Drugs Flashcards

Question

What advantage does aripiprazole have other other atypical antipsychotics

Answer 1

Aripiprazole is a partial dopamine agonist and so is less likely to cause EPSEs than the others.

Answer 2

However, patients on clozapine require regular blood tests to check their neutrophil levels as clozapine can cause agranulocytosis, which is potentially life-threatening.

Answer 3

interferes with inositol triphosphate formation interferes with cAMP formation

Answer 4

Prophylactically in bipolar disorder An adjunct in refractory depression

Answer 5

PK Narrow therapeutic range Long plasma half life PD Excreted primarily by kidneys

Answer 6

nausea/vomiting, diarrhoea fine tremor nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus thyroid enlargement, may lead to hypothyroidism ECG: T wave flattening/inversion weight gain idiopathic intracranial hypertension leucocytosis hyperparathyroidism and resultant hypercalcaemia

Answer 7

Weekly And after each dose change (1 week later and then weekly) Until concentrations are stable Once stable, every 3 months

Answer 8

Every 3 months

Answer 9

Levels: weekly when dose changed or levels not stable (12 hours post dose!) Thyroid function - 6 months Renal function: U&Es and calcium - 6 months

Answer 10

Information booklet Alert card Record book

Answer 11

The management of lithium toxicity is largely supportive and requires specialist input. Stop lithium Maintaining electrolyte balance, monitoring renal function and seizure control are the main aims. IV fluid therapy and alkalisation of the urine are beneficial and enhance excretion of the drug. Benzodiazepines may be used to treat agitation and seizures in lithium toxicity. Haemodialysis can be required if the renal function is poor.

Answer 12

“Lithium works by changing the way your brain processes signals to help stabilise your mood.” Mechanism of action unknown – does all sorts of things in the brain, notably lowering noradrenaline release and increasing serotonin synthesis

Answer 13

Swallow with plenty of water Encourage to take at night Patient must take medication at same time every day Do not stop suddenly or change dose without speaking to a doctor Do not take double dose if missed, just take next dose as normal Carry lithium record book at all times in case of emergency

Answer 14

Increased thirst Increased volume and frequency of urination Tiredness Weight gain Fine tremor

Answer 15

Confusion Drowsiness Problems with vision Loss of appetite Difficulty speaking Seizures Excessive thirst and urination

Answer 16

Lethargy Insipidus (diabetes) Tremor Hypothyroidism Insides (gastrointestinal) Urine (increased) Metallic taste

Answer 17

Can increase serum level of lithium

Answer 18

Taking dose at same time every day Regularly attending blood monitoring

Answer 19

Lithium associated birth defects generally occur within the first trimester of pregnancy when the fetal organs are developing Lithium has been shown to increase the risk of fetal heart defects Lithium is able to pass into the baby’s circulation through breastmilk and breastfeeding should therefore be avoided Advise the patient that they should use a reliable method of contraception such as a subdermal implant or intrauterine system (IUS) to prevent accidental pregnancy whilst taking lithium.

Answer 20

Suicidal ideation and self harm Monitor weekly for first month

Answer 21

Benzodiazapines should not be prescribed for more than 10 days due to risk of dependency and sedation. Use only to overcome symptoms so severe they obstruct initiation of more appropriate psychological treatment Diazepam preferred due to longer half life (less risk of withdrawal symptoms with neurotic symptoms, neurological symptoms like ataxia, paraesthesia, hyperacusis and other major symptoms such as hallucinations, psychosis and epilepsy)

Answer 22

Busipirone (5HT1A¬ agonist) is suitable for short term management Delayed onset of action Diminished efficacy in previous benzo users Side effects: dizziness, headache and nausea Minimal sedation

Answer 23

Prolongation of the QT interval has been associated with haloperidol use, which can increase the risk of ventricular tachyarrhythmia and sudden death. It is therefore recommended that ECG measurements are taken after dose changes of haloperidol, as well as annually.

