Management Flashcards
What are the questions that need to be asked with non-response to pharmacological treatment?
OH-/illicit drug use
Are they taking it
Taking it correctly
Reasonable length of time, reasonable dose
What are the side effects of lithium?
Early: Dry mouth, metallic taste, N, polydipsia, fine tremor, polyuria, fatigue
Late: Diabetes insipidus, hypothyroid, arrhythmia, ataxia, weight gain, dysarthria
What are the signs & symptoms of Lithium toxicity?
Li levels >1.5
Early: Blurred vision, anorexia, N&V, diarrhoea, coarse tremor, ataxia, dysarthria, muscle weakness, polyuria,
Late: Confusion, renal failure, fits, coma, death, arrhythmia
What are the classes of antidepressants?
Monoamine re-uptake inhibitors
Receptor antagonists
Monoamine Oxidase Inhibitors
What are the different types of monoamine re-uptake inhibitors?
Tricyclics: Amitriptyline SSRIs: Citalopram, Fluoxetine NorA re-uptake inhibitors: Reboxetine SNRI: Venlafaxine NorA & specific serotonin antidepressants: Mirtazapine
What are common SE of SSRIs?
Headache Weight gain Drowsiness (take at night) Nausea/ loss of appetite Indigestion/diarrhoea/ constipation Loss of libido/ erectile dysfunction Dizziness/ dry mouth/ blurred vision/ sweatiness Inc suicidal risk in first 2weeks of use
Why are MAOIs rarely used?
Poor tolerability
Interactions
Diet restrictions: Breakdown tyramine in the gut found in cheese, redline, Bovril & can lead to hypertensive crisis
What are the main SE which can occur with all antidepressants?
Suicidal ideas
Serotonin Syndrome
HypoN- SSRI worst
How long should antidepressants be used for?
6-9m post-recovery
Multiple episodes consider for 2years
Use: 4-6weeks before considering changing drug
What are the indications for prescribing Lithium?
Mood stabiliser-Treatment & prophylaxis of: Mania Recurrent depression Bipolar Aggressive/ Self-mutilating behaviour
What are the baseline investigations that need to be done before starting Lithium?
Physical Weight Bloods: U&E, TFT, Ca, FBC ECG Pregnancy test
What monitoring needs to be done for a patient on Lithium?
Lithium levels:
12hours after initial dose
7-10days initially then 3m when stable
Every 6m: Bloods: U&E, TFT, Ca, Weight, ECG
What are the causes of Lithium toxicity?
Drugs: NSAIDs, Diuretics, ACEi
Renal failure
UTI
Dehydration
How is Lithium toxicity managed?
STOP Li!
IV fluids
Start diuresis/dialysis
What are classed as low & high intensity interventions?
Low: Advice, CBT based self-help
High: CBT, IPT, Behavioural activation, couples therapy
What are the SE of Mirtazapine?
Sedative
Weight gain
What needs to be checked when starting an SNRI?
Check BP
ECG
Contraindicated: CV issues
What combination of antidepressants should NOT be taken together? Why?
SSRI + TCA/MAOI
Causes: Serotonin Syndrome
What are the effects of antipsychotics (depending on receptor type)?
Anticholinergic: Dry mouth, blurred vision, constipation, urinary retention
Antiadrenergic: Postural hypoT, Sexual dysfunction
Antihistamine: Sedation, anti-emetic
What investigations need to be done before starting an antipsychotic?
Bloods: FBC, U&E, LFT, RBS/HbA1c, Lipids & Cholesterol, Prolactin
Weight
BP & Pulse
ECG (Prolonged QTc which can lead to Torsade des Pointes)
What are the SE of antipsychotics?
When do they occur?
1st gen: NEURO/MOTOR SE
D2 antagonists
Tardive dyskinesia, Tx= gradual dose reduction, benzos, tetrabenazine
Parkinsonism, Tx= anticholinergics (Procyclidine)
Acute dystonia, occur within 72hrs of Tx
Akathisia, occurs within 60d of Tx, Mx= Beta blockers & benzos
2nd gen: METABOLIC SE
5HT/D2 antagonists
Hyperglycaemia
Weight gain
Dyslipidaemia
When should Clozapine be offered in Schizophrenia?
Illness not responded to Tx despite use of adequate doses of >2 different drugs
>1 drug should be a non-clozapine 2nd gen
Acts on D2 & D4 receptors & subtypes of serotonin receptor
What are the SE of Clozapine?
Agranulocytosis (REGULAR FBC) Weight gain Salivation Sedation Myocarditis Paralytic ileus Lower seizure threshold
What drugs have an effect on the 5HT neurotransmitter?
LSD (hallucinations)
Clozapine
What drugs have an effect on the Glutamate neurotransmitter?
Phencyclidine
What are the risks of antipsychotic use in older people?
Inc stroke risk Inc CV risk Parkinsonian SE Falls Additional deaths
What are the SE of antipsychotics related to increased Prolactin?
Asymptomatic Amenorrhoea Galactorrhoea Gynaecomastia Impotence Weight gain Osteoporosis
What are the EPSE of antipsychotics?
Acute:
Parkinsonism: rigidity, bradykinesia, tremor
Acute dystonia: Trismus, tongue protrusion, spasmodic tortocollis, opisthotonus, oculogyric crisis, grimacing
Akathisia: restlessness, restless leg syndrome
Chronic:
Tardive dyskinesia: Chewing, sucking, grimacing, darting tongue
Choreoathetoid movements
What should be done when starting/stopping someone on SSRIs?
Start: Initiate then review at 2weeks
If <30yo or suicide risk review at 1week
Stop: Reduce tablets over 4weeks unless Fluoxetine
What are the contraindications of Lithium?
Addison’s
Cardiac insufficiency
Fhx/Phx: Brugada syndrome
What drugs can interact with Lithium?
Diuretics: Amiodarone, Bendroflumethiazide ACEi NSAIDs: Ibuprofen, Diclofenac Carbamazepine Chlorpromazine, Citalopram, Clopamide Macrolides
What is the mechanism of action of Lithium?
Widely distributed in the CNS
Interacts with a number of neurotransmitters and receptors
Decreasing norE release and inc serotonin synthesis
What is the mechanism of action for SSRIs?
Selectively inhibiting the re-uptake of serotonin at 5HT receptors.
What are the indications for SSRIs?
Depression Bulimia (Fluoxetine only) OCD Panic PTSD (Sertraline)
What are the contraindications of SSRIs?
Poorly controlled epilepsy
Mania/manic phase
What drugs do SSRIs interact with?
Diuretics Chlorpromazine Macrolides Haloperidol, Risperidone Lithium
