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Psychiatry > Pharmacology of psychiatry > Flashcards

Pharmacology of psychiatry Flashcards

1
Q

What level of lithium classes as toxicity

A

> 1.2mmol/L

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2
Q

which anti-psychotics are most associated with weight gain

A

clozapine and olanzapine

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3
Q

what are the steps of the pharmacological approach to depression

A
  1. SSRI- eg. sertraline, fluoxetine
  2. taper down SSRI and add SNRI eg. venlataxine
  3. augmentation with anti-psychotic or another antidepressant
  4. Electroconvulsive therapy
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4
Q

Presentation of lithium toxicity

A

GI disturbances- D+V
polyuria/polydipsia (nephrogenic DI)
renal failure
sluggishness
ataxia
tremor
fits
ECG T wave flattening/ inversion
thyroid enlargement and hypothyroidism

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5
Q

What drugs can interfere with lithium

A

diuretics
ACEi
ARBs
NSAIDs
-> increase lithium levels

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6
Q

Liver enzyme inducers

A

CRAP GPs
Carbamazepine
Rifampicin
Alcohol
Phenytoin
Gisofulvin(antifungal)
Phenobarbitol
Sulphonyureas

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7
Q

Liver enzyme inhibitors

A

Isoniazid
Ketoconazole
fluconazole
erythromycin
chloramphenicol
metronidazole

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8
Q

Mood stabilisers

A

Lithium
sodium valporate- used in acute mania
Carbamazepine

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9
Q

What should be monitored with someone on lithium?

A

U&Es- renal function and calcium
TFTs- can cause hypothyroidism

every 6months
makesure to check baseline before starting lithium

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10
Q

pharmacological Mx of opioid OD

A

naloxone

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11
Q

Pharmacological Mx of paracetamol OD

A
  1. activated charcoal reduces absorption- must be given within 1 hr
  2. N-acetylecystine (if paracetamol levels over toxic dose (150mg/kg)
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12
Q

Mechanism of action of typical and atypical anti-psychotics

A

typical- inhibiit D2 receptors in the brain and therefore reduces neurotransmission

atypical- block 5-HT receptors and also D2 but weaker than typicals

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13
Q

side effects of antipsychotics

A

Extrapyramidal symptoms
- parkinsonism
- dystonia
- akathisia
-tardive dyskinesia

hyperprolactinaemia
- galactorrhoea
- amenorrhoea
- sexual dysfunction

Weight gain (esp clozapine and olanzepine)

agranulocytosis (clozapine)

hyponatraemia (olanzepine)

inc risk of DM (olanzepine)

dyslipidaemia

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14
Q

Alcohol withdrawal and addiction management pharmacology

A

Acute withdrawal
1. Pabrinex- if risk of wernickes encephalopathy
2. benzodiazepine or carbamazepine if needs some sedation

addiction management
1. Acamprostate - weak NMDA antagonist helps with cravings
2. disulfram: promotes abstinence - alcohol intake causes severe reaction due to inhibition of acetaldehyde dehydrogenase. Patients should be aware that even small amounts of alcohol (e.g. In perfumes, foods, mouthwashes) can produce severe symptoms

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15
Q

Opioid detoxification

A
  1. methadone (liquide)
  2. buprenorphine (sublingual)
  3. clonidine and lofexidine can help withdrawal symptoms
  4. Naloxone for rapid detox in OD
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16
Q

Alzheimers pharmacology

A
  1. Acetylcholinesterase inhibitors eg. donepezil, rivastigmine (milde-moderate alzheimers)
  2. Memantine (NMDA antagonist) severe alzhimers
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17
Q

Non alzheimers dementia pharmacology

A
  1. donepezil
  2. rivastigmine

NB: antipsychotics can worsen lewy body ddementa

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18
Q

Generalised anxiety disorder pharmacology steps

A
  1. SSRI- sertraline
  2. SNRI- venlataxine
  3. pregabilin

other
4. beta-blockers for treor sx (caution with asthma)

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19
Q

MOA of clozapine

A

blocks D1 and D4 receptors

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20
Q

side effects of clozapine

A

sedation
weight gain
agranulocytosis
reduced seizure threshold
GI disturbances
hypersalivation

