Rx Flashcards
Antidepressants BPD medication Anti-psychotics Anxiolytics (62 cards)
1
Q
Antidepressants
Indications [7]
A
Unipolar and bipolar depression Organic mood disorders Schizoaffective disorder Anxiety disorders OCD Impulsivity associated with personality disorders Premenstrual dysphoric disorder
2
Q
Antidepressant
Indications - anxiety disorders [3]
A
PTSD
Panic disorder
Social phobia
3
Q
Antidepressant
First line
How long after therapeutic dose achieved that improvement is seen?
A
SSRI
3-6 weeks after therapeutic dose achieved before improvement seen
4
Q
Antidepressant
5 types
A
SSRI SNRI TCA MAOI Novel antidepressants
5
Q
TCA Tertiary TCA MOA Secondary TCA MOA Side effects [3 headings] Why are the SE's so widespread NB side effects in secondary TCA are generally less severe than tertiary TCA
A
Tertiary TCA MOA:
- acts on serotonin receptors
Secondary TCA MOA:
- blocks noradrenaline
Side effects:
Antihistaminic
Anticholinergic
Anti-adrenergic
Made up of amine side chains which are prone to react with a wide range of receptors
6
Q
Tertiary TCA eg [4]
Secondary TCA eg [2]
A
Amitriptyline
Imipramine
Doxepine
Clomipramine
Desipramine
Nortriptyline
7
Q
Name 2 anti-histaminic SE
A
Sedation and weight gain
8
Q
Name 6 anti-cholinergic SE
A
Dry mouth, eyes
Constipation
Memory deficits
Delirium ~
9
Q
MAOI
MOA [3]
Indication - very effective in… [1]
Eg [2]
A
Binds irreversibly to monoamine oxidase
Prevent inactivation of amines e.g. NE, DA, serotonin
Increased synaptic levels
Very effective in depression
Seligiline
Rasagiline
10
Q
MAOI
SE [7]
Con - strict diet causes [2]
A
Orthostatic hypotension \+ SSRI side effects - Sick stomach, dizziness - Sedation, weight gain - Restlessness, anxiety, nervousness - Insomnia - Sexual dysfunction Hypertensive crises so strict diet required - tyramine rich foods (Cheese Reaction) or sympathomimetics
11
Q
MAOI Serotonin syndrome Causes [1] Sx [7] Serious consequences [3] How to avoid Special instructions for fluoxetine and why
A
Cause: can develop if taken with medication that increases serotonin or have sympathomimetic actions
Sx Shivering Hyper-reflexia + myoclonus Increased temperature - pyrexial Vital sign instability Encephalopathy - delirium Restlessness Sweating - diaphoresis
Serious consequences
Hyperpyrexia
CVS shock
Death
Avoid by waiting 2 weeks before switching from SSRI > MAOI - washout period
5 week washout period if switching from fluoxetine due to long half-life
12
Q
SSRI MOA Indication Eg [6] Pros
A
Blocks presynaptic serotonin re-uptake
Treats both anxiety and depression sx
Eg Paroxetine Sertraline Fluoxetine Citalopram Escatilopram Fluvoxamine
Pros: very little risk of cardio toxicity in overdose
13
Q
SSRI
SE [7]
Pros
Cons [1] and give duration, 4 symptoms of [1]
A
SSRI SE
- Sick stomach, dizziness
- Sedation, weight gain
- Restlessness, anxiety, nervousness
- Insomnia
- Sexual dysfunction
Pros: very little risk of cardio toxicity in overdose Cons - discontinuation syndrome - week long - agitation, nausea, diseqm, dysphoria
14
Q
SSRI - Paroxetine
Pros
Cons
A
Pros
- short half-life so less build up
- sedating properties offering relief from anxiety, insomnia
Cons - - Discontinuation syndrome Significant CYP2D5 inhibition so drug2 interaction - Sedating - Weight gain
15
Q
SSRI - Sertraline
Pros [3]
Cons [2]
A
Pros
- Weak P450 interactions so fewer drug2 interactions
- Short half-life so less build up
- Less sedating that paroxetine
Cons
- Max absorption requires full stomach
- Increased no of GI SE’s
16
Q
SSRI - Fluoxetine
Well known trade name?
