Drugs in Psychiatry Flashcards
(96 cards)
1
Q
ADRs of lithium?
A
nausea and vomiting, abdo pain
weight gain
renal impairment
impaired thyroid function-hypothyroidism, enlarged thyroid
metallic taste in mouth
teratogenic
fine tremor, coarse tremor suggests lithium toxicity
2
Q
caution with lithium in renal failure?
A
must reduce dose or may have to stop as renally excreted so risk of toxic ADRs
3
Q
what psychotropic drugs may cause discontinuation syndrome?
A
antidepressants-espec. SA e.g. venlafaxine (SNRI), and paroxetine (SSRI)
symtoms of anxiety, agitation, nausea and vomiting, insomnia, and sensation of body electricity e.g. ‘brain zaps’-electric shock like experiences.
4
Q
why should an antidepressant alone NOT be prescribed in bipolar?
A
can induce mania
can only be given alongside an antipsychotic or mood stabiliser
only 1 recommended by NICE?-SSRI?
5
Q
what must be considered in all patients who develop drowsiness, confusion or convulsions whilst taking an antidepressant?
A
hyponatraemia, possible result of SIADH-hyponatraemia would be in the context of euvolaemia and urine osmolality more than 500mosmol/kg
been reported more frequently with SSRIs
6
Q
TCA side effects?
A
tachycardia prolonged QT hypotension fine tremor anticholinergic: dry mouth, urinary retention, dry eyes, constipation weight gain lowered seizure threshold cholestatic jaundice allergic skin rashes
7
Q
indications for pregabalin in psychiatry?
A
generalised anxiety disorder
blocks calcium ion channels
8
Q
use of memantine?
A
tment of adult pts with moderate to severe AD
targets glutaminergic neurotransmission, antagonist of NMDA receptors
9
Q
risperidone class?
A
atypical antipsychotic
10
Q
Mood stabilisers that can be used in bipolar?
A
Lithium
Sodium valproate
Lamotrigine
Carbamazepine
11
Q
Risks of BZD use in elderly?
A
Higher falls risk
Disturbed sleep with sedation effects increasing sleep during the daytime
Increased risk of toxicity causing resp depression due to altered pharmacokinetics
12
Q
Why is there a risk of EP side effects with antipsychotics?
A
Anti dopamine on substantia nigra and so produce a Parkinsonian like picture with rigidity, bradykinesia, tremor, and postural hypotension.
13
Q
What is mirtazapine and what is its MOA?
A
Other antidepressant medication-NASSA-noradrenergic and specific serotonergic antidepressant
Centrally acting presynaptic alpha 2 antagonist, which increases noradrenergic and serotonergic neurotransmission by increasing their release into the synaptic cleft. Weak NA reuptake inhibitor, also antihistamine-latter properties responsible for sedative effects.
Can be combined with SSRIs/SNRIs
ADRs-weight gain, increased appetite, sedation
14
Q
Psychotropic drugs especially assoc. with withdrawal syndrome?
A
BZDs
symptoms may include autonomic disturbances e.g. sweating, tremor, disturbed sleep, impaired concentration, depression, pessimistic thoughts.
15
Q
How does the efficacy of antidepressants differ depending on depression severity?
A
Greater efficacy the more severe the depression.
16
Q
Onset of antidepressant action?
A
3 to 6 weeks for clinical effect to be noted by pt so must advise patients that benefit will not be noted straight away.
BUT usually begin working in 2-3 DAYS
17
Q
Serotonin syndrome may occur as a result of the use of antidepressants. What is its classical presentation triad?
A
Autonomic hyperactivity e.g. Tremor
Neuromuscular abnormality e.g. Akathisia
Mental status changes
Syndrome may be noted with antidepressant combinations, recent change in drug or increase in dose or starting new drug.
symptoms usually within 6 hrs of taking provoking drug, and tremor, akathisia and diarrhoea are early features.
18
Q
Monitoring required with venlafaxine?
A
Regular BP checks and ECGs as risks of HTN and hypotension.
19
Q
Why is mirtazapine prescribed at night?
A
Is associated with dizziness and postural hypotension.
20
Q
Risk with BZD overdose?
A
Respiratory depression
21
Q
How is BZD overdose reversed?
A
IV flumazenil 500 micrograms
22
Q
What investigation must be performed before starting acetylcholinesterase inhibitor Alzheimer’s disease medication?
