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Psychiatry Jenna to Sort > Pharmacological Treatment of Affective and Anxiety Disorders > Flashcards

Pharmacological Treatment of Affective and Anxiety Disorders Flashcards

1
Q

Antidepressants - mechanism

A
  • Not fully known
  • To do with the neurotransmitters serotonin and noradrenaline
    • Increase levels of these in brain
    • This changes receptors in the brain
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2
Q

Antidepressants - indications

A
  • Unipolar and bipolar depression
  • Organic mood disorders
  • Schizoaffective disorder
  • Anxiety disorders
    • Including OCD, panic, social phobia, PTSD
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3
Q

Antidepressants - general guidelines

A
  • Antidepressant efficacy is similar, so selection based on past history of response, side effect profile and coexisting medical conditions
  • Delay of 2-4 weeks after therapeutic dose is achieved before symptoms improve
    • If no symptoms seen after at least 2 months and adequate dose, switch to another antidepressant or augment with another agent
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4
Q

What is selection of antidepressant based on?

A
  • Antidepressant efficacy is similar, so selection based on past history of response, side effect profile and coexisting medical conditions
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5
Q

How long do antidepressants take to work?

A
  • Delay of 2-4 weeks after therapeutic dose is achieved before symptoms improve
    • If no symptoms seen after at least 2 months and adequate dose, switch to another antidepressant or augment with another agent
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6
Q

What are the different classess of antidepressants?

A

Classification:

  • Tricyclics (TCAs)
  • Monoamine oxidase inhibitors (MAOIs)
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Serotonin/noradrenaline reuptake inhibitors (SNRIs)
  • Novel antidepressants
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7
Q

What does the following stand for:

  • TCAs
  • MAOIs
  • SSRIs
  • SNRIs
A
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8
Q

What are the 2 types of TCAs?

A
  • Tertiary TCAs
    • Have tertiary amine side chains
    • These are prone to cross react with other types of receptors leading to side effects
    • Drugs – Imipramine, Amitriptyline, Doxepin, Clomipramine
  • Secondary TCAs
    • Often metabolites of tertiary amines
    • Primarily blocks noradrenaline
    • Drugs – Desipramine, Notritriptyline
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9
Q

Mechanism of:

  • tertiary TCAs
  • secondary TCAs
A
  • Tertiary TCAs
    • Have tertiary amine side chains
    • These are prone to cross react with other types of receptors leading to side effects
    • Drugs – Imipramine, Amitriptyline, Doxepin, Clomipramine
  • Secondary TCAs
    • Often metabolites of tertiary amines
    • Primarily blocks noradrenaline
    • Drugs – Desipramine, Notritriptyline
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10
Q

Drugs of:

  • tertiary TCAs
  • secondary TCAs
A
  • Tertiary TCAs
    • Have tertiary amine side chains
    • These are prone to cross react with other types of receptors leading to side effects
    • Drugs – Imipramine, Amitriptyline, Doxepin, Clomipramine
  • Secondary TCAs
    • Often metabolites of tertiary amines
    • Primarily blocks noradrenaline
    • Drugs – Desipramine, Notritriptyline
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11
Q

Effect - TCAs

A
  • Increases both serotonin, dopamine and noradrenaline
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12
Q

Side effects - TCAs

A
  • Potentially unacceptable side effect profile
    • Antihistaminic
    • Anticholinergic
  • Lethal in overdose
  • Can cause QT lengthening
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13
Q

Mechanism - MAOIs

A
  • Bind irreversible to monoamine oxidase, preventing inactivation of amines such as norepinephrine, dopamine and serotonin leading to increased synaptic levels
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14
Q

Indications - MAOIs

A
  • Resistant depression
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15
Q

Side effects - MAOIs

A
  • Orthostatic hypertension
  • Weight gain
  • Dry mouth
  • Sedation
  • Sexual dysfunction
  • Sleep disturbance
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16
Q

Drug interactions - MAOIs

A
  • Tryamine-rich foods or sympathomimetics
    • Causes “cheese reaction”, which is a hypertensive crises
    • Foods include cheese and red wine
  • If taken with meds that increase serotonin or have sympathomimetic actions
    • Serotonin syndrome
    • Side effects – abdominal pain, diarrhoea, sweats, tachycardia, HTN, myoclonus, irritability, delirum. Maybe even hyperpyrexia, cardiovascular shock and death
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17
Q

What is the most commonly used class of antidepressants?

