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Flashcards in Psychiatric Drugs Deck (84):
1

What side effects can adrenergic drugs cause?

Sweating, tremor, headaches, nausea, dizziness

2

What side effect can muscarinic drugs cause?

Dry mouth, difficulty swallowing, thrist, difficulty urinating/urinary retention, hot flushed skin, dry skin

3

What side effect can drugs acting on histamine receptors cause?

Dry mouth, drowsiness, dizziness, N&V

4

What are the types of antidepressants?

SSRIs
SNRIs
Tricyclics
MAOIs

5

Which are the most commonly used antidepressants?

SSRIs

6

Name some SSRIs

Fluoxetine
Paroxetine
Sertraline
Citalopram

7

Which is more effective in mild/moderate depression; a TCA or an SSRI?

They are just as effective as each other

8

Which is more effective in severe depression; a TCA or an SSRI?

A TCA

9

Can SSRIs be used in under 18s?

Nope, no evidence it works (excpet using fluoxetine with caution)

10

When should an SSRI be taken, and why?

In the morning as it disrupts sleep pattern if given at night

11

How do SSRIs work mainly? (MoA)

Reduce neuronal reuptake of serotonin

12

What other low affinity do SSRIs have?

Muscarinic, histaminergic, and adrenergic receptors

13

Which is less dangerous in overdose, SSRIs or TCAs?

SSRIs

14

How do SSRIs work?

Prevent reuptake of serotonin into the presynaptic neurone so more is available. It also causes downregulation of the 5-HT inhibitory receptors.

15

How well are SSRIs absorbed in the gut?

Well absorbed

16

What is the half life of SSRIs?

24 hours

17

How long after an SSRI is started is improvement seen?

2-4 weeks

18

Can SSRIs be combined with MAOIs? Why?

No!
The combination of multiple drugs that increase serotonin levels can lead to dangerous serotonin levels with adverse effects

19

Which SSRIs shouldnt be used with TCAs? Why not?

Paroxetine and fluoxetine

Alter hepatic metabolism of TCAs -> toxicity

20

What side effects can SSRIs cause?

Increased anxiety
Emotional numbness
Headache
Nausea/Vomiting
Dry mouth
Insomnia
Loss of libido
Possible increased risk of suicidal/self harm thoughts

21

What can SSRIs do in epilepsy?

Can prolong a seizure

22

What can SSRIs do to other drugs?

Alter metabolism of some hepatically metabolised drugs

23

What can too much serotonin cause (i.e. when ssris are used with maois)?

Tremor
Hyperthermia
CVS S/Es

24

Can SSRIs be used in bipolar?

Noooooooooooooo

25

Can SSRIs be addictive?

Probably not, but withdrawal symptoms can occur if they are withdrawn too quickly

26

Which SSRI is 1st line?

Sertraline

27

Why is sertraline good?

Safest ssri in CVS disease

28

What can citalopram cause?

Long QT syndrome

29

What should be monitored with citalopram and when?

ECG for long QT syndrome before commencing, and after

30

Which SSRI has the longest half life?

Fluoxetine

31

What class of drug is clozapine?

An atypical antipsychotic

32

Which receptors does clozapine act on?

D1, D2, 5-HT, α1 adrenoceptors, and muscarinic receptors

33

What makes clozapine an atypical antipsychotic?

It acts on serotonin recpetors as well as dopamine receptors

34

How does clozapine act on serotonin receptors?

As an agonist

35

How does clozapine act on dopamine receptors?

As an antagonist

36

What is the indication for cloazpine according to the BNF?

Schizophrenia in patients unresponsive to, or intolerant of, conventional antipsychotic drugs

37

How many conventional drugs should be trialed before commencing cloazpine?

2 others i.e. clozapine is third line

38

What other neuro disease can clozapine be used in?

PD with psychosis

39

What dose should adults aged 18-65 be started on for clozapine?

12.5 mg 1–2 times a day for day 1

40

How should clozapine be escalated?

After day 1, 25–50 mg for day 2, then increased, if tolerated, in steps of 25–50 mg daily, dose to be increased gradually over 14–21 days, increased to up to 300 mg daily in divided doses, larger dose to be taken at night, up to 200 mg daily may be taken as a single dose at bedtime

41

How should clozapine be escalated in 18-65 year olds?

After day 1, 25–50 mg for day 2, then increased, if tolerated, in steps of 25–50 mg daily, dose to be increased gradually over 14–21 days, increased to up to 300 mg daily in divided doses, larger dose to be taken at night, up to 200 mg daily may be taken as a single dose at bedtime

42

How should clozapine be administered in elderly pts?

12.5 mg once daily for day 1, then increased to 25–37.5 mg for day 2, then increased, if tolerated, in steps of up to 25 mg daily, dose to be increased gradually over 14–21 days, increased to up to 300 mg daily in divided doses

43

What has clozapine been associated with that is important for pt safety? (think GI)

Varying degrees of impairment of intestinal peristalsis

44

What type of psychoses is clozapine contraindicated in?

