CNS 3 Flashcards
What is the first line tx for ADHD
Methylphenidate or Lisdexamphetamine
State what drug to offer patients that cannot use Methylphenidate or Lisdex
Atomoxetine
State when atomoxetine may be used as first line tx?
For drug misuse patients
What are methylphenidate counselling advice
Affects driving, effects increased by alcohol
Patient and carer advise for atomoxetine
Monitor for agitation, irritability, suicidal thoughts, self harming, unusual changes in initial months of tx or after dose change
Hepatic impairment
Monitoring for atomoxetine, methylphenidate
Monitor for appearance or worsening of anxiety, depression or tics.
Pulse, blood pressure, psychiatric symptoms, appetite, weight and height should be recorded at initiation of therapy, following each dose adjustment, and at least every 6 months thereafter.
What is bipolar Disorder?
Serious chronic condition where there is a period of depression and periods of Mania or hypomania
Symptoms of mania
Patients with Mania will have 3 or 4 of the following
Grand ideas about self
Increase energy or less sleep
More talkative than usual
Full of new ideas and plans, unreliastic plan
Irritation or agitation
Want to do lots of pleasurable things
Medication use to manage bipolar
Bz
Antisychotics
Carbamezepine
Valproate
Lithium
Facts about Mania and hypomania drugs
They are used to control acute attacks and to prevent recurrent episodes of Mania or hypomania
Duration of tx for bipolar
Continue long term tx of bipolar for atleast 2 years from the last manic episode and up to five years if patient has a risk factor for relapse
When to give Antidepressants in bipolar patients
Give it for depression
Antidepressants in bipolar should be avoided in the following conditions
Rapid cycling bipolar disorder
Recent hx of hypomania
Rapid mood fluctuations
When is Bz used in bipolar disorder?
Eg Lorazepam
For agitation or behavioural disturbance
Avoid long term use as it may cause dependence
State examples of antipsychotics used to treat mania and hypomania
Olanzepine, Quetiapine or risperidone
State what other drug to add to Antisychotics if response is inadequate
Add Lithium or valproate
Facts about discontinuing Antipsychotics
Reduce it gradually over 4weeks if pt is continuing with other anti manic drugs
Do you give Antidepressants in mania or hypomania?
No
Reduce the dose of antipsychotics over how long if pt is stopping anti manic drugs or if there is a hx of relapse in mania
3 months
What’s the indication of Carbamezepine
For prophylaxis of bipolar disorder (manic depressive disorder)
Use in pt with rapid cycling manic depressive illness (4 or More effective episodes/year
State the indication of valproate
It is used to tx and prophylaxis of manic episodes of bipolar
Indication of Lithium salt
Used in prophylaxis for and tx of mania , hypomania and depression in bipolar disorder
The two forms of Lithium have different bioavailabilty. True or false?
True
Eg lithium citrate and carbonate
When does full prophylactic effect of Lithium occur after initiation of therapy?
6-12 months
List some Contraindications with Lithium
Dehydration
Low sodium diets (Increase lithium conc)
Untreated hypothyroidism (lithium affects T4 production sodium can cause hypothyroidism)
Significant renal impairment
Cardiac disease
Addison’s disease
What are the cautions with Lithium
Avoid abrupt withdrawal
Diuretic tx (increases risk of toxicity) eg loops, ace inhibitors
QT interval elongation
Review dose in Diarrhoea, elderly, vomiting, surgery and intercurrent infection)
LTM use has been associated with thyroid disorders and mild cognitive and memory impairment
Monitoring in lithium for long term use
Monitor Thyroid function every 6months
Assess need for continuity regularly and maintain patients after 3-5 years on lithium only if benefits persists
Side effects of Lithium
Arrhythmia
Lowers seizure threshold
Tremor
QT interval elongation
Electrolytes imbalance
Renal dysfunction(polydipsia, polyuria)
Skin reactions
Vision disorder
Cardiomyopathy and AV block
GI disturbance
Drowsiness, unsteadiness and confusion fatigue hair loss and weight gain
Intracranial HTN
Leukocytes
Movement disorders
Signs of Lithium OD
GI ( Nausea and Vomiting)
Visual disturbance
Polyuria, muscle weakness
Fine tremor
CNS disturbance
Cardiac Arrhythmia
AV block
Renal failure
Seizure
Coma and death
What’s the mnemonic for lithium side effects?
LITHIUMS
Levels
Increased urination
Thirst, tremor and teratogenicity
Hypothyroidism
Interaction ( NSaids, ARBS/ DIURETICSS/ ANTACIDS
UPSET STOMACH
MUSCLE WEAKNESS
SKIN EFFECTS ( ACNE, PSORIASIS)
Is lithium safe in Breastfeeding?
Avoid, present in milk and risk of toxicity in infants
What stage of pregnancy should lithium be avoided?
First trimester ( risk of teratogenicity including cardiac abnormality)
Lithium dose is increased during what stage of pregnancy ?
2nd and 3rd trimester but on delivery, return abruptly to normal
State what monitoring is required for pregnant pt on lithium
Monitor serum concentration closely during pregnancy as there is risk of toxicity in neonates
What is the therapeutic range of Lithium
0.6-0.8mmol/L( those prescribed lithium for the first time)
0.8-1 mmol/L( mania and pt who previously relapsed
Elderly: 0.4-0.6mmol/L pt aged 65 and over
Monitoring requirements for Lithium
Take blood samples every 12 hours after dose initiation
Weekly routine serum- lithium conc after initiation and every 3months/year and every 6months thereafter when dose is stable
State what to assess before initiation of Lithium
Cardiac, thyroid, renal function, BMI, FBC and electrolytes
Lithium tx cessation
Abrupt discontinuation increase risk of relapse
Reduce gradually over a period of about 4weeks - 3months
In lithium discontinuation abruptly, consider changing therapy to an atypical antipsychotics or valproate
What is the pt and carer advice for lithium
Report signs and symptoms of Lithium toxicity
Renal dysfunction
Hypothyroidism- weight gain
Maintain adequate fluid intake
Avoid dietary changes which reduce or increase sodium intake
Give tx pack
Persistent headache and visual disturbance
Maintain same brand of Lithium
Which drug increases lithium concentration
Something that reduces sodium will increase Lithium
Ace Inhibit/ARBs
Diuretics/ loop/thiazide
NSAIDs
Metronidazole
Amiodarone
Tetracycline
State mnemonic for drugs that increase Lithium conc
LAND on the MAT
Which drugs decreases lithium conc
Sodium containing antacids and soluble/effervescent analgesics(high salt)
Urinary alkalinizing agents for cystitis
Theophylline
Osmotic and carbonic anhydrase inhibitor diuretics
Drugs which increase neurotoxicity with lithium
Carbamezepine
Antipsychotics
SsRs
Tristan
CCB eg verapemil
Drugs that cause hypokaelamia prolonged QT interval with Lithium eg diuretic, corticosteroids, B agonist.
Drugs which increase serotonin syndrome with lithium
Citalopram
Monoamine oxidase inhibitors
Tramadol
St John’s wort
Sumatriptans
