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Year 4 PSYCH > Pharmacology > Flashcards

Pharmacology Flashcards

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1
Q

What indications are there for lithium?

A

Mania
Bipolar affective disorder
Recurrent depression (augmentation therapy)
Aggressive or self-mutilating behaviour

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2
Q

How is lithium cleared and thus what is it important to monitor?

A

Cleared by kidneys - monitor U&Es, fluid intake and sodium

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3
Q

How does lithium work?

A

Exact function is unknown. Mood stabilising effects

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4
Q

What baseline investigations should you take before starting someone on lithium?

A

Weight, U&Es, TFTs, LFTs, FBCs, Ca
Pregnancy test
ECG

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5
Q

Once we have given someone lithium how do we monitor them thereafter?

A

We take lithium levels 5 days after the first dose to check levels (should always be <1.5)
After that we check it every week until the levels have been stable for 4 weeks
After that we check it every 3/12

ADDITIONAL BLOODS: Every 6 months we monitor U&Es, Ca and TFTs

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6
Q

What are some side effects of lithium that it is important to warn the patient of?

A

EARLY: Dry mouth, metallic taste, nausea, polyuria, polydipsia, fatigue
LATE: Diabetes insipidus, Hypothyroid, arrhythmias, ataxia, dysarthria, weight gain, confusion, seizures

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7
Q

What symptoms of lithium toxicity should you warn patients of and when are they likely to happen?

A

Likely when the patient is dehydrated (hot day, fever, D&V)
- or if patients on other nephrotoxic drugs e.g. NSAIDs
Coarse tremor, blurred vision, anorexia, dysarthria or ataxia, confusion, delirium

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8
Q

How do patients take Lithium?

A

As a tablet once a day

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9
Q

What is the advice surrounding Lithium in pregnancy?

A

ABSOLUTELY CONTRAINDICATED

- Causes Ebstein’s anomaly which is an abnormality in the triscupid valve

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10
Q

What advice should you give to patients on Lithium about other medications?

A

Avoid OTC ibuprofen and must remember to tell doctors they are on lithium (some pain killers, water tablets and diabetes medications cannot be taken at the same time)

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11
Q

What is the first line medication for depression and at what stage should we consider using it? Which drug is usually started?

A

SSRIs
Consider from moderate depression onwards
Usually Sertraline 50mg OD

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12
Q

What are some examples of SSRIs and how do they work?

A

Sertraline, Citalopram, Fluoxetine and Paroxetine

Stopping serotonin being take back up into pre-synaptic neurone thus increasing the concentration of sertraline in the synapses

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13
Q

What information should be given to patients about how to take SSRIs, how long they take them for and how long they take to work?

A

Taken ONCE DAILY as a TABLET
Don’t have to take them forever, we recommend you take them for 6-9months after you start to feel better. That way we minimise the risk of symptoms coming back
Can take 4-6 sometimes 8 weeks to start working to improve mood
Motivation can improve after just 2 weeks - suicide risk in young males

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14
Q

When should you consider follow up appointment for patients started on SSRI?

A

After 2 weeks - important to see if they’re tolerating side effects and monitor their effect

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15
Q

What side effects should you warn patients on SSRIs about?

A 
GI (most common): nausea, vomiting and diarrhoea
Headaches
Drowsiness 
Weight gain 
Fatigue 
Anxiety 
Withdrawal
HYPONATRAEMIA
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16
Q

What effects can SSRIs have in overdose?

A 
Serotonin syndrome 
High body temp 
Agitation
Increased reflexes 
Tremor 
Dilated pupils
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17
Q

Can we use SSRIs in pregnancy? What are the risks?

A

Can use but there are some risks:

  • Slight increase in risk of cardiac abnormalities if used i first trimester (risk particularly high with paroxetine)
  • Increase in risk of pulmonary hypertension if used in third trimester
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18
Q

What medications can be offered to augment SSRI therapy?

A

Lithium
Quetiapine
Risperidone
Aripiprazole

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19
Q

How should SSRIs be discontinued?

A

Should never just stop taking them - can cause nausea, dizziness, vertigo, feeling of electricity in the body, insomnia, nightmares and rebound depression
WEAN DOWN OVER 4 WEEKS
***particularly important with paroxetine

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20
Q

What drugs can interact with SSRIs and should not be offered?

A 
NSAIDs
Warfarin 
Heparin 
Aspirin
Theophylline
Clozapine 
TRIPTAN DRUGS FOR MIGRAINES
Flecainide
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21
Q

What are SNRIs? When are they used?

A

Serotonin and Noradrenaline re-uptake inhibitors

They are another treatment option for depression

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22
Q

What are the most common examples of SNRIs?

