start then yearly thereafter

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14
Q

Why are the following monitored when on antipsychotic treatment?

  • FBC
  • LFTs
  • Lipids
  • HbA1c
  • BP
A

FBC: bone marrow suppression

LFTs: steatohepatitis/metabolic syndrome

Lipids: dyslipidaemia

HbA1c: diabetes and metabolic syndrome

BP: metabolic syndrome

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15
Q

What are the following for Haloperidol:

  • Contraindications
  • Side effects
  • Monitoring
  • Drug Interactions
A

It is less sedating but high risk for sexual dysfunction

Contraindications

Long QT syndrome, Dementia with Lewy bodies, Parkinson’s disease; Progressive supranuclear palsy, QTc-interval prolongation, Recent acute MI, uncorrected hypokalaemia

Side effects

EPSE, NMS, Long QT, Sexual Dysfunction, Orthostatic HTN Depression, eye disorders, headache, hypersalivation, nausea, neuromuscular dysfunction, weight loss

Monitoring

ECG baseline essential then the rest of tests like normal monitoring for antipsychotics e.g PRL, BP, FBC etc

Drug Interactions

Smoking may change dose needed

Anticholinergics, Lithium

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16
Q

What are the following for Chlorpromazine:

  • Contraindications
  • Side effects
  • Monitoring
  • Drug Interactions
A

Contraindications

Comatose, Hypothyroidism, Phaechromocytoma

Side effects

Acute dystonia, Long QT, NMS, Anxiety, glucose tolerance impaired, muscle tone increased

Monitoring

Same as normal but following IM injection should remain supine for 30 mins with regular BP monitoring

Drug Interactions

Parkinson’s meds, Long QT meds, Alcohol and Benzos could cause respiratory depression

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17
Q

What are some drugs that increase the QT interval?

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18
Q

Which antipsychotics have a lower risk of prolonged the QT interval?

A

Atypical Antipsychotics

  • Aripiprazole
  • Clozapine
  • Olanzapine
  • Flupentixol
  • Risperidone
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19
Q

What are the following for Aripiprazole:

  • Contraindications
  • Side effects
  • Monitoring
  • Drug Interactions
A

Less likely to cause weight gain, diabetes, hyperprolactinaemia and long QT compared to other SGAs

Contraindications

Cerebrovascular disease, elderly, risk of aspiration pneumonia

Side effects

Anxiety, appetite increase/weight gain, diabetes, GI discomfort, headache, hypersalivation, nausea, vision disorders

Monitoring

Monitor serum concentrations if signs of toxicity or taking drugs that interfere with metabolism

BP monitoring not mandatory. Rest of normal check up to be done

Drug Interactions

Be careful with other sedatives as respiratory depression

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20
Q

What are the following for Olanzapine:

  • Contraindications
  • Side effects
  • Monitoring
A

High risk of sexual dysfunction

Contraindications

Acute MI, bradycardia, recent heart surgery, severe hypotension, unstable angina

Side effects

Anticholinergic syndrome, Appetite increased/Weight gain, Hyperglycaemia, Glycosuria, Oedema, Sexual dysfunction

Monitoring

If depot monitor BP, pulse, RR for 3 hours post-injection

Blood lipids and weight should be measured at baseline, then every 3 months for a year then yearly with antipsychotic drugs

Fasting blood glucose tested at baseline, after 1 month, then every 4–6 months.

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21
Q

What are the following for Risperidone:

  • Contraindications
  • Side effects
  • Monitoring
A

High risk of sexual dysfunction and hyperprolactinaemia

Contraindications

Cataract surgery (risk of intra-operative floppy iris syndrome), Dehydration, Dementia with Lewy bodies, prolactin-dependent tumours

Side effects

Headache, hypertension, joint disorders; laryngeal pain, muscle spasms, nasal congestion, nausea, oedema, oral disorders, pain, sexual dysfunction; skin reactions, weight loss

Monitoring

Same as normal antipsychotic monitoring

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22
Q

Which antipsychotics cause the most weight gain and sexual dysfunction?