Alcoholic and toxic psychoses

45

What haematological contraindications are there for clozapine?

Hx of agranulocytosis
Hx of neutropenia

46

What CVS conditions is clozapine contraindicated in?

Hx of circulatory collapse
Any severe cardiac disroders

47

What CNS disorders is clozapine contraindicated in?

Severe epilepsy
Severe CNS depression

48

What should be monitored with clozapine, and how regularly?

-FBC (esp for WBCs) every week for 18 weeks, then every 4 weeks after that
-Blood glucose
-Blood lipids and weight
-LFTs

49

What major side effect is associated with clozapine?

Agranulocytosis

50

What is the correct way to stop clozapine?

On planned withdrawal reduce dose over 1–2 weeks to avoid risk of rebound psychosis. If abrupt withdrawal necessary observe patient carefully.

51

What other side effects are experienced with clozapine?

Constipation
Hypersalivation
Weight gain
Sedation

52

What should happenw ith any antipsychotic before commencing it, especially if there is a history of CVS disease?

A baseline ECG should be done

53

What is agranulocytosis?

A severe acute lack of white blood cells, usually due to reduced numbers of neutrophils (but can be any class of WBC in severe shortage)

54

Considering its GI side effects, what should be considered contraindications when starting clozapine?

-Hx of bowel surgery or colonic disease
-Pts receiving drugs that may cause constipation eg anti-muscarinics

55

What happens in a clozapine overdose?

-Depressed consciousness and respiratory drive (although less than with other sedatives)
-Hypotension, hypothermia, sinus tachycardia and arrhythmias may complicate overdose

56

Can clozapine be given in hepatic impairment?

No

57

Can clozapine be given in renal impairment?

Not in severe impairment

58

Can clozapine cause extrapyramidal S/Es?

Yes if at high doses, but not normally as it is an atypical antipsychotic

59

Name some commonly prescribed mood stabilisers

Lithium
Sodium valproate
Carbamezepine
Lamotrigine
Antipsychotics

60

How is clozapine metabolised?

By CYP450 in the liver

61

What is the half life of clozapine?

About 14 hours

62

What is the indication for Lithium according to the BNF?

Treatment and prophylaxis of 1. mania, 2. bipolar disorder, 3. recurrent depression, and 4. aggressive/self harming behaviour

63

What is the issue with the different preparations of lithium?

They have different bioavailabilities so changing the preparation requires the same precautions as initiation of treatment.

64

What precautions should be taken when initiating lithium?

Dose adjusted according to serum-lithium concentration, doses are initially divided throughout the day, but once daily administration is preferred when serum-lithium concentration stabilised.

65

What are the contraindicatiosn for all Lithium salts?

Addison's disease
Heart failure
Untreated hypothyroidism
Hx/FHx of Brugada syndrome
Dehydration or low sodium diets

66

Why is lithium contraindicated in Addison's disease?

Lithium inhibits the action of fludrocortisone in the distal kidney tubules (so treatment of addisons becomes ineffective and hypotension can occur)

67

How does lithium work as a mood stabiliser?

Theory - competition with electrolytes at channels, increases serotonin and decreases 5-HT receptors long term, and possible alteration to neurotransmitter-receptor binding as a second messanger

68

How is lithium metabolised/excreted?

Excreted by kidneys

69

Which drugs is lithium not recommended with, considering its excretion?

NSAIDs and ACE-Is

70

When should bloods be taken to monitor lithium? Why?

12 hours after last dose as it has a narrow therapeutic window

71

What specific blood checks should be done before commencing lithium? How should they be monitored from then on?

Thyroid function and renal function. Every 6 months after commencing lithium,

72

Which mood stabiliser has the best evidence?

Lithium

73

What do 52% of pts on lithium experience?

Memory problems (long term use)

74

What do 34% of pts on lithium experience?

Tremor

75

What do 24% of pts on lithium experience?

Drowsiness

76

How does a lithium overdose manifest?

V&D, coarse tremor, dysarthria, cognitive impairment, restlessness, agitation

77

How should a lithium overdose be treated?

Increase fluid intake
Anticonvulsants
Supportive measures
Haemodialysis may be necessary

78

What is the first step on the depression treatment ladder for any level of suspected depression?

Assess, support and advise.

Psychoeducation, active monitoring and further referral.

79

For persistent subthreshold depressive symptoms, and mild to moderate depression, what is the second step of management?

Low intensity psychosocial interventions
Psychological intervention
Medication
Referral for further assessment.

80

If second step of management for depressive symptoms doesnt work, what is the next step?

Medication
High intensit psychological interventions
Combined treatment and collaborative care

81

What is the management for severe and complex depression, risk to life, or severe self-neglect?

Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care

82

In terms of drug choice for depression, how do we choose what to start with?

Discussing treatment options with the patient

83

After the 1st agent is tried, how do we reassess?

Is the pt happy with the treatment? If so, continue.

If not, try another SSRI or and SNRI.

84

What do we try if 2 SSRIs have already failed?

An SNRI