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YEAR 4 MENTAL HEALTH > Medications > Flashcards

Medications Flashcards

https://cks.nice.org.uk/topics/depression/prescribing-information/antidepressant-dosing-titration/

1
Q

Antipsychotic drugs or neuroleptics have what effects / properties on a patient ?

A
  • sedative
  • anxiolytic
  • antimanic
  • mood stabilising
  • antidepressant properties

https://bnf.nice.org.uk/treatment-summaries/psychoses-and-related-disorders/#antipsychotic-drugs

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2
Q

In what conditions are antipsychotic drugs used ?

A

Mainly
* Schizophrenia
* Bipolar

Sometimes
* severe / difficult to treat anxiety and depression

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3
Q

What advice and monitoring should be implemented before starting an antipsychotic for scizophrenia ?

A

Advice:
* diet / weight control /exercise

Montoring:

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4
Q

The choice of antipsychotic drug depends on many factors. Give some examples of factors to consider

A
  • potential to cause extrapyramidal symptoms (including akathisia)
  • cardiovascular adverse effects
  • metabolic adverse effects (e.g. weight gain / diabetes)
  • hormonal adverse effects (e.g. increase in prolactin concentration)
  • patient and carer preference
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5
Q

When you start an antipsychotic drug:
how many should be started?
how should it be titrated up?

A
  • Always use 1 drug at a time (BNF: ‘explicit individual theraputic trial’)
  • dose should be started low and slowly titrated to minimum effective dose according to pt response and tolerability
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6
Q

How long should a pt trial an anti-pyschotic before it is deemed ineffective

A
  • 4-6 weeks of the drug at optimum dose before can say ineffective
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7
Q

What are first generation (‘typical’) antipsychotic drugs :
1. how do they work
2. Side effect liklihood
3. Example

A
  1. how do they work
    * block D2 receptors in the brain
  2. Side effect liklihood
    * Most likely to cause a range of SE. Especially acute extrapyramidal symptoms and hyperprolactinaemia (compliance issue)
  3. Examples:
    * Chlorpromazine
    * prochlorperazine
    * haloperidol
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8
Q

What are second generation (‘atypical’) antipsychotic drugs :
1. how do they work
2. Side effect liklihood
3. Example

A
  1. how do they work
    * range of receptors e.g. 5HT2A and D2 antag
  2. Side effect liklihood
    * lower risk of acute extrapyramidal sympotms and tardive dyskinesia (varies on drugs)
    * BUT - increased risk of weight gain, hyperglyacaemia, dyslipidaemia
  3. Example
    * Clozapine
    * Risperidone
    * olanzapine
    * quetiapine
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9
Q

Name the licensed 3rd generation antipsychotic and state its MOA

A

Aripiprazole

MOA: dopamine partial agonist

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10
Q

What antipsychotic is given for treatment resistant schizophrenia ?

A

Clozapine

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11
Q

What are some serious adverse side effects / risks to be aware of when prescribing Clozapine?

A
  • Agranulocytosis <0.8% in first year
  • Intestinal obstruction (impairs peristalsis - paralytic ilieus / impaction)
  • caution in pts on antimuscarinic drugs (cause constipation) or those w/ clonic disease / lower abdo durgery
  • Myocarditis and cardiomyopathy - baseline ECG
  • Hypersalivation (not so serious but on pass med!)
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12
Q

What monitoring is needed especially for clozapine?

A

FBC - monitor WBC
blood clozapine concentration
blood lipids
weight and weight circumference
fasting blood glucose

patient, prescribed and supplying pharmacist must be reigistered with appropriate `Patient monitoring service’

https://bnf.nice.org.uk/drugs/clozapine/#important-safety-information

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13
Q

What are common side effects of antipsychotic medications? - (headings for now) -

A
  • Extrapyrimidal SE
  • Hyperprolactinaemia
  • Sexual dysfunction (ask as big cause of non compliance)
  • Weight gain
  • Cardiovascular effects
  • Daytime drowsiness
  • Seizure threshold - lowers threshold
  • Antimuscarinic
  • special patient groups e.g. elderly / children get more side effects and most SGA in breast milk - dont breastfeed
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14
Q

What are extrapyramidal side effects? give examples

A

What: drug induced movement disoders (dose related and more likely in first-gen)

  • Parkinsonian symptoms (including tremor, bradykinesia)
  • slurred speech
  • akathisia (motor restlessness)
  • dystonia (uncontrolled muscle spasms in any part of body - young males)
  • tardive dyskinesia (abnormal involuntary movements of lips, tongue, face and jaw - can be irreversible) * most serious and not any good treatments - often see in elderley femlaes**
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15
Q

In what antipsychotics are extrapyramidal SE rare?

A

rare with
* quetiapine
* clozapine

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16
Q

At high doses of which antipsychotics do extrapyramidal SE occur?

A
  • olanzapine
  • risperidone
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17
Q

What are the clincial symptoms of hyperprolactinaemia?

A
  • sexual dysfunction
  • reduced bone mineral density
  • menstrual disturbances
  • breast enlargement / gynaecomastia
  • galactorrhoea
  • possible increased risk of breast cancer.
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18
Q

Which antispsychotics have a minimal effect on prolactin?

A
  • Aripiprazole (reduces as D2 R partial agonist)
  • clozapine
  • quetiapine
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19
Q

What are the cardiovascular risks associated with antipscychotics?

A
  • tachyarrythmia
  • arrhythimias
  • hypotension (falls e.g. elderly in itial dose titration)
  • QT interval prolongation (especially haloperidol)
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20
Q

Comment on the relationship between hyperglycaemia / diabetes and antipsychotics

A

Schizophrenia is associated with diabetes and insulin resitance on its own.

