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Pharmacology Flashcards

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1
Q

What are the clinical uses of antidepressant drugs

A

Moderate to severe depression
Dysthymia
Generalised anxiety disorder
Panic disorder, OCD, PTSD
Premenstrual dysphoric disorder
Bulimia nervosa
Neuropathic pain

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2
Q

What are the main classes of antidepressant

A

Monoamine oxidase inhibitors
Monoamine reuptake inhibitors which includes:
- tricyclics
- SSRI
- noradrenaline reuptake inhibitors
Atypicals

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3
Q

What are the monoamine neurotransmitters

A

Noradrenlaine
5-HT (serotonin)
Dopamine

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4
Q

How do most anti-depressants work

A

Altering the monoamine neurotransmission in some way
Most enhance their activity at the synapses

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5
Q

How might monoamines be affected in those with depression

A

There is a deficit in monoamine transmitters which causes depression - particularly serotonin and noradrenaline
Drugs that deplete stores of monoamines can induce low mood
CSF from depressed patients have reduced levels of monoamines or metabolites

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6
Q

Name some MAO inhibitors

A

Phenelzine - irreversible
Moclobemide - reversible

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7
Q

How do MAO inhibitors work

A

Irreversible (Phenelzine) or reversible (Moclobemide) inhibitors of monoamine oxidase A and B (enzymes)
MOA A and B are responsible for the metabolism of the monoamine neurotransmitters such as serotonin and noradrenaline
Therefore the inhibitors facilitate their release and storage

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8
Q

What are the side effects of MAO inhibitors

A

Prevents breakdown of dietary tyramine - cheese
Anticholinergic effects
Hypertensive crisis
Insomnia
Postural hypotension
Peripheral oedema

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9
Q

Name common tricyclic antidepressants

A

Imipramine
Amitriptyline - used for pain now and more sedating

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10
Q

How do the tricyclic antidepressants work

A

Block the reuptake of monoamines (mainly noradrenaline and 5-HT) into presynaptic terminals

Named for the 3 rings in their chemical structure

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11
Q

What are the side effects of tricyclic anti-depressants

A

Anticholinergic - blurred vision, dry mouth, constipation, urinary retention
Sedation
Weight gain
Cardiovascular - Postural hypotension, dizziness tachycardia, arrhythmias

Cardiotoxic in overdose - arrhtymia and arrest
Also seizure and coma

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12
Q

Name common SSRIs

A

Fluoxetine
Citalopram / Escitalopram
Sertraline
Paroxetine

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13
Q

How do SSRIs work

A

Selectively inhibit reuptake of serotonin (5-HT) from the synaptic cleft.

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14
Q

List come common side effects of SSRIs

A

Nausea, V and diarrhoea
Increased risk of GI bleeding
Headache and dizziness
Insomnia
Worsened anxiety/agitation
Transient increase in self-harm / suicidal ideation in <25 years
Sweating / vivid dreams
Sexual dysfunction
Hyponatraemia (in elderly)
Discontinuation effects

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15
Q

How do SNRIs work

A

Dual monoamine reuptake inhibitors
They block the reuptake of noradrenaline and 5-HT (seratonin) into presynaptic terminals.
Therefore similar side effects to SSRIs

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16
Q

Name common SNRIs

A

Venlafaxine
Duloxetine

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17
Q

Name common atypical antidepressants

A

Mirtazapine - blocks alpha 2 adreno- and serotonin receptors
Bupropion - dopamine uptake inhibitor

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18
Q

What are the side effects of mirtazapine

A

Weight gain
Increased appetite
Sedation - best to take in the evening
Can be good if patient is complaining of lack of appetite and loss of sleep

Also presents with some SSRI side effects like nausea and sexual dysfunction due to serotonin blockage. Though generally less than other SSRIs

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19
Q

Do anti-depressants start working immediately

A

No
Most have a delayed onset of action of several weeks

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20
Q

Why do you need to be cautious when prescribing anti-depressants to young adults/ teenagers

A

There can be a transient increase in suicidal ideation, self harm and aggressive ideas in this age group when they take the medications

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21
Q

What is the aim of bipolar treatment

A

Acutely it is to treat the symptoms = reduce mood in mania and raise mood in depression

Long term it is to stabilise mood - prevent recurrence of mania or depression

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22
Q

How is lithium used

A

As first-line maintenance in bipolar - mood stabiliser
It reduces both the number and severity of relapses
Offers some protection against antidepressant-induced hypomania if on dual treatment

