Mental Health Flashcards
(189 cards)
1
Q
What are the risks of chronic alcohol consumption in the CNS?
A
Cognitive impairment
Wernicke-Korsakoff syndrome
2
Q
Describe what Wernicke-Korsakoff is:
A
A neuropsychiatric disorder of acute onset caused by thiamine deficiency and includes confabulation (memory gone)
Wernicke’s Encaphalopathy is a neurodegerative brain disorder caused by severe lack of thiamine and presents as confusion, apathy, disorientation, vomiting and disturbed memory
3
Q
What can Wernicke-Korsakoff be treated with?
A
Pabrinex (thiamine supplementation)
4
Q
What is the acute treatment for Wernicke-Korsakoff?
A
One pair of ampoules IM or IV for 3-5 days- essential
5
Q
What is the chronic treatment for Wernicke-Korsakoff?
A
100mg TDS is common but oral absorption is poor
Humans can only absorb up to 4mg an hour so OD dosing is pointless, has to be spread out
6
Q
Name benzodiazepines used in alcohol detoxification:
A
Main- chlordiazepoxide
Lorazepam, oxazepam in hepatic impairment
7
Q
Describe the use of benzodiazepines in alcohol detoxification:
A
Chlordiazepoxide:
-long acting benzo, anticonvulsant, cross tolerant with alcohol
-no need to wait for withdrawl
-usual dose range 20-40mg QDS, then decrease over 9 days
When required ‘on demand’ doses should be prescribed
Withdrawl symptoms measured using CIWA (clinal institute withdrawl assessment for alcohol)
8
Q
Describe the withdrawl symptoms of opioids:
A
Runny nose
Watery eyes
Dilated pupils
Yawning
N&V
Diarrhoea
Restlessness
9
Q
What is the titration dosing of methadone?
A
20-30mg day 1, increase 5-10mg every few days up to max total 30mg above starting dose each week, then increase once or twice weekly (10-15mg) as needed
Take about 5 days for blood levels to reach steady state
10
Q
What are the other effects of methadone?
A
Decrease or absent menstrual cycle- still can become pregnant
Sexual dysfunction
Dry mouth/eyes
Dental problems
Constipation
Constricted pupils
QT prolongation ≥100mg
11
Q
What should be the monitoring requirements for the SE of QT prolongation when taking methadone?
A
Other drugs can increase the risk too e.g SSRIs, lithium, TCA, macrolides
If taking over 100mg a day offer ECG, measure every 6-12 months if normal
12
Q
What should be the requirements if a benzodiazepine is prescribed?
A
Clear treatment plan, discussed and agreed
Have at least 2 +ve drug screens (make sure they’re taking it)
Have no -ve benzo screen in last 4 months
Review reg
13
Q
Describe the detoxification process of benzodiazepines:
A
Very gradually withdrawl (months if not years)
Consider giving in divided doses and loading at night
Consolidate multiple benzos to diazepam first (as long acting)
If withdrawl symptoms, don’t decrease further until symptoms improve
Decrease by 1/8 of daily dose every 2-4* weeks, or longer
14
Q
What are the lowering doses of the gabapentinoids?
