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Psychiatry > Psychopharm > Flashcards

Psychopharm Flashcards

1
Q

side effects of antipsychotics ?

A
  1. antihistamine (sedation, weight gain)
  2. anti-adrenergic (tachycardia, dizziness, impotence, postural hypotension)
  3. anticholinergic (dry mouth, constipation, blurred vision)
  4. hepatic (chronic raise in LFTs)
  5. photosensitivity (chlorpromazine)
  6. blood dycrasias (cloazpine)
  7. metabolic syndrome (primarily the atypical/ second generation)
  8. sexual side effects (decreased libido, anorgasmia)
  9. EPSP
  10. endocrine side effects
  11. cardiac (increased QTc)
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2
Q

what are the symptoms of metabolic syndrome ? (side effect of antipsychotics

A
  1. NAFLD
  2. fatigue and inability to focus
  3. high blood pressure, low HDL cholesterol, high triglyceride level, high fasting blood glucose
  4. central obesity
  5. PCOS in women and erectile dysfunction in men
  6. browning of folds of skin around the neck, armpits etc
    **metabolic syndrome is diagnosed when at least 3 of the following are present
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3
Q

what are the endocrine side effects of antipsychotics? what antipsychotics are more likely to produce endocrine side effects ? what is the mechanism of the side effects

A

*dopamine blockade in the tuberoinfundibular pathway leads to hyperprolactinemia
1. gynecomastia
2. galactorrhea
3. impotence
4. infertility
5. amenorrhea
6. osteoporosis

*greatest risk for high potency D2 blockers such as: risperidone, sulpiride, amisulpiride

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4
Q

what are the 5 extrapyramidal side effects of anti-psychotics ?

A
  1. dystonic reaction
  2. akathisia
  3. parkinsonism
  4. tardive dyskinesia
  5. neuroleptic malignant syndrome
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5
Q

when are each of the extrapyramidal side effects most likely to occur after initiation of antipsychotics ?

A
  1. dystonic reaction: hours to days
  2. akathisia: within 1-2 weeks
  3. parkinsonism: 1-6 weeks
  4. tardive dyskinesia: 6 months to 2 years
  5. neuroleptic malignant syndrome: idiosyncratic
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6
Q

signs and symptoms of dystonic reaction? (antipsychotics)

A

involuntary muscle spasm e.g oculogyric crisis, torticollis. painful and distressing

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7
Q

signs and symptoms of parkinsonism (anti-psychotics) ?

A

tremor =/- rigidity. bradykinesia, bradyphrenia. can be mistaken for negative symptoms of depression

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8
Q

signs and symptoms of akathisia?

A

subjectively, unpleasant state of inner restlessness, strong compulsion to move. can be mistaken for psychotic agitation

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9
Q

signs and symptoms of tardive dyskinesia?

A

involuntary, repetitive movements e.g lip smacking, tongue protrusion, choreiform hand movements

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10
Q

what are the rating scales for the extrapyramidal side effects of antipsychotics ?

A
  1. dystonia: no specific scale
  2. parkinsonism: simpson-angus EPS scale
  3. akathisia: Barnes akathisia scale
  4. tardive dyskinesia: abnormal involuntary movement scale (AIMS)
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11
Q

what is the prevalence of dystonic reaction with antipsychotics ?

A

10%
more common in young males, with higher potency drugs and in neuroleptic naive

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12
Q

what is the prevalence of Parkinsonism (EPSE) with antipsychotics?

A

20%
more common in elderly females and those with pre-existing neurodamage

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13
Q

what is the prevalence of akathisia (EPSE) ?

A

25%
less with atypicals

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14
Q

what is the prevalence of tardive dyskinesia from antipsychotics?

A

5% of patients per year of exposure
more common in elderly women, those with affective illness and those who had acute EPSEs early in treatment

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15
Q

what is the management of dystonia ?

A

anticholinergics - IV/PO/IM

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16
Q

what is the treatment for drug induced parkinsonism as an EPSE of antipsychotics?

A
  1. reduce the dose
  2. change to an atypical antipsychotic
  3. anticholinergic - review use every 3 months. do not prescribe at night
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17
Q

what is the treatment of akathisia?

