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Psychotropic medications Flashcards

1
Q

Examples of SSRIs

A

Citalopram, Escitalopram, Sertraline, Fluoxetine, Fluvoxamine, Paroxetine

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2
Q

Contraindications/precautions to SSRIs

A

High bleeding risk, high risk for angle-closure glaucoma, bipolar disorder, concurrent treatment with other antidepressants (especially MAOIs)

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3
Q

Safety of SSRIs in pregnancy and breastfeeding

A

Category C in pregnancy - DON’T USE (use in 3rd trimester may also cause withdrawal in newborn)

Considered safe in breastfeeding, especially sertraline due to low levels in breast milk - potential drowsiness and irritability in newborn

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4
Q

Side effects of SSRIs

A

SSRI:
Serotonin syndrome
Stimulate CNS (tremor, headache, agitation)
Reproductive dysfunction (reduced libido, impotence)
Insomnia
+ GIT (nausea, diarrhoea)

Significant: hepatitis, increased QT interval, SIADH, abnormal platelet aggregation, acute angle-closure (esp paroxetine), EPS

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5
Q

Zoloft generic name

A

Sertraline

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6
Q

Lexapro generic name

A

Escitalopram

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7
Q

Prozac generic name

A

Fluoxetine

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8
Q

Indications for SSRIs

A

Major depression
Anxiety disorders (Panic disorder, OCD)
Bulimia nervosa
Premenstrual dysphoric disorder

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9
Q

Indications for SNRIs

A

Major depression

duloxetine also indicated in general anxiety disorder and second line in painful diabetic peripheral neuropathy

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10
Q

Contraindications/precautions of SNRIs

A 
CrCl less than 30 (reduced dose)
Hepatic impairment
Bipolar
Epilepsy/increased risk of seizures
High bleeding risk
High risk of angle-closure
High risk of overdose (esp avoid venlafaxine)
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11
Q

Safety of SNRIs in pregnancy and breastfeeding

A

Category B2 - limited studies, use in 3rdT can cause withdrawal in newborns

Low concentrations in breast milk, monitor baby for sedation and FTT, consider using alternative to duloxetine until more data

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12
Q

Side effects of SNRIs

A

Common: Nausea, constipation, dry mouth, sexual dysfunction, sweating, dizziness, headache, reduced appetite, rash

Significant: seizures, myositis, Takotsubo, SIADH, orthostatic hypotension, urinary retention (duloxetine), Steven-Johnson, increased bleeding

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13
Q

Monitoring patient on SNRI

A

Check baseline BP and regularly after commencement for rise
Baseline Na then monitoring soon after commencement especially at risk patients(e.g. elderly)
Monitor frequently and carefully early in treatment for suicidal thoughts and behaviours

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14
Q

Monitoring patient on SSRI

A

Baseline sodium and soon after starting treatment if risk of hypoNa e.g. elderly
Monitor frequently early in treatment for suicidal thoughts and behaviours

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15
Q

Indications for mirtazapine

A

Major depression, especially useful where insomnia or anorexia are prominent features

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16
Q

Mechanism of action of mirtazapine

A

Blocks post-synaptic serotonin receptors and presynaptic alpha-adrenergic receptors

Also a potent H1 antagonist (causes sedation)

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17
Q

Contraindications/precautions to use of mirtazapine

A

Treatment with, or within 14 days of stopping, a MAOI
Epilepsy/increased risk of seizures
Phenylketonuria
Bipolar

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18
Q

Drug class of mirtazapine

A

Serotonin noradrenaline disinhibitor

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19
Q

Side effects of mirtazapine

A

Common: increased appetite, weight gain, sedation, weakness, peripheral oedema

Significant:
Mania, seizures, agranulocytosis, granulocytopaenia

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20
Q

Dosing of mirtazapine

A

Initial dose 15mg nocte - increase to 30-45mg nocte as indicated
Max. dose 60mg nocte
Withdraw over at least 1-2 weeks to minimise withdrawal symptoms

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21
Q

Indications for monoamine oxidase inhibitors

A 
Major depression (third line)
Some anxiety disorders, including phobic disorders and panic disorders
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22
Q

