CNS (ADHD, Bipolar disorder, Depression)

What are the symptoms of ADHD

Hyperactivity

impulsive

inattention

What’s the treatment for ADHD for 5-17 year olds

1st line: Methylphenidate (CD2)

2nd line: Lisdexamfetamine (CD2)

Alternative: Atomoxetine/Guafacine

What’s the treatment for ADHD in adults

1st line: Methylphenidate/Lisdexamfetamine

alternative: Atomoxetine

What’s the MOA of methlyphenidate

potent CNS stimulant, increases dopamine and noradrenaline levels

What are the side effects of Methylphenidate

1.) increased h/r+BP

2.) Growth restriction in kids

3.) Tics and Tourettes syndronme

4.) Appetite/weight loss and insomnia

What monitoring needs to be done with every ADHD drug every 6 months

Pulse

BP

Appetite

Weight+height

Psychiatric symptoms

What are the contraindications of Methylphenidate

1.) CVD

2.) hyperthyroidism

3.) severe HTN

4.) Uncontrolled bipolar disorder

5.) severe depression

What’s the MOA of Atomoxetine

Noradrenaline reuptake inhibitor causes increased levels at synaptic cleft

What are the side effects of Atomexetine

1.) suicidal ideation

2.) hepatotoxicity

3.) QT prolongation

What’s the MOA of Dexamfetamine/Lisdexamfetamine

potent CNS stimulant, increases dopamine and Noradrenaline levels

What are the side effects of dexamfetamine/Lisdexamfetamine

1.) appetite loss or anorexia

2.) increased heart rate and blood pressure

3.) tics+tourettes

4.) growth restriction in children

What are the contraindications of Dexamfetamine/Lisdexamfetamine

1.) CVD

2.) hyperthyroidism

3.) HTN

4.) Agitated states

What is bipolar disorders

extreme mood swings

What are the two types of episodes of bipolar disorders

1.) mania

2.) depression

For acute episodes of mania and hypomania what are the treatments

1.) BZDs=short term use

2.) Antipyschotics= Quetiapine, Risperidone or Olanzapine

3.) lithium added to antipsychotic if monotherapy isn’t enough

4.) Asenapine in moderate-severe maniac episodes

What’s the treatment for prophylaxis of bipolar disorders

1.) Lithium salts

2.) sodium valproate

3.) Olanzapine

4.) Carbamazepine

What are the contraindactions in bipolar disorders

don’t give antidepressants

Lithium and pregnancy

1.) teratogenic

2.) have effective contraception in women of child-bearing age

3.) toxicity occurs in breast feeding

What are the counselling points of lithium

1.) main good salt+water intake

2.) lithium treatment pack given

3.) avoid OTCs such as NSAIDs+antacids

4.) affects driving due to drowsiness (avoid alcohol)

What are the side effects of lithium

1.) thyroid disorders

2.) renal impairment

3.) Benign intracranial hypertension

4.) QT prolongation

5.) Lower seizure threshold

6.) Hyponatraemia leads to toxicity

What are the signs of lithium toxicity

1.) renal symptoms e.g. polyuria,incontinence,hypernatriemia

2.) extrapyrimidal symptoms e.g.ataxia, tremors, nystagamus

3.) visual disturbances

4.) nervous system disturbances

5.) GI effects, e.g. diarrhoea and vomiting

If lithium is more than 2mmol/L what signs would you expect

1.) renal failure

2.) arrhtymias

3.) seizures

4.) coma/death

How to monitor lithium levels

1.) 12 hours post dose

2.) monitor every 3 months

3.) extra monitoring needed if illnesses occur or big changes to diet/water intake

What’s the theraupetic range of lithium

0.4-0.8 for lower end of prophylatic treatment or elderly

0.8-1.0 for acute maniac episodes

What drugs reduces renal excretion of lithium

1.) ACEi/ARBs

2.) NSAIDs

What drugs increase risk of seizures with lithium

1.) SSRIs

2.) Quinolones

What drugs with lithium increase risk of EPS (extrapyrimidal symptoms)

