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Psychiatry > Pharmacology > Flashcards

Pharmacology Flashcards

1
Q

What type of drugs most effectively diffuse across the blood brain barrier?

A. Hydrophilic/ Lipophobic

B. Hydrophobic/ Lipophillic

C. Neither is better than the other

D. None of them do

A

B

To get into the brain drugs must be lipophillic

E.g. Atenolol is ineffective as anti-anxiety medication as it doesn’t actually enter the brain, but propranolol does and so therefore is effective

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2
Q

What class of antidepressants may be used to treat neuropathic pain?

A

tricyclics

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3
Q

What are some antidepressant drug classes?

A
  • Monoamine oxidase inhibitors
  • Monoamine reuptake inhibitors
    • Tricyclics
    • SSRIs
    • Noradrenaline reuptake inhibitors
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4
Q

What of the following neurotransmitters is not a monoamine?

A. Dopamine

B. Glutamate

C. Noradrenaline

D. 5-HT (Seratonin)

A

B

Glutamate is not a monoamine

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5
Q

In which nuclei is seratonin producted?

A

The raphe nuclei of the rostral group

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6
Q

What are some examples of monoamine oxidase inhibitors?

A

Phenelzine and Moclobemide

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7
Q

What is the mode of action of monoamine oxidase inhibitors?

A

Irreversable (Phenelzine) or reversable (Moclobemide) inhibitors of MAO- A and B

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8
Q

What are some side effects of monoamine oxidase inhibitors?

A
  • Cheese reaction/hypertensive crisis- caused by MAO-A inhibition in gut and liver by irreversable drugs which prevents breakdown of dietary tyramine
  • Potentiates effects of other drugs by decreasing their metabolism
  • Insomnia
  • Postural hypotension
  • Peripheral oedema
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9
Q

Which of the following side effects are more likley to be caused by an SSRI than a tricyclic?

A. Blurred vision

B. Constipation

C. Dry mouth

D. Nausea

E. Urinary retention

A

D

Tricyclics are anticholinergic and so A, B, C, and E are all classic side effects

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10
Q

Which of the following antidepressants should be avoided in a 57 year old man with ischaemic heart disease who became depressed following an MI 2 months ago?

A. Citalopram

B. Fluoxetine

C. Imipramine

D. Mirtazapine

E. Sertraline

A

C

Avoid using imipramine in ischameic heart disease

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11
Q

What class do the following antidepressants belong to?

Imipramine, Dosulepin, Amitriptyline, Lofepramine

A

Tricyclic antidepressants

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12
Q

How do tricyclic antidepressants work?

A

Block the reuptake of monoamines (mainly noradrenaline and 5-HT) into presynaptic terminals. This means more is avaliable in the cleft

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13
Q

What are some side effects of tricyclic antidepressants?

A
  • Anticholinergic= blurred vision, dry mouth, constipation, urinary retention
  • Sedation
  • Weight gain
  • CV= postural hypotension, tachycardia, arrythmias
  • Carditoxic in overdose
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14
Q

How do SSRIs work?

A

Selectively inhibit the reuptake of seratonin in the synaptic cleft leading to increased seratonin activity

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15
Q

What class of drugs do the following antidepressants belong to?

Fluoxetine, Citalopram, Sertraline

A

SSRIs

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16
Q

What are some common side effects of SSRIs?

A
  • Nausea
  • Headache
  • Worsened anxiety
  • Transient increase in self harm/ suicidal ideation <25
  • Sweating and vivid dreams
  • Sexual dysfunction
  • Hyponatreamia (elderly)
  • Discontinuation effects
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17
Q

How do SNRIs work and what are some examples?

A

Block the reuptake of monoamines (noradrenaline and 5-HT) into presynsaptic terminals.

Venlaxafine and Duloxetine

Similar side effects to SSRIs

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18
Q

What are the short and long term goals in treatment of Bipolar Disorder?

A

Acute treatment of symptoms- to reduce mood in episodes of mania and raise mood in episodes of depression

Long term treatment- to stabilise mood and prevent recurrence of both mania and depression (prophylaxis)

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19
Q

What of the following side effects would suggest lithium levels in the toxic range?

A. Ataxia

B. Hypothyroidism

C. Nausea

D. Polyuria

E. Tremor

A

A

Ataxia suggests toxic levels

The rest of the list are normal side effects

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20
Q

True or False?

Lithium is subject to extensive hepatic metabolism

A

False- not metabolised at all. Undergoes renal excretion

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21
Q

Lithium ions and sodium ions are indistinguishable to the renal tubules. What will the effect of dehydration be on lithium levels?

A. Decrease in lithium levels

B. Increase in lithium levels

C. No change in lithium levels

A

B

An increase in lithium levels. If dehydrated the tubules will absorb more Na to pull the water in and so will also absorb more lithium

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22
Q

What are the side effects of lithium?

