Psychopharmacology Flashcards
(183 cards)
1
Q
What are the five antidepressant drug class types?
A
Selective Serotonin Reuptake Inhibitors (SSRIs)
Serotonin Noradrenaline Reuptake Inhibitors (SNRIs)
Monoamine Oxidase Inhibitors (MAOIs)
Tricyclics Antidepressants (TCAs)
Alpha2-Adrenoreceptor Antagonists
2
Q
When do antidepressant drugs start to work?
A
2 - 4 weeks
3
Q
What do we do when there are no improvements seen with an antidepressant after two months?
A
We switch to another antidepressant
4
Q
How long do we prescribe antidepressants for after the first depressive episode?
A
6 months to a year
5
Q
How long do we prescribe antidepressants for after the second depressive episode?
A
2 years
6
Q
How long do we prescribe antidepressants for after the third depressive episode?
A
Life-long
7
Q
When are SSRIs prescribed?
A
They are the first line drug class used to manage several psychiatric conditions, including depression and anxiety disorders
8
Q
List five SSRI examples
A
Sertraline
Fluoxetine
Paroxetine
Citalopram
Escitalopram
9
Q
What are the two SSRIs initially administered?
A
Sertraline
Fluoxetine
10
Q
What SSRI is administered in individuals who have chronic illnesses? Why?
A
Sertraline
It doesn’t produce that many drug interactions
11
Q
How do SSRIs work?
A
They work by blocking the presynaptic serotonin reuptake, thus increasing its levels within the brain
12
Q
What syndrome can occur when SSRIs are initially administered?
A
Activation syndrome
13
Q
What is activation syndrome? What are the four clinical features associated?
A
It is caused by increased serotonin levels, in which a state of agitation, anxiety and restlessness occurs
In some cases, suicidal ideation can occur
14
Q
How long does it usually take for activation syndrome to self-resolve?
A
2 – 10 days
15
Q
What syndrome can occur when SSRIs are initially stopped?
A
Discontinuation syndrome
16
Q
What is discontinuation syndrome? What are the three clinical features associated?
A
It is caused by decreased serotonin levels
Dizziness
Paraesthesia
Anxiety
17
Q
How long does it take for discontinuation to present after SSRIs are stopped?
A
A few days
18
Q
How long does it usually take for discontinuation syndrome to self-resolve?
A
Three weeks
19
Q
How can we prevent discontinuation syndrome?
A
We usually wean the drug dose gradually over a period of four weeks.
However, this period is prolonged in individuals who have been taking antidepressants for longer
We can also consider switching patients to one 20mg fluoxetine per day
20
Q
What are the four contraindications of SSRIs?
A
Poorly Controlled Epilepsy
Manic Phase of Bipolar
Hepatic Impairment
Congenital Long QT Syndrome
21
Q
What are the two unique side effects of SSRIs - apart from GI upset?
A
Sexual Dysfunction
Hyponatraemia
22
Q
What are the two main side effects associated with paroxetine?
A
Sedation
Weight gain
23
Q
Due to the increased risk of GI bleeding, which patients do we reconsider administrating SSRIs to?
A
Those taking NSAIDs, aspirin or warfarin
24
Q
Due to the increased risk of hyponatraemia, which patients do we reconsider administrating SSRIs to?
A
Those taking diuretics and PPIs
25
Which three drugs increases the risk of serotonin syndrome?
Tramadol
St John's Wort
Triptans
26
When are SNRIs prescribed?
They are the second line drug class used to manage several psychiatric conditions, including depression and anxiety disorders
27
List two SNRIs examples
Duloxetine
Venlafaxine
28
Which SNRI is prescribed in individuals who have chronic illnesses? Why
Venlafaxine
it doesn't produce many drug interactions
29
Which SNRI is associated with a greater risk of mortality from overdose?
Venlafaxine
30
In which circumstances do we prescribe duloxetine over venlafaxine?
When the patient suffers from hypertension and cardiac arrhythmia
31
How do SNRIs work?
They work by blocking the presynaptic serotonin and noradrenaline reuptake, thus increasing their levels within the brain
32
What syndrome can occur when SNRIs are initially administered?
