BASIC - PSYCHIATRY Flashcards
1
Q
Names of SSRIs?
A
Citalopram, fluoxetine, sertraline, escitalopram
2
Q
Indications of SSRIs?
A
- First-line treatment for moderate-to-severe depression and mild depression if psychological treatments fail
- Panic Disorder
- OCD
3
Q
Mechanisms of SSRIs?
A
- Inhibit neuronal reuptake of serotonin (5-HT) from the synaptic cleft
- Increase availability for neurotransmission
- SSRIs are preferred - fewer adverse effects and less dangerous in overdose
4
Q
SE of SSRIs?
A
- GI upset
- Appetite and weight loss/gain
- Increase risk of bleeding
- Suicidal thoughts and behaviours
o Motivation improves before mood giving period of increased risk. - Hyponatraemia
o esp. older thin females in summer with poor renal function.
o Monitor at risk group
o Can occur with all antidepressants but SSRIs worst, lofepramine/ mirtazapine best. - Lower seizure threshold
- Citalopram/Escitalopram prolong QT interval (if >440ms in men, >470ms in women – prescribe with care/cardiology; >500ms need cardiology input)
5
Q
What is serotonin syndrome?
Causes, symptoms/signs, investigations, Rx?
A
o Excess serotonin (via e.g. SSRI + TCA/MAOI/St John’s Wort/Ecstasy)
o Causes – therapeutic drugs, OD, interactions, cocaine/MDMA
o Triad of autonomic hyperactivity, neuromuscular abnormality and altered mental state
o Sx: Usually within 6 hours - restless, fever, tremor, myoclonus, confusion, fits, arrhythmias
o Ix – Bloods (FBC, U&Es, CK, LFTs), urine drug screen
o Supportive treatment (IV fluids may be needed)/monitoring, stop drug
o Activated charcoal if recent OD
o Most mild and better within 24hrs
6
Q
What happens in sudden withdrawal of SSRIs?
A
Sudden withdrawal can cause GI upset, flu-like symptoms, sleep disturbances
7
Q
Cautions of SSRIs?
A
o Epilepsy
o Peptic Ulcer disease
o Metabolised by liver – reduced dose in hepatic impairment
o Aspirin and NSAIDs – need gastroprotection
8
Q
Contraindications of SSRIs?
A
o Do not give with MAOIs (Serotonin syndrome)
o Avoid drugs which prolong QT (antipsychotics)
o Mania
9
Q
Prescription of SSRIs?
A
- Oral
- Started at low dose, taken regularly and increased according to response
- Improve symptoms over a few weeks, particularly sleep and appetite
10
Q
How long should you continue SSRIs?
A
- Should continue SSRIs for 6 months after they feel better to prevent relapse (2 years for recurrent)
- Do not stop treatment suddenly
11
Q
Monitoring of SSRIs?
A
- Review 1-2 weeks after starting and regularly after that
- If no effect after 4 weeks, change dose or drug – normally adjust dose after 6-8 weeks
12
Q
Treatment of overdose of SSRIs?
A
- Activated charcoal within 1 hour of the overdose reduces drug absorption
13
Q
Names of TCAs?
A
Amitriptyline, Lofepramine, imipiramine
14
Q
Indications of TCAs?
A
- Second line for moderate-to-severe depression where first-line serotonin-specific reuptake inhibitors (SSRIs) are ineffective
- Neuropathic pain
15
Q
Mechanism of TCAs?
A
- Inhibit neuronal reuptake of serotonin (5-HT) and noradrenaline from the synaptic cleft
- Increase availability for neurotransmission
- Block muscarinic, histamine (H1), α-adrenergic (α1 and α2) and dopamine (D2) receptors – adverse effects
16
Q
SE of TCAs?
A
- Blockage of antimuscarinic receptors
o Dry mouth, constipation, urinary retention, blurred mouth - Blockage of H1 and a1 receptors
o Sedation, hypotension - Blockage of dopamine receptors
o Breast changes, sexual dysfunction, extrapyramidal symptoms (tremor, dyskinesia) - Arrhythmias, prolongation of QT and QRS complexes
17
Q
Overdose of TCAs?
