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Phase 3A > Psychiatry pharmacology > Flashcards

Psychiatry pharmacology Flashcards

1
Q

HYPNOTICS - Z DRUGS

Name 2 examples

A

zopiclone

zolpidem

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2
Q

HYPNOTICS - Z DRUGS

What are the indications and the MOA of these drugs

A

Short term tx of insomnia that is distressing - Max 4 weeks

Facilitate and enhance binding of GABA to GABA receptor - GABA agonist
Opens chloride channels making cells more resisitant to depolarisation
Similar effect to BDZs but different strucutually - Act on alpha-2 subunit of the receptor

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3
Q

HYPNOTICS - Z DRUGS

What are the adverse effects and cations for these drugs

A 
daytiem sleepiness 
rebound insomnia 
headache 
confusion 
nightmares

Elderly - increased risk of falls
Don’t drive
Don’t operate complex/heavy machinery

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4
Q

BENZODIAZEPINES

What is the MOA?

A

Enhance effect of inhibitory GABA by increasing frequency of Cl- channels + flow of Cl- ions causing hyperpolarisation of membrane + so prevention of further excitation

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5
Q

BENZODIAZEPINES

Wha are some inidcations for BDZs use?

A 
Anticonvulsant - seizures 
Alcohol withdrawal 
sedation 
axiolytic 
muscle relaxant
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6
Q

BENZODIAZEPINES

What are some adverse effects of BDZs?

A

Dose dependant drowsiness
tolerance
confusion
dizziness

Monitor fro resp depression

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7
Q

BENZODIAZEPINES

Name some examples and how long should they be prescribed for?

A

Diazepam - longer duration
Lorazepam
Temazepam - shorter duration
Chlordiazepoxide

2-4 weeks due to risks of tolerance and dependence

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8
Q

BENZODIAZEPINES

What drugs can BDZs interact with?

A

Anti-hypertensives - Enhanced hypotensive effects

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9
Q

BENZODIAZEPINES
How do you manage a BDZ overdose?
What is the risk of this?

A

IV Flumazenil

Danger of inducing status epilpeticus or death

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10
Q

BENZODIAZEPINES

What is BDZs withdrawal syndrome, how does it occur and present?

A

BDZs withdrawa too quickly
Occurs 3 weeks after stopping long-acting drug

Insomnia 
irritability 
anxiety 
tremor 
loss of appetite 
seizures 
perspiration
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11
Q

BENZODIAZEPINES

What are some cautions for BDZs usage?

A

Elderly - Increased falls risk

Patients with liver disease - Risk of precipitating HE

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12
Q

ANTI-DEPRESSANTS
What moniroing is required for patinets starting on anti-depressants?
When can an anti-depressant be stopped?

A

Monitored twice weekly to ensure dose is working and patient is stable

Weekly if <30 due to increased suicide risk

Carried on for 6m followinf sx resolution to reduce risk of relapse

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13
Q

ANTI-DEPRESSANTS

How should anti-depressants be stopped?

A

Gradual dose reduction over 4 weeks

Suddenly stopping can cause withdrawal effects:
Rebound depression 
pain 
diarrhoea 
vomiting 
sweating 
restlesness
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14
Q

ANTI-DEPRESSANTS

What is the MOA for SSRIs?

A

Preferentially inhibit neuronal reuptak eof serotonin from synaptic cleft by inhibiting reuptake transporter on th epost synaptic membrane

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15
Q

ANTI-DEPRESSANTS

Name some examples of SSRIs?

A 
sertraline 
citalopram 
fluoxetine 
Paroxetine 
citalopram
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16
Q

ANTI-DEPRESSANTS

Name some adverse effects of SSRIs

A 
8 S'
Size - weight gain 
Sick - nausea / vomiting
Serotonin syndrome 
Seizure - Lower threshold 
Stomach upset - abdo pain / constipation / diarrhoea 
Stress - anxiety 
Suicidal thoughts 
Sexual difficulty - Impotence 
Sleep difficulty 
Sodium low - Hyponatraemia
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17
Q

ANTI-DEPRESSANTS

What is one important adverse effect of citalopram?

A

Prolongs QTc interval - Dose dependent

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18
Q

ANTI-DEPRESSANTS

What are some cautions for SSRIs?

A

Increase in suicidal thoughts
May precipitate manic phase in bipolar
Epilpesy patients
Patients wit PUD

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19
Q

ANTI-DEPRESSANTS

What are the risks of SSRIs in preganncy?