Answer 24

Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways

Answer 25

Act on a variety of receptors (D2, D3, D4, 5-HT)

Answer 26

Clozapine Risperidone Olanzapine

Answer 27

Haloperidol Chlopromazine

Answer 28

Parkinsonism acute dystonia sustained muscle contraction (e.g. torticollis, oculogyric crisis) may be managed with procyclidine akathisia (severe restlessness) tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)

Answer 29

antimuscarinic: dry mouth, blurred vision, urinary retention, constipation sedation, weight gain raised prolactin may result in galactorrhoea due to inhibition of the dopaminergic tuberoinfundibular pathway impaired glucose tolerance neuroleptic malignant syndrome: pyrexia, muscle stiffness reduced seizure threshold (greater with atypicals) prolonged QT interval (particularly haloperidol) Elderly patients: increased risk of stroke increased risk of venous thromboembolism EPSEs (parkinsonism, acute dystonia, akathisia (severe restlessness), tardive dyskinesia)

Answer 30

Administer IM or IV anticholinergics – first line is procyclidine Continue for 1 to 2 days after dystonia and consider long-term prophylactic

Answer 31

sustained muscle contraction (e.g. torticollis, oculogyric crisis) Often paniful, producing twisted abnormal postures Most common: neck, tongue, jaw, oculogyric crisis (neck arached eyes rolled back)

Answer 32

late onset of choreoathetoid movements, abnormal, involuntary may occur in 40% of patients taking typical antispychotics may be irreversible most common is chewing and pouting of jaw

Answer 33

Sedation Hyperprolactinaemia Sexual dysfunction Cardiac Arrhythmias Reduction of seizure threshold Increased risk of stroke death in the elderly (when used in demenatia-related psychosis) Increased risk of stroke in the elderly

Answer 34

Weight gain Worsening glycaemic control Dyslipidaemia Hyperprolactinaemia (both first and second gen)

Answer 35

clozapine is associated with agranulocytosis

Answer 36

clozapine olanzapine: higher risk of dyslipidemia and obesity risperidone quetiapine amisulpride aripiprazole: generally good side-effect profile, particularly for prolactin elevation

Answer 37

Clozapine should be introduced if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks.

Answer 38

agranulocytosis (1%), neutropaenia (3%) reduced seizure threshold - can induce seizures in up to 3% of patients constipation (potentially fatal bowel obstruction) - GI hypo-mobility myocarditis: a baseline ECG should be taken before starting treatment hypersalivation hypothyroidism

Answer 39

Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment.

Answer 40

Also annually: Full blood count (FBC) (initially weekly for clozapine) Urea and electrolytes (U&E) Liver function tests (LFT) CVS risk assessment Also at 3 months and then annually: Weight Lipids Also at 6 months and then annually: Fasting blood glucose Prolactin Carefully when titrating dosage: Blood pressure Basline: ECG

Answer 41

Full blood count (FBC) (initially weekly for clozapine) Urea and electrolytes (U&E) Liver function tests (LFT) Lipids Weight Fasting blood glucose Prolactin CVS risk assessment

Answer 42

Weight Lipids And then annually

Answer 43

Fasting blood glucose Prolactin And the annually

Answer 44

Mirtazapine is an antidepressant that works by blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters. Acts as a 5HT-2 and 5HT-3 antagonist

Answer 45

Mirtazapine has fewer side effects and interactions than many other antidepressants and so is useful in older people who may be affected more or be taking other medications. Two side effects of mirtazapine, sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite.

Answer 46

In the evening, due to sedating affects

Answer 47

Inhibition in metabolism of serotonin and noradrenaline (serotonin and noradrenaline are metabolised by monoamine oxidase in the presynaptic cell)

Answer 48

tranylcypromine phenelzine

Answer 49

used in the treatment of atypical depression (e.g. hyperphagia) and other psychiatric disorders not used frequently due to side-effects

Answer 50

hypertensive reactions with tyramine containing foods e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad beans anticholinergic effects: Drowsiness or sedation. Blurred vision. Dizziness. Urinary retention. Confusion or delirium. Hallucinations. Dry mouth.

