Psych medication Flashcards
Name 6 categories of antidepressants
Selective serotonin reuptake inhibitor (SSRI)
Noradrenergic and specific serotonergic antidepressant (NASSA)
Serotonin and noradrenaline reuptake inhibitors (SNRI)
Tricyclic Antidepressants (TCA)
Monoamine oxidase inhibitors (MAOI)
Serotonin 2 antagonist/reuptake inhibitors (SARI)
When should SSRIs be used?
Depression- 1st Line
Bipolar
Anxiety- Panic disorders, social anxiety, PTSD, OCD, chronic pain, eating disorders.
How do SSRIs work?
Selectively inhibits synaptic 5-HT reuptake transporters, thereby increasing synaptic 5-HT concentration
Give some side effects of SSRIs
‘Hangover’- N+V, diarrhoea, headache GI bleeds with NSAID Anxiety Insomnia Sexual dysfunction Hyponatraemia Increased suicide risk Seizures in epileptics Serotonin syndrome
Who should you be cautious giving SSRIs to?
Epileptics- lowers seizure threshold
Congenital long QT syndrome, bradycardia, hypokalaemia, hypomagnesemia, recent acute myocardial infarction, or uncompensated heart failure
Give some example agents of SSRIs
Fluoxetine Sertraline Citalopram Escitalopram Paroxetine
What is paroxetine used as first line for?
Anxiety
What can discontinuation of SSRIs cause?
Shivering, anxiety, dizziness, ‘electric shocks’, headache and nausea
What are NASSAs used for?
Depression- 1st line if have insomnia or poor appetite. 2nd line if SSRI failed. 3rd line in combo with SSRI.
How do NASSAs work?
Increases activity in the NA and 5-HT systems by blocking the negative feedback (presynaptic DA) of NA on presynaptic alpha-2 receptors.
What are some side effects of NASSAs?
Agranulocytosis
Constipation
Dizziness Falls Dry mouth GI upset with alcohol
Sedation
Weight gain
What should NASSAs not be taken with ?
Don’t take with MAOI
Be careful with other sedatives
Give an example of NASSAs
Mirtazapine
What is a potentially useful side effect of mirtazapine?
Sedation
What are SNRIs used for?
Depression- Not 1st line due to SE. Second line if SSRI and NASSA don’t work.
How do SNRIs work?
Potently block 5-HT and NA reuptake but do not block cholinergic receptors
What are some side effects of SNRIs?
Arrhythmias GI bleeds with NSAID Hypertension Insomnia Sexual dysfunction Hyponatraemia Increased suicide risk Cardiac arrhythmias Seizures in epileptics Serotonin syndrome
Who should SNRIs NOT be given to?
Do NOT give to those with hypertension or arrhythmias
Who should venlafaxine not be given to?
Do NOT give to those with hypertension or arrhythmias
Give an example SNRI agent
Venlafaxine
What drug does venlafaxine work well with?
Mirtazapine
What are TCAs used for?
Depression- Not 1st line due to SE and lethal in OD. Use if intolerant or unresponsive to SSRI. Rapid anxiolytic effects
How do TCAs work?
Inhibit presynaptic NA and 5-HT transporters therefore increase concentrations.
Anti-muscarinic.
What are some side effects of TCAs?
Sedation Confusion Dizziness Sexual dysfunction Constipation Tremour Blurred vision Postural hypotension Weight gain Arrhythmias (Long QT)
Who should TCAs not be given to?
Cardiac problems Elderly Suicidal intent (cardiotoxic in OD) Epilepsy (lower seizure threshold) Bipolar- can cause mania
Give some example TCA agents
Amtitriptyline Clomipramine Imipramine Lofepramine Dosulepin
What does cloipramine act on?
5-HT
What are MOAI used for?
Depression- Effective but only use in treatment resistant due to side effects.
Don’t use in bipolar due to ability to cause mania.
How do MOAI work?
MAO breaks down: NA and 5-HT (MAO1) and DA (MAO2). Inhibitors prevent this therefore increased levels.
Give some side effects of MOAI
Postural hypertension Drowsiness Insomnia Nausea Tiredness Constipation
What should MOAI not be taken with?
