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Gp > Prescribing > Flashcards

Prescribing Flashcards

1
Q

Which guideline advises on starting, stopping and switching of antidepressants?

A

The maudsley guideline

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2
Q

Which antidepressants are most dangerous in overdose?

A

Tricyclic antidepressants

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3
Q

What is the main concern with tricyclic antidepressants in overdose?

A

Potentially fatal cardiovascular effects- tachycardia, postural hypotension, slowed cardiac conduction

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4
Q

What are the symptoms of serotonin syndrome?

A

Hyperthermia, confusion, rigidity/ tremor. (Insomnia, nausea, diarrhoea, hypertension, tachycardia, hyper-reflexia, agitation, myoclonus, rigidity)

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5
Q

Why should we worry about serotonin syndrome?

A

It can rapidly lead to resp failure, coma and potentially death.

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6
Q

When are SSRI’s contraindicated?

A

People:
-in a manic state of bipolar
- with poorly controlled epilepsy
- concurrent use of drugs known to prolong the QT interval or already known to have prolonged QT interval (citalopram and escitalopram)
- with severe hepatic impairment (sertraline)

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7
Q

What are common adverse effects of SSRI’s?

A

Cardiac- palpitations
GI- reduced appetite, diarrhoea, nausea, dry mouth
CNS- headache, dizziness, drowsiness, tinnitus, paraesthesia, tremor
Psychiatric- insomnia, anxiety
Skin- rash, hyperhydrosis

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8
Q

What are common interactions with SSRI’s that we should be aware of?

A

-can reduce seizure threshold
- can affect diabetic control
- increased risk of bleeding if taken with other drugs with bleeding risk.
-MAOI’s- risk of serotonin syndrome
(Concurrent use contraindicated)
- hyponatraemia- risk increased if used with other drugs that cause huponatraemia

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9
Q

What are the main three classes of antidepressants?

A

SSRI’s, SNRI’s, MAOI’s

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10
Q

Which class of antidepressants are best?

A

There is very little difference in terms of efficacy. Therefore choice made based on individual patient requirements- comorbidities, existing therapy, suicide risk, previous response to antidepressants.

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11
Q

What is the risk in the first few weeks of starting antidepressants?

A

Increased potential for agitation, anxiety and suicidal ideation.

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12
Q

Why are SSRI’s usually first line?

A

Better tolerated and safer in overdose than other classes. Sertraline shown to be safe in patients with unstable angina or recent MI.

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13
Q

SSRI’s vs Tricyclics?

A

Tricyclics have similar efficacy but are more likely to be discontinued because of side effects. Toxicity in overdose is also an issue.

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14
Q

How soon should patients be reviewed after commencing antidepressants?

A

1- 2 weeks initially.

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15
Q

How long should antidepressants be continued before considering whether to switch or increase?

A

At least 4 weeks (6 weeks in the elderly). If partial response, continue for another 2-4 weeks.

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16
Q

How long should antidepressants be continued after remission of symptoms?

A

6 months (12 months in the elderly and those with generalised anxiety disorder as chance of relapse is higher)

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17
Q

Can antidepressants cause suicidal thoughts/ behaviour?

A

Use of antidepressants has been linked to suicidal thoughts and behaviour especially in children, young people and patients with a history of suicidal behaviour.

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18
Q

Can antidepressants be used for anxiety?

A

For chronic anxiety (4weeks or more) it may be appropriate to use an antidepressant.

19
Q

Which antidepressants can be used for people with generalised anxiety disorder?

A

SSRI- escitalopram, paroxetine or sertraline (unlicensed)
SNRI- Duloxetine and venlafaxine are also recommended
If patient cannot tolerate, or treatment has failed to control symptoms pregabalin can be considered.

20
Q

How do tricyclic antidepressants work?

A

Block re-uptake of both serotonin and noradrenaline, although to different extents

21
Q

Name some sedating tricyclic antidepressants

A

Amitriptyline, clomipramine, dosulepin, doxepin, mianserin, trazodone, trimipramine.

