Psych drugs Flashcards
Someone with BPAD has tried quetiapine but it’s been ineffective. What’s the next step?
Try another of the oral antipsychotics from quetiapine, olanzapine, risperidone, haloperidol
Which TCA is commonly used for neuropathic pain and headache prophylaxis?
amitriptyline
Presentation of serotonin syndrome
- Tachycardia, HTN, fever
- Rigidity, clonus
- Increased reflexes
- Dilated pupils
Mx of neuroleptic malignant syndrome
- stop antipsychotic
- admit to medical ward / ICU
- IV fluids (monitor U+Es as risk of AKI from rhabdomyolysis)
- Dantrolene / bromocriptine if severe
Give 4 side effects on starting lithium
Initially: nausea, diarrhoea, vertigo, muscle weakness, ‘dazed’ feeling, fine tremor, polyuria, polydipsia
Can you breastfeed if you have BPAD?
Yes except if taking lithium
What 3 things need monitoring specifically if taking clozapine / olanzapine and why?
FBC for clozapine bc of neutropenia / agranulocytosis
Smoking bc stopping can increase the doses
At 1 month measure plasma glucose / HbA1c
Give 2 examples of SNRIs
Duloxetine
Venlafaxine
What are the - hyperprolactinaemia Sx seen from antipsychotics?
Galactorrhoea, amenorrhoea, gynaecomastia, hypogonadism, sexual dysfunction, osteoporosis
What are the extrapyramidal Sx seen from antipsychotics? Which types of antipsychotics have these side effects more often?
dystonic reactions, akathisia, tardive dyskinesia, oculogyric crisis, pseudoparkinsonism
More common with 1st generation (typicals)
Give 3 examples of when to avoid lithium
o Cardiac rhythm disorders o Sig. renal impairment o Untreated/untreatable hypothyroidism o Low sodium o Hx of DI o Addison's disease o Brugada syndrome o Breastfeeding o High risk of overdose o Refuse regular blood tests
Which antipsychotics are good if someone’s getting prolactin side effects?
aripiprazole, clozapine, quetiapine, olanzapine
What drugs cause serotonin syndrome?
SSRIs
MAOIs
Ecstasy / novel psychoactive stimulants
Which TCA is best if high risk of overdose?
lofepramine
What are the signs of lithium toxicity and at what levels might you see toxicity?
Signs occur at >1.5mmol/L
D&V, anorexia, muscle weakness, lethargy, dizziness, ataxia, lack of coordination, tinnitus, blurred vision, coarse tremor of extremities and jaw, muscle hyper-irritability, choreoathetoid movements, dysarthria, drowsy
Severe toxicity at >2mmol/L
Hyperreflexia, hyperextended limbs, syncope, toxic psychosis, seizures, polyuria, renal failure, electrolyte imbalance, dehydration, circulatory failure, coma, death
Who shouldn’t take sodium valproate and why?
NICE/MHRA recommend women of childbearing age:
DON’T take sodium valproate
• Unless very severe and no effective alternative
• Risks of fetal malformation, adverse neurodevelopment
Wean off it over 4w if already taking
• BUT only do this after speaking to a specialist
If taking, they should be enrolled in a preg prevention plan
Which antipsychotics are good if someone’s getting lots of sedation?
Amisulpride, Aripiprazole
What drug should you advise pts on lithium to avoid?
NSAIDs
What’s the antidote to lithium?
There isn’t one!
Supportive care
Possibly alkaline diuresis / dialysis
What do you give someone presenting with 9 days of persistently elevated mood who’s lost their job and started gambling? Presume you’re in secondary care
Manic episode
Oral antipsychotic from quetiapine, olanzapine, risperidone, haloperidol
How is lithium monitored?
