Therapeutics Flashcards
(92 cards)
1
Q
NMS clinical features
A
First 10 days of treatment or after increasing dose
- pyrexia
- muscular rigidity
- confusion
- fluctuating consciousness
- autonomic instability (fluctuating pulse & BP)
- delirium
2
Q
NMS investigations
A
- CK - increased (1000s)
- FBC - leucocytosis may be seen
- LFTs - deranged
3
Q
NMS management
A
- emergency referral to A&E
- stop antipsychotic
- monitor vitals
- IV fluids
- cooling
- dantrolene (muscle relaxant), 2nd line - bromocriptine (dopamine agonist)
- consider benzodiazepines for acute behaviour disturbance
4
Q
Delirium tremens
A
Severe end of the spectrum of alcohol withdrawal & peak incidence is at 72 hours
5
Q
Delirium tremens symptoms
A
- confusion
- paranoid delusions
- coarse tremor
- formication - sensation of crawling insects on or under the skin
- autonomic arousal (tachycardia, fever, pupillary dilatation, increased sweating)
6
Q
Delirium tremens treatment
A
- large doses of benzodiazepines (eg. chlordiazepoxide)
- haloperidol for any psychotic features
- IV pabrinex
7
Q
Wernicke’s encephalopathy
A
An acute encephalopathy due to thiamine deficiency
8
Q
Wernicke’s encephalopathy symptoms
A
- delirium
- nystagmus
- ophthalmoplegia: lateral rectus palsy, conjugate gaze palsy
- hypothermia
- ataxia
9
Q
Wernicke’s encephalopathy treatment
A
-parenteral thiamine
10
Q
Korsakoff’s psychosis
A
Profound, irreversible short-term memory loss with confabulation (the unconscious filling of gaps in memory with imaginary events) and disorientation to time
11
Q
Acute dystonias
A
Sustained, often painful, muscular spasms, producing twisted abnormal postures in reaction to an antipsychotic
12
Q
Oculogyric crisis
A
Neck arched and eyes rolled back
13
Q
Acute dystonias treatment
A
- stop antipsychotic
- administer IM/IV anticholinergics (first-line is procyclidine)
- continue for 1-2 days after dystonia & consider long-term prophylactic
14
Q
What makes lithium toxicity worse?
A
- dehydration
- drugs (ACE inhibitors, NSAIDs)
- diuretics (thiazide)
- depletion of sodium
15
Q
Lithium toxicity symptoms
A
- confusion
- coarse tremor
- nausea & vomiting
- ataxia
- seizures
16
Q
Lithium toxicity treatment
A
- stop lithium
- supportive measures - IV fluids, dialysis if necessary, benzodiazepines for seizures
17
Q
Clozapine-induced agranulocytosis treatment
A
- stop clozapine
- stop any other potentially marrow supressing drugs - e.g. sodium valproate
- avoid antipsychotics for a couple of weeks where possible; if needed - aripiprazole
- contact consultant haematologist
- avoid sources of infection, consider broad-spectrum abx
- lithium & G-CSF can be used
18
Q
ECT
A
- passage of a small electrical current through the brain with a view to inducing a modified epileptic seizure which is therapeutic
- usually requires around 6-12 treatment sessions, delivered twice a week
19
Q
ECT procedure
A
- electric current is applied to the patient’s skull, aiming to induce a seizure for at least 30 seconds
- occurs under GA
- muscle relaxant (suxamethonium) is given by the anaesthetist which limits the motor effects of the seizure
- can be bilateral/unilateral
20
Q
ECT indications
A
- prolonged or severe mania
- catatonia
- severe depression (most common)
- treatment-resistant depression
- suicidal ideation or serious risk to others
- life-threatening depression
21
Q
ECT side effects
A
- short-term
- peripheral nerve palsies
- cardiac arrhythmias, confusion
- dental and oral trauma
- anaesthetic risks
- muscular aches & headaches
- short-term memory impairment
- status epilepticus
- long-term
- anterograde & retrograde amnesia
22
Q
ECT contraindications
A
- MI
- major unstable fracture
- cerebral aneurysm
- raised ICP (only absolute contraindication)
- stroke < 1 month ago
- history of status epilepticus
- severe anaesthetic risk
23
Q
SSRIs examples
A
- citalopram
- escitalopram
- fluoxetine
- paroxetine
- sertraline
- fluvoxamine
24
Q
SSRI indications
A
- depression
- panic disorder (citalopram, escitalopram, paroxetine)
- social phobia (escitalopram, paroxetine)
- bulimia nervosa (fluoxetine)
- OCD
- PTSD (paroxetine, sertraline)
