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Year 4 - PAN > Psychiatry - Psychopharmacology > Flashcards

Psychiatry - Psychopharmacology Flashcards

1
Q

Examples of SSRIs

A

Citalopram
Fluoxetine
Paroxetine
Sertraline

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2
Q

Indications for using SSRIs

A

Depression (treatment and prophylaxis in recurrent episodes)
Anxiety disorders (e.g. GAD, panic disorder)
Bulimia (fluoxetine)
OCD
PTSD

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3
Q

What side effects are associated with SSRIs?

A 
GI disturbances (dose related, usually transient) - nausea, vomiting, anorexia, weight loss, diarrhoea 
- increase risk of GI bleeding so gastric protection should be given if patients also taking an NSAID

Sexual - loss of libido, delayed orgasm

Hypersensitivity reaction

Others - headache, anxiety, sleep disturbance, restlessness

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4
Q

Contraindications for using SSRIs

A

Mania, use with caution in bipolar disorder

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5
Q

Important prescribing notes to remember about SSRIs

A

Once daily
Used as first line treatment for depression
May take up to 2 weeks before any effect, and 6 weeks for full effect
- should be reviewed 2 weeks after starting (1 week if under 30 or severe depression)
- continue treatment for 6 months after remission to reduce relapse
Withdrawal or discontinuation symptoms are common (especially with paroxetine)
Relatively safe in overdose but some patients report suicidal ideation

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6
Q

What are discontinuation symptoms?

A 
Symptoms experienced after stopping SSRIs
They include:
- increased mood change
- restlessness
- difficulty sleeping
- sweating 
- GI symptoms: pain, cramping, diarrhoea and vomiting 
- paraesthesia
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7
Q

What side effect is associated with citalopram?

A

Dose dependent QT interval prolongation
Should not be used in patients with congenital long QT syndrome, known pre existing QT interval prolongation or in combination with other drugs that can prolong the QT

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8
Q

Which SSRI is safest after MI?

A

Sertraline

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9
Q

What SSRI is safest for use in children or adolescence?

A

SSRIs should be used with caution in children and adolescence, but if they need to be used fluoxetine is the safest

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10
Q

What drugs do SSRIs interact with?

A

NSAIDs/ aspirin: do not normally offer SSRIs, but if given co prescribe a PPI

Warfarin/ heparin: avoid SSRIs and use mertazapine

Triptans: avoid SSRIs

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11
Q

Examples of tricyclic antidepressants

A

Amitriptyline
Imipramine
Lofepramine
Clomipramine

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12
Q

Indications for TCA use

A

Depression
OCD (clomipramine)
Neuropathic pain (amitriptyline)
Noctunral enuresis in children (imipramine)

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13
Q

Side effects associated with TCAs

A

Antimuscarinic - dry mouth, blurred vision, urinary retention, constipation

Drowsiness

Cardiovascular - postural hypotension, arrhythmia

Toxicity in OD - cardiotoxic, respiratory failure, seizures, convulsions, coma (amitriptyline most dangerous)

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14
Q

Contraindications of TCAs

A

Recent MI
Arrhythmias
Severe liver disease
Mania - use with caution in bipolar disorder

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15
Q

Important prescribing notes about TCAs

A

Given in divided doses or a single dose before bed
May take up to 2 weeks before any effect and 6 weeks for full effect
May cause drowsiness - advise patient to avoid driving
Avoid if high suicide risk in outpatient as can be lethal in overdose (lofepramine is the safest in OD)

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16
Q

Examples of MAOIs

A

Phenelzine

Moclobemide

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17
Q

Indications for using MAOIs

A

Refractory/ atypical depression

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18
Q

Side effects of MAOIs

A

Postural hypotension
Antimuscarinic
Increased appetite and weight gain
Hepatotoxicity
Hypertensive crisis - due to interactions between MAOIs and tyramine containing foods
- release of NA causes tacchycardia, hypertension, and vasoconstriction
- may lead to intracerebral haemorrhage or subarachnoid haemorrhage
- hypertensive crisis may also be precipitated by: sympathomimetics, TCAs, amphetamines, L-dopa
Serotonin syndrome - due to interactions between MAOIs and 5-HT enhancing drugs (e.g. SSRIs)

NB - side effects and interactions are less common with moclobemide as it is reversible

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19
Q

What is serotonin syndrome?

