Medications Flashcards

Question

What are some treatments for the extra-pyramidal side effects of anti-psychotics? Akathisia (i.e. an inability to remain still. It is a neuropsychiatric syndrome that is associated with psychomotor restlessness. intense sensation of unease or an inner restlessness that usually involves the lower extremities)

Answer 1

* distressing * lowest possible dose of drug * trial a second generation drug * propanalol +/- cyproheptadine

Answer 2

* may be irreversible * try tetrabenazine

Answer 3

a life-threatening, neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs - rare pts present with: * hyperthermia * fluctuating level of consciousness * muscle rigidity * autonomic dysfunction * fever * tachycardia * labile blood pressure * sweating

Answer 4

* stop antipsychotic drug for at least 5 days * all signs and symptoms of NMS need to resolve * Bromocriptine and dantrolene can be used

Answer 5

* dry mouth * blurred vision * urinary retention * constipation

Answer 6

* increased risk of stroke * increased risk of VTE

Answer 7

* hunger for 3 hours after taking antipsychotcs * increased thirst (suggest wtaer and sugar free alternatives) * diet, exercise and smoking cessation are all key to address with pts as areas of health promotion

Answer 8

* Smoking induces / speeds up metabolism * this reduces antipsychotic drug plasma levels * may need higher dose if quit * ALWAYS review and adjust dose e.g. clozapine if pts starts or stops smoking during treatment

Answer 9

* patient prefernce after an acute episode * avoiding non-adherence is a priority

Answer 10

* Second generation depot e.g. risperidone may have less extra-pyramidal side effects * few differences in efficacy between first-generation depot but zuclopenthixol decanoate may be better at preventing relapse than other first gen

Answer 11

* Day 1: 12.5 mg 1-2 x a day * Day 2: 25-50 mg * increase in steps pf 25-50 mg daily over 14-21 days * increased up to 300 mg daily in divided doses (larger dose at night)

Answer 12

* Day 1: 12.5 mg 1-2 x a day (oral) * Day 2: 25-50 mg * increase in steps pf 25-50 mg daily over 14-21 days * increased up to 300 mg daily in divided doses (larger dose at night)

Answer 13

First episode schizophrenia * 2-10 mg daily in 1-2 divided doses * usually pts have 2-4 mg daily Multiple episode schizophrenia * up to 10mg daily Dose adjustments * adjust according to response at intervals of 1-7 days * max dose is 20 mg a day

Answer 14

Sedating drugs (enhance sedative effect of antipsychotics) * alcohol * analgesics * tricylic antidepressants * sedating antihistamines Drugs with hypotensive effect * e.g. hypertensives will enhance hypotensive effect of antipsychotics QT interval prolonging drugs * antiarrythmics * macrolides e.g. erythromycin * tricyclic antidepressants (synergistic effect) Diuretics * may cause hypokalaemia (increased risk of arryhtmia) * monitor potassium levels in those taking diuretics Azole antifungals * increase levels of antipschotics Carbamazepine * reduce plasma level of e.g. clozapine, haloperidol, and risperidone by half. * monitor person to ensure antipsychotics are still effective * the antipsychotics increase carbamazepine levels - monitor Grapefruit juice * dont drink increase levels of pimozide - fatal arrythmias e.g. pimozide SSRI's * Increase level of some antipsychotics e;g. haloperidol and risperidone levels are increased by fluoextine Smoking cessation * smoking indices metabolisim of olanzapine and clozapine

Answer 15

* Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the frequency of chloride channels. used for : * sedation * hypnotic e.g. nitrazepam * anxiolytic e.g. diazepam lorazepam * anticonvulsant * muscle relaxant

Answer 16

* short term (2-4 weeks only) releif of severe, disabling anxiety causing the pt distress on its own, associated with insomnia, organic or psychotic illness * short term 'mild' anxiety * insomnia only when severe and disabling ## Footnote https://bnf.nice.org.uk/treatment-summaries/hypnotics-and-anxiolytics/

Answer 17

Short term use (2-4 weeeks) in anxiety (oral) * Adult: 1-4mg daily in divided dose * Elderly: 0/5-2mg daily in divided dose Short term use in insomnia with anxiety (oral) * adult: 1-2 mg daily at bedtime Acute panic attacks (IM / slow IV) * 25-30 micrograms/kg every 6 hours * IM if oral and IV not possible

