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Psychiatric drugs Flashcards

1
Q

What is the cause of neuroleptic malignant syndrome?

A

Initiation or increase in dose of antipsychotics (D2 antagonist)

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2
Q

What are the signs of neuroleptic malignant syndrome?

A

Fever + triad of NM abnormalities (rigidity + hyporeflexia), ANS dysfunction (tachycardia, HT, labile BP, urinary incontinence), fluctuating LOC

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3
Q

How to investigate neuroleptic malignant syndrome?

A

High CPK
High WCC
LRFT: metabolic acidosis, high ALT

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4
Q

How to manage neuroleptic malignant syndrome?

A

Pharm: dantrolene + lorazepam
Supportive: hydration, O2, lower temperature (cooling blanket, antipyretic)

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5
Q

What is the cause of serotonin syndrome?

A

High serotonin e.g. SSRI overdose, DDI between MAOI & SSRI

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6
Q

What are the signs of serotonin syndrome?

A

Fever + triad of NM abnormalities (myoclonus, tremor, hyperreflexia), altered LOC, ANS dysfunction

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7
Q

How to investigate serotonin syndrome?

A

High CPK
High WCC
LRFT: high ALT, metabolic acidosis

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8
Q

How to manage serotonin syndrome?

A

Cyproheptadine (serotonin antagonist)

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9
Q

What are the features of EPSE?

A

Acute dystonia: oculagyral crisis, torticollis, tongue protrusion, grimacing, ophisthotonus
Akathisia: restlessness, agitation, suicidal ideation
Parkinsonism: tremor, rigidity, akinesia, stooped posture
Tardive dyskinesia: chewing/sucking movement, grimacing, akathisia, choreoathetoid movement

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10
Q

How to manage EPSE?

A

Acute dystonia: parenteral anticholinergic (benzatropin)
Akathisia: reduce dose, propanolol, short term BZD
Parkinsonism: oral anticholinergic (benzatropin)
Tardive dyskinesia: stop drug, give vitamin E / BZD / tetrabenazine, switch to clozapine

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11
Q

What are the SE of typical antipsychotics?

A

EPSE, hyperprolactinemia, neuroleptic malignant syndrome, anti-HAM effects

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12
Q

What are the SE of atypical antipsychotics?

A

Metabolic syndrome
Elevated liver enzyme
Prolonged QT
Anti-HAM, HSR1

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13
Q

What are the indications of lithium?

A 
Mania (acute, maintenance)
Depressive episode (BAD, resistant depression)
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14
Q

What are the contraindications of lithium?

A

Pregnancy & breastfeeding

Impaired RFT

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15
Q

What are the SE of lithium?

A

CV: T wave inversion, Ebstein’s anomaly, mild leucocytosis
GI upset
Hypothyroidism
Renal: NDI, edema
CNS: fine tremor, weakness, impaired conc & memory, sedative

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16
Q

Factors that increase lithium levels

A

NSAID, aspirin
Thiazide diuretics
Dehydration (e.g. V/D, pyrexia), hyponatremia
Impaired RFT

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17
Q

What are the signs of lithium toxicity?

A

1.5-2mmol/L: N/V/D, coarse tremor, apathy, ataxia, muscle weakness
>2mmol/L: nystagmus, dysarthria, hyperreflexia, oliguria, hypotension, impaired LOC, convulsion, coma

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18
Q

How to manage lithium toxicity?

A

Supportive: hydration, RFT, electrolyte, ECG
Stop lithium
+/- anticonvulsants, renal dialysis (for RF)

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19
Q

What are the teratogenic effects of lithium?

A

Ebstein’s anomaly: 20X

Neonatal goitre, arrhythmia, hypotonia

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20
Q

How to advice female patient of reproductive age who is on lithium?

A

Advice contraception
Delay pregnancy until taper off
If already pregnant: valproate + folic acid

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21
Q

What are the indications of valproate?

A

Acute mania
Bipolar maintenance
Epilepsy

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22
Q

What are the contraindications of valproate?

A

Pregnancy (neural tube defect)

Weak liver function (monitor LFT & hematological function)

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23
Q

What are the SE of valproate?