A
  • Dry mouth/ strange taste
  • Polydipsia and polyuria
  • Tremor
  • Hypothyroidism
  • Long term reduced renal function
  • Nephropgenic diabetes insipidis
  • Weight gain
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23
Q

What are some of the toxic effects of Lithium?

A
  • Vommiting
  • Diarrhoea
  • Ataxia/ coarse termor
  • Drowsiness / altered concious level
  • Convuslions
  • Coma
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24
Q

A 27 year old women is diagnosed with bipolar disorder. She hopes to get pregnant some time in the future. Which mood stabiliser is to be avoided?

A. Aripiprazole

B. Lamotrigine

C. Lithium

D. Quetiapine

E. Valproic Acid

A

E is contraindicated

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25
Q

What anticonvulsants are used as mood stabilisers in the treatment of BPD?

A

Valproic acid, Lamotrigine and Carbamazepine

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26
Q

What are the side effects of the anti-convulsants used as mood stabilisers?

A
  • Valproate and carbamazepine - drowsiness, ataxia, CV effects, induces liver enzymes
  • Valproate- teratogenicity (neural tube defects)
  • Lamotrigine- very small risk of Stevens-Johnson syndrome
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27
Q

How do antipsychotics work?

A

Dopamine antagonism and 5-HT antagonism

28
Q

What class do these mood stabilisers belong to?

Quetiapine, Aripiprazole, Olanzapine, Lurasidone

A

Antipsychotics

29
Q

What are some side effects of anti-psychotics?

A
  • Sedation, weight gain and metabolic syndrome
  • extra-pyramidal side effects (Aripiprazole)
30
Q

What are the 2 core symptoms of anxiety?

A

Fear- panic and phobia (amygdala-centered circuit)

Worry- anxiety, apprehensions, obsessions (cortico-striatal-thalamic-cortical tract)

31
Q

What does the neurotransmitter GABA do?

A

It is the main inhibitory neurotransmitter in the brain

Reduces the activity of neurons in the amygdala and the CSTC

32
Q

What are the main GABA receptors?

A

GABA-A, GABA-B and GABA-C

33
Q

What GABA receptor is the target of benzodiazepines, barbituates and alcohol

A

GABA-A

34
Q

What class of drugs do the following belong to?

Lorazepam, Diazepam, Chlordiazepoxide

A

Benzodiazepines

35
Q

What are the pharmacological effects of benzodiazepines? (5)

A
  • Reduce anxiety and aggression
  • Hypnosis/ sedation
  • Muscle relaxation
  • Anticonvulsant effect
  • Anterograde amnesia
36
Q

What are the problems associated with benzodiazepines?

A
  • Paradoxical aggression
  • Anterograde amnesia and impaired coordination
  • Tolerance and dependence
37
Q

What is given in benzodiazepine overdose?

A

Flumazenil

38
Q

How should benzodiazepines be withdrawn?

A
  1. Transfer patient to an equivelent daily dose of diazepam or chlordiazepoxide, preferably taken at night
  2. Reduce dose every 2-3 weeks, in steps of 2 or 2.5mg. If withdrawal symptoms occur, maintain this dose till they improve
  3. Reduce dose further- better to reduce too slowly than too quickly
  4. Stop completely- time needed for withdrawal can vary from around 4 weeks to a year
39
Q

How do SSRIs work?

A

Inhibit the reuptake of serotonin which leads to increased levels of it within the synaptic cleft

40
Q

Roughly how long do SSRIs take to have an anxiolytic effect?

A

Around 12 weeks

41
Q

What classes of antidepressants can be used to treat anxiety?

A
  • SSRIs- panic disorder, OCD, PTSD, phobias, GAD
  • Tricyclics- second line for panic disorder
  • Venlafaxine (SNRI)- GAD
  • Moclobemide (MAOI)- social anxiety disorder
42
Q

Other than antidepressants, what other classes of drugs can be used to treat anxirty?

A
  • Pregabalin - Ca+ channel blocker, GABA enhancer
    • Only considered if not responsive to other treatments
  • Beta blockers- e.g. Propranolol
    • Best for somatic symptoms such as palpitation, tremor
43
Q

What are the steps of treatment in the management of GAD?

A
  1. Pyschoeducation
  2. Self help/ psychoeducation groups
  3. CBT or start drug treatment- SSRI
  4. SNRI
  5. Pregabalin
  6. Combination of CBT and drug treatment
44
Q

In GAD, how long should a patient be treated with antidepressants?

A

Takes around 12 weeks for full effect

If works, continue the drug for 18 months

When stopping, reduce the drug gradually to avoid discontinuation

45
Q

What is the steps in the treatment of panic disorder?

A
  1. Self help
  2. CBT or SSRI, if long standing or no benefit from CBT
  3. Tricyclics

Continue treatment for 6 months

46
Q

What is the management steps of OCD?