Answer 18

* decreased alterness * anxirty * ataxia (elderley) * confusion (elderly) * depression * dizziness * drowsiness * dysarthruia * fatigue * headache * hypotension * resp depression * withdrawal syndrome

Answer 19

* Patients commonly develop a tolerance and dependence * withdrawal may produce confusion, toxic psychosis, convulsions, or a condition resembling delirium tremens

Answer 20

* any time up to 3 weeks after stopping a long-acting benzodiazepine * within a day in the case of a short-acting one * symptoms may continue for weeks or months after stopping benzodiazepines

Answer 21

* insomnia * irritabilityon * Some symptoms may be similar to the original complaint and encourage further prescribing

Answer 22

* 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 (longer acting) * 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 23

All increase the CNS depression effect on benzodiazepines * opioids * barbiturates * monoamine oxidase (MAO) inhibitors * antidepressants e.g. Amitriptyline * alcohol * illicit drugs like heroin

Answer 24

* benzodiazipines increase the frequency of chloride channels * barbiturates increase the duration of chloride channel opening **F**requently **B**end - **D**uring **B**arbeque

Answer 25

* SSRIs * Tricyclic antidepressants * MAOIs * SNRIs * NARIs * NASSAs

Answer 26

During the first few weeks of treatment, there is an increased potential for agitation, anxiety, and suicidal ideation.

Answer 27

* Review every 1–2 weeks at the start of antidepressant treatment. * continue for at least 4 weeks (6 weeks in the elderly) before considering whether to switch antidepressant due to lack of efficacy. * In cases of partial response, continue for a further 2–4 weeks (elderly patients may take longer to respond). Following remission, antidepressant treatment should be continued at the same dose for at least: * 6 months (about 12 months in the elderly) * or 12 months in patients receiving treatment for generalised anxiety disorder (as the likelihood of relapse is high).

Answer 28

* SSRIs are better tolerated and are safer in overdose than other classes of antidepressants. SSRIs are less sedating and have fewer antimuscarinic and cardiotoxic effects than tricyclic antidepressants. * TCAs have similar efficacy but more likely to be discontinued due to side effects. Toxicity in overdose also a problem * MAOIs have dangerous interactions with some food and drugs - specialist use only

Answer 29

Sertraline (SSRI) * Start: 50 mg daily * Increase in steps of 50mg at invervals of 1 week * Maintenace: 50 mg daily * Maximum dose 200 mg per day

Answer 30

1st line: SSRI * citalopram (unless QT elongation then give - fluoextine) * sertraline (1st line if hx of MI) * Fluoextie ( 1st line in children and adolescents) 2nd line: * SNRI or another antidepressant if indicated based on previous clinical and treatment history 3rd line: * Mirtazapine (NASSA) - drowsiness at low dose (help with sleep) 4th line: * TCAs / Lithium (but high toxicity)

Answer 31

MOA * Selectively inhibit the re-uptake of serotonin (5-hydroxytryptamine, 5-HT) Dose * 20 mg once daily * increased in steps of 20 mg at intervals of 3–4 weeks * maximum 40 mg per day Route * oral

Answer 32

* dose should be reduced gradually over about 4 weeks (not necessary with fluoxetine) * longer if withdrawal symptoms emerge (e.g. 6 months in patients who have been on long-term maintenance treatment). * Paroxetine has a higher incidence of discontinuation symptoms.

Answer 33

Withdrawl: * with all antidepressants withdrawl effects can occur within 5 days of stopping * mild - severe * risk is worse if suddenly stop and been taking for 8 weeks or more SSRI withdrawal * gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting * headache * restlessness * anxiety * tinnitus * sleep disturbance * paraesthsia * sweating * influenza like symptoms

Answer 34

Hyponatraemia - SIADH is associated with antidepressandt but particularly SSRIs Elderly are more likely to be affected

Answer 35

* GI symptoms are the most common side-effect * Increased risk of GI bleeding in patients taking SSRIs. A PPI should be prescribed if a patient is also taking a NSAID * hyponatraemia * patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI * fluoxetine and paroxetine have a higher propensity for drug interactions * Citalopram effects QT interval - not to be used in pts with QT prolongation or taking drugs that prolong it .