A
ECG as can cause bradycardia
contraindicated if HR less than 50
must monitor HR
23
Q
MOA of TCAs
A
Inhibit re uptake of NA and serotonin, and have anticholinergic, and histamine and adrenergic actions.
24
Q
Which SSRIs are associated with prolonged QTc?
A
Citalopram and escitalopram
25
Duration of treatment with antidepressants following symptom remission?
At least 6 months if 1 episode
| If 2 or more within 5 years treat for at least 2 years.
26
SSRI side effects?
```
GI-dyspepsia, N and V, diarrhoea
insomnia
fatigue
sexual dysfunction
flushing
dizziness
weight loss? and loss of appetite?
increased risk of bleeding-be careful with co-prescribing aspirin/NSAIDs
```
27
2nd line treatment of depression and anxiety?
SNRIs e.g. Venlafaxine and duloxetine
28
Desired dopamine pathway for antipsychotic action?
Mesolimbic pathway
29
Drugs used for rapid tranqulisation?
Haloperidol (typical antipsychotic) and lorazepam
30
Antipsychotic onset of action?
1 to 4 weeks
31
Why must lithium not be stopped suddenly?
Can precipitate mania necessitating hospital admission
32
what is trazodone and what is its MOA?
classed in 'other antidepressants'
thought to potentiate noradrenergic neurotransmission without affecting reuptake of NA, and may have a central antiserotonin effect responsible for its ability to reduce anxiety.
strong sedating properties
few anticholinergic side effects e.g. urinary retention if prostatic hypertrophy
33
TCA used in OCD?
clomipramine (mainly 5HT)
34
least cardiotoxic TCA?
lofepramine (mainly NA reuptake inhibitor)
35
what are agomelatine and tryptophan?
other antidepressants
agomelatine- melatonin receptor agonist, selective serotonin antagonist.
tryptophan- adjunctive therapy for depression
36
MOA of MAOIs?
block intracellular breakdown of dopamine, 5HT, NA and tyramine
37
why is there a risk of a hypertensive crisis with MAOIs?
tyramine hypertensive crisis: if increase tyramine, then more NA is pushed out from cells.
also known as 'cheese reaction' as cheese-high tyramine content.
moclobemide-selective, so less tyramine reaction.
important early symptom of the hypertensive crisis which may result in a cerebral haemorrhage is a severe, usually throbbing, headache.
38
drugs other than antidepressants which may cause the serotonin syndrome?
tramadol
39
indications for use of antipsychotics (neuroleptics)?
```
psychotic symptoms- hallucinations, delusions, thought disorders
schizophrenia
mania
toxic delirium
brain damage
agitated depression
```
40
example of a typical antipsychotic with less risk of EP side effects?
sulpiride-?less antidopaminergic action on the nigrostriatal pathway?
41
Clozapine monitoring?
leucocyte and differential blood counts monitoring
WBC monitoring weekly for 18 weeks, then fortnightly for up to 1yr, then monthly as part of clozapine patient monitoring service. 0.5% risk of agranulocytosis.
close med supervision during initiation as risk of hypotension and convulsions
bld lipids and weight measured at baseline and at 3 mnths (with regular weight measurements during 1st 3 mnths) and then yearly for antipsychotics, measure these parameters every 3 months for the 1st year with clozapine, then yearly.
test fasting blood glucose at baseline, after 1 month, then every 4-6months.
clozapine levels
clozapine register
reduce dose over 1-2wks in planned withdrawal to reduce risk of rebound psychosis
42
complications of neuroleptic malignant syndrome?
pneumonia
renal failure
VTE and PE
43
neuroprotective action of lithium?
may reduce risk of dementia
| but long term use has been associated with mild cognitive and memory impairment?
44
side effects of anticholinesterase drugs e.g. donepezil, used in mild to moderate AD?
```
diarrhoea
nausea and vomiting
bradycardia
syncope
headaches
fatigue
insomnia
muscle cramps
```
45
likely 1st signs of improvement after starting an antidepressant?
improved sleep
46
anxiolytic which may be the exception to the general rule that anxiolytics produce dependency?
buspirone
but its anxiolytic effect develops more slowly and is less intense than that of BZDs
reduces 5-HT transmission
47
MOA of BZDs?
bind to the BZD-receptor site on GABA A receptors, so potentiate inhibitory transmission.
