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CNS drugs Flashcards

1
Q

Treatment stratgies for depression

A

Pharmacological:
tri-cyclic antidepressants
MAOIs
SSRIs
Atypical antidepresant

Psychological: CBT

Medical:
Transcranial magenetic stimulation
Electroconvulsive therapy

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2
Q

Name 3 SSRIs

A

Citalopram

escitalopram

fluoxetine

fluvoxamine

paroxetine

sertraline

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3
Q

Mechanism of action of SSRIs

A

Block serotonin reuptake pumps at the presynaptic membrane.

e.g. fluoxetine, paroxetine, sertraline

Cause GI disturbance and sexual dysfunction

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4
Q

Side effects of SSRIs

A

GI disturbance

Hypersensitivity

Anorexia and weight loss

Dry mouth

Headaches

Sexual dysfunction

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5
Q

Why are SSRIs given to patients with depression who have cardiac disease

A

SSRIs have fewer anticholinergic effects and are less sedating than TCAs.

TCAs have cardiotoxic effect - produce long QT interval, ST elevation, heart block, arrhythmias. Dangerous in overdose.

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6
Q

Drug interactions of SSRIs

A

Increases concentration of TCAs

Should not be started until 2 weeks after stopping MAOI (increased risk of serotonin syndrome)

Increased risk of bleeding if on aspirin/warfarin/NSAIDs

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7
Q

Monoamine oxidase inhibitors used in depression

A

Target MAOI-A

Inhibit monoamine oxidase within nerve endings. Cytosolic NA and 5HT increases and more leaves out into the synaptic cleft.

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8
Q

Function of MAO-A enzyme

A

Breaks down adrenaline, NorA, serotonin, melatonin

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9
Q

State 3 side effects of MAOIs

A

Increase levels of NorA and 5HT. Leads to:

Postural hypotension

Restlessnes

Convulsions

‘Cheese reaction’. Foods containing tyramine normally broken down by MAO in the gut and liver. Increased blood levels can cause increased neurotransmitter relese = severe hypertension.

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10
Q

Name 3 MAOIs used in depression

A

Block MAO-A enzymes

Drugs: Phenelzine, isocarboxazid, tranylcypromide

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11
Q

Indications for using MAOIs for depression

A

Resistant depression, particularly if atypical, hyperchondriacal or hysterical features. Phobic patients.

Should be triend in any patient refractory to treatment with other anti-depressants. Up to 3 weeks for response.

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12
Q

Drug interactions of MAO-A inhibitors

A

Sympathetomimetics

SSRIs and TCAs

L-dopa

Opioids

Accumulation of amine neurotransmitters may result in psychosis, hypersensitive crisis and hyperpyrexia.

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13
Q

What are the main actions of tri-cyclic antidepressants?

A

5HT reuptake blocker

NA reuptake blocker

α1 adrenoreceptor antagonist (postural hypotension)

H1 receptor antagonist (weight gain, sedation)

M1 receptor antagonist (dry mouth, constipation, urinary retention)

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14
Q

Name three TCAs

A

Amitriptyline

lofepramine

imipramine

dosulepin

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15
Q

Name 3 conditions where TCAs could be prescribed

A

Depression

Panic disorder

Neuralgia (chronic pain)

Nocturnel enuresis in children

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16
Q

Why would you give a depressed patient lithium?

A

General mood stabiliser. Used in prophylaxis for manic/depressive illness.

Must be carefully monitored.

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17
Q

Pre-cautions to consider when prescribing TCAs

A

Patients with CV disease - increased risk of arrythmias

Past psychiatry - antidepressant therapy may aggravate suicidal thoughts, psychosis and biplar disorder

Elderly patients more susceptible to side effects

Overdose - small quantities prescribed because side effects dangerous in overdose

Lifestyle - increased sedative effect with alcohol and anti-histamines

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18
Q

Side effects of TCAs

A

Arrythmias

Anxiety

Dizziness

Drowsiness

Anti-muscarinic effects (dry mouth, constipation, retention)

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19
Q

Name three atypical antidepressants

A

NorA reuptake inhibitors (Reboxetine)

Serotonin-NorA reuptake inhibitor (Venlafaxine)

5HT partial agonist (Buspirone)

20
Q

Sedative anti-depressants

A

TCAs

Alpha-adrengergics e.g. Mirtazapine

Block alpha-adrenergic receptors. a2-receptors inhibit presynaptic release. Blocking receptor increases the amount of NorA in synaptic cleft.

No effect on uptake of aminotransmitters.

21
Q

How do you decide which class of anti-depressant drug to precribe?

A

Little difference in classes of antidepressant drugs in terms of efficacy, so choice should be based on the individual patient’s requirements, including the presence of concomitant disease, existing therapy, suicide risk, and previous response to antidepressant therapy.

SSRIs are better tolerated and are safer in overdose. First line

22
Q

Herbal remedy for depression

A

St. John’s Wort

Should not be prescribed or recommended. Enzyme inducer. Amount of active ingredient in preparations differ

23
Q

Management of a patient who presents with 1st episode of depression.

A

SSRI first line treatment (fluoxitine, sertaline, citalopram, paroxetine)

Patients should be reviewed every 1–2 weeks at the start of antidepressant treatment. Continued for at least 4 weeks (6 weeks in the elderly) before considering whether to switch. In partial response, continue for a further 2–4 weeks (elderly patients may take longer to respond).

Patients with a history of recurrent depression should receive maintenance treatment for at least 2 years.

Second line choices - lofepramine, moclobemide, and reboxetine.

