Medications + Organic DDx Flashcards
Organic DDx
‘DEMONS’ drugs, epilepsy, metabolic/endocrine, other (e.g. porphyria), neoplasm, SLE
hypothyroid: depression, ED
hyperthyroid: anxiety/panic, ED
hypocalcaemia: GAD
hypercalcaemia: depression
phaeochromocytoma: panic/anxiety
porphyria: recurrent psychosis
TLE: olfactory hallucinations, GAD, psychosis
SLE: depression
other: infections, glucose, EUC, vitamins, SOL
NMS (low DA)
causative medications: APD, metoclopramide
-usually 4-11 days from dose start/change
- symptoms (3): NM, LOC, SANS (unstable BP)
- NM: lead pipe rigidity, retardation, hypo/bradyreflexia
-Ix: raised CK, ALT/AST, and WCC; met acid
- treatment: stop, supportive (?ITU; cool; IVF), dantroline/bromocrptine (?ECT/BZD)
- complications: 20% mort; pneumo, KF
Serotonin syndrome (high 5HT)
causative medications: ADD (combo, switch), tramadol w/ SSRI/SNRI
- symptoms (3): NM, LOC, SANS (unstable BP)
- NM: agitation, myoclonus/clonus, hyperreflex, tremor, rigid; GI
-Ix: WCC, ALT/AST, CK; med acid
- treatment: stop, support (IVF, ITU, temp); ?BZD, cyproheptadine (5HT antag)
- complications: 0.1% mort; pneumo, KF
EPSEs
APDs, metoclopromide, ?ADD
Rx: procyclovir
resting tremor, cogwheel rigidity, salivation, festination/shuffling, bradykinesia, dysarthria, mask face, postural instability
akithisia: restlessness
parkinsonism (d/w)
acute dystonia (
ADD - indications/course
not addictive
indications: depp/anxiety, BN, IBS/CFS, pain, insomnia, impulsive
course/combo: 2-4 weeks for effect; low and slow; 6/12 after recovery (2y if recurrent), withdrawal
ADD - benefit/SE
effectiveness: 70%
block receptor reuptake
general SEs: N/V, akithisia, dd, sexual, bleeding, sedation
ADD - classes
SSRI (1st): citalopram, sertraline, fluoxetine, paroxetine
TCA: amitriptyline, imipramine
SNRI (2nd): venlafaxine, duolexitine
SARI: Trazadone
NARI: Reboxetine
MAOI: milopramide, phenelzine, isocarboxacid, moclobemide
NaSSA: Mirtazepine
ADD - choice considerations
-interactions, SEs, efficacy (equal) paroxetine, fluoxetine, fluvoxatine most interactions -previous ADD and response SSRI 1st line -current symptoms; ?beneficial SE -treatment goals and SE perception (acceptable/not) -patient preference -suicide/DSH: SSRI safe in O/D
ADD - specific SE
*TCA non-terato
- SSRI: bleeding; increased SI/DSH SSRI); venlafaxine cardio
- MAOIs: HTN crisis (cheese rxn)
- NaSSA (mirtazepine): least sex effect, more weight gain/sedation
- MASSA: less weight/sleep
- TCA: OD risk; sedating; antiM weight
ADD - SSRI
70% effective
SE: mostly minor/short; keep taking
dd, N/V, restless, insomnia, sex, fatigue, bleeding
low and slow; 1-6 weeks (2-4); monthly appt for 3/12; continue 6/12, slow w/d (at least 1/12)
ADD - TCA
non-terato (preggo)
o/d risk (lofepramine least)
antiM: dry mouth, blurry, retention, constipation
other: sedation, weight gain, dizzy, hypoTN, delirium
ADD - withdrawal
mild and transient; worst parox/venla
dizzy, numb/tingling; N/V, headache, sweaty, anx, sleep/dreams, tremor, ‘shocks’
ADD - SE summary:
most weight gain: NaSSA (TCA)
least: SSRI/SNRI
most sex dysFx: SSRI
least: NaSSA
most sedation: NaSSA (TCA)
