Psychiatry Drugs Flashcards
(193 cards)
1
Q
Explain the MOA of benzodiezapines
A
Enhance binding of GABA to GABAa receptors
2
Q
What is the main side effect of benzeodiezapines
A
Dose-dependent sedation and coma
3
Q
Explain presentation of benzodiezapine OD
A
Benzodiazepines do not cause respiratory depression as much as opioids in OD. They do cause of loss of airway reflexes which can lead to obstruction and death
4
Q
What can long-term use of benzodiezapines lead to
A
Dependence
5
Q
What happens if benzodiezapines are suddenly stopped
A
Lead to symptoms of alcohol withdrawal
6
Q
What are 3 relative CI to benzodiezapines
A
- Elderly: need lower dose
- Liver impairment: increases risk of hepatic encephalopathy
- Neuromuscular disease - due to loss of airway reflexes
7
Q
If a person has hepatic encephalopathy, what benzodiezapine should be used
A
Lorazepam - as it depends less on the liver for metabolism
8
Q
What drugs do benzodiezapines interact with
A
Other sedatives (opioids, alcohol)
9
Q
What drugs may increase effect of benzodiezapines
A
CYP450 inhibitors - as they decrease it’s elimination
10
Q
What are 3 long-acting benzodiezapines
A
Diazepam
Chlordiazepoxide
Lorazepam
11
Q
What benzodiezapine are preferred for managing alcohol withdrawal
A
Chlordiazepoxide
12
Q
What benzodiezapines are preferred for managing seizures
A
Lorazepam and Diazepam
13
Q
What type of benzodiezapine is used for sedation during procedures and why
A
Midazolam - due to being short-acting
14
Q
For insomnia and anxiety which benzodiezapine is suggested
A
Temzaopam (medium-acting) for shortest period of time - 2W
15
Q
What is the problem with IV diazepam
A
Thrombophlebitis
16
Q
What should patients not do after taking benzodiazepines
A
Drive, use heavy machinery due to sedative effects
17
Q
What is essential after giving IV benzodiezapines
A
Monitor vital signs
18
Q
What drug is recommended in benzodiezapine OD
A
Flumenazil
19
Q
Why is flumenazil not always given in benzodiezapine OD
A
As it should not be given in mixed overdose
20
Q
What options are therefore for pharmacological management of smoking cessation
A
- Nicotine replacement therapy
- Bupropion
- Varencline
21
Q
What is the MOA of nicotine
A
It binds to nicotinic acetylcholine receptors causing euphoria and relaxation
22
Q
How does nicotine withdrawal present
A
Anxiety, agitation, increased appetite and weight gain
23
Q
How does nicotine replacement therapy work
A
It provides nicotine to bind acetylcholine receptors, reducing effects of withdrawal
24
Q
What is the MOA of varencline
A
Partial agonist at nicotinic acetylcholine receptors
25
How does varencline work
Partial agonist at nicotinic receptors - it reduces side effects and positive effects of nicotine
26
What is the MOA of bupropion
Inhibits re-uptake of noradrenaline and dopamine in the synaptic cleft
27
What are the side effects of nicotine replacement
- Skin irritation (Patches)
- GI upset (Oral)
- Palpitations
- Abnormal dreams
28
What are 3 side effects of varencline
Nausea
Headaches
Insomnia
Abnormal dreams
29
What is a rare, but serious effect of varencline
Suicidal ideation
30
What are 4 side effects of bupropion
Dry Mouth
GI Upset
Neurological effects
Psychiatric effects
31
What are the 3 neurological side effects of burprion
Headaches
Impaired concentration
Dizziness
32
What are 3 psychiatric side effects of bupropion
Insomnia
Agitation
Depression
33
What is a common side effect of burprion
Hypersensitivity - more in the form of rash opposed to anaphylaxis
34
When should nicotine replacement therapy be used with caution
Those with haemodynamic instability - such as significant cardiac morbidity
35
In which individuals should burprion and varencline be used with caution
Those at risk of seizures (including head injury, other drugs that lower seizure threshold, previous seizure) due to causing convulsions
36
When should varencline be used with care
Those with psychiatric illness - as it increases suicidal ideation
37
When should all pharmacological drugs that help with smoking cessation be used with caution
Hepatic and renal impairment
38
What are the interactions of nicotine replacement
No interactions
39
What are the interactions of varencline
No interactions
40
What drugs may reduce or increase the effects of buproprion and why
CYP450 inhibitors - increase effect
CYP450 inducers - decrease effect