Its though that antipsychotics further increase the risk e.g. clozapine and olanzapine

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21
Q

Comment on weight gain and antipscyhotics

A
  • V common with all
  • compliance issues
  • increased CVS, DM risk
  • Clozapine olanzapine commonly cause weight gain

Least chance of weight gain with aripiprazole

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22
Q

What are some treatments for the extra-pyramidal side effects of anti-psychotics?

General approach

A

General:
* try for lowest tolerated dose that works to encourage concordance

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23
Q

What are some treatments for the extra-pyramidal side effects of anti-psychotics?

Parkinsonism

A

Parkinsonism:
* reduce dose
* change to second generation
* procyclidine

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24
Q

What are some treatments for the extra-pyramidal side effects of anti-psychotics?

Acute dystonia

A
  • IM / IV procyclidine
  • starts w/in hours of dose and treatment can take 30 mins to take effect
  • has a antimuscarinic effect so caution
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25
Q

What are some treatments for the extra-pyramidal side effects of anti-psychotics?

Akathisia

(i.e. an inability to remain still. It is a neuropsychiatric syndrome that is associated with psychomotor restlessness. intense sensation of unease or an inner restlessness that usually involves the lower extremities)

A
  • distressing
  • lowest possible dose of drug
  • trial a second generation drug
  • propanalol +/- cyproheptadine
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26
Q

What are some treatments for the extra-pyramidal side effects of anti-psychotics?

tardive dyskinesia

A
  • may be irreversible
  • try tetrabenazine
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27
Q

What is neuroleptic malignant syndrome?

How does it present?

A

a life-threatening, neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs - rare

pts present with:

  • hyperthermia
  • fluctuating level of consciousness
  • muscle rigidity
  • autonomic dysfunction
  • fever
  • tachycardia
  • labile blood pressure
  • sweating
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28
Q

How should you treat neuroleptic malignant syndrome ?

A
  • stop antipsychotic drug for at least 5 days
  • all signs and symptoms of NMS need to resolve
  • Bromocriptine and dantrolene can be used
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29
Q

What are the antimuscarinic side effects of antipsychotics?

A
  • dry mouth
  • blurred vision
  • urinary retention
  • constipation
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30
Q

What specific warning from the MHRA is there for antipsychotic use in eldlery pts.

A
  • increased risk of stroke
  • increased risk of VTE
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31
Q

Compare typical and atypical antipsychotics based on:

MOA
Adverse effects
Examples

A
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32
Q

What are some lifestyle issues you need to make pts aware of on antipsychotics ?

A
  • hunger for 3 hours after taking antipsychotcs
  • increased thirst (suggest wtaer and sugar free alternatives)
  • diet, exercise and smoking cessation are all key to address with pts as areas of health promotion
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33
Q

Comment on smoking and antipsychotic drugs

A
  • Smoking induces / speeds up metabolism
  • this reduces antipsychotic drug plasma levels
  • may need higher dose if quit
  • ALWAYS review and adjust dose e.g. clozapine if pts starts or stops smoking during treatment
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34
Q

Who can be considered for long-acting depot injections of antipschotic drugs?

A
  • patient prefernce after an acute episode
  • avoiding non-adherence is a priority
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35
Q

Are there any differences between first and second generation antipyschotic depot injections?

A
  • Second generation depot e.g. risperidone may have less extra-pyramidal side effects
  • few differences in efficacy between first-generation depot but zuclopenthixol decanoate may be better at preventing relapse than other first gen
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36
Q

Give an example of dose of Clozapine for a pt with treatment resistant schizophrenia for an adult (18-59)

A
  • Day 1: 12.5 mg 1-2 x a day
  • Day 2: 25-50 mg
  • increase in steps pf 25-50 mg daily over 14-21 days
  • increased up to 300 mg daily in divided doses (larger dose at night)
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37
Q

Give an example of dose of Clozapine for a pt with treatment resistant schizophrenia for an adult (18-59)

A
  • Day 1: 12.5 mg 1-2 x a day (oral)
  • Day 2: 25-50 mg
  • increase in steps pf 25-50 mg daily over 14-21 days
  • increased up to 300 mg daily in divided doses (larger dose at night)
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38
Q

What dose for haloperidol ?

A

First episode schizophrenia
* 2-10 mg daily in 1-2 divided doses
* usually pts have 2-4 mg daily

Multiple episode schizophrenia
* up to 10mg daily

Dose adjustments
* adjust according to response at intervals of 1-7 days
* max dose is 20 mg a day

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39
Q

What drug interactions should you be aware of with antipsychotics (long)

https://cks.nice.org.uk/topics/psychosis-schizophrenia/prescribing-information/interactions/

A

Sedating drugs (enhance sedative effect of antipsychotics)
* alcohol
* analgesics
* tricylic antidepressants
* sedating antihistamines

Drugs with hypotensive effect
* e.g. hypertensives will enhance hypotensive effect of antipsychotics

QT interval prolonging drugs
* antiarrythmics
* macrolides e.g. erythromycin
* tricyclic antidepressants (synergistic effect)

Diuretics
* may cause hypokalaemia (increased risk of arryhtmia)
* monitor potassium levels in those taking diuretics

Azole antifungals
* increase levels of antipschotics

Carbamazepine
* reduce plasma level of e.g. clozapine, haloperidol, and risperidone by half.
* monitor person to ensure antipsychotics are still effective
* the antipsychotics increase carbamazepine levels - monitor

Grapefruit juice
* dont drink increase levels of pimozide - fatal arrythmias e.g. pimozide

SSRI’s
* Increase level of some antipsychotics e;g. haloperidol and risperidone levels are increased by fluoextine

Smoking cessation
* smoking indices metabolisim of olanzapine and clozapine

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40
Q

How do benzodiazaepines work?
what are the used for?

A
  • Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the frequency of chloride channels.

used for :
* sedation
* hypnotic e.g. nitrazepam
* anxiolytic e.g. diazepam lorazepam
* anticonvulsant
* muscle relaxant

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41
Q

Indications for benzodiazepines?

