NERVOUS SYSTEM- ADHD + BIPOLAR DISORDER, DEPRESSION Flashcards
1
Q
What is ADHD?
A
Affects behaviour + daily function
2
Q
What are the 6 symptoms of inattention?
A
Short attention span
Easily distracted
careless mistakes
Forgetful / losing things
Cant stick to tedious tasks
Difficulty organising things
3
Q
What are the 9 symptoms of hyper activeness+ impulsive behaviour?
A
can’t sit still
Act without thinking
Constantly fidgeting
Excessive physical movement
Excessive talking
Interrupting conversations
Being unable to wait their turn
Little/no sense of danger
Unable to concentrate
4
Q
What is 1st line drug treatment for ADHD in children aged 6 and over?
A
Methylphenidate OR
Lisdexamfetamine
5
Q
What to do if Methylphenidate NOT tolerated after 6 weeks?
A
Give Lisdexamfetamine
6
Q
What ADHD medication has a longer duration of side effects?
A
Lisdexamfetamine
7
Q
What is an alternative to methylphenidate/lisdexamfetamine which is a non-stimulant?
A
Atomoxetine or Guanfacine
8
Q
What are 4 common SEs of Atomoxetine?
A
Sexual dysfunction
QT prolongation
Hepatotoxicity
Suicidal ideation
9
Q
Why are MR ADHD meds prescribed?
A
prescribed by brand only.
Because better profile, less SE, adherence better.
10
Q
What is MAX dose of Atomoxetine which is unlicensed?
A
Dose maximum of 120 mg not licensed.
11
Q
When can atomoxetine be considered for ADHD?
A
Those intolerant to both methylphenidate hydrochloride + lisdexamfetamine mesilate.
OR
if have NOT responded to separate 6-week trials of both drugs.
12
Q
What is non-drug treatment for ADHD?
A
Changing physical environment.
CBT
13
Q
What is lisdexamfetamine?
A
Prodrug of Dexamfetamine
14
Q
When is Dexamfetamine used in ADHD?
A
If patient is having a beneficial response to lisdexamfetamine but CANNOT tolerate its longer duration of effect.
15
Q
What class are lisdexamfetamine + Dexamfetamine+ methylphenidate?
A
CNS stimulants
16
Q
What is MOA of methylphenidate + amphetamines?
A
Potent CNS stimulant, increase dopamine levels
17
Q
What are 8 SEs of ADHD drugs (CNS stimulants)?
A
High BP, Tachycardia, Arrhythmia
Behaviour/ mood changes
Insomnia
Growth retardation + weight loss
Reduced appetite.
18
Q
What drug schedule is methylphenidate + amfentamines in?
A
CD schedule 2
19
Q
What is 1st line use of Methylphenidate?
A
ADHD
20
Q
What is a 2022 MHRA warning of Methylphenidate modified release?
A
Caution if switching between products due to differences in formulations
21
Q
Why should we be careful when switching from MR to normal for methylphenidate?
A
Differences in dosing frequency, administration with food
22
Q
What is total daily dose equivalence between methylphenidate normal + MR formulations?
A
Total daily dose of 15 mg of standard-release formulation = equivalent to Delmosart® 18 mg OD
23
Q
What are 7 SE of Methylphenidate? (SAWPIT-G)
A
Seretonin syndrome
Appetite (low)
Weight (low)
Psychiatric disorder
Insomnia
Tics/ tourettes
Growth (low)
24
Q
What dose of Concerta XL is not licensed for use in ADHD?
A
Doses of Concerta® XL over 54 mg daily not licensed.
25
What SE is specific for methylphenidate MR formulations?
Dysphagia
26
What 3 things should be monitored in a patient taking ADHD meds?
Weight, Height (measured up to 18 years), BP/ pulse- every 6 MONTHLY
Monitor for psychiatric disorders at initiation
27
What is max dose of lisdexamfetamine in severe renal impairmnent?
Max. dose 50 mg daily.
28
What specific thing to monitor in patients being started on lisdexamfetamine?
Monitor for aggressive behaviour or hostility during initial treatment.
29
What are 3 contraindications for ADHD meds?
Patients with CVD, severe HTN, hyperthyroidism
30
What drug classes interact with amfetamines to increase serotonin syndrome?
Antidepressants (TCA, SSRI, MAOI)
Lithium
Methadone
St John's wort
Tramadol
5HT1 agonists - sumatriptans.
5HT3 antagonists - Ondansetron
31
What do serotonergic drugs means?
Drugs which increase serotonin / act on 5HT receptors.