As buproprion is metabolised by CYP450
41
With which 2 drugs should buproprion not be used with and why
When used with monoamine oxidase inhibitors or TCAs buproprion can lead to increased activation of catecholaminergic pathways
42
How is nicotine replacement prescribed
- Continuous release to reduce cravings
| - Immediate release to control urges
43
When should nicotine replacement be used
Either to reduce number of cigarettes when person is smoking or for cessation
44
When should treatment with varencline or buproprion start
2W before cessation attempt
45
Explain if the individual continues to smoke with smoking cessation management
- NRT can be carried on if individual continues smoking
| - Buproprion or varencline should be stopped
46
When should nicotine patches be put on
- In the morning to hairless skin
| - Remove at night to avoid insomnia
47
What should always be offered with pharmacological management
Psychological management
48
What are the two strong opioids
Oxycodone
| Morphine
49
What is an opiate
Naturally occurring opiate
50
What is an opioid
Synthetically man-made produced opioid
51
What is the predominant MOA of opioids
Bind to u-opioid receptors
52
What is the effect of opioids in the medulla
Blunt response to hypoxia and hypercapnia - reducing respiratory drive
53
What is the effect of opioids by relieving pain, breathlessness and anxiety
Reduce sympathetic NS activation
54
What is the advantage of opioids in pulmonary oedema
Reduce oxygen demand and increase cardiac function
55
What are 7 side effects/OD effects of opioids
1. Respiratory depression - due to binding u-opioid in respiratory centre
2. Pupil constriction - stimulation edinger westphal nucleus
3. Constipation - stimulating u-opioid receptors of the bowel
4. Itching, urticaria, vasodilation - due to stimulating histamine release
5. Continued use can cause tolerance
6. Euphoria. High-doses may cause neurological depression
7. N+V - due to effects in chemoreceptor trigger zone
56
Explain symptoms opioid withdrawal
- Anxiety
- Breathlessness
- Pain
- Skin is cold and dry - with piloerection (Cold Turkey)
57
What are 5 relative contraindications of opioids
1. Renal impairment - dose reduction
2. Hepatic impairment - dose reduction
3. Elderly - dose reduction
4. Respiratory failure (unless palliative)
5. Biliary colic - spasm of sphincter of Oddi
58
Why should opioids be avoided in biliary colic
Causes spasms of sphincter of Oddi
59
What drugs should opioids not be used with
Other sedatives (alcohol, benzodiezapines)
60
When should IV morphine only be given and why
High-intensity pain, due to increasing SEs
61
What are 2 weak opioids
Codeine
| Dihydrocodiene
62
What does codeine produce when metabolised by the liver
Morphine
63
What does dihydrocodiene produce when metabolised by the liver
Diamorphine
64
Why are codeine and dihydrocodiene ineffective in 10% caucascians
As 10% Caucascians are missing enzyme CYP2D6 s cannot metabolise to effective compounds
65
What is a moderate opioid
Tramadol
66
What is tramadol
Synthetic codeine analogue
67
What is the MOA of tramadol
- Binds to u-opioid receptors
| - Also has effects via seratonergic and noradrenaline pathway - thought to act as SNRI
68
What are 4 common side effects of weak opioids
1. Nausea
2. Constipation
3. Dizziness
4. Drowsiness
69
What do opioids cause in OD
Respiratory depression
| Pin point pupils
70
What is the advantage of tramadol
Less likely to cause constipation and respiratory depression
71
What opioids should never been given IV
Codeine and Dihydrocodiene
72
Why should codeine and dihydrocodiene never be given IV
Causes an anaphylaxis-type reaction, which is mediated by histamine (not true allergy)
73
What are 4 relative contraindications of codeine, dihydrocodiene and tramadol
1. Elderly - does reduction
2. Liver failure
3. Hepatic failure
4. Resp depression
74
What is a relative CI of tramadol
Those at risk of seizures - due to lowering seizure threshold
75
What is an absolute CI of tramadol
Epilepsy
76
What drugs should opioids not be used with
Other sedatives
77
What 2 drugs should tramadol not be used with
- Other seratonergic drugs
| - Drugs that lower seizure threshold
78
What is seratonergic syndrome
Syndrome causes by over-stimulation of seratonergic pathways
79
How will serotonin syndrome present
- Neuromuscular excitation = hyper-reflexia, myoclonus, rigidity
- Autonomic NS activation