Can be used in acute mania as well
May be used in recurrent depressive disorder, or schizoaffective disorder

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23
Q

Do you need to monitor lithium doses

A

YES
Very narrow therapeutic index and can lead to toxicity
Also has a very long half life
Monitor blood levels - 12 hours post-dose
Check weekly when starting or changing dose
Levels are checked every 3-6 months once stable

Also need to check thyroid and renal function every 6 months

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24
Q

What are the common side effects of lithium treatment

A

Dry mouth / strange taste
Nausea/vomiting and diarrhoea
Polydipsia and polyuria
Tremor - fine
Hypothyroidism - due to thyroid enlargement
Hyperparathyroidism
Long term reduced renal function
Nephrogenic diabetes insipidus
Weight gain
idiopathic intracranial hypertension
leucocytosis
hyperparathyroidism and resultant hypercalcaemia

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25
What are the symptoms of lithium toxicity
Vomiting Diarrhoea Ataxia / coarse tremor Drowsiness / altered conscious level Convulsions Coma
26
Which anti-convulsant drugs can be used as mood stabilisers
Valproic acid/ sodium valproate Lamotrigine Carbamazepine
27
What are the side effects of valproic acid
Drowsiness Ataxia CV effects Induces liver enzymes Hepatotoxicity Teratogenicity - causes neural tube defects Blood dyscrasia: Thrombocytopenia, leucopoenia, red cell hypoplasia. Weight gain Nausea, vomiting and diarrhoea. Loss of hair Headache, confusion and lethargy. Pancreatitis
28
What are the side effects of carbamazepine
Drowsiness Headache and diplopia Ataxia CV effects Leucopenia Hepatoxicity, liver failure and cholestatic jaundice. Induces liver enzymes - interacts with other drugs Teratogenicity: Spina bifida Risk of SJS and TEN
29
What are the side effects of lamotrigine
Small risk of Stevens-Johnson syndrome Flu-like symptoms Aseptic meningitis Ataxia and blurred vision
30
Which anti-psychotics can be used as mood stabilisers
Quetiapine Aripiprazole Olanzapine Lurasidone
31
What are the side effects of the anti-psychotics used as mood stabilisers
Sedation Weight gain Metabolic syndrome Extra-pyramidal side-effects (Aripiprazole)
32
Which herbal/complementary medicine can cause serotonin syndrome
St John's Wort Functions similarly to an MAOI Higher risk if a conventional antidepressant is prescribed alongside it
33
Which anti-psychotic is most likely to cause extra pyramidal side effects
Chlorpromazine First generation drugs acting on the D2 receptors will cause these symptoms
34
Women of child bearing age should not be prescribed sodium valproate - true or false
True Unless other options are unavailable, AND adequate contraception (ideally depot or IUD) is in place.
35
Which anti-psychotic is most likely to cause weight gain
Clozapine Olanzapine
36
How does acamprosate work to treat alcohol dependence
It acts on the neurotransmitter systems in the brain to reduce the reliance on and craving for alcohol It helps to normalise the brain chemistry that has been disrupted by alcohol Good for those who wish to control their drinking, but is not prepared to commit to abstinence from alcohol
37
List side effects of clozapine
Sialorrhoea - excessive salivation Constipation - severe Nausea and vomiting Seizure Weight gain Hypotension - dose related Neutropenia/agranulocytosis Myocarditis and cardiomyopathy
38
How is dopamine involved in the treatment of psychotic disorders
Some evidence that an increase in dopamine level in the mesolimbic system contributes to psychotic disorders like schizophrenia Many antipsychotics act on dopamine receptors - all act on D2 The more the dopamine receptor binding affinity, the better the therapeutic effect and clinical potency of the antipsychotic agent
39
What symptoms are associated with the mesolimbic pathway
Linked to positive symptoms – delusions, hallucinations, disorganized speech/thinking and disorganized or catatonic behaviour
40
What symptoms are associated with the mesocortical pathway
Linked to negative symptoms – Alogia, affective flattening, avolition
41
List examples of first generation antipsychotics
Chlorpromazine Haloperidol Trifluoperazine Also called typical antipsychotics
42
List examples of extra-pyramidal side effects that may be caused by anti-psychotics
Acute dystonia Drug-induced parkinsonism Akathisia - unpleasant state of motor restlessness Tardive dyskinesia - most common is chewing and pouting of jaw
43
List examples of second generation anti-psychotics
