Pharmacology Flashcards
What is Quetiapine?
Atypical antipsychotic Sedating Anxiolytic at low dose Used in bipolar depression (anti-mania) Increased suicide rates if used for depression in under 25's Avoid in cerebrovascular disease
What is Propranolol?
ß-blocker Avoid in asthma, heart failure Anxiety symptoms Migraine prophylaxis Angina, MI, essential tremor
What is pregabalin?
Anti-convulsant for epilepsy
Neuropathic pain
GAD
What is sertraline?
SSRI, depression, social anxiety, panic, OCD, PTSD
SE: pancreatitis, hepatitis, tachycardia, bleeding
What is vortioxetine?
Serotonin receptor modulator
Major depression
Less impact on sexual function, discontinue if manic
SE: increased seizures,
What is olanzapine?
Atypical antipsychotic
Used in schizophrenia, severe anxiety, bipolar for mania
Weight gain and diabetes risks
Avoid in bone marrow disorders, cardiac issues
What is flupentixol deconoate? (depixol)
Typical antipsychotic Schizophrenia Mood stabiliser in bipolar Psychotic depression SE: hypersalivation, dyspnoea, hyperglycaemia
What is zopiclone?
Z drug anxiolytic and hypnotic (insomnia)
Use for up to 4 weeks
Caution in respiratory insufficiency
Drowsiness the next day
What is clozapine?
Atypical antipsychotic
Used in treatment resistant schizophrenia
Treats negative symptoms
Less extrapyramidal side effects
Decreases fertility, nausea, agranular cytosis, cardiomyopathy, hypersalivation, hypotension
What is sodium valproate?
Anti epileptic Bipolar Migraine prophylaxis Monitor liver function SE: weight gain, tremor, extrapyramidal, hair loss
What is chlordiazepoxide?
Anxiolytic
Anxiety, panic disorder, alcohol withdrawal (short term)
What is fluoxetine?
SSRI, major depression, bulimia nervosa, OCD
SE: bleeding, sexual dysfunction
What is diazepam?
Long acting benzodiazepine
Anxiety, sedative (only short term use)
Dependence, tolerance
Avoid in elderly-> confusion
What are extrapyramidal symptoms?
Parkinsonianisms caused by lack of dopamine in nigrostriatal pathway
Can be caused by D2 antagonists (eg antipsychotics)
Name 7 parkinsonianisms
Cogwheeling and increased tone Bradykinesia Freezing, festinating gait (shuffling) Pill rolling resting tremor Blank face and quiet speech (hypomimia) Postural instability and flexed posture Orthostatic hypotension-> falls
What drugs are most likely to cause extrapyramidal SE?
Fluphenazine
Perphenazine
Haloperidol
Treatment of bipolar?
Cognitive behavioural therapy, interpersonal therapy or behavioural couples therapy
Anti manic therapy (Olanzapine/haloperidol/quetiapine) or anti-depressant fluoxetine depending on presentation
2nd line: Lithium + Valproate
Lamotrigine for prevention
Physical health monitoring (weight, BP, blood glucose, thyroid function, FBC, renal and liver function)
Treatment of bipolar in children
In children, Risperidone is used for grandiosity, no evidence for antidepressants or lithium. Sodium valproate is commonly used.
Treatment of anxiety
• CBT (16-20 sessions) is first line treatment
• Medication of an SSRI is 2nd line (higher dose than for depression, continued for at least 1yr)
• Self help and reading groups is 3rd line
Benzodiazepines in crisis
Treatment of mild depression
Watch and wait for 2 weeks
Psychological therapy (6-8 session)
SSRI, for 6 months after remission
Treatment of moderate depression
SSRI, for 6 months after remission
CBT 16-20 session
Add another drug (eg another SSRI, quetiapine, serotonin receptor modulator)
Treatment of severe depression
SSRI +CBT
Add another drug (mirtazipine, quetiapine, serotonin receptor modulator, lithium)
ECT
Treatment of depression in children?
Fluoxetine is only medication
Young children: family therapy, art therapy, play therapy, address triggers/problems surrounding child
Teenagers: CBT
Risk factors for poor prognosis in depression
Early age of 1st episode (<20 years) Multiple previous episodes Chronic Dysthymia Comorbid substance misuse Severe psychotic depression
Treatment of schizophrenia
Atypical antipsychotic (eg olanzapine, risperidone) as first line. Psychotherapy and social support is also necessary. If 2 atypicals don’t work, clozapine has superior efficacy. However careful monitoring is needed due to SE including agranularcytosis. ECT has similar efficacy as clozapine
Basic management of SSRI prescription
- Antidepressants should be taken every day for at least 6 months after resolution of symptoms.
- SSRIs and SNRIs increase the risk of self harm and suicide in the under 30s when first taken. Therefore these patients should be seen after a week of initiating treatment.
- After 3-4 weeks with no effect, the dose can be increased of SSRIs or the medication can be switched.
What drugs can affect anxiety?
o B2 agonists (salbutamol) o Corticosteroids o Alcohol o Caffeine o Nicotine
Treatment of insomnia if coupled with depression
Sedating antidepressants include mirtazapine and trazodone
Treatment of insomnia
Sleep hygeine
If fails, short courses of Z-drug hypnotics (eg zopiclone)
Agomelatine can restore circadian rhythm
Guidelines for rapid tranquilisation
- Offer oral before parenteral
- Use lowest effective dose
- Benzodiazepines are first line (monitor temp, bp, hr)
- Only use antipsychotic if a psychotic illness is present
- Recent ECG MUST be available if haloperidol is being prescribed
- Diazepam reached peak quickest out of the oral options but has the longest elimination half life
- Olanzapine takes longest to reach peak
Which antipsychotics are most likely to cause raised prolactin and sexual dysfunction?
