Others Flashcards
Describe the:
- use
- mechanism
- contraindications
- side-effects
- monitoring/safety measures
- complications
of Clozapine.
• Clozapine
o Used in treatment-resistant schizophrenia
o Mechanism:blocks D1 and D4 receptors
o Contraindications: previous or current neutropaenia, previous myocarditis, active or progressive liver disease
o Side-Effects: sedation, weight gain, reduced seizure threshold, myocarditis, metabolic syndrome, hypersalivation, GI (swallowing problems, constipation)
NOTE: smoking cessation can lead to a decrease in CYP450 activity resulting in raised clozapine levels
o Register patient with Clozaril patient monitoring service, Dezapine monitoring system or Zaponex treatment access system
o Ensure normal leucocyte count and ECG before starting treatment
o FBC Monitoring:
- Weekly for 18 weeks
- Fortnightly for 1 year
- Monthly thereafter
Side-Effects
Agranulocytosis, neutropaenia
Reduced seizure threshold
- Constipation
- Myocarditis (baseline ECG should be taken before starting treatment)
- Hypersalivation
_____ and ____ are currently the preferred SSRIs
Citalopram and fluoxetine are currently the preferred SSRIs
___ is useful post-MI
Sertraline is useful post-MI
_____ is the drug of choice in children
Fluoxetine is the drug of choice in children
What are side effects of SSRIs?
o GI upset
o GI bleeding (if NSAIDs are being used, it should be given with a PPI)
o Increased anxiety and agitation soon after starting
o Fluoxetine and paroxetine have higher propensity for drug interactions
What SSRIs are associated with Increased QT intervals?
o Citalopram and Escitalopram are associated with a dose-dependent increase in QTc and should not be used in those with pre-existing QT prolongation or in combination with other medicines that prolong the QT interval
o Maximum daily dose of citalopram: 40 mg for adults; 20 mg for > 65 years, 20 mg for hepatic impairment
What drugs do SSRIs interact with?
o NSAIDs and aspirin: if used, give with a PPI
o Warfarin/heparin: avoid SSRIs and consider mirtazapine
o Triptans: avoid SSRIs
o MAOI: risk of serotonin syndrome when given at the same time as SSRIs
How should we decide whether SSRIs should be given during pregnancy? What are the risks of having them?
Weigh up benefits and risks when deciding whether to use SSRIs
1st trimester: increased risk of congenital heart defects
3rd trimester: increased risk of persistent pulmonary hypertension of the newborn
SSRIs that are generally considered safe are sertraline, citalopram and fluoxetine
Paroxetine has an increased risk of congenital malformations, particularly in the 1st trimester
What are the SEs of Lithium?
• Side-Effects
o Nausea/vomiting and diarrhoea
o Fine tremor
o Nephrotoxicity: polyuria (secondary to nephrogenic DI)
o Thyroid enlargement (and hypothyroidism)
o ECG: T wave flattening/inversion
o Weight gain
o Idiopathic intracranial hypertension
How often should we monitor lithium levels?
• Monitoring
o After starting, lithium levels should be performed weekly and after each dose change until concentrations are stable
o Once established, lithium blood levels should be routinely checked every 3 months (levels should be taken 12 hours post-dose)
o Thyroid and renal function should be checked every 6 months
o Patients should be given an information booklet, alert card and record book
Describe the
- MOA
- Use
- Max length of use
- Features of withdrawal
of Benzodiazepines.
Enhances the effect of GABA (increases the frequency of opening of the chloride ion channel)
Used as a sedative, hypnotic, anxiolytic, anticonvulsant and muscle relaxant
Should not be used for longer than 2-4 weeks
Features of Withdrawal
o Insomnia
o Irritability
o Anxiety
o Tremor
o Loss of appetite
o Tinnitus
o Perspiration
o Perceptual disturbance
o Seizures
Note: barbiturates work by increasing the duration of chloride channel opening
How should we interpret an MMSE?
Any score > 24/30 is considered normal
Cognitive Impairment
o Mild: 18-23
• May require some supervision, support or assistance
o Moderate: 10-17
• Clear impairment, may require 24-hour supervision
o Severe: 0-9
• Marked impairment, likely to require 24-hour supervision and assistance with ADLs
The raw score may need to be corrected based on educational attainment and age
Note: patients with depression may often answer with ‘I don’t know’ whereas patients with dementia will attempt to answer all questions
What domains are tested in the MoCA, what is the max score, what is normal? What should we do if a pt scores low?
