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Psychiatry > Rx > Flashcards

Rx Flashcards

Antidepressants BPD medication Anti-psychotics Anxiolytics

1
Q

Antidepressants

Indications [7]

A 
Unipolar and bipolar depression
Organic mood disorders
Schizoaffective disorder
Anxiety disorders
OCD
Impulsivity associated with personality disorders
Premenstrual dysphoric disorder
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2
Q

Antidepressant

Indications - anxiety disorders [3]

A

PTSD
Panic disorder
Social phobia

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3
Q

Antidepressant
First line
How long after therapeutic dose achieved that improvement is seen?

A

SSRI

3-6 weeks after therapeutic dose achieved before improvement seen

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4
Q

Antidepressant

5 types

A 
SSRI
SNRI
TCA
MAOI
Novel antidepressants
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5
Q 
TCA
Tertiary TCA MOA
Secondary TCA MOA
Side effects [3 headings]
Why are the SE's so widespread
NB side effects in secondary TCA are generally less severe than tertiary TCA
A

Tertiary TCA MOA:
- acts on serotonin receptors
Secondary TCA MOA:
- blocks noradrenaline

Side effects:
Antihistaminic
Anticholinergic
Anti-adrenergic

Made up of amine side chains which are prone to react with a wide range of receptors

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6
Q

Tertiary TCA eg [4]

Secondary TCA eg [2]

A

Amitriptyline
Imipramine
Doxepine
Clomipramine

Desipramine
Nortriptyline

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7
Q

Name 2 anti-histaminic SE

A

Sedation and weight gain

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8
Q

Name 6 anti-cholinergic SE

A

Dry mouth, eyes
Constipation
Memory deficits
Delirium ~

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9
Q

MAOI
MOA [3]
Indication - very effective in… [1]
Eg [2]

A

Binds irreversibly to monoamine oxidase
Prevent inactivation of amines e.g. NE, DA, serotonin
Increased synaptic levels

Very effective in depression

Seligiline
Rasagiline

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10
Q

MAOI
SE [7]
Con - strict diet causes [2]

A 
Orthostatic hypotension
\+ SSRI side effects 
- Sick stomach, dizziness
- Sedation, weight gain
- Restlessness, anxiety, nervousness
- Insomnia
- Sexual dysfunction
Hypertensive crises so strict diet required - tyramine rich foods (Cheese Reaction) or sympathomimetics
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11
Q 
MAOI 
Serotonin syndrome
Causes [1]
Sx [7]
Serious consequences [3]
How to avoid 
Special instructions for fluoxetine and why
A

Cause: can develop if taken with medication that increases serotonin or have sympathomimetic actions

Sx
Shivering
Hyper-reflexia + myoclonus
Increased temperature - pyrexial
Vital sign instability
Encephalopathy - delirium
Restlessness
Sweating - diaphoresis

Serious consequences
Hyperpyrexia
CVS shock
Death

Avoid by waiting 2 weeks before switching from SSRI > MAOI - washout period
5 week washout period if switching from fluoxetine due to long half-life

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12
Q 
SSRI
MOA
Indication
Eg [6]
Pros
A

Blocks presynaptic serotonin re-uptake
Treats both anxiety and depression sx

Eg
Paroxetine
Sertraline
Fluoxetine
Citalopram
Escatilopram
Fluvoxamine

Pros: very little risk of cardio toxicity in overdose

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13
Q

SSRI
SE [7]
Pros
Cons [1] and give duration, 4 symptoms of [1]

A

SSRI SE

  • Sick stomach, dizziness
  • Sedation, weight gain
  • Restlessness, anxiety, nervousness
  • Insomnia
  • Sexual dysfunction
Pros: very little risk of cardio toxicity in overdose
Cons
- discontinuation syndrome
- week long
- agitation, nausea, diseqm, dysphoria
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14
Q

SSRI - Paroxetine
Pros
Cons

A

Pros

  • short half-life so less build up
  • sedating properties offering relief from anxiety, insomnia
Cons - 
- Discontinuation syndrome
Significant CYP2D5 inhibition so drug2 interaction
- Sedating
- Weight gain
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15
Q

SSRI - Sertraline
Pros [3]
Cons [2]

A

Pros

  • Weak P450 interactions so fewer drug2 interactions
  • Short half-life so less build up
  • Less sedating that paroxetine

Cons

  • Max absorption requires full stomach
  • Increased no of GI SE’s
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16
Q

SSRI - Fluoxetine
Well known trade name?
Pros [2]
Cons [3]

