Medications

Question 1

Tx for Alcohol Detoxification

Answer 1

• Diazepam
  
  • monitor using CIWAr and physical observations
  • give diazepam doses sufficient to minimise autonomic symptoms/signs and anxiety.
    N.B. Important to prevent development of delirium tremens.
• Thiamine
  
  • ​200mg daily im/iv for 3 days (longer if significant neurological deficit) then 50mg qid orally. (Or see updated guidelines on Intranet.)

Question 2

Medications for alcohol Relapse Prevention

Answer 2

• Naltrexone
  
  • ​oral opioid antagonist.
  • Reduces alcohol craving and subjective “high” from alcohol use resulting in reduction in rate of relapse and in drinking days. (Subsidised treatment available only via CADS specialist programme.) •
• Disulfiram
  
  • ​inhibits aldehyde dehydrogenase.
  • Consumption of alcohol results in flushing, increased PR, palpitations & reduced BP followed by nausea, vomiting, SOB, sweating lasting approx 30 mins.
  • Risk of CV collapse/convulsions if severe.

Question 3

Medication for Substitution Treatment for Drug Addiction

Answer 3

Opioid substitution

• Methadone
  
  • long acting full opioid agonist with half life 15-60 hour (mean 22) (oral liquid formulation used)
• Buprenorphine
  
  • partial opioid agonist with long half life (20-73 hrs) that binds tightly with opioid receptors => prolonged action (sublingual).
  • Prescribed as Suboxone, (buprenorphine plus naloxone) a harm minimisation strategy which reduces the risk of IV misuse.

Benzodiazepine substitution

• Diazepam (occas clonazepam)

Question 4

SSRI’s

Indication:

Mechanism:

Adverse Effects:

Examples:

Answer 4

Indication: Depression, anxiety

Mechanism: Selective Seritonin Reuptake Inhibitors

Adverse Effects: Headaches, GI upset, sexual dysfunction, anxiety, P450 interactions, serotonin syndrome, sleep disturbance, suicidality

Examples:

• Sertraline ( 25-50 → 200mg o.d.)
• Fluoxetine (10mg → 60mg o.d.)
• Citalopram (20mg → 40mg o.d.)

Question 5

SNRI’s

Indication:

Mechanism:

Adverse Effects:

Examples:

Answer 5

Indication: Indicated in some anxiety disorders

Mechanism: Serotonin noradrenaline reuptake inhibitors

Adverse Effects: headache, nausea, sleep disturbance

Examples:

• Venlafaxine (75mg → 375mg o.d.)

Question 6

Antipsychotics

Mechanism:

Adverse Effects:

Examples:

Answer 6

Mechanism: blockade of post-synaptic dopamine receptors

Adverse Effects: Extrapyramidal sx (dystonia, akathisia, parkinsonism), tardive dyskinesia, neuroleptic malignant syndrome (delerium .etc)

Examples:

1. Typical (1^st Gen) Good for + sx (delusions, auditory . hall)
   
   • Chlorpromazine 75–300 mg
   • Phenothiazine
   • Haloperidol 2–20 mg
2. Atypical (2nd and 3rd) Good for + and -
   
   • Risperidone/Paliperidone 2mg → 6mg
   • Olanzapine 5mg → 20mg

Question 7

Side effects of

Risperidone:

Olanzapine:

Answer 7

Risperidone: Headache, Extrapyramidal sx, Long QT

Olanzapine: Weight Gain, metabolic SI (cholesterol, glucose disturbance), dry mouth, dizziness, headaches, long QT

Question 8

Mood Stabilisers

Indication:

Example:

Mechanism

Adverse Effects

Dose

Answer 8

Indications: Good for mania, some good for depression too

Lithium: Gold standard for bipolar disease and mania

Mechanism: unclear

Adverse Effects: NV+ Diarrhoea, fine tremor, nephrotoxic, Î thyroid, weight gain, hyperPTH, ECG change

Dose: 400mg → 1200mg o.d.

Levels should be performed WEEKLY + after any dose change.
Then every 3/12.

Question 9

Biological Tx for Schizophrenia

First Line

Second Line

Answer 9

First Line:

• Risperidone: initial dose 2mg, titrate to 4-6mg o.d.
• Max dose 16mg

Second Line

• Olanzapine: 5mg → 20mg o.d.

ALSO treat concurrent depression, anxiety or bipolar

Question 10

Biological Treatment for Anxiety Disorders;

Answer 10

Generalised Anxiety Disorder:

• Sertraline: 50mg-200mg o.d.

OCD/PTSD

• Fluoxetine: 20mg-60mg o.d.

Question 11

Biological Treatment for Anxiety Disorders;

Answer 11

These are 2^nd Line to psychological interventions!

• Venlafaxine: 37.5mg → 300mg o.d.

Question 12

Biological treatment for Borderline Personality Disorder?

Answer 12

Not usually indicated!

Can use PRN Zopiclone

Question 13

Biological Treatment for Alcohol/substance abuse

For Relapse Prevention:

For Opiod Substitution:

For Benzodiazepine Substitution:

For Stimulant Substitution:

For Alcohol Detoxification:

Answer 13

For Relapse Prevention: Naltrexone 25 mg → 50 mg daily

For Opiod Substitution: Methadone (start at 10-40mg, usual dose 60–120 mg daily)

For Benzodiazepine Substitution: Diazepam 2 mg 3 times daily increased if necessary to 15–30 mg daily i

For Stimulant Substitution: Dexamphetamine

For Alcohol Detoxification: Diazepam/thiamine 5–20 mg; repeated after 2–4 hours if necessary