Pros [2]
Cons [3]
A
Prozac
Pros
- Long half life so less incidence of discontinuation syndromes
- Initially activating providing increased energy
Cons
- Build up not good in patient with hepatic disease
- Significant P450 interactions
- More likely to induce mania than other SSRIs
17
Q
SSRI - Fluoxetine
Good for which group of patients? [1]
Not so good in which group of patients? [3]
A
Good in non-compliant patients due to long half-life
Not so good in…
- hepatic disease due to build-up
- polypharmacy due to significant P450 interactions
- Manic, anxiety
18
Q
SSRI - Paroxetine
Indication
A
Sedating properties are good for relief from anxiety and insomnia
19
Q
SSRI - Citalopram
Half life
Pros [1]
Cons [3]
A
Intermediate half-life
Pros
- Low inhibition of P450 enzymes, fewer drug2 interactions
Cons
- QT prolongation
- Sedating
- GI side effects (but less than sertraline)
20
Q
Which 2 SSRIs cause dose-dependent QT interval prolongation with doses 10-30mg daily and how does this influence precautions when prescribing?
A
Citalopram
Escitalopram
due to this risk doses of >40mg/day not recommended!
21
Q
Which SSRI is associated with an increased no of GI side effects
A
Sertraline
22
Q
Escatilopram Half-life Pros [1] Cons [3] Effectiveness compared to citalopram?
A
Intermediate half-life
Pros
-Low inhibition of P450 enzymes, fewer drug2 interactions
Cons
- QT prolongation
- Nausea
- Headache
- more effective than citalopram in acute response, remission
23
Q
Fluvoxamine
Pros [2]
Cons [6]
A
Pros
- shortest half-life
- analgesic properties
Cons - discontinuation syndrome - GI upset - Headaches Sedation Strong CYP1A2, CYP2C19 inhibitor
24
Q
SNRI Describe MOA, similar to...? Pro [1] Indications [3] Eg [2]
A
SNRI MOA: inhibits both serotonin and NE reuptake Pro: no antihistamine, anticholinergic, antiadrenergic Indications - Anxiety - Depression - ? Neuropathic pain Eg - Venlafaxine - Duloxetine
25
What to do if encounter treatment resistance [4]
Combination of antidepressants
Adjunctive tx with lithium
Adjunctive tx with atypical antipsychotic
ECT
26
Eg of a good combo of antidepressants in refractory cases
SSRI/SNRI with mirtazapine (tetracyclic antidepressant)
27
Eg of 3 atypical antipsychotics as adjunctive treatments in refractory cases
Quetiapine
Olanzapine
Aripriprazole
28
Mood stabilizers
3 indications
3 classifications
Indications
- Bipolar
- Cyclothymia
- Schizoaffective
Classifications: Lithium, anticonvulsants, antipsychotics
29
Mood stabilizers - Lithium
Effective in... [4]
Con
2 things to test for before starting lithium
Reduces suicide rate
Effective in long term prophylaxis of mania and depressive episodes
Classic pure mania
Mania followed by depression
Con: narrow therapeutic window
Before starting lithium...
Get baseline U&E and TSH
Pregnancy test
30
```
Mood stabilizers - Lithium
Monitoring -
Goal in blood level and when to check
When is steady state achieved
Once stable what are the monitoring protocols? [3]
```
```
Goal in blood level: 0.6-1.2 - Check 12 hours after last dose
Steady state achieved 5 days
Once stable...
