Anxiety

Question 1

Methadone co-prescribed with benzo

Answer 1

The respiratory depressant effect of methadone may be delayed so patient should be monitored for at least 2 weeks after initiation.

Question 2

STOPP criteria for elderly on benzos

Answer 2

Duration of 4 weeks or longer- all benzos should be withdrawn gradually if taken for more than 2 weeks as there is risk of benzodiazepine withdrawal syndrome if stopped abruptly
Acute/chronic resp failure PaO2<8kPa
In patients prone to falls (as it is sedative and may impair balance)

Question 3

Benzos during pregnancy

Answer 3

Risk of neonatal withdrawal symptoms

High doses late in pregnancy may cause neonatal hypothermia, hypotonia and respiratory depression.

Question 4

Pre-eclampsia

Answer 4

Affects some pregnant women, usually during the second half of pregnancy (from around 20 weeks) or soon after their baby is delivered.
Early signs of pre-eclampsia include hypertension and proteinuria.
Further symptoms can develop, including:
- swelling of the feet, ankles, face and hands caused by fluid retention (oedema)
- severe headache
- vision problems
- pain just below the ribs

Question 5

ADHD prevalence

Answer 5

Usually 3-7 years

More commonly in males than females

Question 6

First line for ADHD

Answer 6

Lisdexamfetamine mesilate or methylphenidate hydrochloride (Switch to alternative 1st line if no improvements in the first 6 weeks)
If patients are intolerant or have trialled both first lines, alternative is atomoxetine (non-stimulant)

Question 7

Modified release preparations of stimulants

Answer 7

Reduced risk of drug diversion (for non-prescription use or misuse)

Question 8

Monitoring of atomoxetine

Answer 8

Monitor for appearance of anxiety, depression or tics

Record at initiation, at every dose change and every 6 months:

Pulse
BP
Psychiatric symptoms
Appetite
Weight 
Height

Question 9

Atomoxetine patient info

Answer 9

Noticing severe hepatic impairment (malaise, abdominal pain, jaundice, unexplained nausea, darkening of the urine)
Risk of suicidal ideation, depression, irritability or agitation

Question 10

Dexamfetamine sulfate maximum dose

Answer 10

60mg per day

Question 11

Dexamfetamine sulfate cautions

Answer 11

History of epilepsy (stop is seizures occur)
Tics + Tourette syndrome- stop if tics occur

Monitor height and weight as growth restriction may occur during prolonged therapy

Question 12

Lisdexamfetamine mesilate maximum dose

Answer 12

70mg

Question 13

Overdose of amfetamines

Answer 13

Wakefulness
Excessive activity
Paranoia
Hallucinations
Hypertension, followed by exhaustion, convulsions, hyperthermia and coma

Question 14

When should antidepressants be avoided in bipolar disorder or mania?

Answer 14

Patients with rapid-cycling bipolar disorder
History of hypomania
Rapid mood fluctuations

Question 15

First line for acute episodes of mania and hypomania

Answer 15

Antipsychotic drugs e.g. olanzapine, quetiapine, risperidone
If inadequate response, add lithium or valproate
Lithium or valproate can be used in addition to antipsychotic in severe acute mania

Question 16

Long term management of bipolar disorder

Answer 16

Olanzapine can be used if they responded to therapy during manic episode

Question 17

Discontinuining antipsychotics

Answer 17

Reduce dose gradually over at least 4 weeks if they are going to be switched to other antimanic drugs.

If they are not continuing with antimanic drugs or have a history of manic relapse, withdrawal period of up to 3 months can be considered.

Question 18

Carbamazepine in bipolar disorder

Answer 18

Can be used for prophylaxis of bipolar disorder (manic-depressive disorder) in patients unresponsive to the other drugs
Used in patients with rapid-cycling manic-depressive illness (4 or more effective episodes a year)
Shouldn’t usually be increased in acute mania episode

Question 19

Valproate in mania

Answer 19

Used for treatment of manic episodes and used for prophylaxis of bipolar disorder.

Question 20

Lithium

Answer 20

Prophylaxis and treatment of mania, hypomania and depression in bipolar disorder
Also licensed for aggressive or self-harming behaviour

The full prophylactic effect of lithium may not occur for six to twelve months after initiation of therapy.

Question 21

Semisodium valproate

Answer 21

Equimolar amounts of sodium valproate and valproic acid.

Question 22

Liver toxicity with valproate

Answer 22

Usually occurs in the first 6 months
Raised liver enzymes are transient- monitor but withdraw immediately if persistent vomiting and abdominal pain, anorexia, jaundice, oedema, malaise, drowsiness or loss of seizure control

Also discontinue if signs of pancreatitis

Question 23

Valproate dose for increased risk of teratogenicity

Answer 23

Greater than 1g daily

Question 24

Cautions with lithium

Answer 24

Cardiac disease
Concurrent ECT (electroconvulsive therapy) or epilepsy- may lower seizure threshold)

Question 25

Long term use of lithium

Answer 25

Associated with hypothyroidism and mild cognitive and memory impairment Monitor thyroid function every 6 months Need for continued therapy should be assessed regularly and should only be maintained after 3-5 years if beneficial.

Question 26

Lithium overdose

Answer 26

``` GI disturbances (vomiting, diarrhoea) Visual disturbances Polyuria Muscle weakness Fine tremor, increasing to coarse tremor CNS disturbances (confusion and drowsiness increasing to lack of coordination, restlessness) Hypernatraemia Myoclonus Cardiac arrhythmias, heart block ```

Question 27

Lithium in pregnancy

Answer 27

Avoid if possible in 1st trimester, increase dose in 2nd and 3rd but return to normal on delivery

Question 28

Lithium range

Answer 28

Measure 12 hours after dose Serum conc of 0.4-1mmol/l (lower end for maintenance and elderly) Serum conc of 0.8-1mmol/l for acute episodes of mania for those who have relapsed

Question 29

Frequency of lithium monitoring

Answer 29

Every week and after each dose change till stable Then every 3 months for the first year and every 6 months thereafter. Frequency to be increased to every 3 months for patients who are 65 years and older, taking drugs that interact with lithium, at risk of impaired renal or thyroid function, raised calcium levels or other complications, have poor symptom control or poor adherence, or whose last serum-lithium concentration was 0.8 mmol/litre or higher,