Psych pharmacology and treatments Flashcards
what are the different types of SSRI?
- Citalopram
- Escitalopram
- Fluoxetine
- Paroxetine
- Sertraline
what can SSRIs be used for?
first line treatment for depression
post traumatic stress disorder
OCD
what SSRI is useful post MI?
Sertraline
what SSRI is the one of choice in children and adolescents?
Fluoxetine
what are the side effects of SSRIs?
- most common is GI symptoms
- increased risk of GI bleeding, if patient is taking NSAIDs and SSRI a PPI should also be prescribed
- citalopram can cause a dose-dependent QT interval prolongation
- insomnia, increased anxiety and irritability
- sexual side effects - ED
- nausea, vomiting and diarrhoea
- hyponatraemia (SIADH)
what drugs do SSRIs interact with?
NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
aspirin: GI problems
triptans: avoid SSRIs
monoamine oxidase inhibitors (MAOIs) - risk of serotonin syndrome
how long should a patient take an SSRI after remission?
at least 6 months to reduce the risk of relapse
how should patients stop taking SSRIs?
gradually over a 4 week period
(not necessary with fluoxetine)
paroxetine has higher incidence of discontinuation symptoms
what symptoms should make you stop taking SSRI?
increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia
can women take SSRI during pregnancy?
- BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
- Use during the first trimester gives a small increased risk of congenital heart defects
- Use during the third trimester can result in persistent pulmonary hypertension of the newborn
- Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
what are SNRIs?
serotonin-norepinephrine reuptake Inhibitor
Venlafaxine
desvenlafaxine
duloxetine
what can SNRI be used for?
depression
anxiety
panic disorder
effective in reducing pain associated with fibromyalgia and pain caused by neuropathy
what are the side effects of SNRIs?
same as SSRI
may increase blood pressure and heart rate
what are TCAs?
tricyclic antidepressants
amitriptyline
clomipramine
imipramine
what can TCAs be used for?
depression
can also be used in migraine prevention and treatment of neuropathic pain
insomnia
what are the side effects of TCAs?
hypotension dizziness sedation blurred vision dry mouth constipation urinary retention cardiac conduction abnormalities cardiotoxicity and QT prolongation
what are MAOIs?
Monoamine oxidase inhibitors
two types A and B
(type a preferentially metabolises serotonin)
(type B preferentially metabolised dopamine)
Isocarboxazid
phenelzine
selegiline (specifically type B - good for Parkinson’s)
what are MAOIs used for?
depression
what are the the side effects of MAOIs?
drug drug interactions
drug food interactions - avoid tyramine rich food (cheese, cured or smoked meats/fish, some overripe fruits) as they can cause hypertensive crisis and potentially a stoke
other side effects include dry mouth, nausea, diarrhoea, constipation, headache, drowsiness, insomnia
how should SSRIs be monitored?
MONITOR 1-2 weeks (after 1 week if under 30/increased risk of suicide) after starting - agitation and SUICIDAL IDEATION initially - since have more energy but mood hasn’t improved yet
*requires 2-4 weeks to become effective
what is serotonin syndrome?
too much serotonin = restless, fever, tremor, myoclonus, confusion, fits
what is a contraindication to SNRIs?
chronic alcoholic liver
what is an atypical antidepressant and when is it indicated?
- Mirtazapine
- Indicated for depression where sedation or increased oral intake is desirable also indicated for PTSD
what are the side effects of mirtazapine ?
weight gain and sedation
when is lithium used?
- Acute treatment of mania
- Bipolar relapse prevention
- Treatment resistant depression
why does lithium need monitoring?
how is it monitored?
because it is very toxic and has very narrow therapeutic window (avoid in those who have risk of suicide)
TFT - hypothyroid can manifest 6-18 months after
FBC
pregnancy test
kidney function test s
what are the side effects of lithium?
leucocytosis
early side effects - fine tremor, dry mouth, metallic taste, mild diuresis, sick
Late - weight gain, hypothyroidism, hypokalaemia, oedema, teratogenic, diabetes insupidus
- LITHIUM
- Level - 0.6-1 mmol/L, Leukocytosis
- Insipidus - Nephrogenic Diabetes (Increase ADH) • Tremors - mild (ok), coarse? (TOXICITY)
- Hydration - Dry mouth, diarrhoea, thirsty
- Increased - GI, Skin, memory problems
- Under active thyroid (decreased TSH)
- Metallic taste, mum beware - Ebstein anoma
when does lithium toxicity occur?
what can it be caused by
what are the symptoms
and how is it managed?
