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Y4 psychiatry > Therapeutics > Flashcards

Therapeutics Flashcards

1
Q

NMS clinical features

A

First 10 days of treatment or after increasing dose

  • pyrexia
  • muscular rigidity
  • confusion
  • fluctuating consciousness
  • autonomic instability (fluctuating pulse & BP)
  • delirium
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2
Q

NMS investigations

A
  • CK - increased (1000s)
  • FBC - leucocytosis may be seen
  • LFTs - deranged
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3
Q

NMS management

A
  • emergency referral to A&E
  • stop antipsychotic
  • monitor vitals
  • IV fluids
  • cooling
  • dantrolene (muscle relaxant), 2nd line - bromocriptine (dopamine agonist)
  • consider benzodiazepines for acute behaviour disturbance
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4
Q

Delirium tremens

A

Severe end of the spectrum of alcohol withdrawal & peak incidence is at 72 hours

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5
Q

Delirium tremens symptoms

A
  • confusion
  • paranoid delusions
  • coarse tremor
  • formication - sensation of crawling insects on or under the skin
  • autonomic arousal (tachycardia, fever, pupillary dilatation, increased sweating)
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6
Q

Delirium tremens treatment

A
  • large doses of benzodiazepines (eg. chlordiazepoxide)
  • haloperidol for any psychotic features
  • IV pabrinex
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7
Q

Wernicke’s encephalopathy

A

An acute encephalopathy due to thiamine deficiency

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8
Q

Wernicke’s encephalopathy symptoms

A
  • delirium
  • nystagmus
  • ophthalmoplegia: lateral rectus palsy, conjugate gaze palsy
  • hypothermia
  • ataxia
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9
Q

Wernicke’s encephalopathy treatment

A

-parenteral thiamine

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10
Q

Korsakoff’s psychosis

A

Profound, irreversible short-term memory loss with confabulation (the unconscious filling of gaps in memory with imaginary events) and disorientation to time

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11
Q

Acute dystonias

A

Sustained, often painful, muscular spasms, producing twisted abnormal postures in reaction to an antipsychotic

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12
Q

Oculogyric crisis

A

Neck arched and eyes rolled back

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13
Q

Acute dystonias treatment

A
  • stop antipsychotic
  • administer IM/IV anticholinergics (first-line is procyclidine)
    • continue for 1-2 days after dystonia & consider long-term prophylactic
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14
Q

What makes lithium toxicity worse?

A
  • dehydration
  • drugs (ACE inhibitors, NSAIDs)
  • diuretics (thiazide)
  • depletion of sodium
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15
Q

Lithium toxicity symptoms

A
  • confusion
  • coarse tremor
  • nausea & vomiting
  • ataxia
  • seizures
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16
Q

Lithium toxicity treatment

A
  • stop lithium
  • supportive measures - IV fluids, dialysis if necessary, benzodiazepines for seizures
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17
Q

Clozapine-induced agranulocytosis treatment

A
  • stop clozapine
  • stop any other potentially marrow supressing drugs - e.g. sodium valproate
  • avoid antipsychotics for a couple of weeks where possible; if needed - aripiprazole
  • contact consultant haematologist
  • avoid sources of infection, consider broad-spectrum abx
  • lithium & G-CSF can be used
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18
Q

ECT

A
  • passage of a small electrical current through the brain with a view to inducing a modified epileptic seizure which is therapeutic
  • usually requires around 6-12 treatment sessions, delivered twice a week
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19
Q

ECT procedure

A
  • electric current is applied to the patient’s skull, aiming to induce a seizure for at least 30 seconds
  • occurs under GA
  • muscle relaxant (suxamethonium) is given by the anaesthetist which limits the motor effects of the seizure
  • can be bilateral/unilateral
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20
Q

ECT indications

A
  • prolonged or severe mania
  • catatonia
  • severe depression (most common)
    • treatment-resistant depression
    • suicidal ideation or serious risk to others
    • life-threatening depression
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21
Q

