matthew green Flashcards
1
Q
pathophysiology of depression
A
It is potentially associated with low serotonin levels
Can be brought on by many emotionally distressing factors
2
Q
symptoms of depression
A
- loss of interest or pleasure
- fatigue
- feelings of worthlessness or guilt
- weight changes
- altered sleep pattern
- reduced ability to concentrate
3
Q
if a patient displays MILD depression symptoms we…
A
- DONT give any medication
. for mild, medication considered in those who have PHx of mod/severe depression or had subthreshold symp for 2 years - therapy (CBT) or group based physical activities or group based peer support program
- no st johns wort either!
4
Q
first line antidepressant pharmacological intervention is…
A
and SSRI:
- fluoxetine
- citalopram
- sertraline
- paroxetine
- fluvoxamine
provide combination of antidepressant and CBT
5
Q
in elderly on SSRI what should be considered prescribing also?
A
PPI
SSRI comes w inc risk of bleeding
6
Q
citalopram dose and indication
A
SSRI, depressive illness, 20mg initially OD, max 40mg
- can start of 10mg if symptoms not that prominent
- increase dose at intervals of 3-4 after review
7
Q
citalopram counselling points
A
- makes you feel a little sleepy so maybe take at night
- takes 2-4 weeks to feel benefits of medication
- dont abruptly stop, dr will taper down when time to come off
- a long term medication, on it for atleast 4-6 months
- avoid alcohol as can make you feel worse
- can be taken with or without food
- might feel worse for the first few weeks but should pass after
- can get SE like dry mouth– chew sugar-free gum or sugar-free sweets- or sweating a lot– try wearing loose clothing, use a strong anti-perspirant and keep cool using a fan if possible
- Avoid st johns wort
8
Q
citalopram (or depressive illness) lifestyle advice
A
sleep hygiene
- aim for 7-9hrs sleep, keep a regular cycle of sleeping and waking up similar times, hot baths before sleep, no blue light 1hr or so before sleeping
- exercising
- cutting down/stopping smoking
- doing things that make you feel better / happier
9
Q
why is st johns wort not recommended even though it does work?
A
- a lot of interactions
- herbal so every tablet will have a different amount of active ingredient in there
- not technically safer than SSRI (as many think its safer bc herbal)
10
Q
citalopram monitoring
A
- will see gp regularly
- usually every 2-4 weeks for the first 3 months then longer if good response
11
Q
diagnostics of depression
A
comprehensive assessment that does not rely simply on a symptom count.
consider degree of functional impairment and/or disability.
DSM-IV assessment may be conducted - more than 5 symptoms to make diagnosis
Must experience symptoms for at least 2 weeks
12
Q
citalopram withdrawal symptoms
A
- restlessness
- mood swings
- sweating
- altered sensations
13
Q
st johns wort and citalopram
A
interaction - can inc the chances of serotonin syndrome
14
Q
signs of depression
A
. anxious, difficult concentrating, slow thinking, loss of appetite, excessive sleeping
. feeling hopeless and guilt
. psychomotor agitation or retardation
. self-harm, suicide risk, sectioned MHA
At least 2-week duration
15
Q
non-pharmacological management of depression
A
Talking treatments: CBT
• Cognitive behavioural therapy is based on the concept that your thoughts, feelings, physical sensations, and actions are interconnected. Negative thoughts and feelings can trap you in a viscous cycle.
• It helps you deal with problems in a positive manner by breaking things down into smaller parts
• Changing negative patterns to improve the way you feel
16
Q
who can antidepressants be given to?
A
. hx of moderate or severe depression
. initial depressive symptoms presented for at least 2 yrs
. subthreshold symptoms or mild depression persisting after other interventions
17
Q
if depression isn’t maintained with SSRI …
A
Review treatment after an inadequate response
• Check adherence, side effects
• Increase frequency of appointments
• Using a single antidepressant has a low side-effect profile
18
Q
why are AB’s not suitable for sore throats?
