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Meds Flashcards

1
Q

Hypnotics and anxiolytics

A

Act on GABA receptors
Impair ability to drive/operate machinery
Tolerance and dependence
Short term, for anxiety (use anti-depressants long term)

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2
Q

Benzodiazepines

A

Eg. Diazepam (anxiolytic), temazepam (hypnotic), lorazepam (anxiolytic) and triazolam
Mechanism: Enhance GABA at GABA-A receptors
Cautions: Respiratory failure, breast feeding, previous addiction
Adverse effects: Drowsiness, confusion, disinhibition, aggression, dependency and addiction, memory and balance problems
Quite safe in OD alone but dangerous when combined with alcohol or opiates
GABA antagonist Flumazenil used for overdose
Interactions: Potentiate other sedatives (eg alcohol, anti-histamines, anti-depressants, anaesthesia)
Tolerance: 3-14 days
Withdrawal: insomnia, anxiety, sweating, tremor, perceptual disturbance, delirium and seizures. Can manifest from hours to 3 weeks after dose and may persist for months. Use for a maximum of 2-4 weeks for severe, disabling anxiety or insomnia

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3
Q

Barbituates

A

Avoid as dangerous in overdose

Hypnotic/anxiolytic

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4
Q

Chlormethiazole

A

Hypnotic/anxiolytic
Conjunctival, nasal and gastric irritation
Stimulant properties addictive

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5
Q

Z drugs

A

Zopiclone, Zolipidem, Promethazine, Melatonin
Hypnotic (short acting)
GABA-A agonist
Addictive properties similar to benzos

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6
Q

Buspirone

A

Anxiolytic BUT is a 5-HT-1A receptor agonist
No evidence of addiction or abuse potential
May be less potent than benzos and take 2-3 weeks to develop
Mildly anti-depressant

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7
Q

Antidepressants

A

Do not alter normal mood
Takes 2-4 weeks to develop
May also be used in anxiety
Not addictive, but some are very toxic in overdose and a discontinuation sundrome may occur

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8
Q

Tricyclics (eg, mechanism, indications, cautions)

A

Eg. Amitryptaline/dothiepin (sedative), imipramine, lofepramine, clomipramine
Mechanism: 5-HT/noradrenaline re-uptake inhibitors. Takes some weeks to have benefit
Indications: depression, anxiety
Cautions: cardiac disease, glaucoma, prostatism, epilepsy, hepatic impairment, elderly (hyponatraemia/post hypotension risk)

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9
Q

Tricyclics (adverse effects and interactions)

A

Muscarinic antagonism: dry mouth, blurred vision, constipation, urinary retention, impotence, delirium
Histamine antagonism - sedation and weight gain
Andrenergic antagonism - postural hypotension, sweating
Direct membrane effects - reduced seizure threshold, arrhythmia, heart block
5-HT antagonism - weight gain, weight gain
5-HT/NA re-uptake inhibition - mania
Interactions: Hypertensive crisis with adrenaline or MAOIs

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10
Q

MOAIs

A

Eg. Phenelzine, moclobemide
Mechanism: Inhibit monoamine oxidase → block 5-HT and NA metabolism → ↑ levels of 5-HT and NA
Cautions: Cardiac disease, epilepsy, hepatic impairment, ECT
Adverse effects: Anticholinergic, hypotension, oedema, fits, neuropathy, drowsiness, delirium, mania, hepatitis, leucopenia
Interactions: hypertensive crisis with sympathomimetics and tricyclics, potentiates CNS depression with opiates. Tyramine reaction (a sympathomimetic) → can’t eat cheese, red meat, alcohol. Restrictions apply for two weeks after drug is stopped
Last resort drug.
Need a drug holiday after stopping before give another drug

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11
Q

SSRIs

A

eg. Fluoxetine, sertraline, citalopram
Mechanism: 5-HT reuptake inhibitors
Indications: depression, anxiety, panic, OCD, impulse control disorders
Cautions: Renal/hepatic impairment, pregnancy, epilepsy
Adverse effects: short lived - 3 or 4 days following commencement or dose increase, nausea, anorexia, ↑ anxiety. Long term - throughout tx, headache, insomnia, sexual dysfunction, ↑ risk GI bleeds
Interactions: toxicity with MAOIs and anti-migraine drugs such as sumitriptan

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12
Q

Reboxetine

A

NARI
Depression with anergia, poor motivation and concentration
Caution in renal and hepatic impairment, urinary retention and glaucoma
Adverse effects anticholinergic
Interacts with MOAIs

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13
Q

SNRI

A

Venlafaxine, duloxetine
Inhibit 5HT, NA, DA uptake
Severe and treatment resistant depression
Anxiety disorders incl panic disorder and OCD
Caution if hx of MI
Adverse similar to SSRIs, also hypertension at higher doses
Avoid use with MAOIs