- Altered mental state
80
How is seratonergic syndrome managed
IV Fluids
Benzodiazepines
If severe, manage with seratonergic antagonists - chlorpromazine and cyprohepatodine
81
What are first-generation antipsychotics also known as
Typical antipsychotics
82
What are 3 first-generation antipsychotics
1. Haloperidol
2. Prochlorperazine
3. Chlorpromazine
83
What is the MOA of first-generation antipsychotics
Antagonises D2-receptors
84
What are the 4 dopamingeric pathways
1. Mesolimbic
2. Mesocortical
3. Nigrostriatal
4. Tuberoinfundibular
85
Explain mesolimbic pathway
Dopamine is produced in the ventral tegmental area (VTA) and passes to amygdala and nucleus acumbens
86
What is the role of the mesolimbic pathway
Motivation and reward
87
When is the mesolimbic pathway over-active
Over-active in psychoses
88
Explain the mesocortical pathway
Dopamine is produced in VTA
| and passes to pre-frontal cortex
89
What is the role of the mesocortical pathway
Cognition, Motivation, Emotion
90
When is the mesocortical pathway affected
Reduced activity - causes negative symptoms schizophrenia
91
Explain the nigrostriatal pathway
Dopamine is produced in substantial nigra and released in basal ganglia
92
What is the role of the nigrostriatal pathway
Movement
93
What disorder affects the nigrostriatal pathway
Decreased activity in Parkinson's disease
94
What is the tuberoinfundibular pathway
Dopamine is produced in infundibular region of tuberal hypothalamus and passes to medial eminence
95
What is the role of dopamine in the tuberoinfundibular pathway
Inhibits secretion of prolactin - inhibiting lactation
96
What is the effect of typical antipsychotics antagonising D2 receptors in mesolimbic pathway
anti-psychotic effect
97
What is an effect of typical-antipsychotics due to inhibiting D2 receptors in chemoreceptor trigger zone
reduces nausea and vomiting
98
What typical antipsychotic has the most sedative effect
chlorpromazine
99
what are the main side effects of first-generation typical antipsychotics
extrapyramidal SE
100
what are the 3 early extra-pyramidal side effects of
1. Acute dystonia
2. Akathisia
3. Neuroepileptic malignant syndrome
101
what are acute dystonia reactions
Involuntary muscle spasms or Parkinson-like movements
102
what is akathisia
Inner state of restlessness
103
what is neuroepileptic malignant syndrome
Rare syndrome that presents with:
- Rigidity
- Confusion
- Autonomic dysregulation and pyrexia
104
what is a late side effect of typical antipsychotics
Tarditive dyskinesia
105
how does tarditive dyskinesia present
Repetitive involuntary/pointless movements such as lip smacking
106
what is the problem with tardative dyskinesia
May not recover even after treatment ceases
107
Aside from extrapyramidal SE what are 5 other side effects of antipsychotics
1. Drowsiness
2. Hyperprolactinaemia
3. Prolong QT interval
4. Erectile dysfunction
5. Hypotension
108
what are the effects of hyperprolactinaemia
- Breast pain
- Galactorrhoea
- Menstrual disturbance
109
why does hyperprolactinaemia occur
Due to dopamine stimulation in tuberohypophyseal pathway
110
what population should antipsychotic dose be reduced in
elderly
111
why should antipsychotics be avoided in dementia
increases risk of stroke and death
112
why should antipsychotics be avoided in Parkinson's disease
due to inhibiting D2 in extrapyramidal pathway - can make symptoms worse
113
what drugs should antipsychotics be avoided with
other drugs that prolong QT interval
114
what is the risk of giving antipsychotics IV
increases risk of cardiac side effects (QT prolongation) and subsequent arrhythmias (tornadoes de pointes)
115
what medications are licensed for use of intractable hiccups
chlorpromazine - most effective
haloperidol
metclopramide
116
what are second-generation antipsychotics also known as
atypical antipsychotics
117
what are the 4 atypical antipsychotics
(CORQ)
Clozapine
Olanzapine
Risperidone
Quetiapine
118
what is the MOA of atypical antipsychotics
Antagonise post-synaptic D2 receptors (less affinity than first-generation). Bind to 5HT2A receptors
119
what is the benefit of atypical antipsychotics
Particularly effective in treatment-resistant schizophrenia, mainly against negative effects (Clozapine). Reduced extrapyramidal SE
120
what are the main side effects of atypical antipsychotics
Metabolic
121
what are the 3 metabolic side effects of atypical antipsychotics
