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Therapeutics Flashcards

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1
Q

Precautions to using antipsychotics

A
  • Active CD (esp QTC prolongation)
  • Parkinson’s disease
  • Epilepsy
  • Depression
  • Myasthenia gravis
  • BPH
  • Angle closure glaucoma
  • Severe respiratory disease
  • History of jaundice
  • Blood dyscrasia
  • Elderly with dementia
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2
Q

Treatment for acute agitation/psychosis

A

Cooperative:
- PO lorazepam 1-2 mg
- PO antipsychotics (haloperidol 2-5 mg, risperidone 1-2 mg, quetiapine 50-100 mg, olanzapine 5-10 mg)
- Inhaled loxapine 100 mg with standby salbutamol

Uncooperative:
- PO lorazepam 1-2 mg
- IM olanzapine 5-10 mg (not within 1 hour of giving lorazepam)
- IM Aripiprazole 9.75 mg
- IM haloperidol 2.5-10 mg
- IM promethazine 25-50 mg
- IM lorazepam + haloperidol
- IM haloperidol + promethazine

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3
Q

Treatment for acute catatonia in schizophrenia

A

PO/IM lorazepam

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4
Q

Management of dystonia from antipsychotics

A
  • Associated with high potency antipsychotics, treatment-naive patients, young males
  • Treat with IM anticholinergics (benztropine, diphenhydramine)
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5
Q

Management of pseudo-parkinsonism

A
  • Assessed using Simpsons-Angus rating scale
  • Associated with elderly females and those with CNS damages
  • Reduce dose or switch to SGA
  • Use anticholinergics PRN (benzhexol, benztropine)
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6
Q

Management of akathisia

A
  • Due to high potency antipsychotics (risperidone > olanzapine > quetiapine/clozapine)
  • Reduce dose or switch to SGA
  • Use clonazepam PRN low dose
  • Use propanolol 20 mg TDS (max 160 mg/day)
  • Anticholinergics are ineffective
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7
Q

Management of tardive dyskinesia

A
  • Associated with FGA > SGA
  • Worsened by anticholinergics
  • Discontinue any anticholinergics
  • Reduce dose or switch to SGA
  • Consider using clozapine
  • Valbenazine 40-80 mg/day (vesicular monoamine transporter 2 inhibitor)
  • Use clonazepam PRN
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8
Q

Management of hyperprolactinemia

A
  • FGA > risperidone > SGA
  • Reduce dose
  • Use dopamine agonist (amantadine, bromocriptine)
  • Switch to aripiprazole
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9
Q

Antipsychotics associated with orthostasis

A

High: chlorpromazine, clozapine
Low: olanzapine, ziprasidone, aripiprazole, sulpiride

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10
Q

Antipsychotics associated with qtc prolongation

A
  • High doses of antipsychotics
  • IV haloperidol
  • Concomitant hypokalemia

High: chlorpromazine, clozapine, ziprasidone
Low: risperidone, olanzapine

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11
Q

Antipsychotics associated with VTE

A

Low potency FGA

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12
Q

Antipsychotics associated with sedation

A

High: chlorpromazine, clozapine
Low: risperidone, ziprasidone, aripiprazole

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13
Q

Management of seizures due to antipsychotics

A

High: chlorpromazine, clozapine
Low: risperidone, ziprasidone, aripiprazole

  • Use high potency antipsychotics e.g. haloperidol
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14
Q

Management of neuroleptic malignant syndrome

A
  • Associated with high potency antipsychotics
  • Use IV dantrolene 50 mg TDS
  • Use PO dopamine agonists (amantadine, bromocriptine)
  • Switch to SGA
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15
Q

Antipsychotics associated with psychogenic polydipsia & temperature dysregulation

A

Anticholinergics

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16
Q

Antipsychotics associated with hepatotoxicity

A

High: chlorpromazine, other FGAs
Intermediate: olanzapine, quetiapine
Low: other SGAs

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17
Q

Antipsychotics associated with ophthalmic changes

A

Phenothiazines, quetiapine

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18
Q

Antipsychotics associated with derm disorders

A

Phenothiazines

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19
Q

Antipsychotics associated with agranulocytosis

A
  • Clozapine
  • Discontinue if WBC < 3 or ANC < 1.5
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20
Q

Monitoring parameters for antipsychotics

A
  • BMI for weight (monthly x 6 months f/b q3 monthly)
  • Waist circumference (every visit x 6 months f/b annual)
  • FBG/HbA1c (high risk: 3 months after starting SGA, f/b annual)
  • Lipid panel (baseline)
  • Prolactin (baseline)
  • BP (3 months after initiation of SGA, f/b annual)
  • EPS exam (weekly for 2 weeks after initiation, f/b q3 months for FGA, 6 months for SGA)
  • WBC & ANC for clozapine (weekly for 18 weeks, f/b monthly)
  • ECG for ziprasidone (repeat if s/s of qtc prolongation e.g. syncope)
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21
Q