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14
Q

Trazodone

A

5-HT receptor antagonism
GAD/non-specific sedative/augment SSRIs/SNRIs
Very safe
Adverse effect - sedation, rare serious side effect is priapism

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15
Q

Mirtazepine

A

Complex. Adrenergic alpha-2 receptor antagonism → ↑ 5-HT and NA neurotransmission. Also blocks 5-HT2 receptors which helps treat anxiety and 5-HT3 receptors which helps prevent sexual dysfunction. Blocks histamine receptors → sedation
Caution in epilepsy, hepatic/renal impairment, cardiac disorders, urinary retention, DM
Adverse - weight gain, sedation, rarely a reversible agranulocytosis
2nd line or if problems sleeping

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16
Q

Mood stabilisers

A

Primarily prophylaxis for bipolar
Acute episodes of mania
May also be adjuncts to anti-depressants for depression

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17
Q

Lithium

A

Mechanism unknown. Therapeutic window very close to toxicity, important to check levels at least 3 monthly (weekly initially).
Also: U+E, eGFR, TFT, weight, calcium at baseline and 6 monthly
Cautions: renal/cardiac impairment, pregnancy, breastfeeding
Interactions: diuretics, NSAIDs, ACE-I, MAOIs, carbamazepine, high dose antipsychotics
Adverse effects: polyuria, polydipsia, fine tremor, GI disturbance, oedema, weight gain, hypothyroidism, goitre, ECG changes; teratogenic (ebstein’s anomaly)
Intoxication: Anorexia, vomiting, diarrhoea, weakness, twitching, coarse tremor, ataxia, drowsiness, confusion, coma → renal and circulatory failure, convulsions and death
Treat toxicity: Sodium chloride and water

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18
Q

Carbemazepine

A

Anti-epileptic
Mood stabiliser
Not as effective as lithium but less toxic
Adverse effects: drowsiness, neutropenia
Interactions: MAOIs and lithium → neurotoxicity

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19
Q

Sodium Valproate

A

May be as effective as lithium or better for those with high frequency bipolar, with high proportion of manic episodes.
Adverse effects include hepatic dysfunction, blood disorders, nausea, ataxia and tremor

20
Q

Lamotrigene

A

Depressed bipolar disorder and for prophylaxis
Associated with serious and sometimes fatal skin disorder (Stevens-Johnson syndrome)
Introduce drug slowly, warn patients to look out for flu-like symptoms and skin rashes
Other adverse effects - headache, nausea, ataxia
Interactions: other anti-convulsants

21
Q

Antipsychotics

A

Schizophrenia, mania, psychotic depression
Short term sedation
Prophylactic in schizophrenia
May take several weeks for anti-psychotic effect to develop

22
Q

Typical antipsychotics

A

Mechanism: Block dopamine D2 receptors
Orally or depot
Chlorpromazine, haloperidol
Cautions: cardiovascular and cerebrovascular disease, parkinsonism, epilepsy, pregnancy, breast feeding, renal and hepatic impairment, prostatism, glaucoma
Adverse effects: similar to TCAs plus dystonia of jaw, extraocular muscles and neck, parkinsonism, akathisia, tardive dyskinesia (often irreversible), postural hypotension hyperprolactinaemia → gynaecomastis, galactorrhoea, amenorrhoea, blood dyscrasias, hepatitis, skin rashes and photosensitivity
QT prolongation
Neuroleptic malignant syndrome: rare but potentially fatal: rigidity, hyperpyrexia and clouding of consciousness
Interactions: potentiates hypotensives and sedatives

23
Q

Typical antipsychotic examples
Grouped according to adverse effects
(S=sedation, A=anticholinergic, E=extrapyridamal)

A

S+++;A++;E++: Chlorpromazine
S++;A+++;E+: Thioridazine
S+;A+;E+++: Trifluoperazine, Haloperidol, Flupenthixol decanoate/Fluphenozine decanoate (depot)

24
Q

Sulprimide

A

Atypical antipsychotic
‘Clean’ dopamine agonist → fewer side effects than typicals, especially fewer extrapyridamal
Avoid in renal impairment
Less sedating but can still be used in acute psychosis