Answer 36

* 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: avoid SSRIs

Answer 37

* review in 2 weeks * if <25 years / or increased risk of suicide review after 1 week increased risk

Answer 38

* review in 2 weeks * if <25 years / or increased risk of suicide review after 1 week increased risk

Answer 39

* at least 6 months after remission as this reduces the risk of relapse

Answer 40

* at least 6 months after remission as this reduces the risk of relapse

Answer 41

* BNF says to weigh up benefits and risk when deciding whether to use in pregnancy. * Use during the 1st trimester - small increased risk of congenital heart defects (Paroxetine - increased risk of congenital malformations, particularly in the 1 trimester) * Use during the 3rd trimester can result in persistent pulmonary hypertension of the newborn

Answer 42

What? * Serotonin and noradrenaline reuptake inhibitor (SNRI's) are a class of relatively new antidepressants. * Inhibiting reuptake they increases the concentrations of serotonin and noradrenaline in the synaptic cleft leading to the effects. Examples: * venlafaxine * duloxetine.

Answer 43

* major depressive disorders * generalised anxiety disorder * social anxiety disorder * panic disorder * menopausal symptoms

Answer 44

route: * oral Dose: * start with 75 mg daily in 2 doses * increase up to 375 mg in intervals of 2 weeks * max is 375 mg

Answer 45

Route: * oral Dose: * 75 mg once daily * increase up to 225 mg once daily (max) * increase in intervals of 2 weeks No response or not tolerated * pregabalin can be considered

Answer 46

contraindication: * uncontrolled HTN * hepatic impairment (duloextine) * severe renal impairment - (creatinine clearance < 30 ml/min duloextine) Cautions include: * bleeding disorders * high risk cardiac arrythmia * diabetes * heart disease (monitor blood pressure) * hx of epilepsy * hx of bipolar or mania

Answer 47

Cardiac * palpitations ; tachycardia, hypertension, torsade de pointes, QT interval prolongation (rare), hypotension, syncope. Gastrointestinal * dry mouth, altered taste, decreased appetite, nausea ; constipation, vomiting, diarrhoea, , , abdominal pain (common); gastrointestinal haemorrhage, weight changes Central nervous system * headache, somnolence ; dizziness, drowsiness, akathisia, lethargy, tremor, paraesthesia; akathisia, movement disorders, sleep disorders, tinnitus, vision problems Psychiatric * insomnia, confusion, anxiety, abnormal dreams, agitation, suicidal thoughts, depersonalisation. Skin * sweat changes, rash, alopecia, angio-oedema. Other * dyspnoea, flushing, menstrual cycle irregularities, sexual dysfunction (may persist after treatment stopped); urinary symptoms, hyponatraemia (rare), neuroleptic malignant syndrome (rare), serotonin syndrome (rare), neutropenia (rare), syndrome of inappropriate antidiuretic hormone secretion (SIADH, rare), thrombocytopenia (rare).

Answer 48

Aspirin / NSAIDS/ anticoag / antiplatelet * increased risk of bleeding * extra INR monitoring if on warfartin Lithium: * use with SNRI may cause serotonin syndrome * lithium associated with QT interval prolongation = torsade de pointes = syncope or sudden cardiac death Monoamine oxidase inhibitors: * contradincicated with SNRI * fatal reaction may occur (serotonin syndrome) SSRIs (paroextine, sertaline) * risk of serotonin syndrome * monitor for fever, tremors, diarrhoea, agitation etc Sedatives e.g. alchol barbiturates, benzos * sedating effect

Answer 49

* manic phase of bipolar * poorly controlled epilepsy * QT interval prolongation / on drugs which porlong e.g. citalopram * severe hepatic impariment (sertaline) ## Footnote https://cks.nice.org.uk/topics/depression/prescribing-information/ssris/

Answer 50

MAOIs: * inhibit monoamine oxidase, thereby causing an accumulation of amine neurotransmitters. Use: * used much less frequently than tricyclic and related antidepressants, or SSRIs and related antidepressants because of the dangers of dietary and drug interactions * used in the treatment of atypical depression (e.g. hyperphagia) Example: isocarboxazid

Answer 51

Indications : * depression route: * oral Dose: * 30 mg daily (single or divided dose) until see improvement * can increase if needed after 4 weeks up to 60 mg for 4-6 weeks under supervisions * it must then be reduced by 20 mg daily to a maintenace dose (up to 40mg) Elderly : 5-10 mg daily

Answer 52

* Phobic pts * depressed patinets with - atypical, hypochondrial, hysterical features * pts refractory to other treatment - can be dramatic repsonse

