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Psychiatry > Psycho-Pharmacology > Flashcards

Psycho-Pharmacology Flashcards

1
Q

What are indications for anti-depressants?

A

Unipolar and bipolar depression
Organic mood disorders
Schizoaffective disorder
Anxiety disorders

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2
Q

How long is typical delay between achievement of therapeutic dose and symptom improvement in anti-depressants?

A

2-4 weeks

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3
Q

How should you use prophylaxis for depression?

A

First episode continue for 6 months
Second episode continue for 2 years
Third episode discuss life long

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4
Q

Examples of tertiary TCAs?

A

Imipramine
Amitriptyline
Doxepin
Clomipramine

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5
Q

Side effects of TCAs?

A

Anti-cholinergic, Anti-adrenergic
Anti-histaminic
QT lengthening

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6
Q

Examples of secondary TCAs?

A

Desipramine, nortriptyline

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7
Q

Do secondary or tertiary TCAs generally have worse side effects?

A

Tertiary

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8
Q

How do Monoamine Oxidase inhibitors (MAOIs) work?

A

Bind irreversibly to MAO preventing inactivation of amines (noradrenaline, dopamine and serotonin) leading to increased synaptic levels

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9
Q

What are MAOIs effective for?

A

Resistant depression

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10
Q

What are the side effects of MAOIs?

A

Orthostatic hypotension, weight gain, dry mouth, sedation, sexual dysfunction and sleep disturbance

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11
Q

Types of anti-depressants?

A 
TCAs 
Monoamine Oxidase inhibitors
Selective serotonin inhibitors
Serotonin/noreadrenaline reuptake inhibitors
Novel antidepressants
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12
Q

What can develop when MAOIs are taken with tyramine rich foods or sympathomimetics? (cheese reaction)

A

Hypertensive crisis

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13
Q

What can develop if MAOIs taken with medications that increase serotonin?

A

Serotonin syndrome
Sx - abdominal pain, diarrhoea, sweats, tachycardia, HTN, myoclonus
Can lead to hyperpyrexia, cardio shock and death

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14
Q

How can you avoid serotonin syndrome?

A

Wait 2 weeks before switching from SSRI to MAOI

Exception is fluoxetine where wait 5 weeks

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15
Q

How do selective serotonin reuptake inhibitors work? (SSRIs)

A

Block presynaptic serotonin reuptake

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16
Q

What can SSRIs be used to treat?

A

Anxiety and depressive symptoms

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17
Q

What are the most common general side effects of SSRIs?

A

GI upset, sexual dysfunction, anxiety, restlessness, nervousness, insomnia, fatigue, dizziness

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18
Q

What is discontinuation syndrome with SSRIs?

A

Agitation, nausea, disequilibrium and dysphoria

More common in shorter half life drugs

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19
Q

What is activation syndrome?

A

Caused by increased serotonin
Nausea, increased anxiety, panic and agitation
Typically last 2-10 days

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20
Q

What are the Pros and cons of Paroxetine? And what type of drug?

A

SSRI
Pros: short half life, no build up. Sedating properties offer good initial relief
Cons: Sedating, weight gain, anti-cholinergic effects. Likely to cause a discontinuation syndrome

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21
Q

What are the Pros and cons of Sertraline? And what type of drug?

A

SSRI
Pros: weak P450 interactions, short half-life, less sedating than paroxetine
Cons: Max absorption needs full stomach.Increased number GI ADRs

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22
Q

What are the Pros and cons of Fluoxetine? And what type of drug?

A

SSRI
Pros: long half life, good for non-compliance issues, can use to taper off SSRI
Cons: Metabolite build up, P45- interactions, initial anxiety and insomnia increase. More likely to induce mania

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23
Q

What are the Pros and cons of Ciralopram? And what type of drug?

A

SSRI
Pros: few D-D, intermediate half life
Cons: Dose-dependent QT interval prolongation. Cam be sedating, GI side effects

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24
Q

What is the benefit of Escitalopram over ciralopram?

A

More effective in acute response and remission

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25
Q

What are the Pros and cons of fluvoxamine? And what type of drug?