- Check every 3m
- Check TSH and creatinine every 6m
```
31
Mood stabilizers - Lithium
SE [7]
LTHIUM
```
Leukocytosis
Tremors, thirsty
Hypothyroidism, hair loss
Interstitial renal fibrosis
Upset GI, nausea, vomiting, diarrhea
Muscle weakness, mums
Skin (acne), seizure, slowing
```
32
Why does lithium cause polyuria
| What is one serious consequence of this
Secondary to ADH antagonism
| Interstitial renal fibrosis
33
Describe lithium toxicity
Mild lithium toxicity [3]
Moderate lithium toxicity [6]
Severe lithium toxicity [2]
Mild lithium toxicity
- vomiting, diarrhea
- ataxia, dizziness
- nystagmus, slurred speech
Moderate lithium toxicity
- vomiting
- anorexia
- syncope
- blurred vision
- clonic limb movements
- convulsions, delirium
Severe lithium toxicity
- Generalised convulsions
- Oliguria, renal failure
34
```
Mood stabilizers
Lithium ranges
Goal
Mild
Mod
Severe
```
Goal: 0.6-1.2
Mild 1.5-2.0
Mod 2.0-2.5
Severe >2.5
35
Mood stabilizers - valproic acid
Effectiveness and tolerativeness in comparison to lithium? [3]
Factors predicting positive response [4]
Same effectiveness as lithium in mania prophylaxis
Not as effectiveness as lithium in depression prophylaxis
Better tolerated than lithium
Factors:
- rapid cycling patients
- co-morbid substance issues
- mixed patients
- co-morbid anxiety disorders
36
Lithium
| Factors predicting positive response [3]
Prior long term response
or family member with good long term
Classic pure mania
Mania followed by depression
37
Mood stabilizers - valproic acid
Before starting, 3 things
Con [1] influencing management
Before starting
- baseline LFT
- baseline FBC
- pregnancy test
Con: increased risk of neural tube defect so prescribe folic acid supplement
38
Mood stabilizers - valproic acid
When is steady state achieved
When to repeat LFT, FBC
Goal in blood
Steady state achieved 4-5 days
Check in 12 hours after last dose
- Repeat LFT, FBC
Goal in blood: 50-125
39
Mood stabilizers - valproic acid
| SE [6]
```
Vomiting
Alopecia
Liver toxicity hence LFTs
Pancreatitis
Retain fat
Oedema
Appetite increase
Thrombocytopenia
Enzyme inhibitor p450
```
40
Mood stabilizers - carbamazepine
Originally used as
Indications [4] - first line agent for 2
```
Originally used as an anti-epileptic
Indications
- acute mania, mania prophylaxis (first line)
- rapid cyclers
- mixed patients
```
41
Mood stabilizers - carbamazepine
Before starting [3]
Monitoring:
steady state
Goal in blood
Before starting:
- LFT
- FBC
- ECG
Steady state achieved after 5 days
Check 12 hours for FBC, LFT
Goal in blood: 4-12 mcg/mL
Check after 1 month
42
Mood stabilizers - lamotrigine
Og used as...
SE [6]
What are 2 drug-drug interactions?
```
Anticonvulsant
SE:
- Nausea, vomiting
- Sedation
- Dizziness, ataxia, confusion
- Stevens Johnson's syndrome
- Blood dyscrasias
```
Drug interactions
- sertraline
- valproic acid
43
Mood stabilizers - anti-psychotics
2 types
Indications [4]
SE [3]
Typical
Atypical
```
Indications
Schizophrenia
BPD
Psychotic depression
Anxiety disorders as augmenting agent
```
SE
- tardive dyskinesia
- NMS
- EPS
44
Mood stabilizers - anti-psychotics SE's
Explain tardive dyskinesia [2]
NMS is potentially fatal - what are 5 clinical features
3 features of extrapyramidal symptoms
Tardive dyskinesia - involuntary muscle movements not resolving with drug discontinuation
NMS
- Fever
- Encephalopathy
- Vital sign instability
- Enzyme elevation eg raised CPK, LFT, WBC
- Rigidity (leadpipe)
EPS
- Acute dystonia
- PD
- Akathisia
45
```
Mood stabilizers - Typical anti-psychotics
3 examples
MOA [2]
Explain side effect profile:
- high risk of EPS effects
- anti-cholinergic and cardiotoxic
```
Eg
Fluphenazine
Haloperidol
Pimozide
MOA:
D2 dopamine receptor antagonists
Side effect profile:
EPS effects - high potency typical antipsychotics tend to bind to D2 receptor with high affinity
Anti-cholinergic, cardiotoxic - low potency typical antipsychotics bind with less affinity to D2 receptors BUT interact with non-dopaminergic receptors
46
Mood stabilizers - Atypical anti-psychotics
MOA
Why are they named atypical?