A
o Severe hypotension, arrhythmias, convulsions, coma and can be fatal
18
Q
Sudden withdrawal of TCAs?
A
o Cause GI upset, flu-like symptoms, sleep disturbances
19
Q
Caution of TCAs?
A
- Elderly
- CVD
- Epilepsy
- Constipation, BPH or raised intraocular pressure
20
Q
Contraindications of TCAs?
A
- MAOIs
- Augment antimuscarinic effects of other drugs
21
Q
Prescription of TCAs?
A
- Similar efficacy but more adverse effects and dangerous in overdose
- Oral tablets
- Supply small quantity of medication at a time when overdose risk (2 weeks)
- Symptoms improve over few weeks, particularly sleep and appetite
22
Q
How long should TCA treatment last?
A
- Drug treatment should carry on 6 months following symptom resolution to prevent relapse (2 years in recurrent)
- Dose reduction slowly over 4 weeks when discontinuing
23
Q
Monitoring of TCAs?
A
- Review symptoms after 1-2 weeks and then regularly
- If no effect after 4 weeks, change dose or drug – normally adjust dose after 6-8 weeks
24
Q
Treatment of TCA overdose?
A
- Activated charcoal within 1 hour of the overdose reduces drug absorption
- IV lorazepam or IV diazepam (emulsion form) to treat convulsions
25
Names of SNRIs?
- Venlafaxine, duloxetine
26
Indications of SNRIs?
- Option for major depression when first-line SSRIs not tolerated
- GAD
27
Mechanisms of SNRIs?
- Serotonin and noradrenaline reuptake inhibitor in synaptic cleft
- Increase availability of monoamines
- Weaker antagonist of muscarinic and histamine (h1) receptors than TCAs – less side effects
28
SE of SNRIs?
- Dry mouth, diarrhoea, constipation, nausea
- Headache, insomnia, abnormal dreams and confusion
- Hyponatraemia
- Serotonin syndrome
- Suicidal thoughts and behaviours
- Prolong QT interval
29
Sudden withdrawal of SNRIs?
o GI upset, flu-like symptoms, sleep problems (more than other ADs)
30
Cautions of SNRIs?
o Elderly
o Dose reduction in hepatic and renal impairment
o CVD as increased risk of arrhythmias
31
Prescription of SNRIs?
- Oral tablet
- Low dose then titrated up according to response
- Should improve symptoms over few weeks, particularly sleep and appetite
32
How long should drug treatment of SNRIs last?
- Drug treatment should carry on 6 months following symptom resolution to prevent relapse (2 years in recurrent)
- Dose reduction slowly over 4 weeks when discontinuing
33
Monitoring of SNRIs?
- Review symptoms after 1-2 weeks and then regularly
| - If no effect after 4 weeks, change dose or drug – normally adjust dose after 6-8 weeks
34
Name of NaSSa?
Mirtazapine
35
Indications of mirtazapine?
- Option for major depression where first-line SSRIs fail to work
36
Mechanism of mirtazapine?
- Antagonist of inhibitory pre-synaptic Alpha-2-adrenoreceptors
- Potent antagonist of histamine (H1) but not to muscarinic receptors – less side effects
- Increases availability of monoamines
37
SE of mirtazapine?
- Sedative
o Sedative effects more potent at lower doses
o Low doses, antihistamine effects predominate
o Higher doses augmented monoamine transmission counter-acts
- GI upset
- Weight gain
- Headaches, confusion, abnormal dreams
- Hyponatraemia – least in mirtazapine
- Serotonin syndrome
- Suicidal thoughts and behaviours
38
Withdrawal symptoms of mirtazapine?
o GI upset, flu-like
39
Caution of mirtazapine?
o Elderly
| o Dose reduction in hepatic and renal impairment
40
Prescription of mirtazapine?
- Oral tablet
- Low dose then titrated up according to response
- Should improve symptoms over few weeks, particularly sleep and appetite
- Mirtazapine taken at night for best sedative effects
41
Length of treatment of mirtazapine?
