Psych medications Flashcards
what do we need to advise patients to avoid with MAO inhibitor medications?
avoid tyramine containing food
should we use benzodiazepines long term or short term
short term, as they are very addictive
what are the indications for anti-depressants?
depression
anxiety disorders
neuropathic pain
what are TCA generally used for now?
refractive depression and neuropathic pain
what is the anti-depressant that we prescribe for children?
fluoxetine
which anti-depressants usually are associated with withdrawal syndrome?
paroxetine and venlafaxine
what anti-depressant works particularly well in bulimia?
paroxetine
what type of drug is mirtazepine?
alpha 2 antagonist
main side effects of sertraline?
gastrointestinal upset- nausea, diarrhoea
what are some general considerations before starting on anti-depressants?
- that when starting the drug, suicide risk/anxiety increases initially
- caution with history of bleeding- some antidepressants can interfere with platelet number. caution in warfarinised patients
- advise about long term side effects- generally sexual dysfunction is the main one associated with non-compliance
how should we commence anti-depressant therapy? which drug, which dose, how long?
What are the general practice points of anti-depressants
First line is SSRI.
Start with small dose, then escalate to maximum full dose. Trial for 6 weeks- as that is when you start getting effect
If tolerated, treat for 6-12 months
Taper dose/wean at the end of treatment.
If SSRI not tolerated after 6 weeks, taper slowly then change within class or change to drug from another class.
what are some augmenting pharmacological therapies for anti-depressants?
second anti-depressant, thyroxine, second generation agents, lithium
what are the drugs that we can use for anxiety
• Benzodiazepines
• Buspirone
• Anti-depressants
Beta blockers
which psychiatric disorders do we NOT use benzodiazepines with?
OCD and PTSD
how do benzodiazepines work?
act on chloride channels
what is the difference between benzodiazepines used for sleep disturbance as compared to anxiety?
benzos used for sleep disturbance are generally short acting. benzos used for anxiety are generally longer acting
what are some withdrawal effects of benzodiazepines?
• Distorted vision • Depersonalisation • Risk of seizures- abrupt withdrawal • Muscular spasms Change in smell
main adverse effect of benzodiazepines?
psychomotor impairment
what are the z drugs?
Zopiclone + zolpidem
which out of typical and atypical anti-psychotics do we normally use nowadays?
atypical
name the three main anti-psychotics prescribed
risperidone, olanzapine, clozapine
SE of olanzapine?
increases PRL–> galactorrhoea, can also cause extrapyramidal symptoms
SE of risperidone?
weight gain–> pre-diabetes, extrapyramidal side effects, PRL elevation
SE of clozapine?
can cause agranulocytosis/ cardiomyopathy/weight gain–> need to do regular WCC and ECG/echo, risk of type 2 diabetes
+ drowsiness + hypersalivation!!!!
when would we consider intramuscular injection for anti-psychotic medication
when patient is non-compliant
what tests do we do prior to commencing a bipolar patient on lithium?
Need to do TFT, UEC, urinalysis, renal function, FBE, ECG before commencement of lithium
biggest SE of lithium?
polyuria and polydipsia (think diabetes insipidus)
what do we need to regularly check for patients on lithium?
• TFTs need to be done six monthly.
• Plasma levels of lithium needs to be monitored on a regular basis bc narrow therapeutic index
• Minimum effective plasma concentration is 0.4mmol/L
Trough of lithium plasma dose–> needs to be between 0.4 and 0.8 mmol/L (for maintenance/prophylaxis)
SE of lithium
metallic taste, nausea, diarrhoea, epigastric discomfort, weight gain, fatigue, headache, vertigo, tremor, acne, psoriasis, leucocytosis, nephrotoxicity (below), hypothyroidism (usually asymptomatic), hypercalcaemia, hyperparathyroidism, benign T wave changes on ECG
what else other than lithium can we use for bipolar disorder?
anticonvulsants, e.g. valproate, carbamazepine, lamotrigine
when do we avoid lithium in pregnancy?
first trimester, and during breast feeding
what is the mechanism of action of anti-psychotic medications?
- inhibit dopamine 2 receptors
- modulate nerve growth factors
- 2nd gen drugs also serotonin receptors
which out of second generation anti-psychotic medications is most associated with extrapyramidal side effects?
risperidone
how might we manage extrapyramidal side effects of anti-psychotic drugs?
benztropine IM (anti-cholinergic)
name the two most common first gen typical anti-psychotics
haloperidol and chlorpromazine
what are the key symptoms of neuroleptic malignant syndrome as provoked by anti-psychotics?
hypertonia, fever, autonomic instability, delirium
how to treat akathesia?
beta blockers e.g. propanolol
what are some signs of lithium toxicity?
nausea, diarrhoea, tremor, dizziness, thirst/polydipsia, altered consciousness, spasticity/muscle spasms (if severe)
what can cause lithium toxicity?
renal impairment- ACE inhibitors, NSAIDs
dehydration
half life of lithium?
