MEDI3004 MENTAL HEALTH ROTATION -YEAR 3 MBBS. Topic 8 - Psychiatric Drugs.docx

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University of Queensland
Associate Professor Jane Turner

PHARMACOLOGICAL MANAGEMENT OF PSYCHIATRIC DISORDERS ANXIOLYTICS Indications  Transient forms of anxiety disorders  Insomnia  Alcohol withdrawal (especially delirium tremens)  Extrapyrimidal symptoms and akathisia due to antipsychotics  Seizure disorders  Musculoskeletal disorders ANTIDEPRESSANTS  Bipolar Disorder o Monotherapy not advisable  switch from depressive to manic Sx o Initiate therapy with mood stabilizer + SSRI/buproprion RULES OF USE  Onset of effect o Neurovegetative Sx: 1-3 weeks o Emotional and cognitive Sx: 2-6 weeks o Because of this discrepancy, beware of suicide risk in first 2 weeks  Treatment time o 6-12 months for first or second episode o Two years if third episode, elderly, psychotic features, refractory depression or > 2 episodes in 2 years  Discontinue o Abrupt cessation can cause discontinuation syndrome – Sx: anxiety, insomnia, irritability, mood lability, nausea/vomiting, dizziness, headache,d ystonia, tremor, chills, fatigue, lethargy, myalgia o Should slowly taper over several Start SSRI weeks Reassess every 1-2 weeks for 3-4 weeks Strategies for refractory depression 1. Optimisation: ensure adequate dose Full response No/partial response 2. Augmentation: add non-antidepressant agent such as thyroid hormone, lithium, Optimise dose atypical antipsychotic 3. Combination: add another anti- Reassess for 4-8weeks depressant within or outside class. E.g. buproprion + SSRI Partial response No response 4. Substitute: charge primary anti- depressant to another within or outside Continue Combine Augment Substitute class OVERDOSE Tricyclics Management  Three times the therapeutic dose is lethal  Activated charcoal  Presentation: o anticholinergic effect,  Cathartics o CNS stimulation then depression  Supportive treatment o Seizures  IV diazepam for seizure  Physostigmine salicylate for coma  ECG: prolonged QT intervals  DO NOT GIVE Ipecac (rapid SEROTONIN SYNDROME neurologic  Over-stimulation of the serotonergic system deterioration and seizures)  Causes o Medication combos e.g. SSRI + MAOI, SSRI + tryptophan o Adverse reaction to SSRI – especially when switching from MAOI  Sx: o Initial: nausea, diarrhea, palpiations, chils, restlessness, confusion, lethargy o Later: myoclonus, hyperthermia, rigor, hypertonicity  Management o Discontinue medication o Administer emergency medical care  Important to distinguish from neuroleptic malignant syndrome Drug Starting Therapeutic Use MOA Side-effects Dose (mg) Dose (mg) SSRI Fluoxetine (Prozac) 20 20-80  Anxiety States Block serotonin uptake  CNS: Restlessness, Tremor, Insomnia, Headache, only Sertraline (Zoloft) 50 50-200  OCD Drowsiness Paroxetine (Paxil) 10 20-60  Eating disorders  GIT: nausea, vomiting, diarrhea, cramps, weight loss  Seasonal Depression  Sexual dysfunction: impotence, anorgasmia Citalopram (Celexa) 20 20-60  A/typical depression  CVS: HR, QT delay, 5HT syndrome, EPS, SIADH SNRI Venlafaxine (Effexor) 37.5-75 75-225  Depression Block oradrenaline and  5HT: Insomnia Desvenlafaxine (Pristiq) 50 50-400  Anxiety Disorders serotonin reuptake  NA: Tremors, tachycardia, sweating,  diastolic BP Duloxetine (Cymbalta) 