Activation syndrome
33
What syndrome can occur when SNRIs are initially stopped?
Discontinuation syndrome
34
What are the five contraindications of SNRIs?
Cardiac Arrythmias
Uncontrolled Hypertension
Hepatic Impairment
Renal Impairment
Congenital Long QT Syndrome
Monoamine Oxidase Inhibitors
35
Why should SSRIs not be combiend with MAOIs?
There is a risk of serotonin syndrome
36
What are the eight clinical features of serotonin syndrome?
Fever
Confusion
Seizures
Renal impairment
Hepatic impairment
Arrhythmia
Increased muscle tone
Hypersecretion of sweat
37
How do we prevent serotonin syndrome?
There should be a 14 day washout period between SSRIs and MAOIs
38
What are the two unique side effects of SNRIs - apart from GI upset?
Hypertension
Sexual Dysfunction
39
When are MAOIs prescribed?
They are the second/third line drug class used to manage several psychiatric conditions, including depression and anxiety disorders
40
Who usually prescribes MAOIs?
Psychiatrists
GPs tend to continue this prescription, however it tends to be initiated in secondary care
41
List four MAOIs examples
Isocarboxazid
Phenelzine
Selegiline
Tranylcypromine
42
What should phenelzine not be prescribed with? Why?
Fluoxetine
An increased risk of central serotonin syndrome
43
How do MAOIs work?
They work by binding irreversibly to monoamine oxidase on the presynaptic membrane thereby preventing the inactivation of amines, such as serotonin, dopamine and noradrenaline
44
What are the four contraindications of MAOIs?
Cerebrovascular Disease
Manic Phase of Bipolar
Phaeochromocytoma
Severe Cardiovascular Disease
45
What are the three unique side effects of MAOIs - apart from GI upset?
Weight Gain
Postural Hypotension
Hypertensive Crisis
46
How do MAOIs lead to a hypertensive crisis?
When they are administered with tyramine-rich foods, such as cheese
47
When are TCAs prescribed?
They are the second/third line drug class used to manage several psychiatric conditions, including depression and anxiety disorders
48
Who usually prescribes TCAs?
Psychiatrists
GPs tend to continue this prescription, however it tends to be initiated in secondary care
49
What do all TCAs end in?
"ine"
50
List seven TCAs examples
Amitriptyline
Clomipramine
Doxepin
Desipramine
Imipramine
Nortriptyline
Trimipramine
51
Which TCA is used to manage anxiety?
Clompiramine
52
How do TCAs work?
They work by blocking the re-uptake of serotonin, noradrenaline and dopamine, thus increasing their levels within the brain
53
What are the two subtype classifications of TCAs?
Tertiary TCAs
Secondary TCAs
54
What are tertiary TCAs?
They are molecules composed of a three-ring structure, with two methyl groups on the nitrogen atom of the side chain
This means that they have tertiary amine side chains
55
What TCA subtype is associated with more side effects? Why?
Tertiary TCAs
The side chains are prone to cross react with other types of receptors
Tertiary TCAs have tertiary amine side chain
56
List four tertiary TCAs examples
Imipramine
Amitriptyline
Doxepin
Clomipramine
57
What are the two active metabolites of tertiary TCAs?
Desipramine
Nortriptyline
58
What are secondary TCAs?
They result from the metabolism of tertiary TCAs, during which there is loss of one methyl group on the nitrogen side chain
This means that they have secondary amine side chains
59
List two secondary TCAs examples
Desipramine
Nortriptyline
60
What is the main difference between tertiary and secondary TCAs?
Tertiary TCAs - They are more potent in blocking reuptake of serotonin
Secondary TCAs - They are more potent in blocking the reuptake of noradrenaline
61
What are the six contraindications of TCAs?
Arrythmias
Heart Block
Severe Hepatic Impairment
Severe Renal Impairment
Manic Phase of Bipolar
Congenital Long QT Syndrome
62
What are the two unique side effects of TCAs - apart from GI upset?
Weight Gain
Eye Accommodation
63
Which antidepressant has the greatest risk of mortality related to overdose? What does this mean?
