Psychiatric Drugs Flashcards

Question 1

Q

Neuropathic pain treatment

Answer

A

First line;

Only 1 at a time;

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

Rescue therapy;

Tramadol

Localised;

Capsaicin topical (Axsain)

Question 2

Q

Tricyclic Antidepressants (TCAs)

Mechanism

Answer

A

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

Question 3

Q

TCAs

Examples + Indications

Answer

A

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

Question 4

Q

TCAs

COUNCILLING

Answer

A

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)

Question 5

Q

SSRI

Mechanism

Answer

A

Selective Serotonin Reuptake Inhibitors

Block serotonin reuptake!

Question 6

Q

SSRI

SSRI of choice for;

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

Answer

A

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.

Question 7

Q

SSRI

COUNCILLING

Answer

A

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)

Question 8

Q

SSRI

Monitoring

Answer

A

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

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

Question 9

Q

SSRI

Discontinuation Symptoms

Answer

A

Discontinuation symptoms onset

Phase out over 4wks
Especially paroxetine
Not Fluoxetine

Symptoms include

Mood change
Restlessness/ cant sleep
GI

Question 10

Q

SNRI

Mechanism

Answer

A

Serotonin–norepinephrine reuptake inhibitors

Blocks ++Serotonin reuptake Transporter
Blocks +Noradrenaline reuptake Transporter

aka non-tricyclic SNRIs

Question 11

Q

SNRI

Examples + Indications

Answer

A

Switiching in Depression

Venlafaxine

Menopause without HRT vasomotor

Duloxetine

Neuropathic pain

Question 12

Q

SNRI

COUNCILLING

Answer

A

SPECIFIC SNRI (Venlafaxine, Duloxetine)

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

+ SSRI

Question 13

Q

NARI

Mechanism

Answer

A

NorAdrenaline Reuptake Inhibitor

Question 14

Q

NRI

Examples & Indications

Answer

A

Reboxetine

Depression

Question 15

Q

NRI

COUNCILLING

Answer

A

Reboxetine;

Mild & resolve

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

+ SSRI but very rare

Question 16

Q

MAOI

Mechanism

Answer

A

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 +

Question 17

Q

MAOI

Examples + Indications

Answer

A

Depression

Phenelzine (A+B)
Meclobemide (A)

Parkinsons

Selegilline, Rasagilline (B)

Question 18

Q

MAOI

COUNCILLING

Answer

A

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

Question 19

Q

NaSSA

Mechanism

Answer

A

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

Question 20

Q

NaSSA

Examples + Indications

Answer

A

Mirtazapine

Question 21

Q

NaSSA

COUNCILLING

Answer

A

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

Question 22

Q

1st Gen. antipsychotics

Mechanism

Answer

A

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

Question 23

Q

1st Gen antipsychotics

Examples

Answer

A

Chlorpromazine
Haloperidol
Fluphenazine (depot)
Clophenthixol

Question 24

Q

1st Gen antipsychotics

SEs + Management of them

Answer

A

*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)

Question 25

Q

Atypical or 2nd Gen antipsychotics

Mechanism

Answer

A

Blocks

D2
5HT2a (more than D2)

Also

Alpha1
Histamine1
Muscarinic1

aka Serotonin-Dopamine antagonists

Question 26

Q

Atypical or 2nd Gen antipsychotics

Answer

A

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

Question 27

Q

Atypical or 2nd Gen antipsychotics

SEs

Specifically Clozapine

Answer

A

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

Question 28

Q

Illicit drugs that increase dopamine

Answer

A

Cocaine
Amphetamines
L-dopa

Question 29

Q

Neuroleptic Malignant Syndrome

Cause
Signs and symptoms
Investigations
Treatment

Answer

A

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)

Question 30

Q

Antipsychotic monitoring

Answer

A

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

Question 31

Q

TCA

Overdose S+Sx

Answer

A

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

Question 32

Q

TCA

Overdose management

Answer

A

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

Question 33

Q

Lithium

Mechanism + Indications

Answer

A

Lithium ⇒ Mood stabiliser

Mania
Hypomania
Prophylaxis for Bipolar + Recurrent depression
Reduces aggression and self injury

Question 34

Q

Lithium

COUNCILING

Answer

A

Plasma level

Measure 12hr after last dose
Effective >0.4mmol/L, OPTIMAL 0.6-0.75mmol/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
HyPOthyroidism, hyPERparathyroidism
CNS (Course tremor, weakness, ataxia, twitching)
- ⇒ Seizure, coma, death
Teratogenic, benefit>risk?: Cardiac defects

Plasma concentration + drugs;

+ACEi ⇒ x4
+ThiazideD ⇒ x4
+NSAIDs ⇒ Unpredictable

Question 35

Q

Lithium Overdose management

Answer

A

Mild-mod: Volune resus Normal saline
Severe: Haemodialysis

Sodium bicarb?

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Psychiatric Drugs Flashcards

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