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21
Q

Contraindications of clozapine and necessary tests before starting
and follow up monitoring

A

CI:
Hx of neutropenia, Hx of myocarditis, current liver disease

tests:
FBC
LFTs
ECG-

bloods weekly for 18weeks
then every 2 weeks for 1 year
monthly thereafter

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22
Q

SSRI contraindications

A

anyone with pre-existing QT prolongation

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23
Q

SSRI interactions

A

NSAIDS- give with PPI
warfarin/heparin
triptans
MAOI- risk of serotonin syndrome

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24
Q

what is serotonin syndrome

A

serious drug interaction causing build up of serotonin in the synapses

Sx:
adgitation and restlessness
dilated pupils
diarrhoea
raised BP
confusion, reduced GCS
insomnia
autonomic dysfunction- tachycardia
hyperreflexia, myoclonus, hypertonia

incidence <1%

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25
Q

Lithium monitoring

A
  1. baseline U&Es, LFTs and TFTs
  2. weekly lithium level monitoring until dose stabilised
  3. lithium blood levels checked every 3 months (12hrs post dose)
  4. TFTs and renal function every 6 months
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26
Q

When to treat depression with drugs

A

severe depression
If other options eg. computerised CBT, group CBT, 1-1 CBT, talking therapy, lifestyle changes haven’t worked

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27
Q

side effects of SSRIs + complications

A

headache
sleep disturbances/ vivid dreams
nausea, diarrhoea, constipation
sexual dysfunction

Complications:
hyponatraemia
GI bleeding

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28
Q

How long should someone be on SSRI for

A

continue for 6-12 months once pt feels well for first incidence of depression.
continue for 2 years if recurrent depression

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29
Q

MOA of MAOs

A

inc availability of 5-HT +NA in synapses

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30
Q

What is the tyramine interaction

A

when eat foods that are high in tyramine when on MAOs can lead to hypotensive crisis

food egs. Cheese, yoghurt, chocolate

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31
Q

what are the RFs for Serotonin Syndrome

A

anti depressants
combination
lithium
ECT
opiates
antiemetics

32
Q

Complications of Serotonin Syndrome

A

DIC
rhabdomyolisis
renal failure
metabolic acidosis
seizures

33
Q

SE and complications of lithium use

A

SEs:
GI upset
fine tremor
metallic taste in mouth
sedation
Polyuria/polydipsia -> neprogenic DI
T wave flattening
hair changes

Complications:
teratogen (ebsteins anomaly), CKD (nephrogenic DI), arrhythmia, hyperparathyroidism/hypercalcaemia, hypothyroidism

34
Q

Lithium therapeutic window range

A

0.4-1mmol/L
narrow so careful monitoring

35
Q

TCAs MOA and some examples

A

5-HT and NA reuptake inhibition.
Older ‘dirty’ drug

eg. Amitriptyline, nortiptyline, clomipramine, lofepramine

36
Q

starting on lithium

A

FBC, calcium, TFTs, ECG (if RFs or known cardiac disease)

consulting
- stay hydrated
-careful in hot countries

37
Q

Olanzapine uses and SEs

A

anti-psychotic used in
acute mania
off license
rapid effect

38
Q

sodium valporate SEs

A

terato genic -> spina bifida
PCOS
GI upset
tremor
sedation
wt gain
loss of hair
thrombocytopenia

anticonvulsant and mood stabiliser used in acute mania

39
Q

Lamotrigine complications

A

Stevens johnson syndrome- warn about rash and stop, slow titration

40
Q

Mania management

A

1st epidode/ acute mania:
- antipsychotic eg. olanzapine
- if no response could add lithium or valporate
long term (bipolar)- lithium, valporate or carbamazapine

41
Q

Consulting someone strated on SSRIs

A
  1. will need to continue medication for at least 6 months after improvement of Sx then gradually titre down
  2. small evidence of an increased suicide risk- SN and regular reviews
42
Q

SEs and issues with TCAs

A

SE:
antimuscarinic and anticholinergic: dry mouth, bluured vision, constipation, urinary retention
Cardiotoxis- prolonged QT, ST elevation, AV block
antihistaminergic: sedation, postural hypotension

discontinuation syndrome
lethal in overdose

just as effective as SSRIs!

