CNS

Question 1

Which MAOI’s is hepatotoxicity most likely?

Answer 1

Phenelzine

Isocarboxazid

Question 2

Which MAOI more likely to cause hypertensive crisis?

Answer 2

Tranylcypramine

Question 3

Which MAOI has no wash-out period?

Answer 3

Moclobemide

Question 4

What to look out for with MAOI’s?

Answer 4

• Throbbing headache - D/C
• Indicates hypertensive crisis
• Increased risk with:
  Pseudoephedrine
  Adrenaline/Noradrenaline
  Levodopa
  TCA’s (esp clomipramine)

Question 5

S/E of MAOI’s

Answer 5

• Hepatotoxicity
• Hypertensive crisis
• Postural hypotension / hypertensive responses - D/C if palpitations or frequent headaches

Question 6

Which SSRI safe in MI / Unstable angina

Answer 6

Sertraline

Question 7

Which SSRI licensed in children?

Answer 7

Fluoxetine

Question 8

Which SSRI has an increased risk of withdrawal reactions?

Answer 8

Paroxetine

Question 9

SSRI’s causing QT interval prolongation?

Answer 9

Citalopram

Escitalopram

Question 10

Antidepressant withdrawal?

Answer 10

• Withdrawal effects may occur within 5 days of cessation
• Higher risk if >8wks treatment
• Taper over 4 few weeks (6 months if long term maintenance treatment)
• Abrupt withdrawal may cause FLU-LIKE symptoms

Question 11

ADR’s of SSRI’s

Answer 11

G - GI disturbance
A - Appetite / weight disturbance
S - Serotonin syndrome
H - Hypersensitivity reactions - stop if RASH occurs

• ⬇️ seizure threshold : C/I in uncontrolled epilepsy
• ⬆️ bleeding risk (NSAIDS, anticoags)
• QT interval prolongation
• Movement disorders

Question 12

How long do SSRI’s take to work?

Answer 12

• 2 to 4 weeks
• 4 weeks of treatment before deeming ineffective
• If partial response continue for further 2-4 weeks

Question 13

How often should SSRI treatment be reviewed?

Answer 13

Every 1-2 weeks at start of treatment

Question 14

How long should SSRI’s be continued following remission?

Answer 14

• 6 months
• Elderly & GAD = 12 months
• Recurrent depression = 2 years

Question 15

Drug management of depression?

Answer 15

1st line: SSRI

2nd line:

• Increase dose
• Switch to different SSRI or Mirtazepine
• Other options: Lofepramine, Moclobomide, Reboxetine

3rd line:

• Addition of another antidepressant of different class
• Use of augmenting agent (lithium/aripiprazole/quetiapine etc)

Question 16

Washout periods?

SSRI’s, TCA’s, MAOI’s

Answer 16

SSRI = 1 week (sertaline = 2wks  fluoxetine = 5 wks)
TCA = 1-2 weeks (clomipramine/imipramine = 3wks)
MAOI's = 2 weeks (moclobemide = no wash out period)

Question 17

Sedating TCA’s

Answer 17

Amitriptylline
Clomipramine
Dosulepin
Doxepin
Trimipramine

Question 18

Less-sedating TCA’s

Answer 18

Imipramine
Lofepramine
Nortriptylline

Question 19

What TCA has the most antimuscarinic effects?

Answer 19

Imipramine

Question 20

TCA most dangerous in overdose?

Answer 20

Dosulepin - specialist use

Question 21

Effects of TCA’s

Accronym: TCAS

Answer 21

T - more TOXIC in overdose
C - Cardiac S/E - QT prolongation, arrhythmias, heart block
A - Antimuscarinic effects
S - Seizures

Question 22

TCA contraindications

Answer 22

• Arrhythmias
• Heart block
• Manic phase of bipolar
• Immediate recovery after MI

Question 23

Focal seizures

Answer 23

1st line: Carbamazepine or Lamotrigine

2nd line:

• Oxcarbazepine
• Sodium Val
• Levetiracetam

Question 24

Tonic-clonic

Answer 24

1st line: Sodium Val (except in pre-menopausal females)

2nd line: Lamotrigine (may exacerbate myoclonic seizures)

Can also consider Carbamazepine or Oxcarbazepine

Question 25

Absence

Answer 25

1st line: Ethosuximide or Sodium Val

2nd line: Lamotrigine

If monotherapy ineffective can combine any 2 of the above

Question 26

Myoclonic

Answer 26

1st line: Sodium Val

2nd line: Levetiracetam or Topirimate (worse S/E)

Question 27

Atonic and Tonic

Answer 27

1st line: Sodium Val

2nd line: Lamotrigine (adjunct)