Tranquilisers and stimulants Flashcards
What are the 3 NICE steps in de-escalation?
- Risk assessment
- De-escalation
- Intervention
- Physical intervention or ‘restraint’
- Seclusion
- Rapid tranquilisation (chemical restraint)
List 3 possible medications used for rapid tranquilisation, their routes and doses.
- Lorazepam 2mg PO (max 4mg total)
- OR Lorazepam 2mg IM (max 4mg total)
- Haloperidol 5mg PO (max 12mg total)
- OR Haloperidol 5mg IM (max 20mg total)
- Promethazine 50mg PO (max 150mg total)
- OR Promethazine 50mg IM (max 150mg total)
Name a short acting benzodiazepine which is first line for RT. Name 3 antipsychotics which are licensed be used for RT.
Benzodiazepine: Lorazepam
Antipsychotics: Olanzapine, Aripiprazole and Haloperidol
List 3 risks associated with antipsychotic use as RT.
- arrythymia/death,
- NMS,
- EPSEs
Other than benzo/antipsychotic, what other drug may be used for RT?
Promethazine - sedatinh antihistamine
What are 3 risks of benzo use as RT?
- falls
- sedation
- reduced respiratory rate
Which of these vitals need to be monitored during RT administration?
- HR
- BP
- Full neuro obs
- GCS
- ECG tracing
- Temperature
- BM
- GCS - sedation
- HR - arrhythmias
- RR - benzo use may reduce this
- Temp - NMS risk
- BP
ECG and full neuro obs are not required
Define sedative medication. How do they usually work?
Drug that has a hypnotic +/- anxiolytic effects
Usually work by enhancing the effects of GABA (γ-aminobutyric acid)
List 2 types of medications and 2 types of recreational compounds which are sedatives.
Medications:
- Benzodiazepines
- Z drugs
Recreational:
- Alcohol
- GHB (roofies, date rape drug)
Withdrawal from sedatives is easy. True or false?
Withdrawals are potentially lethal
List 3 psychiatric and 3 medical uses for benzodiazepines.
Psychiatric:
- Insomnia (Short term),
- Severe anxiety (Short term),
- Sedation in Acute mania/psychosis (RT)
Medical:
- Alcohol withdrawals,
- Epilepsy prophylaxis,
- Seizure,
- Muscle spasm
- Anaesthesia
What is the MOA of benzodiazepines?
Bind GABA-A receptor at different allosteric sites
–> Receptor has greater affinity for GABA
–> Increased frequency of opening Cl- channel
–> Hyperpolarization of postsynaptic membrane
–> Reduced neuronal excitability/CNS depression
*NB barbituates increase duration of opening of the chloride channels.
Which benzodiazepines have a long vs short half life?
Midazolam and lorazepam have short half life
Diazepam and clonazepam have a long half life
What are the risks of benzodiazepine use in the elderly?
- Respiratory disease (COPD, OSA)
- Older patients
- Liver failure
- Falls risk (hypotension)
- Delirium and confusion
- Abuse potential/overdose
Another SE is sedation which sometimes is the desired effect but if not then risk when operating machinery and driving***
What is the antidose to benzodiazepines?
GABA-A antagonist called Flumazenil (given IV every minute)
Which benzodiazepines can be used in liver impairment?
What are the benzo options in liver impairment? LOTZ!
- Lorazepam
- Oxazepam
- Temazepam
- Z drugs (3.7mg zopiclone)
What are the withdrawal/dependance symptoms of benzodiazepines?
- rebound insomnia,
- tremor,
- anxiety,
- restlessness,
- appetite disturbance,
- weight loss,
- sweating,
- convulsions,
- confusion. (withdrawal potentially lethal)
Name 3 Z drugs. What is their half life range?
- Zaleplon
- Zolpidem
- Zopiclone
What is the main use of Z drugs?
Short term use for insomnia
What is the MOA of Z drugs?
Bind to GABA-A (near the BZD receptor complex; called nonbenzodiazepines because were developed with claims to do the same but not to cause next day sedation or physical dependance which isn’t true)
Also bind to GABA-B
What are the other hypnotics apart from Z drugs?(2)
Promethazime - sedating antihistamines; non-addictive, anticholinergic side effects
Pregabalin - anticonvulsant licensed third line for GAD; similar structure to GABA (but via a different mechanism); big potential for abuse so not prescribed much.
