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Psychiatry > Psych Drugs > Flashcards

Psych Drugs Flashcards

1
Q

Examples of First Gen Anti-psychotics

A

Haloperidol, Prochlorperazine, Chlorpromazine

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2
Q

MoA of 1st Gen anti-psychotics

A

D2 blockage mainly in the mesolimbic and mesocortical system
Also act on the Nigrostriatal pathway (EPSE)
And Tuberohypophyseal pathways (Prolactin SE)

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3
Q

Main Problem with 1st Gen Anti-psychotics

A

EPSE

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4
Q

What are the 4 variants of EPSEs associated with 1st Gen Anti-psychotics?

A

Acute dystonic reactions
Akathisia
Neuroepileptic malignant syndrome
Tardive dyskinesia

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5
Q

What is an Acute dystonic reaction (EPSE)?

A

Parkinsonian movements- Spasms
Torticollis
Oculogyric crisis (Eyes up)

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6
Q

What is Akathisia (EPSE)?

A

Inner restlessness so they cannot stop moving

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7
Q

What is Neuroepileptic Malignant syndrome (EPSE)?

A

Hypertonia, Hyperreflexia, Altered consciousness
AN dysregulation- Inc HR/Temp, Inc/Dec BP
Muscle breakdown can lead to Rhabdomyolysis and kidney failure

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8
Q

What is Tardive dyskinesia (EPSE)?

A

A late side effect of Anti-psychotics: Months to Years
Pointless repetitive movements like chewing
(Give Tetrabenazine)

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9
Q

Risk factors for Neuroepileptic Malignant syndrome when on Anti-psychotics?

A

Haloperidol
High dose
Young male patient

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10
Q

How do you manage Neuroepileptic Malignant syndrome?

A

Stop the causative drug
Iv fluids +/- Iv Benzos if agitated
+/- Dantrolene/Bromocriptine/Amantadine

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11
Q

Aside from Sz what can you give antipsychotics for?

A

N+V in palliative care

Severe Psychomotor agitation B/C they have a calming effect

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12
Q

What are the CI/Cautions to 1st Gen Antipsychotics?

A

Elderly have increase stroke/VTE/Sensitivity risk
Dementia- PARTICULARLY LBD
Parkinson’s- EPSEs make it worse

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13
Q

What is a good alternative to Antipsychotics for agitation in a Parkinson’s patient?

A

Lorazepam

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14
Q

Aside from EPSEs, what are the other SEs for anti-psychotics (5 key domains)?

A

Anti-adrenergic- Low BP, Inc QT, Erectile dysfunction
Hyperprolactinaemia- Menstrual disturbance
Antimuscarinic- X See/Pee/Poo/Spit
AntiHistamine- Wx inc, Sedation
Drowsiness

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15
Q

Antipsychotic treatment for acute agitation or violent behaviour

A

0.5-3mg IM Haloperidol

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16
Q

Key monitoring points for anti-psychotics?

A

Frequent review of symptoms
3 month then annually for Wx and Lipids
6 month then annually for Blood glucose
Annual- Bloods, ECG,

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17
Q

What should be investigated before starting on an Antipsychotics?

A

Bloods- FBC, LFTS, U&Es, Lipids, Prolac, Gluc, Chol
Wx
ECG for QT prolongation

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18
Q

Examples of SGAs?

A

Olanzapine, Risperidone, Aripiprazole, Clozapine, Quetiapine

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19
Q

Differences between SGAs and FGAs?

A 
SGAs:
Wider therapeutic range
Better for -ve symptoms + Better efficacy
FEWER EPSEs
MORE METABOLIC SEs
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20
Q

In what co-morbid condition is Olanzapine bad for?

A

DM

Increases weight and cholesterol

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21
Q

What are the Side effects of SGAs (Excluding Clozapine)?

A

EPSEs (Fewer vs FGAs)

Metabolic: Wx gain, DM, Lipid changes
Risperidone not great for sleep
Sexual dysfunction, Menstrual disturbance, Antimuscarinic SEs, Drowsiness

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22
Q

When is Clozapine typically indicated in Sz?

