Common, usually settle; a-Adrenergic receptor Postural hypotension, nausea & dizziness Histamine receptor Sedation Muscarinic acetylcholine receptor Blurred vision, dry mouth & constipation OK in pregnancy & breastfeeding (except Doxepin)

Selective Serotonin Reuptake Inhibitors Block serotonin reuptake!

Side effects - Usually resolve/ few wks! GI: Nausea + Constipation/ Diarrhoea 1/10 Dizziness + headache Sexual Dysfunction 60% (low libido & delayed orgasm) CI pregnancy + (ideally) breastfeeding HYPOnatraemia first 30d Bleeding (inhibit 5HT from PLTs..) QTc prolongation → Torsades (esp citalopram) All anti-depressants; initial Increased suicidal ideation until treatment starts working - KEEP TAKING! Discontinuation symptoms (phase)

2wks (1wk if higher risk), review; Symptoms (subside in few wks) initial Suicidal ideation (subsides also) ECG: Long QTc U+Es: HYPOnatraemia

Serotonin–norepinephrine reuptake inhibitors Blocks ++Serotonin reuptake Transporter Blocks +Noradrenaline reuptake Transporter aka non-tricyclic SNRIs

SPECIFIC SNRI (Venlafaxine, Duloxetine) HyPER- or hypo-tensive Cardiotoxic in OD Glycaemic Control (monitor DM) + SSRI

Reboxetine; Mild & resolve GI: Nausea + Constipation/ Diarrhoea 1/10 Dizziness + headache Sweating + SSRI but very rare

Psychiatric Drugs Flashcards by Sean Simpson

Neuropathic pain treatment

First line;

Only 1 at a time;

Gabapentin
Amitriptyline (10-75mg at night)
Pregabalan
Duloxetine (SNRI)

Rescue therapy;

Tramadol

Localised;

Capsaicin topical (Axsain)

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Tricyclic Antidepressants (TCAs)

Mechanism

Serotonin-Noradrenaline Reuptake Inhibitors (SNRI)

Blocks +Serotonin reuptake Transporter
Blocks ++Noradrenaline reuptake Transporter

Additionally

a-Adrenergic receptor
- Postural hypotension/ dizziness
Histamine receptor
- Sedation
Muscarinic acetylcholine receptor
- Blurred vision, dry mouth & constipation

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TCAs

Examples + Indications

Largely not used for depression now.

Amitryptiline (10mg to 75mg)

Neuropathic pain
Prophylaxis Tension headache (tightband bilat, no aura)

Nortryptyline

2nd line: Prophylaxis Tension headache
Parkinson’s Depression+Anxiety

More sedative: Amitryptyline

Less sedative: Imipramine, Nortriptyline

Less antimuscarinic SE: Lofepramine, Trazodone

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TCAs

COUNCILLING

Common, usually settle;

a-Adrenergic receptor
- Postural hypotension, nausea & dizziness
Histamine receptor
- Sedation
Muscarinic acetylcholine receptor
- Blurred vision, dry mouth & constipation

OK in pregnancy & breastfeeding (except Doxepin)

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SSRI

Mechanism

Selective Serotonin Reuptake Inhibitors

Block serotonin reuptake!

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SSRI

SSRI of choice for;

Depression
- Generally
- Post MI?
- Young people?
OCD
GAD
Breastfeeding
On anti-epileptic medication
Bulimia nervosa
Menopause without HRT

Depression

1st. Citalopram or Fluoxetine
Post-MI: Sertraline
Young people: Fluoxetine

OCD: 1st. Fluoxetine

Anxiety: Sertraline

Breastfeeding: Sertraline

Anti-epileptic medication: Citalopram (least likely to pharmokinetically react)

Bulimia nervosa: Fluoxetine

Menopause without HRT: Fluoxetine

NB: Others often used, only bold are fixed.

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SSRI

COUNCILLING

Side effects - Usually resolve/ few wks!

