Psychiatric Pharmacology Flashcards
1
Q
What is the rationale behind SSRIs?
A
Selective Serotonin Reuptake Inhibitors
Deficiency in serotonergic activity in depressed patients
2
Q
Give three indications for commencing SSRIs
A
- Mild to Moderate depression where low intensity psychosocial interventions have not helped
- Patients with subthreshold depression
- Mod to Severe depression with concomitant high intensity psychological intervention
3
Q
Describe the efficacy of SSRIs
A
Same efficacy as TCAs
Fewer Anti-muscarinic Side Effects
Less Cardiotoxic
4
Q
What is the SSRI licensed for Major Depression?
A
Paroxetine
5
Q
What is the SSRI licensed for Bulimia Nervosa?
A
Fluoxetine
6
Q
Name two contraindications to SSRIs
A
Children (unless seen by psychiatrist)
Mania
7
Q
Name two instances in which SSRIs should be cautioned
A
Epilepsy
Suicidal Ideation
8
Q
Name two DDIs of SSRIs
A
Some platelet interference
NSAIDs
Warfarin/Heparin
9
Q
Name three side effects of SSRIs
A
Decreased alertness
Suicidal feelings
Dyspepsia
10
Q
Name four causes of Serotonin Syndrome
A
- Drug is started too high/Dose escalated
- Addition of another serotinergic
- Replacement of antidepressants without long enough clearance period
- SSRI and MAOI
11
Q
How does Serotonin Syndrome present?
A
Neuromuscular Hyperactivity
Autonomic Dysfunction (tachycardia, hyperthermia, shivering)
Altered mental state
12
Q
How is Serotonin Syndrome managed?
A
Withdrawal of medication
13
Q
State three pieces of advice that should be given to patients when starting SSRIs
A
May take a few weeks to work
Must stop if they develop a rash
After remission of symptoms, needs to be continued for another 4-6 months
14
Q
When should patients on SSRIs be reviewed
A
After 1-2 weeks of starting
After 4-8 weeks to determine response
15
Q
What is the first line SSRI for children?
A
Fluoxetine
16
Q
What is the first line SSRI for patients post MI?
A
Sertraline
17
Q
What is the max dose of Fluoxetine, Sertraline, Citalopram and Paroxetine?
A
Fluoxetine - 60mg
Sertraline - 200mg
Citalopram - 40mg
Paroxetine - 50mg
18
Q
How should SSRIs be withdrawn?
A
Reduce dose gradually over a four week period
Any abrupt stop - Discontinuation Syndrome (restlessness, problems sleeping, sweating)
19
Q
Which SSRI commonly causes weight gain?
A
Paroxetine
20
Q
Give three indications for SNRIs
A
Major depressive disorder
Anxiety Disorder
OCD
21
Q
When should SNRIs be taken?
A
Recommend to take in the morning as can cause insomnia in some patients if taken at night
22
Q
Name two contraindications to SNRIs
A
If they have taken MAOI in the past two weeks
NSAIDs
23
Q
Name three general Side Effects
A
Loss of Appetite
Increased suicidal thoughts
Sexual Dysfunction (Low libido, anorgasmia)
24
Q
How should SNRIs be withdrawn?
A
Slowly taper to avoid discontinuation syndrome
This is common with Venlafaxine due to short half life
25
Name an indication and contraindication for Venlafaxine as a choice of SNRI
Good for Geriatrics
| CI - High Arrhythmic Risk, Uncontrolled Htn
26
Give an advantage and disadvantage to Duloxetine as a choice of SNRI
Effective for physical depression symptoms
Can’t break capsules due to instability in stomach
27
Name three populations unsuitable to take Mirtazepine as a choice of SNRI
Elderly
Hypertensive
Urinary retention
28
Name two SE of Mirtazepine
Weight Gain
| Sedative
29
What is the mechanism of action of TCAs? Give two examples
Blocks Serotonin and Noradrenaline reuptake (first generation as opposed to SNRIs)
Amitryptyline, Imipramine
30
Name three indications for TCAs
Depression
Anxiety
Chronic Bed Wetting
31
Describe some interactions of TCAs
CYP450
32
TCAs can cause weight gain and colnvulsions. Give three other categories of side effects
Antimuscarinic
Antihistaminic
Antiadrenergic
33
Name two cautions and two contraindications for TCAs
Caution: Epilepsy, Cardiac Disease
Contraindication: Mania, Recent MI
34
How quickly does a TCA overdose become apparent?
