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308: Clinical Pharamacology & Therapeutics > Psychiatric drugs > Flashcards

Psychiatric drugs Flashcards

1
Q

What are the broad categories of pharmacological treatments available for depression

A
  1. SSRIs
  2. SNRIs
  3. TCAs
  4. MAOIs (RIMA)
  5. NA reuptake inhibitors
  6. Noradrenergic and specific serotonergic antidepressanrs
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2
Q

Consider SSRIs

  • examples
  • indications
  • what is their onset of action?
  • how do they work?
A
  • Indications: depression, anxiety disorders, PD, OCD, PTSD
  • Sertraline, fluoxetine, paroxetine, citalopram
  • Delayed onset of action (0-14 days)
  • blocks uptake of serotonin into presynaptic neuron
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3
Q

Compare the half life of paroxetine to fluoxetine

What does this mean for patients?

A

Paroxetine has a half-life of 20 hours (shortest), fluoxetine has the longest (2-4 days)

Short half-life makes the effects of missed pill more pronounced as the active agent remains in body for less time. (DISCONTINUATION SYNDROME, if stopped abruptly)

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4
Q

A patient has been prescribed paroxetine for depression. They visit their GP as they havent felt themselves in recent days. The patient complains of nausea and diarrhoea. He appears agitated.

After asking about the patients compliance to medication you learn that he has missed his medication over the past week.

1) What is the likely diagnosis?
2) What other symptoms should you ask about/expect?
3) How would you treat?

A

1) Discontinuation syndrome
2) agitation, anxiety, dizziness, balance problems, nausea, diarrhoea, flu-like symptoms
3) Reassurance and monitoring; reintroduction of drug with tapered withdrawal; consider alternative antidepressant or anxiolytic

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5
Q

Give an example of a TCA

How does it work?
Describe the side effect profile

A

e.g. Amitriptyline

MOA: Binds to NA and serotonin reuptake transporters –> increased availability of monamines in synaptic cleft

Has anticholinergic effects: dry mouth, constipation, urinary retention, cognitive effects

psychotrophic effects (agitation, nightmares), sexual dysfunction, akathisia, muscle twitches, cardiac arrhythmias

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6
Q

You are the psychiatric trainee on-call in A&E. You are asked to see a patient known who has presented confused with tachycardia and hypotension. O/E his pupils are dilated

James Smith, 27, has been taking amitriptyline for his depression. No other relevant PMH

1) What is the most likely cause for this presentation?
2) What is the patient at risk of?

A

1) TCA overdose

2) Seizures, coma, cardiorespiratory arrest

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7
Q

Consider venlafaxine

1) What kind of drug is this?
2) How does is work?
3) Indications
4) Side effects
5) Give an example of another drug in this class

A

1) SNRI
2) Blocks uptake of serotonin and NA into presynaptic neuron
3) Depression, mixed anxiety
4) HEADACHE, nausea, hypertension, risk of discontinuation syndrome
5) Duloxetine

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8
Q

When would you consider using a RIMA drug?

How do they work?

A

Reserved for treatment resistant depression or atypical depression

Prevent action of monamine oxidase from breaking down serotonin, dopamine and noradrenaline (in presynaptic knob)

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9
Q

1) Give two examples of RIMAs
2) Before prescribing these drugs what must you discuss with the patient
3) What drugs should be avoided with these?

A

1) Moclobemide, selegiline

2) Tyramine-food interactions: cheese, red whine, broad bean pods and tyramine
- -> hypertensive effect –> hypertensive crisis (less with moclobemide)

3) Do not combine with SSRIs –> serotonin syndrome ;
interacts with adrenaline, NA, Levodopa

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10
Q

Reboxetine is an example of which class of drug?

A

NA reuptake inhibitor

- highly selective

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11
Q

How do NaSSa drugs work?

Give an example

A

Noradrenergic and specific serotonergic antidepressant

MOA: Increases release of serotonin and NA via alpha-2 receptors on presynaptic neuron

Mirtazapine

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12
Q

What are antipsychotics used to treat?

A
  • psychotic illnesses (e.g. schizophrenia, schizoaffective disorder)
  • bipolar
  • adjunct therapy for depressive episodes

(Off license use: behavioural disturbance in dementia and LD, conduct disorder, PD, PTSD, anxiety)

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13
Q

How do the following drugs cause psychotic symptoms?

a) Cocaine, MDMA, ecstasy
b) LSD
b) PCP

A

a) Dopaminergic drugs can produce schizo-like symptoms. They block the action of dopamine via D2 receptor blockade
b) Hallucinergic drugs are structurally similar to serotonin, act at their receptors
c) PCP is a glutamate agonist and can produce schizo-affective symptoms

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14
Q

Give three examples of typical antipsychotics

A

Butyrophenones:
- Haloperidol

Phenothiazines:

  • Chlorpromazine
  • Trifluoperazine
  • Fluphenazine

Thioxanthines:
- Flupenthixol

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15
Q

Describe the side effect profile of the typical antipsychotics. Why is this?

