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CASC 3 > Medications > Flashcards

Medications Flashcards

1
Q

ACEi - Donepezil, Rivastigmine, Galantamine

Efficacy

A

40-50% benefit

1/3 improve

1/3 plateau

1/3 don’t respond

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2
Q

Sodium Valproate - Teratogenicity

A
  • 1/10 risk of malformation (2-3/100 baseline)
  • Spina Bifida/NTDs - 1.5% risk (0.2-0.5% background)
  • Deformities of limbs/kidneys/heart/urogenital tract possible
  • Cleft lip/palate
  • 30-40% have intellectual development difficulties e.g. autism/ADHD/low IQ
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3
Q

Sodium Valproate Side Effects - Common/Dose Related

A
  • GI upset (anorexia, nausea and vomiting, diarrhoea, dyspepsia)
  • Deranged LFTs
  • Tremor
  • Sedation
  • Headache
  • Irregular/delayed periods
  • Dry mouth/swollen gums
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4
Q

Sodium Valproate - Initiation, Monitoring and Withdrawal

A
  • Check FBC, LFTs and BMI before starting
  • Dose depends on indication
  • Plasma level monitoring not useful unless evidence of ineffectiveness, poor compliance or toxicity
  • FBC/LFTs/BMI - 6 months after initiation and yearly thereafter
  • Check FBC and clotting before surgery
  • Avoid abrupt withdrawal - reduce dose gradually over at least 4 weeks
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5
Q

Lithium - Monitoring

A
  • Lithium levels - weekly after initiation until dose stable
  • Then every 3 months
  • eGFR/TFTs every 6 months
  • Weight/BMI when indicated
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6
Q

Lithium Toxicity - Symptoms

A

Occurs at levels >1.5 mmol/L

  • Diarrhoea
  • Vomiting
  • Coarse tremor
  • Hyperreflexia
  • Muscle weakness
  • Ataxia
  • Confusion
  • Seizures
  • Kidney damage
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7
Q

Lithium Adverse Effects - Long Term

A
  • Weight Gain
  • Hypothyroidism
  • Deranged renal function/kidney damage
  • SIADH
  • ECG changes (T-wave flattening)
  • Skin changes - acne/psoriasis
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8
Q

Lithium Adverse Effects - Short-term/Common

A
  • Thirst
  • Polyuria
  • Metallic taste
  • Fine tremor
  • Nausea/vomiting
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9
Q

Antidepressants - Efficacy

A
  • 60-70% respond
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10
Q

Methylphenidate - Monitoring

A
  • Cardiovascular status (HR/BP) - every 3/12
  • Height/weight - every 6/12
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11
Q

Methylphenidate - Efficacy

A
  • 70% respond
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12
Q

Sodium Valproate - Rare/Serious Side Effects

A
  • Hepatic failure
  • Pancreatitis
  • Agranulocytosis
  • Polycystic ovaries
  • Increased suicidal thoughts - as early as one week after starting
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13
Q

Sodium Valproate - Side Effects (Unpredictable)

A
  • Hair loss - with curly regrowth
  • Peripheral oedema
  • Leucopaenia/thrombocytopenia
  • Weight gain
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14
Q

Lithium in Pregnancy/Teratogenicity

A
  • Teratogenicity
    • Possible risk of increased heart defects - now debated
    • Ebstein’s anomaly 1:1000 risk (1:20000 baseline)
  • Pregnant women taking lithium should have a level 2 USS at 6 + 18 weeks
  • Lithium levels should be checked:
    • Monthly during early pregnancy
    • Weekly after 36 weeks
    • Before and after delivery
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15
Q

Lithium During Pregnancy

A
  • Best to stop
    • Gradually reduce and stop over 4 weeks
    • Switch to an alternative e.g. anyipsychotic
    • Restart after delivery (but not if breastfeeding)
  • Alternatively omit for first trimester only
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16
Q

Clozapine - Risk of Neutropenia/Agranlucytosis

A
  • Neutropaenia 2-3/100
  • Agranulocytosis <1/100
    • Fatal 1/8000
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17
Q