TCAs
They should be carefully prescribed to individuals who experience suicidal ideation
64
When are alpha2-adrenoreceptor antagonists prescribed?
They are the second/third line drug class used to manage several psychiatric conditions
65
What condition do alpha2-adrenoreceptor antagonists treat?
Depression
66
List an alpha2-adrenoreceptor antagonist
Mirtazapine
67
How do alpha2-adrenoreceptor antagonists work?
They work by antagonising the adrenergic alpha2-autoreceptors and alpha2-heteroreceptors as well as blocking 5-HT2 and 5-HT3 receptors
This blocks reuptake of serotonin and noradrenaline, thus increasing their levels within the brain
68
What are the five contraindications of mirtazapine?
Cardiac Disorders
Diabetes Mellitus
Manic Phase of Bipolar
Hypotension
Psychosis
69
What are the two unique side effects of mirtazapine - apart from GI upset?
Weight Gain
Postural Hypotension
70
What are two mood stabiliser drug class types?
Lithium salts
Anticonvulsants
71
When are lithium salts prescribed?
They are the first line drug class used to manage psychiatric conditions, including bipolar disorder and schizophrenia
They can be used for the treatment of acute episodes of mania associated with bipolar disorder or the long-term management of bipolar disorder to prevent recurrence of acute episodes
72
List two lithium salt examples
Lithium carbonate
Lithium citrate
73
How do lithium salts work?
They work by increasing GABA levels, which is an inhibitory transmitter that also plays a role in modulating glutamate and dopamine
In bipolar disorder, individua’s have diminished GABA neurotransmission. Thus, low GABA levels can result in excitatory toxicity
74
What two investigations should be conducted prior to the administration of lithium?
Baseline bloods (U&Es, TSH)
Pregnancy test
75
How long post-dose should we measure lithium blood levels?
12 hours
76
Why do we conduct a pregnancy test prior to the administration of lithium?
This is due to the associated teratogenic risk of Ebstein’s anomaly
77
How do we administer lithium?
An initial dose of lithium (400mg, twice daily) is administered, which after 5-7 days is reviewed
The dose is gradually titrated up until a stable therapeutic level of 0.6 – 1.2 is achieved
78
What investigations should be conducted when administrating lithium? Why?
LFTs every 3 months
TFTs and U&Es every six months
To monitor for lithium toxicity
79
At what serum lithium concentration does lithium toxicity occur?
> 1.5mmol/L
80
What are the eight clinical features of lithium toxicity?
Diarrhoea
Vomiting
Dizziness
Coarse tremor
Blurred vision
Ataxia
Clonic limb movements
Convulsions
81
Which endocrine disorder is most commonly associated with chronic lithium toxicity?
Hypothyroidism
82
In which patients is lithium toxicity risk the greatest?
Those with chronic illnesses
83
How do we manage patients with suspected lithium toxicity?
It is recommended that an urgent lithium level is conducted immediately, and specialist advice is obtained
84
What are the eight contraindications of lithium?
Cardiac Arrythmias
Severe Renal Impairment
Hypothyroidism
Brugada Syndrome
Addison’s Disease
Diabetes Insipidus
Breastfeeding
Pregnancy
85
What are the five unique side effects of lithium?
Urinary Frequency
Weight Gain
Fine Tremor
Altered Taste Sensation
Thyroid Abnormalities
86
Which drugs are avoided when prescribing lithium?
Nephrotoxic drugs, such as ACEI, NSAIDs and diuretics
87
When are anticonvulsants prescribed?
They are the second line drug class used to manage psychiatric conditions, including bipolar disorder and schizophrenia
It can be used in individuals in which lithium is contraindicated or not tolerated
They can be used for the treatment of acute episodes of mania associated with bipolar disorder or the long-term management of bipolar disorder to prevent recurrence of acute episodes
88
List three anticonvulsant examples
Sodium valproate
Carbamazepine
Lamotrigine
89
How do anticonvulsants work?
They work by increasing GABA levels, which is an inhibitory transmitter that also plays a role in modulating glutamate and dopamine
In bipolar disorder, individua’s have diminished GABA neurotransmission. Thus, low GABA levels can result in excitatory toxicity
90
When do we prescribe sodium valproate?