Answer 53

* other antidepressants should not be started for 2 weeks after treatment with MAOI's have been stopped. Should not start an MAOI: * at least 2 weeks after a preivous MAOI has been stopped * 7-14 days after a trciylic antidepressant * 1 week after SSRI (5 weeks after fluoextine)

Answer 54

Include: * anticholinergic effects, Akathisia; anxiety; appetite increased; arrhythmia; asthenia; behaviour abnormal; blood disorder; confusion; constipation; dizziness; drowsiness; dry mouth; dysuria; hallucination * hypertensive reactions with tyramine containing foods e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad beans * Risk of postural hypotension and hypertensive responses. Discontinue if palpitations or frequent headaches occur. Isocaarboxazid: * Granulocytopenia; peripheral oedema; sexual dysfunction

Answer 55

* Monitor blood pressure (risk of postural hypotension and hypertensive responses).

Answer 56

* Tricyclic and related antidepressants block the re-uptake of both serotonin and noradrenaline, although to different extents * less commonly now for depression due to their side-effects and toxicity in overdose

Answer 57

* Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) have the highest toxicity in overdose. * Venlafaxine and Mirtazapine are less toxic that TCA's but higher risk than other SSRIs

Answer 58

Neuromuscular excitation * hyperreflexia * myoclonus * rigidity autonomic nervous system excitation * hyperthermia * sweating altered mental state * confusion More extensive from NICE: * Insomnia, anxiety, nausea, diarrhoea, hypertension, tachycardia, hyper-reflexia, agitation, myoclonus, tremor, flushing, low-grade fever, hyperthermia, confusion, rigidity, respiratory failure, coma, or death.

Answer 59

* monoamine oxidase inhibitors * SSRIs * St John's Wort, often taken over the counter for depression, can interact with SSRIs to cause serotonin syndrome * tramadol may also interact with SSRIs * ecstasy * amphetamines

Answer 60

* supportive including IV fluids * benzodiazepines * more severe cases are managed using serotonin antagonists such as cyproheptadine and chlorpromazine

Answer 61

* baseline BP * ECG monitoring for CVS side effects

Answer 62

* FBC - anaemia (GI Bleeding with NSAID use) * U&E (hyponatraemia) * Citalopram (ECG as dose dependant QTC prolongation) Side effect: * discontinution / withdrawal syndrome should be discussed with patients * sexual side effects ( often reason it is stopped )

Answer 63

* More sedative and less sedative * Agitated and anxious patients tend to respond best to the sedative compounds, whereas withdrawn and apathetic patients will often obtain most benefit from the less sedating ones * often used to treat neuropathic pain (smaller doses than depression)

Answer 64

Antimuscarinic and cardiotoxic: * drowsiness * dry mouth * blurred vision * constipation * urinary retention * lengthening of QT interval * The BNF states that extrapyramidal side effects (such as acute dystonia and tardive dyskinesia) and neuroleptic malignant syndrome are possible, but very rare Pass med questions: clomipramine can cause dry mouth (anticholinergic) and weight gain (antihistaminic) side effects

Answer 65

Choice of tricyclic * low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine) * lofepramine has a lower incidence of toxicity in overdose * amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose

Answer 66

monitor cardiac and hepatic function during long-term use

Answer 67

* 10 mg daily * increased up to 30-150mg in divided doses * increase gradually * can also take once daily at bedtime * (max is 250mg per day)

Answer 68

* potentially fatal cardiovascular effects (tachycardia, postural hypotension, slowed cardiac conduction) when taken in overdose. * Overdose can also cause sedation, coma, and seizures.

Answer 69

* prolongs the QT interval toxic effects in overdose include: * hypertensive crisis * serotonin and noradrenaline toxicity * agitation * aggressiveness * behavioural changes.

Answer 70

* prolongs the QT interval toxic effects in overdose include: * hypertensive crisis * serotonin and noradrenaline toxicity * agitation * aggressiveness * behavioural changes.

