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Mental Health > Psychiatric Medication > Flashcards

Psychiatric Medication Flashcards

1
Q

What are some common adrenergic effects?

A 
Sweating 
Tremor 
Headaches
Nausea 
Dizziness
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2
Q

What are some common muscarinic effects?

A 
Dry mouth
Difficulty swallowing 
Thirst 
Difficulty urinating 
Urinary retention 
Hot flushes 
Dry skin
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3
Q

What are some common effects of histamine?

A

Dry mouth
Drowsiness
Dizziness
Nausea and vomiting

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4
Q

Most antidepressants have their effect in how many weeks?

A

2 to 3 (up to 4-6)

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5
Q

What are the most commonly used antidepressants?

A

SSRIs

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6
Q

Other than SSRIs, what other types of antidepressants are there?

A

SNRIs
Mirtazapine
Tricyclics
MAOIs

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7
Q

How do SSRIs work?

A

They reduce presynaptic reuptake of serotonin after its release into the cleft.

As a result, more seratonin is in the nerve junction.

This also leads to a down regulation of post synaptic receptors

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8
Q

What are common side effects of SSRIs?

A

Sense of restlessness, agitation on initiation
Nausea, GI disturbance
Headache
Weight changes
Sexual dysfunction
Less common: bleeding and suicidal ideation

(One of the first things to improve is motivation rather than outlook. More likely to carry out harmful acts - follow up within 2 weeks of prescribing)

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9
Q

SSRIs have low risk of bleeding so ask about other drugs that can cause bleeding e.g aspirin and cover with ….

A

A PPI

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10
Q

What are some common SSRIs and dose range?

A

Sertraline 50-200mgs (therapeutic dose is 100mgs but start lower)
Citalopram 20-40mgs
Fluoxetine 20-60mgs
Paroxetine 20-60mgs

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11
Q

Sertraline is safest in what type of disease?

A

Cardiac

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12
Q

What is there a risk of with citalopram?

A

QTc prolongation

Not used in older patients for this reason

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13
Q

Fluoxetine has a long half life, so when switching what is the risk?

A

Serotonin syndrome

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14
Q

Does paroxetine have a short or long half life?

A

Short

Need to watch out for discontinuation syndrome

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15
Q

How do SNRIs work?

A

Act in the same way as SSRIs but bind to noradrenaline reuptake receptors as well.

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16
Q

What are the common side effects of SNRIs?

A

Similar to SSRIs but greater potential for sedation, nausea and sexual dysfunction

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17
Q

Give two examples of SNRIs

A

Duloxetine (60-120mgs) low dose range

Venlafaxine (75-375mgs) greater efficacy and can go to a higher dose. Caution with higher doses in heart disease, monitor BP at doses above 225mgs

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18
Q

What is mirtazapine?

A

Noradrenergic and Specific Serotonergic Antidepressant (NASSA)

Acts as a 5HT-2 and 5HT-3 antagonist

Strong H1 activity - hence sedation and increased appetite

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19
Q

What are the major side effects of mirtazapine?

A

Sedation
Weight gain

These side effects can be used to therapeutic advantage e.g if depression complicated by anxiety or trouble sleeping

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20
Q

Tricyclic antidepressants are useful in what situation?

A

For those who do not respond well to SSRIs

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21
Q

Why are SSRIs favoured over TCAs?

A

Better tolerated side effect profile

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22
Q

What is the action of TCAs?

A

Block the reuptake of noradrenaline and seratonin at the synaptic cleft

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23
Q

What side effects are associated with TCAs?

A

Muscarinic and histaminic side effects

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24
Q

Why can TCAs be fatal in overdose?

A

Cause QTc prolongation and arrhythmias

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25
Q

In low doses TCAs can be used for what purpose?

A

Neuropathic pain

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26
Q

Give some examples of TCAs

A

amitriptyline, clomipramine, imipramine

lofepramine, nortriptyline = newer TCAs and are tolerated better than older TCAs

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27
Q

How do monoamine oxidase inhibitors work?