- GAD (paroxetine)
25
SSRIs mechanism of action
- work by inhibiting the reuptake of serotonin from the synaptic cleft into pre-synaptic neurones
- SSRIs increase the concentration of serotonin in the synaptic cleft
26
SSRIs SEs
- GI: nausea, dyspepsia, bloating, flatulence, diarrhoea and constipation
- sweating
- tremor
- rashes
- EPSEs (uncommon)
- sexual dysfunction
- somnolence
- discontinuation syndrome - GI symptoms, ‘chills’, insomnia, hypomania, anxiety and restlessness
27
SSRIs contraindications & cautions
- cautions
- history of mania
- epilepsy
- cardiac disease
- acute angle-closure glaucoma
- diabetes mellitus
- contraindications
- mania
28
SSRIs route
oral
29
SNRIs examples
- venlafaxine
- duloxetine
30
SNRIs indications
- second/third line treatment for depression and anxiety
- have a faster onset & more effective than SSRIs (for major depression)
31
SNRIs mechanism of action
- work by preventing the reuptake of noradrenaline and serotonin
- do not block the cholinergic receptors and therefore do not have as many anti-cholinergic side effects as TCAs
32
SNRIs SEs
- nausea
- dry mouth
- headache
- dizziness
- sexual dysfunction
- hypertension
33
SNRIs contraindications & cautions
- cautions: similar to SSRIs
- contraindications: high risk of cardiac arrhythmia, uncontrolled hypertension
34
SNRIs route
oral
35
Mirtazapine indications
- second line for depressed patients who:
- would benefit from weight gain
- suffer from insomnia
36
Mirtazapine mechanism of action
- weak noradrenaline reuptake inhibiting effect
- has anti-histaminergic properties
- alpha-1 and alpha-2 blocker
- therefore increases appetite and is a sedative
37
Mirtazapine SEs
- increases appetite
- weight gain
- dry mouth
- postural hypotension
- oedema
- drowsiness
- fatigue
- tremor
- dizziness
- less common: syncope, mania, hallucinations, movement disorders
38
Mirtazapine contraindications & cautions
- cautions
- elderly
- cardiac disorders
- hypotension
- urinary retention
- diabetes
- psychoses
39
Mirtazapine route
oral
40
TCA examples
- amitriptyline
- clomipramine
- imipramine
- nortriptyline
41
TCA indications
- depressive illness
- nocturnal enuresis in children
- neuropathic pain (unlicensed)
- migraine prophylaxis (unlicensed)
42
TCA mechanism of action
- work by inhibiting the reuptake of adrenaline and serotonin in the synaptic cleft
- also have affinity for cholinergic receptors & 5HT2 receptors → contribute to side effects
43
TCA SEs
- anticholingeric: dry mouth, constipation, urinary retention
- cardiovascular: arrhythmias, postural hypotension, tachycardia
- hypersensivity: urticaria, photosensitivity
- psychiatric: confusion, delirium (especially in elderly)
- metabolic: increased appetite and weight gain
- endocrine: testicular enlargement
- neurological: convulsions, movement disorders
44
TCAs contraindications & cautions
- cautions
- cardiac disease
- history of epilepsy
- pregnancy
- breast feeding
- elderly
- contraindications
- recent MI
- arrhythmias (particularly heart block)
- mania
45
TCAs route
oral - tablet/solutions
46
MAOI examples
- irreversible: phenelzine, isocarboxide
- reversible: moclobemide
47
MAOI indications
- third-line treatment for depression: atypical/treatment-resistant depression
- social phobia
48
MAOI mechanism of action
inactivate monoamine oxidase enzymes that oxidise the monoamine neurotransmitters dopamine, noradrenaline, serotonin & tyramine
49
MAOI SEs
- CVS: postural hypotension, arrhythmias
- neuropsychiatric: drowsiness/insomnia, headache
- GI: increased appetite, weight gain
- anorgasmia
- increased LFTs
- hypertensive reactions with tyramine containing foods
50
MAOI contraindications & cautions
- cautions
- avoid in agitated/excited patients
- thyrotoxicosis
- hepatic impairment
- bipolar disorders
- contraindications
- acute confusional states
- phaeochromocytoma
50
MAOI route
oral
51
NARI examples
reboxetine
52
NARI indications
second or third-line for major depression
53
NARI mechanism of action
highly specific noradrenaline reuptake inhibitor
54
NARI SEs
- nausea
- dry mouth
- constipation
- anorexia
- tachycardia
