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Psychiatry Medication (Antipsychotics (Indications (Contraindications…

- - - - Myasthenia Gravis, Addisons disease, closed angle glaucoma, granulocytosis
        
        Cautions
        
        Blood dyscrasias
        
        CVD
        
        Seizure predisposition
        
        Depression
        
        Diabetes
        
        Parkinsons
      - Amisulpride - CNS depression, phaeochromocytoma
  - - - Metabolic disturbances
        QT-prolongation
        Bradycardia
    - - Depression
        
        Weight loss
        Less sedating and fewer antimuscarinic effects than other antipsychotic drugs
        
        Neuroleptic Malignant Syndrome
        
        Associated with haloperidol, chlorpromazine & flupenthixol
        
        Fever
        
        Muscular rigidity
        
        Altered mental status
        
        Autonomic dysfunction
        
        Lasts 5-10 days after the discontinuation of drug therapy - ITU support is necessary
  - - - Few extra-pyramidal adverse effects
      - Major side effect = neutropenia
- - - - Lorazepam
      - Haloperidol
      - Olanzapine
      - Rapid tranquilisation can be achieved by lorazepam & haloperidol in combination
  - - - Neuroprotective effects: hippocampus, paralimbic cortex & amygdala
        
        Shown by neuroimaging findings
      - Inhibition of excitatory neurotransmitters e.g. dopamine, glutamate & GABA
        
        Cyclical dysregulation hypothesis of mania: dopamine neurotransmission is increased, causing downregulation of receptors, thus clinical depression occurs
      - Downregulation of NMDA
      - Promotion of GABAergic neurotransmission
      - Cellular mechanisms
    - - Prophylaxis & treatment of mania, bipolar, recurrent depression & aggressive or self-harming behaviour
      - Contra-indications
        
        Addisons
        
        Increased risk of toxicity in hyponatremia
        
        Cardiac insufficiency
        
        History of Brugada syndrome
        
        Avoid abrupt withdrawal and concurrent ECT due to lower seizure threshold
        
        Bradycardia (remember patient in Dr Hand's clinic in Oakham who had slow HR and therefore couldn't have lithium prescribed so suggested he goes down the non-pharmacological route and seek psychotherapy privately)
      - Pregnancy
        
        Avoid if possible
        
        Requirements increased during 2nd & 3rd trimesters
    - - Narrow therapeutic/toxic ratio, thus aim to achieve concentration of 0.8-1mmol/litre for acute mania. Routine monitoring performed weekly until concentrations are stable, then every 3 months thereafter
      - Long-term use should be avoided due to association with thyroid disorders and mild-cognitive/memory impairment.
        Renal function, cardiac & thyroid monitored at baseline and every 6 months thereafter
    - - Arrythmia (AV block, bradycardia, ECG changes)
        
        Benign intracranial hypertension
        
        Cardiomyopathy
        
        Cognitive impairment
        
        GI disturbances
        
        & many more
      - Signs of toxicity
        
        Increasing GI disurbances
        
        Visual disturbances
        
        Polyuria
        
        Muscle weakness
        
        Fine tremor -> coarse tremor
        
        CNS disturbances including abnormal reflexes, confusion, restlessness, stupor, myoclonus
  - - - Main treatment for all forms of epilepsy (particularly petit mal), but also used as a mood stabiliser in patients with mania
      - Dose = 750mg daily -> 1-2g daily
      - Contraindications
        
        Personal or family history of severe hepatic dysfunction
        
        Systemic lupus erythematosus
      - Pregnancy
        
        SIGNIFICANT TERATOGENIC EFFECTS
        
        30-40% risk of serious developmental disorders
        
        Dose-dependent.
        
        Delays in early development e.g. talking, walking, intellectual abilities, language skills & memory problems
        
        11% risk of congenital malformations
        
        Neural tube defects
        
        Hypospadias
        
        Heart defects
    - - LIVER TOXICITY
        
        Usually in the first 6 months, usually involving multiple antiepileptic therapy
        
        Monitoring - LFT's before and during first 6 months of therapy
        
        Withdraw treatment immediately if persistent vomiting, abdominal pain, anorexia, jaundice, oedema, malaise, drowsiness or loss of seizure control
      - Common
        
        Aggression
        
        Anaemia
        
        Confusion
        
        Convulsion
        
        Extrapyramidal disorders
        
        Thrombocytopenia
      - PANCREATITIS
    - - Inhibits the breakdown and re-uptake of the inhibitory neurotransmitter GABA.
  - - - Anti-convulsant and analgesic drug that is used in the treatment of pain associated with trigeminal neuralgia and in epilepsy
        NICE guidance also indicates this in:
        