A

They inhibit one or both monoamine oxidase enzymes MAOI-A, MAOI-B and thus inhibit the breakdown of monoamine neurotransmitters

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28
Q

What does MAOI-A work more on?

A

Serotonin

MAOI-B works more on dopamine

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29
Q

What are MAOIs generally reserved for?

A

Atypical depression

Dysthymia - chronic treatment resistant depression

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30
Q

Which MAOIs bind irreversibly and are more dangerous?

A

Phenelzine

Isocarboxazid

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31
Q

Which MAOIs bind reversibly?

A

Moclobamide

Tranylcypromine

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32
Q

MAOIs have the potential to cause what type of reaction leading to hypertensive crisis?

A

Tyramine reaction

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33
Q

What should be avoided when taking MAOIs?

A

Cheese, pickled meats, wine and other tyramine products

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34
Q

How long should the washout period be after taking MAOIs?

A

Up to 6 weeks

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35
Q

How does vortioxetine work?

A

All sorts of serotonergic activity

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36
Q

When should vortioxetine be considered?

A

No improvement after 2 other antidepressants have been tried

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37
Q

What is the most common side effect for vortioxetine?

A

Nausea

But generally well tolerated

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38
Q

What should be considered when deciding on an antidepressant?

A

What has been used before and was it effective/ tolerated?

Are there comorbidities that can be addressed e.g weight loss, insomnia, neuropathic pain

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39
Q

Which antidepressant should be used in new cases with no previous treatment (and no major weight loss or sleep difficulty)?

A

Start with SSRI - SERTRALINE

In most cases start with SSRI, then switch to different SSRI if no effect, then try SNRI or Mitazapine

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40
Q

What type should be considered if comorbid neuropathic pain?

A

SNRI

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41
Q

For depression, if an antidepressant has no benefit at typical dose is it worth increasing dose?

A

No

If partial benefit can increase dose

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42
Q

For anxiety especially OCD, should you consider increasing the dose of antidepressant if no initial benefit at typical dose?

A

Yes

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43
Q

What is discontinuation syndrome?

A

Symptoms that occur after antidepressant is stopped

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44
Q

What symptoms are associated with discontinuation syndrome?

A

Sweating, shakes, agitation, insomnia, headaches, irritability, N&V, paraesthesia, clonus

Symptoms influenced by half life - shorter half life bigger the problem

45
Q

What antidepressants are most difficult to stop - risk of discontinuation syndrome?

A

Paroxetine

Venlafaxine

46
Q

Why can switching to fluoxetine help in preventing discontinuation syndrome?

A

It has a very long half life

47
Q

What is serotonin syndrome?

A

A group of symptoms that occur due to taking serotonergic drugs, typically 2 at the same time e.g an SSRI and SNRI

48
Q

What symptoms are associated with serotonin syndrome?

A

Cognitive – headaches, agitation, hypomania, confusions, coma

Autonomic – shivering, sweating, hyperthermia, tachycardia, nausea
and diarrhoea

Somatic – myoclonus, hyper-reflexia and tremor

49
Q

How is serotonin syndrome treated?

A

Usually supportive - fluids and monitoring

50
Q

What are antipsychotics also called?

A

Neuroleptics

51
Q

How do current antipsychotics work?

A

Reduce level of dopamine activity at D2 receptors

52
Q

What dopaminergic pathways do antipsychotic medication target?

A

Mesocortical and mesolimbic

53
Q

The unwanted effects of antipsychotics common from action at what pathways?

A

Nigrostriatal (movement) and tuberoinfundibular (HPA axis)

54
Q

What side effects do all antipsychotics have the potential for?

A 
Sedation
Extrapyramidal side effects 
Weight gain 
QTc prolongation 
Acute dystonia 
Oculogyric crisis
55
Q

What are some characteristics of typical antipsychotics?