A
  1. reduce dose
  2. change to an atypical antipsychotic
  3. propanolol (poor evidence)
  4. low dose clonazepam
  5. 5-HT2 antagonists e.g Mirtazapine
    *anticholinergics are unhelpful
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18
Q

what is the treatment of tardive dyskinesia

A
  1. stop any anticholinergic
  2. reduce dose
  3. change to atypical
  4. trial of clozapine
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19
Q

what are the indications for benzodiazepines?

A
  1. insomnia (short term and with close monitoring)
  2. anxiety (try to avoid but if needed ensure short term)
  3. alcohol withdrawl states
  4. rapid tranquillization
  5. status epilepticus
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20
Q

what are examples of long acting benzodiazepines

A
  1. diazepam
  2. chlordiazepoxide
  3. Nitrazepam
  4. pramazepam
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21
Q

what are examples of short acting benzodiazepines?

A
  1. lorazepam
  2. temazepam
  3. alprazolam
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22
Q

treatment algorithm for schizophrenia

A
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23
Q

antipsychotic monitoring

A
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24
Q

clozapine side effects ?

A
  1. sedation
  2. weight gain
  3. constipation
  4. nocturnal enuresis
  5. tachycardia
  6. hypotension
  7. hypertension
  8. neutropenia/ agranulocytosis
  9. fever
  10. hyperventilation
  11. seizures
  12. thromboembolism
  13. myocarditis
  14. cardiomyopathy
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25
Q

monitoring required while on clozapine ?

A
  1. FBC
    - baseline
    - weekly for 18 weeks
    - every 2 weeks thereafter until 1 year
    - monthly thereafter
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26
Q

describe the red, amber and green alert for clozapine?

A

this refers guidelines based on the WBC count for patients on clozapine
1. Green: continue clozapine
2. amber: continue clozapine but daily FBC and monitor for infection
3. red: stop clozapine

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27
Q

benzodiazepine withdrawl symptoms ?

A
  1. aches/pains
  2. insomnia
  3. depression
  4. anxiety/ panic attacks
  5. nausea
  6. grand mal seizures
  7. delirium/ detachment from reality
  8. muscle spams
  9. abnormal body sensations
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28
Q

with regard to neuroleptic malignant syndrome, it is a lifethreatening, …. reaction to … medication. an … severe syndrome. a disorder of … and …. control. associated with significant …. and … especially in … people

A
  1. idiosyncratic
  2. antipsychotic (neuroleptics)
  3. acute
  4. thermoregulation
  5. neuromotor
  6. morbidity
  7. mortality
  8. older
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29
Q

signs and symptoms of neuroleptic malignant syndrome?

A
  • can be broadly divided into autonomic, neuromuscular and mental state. they include;
  • fever
  • diaphoresis
  • altered mental state
  • rigidity (lead pipe)
  • autonomic dysfunction
  • risk of rhabdomylosis and renal failure
30
Q

investigations for neuroleptic malignant syndrome ?

A
  1. elevated creatine kinase
  2. leucocytosis
  3. altered LFTs
31
Q

neuroleptic malignant syndrome differential diagnosis ?

A
  1. serotonin syndrome
  2. malignant hyperthermia
  3. encephalitis
  4. heat stroke
  5. catatonia
  6. cocaine/ amphetamine intoxication
  7. status epilepticus
32
Q

risk factors for neuroleptic malignant syndrome ?

A
  1. high potency first generation antipsychotics but is associated with all antipsychotics
  2. recent or rapid dose increases
    abrupt withdrawl of anticholinergic agents
  3. antipsychotic polypharmacy
  4. males
  5. younger age
  6. agitation
  7. dehydration
  8. psychosis
  9. organic brain disease
  10. alcoholism
  11. parkinsons disease
  12. hyperthyroidism
  13. psychomotor agitation
  14. intellectual disability
  15. co prescription of lithium. SSRIs also increase the risk
33
Q

management of neuroleptic malignant syndrome ?

