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1 - Y5 Psych > Psych Pharmacology > Flashcards

Psych Pharmacology Flashcards

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1
Q

Name the main drug classes of antidepressants

A
  • SSRIs
  • SNRIs
  • TCAs
  • NaSSAs
  • SARIs
  • MAOIs
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2
Q

What does SSRI stand for?

A

Selective Serotonin Reuptake Inhibitor

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3
Q

What does SNRI stand for?

A

Serotonin and noradrenaline reuptake inhibitor (SNRI)

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4
Q

What does TCA stand for?

A

Tricyclic antidepressant

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5
Q

What does NaSSA stand for?

A

Noradrenergic and specific serotonergic antidepressant (NaSSA)

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6
Q

What does SARI stand for?

A

serotonin reuptake inhibitor (SARI)

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7
Q

What does MAOI stand for?

A

Monoamine oxidase inhibitor (MOAI)

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8
Q

Name some egs of SSRIs

A
  • Fluoxetine,
  • sertraline,
  • paroxetine,
  • citalopram,
  • fluvoxamine
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9
Q

Name some egs of SNRIs

A
  • Venlafaxine,
  • Duloxetine
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10
Q

Name some egs of TCAs

A
  • Amitriptyline,
  • lofepramine,
  • clomipramine,
  • imipramine
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11
Q

Name an eg of NaSSAs

A

Mirtazapine

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12
Q

Name an eg of SARIs

A

Trazodone

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13
Q

Name some egs of MAOIs

A
  • Phenelzine,
  • tranylcypromine,
  • isocarboxazid
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14
Q

What are the actions of SSRIs

A

Antagonises:

  • serotonin reuptake pump
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15
Q

What are the actions of SNRIs

A

Antagonises:

  • serotonin reuptake pump
  • noradrenaline reuptake pump
  • dopamine reuptake pump (in high doses)
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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
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17
Q

What are the actions of NaSSAs

A

Antagonises:

  • 5HT (serotonin) receptor
  • a2-adrenergic receptor
  • muscarinic receptor (slightly)
  • histamine-1 receptor
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18
Q

What are the actions of SARIs

A

Antagonises:

  • a1-adrenergic receptor
  • muscarinic receptor (slightly)
  • histamine-1 receptor
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19
Q

What are the actions of MAOIs?

A

Nonselective and irreversible inhibition of:

  • monoamine oxidase A and B
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20
Q

What are the SEs of SSRIs?

A
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21
Q

What are the SEs of SNRIs?

A

Same as SSRIs but greater

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22
Q

What are the SEs of TCAs?

A
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23
Q

What are the SEs of NaSSAs?

A
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24
Q

What are the SEs of SARIs?

A

same as TCAs

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25
Q

What are the side effects of MAOIs?

A
  • 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
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26
Q

Which food/drugs must be avoided in conjunction with MOAIs?

A
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27
Q

What is discontinuation syndrome?

A
  • 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
Q

Name egs of mood stabilisers

A

lithium

anticonvulsants:

  • sodium valproate,
  • carbamazepine
  • lamotrigine
29
Q

How does lithium work as a mood stabiliser?

A

modulate the neurotransmitter-induced activation of second messenger systems

30
Q

How do sodium valproate, carbamazepine and lamotrigine work as mood stabilisers?

A
  • inhibit activity voltage-gated sodium channels
  • enhance GABA- ergic neurotransmission
31
Q

What are the indications of lithium?

A
  • Acute mania
  • Prophylaxis of bipolar affective disorder (prevention of relapse)
  • Treatment-resistant depression (lithium augmentation)
32
Q

What are the indications of sodium valproate?

A
  • Epilepsy
  • Acute mania
  • Prophylaxis of bipolar affective disorder (second-line)
33
Q

What are the indications of Carbamazepine?

A
  • Epilepsy
  • Prophylaxis of bipolar affective disorder (third-line)
34
Q

What are the indications of Lamotrigine?

A
  • Epilepsy
  • Prophylaxis of depressive episodes in bipolar affective disorder (third-line)
35
Q

What is the therapeutic window of lithium?

A

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
Q

When might lithium levels in the blood rise, other than due to increased dose?

A

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
Q

What are the SEs of lithium?

A
  • 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
Q

What are the signs of lithium toxicity?

A
  • 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
Q

Which Ix are required before starting lithium?

A
  • FBC
  • U&Es
  • Calcium
  • Thyroid function
  • Pregnancy test (in women of childbearing age)
  • ECG (if cardiac disease or risk factors)
40
Q

Describe the blood monitoring prior to lithium Tx

A

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
Q

What are the SEs of sodium valproate?

A
  • 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
Q

What are the SEs of carbamazepine?

A
  • 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
Q

What are the SEs of lamotrigine?

A
  • 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
Q

Compare the different monitoring required of different mood stabilisers

A
  • 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
Q

Compare NICE guidelines for women of childbearing age using the different mood stabilisers

A
  • 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
Q

What are the contraindications of lithium?

A
  • 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
Q

What are the contraindications of sodium valproate?

A
  • Hepatic dysfunction
  • Porphyria
  • Pregnancy and breastfeeding
48
Q

What are the contraindications of carbamazepine?

A
  • Atrioventricular conduction abnormalities (unless paced)
  • History of BM depression
  • Acute porphyria
  • Pregnancy and breastfeeding
49
Q

What are the contraindications of lamotrigine?

A
  • Caution in myoclonic seizures and Parkinson’s (may be exaggerated)
  • Caution in hepatic and renal failure
50
Q

Summarise the contraindications of the mood stabilisers

A
  • 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
Q

Name the typical antipsychotics

A
  • Chlorpromazine
  • Haloperidol
  • Sulpiride
  • Flupentixol
  • Zuclopenthixol
52
Q

Name the atypical antipsychotics

A
  • clozapine
  • olanzapine
  • quetiapine
  • risperidone
  • aripiprazole
53
Q

Which antipsychotics can be given IM (long-acting depot)?

A

Typical:

  • haloperidol
  • flupentixol
  • zuclopenthixol

Atypical:

  • Olanzapine
  • Risperidone
  • Aripiprazole
54
Q

How do all antipsychotics work (except clozapine)?

A

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
Q

Summarise the dopamine pathways in the brain

A
56
Q

Which dopamine pathways cause the positive and negative symptoms of schizophrenia?

A
57
Q

How does clozapine work?

A
  • antagonism of 5-HT-2A receptors and D4 receptors,
  • among many other receptor targets.
58
Q

What are the common side effects of all antipsychotics?

A
59
Q

What are EPSEs? What is the Tx for each of them?

A
60
Q

Name the SEs that are specific to atypical antipsychotics

A
  • greater risk of metabolic syndrome than typical antipsychotics
  • less risk of EPSEs than typical antipsychotics
61
Q

What are the SEs that are specific to clozapine?

A
  • greater risk of metabolic syndrome than typical antipsychotics
  • agranulocytosis
  • myocarditis
  • cardiomyopathy
62
Q

What are the SEs specific to clozapine?

A
  • greater risk of metabolic syndrome than typical antipsychotics
  • agranulocytosis
  • myocarditis
  • cardiomyopathy
63
Q

How does monitoring vary between typical, atypical antipsychotics and clozapine?

A
  • 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
Q

How do contraindications vary according to typical, atypical antipsychotics and clozapine?

A
  • 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
Q

Compare and contrast neuroleptic malignant syndrome (due to antipsychotics) and serotonin syndrome (due to antidepressants)

A

1 - Y5 Psych (23 decks)

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