A
  1. Low intensity psychological intervention- CBT or ERP
  2. More intensive psychological intervention or SSRI
    • If effective continue for a year
  3. Consider an increase in dose after 4-6 weeks
  4. SSRI + ERP and CBT
  5. Clomipramine
  6. Augmentation with antipsychotic or clomipramine + citalopram
47
Q

What are the steps in the management of PTSD?

A
  1. Mild and less than 4 weeks since trauma= watchful waiting
  2. Within 3 months of trauma:
    • Trauma focussed CBT
    • Hypnotic medication for sleep disturbance
  3. More than 3 months after trauma
    • Trauma focussed CBT or EMDR
  4. Limited evidence for drug treatment
    • Paroxetine or Mirtazepine
    • Amitryptiline or phenelzine
48
Q

What are the steps in the management for social anxiety?

A
  1. Individual CBT
  2. SSRI (escitalopram or sertraline)- review at 12 weeks
  3. SSRI + CBT
  4. Alternative SSRI (e.g. fluoxetine) or SNRI (venlafaxine)
  5. MAOI (moclobemide)
49
Q

Describe the mesolimbic pathway

A

Begins at the VTA

Projects dopaminergic action potentials into the nucleus accumbens

Involved in pleasure and reward

50
Q

Describe the mesocortical pathway

A

Starts in the VTA and then action potentials travel to the prefrontal cortex

Involved in cognition, working memory and decision making

51
Q

Describe the nigrostriatal pathway

A

Involved in motor planning and purpousful movement

Dopamine projections start in the substantia nigra and go to the caudate and putamen of the basal ganglia

52
Q

What side effects result from D2 antagonists in the nigrostriatal pathway?

A

Extra-pyramidal side effects

e.g. parkinsonism, tardive dyskinesia

53
Q

Describe the tuberoinfundibular pathway

A

Dopamine neurones from the hypothalamus project into the infundibular region

Dopamine is released into the portal circulation that connects this region to the pituitary gland, where dopamine functions to inhibit prolactin release

54
Q

What happens when dopamines inhibition of prolactin relase is blocked by antipsychotics?

A

Levels of prolactin increases which can lead to- menstrual cycle effects, decreased libido, fertility issues, bone problems, gynacomastia and galactorrhoea

55
Q

What would the ideal antipsychotic inhibit?

A

D2 receptors in the mesolimbic pathway

56
Q

What are the groups of antipsychotics?

A

1st generation (typicals)

2nd generation (atypicals)

57
Q

What group of antipsychotics do the following belong to?

Chlorpromazine, Haloperidol, Fluphenazine

A

1st generation antipsychotics

58
Q

What class of antipsychotics do the following drugs belong to?

Aripiprazole, Lurasidone, Olanzapine, Quetiapine, Risperadone, Ziprasidone and Clozapine

A

2nd generation antipsychotics

59
Q

What group of antipsychotics are more likely to cause extra-pyramidal side effects?

A

1st generation

2nd gen are more likely to cause symptoms such as weight gain and sedation

60
Q

2nd generation antipsychotics only block D2 receptos

True or False?

A

False

Also block serotonin receptors such as 5-HT2A

61
Q

What antipsychotic can cause agranulocytosis and so patients on this require regular blood checks?

A

Clozapine

62
Q

What are the extra-pyramidal side effects?

A
  • Acute dystonic reaction (onset in minutes)
  • Parkinsonism
  • Tardice Dyskinesia (long-term and often permanent)
63
Q

What are the dopaminergic side effects caused by antipsychotics?

A
  • Extra pyramidal side effects
  • Neuroleptic malignant syndrome
  • Hyperprolactinaemia
  • Akathisia/ restless leg syndrome
64
Q

What is neuroleptic malignant syndrome?

A

Life threatnening condition that can occur in response to antipyschotics

Symptoms are high fever, confusion, rigid muscles, variable BP, sweating and fast HR

65
Q

What is the treatment of neuroleptic malignant syndrome?

A
  1. Stop the antipsychotic
  2. Rapid cooling and renal support
  3. Skeletal muscle relaxants e.g. Dantrolene
  4. Dopamine agonists e.g. bromocriptine
66
Q

What is the treatment of Akathisia?

A

1st line is propranolol

2nd line is a long acting benzodiazepine like clonazepam

67
Q

In what order are antipsychotics selected?

A
  1. Start on 2nd generation and titrate up for 6-8 weeks. Assess the effects. If it works, keep going.
  2. If step 1 doesnt work, choose either a 1st or 2nd generation. Titrate up for 6-8 weeks.
  3. If doesnt work- check diagnosis, consider psychological input, optimise social supports, check complience (depot?)
  4. Consider Clozapine

Psychiatry (4 decks)

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