A

When they have not responded to two or more antipsychotics with at least 1 being an SGA

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23
Q

What is different about Clozapine’s MoA vs other SGAs?

A

Less D2 receptor blockage

Increased D4 receptor and 5-HT R subtype blockage

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24
Q

Main risks associated with Clozapine?

A 
AGRANULOCYTOSIS
myocarditis
Wx increase
Seizures
Excess Salivation
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25
Q

Describe the agranulocytosis associated with Clozapine

A

Leukopenia… neutrophils <500/ul blood

Infection risk

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26
Q

When is Clozapine CI?

A

With Carbamazepine

History of neutropenia or Heart disease or other blood dyscrasias

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27
Q

What drugs does SGAs/clozapine interact with?

A

Dopamine blocking antiemetics
QT prolonging drugs
Sedatives

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28
Q

How do you monitor Clozapine?

A

Usual Antipsych monitoring
+ Weekly FBC initially
+ Must report infective symptoms!

If Red result can never have again, Amber= Monitor

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29
Q

How can SGAs be administered?

A

Oral or slow release IM depot

Test dose then fortnightly-> Monthly for depot

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30
Q

When should you be cautious prescribing a SGAs?

A

CVD

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31
Q

What pathways do anti-psychotics impact to cause side effects?

A 
Mesolimbic/Mesocortical 
Nigrostriatal
Tuberoinfundibular/Tuberohypophyseal
Anticholinergic
Anti-Adrenergic
Anti-histamine
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32
Q

What is lithium?

A

A mood stabiliser

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33
Q

What are the side effects of Lithium?

A 
GI upset 
DM like- Frequency, Polydipsia, polyuria 
Impaired urine conc= Oedema and Wx gain
HYPOthyroidism 
Metallic taste
Flattens T waves
Psoriasis worsens
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34
Q

What are the CI to Lithium treatment?

A

Cardiac and Addison’s disease as it can cause Na+ Depletion
Severe renal insufficiency as it is cleared via kidneys
Hypothyroidism
Pregnancy- Teratogenic

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35
Q

What two factors influence Lithium clearance?

A

Renal function

Fluid and sodium intake

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36
Q

What is the therapeutic level of lithium?

A

0.4-1mmol/L

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37
Q

What is the toxic level of lithium?

A 
>1.5= Some symptoms 
>2= Life Threatening
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38
Q

What drugs precipitate lithium toxicity?

A

ACEi, ARB, Thiazides, MethylDopa, NSAIDS

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39
Q

What factors facilitate lithium toxicity?

A

Drugs (see other) mostly those that are nephrotoxic
THINK: Dehydration (D+V, UTI, Hot weather, Alcohol)
OD

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40
Q

What are the symptoms of lithium toxicity? When would you consider it to be life threatening?

A

Blurring, Ataxia, Coarse tremor, Worsening GI symptoms

Hyperreflexia, convulsions, psychosis and renal failure= ?Death

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41
Q

How do you manage lithium toxicity?

A

Stop lithium
IV fluids
Dialysis
Treat cause

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42
Q

Drugs associated with serotonin syndrome?

A

SSRIs, MAOIs, Lithium (if used with others), SNRI and NaSSa

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43
Q

What baseline investigations are needed before starting lithium treatment?

A

Bloods- Especially renal function
ECG
PT

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44
Q

How is lithium administrated

A

Usually split doses throughout the day then once established take at night once

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45
Q

How do you monitor lithium treatment?

A

Weekly levels until stable concentration then 3 monthly
TFTS, U&Es and Ca2+ every 6 months
Do monitoring 12 hours post dose change

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46
Q

Stopping Lithium treatment

A

Gradually

Over 1-3 months

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47
Q

Important advice for patients on lithium regarding lifestyle

A

Maintain good fluid intake also avoid large changes in salt intake

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48
Q

Maximum recommended length of lithium treatment

A

<3-5 years

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49
Q

SSRI examples

A

Citalopram, Fluoxetine, Sertraline, Escitalopram

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50
Q

Key Side effects of SSRIs

A 
GI upset 
Appetite change
Restlessness that can disturb sleep
Hyponatraemia 
Decreased libido (ED)
Inc QT
Lower seizure threshold
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51
Q

