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PRE-REG-Thuri > NERVOUS SYSTEM- ADHD + BIPOLAR DISORDER, DEPRESSION > Flashcards

NERVOUS SYSTEM- ADHD + BIPOLAR DISORDER, DEPRESSION Flashcards

1
Q

What is ADHD?

A

Affects behaviour + daily function

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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

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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

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4
Q

What is 1st line drug treatment for ADHD in children aged 6 and over?

A

Methylphenidate OR

Lisdexamfetamine

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5
Q

What to do if Methylphenidate NOT tolerated after 6 weeks?

A

Give Lisdexamfetamine

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6
Q

What ADHD medication has a longer duration of side effects?

A

Lisdexamfetamine

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7
Q

What is an alternative to methylphenidate/lisdexamfetamine which is a non-stimulant?

A

Atomoxetine or Guanfacine

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8
Q

What are 4 common SEs of Atomoxetine?

A

Sexual dysfunction

QT prolongation

Hepatotoxicity

Suicidal ideation

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9
Q

Why are MR ADHD meds prescribed?

A

prescribed by brand only.

Because better profile, less SE, adherence better.

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10
Q

What is MAX dose of Atomoxetine which is unlicensed?

A

Dose maximum of 120 mg not licensed.

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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.

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12
Q

What is non-drug treatment for ADHD?

A

Changing physical environment.

CBT

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13
Q

What is lisdexamfetamine?

A

Prodrug of Dexamfetamine

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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.

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15
Q

What class are lisdexamfetamine + Dexamfetamine+ methylphenidate?

A

CNS stimulants

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16
Q

What is MOA of methylphenidate + amphetamines?

A

Potent CNS stimulant, increase dopamine levels

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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.

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18
Q

What drug schedule is methylphenidate + amfentamines in?

A

CD schedule 2

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19
Q

What is 1st line use of Methylphenidate?

A

ADHD

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20
Q

What is a 2022 MHRA warning of Methylphenidate modified release?

A

Caution if switching between products due to differences in formulations

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21
Q

Why should we be careful when switching from MR to normal for methylphenidate?

A

Differences in dosing frequency, administration with food

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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

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23
Q

What are 7 SE of Methylphenidate? (SAWPIT-G)

A

Seretonin syndrome
Appetite (low)
Weight (low)
Psychiatric disorder
Insomnia
Tics/ tourettes

Growth (low)

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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.

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25
Q

What SE is specific for methylphenidate MR formulations?

A

Dysphagia

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26
Q

What 3 things should be monitored in a patient taking ADHD meds?

A

Weight, Height (measured up to 18 years), BP/ pulse- every 6 MONTHLY

Monitor for psychiatric disorders at initiation

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27
Q

What is max dose of lisdexamfetamine in severe renal impairmnent?

A

Max. dose 50 mg daily.

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28
Q

What specific thing to monitor in patients being started on lisdexamfetamine?

A

Monitor for aggressive behaviour or hostility during initial treatment.

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29
Q

What are 3 contraindications for ADHD meds?

A

Patients with CVD, severe HTN, hyperthyroidism

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30
Q

What drug classes interact with amfetamines to increase serotonin syndrome?

A

Antidepressants (TCA, SSRI, MAOI)

Lithium

Methadone

St John’s wort

Tramadol

5HT1 agonists - sumatriptans.

5HT3 antagonists - Ondansetron

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31
Q

What do serotonergic drugs means?

A

Drugs which increase serotonin / act on 5HT receptors.

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32
Q

Interaction between serotonergic drugs + amfetamines causes increase in —-

A

Serotonin syndrome

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33
Q

What do amfetamines do to the heart?

A

Increases BP + causes tachycardia

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34
Q

Max dose of Lisdexamfetamine mesilate?

A

70mg per day

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35
Q

Describe the 2 step process of amfetamine overdose?

A

Wakefulness, paranoia, hypertension, hallucination

Then drops to exhaustion, convulsions, hyperthermia + coma

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36
Q

What is bipolar disorder?

A

Extreme mood swings that lasts several weeks/ months

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37
Q

What are 9 symptoms of mania?

A

High energy

Overly ambitious plans

Risky/Harmful acts

Talking very quickly

Easily distracted, irritated

Not eating/ sleeping

Self-importance

Hallucinations, delusions

Out-of- character

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38
Q

What are negative symptoms of Bipolar disorder?

A

Depression / low mood

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39
Q

What are 3 drug treatment options for acute episodes + maintenance of bipolar disorder?