A
  • short term (2-4 weeks only) releif of severe, disabling anxiety causing the pt distress on its own, associated with insomnia, organic or psychotic illness
  • short term ‘mild’ anxiety
  • insomnia only when severe and disabling

https://bnf.nice.org.uk/treatment-summaries/hypnotics-and-anxiolytics/

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42
Q

Give examples of indications for Lorazepam and dosage

A

Short term use (2-4 weeeks) in anxiety (oral)
* Adult: 1-4mg daily in divided dose
* Elderly: 0/5-2mg daily in divided dose

Short term use in insomnia with anxiety (oral)
* adult: 1-2 mg daily at bedtime

Acute panic attacks (IM / slow IV)
* 25-30 micrograms/kg every 6 hours
* IM if oral and IV not possible

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43
Q

What are common side effects of benzodiazepines?

A
  • decreased alterness
  • anxirty
  • ataxia (elderley)
  • confusion (elderly)
  • depression
  • dizziness
  • drowsiness
  • dysarthruia
  • fatigue
  • headache
  • hypotension
  • resp depression
  • withdrawal syndrome
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44
Q

Why must you be careful when prescirbing benzodiazepines ?

A
  • Patients commonly develop a tolerance and dependence
  • withdrawal may produce confusion, toxic psychosis, convulsions, or a condition resembling delirium tremens
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45
Q

When may benzodiazepine withdrawal syndrome occur?

A
  • any time up to 3 weeks after stopping a long-acting benzodiazepine
  • within a day in the case of a short-acting one
  • symptoms may continue for weeks or months after stopping benzodiazepines
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46
Q

What are the features of benzodiazepine withdrawal syndrome ?

A
  • insomnia
  • irritabilityon
  • Some symptoms may be similar to the original complaint and encourage further prescribing
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47
Q

How do the BNF advise to withdraw benzodiazepines?

A
  • The dose should be withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight.

A suggested protocol for patients experiencing difficulty is given:

  • switch patients to the equivalent dose of diazepam (longer acting)
  • reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
  • time needed for withdrawal can vary from 4 weeks to a year or more
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48
Q

What are some drug interactions with benzodiazepines?

A

All increase the CNS depression effect on benzodiazepines

  • opioids
  • barbiturates
  • monoamine oxidase (MAO) inhibitors
  • antidepressants e.g. Amitriptyline
  • alcohol
  • illicit drugs like heroin
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49
Q

Both benzodiazepines and Barbiturates are GABAa drugs. How does their MOA differ?

A
  • benzodiazipines increase the frequency of chloride channels
  • barbiturates increase the duration of chloride channel opening

Frequently Bend - During Barbeque

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50
Q

What are classes of antipressants ?

A
  • SSRIs
  • Tricyclic antidepressants
  • MAOIs
  • SNRIs
  • NARIs
  • NASSAs
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51
Q

When starting an antidepressant what should patients be aware of ?

A

During the first few weeks of treatment, there is an increased potential for agitation, anxiety, and suicidal ideation.

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52
Q

How often should pts be reviewed when starting an antidepressant? How long to see if antidepressant is working?

A
  • Review every 1–2 weeks at the start of antidepressant treatment.
  • continue for at least 4 weeks (6 weeks in the elderly) before considering whether to switch antidepressant due to lack of efficacy.
  • In cases of partial response, continue for a further 2–4 weeks (elderly patients may take longer to respond).

Following remission, antidepressant treatment should be continued at the same dose for at least:
* 6 months (about 12 months in the elderly)
* or 12 months in patients receiving treatment for generalised anxiety disorder (as the likelihood of relapse is high).

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53
Q

Which class of antidepressant is best tolerated / safest? compare to other classes

A
  • SSRIs are better tolerated and are safer in overdose than other classes of antidepressants. SSRIs are less sedating and have fewer antimuscarinic and cardiotoxic effects than tricyclic antidepressants.
  • TCAs have similar efficacy but more likely to be discontinued due to side effects. Toxicity in overdose also a problem
  • MAOIs have dangerous interactions with some food and drugs - specialist use only
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54
Q

For apatient with a history of usntable angina or recent MI what antidepressant is safe?
What dose?

A

Sertraline (SSRI)

  • Start: 50 mg daily
  • Increase in steps of 50mg at invervals of 1 week
  • Maintenace: 50 mg daily
  • Maximum dose 200 mg per day
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55
Q

What drug options are there for depression (1st line, 2nd, 3rd line etc)

A

1st line: SSRI
* citalopram (unless QT elongation then give - fluoextine)
* sertraline (1st line if hx of MI)
* Fluoextie ( 1st line in children and adolescents)

2nd line:
* SNRI or another antidepressant if indicated based on previous clinical and treatment history

3rd line:
* Mirtazapine (NASSA) - drowsiness at low dose (help with sleep)

4th line:
* TCAs / Lithium (but high toxicity)

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56
Q

MOA, dose and route of citalopram for depression

A

MOA
* Selectively inhibit the re-uptake of serotonin (5-hydroxytryptamine, 5-HT)

Dose
* 20 mg once daily
* increased in steps of 20 mg at intervals of 3–4 weeks
* maximum 40 mg per day

Route
* oral

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57
Q

How should you withdraw citalopram?

A
  • dose should be reduced gradually over about 4 weeks (not necessary with fluoxetine)
  • longer if withdrawal symptoms emerge (e.g. 6 months in patients who have been on long-term maintenance treatment).
  • Paroxetine has a higher incidence of discontinuation symptoms.
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58
Q

What are the risks in stopping an SSRI antidepressant?

A

Withdrawl:
* with all antidepressants withdrawl effects can occur within 5 days of stopping
* mild - severe
* risk is worse if suddenly stop and been taking for 8 weeks or more

SSRI withdrawal
* gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
* headache
* restlessness
* anxiety
* tinnitus
* sleep disturbance
* paraesthsia
* sweating
* influenza like symptoms

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59
Q

What should you consider as a diagnosis in a patient who experiences drowsiness, confusion or convulsions when taking an antidepressant ?