A

Precipitated by:

  • MAOIs
  • SSRIs
  • amphetamine
  • ecstasy

Features:

  • neuromuscular excitation (e.g. hyperreflexia, myoclonus, rigidity)
  • autonomic nervous system excitation (e.g. hyperthermia)
  • altered mental state
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20
Q

Contraindications for using MAOIs

A

Mania - use with caution in bipolar disorder
Hepatic impairment
Cerebrovascular disease
Phaeochromocytoma

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21
Q

What foods should patients avoid when taking MAOIs?

A 
Cheese
Non fresh fish, meat and poultry
Broad beans 
Marmite, bovril and Oxo
Alcohol
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22
Q

How long after stopping other anti-depressants can an MAOI be started?

A

MAOIs should not be started until at least 1 week after cessation of other anti-depressants
Other antidepressants should not be prescribed until 2 weeks after discontinuing MAOIs

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23
Q

What is venlafaxine?

A

SNRI - serotonin and noradrenaline reuptake inhibitor

Used to treat depression and GAD

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24
Q

Side effects of venlafaxine

A 
Constipation
Nausea 
Dizziness
Sleep disturbance 
Hypertension
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25
Q

Contraindications to using venlafaxine

A

High risk of cardiac arrhythmia
Uncontrolled hypertension
Pregnancy

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26
Q

What is mirtazapine?

A

Presynaptic alpha 2 antagonist

Indicated in depression

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27
Q

Side effects of mirtazapine

A

Increased appetite
Oedema
Sedation

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28
Q

Important prescribing notes for venlafaxine and mirtazapine

A

Mirtazapine is given before bedtime as it aids sleep
It has few antimuscarinic side effects so can be useful in elderly patients

Venlafaxine can be given as a once daily modified release prep
It should be used as a second line treatment under specialist supervision
Requires monitoring of BP

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29
Q

How should you switch between SSRIs?

A

(Maudesly hospital guidelines)
Switching between citalopram, sertraline or paroxetine and other SSRIs
- first SSRI should be withdrawn (gradually reduce the dose then stop) before the others are given

Switching from fluoxetine to other SSRIs
- withdraw then leave a gap of 4-7 days (as it has a long half life) before starting a low dose of the alternative SSRI

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30
Q

How should you switch between an SSRI and a TCA?

A

Cross tapering is recommended - current dose is reduced slowly whilst the dose of the new drug is increased slowly

The exception is fluoxetine which should be withdrawn prior to TCAs being started

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31
Q

How do you switch between an SSRI and venlafaxine

A

Cross taper cautiously. Start venlafaxine 37.5mg per day and taper up slowly

Fluoxetine is the exception. Withdraw and then start venlafaxine at 37.5mg per day and increase slowly

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32
Q

Examples of atypical antipsychotics

A 
Olanzapine
Risperidone
Queitiapine
Aripiprazole 
Amisulpride
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33
Q

Indications for using atypical antipsychotics

A 
Schizophrenia 
Other psychotic illnesses 
Mania
Prophylaxis in bipolar affective disorder (olanzapine)
Agitation

Atypical antipsychotics are preferred 1st line over typicals due to their more favourable side effect profile

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34
Q

What side effects are associated with atypical antipsychotics?

A 
Weight gain
Postural hypotension
Drowsiness
Extrapyramidal side effects do occur but are less common than with typical antipsychotics 
Diabetes
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35
Q

Contraindications for atypical antipsychotics

A

Use with caution in those with cardiovascular disease, epilepsy and the elderly

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36
Q

What monitoring is recommended for atypical antipsychotics?

A 
Weight 
BP
ECG
Lipids
Glucose/ HbA1c
FBC
U&E
LFTs
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37
Q

Examples of typical antipsychotics

A

Phenothiazines - chlorpormazine, fluphenazine, thioridazine, prochlorperazine
Butyrophenones - haloperidol, droperidol
Thioxanthine - flupenthixol
Benzamide - sulpride

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38
Q

Indications for using typical antipsychotics

A

Schizophrenia
Other psychotic illness
Mania
Agitation

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39
Q

What extrapyramidal side effects are associated with typical antipsychotics?

