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Mental Health > Pharmacology > Flashcards

Pharmacology Flashcards

1
Q

What are indications for antidepressants?

A
  • Unipolar depression
  • Organic mood disorders
  • Schizoaffective disorders
  • Anxiety disorders including GAD, panic disorder, OCD, social phobia, PTSD
  • Premenstrual dysphoric disorder
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2
Q

What is the length of treatment for antidepressants?

A
  • There is a delay, typically of 3-6 weeks after a therapeutic dose is achieved before symptoms improve
  • If no improvement is seen after a trial of adequate length (at least 2 months) and adequate dose either switch to another antidepressant or augment with another agent
  • When symptoms start to improve/treated, the therapeutic dose needs to be continued up to 6 months after recovery
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3
Q

What are the side effects of TCAs?

A
  • Lower seizure threshold
  • Cardiotoxic - prolong QTc interval, even at therapeutic serum level
  • Lethal in overdose
  • Anticholinergic effects - dry mouth, blurred vision, constipation, urinary retention, confusion, cognitive/memory problems
  • Antiadrenergic effects (alpha 1 + 2 receptors) - postural hypotension, sexual dysfunction, tachycardia
  • Antihistaminic effects - sedation, weight gain
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4
Q

Describe tertiary TCAs

A
  • Act primarily on serotonin receptors
  • SEs: antihistaminic (sedation + weight gain), anticholinergic (dry mouth + eyes, constipation, memory deficits + potentially delirium), antiadrenergic (orthostatic hypotension, sedation, sexual dysfunction
  • Examples: imipramine, clomipramine, amitriptyline, doxepin
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5
Q

Describe secondary TCAs

A
  • Act primarily on norepinephrine receipts
  • SEs: same as tertiary but generally less severe
  • Examples: desipramine, nortriptyline
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6
Q

Describe SSRIs

A
  • 1st line in anxiety and depression
  • Block presynaptic serotonin reuptake
  • Very little risk of cardio toxicity in overdose
  • SEs: GI upset, sexual dysfunction, anxiety, restlessness, nervousness, insomnia, fatigue, dizziness
  • Can develop discontinuation syndrome - agitation, nausea, disequilibrium + dysphoria
  • Examples: fluoxetine, sertraline, citalopram, escitalopram, paroxetine
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7
Q

Describe SNRIs

A
  • If no response to SSRI can switch to an SNRI
  • Inhibit both serotonin and norepinephrine reuptake
  • Like TCAs but without antihistaminic, antiadrenergic or anticholinergic side effects
  • Licensed for both depression and anxiety
  • Examples: venlafaxine (also for menopausal symptoms) + duloxetine (also for diabetic neuropathy)
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8
Q

Describe MAOIs

A
  • Bind to monoamine oxidase thereby preventing inactivation of biogenic amines such as norepinephrine, dopamine and serotonin leading to increased synaptic levels
  • Very effective for depression
  • SEs: orthostatic hypotension, weight gain, dry mouth, sedation, sexual dysfunction + sleep disturbance
  • Hypertensive crisis can develop when MAOIs are taken with tyramine-rich food or sympathomimetics
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9
Q

What is serotonin syndrome?

A

Medical emergency due to excessive serotonin

  • Autonomic dysfunction: hyperthermia, HTN, hyperreflexia, tachycardia, tremor, agitation, irritability, sweating, diarrhoea, dilated pupils
  • Abdo pain, myoclonus, delirium, CV shock + death
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10
Q

What is the treatment for serotonin syndrome?

A
  • Discontinue medication
  • Benzodiazepines for agitation
  • Severe - cyproheptadine-serotonin antagonist
  • Active cooling
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11
Q

What are the indications for mood stabilisers?

A
  • Bipolar disorder
  • Schizoaffective disorder
  • Lithium is also licensed for: prophylaxis + treatment of recurrent unipolar depression and impulse control + treatment of aggressive or self-harming behaviour
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12
Q

What are the classes of mood stabilisers?

A
  • Lithium
  • Anticonvulsants - depakote, lamotrigine, carbamazepine
  • Atypical antipsychotics - olanzapine, risperidone, quetiapine, aripiprazole
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13
Q

Describe the use of lithium

A
  • GOLD STANDARD of mood stabilisers
  • Effective in long term prophylaxis of both mania and depressive episodes in >70% of BPAD Type 1 patients
  • Factors predicting positive response to lithium: prior long term response or family member with good response, classic pure mania and mania is followed by depression
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14
Q

What do you need to check before starting lithium?

A
  • Baseline U+Es, TFTs, FBC, weight, BMI + ECG

- Check for pregnancy - teratogenic during 1st trimester, associated with Ebstein’s anomaly

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15
Q

What is the monitoring for lithium?

