Other Flashcards
(33 cards)
Antipsychotics
Clozapine
Used in treatment-resistant schizophrenia
Mechanism: blocks D1 and D4 receptors
Contraindications: previous or current neutropaenia, previous myocarditis, active or progressive liver disease
Side-Effects: sedation, weight gain, reduced seizure threshold, myocarditis, metabolic syndrome, hypersalivation, GI (swallowing problems, constipation)
- smoking cessation can lead to a decrease in CYP450 activity resulting in raised clozapine levels
Register patient with Clozaril patient monitoring service, Dezapine monitoring system or Zaponex treatment access system
Ensure normal leucocyte count and ECG before starting treatment
FBC Monitoring:
- Weekly for 18 weeks
- Fortnightly for 1 year
- Monthly thereafter
Side-Effects
- Agranulocytosis, neutropaenia
- Reduced seizure threshold
- Constipation
- Myocarditis (baseline ECG should be taken before starting treatment)
- Hypersalivation
SSRI choice
Citalopram and fluoxetine are currently the preferred SSRIs
Sertraline is useful post-MI
Fluoxetine is the drug of choice in children
SSRI side effects
GI upset
GI bleeding (if NSAIDs are being used, it should be given with a PPI)
Increased anxiety and agitation soon after starting
-Usually occurs in first 2 weeks, then tends to settle but must warn patient and
arrange follow-up during this period
Fluoxetine and paroxetine have higher propensity for drug interactions
Citalopram and Escitalopram are associated with a dose-dependent increase in QTc and should not be used in those with pre-existing QT prolongation or in combination with other medicines that prolong the QT interval
- Maximum daily dose of citalopram: 40 mg for adults; 20 mg for > 65 years, 20
mg for hepatic impairment
SSRI interactions
NSAIDs and aspirin: if used, give with a PPI
Warfarin/heparin: avoid SSRIs and consider mirtazapine
Triptans: avoid SSRIs
MAOI: risk of serotonin syndrome when given at the same time as SSRIs
SSRI in pregnancy
Weigh up benefits and risks when deciding whether to use SSRIs
1st trimester: increased risk of congenital heart defects
3rd trimester: increased risk of persistent pulmonary hypertension of the newborn
SSRIs that are generally considered safe are sertraline, citalopram and fluoxetine
Paroxetine has an increased risk of congenital malformations, particularly in the 1st trimester
Switching antidepressant
Switching from citalopram, escitalopram, sertraline or paroxetine to another SSRI
- First should be withdrawn before the alternative is started
Switching from fluoxetine to another SSRI
- Withdraw then leave a gap of 4-7 days (fluoxetine has a long half-life) before starting a low-dose of the new SSRI
Switching from SSRI to TCA
- Cross-tapering is recommended
- Exception: fluoxetine should be withdrawn before TCAs are started
Switching from citalopram, escitalopram, sertraline or paroxetine to venlafaxine
- Cross-taper cautiously (start venlafaxine 37.5 mg OD and increase very slowly)
Switching from fluoxetine to venlafaxine
- Withdraw then start venlafaxine at 37.5 mg OD and increase very slowly
Lithium side effects
Nausea/vomiting and diarrhoea
Fine tremor
Nephrotoxicity: polyuria (secondary to nephrogenic DI)
Thyroid enlargement (and hypothyroidism)
ECG: T wave flattening/inversion
Weight gain
Idiopathic intracranial hypertension
Lithium monitoring
After starting, lithium levels should be performed weekly and after each dose change until concentrations are stable
Once established, lithium blood levels should be routinely checked every 3
months (levels should be taken 12 hours post-dose)
Thyroid and renal function should be checked every 6 months
Benzodiazepine
Enhances the effect of GABA (increases the frequency of opening of the chloride ion channel)
Used as a sedative, hypnotic, anxiolytic, anticonvulsant and muscle relaxant
Should not be used for longer than 2-4 weeks
Features of Withdrawal
- Insomnia
- Irritability
- Anxiety
- Tremor
- Loss of appetite
- Tinnitus
- Perspiration
- Perceptual disturbance
- Seizures
MMSE interpretation
Any score ≥ 24/30 is considered normal
Cognitive Impairment
- Mild: 18-23 - may require some supervision, support or assistance
- Moderate: 10-17 - clear impairment, may require 24-hour supervision
- Severe: 0-9 - marked impairment, likely to require 24-hour supervision and assistance with ADLs
Patients with depression may often answer with ‘I don’t know’ whereas patients with dementia will attempt to answer all questions
Montreal cognitive assessment
Domains tested: visuospatial and executive functioning, animal naming, attention,