Eg
MOA: serotonin-dopamine 2 antagonists
Considered atypical in the way that they affect DA and serotonin neurotransmission
```
Eg
Risperidone
Olanzapine
Quetiapine
Aripiprazole
Clozapine
```
47
Mood stabilizers - Atypical anti-psychotics
| Risperidone SE [3]
Increased EPS effects
Hyperprolactinemia
Weight gain, sedation
48
Which 2 atypical anti-psychotic is only available in tablets
| NB the rest are available in tablets, IM and depot
Clozapine
| Quetiapine
49
Mood stabilizers - Atypical anti-psychotics
| Olanzapine SE [4]
Hypertriglyceridemia, high cholesterol
Hyperprolactinemia~
Weight gain, hyperglycemia
Abnormal LFTs ~
50
Mood stabilizers - Atypical anti-psychotics
Quetiapine SE
similar SE profile to another atypical antipsychotic
```
Same as olanzapine but most likely to cause orthostatic hypotension
Hypertriglyceridemia, high cholesterol
Hyperprolactinemia~
Weight gain, hyperglycemia
Abnormal LFTs ~
```
51
```
Mood stabilizers - Atypical anti-psychotics
Aripiprazole
MOA
3 Pros
SE [1]
```
MOA: d2 partial agonist
Pros: not associated with weight gain, low sedation, low EPS effects
SE: CYP2D6, 3A4 interactions
52
```
Mood stabilizers - Atypical anti-psychotics
Clozapine
Indications
SE (highest risk)
- NB side effect profile can be fatal
```
```
Reserved for tx resistant pt
SE
Agranulocytosis
Increased risk of seizures
Most sedation, weight gain, abnormal LFTs
```
Hypertriglyceridemia, high cholesterol
Hyperprolactinemia~
Hyperglycemia
Non-ketotic hyperosmolar coma
53
EPS agents [3]
| Give at least 1 example of each
Anticholinergics
Dopamine facilitators - amantadine
Beta blockers - propanolol
54
EPS agents - anticholinergics
3 eg
Watch out for...
Eg
Benztropine
Trihexyphenidyl
Diphenhydramine
Watch for anticholinergic SE esp if taken with TCAs (additive anticholinergic activity)
55
```
Anxiolytics
Indications [4]
Buspirone and its MOA
Pros [2]
Cons [2]
```
```
Panic disorder
GAD
Substance related disorders
Used in combination with SSRI, SNRI [augmentation]
Eg: Buspirone
MOA: 5HT1A agonist
```
Pros
- augmentation strategy
- no sedation
Cons
- 2 weeks before improvments
- will not reduce anxiety in pt that are used to taking BDZ because no sedation effect to take edge off
56
Anxiolytics - BDZs
Indications 4
5 SE
```
• Indications
• Insomnia
• Parasomnia
• Anxiety disorder
• CNS depressant withdrawal protocols eg alcohol withdrawal
• SE
• Somnolence
• Cognitive deficits
• Amnesia
• Disinhibition
Tolerance, dependence
```
57
Psychological Treatment
CBT
Name 4 features
Focus on now
short term
Problem focused
Goal oriented
58
Psychological Treatment
CBT
Therapist helps client by... [4]
Identify thoughts, feelings and behaviours
Assess thinking errors
What can change
Client engages in homework
59
Psychological Treatment
CBT
Thinking errors [8]
Homework [2]
```
Automatic negative thoughts
Unrealistic beliefs
Cognitive distortion
Catastrophizing
Black and white thinking
Perfectionism
Over-generalisation
Mind reading
```
Homework:
errors
Graded exposure
Response prevention
60
Psychological Treatment
Behavioral activation in treatment of depression
3 key features
3 features of its structure
Focus on avoidance issues in depression
Predictors and perpetuators of avoidance
Client taught to analyse unintended consequences of their response to triggering situations
3 features of its structure:
structured agenda
review progress
make small changes to build long term goals
61
Interpersonal therapy
Effective for 2 conditions
4 features
Cons 2
Indications - depression, anxiety
Time limitation: 12-16 weeks
4 features:
- CBT without homework
- Allows patient to be invested in sick role
- Acknowledges depression often follows major life event
- construct an interpersonal map
Cons:
requires degree of ability to reflect
limited where there are poor social networks
62
```
Motivational interviewing
Based on what theory
More effective than
Indications
Pros:
```
Based on Prochaska and Diclemente's stages of change
More effective than advice giving
Indications: where behaviour change is being considered but patient is unmotivated or ambivalent (mixed feelings) to change
Pros: patient sets the agenda, self-efficacy