- Drug treatment should carry on 6 months following symptom resolution to prevent relapse (2 years in recurrent)
- Dose reduction slowly over 4 weeks when discontinuing
42
Monitoring of mirtazapine?
- Review symptoms after 1-2 weeks and then regularly
| - If no effect after 4 weeks, change dose or drug – normally adjust dose after 6-8 weeks
43
Name of MAOIs?
- Phenelzine, Moclobemide (Reversible inhibitor – RIMA)
44
Indications of MAOIs?
- Option in Major depression when first-line SSRIs fail
45
Mechanism of MAOIs?What foods should be avoided and why?
- Inhibit monoamine oxidase (MAO-A & MAO-B)
- Increase availability of monoamines
- Monoamine oxidase breaks down tyramine in your gut
o If you eat tyramine containing food: cheese, red wine, bovril there is potential for hypertensive crisis
46
SE of MAOIs?
- Dizziness, postural hypotension
- Hypertensive crisis
- Serotonin syndrome
- Withdrawal symptoms
47
Cautions of MAOIs?
o Blood disorders
o CVD
o ECT therapy
o Elderly, epilepsy
48
Contraindications of MAOIs?
o Stroke
o Mania
o Pheochromocytoma
o Hepatic impairment
49
Monitoring in MAOIs?
- Monitor BP
- Review symptoms after 1-2 weeks and then regularly
- If no effect after 4 weeks, change dose or drug – normally adjust dose after 6-8 weeks
50
Prescription of MAOIs?
- Oral tablet
- Low dose then titrated up according to response
- Should improve symptoms over few weeks, particularly sleep and appetite
51
Avoid what foods when on treatment of MAOIs?
- Avoid food that is stale, avoid game, avoid alcoholic/de-alcoholised drinks - interaction for up to 2 weeks after treatment cessation
52
Length of treatment of MAOIs?
- Drug treatment should carry on 6 months following symptom resolution to prevent relapse (2 years in recurrent)
- Dose reduction slowly over 4 weeks when discontinuing
53
Name of benzodiazepines?
Diazepam, Temazepam, Lorazepam, Chlordiazepoxide, Midazolam
54
Indications of benzodiazepines?
```
1st line – Seizures, status epilepticus
- Long-acting lorazepam/diazepam
1st line – alcohol withdrawal
- Oral long-acting chlordiazepoxide
Sedation for interventional procedures
- Short-acting midazolam
Short-term treatment of severe anxiety, insomnia
- Intermediate-acting temazepam given at bedtime
```
55
Mechanisms of benzodiazepines?
- γ-aminobutyric acid type A (GABAA) receptor is a chloride channel
- Opens in response to GABA, making the cell more resistant to depolarisation, the main inhibitory neurotransmitter in the brain
- Benzodiazepines facilitate and enhance binding of GABA to the GABAA receptor
- Depressant effect on synaptic transmission
56
SE of benzodiazepines?
- Dose-dependent drowsiness, sedation and coma
- Relatively little cardiorespiratory depression in benzodiazepine overdose
- Loss of airway reflexes can lead to airway obstruction and death
57
Withdrawal symptoms of benzodiazepines?
- Withdrawal symptoms
| o Anxiety, insomnia, tremor, agitation, nausea, sweating, seizures, delirium
58
What happens if you use benzos regularly?
- If used regularly, tolerance and dependence develop
59
Interactions of benzodiazepines?
- Additive to sedating drugs (alcohol, opioids)
| - Depend on CYP450 enzymes for elimination – effects increased/decreased with inducers/inhibitors
60
Cautions of benzodiazepines?
o Elderly more susceptible to effects (lower dose)
| o Avoid in respiratory impairment, neuromuscular disease (myasthenia gravis), liver failure (lorazepam if needed)
61
Prescription of benzodiazepines?
- Water-based solution or oil in water emulsion
- Solution more irritant to veins
- Therapy only short-term for anxiety or insomnia
o Risk of dependence (<4 weeks)
- Do not drive or operate heavy machinery after taking drug
- Sedation may persist for a few days
62
Treatment of overdose of benzodiazepines?
