Psychiatric Meds Flashcards by Katie Wilkinson

What are some of the common muscarinic side effects?

Dry mouth
Difficulty swallowing
Thirst
Urinary retention
Hot and flushed skin
Dry skin

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What are some of the common histamine medication side effects?

Dry mouth
Drowsiness
Dizziness
N+V

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What are some of the common side effects of SSRIs?

Restlessness and agitation
N&V / GI disturbance
Headache
Weight changes (up or down, usually down)
Sexual dysfunction
Less common = bleeding
Increasing suicidal ideation in first 2 weeks

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What class of drugs should be prescribed with caution if taking SSRI? 
Why?
What can be taken alongside?

NSAIDs
Risk of GI bleed
Co-prescribe PPI

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Which SSRI do you need to watch for QTc prolongation with?

Citalopram

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Which SSRI is safest in cardiac disease

Sertraline

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Name 2 SNRIs

Venlafaxine

Duloxetine

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What are the side effects of SNRIs?

Same as SSRIs but greater potential for sedation, nausea and sexual dysfunction

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What class of drug is Mirtazapine?

Noradrenergic and Specific Serotonergic Antidepressant

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What are the major side effects of mirtazipine? How can this be utilised to therapeutic advantage?

Sedation
Weight gain

Take at night to help with sleep
Good if underweight

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Name 3 Tricyclic Antidepressants

Lofepramine
Nortriptyline
Amitriptyline (used for for low dose neuropathic pain)

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What are the main side effects of TCAs?

Muscarinic and Histaminic side effects

Dry mouth
Difficulty swallowing
Thirst
Urinary retention
Hot and flushed skin
Dry skin
Dizziness
Drowsiness
N&V

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Why can TCAs be fatal in overdose?

Due to QTc prolongation causing fatal arrhythmia

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What are the 2 types of monoamine oxidase inhibitors and which pathways do they each work on?

MAOI- A = works on serotonin

MAOI-B = works more on dopamine

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What serious complication do patients on MAOI need to be warned about

Potential for tyramine reaction leading to hypertensive crisis
Need to avoid tyramine rich foods:
- Cheese
- Pickled meats
- Wine

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What washout period is required if switching from an MAOI to another antidepressant?

6 weeks due to long t 1/2

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What is the usual antidepressant of choice to start a patient on?

SSRI unless struggling with sleep/ major weight loss then choose mirtazipine

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What should be done if an SSRI has no effect?

Switch to a different SSRI
If still no effect switch to an SNRI
If there is a partial effect then increase the dose

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How long should you wait for an antidepressant to consider whether it’s had an effect or not

4 weeks (but can usually tell in 3 weeks)

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What is discontinuation syndrome?

Sweating, weakness, shakes, agitation, insomnia, headaches, irritability, N&V, paraesthesia and clone
Caused by stopping antidepressants

Worse with Paroxetine and Venlafaxine due to short t 1/2

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What is serotonin syndrome?

Vague presentation of:

Cognitive - headaches, agitation, hypomania, confusion or coma
Autonomic - shivering, sweating, hyperthermia, tachycardia, nausea and diarrhoea
Somatic - myoclonus, hyper-reflexia and tremor

How is serotonin syndrome treated?

Supportive management: fluids and monitoring

Which dopaminergic pathways do antipsychotics target?

Mesocortical and mesolimbic

Which dopaminergic pathways are responsible for the unwanted side effects of antipsychotics?

Nigrostriatal (movement) and Tuberoinfundibular (HPA axis)

What are the common side effects of all antipsychotics?

- sedation - extrapyramidal side effects - weight gain - QTc prolongation Can all cause - acute dystonia - oculogyric crisis

What is the difference between ariprazole and other anti-psychotics?

It is a partial D2 agonist (not an antagonist) | Sits at the receptor site of dopamine but less effective than dopamine therefore fewer side effects

Which side effects are more common from typical antipsychotics?