43
Q

Example of a newer version of MAO

A

moclobemide

44
Q

NaSSA MOA side effects and example

A

blocks presynaptic alpha-2
adrenergic receptors. Autoreceptor
hence less feedback and more NA
release

SE:
Weight gain, increased appetite, drowsiness

eg. Mirtazapine
(useful drug to give to someone who needs to put on weight eg in anorexia nervosa)

45
Q

What is discontinuation syndrome

A

symptoms experienced when stopping antidepressents especially SSRIs.
not the same as withdrawal

Sx:
trouble sleeping
flu like Sx
anxiety
‘electrick shocks’
GI disturbances
dizziness
headaches

46
Q

management of serotonin syndrome

A

stop causative medications
A-E approach: manage airways, fluids, renal support, temp control
cyproheptadine- anti-histamine and serotonin antagonist

46
Q

management of serotonin syndrome

A

stop causative medications
A-E approach: manage airways, fluids, renal support, temp control
cyproheptadine- anti-histamine and serotonin antagonist

47
Q

Carbemazepine uses and SEs

A

mood stabiliser and anticonvulasant
Not really recommended by nice

strong CYP450 inducer
N+V
blurred vision
agranulocytosis

48
Q

Management of acute mania

A
  1. stop any antidepressants, recreational drugs, steroids that may induce mania
  2. Monitor fluids
  3. if not on any medication give an antipsychotic and short course of benzo
    -olanzepine, quitiepine
  4. if already on medication check compliance, adjust dose, consider adding antipsychotic
  5. ECT if unresponsive to medication
49
Q

managament of bipolar depression

A

dont use SSRI alone- may precipitate mania. augment with antipsychotic

eg. orlanzepine with fluoxetine OR lamotrigine

50
Q

what are the 4 systems affected in the brain by anti-psychotics according to the dopamine theory- and what aspects of schizophrenia do they target

A

Mesolimbic pathway –> +ve symptoms

Mesocortical pathway –> -v3 symptoms

Nigrostriatal –> EPSEs

tuberoinfundibular –> prolactin

51
Q

what are some uses of antipsychotics in medicine

A

psychosis
mood stabilisation in BPAD
antidepressant augmentation
Tourettes

52
Q

give some examples of typical antipsychotics

A

Haloperidol, zuclopenthixol, chlorpromazine

53
Q

give some examples of atypical antipsychotics

A

Clozipine, olanzipine, risperidone, aripriprazole

54
Q

what are the pros and cons of clozapine?

A

pros:
-best drug for treating psychosis
-only antipsychotic that has evidence for treatng the negative Sx

Cons:
-dirty drug binding to 30+ receptors means it has lots of adverse effects and SEs
- high risk of rebound psychosis if stopped abruptly
SEs:
-sedation
-neutropenia/ leukopenia/agranulocytosis
- myocarditis, cardiomyopathy
-increased appetite and wt gain
-lowers seizure threshold
- prothrombotic
-severe constipation -> bowel perf
-low BP, dizziness
-double vision
-hypersalivation

NB: due to all these SEs, clozipine is only used in Rx resistant psychosis

55
Q

What needs to be monitored before and during antipsychotic treatment

A

starting ECG and regular checks (QTc prologation)
regular FBCs (esp clozipine)

56
Q

examples of some antipsychotics available as depots

A

zuclopenthixol
flupentixol
haloperidol
olanzepine
aripriprizole
paliperidone

57
Q

how long does it take for the sedative and antipsychotic effects to kick in

A

sedative –> rapid, within mins-hrs

antipsychotic –> within 1-2weeks, peak benefit after 6 weeks

58
Q

what do you use for rapid tranquilisation in a severely agitated psychiatric pt

A

IM olanzepine or haloperidol

(in medicine usually use short acting benzo eg. lorazepam for sedation in severely agitatied)

59
Q

What do you need to be aware of/ cautious about when giving IM olanzepine?