- palpitations
- vasodilatations
55
NARI contraindications & cautions
- cautions
- history of cardiovascular disease
- bipolar disorder
- urinary retention
- prostatic hypertrophy
- pregnancy
56
NARI route
oral
57
typical anti-psychotics examples
- haloperidol
- chlorpromazine
- flupentixol
- fluphenazine
- sulpiride
- zuclopenthixol
58
typical anti-psychotic indications
- indicated for patients suffering from psychotic symptoms eg. delusions and hallucinations
- can be used for other conditions when they present with positive psychotic symptoms
- depression
- mania
- delusional disorders
- acute & transient psychotic disorders
- delirium
- dementia
- violet/dangerously impulsive behaviour and psychomotor agitation
59
typical anti-psychotic mechanism of action
reducing abnormal transmission of dopamine through blocking dopamine receptors in the brain
60
typical anti-psychotic SEs
- sedation
- weight gain
- QTc prolongation
- extra-pyramidal side effects - bradykinesia, muscle stiffness and tremor, tardive dyskinesia, akathisia
- anti-cholinergics used to treat EPSEs
- procyclidine (potential for misuse)
61
typical anti-psychotics monitoring
- baseline: FBC, lipids, LFT, HbA1c, weight, ECG, blood pressure & pulse
- weekly: weight in an ideal world
- three months: FBC, lipids, LFT, HbA1C, weight, ECG, blood pressure & pulse
- yearly: FBC, lipids, LFT, HbA1C, weight, ECG, blood pressure & pulse
62
typical anti-psychotics contraindications & cautions
- cautions
- CVD
- parkinson’s disease
- epilepsy
- depression
- myasthenia gravis
- prostatic hypertrophy
- contraindications
- comatose states
- CNS depression
- phaeochromocytoma
63
typical anti-psychotics route
- usually oral
- can also be given by short-acting IM injection
- some antipsychotics can be given as depot injections every 1-4 weeks (long acting, slow release)
- numerous eg. flupentixol, fluphenazine, zuclopenthixol
64
atypical antipsychotics examples
- olanzapine
- risperidone
- quetiapine
- amisulpride
- aripiprazole
- clozapine
65
atypical antipsychotics indications
- indicated for patients suffering from psychotic symptoms eg. delusions and hallucinations (mainstay of treatment for schizophrenia)
- can be used for other conditions when they present with positive psychotic symptoms
- depression
- mania
- delusional disorders
- acute & transient psychotic disorders
- delirium
- dementia
- violet/dangerously impulsive behaviour and psychomotor agitation
- clozapine - third-line treatment for schizophrenia
- should only be prescribed after failing to respond to two other antipsychotics (treatment-resistant schizophrenia)
66
atypical antipsychotics mechanism of action
- specific dopaminergic action, blocking the D2 receptor
- also have serotonergic effects
67
atypical antipsychotics SEs
- sedation
- weight gain
- QTc prolongation
- dyslipidaemia
- diabetes
- metabolic syndrome
- clozapine
- agranulocytosis
- constipation, potentially fatal bowel obstruction
- hypersalivation
- urinary incontinence
68
atypical antipsychotics monitoring
- baseline: FBC, lipids, LFT, HbA1c, weight, ECG, blood pressure & pulse
- weekly: weight in an ideal world
- three months: FBC, lipids, LFT, HbA1C, weight, ECG, blood pressure & pulse
- yearly: FBC, lipids, LFT, HbA1C, weight, ECG, blood pressure & pulse
- clozapine
- weekly FBC for first 18 weeks, then fortnightly for up to a year, then monthly
69
atypical antipsychotics contradications & cautions
- cautions
- CVD
- parkinson’s disease
- epilepsy
- depression
- myasthenia gravis
- prostatic hypertrophy
- contraindications
- comatose states
- CNS depression
- phaeochromocytoma
70
atypical antipsychotics route
- usually oral
- some can also be given by short-acting IM injection
- some can also be given as depot injections
- risperidone
- olanzapine
- aripiprazole
71
Benzodiazepines examples
- long acting (> 24 hours duration)
- diazepam
- nitrazepame
- chlordiazepoxide
- short-acting (< 12 hours duration)
- lorazepam
- oxazepam
- midazolame
72
Benzodiazepines indications
- insomnia (short-term)
- anxiety disorders
- delirium tremens and alcohol detoxification
- acute psychosis