A

Hyponatraemia - SIADH is associated with antidepressandt but particularly SSRIs

Elderly are more likely to be affected

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60
Q

What are some adverse side effects of SSRIs?

A
  • GI symptoms are the most common side-effect
  • Increased risk of GI bleeding in patients taking SSRIs. A PPI should be prescribed if a patient is also taking a NSAID
  • hyponatraemia
  • patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
  • fluoxetine and paroxetine have a higher propensity for drug interactions
  • Citalopram effects QT interval - not to be used in pts with QT prolongation or taking drugs that prolong it .
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61
Q

What are some drug-drug interactions with SSRIs?

A
  • NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
  • warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
  • aspirin: see above
  • triptans: avoid SSRIs
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62
Q

When should you review a pt after starting an SSRI?

A
  • review in 2 weeks
  • if <25 years / or increased risk of suicide review after 1 week increased risk
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63
Q

When should you review a pt after starting an SSRI?

A
  • review in 2 weeks
  • if <25 years / or increased risk of suicide review after 1 week increased risk
64
Q

A pt is started on an SSR and has a good response. How long should they be on treatment for?

A
  • at least 6 months after remission as this reduces the risk of relapse
65
Q

A pt is started on an SSR for depression and has a good response. How long should they be on treatment for?

A
  • at least 6 months after remission as this reduces the risk of relapse
66
Q

Are there risks of taking SSRI’s during pregnancy?

A
  • BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
  • Use during the 1st trimester - small increased risk of congenital heart defects (Paroxetine - increased risk of congenital malformations, particularly in the 1 trimester)
  • Use during the 3rd trimester can result in persistent pulmonary hypertension of the newborn
67
Q

What are SNRI’s?
give examples

A

What?
* Serotonin and noradrenaline reuptake inhibitor (SNRI’s) are a class of relatively new antidepressants.
* Inhibiting reuptake they increases the concentrations of serotonin and noradrenaline in the synaptic cleft leading to the effects.

Examples:
* venlafaxine
* duloxetine.

68
Q

What are SNRI’s indicated for ?

A
  • major depressive disorders
  • generalised anxiety disorder
  • social anxiety disorder
  • panic disorder
  • menopausal symptoms
69
Q

What dose would you give of Venlafaxine for depression? route?

A

route:
* oral

Dose:
* start with 75 mg daily in 2 doses
* increase up to 375 mg in intervals of 2 weeks
* max is 375 mg

70
Q

What dose would you give of Venlafaxine for GAD? route?
if this does not work what else could you try?

A

Route:
* oral

Dose:
* 75 mg once daily
* increase up to 225 mg once daily (max)
* increase in intervals of 2 weeks

No response or not tolerated
* pregabalin can be considered

71
Q

Contraindications and cautions with SNRI’s?

https://cks.nice.org.uk/topics/depression/prescribing-information/snris/

A

contraindication:
* uncontrolled HTN
* hepatic impairment (duloextine)
* severe renal impairment - (creatinine clearance < 30 ml/min duloextine)

Cautions include:
* bleeding disorders
* high risk cardiac arrythmia
* diabetes
* heart disease (monitor blood pressure)
* hx of epilepsy
* hx of bipolar or mania

72
Q

What are some side effects of venlafaxine?

A

Cardiac
* palpitations ; tachycardia, hypertension, torsade de pointes, QT interval prolongation (rare), hypotension, syncope.

Gastrointestinal
* dry mouth, altered taste, decreased appetite, nausea ; constipation, vomiting, diarrhoea, , , abdominal pain (common); gastrointestinal haemorrhage, weight changes

Central nervous system
* headache, somnolence ; dizziness, drowsiness, akathisia, lethargy, tremor, paraesthesia; akathisia, movement disorders, sleep disorders, tinnitus, vision problems

Psychiatric
* insomnia, confusion, anxiety, abnormal dreams, agitation, suicidal thoughts, depersonalisation.

Skin
* sweat changes, rash, alopecia, angio-oedema.

Other
* dyspnoea, flushing, menstrual cycle irregularities, sexual dysfunction (may persist after treatment stopped); urinary symptoms, hyponatraemia (rare), neuroleptic malignant syndrome (rare), serotonin syndrome (rare), neutropenia (rare), syndrome of inappropriate antidiuretic hormone secretion (SIADH, rare), thrombocytopenia (rare).

73
Q

What are some drug interactions for SNRI (see footnote for link to detail)

https://cks.nice.org.uk/topics/depression/prescribing-information/snris/

A

Aspirin / NSAIDS/ anticoag / antiplatelet
* increased risk of bleeding
* extra INR monitoring if on warfartin

Lithium:
* use with SNRI may cause serotonin syndrome
* lithium associated with QT interval prolongation = torsade de pointes = syncope or sudden cardiac death

Monoamine oxidase inhibitors:
* contradincicated with SNRI
* fatal reaction may occur (serotonin syndrome)

SSRIs (paroextine, sertaline)
* risk of serotonin syndrome
* monitor for fever, tremors, diarrhoea, agitation etc

Sedatives e.g. alchol barbiturates, benzos
* sedating effect

74
Q

Contraindications for SSRIs?

A
  • manic phase of bipolar
  • poorly controlled epilepsy
  • QT interval prolongation / on drugs which porlong e.g. citalopram
  • severe hepatic impariment (sertaline)

https://cks.nice.org.uk/topics/depression/prescribing-information/ssris/

75
Q

What are Monoamine-oxidase inhibitors / how do they work? are they used often for depression?
give an example

A

MAOIs:
* inhibit monoamine oxidase, thereby causing an accumulation of amine neurotransmitters.