ECT side effects

A
  • short-term
    • peripheral nerve palsies
    • cardiac arrhythmias, confusion
    • dental and oral trauma
    • anaesthetic risks
    • muscular aches & headaches
    • short-term memory impairment
    • status epilepticus
  • long-term
    • anterograde & retrograde amnesia
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22
Q

ECT contraindications

A
  • MI
  • major unstable fracture
  • cerebral aneurysm
  • raised ICP (only absolute contraindication)
  • stroke < 1 month ago
  • history of status epilepticus
  • severe anaesthetic risk
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23
Q

SSRIs examples

A
  • citalopram
  • escitalopram
  • fluoxetine
  • paroxetine
  • sertraline
  • fluvoxamine
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24
Q

SSRI indications

A
  • depression
  • panic disorder (citalopram, escitalopram, paroxetine)
  • social phobia (escitalopram, paroxetine)
  • bulimia nervosa (fluoxetine)
  • OCD
  • PTSD (paroxetine, sertraline)
  • GAD (paroxetine)
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25
Q

SSRIs mechanism of action

A
  • work by inhibiting the reuptake of serotonin from the synaptic cleft into pre-synaptic neurones
  • SSRIs increase the concentration of serotonin in the synaptic cleft
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26
Q

SSRIs SEs

A
  • GI: nausea, dyspepsia, bloating, flatulence, diarrhoea and constipation
  • sweating
  • tremor
  • rashes
  • EPSEs (uncommon)
  • sexual dysfunction
  • somnolence
  • discontinuation syndrome - GI symptoms, ‘chills’, insomnia, hypomania, anxiety and restlessness
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27
Q

SSRIs contraindications & cautions

A
  • cautions
    • history of mania
    • epilepsy
    • cardiac disease
    • acute angle-closure glaucoma
    • diabetes mellitus
  • contraindications
    • mania
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28
Q

SSRIs route

A

oral

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29
Q

SNRIs examples

A
  • venlafaxine
  • duloxetine
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30
Q

SNRIs indications

A
  • second/third line treatment for depression and anxiety
  • have a faster onset & more effective than SSRIs (for major depression)
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31
Q

SNRIs mechanism of action

A
  • work by preventing the reuptake of noradrenaline and serotonin
    • do not block the cholinergic receptors and therefore do not have as many anti-cholinergic side effects as TCAs
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32
Q

SNRIs SEs

A
  • nausea
  • dry mouth
  • headache
  • dizziness
  • sexual dysfunction
  • hypertension
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33
Q

SNRIs contraindications & cautions

A
  • cautions: similar to SSRIs
  • contraindications: high risk of cardiac arrhythmia, uncontrolled hypertension
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34
Q

SNRIs route

A

oral

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35
Q

Mirtazapine indications

A
  • second line for depressed patients who:
    • would benefit from weight gain
    • suffer from insomnia
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36
Q

Mirtazapine mechanism of action

A
  • weak noradrenaline reuptake inhibiting effect
  • has anti-histaminergic properties
  • alpha-1 and alpha-2 blocker
    • therefore increases appetite and is a sedative
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37
Q

Mirtazapine SEs

A
  • increases appetite
  • weight gain
  • dry mouth
  • postural hypotension
  • oedema
  • drowsiness
  • fatigue
  • tremor
  • dizziness
  • less common: syncope, mania, hallucinations, movement disorders
38
Q

Mirtazapine contraindications & cautions

A
  • cautions
    • elderly
    • cardiac disorders
    • hypotension
    • urinary retention
    • diabetes
    • psychoses
39
Q

Mirtazapine route

A

oral

40
Q

TCA examples

A
  • amitriptyline
  • clomipramine
  • imipramine
  • nortriptyline
41
Q

TCA indications

A
  • depressive illness
  • nocturnal enuresis in children
  • neuropathic pain (unlicensed)
  • migraine prophylaxis (unlicensed)
42
Q