What is serotonin syndrome

A 
AN hyperactivity- HR/BP/Sweating all increase 
Altered mental state
Neuromuscular excitation 
D&amp;V
Mydriasis (Dilation)
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52
Q

Who is at higher risk of adverse effects from SSRIs

A

Epileptics
Peptic ulcer disease patients
Young people
Liver disease

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53
Q

SSRIs and pregnancy

A

Increase heart defects if taken in 1st TM

Persistent Pulmonary HTN of the newborn if take in 3rd TM

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54
Q

Drugs associated with QT prolongation

A

SSRIs, Antipsychotics, Venlafaxine

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55
Q

What does using SSRIs with NSAIDS increase the risk of?

A

Peptic ulceration

Same for Aspirin

56
Q

Bleeding risk with SSRIs

A

Technically does increase the risk

Especially if used with anticoagulants etc

57
Q

Length of treatment with Antidepressants

A

Continue 4-6/12 after they feel better, 2 years if recurrent

Delayed onset of effects (4/52) although sleep and appetite should improve in a few weeks

58
Q

Review of SSRIs

A

1-2 weeks after starting

?Change if nil effect after 4 weeks or increase dose

59
Q

Stopping SSRIs

A

Dose reduction over 4/52

Otherwise will get flu-like symptoms

60
Q

Examples of MAOIs

A

Phenelzine, Isocarboxazid, Tranylcypromine, Iproniazid, Moclobemide

61
Q

Indications for MAOIs

A

2nd line for depression

Especially useful if phobias or atypical symptoms

62
Q

4 Categories of side effects seen in MAOIs

A

CNS effects
AN effects
GI effects
Hyponatramia + confusion

63
Q

CNS side effects of MAOIs

A

Think Increased activity

Insomnia, Agitated, Overstimulation, Anxiety

64
Q

AN effects of MAOIs

A

Dry mouth
Blurring
Postural hypotension

65
Q

Tyramine reaction

A

Associated with MAOI use as there is compromised amino acid metabolism

HTN CRISIS= Headaches, palpitations, Sweating, N&V

66
Q

How is someone’s diet altered when using MAOIs

A

Avoid strong cheeses, Meat, Marmite, Red wine, Poultry, Alcohol, Soy

MUST REDUCE THE TYRAMINE INTAKE

67
Q

MAOIs interactions with other drugs

A

Serotonin syndrome associated drugs
Hypoglycaemia inducing drugs are more potent
Other AD
Tyramine based drugs

68
Q

Who should MAOIs be avoided in?

A

HTN
CV or heart problems
Psychosis History
Liver dysfunction

69
Q

SNRI examples

A

Venlafaxine, Duloxetine

70
Q

Noradrenergic and specific serotonergic antidepressants (NaSSa) example

A

Mirtazapine

71
Q

MoA of SNRI and NaSSa

A

Both increase the availability of monamines
Weaker antagonism of muscarinic receptors so fewer antimuscarinic SE vs TCAs

NaSSa also have potent histamine antagonism

72
Q

General side effects of SNRI and NaSSa

A 
GI upset
Insomnia
Anxiety
Serotonin syndrome 
Suicidal ideation may increase!
73
Q

How does the MoA of NaSSa lead to specific side effects

A

Sedation and Appetite increase

This is because of strong histamine antagonism

74
Q

Sudden withdrawal of antidepressants

A

Flu-like symptoms
GI upset
Sleep disturbance

75
Q

Minimum time on Antidepressants

A

6 months usually

Can consider dose change from 4/52 and in special circumstances a drug change if poorly tolerated

76
Q

Principles of prescribing antidepressant dosages

A

Start on low dose and titrate up from this

77
Q

Examples of Tricyclic Antidepressants

A

Amitryptyline, Lofepramine, Clomipramine

78
Q

Mechanism of action of TCAs?

Which receptors are blocked?

