Meds_Guidlines_3 Flashcards
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
A med that should be avoided in bipolar when compliance is assumed to be erratic
Lithium (narrow therapeutic index)
Tappering period for lithium in bipolar
1 month
It is indicated when quick action is required in acute mania
Valproic acid
Risperidone
Olan
(NICE)
(Lithium =for longer term )
it is used primarily in maintenance phase of bipolar & to prevent depression episodes
Lamotrigine
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
When can you add lamotrigine to valproate in bipolar?
If low mood was present despite optimised dose of valproate
1st line Rx in long-term bipolar treatment in adults
Lithium
What should be monitored in lithium therapy
Renal
Thyroid
What does NICE suggest if lithium failed in prophylaxis treatment of bipolar?
-Consider Olan monoRx
-Asenapine
Adults with bipolar presented with moderate depression
NICE: olanzapine + fluoxetine
Gold standard Rx in Bipolar maintenance Rx (both hix of depression and mania)
Lithium monotherapy
Licensed medication to augment lithium therapy in biplar patients with manic episode
Olanzapine
An option to augment carbamazepine with in a bipolar case with manic episode
Quetiapine
Best action in a previously stable patient on below max dose of aripiprazole who presents with mania?
Increase the dose of aripiprazole
best agent for augmenting mood stablizers (lithium and valproate combination) at their max dose when stable mood is not yet achieved
Quetiapine
An option in long term bipolar prophylaxis Rx when lithium (needle phobia) and valproate (childbearing age) are not suitable
Olanzapine
A preferred treatment for pregnant lady with mixed affective state?
Haloperidol ( an antipsychotic)
Bipolar lady get pregnant while on antipsychotics and you know she will relapse if stopped medication
Continue the antipsychotics and monitor regularly
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
A stable bipolar patient on long term lithium gets pregnant…what’s next?
Stop lithium over 4 weeks and offer an antipsychotic
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
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
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
3%
Risk percenrage for agranulocytosis in clozapine use
1%
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
