Pharmacological Therapy Flashcards Preview

Toni's Psych > Pharmacological Therapy > Flashcards

Flashcards in Pharmacological Therapy Deck (74)
Loading flashcards...
1

What are the TCAs?

Amitriptyline - most tox, sed
Imipramine - less sed
Lofepramine - least tox in OD, less sed
Clomipramine - sed
Dosulepin - most tox, sed
Trazodone - sed

2

SSNRIs
Selective serotonin and noradrenaline reuptake inhibitor

Venlafaxine
Duloxetine

3

What are Mirtazapine's SEs?

Increased appetite/weight gain
Sedation
Oedema

4

What are the SSRIs?

Sertraline
Paroxetine
Citalopram
Fluoxetine
Fluvoxamine
Escitalopram

5

What are the atypical antipsychotics?

Dopamine D2 receptor blockade
Olanzapine +ve sx
Risperidone
Clozapine
Aripiprazole red EPSE
Quetiapine
Amisulpride

6

What are the typical antipsychotics?

Dopamine D2 receptor blockade
Haloperidol
Chlorpromazine
Flupentixol decanoate - depot assoc with v severe EPSEs
Tend to cause distressing EPSEs at normal treatment doses

7

What are SEs of typical antipsychotics?

EPSE: extra pyramidal side effects
Hyperprolactinaemia
Weight gain, dyslipidaemia + increased risk diabetes
Sedation
Anticholinergic SE
Arrhythmias
Seizures
Neuroleptic malignant syndrome
Hypotension
Tachycardia

8

Clozapine


Most common side effect= hypersalivation
1-2% Agranulocytosis rate
Myocarditis
Arrhythmia

9

Quetiapine

Diabetes
Weight gain
Lipid abnormalities

10

Risperidone

Increased prolactin levels

11

Olanzapine

Diabetes
Weight gain
Lipid abnormalities

12

What are the benzodiazepines?

Incr Cl channel freq = enhance GABA

Diazepam
Clonazepam
Alprazolam

13

What are the MAOIs?

Irreversible MAO inhibition
Phenelzine
Moclobemide: reversible inhibition
Trancypromine

14

How would you counsel patients regarding SSRIs?

Avoid drinking alcohol whilst in antidepressants due to increased sedation
Never drive if feeling drowsy on antidepressants
Onset of action is delayed
Outline side effects

15

What are common side effects of SSRIs?

Nausea, vomiting
Appetite, weight change
Blurred vision
Anxiety + agitation
Insomnia, tremor, dizziness
Headache
Sweating

16

What are common side effects for SSNRIs

Same as SSRIs plus
Constipation
Hypertension
Raised cholesterol

17

NASSAs
Noradrenergic and Specific Serotonin Antidepressant

Mirtazapine

18

What are the SEs of TCAs?

Tachycardia, arrhythmia
Dry mouth, blurred vision,
Constipation, urinary retention
Postural hypotension
Sedation
Nausea, weight gain

19

What are the common side effects of MAOIs?

Hypertensive crisis "cheese reaction"
Postural hypotension, dizziness
Drowsiness, insomnia
Headache, blurred vision
Nausea, vomiting
Constipation

20

What are the side effects of St John's Wort?

As effective as TCAs for mild-mod depression
Photosensitivity
Anxiety dizziness
GI symptoms
Fatigue, headache
Induces P52 risks drug interactions: reduces warfarin, ciclosporin, COCP

21

What are discontinuation symptoms?

Occur when antidepressant stopped suddenly:
Flu like sx, electric shock sensations, headaches, vertigo, irritability
To avoid withdraw over a few weeks

22

What should you be careful of when swapping antidepressants?

If of different classes they might interact dangerously: check!
SSRI-> TCA: cross-taper
Drug free washout period: fluoxetine 1 wk
Start venlafaxine v slowly 37.5mg each day

23

What is serotonin syndrome?

Excess serotonin
Potentially life-threatening
Sx: restlessness, sweating, myoclonus, confusion, fits

24

Buspirone

Acts on 5HT1a receptor
Anxiolytic
No antidepressant action alone
May synergistic effect in combination with SSRIs

25

What are the mood stabilisers?

Lithium
Sodium valproate
Carbamazepine
?action on Na channels / GABA

26

Lithium

Unknown mech of action ? cAMP inhibition
Therapeutic range: 0.6-1mmol/L
>1.2 mmol/L = toxic
Monitored weekly after start/ dose change until a steady therapeutic level achieved
U+Es & TFTs every 3-6 months
Can cause renal impairment + hypothyroidism

27

Valproate

Active drug= valproic acid
An anticonvulsant
Plasma levels don't require monitoring
Dose related toxicity not an issue

28

Carbamazepine

2nd line, less effective than lithium
Anticonvulsant
Can cause toxicity at high doses
Induces liver enzymes
Levels must be carefully monitored

29

Lithium SEs

Mild tremor
Nausea + vomiting
Polyuria, polydipsia
Arrhythmia
Hypothyroidism
Weight gain

30

Valproate SEs

Nausea, vomiting, diarrhoea
Liver failure
Thrombocytopenia
Hair loss
Weight gain

31

Carbamazepine SEs

Rash
Leukopenia
Dizziness, ataxia
Drowsiness, fatigue
Nausea, vomiting
Oedema, weight gain, hyponatraenia

32

Lithium toxicity

Presents: GI disturbance, sluggishness, giddiness, ataxia, gross tremor, fits, renal failure
Triggers: salt balance changes, drugs affecting lithium excretion (NSAIDs, diuretics, ACEi), OD
Management: stop lithium, medics: rehydration, osmotic diuresis

33

Mood stabilisers and pregnancy, what are the risks and how are they mitigated?

