Psychopharmacology 2 Flashcards
When would you use a mood stabiliser
Bipolar disorder
Cyclothymia (sub clinical depression)
Schizioaffective
Lithium, anticonvulsants, antipsychotics
What is lithium
Only medication to reduce suicide rates
Effective in long term prophylaxis or long term and manic episodes
What to do before lithium use
U&E’s toxic to kidneys, causes small vessel damage, causes thyroid dysfunction so do TFT
Causes Epstein’s abnormality- females of childbearing age this is a problem,don’t give to woman of childbearing age but if you have to get pregnancy test
What is it therapeutic range?
Blood level between 0.6-1.2
A steady state is achieved after 5 days, check 12 hours after last dose. Once stabilised check every 3 months and TFT and creatinine every 6 months
What are the side effects of lithium
Hypothyroidism/ thyroid abnormalities
Polyuria
GI stress, reduced appetite, nausea and vomiting
Thyroid abnormalities
Non-significant leukocystosis
Polyuria/polydypsia secondary to ADH antagonism
Hair loss, acne
Reduces seizure threshold, cognitive slowing
What is the main side effects of lithium toxicity
Quite toxic,
Mild- vomiting, dizziness, ataxia, dizziness, slurred speech, nystagmus
Moderate-2.0-2,5 nausea, vomiting, anorexia, blurred vision, clonic limb movements, convulsions, delirium, syncope
Severe>2.5 generalised convulsions, oliguria and renal failure
What is valproic acid
When do you use it
Anticonvulsant
Effective as lithium in mania but not so good in depression
Use in
Rapidcycline patients (females>males)
Co-morbid substance issue
Patients with co-morbid anxiety disorders
What is done before starting valproic acid
How do you monitor an individual on valproic acid
LFT, pregnancy test, FBC
Monitoring- steady state achieved after 4-5days, check 12 hours after last dose and repeat CBC and LFT’s
Target 50-125
What are the side effects of valporic acid?
Thrombocytopenia and platelet dysfunction
nause vomiting and weight gain
Sedation tremor
Increased risk of neural tube defect due to reduction of folic acid
Hair loss
What is carbamazepine
FIRST LINE FOR MANIA
Indicated for rapid cyclers and mixed patients?
What should you do before starting carbamazepine
LFT, FBC, ECG
Target 4-12mcg/ml
Steady state achieved after 5 days, check 12 hours after last dose and then repeat CBC and LFT’s
Need to check dose and adjust after a month as this induces its own metabolism
What are the side effects of carbamazepine
Rash most commonly seen Nausea,vomiting, diarrhea Sedatoin, dizziness, ataxia, confusion AV coduction delays Aplastic anemia and agranulocytosis Water retention due to vasopressin like which result in hyponatremia Drug-drug interactions
What are the drug to drug interactions of carbamazepine
Do you need to know ? Very extensive
What is lamotrigines side effects?
Nausea and vomiting
Sedation, dizziness, ataxia and confusion
Most sever are toxic epidermal necrolysis and Steven Johnson’s syndrome.
What are approved indications for bipolar diesel
Consult that table
When use antipsychotics
When am individual is in a manic phase,
particularly manic with psychotic symptoms
How would you treat a 33y/o female with a singke episode of mania, no previous hsitory of deperssive episoed.No drug or ETOH history and has no medical issues.
She develops mild diarrhoea, does this change you management?
Stistically first presentation of mania will do best of lithium
Check pregnancy test, serum creatnine, and TSH before treatment
this is common in early treatment, encourage to drink plenty
How would you treat a 27 year old wih 5-6 manic and depressive episodes a year. Struggles with alcohol abuse
His LFT’s increase on treatment What do you do?