Clozapine Risperidone Olanzapine Quetiapine Aripiprazole Also known as atypicals
44
Which receptors do second generation anti-psychotics act on
Lower D2 receptor affinity. Work on a variety such as D2,3,4 and 5-HT High serotonin/dopamine binding ratio.
45
List side effects of olanzipine
Sedation Weight gain Metabolic syndrome - dyslipidaemia Dry mouth and constipation (anti-muscarinic)-
46
What is risperidone used to treat
Schizophrenia Acute treatment of mania
47
Which ECG changes can be caused by antipsychotics
QT prolongation Particularly haloperidol
48
Anti-psychotics are used for which conditions
Schizophrenia Mania Other psychoses including psychotic depression and schizoaffective disorder As augmenting agents in the treatment of obsessive-compulsive disorder and in the control of severely disturbed behaviour
49
Clozapine is used in which conditions
It is licensed for treatment-resistant schizophrenia - used 3rd line if others have not worked Can improve manic symptoms in treatment resistant bipolar disorder
50
Those on clozapine must be monitored - true or false
True Severe side effect profile so must be checked e.g. FBC weekly for first 18 weeks due to neutropenia/agranulocytosis risk
51
Which antipsychotics can cause SIADH
Haloperidol, risperidone, quetiapine, olanzapine and clozapine Presents with mild hyponatreamia - confusion, cramps, nausea etc
52
Which antipsychotics can cause an increase in prolactin
Risperidone and paliperidone are the worst Olanzapine has a transient minimal effect May present with galactorrhoea
53
List common anti-cholinergic side effects
Dry mouth, blurred vision, urinary retention and constipation Seen with chlorpromazine and clozapine
54
What is Neuroleptic Malignant Syndrome
Life-threatening condition seen in some patients started on anti-psychotics - typically with sudden dose increases Presents with hyperthermia, muscular rigidity, decreased conscious level and labile blood pressure Acute onset
55
Which drugs are used first line in the treatment of depression
SSRIs
56
What are the contraindications for tricyclic antidepressant use
Arrhythmias Recent MI Heart block Avoided in elderly due to cardiotixc events Mania and hypomania - can causes manic switch Acute porphyria
57
In which types of depression are MAOIs mainly used
severe depression, treatment resistant depression and atypical depression
58
Which antidepressant is the only one recommended for use in children and young people
Fluoxetine is the only one with the evidence that shows that benefits outweigh risks in the treatment of moderate to severe depression
59
What is the risk of prescribing an antidepressant to a child or young person
Associated with an increase in suicidal behaviour, self‑harm or hostility, particularly at the beginning of treatment. Must be closely monitored and is only used in extreme circumstances
60
How does ECT work
It involves induction of seizure by applying an electrical stimulus to the brain The exact mechanism of action is still under investigation - may induce changes in neurotransmitters, neuroplasticity and functional connectivity
61
How is ECT carried out
The patient is given general anaesthesia and a muscle relaxant Monitoring is performed throughout - ECG, EEG etc. Electrodes are placed on the head - bilateral or unilateral A short electrical impulse is passed through the head to induce a seizure Patient is taken to recovery and are usually fine within an hour Usually delivered 2 to 3 treatments per week
62
There are no absolute contraindications for ECT - true or false
True
63
What is ECT used for
Acute treatment of moderate to severe depression, mania or catatonia in patients who have failed in responding to other treatments It is the most effective treatment for major depression
64
List some of the potential side effects of ECT
Adverse effects relating to use of general anaesthesia. Confusion, headache and nausea. Cognitive impairment - usually short term and resolves but has been permanent in some patients Memory loss of events prior to ECT Cardiac arrhythmia
65
Which drugs are used first line in treatment of anxiety disorders
SSRIs Clomipramine for OCD
66
How are benzodiazpeines used in anxiety
Used in the short term only for severe anxiety
67
Which benzos are short and long acting
Short - lorazepam Long - diazepam
68
List side effects of benzodiazepines
Drowsiness and dizziness Confusion (elderly) Respiratory depression Cognitive and psychomotor impairment. Tolerance and cross-tolerance with alcohol. Withdrawal and discontinuation symptoms Addiction
69
List some common anxiolytic drugs