A

SSRIs

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18
Q

Drugs - SSRIs

A
  • Sertraline
  • Fluoxetine (Prozac)
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19
Q

Mechanism - SSRIs

A
  • Block the presynaptic serotonin reuptake
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20
Q

Indications - SSRIs

A
  • Anxiety
  • Depression
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21
Q

Side effects - SSRIs

A
  • GI upset
  • Sexual dysfunction (30+%)
  • Anxiety
  • Restlessness
  • Nervousness
  • Insomnia
  • Fatigue or sedation
  • Dizziness
  • Very little risk of cardiotoxicity in OD
  • Can develop a discontinuation syndrome with agitation, nausea, disequilibrium and dysphoria if stopped quickly
  • Activation syndrome
    • Caused by increase in serotonin
    • Symptoms – nausea, increased anxiety, panic and agitation
    • Typically lasts 2-10 days
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22
Q

What is activation syndrome caused by?

A
  • Caused by increase in serotonin
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23
Q

What are symptoms of activation syndrome?

A
  • Symptoms – nausea, increased anxiety, panic and agitation
  • Typically lasts 2-10 days
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24
Q

Drugs - SNRIs

A
  • Venlafaxine
  • Duloxetine
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25
Mechanism - SNRIs
* Inhibit serotonin and noradrenergic reuptake like the TCAs * But without the antihistamine, antiadrenergic or anticholinergic side effects
26
Indications - SNRIs
* Depression * Anxiety * Possibly neuropathic pain
27
Drugs - novel antidepressants
* Mirtazapine
28
Mechanism - novel antidepressants
* 5HT2 and 5HT3 receptor antagonist
29
Side effects - noval antidepressants
* Increase of serum cholesterol * Sedating * Weight gain
30
What can be done to overcome treatment resistance?
* Combination of antidepressants * Such as SNRI with Mirtazepine * Or adjunctive treatment with lithium * Or adjunctive treatment with atypical antipsychotic * Such as Quetipaine, Olanzapine or Aripiprazole * ECT
31
What is a typical combination of antidepressants to overcome treatment resistance?
* Such as SNRI with Mirtazepine
32
What are examples of atypical antipsychotis combined with antidepressants to overcome treatment resistance?
* Such as Quetipaine, Olanzapine or Aripiprazole
33
How is medication used for prophylaxis?
When you treat someone for an episode, continue medication for prophylaxis for future relapse: * First episode * Continue for 6 months to year * Second episode * Continue for 2 years * Third episode * Discuss lifelong
34
How long should someone be given prophylaxis antidepressants after: - first episode - second episode - third episode
* First episode * Continue for 6 months to year * Second episode * Continue for 2 years * Third episode * Discuss lifelong
35
Describe the pharmacological management of anxiety?
* Serotonergic anti-depressant agents so SSRIs and SNRIs * Tricyclic Chlomipramine * Adjunctive treatments mainly anti-psychotics Risperidone or Quetiapine * Avoid symptomatic relief such as diazepam
36
What are indications for mood stabilisers?
* Bipolar * Cyclothymia * Schizoaffective
37
What are the different classes of mood stabilisers?
* Lithium * Anticonvulsants * Antipsychotics
38
How do you decide what mood stabiliser to use?
Which one you select depends on what you are treating and side effect profile
39
Lithium - mechanism
* Not sure completely how it works
40
Lithium - indications
* Long term prophylaxis for * Mania * Depressive episodes
41
What are some factors predicting a positive response to lithium?
* Prior long-term response or family member with good response * Classic pure mania * Mania is followed by depression
42
What should be done before starting lithium?
* **Before starting** * **Baseline U&E and TSH** * **In woman, pregnancy test as during first trimester associated with Ebsteins anomaly** * Monitoring * Steady state achieved after 5 days, check 12 hours after last dose * Once stable check level 3 months and TSH and creatinine 6 months * Goal * Blood level between 0.6-1.2
43
How is lithium use monitored?
* Before starting * Baseline U&E and TSH * In woman, pregnancy test as during first trimester associated with Ebsteins anomaly * **Monitoring** * **Steady state achieved after 5 days, check 12 hours after last dose** * **Once stable check level 3 months and TSH and creatinine 6 months** * Goal * Blood level between 0.6-1.2
44
What are the goal levels for lithium use?
* Blood level between 0.6-1.2
45
Lithium - side effects