22
Q

Name some less sedating tricyclic antidepressants

A

Imipramine, lofepramine, nortripyline.

23
Q

Name some SNRI’s

A

Venlafaxine, duloxetine, desvenlafaxine

24
Q

What is the difference between tricyclic antidepressants and SNRI’s?

A

Both block reabsorption of serotonin and noradrenaline, increasing the concentration of these neurotransmitters. Tricyclic antidepressants also block muscarinic, alpha 1 dare ethic and histamine receptors which gives a greater side effect profile.

25
Q

What are anticholinergic side effects of TCA’s?

A

Blurred vision, urinary retention, constipation, acute angle glaucoma.

26
Q

What do Hypnotics and anxiolytics do?

A

Sedatives- anxiolytics usually induce sleep at night and hypnotics sedate in the day

27
Q

What issues are there with prescribing hypnotics and anxiolytics?

A

Dependence and tolerance can make withdrawal difficult therefore should only be used in the short term for conditions with known cause

28
Q

What are the most commonly used anxiolytics and hypnotics?

A

Benzodiazepines

29
Q

What drugs are in the benzodiazepine class?

A

Diazepam/clonazepam/lorazepam/chlordiazepoxide/temazepam

30
Q

What are the indications for benzodiazepines?

A

Short term relief (2-4 weeks) of anxiety that is severe, disabling or causing the patient unacceptable distress- alone or in combination with insomnia or psychotic illness

31
Q

Can benzodiazepines be used to treat insomnia?

A

Only when it is severe, disabling or causing the patient extreme distress

32
Q

How should benzo’s be stopped?

A

Gradually because abrupt withdrawal may produce confusion, toxic psychosis, convulsions or a condition resembling delirium tremens.

33
Q

What are the symptoms of benzodiazepine withdrawal syndrome?

A

Insomnia, anxiety, loss of appetite, tremor, perspiration, tinnitus and perceptual disturbances.

34
Q

Over what timeframe does benzodiazepine withdrawal syndrome occur?

A

May develop at any time up to three weeks after stopping a long-acting benzodiazepine and within a day of a short acting one. Some symptoms may continue for weeks or months after stopping benzodiazepines.

35
Q

How long does it take to wean off benzodiazepines?

A

Short term users (2-4 weeks) can usually taper off within 2-4 weeks. However long term users should be withdrawn over a much longer period of several months or more.

36
Q

What should be clarified before prescribing hypnotics?

A

Cause of insomnia.
Sleep expectations.
Alcohol/ drug consumption

37
Q

What is transient insomnia?

A

People who normally sleep well and extraneous factors such as noise, shift work and jet lag are causing poor sleep. If hypnotic is indicated it should be short acting and only one or two doses.

38
Q

What is Short-term insomnia?

A

Usually related to an emotional problem or serious medical illness. May last a few weeks and May reoccur. A hypnotic may be useful but should not be given for more than three weeks. (Preferably only one week).

39
Q

What is chronic insomnia?

A

Long term difficulty sleeping usually caused by psychiatric disorders, abuse of drugs and alcohol. Other causes include daytime napping, pain, pruritis and dyspnoea.

40
Q

What are Zolpidem and Zopiclone?

A

Non- benzodiazepine hypnotics (sometimes referred to as z-drugs). They have a short duration of action and are not licensed for long term use.

41
Q

Can anti-histamines be used for insomnia?

A

Yes, such as promethazine, however prolonged duration of action can lead to drowsiness the following day. Sedative effect can diminish after a few days of continued use. Side effects include headaches, psychomotor impairment and antimuscarinic effects.

42
Q

What is the effect of alcohol on sleep?

A

It is a poor hypnotic because the diuretic action interferes with sleep during the latter part of the night. Also it disrupts sleep patterns

43
Q

What is the STOPP criteria?

A

Screening tool of older peoples potentially inappropriate prescriptions

44
Q

What is a medication review?

A

A structured, critical examination of a patients medicines with the objective of reaching an agreement with the patient about treatment, optimising impact of medicines, minimising the number of medication-related problems and reducing waste.

Gp (2 decks)

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