A
Pregabalin: decrease daily dose at a max of 50-100mg/week
Gabapentin: decrease daily dose at a max rate of 300mg every 4 days
15
Q
Describe the ICD10 diagnosis of depression:
A
At least TWO key symptoms, most days, most of the time for at least 2 weeks, minimum 4 symptoms
16
Q
Describe the DSM IV diagnosis of depression:
A
At least ONE key symptom, most days most of the time for at least 2 weeks, minimum of 5 symptoms
17
Q
Name the key symptoms of depression:
A
Persistent sadness or low mood
Marked loss of interests or pleasure
Lack of energy (ICD10 only)
18
Q
Name the associated symptoms of depression:
A
Disturbed sleep (increase or decrease)
Increased/decreased appetite and/or weight
Fatigue or loss of energy
Agitation or slowing of movements
Poor conc or indecisiveness
Feelings of worthlessness/ or excessive guilt
Suicidal thoughts/ acts
19
Q
Name the 5 grades that NICE (CG90) has subdivided depression into:
A
Sub-threshold
Mild
Moderate
Severe
Complex
20
Q
Describe Step 1 in the stepped-care model of depression treatment:
A
For all suspected presentations of depression
Assessment
Support
Psycho-education
Active monitoring
Onward referral for further assessment and intervention
21
Q
Describe Step 2 in the stepped-care model of depression treatment:
A
Mild to moderate depression
Low intensity psychological interventions
Medications (for moderate+) but for mild if past Hx/ other factors
Onward referral
22
Q
Describe Step 3 in the stepped-care model of depression treatment:
A
Moderate to severe depression
Medication
High-intensity psychological interventions
Combine treatments
Onward referral
23
Q
Describe Step 4 in the stepped-care model of depression treatment:
A
Severe/complex
Medication
ECT
Combined treatment
High intensity
Crisis service
Multiprofessional inpatient care
24
Q
Describe low intensity psychological interventions:
A
Guided self help (books)
Being active
Computer/team based CBT
25
Describe high intensity psychological interventions:
Psychological therapies, CBT
IPT (interpersonal therapies)
General support and advice
ECT (electroconvulsive therapy) for acute severe depression- max 12
TMS (transcranial magnetic stimulation)
26
Describe the starting dose of antidepressants:
Almost all antidepressants (except mirtazapine) are more tolerable if started at a lower initial dose (half standard) and increased to the target dose over a few days/weeks
27
What is the starting dose/ exception of mirtazapine?
30mg is less sedating than 15mg OD
28
What is the specialist combination/augmentation if antidepressants fail?
Can consider lithium, an antipsychotic or another antidepressant
Be aware of increased SE burden and monitoring
29
What is the first and second line therapy for depression?
1st line SSRIs
TCA are difficult to get to the therapeutic dose due to the wide range of SEs giving poor tolerability
30
Name the antipsychotics used for depression:
Aripiprazole
Olanzapine
Quetiapine
Risperidone
31
Name examples of SSRIs first line in depression:
Citalopram
Escitalopram
Sertraline
Fluoxetine
Votioxetine (with cognitive enhancement)
32
Name examples of SNRIs:
Duloxetine
Venlafaxine
33
What is the problem with TCA and an outcome?
Toxicity at higher doses and alcohol expect lofepramine
34
Name examples of TCA first line in depression:
Clomipramine
Lofepramine
35
Name second line SSRIs for depression:
Fluvoxamine
Paroxetine
36
Name related antidepressants for second line depression:
Agomelatine
Reboxetine
Trazadone (SSRI with 5HT2 antagonist)
37
Name second line TCA for depression:
Amitriptyline
Dosulepin
Doxepin
Imipramine
Nortriptyline
Trimipramine
38
Name irreversible MAO inhibitors second line for depression:
Isocarboxazid
Phenelzine
Tranylcypromine
39
Name reversible MAO inhibitors second line for depression:
Moclobemide
40
What are the requirements to avoid when taking irreversible MAOi?
Tyramine free diet
41
Describe the STAR*D approach to treating depression:
Focus on remission not just response
Give pt 4 weeks to start to fully respond
Augmentation may be better if partial or incomplete response
Switching to another SSRI is as effective as other switches
Response decrease with more switches (esp after 2)
42
When should you take most antidepressants and why?
Taken in the morning
During dreaming, serotonin and dopamine need to be completely suppressed for dreaming
43
Which antidepressants should be taken at night and why?
Mirtazapine- as serotonin repuptake counteracted by 5HT2- a histamine blocker, histamine keeps us awake
Agomelatine is a melatonin receptor agonist and improves sleep
44
What is the onset of action of antidepressants?
Response is not immediate, can take 2-6 weeks to work (4-6 for optimum effect), although some can see benefit after 1 week
The patient should be seen every 2-4 weeks for the first 3 months, then less frequently if treatment working
45
What if there is no improvement after 4 weeks of taking an antidepressant?
If no improvement (even minimal) after 4 weeks of therapeutic dose, check adherence then switch to another
If minimal improvement occurs, continue until week 6
46
What is the onset of action like of an antidepressant in elderly?
Time may need to be increased as response may be slower
47
What are the cautions when switching to another antidepressant from fluoxetine?
It has a long half life so caution of serotonin syndrome
To a reversible MAOi, taper and stop fluoxetine and wait 5-6 weeks
48
What should be the cautions when switching to another antidepressant from an irreversible MAOi?
A 2 week washout period is required
49
What should you review if there is any more than 2 failed ADs?
