amitriptyline is what type of anti-depressant?
tricyclic
fluoxetine and citalopram are what types of anti-depressants?
SSRIs
reboxetine is what type of anti-depressant?
noradrenaline re-uptake inhibitor
venlafaxine is what type of anti-depressant?
serotonin noradrenaline re-uptake inhibitors
mirtazapine is what type of anti-depressant?
noradrenaline and specific serotonin antidepressant
how long should anti-depressants be trialled for before switching?
a) 1 week
b) 3 weeks
c) 6 weeks
d) 3 months
c) 6 weeks
should patients be weaned off their current anti-depressants to avoid withdrawal before commencing new meds?
a) yes
b) no
a) yes
how do tricyclic antidepressants work?
inhibit re-uptake of noradrenaline and serotonin from synaptic cleft
also block histamine, dopamine, a-adrenergic and muscarinic receptors
why should tricyclic antidepressants be used with caution in those with suicide?
easier to OD than SSRIs
are TCAs 1st or 2nd line for depression?
2nd
what is the major contraindication for TCAs in men?
prostatic hypertrophy
what is the major contraindication for TCAs in women?
pregnancy
what are the anticholinergic side effects of TCAs?
hot as a hare blind as a bat dry as a bone red as a beet mad as a hatter
what are the H1 and H1 side effects of TCAs?
sedation
hypotension
what are the dopamine side effects of TCAs?
EPSEs
breast changes
sexual dysfunction
what are the cardiac side effects of TCAs?
prolonged QT, arrhythmia
why should TCAs not be used alongside class 1 and class 3 anti-arrhythmics?
prolong depolarisation and can increase risk of QT elongation
how are TCAs metabolised?
p450 inhibitors
how do SSRIs work?
inhibit neuronal re-uptake of serotonin from synaptic cleft
why do SSRIs have fewer side effects and are less dangerous in overdose?
don’t inhibit noradrenaline uptake
in what percentage of people are SSRIs effective?
a) 5-10%
b) 25-40%
c) 55-75%
d) 100%
c) 55-75%
are SSRIs 1st or 2nd line treatment for depression?
1st
what is the minimum time for a course of SSRIs?
a) 1 months
b) 3 months
c) 6 months
d) 1 year
c) 6 months
why are SSRIs contraindicated in epilepsy?
lower seizure threshold
why are SSRIs contraindicated in peptic ulcer disease?
risk of upper GI bleed
why are SSRIs used with caution in young people?
increased risk of aggression, DSH and suicidal behaviours
why should SSRIs be used with caution in those with renal/hepatic impairment?
metabolised by the liver
citalopram is best for these patients
why should SSRIs only be used if the benefit really outweighs the risk in pregnant women?
excreted at high levels in breast milk
what electrolyte imbalance are elderly women at risk of with SSRIs?
hyponatraemia
what cardiac abnormality is a particular risk with citalopram (SSRI)?
QT prolongation
how are SSRIs excreted?
liver P450 inhibitor
how do mono-amine oxidase inhibitors work?
inactive an enzyme which oxidises dopamine, serotonin and tyramine
when are MAOIs used nowadays?
rarely used, resistant or atypical depression
what are the dietary restrictions of MAOIs?
tyramine containing foods e.g. cheese, game, liver, broad beans, marmite, red wine
what is the emergency tyramine reaction that can occur with MAOIs?
hypertensive crisis leading to SAH
why is reboxetine (NARI) used in those with bipolar and epilepsy?
less likely to trigger mania or seizures
name 2 side effects of reboxetine
dry mouth
constipation
insomnia
when is venlafaxine (SNARI) indicated?
treatment resistant depression
how can venlafaxine affect blood pressure?
hypertension
which two classes of antidepressant cannot be augmented together?
TCAs and SSRIs
true or false:
if patients are started early in their degree progression on anti-psychotic medication, their response is better
a) true
b) false
a) true
the tranquillising effects of anti-psychotics start to take effect in:
a) minutes
b) hours
c) days
d) weeks/months
b) hours
the side effects of anti-psychotics start to take effect in
a) minutes
b) hours
c) days
d) weeks/months
c) days
the anti-psychotic effects of anti-psychotics start to take effect in
a) minutes
b) hours
c) days
d) weeks/months
d) weeks/months
what is the minimum time period that anti-psychotics should be taken for?
6 months
what is the preferred total period of time that anti-psychotics should be taken for?
a) 6 months
b) 1 year
c) 18 months
d) 2 years
d) 2 years
haloperidol, chlorpromazine, fluphenazine, flupenthixol are all examples of what generation of antipsychotics?
first (typical)
how do anti-psychotics work?
dopamine receptor antagonists
why do atypical anti-psychotics take time to work?
a) body has to ‘adjust’
b) poor adherance by patients
c) effective only when 60% of receptors blocked
c) effective only when 60% of receptors blocked
what ‘line’ treatment are typical (first-gen) anti-psychotics?
second
except for orally, how can anti-psychotics be administered?
depot injection
fill in the blanks
1st generation anti-psychotics have more ____________ side-effects, 2nd generation anti-psychotics have more _________ side-effects
metabolic/neurological
1st gen = neurological
2nd gen = metabolic
dystonia, akathisia, parkinsonism and tardive dyskinesia are all features of which group of side effects associated with 1st gen anti-psychotics?
extra pyramidal side effects (EPSEs)
which cardiac side effect is common with 1st gen anti-psychotics (ESPECIALLY HALOPERIDOL)
prolonged QT
what are anti-cholinergic side effects of 1st gen anti-psychotics?
