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Quiz 4

Medications

 

For this quiz, it would be helpful to have read up on neurotransmitters (serotonin, dopamine, noradrenaline, glutamate, GABA, acetylcholine) and understand how they work and the role they have in mental health disorders. It should then make sense as to how the drugs work by targeting these.  

 

  1. Can you identify the type of medication (eg antipsychotic/antidepressant) and maybe the mode of action?

All these drugs are important to know about. Just something you have to learn in the beginning. But you will also see patients on most of these either during your studies or careers

  • Amitriptyline

  • Fluoxetine

  • Phenelzine

  • Aripiprazole

  • Haloperidol

  • Lithium

  • Donepezil: 

  • Acamprosate

  • Olanzapine

  • Memantine

  • Sertraline

  • Venlafaxine

  • Diazepam

  • Promethazine

  • Disulfiram- 

  • Citalopram- 

 

 

 

2. Select all the side effects that are most commonly associated with Selective Serotonin Reuptake Inhibitors (SSRIs)

 

  • Nausea

  • Diarrhea

  • seizures,

  • prolonged QT interval, 

  • hyponatraemia,

  • altered libido, 

  • double vision, 

  • limb pain, 

  • headache,

  • myocarditis.  

 

 

3. What are the main clinical features and causes of Serotonin Syndrome? Answer in free text - bullets, notes or sentences. 100-word limit

 

 

4. Antipsychotic side effects

                                                                                    

Fill in the blanks: 

Extrapyramidal side effects (EPSEs) are most common in [BLANK] antipsychotics. They are understood to be caused by the blockage of dopamine in the [BLANK] pathway.

The EPSES are:

  • [BLANK](restlessness)

  • [BLANK](muscle abnormalities). These includes  

    • [BLANK] (a head tilt to one side, also with chin lift), and  

    • [BLANK](abnormal rotation of the eyeballs).

  • Parkinsonism:

    •  Tremor),  

    • (BLANK],  

    • [BLANK]).

  • [BLANK] – which are involuntary, repetitive body movements. This may include grimacing, sticking out the tongue, or smacking the lips

Can you think of any other common side effects of antipsychotic medication?- name 5 if you can

 

 

5. Clozapine monitoring

 

Fill in the blanks: 

 

Clozapine is a [BLANK] antipsychotic used after a trial of [BLANK]other antipsychotics, at least one of which should be [[BLANK]

 

Clozapine may only be prescribed to patients who are enrolled with a Patient Monitoring Service due to the risk of [[BLANK]]. 

 

Other important side effects include [[BLANK]], [[BLANK]], [[BLANK]].

 

Clozapine monitoring:

What is required? 

 

 

6. Neuroleptic Malignant Syndrome:

 

Neuroleptic Malignant Syndrome is the main psychiatric emergency to be aware of. It is a life-threatening reaction to antipsychotic medication. It is rare but the possibility of it should never be ignored.

 

It is potentially fatal (untreated mortality in [BLANK])

 

The main symptoms are:

  • [BLANK]- main suggestive symptom

  • Severe muscle rigidity

  • Autonomic instability (what would suggest this? [BLANK], [BLANK]], [BLANK]], sweating)

  • Fluctuating [BLANK]

  • Increased [BLANK] levels (lab test)

The treatment is [BLANK]

 

7. Mood stabilisers

 

Lithium

Think of any side effects you can of Lithium and the symptoms of Lithium toxicity. Max. 100 words

 

 

 

.  

Done! :-)

 

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ANSWERS

 

  1. Select the most appropriate description that best describes the medication's mode of action. 

 

Amitriptyline- Tricyclic Antidepressant (TCA)

Fluoxetine: Selective Serotonin Reuptake Inhibitor (SSRI)

Phenelzine: Monoamine Oxidase inhibitor (MAOI)

Aripiprazole: Atypical/second generation Antipsychotic –partial dopamine (D2) agonist

Haloperidol: Typical/first generation Antipsychotic, dopamine antagonist

Lithium: mood stabiliser. Unclear mechanism. Thought to affect intracellular secondary messenger systems. 

Donepezil: Acetylcholinesterase inhibitor

Acamprosate- Glutamate receptor antagonist and GABA-A agonist

Olanzapine- Atypical/second generation antipsychotic dopamine antagonist

Memantine: NMDA antagonist

Sertraline- Selective serotonin reuptake inhibitor (SSRI)

Venlafaxine- Serotonin and noradrenaline reuptake inhibitor (SNRI)

Diazepam- a Benzodiazepine GABA-A agonist

Promethazine- an Antihistamine H1-antagonists. Used on the wards as part of the rapid tranquilisation protocol

Disulfiram- Binds irreversibly to aldehyde dehydrogenase

Citalopram- Selective serotonin reuptake inhibitor (SSRI)

 

You are unlikely to need to know this off-by-heart in too much detail but you need to have a basic understanding, as the complex molecular of anti-psychotic medication help us understand the side effects patients can report. See the attachment for further details.

 

 

 

2. Select all the side effects that are most commonly associated with Selective Serotonin Reuptake Inhibitors (SSRIs)

 

Nausea, diarrhoea, seizures, prolonged QT interval, hyponatraemia, altered libido, double vision, limb pain,headache, myocarditis.  

 

Important SSRI side effects include headache, GI symptoms, altered libido. Hyponatraemia and prolonged QT interval are quite likely with particular drugs. In the first 2 weeks, There is a small but real risk of increased suicidal thoughts –especially in children. SSRIs can take 2-6 weeks before clinical benefit is seen.