A
  1. Benzos
  2. Anti-psychotics (haloperidol, quetiapine, Olanzapine, risperidone)
    3.lithium
    4.valproate
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40
Q

What drug class cannot be given in acute episodes of bipolar disorder?

A

Anti-depressants

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41
Q

What 2 anti-psychotics are ONY given in acute episodes of BP disorder?

A

Quetiapine

Risperidone

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42
Q

What is MOA of lithium?

A

Not understood

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43
Q

What is indication of lithium?

A

Bipolar disorder

Recurrent depression, agressive/self harm

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44
Q

What is therapeutic index for lithium for maintenance therapy and elderly?

A

0.4-1mmol/L

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45
Q

How do we do therapeutic drug monitoring for lithium?

A

Check plasma concentration 12 hrs after dose.

Weekly bloods until stable.

3monthly for 1 year.

Regular monitoring 3 to 6 months.

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46
Q

How often do we monitor lithium levels once stable?

A

3 to 6 months

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47
Q

What are 5 signs of lithium toxicity? (GREEN)

A

Gastro effect - vomit + diarrhoea

Renal effect. e.g. Polyuria + hypernatremia

Eyes- blurred vision

Extrapyramidal symptoms e.g. tremor

Nervous system e.g. confusion, drowsy

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48
Q

How to describe lithium toxicity?

A

SICK + TREMOR

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49
Q

What 2 renal effects are seen in lithium toxicity?

A

Polyuria

Hypernatremia

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50
Q

How is lithium prescribed?

A

Prescribed via brand e.g. priadel

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51
Q

What are 5 contraindications for using lithium?

A

Patients on low sodium diet

Dehydration

Untreated hypothyroidism

Addison’s disease

Cardiac disease

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52
Q

What 2 counselling points to tell patients who are on lithium?

A

Avoid diet changes that affect sodium.

Stay hydrated.

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53
Q

What is a risk of lithium use?

A

Renal impairment caused by low sodium and low fluids

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54
Q

What are 6 SEs of lithium use?

A

Hypothyroidism

Nephrotoxicity

QT prolongation

Benign intracranial Hypertension

Lowers seizure threshold

Rhabdomyolysis

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55
Q

What is the risk of giving lithium to patients with epilepsy?

A

Lithium lowers seizure threshold

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56
Q

What 4 things to monitor in patient taking lithium?

A

Lithium levels.

TFTs- hypothyroidism

Calcium levels

Renal profile (egfr, electrolytes) - nephrotoxic

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57
Q

What are 2 symptoms of hypothyroidism?

A

weight gain

cold intolerance

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58
Q

What to monitor if patient at risk of QT prolongation?

A

Cardiac function, ECG if CVD risk factors

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59
Q

Can lithium be used in pregnancy?

A

NO- Avoid if possible, particularly in the first trimester (cardiac abnormalities)

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60
Q

What is target lithium concentration in acute episodes of mania?

A

0.8–1 mmol/L

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61
Q

How to counsel patients on lithium regarding side effect, benign intracranial hypertension?

A

Ask patient to report persistent headaches + if visual disturbances

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62
Q

What 2 drug classes increase lithium toxicity?

A

Diuretics

Nephrotoxic drugs- ARB/ACEi, NSAIDs

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63
Q

What OTC meds reduce lithium concentration?

A

Effervescent analgesics e.g. paracetamol, na+ antacids

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64
Q

What 7 drug classes interact with lithium to increase serotonin syndrome?

A

Antidepressants (TCA, SSRI, MAOI)

Lithium

Methadone

St John’s wort

Tramadol

5HT1 agonists - sumatriptans.

5HT3 antagonists - Ondansetron

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65
Q

What 2 things lead to lithium overdose?

A

HypOnatraemia

Reduced renal excretion

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66
Q

What 2 drug classes can interact with lithium and cause neurotoxicity?

A

Anti-psychotic

TCA antidepressants

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67
Q

What drug classes can interact with lithium and cause QT prolongation + Arrhythmiad?

A

Antipsychotic, anti-arrhythmic drugs e.g. sotalol, SSRIs, Clomipramine (TCA), Macrolides, quinolone, Ondansetron, methadone, domperidone, Hydroxyzine

B- agonists-e.g. salbutamol, diuretics, theophyline, corticosteroids

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68
Q

What dangerous CVD condition can hypokalaemia lead to?

A

Torsade de pointes

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69
Q

What is depression?

A

Low mood that lasts for weeks or months + affects daily life.

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70
Q

What are 10 symptoms of depression?

A

Low mood

Helpless
Pessimistic

Low self-esteem

Suicidal thoughts

Apathy

Worry + anxiety

Memory loss/ poor concentration

Guilt, dispair

Irritability

Poor decision- making

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71
Q

What are 5 physical symptoms of depression?