A

Common: sedative, dizzy, tremor, N/V
Less common: HBP (hepatotoxicity, pancreatitis), hemat (thrombocytopenia, leukopenia), constitutional (weight gain, hair loss)

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24
Q

What are the indications of carbamazepine?

A

Mania
Epilepsy
Trigeminal neuralgia

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25
Q

What are the contraindications of carbamazepine?

A

Weak liver function (monitor LFT & hematological function)
CV: conduction defect, HF
On MAOI & lithium (neurotoxicity)
HLA-B1502 gene

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26
Q

What are the SE of carbamazepine?

A 
Common: ataxia, diplopia, dizzy/drowsy, nausea
Agranulocytosis, aplastic anemia
Water retention
Teratogenic (neural tube defect)
Liver failure, hepatitis
SJS, TEN
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27
Q

Can valproate and carbamazepine be used in pregnancy?

A

Risk of neural tube defect -> avoid if possible
Valproate higher risk than carbamazepine
If necessary: low dose monotherapy + folic acid (5mg daily) for 1m before conception
Carbamazepine in 3rd trimester: vitamin K for mother & baby

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28
Q

What are the indications of lamotrigine?

A

Bipolar depression

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29
Q

What are the contraindications of lamotrigine?

A

HLA-B1502 gene
Depression
Suicidal

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30
Q

What are the SE of lamotrigine?

A

Neuro: ataxia, dizzy/drowsy, diplopia, headache, sedation
SJS
Teratogenic (cleft palate)

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31
Q

Examples of typical antipsychotics

A

Chlorpromazine, phenothiazine
Loxapine
Haloperidol

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32
Q

Examples of atypical antipsychotics

A

Olanzapine
Risperidone
Quetiapine
Clozapine

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33
Q

Examples of mood stabilizers

A

Lithium
Valproate
Carbamazepine
Lamotrigine

34
Q

Examples of SSRI

A 
Fluoxetine
Sertraline
Paroxetine
Citalopram
Escitalopram
35
Q

Examples of SNRI

A

Venlafaxine

Duloxetine

36
Q

Examples of TCA

A

Clomipramine
Imipramine
Amitryptiline

37
Q

What are the contraindications of TCA?

A

Significant CV disease

38
Q

What are the SE of TCA?

A

Cardiac arrhythmia
Postural hypotension
Sedation
Anticholinergic: dry mouth, blurred vision, nausea, urinary retention

39
Q

What are the indications of clozapine?

A

TRS, tardive dyskinesia

40
Q

What are the contraindications of clozapine?

A

Neutropenia

Cardiac, renal & liver problems

41
Q

What are the SE of clozapine?

A

Common: anticholinergic (constipation), antiadrenergic (hypotension), ANS (hypersalivation, sweating, weight gain), sedation, seizure, prolonged QT
Serious: agranulocytosis, HBP (hepatitis, pancreatitis), impaired temperature regulation, neuroleptic malignant syndrome, CV (circulatory collapse, infection)

42
Q

What should you do when initiating clozapine?

A

CBC weekly for 18w, then every 4w indefinitely for agranulocytosis

43
Q

When should you discontinue clozapine?

A

Reappearance of psychotic symptoms

Cholinergic rebound: profuse sweating, headache, N/V/D

44
Q

What are the DDI of clozapine?

A

Lithium & ACEI, caffeine, smoking

45
Q

What are the indications of benzodiazepine?

A

Short term treatment: insomnia, anxiety, alcohol withdrawal, seizures, acute mania or psychosis
Augment antidepressants in first month
Maintenance for panic disorder

46
Q

What are the contraindications of benzodiazepine?

A

Depression, hx of alcohol/SA, pregnancy

47
Q

What are the SE of benzodiazepine?

A

Sedation, muscle relaxant (fall, respiratory depression), amnesic

48
Q

How to manage benzodiazepine overdose?

A

Flumazenil

49
Q

What are the concerns of prescribing SSRI to elderly?

A

SIADH

DDI w/ NSAID & warfarin (CYP ihb -> increased risk of bleeding)

50
Q

What are the contraindications of propanolol?