Within the first hour due to easy absorption from small intestine
35
Name five effects of TCA overdose
```
Confusion
Hypotension
Syncope
Hypo ventilations
Decreased/Absent bowel sounds
```
36
How is TCA overdose managed?
IV Sodium Bicarbonate
37
Name the two types of MAOI
Irreversible - Phenelzine, Isocarboxazid
| Reversible - Moclobamide (MAOI- A selective)
38
Name three indications for MAOI
3rd line for depression
Social Phobia
Panic Disorder
39
Name some interactions of MAOI
Lethal - SSRIs, TCA
| May potentiate cigarette effects
40
How should MAOI be stopped?
Withdrawn over a four week period with a two week washout
41
Name three side effects of MAOI
Orthostatic Hypotension
Dry Mouth
Anorgasmia
42
What is a Hypertensive Crisis with MAOI?
Excess tyramine causes release of Norepinephrine (causing continuous vasoconstriction)
Avoid tyramine rich foods (Alcohol, cheese, fermented foods)
Not required with Moclobamide
43
When are Antipsychotics required?
Any psychiatric conditions where patient has Delusions and/or Hallucinations
44
Describe the four dopamine pathways in the CNS
Mesolimbic - too much dopamine in psychosis
Mesocortical - too little dopamine in psychosis
Nigrostriatal - Dopamine dependent movement
Tuberoinfundibular - the pathway that can result in hyperprolactinaemia
45
What is the MOA of typical antipsychotics?
D2 Receptor Antagonists
46
Name the three types of typical antipsychotics and give an example of each
High Potency - Haloperidol
Mid Potency - Perphenazine
Low Potency - Chlorpromazine
High potency has much higher risk of Extra Pyramidal SE than Low Potency
47
Name three side effects of Haloperidol
Akathisia
Parkinsonism
Dystonia
All EPS
48
Name three contraindications to Haloperidol
Acute stroke
Severe intoxication
Known cardiac disease
49
How would an overdose of Haloperidol present?
Often just severe forms of the classical side effects
50
How is a Haloperidol overdose managed?
Activated charcoal if within first hour
Monitor for Long QT
Ropinorole/Bromocriptine for EPS
51
What should be monitored with Haloperidol?
BMI
BP
Fasting BGC
52
Name three SE to Chlorpromazine
Dose dependent increase in seizure risk
Weight Gain
Sedation
53
Name two interactions of Chlorpromazine
Decreased absorption if full stomach/alcohol
Can inhibit own metabolism as it is a CYP2D6 substrate AND inhibitor
54
What is the MOA of a Atypical Antipsychotics?
Serotonin Dopamine 2 Antagonists
55
Name three effects more likely with Atypical Antipsychotics (than typical)
Metabolic Syndrome
Weight Gain
T2DM
56
How long should Atypical Antipsychotics be continued for?
Up to 5 years
57
If stopping antipsychotics, how long should they be tapered over?
3 months
58
Describe three side effects of Risperidone
Hyperprolactinaemia
Weight Gain
In doses over 6mg it functions more like a typical - Extrapyramidal
59
Describe three side effects of Olanzepine
Weight Gain
Hyperprolactinaemia
Hypertriglyceridaemia
60
How are the effects of Olanzepine monitored?
Fasting BGC at baseline
Then every 4-6 monthly
Then yearly
61
Depot administration is not an option for Quetiapine. Give three side effects
Weight Gain
Orthostatic Hypotension
Metabolic Syndrome
62
Name the Atypical Antipsychotic that is NOT KNOWN to cause Metabolic Syndrome
Aripiprazole
Because it’s a partial agonist
63
Clozapine is an Atypical Antipsychotic with severe SE. When is it used?