1. Weight Gain
2. Lipid Changes
3. DM
122
what are the cardiac effects of atypical antipsychotics
Prolong QT interval - lead to arrhythmias
123
what is a particular side effect of risperidone
Highly effective tuberohypophyseal pathway - therefore lead to breast symptoms in males and females: Brest pain, galactorrhea, sexual dysfunction
124
what are two serious side effects of clozapine
myocarditis
| agranulocytosis
125
when should antipsychotics be used carefully
heart disease
126
what are two absolute contraindications of clozapine
heart disease, neutropenia
127
what drugs should atypical antipsychotics not be used with
- dopamine-blocking anti-emetics (metclopramide)
| - other drugs that prolong the QT interval
128
when are antipsychotic medications best taken
bedtime
129
what is required before starting antipsychotics
LFTs, Renal Function Tests and FBC
130
what medication is an intensive monitoring regimen required form
clozapine - due to risk agranulocytosis
131
what is important monitoring for second generation antipsychotics and why
weight
lipid profile
fasting blood glucose
= due to metabolic effects
132
Name 4 SSRIs
Fluoxetine
Paroxetine
Escitalopram
Citalopram
133
What is the MOA of SSRIs
Inhibit re-uptake of 5-HT
134
Why are SSRIs preferred to TCAs
Fewer side effects
135
What are 7 side effects of SSRIs
1. Prolong QT
2. Change in appetite and weight
3. Suicidal Ideation
4. Bleeding - high doses
5. Lower seizure threshold
6. Hyponatraemia
7. Hypersensitivity
136
What is the problem if SSRIs are used with other seratonergic drugs
can cause serotonin syndrome
137
how does serotonin syndrome present
Triad of
- Neuromuscular excitation
- Altered mental status
- Autonomic dysfunction
138
how will sudden withdrawal of SSRIs present
- sleep disturbance
| - influenza-like symptoms
139
what are 3 relative contraindications of epilepsy
- Seizures = due to reducing threshold
- Peptic ulcers = increases risk GI symptoms
- Young people = increases risk of suicidal ideation and self-harm
140
when should dose of SSRIs be reduced
- hepatic impairment, due to SSRIs metabolised by the liver
141
what drug is an absolute CI to give with SSRIs and why
monoamine oxidase inhibitors - due to seratonergic syndrome
142
what drug may be given with SSRIs
gastroprotection if taking with NSAIDs or aspirin
143
when prescribed with what drugs do SSRIs increase risk of bleeding
anticoagulants
144
what drugs should SSRIs not be given with
drugs prolong QT interval
145
how long do SSRIs take to work
several weeks
146
how long should SSRIs be carried on for
6m - to prevent recurrence depression for 2-years
147
when stopping treatment, how long should dose be tapered down for
4W
148
what SSRI has lowest risk of withdrawal symptoms
fluoxetine
149
name 2 TCAs
- amitryptiline
| - lofepramine
150
what is the MOA of TCAs
- Inhibit re-uptake of NA and 5-HT
| - Block a1, a2, D2, H1 and muscarinic receptors
151
What are the SE of blocking muscarinic receptors by TCAs
- Dry mouth
- Blurred vision
- Constipation
- Urinary retention
152
What are the side effects of blocking a1 and H1 receptors
Hypotension and Sedation
153
What are the cardiac effects of TCAs
ECG changes: prolong QT and QRS
| Arrhythmias
154
What are 3 neurological effects of TCAs
- Convulsions
- Hallucinations
- Mania
155
What does antagonism of D2 by TCAs cause
- Breast changes: pain, galactorrhea, menstrual disturbance
| - Extrapyramidal SEs
156
How do TCAs present in overdose
Dangerous in OD:
- Hypotension
- Arrhythmias
- Convulsions
- Coma
- Respiratory Failure
157
How will sudden withdrawal of TCAs present clinically
Flu-like illness
158
What 3 patient groups should caution be taken in and why
Elderly
CVD
Epilepsy
= Increased risk of adverse effects
159
What two conditions should TCAs be used carefully in and why
- Constipation
- Glaucoma
- Prostatic hypertrophy
= due to antimuscarinic SEs
160
What drugs should TCAs not be given with
MAOIs
161
Why should TCAs and MAOIs not be given together
Lead to hypertension, hyperthermia and serotonin syndrome
162
With what drugs should TCAs be prescribed with care
Those with antimuscarinic SEs
163
When should patients on TCAs be reviewed
Symptoms reviewed after 1W, regularly thereafter
164
When are venlafaxine and mertazapine used
Severe treatment-resistant depression
165
What is the MOA of velfaxine
SNRI inhibitor.