A

Inhibit the uptake of Nor A and 5-HT

Blockade of: Muscarinic, Histamine, Alpha-adrenergic and Dopamine D2 receptors (MORE THAN SSRIs)

79
Q

Classification of the side effects of TCAs

A 
Antimuscarinic
Antihistamine/Anti-adrenergic
Cardiac
Brain
Dopamine blockade
80
Q

What are the antimuscarinic side effects of TCAs

A

Dry mouth, Constipation, Blurring, Retention

Cant spit, can’t poo, can’t wee, can’t see”

81
Q

Presentation of a TCA overdose

A 
Severe hypotension
Arrhythmias 
Convulsions 
Respiratory failure 
Coma
82
Q

What does TCA Overdose present as on an ECG

A

BROAD COMPLEX TACHYCARDIA

83
Q

How do you manage a TCA overdose

A

Stop the TCAs
IV Bicarb
IV lipid emulsion
Fluids etc

84
Q

Antihistamine/Antiadrenergic side effects of TCAs

A

Sedation, Hypotension and Wx gain

85
Q

Cardiac side effects of TCAs

A

Arrhythmias and ECG changes (Broad complex Tachy)

86
Q

Brain/CNS side effects of TCAs

A

Convulsions
Hallucinations
Mania

87
Q

Dopamine-blockage related side effects of TCAs

A

Breast changes
Sexual Dysfunction
EPSE

88
Q

Who is at higher risk of side effects from TCAs

A

Elderly, CVD, Epileptics

89
Q

Which Antidepressants should absolutely not be given with TCAs

A

MAOIs
Both increase serotonin
Can induce HTN, Hyperthermia (serotonin syndrome)

90
Q

Why are SSRIs preferred over TCAs for management of depression?

A

Overdose risk is very high and very dangerous in TCAs

91
Q

MoA of Sodium Valproate

A

Increase GABA

Inhibits Na+ channels to decrease neuronal excitability

92
Q

Indications for Valproate

A

Generalised and Absence seizures

BPD manic episodes and prophylaxis

93
Q

Common non-life threatening side effects of valproate

A 
GI upset
Thrombocytopenia
Hyponatraemia 
Liver enzyme inc transiently
Dose related tremor, ataxia, behavioural change
Curly hair growth
94
Q

Rare and potentially life threatening side effects of Valproate

A

Severe liver injury
Pancreatitis
BM failure
Antiepileptic hypersensitivity syndrome

95
Q

What are the features of Antiepileptic Hypersensitivity syndrome

A

1-8 weeks post-exposure
Fever, Rash, Lyphadenopathy
Liver, Haematological, renal dysfunction
Multi-organ failure

96
Q

Valproate and CYP450 enyzmes

A

INHIBITOR

also metabolised by CYP450…

97
Q

CYP450 inhibitors

A

Valproate, Macrolides, Fluconazole, Metronidazole, Alcohol binge

98
Q

Valproate and pregnancy

A

Contraception must be used
Teratogenic
NTDs

99
Q

Causes of Anti-epileptic Hypersensitivity syndrome

A

Most anti-epileptic drugs

100
Q

Review of Valproate medication

A

Initially in 1-2 weeks after starting
The regularly
?Dose/Drug change at 4 weeks

101
Q

Indications for Carbamazepine

A

Non-Lithium responsive BPD
3rd line for acute mania
Partial seizures
Neuropathic pain

102
Q

MoA of Carbamazepine

A

Increases the refractory period of Na+ channels

103
Q

Who should the use of Valproate be avoided in?

A

Pregnancy especially 1st TM

Hepatic and Renal impairment

104
Q

Side effects of carbamazepine

A 
Hyponatraemia
Agranulocytosis
Dizziness
Drowsiness
Headahce
SJS
Visual disturbance
Diplopia
105
Q

Examples of Benzodiazepines

A

Diazepam, Temazepam, Lorazepam, CHlordiazepoxide, Midazolam

106
Q

How do Benzodiazepines work?

A

Enhanced GABAa receptor binding= Cl- enters cells to increase depolarisation resistance
Leading to widespread CNS depressant effect

107
Q

Indications for Benzodiazepines

A

1st line for seizures and alcohol withdrawal
Sedation
Severe anxiety/insomnia

108
Q

CI and cautions for Benzo use

A

Elderly- Increases falls and cognitive impairment
Respiratory impairment/NM disease
Liver failure- Hepatic encephalopathy

109
Q

Which Benzo is metabolised least by the liver?