ECG before starting if risk of/existing CVD
Measure lithium levels:
12 hours post-dose
Aim for plasma level 0.6-0.8mmol/L (0.8-1.0mmol/L if still sub-threshold Sx or previously relapsed)
1w after staring and 1w after every dose change
Weekly until levels stable, then every 3m
Measure BMI, U&Es, eGFR, Ca, TFTs every 6m
Which antipsychotics should be avoided if someone’s at increased risk of stroke and they’re elderly?
Risperidone
Olanzapine
Common side effects of TCAs
drowsiness dry mouth blurred vision constipation urinary retention lengthening of QT interval
What medication for OCD?
SSRI e.g. fluoxetine
Which antipsychotics are good if someone’s at risk of long QT?
Aripiprazole
Give 2 examples of SSRIs
- Sertraline
- Paroxetine
- Escitalopram
What drugs cause neuroleptic malignant syndrome?
Antipsychotics
Can also occur when stopping/reducing dopaminergic drugs suddenly (e.g. levodopa for Parkinson’s)
What are 4 risks of taking sodium valproate which you should advise pts
Be aware of signs of bleeding, liver disorders, pancreatitis
Teratogenic
Which antipsychotic’s ass.w. oculogyric crisis?
Aripiprazole
Which antipsychotic in particular should be avoided if someone’s at increased risk of seizures?
Clozapine
Give 4 risks of taking lithium long term
Hypothyroidism: continue lithium but give levothyroxine
Hyperthyroidism: specialist advice
Hyperparathyroidism: stop lithium
Nephrotoxicity, interstitial nephritis, nephrogenic DI, renal tumours
Rhabdomyolysis
What are the anticholinergic Sx seen from antipsychotics?
Dry mouth, blurred vision, urinary retention, constipation, cutaneous flushing
What needs monitoring if taking antipsychotics?
- Pulse and bp
- ECG
- BMI
- Lipids, plasma glucose/HbA1c
- Prolactin
Which antipsychotics are best avoided if breast feeding?
carbamazepine or clozapine
Someone with BPAD has tried olanzapine and risperidone but it’s been ineffective. What’s the next step?
Add lithium to one of their antipsychotics
What drugs can be given for severe cases of serotonin syndrome?
Cyproheptadine or chlorpromazine
Someone with a Hx of BPADI has been feeling really low and tired for the last 3 weeks. What do you give? Presume you’re in secondary care
Depressive episode can have one of:
o Quetiapine
o Olanzapine (+fluoxetine)
o Lamotrigine
Is lithium safe in breast feeding
Nah
Give 10 side effects / risks of antipsychotics
- Extrapyramidal Sx (dystonic reactions, akathisia, tardive dyskinesia, oculogyric crisis, pseudoparkinsonism)
- Anticholinergic Sx (dry mouth, blurred vision, urinary retention, constipation, cutaneous flushing)
- Salivary hypersecretion
- Weight gain
- Dyslipidaemia
- HTN
- Impaired glucose tolerance
- Increase stroke risk
- Increased VTE risk
- Hyperprolactinaemia (galactorrhoea, amenorrhoea, gynaecomastia, hypogonadism, sexual dysfunction, osteoporosis)
- Sedation
- QT interval prolongation
- Reduced seizure threshold
- Postural hypotension
- Abnormal LFTs
- Neuroleptic malignant syndrome
What are the signs of neuroleptic malignant syndrome? And the blood markers?
Fever, sweating, rigidity, confusion, fluctuating consciousness, fluctuating bp, tachycardiac
Raised CK, leucocytosis, raised LFTs, reduced reflexes
Which antipsychotics could you try if someone’s getting metabolic syndrome?
Aripirazole
Amisulpride
Which antipsychotics should be avoided if someone’s worried about weight gain?
2nd generation (atypicals), especially:
Clozapine
Olanzapine
Give 2 examples of drugs and doses for generalised anxiety disorder
All po od
- Sertraline 25mg
- Paroxetine 20mg
- Escitalopram 10mg
Others
- Citalopram 20mg
- Fluoxetine 20mg
- Fluvoxamine 50mg
- Venlafaxine (2nd line) 75mg
