lecture - pharm Flashcards
who would prescribe drugs such as lithium and sodium valproate?
psychiatrists or gp
when are mood stabilisers used?
BPAD
Recurrent depression
Schizoaffective disorder
what are the mood stabiliser drugs?
Lithium - gold standard!!
Anti-epileptics: lamotrigine, carbamazepine, sodium valproate
Atypical antipsychotics
what are the mood stabiliser drugs?
Atypical antipsychotics; olanzipine, quetiapine
(1st line acute mania)
Lithium - gold standard!!
Anti-epileptics: lamotrigine, carbamazepine, sodium valproate
List some uses of lithium?
BPAD
Schizoaffectivee
Depression - treatment resistant
ebsteins anomaly is caused by? what it affect?
lithium
affects tricuspid valve
list some complications of lithium use
Common: Fine tremor Sedation - sleepiness Metallic taste in mouth - lithium is a metal lol GI upset Weight gain
Hypothyroid - check bloods Hyperparathyroid polyura + polydipsia Nephrogenic diabetes inspipidus Chronic renal failure - check bloods Hair texture changing; curly/thinning
Arrythmia - monitro ECG
Teratogen
what ecg changes may you see with lithium use?
t wave flattening
what are the signs of lithium toxicity?
management?
Coarse tremor - instead of fine ataxia renal failure - AKI dysarthria eepileptic seizures nystagmus impaired conscious - low gcs
marked GI upset - eg continuous throwing up
coma, DEATH
these guys need ITU, when lithium about 2 maybe.
what to do if patient complains of the metallic taste ?
tell them it often will just go by itself
what to do before prescribing lithium?
Bloods; FBC, UEs (renal function), Calcium (parathyroid function), TFT (thyroid function), ECG - baseline
how to monitor lithium?
what advice to give to patient?
initially weekly
once stable; 3 monthly checks of;
UEs, eGFR, Lithium levels, TFTs
Advice:
stay hydrated
tell doctor if get febrile illness, diarrhoea or vomiting or travelling to a hot country.
which drugs have interactions with lithium?
NSAIDs
Diuretics eg ACEi, loop diuretics
they cannot take these drugs!!
which is the only licensed drug for BPAD treament?
Olanzipine
others are used off licence; eg quetiapine
which m stabiliser can be used in acute treatment AND prophylaxis of bpad
valproate
olanzapine
lithium
whats the effect of valproate on bone?
thrombocytopaenia
leucopaenia
curly hair, ankle swelling are complications of?
s valproate
fever
blisters; mouth, genitals
rash; macullopapular, bullae etc
are sx of? what drug is associated with this?
what advice to give to a patient about to go on this drug?
Steven johnson syndrome
Lamotrigine - sjs is rare though
advice to patients; if you get a fever or rash, stop taking this drug straight away and go to AnE and tell them youre taking lamotrigine.
when is lamotrigine used as a mood stabiliser?
as prophylaxis - slowly titrated
never for acute treatment
patient presents with acute manic episode.
psh: BPAD
is on lithium but no other prescribed drugs.
been stable on lithium 3 years till now.
what do you want to know/do to guide your next steps?
what treatment would you advise?
collateral hx - speak to gp or family, has he stopped taking meds?
any new medications - over the counter perhaps?
check lithium levels
urine drug screen - any illicit drugs?
does he think he needs the drug?
treatment:
lithium wouldve been good but issues are now oral intake and need for monitoring - doubt he can keep up.
cant give valproate as injection.
best option;
Mood stabiliser - Olanzipine injection
-very acutely: lorazepam to calm down
what are options for tretment for acute mania presentatoin in someone with known BPAD?
FIRST LINE - increase dose of mood stabiliser
- augment with antipsychotic ; consider adding quetiapine, haloperidol, olanzpine etc
- ECT - last resort
if someone has cod, which drug should you NOT give?
Lithium
what monitoring is needed for antipsychotic prescription?
blood pressure, liver function, lipid profile and glucose. These parameters should be checked every 1–3 months initially, then annually.
due to cvd and dm risk
what monitoring is needed for clozapine?
FBC - Weekly; looking for agranulocytosis - neutropenia
blood pressure, liver function, lipid profile and glucose.
Which levels of lithium are considered toxic?
therapeutic limit is 1.2mmol
toxicity is 1.5-2+
at 2 it is sever & life threatening
what type of drug is Memantine and what is it used for?
- NMDA receptor antagonist (anti-glutamate)
* Recommended for mod-severe Alzheimers or those who cannot tolerate AChEi
what are the treatments for vascualr and FTLD dementia?
Vascular dementia- managing vascular risk factors
Frontotemporal dementia- no drug licensed
in the management of behavioural and psychological symptoms of dementia, if you have to prescribe, an antipsychotic what do you have to remember about the choice and what must you inform the family?
Risperidone is licensed for short term use only (12 weeks).
Discuss with family etc and explain 3X increase risk of stroke.
a kid taking methylphenidate for ADHD at school is experiencing bullying for it. what are his other options
change to Concerta XL which is a long acting formulation of methylphenidate
1 dose per day
lasts 12hours
boy with adhd develops ticks on methylphenidate. should he continue med? other options?
even if well controlled, he can just change to Atomoxetine (or clonidine)
List some side effects of Atomoxetine?
