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Pharmacology - MRCPsych A > MRCPsych > Flashcards

MRCPsych Flashcards

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1
Q

Name some markers for Clozapine associated myocarditis?

A

Troponin T and I are the most specific

Other markers to check include LDH, AST, CK and Myoglobin

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2
Q

Which dementia drugs are broken down by hepatic enzymes?

A

Donepezil (minor) and Galantamine - both mainly by CYP2D6 and CYP3A4

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3
Q

Name some symptoms of discontinuation syndrome?

A

Anxiety
Vivid dreams
Crying spells
Dizziness
Flu-like symptoms
Electric shock sensations
Irritability
Crying sensations

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4
Q

Which anti-depressants are most likely to cause discontinuation symptoms?

A

Paroxetine
Venlafaxine
Amitriptyline
Imipramine

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5
Q

Name some factors that would lead to a higher rate of discontinuation symptoms?

A

Taking for 8 weeks or longer
Higher doses
Receiving other central acting drugs - antihistamines, antipsychotics, anti-hypertensives
Young people
Anxiety symptoms on anti-D initiation

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6
Q

What medications should be avoided when prescribing MAOIs

A

SSRI
SNRI
TCAs particularly Imipramine and Clomipramine due to risk of serotonin syndrome
Triptan migraine products
St John’s Wart
Cold products - dextromethorphan and chlorpheniramine
Opiods

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7
Q

Which dietary products lead to the cheese reaction?

A

Dairy:
- All mature/aged cheese

Meat/fish/poultry:
- Fermented meat - salami
- Improperly stored meat

Fruit/veg:
- Fava or broad bean pods
- Banna peel

Drinks:
- Tap beer

Misc:
- Marmite
- Saurkraut
- Soy sauce
- Tyramine containing nutritional supplements

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8
Q

Outline the Gell and Coombs system that classifies immune mediated drug reactions

A

Type I - IgE mediated - these occurs minutes to hours after drug. Drug IgE complex get detected by mast cells and release histamine - classic urticaria, anaphylaxis, rash, angioedema

Type II - IgG and IgM mediated these occur longer after - neutropenia, thrombocytopenia

Type III - complement mediated reaction, symptoms include rash, fever, vasculitis occur 1-3 weeks after

Type IV - MHC system presents drug complexes to T cells occurs 2-7 days after drug and includes symptoms of dermatitis and rash

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9
Q

Which ADHD drugs are metabolised by CYP450

A

Atomoxetine - CYP2D6

Guanfanacine - CYP3A4/5

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10
Q

How does sodium valproate work as a mood stabiliser?

A

GABA agonism and NMDA antagonism

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11
Q

Why does a proportional increase body fat in the elderly matter regarding pharmacokinetics?

A

Lipid-soluble drugs will be distributed more readily - therefore lipid-soluble drugs half lives decrease

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12
Q

Which anti-depressants have the highest risk on sexual desire, sexual arousal and orgasm?

A

SSRIs, MAOI, TCAs & Venlafaxine: ++ in all domains

Duloxetine ++ on sexual desire, + on sexual arousal and ++ on orgam

Mirtazapine, Bupropion, Vortioxetine, Moclobemide, Reboxetine and Nefazadone lower effecting

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13
Q

What are the half-lives of the following drugs

Diazepam
Lorazepam
Chlordiazepoxide
Nitrazepam
Temazepam
Zopiclone
Zolpidem

A

Diazepam 20-100 hrs (36-200 hrs for active metabolite)
Lorazepam 10-20hrs
Chlordiazepoxide 5-30 hrs (36-200 hrs for active metabolite)
Nitrazepam 15-38 hrs
Temazepam 8-22 hrs

Zopiclone 4-6 hrs
Zolpidem 2-6 hrs

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14
Q

What is pethidine?

A

An opioid - has been associated to the onset of delirium

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15
Q

Name some GABA agonists

A

BDZ
Z-drugs
Valproate
Topiramate

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16
Q

Which enzyme is encoded for by CYP2D6

A

Debrisoquine hydroxylase.

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17
Q

Name the active metabolite of Fluoxetine

A

Norfluoxetine - has a very long half life of up to 14 days

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18
Q

What is the most selective SSRI?

A

Citalopram and Escitalopram

  • Fluoxetine is a weak noradrenaline reuptake inhibitor
  • Setraline weakly inhibits noradrenaline and dopamine
  • At high doses Paroxetine has anticholinergic effects
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19
Q

Name some interactions with Fluvoxamine?