Benzodiazepines - short-term SSRIs - 1st line Buspirone - rare Pregabalin - GAD and social phobia Beta Blockers - reduces physical symptoms
70
In which form is lithium usually given
Normally as lithium carbonate
71
Can lithium be used in pregnancy and breastfeeding
Not safe in first trimester due to risk of Ebstein’s heart anomaly Not advisable in breastfeeding mums either - can affect the baby
72
The adverse effects of lithium are dependent on the serum concentration - ture or false
True
73
Which tests must be done before starting lithium treatment
Serum electrolyte, urea and creatinine, thyroid function and ECG UandE and TFTs are rechecked every 6 months
74
Valproate is used in the treatment of which conditions
As a mood stabiliser in mania, rapid cycling bipolar and as maintenance in bipolar
75
Carbamazepine is used in the treatment of which conditions
Prophylaxis of bipolar disorder which has been unresponsive to lithium Acts as a mood stabiliser
76
Which drugs does carbamazepine increase the metabolism of
Psychotropic medications – antidepressants, antipsychotics, valproate etc. Oral contraceptive agents leading to failure. Anticoagulants
77
Lamotrigine is used in the treatment of which conditions
Has a modest antidepressant activity Used as a adjunct in bipolar - can prevent depressive relapse
78
How do you treat acute mania
STOP antidepressant medication. Atypical Antipsychotics: Risperidone, quetiapine, olanzapine etc. Mood Stabilisers: Lithium and Valproate
79
How do you treat alcohol withdrawal
Use benzodiazepines - typically chlordiazepoxide on a reducing schedule (dose dependent on severity of withdrawal) Can also use diazepam Carbemazepine can be effective Also give Pabrinex to avoid development of Wernicke’s encephalopathy
80
How does disulfiram work to reduce alcohol dependence
It inhibits aldehyde dehydrogenase resulting in the accumulation of acetaldehyde in the body Therefore when you drink on top of it it makes you sick - flushing, hypotension, palpitation and nausea and vomiting
81
How is methadone used
It is a long acting opioid that aims to wean people off IV opioid use to reduce harm
82
How is naltrexone used
It is an opiate antagonist, effective in the treatment of alcohol and opiate dependence Reduces craving and relapses in alcohol dependent people
83
Which drugs can be used for symptom relief in dementia
Donepezil Galantamine Memantine
84
How does memantine work in symptom control in dementia
It is an NMDA receptor antagonist It stops excitatory cell death in Alzheimer’s and vascular dementia
85
How do donepezil/galantamine work in symptom control in dementia
The are acetylcholinesterase inhibitors Prevent metabolisation of ACh so increase the duration of action Cholinergic neurons are lost in Alzheimers so there is a decrease in ACh
86
How can you treat acute dystonia caused by antipsychotic drugs
Procyclidine
87
Anti-psychotic drugs can increase the risk of stroke in the elderly - true or false
True Increased risk of stroke and VTE
88
Which atypical anti-psychotic has the best side-effect profile
Aripiprazole Particularly good for those who have experienced raised prolactin on other drugs
89
List the major side effects of clozapine
Agranulocytosis and neutropenias - need regular FBC Reduced seizure threshold Constipation Myocarditis - need a baseline ECG Hypersalivation
90
How does smoking affect the action of clozapine
Smoking can reduce the amount of clozapine in the body If someone suddenly stops smoking their levels can go up risking side effects If they start smoking or smoke more, levels may go down Dose adjustments may be needed
91
List symptoms of benzodiazepine withdrawal
Insomnia irritability anxiety tremor loss of appetite tinnitus perspiration perceptual disturbances seizures
92
Describe the action of benzodiazepines
They enhance the action of GABA - main inhibitory neurotransmitter - buy increasing the frequency of chloride channels
93
What is the SSRI of choice post-MI
Sertraline
94
What is the SSRI of choice in children and adolescents
Fluoxetine
95
Which SSRI is at higher risk of QT prolongation
Citalopram
96
List the symptoms that may be experienced on discontinuation of SSRIs
increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia
97
What are the risks of using SSRIs in pregnancy
Use during the first trimester gives a small increased risk of congenital heart defects Paroxetine has an increased risk of congenital malformations, particularly in the first trimester Use during the third trimester can result in persistent pulmonary hypertension of the newborn

Psychiatry (14 decks)

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