Answer 51

sertraline is useful post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants Significant in that MI has a particularly increased risk of developing depression

Answer 52

Fluoxetine

Answer 53

there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID

Answer 54

fluoxetine and paroxetine

Answer 55

it advised that citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval the maximum daily dose is now 40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment

Answer 56

NSAIDs: NICE guidelines advise 'do not normally offer SSRIs', but if given co-prescribe a proton pump inhibitor warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine aspirin: see above triptans - increased risk of serotonin syndrome monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome

Answer 57

mirtazapine

Answer 58

Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks. For patients under the age of 25 years or at increased risk of suicide should be reviewed after 1 week

Answer 59

Fluoxetine

Answer 60

Paroxetine (short half life)

Answer 61

increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia shaking adgitation headaches clonus irritability

Answer 62

- BNF says to weigh up benefits and risk when deciding whether to use in pregnancy. - Use during the first trimester gives a small increased risk of congenital heart defects - Use during the third trimester can result in persistent pulmonary hypertension of the newborn - Paroxetine has an increased risk of congenital malformations, particularly in the first trimester

Answer 63

Serotonin and noradrenaline reuptake inhibitor (SNRI's) are a class of relatively new antidepressants They are used to treat major depressive disorders, generalised anxiety disorder, social anxiety disorder and panic disorder and menopausal symptoms.

Answer 64

Inhibiting the reuptake increases the concentrations of serotonin and noradrenaline in the synaptic cleft leading to the effects.

Answer 65

venlafaxine duloxetine

Answer 66

lofepramine has a lower incidence of toxicity in overdose amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose

Answer 67

Amitriptyline Clomipramine Dosulepin Trazodone (technically a tricylic related antidepressant)

Answer 68

Imipramine Lofepramine Nortriptyline

Answer 69

sedation hypnotic anxiolytic anticonvulsant muscle relaxant

Answer 70

Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the frequency of chloride channels.

Answer 71

a short period of time (2-4 weeks)

Answer 72

The dose should be withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight. A suggested protocol for patients experiencing difficulty is given: switch patients to the equivalent dose of diazepam reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg time needed for withdrawal can vary from 4 weeks to a year or more

Answer 73

If patients withdraw too quickly from benzodiazepines they may experience benzodiazepine withdrawal syndrome, a condition very similar to alcohol withdrawal syndrome. This may occur up to 3 weeks after stopping a long-acting drug. Features include: insomnia irritability anxiety tremor loss of appetite tinnitus perspiration perceptual disturbances seizures

Answer 74

GABAa drugs benzodiazipines increase the frequency of chloride channels barbiturates increase the duration of chloride channel opening Barbidurates increase duration & Frendodiazepines increase frequency

Answer 75

daytime sedation poor motor coordination cognitive impairment related concerns about accidents and injuries In addition, tolerance to the hypnotic effects of benzodiazepines may be rapid (within a few days or weeks of regular use).

Answer 76

Z drugs have similar effects to benzodiazepines but are different structurally. They act on the α2-subunit of the GABA receptor.

Answer 77

Imidazopyridines: e.g. zolpidem Cyclopyrrolones: e.g. zopiclone Pyrazolopyrimidines: e.g. zaleplon

Answer 78

Methamphetamine acts at TAAR1 (Trace Amine-Associated Receptor 1) receptors.

Answer 79

Cocaine acts at dopamine receptors.

Answer 80

Both are stimulants Both, in low doses, produce a feeling of increased concentration and focus. Both increase the available amount of dopamine in the brain, producing the associated pleasurable effects of the drugs.

Answer 81

Serotonin syndrome (SS) is a potentially life-threatening disorder that is characterised by altered mental status (i.e. confusion), autonomic hyperactivity, and neuromuscular abnormalities (e.g. rigidity, clonus, hyperreflexia).

Answer 82

It is due to increased serotonergic activity in the central nervous system (CNS) that can be induced by a range of medications that increase serotonergic transmission by altering the neurotransmitter serotonin.