48
ADRs of BZDs?
```
drowsiness
ataxia at larger doses, espec in the elderly-loss of full control of body movements
dependence
tolerance
resp depression in OD
confusion
headaches
fatigue
dizziness
muscle weakness
can release aggression by reducing inhibitions in people with a tendency towards this type of behviour
effects potentiated by alcohol
increased risk of falls and assoc. fractures in the elderly
```
49
BZD withdrawal symptoms?
```
tremor
insomnia
apprehension and anxiety
heightened sensitivity to stimuli
muscle twitching
seizures (rarely)
```
50
general advice on prescribing anxiolytics?
use sparingly-often attention to life problems, talking about feelings, and reassurance can be enough to reduce anxiety
brief treatment-don't give BZDs for more than 3 weeks
withdraw drugs gradually-to reduce withdrawl effects, warn pt will feel more tense for a few days after drug stopped
SA or LA-SA if anxiety intermittent, if throughout day give a LAD
consider an alternative-some antidepressants and antipsychotics can have anxiolytic effects and may be used as alternative to BZDs
51
how does zopiclone act as a hypnotic drug?
binds selectively to omega 1 BZD sites on GABA receptors
52
why is the measurement of antipsychotic plasma concentrations NOT useful to the clinician?
the drugs are metabolised in the liver to active compounds
53
common or very common ADRs of clozapine?
```
anorexia
constipation
hypersalivation-can be treated with hyoscine hydrobromide
malaise
speech disorders
urinary incontinence
```
54
cautions for starting clozapine therapy?
agranulocytosis risk, leucocyte and differential blood counts should be normal before starting. avoid use with other drugs at risk of causing agranulocytosis e.g. cytotoxics, chloramphenicol, carbimazole, carbamazepine, penicillamine, sulfonamides
fatal myocarditis and cardiomyopathy-ensure pt examined and full medical history before starting, do not start if severe heart disease or risk outweights benefit. do ECG if admitted as inpt, CVS risk factors of history of CVD.
intestinal obstruction-use with caution if other antimuscarinic drugs prescribed that may cause constipation, or history of colonic disease or lower abdominal surgery
taper off other antipsychotics before starting
cautions: age over 60, prostatic hypertrophy, susceptibility to angle-closure glaucoma
55
indications for clozapine treatment?
schizophrenia in patients unresponsive to, or intolerant of, conventional antipsychotic drugs-not responsed to at least 2 antipsychotics, at least 1 of which should be a non-clozapine atypical antipsychotic.
56
clozapine MOA?
dopamine D1, dopamine D2, 5-HT2A, alpha1-adrenoceptor, and muscarinic-receptor antagonist
57
when does tardive dyskinesia tend to occur in antipsychotic treatment?
as a late complication
may occur due to supersensitivity of dopamine receptors resulting from prolonged dopamine blockage
may not be alleviated once AP tment stopped, and responds poorly to treatment
58
clinical features of tardive dyskinesia?
chewing and sucking movements
grimacing
choreoathetoid movements of the upper limbs-ceaseless occurrence of rapid, highly complex jerky movements that appear to be well coordinated but are performed involuntarily
akathisia
59
clinical features of acute dystonia?
```
torticollis
tongue protrusion
grimacing
spasm of ocular muscles
opisthotonus-hyperextension of head, neck and spine
```
this occurs soon after AP tment begins (days)
60
lab findings in neuroleptic malignant syndrome?
raised WCC
| raised creatine phosphokinase (CPK)/CK
61
in relation to ADRs of antipsychotics, why must particular attention be paid to routine monitoring of blood sugar in schizophrenic patients?
many schizophrenia patients have RFs for developing diabetes
| drugs of part. note=olanzapine, risperidone
62
ADR assoc with combining clozapine and a BZD?
respiratory depression
63
antipsychotics with fewer EP side effects?
sulpiride (typical)
atypicals should in general
amisulpride (atypical) can be used in schziophrenia when -ve symptoms predominate, and the incidence of EP side effects remains very low in those treated with predom. negative symptoms.
64
what is it important to monitor the emergence of when starting antidepressant medication of any kind?
suicidal thoughts
65
why should SSRIs be given in the 1st half of the day?
can cause insomnia
66
3 circumstances that can cause plasma lithium concentrations to rise?
dehydration
sodium depletion
thiazide therapy
67
when are plasma concentrations of lithium measured during treatment?
