Psychopharmacology Flashcards
What two types of antipsychotics are there, and under the typical what two levels are there?
Typical antipsychotics:
- high potency = haloperidol, fluphenazine
- low potency = thioridazine, chlorpromazine
(MOA: primarily D2 dopamine receptor antagonists, effective for +ve symptoms of schizophrenia)
Atypical antipsychotics
- risperidone, quetiapine, olanzipine, aripiprazole, clozapine
Currently FIRST LINE FOR SCHIZOPHRENIA (fewer EPS + anti cholinergic effects) clozapine reserved for severe treatment resistance and severe tardive dyskinesia
What are the main side effects of the class of Typical antipsychotics: haloperidol, fluphenazine vs thioridazine, chlorpromazine ?
High potency e.g. haloperidol =
- EXTRA PYRAMIDAL SX e.g. Dystopia, akinesia, akathisia
- QT prolongation, torsades
- Neuroleptic malignant syndrome
Low potency e.g. Chlorpromazine =
1. ANTICHOLINERGIC (dry mouth, urinary retention, constipation)
2. More sedative
3. Inc risk of orthostatic hypotension
(Thioridazine causes QT prolongation and irrev. Retinal pigmentation
What are some side effects of atypical antipsychotics? In particular that of clozapine?
Weight gain, T2DM, somnolence, sedation, QTc prolongation.
Clozapine (used for severe treatment resistance and severe tardive dyskinesia) can cause agranulocytosis, requiring weekly FBE monitoring during first 6 months of neutrophil levels.
What are the 4 main categories of Extra pyramidal symptoms?
Acute dystonia - prolonged painful tonic muscle contraction or spasm e.g. Torticollis (hours)
Dyskinesia - Pseudoparkinsonism (shuffling gait, cogwheel rigidity) (days)
Akathisia - subjective/objective restlessness that is perceived as being distressing (weeks)
Tardive dyskinesia - stereotypic involuntary painless oral facial movements. Probably from dopamine receptor sensitization from chronic dopamine blockade. Often irreversible (months)
What is neuroleptic malignant syndrome ?
Fever, muscle rigidity, autonomic instability, elevated CK and WBC, clouded consciousness
Can happen anytime from antipsychotics (commonly high dose haloperidol)
What are the four main classes for anxiolytics medication?
- SSRI (fluoxetine, sertraline, paroxetine, citalopram). Indicated for General anxiety disorder, OCD, panic disorder. S/E nausea, GI upset, somnolence, sexual dysfunction, agitation.
- Buspirone. Indicated for GAD, social phobia. No tolerance, dependence or withdrawal. S/E seizures with chronic use
- B-blockers. Indicated for Phobic disorders (best when given prior to exposure). S/E bradycardia, hypotension
- Benzodiazepines. Indicated for anxiety, insomnia, ETOH withdrawal, muscle spasm, night terrors, sleepwalking. S/E risk of abuse, tolerance, dependence, disinhibition, confusion, decrease sleep.
What are the main 5 classes used in common anti-depressants?
SSRIs (fluoxetine, sertraline paroxetine, citalopram)
Atypicals (bupropion mirtazapine, trazodone)
SNRIs (cenlafaxine, duloxetine)
TCA (nortriptyline, desipramine, amitryptyline, imipramine)
MAOIs (phenelzine, tranylcypromine, selegiline)
Indications and Side effects of
- SSRI
- Atypical antidepressants and
- SNRIs
- SSRI Indication: Depression, anxiety. S/E: sexual, GI distress, agitation, insomnia, tremor, diarrhea. SEROTONIN SYNDROME (fever, myoclonus, mental state changes, CDV collapse) can occur if SSRI is used with MAOI, illicit drugs or herbal medication.
(Paroxetine can cause pulmonary HTN in fetus, avoid in pregnancy) - Atypical antidepressants Indication depression, anxiety. Side effects: Bupropion - decrease seizure threshold, CIx in eating disorders and seizure pt.
Mirtazapine - weight gain, sedation
Trazodone - highly sedating, priapism - SNRI IndicationL depression, anxiety and chronic pain.
Venlafaxine S/E diastolic hypertension
What are the indications and side effects of TCAs and MAOIs.
TCA:
Indication - depression, anxiety, chronic pain, migraine headaches, enuresis.
S/E - lethal overdose resulting from cardiac conduction arrhythmia (long QRS). Anticholinergic effects (dry mouth, constipation, urinary retention, sedation.