A

Prozac
Pros
- Long half life so less incidence of discontinuation syndromes
- Initially activating providing increased energy

Cons

  • Build up not good in patient with hepatic disease
  • Significant P450 interactions
  • More likely to induce mania than other SSRIs
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17
Q

SSRI - Fluoxetine
Good for which group of patients? [1]
Not so good in which group of patients? [3]

A

Good in non-compliant patients due to long half-life

Not so good in…

  • hepatic disease due to build-up
  • polypharmacy due to significant P450 interactions
  • Manic, anxiety
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18
Q

SSRI - Paroxetine

Indication

A

Sedating properties are good for relief from anxiety and insomnia

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19
Q

SSRI - Citalopram
Half life
Pros [1]
Cons [3]

A

Intermediate half-life
Pros
- Low inhibition of P450 enzymes, fewer drug2 interactions

Cons

  • QT prolongation
  • Sedating
  • GI side effects (but less than sertraline)
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20
Q

Which 2 SSRIs cause dose-dependent QT interval prolongation with doses 10-30mg daily and how does this influence precautions when prescribing?

A

Citalopram
Escitalopram
due to this risk doses of >40mg/day not recommended!

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21
Q

Which SSRI is associated with an increased no of GI side effects

A

Sertraline

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22
Q 
Escatilopram
Half-life
Pros [1]
Cons [3]
Effectiveness compared to citalopram?
A

Intermediate half-life
Pros
-Low inhibition of P450 enzymes, fewer drug2 interactions

Cons

  • QT prolongation
  • Nausea
  • Headache
  • more effective than citalopram in acute response, remission
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23
Q

Fluvoxamine
Pros [2]
Cons [6]

A

Pros

  • shortest half-life
  • analgesic properties
Cons
- discontinuation syndrome
- GI upset
- Headaches
Sedation
Strong CYP1A2, CYP2C19 inhibitor
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24
Q 
SNRI
Describe MOA, similar to...?
Pro [1]
Indications [3]
Eg [2]
A 
SNRI
MOA: inhibits both serotonin and NE reuptake 
Pro: no antihistamine, anticholinergic, antiadrenergic
Indications
- Anxiety
- Depression
- ? Neuropathic pain
Eg 
- Venlafaxine
- Duloxetine
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25
Q

What to do if encounter treatment resistance [4]

A

Combination of antidepressants
Adjunctive tx with lithium
Adjunctive tx with atypical antipsychotic
ECT

26
Q

Eg of a good combo of antidepressants in refractory cases

A

SSRI/SNRI with mirtazapine (tetracyclic antidepressant)

27
Q

Eg of 3 atypical antipsychotics as adjunctive treatments in refractory cases

A

Quetiapine
Olanzapine
Aripriprazole

28
Q

Mood stabilizers
3 indications
3 classifications

A

Indications

  • Bipolar
  • Cyclothymia
  • Schizoaffective

Classifications: Lithium, anticonvulsants, antipsychotics

29
Q

Mood stabilizers - Lithium
Effective in… [4]
Con
2 things to test for before starting lithium

A

Reduces suicide rate
Effective in long term prophylaxis of mania and depressive episodes
Classic pure mania
Mania followed by depression

Con: narrow therapeutic window

Before starting lithium…
Get baseline U&E and TSH
Pregnancy test

30
Q 
Mood stabilizers - Lithium
Monitoring - 
Goal in blood level and when to check
When is steady state achieved
Once stable what are the monitoring protocols? [3]
A 
Goal in blood level: 0.6-1.2 - Check 12 hours after last dose
Steady state achieved 5 days
Once stable...
- Check every 3m
- Check TSH and creatinine every 6m
31
Q

Mood stabilizers - Lithium
SE [7]
LTHIUM

A 
Leukocytosis
Tremors, thirsty
Hypothyroidism, hair loss
Interstitial renal fibrosis
Upset GI, nausea, vomiting, diarrhea
Muscle weakness, mums
Skin (acne), seizure, slowing
32
Q

Why does lithium cause polyuria

What is one serious consequence of this

A

Secondary to ADH antagonism

Interstitial renal fibrosis

33
Q

Describe lithium toxicity
Mild lithium toxicity [3]
Moderate lithium toxicity [6]
Severe lithium toxicity [2]

A

Mild lithium toxicity

  • vomiting, diarrhea
  • ataxia, dizziness
  • nystagmus, slurred speech

Moderate lithium toxicity

  • vomiting
  • anorexia
  • syncope
  • blurred vision
  • clonic limb movements
  • convulsions, delirium

