Medications + Organic DDx

Question 1

Organic DDx

Answer 1

‘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

Question 2

NMS (low DA)

causative medications: APD, metoclopramide
-usually 4-11 days from dose start/change

Answer 2

• 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

Question 3

Serotonin syndrome (high 5HT)

causative medications: ADD (combo, switch), tramadol w/ SSRI/SNRI

Answer 3

• 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

Question 4

EPSEs

APDs, metoclopromide, ?ADD

Rx: procyclovir

Answer 4

resting tremor, cogwheel rigidity, salivation, festination/shuffling, bradykinesia, dysarthria, mask face, postural instability

akithisia: restlessness
parkinsonism (d/w)
acute dystonia (

Question 5

ADD - indications/course

not addictive

Answer 5

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

Question 6

ADD - benefit/SE

Answer 6

effectiveness: 70%
block receptor reuptake

general SEs: N/V, akithisia, dd, sexual, bleeding, sedation

Question 7

ADD - classes

Answer 7

SSRI (1st): citalopram, sertraline, fluoxetine, paroxetine
TCA: amitriptyline, imipramine
SNRI (2nd): venlafaxine, duolexitine
SARI: Trazadone
NARI: Reboxetine
MAOI: milopramide, phenelzine, isocarboxacid, moclobemide
NaSSA: Mirtazepine

Question 8

ADD - choice considerations

Answer 8

-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

Question 9

ADD - specific SE

*TCA non-terato

Answer 9

• 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

Question 10

ADD - SSRI

Answer 10

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)

Question 11

ADD - TCA

Answer 11

non-terato (preggo)
o/d risk (lofepramine least)

antiM: dry mouth, blurry, retention, constipation
other: sedation, weight gain, dizzy, hypoTN, delirium

Question 12

ADD - withdrawal

Answer 12

mild and transient; worst parox/venla

dizzy, numb/tingling; N/V, headache, sweaty, anx, sleep/dreams, tremor, ‘shocks’

Question 13

ADD - SE summary:

Answer 13

most weight gain: NaSSA (TCA)
least: SSRI/SNRI

most sex dysFx: SSRI
least: NaSSA

most sedation: NaSSA (TCA)
least: SSRI (SNRI)

Question 14

ECT

Answer 14

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

Question 15

anxiolytics/BZD

buspiridone 5HT agonist in GAD

Answer 15

• 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

Question 16

mood stabilisers

V=acute/PPx
C=acute, PPx, bip depp, TRD aug
La=Bip depp, PPx, TRS/TRD augmentation

Answer 16

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

Question 17

Lithium - 80% effective (reduced risk)

Answer 17

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

Question 18

APD - indication/examples

Atypical 1st; pos, ?neg/mood/cognition, less EPSE
typical 2nd; pos, ?worse neg

Answer 18

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

Question 19

APD - mech/course

Answer 19

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

Question 20

APD - effect/SE

Answer 20

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

Question 21

APD - SE summary

metabolic, EPSE, ANS, PL, confusion, depression, apathy/sedation, arrhy, fits
hypersensitivity (live/bone/skin)

Answer 21

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

Question 22

APD - choice considerations

Answer 22

• PMH/FH: DM, metabolic syndrome
• obesity, weight concerns, sedation impact
• childbearing: LARCs preferred, typicals better

Question 23

APD - specific SE

Answer 23

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>

Question 24

Clozapine:

D2, D3, D4, 5HT, m-ACh, H, AA

Answer 24

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