Psych Pharmacology Flashcards
1
Q
Name the main drug classes of antidepressants
A
- SSRIs
- SNRIs
- TCAs
- NaSSAs
- SARIs
- MAOIs
2
Q
What does SSRI stand for?
A
Selective Serotonin Reuptake Inhibitor
3
Q
What does SNRI stand for?
A
Serotonin and noradrenaline reuptake inhibitor (SNRI)
4
Q
What does TCA stand for?
A
Tricyclic antidepressant
5
Q
What does NaSSA stand for?
A
Noradrenergic and specific serotonergic antidepressant (NaSSA)
6
Q
What does SARI stand for?
A
serotonin reuptake inhibitor (SARI)
7
Q
What does MAOI stand for?
A
Monoamine oxidase inhibitor (MOAI)
8
Q
Name some egs of SSRIs
A
- Fluoxetine,
- sertraline,
- paroxetine,
- citalopram,
- fluvoxamine
9
Q
Name some egs of SNRIs
A
- Venlafaxine,
- Duloxetine
10
Q
Name some egs of TCAs
A
- Amitriptyline,
- lofepramine,
- clomipramine,
- imipramine
11
Q
Name an eg of NaSSAs
A
Mirtazapine
12
Q
Name an eg of SARIs
A
Trazodone
13
Q
Name some egs of MAOIs
A
- Phenelzine,
- tranylcypromine,
- isocarboxazid
14
Q
What are the actions of SSRIs
A
Antagonises:
- serotonin reuptake pump
15
Q
What are the actions of SNRIs
A
Antagonises:
- serotonin reuptake pump
- noradrenaline reuptake pump
- dopamine reuptake pump (in high doses)
16
Q
What are the actions of TCAs
A
Antagonises:
- serotonin reuptake pump
- noradrenaline reuptake pump
- a-adrenergic receptor
- dopamine reuptake pump (slightly)
- muscarinic receptors
- histaminergic receptors
17
Q
What are the actions of NaSSAs
A
Antagonises:
- 5HT (serotonin) receptor
- a2-adrenergic receptor
- muscarinic receptor (slightly)
- histamine-1 receptor
18
Q
What are the actions of SARIs
A
Antagonises:
- a1-adrenergic receptor
- muscarinic receptor (slightly)
- histamine-1 receptor
19
Q
What are the actions of MAOIs?
A
Nonselective and irreversible inhibition of:
- monoamine oxidase A and B
20
Q
What are the SEs of SSRIs?
A
21
Q
What are the SEs of SNRIs?
A
Same as SSRIs but greater
22
Q
What are the SEs of TCAs?
A
23
Q
What are the SEs of NaSSAs?
A
24
Q
What are the SEs of SARIs?
A
same as TCAs
25
What are the side effects of MAOIs?
* **Hypertensive crisis** (secondary to tyramine ingestion i.e. cheese reaction)
* **Serotonin syndrome**
* Occurs because MAOIs increase 5-HT
* Giving other antidepressants with a strong serotonergic effect (SSRIs, clomipramine, imipramine) at the same time as MAOIs increases the risk of serotonin syndrome; so does giving opiates
* Triad of neuromuscular abnormalities, altered consciousness, autonomic instability
26
Which food/drugs must be avoided in conjunction with MOAIs?
27
What is discontinuation syndrome?
* abrupt withdrawal of any antidepressant (except fluoextine)
* SSRIs with short half-lives (e.g. paroxetine, sertraline) and venlafaxine are particular culprits
* ~ → discontinuation syndrome
* symptoms:
* GI disturbance,
* agitation,
* dizziness,
* headache,
* tremor
* insomnia.
28
Name egs of mood stabilisers
**lithium**
_anticonvulsants_:
* **sodium valproate,**
* **carbamazepine**
* **lamotrigine**
29
How does lithium work as a mood stabiliser?
modulate the neurotransmitter-induced activation of second messenger systems
30
How do sodium valproate, carbamazepine and lamotrigine work as mood stabilisers?
* inhibit activity voltage-gated sodium channels
* enhance GABA- ergic neurotransmission
31
What are the indications of lithium?
* **Acute mania**
* **Prophylaxis of bipolar affective disorder** (prevention of relapse)
* **Treatment-resistant depression** (lithium augmentation)
32
What are the indications of sodium valproate?
* **Epilepsy**
* **Acute mania**
* **Prophylaxis of bipolar affective disorder** (second-line)
33
What are the indications of Carbamazepine?
* **Epilepsy**
* **Prophylaxis of bipolar affective disorder** (third-line)
34
What are the indications of Lamotrigine?
