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Pharmacology of psychiatry Flashcards

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1
Q

What level of lithium classes as toxicity

A

> 1.2mmol/L

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2
Q

which anti-psychotics are most associated with weight gain

A

clozapine and olanzapine

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3
Q

what are the steps of the pharmacological approach to depression

A
  1. SSRI- eg. sertraline, fluoxetine
  2. taper down SSRI and add SNRI eg. venlataxine
  3. augmentation with anti-psychotic or another antidepressant
  4. Electroconvulsive therapy
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4
Q

Presentation of lithium toxicity

A

GI disturbances- D+V
polyuria/polydipsia (nephrogenic DI)
renal failure
sluggishness
ataxia
tremor
fits
ECG T wave flattening/ inversion
thyroid enlargement and hypothyroidism

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5
Q

What drugs can interfere with lithium

A

diuretics
ACEi
ARBs
NSAIDs
-> increase lithium levels

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6
Q

Liver enzyme inducers

A

CRAP GPs
Carbamazepine
Rifampicin
Alcohol
Phenytoin
Gisofulvin(antifungal)
Phenobarbitol
Sulphonyureas

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7
Q

Liver enzyme inhibitors

A

Isoniazid
Ketoconazole
fluconazole
erythromycin
chloramphenicol
metronidazole

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8
Q

Mood stabilisers

A

Lithium
sodium valporate- used in acute mania
Carbamazepine

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9
Q

What should be monitored with someone on lithium?

A

U&Es- renal function and calcium
TFTs- can cause hypothyroidism

every 6months
makesure to check baseline before starting lithium

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10
Q

pharmacological Mx of opioid OD

A

naloxone

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11
Q

Pharmacological Mx of paracetamol OD

A
  1. activated charcoal reduces absorption- must be given within 1 hr
  2. N-acetylecystine (if paracetamol levels over toxic dose (150mg/kg)
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12
Q

Mechanism of action of typical and atypical anti-psychotics

A

typical- inhibiit D2 receptors in the brain and therefore reduces neurotransmission

atypical- block 5-HT receptors and also D2 but weaker than typicals

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13
Q

side effects of antipsychotics

A

Extrapyramidal symptoms
- parkinsonism
- dystonia
- akathisia
-tardive dyskinesia

hyperprolactinaemia
- galactorrhoea
- amenorrhoea
- sexual dysfunction

Weight gain (esp clozapine and olanzepine)

agranulocytosis (clozapine)

hyponatraemia (olanzepine)

inc risk of DM (olanzepine)

dyslipidaemia

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14
Q

Alcohol withdrawal and addiction management pharmacology

A

Acute withdrawal
1. Pabrinex- if risk of wernickes encephalopathy
2. benzodiazepine or carbamazepine if needs some sedation

addiction management
1. Acamprostate - weak NMDA antagonist helps with cravings
2. disulfram: promotes abstinence - alcohol intake causes severe reaction due to inhibition of acetaldehyde dehydrogenase. Patients should be aware that even small amounts of alcohol (e.g. In perfumes, foods, mouthwashes) can produce severe symptoms

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15
Q

Opioid detoxification

A
  1. methadone (liquide)
  2. buprenorphine (sublingual)
  3. clonidine and lofexidine can help withdrawal symptoms
  4. Naloxone for rapid detox in OD
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16
Q

Alzheimers pharmacology

A
  1. Acetylcholinesterase inhibitors eg. donepezil, rivastigmine (milde-moderate alzheimers)
  2. Memantine (NMDA antagonist) severe alzhimers
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17
Q

Non alzheimers dementia pharmacology

A
  1. donepezil
  2. rivastigmine

NB: antipsychotics can worsen lewy body ddementa

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18
Q

Generalised anxiety disorder pharmacology steps

A
  1. SSRI- sertraline
  2. SNRI- venlataxine
  3. pregabilin

other
4. beta-blockers for treor sx (caution with asthma)

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19
Q

MOA of clozapine

A

blocks D1 and D4 receptors

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20
Q

side effects of clozapine

A

sedation
weight gain
agranulocytosis
reduced seizure threshold
GI disturbances
hypersalivation

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21
Q

Contraindications of clozapine and necessary tests before starting
and follow up monitoring

A

CI:
Hx of neutropenia, Hx of myocarditis, current liver disease

tests:
FBC
LFTs
ECG-

bloods weekly for 18weeks
then every 2 weeks for 1 year
monthly thereafter

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22
Q

SSRI contraindications

A

anyone with pre-existing QT prolongation

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23
Q

SSRI interactions

A

NSAIDS- give with PPI
warfarin/heparin
triptans
MAOI- risk of serotonin syndrome

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24
Q

what is serotonin syndrome

A

serious drug interaction causing build up of serotonin in the synapses

Sx:
adgitation and restlessness
dilated pupils
diarrhoea
raised BP
confusion, reduced GCS
insomnia
autonomic dysfunction- tachycardia
hyperreflexia, myoclonus, hypertonia