GI: Nausea + Constipation/ Diarrhoea 1/10
Dizziness + headache
Sexual Dysfunction 60% (low libido & delayed orgasm)
CI pregnancy + (ideally) breastfeeding
HYPOnatraemia first 30d
Bleeding (inhibit 5HT from PLTs..)
QTc prolongation → Torsades (esp citalopram)

All anti-depressants;

initial Increased suicidal ideation until treatment starts working - KEEP TAKING!
Discontinuation symptoms (phase)

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SSRI

Monitoring

2wks (1wk if higher risk), review;

Symptoms (subside in few wks)
initial Suicidal ideation (subsides also)
ECG: Long QTc
U+Es: HYPOnatraemia

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SSRI

Discontinuation Symptoms

Discontinuation symptoms onset

Phase out over 4wks
Especially paroxetine
Not Fluoxetine

Symptoms include

Mood change
Restlessness/ cant sleep
GI

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SNRI

Mechanism

Serotonin–norepinephrine reuptake inhibitors

Blocks ++Serotonin reuptake Transporter
Blocks +Noradrenaline reuptake Transporter

aka non-tricyclic SNRIs

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SNRI

Examples + Indications

Switiching in Depression

Venlafaxine

Menopause without HRT vasomotor

Duloxetine

Neuropathic pain

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SNRI

COUNCILLING

SPECIFIC SNRI (Venlafaxine, Duloxetine)

HyPER- or hypo-tensive
Cardiotoxic in OD
Glycaemic Control (monitor DM)

+ SSRI

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NARI

Mechanism

NorAdrenaline Reuptake Inhibitor

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NRI

Examples & Indications

Reboxetine

Depression

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NRI

COUNCILLING

Reboxetine;

Mild & resolve

GI: Nausea + Constipation/ Diarrhoea 1/10
Dizziness + headache
Sweating

+ SSRI but very rare

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MAOI

Mechanism

Mono-Amine Oxidase Inhibitor

MAO-A (therapeutic) and MAO-B

A selective reversible
Meclobemide
A+B non-selective irreversible
Phenelzine
B selective irreversible
Selegiline, rasagiline

A - serotonin, noradrenaline, dopamine

B - dopamine +

MAOI

Examples + Indications

Depression

Phenelzine (A+B)
Meclobemide (A)

Parkinsons

Selegilline, Rasagilline (B)

MAOI

COUNCILLING

Moclobemide

MAO-A selective, reversible, competitive
Milder and transient SEs

Phenelzine

MAO-A+B non-selective, irreversible, non-competitive

SEs

Postural hypotension
HYPERtension + Tyrosine
Muscarinic: Dry mouth, blurred vision, urinary retention
CNS: Restlessness, insomnia

Hx of Agitation/ Excition prominent - CI or add Benzodiazepine/2-3wks

NaSSA

Mechanism

Noradrenergic and Specific Serotinergic Antidepressent

Blocks Noradrenaline a2-auto and heteroceptors (both sides)
Prevents negative feedback on 5HT and noradrenaline neurotransmission
ALSO block 5HT2 and 3 increasing 5HT1 transmission

NaSSA

Examples + Indications

Mirtazapine

NaSSA

COUNCILLING

Weight gain + inc appetite
Drowsiness (transient, not dose-related)
Agranulocytosis (rare, reversible, stop)
- REPORT sore throat!

1st Gen. antipsychotics

Mechanism

D2 antagonist;

mesoCortical ⇒ Helps neg. symptoms
mesoLimbic system ⇒ Helps positive symptoms
Nigro-Striatal ⇒ Muscular extra-pyramidal SEs
Tubero-infundibular ⇒ High Prolactin SEs
Chemoreceptor trigger zone ⇒ Antiemetic

Additionally blocked;

Muscarinic1
Histamine1 ⇒ Sedation, allergies
Alpha1

1st Gen antipsychotics

Examples

Chlorpromazine
Haloperidol
Fluphenazine (depot)
Clophenthixol

1st Gen antipsychotics

SEs + Management of them

*D2 Blocked;**
*Nigro-Striatal** ⇒ Muscular extra-pyramidal SEs
Short term
- Acute dystonia
- Occulogyric crisis (agitation, eyes up)
- Akathisia
Medium
- Parkinsonism
Long term
- Tardive dyskinesia
Treatment: Procyclidine

