Pharm

Question 1

Pharm antidep SSRI

Answer 1

MoA: presynaptic blockade of serotonin reuptake pumps
SE: GI disturbance, anxiety +agitation, insomnia, wt loss, sexual dysfunction, inc. risk of bleeding

Question 2

Pharm antidep NaSSA

Answer 2

moa: noradrenergic specific serontinergic antidepressant (presynaptic a2 blockade results in increased NA and 5-HT)
SE: sedation, wt gain, inc. appetite

Question 3

Pharm antidep TCA

Answer 3

High sedation: amitriptyline, clomipramine, dosulepin, tradazone
Low sedation: imipramine, lofepramine, nortriptyline
MoA: Presynaptic NA + 5-HT reuptake pump blockage, block of muscarinic, histaminergic and a-adrenergic Rs
SE: dry mouth, constip., postural hypotension, wt gain, QT pronlongation, arrhythmia, destabilising BPAD

Question 4

Pharm antidep MAO-A

Answer 4

Eg. selegiline, phenelzine, moclobemide (reversible)
MoA: inhibits MOA-A -> inc. synaptic NA, 5-HT, DA
Risk: cheese reaction, cant break down tyramine causes hypertensive crisis

Question 5

Pharm antidep Lithium

Answer 5

Renal excretion

drugs that affect level: diuretic, NSAID, ACEi

Question 6

Pharm antipsych typical (1st gen)

Answer 6

e.g. Haloperidol, chlorpromazine, flupentixol, zuclopethixol
MoA: block D2R in mesolimbic
SE: EPSE (acute dystonia, tardive dyskinesia, akathisia, Parkinsonism, hyperprolactin aemia)

Question 7

Pharm antipsych atypical (2nd Gen)

Answer 7

Eg Clozapine, olanzapine, risperidone, quetiapine, apiprazole. amisulpride

Question 8

Pharm antipsych Clozapine

Answer 8

Used in Treatment resistant schizophrenia
MoA: blocks D1+4R
CI: prev./current neutropenia, hx myocarditis, active/progressive liver Dx
SE: sedation, wt gain, reduced seizure thresh, myocarditis, metabolic synd.
NB. smoking cessation decreases CYP450 levels and raises clozapine level
Register pt w/clozaril pt monitoring service
Ensure normal leucocyte count and ECG before Rx
FBC: wkly for 18wk, 2wkly for 1yr, monthly after

Question 9

EPSE Rx

Answer 9

Acute dystonia: procyclidine (anitchol.)
Pseudoparkinsonism: antichol.
Akathsia: reduce antipsych. OR propranolol OR low dose clonazepam
Tardive dyskinesia: tetrabenzene (made WORSE by procyclidine)

Question 10

SSRI Choice

Answer 10

Citalopram and fluoxetine currently preferred
Sertraline useful post MI
Fluox in children

Question 11

SSRI SE

Answer 11

GI upset
GI bleed (If using NSAID give PPI)
Inc. anxiety and agitation shortly after starting
Fluox and parox higher propensity for drug interactions

Question 12

QT interval and antideps?

Answer 12

(Es)citalopram a/w dose dependent QTc prolongation and should not be used in those w/preexisiting long QT or in combo w/other QT lengthening
Max citalopram dose: 40mg/d 20 for >65 or hepatic impairment

Question 13

Interactions of antidepressants

Answer 13

NSAID and aspirin: give PPI
Warfarin/heparin: avoid SSRI consdier mirtazipine
Triptans: avoid SSRI
MAOI: risk serotonin syndrome when given w/SSRI

Question 14

SSRI in pregnancy

Answer 14

weight up benefits vs risk
1st trim: inc. risk congenital heart defect
3rd: inc. risk persistent pulmonary htn of newborn
Parox has inc. risk congenital malformations (first trim in particular)
Safest: sertraline, citalopram, fluoxetine

Question 15

Antipsych in elderly pts risk

Answer 15

Increased risk stroke and VTE

Question 16

non EPSE of antipsych

Answer 16

antimusc: blurred vision, retention, constipation,
sedation and weightgain
Hyperprolactin
Neuroleptic malignant syndrome:pyrexia and stiffness
Red. seizure threshold
Prolonged QT

Question 17

TCA SE

Answer 17

Drowsiness
Dry mouth
Blurred vision
Constipation + retention
QT prolongation

Question 18

Choosing TCA

Answer 18

Low dose amitriptyline fofr neuropathic pain and headache prophylaxis (tension/migraine)
Lofepramine: lower tox. in OD (safer)
Amitriptyline + doselepin are most dangerous in OD
More sedative: amitriptyline, clomipramine, dosulepin, trazadone
Less sedative: impramine, lofepramine, nortriptyline

Question 19

Switching Antidep.

Answer 19

1. From (es)citalopram, sertraline, paroxetine to another SSRI: withdraw before starting new
2. From fluox. to another SSRI: w/d then leave 4-7d gap (long t1/2), low dose new SSRI
3. From SSRI to TCA: cross taper (except fluox - withdraw before new)
4. From (es)citalopram, sert., parox. to venlaflaxine: cross taper cautiously (start 37.5OD and inc v slowly)
5. From fluox. to venla. (w/d and start ven. at 37.5 OD and inc v slowly)
   TAKE HOME: Fluox has long t1/2 to long switch

Question 20

Clozapine SE

Answer 20

agranulocyosis, neutropenia
Red. seizure threshold
Constip. 
Myocarditis (baseline ECG before starting Rx)
Hypersalivation

Question 21

Li SE and monitoring

Answer 21

N+V + diarrhoea
Fine tremor
Nephrotox.(polyuria 2ndry to nephrohgenic DI)
Thyroid enlargement (and hypothyroid)
ECG: T wave flattening/inversion
Wt gain
Idiopathic intracranial htn

Question 22

Li monitoring

Answer 22

Li levels wkly after starting and after each dose change until levels are stable
Once estab. Li levels checked 3monthly
Thyroid and renal 6mly
Pts given info booklet, alert card, record book

Question 23

Benzodiazepines pharm

Answer 23

Enhances GABA (inc. freq. of opening)
Barbs inc. duration
Sedative, hypnotic, anxiolytic, antconvulsant, muscle relax
Should not use >4wk

Question 24

Bz w/d

Answer 24

Insomnia
Irritability
Anxiety
Tremor
Loss of appetite
Tinnitus
Perspiration
Perceptual disturbance
Seizure

Question 25

Z-drugs pharm

Answer 25

Similar effects to BZ but structurally different
act on a-2 subunit of GABA R
3 groups:
1. imadazopyridines - zolpidem
2. Cyclopyrrolones - zopiclone
3, Pyrazolopyrimidines - zaleplon
Similar adverse effects as BZ
Inc risk of fall (elderly)

Question 26

Clozapine monitoring

Answer 26

A. FBC: wkly 18 weeks, every 2wks for 1yr, then monthly
B. Lipids = wt.: baseline, 3moly for 1y, annually
C. Fasting BM: baseline, 1m, 4-6m
D. Prolactin: baseline, 6m, annually
E. U+E and LFT: start, annually
F BP: baseline, frequently during titration
ECG: baseline
CV risk assessment: annually
If dose missed >48hr dose needs to be carefully retitrated as if from scratch