blind as a bat hot as a hare mad as a hatter red as a beet dry as a bone
what are the anti-histaminergic side effects of 1st gen anti-psychotics?
weight gain
sedation
what are the anti-adrenergic side effects of 1st gen anti-psychotics?
postural hypotension
tachycardia
what are the serotoninergic side effects of 1st gen anti-psychotics?
hyperglycaemia, DMII, weight gain (appetite increase), anxiety, insomnia
what are the effects of hyperprolactinaemia in 1st gen anti-psychotics?
galactorrhoea, amenorrhoea
weight gain
osteoporosis
reduced libido
risperidone, olanzapine, aripiprazole, amisulpride, ziprasidone, palliperidone and clozapine are all examples of what generation of anti-psychotic?
second (atypical)
why do second gen anti-psychotics have less EPSEs than 1st-gen?
higher therapeutic index
clozapine works well with D2 AND D4 receptors. what situation is it used for?
treatment resistant psychosis (last resort)
what ‘line’ treatment are atypical (2nd-gen) anti-psychotics?
first
name 4 metabolic side effects of 2nd-gen anti-psychotics
hyperglycaemia weight gain dyslipidemia insulin resistance drowsiness
name a sexual side effect of 2nd-gen anti-psychotics
low libido
agranulocytosis, hyper-salivation and lower seizure threshold are side effects of which 2nd-gen anti-psychotic?
clozapine
in what psychiatric disorder are anti-convulsants often used?
bipolar
what alternative therapy is indicated in treatment resistant or pharmacology-contraindicated mania or depression?
ECT
how does lithium work?
mode unclear, affects the CNS
what drug is indicated to prevent relapse in bipolar?
a) lithium
b) midazolam
c) citalopram
d) oxytocin
a) lithium
at what blood concentration is lithium toxic?
a) 0.1mmol/L
b) 1.5mmol/L
c) 15mmol/L
d) 50mmol/L
b) 1.5mmol/L
why should lithium only be prescribed if intended use is consistent around 3 years?
poor compliance or quick finishing could lead to rebound mania
why does plasma lithium have to be measured after every dose for 5-7 days when the course is started?
to avoid toxicity which is v dangerous
which of these is NOT a short term side effect of lithium
a) fine tremor and muscle weakness
b) GI disturbances
c) hypotension
d) polyuria & polydipsia
e) metallic taste in mouth
c) hypotension
which of these is NOT a long term side effect of lithium?
a) weight gain
b) oedema
c) goitre (hypothyroidism & hyperparathyroidism)
d) muscle wasting
e) irreversible renal damage
f) T wave flattened on ECG
d) muscle wasting
why is lithium contra-indicated in pregnancy and advised against during breastfeeding?
a) einstein abnormality
b) albert abnormality
c) napoleon abnormality
d) epstein abnormality
d) epstein abnormaloty - downwards displacement of tricuspid valve to right ventricle - tricuspid regurg and stenosis
nystagmus, coarse tremor, dysarthria and ataxia are all symptoms of what adverse reaction to lithium therapy?
toxicity
how do you manage lithium toxicity?
a) lithiite antidote
b) saline or haemodialysis
c) anti-convulsants
d) morphine
b) saline or haemodialysis
how does lithium interact with diuretics (especially thiazides)?
sodium depletion which increases lithium leading to toxicity
why shouldn’t lithium and carbamazepine be used together?
neurotoxicity - use valproate instead
which blood pressure medications should not be prescribed with lithium?
ace-inhibitors
how is lithium excreted?
unchanged by kidneys, half life related to kidney function
how do BZDPs work?
GABA receptor agonist - increase its effect
alprazolam and lorazepam have a ____ potency and a _____ half life
high
short
clonazepam has a ____ potency and a ____ half life
high
long
oxazepam and temazepam have a ___ potency and a _____ half life
low
short
chlordiazepoxide has a ____ potency and a _____ half life
low
long
used to treat alcohol withdrawal
why are BZDPs only given as a short course when possible?
risk of dependence
which of these is NOT a symptom of BZDP withdrawal?
a) anxiety
b) irritability
c) incontinence
d) tremor
e) insomnia
f) altered perception
c) incontinence
what is the antidote for BZDP overdose?
flumezanil
which of these is NOT an example of a hypnotic to induce sleep?
a) donepezil
b) barbiturates
c) zolpidem
d) zopiclone
e) chlormethiazine/promethiazine
a) donepezil
donepezil, rivastigmine, galantamine and tacrine are examples of what type of drug used in dementia?
cholinesterase inhibitors
cholinesterase inhibitors improve cognitive and behavioural performance
a) temporarily
b) permanently
a) temporarily - maximum effect only lasts 9-12 months
what body system most commonly experiences side effects of cholinesterase inhibitors
GI
how many people respond well to cholinesterase inhibitors?
1/3 respond
1/3 won’t
1/3 unknown
how does mementine (NMDA receptor antagonist) work in dementia?
protects neurones against neurotoxicity
which anti-psychotic is liscenced for use in dementia?
risperidone
which form of dementia should anti-psychotics never be prescribed in?
lewy body
why should levodopa and carbidopa be prescribed together in parkinson’s disease?
levodopa = DOPA decarboxylase which activates all dopamine receptors including peripheral ones (N&V), carbidopa reduces peripheral side effects - DOPA decarboxylase inhibitor which cannot cross blood brain barrier
what drug can be given in parkinson’s if the patient is unable to tolerate oral medication?
rivistigmine patch
