Psychiatric drugs Flashcards
What are the risks of SSRI use during pregnancy?
Cardiac malformations doubled (2% risk)
3-5x risk of pulmonary hypertension in new born
Neonatal adaption syndrome - 10%
What are the methylphenidate medications used for ADHD, and what are their side effects?
Ritalin - fast acting 4 hours
Concerta - long acting - 12 hours
Side effects:
- increased BP
- headaches
- insomnia
- Appetite suppression
- seizures
What is an alternative drug to methylphenidate and how does it work?
Dexamphetamine
- Noradrenaline - dopamine reuptake inhibitor
How does atomoxetine work? what are some side effects and name contraindication:
Noradrenaline reuptake inhibitor
Insomnia
Reduced appetite
Nausea
sexual dysfunction
Phaeochromocytoma
Name some less common use medications for ADHD:
Clonidine: alpha agonist
Bupropion: DA and NA reuptake inhibitor
Modafinil: NA reuptake inhibitor
What should be checked first before starting treatment for ADHD?
Baseline:
- BP
- Weight
**BP and HR need to checked 6 monthly
Which drug is licenced for adolescents with depression, and why?
Fluoxetine
SSRI can induce thoughts of suicide, especially in younger people. Fluoxetine is least likely to do this.
What are some of the common side effects of SSRIs?
G.I upset
Change in appetite
Hyponatraemia
- especially in elderly
Increased suicidal thoughts
- especially in young
Prolonged QT
- Citalopram
Bleeding
- effect 5HT3 uptake by platelets
Serotonin syndrome
How long should SSRIs be used for? and what advice should you give the patient taking them?
A further 6 months on from when they start to feel better
Advice
- do not stop suddenly as will cause flu like symptoms.
Decrease gradually over 4 weeks
or 1 year for anxiety
What are the two most common class of drugs prescribed for depression and what drug class do you need to be careful with?
SSRIs
SNRIs
TCAs can be fetal if overdosed on. As such should be avoided or given in low volume to those at risk of suicide.
What are some important side effects of TCAs?
Urinary retention
QT prolongation
Arrhythmias
Postural hypotension
Weight gain
Mania - rare
What are some of the major risk factors for suicide?
SAD PERSONS
- Sex - Male
- Age >40 years
- Depression
- Previous attempts
- Ethanol
- Rational thinking lost - psychosis
- Social isolation
- Organised plan - leaving notes, writing wills
- No hobbies
- Sickness (chronic pain)
What screening tests/ monitoring should be done prior/ during lithium administration?
TFTs
- induces hypothyroidism
Parathyroid function
- can induce hyperparathyroidism
Renal function
- induces diabetes insipidus (nephrogenic)
- Reduces glomeruli filtration rate
What warnings should be given to someone taking lithium?
Carry card explaining they are on lithium
Avoid dehydration
- leads to chronic accumulation
Avoid interactive drugs
- NSAIDs
- Diuretics
What is the most common endocrinological side effect of lithium?
Hypothyroidism
What antipsychotic provides the least side effect profile?
Aripiprazole
What investigations or monitoring should be done for people on SSRIs?
FBC - G.I bleeding
U&Es - Hyponatraemia - SIADH
ECG
- if on citalopram - increased risk of QTc elongation
What SSRI can increase QT length?
Citalopram
“in the Citi” there are long queues
Which SSRI should be used in someone with a previous M.I?
Sertraline
What are some important drug interaction with SSRIs:
NSAIDs and Aspirin - should be give PPI alongside
Triptans - increases risk of serotonin syndrome
Warfarin and heparin
- if needed recommended to be placed on mirtazapine
How do benzodiazepines works?
Bind to GABBA receptors and promote more of an influx of Cl- into the cell, hyperpolarising it.
- induces calm
- hypnotic effect
- muscle relaxation as GABA are found in spinal cord
What are the common side effects of benzodiazepines? and what is the serious side effects with an overdose and how is it treated?
Impaired motor co-ordination
Drowsiness
Inability to concentrate
Serious:
- respiratory arrest
- coma
Flumazenil
*caution if suspected overdosed with other substances
How do Barbiturates work?
Prolong the opening of GABA receptors increasing Cl- influx
High doses can stimulate the GABA receptors.
- causing strong CNS depression
- phenobarbital
How long following doses of Clozapine will the dose need to be restarted again slowly?
48 hours
What are the common side effects of anti-psychotic drugs?
Within hours:
- Acute dystonia (opisthotonus, Torticollis)
- procyclidine management
Within days:
- Akathisia
(unable to sit still)
Within weeks/ months:
- Parkinsonism
Years:
- Tardive dyskinesia
involuntary facial movements
Other important side effects:
- weight gain
- metabolic syndrome
- QT prolongation (haloperidol)
*increased DVT and stroke risk in elderly patients
Which anti-psychotic drugs are less likely to cause adverse effects such as tardive dyskinesia, acute dystonia etc?
Atypical/ second generation anti-psychotics:
Risperidone
Olanzapine
Clozapine
Quetiapine
After changing the dose of lithium, when will levels need to be rechecked?
1 week 12 hours after dose
What are the adverse effects of lithium?
Nausea and vomiting
Nephrotoxicity / Diabetes insipidus
Thyroid enlargement - hypothyroidism
T wave flattening/ inversion
Hyperparathyroidism - hypercalcaemia
What SSRIs are associated with increased risk in pregnancy?
Fluoxetine: 3rd trimester persistent pulmonary hypertension
Paroxetine: 1st trimester - congenital heart defects
If a patient on lithium develops low mood, constipation, difficult concentrating and abdominal pain - why might this be?
Hyperparathyroidism
- hypercalcaemia
What are some important side effects of SSRIs?
Increased suicide idealisation when first starting
- especially in <25 years
G.I upset/ bleeding
Hyponatremia
Increased QT interval
List two SNRI:
Venlafaxine
Duloxetine
name some TCAs and list some serious side effects:
- Amitriptyline
- Clomipramine
- Nortriptyline
- Imipramine
- drugs are anti-muscarinic and alpha antagonists.
- expect side effects accordingly
Side effects:
- fatal arrhythmias
- Urinary retention
- Hypotension
- sedation
In MAOIs what is the chemical which competes with it to cause hypertensive crisis?
Tyramine
- which induces wide spread vasoconstriction
What type of drug is mirtazapine?
Noradrenageric and specific serotonin antidepressant
NaSSAs
What is the chronological order of how symptoms from antipsychotics begin?
Acute dystonic reactions
Akathisia (inability to sit still, restless)
- days to weeks
Parkinsonism
- weeks to months
Tardive dyskinesia
- months to years
Is procyclidine? and when is it used?
An anti-cholinergic drug
- used for acute dystonia
What are the side effects of hyper-prolactinaemia caused by second generation anti-psychotics?
Gynecomastia Galactorrhoea Infertility Osteoporosis Breast cancer
Outwith lithium, name some other mood stabilisers:
Carbamazepine
Lamotrigine
Sodium valproate
What are the indications for benzodiazepines?
Short term anxiety Alcohol detoxification Short term insomnia Sleep disorders Emergancy termination of seizures
What patients have a paradoxical reaction to benzodiazepines?
Lewy body dementia
- neuroleptic malignant syndrome risk
What is the course of ECT?
Twice weekly in a course of 6-12 treatments
What are some indications to ECT and some side effects?
Indications:
- Unipolar depression
- Bipolar depression
- catatonia
- mania
- schizophrenia
side effects:
- most side effects are GA related
- antegrade memory loss
- headache
- increased risk of suicide due to increased motivation to begin with