Depakote due to patient having many cycles (4 or more per year) and because of alcohol abuse
Not unusual for LFT’s to increase adn as long as they do not more than triple then therapy is indicated
What are antipsychotics
Drugs used to reduce psychosis. For diseases such as
Schizophrenia
Schizoaffective disorder
Bipolar disorder
Used for mood stabilisation and/or when psychotic features are present, psychotic depression, augmenting agent in treatment resistant anxiety disorders
What is the mesocortical pathway?
Projects from the ventral tegmentum (brain stem) to the cerebral cortex. This pathway is felt to be where the negative symptoms and cognitive disorders arise.
Problem here for psychotic patients is too little dopamine
What is the Mesolimbic pathway?
Where the positive symptoms come from (hallucinations, delusions and thought disorders) due to too much dopamine.
Projects from the dopaminergic cell bodies in the brain stem to the limbic system. Problem here in a psychotic patient is there is too much dopamine
What is the nigrostriatal system?
Projects from the dopaminergic cell bodies in the substantia nigra to the basal ganglia. This pathway is involved in movement regulation. Remember that the dopamine suppresses acetylcholine activity.
Dopamine hypoactivity causes parkinsonian movements i.e. rigidity, bradykinesia, tremors, akathisia and dystonia
What is the tuberoinfundibular pathway
Projects from the hypothalamus to the anterior pituitary. dopamine regulates (inhibits) prolactin release. Blocking dopamine in this pathway will predispose your patient to hyperprolactinemia
(gyeacomastia, galactorrhea, decreased libido. menstrual dysfunction)
There are two types of anti psychotics. What is type 1?
Typical anti psychotics.
D2 dopamine receptors antagonists
High potency typical antipsychotics bind to the D2 receptor with a high affinity, as a result they have higher risk of extrapyramidal side effects
What about low potency typical antipsychotics ?
They have less affinity for the D2 receptors but tend to interact with nondopaminergic receptors resulting in more cardiotoxic and anticholinergic adverse effects including sedation and hypotension
examples include chlorpromazine and thioridazine
What are some examples of typical antipsychotics?
Fluphenazine, Haloperidol, Pimozide
What are atypical antipsychotics
They are serotonin- dopamine 2 antagonists. They are considered atypical as they affect dopamine and serotonin neurotransmission in the four key dopamine pathways in the brain
Discuss resperidone
An atypical antipsychotics used regularly
Rapidly dissolving tablets or IM injection
Functions more like a typical antipsychotics
Increased extrapyramidal side effects
Most likely atypical to induce hyperprolactinemia
Discuss olanzapine
Regularly used atypical antipsychotic
Tablet or IM injection Works slightly quicker than others Causes weight gain (30-50lbs) May cause hypertriglyceridmeia, hypercholesterolemia, hyperglycemia May cause hyperprolactinemia (
Discuss quetiapine
Available in regular tablet form only
May cause abnormal LFT’s (6%) of all aptients
May be associated with weight gain, though less eevre than olanzapine
May cause hypertriglyceridmeia, hypercholesterolemia, hyperglycemia (less than seen with olanzapine)
Discuss aripiprazole
Available in regular tabs, immediate release IM formulation and depo form.
Unique mechanism of action as a D2 partial agonist
Low EPS no QT prolongation, low sedation
Interacts with fluoxetine and paroxetine, carbamezapine and ketoconazole
Not associated with weight gain
What to know for exams (antipsychotics)
Antipsychotics- atypical - new type
Typical- old type
Side effects-
How do you pick your antipsychotic
Side effects
What drug do you use for treatment resistant psychosis
Treatment resistance- tried 2 drugs and not worked
Clozapine
Available in an oral form
What are the side effects of clozapine:
Agranulocytosis- need blood tests every week for 6 months and then 2 weeks for the next 6 months
Increased risk of seizures (especially if lithium is also on board)
Associated with the most sedation, weight gain and abnormal LFT’s
May cause hypertriglyceridmeia, hypercholesterolemia, hyperglycemia
What is clozapine doesn’t work?
Add another antipsychotic to clozapine
Add lithium/anticonvulsant
ECT