A

1st trimester - Risk of Congenital heart defects

3rd trimester - Risk of persistent pulmonary HTN of newborn

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20
Q

ANTI-DEPRESSANTS

What is the influence of paroxetine in pregnancy?

A

Increased risk of congenital malformations - particualry in 1st trimester

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21
Q

ANTI-DEPRESSANTS

Why are SSRIs preffered over TCAs?

A

Fewer adverse side effects

Less dangerous on overdose

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22
Q

ANTI-DEPRESSANTS

Name some SSRIs interactions

A
  • Warfarin / Heparin
  • Triptans (Can cause SS)
  • Aspirin + NSAIDs (Add PPI due to risk of GI bleed)
  • Antipsychotics (QT prolongation)
  • MAOI (Both increase syanptic serotonin levels –>SS) Have to wait 2weeks
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23
Q

ANTI-DEPRESSANTS
What is the mechanism of action of SNRIs?
Give some examples

A

Prevents reuptake + subsequent degradation of serotonin AND noradrenaline from synaptic cleft by inhibiting reuptake transporters on post-synaptic membrane

  • Venlafaxine, duloxetine
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24
Q

ANTI-DEPRESSANTS

Name some adverse effects of SNRIs?

A 
Similar to SSRIs
Size - weight gain 
Sick - nausea / vomiting
Serotonin syndrome 
Seizure - Lower threshold 
Stomach upset - abdo pain / constipation / diarrhoea 
Stress - anxiety 
Suicidal thoughts 
Sexual difficulty - Impotence 
Sleep difficulty
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25
Q

ANTI-DEPRESSANTS
What is the mechanism of action of monoamine oxidase inhibitors (MAOI)?
Give some examples.

A

Inhibits monoamine oxidase enzyme which reduces breakdown of adrenaline, noradrenaline + serotonin so increases level

Isocarboxazid
Phenelzine
Selegiline

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26
Q

ANTI-DEPRESSANTS

What is different about selegiline in comparison to other MAIOs?

A

Selegiline is selective MAO-B inhibitor which also increases dopamine

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27
Q

ANTI-DEPRESSANTS

What are some adverse effects to MAOIs?

A 
sexual dysfunction 
hypotension 
weight gain 
dry mouth 
dizziness 
migraines
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28
Q

ANTI-DEPRESSANTS

What is the link between tyramine and MAOIs?

A

MAO breaks down tyramine (cheese, cured/smoked meet, alcohol)
MAO-I= increased tyramine
Tyramine mimics noradrenaline= hypertensive crisis
->headache, increased HR, palpitations, chest pain, N/V, anxiety

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29
Q

ANTI-DEPRESSANTS

What foods increase the risk of a hypertensive crisis from MAOIs?

A

High tyramine foods

  • aged cheese
  • cured meats
  • broad beans
  • wine
  • marmite
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30
Q

ANTI-DEPRESSANTS
What is the mechanism of action of tricyclic antidepressants (TCAs)?
Give some examples

A

Inhibit neuronal reuptake of serotonin
(5-HT) and noradrenaline from the synaptic cleft, thereby increasing
their availability for neurotransmission.
Tricyclic antidepressants also block a wide array of receptors,
including muscarinic, histamine (H1), α-adrenergic (α1 and α2) and
dopamine (D2) receptors.

Amitryptiline
Dosilepin

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31
Q

ANTI-DEPRESSANTS

What are the side effects of TCAs?

A 
Anticholinergic - think/see/pee/spit
blurred vision 
urinalry retention 
constipation 
dry mouth 
confusion

Anti-adrenergic
Postural hypotension
impotence

Other 
Arrthymias 
Cardiotoxicity 
seizures 
weight gain
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32
Q

ANTI-DEPRESSANTS

What cautions are there for TCAs?

A

Caution in CVD - Avoid following MI
Cardiotoxicity in overdose - caution in suicidal patients
(QTc prolongation)

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33
Q

ANTI-DEPRESSANTS
In terms of TCA overdose…

i) mild-moderate Sx?
ii) severe Sx?
iii) ECG signs?
iv) management?

A

i) Dilated pupils, dry mouth, urinary retention, increased tendon reflexes + extensor plantars
ii) Fits, coma, cardiac arrhythmias > arrest
iii) Sinus tachy, wide QRS, prolonged QT interval
iv) Sodium bicarbonate

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34
Q

ANTI-DEPRESSANTS
What is the mechanism of action of mirtazapine?
What are some side effects?

