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Year 3 - Psychiatry > Psychopharmacology 1 + 2 > Flashcards

Psychopharmacology 1 + 2 Flashcards

1
Q

• Discuss the use and adverse effects of psychiatric drugs

Identify general pharmacologic strategies

Discuss antidepressants including indications for use and side effects

Describe mood stabilizers including indications for use and side effects

Review antipsychotics including how to choose an antipsychotic and side effects (none is better than the other; chosen based on side effect profile)

Identify anxiolytic classes and indications for use

A

.

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2
Q

What conditions are indicated for antidepressant use (5)

A

Unipolar and bipolar depression

Organic mood disorders

Schizoaffective disorder

Anxiety disorders including OCD, panic, social phobia

PTSD

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3
Q

No antidepressant Is better than another. The choice is based on past history of the response to the drug, side effects experienced and co-existing conditions

How much time delay is there before symptoms improve with antidepressants?

A

3-6 weeks of continuous medication

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4
Q

Classes of antidepressants (5)

A

Tricyclic antidepressants (TCAs)

Monoamine Oxidase Inhibitors (MAOIs)

Selective Serotonin Reuptake Inhibitors (SSRIs)

Serotonin/Noradrenaline Reuptake Inhibitors (SNRIs) or dual reuptake inhibitors

Novel antidepressants

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5
Q

Mode of action of TCAs

A

Inhibit reuptake of amines, mostly noradrenaline or serotonin

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6
Q

Give examples of side effects of TCAs

  • antihistaminic
  • anticholinergic
  • antiadrenergic
A

Sedation, weight gain

Dry mouth, dry eyes, constipation, memory deficits

Orthostatic hypotension, sedation, sexual dysfunction

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7
Q

TCAs are effective but what are the disadvantages (3)

A

Bad side effects - ‘dirty’ drugs
Lethal if overdosed
Lengthens QT interval

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8
Q

Tertiary TCAs have amine side chains which make them prone to what

A

Read with other types of receptors –> MORE SIDE EFFECTS

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9
Q

Examples of

  • tertiary TCAs (primarily block serotonin receptors)
  • secondary TCAs (primary block NA receptors)
A

Amitriptyline
Imipramine
Doxepin
Clomipramine

Desipramine
Nortriptyline

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10
Q

Mode of action of monoamine oxidase inhibitors (MAOIs)

A

Bind irreversibly to monoamine oxidase which inhibits its activity, thus preventing the breakdown of monoamine neurotransmitters (such as norepinephrine, dopamine, serotonin) and thereby increasing their availability (increased synaptic levels of it)

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11
Q

Side effects of MAOIs

A 
Orthostatic hypotension, 
Weight gain, 
Dry mouth, 
Sedation, 
Sexual dysfunction
Sleep disturbance
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12
Q

Drug interactions of MAOIs

A

HYPERTENSIVE CRISIS if taken with tyramine rich foods, e.g. cheese, red wine, processed meats, beans

SEROTONIN SYNDROME (abdo pain, diarrhoea, sweating, tachycardia, hypertension, myoclonus) if taken with medications that increase serotonin

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13
Q

Examples of MAOIS

A 
Selegiline
Rasagiline
Isocarboxazid
Phenelzine
Tranylcypromine
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14
Q

Mode of action of SSRIs

A

Block presynaptic serotonin reuptake
(increasing the extracellular level of serotonin by limiting its reabsorption (reuptake) into the presynaptic cell, increasing the level of serotonin in the synaptic cleft available to bind to the postsynaptic receptor)

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15
Q

Side effects of SRRIs

A 
GI upset
Sexual dysfunction (+30%)
Anxiety
Restlessness
Nervousness
Insomnia
Fatigue or sedation
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16
Q

Advantage of SSRIs

A

Little risk of cardiotoxicity when overdosed

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17
Q

What can develop when SSRIs are stopped

A

Discontinuation syndrome (agitation, nausea, disequilibrium and dysphoria)

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18
Q

Examples of SSRIs

A 
Paroxetine
Sertraline
Fluoxetine
Citalopram
Escitalopram
Fluvoxamine
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19
Q

Pros and Cons of PAROXETINE

A

Pros

  • Short half life
  • No active metabolite so no build up of the drug
  • good sedating effect for initial relief from anxiety and insomnia

Cons

  • Antihistaminic (sedating, weight gain), anticholinergic (dry mouth/eyes etc) side effects
  • Likely to cause discontinuation syndrome
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20
Q

Pros and cons of SERTRALINE

A

Pros

  • weak cytochrome P450 interaction
  • short half life
  • less sedating than paroxetine

Cons

  • max absorption requires full stomach
  • increased GI side effects
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21
Q

Pros and cones of FLUOXETINE

A

Pros

  • long half life so lower incidence of discontinuation syndrome
  • good for those with non-compliance issues
  • initially activating (ACTIVATION SYNDROME) so may provide increased energy

Cons

  • long half life and active metabolite may build up
  • significant P450 interactions
  • initial activation can increase anxiety + insomnia
  • can induce mania
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22
Q