A

Selective dopamine receptor blockade –>

(Via nigrostriatal pathway)
EPS, parkinsonism, dystonias, tardive dyskinesia

(Via infundibular pathway)
Hyperprolantinaemia

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16
Q

Why do newer antipsychotics have a lower propensity to cause EPS?

Give 3 examples of atypical antipsychotics

A
  • Less specificity for D2 receptors
  • Also act on serotonin system

Risperidone, olanzepine, quetiapine, aripiprazole

17
Q

Describe the side effect profile of the atypical antipsychotics. Why is this?

A

Anti-HAM side effects

Anti-Histaminic: sedation
Anti-alpha adrenergic: sexual dysfunction, orthostatic hypotension, palpitations, vertigo
Anti-muscarinic: dry mouth, tachycardia, urinary retention, constipation, blurry vision, dizziness, somnolence, impaired memory and cognition

Weight gain and metabolic syndrome

18
Q

What kind of drug is clozapine?
When is it used?
Describe its side effect profile

A
  • Atypical antipsychotic
  • reserved for treatment resistant cases (although most effect antipsychotic)
  • Most severe: granulocytosis (which necessitates blood test monitoring);
    low propensity to cause EPS;
    hypersalivation and hypotension;
    extreme sedation;
    metabolic syndrome
19
Q

When is rapid tranquillisation needed?

What agents would you use?

A

Acute agitation/aggression where there is risk to self or others.
- always try to talk down first and offer oral medication

IM administration of
(1) antipsychotic: olanzepine/ haloperidol which have immediate sedative effect
or;
(2) benzodiazepines: lorazepam/midazolam

Also treat the underlying cause (e.g. sepsis)

20
Q

What is the number one mood stabiliser indicated for long term maintenance therapy?

We dont completely understand its MOA but what do we know?

A

Lithium

  • Causes inhibition of inositol via 2nd messenger model
  • causes regulation of gene expression- protein kinase C
21
Q

Lithium has a narrow therapeutic range which increases its risk of toxicity.

How might a person with lithium toxicity present?

What may precipitate this kind of reaction?

A
  • nausea
  • vomiting
  • ataxia
  • cerebellar signs
  • confusion

Precipitants:
- salt depletion; dehydration i.e. in diarrhoea or vomiting; drug interactions with thiazides, NSAIDs; deteriorating renal function

22
Q

Discuss the side effect profile of lithium as:

a) short term
b) long term

A

a) polydipsia, polyuria, nausea, fine tremor, loose stool

b) hypothyroidism, renal impairment, weight gain, acne

23
Q

Why is it important to maintain adherance to lithium therapy?

A
  • there is loss of efficacy if you keep stopping and starting
24
Q

This question is about carbemazepine

  • Indication
  • Why should it be prescribed with caution in a person with multiple comorbidites?
A
  • Antimanic mood stabiliser with lower efficacy than lithium
  • Major drug interactions; induces liver enzymes so reducing levels of other agents and these agents in turn alter carbemazepine metabolism
25
Q

This question is about valproate

  • how does it work?
  • why might patients prefer this over other mood stabilisers?
  • why might patients not want to take it?
  • who should not be offered it?
A
  • MOA: inhibition of Ca and Na channels, enhances inhibitory GABA and reduces excitatory glutamate
  • Easy to use, improved tolerability
  • Weight gain
  • Teratogenic + developmental disorders. DONT GIVE TO WOMEN OF CHILDBEARING AGE
26
Q

Give an example of a short acting and long acting benzodiazepine

A

Short acting
- lorazepam

Long acting

  • clonazepam
  • diazepam
27
Q

What is the indication for benzodiazepine use?

A
  • hypnotics
  • anxiolytics
  • minor tranquilisers
  • management of alcohol withdrawal
  • clobazam is used as anticonvulsant and muscle relaxant
28
Q

How do benzodiazepines work?

A

Bind to the benzodiazepine site on GABA-a receptor

The GABAa receptor is a ligand gated Cl- channel

Increased conduction of chloride puts the cell in a hyperpolarised state (so a greater voltage is needed for firing) –> less frequent depolarisation –> reduced cortical and limbic system arousal

29
Q

What happens if you abruptly stop somebodys long term benzodiasepam?

A

DEPENDENCY ISSUES
(remember GABA is a major inhibitory neurotransmitter)

  • May precipitate acute delirium, psychosis and convulsions
  • other withdrawal symptoms: nausea, hyperacusis, dizziness and imbalance, tinnitus, depersonalisation
30
Q

How do you avoid tolerance in benzodiazepine use?

A
  • avoid lengthy prescriptions

- taper withdrawal using diazepam equivalents

31
Q

Other than benzodiazepines what other anxiolytics can be used?

How do they work?
indications?

A
  1. Buspirone
    - partial serotonin (5HT-1a) agonist
    - GAD, may have tole in decreasing side effects of PD and behavioural distrubance in dementia
  2. Pregabalin
    - Binds to and modulates voltage gated calcium channels in CNS
    - indications: neuropathic pain, anxiety and PD, seizures

308: Clinical Pharamacology & Therapeutics (10 decks)

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