A

Lorazepam

Good for hepatic impairment

110
Q

Dose dependent side effects of Benzos

A

Drowsiness, Sedation, Coma

111
Q

Presentation of a Benzo OD? What do you give?

A

Lack of airway reflexes leads to obstruction
Cardio-respiratory depression

Flumazenil

112
Q

Maximum length of time recommended for Benzo use

A

4 weeks

113
Q

How do you reduce the risk of Benzo dependence

A

PRN

Limit treatment length <4 weeks

114
Q

What drugs could Benzos adversely interact with

A

Additive effects with other sedating drugs
Alcohol, Opioids
Cytochrome P450 inhibs may increase effects

115
Q

If there is an addiction to Benzos what should be used to wean them off?>

A

Diazepam

Long acting

116
Q

Advice to the patient regarding ADLs on Benzos

A

Do not drive or operate heavy Machinery after taking

117
Q

Best Benzos for seizures

A

Lorazepam 4mg Iv or Diazepam 10mg Iv

These are long acting

118
Q

Best Benzo for alcohol withdrawal

A

Oral Chlordiazepoxide

119
Q

Best Benzo for sedation

A

Midazolam as it is short acting

120
Q

Best Benzo for treating Insomnia

A

Temazepam 10mg PO bedtime

121
Q

Key side effects of Pregabalin

A 
GI disturbance- Constipation, Diarrhoea, Appetite change, Distension 
Confusion
Impaired concentration 
Headahce
Drowsiness 
ADDICTION
122
Q

Indications for Pregabalin

A

Focal seizures
Neuropathic pain
GAD

123
Q

Acetlycholinesterase inhibitors

A

Donepezil, Rivastigmine, Galatamine

124
Q

How do acetylcholinesterase inhibitors work

A

Increase cholinergic transmission

Both Muscarinic and Nicotinic

125
Q

Indications for Acetylcholinesterase inhbitors

A

Alzheimer’s Disease
Myasthenia Gravis
Reversal of pupillary dilatation
UMN lesion neurogenic bladder

126
Q

Non-CNS effects of Acetylcholinesterase inhibitors

A 
Relaxes bladder and bowel sphincter 
Stimulates bladder SM
Constricts pupils
Opens canal of Schlem 
Increases Sweat, Saliva and Bronchial secretions
127
Q

What are the side effects of Acetylcholesterase treatment

A

Abnormal dreams, Aggression, Agitation

MUSCARINIC- Cramps, Bradycardia, sweating, Hypersalivation, Bronchial secretions

NICOTINIC- muscle cramps

Cholinergic crisis

128
Q

What is a Cholinergic Crisis

A

Induced by ACHesterase Inhibitors

Bradycardia, Pupilalry constriction,
NMJ overstimulation
Weak muscles and fasiculations
Convulsions

129
Q

Cholinergic crisis vs Myasthenia Gravis

A

In latter the pupils are normal, No excess secretions

There is also a Tachycardia

130
Q

Who should Acetylcolinesterases be avoided in

A

Pregnancy
Breast feeding
Asthma/COPD (Inc bronchial secretions!)
CV disease (Bradycardia, Hypotension risk)

131
Q

What is Memantine

A

Uncompetitive NMDA R antagonist
Blocking the impact of a tonic increased Glutamate
To ameliorate neuronal dysfunction

132
Q

Indications for Memantine

A

Generally 2nd line for AD- Adjunct or alternative if other therapies don’t work
Monotherapy if severe

133
Q

Side effects of Memantine

A

Dizziness, Headahces, Constipaiton, Somnolence

Inhibits Prolactin release

134
Q

Monitoring of Dementia drugs (Acetylcholiesterase inhibitors and Memantine)

A

6/12 reviews
Use MMSE and Global/Functional/Behvaioural assessments
CHECK ECG AND HR Prior to starting at at reviews

135
Q

Importance of checking ECG/HR regularly when using Anti-Dementia Medication

A

Can cause AV Block

Psychiatry (2 decks)

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