Answer 71

* Lithiuk - neurotoxicity, serotonin syndrome, neuroleptic malignant syndrome, torsades des pointes and QT prolongation * MOAIs - fatal reactions e.g serotonin syndrome * sedative drugs e.g. alcohol, barbiturates, benzodiazepines - synergistic effect * tramadol - increased risk of serotonin syndrome * SSRIs - increased TCA conc and linked to QT interval prolongation - risk arrythmias

Answer 72

* pre-synaptic alpha2-adrenoreceptor antagonist which increases the release of central noradrenergic and serotonergic neurotransmitters * class: noradrenergic and specific serotonergic antidepressant (NaSSA)

Answer 73

Good for use in older people Why? * Fewer side effects and interactions than any other antidepressants (older ppl more likely to be taking more drugs) * sedation and increased appetite (side effects) can be useful in older people who are more likely to be experiencing insomnia and poor appetite

Answer 74

Indication : depression Dose: (oral) starting: 15-30 mg usual minimum daily effective dose : 30 mg Max dose: 45 mg often taken in the evening as sedative

Answer 75

Anxiety; appetite increased; arthralgia; back pain; confusion; constipation; diarrhoea; dizziness; drowsiness; dry mouth; fatigue; headache (on discontinuation); myalgia; nausea; oedema; postural hypotension; sleep disorders; tremor; vomiting; weight increased

Answer 76

* Antiepileptics - Mirtzazapine can reduce seizure threshold. AE can reduced Mirtazapine levels * MAOIs - increased risk of serotonin syndrome (avoid use 2 weeks after stopping either drug) * Rifampicin - decrease level of mirtazapine * sedative drugs e.g. alcohol, barbiturates, benzodiazepines) — mirtazapine is sedating and co-administration with other sedating drugs may have a synergistic effect.

Answer 77

* Z drugs have similar effects to benzodiazepines but are different structurally. They act on the α2-subunit of the GABA receptor. * Zopiclone is a type of Z drug * It is also described as a hypnotic (drug used to induce / maintain sleep)

Answer 78

* should only be prescribed for short courses in acutely distressed * tolerance to effect can develop within 3-14 days of continuous use * danger with long term use is that when they are withdrawn they can cause rebound insomnia and a withdrawal syndrome

Answer 79

Indications: insomnia (short term) Dose: Adult: 7.5 mg once daily for up to 4 weeks, dose to be taken at bedtime. Elderly : Initially 3.75 mg once daily for up to 4 weeks, dose to be taken at bedtime, increased if necessary to 7.5 mg daily.

Answer 80

Elderly pts * think of STOPP cirteria for hypnotic Z drugs as can cause protracted daytime sedation and /or ataxia * Falls a big risk (also with benzos)

Answer 81

Common: Dry mouth; taste bitter Uncommon Anxiety; dizziness; fatigue; headache; nausea; sleep disorders; vomiting

Answer 82

Antifungals - increase zopiclone carbamazepine alcohol- both have depressant CNS effects amitriptyline - CNS depressant effects

Answer 83

* peripheral and central neuropathic pain * adjunct in focal seizures * GAD (used as an anxiolytic)

Answer 84

start: * 150mg daily in 2-3 divided doses * increased in steps of 150mg if needed * increase in 1week intervals * max 600 mg daily in 2-3 divided doses

Answer 85

Conditions that may precipitate encephalopathy; elderly; history of substance abuse; respiratory depression; seizures (may be exacerbated); severe congestive heart failure

Answer 86

Abdominal distension; appetite abnormal; asthenia; cervical spasm; concentration impaired; confusion; constipation; diarrhoea; dizziness; drowsiness; dry mouth; feeling abnormal; gait abnormal; gastrointestinal disorders; headache

Answer 87

monitor for pregabalin abuse

Answer 88

Alcohol amitriptuline baclofen Bupivacaine Cannabidiol Chlordiazepoxide Chlorpromazine (above all CNS depressant effects - worsened if you take pregabalin as well )

Answer 89

Lithium - lithium carbonate and lithium citrate Carbamazepine valporate - sodium valporate and valproic acid lamotrigine

Answer 90

BNF: * Treatment and prophylaxis of mania, * Treatment and prophylaxis of bipolar disorder, * Treatment and prophylaxis of recurrent depression, * Treatment and prophylaxis of aggressive or self-harming behaviour * PASSMED: mainly bipolar prophylaxis and refractory depression MOA: * not understood but below theories * interferes with inositol triphosphate formation * interferes with cAMP formation

Answer 91

1. theraputic range * very narrow therapeutic range (0.4-1.0 mmol/L) 2. plasma half life * a long plasma half-life being excreted primarily by the kidneys