Severe lithium toxicity

  • Generalised convulsions
  • Oliguria, renal failure
34
Q 
Mood stabilizers 
Lithium ranges
Goal
Mild
Mod
Severe
A

Goal: 0.6-1.2
Mild 1.5-2.0
Mod 2.0-2.5
Severe >2.5

35
Q

Mood stabilizers - valproic acid
Effectiveness and tolerativeness in comparison to lithium? [3]
Factors predicting positive response [4]

A

Same effectiveness as lithium in mania prophylaxis
Not as effectiveness as lithium in depression prophylaxis
Better tolerated than lithium

Factors:

  • rapid cycling patients
  • co-morbid substance issues
  • mixed patients
  • co-morbid anxiety disorders
36
Q

Lithium

Factors predicting positive response [3]

A

Prior long term response
or family member with good long term
Classic pure mania
Mania followed by depression

37
Q

Mood stabilizers - valproic acid
Before starting, 3 things
Con [1] influencing management

A

Before starting

  • baseline LFT
  • baseline FBC
  • pregnancy test

Con: increased risk of neural tube defect so prescribe folic acid supplement

38
Q

Mood stabilizers - valproic acid

When is steady state achieved
When to repeat LFT, FBC
Goal in blood

A

Steady state achieved 4-5 days
Check in 12 hours after last dose
- Repeat LFT, FBC

Goal in blood: 50-125

39
Q

Mood stabilizers - valproic acid

SE [6]

A 
Vomiting
Alopecia
Liver toxicity hence LFTs
Pancreatitis
Retain fat
Oedema
Appetite increase
Thrombocytopenia
Enzyme inhibitor p450
40
Q

Mood stabilizers - carbamazepine
Originally used as
Indications [4] - first line agent for 2

A 
Originally used as an anti-epileptic
Indications
- acute mania, mania prophylaxis (first line)
- rapid cyclers
- mixed patients
41
Q

Mood stabilizers - carbamazepine

Before starting [3]

Monitoring:
steady state
Goal in blood

A

Before starting:

  • LFT
  • FBC
  • ECG

Steady state achieved after 5 days
Check 12 hours for FBC, LFT
Goal in blood: 4-12 mcg/mL
Check after 1 month

42
Q

Mood stabilizers - lamotrigine
Og used as…
SE [6]
What are 2 drug-drug interactions?

A 
Anticonvulsant
SE:
- Nausea, vomiting
- Sedation
- Dizziness, ataxia, confusion
- Stevens Johnson's syndrome
- Blood dyscrasias

Drug interactions

  • sertraline
  • valproic acid
43
Q

Mood stabilizers - anti-psychotics
2 types
Indications [4]
SE [3]

A

Typical
Atypical

Indications
Schizophrenia
BPD
Psychotic depression
Anxiety disorders as augmenting agent

SE

  • tardive dyskinesia
  • NMS
  • EPS
44
Q

Mood stabilizers - anti-psychotics SE’s
Explain tardive dyskinesia [2]
NMS is potentially fatal - what are 5 clinical features
3 features of extrapyramidal symptoms

A

Tardive dyskinesia - involuntary muscle movements not resolving with drug discontinuation

NMS

  • Fever
  • Encephalopathy
  • Vital sign instability
  • Enzyme elevation eg raised CPK, LFT, WBC
  • Rigidity (leadpipe)

EPS

  • Acute dystonia
  • PD
  • Akathisia
45
Q 
Mood stabilizers - Typical anti-psychotics
3 examples
MOA [2]
Explain side effect profile:
- high risk of EPS effects
- anti-cholinergic and cardiotoxic
A

Eg
Fluphenazine
Haloperidol
Pimozide

MOA:
D2 dopamine receptor antagonists

Side effect profile:
EPS effects - high potency typical antipsychotics tend to bind to D2 receptor with high affinity
Anti-cholinergic, cardiotoxic - low potency typical antipsychotics bind with less affinity to D2 receptors BUT interact with non-dopaminergic receptors

46
Q

Mood stabilizers - Atypical anti-psychotics
MOA
Why are they named atypical?
Eg

A

MOA: serotonin-dopamine 2 antagonists

Considered atypical in the way that they affect DA and serotonin neurotransmission

Eg
Risperidone
Olanzapine
Quetiapine
Aripiprazole
Clozapine
47
Q

Mood stabilizers - Atypical anti-psychotics

Risperidone SE [3]