25
Clozapine
5-HT2/D2 agonist Higher efficacy than typical antipsychotics in treatment resistant schizophrenics Associated with fatal agranulocytosis, must have regular blood counts Other adverse effects: sedation, hypersalivation, anticholinergic effects BUT LESS EPS than typicals
26
Risperidone, Olanzapine, Quetiapine
Varying degrees of 5-HT2/D2 agonism Marked weight gain but fewer EPS than typicals Risperidone: anticholinergic, hyperprolactinaemic, EPS at high doses Olanzapine: sedative, contraindicated in glaucoma, caution in myeloproliferative disease
27
Acetylcholinesterase inhibitors
Mild -> mod dementia Eg. Donepezil (1st line), rivastigmine (2nd line) Mechanism: anticholinesterase → ↑ acetycholine Cautions: cardiac conductive problems, asthma, COPD, peptic ulceration Adverse effects: nausea, vomiting, diarrhoea, bradycardia, AV block, peptic ulceration, incontinence Interactions: antiarrhythmics, beta blockers
28
Disulfiram
Alcohol dependency Patient must be motivated to take the medication regularly Unpleasant systemic reaction (tachycardia, palpitations, flushing, headache) if drink alcohol Large doses of alcohol can produce a severe reaction that can be fatal Drowsiness, nausea and vomiting Adverse effects: drowsiness, nausea, vomiting
29
Acamprosate
Aids abstinence in alcohol dependence GABA agonist/glutamate antagonist Can cause gastro-intestinal disturbance Continued alcohol consumption negates therapeutic effect
30
Smoking cessations
Bupropion: NA/dopamine reuptake inhibitor Used in US as antidepressant In UK to help stop smoking Varencline: Nicotine receptor partial agonist Risk of suicidal thoughts
31
Serotonin Syndrome
Neuromuscular hyperacivity: tremor, hyperreflexia, clonus, myoclonus, rigidity Autonomic dysfunction: Shivering, tachycardia, blood pressure changes, hyperpyrexia, diaphoresis (sweating), diarrhoea Altered mental state: Agitation, confusion, mania Risk is increased by drugs that enhance serotonin transmission - MAOIs, triptans, St John's wort Treatment: withdraw serotonergic medication, supportive care, specialist advice
32
Depression treatment
Anti-depressants usually require 3-4 weeks for therapeutic effect 1st episode mild depression: at least 6 months 2nd episode or mod/severe depression: at least 2 years. premature dose reduction or withdrawal → increased risk of relapse
33
If antidepressant fails
Try different class or different drug in same class Reduce first then start second Before/after MAOIs: Need holiday (usually 2 weeks, 2 weeks for TCAs, 5 weeks for fluoxetine) Refractory depression: failure to respond to 2 or more antidepressants
34
Refractory depression options
``` CBT Lithium augmentation Venlafaxine up to BNF limits Atypical antipsychotics Phenelzine (MAOI) ```
35
SIADH
Hyponatraemia, no oedema Lethargy, headache, insomnia, apathy, agitation, confusions, convulsions, coma Concentrated urine (>300mOsm/kg); low blood urea nitrogen, serum uric acid, creatinine and albumin SSRIs>TCAs, esp fluoxetine. Use with caution in the elderly Other causes: diuretics, tumours, hypothyroidism, resp and CNS diseases
36
ECT
Small electrical charge across the brain to induced tonic clonic seizure Under GA Severe depression where pharmalogical treatment has been unsuccessful or when rapid improvement is important
37
EPSE
``` Blocking of dopamine pathways Dystonias (abnormal movement of tongue and facial muscles) Bradykinesia Rigidity Tremor Treatment: Procyclidine ```
38
Akathisia
Motor and psychological restlessness Foot tapping, moving legs repetitively Unable to settle or relax Treatment: beta blockers
39
Tardive dyskinesias
Abnormal movements Tongue protrusion, lip smacking, rotational tongue movements, facial grimacing Twisting/gyrating of whole body Dose reduction or change to atypical
40
Cardiovascular SE of antipsychotics
``` Postural hypotension (alpha blockade) Dose related Prolonged QT -> ventricular arrythmias and sudden death Haloperidol and pimozide: mandatory ECG ```
41
Prolactin increase
Blockage of D receptors in tuberoinfundibular pathway -> gynaecomastia, galactorrhoea and menstrual disturbance Change to atypical or adding a DA may help
42
Other SEs of antipsychotics
``` Sedation Weight gain Seizures Hypo/hyperthermia Skin problems (photosensitivity) Sexual dysfunction Retinal pigmentation (chlorpromazine) Corneal and lens opacities Blood dyscrasias Osteoporosis Jaundice ```
43
Acute mania
Stop antidepressants Benzos Anti-psychotics
44
Long term management of mania
Mood stabilisers | eg Carbamazepine, valproate, lamotrigine, lithium (most effective for long term use)
45
Memantine
Mod dementia, AchEi not tolerated or severe dementia Glutamate receptor antagonist SE: hypertension, headaches, dizziness, drowsiness

Med school Mental Health (7 decks)

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