least: SSRI (SNRI)
ECT
safe controlled electric shocks; resets NT
80% effective; rapid
SE: mm, confusion, sedation, n/v, mort 1/100,000, memory loss
course: 2-3/w; 6-12 per course; repeated; combo BPS
anxiolytics/BZD
buspiridone 5HT agonist in GAD
- indications: sleep, anx, alcohol w/d, akathisia, sedation, seizures, spasm
- very effective
- SE: dependence, tolerance, w/d; sedation, ataxia/coordination, confusion, resp depp
- course: ST only, 3 weeks max, slow wean off
mood stabilisers
V=acute/PPx
C=acute, PPx, bip depp, TRD aug
La=Bip depp, PPx, TRS/TRD augmentation
indications: bipolar, acute mania, depression augmentation
course: 2y/5y (recurrent)
SE: teratogenic
combo:
lamotrigine good for BAD-II or bipolar depression; L+C good if resistant to comboRx
Lithium - 80% effective (reduced risk)
SE: ‘LITHIUM’ leucocytosis, DI, Tremors, Hypothyroid, Increased weight, upset tummy (N/V), Myocardial;
toxicity signs (1.5/2.5): coarse tremor, ataxia, dysarthria, nystagmus, confusion, convulsion *avoid salt, dehydration, NSAIDs/ACEI/diuretics
monitoring:
- what: TFT, EUC, [conc] levels 0.4-1.2 (0.6-0.8)
- when: 5/7 after change, 1/52 (4), 1/12 (6), 3/12
APD - indication/examples
Atypical 1st; pos, ?neg/mood/cognition, less EPSE
typical 2nd; pos, ?worse neg
indications: psychosis, acute mania (ola), BAD, delirium, dementia BPSD, agitation/anxiety/aggro, tranq, insomnia, tics/hiccups
* not used for psychotic Sx in depression
examples: halo, quet, risp, flupenthixol, cloz, olanx
depot: halo, flupen, zuclo, fluphenazine, risp, olanz
APD - mech/course
mech: D2 antagonists (block ML), and 5HT (Atypicals)
course/combo: 2-4/52 for effect, 6-8/52 before failure; usually 6-8/12 duration
monitor: pre-test + post + yearly
- FBC, EUC, LFT, Lipids, PL, BM; BP, BMI, ECG
APD - effect/SE
effectiveness: 60-70%; relapse only 10-30%; but up to 80% non-concordant
SE: SHADE - sedation, hypoTN, ACh, Dermatological, Endocrine (impotence, gynaecomastia, galacto) and EPSE
‘LAND SHACS’ - lost appetite, akathesia +EPSE, N/V, dd, sedation, sexual dysfunction, hypoTn, ACh, cardiac arrhythmia, seizure
APD - SE summary
metabolic, EPSE, ANS, PL, confusion, depression, apathy/sedation, arrhy, fits
hypersensitivity (live/bone/skin)
most sedating: chlorpromo, Clozapine, olanz (Quet)
-least: aripiprazole (risp)
most EPSE: haloperidol, risperidone
-least
most weight gain: olanzapine (+DM), clozapine, (?Q)
-least: aripiprazole (rare)
most metabolic: Cloz, olanz
-least: aripiprazole
most prolactin: risperidone
APD - choice considerations
- PMH/FH: DM, metabolic syndrome
- obesity, weight concerns, sedation impact
- childbearing: LARCs preferred, typicals better
APD - specific SE
Ol: sedation, weight gain, TAG/DM, dizzy, anti-ACh; less PL/EPSE
Ris: PL, sex, EPSE, weight, sedation
Q: titrate; sedation, weight gain, metab (<ol></ol>
Clozapine:
D2, D3, D4, 5HT, m-ACh, H, AA
TRS; 60% successful;
SE: agranulocytosis (1%), hypoTN, BO, myocarditis, hypersalivation, metabolic, seizures
monitoring:
- what: vitals, BMI; FBC, lipids, EUC, LFT, BM
- when: weekly x18, 2-wk for 1y, then monthly
- daily vitals for 2 weeks