- Activated charcoal can be given within 1 hour of ingesting a significant quantity of benzodiazepine
63
Name of Z drugs?
Zopiclone, Zolpidem
64
Indications of Z drugs?
Short-term insomnia treatment when debilitating (<4 weeks)
65
Mechanism of Z drugs?
- Facilitate and enhance binding of GABA on GABAA receptor
- Allows chloride to enter cell and make cell more resistant to depolarisation
- GABA main inhibitory neurotransmitter
- Z-drugs have a shorter duration of action than benzodiazepines
66
SE of Z drugs?
- Daytime sleepiness, which may affect ability to drive or perform complex tasks during day
- Rebound insomnia when drugs are stopped
- Headache, confusion, nightmares, amnesia (rare)
- Zopiclone
o Taste disturbances
- Zolpidem
o GI upset
67
Withdrawal symptoms of Z drugs?
- Withdrawal symptoms (used >4 weeks lead to dependence)
| o Headaches, muscle pains, anxiety
68
Overdose symptoms of Z drugs? Antidote?
o Drowsiness, coma and respiratory depression
| o Flumazenil antidote
69
Cautions of Z drugs?
- Elderly – more sensitive to drugs with CNS effects
70
Contraindications of Z drugs?
- Obstructive sleep apnoea
| - Respiratory muscle weakness/depression
71
Interactions of Z drugs?
- Enhance sedative effects of alcohol, antihistamines, benzodiazepines
- Enhance hypotensive effects of antihypertensives
- Metabolised by CYP450 enzymes – affects by inhibitors/inducers
72
Prescription of Z drugs?
- Maximum of 4 weeks
- Taken at bedtime
- Oral tablet or capsules
73
Communication of Z drugs?
- Explain ‘sleeping tablets’ should only be short-term measure to help them get over a bad patch
- Discuss reasons why they are not sleeping and offer advice on ‘sleep hygiene’
- Take only when really needed, as the body can get used to them if taken regularly
- Not to drive or operate complex or heavy machinery after taking the drug and explain that sometimes sleepiness may persist the following day
74
Indications of pregabalin?
```
Generalised anxiety disorder
Neuropathic pain (1st line in neuropathies, 2nd line in diabetic neuropathy)
Focal epilepsies when 1st line treatment does not work
```
75
Mechanism of pregabalin?
- Structural analogue of gabapentin
- Gabapentin is closely related to γ-aminobutyric acid (GABA)
- Binds with voltage-sensitive calcium (Ca2+) channels, where it prevents inflow of Ca2+and inhibits neurotransmitter release
- Reduces neuronal excitability
76
SE of pregabalin?
- Drowsiness, dizziness, ataxia (usually improves over first few weeks)
77
Dose reduction of pregabalin?
- Eliminated by kidneys so reduced dose in renal impairment
78
Interactions of pregabalin?
- Sedative effect enhanced by sedating drugs (benzodiazepines, alcohol, antihistamines, Z drugs)
- Few drug interactions compared to other antiepileptics
79
Prescription of pregabalin?
- Taken orally, started at low dose and increased to reach optimum balance
80
Communication of pregabalin?
- Explain that you are offering a medicine which you anticipate will reduce the severity of their symptoms
- Medicine commonly causes some drowsiness or dizziness
- Explain that these side effects should improve over the first few weeks
- Avoid driving or operating machines until they are confident that the symptoms have settled
81
Names of lithium salts?
Lithium carbonate, citrate
82
Indications of lithium salts?
- Mania: treatment and prophylaxis
- Bipolar Affective Disorder
- Recurrent depression - augmentation
- Aggressive or self-mutilating behaviour
83
Mechanisms of lithium salts?
- Lithium can substitute Na, K, Ca, Mg and may affect cell membrane electrophysiology
- Within cells, interacts with release of neurotransmitters, 2nd messengers to block action
- Reduction in receptor up-regulation
84
SE of lithium salts?
| Early? Late?