Answer 83

Serotonin is a monoamine neurotransmitter that is derived from the amino acid tryptophan. It has important functions in the CNS and peripheral nervous system (PNS): CNS: modulates thermoregulation, behaviour, and attention PNS: regulates GI motility, vasoconstriction, bronchoconstriction, and uterine contraction Other: promotes platelet aggregation (thus, combined use with anti-platelets can increase bleeding risk)

Answer 84

Amphetamines MDMA (ecstasy) Cocaine

Answer 85

SSRIs SNRIs MDMA Tricycle antidepressants Serotonin modulators

Answer 86

Monoamine oxidase inhibitors

Answer 87

Buspirone Triptans

Answer 88

Altered mental status: may present as anxiety, restlessness, disorientation, or agitation Sweating Fever Vomiting Diarrhoea

Answer 89

Dilated pupils Flushed skin, diaphoresis Tachycardia, hypertension Hyperthermia (>38.0º) Hyperreflexia Clonus: repeated, rhythmic contractions Myoclonus: sudden jerky or spastic contraction Rigidity Bilateral upgoing plantars (Babinski sign)

Answer 90

Hunter criteria SS can be diagnosed in a patient taking a serotonergic agent (e.g. SSRI) and presents with one of the following features: - Spontaneous clonus - Inducible/ocular clonus and agitation or diaphoresis - Tremor and hyperreflexia - Hyperthermia, hypertonia, and ocular/inducible clonus

Answer 91

Investigations are useful to determine the severity of SS and to exclude alternative causes. Bedside: ECG, cardiac monitoring (particularly if profound autonomic symptoms), blood glucose, urine dip Bloods: full blood count, urea & electrolytes, LFTs, coagulation, blood cultures (if febrile), creatine kinase, and blood gas. Patients may have features of neutrophilia, acute kidney injury, or elevated CK levels. Severe cases of SS can lead to rhabdomyolysis (i.e. skeletal muscle necrosis). Imaging: cerebral imaging (i.e. CT/MRI) may be needed in patients with new-onset altered mental status to exclude an alternative cause. A chest x-ray is usually needed as part of a septic screen if patients are febrile. Special: a lumbar puncture may be needed to exclude an intracerebral infection or investigate for an alternative cause of confusion (e.g. autoimmune encephalopathy).

Answer 92

Neuroleptic malignant syndrome Malignant hyperthermia Recreational drug use

Answer 93

a rare genetic disorder characterised by hyperthermia, muscle rigidity, and dysautonomia in the setting of exposure to certain anaesthetic agents (e.g. succinylcholine) or vigorous exercise.

Answer 94

The management of SS largely depends on the severity of symptoms. In mild cases, patients may be observed for 4-6 hours and then discharged. In severe cases, patients may need organ support in intensive care. Serotonin antagonists can be given in severe cases although evidence for their use is incomplete.

Answer 95

The serotonergic agent should be stopped and patients should be monitored in the appropriate setting. Cardiac monitoring is usually required due to dysautonomia. Patients should be monitored and specific complications treated (e.g. electrolyte imbalance, acute kidney injury, rhabdomyolysis). In severe cases, patients may require organ support (e.g. intubation & ventilation, haemofiltration) and admission to intensive care. Specific interventions that are helpful: include intravenous fluids to maintain euvolaemic state, antipyretics and cooling blankets for hyperthermia, specific antihypertensive agents for profound hypertension, benzodiazepines as necessary for agitation. In severe hyperthermia (>41º), antipyretics are unlikely to work as the increased body temperature is due to muscular activity not altered hypothalamic regulation. Therefore, sedation, paralysis, and tracheal intubation are usually required.

Answer 96

If supportive measures including the use of benzodiazepines fail to improve vital signs or agitation, patients can be considered for serotonin antagonists (e.g. Cyproheptadine). Cyproheptadine is a histamine receptor antagonist with action against serotonin receptors.

Answer 97

SS usually resolves within 24 hours of stopping the serotonergic medication. Patients will mild symptoms who recover quickly may only need observation for 4-6 hours. Advice should always be sought from ‘Toxbase’ or a toxicologist if in doubt. This is particularly important in patients where an overdose has been taken. It is important to avoid co-prescription of multiple serotonergic agents to prevent the development of SS.

Answer 98

Cardiac arrest Cardiac arrhythmias Acute kidney injury Rhabdomyolysis Disseminated intravascular coagulation Seizures Respiratory failure Venous thromboembolism

Answer 99

Neuroleptic malignant syndrome (NMS), is a rare, life-threatening disorder that is associated with the use of antipsychotic drugs (previously known as neuroleptic medications) but the exact cause is unknown.