Amisulpride & risperidone
Which antipsychotic is least likely to cause EPSE and sexual dysfunction
Quetiapine
Which antipsychotic is most likely to cause weight gain and impaired glucose tolerance?
Olanzapine
Which antipsychotic is the least sedating?
Aripriprazole- alerting not sedating
What can help with the hypersalivation caused by clozapine?
Atropine eye drops
Hyoscine pills
Absorbent pillows
What in the social and PM history may affect dose of clozapine?
Coffee drinkers need less
Smokers need more
(CytP450)
Macrolide antibiotics should be avoided
What happens is a dose of clozapine is missed?
Missed for more than 48hrs?
Start at 12.5mg and work up again
How long do you treat someone with antipsychotics after an acute episode of schizophrenia?
5 years
High risk of relapse if stopped 1-2 years after
What must be considered when prescribing an antidepressant in bipolar?
Antidepressants may precipitate mania
Should be prescribed with a mood stabilising drug
Discontinue antidepressant if pt present in an acute manic episode
What needs to be considered when treating a pregnant woman with bipolar?
Lithium and valproate are both teratogenic
Treatment of panic disorder
SSRI
CBT
TCAs if SSRIs are ineffective
Name 3 typical antipsychotics
Chlorpromazine
Haloperidol
Fluoentixol
Which antipsychotics can be given by IM depot injection?
Fupentixol (typical)
Fluphenazine (typical)
Risperidone (atypical)
Which antipsychotics are licensed for acute mania?
Risperidone
Olanzapine
Quetiapine
Name some anticholinergic SE of antipsychotics
Dry mouth
Urinary retention
Constipation
Confusion
Name some antihistamine SE of antipsychotics
Sedation, weight gain
Name some antiadrenergic SE of antipsychotics
Postural hypotension (esp chlorpromazine)
Impotence
Dizziness
What is neuroleptic malignant syndrome?
Hyperpyrexia Autonomic instability Confusion Increased muscle tone Increased creatine phosphokinase Incontinence Profuse sweating Ataxia and convulsions if severe
What cardiac SE are there with antipsychotics?
Prolonged QT interval
Arrythmias
2x risk of sudden cardiac death
esp with haloperidol and pimozide
What can be given to patients with extrapyramidal dystonia and parkinsonism SE?
Procyclidine (anticholinergic)
What can be given to patients with tardive dyskinesia?
Reduction of cessation of anticholinergics
Cessation of typical antipsychotics where possible
Clozapine?
What is part of the physical health monitoring done for people on antipsychotics?
BMI + waist circumference
ECG
FBC, U+Es, lipid profile, LFTs, glucose, HBA1c, prolactin
Name 2 SNRIs and main SEs
Venlafaxine Duloxetine Suicidal ideation BP changes Sexual dysfunction, headache, anorexia
Name 2 TCAs and main SEs
Amitriptyline Imipramine Anticholinergic (eg dry mouth, urinary retention) Antiadrenergic (eg postural hypotension) Cardiac arrhythmias Seziures
Name a MAOi and main SEs
Phenelzine
Anticholinergic (eg dry mouth, urinary retention)
Antiadrenergic (eg postural hypotension)
Tyramine reaction
What is St John’s Wort?
Herbal preparation
Similar to a MAOi
Lots of interactions
How to MAOi work?
Inhibit breakdown of serotonin at synaptic cleft
When is lithium prescribed?
Prophylaxis of bipolar Acute mania Augmentation of antidepressants in resistant depression Schizoaffective illness The control of aggression
What needs to be monitored in lithium prescribing?
Serum lithium levels (0.4-1mmol/L)
Thyroid and renal function
(dehydration and diuretics can lead to toxicity)
Pregnancy avoidance
Signs of lithium toxicity
D+V Coarse tremor Slurred speech Ataxia Drowsiness and confusion Convulsions and coma
When are benzodiazepines used? Mechanism?
GABA agonist Insomnia Short term crisis in GAD Alcohol withdrawal states Control of violent behaviour
Treatment of ADHD
Methylphenidate
Atomoxetine
What must be taken into consideration when prescribing for someone with learning difficulties?
Some medications (eg antipsychotics) are proconvulsant Avoid polypharmacy as pts might not be able to communicate SEs
Main SEs of dexamphetamine
• Common - appetite decrease - sleep onset delay - abdominal pain - headache • Uncommon-rare - angina - sweating - visual disturbances
What needs to monitored in a child taking dexamphetamine
Growth (height and weight)
Appetite
Sleep
BP
Name 2 old antidepressant classes and 2 examples
5-HT 2 antagonist and reuptake inhibitor (trazodone)
Noradrenaline and specific serotonergic antagonist (mirtazapine)
4 uses of bezodiazepines and method of administration
- Anxiolysis with low dose of long-acting compound
- Sleep induction with high dose of short-acting compound
- IV use in treatment of status epilepticus (diazepam, clonazepam)
- IV use in anaesthetic pre-medication (lorazepam, diazepam)
Adverse effects of bezodiazepines
Dangerous when combined with alcohol, barbiturates
Memory disturbance
Impaired driving ability
Tolerance to hypnotic effect
Discontinuation symptoms on stopping
Risk of dependence in vulnerable patients
Recommended for short-term treatment (4 weeks) only
SE of lithium
Thirst, polydipsia, polyuria Fine tremor, weight gain Mild impairment of attention and memory Hypothyroidism (5%) Impaired renal tubular function (5-10%) Lithium toxicity
When is the effect of antidepressants seen by?
2 weeks