language, abstraction, delayed recall (short-term memory), orientation, education level (1 point added if < 12 years of formal education)
Maximum: 30 points
Normal: > 26 points
Does not differentiate between mild, moderate and severe cognitive impairment
If a patient score < 25, consider referral for further cognitive assessment
Depression and anxiety questionnaires
PHQ-9
- Ask the patient ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
- 9 items which are scored 0-3
- Includes items about thoughts of self-harm
Hospital Anxiety and Depression Scale (HAD)
- Consists of 14 questions: 7 anxiety + 7 depression
- Focuses on the last week
- Each item scored from 0-3
- Produces a score out of 21 for both anxiety and depression
- Interpretation
- Normal: 0-7
- Borderline: 8-10
- Anxiety/Depression: 11-14
GAD-7
- Asks about 7 symptoms and their frequency (each is worth a maximum of 3 points)
- Focuses on the last 2 weeks
- Interpretation
- Mild: 5-9
- Moderate: 10-14
- Severe: 15+
- Maximum = 21
Alcohol questionnaires
CAGE – screening tool
Alcohol Use Disorders Identification Test (AUDIT) – screening tool
Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) – determines the
severity of withdrawal (useful for determining the next stage in treatment)
Electroconvulsive therapy (ECT)
Indications
- Catatonia
- Prolonged or severe manic episode
- Severe depression that is life-threatening
- it is effective in pregnant women
Short-Term Side-Effects
- Headache
- Nausea
- Short-term memory impairment
- Memory loss of events prior to ECT
- Cardiac arrhythmia
Long-Term Side-Effects
- Impaired memory
Insomnia
Difficulty initiating or maintaining sleep, or early morning awakening that leads to dissatisfaction with sleep quantity or quality.
Chronic Insomnia: diagnosed if a person has trouble falling asleep or staying asleep at least 3 nights per week for 3 months
Investigation
- Usually based on history, may use sleep diary, rarely use polysomnography
Management
- Identify potential causes (e.g. mental or physical health issues or poor sleep hygiene)
- Advise against driving when sleepy
- Advise good sleep hygiene (no screens before bed, limited caffeine intake,
fixed bed times)
- Only consider hypnotics if impairment is severe
- Recommended hypnotics include short-acting benzodiazepines (e.g.
temazepam) or non-benzodiazepines (e.g. zopiclone)
- Use lowest effective dose for shortest duration
- Review after 2 weeks and consider referral for CBT
- Side-Effects of Sleeping Pills: daytime sedation, poor motor coordination, cognitive impairment, addiction
Applied relaxation therapy
Used for people with anxiety disorders
Based on the premise that these patients have lost the ability to relax
Consists of a series of exercises that teach the patient how to:
- Spot the signs and feelings of tension
- Relax your muscles and relieve tension
- Use these techniques in stressful situations to prevent you feeling tense and panicky
Consists of 12-15 weekly sessions
Metallisation based therapy
Form of therapy that focuses on the patient’s ability to attend to mental states in
themselves and in others
This helps them understand their actions and the actions of others
This leads to more successful social interactions and relationships
Mainly used for emotionally unstable personality disorder and self-harm
Transference-focused therapy
Based on a theoretical process by which emotions are transferred from one person to another
It is presumed that your feelings about certain important people are transferred onto the therapist
You then feel about and react to the therapist as you would to these important people
The therapist can observe how you interact and help you build healthier relationships
This is mainly used for emotionally unstable personality disorder
Lithium
Check U&Es and TFTs every 3 months (renal impairment and hyponatraemia)
Can cause Ebstein’s abnormality
Can cause benign leucocytosis
Sodium valproate
Can cause spina bifida
Carbamazepine
Can cause toxicity at high
doses.
Induces liver enzymes.
Levels must be closely
monitored.
2nd line for BPAD prophylaxis.
Can cause spina bifida
Risperidone
Only atypical antipsychotic
available as depot injection
Hyperprolactinaemia.
Clozapine
Weight gain
Agranulocytosis – weekly blood tests.
Excessive salivation.
Arrhythmias.
Seizures (reduced threshold).
Smoking cessation can cause a rise in clozapine levels.
If missed for > 48 hours, restart with a dose of 12.5mg daily.
Naltrexone
Given after detoxification to
prevent relapse as it blocks the euphoric effects of opiates.