Examples of SNRIs

A

Venlafaxine, desvenlafaxine, duloxetine

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23
Q

Generic name of Efexor

A

Venlafaxine

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24
Q

Generic name of Pristiq

A

Desvenlafaxine

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25
Generic name of Cymbalta
Duloxetine
26
Examples of MAOIs
Phenelzine Tranylcypromine Moclobemide - selective for type A (second line)
27
Mechanism of action of MAOIs
IRREVERSIBLE inhibition of monoamine oxidase A and/or B - increased synaptic concentrations of adrenaline, noradrenaline, dopamine and serotonin
28
Contraindications/precautions to using MAOIs
Catecholamine-secreting tumours (e.g. phaeochromocytoma) Cerebrovascular or cardiovascular disease Angina/CAD (may reduce pain associated with MI) Epilepsy/high risk of seizures Bipolar Diabetes (may reduce BGL) Significant liver disease
29
Safety of MAOIs in pregnancy and breastfeeding
Category B2/3 - avoid in pregnancy until more data Moclobemide appears safe in breastfeeding, limited data for other MAOIs
30
Side effects of MAOIs
Common: Orthostatic hypotension, sleep disturbance, headache, drowsiness, weakness, myoclonus, agitation, tremors/twitching, sexual dysfunction (less likely with moclobemide), nausea, diarrhoea/constipation Significant: hypertensive crisis (usually precipitated by tyramine or med interactions), SIADH, hepatic damage, blurred vision
31
Usage guidelines for MAOIs
Best taken with food. Best to take last dose before 3pm (reduce sleep disturbance) Avoid tyramine containing foods, including for 2 weeks after ending treatment: (matured or out of date cheese, aged meat products e.g. salami, protein extracts, yeast extracts e.g. vegemite, soy bean extracts e.g. tofu, miso)
32
Monitoring during use of MAOIs
Monitor frequently early in treatment for suicidal thoughts and behaviours Monitor BP
33
Withdrawal symptoms of MAOIs
Nausea, vomiting, panic, hallucinations Post-phenelzine: seizures, psychosis Post-tranylcypromine: delirium
34
Indications for TCAs
Major depression OCD, Panic disorder, cataplexy Pain relief adjunct, migraine prophylaxis (amitriptyline) Nocturnal enuresis, urinary incontinence
35
Examples of TCAs
Amitriptyline, nortriptyline, dothiepin, imipramine, clomipramine
36
Generic name for Endep
Amitriptyline
37
Mechanism of action of TCAs
Inhibit reuptake of NorAd and serotonin into presynaptic terminals Also block cholinergic, histaminergic, alphar-adrenergic and serotonergic receptors - unrelated to therapeutic effects
38
Contraindications/precautions to TCA therapy
Prostatic hypertrophy (may precipitate retention), risk of acute angle-closure, hyperthyroidism, epilepsy/risk of seizures, heart block or post-MI, coronary artery disease, orthostatic hypotension, Long QT, bipolar, suicidal ideation or high risk of overdose, hepatic impairment
39
Safety of TCAs in pregnancy and breastfeeding
Category C i.e. do not use in pregnancy | Can be used while breastfeeding (avoid doxepin - neonatal respiratory depression)
40
Side effects of TCAs
Common: sedation, dry mouth, blurred vision, mydriasis, weight gain, constipation, orthostatic hypotension, urinary retention, sexual dysfunction, dizziness, sweating, insomnia, anxiety, confusion Significant: arrhythmias, raised IOP, SIADH, seizures, hepatitis, paralytic ileus
41
Usage of TCAs
Take at night to reduce daytime drowsiness Dosing same for all TCAs in major depression: Initially 25-75mg, increase by 25-50mg every 2-3 days to 75-150mg daily May split to BD dosing Max dose 300mg/day
42
Indications for melatonin agonists
Major depression
43
Example of melatonin agonists
Agomelatine (valdoxan)
44
Generic name for Valdoxan
Agomelatine
45
Mechanism of action of agomelatine
Unclear : melatonin receptor agonist, serotonin receptor antagonist
46
Contraindications/precautions to agomelatine therapy
Bipolar disorder Hepatic impairment Elderly over 75y
47
Safety of agomelatine in pregnancy
Category B1 - very little data i.e. discourage use | No data re: breastfeeding, therefore avoid in breastfeeding mothers
48
Side effects of agomelatine
Increased aminotransferases, dizziness, abdo pain Significant: hepatitis, blurred vision
49
Monitoring of patients on agomelatine
Baseline LFTs, then at 3, 6, 12, 24 weeks after starting/dose increase. Cease if increase to over 3 times upper limit of normal
50
Indications of lithium
Prevention of manic or depressive episodes in bipolar disorder Treatment of acute mania Schizoaffective disorder Chronic schizophrenia (rarely used) Augmentation for treatment-resistant depression
51
Types of lithium available
Normal release "Lithicarb" | Slow release "Quilonum SR"
52
Mechanism of action of lithium
Inhibition of dopamine release, enhancement of serotonin release, reduced formation of intracellular second messengers
53
Contraindications/precautions to lithium treatment