- EPSE (bradykinesia, muscle stiffness, rigidity, tardive dyskinesia - Dizziness - Sexual Dysfunction

Which side effects are more common from atypical antipsychotics?

- weight gain | - dyslipidaemia and diabetes

What are the monitoring requirements of antipsychotics?

FBC , LFTs, HbA1c, ECG, BP and pulse to be done at baseline, 3 months and then yearly Weight ideally done weekly

What are the features of neuroleptic malignant syndrome?

- Fever - Confusion - Muscle rigidity (usually lead pipe) - Sweating - Autonomic dysfunction

What typically causes death in neuroleptic malignant syndrome?

- Rhabdomyolysis - Renal failure - Seizure

What are the risk factors for developing neuroleptic malignant syndrome?

- Typical antipsychotics - Antipsychotic naiive patients - High doses of antipsychotics - Young men

How should neuroleptic malignant syndrome be managed?

- Emergency A&E referall - Stop antipsychotics - Benzos for acute behavioural disturbance - fluid resuscitation - reduce temperature (cooling blankets) - O2 - Rhabdomyolysis - give fluids and sodium bicarb to alkalise urine - To relax muscles: 1st line lorazepam, 2nd line bromocriptine

How can extra pyramidal side effects be managed?

Anticholinergics: reduces amount of acetylcholine to improve the acetylcholine: dopamine ratio Procyclidine (most common) - use with caution as potential for misuse Benzatropine Trihexphenidyl

When is clozapine used?

For Schizophrenia where 2 other antipsychotics has not been effective

What are the serious side effects of clozapine?

- Agranulocytosis | - Gastrointestinal hypo-mobility ; constipation leading to potentially fatal bowel obstruction

What are the monitoring requirements of clozapine?

- FBC monitored weekly for 1st 18 weeks then fortnightly for up to 1 year then monthly - Monitor vital signs for autonomic dysregulation - Weight as causes central weight gain

How should clozapine induced agranulocytosis be treated?

- stop clozapine - stop any other marrow suppressing drugs e.g sodium valporate - avoid other antipsychotics for a few weeks if possible - avoid sources of infection - consider prophylactic abx - Lithium sometimes used to increase WCC and neutrophil count

What is the MOA of benzodiazepines?

Potentiate the effect of GABA therefore reduce excitability of neurones (positive allosteric modulators)

How long should benzodiazepines ideally be used for?

No longer than 6 weeks

Which bentos have the shorter and longer t 1/2

``` Diazepam = longer Lorazepam = shorter ```

How does pregabalin work?

Binds to Voltage gated Calcium channels in neurones | Reduces neuronal activity

What is the treatment regime with zopiclone?

2 weeks max | Take for 5 out of 7 days

Why is zopiclone used for only 5/7 days?

Get post synaptic GABA downregulation therefore potential for tolerance build up

What is the therapeutic window for lithium?

0.6 - 1.0 mmol/L

What monitoring requirements are needed for patients taking lithium?

Weekly lithium levels until stable then 3 monthly U&Es annually TFTs annually

What are some of the side effects of lithium?

- GI disturbance - Metallic taste - Dry mouth - Fine tremor - Polydipsia and polyuria - Weight gain - Long term: renal impairment and hypothyroidism

What are the signs of lithium toxicity? (potentially fatal)

- Confusion - Coarse tremor - N&V - Ataxia - Seizures

How is lithium toxicity managed?

- Stop lithium - Supportive measures , IV fluids - Dialysis is necessary - Benzodiazepines for seizure

What other drugs can interact with lithium causing dangerous levels?

- ACE inhibitors - NSAIDs - Loop diuretics

Which drugs are most commonly used to treat ADHD/ ADD?

CNS stimulants | Methylphenidate most commonly prescribed

What monitoring requirements are needed for patients on CNS stimulants?

- Weight - Height - Pulse - BP