A
  1. withdraw antipsychotics
  2. monitor temp/ HR / BP
  3. consider benzodiazepines e.g IM lorazepam
  4. rehydrate
  5. bromocriptine - DA receptor agonist
  6. dantrolene - muscule relaxant to reduce rigidity
  7. may need artificial ventilation
  8. may need to consider ECT for treatment of psychosis
  9. mortality rate of up to 10% even with treatment. higher if undiagnosed
34
Q

neuroleptic malignant syndrome - restarting antipsychotics?

A
  1. allow symptoms to fully resolve, at least 5 days
  2. rechallenge is associated with risk of recurrence
  3. consider using a different family of antipsychotic
  4. avoid depot/ LAI and high potency first generation antipsychotics
  5. start low, go slow
  6. monitor temp/bp/pulse/ C
35
Q

causes of serotonin syndrome ?

A
  1. psychotropic medication including
    - SSRI
    - MAOi
    - TCAs
    - SNRIs
    - antipsychotics
  2. Drug interactions
  3. recreational drug use e.g opioids, amphetamines, cocaine
  4. overdoses - accidental/ intentional
36
Q
A
37
Q

signs and symptoms of serotonin syndrome? mild, moderate, severe

A
  • can be broadly divided into autonomic, neuromuscular, and mental state
  • mild: high BP, tachycardia
  • moderate/severe: agitation, confusion, delirium, shivering, fever, diaphoresis, rigidity, myoclonus (intermittent jerking/ twitching), hyperreflexia, tremor, sweating, mydriasis, diarrhea, arrhythmia
  • risk of rhabdomyolysis and renal failure
38
Q

investigations for serotonin syndrome ?

A
  1. elevated creatinine kinase
  2. leucocytosis
39
Q

serotonin syndrome - differential diagnosis ?

A
  1. neuroleptic malignant syndrome
  2. anticholinergic toxicity
  3. discontinuation syndrome
  4. malignant hyperthermia
  5. encephalitis
  6. drug intoxication/ withdrawl
40
Q

serotonin syndrome risk factors ?

A
41
Q

management of serotonin syndrome ?

A
  1. withdraw offending agents
  2. monitor temp/BP/HR
  3. consider benzodiazepines
  4. rehydrate
  5. cyproheptadine - 5HT antagonist
42
Q

serotonin syndrome vs neuroleptic malignant syndrome ?

A
43
Q

treatment of depression - NICE guidelines

A
  1. mild depressive episode
    - life-style changes and stress management
    - psychotherapy is first line (supportive, CBT, IPT)
    - antidepressants are not significantly more effective than placebo
    - antidepressants used when no clear response to lifestyle and psychotherapy
  2. moderate depressive episode
    - antidepressants indicated for the treatment of moderate to severe depression
    - generic SSRI recommended as first line therapy
    - lifestyle changes
    - best results when combined with psychotherapy
  3. severe depressive episode
    - antidepressants recommended as first line therapy
    - addition of antipsychotic if psychotic symptoms e.g olanzapine/ quetiapine
    - psychotherapy e.g supportive or CBT
    - life-style changes
44
Q

what are the different classes of antidepressant medications?

A
  1. SSRI
  2. vortioxetine (SSRI activit, also modulates 5HT receptors
  3. SNRI
  4. Mirtazapine
  5. TCAs
  6. MAOis
45
Q

what are examples of SSRIs?

A
  1. citalopram
  2. escitalopram
  3. sertraline
  4. fluoxetine
46
Q

examples of SNRIs?

A
  1. venlafaxine
  2. duloxetine
47
Q

drug treatment algorithm for depression

A
48
Q

important to remember about antidepressants

A
49
Q

new and novel medications for depression ?

A
  1. Esketamine
    - nasal spray/IV
    - approved under supervision in US and Europe
    - for use only in refractory depression
  2. Brexanolone
    - IV formulation of allopregnanolone
    - positive allosteric modulator of GABAa receptor
    - shown efficacy in phase 3 trials
  3. Zuranolone
    - oral positive allosteric modulator of GABA a receptors
    - shown efficacy in phase 2 trials in MDD
  4. other medications and targets under investigation
    - psychedelic psilocybin
    - modulators of metabotropic glutamate receptors and AMPA receptors
    - immune inflammatory systems
    - opiodergic systems
50
Q

treatment algorithm of acute mania or hypomania ?

