Drug Therapy

Question 1

Major side effect of hypnotics and anxiolytics

Answer 1

“hangover effect”

Question 2

Use of hypnotics in children

Answer 2

night terrors and sleepwalking

Question 3

2 common hypnotics and uses and side effects

Answer 3

Chloral hydrate: night time sedation
- S.E: GI probs, headache, rashes, lightheadedness, ataxia, vertigo

Promethazine (anti-histamine): night time sedation & insomnia
- S.E: drowsiness, headache, dry mouth, blurred vision, urinary retention, palpitations, light sensitive rash

Question 4

Ataxia

Answer 4

lack of voluntary muscle coordination

Question 5

Use of anxiolytics

Answer 5

Relieve acute anxiety and related insomnia caused by fears

- lowest possible dose for lowest amount of time

Question 6

Mode of action of benzodiazepines

Answer 6

Increase the inhibitory effect of GABA preventing excessive brain activity that causes anxiety

Question 7

Common anxiolytic

Answer 7

Diazepam (benzodiazepine): short term relief of anxiety that is severe, disabling or subjecting the individual to unacceptable distress

• Also night terrors and sleepwalking
• S.E: drowsiness, light headedness next day, confusion, ataxia, amnesia, dependence, paradoxical increase in aggression, muscle weakness

Question 8

Use of anti-psychotics

Answer 8

• generally tranquillize without impairing consciousness

- Short term: calm disturbed children, alleviate anxiety

Question 9

Anti-psychotics use in schizophrenia

Answer 9

Relieve florid psychotic symptoms:

• thought disorder
• hallucinations
• delusions
• prevent relapse

Question 10

Mode of action of anti-psychotics

Answer 10

Anti-psychotics bind to receptors making brain less sensitive to dopamine

Question 11

Relation of dopamine and psychosis

Answer 11

In psychosis, the brain cells release too much dopamine resulting in excessive stimulation
- this disrupts the normal thought processes and produces abnormal behaviour

Question 12

Side effects of anti-psychotics (2)

Answer 12

• Extra pyramidal side effects - part of NS that controls muscle reflexes
• more common with typical anti-psychotics

Question 13

What are the extra pyramidal side-effects? (6)

Answer 13

1. Parkinsonian symptoms: tremor, slowed motion, rigid muscles, loss of posture and balance, loss of autonomic movements
   - may gradually appear but manifest less commonly in adults
2. Dystonia: abnormal face and body movements
3. Dyskinesia: difficulty in performing voluntary movements
   - appear only after a few doses
   - TARDIVE DYSKINESIA: rhythmic voluntary movements of tongue, face and jaw
   
   • usually on long term treatment and high dosages
4. Akathisia : restlesness
   - occurs after large doses (may resemble an exacerbation of the condition being treated)
5. Hypotension & interference with temp regulation (dose related)
6. Neuroleptic malignant syndrome (altered mental status, muscle rigidity, and autonomic dysfunction.) - hyperthermia, fluctuating levels of consciousness, muscle rigidity, tachycardia, sweating, urinary incontinence
   - rare but potentially fatal

Question 14

Other side effects of anti-psychotics

Answer 14

• Anti-muscarinic symptoms: dry mouth, constipation, difficulty with micturation (passing urine), blurred vision
• Endocrine effects: menstrual disturbances,galactorrhea, gynaecomastia, impotence, weight gain.
• drowsiness, apathy, agitation, excitement, insomnia, convulsions, dizziness, headache, confusion, GI disturbances, nasal congestion

Question 15

Typical anti-psychotics

Answer 15

• haloperidol
• chlorpromazine: sedating effect, treat violent children without causing stupor
• sulpiride: high doses control florid symptoms, low doses have an alerting effect on apathetic withdrawn schizophrenia, Tourette’s