Causes dangerous hypertension when combined with tyramine
What foods contain tyramine?
Cheese, alcohol, red meat, caffeine
What can taking MOAI with tyramine cause?
Hypertensive crisis
What are some symptoms of a hypertensive crisis?
Headache, SOB, epistaxis, anxiety
Give some example agents of MOAI
Phenelzine
Tramylcypromine
Isocarboxazid
Moclobemide
When are SARI used?
Depression- When sedation is needed or as an add on to others
How do SARI work?
Block serotonin R and transporter
What are some side effects of SARI?
GI upset Dizziness Sedation Tiredness Headache Hypotension Oedema Priapism- Painful erection
Give an example SARI agent
Trazodone
Name three mood stabalisers
Lithium carbonate
Sodium valproate
Lamotrigine
What is Li2CO3 used for?
Bipolar- Relapse prevention. Good for both mania and depression.
Depression- Add to antidepressants in treatment resistant depression.
How does Li2CO3 work?
Decreases NA release and increases serotonin release
What are some side effects of Li2CO3
N+D Dry mouth Feeling of weakness Sedation Weight gain Fine tremor Polydipsia + polyuria Ankle swelling Renal impairment Arrhythmias Hypothyroidism and hypoparathyroidism
What is an issue for Li2CO3?
Therapeutic dose close to toxic dose. Causes Li toxicity
How do you treat Li toxicity?
Stopping Li and starting IV fluids
What are some symptoms of Li toxicity?
GI Upset Blurred vision Coarse tremor Ataxia Drowsiness Confusion Loss of consciousness Seizures Coma Death
How long does Li2CO3 take to have full effect?
18 months
What is sodium valproate used for?
Bipolar- Fast acting so good when rapid treatment needed or for cycling between mania and depression. Good when Li is ineffective, contraindicated or not tolerated.
How does sodium valproate work?
Blocks voltage sensitive sodium channels. Increase levels of GABA
What are some side effects of sodium valproate?
Sedation Tremour Dizziness GI Upset Tiredness Weight Gain
When must a woman NOT get sodium valproate?
When pregnant or trying to get pregnant.
What should you do before starting sodium valproate?
Check platelets and LFTs
What is lamotrigine used for?
Bipolar- Treatment and prophylaxis of depressive episodes.
How does lamotrigine work?
Blocks voltage sensitive sodium and calcium channels, and decreases glutamate release
Give some examples of lamortigine
Rash GI Upset Insomnia Sedation Dizziness Ataxia Stevens Johnson syndrome- Life threatening skin condition
What must you NEVER combine lamotrigine with and why?
Carbamazepine as causes neurotoxicity
What are the two categories of antipsychotics?
Typical
Atypical
What are the two categories of typical antipsychotics?
Phenothiazines
Butyrophenones
Name the most common phenothiazine
Chlorpromazine
Name the most common butyrophenone
Haloperidol
What are typical antipsychotics used for?
Bipolar- Treatment and prophylaxis of hypo/manic and depressive episodes.
Depression- Adjunct to antidepressants Psychosis- Acute positive symptoms
How do typical antipsychotics work?
Block DA1+2R thus reducing DA activity
Give some side effects of antipsychotics
Extrapyramidal- (Parkinsonism- Akinesia (inability to initiate movement), Akathisia (inability to remain motionless), bradykinesia, dystonia) Sedation Dizziness QT prolongation Neuroleptic Malignant Syndrome (Fever, muscle rigidity, altered mental state) Hypotension Dry mouth Urine retention Constipation Blurred vision Weight gain Glaucoma Arrhythmias Seizures
What kind of drug is chlorpromazine?
Phenothiazine typical antipsychotic
What is chlorpromazine used for?
Use for acute treatment resistant psychosis
What is a drawback of chlorpromazine?
Severe extrapyramidal symptoms
What kind of drug is haloperidol?
Butyrophenone typical antipsychotic
What is a benefit of butyrophenones over phenothiazine?
Less sedation
What are butyrophenone good for?
Acute psychosis and mania
What is haloperidol used for?
Use for alcohol withdrawal, delirium and acute psychosis
What should you prescribe along with antipsychotics?