A

Weight gain: Olanzapine, Clozapine

Sexual Dysfunction: Risperidone, Haloperiodol, Olanzapine

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23
Q

What are the following for Quetiapine:

  • Contraindications
  • Side effects
  • Monitoring
A

High risk of hypotension but low chance of sexual dysfunction

Contraindications

Cerebrovascular disease, elderly, treatment of depression in patients under 25  years (suicide risk)

Side effects

Weight gain, dyspnoea, headache; irritability; palpitations, suicidal behaviour, syncope, vision blurred, withdrawal syndrome

Monitoring

Same as normal antipsychotic monitoring

24
Q

What are the following for Clozapine:

  • Contraindications
  • Side effects
  • Monitoring
A

Contraindications

Age over 60, Prostatic hypertrophy, Susceptibility to angle-closure glaucoma, taper off other antipsychotics before starting

Side effects

AGRANULOCYTOSIS, Cardiomyopathy, Myocarditis, Constipation/ Intestinal Obstruction, weight gain, postural hypotension, hyper salivation, urinary incontinence

Monitoring

FBC (WCC) weekly for 18 weeks, then fortnightly for up to one year, and then monthly as part of the clozapine patient monitoring service

Blood clozapine concentration should be monitored in certain clinical situations

Close medical supervision during initiation (risk of collapse because of hypotension and convulsions).

Blood lipids and weight: every 3 months for the first year, then yearly.

Fasting blood glucose: baseline, after 1 month, then every 4–6 months

25
Q

How can you treat hypersalivation with Clozapine treatment?

A

Hyoscine Hydrobromide

26
Q

How are the following serious complications of clozapine treatment avoided/monitored?

  • Agranulocytosis (Neutropenia)
  • Cardiomyopathy
  • Intestinal Obstruction
A

Agranulocytosis

  • If leucocyte count below 3000 /mm3 or if absolute neutrophil count below 1500 /mm3 discontinue permanently
  • Avoid drugs which depress leucopoiesis
  • Patients should report immediately symptoms of infection, especially influenza-like illness.

Myocarditis and cardiomyopathy

  • Perform physical examination and take full medical history before starting
  • Persistent tachycardia especially in first 2 months should prompt observation for other indicators for myocarditis or cardiomyopathy
  • Discontinue permanently in clozapine-induced myocarditis or cardiomyopathy

Intestinal obstruction

  • Clozapine should be used with caution in patients receiving drugs that may cause constipation (e.g. antimuscarinic drugs) or in those with a history of colonic disease or lower abdominal surgery
  • Recognise and treat constipation promptly
27
Q

If SSRIs are not working for OCD, what can be used instead?

A

Clomipramine (TCA)

Need to warn they can be sedating unlike SSRIs so be careful driving

28
Q

Why is Aripiprazole’s MOA different to other SGAs?

A

Partial D2 agonist not antagonist!!!

Good tolerability

29
Q

What are the dopamine target pathways in antipsychotics?

A

Targets: Mesocortical and Mesolimbic

Unwanted SEs: Nigrostriatal and Tuberoinfundibular (HPA axis)

30
Q

How can EPSEs be managed with FGA?

A

Procyclidine

EPSEs due to ratio of dopamine:acetylcholine so reduce quantities of Ach with above

May exacerbate tardive dyskinesia

31
Q

Why is Clozapine dose slowly upped over 2 weeks when starting?

A

Risk of autonomic dysregulation when first starting

32
Q

What are some classes of drugs used as anxiolytics?

A
  • B-Blockers
  • Benzodiazepines
  • Pregablin
  • Antidepressants (SSRIs - high dose in OCD)
33
Q

How do B-Blockers work as an anxiolytic, what is an example, what are the contraindications and what are the side effects?

A

Propanolol: B-blocker, decreases ANS activation so less physical autonomic symptoms, does not treat psychological symptoms

CI: asthma, enduring anxiety

Side effects: hypotension, bradycardia, nausea, tired

34
Q

How do Benzodiazepines work as an anxiolytic, what are some examples, what are the contraindications and what are the side effects?

A
  • Bind to GABA receptors to potentiate the effect of GABA so reduce excitability of neurones. Useful for acute anxiety, only use for 2-4 weeks max
  • Examples: Diazepam, Lorazepam
  • CI: substance misuse history, COPD
  • Side effects: dependence, paradoxical disinhibition (at low doses), sedation, confusion, respiratory depression
35
Q

How does Pregablin work as an anxiolytic, what are the contraindications and what are the side effects?

A
  • Binds to VGCC to reduce neuronal activity
  • Used for anxiety, neuropathic pain, epilepsy
  • Not addictive
  • CI: hypersensitivity to drug, previous substance misuse
  • SE: sedation, weight gain, sexual dysfunction
36
Q

How are antidepressants used as anxiolytics?

A

Same as for depression but higher doses and stay on for 1 year instead of 6 months

37
Q

What is the difference between hypnotics and anxiolytics?