• Occurs when levels are GREATER than 1.0-1.5mmol/L • Can be caused by:
- Fluid depletion (vomiting, diarrhoea, dehydration)
- Changes in salt level in diet
- Reduced renal function
- Certain medications e.g. diuretics, NSAIDs, blood pressure medication
- Change in brand of lithium • Onset usually sudden
• Symptoms:
- Coarse tremor, hyperreflexia, seizures, heart block - Muscle weakness, ataxia, coma
- Dysarthria, dysphasia
• Management:
- STOP LITHIUM & TREAT cause - Give fluids
- Haemodialysis (if severe)
what can antipsychotics be used for?
- Relieve positive symptoms i.e. hallucinations, thought disorder, delusions
- Treat schizophrenia
- Control acute mania
- Provide rapid tranquillisation
- Treat psychotic depression
what can antipsychotics not do?
- Relieve negative symptoms i.e. blunted emotions, apathy
- Change personalities
apart from clozapine
before starting antipsychotics what tests need to be performed?
- Bloods - FBC, U&E, LFT, lipids, BM, cholesterol, prolactin
- Physical - weight, BP, pulse
- ECG - Risk of prolonged QT syndrome/arrhythmias
what are some first generation/typical anti-psychotic?
Haloperidol
Chlorpromazine
what are the side effects of first generation antipsychotics?
worsening negative symptoms
extrapyramidal side effects (acute dystonic reaction, Parkinsonism, akathisia, tardive dyskinesia (involuntary, repetitive body movements))
anticholinergic side effects - dry mouth, constipation, blurred vision, urinary retention
antiadrenergic - postural HTN
antihistaminergic - sedation and weight gain
prolactinaemia and gynocomastia in men
what are some examples of second generation/atypical antipsychotics?
Olanzapine, Clozapine, Risperidone, Quetiapine
what are the side effects of 2nd gen antipsychotics?
- Metabolic - weight gain, hyperglycaemia and dyslipidemia
* Hyperprolactinaemia
when is clozapine used?
in treatment resistant schizophrenia
used when 2 other treatments have networked
what are the side effects of clozapine?
Agranulocytosis (bone marrow suppression)
neutropenia, myocarditis, cardiomyopathy, constipation)
- requires regular blood test for neutropenia
- staring/stoping smoking can alter the drug metabolism
what is the neuroleptic malignant syndrome?
Rare life threatening reaction to antipsychotics (both typical and atypical)
Carries a mortality of 10%
More common in young male patients Features:
• Onset usually in first 10 days of treatment or after increasing dose • Pyrexia, rigidity, tachycardia
• Severe motor/mental/autonomic dysfunction
• Increased sweating, dysphagia, urinary incontinence
• Raised creatine kinase in most cases
- AKI (secondary to rhabdomyolysis) may develop in severe
cases
how is neuroleptic malignant syndrome managed?
stop antipsychotic
IV fluids to prevent renal failure
Bromocriptine may be used
what can sodium valproate be used for?
epilepsy
acute mania
bipolar
what are the side effects of sodium valproate?
VALPROATE: • Vomiting • Ataxia • Liver toxicity • Pancreatitis • Tremor • Extra weight-gain
what can carbamazepine be used for?
epilepsy
2nd line for bipolar prophylaxis
what are some examples of anxiolytics and hypnotics?
Benzodiazepines e.g. Diazepam and ‘z’ drugs (zopiclone, zolpiden, zaleplon)
what are the side effects of anxiolytics and hypnotics?
and how is an overdose managed?
- ALL result in TOLERANCE, DEPENDENCE and WITHDRAWAL - When used in combination with alcohol can become addictive - Respiratory depression when used with alcohol or opiates
- Overdose management:
• Flumazenil - an antagonist of benzodiazepine receptor -> reverses effects