A

Reduces the clearance of diazepam - do not generally co-administer both

Inhibits CYP1A2 - can increase level of theophylline therefore 1/3 of the original dose & can increase levels of warfarin

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20
Q

Which SSRIs have non-linear kinetics

A

Fluoxetine, Fluvoxamine and Paroxetine

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21
Q

What SSRI has the longest half-life?

A

Fluoxetine 1.9 days

Shortest half life is Paroxetine (10hr), Fluvoxamine and then Sertraline (26hr)

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22
Q

How does Buspirone work?

A

5HT-1A agonism - inhibits release of serotonin presynaptically reducing anxiety

Post-synaptic agonism leads to anti-D properties

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23
Q

What is the half-life of Mirtazapine?

A

20-40hrs

Paroxetine/Fluoxetine can increase levels but no clinical consequences
Carbamezepine can reduce levels

Mirtazapine does not inhibited CYP enzymes.

It undergoes extensive 1st pass metabolism producing a bioavailability of 50%

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24
Q

Why is it important to maintain a steady sodium intake with lithium?

A

Sodium is excreted in the proximal tubules and as a compensatory mechanism Lithium is reabsorbed. Increasing sodium intake can lead to toxicity.

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25
What is the half life of Lithium
Initially 18hrs then increases to 36hrs - Lithium takes 4-5 days to reach a steady state
26
What agents may increase Lithium levels?
ACEi, loop diuretics, thiazide diuretics, Fluoxetine and NSAIDs
27
Name some agents that may decrease Lithium levels?
Osmotic diuretics Caffeine Carbonic anhydrase inhibitors Aminophylline and Theophylline
28
Divide benzodiazepines into long, intermediate/short and very short acting:
Long acting - Diazepam: 30-hr half life, metabolite desmethyldiazepam - Clonazepam - Chlordiazepoxide Intermediate or short acting (less daytime impairment, rebound insomnia and anterograde amnesia) - Lorzepam - 15 hrs half life - Oxazepam - Temezepam - 10hrs - Alprazolam Very short acting: - Triazolam
29
How do the Z drugs differ with regards to effect on sleep onset or maintenance?
Zopiclone - for maintenance. Onset within 45 minutes, half life of 4-5hrs. Acts up to 8hrs Zolpidem - for sleep onset problems. Onset within 30 mins, half life of 1-4hrs. Acts up to 6hrs Zaleplon - for sleep onset problems. Onset within 30 mins, half life 1-2hrs, acts up to 4hrs
30
How does Agomelatine work?
5HT2C antagonism - DA and NAA release in frontal cortex M1 and M2 melatnonin receptor agonism
31
Name two anti-D licensed for PTSD
Sertraline and Paroxetine
32
How long does Olanzapine take to reach a steady state?
7 days
33
Moclobemide has a minimum effective dose of what for depression?
300mg a day
34
What are biogenic amines?
Compounds derived from amino acids they include HANDS Histamine Adrenaline Noradrenaline Dopamine Serotonin
34
What are biogenic amines?
Compounds derived from amino acids they include HANDS Histamine Adrenaline Noradrenaline Dopamine Serotonin
35
What is zopiclone contraindicated in?
Unstable myasthenia gravis Sleep apnoea Respiratory failure Neuromuscular respiratory weakness
36
Which antipsychotics are least likely to result in EEG changes?
Quetiapine - Clozapine most likely to cause EEG changes
37
5% of patients per year taking a typical antipsychotic develop...
Tardive Dyskinesia - More commonly seen in elderly patients, those with an affective illness, those with EPSE's earlier on - Switch to atypical (Clozapine/Quetiapine) if develop - Takes months to years to develop - Can also prescribe Tetrabenazine, Ginkgo biloba
38
5% of patients per year taking a typical antipsychotic develop...
Tardive Dyskinesia - More commonly seen in elderly patients, those with an affective illness, those with EPSE's earlier on - Switch to atypical (Clozapine/Quetiapine) if develop - Takes months to years to develop - Can also prescribe Tetrabenazine, Ginkgo biloba
39
Outline the treatments for a) Dystonia b) Akasthesia c) Parkinsonism d) Tardive dyskinesia