32
Interaction between serotonergic drugs + amfetamines causes increase in ----
Serotonin syndrome
33
What do amfetamines do to the heart?
Increases BP + causes tachycardia
34
Max dose of Lisdexamfetamine mesilate?
70mg per day
35
Describe the 2 step process of amfetamine overdose?
Wakefulness, paranoia, hypertension, hallucination
Then drops to exhaustion, convulsions, hyperthermia + coma
36
What is bipolar disorder?
Extreme mood swings that lasts several weeks/ months
37
What are 9 symptoms of mania?
High energy
Overly ambitious plans
Risky/Harmful acts
Talking very quickly
Easily distracted, irritated
Not eating/ sleeping
Self-importance
Hallucinations, delusions
Out-of- character
38
What are negative symptoms of Bipolar disorder?
Depression / low mood
39
What are 3 drug treatment options for acute episodes + maintenance of bipolar disorder?
1. Benzos
2. Anti-psychotics (haloperidol, quetiapine, Olanzapine, risperidone)
3.lithium
4.valproate
40
What drug class cannot be given in acute episodes of bipolar disorder?
Anti-depressants
41
What 2 anti-psychotics are ONY given in acute episodes of BP disorder?
Quetiapine
Risperidone
42
What is MOA of lithium?
Not understood
43
What is indication of lithium?
Bipolar disorder
Recurrent depression, agressive/self harm
44
What is therapeutic index for lithium for maintenance therapy and elderly?
0.4-1mmol/L
45
How do we do therapeutic drug monitoring for lithium?
Check plasma concentration 12 hrs after dose.
Weekly bloods until stable.
3monthly for 1 year.
Regular monitoring 3 to 6 months.
46
How often do we monitor lithium levels once stable?
3 to 6 months
47
What are 5 signs of lithium toxicity? (GREEN)
Gastro effect - vomit + diarrhoea
Renal effect. e.g. Polyuria + hypernatremia
Eyes- blurred vision
Extrapyramidal symptoms e.g. tremor
Nervous system e.g. confusion, drowsy
48
How to describe lithium toxicity?
SICK + TREMOR
49
What 2 renal effects are seen in lithium toxicity?
Polyuria
Hypernatremia
50
How is lithium prescribed?
Prescribed via brand e.g. priadel
51
What are 5 contraindications for using lithium?
Patients on low sodium diet
Dehydration
Untreated hypothyroidism
Addison’s disease
Cardiac disease
52
What 2 counselling points to tell patients who are on lithium?
Avoid diet changes that affect sodium.
Stay hydrated.
53
What is a risk of lithium use?
Renal impairment caused by low sodium and low fluids
54
What are 6 SEs of lithium use?
Hypothyroidism
Nephrotoxicity
QT prolongation
Benign intracranial Hypertension
Lowers seizure threshold
Rhabdomyolysis
55
What is the risk of giving lithium to patients with epilepsy?
Lithium lowers seizure threshold
56
What 4 things to monitor in patient taking lithium?
Lithium levels.
TFTs- hypothyroidism
Calcium levels
Renal profile (egfr, electrolytes) - nephrotoxic
57
What are 2 symptoms of hypothyroidism?
weight gain
cold intolerance
58
What to monitor if patient at risk of QT prolongation?
Cardiac function, ECG if CVD risk factors
59
Can lithium be used in pregnancy?
NO- Avoid if possible, particularly in the first trimester (cardiac abnormalities)
60
What is target lithium concentration in acute episodes of mania?
0.8–1 mmol/L
61
How to counsel patients on lithium regarding side effect, benign intracranial hypertension?
Ask patient to report persistent headaches + if visual disturbances
62
What 2 drug classes increase lithium toxicity?
Diuretics
Nephrotoxic drugs- ARB/ACEi, NSAIDs
63
What OTC meds reduce lithium concentration?
Effervescent analgesics e.g. paracetamol, na+ antacids
64
What 7 drug classes interact with lithium to increase serotonin syndrome?
Antidepressants (TCA, SSRI, MAOI)
Lithium
Methadone
St John's wort
Tramadol
5HT1 agonists - sumatriptans.
5HT3 antagonists - Ondansetron
65
What 2 things lead to lithium overdose?
HypOnatraemia
Reduced renal excretion
66
What 2 drug classes can interact with lithium and cause neurotoxicity?
Anti-psychotic
TCA antidepressants
67
What drug classes can interact with lithium and cause QT prolongation + Arrhythmiad?