Need for review of the diagnosing e.g bipolar
50
What are main antidepressants which can show discontinuation symptoms?
Paroxetine
Venlafaxine
51
What are the symptoms of serotonin syndrome?
Restlessness
Myoclonus
Tremor and rigidity
Hyperfelxia
Shifting/elevated temp
Arrhythmias
It can be fatal due to cardiac collapse
52
What medication combinations can cause serotonin syndrome (serotohergic drugs)?
SSRIs
SNRIs
Tramadol
Triptans (not to be used with SSRIs)
53
How long should antidepressants be used for after the first episode of depression?
As long as needed to decrease relapse
6 months after recovery at same dose
54
How long should antidepressants be used for after the second episode of depression?
1-2 years may reduce relapse
55
How long should antidepressants be used for after the third or more episode of depression?
3-5 years of longer
56
What are the characteristics of antidepressant discontinuation/ withdrawl phenomena?
Commence within 1-3 days of stopping or decreasing doses
Usually short lived (1-2 weeks)
Are rapidly suppressed by re-intro of drug
Distinct from relapse of recurrence which can occur 2+ weeks after discontinuation
57
Describe the discontinuation symptoms of SSRIs:
Dizziness, light headedness
Sleep disturbances
Agitation
Electric shocks in the head
Nausea, fatigue, headache
'Flu-like' symptoms
58
Describe the discontinuation symptoms of SNRIs:
Same as SSRIs but also:
Restlessness
Abdominal distension
Congested sinuses
59
What is the further advise for discontinuing antidepressants?
Avoid stopping while still in the higher relapse risk time period
For less than 8 weeks treatment, withdraw stepwise over 1-2 weeks
After 6-8 months treatment, taper over a 6-8 week period
After long term maintenance treatment, decrease dose by 25% every 4-6 weeks
60
Name common SEs of SSRIs:
Nausea
Sexual dysfunction
Weight
61
Name common SEs of TCA:
Anticholingeric
Sedation
Decreased BP
Weight
Sexual dysfunction
Nausea
62
Name the common SEs of Mirtazapine:
Sedation
Weight
63
Name common side effects of SNRIs:
Sedation
Decreased BP
Nausea
Sexual dysfunction
64
Name common SEs of trazodone:
Sedation
Decreased BP
Weight
Sexual dysfunction
Nausea
65
Name common SEs of MAOi:
Anticholinergic
Decreased BP
Sexual dysfunction
Weight
66
Which antidepressants are least affected by alcohol?
SSRIs
Venlafaxine
Votioxetine
Noritryptiline
Clomipramie
67
Which antidepressants give some additive sedation with alcohol?
Mirtazapine
Mianserin
Trazodone
Amitriptyline
Dozepin
TCA- may lower seizure threshold
68
Describe the interaction of NSAIDs and antidepressants?
SSRIs around 2x increase risk of upper GI bleeds and this is increased to 3 fold by concurrent NSAIDs, but decreases with concurrent PPIs
Duloxetine less of a problem
69
Describe the interaction of warfarin and antidepressants:
SSRIs significantly increase INR- fluoxetine and paroxetine
Least effect is citalopram and sertraline
Duloxetine
No INR- mirtazapine
70
Describe the interaction with an SSRI and tamoxifen:
Paroxetine may increase the risk of recurrence of breast cancer
71
Name medications that can decrease levels of antidepressants:
Smoking decrease (50%) duloxetine levels
St Johns wort
Antiretrovirals, ciclosporin, oral contraceptives, digoxin
72
Describe the interaction with Fluvoxamine and clozapine:
Increase clozapine levels- CYP1A2inhibition due to toxicity
73
Describe interactions with anticonvulsants and TCAs:
Carbamazepine decreases TCA (Cyp3A4)
Valproate increases TCA x2
Cannabis- delerium, tachycardia, mania
74
Describe the prescribing suggestions with antidepressants in children and adolescence:
NICE recommends fluoxetine 1st line, WITH psychological therapies, with sertraline or citalopram as second line
Fluoxetine is the only antidepressant licensed for depression (8-17) if unresponsive to 4-6 sessions of psychological therapies
Sertraline is licensed of OCD in ages 6-17 (but not depression and citalopram SmPC states it should not be used in U18s
75
Describe the use of antidepressants in pregnancy:
Risk of depression (poor bonding or self care) may be higher than the risk of antidepressants
There is some link between SSRIs and the incidence of autism
Paroxetine is best avoided
Most of the other ADs may have some risks but these can usually be manages