Etiological factors for MDD

A
  • Biological (increased cortisol, monoamine deficiency)
  • Psychological
  • Psychosocial
  • Genetics
  • Medical conditions
  • Drug-induced
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22
Q

Medical conditions associated with depression

A
  • Endocrine (hypothyroidism, Cushing’s syndrome, bidirectional with DM)
  • Deficiency states (anemia, wernicke’s encephalopathy)
  • Infections (CNS, STD/HIV, TB)
  • Metabolic (electrolyte imbalance, hepatic encephalopathy)
  • CV (CAD, HF, MI)
  • Neuro (Alzheimer’s , epilepsy, pain, Parkinson’s, post-stroke)
  • Malignancy
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23
Q

Psychiatric conditions associated with MDD

A
  • Alcoholism
  • Anxiety
  • Eating disorders
  • Schizophrenia
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24
Q

Drugs that can induce MDD

A
  • Lipid-soluble beta blockers
  • Psychotropics (CNS depressants, ASM, tetrabenazine)
  • Withdrawal from alcohol, stimulants
  • Systemic glucocorticoids
  • Isotretinoin
  • Interferon beta-1a
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25
Q

DSM-5 diagnostic criteria for MDD

A
  • Interest
  • Sleep
  • Appetite
  • Depressed mood
  • Concentration
  • Activity (psychomotor retardation, agitation)
  • Guilt
  • Energy
  • Suicidal
  • At least 5 symptoms present for the same 2 week period
  • Symptoms must have caused significant functional impairment
  • Symptoms not caused by medical conditions or substance
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26
Q

Antidepressants indicated for OCD

A
  • Clomipramine
  • Fluoxetine
  • Fluvoxamine
  • Paroxetine
  • Sertraline
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27
Q

Antidepressants indicated for eating disorder

A

Fluoxetine (bulimia)

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28
Q

Antidepressants indicated for pain

A
  • Amitriptyline (neuropathy, migraine)
  • Nortriptyline (neuropathy)
  • Duloxetine (diabetic neuropathy, fibromyalgia, MSK pain)
29
Q

Medical conditions associated with anxiety

A
  1. Cardiovascular (arrhythmias, HF, IHD)
  2. Endocrine (hyperthyroidism. Cushing’s syndrome, hyperkalemia, hyponatremia, hypoglycemia)
  3. Neurologic (dementia, delirium, parkinson’s, seizures, pain)
  4. Pulmonary (asthma, COPD)
  5. Others (anemia, SLE, vestibular dysfunction)
30
Q

Drugs that can precipitate anxiety

A
  1. Sympathomimetics (pseudoephedrine)
  2. Stimulants
  3. Methyxanthines (theophylline, caffeine)
  4. Thyroid hormone (levothyroxine)
  5. Systemic steroids
  6. Antidepressants (SSRI, TCA during initiation & dose escalation)
  7. Dopamine agonists (levodopa)
  8. beta agonist (salbutamol)
  9. Antihypertensive (felodipine)
  10. Anticonvulsants (carbamazepine)
  11. Antibiotics (quinolones, isoniazid)
  12. NSAIDs
  • Drug withdrawal
  • Drug intoxication (anticholinergics, antihistamines, digoxin)
  • Akathisia from antipsychotics
31
Q

Benzodiazepines & Z-hypnotics should not be used in?

A
  • Acute narrow angle glaucoma
  • Acute pulmonary insufficiency, respiratory depression
  • Neuromuscular weakness e.g. myastheniania gravis
32
Q

Sedating antihistamines should not be used in?

A
  • Prostatic hypertrophy
  • Urinary retention
  • Angle closure glaucoma
  • Pyloroduodenal obstruction
  • Epilepsy
  • QC prolongation (hydroxyzine)
  • Coronary artery disease (promethazine)
33
Q

Lemborexant should not be used in?