Clozapine - Efficacy

A
  • 60-70% of patients
    • 30% respond after 6/52
    • 20% after 3/12
    • 20% after 6/12
    • 30% never respond
18
Q

ACE inhibitors - Side Effects

A
  • Cholinergic
    • Nausea
    • Diarrhoea
    • Urinary incontinence
    • Insomnia
  • Bradycardia
  • Donepezil specifically contraindicated in asthma
19
Q

Sodium Valproate - Indications and Contraindications

A
  • Used for BPAD and epilepsy
  • Avoid using in women of childbearing age if possible
    • If no alternative must be enrolled in PREVENT pregnancy prevention program
  • Use with caution in those with lupus
  • Avoid in:
    • Severe liver disease
    • Personal/family history of drug related hepatic dysfunction
    • Porphyria
    • Mitochondrial disorders
20
Q

Sodium Valproate Use In Women of Childbearing Age

A
  • Avoid if at all possible
  • Annual reviews under PREVENT pregnancy prevention program
  • Regularly re-evaluate need for treatment - consider dose reduction or switch
  • Complete and sign annual risk acknowledgement form - copies to patient/carer and GP
21
Q

Sodium Valproate Use During Pregnancy

A
  • If to be withdrawn recommend dose be slowly tapered down over a few weeks to reduce relapse risk
    • In acute mania faster cross-taper to substitute
  • If patient has to continue:
    • High dose folic acid 5mg/day
    • Use lowest dose possible
    • Small split doses or extended release formulation to minimise peaks
    • Plasma levels should not exceed 1g/day
  • Present in small amounts in milk - avoid if baby premature or has kidney problems
22
Q

Sodium Valproate Interactions

A

P450 Inhibitor

  • Aspirin and Warfarin - displace valproate from albumin and may –> toxicity
  • Cytochrome P450 inhibitors can increase levels:
    • Erythromycin
    • Fluoxetine
    • Cimetidine
  • TCAs - inhibits metabolism increasing levels
  • Carbapenem antibiotics - decrease valproate levels
  • Quetiapine - co-administration increases risk of neutropaenia/leucopaenia
  • Lamotrigine - increases level of Lamotrigine
  • Nimodipine - increases levels of Nimodipine
23
Q

Clozapine - Initiation

A
  • Prior to starting:
    • FBC, LFTs, prolactin, CRP
    • ECG - refer to cardiology if concerns
  • Dose usually starts at 12.5mg and then titrated up
24
Q

Clozapine - Monitoring

A
  • Monitoring of FBC - registration through ZTAS
    • FBC weekly for first 18 weeks
    • Every 2 weeks for rest of year
    • Every month thereafter
  • Review treatment every 3-6 months
  • Monitor for SEs including constipation and chest pain
  • Risk of relapse if stopped suddenly
25
Q

Clozapine - Common Side Effects

A
  • Drowsiness
  • Constipation
  • Postural hypotension
  • Hypersalivation
  • Fever
  • Palpitations
  • Weight gain
26
Q

Clozapine - Serious Side Effects

A
  • Agranulocytosis - <1/100
  • Myocarditis
  • Reducted seizure threshold (risk increased when combined with lithium)
  • Bowel ileus
27
Q

Clozapine During Pregnancy/Breastfeeding

A
  • Limited data on effects in pregnancy - no evidence of teratogenicity
  • Crosses the placenta and accumulates in foetus at higher levels therefore minimum effective dose should be used - can cause foetal bradycardia
  • Double risk of gestational diabetes in the mother
  • Neonatal withdrawal - hypotonia (floppy baby), seizures
  • Accumulates in breastmilk and can cause agranulocytosis in infants therefore breastfeeding should be avoided
28
Q

Lithium - Therapeutic Range

A
  • Overall - 0.4-1.0 mmol/L
    • Acute mania 0.8-1
    • Maintenance treatment 0.6-0.8
    • Minimum effective dose >0.4
29
Q