TCA mechanism of action

A
  • work by inhibiting the reuptake of adrenaline and serotonin in the synaptic cleft
  • also have affinity for cholinergic receptors & 5HT2 receptors → contribute to side effects
43
Q

TCA SEs

A
  • anticholingeric: dry mouth, constipation, urinary retention
  • cardiovascular: arrhythmias, postural hypotension, tachycardia
  • hypersensivity: urticaria, photosensitivity
  • psychiatric: confusion, delirium (especially in elderly)
  • metabolic: increased appetite and weight gain
  • endocrine: testicular enlargement
  • neurological: convulsions, movement disorders
44
Q

TCAs contraindications & cautions

A
  • cautions
    • cardiac disease
    • history of epilepsy
    • pregnancy
    • breast feeding
    • elderly
  • contraindications
    • recent MI
    • arrhythmias (particularly heart block)
    • mania
45
Q

TCAs route

A

oral - tablet/solutions

46
Q

MAOI examples

A
  • irreversible: phenelzine, isocarboxide
  • reversible: moclobemide
47
Q

MAOI indications

A
  • third-line treatment for depression: atypical/treatment-resistant depression
  • social phobia
48
Q

MAOI mechanism of action

A

inactivate monoamine oxidase enzymes that oxidise the monoamine neurotransmitters dopamine, noradrenaline, serotonin & tyramine

49
Q

MAOI SEs

A
  • CVS: postural hypotension, arrhythmias
  • neuropsychiatric: drowsiness/insomnia, headache
  • GI: increased appetite, weight gain
  • anorgasmia
  • increased LFTs
  • hypertensive reactions with tyramine containing foods
50
Q

MAOI contraindications & cautions

A
  • cautions
    • avoid in agitated/excited patients
    • thyrotoxicosis
    • hepatic impairment
    • bipolar disorders
  • contraindications
    • acute confusional states
    • phaeochromocytoma
50
Q

MAOI route

A

oral

51
Q

NARI examples

A

reboxetine

52
Q

NARI indications

A

second or third-line for major depression

53
Q

NARI mechanism of action

A

highly specific noradrenaline reuptake inhibitor

54
Q

NARI SEs

A
  • nausea
  • dry mouth
  • constipation
  • anorexia
  • tachycardia
  • palpitations
  • vasodilatations
55
Q

NARI contraindications & cautions

A
  • cautions
    • history of cardiovascular disease
    • bipolar disorder
    • urinary retention
    • prostatic hypertrophy
    • pregnancy
56
Q

NARI route

A

oral

57
Q

typical anti-psychotics examples

A
  • haloperidol
  • chlorpromazine
  • flupentixol
  • fluphenazine
  • sulpiride
  • zuclopenthixol
58
Q

typical anti-psychotic indications

A
  • indicated for patients suffering from psychotic symptoms eg. delusions and hallucinations
  • can be used for other conditions when they present with positive psychotic symptoms
    • depression
    • mania
    • delusional disorders
    • acute & transient psychotic disorders
    • delirium
    • dementia
  • violet/dangerously impulsive behaviour and psychomotor agitation
59
Q

typical anti-psychotic mechanism of action

A

reducing abnormal transmission of dopamine through blocking dopamine receptors in the brain

60
Q

typical anti-psychotic SEs

A
  • sedation
  • weight gain
  • QTc prolongation
  • extra-pyramidal side effects - bradykinesia, muscle stiffness and tremor, tardive dyskinesia, akathisia
    • anti-cholinergics used to treat EPSEs
      • procyclidine (potential for misuse)
61
Q

typical anti-psychotics monitoring

A
  • baseline: FBC, lipids, LFT, HbA1c, weight, ECG, blood pressure & pulse
  • weekly: weight in an ideal world
  • three months: FBC, lipids, LFT, HbA1C, weight, ECG, blood pressure & pulse
  • yearly: FBC, lipids, LFT, HbA1C, weight, ECG, blood pressure & pulse
62
Q