What is ADHD aka? What is the triad?
ADHD = hyperkinetic disorder
- Inattention
- Hyperactivity
- Impulsivity
Describe using examples each of the 3 features of ADHD.
Inattention -
- short attention span and therefore can present as ‘distractable’
- difficulty completing tasks
- forgetful
- struggle to concentrate (especially tasks requiring prolonged mental effort) or organise tasks
- careless mistakes at work/school
- losing belongings
Hyperactivity -
- excess physical movement
- restlessness
- fidgeting
- running/jumping (espeically inappropriate situations)
- excessive talking and may interrupt others in conversation
Impulsivity -
- difficulty controlling impulses so will struggle to be patient
- may not let other children answer questions asked by the teacher
- risk taking behaviours without appreciation for danger
What is the management of suspected ADHD?
- Referral to specialist e.g. psychiatrist or paediatrician
- Full assessment including developmental and psychiatric and medical history, collateral and psychosocial assessment
- Exclude differential diagnoses e.g. personality disorder, anxiety/mood disorder, thyroid disease, substance misuse
What is the management of diagnosed ADHD?
Psychosocial - usually first line in children with mild-moderate ADHD
Assessment of social needs e.g. parental education and training. social skills training, CBT, educational needs (does the child need extra support)
True or false?
- Methylphenidate causes long term growth retardation
- Atomoxetine causes insomnia
- Atomoxetine can increase suicidal thoughts in children T/F?
- Dexamphetamine is the best option if there is concern about abuse potential
- Atomoxetine exacerbates tics
- Atomoxetine can cause liver dysfunction
- BP and HR should be monitored with ADHD medication
Answers:
- Methylphenidate causes long term growth retardation - false - short term growth retardation then children catch up
- Atomoxetine causes insomnia - false - this is a feature of methylphenidate
- Atomoxetine can increase suicidal thoughts in children? - true - all potentially cause this
- Dexamphetamine is the best option if there is concern about abuse potential - false - this is atomoxetine
- Atomoxetine exacerbates tics - false - methylphenydate does this
- Atomoxetine can cause liver dysfunction - true - all can do this and were previously monitored but now not as much
- BP and HR should be monitored with ADHD medication - true
Who can start a patient on methylphenidate?
Only a specialist as it is a controlled drug
What is the MOA of stimulants like methylphenidate?
Release NA, dopamine and sertraline, increasing extracellular dopamine –> ‘inhibit’ impulses, helping persistance in motor and cognitive functions
How fast do stimulants act?
Rapidly absorbed after oral administration e.g. methylphenidate onset is 1-3 hours
When is medication recommended in ADHD?
NICE:
- moderate ADHD who have failed to respond to psychosocial intervention OR
- severe ADHD
What are the cautions and SE of methylphenidate?
Requires careful titration and close monitoring for:
- Common:
- aggression/hostility,
- decreased appetite,
- sleep disorders,
- GI discomfort
- Arrythmia: consider baseline ECG (referral to cardiology) and pulse
- HTN: monitor BP
- Anorexia and growth suppression; monitor height and weight comparing to growth charts and BMI in adults
- Tics
What is the second line medication used in ADHD? Why would it be considered?
- Dexamfetamine/lisdexamfetamine (Adderall)- also stimulants - OR
- Atomoxetine - NARI antidepressant medication
Used when there is a poor response to methylphenidate or it is poorly tolerated. Or atomoxetine is used when there is concern about abuse of stimulants.
What are the SE which should be monitored for in dexamfetamine use?
arrythmia, hypertension and anorexia
What are the benefits of atomoxetine? What are its SE/cons?
Pros:
- little or no insomnia
- no tics
- may help comorbid depression
Cons/SE:
- weight loss
- decreased appetite
- GI
- fatigue
- probable mild growth slowing
- slower to work
What may need to be monitored for all ADHD medications?
- LTFs - may become deranged on all
- Suicidal thoughts - may increase
- BP and HR
What is the criteria (briefly) for diagnosing ADHD?
Difficulties in three domains and need to cause significant functional impairment in at least two settings e.g. school and home.
Symptoms need to be present for at least 6 months and before age 12yrs old.