Little evidence of any detrimental effect on post natal development
76
Describe the use of antidepressants in the elderly:
No ideal antidepressant
SSRIs better tolerated than TCA but increase risk of GI bleeds
Increased risk of hyponatreamia, post. hypotension, falls and hemorrhagic stroke with SSRIs
Start low and go slow
77
Describe the use of antidepressants with cardiac disease:
SSRIs generally recommended
Mirtazapine maybe suitable alternative
SSRIs may protect against MI
Sertraline best choice post MI
CBT may be ineffective post MI, unless depression present pre MI
BB continue use PCI decreases risk of depression
78
Describe the cardiovascular effect of antidepressants:
Can increase QT interval- esp SSRIs and TCA
Citalopram CI if known QT, meds known to prolong QT and should only be used with caution with electrolyte disturbances and bradycardia- need ECG before
Escitalopram is also CI with QT prolongation, drugs causing QT and should be used with caution in pts at risk of Torsades do Pointes, recent MI, bradyarrthrimis, hypokalaemia, hypo magnesia
79
Describe the use of antidepressants in renal impairment:
No clear preferrered AD
Greater renal impairment, greater drug accumulation
ADRs such as confusion, post. hypotension and sedation may be more common
Start low and go slow
Care is needed with anticholingeric which may cause urinary retention and interfere with U&E measurements
80
Describe the use of antidepressants in hepatic impairment:
Start low and go slow, monitor LFTs regularly
More sensitive to common/ predictable SEs
Care needed with drugs with a high first pass clearance
In severe liver disease, avoid drugs causing marked sedation and/or constipation
Paroxetine is used by some specialised liver units
81
Name the main treatments for anxiety:
SSRIs (1st)
Benzodiazepines
Antipsychotics
Venlafaxine and duloxetine (GAD)
TCA (panic disorder)
Pregabalin (GAD)
82
Name SSRIs as a first line treatment for anxiety:
Escitalopram and paroxetine are licensed, other SSRIS likely to have similar efficacy and are widely used
83
Describe the counselling advise for SSRIs with anxiety:
Response isn't immediate- 12 weeks
Initial worsening of symptoms common with SSRIs and venlafaxine- start off with low dose and only increase when SEs have decreased
Long term treatment may be required for severe
Stopping suddenly not recommended- discontinue over 4 weeks or longer
84
Describe step 1 in the stepped care model for anxiety (NICE):
Assess GAD- all presentations
85
Describe step 2 in the stepped care model for anxiety:
Diagnosed GAD that has not improved after monitoring- low intensity psychological interventions
86
Describe step 3 in the stepped care model for anxiety:
GAD with inadequate response to step 2 marked functional impairment, choice of high intensity interventions or drug treatment
87
Describe step 4 in the stepped care model for anxiety:
Complex, refractory GAD- very functional impairment, specialist treatment, inpatient, crisis team
88
Name and describe the first treatment in the first line therapy for GAD:
SSRIs- fluoxetine/ sertraline- NICE recommends but is off licence
Withdraw after at least 12 months of treatment- for all
89
Name and describe the second treatment in the first line therapy for GAD:
Venlafaxine
Initially 75mg up to 225mg
90
Name and describe the third treatment in the first line therapy for GAD:
Pregabalin
Initially 150mg (2-3 divided doses) if required up to 600mg a day
Response time unclear but some effect in a week
91
Name and describe second line therapy/ short term adjuncts for GAD/ anxiety:
Benzodiazepines
BB- low dose short term
Antihistamines- low dose short term
Anti-psychotics- low dose short term
Venlafaxine/ mirtazapine
Prefab, often seen with SSRI
Busprione
92
Name and describe the first line treatment for OCD:
SSRI or clomipramine (TCA)
Other ADs seem ineffective
93
Describe the treatment for social anxiety:
SSRIs (e.g escitalopram) and venlafaxine licensed
Should be for at least 12 weeks
94
What is the first line treatment for moderate- severe panic disorder?
Self help and CBT should be encouraged
SSRIs first line- escitalopram, sertraline, citalopram, paroxetine and venlafaxine licensed
95
What does euthymia mean?
Mood is stable
96
What are the general prescribing points for mania?