| Weak antagonist at H1 and muscarinic receptors.
166
What is the MOA of mirtazapine
Inhibits pre-synaptic a2 receptors.
| Weak antagonist of H1 receptors.
167
What are common side effects of venlafaxine and mirtazapine
GI disturbance
| Neurological disturbance
168
What is a serious SE of venlafaxine
- hyponatraemia
| - seratonin syndrome
169
what are two SE of venlafaxine
- Increase suicidal ideation
| - Prolong QT and increases risk of ventricular arrythmias
170
what is the problem with venlafaxine
associated with increased risk of withdrawal effects
171
what are 4 relative CI to venlafaxine
Elderly
Hepatic impairment
Renal impairment
Arrhythmias
172
What are the uses of valproate in psychiatry
can be used for bipolar disorder
173
What are two mechanisms of valproate
- Inhibits sodium channels stabilising membrane potential - Increases GABA
174
What are the 4 dose-related effects of valproate
- GI Disturbance
- Neurological Disturbance
- Transient increase liver enzymes
- Thrombocytopenia
175
What hypersensitivity reaction can valproate cause
Hair loss - hair re-growth may be curly than original
176
What are 4 rare idiosyncratic SE of valproate
1. Liver failure
2. Pancreatitis
3. Bone marrow failure
4. Anti-epileptic hypersensitivity syndrome
177
What may be seen on LFTs when using valproate
Increase AST and ALT
178
What may be seen on FBC when using valproate
Thrombocytopenia
179
What is an absolute CI to valproate
Women child-bearing age, pregnant, first-trimester
180
Why should valproate be avoided during pregnancy
Most teratogenic anti-epileptic: causes foetal valproate syndrome (Neural tube defect, Craniofacial abnormalities)
181
What are 2 relative CI to valproate
Hepatic impairment
Renal impairment
= Reduce dose
182
What is the effect of valproate on CYP450
Inhibits CYP450 - can lead to increased SE of other drugs
183
What enzyme is valproate metabolised by
CYP
184
What is the effect of the following on valproate
a. CYP450 inducers
b. CYP450 inhibitors
a. Decrease concentration - increase risk seizures
| b. Increase concentration - lead to adverse effects
185
What reduces efficacy of valproate
Drugs that decrease seizure threshold
186
What investigation should be ordered before starting valproate and at 6m
LFTs
187
When is thiamine (vitamin B1 given)
Wernicke's disease KorsaKoffs
188
When is folic acid (vitamin B9) given
- Pregnancy to reduce NTD
| - Megaloblastic anaemia
189
What is hydroxocobalamin
synthetic form of cobalamin and vitamin B12
190
when is hydroxocobalamin given
subacute combined degeneration spinal cord and megaloblastic anaemia - treat vitamin B12 deficiency
191
what is phytomenadione
vitamin K
192
when is vitamin K given
all new-born babies to prevent bleeding and to revers warfarin
193
if an individual is folate and vitamin B12 deficiency, which do you replace first and why
replace both simultaneously.
| otherwise giving folate first can pre-dispose to neurological manifestations of vitamin B12 deficiency.
