Psychotropics Flashcards
Mirtazapine
C-Tetracyclic antidepressant
I- Major depression, low doses- insomnia (h1 blockade dominates)
D-15-60mg nocte
M-increased suicidal thoughts, weight (causes weight gain), blood pressure (orthostatic hypotension), resolution of depression, sedation
C- drowsiness and increased effects of alcohol- do not drive if affected, do not stop suddenly, may to 4-6 weeks to working, increases appetite- diet counselling, wafer place on tongue and allow to dissolve
CAL- 1, 5, 9, 13
Tricyclic Antidepressants
TCA- tricyclic antidepressants
I-Major depression- all,
amitriptyline- noctural enuresis, pain management, migraine prophylaxis
Clomipramine- OCD, cataplexy associated with narcolepsy, pain disorder (second line)
Imipramine- noctural enuresis, panic disorder (second line)
D
Amitriptyline- 10-150mg daily divided or single dose at night. Max depression dose 300mg, max pain dose 150mg, max migraine prophylaxis dose 75mg
M- anticholinergic AE (constipation, dry mouth, blurred vision, dizziness), sedation, BP (orthostatic hypotension), pain/depression/migrain resolution, weight gain, psychiatric state (fatal in overdose), ECG (prolonged QT), serotonin syndrome (esp clomipramine)
C- take at night due to drowsiness, causes sedation and increases effects of alcohol- avoid driving if affected, AE- blurred vision, dry mouth and drowsiness may decrease after ~7days, dizziness on standing- get up slowly from sitting or lying, do not stop taking suddenly, takes time to work- 4-6 weeks, increased low mood on starting, can cause weight gain- importance of healthy balanced diet
CAL- 1, 5, 9, 13, 16
Anti-psychotics
C- antipsychotics primarily work through dopamine antagonism
I- Acute psychosis, schizophrenia, bipolar disorder
Additional/explained indications
Clozapine
Treatment resistant schizophrenia (lack of response or intolerable AE with at least 2 other antipsychotics one of which was atypical).
Olanzapine
Risperidone
Dementia behaviours resistant to non-drug measures, behavioural disorders in patients with lower subaverage interlectual functioing or mental retardation, behavioural disorders in autism
Quetiapine- generalised anxiety disorder
Doses
Clozapine- titrated as an inpatient starting at 12.5mg once daily increased by 25-50mg increments up to 300mg daily within 2-3 weeks. Then increase 50-100mg increments at 4-7 day intervals. Usual maintenance 200-600mg daily (max 900mg daily). Doses >300mg need dividing. Single doses given at night. If >2 days are missed retitration is require
Olanzapine- oral 2.5-20mg once daily (max 20mg/day). IM long acting 150-300mg every 2 weeks or 300-405mg every 4 weeks depending on previous oral dose required.
Quetiapine- 25-800mg daily in one (CR) or two (IR) doses
Risperidone- 1-6mg daily. Doses daily >4mg need to be divided
Special patient groups:
Parkinsons- quetiapine or clozapine preferred
Lewy body dementia- all antipsychotics worsen symptoms. consider low dose quetiapine
Seizures- lower seizure threshold avoid clozapine and chlorpromazine, use trifluoperazine, haloperidol or risperidone
M- seizures (lower seizure threshold), ECG- prolong QT, LFTs (dose reduction in hepatic impairment), compliance, EPSE, FBC (blood dyscrasia, agranularcytosis, neutropenia- especially clozapine WCC neutrophils), weight gain, blood lipids, sedation, blood pressure (orthostatic hypotension), blood glucose (hyperglycaemia/ development of diabetes), prolactin level, Neuroleptic malignant syndrome, Anticholinergic AE- constipation, dry eyes/mouth, urinary retention, sedation, smoking status (clozapine and olanzapine), serum clozapine levels (guide dosing and asses compliance)
C- label 1- increase sedation and increased effects of alcohol dont drive if effected, label 16- dizziness on standing get up slowly from sitting or lying, compliance and importance of taking regularly, consider LA IM injection if remembering tablets is difficult, avoid illicit drugs- increase risk of relapse, if you get any muscle pain stiffness motor restlessness tremor involuntary movements of face or mouth (EPSE) see doctor, weight gain and metabolic effects- importance of balanced diet and exercise