a) Botulism toxim, anticholinergic drugs (trihexyphenidyl, procyclidine,, orphenadrine, benztropine. Note diphenhydramine (an antihistamine is also used due to its anticholinergic properties) b) Beta-blockers, BDZs, Cryprohepadine, Clonidine, Mirtazapine or Mianserin (low dose) c) Tetrabenazine, Ginko Biloba Note for all reducing the dose and alternative atypical options should be considered
40
How does Disulfiram put individuals off alcohol?
Bind irreversibly to aldehyde dehydrogenase - this leads to a build up of acetaldehyde that causes facial flushing, N&V, hypertension, respiratory distress. These effects start within 15-30 minutes of starting and can last several hours
41
Name the secondary amines?
Nortryptiline Desipramine Protriptyline Amoxapine
42
What does the Amdisen scale assess for?
Lithium toxicty: - 0 = no clinical signs - 1 = mild, nausea + vomiting, coarse tremor, hyperreflexia, agitation - 2 = moderate. stupor, rigidity, hypertonia and hypotension - 3 = severe toxicity (myoclonus, coma)
43
Name some notable contraindications for Carbamazepine?
Bone marrow suppression MAOIs
44
What are the indications of Carbamazepine?
Neuropathic pain Partial focal epilepsy Maintenance bipolar disorder
45
Name some very common side effects with Carbamazepine?
Leucopenia Ataxia, Dizziness, Somnolence Nausea and vomiting Urticaria Fatigue
45
Name some very common side effects with Carbamazepine?
Leucopenia Ataxia, Dizziness, Somnolence Nausea and vomiting Urticaria Fatigue
46
Does Diazepam or Clonazepam have longer half lives?
Diazepam (20-100hrs) > Clonazepam (18-50hrs)
47
How does Flumazenil work?
GABA-A receptor antagonism to stop BDZ binding to receptor and reverses effects of substances bound Given IV Short half life of 60 mins Reverses other agents like Zopiclone
48
How is a diagnosis of SIADH confirmed?
Low serum osmolality < 275 mOsm/kg Increased urine osmolality > 100 mOsm/kg Euvolaemic Raised urinary sodium > 20ml/L No other caused of hyponatraemia
49
Name some psychotropic drugs that can cause SIADH
Carbamazepine, oxcarbazepine, chlorpropamide, cyclophosphamide, and selective serotonin reuptake inhibitors (SSRI).
50
How is SIADH treated?
Fluid restriction or demeclocycline
51
Which antipsychotics have a low propensity for elevating prolactin?
Aripiprazole Quetiapine Clozapine Asenapine Low - moderate risk: - Olanzapine - Lurasidone - Ziprasidone High risk: - All typicals - Palpileridone/Rispeidone - Amisulpride/Sulpride
52
Name the side effects of Topiramate
Weight loss, nephrolithiasis and metabollic acidosis - it does this as it inhibits carbonic anhydrase - calcium phosphate stones can develop Used epilepsy and as a mood stabiliser in BPAD - inhibits voltage gated sodium channels suppressing action potentials, it also increases GABA
53
Name the minimum effective doses of Agomelatine, Trazadone, Duloxetine, Fluvoxamine, Moclobemide
Agomelatine - 25mg/day Fluvoxamine - 50mg/day Trazadone - 150mg/day Moclobemide - 300mg/day Duloxetine - 60mg/day
54
What medications can be added to Olanzapine or Clozapine to reduce weight gain
Aripiprazole - Orlistat - Liraglutide - Metformin
55
Name some non-psychiatric drugs that can increase QTc?
Antimalarials - chloroquinine and quinine Antibiotics - Erythromycin and Ampicilin Anti-arrhythmics - sotalol and amiodarone Methadone Tamoxifen Amantadine
56
What percentage of D2 receptors need to be blocked for a therapeutic effect and for ESPE's to occur?
65-80% is the therapeutic window > 80% EPSE's likely
57
Which anti-D is least likely to associate with withdrawal syndrome?
Agomelatine
58
Outline the triad of symptom clusters for serotonin syndrome?
Confusion/altered mental state, neuromuscular abnormalities and autonomic dysfunction Neuromuscular abnormalities are more prominent in the lower limbs and include: - Clonus - nearly always present - contraction on stretching of the muscle - Hyperreflexia - Rigidity - Tremor A temperature indicates immediate action
59
What tool is helpful in diagnosis of serotonin syndrome?
Hunter's tool
60
What pharmacological changes may induce serotonin syndrome?
Over dose of a serotonergic drug - 16% of SSRI overdoses may lead to serotonin syndrome Increasing the dose of a serotonergic drug Combination of two serotonergic drugs Administration of drugs that inhibit the P450 enzyme system - typically symptoms begin within 24hrs however subacute presentations ma occur