incidence <1%

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25
Lithium monitoring
1. baseline U&Es, LFTs and TFTs 2. weekly lithium level monitoring until dose stabilised 3. lithium blood levels checked every 3 months (12hrs post dose) 4. TFTs and renal function every 6 months
26
When to treat depression with drugs
severe depression If other options eg. computerised CBT, group CBT, 1-1 CBT, talking therapy, lifestyle changes haven't worked
27
side effects of SSRIs + complications
headache sleep disturbances/ vivid dreams nausea, diarrhoea, constipation sexual dysfunction Complications: hyponatraemia GI bleeding
28
How long should someone be on SSRI for
continue for 6-12 months once pt feels well for first incidence of depression. continue for 2 years if recurrent depression
29
MOA of MAOs
inc availability of 5-HT +NA in synapses
30
What is the tyramine interaction
when eat foods that are high in tyramine when on MAOs can lead to hypotensive crisis food egs. Cheese, yoghurt, chocolate
31
what are the RFs for Serotonin Syndrome
anti depressants combination lithium ECT opiates antiemetics
32
Complications of Serotonin Syndrome
DIC rhabdomyolisis renal failure metabolic acidosis seizures
33
SE and complications of lithium use
SEs: GI upset fine tremor metallic taste in mouth sedation Polyuria/polydipsia -> neprogenic DI T wave flattening hair changes Complications: teratogen (ebsteins anomaly), CKD (nephrogenic DI), arrhythmia, hyperparathyroidism/hypercalcaemia, hypothyroidism
34
Lithium therapeutic window range
0.4-1mmol/L narrow so careful monitoring
35
TCAs MOA and some examples
5-HT and NA reuptake inhibition. Older 'dirty' drug eg. Amitriptyline, nortiptyline, clomipramine, lofepramine
36
starting on lithium
FBC, calcium, TFTs, ECG (if RFs or known cardiac disease) consulting - stay hydrated -careful in hot countries
37
Olanzapine uses and SEs
anti-psychotic used in acute mania off license rapid effect
38
sodium valporate SEs
terato genic -> spina bifida PCOS GI upset tremor sedation wt gain loss of hair thrombocytopenia anticonvulsant and mood stabiliser used in acute mania
39
Lamotrigine complications
Stevens johnson syndrome- warn about rash and stop, slow titration
40
Mania management
1st epidode/ acute mania: - antipsychotic eg. olanzapine - if no response could add lithium or valporate long term (bipolar)- lithium, valporate or carbamazapine
41
Consulting someone strated on SSRIs
1. will need to continue medication for at least 6 months after improvement of Sx then gradually titre down 2. small evidence of an increased suicide risk- SN and regular reviews
42
SEs and issues with TCAs
SE: antimuscarinic and anticholinergic: dry mouth, bluured vision, constipation, urinary retention Cardiotoxis- prolonged QT, ST elevation, AV block antihistaminergic: sedation, postural hypotension discontinuation syndrome lethal in overdose just as effective as SSRIs!
43
Example of a newer version of MAO
moclobemide
44
NaSSA MOA side effects and example
blocks presynaptic alpha-2 adrenergic receptors. Autoreceptor hence less feedback and more NA release SE: Weight gain, increased appetite, drowsiness eg. Mirtazapine (useful drug to give to someone who needs to put on weight eg in anorexia nervosa)
45
What is discontinuation syndrome
symptoms experienced when stopping antidepressents especially SSRIs. not the same as withdrawal Sx: trouble sleeping flu like Sx anxiety 'electrick shocks' GI disturbances dizziness headaches
46
management of serotonin syndrome
stop causative medications A-E approach: manage airways, fluids, renal support, temp control cyproheptadine- anti-histamine and serotonin antagonist
46
management of serotonin syndrome
stop causative medications A-E approach: manage airways, fluids, renal support, temp control cyproheptadine- anti-histamine and serotonin antagonist
47
Carbemazepine uses and SEs
mood stabiliser and anticonvulasant Not really recommended by nice strong CYP450 inducer N+V blurred vision agranulocytosis
48
Management of acute mania
1. stop any antidepressants, recreational drugs, steroids that may induce mania 2. Monitor fluids 3. if not on any medication give an antipsychotic and short course of benzo -olanzepine, quitiepine 4. if already on medication check compliance, adjust dose, consider adding antipsychotic 5. ECT if unresponsive to medication
49
managament of bipolar depression
dont use SSRI alone- may precipitate mania. augment with antipsychotic eg. orlanzepine with fluoxetine OR lamotrigine
50
what are the 4 systems affected in the brain by anti-psychotics according to the dopamine theory- and what aspects of schizophrenia do they target
Mesolimbic pathway --> +ve symptoms Mesocortical pathway --> -v3 symptoms Nigrostriatal --> EPSEs tuberoinfundibular --> prolactin
51
what are some uses of antipsychotics in medicine
psychosis mood stabilisation in BPAD antidepressant augmentation Tourettes
52
give some examples of typical antipsychotics
Haloperidol, zuclopenthixol, chlorpromazine
53