Lithium: Ebstein's anomaly
Valproate + Carbamazepine: spina bifida
Teratogenic risk must be weighed against harm of a manic relapse!
Women of childbearing age: contraceptive advice + folate supplement
If medications are used during pregnancy close monitoring of fetus req

34

What are the EPSEs associated with antipsychotics?

Dystonia: involuntary painful sustained muscle spasm - within hours - torticolis, oculogyric spasms
Akathisia: unpleasant feeling of restlessness -> pacing/jiggling - hours to weeks
Parkinsonism: resting tremor, rigidity, bradykinesia - days to weeks
Tardive dyskinesia: rhythmic involuntary movements, often grimacing, sucking or chewing movements - months to years

35

How are EPSEs of antipsychotics treated?

Dystonia = anticholinergics e.g. Procyclidine
Akathisia = decr dose/change antipsychotic, add propanolol or benzos
Parkinsonism = decr dose/change antipsychotic, anticholinergic
Tardive dyskinesia (oft irreversible) = stop antipsychotic/decr dose avoid anticholinergics, switch to atypical / clozapine

36

What factors are associated with increased risk of violence in schizophrenics?

Past Hx violence
Substance misuse
Acute psychotic symptoms
Non-concordance with treatment
Access to weapons
Specific threats to a victim
Comorbid personality disorder

37

What risk is a schizophrenic to themself?

Lifetime suicide risk= 10%
Self neglect
Social decline
Risk highest in early years after diagnosis, following 1st admission or where there are depressive symptoms

38

What is the prognosis in schizophrenia?

25% experience no further issues after one episode
66% remain liable to relapse
10% seriously and continuously disabled

39

What SSRI is preferred post MI?

Sertraline

40

What SSRI is preferred in children + young adults?

Fluoxetine

41

Which SSRI should be avoided in those with known long QT or taking other drugs which could prolong QT

Citalopram

Also assoc with sexual dysfunction

42

If prescribing SSRI to a patient on NSAIDs what must you also prescribe?

PPI!

43

If prescribing SSRIs what might give you cause to reconsider?

Warfarin/heparin - avoid SSRIs -> mirtazapine
NSAIDS - avoid/ coprescribe PPI!
Triptans - avoid SSRIs
Renal impairment -> incr risk SIADH: monitor renal function + U + Es

44

When should SSRI use be reviewed?

In

45

How do you avoid discontinuation symptoms following SSRI use?

Gradually reduce dose over 4 wks when stopping

Except fluoxetine which can be stopped straight away

Incr risk of sx with paroxetine

46

What are the discontinuation sx seen following abrupt end to SSRI use?

Mood changes
Restlessness
Difficulty sleeping
Unsteadiness
Sweating
GI sx
Paraesthesia

47

When would clozapine be offered?

With treatment resistant schizophrenia
Only after:
2 other antipsychotics, one being an atypical
Which were trialled for 6-8 wks without effect

48

What increased risks are associated with antipsychotic use on the elderly?

Incr stroke risk
Incr VTE risk

49

What are the non EPSEs of antipsychotics?

Anti muscarinic sx
Sedation
Weight gain
Incr prolactin: galactorrhoea, red glucose tolerance
Neuroleptic malignant syndrome: pyrexia muscle stiffness
Red seizure threshold
Prolonged QT

50

Causes of long QT syndrome

Normal=

51

How do you treat TCA overdoses presenting with widened QRS complexes

IV bicarbonate

52

How do you treat lithium OD?

Mild/mod: fluid resus with IV normal saline
Severe: haemodialysis

53

How do you treat benzo OD?

Flumazenil

54

How do you treat opiate OD?

Naloxone

55

How do you treat paracetamol OD?

Ingestion

56

How do you treat salicylate OD

Haemodialysis

(Urine alkalinisation if mild but CI in cerebral + pulm oedema

57

How do you treat warfarin OD?

Vit K
Prothrombin complex

58

How do you treat heparin OD?

Protamine sulphate

59

How do you treat beta blocker OD?

If bradycardic give atropine
If resistant give glucagon

60

How do you treat ethylene glycol OD?

Fomepizole

61

How do you treat methanol poisoning

Fomepizole or ethanol
Haemodialysis

62

How do you treat organophosphate poisoning?

Atropine

63

How do you treat digoxin OD

Digoxin specific antibody fragments
Aka digibind

64

How do you treat iron overload?

Desferrioxamine

65

How do you treat lead poisoning?

Dimercaptol
Calcium edatate

66

How do you treat cyanide poisoning?

Hydroxycobalamin
Amylnitrite, sodium nitrite + sodium thiosulphate

67

What is neuroleptic malignant syndrome?

Oft just commenced antipsychotics ATN + renal failure
10% mortality

68

How do you manage neuroleptic malignant syndrome?

Stop antipsychotics
IV fluids to prevent renal failure
Dantrolene
Bromocriptine

69

TCA CIs

Recent MI
Prostatic hypertrophy
Narrow angle glaucoma

70

How do you withdraw benzodiazepines?

1/8 of daily dose reduction every fortnight
Difficulty:
Or switch to equivalent dose diazepam and reduce 2-2.5 mg fortnightly
May take 4 wks to a year to withdraw

71

Sx of benzo withdrawal

Up to 3 wks after stopping:
Insomnia
Irritability
Anxiety
Tremor
Loss of appetite
Tinnitus
Perspiration
Perceptual disturbances
Seizures

72

Barbituates

Enhance GABA by incr duration of Cl channel opening

73

Rapid tranquilisation

Only after failure of non pharm methods and refusal of oral meds
With sufficient risk to themselves / others
With sufficient flumazenil on site
2mg IM lorazepam
10mg IM haloperidol

74

Medication which can cause priapism

Trazodone
Chlorpromazine