Answer 100

Altered mental status (i.e. confusion) Fever Muscular rigidity Dysautonomia (i.e. autonomic instability).

Answer 101

The exact cause of NMS remains unknown. The condition is associated with the use of antipsychotics, but predominantly potent first-generation or ‘typical’ antipsychotics that are dopamine (D2) receptor antagonists. This includes haloperidol and fluphenazine. Rarely, other drugs with central dopamine antagonism can cause NMS (e.g. metoclopramide).

Answer 102

It is suspected that central blockade of dopamine in the hypothalamus leads to hyperthermia and dysautonomia. Blockade of other central pathways can give rise to movement disorders (e.g. tremor, rigidity) that are well recognised side-effects even in the absence of NMS. Alternatively, there may be direct toxic effects of these drugs on peripheral muscle or disruption of the sympathetic nervous system. A genetic predisposition has also been suggested.

Answer 103

NMS will typically occur within the first two weeks of starting an antipsychotic. However, it can occur after a single dose or after many years of using the medication.

Answer 104

The majority of episodes will resolve within two weeks of stopping the drug, although patients may require a prolonged period of supportive management and mortality can be up to 20%.

Answer 105

Higher antipsychotic doses High-potency antipsychotics Concomitant drug use (e.g. lithium) Depot formulations (i.e. long-acting) Acute medical illness (e.g. trauma, infection) Acute catatonia (state or immobility) Previous NMS

Answer 106

ALTERED MENTAL STATUS: often presents with agitation and delirium. CATONIA: May progress to severe encephalopathy and coma. RIDGIDITY felt as a generalised increase in tone and may be severe. Other motor abnormalities can be present. FEVER (>38º): less pronounced with second-generation antipsychotics. May be >40º. DYSAUTONOMIA: describes abnormalities in the autonomic nervous system. Thus, often termed ‘autonomic instability’. Leads to tachycardia, labile blood pressure, profuse sweating (i.e. diaphoresis) and/or arrhythmias.

Answer 107

Serotonin syndrome: similar presentation to NMS in association with selective serotonin reuptake inhibitor (SSRI) drug use. Characterised by nausea, vomiting, diarrhoea, shivering, hyperreflexia, myoclonus, and ataxia. Malignant hyperthermia: a rare genetic disorder characterised by hyperthermia, muscle rigidity, and dysautonomia in the setting of exposure to certain anaesthetic agents (e.g. succinylcholine) or vigorous exercise. Recreational drug use: both use of MDMA (i.e. ecstasy) and cocaine have been associated with an NMS-like syndrome.

Answer 108

The antipsychotic drug should be stopped and patients should be monitored in the appropriate setting. Cardiac monitoring is usually required due to dysautonomia. Patients should be monitored and specific complications treated (e.g. electrolyte imbalance, acute kidney injury, rhabdomyolysis). In severe cases, patients may require organ support (e.g. intubation & ventilation, haemofiltration) and admission to intensive care. Specific interventions that are helpful include intravenous fluids to maintain euvolaemic state, antipyretics and cooling blankets for hyperthermia, antihypertensive agents (e.g. clonidine) for profound hypertension and benzodiazepines as necessary for agitation.

Answer 109

The use of specific medical therapies in NMS is controversial due to inconsistent evidence. In moderate to severe cases, dantrolene or bromocriptine may be used alongside supportive measures. Dantrolene: ryanodine receptor antagonist (causes skeletal muscle relaxation). Helps treat hyperthermia and rigidity. Bromocriptine: dopamine agonist. Prescribed to restore ‘dopaminergic tone’.