24
Q

Treatment methods for epilepsy

A

Pharmacological - anticonvulsants

Surgical - removal of abnormal areas seen on MRI/CT

Implants - vagal nerve stimulation

25
Q

Treatment for tonic-clonic seizures

A

Sodium valproate is the first-line treatment for newly diagnosed generalised tonic-clonic seizures. Lamotrigine is the alternative choice if sodium valproate is not suitable, but may exacerbate myoclonic seizures.

Could also use carbamazepine/oxcarbazepine

26
Q

Treatment of myoclonic seizures

A

Sodium valproate first line.

Topiramate/ levetiracetam can be given if unsuitable.

27
Q

Treatment of atonic seizures

A

Sodium valproate

Lamotrigine can be given as adjunct.

28
Q

Treatment of absence seizures

A

Ethosuxamide

Sodium valproate

29
Q

Mechanism of action of anti-convulsants

A

Inhibit Na+ channels: Carbimazepine, valproate, phenytoin. Bind to inactivated Na+ channels to prevent high frequency repetitive activtity. Side effects - peripheral neuropathy, osteomalacia, visual impairment

Enhance GABA action: benzodiazepines, vigabatrin, tiagabine. Increase brain levels of GABA by inhibiting uptake and breakdown

Inhibit Ca2+ channels: Reduces oscillatory activity between the thalamus and the cortex produced in absence seizures. ethoxusamide and lamotrigine.

30
Q

Carbamazepine can be prescribed for

A

Epilepsy (1st line for simple and complex focal seizures, general tonic-clonic)

Prophylaxis of biplar disorder

Trigeminal neuralgia

Initiate at a low dose and build up increments of 100-200mg

31
Q

Cautions and contraindications of carbamazepine

A

BM suppression (leukopenia)

Cardiac conduction abnormalities

N+V

Reduces effect of warfarin

32
Q

Gabapentin and pregabalin

A

Used for the treatment of focal seizures with or without secondary generalisation. They are not recommended if tonic, atonic, absence or myoclonic seizures are present.

Can also be given for neuopathic pain

33
Q

Treatment options for Parkinsons

A

Pharmacological: dopamine replacement. Treats symptoms only.

Deep brain stimulation

Radiosurgery

Surgical intervention

34
Q

Use of L-Dopa in Parkinson’s

A

Should be started at the minimal effective dose in combination with a decaarboxylase inhibitor to prevent L-dopa metabolism in the periphery

Can give dopamine antagonist to reduce side effects.

35
Q

When are DA agonists used in Parkinsons?

A

Synthetic agonists replace DA loss by acting on receptors.

Given as initial therapy to younger patients and in late stages of disease to reduce ‘off’ effects.

e.g. ropinirole, pramipexole, rotigotine

36
Q

Mechanism of action of L-dopa

A

Levodopa is the immediate precursor of dopamine and is able to penetrate the brain where it is converted.

37
Q

What are anticholinergics given in Parkinson’s

A

As the nigrotriatal neurones decline in Parkinson’s, the releaase of DA neurones (inhibitory) declines and cholinergic neurones (excitatory) become overactive.

Can be used to reduce tremor.

Useful for drug-induced Parkinsonism

38
Q

Complication of long term L-dopa treatment

A

Gradual recurrence of akinesia.

Over time the duration of action of L-dopa shortens, and leads to dyskinesia.

Patients experience on-off effect which corresponds to the peaks and troughs of l-dopa plasma levels.

39
Q

Mechanism of action of anti-psychotic drugs

A

Antipsychotics are dopamine D2 antagonists. .

  • Block the mesolimbic/mesocortical pathway to remove positive symptoms. (also results in apathy and sedation)
  • Blocks nigrostriatal pathway, causes extrapyramidal symptoms
  • Blocks tuberinfindibular pathway, increases prolactin, results in galactorrhoea, gynaecomastia and amenorrhoea.

Also affect a1-adrenoreceptors, H1 and 5HT receptors.

40
Q

Side effects of neuroleptic drugs

A

Movement disorders:

  • Dystonias (spasm of face and muscles),
  • Parkinsonian symptoms
  • Sedation
  • Tardive dyskinesia (repetitive tic movements)

Endocrine effects: Gynaecomastia, Galactorrhoea, Impotence, Weight gain

41
Q

Benzdiazepines

A

Benzodiazepines act on the gamma subunit of the GABAaR. Increases affinity of GABA for receptor and opens Cl-channels, results in hyperpolariation of the membrane.

Should be used short term as tolerance and dependence can develop. Causes impaired motor coordination and cognitive performance, sedation, withdrawal.

42
Q

Tiagabine and Vigabatrin

A

Both affect recycling of GABA

Vigabatrin is an irreversible inhibitor of GABA-ransaminase, which increases GABA brain levels

Tiagabine inhibits reuptake of GABA. Increasing the amount of GABA in the synaptic cleft increases central inhibition.

Side effects: confusion, sedation, dizziness, weight gain

43
Q

Classes of drugs used in treatment for Parkinsons

A

Levodopa + decarboxylase inhibitor (carbodipa)

Dopamine receptor agonists: bromocriptine, apomorphine

MAOI-B: segiline

COMT inhibitors: entacapone

Anticholinergics: procyclidine hydrochloride

Glutamate antagonists: amantadine

44
Q

Name 5 anti-epileptic drugs

A

Carbamazepine

Ethosuzamide

Gabapentin

Lamotrigine

Phenytoin

Retigabine

Vigabatrin

Valproate

45
Q

Name 4 benzodiazepines

A

Diazepam - anxiety, insomia, sedation

Lorazepam - anxiety, insomia

Midazolam

Temazepam - anxiolytic, sedative

Clordiazepoxide

Clonazepam - anti-epileptic

Drugs (6 decks)

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