Treatment resistant Schizophrenia
64
Name four SE of Clozapine
Hypersalivation
Incontinence
Increased Seizure Risk
Sedation
65
How is Clozapine monitored?
Weekly blood draws for 5 months
Fortnightly blood draws for 6 months
Then monthly
66
Name three general SE for Atypical Antipsychotics
Tardive Dyskinesia (involuntary muscle movement)
Neuroleptic Malignant Syndrome
Extrapyramidal SE
67
Give three indications for commencing a Mood Stabiliser
Bipolar
Augmenting resistant depression
Schizoaffective
68
What is the first line mood stabilisers for BPAD?
Lithium
69
Name five bloods that should be done before commencing Lithium treatment
```
FBC
U&Es
TFTs
eGFR
Pregnancy
```
70
How should Lithium therapy be monitored?
- Lithium levels should be checked 12 hours after first dose, and then 3 monthly (therapeutic range is 0.4-1)
- 6 monthly U and Es
- Yearly TFTs
71
Give three SE of Lithium Therapy
GI distress
Metallic Taste
Fine tremor
72
Give three contraindications to a Lithium Therapy
Renal Failure
Pregnancy
Breast Feeding
73
Describe the effects of Lithium Toxicity
Mild (1.5-2) - Ataxia, Dizziness, Coarse Tremor
| Severe (>2.5) - Generalised Convulsions, Dysuria, Renal Failure
74
What could you advise the patient about avoiding Lithium Toxicity?
Stay hydrated
75
Describe the proposed MOA of Valproate
Inhibits GABA breakdown
76
Give three indications for use of Valproate
```
BPAD prophylaxis (Second line)
Rapid Cycling (+ Lithium)
Mania
```
77
What should be measured prior to commencing Valproate?
FBC
LFT
BMI
78
How should Valproate therapy be monitored?
6 monthly FBC and LFTs
79
Name three SE of Valproate
Weight Gain
Tremor
Teratogenic
80
Describe the proposed MOA of Carbamazepine
Blocks voltage gated sodium channels (preventing repetitive firing)
Reduces glutamate release
81
How is Carbemazepine therapy monitored?
6 monthly FBC and LFTs
82
Give three SE of Carbemazepine
Rash
Hyponatraemia
Nausea and Vomiting
83
Describe the proposed MOA of Lamotrigine
Inhibits presynaptic sodium and potassium channels, reducing action potentials
84
What should be measured before commencing Lamotrigine therapy?
LFTs
FBC
U and Es
85
How should Lamotrigine therapy be initiated?
Start at 25mg for 2/52
Increase slowly up to 100mg
If stopped for >5d, need to restart at 25mg
86
Lamotrigine is the drug of choice in child bearing age as it is NOT teratogenic. However, give three other SE
Sedation
Headache
Steven Johnson Syndrome
87
Name 5 Anxiolytics
```
Benzodiazepines
Pregabalin
Buspirone
Propranolol
Zopiclone
```
88
What is the MOA of Benzodiazepines?
GABA Potentiators
89
Name three SE of Benzodiazepines
Somnolence
Amnesia
Disinhibition
90
Overdose of Benzodiazpeones causes respiratory depression, what is the antidote?
Flumazenil
91
Name two short acting and two long acting Benzodiazepines
Short acting - Lorazepam, Midazolam
| Long acting - Diazepam, Chlordiazepoxide
92
What is the MOA of Pregabalin?
Glutamate, Noradrenaline and Substance P inhibitor
93
Other than being an Anxiolytic, what other actions can Pregabalin have?
Epilepsy control
| Pain control
94
Give three SE of Pregabalin
Headache
Dizziness
Sleepiness
95
Buspirone is a Non Sedating Anxiolytic. What is it’s MOA?
Serotonin 5HT1A receptor agonist
96
Give three contraindications to Buspirone
Metabolic Acidosis
MAO Inhibitors
Severely compromised liver/renal function
97
What can be used as long term management for Anxiety?