A

Asthma, COPD, bradycardia, HB

51
Q

What are indications of ECT?

A 
Mania
Depression
Postpartum psychosis
Catatonia
(Schizophrenia, NMS, epilepsy)
52
Q

What are the contraindications of ECT?

A

Heart: CVD, recent MI
Brain: raised ICP, aneurysm, risk of cerebral bleeding

53
Q

What are the SE of ECT?

A

Amnesia
Myalgia, dislocation
Headache, confusion, nausea

54
Q

What are the risks of ECT?

A

GA: respiratory depression, allergy, aspiration
CV: induce arrhythmia, stroke
Fracture, supraphysiological bite (bite block)

55
Q

What is the regimen of ECT?

A

2-3 times per week, once per week for elderly

Usually 6-8 treatments, at most 12

56
Q

What are the risks of MAOI?

A 
Cheese effect (HT crisis)
Serotonin syndrome
57
Q

Which psychiatric drug has the least CV complications?

58
Q

What antipsychotic is least likely to cause weight gain?

A

Aripriprazole, sulphride, trifluoperazine, ziprasidone

59
Q

What antipsychotic is most likely to cause weight gain?

A

Olanzapine, clozapine, zotepine

60
Q

Which anti-Parkinsonian drug is least likely to precipitate psychosis?

A

Benzatropin

61
Q

Examples of Anti-Parkinsonian drugs

A

Amantadine (NMDA antagonist)
Bromocriptine (dopamine agonist)
Levadopa (dopamine precursor)
Selegiline (MAOI)

62
Q

Which antipsychotic is best for treating negative symptoms of schizophrenia?

A

SGA e.g. clozapine

63
Q

For how long does an antidepressant have to be maintained at an effective dose in order to have optimal effect?

64
Q

What are the indications of MAOI?

A

Atypical depression (refractory to SSRI)
Resistant depressant
Refractory anxiety states e.g. panic disorder
Narcolepsy

65
Q

What are the contraindications of MAOI?

A

Mania
Pheochromocytoma
Cerebrovascular disease
Liver impairment

66
Q

What drug can trigger rapid cycling of bipolar?

67
Q

Can antidepressants be used during pregnancy?

A

Older drugs ok (TCA, sertraline, fluoxetine)
3rd trimester a/w withdrawals
SSRI: low birth weight, spontaneous abortion, neonatal pul HT

68
Q

Can antipsychotics be used during pregnancy?

A

FGA okay

Olanzapine, clozapine: GDM, macrosomia

69
Q

Can mood stabilizers be used during pregnancy?

A

Li: Ebstein’s anomaly
Valproate: neural tube defect
Carbamazepine: neural tube defect, cog deficit, craniofacial & limb defect
Lamotrigine: cleft palate

70
Q

Can anxiolytics be used during pregnancy?

A

BZD: cleft lip & palate, floppy baby, withdrawal

Z drug: x recommended

71
Q

What are the contraindications of psychotropic drugs during breastfeeding?

A

Infant is premature or suffering from renal/cardiac/hepatic/neuro disorders

72
Q

Can antidepressants be used during breastfeeding?

A

TCA & sertraline OK

Avoid paroxetine

73
Q

Can antipsychotics be used during breastfeeding?

A

Not clozapine (agranulocytosis)

74
Q

Can mood stabilizers be used during breastfeeding?

A

Not lithium (narrow TI + infant has immature RF), lamotrigine (SJS)

75
Q

Can BZD be used during breastfeeding?

A

Prefer short acting (e.g. lorazepam) over long acting (e.g. diazepam)

76
Q

What are the SE of SSRI?

A 
GI upset
CNS: anxiety/agitation, poor sleep
Elderly: SIADH
Young: suicide
Sexual dysfunction
77
Q

How long do you continue treatment after remission for first episode depression?

78
Q

What is the major consideration for maintenance treatment for schizophrenia?

A

Number of episodes (2nd episode -> lifelong treatment)

79
Q

What are the RF of acute dystonia?

A

Young, M, high dose antipsychotic (FGA & SGA), hx of dystonia

80
Q

What is delusional perception?

A

Genuine perception with delusional meaning attached

Psychiatry (10 decks)

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