61
How do you treat serotonin syndrome?
Remove serotonergic agent BDZ and fluids if mild case May administer 5HT2A antagonist - cyproheptadine
62
How may one differentiate between NMS and Serotonin syndrome?
NMS - develops slower and remits slower 9-14 days of appropriate treatment. Often associated with bradykinesia and leadpiping rigidity (uniform) and hyporeflexia. Pupils will be normal SS - faster onset and rapid improvement with treatment. Pupillary dilatation. Hyperactive bowel sounds. Hyperreflexia
63
Which antipsychotic has the longest half life (75hrs)?
Aripiprazole
64
Name some features of hydrophilic drugs?
Poorly absorbed Rapidly excreted Little 1st pass metabolism Little protein binding Experience tubular reabsorption
65
Name the features of NMS
- Mental state changes - Muscular rigidity (also hyporeflexia) - Autonomic instability - especially tachycardia Fever Diaphoresis Rigidity Confusion Flutuating consciousness Fluctuating blood pressure Tachycardia Elevated CK Leukocytosis Altered LFTs
66
What is the treatment of NMS
- Stop antipsychotic + BDZ in psychiatric unit - Bromocriptine + Dantrolene in medical unit - When re-starting choose low dose monitoring temp, BP and HR - Choose structurally different or that with low D2 affinity (Quetiapine/Clozapine) - Avoid depot - Avoid FGA
67
Is anti-depressant induced hyponatraemia dose related?
No - Often begins within 30 days of initiation
68
What diuretics are safer with a patient on Lithium?
Loop diuretics and K+ sparing diuretics
69
Name the teratogenic effects of Carbamazepine?
Fingernail hypoplasia and craniofacial defects
70
Name some anti-D that undergo little metabolism via the Liver and therefore would be suitable if hepatic impairment is present?
Citalopram Sertraline Paroxetine Vortioxetine Avoid TCAs and MAOI
71
What heart rate is optimum for Bazzett's formula?
60-100 BPM At < 60 bpm it under-corrects At > 100 bpm it over corrects
72
Name some of the side effects of alpha 1 blockade?
Orthostatic hypotension Sexual dysfunction Sedation Priapism
73
What are the side effects of Varencicline?
Nasopharyngitis Headaches Nausea Abnormal dreams
74
Name some medications associated with priapism?
Tazadone Chlorpromazine Thioridazine
75
What are the risk factors for prolonged QT interval?
Cardiac: - Bru
76
What are the risk factors for prolonged QT interval?
Cardiac: - Bradycardia - Long QT syndrome - IHD - Myopathy - LVH Electrolyte: - Hypomagnesia - Hypokalaemia - Hypocalcaemia Other: - Female - Anorexia Nervosa - Stress/Shock - Extremities of age
77
Which antipsychotics are/are not associated with postural hypotension
Are associated with postural hypotension: - Risperidone - Olanzapine - Quetiapine - Clozapine - Ziprasidone Are not: - Aripiprazole - Amisulpride - Sulpride - Haloperidol - Trifluperozine
78
Severe liver damage and Pancreatitis are the severe/rare complications of which AED?
Sodium Valproate
79
Name some drugs that should not be included in dosette boxes due to poor drug stability?
Sodium valproate Zopiclone Venlafaxine Topiramate Methylphenidate Mirtazapine Olanzapine Amisulpride Aripiprazole
80
What anti-depressant is licenced for Bullimia?
Fluoxetine
81
What are the contraindications for first generation anti-histamines?
Acute angle closure glaucoma Pyloric stenosis BPH 1st generation anti-histamines include: Diphenhydramine Promethazine Hydroxyzine Chlorpheniramine Cyproheptadine Cyclizine Ketotifen
82
Acamprosate is a positive allosteric modulator of what?
GABA-A Acamprosate is also an NMDA antagonist
83
Which is the least cardiotoxic TCA?
Lofepramine
84
Is teratogenicity in valproate dose dependent?
Yes Valproate is a GABA agonist and NMDA antagonist
85
Vitamin involved in Carbohydrate catabolism?
Thiamine
86
Is Duloxetine allowed in hepatic impairment?
No
87
Which SSRI has been linked to ESPE?
Fluoxetine
88
Which SSRI has been linked to ESPE?
Fluoxetine
89
Is Reboxetine associated with sexual dysfunction?
No
90
Do depot or oral antipsychotics carry a higher risk for NMS?
The risk is the same!

Pharmacology - MRCPsych A (5 decks)

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