A
  • Steady state achieved after 5 days
  • Blood sample taken 12hrs after first dose, then after 5 days
  • TSH + U+Es 6 monthly
  • Then check every week until stable for 4 weeks
  • Once stable check 3 monthly
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16
Q

What are the side effects of lithium?

A
  • GI disturbance - abdo pain, nausea
  • Metallic taste
  • Fine tremor
  • Water symptoms: thirst, polyuria, weight gain, oedema
  • Hair loss, acne
17
Q

What are the symptoms of lithium toxicity?

A
  • GI - anorexia, diarrhoea, vomiting
  • Neuromuscular - dizziness, tremor, twitching, unable to walk straight, reduced coordination
  • Others - drowsiness, restlessness, lack of interest or enthusiasm
  • If any of these are experience - patient contacts doctor urgently, especially if d+v as can cause dehydration leading to increased lithium
  • Stop lithium, check level and refer for urgent assessment (encourage fluids (lithium excreted via kidneys), stop diuretics, monitor electrolytes and renal function)
  • Don’t take NSAIDs with lithium - NSAIDs can reduce renal function
18
Q

What are the complications of lithium?

A
  • Renal impairment
  • Nephrogenic diabetes insipidus
  • Clinical or sub clinical hypothyroidism
  • Cardiac Arrhythmias, leucocytosis, reduced seizure threshold, cognitive slowing
19
Q

What are the contraindications of lithium?

A
  • 1st trimester pregnancy
  • Breastfeeding - can pass to baby
  • Cardiac disease
  • Significant renal impairment
  • Addison’s
  • Low sodium diets
  • Untreated hypothyroidism
  • Avoid alcohol if possible - do not drink >1-2 units of alcohol/day
20
Q

What are the lithium toxicity ranges?

A
  • Mild (1.5-2.0mmol/l) - vomiting, diarrhoea, ataxia, dizziness, slurred speech, nystagmus
  • Moderate (2.0-2.5mmol/l) - nausea, anorexia, blurred vision, clonic limb movements, convulsions, delirium, syncope
  • Severe (>2.5mmol/l) - generalised convulsions, oliguria + renal failure
21
Q

Describe sodium valproate

A
  • Anti-epileptic drug - epilepsy, seizures
  • Better tolerated than lithium in mania + less monitoring
  • Adults and children
22
Q

What is the treatment programme of sodium valproate?

A
  • Take at same time everyday
  • If you forget to take a dose, take it as soon as you remember, unless it is time for next dose then leave out missed dose
  • Generally lifelong unless unresponsive, contraindicated or other medications trialled to achieve best outcome
  • May take a few weeks to start working, don’t stop even if symptoms such as seizures are experienced as dose monitored and tailored to patient
  • Bloods before and during treatment
23
Q

What are the side effects of sodium valproate?

A 
Very common:
- Nausea/abdo pain - avoid spicy foods
- Feeling shaky - can speak to doctor
Common:
- Hair loss - temporary
- Headache
- Drowsiness - avoid alcohol/driving
- Diarrhoea
- Increased weight - good diet
- Liver problems - LFTs monitoring
24
Q

What are complications of sodium valproate?

A
  • Unexplained bruising/bleeding (thrombocytopenia) - more important if undergoing surgery
  • Unexplained sore throat/cough
  • Extreme tiredness
  • Yellowing of eyes and skin
  • Sickness
  • Dark urine
25
Q

What are contraindications of sodium valproate?

A
  • PREGNANCY
  • Breastfeeding
  • Personal or FH of liver issues
  • Renal impairment
  • SLE
  • Porphyria - inherited blood disorder
26
Q

What is the indication for lamotrigine?

A

Indicated for bipolar type 2, when patients mainly have depression symptoms, with brief period of hypomania (antidepressant mood stabiliser). NOT indicated for mania.

27
Q

What is the treatment plan for lamotrigine?

A
  • Initiation/titration: start with 25mg OD x2wks, then increase to 50mg x2wks then to 100mg
  • Faster titration has higher incidence of serious rash
  • Be careful when switching from sodium valproate to lamotrigine as sodium valproate will increase availability of lamotrigine
  • Before starting check LFTs - dose adjustment in hepatic impairment
28
Q

What are the side effects of lamotrigine?

A
  • N+v
  • Sedation, dizziness, ataxia, confusion
  • Most severe is toxic epidermal necrolysis (TENs) and Stevens Johnson’s Syndrome (SJS) - if any rash develops stop using immediately
  • Blood dyscrasias seen in rare cases
29
Q

What are the drug interactions of lamotrigine?

A

Sertraline and valproic acid increases levels

Mental Health (12 decks)

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