typical anti-psychotics contraindications & cautions

A
  • cautions
    • CVD
    • parkinson’s disease
    • epilepsy
    • depression
    • myasthenia gravis
    • prostatic hypertrophy
  • contraindications
    • comatose states
    • CNS depression
    • phaeochromocytoma
63
Q

typical anti-psychotics route

A
  • usually oral
  • can also be given by short-acting IM injection
  • some antipsychotics can be given as depot injections every 1-4 weeks (long acting, slow release)
    • numerous eg. flupentixol, fluphenazine, zuclopenthixol
64
Q

atypical antipsychotics examples

A
  • olanzapine
  • risperidone
  • quetiapine
  • amisulpride
  • aripiprazole
  • clozapine
65
Q

atypical antipsychotics indications

A
  • indicated for patients suffering from psychotic symptoms eg. delusions and hallucinations (mainstay of treatment for schizophrenia)
  • can be used for other conditions when they present with positive psychotic symptoms
    • depression
    • mania
    • delusional disorders
    • acute & transient psychotic disorders
    • delirium
    • dementia
  • violet/dangerously impulsive behaviour and psychomotor agitation
  • clozapine - third-line treatment for schizophrenia
    • should only be prescribed after failing to respond to two other antipsychotics (treatment-resistant schizophrenia)
66
Q

atypical antipsychotics mechanism of action

A
  • specific dopaminergic action, blocking the D2 receptor
  • also have serotonergic effects
67
Q

atypical antipsychotics SEs

A
  • sedation
  • weight gain
  • QTc prolongation
  • dyslipidaemia
  • diabetes
  • metabolic syndrome
  • clozapine
    • agranulocytosis
    • constipation, potentially fatal bowel obstruction
    • hypersalivation
    • urinary incontinence
68
Q

atypical antipsychotics monitoring

A
  • baseline: FBC, lipids, LFT, HbA1c, weight, ECG, blood pressure & pulse
  • weekly: weight in an ideal world
  • three months: FBC, lipids, LFT, HbA1C, weight, ECG, blood pressure & pulse
  • yearly: FBC, lipids, LFT, HbA1C, weight, ECG, blood pressure & pulse
  • clozapine
    • weekly FBC for first 18 weeks, then fortnightly for up to a year, then monthly
69
Q

atypical antipsychotics contradications & cautions

A
  • cautions
    • CVD
    • parkinson’s disease
    • epilepsy
    • depression
    • myasthenia gravis
    • prostatic hypertrophy
  • contraindications
    • comatose states
    • CNS depression
    • phaeochromocytoma
70
Q

atypical antipsychotics route

A
  • usually oral
  • some can also be given by short-acting IM injection
  • some can also be given as depot injections
    • risperidone
    • olanzapine
    • aripiprazole
71
Q

Benzodiazepines examples

A
  • long acting (> 24 hours duration)
    • diazepam
    • nitrazepame
    • chlordiazepoxide
  • short-acting (< 12 hours duration)
    • lorazepam
    • oxazepam
    • midazolame
72
Q

Benzodiazepines indications

A
  • insomnia (short-term)
  • anxiety disorders
  • delirium tremens and alcohol detoxification
  • acute psychosis
  • violent behaviour
73
Q

Benzodiazepines mechanism of action

A
  • enhance the effect of the inhibitory neurotransmitter GABA by increasing the frequency of chloride channels via the benzodiazepine-binding site of the GABA-A receptor
    • receptors are located throughout the cortex and limbic system in the brain & function to inhibit neuronal activity
74
Q

Benzodiazepines side effects

A
  • drowsiness & light-headedness the next day
  • confusion and ataxia, especially in the elderly
  • amnesia
  • dependence
  • paradoxical increase in aggression
  • muscle weakness
  • respiratory depression
75
Q

