Psych Drugs, Tx and SE's Flashcards
What are some typical and atypical antipsychotics? How do they differ in action?
Typical - block D2 receptors
- > Chlorpromazine
- > Haloperidol
Atypical - block D2, D3, D4, D5 and 5HT receptors, more selective than typical antipsychotics so less SEs
- > Aripiprazole
- > Risperidone
- > Clozapine (acts on D1+D4)
- > Olanzapine
What is the normal 1st line treatment for schizophrenia? What are some risks associated with these drugs?
1st line for Schizophrenia = atypical antipsychotic due to heavy SEs of typical antipsychotics + relapse risk
However
INCREASED risk of stroke and VTE in the elderly
What are the common side effects of typical and atypical antipsychotics? Specific drug SEs/risks?
Typical =
- > EPSEs (acute dystonia, akathisia, parkinsonisms and tardive dyskinesia)
- > Hyperprolactinaemia
Atypical =
- > Fewer EPSEs (acute dystonia, akathisia, parkinsonisms and tardive dyskinesia)
- > Less hyperprolactinaemia (Aripiprazole is good for this, Risperidone is NOT; also makes pregnancy harder)
- > Olanzapine = metabolic syndrome and hyperglycaemia, weight gain, sedation, anticholinergic
- > Quetiapine = QT prolongation
- > Clozapine = agranulocytosis (1%), sedation, weight gain, hyperglycaemia, lithium interaction, lowers seizure threshold, anticholinergic, myocarditis
What is an important SHx question to ask when on Clozapine?
Smoking + cessation - clozapine levels go up if the patient stops smoking suddenly, so if aware then can adjust accordingly
What is neuroleptic malignant syndrome? How is it Ix and managed?
Rare but life-threatening side effect of antipsychotics (most likely Haloperidol)
Gradual onset triad (4-11d later) of:
- Mental status change (Catatonia)
- Muscular rigidity
- Autonomic instability (hyperthermia >40degrees, labile BP, high HR, RR and sweating)
Ix:
- FBC –> Leucocytosis
- Rigidity –> rhabdomyolysis –> high CK >1000
- U&Es deranged
Mx:
- A-E approach
- Stop antipsychotics
- Supportive - fluids, dialysis
- Dantrolene, bromocriptine (muscle relaxant, dopamine agonist)
What relieving drugs can be used for which EPSEs?
Acute dystonia (early, sometimes within hours) - anticholinergic e.g. Procyclidine
Akathisia (hours to weeks) - switch drug/lower dose OR
+ Proporanolol/BDZ
Parkinsonism (days-weeks) - switch/lower dose OR anticholinergic e.g. procyclidine
Tardive dyskinesia (months-years) - switch medications (typical or clozapine) OR Tetrabenazine
What can antidepressants be used to treat? What are the different types of ADs?
Includes SSRIs, SNRIS, TCAs, NaSSAs, MAOIs, RIMAs + NARIs
Tx for:
- Depression
- Anxiety disorders
- OCD
- EDs
- PDs
What are the ‘discontinuation’ symptoms if you suddenly stop SSRIs?
'FIRM STOP': Flu-like Sx Insomnia Restlessness Mood swings
Sweating
Tummy problems (D&V, pain)
Off balance (Ataxia)
Paraesthesia
How do SSRIs work (time taken etc)? What are some specific drug indications? What are some CI drugs to be aware of?
SSRIs - block reuptake of 5HT in the synaptic cleft
Initially make you feel worse before you feel better (1-2w) as 5HT immediately increases but glutamate takes longer/initially suppressed and this discrepancy in timing causes slight worsening of Sx. Also increases anxiety, SH and suicide risk so must follow up those with high risk/<30 within 1w, otherwise 2w later!! Takes 2-4/4-6w to work
Specific indications:
Fluoxetine - depression in children/teenagers
Citalolopram - QT prolongation
Sertraline - good in those post-MI/CVD
Paroxetine - higher chance of discontinuation Sx
AVOID:
- Triptans –> ask if have migraines
- NSAIDs –> if need to be taken, prescribe PPI also
- > TCAs, MAOIs, venlafaxine for high suicide risk
How long must you take antidepressants for? How are they stopped or switched?
Take 4-6w to work, with worsening Sx in first 1-2w
Continue for at least 6m after remission if 1st episode
OR
2 years if a recurrence
Gradually stopped over 4w to avoid discontinuation symptoms
Switching:
Fluoxetine - reduce dose over 2w and wait another 4-7d after stopping before starting another SSRI (due to long half life)
Guidance online for class-switching also
What are some SE of SSRIs? What is serotonin syndrome and how is it managed?
5 S’s:
Suicide ideation (for 1-2w)
Stomach (N&V, diarrhoea, weight gain, dyspepsia; 5-10d)
Sexual dysfunction
Sleep (insomnia, 5-10d)
Serotonin syndrome (abrupt onset triad of change in mental status i.e. confusion/agitation/coma, neuromuscular changes i.e. jerking/twitching/hyperreflexia and autonomic instability (hyperthermia, hypertension, high HR/RR, sweating) and D&V –> Mx with A-E approach, stop antidepressant, BDZ e.g. Clonazepam and supportive Tx
+++
- Hyponatremia
- Akathisia
- Tremor, dizziness, blurred vision, sweating, headaches
How do SNRIs work and what is a common SE?