``` Hyponatremia (inc. Li conc) Hypothyroidism Psoriasis Treatment with drugs that may contribute to serotonin toxicity Reduced CrCl (renally reduced dose) Pregnancy ```
54
Safety of lithium in pregnancy/breastfeeding
Category D - TERATOGENIC Avoid in breastfeeding
55
Side effects of lithium
``` LITHIUM: Lethargy/Leucocytosis Intention tremor Teratogenicity (Ebstein's anomaly) Hypothyroidism Insipidus (DI, nephrotoxicity, RTA, Nephrotic syndrome) Urine Excess (polyuria without DI) Metallic taste ``` + GI symptoms (nausea, diarrhoea, epigastric discomfort)
56
Therapeutic range of lithium
Acute mania: 0.5-1.2mmol/L Prophylacis: 0.4-1mmol/L
57
Lithium toxicity concentration and presentation
Serum Li higher than 1.5 (1.2 in elderly) GI symptoms (nausea, vomiting, cramping, diarrhoea) Neuromuscular signs (tremor, dystonia, hyperreflexia, ataxia) T wave flattening
58
Lithium monitoring
Measure serum Li 5-7 days after commencing treatment, and after every dose change until stabilised, then every 3 months Monitor more frequently during illness, manic/depressive periods, pregnancy Take level at least 8-12 hours after last dose
59
Mood stabilising medications
Lithium Sodium Valproate Carbamazepine Lamotrigine
60
Indications for sodium valproate
Epilepsy Bipolar disorder Migraine prophylaxis (when other treatments have failed)
61
Brand names for sodium valproate
Epilim, valpro
62
Contraindications to sodium valproate therapy
Pancreatic dysfunction Porhypria Urea cycle disorders POLG gene mitochondrial disorders
63
Sodium valproate in pregnancy and breastfeeding
Category D pregnancy (spina bifida/other neural tube defects), monitor closely with 5mg folic acid supplementation Should be safe in breastfeeding
64
Side effects of sodium valproate
``` VALPROATE Vomiting Alopecia (usually temporary) Liver toxicity Pancreatitis, pancytopenia Retention of fat (weight gain) Oedema (peripheral) Appetite increase Tremor Enzyme inducer (liver) ```
65
Normal doses of valproate for bipolar
Initial dose 300mg BD, maintenance 1-2g daily
66
Brand name for carbamazepine
Tegretol
67
Contraindications for use of carbamazepine
AV conduction abnormalities History of bone marrow depression Porphyria
68
Precautions in valproate therapy
Diabetes - use sugar-free oral liquid or tablets (epilim syrup contains a lot of sucrose) Avoid if possible in hepatic impairment and pregnancy
69
Major drug interactions with carbamazepine
Thyroxine: may need to increase thyroxine dose due to increased metabolism COCP: reduced COCP concentration, therefore use alternative contraceptive method Clozapine: increased risk of serious haematological adverse effects Warfarin: monitor INR and increase warfarin as needed (may need to be doubled)
70
Safety of carbamazepine in pregnancy and breastfeeding
Category D: spina bifida, minor craniofacial defects, developmental disability - give with 5mg folic acid supplementation if cannot avoid. CAN ALSO CAUSE VIT K DEF IN NEWBORN - prophylactic vit K to mother prior to delivery Safe in breastfeeding: monitor for drowsiness and poor suckling
71
Side effects of carbamazepine
``` CARBAMAZEPINE Congestive heart failure Ataxia Renal damage Blurred vision Agranulocytosis Migraine Aplastic anaemia Z (nothing) Erythematous skin (most reactions are transient) Platelet reduction Increased risk of SLE Nausea Emesis ``` Also associated with severe skin reactions (DRESS, exfoliative dermatitis, Steven-Johnson Syndrome and toxic epidermal necrolysis)
72
Precautions in treatment with lamotrigine
Myoclonic seizures Allergy/rash with other anticonvulsants Child-Pugh B or C hepatic impairment Children (higher risk of severe skin reactions)
73
Major drug interactions with lamotrigine
COCP: COCPs increase lamotrigine's metabolism - reducing concentration therefore consider taking COCP without a pill-free period (reduce possible rise in lamotrigine during this time) or use an alternative contraception Valproate: increases lamotrigine concentration
74
Safety of lamotrigine in pregnancy and breastfeeding
Category D: less data than other anticonvulsants, potentially associated with oral clefts BUT lamotrigine clearance increases during pregnancy, therefore monitor plasma concentrations closely to make sure therapeutic (especially important if indication = epilepsy) Lamotrigine is passed into breast milk, contact specialist
75
Side effects of lamotrigine
``` Laziness (somnolence) Ataxia Muscle spasms (hyperkinesia) Ophthalmic (diplopia, blurred vision) Thrombocytopaenia, neutropenia (rare) Rash (most commonly maculopapular, rarely Steven Johnson Syndrome) Irritating headache Giddiness (dizziness) Interactions with other medications (valproate, COCP) No hair (alopecia) Emesis, nausea ```
76
Monitoring of lamotrigine
Not necessary except in pregnancy - monitor plasma levels to ensure remains therapeutic

Psychiatry (2 decks)

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