A

SSRI
Pros: shortest 1/2 life, some analgesic properties
Cons: shortest 1/2life, GI distress, headaches, sedation, weakness. Strong inhibitor of some P450

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26
Q

How do seritonin/noradrenaline reuptake inhibitors work? (SNRIs)

A

Inhibit serotonin and noradrenergic reuptake like TCAs without their side effects

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27
Q

What are SNRIs used for?

A

Depression, anxiety

Possibly neuropathic pain

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28
Q

What are the Pros and cons of Venlafaxine? And what type of drug?

A

SNRI
Pros: minimal d-d and little P450, short half life and fast renal clearance
Cons: increase in DBP, nausea, discontinuation syndrome, sexual side effects

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29
Q

What are the Pros and cons of Duloxetine? And what type of drug?

A

SNRI
Pros: far less BP increase
Cons: P450 effects, active ingredient not stable in stomach

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30
Q

What are the Pros and cons of Mirtazapine? And what type of drug?

A

Novel antidepressant
Pros:good augmentation to SSRIs, hypnotic at lower doses
Cons: Increase cholesterol, sedating, weight gain

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31
Q

What are the Pros and cons of Buproprion? And what type of drug?

A

Novel antidepressant
Pros: Augmenting agent No weight gain, sexual side effects sedation or cardiac interaction, second line ADHD agent
Cons: may increase seizure risk (avoid TBI, anorexia, bulimia. Not anxiety Rx. Abuse potential due to psychosis

32
Q

How could you treat treatment resistant depression?

A

Combination of antidepressants
Adjunctive treatment with lithium
Adjunctive treatment with atypical antipsychotic
ECT

33
Q

What are indications for mood stabilisers?

A

Bipolar, cyclothymia, schizoaffective

34
Q

What are the classes of mood stabilisers?

A

Lithium
Anticonvulsants
Antipsychotics

35
Q

What is the only medication to reduce suicide rate?

A

Lithium

36
Q

What is lithium useful for prophylactically?

A

Mania and depressive episodes

37
Q

What are factors predicting a positive repose to lithium?

A

Prior long term response or family member with good response
Classic pure mania
Mania followed by depression

38
Q

What do you need to check before starting lithium?

A

Baseline U&E and TSH

Pregnancy test

39
Q

What do you need to monitor with lithium?

A

Steady state achieved after 5 days - check 12 hours after last dose
Level 3 months once stable Goal blood level between 0.6-1.2
TSH and creatinine 6 months

40
Q

What are lithium side effects?

A

GI distress
Thyroid abnormalities
Nonsignificant leukocytosis
Polyuria/polydipsia secondary to ADH antagonism
Hair loss, acne
Reduces seizure threshold, cognitive slowing, intention tremor

41
Q

Is valproic acid more effective for mania or depression prophylaxis?

A

Mania

42
Q

What factors predict a positive response in valproic acid?

A

Rapid cycling patients F>M
Comorbid substance issues
Mixed patients
Patients with comorbid anxiety disorders

43
Q

Is lithium or valproic acid better tolerated?

A

Valproic acid

44
Q

What should be measured before starting valproic acid?

A

Base line LFTs
Pregnancy test
FBC

45
Q

Why should valproic acid be avoided in woman of child bearing age?

A

Neural tube defects

46
Q

What is the monitoring for valproic acid?

A

Steady state achieved after 4-5 days, check 12
hours after last dose and repeat FBC and LFTs
Goal target between 50 and 125

47
Q

What are valproic acid side effects?

A

Thrombocytopenia and platelet dysfunction
N+V, weight gain
Sedation, tremor
Hair loss

48
Q

What is use for carbamazepine and what patients is it indicated in?

A

First line agent for acute mania and mania prophylaxis

Indicated for rapid cyclers and mixed patients

49
Q

What should be done before starting carbamazepine?

A

Baseline LFTs
FBC
ECG

50
Q

What monitoring should be done with carbamazepine?

A

Steady state after 5 days - 12 hours after last dose
Repeat FBC and LFTs
Goal 4-12mcg/ml
Need to check level and adjust dosing after around a month as induces own metabolism

51
Q

What are side effects of carbamazepine?

A 
Rash
N+V, diarrhoea
Sedation, dizziness, ataxia, confusion
AV conduction delays
Water retention due to vasopressin like effect --> hyponatremia
D-D
52
Q

What tests need to be done before lamotrigine?