Anticholinergics- to treat extrapyramidal symptoms
How do you treat the extrapyramidal symptoms in antipsychotics?
Antipsychotics
What are atypical antipsychotics used for?
Bipolar- Treatment and prophylaxis of hypo/manic and depressive episodes.
Depression- Adjunct to antidepressants Psychosis- First line chronic
How do atypical antipsychotics work?
Block DA1R thus reducing DA activity
What are some side effects of atypical antipsychotics?
Sedation Weight Gain Metabolic syndrome Diabetes Mellitus Extrapyramidal Stroke Constipation QT prolongation Neuroleptic Malignant Syndrome
Give some example agents of atypical antipsychotics
Olanzapine Risperidone Quetiapine Clozapine Amisulpride
What is olanzapine additionally used for?
Also used in PTSD
What are some additional side effects of olanzapine?
Bad for weight gain and hyperglycemia (T2DM)
What is a benefit of risperidone?
Low extrapyramidal SE
What is clozapine used for?
Use for treatment resistant schizophrenia, aggression and suicidal
What are some additional side effects of clozapine?
Bad for weight gain and hyperglycemia (T2DM). Agranulocytosis
What do you need to check before and after starting clozapine?
Full check (BP, FBC, U&E etc) prior to initiation, at 1 month and yearly thereafter.
Give some examples of anxiolytics?
Benzodiazepines
Beta Blockers
What are bzd used for?
Anxiety, panic disorder, phobic anxiety and insomnia- Relief
Acute psychosis- Sedation
Alcohol withdrawal and delirium
How do bzd work?
GABAR Agonist
What are some side effects of bzd?
Drowsiness 'Hangover' Nausea Delirium Aggression
What is a major issue with bzd?
Sedation can interfere with driving.
What should you not do while on bzd?
Drive
Give some example agents of bzd
Diazepam
Lorazepam
How should you stop bzd?
Tapper down dose to prevent withdrawal symptoms: insomnia, anxiety, twitching, visual hallucinations, hypersensitivity
What are BB used for?
Anxiety- Relief somatic symptoms
Who should you not give BB to?
Avoid in asthmatics
What is the most widely used BB in psych?
Propranolol
What are some symptoms of serotonin syndrome?
- Tachycardia
- Shivering
- Sweating
- Hyperthermia
- Hyperreflexia
- Renal failure
- Shock
Combinations of which drugs can cause serotonin syndrome?
SSRI
MAOIs
Lithium
St John Wort
What is agranulocytosis?
Severely low WCC
Give some symptoms of extrapyramidal side effects
- Acute dystonia – painful contraction of muscles in the neck, jaw or eyes
- Parkinsonism – decreased facial movements, shuffling gait, stiffness and sometimes tremor. Common in early weeks of treatment
- Akathisia – a feeling of restlessness and a need to walk around
- Tardive dyskinesia – uncontrollable grimacing movements of the face, tongue or upper body
What can Parkinsonism be mistaken for?
Negative symptoms in Schizophrenia
How do you treat Akathisia?
Reduce dose or give BB
What drugs can cause neuroleptic malignant syndrome?
Antipsychotics
What are some symptoms of neuroleptic malignant syndrome?
Pyrexia
Stiffness
Autonomic
Instability (tachycardiac, fluctuating blood pressure) Seizures
What are some signs of neuroleptic malignant syndrome?
Raised serum creatine kinase
Metabolic acidosis
Leukocytosis
When should you suspect NMS?
Fever without obvious cause
Which antipsychotic is closely associated with NMS?
Haloperidol
Which antidepressants are safe in pregnancy?
SSRI
TCA
ECT
Which mood stabilizers should not be used in pregnancy?
Lithium carbonate
Sodium valproate
How should antidepressants be stopped in an episode of mania?
Abruptly.
What neurotransmitter is closely associated with bipolar and schizophrenia?
Dopamine
What neurotransmitter is closely associated with depression and anxiety?
Serotonin
Which antipsychotic is good in pregnancy?
Olanzapine
What is the LD50 of diazepam?
2g/70kg
How should you decrease diazepam levels?
By 1mg per week