Lithium - Initiation and Monitoring

A
  • Prior to starting Lithium
    • FBC, U+Es, TFTs
    • ECG
  • Dosing varies according to brand/formulation
  • Check Lithium levels 5-7 days after initiation and any changes
  • Once dose stable check levels every 3-6 months
  • Check TFTs and ECG every 6 months
30
Q

Lithium - Interactions

A
  • Diuretics
  • NSAIDs
  • Haloperidol
  • ACEi
  • SSRIs
  • Carbamazepine
  • Alcohol
31
Q

Lithium After Delivery

A
  • Breastfeeding not recommended as Lithium accumulates in milk and can lead to toxicity in newborn.
  • Foetal Lithium toxicity signs:
    • Arrythymia
    • Hypotonia
    • Lethargy
    • Poor reflexes
    • Respiratory difficulties
32
Q

Substance Misuse in Pregnancy - General Risks

A
  • Miscarriage
  • Reduced growth
  • Premature birth
  • Neonatal withdrawal syndromes - requires specialist input.
33
Q

EtOH Abuse in Pregnancy Risks

A
  • Facial abnormalities
  • Stunted growth
  • Heart defects, renal and bone problems
  • Hearing and vision problems
  • Cognitive and behavioural problems - mild LD, specific cognitive deficits and hyperactivity
  • Foetal alcohol syndrome (severe form)
  • Withdrawal syndrome on delivery:
    • Irritability
    • Hypotonia
    • Tremors
    • Seizures
34
Q

Benzodiazepine Abuse in Pregnancy Risks

A
  • Breathing problems
  • Withdrawal symptoms
  • Can be passed to baby through breastmilk
35
Q

Opiate Abuse During Pregnancy - Risks

A
  • Not inherently teratogentic
  • Neonatal withdrawal syndrome
    • Mild
      • Tremor
      • Sleep problems
      • High pitched cry
      • Sneezing
      • Colic
    • Severe
      • Feeding problems
      • Seizures
36
Q

Cocaine Abuse During Pregnancy - Risks

A
  • Teratogenicity
    • Abnormal skull shape
    • Urogenital deformities
  • Placental abruption
  • Neonatal withdrawal syndrome can lead to:
    • Tremors
    • Irritability
    • Trouble sleeping
    • Excess crying
  • Some evidence of long term behaviour/attention/memory problems
37
Q

Clozapine - Indication and Mechanism

A
  • Used in treatment resistent Schizophrenia when at least 2 other antipsychotics - 1 atypical - have been tried for an adequate duration at an adequate dose
  • Works by blocking dopamine and decreasing dopamine levels in the brain
38
Q

Clozapine - Interactions with Smoking/Drinking

A
  • Clozapine metabolised by P450 enzyme CYP1A2 which smoking inhibits
    • Smoking lowers serum Clozapine levels
      • May need higher dose
      • Inform if planning on stopping smoking
  • Drinking alcohol whilst on Clozapine may increase drowsiness
39
Q

ECT Efficacy in Treatment Resistent Depression

A
  • 80% of people benefit
40
Q

Sodium Valproate - Advice

A
  • Advise patient/carer to recognise signs and symptoms of:
    • Blood disorders - abnormal bleeding, bruising, fever or malaise
    • Liver disorders - weakness malaise, lethargy, jaundice, oedema
    • Pancreatitis - abdominal pain, nausea and vomiting
  • Seek urgent medical help if these develop
41
Q

ECT Contraindications

A
  • Cardiovascular
    • Recent MI <3 months
    • Severe angina
    • CHF
    • Major blood vessel aneurysm
    • Phaeochromocytoma
  • CNS
    • Cerebral tumour or aneurysm
    • Recent CVA <1months ago
    • Cochlear implant
  • Respiratory
    • Severe respiratory failure
42
Q

ECT Relative Contraindications

A
  • Pregnancy
  • Thyrotoxicosis
  • Cardiac dysrhythmias
  • Glaucoma
  • Retinal detatchment

CASC 3 (7 decks)

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