        Prophylaxis of bipolar disorder unresponsive to lithium (400-600mg)
        
        Adjunct in acute alcohol withdrawal (800mg->200mg)
      - Contraindications
        
        AV-conduction abnormalities
        
        History of bone-marrow depression
        
        Cautions
        
        Cardiac disease
        
        History of haematological reactions
        
        Seizure exaccerbations
        
        Skin reactions
        
        Susceptibility to angle-closure glaucoma
        
        Should be withdrawn immediately in cases of aggravated liver dysfunction or acute liver disease, or leucopenia if severe, progressive or associated with clinical symptoms
    - - Dose related:
        
        GI disturbances
        
        Drowisness, dizziness & headache
        
        Ataxia
      - Idiosyncratic:
        
        Skin rashes
        
        Blood dyscrasias
      - Serious:
        
        Cholestatic jaundice
        
        Acute renal failure
        
        SJS & TEN
        
        Alopecia
        
        Thromboembolism
  - - - Partial seizures
        
        Tonic clonic seizures
        
        Lennox-Gastaut
        
        Generalised absenses
        
        Myoclonic epilepsy
      - Contraindications
        
        Severe liver impairment
        
        Should be withdrawn in patients whom's seizures are exacerbated
      - Pregnancy
        
        Some clinicians favour lamotrigine as the anti-epileptic drug of choice in pregnancy
        
        However there is a lack of evidence surrounding the efficacy and safety of these drugs in pregnancy and there is still a risk of neural tube defects #
      - Dose: initial dose = 25mg OD, increased gradually up until 200mg daily or 100mg with valproate
    - - Stabilises neuronal membranes & reduces the release of excitatory aminoacids.
      - BLOCKS VOLTAGE-SENSITIVE SODIUM CHANNELS - Especially glutamate
    - - Common:
        
        Headache
        
        N/V
        
        Diplopia
        
        Dizziness
        
        Ataxia
      - Serious:
        
        SJS
        
        Toxic Epidermal necrolysis
        
        Blood dyscrasias
- - - - Potentiates GABA - inhibitory neurotransmitter
      - Exerts it's affects as a hypnotic & anxiolytic
      - Half life = 3 days
    - - Short term relief of severe, disabling or unacceptable stress due to anxiety
      - 2-4 weeks only
      - Use of benzodiazepines to treat short-term "mild" anxiety is inappropriate
    - - Worsen motor skills, attention and memory
      - Oversedation
        
        Dose related
        
        Drowsiness, poor concentration, in co-ordination, muscle weakness, dizziness & mental confusion
      - Drug interaction
        
        Antidepressants
        
        Antipsychotics
        
        Anticonvulsants
        
        Antihistamines
        
        Opiates
        
        Alcohol
      - Memory impairment
        
        Impaired acquisition of new information & episodic memory
      - Paradoxical stimulant effect
        
        Increased anxiety
        
        Insomnia
        
        Nightmares
        
        Hallucinations
        
        Frequently seen in anxious and aggressive individuals, children & the elderly
      - Elderly
        
        More susceptible to CNS depressant effects
        
        Confusion
        
        Night wandering
        
        Amnesia
    - - Both psychological and physical dependence may occur within a few weeks or months of regular or repeated use
  - - - Thought to act at a specific serotonin receptor.
    - - Short term anxiety use
      - Doesn't alleviate benzodiazepine withdrawal
      - Contraindications
        
        Epilepsy
        
        Acute prophyria
        
        Reduced dose in hepatic & renal disease
    - - Nausea
        
        Dizziness
        
        Headache
        
        Nervousness
        
        Excitement
- - - - Mild-Moderate Alzheimer's
        
        Galantamine
        
        Rivastigmine
      - All severities
        
        Donepezil
      - No clear difference in efficacy between the 3
        Differences = administration schedule, compliance & drug interactions
    - - General Side Effects: N/V/D, headache, muscle cramps, tiredness
      - Systemic (& more serious) Effects: bradycardia, uncontrollable movements, sweating, agitation
    - - Alzheimer's pathology = reduced ACh in the brain. Therefore these drugs decrease the breakdown of ACh and thus increase the levels in the brain
      - Only slows the progression of the disease, because there is underlying reasons for reduced ACh & ?some receptor changes
    - - e.g. asthma, difficulty passing urine
  - - - Memantine
    - - Voltage dependent, moderate affinity, uncompetitive
      - Neuronal dysfunction may be caused by elevated levels of glutamate
    - - Common: balance disorders, constipation, dizziness, drowsiness, hypertension
      - Serious: hallucinations, heart failure, thrombosis, seizures, hepatitis, pancreatitis, psychosis, suicidal ideation