Neuropharmacology Flashcards
drug used for MDD that causes confusion on a hot day (?)
escitalopram (SSRI)
what are some serious side effects of ecitalopram?
increased suicidal risk for first few weeks of therapy
birth defect for pregnant mothers
serotonin syndrome
discontinuation syndrome
sedative drug that causes visual hallucinations?
diazepam
MDD drug that causes weight gain and sedation
mirtazepine
mood stabilizer that causes confusion and unsteadiness when used in cojunction with a diuretic
lithium d/t changes in body concentration
what medication do you use for dystonia for antipsychotics?
benztropine
what medication can be offered IM for an acute agitated psychiatric patient?
midazolam
what are the clinical manifestations of hyperprolactinemia from anti-psychotics?
gynecomastia, galatorrhea, menstrual cycle disturbance, anovulation, decreased libido, impaired sexual arousal, impotence
what are common drugs that cause hyperprolactinemia?
amisulporide, paliperidone, risperidone, first-generation anti-psychotics
what is the treamtent to hyperprolactenmia?
reduce dosage of medication
switch to medication w/ low risk = ariprazole and clozapine
if not able to switch medicatins = add low dose 5mg ariprazole
prevention: regular prolactin monitoring, actively ask for symptoms of prolactinemia (menstrual changes, sexual changes)
what are the common anti-psychotics drugs that causes weight gain and other cardiometabolic changes?
clozapine and olazapaine
chlorpromazine
what si the treatment to cardiometabolic changes and weight gain?
monitoring: weight, bmi, waist circumference, BP, fasting blood glucose, full lipid profile (done at baseline, then 3 monthly, 6 monthly for the duration of therapy)
management of metabolic symptoms:
ongoing lifestyle interventions: education on healthy eating, weight reduction programmes
review of concurrent drugs that contribute to weight gain
phramcothreapy for: bp, dyslipidemia, t2dm (consider metformin)
what is the antipsychotic medication that causes lengthening of QT intervla
sertindole - has serotonin and dopamine receptors effect
what is the management of QT interval lengthening?
assess and manage risk factors: female congenital disposition hypocalcemia hypokalemia hypomagnesemia other medications that lengthen QT interval
mostly prevention: do ECG before starting treatment
ECG monitoring during treatment with sertindole
what is the management of medium-long term sedation in anti-psychotic drugs?
start low and go slow
reassurance that sedation wil go away in 2 weeks
avoid driving/machinery driving
if sedation remains - lower dose, change to less sedating anti-psychotics (such as aripiprazole)
orthostatic hypotension culprit anti-psychotic drugs?
risperidone, paliperidone
what culprit anti-psychotic drugs for anticholinergic effects?
clozapine
chlorpromazine
pericyazine
what are the symptoms of EPS - antipsychotics?
dystonia (sustained/brief muscle contraction that results in twisting movements or abnormal postures)
Parkinsonism
tardive dyskinesia (chronic repetitive involuntary choreiform movements - tongue, lips, mouth)
akathisia (abnormal/uncomfortable sensation of restlessness that is relieved upon movement)
what are medications more likely to cause EPS?
first generation anti-psychotics (chlorpromazine, haloperidol, flupenthixol)
what anti psychotic medications are less likely to cause EPS
clozapine, sertindole, olanzapine
what is the management of EPS?
acute dystonia = benztropine (IM/IV acute) and oral for maintenance for weeks
akathisia = lower dosage, start altnerative anti-psychotics, give propanolol short term OR diazepam short term
tardive dyskinesia = change to a second gen antipsychotic
Parkinsonism = use benztropine 0.5 - 2mg oral
what is neuroleptic malignant syndrome?
severe muscle rigidity, dystonia, akinesia, high fever, autonomic instability, raised creatine kinase (rhabdomyolysis), delirium
what is managemnet of neuroleptic malignant syndrome?
discontinue anti-psychotics, if need to continue, wait at least 5 days before anti-psychotic rechallenge and use a different anti-psychotic, start low go slow, measure and monitor vitals ensure adequate hydrations w/ IV fluids give DVT prophylaxis consider the use of diazepam
what is the management of akathesia in a patient on anti-psychotics?
first line BDZ long acting (ie lorezapam)
OR
second line B-blocker (propanolol) or benztropine
what is the shortest acting benzodiazepines?
midazolam (because you give it for acute psychiatric agitations!)
what is the management of parkinsonism in a patient on anti-psychotics?
(first line) benztropine.
if already on anti-cholinergic OR unable to tolerate (dementia/glaucoma), give amantidine
what is the management of acute dystonia in a patient on anti-psychotics?
benztropine
what second gen anti-psychotic is most assoc. w/ weight gain?
olly the elephant olanzapine
and clozapine
what second gen anti-psychotic is most assoc w/ EPS?
risperidone
what medication should not be given together with SSRI?
MAO-Inhibitor - causes serotonin syndrome
what are some side effects of SSRI
sexual dysfunction
GI adverse effects: n/v, diarhoea, anorexia, dyspepsia, weight gain, headaches
anxiety
insomnia and sedation/vivid dreams and nightmares
EPS is rare
serotonin syndrome (especially when mixed with a MAO-Inhibitor)
what are some of the symptoms of serotonin syndrome?