- 75% of people get side effects
- Early
o Dry mouth, metallic taste, nausea, fine tremor, fatigue, polyuria, polydipsia
- Late
o Diabetes insipidus, hypothyroidism, arrhythmias, ataxia, dysarthria, weight gain
85
```
Toxicity of lithium salts?
Causes?
levels?
Symptoms?
Ix?
Rx?
```
o Causes – OD, poor renal function, NSAIDs, diuretics, ACEi, Dehydration
o Levels >1.5mmol/L, >2.0mmol/L is severe and life-threatening
o Early: blurred vision, anorexia, nausea, vomiting, diarrhoea, coarse tremor, ataxia, dysarthria, convulsions
o Late: confusion, renal failure, delirium, fits, coma, death
o Ix – Bloods (FBC, U&Es, LFTs, TFTs), ECG
o Rx - Stop lithium, give IV fluids and diuretics – encourage diuresis – may need dialysis
86
Contraindications of lithium salts?
o Psoriasis, CVD, kidney or thyroid problems
87
Excretion of lithium salts?
- Excretion via the kidneys, clearance depends on renal function, fluid intake, Na intake
88
Interactions of lithium salts?
```
- Increased plasma concentration
o ACEi, ARBs, NSAIDs, antidepressants, diuretics, antiepileptics, antipsychotics, Ca channel blockers, metronidazole
o Renal failure, UTI, dehydration
- Reduced plasma concentration
o Antacids, theophylline
```
89
What baseline investigations to be done when taking lithium salts?
o Physical and weight, FBC, U&Es, LFTs, TFTs, creatinine, ECG
o Pregnancy test – increased risk of Ebstein’s anomaly
90
How and when to take lithium salts?
Oral tablet/solution given at night
Takes 1-2 weeks to take effect
Do not chew or crush tablet
91
What to do if dose missed?
If <3 hours take normal dose
| Otherwise do not double dose
92
Monitoring of lithium salts?
Check lithium levels 5 days after starting and 5 days after each dose change
Once stable (0.6-1.2), lithium level & U&Es every 3 months
TFTs 6 months and creatinine every 12 months
Regular review by psychiatrist
93
What is a lithium card?
o Lithium card needed
| Recognise lithium toxicity and go to hospital
94
Name of sodium valproate - mood stabiliser?
Semisodium Valproate (Depakote)
95
Indications of Semisodium Valproate (Depakote)
Acute mania
Acute depressive episode in BAD
Prophylaxis of BAD (more effective in rapid cycling)
96
Mechanism of Semisodium Valproate (Depakote)
- Uncertain
- Modulates voltage-sensitive Na channels, stabilising resting membrane potentials and reducing neuronal excitability
- Increases GABA bioavailability
- Acts on 2nd messenger systems
97
SE of Semisodium Valproate (Depakote)
| Rarely?
- GI upset (nausea, gastric irritation, diarrhoea)
- Tremor, ataxia, behavioural disturbances
- Leukopenia and thrombocytopenia
- Increased LFTs
- Weight gain
- Hair loss and curly regrowth
- Rare
o Liver failure, Pancreatitis, Agranulocytosis
o Antiepileptic hypersensitivity syndrome
SJS, TEN, fever and lymphadenopathy
98
Interactions of Semisodium Valproate (Depakote)
- Inhibits CYP450 enzymes
- Metabolised by CYP450 enzymes
- Efficacy of valproate reduced by drugs that lower seizure threshold (SSRIs, TCAs, Aps, tramadol)
99
Contraindications of Semisodium Valproate (Depakote)
o Women of child-bearing age
o First trimester of pregnancy – foetal abnormalities
o Hepatic impairment
100
Cautions of Semisodium Valproate (Depakote)
o Reduce dose in renal impairment
101
Prescription of Semisodium Valproate (Depakote)
- Available in tablet, liquid, solution, syrup, enteric coated form
- Depakote contains valproic acid and sodium valproate
- Starting dose is then tailored up to maximum effective dose
102
Communication of Semisodium Valproate (Depakote)
o Warn patients that they may have some indigestion when starting valproate, but should settle in a few days and can be reduced by taking tablets with food
o Seek urgent medical advice for unexpected symptoms including lethargy, loss of appetite, vomiting or abdominal pain (may indicate liver poisoning) or bruising, a high temperature or mouth ulcers (may indicate blood abnormalities)
o Discuss contraception and pregnancy
103
Monitoring of Semisodium Valproate (Depakote)
```
o Baseline
Medical history, examination
FBC, LFTs, ECG
o Check serum levels when tailoring up
o Once established
```
104
Indications of lamotrigine?