Antipsychotic, anti-arrhythmic drugs e.g. sotalol, SSRIs, Clomipramine (TCA), Macrolides, quinolone, Ondansetron, methadone, domperidone, Hydroxyzine
B- agonists-e.g. salbutamol, diuretics, theophyline, corticosteroids
68
What dangerous CVD condition can hypokalaemia lead to?
Torsade de pointes
69
What is depression?
Low mood that lasts for weeks or months + affects daily life.
70
What are 10 symptoms of depression?
Low mood
Helpless
Pessimistic
Low self-esteem
Suicidal thoughts
Apathy
Worry + anxiety
Memory loss/ poor concentration
Guilt, dispair
Irritability
Poor decision- making
71
What are 5 physical symptoms of depression?
Fatigue
Weight/ appetite gain or loss
Insomnia
Excessive sleeping
Low sex drive
72
What is 1st line treatment for moderate- severe depression?
SSRI + CBT
73
What is 2nd line treatment for moderate- severe depression?
Increase SSRI dose, try different SSRI
OR
Add in Mirtazapine (TeCA)
74
When is MAOI used in depression?
when initiated by specialist
75
When is TCA or venlafaxine used in depression?
If severe depression
76
What is an option for severe depression + rapid response?
Electroconvulsive therapy
77
How long is treatment continued for depression ?
6 months
78
How long is drug treatment continued for depression if in remission in elderly patients?
1 year
79
How long is drug treatment continued for recurrent depression?
2 years
80
What are some risk factors of depression?
FHx of depressive illness, Hx of other mental health conditions, chronic co-morbidities, female, recent childbirth, older age, + psychosocial issues (poverty)
81
How are patients diagnosed with depression?
patient has been classed as having chronic depression symptoms for the past 2 years, OR persistent low mood, OR persistent sub-threshold symptoms OR continually meet criteria for major depressive episode
82
What should patients being initiated on treatment be monitored for in depression?
suicidal ideation or behavioural symptoms
83
When should patients be reviewed after starting medication for depression?
2 to 4 weeks after initiation.
Patients on antidepressants should usually be reviewed within 2 weeks of initiation.
84
Which 2 patient groups are reviewed 1 week after starting treatment for depression?
Patients at risk of suicide OR those aged 18-25 years
85
When should those at risk of suicide OR those are aged 18 to 25 years be reviewed after starting anti-depressants?
should be reviewed 1 week after starting treatment
86
When are anti-depressant effects usually seen?
within 4 weeks of initiation
87
When are anti-depressant effects usually seen in elderly?
Within 6 weeks of treatment before deemed ineffective
88
Why should patients not suddenly stop their anti-depressants?
Withdrawal symptoms can arise
89
Give 2 examples of SNRIs?
Duloxetine
Venlafaxine
90
What is 1 thing that needs to be monitored in SNRIs?
BP
91
What are the 4 main drug classes used as anti-depressants?
MAOI
TCA
SSRIs
Tricyclic related anti-depressants
92
What 2 parts are MAOI drugs divided into?
Irreversible
Reversible
93
List 3 irreversible MAOI?
Phenelzine
Isocarboxazid
Tranylcypromine
94
What is a common risk for Phenelzine +
Isocarboxazid ?
Increased risk of hepatotoxicity
95
List 1 reversible MAOI?
Moclobemide
96
What is a risk of Tranylcypromine?
Increased risk of hypertensive crisis
97
When to stop using Tranylcypromine?
Discontinue if palpitations or frequent headaches occur.
98
What is a short acting reversible MAOI?
Moclobemide
99
List 6 SSRIs?
Citalopram
Escitalopram
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
100
What 2 SSRIs can cause QT prolongation?
Citalopram
Escitalopram
101
What SSRI is recommended to be used in children for depression?
Fluoxetine
102
What SSRI is known to have increased withdrawal reactions?
Paroxetine
103
What SSRI is safe in MI + unstable angina?
Sertraline
104
Can MAOIs be used in pregnancy?
Avoid - can cause abnormalities
105
List 8 TCA drugs?
Amitriptyline
Clomipramine
Doselupin
Doxepin
Imipramine
Lofepramine
Nortriptylline
Trimipramine
106
What 2 TCAs are also used for neuropathic pain?
Amitriptyline
Nortriptylline
107
Which TCA is the safest TCA?
Loferpramine
108
Which TCA is dangerous as there is increased risk of fatality?
Doselupin
109
Which TCA has increased antimuscarinic affects?
Impramine
110
What are 2 tricyclic related anti-depressants?
Mianserin
Mirtazapine
111
Which anti-depressant is good if patient has bleeding disorders?