Clozapine- you will require regular blood tests, can cause severe constipation- talk to dr or pharm, changes in dose with caffeine intake and smoking level
Olanzapine- label 8 increased sun effects
CALs
Clozapine- 1, 9, 12, 13, 16
Olanzapine- 1, 8, 16 (13 for wafer)
Quetiapine- 1, 9, 12, 16, 18, A (for CR)
Risperidone- 1, 16, 21, A (tablet), 13 (wafer)
Others- Amisulpride, Aripiprazole, Asenapine, Bexpiprazole, Chlorpromazine, Droperidol (more commonly used for NV), Flupentixol, Haloperidol, Lurasidone, Paliperidone, Periciazine, Trifluoperazine, Ziprasidone, Zuclopenthixol
Benzodiazapines
C- Benzodiazapines, potentiate inhibitory effects of GABA
Very short acting <6h
Midazolam
I- Status epilipticus, conscious sedation
D- 5-10mg IM/IV/intranasal/buccal repeated once after 10-15min. IM/IV is commonly followed by infusion
Short acting 6-12h Alprazolam (S8) I-Anxiety disorder, panic disorder D-0.5-4mg daily in divided doses (max 10mg daily) Oxazepam I- Anxiety D- 7.5-30mg tds-qid Temazapam I-insomnia D-5-20mg nocte
Medium Acting 12-24h
Bromazepam
I-Anxiety
D- 3-12mg bd-tds (max 6mg as single dose)
Lorazepam
I-Anxiety, insomnia associated with anxiety, premedication, anticipatory NV with chemo
D-2-3mg daily in 1-3 doses. Max 4mg/day
Long acting >24h
Clobazam
I-Anxiety, insomnia associated with anxiety, Epilepsy
D- 10-30mg daily as single or divided doses
Clonazepam
I-Epilepsy refractory to other AEDs, status epilipticus
D-2-8mg daily in divided doses
Diazepam
I-anxiety/aggitation, acute alcohol withdrawal, muscle spasm/spasticity, premedication, conscious sedation, status epilipticus, benzodiazapine withdrawal
D-2-10mg repeated as nessesary. max 30mg/d
Flunitrazapam (S8)
I-insomnia
D- 0.5-2mg nocte
Nirtazepam
I-Insomnia
D- 2.5-10mg nocte
M- respiratory depression (and other sedating drugs eg opioids), muscle weakness (CI is myasthenia gravis), dependence/abuse/tolerance (monitor for repeat interval, PSB for S8s, drug seeking behaviour, forgeries), withdrawal, renal function (increased sensitivity to sedatory effects), LFTs (CI in severe hepatic impairment)
C- drowsiness which may continue to the following day avoid driving, avoid alcohol and other sedating medications, if taken for more than 2-4 weeks your body adjusts to requiring medication and you may need higher doses or experience withdrawal (insomnia/anxiety)- talk to doctor about stopping rather than stopping abruptly
CALS- Alpraz- 1, 9, 18 Bromazepam- 1, 3b, 9 Clobazam- 1, 9 Clonazepam- 1, 9, 21, A (tablet) Diazepam- 1, 9 Flunitrazepam- 1 or 1a, 9 Lorazepam-1 or 1a, 9 Midazolam- 1 Nitrazepam-1 or 1a, 9 Oxazepam- 1 or 1a, 9 Temazepam- 1 or 1a, 9, 21, A
SSRIs
Selective Serotonin Re-uptake Inhibitors
I- major depression, anxiety disorders, OCD (larger doses required), eating disorders, PTSD (fluoxetine, paroxetine)
Citalopram- 20-40mg mane Escitalopram- 10-20mg mane Fluoxetine- 20-80mg mane Fluvoxamine- 100-300mg mane with food (max 300mg) Paroxetine- 20-50mg mane with food Sertraline- 50-200mg mane
M- depression resolution, self harm, suicidal actions or ideation, mania (esp pts with bipolar), signs of bleeding (increased bleeding risk), angle closure glaucoma (increased risk), sodium (risk of hyponatreamia), serotonin syndrome (diarrhoea, anxiety, hyperreflexia, clonus, tremor, fever), LFTs (dose reduction in impairment), QT prolongation (citalopram, escitalopram, fluoxetine), drug interactions (esp citalopram)
C- take in the morning (if somnolence occurs give at night), dont drive until you know how medication affects you, dont stop abruptly, may increase anxiety/suicidal thoughts and behaviour when starting, may take 1-3 weeks to notice a difference and 6-8 weeks for full effect, ask dr/pharm before starting any medication inc OTC/CAM
CALs- 5, 9, 12, Paroxetine add 21, A, B
Lithium
C- Bipolar drug- unknown mode of action; inhibits dopamine release, enhances serotonin release and decreases formation of intracellular second messengers
I-Prevention of manic or depressive episodes in bipolar, treatment of acute main, schizoaffective disorder and chronic schizophrenia (rarely), augmentation of treatment resistant depression
D- initially 250-1000mg (750-1000mg for acute mania) daily in divided doses (every 12h for quilonum SR), increase by 250-500mg increments guided by serum concentration.