SNRIs - block 5HT and also NA reuptake (at high doses, blocks dopamine reuptake)
Key SE = Headache + SSRI SEs
E.g. Venlafaxine, Duloxetine
How do TCAs work? What are some SEs and CI’s?
TCAs - block reuptake of 5HT and NA, at high doses blocks all receptors and used in depression, at low doses blocks H1 and 5HT receptors and used for aiding sleep
Note:
- Can be fatal in OD - not given to those with suicide risk
- Do not give alongside MAO medications
SEs:
- Thrombocytopaenia
- Cardiac SEs - arrythymias, MI, stroke, postural hypertnesion
- Anticholinergic - tachycardia, urinary retention, dry mouth, constipation
- Seizures
- HYPONATREMIA
E.gs: Amitriptyline, Clomipramine, Imipramine, Lofepramine, Dolulepin
What are some NaSSA’s and NARI’s ? What SEs do they have?
NaSSA - noradrenergic ad specific serotonin antidepressant = Mirtazapine
SEs = sedation, weight gain (indicated when depressed + loss of appetite and insomnia)
NARIs = noradrenaline reuptake inhibitor e.g. Reboxetine, Atomoxetine
SEs = anticholinergic i.e. dry mouth, constipation, sweating, urinary problems
What are MOAI and RIMA’s? What are some risks/SEs?
MAOI - inhibits MAO inside the presynaptic neurone, reduction in use now
- Risk of hypertensive ‘cheese’ (tyramine) reaction
- NOT combined with other antidepressants, especially SSRIs, to avoid serotonin syndrome
E.g.s = Phenelzine, Isocarboxacid, Selegiline and Tranylcypromine
SEs = anticholinergic, cheese HTN reaction
RIMAs = reversible inhibitors of MAO e.g. Moclobemide
SEs = agitation/anxiety, sleep disturbance, nausea and HTN
How do BDZ work and what are their effects? What are Z-drugs and SEs?
BDZ = enhance GABA transmission by increasing FREQUENCY of the Cl- channels opening f (Barbs no longer used due to danger but inc length of time open)
Effects of BDZ:
- Anxiolytic
- Sedative
- Hypnotic
Z-drugs i.e. Zopiclone are like BDZ which treat insomnia if severe
SEs = increased fall risk, agitation, bitter taste, constipation, hypotonia, dry mouth, risk of dependency
What are the positive and negative effects of BDZ? What can be used to reverse its effects?
Positive:
- Wide therapeutic window (Flumanezil is a BDZ antagonist which can reverse effects)
- Mild effect on REM sleep
- Doesn’t induce liver enzymes
Negative:
- Sedation, confusion, anterograde amnesia, ataxia
- Potentiates other CNS depressants e.g. ALCOHOL
- Tolerance and dependence risk
- Cleft lip risk if used in 1st trimester
- Co-admin with warfarin/heparin increases free plasma concentration
What are mood stabilisers used for and what are the side effects and risks of each? What occurs in Li toxicity?
Mood stabilisers = Lithium, Valproate, Lamotrigine and Carbemazepine
Used for BPAD and Schizoaffective disorder
Lithium dose = 0.6-1.0mmol/L
SEs:
- Mild tremor
- Benign leucocytosis
- N&V
- Hypothyroidism and Hyperparathyroidism (high Ca)
- Nephrogenic DI
- Weight gain
- N&V
- OD = >1.2mmol/L –> coarse tremor, hyperreflexia, nystagmus, GI and CNS (ataxia, seizureS). May occur if dehydrated, on other drugs like NSAIDs, ACEi and diuretics which interrupt renal excretion, or deliberate OD.
- If suddenly discontinue then will RELAPSE
- Ebstein’s abnormality in pregnancy but weigh risk with patient
- Monitor 12h after first dose, 1w after and weekly until level is steady (~5w) and then 3m lithium levels and 6m U&Es and TFTs
Valproate:
- Highly teratogenic so not prescribed to women of childbearing age (spina bifida in pregnancy)
- N&V and diarrhoea
- Liver failure/DILI
- Hair loss
- Weight gain
- Thrombocytopenia
Lamotrigine:
- Severe skin rash (SJS)
Carbemazepine:
- Monitoring required
- Pregnancy use causes spina bifida
- Induces liver enzymes
What is ECT and what are its indications? What are the side effects? What are some CIs?
ECT induces a generalised tonic-clonic seizure under GA
- > Prolonged/Severe mania episode
- > Severe life-threatening, treatment resistant depression
- > Catatonia
Absolutely CI in raised ICP!!
SEs:
- Headache and nausea
- Muscle aches
- Cardiac arrhythmia
- Memory problems (retrograde»>anterograde amnesia)
- Long-term impact on memory is poorly understood but impairment can occur
What are some risk factors and protective factors for suicide?
Note: hanging/strangulation is the most common cause
Risk factors:
- M>F (3:1)
- Mental illness - BPAD, Depression
- Young male
- Occupation (Dr, Vet)
- Alone/unmarried/divorced or widowed
- Lower social class
- Substance abuse
Higher suicide intent after DSH:
- Preplanning
- Attempts to conceal
- Lack of help seeking after previous act
- Actions - will, note
- Violent methods
Protective factors:
- Married
- Lithium medication
- Religion/Faith
- No substance abuse