- violent behaviour
73
Benzodiazepines mechanism of action
- enhance the effect of the inhibitory neurotransmitter GABA by increasing the frequency of chloride channels via the benzodiazepine-binding site of the GABA-A receptor
- receptors are located throughout the cortex and limbic system in the brain & function to inhibit neuronal activity
74
Benzodiazepines side effects
- drowsiness & light-headedness the next day
- confusion and ataxia, especially in the elderly
- amnesia
- dependence
- paradoxical increase in aggression
- muscle weakness
- respiratory depression
75
Benzodiazepine withdrawal syndrome
May develop at any time up to 3 weeks after stopping a long-acting benzodiazepine, but may occur within a day in the case of a short-acting one
SE: insomnia, anxiety, loss of appetite, tremor, muscle twitching, sweating, tinnitus, perceptual disturbances & seizures (rarely)
76
Benzodiazepine cautions & contraindications
- respiratory depression
- hepatic impairment
77
Benzodiazepines route
- PO
- IM, IV & PR benzodiazepine preparations are mainly for non-compliant patients & status epilepticus
78
Pregabalin use in anxiety
Inhibitor of glutamate, noradrenaline and substance P
Uses: GAD, neuropathic pain, epilepsy
SE: dizziness, drowsiness, blurred vision, diplopia, confusion, vivid dreams, sedation, weight gain
79
Beta blockers use in anxiety
Notably propranolol, at a starting dose of 40mg, can be used in anxiety disorder for reducing somatic symptoms eg. tachycardia, palpitations & tremor
Contraindicated in asthma, COPD, bronchospasm, heart block, marked hypotension & acute LVF
80
Buspirone use in anxiety
Non-sedating anxiolytic used for GAD
Works as a 5HT-1A agonist
Does not cause dependence, but its anxiolytic effect develops more slowly
SE: nausea, headache, light-headedness & dizziness
81
Hypnotics types
Benzodiazepines - temazepam, lormatazepam & nitrazepam
Nonbenzodiazepines - zopiclone, zolpidem
82
Hypnotics ('Z drugs') mechanism of action
Work like BZDs by enhancing GABA transmission but are mainly used as hypnotics as they have:
- shorter half lives
- reduced risk of tolerance & dependence
- reduced psychomotor & hangover effects
83
Hypnotics use
Only for two weeks and take for only 5 out of 7 days each week to reduce potential for tolerance
84
Mood stabilisers
Used to treat bipolar mood disorder
Come from one of the following groups:
- lithium
- anticonvulsants
- second generation antipsychotics
85
Lithium indications
One of the most effective mood stabilisers
Reduction of self-harm
Augment antidepressants
86
Lithium monitoring
Narrow therapeutic window → regular serum lithium levels → weekly after dose change until level stable then 3 monthly once stable
Sample taken 12 hours post-dose
U&Es and TFTs every 6 months
87
Lithium SEs
GI disturbance, metallic taste and/or dry mouth, fine tremor, polydipsia & polyuria, weight gain
Long-term effects: hypothyroidism (usually reversible), renal impairment (usually irreversible)
88
Lithium interactions
Following can increase levels dangerously include:
- NSAIDs
- loop diuretics
- ACE inhibitors
89
SGAs in bipolar mood disorder
Quetiapine now first line treatment for bipolar
All SGAs have effectiveness & so do FGAs
Doses and monitoring the same as for psychosis
90
Anticonvulsants as mood stabilisers
Various modes of action - GABA receptors, calcium channels, sodium channels
Most common used:
- sodium valproate - avoid in women of child bearing age due to teratogenicity; check LFTs before and soon after starting
- carbamazepine
- lamotrigine - potential for Stevens Johnson Syndrome
Most anticonvulsants have potential to cause thrombocytopenia so check FBC
SEs: sedation & weight gain
91
ADD & ADHD medication
Most treatments are CNS stimulants
1) methylphenidate
- most commonly prescribed
- often given with a combination of immediate & sustained release
2) dextroamphetamine
- stimulants have potential for misuse & dependency
- monitor weight, height (in children) & pulse
Atomoxetine - noradrenaline re-uptake inhibitor
- used according to patient preference, unable to tolerate stimulants or in instances of previous drug dependence