Answer 110

Mortality from NMS ranges from 5-20% depending on the patient population studied. NMS may be life-threatening and a number of severe complications can develop: Cardiac arrest Cardiac arrhythmias Acute kidney injury Rhabdomyolysis Disseminated intravascular coagulation Seizures Respiratory failure Venous thromboembolism

Answer 111

ataxia COARSE tremor confusion nystagmus nausea and vomiting seizures Coarse tremor impaired coordination dysarthria Arrhythmias Visual disturbance

Answer 112

Flumazenil is a benzodiazepine antagonist and can be used in the treatment of benzodiazepine overdose. However, it is not commonly used since there are several risks associated with this medication. Firstly, in benzodiazepine-dependent patients it can precipitate seizures and so should be avoided. It is also often avoided if there is a possibility of a mixed overdose since the benzodiazepine may actually be inhibiting some of the harmful effects of the other drugs that have been taken and flumazenil can reverse this protective effect, precipitating features such as seizures and cardiac arrhythmias from the other drugs.

Answer 113

Restlessness and agitation

Answer 114

Caution with higher doses in heart disease – monitor blood pressure at doses above 225mgs.

Answer 115

sedation nausea sexual dysfunction

Answer 116

Dry mouth Drowsiness Dizziness Nausea and vomiting

Answer 117

Dry mouth, difficulty swallowing, thirst Difficulty urinating, urinary retention Hot and flushed skin. Dry skin

Answer 118

Sweating Tremor Headaches Nausea Dizziness

Answer 119

Weight changes (usually loss, can be gain) Sexual dysfunction - arousal, orgasm

Answer 120

Energy and volition may improve before outlook on life improves as depression treated - therefore may be motivated to action thoughts of 'not wanting to be here'

Answer 121

Act in the same way as SSRI’s (increase serotonin activity by reducing the presynaptic reuptake of serotonin after release) but also bind to noradrenaline reuptake receptors

Answer 122

Long half life

Answer 123

Short half life

Answer 124

Treatment of neuropathic pain

Answer 125

Strong H1 (histamine) receptor activity (antagonist) - occupying most receptors even at low doses

Answer 126

SSRIs - tolerated better TCA - QTc prolongation, higher risk in toxicity in overdose TCAs - do not cause insomnia as SSRIs do and have a sedative affect - can help with sleep SSRIs - more likely to cause GI upset and nausea SSRIs- less CVS side effects TCA - less likely to cause sexual dysfunction

Answer 127

Inhibit enzyme that breaks down tyramine - potential for tyramine reaction leading to hypertensive crisis - avoid cheese, pickled meats, wine and other tyramine products Potential significant and dangerous interaction with other drugs If changing to another antidepressant a washout period of up to 6 week is required

Answer 128

Reversable MAOI

Answer 129

Monoamine oxidase inhibitors – MAOI – A (work more on serotonin) and MAOI – B (work more on dopamine). All can potentially increase adrenaline.

Answer 130

Multiple different affects on serotonergic activity - differs according to receptor Well tolerated – most common side effect is nausea (but less severe than Venlafaxine) Evidence for improvement in difficult to treat cognitive symptoms

Answer 131

If an antidepressant is going to work there will usually be an effect within the first 3 weeks, but wait 4 weeks before making a final decision. For depression: if an antidepressant has absolutely no benefit at a typical dose it’s not worth increasing the dose – switch. If partial benefit increase the dose. For anxiety (especially OCD): consider increasing dose if no initial benefit. If an antidepressant has significant side-effects these may get better in a couple of weeks but if they cause a big problem for the patient – switch.

Answer 132

What has been used before? Was it effective and/or tolerated? Are there particular symptoms or comorbidities you may want to address: Weight loss/Insomnia/Neuropathic pain In new cases with no previous treatment start with an SSRI unless there is major weight loss or major sleep difficulty – in which case consider Mirtazapine, or comorbid neuropathic pain, in which case consider and SNRI In most cases start with an SSRI, if no effect switch to a different SSRI, if no effect switch to SNRI Venlafaxine or Mirtazapine Patient ICE

Answer 133

Encourages changes feeding into a sense of well being, creates habit, motivates routine

Answer 134

Men 450ms Women 470ms

Answer 135

All current antipsychotics reduce level of dopamine activity at D2 receptors. Target dopaminergic pathways in the brain are mesocortical and mesolimbic Unwanted effects come from action at nigrostriatal (movement) and tuberoinfundibular (hypothalamic-pituitary-adrenal axis) All antipsychotics have potential for sedation, extrapyramidal side-effects and weight gain All antipsychotics can cause acute dystonia, including oculogyric crisis

Answer 136

Less effective Better side effect profiles D2 partial agonist (not antagonist)

Answer 137

NASH and hepitatis risk

Answer 138

Typical tend to bind more to muscarinic and histaminic receptors Atypical tend to have more serotonergic activity.