A

Extra pyramidal symptoms occur because typical antipsychotics block dopamine D2 receptors in the mesolimbic pathway.

1) Acute dystonia
- presents with grimacing, abnormal movements and facial spasms, especially masseter muscles
- may even lead to jaw dislocation, torticolis, limb rigidity, and altered behaviour
- treat with procyclidine bolus 5 mg i.m. Symptoms should improve quickly, then continue with oral procyclidine 8 hourly as necessary

2) Parkinsonism
- tremor
- rigidity
- bradykinesia
- treated with procyclidine or another antimuscarinic drug

3) Akathisia (restlessness)
- difficult to treat
- review medication
- consider propranolol

4) Tardive dyskinesia (involuntary movements usually of the oral-lingual region)
- consider changing medication
- tends to be reversible

40
Q

What is neuroleptic malignant syndrome? How does it present?

A

Rare but potentially fatal complication of antipsychotic treatments

Presents with hyperthermia, fluctuating levels of consciousness, muscular rigidity, autonomic dysfunction with pallor, tachycardia, labile BP, sweating and urinary incontinence

Increased white cells and creatine phosphokinase

Stop antipsychotic and provide cardiovascular and respiratory support (ideally on ITU). Bromocriptine and dantrolene may be used but there is no proven effective treatment

Usually lasts for 5-7 days after discontinuation of the antipsychotic

41
Q

Other side effects of typical antipsychotics

A

Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
Sedation, weight gain
Raised prolactin: galactorrhoea, impaired glucose tolerance
Reduced seizure threshold (greater with atypicals)
Prolonged QT interval (particularly haloperidol)

42
Q

What are the indications for using clozapine?

A

Clozapine is an atypical antipsychotic used for treatment resistant schizophrenia (psychotic symptoms which have failed to respond to adequate trials of two antipsychotics, at least one of which is atypical)

43
Q

Side effects associated with clozapine

A

Agranulocytosis (rare but potentially fatal)
Constipation (laxatives can be used)
Tachycardia (can be treated with beta blockers)
Hypersalivation (can be treated with hyoscine)
Sedation (give smaller doses in the morning)
Hypertension
Weight gain
Diabetes (treat accordingly)
Convulsions (valproate can be given)
Myocarditis

44
Q

What are the contraindications for treatment with clozapine?

A

Severe cardiac disease
Active liver disease
Severe renal impairment
History of bone marrow disorders

45
Q

What monitoring is required for clozapine?

A

Clozapine is effective and reduces mortality (largely by reducing suicide rate) but it can cause considerable side effects. Risk of agranulocytosis is well managed by the mandatory clozipine monitoring systems. These involve the patient having regular blood tests and results being checked before clozapine is dispensed. Blood tests are for the first 18 weeks, then fortnightly for the remainder of the year, then monthly thereafter

All side effects are more likely to occur in early stages so careful monitoring and dose titration are needed

BP, pulse and temperature are monitored very closely during titration of dose. Long term monitoring requires:

  • weight
  • ECG
  • lipids
  • glucose/ HbA1c
  • LFTs

If the patient misses more than 2 days of clozipine they will need to be recommenced on their treatment at the beginning with dose titration

46
Q

Examples of anxiolytics

A

Diazepam, nitrazepam - prolonged action

Lorazepam, temazepam - short action

47
Q

What are the indications for anxiolytic therapy?

A 
Short term relief of anxiety
Insomnia (hypnotic effect)
Alcohol withdrawal (chlordiazepoxide) 
Status epilepticus (diazepam)
Premedication before surgery
48
Q

What are the side effects of anxiolytics?

A 
Drowsiness
Paradoxical agitation and aggression
Confusion
Dependence and tolerance with prolonged use, so should only be prescribed for the short term
Withdrawal syndrome after prolonged use
49
Q

Features that characterise the withdrawal syndrome of anxiolytics

A 
Insomnia
Anxiety
Loss of appetite and weight 
Tremor
Sweating 
Perceptual disturbances

Transfer patients to equivalent daily dose of diazepam and withdraw in gradual steps

50
Q

Contraindications of anxiolytics

A

Respiratory depression

Severe hepatic impairment (benzodiazepines are metabolised in the liver, so accumulation of active metabolites occurs

51
Q

What other factors should you consider when prescribing anxiolytics?