* **Epilepsy**
* **Prophylaxis of depressive episodes in bipolar affective disorder** (third-line)
35
What is the therapeutic window of lithium?
Therapeutic levels:
* **0.4–0.8 mmol/L** when used adjunctively for depression;
* **0.6–1.0 mmol/L** for treatment of acute mania and for bipolar disorder prophylaxis
36
When might lithium levels in the blood rise, other than due to increased dose?
_Decreased clearance:_
* renal impairment (e.g. in older adults, dehydration)
* dehydration (D&V, inadequate fluid intake)
* sodium depletion.
_Drugs that increase lithium levels:_
* diuretics (especially thi- azides),
* NSAIDS
* angiotensin-converting enzyme (ACE) inhibitors
37
What are the SEs of lithium?
* **General**:
* Thirst, polydipsia, polyuria, weight gain, oedema, Fine tremor, Precipitates or worsens skin problems, Teratogenicity
* **Neuro**:
* Concentration and memory problems
* **Endo**:
* Hypothyroidism, Hyperparathyroidism
* **Renal**:
* Impaired renal function
* **Cardiac**:
* T-wave flattening or inversion
* **Haem**:
* Leucocytosis
38
What are the signs of lithium toxicity?
* **1.5–2mmol/L:**
* **GI**: nausea and vomiting,
* **neuro**: apathy,
* **MSK**: coarse tremor, ataxia, muscle weakness
* **\>2mmol/L:**
* **neuro**: nystagmus, dysarthria, impaired consciousness, hyperactive tendon reflexes, convulsions, coma
* **renal**: oliguria,
* **CV**: hypotension
39
Which Ix are required before starting lithium?
* FBC
* U&Es
* Calcium
* Thyroid function
* Pregnancy test (in women of childbearing age)
* ECG (if cardiac disease or risk factors)
40
Describe the blood monitoring prior to lithium Tx
**_Lithium blood levels:_**
* monitored **weekly** after starting Tx **until a therapeutic level has been stable for 2 consecutive weeks**
* then **every 3 months** for the **1st year**,
* then **every 6 months** (unless the patient is at high risk for complications from lithium or has poor concordance).
**_Renal function, calcium and thyroid function:_**
* monitored **every 6 months** or more frequently if there is any evidence of impairment
41
What are the SEs of sodium valproate?
* **GI**:
* Increased appetite and weight gain
* Nausea and vomiting
* **Neuro**:
* Sedation and dizziness
* **CVS**:
* Ankle swelling
* **Misc**:
* Hair loss
* Tremor
* Haematological abnormalities (prolongation of bleeding time, thrombocytopenia, leucopenia)
* Raised liver enzymes (liver damage very uncommon)
42
What are the SEs of carbamazepine?
* **GI**:
* Nausea and vomiting
* Raised liver enzymes (hepatic or cholestatic jaundice, rarely)
* **Derm**:
* Skin rashes
* **Neuro**:
* Blurred or double vision (diplopia)
* Ataxia
* drowsiness,
* fatigue
* **Haem:**
* Hyponatraemia and fluid retention
* Haematological abnormalities (leucopenia, thrombocytopenia, eosinophilia)
43
What are the SEs of lamotrigine?
* **GI**:
* Nausea and vomiting
* **Derm**:
* Skin rashes (consider withdrawal) - ?Stephen-Johnsons syndrome (particularly in first 8 weeks of use)
* **Neuro**:
* Headache
* Aggression, irritability
* Sedation & dizziness
* **Misc**:
* Tremor
44
Compare the different monitoring required of different mood stabilisers
* **Lithium**:
* _Prior to starting:_
* Medication review, blood tests (FBC, U&Es, eGFR, TFTs, Ca), pregnancy test, (ECG if CVD)
* _Once started:_
* Lithium plasma levels weekly (12hrs post-dose), until level has been stable for 4wks, then every 3 months (start monitoring from start if dose changed);
* Every 6 months: FBC, U&Es, eGFR, TFTs, Ca
* **Sodium valproate:**
* _Prior to starting_:
* BMI, FBC, LFTs, pregnancy test
* _Once started_:
* BMI, FBC, LFTs & prothrombin time 6 months after treatment initiated, and yearly thereafter
* **Carbamazepine:**
* _Prior to starting_:
* FBC, U&Es, _LFTs_
* _Once started_:
* Periodic FBC, U&Es, _LFTs_
* **Lamotrigine**
* **none required**
45
Compare NICE guidelines for women of childbearing age using the different mood stabilisers
* **Lithium** → use reliable contraception, but avoid in those breastfeeding
* **Sodium valproate** → use with extreme caution in women of childbearing age (risk of foetal malformations if taken during pregnancy) → enrol on pregnancy prevention programme
* **Carbamazepine** → no teratogenic effects
* **Lamotrigine** → no teratogenic effects
46
What are the contraindications of lithium?