It is recommended in individuals who suffer from several manic/depressive episodes a year
It is recommended in individuals who suffer from comorbid alcohol/substance use
91
How do we administer and monitor sodium valporate?
An initial dose of sodium valproate (500mg daily) is administered, which after 4-5 days is reviewed
The dose is gradually titrated up until a stable therapeutic level of 50– 125 is achieved, after which annual blood checks are conducted
92
What are the four contraindications of sodium valproate?
Acute Porphyria
Severe Hepatic Impairment
Urea Abnormalities
Mitochondrial Disorders
93
What are the three unique side effects of sodium valproate - apart from GI upset?
Weight Gain
Tremors
Hair Loss
94
How do we administer and monitor carbamazepine?
An initial dose of carbamazepine (100mg-200mg, 1-2 times daily) is administered, which after 5 days is reviewed
The dose is gradually titrated up until a stable therapeutic level of 4– 12 is achieved, after which monthly blood checks are conducted
95
What are the three contraindications of carbamazepine?
Acute Porphyria
AV Conduction Abnormalities
Bone Marrow Depression
96
What are the three unique side effects of carbamazepine - apart from GI upset?
Weight Gain
Rash
Fluid Imbalance
97
How do we administer and monitor lamotrigine?
An initial dose of lamotrigine (25mg daily on alternate days) is administered. The dose is gradually titrated up to 50mg daily after two weeks, and then 100mg daily after a further two weeks
In cases where patients experience compliance issues and stop administrating lamotrigine for 5 days, it is recommended that they start back at the initial dose
98
What are the three contraindications of lamotrigine?
Myoclonic Seizures
Parkinson’s Disease
Brugada Syndrome
99
What are the two unique side effects of lamotrigine - apart from GI upset?
Rash
Irritability
100
It is normal for individuals on anticonvulsants to experience deranged LFTS. When should we raise concerns?
If LFTs are increased three times greater than the baseline
101
When are anti-psychotics prescribed?
They are indicated in the management of psychotic disorders, including schizophrenia, bipolar disorder and psychotic depression
102
What two medications are antipsychotics commonly administered in conjunction with?
Lithium
Sodium valproate
103
How do antipsychotics work?
They work by inhibiting dopaminergic neurotransmission via four dopaminergic pathways
104
What are the four dopaminergic pathways?
Mesocortical Pathway
Mesolimbic Pathway
Nigrostriatal Pathway
Tuberoinfundibular Pathway
105
Where does the mesocortical pathway extend?
It connects the ventral tegmentum to the prefrontal cortex
106
What is the function of the mesocortical pathway?
It is thought to be involved in cognitive control, motivation and emotional response
107
What abnormalities in the mesocortical pathway results in psychotic disorders?
There are reduced levels of dopamine
108
What psychotic clinical features arise as a result of mesocortical pathway abnormalities?
Negative clinical features, such as anergia, anhedonia, lack of motivation, etc
109
Where does the mesolimbic pathway extend?
It connects the ventral tegmentum to the ventral striatum in the forebrain
110
What is the function of the mesolimbic pathway?
It is involved in reinforcement and reward-related motor function learning
111
What is another term of mesolimbic pathway?
Reward pathway
112
What abnormalities in the mesolimbic pathway results in psychotic disorders?
There are increased levels of dopamine
113
What psychotic clinical features arise as a result of mesolimbic pathway abnormalities?
Positive clinical features, such as hallucinations, delusions and thought disorders
114
Where does the nigrostriatal pathway extend?
It connects the substantia nigra in the midbrain to the basal ganglia in the forebrain
115
What is the function of the nigrostriatal pathway?
It is thought to be involved in movement regulation, by suppressing acetylcholine activity
116
What abnormalities in the nigrostriatal pathway results in psychotic disorders?
There are reduced levels of dopamine
117
What psychotic clinical features arise as a result of nigrostriatal pathway abnormalities?
Sympathetic motor deficits, such as bradykinesia, dyskinesia, tremors, rigidity, akathisia and dystonia
118
Where does the tuberoinfundibular pathway extend?