Answer 139

NMS (neuroleptic malignant syndrome): Rare, life threatening reaction to antipsychotics Fever, confusuion, muscle rigidity, sweating, autonomic instablity May cause death: rhabdomyolysis, renal failure, seziures Risks: young men, high doses, antispychtoic naive, high potency dopamine antagonists (typicals) Mgx: emergency ref to A&E, stop antipsychtoics, give benzodiazepine for acute behavioural distrubance, reduce temp (cooing blankets), O2 if needed, rhabdomyolysis - fluid and sodium bicarbonate (alkalise urine), relax muscles - 1st line dantrolene or lorazepam, second line bromocriptine

Answer 140

1st line: Dantrolene ( ryanodine receptor antagonist, also helps with hyperthermia) Lorazepam (benzodiazepine, also helps with acute behavioural disturbance 2nd line: Bromocriptine (dopamine agonist, restores 'dopaminergic tone'

Answer 141

Relative decrease of dopamine relative to acetylcholine in nigrostriatal pathway due to antipsychotics Anti-cholinergics antagonise the acetylcholine receptors to reduce EPSEs

Answer 142

Dose titrated slowly upward over two weeks and vital signs monitored due to potential dysregulation Close monitoring of FBC: weekly for first 18 weeks, then fortnightly for up to a year, then monthly

Answer 143

Stop clozapine Stop any other potentially marrow supressing drugs - e.g. soddium valproate Avoid other antipsychotics for 2 weeks if possible, if not aripiprazole has less potential for bone marrow supression Contact Consultant Haematologist as an emergency Avoid sources of infection. Consider prophylactic broad-spectrum antibiotics Sometimes lithium is used to increased WCC and neutrophil count Granulocyte colony-stimulating factor (G-CSF) has been used

Answer 144

NMS Less potent D2 receptor antagonist

Answer 145

A movement disorder causing a feeling of restlessness and an inability to stay still.

Answer 146

Anxiolytics (anti anxiety)

Answer 147

Bind to GABA receptors to potentiate the effect of GABA and therefore reduce the excitability of neurones. Therefore they are positive allosteric modulators of GABA receptor

Answer 148

Benzodiazepines - increased dosage should address this

Answer 149

Used in anxiety, neuropathic pain and epilepsy

Answer 150

Binds to voltage gated calcium channels on neurones Reduces neuronal activity (i.e. is a CNS depressant)

Answer 151

Causes sedation and can cause weight gain Less potential for misuse and dependence (and tolerance) than benzodiazepines – but still misused – nickname “Budweisers”

Answer 152

Benzodiazepines: Temazepam, Lormatazepam, Nitrazepam Nonbenzodiazepines: Act in a very similar way (positive allosteric modulators) but are structurally different to benzodiazepines Also called Z drugs Zopiclone, Zolpidem

Answer 153

Lithium Anticonvulsants Second Generation (Atypical) Antipsychotics

Answer 154

Significant potential for misuse, dependence, rebound insomnia. Use for up to 6 weeks Use for only two weeks and take for only 5 out of 7 days each week to reduce potential for tolerance (ideally not two days in a row)

Answer 155

Bipolar disorder Also used to augment antidepressants

Answer 156

Hypothyroidism - usually reversable and can prescribe levothyroxine Renal impairment - usually reversable and occurs most above therapeutic dose

Answer 157

Significant evidence that lithium reduces suicide – and it has a licence for reduction of self-harm

Answer 158

Fine tremor - side effect Coarse tremor - toxicity

Answer 159

Not excreted by sweat Patients will need to drink plenty of water to ensure blood levels do not become too high leading to toxicity

Answer 160

NSAIDS Loop diuretics ACE inhibitors

Answer 161

Sodium valproate Carbamazepine Lamotrigine

Answer 162

avoid in women of child bearing age due to teratogenicity. Check LFTs before and soon after starting

Answer 163

potential for Stevens Johnson Syndrome

Answer 164

Theory that ascending reticular activating system under fires Stimulants increase activity at ARS - hedonic tone

Answer 165

Atomoxetine: noradrenaline re-uptake inhibitor

Answer 166

Loss of consciousness Airway obstruction Respiratory depression Hypertension Cardiac EPSE

Answer 167

If AKI develops during an episode of NMS this can increase mortality significantly.