1st after 4-7 days
then weekly for 3 weeks
then if steady state, once every 3 mnths for 1st yr
must ensure weekly measurement until stable levels, and after every dose change
concentrations usually measured 12 hrs after last dose as after oral dose, plasma levels rise by a factor of 2 or 3 within about 4 hrs before falling to a steady state level which it is important to measure, therefore if an unexpectedly high lithium conc found, 1st thing to do is check pt hasn't inadvertently taken the morning dose before the blood sample was taken.
prophylaxis conc and maintenance tment: 0.4-1.0mmol/L
acute mania tment: 0.8-1.0 mmol/L
TFTs every 6 months
renal function testing every 6 mnths (Us and Es includ Ca2+ and eGFR), some pts develop nephrogenic diabetes insipidus due to interference with ADH
cardiac function measure at start, and every 6mnths thereafter
after 1st yr, measure plasma lithium every 6mnths, or every 3 mnths if older person, taking drugs that interact with lithium, people at risk of impaired renal or thyroid function, rasied Ca2+ or other complications, poor symptom control, poor adherence or last plasma lithium 0.8 or higher.
ensure signs of neurotoxicity examined for at each appointment e.g. ataxia, tremor, paraesthesia and cognitive impairment which can occur at therapeutic levels.
68
ECG changes that may occur with lithium treatment?
T wave flattening
| QRS widening
69
toxic effects of lithium?
```
nausea, vomiting
diarrhoea
fine tremor increasing to coarse tremor
ataxia, dysarthria
muscle twitching, hypereflexia
confusion, coma
visual disturbances
polyuria
convulsions
renal failure
CVS collapse
```
should stop lithium and give high fluid intake, with extra NaCl to stimulate an osmotic diuresis.
may need renal dialysis
above 2mmol/L assoc with cardiac arrhythmias e.g. SAN block, 1st degree HB and bradycardia, seizures, BP changes, renal failure, coma and sudden death.
70
can lithium be taken in pregnancy?
should be avoided in 1st trimester as crosses placenta and assoc with increased rates of fetal abnormalities, most affecting the heart
stop a week before delivery or reduced by half and stopped during labour
secreted in breast milk so bottle feeding advisable
71
indications for lithium?
treatment and prophylaxis of mania
treatment and prophylaxis of bipolar
treatment and prophylaxis of recurrent depression
treatment and prophylaxis of aggressive or self-harming behaviour
72
contraindications to use of lithium?
```
Addison’s disease
cardiac insufficiency
dehydration
family history of Brugada syndrome
low sodium diets
personal history of Brugada syndrome
rhythm disorder
untreated hypothyroidism
```
caution with using other drugs that prolong QT interval
avoid concurrent use of diuretics, espec. thiazides, as sodium depletion assoc with lithium toxicity.
73
how do antipsychotics raise plasma prolactin levels?
antagonism of dopamine via the tubero-infundibular system
74
when should renal function be monitored more regularly than every 6mnths in lithium tment?
if concomitant use of drugs that may effect renal system/metabolised by renal route e.g. NSAIDs, ACEIs
75
clozapine effect on mortality in schizophrenia?
reduces overall mortality
76
licenses for ECT?
prolonged/treatment resistant mania
severe depression that is life threatening or tment resistant
catatonia
77
why must SSRIs be used with caution in epilepsy?
affect seizure threshold
78
indications for sodium valproate?
manic episode in bipolar treatment when lithium CI or not tolerated, continuation of tment after manic episode may be considered in those who responded for acute mania.
79
monitoring required for valproate?
plasma concentrations NOT useful index
monitor liver function before and during 1st 6 months
measure FBC and ensure no undue potential for bleeding before starting and before surgery, and again measure at 6 mnths
measure weight/BMI before starting, and after 6 mnths
all then monitor yrly
monitor sedation, tremor and gait disturbance carefully in older people
80
antipsychotic monitoring?
pulse and BP after each dose change
weight or BMI weekly for 1st 6 weeks, then at 12 weeks
HbA1c or blood glucose, and blood lipid profile at 12 weeks
treatment response
ADRs
adherence
emergence of movement disorders
81
what must be measured and recorded before starting antipsychotic medication?