A

Duloxetine and Venlafaxine

technically also tramadol

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23
Q

What other drug is commonly given with venlafaxine that seems to work well in combination?

A

Mirtazapine

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24
Q

What are some side effects of SNRIs?

A

The same serotonergic side effects of SSRIs: weight change, insomnia, appetite change, reduced libido, drowsiness, dizziness, fatigue and headache

Also noradrenergic effects: Increased HR, Increased BP, Anxiety, prolongation of QT interval

***always measure BP before starting SNRI and control if high

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25
Q

What are some examples of tricyclic anti-depressants and how do they work?

A

Amitriptyline, Nortriptyline and imipramine

They block serotonin and noradrenaline transporters to increase the concentration of both

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26
Q

When are TCAs used?

A

They used to be used more for depression but now used as second or third line (often behind MAOIs)
Can also be used for neuropathic pain

27
Q

What are some of the side effects of TCAs?

A

Side effects related to their anti-muscarinic properties

  • Dry mouth
  • Blurred vision
  • Dizziness and drowsiness
  • Muscle twitches
  • Nausea and vomiting
  • Hypotension
  • Tachycardia
28
Q

What problems can be caused by discontinuation of TCAs?

A

Anxiety, Insomnia, Headache, Nausea
***Can also cause problems in overdose (tachycardia, hypertension, coma, divergent squint, increased muscle tone, reflexes, myoclonus)

29
Q

What are some examples of monoamine oxidase inhibitors and how do they work?

A

Hydrazine, Hydrocarbazine, Isocarboxazid, Selegiline
(big variety in how selective they are and thus side effect profile)

They inhibit monoamine oxidase which is the enzyme which breaks down serotonin in the synapse - increases concentration

30
Q

At what stage might we use MAOIs to treat depression?

A

They are particularly good for treatment-resistant depression (especially when other medications haven’t worked or been tolerated)

31
Q

What advice should people taking MAOIs be given with regards to their lifestyle and why?

A

Limit tyramine rich foods in the diet? E.g. cheese, liver and alcohol)
***Interaction between tyramine and monoamine oxidase can lead to HYPERTENSIVE CRISIS

32
Q

What are some examples of NASSAs and how do they work?

A

Noradrenenergic and specific serotoninergic antidepressants
Act as antagonists to increase concentration of Serotonin and noradrenaline

MIRTAZAPINE MOST WIDELY USED

33
Q

What is the side effect profile of NASSAs like?

A

Very good - they have very specific serotoninergic effects so side effects are limited
They can be slightly sedative but this might be desirable

SIDE EFFECTS: Dry mouth, weight gain, sleepiness and constipation

34
Q

In what contexts is mirtazapine useful?

A

A complicated depression

E.g. depression with anxiety and difficulty sleeping

35
Q

Given its side effects when do we usually tell people to take mirtazapine?

A

Quite sedative so usually tell people to take it an hour before bed
Should withdraw over 4 weeks - do NOT discontinue immediately

25-30mg starting dose (up to max 45mg)

36
Q

When treating schizophrenia which anti-psychotic class should you consider?

A

Discuss the side effect profile of both and let the patient decide
If this is not possible then consider starting ATYPICAL

37
Q

After starting a patient on the starting dose of an anti-psychotic medication what should the next stages be?

A

Titrate the dose up to a therapeutic value
Review them every 2-3 weeks
If the first a/p isn’t working then consider a second - review compliance and consider a DEPOT
if this one isn’t working then consider CLOZAPINE

38
Q

Which drugs are the most common to be offered as the second line a/p?

A

Risperidone and Olanzapine (most often olanzapine)

39
Q

When switching from one a/p to another how should this be done?

A

Make sure to leave a MEDICINE FREE INTERVAL
- wean off first a/p slowly and then leave an interval before starting the next

  • **if you make another switch later you DO NOT NEED TO LEAVE AN INTERVAL
  • for subsequent switches after this consider partial and then full overlaps between medications
40
Q

What tests should a patient have done before starting an anti-psychotic?

A

ECG - they can all cause QT prolongation so it is a good idea to get a baseline ECG
Other tests done throughout treatment include FBC, U&E, TFT, Lipids, Ca, HbA1c

41
Q

How do anti-psychotics work in general?

A

Decrease/Antagonise the high levels of dopamine in the brain

Aim is to target mesolimbic pathway specifically (D2 receptors)

42
Q

What sort of side effects are more associated with typical a/ps and what are some examples of typical a/ps?