Mirtazapine
112
Which 3 TCAS are less sedating? (LIN)
Lofepramine
Imipramine
Nortriptylline
113
Which class of antidepressant is more dangerous as leads to overdose?
TCA
114
What class of drug is Duloxetine?
SNRI
115
What other indication is Duloxetine also used for?
Diabetic neuropathy
116
What SNRI has increased withdrawal reaction?
Venlafaxine
117
What is a risk of using Agomelatine for depression?
Hepatotoxicity
118
What is an OTC product used in depression but not useful?
St John's Wort
119
What antidepressant drug may be considered as a treatment option for patients with limited/ NO response to at least 2 antidepressant drugs?
Vortioxetine
120
What is Trazodone?
Serotonin uptake inhibitor
121
What are 4 SEs of anti-depressants?
Drowsiness - e.g. No driving
Suicidal ideation/ behaviour
HypOnatraemia (e.g. SSRIs)
Withdrawal
122
What electrolyte related SE is common in SSRIs?
HypOnatraemia
123
What 2 antidepressants are at higher risk of withdrawal reactions?
Paroxetine
Venlafaxine
124
What to do when switching anti-depressants?
Wash out period to avoid serotonin syndrome
125
Why is there a wash out period between changing anti-depressants?
to avoid serotonin syndrome
126
What MAOI does not need a washout period?
Moclobemide (0 weeks needed for this drug to switch to another)
127
How long is washout period for MAOI?
2 weeks
128
How long is washout period for SSRIs?
1 week
129
What SSRI requires a longer washout period of 2 weeks?
Sertraline
130
What SSRI requires a longer washout period of 5 weeks?
Fluoxetine
131
How long is washout period for TCA?
1-2 weeks
132
What 2 TCAs have a longer washout perioid of 3 weeks?
Clomipramine
Imipramine
133
What 3 symptoms make up serotonin syndrome?
1. Neuromuscular hyperactivity (e.g. tremor, myoclonus, muscle rigidity)
2. Altered mental state
3. Autonomic dysfunction
134
Describe 3 symptoms for Neuromuscular hyperactivity (serotonin syndrome)?
tremor, myoclonus, muscle rigidity
135
Describe 3 symptoms for Altered mental state (serotonin syndrome)?
Confusion
agitation
mania
136
Describe 7 symptoms for Autonomic dysfunction (serotonin syndrome)?
Tachycardia
labile bp (changes)
Urination
Hyperthermia
Diarrhoea
Pallor
Shiver or sweat
137
What is MOA of SSRI?
Selectively block re-uptake of 5-HT
Causes increase in serotonin
138
What is indication of SSRI?
1st line Depression + Anxiety
139
What are 7 main SEs of SSRIs? (sighsqa)
Serotonin syndrome + sexual dysfunction
Increased bleeding risk
Gastro intestinal - N,V + D
Hypersensitivity/ Hyponatraemia. e.g. rash
Seizure threshold reduced
QT prolongation
Appetite (gain)
140
When is a better time to take SSRIs + why?
Morning as can cause insomnia
141
What are 3 cautions of SSRIs?
Patient with Hx of GI bleeding, Epilepsy, CVD.
142
Interaction between grapefruit juice + SSRIs?
Increases levels of SSRI (as enzyme inhibitor)
143
What is maximum dose of sertraline per day?
200mg per day
144
Interaction between SSRIs + TCA/MAOI?
Hyponatraemia
145
What 5 drugs can interact with SSRIs to cause hyponatraemia?
Anti-depressants, Carbamazepine, desmopressin, diuretics, NSAIDs
146
What does alcohol + SSRI do?
Can increase bleeding risk.
147
What 6 drugs can interact with SSRI + cause bleeding risk?
Alcohol
Anticoagulants
Corticosteroids
NSAIDs
Venlafaxine
148
What 6 drugs/classes interact with SSRIs to cause serotonin syndrome?
Antidepressants, lithium, St john's wort, tramadol, sumatriptan, ondansetron
149
What drug classes can interact with SSRIs to cause QT prolongation?
B agonists (causing hypokalaemia = Torsade)
Antipsychotics, Anti-arrhythmic drugs, TCA, Macrolide, Domperidone, lithium , methadone
150
What is MOA of TCA?
Blood re-uptake of 5 HT + NA from synapse - increases these levels
151
When is TCA usually taken?
At night- sedating
152
What is indication of TCA?
Depression , anxiety
153
What are 4 main SE of TCAs?