Answer 92

Preparations vary widely in bioavailability So on starting lithium: * dose adjusted according to serum lithium concentration and divided throughout the day. * once serum lithium conc is stablised can do once a day For Camcolit immeidate release tablet Adult: * initially 1.5 g daily (adjust to serum lithium conc) initially divded across day until serum conc stabilised Elderly: * reduced initial dose and as above adjust and divide until stabilised

Answer 93

* Addison’s disease; cardiac disease associated with rhythm disorder; cardiac insufficiency; dehydration; family history of Brugada syndrome; low sodium diets; personal history of Brugada syndrome; untreated hypothyroidism

Answer 94

* 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 95

* thyroid disorders and mild cognitive and memory impairment * monitor thyroid function every 6 months * The need for continued therapy should be assessed regularly and patients should be maintained on lithium after 3–5 years only if benefit persists.

Answer 96

ACE inhibitors, angiotensin II receptor antagonists (sartans), diuretics, and non-steroidal anti-inflammatory drugs (NSAIDs) Amitriptyline , Amiodarone (prolong QT), acetazolamide

Answer 97

* when checking lithium levels, the sample should be taken 12 hours post-dose * after starting lithium levels should be performed weekly and after each dose change until concentrations are stable * once established, lithium blood level should 'normally' be checked every 3 months * after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable.

Answer 98

Beofre treatment initiation: * assess renal, cardiac and thyroid function * ECG for pts with CVD or risk factors * Body weight , BMI * serum electrolytes * FBC During treatment: every 6 months : * monitor body weight / BMI * serum electrolytes * eGFR * thyroid * cardiac - regularly * if impaired renal / thyroid function or increased calcium monotor more often

Answer 99

Be aware of and report signs of lithium toxicity * hypothyroidsin * renal dysfunction (including polyuria and polydipsia) * benging intracranial HTN (persistant headache and visual disturbance) * Maintain fluids intake * avoid dietary changes which reduce or increase sodium intake Lithium treatment pack * all pts should get it contains pt info booklet, lithium alert card and record book for tracing serum-lithium concentration Withdrawal * should gradually reduce over at least 4 weeks (preferably over 3 months) as risk of relapse if stop suddenly

Answer 100

* teatment of manic episodes associated with bipolar disorder if lithium is not tolerated or contra-indicated. * Also used for long-term management of bipolar disorder to prevent recurrence of acute episodes, in combination with lithium (if lithium alone is ineffective, or as monotherapy if lithium is not tolerated or contra-indicated.)

Answer 101

Adult: * initially 7050mg daily in 1-2 divided doses * usual dose is 1-2g daily in diided doses * any dose >45mg/kg needs careful monitoring

Answer 102

* Abdominal pain; agitation; alopecia (regrowth may be curly); anaemia; behaviour abnormal; concentration impaired; confusion; deafness; diarrhoea; drowsiness; haemorrhage; hallucination; headache; hepatic disorders and dysfunction; hypersensitivity; hyponatraemia, pancreatitis ## Footnote https://bnf.nice.org.uk/drugs/sodium-valproate/#indications-and-dose

Answer 103

Theraputic drug monitoring: * not rotuinely monitored as palsma -valporate conc doesnt give a good idea of efficacy Patient parameters: * Monitor liver function before therapy and during first 6 months especially in patients most at risk. * Measure full blood count and ensure no undue potential for bleeding before starting and before surgery

Answer 104

False-positive urine tests for ketones.

Answer 105

Acetazolamide - increase toxicity cannabidiol lamotrigine Meropenem Methylphenidate olanzapine Phenytoin propofol

Answer 106

Avoid abrupt withdrawal; if treatment with valproate is stopped, reduce the dose gradually over at least 4 weeks.

Answer 107

Pregnancy Prevention Programme * Pharmacists must ensure that female patients have a patient card Pancreatitis * pts to be told how to recognise signs of pancreatitis and seek medical help e.g. abdominal pain, nausea, or vomiting Blood or hepatic disorders * recognise signs of blood or liver disorders e.g. persistent vomiting and abdominal pain, anorexia, jaundice, oedema, malaise, drowsiness, or loss of seizure control

Answer 108

* oral immediate release Adult: * Initialyl 400 mg daily in divided doses * increase until symptoms controlled * usual dose 400-600 mg * max 1.6 g a day

Answer 109

Therapeutic drug monitoring * Plasma concentration for optimum response 4–12 mg/litre (20–50 micromol/litre) measured after 1–2 weeks. Monitoring of patient parametersFor carbamazepine * blood counts and hepatic and renal function tests