A

Care with alcohol and other minor tranquilizers as they enhance the sedative effect of benzodiazepines
Hangover effect can impair the ability to drive and operate machinery
Flumazenil is a benzodiazepine antagonist that can be given as an antidote in overdose

Administered orally, i.m., i.v., or p.r., in divided daily doses depending on particular drug and clinical circumstances

52
Q

Medications used for ADHD

A

Methylphenidate - ADHD
Dexamphetamine - refractory ADHD and narcolepsy
Atomoxetine

All should be prescribed under strict specialist supervision

53
Q

What side effects are associated medication used to treat ADHD?

A

Decreased appetite with resultant weight loss and possible growth retardation
Rebound hyperactivity
Depression
Insomnia
Headache
GI symptoms (e.g. stomach pain/ GI upset)
Theoretically may worsen epilepsy

54
Q

Contraindications to ADHD medication

A

Cardiovascular disease
Hyperthyroidism
Predisposition to tics or Tourette’s syndrome

55
Q

Factors to consider when prescribing ADHD medication

A

Very rarely prescribed for children under 6
Drug treatment should be reserved for severe cases that have not responded to other measures
High doses may cause growth retardation
Drugs may be needed for months to years and careful monitoring of height and weight is essential
Need to give doses every 4 hours (morning, lunchtime and evening) as methylphenidate has a short half life

56
Q

What is ECT? When is it used?

A

A medical procedure used under controlled conditions to treat some major psychiatric disorders including severe depressive illness, mania, puerperal psychosis and catatonic schizophrenia

Used when illness remains unresponsive to other treatments or when a very rapid response is needed (e.g. patient not eating or drinking due to depressive stupor)

Patient is anaesthetised and given a muscle relaxant; seizures are then induced by delivering brief electrical stimuli to the brain via scalp electrodes

Patients usually receive a total of 6-12 treatments, given twice weekly

57
Q

Under what circumstances can ECT be performed?

A

Amended MHA:

  • patient understands the treatment and consents
  • the patient does not have capacity to consent and a second opinion approved doctor is consulted and agrees and it does not conflict with an advance directive by the patient

Emergency ECT can be given under section 62 while awaiting a second opinion if:

  • it is immediately necessary to prevent serious suffering
  • it is immediately necessary to prevent the presenting a danger to themselves or others
58
Q

What should be done prior to ECT?

A

Patients must have a full operative workup, including any necessary investigations - e.g. CXR, U&E, FBC, ECG

Antiepileptics and benzodiazepines should be discontinued before treatment if possible as they increase the risk of seizure threshold

59
Q

Side effects of ECT

A

Confusion
Headache
Short term memory loss

60
Q

Complications of ECT

A

Anaesthetic problems
Status epilepticus
The risk is the same as that for a general anaesthetic for other minor procedures (NB: 10% of those with depression will commit suicide)

61
Q

Contraindications of ECT

A 
Serious anaesthetic risk
Raised ICP (as ICP rises further during treatment)
62
Q

Examples of medication used to treat dementia

A

Acetylcholine esterase inhibitors: donepezil, galantamine, rivastigmine
NMDA receptor antagonists: memantine

63
Q

What are the indications for using the anti-dementia medications?

A

Acetylcholine esterase inhibitors:

  • mild to moderate dementia related to AD
  • mild to moderate dementia related to PD (rivastigmine only)

Memantine: moderate to severe dementia related to AD

64
Q

What side effects are associated with acetylcholine esterase inhibitors?