SSRI
98
What is the first line medication for ADHD? What is it’s MOA?
Methylphenidate/Ritalin
Increases dopamine and noradrenaline in synaptic cleft
99
Give three SE of Ritalin
Difficulty sleeping
Decreased Appetite
Anxiety
100
When is Ritalin Contraindicated?
MAOI
Tics
Glaucoma
101
Other than Ritalin, name two other drugs used in ADHD
Amphetamines
| Atomoxetine
102
Give four SE of Amphetamines
Raynaud
ED
Difficulty Urinating
Increased Alertness
103
What is the MOA of Atomoxetine?
Inhibits Noradrenaline reuptake
104
Give two contraindications for Atomoxetine
Symptomatic Cardiac Disease
| Phaeochromocytoma
105
What are Hypnotics? How are they different to Sedatives?
Psychoactive drug whose primary function is to increase sleep
Different to sedatives: Sedatives calm or relieve anxiety
106
Give four examples of Hypnotic Drugs
Barbiturates
Benzodiazepines
Zopiclone
Melatonin
107
What is the MOA of Zopiclone?
GABA receptor Agonist
Reduces amount of time in REM
108
Give three SE of Zopiclone
Metallic taste
Nausea
Dizziness
109
Describe the options for electrode placement in ECT
Bitemporal (4cm above midline between tragus and outer eye)
Bifrontal
Unilateral (both on non dominant hemisphere)
110
Describe the physical principles of ECT
- Small electrical current passed through the brain of an anaesthetised patient with a muscle relaxant
- Voltage causes neurone firing to be recurrent and synchronous
- Induces neuroplastic changes faster and more powerfully than antidepressants
111
How often is ECT administered?
Generally 6-12 sessions in total
| Roughly two a week
112
Describe the indication for ECT in terms of depression
Recommended against routine use, but when other treatments have failed
Can use maintenance ECT - patient continues to have ECT at a reduced frequency, alongside meds to maintain remission
113
Describe the indication for ECT in terms of psychoses
Recommended for a prolonged or severe manic episode
114
Describe the indication for ECT in terms of catatonia
Recommended as Catatonia is often the final common pathway for severe mental illness
115
The higher the voltage above the seizure threshold, the more efficacious. Give an example of a drug that increases the seizure threshold, and one that decreases it.
Increased by Anaesthetics
| Decreased by Antipsychotics
116
After a full medical examination, what anaesthetic is used for ECT?
Short acting barbiturate anaesthetics such as Methohexitone Sodium
117
Give three contraindications to ECT
Status Epilepticus
MI less than 3 months ago
Raised ICP
118
What is the most common complication of ECT?
Cardiac complications
Bigeminy and SVT
The presence of arrhythmias pre ECT predicts the outcome post ECT
119
Other than cardiac, give four other potential complications of ECT
Dental Fractures
Aspiration Pneumonitis
Peripheral Nerve Palsies
Anterograde/Retrograde Amnesia
120
What is Neuroleptic Malignant Syndrome?
Disorder characterised by hyperthermia, muscle rigidity, autonomic dysfunction and depressed/fluctuating levels of arousal over 24-72 hours
121
Describe the aetiology of Neuroleptic Malignant Syndrome
- Sudden and marked Dopamine receptor blockade India Nigrostriatal/Hypothalamic/Mesocortical and Mesolimbic pathways
- Common with typical antipsychotics such as Haloperidol
- Leads to impaired thermoregulation in hypothalamus and basal ganglia
122
Give two differentials for Neuroleptic Malignant Syndrome
Phaeochromocytoma
| Thyrotoxicosis
123
Using the mnemonic FEVER, describe the clinical features of Neuroleptic Malignant Syndrome
Fever (higher than 40 degrees Celsius in 40% of patients)
Elevated Enzymes (Creatine Kinase)
Vital Sign Instability (Tachycardia, Elevated/Labile BP, Postural Hypotension)
Encephalopathy
Rigidity
124
How would you investigate Neuroleptic Malignant Syndrome?