Mode of action of Serotonin/Norepinephrine reuptake inhibitors (SNRIs) [dual reuptake inhibitors]

A

Inhibit both serotonin and noradrenergic reuptake like the TCAS but without the antihistamine, antiadrenergic or anticholinergic side effects

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23
Q

What conditions are SNRIs used for

A

Depression
Anxiety
Maybe neuropathic pain

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24
Q

Examples of SNRIs

A

Venlafaxine

Duloxetine

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25
Pros and cons of VENLAFAXINE
Pros - minimal drug interactions - short half life - fast renal clearance so avoids build up Cons - can increase BP - nausea - bad discontinuation syndrome - prolongs QT interval - sexual dysfunction side effects
26
Pros and cons of DULOXETINE
Pros -far less BP increase than velafaxine Cons - CYP2D6 and CPY1A2 inhibitor - cannot break drug capsule as active ingredient unstable in stomach
27
Examples of novel antidepressants
Mirtazapine | Buproprion
28
For a patient presenting with depression associated with hypersomnolence, would be appropriate to give a less sedating SSRI Name the less sedating ones (3)
Citalopram, Fluoxetine or Sertraline
29
If drug resistance occurs, what options are there?
Combine different antidepressants Add lithium Add atypical antipsychotic, e.g. quetiapine ECT
30
What conditions are indicated for use of mood stabilisers
Bipolar affective disorder Cyclothymia (alternating symptoms of depression and mania but not enough to be a major depressive episode or hypomania) Schizoaffective disorders
31
Classes of mood stabilisers (3)
Lithium Anticonvulsants Antipsychotics
32
Side effects of lithium* *good mania and depression long term prophylaxis
``` Fine tremor Dry mouth Altered taste Increased thirst Urinary frequency GI distress - reduced appetite, N/V, diarrhoea Hypothyroidism Leukocytosis Hair loss, acne Teratogenic - Ebstein's anomaly Nephrotoxic so avoid other nephrotoxic drugs ```
33
Blood therapeutic range of lithium should be between 0.6-1.2 Mild lithium toxicity = 1.5-2 What symptoms do you get?
vomiting, diarrhea, ataxia, dizziness, slurred speech, nystagmus
34
Moderate lithium toxicity = 2-2.5 What symptoms do you get?
nausea, vomiting, anorexia, blurred vision, clonic limb movements, convulsions, delirium, syncope
35
Moderate lithium toxicity = >2.5 What symptoms do you get?
generalized convulsions, oliguria and renal failure
36
Name some anticonvulsants
Valproic acid Carbamazepine Lamotrigine
37
Side effects of valproic acid
Thrombocytopenia and platelet dysfunction Nausea, vomiting, weight gain Sedation, tremor Increased risk of neural tube defect (very little) Hair loss
38
Before starting any mood stabilisers, what baseline investigations should be done
``` U+Es LFTs - then 6 monthly TFTs - then 6 monthly FBC Pregnancy test ```
39
The anticonvulsant, carbamazepine, is the 1st line agent for treating (2)
Acute mania | Mania prophylaxis
40
Side effects of carbamazepine
Rash - COMMONEST Nausea, vomiting, diarrhea Sedation, dizziness, ataxia, confusion AV conduction delays
41
Drugs that interact with carbamazepine and increase its level/toxicity
acetazolamide, cimetidine, clozapine, diltiazem, INH, fluvoxamine erythromycin, clarithromycin, metronidazole fluconazole, itraconazole, ketoconazole
42
Side effects of lamotrigine
Nausea/vomiting Sedation, dizziness, ataxia and confusion If severe - TEN, SJS
43
Drugs that interact with lamotrigine and increase its levels
Valproic acid | Setraline
44
What does the term 'rapid cycler' mean
4 or more depressive or manic episodes/year
45
What anticonvulsants are indicated for rapid cyclers (4 or more depressive or manic episodes/year)
Valproic acid | Carbamazepine
46
Anticonvulsants often increase baseline LFTs but don't need to change or stop drug unless
LFTs have tripled from baseline
47
What conditions are indicated for antipsychotic use (5)
``` Schizophrenia, Schizoaffective disorder, Bipolar disorder Psychotic depression, Augmenting agent in treatment resistant anxiety disorders ```
48
Key pathways affected by dopamine in the brain (4)
Mesocortical Mesolimbic Nigrostriatal Tuberoinfundibular
49
Describe the mesocortical pathway - anatomy - gives rise to what kind of symptoms - too much or too little dopamine in this pathway in psychotic patients
Projects from the ventral tegmentum (brain stem) to the cerebral cortex. Felt to be where the negative symptoms and cognitive disorders (lack of executive function) arise Problem - TOO LITTLE dopamine
50
Describe the mesolimbic pathway - anatomy - gives rise to what kind of symptoms - too much or too little dopamine in this pathway in psychotic patients
Projects from the dopaminergic cell bodies in the ventral tegmentum to the limbic system. Where the positive symptoms come from (hallucinations, delusions, and thought disorders). Problem - TOO MUCH dopamine