A

Blocks alpha-2 adrenergic receptors > increased release of neurotransmitters

  • Increased appetite + weight gain
  • Sedation / Drowsy
  • increased triglyceride levels
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35
Q

MOOD STABALISERS

Name some examples

A

Lithium
sodium valporate
Carbamazepine
Lamogitrine

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36
Q

MOOD STABALISERS

What is lithium’s MOA and what is the target range for blood levels?

A

Lithium inhibits cAMP production which inhibits monamines

Narrow theraputic range (0.4 - 1.0 mmol/L)

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37
Q

MOOD STABALISERS

What are the adverse effects of lithium at a theraputic dose?

A 
fine tremor 
dry mouth 
GI disturbance - Increased GI motility 
Hypothyroidism 
Increased thirst 
Increased urination 
Hypothyroidism 
Drowsiness 
weight gain
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38
Q

MOOD STABALISERS

What is the presentation of lithium toxicity?

A 
Tremor (COARSE)
Oliguric (renal failure)
ataXia
Increased reflexes
Convulsions - seizures 
Coma
Consciousness reduced

Nausea
muscle weakness
Dysarthria
Nystagmus

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39
Q

MOOD STABALISERS

What must be checked prior to initiating Lithium?

A 
Renal function - eGFR 
FBC 
U+E
TFTs
BMI 
ECG
40
Q

MOOD STABALISERS

What drugs dos lithium interact with?

A

NSAIDs
ACEi
ARBs
Diuretics - Increase lithium levels due to dehydration

41
Q

MOOD STABALISERS

What regualr monitoring is required for lithium?

A

Weekly serum lithium levels after initiation and dose changes until stable

  • Every 3m for a year
  • Every 6m
42
Q

MOOD STABALISERS

How long should a lithium blood sample be taken after dose?

43
Q

MOOD STABALISERS

What bloods must be checked every 6m on lithium?

A

TFTs
U+Es
eGFR

44
Q

MOOD STABILISERS

What might carbamazepine and lamotrigine interfere with?

A

Contraceptive pill

45
Q

DRUG INTERACTIONS

what are CYP450 Inducers and name some examples

A

Reduce the concetration of drugs metabolised by CYP450 system

CRAPS 
Carbamazepine 
Rifampicin 
Barbituates 
Phenytoin 
St Johns wort
46
Q

DRUG INTERACTIONS

what are CYP450 Inhibtirors

A

Increase the concetration of drugs metabolised by CYP450 system

47
Q

DRUG INTERACTIONS

What is the mneumonic for CYP450 inhibtiors

A

Some certain silly compounds annoyingly inhibit enzymes Grrrrr

48
Q

DRUG INTERACTIONS

Name some examples of CYP450 inhibitors

A 
sodium valporate 
ciprofloxacin 
sulphonamide 
cimetidine / omeprazole 
antifungals / amiodarone 
isoniazid 
erythromycin / clarithromycin 
grapfruit juice
49
Q

DRUG INTERACTIONS

Name some examples of drugs which interact with CYP450 inhibitors / inducers

A 
Warfarin 
COCP 
Theophyline 
corticosteroids 
tricyclics 
statins
50
Q

ANTI-PSYCHOTICS
What are the 2 types of anti-psychotics?
Give some examples

A

Typicals/1st gen - Haloperidol / chlorpromazine

Atypicals / 2nd gen - Olanzapine / Risperidone (d) / Clozapine / Aripripazole (d) / Quetiapine

51
Q

MOOD STABALISERS

What are the indications for mood stabalisers usage?

A

Prophylaxis for bipolar
acute treatemnt of mania
augmentation of antidepressants in resistant depression
schizoaffective disorder

52
Q

ANTI-PSYCHOTICS

Inidcations for typical anti-psychotic use?

A
  1. Psychomotor agitation
  2. Schizophrenia when metabollic side effects of atypicals are likely to be problematic
  3. Bipolar - acute mania
53
Q

ANTI-PSYCHOTICS

What is the MOA for typical anti-psychotics?

A

Antipsychotic drugs block post-synaptic dopamine D2 receptors in the mesolimbic pathway

54
Q

ANTI-PSYCHOTICS

What is the theraputic range that once exceeded results in unwanted extra-pyramidal side effects?

A

Effects occur if blockade of dopamine receptors exceeds 65-80%

55
Q

ANTI-PSYCHOTICS
What pathway do anti-psychotics act on to…
i) have anti-psychotic effects
ii) cause side effects

A

i) Mesolimbic (Reduces +ve sx)

ii) Nigrostriatal -Parkinsoism
Tuberoinfundibular - Prolactin

56
Q

ANTI-PSYCHOTICS

What is the MOA for atypical anti-psychotics?