A

GI - nausea, vomiting, gastric and duodenal ulcers, GI haemorrhage
Cardiovascular - dizziness, syncope, bradycardia, AV heart blocks, MI
Psychiatric - hallucinations, agitation
Others - rash, muscle cramps

65
Q

Side effects associated with memantine

A 
Constipation
Hypertension
Seizures
Dizziness
Depression
66
Q

Contraindications to anti-dementia medication

A

Acetylcholine esterase inhibitors:

  • renal impairment (galantamine)
  • caution in cardiac disease and those with susceptibility to peptic ulcers

Memantine:
- caution in renal impairment and those with history of seizures

67
Q

Factors to consider when prescribing anti-dementia medication

A

Start with the lowest dose possible and gradually increase whilst monitoring for side effects
With acetylcholine esterase inhibitors, monitor congition and pulse regularly (at least every 6 months)
Review appropriateness of acetylcholine esterase inhibitors in severe dementia (MMSE < 10)

68
Q

Examples of hypnotic medication

A

Zopiclone
Zolpidem
Also temazepam and diazepam (as anxiolytics)

Indicated only for short term treatment of insomnia
Hangover effect occurs
Should only be prescribed when other methods have failed

69
Q

Side effects of hypnotic medication

A

GI disturbances
Headache
Dependence
Memory disturbances

70
Q

What are the contraindications to using hypnotic medication?

A 
OSA
Respiratory failure
Myasthenia gravis 
Pregnancy and breast feeding 
Caution in a history of alcohol or drug abuse
Caution in hepatic or renal impairment
71
Q

What medication is used for alcohol dependence?

A

Disulfiram (aversive)
Acamprosate (anti-craving)

Indicated for maintaining abstinence from alcohol in dependence

72
Q

What are the side effects associated with drugs used for alcohol dependence?

A

Disulfiram - fatigue, halitosis, reduced libido, rarely psychosis

Acamprosate - GI disturbance, rash

73
Q

Contraindications for using alcohol dependence drugs

A

Disfulfiram - cardiac disease, hypertension, previous CVA, psychosis

Acamprosate - severe hepatic or renal failure

74
Q

What is important to counsel a patient when taking drugs used to treat alcohol dependence?

A

Consuming even a small amount of alcohol while taking disulfiram leads to a build up of acetaldehyde, causing an extremely unpleasant reaction, including:

  • facial flushing
  • headache
  • palpitations
  • nausea and vomiting

Compliance is increased if it is monitored by a spouse or family member

Discontinue acamprosate if the patient returns to regular drinking

75
Q

What drugs are used to treat opioid dependence?

A 
Methadone
Buprenorphine (partial opioid agonist)

Indicated as substitute prescribing for opiates as a means of harm reduction

76
Q

Side effects associated with drugs used to treat opioid dependence

A

Methadone

  • fatal overdose
  • QT prolongation

Buprenorphine

  • abdominal pain
  • fatigue
  • anxiety
77
Q

What are the contraindications to prescribing drugs to treat opioid dependence?

A

Caution when prescribing methadone and buprenorphine in those using alcohol and benzodiazepines as this will increase mortality

Caution with severe hepatic and renal failure which will reduce the metabolism and elimination of methadone and so increase the risk of overdose

Methadone is considered safer than buprenorphine in pregnancy and breastfeeding

78
Q

What should be done before initiating drugs to treat opioid dependence?

A

Before prescribing, confirm opioid dependence by positive urine results and objective signs of withdrawel (lactorrhoea, rhinorrhea, agitation, sweating, yawning, dilated pupils)

First 2 weeks of methadone treatment are associated with a substantially increased risk of death due to overdose, and so careful assessment, titration of dose and monitoring are essential

Initial dose is low to reduce risk of OD and gradually increased depending on withdrawel symptoms

Supervised daily consumption is recommended for the first 3 months

Once patients are stable and not using ellicit drugs, consideration should be given to gradually reducing the dose with the aim of discontinuing treatment

79
Q

What should be prescribed alongside buprenorphine or methadone?

A

Naloxone in the event of buprenorphine or methadone OD

80
Q

How should buprenorphine be started?

A

Commencing buprenorphine may cause precipitated withdrawal and so the first dose
should be given when the patient is experiencing withdrawal symptoms to reduce this risk.

81
Q

What are the indications for using carbamazepine?

A

Prophylaxis of bipolar disorder

Treatment of epilepsy and trigeminal neuralgia

82
Q

What are the side effects of carbmazepine?