A

Older
More likely to cause extra-pyramidal side effects
Tend to bind more to muscarinic and histaminic receptors

56
Q

What are other names for typical and atypical antipsychotics?

A 
Typical = first generation 
Atypical = second generation
57
Q

Give some examples of typical antipsychotics

A 
Haloperidol 
Flupenthixol 
Zuclopenthixol 
Chlorpromazine 
Sulpride
58
Q

Give some examples of atypical antipsychotics

A 
Clozapine 
Olanzapine 
Risperidone
Quetiapine
Amisulpride 
Aripiprazole
59
Q

What side effects are associated with typical antipsychotics?

A

Extra-pyramidal side effects including Parkinsonism (bradykinesia, muscle stiffness, tremor), tarditive dyskinesia, akathisia

Dizziness
Sexual dysfunction

60
Q

What is akathisia?

A

A movement disorder characterised by a feeling of inner restlessness and inability to stay still

61
Q

What is tardive dyskinesia?

A

Involuntary repetitive body movements e.g sticking tongue out, lip smacking, grimacing.

There may also be jerky movements

62
Q

What side effects are associated with atypical antipsychotics?

A

Weight gain
Dyslipidaemia
Diabetes

63
Q

Outline the monitoring that should be done for antipsychotics

A

Baseline: FBC, lipids, LFT, HbA1c, weight, ECG, BP and pulse

Weekly: weight

Three months: FBC, lipids, LFT, HbA1c, weight, ECG, BP and pulse

Yearly: same as above

64
Q

What is neuroleptic malignant syndrome?

A

A rare, life threatening reaction to antipsychotics

65
Q

What characteristics are associated with neuroleptic malignant syndrome?

A

Fever, confusion, muscle rigidity, sweating, autonomic instability

66
Q

In NMS what is death usually caused by?

A

Rhabdomyolysis
Renal failure
Seizures

67
Q

What are risk factors for NMS?

A

High potency dopamine antagonists (typical antipsychotics) in antipsychotic naive, high doses, young men

68
Q

What will bloods likely show in NMS?

A

Raised CK

Raised WCC

69
Q

How do you treat NMS?

A

Stop antipsychotics
Benzodiazepine for acute behavioural disturbance
Fluid resuscitation
Reduce temp - cooling blankets
Oxygen if necessary
If rhabdomyolysis - fluids and sodium bicarbonate
To relax muscles - dantrolene or lorazepam

70
Q

What medication is used to treat extra pyramidal side effects?

A

Anticholinergics (Ach antagonists)

71
Q

Extra pyramidal side effects are due to what ratio in the nigrostriatal pathway?

A

Dopamine: acetylcholine

72
Q

If there is too much acetylcholine in relation to dopamine and dopamine cannot be increased, what should be done?

A

Reduce acetylcholine

73
Q

What is the most commonest drug used for EPSE?

A

Procyclidine

74
Q

Are anticholinergics effective for tardive dyskinesia?

A

No - may exacerbate

75
Q

What is acute dystonia?

A

Sustained, often painful muscular spasms producing twisted, abnormal postures.

Most common: neck, tongue, jaw, oculogyric crisis

76
Q

What is oculogyric crisis?

A

Neck arched and eyes rolled back

77
Q

How do you treat acute dystonias?

A

Stop antipsychotics
IM or IV anticholinergics - procyclidine
Continue for 1 to 2 days after dystonia and consider long term prophylactic

78
Q

What was the first atypical antipsychotic?

A

Clozapine

79
Q

What is the most efficacious antipsychotic?

A

Clozapine

80
Q

What receptors does clozapine act on?

A

D2 antagonist

5HT-2 antagonist

81
Q

When should clozapine be used?

A

After 2 other antipsychotics have not been effective

82
Q

What side effects are associated with clozapine?

A

Significant potential for agranulocytosis (especially neutrophils)
- close FBC monitoring weekly for first 18 weeks then fortnightly for up to a year then monthly

Significant potential for gastrointestinal hypo-mobility: constipation, potentially fatal bowel obstruction

Hypersalivation
Urinary incontinence
Autonomic dysregulation - dose titrate slowly up over 2 weeks and monitor vitals

83
Q

How do you treat agranulocytosis associated with clozapine?