M- serum lithium levels TDM (5-7 days after starting, 8-12h post dose (trough) acute main target 0.5-1.2mmol/L, prophylaxis 0.4-1mmol/L), hyponatreamia (increased risk of lithium toxicity- avoid in vomiting, diarrhoea, diuretics, dehydration), Hypothyroidism TFT T4 TSH (lithium can cause hypothyroid), psosiasis (can be exacerbated), serotonin syndrome, renal function (toxicity can occur in impairment, avoid NSAIDS), surgery (consider WH due to fasting/changes in fluid status), elderly (lower doses, poorer renal function), pregnancy/contraception, weight/BMI (can increase weight), serum calcium, parathyroid, ECG (esp if significant cardiac disease)
AE- metallic taste, ND, weight gain,
Signs of toxicity- blurred vision, increased DNV, muscle weakness, drowsiness, apathy, ataxia, flu-like illness, increased muscle tone, hyperreflexia, myoclonic jerks, tremor, seizures, psychosis
C- SR swallow whole, take with food, dont take with hot drinks, regular blood tests are important, know the signs of toxicity- extreme thirst, polyuria, NVD- especially during illness, excessive sweating or low fluid intake, if toxicity occurs stop taking and go to hospital, maintain normal healthy diet (to prevent weight gain) with regular salt and fluid intake, drink more non-alcoholic fluids during hot weather to avoid toxicity, avoid sodium bicarbonate (found in some antacids, salvital, ural, citralite, citravescent)- these make lithium less effective, dont stop taking abruptly, talk to doctor/pharm before starting any new medications
CALs- 5, 13, 21, A, B
SNRIs
C- Seretonin and Noradrenaline reuptake inhibitors
Desvenalfaxine
I-Major depression
D- 50-100mg mane (max 200mg/d)
Duloxetine
I-Major depression, Generalised anxiety disorder, neuropathic pain,
D- 30-120mg mane
Milnacipran
I-Fibromyalgia
D-25-100mg bd
Venlafaxine
I-Major depression, generalised anxiety disorder, panic disorder, social phobia
D-75-225mg mane
M- efficacy, suicidal thoughts of behaviours, blood pressure (increases BP), cardiovascular risk, hyponatraemia, serotonin syndrome, angle closure glaucoma acute attack precipitation, bleeding risk (increased bleeding), LFTs (can cause abnormal LFTs), renal impairment (dose reduction CrCl<30ml/min), ECG (can cause ECG changes)
C- take in the morning (if causes drowsiness take at night), take with food (duloxetine and venalfaxine), swallow whole (all but milnacipran) dont stop taking abruptly, can cause dizziness/affect mental awareness- dont drive until you know how you’re affects (duloxetine CAL 1- avoid driving if drowsy, increased effects of alcohol), can cause increase in anxiety/suicidal thoughts when starting- this will improve with continued use, can take 1-3 weeks to notice a difference and 6-8 weeks for full effect, ask dr/pharm before starting any other medications, AE- N dry mouth constipation sweating increased BP sexual dysfunction
CAL- Desvenlafaxine- 5, 9, 12, A Duloxetine- 1, 5, 9, 12, A Milnacipran-5, 9, 12 Venlafaxine- 5, 9, 12, A, B