(in the following order)
diarrhoea
restlessness
extreme agitation/hyperreflexia/autonomic instability w/ possible fluctuations in vitals (tachycarida, elevated bp)
myoclonus, seizures, hyperthermia, uncontrollable shakes, rigidity
delirium, coma, status epilepticus, cardiovascular collapse, death
what are the symptoms of SSRI withdrawal?
dizziness, weakness, nausea, headache, rebound depression, anxiety, imsomnia, poor concentration
good drugs for hyperprolactanemia?
quietiapine and clozapine
aripripazole
good drugs for EPS?
clozapine and quietiapine
good drugs against weight gain and cardiometabolic?
ziprasidone (excellent)
haloperidol/aripripazole (not bad)
half life of SNRI vs SSRI
SNRI generally has a shorter half life than SSRI. fluoxetine (SSRI) in particular has a long half life
what are some s.e of SNRI?
venlafaxine: GI upset: n/v, constipation somnolence dry mouth dizziness nervousness weakness erectile disturbances and impotency increase in b.p
duloxetine similar except less GI upset
what are the indications for TCA?
second line depression
second line depression in bipolar I
headaches: preventive for migraine and preventive for frequent tension headaches
what are some of the common side effects of TCA?
anti cholinergic symptoms: dry mouth, dry eyes, constipation, blurred vision, urinary retention, if severe (cause delirium and confusion)
sedation
orthostatic hypotension
cardiac effects: tachycardia, prolonged QT intervals, depressed ST segments
neurological: psychomotor agitation, myoclonic twitches. tremor of the tongue and upper extremities
weight gain
what are medications that can be used for neuroleptic malignant syndrome (NMS)?
bromocriptine
dantrolene
what are the main risks of clozapine?
agranulocyotsis
lowers seizures threshold
orthostatic hypotension
what are the drug interactions between SSRI and NSAIDS/warfarin?
bleeding tendency
what are the main indications for clozapine?
patients w/ parkinson’s
patinets suffering w/ severe tardive dyskinesia or EPS symptoms
patients refractory to prev treatmnet
what antipsychotics are effective for negative symptoms of schizophrenia?
olanzapine and clozapine
what are the drug interactions between SSRI and NSAIDS/warfarin?
bleeding tendency
what are good anti-depressants for the elderly?
SSRIs (fluoxetine, paroxetine, setraline, citalopram, fluvoxamine), venlfaxafine, bupropion, mirtazapine
do not cause anti cholinergic effects, do not cause cardiotoxic s.e, do not cuase orthostatic hypotension
what is the definition of akathisia?
feeling of restlessness, inability to stay still.
patient will pace, shift positions, constant leg movements.
arises in the first few days of treatment
what are some anti-depressants that do not affect erectile function?
bupropion, mirtazapine
what are second line (not ideal) anti-depressants for the elderly and why?
TCA (amitriptyline, imipramine, desipramine) - anticholinergic, sedation
MAO-Inhibitors (phenelzine, tranylcypromine) causes hypotension
what is the treatment of lithium toxicity?
mild to moderate (serum level
what is the fatal dose of TCA
around 2 - 3mg. makes it unsuitable for highly suicidal patients
what are the relative contraindications of ECT?
recent MI, raised intracranial pressure, bleeding disorder, cerebral aneurysms, recent cerebrovascular events, medical disorder that can disrupt the blood-brain barrier
medications that can interact w/ lithium levels
NSAID, AT2, ACEI, diuretics
what do high potency neuroleptics vs low potency neuroleptics presidpose patients to?
high potency: EPS, hyperprolactinemia
low potency: sedating, hypotension, anti cholinergics
what are some high potency neuroleptics?
haloperidol, fluphenazine
what are some low potency neuroleptics?
chlropromazine, thioridazine
what are some rare, serious complicaitons of carbamazepine?
aplastic anemia
steven-johnson syndrome
what are the preferred treatment for acute mania in a pregnant patient?
neuroleptics (olanzapine, risperidone)
not carbamazepine/valproate as they cause an increased risk of neural tube defects and spina bifida that occur in the first trimester of pregnancy
what are the pharmacotherapy for narcolepsy?
CNS sitmulants for day time sleepiness: methylphenidate, amphetamine
to reduce REM sleep and cataplexy: TCA/SSRI
how long does lithium take to reach steady state?
5 - 7 days
what are the lithium congenital anomalies?
Ebstein’s anomaly (cardiovascular - distorted tricuspid valve into the RV)
what are the SSRIs that has to be slowly weaned off, and what are the SSRIs that does not require any weaning?
paroxetine, setraline (shorter half life - require to wean)
fluoxetine (long half life - can be stopped abruptly)
what dietary requirement for MAO-I?
avoid tyramine rich food such as aged cheese, salami, pepperoni, red wine, overripe fruits
what are the features of neuroleptic malignant syndrome/
hyperthermia, severe muscular rigidity, autonomic instability, changes in mental status
show increased CPK, ALT, leukocytes and myglobunuria
what level of lithium represents where costs may outweigh the potential benefits/
1.5meq/L
what is the most common cardiovacscular s.e of using a TCA?
slowing of cardiac conduction, prolonging QT
what is the treatment of lithium induced tremor?
supportive: dose reduction, elimination of caffeine, slow release lithium preparations
give Beta blocker s
what are the symptoms of dystonia?
intermittent, sustained muscle spasms - usually affecting the head and neck
such as torticollis (neck spasms), tongue spasms, oculogyric crises (eye forced in upward and lateral gaze)