Domains tested: visuospatial and executive functioning, animal naming, attention, language, abstraction, delayed recall (short-term memory), orientation, education level (1 point added if < 12 years of formal education)
Maximum: 30 points
Normal: > 26 points
Does not differentiate between mild, moderate and severe cognitive impairment
If a patient score < 25, consider referral for further cognitive assessment
What is the AMTS comprised of?
What are the depression and anxiety questionnaires?
- PHQ-9
- HADS
- GAD-7
How should we conduct a PHQ-9 score? How should it be interpreted?
o Ask the patient ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
o 9 items which are scored 0-3
o Includes items about thoughts of self-harm
o Interpretation
o None: 0-4
o Mild: 5-9
o Moderate: 10-14
o Moderately Severe: 15-19
o Severe: 20-27
How should we conduct a HADS? How should it be interpreted?
• Hospital Anxiety and Depression Scale (HAD)
o Consists of 14 questions: 7 anxiety + 7 depression
o Focuses on the last week
o Each item scored from 0-3
o Produces a score out of 21 for both anxiety and depression
o Interpretation
o Normal: 0-7
o Borderline: 8-10
o Anxiety/Depression: 11-14
How should a Gad-7 score be conducted? How should it be interpreted?
o Asks about 7 symptoms and their frequency (each is worth a maximum of 3 points)
o Focuses on the last 2 weeks
o Interpretation
o Mild:5-10
o Moderate:10-15
o Severe:15+
o Maximum=21
What are the alcohol questionnaires?
CAGE – screening tool
Alcohol Use Disorders Identification Test (AUDIT) – screening tool
Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) – determines the severity
of withdrawal (useful for determining the next stage in treatment)
What are the
- indications
- Short term SEs
- Long term SEs
for ECT?
Indications
o Catatonia
o Prolonged or severe manic episode
o Severe depression that is life-threatening
o NOTE: it is effective in pregnant women
Short-Term Side-Effects
o Headache
o Nausea
o Short-term memory impairment
o Memory loss of events prior to ECT
o Cardiac arrhythmia
Long-Term Side-Effects
o Impaired memory
Define insomnia.
difficulty initiating or maintaining sleep, or early morning awakening that leads to dissatisfaction with sleep quantity or quality.
Define chronic insomnia.
diagnosed if a person has trouble falling asleep or staying asleep at least 3 nights per week for 3 months
How do we investigate and manage insomnia?
Investigation: usually based on history, may use sleep diary, rarely use polysomnography
Management
o Identify potential causes (e.g.mental or physical health issues or poor sleep hygiene)
o Advise against driving when sleepy
o Advise good sleep hygiene (no screens before bed, limited caffeine intake, fixed bed times)
o Only consider hypnotics if impairment is severe
o Recommended hypnotics include short-acting benzodiazepines (e.g. temazepam) or non-benzodiazepines (e.g. zopiclone)
o Use lowest effective dose for shortest duration
o Review after 2 weeks and consider referral for CBT
o Side-Effects of Sleeping Pills: daytime sedation, poor motor coordination, cognitive impairment, addiction
How should we manage chronic insomnia?
Defined as difficulty getting to sleep or maintaining sleep on 3 or more nights of the week for 3 months
May be investigated using a sleep diary and actigraphy
Identify potential causes (e.g. depression and anxiety)
Advice on sleep hygiene and not to drive when tired
CBT-I for insomnia
Consider hypnotics if major day time impairment
o Short-acting benzodiazepines (e.g.lorazepam) or Z-drugs can be used
o Use lowest possible dose for the shortest possible time
o Review in 2 weeks and consider CBT
When is applied relaxation therapy used, what does it consist of?
Used for people with anxiety disorders
Based on the premise that these patients have lost the ability to relax
Consists of a series of exercises that teach the patient how to:
o Spot the signs and feelings of tension
o Relax your muscles and relieve tension
o Use these techniques in stressful situations to prevent you feeling tense and panicky
Consists of 12-15 weekly sessions
When is mentalisation-based therapy used, what does it consist of?
Form of therapy that focuses on the patient’s ability to attend to mental states in themselves and in others
This helps them understand their actions and the actions of others
This leads to more successful social interactions and relationships
Mainly used for borderline personality disorder and self-harm
Rapid tranquillisation prescription
Lorazepam 2mg PO (max 4mg total) OR
Lorazepam 2mg IM (max 4mg total)
Haloperidol 5mg PO (max 12mg total) OR
Haloperidol 5mg IM (max 20mg total)
Promethazine 50mg PO (max 150mg total) OR
Promethazine 50mg IM (max 150mg total)