1. discontinue any manicogenic agents, inc ADs and stimulants
2. stabilise any medical conditions
3. start non specific calming meds e.g benzos, antipsychotics
4. start specific mood stabilisers or relapse prevention agents, preferable when pt is able to consent
5. hypnotic/ sedative should be considered
6. any co-morbid substance misuse must be tackled
97
Name the first line mood stabilisers/ relapse prevention agents for BPD:
Lithium
Quetiapine
Olanzapine
Aripiprazole
Lamotrigine
Valproate
98
Describe the licensing of quetiapine for BPD:
Licensed as monotherapy for acute mania and relapse prevention acute BPD (only one licensed) and relapse prevention
Also acute mania and relapse prevention in people who response in acute state over 2 years
99
Name the baseline monitoring for quetiapine:
Weight/ BMI
Pulse/ BP (HTN risk)
Lipid abnormality
ECG if at risk (as can increase QT)
100
Name the ongoing monitoring for quetiapine:
Pulse and BP after each dose change
Weight/ BMI weekly for 6 weeks, then at 12 weeks
BG or HBA1C
Blood lipid profile at 12 weeks
Response to treatment
SEs
Emergence of movement disorders
Adherence
101
Name the SEs of quetiapine:
Very common: sleepiness, dizziness, dry mouth (anticholinergic), weight gain, post hypo
Common: headache, akathisia, anticholinergic SEs
102
Describe the prescribing advice for quetiapine:
Initial dose titration must be slow due to risk of post hypotension an about 16% of pts
Although highly sedative at low doses (e,g 25mg) the sedation is not proportional to dose
103
Describe the licensing for olanzepine in BPD:
Licensed for mania and relapse prevention in people who have responded to it acutely and are lithium or valproate non responders
Widely used as an anti manic and as a mood stabilisers
104
Describe the monitoring requirements for olanzapine:
Same as quetiapine
105
What are the very common SEs of olanzapine?
Sedation- so take at night
Weight gain
106
What are the common SEs of olanzapine?
Post hypotension
Dry mouth, constipation
Peripheral oedema
Diabetes
Long term weight gain
Metabolic syndrome e.g diabetes, raised lipids and cholesterol
107
Describe the smoking interaction with olanzapine:
Smoking induces CYP1A2 enzyme that metabolised olanzapine
If stopping smoking can increase levels
108
What is the prescribing advice for olanzapine?
Starting dose in acute mania is 15mg/d as monotherpay or 10mg/d as adjunct
Don't give benzo within an hour of short acting IM olanzapine as reports of death
109
Describe the licensing of aripiprazole in BPD:
Licensed for acute mania and main presentation in people who have responded acutely including in adolescents aged 13 years or older
110
What are the monitoring requirements of aripiprazole?
Same as quetiapine
111
What are the very common SEs of aripiprazole?
Akathisia
Insomnia- take in morning
Stomach upset
Constipation
Blurred vision
112
What are the common SEs of aripiprazole?
Movement disorders (extra-pyramidal SEs)
Post hypotension
Palpitations
113
What is the prescribing advice for aripiprazole?
For mania start at 15mg and increased to 30mg/d
Relapse prevention dose can be 15-30mg/d
Due to its partial agonism, start it at 5mg/d if patient has had another antipsychotic in their system
114
Describe the licensing of lamotrigine for BPD:
Licensed for prevention of relapse of BPD
No efficacy in mania, mixed, rapid-cycling or unipolar depression nor acute BPD (due to long titration)
Efficacy shown in severely depressed pts
115
Describe the prescribing points of lamotrigine:
Must be titrated 'by the book'
Starting dose must be low and slowly titrated as per BNF
25mg/d for 2 weeks, 50mg/d for 2 weeks then increase by 50-100mg/d every 1-2 weeks
Half this if used with valproate (e.g 25mg alternative days for 2 weeks, taking 6 weeks to reach 200mg/d)
116
Why is the dosing of lamotrigine so specific?
Almost abolished the risk of potential fatal rashes
117
What are the most common SEs of lamotrigine?
Drowsiness, headache, dizziness, nausea, blurred vision
118
What are the rare but serious SEs of lamotrigine?