40 40-60 Tricyclics Amitryptyline (Elavil) 75-100 150-300  OCD Block noradrenaline and  Anticholinergic  Melancholic serotonin reuptake  NA effects: tremors, tachycardia, sweating, insomnia, Imipramine (Tofranil) 75-100 150-300 Nortriptyline (Aventyl) 75-100 75-150 Depression erectile and ejaculation problems Desipramine 100-200 150-300   adrenergic: orthostatic hypotension  Antihistamine: sedation, weight gain (Norpramine)  CNS: sedation, stimulation,  seizure threshold  CVS: HR, conduction delay (QT)  Toxic in OD (3x dose is lethal) NDRI Bupropion 100 300-450  Depression Block noradrenaline and  CNS: dizziness, headache, tremor  Seasonal depression dopamine reuptake  CVS: dysrhythmia, hypertension  GIT: dry mouth, N/V, constipation,  appetite  Agitation, anxiety, anaphylaxis NASSA Mirtazapine (Remeron) 15 15-45  Insomnia, agitation/ Enhance NA & 5HT  CNS: somnolence, dizziness, seizure depression with activity by inhibiting 2  Endocrine: u cholesterol,  triglycerides cachexia adrenergic receptors  GIT: constipation, ALT MAOI Phenelzine (Nardil) 45 60-90  Depression Irreversible inhibition od Hypertensive crisis from tyramine rich foods unresponsive to SSRI monoamine oxidase A (wine/cheese), headache, flushes, palpitationsm N/V, Tranylcypromine 30 10-60  Atypicla depression and B   NA and 5HT photophobia  Dizziness, reflex tachycardia, postural hypotension, sedation, insomnia  Weight gain, social dysfunction, energizing MOOD STABILISERS Baseline tests Screen for LITHIUM (VALPROIC ACID)  First line  FBC  Pregnancy  Therapeutic response  ECG (>45yrs/CVD risk)  Thyroid disease within 7-14 days  Urinalysis  Seizure disorder  BUN  Neurological disease  Unknown MOA  Cr  Renal disease  Electrolytes  Cardiovascular disease  TSH Monitoring  Therapeutic dose is 0.5-1.2mmol of 1.0-1.25mmol/L for isellaneous: ECG changes, acne acute mania omViting and nausea  Serum levels until therapeutic nIcreased weight  Monitor biweekly or monthly until a steady state is ypHothyroidism reached, then q2months remor, Teratogenicity  Monitor thyroid function q6months, creatinine q6months nIsipidus (diabetes) and urinalysis q1year eLkocytosis Side Effects (LITHIVM) OTHERS Drug Dose (adult) Indications Side Effects mg/d Lithium 600-1500  Bipolar maintenance  GIT: N/V, diarrhea, abdo pain  Acute mania  GU: polyuria/dipsia, GN, CRF, DI  MDE/OCD augmentation  CNS: fine tremor, lethargy, headache with antidepressant  Reversible leukocytosis  Schizoaffective disorder  Teratogenicity (Ebstein’s heart)  Recurrent depression  Weight , acne, edema, psoariasis Lamotrigine 12.5-15 (max  Bipolar disorder  GI: N/V, diarrhea (Lamictal) 500)  Rapid cycling bipolar  CNS: ataxia, dizziness, diplopia,  Mixed phase/dysphoric headache, somnolence mania  Skin rash (Stevens-Johns syndrome)  Prevention of mania/depression Divalproex 750-2500  Bipolar maintenance  GI: liver dysfunction, N/V, diarrhea (Epival)  Acute mania  CNS: ataxia, drowsiness, tremor,  Rapid cycling bipolar sedation, cognitive blurring  Mixed phase/dysphoric  hair loss, weight gain, neural tube mania defects, thrombocytopenia Carbamazepine 400-1600  Bipolar maintenance  GI: hepatic toxicity ( LFTS) (Tegretol)  Acute mania  CNS: ataxia, dizziness, slurred speech,  Rapid cycling bipolar drowsiness, nstagmus
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