- Maintenance mood stabiliser of bipolar disorder
105
Mechanism of lamotrigine?
- Inhibits voltage-gated Na channels and glutamate release
| - Weak 5-HT receptor inhibitor
106
SE of lamotrigine?
- Dizziness, headache, blurred vision, ataxia, nausea and vomiting
- Insomnia
- Liver failure
- Blood dyscrasias and pancytopenia
- Rash
o 10% occurs within 2-8 weeks and drug should be discontinued if rash appears
o Can progress to SJS and TENS
107
Interactions of lamotrigine?
- Drugs that increase clearance
o Carbamazepine, oxcarbazepine, phenobarbital, phenytoin, OCP
- Drugs that decrease clearance
o Valproate so need reduced dose
108
Contraindications of lamotrigine? Safe in pregnancy?
- Blood disorders
| - The safest anticonvulsant in pregnancy
109
Prescription of lamotrigine?
- Oral administration
110
What to do prior to starting of lamotrigine?
o Pregnancy test
o Start low dose and then increase every 2 weeks until dose
o If stop taking for >5 days, then initial dosing recommendations should be follower
o Warn patient of rash and signs of hypersensitivity – warrants urgent assessment
111
Withdrawal instructions of lamotrigine?
o Withdrawal needs to be tapered off for 2 weeks
112
Names of acetylcholinesterase inhibitors?
Donepezil, Rivastigmine, Galantamine
113
Indications of acetylcholinesterase inhibitors?
- Mild to moderate Alzheimer’s Dementia
114
Mechanism of acetylcholinesterase inhibitors?
- Enhancing ACh at cholinergic synapses in CNS
- Reversible inhibitors of acetylcholinesterase
- May slow progression of disease but does not cure disease
- Benefit cognitive, functional and behavioural symptoms
115
SE of acetylcholinesterase inhibitors?
- GI upset – D&V, nausea
- Headache
- Insomnia
- Hepatotoxicity
- Bradycardia
- Hypotension
- Weight loss/Lack of Appetite
- Dizziness/Syncope
116
Contraindications of acetylcholinesterase inhibitors?
- Avoid in severe liver/renal impairment
- Surgery with general anaesthetic
- Cardiac conduction abnormalities
- Peptic Ulcers
117
Monitoring of acetylcholinesterase inhibitors?
- Monitor drug effects and cognitive assessment every 6 months
118
When to withdraw acetylcholinesterase inhibitors?
- If MMSE falls below 10 then withdraw drugs
119
Prescription of acetylcholinesterase inhibitors?
- Oral tablets taken
| - Initially 5 mg once daily for one month, then increased if necessary up to 10 mg daily, doses to be given at bedtime
120
Name of NMDA antagonists?
Memantine
121
Indications of memantine?
- Alternative to AChEI’s if not tolerated or augmented in patients with Alzheimer’s Dementia
122
Mechanism of memantine?
- Non-competitive, PCP-site NMDA antagonist
- Protects neurones from glutamate-mediated excitotoxicity
- NMDA receptor binds glutamate and has a role in LTP and memory
123
SE of memantine?
- Balance problems
- Constipation
- Dizziness
- Headache
- Drowsiness
- Hypertension
- Seizures rarely
124
Cautions of memantine?
o Epilepsy, history of epilepsy
125
Contraindications of memantine?
o Avoid in severe hepatic and renal impairment
126
Prescription of memantine? How to take drug?
- Oral tablet, started at low dose and then increase to maintenance daily dose
- Oral solution - solution should be dosed onto a spoon or into a glass of water.