Use:
* used much less frequently than tricyclic and related antidepressants, or SSRIs and related antidepressants because of the dangers of dietary and drug interactions
* used in the treatment of atypical depression (e.g. hyperphagia)

Example:
isocarboxazid

76
Q

Indications, route and dose for (MOAI) isocarboxazid

A

Indications :
* depression

route:
* oral

Dose:
* 30 mg daily (single or divided dose) until see improvement
* can increase if needed after 4 weeks up to 60 mg for 4-6 weeks under supervisions
* it must then be reduced by 20 mg daily to a maintenace dose (up to 40mg)

Elderly : 5-10 mg daily

77
Q
A
78
Q

Which patients are thought to respond well to MOAI?

A
  • Phobic pts
  • depressed patinets with - atypical, hypochondrial, hysterical features
  • pts refractory to other treatment - can be dramatic repsonse
79
Q

Describe MAOIs interactions with other antidepressants, what does this mean for prescribing?

A
  • other antidepressants should not be started for 2 weeks after treatment with MAOI’s have been stopped.

Should not start an MAOI:
* at least 2 weeks after a preivous MAOI has been stopped
* 7-14 days after a trciylic antidepressant
* 1 week after SSRI (5 weeks after fluoextine)

80
Q

What are side effects of MOAI?

A

Include:
* anticholinergic effects, Akathisia; anxiety; appetite increased; arrhythmia; asthenia; behaviour abnormal; blood disorder; confusion; constipation; dizziness; drowsiness; dry mouth; dysuria; hallucination

  • hypertensive reactions with tyramine containing foods e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad beans
  • Risk of postural hypotension and hypertensive responses. Discontinue if palpitations or frequent headaches occur.

Isocaarboxazid:
* Granulocytopenia; peripheral oedema; sexual dysfunction

81
Q

What monitoring requirments for MOAI’s?

A
  • Monitor blood pressure (risk of postural hypotension and hypertensive responses).
82
Q

What are Tricyclic antidepressants (TCAs) ? How do they work?

A
  • Tricyclic and related antidepressants block the re-uptake of both serotonin and noradrenaline, although to different extents
  • less commonly now for depression due to their side-effects and toxicity in overdose
83
Q

What antidepressants are the biggest risk for toxiciity in overdose?

A
  • Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) have the highest toxicity in overdose.
  • Venlafaxine and Mirtazapine are less toxic that TCA’s but higher risk than other SSRIs
84
Q

How might serotonin syndrome present?

A

Neuromuscular excitation
* hyperreflexia
* myoclonus
* rigidity

autonomic nervous system excitation
* hyperthermia
* sweating

altered mental state
* confusion

More extensive from NICE:
* Insomnia, anxiety, nausea, diarrhoea, hypertension, tachycardia, hyper-reflexia, agitation, myoclonus, tremor, flushing, low-grade fever, hyperthermia, confusion, rigidity, respiratory failure, coma, or death.

85
Q

What drugs can cause serotonin syndrome?

A
  • monoamine oxidase inhibitors
  • SSRIs
  • St John’s Wort, often taken over the counter for depression, can interact with SSRIs to cause serotonin syndrome
  • tramadol may also interact with SSRIs
  • ecstasy
  • amphetamines
86
Q

How do you manage serotonin syndrome?

A
  • supportive including IV fluids
  • benzodiazepines
  • more severe cases are managed using serotonin antagonists such as cyproheptadine and chlorpromazine
87
Q

Compare and contrast serotonin syndrome to neuroleptic malignant syndrome

A
88
Q

Venlafaxine can be useful in patients with depression who are anxious but what monitoring does it require?

A
  • baseline BP
  • ECG monitoring for CVS side effects
89
Q

What monitoring should be done with any SSRI?
what side effects should be discussed with everyone as often a reason it is stopped?

A
  • FBC - anaemia (GI Bleeding with NSAID use)
  • U&E (hyponatraemia)
  • Citalopram (ECG as dose dependant QTC prolongation)

Side effect:
* discontinution / withdrawal syndrome should be discussed with patients
* sexual side effects ( often reason it is stopped )

90
Q

How can TCA’s be divided based on their effect? (examples)
What are they often used for (other than depression )

A
  • More sedative and less sedative
  • Agitated and anxious patients tend to respond best to the sedative compounds, whereas withdrawn and apathetic patients will often obtain most benefit from the less sedating ones
  • often used to treat neuropathic pain (smaller doses than depression)
91
Q

What are some common side effects of TCA’s?

A

Antimuscarinic and cardiotoxic:
* drowsiness
* dry mouth
* blurred vision
* constipation
* urinary retention
* lengthening of QT interval
* The BNF states that extrapyramidal side effects (such as acute dystonia and tardive dyskinesia) and neuroleptic malignant syndrome are possible, but very rare

Pass med questions: clomipramine can cause dry mouth (anticholinergic) and weight gain (antihistaminic) side effects

92
Q

What are some things to consider when prescirbing TCAs (pass med) i.e. factors about the use of different TCAs

A

Choice of tricyclic
* low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine)
* lofepramine has a lower incidence of toxicity in overdose
* amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose

93
Q

What monitoring for TCAs e.g. clomipramine

A

monitor cardiac and hepatic function during long-term use

94
Q

What route and dose for a TCAs e.g. clopiramine

A
  • 10 mg daily
  • increased up to 30-150mg in divided doses
  • increase gradually
  • can also take once daily at bedtime
  • (max is 250mg per day)
95
Q

What are the toxicity in overdose effects of TCAs?

A
  • potentially fatal cardiovascular effects (tachycardia, postural hypotension, slowed cardiac conduction) when taken in overdose.
  • Overdose can also cause sedation, coma, and seizures.
96
Q

What are the toxicity in overdose effects of MOAISs?

A
  • prolongs the QT interval
    toxic effects in overdose include:
  • hypertensive crisis
  • serotonin and noradrenaline toxicity
  • agitation
  • aggressiveness
  • behavioural changes.
97
Q

What are the toxicity in overdose effects of MOAISs?