 

3. What are the main clinical features and causes of Serotonin Syndrome? Answer in free text - bullets, notes or sentences. 100 word limit

 

Clinical features of Serotonin Syndrome

- Autonomic instability: hyperthermia, tachypnoea, tachycardia, sweating, mydriasis

- Altered mental state: agitation, excitation, confusion or coma

- Altered neuromuscular excitability: clonus, hyperreflexia, myoclonus, tremor or rigidity

 

Complications: seizures, rhabdomyolysis, DIC, multiple organ failure

 

Main differentials: Neuroleptic Malignant Syndrome, Malignant Hyperthermia, CNS infections

 

Cause: usually a result of taking a combination of serotonergic agents

Most commonly known serotonergic agents: SSRIs, SNRIs, Tricyclic Antidepressants, Monoamine Oxidase Inhibitors,

Other medications with serotonergic actions: Opioids, 5HT antagonists, Triptans, Trazodone, Mirtazapine and Trazodone, Methylene blue

 

 

 

4. Antipsychotic side effects

                                                                                    

 

Extrapyramidal Effects (more common in typical, first generation)– these result from D2 blockade in the nigrostriatal pathways – examples of the side effects include:

  • Akathesia – restlessness

  • Acute dystonia – These includes    tongue protrusion, torticollis (a head tilt to one side, also with chin lift) and oculogyric crisis (abnormal rotation of the eyeballs)

  • Parkinsonism – tremor, rigidity, brady-kinesia

  • Tardive dyskinesia. involuntary, repetitive body movements. This may include grimacing, sticking out the tongue, or smacking the lips

 

Others include:

  • Sedation and weight gain - due to H1 antagonism (esp olanzapine, clozapine, quetiapine)

  • High prolactin (esp typical/first gen. and risperidone) which can result in galactorrhoea, gynaecomastia, amennorhoea, impotence. - due to Dopamine2 blockade in the tubero-infundibular (tubero-hypophyseal) dopamine pathways

  • Dry mouth, constipation, blurred vision, urinary retention- due to M1 antagonism: Antimuscarinic effects – As well as these peripheral effects, a CNS muscarinic blockade can cause confusion.

  • Postural hypotension, problems ejaculating, nasal stuffiness - due to Alpha1 antagonism

  • ↑risk of seizures –especially in those already with epilepsy

  • Prolonged Q-T – predisposing to ventricular arrhythmias

 Remember the 4 dopamine pathways in schizophrenia.

- Mesolimbic: linked to positive symptoms in schizophrenia

- Mesocortical: linked to negative symptoms in schizophrenia

- Nigrostriatal

- Tuberoinfundibular

The problem with treating schizophrenia by targeting the dopamine pathways in the brain is that it will deplete the dopamine levels in the other 2 pathways as well- leading to side effects. EPSEs due to the nigrostriatal pathway and high prolactin due to the tuberoinfundibulnar pathway.

 

 

 

5. Clozapine monitoring

Clozapine is a [2ndgeneration/atypical] antipsychotic used after a trial of [2] other antipsychotics, at least one of which should be [2ndgeneration].

 

Clozapine may only be prescribed to patients who are enrolled with a Patient Monitoring Service due to the risk of [neutropaenia, agranulocytosis]. 

 

Other important side effects include [intestinal obstruction and paralytic ileus], [myocarditis & cardiomyopathy], [dyslipidaemia and altered glucose tolerance].

 

Clozapine monitoring:

[Wbc monitoring at baseline and weekly for 18 weeks, fortnightly for 1 year, monthly thereafter]

[regular lipids and weight screens]

[regular fasting blood sugar screens]

 

 

6. Neuroleptic:

 

Neuroleptic Malignant Syndrome is the main psychiatric emergency to be aware of. It is a life-threatening reaction to antipsychotic medication. It is rare but the possibility of it should never be ignored.

 

It is potentially fatal (untreated mortality in 10-30%)

 

The main symptoms are:

  • Hyperthermia

  • Severe muscle rigidity

  • Autonomic instability (raisedHR/tachycardia, [increased BP/hypertension, raisedrespiratory rate/ tachypnoea, sweating)

  • Fluctuating consciousness]

  • Increased creatininephosphokinase levels  

 

The treatment is ABC, stop antipsychotic, fluid balance, supportive management.

 

 

7. Mood stabilisers

 

Lithium

List the common side effects of Lithium and the symptoms of Lithium toxicity. Max. 100 words

 

Lithium is a mood stabiliser and has numerous effects on biological systems. It can substitute for sodium/potassium/calcium/magnesium and enters the cells, interfering with transmitter release and second messenger systems. Hence, it can block release of certain transmitters and hormones.

 

Indications for Lithium include: Management of acute manic or hypomanic episodes, recurrent depressive disorder and prophylaxis of bipolar affective disorder..

 

Common and early side effects of Lithium include abdominal pain, nausea, metallic taste, fine tremor, thirst, polyuria, weigh gain, oedema.After longer term use, people commonly develop thyroid dysfunction and renal impairment.

 

Lithium has a narrow therapeutic window. Lithium is excreted renally and is treated by the body much like sodium. Plasma Lithium levels are affected by hydration levels and by other medications that affect the kidneys, eg diuretics and NSAIDS.

 

Symptoms of Lithium toxicity include reduced consciousness, cerebellar ataxia, coarse tremor, dysarthria, diarrhoa and vomiting. This will develop if untreated to seizures, cardiac arrest, renal failure, coma, death.