Medication Flashcards
Lithium Explanation
Indication
- Bipolar disorder (both mania and hypo-mania)
- Recurrent depressive episodes which have not responded to anti-depressants
Action
- “Lithium works by changing the way your brain processes signals to help stabilise your mood.”
Timeline
- Once daily, usually at night
How to take
- Oral tablet, plenty of water, same time every day
- If dose missed do not to take a double dose and instead to take their next dose as normal
Length of Treatment
- BPAD = at least 2yrs (better at
least three years)
Effects - time before
- Several weeks
Tests
- Before: Bloods (FBC, U&E, eGFR, TFTs), ECG, BMI
- Lithium Level: 1/52 until stable (or after dose change), 3/12 for the 1st year, then 6/12.
- Other bloods: 6/12
Important Side effects
- Very Common: Fine tremor (atenolol), nausea, diarrhoea, polyuria, polydipsia, metallic taste.
- Common: Hypothryoid, fluid retention
Complications
- Toxicity: course tremor, confusion, ataxia
Contraindications
- Addison’s disease
- Cardiac disease associated with rhythm disorder
- Cardiac insufficiency
- Dehydration
- Brugada syndrome (incl FH);
- Low sodium diets
- Untreated hypothyroidism
Supplementary advice
- Narrow therapeutic window
- lithium record book
Pregnancy
- Avoid if possible, particularly in the first trimester (risk of teratogenicity, including cardiac abnormalities).
- Dose requirements increased during the second and third trimesters (but on delivery return abruptly to normal).
- Close monitoring of serum-lithium concentration advised in pregnancy (risk of toxicity in neonate).
Clozapine Explanation
Indication
- TR Schizoprenia - not responded to treatment with at least two other antipsychotics (usually one FGA + one SGA) or those who have not tolerated other medication
Action
- D1, D2, 5-HT2A, alpha1-adrenoceptor, and muscarinic-receptor antagonist
- Blocks various receptors in the brain, rebalancing the chemical messengers in the brain.
Timeline (e.g. once daily)
- 1-2 times a day, starting with 12.5mg
How to take
- Night time first, as it makes you sleepy, with or without food
Length of Treatment
- Many years
Effects - time before
- Several weeks
Tests
- Baseline: ECG, WCC, lipids, weight, glucose, BP
- WCC: weekly for 18/52, fortnightly for a year, then monthly
Important Side effects
- Common: Constipation, drowsiness, dizziness, tachycardia, increased saliva
Complications
- Serious: Low WCC, Seizures, bowel obstruction, myocarditis, cardiomyopathy
Contraindications
- bone-marrow disorders, history of agranulocytosis; history of circulatory collapse; history of neutropenia; paralytic ileus; severe cardiac disorders (e.g. myocarditis); severe CNS depression; uncontrolled epilepsy
Supplementary advice
- Pregnancy: Use with caution
- Breast-feeding: Avoid
Lithium in Pregnancy
General Risks to baby
- Transient sedation
- Difficulty feeding
- Hypotonia
Birth Defects
- Ebstein’s Anomaly 1:1000 (1:20,000) - TV defect
Management Options
- Stable Mental state: Switch to safe antipsychotic or stop preconception / first trimester (highest risk) (Olanzapine, Quetiapine)
- Severe BPAD: Continue
- Increase lithium as BV and kidney function increase (balance relapse vs toxicity)
Monitoring Lithium levels
- Monthly throughout pregnancy
- Weekly after 36 gestation
Breastfeeding
- Not recommended as high levels pass to baby
Positive
- Small studies have followed up children exposed to Lithium in pregnancy until the age of six.
- These have not found any increase in physical health, learning or developmental problems
Methadone in Pregnancy
Action
- Long acting opioid agonist
Medication
- Maintenance therapy for patient who are dependent on heroin
Risks to baby
- Relatively safe in pregnancy
Risks of stopping methadone
- Relapsing into illicit drug use
- 1st Trimester: Spontaneous abortion
- 3rd Trimester: Premature delivery and still birth
Management
- Stable on methadone: Advised to continue. Inform midwife at booking visit and obstetrician (affects pain relief during childbirth). Dose may need increasing in 3rd trimester
- If wanting to stop: 2nd trimester, close supervision of substance misuse specialist and obstetric team
Neonatal Abstinence Syndrome (NAS)
- In babies of mothers who continue methadone
- Symptoms develop after 48 hours, however can be delayed
- Symptoms: Ineffective feeding, D&V, Yawning & sneezing, high pitched cry, difficulty sleeping
- Rare: Seizures
Breastfeeding
- Encouraged: Promotes bonding, provides nutritional benefits
- Reduces symptoms of NAS: small amount of methadone in breastmilk.
- Should gradually stop to reduce withdrawal
Sodium Valproate in Pregnancy
Introduction
- Thoughts and concerns about their mental health in the perinatal period and about their current medication
BPAD
- High risk of relapse in the immediate postpartum period (roughly 50%) and could be at risk of relapse at other points without effective prophylaxis
- Risk of puerperal psychosis
Risks to Baby
- Congenital malformations - 13% (3% normally): Heart defects, spina bifida
- Adverse neurobehavioural outcomes for exposed infants: learning, behavioural and emotional problems (20-60%)
- Dose dependent, but risk still there for low dose
Monitoring
- If remained on valproate: monitor in hospital for withdrawal Sx (jittery), jaundice, PU / BO, feeding
Management
- Commence folic acid - reduce neural tube defects
- Switch to Olanzapine (safe in preg and B/F)
Safe for Pregnancy
Antidepressants
- Sertraline
- Fluoxetine
- Mirtazapine (slight breathing difficulties at birth)
- Citalopram (could affect heart)
- Venlafaxine
- Amitriptyline
Antipsychotics
- SGA: olanzapine, quetiapine, clozapine, risperidone or aripiprazole
-
Psychotropics
- Lithium
- Methadone
Not Safe for Pregnancy
- Vortioxetine (not enough evidence)
- Paroxetine (cardiac malformations)
Safe for breastfeeding
Antidepressants
- Sertraline
- Mirtazapine
- Citalopram
- Fluoxetine
- Venlafaxine
- Vortioxetine
- Amitriptyline
Antipsychotics
- Olanzapine
- Clozapine - although increased risk of gestational diabetes
- Risperidone
- Quetiapine
Psychotropics
- Methadone
Not safe for breastfeeding
Antipsychotics
- Aripiprazole - reduced prolactin and breast milk production
- Clozapine
Psychotropics
- Lithium