* **Lithium**:
* untreated hypothyroidism,
* heart failure,
* cardiac arrhythmia
* Pregnancy and breastfeeding
* *Caution in renal disease, cardiac disease and thyroid disease*
* *Caution in conditions causing Na imbalance, e.g. Addison’s disease*
47
What are the contraindications of sodium valproate?
* Hepatic dysfunction
* Porphyria
* Pregnancy and breastfeeding
48
What are the contraindications of carbamazepine?
* Atrioventricular conduction abnormalities (unless paced)
* History of BM depression
* Acute porphyria
* Pregnancy and breastfeeding
49
What are the contraindications of lamotrigine?
* *Caution in myoclonic seizures and Parkinson’s (may be exaggerated)*
* *Caution in hepatic and renal failure*
50
Summarise the contraindications of the mood stabilisers
* **Lithium**:
* untreated hypothyroidism,
* heart failure,
* cardiac arrhythmia
* Pregnancy and breastfeeding
* *Caution in renal disease, cardiac disease and thyroid disease*
* *Caution in conditions causing Na imbalance, e.g. Addison’s disease*
* **Sodium valproate:**
* Hepatic dysfunction
* Porphyria
* Pregnancy and breastfeeding
* **Carbamapezine**:
* Atrioventricular conduction abnormalities (unless paced)
* History of BM depression
* Acute porphyria
* Pregnancy and breastfeeding
* **Lamotrigine:**
* *Caution in myoclonic seizures and Parkinson’s (may be exaggerated)*
* *Caution in hepatic and renal failure*
51
Name the typical antipsychotics
* Chlorpromazine
* Haloperidol
* Sulpiride
* Flupentixol
* Zuclopenthixol
52
Name the atypical antipsychotics
* clozapine
* olanzapine
* quetiapine
* risperidone
* aripiprazole
53
Which antipsychotics can be given IM (long-acting depot)?
Typical:
* haloperidol
* flupentixol
* zuclopenthixol
Atypical:
* Olanzapine
* Risperidone
* Aripiprazole
54
How do all antipsychotics work (except clozapine)?
_Therapeutic effect:_
* Antagonism of dopamine D2 receptors in the mesolimbic dopamine pathway
_Side-effects_
* Antagonism of dopamine D2 receptors throughout the brain
* Antagonism of muscarinic, histaminergic and α-adrenergic receptors
55
Summarise the dopamine pathways in the brain
56
Which dopamine pathways cause the positive and negative symptoms of schizophrenia?
57
How does clozapine work?
* antagonism of 5-HT-2A receptors and D4 receptors,
* among many other receptor targets.
58
What are the common side effects of all antipsychotics?
59
What are EPSEs? What is the Tx for each of them?
60
Name the SEs that are specific to atypical antipsychotics
* **greater risk of metabolic syndrome** than typical antipsychotics
* **less risk of EPSEs** than typical antipsychotics
61
What are the SEs that are specific to clozapine?
* **greater risk of metabolic syndrome** than typical antipsychotics
* **agranulocytosis**
* **myocarditis**
* **cardiomyopathy**
62
What are the SEs specific to clozapine?
* **greater risk of metabolic syndrome** than typical antipsychotics
* **agranulocytosis**
* **myocarditis**
* **cardiomyopathy**
63
How does monitoring vary between typical, atypical antipsychotics and clozapine?
* **Typical**:
* BP,
* pulse,
* ECG
* **Atypical**:
* weight,
* BP,
* ECG,
* lipids,
* glucose/HbA1c,
* FBC,
* U&Es,
* LFTs
* **Clozapine**:
* weight,
* lipids,
* ECG,
* LFTs
* Before starting, weekly FBC for 1st 18wks, then fortnightly, then monthly
* If leukocyte count \<3000/mm3 or absolute neutrophil count \<1500mm3 → discontinue permanently and refer to haematologist
64
How do contraindications vary according to typical, atypical antipsychotics and clozapine?
* **Typical**:
* Parkinson’s,
* Bradycardia,
* QT prolongation
* **Atypical**:
* CVD,
* metabolic syndrome,
* epilepsy
* elderly
* **Clozapine**:
* Severe cardiac disease,
* Acute liver disease,
* Severe renal impairment,
* History of bone marrow disorders
65
Compare and contrast neuroleptic malignant syndrome (due to antipsychotics) and serotonin syndrome (due to antidepressants)