A
- most sore throat infections are VIRAL hence AB’s wont work on them
- give lifestyle advice and OTC FIRST
19
Q
advice for sore throat?
A
- Gargle warm salty water
- Fluids up!
- Rest
- Non-medicated pastilles for soothing the throat
- Lozenges, sprays or mouthwashes with some anti-inflam / anaesthetic to help soothe the throat if painful
- Paracetemol / ibu
- If symptoms don’t get better in 7-10 days then see GP
- watch out for red flag symptoms:
not eating and drinking, cough for over 3 weeks, temperature between 38-39 for more than 2/3 days
20
Q
lower UTI first line treatment
A
in MEN –> trimethoprim 200mg BD 7 days (with glass of water)
in non-preg, 16+ WOMAN –> nitrofurantoin 100mg BD 3 days (with food or milk)
21
Q
lower UTI symptoms
A
- cloudy foul smelling urine
- pain on urination
- lower back pain
- inc freq and urgency in urine
22
Q
lower UTI counselling / lifestyle
A
- have whole course of antibiotics
- if comes back see dr again, may need to prescribe diff AB’s
- drink plenty of water to flush bact out of system
- may help to avoid sex as can be painful until symptoms go but cant pass onto partner
- (for women) wipe back to front to prevent bact getting into vaginal area
- go to toilet very soon after sex
- dont drink too much OH or sugary drinks
- try to avoid tight underwear, opt for loose cotton
23
Q
cancer risk factors modifiable and non-mod
A
mod:
- alcohol
- smoking
- carcinogens
- obesity
- radiation
- sunlight
non-mod:
- age
- sex
- family history
- ethnicity
24
Q
why might surgery not be suitable for some cancer pts?
A
- metastasis so cancer spread too much to operate
- tumour in place where hard to perform surgery
- tumour too small to be seen by surgeon
- if a surgery would make pts health worse (elderly, immunocompromised etc)
25
what are targeted cancer therapies?
- drugs which block the growth and spread of cancer by interfering with molecular targets of the cancer
- can be hormone therapies (tamoxifen), TK rec inhibitors or MAB
26
what is radiotherapy?
high energy waves used to kill cancer cells
| - pt can have radiother more than once
27
what is chemotherapy?
- cytotoxic drugs which kill not only cancerous cells but also healthy body cells
- also able to treat metastasis
- curative --> totally "cure" cancer
- adjuvant --> reduce risk of cancer reoccurance after chemo/radio
- neo-adjuvant --> make other therapy more effective so usually combined with radio/chemo
- palliative --> reduce symptoms of cancer just before death
28
pt says their AD isnt working well and trouble sleeping - what steps are suitable?
- optimise their medication (so up the dose)
- switch our their SSRI for a different SSRI or a different AD (try avoid TCA or MAOI as less well tolerated)
- CANT COMBINE DIFF CLASSES OF AD'S IN PRIMARY CARE WITHOUT PHSYC APPROVAL
- advise on sleep hygiene
29
pt on SSRI and enters mania
STOP SSRI
| - pt with mania should not TAKE SSRI --> contraindicated
30
before starting an antipsychotic when should an ECG be done?
- if in drug spc
- an inpateint
- fhx of CVD
- has CVD
31
haloperidol indication and dosing
- mod to severe mania associated with bipolar disorder
| - 2-10mg in 1-2 divided doses dose adjusted according tp response every 1-3 days
32
haloperidol side effects
extrapyrimidal side effects: involuntary or uncontrollable movements, tremors, shakes, restlessness, stiffness
33
if first antipsych given not suitable what steps after?
- diff antip of same family
- lithium (routine blood monitoring required)
- valproate (not for young females/childbearing age females unless PPP in place)
34
haloperidol counselling points
- may need to have blood tests to monitor K+/Na+ levels
| - OH consumption may make feel sleepy so avoid where possible
35
how long can metoclopramide be prescribed for?