30 hrs
what is cymbalta?
duloxetine
what is lexapro?
escitalopram
what is prestiq?
desvenlafaxine
what is valdoxen?
aglomelatonin
what is seroquel?
quetiapine- antipsychotic
what SE of quetiapine is useful for some patients?
helps with sleep
how long on anti-psychotics does it take for psychotic symptoms to remit? And what would we consider if the symptoms do not remit?
usually reduced psychotic symptoms occur between 3-6months after commencing anti-psychotics. If not resolved, then we consider chlozapine
a patient is on both anti-psychotic medication and benzodiazepines. Which would need to be ceased if the patient commences ECT?
benzodiazepine would need to be ceased as it is an anti-convulsant- e.g. increases seizure threshold, shortens seizure duration and decreases the intensity of ECT seizure
what is paroxetine particularly good for?
PTSD and bulimia
if a patient is on lithium and is about to commence ECT, should we be worried?
yes- as it can cause acute delirium in high doses. So need to taper slightly e.g. withhold few doses prior to ECT or reduce the dose
what is the most addictive benzodiazepines?
alprazolam (xanax)
what type of benzodiazepines are more addictive than others?
short half life benzodiazepines
what can you use for emergency situations of anxiety (drugs)?
IV valium
IM midazolam
what is stilnox?
zolpidem
what is imovane?
zopiclone
what is normison
temazepam
what are some sedative anti-depressants?
agomelatine, mirtazepine, mianserin, amitriptyline
what are some sedative anti-psychotics?
quetiapine, chlorpromazine, pericyazine
SE/risks of zolpidem?
automatic actions + amnesia + addiction
why does lithium have a narrow therapeutic index of action?
it is an ion. Li2+. So this means that it has a narrow therapeutic index and you have to regularly measure serum lithium levels. If lithium is too low, it will be ineffective. If lithium is too high, then you can cause toxicity.
what are the therapeutic levels for lithium in management of acute mania and prophylaxis/maintenance?
Acute mania: 0.5–1.2 mmol/L.
Prophylaxis: 0.4–1 mmol/L.
what are some things that can alter lithium serum concentration?
Dehydration (may occur with gastrointestinal viral infections or high fever) causes higher lithium levels/ excessive sweating
●Increasing sodium intake causes increased sodium and lithium excretion and lower lithium levels
●Decreased sodium intake causes sodium and lithium reabsorption in the proximal tubule and an increase in serum lithium levels.
drug interactions such as diuretics/NSAIDs and ACE inhibitors
who are at risk of lithium toxicity?
- ill and dehydrated patients
- those with underlying renal impairment
- elderly who have reduced eGFR
- patients who are on drugs that increase lithium level
usual daily dose range for fluoxetine?
20-40mg
usual daily dose range for sertraline?
50-200mg
usual daily dose range for escitalopram?
10-20mg
usual daily dose range for paroxetine?
20-40mg
usual daily dose range for venlafaxine?
75-150mg
usual daily dose for desvenlafaxine?
50mg
what is effexor?
venlafaxine
what is arapax?
paroxetine
what is cymbalta?
duloxetine
what is prozac?
fluoxetine
main use for clozapine?
treatment resistant schizophrenia
need to try at least two other anti-psychotic medications
what are some depot forms of anti-psychotics?
risperidone
olanzapine (not commonly used now)
apiprazole
haloperidol
how do you manage acute mania pharmacologically?
lithium +/- anti-psychotics (olanzapine/risperidone/quetiapine)
perinatal complication of lithium in pregnancy
increased risk of ebstein’s anomaly (congenital tricuspid valve malformation)
what are some side effects of discontinuation syndrome in antidepressants?
Dizziness” • Tiredness” • Headache” • Depression” • Anxiety” • Insomnia” • Nausea
• Diarrhoea” • Emotional lability” • Poor concentration” • Flu-like symptoms” • Paraesthesia” • Visual disturbance”
what is largactil?
chlopromazine
what is zyprexa?
olanzapine
what is abilify? and what is good about it?
aripiprazole- less weight gain, no PRL elevation, less EPSE, no anticholinergic effects
what are the key differences between first and second gen antipsychotics
- 2nd gen less EPSE
- different receptor profile
- 2nd gen better at managing negative symptoms
- 2nd gen better efficacy in general (e.g. clozapine)
how might serotonin syndrome be precipitated?
- SSRI + SSRI
- SSRI + Li
- SSRI + Maoi/TCA
- SSRI + tryptan
what are some things you need to warn a patient about who is on chlopromazine?
can cause erythema when exposed to sunlight
can cause cholestatic liver dysfunction
higher risk of EPSE and tardive dyskinesia
can cause retinal pigmentation
other SE such as metabolic syndrome/PRL/sedation/orthostatic hypotension
what is the relationship between smoking and clozapine??
smoking –> increased metabolism of clozapine so clozapine levels decrease
so if the patient has stopped smoking, clozapine levels will rise
which SSRIs should we avoid in pregnancy/breastfeeding and why?
fluoxetine (long half life–> particular concern during breastfeeding)
paroxetine (fetal heart defect)
what electrolyte disturbance can SSRIs cause?
hyponatremia
