Medications Flashcards
1
Q
ACEi - Donepezil, Rivastigmine, Galantamine
Efficacy
A
40-50% benefit
1/3 improve
1/3 plateau
1/3 don’t respond
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
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
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
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
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
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
8
Q
Lithium Adverse Effects - Short-term/Common
A
- Thirst
- Polyuria
- Metallic taste
- Fine tremor
- Nausea/vomiting
9
Q
Antidepressants - Efficacy
A
- 60-70% respond
10
Q
Methylphenidate - Monitoring
A
- Cardiovascular status (HR/BP) - every 3/12
- Height/weight - every 6/12
11
Q
Methylphenidate - Efficacy
A
- 70% respond
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
13
Q
Sodium Valproate - Side Effects (Unpredictable)
A
- Hair loss - with curly regrowth
- Peripheral oedema
- Leucopaenia/thrombocytopenia
- Weight gain
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
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
16
Q
Clozapine - Risk of Neutropenia/Agranlucytosis
A
- Neutropaenia 2-3/100
- Agranulocytosis <1/100
- Fatal 1/8000
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
Clozapine - Common Side Effects
* Drowsiness
* Constipation
* Postural hypotension
* Hypersalivation
* Fever
* Palpitations
* Weight gain
26
Clozapine - Serious Side Effects
* Agranulocytosis - \<1/100
* Myocarditis
* Reducted seizure threshold (risk increased when combined with lithium)
* Bowel ileus
27
Clozapine During Pregnancy/Breastfeeding
* 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
Lithium - Therapeutic Range
* Overall - 0.4-1.0 mmol/L
* Acute mania 0.8-1
* Maintenance treatment 0.6-0.8
* Minimum effective dose \>0.4
29
Lithium - Initiation and Monitoring
* 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
Lithium - Interactions
* Diuretics
* NSAIDs
* Haloperidol
* ACEi
* SSRIs
* Carbamazepine
* Alcohol
31
Lithium After Delivery
* 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
Substance Misuse in Pregnancy - General Risks
* Miscarriage
* Reduced growth
* Premature birth
* Neonatal withdrawal syndromes - requires specialist input.
33
EtOH Abuse in Pregnancy Risks
* 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
Benzodiazepine Abuse in Pregnancy Risks
* Breathing problems
* Withdrawal symptoms
* Can be passed to baby through breastmilk
35
Opiate Abuse During Pregnancy - Risks
* Not inherently teratogentic
* Neonatal withdrawal syndrome
* Mild
* Tremor
* Sleep problems
* High pitched cry
* Sneezing
* Colic
* Severe
* Feeding problems
* Seizures
36
Cocaine Abuse During Pregnancy - Risks
* 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
Clozapine - Indication and Mechanism
* 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
Clozapine - Interactions with Smoking/Drinking
* 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
ECT Efficacy in Treatment Resistent Depression
* 80% of people benefit
40
Sodium Valproate - Advice
* 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
ECT Contraindications
* 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
ECT Relative Contraindications
* Pregnancy
* Thyrotoxicosis
* Cardiac dysrhythmias
* Glaucoma
* Retinal detatchment