5 days max, short term use only
36
medication considerations when having chemo
- no high dose steroids (immunosuppression)
| - no chem close to surgery
37
what sort of info is on a chemo alert card?
symptoms of neutropenic sepsis and the help line info to directly go through to nurses
38
symptoms of neutropenic sepsis
- high temp
- shivery / flu like symptoms
- generally unwell
want to call hospital ASAP, LIFETHREATENING
- dont give nay antipyretics, hospital helpline call immediately
39
what is neutropenic sepsis
potentially life-threatening complication of neutropenia (low neutrophil count).
- temperature of greater than 38°C
- symptoms and/or signs of sepsis in a person with an absolute neutrophil count of 0.5 x 109/L or lower.
40
what is sepsis (signs and symptoms too)
```
when immune system overreacts to an infection due to presence of bact into systemic circ and damages bodies organs/tissues
signs/symp:
- dizzy/faint
- slurred speech
- less urine production than usual
- SOB
- Fever
- blotchy pale skin
```
41
neutropenic sepsis treatment
- iv broadspectrum AB ASAP (usually piperacillin with tazobactam or cefuroxime (pen allergy) or metronidazole if anaerobic)
- do FBC
- lactates
- O2 if low O2 sat
- iV fluids
- urine samples
42
causes of neutropenic sepsis
- cytotox chemo
- immunosupression
- infections
43
can nurses adminsiter IV AB for neutropenic sepsis?
YES
| - don't want any delay, need to give AB ASAP so according to PGD they can
44
benefits from switching to oral from IV
- reduced need for specialist tretament (no nurses needed)
- dont need to be in hospital so more beds available
- cheaper
- reduces risk of iV infections
- reduced pt discomfort
45
how to switch between antipsychotics
reduce dose of one over atleast 4 weeks gradually and start the other medication at lowest dose possible whilst reducing the old one
- THIS IS THE ONLY TIME ANTIP'S CAN BE COMBINED (as short term)
46
if haloperidol (1st gen) doesnt work well what can be given?
2nd gen --> risperidone, olanzapine, quetiapine
47
what to do if safeguarding issue arises
- Duty of care so do not ignore the situation (care act 2014)
- Report to senior line manager
- Refer to local guidelines and policies
- See RPS, GMC or MEP guidelines
- Employers’ responsibility to offer safeguarding to vulnerable adults to employees.
48
for breakthrough how much of a morphine dose should be taken in comp to maintenance
1/6-1/10th daily normal morphine dose repeated every 2-4 hours prn
49
issues with big bottles of oramorph
- only meant to be taken for breakthrough pain
- OD / addiction risk bc so much
- doesnt have that long a shelf life so will go deteriorate quickly
50
constipation and opioids
- very common
- prescribed laxative
- NOT BULK FORMING
- osmotic (lactulose) or stool softener (bisacodyl)
51
morphine and oramorph counselling
- dont suddenly stop taking, dr will advise when its suitable to stop taking
- contact doctor if have any SOB or difficulty breathing
- dont drink as can make more drowsy etc
- dont crush or chew, have whole w glass of water
- if more than 4hrs late to take dose SKIP
- shake oramorph bottle and take when feel liek capsule isnt controlling pain well enough
52
lithium monitoring
- regular blood tests to ensure plasma lithium levels between 0.6-0.8mmol/L
- initally 5-7 days after starting so reaches steady state (12hrs after last dose)
- then every 3 months (more freq if on ramipril or interaction med)
- renal and thyroid every 6 months
- if high, withhold med until comes down
53
signs of lithium tox
- feeling thirsty
- blurred vision
- lethargy
- ataxia (disorder that affects balance, coordination and speech, eg: trouble walking)
- muscle weakness
54
counselling for lithium
- take at night
- will have regular blood tests and contact w GP in first few weeks
- takes 5-7 days to feel effects as this when med completely stabilised in body
- dont abruptly stop, doctor will gradually reduce dose over few months when time to stop
- dont drink alcohol as this caan worsen symptoms and more exposure to lithium
- no NSAIDS with lithium, paracetemol is fine
- remember your purple lithium book as this is info in it regarding info on the med an alert card and blood test results
- want to drink and eat around the same amount of salt in a day all the time, stay hydrated and dont do anything which can cause excessive sweating (saunas) and not altering the amount of caffeine u drink drasticaly
55
initiating lithium after risperidone
- cross-taper
- reduce risp dose and start lithium over a few weeks
- keep an eye and monitor heart as can get prolonged QT
56
what are anticipatory prescribing/medications?