It connects the infundibular nucleus in the hypothalamus to the anterior pituitary gland
119
What is the function of the tuberoinfundibular pathway?
It is thought to be inhibit the secretion of prolactin from the anterior pituitary lactotrophs by binding to D2 receptors
120
What is a common complication when administering antipsychotics that bock the tuberoinfundibular pathway?
Hyperprolactinemia
121
What are the four main clinical features of hyperprolactinaemia?
Gynaecomastia
Galactorrhoea
Decreased libido
Menstrual dysfunction
122
What are the two classifications of antipsychotics?
Typical Antipsychotics
Atypical Antipsychotics
123
What is the mechanism of typical antipsychotics?
D2 dopamine receptor antagonists
124
When do we prescribe typical antipsychotics? Why?
They are used to manage severe psychotic conditions, which are resistant to newer medications
Due to the high risk of extrapyramidal and cardiotoxic/anticholinergic side effects
125
What type of typical antipsychotics are associated with extrapyramidal side effects?
High potency
126
List three high potency typical antipsychotics
Fluphenazine
Haloperidol
Pimozide
127
What are five extra-pyramidal features?
Parkinsonism
Acute dystonia
Sustained muscle contraction
Akathisia
Tardive dyskinesia
128
What are the two types of extra-pyramidal sustained muscle contractions?
Oculogyric crisis
Torticollis
129
What is oculogyric crisis?
It is a dystonic reaction that occurs shortly after initiation of anti-psychotics, resulting in an upward deviation of both eyes.
130
What are the two management options for oculogyric crisis?
Drug cessation
Anti-muscarinic administration - procyclidine
131
What are the three features of an acute dystonic reaction?
Oculogyric crisis
Tongue protrusion
Jaw spasm
These all occur suddenly
132
What is akasthesia?
Restlessness
133
What is tardive dyskinesia?
It is late onset of choreoathetoid movements, abnormal, involuntary - chewing and pouting of jaw
134
What is the cause of tardive dyskinesia?
The blockade of the dopamine receptor promotes hypersensitivity of the D2 receptor in the nigrostriatal pathway, thus giving rise to excessive movements.
135
What increases the risk of tardive dyskinesia?
Long-term use of antipsychotic drugs
136
How do we treat extra-pyramidal side effects?
We administer anti-cholinergics and beta-blockers
137
What three anticholinergics are used to treat extra-pyramidal features?
Benxtropine
Trihexyphenidly
Diphenhydramine
138
What beta-blocker is used to treat extra-pyramidal side effects?
Propanolol
139
What should we be cautious about when treating extra-pyramidal side effects?
If the patient is taking other meds with anticholinergic activity, such as TCAs
140
What type of typical antipsychotics are associated with cardiotoxic, anticholinergic side effects?
Low potency
141
List two low potency typical antidepressants
Chlorpromazine
Thioridazine
142
Why do the low potency typical antipsychotics cause cardiotoxic and anticholinergic adverse effects?
They have a lower affinity for the D2 receptors and tent to interact with nondopaminergic receptors
143
What are the four common side effects associated with typical antipsychotics?
Extrapyramidal features
Neuroleptic malignant syndrome
Hyperprolactinaemia
Prolonged QT interval
Metabolic syndrome
144
What is neuroleptic malignant syndrome?
It is a life threatening condition which can occur in individuals taking antipsychotic and dopaminergic medications
145
How soon after starting an antipsychotic can neuroleptic malignant syndrome occur?
Hours to days
146
What are the six clinical features of neuroleptic malignant syndrome?
Fever
Muscle rigidity
Hypertension
Tachycardia
Tachypnoea
Delirium
147
What are the two blood test results indicative of neuroleptic malignant syndrome?
Increased creatinine kinase levels
Increased leucocyte levels
148
What are the five management options of neuroleptic malignant syndrome?
Stop antipsychotic
IV fluids
Dantrolene
Bromcriptine
Dopamine agonist
149
What is the advantage of typical antipsychotics?
There is no weight gain
150
What is a contraindication of typical antipsychotics? What is administered instead?