Oedema
Bone marrow suppression
Skin rashes
119
Describe the skin rash side effect of lamotrigine:
Stevens-Johnson syndrome (SJS) or Toxic Epidermal Necrolysis (TEN)
Red rashes across the face and body, blisters and inflammation in the nose, mouth and eyes, looks like serious sunburn
120
Describe the licensing of valproate for BPD:
For mania and relapse prevention
Depakote (semi sodium valproate) and Episenta are licensed for BPD
Epilim is available in tabs, MR and liquid
121
What is the baseline monitoring for valproate?
Height, weight, FBC, LFTs
Blood cell count, inc platelet count, bleeding time and anticoagulation before treatment starts then during first 6 months
LFTs then at 6 months
122
What is the dosing of valproate?
Oral LD 20mg/kg/ day may give a rapid response often within 3 days
MD not full established
123
What are the very common SEs of valproate?
Weight gain, increased appetite
124
What are the common SEs of valproate?
Gastric irritation, diarrhoea, hair loss, nausea
125
What are the rare but serious SEs of valproate?
Thrombocytopenia and impaired platelet function
Hepatic dysfunction in first 6 months
Pancreatitis- abdominal pain, N&V
PCOS
126
What are interactions with valproate?
Carbapenem antibiotics decrease valproate
Lamotrigine (variable effects):
-34% have more 25% increase in V levels
-14% have an increase of more 50% in V levels
-5% have a more 25% decrease in V levels
127
Name other second line treatments for BPD:
Carbamazepine
Haloperidol
Risperidone
Benzodiazepines
Antidepressants
128
What is the combination therapy for bipolar mania?
Antipsychotic and/ or mood stabiliser+ benzo
129
What is the combination therapy for bipolar depression?
Any combo of lithium, lamotrigine or valproate, quetiapine, risperidone or olanzepine
130
What is the combination therapy for relapse prevention?
Mood stabilisers
Mood stabilisers plus ADs
Lamotrigine plus ADs
131
Which mood stabilisers pose the greatest risk during pregnancy?
No safe mood stabiliser in pregnancy
Lithium, valproate and carbamazepine pose greatest risk
132
What is the mood stabiliser used in hepatic impairment?
Amisulpride exception, everything else metabolised by liver
133
What is the mood stabiliser used in renal impairment?
Avoid lithium and amisulpride
134
What is the DSM V diagnosis of mania?
Duration of elevated and irritable mood needs to be for 7 days or more
Severe functional impairment
May have psychotic symptoms
135
What are the DSM V diagnosis of hypomania?
Duration of elevated and irritable mood needs to be for 4 days or more
Decrease or increased function
Psychotic features absent
136
Describe how preparations of lithium vary widely in bioavailability:
Need to always stay on same brand
Priadel MR tabs 200/400 and Priadel liquid 520mg/5ml
5ml of liquid is equal to ONE lithium carbonate 200mg tab
137
What are the CI of lithium therapy?
Hypersensitivity to lithium
Cardiac disease/ insufficiency (QT)
Severe renal impairment
Untreated hypothyroidism, Addison's
Breast feeding
Pt with low body Na e.g dehydrated or low Na diets
Brugada syndrome hereditary disease of the cardiac sodium channel
138
What are the cautions of lithium therapy?
Pregnancy- AVOID unless exceptional circumstances esp in first trimester
Renal impairment (mild-moderate)
ECT and other meds that can decrease epileptic threshold
QT interval prolongation and other meds that do this
139
What is the monitoring prior to initiating lithium theory?
ECG- QT interval increased
Renal function (eGFR)- excreted via kidneys
Thyroid function- hypo can be mistaken for depression
Weigh gain/BMI, Ca (hyper), U&E, FBC
140
What are the dose monitoring requirements during lithium therapy?
Regular blood tests required to ensure therapeutic dose maintained as narrow window
Plasma levels must be taken weekly until stable conc maintained for 4 weeks
Plasma levels should 4-7 days after each dose change
NICE- take plasma every 3 months for 1st year then 6 monthly unless at risk
141
When should blood tests be taken to measure lithium dose?
12 hours post dose so take it at night
142
What should the blood test range be for lithium therapy?
0.4-1mmol/L (higher 0.8mmol in mania)
Lower in elderly
143
What are additional ongoing monitoring requirements with lithium therapy?
Renal function
Thyroid (TSH, T4)
Every 6 months ^
Weight, BMI, Ca, U&E's
144
What are specific patient factors which would mean they have a reduced dose of lithium?