A

Increased EPS effects
Hyperprolactinemia
Weight gain, sedation

48
Q

Which 2 atypical anti-psychotic is only available in tablets

NB the rest are available in tablets, IM and depot

A

Clozapine

Quetiapine

49
Q

Mood stabilizers - Atypical anti-psychotics

Olanzapine SE [4]

A

Hypertriglyceridemia, high cholesterol
Hyperprolactinemia~
Weight gain, hyperglycemia
Abnormal LFTs ~

50
Q

Mood stabilizers - Atypical anti-psychotics
Quetiapine SE
similar SE profile to another atypical antipsychotic

A 
Same as olanzapine but most likely to cause orthostatic hypotension
Hypertriglyceridemia, high cholesterol
Hyperprolactinemia~
Weight gain, hyperglycemia
Abnormal LFTs ~
51
Q 
Mood stabilizers - Atypical anti-psychotics
Aripiprazole 
MOA
3 Pros
SE [1]
A

MOA: d2 partial agonist
Pros: not associated with weight gain, low sedation, low EPS effects

SE: CYP2D6, 3A4 interactions

52
Q 
Mood stabilizers - Atypical anti-psychotics
Clozapine
Indications
SE (highest risk)
- NB side effect profile can be fatal
A 
Reserved for tx resistant pt 
SE
Agranulocytosis
Increased risk of seizures
Most sedation, weight gain, abnormal LFTs

Hypertriglyceridemia, high cholesterol
Hyperprolactinemia~
Hyperglycemia
Non-ketotic hyperosmolar coma

53
Q

EPS agents [3]

Give at least 1 example of each

A

Anticholinergics
Dopamine facilitators - amantadine
Beta blockers - propanolol

54
Q

EPS agents - anticholinergics
3 eg
Watch out for…

A

Eg
Benztropine
Trihexyphenidyl
Diphenhydramine

Watch for anticholinergic SE esp if taken with TCAs (additive anticholinergic activity)

55
Q 
Anxiolytics
Indications [4]
Buspirone and its MOA
Pros [2]
Cons [2]
A 
Panic disorder
GAD
Substance related disorders
Used in combination with SSRI, SNRI [augmentation]
Eg: Buspirone
MOA: 5HT1A agonist

Pros

  • augmentation strategy
  • no sedation

Cons

  • 2 weeks before improvments
  • will not reduce anxiety in pt that are used to taking BDZ because no sedation effect to take edge off
56
Q

Anxiolytics - BDZs
Indications 4
5 SE

A 
• Indications
		• Insomnia
		• Parasomnia
		• Anxiety disorder
		• CNS depressant withdrawal protocols eg alcohol withdrawal
	• SE
		• Somnolence
		• Cognitive deficits
		• Amnesia
		• Disinhibition
Tolerance, dependence
57
Q

Psychological Treatment
CBT
Name 4 features

A

Focus on now
short term
Problem focused
Goal oriented

58
Q

Psychological Treatment
CBT
Therapist helps client by… [4]

A

Identify thoughts, feelings and behaviours
Assess thinking errors
What can change
Client engages in homework

59
Q

Psychological Treatment
CBT
Thinking errors [8]
Homework [2]

A 
Automatic negative thoughts
Unrealistic beliefs
Cognitive distortion
Catastrophizing
Black and white thinking
 Perfectionism
Over-generalisation
Mind reading

Homework:
errors
Graded exposure
Response prevention

60
Q

Psychological Treatment
Behavioral activation in treatment of depression
3 key features
3 features of its structure

A

Focus on avoidance issues in depression
Predictors and perpetuators of avoidance
Client taught to analyse unintended consequences of their response to triggering situations

3 features of its structure:
structured agenda
review progress
make small changes to build long term goals

61
Q

Interpersonal therapy
Effective for 2 conditions
4 features
Cons 2

A

Indications - depression, anxiety
Time limitation: 12-16 weeks
4 features:
- CBT without homework
- Allows patient to be invested in sick role
- Acknowledges depression often follows major life event
- construct an interpersonal map

Cons:
requires degree of ability to reflect
limited where there are poor social networks

62
Q 
Motivational interviewing
Based on what theory
More effective than
Indications
Pros:
A

Based on Prochaska and Diclemente’s stages of change
More effective than advice giving
Indications: where behaviour change is being considered but patient is unmotivated or ambivalent (mixed feelings) to change
Pros: patient sets the agenda, self-efficacy

Psychiatry (8 decks)

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