A
  • prolongs the QT interval
    toxic effects in overdose include:
  • hypertensive crisis
  • serotonin and noradrenaline toxicity
  • agitation
  • aggressiveness
  • behavioural changes.
98
Q

What are some drug interactions with TCAs?

A
  • Lithiuk - neurotoxicity, serotonin syndrome, neuroleptic malignant syndrome, torsades des pointes and QT prolongation
  • MOAIs - fatal reactions e.g serotonin syndrome
  • sedative drugs e.g. alcohol, barbiturates, benzodiazepines - synergistic effect
  • tramadol - increased risk of serotonin syndrome
  • SSRIs - increased TCA conc and linked to QT interval prolongation - risk arrythmias
99
Q

How does Mirtazapine work? class?

A
  • pre-synaptic alpha2-adrenoreceptor antagonist which increases the release of central noradrenergic and serotonergic neurotransmitters
  • class: noradrenergic and specific serotonergic antidepressant (NaSSA)
100
Q

what pts is Mirtazapine useful to use with ? Why?

A

Good for use in older people

Why?
* Fewer side effects and interactions than any other antidepressants (older ppl more likely to be taking more drugs)
* sedation and increased appetite (side effects) can be useful in older people who are more likely to be experiencing insomnia and poor appetite

101
Q

What is indication and dose for Mirtazapine ?

A

Indication : depression

Dose: (oral)
starting: 15-30 mg
usual minimum daily effective dose : 30 mg
Max dose: 45 mg
often taken in the evening as sedative

102
Q

What are some common side effects of Mirtazapine?

A

Anxiety; appetite increased; arthralgia; back pain; confusion; constipation; diarrhoea; dizziness; drowsiness; dry mouth; fatigue; headache (on discontinuation); myalgia; nausea; oedema; postural hypotension; sleep disorders; tremor; vomiting; weight increased

103
Q

What are drug interactions with Mirtazapine?

A
  • Antiepileptics - Mirtzazapine can reduce seizure threshold. AE can reduced Mirtazapine levels
  • MAOIs - increased risk of serotonin syndrome (avoid use 2 weeks after stopping either drug)
  • Rifampicin - decrease level of mirtazapine
  • sedative drugs e.g. alcohol, barbiturates, benzodiazepines) — mirtazapine is sedating and co-administration with other sedating drugs may have a synergistic effect.
104
Q

Zopiclone is what kind of drug?

A
  • Z drugs have similar effects to benzodiazepines but are different structurally. They act on the α2-subunit of the GABA receptor.
  • Zopiclone is a type of Z drug
  • It is also described as a hypnotic (drug used to induce / maintain sleep)
105
Q

How long should hypnotics like Zopiclone be prescibred for?
How soon does tolerance develop?

A
  • should only be prescribed for short courses in acutely distressed
  • tolerance to effect can develop within 3-14 days of continuous use
  • danger with long term use is that when they are withdrawn they can cause rebound insomnia and a withdrawal syndrome
106
Q

What is the indications and dose for zopiclone?

A

Indications:
insomnia (short term)

Dose:
Adult: 7.5 mg once daily for up to 4 weeks, dose to be taken at bedtime.
Elderly : Initially 3.75 mg once daily for up to 4 weeks, dose to be taken at bedtime, increased if necessary to 7.5 mg daily.

107
Q

Who should you be cautious of prescribing zopiclone to?

A

Elderly pts
* think of STOPP cirteria for hypnotic Z drugs as can cause protracted daytime sedation and /or ataxia
* Falls a big risk (also with benzos)

108
Q

What are some side effects of zopiclone?

A

Common:
Dry mouth; taste bitter

Uncommon
Anxiety; dizziness; fatigue; headache; nausea; sleep disorders; vomiting

109
Q

What are some drug interactions with zopiclone ?

A

Antifungals - increase zopiclone
carbamazepine
alcohol- both have depressant CNS effects
amitriptyline - CNS depressant effects

110
Q

What are indications for Pregabalin?

A
  • peripheral and central neuropathic pain
  • adjunct in focal seizures
  • GAD (used as an anxiolytic)
111
Q

What dose of pregabalin for GAD?

A

start:
* 150mg daily in 2-3 divided doses
* increased in steps of 150mg if needed
* increase in 1week intervals
* max 600 mg daily in 2-3 divided doses

112
Q

cautions for pregablin use?

A

Conditions that may precipitate encephalopathy; elderly; history of substance abuse; respiratory depression; seizures (may be exacerbated); severe congestive heart failure

113
Q

What are common side effects of pregablin ?

A

Abdominal distension; appetite abnormal; asthenia; cervical spasm; concentration impaired; confusion; constipation; diarrhoea; dizziness; drowsiness; dry mouth; feeling abnormal; gait abnormal; gastrointestinal disorders; headache

114
Q

What monitoring is needed for pregabalin?

A

monitor for pregabalin abuse

115
Q

What are some drug interactions to be aware of with pregabalin?

A

Alcohol
amitriptuline
baclofen
Bupivacaine
Cannabidiol
Chlordiazepoxide
Chlorpromazine
(above all CNS depressant effects - worsened if you take pregabalin as well )

116
Q

What are some examples of dtugs used as mood stabilisers?

A

Lithium - lithium carbonate and lithium citrate
Carbamazepine
valporate - sodium valporate and valproic acid
lamotrigine

117
Q

What are the indications for lithium use ? What is its MOA?

