Meds_guidlines_4 Flashcards
In a schizo patient who’s suspected to to be compliant with oral antipsychotics…what is next
I.M antipsychotic
Investigation in suspect clozapin induced myocardial infarction
Troponin
name one One medication that used in patients on clozapine to reduce siezure chances?
Valproate
Normal serum level for quetiapine
50-500 μg/L
Normal serum level for clozapine
350-600 μg/L
Normal serum level for Lithium
0.6-1.1 mg /L
> .9 mg/L is safe
Normal serum level for valproate
50-100 mg/L
Which one is more strongly assoiated with suicidality decline?
1_Arip
2_QUE
3_Olan
4_Risp
5_Clozapime
Clozapine
Percetage of treatment resistent patients (30%) that is thought to respond to clozapine
60%
Which patient require lower clozapine dose?
Females
patients on flouxetine
A treatment that in combination with another antipsychotic is suggested when clozapine failed to work?
Allopuridone (modulate glutamatergics)
example: olan and allopuridon
What medication is thought to increase white cells in neutropenia?
Lithium
If serum clozapine is as high as 1.1 mg/L, and patient is still stable… what would you be concerned about and what would you do?
siezure
1-Stop clozapine for 1 day —-immideate reduces the siezure risk
2- Restart at half of previous dose —still effective at this dose most likely
3- Add sodium valproate to prevent siezure
What would you do if amber appeared on clozapine patient monitoring system (CPMS)?
Continue same dose and re send for test in 2 days, the continue 2wice weekly until returns to normal range
Fatality due to clozapine induced agranulocytosis?
1 in 10k
Estimated rate of agranulocutosis in clozapine therapy
1%
drug that if given to a patient with clozapine induced neutropenia may benefit by increase the white cells
Mr. Lithium
Is hypersalivation caused by clozapine life threatening?
Yes
Not allowed to be given inpatients on clozapine
Carbamazepine
Drug used to treat hypersalivation
hyocine hydrobromide
Receptors involved with clozapine induced hypersalivation
Muscarinic and adrenergic
Best evidence based suggestion for a prophylactic agent to prevent postoperative delirium
Haloperidol
Pharamacologialtreatment for delirium
Haloperidol (1st line in reducing aggitation and aggression) [NICE]
most likely to cause delirium in elderly?
pethidine
which TCAs carry least risk for delirium in ssri resistent depressed elderly with cognitive impairment due to their anticholinergic effects?
Nortriptyline
Desipramine
An antihistamine available over the counter that can cause delirium in elderly
Diphenhydramine
Drug licenced to be used in behavioural problem associated with dementia (Alzheimer’s)
Risperidone
Rx of choice for a 65 y o with moderate cognitive impairment with cerebral and white matter atrophy on CT!
donepezil (AchE-I)
Drugs most effective to treate lewy body psychosis (hallucinations)
Clozapine
Quetiapine (alternative)
Least suitable treatment for behavioural problems in dementia
Lorazepam
Max dose licensed for risperidone in dementia related behavioural problems
1 mg BD (BNF)
2nd line of treatment for dementia with lewy body
memantine
1st line treatment for dementia with lewy body
AChE-I
What is next for an alzheimer patient whose donepezil was increased and developed urinary incontinence?
Reduce the dose and continue
When Memantine is indicated for alzheimer’s
Severe cases amd moderates who don’t tolerate ache-I.
A medication recommended by NICE for SSRI ressistant PTSD
venlafaxine
activated charcoal is unlike to be helpful with overdose of
Lithium
Iron
Alcohol
What is a evidence based augmentation suggestion for depression in a patient who has not responded properly to a SSRI trials
Add Lithium but monitor for toxicity esp. in elderly
NICE recommend what for 1st line of treatment in severe depression
SSRI Alone
How long antidepressants should be continued at least after remission?
6 monthsp
Which SSRI is associated with higher risk of withdrawal syndrome
Paroxetine
Maudsley supports what combinations in treatment resistant depression?
Venlafaxine and Mirtazapine
When should you reveiw a non suicidal patient (above 25) who you put on antidepressants, according to NICE?
in 2 weeks
When should you reveiw a patient (below 25) who you put on antidepressants, according to NICE?
1 week
Least like TCI to be assoiated with overdose?
Lofepramine
1st line antidepressant in patient with co-morbid physical health issues, accordint to NICE
CITALOPRAM (CYP3A4 AND CYP2C19)
best antidepressant for patients on NSAIDS
Mirtazapine—-less increase in serotonin level in blood—»> less chance of GI bleeding associated with combination of SSRI AND NSAIDS
How fluvoxamine can increase clozapine
By inhibiting CYP1A2 which is crucial in metabolism of clozapine
How can fuvoxamine induced increase in clozapine level can manifest in patients?
Sedation
confusion
flu like symptom (fever + sore throat)
excessive salivation
tachycardia
Antidepressant that is safe to be used with warfarin
Reboxetine
In refractory depression what medication is recommended by NICE?
Vortioxetine
Whatbis so special about vortioxetine?
It is called serotonin modulator and stimulator due to its effect not only as reuptake inhibitor but also modulating 5-HT receptors (agonist at 5-HT1A, Antagonist at 5-HT3,5-HT7, 5-HT1D).
as a result it has anxiolytic and cognitive improving effects.
What associations were found in Clozapine users regarding cytochrome P450 activity?
Reduced cytochrome P450, 2C19, and 1A2 activity is associated with a higher risk of pneumonia
This suggests a potential link between metabolic activity and pneumonia risk in patients taking Clozapine.
Why is it important to monitor Clozapine levels in patients with fever or pulmonary symptoms?
Inflammatory cytokines block 1A2 and increase clozapine levels
Elevated clozapine levels can lead to adverse effects and complications.
What intervention may be critical for acutely ill patients admitted to a medical hospital taking Clozapine?
Reducing the clozapine level
This helps avoid very high clozapine levels and reduces pneumonia lethality.
True or False: Increased activity of cytochrome P450, 2C19, and 1A2 is linked to a lower risk of pneumonia in Clozapine users.
False
Reduced activity is associated with a higher risk of pneumonia.
Fill in the blank: Inflammatory cytokines block _______ and increase clozapine levels.
1A2
This mechanism contributes to the management of clozapine in patients with pulmonary symptoms.