give some examples of atypical antipsychotics
Clozipine, olanzipine, risperidone, aripriprazole
54
what are the pros and cons of clozapine?
pros: -best drug for treating psychosis -only antipsychotic that has evidence for treatng the negative Sx Cons: -dirty drug binding to 30+ receptors means it has lots of adverse effects and SEs - high risk of rebound psychosis if stopped abruptly SEs: -sedation -neutropenia/ leukopenia/agranulocytosis - myocarditis, cardiomyopathy -increased appetite and wt gain -lowers seizure threshold - prothrombotic -severe constipation -> bowel perf -low BP, dizziness -double vision -hypersalivation NB: due to all these SEs, clozipine is only used in Rx resistant psychosis
55
What needs to be monitored before and during antipsychotic treatment
starting ECG and regular checks (QTc prologation) regular FBCs (esp clozipine)
56
examples of some antipsychotics available as depots
zuclopenthixol flupentixol haloperidol olanzepine aripriprizole paliperidone
57
how long does it take for the sedative and antipsychotic effects to kick in
sedative --> rapid, within mins-hrs antipsychotic --> within 1-2weeks, peak benefit after 6 weeks
58
what do you use for rapid tranquilisation in a severely agitated psychiatric pt
IM olanzepine or haloperidol (in medicine usually use short acting benzo eg. lorazepam for sedation in severely agitatied)
59
What do you need to be aware of/ cautious about when giving IM olanzepine?
1. not to give IM olanz within 1hr of IM lorazepam due to risk of respiratory depression 2. no more than 3 days of IM olanzepine due to risk of post injection syndrome
60
what are the Sx of hyperprolactinaemia in women
reduced libido amenorrhoea galactorrhea osteoporosis (dop potentiates effects of oestrogen)
61
what are the Sx of hyperprolactinaemia in men
reduced libido erectile dysfunction gynaecomastia galactorrhea
62
what antipsychotics do not affect prolactin
quetiapine ziprasidone use with aripriprazole
63
what are the normal QT intervals and when is it really concerning?
men <440ms women <470ms if over >500ms v.v dangerous!
64
what does the QT interval represent and what happens if it is prolonged
ventricular depolarisation and repolarisation prolongation risks developing torsades de pointes --> polymorphic VT --> reduced CO --> shock --> death
65
what are the causes of prolonged QT interval
long QT syndrome electrolytes: low k, low Mg, low Ca drugs: antipsychotics (esp haloperidol), citalopram, venlafaxine, clarithromycin, fluconazole
66
which antipsychotics have no to low effect on QTc
no- aripriprazole, zuclopenthixole, lurasidone low- clozapine, olanzepine, risperidone
67
neuroleptic malignant syndrome: RFs, features, investigations, management
RFs: high dose typicals, rapid dose change, male, younger age features: hyperthermia/fever, rigidity/tremor, hyperreflexia, clonus, low BP, tachycardia Investigations: Bloods: leukocytosis, enzymes high CK, renal function tests (rhabdomyolysis), LFTs deranged Managament 1. stop antipsychotic 2. admit to medical ward/ ITU 3. supportive with fluids, electrolytes and cool 4. benzos for rigidity 5.bromocriptine (dop agonist)
68
what are the features of EPSEs?
Parkinsonism: -rigidity, tremor, bradykinesia, shuffle, pin rolling, hypomimia, reduced arm swing, stooped acute dystonia: - gurning, upward eye movements (oculogyric crisis), head and neck twisting (torticollis), compromised airway (laryngeal dystonia) --> Mx with anticholinergics eg. procyclidine akanthisia - restlessness, trouble staying still, pacing, rocking back and forth --> Mx: change meds, diphrenhydramine, propranolol tardive dyskinesia (chronic antipsychotic use) - lip smacking, tongue protrusion, chewing
69
What metabolic effects to antpsychotics have? +Mx
more common in atypicals wt gain, dyslipidaemia, insulin insensitivity (T2DM) esp- clozipine, quetiapine, olanzeptine (those which affect the H1 receptor) Mx: monitor wt, BP, lipids, HbA1c education on lifestyle statins, diabetic meds, antihypertensives
70
MOA of SSRIs
Stops the channels from clearing serotonin from the gap between neurones which means there is a build up of serotonin and this is able to stimulate the nerves in your brain
71
How does lithium work (explaining to a pt)
Its not fully understood but it basically works to change the release of certain chemicals in your brain allowing you to have more control over your emotions
72
drugs CI in pregnancy
Lithium --> ebsteins anomaly sodium valporate, carbamazepine --> NTD SSRI (paroxetine highest risk of CHD in 1st trim or persistant pulmonary hypertension in 3rd trim)- encourage psychological approaches
73
drugs CI in breastfeeding (All for Obs)
BREAST Benzodiazepines Radioactive isotopes Ergotamine/ caffeine Amiodarone, amphetimines Sex hormones, stimulant laxatives Tetracyclines
74
side effects of SSRIs
the 5 S's Suicidal ideation Sexual dysfunction Sleep disturbances (vivid dreams) Stomach (wt gain, N&V) Serotonin syndrome

Psychiatry (4 decks)

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