Renal impairment (avoid if possible)
Patients less than 50kg
145
What are the SEs of lithium?
Upset stomach- esp at start
FINE tremor of hands
Metallic taste in mouth
Swelling of ankles- dose reduction
Increase thirst and urine output- renal impairment
Weight gain- up to 27kg
146
Describe blood results which would indicate lithium toxicity:
Blood conc over 1.5mmol/L (overdose) and may be fatal and toxic effect
Blood conc over 2mmol/L (severe overdose) requires urgent medical attention- check compliance
147
What are the signs and symptoms of lithium toxicity?
SEVERE hand tremor
Stomach ache with nausea and diarrhoea
Muscle weakness
Unsteady on feet
Slurring of words
Blurred vision
Confusion
Unusually sleepy
Muscle twitches
148
Name drug interactions that can increase lithium levels:
ACEi/ ARBs (renal, increase Na+ loss)
NSAIDs
COX2i e.g ketorolac avoid
Metronidazole
SSRIs
Diuretics and aldosterone agonists (thiazides worst) e.g bumetanide/ furosemide (least risk)
149
Name drug interactions that can decrease lithium levels:
Sodium bicarbonate containing products
Caffeine
150
Name other drug interactions with lithium:
Ventricular arrythmia can be caused by concomitant use with amiodarone- avoid
Increase risk of neurotoxicity with methyldopa and some antipsychotics e.g clozapine
151
Describe the counselling points for lithium:
OD at night
Effectiveness takes 6/12 months to fully establish
Duration of treatment 2-3 years min
Stop stepwise over at least 4 weeks, preferably longer
Plasma levels monitoring (3 months)
Medical attention if d&v
May lose efficacy if stopped and restarted
No OTC NSAIDs
152
Describe the ICD-10 diagnosis of sz:
At least ONE of the main
At least TWO of the other
Last at least a month
153
Describe the DSM 5 diagnosis of sz:
Two symptoms present for at least a month:
-delusions, hallucinations, disorganised speech, grossly disorganised catatonic behaviour, negative symptoms
Social/ occupational dysfunction
Duration- continuous for at least 6 months
154
Describe the features of FGA's:
Chlorpromazine
D2 antagonist
Similar SE profile- EPSEs
Same efficacy but different SEs
155
Describe the features of SGA's:
Chemically related to TCA
5HT2A antagonism, fast D2 dissociation (less D2 specific), 5HT1A antagonism
Possibly superior efficacy against -ve symptoms
Different SE profile:
-lower EPSEs but increase metabolic syndrome
156
Name some SGAs licensed to treat mood disorders:
Risperidone
Quetiapine
Olanzapine
Aripirazole
157
Name classes and examples of FGAs:
Phenothiazine:
-chlopromazine, pericyazine, levopromazine
Butyrophenones:
-haloperidol, benpenidol
Thioxanthenes:
-flupentixol, zuclopethixol
Substituted bezamides:
-sulpride, amisulpride
158
Name different examples of SGAs:
Clozapine
Risperidone
Quetipaine
Aripirazole
Lurasidone
159
What are the requirements when using a FGA LAI?
A small test dose is given to test for sensitivity to EPSEs and to the oil base
160
What are the requirements when using a SGA LAI?
Oral treatment is required first, to see if it works and SEs as can't reverse after injected
161
What is the problem with olazapine LAI?
Post injection syndrome- needs to be monitored for 3 hours after
162
What should occur if a patient is on HDAT?
Clinical needs to review and document:
-target symptoms
-SEs
-therapeutic response
-close physical monitoring inc ECG
163
What is the NICE recommend drugs for rapid tranquilisation?
IM lorazepam on its own
IM haloperidol with IM promethazine
164
What are the monitoring requirements of rapid tranquilisation med?
SES
Pulse/BP
Resp rate
Hydration
Conscious levels
Every 15 mins if max dose exceeded
Every hour if not
165
What is treatment resistant psychosis?
A lack of satisfactory clinical improvement despite use of adequate doses of at least 2 different APs, including SGAs prescribed for at least 4-6 week trial
166
What is the AP used in treatment resistant psychosis?
Clozapine only AP licensed
167
What are the monitoring requirements when starting on clozapine?