A

BNF:
* Treatment and prophylaxis of mania,
* Treatment and prophylaxis of bipolar disorder,
* Treatment and prophylaxis of recurrent depression,
* Treatment and prophylaxis of aggressive or self-harming behaviour
* PASSMED: mainly bipolar prophylaxis and refractory depression

MOA:
* not understood but below theories
* interferes with inositol triphosphate formation
* interferes with cAMP formation

118
Q

Comment on lithium’s
1. theraputic range
2. plasma half life

A
  1. theraputic range
    * very narrow therapeutic range (0.4-1.0 mmol/L)
  2. plasma half life
    * a long plasma half-life being excreted primarily by the kidneys
119
Q

What dose of lithium for mania, bipolar, recurrent depression or behaviour? What precautions in starting treatment

A

Preparations vary widely in bioavailability
So on starting lithium:
* dose adjusted according to serum lithium concentration and divided throughout the day.
* once serum lithium conc is stablised can do once a day

For Camcolit immeidate release tablet
Adult:
* initially 1.5 g daily (adjust to serum lithium conc) initially divded across day until serum conc stabilised
Elderly:
* reduced initial dose and as above adjust and divide until stabilised

120
Q

Contrainidications for lithium?

A
  • Addison’s disease; cardiac disease associated with rhythm disorder; cardiac insufficiency; dehydration; family history of Brugada syndrome; low sodium diets; personal history of Brugada syndrome; untreated hypothyroidism
121
Q

What are some adverse effects of lithium ?

A
  • nausea/vomiting, diarrhoea
  • fine tremor
  • nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
  • thyroid enlargement, may lead to hypothyroidism
  • ECG: T wave flattening/inversion
  • weight gain
  • idiopathic intracranial hypertension
  • leucocytosis
  • hyperparathyroidism and resultant hypercalcaemia
122
Q

What can long term use of lithium cause?

https://bnf.nice.org.uk/drugs/lithium-carbonate/#indications-and-dose

A
  • thyroid disorders and mild cognitive and memory impairment
  • monitor thyroid function every 6 months
  • The need for continued therapy should be assessed regularly and patients should be maintained on lithium after 3–5 years only if benefit persists.
123
Q

What drug interactions with lithium ?

A

ACE inhibitors, angiotensin II receptor antagonists (sartans), diuretics, and non-steroidal anti-inflammatory drugs (NSAIDs)
Amitriptyline , Amiodarone (prolong QT), acetazolamide

124
Q

What monitoring needs to be done for lithium in terms of serm drug concentration?

(monitoring other patient paramedets later)

A
  • when checking lithium levels, the sample should be taken 12 hours post-dose
  • after starting lithium levels should be performed weekly and after each dose change until concentrations are stable
  • once established, lithium blood level should ‘normally’ be checked every 3 months
  • after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable.
125
Q

What monitoring needs to be done for lithium in terms of monitoring patient parameters?

A

Beofre treatment initiation:
* assess renal, cardiac and thyroid function
* ECG for pts with CVD or risk factors
* Body weight , BMI
* serum electrolytes
* FBC

During treatment:
every 6 months :
* monitor body weight / BMI
* serum electrolytes
* eGFR
* thyroid
* cardiac - regularly
* if impaired renal / thyroid function or increased calcium monotor more often

126
Q

What advice / safety netting to patients needs to be given when starting lithium

A

Be aware of and report signs of lithium toxicity
* hypothyroidsin
* renal dysfunction (including polyuria and polydipsia)
* benging intracranial HTN (persistant headache and visual disturbance)
* Maintain fluids intake
* avoid dietary changes which reduce or increase sodium intake

Lithium treatment pack
* all pts should get it contains pt info booklet, lithium alert card and record book for tracing serum-lithium concentration

Withdrawal
* should gradually reduce over at least 4 weeks (preferably over 3 months) as risk of relapse if stop suddenly

127
Q

When is valporate used in treatment of bipolar?

A
  • teatment of manic episodes associated with bipolar disorder if lithium is not tolerated or contra-indicated.
  • Also used for long-term management of bipolar disorder to prevent recurrence of acute episodes, in combination with lithium (if lithium alone is ineffective, or as monotherapy if lithium is not tolerated or contra-indicated.)
128
Q

What dose of sodium valporate for mania?

A

Adult:
* initially 7050mg daily in 1-2 divided doses
* usual dose is 1-2g daily in diided doses
* any dose >45mg/kg needs careful monitoring

129
Q

What are some side effects of sodium valporate?

A
  • Abdominal pain; agitation; alopecia (regrowth may be curly); anaemia; behaviour abnormal; concentration impaired; confusion; deafness; diarrhoea; drowsiness; haemorrhage; hallucination; headache; hepatic disorders and dysfunction; hypersensitivity; hyponatraemia, pancreatitis

https://bnf.nice.org.uk/drugs/sodium-valproate/#indications-and-dose

130
Q

What monitoring requirements for sodium valporate?

A

Theraputic drug monitoring:
* not rotuinely monitored as palsma -valporate conc doesnt give a good idea of efficacy

Patient parameters:
* Monitor liver function before therapy and during first 6 months especially in patients most at risk.

  • Measure full blood count and ensure no undue potential for bleeding before starting and before surgery
131
Q

What common lab test can lithium treatment effect with a false positive result?

A

False-positive urine tests for ketones.

132
Q

Drug interactions for sodium valporate

A

Acetazolamide - increase toxicity
cannabidiol
lamotrigine
Meropenem
Methylphenidate
olanzapine
Phenytoin
propofol

133
Q

Treatment cessation of sodium valporate

A

Avoid abrupt withdrawal; if treatment with valproate is stopped, reduce the dose gradually over at least 4 weeks.

134
Q

Patient advice / safety netting for sodium valporate

A

Pregnancy Prevention Programme
* Pharmacists must ensure that female patients have a patient card

Pancreatitis
* pts to be told how to recognise signs of pancreatitis and seek medical help e.g. abdominal pain, nausea, or vomiting

Blood or hepatic disorders
* recognise signs of blood or liver disorders e.g. persistent vomiting and abdominal pain, anorexia, jaundice, oedema, malaise, drowsiness, or loss of seizure control

135
Q

Dose of carbamazepine for bipolar unresponsive to lithium ?

