Meds_Guidlines_3 Flashcards by Arteen Ahmed

What is next step in a stable bipolar patient on lithium who develops episodes of hypomania?

Continue with lithium and:

Add olanzapine —>NICE

Add mood stabilizer (valproate)—>Maudsley

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A med that should be avoided in bipolar when compliance is assumed to be erratic

Lithium (narrow therapeutic index)

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Tappering period for lithium in bipolar

1 month

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It is indicated when quick action is required in acute mania

Valproic acid
Risperidone
Olan
(NICE)

(Lithium =for longer term )

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it is used primarily in maintenance phase of bipolar & to prevent depression episodes

Lamotrigine

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If a bipolar patient on low dose of Valproate still had low mood, what should you do?

Check adherence
Increase the dosage
consider side effects

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When can you add lamotrigine to valproate in bipolar?

If low mood was present despite optimised dose of valproate

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1st line Rx in long-term bipolar treatment in adults

Lithium

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What should be monitored in lithium therapy

Renal
Thyroid

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What does NICE suggest if lithium failed in prophylaxis treatment of bipolar?

-Consider Olan monoRx
-Asenapine

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Adults with bipolar presented with moderate depression

NICE: olanzapine + fluoxetine

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Gold standard Rx in Bipolar maintenance Rx (both hix of depression and mania)

Lithium monotherapy

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Licensed medication to augment lithium therapy in biplar patients with manic episode

Olanzapine

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An option to augment carbamazepine with in a bipolar case with manic episode

Quetiapine

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Best action in a previously stable patient on below max dose of aripiprazole who presents with mania?

Increase the dose of aripiprazole

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best agent for augmenting mood stablizers (lithium and valproate combination) at their max dose when stable mood is not yet achieved

Quetiapine

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An option in long term bipolar prophylaxis Rx when lithium (needle phobia) and valproate (childbearing age) are not suitable

Olanzapine

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A preferred treatment for pregnant lady with mixed affective state?

Haloperidol ( an antipsychotic)

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Bipolar lady get pregnant while on antipsychotics and you know she will relapse if stopped medication

Continue the antipsychotics and monitor regularly

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If a bipolar patient on valproate and a reliable contraception end up getting pregnant…what should be done

Stop valproate and switch to a anti psychotic for prophylaxis

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A stable bipolar patient on long term lithium gets pregnant…what’s next?

Stop lithium over 4 weeks and offer an antipsychotic

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If pregnant bipolar lady insisted to stay on lithium what should be done?

respect her dicision.
Just give her all info you have about tetragenic effects…
monitor her every month till 36 week, the weekly till end.
lithium drops during pregnancy so keep in in the therapeutic index

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If pregnant bipolar lady insisted to stay on lithium what should be done?

Mild depression in bipolar pregnant women with no Rx can be helped with

Guided self help

A heroin addict wants to quit but not with methadon and buprenorphine... he wants something not addictive

Lofexidine (alleviates withdrawal symptoms)

The hormone that offers theoretical Rx for bulimea

Cholecystokinin

Induces vomiting in bulimia

Ipecac

Side effects of ipecac in bulimia

Cardiomayopathy

Responsible for psychoactive effect of cannabis

Tetrahydrocannabinol

1st line Rx for catatonia

lorazepam (NICE)

Best medication with strong evidence to reduce violence in schizophrenia

Clozapine

Risk factor for agranulocytosis in clozapine use

Being asian older age

Risk percenrage for neutropenia in clozapine use

Risk percenrage for agranulocytosis in clozapine use

Sialorhoea proportion in clozapine use

30%

What medication is suggested as evidence based agent for augmentation in clozapine resistant schizophrenia?

Lamotrigine (no response to clozapine) Sodium Valproate (if partially responded to clozapie) Amisulpride Omega 3 triglyceride (neuroprotective &antiinflammatory)

Monitoring protocol in clozapine

Weekly for 18 weeks then monthly lifelong (agranulocytosis)

In a schizophrenia case who has not responded to two antipsychotics what is next?

Clozapine

What side effect in clozapine treatment is dose dependent?

Constipation Sialorrhoea Sedation

In a excessively sedated psychotic patient whose plasma level of clozapine is higher than 1000 μg/L with normal ECG, what should you do?

Add anticonvulsant (to reduce risk of siezure) and simultaneously reduce clozapine level to below 1000 μg/L. Discontinue the anticonvulsant once the reduction achieved

do all clozapine induced myocarditis present with chest pain?

nope only 25% do.

Presenting features in clozapine induced myocarditis

Abnormal ECG 90% Dyspnoea 90% Palpitation 70% elevated cardiac markers 70% influenza like illness 50% tackycardia 40% leucocytosis 35% chest pain 25%

Percentage of treatment resistant schizophrenia

30%

If a patient on clozapine shows a plazma level of 1.1 mg/L with no side effects what should be done

dose for the effect is👌 thought plama level is a bit high 🥶 so monitor routinely Add an anticonvulsant to reduce risk of siezure

What is the **average** ratio of clozapine to norclozapine

1.3 (0.5-2.5)

Why is clozapine / norclozapine ratio is clinically useful?

To understand pharmavokinetic and compliance

What does 🚬 does to clozapine?

Reduces its level in plasma

Least likely dose dependent side effect of clozapine

Agranulocytosis

A patient on clozapine is presented with fever, tired and unwell, what is the test you need to perform?

Full blood count for signs of agranulocytosis or neutropenia

What condition can cholinergic effects of clozapine exacerbate and therefore be used with caution?

Susceptibility to angle-closure gaucoa

What condition can cholinergic effects of clozapine exacerbate and therefore be used with caution?

Susceptibility to angle-closure gaucoa

Safe meds to be used for mania in breastfeeding mothers?

Quetiapine Olanzapine

PMDD 1st line of treatment

SSRIS (NICE) like fluoxetine

A med that if combined with Oral contraceptives can help with MPDD

drospirenone (synthetic progesterone)

What dose Drospirenone COCs help patients with?

Oedema (spironolactone like effects) psychological