Benzodiazepine withdrawal syndrome

A

May develop at any time up to 3 weeks after stopping a long-acting benzodiazepine, but may occur within a day in the case of a short-acting one

SE: insomnia, anxiety, loss of appetite, tremor, muscle twitching, sweating, tinnitus, perceptual disturbances & seizures (rarely)

76
Q

Benzodiazepine cautions & contraindications

A
  • respiratory depression
  • hepatic impairment
77
Q

Benzodiazepines route

A
  • PO
  • IM, IV & PR benzodiazepine preparations are mainly for non-compliant patients & status epilepticus
78
Q

Pregabalin use in anxiety

A

Inhibitor of glutamate, noradrenaline and substance P
Uses: GAD, neuropathic pain, epilepsy
SE: dizziness, drowsiness, blurred vision, diplopia, confusion, vivid dreams, sedation, weight gain

79
Q

Beta blockers use in anxiety

A

Notably propranolol, at a starting dose of 40mg, can be used in anxiety disorder for reducing somatic symptoms eg. tachycardia, palpitations & tremor

Contraindicated in asthma, COPD, bronchospasm, heart block, marked hypotension & acute LVF

80
Q

Buspirone use in anxiety

A

Non-sedating anxiolytic used for GAD

Works as a 5HT-1A agonist

Does not cause dependence, but its anxiolytic effect develops more slowly

SE: nausea, headache, light-headedness & dizziness

81
Q

Hypnotics types

A

Benzodiazepines - temazepam, lormatazepam & nitrazepam

Nonbenzodiazepines - zopiclone, zolpidem

82
Q

Hypnotics (‘Z drugs’) mechanism of action

A

Work like BZDs by enhancing GABA transmission but are mainly used as hypnotics as they have:

  • shorter half lives
  • reduced risk of tolerance & dependence
  • reduced psychomotor & hangover effects
83
Q

Hypnotics use

A

Only for two weeks and take for only 5 out of 7 days each week to reduce potential for tolerance

84
Q

Mood stabilisers

A

Used to treat bipolar mood disorder

Come from one of the following groups:

  • lithium
  • anticonvulsants
  • second generation antipsychotics
85
Q

Lithium indications

A

One of the most effective mood stabilisers

Reduction of self-harm

Augment antidepressants

86
Q

Lithium monitoring

A

Narrow therapeutic window → regular serum lithium levels → weekly after dose change until level stable then 3 monthly once stable

Sample taken 12 hours post-dose

U&Es and TFTs every 6 months

87
Q

Lithium SEs

A

GI disturbance, metallic taste and/or dry mouth, fine tremor, polydipsia & polyuria, weight gain

Long-term effects: hypothyroidism (usually reversible), renal impairment (usually irreversible)

88
Q

Lithium interactions

A

Following can increase levels dangerously include:

  • NSAIDs
  • loop diuretics
  • ACE inhibitors
89
Q

SGAs in bipolar mood disorder

A

Quetiapine now first line treatment for bipolar

All SGAs have effectiveness & so do FGAs

Doses and monitoring the same as for psychosis

90
Q

Anticonvulsants as mood stabilisers

A

Various modes of action - GABA receptors, calcium channels, sodium channels

Most common used:

  • sodium valproate - avoid in women of child bearing age due to teratogenicity; check LFTs before and soon after starting
  • carbamazepine
  • lamotrigine - potential for Stevens Johnson Syndrome

Most anticonvulsants have potential to cause thrombocytopenia so check FBC

SEs: sedation & weight gain

91
Q

ADD & ADHD medication

A

Most treatments are CNS stimulants

1) methylphenidate

  • most commonly prescribed
  • often given with a combination of immediate & sustained release

2) dextroamphetamine

  • stimulants have potential for misuse & dependency
  • monitor weight, height (in children) & pulse

Atomoxetine - noradrenaline re-uptake inhibitor

  • used according to patient preference, unable to tolerate stimulants or in instances of previous drug dependence

Y4 psychiatry (8 decks)

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