- Soluble tablets - drink resulting solution immediately when dissolved in water
127
Names of typical 1st generation anti-psychotics?
Haloperidol, chlorpromazine, prochlorperazine, flupentixol, levomepromazine
128
Indications of typical 1st generation anti-psychotics?
- Urgent treatment for psychomotor agitation
- Schizophrenia, when 2nd generation likely to be problematic
- Bipolar disorder, in acute mania or hypomania
- Nausea and vomiting, particularly in the palliative care setting
129
Mechanisms of typical 1st generation anti-psychotics?
| 3 Main dopamine pathways?
Block post-synaptic dopamine D2receptors
3 main dopamine pathways:
o Mesolimbic/mesocortical
Runs between midbrain and frontal cortex
Probably main mechanism of anti-psychotic action
o Nigrostriatal
Connects substantia niagra with corpus striatum of basal ganglia
Gives EPSE, TD, NMS – Parkinsonism
o Tuberohypophyseal
Connects hypothalamus with pituitary gland
Gives hyperprolactinaemia, sexual dysfunction and weight gain
o All antipsychotics, but particularly chlorpromazine, have some sedative effect
130
Interactions of typical 1st generation anti-psychotics?
- Lots of interactions – consult BNF
| - Avoid in drugs that prolong QT interval
131
Differences in SE in 1st and 2nd generation antipsychotics?
1st gen - higher risk of neurological side effects (tardive dyskinesia, extrapyrimidal symptoms)
2nd gen - higher risk of metabolic side effects (hyperglycaemia, weight gain, dyslipidaemia)
132
Contraindications of typical 1st generation anti-psychotics?
- Avoid in dementia
| - Avoid in Parkinson’s disease
133
Cautions of typical 1st generation anti-psychotics?
o Elderly need lower dose, epilepsy
134
Baseline tests needed for treatment of typical 1st generation anti-psychotics?
- Baseline Tests
o FBC, U&Es, LFTs, TFTs, HbA1c, Prolactin, Lipids, cholesterol
o Weight, BP, pulse
o ECG
135
Monitoring of typical 1st generation anti-psychotics?
```
- 3 months
o Prolactin, lipids
- 6 months
o HbA1c
- Annually
o FBC, U&Es, LFTs, TFTs, ECG, lipids, glucose
```
136
Prescription of typical 1st generation anti-psychotics?
| Communication of 1st generation anti-psychotics?
o Single dose may be needed in acute behaviour control IM haloperidol
o Regular administration – oral (tablet or liquid) or IM depot
o Communicate aims and benefits of treatment, as well as its potential side effects
o Emphasise that patients should report that they are taking antipsychotics to other healthcare professionals involved in their care
o May take several weeks to work and dose may need to be adjusted
137
Assessment of response of typical 1st generation anti-psychotics?
o Assess over 2-3 weeks
No effect- change dose or medication
Some effect- continue for 4 weeks
o Consider starting Clozapine [after 2 a/p tried and unsuccessful]
138
Duration of typical 1st generation anti-psychotics?
o Continue antipsychotic medication for 1-2 years
139
Names of 2nd generation anti-psychotics?
Quetiapine, Olanzapine, Risperidone, Clozapine (covered in more detail later)
140
Indications of 2nd generation anti-psychotics?
- Urgent severe psychomotor agitation – violent behaviour (can be seen in dementia)
- Schizophrenia – when EPSEs not tolerated in 1st Aps
o Clozapine – Used 3rd line when >2 APs tried and failed in schizophrenia
- Bipolar disorder – acute episodes of mania/hypomania
- Aripiprazole given if concerns about prolonged QT patients
141
Mechanism of 2nd generation anti-psychotics?
- Block post-synaptic dopamine D2receptors
- Three main dopaminergic pathways
o Mesolimbic/mesocortical pathway
Runs between the midbrain and the limbic system/frontal cortex.