1.) Halopiderol

2.) Clozapine

3.) Phenothiazines

4.) Metoclopramide

What drugs with lithium increase risk of serotonin syndrome

1.) SSRIs

2.) Sumitriptan

3.) MAOIs

What drugs with lithium increase the risk of neurotoxicity

1.) phenytoin

2.) carbamazepine

3.) antipsychotics

4.) amitriptyline

What drugs with lithium can lead to hyponatraemia

1.) diuretics

2.) SSRIs

What drugs with lithium lead to increased QT prolongation

1.) Quinolones

2.) Citalopram

3.) Macrolides

4.) Amiodarone

What are common s/e of Antidepressants

1.) hyponatraemia especially in SSRIs

2.) Suicideal ideation and behaviour

3.) Serotonin syndrome

What are the symptoms of serotonin syndrome

1.) neuromuscular hyperactivity

2.) altered mental state

3.) autonomic dysfunction

How to swtich between antidepressants

1.) MAOIs wait 2 weeks

2.) SSRIs wait 1 week (2 weeks if Sertraline and 5 weeks if fluoxetine)

3.) TCAs wait 1-2 weeks (3 weeks if Imipramine or Clomipramine)

What’s the MOA of SSRIs

selectively inhibit reuptake of 5HT from synaptic cleft

Give examples of SSRIs

1.) Citalopram

2.) Sertraline

3.) Fluoxetine

4.) Paroxetine

5.) Escitalopram

What are the side effects of SSRIs

1.) GI disturbances

2.) Appetite or weight disturbances

3.) Serotonin syndrome

4.) Hypersensitivity reactions

What’s the interaction between SSRIs and grapefruit juice

increased plasma conc of SSRIS

What drugs when taken alongside with SSRIs causes hyponatraemia

1.) Diuretics

2.) desmopressin

3.) NSAIDs

4.) Carbamazepine

What drugs alongside with SSRIs causes Serotonin syndrome

1.) St John Worts

2.) Sumatriptan

3.) TCAs/MAOIs

What drugs increase risk of bleeding of SSRIs

1.) aspirin

2.) antiplatelet

3.) NSAIDs

4.) anticoagulants

What’s the maximum dose for elderly patients for depression for Citalopram

20mg

What drugs with SSRIs increase risk of QT prolongation

1.) macrolides

2.) TCAs

3.) Sotalol

4.) antimalarials

What’s the only licensed SSRI for children

fluoxetine

What’s the MOA of TCAs

inhibits reuptake of 5-HT and NA

What are the benefits of SSRIs over TCAs

less sedating, less cardio toxic, less antimuscarinic, less epilotegenic

more toxic in overdose

What are the side effects of TCAs

1.) antmuscarnic side effects: dry mouth, blurred vision

2.) seizures

3.) cardiac s/e: QT prolongation,HTN, heart block

What drugs interacts with TCAs to cause reduced plasma conc

1.) Carbamazepine

What drugs interacts with TCAs to cause increased plasma conc

Cimetidine

What drugs with TCAs. increases risk of hyponatraemia

diuretics

desmopressin

Carbamazepine

What drugs can increase antimuscarinic effects of TCAs

1.) antimuscarnic drugs

2.) antihistamines

3.) Atropine

4.) antipsychotics

What drugs increase risk of hypotension with TCAs

1.) Alpha blockers

2.) Beta-blockers

3.) Antihypertensive

What drugs can increase the risk of Serotonin syndrome with TCAs

1.) SSRIs

2.) 5HT1 antagonists

3.) MAOIs

4.) Selegilline

What are the side effects of MAOIs

1.) hepatotoxicity

2.) postural hypotension /hypertensive responses

3.) hypertensive crises- most likely with tranlycyopramine

What’s the patient counselling for MAOIs

1.) avoid food containing tyramine

2.) eat only fresh food

3.) avoid alcohol

What are the examples of irreversible MAOIs

1.)Phenelzine

2.)Tranylcypromine

3.) Isocarboxazid

What are some examples of reversible MAOIs

moclobenemide

What’s the MOA of MAOI

blocks monoamine oxidase enzyme, increasing levels of neurotransmitters like serotonin, noradrenaline, and dopamine.

What interactions with MAOIs causes hypertensive crisises

1.) adrenaline/noradreanline

2.) Levodopa, MAO-B inhibitors

What’s the treatment line of Depression

1st line= SSRIs

2nd line= increased dose of SSRIs or Mirtazapine

3rd line= another AD class, lithium/antipsychotics

What are the sedating TCAs

1.) Amitriptyline

2.) Clomipramine

3.) Trimipramine

What are the less sedating of TCAs

1.) nortriptyline

2.) Imipramine

3.) Lofepramine

What’s examples of Tetracyclic antidepressants

1.) miaserin

2.) trazodone