Parkinson's disease
IM Lorazepam
151
What is the mechanism of atypical antipsychotics?
Serotonin-dopamine 2 antagonists (SDAs)
152
Why are atypical antipsychotics considered atypical?
They affect dopamine and serotonin neurotransmission in the four dopaminergic pathways of the brain
153
When do we prescribe atypical antipsychotics? Why?
They are the first line antipsychotics administered
They are associated with fewer side effects
154
List five atypical antidepressants
Risperidone
Olanzapine
Quetiapine
Aripiprazole
Clozapine
155
What is the first line antipsychotic prescribed?
Risperidone
156
What is the maximum dose of risperidone? Why?
6mg
A greater dose can result in adverse side effects
157
What are the five side effects commonly associated with risperidone?
Weight gain
Sedation
Hyperprolactinaemia
Extra-pyramidal features
Sexual dysfunction***
158
When is risperidone prescribed?
It is the first line antipsychotic used to treat manic and mixed bipolar episodes
It is also used in terms of long term maintenance of bipolar disorder
159
When is olanzapine prescribed?
It is used to treat manic, depressive and mixed bipolar episodes
160
What are the four side effects associated with olanzapine?
Weight gain***
Sedation
Hyperlipidaemia
Deranged LFTs
161
When is quetiapine prescribed?
It is used to treat manic and depressive bipolar episodes
It is also used in terms of long term maintenance of bipolar disorder
162
What are the four side effects associated with quetiapine?
Weight gain
Hyperlipidaemia
Deranged LFTs
Hypotension
163
When is aripiprazole prescribed?
It is used to treat manic and mixed bipolar episodes
It is also used in term of long term maintenance of bipolar disorder
164
What are the two side effects associated with aripiprazole?
Akathisia
Activation
However, there are generally fewer side effects compared to the other atypical antipsychotics
165
Which antipsychotic has the fewest side effects compared to to other typical antipsychotics?
Aripiprazole
It is particularly good for managing prolactin elevation
166
When is clozapine prescribed?
It is used to treat resistant psychotic disorders, in which two antipsychotics have been ineffectively trialled for a period of eight weeks respectively
167
What are the six side effects associated with clozapine?
Agranulocytosis****
Seizures
Sedation
Weight gain
Hyperlipidaemia
Deranged LFTs
168
Which blood test is used to work out if olanzapine has caused agranulocytosis?
FBC
169
What are the six contraindications of antipsychotics?
Cardiovascular Disease
Diabetes
Epilepsy
Myasthenia Gravis
Parkinson’s Disease
Prostatic Hypertrophy
170
What are the two administration methods for antipsychotics?
Oral route
Intramuscular route
171
What administration route is opted for after the third episode of schizophrenia? Why?
Intramuscular
This is due to reduced functioning and lower IQ symptoms resulting in compliance issues
172
What four blood tests are conducted prior to antipsychotic administration?
Fasting lipid profiles
Fasting blood sugars
LFTs
FBC
173
What ongoing monitoring is conducted when patients are administered antipsychotics? Why?
ECG
Due to the risk of QT prolongation
174
How long do we prescribe antipsychotics for? Why?
Life-long
This is due to the inevitable relapse of psychotic disorders
175
What four drugs are used to treat insomnia?
Melatonin
Benzodiazepines
Zopiclone
Temazepam
176
What is the main side effect of benzodiazepines?
Respiratory depression
177
What is the mechanism of action of zopiclone?
It is a non-benzodiazepine hypnotic acting on the α2-subunit of the GABA receptor
178
What are the two indications for melatonin administration in insomnia patients?
Patient - > 55 years old
Short term use - < 13 weeks use
179
How long does it take for insomnia patients to fall asleep after pharmacological intervention?
22 minutes
It doesn't maintain sleep!!!
180
What two drugs are used to manage ADHD?
Atomoxetine
Methylphenidate
181
What is the mechanism of atomoxetine?
It is a norepinephrine reuptake inhibitor
182
What is the mechanism of action of methylphenidate?
It is a dopamine/norepinephrine reuptake inhibitor
183
Which high potency typical antidepressant?
x