NB: TCA toxicity is the 3Cs. Coma, convulsions, cardiac arrhythmia
MAOI
Indication: depression, especially atypical
S/E: Hypertensive crisis if taken with high tyramine food, cheese wine
Sexual side effects, orthostatic hypotension, weight gain
What are the four main type of drugs for Mood disorders?
- Lithium (first line mood stabilizer)
- Carbamazepine (second line mood stabilizer, Trigem neuralgia, anticonvulsant)
- Valproate acid (BPD, anticonvulsant)
- Lamotrigine (second line mood stabilizer, anticonvulsant)
What are the indications and side effects of Lithium ?
Lithium is used as a first line mood stabilizer in acute mania (with antipsychotics), for prophylaxis in borderline personality disorder, and for augmentation in depression treatment.
Lithium side effects include: thirst, polyuria, diabetes insipidus, tremor, weight gain, hypothyroidism, nausea, diarrhea, seizures, teratogen, acne, vomiting.
Li has a narrow therapeutic window, 0.6-1.0, but blood levels can be monitored. Toxic levels are >1.5mEq/L. Presents with ataxia, dysarthria, delirium, acute renal failure.
Name three side effects of clozapine
Agranulocytosis
Myocarditis
Constipation
Hypersalivation
Escitalopram- S/E
Prolonged QT interval
Paroxetine (lavapro) S/E
Sexual dysfunction
Sertraline (Zoloft) S/E
GI upset
Duloxetine use
best for back pain
Bows SIGHSS S/E of SSRI
Bleeding Orthostatic Hypotension Weight Gain Sexual dysfunction Sedation or agitation Insomnia GI upset Hyponatraemia Serotonin syndrome Sweating
Mirtazapine (Avanza) S/E
Good for insomniac and weight loss depressed patients
SNRI vs SSRI
SNRI = hypertension , more effective and toxic than SSRI
TCA S/E HAM + CCC
Anti histamine - sedation
Anti adrenergic - orthostatic hypo, tachycardia, arrhythmias,
Anti muscarnic - anti SLUDGE
Convulsion, Coma, Cardiotoxicity
Lithium Side effect - (T x6)
Thirst hypoThyroidism Tremor Tone (muscle tremor) Thinking (mild cognitive impairment) Toxicity
Lithium Toxicity Side effect
GAIT
GI disturbance
Ataxia
Impaired concentration
Tremor - coarse
What tests to monitor Li? (4 tests)
Lithium levels
PTH
UEC/ eGFR
TFT
Carbamazepine and Sodium Valproate - main S/E
Teratogenicity
Carbamazepine - agranulocytosis
Sodium valproate - liver toxicity
Management of Bipolar Disorder?
Acute mania - Li + AGAP
Prophylaxis - Li
Depression - Li + Anti depressant OR SGAP
Olanzapine - (Zypreza) S/E
WEIGHT
Quetiapine (Seroquel) S/E
Sedating zzz, wide used in Parkinson’s
Aripiprazole (Abilify) S/E
least sedating
Clozapine S/E and monitoring
Cardiomyopathy-Trops/CRP, ECG, Echo
Agranulocytosis + neutropenia - FBE
Metabolic Effects- Lipid
Liver kidney effects - LFT UEC
What two tests go with each category
- Weekly for 18 months then monthly:
- 3 months then every 6 months:
- Annually?
Weekly for 18 months then monthly: - Troponins and CRP - FBE 3 months then every 6 months: - ECG - Lipids Annually - Echo - LFT UEC
Temazepam
Medium acting - used for insomnia
Oxazepam
Short acting -Plane flights, before surgery
Diazepam
Long acting, anxiety and alcohol withdrawal
Propanolol
Short term use for performance anxiety
Antipsychotic for induced muscle spasm
Benztropine
Agitation and refusal of oral medication
Midazolam
can be buccal for kids or IM
Antipsychotic for psychosis in Parkinson’s
Quetiapine
Prevention of progression of mild cognitive impairment
donepezil (cholinesterase inhibitor)
Galantamine
Antidepressant of choice for back pain
TCA (or duloxetine)
Antidepressant causing confusion on hot day in elderly woman
Escitalopram (hyponatraemia)
Antidepressant causing +++ weight gain and sedation
MIrtazapine
Antipsychotic causing most EPSE
haloperidol
Drug causing delirium post MVA
Diazepam ?
Diuretics and NSAIDs cause toxicity
lithium
Clozapine + SOB
FBE?
