Pharmacology

Question 1

Indication for antidepressants

Answer 1

Unipolar or Bipolar depression
Organic mood disorder
Schizoaffective disorder
Anxiety disorders

Question 2

How long is the delay for effect in antidepressant medication?

Answer 2

3-6 weeks

Question 3

How long should a patient persist with an antidepressant medication before considering a switch or augmenting?

Answer 3

At least 2 months

Question 4

Types of Antidepressants

Answer 4

Tricyclics (TCA)
Monoamine Oxidase Inhibitors (MAOI)
Selective Serotonin Reuptake Inhibitors (SSRIs)
Serotonin/Noradrenaline Reuptake Inhibitors (SNRIs)
Novel antidepressants

Question 5

What mechanism is used in Tricyclic Antidepressants?

Answer 5

Act mainly on serotonin receptors to inhibit serotonin and adrenaline

Question 6

What side effects occur with TCAs?

Answer 6

Anticholinergic
Antiadrenergic
Antihistaminic

QT lengthening
Can be lethal in Overdose (OD)

Question 7

Why are TCAs known to cause side effects?

Answer 7

Tertiary amine side chains prone to cross reaction with other receptors

Question 8

Describe antihistaminic side effects seen in TCA use

Answer 8

Sedation

Weight gain

Question 9

Describe anticholinergic side effects seen in TCA use

Answer 9

Dry mouth
Dry eyes
Constipation
Memory deficits
Delirium

Question 10

Describe antiadrenergic side effects seen in TCA use

Answer 10

Orthostatic hypotension
Sedation
Sexual dysfunction

Question 11

Examples of TCAs

Answer 11

Amipramine
Amitriptyline
Clomipramine
Doxepin

Question 12

What are secondary TCAs and what is their mechanism of action?

Answer 12

Metabolites of tertiary amines

Block Noradrenaline

Question 13

Examples of secondary TCAs

Answer 13

Desipramine

Nortriptyline

Question 14

What is the mechanism of action of MAOIs?

Answer 14

Irreversible monoamine oxidase binding

Blocks Noradrenaline, dopamine and serotonin

Question 15

Side effects of MAOIs

Answer 15

Orthostatic hypotension
Weight gain
Dry mouth 
Sedation
Sexual Dysfunction
Sleep disturbance

Hypertensive Crisis

Serotonin Sydrome

Question 16

What can contribute to Hypertensive Crisis occuring with use of MAOIs?

Answer 16

Tyramine rich foods
Sympathomimetics

‘Cheese Reaction’ - red wine, processed meats, beans

Question 17

What taken in addition to MAOIs can cause Serotonin Syndrome>

Answer 17

Medications increasing serotonin levels or sympathomimetics

Question 18

Symptoms of Serotonin Syndrome

Answer 18

Abdominal pain
Diarrhoea
Sweats
Tachycardia
Hypertension
Myoclonus
Irritability
Delirium

Question 19

Cosequences of serotonin syndrome

Answer 19

Hyperpyrexia
Cardiovascular Shock
Death

Question 20

Name a step to avoid Serotonin Syndrome

Answer 20

Wait period of 2 weeks before switching SSRI to MAOI

Except with fluoxetine- 5 week wait

Question 21

SSRIs mechanism of action

Answer 21

Inhibit presynaptic serotonin reuptake

Question 22

Side effects of SSRIs

Answer 22

GI upset
Sexual dysfunction

Anxiety
Restlessness
Insomnia
Fatigue
Sedation
Dizziness

Question 23

Describe discontinuation syndrome

Answer 23

Agitation, nausea, disequilibrium and dysphoria
Experienced when medication stopped
Typical to SSRI use

Question 24

Compare the risks in overdose between TCAs and SSRIs

Answer 24

Risk of cardiotoxicity in SSRI overdose low

Lethality in TCA overdose

Question 25

Examples of SSRI

Answer 25

Fluoxetine, Sertraline, paroxetine, Citalopram, Escitalopram | Fluvoxamine- not used

Question 26

Mechanism of Action in SNRIs

Answer 26

Inhibit serotonin and NA reuptake

Question 27

Side effects of SNRIs

Answer 27

Anticholinergic in higher doses

Question 28

Examples of SNRIs

Answer 28

Duloxetine (less BP increase) | Venlaflaxine (fast renal clearance, good in geriatrics)