Palpitations
Loss of appetite
Dyspepsia
Suicidal ideation
postural hypotension
List some side effects of methylphenidate?
Growth restriction - hence drug holidays
Tachycardia
Palpitations
Tics
Loss of appetite
Insomnia
list some side effects of clozapine?
hyper salivation
Intestinal obstruction - severe constipation
Myocarditis/cardiomyopathy - high HR, etc
agranulocytosis
which medication is REALLY good for treating the negative symptoms of schizophrenia?
Clozapine
what are the symptoms of a cannabinoid novel psychoactive substance intoxication?
psychosis confusion aggressive behaviour COLLAPSE! vomiting
PHARM LECTURE 2
PHARM LECTURE 2
Repeat; How do you manage a patient on psych ward who is seems to pose a potential threat to others on ward?
Verbal de-escalation: sometimes just ask them why they aree agitated, may bee simply.
chemical restraint: rapid tranquillisation
- follow local protocols!
- consider allergy, other meds, age
- Benzo’s 1st line (safer than antipsychotics, shorter acting, neuroleptic naivety,)
- Antipsychotics 2nd line - do ecg first
physical restraint
seclusion rooms
potential side effcts of Benzodiazepines ?
who must you bee careful prescribing benzos to?
Sedation - dont drive/operate heavy machinery
Falls - due to hypotension
Respiratory depression - so monitor them; resp rate!
Dependency + tolerance
conditions to be careful:
- Liver diseases
- COPD - careful response depression
- Sleep apnoea
why is lorazepam usually the first line benzo in rapid tranq?
shortest acting?
why is IM olanzipine and lorazepam not given together?
Can cause Low BP - post injection syndrome
what is the MOA of sedatives?
enhance effects of GABA - GABA-A agonist
which recreational drugs are GABA-A agonists (positive allosteric modulators)?
what side effects can they all therefore have?
alcohol - also binds gaba-a
GHB (illicit drug)
Baclofen
Z drugs - zopiclone, zolpidem
SEs:
tolerance, dependence, withdrawal symptoms - can be lethal (seizures etc)
list some indications of benzodiapines?
short-term anxiolytic - for severe anxiety
sedation: acute mania/psychosis, acute agitation ,
anaesthesia
short term insomnia
Epilepsy prophylaxis
Alcohol withdrawal - chlordiazepoxide
msucle spasm
list some long acting and short acting benzos?
Long acting:
chlordiazepoxide
diazepam
Short acting:
lorazepam
midazolam
name the drug used in Benzo overdose - or gaba-a potentiator drug overdoses?
Flumazenil
give IV every minute (short burst due to short half life)
what is the MOA of barbituates???
binds GABA-A, at a diff site to benzo’s
and GABA-B
name some other hypnotics
promthezine - antihistamine w/anticholinergic effects
pregabalin - 3rd line GAD
list some rating sclaes used in kids and adult ADHD?
Kids:
Conners rating scale
Adults:
Adult ADHD self reporting scale
what is lisdexamphetamine?
pro-drug to dexamphetamine
reduces chane of abuse
when methylphenidate is prescribed what must be monitored closely?
BP - hypertension risk
Growth stunting - usually due to anorexia
Cardiac risk - arrhythmias
how is restless legs syndrome treated pharmacologically?
dopamine agosnists eg
Pramipexole and Ropinirole
what are the differences between typical and atypical antipsychotics in terms of receptor binding?
typical:
D2 receptor antagonists
atypical:
D2 antagonists - but dissocaite very quickly
5HT2A - antagonists
5HT1A agonist (some)- eg clozapine, quetiapine
what is ther order or risk of teratogenecity with mood stabilisers?
valproate > carbamazepine > lithium
there is a risk in lithium but it is low compared to the other 2
How is Premenstual syndrome managed - NICE?
Mild:
healthy eating, stress reduction, regular sleep and regular exercise, particularly during the luteal phase.
Moderate:
The oral contraceptive pill, ibuprofen and CBT
Severe:
SSRIs
which psych theerapy is gold-standard recommended in EUPD?
Dialectical behavioural therapy
insomnia, anxiety, loss of appetite
tremor, tinnitus,
sweating, visual disturbance
are sx associated with withdrawl from which drug?
Benzodiazepines
name a street name for some benzos?
Valium - diazepam
rohypnol
what are some street names for PCP - phenylcyclidine
angel dust
rock fuel
elephant tranquilliser
wack, ozone, peace pill
difference between methadone and heroin? - if a patient asks?
comes in liquid form for consumption orally.
are injectable forms as well
same effects as heroin though less intense but prolonged
what is the medical name for the date rape drug/liquid X?
What effects does it have?
what is the antidote and how do we test a patient for it?
GHB - Gamma hydroxybutaric acid
effects at high dose: respiratory depression, bradycardia, seizures, hypothermia, coma, death
antidote: none
test: doesnt show in urine
according to ICD-10, what do you need to diagnose dependency syndrome?
3+ of the following in 12 months:
- strong desire/compulsion to drink
- problems abstaining/stopping
- neeglect in other activities
- withdrawal
- tolerance