A

Fatigue

Weight/ appetite gain or loss

Insomnia

Excessive sleeping

Low sex drive

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72
Q

What is 1st line treatment for moderate- severe depression?

A

SSRI + CBT

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73
Q

What is 2nd line treatment for moderate- severe depression?

A

Increase SSRI dose, try different SSRI

OR

Add in Mirtazapine (TeCA)

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74
Q

When is MAOI used in depression?

A

when initiated by specialist

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75
Q

When is TCA or venlafaxine used in depression?

A

If severe depression

76
Q

What is an option for severe depression + rapid response?

A

Electroconvulsive therapy

77
Q

How long is treatment continued for depression ?

78
Q

How long is drug treatment continued for depression if in remission in elderly patients?

79
Q

How long is drug treatment continued for recurrent depression?

80
Q

What are some risk factors of depression?

A

FHx of depressive illness, Hx of other mental health conditions, chronic co-morbidities, female, recent childbirth, older age, + psychosocial issues (poverty)

81
Q

How are patients diagnosed with depression?

A

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
Q

What should patients being initiated on treatment be monitored for in depression?

A

suicidal ideation or behavioural symptoms

83
Q

When should patients be reviewed after starting medication for depression?

A

2 to 4 weeks after initiation.

Patients on antidepressants should usually be reviewed within 2 weeks of initiation.

84
Q

Which 2 patient groups are reviewed 1 week after starting treatment for depression?

A

Patients at risk of suicide OR those aged 18-25 years

85
Q

When should those at risk of suicide OR those are aged 18 to 25 years be reviewed after starting anti-depressants?

A

should be reviewed 1 week after starting treatment

86
Q

When are anti-depressant effects usually seen?

A

within 4 weeks of initiation

87
Q

When are anti-depressant effects usually seen in elderly?

A

Within 6 weeks of treatment before deemed ineffective

88
Q

Why should patients not suddenly stop their anti-depressants?

A

Withdrawal symptoms can arise

89
Q

Give 2 examples of SNRIs?

A

Duloxetine

Venlafaxine

90
Q

What is 1 thing that needs to be monitored in SNRIs?

91
Q

What are the 4 main drug classes used as anti-depressants?

A

MAOI

TCA

SSRIs

Tricyclic related anti-depressants

92
Q

What 2 parts are MAOI drugs divided into?

A

Irreversible

Reversible

93
Q

List 3 irreversible MAOI?

A

Phenelzine

Isocarboxazid

Tranylcypromine

94
Q

What is a common risk for Phenelzine +
Isocarboxazid ?

A

Increased risk of hepatotoxicity

95
Q

List 1 reversible MAOI?

A

Moclobemide

96
Q

What is a risk of Tranylcypromine?

A

Increased risk of hypertensive crisis

97
Q

When to stop using Tranylcypromine?

A

Discontinue if palpitations or frequent headaches occur.

98
Q

What is a short acting reversible MAOI?

A

Moclobemide

99
Q

List 6 SSRIs?

A

Citalopram

Escitalopram

Fluoxetine

Fluvoxamine

Paroxetine

Sertraline

100
Q

What 2 SSRIs can cause QT prolongation?

A

Citalopram

Escitalopram

101
Q

What SSRI is recommended to be used in children for depression?

A

Fluoxetine

102
Q

What SSRI is known to have increased withdrawal reactions?

A

Paroxetine

103
Q

What SSRI is safe in MI + unstable angina?

A

Sertraline

104
Q

Can MAOIs be used in pregnancy?

A

Avoid - can cause abnormalities

105
Q

List 8 TCA drugs?

A

Amitriptyline

Clomipramine

Doselupin

Doxepin

Imipramine

Lofepramine

Nortriptylline

Trimipramine

106
Q

What 2 TCAs are also used for neuropathic pain?

A

Amitriptyline

Nortriptylline

107
Q

Which TCA is the safest TCA?

A

Loferpramine

108
Q

Which TCA is dangerous as there is increased risk of fatality?

109
Q

Which TCA has increased antimuscarinic affects?

110
Q

What are 2 tricyclic related anti-depressants?

A

Mianserin

Mirtazapine

111
Q

Which anti-depressant is good if patient has bleeding disorders?

A

Mirtazapine

112
Q

Which 3 TCAS are less sedating? (LIN)

A

Lofepramine

Imipramine

Nortriptylline

113
Q

Which class of antidepressant is more dangerous as leads to overdose?

114
Q

What class of drug is Duloxetine?

