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Pharmacology Flashcards

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1
Q

What indications are there for lithium?

A

LITHIUM IS A MOOD STABALISER

  • 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

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

A
  • BMI (weight gain is S/E)
  • FBC (agranulacytosis is S/E)
  • U+Es (cleared by kidneys)
  • TFTs (hypOthyroid is S/E)
  • Pregnancy test
  • ECG
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4
Q

H

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 their bloods?

A
  • We take lithium levels 7 days after the first dose (or when changing) 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 months for 1st year, then 6 months thereafter
  • ADDITIONAL BLOODS*
  • Every 6 months we monitor U+Es, BMI, TFTs, calcium

CHECK 12 hours post-dose

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6
Q

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

(early vs late- or use the lithium neumonic)

A

EARLY:

  • Metallic taste
  • GI (nausea)
  • Fatigue

LATE:

  • Diabetes insipidus (dry mouth, polyuria, polydipsia, but NORMAL glucose)
  • HypOthyroid
  • Arrhythmias
  • Weight gain
  • Ataxia, dysarthria (walk/talk)
  • Confusion, seizures
L-ethargic
I-nsides (GI)
T-remor (fine)
H-hypOthyroidim
I-nsipidus (dry mouth, polyuria, polydipsia but normal glucose)
Up your calcium 
M-etallic taste
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7
Q

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

A
  • COURSE tremor
  • blurred vision
  • anorexia
  • dysarthria or ataxia
  • confusion>siezure>coma

More likely when:

  • dehydrated (hot day, fever, D+V)
  • taking other nephrotoxic drugs e.g. NSAIDs
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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 
SSRIs 
When do you take?
How long do you take for?
How long do they take to start working?
How do you stop taking?
A
  • taken ONCE DAILY as a TABLET
  • take for 6 moths after you feel better
  • take 4-6 weeks to start working
  • to stop, wean down over 4 WEEKS

**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

-OR 1 WEEK FOR UNDER 30 YEAR OLDS OR SUICIDAL

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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

Explain serotonin syndrome

Whats the treatment?

A

Serotonin syndrome triad:

  1. nueormuscular excitability (increased reflexes, tremor)
  2. autonomic dysfunction (dilated pupils, fever)
  3. altered mental state (agitation,

H-HYPERTHERMIA
A-AUTONOMIC (dilated pupils, altered mental state)
R-RIGIDITY
M-Muscles (increased reflexes, tremor)

Treatment: supportive (stop serotonin drugs, antihypertensives, fluid replacement

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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 PAROXITINE)
  • 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

Side effects of stopping SSRIs suddenly?

How should SSRIs be discontinued?

A 
Side effects (should never just stop taking)
 -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

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27
Q

What are some of the side effects of TCAs? (think of receptors)

A

Side effects related to their receptors
HISTAMINE H1 blockade
-sedation

A ADRENORECEPTOR blockade
-postural hypotension

MUSCARINIC/ACETYLCHOLINE receptor blockade (blocks parasympathetic/autonomic system)

  • blurred vision
  • dry mouth
  • tremor
  • constipation
  • tachycardia
  • muscle twitches)

*also lower siezure threshold

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28
Q

What problems can be caused by discontinuation of TCAs?

A

Anxiety, Insomnia, Headache, Nausea
***Can also cause problems in overdose (prolonged hypotension, cardiac arrhythmias, and seizure, cardiovascular collapse, divergent squint)

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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

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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)

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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 1st line is ATYPICAL (2nd gen) because less EPSE

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 after 2-3 weeks
-If the first a/p isn’t working then consider changing to a different one (and review compliance)
-consider a DEPOT
-if this one isn’t working then consider CLOZAPINE (must have tried 2 AP before, used for 6-8 weeks)

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

Some examples of 1st gen/typical antipsychotics?

A

1st gen/typical

HALOPERIDOL, CHLORPROMAZINE

43
Q

What sort of side effects are more associated with 1st gen/typical antipsychotics?

How do you treat these side effects?

A

Side effects of 1st gen antipsychotics due to dopamine antagonism in the Extra-pyramidal zone (nigro-striatal pathway):
‘ADAPT’ (they are in order of when they occur)
AD Acute dystonia e.g. torticollis or oculogyric crisis
A-Akathisia (acute restlessness)
P-Parkinsonism
T-Tardive Dyskinesia (involuntary, repetitive body movements e.g. grimacing or shaking)

1st line treatment=PROCYCLIDINE (anticholinergic) (except for tar dive dyskinesia-makes it worse)

1st line treatment for tardive dyskinesia=TETRABENAZINE

44
Q

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

A 
RISPERIDONE, 
ONLANZAPINE (worst for weight gain) 
ARIPIPRAZOLE, 
QUETIAPINE 
CLOZAPINE (worst for weight gain)

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 known for causing problems with prolactin

What effects does this have?