TCAs are more toxic
Cardiac effect
Anti-muscarinic effect
Seizures
154
Why are TCAS more dangerous?
Sedating + higher risk of toxicity in overdose
155
What are 7 cautions of using TCAs?
Suicide risk, CVD, QT prolongation, Hyperthyroidism, urinary retention, enlarged prostate, constipation, closed- angle glaucoma, epilepsy
156
What is a caution related to TCA clomipramine?
QT prolongation
157
What are 4 anti-muscarinic effects to be aware of in TCAs?
Constipation, enlarged prostate, urinary retention, close- angle glaucoma
158
In what condition should TCA treatment be stopped?
Treatment should be stopped if the patient enters a manic phase.
159
Can SSRIs be used in pregnany?
Maybe- risks and benefits of use must be considered
160
What is a MHRA warning related to use of SSRI/SNRI + pregnancy?
small increased risk of postpartum haemorrhage when used in the month before delivery.
161
What are 2 contra-indications of SSRIs?
Should NOT be used in poorly controlled epilepsy.
SSRIs should not be used if the patient enters a manic phase
162
Which type of patients are less sedating TCAs good for?
Withdrawn + apathetic
163
What is max dose of amitriptyline for Neuropathic pain/migraine?
75mg a day
164
What is max dose of amitriptyline for Major depressive disorder if needed to be used?
150mg daily - 2 divided doses
165
What 5 drug classes can interact with TCA + cause hypOnatraemia?
Anti-depressants,
Carbamazepine
Desmopressin
Diuretics
NSAIDs
166
What 3 drugs can interact with TCA to increase anti-muscarininc effects?
Anti-histamines
Antimuscarinic (hyoscine)
Antipsychotics
167
What 7 drugs can interact with TCA to increase CNS depressant effects?
alcohol
Sedating anti-histamines,
Antipsychotics
Benzos
Z drugs
Opioids
Barbiturate
168
What 6 drug classes can interact with TCAs to cause hypotension?
Anti-hypertensives
Dopaminergic drugs
SGLT2 inhibitors
Diuretics
Nitrate
Phosphodiesterase type-5 inhibitor - sildenafil
169
List 4 more sedating TCA drugs? (CADT)
Clomipramine
Amitriptyline
Doselupin
Trazadone
170
What 2 TCAs are rarely used due to overdose issues?
Amitriptyline
Doselupin
171
interaction between Amitriptyline + Adrenaline/epinephrine?
TCA increases effect of adrenaline = avoid
172
Interaction between TCA + grapefruit juice?
increases TCA concentration - causes toxicity
173
What is MOA of MAOI?
Blocks Monoamine oxidase, causes build up in blood.
Increase in serotonin, dopamine + noradrenaline levels
174
What is an indication of MAOIs + how often used?
Depression - rarely used
175
What are 3 Main SE of MAOIs?
Hypertensive crisis
Hepatotoxicity
Postural hypotension
176
When to stop using MAOIs in postural hypotension?
Stop if patient has palpitations or frequent headaches
177
What are 2 cautions of MAOIs?
CVD,
Cerebrovascular disease
178
What are 2 contra-indications specific to tranylcypromine (MAOI)?
History of hepatic disease
hyperthyroidism
179
Interaction between TCAs + MAOIs?
SERIOUS- toxic reaction
Manufacturer advises avoid TCA and for 14 days after stopping the MAOI.
180
What is a food group that interacts severely with MAOIs + how to counsell?
Avoid tyramine rich/dopa rich foods up to 2 weeks of stopping.
Avoid alcohol
181
Why should patients avoid tyramine rich foods when taking MAOIs?
Can cause hypertensive crisis
182
Examples of tyramine rich/dopa rich foods?
Mature cheese, salami, pickled herring, Bovril®, Oxo®, Marmite® OR any similar meat or yeast extract, fermented soya bean extract, + some beers, lagers or wines
OR
Foods containing dopa (such as broad bean pods
183
What class of drugs can increase hypertensive crisis in patients taking MAOIs?
Ephedrine, phenylephrine, OTC Pseudoephedrine, Adrenaline, amfetamines, B2 agonists (Sympathomimetics)
184
What OTC med interacts with MAOIs + what does it cause?
Pseudoephedrine - hypertensive crisis
185
What 9 drugs interact with MOAIs to cause serotonin syndrome?
Anti-depressants, amfetamines, lithium, Methadone, MAO-B inhibitors, St john's wort, Tramadol, sumatriptan, Ondansetron
186
What TCA can NEVER be given with MAOIs?
Clomipramine