Answer 110

* Dizziness; drowsiness; dry mouth; eosinophilia; fatigue; fluid imbalance; gastrointestinal discomfort; headache; hyponatraemia; leucopenia; movement disorders; nausea; oedema; skin reactions; thrombocytopenia; vision disorders; vomiting; weight increased

Answer 111

Apixiban rivarooxoban warfarin clozapine - increased mylosuppression clarithromycin erythromycin flucanazole

Answer 112

* methylphenidate hydrochloride * Lisdexamfetamine mesilate * If symptoms do not improved after a 6 weeks, switch to the alternative first-line treatment

Answer 113

* Pharmacokinetic profile * convenience * improved adherence * reduced risk of drug diversion (drugs being forwarded to others for non-prescription use or misuse) * lack of need to be taken to work

Answer 114

when more flexible dosing regimens are required or during initial dose titration

Answer 115

* ADHD * Narcolepsy

Answer 116

Child 6-17 years * Initially 5mg 1-2 times a day * increased in steps of 5-10 mg in weekly intervals * increased up to 60mg daily in 2-3 divided doses * discontinue after 1 month if no response Adult * initially 5mg 1-2 times a day * increased up to 100 mg daily in 2-3 divided doses

Answer 117

alchohol amitriptyline risperidone - increase risk of dyskinesia valporate - enhance effect of methlphenidate Carbamzaepine - decrease methylphenidate

Answer 118

Monitor for psychiatric disorders. Pulse, blood pressure, psychiatric symptoms, appetite, weight and height should be recorded at initiation of therapy, following each dose adjustment, and at least every 6 months thereafter.

Answer 119

Monitor for psychiatric disorders. Pulse, blood pressure, psychiatric symptoms, appetite, weight and height should be recorded at initiation of therapy, following each dose adjustment, and at least every 6 months thereafter.

Answer 120

* Aggression (or hostility); alopecia; anxiety; appetite decreased; arrhythmias; arthralgia; behaviour abnormal; cough; depression; diarrhoea; dizziness; drowsiness; dry mouth; fever; gastrointestinal discomfort; growth retardation (in children); headaches; hypertension; laryngeal pain; mood altered; movement disorders; nasopharyngitis; nausea; palpitations; sleep disorders; vomiting; weight decreased

Answer 121

* Electroconvulsive therapy * considered when: -condition is life-threatening and you need to get better quickly to save your life -is causing you immense suffering -has not responded to other treatments, such as medication and psychological therapy -has responded well to ECT in the past

Answer 122

* severe depression * catatonia * manic phase of bipolar * pts who have mixed symptoms of depression and mania

Answer 123

Bilaterla or unilateral electrode placement Adminsitered 2 x a week Course up to 12 treatments Stopped as soon as pt feels benefit Inpatient or Outpatient

Answer 124

Strict infection control measures as ECT is an aerosol generating procedure under anaesthesia

Answer 125

* CNS --> raised intracranial pressure, cerebral aneurysm, recent cerebrovasculat event/stroke * Cardiac/circ --> recent MI in last 3 months, unstable angina, DVT, potassium imbalance, uncontrolled HR or BP * Resp --> acute resp infection or resp conditions * PMH --> cochlear implants, phaeochromocytoma, unstable fractures, bariatric pts * Other --> recent food, chewing gum, sweets, cigs Caution in pregnancy, controlled epilepsy and pacemaker pts

Answer 126

1. from ECT --> confusion, headache, status epilepticus, stroke, arryhtmia, bleeding ulcers, PE, subconjunctival haemorrhages, reaised intraocular pressure, broken teeth 2. risks of anaesthesia --> MI, arrythmia, aspiration pneumonia, prolonged apnoea, nausea, malignant hyperthermia, muscle aches, death, adrenocortical supression (if using etomidate) 3. memory loss --> short term retrograde amnesia; will depend on total energy used and site of electrode.

Answer 127

1 week later Lithium monitoring should be performed weekly after initiation and after each dose change until concentrations are stable. It is usually checked 12 hours after the dose is taken.

Answer 128

* **Aripiprazole** * He has features of hyperprlocatinaemia * Aripiprazole has the most tolerable side effect profile of the atypical antispsychotics, particularly for prolactin elevation

Medications Flashcards

https://cks.nice.org.uk/topics/depression/prescribing-information/antidepressant-dosing-titration/ (155 cards)