Question 29

Novel antidepressants

Answer 29

Mirtazepine- good to augment SSRIs | Bupropion

Question 30

Side effects of Mirtazepine

Answer 30

Increase serum cholesterol Sedation Weight gain (Appetite)

Question 31

Management of antidepressant treatment resistance

Answer 31

Combination of SSRI/SNRI with Mirtazepine Adjunctive lithium Adjunctive with atypical antipsychotic - olanzapine, aripiprazole Electroconvulsive therapy Typically SSRI - SNRI - Mirtazepine - Lithium

Question 32

Indication for mood stabilisers

Answer 32

Bipolar Cycothymia Schizoaffective

Question 33

Factors predicting positive response to Lithium

Answer 33

Prior long-term response Family member with good response Classic pure mania Mania followed by depression

Question 34

Adverse effects of Lithium

Answer 34

Renal toxicity Hypothyroidism Teratogenic ``` GI distress Thyroid abnormalities Nonsignificant leukocytosis Polyuria/Polydypsia Interstitial renal fibrosis Hairloss Acne Reduce seixure threshold Cognitive slowing Intention tremor ```

Question 35

Symptoms of Lithium toxicity

Answer 35

Mild- vomiting, diarrhoea, ataxia, dizziness, slurred speech, nystagmus Moderate - anorexia, blurred vision, clonic limb movement, convulsions, delirium, syncope Severe- Generalised convulsions, Oliguria, Renal failure

Question 36

Indication for anticonvulsants

Answer 36

Mania prophylaxis

Question 37

Factors predicting a positive response to valproic acid

Answer 37

Rapid cycling patients (females more than males) Comorbid substance issues Mixed patients Comorbid anxiety disorders

Question 38

Which tests are needed to monitor lithium toxicity?

Answer 38

U&Es | Thyroid

Question 39

Which tests and supplements are required for valproic acid/anticonvulsant use?

Answer 39

Baseline liver function Pregnancy test Full Blood Count Folic acid supplement

Question 40

Side effects of valproic acid

Answer 40

``` Thrombocytopenia Platelet dysfunction Nausea, vomiting, Weight gain Sedation Tremor Neural Tube defect Hair Loss ```

Question 41

Carbamazepine is a first line agent for which conditions

Answer 41

Acute mania Mania Prophylaxis Rapid cyclers, mixed patients

Question 42

Side effects of carbamazepine

Answer 42

``` RASH Nausea, vomiting, diarrhoea Sedation, dizziness, ataxia, confusion AV conduction delays Aplastic anaemia and agranulocytosis Water retention ```

Question 43

Drugs that increase lamotrigine levels

Answer 43

VPA | Sertraline

Question 44

Indication for antipsychotic medication

Answer 44

Schizophrenia Schizoaffective disorder Bipolar disorder

Question 45

Mechanism of action of TYPICAL Antipsychotics

Answer 45

D2 dopamine receptor antagonists

Question 46

Risk of TYPICAL Antipsychotic use

Answer 46

Extrapyramidal effects

Question 47

Examples of typical antipsychotics

Answer 47

Fluphenazine Haloperidol Pimozide

Question 48

Mechanism of action of atypical antipsychotics

Answer 48

Serotonin Dopamine 2 Antagonists

Question 49

Examples of atypical antipsychotics

Answer 49

``` Risperidone Olanzapine Queitapine Aripiprazole Clozapine ```

Question 50

Extrapyramidal side effects

Answer 50

Acute dystonia Parkinson Syndrome Akathisia

Question 51

Adverse side effects of antipsychotics

Answer 51

Tardive Dyskinesia Neuroleptic Malignant Syndrome Extrapyramidal SE

Question 52

What is tardive dyskinesia?

Answer 52

Involuntary muscle movements | May not cease on drug withdrawal

Question 53

Describe some features of Neuroleptic Malignant Syndrome

Answer 53

``` Severe muscle rigidity Fever Altered mental status Autonomic instability Elevated WBC Elevated CPK Elevated LFTs ```

Question 54

How might you treat extrapyramidal side effects?

Answer 54

Anticholinergics - benzotropine Dopamine facilitators - amantadine Beta blockers - propanolol

Question 55

Indications for anxiolytics

Answer 55

Panic disorder Generalised Anxiety Disorder Substance related disorders and withdrawal Insomnia

Question 56

Examples of anxiolytics

Answer 56

Buspirone | Benzodiazepines

Question 57

Side effects of benzodiazepines

Answer 57

``` Somnolence Cognitive defects Amnesia Disinhibition Tolerance Dependence ```