Bloods (Creatine Kinase, FBC, U and Es, Drug Titre)
Urinary Myoglobin
ABG
125
Name four management options for Neuroleptic Malignant Syndrome
Hydration
Active Cooling
IV Benzodiazepines
Bromocriptine (Dopamine Agonist)
126
Name three reasons Thiamine is reduced in Wernicke’s Encephalopathy
Inadequate nutritional Thiamine intake
Decreased GI absorption of Thiamine
Impaired Thiamine utilisation in cells
127
What is the triad of Wernickes Encephalopathy?
Ataxia
Ophthalmoplegia
Confusion
128
Name five bloods you would do to investigate Wernicke’s Encephalopathy
```
FBC
LFTs
Thiamine (Low)
Pyruvate (High)
ABG
```
129
How would you manage Wernicke’s Encephalopathy?
Thiamine (Oral/IV/IM) plus Vitamin B Complex/Multivitamins
130
When should prophylactic Thiamine be given?
If they are malnourished (50g/day)
| If they have decompensated Liver Disease
131
What is the main complication of Wernicke’s Encephalopathy?
Korsakoff’s Syndrome (Permanent memory features of Confabulation and Amnesia etc)
132
What is Delirium Tremens?
A disorder of acute alcohol withdrawal
133
Symptoms normally begin 24-72 hours after cease of Alcohol a Consumption. Give four clinical features of Delirium Tremens
Hallucinations
Confusion
Delusions
Severe Agitation
134
Give three risk factors which puts a patient more at risk of Delirium Tremens during alcohol withdrawal
Co-Existing medical condition
Older age
Abnormal liver function
135
Give four managements of Delirium Tremens
A to E
Treat any Hypoglycaemia
Benzodiazepine Sedation
Start Pabrinex (likely to have coexisting Wernicke’s)
136
What is Acute Dystonia?
Reversible Extrapyramidal effects that can occur after admin of a neuroleptic drug
137
Describe the aetiology of Acute Dystonia
Drug induced alteration of Dopaminergic/Cholinergic balance in Basal Ganglia
D2 receptor blockade leads to excess cholinergic output
138
Mental Status and Vital Signs are usually unaffected in Acute Dystonia. Give three clinical features
Oculogyric Crisis (fixed deviation of eyes in one direction)
Protrusion of tongue
Trismus (lock jaw)
139
Name three potential medications for Acute Dystonia
Anticholinergics - Benztropine
Antihistamine - Diphenhydramine
Benzodiazepines
140
When does Lithium Toxicity occur?
Safe levels are 0.4-1 mEq/l
Toxicity occurs at >1.5, severe at >2 and >3 is a medical emergency
141
Give three features of Mild to Moderate Lithium Toxicity
Diarrhoea
Vomiting
Stomach Pain
142
Give three features of Severe Lithium Toxicity
Seizures
Agitation
Slurred Speech
143
Describe the three types of Lithium Toxicity
Acute - Too much lithium at once (accidentally or on purpose)
Chronic - Too much lithium daily over a long period of time (affected by dehydration, kidney problems)
Acute on Chronic - Can happen if you take too much for a long time, then suddenly take more
144
Name three investigations for Lithium Toxicity
ECG
Bloods (U and Es, Glucose)
Lithium levels (Urine or Blood)
145
How would you treat Mild Lithium Toxicity?
Normally goes away on its own
| Drink extra fluids and monitor
146
How would you treat Moderate to Severe Lithium Toxicity?
If taken in last hour - Gastric Lavage/Activated Charcoal
IV fluids
Haemodialysis
147
What drug commonly causes Agranulocytosis (<500/cm2)?
Clozapine
148
What are three granulocytes?
Neutrophils
Eosinophils
Basophils
149
How should Clozapine induced Agranulocytosis be avoided?
WBC monitoring carried out weekly for the first 18 months
150
How is Clozapine Induced agranulocytosis managed?
Stop drug and treat and infections
151
What kind of seizure does ECT induce?
Generalised Tonic Clonic