A
  1. not to give IM olanz within 1hr of IM lorazepam due to risk of respiratory depression
  2. no more than 3 days of IM olanzepine due to risk of post injection syndrome
60
Q

what are the Sx of hyperprolactinaemia in women

A

reduced libido
amenorrhoea
galactorrhea
osteoporosis (dop potentiates effects of oestrogen)

61
Q

what are the Sx of hyperprolactinaemia in men

A

reduced libido
erectile dysfunction
gynaecomastia
galactorrhea

62
Q

what antipsychotics do not affect prolactin

A

quetiapine
ziprasidone

use with aripriprazole

63
Q

what are the normal QT intervals and when is it really concerning?

A

men <440ms
women <470ms

if over >500ms v.v dangerous!

64
Q

what does the QT interval represent and what happens if it is prolonged

A

ventricular depolarisation and repolarisation

prolongation risks developing torsades de pointes –> polymorphic VT –> reduced CO –> shock –> death

65
Q

what are the causes of prolonged QT interval

A

long QT syndrome
electrolytes: low k, low Mg, low Ca
drugs: antipsychotics (esp haloperidol), citalopram, venlafaxine, clarithromycin, fluconazole

66
Q

which antipsychotics have no to low effect on QTc

A

no- aripriprazole, zuclopenthixole, lurasidone

low- clozapine, olanzepine, risperidone

67
Q

neuroleptic malignant syndrome:
RFs, features, investigations, management

A

RFs:
high dose typicals, rapid dose change, male, younger age

features:
hyperthermia/fever, rigidity/tremor, hyperreflexia, clonus, low BP, tachycardia

Investigations:
Bloods:
leukocytosis, enzymes high CK, renal function tests (rhabdomyolysis), LFTs deranged

Managament
1. stop antipsychotic
2. admit to medical ward/ ITU
3. supportive with fluids, electrolytes and cool
4. benzos for rigidity
5.bromocriptine (dop agonist)

68
Q

what are the features of EPSEs?

A

Parkinsonism:
-rigidity, tremor, bradykinesia, shuffle, pin rolling, hypomimia, reduced arm swing, stooped

acute dystonia:
- gurning, upward eye movements (oculogyric crisis), head and neck twisting (torticollis), compromised airway (laryngeal dystonia)
–> Mx with anticholinergics eg. procyclidine

akanthisia
- restlessness, trouble staying still, pacing, rocking back and forth
–> Mx: change meds, diphrenhydramine, propranolol

tardive dyskinesia (chronic antipsychotic use)
- lip smacking, tongue protrusion, chewing

69
Q

What metabolic effects to antpsychotics have?
+Mx

A

more common in atypicals
wt gain, dyslipidaemia, insulin insensitivity (T2DM)

esp- clozipine, quetiapine, olanzeptine (those which affect the H1 receptor)

Mx:
monitor wt, BP, lipids, HbA1c
education on lifestyle
statins, diabetic meds, antihypertensives

70
Q

MOA of SSRIs

A

Stops the channels from clearing serotonin from the gap between neurones which means there is a build up of serotonin and this is able to stimulate the nerves in your brain

71
Q

How does lithium work (explaining to a pt)

A

Its not fully understood but it basically works to change the release of certain chemicals in your brain allowing you to have more control over your emotions

72
Q

drugs CI in pregnancy

A

Lithium –> ebsteins anomaly
sodium valporate, carbamazepine –> NTD
SSRI (paroxetine highest risk of CHD in 1st trim or persistant pulmonary hypertension in 3rd trim)- encourage psychological approaches

73
Q

drugs CI in breastfeeding (All for Obs)

A

BREAST

Benzodiazepines
Radioactive isotopes
Ergotamine/ caffeine
Amiodarone, amphetimines
Sex hormones, stimulant laxatives
Tetracyclines

74
Q

side effects of SSRIs

A

the 5 S’s

Suicidal ideation
Sexual dysfunction
Sleep disturbances (vivid dreams)
Stomach (wt gain, N&V)
Serotonin syndrome

Psychiatry (4 decks)

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