A
  • oral immediate release
    Adult:
  • Initialyl 400 mg daily in divided doses
  • increase until symptoms controlled
  • usual dose 400-600 mg
  • max 1.6 g a day
136
Q

Monitoring for carbamazepine

A

Therapeutic drug monitoring
* Plasma concentration for optimum response 4–12 mg/litre (20–50 micromol/litre) measured after 1–2 weeks.

Monitoring of patient parametersFor carbamazepine
* blood counts and hepatic and renal function tests

137
Q

Common side effects for carbamazepine

A
  • Dizziness; drowsiness; dry mouth; eosinophilia; fatigue; fluid imbalance; gastrointestinal discomfort; headache; hyponatraemia; leucopenia; movement disorders; nausea; oedema; skin reactions; thrombocytopenia; vision disorders; vomiting; weight increased
138
Q

drug interactions for carbamazepine

A

Apixiban
rivarooxoban
warfarin
clozapine - increased mylosuppression
clarithromycin
erythromycin
flucanazole

139
Q

First line treatment for ADHD?

A
  • methylphenidate hydrochloride
  • Lisdexamfetamine mesilate
  • If symptoms do not improved after a 6 weeks, switch to the alternative first-line treatment
140
Q

Why are modified releases of stimulants e.g. methylphenidate preferred?

A
  • Pharmacokinetic profile
  • convenience
  • improved adherence
  • reduced risk of drug diversion (drugs being forwarded to others for non-prescription use or misuse)
  • lack of need to be taken to work
141
Q

What would be reasons to give immediate release stimulants?

A

when more flexible dosing regimens are required or during initial dose titration

142
Q

Indications for methylphenidate ?

A
  • ADHD
  • Narcolepsy
143
Q

Dose for methylphenidate ?

A

Child 6-17 years
* Initially 5mg 1-2 times a day
* increased in steps of 5-10 mg in weekly intervals
* increased up to 60mg daily in 2-3 divided doses
* discontinue after 1 month if no response

Adult
* initially 5mg 1-2 times a day
* increased up to 100 mg daily in 2-3 divided doses

144
Q

Drug interactions for methylphenidate

A

alchohol
amitriptyline
risperidone - increase risk of dyskinesia
valporate - enhance effect of methlphenidate
Carbamzaepine - decrease methylphenidate

145
Q

What monitoring for methlyphenidate ?

A

Monitor for psychiatric disorders.

Pulse, blood pressure, psychiatric symptoms, appetite, weight and height should be recorded at initiation of therapy, following each dose adjustment, and at least every 6 months thereafter.

146
Q

What monitoring for methlyphenidate ?

A

Monitor for psychiatric disorders.

Pulse, blood pressure, psychiatric symptoms, appetite, weight and height should be recorded at initiation of therapy, following each dose adjustment, and at least every 6 months thereafter.

147
Q

Side effects for methlyphenidate?

A
  • Aggression (or hostility); alopecia; anxiety; appetite decreased; arrhythmias; arthralgia; behaviour abnormal; cough; depression; diarrhoea; dizziness; drowsiness; dry mouth; fever; gastrointestinal discomfort; growth retardation (in children); headaches; hypertension; laryngeal pain; mood altered; movement disorders; nasopharyngitis; nausea; palpitations; sleep disorders; vomiting; weight decreased
148
Q

What is ECT?
When is ECT considered?

A
  • Electroconvulsive therapy
  • considered when:
    -condition is life-threatening and you need to get better quickly to save your life
    -is causing you immense suffering
    -has not responded to other treatments, such as medication and psychological therapy
    -has responded well to ECT in the past
149
Q

What conditions is ECT used for?

A
  • severe depression
  • catatonia
  • manic phase of bipolar
  • pts who have mixed symptoms of depression and mania
150
Q

Describe the ECT procedure

from BB lec

A

Bilaterla or unilateral electrode placement
Adminsitered 2 x a week
Course up to 12 treatments
Stopped as soon as pt feels benefit
Inpatient or Outpatient

151
Q

Describe infection control measures surrounding ECT procedure

A

Strict infection control measures as ECT is an aerosol generating procedure under anaesthesia

152
Q

What are contraindications to ECT?

A
  • CNS –> raised intracranial pressure, cerebral aneurysm, recent cerebrovasculat event/stroke
  • Cardiac/circ –> recent MI in last 3 months, unstable angina, DVT, potassium imbalance, uncontrolled HR or BP
  • Resp –> acute resp infection or resp conditions
  • PMH –> cochlear implants, phaeochromocytoma, unstable fractures, bariatric pts
  • Other –> recent food, chewing gum, sweets, cigs

Caution in pregnancy, controlled epilepsy and pacemaker pts

153
Q

What are side effects of ECT?

A
  1. from ECT –> confusion, headache, status epilepticus, stroke, arryhtmia, bleeding ulcers, PE, subconjunctival haemorrhages, reaised intraocular pressure, broken teeth
  2. risks of anaesthesia –> MI, arrythmia, aspiration pneumonia, prolonged apnoea, nausea, malignant hyperthermia, muscle aches, death, adrenocortical supression (if using etomidate)
  3. memory loss –> short term retrograde amnesia; will depend on total energy used and site of electrode.
154
Q

You increase lithium dose for a pt. When should you re-check lithium plasma levels?

A

1 week later

Lithium monitoring should be performed weekly after initiation and after each dose change until concentrations are stable.

It is usually checked 12 hours after the dose is taken.

155
Q

Male pt with schizophrenia comes to clinic for follow up.

He is distressed as he is expereincing wieght gain, low sex drive, gynaecomastia and galactorrheoa. He is compliant with meds.

What antipsychotic good to change him to?

A
  • Aripiprazole
  • He has features of hyperprlocatinaemia
  • Aripiprazole has the most tolerable side effect profile of the atypical antispsychotics, particularly for prolactin elevation

YEAR 4 MENTAL HEALTH (16 decks)

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