* GI distress * Including reduced appetite, nausea/vomiting, diarrhoea * Most common * Thyroid abnormalities * Nonsignificant leukocytosis * Polyurua/polydipsia secondary to ADH antagonist * Small number can interstitial renal fibrosis leading to renal failure * Hair loss, acne * Reduces seizure threshold, cognitive slowing, intention tremor * Lithium toxicity
46
What are the different severities of lithium toxicity?
* Mild * Levels 1.5-2 * See vomiting, diarrhoea, ataxia, dizziness, slurred speech, nystagmus * Moderate * Levels 2-2.5 * See nausea, vomiting, anorexia, blurred vision, clonic limb movements, convulsions, delirium, syncope * Severe * \>2.5 * Generalised convulsions, oligura and renal failure
47
What are clinical features of lithium toxicity: - mild - moderate - severe
* Mild * Levels 1.5-2 * See vomiting, diarrhoea, ataxia, dizziness, slurred speech, nystagmus * Moderate * Levels 2-2.5 * See nausea, vomiting, anorexia, blurred vision, clonic limb movements, convulsions, delirium, syncope * Severe * \>2.5 * Generalised convulsions, oligura and renal failure
48
What are lithium blood levels for the following severities of lithium toxicity: - mild - moderate - severe
* Mild * Levels 1.5-2 * See vomiting, diarrhoea, ataxia, dizziness, slurred speech, nystagmus * Moderate * Levels 2-2.5 * See nausea, vomiting, anorexia, blurred vision, clonic limb movements, convulsions, delirium, syncope * Severe * \>2.5 * Generalised convulsions, oligura and renal failure
49
Anticonvulants - drugs
* Valproic acid (Depakote) * Carbamazepine (Tegretol) * Lamotrigine (Lamictal)
50
Valproic acid - indications
* Mania prophylaxis * As effective as lithium, not as effective in depression prophylaxis
51
What are factors predicting a positive response to Valproic acid?
* Rapid cycling patients (F\>M) * Comorbid substance issues * Mixed patients * Patients with comorbid anxiety disorders
52
What should be done before giving Valproic acid?
* **Before** * **Baseline LFT, pregnancy test and FBC** * Monitoring * Steady state achieved after 4 days, check 12 hours after last dose and repeat CBC and LFTs * Goal * Target level between 50-125
53
How is Valproic acid monitored?
* Before * Baseline LFT, pregnancy test and FBC * **Monitoring** * **Steady state achieved after 4 days, check 12 hours after last dose and repeat CBC and LFTs** * Goal * Target level between 50-125
54
What is the target blood level of Valproic acid?
* Before * Baseline LFT, pregnancy test and FBC * Monitoring * Steady state achieved after 4 days, check 12 hours after last dose and repeat CBC and LFTs * **Goal** * **Target level between 50-125**
55
Valproic acid - contraindications
* Woman of child bearing age
56
Valproic acid - side effects
* Thrombocytopenia and platelet dysfunction * Nausea, vomiting and weight gain * Sedation, tremor * Hair loss
57
Carbamazepine - indications
* First line treatment for acute mania and mania prophylaxis * Rapid cyclers and mixed patients
58
What should be done before giving Carbamazepine?
* **Before** * **Baseline LFT, FBC, ECG** * Monitoring * Steady state achieved after 5 days, check 12 hours after last dose and repeat CBC and LFTs * Goal * Target level 4-12mcg/ml
59
How is Carbamazepine monitored?
* Before * Baseline LFT, FBC, ECG * **Monitoring** * **Steady state achieved after 5 days, check 12 hours after last dose and repeat CBC and LFTs** * Goal * Target level 4-12mcg/ml
60
What is the goal blood level of Carbamazepine?
* Before * Baseline LFT, FBC, ECG * Monitoring * Steady state achieved after 5 days, check 12 hours after last dose and repeat CBC and LFTs * **Goal** * **Target level 4-12mcg/ml**
61
Carbemazepine - side effects
* Rash * Most common * Nausea, vomiting, diarrhoea * Sedation, dizziness, ataxia, confusion * AV conduction delays * Aplastic anaemia and agrunocytosis * Water retention * Drug-drug interactions * Check BNF
62
Lamotrigine - indications
* Similar to other anticonvulsants * Also used for neuropathic/chronic pain
63
What should be done before giving lamotrigine and what dose should be used?
* Before * Baseline LFT * Initiation * Start with 25mg daily for 2 weeks then increase to 50mg after 2 weeks then increase to 100mg after 2 weeks
64
Lamotrigine - side effects
* If titrate up doses to quickly * Serious rash – toxic epidermal necrolysis and Stevens Johnson’s syndrome * If any rash develops, discontinue medication immediately * Nausea/vomiting * Sedation, dizziness, ataxia, confusion
65
Lamotrigine - drug interactions
* Drugs that increase Lamotrigine levels * VPA (doubles concentration so use slower dose titration) * Sertraline
66
What antipsychotics can be used as mood stabilisers?

Psychiatry Jenna to Sort (20 decks)

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