A
  • Narcolepsy
  • Moderate-strong 3A inhibitors/inducers
  • Severe hepatic impairment
34
Q

Precautions for benzodiazepines

A
  • Renal/hepatic impairment
  • Pregnancy / breastfeeding
  • History of substance abuse or psychiatric disorders e.g. psychosis
  • Prolonged useage
  • Undergoing ECT
  • Patients taking opioids
35
Q

Drugs that can contribute to BPSD in dementia

A
  • Anticholinergics
  • Anticonvulsants
  • Systemic steroids
  • Sedatives
  • Anti-Parkinsonian drugs
36
Q

Mood stabilisers for pregnant patients

A
  • SGA (quetiapine, olanzapine, risperidone) but monitor for gestational diabetes
  • FGA (generally not teratogenic)
  • ECT for severe mania
37
Q

Mood stabiliser for patients with cardiac disease

A

Valproate (monitor BP, HR, peripheral edema)

38
Q

Mood stabiliser for liver impairment

A

Lithium

39
Q

Mood stabiliser for renal impairment

A

Valproate

40
Q

Mood stabiliser for children & adolescents

A

Lithium, valproate

41
Q

Mood stabilisers for elderly

A
  • Avoid renally excreted drugs
  • Avoid carbamazepine (hyponatremia)
  • Consider lamotrigine
42
Q

Mood stabiliser for aggression or violence

A
  • Optimise existing lithium or valproate
  • Consider adding antipsychotics
43
Q

Antidepressants in obese patients

A

Consider bupropion, SSRI (except paroxetine), SNRI
Avoid mirtazapine, TCA, MAOI

44
Q

Antidepressants in CVD patients

A

Consider sertraline
Avoid TCA, escitalopram

45
Q

Antidepressants in cerebrovascular events

A

Consider SSRI (fluoxetine)

46
Q

Antidepressants in DM

A

Avoid TCAs

47
Q

Antidepressants in renal insufficiency

A

Avoid duloxetine
Use paroxetine, vortioxetine with caution

48
Q

Antidepressants in hepatic insufficiency

A

Avoid agomelatine, duloxetine
Use paroxetine, escitalopram with caution

49
Q

Antidepressants in hypertension

A

Avoid TCA, SNRI

50
Q

Antidepressants in pregnancy

A

Avoid paroxetine, bupropion
Consider nortriptyline in late stage pregnancy

51
Q

Antidepressants in breastfeeding

A

Consider sertraline, mirtazapine

52
Q

Antidepressants in postpartum depression

A

Consider brexanolone

53
Q

Antidepressants safer for hyponatremia

A

Agomelatine, mirtazapine, bupropion

54
Q

Antidepressant safest for bleeding risk

A

Agomelatine

55
Q

Antidepressants associated with discontinuation syndrome

A

Worst: paroxetine, venlafaxine
Safest: fluoxetine, bupropion

56
Q

Antipsychotics for pregnancy

A

Olanzapine, clozapine

57
Q

Antipsychotics for breastfeeding

A

Olanzapine, quetiapine
Clozapine to not breastfeed

58
Q

Antipsychotics for renal impairment

A

PO aripiprazole
Avoid sulpiride, amisulpride

59
Q

Antipsychotics for hepatic impairment

A

Sulpiride, amisulpride

60
Q

Hoehn and Yahr staging

A

1: Unilateral symptoms
2: Bilateral symptoms
3: Postural instability
4: Severe disability
5: Bedridden

61
Q

Non-motor symptoms of PD

A

Cognitive: dementia
Psychiatric: depression, psychosis
Sleep: REM sleep behavioural disorder
Autonomic: N/C, orthostasis, sialorrhea
Fatigue

62
Q

Medications causing parkinsonism

A

High:
D2 antagonist (antipsychotics)
Dopamine depleters (tetrabenazine, reserpine)
Dopamine synthesis inhibitors (a-methyldopa)
P-calcium channel antagonists (flunarizine, cinnarizine)

Moderate:
Ziprasidone
Antiemetic agents
L-calcium channel antagonists
Antiepileptics (phenytoin, valproate, levetiracetam)
Lithium

Low:
Antiarrhythmics (amiodarone, procaine)
Immunosuppressants (cyclosporin, tacrolimus)
Antidepressants (MAOi, TCA, SSRI)
Antibacterials (bactrim)
Antivirals (anti-HIV, acyclovir)
Statins
Amphotericin B
Levothyroxine, methdroxyprogesterone, epinephrine

63
Q

Drugs to treat drug-induced parkinsonism

A

Anticholinergics
Amantadine

64
Q

Medications indicated for GAD

A

Escitalopram
Paroxetine
Venfalaxine XR
Duloxetine
Alprazolam
Diazepam
Lorazepam
Hydroxyzine
Pregabalin

65
Q

Medications indicated for PD

A

Fluoxetine
Paroxetine
Sertraline
Venlafaxine XR
Alprazolam
Clonazepam

66
Q

Medications indicated for SAD

A

Fluvoxamine
Paroxetine
Sertraline
Venlafaxine XR

67
Q

Medications indicated for OCD

A

Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
Clomipramine

68
Q

Medications for PTSD

A

1st line: CBT
Paroxetine
Sertraline

Psych (5 decks)

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