A

Antagonists at dopamine D2 receptors but more selective in dopamine blockade + so block serotonin 5-HT2a

57
Q

ANTI-PSYCHOTICS

What is the benefit of atypical anti-psychotics and what is this due to?

A

More useful in treating -ve Sx of schizophrenia, resistant schizophrenia + less likely to cause EPSEs

  • Higher affinity for other receptors
  • Looser binding to D2 receptors
58
Q

ANTI-PSYCHOTICS

What anti-psychotic has a reduced side effect profile

A

Aripripazole - partial agonist

59
Q

ANTI-PSYCHOTICS
What is the most crucial adverse effect of clozapine?
What is the most common adverse effect?
What other adverse effects may it have?

A

Severe life-threatening agranulocytosis

  • Constipation (big issue in elderly)
  • Reduced seizure threshold, hypersalivation (Rx hyoscine hydrobromide), myocarditis
60
Q

ANTI-PSYCHOTICS

What lifestyle factors should a pateint taking clozapine report?

A

Smoking cessation - rise in clozapine elvels

Alcohol cessation - reduction in clozapine levels

61
Q

ANTI-PSYCHOTICS

How many days must be missed of clozapine levels for re-titration to start?

62
Q

ANTI-PSYCHOTICS

What is the blood regimine required for clozapine?

A

FBC weekly 18 weeks

2-weekly for a year

then monthly

63
Q

ANTI-PSYCHOTICS

What are the 5 broad categories of SEs caused by anti-psychotics?

A

Extra-pyramidal side effects (EPSEs)

  • Hyperprolactinaemia
  • Metabolic
  • Anticholinergic
  • Neurological
64
Q

ANTI-PSYCHOTICS

What are the EPSEs?

A

Acute dystonic reaction

  • Parkinsonism
  • Akathisia
  • Tardive dyskinesia
65
Q

ANTI-PSYCHOTICS
How does Parkinsonism present?
How is it managed?

A

Bradykinesia, rigid, resting pill-rolling tremor + postural instability

  • Reduce dose or switch to atypical anti-psychotic
  • Procyclidine
66
Q

ANTI-PSYCHOTICS
How does akathisia present?
What is a risk of this?
How is it managed?

A
  • Motor restlessness, typically lower legs (can’t sit still)
  • Massive RF for suicide in young men with schizophrenia
  • Reduce dose, introduce beta-blocker (propranolol)
67
Q

ANTI-PSYCHOTICS
How does tardive dyskinesia present?
When does it present?
How is it managed?

A
  • Purposeless involuntary movements (chewing, lip smacking, blinking, tongue protrusion)
  • After months-years of Tx
  • Prevention crucial, switch to atypical anti-psychotic, tetrabenazine (dopamine agonist) used if mod–severe but unlikely to completely resolve
68
Q

ANTI-PSYCHOTICS

What are the SEs from hyperprolactinaemia?

A
  • Sexual dysfunction (+ anti-adrenergic)
  • Osteoporosis risk
  • Amenorrhoea
  • Galactorrhoea, gynaecomastia + hypogonadism in men
69
Q

ANTI-PSYCHOTICS

What are the metabolic SEs?

A

Weight gain (esp. olanzapine)

  • Hyperlipidaemia, risk of stroke + VTE in elderly
  • T2DM risk + metabolic syndrome
  • Lipid changes
70
Q

ANTI-PSYCHOTICS

What are the anticholinergic SEs?

A 
Can't see, pee, spit, shit –
- Blurred vision
- Urinary retention
- Dry mouth
- Constipation
\+ tachycardia
71
Q

ANTI-PSYCHOTICS

What are the neurological SEs?

A
  • Seizures (reduced threshold)
  • Postural hypotension (anti-adrenergic)
  • Sedation
  • Headaches
72
Q

ANTI-PSYCHOTICS

What baseline investigations are done for people starting on anti-psychotics?

A
  • FBC, U+Es, LFTs, lipids, BMI, fasting glucose, prolactin, BP, ECG (QTc prolongation) + smoking status (can reduce effects by enhancing metabolism so issues if suddenly stop)
73
Q

ANTI-PSYCHOTICS

What regular investigations are done for people on anti-psychotics?