A

Anxiolytics (‘sedatives’) will induce sleep when given at night and most hypnotics will sedate when given during the day

38
Q

When can a benzodiazepine be used for insomnia?

A

When it is severe, disabling, or causing the patient extreme distress

2-4 weeks max

39
Q

What are the symptoms of Benzodiazepine Withdrawal Syndrome and how can you withdraw someone from Benzos?

A

Symptoms: insomnia, anxiety, loss of appetite and weight, tremor, perspiration, tinnitus, and perceptual disturbance

Withdrawal: Short term users can be tapered off in 2-4 weeks, Long term users over a few months

40
Q

How long does it take for Benzodiazepine withdrawal syndrome to occur?

A

Short acting (Lorazepam): One day

Long acting (Diazepam): 3 weeks

41
Q

What are some examples of hypnotics?

A
  • Benzodiazepines: Temazepam, Lormatazepam, Nitrazepam
  • Non-Benzos (Z-Drugs): Zopiclone, Zolpidem

Z drugs still act on benzodiazepine receptor

42
Q

What are some questions that need to be asked before prescribing a hypnotic?

A
  • Find out cause of insomnia
  • Address factors e.g unrealistic sleep expectations, alcohol consumption

Causes

Transient insomnia: normally sleep well and may be due to extraneous factors such as noise, shift work, and jet lag. Only give 1 or 2 doses

Short-term insomnia: emotional problem or serious medical illness, may last for a few weeks and may recur; a hypnotic can be useful but should not be given for more than three weeks

Chronic insomnia is rarely benefited by hypnotics and is sometimes due to mild dependence caused by injudicious prescribing of hypnotics

43
Q

What is the issue of prescribing hypnotics for insomnia?

A
  • Rebound insomnia with vivid dreams for several weeks
  • Withdrawal symptoms
44
Q

Should you prescribe hypnotics in the elderly?

A

No as greater risk of ataxia, confusion and falls

45
Q

What patients are at risk of dependence when taking benzodiazepines?

A
  • History of drug or alcohol abuse
  • Personality disorder
46
Q

What are some medications used for ADHD?

A

Work by increasing activity in the brain in the areas responsible for controlling attention and behaviour

  • methylphenidate
  • lisdexamfetamine
  • dexamfetamine
  • atomoxetine
  • guanfacine
47
Q

What is the mechanism of action of Methylphenidate for ADHD and what are contraindications to this?

A

Non-competitively blocks the reuptake of dopamine and noradrenaline into the terminal by blocking dopamine transporter (DAT) and noradrenaline transporter (NAT) increasing levels of dopamine and noradrenaline in the synaptic cleft

48
Q

What are the side effects of Methylphenidate?

A

Non-competitively blocks the reuptake of dopamine and noradrenaline into the terminal by blocking dopamine transporter (DAT) and noradrenaline transporter (NAT) increasing levels of dopamine and noradrenaline in the synaptic cleft

Side effects

  • a small increase in blood pressure and heart rate
  • loss of appetite, which can lead to weight loss or poor weight gain
  • insomnia
  • headaches
  • stomach aches
  • feeling aggressive, irritable, depressed, anxious or tense
  • dependance
49
Q

What drugs may interact with Methylphenidate?

A
50
Q

What monitoring needs to be done whilst on Methylphenidate?

A

Start: Pulse, BP, psychiatric symptoms, appetite, weight and height

Every 6 months: Pulse, BP, psychiatric symptoms, appetite, weight and height

Also monitor for development of tics

51
Q

When is Atomoxetine favoured over Methylphenidate for ADHD?

A

History of dependence

Methylphenidate has potential for dependence

52
Q

What is the mechanism of action of Atomoxetine and what are some of the side effects?

A

SNRI/NoRI so not addictive

Side effects:

  • Suicidal thoughts
  • Sexual dysfunction
  • Liver impairment
  • Small increase in blood pressure and heart rate
  • Nausea and vomiting
  • Stomach aches
  • Trouble sleeping
53
Q

What monitoring needs to be done whilst on Atomoxetine?

A

Start: Pulse, BP, psychiatric symptoms, appetite, weight and height

Every 6 months: Pulse, BP, psychiatric symptoms, appetite, weight and height

Also monitor for development of tics, depression, anxiety, suicidal thoughts!!

54
Q

What are the two main things you need to warn parents of when starting ADHD medication?

A
  • Suicidal thoughts
  • Hepatic Impairment
55
Q

Which ADHD medication are tics more common in?

A

Stimulants