A

Baseline LFTs

53
Q

What is the procedure for initiation/titration of lamotrigine?

A

Start 25mg daily for 2 weeks then increase to 50mg for 2 weeks then 100mg if patient stops med for >/=5 days then must start 25mg again

54
Q

Side effects of lamotrigine?

A

N+V
Sedation, dizziness, ataxia and confusion
Toxic epidermal necrolysis and stevens johnson’s syndrome - IF any rash develops discontinue use immediately
VPA increases lamotrigine levels as dose sertraline

55
Q

Indications for antipsychotic use?

A

Schizophrenia, schizoaffective disorder
Bipolar for mood stabilisation and/or psychotic features
Psychotic depression
Augmenting agent in treatment resistant anxiety disorders

56
Q

What are the key pathways affected by dopamine in the bra

A

Mesocortical (negative symptoms and cognitive disorders, too little dopamine)
Mesolimbic (positive symptoms, too much dopamine)
Nigrostriatal (movement regulation)
Tuberoinfundibular (blocking dopamine here –> hyperprolactinaemia)

57
Q

What are typical antipyschotics?

A

D2 dopamine receptor antagonist (high affinity)

Higher risk of extrapyramidal sid effects

58
Q

What are examples of high potency typical antipsychotics?

A

Fluphenazine
Haloperidol
Pimozide

59
Q

What are examples and side effects of low potency typicals?

A

Cardiotoxic and anticholinergic - sedation, hypotension
Chlorpromazine
Thioridazine

60
Q

What are antipsychotic atypicals?

A

Serotonin dopamine 2 antagonists

Affect dopamine and serotonin in four key dopamine pathways in brain

61
Q

About risperidone?

A

Regular tabs, IM and rapidly dissolving tablet
More like typical at doses > 6mg
Increased extrapyramidal side effects
Most likely atypical to induce hyperprolactinaemia
S/E of weight gain and sedation

62
Q

About onlazapine?

A

Regular tabs, immediate release IM, rapidly dissolving tab, demo form
Weight gain
Hypertriglyceridaemia and hypercholesterolaemia, hyperglycaemia

63
Q

About quetiapine?

A 
Regular tablet form only
Abnormal LFTS(6%)
Weight gain less than onlazapine
Same hypers as onlaxapine but less
Orthostatic hypotension
64
Q

About ariprazole?

A

Regular tabs, immediate release IM and depo
D2 partial antagonist
LOW EPS, no QT, low sedation
Interactions with other psychiatric meds (fluoxetine and paroxetine and carbamazepine)
No weight gain

65
Q

About clozapine?

A

Regular tablet
Reserved for treatment resistant
Weekly blood draws x 6 months then Q- 2weeks x 6months
Increased risk of seizures (esp + lithium)
Most sedation, weight gain and abnormal LFTs)

66
Q

What are indications for anxiolytics?

A

Panic disorder, generalised anxiety, substance related and withdrawal, insomnias and paraomnias

67
Q

Agents for extrapyramidal side effects?

A 
Anticholinergics (benztropine)
Dopamine facilitators (amantadine)
Beta bockers (propranolol)
68
Q

About buspirone?

A

Pros: good augmentation and no sedation
Cons: 2 weeks till patient notices results. Wont reduces anxiety in patient used to taking BZDs

69
Q

About benzodiazepines?

A

Treat insomnia, parasomnias and anxiety
CNS depressant withdrawal protocols
S/E somnolence, conginitve deficits, amnesia, disinhibition, tolerance, dependence

70
Q

What would you use in a treatment naive patient with depression first line?

A

SSRI

71
Q

What are some less sedating SSRIs?

A

Citalopram
Fluoxetine
Sertraline

72
Q

What are some anti-depressantsassociated with weight gain?

A

Paroxetine

Mirtazapine

73
Q

When would you move on to a duel reuptake inhibitor in a depression patient?

A

No remission with two SSRIs or a novel agent

74
Q

What would you discuss in a women of child bearing age when prescribing lithium?

A

Contraception methods

75
Q

What is a rapid cycler?

A

4 or more depressive or manic episodes per year

76
Q

What increase in LFTs on anticonvulsants would warrant considering changes in therapy?

A

More than triple baseline

Psychiatry (13 decks)

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