PSA Specialties- Psych Flashcards
1st line drug depression
SSRIs:
Citalopram + Fluoxetine preferred
Sertraline useful post=MI
Fluoxetine for <16s
Most common SE of SSRIs
GI Sx
(+increased risk of bleeding, prescribe PPI if use of NSAID)
Most important counselling point for SSRIs
Be vigilant for increased anxiety, suicidal ideation, DSH + agitation after starting a SSRI
Which SSRI is associated with dose dependent prolongation of QT interval? What is the maximum daily dose?
Citalopram (+escitalopram)
Max: 40mg (20 for >65s/ hepatic Impairment)
Name 2 drugs that increase risk of serotonin syndrome in patents taking SSRIs
Triptans
Monoamine oxidase inhibitors
Which SSRI has increased risk of congenital malformation in pregnancy?
Paroxetine
When should SSRIs be reviewed?
<25y: 1w after initiation
>25y: 2w after initiation
Continue for at least 6 months after remission
First line drug for generalised anxiety disorder
Sertraline
First line drug for panic disorder
SSRIs
How should SSRIs be stopped?
Gradually reduce over 4w
Not necessary with fluoxetine
7 discontinuation symptoms of SSRIs
Increased mood change
Restlessness
Difficulty sleeping
Unsteadiness
Sweating
GI Sx: pain, cramping, D+V
Paraesthesia
Therapeutic range of lithium. At what concentrations does toxicity typically occur?
0.4-1.0 mmol/L
Toxicity: >1.5mmol/L
Excretion of Lithium
Long plasma half-life
Primarily excreted by kidneys
3 precipitants to lithium toxicity
dehydration
renal failure
drugs
4 drugs that can precipitate lithium toxicity
Diuretics (esp. thiazides)
ACE inhibitors/ ARBs
NSAIDs
Metronidazole.
6 features of Lithium toxicity
Coarse tremor (a fine tremor is seen in therapeutic levels)
Hyperreflexia
Acute confusion
Polyuria
Seizure
Coma
Management of Lithium toxicity
Mild-mod: volume resus with normal saline
Severe: Haemodialysis
+/- Sodium bicarbonate (limited evidence)- increases alkalinity of urine, promotes lithium excretion
10 Adverse effects of Lithium use
N+V
Diarrhoea
Fine tremor
Nephrotoxicity: polyuria, secondary to nephrogenic DI
Thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/ inversion
Weight gain
Idiopathic intracranial HTN
Leucocytosis
Hyperparathyroidism + hypercalcaemia
What is Lithium most commonly used for?
Mood stabilising in bipolar disorder
When should samples be taken to measure Lithium level?
12h post-dose
Describe monitoring requirements for lithium
Weekly + after each dose change until concentrations are stable
Once established, lithium blood level should ‘normally’ be checked every 3 months
Thyroid + renal function: every 6 months
2 examples of typical antipsychotics
Haloperidol
Chlorpromazine
3 examples of atypical antipsychotics
Clozapine
Risperidone
Olanzapine
List 4 extrapyramidal side effects associated with typical antipsychotics
Parkinsonism
Acute dystonia (Torticollis, Oculogyric crisis)
Akathisia (restlessness)
Tardive dyskinesia
List 4 antimuscarinic side effects associated with antipsychotics
Dry mouth
Blurred vision
Urinary retention
Constipation
Which class of antipsychotics has greater association with hyperprolactinaemia? What is a possible complication of this?
Typical
Galactorrhoea
List 3 antipsychotics that rarely cause hyperprolactinaemia
Aripiprazole
Clozapine
Quetiapine
Management of acute dystonia caused by antipsychotics
Procyclidine
Which antipsychotic is particularly associated with prolonged QT?
Haloperidol
Which class of antipsychotics has greater association to reduced seizure threshold?
Atypical
4 features of neuroleptic malignant syndrome
Pyrexia
Muscle rigidity
Autonomic lability: HTN, tachycardia + tachypnoea
Agitated delirium with confusion
Investigations for neuroleptic malignant syndrome
High CK
AKI (secondary to rhabdomyolysis) in severe cases
+/- leukocytosis
Management of neuroleptic malignant syndrome
STOP antipsychotic
Transferr to a medical ward
IV fluids to prevent renal failure
Dantrolene
or
Bromocriptine
For what period should benzodiazepines be prescribed for?
2-4w
Patients commonly develop a tolerance + dependence
What may happen if a patient withdraws too quickly from benzos?
Benzodiazepine withdrawal syndrome
very similar to alcohol withdrawal syndrome
may occur up to 3w after stopping a long-acting drug
List 9 features of benzodiazepine withdrawal syndrome
Insomnia
Irritability
Anxiety
Tremor
Loss of appetite
Tinnitus
Perspiration
Perceptual disturbances
Seizures
Describe monitoring of FBC, U&Es, LFTs when on antipsychotics
at the start of therapy
Annually
cCozapine requires much more frequent monitoring of FBC (initially weekly)
Describe monitoring of lipids and weight on antipsychotics
at the start of therapy
at 3 months
Annually
Name 2 antipsychotics that commonly cause weight gain
Clozapine
Olanzapine
Describe monitoring of fasting blood glucose and prolactin on antipsychotics
at the start of therapy
at 6 months
Annually
Describe monitoring of BP on antipsychotics
Baseline
Frequently during dose titration
Describe ECG monitoring on antipsychotics
Baseline
Describe cardiovascular risk assessment on antipsychotics
Annually
Why is frequent FBC monitoring essential during treatment with Clozapine?
Significant risk of Agranulocytosis
When is clozapine indicated?
If schizophrenia is not controlled despite the sequential use of >,2 antipsychotics (one of which should be a 2nd-gen antipsychotic), each for at least 6–8w
List 6 adverse effects of Clozapine
Agranulocytosis (1%)
Neutropaenia (3%)
Reduced seizure threshold
Constipation
Myocarditis: baseline ECG should be taken before starting Tx
Hypersalivation
Describe the effect of smoking on Clozapine concentration
Smoking (inc. cannabis) reduces amount of clozapine
High dose of Clozapine required if smokes
Describe initial management of delirium
Tx of underlying cause
Modification of the environment
What is the first line sedative used in delirium?
Haloperidol 0.5mg
How should delirium in Parkinson’s patients be managed?
AVOID antipsychotics (worsen Sx)
If urgent Tx required: Quetiapine/ Clozapine
When should Mirtazapine be taken?
Evening
as can be sedative
2 side effects of Mirtazapine
Increased appetite
Sedation