What is a good alternative if someone hates the prolactin affects?

A

HYPERPROLACTINAEMIA

  • most commonly causes by 1st gen (haloperidol)
  • from the 2nd gen> Risperidone is the worst

Leads to gynecomastia and galactorrhea and ammenorrhea

SWITCH TO ARIPIPRAZOLE if they hate prolactin side effects

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?
hello

A

AGRANULOCYTOSIS
e.g. clozapine and carbamazepine

PROLONGED QT
-e.g. quetiapine, erythromycin, citalopram

DOPAMINE DRUGS

  • X L-dopa (will cancel out)
  • X metoclopramide (EPSEs)

CP450 PATHWAY

  • e.g. anti epileptics
    e. g. some ABs (clarithromycin)
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+Es 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
  1. Agranulocytosis - increasing susceptibility to infection meaning infections can also become overwhelming and potentially fatal
  2. Constipation (paralytic ilius)
  3. Myocarditis
    - 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

  • EVERY WEEK for the first 18 weeks to monitor WCC for neutropenia
  • 2 WEEKLY for 1 year. Then after 1 year total of being on clozapine can go down to monthly.

LIPIDS and BMI
-3 monthly for first year, then yearly

***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

64
Q

What is an acute dystonic reaction?

How does it present?

How do you treat?

A

Acute dystonic reaction
-acute reaction to neuroleptics/ anti-emetic metoclopramide (normally within first 48 hours)

  • presents with neck extension and oculogyric crisis (strange eye movements)
  • treatment: IV antimuscarinic benzatropine or procyclidine (should work within 5 mins)
65
Q

What is Malignant neuroleptic syndrome?

How can you tell the difference between serotonin syndrome and MNS?

A

Reaction to anti psychotic

  • HIGH FEVER and SWEATING
  • RIGIDITY
  • CONFUSION
  • TACHYCARDIA (variable BP)

(also high WCC and high CK-wheres serotonin syndrome doesn’t)

66
Q

How do you treat Malignant neuroleptic syndrome?

A

Treat Malignant neuroepileptic syndrome with bromocriptine

67
Q

What are the effects of TCA OD?

How do you treat?

A

TCA OD

  • Wide complex tachycardia (VT)
  • If QRS widening (>0.08-0.1sec): treat with IV bicarb
68
Q

What are the 2 tremors in lithium?

A

LITHIUM
fine tremor=normal side effect

course tremor=OD

69
Q

How can we reduce the effect of serotonin syndrome when swapping between SSRI and MAOI

A

Serotonin syndrome
-SSRIS should be discontinued 2 weeks before starting MAOI

-FLUOXITINE SHOULD BE DISCOUNTINUED 5 WEEKS before MAOI treatment

70
Q

nemonic for remembering 1st/nd gen antipsychotics?

Whats the difference between 1st gen and 2nd gen antipsychotics?

A

1st gen/typical=non selective
-FGAs are OLd and still reading magaZINES

2nd gen/atypical=more selective
-SGAs are what people PINE over now

71
Q

Serotonin syndrome vs NMS?

A
  • Serotonin syndrome has HYPER-reflexia, whereas in NMS the reflexes are depressed
  • Serotonin syndrome features automatic dilated pupils - NMS does not
  • NMS has high CK (lead pipe rigidity)
72
Q

What happens when dopamine gets blocked in the tuberofundibular pathway?

A

Blocking of dopamine in tuberofundibular pathway causes ELEVATED PROLACTIN

73
Q

What is the mesocortical pathway?

What affect does it have on symptoms in schizophrenia?

A

MESOCORTICAL=cognition and executive function

-low levels in schizophrenia cause NEGETIVE SYMPTOMS
antipsychotics are not good at working on this area

74
Q

What is the mesolimbic pathway?

What affect does it have on symptoms in schizophrenia?

A

MESOLIMBIC pathway=motivation, emotion, reward

-high levels in schizophrenia cause POSITIVE SYMPTOMS (this is the intended site of antipsychotic action)

75
Q

How do opioids work

A

agonists of opioid μ-receptors> inhibit GABA

76
Q

Missed a dose of clozapine-what should you do?

A

If clozapine doses are missed for more than 48 hours the dose will need to be restarted again slowly

Psych (22 decks)

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