```
weight or BMI
pulse
BP
fasting blood glucose or HbA1c
blood lipid profile
```
82
how are antipsychotic drugs stopped?
dose gradually reduced over at least 4 weeks to minimise risk of relapse
83
advice to patients taking lithium?
seek medical attention if they develop diarrhoea or vomiting or become acutely ill for any reason
ensure they maintain their fluid intake, particularly after sweating (for example, after exercise, in hot climates or if they have a fever), if they are immobile for long periods or if they develop a chest infection or pneumonia
talk to their doctor as soon as possible if they become pregnant or are planning a pregnancy.
Warn people taking lithium not to take over‑the‑counter NSAIDs and avoid prescribing these drugs for people with bipolar disorder if possible; if they are prescribed, this should be on a regular (not p.r.n.) basis and the person should be monitored monthly until a stable lithium level is reached and then every 3 months.
84
what must be done when starting lithium?
advise the person that poor adherence or rapid discontinuation may increase the risk of relapse
measure the person's weight or BMI and arrange tests for Us and Es including calcium, eGFR, TFTs and FBC.
arrange an ECG for people with cardiovascular disease or risk factors for it
ensure the person is given appropriate national information (or a locally available equivalent) on taking lithium safely
establish a shared‑care arrangement with the person's GP for prescribing lithium and monitoring adverse effects
85
CIs to use of valproate?
do not offer for long term or acute treatment in women of childbearing potential
personal or family history of severe hepatic dysfunction
known mitochondrial disorders-higher rates of acute liver failure and liver related deaths.
86
monitoring for lamotrigine which may be started for acute treatment of bipolar depression?
do not routinely monitor plasma levels
ensure FBC, Us and Es and LFTs measured before therapy starting
be aware of interaction with valproate*-increased risk of serious skin reactions
advise to contact dr immedidately if develop rash while dose being increased-risk of Stevens-Johnson syndrome and toxic epidermal necrolysis, and tell dr if pregnant or planning a pregnancy
reduce dose gradually over 4 wks if stopping to reduce relapse risk.
87
symptoms of nephrogenic diabetes insipidus that may occur with lithium treatment?
polyuria
polydipsia
dehydration
symptoms of hypernatraemia-lethargy, weakness, irritability, confusion
88
drugs other than lithium that can cause nephrogenic DI?
demeclocycline- used in tment of hyponatraemia assoc with SIADH
89
how is nephrogenic DI diagnosed?
water deprivation test-8hr
in contrast to cranial DI, there will be no increase in urine osmolality after desmopressin (synthetic ADH) is given, as CD will not respond to the ADH so urine will unable to be concentrated
psychogenic polydipsia-urine osmolality will increase with water deprivation
90
use of procyclidine in tment of psychotic disorders?
procyclidine is an antimuscarinic drug indicated for EP symptoms except tardive dyskinesia which may occur with antipsychotic tment of psychosis e.g. in schizophrenia or mania.
drug exerts in antiparkinsonian action by reducing effects of relative central cholinergic excess that occurs as result of dopamine deficiency. Dopamine release from the substantia nigra normally has inhibitory effect on the corpus striatium, which also receives excitatory cholinergic innervation. Without dopamine, the striatum is bombarded with excitatory cholinergic innervation which results in the production of EP symptoms, therefore tment with an anticholinergic can be given to combat this.
91
indications for pregabalin in tment of neurosis?
recommended for treatment of generalised anxiety disorder (GAD)
92
antipsychotic use in patients with alzheimer's dementia?
may give risperidone for ST relief (up to 6 weeks) of persistent aggression symptoms in those with moderate to severe AD unresponsive to non-pharamcological interventions and with risk to self or others.
? better AP to use in elderly as no anticholinergic action which may cause cognitive decline in the elderly.
93
type of antipsychotics which cause hyperprolactinaemia?
phenothiazines e.g. chlorpromazine-typical antipsychotics
94
use of oral naltrexone in alcohol dependence?
opioid antagonist used to reduce alcohol cravings, reduce relapse risk and support tment in abstinence.
consider use with psychological intervention after successful alcohol WD in patients with moderate to severe alcohol dependence.
WD with chlordiazepoxide or diazepam, and BZD is reduced gradually over 7-10 days to reduce risk of alcohol WD symptoms recurring.
95
why might a pt not want to take valproate in relation to concerns over their appearance?
can cause hair loss
| weight gain
96
why so important to maintain hydration when treated with lithium?
lithium reabsorbed renally