A

HALOPERIDOL, CHLORPROMAZINE
Side effects due to dopamine antagonism in the Extra-pyramidal zone (nigro-striatal pathway):
- Parkinsonism
- Acute dystonia e.g. torticollis or oculogyric crisis
- Akathisia (acute restlessness)
- Tardive Dyskinesia (involuntary, repetitive body movements e.g. grimacing or shaking)

43
Q

What medications should people be given if they develop tardive dyskinesia?

A

TETRABENAZINE

44
Q

What are some examples of atypical a/ps and what sort of side effects do they cause?

A

RISPERIDONE, ONLANZAPINE, ARIPIPRAZOLE, CLOZAPINE
They cause dopamine antagonism in the tuberofundibular pathway causing more METABOLIC COMPLICATIONS
- Hyperlipidaemia
- `Blood sugar problems
- Sexual dysfunction
- weight gain

45
Q

Which anti-psychotics are know for causing problems with prolactin and what effects does this have?

A 
HYPERPROLACTINAEMIA
Aripiprazole 
Clozapine 
Quetiapine 
Onlanzapine

Leads to gynecomastia and galactorrhea

46
Q

Which a/ps are the highest risk for causing poor blood sugar control?

A

Clozapine, onlanzapine and quetiapine and risperidone (last 2 lower risk)

47
Q

What common side effects do all a/ps share?

A 
Blocking M1 cholinergic receptors:
- Dry mouth 
- Dizziness 
- Blurred vision
- Constipation
Blocking Histaminergic receptors:
- Sedation
- Weight gain

QT PROLONGATION

48
Q

What a/ps are the most appropriate to give in pregnancy?

A

Haloperidol or possibly onlanzapine

49
Q

What important drug reactions should be kept in mind for the anti-psychotics?

A

CLOZAPINE and Carbamazepine should not be used in combination - both cause agranulocytosis
QUETIAPINE and Erythromycin (prolong QT)
ANY ANTIPSYCHOTICS and metaclopramide (both are anti-cholinergic)

50
Q

What is the monitoring regime for patients on A/Ps?

A

BEFORE STARTING: FBC, U&E, TFT, Prolactin, HbA1c, blood pressure, ECG, lipids and weight

FBC, U&E LFTs at least annually (weekly if clozapine)
Lipids and weight after 3 months

Fasting blood glucose and prolactin after 6/12

51
Q

When should we consider giving medications for anxiety and what medications should we offer?

A

Consider in MODERATE GAD (consider psychotherapies before this)
First line medication in GAD is SSRI with an SNRI alternative

52
Q

What should we consider if someone isn’t responding to SSRI therapy in GAD?

A

Can consider SNRI (duloxetine or venlafaxine)
And if they don’t respond to this they need to be referred for specialist care
Can also consider imipramine and clomipramine (TCAs)

53
Q

What medications can we consider to treat acute episodes of anxiety?

A

BETA-BLOCKERS - PROPANOLOL…really good at treating physical symptoms (shaking, sweating, palpitations, tremor)
BENZODIAZEPINES can be prescribed PRN for acute attacks of anxiety (usually diazepam) but should NOT be given over an extended period of time (max 2 weeks before review)

54
Q

What medication can be offered to people who are struggling to sleep due to anxiety and what dose can it be given in?

A

ZOPICLONE 3.75-7.5mg - Use smaller doses in elderly because of falls risk

55
Q

What other drugs are useful hypnotics/sedatives to help with sleep?

A

Melatonin

Chloral hydrate

56
Q

When should benzodiazepines not be used?

A

In someone who is drinking heavily

In someone who has hepatic impairment

57
Q

What are the important side effects of clozapine?

A

Agranulocytosis - increasing susceptibility to infection meaning infections can also become overwhelming and potentially fatal
Also lowers the seizure threshold

58
Q

What blood tests should be done before staring clozapine?

A

FBC, U&E, LFT, TFT, Ca

59
Q

How do we monitor patients on clozapine?

A

FBCs taken EVERY WEEK for the first 18 weeks to monitor WCC for neutropenia
After that can be done fortnightly and after 1 year total of being on clozapine can go down to monthly
***always counsel about signs of infection and importance of seeking medical attention

60
Q

What is valproate and what is it used to treat?

A

It is a MOOD STABILISER than can be used in the treatment of BAD (in particular manic episodes)

61
Q

What form does valproate come in?

A

DEPAKOTE FORM IS INJECTABLE - can be good for patients struggling with compliance

62
Q

Is valproate safe to use in pregnancy?

A

NO - highly teratogenic

63
Q

What are some side effects of valproate to be aware of?

A

Gastric irritation
Hair loss with curly regrowth
Dose related tremor
Thrombocytopenia

Year 4 PSYCH (18 decks)

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