115
Q

What other indication is Duloxetine also used for?

A

Diabetic neuropathy

116
Q

What SNRI has increased withdrawal reaction?

A

Venlafaxine

117
Q

What is a risk of using Agomelatine for depression?

A

Hepatotoxicity

118
Q

What is an OTC product used in depression but not useful?

A

St John’s Wort

119
Q

What antidepressant drug may be considered as a treatment option for patients with limited/ NO response to at least 2 antidepressant drugs?

A

Vortioxetine

120
Q

What is Trazodone?

A

Serotonin uptake inhibitor

121
Q

What are 4 SEs of anti-depressants?

A

Drowsiness - e.g. No driving

Suicidal ideation/ behaviour

HypOnatraemia (e.g. SSRIs)

Withdrawal

122
Q

What electrolyte related SE is common in SSRIs?

A

HypOnatraemia

123
Q

What 2 antidepressants are at higher risk of withdrawal reactions?

A

Paroxetine

Venlafaxine

124
Q

What to do when switching anti-depressants?

A

Wash out period to avoid serotonin syndrome

125
Q

Why is there a wash out period between changing anti-depressants?

A

to avoid serotonin syndrome

126
Q

What MAOI does not need a washout period?

A

Moclobemide (0 weeks needed for this drug to switch to another)

127
Q

How long is washout period for MAOI?

128
Q

How long is washout period for SSRIs?

129
Q

What SSRI requires a longer washout period of 2 weeks?

A

Sertraline

130
Q

What SSRI requires a longer washout period of 5 weeks?

A

Fluoxetine

131
Q

How long is washout period for TCA?

132
Q

What 2 TCAs have a longer washout perioid of 3 weeks?

A

Clomipramine

Imipramine

133
Q

What 3 symptoms make up serotonin syndrome?

A
  1. Neuromuscular hyperactivity (e.g. tremor, myoclonus, muscle rigidity)
  2. Altered mental state
  3. Autonomic dysfunction
134
Q

Describe 3 symptoms for Neuromuscular hyperactivity (serotonin syndrome)?

A

tremor, myoclonus, muscle rigidity

135
Q

Describe 3 symptoms for Altered mental state (serotonin syndrome)?

A

Confusion

agitation

mania

136
Q

Describe 7 symptoms for Autonomic dysfunction (serotonin syndrome)?

A

Tachycardia

labile bp (changes)

Urination

Hyperthermia

Diarrhoea

Pallor

Shiver or sweat

137
Q

What is MOA of SSRI?

A

Selectively block re-uptake of 5-HT

Causes increase in serotonin

138
Q

What is indication of SSRI?

A

1st line Depression + Anxiety

139
Q

What are 7 main SEs of SSRIs? (sighsqa)

A

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
Q

When is a better time to take SSRIs + why?

A

Morning as can cause insomnia

141
Q

What are 3 cautions of SSRIs?

A

Patient with Hx of GI bleeding, Epilepsy, CVD.

142
Q

Interaction between grapefruit juice + SSRIs?

A

Increases levels of SSRI (as enzyme inhibitor)

143
Q

What is maximum dose of sertraline per day?

A

200mg per day

144
Q

Interaction between SSRIs + TCA/MAOI?

A

Hyponatraemia

145
Q

What 5 drugs can interact with SSRIs to cause hyponatraemia?

A

Anti-depressants, Carbamazepine, desmopressin, diuretics, NSAIDs

146
Q

What does alcohol + SSRI do?

A

Can increase bleeding risk.

147
Q

What 6 drugs can interact with SSRI + cause bleeding risk?

A

Alcohol

Anticoagulants

Corticosteroids

NSAIDs

Venlafaxine

148
Q

What 6 drugs/classes interact with SSRIs to cause serotonin syndrome?

A

Antidepressants, lithium, St john’s wort, tramadol, sumatriptan, ondansetron

149
Q

What drug classes can interact with SSRIs to cause QT prolongation?

A

B agonists (causing hypokalaemia = Torsade)

Antipsychotics, Anti-arrhythmic drugs, TCA, Macrolide, Domperidone, lithium , methadone

150
Q

What is MOA of TCA?

A

Blood re-uptake of 5 HT + NA from synapse - increases these levels

151
Q

When is TCA usually taken?

A

At night- sedating

152
Q

What is indication of TCA?

A

Depression , anxiety

153
Q

What are 4 main SE of TCAs?

A

TCAs are more toxic

Cardiac effect

Anti-muscarinic effect

Seizures

154
Q

Why are TCAS more dangerous?