A

Stop clozapine
Stop marrow suppressing drugs e.g sodium valproate
Avoid other psychotics for a few weeks (if not possible use Aripiprazole as less marrow suppression potential)
Contact haematologist
Consider broad spec antibiotics
Lithium can increase WCC and neutrophils
GCSF (although tends to increase release of WBCs from marrow, not increasing turnover)

84
Q

What are the main classes of drugs used in the treatment of anxiety?

A

Beta blockers (physical symptoms)
Benzodiazepines
Pregabalin
Antidepressants

85
Q

How do beta blockers work in the treatment of anxiety?

A

Reduce autonomic nervous system activation.

86
Q

What is the most often used beta blocker in the treatment of anxiety?

A

Propranolol

87
Q

Propranolol should not be prescribed if the patient has…

A

Asthma

88
Q

Which benzodiazepines are most typically used in the treatment of anxiety?

A

Diazepam (long half life)

Lorazepam (shorter half life)

89
Q

How do benzodiazepines work?

A

Bind to GABA receptors to potentiate the effect of GABA and therefore reduce the excitability of neurones.

= positive allosteric modulators of GABA receptor

90
Q

Why should benzodiazepines be prescribed cautiously?

A

Significant potential for tolerance and dependence

91
Q

What is the maximum amount of time benzodiazepines should be used for?

A

No more than 6 weeks

92
Q

What are some examples of mood stabilisers?

A

Lithium
Anticonvulsants
Atypical antipsychotics

93
Q

How does lithium act on the brain?

A

Mechanism unknown

Lowers NA release and increases serotonin synthesis

94
Q

Does lithium have a narrow or large therapeutic window?

A

Narrow

95
Q

How regularly should serum lithium levels be measured?

A

Weekly after dose change until levels stable then every 3 months

96
Q

Is it true or false that lithium reduces suicide?

A

True

It also has a licence for reduction of self harm

97
Q

What are the side effects of lithium?

A 
GI disturbance 
Metallic taste and or dry mouth 
Fine tremor 
Polydipsia and polyuria 
Weight gain
98
Q

What are the long term effects of lithium?

A

Hypothyroidism - usually reversible
Renal impairment - usually irreversible (occurs mostly above therapeutic doses)
Therefore U&Es and TFTs every 6 months

99
Q

What are the symptoms/ signs of lithium toxicity?

A

Can be fatal

Confusion, coarse tremor, incontinence, nausea and vomiting, ataxia, seizures

100
Q

How do you manage lithium toxicity?

A

Stop lithium

Supportive measures - IV fluids, dialysis if necessary, benzodiazepines for seizures

101
Q

How is lithium excreted?

A

Via kidneys

102
Q

The potential for toxicity increases with what?

A

Dehydration

103
Q

What drugs have the potential to interact with lithium and increase toxicity risk?

A

NSAIDS
loop diuretics
ACE inhibitors

104
Q

What is the first line drug treatment for bipolar?

A

Quetiapine

105
Q

What are the most commonly used anticonvulsants used in bipolar disorder?

A

Sodium valproate- avoid in women of child bearing age, check LFTs before and soon after starting
Carbamazepine
Lamotrigine - potential for Stevens Johnson Syndrome

Most anticonvulsants have potential for thrombocytopenia so check FBC

106
Q

Abrupt cessation of lithium precipitates mania in up to what percentage of people?

A

50%

Discontinuation should be over 2-4 weeks

107
Q

What is the target plasma level of lithium?

A

0.6-1 mmol/L

108
Q

TCAs have antimuscarinic side effects. What are they?

A

Can’t pee
Can’t see (blurred vision)
Can’t spit (reduced saliva)
Can’t shit (constipation due to reduced GI motility)

Mental Health (13 decks)

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