mental health update Flashcards
what are the different types of antipsychotic medication?
typicals and atypicals
what are the characteristics of atypical antipsychotic medication?
metabolic effects
anticholinergic
QT prolongation
lowered seizure threshold
antiadrenergic
NMS
sedation
what are the characteristics of typicals antipsychotic medication?
EPSE
anticholinergic
QT prolongation
lower seizure threshold
antiadrenergic
NMS
sedation
what should you monitor before initiating therapy?
- Weight
- Waist circumference
- Pulse and BP
- Fasting blood glucose, glycosylated haemoglobin
- Blood lipid profile
- Prolactin levels
- Movement disorders
- Nutritional status, diet and level of physical activity
- ECG
what should you monitor during antipsychotic therapy?
- Response to treatment,
changes in symptoms and
behaviour - Side effects of treatment
- Weight
- Adherence
- Overall physical health
– Cardiovascular
what is GASS?
The Glasgow Antipsychotic Side-effect Scale
(GASS) is an easy to use self-reporting
questionnaire aimed at identifying the side
effects of antipsychotic medication. It consists
of 22 questions with points assigned based on
answers given by the patient.
what is NMS?
Neuroleptic malignant syndrome is a life-threatening, neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs. Symptoms include:
High fever
Sweating
Unstable blood pressure
Stupor
Muscular rigidity
Autonomic dysfunction
when does NMS usually develop?
In most cases, the disorder develops within the first two weeks of treatment with the drug; however, the disorder may develop at any time during the therapy period. The syndrome can also occur in people taking anti-Parkinsonism drugs
when is clozapine given?
Schizophrenia in patients unresponsive to, or
intolerant of, conventional antipsychotic drugs
when must clozapine be re-titrated?
If a patient misses 48 hours or more of
clozapine doses the clozapine must be
discontinued and slowly re-titrated
what is a fatal risk of clozapine?
Potentially fatal risk of intestinal obstruction,
faecal impaction, and paralytic ileus
Neutropenia and potentially fatal
agranulocytosis reported
because of the toxicity surrounding clozapine- what should be monitored?
blood concentration of clozapine for toxicity in certain clinical situations such as when:
* a patient stops smoking or switches to an e-cigarette;
* concomitant medicines may interact to increase blood clozapine levels;
* a patient has pneumonia or other serious infection;
* reduced clozapine metabolism is suspected;
* toxicity is suspected.
Clozapine blood concentration monitoring should be carried out in addition to
the required blood tests to manage the risk of agranulocytosis
what are the key adverse effects of SSRIs?
insomnia/ anxiety/ agitation
GI bleed
sexual dysfunction
serotonin syndrome
suicidal thoughts
‘FINISH’ withdrawl
physiological symptoms
what are the key adverse effects of antidepressants?
anti-histamine
anti-andrergic
anti-cholinergic
cardiac
what are the key adverse effects of MAOIs?
hypertensive crisis
postural hypotension
anti-cholinergic
serotonin syndrome
hepatoxicity (phenelzine)
weight gain
what does FINISH mean?
FINISH: remembering the discontinuation
syndrome. Flu-like symptoms, Insomnia,
Nausea, Imbalance, Sensory disturbances, and
Hyperarousal (anxiety/agitation)
what are the key adverse effects of venlafaxine?
cardiac effects
blood dyscrasias/ bleed risk
SIADH
suicidal behaviour
withdrawal syndrome
what are the key adverse effects with reboxetine?
cardiac effects
hyponatraemia
hypokalaemia on prolonged Tx
suicidal behaviour
urinary retention
impaired vision (caution in glaucoma)
what are the key adverse effects of moclobemide?
lower risk of hypertensive crisis
troublesome interactions
hyponatraemia
what are the key adverse effects of mirtazipine?
not many anti-muscarinic effects
sedating
BLOOD DISORDERS
withdrawal syndrome
weight gail
psychotic symptoms
what are the common adverse effects of antidepressants (general)?
- Potential for an initial increase in agitation,
anxiety on starting tx - Hyponatraemia (see next slide)
- Sexual dysfunction
- Withdrawal effects
- Bleeding risk
what antidepressants can cause hyponatraemia?