A
51
Q

factors that increase risk of lithium toxicity ?

A
  1. age
  2. physical illness (addison disease - salt)
  3. organic brain disease
  4. renal disease
  5. dehydration (vomitting and diarrhea, high summer temp)
  6. salt depletion
  7. interactions - thiazides, ACEi, NSAIDs
52
Q

over what concentration in blood does lithium cause toxicity ?

A

1.2-2 mmol/L

53
Q

manifestations of lithium and what concentration do they tend to occur at?

A
  • vomitting
  • diarrhea
  • coarse tremor
  • slurred speech/ dysarthria
  • muscle weakness/ twitching
  • ataxia
  • drowsiness
  • confusion
    ** these occur at concentrations of 1.2-2 mmol/L
  • hyperreflexia and hyperextension
  • nystagmus
  • renal impairment/ oligouria
  • convulsions
  • coma
  • death
    *these occur at concentrations > 2 mmol/L
54
Q

other uses of lithium

A
  1. can be used to raise WCC in those taking clozapine
  2. useful in the treatment and prophylaxis of steroid induced psychosis
55
Q

what are other mood stabilisers beside lithium ?

A
  1. sodium valproate
  2. lamotrigine
  3. carbamazepine
  4. antipsychotics
56
Q

indications for sodium valproate?

A
  • antiepileptic
  • acute mania
  • prophylaxis in BPAD
  • treatment of aggression
57
Q

side effects of sodium valproate ?

A
  • weight gain
  • tremor
  • thrombocytopenia
  • leukopenia
  • red cell hypoplasia (anemia)
  • liver failure
    *may be better tolerated than lithium
58
Q

what are the potential complications of sodium valproate in pregnancy?

A

it is a significant teratogen
- spina bifida
- ADHD
- cognitive impairment
*should not be prescribed to women under 50 years. full discussion and informed consent/ contraceptive required if prescribed

59
Q

baseline investigations needed when starting someone on sodium valproate?

A
  1. FBC
  2. LFTs
  3. weight/BMI
60
Q

monitoring for sodium valproate ?

A

monitor LFT regularly in first 6 months and FBC, LFTs and weight every 6 months thereafter

61
Q

indications for lamotrigine ?

A
  • antiepileptic and mood stabiliser
62
Q

side effects of lamotrigine ?

A
  • headaches
  • skin rash
  • tremor
  • poor sleep
  • GI upset
  • sedation
  • irritability
  • osteoporosis (with long term treatment)
63
Q

what is a rare but serious side effect of lamotrigine ?

A

steven johnson syndrome
- usually occurs early on in treatment or if dose increased too quickly
- increased risk if also on valproate

64
Q

can lamotrigine be continued in pregnancy ?

A
  • may be continued in pregnancy
  • baby will be observed for withdrawal symptoms
65
Q

what medication can lamotrigine interfere with?

A

OCP

66
Q

indications for carbamezapine?

A
  • antiepileptic
  • trigeminal neuralgia
  • prophylaxis of BPAD, 3rd line
67
Q

side effects of carbamezapine?

A
  • dry mouth
  • edema
  • hyponatremia
  • sexual dysfunction
  • rash
  • reduced WCC with risk of agranulocytosis and aplastic anemia
68
Q

investigations needed before starting someone on carbamazepine and during treatment

A
  • FBC, and U and E and LFT, weight at baseline
  • repeat these every 6 months
69
Q

carbamazepine and pregnancy?

A

it is a significant teratogen. must be prescribed with contraceptives

70
Q

carbamazepine and drug interactions ?

A

it is a known inducer of hepatic CYP enzymes, therefore can reduce the levels of most psychotropic medications and oral contraceptives

71
Q

antipsychotics as mood stabilisers ?

A
  • many possess sedative, anxiolytic, antimanic, mood-stabilising and antidepressant properties
  • olanzapine, risperidone, quetiapine, aripiprazole
  • most often combined with traditional mood stabilisers for optimal effect

Psychiatry (22 decks)

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