Side effects of Clozapine?
- Agranulocytosis
- Neutropenia
- Weight gain
- Excessive salivation
- Myocarditis (a baseline ECG should be taken before starting treatment)
- Arrhythmias
Clozapine, one of the first atypical agents to be developed, carries a significant risk of agranulocytosis and FBC monitoring is essential during treatment.
Clozapine should be introduced if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks.
Anorexia nervosa clinical and physiological features?
- Reduced BMI
- Bradycardia
- Hypotension
- Enlarged salivary glands
- Most things low: Hypokalaemia, low FSH, LH, oestrogen and testosterone. Low T3. Impaired glucose tolerance.
- G’s and C’s raised: Growth hormone, Cortisol, Glucose, salivary Glands, Cholesterol, Carotinaemia
Somatisation disorder
- Multiple physical SYMPTOMS present for at least 2 years
- Patient refuses to accept reassurance or negative test results
Hypochondrial disorder
- Persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
- Patient again refuses to accept reassurance or negative test results
Factitious disorder/ Munchausen’s syndrome
The intentional production of physical or psychological symptoms (for example self poisoning)
Conversion disorder
Typically involves loss of motor or sensory function
Side effects of Antipsychotics?
Extrapyramidal side-effects (EPSEs) more common in typical antipsychotics: DAPT
- Acute Dystonia: sustained muscle contraction (e.g. torticollis, oculogyric crisis)
- Akathisia (severe restlessness)
- Parkinsonism
- Tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)
- EPSEs may be managed with Procyclidine
- Increased risk of stroke and VTE in the elderly
Other side-effects:
- Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
- Sedation, weight gain
- Hyperprolactinaemia, may result in galactorrhoea
- Impaired glucose tolerance
- Neuroleptic malignant syndrome: pyrexia, muscle stiffness
- Reduced seizure threshold (greater with atypicals)
- Prolonged QT interval (particularly Haloperidol)
Examples of atypical antipsychotics?
- clozapine
- olanzapine: higher risk of dyslipidemia and obesity
- risperidone
- quetiapine
- amisulpride
- aripiprazole: generally good side-effect profile, particularly for prolactin elevation
Drug treatment for generalised anxiety disorder?
NICE suggest sertraline should be considered the first-line SSRI
Schneider’s first rank symptoms of schizophrenia?
- Auditory hallucinations of a specific type:
- two or more voices discussing the patient in the third person
- thought echo
- voices commenting on the patient’s behaviour - Thought disorder:
- thought insertion
- thought withdrawal
- thought broadcasting - Passivity phenomena:
- bodily sensations being controlled by external influence
- actions/impulses/feelings - experiences which are imposed on the individual or influenced by others - Delusional perceptions:
- a two stage process, where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. ‘The traffic light is green therefore I am the King’.
Schizophrenia management?
- Oral atypical antipsychotics are first-line
- Cognitive behavioural therapy should be offered to all patients
Which drug is commonly used in the management of neuropathic pain?
Low-dose Amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine).
Tricyclic antidepressants (TCAs) are used less commonly now for depression due to their side-effects and toxicity in overdose.
Common side-effects: (Anticholinergic SEs) - drowsiness - dry mouth - blurred vision - constipation - urinary retention - lengthening of QT interval
Side effects of SSRIs?
Adverse effects:
- Gastrointestinal symptoms are the most common side-effect
- Increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
- Hyponatraemia
- Patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
- Citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval
Which SSRI is recommended post myocardial infarct?
Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for the majority of patients with depression.
- Citalopram (re: QT interval) and fluoxetine are currently the preferred SSRIs
- Sertraline is useful post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants
- Fluoxetine is the drug of choice when an antidepressant is indicated
After starting on antidepressants, how soon should the patient be reviewed?
Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks. For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week.
If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.
How do you discontinue a SSRI?
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
Discontinuation symptoms:
- increased mood change
- restlessness
- difficulty sleeping
- unsteadiness
- sweating
- gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
- paraesthesia
What is neuroleptic malignant syndrome? What causes it and what symptoms are seen?
Neuroleptic malignant syndrome is a rare but dangerous condition seen in patients taking Antipsychotic medication. Mortality of up to 10% and can also occur with atypical antipsychotics. It may also occur with dopaminergic drugs (such as levodopa) for Parkinson’s disease. The underlying mechanism involves blockage of dopamine receptors induced by antipsychotics.
- It occurs within hours to days of starting an antipsychotic.
- Pyrexia
- Muscle rigidity
- Autonomic lability: Hypertension, Tachycardia and Tachypnoea
- Agitated delirium with confusion
A raised creatine kinase is present in most cases. Acute kidney injury (secondary to rhabdomyolysis) may develop in severe cases. A leukocytosis may also be seen.
What is the management for neuroleptic malignant syndrome?
- Stop antipsychotic
- IV fluids to prevent renal failure
- Dantrolene may be useful in selected cases
- Bromocriptine, dopamine agonist, may also be used
What are the differences between neuroleptic malignant syndrome and serotonin syndrome?
Serotonin syndrome caused by SSRIs, MAOIs.
Faster onset (hours).
Hyperreflexia, clonus.
Mx: Cyproheptadine, chlorpromazine
NMS caused by antipsychotics.
Slower onset (hours - days).
Hyporeflexia
Mx: Dantrolene
SSRI of choice in adolescents and children?
Fluoxetine.
Fluoxetine is the first-line SSRI for children and adolescents under 18 years with moderate to severe depression. This recommendation is due to its proven efficacy and safety profile in this age group.
MOA of Benzodiazepines?
Benzodiazepines enhance the effect of GABA, the main inhibitory neurotransmitter.
-
ENT3
-
Ethics and Legal issues14
-
Opthalmology16
-
Metabolic Medicine18
-
Obstetrics18
-
Psychiatry21
-
Contraception23
-
Oncology + Immunology + Geri25
-
Orthopaedics29
-
Pharmacology31
-
Haematology36
-
DERMATOLOGY38
-
Nephrology38
-
Rheumatology41
-
Respiratory52
-
Surgery61
-
Endocrinology64
-
Gynaecology71
-
Gastroenterology77
-
Neurology78
-
Cardiology83