A

Erythematous rash may occur in a large number of patients

GI disturbances - diarrhoea, nausea, vomiting, anorexia

Neurological - dizziness, headache, ataxia, diplopia

Haematological - leucopenia, thrombocytopaenia, agranulocytosis (1 in 20,000), aplastic anaemia (1 in 20,000)

Biochemical - hyponatraemia

83
Q

What are the contraindications to carbamazepine therapy?

A 
Atrioventricular conduction abnormalities (unless paced)
History of bone marrow depression
Acute porphyria  
Pregnancy 
Pregnancy and breast feeding
84
Q

What investigations are required before carbamazepine therapy can be started?

A

Blood tests - FBC, LFT, U&E
Pregnancy test
ECG

Regular blood monitoring is required throughout treatment

85
Q

What are the indications for sodium valproate therapy?

A

Mania in bipolar affective disorder
Prophylaxis in bipolar affective disorder
Refractory depression
Epilepsy

86
Q

Side effects of sodium valproate

A 
Vomiting 
Alopecia 
Liver toxicity
Pancreatitis/ pancytopaenia 
Retention of fats (weight gain)
Oedema 
Anorexia
Tremor
Enzyme inhibitor
87
Q

Contraindications to sodium valproate treatment

A

Hepatic dysfunction
Porphyria
Pregnancy and breast feeding

88
Q

Important prescribing features of sodium valproate

A

It may be particularly useful in patients who undergo rapid cycling (four or more episodes per year)
Liver function tests should be checked regularly
Fewer adverse side effects than other anti-epileptics
Patients should be given a leaflet about recognising haematological/ hepatic side effects
It is teratogenic and most foetal malformations are neural tube defects. Adequate contraception should be ensured in women of child bearing age, particularly as manic women can be sexually disinhibited

89
Q

What are the indications for lithium therapy?

A

Prophylaxis in bipolar effective disorder (decreases frequency and severity of manic and depressive episodes)
Augments antidepressants in treatment of refractory depression
Mania (use limited by difficulties achieving therapeutic serum levels rapidly)
Aggressive or self mutilating behaviours

90
Q

Side effects of lithium

A

General - weight gain, oedema, fine tremor, muscle weakness, worsening of acne and psoriasis

Gastrointestinal - diarrhoea, nausea, vomiting, metallic taste

Renal - nephrogenic diabetes insipidus (polyuria and polydipsia), long term use can result in impaired renal function

Endocrine - hypothyroidism, hyperparathyroidism

Cardiac - T wave inversion

Haematological - leucocytosis

91
Q

What are the contraindications to lithium therpay?

A

Pregnancy
Caution in renal disease and cardiac disease
Caution in conditions causing sodium imbalance such as Addison’s disease

92
Q

What is the therapeutic range of lithium?

A

Lithium has a narrow therapeutic index
0.6-1.0 mmol/L
Increased side effects above 1.2 mmol/L
Risk of toxic effects above 1.5 mmol/L

93
Q

What investigations are needed before and during lithium therapy?

A

Before lithium therapy:

  • medication review (NSAIDs and ACEi interact)
  • blood tests - FBC, U&E, thyroid screen, pregnancy test
  • ECG

Investigations during treatment:

  • lithium plasma level (every 3 months after dose has stabilised)
  • regular monitoring of FBC, U&E, Ca and TFT

Advise patients to consume adequate fluid intake and avoid diets with excess sodium

94
Q

Why is good adherence important for lithium therapy?

A

Long term treatment with lithium reduces the risk of suicide in bipolar affective disorder to the level of the general population

There is some evidence that intermittent treatment with lithium may worsen the natural course of bipolar affective disorder and so it should only be commenced if it is intended to continue for the long term

95
Q

When does lithium toxicity occur?

A

Toxic levels occur over 1.5 mmol/L
Antidepressants, anticonvulsants, antipsychotics, and Ca channel blockers as well as any cause of dehydration can all precipitate toxicity

96
Q

Presentation of lithium toxicity

A 
Severe nausea
Vomiting 
Diarrhoea 
Disorientation
Seizures
Drowsiness
97
Q

Management of lithium toxicity

A

Lithium should be stopped and an urgent lithium level obtained and fluids given. Specialist input should be sought as haemodialysis may be needed.

Year 4 - PAN (43 decks)

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