D2 blockade probably the main determinant of AP effect
o Nigrostriatal pathway
Runs substantia nigra with the corpus striatum of the basal ganglia
o Tuberohypophyseal pathway
Connects the hypothalamus with the pituitary gland
- Improved efficacy in ‘treatment-resistant’ schizophrenia (particularly true of clozapine – increased affinity in D4)
- Lower risk of extrapyramidal symptoms
142
SE of 2nd generation anti-psychotics?
| Specific SEs of risperidone and clozapine?
- Sedation
- Blocking dopamine
o EPSEs – less common in 2nd APs
o Dystonia, Parkinsonism, Akathisia, Tardive dyskinesia
- Metabolic disturbances
o Weight gain, diabetes mellitus, lipid changes
- Prolong QT interval, arrhythmias
- Anti-histamine
o Sedation, drowsiness
- Anticholinergic
o Dry mouth, blurred vision, difficulty passing urine, constipation
- Antiadrenergic
o Postural hypotension, erectile dysfunction
- Specific Drugs
o Risperidone
Increases prolactin causing breast symptoms, sexual dysfunction
o Clozapine
Agranulocytosis (1%), myocarditis
143
Interactions of 2nd generation anti-psychotics?
- Increased sedation with other sedating drugs
- Do not combine with dopamine-blocking antiemetics (metoclopramide, domperidone), drugs that prolong the QT interval (amiodarone, quinine, macrolides, SSRIs)
144
Differences between 1st gen and 2nd generation anti-psychotics SE?
1st gen - higher risk of neurological side effects (tardive dyskinesia, extrapyrimidal symptoms)
2nd gen - higher risk of metabolic side effects (hyperglycaemia, weight gain, dyslipidaemia)
145
Cautions of 2nd generation anti-psychotics?
o CVD
146
Contraindications of 2nd generation anti-psychotics?
o Clozapine not used in CHD or history of neutropenia
147
Prescription of 2nd generation anti-psychotics?
- Specialist input
- Options include daily oral, IM (depot) injections
- Best taken at bedtime
- Make sure you make healthcare professionals aware if you’re on antipsychotics as can interfere with other medications
148
Baseline tests of 2nd generation anti-psychotics?
o Baseline Tests
FBC, U&Es, LFTs, TFTs, HbA1c, Prolactin, Lipids, cholesterol
Weight, BP, pulse
ECG
149
Monitoring of 2nd generation anti-psychotics?
```
o 3 months
Prolactin, lipids
o 6 months
HbA1c
o Annually
FBC, U&Es, LFTs, TFTs, ECG, lipids, glucose
```
150
Clozapine tests and monitoring needed?
| Withdrawal?
o Baseline bloods and must have normal leukocyte count
o FBC done weekly for 1st 18 weeks and then fortnightly until 1 year, monthly thereafter
o Registered with Clozaril Patient Monitoring Service (CPMS)
o Dose started on low dose and then increased to maximum effective dose
o Gradual discontinuation over 1-2 weeks
o Report infective symptoms immediately with worry of agranulocytosis
151
Names of depot antipsychotics?
Typical - Flupentixol, Fluphenazine, Haloperidol, Pipotiazine, Zuclopenthixol,
Atypical - Olanzapine, Paliperidone, Risperidone
152
Indications of depot antipsychotics?
- Poor compliance with oral tablet
- Failure to respond to oral medication
- Inability to take medicines regularly
- If treatment order for detained patients under MHA
153
Mechanisms of depot antipsychotics?
- Long-acting depot injection (active drug in oily suspension)
- Same mechanism as oral antipsychotics
154
SE of depot antipsychotics?
- Pain/Swelling at injection site
- Abscesses
- Nerve palsies
- Same side-effects as oral medication but may take 2-3 days to come on and may persist for weeks after discontinuation
155
Contraindications of depot antipsychotics?
- As for oral antipsychotics
156
Prescription of depot antipsychotics?
- Injected IM - usually gluteus maximus
- Sustained release over 1-4 weeks – usually every 4 weeks, patients can have it at home via district nurse
- Patients given small test dose – to see if there’s any side effects as they can be maintained over the period of release
157
Monitoring of depot antipsychotics?
- Monitoring as per oral antipsychotic guides