51
Describe the nigrostriatal pathway - anatomy - regulation of what - what happens when this pathway degenerates
Projects from the dopaminergic cell bodies in the substantia nigra to the basal ganglia. Pathway is involved in movement regulation. Degeneration of substantia nigra --> decreased dopamine production --> dopamine hypoactivity --> cause Parkinsonian movements i.e. rigidity, bradykinesia, tremors, akathisia and dystonia.
52
Describe the tuberoinfundibular pathway - anatomy - dopamine release in this pathway regulates what - what happens if dopamine is blocked in this pathway
Projects from the hypothalamus to the AP Inhibits/regulates prolactin release. Blocking dopamine in this pathway will predispose to hyperprolactinemia (gynecomastia/galactorrhea/decreased libido/menstrual dysfunction).
53
If wanting to start an antipsychotic, ideally would start with a typical or atypical
Atypical
54
'Typical' antipsychotics are D2 dopamine receptor antagonists What side effect profile do these have?
Extrapyramidal side effects (due to excessive DA blockade) - akathasia - restless - parkinsonism - tremor, slow movements, rigid, stiffness - tardive dyskinesia - uncontrollable facial movements - acute dystonias - muscles involuntarily contract
55
Examples of typical antipsychotics
High potency: - Fluphenazine, - Haloperidol, - Pimozide Low potency: - Chlorpromazine, - Thioridazine
56
Atypical antipsychotics are serotonin-dopamine 2 antagonists (SDAs) 'Atypical' because they affect dopamine AND serotonin neurotransmission in the 4 key dopamine pathways in the brain What side effect profile do these have?
``` Sedation Weight gain Hyperprolactinaemia Drowsy Agitated Dry mouth Blurred vision Menstrual abnormalities Hypotension Abnormal LFTs Hypertriglyceridemia, hypercholesterolemia, hyperglycemia ```
57
Examples of atypical antipsychotics
Risperidone - can still cause akathisia EPSE despite being an atypical, hyperprolactin Olanzapine* Quetiapine* Apriprazole - no weight gain, low sedation! Clozapine - for treatment resistant patients *can cause hypercholesterolaemia so avoid in those with high cholesterol
58
Antipsychotic drug given for treatment resistant patients
Clozapine
59
What is the only psychiatric emergency condition
Neuroleptic Malignant Syndrome (NMS) | -characterised by severe muscle rigidity, fever, altered mental status, autonomic instability
60
To overcome extrapyramidal side effects of, usually, typical antipsychotics, what type of drug is given
Anticholinergics Dopamine facilitators Beta blockers
61
What baseline bloods to do before starting an antipsychotic
Fasting lipid profile Fasting blood sugar LFTs FBC
62
What conditions are indicated for anxiolytic* use (3) *not great
Panic disorder, Generalized Anxiety disorder - used alongside SSRI or other Substance-related disorders and their withdrawal, insomnias and parasomnias
63
Example of an anxiolytic
Buspirone
64
What conditions are indicated for benzodiazepine use (4)
Insomnia, Parasomnias, Anxiety Withdrawal syndromes
65
Side effects of benzodiazepines
``` Somnolence Cognitive deficits Amnesia Disinhibition Tolerance Dependence ```
66
Examples of benzodiazepines
Diazepam | Lorazepam
67
TRUE OR FALSE A) Typical antipsychotics are more effective in controlling the positive symptoms of schizophrenia than the atypicals B) Atypicals have less side-effects than the typicals C) Atypicals cause no EPSE (extra-pyramidal side effects) D) Only Clozapine has been shown to cause no Tardive Dyskinesia E) Atypical Antipsychotics are only indicated in the treatment of schizophrenia
``` F F F T F ```
68
Only antipsychotic to not cause tardive dyskinesia
Clozapine
69
Side effects of clozapine
``` Neutropenia Seizures Idiopathic hyperthermia Weight gain Hypersalivation ```
70
Psychiatric drugs can directly cause physical disease. 3 main conditions to be aware of:
Weight Gain and Obesity (esp clozapine + olanzapine) Diabetes Metabolic Syndrome (syndrome of Obesity, Hypertension, Dyslipidaemia and Abnormal Glucose Metabolism) 3 or more of: -BP >130/85 -Serum HDL Cholesterol >1.04 (male) or >1.29 (female) -Serum Triglyceride >1.69 -Fasting Glucose >6.1 -Waist Circumference >102cm (male) or >88cm (female)
71
Cardiac effects of antipsychotics
Prolong QTc interval --> torsade de pointes
72
Baseline tests before starting antipsychotics
BMI | ECG
73
What to monitor for on ECG with antipsychotic use
QTC prolongation
74
Lithium levels should be monitored how often
Weekly after initiation and after each dose change until concentrations are stable, then every 3 months for the first year
75
Symptoms of lithium toxicity
``` Vomiting and diarrhoea Coarse tremor (larger movements, especially of hands) Muscle weakness Lack of coordination including ataxia Slurred speech Blurred vision Lethargy Confusion Seizures ```

Year 3 - Psychiatry (7 decks)

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