Tubero-infundibular ⇒ High Prolactin SEs

Amenorrhoea (linked to osteoporosis)
Gynaecomastia
Galactorrhoea

Serious: Neuroleptic Malignant Syndrome (other card)

Additionally blocked;

Muscarinic1
- Constipation, dry mouth, blurred vision
Histamine1
- Sedation
Alpha1
- Postural hypotension, Ejaculation problem

Haloperidol: LONG QT Syndrome

ALL Phenothiazines “ZINES”: Fetal anomalies by extra 4/1000 (chlorpromazine)

Atypical or 2nd Gen antipsychotics Mechanism

Blocks * **D2** * **5HT2a** (more than D2) Also * Alpha1 * Histamine1 * Muscarinic1 aka Serotonin-Dopamine antagonists

Atypical or 2nd Gen antipsychotics

* Olanzapine * Quetiapine * Clozapine (actually D4) (refractory schizophrenia) * Resperidone * Aripiprazole (partial dopamine agonist, sometimes called 3rd generation)

Atypical or 2nd Gen antipsychotics SEs Specifically Clozapine

LESS musclar/ extra-pyramidal SEs (but still occur) MORE metabolic SEs * **Weight gain** * Potential **glucose intolerance** * Potential **lipids increase** **Aripiprazole:** LESS metabolic SEs **Risperidone:** Insomnia & agitation (CNS) **Clozapine** (refractory schizophrenia) * Agranulocytosis * Cardiotoxic * Salivation (M4) * CNS

Illicit drugs that increase dopamine

* Cocaine * Amphetamines * L-dopa

Neuroleptic Malignant Syndrome * Cause * Signs and symptoms * Investigations * Treatment

Cause * Genetic varient of D2 receptor: Abnormal blockade in striatum & hypothalamus * RF: Change in medications, any psychiatric condition Signs and symptoms * **Fluctuating BP** * **Flutuating consciousness/ Delirium** * **Rigidity** + extra-pyramidal SEs * **Fever** + Sweating Investigations * **CK HIGH!** * Leucocytes high * Abnormal LFTs Treatment * Withdraw treatment immediately (death!) * **Dopamine agonist** (may take 2wks)

Antipsychotic monitoring

All require; * BP + pulse (Alpha1) * weight + height * Bloods * **Glucose/ HbA1c** and **Lipid profile** (esp 2nd gen) * LFTs + U&Es * Prolactin (Tubero-infundibular) * ECG: **Clozapine**: FBC (neutropenia/ agranulocytosis) 2ndary care NMS suspected: CK

TCA Overdose S+Sx

* Arrhythmias - ECG * Sinus tachycardia * Wide QRS ⇒ \>0.1 **Seizures** ⇒ \>0.16 **VT/VF** * Prolonged QT * Seizures * Metabolic acidosis * Coma

TCA Overdose management

* Acutely: Activated charcoal * Acidosis?: IV Bicarbonate (lower seizure/ arrythmia risk) * IV Lipid emulsion **DO NOT**; * Dialysis ineffective * Class 1 (a+c) ⇒ Prolong depolarisation * Class 3 ⇒ Prolong QT

Lithium Mechanism + Indications

Lithium ⇒ Mood stabiliser * Mania * Hypomania * Prophylaxis for Bipolar + Recurrent depression * Reduces aggression and self injury

Lithium COUNCILING

Plasma level * Measure **12hr** after last dose * **Effective \>0.4**mmol/L, **OPTIMAL 0.6-0.75**mmol/L * Toxic \>1.5mmol/L ⇒ SEs Patient NEED; * Information booklet * Record book * Lithium Alert Card SEs * **GI** (D+N+V) * **Kidney** impairment (polyuria, polydipsia) * **Weight gain** * Hy**POthyroidism**, hy**PERparathyroidism** * CNS (**Course tremor**, weakness, ataxia, twitching) * ⇒ Seizure, coma, death * Teratogenic, benefit\>risk?: Cardiac defects Plasma concentration + drugs; * **+ACEi** ⇒ x4 * **+ThiazideD** ⇒ x4 * **+NSAIDs** ⇒ Unpredictable

Lithium Overdose management

* Mild-mod: Volune resus Normal saline * Severe: Haemodialysis Sodium bicarb?