A

Sedating + higher risk of toxicity in overdose

155
Q

What are 7 cautions of using TCAs?

A

Suicide risk, CVD, QT prolongation, Hyperthyroidism, urinary retention, enlarged prostate, constipation, closed- angle glaucoma, epilepsy

156
Q

What is a caution related to TCA clomipramine?

A

QT prolongation

157
Q

What are 4 anti-muscarinic effects to be aware of in TCAs?

A

Constipation, enlarged prostate, urinary retention, close- angle glaucoma

158
Q

In what condition should TCA treatment be stopped?

A

Treatment should be stopped if the patient enters a manic phase.

159
Q

Can SSRIs be used in pregnany?

A

Maybe- risks and benefits of use must be considered

160
Q

What is a MHRA warning related to use of SSRI/SNRI + pregnancy?

A

small increased risk of postpartum haemorrhage when used in the month before delivery.

161
Q

What are 2 contra-indications of SSRIs?

A

Should NOT be used in poorly controlled epilepsy.

SSRIs should not be used if the patient enters a manic phase

162
Q

Which type of patients are less sedating TCAs good for?

A

Withdrawn + apathetic

163
Q

What is max dose of amitriptyline for Neuropathic pain/migraine?

A

75mg a day

164
Q

What is max dose of amitriptyline for Major depressive disorder if needed to be used?

A

150mg daily - 2 divided doses

165
Q

What 5 drug classes can interact with TCA + cause hypOnatraemia?

A

Anti-depressants,

Carbamazepine

Desmopressin

Diuretics

NSAIDs

166
Q

What 3 drugs can interact with TCA to increase anti-muscarininc effects?

A

Anti-histamines

Antimuscarinic (hyoscine)

Antipsychotics

167
Q

What 7 drugs can interact with TCA to increase CNS depressant effects?

A

alcohol

Sedating anti-histamines,

Antipsychotics

Benzos

Z drugs

Opioids

Barbiturate

168
Q

What 6 drug classes can interact with TCAs to cause hypotension?

A

Anti-hypertensives

Dopaminergic drugs

SGLT2 inhibitors

Diuretics

Nitrate

Phosphodiesterase type-5 inhibitor - sildenafil

169
Q

List 4 more sedating TCA drugs? (CADT)

A

Clomipramine

Amitriptyline

Doselupin

Trazadone

170
Q

What 2 TCAs are rarely used due to overdose issues?

A

Amitriptyline

Doselupin

171
Q

interaction between Amitriptyline + Adrenaline/epinephrine?

A

TCA increases effect of adrenaline = avoid

172
Q

Interaction between TCA + grapefruit juice?

A

increases TCA concentration - causes toxicity

173
Q

What is MOA of MAOI?

A

Blocks Monoamine oxidase, causes build up in blood.

Increase in serotonin, dopamine + noradrenaline levels

174
Q

What is an indication of MAOIs + how often used?

A

Depression - rarely used

175
Q

What are 3 Main SE of MAOIs?

A

Hypertensive crisis

Hepatotoxicity

Postural hypotension

176
Q

When to stop using MAOIs in postural hypotension?

A

Stop if patient has palpitations or frequent headaches

177
Q

What are 2 cautions of MAOIs?

A

CVD,

Cerebrovascular disease

178
Q

What are 2 contra-indications specific to tranylcypromine (MAOI)?

A

History of hepatic disease

hyperthyroidism

179
Q

Interaction between TCAs + MAOIs?

A

SERIOUS- toxic reaction

Manufacturer advises avoid TCA and for 14 days after stopping the MAOI.

180
Q

What is a food group that interacts severely with MAOIs + how to counsell?

A

Avoid tyramine rich/dopa rich foods up to 2 weeks of stopping.

Avoid alcohol

181
Q

Why should patients avoid tyramine rich foods when taking MAOIs?

A

Can cause hypertensive crisis

182
Q

Examples of tyramine rich/dopa rich foods?

A

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
Q

What class of drugs can increase hypertensive crisis in patients taking MAOIs?

A

Ephedrine, phenylephrine, OTC Pseudoephedrine, Adrenaline, amfetamines, B2 agonists (Sympathomimetics)

184
Q

What OTC med interacts with MAOIs + what does it cause?

A

Pseudoephedrine - hypertensive crisis

185
Q

What 9 drugs interact with MOAIs to cause serotonin syndrome?

A

Anti-depressants, amfetamines, lithium, Methadone, MAO-B inhibitors, St john’s wort, Tramadol, sumatriptan, Ondansetron

186
Q

What TCA can NEVER be given with MAOIs?

A

Clomipramine

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