Pharmacotherapy

Question 1

Antipsychotic drug indications.

Answer 1

1. Schizophrenia, schizoaffective disorder, delusional disorder
2. Bipolar disorder (especially manic phase)
3. Major depression with psychotic features
4. Some autism or Tourette’s syndrome
5. Psychosis associated with dementia or delirium

Question 2

Antipsychotic drug mechanisms of action.

Answer 2

1. Dopamine receptor blockers in the CNS
2. G-protein coupled receptors
3. Antipsychotic effect through blockade of post-synaptic D2 receptors
4. Blockade leads to up-regulation of dopamine receptors

Question 3

The four dopaminergic pathways.

Answer 3

1. Mesolimbic pathway
2. Mesocortical pathway
3. Nigrostriatal pathway
4. Tubuloinfundibular pathway

Question 4

Dopamine blockades clinical effect on the dopaminergic pathways.

Answer 4

1. Mesolimbic pathway: improves positive psychotic symptoms.
2. Mesocortical pathway: worsens cognition and negative symptoms.
3. Nigrostriatal pathway: extrapyramidal side effects.
4. Tubuloinfundibular pathway: increased prolactin.

Question 5

Antipsychotic drug classes.

Answer 5

1. 1st Generation - Typical
2. 2nd Generation - Atypical
3. 3rd Generation (not recognised) partial D2 antagonists.

Question 6

Generic names of (3) 1st Generation (Typical) antipsychotic drugs.

Answer 6

1. Haloperidol
2. Chlorpromazine
3. Pericyazine

Question 7

Generic names of (5) 2nd Generation (Atypical) antipsychotic drugs.

Answer 7

1. Aripiprazole
2. Clozapine
3. Olanzapine
4. Quetiapine
5. Risperidone

Question 8

Extrapyramidal Side Effects

Answer 8

1. Dystonia
2. Akathisia
3. Parkinsonism
4. Tardive dyskinesia

Question 9

Management plan for onset of Extrapyramidal Side Effects.

Answer 9

1. Reduce the dose or change antipsychotic.
2. Consider anticholinergic agents Benzotropine and Benzhexol to treat dystonia and parkinsonism.
3. Anticholinergics are ineffective for akathisia and tardive dyskinesia.

Question 10

Benzotropine dosage for extrapyramidal side effects.

Answer 10

1. Dystonia; 2mg IM intial then PRN

2. Parkinsonism; 1-2 mg PO BD or TDS (half dose for elderly)

Question 11

Metabolic adverse effects of antipsychotic medications.

Answer 11

1. Weight gain
2. Hyperglycaemia
3. Hyperlipidaemia
4. Glucose intolerance and diabetes

Question 12

Other adverse effects of antipsychotic medications.

Answer 12

1. Sedation
2. Postural hypotension.
3. Constipation
4. Hyperprolactinaemia
5. Neuroleptic malignant syndrome.
6. Prolongation of the QTc interval and sudden cardiac death

Question 13

Potential adverse effects of hyperprolactinaemia with antipsychotic medication use.

Answer 13

1. Amenorrhoea
2. Galactorrhoea
3. Gynaecomastia
4. Erectile dysfunction

Question 14

Additional adverse effects of Clozapine.

Answer 14

1. Agranulocytosis.
2. Myocarditis.
3. Smoking induces livers metabolism clozapine.

Question 15

Blood tests for Clozapine.

Answer 15

1. WBC’s and Serum Clozapine Levels
2. Weekly for first 18 weeks and then monthly
3. WBC must be greater than 3.5x 10-9L and neutrophils greater than 2.0x 10-9L

Question 16

The 4 common broad actions of benzodiazepines.

Answer 16

1. Anxiolytic
2. Sedative-hypnotic
3. Anticonvulsant
4. Muscle relaxant

Question 17

Generic names for short acting benzodiazepines.

Answer 17

1. Lorazepam

2. Temazepam

Question 18

Generic names for long acting benzodiazepines.

Answer 18

1. Clonazepam

2. Diazepam

Question 19

Class effects of benzodiazepines.

Answer 19

1. Drowsiness and cumulative sedation
2. Ataxia, dizziness
3. Respiratory depression
4. Ante-retrograde amnesia
5. Disinhibition

Question 20

Class interactions of benzodiazepines.

Answer 20

1. Increased effect with other CNS depressants
2. Ataxia and dysarthria with Lithium and antipsychotics
3. Delirium with Clozapine
4. Increases plasma concentrations of digoxin and phenytoin

Question 21

The 2 drug classes used for cognitive impairment in dementia.

Answer 21

1. Cholinesterase inhibitors aka (acetylcholinesterase inhibitors)
2. N-methyl-D-aspartate (NMDA) agonist

Question 22

The 3 cholinesterase inhibitors used to treat cognitive impairment in dementia.

Answer 22

1. Donepezil
2. Rivastigmine
3. Galantamine

Question 23

The NMDA agonist used as a potential adjunct therapy in dementia.

Answer 23

1. Memantine

Question 24

The mechanism of action for cholinesterase inhibitors.

Answer 24

1. Prevents acetlycholinesterase (enzyme) from breaking down acetlycholine (neurotransmitter) into choline and acetate.
2. This increases the levels of acetlycholine within the synaptic cleft.

Question 25

Common class adverse effects of cholinesterase inhibitors.

Answer 25

1. Increased dreams 2. Anorexia, nausea, vomiting, diarrhoea 3. Bronchoconstriction 4. Muscle cramps 5. Bradycardia, heart block, syncope

Question 26

Clinical approach to starting cholinesterase inhibitors for dementia.

Answer 26

1. Confirm probable diagnosis 2. Baseline cognitive function - MMSE 10-24 3. Check for history of PUD or GI problems 4. Select appropriate medication 5. Warn of potential side effects. 6. Arrange later review.

Question 27

First line medication (cholinesterase inhibitor) for dementia.

Answer 27

1. Donepezil

Question 28

What is the preferred medication (cholinesterase inhibitor) choice if there is a history of significant GI disease in the dementia patient.

Answer 28

1. Rivastigmine (transdermal patch)

Question 29

Indications for antipsychotic medications in patients with dementia.

Answer 29

1. Severe agitation and aggression with risk of harm. 2. Delusions and hallucinations. 3. Co-morbid pre-existing mental health conditions.

Question 30

What antipsychotic is currently the recommended first-line choice for behavioural and psychological symptoms of dementia.

Answer 30

1. Risperidone.

Question 31

Specific risks associated with antipsychotic use in dementia patients.

Answer 31

1. Increased risk of cerebrovascular events.

Question 32

Common SSRI's

Answer 32

1. Sertaline 2. Citalopram 3. Escitalopram 4. Fluoxetine

Question 33

Common SNRI's

Answer 33

1. Venlafaxine | 2. Duloxetine

Question 34

Common NaSSA's (Noradrenaline and specific serotonergic antidepressants)

Answer 34

1. Mirtazapine | 2. Mianserin

Question 35

Common TCA

Answer 35

1. Amitriptyline