making sure that someone has access to medicines they will need if they develop distressing symptoms at home or in a care home to enable rapid relief and usually before the end of life stage in prep for pt rapidly deteriorating
57
advantages of syringe driver
- can give constant dose/infusion
- less poeple coming and administering medication so less disturbances
- SC less invasive than IV
58
anti-emetics given in palliative care
- metoclopramide
- haloperidol
- cyclizine
- hyoscine
- levomepromazine
- preferably given orally but syringe if severe
59
syringe drivers and compatibility
- dont mix more than 3 drugs as inc risk of incompatibility
- if pain or inflammation at site of injection then change but swelling or firmness dont need to change
- injections mixed with water
60
how to decide which medicines would be appropriate to deprescribe?
meds where
- Benefits no longer outweigh risk of adverse effects
- time benefit is longer than time remaining to live
- medication isnt focused towards pt's aims of treatment
eg: statins, bisphospanates, vitamins, anti-hypertensives
deprescibe in a step-wise manner so easier to spot any issues that arise
61
cyclizine and diamorphine are incompatible in syringe driver. what can be done?
- Stop the infusion
- switch diamorphine to morphine
- separate into different pumps
- Report error (NRLS - pt safety incident reporting database)
62
WHY can metoclopramide only be used for a max 5 days?
Dopamine antagonist
• Prolonged blockade leads to supersensitivity of dopaminergic receptors
• Increased risk of serious neurological adverse effects:
❖ Acute dystonic reactions
❖ Parkinsonism
❖ Tardive dyskinesia
63
anti-emetics given for CINV
- metoclopramide (5 days)
- ondansetron
- prochlorperazine
- dexamethasone
64
life style advice for bipolar disorder treatment
- stick to usual day to day
- avoid drugs/OH
- exercise
- regular sleep pattern
- track moods daily
65
can pts on chemo use paracetemol?
techically yes BUT not advised as can mask symptoms of neutropenic sepsis
- advised to check temp before have para
- for PAIN opioids more likely to be used
66
what is serotonin syndrome?
Excessive serotonergic activity in the central and peripheral nervous systems.
- caused by interacting drugs upregualting the amounr of serotinin in brain
symp include:
- insomnia
- anxiety
- agitation
- resp failure
67
why do we titrate opioid doses when starting treatment on opioid naive pts?
to reach a balance between relief and side effects
68
why cant bulk forming be prescribed?
bulk forming initiates peristalsis and increases bulk of stools whilst opioids prevent it hence can get bowel obstruction bc got more stools but it cant really move anywhere
69
barriers faced when deprescribing
- family feel like youre giving up on pt
| - pt attachement to chronic meds
70
how can we treat extrapyramidal side effects from haloperiodol
- reduce the dose
- switch to a 2nd gen antipsych
- give procyclidine (an anticholinergic)
71
dexamethasone counselling points when used as appetite stimulant
- Medication should be taken with or just after food in the morning and no later than 4pm (can cause insomnia as effects pt energy levels)
- side effects: psychiatric reactions (irritability, psychotic reactions and behavioural disturbances).
72
life style advice for appetite stimulant dexamethasone
- Eat energy rich foods
- Food fortification (fortified cereals, breads etc)
- Encourage snacking (frequent small meals)
- Possibly speak to a dietitian
73
switchinf between brands of lithium
requires the same precautions as the initiation of treatment as lithium preparations vary widely in bioavailability
- so after switch 5-7 days after need to do bloods for li levels and ca levels (raised ca can indicate hyperparathyroidism)