Pt must be registered with an approved clozapine blood monitoring service to minimise risk of agranulocytosis and neutropenia
Blood monitoring before starting then weekly for first 18 weeks, then twice weekly until 1 year, then monthly after
Can only be supplied if valid blood result
168
What is the green blood result for clozapine?
WBC count ≥3500/mm3 or the neutrophil ≥2000/mm3
Means it can be supplied
169
What is the amber blood result for clozapine?
WBC 3500-3000/mm3 or the neutrophil between 2000-1500/mm3
Repeat twice weekly until either green or red- can still supply
170
What is the red blood result for clozapine?
WBC below 3000mm3 and/or absolute neutrophil below 1500mm3
Immediate cessation of therapy sample blood daily until pt has recovered
No further prescribing allowed unless error occurred or consultant takes full responsibility
171
What are the discontinuation symptoms of APs?
Occur within 4 days and may last 1-2 weeks
N&V, sweating, muscle pains, insomnia, restlessness, anxiety, seizures, EPSEs, akathisia dystonia, dyskinesia
172
What are the adverse effects of FGAs?
Neurological SEs:
EPSEs
Acute- akathisia, dystonia, Parkinsonism
Tardive dykinesia
173
What are the adverse effects of SGAs:
Metabolic SEs:
-weight gain
-hyperglycaemia
-hyerlipidaemia
174
What are the adverse effects of all APs:
Anticholinergic
Cardiac
Hyperprolactinamia
Sexual dysfunction
175
What is the monitoring recommended by NICE for metabolic syndrome?
Baseline then repeat at 12 weeks then annually
-waist circumference, fasting blood glucose, HbA1C, blood lipid level
Every 3 months for first year for clozapine and olanzapine
Weekly weight for first 6 weeks, at 3 months, 12 months then annually
176
Which drugs are high risk of causing hyperprolactinamyia?
Amisulpridie
Palperidone
Risperidone
Sulpuride
FGAs
177
What is the management of hyperprolactinamyia?
Decrease dose, switch to a prolactin sparing AP e.g aripirazole
Consider adding low dose aripirazole e.g 2.5-5mg day
178
What is the management for sexual dysfunction when using AP?
Monitor prolactin levels
Adjust dose- either decrease, omit selected or consider single daily
Switch or stop
Add 3-6 mg aripirazle (off license)
PD5i via specialist only
179
What is the monitoring for the cardiac SEs of APs?
Baseline BP, pulse, ECG repeat at 12 weeks then annually
180
What is the management for constipation due to clozapine?
Dietary and exercise
Laxatives- stim (1st line) + stool softeners
Avoid bulk forming as may cause impaction
181
What is neuroleptic malignant syndrome (NMS)?
An acute disorder of thermoregulation and neuromotor control
Rare but serious or even fatal
0.11-0.16% incidence
182
What are the signs and symptoms of NMS?
Fever
Diaphoresis
Rigidity
Fluctuating level of consciousness
Tachycardia
Fluctuating BP
Sweating
Elevated creatinine kinase, leukocytosis, altered LFTs
183
What are the risk factors for NMS?
High potency FGAs, recent or rapid dose increase/ reduction, abrupt withdrawl of ACH drugs, AP polypharmacy
Psychosis, organic brain disease, alcoholism, PD, hyperthyroidism
Male and younger age
184
What is the treatment for NMS?
Stop AP, monitor temp, pulse, BP
Consider benzo
Call ambulance- rehydration, bromocriptine, dantrolene, sedation with benzo, artificial ventilation
185
What are the requirements of restarting an AP after a patient has had NMS?
Allow at least 5 days before attempting to restart
Start low
Consider AP that is structurally unrelated to causative agent or with lower dopamine affinity e.g quetiapine, olanzapine, aripirazole
AVOID depot or LAI
186
What are the AP that can cause QT prolongation?
Haloperidol
Quetipaine
Pimozide
187
Name other drugs that can cause QT prolongation:
Escitalopram, amiodarone
Mycin ABs
Citalopram
Tamoxifen
188
Name the APs that interact with smoking?
Clozapine (50% decrease)
Olanzapine (50%)
Haloperidol (20%)
189
What are the requirements when someone is a smoker when taking clozapine?
Take plasma level before stopping or starting smoking and repeat after 1 week
When stopping smoking, decrease dose gradually (over 1 week) until around 75% of original dose reached, decrease further if needed
If restarting smoking increase dose to previous smoking dose over 1 week