Answer 168

Lead-pipe type muscular rigidity Hyperthermia (above 38degrees) Tachycardia Hypotension/Hypertension – Fluctuating BP usually. Incontinence. CK elevated. U&Es may show metabolic disturbance (due to AKI or acidosis). Bone profile may show hypercalcaemia. FBC may show leucocytosis. LFTs may be deranged and LDH raised. ABG may show metabolic acidosis.

Answer 169

- Paliperidone is a depot version of Risperidone. - Paliperidone does not require oral medication (Risperidone) to be taken during initiation, so is a good choice in a patient who is currently refusing all oral medications. - It is initiated through loading doses of IM injections (Day 1 and Day 8 of treatment, then monthly thereafter). -If a patient remains stable for at least four months on the monthly dose of IM Paliperidone, they can instead be given a formulation which only requires administration every 3 months.

Answer 170

Aripiprazole

Answer 171

Parkinsonism:shuffling gate

Answer 172

Constipation

Answer 173

Aripiprazole - doesn’t cause QTc prolongation

Answer 174

NSAIDs, as they may increase the concentration of lithium

Answer 175

Lithium or sodium valproate Atypical antipsychotic e.g. Olanzapine or quetiapine

Answer 176

Lamotrigine - used to treat bipolar depression

Answer 177

Sodium valproate

Answer 178

Stevens-Johnson syndrome & toxic epidermal necrolysis are rare side effects with Lamotrigine, which can be used sometimes for treatment resistant depression. Patients are advised to see their doctor immediately if they develop a rash

Answer 179

Tetrabenazine may be used to treat moderate/severe tardive dyskinesia

Answer 180

Methylphenidate, more commonly known as 'Ritalin', is a stimulant prescription drug usually used in the treatment of Attention Deficit Hyperactivity Disorder. However, it has potential for illicit abuse and can be found among student populations who believe it improves their concentration and focus. This woman presents with insomnia, restlessness, increased temperature, increased blood pressure and increased heart rate, all likely to be caused by the illicit use of Methylphenidate

Answer 181

If doses are missed for more than 2 consecutive days (48 hours), you will need to restart their clozapine slowly (like when they first started on it). This restart of treatment needs to be under the direction of a Psychiatrist. This is because when you start Clozapine after a break of >48 hours, it can make side effects worse, such as blood pressure changes, drowsiness and dizziness. If there is a gap in treatment of 3 days (72 hours) then you may also require more frequent blood tests for a short period.

Answer 182

Akathisia is a sense of inner restlessness and inability to keep still

Answer 183

Benign leucocytosis is a relatively common finding associated with various drugs, most commonly corticosteroids, lithium and beta-blockers. Together with an unremarkable examination, safety netting for infective or malignant signs, and continuing the normal monitoring schedule is most appropriate in this case

Answer 184

Mydriasis (pupil dilation)

Answer 185

Thrombocytopaenia Cardiac (arrhythmias, MI, stroke, postural hypotension) Anticholinergic (tachycardia, urinary retention, dry mouth, blurry vision, constipation) - Cant see, cant pee cant spit, cant sh*t Seizures

Answer 186

CHLORDIAZEPOXIDE first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam. Lorazepam may be preferable in patients with hepatic

Answer 187

Aripiprazole

Answer 188

It can cause an increase in blood pressure and heart rate. It is contraindicated in patients with uncontrolled hypertension. Hence, regular blood pressure monitoring is required.

Answer 189

quetiapine, olanzapine, risperidone haloperidol.

Answer 190

clomipramine

Answer 191

tuberoinfundibular pathway

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