Question 16

Atypical anti-psychotics

Answer 16

Better tolerated than other anti-psychotics

• Olanzapine
• Risperidone
• Clozapine: used in schizophrenia when other anti-psychotics are ineffective/ not tolerated

less extra pyramidal symptoms

Question 17

Haloperidol indications

Answer 17

Typical anti-psychotic

• motor tics (Tourette)
• schizophrenia & other psychoses
• mania
• short term adjunctive management of psychomotor agitation
• excitement & violent / dangerously impulsive behaviour
• preferred for rapid control of hyperactive states

Question 18

Side effects of haloperidol

Answer 18

Same as S.E of anti-psychotics but:

• less sedating
• fewer antimuscarinic & hypotensive symptoms

Question 19

Asthenia

Answer 19

abnormal physical weakness or lack of energy

Question 20

Side effects of atypical anti-psychotics

Answer 20

better tolerated than typical anti-psychotics
- EPS less frequent

• weight gain, dizziness, postural hypotension
• occasional tardive dyskinesia on long term admin.
• hyperglycemia and sometimes diabetes (clozapine & olanzapine) IMP to monitor weight and plasma glucose

Question 21

Olanzapine

Answer 21

Atypical anti-psychotic

• schizophrenia & mania
• not licensed for use in children (dose recommendations from 12 yrs onward)

S.E:

• previous +
• mild transient anti muscarinic effects
• drowsiness
• speech difficulty
• akathisia
• asthenia
• increased appetite
• oedema

Question 22

Risperidone

Answer 22

Atypical antipsychotic

• acute & chronic psychoses
• not licensed for use in chldren under 15 yrs

S.E: previous +

• insomnia, agitation, headache, anxiety, drowsiness, impaired c, fatigueoncentration
• blurred vision
• GI problems

Question 23

What is the purpose of drugs used in mania?

Answer 23

• control acute attacks

- prevent recurrence

Question 24

Indications of Lithium

Answer 24

• prophylaxis & treatment of mania
• prophylaxis of bipolar disorder
• prophylaxis of recurrent depression
• aggressive or self-mutilating behaviour

Question 25

Lithium (3) + Side effects

Answer 25

• Anti-manic drug
• has a narrow therapeutic window
• preparations vary widely in bioavailability
• licensed for children over 12 yrs (all others not licensed in children)

S.E:

• increase in urine/ thirst
• nausea, vomiting, diarrhoea
• tremor
• weight gain
• drowsiness/ lethargy
• blurred vision
• unsteadiness

Question 26

Other drugs used in mania

Answer 26

• Benzodiazepines: only initial stages until lithium takes full effect
• antipsychotics: as above, can be given concurrently with lithium
• carbamazepine: used for prophylaxis of bipolar disorder in children unresponsive to lithium

Question 27

Major classes of antidepressants and respective drugs

Answer 27

1. Tricyclic Antidepressants
   - Amitriptyline
   - Imipramine
   - Nortriptyline
2. Selective serotonin reuptake inhibitors
   - Fluoxetine
   - Fluvoxamine
   - Sertraline
3. Monoamine oxidase inhibitors (MAOI’s)
   - not usually used in children

Question 28

Choice of antidepressant is based on: (5)

Answer 28

1. individual child’s requirements
2. presence of concomitant disease
3. existent therapy
4. suicide risk
5. previous response to antidepressant therapy

Question 29

Antidepressants mode of action

Answer 29

• neurotransmitters in the brain are constantly being reabsorbed and broken down by an enzyme called monoamine oxidase
• in depression, fewer neurotransmitters are released
• the levels of neurotransmitters are raised by anti-depressant drugs by blocking the reabsorption of the neurotransmitter
• tricyclic antidepressents block the reuptake of serotonic and noradrenaline
• SSRI’s block the reuptake of serotonin

Question 30

Symptoms of withdrawal from antidepressants (after more than 8 weeks use and stopped suddenly)

Answer 30

• dose should be reduced gradually
• GI. symptoms: nausea, vomiting, anorexia + headache
• giddiness, chills and insomnia
• sometimes hypomania
• panic anxiety, extreme motor restlessness