A
  • Lipids + BMI at 3m
  • Fasting glucose + prolactin at 6m
  • Frequent BP during dose titration
  • FBC, U+Es, LFTs, lipids, BMI, fasting glucose, prolactin + CV risk yearly
74
Q

ANTI-PSYCHOTICS

How do oral and IM doses of anti-psychotics differ?

A

IM dosage lower due to oral first pass metabolism

IM dosage lasts up to 12 weeks

75
Q

ANTI-PSYCHOTICS

What must be communicated to a patient on anti-psychotics?

A

Continue for up to 5 years after acute episode

Taper down over 3+ weeks when discontinuing

Best taken before bedtime

76
Q

OLD AGE PSYCHIATRY

What are the risks for anti-psychotic use in the elderly?

A

stroke

VTE

77
Q

OLD AGE PSYCHIATRY

Why are lower doses of BDZs required in the elderly?

A

Higher proportion of fat/water as you age impacts distributions of drugs
Benzos – water soluble so hang around for longer –> Lower doses required

78
Q 
ANTI-PSYCHOTICS 
How long do these conditions take to develop?
Acute dystonia
akathisia 
parkinsism 
tardive dyskinesia
A

Hours = Acute dystonic reaction (muscle spasms)

4 weeks = Parkinsonism (tremor, bradykinesia)

6-60 days = Akasthesia (inner restlessness)

Long term use = Tardive dyskinesia

79
Q

ANTI-PSYCHOTICS

How do you prevent EPSE’s?

A

Start dose low and slowly titrate up

80
Q

ANTI-PSYCHOTICS

What safety netting advice is required for patient’s on clozapine?

A

Any sign of infection go straight to A+E immedietly as high risk for sepsis

  • sore throat
  • fever
  • cough
81
Q

MOOD STABALISERS

What is the management for lithium toxicity?

A

ABCDE
Fluid resuscitation
Haemodyalisis - if severe

82
Q

ANTI-PSYCHOTICS

What must be tried prior to administering anti-psychotics for agitation?

A

De-escalation techniques

  • Quiet room
  • talk them down
  • turn on hearing aids
83
Q

ANTI-DEPRESSANTS

What anti-depressant is safe for use with warfarin

A

Mirtazapine

84
Q

ANTI-DEPRESSANTS

Are SSRIs CYP450 inducers or inhibitors

A

Inhibitors

85
Q

SCHIZOPHRENIA

treatment of EPSEs?

A

Procycladine

Propanolol +/- cyproheptadine

Tetrabenazine

86
Q

SCHIZOPHRENIA

What does dopamine inhibit and what is the clinical effects of inhibtion?

A

Prolactin = therefore dopamine antagonism increases prolactin

Hyperprolactinaemia Side Effects:

  • Galactorrhoea
  • Amenorrhoea and infertility
  • Sexual dysfunction
87
Q

SCHIZOPHRENIA

What is Procycladine used for?

A

Treatment of the EPSE of Acute Dystonia/ Parkinsonism

88
Q

SCHIZOPHRENIA

What is propanalol/ cyproheptadine used for?

A

Treatment of the EPSE of Akathesia

89
Q

SCHIZOPHRENIA

What is Tetrabenazine used for?

A

Treatment of EPSE of Tardive Dyskinesia although its generally irreversible

90
Q

SCHIZOPHRENIA

Main dopamine and serotonin receptors?

A

D = D2

S = 5HT2a

91
Q

SCHIZOPHRENIA

Hyperprolactinaemia is a common SE of antipsychotics.

What is it generally not seen in?

A

Aripiprazole

Quetiapine

Clozapine

92
Q

PHARMACOLOGY

What is pharmacokinetics

A 
The Body's effect on the drug 
ADME 
Absorption 
Distribution 
Metabolism 
Elimination
93
Q

PHARMACOLOGY

What is pharmacodynamics

A

The drug’s effect on the body

  • Receptor sensitivity
  • Receptor agonism / antagonism
94
Q

Name some advice for sleep hygeine

A
  1. Limit caffeine / alcohol
  2. Less noise / lights / screen use
  3. Regular pattern
95
Q

ALZHEIMERS

Adverse effects of Acetylcholinesterase inhibitors

A

bradycardia
diarrhoea
headache

96
Q

ALZHEIMERS

Adverse effects of NDMA receptor antagonists?

A

confusion
hallucinations
dizziness
seizures

97
Q

ANTI - EPILEPTICS

Name some adverse effects of lamotrigine

A 
Steven johnson syndrome 
agitation 
agression 
arthralgia 
dizziness

Phase 3A (12 decks)

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