Most antidepressants can cause but SSRIs are highest risk
* More common in elderly
what are the symptoms of hyponatraemia?
dizziness, drowsiness, confusion, nausea, muscle cramps, or seizures
when does hyponatraemia with antidepressants usually occur?
normally within 30 days of starting
what should you do if hyponatraemia with antidepressants occurs?
If identified stop antidepressant & sodium levels should normalise within 1-2 weeks
* Urgent care if severe (Na < 125mmol/L)
* Withdrawal symptoms may occur (less likely at beginning of treatment)
* Once sodium normalised, choose different antidepressant (try different class)
why do SSRIs/ SNRIS cause a bleed risk?
By reducing the uptake of serotonin by platelets, SSRIs reduce the ability of platelets to aggregate and thereby increase the risk of
haemorrhage, particularly gastrointestinal bleeding
what factors increase the risk of bleeding with SSRIs/ SNRIs?
– Elderly
– Patients with a history of peptic ulcers
– Excessive use of alcohol
– Co-administration with other drugs associated with the risk of bleeding
* NSAIDs, antiplatelet drugs, corticosteroids, and warfarin
what are the risk reduction measures that can be done reduce SSRI bleed risk?
– Avoid SSRIs/ SNRIs if possible if at increased risk
– Avoid concomitant drugs which increase bleeding risk
– If no suitable alternative can be found, consider gastroprotection
– NICE suggests gastroprotection in older people who are taking NSAID/aspirin
what are some cautions and contraindications with antidepressants?
– Antidepressants can cause QT prolongation, risk varies with each antidepressant
– Thorough medical history, laboratory monitoring, and a baseline electrocardiogram (ECG) necessary to identify patients at risk for QT prolongation before starting an antidepressant that may prolong QT
interval.
what are some risk factors that can prolong QT interval?
cardiac conditions- bradycardia, MI, HF
electrolyte disturbances- hypokalemia, hypomg, hypocalcemia
female
genetic predispositions
65+
congenital long QT syndrome
what drug safety update is associated with citalopram and escitalopram? when should you avoid it?
dose-dependent QT interval
prolongation. Avoid use in;
– congenital long QT syndrome
– known pre-existing QT interval prolongation
– or in combination with other medicines that prolong the QT interval
what should be done prior to starting citalopram and escitalopram?
ECG measurements for patients with cardiac disease
* Electrolyte disturbances should be corrected before starting treatment
what are the max doses for citalopram and escitalopram?
Citalopram maximum daily dose:
– 40 mg for adults
– 20 mg for patients older than 65 years
– 20 mg for those with hepatic impairment
* Escitalopram maximum daily dose:
– older than 65 years is now reduced to 10 mg/day
when are further dose reductions required for citalopram/escitalopram?
- Further dose reductions in the first two weeks of treatment is recommended in patients with mild or moderate hepatic impairment or in poor metabolisers of CYP2C19
- Remember importance of drug interactions
- Take care with patients prescribed CYP2C19
inhibitors - for example omeprazole (NICE 2011
recommend gastroprotection with SSRI in patients at risk of bleeding disorder)
what is a person at increased risk of with antidepressants> TCAs and SSRIs?
fracture risk- use of TCAs and SSRIs
when is someone at risk of postpartum haemorrhage?
SSRI/SNRI antidepressant
medicines: small increased risk of postpartum
haemorrhage when used in the month before
delivery (January 2021)
what are the symptoms of serotonin syndrome?
Characterized by altered mental status, neuromuscular hyperactivity, and
autonomic instability
Symptoms include agitation, confusion, delirium, and hallucinations
profound shivering, tremor, teeth grinding, myoclonus, and hyperreflexia
– Tachycardia, fever, and hypertension or hypotension
– Flushing, diarrhoea, and vomiting are also common
what increases the risk of serotonin syndrome?
Concomitant use of antidepressants with other serotonergic drugs (tramadol, triptans) or dopaminergic drugs (selegiline) can increase the risk
when do you have to consider safety in overdose with antidepressants?
Tricyclic antidepressants (TCAs) and venlafaxine very harmful in cases of overdose
how should you withdraw antidepressants?
- When stopping an antidepressant, gradually
reduce the dose, normally over a 4-week
period, although some people may require
longer periods, particularly with drugs with a
shorter half-life (such as paroxetine and
venlafaxine). - This is not required with fluoxetine because of
its long half-life
